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ðñùôïâÜèìéá Ôüìïò 16, Ôåý÷ïò 2, Áðñßëéïò - Éïýíéïò 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 2, Áðñßëéïò - Éïýíéïò 2004, Volume 16, Number 2, Ápril - June 2004

Ôçò Óýíôáîçò 54

Á. Ìáñéüëçò, ×. ËéïíÞò: 16ï ÐáíåëëÞíéï ÓõíÝäñéï ÃåíéêÞò ÉáôñéêÞò: Áöåôçñßá ãéá ìéá íÝá åðï÷Þ óôç ÃåíéêÞ ÉáôñéêÞ; Âñáâåõèåßóá Åñãáóßá óôï Äéáãùíéóìü "Ä. ºêêïõ"

56

Á. ÂÞôáò, ×. Óåìåñôæßäçò, Åõáããåëßá ÍåñáíôæÜêç: ÄéÜãíùóç ôçò åëÜóóïíïò â-èáëáóóáíáéìßáò áðü ôïõò äåßêôåò ôùí åñõèñþí áéìïóöáéñßùí ôïõ áßìáôïò Âñáâåõèåßóåò Åëåýèåñåò Áíáêïéíþóåéò

62

É. ÄñõãéáííÜêçò, Á. Ëáëéþôçò, Á. Ìåëéäïíéþôçò, Êáëëéüðç Óôåöáíïðïýëïõ, Ä. ÄñõãéáííÜêçò, Í. ÐáðáäÜêçò, Á. Ìðáôßêáò: Ç åêôßìçóç ôçò ïñèÞò óõíôáãïãñÜöçóçò áíôáãùíéóôþí ôùí õðïäï÷Ýùí-2 éóôáìßíçò (Ç 2-RAs) êáé áíôáãùíéóôþí ôçò áíôëßáò ðñùôïíßùí (PPIs) óôçí ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

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Ê. Óõñéáíüò, Âéêôùñßá ËÝôôá, ÊëåïðÜôñá ÊïõñÜêç, ÄÞìçôñá ÊáêëáìÜíïõ-Âñåôôïý: Ïé áíáêñßâåéåò óôçí ðéóôïðïßçóç ôçò áéôßáò èáíÜôïõ

87

Ê. Óïõëéþôçò, Á. Ìáñéüëçò: Ç äéáìüñöùóç åíüò ÏëïêëçñùìÝíïõ ÓõóôÞìáôïò ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò óôçí ÅëëÜäá Áíáóêüðçóç

Ðáðáäéáìáíôïðïýëïõ 4, 115 28 ÁÈÇÍÁ

Áñéèìüò ¢äåéáò 451/91

ÁèçíÜ Ñüäç, Ðáíáãéþôá ÓïõñôæÞ, Å. ÂåëïíÜêçò: Ç ÷ñçóéìüôçôá ôçò óôáôéóôéêÞò åðåîåñãáóßáò ôùí Ðéóôïðïéçôéêþí ÈáíÜôïõ óôçí åêðüíçóç ìåëåôþí èíçóéìüôçôáò

ÐËÇÑÙÌÅÍÏ ÔÅËÏÓ Ôá÷. Ãñáöåßï Ê. Ä. Áèçíþí

ÐÑÙÔÏÂÁÈÌÉÁ ÖÑÏÍÔÉÄÁ ÕÃÅÉÁÓ – Primary Health Care

94

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 Executive Board of the Greek Association of General Practitioners

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

Ä. ÃëÜñïò, ÊáèçãçôÞò ÉáôñéêÞò ÖõóéêÞò Ðáí/ìßïõ Éùáííßíùí

D. Glaros, Professor of University of Ioannina

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

K. Óéáìüðïõëïò, ÊáèçãçôÞò Íåöñïëïãßáò Ðáí/ìßïõ Éùáííßíùí

K. Siamopoulos, Professor of University of Ioannina

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

Ôçë.: (2810) 394615, (28310) 25833 e-mail: tasrom@yahoo.co.uk

Ë. ÓðÜñïò, Ïìüôéìïò ÊáèçãçôÞò ÊïéíùíéêÞò ÉáôñéêÞò Ðáí/ìßïõ Áèçíþí

L. Sparos, Åmeritus Professor of University of Athens

Åêôýðùóç:

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

President Bodosakis-Prodromos Merkouris Vice-President A Christos Lionis Vice-President B Antonis Karotsis General Secretary Treasurer Athanasios Symeonidis Special Secretary Stella Argiriadou Members Anargiros Mariolis Antonis Batikas Ãñáììáôåßá Óýíôáîçò: Áíáóôáóßá Ñùìáíßäïõ

ÔÅ×ÍÏÃÑÁÌÌÁ Ì. ÁõãÝñç 12, 153 43 Áã. ÐáñáóêåõÞ Ôçë.: 210.60.00.643, Fax: 210.6002295 E-mail: techn@hol.gr


ÁÍÁÓÊÏÐÇÓÇ REVIEW

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 2, Áðñßëéïò - Éïýíéïò 2004, Volume 16, Number 2, April - June 2004

ÐÅÑÉÅ×ÏÌÅÍÁ Ôçò Óýíôáîçò Á. Ìáñéüëçò, ×. ËéïíÞò: 16ï ÐáíåëëÞíéï ÓõíÝäñéï ÃåíéêÞò ÉáôñéêÞò: Áöåôçñßá ãéá ìéá íÝá åðï÷Þ óôç ÃåíéêÞ ÉáôñéêÞ; ................................................................................................................................................................ 54 Âñáâåõèåßóá Åñãáóßá óôï Äéáãùíéóìü "Ä. ºêêïõ" Á. ÂÞôáò, ×. Óåìåñôæßäçò, Åõáããåëßá ÍåñáíôæÜêç: ÄéÜãíùóç ôçò åëÜóóïíïò â-èáëáóóáíáéìßáò áðü ôïõò äåßêôåò ôùí åñõèñþí áéìïóöáéñßùí ôïõ áßìáôïò ......................................................................................................................................... 56 Âñáâåõèåßóåò Åëåýèåñåò Áíáêïéíþóåéò É. ÄñõãéáííÜêçò, Á. Ëáëéþôçò, Á. Ìåëéäïíéþôçò, Êáëëéüðç Óôåöáíïðïýëïõ, Ä. ÄñõãéáííÜêçò, Í. ÐáðáäÜêçò, Á. Ìðáôßêáò: Ç åêôßìçóç ôçò ïñèÞò óõíôáãïãñÜöçóçò áíôáãùíéóôþí ôùí õðïäï÷Ýùí-2 éóôáìßíçò (Ç2-RAs) êáé áíôáãùíéóôþí ôçò áíôëßáò ðñùôïíßùí (PPIs) óôçí ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò. ........................................................................ 62 Ê. Óõñéáíüò, Âéêôùñßá ËÝôôá, ÊëåïðÜôñá ÊïõñÜêç, ÄÞìçôñá ÊáêëáìÜíïõ-Âñåôôïý: Ïé áíáêñßâåéåò óôçí ðéóôïðïßçóç ôçò áéôßáò èáíÜôïõ .................................................................................................................................................... 80 Ê. Óïõëéþôçò, Á. Ìáñéüëçò: Ç äéáìüñöùóç åíüò ÏëïêëçñùìÝíïõ ÓõóôÞìáôïò ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò óôçí ÅëëÜäá ................................................................................................................................................................................................................................................. 87 ÁíáóêïðÞóç ÁèçíÜ Ñüäç, Ðáíáãéþôá ÓïõñôæÞ, Å. ÂåëïíÜêçò: Ç ÷ñçóéìüôçôá ôçò óôáôéóôéêÞò åðåîåñãáóßáò ôùí Ðéóôïðïéçôéêþí ÈáíÜôïõ óôçí åêðüíçóç ìåëåôþí èíçóéìüôçôáò ................................................................................................................ 94

CONTENTS Editorial A. Mariolis, C. Lionis: 16th National Congress of General Practice: Is it a staring point? ....................................................................... 54 Awarded Paper in the Memory of Prof. “D. Ikkos” A. Vitas, C. Semertzidis, Evaggelia Nerantzaki: Diagnosis of heterozygous (minor) beta-thalassemia based on blood erythrocyte indexes ............................................................................................................................................................................................................ 56 Awarded Freestanding Papers I. Drygiannakis, A. Laliotis, A. Melidoniotis, Kalliopi Stefanopoulou, D. Drygiannakis, N. Papadakis, A. Batikas: Assessing rational prescription of histamine-2 receptor antagonists (Ç2-RAs) and proton pump inhibitors (PPIs) in Primary Health Care .......................................................................................................................................................................................................................... 62 K. Syrianos, Victoria Letta, Kleopatra Kouraki, Dimitra Kaklamanou-Vrettou: The inaccuracies in the certification of cause of death ...................................................................................................................................................................................................................................... 80 K. Souliotis, A. Mariolis: The development of an Intergrading Primary Health Care System in Greece ......................................... 87 Review Athina Rodi, Panagiota Sourtzi, E. Velonakis: The importance of Death Certificate’s in the mortality statistics ..................... 94


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Á. Ìáñéüëçò, ×. ËéïíÞò

THÓ ÓÕÍÔÁÎÇÓ ÅDITORIAL Primary Heatlh Care, Volume 16, Number 2, 54-55, 2004 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 16, Ôåý÷ïò 2, 54-55, 2004

16ï ÐáíåëëÞíéï ÓõíÝäñéï ÃåíéêÞò ÉáôñéêÞò: Áöåôçñßá ãéá ìéá íÝá åðï÷Þ óôç ÃåíéêÞ ÉáôñéêÞ; Ôï ÅôÞóéï ÓõíÝäñéï ôçò ÅëëçíéêÞò Åôáéñåßáò ÃåíéêÞò ÉáôñéêÞò áðïôåëåß åäþ êáé äåêáÝîé ÷ñüíéá Ýíá óçìáíôéêü óôáèìü ãéá ôçí êïéíïðïßçóç ôùí èÝóåùí ôçò ÅËÅÃÅÉÁ ãéá ôçí åêðáßäåõóç, ôçí Ýñåõíá, ôçí ðïéüôçôá ôùí õðçñåóéþí óôï ðåäßï ôçò ÃåíéêÞò/ÏéêïãåíåéáêÞò ÉáôñéêÞò, áëëÜ êáé ôç óõæÞôçóç ôùí óçìáíôéêüôåñùí åîåëßîåùí óôçí Åõñþðç êáé ôïí êüóìï. Ôï 16ï ÐáíåëëÞíéï ÓõíÝäñéï ÃåíéêÞò ÉáôñéêÞò ðñáãìáôïðïéÞèçêå óôçí Êù, óôï Óõíåäñéáêü ÊÝíôñï “KICC” áðü 14 ùò 18 Áðñéëßïõ 2004, êáé ôéò åñãáóßåò ôïõ ðáñáêïëïýèçóáí ðÜíù áðü 1350 óýíåäñïé áðü üëç ôçí ÅëëÜäá, ìå ìåãÜëç óõììåôï÷Þ ôüóï åéäéêåõìÝíùí üóï êáé åéäéêåõïìÝíùí éáôñþí ÃåíéêÞò ÉáôñéêÞò, êáèþò êáé éáôñþí Üëëùí åéäéêïôÞôùí. Ôçí Ýíáñîç ôïõ óõíåäñßïõ êÞñõîå ï Õðïõñãüò Õãåßáò êáé ÊïéíùíéêÞò Áëëçëåããýçò ê. Í. ÊáêëáìÜíçò, óõììåôÝ÷ïíôáò ó’ Ýíá óôñïããõëü ôñáðÝæé, ôï ïðïßï õðïãñÜììéóå ôïí óçìáíôéêü ñüëï ôïõ Ãåíéêïý Éáôñïý óôçí åäñáßùóç ôçò ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò óôç ÷þñá ìáò. Ðïéü Þôáí ôï êáéíïýñãéï ôïõ Óõíåäñßïõ áõôïý, åêôüò áðü ôï ðëïýóéï åðéóôçìïíéêü ðñüãñáììá ðïõ ðåñéåëÜìâáíå 15 óôñïããõëÝò ôñÜðåæåò, 8 äéáëÝîåéò, 5 êëéíéêÜ öñïíôéóôÞñéá, 3 óõíáíôÞóåéò ìå ôïí åéäéêü, êáèþò åðßóçò êáé 514 áíáêïéíþóåéò åñãáóéþí (353 åëåýèåñåò – 161 áíáñôçìÝíåò); ÁñêåôÝò êáéíïôïìßåò ðïõ åéóÞ÷èçêáí óôï öåôéíü óõíÝäñéï óêéáãñáöïýí ôç ìåôÜâáóÞ ôïõ óå ìéá íÝá åðï÷Þ. Ç ïñãÜíùóç óõæçôÞóåùí õðü ìïñöÞ óôñïããõëþí ôñáðåæéþí óå åðßêáéñá èÝìáôá, üðùò ç “ÄéïéêçôéêÞ êáé ïñãáíùôéêÞ áõôïôÝëåéá êáé áõôïäõíáìßá ôùí ÊÝíôñùí Õãåßáò”, ï “ÍÝïò åõñùðáúêüò ïñéóìüò ôçò ÃåíéêÞò/ÏéêïãåíåéáêÞò ÉáôñéêÞò. ÁëëÜæåé êÜôé;” áëëÜ êáé ç ðá54

ñïõóßáóç óçìáíôéêþí óõíåñãáóéþí óå äéåèíÝò åðßðåäï, üðùò áõôÞ ìå ôçí ÔïõñêéêÞ Åôáéñåßá ÃåíéêÞò ÉáôñéêÞò ìå èÝìá “Towards to the development of a mutual collaboration between Greek and Turkish general practice/family medicine: The first experiences learnt”, äéåýñõíáí ôï èåìáôéêü ðåäßï ôïõ Óõíåäñßïõ êáé áíÝäåéîáí ôéò äõíáôüôçôÝò ôïõ óôç óõæÞôçóç ôïõ íÝïõ. Ç ïñãÜíùóç êëéíéêþí öñïíôéóôçñßùí ðïõ êÜëõøáí äõíáôüôçôåò Ýêèåóçò êáé åêðáßäåõóçò ôùí óõíÝäñùí óå êëéíéêÜ áíôéêåßìåíá, ãéá ôçí áðüêôçóç ü÷é ìüíï ãíþóåùí, áëëÜ êáé äåîéïôÞôùí, Þôáí êÜôé ðïõ áðïõóßáæå áðü ôá ðñïçãïýìåíá óõíÝäñéá. ÔÝëïò, óôéò êáéíïôïìßåò ôïõ óõíåäñßïõ óõãêáôáëÝãåôáé ç óõíÜíôçóç üëùí ôùí Ðåñéöåñåéáêþí ÔìçìÜôùí ÅËÅÃÅÉÁ (5ìåëåßò Äéïéêïýóåò ÅðéôñïðÝò), üðïõ áíáðôý÷èçêå óçìáíôéêüò äéÜëïãïò ãéá ôïí ôñüðï ëåéôïõñãßáò ôïõò áëëÜ êáé ôçí äéáóýíäåóÞ ôïõò ìå ôéò åðéôñïðÝò åêðáßäåõóçò, Ýñåõíáò, ðïéïôéêÞò åîáóöÜëéóçò êáé ôï Ðåñéïäéêü “ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò”. Ç óõíÜíôçóç èá ðñáãìáôïðïéåßôáé óå êÜèå óõíÝäñéï êáé öéëïäïîåß íá áðïôåëÝóåé ðåäßï ðáñïõóßáóçò ôïõ Ýñãïõ ðïõ åðéôåëåßôáé óå êÜèå ðåñéöåñåéáêü ôìÞìá, áëëÜ êáé áíôáëëáãÞò éäåþí êáé áðüøåùí ãéá ôï ìÝëëïí ôçò ÃåíéêÞò ÉáôñéêÞò. Åßíáé áëÞèåéá üôé ìÝíïõí ðïëëÜ áêüìç íá óõæçôçèïýí êáé éäéáßôåñá èÝìáôá ó÷åôéêÜ ìå ôïí ôñüðï ðáñïõóßáóçò ôùí åñãáóéþí êáé ôç óõæÞôçóÞ ôïõò. Ôçí ðåñßïäï ðïõ ç Ðáãêüóìéá Åôáéñåßá ÃåíéêÞò ÉáôñéêÞò (WONCA World) äçìïóéåýåé óõóôÜóåéò ãéá ôçí áíÜðôõîç õðïäïìþí óôçí Ýñåõíá óôç ÃåíéêÞ ÉáôñéêÞ1 êáé õðïãñáììßæåôáé ç áíÜãêç áíÜðôõîçò ôçò áêáäçìáúêÞò óôáäéïäñïìßáò óôï áíôéêåßìåíï áõôü óôç Íüôéá Åõñþðç2, ôï äå ÓõíÝäñéï ôçò ÃåíéêÞò ÉáôñéêÞò áíáæçôÜ ôç èÝóç


Ôüìïò 16, Ôåý÷ïò 2, 2004

Á. Ìáñéüëçò, ×. ËéïíÞò

óôç óõæÞôçóç ôïõ state of the art óôç ÃåíéêÞ ÉáôñéêÞ óôç ÷þñá ìáò, ôï 16ï ÐáíåëëÞíéï ÓõíÝäñéï ÃåíéêÞò ÉáôñéêÞò ßóùò áðïôåëÝóåé ôçí áöåôçñßá ãéá ìéá íÝá åðï÷Þ óôçí åéäéêüôçôá ôçò ÃåíéêÞò ÉáôñéêÞò óôçí ÅëëÜäá. Á. Ìáñéüëçò, Éáôñüò ÃåíéêÞò ÉáôñéêÞò, Ê. Õ. Âýñùíá ÌÝëïò Ä.Ó. ÅËÅÃÅÉÁ

×. ËéïíÞò, Áí. ÊáèçãçôÞò, Áíôéðñüåäñïò Ä.Ó. ÅËÅÃÅÉÁ

Âéâëéïãñáößá 1. Van Weel C, Rosser WW. Improving Health Care Globally: A Critical Review of the Necessity of Family Medicine Research and Recommendations to Build Research Capacity. Ann Fam Med 2:S5-S16, 2004. 2. Lionis C, Carelli F, Soler JK. Developing academic career in family medicine within the Mediterranean setting. Fam Pract 21; 5 (in press).

European Section of the International Journal of Rural and Remote Health ü Ôï íÝï äéåèíÝò çëåêôñïíéêü ðåñéïäéêü ãéá ôïõò õãåéïíïìéêïýò ðïõ åñãÜæïíôáé óå áãñïôéêÝò ðåñéï÷Ýò ü Ôï åðßóçìï ðåñéïäéêü ôïõ EURIPA

Åðéóêåöèåßôå ôï óôç äéåýèõíóç http://rrh.deakin.edu.au êáé åããñáöåßôå äùñåÜí

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ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Áè.Ã. ÂÞôáò êáé óõí.

ÂÑÁÂÅÕÈÅÉÓÁ ÅÑÃÁÓÉÁ ÓÔÏ ÄÉÁÃÙÍÉÓÌÏ ÔÏÕ "Ä. IKÊOY" AWARDED PAPER IN THE MEMORY OF PROF. "D. IKKOU" Primary Heatlh Care, Volume 16, Number 2, 56-61, 2004 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 16, Ôåý÷ïò 2, 56-61, 2004

ÄéÜãíùóç ôçò åëÜóóïíïò â-èáëáóóáíáéìßáò áðü ôïõò äåßêôåò ôùí åñõèñþí áéìïóöáéñßùí ôïõ áßìáôïò ÁèáíÜóéïò Ã. ÂÞôáò1, ×ñÞóôïò Ë. Óåìåñôæßäçò2, Åõáããåëßá É. ÍåñáíôæÜêç3

Ðåñßëçøç Óôçí ðáñïýóá óõã÷ñïíéêÞ åñãáóßá ìåëåôÞèçêå ç åîåýñåóç åíüò ãñÞãïñïõ, áðëïý, áóöáëïýò êáé åý÷ñçóôïõ äéáãíùóôéêïý ìÝóïõ, âáóéæüìåíïõ óôçí ðáñáôÞñçóç ôùí åñõèñïêõôôáñéêþí äåéêôþí ôïõ áßìáôïò, ãéá ôïí ðñïóäéïñéóìü ôïõ óôßãìáôïò ôçò â-ìåóïãåéáêÞò áíáéìßáò (Óâ-ÌÁ). Ãéá ôï óêïðü áõôü äéåíåñãÞèçêå screening test óå 784 Âïñåéïåëëáäßôåò ðïõ ðåñéëÜìâáíå ëÞøç éóôïñéêïý, áéìáôïëïãéêü Ýëåã÷ï êáé êëéíéêÞ åîÝôáóç. ÁîéïëïãÞèçêáí Ýîé äéáãíùóôéêÜ åñãáëåßá, (formulas). ¾ðáñîç Óâ-ÌÁ åðéâåâáéþèçêå óå 62 (7,9%) áóèåíåßò. Ïé ôýðïé ôùí Green-King, ôùí Shine-Lal êáé ç ó÷Ýóç RDW/RBC öÜíçêå üôé áðïôåëïýí áîéüðéóôá åñãáëåßá äéáëïãÞò ãéá ôïí åíôïðéóìü ôïõ Óâ-ÌÁ, óôïí ðëçèõóìü ðïõ åîåôÜóôçêå. Óõæçôþíôáé áêüìç, ç åõáéóèçóßá êáé ç åéäéêüôçôá ôçò êÜèå äïêéìáóßáò êáèþò êáé ôá áðïôåëÝóìáôá ðáñüìïéùí ìåëåôþí áðü ôçí ðáãêüóìéá âéâëéïãñáößá. 1

ÅÊÁ ÊïæÜíçò, 2ÊÝíôñï Õãåßáò ÓéÜôéóôáò ÊïæÜíçò, 3Ã.Í. ÊïæÜíçò

Diagnosis of heterozygous (minor) beta-thalassemia based on blood erythrocyte indexes A. Vitas, C. Semertzidis, Evaggelia Nerantzaki Summary To evaluate the determination of a fast, simple, cheap, sure and functional diagnostic model, based in blood erythrocyte indexes for the localization of heterozygous (minor) beta-thalassemia (HBT), in primary health care ambiance. In order to achieve this screening tests were held in northern Greece. The participants were 784 in number. A clinical examination took place; personal history and blood tests were taken. Six diagnostic modes were evaluated. The diagnosis of HBT was confirmed in 62 (7.9%) patients. The Green-King and Shine-Lal formulas with RDW/RBC ratio appeared that they constitute awful screening instrument for the location of HBT, in northland Greek population. Discussed the sensitivity and the specificity of each assay as well as the results of similar studies by the international bibliography. Key Words: Heterozygous (minor) Beta-Thalassemia, Diagnosis, Screening Test, Validation of Screening Instruments.

56

ÅéóáãùãÞ Óôá èáëáóóáíáéìéêÜ óýíäñïìá õðÜãåôáé ìéá ïìÜäá êëçñïíïìéêþí äéáôáñá÷þí ìå êýñéï ÷áñáêôçñéóôéêü ôç ìåßùóç, óå ðïéêßëï âáèìü, ôçò ðáñáãùãÞò ìéáò Þ/êáé ðåñéóóïôÝñùí óöáéñéíéêþí áëõóßäùí. Ï üñïò èáëáóóáíáéìßá ÷ñçóéìïðïéÞèçêå áñ÷éêÜ ãéá íá äçëþóåé ôçí áíáéìßá ðïõ åìöáíéæüôáí óôïõò ëáïýò ðïõ êáôïéêïýóáí óå ðáñáèáëÜóóéåò ðåñéï÷Ýò. ÓÞìåñá ï üñïò ÷ñçóéìïðïéåßôáé ãéá ôçí áíáöïñÜ óôéò ðïóïôéêÝò êëçñïíïìéêÝò äéáôáñá÷Ýò ôçò âéïóýíèåóçò ôùí óöáéñéíéêþí áëõóßäùí. Ç ìïñéáêÞ âëÜâç óôç â-ìåóïãåéáêÞ áíáéìßá ðñïêáëåßôáé ìå áðëÞ áíôéêáôÜóôáóç ìéáò âÜóçò DNA áðü Üëëç (óçìåéáêÞ ìåôÜëëáîç) Þ ìå Ýëëåéøç (deletion) Þ ìå ðñïóèÞêç (insertion) ËÝîåéò êëåéäéÜ: Óôßãìá â-ÌåóïãåéáêÞò Áíáéìßáò, ÄéÜãíùóç, Ìáæéêüò Ðñïóõìðôùìáôéêüò ¸ëåã÷ïò, Áîéïëüãçóç ôùí Åñãáëåßùí ÄéáëïãÞò. ÕðïâëÞèçêå: Ç åñãáóßá õðïâëÞèçêå óôï äéáãùíéóìü "Ä. ºêêïõ" óôá ðëáßóéá ôïõ 16ïõ Ðáíåëëçíßïõ Óõíåäñßïõ ÃåíéêÞò ÉáôñéêÞò (Êùò, 14-18 Áðñéëßïõ 2004) êáé âñáâåýèçêå áðü ôçí ÅðéôñïðÞ Êñßóçò, Äçìïóéåýåôáé ìå êïéíÞ áðüöáóç ôçò ÓõíôáêôéêÞò ÅðéôñïðÞò ôïõ Ðåñéïäéêïý êáé ôçò ÏñãáíùôéêÞò ÅðéôñïðÞò ôïõ Óõíåäñßïõ Õðåýèõíïò áëëçëïãñáößáò: ÁèáíÜóéïò Ã. ÂÞôáò, Náõáñßíïõ 7, 661 00 ÄñÜìá, Ôçë.: (25210) 32009, e-mail: athanasiosvitas@yahoo.gr


Ôüìïò 16, Ôåý÷ïò 2, 2004

Áè.Ã. ÂÞôáò êáé óõí.

ìéêñïý âáèìïý âÜóåùí êáé óðáíéüôåñá ìå åîÜëåéøç âÜóåùí óå ìåãáëýôåñç Ýêôáóç ôïõ DNA. Óôç â-ìåóïãåéáêÞ áíáéìßá õðÜñ÷åé ìåñéêÞ Þ ïëéêÞ Ýëëåéøç ôçò â áëõóßäáò, åíþ ç áëõóßäá á ðáñÜãåôáé óå öõóéïëïãéêÜ åðßðåäá. Ç ìåéùìÝíç óýíèåóç ôçò â áëõóßäáò óõíåðÜãåôáé ìåßùóç ôçò óýíèåóçò ôçò áéìïóöáéñßíçò (Hb), ìå áðïôÝëåóìá ðáñïõóßá Ýíôïíçò õðï÷ñùìßáò êáé ìéêñïêõôôÜñùóçò1. Ç åëÜóóùí â-ìåóïãåéáêÞ áíáéìßá, áíáöÝñåôáé óôç âéâëéïãñáößá êáé ùò óôßãìá â-ìåóïãåéáêÞò áíáéìßáò (Óâ-ÌÁ). Ç äéÜãíùóç ôßèåôáé ãåíéêÜ óå áóèåíåßò ðïõ áîéïëïãïýíôáé ãéá Þðéá áíáéìßá Þ óå ðáñáêïëïýèçóç áíùìáëéþí ðïõ âñÝèçêáí óôï óõíÞèç áéìáôïëïãéêü Ýëåã÷ï. Ç çëåêôñïöüñçóç ôçò Hb åßíáé ðïëý ÷ñÞóéìç óôç äéÜãíùóç ôïõ Óâ-ÌÁ. ¼ìùò, ôá ðåñéóóüôåñá Üôïìá ìå Óâ-ÌÁ äéáöåýãïõí ôçò äéÜãíùóçò, ìå ïëÝèñéåò óõíÝðåéåò2. Óêïðüò ôçò ðáñïýóáò óõã÷ñïíéêÞò åñãáóßáò Þôáí ç áíáæÞôçóç êáé ç åðéëïãÞ åíüò ãñÞãïñïõ, öèçíïý, áóöáëïýò êáé åý÷ñçóôïõ äéáãíùóôéêïý ìÝóïõ, ãéá ôïí ðñïóäéïñéóìü ôïõ Óâ-ÌÁ, óå ðåñéâÜëëïí ðñùôïâÜèìéáò ðåñßèáëøçò.

Ðëçèõóìüò ìåëÝôçò – ÌÝèïäïò Óôéò áñ÷Ýò ôïõ ðñïçãïýìåíïõ Ýôïõò äéåíåñãÞèçêå ðñïóõìðôùìáôéêüò Ýëåã÷ïò ãéá ôïí åíôïðéóìü ôïõ Óâ-ÌÁ óå 784 êáôïßêïõò (üìïéáò öõëåôéêÞò ìïñöïëïãßáò) ôçò Âïñåßïõ ÅëëÜäïò, çëéêßáò áðü 12-75 åôþí (Ì.Ç.: 44±11,7). Ç äéáäéêáóßá äéáëïãÞò ðåñéëÜìâáíå ðëÞñåò áôïìéêü éóôïñéêü, êëéíéêÞ åîÝôáóç êáé áéìáôïëïãéêü Ýëåã÷ï. Áðü ôç ãåíéêÞ åîÝôáóç ôïõ áßìáôïò êáôáãñáöüôáí: 1) Ï áéìáôïêñßôçò (Ht – Ö.Ô.: Üíäñåò 40-54%, ãõíáßêåò 36-48%). 2) Ç Hb (Ö.Ô.: Üíäñåò 14-18g/dl, ãõíáßêåò 12-14g/dl). 3) Ï áñéèìüò ôùí åñõèñþí áéìïóöáéñßùí ôïõ áßìáôïò (RBC X 106/ìL – Ö.Ô.: Üíäñåò 4,5-6M/ul, ãõíáßêåò 3,8-5,8M/ul). 4) Ï ìÝóïò üãêïò åñõèñþí áéìïóöáéñßùí (MCV – Ö.Ô.: 80-95fl). 5) Ç ìÝóç ðåñéåêôéêüôçôá Hb êáôÜ åñõèñü (MCH – Ö.Ô.: 2734pg) êáé 6) Ôï åýñïò êáôáíïìÞò ôùí åñõèñþí (RDW – Ö.Ô.: 11,5-14,5%). Ôï ðñüãñáììá äéáëïãÞò, âáóßóôçêå êõñßùò, óôïõò ðáñáêÜôù Ýîé (6) ôýðïõò, (formulas): · Green-King: MCV2 X RDW/Hb X 100. Õðüíïéá Óâ-ÌÁ åÜí <72.3 · Shine-Lal: MCV2 X MCH/100. Õðüíïéá

Óâ-ÌÁ åÜí <1.5304. · Mentzler: MCV/RBC. Õðüíïéá Óâ-ÌÁ åÜí <135. · MCH\RBC ratio. Õðüíïéá Óâ-ÌÁ åÜí <4,46. · RDW\RBC ratio. Õðüíïéá Óâ-ÌÁ åÜí <3,37. · England-Fraser: MCV – 5 X Hb + RBC + K (óôáèåñÜ ðïõ ëáìâÜíåé ôéìÞ 3,4 üôáí ï Ht åßíáé åíôüò öõóéïëïãéêþí ïñßùí êáé 8,4 üôáí åßíáé ÷áìçëüò êáé áðáéôåßôáé äéüñèùóç). Õðüíïéá Óâ-ÌÁ åÜí <08. Óôá Üôïìá ìå èåôéêü åýñçìá Þ óçìáíôéêÞ ìéêñïêõôôÜñùóç, äõóáíÜëïãç ôçò öõóéïëïãéêÞò Hb Þ ôçò Þðéáò áíáéìßáò, åîåôáæüôáí ï óßäçñïò ôïõ ïñïý êáé åðéðëÝïí ãéíüôáí çëåêôñïöüñçóç Hb (åöüóïí äåí åß÷áí õðïâëçèåß óå çëåêôñïöüñçóç Hb óôï ðáñåëèüí), þóôå íá ôåêìçñéùèåß ç äéÜãíùóç. Áðïêëåßóôçêáí áðü ôç ìåëÝôç áóèåíåßò õðü óéäçñïèåñáðåßá, üóïé áíÝöåñáí ðñüóöáôç ìåôÜããéóç áßìáôïò Þ ðåñéðôþóåéò üðïõ äéáðéóôùíüôáí óõíýðáñîç Ýíäåéáò óéäÞñïõ êáé Óâ-ÌÁ. Ïé óõíå÷åßò ðáñÜìåôñïé åêöñÜóèçêáí ùò ìÝóåò ôéìÝò (mean values), ìå ìéá óôáèåñÞ áðüêëéóç (±SD). Ç ðñáãìáôïðïßçóç ôùí õðïëïãéóìþí, ç áíÜëõóç ôùí ðëçñïöïñéþí êáèþò êáé ç åêôßìçóç ôçò åõáéóèçóßáò êáé ôçò åéäéêüôçôáò êÜèå äïêéìáóßáò, äéåíåñãÞèçêáí ìå ôï Microsoft Excel. Ãéá ôç óôáôéóôéêÞ áíÜëõóç ôùí äéáèÝóéìùí äåäïìÝíùí ÷ñçóéìïðïéÞèçêå ôï ëïãéóìéêü Statistical Package for the Social Sciences (S.P.S.S. v.11). ¼ñéï óôáôéóôéêÞò óçìáíôéêüôçôáò èåùñÞèçêå ôï p£0,05 (p£5%), êÜèå Üëëç ðéèáíüôçôá èåùñÞèçêå ìç óçìáíôéêÞ (Not Significant - NS).

ÁðïôåëÝóìáôá Áðü ôïõò 784 åîåôáæüìåíïõò ïé 431 (54,9%) Þôáí Üññåíåò êáé ïé 353 (45%) èÞëåéò. ÅâäïìÞíôá ôÝóóåñéò (9,4%) Þôáí Ýöçâïé 12-18 åôþí (Ì.Ç: 14,5+3,1), 398 (50,7%) åíÞëéêåò 19-60 åôþí (Ì.Ç: 34,9+11,2) êáé 312 (39,7%) çëéêéùìÝíïé 61-75 åôþí (Ì.Ç: 69,8±3,4). Åðéâåâáéþèçêå Óâ-ÌÁ óå 62 (7,9%) áóèåíåßò, 29 (46,7%) Þôáí Üññåíåò êáé 33 (53,2%) èÞëåéò. Ïé 3 (4,8%) Þôáí Ýöçâïé, ïé 29 (46,7%) åíÞëéêåò êáé ïé õðüëïéðïé 30 (48,3%) çëéêéùìÝíïé. Áðü áõôïýò ïé 41 (66%) ãíþñéæáí ôç íüóï ôïõò, åíþ ïé õðüëïéðïé 21 (33,8%) öÜíçêå üôé ôçí áãíïïýóáí. 57


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Áè.Ã. ÂÞôáò êáé óõí.

Ïé ìÝóåò ôéìÝò ðïõ õðïäÞëùíáí ôçí ýðáñîç ôïõ Óâ-ÌÁ Þôáí: 1) Green-King= 59,3±4,07, 2) Shine-Lal= 828,2±288,6, 3) Mentzler= 11,8±0,7, 4) MCH/RBC ratio= 3,6±0,2, 5) RDW/RBC ratio= 2,8±0,1, 6) England-Fraser= -1,1±0,7. Ïé áíôßóôïé÷åò ìÝóåò ôéìÝò ôùí õãéþí (ùò ðñïò ôï Óâ-ÌÁ), áôüìùí Þôáí: 1) Green-King= 158,3± 15,9 (p <0,002), 2) Shine-Lal= 2) 456±568,1 (p <0,001), 3) Mentzler= 37,5±3,4 (p <0,003), 4) MCH/RBC ratio= 11,2±3,1 (p <0,003), 5) RDW/ RBC ratio= 6,1±1,7 (p<0,004), 6) England-Fras-

er= 4,7±2,1 (p <0,004). Ïé ìÝóåò ôéìÝò ôïõ áéìáôïëïãéêïý åëÝã÷ïõ ôùí ðáó÷üíôùí áðü ôï Óâ-ÌÁ Þôáí: Ht= 35,1±3,9%, Hb= 10,2±3,1g/dl, MCV= 66,9±2,1fl, MCH= 21,5±1,6pg, RBC= 5,3±0,2M/ì, RDW= 12,4±0,9%. Ïé áíôßóôïé÷åò ôéìÝò óôï õðüëïéðï äåßãìá ðëçèõóìïý Þôáí: Ht= 36,7±11,8% (p NS), Hb= 13,2±4,3g/ dl (p=0,05), MCV= 85,1±13,3fl (p <0,006), MCH= 27,6±5,2pg (p <0,02), RBC= 3,5±1,09M/ì (p <0,05), RDW= 15,6±2,1% (p=0,05). H åõáéóèçóßá êáé ç åéäéêüôçôá êÜèå äïêéìá-

Ðßíáêáò 1. Ç åõáéóèçóßá êáé ç åéäéêüôçôá ôùí ÷ñçóéìïðïéçèÝíôùí äéáãíùóôéêþí ìåèüäùí ðñïóäéïñéóìïý ôïõ Óâ-ÌÁ Ôýðïò ôùí Green-King (Óâ-ÌÁ <72)

Óýíïëï

ÏñèÜ èåôéêÜ

ÅóöáëìÝíá èåôéêÜ

Óýíïëï 62

60

1

ÅóöáëìÝíá áñíçôéêÜ

ÏñèÜ áñíçôéêÜ

2 62

721 722

723 n=784

ÏñèÜ èåôéêÜ

ÅóöáëìÝíá èåôéêÜ

Óýíïëï 71

Åõáéóèçóßá= 96%, Åéäéêüôçôá=99% Ôýðïò ôùí Shine-Lal (Óâ-ÌÁ <1530)

Óýíïëï

60

11

ÅóöáëìÝíá áñíçôéêÜ

ÏñèÜ áñíçôéêÜ

2 62

711 722

713 n=784

ÏñèÜ èåôéêÜ

ÅóöáëìÝíá èåôéêÜ

Óýíïëï

58

9

67

ÅóöáëìÝíá áñíçôéêÜ

ÏñèÜ áñíçôéêÜ

4 62

713 722

717 n=784

ÏñèÜ èåôéêÜ

ÅóöáëìÝíá èåôéêÜ

Óýíïëï

57

12

69

ÅóöáëìÝíá áñíçôéêÜ

ÏñèÜ áñíçôéêÜ

5 62

710 722

715 n=784

ÏñèÜ èåôéêÜ

ÅóöáëìÝíá èåôéêÜ

Óýíïëï 64

Åõáéóèçóßá= 96%, Åéäéêüôçôá= 98%. Ôýðïò ôïõ Mentzler (Óâ-ÌÁ <13)

Óýíïëï Åõáéóèçóßá= 93%, Åéäéêüôçôá= 98%. ÁñéèìçôéêÞ ó÷Ýóç MCH\RBC (Óâ-ÌÁ <4.4)

Óýíïëï Åõáéóèçóßá= 91%, Åéäéêüôçôá= 98%. ÁñéèìçôéêÞ ó÷Ýóç RDW\RBC (Óâ-ÌÁ <3.3)

Óýíïëï

59

5

ÅóöáëìÝíá áñíçôéêÜ

ÏñèÜ áñíçôéêÜ

3 62

717 722

720 n=784

ÏñèÜ èåôéêÜ

ÅóöáëìÝíá èåôéêÜ

Óýíïëï 57

Åõáéóèçóßá= 95%, Åéäéêüôçôá= 99%. Ôýðïò ôùí England-Fraser (Óâ-ÌÁ <0)

Óýíïëï Åõáéóèçóßá= 79%, Åéäéêüôçôá= 98%. 58

49

8

ÅóöáëìÝíá áñíçôéêÜ

ÏñèÜ áñíçôéêÜ

13 62

714 722

727 n=784


Áè.Ã. ÂÞôáò êáé óõí.

óßáò ðáñáôßèåíôáé óôïí Ðßíáêá 1. ºêôåñïò (êëéíéêÞ ðáñïõóßá êßôñéíçò ÷ñïéÜò äÝñìáôïò, åðéðåöõêüôùí êáé âëåííïãüíùí) ðáñáôçñÞèçêå óå 5 (8,1%) ðÜó÷ïíôåò. ÌÝôñéá Þ ìéêñÞ óðëçíéêÞ äéüãêùóç äéáðéóôþèçêå óå 13 (20,9%) óõíïëéêÜ áóèåíåßò.

ÓõæÞôçóç ÊáôÜ ôç äéåèíÞ âéâëéïãñáößá, ï üñïò èáëáóóáíáéìßá áíáöÝñèçêå ãéá ðñþôç öïñÜ ôï 1925 óôç âüñåéï ÁìåñéêÞ, áðü ôïí Thomas Cooley êáé áðïäüèçêå óå ðáéäéÜ Éôáëþí êáé ÅëëÞíùí ìåôáíáóôþí. Ëüãù ãåùãñáöéêÞò êáôáíïìÞò ëÝãåôáé êáé ÌåóïãåéáêÞ áíáéìßá. ÓõíáíôÜôáé, êõñßùò, óå ðëçèõóìïýò Ìåóïãåéáêþí ÷ùñþí: ÅëëÜäá, Éôáëßá, Íüôéá Ãáëëßá, ÌÜëôá, Êýðñï, Ôïõñêßá êáé óôéò ÷þñåò ôçò Âüñåéáò ÁöñéêÞò. ¸÷åé ðåñéãñáöåß üìùò óå üëá ôá ìÝñç ôïõ êüóìïõ êáé óå üëåò ôéò öõëÝò. Óôç ÷þñá ìáò ç óõ÷íüôçôá ôïõ Óâ-ÌÁ õðïëïãßæåôáé ðåñßðïõ 7,5%9. Ç èáëáóóáíáéìßá áðïäåß÷ôçêå üôé åßíáé êëçñïíïìéêÞ ðÜèçóç êáé äéáêñßíåôáé ìå âÜóç ôç âáñýôçôÜ ôçò óå ôñåéò êáôçãïñßåò: á) Ìåßæùí èáëáóóáíáéìßá (íüóïò ôïõ Cooley), â) ÅëÜóóùí èáëáóóáíáéìßá (íüóïò ôùí Rietti – Greppi – Micheli) êáé ã) ÅëÜ÷éóôç èáëáóóáíáéìßá. Ôï Óâ-ÌÁ áíáðôýóóåôáé ìåôáîý 3ïõ êáé 10ïõ Ýôïõò ôçò æùÞò êáé óõíÞèùò ôüôå äåí ðáñïõóéÜæåé êëéíéêÝò åêäçëþóåéò. Óôç ãåíéêÞ åîÝôáóç ôïõ áßìáôïò áíåõñßóêåôáé áýîçóç ôïõ áñéèìïý ôùí RBC ðïõ åßíáé ìéêñüôåñá óå ìÝãåèïò êáé Ý÷ïõí ÷áìçëüôåñç ðåñéåêôéêüôçôá óå Hb (ôéìÝò MCV – MCH ìéêñüôåñåò ôïõ öõóéïëïãéêïý). Ï óßäçñïò ôïõ ïñïý åßíáé öõóéïëïãéêüò Þ áõîçìÝíïò. Óôï åðß÷ñéóìá ôïõ ðåñéöåñéêïý áßìáôïò áíåõñßóêåôáé õðï÷ñùìßá, ìéêñïêõôôÜñùóç, áíéóïêõôôÜñùóç, óôï÷ïêõôôÜñùóç êáé ðïéêéëïêõôôÜñùóç. ÓðÜíéá ðáñáôçñåßôáé Þðéá ìéêñïêõôôáñéêÞ áíáéìßá, óõ÷íÜ óõíõðÜñ÷åé óéäçñïðåíéêÞ áíáéìßá êáé ç ÷ïñÞãçóç óéäÞñïõ Þ/êáé öõëëéêïý ïîÝïò, âåëôéþíåé, áëëÜ ü÷é ðëÞñùò ôçí áíáéìßá. ÊáôÜ ôçí çëåêôñïöüñçóç Hb âñßóêåôáé áýîçóç ôçò Hb A2 (ðåñéóóüôåñï áðü 3,5%), åíþ ç Hb F åßíáé óõíÞèùò öõóéïëïãéêÞ. Ç Hb óáí ðñùôåÀíç êéíåßôáé óå Ýíá çëåêôñéêü ðåäßï ðñïò ìéá êáôåýèõíóç êáé ìéá áðüóôáóç áíÜëïãá ìå ôï çëåêôñéêü öïñôßï ôïõ ìïñßïõ ôçò (åîáñôÜôáé áðü ôï éóïçëåêôñéêü óçìåßï ôçò ðñù-

Ôüìïò 16, Ôåý÷ïò 2, 2004

ôåÀíçò êáé ôï pH ôïõ äéáëýìáôïò). Óå áëêáëéêü pH ç Hb Ý÷åé êáèáñÜ áñíçôéêü öïñôßï êáé êéíåßôáé ðñïò ôï èåôéêü ðüëï, åíþ óå üîéíï äéÜëõìá Ý÷åé èåôéêü öïñôßï êáé êéíåßôáé ðñïò ôïí áñíçôéêü ðüëï. Ç çëåêôñïöüñçóç óå ïîåéêÞ êõôôáñßíç óå pH 8,9 åßíáé ç êáëýôåñç ìÝèïäïò ðïóïôéêïý ðñïóäéïñéóìïý ôùí áéìïóöáéñéíþí ðáñÜ óáí ìÝèïäïò screening êáé ÷ñçóéìïðïéåßôáé éäéáßôåñá ãéá ôçí ðïóïôéêÞ ìÝôñçóç ôçò Hb A2 (äéÜãíùóç öïñÝùí â-ìåóïãåéáêÞò áíáéìßáò)10. Ç ðñüëçøç ðåñéëáìâÜíåé: á) ôçí åíçìÝñùóç ôïõ êïéíïý, â) ôçí áíåýñåóç ôùí åôåñïæõãùôþí (öïñÝùí), ã) ôç ãåííçôéêÞ êáèïäÞãçóç ôùí æåõãáñéþí (åÜí êáé ôá äýï ìÝëç ôïõ æåýãïõò ðÜó÷ïõí áðü åëÜóóïíá â-èáëáóóáíáéìßá èåùñåßôáé üôé õðÜñ÷åé êßíäõíïò 25%, Þ êáô’ Üëëïõò ðåñéóóüôåñï, ôùí ðáéäéþí ôïõò íá ðñïóâëçèïýí áðü âáñéÜ ïìüæõãï èáëáóóáíáéìßá) êáé ä) ôçí ðñïãåííçôéêÞ äéÜãíùóç ôçò íüóïõ. ÁõôÞ ãßíåôáé óôï ðñþôï ôñßìçíï ôçò åãêõìïóýíçò ìå ôç ìåëÝôç ôïõ åìâñõúêïý DNA ðïõ ãéíüôáí áñ÷éêÜ ìåôÜ áðü äéáêïëðéêÞ âéïøßá ôñïöïâëÜóôçò êáé óôç óõíÝ÷åéá äéáêïéëéáêÜ êáôÜ ôçí 10ç-12ç åâäïìÜäá ôçò êýçóçò11. Ï ðñïãáìéáßïò Ýëåã÷ïò ãéá ôçí áíß÷íåõóç ôïõ Óâ-ÌÁ åßíáé áíáãêáßïò ãéá íá áðïöåõ÷èåß ç ôõ÷üí ãÝííçóç ðáéäéþí ìå ìåóïãåéáêÞ áíáéìßá. Ôï Õðïõñãåßï Õãåßáò êáôáâÜëåé óçìáíôéêÝò ðñïóðÜèåéåò ìå ôï ðñüãñáììá “äéáöþôéóçò ðñïãáìéáßïõ åëÝã÷ïõ – áíáãíþñéóçò öïñÝùí êáé ðñïãåííçôéêÞò äéÜãíùóçò”, ó÷åôéêÜ ìå ôç ìåóïãåéáêÞ áíáéìßá. Ïé ìïíÜäåò ðñüëçøçò êáé íïóçëåßáò ôçò ìåóïãåéáêÞò áíáéìßáò óôá íïóïêïìåßá ôçò ÅëëÜäáò, áõôÞ ôç óôéãìÞ åßíáé ðåñéóóüôåñåò áðü ôñéÜíôá, åê ôùí ïðïßùí ìüíï ïé ìéóÝò êáëýðôïõí ôéò áíÜãêåò ôçò åðáñ÷ßáò. Åýêïëá áíôéëáìâÜíåôáé êÜèå ëåéôïõñãüò ðñùôïâÜèìéáò ðåñßèáëøçò ôï üöåëïò áëëÜ êáé ôçí áíáãêáéüôçôá ðñüóêôçóçò åíüò áîéüðéóôïõ åñãáëåßïõ ãéá ôçí áíß÷íåõóç ôïõ Óâ-ÌÁ. Åäþ èá ðñÝðåé íá ôïíßóïõìå üôé óôç ÷þñá ìáò, ç çëåêôñïöüñçóç Hb óôá ðëáßóéá ôïõ ðñïãáìéáßïõ Þ ðñïãåííçôéêïý åëÝã÷ïõ, óýìöùíá ìå ôç ó÷åôéêÞ õðïõñãéêÞ áðüöáóç áñ. Ö7/ïéê. 1624, èá ðñÝðåé íá äßíåôáé ìüíï “åö’ üóïí õðÜñ÷ïõí óõãêåêñéìÝíåò åíäåßîåéò” êáé ü÷é ùò åîÝôáóç ñïõôßíáò Þ screening. ÓõãêåêñéìÝíá, óýìöùíá ìå ôçí õð’ áñéè. 5803/ 98 (1178/Â) êïéíÞ áðüöáóç ôïõ Ðñùèõðïõñãïý êáé ôïõ Õðïõñãïý Õãåßáò & Ðñüíïéáò áðïöáóßæåôáé, ìåôáîý Üëëùí, üôé: “...Ìå óêïðü ôçí Ýãêáé59


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

ñç äéÜãíùóç êáé ôç ëÞøç ìÝôñùí ãéá ôçí ðñüëçøç ôçò åêäÞëùóçò Þ ôçí áðïôñïðÞ åìöÜíéóçò íïóçñþí êáôáóôÜóåùí êáèéåñþíïíôáé ãéá ôïõò áóöáëéóìÝíïõò ôïõ äçìïóßïõ êáé ôùí Üëëùí áóöáëéóôéêþí ïñãáíéóìþí êáèþò êáé ãéá ôá ìÝëç ôùí ïéêïãåíåéþí ôïõò, ïé õðï÷ñåùôéêÝò ðáñï÷Ýò ðñïëçðôéêÞò éáôñéêÞò ðïõ Ý÷ïõí ùò åîÞò: “...2. ÅîåôÜóåéò ðñïãåííçôéêïý åëÝã÷ïõ, óå ãõíáßêåò êáé Üíäñåò ìå óêïðü ôç ãÝííçóç õãéþí ðáéäéþí. Åéäéêüôåñá: á) áéìáôïëïãéêÝò åîåôÜóåéò (ãåíéêÞ áßìáôïò, öåñéôßíçò êáé åãêëßóôùí) ãéá ôç äéáðßóôùóç ôùí åôåñïæõãùôþí ôçò ìåóïãåéáêÞò áíáéìßáò êáé â) çëåêôñïöüñçóç Hb, åöüóïí ðñïêýøïõí åíäåßîåéò áðü ôéò ðáñáðÜíù åîåôÜóåéò” 12. Áðü ôá Ýîé åñãáëåßá äéáëïãÞò ôïõ Óâ-ÌÁ ðïõ ìåëåôÞèçêáí, ôçí õøçëüôåñç åõáéóèçóßá êáé åéäéêüôçôá åß÷áí: 1) ï ôýðïò ôùí Green-King (96%-99% áíôßóôïé÷á), 2) ç ó÷Ýóç RDW/RBC (95%-99%) êáé 3) ï ôýðïò ôùí Shine-Lal (96%98%). Ç ìåãáëýôåñç èåôéêÞ äéáãíùóôéêÞ áîßá áíÞêå óôç äïêéìáóßá ôùí Green-King: 96% êáé áêïëïõèïýóáí ç áíáëïãßá RDW/RBC: 92% êáé ï ôýðïò ôùí Shine-Lal: 84%. Ç áñíçôéêÞ äéáãíùóôéêÞ áîßá âñÝèçêå 99% êáé ãéá ôéò ôñåéò äïêéìáóßåò. Óçìáíôéêüôáôç Þôáí åðßóçò ç óõìâïëÞ ôïõò óôç äéáöïñéêÞ äéÜãíùóç ôïõ Óâ-ÌÁ áðü ôá Üëëá áíáéìéêÜ óýíäñïìá. Óå Üôïìá ðïõ ðñüêåéôáé íá åëåã÷èïýí ãéá ôï Óâ-ÌÁ ìå ôá ðñïáíáöåñèÝíôá äéáãíùóôéêÜ åñãáëåßá êáé óõìâáßíåé íá Ý÷ïõí ÷áìçëü Ht, ïðïéáóäÞðïôå áéôéïëïãßáò, èá ðñÝðåé íá åëÝã÷ïíôáé ìå ôïí ôýðï ôùí England-Fraser (Ý÷åé ôç ìåãáëýôåñç äéáãíùóôéêÞ áîßá óôïõò áóèåíåßò ìå ÷áìçëü Ht)13,14. Áêüìç, üôáí ôï áðïôÝëåóìá áðü ôç ó÷Ýóç RDW\RBC åßíáé >3,3, Þ áðü ôïí ôýðï ôïõ Mentzler >13, Þ ôçò ó÷Ýóçò MCH/ RBC >4,4, ôüôå óõíÞèùò ðñüêåéôáé ãéá Ýëëåéøç óéäÞñïõ. Ó’ áõôÝò ôéò ðåñéðôþóåéò, ïé ðéèáíÝò åëëåßøåéò óéäÞñïõ ìðïñïýí íá åíôïðéóôïýí “ðñþéìá” (ðñéí ôïí åñãáóôçñéáêü Ýëåã÷ï), ìå ôïõò åîÞò ôýðïõò: MCV – (5 × Hb) – RBC – 8,4 Þ 0,01 × MCH × MCV2 Þ MCV/RBC ratio15,16. ÁñêåôÝò äéåèíïýò êýñïõò åñãáóßåò, ðïõ ìåëÝôçóáí ôç äéáêýìáíóç ôùí åñõèñïêõôôáñéêþí äåéêôþí ðáãêïóìßùò óå äéáöïñåôéêÞò öõëåôéêÞò ìïñöïëïãßáò Üôïìá, óõìöùíïýí üôé ïé óõãêåêñéìÝíåò ôñåéò äïêéìáóßåò áðïôåëïýí ðïëýôéìá åñãáëåßá äéáëïãÞò ôïõ Óâ-ÌÁ. ÌÜëéóôá ôïíßæåôáé ôï óçìáíôéêü ðëåïíÝêôçìá ôïõ êüóôïõò áëëÜ êáé ôçò äõíáôüôçôáò äéåîáãùãÞò åíüò Üìåóïõ óõìðå60

Áè.Ã. ÂÞôáò êáé óõí.

ñÜóìáôïò áðü ôïí Ýëåã÷ï ôùí äåéêôþí ôùí åñõèñþí áéìïóöáéñßùí ôïõ áßìáôïò ìßáò êáé ìüíï åîÝôáóçò ç ïðïßá ìðïñåß íá äéåíåñãÞèçêå áêüìç êáé óôï ðáñåëèüí (ü÷é üìùò íùñßôåñá áðü ôçí çëéêßá ôùí äþäåêá åôþí)17-19. Óå ìéá Üëëç ìåëÝôç ðïõ åêðïíÞèçêå óôéò áñ÷Ýò ôçò ðñïçãïýìåíçò äåêáåôßáò áðü Åõñùðáßïõò åñåõíçôÝò êáé ðïõ åîåôÜóôçêáí äéáêüóéåò ðåñéðôþóåéò áóèåíþí ìå óïâáñÝò êáé ðïéêßëåò áíáéìßåò, öÜíçêå üôé ï ôýðïò ôùí England-Fraser êáé ç ó÷Ýóç RDW/RBC áðïôåëïýí áñêåôÜ áêñéâåßò äïêéìáóßåò ãéá ôïí ðñïóäéïñéóìü ôïõ Óâ-ÌÁ óôïí éôáëéêü áëëÜ êáé ôï ãåñìáíéêü ãåíéêü ðëçèõóìü20. ÔÝëïò, åìåßò èá èÝëáìå íá âïçèÞóïõìå ìå êÜèå ôñüðï óôçí åêðüíçóç êáé Üëëùí ðáñüìïéùí åñãáóéþí, áðü óõíáäÝëöïõò ðïõ áóêïýí ðñùôïâÜèìéá öñïíôßäá õãåßáò óå äéÜöïñåò ðåñéï÷Ýò ôçò ÷þñáò ìáò, þóôå íá óõíåêôéìÞóïõìå åíäåëå÷þò, óå ðáíåëëÞíéï åðßðåäï, ôçí áðïôåëåóìáôéêüôçôá êáé ôï üöåëïò ôùí óõãêåêñéìÝíùí åñãáëåßùí äéáëïãÞò. ÄåäïìÝíïõ üôé ç ÅëëçíéêÞ âéâëéïãñáößá óôåñåßôáé ðáñüìïéùí ìåëåôþí.

ÓõìðåñÜóìáôá Ï åðéðïëáóìüò ôïõ Óâ-ÌÁ óôï áíôéðñïóùðåõôéêü äåßãìá ðëçèõóìïý ôçò óõãêåêñéìÝíçò ãåùãñáöéêÞò æþíçò ðïõ ìåëåôÞèçêå, êáôÜ ôï Ýôïò 2003, Þôáí (62/784 ×100) 7,9%. Ïé ôýðïé (formulas) ôùí Green-King, ôùí Shine-Lal êáé ç ó÷Ýóç RDW\RBC öÜíçêå üôé áðïôåëïýí áîéüðéóôá åñãáëåßá äéáëïãÞò ãéá ôïí åíôïðéóìü ôïõ Óâ-ÌÁ (áëëÜ êáé ãéá ôç äéáöïñïäéÜãíùóÞ ôïõ áðü ôá Üëëá åßäç ôùí áíáéìéþí), óôï óõãêåêñéìÝíï åëëçíéêü ðëçèõóìü. Äå âñÝèçêå óôï äåßãìá ðëçèõóìïý ðïõ åîåôÜóôçêå êáíÝíáò áóèåíÞò ìå Óâ-ÌÁ êáé MCV >70fl. Ïé êëéíéêÝò åêäçëþóåéò ôïõ Óâ-ÌÁ (áíåîáñôÞôùò ôçò çëéêéáêÞò ïìÜäáò áóèåíþí), üôáí õðÞñ÷áí Þôáí åëÜ÷éóôåò êáé äåí ìðïñïýóáí áðü ìüíåò ôïõò íá èÝóïõí âÜóéìåò õðïøßåò ãéá ôçí ýðáñîç Þ ôïí áðïêëåéóìü ôçò íüóïõ.

Âéâëéïãñáößá 1. Ðáðáäçìçôñßïõ Ì, Éùáííßäïõ – ÐáðáãéáííÜêç


Áè.Ã. ÂÞôáò êáé óõí.

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Å. ÅóùôåñéêÞ Ðáèïëïãßá. ÐïóïôéêÝò Äéáôáñá÷Ýò ôçò Óýíèåóçò ôçò Áéìïóöáéñßíçò – ÈáëáóóáíáéìéêÜ Óýíäñïìá Þ ÌåóïãåéáêÞ Áíáéìßá. Èåóóáëïíßêç 1998. University Studio Press. 2ïò Ôüìïò. Óåë. 1097-1220. Harrison.ÅóùôåñéêÞ Ðáèïëïãßá. Äéáôáñá÷Ýò ôçò ÄïìÞò, ôçò Ëåéôïõñãßáò êáé ôçò ÓõíèÝóåùò ôçò Áéìïóöáéñßíçò. ÁèÞíá 1998. Ôüìïò Ã. 10ç ¸êäïóç. Êåö. 330. Óåë. 2489-2492. Green R, King R. A New Red Cell Discriminate Incorporating Volume Dispersion for Differentiating Iron Deficiency Anaemia from Thalassemia Minor. Blood Cells, 15:481-495, 1989. Shine I, Lal S. A Strategy to Detect Beta-thalassemia Minor. Lancet, 1:692-694, 1977. Mentzler W. Differentiation of Iron Deficiency from Thalassemia Trait. Lancet, 1:882, 1973. D’ Onofrio G. Automated Measurement of Red Blood Cell Microcytosis and Hypochromia in Iron Deficiency and Beta-thalassemia trait. Arch Pathol Lab Med, 116:84-89, 1992. Ricerca B, Storti S, D’ Onofrio G. Differentiation of Iron Deficiency from Thalassemia Trait: A New Approach. Haematologica, 72:409-413, 1987. England J, Fraser P. Differentiation of Iron Deficiency from Thalassemia Trait by Routine Blood Count. Lancet, 1:449-452, 1973. Áäáìüðïõëïò Ð. Ç Ðáèïëïãßá óôçí ÉáôñéêÞ ÐñÜîç. ÍïóÞìáôá ôïõ Áßìáôïò. ÁèÞíá, 1998. ÌÝñïò 10o, 2ïò Ôüìïò, Óåë. 823-882. ÌåëÝôçò É. Áðü ôï Áéìáôïëïãéêü Åýñçìá óôç ÄéÜãíùóç. Áíáéìßåò - ÌåóïãåéáêÜ Óýíäñïìá. ÁèÞíá. 1996. 3ç ¸êäïóç. Óåë. 185-196. Êáôñéïý Ä, Êñåìåíüðïõëïò Ã, Ðáíôåëßäçò ×, Áèáíáóßïõ-ÌåôáîÜ Ì. ÐáéäéáôñéêÞ. Áéìïðïéçôéêü Óýóôçìá. ÌåóïãåéáêÜ Óýíäñïìá. Èåóóáëïíßêç. 1997. Óåë. 441-449.

Ôüìïò 16, Ôåý÷ïò 2, 2004

12. ÕðïõñãéêÝò ÁðïöÜóåéò Ö.Å.Ê.: Ôåý÷ïò Â’ – Áñ. Öýëëïõ 2053/24-11-99. ÁèÞíá 04 Íïåìâñßïõ 1999. 13. D’Onofrio G. Automated Measurement of red Blood Cell Microcytosis and Hypochromia in Iron Deficiency and Beta-thalassemia Trait. Arch Pathol Lab Med, 116:84-89, 1992. 14. Lafferty J, Crowther M. The Evaluation of Various Mathematical RBC Indices and their Efficacy in Discriminating Between Thalassemic and Non-Thalassemic Microcytosis. Am J Clin Pathol, 106:201-205, 1996. 15. Johnson C, Tegos C, Beutler E. Thalassemia Ìinor: Ñoutine Erythrocyte Measurements and Differentiation from Iron Deficiency. Am J Clin Pathol, 80:31-36, 1983. 16. Wallach J. Interpretation of Laboratory Tests 6th Edition. Little Brown and Company, 1996, pp: 334-356. 17. Rowley P. The Diagnosis of Beta-thalassemia Trait: A Review. American Journal of Haematology, 1:129-37, 1976. 18. Thool A, Walde M, Shrikhande A, Talib V. A Simple Screening Test for the Detection of Heterozygous Beta-thalassemia. Indian Journal of Pathology & Microbiology, 4:423-6, 1998. 19. Soffritti E, Bernardoni R, Pelizzola D, Scaglianti G. Value of Various Haematological Indexes Proposed for Identifying Healthy Carriers of the Beta-thalassemia Trait. Quad Sclavo Diagn, 4:447-54, 1985. 20. Junca J, Flores A, Roy C, Alberti R, Milla F. Red Cell Distribution Width, Free Erythrocyte Protoporphyrin, and England-Fraser Index in the Differential Diagnosis of Microcytosis due to Iron Deficiency or Beta-thalassemia Trait. A Study of 200 Cases of Microcytic Anaemia. Haematology & Pathology Journal, 1:33-6, 1991.

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ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

É. ÄñõãéáííÜêçò êáé óõí.

ÂÑÁÂÅÕÈÅÉÓÁ ÅËÅÕÈÅÑÇ ÁÍÁÊÏÉÍÙÓÇ AWARDED FREESTANDING PAPER Primary Heatlh Care, Volume 16, Number 2, 62-79, 2004 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 16, Ôåý÷ïò 2, 109-114, 2004

Ç åêôßìçóç ôçò ïñèÞò óõíôáãïãñÜöçóçò áíôáãùíéóôþí ôùí õðïäï÷Ýùí-2 éóôáìßíçò (H2-RAs) êáé áíôáãùíéóôþí ôçò áíôëßáò ðñùôïíßùí (PPIs) óôçí ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò É. ÄñõãéáííÜêçò1, Á. Ëáëéþôçò2, Á. Ìåëéäïíéþôçò1, Êáëëéüðç Óôåöáíïðïýëïõ1, Ä. ÄñõãéáííÜêçò1, Í. ÐáðáäÜêçò1, Á. Ìðáôßêáò1 Ðåñßëçøç Óêïðüò: Ç äéåñåýíçóç ôçò ïñèüôçôáò ôçò äéÜãíùóçò êáé ôçò èåñáðåßáò ôùí íïóçìÜôùí ôïõ óôïìÜ÷ïõ êáé ôïõ ïéóïöÜãïõ, ìå ôçí per os ÷ïñÞãçóç H2-RAs êáé PPIs, óå ó÷Ýóç ìå ôéò äéåèíåßò ïäçãßåò. Õëéêü- ÌÝèïäïò: Äéáìïñöþèçêå åñùôçìáôïëüãéï ãéá ôçí êáôáãñáöÞ ôçò áéôßáò ëÞøçò ôùí H2-RAs êáé PPIs (ÃáóôñïïéóïöáãéêÞ Ðáëéíäñüìçóç- ÃÏÐ, Ãáóôñßôéäá, Ðåðôéêü ¸ëêïò- ÐÅ, ×ñÞóç ìç óôåñïåéäþí áíôéöëåãìïíùäþí öáñìÜêùí- NSAIDs), êáèþò êáé ôïõ êëéíéêïý êáé åñãáóôçñéáêïý éóôïñéêïý ôùí õðü åîÝôáóç áóèåíþí. Ôá åñùôçìáôïëüãéá óõìðëçñþèçêáí áðü ôïí ãéáôñü ìÝóù áôïìéêÞò óõíÝíôåõîçò. ÁðïôåëÝóìáôá: · Óõìðëçñþèçêáí åñùôçìáôïëüãéá, ðïõ áöïñïýóáí óå 182 áóèåíåßò, 66 Üíäñåò (36,3%) êáé 116 ãõíáßêåò (63,7%), ìå ìÝóï üñï çëéêßáò ôá 70,8 Ýôç. · Ôï (75,8%) ôùí áóèåíþí, äçë. 138/182, öáßíåôáé üôé åß÷áí êÜðïéá áíé÷íåýóéìç áéôßá ëÞøçò H2-RAs Þ PPIs. · Ïé 123 áðü ôïõò 182 áóèåíåßò, (67,6%), äåí ëÜìâáíáí ôçí åíäåäåéãìÝíç èåñáðåßá. · Äéáðéóôþèçêå éó÷õñÞ óõó÷Ýôéóç ôçò ïñèÞò Þ ëáíèáóìÝíçò ëÞøçò áãùãÞò óå ó÷Ýóç ìå ôç íüóï (÷2=6,8x10-8). Ç ðñïôåéíüìåíç èåñáðåõôéêÞ áãùãÞ ãéá ôçí ðñïóôáóßá ôïõ ãáóôñéêïý âëåííïãüíïõ áðü NSAIDs öáßíåôáé üôé Þôáí ïñèüôåñç óå áíôßèåóç ìå ôéò èåñáðåßåò ãéá ôéò ÃÏÐ, ÐÅ, ËåéôïõñãéêÞ Ãáóôñßôéäá. · Ãéá ôçí áãïñÜ ôùí H2-RÁs êáé ôùí PPIs ç äáðÜíç åêôéìÞèçêå óôá 319,63€ áíÜ Üíèñùðï-Ýôïò. Ôï êüóôïò ôçò ìç åíäåäåéãìÝíçò èåñáðåßáò áíåñ÷üôáí óôá 258,55€ áíÜ Üíèñùðï-Ýôïò, (80,9%). · Ìüíï ïé 14 (7,7%) áðü ôïõò 73 (40,1%), ðïõ Ýðñåðå íá åíäïóêïðçèïýí (40,1%), åíäïóêïðÞèçêáí. ÓõìðåñÜóìáôá: Óôéò ðåñéï÷Ýò ôçò ìåëÝôçò ç óõíôáãïãñÜöçóç H2-RAs êáé PPIs óå ìåãÜëï ðïóïóôü (67,6%) äåí ãßíåôáé óýìöùíá ìå ôéò äéåèíåßò ïäçãßåò êáé äáðáíþíôáé ìåãÜëá ðïóÜ ÷ùñßò ôï åðéèõìçôü èåñáðåõôéêü áðïôÝëåóìá. Ç ÷ñÞóç ôçò åíäïóêüðçóçò åßíáé åëëéðÞò êáé ðåñéïñßæåôáé óôï 19,2% üóùí èá Ýðñåðå íá åíäïóêïðçèïýí, óýìöùíá ìå ôéò êáôåõèõíôÞñéåò ïäçãßåò. Ïé éáôñïß ôçò ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò ðñÝðåé íá åíçìåñþíïíôáé ãéá ôéò äéåèíþò áíáãíùñéóìÝíåò ïäçãßåò êáé íá óõììïñöþíïíôáé ìå áõôÝò Ýôóé þóôå íá ðáñÝ÷ïõí áðïôåëåóìáôéêÞ äéá÷åßñéóç ôùí íïóçìÜôùí ôïõ ðåðôéêïý óõóôÞìáôïò. 1

ÊÝíôñï Õãåßáò (Ê.Õ.) ÐåñÜìáôïò Ñåèýìíçò, 2Ê.Õ. Ìïéñþí Çñáêëåßïõ

62

ÅéóáãùãÞ Óôçí ðáñïýóá ÝñåõíÜ ìáò þèçóå ç áäñÞ êáé âáóéóìÝíç óôçí åìðåéñßá ìáò äéáðßóôùóç ôçò õðåñ-óõíôáãïãñÜöçóçò Áíôáãùíéóôþí ôùí Õðïäï÷Ýùí 2 ôçò Éóôáìßíçò (Histamine2 Receptor Antagonists - H2-RAs) êáé ÁíáóôïëÝùí ôçò Áíôëßáò Ðñùôïíßùí (Proton Pump Inhibitors - PPIs) óôçí ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò (ÐÖÕ), êáèþò êáé ç ðáñáôÞñçóç üôé óõíôáãïãñáöïýíôáé PPIs åîáñ÷Þò, ÷ùñßò íá ðñïçãçèåß äïêéìÞ ôùí H2-RAs, üôé ëáìâÜíïíôáé ùò ìüíéìç áãùãÞ, áíôß ãéá óõãêåêñéìÝíï ÷ñïíéêü äéÜóôçìá, óõ÷íÜ óå ëáíèáóìÝíç äüóç êáé üôé äåí ãßíåôáé ðáñáðïìðÞ ãéá åíäïóêüðçóç, (ïéóïöáãïóêüðçóç êáé ãáóñïóêüðçóç), ìå ôïí êßíäõíï êëéíéêÞò êÜëõøçò íåïËÝîåéò êëåéäéÜ: ÓõíôáãïãñÜöçóç, ÁíôáãùíéóôÝò õðïäï÷Ýùí-2 éóôáìßíçò, ÁíôáãùíéóôÝò áíôëßáò ðñùôïíßùí, ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò. ÕðïâëÞèçêå: Ç åñãáóßá õðåâëÞèçêå ùò åëåýèåñç áíáêïßíùóç óôï 16ï ÐáíåëëÞíéï ÓõíÝäñéï ÃåíéêÞò ÉáôñéêÞò (Êùò, 14-18 Áðñéëßïõ 2004) êáé âñáâåýèçêå áðü ôçí ÅðéôñïðÞ ÊñÞóçò. Äçìïóéåýåôáé ìå êïéíÞ áðüöáóç ôçò ÓõíôáêôéêÞò ÅðéôñïðÞò ôïõ Ðåñéïäéêïý êáé ôçò ÏñãáíùôéêÞò ÅðéôñïðÞò ôïõ Óõíåäñßïõ Õðåýèõíïò áëëçëïãñáößáò: Áíôþíçò Ìðáôßêáò, ÊÝíôñï Õãåßáò ÐåñÜìáôïò Ñåèýìíïõ, Ôçë.: (28340) 23074, e-mail: antbatika@hotmail.com


Ôüìïò 16, Ôåý÷ïò 2, 2004

É. ÄñõãéáííÜêçò êáé óõí.

Assessing rational prescription of histamine 2 receptor antagonists (H2-RAs) and proton pump inhibitors (PPIs) in Primary Health Care I. Drygiannakis, A. Laliotis, A. Melidoniotis, Kalliopi Stefanopoulou, D. Drygiannakis, N. Papadakis, A. Batikas Summary Aim: Propriety investigation of diagnosis and treatment of gastrointestinal diseases by administering per os H2-RAs and PPIs in view of international guidelines. Study population-Method: A questionnaire was formed on the recording of H2-RAs and PPIs administration cause (Gastroesophageal Reflux Disease- GERD, Gastritis, Peptic Ulcer- PU, Use of Non-Steroidal Anti-Inflammatory Drugs- NSAIDs) and clinical and laboratorial evaluation. A physician via interview completed the questionnaires. Results: · Questionnaires were completed for 182 patients, 66 men (36,3%) and 116 women (63,7%) with a mean age of 70,8 years. · 138/182 (75,8%) appeared to have a detectable cause of H2-RAs’ or PPIs’ administration. · A powerful correlation between suitable or erroneous drug reception and disease was detected (÷2= 6,8x10-8). The proposed treatment for the protection of gastric mucous against NSAIDs appears to be more suitable in contrast to treatments for GERD, PU, and Functional Dyspepsia. · 123/182 (67,6%) did not receive the most appropriate treatment. · Expenses for H2-RAs and PPIs were estimated as 319,63 €/man-year, while the cost of non-advisable treatment amounted in 258,55 €/man-year (80,9%). · Only 14 (7,7%) from those who should be evaluated by endoscopy (7340,1%) underwent endoscopy. Conclusions: Prescription of H2-RAs and PPIs does not follow guidelines in a great percentage of patients (67,6%) and much money is spent without the desirable therapeutic effect. The use of endoscopy is inadequate (19,2% of those who should undergo endoscopy according to the international guidelines). The PHC doctors should be educated for guidelines and comply with them so as to provide effective management of gastroesophageal diseases.

ãçóç PPIs Þ H2-RÁs, èá ìðïñïýóáí íá äéï÷åôåõèïýí óôçí ïñèÞ äéåñåýíçóç ôùí ðåñéðôþóåùí ìå êýñéï óêïðü ôçí Ýãêáéñç äéÜãíùóç íåïðëáóéþí êáé ôçí ïñèÞ áíôéìåôþðéóç ôçò ëåéôïõñãéêÞò ãáóôñßôéäáò ðÝñá áðü ôç ÷ïñÞãçóç öáñìáêåõôéêÞò áãùãÞò.

Ðëõèõóìüò ìåëÝôçò - ÌÝèïäïò Õëéêü

Ðñüêåéôáé ãéá ìéá áíáäñïìéêÞ ðëçèõóìéáêÞ ìåëÝôç, ðïõ ðñáãìáôïðïéÞèçêå êáôÜ ôç äéÜñêåéá 13,5 ìçíþí (áðü 01-01-2003 Ýùò êáé 16-022004). ÌåëåôÞèçêáí 182 Üôïìá, áðü ôá ïðïßá 66 Þôáí Üíäñåò (36,3%) êáé 116 Þôáí ãõíáßêåò (63,7%). Ç çëéêßá ôïõò Þôáí êáôÜ ìÝóï üñï ôá 70,8 Ýôç ìå óôáèåñÜ áðüêëéóçò (SD) ôá 12,8 Ýôç êáé åýñïò 69 Ýôç (29-98). Ïé ðåñéóóüôåñïé, 179/182 (98,4%) äéÝìåíáí ìüíéìá óå áãñïôéêÝò ðåñéï÷Ýò (ðëçèõóìüò <5.000 êÜôïéêïé), åíþ, ìüëéò 3, (1,6%), Þôáí ìüíéìïé êÜôïéêïé çìéáóôéêþí ðåñéï÷þí (ðëçèõóìüò 5.00010.000 êÜôïéêïé) êáé êáíåßò (0%) áóôéKey Words: Prescription, Histamine-2 receptor antagonists, Proton pump inhiêþí ðåñéï÷þí (>10.000 êÜôïéêïé). Ïé bitors. Primary Health Care 153 (84,1%) Þôáí êÜôïéêïé ôïõ íïìïý Çñáêëåßïõ êáé ïé 29 (15,9%) ôïõ íïðëáóßáò, ï ïðïßïò åßíáé áõîçìÝíïò óå ðëçèõóìïýò ìïý Ñåèýìíïõ ôçò íÞóïõ ÊñÞôçò. Ôá ðáñáðÜíù ìå áõîçìÝíï ìÝóï üñï çëéêßáò. óõíïøßæïíôáé óôïí ðßíáêá 1. ¢ëëç óçìáíôéêÞ ðáñÜìåôñïò, åßíáé ôï äõóâÜóôáêôï, ãéá ôï óýóôçìá õãåßáò, ïéêïíïìéêü êüóôïò ôçò ôüóï åêôåôáìÝíçò óõíôáãïãñÜöçóçò Ðßíáêáò 1. ÄçìïãñáöéêÜ óôïé÷åßá äåßãìáôïò ôùí åí ëüãù öáñìÜêùí, êáèþò ïé áíôßóôïé÷åò Í % íüóïé Ý÷ïõí ìåãÜëï åðéðïëáóìü. Áðü äõóðåøßá Óôïé÷åßï Öýëï åêôéìÜôáé üôé ðÜó÷åé ðåñßðïõ ôï 25% ôïõ ðëçèõ116 63,7 óìïý6. Ç ËåéôïõñãéêÞ Ãáóôñßôéäá áðïôåëåß ôï áßôéï Ãõíáßêåò ¢íäñåò 66 36,3 óôï 60% ôùí äõóðåðôéêþí åíï÷ëçìÜôùí, áëëÜ, Çëéêßá óôéò êëéíéêÝò ìåëÝôåò, êáôáëáìâÜíåé ìéêñüôåñï ÌÝóïò ¼ñïò 70,8 ðïóïóôü äéüôé ðïëý ìéêñüôåñï åßíáé êáé ôï ðïóï- SD 12,8 69 óôü ôùí áóèåíþí, ðïõ ðñïóÝñ÷åôáé ãéá ôï ëüãï Åýñïò áõôü óôïí ãéáôñü88,89. Ç ÃáóôñïïéóïöáãéêÞ Ðá- Ðåñéï÷Þ Êáôïéêßáò ÁãñïôéêÞ 179 98,4 ëéíäñüìçóç åìöáíßæåôáé óôï 33% ôïõ ãåíéêïý ÇìéáóôéêÞ 3 1,6 ðëçèõóìïý90! Ç Ãáóôñßôéäá ðñïêáëåß ôï 15-25% Íïìüò Êáôïéêßáò ôùí äõóðåøéþí, åíþ ôï Ðåðôéêü ¸ëêïò, ìüëéò ôï Çñáêëåßïõ 153 84,1 29 15,9 5-25%88,89. Ôá ðïóÜ ðïõ îïäåýïíôáé, ãéá ôç ÷ïñÞ- Ñåèýìíïõ 63


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

ÌÝèïäïò Äéáìïñöþèçêå åñùôçìáôïëüãéï ìåôÜ áðü åêôåíÞ áíáóêüðçóç, ìå ôç ÷ñÞóç ôïõ äéáäéêôýïõ, Üñèñùí äçìïóéåõìÝíùí óå éáôñéêÜ ðåñéïäéêÜ, ðïõ åßíáé åíôáãìÝíá óôï Index Medicus áðü ôï 1980 ìÝ÷ñé óÞìåñá. Åðßóçò, åëÞöèçóáí õðüøç ôá êåßìåíá ôùí ôåëåõôáßùí åêäüóåùí óýã÷ñïíùí óõããñáììÜôùí Ðáèïëïãßáò êáé ïé ïäçãßåò ôçò ÁìåñéêáíéêÞò ÃáóôñåíôåñïëïãéêÞò ¸íùóçò (AGA)6, ôçò ÂñåôáíéêÞò Åôáéñßáò Ãáóôñåíôåñïëïãßáò7 êáé ôïõ Institute for Clinical System Improvement (ISCI)39. Ïé ôåëåõôáßåò åßíáé ïé ðéï ðñüóöáôåò êáé áðåõèýíïíôáé óôïõò áóêïýíôåò ÐÖÕ. ÃåíéêÜ, äåí õðÜñ÷ïõí ïìüöùíá áðïäåêôÝò êáôåõèõíôÞñéåò ïäçãßåò ãéá ôï óýíïëï ôùí äõíáôþí êëéíéêþí ðåñéðôþóåùí, ðïõ íá êáëýðôïõí ðëÞñùò ôï èÝìá ôïõ ðüôå ðñÝðåé íá ÷ïñçãïýíôáé H2-RAs, PPIs Þ ïðïéáäÞðïôå áðü ôéò äýï áãùãÝò. Ùò ðñïò ôçí áêñéâÞ äéáôýðùóç ôùí åñùôçìÜôùí ðñïò ôïõò áóèåíåßò óõíåéóÝöåñå ïìÜäá ãéáôñþí ìå ðåßñá ùò ðñïò ôï ãíùóôéêü åðßðåäï êáé ôï ãëùóóéêü éäßùìá ôïõ õðü ìåëÝôç ðëçèõóìïý. Åðßóçò, ç ïìÜäá áõôÞ äéÝèåôå ðåßñá óôç ÷ïñÞãçóç ôÝôïéùí óêåõáóìÜôùí. ÁêïëïõèÞèçêå ç ìÝèïäïò ôçò ðñïóùðéêÞò óõíÝíôåõîçò áðü Ýíáí ãéáôñü ÷ùñßò ôçí ðáñïõóßá Üëëïõ ðñïóþðïõ óå ÷þñï éáôñåßïõ (ÐåñéöåñåéáêÜ Éáôñåßá- ÊÝíôñá Õãåßáò) Þ óôï óðßôé ôïõ áóèåíïýò. Ï ãéáôñüò áõôüò, óôéò ðåñéóóüôåñåò ðåñéðôþóåéò, åß÷å êáé ðñïçãïýìåíç åðáöÞ ìå ôïí áóèåíÞ êáé åðñüêåéôï íá Ý÷åé êáé åðüìåíç, êáèþò Þôáí õðåýèõíïò ãéá ôçí ðáñï÷Þ ÐÖÕ óå áõôüí. ×Üñç óôçí Þäç äïìçìÝíç ó÷Ýóç ìåôáîý ôïõò åëÞöèçóáí ïé áêñéâÝóôåñåò äõíáôÝò ðëçñïöïñßåò. Ï áóèåíÞò åíçìåñþèçêå ãéá ôïí óêïðü ôçò ìåëÝôçò êáé äéáâåâáéþèçêå ãéá ôï áðüññçôï ôçò óõíÝíôåõîçò êáé ôçò êëéíéêÞò åîÝôáóçò. Êáôüðéí æçôÞèçêå ç ðñïöïñéêÞ óõãêáôÜèåóÞ ôïõ êáé ìüíï áí áõôÞ äéäüôáí ï áóèåíÞò óõììåôåß÷å óôç ìåëÝôç. Óå ìåñéêÝò ðåñéðôþóåéò æçôÞèçêå êáé äåýôåñç åðßóêåøç óôïí ßäéï ãéáôñü ãéá ôçí ðñïóêïìéäÞ åããñÜöùí, åîåôÜóåùí Þ óõóêåõáóéþí ôùí óêåõáóìÜôùí ðïõ ðñáãìáôéêÜ êáôáíÜëùíå ìå óêïðü ôçí ðëçñÝóôåñç äéåñåýíçóç. Åðß ìç åðáíüäïõ ï áóèåíÞò åîáéñïýôáí áðü ôç ìåëÝôç. Ãéá ôá áßôéá ëÞøçò ôùí H2-RAs êáé ôùí PPIs ÷ñçóéìïðïéÞèçêå êÜèå Üëëç ðçãÞ, åêôüò áðü ôçí áíáãñáöüìåíç ðÜèçóç óôï óõíôáãïëüãéï ôïõ áóèåíïýò, ëüãù ôçò åíáëëáêôéêÞò êáé 64

É. ÄñõãéáííÜêçò êáé óõí.

áäéáöïñïðïßçôçò ÷ñÞóçò ôùí üñùí ÃáóôñïïéóïöáãéêÞ Ðáëéíäñüìçóç (ÃÏÐ), Ãáóôñßôéò, Ðåðôéêü ¸ëêïò (ÐÅ) êáé Ãáóôñïðñïóôáóßá êáôÜ ôç óõíôáãïãñÜöçóç. ÔÝôïéåò ðçãÝò Þôáí: åíõðüãñáöåò éáôñéêÝò ãíùìáôåýóåéò áðü åéäéêåõìÝíï éáôñü, ôá áðïôåëÝóìáôá åîåôÜóåùí (áéìáôïëïãéêþí, âéï÷çìéêþí, áêôéíïëïãéêþí êáé Üëëùí), ç óõíÝíôåõîç êáé ç êëéíéêÞ åîÝôáóç. ÅðåëÝãçóáí ìüíï ïé áóèåíåßò ìå ôïõò ïðïßïõò ç óõíåííüçóç Þôáí åõ÷åñÞò êáé ìðïñïýóáí áîéüðéóôá íá äþóïõí ðëçñïöïñßåò ãéá ôá óõìðôþìáôá êáé ôï éóôïñéêü ôïõò. Áðïêëåßóèçêáí áðü ôç ìåëÝôç áóèåíåßò ìå ðáèÞóåéò üðùò ç ãåñïíôéêÞ Üíïéá, ç ó÷éæïöñÝíåéá, ïé óùìáôüìïñöåò êáé ïé äéðïëéêÝò óõíáéóèçìáôéêÝò äéáôáñá÷Ýò. Áêüìç, áðïêëåßóèçêáí ïé áóèåíåßò ìå ïîý Üëãïò ïðïéáóäÞðïôå áéôéïëïãßáò, áöïý äå èá Þôáí üóï áíáëõôéêÞ êáé áíôéêåéìåíéêÞ èá Ýðñåðå ç éáôñéêÞ óõíÝíôåõîç. Åðßóçò, áðïêëåßóèçêáí áóèåíåßò ìå ðñïåîÜñ÷ïíôá óõìðôþìáôá áðü ôï áíþôåñï ðåðôéêü, ðïõ ïäçãïýí ôç äéáãíùóôéêÞ óêÝøç ðñïò äéáöïñåôéêÜ íïóÞìáôá. ÔÝôïéïé Þôáí áõôïß ìå äõóöáãßá (äéåñåýíçóç ðñùôßóôùò ãéá ðåðôéêÞ óôÝíùóç, äéáôáñá÷Ýò êéíçôéêüôçôáò ïéóïöÜãïõ, ïéóïöáãéêïýò äáêôõëßïõò Þ ìåìâñÜíåò, ðëáêþäåò êáñêßíùìá Þ áäåíïêáñêßíùìá êáôþôåñïõ ïéóïöÜãïõ)24,25 êáé ïäõíïöáãßá (ëïéìþäåò Þ öáñìáêåõôéêü áßôéï). Óôçí ðåñßðôùóç áõôÞ áðáéôåßôáé Üìåóç åêôÝëåóç âáñéïý÷ïõ ãåýìáôïò Þ/êáé åíäïóêüðçóçò, áíÜëïãá ìå ôï âáèìü õðïøßáò ôïõ êëéíéêïý éáôñïý ãéá á÷áëáóßá, ìå ôï âáñéïý÷ï ãåýìá íá åßíáé ðéï åõáßóèçôï óôçí ôåëåõôáßá ðÜèçóç38. Ôï äåßãìá áðïôåëåßôáé áðü ôõ÷áßá åðéëåãìÝíïõò áóèåíåßò ðïõ åëÜìâáíáí H2-RAs Þ PPIs êáé ãéá äéÜöïñïõò ëüãïõò åðéóêÝöèçêáí ôïõò ãéáôñïýò ðïõ óõììåôåß÷áí óôç ìåëÝôç. Óôï ðñþôï ôìÞìá ôïõ åñùôçìáôïëïãßïõ, ðïõ óõìðëÞñùíå ï éáôñüò, êáôáãñÜöïíôáí õðï÷ñåùôéêÜ ôï ïíïìáôåðþíõìï, ôï Ýôïò ãÝííçóçò, ï ôüðïò êáôïéêßáò ôïõ áóèåíïýò, ôá ëáìâáíüìåíá H2RAs Þ/êáé PPIs, ï ÷ñüíïò ëÞøçò ôïõ êáèåíüò áðü áõôÜ, ôï áí ëáìâÜíïíôáí óõíå÷þò Þ äéáëåéðüíôùò êáèþò êáé ç óõìðôùìáôïëïãßá Þ êÜèå Üëëïò ëüãïò ãéá ôïí ïðïßï ðßóôåõå üôé ôá ëÜìâáíå. ÐñïáéñåôéêÜ êáôáãñÜöïíôáí ôï ðáôñþíõìï ôïõ áóèåíïýò êáé ï ôçëåöùíéêüò áñéèìüò ôïõ. Ôï äåýôåñï ôìÞìá ôïõ åñùôçìáôïëïãßïõ ðñïóðáèïýóå íá áíé÷íåýóåé áí ï áóèåíÞò ìðïñïýóå íá êáôçãïñéïðïéçèåß óå ìßá áðü ôéò ôÝóóåñéò âáóéêÝò áéôßåò ëÞøçò H2-RAs Þ/êáé PPIs: ôç ÃÏÐ,


É. ÄñõãéáííÜêçò êáé óõí.

ôçí Ãáóôñßôéäá, ôï ÐÅ (Ãáóôñéêü Þ Äùäåêáäáêôõëéêü) êáé ôç ËÞøç Ìç Óôåñïåéäþí Áíôéöëåãìïíùäþí ÖáñìÜêùí (NSAIDs). Ðáñå÷üôáí ÷þñïò êáé åß÷å äïèåß ç ðáñüôñõíóç óôïõò éáôñïýò íá êñáôÞóïõí óçìåéþóåéò ãéá ôï ëïéðü éóôïñéêü ôïõ áóèåíïýò, ôçí ëáìâáíüìåíç áãùãÞ, áëëÜ êáé ôçí Üðïøç ôùí éäßùí êáèþò êáé ôùí áóèåíþí áõôþí ãéá ôá áßôéá ëÞøçò ôùí H2-RAs êáé PPIs. Ôï ôìÞìá áõôü ôçò óõíÝíôåõîçò êáé ôçò éáôñéêÞò åîÝôáóçò åß÷å ùò óôü÷ï íá áíé÷íåýóåé óõìðôþìáôá êáé óçìåßá Þ åîåôÜóåéò áðü ôéò ïðïßåò ðñïÝêõðôå ïðïéáäÞðïôå áðü ôéò ôÝóóåñéò ðñïáíáöåñèåßóåò áéôßåò ëÞøçò ôçò åí ëüãù áãùãÞò, êáèþò êáé ôç óõíýðáñîç êÜðïéáò áðü ôéò õðüëïéðåò ôñåéò. Óôïõò áëãïñßèìïõò ðïõ ðáñïõóéÜæïíôáé ðáñáêÜôù åííïåßôáé, ÷ùñßò íá áíáöÝñåôáé, üôé óôéò ðåñéðôþóåéò ðïõ ï áóèåíÞò äåí ìðïñïýóå íá êáôçãïñéïðïéçèåß óå êÜðïéá áðü áõôÝò Þ óôéò ðåñéðôþóåéò ìåñéêÞò Þ ìçäåíéêÞò áíôáðüêñéóçò óôçí áãùãÞ, óôïõò ÷ñüíïõò ðïõ êÜèå öïñÜ ïñßæïíôáé, åêôåëåßôáé, ìåôÜ ôçí ðáñÝëåõóÞ ôïõò, áðåéêïíéóôéêüò êáé åñãáóôçñéáêüò Ýëåã÷ïò, ìå áêñïãùíéáßï ëßèï ôçí åíäïóêüðçóç. Áõôü äåí éó÷ýåé óôéò ðåñéðôþóåéò ðïõ áðáéôïýí åîáñ÷Þò ôÝôïéï Ýëåã÷ï6. Ç èíçôüôçôá áðü åíäïóêïðéêü Ýëåã÷ï åßíáé ÷áìçëÞ êáé êõìáßíåôáé áðü 1/3300 ùò 1/400006. Ç íïóçñüôçôá áíáöÝñåôáé áðü 1/330 ùò 1/27006. Ãéá ôç äéÜãíùóç ôçò ÃÏÐ óçìåéþíïíôáí Ö Þ × óôá áíôßóôïé÷á ôåôñáãùíßäéá, áí ï áóèåíÞò åìöÜíéæå êÜðïéá ôá áðü êýñéá óõìðôþìáôá (ïðéóèïóôåñíéêüò êáýóïò, áíáãùãÝò, åñõãÝò) Þ äåõôåñåýïíôá óõìðôþìáôá (ðáñïîõóìéêÞ äýóðíïéá37, ðáñïîõóìéêüò âÞ÷áò37, ïðéóèïóôåñíéêü Üëãïò, âñÜã÷ïò öùíÞò, íáõôßá, ðñþéìïò êïñåóìüò ðåßíáò), êáèþò êáé óõìðôþìáôá, óçìåßá Þ/êáé óôïé÷åßá ôïõ éóôïñéêïý, ðïõ áðáéôïýí åðåßãïõóá Þ åðåìâáôéêÞ ðñï ôçò èåñáðåßáò äéåñåýíçóç Þ/êáé áíôéìåôþðéóç1 êáèþò êáé ôï áí áõôü Ýãéíå óôï ÷ñüíï ðïõ Ýðñåðå. Áí õðÜñ÷ïõí ìüíï äåõôåñåýïíôá óõìðôþìáôá êáé äåí áíåõñßóêåôáé Üëëï ðéèáíüôåñï áßôéï, áðáéôåßôáé 24-ùñç pH-ìåôñßá ïéóïöÜãïõ Üìåóá, ðñïò äéåñåýíçóç ôçò ÃÏÐ, ðñéí äïèåß ïðïéáäÞðïôå èåñáðåßá37. Ãéá ôçí áíôéìåôþðéóç ôçò ÃÏÐ ôï ðñþôï âÞìá Þôáí ç êáôÜ ôïí éáôñü ôáîéíüìçóç ôçò íüóïõ óå: Þðéá, ìÝôñéá Þ óïâáñÞ ÃÏÐ. Óôçí Þðéá, áñêïýóáí ïé ðëÞñåéò êáé óùóôÝò óõóôÜóåéò ãéá áðïöõãÞ êáôÜêëéóçò ðñéí áðü ôçí ðÜñïäï 3h ìåôÜ ôï ãåýìá Þ ôï äåßðíï, áíýøùóç ôçò êåöá-

Ôüìïò 16, Ôåý÷ïò 2, 2004

ëÞò óôï êñåâÜôé êáôÜ ôçí êáôÜêëéóç, áðïöõãÞ êáôáíÜëùóçò ôïìÜôáò, üîéíùí öñïýôùí, üîéíùí ÷õìþí, ðéêÜíôéêùí, êáöÝ, óïêïëÜôáò, ëéðþí, áëêïüë, áðïöõãÞ êáðíßóìáôïò êáé ëÞøç áíôéüîéíùí êáé H2-RAs ðåñéóôáóéáêÜ. Óôç ìÝôñéá, åêôüò áðü ôá ðáñáðÜíù, èåùñåßôáé óêüðéìï íá óõíôáãïãñáöïýíôáé H2-RAs ãéá 6 åâäïìÜäåò êáé áí äåí õöåèïýí ôá óõìðôþìáôá íá áëëá÷èåß ç áãùãÞ óå PPI óå äüóç 1´1 ãéá 8-12 åâäïìÜäåò. Áí õöåèïýí, èåùñåßôáé óêüðéìï íá óõíå÷éóèïýí ãéá Üëëåò 2-6 åâäïìÜäåò ïé H2-RAs. Óôç óïâáñÞ, ðñÝðåé íá äïèåß åîáñ÷Þò PPI óå äüóç 1´1 êáé áí ôá óõìðôþìáôá äåí õöåèïýí óå 2-4 åâäïìÜäåò, íá áõîçèåß ç äüóç óå 1´2 êáé ç èåñáðåßá íá ëçöèåß ãéá 8-12 åâäïìÜäåò óõíïëéêÜ. ÓùóôÞ èåùñÞèçêå êáé áãùãÞ ãéá ìåãáëýôåñï ÷ñïíéêü äéÜóôçìá áðü ôá ðáñáðÜíù, êáèþò áñêåôÝò Ýãêõñåò Ýñåõíåò Ý÷ïõí áðïäåßîåé ôçí ðïëý óõ÷íÞ õðïôñïðÞ ôçò ÃÏÐ, åéäéêÜ óôïõò 6 ìÞíåò ìåôÜ ôçí ðáýóç 12 åâäïìÜäùí åðéôõ÷ïýò èåñáðåßáò91. Êáôáãñáöüôáí åðßóçò, áí åìöáíßóèçêå êÜðïéá áðü ôéò êýñéåò åðéðëïêÝò ôçò ÃÏÐ: ïéóïöÜãïò Barrett (åíäïóêïðéêÞ äéÜãíùóç) êáé óôÝíùóç ïéóïöÜãïõ (êëéíéêÞ äéÜãíùóç ëüãù äõóêáôáðïóßáò Þ äéÜãíùóç åíäïóêïðéêÜ Þ ìå âáñéïý÷ï ãåýìá)9-12,17. Ãéá ôç äéÜãíùóç ôçò ãáóôñßôéäáò êáôáãñÜöïíôáí ìå Ö Þ × óôá áíôßóôïé÷á ôåôñáãùíßäéá áí ï áóèåíÞò Ýðáó÷å áðü ïäçãÜ óõìðôþìáôá (áíïñåîßá, åðéãáóôñáëãßá, íáõôßá, åìÝôïõò, áßóèçìá ðëçñüôçôáò, ìåôåùñéóìü) Þ êÜðùò ðéï óðÜíéá óõìðôþìáôá êáé êáôåõèýíïíôá ðñïò åðåßãïõóá äéåñåýíçóç Þ/êáé áíôéìåôþðéóç, üðùò áõôÜ ðñïáíáöÝñèçêáí. Ç áñ÷éêÞ áíôéìåôþðéóç äéáöÝñåé áíÜëïãá ìå ôï áí ôá óõìðôþìáôá ïäçãïýí ðñïò ôç äéÜãíùóç ôçò áéìïññáãéêÞò- äéáâñùôéêÞò ãáóôñßôéäáò (åðéãáóôñáëãßá êõñßùò) Þ ôç äéÜãíùóç ôçò ëåéôïõñãéêÞò ãáóôñßôéäáò (áßóèçìá ðëçñüôçôáò, ìåôåùñéóìüò) êáé áíáëüãùò ôïõ áéôßïõ áõôÞò êáé ôùí äéáöüñùí óõíõðáñ÷ïõóþí óçìåßùí, óõìðôùìÜôùí êáé åðéâáñõíôéêþí ðáñáãüíôùí, üðùò öáßíåôáé óôïí áëãüñéèìï 1. Óçìåéþíåôáé üôé ç äéÜãíùóç ëïßìùîçò áðü Helicobacter pylori ãßíåôáé ìå ìç åðåìâáôéêü ôñüðï ìå ïñïëïãéêÝò ìå1 ×áñáêôÞñåò åðåßãïíôïò: áíáéìßá (7-10) çìÝñåò, åðéìÝíïíôåò Ýìåôïé (1 çìÝñá), áéìáôÝìåóç (7-10) çìÝñåò, ìÝëáéíåò êåíþóåéò (1 çìÝñá), áðþëåéá âÜñïõò >5%, áêïýóéá (7-10 çìÝñåò), áéìáôï÷åóßá, çëéêßá >45 åôþí, ïîåßá äõóöáãßá (1 çìÝñá), åììÝíïíôá, óõíå÷Þ Þ äéáëåßðïíôá, ÷ñüíéá óõìðôþìáôá.

65


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

É. ÄñõãéáííÜêçò êáé óõí.

á) ÄéáâñùôéêÞ- ÁéìïññáãéêÞ i) Stress H2-RAs IV ii) NSAIDs a) ×ùñßò ðñüóèåôïõò ðáñÜãïíôåò êéíäýíïõ (âëÝðå 2-Â-á-ii-b) Ìåßùóç Äüóçò ÓõãêáôáíÜëùóç ìå ãåýìáôá Ðáýóç ÓõìðôùìÜôùí ® ÍÁÉ Ðáýóç Ï×É

Åíäïóêüðçóç b) iii)

® H2-RAs

Þ PPIs

Ìå ³1 áðü ôïõò áêüëïõèïõò ðáñÜãïíôåò êéíäýíïõ: Éóôïñéêü Ðåðôéêïý ¸ëêïõò ËÞøç êïñôéêïóôåñïåéäþí ËÞøç áíôéðçêôéêþí ÓïâáñÞ Íüóïò >70 åôþí ÊÜðíéóìá ÐéñïîéêÜìç Áæáðñïðáæüíç Áëêïüë

H2-RAs

â) Ìç äéáâñùôéêÞ-Ìç åéäéêÞ (ËåéôïõñãéêÞ) i) Ìå ³1 áðü ôïõò áêüëïõèïõò ðáñÜãïíôåò êéíäýíïõ: - Ðñïçãïýìåíï Ðåðôéêü ¸ëêïò - MALT ËÝìöùìá - Ïéêïãåíåéáêü Éóôïñéêü Ãáóôñéêïý ÍåïðëÜóìáôïò (ÁóéÜôåò éäéáßôåñá)

¸ëåã÷ïò ãéá H. pylori

Áëãüñéèìïò 1

èüäïõò Þ ôç äïêéìáóßá åêðíïÞò ïõñßáò (Urea Breath Test), ìå ðñïôßìçóç óôç äåýôåñç ëüãù ôçò ìåãáëýôåñçò åõáéóèçóßáò ôçò26. Áí ç äïêéìáóßá áðïâåß èåôéêÞ, áðü ìåñéêïýò óõíéóôÜôáé, åéäéêÜ óå ðëçèõóìïýò ìå õøçëü åðéðïëáóìü ãáóôñéêþí íåïðëáóìÜôùí (ÁóéÜôåò, >45 åôþí) êáé Üìåóç åíäïóêüðçóç6. Ãéá ôç äéÜãíùóç ôïõ ðåðôéêïý Ýëêïõò, (ãáóôñéêü Þ äùäåêáäáêôõëéêü), ôá áíáæçôïýìåíá óõìðôþìáôá Þôáí êõñßùò ç åðéãáóôñáëãßá, ìå ïñéóìÝíïõò éäéáßôåñïõò ÷áñáêôÞñåò, (áìâëý Üëãïò, áöõðíßæïí Üëãïò, ñõèìéêü Üëãïò, Üëãïò ùò ðåßíá) êáé äåõôåñåõüíôùò, ç íáõôßá êáé ç áíïñåîßá. ÐåðôéêÜ Ýëêç âñßóêïíôáé óõ÷íÜ ìåôÜ áðü áðïôõ÷ßá ôùí áãùãþí ãéá ÃÏÐ êáé ãéá ãáóôñß-

ôéäá êáé áêüëïõèç åíäïóêüðçóç Þ êáé óôéò ðåñéðôþóåéò Üìåóçò, ðñéí ôç ëÞøç áãùãÞò, åíäïóêüðçóçò. Ç áíôéìåôþðéóç äéáöÝñåé áíÜëïãá ìå ôï áßôéï, üðùò öáßíåôáé óôïí áëãüñéèìï 2, (ôìÞìá ôïõ åñùôçìáôïëïãßïõ). ÔÝëïò, äéêáéïëïãçìÝíç èåùñåßôáé ç óõã÷ïñÞãçóç PPIs (êáé ü÷é H2-RAs, ðïõ Ý÷ïõí áðïäåé÷èåß áíåðáñêþò áðïôåëåóìáôéêÜ áêüìç êáé óå ìåëÝôåò cost-effect) óå áóõìðôùìáôéêÜ Üôïìá, ðïõ ëáìâÜíïõí NSAIDs, (“ãáóôñïðñïóôáóßá”), ãéá üóï ÷ñïíéêü äéÜóôçìá ôá ëáìâÜíïõí, ìüíï áí óõíõðÜñ÷åé Ýíáò Þ ðåñéóóüôåñïé áðü ôïõò åîÞò ðáñÜãïíôåò: çëéêßá >80 åôþí, ðåðôéêü Ýëêïò, êÜðíéóìá, óõ÷íÝò ãáóôñåíôåñéêÝò åðéðëïêÝò ìå NSAIDs, óôåñïåéäÞ, áíôéðçêôéêÜ, óïâáñÞ íüóïò,

á) NSAIDs ® ¼ðùò óôá NSAIDs â) Helicobacter pylori ® ÁíôéâéïôéêÜ + PPIs (12äÜêôõëï-2-4 åâäïìÜäåò - Óôüìá÷ïò 4-6 åâäïìÜäåò ã) Óýíäñïìï Zollinger-Ellison ® ÌåôáóôÜóåéò ® ÍÁÉ PPIs (1´2) ? Ï×É ×åéñïõñãéêÞ ÅðÝìâáóç

Áëãüñéèìïò 2 66

)


É. ÄñõãéáííÜêçò êáé óõí.

ëÞøç ðéñïîéêÜìçò Þ áæáðñïðáæüíçò. Ôá äýï ôåëåõôáßá åßíáé NSAIDs, ðïõ ðñïêáëïýí áõîçìÝíç óõ÷íüôçôá ãáóôñåíôåñéêþí åðéðëïêþí êáé äéêáéïýìáóôå íá óõíôáãïãñáöÞóïõìå PPIs, Ýóôù êáé áðïõóßá óõìðôùìÜôùí Þ Üëëùí áðü ôïõò ðéï ðÜíù ðáñÜãïíôåò. ÌåôÜ áðü ôçí ðáñáðÜíù äéåñåýíçóç áðáíôÞèçêáí 5 åñùôÞìáôá- êëåéäéÜ ôçò ìåëÝôçò ãéá êÜèå áóèåíÞ: · ¹ôáí ç áãùãÞ óùóôÞ (ïõóßá, äïóïëïãßá, ÷ñüíïò ëÞøçò, áðïôåëåóìáôéêüôçôá); · Ðïéá Þôáí ç ðñáãìáôéêÞ ðÜèçóç (åöüóïí ôá óôïé÷åßá ðïõ ìáò ðáñÝ÷ïíôáí áñêïýóáí ãéá ôç äéÜãíùóç); · ¸ãéíå åíäïóêüðçóç; · Óõóôçíüôáí íá ãßíåé; · Ðïéï Þôáí ôï áðïôÝëåóìÜ ôçò;

ÓôáôéóôéêÞ ÁíÜëõóç Ôá äåäïìÝíá ìåôáöÝñèçêáí óôï ðñüãñáììá óôáôéóôéêÞò åðåîåñãáóßáò äåäïìÝíùí SPSS, Ýêäïóç 11.5 ìå êùäéêïðïßçóç ôùí äåäïìÝíùí, ðïõ áíôéóôïé÷ïýóáí óå áñéèìïýò Þ êáôáóôÜóåéò, óå áêÝñáéïõò áñéèìïýò, ãéá äéåõêüëõíóç ôçò óôáôéóôéêÞò åðåîåñãáóßáò. ÕðÞñ÷áí ìåôáâëçôÝò äýï åéäþí: êáôçãïñéêÝò êáé áñéèìçôéêÝò. Áñ÷éêÜ ðñáãìáôïðïéÞèçêå ðåñéãñáöéêÞ óôáôéóôéêÞ áíÜëõóç åóôéÜæïíôáò êõñßùò óôá óôáôéóôéêÜ ìåãÝèç ìÝóïò üñïò, äéÜìåóïò, êïñõöÞ, óôáèåñÜ áðüêëéóçò, åëÜ÷éóôï, ìÝãéóôï, åýñïò, ãéá üóåò ìåôáâëçôÝò âÝâáéá åß÷å íüçìá ôï êáèÝíá áðü áõôÜ. Áêïëïýèùò, äéåñåõíÞèçêáí ç åóùôåñéêÞ óôÜèìéóç ôïõ äåßãìáôïò êáé ïé ðéèáíÝò óôáôéóôéêÝò óõó÷åôßóåéò ìåôáîý ôùí äéáöüñùí ìåôáâëçôþí ìå ôï Pearson’s ÷2 ãéá êáôçãïñéêÝò ìåôáâëçôÝò êáé ôï Independent Samples’ t test ãéá áñéèìçôéêÞ ìå êáôçãïñéêÞ äé÷ïôïìéêÞ ìåôáâëçôÞ. Ìå áíÜëõóç One-Way ANOVA åðé÷åéñÞèçêå ç óõó÷Ýôéóç áñéèìçôéêÞò ìå êáôçãïñéêÞ, ôñé÷ïôïìéêÞ Þ ìå ðåñéóóüôåñåò ôéìÝò, ìåôáâëçôÞ.

ÁðïôåëÝóìáôá ÐåñéãñáöéêÞ ÓôáôéóôéêÞ ÁíÜëõóç ¼ðùò öáßíåôáé óôï ó÷Þìá 1, 100/182 äçë. ôï (54,9%) ôùí áóèåíþí ëáìâÜíïõí Ïìåðñáæü-

Ôüìïò 16, Ôåý÷ïò 2, 2004

Ó÷Þìá 1. ÖáñìáêåõôéêÞ ïõóßá.

ëç, 49 (26,9%) Ñáíéôéäßíç, 13 (7,1%) Ëáíóïðñáæüëç, 12 (6,6%) Ðáíôïðñáæüëç, 7 (3,8%) Ñáìåðñáæüëç êáé 1 (0,5%) S-ïìåðñáæüëç. ÓõãêåíôñùôéêÜ ïé 133 áðü ôïõò 182 , Þôïé ôï (73,1%) ôùí áóèåíþí ëáìâÜíïõí PPI (ðñáæüëåò), åíþ ïé 49 (26,9%) ëáìâÜíïõí H2-RA (ñáíéôéäßíç). ¼ðùò åßíáé öáíåñü, ôç ìÝãéóôç êáôáíÜëùóç Ý÷åé ç Ïìåðñáæüëç êáé áêïëïõèåß ç Ñáíéôéäßíç. Óôï ðáñåëèüí 3 áóèåíåßò (1,6%) êáôáíÜëùíáí ñáíéôéäßíç áíôß ðñáæüëçò. Ç äüóç ôçò Ñáíéôéäßíçò åßíáé ç ïñèÞ óå 43/ 182, äçë. óôï (87,8%) ôùí áóèåíþí ðïõ ôç ëáìâÜíïõí, åíþ åßíáé ëáíèáóìÝíç óå 6 (12,2%). Ç äüóç 150 mg x 1, ëáìâáíüìåíç äéáëåéðüíôùò, åßíáé óùóôÞ ãéá áóèåíåßò ìå Þðéá ÃÏÐ êáé ÷ùñßò áíÜãêç ðåñáéôÝñù äéåñåýíçóçò, áëëÜ äåí åß÷áìå ôÝôïéåò ðåñéðôþóåéò. Áêüìç, óôçí ÅëëÜäá äåí êõêëïöïñåß Ñáíéôéäßíç óå ìéêñüôåñç áðü ôçí åëÜ÷éóôç èåñáðåõôéêÞ äüóç, ðïõ èåùñåßôáé ïñèÞ åðéëïãÞ ãéá èåñáðåßá ôÝôïéùí ðåñéðôþóåùí ëáìâáíüìåíç åðß óõìðôùìÜôùí. ÔÝôïéá õðÜñ÷åé óå Üëëá êñÜôç êáé ðùëåßôáé ÷ùñßò óõíôáãÞ éáôñïý. Ç äüóç ôùí Ðñáæïëþí Þôáí ç åëÜ÷éóôç èåñáðåõôéêÞ Üðáî çìåñçóßùò óå 125 (94%) ôùí áóèåíþí, äéò çìåñçóßùò óå 6 (4,5%) ôùí áóèåíþí êáé õðïèåñáðåõôéêÞ óå 2 áóèåíåßò, (1,5%). Óõìðåñáßíïõìå üôé ãåíéêÜ ç ëÞøç óùóôÞò äïóïëïãßáò äåí áðïôåëåß éäéáßôåñï ðñüâëçìá, ìå ìéá áóôï÷ßá ìüëéò 4,4%. Ï ìÝóïò ÷ñüíïò ëÞøçò ôçò ðáñáðÜíù áãùãÞò åßíáé 14,5 ìÞíåò, äçëáäÞ ðïëý ðåñéóóüôåñï áðü ïðïéïäÞðïôå áðïäåêôü äéÜóôçìá ëÞøçò ôçò åí ëüãù áãùãÞò. Ôï åëÜ÷éóôï åßíáé 0,07 ìÞíáò, ôï ìÝãéóôï 120 ìÞíåò êáé ç êïñõöÞ 0,5 ìÞíáò. 67


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

É. ÄñõãéáííÜêçò êáé óõí.

Ó÷Þìá 2. ×ñüíïò ëÞøçò áãùãÞò.

163 áóèåíåßò, (89,6%), ëáìâÜíïõí ôçí áãùãÞ óõíå÷þò êáé 19, (10,4%), äéáëåéðüíôùò. Áíáëõôéêüôåñá ïé ÷ñüíïé ëÞøçò áãùãÞò öáßíïíôáé óôï ó÷Þìá 2. Ç óõìðôùìáôïëïãßá ðïõ ï êÜèå áóèåíÞò áíáöÝñåé ùò õðåýèõíç ãéá ôç ëÞøç ôçò áãùãÞò áõôÞò öáßíåôáé óôïí ðßíáêá 2. ÊáôáãñÜöåôáé ç áéôéþìåíç íüóïò, áí ï áóèåíÞò äåí åßíáé óå èÝóç íá èõìçèåß ôá óõìðôþìáôá Þ áí ç áéôßá åßíáé ðÝñá áðü êÜèå áìöéóâÞôçóç ëüãù åñãáóôçñéáêÞò äéåñåýíçóçò. Åðéêñáôåß ç Ãáóôñïðñïóôáóßá ìå 42,9% êáé áêïëïõèïýí ç Åðéãáóôñáëãßá ìå

29,7% êáé ï Ïðéóèïóôåñíéêüò Êáýóïò ìå 13,2 %. Ç ëáìâáíüìåíç áãùãÞ åßíáé ëáíèáóìÝíç, (åßôå ùò öáñìáêåõôéêÞ ïõóßá, åßôå ùò äïóïëïãßá, åßôå ùò ÷ñüíïò ëÞøçò, åßôå ëüãù áíáðïôåëåóìáôéêüôçôáò ìåôÜ áðü äéáöïñåôéêü ãéá êÜèå ðÜèçóç ÷ñïíéêü äéÜóôçìá, åßôå åðåéäÞ ÷ñåéÜæåôáé ðñüôåñç äéåñåýíçóç (åíäïóêïðéêÜ, äïêéìáóßåò áíß÷íåõóçò Helicobacter pylori)), óå 123/182 áóèåíåßò, (67,6%), êáé ïñèÞ óå 59/182 áðü áõôïýò, (32,4%), (ó÷Þìá 3). ÅðáíáëáìâÜíïõìå åäþ ôçí åëáóôéêüôçôá ôùí êñéôçñßùí ðïõ ÷ñçóéìïðïéÞóáìå, åéäéêÜ óôçí áãùãÞ ôçò ÃÏÐ, áëëÜ êáé óôéò Üëëåò 3

Ðßíáêáò 2. Áíáöåñüìåíá áßôéá ëÞøçò H2-RAs Þ PPIs Áßôéï Ãáóôñïðñïóôáóßá Åðéãáóôñáëãßá Ïðéóèïóôåñíéêü Êáýóïò Áßóèçìá Ðëçñüôçôáò Ðåðôéêü ¸ëêïò Åðéãáóôñáëãßá + Ïðéóèïóôåñíéêü Êáýóïò Ãáóôñßôéò Áßóèçìá Ðëçñüôçôáò + Ïðéóèïóôåñíéêü Êáýóïò Ãáóôñïðñïóôáóßá + Ïðéóèïóôåñíéêü Êáýóïò Äåí ãíùñßæù Åðéãáóôñáëãßá + Ìåôåùñéóìüò Óýíïëï 68

Í

%

78 54 24 6 6 4

42,9 29,7 13,2 3,3 3,3 2,2

3 2

1,6 1,1

2

1,1

2 1 182

1,1 0,5 100

Ó÷Þìá 3. ÏñèÞ áíôéìåôþðéóç;


Ôüìïò 16, Ôåý÷ïò 2, 2004

É. ÄñõãéáííÜêçò êáé óõí.

áóèåíåßò. ¢óêïðá äåí Ýãéíå óå êáíÝíá áóèåíÞ, åíþ ïñèþò Ýãéíå óå 14 (7,7%)13. Ôá áðïôåëÝóìáôÜ ôçò öáßíïíôáé óôïí ðßíáêá 3. ÅéäéêÜ ãéá ôç ÃÏÐ, ç ïðïßá áöïñïýóå 39 Üôïìá (21,4%), ôá 38 áðü áõôÜ, (97,4%), åß÷áí êýñéá óõìðôþìáôá, 2 (5,1%) Üôõðá ìå ìïíáäéêü ôï ïðéóèïóôåñíéêü Üëãïò, 1 äçëáäÞ (2,6%), ìüíï Üôõðá, åíþ ïé 33/39, (84,6%), Ýðñåðå íá äéåñåõíçèïýí åíäïóêïðéêÜ, äéüôé Þôáí >45 åôþí. ÁíáëõôéêÜ, ç ðïéêéëßá ôùí êýñéùí óõìðôùìÜôùí öáßíåôáé óôïí ðßíáêá 4. Ç óïâáñüôçôá ôçò ÃÏÐ öáßíåôáé óôï ó÷Þìá 5. Ïé áðáñáßôçôåò ïäçãßåò ãéá áëëáãÞ óõìðåñéöïñÜò åß÷áí äïèåß ðëÞñùò óå 25 áóèåíåßò (64,1%), ìåñéêþò óå 5 (12,8%) êáé êáèüëïõ óå 9 (23,1%). ÖáñìáêåõôéêÞ áãùãÞ ëÜìâáíáí 36 (92,3%) êáé äåí ëÜìâáíáí 3 (7,7%). ÁõôÞ äåí Þôáí áðáñáßôçôç åîáñ÷Þò óå 10 (25,6%), äéüôé åß÷áí Þðéá ÃÏÐ. ÄçëáäÞ 7 Üôïìá (17,9%) ëÜìâáíáí öáñìáêåõôéêÞ áãùãÞ, åíþ äåí Ýðñåðå. Ìüíï óå 8, äçë. óôï (20,5%) ôùí áóèåíþí åß÷å áêïëïõèçèåß ï áëãüñéèìïò ôçò áíôéìåôþðéóÞò ôçò.

Ó÷Þìá 4. Íüóïé.

êáôáóôÜóåéò, åéäéêÜ ùò ðñïò ôï ÷ñüíï ëÞøçò ôçò áãùãÞò. Ïé áðüëõôïé áñéèìïß êáé ôá ðïóïóôÜ ôùí ðáèÞóåùí ðïõ äéáãíþóôçêáí ìå ôç âïÞèåéá ôïõ éóôïñéêïý, ôçò êëéíéêÞò åîÝôáóçò êáé ôùí åñãáóôçñéáêþí åîåôÜóåùí öáßíïíôáé óôï ó÷Þìá 4. Åíôýðùóç ðñïêáëåß üôé ôï 25% ôùí áóèåíþí ïõäÝðïôå ðáñïõóßáóáí êÜðïéï ëüãï ëÞøçò PPIs Þ H2-RAs. Õðïãñáììßæïõìå åäþ ôçí ðéèáíÞ õøçëüôåñç óõ÷íüôçôá, áðü ôçí êáôáãñáöüìåíç åäþ, ôïõ ðåðôéêïý Ýëêïõò, åéäéêÜ óôéò ðåñéðôþóåéò ëÞøçò NSAIDs, ïðüôå êáé ôá óõìðôþìáôá åßíáé ëéãüôåñï Ýíôïíá áðü ü,ôé óå ðåðôéêÜ Ýëêç Üëëçò áéôéïëïãßáò. Áõôü ìðïñåß íá äéáðéóôùèåß ìüíï ìå åíäïóêüðçóç, ç ïðïßá Ýðñåðå íá Ý÷åé ðñáãìáôïðïéçèåß êáé äåí ðñáãìáôïðïéÞèçêå óå 59 (32,4%)

Ðßíáêáò 4. Êýñéá óõìðôþìáôá ÃáóôñïïéóïöáãéêÞò Ðáëéíäñüìçóçò Óýìðôùìá Ïðéóèïóôåñíéêü êáýóïò Ïðéóèïóôåñíéêü êáýóïò + ÅñõãÝò Ïðéóèïóôåñíéêü Êáýóïò + ÁíáãùãÝò ÏõäÝí Óýíïëï

Í

%

22 14 2 1 39

56,4 35,9 5,1 2,6 100

Ðßíáêáò 3. ÅõñÞìáôá åíäïóêüðçóçò Åýñçìá Ãáóôñßôéò Åíåñãü ¸ëêïò ÃÏÐ Ãáóôñßôéò + H. Pylori ÅðïõëùèÝí ¸ëêïò Íåïðëáóßá ÓôïìÜ÷ïõ Ðåðôéêü ¸ëêïò + ÃÏÐ ÏõäÝí Óýíïëï

Í

%

4 3 2 1 1 1 1 1 14

28,6 21,5 14,4 7,1 7,1 7,1 7,1 7,1 100

Ó÷Þìá 5. Óïâáñüôçôá ÃÏÐ. 69


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

É. ÄñõãéáííÜêçò êáé óõí.

Óôï ðïóïóôü ðåñéëáìâÜíïíôáé êáé áãùãÝò ìåãáëýôåñçò äéÜñêåéáò áðü áõôÞ ðïõ ðñïâëÝðïõí ïé áëãüñéèìïé, ëüãù ôùí óõ÷íþí õðïôñïðþí ôçò ÃÏÐ (ùò >90% óôïõò 6 ìÞíåò åðß åíäïóêïðéêÜ äéáðéóôùìÝíçò ïéóïöáãßôéäáò91). Óå 6 (15,4%) äå äéåñåõíÞèçêáí åíäïóêïðéêÜ ïé ðéèáíÝò åðéðëïêÝò ôçò ÃÏÐ ëüãù åðéìïíÞò Ýóôù êáé ëéãüôåñùí Ýíôïíùí óõìðôùìÜôùí ìåôÜ áðü 3 ìÞíåò èåñáðåßáò, åíþ áõôü Ýðñåðå íá ãßíåé. ÐáñÜ ôáýôá, ôï 74,4% ôùí áãùãþí Þôáí ðëÞñùò åðéôõ÷çìÝíåò, üðùò öáßíåôáé êáé óôï ó÷Þìá 6. Ôá óõìðôþìáôá áõôþí ðïõ åß÷áí ãáóôñßôé-

äá êáé Þôáí 66/182, (36,3%) öáßíïíôáé óôï ó÷Þìá 7. Ïé ãáóôñßôéäåò Þôáí åê ôçò óõìðôùìáôïëïãßáò êáôÜ 80,3% äéáâñùôéêÝò- áéìïññáãéêÝò êáé êáôÜ 19,7% ëåéôïõñãéêÝò. Ùò ðñïò ôïõò ðáñÜãïíôåò ðïõ ôéò ðñïêÜëåóáí, 26 áðü áõôÝò, (39,4%), ðñïêëÞèçêáí áðü NSAIDs êáé óå 19, (73%), óõíõðÞñ÷å êáé Üëëïò ðáñÜãïíôáò. ÁíáëõôéêÜ ôï ðïéïé Þôáí áõôïß ïé åðéðëÝïí ðáñÜãïíôåò öáßíåôáé óôïí ðßíáêá 5. Ï áëãüñéèìïò áíôéìåôþðéóçò ôçò ãáóôñßôéäáò ôçñÞèçêå óôï 40,9% ôùí ðåñéðôþóåùí. Ôá óõìðôþìáôá ðïõ ìáò ïäÞãçóáí óôçí éó÷õñÞ ðåðïßèçóç üôé ðñüêåéôáé ãéá ðåðôéêü Ýëêïò (12 áóèåíåßò, 6,6%) öáßíïíôáé óôïí ðßíáêá 6. Ôï áßôéï ôïõ Ýëêïõò Þôáí ôá NSAIDs óå 4 áóèåíåßò (33,3%), åíþ Þôáí Üãíùóôï óå 8 (66,7%). Ìüíï óå 4 (33,3%) áêïëïõèÞèçêáí ïé áëãüñéèìïé äéåñåýíçóçò êáé èåñáðåßáò. ÍSAIDs ëÜìâáíáí 61 Üôïìá (33,5%), åíþ áõôÜ Þôáí ï ìüíïò ðáñÜãïíôáò ãéá ôç óõíôáãïãñÜöçóç PPIs (÷ùñßò êáìßá ðáñïýóá óõìðôùìáôïëïãßá) óå 33 áóèåíåßò, (18,13%), åíþ óõíõðÞñ÷å êáé ÃÏÐ óå 1 áðü áõôïýò, (0,5%). Ïé 33 óôïõò 34, (97%), ðáñïõóßáæáí ³1 ðáñÜãïíôåò êáé Ýôóé Þôáí äéêáéïëïãçìÝíç ç ÷ïñÞãçóç NSAIDs. ÁíáëõôéêÜ ïé ðáñÜãïíôåò áõôïß öáßíïíôáé óôï ó÷Þìá 8.

Ó÷Þìá 6. Áðïôåëåóìáôéêüôçôá èåñáðåßáò ÃÏÐ.

Ðßíáêáò 5. Åðéâáñõíôéêïß ðáñÜãïíôåò ãáóôñßôéäáò áðü NSAIDs ÐáñÜãïíôáò >70 åôþí ÊïñôéêïóôåñïåéäÞ >70 åôþí + ÊïñôéêïóôåñïåéäÞ >70 åôþí + ÊÜðíéóìá ÊÜðíéóìá > 70 åôþí + ÁíôéðçêôéêÜ Óýíïëï

Í 8 5 3 1 1 1 19

% 42 26,3 15,8 5,3 5,3 5,3 100

Ðßíáêáò 6. Óõìðôùìáôïëïãßá ðåðôéêïý Ýëêïõò ÐáñÜãïíôáò

Ó÷Þìá 7. Óõìðôþìáôá ãáóôñßôéäáò. 70

Í

%

¸íôïíç êáé åíôïðéóìÝíç åðéãáóôñáëãßá 4 33,3 Åðéãáóôñáëãßá ùò ðåßíá 2 16,7 êáé áöõðíßæïí Üëãïò Åðéãáóôñáëãßá ùò áìâëý Üëãïò 2 16,7 Åðéãáóôñáëãßá ùò ðåßíá êáé áìâëý Üëãïò 1 8,3 Åðéãáóôñáëãßá ùò áöõðíßæïí Üëãïò 1 8,3 ÑõèìéêÞ áöõðíßæïõóá åðéãáóôñáëãßá 1 8,3 Åðéãáóôñáëãßá + ÌÝëáéíá êÝíùóç 1 8,3 Óýíïëï 12 100


Ôüìïò 16, Ôåý÷ïò 2, 2004

É. ÄñõãéáííÜêçò êáé óõí.

Ó÷Þìá 8. ÓõãêåêñéìÝíïò Üëëïò ðáñÜãïíôáò ðëÝïí ëÞøçò NSAIDs.

ÓôáôéóôéêÞ ÓôÜèìéóç Äåßãìáôïò Ôï äåßãìá ìáò åßíáé åóùôåñéêÜ óôáèìéóìÝíï, êáèþò äåí ðñïêýðôïõí óôáôéóôéêÜ óçìáíôéêÝò äéáöïñÝò ìåôáîý ôùí ìåôáâëçôþí ðïõ áðïìÝíïõí, áí ïðïéáäÞðïôå áðü ôéò ìåôáâëçôÝò áõôÝò, (öýëï-çëéêßá-ðåñéï÷Þ êáôïéêßáò-íïìüò êáôïéêßáò), ÷ñçóéìïðïéçèåß ãéá ôç äéÜôìçóç ôïõ äåßãìáôïò. Áõôü ðñïêýðôåé äéüôé óå üëåò ôéò ðåñéðôþóåéò óýãêñéóçò êáôçãïñéêþí ìåôáâëçôþí ç äïêéìáóßá Pearson’s ÷2 åßíáé >0,05, åíþ óå üëåò ôéò ðåñéðôþóåéò óýãêñéóçò êáôçãïñéêÞò ìå áñéèìçôéêÞ ìåôáâëçôÞ ç äïêéìáóßá Independent Samples’ t test åßíáé >0,05, üðùò öáßíåôáé óôïí ðßíáêá 7.

ÓôáôéóôéêÝò Óõó÷åôßóåéò ÃåíéêÜ, ôï áí äßíåôáé óùóôÞ Þ ü÷é èåñáðåßá äåí öáßíåôáé íá óõó÷åôßæåôáé ìå ôï öýëï (÷2=0,597). Ôï ßäéï éó÷ýåé êáé ãéá ôï öýëï êáé ôïí áíáöåñüìåíï ëüãï ëÞøçò (÷2=0,346), ôç íüóï (÷2=0,777), ôï åßäïò ôçò ÷ïñçãïýìåíçò áãùãÞò (÷2=0,173), ôçí êáôçãïñéïðïßçóç ëÞøçò PPIs Þ H2-RAs (÷2=0,936) êáé ôï ÷ñüíï ëÞøçò ôçò áãùãÞò (t-test=0,839). Áêüìç, óõó÷Ýôéóç äåí ðñïêý-

ðôåé ìåôáîý ôïõ öýëïõ êáé ôïõ óõíïëéêïý ïéêïíïìéêïý êüóôïõò ôçò èåñáðåßáò (÷2=0,608), üðùò êáé ìåôáîý öýëïõ êáé áíþöåëùí äáðáíþí (÷2=0,49). ÔÝëïò, óõó÷Ýôéóç äåí õðÜñ÷åé ìåôáîý öýëïõ êáé ðñáãìáôïðïßçóçò Þ ü÷é åíäïóêüðçóçò (÷ 2=0,108) Þ áðïôåëÝóìáôïò åíäïóêüðçóçò (÷2=0,641). ÕðÜñ÷åé óáöÞò óõó÷Ýôéóç ìåôáîý ôïõ åßäïõò ôçò öáñìáêåõôéêÞò áãùãÞò êáé ôïõ ÷ñüíïõ ëÞøçò (t-test=2,6x10-11), õðÝñ ôçò ðéï ìáêñï÷ñüíéáò ëÞøçò H2-RAs, ìå ìÝóç äéáöïñÜ áðü ôç ëÞøç PPIs, 22,26 ìÞíåò. Äåí õðÜñ÷åé óõó÷Ýôéóç ìåôáîý åßäïõò öáñìáêåõôéêÞò áãùãÞò êáé óõíïëéêïý êüóôïõò (t-test=0,111), áëëÜ óõó÷Ýôéóç åìöáíßæåôáé ìåôáîý åßäïõò öáñìáêåõôéêÞò áãùãÞò êáé áíþöåëùí äáðáíþí (t-test=0,03), êáôáäåéêíýïíôáò ôá ìåãáëýôåñá óðáôáëçèÝíôá ðïóÜ óå H2-RAs, ðéèáíþò ëüãù ôïõ ìáêñïý ÷ñüíïõ ôçò áãùãÞò. Óõó÷Ýôéóç õðÜñ÷åé ìåôáîý ôïõ åßäïõò ôçò áãùãÞò êáé ôïõ ôñüðïõ ëÞøçò áõôÞò (÷2=0,008), õðÝñ ôçò äéáëåßðïõóáò ëÞøçò ôùí H2RAs. ÏñéáêÞ åìöáíßæåôáé ç óõó÷Ýôéóç ìåôáîý åßäïõò öáñìáêåõôéêÞò áãùãÞò êáé áíáöåñüìåíçò áéôßáò ëÞøçò (÷2=0,048). Óõó÷Ýôéóç õðÜñ÷åé ìåôáîý åßäïõò öáñìáêåõôéêÞò áãùãÞò êáé éó÷ýïò áõôÞò (÷2=0,002) õðÝñ ôçò ðåñéóóüôåñï ïñèÞò áãùãÞò, üôáí óõíôáãïãñáöïýíôáé PPIs, (39,1%), ðáñÜ üôáí óõíôáãïãñáöïýíôáé H2-RAs, (14,3%). Äåí õðÜñ÷åé óõó÷Ýôéóç ìåôáîý åßäïõò öáñìáêåõôéêÞò áãùãÞò êáé íüóïõ (÷2=0,144). Óõó÷Ýôéóç õðÜñ÷åé ìåôáîý öáñìáêåõôéêÞò áãùãÞò êáé åíäïóêüðçóçò (÷2=0,008), õðÝñ ôçò åíäïóêïðéêÞò äéåñåýíçóçò, ðéï óõ÷íÜ, ôùí ëáìâáíüíôùí PPIs, (26,9%), áðü ôïõò ëáìâÜíïíôåò H2-RAs, (0%). Åìöáíßæåôáé óõó÷Ýôéóç ìåôáîý ÷ñüíïõ ëÞøçò áãùãÞò êáé óõíå÷ïýò Þ äéáëåßðïõóáò ëÞøçò ôçò áãùãÞò (t-test=3,87x10-10), õðÝñ ôçò ðéï ìáêñï÷ñüíéáò ëÞøçò äéáëåßðïõóáò áãùãÞò, ãåãïíüò áíáìåíüìåíï. Óõó÷Ýôéóç åìöáíßæåôáé ìåôáîý ôïõ ÷ñüíïõ ëÞøçò áãùãÞò êáé ôçò áíáöåñüìåíçò áéôßáò ëÞøçò (one-way ANOVA significance= 3,8x10-3), õðÝñ ôçò ìáêñü÷ñïíçò ëÞøçò áãùãÞò

Ðßíáêáò 5. ÓôÜèìéóç äåßãìáôïò ùò ðñïò ôá äçìïãñáöéêÜ ôïõ óôïé÷åßá Öýëï Öýëï Çëéêßá Ðåñéï÷Þ Êáôïéêßáò Íïìüò Êáôïéêßáò

t=0,192 ÷2=0,269 ×2=0,295

Çëéêßá t=0,192 t=0,843 t=0,757

Ðåñéï÷Þ Êáôïéêßáò 2

÷ =0,269 t=0,843 ÷2=0,447

Íïìüò Êáôïéêßáò ÷2=0,295 t=0,757 ÷2=0,447 71


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Ó÷Þìá 9. Áíáöåñüìåíïò ëüãïò ëÞøçò.

óôéò ðåñéðôþóåéò áéóèÞìáôïò ðëçñüôçôáò êáé óõìðôùìÜôùí ÃÏÐ (ó÷Þìá 9), ãåãïíüò ðïõ öáíåñþíåé ôï Üôïðï ôçò èåñáðåõôéêÞò áíôéìåôþðéóçò ìüíï ìå PPIs Þ H2-RAs ôçò ëåéôïõñãéêÞò ãáóôñßôéäáò. Áõôü, Üëëùóôå, åðéâåâáéþíåôáé êáé óõãêñßíïíôáò ìå ôçí ßäéá ìÝèïäï ÷ñüíï ëÞøçò áãùãÞò êáé íüóïõ (significance=8,6x10-4). ÔÝëïò äåí õðÜñ÷åé óõó÷Ýôéóç ìåôáîý ÷ñüíïõ ëÞøçò áãùãÞò êáé ðñáãìáôïðïßçóçò Þ ü÷é åíäïóêüðçóçò (t-test=0,131), êÜôé ðïõ åðßóçò öáíåñþíåé ôçí áóôï÷ßá ôçò äéáãíùóôéêÞò áíôéìåôþðéóçò: áóèåíåßò ðïõ ðáñáðïíïýíôáé åðß ìáêñüí ãéá óõìðôùìáôïëïãßá äåí ðáñáðÝìðïíôáé ãéá åíäïóêüðçóç, üðùò èá Ýðñåðå. ÓçìáíôéêÞ óôáôéóôéêÞ óõó÷Ýôéóç õðÜñ÷åé ìåôáîý êüóôïõò êáé óõìðôùìáôïëïãßáò (one-way ANOVA significance=7x10-4), õðÝñ ôïõ ìåãÜëïõ êüóôïõò áíôéìåôþðéóçò ôçò ãáóôñßôéäáò. Ôï óõíïëéêü êüóôïò äåí öáßíåôáé íá óõó÷åôßæåôáé ìå ôçí ïñèüôçôá Þ ü÷é ôçò èåñáðåßáò (t-test=0,482). ÓçìáíôéêÞ óôáôéóôéêÞ óõó÷Ýôéóç õðÜñ÷åé êáé ìåôáîý êüóôïõò êáé íüóïõ (one-way ANOVA significance=7,3x10-3), õðÝñ ôïõ ìåãÜëïõ êüóôïõò áíôéìåôþðéóçò ôçò ëåéôïõñãéêÞò ãáóôñßôéäáò êáé ôçò ÃÏÐ. Åðßóçò, óçìáíôéêÞ óôáôéóôéêÞ óõó÷Ýôéóç õðÜñ÷åé ìåôáîý áðñüóöïñá äáðáíçèÝíôùí ÷ñçìÜôùí êáé óõìðôùìáôïëïãßáò (one-way ANOVA significance=3,5x10-4), õðÝñ ôïõ ìåãÜëïõ êüóôïõò 72

É. ÄñõãéáííÜêçò êáé óõí.

áíôéìåôþðéóçò ôïõ ïðéóèïóôåñíéêïý êáýóïõò êáé ôïõ áéóèÞìáôïò ðëçñüôçôáò. Ôï áðñüóöïñá äáðáíçèÝí ðïóü óõó÷åôßæåôáé ìå ôçí ïñèüôçôá Þ ü÷é ôçò èåñáðåßáò (t-test=1,16x10-7), öõóéêÜ õðÝñ ôùí ìåãáëõôÝñùí ðïóþí óôç ëáíèáóìÝíç áãùãÞ (ìÝóïò üñïò: 486,5 €/Üôïìï) êáé ôùí ìéêñüôåñùí óôçí ïñèÞ (ìÝóïò üñïò: 24,78 €/Üôïìï). ÓçìáíôéêÞ óôáôéóôéêÞ óõó÷Ýôéóç õðÜñ÷åé êáé ìåôáîý áðñüóöïñá äáðáíçèÝíôïò ðïóïý êáé íüóïõ (oneway ANOVA significance=0,003), õðÝñ ôïõ ìåãÜëïõ êüóôïõò áíôéìåôþðéóçò ôçò ëåéôïõñãéêÞò ãáóôñßôéäáò êáé ôçò ÃÏÐ. Óõó÷Ýôéóç äå öáßíåôáé íá õðÜñ÷åé ìåôáîý ôçò óõíå÷ïýò Þ äéáëåßðïõóáò áãùãÞò êáé ôçò óõìðôùìáôïëïãßáò (÷2=0,307) Þ ôçò ïñèüôçôáò ôçò èåñáðåßáò (÷2=0,102) Þ ôçò íüóïõ (÷2=0,125) Þ ôçò ðñáãìáôïðïßçóçò åíäïóêüðçóçò (÷2=0,356). Óõó÷Ýôéóç åìöáíßæåôáé ìåôáîý áíáöåñüìåíïõ óõìðôþìáôïò êáé ïñèüôçôáò áãùãÞò (÷2=0,017), êõñßùò õðÝñ ôçò ëáíèáóìÝíçò áíôéìåôþðéóçò ôïõ ïðéóèïóôåñíéêïý êáýóïõò (91,67%). ÓáöÞò óõó÷Ýôéóç õðÜñ÷åé ìåôáîý áíáöåñüìåíïõ óõìðôþìáôïò êáé åêôÝëåóçò åíäïóêüðçóçò Þ ü÷é (÷2=0,014), õðÝñ ôçò åêôÝëåóçò åíäïóêüðçóçò óå åðéãáóôñáëãßåò (óôï 20% áõôþí). ÅðéðñïóèÝôùò, äéáðéóôþèçêå, éó÷õñÞ óõó÷Ýôéóç ïñèÞò Þ ëáíèáóìÝíçò áíôéìåôþðéóçò óå ó÷Ýóç ìå ôç íüóï (÷2=6,8x10-8). Ç ðñïôåéíüìåíç èåñáðåõôéêÞ áãùãÞ ãéá ôçí ðñïóôáóßá ôïõ ãáóôñéêïý âëåííïãüíïõ áðü NSAIDs öáßíåôáé üôé Þôáí ïñèüôåñç óå áíôßèåóç ìå ôéò èåñáðåßåò ãéá ôéò ÃÏÐ, ÐÅ, ËåéôïõñãéêÞ Ãáóôñßôéäá. ÁíáëõôéêÜ áõôÜ ðáñïõóéÜæïíôáé óôï ó÷Þìá 10. ÔÝëïò äåí öáßíåôáé íá õðÜñ÷åé óõó÷Ýôéóç ìåôáîý íüóïõ êáé åêôÝëåóçò åíäïóêüðçóçò Þ ü÷é (÷2=0,38).

ÓõæÞôçóç Óå ìßá ìåëÝôç óôçí Áõóôñáëßá, ç ïðïßá èÝëçóå íá åîåôÜóåé ôçí ïñèüôçôá óõíôáãïãñÜöçóçò PPIs óå áóèåíåßò êáôÜ ôçí Ýîïäü ôïõò áðü ôï íïóïêïìåßï, üðïõ íïóçëåýèçêáí, óôï 62,9% áõôÞ äåí õðÜêïõå óôéò äéáìïñöùìÝíåò ïäçãßåò1. Óýìöùíá ìå ôçí ßäéá ìåëÝôç, ôï 66,9% õðÝóôç åíäïóêüðçóç êáé ìüíï óôï 59,1% äïêéìÜóôçêáí åðáñêþò ðñéí ïé H2-RAs1. Ôï äéêÜ ìáò áíôßóôïé÷á ðïóïóôÜ, ëáìâÜíïíôáò õðüøç ìüíï üóïõò ëáìâÜíïõí PPIs, åßíáé: 60,9%, 10,5%, 14,3% êáé


É. ÄñõãéáííÜêçò êáé óõí.

Ó÷Þìá 10. ÏñèÞ Þ ëáíèáóìÝíç áíôéìåôþðéóç óå ó÷Ýóç ìå ôç âáóéêÞ íüóï.

ôï ìåóáßï äéêáéïëïãåßôáé áðü ôçí áäõíáìßá åýêïëçò ðñüóâáóçò óå åíäïóêïðéêü éáôñåßï. Óôçí ìåëÝôç áõôÞ ôï 17,1% ôùí óõíôáãïãñáöïýìåíùí PPIs áöïñïýóå ðåñéðôþóåéò Þðéáò Þ ìÝôñéáò ÃÏÐ1, åíþ óôç äéêÞ ìáò Ýñåõíá, áí óõìðåñéëÜâïõìå ìüíï üóïõò ëáìâÜíïõí ôÝôïéá öÜñìáêá, ôï ðïóïóôü Þôáí 12%, ðéèáíþò ëüãù ôïõ üôé ïé áóèåíåßò ìáò ðñïÝñ÷ïíôáí áðü ôçí ÐÖÕ, åíþ ç ìåëÝôç áõôÞ áöïñïýóå êõñßùò íïóïêïìåéáêïýò áóèåíåßò1. Ôï ðïóïóôü ÷ïñÞãçóçò PPIs ÷ùñßò ðñïçãïýìåíç åðáñêÞ äïêéìÞ H2-RAs (üðïõ áõôÞ Þôáí äüêéìç) åßíáé 24% óýìöùíá ìå Üëëç ìåëÝôç, ç ïðïßá üìùò åß÷å óôáôéóôéêÜ óçìáíôéêü ìåãáëýôåñï ðïóïóôü áóèåíþí ìå ÃÏÐ áðü ôç äéêÞ ìáò (55% ðñïò 15,4%)22. Äéåèíþò, Üëëùóôå, ç Üóêïðç óõíôáãïãñÜöçóç PPIs áðïôåëåß ìåßæïí èÝìá, ùò ðñïò ôçí ïéêïíïìéêÞ ôïõ ðëåõñÜ, ùò ðñïò ôéò ìáêñï÷ñüíéåò äõíáôÝò ðáñåíÝñãåéåò ðïõ ìðïñïýí áõôïß íá Ý÷ïõí êáé ùò ðñïò ôçí ðáñÜëåéøç ôùí óõóôÜóåùí ìç öáñìáêåõôéêÞò èåñáðåßáò2,3. ÔÜóåéò áýîçóçò ðáñáôçñïýíôáé óå üëåò ôéò ÷þñåò, áíåðôõãìÝíåò êáé áíáðôõóóüìåíåò. Ãéá ðáñÜäåéãìá óôçí ÔáúâÜí áðü ôï 1997 ùò ôï 2000 ç óõíôáãïãñÜöçóç ôùí PPIs, ðåñßðïõ, äéðëáóéÜóôçêå19. Ôï Âñåôáíéêü Åèíéêü Éíóôéôïýôï ãéá ôçí ÊëéíéêÞ Áñéóôåßá (NICE) óõíéóôÜ ôïí åðáíÝëåã÷ï ôçò ÷ïñÞãçóçò üëùí ôùí PPIs êáé ðñïôåßíåé üôé ç êáôáíÜëùóÞ ôïõò èá ìðïñïýóå íá ìåéùèåß ùò 15% êáé áõôü

Ôüìïò 16, Ôåý÷ïò 2, 2004

èá ìåßùíå êáôÜ 40-50 åêáôïììýñéá £ áíÜ Ýôïò ôá öáñìáêåõôéêÜ Ýîïäá óå Áããëßá êáé Ïõáëëßá. ÐÜíôùò ç áëëáãÞ ôçò áãùãÞò óå H2-RAs öáßíåôáé åöéêôÞ, åéäéêÜ óôï ðåñéâÜëëïí ôçò ÐÖÕ óôéò áãñïôéêÝò êáé çìéáóôéêÝò ðåñéï÷Ýò ôçò ÅëëÜäáò, ëüãù ôçò ðñïóùðéêÞò åðáöÞò ôïõ éáôñïý ìå ôïí áóèåíÞ, åöüóïí êÜôé ôÝôïéï ðñáãìáôïðïéÞèçêå óå ìßá ìåëÝôç óôï Portland ôùí ÇíùìÝíùí Ðïëéôåéþí ôçò ÁìåñéêÞò. Ï ìÝóïò áñéèìüò óõíôáãþí PPIs áíÜ õðïøÞöéï áóèåíÞ ìåéþèçêå áðü 0,39 óôïõò 9 ìÞíåò, ðñéí áðü ôçí åíçìÝñùóç ôùí éáôñþí, óå 0,27 óôïõò 9 ìÞíåò ìåôÜ áðü ôçí ðáñÝìâáóç20. Åðßóçò, èåìéôÞ, óýìöùíá ìå ôç âéâëéïãñáößá, åßíáé êáé ç ðñïóðÜèåéá step-down èåñáðåßáò óôïõò áóèåíåßò ìå ÃÏÐ, ðïõ ëáìâÜíïõí èåñáðåõôéêÞ äüóç PPI äéò çìåñçóßùò, åöüóïí äåí Ý÷ïõí ðëÝïí óõìðôþìáôá, êáèþò ôï 79,5% áõôþí äåí áíáöÝñïõí õðïôñïðÞ óôïõò 6 ìÞíåò21. ÂÝâáéá óôç äéêÞ ìáò ìåëÝôç ôÝôïéïé áóèåíåßò äåí õðÞñ÷áí. Áêüìç êáëýôåñá ðáñïõóéÜæïíôáé ôá áðïôåëÝóìáôá ðáñüìïéáò ðáñÝìâáóçò óôï HongKong23. Ï ðëçèõóìüò ôçò õðáßèñïõ ôïí ïðïßï êõñßùò ìåëåôÞóáìå (áãñïôéêüò- çìéáóôéêüò), ðéèáíþò ëüãù ôçò áðüóôáóçò áðü ôá ìåãÜëá íïóïêïìåßá êáé ôïõ åëëåßììáôïò åíçìÝñùóÞò ôïõ, äåí õößóôáôáé åíäïóêïðéêÞ ìåëÝôç ôïõ áíùôÝñïõ ðåðôéêïý ôïõ óõóôÞìáôïò, áí êáé áõôü óõíéóôÜôáé óõ÷íÜ, (40,1%), ëüãù êõñßùò ôçò çëéêßáò ôïõ êáé äåõôåñåõüíôùò ôçò óõìðôùìáôïëïãßáò. Áíôßèåôá, äåí êáôáãñÜöçêå êáìéÜ ìç-áíáãêáßá åíäïóêüðçóç. ÌÝíåé ìå íÝåò ìåëÝôåò íá áðïäåé÷èåß ôï áí óõìâáßíåé ôï ßäéï óôïí áóôéêü ðëçèõóìü Þ áí óå áõôüí óõìâáßíåé ôï áíôßóôñïöï. ÐÜíôùò óå ìßá ìåëÝôç óôçí Åëâåôßá, óå ðëçèõóìü ðïõ åñ÷üôáí óå åðáöÞ ìå ôçí ÐÖÕ, ðñïÝêõøå üôé ôï 49% ôùí åíäïóêïðÞóåùí ðïõ ðáñáããÝëëïíôáí Þôáí ìç áíáãêáßåò14,15. Áßôéá ãéá áõôü õðÞñîáí ç ëåéôïõñãéêÞ ãáóôñßôéò êáé ç áðïôõ÷çìÝíç Þ ìåñéêþò ðåôõ÷çìÝíç ðñïçãïýìåíç áãùãÞ14,15. Áíôßèåôá, äåí ðáñáðÝìöèçêáí ãéá åíäïóêüðçóç ôï 11,8% ôùí áóèåíþí êáé ôï ðïóïóôü áõôü áíÝâçêå óôï 13,6% ãéá Üôïìá >65 åôþí14,15. Óå Üëëç ìåëÝôç ôï ôåëåõôáßï ðïóïóôü áíåñ÷üôáí óå 27,7% ãéá ôï óýíïëï ôùí áóèåíþí ôçò22. O êßíäõíïò êëéíéêÞò åðéêÜëõøçò ãáóôñéêÞò íåïðëáóßáò óôéò ðåñéðôþóåéò ðïõ õößóôáíôáé åîáñ÷Þò öáñìáêåõôéêÞ èåñáðåßá, ÷ùñßò ðñïçãïýìåíç åíäïóêüðçóç, åßíáé õðáñêôüò, åéäéêÜ üôáí ìéëÜìå ãéá áóèåíåßò ôçò ôñßôçò çëéêßáò, üðùò ç ðëåéïíü73


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

ôçôá áõôþí ôçò ìåëÝôçò ìáò. Óå ìßá ìåëÝôç ôï ðïóïóôü áõôü áíÞëèå óôï 35,5% óå áíôßèåóç ìå ôï 1,9% óôçí ðåñßðôùóç ÷ñÞóçò áíôéüîéíùí Þ êáìßáò èåñáðåßáò4. Óôï óçìåßï áõôü âïçèÜ ôï áí ï áóèåíÞò åßíáé >45 åôþí Þ áí Ý÷åé êÜðïéï áðü ôá ÷áñáêôçñéóôéêÜ ðïõ áðáéôïýí åðåßãïõóá áíôéìåôþðéóç, äéüôé, áí äåí óõìâáßíåé êÜôé áðü áõôÜ, ôá ðïóïóôÜ íåïðëáóéþí åßíáé ðïëý ÷áìçëÜ (<0,1%)5. ÐÜíôùò, óôï äéêü ìáò ðåñéâÜëëïí, ç áðïäï÷Þ áðü ôïí áóèåíÞ ôçò ãáóôñïïéóïöáãïóêüðçóçò ùò ìßáò åðåìâáôéêÞò äéáäéêáóßáò ðïõ èá ôïí áíáêïýöéæå áðü ôçí áãùíßá ôçò áêñéâïýò äéÜãíùóçò, ðáñÜ ôç óùìáôéêÞ ôáëáéðùñßá ðïõ áõôüò èá õößóôáôï, Þôáí ðïëý ðåñéïñéóìÝíç, áíôßèåôá áðü Üëëåò ìåëÝôåò8. ÅéäéêÜ, ùò ðñïò ôï èÝìá ôçò óõãêáôáíÜëùóçò PPIs Þ H2-RAs ìå NSAIDs, ôï ðïóïóôü åðéãáóôñéêïý Üëãïõò áíÝñ÷åôáé óôï 36%27. Ç èíçôüôçôá áðü NSAIDs áíÝñ÷åôáé óå 0,22%/Ýôïò êáé ï ó÷åôéêüò êßíäõíïò óå ó÷Ýóç ìå ôïõò ìç ÷ñÞóôåò óå 4,21, ìå ôá ìåãÝèç áõôÜ íá áöïñïýí êõñßùò áóèåíåßò ìå ÑåõìáôïåéäÞ Áñèñßôéäá êáé Ïóôåïáñèñßôéäá28. Åëðéäïöüñïé áñ÷éêÜ öÜíçêáí ïé åêëåêôéêïß COX-2 áíáóôïëåßò (ñïöåêïîßìðç, óåëåêïîßìðç -á’ ãåíåÜò êáé âáëäåêïîßìðç- â’ ãåíåÜò) óôç ìåßùóç ôùí óïâáñþí åðéðëïêþí áðü ôï áíþôåñï ãáóôñåíôåñéêü óýóôçìá, ìå ðáñüìïéá, áëëÜ ü÷é êáëýôåñç áðïôåëåóìáôéêüôçôá áðü ôá êëáóéêÜ NSAIDs29-31. ÂÝâáéá, ãéá ôç óåëåêïîßìðç, ç ïñéáêÜ óôáôéóôéêÜ óçìáíôéêÞ ìåßùóç ôùí óïâáñþí åðéðëïêþí áðü ôï áíþôåñï ðåðôéêü, áðü 1,27%/Ýôïò óå 0,44%/Ýôïò (p=0,04) óå áóèåíåßò, ðïõ äåí ëÜìâáíáí ÷áìçëÞ äüóç áóðéñßíçò (£325mg), ãéíüôáí óôáôéóôéêÜ ìç óçìáíôéêÞ ãéá áóèåíåßò ðïõ åëÜìâáíáí ÷áìçëÞ äüóç áóðéñßíçò (2,12% ðñïò 2,01% ìå p=0,92) [ìåëÝôç CLASS]32. ¼ìùò, ôá ðáñáðÜíù áöïñïýóáí áöåíüò õøçëÝò äüóåéò NSAIDs êáé áöåôÝñïõ äåí óõìðåñéëÜìâáíáí áðëÜ äõóðåðôéêÜ åíï÷ëÞìáôá êáé ïðéóèïóôåñíéêü êáýóï32. Ðáñüìïéá êñéôÞñéá åß÷å êáé ç ìåëÝôç VIGOR ãéá ôç ñïöåêïîßìðç, óôçí ïðïßá üìùò ç ìåßùóç áðïäåß÷èçêå óôáôéóôéêÜ óçìáíôéêÞ (1,4 ðñïò 0,6%/Ýôïò ìå p <0,005)33. Óôç ìåëÝôç áõôÞ óôáôéóôéêÜ óçìáíôéêÞ Þôáí êáé ç ìåßùóç ãåíéêÜ êÜèå êëéíéêÞò åðéðëïêÞò áðü ôï ãáóôñåíôåñéêü (4,5 ðñïò 2,1%/ Ýôïò ìå p<0,001)33. ÅéäéêÜ ôï èÝìá ôçò ðñüêëçóçò ëåéôïõñãéêÞò äõóðåøßáò áðü NSAIDs äåí Ý÷åé äéåñåõíçèåß ðëÞñùò, áëëÜ êáé åäþ ç èåñáðåßá ìå PPIs öáßíåôáé áðïåëåóìáôéêÞ85-87. ÐÜíôùò, åðåé74

É. ÄñõãéáííÜêçò êáé óõí.

äÞ íïóçëåýåôáé ãéá íüóï ôïõ áíþôåñïõ ãáóôñåíôåñéêïý 1 óôïõò (80-300), ðïõ ëáìâÜíïõí NSAIDs53-72, ç ÷ïñÞãçóç ãáóôñïðñïóôáóßáò óå üëïõò äåí èåùñåßôáé óùóôÞ ôáêôéêÞ. ÐÜíôùò, ç ðñáêôéêÞ áõôÞ åßíáé óùóôÞ óßãïõñá ãéá áóèåíåßò ìå éóôïñéêü ðåðôéêïý Ýëêïõò, üðïõ ï êßíäõíïò ãéá ðåðôéêü Ýëêïò ôåôñáðëáóéÜæåôáé62,73,74,76-84. Ôï ßäéï éó÷ýåé ãéá áóèåíåßò >80 åôþí êáé ãéá áóèåíåßò >60 åôþí, ðïõ ëáìâÜíïõí õøçëÝò äüóåéò Þ ëáìâÜíïõí êáé êïñôéêïóôåñïåéäÞ52. Óýã÷õóç õðÜñ÷åé ùò ðñïò ôç ÷ñÞóç áíôéðçêôéêþí, áëëÜ èåëÞóáìå íá ôá óõìðåñéëÜâïõìå óôïí áëãüñéèìü ìáò52. ÃåíéêÜ, ùò ðñïò ôçí åêñßæùóç ôïõ Helicobacter pylori óôç ëÞøç NSAIDs, åðéêñáôïýí áíôéêñïõüìåíåò áðüøåéò52. Ùò ðñïò ôçí ðñïóôáóßá áðü óõìâÜìáôá ôïõ áíþôåñïõ ãáóôñåíôåñéêïý óõóôÞìáôïò óå áóèåíåßò ðïõ ëáìâÜíïõí NSAIDs êáé Ý÷ïõí éóôïñéêü ôÝôïéùí, óáöþò ïé PPIs ðñïóôáôåýïõí ðïëý êáëýôåñá áðü ôç ìéóïðñïóôüëç êáé ôïõò H2-RAs. Ãéá ðáñÜäåéãìá, ôá ðïóïóôÜ ðñïóôáóßáò áðü åðáíåîÝëêùóç ôïõ äùäåêáäáêôýëïõ, óå ôÝôïéåò ðåñéðôþóåéò, åßíáé 3% ãéá ôçí ïìåðñáæüëç, 10% ãéá ôçí ìéóïðñïóôüëç êáé 12% ãéá ôçí ïìÜäá åëÝã÷ïõ óå äéðëÞ ôõöëÞ ìåëÝôç åëåã÷üìåíç ìå ïìÜäá placebo34. Áêüìç, öÜíçêå óå Üëëç ðñïïðôéêÞ, ôõ÷áéïðïéçìÝíç, äéðëÞ ôõöëÞ ìåëÝôç üôé ç óåëåêïîßìðç õðåñôåñåß ùò ðñïò ôá óõìâÜìáôá áðü ôï áíþôåñï ãáóôñåíôåñéêü áðü ôï óõíäõáóìü äéêëïöåíÜêçò êáé ïìåðñáæüëçò35. ÂÝâáéá, ç äéêëïöåíÜêç ßóùò áðïôåëåß ó÷åôéêÜ áóöáëÝò ãéá ôï ãáóôñåíôåñéêü NSAID êáé ôï áðïôÝëåóìá åîçãåßôáé Ýôóé36. ÅéäéêÜ ç áìéãÞò ëåéôïõñãéêÞ äõóðåøßá92, ìå êýñéá óõìðôþìáôá ôïí ôõìðáíéóìü êáé ôï áßóèçìá ðëçñüôçôáò ìåôÜ áðü êáôáíÜëùóç ìéêñÞò ðïóüôçôáò ôñïöÞò, áðïôåëåß Ýíá èÝìá äýóêïëá äéåñåõíÞóéìï ìå ôá óõíÞèç åñãáóôçñéáêÜ ìÝóá52. Áðïôåëåß ôï áßôéï óôï 60% ôùí äõóðåøéþí, áëëÜ óôéò ìåëÝôåò êáôáëáìâÜíåé ìéêñüôåñï ðïóïóôü äéüôé ðïëý ìéêñüôåñï ðïóïóôü ôùí áóèåíþí ðáñïõóéÜæåôáé ãéá ôï ëüãï áõôü óôïí éáôñü88-89. ÅðåéäÞ ç äéêÞ ìáò ìåëÝôç åß÷å ôõ÷áßï äåßãìá áóèåíþí, áëëÜ ü÷é ãáóôñåíôåñïëïãéêþí áóèåíþí, èá áíáìÝíáìå ìéá õøçëüôåñç óõ÷íüôçôÜ ôçò áðü ôï 15,4% ðïõ âñÞêáìå. H óõíÞèçò áãùãÞ ðåñéëáìâÜíåé ôá êïéíÜ áðïäåêôÜ ðñïêéíçôéêÜ44 öÜñìáêá, ìå Þ ÷ùñßò H2-RAs. ÕðÜñ÷ïõí åíäåßîåéò üôé, ôá ìéêñÜ, óõ÷íÜ ãåýìáôá êáé ç áðïöõãÞ ëéðáñþí ôñïöþí âïçèïýí40,41. ÌéêñÜ ðëåïíåêôÞ-


Ôüìïò 16, Ôåý÷ïò 2, 2004

É. ÄñõãéáííÜêçò êáé óõí.

ìáôá öáßíïíôáé íá ðñïóöÝñïõí ïé PPIs êáé ç èåñáðåßá åêñßæùóçò ôïõ H. Pylori. ¼ëá ôá ðáñáðÜíù öÜñìáêá Ý÷ïõí áðïäåé÷èåß áíþôåñá áðü ôï placebo43. Óå åììÝíïíôá óõìðôþìáôá, öáßíåôáé íá âïçèÜ ç ÷ïñÞãçóç ôùí íåüôåñùí åêëåêôéêþí áíáóôïëÝùí åðáíáðñüóëçøçò óåñïôïíßíçò (SSRIs), üðùò ç ðáñïîåôßíç45, Þ åêëåêôéêþí áãùíéóôþí ôçò óåñïôïíßíçò óôïõò õðïäï÷åßò 1D 46-49. Ç óéëíôåíáößëç (áíáóôïëÝáò ôçò öùóöïäéåóôåñÜóçò ôýðïõ 5)50 êáé ç êëïíéäßíç (êåíôñéêüò áãùíéóôÞò á2 õðïäï÷Ýùí)51 ìåéþíïõí ôï ìõúêü ôüíï ôïõ óôïìÜ÷ïõ êáé åßíáé öÜñìáêá ðïõ ßóùò óôï ìÝëëïí áðïäåé÷èïýí ÷ñÞóéìá. Óôç äéêÞ ìáò ìåëÝôç óå êáíÝíá áðü ôïõò ðÜó÷ïíôåò áðü ëåéôïõñãéêÞ äõóðåøßá äåí åß÷å ðñïóôåèåß ðñïêéíçôéêÞ áãùãÞ. Ç ëåéôïõñãéêÞ äõóðåøßá óõíäõÜæåôáé óôï 46% ôùí áóèåíþí ìå óýíäñïìï åõåñÝèéóôïõ åíôÝñïõ êáé áðáéôåßôáé ç õðïøßá ôïõ éáôñïý ôçò ÐÖÕ ãéá ôç äéÜãíùóç êáé ôïõ óõíäñüìïõ áõôïý ìáæß ìå ôç ëåéôïõñãéêÞ äõóðåøßá42. Ùò ðñïò ôï óõíïëéêü êüóôïò ôçò ÷ïñçãçèåßóáò èåñáðåßáò áõôü áíÝñ÷åôáé óå 319,63 €/Üíèñùðï-Ýôïò êáé åßíáé ìéêñüôåñï ìå ôçí êáôáíÜëùóç Ñáíéôéäßíçò (205,6 €/Üíèñùðï-Ýôïò 34%) êáé õøçëüôåñï ìå ðñáæüëåò (525,78 €/ÜíèñùðïÝôïò- 66%). Ãéá ôïõò áóèåíåßò ðïõ êáôáíáëþíïõí äéáëåéðüíôùò ôçí áãùãÞ ôïõò õðïëïãßóèçêå ôï êüóôïò ìå âÜóç ôçí êáôáíÜëùóç óôï 50% ôùí çìåñþí. Óáöþò óôïõò õðïëïãéóìïýò ìáò õðåéóÝñ÷ïíôáé ôá óöÜëìáôá ôçò ìç óùóôÞò ìíÞìçò ôïõ áêñéâïýò ÷ñüíïõ ëÞøçò ôçò áãùãÞò, ôçò èåþñçóçò ôïõ óçìåñéíïý (êáé öèçíüôåñïõ) êüóôïõò êáé ôïõ õðïëïãéóìïý ôïõ êüóôïõò áíÜ çìÝñá, ìå âÜóç ôï ïéêïíïìéêÜ ðéï óõìöÝñïí óêåýáóìá áðü ðëåõñÜò áñéèìïý äéóêßùí êáé ôéìÞò. ¼ëá áõôÜ ôåßíïõí íá êïóôïëïãÞóïõí ëéãüôåñï ôç èåñáðåßá áðü ôçí ðñáãìáôéêüôçôá. Ç ïéêïíïìéêÞ æçìßá áíÝñ÷åôáé óôï óýíïëï ôùí 60.328,46 € õðïëïãßæïíôáò ìüíï ôï ÷ñïíéêü äéÜóôçìá óôï ïðïßï ç ëÞøç Þôáí áðïëýôùò áäéêáéïëüãçôç. Ôï ðïóü áõôü áðïôåëåß ôï 80,9% ôùí ÷ñçìÜôùí, ðïõ óõíïëéêÜ êüóôéóáí ïé öáñìáêåõôéêÝò áãùãÝò (74.580,96 €) ôçò ìåëÝôçò. ÄéáöïñåôéêÜ, áõôü ìåôáöñÜæåôáé óå 258,55 €/ Üíèñùðï-Ýôïò, ðïõ Ýñ÷åôáé óå åðáöÞ ìå ôçí ÐÖÕ. Ãéá ôç Ñáíéôéäßíç áõôü åßíáé 189,16 €/ÜíèñùðïÝôïò êáé ãéá ôéò ðñáæüëåò 395,29 €/ÜíèñùðïÝôïò. Ç åöéêôÞ ìåßùóç ôùí ïéêïíïìéêþí áðùëåéþí, èåùñþíôáò ôá ðáñáðÜíù ðïóÜ, îåðåñíÜ êáôÜ ðïëý ôï óôü÷ï ôçò êáôÜ 15% ìåßùóçò ôçò

óõíôáãïãñÜöçóçò PPIs ðïõ èÝôåé ôï NICE93.

ÓõìðåñÜóìáôá ÓõíïëéêÜ èá ðáñáôçñïýóáìå ôéò åîÞò áäõíáìßåò óôçí ðñáêôéêÞ ôùí éáôñþí: 1) ÁíåðáñêÞò äéåñåýíçóç ðñéí ôçí Ýíáñîç áãùãÞò, 2) Ìç ôÞñçóç ôùí ïäçãéþí ãéá ôçí áíôéìåôþðéóç ôùí ðáñáðÜíù íüóùí, 3) Õðåñ÷ñçóéìïðïßçóç ôùí PPIs, 4) ÁíåðáñêÞò åðáíÝëåã÷ïò ôùí áóèåíþí óôï ÷ñüíï, 5) ¢ãíïéá êáé ìç ðáñÝìâáóç ùò ðñïò ôç ëïéðÞ áãùãÞ ôùí áóèåíþí, ðïõ óõ÷íÜ åðéâáñýíåé ôéò íüóïõò áõôÝò. Ç äéáðßóôùóç äåí ìðïñåß íá åßíáé Üëëç áðü ôçí åðéôáêôéêÞ áíÜãêç åíüò éáôñïý óõíôïíéóôÞ êáé õðåýèõíïõ ãéá ôï óýíïëï ôùí ðñïâëçìÜôùí õãåßáò ôïõ áóèåíÞ, ìå ôïí ïðïßï ç åðáöÞ èá îåöåýãåé áðü ôç óõíÞèç -äõóôõ÷þò- ðåñéóôáóéáêÞ êáé áðïóðáóìáôéêÞ1 áíôéìåôþðéóç. Óôï äßëçììá áí ðñÝðåé íá ðáñáðÝìøïõìå ãéá åíäïóêüðçóç Þ ü÷é ðÝñá áðü ôá ðáñáðÜíù áò óêåöèïýìå ôïí áõîçìÝíï êßíäõíï íåïðëáóßáò óå çëéêßåò ìåãáëýôåñåò ôùí 45 åôþí, ðïõ óõíÞèùò áöïñïýí ìåãÜëï ðïóïóôü ôçò åñãáóßáò ìáò êáé ôï üôé ï áóèåíÞò åßíáé ìßá éäéáßôåñç ìïíÜäá êáé ü÷é áðüëõôá ôìÞìá ìéáò óôáôéóôéêÞò ïìÜäáò16. Ôï óðáôáëïýìåíï ðïóü óå öáñìáêåõôéêÝò áãùãÝò ìç êáôÜëëçëåò êáé óå ðïëëÝò ðåñéðôþóåéò åíôåëþò ðåñéôôÝò åßíáé éêáíü íá áíáäåßîåé ôï ðñüâëçìá ôçò åóöáëìÝíçò óõíôáãïãñÜöçóçò ôÝôïéùí ïõóéþí. ÐÜíôùò, üðùò öáßíåôáé êáé áðü ôç óõíïëéêÞ áíáóêüðçóç ìåëåôþí óå êáìéÜ ðåñßðôùóç äåí åßíáé ìå âåâáéüôçôá ãíùóôÞ ìßá áäéáìöéóâÞôçôá áðïôåëåóìáôéêüôåñç èåñáðåßá ãéá ôéò ðáñáðÜíù íüóïõò. Ôá óõìðåñÜóìáôá åßíáé áêüìç ðéï áóáöÞ üôáí óõíõðïëïãßóïõìå ôï ïéêïíïìéêü êüóôïò ôùí íïóçìÜôùí áõôþí.18 Óå ãåíéêÝò ãñáììÝò äéáöáßíåôáé ôï ðüóï ìåãÜëç åßíáé ç áíÜãêç ïé éáôñïß ôçò ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò íá åíçìåñþíïíôáé ãéá ôéò äéåèíþò áíáãíùñéóìÝíåò ïäçãßåò êáé íá óõììïñöþíïíôáé ìå áõôÝò Ýôóé þóôå íá ðáñÝ÷ïõí áðïôåëåóìáôéêÞ äéá÷åßñéóç ôùí ãáóôñïïéóïöáãéêþí íïóçìÜôùí. 75


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É. ÄñõãéáííÜêçò êáé óõí.

69. Singh G. Recent considerations in nonsteroidal anti-inflammatory drug gastropathy. Am J Med, 105(Suppl):31S-8S, 1998. 70. Singh G, Triadafilopoulos G. Epidemiology of NSAID induced gastrointestinal complications. J Rheumatol, 26:18–24, 1999. 71. Langman MJ, Jensen DM, Watson DJ, Harper SE, Xhao P-L, Quan H. Incidence of upper gastrointestinal perforations, symptomatic ulcers and bleeding (PUBS). Rofecoxib compared to NSAIDs. JAMA, 282:20:1929-33, 1999. 72. Bombardardier C, Laine L, Reicin A, et al. Comparison of upper gastrointestinal toxicity in rofecoxib and naproxen in patients with rheumatoid arthritis. N Engl J Med, 343:1520–1528, 2000. 73. Hawkey CJ. Non-steroidal anti-inflammatory drugs and ulcersfacts and figures multiply, but do they add up? BMJ, 300:278-84, 1990. 74. Gabriel SE, Jaakkimainen L, Bombardier C. Risk for serious gastrointestinal complications related to use of nonsteroidal anti-inflammatory drugs. A meta-analysis. Ann Intern Med, 115:787-96, 1991. 75. García Rodríguez LA, Jick H. Risk of upper gastrointestinal bleeding and perforation associated with individual non-steroidal anti-inflammatory drugs. Lancet, 343:769-72, 1994. 76. Langman MJ, Weil J, Wainwright P, et al. Risks of bleeding peptic ulcer associated with individual non-steroidal anti-inflammatory drugs. Lancet, 343:1075-8, 1994. [comment in: Lancet, 343:1051–1052, 1994]. 77. Elliott SL, Yeomans ND, Buchanan RR, Smallwood RA. Efficacy of 12 months misoprostol as prophylaxis against NSAID-induced gastric ulcers. A placebo-controlled trial. Scand J Rheumatol, 23:171-6, 1994. 78. Lanas AI, Remacha B, Esteva F, Sainz R. Risk factors associated with refractory peptic ulcers. Gastroenterology, 109:1124-33, 1995. 79. Hansen JM, Hallas J, Lauritsen JM, Bytzer P. Non-steroidal anti-inflammatory drugs and ulcer complicationsa risk factor analysis for clinical decision-making. Scand J Gastroenterol, 31:126-30, 1996. 80. Simon LS, Hatoum HT, Bittman RM, Archambault WT, Polisson RP. Risk factors for serious nonsteroidal-induced gastrointestinal complications- regression analysis of the MUCOSA trial. Fam Med, 28:204-10, 1996. 81. Perez-Gutthann S, García Rodríguez LA, Raiford DS. Individual nonsteroidal antiinflamma-

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tory drugs and other risk factors for upper gastrointestinal bleeding and perforation. Epidemiology, 8:18-24, 1997. Wolfe MM, Lichtenstein DR, Singh G. Gastrointestinal toxicity of nonsteroidal antiinflammatory drugs. N Engl J Med, 340:1888-99, 1999. Weil J, Langman MJ, Wainwright P, et al. Peptic ulcer bleedingaccessory risk factors and interactions with non-steroidal anti-inflammatory drugs. Gut, 46:27-31, 2000. Hernandez Diaz S, García Rodríguez LA. Association between non-steroidal anti-inflammatory drugs and upper gastrointestinal bleed/perforation: an overview of epidemiological studies published in the 1990s. Arch Intern Med, 2000 (in press). Bijlsma JWJ. Treatment of endoscopy-negative NSAID induced upper gastrointestinal symptoms with cimetidinean international multicentre collaborative study. Aliment Pharmacol Ther, 2S:75-83, 1988. Bijlsma JWJ. Treatment of NSAID-induced gastrointestinal lesions with cimetidinean international multicentre collaborative study. Aliment Pharmacol Ther, 2S:85-96, 1988. Van Groenendael JH, Markusse HM, Dijkmans BA, Breedveld FC. The effect of ranitidine on NSAID related dyspeptic symptoms with and without peptic ulcer disease of patients with rheumatoid arthritis and osteoarthritis. Clin Rheumatol, 15:450-6, 1996. Drossman DA, Li Z, Andruzzi E, Temple RD, Talley NJ, Thompson WG, et al. US householder survey of functional gastrointestinal disorders: prevalence, sociodemography, and health impact. Dig Dis Sci, 38:1569-80, 1993. Jones RH, Lydeard SE, Hobbs FD, Kenkre JE, Williams EI, Jones SJ, et al. Dyspepsia in England and Scotland. Gut, 31:401-5, 1990. Åëëçíéêü ºäñõìá Ãáóôñåíôåñïëïãßáò & ÄéáôñïöÞò 2002. Harris RA, Kuppermann M, Richter JE. Prevention of recurrences of erosive reflux esophagitis: a cost- effectiveness analysis of maintenance proton pump inhibition. Am J Med, 102: 78-88, 1997. Simrén M, Tack J. Functional dyspepsia: evaluation and treatment Gastroenterology Clinics North Am, 32:577-99, 2003. Arasaradnam RP, Woodward T, Parrack L, Bartlett J, Bolton RP. Audit of proton pump inhibitor (PPI) prescribing: are NICE guidelines being followed? Clin Med, 3:387-8, 2003.

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ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Ê. Óõñéáíüò êáé óõí.

ÂÑÁÂÅÕÈÅÉÓÁ ÅËÅÕÈÅÑÇ ÁÍÁÊÏÉÍÙÓÇ AWARDED FREESTANDING PAPER Primary Heatlh Care, Volume 16, Number 2, 80-86, 2004 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 16, Ôåý÷ïò 2, 80-86, 2004

Ïé áíáêñßâåéåò óôçí ðéóôïðïßçóç ôçò áéôßáò èáíÜôïõ Êá÷ëÜí Óõñéáíüò1, Âéêôùñßá ËÝôôá2, ÊëåïðÜôñá ÊïõñÜêç2, ÄÞìçôñá ÊáêëáìÜíïõ-Âñåôôïý3

Ðåñßëçøç Ôá ðéóôïðïéçôéêÜ èáíÜôïõ åßíáé óçìáíôéêÞ ðçãÞ ðëçñïöïñéþí êáé ïé óôáôéóôéêÝò íïóçñüôçôáò êáé èíçóéìüôçôáò, ðïõ ÷ñçóéìïðïéïýíôáé ãéá ôçí áíÜðôõîç ðñïãñáììÜôùí õãåßáò, âáóßæïíôáé ó’ áõôÝò ôéò ðëçñïöïñßåò. Óêïðüò ôçò ìåëÝôçò åßíáé ç êáôáãñáöÞ ôçò óõ÷íüôçôáò åìöÜíéóçò ôõðéêþí êáé ïõóéáóôéêþí áíáêñéâåéþí óôá ðéóôïðïéçôéêÜ èáíÜôïõ êáé ç áîéïëüãçóç ôçò åðÜñêåéÜò ôïõò óôçí ðáñï÷Þ ðëçñïöïñéþí ãéá ôéò áéôßåò èáíÜôïõ. Õëéêü êáé ìÝèïäïò: êÜíáìå áíÜëõóç 86 ðéóôïðïéçôéêþí èáíÜôïõ, 49 áðü ôá êÝíôñá õãåßáò êáé 37 áðü íïóïêïìåéáêÝò ìïíÜäåò ôçò ÄõôéêÞò Ìáêåäïíßáò. Ïé ãéáôñïß ðïõ ðéóôïðïßçóáí ôï èÜíáôï óôá êÝíôñá õãåßáò Þôáí Ãåíéêïß ãéáôñïß êáé áãñïôéêïß ãéáôñïß. Ôá ðéóôïðïéçôéêÜ áðü ôéò íïóïêïìåéáêÝò ìïíÜäåò Þôáí áðü ãéáôñïýò äéÜöïñùí åéäéêïôÞôùí. Áñ÷éêÜ åîåôÜóáìå ôç óõììüñöùóç ôùí ãéáôñþí ìå ôéò ïäçãßåò ðïõ áíáãñÜöïíôáé ðÜíù óôá Ýíôõðá ðéóôïðïßçóçò êáé óôç óõíÝ÷åéá êÜíáìå áíÜëõóç, âáóéóìÝíç óôéò ïäçãßåò ðéóôïðïßçóçò èáíÜôïõ ðïõ äçìïóéåýôçêáí óôï American Family Physician ôï 1997, åðåéäÞ ç ÅëëÜäá õéïèåôåß ôï áìåñéêÜíéêï ðñüôõðï ðéóôïðïßçóçò. ÁðïôåëÝóìáôá: Ôï ðéï óõ÷íü êïéíü óöÜëìá ðïõ åíôïðßóáìå óôá ðéóôïðïéçôéêÜ èáíÜôïõ Þôáí ç ÷ñÞóç ôçò êáñäéáêÞò Þ ôçò êáñäéïáíáðíåõóôéêÞò áíáêïðÞò ùò áéôßá èáíÜôïõ. Áõôüò ï üñïò åßíáé ìéá ðåñéãñáöÞ ôçò ýðáñîçò íåêñïý êáé äåí ðáñÝ÷åé êáìéÜ ðëçñïöïñßá ùò ðñïò ôïí õðïêñõðôüìåíï ôñáõìáôéóìü Þ íüóï ç äéáäéêáóßá, áñìüäéá ãéá ôçí ðñüêëçóç ôïõ èáíÜôïõ. Áõôüò ï üñïò ÷ñçóéìïðïéåßôáé ùò áéôßá èáíÜôïõ óå 32% ôùí ðéóôïðïéçôéêþí ôùí ÊÕ êáé óå 58% ôùí ðéóôïðïéçôéêþí ôùí íïóïêïìåéáêþí ìïíÜäùí. Åíôïðßóáìå åðßóçò óöÜëìáôá áëëçëïõ÷ßáò ùò ðñïò ôçí Üìåóç, ôçí åíäéÜìåóç êáé ôçí õðïêñõðôüìåíç áéôßá èáíÜôïõ óå 47% ôùí ðéóôïðïéçôéêþí, áíôáãùíéóôéêÝò áéôßåò èáíÜôïõ óå 19%, ìç êáôáãñáöÞ ôïõ ÷ñïíéêïý äéáóôÞìáôïò ìåôáîý Ýíáñîçò ôçò íüóïõ êáé ôïõ èáíÜôïõ óå 94% êáé Üëëåò áíáêñßâåéåò, ðïõ ðáñïõóéÜæïíôáé êáé áíáëýïíôáé. ÓõìðåñÜóìáôá: Ôá ðéóôïðïéçôéêÜ èáíÜôïõ äåí ìðïñïýí, ìå ôïí ôñüðï üðùò óõìðëçñþíïíôáé óÞìåñá, íá áðïôåëïýí áîéüðéóôç ðçãÞ ãéá óôáôéóôéêÝò ìåëÝôåò. Áðáéôåßôáé ßóùò ìéá åðåîåñãáóßá åèíéêþí êáôåõèõíôÞñéùí ïäçãéþí ãéá íá îåðåñáóôåß áõôÞ ç áäõíáìßá.

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ÅÊÁ ÊïæÜíçò, 2ÊÝíôñï Õãåßáò ÓéÜôéóôáò ÊïæÜíçò, 3Ã.Í. ÊïæÜíçò

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ÅéóáãùãÞ Ôá óôïé÷åßá ãéá ôç èíçóéìüôçôá, ðïõ áíôëïýíôáé áðü ôá ðéóôïðïéçôéêÜ èáíÜôïõ áðïôåëïýí ôïí áêñïãùíéáßï ëßèï ôùí åðéäçìéïëïãéêþí ìåëåôþí óå Ýíá ðëçèõóìü. Åêôüò áðü ôïí ðñïóäéïñéóìü ôçò åðßðôùóçò ôùí äéÜöïñùí áéôéþí ôïõ èáíÜôïõ óå Ýíáí ðëçèõóìü, áõôÜ ôá óôïé÷åßá ÷ñçóéìïðïéïýíôáé ãéá ôïí êáèïñéóìü óôñáôçãéêþí ðñüëçøçò, ãéá ôç äéáíïìÞ ôùí ðüñùí ôçò õãåéïíïìéêÞò ðåñßèáëøçò, ãéá ôç ÷ñçìáôïäüôçóç ðñïãñáììÜôùí Ýñåõíáò ôùí äéÜöïñùí íïóçìÜôùí êáé ôÝëïò ãéá ôçí áîéïëüãçóç ôçò áðïôåëåóìáôéêüôçôáò ôùí äçìüóéùí ðñïãñáììÜôùí õãåßáò1,2. Ï âáèìüò åãêõñüôçôáò ôùí óôïé÷åßùí ðïõ áíôëïýíôáé áðü ôá ðéóôïðïéçôéêÜ èáíÜôïõ åîáñôÜôáé áðü ôçí ËÝîåéò êëåéäéÜ: ¢ìåóç áéôßá èáíÜôïõ, Ìç÷áíéóìüò èáíÜôïõ, Ôñüðïò ôïõ èáíÜôïõ, Ðéóôïðïßçóç èáíÜôïõ, Õðïêñõðôüìåíç áéôßá èáíÜôïõ ÕðïâëÞèçêå: Ç åñãáóßá õðïâëÞèçêå ùò åëåýèåñç áíáêïßíùóç óôï 16ï ÐáíåëëÞíéï ÓõíÝäñéï ÃåíéêÞò ÉáôñéêÞò (Êùò, 14-18 Áðñéëßïõ 2004) êáé âñáâåýèçêå áðü ôçí ÅðéôñïðÞ Êñßóçò, Äçìïóéåýåôáé ìå êïéíÞ áðüöáóç ôçò ÓõíôáêôéêÞò ÅðéôñïðÞò ôïõ Ðåñéïäéêïý êáé ôçò ÏñãáíùôéêÞò ÅðéôñïðÞò ôïõ Óõíåäñßïõ Õðåýèõíïò áëëçëïãñáößáò: Êá÷ëÜí Óõñéáíüò, Áãßáò ÐáñáóêåõÞò 23, 501 00, ÊïæÜíç, Ôçë.: (24610) 21065, (24610) 32988


Ê. Óõñéáíüò êáé óõí.

Ôüìïò 16, Ôåý÷ïò 2, 2004

óôï 0,90, åíþ ãéá ôï êáñäéáããåéáêü óýóôçìá åßíáé ðåñßðïõ 0,286. Ïé ìåëÝôåò áðü ôç Óïõçäßá áíáöÝñïõí üôé Summary áõôÞ ç åõáéóèçóßá åßíáé ìåéùìÝíç ãéá Aim: To study the frequency of essential inaccuracies in death certificates and áóèÝíåéåò, üðùò ï óáê÷áñþäçò äéáâÞthe evaluation of their sufficiency to provide information on the causes of death. Study population-Method: eighty-six death certificates were analysed, 49 from ôçò êáé ç ñåõìáôéêÞ íüóïò ôçò êáñhealth centres and 37 from hospitals of Western Macedonia. The doctors that äéÜò7. Óôéò áíáêñßâåéåò ðïõ åìöáíßæïcertified the death in the centres of health were General Doctors and rural íôáé óôá ðéóôïðïéçôéêÜ èáíÜôïõ áðïdoctors. Doctors of different specialties completed the certificates from the äßäïíôáé ïé ðëáóìáôéêÝò áõîçôéêÝò hospitals. The assessment of the certificates was based on the directives of ôÜóåéò ôçò èíçóéìüôçôáò óôïí êáñêßcertification of death, published in the journal "American Family Physician" in 1997, as a result of Greece adopting the American model of certification of íï ôïõ ðñïóôÜôç8-10. death. Results: The most frequent common error in death certificates was the ÐïëëÜ óöÜëìáôá óôçí ðéóôïðïßçuse of cardiac or cardio-respiratory arrest as a cause of death. This term is óç ôïõ èáíÜôïõ ðñïÝñ÷ïíôáé áðü ôç used as a cause of death in 32% of certificates from the health centres and in óýã÷õóç ôùí üñùí “áéôßá” êáé “ôñü58% of certificates from hospitals. Sequence errors were identified in 47% of ðïò” ôïõ èáíÜôïõ, áðü ôçí ðåñéãñácertificates, competitive causes of death in 19%, absence of time intervals between the beginning of illness and death, in 94%. Other inaccuracies are öÞ ôçò áêïëïõèßáò ôùí íïóïëïãéêþí presented and analyzed. Conclusions: the way, in which death certificates are êáôáóôÜóåùí áðü ôçí õðïêñõðôüìåbeing completed today, cannot constitute a reliable source for statistical studiíç Ýùò ôçí Üìåóç áéôßá ôïõ èáíÜôïõ es. Perhaps there is a need for national guidelines to improve the accuracy of êáé áðü ôç óýã÷õóç ìåôáîý ôçò õðïdeath certificates. êñõðôüìåíçò êáé óõìâÜëëïõóáò ðÜèçKey Words: Death certificates, Cause of death, Immediate cause of death, Mechanism of death, Manner of Death, Underlying cause of death óçò3. Ïé ãéáôñïß ìå ðåñéóóüôåñç ðñïóï÷Þ ìðïñïýí íá îåêáèáñßóïõí ôçí êÜèå Ýííïéá áð´ áõôÝò êáé íá óõìâÜëëïõí óôç âåëôßùóç ôùí åðéäçìéïëïãéáêñßâåéá ìå ôçí ïðïßá äéåíåñãåßôáé ç ðéóôïðïßç- êþí ìåëåôþí Üëëá êáé íá åêðëçñþóïõí ôï ÷ñÝïò óç, ç ïðïßá åßíáé áñìïäéüôçôá ôùí ãéáôñþí, ç ðïõ Ý÷ïõí áðÝíáíôé óôéò ïéêïãÝíåéåò ôùí èáíüðëåéïøçößá ôùí ïðïßùí äåí ëáìâÜíåé åðßóçìç íôùí, ðñïóöÝñïíôáò êáëýôåñç êáôáíüçóç, ôé åõêáôÜñôéóç óôïí êáèïñéóìü ôçò áéôßáò êáé ôïõ èýíåôáé ãéá ôï èÜíáôï ôïõ áíèñþðïõ ôïõò1. Ç ðáñïýóá ìåëÝôç ðñïóðáèåß íá áîéïëïãÞôñüðïõ ôïõ èáíÜôïõ3. Ïé Ýñåõíåò äåß÷íïõí üôé ìüíï ôï 56% ôùí åéäéêåõïìÝíùí êáé 56,9% ôùí óåé ôçí åðÜñêåéá ôùí ðéóôïðïéçôéêþí èáíÜôïõ, åéäéêåõìÝíùí ãéáôñþí åßíáé óå èÝóç íá äéáôõðþ- ðïõ óõìðëçñþíïíôáé áðü ôïõò ãéáôñïýò ôùí õãåéïóïõí óùóôÜ ôçí áéôßá èáíÜôïõ2,3, ãé’ áõôü ïé íïìéêþí ìïíÜäùí, óôçí ðáñï÷Þ ðëçñïöïñéþí ãéá åñåõíçôÝò ðñÝðåé íá åßíáé éäéáßôåñá ðñïóåêôéêïß ôéò áéôßåò èáíÜôïõ. ÅîåôÜæåé ôç óõ÷íüôçôá åìöÜóôç ÷ñÞóç ôùí ðéóôïðïéçôéêþí èáíÜôïõ ãéá ôéò íéóçò ôõðéêþí êáé ïõóéáóôéêþí áíáêñéâåéþí ó’ áéôéïëïãéêÝò ìåëÝôåò ëüãù ôçò äõíáôüôçôáò óç- áõôÜ ôá ðéóôïðïéçôéêÜ êáé ôç óõììüñöùóç ôùí ìáíôéêÞò áðüêëéóçò áðü ôçí ðñáãìáôéêüôçôá. ãéáôñþí ìå ôéò ïäçãßåò, ðïõ áíáãñÜöïíôáé óôá ÐïëëÝò ìåëÝôåò áó÷ïëÞèçêáí ìå âáèìü åãêõ- Ýíôõðá ðéóôïðïßçóçò. ñüôçôáò ôùí ðéóôïðïéçôéêþí èáíÜôïõ óôçí ðáñï÷Þ ðëçñïöïñéþí ãéá ôéò åðéäçìéïëïãéêÝò ìåëÝôåò. Óôéò ÇÐÁ ïé ìåëÝôåò áðÝäåéîáí üôé ôá ðé- Ðëçèõóìüò ìåëÝôçò - ÌÝèïäïò óôïðïéçôéêÜ èáíÜôïõ áðïäßäïõí 24,3% ðåñéóóüôåñïõò èáíÜôïõò óôç óôåöáíéáßá íüóï óôï ãåíéÕëéêü ôçò ìåëÝôçò åßíáé 86 ðéóôïðïéçôéêÜ êü ðëçèõóìü êáé ðåñßðïõ ôï äéðëÜóéï ðïóïóôü èáíÜôïõ, ðïõ åðéëÝ÷èçêáí ôõ÷áßá áðü ôá ÊÝóôïõò çëéêéùìÝíïõò4,5. Áðü ôç óýãêñéóç ôùí áé- íôñá Õãåßáò êáé ôá Íïóïêïìåßá ôïõ Íïìïý Êïôéþí èáíÜôïõ ðïõ áíáãñÜöïíôáé óôá ðéóôïðïéç- æÜíçò. Ôá 49 ðéóôïðïéçôéêÜ åß÷áí óõìðëçñùèåß ôéêÜ ìå ôá áðïôåëÝóìáôá ôçò íåêñïøßáò ðñïÝêõ- áðü ãåíéêïýò êáé áãñïôéêïýò ãéáôñïýò ôùí ÊÝøå üôé ç åõáéóèçóßá áõôþí ôùí ðéóôïðïéçôéêþí íôñùí Õãåßáò êáé ôá õðüëïéðá 37 áðü íïóïêïóôïí åíôïðéóìü ôçò áéôßáò èáíÜôïõ åßíáé ãåíéêþò ìåéáêïýò ãéáôñïýò. Ç ìåëÝôç ðåñéïñßæåôáé óôçí ãýñù óôá 0,47 êáé êõìáßíåôáé áðü óýóôçìá óå åîÝôáóç ôùí ðéóôïðïéçôéêþí èáíÜôïõ, ÷ùñßò íá óýóôçìá. Ãéá ôï íåõñïëïãéêü óýóôçìá åßíáé ãýñù áíáæçôÞóåé ðëçñïöïñßåò áðü ôïõò éáôñéêïýò öáThe inaccuracies in the certification of cause of death. K. Syrianos, Victoria Letta, Kleopatra Kouraki, Dimitra Kaklamanou-Vrettou

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ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Ê. Óõñéáíüò êáé óõí.

êÝëïõò Þ áðü Üëëåò ðçãÝò. Äåí åîåôÜæåé ôç ó÷Ýóç ôùí äåäïìÝíùí ìå ôïõò èáíüíôåò, áëëÜ ôç ó÷Ýóç ôùí äåäïìÝíùí ìåôáîý ôïõò. Ãé áõôü ôï óêïðü ÷ñçóéìïðïéåß êñéôÞñéá áîéïëüãçóçò âáóéóìÝíá óôéò ðñïôÜóåéò ôïõ Ðáãêüóìéïõ Ïñãáíéóìïý Õãåßáò. ÁõôÜ ôá êñéôÞñéá áðïôåëïýíôáé áðü Ýîé åñùôÞìáôá: 1) Áí õðÞñîå ìéá áðïäåêôÞ áéôßá ôïõ èáíÜôïõ, 2) ÅÜí ïé ìç÷áíéóìïß ôïõ èáíÜôïõ ðïõ êáôáãñÜöçêáí, åîçãÞèçêáí åðáñêþò áðü ìéá õðïêñõðôüìåíç áéôßá ôïõ èáíÜôïõ, 3) Áí õðÞñîáí ïðïéáäÞðïôå óöÜëìáôá áëëçëïõ÷ßáò, 4) Áí åìöáíßóèçêáí óôç ëßóôá áíôáãùíéóôéêÝò áéôßåò ôïõ èáíÜôïõ, 5) Áí êáôáãñÜöçêáí ôá ÷ñïíéêÜ äéáóôÞìáôá ìåôáîý ôçò Ýíáñîçò ôçò ðÜèçóçò êáé ôïõ èáíÜôïõ, êáé 6) Áí êáôáãñÜöçêáí ïðïéåóäÞðïôå Üëëåò áêáôÜëëçëåò ðëçñïöïñßåò11. ÅðåéäÞ ç ÅëëÜäá ÷ñçóéìïðïéåß ôï áìåñéêÜíéêï ðñüôõðï ðéóôïðïßçóçò èáíÜôïõ ÷ñçóéìïðïéÞóáìå ôéò ïäçãßåò, ðïõ äçìïóéåýôçêáí óôï American Family Physician ôï 1997 êáé Üëëåò âéâëéïãñáöéêÝò áíáöïñÝò ãéá ôïí áêñéâÞ ïñéóìü ôùí ÷ñçóéìïðïéçìÝíùí üñùí 3,12. Ïé ÷ñçóéìïðïéçìÝíïé üñïé öáßíïíôáé óôï ðáñÜñôçìá óôïí ðßíáêá 2. Ãéá ôçí ôáîéíüìçóç ôùí óöáëìÜôùí, ðïõ åíôïðßóôçêáí ÷ñçóéìïðïéÞóáìå ôï óýóôçìá, ðïõ ÷ñçóéìïðïßçóå ç Myers óôéò ìåëÝôåò ôçò ðïõ äéåíÝñãçóå óôïí ÊáíáäÜ12. Ç ÷ñçóéìïðïéçìÝíç ïñïëïãßá êáé ç ôáîéíüìçóç ôùí óöáëìÜôùí öáßíïíôáé óôïí ðßíáêá 2 êáé 3 ôïõ ðáñáñôÞìáôïò. Ðåñéïñßóáìå ôçí åîÝôáóÞ ìáò óôïí åíôïðéóìü ôñéþí ìåßæïíùí óöáëìÜôùí êáé ôñéþí åëÜóóïíùí óöáëìÜôùí. Ùò ìåßæïíá óöÜëìáôá èåùñÞóáìå ôçí åìöÜíéóç ôïõ ìç÷áíéóìïý èáíÜôïõ, ùò áéôßá èáíÜôïõ, ÷ùñßò íá óõíïäåýåôáé áðü ìéá õðïêñõðôüìåíç áéôßá, ôá óöÜëìáôá áëëçëïõ÷ßáò êáé ôçí åìöÜíéóç, óôï ðñþôï ìÝñïò ôçò ëßóôáò,

äõï áíôáãùíéóôéêþí áéôéþí èáíÜôïõ êáé ùò åëÜóóïíá óöÜëìáôá ôç ìç áíáãñáöÞ ôïõ ÷ñïíéêïý äéáóôÞìáôïò áðü ôçí åìöÜíéóç ôçò ðÜèçóçò ìÝ÷ñé ôï èÜíáôï, ôç ÷ñÞóç óõíôïìåýóåùí êáé ôç ÷ñÞóç ôïõ ìç÷áíéóìïý èáíÜôïõ, áëëÜ óõíïäåõüìåíïõ áðü ìéá ëïãéêÞ õðïêñõðôüìåíç áéôßá. Ùò ìç÷áíéóìü èáíÜôïõ èåùñïýìå, ëüãïõ ÷Üñç, ôçí êáñäéáêÞ áíåðÜñêåéá, ôçí áíáðíåõóôéêÞ áíåðÜñêåéá ê.ëð. Äå èåùñïýìå ôçí êáñäéáêÞ áíáêïðÞ ìç÷áíéóìü èáíÜôïõ, äéüôé ðñüêåéôáé áðëþò ãéá ìéá ðåñéãñáöÞ ôïõ èáíÜôïõ.

ÁðïôåëÝóìáôá ÔïõëÜ÷éóôïí Ýíá ìåßæïí óöÜëìá åíôïðßóèçêå óôï 58% ôïõ óõíüëïõ ôùí ðéóôïðïéçôéêþí, óôï 12 % åß÷å áíáöåñèåß ï ìç÷áíéóìüò èáíÜôïõ ùò áéôßá, óôï 47% õðÞñ÷å åóöáëìÝíç áëëçëïõ÷ßá êáé óôï 19% åìöáíßóèçêáí ôïõëÜ÷éóôïí äõï áíôáãùíéóôéêÝò áéôßåò èáíÜôïõ óôï ðñþôï ìÝñïò ôïõ ðéóôïðïéçôéêïý. Óå ü,ôé áöïñÜ ôá åëÜóóïíá óöÜëìáôá, Ýíá ôïõëÜ÷éóôïí åìöáíßæåôáé óôï 95% üëùí ôùí ðéóôïðïéçôéêþí, óôï 94% äåí õðÞñ÷áí ÷ñïíéêÜ äéáóôÞìáôá, óôï 44% Ýãéíå ÷ñÞóç óõíôïìåýóåùí êáé óôï 19% åìöáíéæüôáí ï ìç÷áíéóìüò èáíÜôïõ, ìáæß ìå ìéá ëïãéêÞ õðïêñõðôüìåíç áéôßá. ÕðÞñ÷áí êÜðïéåò äéáöïñÝò óôç óõ÷íüôçôá åìöÜíéóçò óöáëìÜôùí ìåôáîý ôùí ãéáôñþí ôùí êÝíôñùí õãåßáò êáé ôùí ãéáôñþí ôùí íïóïêïìåßùí. Äåí ðñï÷ùñÞóáìå óå ìéá ëåðôïìåñÞ óôáôéóôéêÞ áíÜëõóç áõôþí ôùí äéáöïñþí, äéüôé áõôü äåí Þôáí ï óêïðüò ôçò ìåëÝôçò, üìùò öáßíåôáé ãåíéêÜ üôé ïé ãéáôñïß ôùí ÊÝíôñùí Õãåßáò êÜíïõí ëéãüôåñá óöÜëìáôá óôçí ðéóôïðïßçóç ôïõ èáíÜôïõ.

Ðßíáêáò 1. Ï áñéèìüò, ôï ðïóïóôü êáé ôï åßäïò ôùí óöáëìÜôùí ðïõ åíôïðßóèçêáí óôá ðéóôïðïéçôéêÜ èáíÜôïõ ôùí Ê.Õ. êáé ôùí íïóïêïìåßùí Åßäïò óöÜëìáôïò Ìåßæïíá óöÜëìáôá Ìüíï ï ìç÷áíéóìüò ÅóöáëìÝíç áëëçëïõ÷ßá ÁíôáãùíéóôéêÝò áéôßåò ÔïõëÜ÷éóôïí Ýíá

ÊÝíôñá Õãåßáò

Íïóïêïìåßá

Ãåíéêü Óýíïëï

Áñéèìüò

Ðïóïóôü

Áñéèìüò

Ðïóïóôü

Áñéèìüò Ðïóïóôü

02 20 06 29

04% 41% 12% 59%

08 20 10 21

22% 54% 27% 57%

10 40 16 50

12% 47% 19% 58%

47 22 08 47

96% 45% 16% 96%

34 16 08 35

92% 43% 22% 95%

81 38 16 82

94% 44% 19% 95%

ÅëÜóóïíá óöÜëìáôá Äåí áíáöÝñïíôáé ÷ñïíéêÜ äéáóôÞìáôá ×ñÞóç óõíôïìåýóåùí Ìç÷áíéóìüò + ËïãéêÞ õðïêñõðôüìåíç áéôßá ÔïõëÜ÷éóôïí Ýíá 82


Ôüìïò 16, Ôåý÷ïò 2, 2004

Ê. Óõñéáíüò êáé óõí. Ðßíáêáò 2. Ïñïëïãßá ôïõ ðéóôïðïéçôéêïý èáíÜôïõ12 ¼ñïò

Ïñéóìüò

ÄÞëùóç áéôßáò èáíÜôïõ ÓõìðëÞñùóç ôïõ ìÝñïõò É êáé ôïõ ìÝñïõò ÉÉ ôïõ ðéóôïðïéçôéêïý èáíÜôïõ Ç Õðïêñõðôüìåíç áéôßá ôïõ èáíÜôïõ Ç êáôÜóôáóç Þ ç ðÜèçóç ðïõ ðñïêÜëåóå ôçí áëõóßäá ôùí ãåãïíüôùí ðïõ ïäçãïýí óôï èÜíáôï. Ç ðéï áðüìáêñç ÷ñïíéêÜ, áëëÜ áéôéïëïãéêÜ õðåýèõíç êáôÜóôáóç. Ç ¢ìåóç áéôßá ôïõ èáíÜôïõ Ç ôåëéêÞ åðéðëïêÞ ðïõ ðñïêëÞèçêå ùò áðïôÝëåóìá ôçò õðïêñõðôüìåíçò áéôßáò ôïõ èáíÜôïõ, ðïõ åìöáíßæåôáé íá óõíäÝåôáé óôåíÜ ìå ôç ÷ñïíéêÞ óôéãìÞ ôïõ èáíÜôïõ êáé íá ôï ðñïêáëåß Üìåóá ÅíäéÜìåóç áéôßá ôïõ èáíÜôïõ Ìéá ðÜèçóç Þ êáôÜóôáóç ðïõ åìöáíßóèçêå, ùò áðïôÝëåóìá ôçò õðïêñõðôüìåíçò áéôßáò ôïõ èáíÜôïõ áëëÜ äåí Þôáí ç ôåëéêÞ åðéðëïêÞ Þ ç Üìåóç áéôßá ôïõ èáíÜôïõ Ï ìç÷áíéóìüò ôïõ èáíÜôïõ Ìéá öõóéïëïãéêÞ Þ âéï÷çìéêÞ äéáôáñá÷Þ äéÜìåóùí ôçò ïðïßáò ç áéôßá ôïõ èáíÜôïõ áóêåß ôç èáíáôçöüñá åðßäñáóÞ ôçò (ð.÷. ç êáñäéáêÞ Þ áíáðíåõóôéêÞ áíáêïðÞ) êáé äåí ðñÝðåé íá ÷ñçóéìïðïéçèåß ùò õðïêñõðôüìåíç áéôßá ôïõ èáíÜôïõ. Ìç åéäéêÞ êáôÜóôáóç Ìéá áíáôïìéêÞ Þ ëåéôïõñãéêÞ äéáôáñá÷Þ ðïõ ìðïñåß íá Ý÷åé ðåñéóóüôåñåò áðü ìéá ðéèáíÞ áéôßá (ð.÷. ç óçøáéìßá, áéìïññáãßá, êáñäéáêÞ áíåðÜñêåéá, íåöñéêÞ áíåðÜñêåéá êëð.) êáé äåí ðñÝðåé íá ÷ñçóéìïðïéçèåß ùò õðïêñõðôüìåíç áéôßá ôïõ èáíÜôïõ. Ï ôñüðïò ôïõ èáíÜôïõ Ìéá ôáîéíüìçóç ôïõ èáíÜôïõ ðïõ âáóßæåôáé óôïí ôýðï ôùí êáôáóôÜóåùí ðïõ ðñïêáëïýí ôï èÜíáôï êáé óôéò ðåñéóôÜóåéò êÜôù áðü ôéò ïðïßåò åìöáíßóèçêáí (ð.÷. öõóéêüò èÜíáôïò, ðïõ ïöåßëåôáé ìüíï óå ìéá ðÜèçóç, áíèñùðïêôïíßá, áõôïêôïíßá, áôý÷çìá ôõ÷áßùí Þ Üãíùóôçò áéôéïëïãßáò)

Ðßíáêáò 3. Ïñéóìüò ôùí ìåßæïíùí êáé åëÜóóïíùí óöáëìÜôùí óôá ðéóôïðïéçôéêÜ èáíÜôïõ12 Ï ôýðïò ôïõ óöÜëìáôïò Ìåßæïíá óöÜëìáôá Åìöáíßæåôáé óôç ëßóôá ï ìç÷áíéóìüò ôïõ èáíÜôïõ ÷ùñßò ìéá õðïêñõðôüìåíç áéôßá ÁíÜñìïóôç áëëçëïõ÷ßá Þ óöÜëìáôá áëëçëïõ÷ßáò

ÁíôáãùíéóôéêÝò áéôßåò ÅëÜóóïíá óöÜëìáôá ÓõíôìÞóåéò Áðïõóßá ÷ñïíéêþí äéáóôçìÜôùí ÁíáöÝñåôáé ùò áéôßá ï ìç÷áíéóìüò ôïõ èáíÜôïõ, áëëÜ áêïëïõèåßôáé áðü ìéá ëïãéêÞ õðïêñõðôüìåíç áéôßá èáíÜôïõ

Ïñéóìüò Ï Ìç÷áíéóìüò ôïõ èáíÜôïõ Þ ìéá ìç åéäéêÞ êáôÜóôáóç åìöáíßæïíôáé óôç ëßóôá ùò õðïêñõðôüìåíç áéôßá ôïõ èáíÜôïõ Ç áêïëïõèßá ôùí ãåãïíüôùí äåí âãÜæåé íüçìá Þ ç õðïêñõðôüìåíç áéôßá ôïõ èáíÜôïõ äåí åìöáíßæåôáé óôç ëßóôá óôï ôåëåõôáßï ðåäßï ôïõ ìÝñïõò É Äýï Þ ðåñéóóüôåñåò áéôéïëïãéêÜ áíåîÜñôçôåò, åéäéêÝò ðáèÞóåéò åìöáíßæïíôáé óôç ëßóôá óôï ìÝñïò É ×ñçóéìïðïéïýíôáé ÓõíôìÞóåéò ãéá ôïí ðñïóäéïñéóìü ôùí ðáèÞóåùí Äåí áíáãñÜöïíôáé ôá ÷ñïíéêÜ äéáóôÞìáôá óôï ìÝñïò É êáé ÉÉ ôçò ëßóôáò ×ñÞóç ôïõ ìç÷áíéóìïý èáíÜôïõ ìáæß ìå ìéá áéôéïëïãéêÜ êáôÜëëçëç óõãêåêñéìÝíç áéôßá èáíÜôïõ

Ç ðñþôç åíôýðùóç ðïõ äçìéïõñãåßôáé áðü ôçí åîÝôáóç ôùí ðéóôïðïéçôéêþí èáíÜôïõ åßíáé ç ðïëý ìåãÜëç ÷ñÞóç ôïõ üñïõ “êáñäéáêÞ áíáêïðÞ”, ùò áéôßá èáíÜôïõ êáé ìåñéêÝò öïñÝò ÷ùñßò áíáöïñÜ óå ìéá õðïêñõðôüìåíç áéôßá ðïõ ôçí ðñïêáëåß. Ç êáñäéáêÞ áíáêïðÞ åìöáíßæåôáé óôï 32% ôùí ðéóôïðïéçôéêþí áðü ôá ÊÝíôñá Õãåßáò êáé óôï 58% ôùí ðéóôïðïéçôéêþí ôùí íïóïêïìåßùí.

ÅíäéáöÝñïí åðßóçò ðáñïõóéÜæåé ç óõ÷íüôçôá åìöÜíéóçò ôïõ üñïõ “ãåñïíôéêüò ìáñáóìüò” óôá ðéóôïðïéçôéêÜ èáíÜôïõ ôùí èáíüíôùí ìåãáëýôåñçò çëéêßáò. Áõôüò ï üñïò ÷ñçóéìïðïéåßôáé ðïëý ðéï óõ÷íÜ áðü ôïõò ãéáôñïýò ôùí ÊÝíôñùí Õãåßáò (óôï 71% ôùí ðéóôïðïéçôéêþí èáíüíôùí çëéêßáò Üíù ôùí 85 åôþí). ÁíáëõôéêÜ üëá ôá óöÜëìáôá ðïõ åíôïðßóèçêáí åìöáíßæïíôáé óôïí ðßíáêá 1 êáé óôï ó÷Þìá 83


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Ê. Óõñéáíüò êáé óõí.

1 êáé 2. Óôïõò ðßíáêåò 4, 5 êáé 6 ðáñïõóéÜæïíôáé ÷áñáêôçñéóôéêÜ äåßãìáôá.

ÓõæÞôçóç ÊÜíïíôáò ìéá áíáóêüðçóç óôç äéåèíÞ âéâëéïãñáößá äéáðéóôþíïõìå üôé ôï ðñüâëçìá ìå ôéò áíáêñßâåéåò óôçí ðéóôïðïßçóç ôïõ èáíÜôïõ åìöáíßæåôáé óå üëåò ôéò ÷þñåò ìå äéáöïñåôéêÞ Ýíôáóç. Ïé ìåëÝôåò áíáöÝñïõí ðïóïóôü óöÜëìáôïò, ðïõ êõìáßíåôáé áðü 29%13,14 Ýùò êáé 62,9%15-18. Óå ìéá ìåëÝôç áíáöÝñèçêå üôé åíôïðßóèçêáí 55 óöÜëìáôá óå 45 ðéóôïðïéçôéêÜ èáíÜôïõ19. Ç óõ÷íüôç-

ÊÝíôñá õãåßáò Õ 60% 50% 40% 30% 20% 10% 0%

ôá åìöÜíéóçò óöáëìÜôùí ðïéêßëëåé êáé ìåôáîý ôùí íïóçìÜôùí êáé çëéêéáêþí ïìÜäùí. Ëéãüôåñá óöÜëìáôá åìöáíßæïíôáé óôéò êáêïÞèåéåò 4,15, ðåñéóóüôåñá óôá êáñäéáããåéáêÜ4-6 êáé óôéò ìåãáëýôåñåò çëéêßåò1,20. Ç óõ÷íüôçôá åìöÜíéóçò ôïõ ïñïý “ãåñïíôéêüò ìáñáóìüò” óôï äåßãìá ìáò (71% óôá Üôïìá Üíù ôùí 85 åôþí) åßíáé õðåñâïëéêÞ. Óå ìéá ìåëÝôç ðïõ áó÷ïëÞèçêå ì’ áõôü ôï æÞôçìá áíáöÝñåôáé üôé ìüíï ôï 5% ôùí èáíÜôùí áôüìùí Üíù ôùí 90 åôþí, ìðïñåß íá áðïäïèåß óå ãåñïíôéêü ìáñáóìü êáé åêöñÜæåôáé ç Üðïøç üôé ç ÷ñÞóç áõôïý ôïõ üñïõ ó’ áõôÝò ôéò ðåñéðôþóåéò áíôéóôïé÷åß óôïí üñï “Üãíùóôçò áéôéïëïãßáò”21.

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100% 80% 60% 40% 20%

ÔïõëÜ÷éóôïí

ÅóöáëìÝíç ÁíôáãùíéóôéêÝò Á íáöÝñåôáé

Ýíá óöÜëìá

áëëçëïõ÷ßá

áéôßåò

ìüíï ï ìç÷áíéóìüò

Ó÷Þìá 1. Ç óõ÷íüôçôá åìöÜíéóçò ìåßæïíùí óöáëìÜôùí óôá ðéóôïðïéçôéêÜ èáíÜôïõ.

0%

¸íá ôïõëÜ÷éóôïí ×ùñßò ÷ñïíéêÜ óöÜëìá

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Ìç÷áíéóìüò êáé

óõíôïìåýóåùí õðïêñõðôüìåíç áéôßá

Ó÷Þìá 2. Ç óõ÷íüôçôá åìöÜíéóçò åëÜóóïíùí óöáëìÜôùí óôá ðéóôïðïéçôéêÜ èáíÜôïõ.

Ðßíáêáò 4. ÐáñÜäåéãìá Á ôùí óöáëìÜôùí óôç óõìðëÞñùóç ôùí ðéóôïðïéçôéêþí èáíÜôïõ ÐáñÜäåéãìá óõìðëÞñùóçò Áéôßá èáíÜôïõ

×ñïíéêü äéÜóôçìá áðü ôçí Ýíáñîç Ýùò ôï èÜíáôï

Åßäïò ôïõ óöÜëìáôïò Ìåßæïí

ÅëÜóóïí

É. Ðñþôï ìÝñïò: Áéôßá èáíÜôïõ (óùìáôéêÞ): Íüóïò ç íïóçñÜ êáôÜóôáóç ðñïêáëÝóáóá êáô’ åõèåßáí ôï èÜíáôï Áéôßá èáíÜôïõ (á) ÊáñäéáêÞ ÁíáêïðÞ — Ç êáñäéáêÞ áíáêïðÞ áðïôåëåß ðåñéãñáöÞ ôïõ èáíÜôïõ êáé ü÷é ôçí áéôßá Ïöåéëüìåíç óå Þ áðüôïêïò — ÁíáöÝñåôáé ï ìç÷áíéóìüò Äåí áíáöÝñåôáé (â) ÁíáðíåõóôéêÞ áíåðÜñêåéá ôïõ èáíÜôïõ ÷ùñßò ôçí áéôßá ôï ÷ñïíéêü äéÜóôçìá áðü ôçí Ýíáñîç Ýùò ôï èÜíáôï Ïöåéëüìåíç óå Þ áðüôïêïò (ã) - - - - - ÉÉ. Äåýôåñï ìÝñïò: ¢ëëåò áîéüëïãåò ðáèïëïãéêÝò åêäçëþóåéò: (á) Áéìïññáãßá Êáôþôåñïõ ðåðôéêïý (â) ÊÅÊ (ã) — 84

×ñçóéìïðïéåßôáé óõíôüìåõóç


Ôüìïò 16, Ôåý÷ïò 2, 2004

Ê. Óõñéáíüò êáé óõí.

Ç äéáöïñÜ óôç óõ÷íüôçôá åìöÜíéóçò óöáëìÜôùí ìåôáîý ôùí ãåíéêþí êáé íïóïêïìåéáêþí ãéáôñþí Ý÷åé ðáñáôçñçèåß êáé óå ìåëÝôåò áðü ôï äéåèíÞ ÷þñï. Ïé ìåëÝôåò áðü ôç Âñåôáíßá áíáöÝñïõí ìåãáëýôåñç óõ÷íüôçôá åìöÜíéóçò óöáëìÜôùí ðéóôïðïßçóçò óôïõò íïóïêïìåéáêïýò ãéáôñïýò, üðïõ åíôïðßæïíôáé ëÜèç óôï 62% ôùí ðéóôïðïéçôéêþí ôùí íïóïêïìåéáêþí ãéáôñþí Ýíáíôé 38% ôùí ãåíéêþí ãéáôñþí22,23. Ìå êáôÜëëçëåò ðáñåìâÜóåéò ìðïñåß ôï ðïóïóôü óöáëìÜôùí íá ìåéùèåß óçìáíôéêÜ. Óå ìéá ìåëÝôç ðáñÝìâáóçò óôïí ÊáíáäÜ, óå Ýíá ó÷åôéêÜ ìéêñü ÷ñïíéêü äéÜóôçìá, óçìåéþèçêå ìåßùóç ôçò

óõ÷íüôçôáò åìöÜíéóçò óöáëìÜôùí áðü 32,9% óå 15,7%12.

ÓõìðåñÜóìáôá Ç óõ÷íüôçôá åìöÜíéóçò óöáëìÜôùí óôá ðéóôïðïéçôéêÜ èáíÜôïõ åìöáíßæåôáé óçìáíôéêÜ ìåãÜëç. Áõôü ôï ãåãïíüò ôá êÜíåé ëéãüôåñï áîéüðéóôá ãéá ôçí ðáñï÷Þ ðëçñïöïñéþí ãéá óôáôéóôéêÝò ìåëÝôåò, êÜôé ðïõ ðñÝðåé íá ëÜâïõìå óïâáñÜ õðüøç. Áðü ôçí Üëëç ðëåõñÜ ðñÝðåé íá õðÜñ÷ïõí ðáñåìâÜóåéò ãéá ôçí áíôéìåôþðéóç áõôÞò

Ðßíáêáò 5. ÐáñÜäåéãìá  ôùí óöáëìÜôùí óôç óõìðëÞñùóç ôùí ðéóôïðïéçôéêþí èáíÜôïõ ÐáñÜäåéãìá óõìðëÞñùóçò Áéôßá èáíÜôïõ

×ñïíéêü äéÜóôçìá áðü ôçí Ýíáñîç Ýùò ôï èÜíáôï

Åßäïò ôïõ óöÜëìáôïò Ìåßæïí

ÅëÜóóùí

É. Ðñþôï ìÝñïò: Áéôßá èáíÜôïõ (óùìáôéêÞ): Íüóïò ç íïóçñÜ êáôÜóôáóç ðñïêáëÝóáóá êáô’ åõèåßáí ôïí èÜíáôï Áéôßá èáíÜôïõ (á) Ãåñïíôéêüò Ìáñáóìüò — Ïöåéëüìåíç óå Þ áðüôïêïò Äåí áíáöÝñåôáé (â) Ôåôñáðëçãßá — ôï ÷ñïíéêü äéÜóôçìá áðü ôçí Ýíáñîç Ýùò ôï èÜíáôï Ïöåéëüìåíç óå Þ áðüôïêïò Äåí õðÜñ÷åé (ã) ÃåñïíôéêÞ ¢íïéá — ëïãéêÞ áëëçëïõ÷ßá ÉÉ. Äåýôåñï ìÝñïò: ¢ëëåò áîéüëïãåò ðáèïëïãéêÝò åêäçëþóåéò: (á) — (â) — (ã) —

Ðßíáêáò 6. ÐáñÜäåéãìá à ôùí óöáëìÜôùí óôç óõìðëÞñùóç ôùí ðéóôïðïéçôéêþí èáíÜôïõ ÐáñÜäåéãìá óõìðëÞñùóçò Áéôßá èáíÜôïõ

×ñïíéêü äéÜóôçìá áðü ôçí Ýíáñîç Ýùò ôï èÜíáôï

Åßäïò ôïõ óöÜëìáôïò Ìåßæïí

ÅëÜóóùí

É. Ðñþôï ìÝñïò: Áéôßá èáíÜôïõ (óùìáôéêÞ): Íüóïò ç íïóçñÜ êáôÜóôáóç ðñïêáëÝóáóá êáô’ åõèåßáí ôïí èÜíáôï Áéôßá èáíÜôïõ Äåí áíáöÝñåôáé (á) Óôåöáíéáßá Íüóïò — ôï ÷ñïíéêü äéÜóôçìá áðü ôçí Ýíáñîç Ýùò ôï èÜíáôï Ïöåéëüìåíç óå Þ áðüôïêïò ÕðÜñ÷ïõí äõï ×ñçóéìïðïéåßôáé (â) ÁÅÅ - áíôáãùíéóôéêÝò áéôßåò óõíôüìåõóç Ïöåéëüìåíç óå Þ áðüôïêïò Äåí õðÜñ÷åé ëïãéêÞ (ã) Ãåñïíôéêüò Ìáñáóìüò — áëëçëïõ÷ßá ÉÉ. Äåýôåñï ìÝñïò: ¢ëëåò áîéüëïãåò ðáèïëïãéêÝò åêäçëþóåéò: (á) — (â) — (ã) — 85


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

ôçò áäõíáìßáò. Ôï ðñþôï âÞìá ðñÝðåé íá ãßíåé áðü ôïõò ßäéïõò ãéáôñïýò. Ç áðëÞ óõììüñöùóç ìå ôéò ïäçãßåò, ðïõ õðïóçìåéþíïíôáé óôá ßäéá ôá ðéóôïðïéçôéêÜ èáíÜôïõ, ìðïñåß íá âåëôéþóåé, óå óçìáíôéêü âáèìü, áõôÞ ôçí åéêüíá. ºóùò ÷ñåéÜæåôáé êáé ìéá ðéï óõóôçìáôéêÞ ðñïóðÜèåéá, óå åèíéêü åðßðåäï, ëüãïõ ÷Üñç, ìÝóù êáôåõèõíôÞñéùí ïäçãéþí. Óå êÜèå ðåñßðôùóç ðéóôåýïõìå üôé ç ðéóôïðïßçóç èáíÜôïõ äåí áðïôåëåß ìéá êáôþôåñçò óçìáóßáò éáôñéêÞ ðñÜîç. Áíôßèåôá, ðéóôåýïõìå üôé ç ïñèÞ êáé ÷ùñßò áíáêñßâåéåò ðéóôïðïßçóç ôïõ èáíÜôïõ áðïôåëåß ìéá Üëëç óçìáíôéêÞ éáôñéêÞ ðñïóöïñÜ óôçí ðñïóôáóßá ôçò õãåßáò êáé ôçò æùÞò.

Ê. Óõñéáíüò êáé óõí.

10.

11.

12. 13.

14.

Âéâëéïãñáößá 1. Lenfant C, Friedman L, Thom T. Fifty Years of Death Certificates, the Framingham Heart Study, Ann Intern Med, December 1998, Volume 129 Issue 12, p.p. 1066-1067. 2. Huffman GB. Death Certificates: Why It Matters How Your Patient Died, American Family Physician, 56:5, 1997. 3. Magrane BP, Gilliland MGF, King DE. Certification of death by family physicians. Am Fam Physician, 56:1433-8, 1997. 4. Lloyd-Jones DM, Martin DO, Larson MG, Levy D. Accuracy of Death Certificates for Coding Coronary Heart Disease as the Cause of Death, Ann Intern Med, 129:1020-6, 1998. 5. Modelmog D, Rahlenbeck S, Trichopoulos D. Accuracy of death certificates: a population-based, complete-coverage, one-year autopsy study in East Germany. Cancer Causes Control, 3:5416, 1992. 6. Sington J D, Cottrell B J. Analysis of the sensitivity of death certificates in 440 hospital deaths: a comparison with necropsy findings, Journal of Clinical Pathology, 55:499-502, 2002. 7. De Faire U, Friberg L, Lorich U, Lundman T. A validation of cause-of-death certification in 1,156 deaths, Acta Med Scand, 200:223-8, 1976. 8. Penson D, Albertsen P, Nelson P, Barry M, Stanford J. Determining Cause of Death in Prostate Cancer: Are Death Certificates Valid? Journal of the National Cancer Institute, 93, 23:18221823, 2001. 9. Grulich AE, Swerdlow AJ, dos Santos Silva I,

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Beral V. Is the apparent rise in cancer mortality in the elderly real? Analysis of changes in certification and coding of cause of death in England and Wales, 1970–1990. Int J Cancer, 63:164-8, 1995. Satariano WA, Ragland KE, Van Den Eeden SK. Cause of death in men diagnosed with prostate carcinoma. Cancer, 83:1180-8, 1998. Jordan JM, Bass MJ. Errors in death certificate completion in a teaching hospital, Clin Invest Med, 16:249-55, 1993. Myers K, Farquhar D. Improving the accuracy of death certification, CMAJ, 158:1317-23, 1998. Slater DN. Certifying the cause of death: an audit of wording inaccuracies, J Clin Pathol, 46:232-4, 1993. Vanatta PR, Petty CS. Limitations of the forensic external examination in determining the cause and manner of death, Hum Pathol, 18:170-4, 1987. Johansson L, Westerling R. Comparing Swedish hospital discharge records with death certificates: implications for mortality statistics, International Journal of Epidemiology, 29:495-502, 2000. Egnerova A, Slugen I. Reliability of data on the major causes of death, Cesk Zdrav, 37:526-34, 1989. Swift B, West K. Death certification: an audit of practice entering the 21st century, J Clin Pathol, 55:275-9, 2002. James DS, Bull AD. Information on death certificates: cause for concern? J R Coll Physicians Lond. J Clin Pathol, 49:213-6, 1996. Doyle YG, Harrison M, O’Malley F. A study of selected death certificates from three Dublin teaching hospitals, J Public Health Med, 12:11823, 1990. Kohn RR. Cause of death in very old people. JAMA, 247:2793-7, 1982. Koelmeyer J. The forensic pathology of nonagenarians and centenarians: do they die of old age? (The Auckland experience), Am J Forensic Med Pathol, 22:150-4, 2001. Armour A, Bharucha H. Nosological Inaccuracies in death certification in Northern Ireland. A comparative study between hospital doctors and general practitioners, Ulster Med J, 66:137, 1997. James DS, Bull AD. Death certification: is correct formulation of cause of death related to seniority or experience? J R Coll Physicians Lond, 29:424-8, 1995.


Ôüìïò 16, Ôåý÷ïò 2, 2004

Ê. Óïõëéþôçò, Á. Ìáñéüëçò

ÂÑÁÂÅÕÈÅÉÓÁ ÅËÅÕÈÅÑÇ ÁÍÁÊÏÉÍÙÓÇ AWARDED FREESTANDING PAPER Primary Heatlh Care, Volume 16, Number 2, 87-93, 2004 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 16, Ôåý÷ïò 2, 87-93, 2004

Ç äéáìüñöùóç åíüò ÏëïêëçñùìÝíïõ ÓõóôÞìáôïò ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò óôçí ÅëëÜäá Ê. Óïõëéþôçò1, Á. Ìáñéüëçò2

Ðåñéëçøç Óêïðüò: Ç åñãáóßá áðïóêïðåß óôç ìåëÝôç êáé áîéïëüãçóç ôùí âáóéêþí ïñãáíùôéêþí êáé ëåéôïõñãéêþí ÷áñáêôçñéóôéêþí, êáèþò êáé ôùí äåéêôþí åðÜñêåéáò êáé áðïäïôéêüôçôáò ôùí äïìþí ðñùôïâÜèìéáò öñïíôßäáò õãåßáò óôçí ÅëëÜäá, ðñïò ôçí êáôåýèõíóç ôçò äéáìüñöùóçò åíüò ïëïêëçñùìÝíïõ óõóôÞìáôïò. Õëéêü êáé ìÝèïäïò: Ç åñãáóßá âáóßæåôáé óå óôïé÷åßá ôçò ðñïóöïñÜò êáé ôçò æÞôçóçò, ìå óçìåßï áíáöïñÜò ôçí ðåñéöåñåéáêÞ óõãêñüôçóç ôïõ óõóôÞìáôïò õãåßáò. Óå ü,ôé áöïñÜ ôçí ðñïóöïñÜ, áîéïëïãïýíôáé ç äéÜñèñùóç êáé ç åðÜñêåéá ôùí õëéêþí êáé áíèñþðéíùí ðüñùí ôïõ óõóôÞìáôïò õãåßáò, õðü ôï ðñßóìá ôçò áðïêåíôñùôéêÞò ëïãéêÞò ðïõ äéÝðåé ôç ëåéôïõñãßá ôïõ. ËáìâÜíïíôáé õðüøç üëåò ïé äïìÝò, ìå êñéôÞñéï ôçí Ýíôáîç ôùí ðáñå÷ïìÝíùí õðçñåóéþí óôéò ðáñï÷Ýò ðïõ ðñïêýðôïõí óôï ðëáßóéï ôùí êïéíùíéêï-áóöáëéóôéêþí äéêáéùìÜôùí ôùí ðïëéôþí, áíåîáñôÞôùò äéïéêçôéêÞò õðáãùãÞò ôùí öïñÝùí. Ç ðïóïôéêÞ áíÜëõóç óõíäÝåé ôç äéÜóôáóç áõôÞ ìå óôïé÷åßá áíáãêþí, üðùò áõôÝò ðñïêýðôïõí áðü åðéäçìéïëïãéêÜ ðåñéöåñåéáêÜ äåäïìÝíá êáé äåäïìÝíá ãéá ôç æÞôçóç êáé ôç ÷ñçóéìïðïßçóç ôùí õðçñåóéþí. ÁðïôåëÝóìáôá: Ç ìåëÝôç ôùí äåäïìÝíùí áíáäåéêíýåé ìßá óçìáíôéêÞ áíôßöáóç ìåôáîý ôçò óõíïëéêÞò åðÜñêåéáò ôùí ðüñùí, ç ïðïßá Ý÷åé óå ìåãÜëï âáèìü åðéôåõ÷èåß, êáé ôçò ðåñéöåñåéáêÞò åðÜñêåéáò, ç ïðïßá ðñïêáëåß ìéá áíéóüôçôá óå âÜñïò ìÜëéóôá ôùí áóôéêþí ðåñéï÷þí, ïé ïðïßåò üìùò õðåñÝ÷ïõí óå Üëëåò ðåñéï÷Ýò ôïõ óõóôÞìáôïò õãåßáò, üðùò ð.÷. ïé äïìÝò íïóïêïìåéáêÞò ðåñßèáëøçò. Áðü ìßá Üëëç ïðôéêÞ, ôï áðïôÝëåóìá ôçò áíÜëõóçò ôùí äåäïìÝíùí áíôáíáêëÜ ôïõò ïñãáíùôéêïýò – ëåéôïõñãéêïýò ðåñéïñéóìïýò ðïõ êáôÝóôçóáí áíÝöéêôç ôç äéáìüñöùóç åíüò ïëïêëçñùìÝíïõ êáé åíéáßïõ óõóôÞìáôïò ðñùôïâÜèìéáò öñïíôßäáò õãåßáò óôç ÷þñá ìáò. ÓõìðåñÜóìáôá: Ç åñãáóßá ëáìâÜíïíôáò õðüøç ôéò óõíïëéêÝò äõíáôüôçôåò ôïõ óõóôÞìáôïò õãåßáò óôçí ÅëëÜäá, ôçí Ýêôáóç êáé ôï ÷áñáêôÞñá ôùí ðñïâëçìÜôùí ôçò ðñùôïâÜèìéáò öñïíôßäáò õãåßáò êáé ôï íÝï èåóìéêü ðëáßóéï äéáìüñöùóÞò ôçò, êáôáëÞãåé óôç äéáôýðùóç ðñïôÜóåùí, ïé ïðïßåò áðïóêïðïýí óôï íá êáôáóôåß åöéêôÞ ç Ýíôáîç ëïãéêþí êáé ÷áñáêôçñéóôéêþí “óõóôÞìáôïò” óôçí ðñùôïâÜèìéá öñïíôßäá õãåßáò, åíþ ðáñÜëëçëá áíáäåéêíýåé ôá ïöÝëç ôïõ óõóôÞìáôïò õãåßáò óôï óýíïëü ôïõ, áðü ìéá ôÝôïéá ðñïïðôéêÞ.

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ÅèíéêÞ Ó÷ïëÞ Äçìüóéáò Õãåßáò, ÁèÞíá, 2ÊÝíôñï Õãåßáò Âýñùíá, ÁèÞíá

1. ÅéóáãùãéêÝò ðáñáôçñÞóåéò - Óêïðüò Ç “ðåñéðÝôåéá” ôçò ìåôáññýèìéóçò ôïõ Åèíéêïý ÓõóôÞìáôïò Õãåßáò óôçí ÅëëÜäá áðïôåëåß Ýíá åðßêáéñï êáé äéá÷ñïíéêü áíôéêåßìåíï ìåëÝôçò ôçò Ýñåõíáò õðçñåóéþí õãåßáò, ëüãù ôùí éäéáéôåñïôÞôùí óôï åðßðåäï ôçò áñ÷éêÞò óõãêñüôçóçò1, ôçò åîÝëéîçò, ôùí ðïëëáðëþí äéïéêçôéêï-ïñãáíùôéêþí ôïìþí êáé ôçò ðÜãéáò áäõíáìßáò ùò ðñïò ôçí áíôéìåôþðéóç ôùí “åêêñåìïôÞôùí” ôçò ÷ñçìáôïäüôçóçò êáé ôçò ðñùôïâÜèìéáò öñïíôßäáò õãåßáò. Ç ðáñïýóá åñãáóßá ðñïóåããßæåé ôá äåäïìÝíá, ôéò åõêáéñßåò êáé ôéò ðñïïðôéêÝò áíÜðôõîçò åíüò ïëïêëçñùìÝíïõ óõóôÞìáôïò ðñùôïâÜèìéáò öñïíôßäáò õãåßáò, åðé÷åéñþíôáò ðáñÜëëçëá íá áíáäåßîåé ôá ïöÝëç ôïõ óõóôÞìáôïò õãåßáò óôï óýíïëü ôïõ, áðü ìéá ôÝôïéá ðñïïðôéêÞ. ËÝîåéò êëåéäéÜ: Åèíéêü Óýóôçìá Õãåßáò, ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, ÅëëÜäá ÕðïâëÞèçêå: Ç åñãáóßá õðïâëÞèçêå ùò åëåýèåñç áíáêïßíùóç óôï 16ï ÐáíåëëÞíéï ÓõíÝäñéï ÃåíéêÞò ÉáôñéêÞò (Êùò, 14-18 Áðñéëßïõ 2004) êáé âñáâåýèçêå áðü ôçí ÅðéôñïðÞ Êñßóçò, Äçìïóéåýåôáé ìå êïéíÞ áðüöáóç ôçò ÓõíôáêôéêÞò ÅðéôñïðÞò ôïõ Ðåñéïäéêïý êáé ôçò ÏñãáíùôéêÞò ÅðéôñïðÞò ôïõ Óõíåäñßïõ Õðåýèõíïò áëëçëïãñáößáò: ÊõñéÜêïò Óïõëéþôçò, ÅèíéêÞ Ó÷ïëÞ Äçìüóéáò Õãåßáò, Ë. ÁëåîÜíäñáò 196, 115 24, ÁèÞíá, Ôçë.: (210)6435328, e-mail: souliotis@hol.gr 87


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Ê. Óïõëéþôçò, Á. Ìáñéüëçò

óôï óýóôçìá õãåßáò óå åðßðåäï áñ÷þí (éóüôçôá – áðïäïôéêüôçôá). Åéäéêüôåñá, ç èåóìéêÞ ìåôåîÝëéîç ôïõ ÅÓÕ ðåñéëáìâÜíåé ôÝóóåñéò ìåôáññõèìéóôéêÝò Summary Aim: To assess and evaluate the basic organizational and functional characðñïóðÜèåéåò: teristics as well as the indicators of sufficiency and efficiency of primary care á) Íüìïò 2071/1992 - Åêóõã÷ñïin Greece. Material-Method: The study is based on supply and demand data íéóìüò êáé ÏñãÜíùóç ôïõ ÓõóôÞìáwith a reference point of regional organization of health system. Results: The ôïò Õãåßáò: ÁëëáãÞ ôçò öéëïóïößáò data studies show significant contradictions between the total sufficiency of ôïõ óõóôÞìáôïò, Ýìöáóç óôçí áðïäïresources and the regional one. This causes inequality in favor of rural areas. Data analysis reflects the organizational and functional limitations that render ôéêüôçôá êáé ôç óõãêñÜôçóç ôïõ êüunfeasible the construction of a complete and united primary care system in óôïõò (ðåñéïñéóìÝíç åöáñìïãÞ). our country. Conclusions: The study takes into consideration the overall capâ) Íüìïò 2194/1994 - ÁðïêáôÜabilities of the Greek Health System, the problems in primary care and the new óôáóç ôïõ Åèíéêïý ÓõóôÞìáôïò Õãåßáò framework, and as a result leads to the formulation of proposals regarding the êáé Üëëåò äéáôÜîåéò: primary care system in Greece. i. ÅðáíáöïñÜ ôùí áñ÷éêþí ÷áñáKey Words: Greek Health System, Primary Health Care êôçñéóôéêþí ôïõ ÅÓÕ (åöáñìïãÞ) ii. Óõãêñüôçóç åðéôñïðÞò åìðåéñïãíùìüíùí Ç Ýìöáóç óôçí ðñùôïâÜèìéá öñïíôßäá õãåßáò õðáãïñåýåôáé áðü äýï êõñßùò ëüãïõò: á) áðïôå- ãéá ôçí åðåîåñãáóßá ðïñßóìáôïò ìå óêïðü ôçí ëåß ôçí ðåñéï÷Þ ôïõ õãåéïíïìéêïý ôïìÝá óôç ÷þñá ïñéïèÝôçóç åíüò íÝïõ ðëáéóßïõ ëåéôïõñãßáò ôïõ ìáò áðü ôçí ïðïßá áðïõóéÜæåé ç ëïãéêÞ ôïõ “óõ- ÅÓÕ (ìç õëïðïßçóç) ã) Íüìïò 2519/1997 - ÁíÜðôõîç êáé åêóõãóôÞìáôïò”2 êáé â) äéá÷ñïíéêÜ, áðïôåëåß ôïí êýñéï ðáñÜãïíôá áêýñùóçò ôçò áóöáëéóôéêÞò êÜ- ÷ñïíéóìüò ôïõ Åèíéêïý ÓõóôÞìáôïò Õãåßáò, ïñëõøçò áðïññïöþíôáò ôï ìåãáëýôåñï ðïóïóôü ôùí ãÜíùóç ôùí õãåéïíïìéêþí õðçñåóéþí, ñõèìßóåéò éäéùôéêþí äáðáíþí õãåßáò3. ãéá ôï öÜñìáêï êáé Üëëåò äéáôÜîåéò: ÅðéðëÝïí, ôüóï ç äéåèíÞò üóï êáé ç åëëçíéêÞ ÊáéíïôïìéêÝò ñõèìßóåéò, Ýìöáóç óôç ëåéôïõñâéâëéïãñáößá Ý÷ïõí áíáäåßîåé ôï ñüëï ôçò ðñù- ãéêÞ áíáäéïñãÜíùóç ôïõ óõóôÞìáôïò êáé ôçí ôïâÜèìéáò öñïíôßäáò õãåßáò óôç äéáìüñöùóç åíüò áðïäïôéêüôçôá (ðåñéïñéóìÝíç åöáñìïãÞ). ðëáéóßïõ ïñéæüíôéáò êáé êÜèåôçò äéáóýíäåóçò ôùí ä) Íüìïò 2889/2001 - Âåëôßùóç êáé Åêóõãäïìþí, ôçò åðßôåõîçò êáëýôåñçò áîéïðïßçóçò ôùí ÷ñïíéóìüò ôïõ Åèíéêïý ÓõóôÞìáôïò Õãåßáò êáé äéáèÝóéìùí ðüñùí êáé ôïõ ðåñéïñéóìïý ôïõ êü- Üëëåò äéáôÜîåéò: óôïõò ôùí õðçñåóéþí õãåßáò4. Óõíåðþò, ç áíßÑéæéêÞ ìåôáññõèìéóôéêÞ ëïãéêÞ, ðåñéöåñåéá÷íåõóç ôùí âáóéêþí ïñãáíùôéêþí êáé ëåéôïõñãé- êÞ óõãêñüôçóç ôïõ óõóôÞìáôïò, äéïéêçôéêÞ ðáêþí ÷áñáêôçñéóôéêþí, êáèþò êáé ôùí äåéêôþí ñÝìâáóç. åðÜñêåéáò êáé áðïäïôéêüôçôáò ôùí äïìþí ðñùÓôéò ðáñåìâÜóåéò áõôÝò, ç ðñùôïâÜèìéá öñïôïâÜèìéáò öñïíôßäáò õãåßáò óôçí ÅëëÜäá, ðñïò íôßäá õãåßáò äåí áðïôÝëåóå áíôéêåßìåíï åõñåßáò ôçí êáôåýèõíóç ôçò äéáìüñöùóçò åíüò ïëïêëç- ñýèìéóçò, ìå åîáßñåóç ôï ó÷åäéáóìü ôçò áíÜðôõñùìÝíïõ óõóôÞìáôïò, áðïôåëåß áêüìá Ýíá “áíïé- îçò “äéêôýùí” ðñùôïâÜèìéáò öñïíôßäáò õãåßáò êôü” èÝìá, ôüóï óå åðßðåäï åðéóôçìïíéêþí ðñï- ðïõ ðåñéëáìâÜíåôáé óôïí Í. 2519/1997, ï ïðïßïò óåããßóåùí üóï êáé óå åðßðåäï ó÷åäéáóìïý êáé üìùò äåí õëïðïéÞèçêå5. Óå áíôßóôïé÷ïõò ðñïóáíáôïëéóìïýò – ðñïò ôçí êáôåýèõíóç ôçò ëåéôïõñÜóêçóçò ðïëéôéêÞò õãåßáò. ãéêÞò áíáóõãêñüôçóçò – êéíåßôáé êáé ç ôåëåõôáßá èåóìéêÞ ñýèìéóç, ìå íüìï ðïõ áöïñÜ áðïêëåéóôé2. Ç ðñùôïâÜèìéá öñïíôßäá õãåßáò óôçí ÅëëÜäá - êÜ óôçí ðñùôïâÜèìéá öñïíôßäá õãåßáò (Í. 3235/ 2004)6. ÄåäïìÝíá Óå êÜèå ðÜíôùò ðåñßðôùóç êáé óýìöùíá êáé ÌåôÜ ôï ðÝñáò ôçò äåýôåñçò äåêáåôßáò ëåé- ìå ôç äéåèíÞ åìðåéñßá ôùí ìåôáññõèìßóåùí êáé ôïõñãßáò ôïõ ÅÓÕ óôç ÷þñá ìáò, ï áðïëïãéóìüò ôïõ óôñáôçãéêïý ó÷åäéáóìïý, áíåîÜñôçôá áðü ôï ôçò èåóìéêÞò éóôïñßáò – “ðåñéðÝôåéáò” ôùí ìå- ðåñéå÷üìåíï ôïõ èåóìéêïý ðëáéóßïõ åßíáé áðáñáßôáññõèìßóåùí, îåêéíÜ áðü ôç äéáðßóôùóç ôçò äé- ôçôç ç äéáãíùóôéêÞ ðñïóÝããéóç ôïõ åõñýôåñïõ ëçììáôéêÞò ëïãéêÞò ðïõ äéÝðåé ôéò ðáñåìâÜóåéò ðåäßïõ åöáñìïãÞò ôùí ìÝôñùí, ðñïêåéìÝíïõ íá The development of an Intergrading Primary Health Care System in Greece. K. Souliotis, A. Mariolis

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Ê. Óïõëéþôçò, Á. Ìáñéüëçò

êáôáóôåß åöéêôÞ ç ìåëÝôç ôçò åöéêôüôçôáò, ôïõ ÷ñïíïäéáãñÜììáôïò õëïðïßçóçò êáé ôïõ êüóôïõò åöáñìïãÞò7. Õðü ôï ðñßóìá áõôü, ç ðñùôïâÜèìéá öñïíôßäá õãåßáò óôç ÷þñá ìáò, ðáñïõóéÜæåé ôá åîÞò ãåíéêÜ ÷áñáêôçñéóôéêÜ: á) Ùò ðñïò ôçí ðáñï÷Þ ôùí õðçñåóéþí • Ç ðáñï÷Þ ôùí õðçñåóéþí âáóßæåôáé óôç ëåéôïõñãßá åíüò Üôõðïõ “äéêôýïõ” ôï ïðïßï áðïôåëåßôáé áðü 200 ðåñßðïõ êÝíôñá õãåßáò óôéò çìéáóôéêÝò êáé áãñïôéêÝò ðåñéï÷Ýò êáé 250 ðåñßðïõ ðïëõúáôñåßá ôïõ ÉÊÁ óôéò áóôéêÝò ðåñéï÷Ýò. • Ïé äéêáéïý÷ïé ôùí áóöáëéóôéêþí öïñÝùí ðïõ äåí äéáèÝôïõí äéêÝò ôïõò õðçñåóßåò õãåßáò, êáëýðôïíôáé ìÝóù óõìâÜóåùí ìå éäéùôéêÜ ó÷Þìáôá êáé ãéáôñïýò, ÷ùñßò üìùò íá äéáóöáëßæåôáé ç åðÜñêåéá êáé ç ðïéüôçôá ôùí õðçñåóéþí, åíþ áðïõóéÜæïõí ç ðñïëçðôéêÞ êáé ç ìåôáíïóïêïìåéáêÞ öñïíôßäá. • Ôï êåíü ôçò ÷ñïíéêÞò äéáèåóéìüôçôáò ôùí ðüñùí óôïõò ðïëßôåò ôï ïðïßï ÷áñáêôçñßæåé ôç äçìüóéá ðáñáãùãÞ ÐÖÕ, åß÷å óáí áðïôÝëåóìá ôçí Ýíôïíç åðåíäõôéêÞ äñáóôçñéüôçôá ôïõ éäéùôéêïý ôïìÝá óôçí åîùíïóïêïìåéáêÞ ðåñßèáëøç, ìå ôçí ßäñõóç éäéùôéêþí äéáãíùóôéêþí êÝíôñùí, ôá ïðïßá õðåñâáßíïõí ôá 400 êáé õðïëïãßæåôáé üôé åìöáíßæïõí êýêëï åñãáóéþí ï ïðïßïò ôï 2000 îåðÝñáóå ôá 100 äéó. äñ÷. â) Ùò ðñïò ôç ÷ñçìáôïäüôçóç ôùí õðçñåóéþí • Óå ü,ôé áöïñÜ ôéò äçìüóéåò äáðÜíåò õãåßáò, ç óýíèåóÞ ôïõò áíôáíáêëÜ ôçí Ýìöáóç óôç íïóïêïìåéáêÞ ðåñßèáëøç ç ïðïßá áðïññïöÜ ôï 55% ðåñßðïõ åðß ôïõ óõíüëïõ ôùí äçìïóßùí äáðáíþí õãåßáò, Ýíáíôé 23,5% ðïõ äáðáíÜôáé êõñßùò ãéá õðçñåóßåò éáôñþí (22%) êáé ðïëý ëéãüôåñï ãéá ïäïíôéáôñéêÞ ðåñßèáëøç (1,5%). • Óå ü,ôé áöïñÜ ôéò éäéùôéêÝò äáðÜíåò, ôï ìåãáëýôåñï ðïóïóôü áðïññïöÜôáé ãéá åîùíïóïêïìåéáêÞ ðåñßèáëøç (63% ðåñßðïõ). Áõôü åðéìåñßæåôáé óå ðïóïóôü ðïõ áíÝñ÷åôáé óå 33% ãéá ôçí ïäïíôéáôñéêÞ êáé 29% ãéá ôçí éáôñéêÞ ðåñßèáëøç. Áíôßèåôá, ç óõììåôï÷Þ ôçò äáðÜíçò ãéá íïóïêïìåéáêÞ ðåñßèáëøç óôéò éäéùôéêÝò äáðÜíåò õãåßáò, êõìáßíåôáé óå ÷áìçëÜ åðßðåäá (14% ðåñßðïõ). Ç óýíèåóç áõôÞ áðïôõðþíåé ôçí áõôüìáôç õðïêáôÜóôáóç ìåôáîý äçìüóéáò êáé éäéùôéêÞò ÷ñçìáôïäüôçóçò, óôï ðëáßóéï ôçò ïðïßáò ïé ðï-

Ôüìïò 16, Ôåý÷ïò 2, 2004

ëßôåò êáëýðôïõí ïéêïíïìéêÜ ôçí õðï÷ñçìáôïäüôçóç ôïõ äçìüóéïõ óõóôÞìáôïò ðñùôïâÜèìéáò öñïíôßäáò õãåßáò8. Óôï óçìåßï áõôü, åßíáé áðáñáßôçôç ç åðéóÞìáíóç åíüò ðáñÜäïîïõ öáéíïìÝíïõ: åíþ ç õðïêáôÜóôáóç óå åðßðåäï ÷ñçìáôïäüôçóçò åßíáé óáöÞò, óå ü,ôé áöïñÜ ôçí åðÜñêåéá ôùí ðñïóöåñïìÝíùí õðçñåóéþí, äåí ðñïêýðôåé áíôßóôïé÷ç óõìðåñéöïñÜ ôùí ÷ñçóôþí. ÓõãêåêñéìÝíá, üðùò öáßíåôáé óôï ÄéÜãñáììá1, ôï ðïóïóôü ôçò éäéùôéêÞò äáðÜíçò õãåßáò ôï 2001 êéíåßôáé óôá ßäéá åðßðåäá ìå ôï 1980, áíåîÜñôçôá áðü ôç ñáãäáßá áíÜðôõîç ôùí õðçñåóéþí ôïõ ÅÓÕ. Áíôéóôïß÷ùò, óôá ßäéá åðßðåäá ìå ôçí ðñï ÅÓÕ ðåñßïäï êéíåßôáé êáé ç óõììåôï÷Þ ôçò ðñùôïâÜèìéáò öñïíôßäáò õãåßáò óôéò éäéùôéêÝò äáðÜíåò õãåßáò (ÄéÜãñáììá 2), ãåãïíüò ôï ïðïßï áðïôõðþíåé ôïí ïñãáíùôéêï – ëåéôïõñãéêü ÷áñáêôÞñá ôùí ðñïâëçìÜôùí ðïõ ùèïýí ôïõò ðïëßôåò óå åðéâÜññõíóç ôùí áôïìéêþí ôïõò åéóïäçìÜôùí ãéá Ýíá “ðñïúüí” ôï ïðïßï ôï äçìüóéï óýóôçìá ðáñÝ÷åé “äùñåÜí”. Ìå äåäïìÝíá ôá ðáñáðÜíù, ôï åðßêåíôñï ôïõ ðñïâëçìáôéóìïý ãýñù áðü ôç äéáìüñöùóç åíüò ïëïêëçñùìÝíïõ óõóôÞìáôïò ðñùôïâÜèìéáò öñïíôßäáò õãåßáò, ìåôáôßèåôáé óôçí áóöáëéóôéêÞ æÞôçóç, ôï êüóôïò ÷ñüíïõ êáé ôçí ðïéüôçôá ôùí ðáñå÷ïìÝíùí õðçñåóéþí. Åßíáé åíäåéêôéêü üôé ðñüóöáôåò ó÷åôéêÝò ìåëÝôåò, êáôáãñÜöïõí õøçëÜ ðïóïóôÜ éêáíïðïßçóçò áðü ôá ÊÝíôñá Õãåßáò ôïõ ÅÓÕ (79,3%), åíþ áíôßèåôá óôéò ìïíÜäåò ôùí Áóöáëéóôéêþí ÖïñÝùí ðáñáôçñïýíôáé ÷áìçëüôåñá ðïóïóôÜ (52,5%). Áõôü ðéèáíüí áíôáíáêëÜ ôç äõóáñÝóêåéá ôùí ðïëéôþí ùò ðñïò ôéò äéáäéêáóßåò åðéâåâáßùóçò ôïõ áóöáëéóôéêïý äéêáéþìáôïò êáé ëéãüôåñï ôçí áñíçôéêÞ ôïõò ãíþìç ãéá ôéò ðñïóöåñèåßóåò õðçñåóßåò9. Óôï óçìåßï áõôü, ðñéí ôç äéáôýðùóç óêÝøåùí êáé ðñïâëçìáôéóìþí ãéá ôç äéáìüñöùóç ìåôáññõèìéóôéêïý ó÷åäßïõ, ðñüôáóçò, Þ êáé åðéìÝñïõò ñõèìßóåùí, èåùñåßôáé éäéáßôåñá ÷ñÞóéìç ìéá “åðé÷åéñçóéáêÞ ðñïóÝããéóç” ôçò õöéóôÜìåíçò ðñáãìáôéêüôçôáò óôçí ÐÖÕ, ç ïðïßá ðáñïõóéÜæåôáé ó÷çìáôéêÜ ðáñáêÜôù: Ç ðñïóÝããéóç áõôÞ åðéâåâáéþíåé ôçí áñ÷éêÞ õðüèåóç üôé áíåîáñôÞôùò ôùí áäõíáìéþí ðïõ Ý÷ïõí êáôáãñáöåß, ç ðïñåßá ôïõ Å.Ó.Õ. ôá ôåëåõôáßá ÷ñüíéá Ý÷åé íá åðéäåßîåé óçìáíôéêÞ âåëôßùóç óå áñêåôÝò ðôõ÷Ýò ôçò ëåéôïõñãßáò ôïõ. Ôçí ßäéá óôéãìÞ åðéâåâáéþíïíôáé ïé “åêêñåìüôçôåò” 89


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Ê. Óïõëéþôçò, Á. Ìáñéüëçò

É Ä É Ù Ô É Ê ÅÓ Ä Á Ð Á Í Å Ó Õ Ã ÅÉ Á Ó Ù Ó Ð Ï Ó Ï Ó Ô Ï Å Ð É Ô Ï Õ Ó Õ Í Ï Ë Ï Õ Ô Ù Í Ä Á Ð Á Í Ù Í

60

49,8

46,3

50

45,9 44,4

30

45,5

46,6

44,1

40,1

40

47,9

45,4 48

43,9 47

47,2

44

46,6

ÅÓÕ

20

10

Õ ð ïä ïì Þ Ð Ö Õ : 1 2 6

Õ ð ïä ï ìÞ Ð Ö Õ : 1 7 0 Ê Ý í ô ñ á

Õ ã åéï íï ìé ê ïß Ó ô á è ì ïß êá é

Õ ã å ßá ò ê áé 1 3 1 1

Õ ð ï äï ìÞ Ð Ö Õ : 2 0 1 Ê Ýí ô ñ á

1 4 1 1 Á ã ñ ïô é ê Ü É áô ñåßá

Ð åñ éö åñ åéáê Ü É áô ñåß á

Ð å ñéö åñ åéá êÜ Éá ô ñå ßá

2 2 7 4 êÜ ô ï éê ï é á í Ü ã éáô ñ ü

1 9 9 0 ê Ü ô ïé ê ïé á í Ü ã é áôñ ü

~ 8 0 0 ê Üô ïé ê ïé á í Ü ã éá ô ñ ü

Ð ÖÕ

Ð ÖÕ

Ð ÖÕ

Õ ã åß áò

êá é 1 4 7 8

0 1980

1987

1988

1989

199 0

1991

19 92

1993

1 994

1995

1996

1997

1998

1999

2000

2001

Ð ç ã Þ : Ó ï õ ë éþ ô ç ò Ê. ( 2 0 0 1) Ï Ñ ü ë ï ò ô ï õ É ä é ù ô éê ï ý Ô ï ì Ý á ó ô ï Å ë ë ç í éê ü Ó ý ó ô ç ì á Õ ã å ßá ò , Ð á ð á æ Þ ó ç ò , Á è Þ í á .

ÄéÜãñáììá 1.

Á Í Á Ë Õ Ó Ç Ô Ù Í É Ä É Ù Ô É Ê Ù Í Ä Á Ð Á Í Ù Í Õ Ã Å É Á Ó Ó Ô Ç Í ÅË Ë Á Ä Á ( 19 81 - 2 0 00 )

70

63 ,3 8

67 ,8 3

62 ,2 4

64 ,3 5

60 50 40

ÐÖÕ Í ÏÓÏ ÊÏÌÅÉÁÊÇ

30

Ö ÁÑ ÌÁÊÅÕÔ ÉÊÇ

20 10 0 1981

1987

1993

2000

Ð ç ã Þ : Ó ï õ ë éþ ô ç ò Ê . ( 2 0 0 1 ) Ï Ñ ü ë ï ò ô ï õ É ä é ù ô éê ï ý Ô ï ì Ý á ó ôï Å ë ë ç í éê ü Ó ý ó ôç ì á Õ ã åß á ò , Ð á ð á æ Þ ó ç ò , Á è Þ í á .

ÄéÜãñáììá 2. 90


Ôüìïò 16, Ôåý÷ïò 2, 2004

Ê. Óïõëéþôçò, Á. Ìáñéüëçò

SW O T

A n a l y s is – õ ö éó ô Ü ì åí ç ð ñ á ã ì á ô é ê ü ô ç ô á

Ð ËÅÏÍÅÊ ÔÇ ÌÁÔ Á

?Å ð Ü ñ ê å éá

ÌÅÉÏÍÅÊ ÔÇ ÌÁÔÁ

?

õë éê þ í ê é á íè ñ þ ð éí ù í

Á ð ïõ ó ßá ä ï ì þ í ó ôéò á ó ô éêÝ ò ð åñ éï ÷ Ý ò

ð ü ñùí

?Å ð á ñ ê Ý ò

?Á ð ï õ ó ßá åí éá ßï õ ÷ ñ ç ì á ôï ä ï ôéê ï ý ð ëá éó ßï õ

ð ë á ßó éï ä ïì þ í ó ô éò

á ã ñ ïô éê Ýò ê áé çì éá ó ô éê Ýò ð åñ éï ÷ Ýò

?Å õñ ý

?¸ ëë åé ø ç

ä ßê ô õï éäé ù ô éê þ í ä ï ì þ í

à å í éê þ í ã éá ôñ þ í

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áô ï ì éêÞ åð éâ Ü ñ õ íó ç ó å

ü ñ ï õ ò ê ü óô ï õ ò ÷ ñ Þ ìá ô ï ò ê á é ê üó ô ï õ ò ÷ ñ üí ï õ

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õ ã åßá ò ê á é á íÜ ëõ ó ç ôù í

á íá ã ê þ í ê á é ô ù í ä éá ô éè Ý ìå í ù í

éá ô ñ éêü ò ð ëç è ù ñéó ì ü ò - ð ñ ï ê ëç ôÞ

ð ü ñ ù í ó å ð å ñ éö åñ å éá ê ü åð ßð åä ï

?Å í ßó÷ õ ó ç

æ Þ ô ç óç ê ë ð )

ôù í ð å ñéö å ñ åéá ê þ í

ä ï ìþ í

?Ð ñ ù ôï â ï õ ë ßå ò ?Å ê ì åô Ü ëë å õ óç

ÉÊ Á

?Á íå î Ýë åã ê ôç

á ý î ç ó ç ôï õ ê ü ó ôï õ ò

?Á íå î Ýë åã ê ôç

ä éå ýñ õ í ó ç ôï õ

éä éù ôéê ï ý ô ï ìÝ á

éä é ù ô éêÞ ò õ ð ï äï ì Þ ò

?× ñ çì á ô ïä ï ô éê ïß

ÅÕÊ ÁÉÑÉÅ Ó

ôçò ðïëéôéêÞò õãåßáò ãýñù áðü ôá áêáíèþäç æçôÞìáôá ôçò ÷ñçìáôïäüôçóçò (õøçëÞ éäéùôéêÞ äáðÜíç) êáé ôçò Ýëëåéøçò êëéíþí óôá íïóïêïìåßá ôçò ÁôôéêÞò, êáôÜ ôç äéÜñêåéá ôùí åöçìåñéþí (ñÜíôæá). Êáé ôá äýï æçôÞìáôá óõíäÝïíôáé ìå ôçí ðïëéôéêÞ ãéá ôçí ÐÖÕ, äåäïìÝíïõ üôé ç áíáäéïñãÜíùóÞ ôçò èá åðÝôñåðå ôüóï ôïí Ýëåã÷ï ôïõ êüóôïõò, üóï êáé ôïí ðåñéïñéóìü ôïõ öáéíïìÝíïõ ôçò Üóêïðçò ðñïóöõãÞò óôá íïóïêïìåßá, óôá ïðïßá ðïëëÝò öïñÝò êáé êõñßùò ëüãù ôçò åëëéðïýò ÷ñïíéêÞò äéáèåóéìüôçôáò ôùí õðçñåóéþí ÐÖÕ, ðáñÝ÷ïíôáé öñïíôßäåò ãéá ôéò ïðïßåò äåí áðáéôïýíôáé íïóïêïìåéáêÝò äïìÝò.

åê ô ßìç ó ç ò ô çò

ì å ëë ï íô éê Þò æÞ ô ç ó çò ( ì åô á íÜ ó ô åõ ó ç ,

ð å ñéï ñ éó ì ï ß

ÁÐÅ ÉËÅÓ

3. ÓõæÞôçóç Ï ÷áñáêôÞñáò ôùí ðñïâëçìÜôùí ôçò ðñùôïâÜèìéáò öñïíôßäáò õãåßáò óôçí ÅëëÜäá áðáéôåß ëýóåéò “éáôñïáóöáëéóôéêïý” ðåñéå÷ïìÝíïõ. ÏõóéáóôéêÜ, óå åðßðåäï õëïðïßçóçò, ìéá ìåôáññõèìéóôéêÞ ðñüôáóç èá ìðïñïýóå íá âáóéóôåß óôï ðñüôõðï ôùí Ïñãáíéóìþí ÄéáôÞñçóçò ôçò Õãåßáò óôéò ÇÐÁ10-12, ìÝóù ôçò “åêìåôÜëëåõóçò” êáé âåëôßùóçò ôùí õðçñåóéþí ôïõ ÉÊÁ óôá áóôéêÜ êÝíôñá, ôçò áîéïðïßçóçò ôçò éäéùôéêÞò õðïäïìÞò êáé ôçò äéáìüñöùóçò åíüò ðëáéóßïõ ëåéôïõñãßáò ôçò áãïñÜò õðçñåóéþí õãåßáò, âáóéóìÝíïõ óå Ýíá

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ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

ðëÝãìá óõìâïëáßùí êáé óõìâÜóåùí13. Ôï óýóôçìá ôï ïðïßï èá ðñïêýøåé áðü ìéá ôÝôïéá ëïãéêÞ èá (ðñÝðåé íá) éêáíïðïéåß ôéò áñ÷Ýò ôçò óõíÝ÷åéáò êáé ôçò ïëïêëçñùìÝíçò öñïíôßäáò êáé íá ðñïóáíáôïëßæåôáé óôïí ðïëßôç. Âáóéêü ðëåïíÝêôçìá ôïõ ó÷åäßïõ ãéá ôç ëåéôïõñãéêÞ áíáäéïñãÜíùóç ôùí õðçñåóéþí ÐÖÕ, åßíáé üôé áíáìÝíåôáé íá ðñïóäþóåé Ýíáí ðëïõñáëéóôéêü ÷áñáêôÞñá óôï óýóôçìá, åìðëïõôßæïíôáò ôï ìåßãìá ôùí ðáñå÷üìåíùí öñïíôßäùí ìå õðçñåóßåò ðÝñáí ôùí ðáñáäïóéáêþí êëéíéêïåñãáóôçñéáêþí äñáóôçñéïôÞôùí, äçëáäÞ ðñüëçøçò ôçò íüóïõ êáé ðñïáãùãÞò ôçò õãåßáò, äéá÷åßñéóçò ôùí ìåéæüíùí ðáñáãüíôùí êéíäýíïõ14,15. Åðéóçìáßíåôáé üôé ç ðñüôáóç áõôÞ ç ïðïßá ïõóéáóôéêÜ áöïñÜ óôç ëåéôïõñãéêÞ åíóùìÜôùóç ôùí õðçñåóéþí ôïõ ÉÊÁ óôï ðëÝãìá ôùí õðçñåóéþí ôïõ ÅÓÕ, äåí Ýñ÷åôáé óå áíôéðáñÜèåóç ìå ôï ó÷Ýäéï ôçò äéïéêçôéêÞò ìåôáññýèìéóçò êáé ôçò åíéáßáò ïñãáíùôéêÞò äïìÞò ôçò ðñùôïâÜèìéáò öñïíôßäáò õãåßáò, áëëÜ áíôßèåôá óõíéóôÜ áðáñáßôçôç ðñïûðüèåóç ãéá ôçí õëïðïßçóç êáé ôçí áëëáãÞ ôçò ïñãáíùôéêÞò öéëïóïößáò ôïõ óõóôÞìáôïò. Ùò áðïôÝëåóìá ôçò ðñþôçò áõôÞò áðüðåéñáò äéáìüñöùóçò “äéêôýïõ” õðçñåóéþí, áíáìÝíåôáé íá åßíáé ç ïñèïëïãéêïðïßçóç óôç ÷ñÞóç ôùí ðüñùí êáé ç âåëôßùóç ôçò áðïäïôéêüôçôáò ôïõ óõóôÞìáôïò, åíþ óå áõôü áíáìÝíåôáé íá óõìâÜëëïõí êáé ôá ìÝôñá åëÝã÷ïõ ôçò êëéíéêÞò áðïôåëåóìáôéêüôçôáò (ðñùôüêïëëá êëéíéêïý éáôñéêïý åëÝã÷ïõ-medical audit) ôá ïðïßá èá ìðïñïýí íá åöáñìüæïíôáé åíéáßá óå üëåò ôéò äïìÝò ÐÖÕ. Âáóéêïß ðáñÜãïíôåò – ðñïûðïèÝóåéò ãéá ôçí åðéôõ÷ßá ôïõ åã÷åéñÞìáôïò, åßíáé ç áðïöõãÞ ðåñéïñéóôéêþí ëïãéêþí óôçí åíóùìÜôùóç èåóìþí üðùò ï ïéêïãåíåéáêüò éáôñüò (ð.÷. gate keeping), ç äéåýñõíóç ôïõ ÷ñüíïõ ëåéôïõñãßáò ôùí ìïíÜäùí ÐÖÕ, ç ïñãÜíùóç ôùí éáôñéêþí åéäéêïôÞôùí ðïõ ëåéôïõñãïýí óå áõôÝò êáé ç åéóáãùãÞ êéíÞôñùí ãéá ôçí áýîçóç ôçò ðáñáãùãéêüôçôáò ôùí éáôñþí êáé ôç óõãêñÜôçóç ôïõ ðëçèõóìïý áíáöïñÜò åíôüò ôçò ìïíÜäáò ÐÖÕ. ÅðéðñïóèÝôùò, ç äéáìüñöùóç ìéáò íÝáò ïñãáíùôéêÞò – äéïéêçôéêÞò êïõëôïýñáò óôçí ÐÖÕ, åßíáé ôáõôüóçìç ìå ôçí åîáóöÜëéóç ôùí ðñïûðïèÝóåùí ãéá ôçí ôÞñçóç éáôñéêïý öáêÝëïõ, ï ïðïßïò áíáìÝíåôáé íá óõìâÜëåé óôçí åêôßìçóç ôùí áíáãêþí õãåßáò ôùí ðïëéôþí êáé óôçí áõôïìáôïðïßçóç ôùí äéáäéêáóéþí êáôáãñáöÞò ôùí êëéíéêþí êáé åñãáóôçñéáêþí ðëçñïöïñéþí ðïõ åßíáé áðáñáßôçôåò 92

Ê. Óïõëéþôçò, Á. Ìáñéüëçò

óå êÜèå åðáöÞ ôùí ðïëéôþí ìå ôéò õðçñåóßåò õãåßáò, áëëÜ êõñßùò óôçí åêôßìçóç ôçò áðïôåëåóìáôéêüôçôáò ôïõ íÝïõ óõóôÞìáôïò. Ìå ôï ßäéï óêåðôéêü, âáóéêü óõóôáôéêü ôçò ëåéôïõñãßáò ôïõ õðïäåßãìáôïò åßíáé ç ïëïêëÞñùóç ôïõ Õãåéïíïìéêïý ×Üñôç, ï ïðïßïò èá åðéôñÝøåé ôçí åðßôåõîç ôçò ìåãáëýôåñçò äõíáôÞò áíôáðïêñéóéìüôçôáò ôùí íÝùí äïìþí óôéò áíÜãêåò ôùí ðïëéôþí. ÔÝëïò, áí êáé üðùò ðñïáíáöÝñèçêå ç åíóùìÜôùóç ëïãéêÞò “óõóôÞìáôïò” óôçí ðñùôïâÜèìéá öñïíôßäá õãåßáò óôç ÷þñá ìáò áðïôåëåß ðÜãéá “åêêñåìüôçôá” ôçò ðïëéôéêÞò õãåßáò, åðéóçìáßíåôáé üôé óôçí ðáñïýóá óõãêõñßá ôçò èåóìéêÞò ïëïêëÞñùóçò êáé ôçò ùñßìáíóçò ôùí åðéóôçìïíéêþí ðñïóåããßóåùí ãéá ôç ëåéôïõñãéêÞ áíáóõãêñüôçóç ôçò ÐÖÕ, õðÜñ÷ïõí óõíèÞêåò ðïõ åõíïïýí ðáñåìâÜóåéò ðñïò ôçí êáôåýèõíóç ôçò âåëôßùóçò ôçò ÐÖÕ êáé êáô´ åðÝêôáóç ôçò ëåéôïõñãßáò ôïõ óõóôÞìáôïò õãåßáò óôï óýíïëü ôïõ.

Âéâëéïãñáößá 1. Óïõëéþôçò Ê. (2001) Ï Ñüëïò ôïõ Éäéùôéêïý ÔïìÝá óôï Åëëçíéêü Óýóôçìá Õãåßáò, ÐáðáæÞóçò, ÁèÞíá. 2. Souliotis K, Lionis C. Creating an Integrated Health Care System in Greece: A Primary Care Perspective, Journal of Medical Systems (in press). 3. Souliotis K, Kyriopoulos J. The Hidden Economy and Health Expenditures in Greece: Measurement Problems and Policy Issues, Applied Health Economics and Health Policy, 3:129134, 2003. 4. ËéïíÞò ×, Ìåñêïýñçò Ì-Ð. “Áðüøåéò ãéá ôç óçìåñéíÞ êáôÜóôáóç óôçí ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò êáé ðñïôÜóåéò ãéá ôç âåëôßùóÞ ôçò”, ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, 12:7-9, 2000. 5. Êõñéüðïõëïò Ã, ËéïíÞò ×, ÄçìïëéÜôçò Ã, êáé óõí.: Ç ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò ùò èåìÝëéï ôçò õãåéïíïìéêÞò ìåôáññýèìéóçò, ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, 12:169-188, 2000. 6. Óïõëéþôçò Ê, ËéïíÞò ×. ËåéôïõñãéêÞ Áíáóõãêñüôçóç ôçò ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò: Ìéá Ðñüôáóç ãéá ôçí ¢ñóç ôïõ Áäéåîüäïõ, Áñ÷åßá ÅëëçíéêÞò ÉáôñéêÞò, 20:466-476, 2003. 7. Glied S. Chronic Condition: Why Health Reform Fails? Harvard University Press, Cambridge, 1997. 8. Óïõëéþôçò Ê. ÁíÜëõóç ôùí Äáðáíþí Õãåßáò óôçí ÅëëÜäá 1989-2000. ÌåèïäïëïãéêÝò Äéåõêñéíß-


Ôüìïò 16, Ôåý÷ïò 2, 2004

Ê. Óïõëéþôçò, Á. Ìáñéüëçò

óåéò êáé Äéáðéóôþóåéò ãéá ôï Óýóôçìá Õãåßáò, óôï Êõñéüðïõëïò Ê., Óïõëéþôçò Ê. (åðéì.) Ïé ÄáðÜíåò Õãåßáò óôçí ÅëëÜäá. ÌåèïäïëïãéêÜ ÐñïâëÞìáôá óôç ÌÝôñçóç êáé ÓõíÝðåéåò ãéá ôéò ÐïëéôéêÝò Õãåßáò, ÐáðáæÞóçò, 2001, ÁèÞíá. 9. Óïõëéþôçò Ê., Äüëãåñáò Á., Êõñéüðïõëïò Ã. Ç Éêáíïðïßçóç ôùí ×ñçóôþí áðü ôéò Õðçñåóßåò Õãåßáò: ÅñåõíçôéêÜ ÁðïôåëÝóìáôá áðü ôçí Ðåñéï÷Þ ôçò ÁèÞíáò, óåë. 279-296, óôï Êõñéüðïõëïò Ã, ËéïíÞò ×, Óïõëéþôçò Ê, ÔóÜêïò Ã, (åðéì.): Ç Ðïéüôçôá óôéò Õðçñåóßåò Õãåßáò, ÈåìÝëéï, 2003, ÁèÞíá. 10. Luft HS. “Health Maintenance Organizations: Dimensions and Performance, John Wiley and Sons, New York, 1981. 11. Luft HS. “Translating the U.S. HMO Experience to Other Health Systems”, Health Affairs, 10: 172-186, 1991.

12. Lawrwnce D. From Chaos to Care: The promise of Team-Based Medicine, Da Capo Press, Cambridge, 2002. 13. Flynn R, Williams G. “Contracting For Health. Quasi-Markets and the National Health Service”, Oxford University Press, New York, 1997. 14. Lionis C, Chatziarsenis M, Antonakis N, Gianoulis Y, Fioretos M. Assessment of vaccine coverage of school children in three Primary Health Care areas in rural Crete, Greece. Family Practice, 15: 443-448, 1998. 15. Chatziarsenis M, Miyakis S, Faresjö T, Fioretos M, Vlachonicolis J, Trell E, Lionis C. Is there room for General Practice in Penitentiary Institutions: Screening and vaccinating high risk groups against hepatitis. Family Practice, 16: 366-368, 1999.

The European Journal of General Practice ü Ôþñá óôï Index Medicus ü Ôï åðßóçìï ðåñéïäéêü ôçò WONCA Europe ü Åðéóêåöèåßôå ôï óôç äéåýèõíóç http://www.ejgp.com

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ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Á. Ñüäç êáé óõí

ÁÍÁÓÊÏÐÇÓÇ REVIEW Primary Heatlh Care, Volume 16, Number 2, 94-100, 2004 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 16, Ôåý÷ïò 2, 94-100, 2004

Ç ÷ñçóéìüôçôá ôçò óôáôéóôéêÞò åðåîåñãáóßáò ôùí Ðéóôïðïéçôéêþí ÈáíÜôïõ óôçí åêðüíçóç ìåëåôþí èíçóéìüôçôáò ÁèçíÜ Ñüäç1, Ðáíáãéþôá ÓïõñôæÞ2, Å. ÂåëïíÜêçò3

Ðåñßëçøç Óôçí åñãáóßá áõôÞ ìåëåôÞèçêå ç ÷ñçóéìüôçôá ôçò óôáôéóôéêÞò åðåîåñãáóßáò ôïõ ðéóôïðïéçôéêïý èáíÜôïõ óôçí åêðüíçóç ìåëåôþí èíçóéìüôçôáò. ÁíáöÝñïíôáé ç áîßá êáé ïé ðåñéïñéóìïß ôùí ìåëåôþí êáôÜ áéôßåò èíçóéìüôçôáò, ðáñáðÝìðïíôáò óå åñãáóßåò ðïõ ìåëÝôçóáí íüóïõò êáé êáôáóôÜóåéò ðïõ åõèýíïíôáé ãéá ôïõò ðåñéóóüôåñïõò èáíÜôïõò óôçí åðï÷Þ ìáò. ¸ãéíå áíÜëõóç ôïõ åßäïõò ôùí ðëçñïöïñéþí ðïõ ðåñéÝ÷åé ôï ðéóôïðïéçôéêü èáíÜôïõ êáé áíáöÝñèçêáí óôïé÷åßá ðïõ áöïñïýí óôçí áîéïðéóôßá óõìðëÞñùóÞò ôïõ ôüóï óôçí ÅëëÜäá, üóï êáé óå Üëëåò ÷þñåò. ÐåñéãñÜöåôáé ç äéáäéêáóßá óõãêÝíôñùóçò êáé åðåîåñãáóßáò ôùí äåäïìÝíùí, îåêéíþíôáò áðü ôç óõìðëÞñùóç ôïõ “Éáôñéêïý Ðéóôïðïéçôéêïý ÈáíÜôïõ” áðü ôï ãéáôñü Ýùò ôçí ôåëéêÞ äçìïóßåõóç ôùí óôïé÷åßùí êáé ôùí óôáôéóôéêþí èíçóéìüôçôáò áðü ôçí ÅèíéêÞ ÓôáôéóôéêÞ Õðçñåóßá ôçò ÅëëÜäïò (ÅÓÕÅ). Åðéðñüóèåôá, ãßíåôáé áíáöïñÜ óôçí ðñïóâáóéìüôçôá óôéò ðëçñïöïñßåò ôçò ÅÓÕÅ, êáèþò êáé ãéá ôï åßäïò ôùí äåäïìÝíùí ðïõ õðÜñ÷ïõí óôïõò Ïñãáíéóìïýò ÔïðéêÞò Áõôïäéïßêçóçò (ÏÔÁ) êáé ãéá ôïí ôñüðï ðïõ áõôÜ ôá äåäïìÝíá åðåîåñãÜæïíôáé êáé ÷ñçóéìïðïéïýíôáé áðü ôéò áíôßóôïé÷åò õðçñåóßåò. ÔÝëïò, ãßíïíôáé ðñïôÜóåéò ïé ïðïßåò èá ìðïñïýóáí íá âåëôéþóïõí ôéò åëëåßøåéò êáé ðáñáëåßøåéò ôüóï óôï ðéóôïðïéçôéêü èáíÜôïõ, üóï êáé óôç äéáäéêáóßá ôçò åðåîåñãáóßáò ôùí äåäïìÝíùí Ýôóé þóôå íá áõîçèåß ç áîéïðéóôßá ôùí äåäïìÝíùí ðïõ ðñïêýðôïõí áðü ôá ðéóôïðïéçôéêÜ èáíÜôïõ. Ç ×ñçóéìüôçôá ôçò ÓôáôéóôéêÞò Åðåîåñãáóßáò ôùí Ðéóôïðïéçôéêþí ÈáíÜôïõ óôçí Åêðüíçóç Ìåëåôþí Èíçóéìüôçôáò.

1 Íïóçëåýôñéá ÐÅ, 2Íïóçëåýôñéá, Åðßêïõñç ÊáèçãÞôñéá, 3Éáôñüò, ÁíáðëçñùôÞò ÊáèçãçôÞò ÔïìÝáò Äçìüóéáò Õãåßáò, ÔìÞìá ÍïóçëåõôéêÞò, ÐáíåðéóôÞìéï Áèçíþí

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1. ÅéóáãùãÞ Ïé ôáêôéêÝò óôáôéóôéêÝò óåéñÝò áðïôåëïýí óçìáíôéêÞ ðçãÞ ãéá ôç óõëëïãÞ åðéäçìéïëïãéêþí äåäïìÝíùí1-3. Ïé ðåñéóóüôåñåò äçìéïõñãÞèçêáí ìå óêïðü ôçí êÜëõøç íïìéêþí, ìáêñïïéêïíïìéêþí êáé äçìïãñáöéêþí áíáãêþí, üìùò Ýììåóá åîõðçñåôïýí êáé ôçí åðéäçìéïëïãßá4. Ôá äåäïìÝíá ðïõ áðïññÝïõí áðü ôéò ôáêôéêÝò óôáôéóôéêÝò óåéñÝò óõìâÜëëïõí óôçí áðïôýðùóç ôçò óõ÷íüôçôáò, ôçò êáôáíïìÞò êáé ôçò äéá÷ñïíéêÞò åîÝëéîçò ôùí íïóçìÜôùí2. Ïé ôáêôéêÝò óôáôéóôéêÝò óåéñÝò äåí ðñïóöÝñïíôáé ãéá ôïí Ýëåã÷ï óõãêåêñéìÝíùí áéôéïëïãéêþí õðïèÝóåùí, Ý÷ïõí üìùò ôï ðëåïíÝêôçìá üôé åßíáé ðñïóéôÝò êáé ìðïñïýí íá áíáíåþíïíôáé ðåñéïäéêÜ, ÷ùñßò íá áðáéôåßôáé éäéáßôåñç äáðÜíç Þ ðñïóðÜèåéá áðü ôïõò åñåõíçôÝò. Áðü ôçí Üëëç ìåñéÜ, ðáñïõóéÜæïõí êáé óçìáíôéêÜ ìåéïíåêôÞìáôá óå ó÷Ýóç ìå ôçí áêñßâåéá, ôçí ðïéüôçôá êáé ôçí ðëçñüôçôá ôùí ËÝîåéò êëåéäéÜ: Ðéóôïðïéçôéêü èáíÜôïõ, åðéäçìéïëïãßá, èíçóéìüôçôá, äçìïãñáößá, ôáêôéêÝò óôáôéóôéêÝò óåéñÝò ÕðïâëÞèçêå: 16 Éáíïõáñßïõ 2004 ÅðáíõðïâëÞèçêå: 2 Ìáñôßïõ 2004 ¸ãéíå äåêôÞ ãéá äçìïóßåõóç: 26 Ìáñôßïõ 2004 Õðåýèõíïò áëëçëïãñáößáò: Ð. ÓïõñôæÞ, Ðáðáäéáìáíôïðïýëïõ 123, 11527, ÁèÞíá, Ôçë. 210-7461474, fax: 210-7461491, e-mail: psourtzi@nurs.uoa.gr


Ôüìïò 16, Ôåý÷ïò 2, 2004

Á. Ñüäç êáé óõí

The importance of Death Certificate's in the mortality statistics Áthina Rodi, Panagiota Sourtzi, Å. Velonakis Summary To assess the usefulness of statistic processing of the Death Certificate in mortality studies and the value and limitations of mortality studies according to the cause of death as well as important studies, which are concerned with illnesses and circumstances responsible for most deaths today. Analysis of the information contained in the Death Certificate was made and facts were mentioned which concern the reliability of its completion in Greece and in other countries. The complete selection and processing of the data was described in detail beginning with the completion of the "Medical Death Certificate" by the doctor to the final publication of the facts and the death-rate statistics by the National Statistics Department of Greece (NSDG). In addition, a report of the ability to gain access to the information of the NSDG was also made. A report of the type of data that exist in the Local Municipal Organizations (LMO), was made as well as the way that this data are elaborated and used by the corresponding services. Finally, suggestions are mentioned, which could supplement the deficiencies on the completion of the current Death Certificate and of the data process procedure, which can contribute to the improvement of rendering information as well as the reliability of the Death Certificate. Key Words: Death Certificate, Epidemiology, Mortality

óôïé÷åßùí. ÅðéðëÝïí, ôá äåäïìÝíá ôùí ôáêôéêþí óôáôéóôéêþí óåéñþí óõíÞèùò äçìïóéåýïíôáé ìå êáèõóôÝñçóç êáé ÷ùñßò ëåðôïìÝñåéåò ðïõ èá éêáíïðïéïýóáí üëïõò ôïõò åíäéáöåñüìåíïõò åñåõíçôÝò. Ìå ôç âïÞèåéá ôùí óôïé÷åßùí ðïõ êáôáãñÜöïíôáé óôá ðéóôïðïéçôéêÜ èáíÜôïõ êáé ìåôÜ áðü ìéá áêïëïõèßá óõãêÝíôñùóçò êáé åðåîåñãáóßáò ôùí äåäïìÝíùí áðü ôéò ÓôáôéóôéêÝò Õðçñåóßåò êÜèå ÷þñáò, äçìéïõñãïýíôáé äéÜöïñïé ðßíáêåò êáé óôáôéóôéêÝò èíçóéìüôçôáò. Ìå âÜóç áõôÝò ôéò óôáôéóôéêÝò åêðïíïýíôáé ìåëÝôåò ðïõ áöïñïýí ôç èíçóéìüôçôá êáé ðñïâÜëëïõí ôç öýóç ôùí õãåéïíïìéêþí ðñïâëçìÜôùí ðïõ ðáñïõóéÜæïíôáé óôï óõãêåêñéìÝíï ðëçèõóìü êáé åêôéìÜôáé ç êáôÜóôáóç õãåßáò ôïõ5. Åéäéêüôåñá ïé óôáôéóôéêÝò èíçóéìüôçôáò óõìâÜëëïõí óôá åîÞò: Ø áîéïëüãçóç ôïõ ìåãÝèïõò ôùí ðñïâëçìÜôùí õãåßáò óôïí ðëçèõóìü, Ø ó÷åäéáóìü êáé äçìéïõñãßá ðñïãñáììÜôùí ðñüëçøçò êáé ðñùôïâÜèìéáò öñïíôßäáò õãåßáò áðü ôçí ðïëéôåßá5, Ø Ýëåã÷ï êáé âåëôßùóç ôùí ðñïãñáììÜôùí ðñüëçøçò êáé ôùí õðçñåóéþí õãåßáò6,7, Ø åêôßìçóç ôçò áðïôåëåóìáôéêüôçôáò êáé ôç âåëôßùóç ôùí èåñáðåõôéêþí ìåèüäùí áðü ôçí Üëëç6,7, Ø Ýãêáéñç åðéóÞìáíóç åðéäçìéêþí åêñÞîåùí áðü ãñßðç, áôìïóöáéñéêÞ ñýðáíóç Þ Üëëåò áé-

ôßåò, êáé åðïìÝíùò óôçí ôá÷ýôåñç êáé áðïôåëåóìáôéêüôåñç áíôéìåôþðéóÞ ôïõò2.

2. Ôï ðéóôïðïéçôéêü èáíÜôïõ ùò ðçãÞ ðëçñïöïñéþí

Ç êõñéüôåñç éáôñéêÞ óõìâïëÞ óôç äçìéïõñãßá ôùí óôáôéóôéêþí öõóéêÞò êßíçóçò ôïõ ðëçèõóìïý åßíáé ç óýíôáîç ôïõ éáôñéêïý ðéóôïðïéçôéêïý èáíÜôïõ. Ç éóôïñéêÞ åîÝëéîç ôçò äéáìüñöùóçò ôïõ ðéóôïðïéçôéêïý èáíÜôïõ ìÝ÷ñé ôç ìïñöÞ ðïõ Ý÷åé óÞìåñá áíáêëÜ ôéò ðñïóðÜèåéåò âåëôßùóçò ôçò ðëÞñïõò êáôáãñáöÞò ôùí èáíÜôùí êáé ôçò áêñéâïýò äéÜãíùóçò ôçò áéôßáò èáíÜôïõ8. Äõó÷Ýñåéåò óôçí ôáîéíüìçóç ôùí áéôéþí èáíÜôïõ äçìéïõñãïýíôáé üôáí äýï Þ ðåñéóóüôåñåò ðáèïëïãéêÝò êáôáóôÜóåéò óõìâÜëëïõí óôï èÜíáôï9. Ôüôå, èá ðñÝðåé íá åðéëÝîïõìå ìéá áðü ôéò áéôßåò áõôÝò êáé ìÜëéóôá ôçí “áñ÷éêÞ áéôßá èáíÜôïõ”, ðïõ èåùñåßôáé: á) ç íüóïò Þ ç êÜêùóç ðïõ ðñïêÜëåóå ôçí áëõóßäá ôùí íïóçñþí öáéíïìÝíùí ðïõ ïäÞãçóáí óôï èÜíáôï Þ, â) ïé óõíèÞêåò êÜôù áðü ôéò ïðïßåò Ýëáâå ÷þñá ôï áôý÷çìá Þ ç êÜêùóç ðïõ ðñïêÜëåóå èáíáôçöüñï ôñáõìáôéóìü. Ï ãéáôñüò åßíáé õðåýèõíïò ãéá ôç óýíôáîç ôïõ éáôñéêïý ðéóôïðïéçôéêïý áéôßáò èáíÜôïõ Ýôóé, þóôå íá äéåõêïëýíåôáé ç åðéëïãÞ ôçò “áñ÷éêÞò áéôßáò èáíÜôïõ”, üôáí åßíáé êáôá÷ùñçìÝíåò ðåñéóóüôåñåò áðü ìßá8. Ôï éáôñéêü ðéóôïðïéçôéêü èáíÜôïõ áðïôåëåßôáé áðü äýï ìÝñç. Óôï ðñþôï ìÝñïò ðåñéÝ÷ïíôáé ðñïóùðéêÜ ÷áñáêôçñéóôéêÜ ôïõ áðïèáíüíôïò, ï ôüðïò èáíÜôïõ, êáèþò êáé áí ï ðéóôïðïéþí ãéáôñüò åßíáé ï èåñÜðùí Þ Üëëïò. Ôï äåýôåñï ìÝñïò ôïõ éáôñéêïý ðéóôïðïéçôéêïý èáíÜôïõ âáóßæåôáé óôï áíôßóôïé÷ï õðüäåéãìá ôçò “Äéåèíïýò Ôáîéíüìçóçò ÍïóçìÜôùí” (International Classification of Diseases - ICD) ôïõ Ðáãêüóìéïõ Ïñãáíéóìïý Õãåßáò (ÐÏÕ) êáé áöïñÜ ôéò íïóïëïãéêÝò óõíèÞêåò ðïõ ïäÞãçóáí óôï èÜíáôï9-11. Ôï äåýôåñï ìÝñïò ôïðïèåôåßôáé óå ðåñßãñáììá êáé áðïôåëåßôáé áðü ôñßá ôìÞìáôá: ôï É, ôï ÉÉ êáé ôï “åðß âéáßïõ èáíÜôïõ”. 95


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Óôï ôìÞìá É öáßíåôáé ç áéôéïëïãéêÞ áêïëïõèßá ðïõ ïäÞãçóå óôï èÜíáôï. ÓõãêåêñéìÝíá, óôç èÝóç (á) óõìðëçñþíåôáé ç íüóïò Þ ç êáôÜóôáóç åêåßíç ðïõ áðïôÝëåóå ôçí Üìåóç áéôßá èáíÜôïõ. Ùò Üìåóç áéôßá èáíÜôïõ èåùñåßôáé ç ßäéá ç íüóïò, ç êÜêùóç Þ ç åðéðëïêÞ ðïõ ðñïêÜëåóå ôï èÜíáôï, ü÷é üìùò ç ðáèïëåéôïõñãéêÞ äéáôáñá÷Þ Þ ï ìç÷áíéóìüò ôïõ èáíÜôïõ. Áí ç íüóïò Þ ç êáôÜóôáóç ôçò èÝóçò (á) Þôáí óõíÝðåéá ìéáò Üëëçò íüóïõ Þ êáôÜóôáóçò, ôüôå áõôÞ ç Üëëç íüóïò Þ êáôÜóôáóç èá ãñáöôåß óôç èÝóç (â) êáé ïýôù êáè’ åîÞò. Ç áñ÷éêÞ íüóïò Þ êáôÜóôáóç, ðïõ îåêßíçóå ôçí áëëçëïõ÷ßá ôùí íïóçìÜôùí ðïõ ïäÞãçóå óôï èÜíáôï, üðùò åðßóçò êáé ïé ðåñéðôþóåéò áôõ÷Þìáôïò Þ âßáò ðïõ åß÷áí ùò áðïôÝëåóìá ôç èáíáôçöüñï âëÜâç3 ïíïìÜæïíôáé “õðïêåßìåíç áéôßá èáíÜôïõ”, óýìöùíá ìå ôç óýóôáóç ôïõ ÐÏÕ9. Ôï óêåðôéêü ôçò óõãêåêñéìÝíçò áðüöáóçò Þôáí üôé áðü ôç ìéá ìåñéÜ ï êÜèå èÜíáôïò èá Ýðñåðå íá åß÷å ìßá ìüíï “ïíïìáóôéêÞ” áîßá (ãéáôß ôï áíôßèåôï áí êáé åßíáé âéïúáôñéêÜ ðéï óùóôü, èá ðñïêáëïýóå ðïëý ìåãÜëç óýã÷õóç óôéò óôáôéóôéêÝò èíçóéìüôçôáò). Áðü ôçí Üëëç ìåñéÜ, ç áíôéìåôþðéóç ôçò áñ÷éêÞò áéôßáò èáíÜôïõ áðïôåëåß êáé ôç ëïãéêüôåñç ôáêôéêÞ ãéá ôçí áíáêïðÞ ôçò èáíáôçöüñáò áëëçëïõ÷ßáò. Ç áíáãñáöÞ óôç äåîéÜ ðëåõñÜ ôïõ ÷ñüíïõ ðïõ ðÝñáóå áðü ôçí Ýíáñîç ôçò êÜèå íüóïõ Þ êáôÜóôáóçò ìÝ÷ñé ôç óôéãìÞ ôïõ èáíÜôïõ, äéåõêïëýíåé ôç ÷ñïíïëïãéêÞ éåñÜñ÷çóç ôùí íïóçìÜôùí. Áí ç õðïêåßìåíç áéôßá èáíÜôïõ åßíáé êÜêùóç Þ äçëçôçñßáóç, ôüôå ç åîùôåñéêÞ áéôßá ðïõ ðñïêÜëåóå ôçí êÜêùóç ðåñéãñÜöåôáé áíáëõôéêÜ óôï ôñßôï ôìÞìá ôïõ éáôñéêïý ðéóôïðïéçôéêïý, “åðß âéáßïõ èáíÜôïõ”. ÐáñÜëëçëá óçìåéþíåôáé áí ï èÜíáôïò ðïõ åðÞëèå ïöåßëåôáé óå áôý÷çìá, áõôïêôïíßá Þ áíèñùðïêôïíßá. Óôï ôìÞìá ÉÉ áíáãñÜöïíôáé ìå öèßíïõóá áîéïëïãéêÞ óåéñÜ üëåò ïé Üëëåò íüóïé Þ êáôáóôÜóåéò ðïõ Þôáí ðáñïýóåò êáôÜ ôï èÜíáôï êáé ïé ïðïßåò ìðïñåß íá åðçñÝáóáí áñíçôéêÜ ôç íïóïëïãéêÞ åîÝëéîç. ÁõôÝò üìùò äåí áðïôåëïýí “êñßêï” ôçò âáóéêÞò áéôéïëïãéêÞò áëëçëïõ÷ßáò. Äåí åßíáé ëßãåò ïé öïñÝò ðïõ åßíáé äýóêïëï íá áðïöáóßóåé êáíåßò åÜí Ýíá íüóçìá ðñÝðåé íá ðåñéëçöèåß óôï ôìÞìá É Þ óôï ôìÞìá ÉÉ ôïõ éáôñéêïý ðéóôïðïéçôéêïý èáíÜôïõ.

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Á. Ñüäç êáé óõí

3. Áîéïðéóôßá óõìðëÞñùóçò ôïõ ðéóôïðïéçôéêïý èáíÜôïõ Åßíáé ãåãïíüò üôé ç êáôáãñáöÞ ôùí èáíÜôùí óôéò ðåñéóóüôåñåò áíáðôõãìÝíåò ÷þñåò ôïõ êüóìïõ åßíáé ó÷åäüí ðëÞñçò. Ôï ßäéï óõìâáßíåé êáé óôçí ÅëëÜäá. Åíþ üìùò ïé äåßêôåò ôçò áäñÞò èíçóéìüôçôáò, áëëÜ êáé ôçò êáôÜ öýëï êáé çëéêßá èíçóéìüôçôáò õðïëïãßæïíôáé ìå áñêåôÞ áêñßâåéá, äå óõìâáßíåé ôï ßäéï êáé ãéá ôïõò äåßêôåò ôçò åéäéêÞò êáôÜ áéôßá èíçóéìüôçôáò12-14. Ðïëëïß ðáñÜãïíôåò óõìâÜëëïõí óôç äçìéïõñãßá áõôïý ôïõ öáéíïìÝíïõ: É) åßíáé ðéèáíü ï ãéáôñüò ðïõ óõìðëçñþíåé ôï ðéóôïðïéçôéêü èáíÜôïõ íá ìç ãíùñßæåé ôçí ðñáãìáôéêÞ áéôßá èáíÜôïõ. Áõôü ìðïñåß íá óõìâáßíåé ãéá äéÜöïñïõò ëüãïõò, üðùò: á) ç íüóïò áðü ôç öýóç ôçò åßíáé äõóäéÜãíùóôç â) äåí æçôÞèçêå Þ äåí Ýãéíå íåêñïôïìÞ ã) äåí õðÞñ÷áí ôá êáôÜëëçëá äéáãíùóôéêÜ ôå÷íïëïãéêÜ ìÝóá ä) ï ãéáôñüò ðïõ ðéóôïðïéåß ôï èÜíáôï äåí åßíáé ï èåñÜðùí ãéáôñüò å) ï ãéáôñüò ðïõ óõìðëçñþíåé ôï ðéóôïðïéçôéêü èáíÜôïõ äåí åßíáé áñêåôÜ êáôáñôéóìÝíïò Þ åíçìåñùìÝíïò ÉÉ) ï ãéáôñüò ðïõ ðéóôïðïéåß ôï èÜíáôï ìðïñåß íá ãíùñßæåé ôçí ðñáãìáôéêÞ áéôßá ðïõ ôïí ðñïêÜëåóå, üìùò äå ãíùñßæåé ìå ðïéï ôñüðï ðñÝðåé íá óõìðëçñùèåß ôï ðéóôïðïéçôéêü èáíÜôïõ. ÉÉÉ) ï ãéáôñüò ãíùñßæåé ôçí áéôßá èáíÜôïõ, áëëÜ áäéáöïñåß ãéá ôç óõìðëÞñùóç ôïõ ðéóôïðïéçôéêïý èáíÜôïõ, ãéáôß ôï áíôéìåôùðßæåé óáí ìéá åíï÷ëçôéêÞ ãñáöåéïêñáôéêÞ äéáäéêáóßá. IV) åßíáé ðéèáíü íá ãßíïíôáé óöÜëìáôá êáôÜ ôçí êùäéêïðïßçóç ôùí áéôéþí èáíÜôïõ. Áõôü ìðïñåß íá óõìâáßíåé ôüóï óôá Ëçîéáñ÷åßá, üóï êáé óôéò êåíôñéêÝò óôáôéóôéêÝò õðçñåóßåò. ÁñêåôÝò öïñÝò óõìâáßíåé óôçí ðñüêëçóç ôïõ èáíÜôïõ íá óõìâÜëëïõí ðåñéóóüôåñåò áðü ìßá áéôßåò. Ôüôå äçìéïõñãåßôáé ðñüâëçìá ùò ðñïò ôç óõìðëÞñùóç ôïõ éáôñéêïý ðéóôïðïéçôéêïý èáíÜôïõ2. Éäéáßôåñá óå ðåñéðôþóåéò ðïõ õðÜñ÷åé ôñáõìáôéóìüò êáé ï áóèåíÞò äåí ðåèáßíåé áìÝóùò, áëëÜ êáôáëÞãåé áñãüôåñá áðü Üëëåò åðéðëïêÝò, áíáìåíüìåíåò Þ ü÷é. Åðßóçò, óå ðåñéðôþóåéò ðïõ ï èÜíáôïò åðÝñ÷åôáé êáôÜ ôç äéÜñêåéá ìéáò ÷åé-


Á. Ñüäç êáé óõí

ñïõñãéêÞò åðÝìâáóçò Þ ðåñéåã÷åéñçôéêÜ15. Ç áíáêñßâåéá êáôÜ ôç óõìðëÞñùóç ôïõ ðéóôïðïéçôéêïý èáíÜôïõ óõ÷íÜ ïöåßëåôáé óôç óýã÷õóç ðïõ ðñïêáëåßôáé, üôáí óõã÷Ýåôáé ç “õðïêåßìåíç áéôßá èáíÜôïõ” ìå ôçí “Üìåóç áéôßá èáíÜôïõ”16. Ãéá ðáñÜäåéãìá, óå ìßá Ýñåõíá 68 óõìðëçñùìÝíùí ðéóôïðïéçôéêþí, äåí õðÞñ÷å ïýôå Ýíá ðïõ íá ðåñéÝ÷åé ôç óùóôÞ “õðïêåßìåíç áéôßá” áðü áõôÝò ðïõ åß÷áí áíáãñáöåß17, åíþ åîßóïõ áíçóõ÷çôéêÜ åõñÞìáôá ðñïêýðôïõí êáé áðü Üëëåò ðñüóöáôåò ìåëÝôåò óôçí ÅëëÜäá êáé óôï åîùôåñéêü13,14,18. Ç ðéóôïðïßçóç ôïõ èáíÜôïõ áðü Üôïìï Üëëï, åêôüò ôïõ ãéáôñïý, áðïôåëåß ëüãï ãéá ðéèáíÜ óöÜëìáôá êáôÜ ôç óõìðëÞñùóç ôïõ ðéóôïðïéçôéêïý èáíÜôïõ. Óôç ÷þñá ìáò óÞìåñá ðñáêôéêÜ äåí óõìâáßíåé, áöïý óå óýíïëï 102.668 èáíÜôùí ôï 1998 ïé 102.323 (99,7%) ðéóôïðïéÞèçêáí áðü ôï èåñÜðïíôá Þ Üëëï ãéáôñü4. Ôá êõñéüôåñá óöÜëìáôá óôçí ÅëëÜäá öáßíåôáé üôé Þôáí ç åëëéðÞò êáôáìÝôñçóç ôùí âñåöéêþí èáíÜôùí êáé ôùí ãåííÞóåùí íåêñþí, êáèþò êáé ôï ó÷åôéêÜ ìåãÜëï ðïóïóôü ôùí èáíÜôùí ìå Üãíùóôç áéôßá, óýìöùíá ìå ôá óôïé÷åßá ôïõ 1980 ôçò ÅÓÕÅ. Ôï ðïóïóôü áõôü ðáñïõóéÜæåé ìåßùóç êáé óõìâáäßæåé ìå ôçí áýîçóç ôïõ ðïóïóôïý ôùí èáíÜôùí ðïõ óõìâáßíïõí óå íïóïêïìåßá êáé êëéíéêÝò êáé ìå ôçí Ýóôù êáé ìéêñÞ âåëôßùóç ôçò êáôáíïìÞò ôùí êÝíôñùí õãåßáò óôéò äéÜöïñåò ðåñéï÷Ýò ôçò ÷þñáò16. ÊáôÜ ðïëëïýò åðéóôÞìïíåò, ïé áíáêñßâåéåò óôá ðéóôïðïéçôéêÜ èáíÜôïõ äéåèíþò, äåí Ý÷ïõí ðëÞñùò åêñéæùèåß, ìå áðïôÝëåóìá áõôÜ íá ìçí åßíáé ðëÞñùò áîéüðéóôá19,20. Óýìöùíá ìå Ýñåõíåò ðïõ Ý÷ïõí ðñáãìáôïðïéçèåß, ìüíï ôï 35% ôïõ ðáãêüóìéïõ ðëçèõóìïý êáëýðôåôáé áðü åðáñêÝò óýóôçìá êáôáãñáöÞò êáé ðéóôïðïßçóçò ôùí èáíÜôùí21. ÊáôÜ ðáñáäï÷Þ ôùí ßäéùí ôùí ãéáôñþí, ðïëëÝò öïñÝò ç óõìðëÞñùóç ôçò áéôßáò èáíÜôïõ óôï ðéóôïðïéçôéêü èáíÜôïõ ãßíåôáé ìå âÜóç õðïøßåò êáé õðïèÝóåéò22. Õðü áìöéóâÞôçóç ôßèåíôáé åðïìÝíùò êáé ïé óôáôéóôéêÝò ðïõ âáóßæïíôáé óôçí êáôÜ áéôßá èíçóéìüôçôá23-25. Áðü ìéá ìéêñÞ ìåëÝôç ôùí “Éáôñéêþí Ðéóôïðïéçôéêþí ÈáíÜôïõ” (ðïõ óõìðëçñþèçêáí áðü ôïí ÉáíïõÜñéï ìÝ÷ñé ôï ÓåðôÝìâñéï ôïõ 2001) ðïõ ðñáãìáôïðïéÞèçêå óå ÄÞìï ôçò ÄõôéêÞò ÁôôéêÞò, äéáðéóôþèçêå üôé ç óõìðëÞñùóÞ ôïõò áðü ôïõò ãéáôñïýò åßíáé ôïõëÜ÷éóôïí áíåðáñêÞò26. Óôï 50% ðåñßðïõ áðü ôá 199 ðéóôïðïéçôéêÜ

Ôüìïò 16, Ôåý÷ïò 2, 2004

èáíÜôïõ äåí Þôáí óõìðëçñùìÝíá ðáñÜ ìüíï ôá âáóéêÜ óôïé÷åßá ôïõ èáíüíôïò, äçëáäÞ ôï ïíïìáôåðþíõìï êáé ç ìüíéìç êáôïéêßá ôïõ, êáèþò êáé ôá óôïé÷åßá ôïõ ãéáôñïý ðïõ ðéóôïðïßçóå ôï èÜíáôï êáé ïé áéôßåò èáíÜôïõ. Óå ü,ôé áöïñÜ ôç óõìðëÞñùóç ôïõ åðáããÝëìáôïò, üôáí áõôÞ ãßíåôáé åßíáé ðïëý ãåíéêÞ (ð.÷. óõíôáîéïý÷ïò, äçìüóéïò õðÜëëçëïò ê.ëð.), ðáñÜ ôéò óáöåßò ïäçãßåò áðü ôçí ÅÓÕÅ üôé ðñÝðåé íá áðïöåýãïíôáé ïé ãåíéêüôçôåò êáé íá áíáãñÜöåôáé ç åéäéêüôçôá ôçò áðáó÷üëçóçò êáé ôï åßäïò ôçò áôïìéêÞò åñãáóßáò. Óôéò ìéóÝò ðåñßðïõ ðåñéðôþóåéò óõìðëçñþíåôáé êáé ôï ìÝñïò üðïõ óõíÝâç ï èÜíáôïò. Áðü ôá ðéóôïðïéçôéêÜ ðïõ åß÷áí óõìðëçñùìÝíï áõôü ôï åñþôçìá, ïé ðåñéóóüôåñïé èÜíáôïé óõíÝâçóáí åßôå óôá íïóïêïìåßá, åßôå óå éäéùôéêÝò êáôïéêßåò. Óôç óõìðëÞñùóç ôùí áéôéþí èáíÜôïõ ãßíåôáé ðñáãìáôéêÜ áíôéëçðôü áõôü ðïõ óôç âéâëéïãñáößá áíáöÝñåôáé ùò óõìðëÞñùóç ôùí áéôéþí “êáôÜ ôï äïêïýí”. Åßíáé ÷áñáêôçñéóôéêü üôé áðü ôá 199 ðéóôïðïéçôéêÜ ðïõ åîåôÜóôçêáí ìüíï ôá 17 Þôáí óùóôÜ êáé ðëÞñùò óõìðëçñùìÝíá. Óôéò õðüëïéðåò ðåñéðôþóåéò, ç ÷ñïíéêÞ äéÜñêåéá äåí Þôáí óõìðëçñùìÝíç êáé ïé áéôßåò åßôå äåí Þôáí ìå ôç óùóôÞ óåéñÜ (ç õðïêåßìåíç áéôßá áíáöåñüôáí ðñþôç êáé ç êáôÜóôáóç ðïõ ðñïêÜëåóå ôï èÜíáôï ôåëåõôáßá), åßôå ÷áñáêôçñéæüôáí áðü ãåíéêüôçôåò, åßôå êáôáãñáöüôáí ï ôñüðïò èáíÜôïõ êáé ü÷é ç êáôÜóôáóç ðïõ ôïí ðñïêÜëåóå. Óå áñêåôÝò ðåñéðôþóåéò (29 [15%] ðéóôïðïéçôéêÜ) ôá ðéóôïðïéçôéêÜ äåí Þôáí åõáíÜãíùóôá ìå áðïôÝëåóìá íá áðáéôïýíôáé äéåõêñéíßóåéò áðü ôïõò ãéáôñïýò ðïõ ôá óõìðëÞñùóáí.

4. Áêïëïõèßá óõãêÝíôñùóçò êáé åðåîåñãáóßáò äåäïìÝíùí Ï ãéáôñüò åßíáé åêåßíïò ðïõ ðéóôïðïéåß êáé êáôáãñÜöåé ôï óõìâÜí óôï “Éáôñéêü Ðéóôïðïéçôéêü ÈáíÜôïõ”. Ï èÜíáôïò êáôá÷ùñåßôáé, êáôÜ êáíüíá, óôï Ëçîéáñ÷åßï ôïõ ÄÞìïõ ôçò ðåñéï÷Þò üðïõ óõíÝâç åíôüò 24 ùñþí, ìå âÜóç ôï Éáôñéêü Ðéóôïðïéçôéêü ÈáíÜôïõ êáé ôçí ôáõôüôçôá ôïõ íåêñïý Þ õðåýèõíç äÞëùóç áðþëåéáò áõôÞò. ¼ôáí ôá ðáñáðÜíù ðñïóêïìéóèïýí ôüôå åêäßäåôáé ç Âåâáßùóç ÈáíÜôïõ êáé ç ¢äåéá TáöÞò áðü ôï ÄÞìï óôïí ïðïßï èá ãßíåé ç ôáöÞ. Ôï ðáñáðÜíù Ýíôõðï ðåñéÝ÷åé ôüóï ôçí õðïãñáöÞ ôïõ Ëçîßáñ÷ïõ, üóï êáé áõôÞí ôïõ ÄçìÜñ÷ïõ. Ç 97


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

âåâáßùóç èáíÜôïõ êáé ç Üäåéá ôáöÞò áðïôåëåßôáé áðü ôñßá (3) ðáíïìïéüôõðá áðïêüììáôá: Ýíá ãéá ôï ÄÞìï (íåêñïôáöåßï), Ýíá ãéá ôïí åíäéáöåñüìåíï (óõíÞèùò ç ïéêïãÝíåéá ôïõ íåêñïý) êáé Ýíá ãéá ôïí éåñÝá ðïõ èá ôåëÝóåé ôç íåêñþóéìç áêïëïõèßá. Ìå ôïí ôñüðï áõôü áðïöåýãåôáé ç ðáñÜëåéøç êáôáãñáöÞò ôïõ èáíÜôïõ, áëëÜ êáé ç äéðëÞ åããñáöÞ ôïõ. Óå üëá ôá Ëçîéáñ÷åßá ç êáôá÷þñéóç ôçò Ëçîéáñ÷éêÞò ÐñÜîçò ÈáíÜôïõ ãßíåôáé óå åéäéêïýò ôüìïõò êáé ü÷é çëåêôñïíéêÜ. Ôï Ëçîéáñ÷åßï åêäßäåé ôï Äåëôßï ÈáíÜôïõ ìå âÜóç ôï éáôñéêü ðéóôïðïéçôéêü. ÁñêåôÜ áðü ôá óôïé÷åßá ðïõ äåí óõìðëçñþíïíôáé áðü ôï ãéáôñü óôï ðéóôïðïéçôéêü èáíÜôïõ (üðùò ð.÷. ôüðïò ãÝííçóçò, åðßðåäï åêðáßäåõóçò, ïéêïãåíåéáêÞ êáôÜóôáóç ê.ëð.) êáôáãñÜöïíôáé áðü ôï Ëçîßáñ÷ï êáé ôïõò õðáëëÞëïõò ôïõ Ëçîéáñ÷åßïõ êáôÜ ôç äÞëùóç ôïõ èáíÜôïõ óôïí áíôßóôïé÷ï ÄÞìï ïýôùò þóôå ôï “Äåëôßï ÈáíÜôïõ” ðïõ áðïóôÝëëåôáé óôçí áñìüäéá Õðçñåóßá ÓôáôéóôéêÞò ôïõ Íïìïý íá åßíáé ðëÞñùò óõìðëçñùìÝíï. Ç Õðçñåóßá ÓôáôéóôéêÞò êÜèå Íïìïý, áöïý óõãêåíôñþóåé êáé åëÝãîåé ôá Äåëôßá ÈáíÜôïõ, ôá áðïóôÝëëåé óôç “Äéåýèõíóç Ðëçèõóìïý êáé Áðïãñáöþí” ôçò ÅèíéêÞò ÓôáôéóôéêÞò Õðçñåóßáò (ÅÓÕÅ), üðïõ ãßíåôáé ç êùäéêïðïßçóç áðü ÷åéñéóôÝò çëåêôñïíéêþí õðïëïãéóôþí. Óå ü,ôé áöïñÜ ôïí Ýëåã÷ï ãéá ôéò áéôßåò èáíÜôïõ åéäéêüôåñá, õðÜñ÷ïõí óôçí ÅÓÕÅ äýï Üôïìá ðïõ åñåõíïýí åðéðñüóèåôá Ýíá-Ýíá ôá áðïóôåëëüìåíá “Äåëôßá ÈáíÜôïõ” ãéá íá äéáðéóôþóïõí åÜí õðÜñ÷åé êÜðïéï ëÜèïò êáôÜ ôç óõìðëÞñùóÞ ôïõò. Ôï Ýíá Üôïìï áó÷ïëåßôáé ìå ôçí ôáîéíüìçóç ôùí üãêùí, åíþ ôï Üëëï ìå üëåò ôéò õðüëïéðåò ðåñéðôþóåéò èáíÜôïõ. ¼ôáí ïëïêëçñùèåß ï áðáéôïýìåíïò Ýëåã÷ïò, ôüôå ðñáãìáôïðïéåßôáé ç åðåîåñãáóßá ôùí äåäïìÝíùí çëåêôñïíéêÜ. ÁðïôÝëåóìá ôçò åðåîåñãáóßáò åßíáé ç êáôÜñôéóç ðéíÜêùí áéôéþí, ðïõ öèÜíïõí ôïí áñéèìü 130. Áðü áõôïýò äçìïóéåýïíôáé ìüíï ïé 35, óôç “ÓôáôéóôéêÞ ôçò ÖõóéêÞò Êßíçóçò ôïõ Ðëçèõóìïý ôçò ÅëëÜäïò”, áí êáé ìå êáèõóôÝñçóç ôñéþí Ýùò ôåóóÜñùí åôþí4. Ç êùäéêïðïßçóç ãéá ôéò áéôßåò èáíÜôïõ ãßíåôáé óýìöùíá ìå âÜóç ôç “ÄéåèíÞ Ôáîéíüìçóç ÍïóçìÜôùí” (ICD) ôïõ ÐÏÕ, ãéá äå ôá åðáããÝëìáôá ìå âÜóç ôç ÓôáôéóôéêÞ Ôáîéíüìçóç ôùí ÅðáããåëìÜôùí ðïõ åêäüèçêå ôï 1992 (ÓÔÅÐ92), ç ïðïßá âáóßæåôáé óôç ÄéåèíÞ ÔõðïðïéçìÝíç Ôáîéíüìçóç ôùí ÅðáããåëìÜôùí (International 98

Á. Ñüäç êáé óõí

Classification of Occupations-ISCO)9,10,27,28. Áðü ôá ðáñáðÜíù åßíáé åìöáíÝò üôé ç êùäéêïðïßçóç åßíáé ìéá äéáäéêáóßá áñêåôÜ ðïëýðëïêç, ãé’ áõôü êáé áðáéôåßôáé êáé éäéáßôåñç ðñïóï÷Þ üôáí áõôÞ ãßíåôáé.

5. Ðñïóâáóéìüôçôá óôéò ðëçñïöïñßåò ôçò ÅÓÕÅ Ï üãêïò ôùí ðëçñïöïñéþí ðïõ åðåîåñãÜæåôáé ç ÅÓÕÅ åßíáé ôåñÜóôéïò. ÁíÜëïãçò äéÜóôáóçò åßíáé êáé ïé ðëçñïöïñßåò ðïõ áðïññÝïõí áðü ôçí ðáñáðÜíù åðåîåñãáóßá. Ïé óôáôéóôéêÝò ðïõ äçìïóéåýïíôáé óôï ðëáßóéï ôïõ åèíéêïý óôáôéóôéêïý ðñïãñÜììáôïò áðïôåëïýí äçìüóéï áãáèü, ðñïóéôü óôï êïéíü29. Ï ïðïéïóäÞðïôå åíäéáöåñüìåíïò ìðïñåß íá Ý÷åé ðñüóâáóç óôéò ðëçñïöïñßåò ó÷åôéêÜ ìå ôï èÝìá ðïõ ôïí åíäéáöÝñåé, áöïý üëåò ïé åêäüóåéò (åëëçíéêÝò êáé ïé êõñéüôåñåò äéåèíåßò) âñßóêïíôáé óôç ÂéâëéïèÞêç ôçò ÅÓÕÅ. Åêåß ï åíäéáöåñüìåíïò ìðïñåß íá êÜíåé áßôçóç ãéá ðáñï÷Þ áêüìç êáé óôïé÷åßùí ðïõ äåí åßíáé äçìïóéåõìÝíá êáé íá åíçìåñùèåß ãéá ôï ðåäßï áíáöïñÜò êáé ôïí ôñüðï áðüêôçóçò ôùí óôáôéóôéêþí ðëçñïöïñéþí ðïõ åðéèõìåß. Ç áßôçóÞ ôïõ ãßíåôáé äåêôÞ êáé éêáíïðïéåßôáé ìüíïí åöüóïí äåí ðñïóâÜëëåé ôï áðüññçôï ôùí ðëçñïöïñéþí. Óýìöùíá ìå ôïõò êáíüíåò ëåéôïõñãßáò ôçò ÅÓÕÅ, üëåò ïé ðëçñïöïñßåò ðïõ óõëëÝãïíôáé ìÝóù áðïãñáöþí, åíäéÜìåóùí áðïãñáöþí, åñåõíþí êáé ëïéðþí åñãáóéþí áðü êñáôéêÜ ìçôñþá êáé áñ÷åßá (ÄÞìïé, Õðçñåóßåò ÓôáôéóôéêÞò ôùí Íïìþí, ÅÓÕÅ) ÷ñçóéìïðïéïýíôáé áðïêëåéóôéêÜ êáé ìüíï ãéá óôáôéóôéêïýò óêïðïýò, èåùñïýíôáé åìðéóôåõôéêÝò êáé äå äçìïóéåýïíôáé ùò Ý÷ïõí. ÄçëáäÞ, óå êáìßá ðåñßðôùóç äåí åðéôñÝðåôáé íá äçìïóéïðïéïýíôáé ôá óôïé÷åßá åíüò ðéóôïðïéçôéêïý èáíÜôïõ, üðùò åêåßíï Ý÷åé óõìðëçñùèåß åßôå áðü ôï ãéáôñü ðïõ ðéóôïðïßçóå ôï èÜíáôï, åßôå áðü ôïí áñìüäéï õðÜëëçëï ôïõ Ëçîéáñ÷åßïõ üðïõ äçëþèçêå26,27. Ôï ßäéï éó÷ýåé êáé óôçí ðåñßðôùóç ôùí ÄÞìùí, äçëáäÞ åÜí êÜðïéïò åðéèõìåß íá óõëëÝîåé Þ íá åñåõíÞóåé óôïé÷åßá ó÷åôéêÜ ìå ôïõò èáíÜôïõò ìðïñåß íá ôï êÜíåé îåöõëëßæïíôáò ôá ìçôñþá, áëëÜ äåí åðéôñÝðåôáé íá óçìåéþíåé êáé ôá ïíüìáôá ìáæß ìå ôéò ëïéðÝò ðëçñïöïñßåò. ¼ôáí êÜðïéïò áíáæçôÞóåé óôïé÷åßá áðü ôçí ÅÓÕÅ ðïõ èåùñïýíôáé åìðéóôåõôéêÜ, ôüôå óõíÝñ÷åôáé åéäéêÞ åðéôñïðÞ, ðïõ ïíïìÜæåôáé “ÅðéôñïðÞ Óôáôéóôéêïý ÁðïññÞôïõ”29 êáé êñßíåé åÜí åß-


Ôüìïò 16, Ôåý÷ïò 2, 2004

Á. Ñüäç êáé óõí

íáé óêüðéìï íá äïèïýí ôá áéôïýìåíá óôïé÷åßá. Óôïõò ÄÞìïõò, åßíáé áíáãêáßá ç åéóáããåëéêÞ Üäåéá ãéá ôçí áíáæÞôçóç êáé äéåñåýíçóç ôùí æçôïýìåíùí óôïé÷åßùí. Ç äçìïóéïðïßçóç ôùí óôïé÷åßùí ðïõ ðñïêýðôïõí áðü ôçí åðåîåñãáóßá ôùí ðëçñïöïñéþí ôçò ÅÓÕÅ óýìöùíá ìå ôï Üñèñï 7 ôïõ Í 2392/ 9629, åðéôñÝðåôáé íá ãßíåôáé ìüíï óå óõãêåíôñùôéêïýò ðßíáêåò, þóôå íá áðïêëåßåôáé ç Üìåóç Þ Ýììåóç áðïêÜëõøç ôçò ôáõôüôçôáò åêåßíùí ôïõò ïðïßïõò áöïñÜ ôï ðñùôïãåíÝò óôáôéóôéêü õëéêü êáé íá äéáóöáëßæåôáé ðëÞñùò ç åìðéóôåõôéêüôçôá ôùí óôïé÷åßùí.

6. ÐñïôÜóåéò óõìðëÞñùóçò-âåëôßùóçò ¸÷ïíôáò õðüøç ôéò äéáðéóôþóåéò ðïõ åêôßèåíôáé ðéï ðÜíù, ðñïôåßíïíôáé ïé ðáñáêÜôù âåëôéþóåéò þóôå ôï ðñïôåéíüìåíï áðü ôïí ÐÏÕ ðéóôïðïéçôéêü èáíÜôïõ íá óõìðëçñþíåôáé êáé íá êùäéêïðïéåßôáé ìå ìåãáëýôåñç áêñßâåéá, êáèþò êáé íá áíáëýåôáé ìå ôñüðï ðïõ ôá óôïé÷åßá íá åßíáé ÷ñÞóéìá óôïõò åñåõíçôÝò êáé ó’ üóïõò Ý÷ïõí åõèýíç ãéá ôïí ðñïãñáììáôéóìü ôùí õðçñåóéþí õãåßáò1-3,5,16,21-24,30. Ïé âåëôéþóåéò áõôÝò ìðïñåß íá ðåñéëáìâÜíïõí: • ×ñÞóç ôïõ åéäéêïý ðéóôïðïéçôéêïý íåêñïãÝííçóçò êáé èáíÜôïõ íåïãíïý, ðïõ ðñïôåßíåôáé áðü ôïí ÐÏÕ êáé Ý÷åé áðïäå÷ôåß ç ÷þñá ìáò9, • ÐëçñÝóôåñç åêðáßäåõóç ôùí öïéôçôþí ãéá ôïí ôñüðï óõìðëÞñùóçò ôïõ ðéóôïðïéçôéêïý èáíÜôïõ êáé ãéá ôç óçìáóßá ôçò áêñéâïýò äéÜãíùóçò óýìöùíá ìå ôï ëåðôïìåñÞ êáôÜëïãï ôçò ÄÔÍ, áëëÜ êáé áîéïëüãçóç ôùí ãéáôñþí óôç óõìðëÞñùóç ôïõ ðéóôïðïéçôéêïý èáíÜôïõ, • óõìðëÞñùóç ôïõ ðéóôïðïéçôéêïý èáíÜôïõ áðü äýï Üôïìá îå÷ùñéóôÜ (äåýôåñï éáôñü Þ êáé íïóçëåõôÞ), • ðáñáêïëïýèçóç åéäéêþí óåìéíáñßùí áðü ôïõò õðáëëÞëïõò ôùí Ëçîéáñ÷åßùí êáé ôçò ÅÓÕÅ ãéá ôïí ôñüðï óõìðëÞñùóçò êáé êùäéêïðïßçóçò ôùí Äåëôßùí ÈáíÜôïõ, • ÷ñçóéìïðïßçóç ðåñéóóïôÝñùí “äéêëåßäùí áóöáëåßáò” êáôÜ ôçí êùäéêïðïßçóç óôçí ÅÓÕÅ, • ôõ÷áßïò äåéãìáôïëçðôéêüò Ýëåã÷ïò áðü ôá áñ÷åßá ôçò ÅÓÕÅ, þóôå íá äéáðéóôþíåôáé

• •

åÜí Ý÷ïõí óõìðëçñùèåß êáé êùäéêïðïéçèåß óùóôÜ ôá Äåëôßá ÈáíÜôïõ, çëåêôñïíéêÞ êáôáãñáöÞ Þ êáé êùäéêïðïßçóç óôá Ëçîéáñ÷åßá êáé áðïóôïëÞ óôçí ÅÓÕÅ ãéá ðåñáéôÝñù Ýëåã÷ï, ðéíáêïðïßçóç êáé åêðüíçóç óôáôéóôéêþí èíçóéìüôçôáò, åðéðñüóèåôç êáôá÷þñéóç óôï Äåëôßï ÈáíÜôïõ êáé êùäéêïý áñéèìïý (ð.÷. ÁÖÌ), üðùò åðßóçò ôïõ ôüðïõ ãÝííçóçò, ôçò õðçêïüôçôáò êáé ôçò äéÜñêåéáò äéáìïíÞò óôç ìüíéìç êáôïéêßá, åðéðÝäïõ ìüñöùóçò êáé ïéêïíïìéêÞò êáôÜóôáóçò, áíáëõôéêüôåñç êùäéêïðïßçóç óôï åðÜããåëìá ôïõ èáíüíôá ìå âÜóç ôçí ôáîéíüìçóç åðáããåëìÜôùí ôïõ Äéåèíïýò Ãñáöåßïõ Åñãáóßáò, êáôáãñáöÞ ãéá ôï åÜí Ý÷åé ãßíåé íåêñïôïìÞ, ðåñéïñéóìüò ôùí åíôýðùí ðïõ áðáéôïýíôáé êáé óõìðëçñþíïíôáé óôá Ëçîéáñ÷åßá ôùí ÄÞìùí (ð.÷. âåâáßùóç èáíÜôïõ, åíïðïßçóç Éáôñéêïý Ðéóôïðïéçôéêïý êáé Äåëôßïõ ÈáíÜôïõ).

7. ÓõìðåñÜóìáôá Ç óçìáóßá ôçò ïñèÞò óõìðëÞñùóçò ôïõ ðéóôïðïéçôéêïý èáíÜôïõ åßíáé ìåãÜëç ãéá ôçí åîáãùãÞ ðïëýôéìùí åñåõíçôéêþí óõìðåñáóìÜôùí. Ç âåëôßùóç ôïõ ôñüðïõ óõìðëÞñùóçò ôçò áéôßáò èáíÜôïõ óôï ðéóôïðïéçôéêü èáíÜôïõ áðü ôïõò éáôñïýò, óýìöùíá ìå ôéò ïäçãßåò ôïõ ÐÏÕ, åßíáé ðñùôáñ÷éêÞò óçìáóßáò. Ï åìðëïõôéóìüò ôïõ åíôýðïõ ðïõ ÷ñçóéìïðïéåßôáé óÞìåñá ìå ðåñéóóüôåñåò ðëçñïöïñßåò ãéá ôï èáíüíôá, èá ìðïñïýóå íá áðïäåé÷ôåß ìáêñïðñüèåóìá ÷ñÞóéìç. ÔÝëïò ç áðëïýóôåõóç ôçò äéáäéêáóßáò äÞëùóçò êáé êáôáãñáöÞò áðü ôï Ëçîéáñ÷åßï êáé ôçí ÅÓÕÅ èá ðåñéïñßóåé ôçí ðéèáíüôçôá ëÜèïõò êáé èá êÜíåé åõ÷åñÝóôåñç ôçí åðåîåñãáóßá ôùí äåäïìÝíùí.

Âéâëéïãñáößá 1. Êáôóïõãéáííüðïõëïò Â×. ÕãéåéíÞ êáé ÊïéíùíéêÞ ÉáôñéêÞ, ôüìïò 2ïò, Åêäïôéêüò ïßêïò Áöùí Êõñéáêßäç Á.Å, 1997. 2. Ôñé÷üðïõëïò Ä. Åðéäçìéïëïãßá-áñ÷Ýò, ìÝèïäïé, åöáñìïãÝò. ÅðéóôçìïíéêÝò åêäüóåéò Ãñ. ÐáñéóéÜíïò, 1982. 3. ÄçìïëéÜôçò ÃÄ. ÂéïóôáôéóôéêÞ äéåñåýíçóç ôçò èíçóéìüôçôáò óôçí ÅëëÜäá, 1956-1982. Äéäá99


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êôïñéêÞ äéáôñéâÞ, ÉùÜííéíá 1988. 4. ÓôáôéóôéêÞ ôçò ÖõóéêÞò Êßíçóçò ôïõ Ðëçèõóìïý ôçò ÅëëÜäáò, Ýôïõò 1998. ÅÓÕÅ, 1999. 5. ÐáðáåõáããÝëïõ Ã, Ôóßìðïò Ê. ÌåëÝôç ôçò åîåëßîåùò ôçò èíçóéìüôçôáò áðü êáñäéáêÝò ðáèÞóåéò óôçí ÅëëÜäá. Áñ÷ Åëëçí ÉáôñéêÞò, 1:476482, 1984. 6. Êïãåâßíáò Ì, ÊáôóïõãéÜííç Ê, Maisonneuve P, Ôñé÷üðïõëïò Ä. Èíçóéìüôçôá áðü êáêïÞèç íåïðëÜóìáôá óôéò ÷þñåò ôçò ÅÏÊ, 1955-1987. ÉáôñéêÞ 64:264-274, 1993. 7. Huffman GB. Death Certificates: Why it Matters How Your Patient Died. Am Fam Physician, 56:1287-1290, 1997. 8. ÐáðáåõáããÝëïõ Ã, Ôóßìðïò Ê. ÉáôñéêÞ Äçìïãñáößá êáé ïéêïãåíåéáêüò ðñïãñáììáôéóìüò. Åêäüóåéò ÂÇÔÁ, ÁèÞíá, 1993. 9. ICD-10. International Statistical Classification of Diseases and Related Health Problems. Tenth Revision. Volume 2. WHO, Geneva, 1993. 10. World Health Organization. Medical certification of cause of death. Instructions for physicians on use of international form of medical certificate of causes of death. Geneva, WHO, 1979. 11. Õðïõñãåßï Åóùôåñéêþí. Íüìïé êáé ðñïåäñéêÜ äéáôÜãìáôá ðåñß ëçîéáñ÷éêþí ðñÜîåùí. Ïäçãßåò ãéá ôçí åöáñìïãÞ ôùí äéáôÜîåùí áõôþí. ÁèÞíá, Åèíéêü Ôõðïãñáöåßï, 1977. 12. Dallas RJ. Accuracy of death certification. N Z Med J, 113:385-6, 2000. 13. Lionis CD, Koutis AD, Antonakis N, Isacsson A, Lindholm LH, Fioretos M. Mortality rates in a cardiovascular “low-risk” population in rural Crete. Family Practice, 10:300-4, 1993. 14. Lionis C, Sasarolis S, Kasotakis GI, Lapidakis GM, Stathopoulos AI. Investigation of accuracy of death certificate completion and implications on mortality statistics in Greece. Letter to the editor. European Journal of Epidemiology, 16:1081, 2000. 15. Mason. Paediatric forensic Medicine and Pathology, Chapman and Hall Medical, London, pages 411-412, 414, 1989. 16. ÐáðáåõáããÝëïõ Ã, Ôóßìðïò Ê. ÊïéíùíéêÝò êáé õãåéïíïìéêÝò åðéðôþóåéò áðü ôéò äçìïãñáöéêÝò åîåëßîåéò ôïõ åëëçíéêïý ðëçèõóìïý: 1960- 2001, ÁèÞíá 1983.

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17. Magrane BP, Gilliland MGF, King DE. Certification of death by family physicians. Am Fam Physician, 56:1433-8, 1997. 18. Cina SJ, Selby DM, Clark B. Accuracy of death certification in two tertiary care military hospitals. Mil Med., 164:897-9, 1999. 19. Messite J, Stellman SD. Accuracy of death certificate completion: the need for formalized physician training. JAMA, 275:794-6, 1996. 20. Morton L, Omar R, Carroll S, Beirne M, Halliday D, Taylor KM. Incomplete and inaccurate death certification–the impact on research. J Public Health Med., 22:133-7, 2000. 21. Ðïëõ÷ñïíüðïõëïò Ð, Ðáó÷Üëçò ×. ÅðéäçìéïëïãéêÜ ÷áñáêôçñéóôéêÜ ôùí áããåéáêþí åãêåöáëéêþí åðåéóïäßùí. ÉáôñéêÞ, 71:31-41, 1997. 22. Newman DM. Quality of death statistics. (letter) Am J Public Health, 77, 1230, 1987. 23. Moriyama IM. Problems in Measurement of Accuracy of Cause-of-Death Statistics. Am J Public Health, 79:1349-1350, 1989. 24. Hanzlick R, Parrish RG, Ing R. Classifying unspecified and/or unexplained causes of death. Am J Public Health, 83:1492-3, 1993. 25. Chen L, Walker S, Tong S. The impact of the variation in death certification and coding practices on trends in mortality from ischaemic heart disease. Aust Health Rev, 25:189-97, 2002. 26. Ñüäç Á. Ç ÷ñçóéìüôçôá ôçò óôáôéóôéêÞò åðåîåñãáóßáò ôùí ðéóôïðïéçôéêþí èáíÜôïõ óôçí åêðüíçóç ìåëåôþí èíçóéìüôçôáò. Áäçìïóßåõôç Ì.Ä.Å. ÔìÞìá ÍïóçëåõôéêÞò, ÅÊÐÁ, 2001. 27. World Health Organization. International classification of diseases for oncology. Geneva, WHO, 1990. 28. ÓôáôéóôéêÞ Ôáîéíüìçóç ôùí ÅðáããåëìÜôùí ÓÔÅÐ-92, ÁèÞíá, ÅÓÕÅ, 1995. 29. N. 2392/96. Ðñüóâáóç ôçò ÃåíéêÞò Ãñáììáôåßáò ôçò ÅèíéêÞò ÓôáôéóôéêÞò Õðçñåóßáò ôçò ÅëëÜäïò óå äéïéêçôéêÝò ðçãÝò êáé äéïéêçôéêÜ áñ÷åßá, ÅðéôñïðÞ Óôáôéóôéêïý ÁðïññÞôïõ, ñýèìéóç èåìÜôùí äéåíÝñãåéáò áðïãñáöþí êáé óôáôéóôéêþí åñãáóéþí, êáèþò êáé èåìÜôùí ôçò ÃåíéêÞò Ãñáììáôåßáò ÅèíéêÞò Õðçñåóßáò ôçò ÅëëÜäïò (Ã.Ã.Å.Ó.Õ.Å.). ÖÅÊ Á60/1996. 30. Myers KA, Farquhar DR. Improving the accuracy of death certification. CMAJ, 158:131723, 1998.


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.

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