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ðñùôïâÜèìéá Ôüìïò 14, Ôåý÷ïò 2, Áðñßëéïò - Éïýíéïò 2002

öñïíôßäá õãåßáò

Primary Health Care Ôñéìçíéáßá ¸êäïóç ôçò ÅëëçíéêÞò Åôáéñåßáò ÃåíéêÞò ÉáôñéêÞò Quarterly edited by the Greek Association of General Practitioners Ôüìïò 14, Ôåý÷ïò 2, Aðñßëéïò - Éïýíéïò 2002, Volume 14, Number 2, April - June 2002

Ôçò Óýíôáîçò 53

Å.Á. Èçñáßïò: 14O ÐáíåëëÞíéï ÓõíÝäñéï ÃåíéêÞò ÉáôñéêÞò Åðáéíåèåßóåò Åñãáóßåò óôï Äéáãùíéóìü "Ä. ºêêïõ"

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Â. ÑïêÜ, Å. Êïõôóïýêïõ-×áñôþíá, Ì. ÂåíéæÝëïò: Äéåñåýíçóç ôçò êáôáãñáöÞò åíüò ëïéìþäïõò íïóÞìáôïò (âñïõêÝëëùóç) óå Ýíá íïìü ôçò ÊåíôñéêÞò ÅëëÜäáò

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Âáñ. Ðáðáãåùñãßïõ, Ð. ÓôáöõëÜò, Ìáñßá Æïýêá, Á. Âáñäáñéíüò, Â. Ðáðáãåùñãßïõ, Ä. Ðáñáóêåõüðïõëïò, Á. Ôóá÷ïõñßäçò: Åðéäçìéïëïãßá ôñï÷áßùí áôõ÷çìÜôùí óôï íïìü ×áëêéäéêÞò óôçí ðåñßïäï 1986 - 2001

ÐÑÙÔÏÂÁÈÌÉÁ ÖÑÏÍÔÉÄÁ ÕÃÅÉÁÓ – Primary Health Care

Âñáâåõèåßóåò Åëåýèåñåò Áíáêïéíþóåéò 71

Ã. Ôæáíßäçò, Ð. ÓêáðéíÜêçò, Áéêáôåñßíç Êáëýâá, Óôáõñïýëá ÂïñãéÜ, Áíäñïíßêç ÌáõñÜêç, Ðáãþíá Ðáðáäçìçôñßïõ, Áëåîßá Ôæáíßäïõ, Å. Óêëçñüò: Ìåéþíïíôáò ôïí ðüíï ôùí ðáéäéþí óå ìáæéêü åìâïëéáóìü. Ðïéá åßíáé ç áðïôåëåóìáôéêüôåñç ìÝèïäïò;

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ÖùôåéíÞ Ãåùñãïðïýëïõ, Å. Èçñáßïò, Êáëëéüðç ÊáëáúôæÜêç, Åýá ×ïõäåëïýäç, ÁããåëéêÞ Áñþíç, Í. Âëá÷ïãéÜííçò, Ó. Ðïëïíýöçò: Ç åêôßìçóç ôïõ âáèìïý ôçò ðéèáíÞò ðåñéöåñéêÞò íåõñïðÜèåéáò óå äéáâçôéêïýò áóèåíåßò ìå ôç ÷ñÞóç åíüò äéáãíùóôéêïý åñãáëåßïõ

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ÅëÝíç Êñåììýäá, Óð. Äåäåãêßêáò, ÁñãõñÞ ÐÝôóá, Ìé÷. Áíèñáêüðïõëïò, ×ñõóÞ Ëõêïýñåóç, Áöñïäßôç ÌÞôóéêá, ¼ëãá ÐåñäéêÜêç, ÐçãÞ ÐåñäéêÜêç: Áíß÷íåõóç ôçò ðéèáíüôçôáò ðáéäéêÞò êáêïðïßçóçò êáé ðñïâëçìáôéêþí ðåñéðôþóåùí óôçí áíáôñïöÞ êáé öñïíôßäá ðáéäéþí Ýùò 14 åôþí

ÅÍÔÕÐÏ ÊËÅÉÓÔÏ ÁÑÉÈ. ÁÄÅÉÁÓ 451/91 ÊÄÁ ÅËËÇÍÉÊÇ ÅÔÁÉÑÅÉÁ ÃÅÍÉÊÇÓ ÉÁÔÑÉÊÇÓ Ðáðáäéáìáíôïðïýëïõ 4, 115 28 ÁÈÇÍÁ

ISSN 1105-7432


ðñùôïâÜèìéá

öñïíôßäá õãåßáò

Primary Health Care

ÅÊÄÏÔÇÓ:

ÌðïäïóÜêçò-Ðñüäñïìïò Ìåñêïýñçò Ì. ×ïõñìïýæç 28 Ê. Ôïýìðá 544 53 Èåóóáëïíßêç Ôçë. (0310) 910342

Äéïéêçôéêü Óõìâïýëéï ôçò ÅëëçíéêÞò Åôáéñåßáò ÃåíéêÞò ÉáôñéêÞò Ðñüåäñïò ÌðïäïóÜêçò-Ðñüäñïìïò Ìåñêïýñçò Áíôéðñüåäñïò Á Êþóôáò ÌùñáÀôçò Áíôéðñüåäñïò  Áíôþíçò Êáñüôóçò Ãåíéêüò ÃñáììáôÝáò-Ôáìßáò ÁèáíÜóéïò Óõìåùíßäçò ÌÝëç ÐçãÞ ÐåñäéêÜêç ÓôÜèçò Óêëçñüò ÌÜñéïò ×áôæçáñóÝíçò

Executive Board of the Greek Association of General Practitioners President Bodosakis-Prodromos Merkouris Vice-President A Kostas Moraitis Vice-President B Antonis Karotsis General Secretary Treasurer Athanasios Symeonidis Members Marios Chatziarsenis Pigi Perdikaki Stathis Skliros Ãñáììáôåßá Óýíôáîçò: Áíáóôáóßá Ñùìáíßäïõ Ôçë.: (08310) 394615, (08310) 25833 e-mail: primcare@fammed.med.uoc.gr Åêôýðùóç: ÔÅ×ÍÏÃÑÁÌÌÁ Ì. ÁõãÝñç 12, 153 43 Áã. ÐáñáóêåõÞ Ôçë.: 010.60.00.643, Fax: 010.6002295 E-mail: techn@hol.gr

ISSN 1105-7432

ÄéåõèõíôÞò Óýíôáîçò

Editor-in-Chief:

×ñÞóôïò ËéïíÞò Åðßêïõñïò ÊáèçãçôÞò ÔìÞìá ÉáôñéêÞò ÐáíåðéóôÞìéï ÊñÞôçò Ô.È. 1393, ÇñÜêëåéï Ôçë. +30 810 39 46 21 Fax. +30 810 39 46 06 E-mail: lionis@med.uoc.gr

Christos Lionis Ássistant Professor Faculty of Medicine University of Crete P.O. Box 1393, Heraklion Tel: +30 810 39 46 21 Fax: +30 810 39 46 06 E-mail: lionis@med.uoc.gr

ÁíáðëçñùôÝò Ä/íôÝò Óýíôáîçò

Associate Editors

Íßêïò ÁíôùíÜêçò E-mail: antonakisnikos@yahoo.gr ÓôÜèçò Óêëçñüò E-mail: eskliros@otenet.gr

Nick Antonakis E-mail: antonakisnikos@yahoo.gr Stathis Skliros E-mail: eskliros@otenet.gr

Åðßêïõñïé Ä/íôÝò Óýíôáîçò

Assistant Editors

ÈùìÜò Áããåëüðïõëïò (Èåóóáëïíßêç) Ðáýëïò ÈåïäùñÜêçò (ÉùÜííéíá) ÅëåõèÝñéïò Èçñáßïò (ÁèÞíá) E-mail: ethireos@hol.gr Êïñíçëßá ÌáêñÞ (ÇñÜêëåéï)

Thomas Aggelopoulos (Thessaloniki) Pavlos Theodorakis (Ioannina) Åleftherios Thireos (Athens) E-mail: ethireos@hol.gr Kornilia Makri (Heraklion)

ÌÝëç ÓõíôáêôéêÞò ÅðéôñïðÞò

Members of Editorial Board

ÓôÝëéïò ÅõáããÝëïõ ÃéÜííçò ÌïíÝäáò ÐçãÞ ÐåñäéêÜêç ¸öç Öñáãêïýëç

Stelios Euaggelou Ioannis Monedas Pigi Perdikaki Efi Fragouli

ÁíôáðïêñéôÝò Óýíôáîçò

Corresponding Editors

Êýðñïò ¸ëåíá ÅõáããåëÜêç Èåïäþñá Æá÷áñéÜäïõ Áëâáíßá Llukan Rrumbullaku

Cyprus Elena Euaggelaki Theodora Zaxariadou Albania Llukan Rrumbullaku

ÓõìâïõëåõôéêÞ ÅðéôñïðÞ

Advisory Board

Ð. ÂÜñäáò, ÊáèçãçôÞò Êáñäéïëïãßáò Ðáí/ìßïõ ÊñÞôçò

P. Vardas, Professor of University of Crete

É. Âëá÷ïíéêïëÞò, Áíáðë. ÊáèçãçôÞò ÂéïóôáôéóôéêÞò Ðáí/ìßïõ ÊñÞôçò

J. Vlachonikolis, Associate Professor of University of Crete

Ä. ÃëÜñïò, ÊáèçãçôÞò ÉáôñéêÞò ÖõóéêÞò Ðáí/ìßïõ Éùáííßíùí Á. Êñáíßäçò †,

D. Glaros, Professor of University of Ioannina A. Cranidis †,

ÊáèçãçôÞò Ïõñïëïãßáò Ðáí/ìßïõ ÊñÞôçò

Professor of University of Crete

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

Í. ÓéáöÜêáò, ÊáèçãçôÞò Ðíåõìïíïëïãßáò Ðáí/ìßïõ ÊñÞôçò

N. Siafakas, Professor of University of Crete

Ó. ÓìðõñÜêéò, ÊáèçãçôÞò ÐáéäéáôñéêÞò Ðáí/ìßïõ ÊñÞôçò

S. Smpyrakis, Professor of University of Crete

Ë. ÓðÜñïò, ÊáèçãçôÞò ÊïéíùíéêÞò ÉáôñéêÞò Ðáí/ìßïõ Áèçíþí

L. Sparos, Professor of University of Athens

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

A. Philalithis, Associate Professor of University of Crete

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

G. Christodoulou, Professor of University of Athens


ðñùôïâÜèìéá

öñïíôßäá õãåßáò

Primary Health Care Ôñéìçíéáßá ¸êäïóç ôçò ÅëëçíéêÞò Åôáéñåßáò ÃåíéêÞò ÉáôñéêÞò Quarterly edited by the Greek Association of General Practitioners Ôüìïò 14, Ôåý÷ïò 2, Áðñßëéïò - Éïýíéïò 2002, Volume 14, Number 2, Ápril - June 2002

ÐÅÑÉÅ×ÏÌÅÍÁ Ôçò Óýíôáîçò Å.Á. Èçñáßïò: 14O ÐáíåëëÞíéï ÓõíÝäñéï ÃåíéêÞò ÉáôñéêÞò HñÜêëåéï ÊñÞôçò, 8-12 ÌáÀïõ 2002 ................................................... 53 Åðáéíåèåßóåò Åñãáóßåò óôï Äéáãùíéóìü "Ä. ºêêïõ" Â. ÑïêÜ, Å. Êïõôóïýêïõ-×áñôþíá, Ì. ÂåíéæÝëïò: Äéåñåýíçóç ôçò êáôáãñáöÞò åíüò ëïéìþäïõò íïóÞìáôïò (âñïõêÝëëùóç) óå Ýíá íïìü ôçò ÊåíôñéêÞò ÅëëÜäáò ................................................................................................................................................. 56 Âáñ. Ðáðáãåùñãßïõ, Ð. ÓôáöõëÜò, Ìáñßá Æïýêá, Á. Âáñäáñéíüò, Â. Ðáðáãåùñãßïõ, Ä. Ðáñáóêåõüðïõëïò, Á. Ôóá÷ïõñßäçò: Åðéäçìéïëïãßá ôñï÷áßùí áôõ÷çìÜôùí óôï íïìü ×áëêéäéêÞò óôçí ðåñßïäï 1986 - 2001 ............................... 62 Âñáâåõèåßóåò Åëåýèåñåò Áíáêïéíþóåéò Ã. Ôæáíßäçò, Ð. ÓêáðéíÜêçò, Áéêáôåñßíç Êáëýâá, Óôáõñïýëá ÂïñãéÜ, Áíäñïíßêç ÌáõñÜêç, Ðáãþíá Ðáðáäçìçôñßïõ, Áëåîßá Ôæáíßäïõ, Å. Óêëçñüò: Ìåéþíïíôáò ôïí ðüíï ôùí ðáéäéþí óå ìáæéêü åìâïëéáóìü. Ðïéá åßíáé ç áðïôåëåóìáôéêüôåñç ìÝèïäïò; ............................................................................................................................................................................................. 71 ÖùôåéíÞ Ãåùñãïðïýëïõ, Å. Èçñáßïò, Êáëëéüðç ÊáëáúôæÜêç, Åýá ×ïõäåëïýäç, ÁããåëéêÞ Áñþíç, Í. Âëá÷ïãéÜííçò, Ó. Ðïëïíýöçò: Ç åêôßìçóç ôïõ âáèìïý ôçò ðéèáíÞò ðåñéöåñéêÞò íåõñïðÜèåéáò óå äéáâçôéêïýò áóèåíåßò ìå ôç ÷ñÞóç åíüò äéáãíùóôéêïý åñãáëåßïõ ..................................................................................................................................................................... 81 ÅëÝíç Êñåììýäá, Óð. Äåäåãêßêáò, ÁñãõñÞ ÐÝôóá, Ìé÷. Áíèñáêüðïõëïò, ×ñõóÞ Ëõêïýñåóç, Áöñïäßôç ÌÞôóéêá, ¼ëãá ÐåñäéêÜêç, ÐçãÞ ÐåñäéêÜêç: Áíß÷íåõóç ôçò ðéèáíüôçôáò ðáéäéêÞò êáêïðïßçóçò êáé ðñïâëçìáôéêþí ðåñéðôþóåùí óôçí áíáôñïöÞ êáé öñïíôßäá ðáéäéþí Ýùò 14 åôþí ................................................................................................................... 92

CONTENTS Editorial E. Thireos: 14th National Congress of General Practice ........................................................................................................................................... 53 The Second Awarded Papers in the Memory of Prof. "D. Ikkos" V. Roka, E. Koutsoukou-Hartona, M. Vevizelos: Evaluation of the report of the new cases of brucellosis in a region of central Greece (Larissa) ............................................................................................................................................................................... 56 Var. Papageorgiou, A. Vardarinos, Maria Zouka, V. Papageorgiou, D. Paraskevopoulos, P. Stafilas, A. Tsachourides: Epidemiology of road accidents in the Prefecture of Chalkidiki during 1986 - 2001 ....................................... 62 Awarded Freestanding Papers G. Janidis, P. Skapinakis, A. Kaliva, S. Voria, A. Mavraki, P. Papadimitriou, A. Janidou, E. Skliros: Effects of a cognitive intervention versus distraction versus both on children's reactions during mass vaccination ............................................................................................................................................................................................................... 71 Fotini Georgopoulou, E. Thireos, Kalliopi Kalaitzaki, Eva Houdeloudi, Angela Aroni, N. Vlahogiannis: The Assessment and staging of possible peripheral neuropathy in diabetic patients: the usage/use of an instrument. .............................................................................................................................................................................................. 81 Kremida Eleni, Dedegikas Sp., Petsa Argyri, Anthrakopoulos Michael, Likouresi Chrisi, Mitsika Afrodite, Perdikaki Olga, Perdikaki Pigi: Screening the possibility of child abuse and difficult cases in raising and caring for children up to 14 years of age ................................................................................................................................................................ 92


Ôüìïò 14, Ôåý÷ïò 2, 2002

Å. Èçñáßïò

THÓ ÓÕÍÔÁÎÇÓ EDITORIAL Primary Heatlh Care, Volume 14, Number 2, 53-55, 2002 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 13, Ôåý÷ïò 2, 53-55, 2002

14O ÐáíåëëÞíéï ÓõíÝäñéï ÃåíéêÞò ÉáôñéêÞò HñÜêëåéï ÊñÞôçò, 8-12 ÌáÀïõ 2002 Å.Á. Èçñáßïò

Ôï 14ï ÐáíåëëÞíéï ÓõíÝäñéï ÃåíéêÞò ÉáôñéêÞò ðñáãìáôïðïéÞèçêå óôï îåíïäï÷åßï Knossos Royal, óôï ÇñÜêëåéï ÊñÞôçò, áðü 8-12 ÌáÀïõ 2002 êáé áðïôÝëåóå êáé ðÜëé ôï ôüðï óõíÜíôçóçò ôùí Ãåíéêþí Éáôñþí êáé ôùí ößëùí ôçò ÃåíéêÞò ÉáôñéêÞò áð' üëç ôçí ÅëëÜäá. ¸íá ÓõíÝäñéï, ïé åñãáóßåò ôïõ ïðïßïõ óõíïäåýôçêáí áðü èåôéêÜ ó÷üëéá, ãéá ôçí ðñïóðÜèåéá ôçò ÏñãáíùôéêÞò ÅðéôñïðÞò íá áíôáðïêñéèåß óôéò êáëüðéóôåò êñéôéêÝò ðáñåëèüíôùí åôþí êáé íá óõíèÝóåé Ýíá ðñüãñáììá ðéï êïíôÜ óôéò áíÜãêåò ãéá óõíå÷éæüìåíç åêðáßäåõóç ôùí Ãåíéêþí Éáôñþí êáé éäéáßôåñá ôùí åéäéêåõïìÝíùí. ÌåôÜ ôïõò ÷áéñåôéóìïýò êáé ôéò ðñïóöùíÞóåéò êáôÜ ôçí åíáñêôÞñéá ôåëåôÞ, áêïëïýèçóå ç åíáñêôÞñéá äéÜëåîç ðïõ, üðùò åßèéóôáé, Þôáí ç âñáâåõèåßóá åñãáóßá ìå ôï âñáâåßï "Ä. ºêêïõ" óôï 13ï ÐáíåëëÞíéï ÓõíÝäñéï ÃåíéêÞò ÉáôñéêÞò, ìå èÝìá "ÌåëÝôç ðáñáãüíôùí ðïõ åðéäñïýí óôç ñýèìéóç ôçò áñôçñéáêÞò ðßåóçò õðåñôáóéêþí áóèåíþí" êáé ïìéëçôÞ ôïí ê. Å. Óêëçñü. Ç óôñïããõëÞ ôñÜðåæá ìå èÝìá: "Õãåßá êáé Õðçñåóßåò Õãåßáò óôïí åëëçíéêü ðëçèõóìü: ÁðïôåëÝóìáôá Ýñåõíáò ãéá ôçí áõôïáîéïëüãçóç ôïõ åðéðÝäïõ õãåßáò, ôçí ÷ñçóéìïðïßçóç êáé ôçí áíôáðïêñéóéìüôçôá ôùí õðçñåóéþí õãåßáò êáé ôç äßêáéç êáôáíïìÞ ôùí ðüñùí óôç ÷ñçìáôïäüôçóç", áðïôÝëåóå ôçí êáëýôåñç åéóáãùãÞ óôéò åñãáóßåò ôïõ Óõíåäñßïõ, ìéáò êáé ðñïóÝöåñå óçìáíôéêü õëéêü ãéá ãüíéìï ðñïâëçìáôéóìü êáé äéÜëïãï. Åß÷å óõíôïíéóôÝò, ôïí åðéóôçìïíéêü õðåýèõíï ôçò Ýñåõíáò ÊáèçãçôÞ óôïí ÔïìÝá Ïéêïíïìéêþí ôçò Õãåßáò ôçò ÅèíéêÞò Ó÷ïëÞò Äçìüóéáò Õãåßáò (ÅÓÄÕ) ê.

É. Êõñéüðïõëï êáé ôïí Ðñüåäñï ôçò ÅëëçíéêÞò Åôáéñåßáò ÃåíéêÞò ÉáôñéêÞò (ÅËÅÃÅÉÁ) ê. Ì.Ð. Ìåñêïýñç. Óêïðüò ôçò Ýñåõíáò Þôáí ç äéåñåýíçóç ôïõ âáèìïý óôïí ïðïßï ôï óýóôçìá õãåßáò ôçò ÷þñáò åðéôõã÷Üíåé óôçí åêðëÞñùóç ôñéþí âáóéêþí óôü÷ùí-êñéôçñßùí ôïõ Ð.Ï.Õ. ãéá ôçí áîéïëüãçóç ôùí óõóôçìÜôùí õãåßáò: åðßôåõîç êáëïý åðéðÝäïõ õãåßáò ôïõ ðëçèõóìïý, áíôáðüêñéóç ôùí õðçñåóéþí õãåßáò óôéò ðñïóäïêßåò ôùí ðïëéôþí êáôÜ ôçí êáèçìåñéíÞ åðáöÞ ôïõò ìå ôï óýóôçìá õãåßáò, äéêáéïóýíç óôçí êáôáíïìÞ ôùí âáñþí óôç ÷ñçìáôïäüôçóç ôïõ óõóôÞìáôïò õãåßáò êáé ôçí ðñïóôáóßá ôùí íïéêïêõñéþí Ýíáíôé ôïõ ïéêïíïìéêïý êéíäýíïõ ëüãù Ýëåõóçò êÜðïéáò áóèÝíåéáò. Áðü ôïõò åéóçãçôÝò-åñåõíçôÝò ôçò ÅÓÄÕ ê.ê. ÓïõæÜíá ÃêñÝãêïñõ, ×, Ïéêïíüìïõ, Ä. ÆáâñÜ êáé ÍáôÜóá Äáíéçëßäïõ, ðáñïõóéÜóôçêáí ôá áðïôåëÝóìáôá ôçò Ýñåõíáò, ðïõ Þôáí ôáõôü÷ñïíá êáé ìéá ðñüôáóç-ðñüêëçóç ðñïò ôçí Ðïëéôåßá ãéá ôïí ó÷åäéáóìü êáé åöáñìïãÞ åíüò ïëïêëçñùìÝíïõ ó÷åäßïõ ðáñÝìâáóçò ðÜíù óå ôñåéò Üîïíåò: åíåñãçôéêÞ ðïëéôéêÞ êáôáðïëÝìçóçò ôçò öôþ÷åéáò êáé ôïõ êïéíùíéêïý áðïêëåéóìïý ïé ïðïßåò èá âåëôéþóïõí ôï åðßðåäï äéáâßùóçò ôïõ ðëçèõóìïý, ìåôáññýèìéóç ôïõ ôñüðïõ ÷ñçìáôïäüôçóçò ôùí õðçñåóéþí õãåßáò óôá ðëáßóéá ìéáò åõñýôåñçò áíáìüñöùóçò ôïõ öïñïëïãéêïý êáé ôïõ êïéíùíéêïáóöáëéóôéêïý óõóôÞìáôïò, ðáñåìâÜóåéò óôï ßäéï ôï óýóôçìá õãåßáò ìå Ýìöáóç óôçí ðïéïôéêÞ áíáâÜèìéóç ôùí ðáñå÷ïìÝíùí õðçñåóéþí êáé ôçí åðÝíäõóç óôï áíèñþðéíï äõíáìéêü. Óôá èåôéêÜ óõìðåñÜóìáôá ôçò Ýñåõíáò åßíáé, ç éóüôéìç äéÜ÷õóç ôïõ åðéðÝäïõ õãåßáò áíÜìåóá óôéò ðåñéöÝ53


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

ñåéåò, åðßðåäï õãåßáò ôï ïðïßï êáé áîéïëïãïýí ïé ¸ëëçíåò óáí ðïëý êáëü Þ ó÷åôéêÜ êáëü, êáëýôåñá áðü Üëëåò ÷þñåò ìå åîáßñåóç ôçí Éóëáíäßá. Óôá áñíçôéêÜ, åíäåéêôéêü ôçò êïéíùíéêïïéêïíïìéêÞò áíéóüôçôáò, åßíáé üôé ïé äåßêôåò ôïõ åðéðÝäïõ õãåßáò êáé ôçò áíôáðïêñéóéìüôçôáò óõíäÝïíôáé ìå ôï ÷áìçëü åéóüäçìá êáé ôç ÷áìçëÞ åêðáßäåõóç, åíþ õðÜñ÷åé ìéá õðåñï÷Þ ôïõ éäéùôéêïý ôïìÝá éäéáßôåñá óôçí ðñþôçò ðñïôåñáéüôçôáò Ýãêáéñç ðñïóï÷Þ ðñïò ôïí áóèåíÞ. ÔåëéêÜ, üðùò åýóôï÷á åðåóÞìáíå ï ÊáèçãçôÞò ê. Êõñéüðïõëïò, ôï ðñüâëçìá ôïõ óõóôÞìáôïò åßíáé ðñüâëçìá éóüôçôáò êáé ü÷é áðïññüöçóçò êáé êáôáíïìÞò ôùí ðüñùí. Áîßæåé áêüìá íïìßæïõìå íá óôáèïýìå. óôçí ðïëý åíäéáöÝñïõóá äéÜëåîç ôïõ ê. Êùíóôáíôßíïõ Ìáñêüðïõëïõ, e-Business Manager, ìå áíôéêåßìåíï ôï E-Learning êáé ôïõò íÝïõò ïñßæïíôåò óôçí éáôñéêÞ åêðáßäåõóç ôïõ Ãåíéêïý Éáôñïý. ÊáíÝíáò ðëÝïí äåí áìöéâÜëåé, ãéá ôéò åðéäñÜóåéò ðïõ õößóôáôáé ç ÉáôñéêÞ áðü ôïí åñ÷ïìü ôïõ Äéáäéêôýïõ óôçí êáèçìåñéíÞ æùÞ ôùí áíèñþðùí. Åéäéêüôåñá, ìÝóï ôçò åî´ áðïóôÜóåùò çëåêôñïíéêÞò ìÜèçóçò (e-Learning), Ýíáò ïñãáíéóìüò Ý÷åé ôçí äõíáôüôçôá íá äçìéïõñãÞóåé ìßá åéêïíéêÞ áßèïõóá, üðïõ üëïé ïé óõììåôÝ÷ïíôåò èá ìðïñïýí æùíôáíÜ íá åðéêïéíùíÞóïõí êáé íá áíôáëëÜîïõí áðüøåéò ãéá ôá æçôÞìáôá ðïõ ôïõò åíäéáöÝñïõí. Ç çëåêôñïíéêÞ ìÜèçóç äåí áíôéêáèéóôÜ ôçí öõóéêÞ ðáñïõóßá ôùí áíèñþðùí óå ìßá ôÜîç. ÂïçèÜ, üìùò, ðÜñá ðïëý óôçí åðéêïéíùíßá êáé óôçí äéÜ÷õóç ôçò ãíþóçò ÷ùñßò ÷ñïíéêïýò êáé ãåùãñáöéêïýò ðåñéïñéóìïýò. Éäéáßôåñá ìÜëéóôá óå ìéá ÷þñá üðùò ç ÅëëÜäá, ðïõ åßíáé ãåùãñáöéêÜ êáôáêåñìáôéóìÝíç, Ý÷ïõìå ôçí äõíáôüôçôá íá ðñïóöÝñïõìå (ìÝóù ôçò õðçñåóßáò ôïõ e-Learning) êáëýôåñç êáé Ýãêáéñç ðëçñïöüñçóç, åíþ ìå ôçí âïÞèåéá ôùí ðïëõìÝóùí (multimedia) ðïõ åßíáé äéáèÝóéìá, äçìéïõñãïýíôáé ôåëéêÜ êáëýôåñåò ðñïûðïèÝóåéò ìÜèçóçò. Ôï e-Learning, ç íÝá áõôÞ ðñüêëçóç áëëÜ êáé äõíáôüôçôá, ðéóôåýåôáé üôé èá áíáðôõ÷èåß ìå ôá÷ýôáôï ñõèìü ôá åðüìåíá ÷ñüíéá ìéáò êáé åßíáé ìßá êáéíïôüìïò ìÝèïäïò åêðáßäåõóçò, ìÝóù åíüò íÝïõ êáíáëéïý åðéêïéíùíßáò (Internet), ôï ïðïßï åßíáé ðñïóâÜóéìï 24 þñåò ôçí çìÝñá, 365 çìÝñåò ôïí ÷ñüíï êáé ðïõ óõíÜìá ðñïóöÝñåé ÷áìçëïý êüóôïõò (áñêåß Ýíáò ìÝóïò çëåêôñïíéêüò õðïëïãéóôÞò ìå ç÷åßá êáé ìéêñüöùíï, âáóéêÝò ãíþóåéò ÷ñÞóçò Ç/Õ êáé ìÝóù ôçëåöùíéêÞò ãñáììÞò óýíäåóç óôï internet) êáé ìå öéëéêü óôï ÷ñÞóôç óýóôçìá åêðáßäåõóçò, ìéá 54

Å. Èçñáßïò

áëëçëåðéäñáóôéêÞ (interactive) æùíôáíÞ åðéêïéíùíßá ÷ùñßò ãåùãñáöéêÜ üñéá êáé "ðåñéïñéóìü èÝóåùí". Ôï åðéóôçìïíéêü ðñüãñáììá ôïõ óõíåäñßïõ, óôï ïðïßï õðÞñ÷áí êáé ôñßá ðñïãñáììáôéóìÝíá êëéíéêÜ öñïíôéóôÞñéá, ðåñéåëÜìâáíå: 15 óôñïããõëÝò ôñÜðåæåò, 7 äéáëÝîåéò, 269 åëåýèåñåò áíáêïéíþóåéò êáé 132 áíáñôçìÝíåò áíáêïéíþóåéò (poster). Ôá èÝìáôá ôùí êëéíéêþí öñïíôéóôçñßùí, ôùí óôñïããõëþí ôñáðåæþí êáé ôùí äéáëÝîåùí Þôáí:

ÊëéíéêÜ öñïíôéóôÞñéá · Áíôéìåôþðéóç õðåñôáóéêïý áóèåíïýò óôçí êáè' çìÝñá ðñÜîç. ÅêðáéäåõôÝò: È. ÌïõíôïêáëÜêçò, ÊáèçãçôÞò Ðáíåðéóôçìßïõ Áèçíþí, Ã. Óôåñãßïõ, ËÝêôïñáò Ðáíåðéóôçìßïõ Áèçíþí, Á. Êáñüôóçò, Ãåíéêüò Éáôñüò, Á. Óõìåùíßäçò, Ãåíéêüò Éáôñüò · ÊáñäéïðíåõìïíéêÞ Áíáæùïãüíçóç (ÊÁÑÐÁ). ÅêðáéäåõôÝò: Á. ÊõñéáæÞò, Åðéì. Á´ ÅÊÁÂ, Á. Ìáñéüëá, Åðéì. Á´ ÅÊÁÂ, Á. Æõãïýñá, Åðéì. Á´ ÅÊÁÂ, Ì. Ãáôóïýëç, Åðéì. Á´ ÅÊÁÂ, Ä. Âïõñâá÷Üêçò, Åðéì. Á´ ÅÊÁÂ

ÓôñïããõëÝò ôñÜðåæåò · Õãåßá êáé Õðçñåóßåò Õãåßáò óôïí åëëçíéêü ðëçèõóìü: ÁðïôåëÝóìáôá Ýñåõíáò ãéá ôçí áõôïáîéïëüãçóç ôïõ åðéðÝäïõ õãåßáò, ôçí ÷ñçóéìïðïßçóç êáé ôçí áíôáðïêñéóéìüôçôá ôùí õðçñåóéþí õãåßáò êáé ôç äßêáéç êáôáíïìÞ ôùí ðüñùí óôç ÷ñçìáôïäüôçóç. · ¸ñåõíá óôç ÃåíéêÞ ÉáôñéêÞ: Áñ÷éêüò ó÷åäéáóìüò - õëéêü, ìÝèïäïò, óôáôéóôéêÞ áíÜëõóç. · Åêðáßäåõóç óôç ÃåíéêÞ ÉáôñéêÞ: ÁíÜãêåò êáé ðñïïðôéêÝò. · ÐáñÜãïíôåò êéíäýíïõ êáñäéáããåéáêÞò íüóïõ: Ðáñïõóßáóç - ÓõæÞôçóç ðåñéóôáôéêþí. · ÅñðçôéêÝò ëïéìþîåéò êáé Ãåíéêüò Éáôñüò. · Äéïßêçóç êáé ïñãÜíùóç ìïíÜäùí ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò. · Éïãåíåßò çðáôßôéäåò. · ÍÝåò ðñïïðôéêÝò óôç èåñáðåßá ôçò áëëåñãßáò. · Íåüôåñåò åîåëßîåéò óôçí áíôéìåôþðéóç ôçò õðåñëéðéäáéìßáò - Ðáñïõóßáóç, áíÜëõóç êáé óõæÞôçóç ðåñéóôáôéêþí.


Å. Èçñáßïò

· ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò: ÁíáðíåõóôéêÜ ðñïâëÞìáôá ôçò êáè' çìÝñá ðñÜîçò. · Áíôéìåôþðéóç ôùí áíïéþí óôçí êáèçìåñéíÞ êëéíéêÞ ðñÜîç. · ¢óèìá Þ ×ñüíéá ÁðïöñáêôéêÞ ÐíåõìïíïðÜèåéá: Äéáöïñåôéêü ðñüâëçìá, äéáöïñåôéêÞ ëýóç; · ÁíôéõðåñôáóéêÞ èåñáðåßá êáé áããåéáêÜ åãêåöáëéêÜ åðåéóüäéá: ÍÝåò ðñïïðôéêÝò êáé äåõôåñïãåíÞ ðñüëçøç. · Ôá éäéáßôåñá ÷áñáêôçñéóôéêÜ ôçò åêðáßäåõóçò áíÜëïãá ìå ôç ãåùãñáöéêÞ èÝóç ôùí Íïóïêïìåßùí êáé ôùí ÊÝíôñùí Õãåßáò åéäéêüôçôáò: ÐñïôÜóåéò êáé ðñïâëçìáôéóìïß. · Ï ñüëïò ôïõ åëÝã÷ïõ ôùí ëéðéäßùí óôçí ðñùôïãåíÞ êáé äåõôåñïãåíÞ ðñüëçøç ôùí êáñäéáããåéáêþí óõìâáìÜôùí. Ç Üðïøç ôïõ Ãåíéêïý êáé ôïõ Åéäéêïý Éáôñïý.

ÄéáëÝîåéò · E-Learning óôçí õðçñåóßá ôïõ Ãåíéêïý Éáôñïý. · ÌåëÝôç ABC-GP õðÝñôáóçò. · ÅðéëïãÞ áíôéõðåñôáóéêÞò áãùãÞò óôï äéáâçôéêü áóèåíÞ. · ÄéÜãíùóç - èåñáðåßá ôçò ãåíéêåõìÝíçò áã÷þäïõò äéáôáñá÷Þò óôçí ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò. · ÄéáóöÜëéóç ðïéüôçôáò ðáñå÷üìåíùí õðçñåóéþí áðü ôïí Ãåíéêü Ïéêïãåíåéáêü Éáôñü. · Ëïéìþîåéò áíáðíåõóôéêïý: Íåüôåñåò êáôåõèõíôÞñéåò ïäçãßåò. · Äõóðåøßá: Áðü ôçí äéÜãíùóç óôç èåñáðåßá. Ïé åñãáóßåò ôïõ óõíåäñßïõ Ýêëåéóáí ìå ôçí áðïíïìÞ ôùí âñáâåßùí, ôá ïðïßá Ýëáâáí: ¸ðáéíïé Êáèçãçôïý "Ä. ºêêïõ" "Äéåñåýíçóç ôçò êáôáãñáöÞò åíüò ëïéìþäïõò íïóÞìáôïò (âñïõêÝëëùóç) ó' Ýíá Íïìü ôçò ÊåíôñéêÞò ÅëëÜäáò", ôùí óõíáäÝëöùí Â. ÑïêÜ, Å. Êïõôóïýêïõ-×áñôþíá, Ì. ÂåíéæÝëïõ, áðü ôï ÊÝíôñï Õãåßáò Ãüííùí êáé ôï Êôçíéáôñéêü ÅñãáóôÞñéï ËÜñéóáò. "Åðéäçìéïëïãßá ôñï÷áßùí áôõ÷çìÜôùí óôï Íïìü ×áëêéäéêÞò óôç ðåñßïäï 1986-2001", ôùí óõíáäÝëöùí Âáñ. Ðáðáãåùñãßïõ, Á. Âáñäáñéíü,

Ôüìïò 14, Ôåý÷ïò 2, 2002

Ì. Æïýêá, Â. Ðáðáãåùñãßïõ, Ä. Ðáñáóêåõüðïõëï, Ð. ÓôáöõëÜ, Á. Ôóá÷ïõñßäç, áðü ôï ÊÝíôñï Õãåßáò Êáóóáíäñåßáò. Âñáâåßá åëåõèÝñùí áíáêïéíþóåùí "Ìåéþíïíôáò ôïí ðüíï ôùí ðáéäéþí óå ìáæéêü åìâïëéáóìü. Ðïéá åßíáé ç áðïôåëåóìáôéêüôåñç ìÝèïäïò;", ôùí óõíáäÝëöùí Ã. Ôæáíßäç, Ð. ÓêáðéíÜêç, Á. Êáëýâá, Ó. ÂïñãéÜ, Á. ÌáõñÜêç, Ð. Ðáðáäçìçôñßïõ, Á. Ôæáíßäïõ, Ó. Óêëçñü. "Ç åêôßìçóç ôïõ âáèìïý ôçò ðéèáíÞò ðåñéöåñéêÞò íåõñïðÜèåéáò óå äéáâçôéêïýò áóèåíåßò ìå ôç ÷ñÞóç åíüò äéáãíùóôéêïý åñãáëåßïõ", ôùí óõíáäÝëöùí Ö. Ãåùñãïðïýëïõ, Å. Èçñáßïõ, Ê. ÊáëáúôæÜêç, Å. ×ïõäåëïýäç, Á. Áñþíç, Í. Âëá÷ïãéÜííç. "Áíß÷íåõóç ôçò ðéèáíüôçôáò ðáéäéêÞò êáêïðïßçóçò êáé ðñïâëçìáôéêþí ðåñéðôþóåùí óôçí áíáôñïöÞ êáé öñïíôßäá ðáéäéþí Ýùò 14 åôþí", ôùí óõíáäÝëöùí Å. Êñåììýäá, Ó. Äåäåãêßêá, Á. ÐÝôóá, Ì. Áíèñáêïðïýëïõ, ×. ËõêïõñÝóç, Á. ÌÞôóéêá, Ï. ÐåñäéêÜêç, Ð. ÐåñäéêÜêç. ¸ðáéíïé åëåõèÝñùí áíáêïéíþóåùí "Óõó÷åôéóìüò óùìáôïìåôñéêþí äåéêôþí êáé áñôçñéáêÞò ðßåóçò óå ìáèçôÝò áãñïôéêÞò ðåñéï÷Þò Íüôéáò ÊÝñêõñáò", ôùí óõíáäÝëöùí Í. ÄçìçóéÜíïõ, È. ÄÜóéá, Ô. ÍôÜöç, Â. Óôáóéíü, Â. ÌÞëéá, Í. Ðáôïýíç, Å. ÑÝããéïõ, Á. Èáíïðïýëïõ, É. ÌïíÝäá. "Ðñüëçøç, áíôéìåôþðéóç êáé óõìðåñéöïñÜ ôùí éáôñþí óå èÝìáôá õãåßáò ôïõò", ôùí óõíáäÝëöùí Ã. Ôóßñïõ, Ä. Êáëïãåñüðïõëï, Ð. Âïúëá, ×. Âüóóïõ, Ã. ÊáñäÜôï, Ã. ÌïõæÜêç, Í. ÌáãêëÜñá, Ð. Áèáíáóüðïõëï, Á. Ãáôïðïýëïõ. "Áîéïëüãçóç ôùí áðïôåëåóìÜôùí ôçò ðáñÝìâáóçò ôïõ éáôñïý Ðåñéöåñåéáêïý éáôñåßïõ óå ãíùóôü ðëçèõóìü óáê÷áñïäéáâçôéêþí ôçò ðåñéï÷Þò åõèýíçò ôïõ ìåôÜ ðáñÝëåõóç åíüò Ýôïõò", ôùí óõíáäÝëöùí Ó. Ãêïíôüëéá, Ê. Óôåöáíïðïýëïõ, ×. ÓðõñÜêç, Á. Ðáñáóýñç, Á. ÐåôñÜêç, Í. ÐáðáäÜêç, Á. Ìðáôßêá Âñáâåßï Êáèçãçôïý "Ã. Ìåñßêá" Óôï óõíÜäåëöï Á. Ìáñéüëç ãéá ôçí åñãáóßá ôïõ ìå ôßôëï: "Ðïéüôçôá æùÞò õðåñôáóéêþí áóèåíþí". 55


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Â. ÑïêÜ êáé óõí.

ÅÐÁÉÍÅÈÅÉÓÁ ÅÑÃÁÓÉÁ ÓÔÏ ÄÉÁÃÙÍÉÓÌÏ "Ä. ÉÊÊÏÕ" THE SECOND AWARDED PAPER IN THE MEMORY OF PROF. D. IKKOS Primary Heatlh Care, Volume 14, Number 2, 56-61, 2002 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 14, Ôåý÷ïò 2, 56-61, 2002

Äéåñåýíçóç ôçò êáôáãñáöÞò åíüò ëïéìþäïõò íïóÞìáôïò (âñïõêÝëëùóç) óå Ýíá íïìü ôçò ÊåíôñéêÞò ÅëëÜäáò Â. ÑïêÜ1, Å. Êïõôóïýêïõ-×áñôþíá2, Ì. ÂåíéæÝëïò3

Ðåñßëçøç Óêïðüò ôçò ðáñïýóáò ìåëÝôçò Þôáí ï õðïëïãéóìüò ôïõ ðïóïóôïý äÞëùóçò ôùí íÝùí êñïõóìÜôùí ìåëéôáßïõ ðõñåôïý (âñïõêÝëëùóçò) ôï Ýôïò 1999 óôï íïìü ËÜñéóáò. Õëéêü êáé ìÝèïäïò. ¸ãéíå ðñïóðÜèåéá êáôáãñáöÞò üëùí ôùí íÝùí êñïõóìÜôùí âñïõêÝëëùóçò êáôÜ ôï óõãêåêñéìÝíï Ýôïò êáé óýãêñéóç áõôþí ìå ôá óôïé÷åßá ôïõ åðßóçìïõ öïñÝá ôïõ Õðïõñãåßïõ Õãåßáò. Ùò õëéêü ÷ñçóéìïðïéÞèçêáí ôá âéâëßá ìçôñþïõ áóèåíþí ôùí Êëéíéêþí ôïõ Ãåíéêïý Íïóïêïìåßïõ ËÜñéóáò, ôá âéâëßá ìçôñþïõ áóèåíþí ôùí ÊÝíôñùí Õãåßáò ôïõ íïìïý, ôá óôïé÷åßá ðïõ äéáèÝôåé ôï Êôçíéáôñéêü ÅñãáóôÞñéï ôïõ íïìïý êáé ôÝëïò ôá áñ÷åßá ôçò Äéåýèõíóçò ÕãéåéíÞò êáé ôïõ Õðïõñãåßïõ Õãåßáò. Áöïý óõëëÝ÷èçêáí ôá ïíüìáôá üëùí ôùí íÝùí êñïõóìÜôùí, üðùò åß÷áí êáôáãñáöåß óôéò ôñåéò ðñþôåò ðçãÝò, Ýãéíå ìéá áíôéðáñáâïëÞ ìåôáîý ôïõò, ãéá íá âñåèïýí üóá ïíüìáôá åß÷áí ðåñéëçöèåß óå ðåñéóóüôåñåò áðü ìßá ðçãÝò êáé ôåëéêÜ ðñïÝêõøå ï óõíïëéêüò áñéèìüò íÝùí êñïõóìÜôùí. ÁðïôåëÝóìáôá. Ï áñéèìüò áõôüò ôùí 219 íÝùí êñïõóìÜôùí âñïõêÝëëùóçò èåùñÞèçêå ï ðñáãìáôéêüò áñéèìüò íÝùí êñïõóìÜôùí êáé Ýãéíå áíôéðáñáâïëÞ áõôïý ìå ôá äçëùèÝíôá óôç Äéåýèõíóç ÕãéåéíÞò ôïõ íïìïý, üðùò óôïí åðßóçìï öïñÝá ôïõ Õðïõñãåßïõ Õãåßáò ôï ÊÅÅË (ÊÝíôñï ÅëÝã÷ïõ Åéäéêþí Ëïéìþîåùí). ÐñïÝêõøå ëïéðüí üôé ìüíï ôï 20% ôùí íÝùí êñïõóìÜôùí âñïõêÝëëùóçò ôïõ íïìïý ËÜñéóáò åß÷áí äçëùèåß åðßóçìá óôï Õðïõñãåßï Õãåßáò êáôÜ ôï Ýôïò 1999. ÓõìðåñÜóìáôá. Åßíáé ãíùóôü üôé ç åðéäçìéïëïãéêÞ ðáñáêïëïýèçóç ôçò âñïõêÝëëùóçò óôçí ÅëëÜäá õóôåñåß. Óôçí ðáñïýóá åñãáóßá äéáðéóôþèçêå üôé ìüëéò Ýíá óôá ðÝíôå íÝá êñïýóìáôá âñïõêÝëëùóçò äçëþíåôáé Ïé ãéáôñïß èá ðñÝðåé íá äçëþíïõí êÜèå íÝï êñïýóìá, êáèþò ìüíï Ýôóé èá åßíáé äõíáôÞ ç êáôÜñôéóç ðñïãñáììÜôùí ãéá ôç óõóôçìáôéêÞ åèíéêÞ ðïëéôéêÞ ðáñáêïëïýèçóçò êáé ðñüëçøçò ôùí âñïõêåëëþóåùí.

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Åéäéêåõüìåíç ÃåíéêÞò ÉáôñéêÞò ÊÝíôñï Õãåßáò Ãüííùí, 2Êôçíéáôñéêü ÅñãáóôÞñéï ËÜñéóáò, ÄéåõèõíôÞò ÊÝíôñïõ Õãåßáò Ãüííùí

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ÅéóáãùãÞ Ç âñïõêÝëëùóç åßíáé ìéá áíèñùðïæùïíüóïò ðïõ ðåñéãñÜöçêå ãéá ðñþôç öïñÜ ôçí åðï÷Þ ôïõ ÉððïêñÜôç. Áí êáé äåí åßíáé ãíùóôÞ ç åðßðôùóç ôçò âñïõêÝëëùóçò óôç ÷þñá ìáò, ôï ðñüâëçìá öáßíåôáé íá åßíáé áñêåôÜ óõ÷íü óå ïñéóìÝíåò áãñïôéêÝò ðåñéï÷Ýò, üðùò ôçí ÁíáôïëéêÞ ÓôåñåÜ ÅëëÜäá, ôç Èåóóáëßá, ôçí ¹ðåéñï êáé ôçí ÊåíôñéêÞ Ðåëïðüííçóï1. Ôï ìüíï áðïôåëåóìáôéêü ìÝóï ãéá ôçí ðñüëçøç ôçò âñïõêÝëëùóçò óôïõò áíèñþðïõò èåùñåßôáé ï Ýëåã÷ïò ôçò íüóïõ óôá æþá, áõôüò üìùò åßíáé äýóêïëïò êáé áñêåôÜ äáðáíçñüò. Óôéò ðåñéóóüôåñåò ÷þñåò ï Ýëåã÷ïò ôçò âñïõêÝëëùóçò, Ý÷åé âáóéóôåß óôçí åãêáôÜóôáóç óõóôçìÜôùí áíáöïñÜò ôùí êñïõóìÜôùí óôïõò áíèñþðïõò êáé óôá æþá2. Ôç äåêáåôßá ôïõ 1980, 5958 ðåñéðôþËÝîåéò êëåéäéÜ: ÂñïõêÝëëùóç, êñïýóìáôá, åðéäçìéïëïãßá, ÅëëÜò ÕðïâëÞèçêå: Ç åñãáóßá õðïâëÞèçêå óôï äéáãùíéóìü "Ä. ºêêïõ" óôá ðëáßóéá ôïõ 14ïõ Ðáíåëëçíßïõ Óõíåäñßïõ ÃåíéêÞò ÉáôñéêÞò (ÊñÞôç, 8-12 ÌáÀïõ 2002) êáé Ýëáâå Ýðáéíï áðü ôçí ÅðéôñïðÞ Êñßóçò. Äçìïóéåýåôáé ìå êïéíÞ áðüöáóç ôçò ÓõíôáêôéêÞò ÅðéôñïðÞò ôïõ ðåñéïäéêïý êáé ôçò ÏñãáíùôéêÞò ÅðéôñïðÞò ôïõ Óõíåäñßïõ. Õðåýèõíïò áëëçëïãñáößáò: ÑïêÜ ÂéïëÝôá, ÌÜíäñá ËÜñéóáò, Ô.Ê. 41500 ôçë. 0410821342, e-mail: lavdas@med.uth.gr


Â. ÑïêÜ êáé óõí.

Ôüìïò 14, Ôåý÷ïò 2, 2002

êþí Ëïéìþîåùí). ÓõãêåêñéìÝíá, óõëëÝ÷èçêáí ôá ïíüìáôá êáôïßêùí ôïõ Íïìïý ðïõ êáôÜ ôç äéÜñêåéá ôïõ Ýôïõò 1999 íüóçóáí áðü ìåëéôáßï ðõñåôü Summary êáé åßôå íïóçëåýôçêáí óå êÜðïéá êëéThe objective of this study was to assess the percentage of new cases of brucellosis which were officially reported during 1999, in the region of Larissa. íéêÞ ôïõ Íïóïêïìåßïõ, åßôå ðáñáêïAll new cases were collected and then compared to the records of the Ministry ëïõèÞèçêáí óôá Éáôñåßá ôùí ÊÝíôñùí of Health. The information used for the study was collected from the clinics of Õãåßáò, åßôå ôÝëïò êáôÝöõãáí óôï Êôçthe General Hospital of Larisa, the Health Centres of the area, the data from íéáôñéêü åñãáóôÞñéï ãéá åñãáóôçñéáthe Veterinary Laboratory and finally the records of the Ministry of Health. The êü Ýëåã÷ï. Ï óõíïëéêüò áñéèìüò íÝùí number of cases for the first three sources, were added and a total of 219 new cases was calculated. This number was then compared to the 44 new cases êñïõóìÜôùí ðïõ õðïëïãßóôçêå óõãêñßthat had been reported to the Ministry of Health. Therefore, the percentage èçêå ìå ôá óôïé÷åßá ôçò Äéåýèõíóçò difference of the number of cases, reported officially was 20%. Brucellosis is ÕãéåéíÞò êáé ôïõ ÊÅÅË. underreported in our country and an epidemiological study should now be Ïé ÊëéíéêÝò ôïõ Íïóïêïìåßïõ, undertaken. This makes it imperative that doctors report every new case, beóôùí ïðïßùí ôá âéâëßá ìçôñþïõ áóèåcause only in this way it will it be feasible for the government to apply regulations for its eradication. íþí áíáôñÝîáìå, Þôáí ïé äýï ÐáèïKey Words: Brucellosis, new cases, report systems ëïãéêÝò ÊëéíéêÝò (Á êáé Â), ç ÏñèïðáéäéêÞ êáé ç ÐáéäéáôñéêÞ. Óå áõôÜ Health Center of Gonni, Larissa Þôáí êáôáãåãñáììÝíá ôá óôïé÷åßá ôùí áóèåíþí, ìå ôç äéÜãíùóç åîüäïõ êáé óåéò âñïõêÝëëùóçò åß÷áí áíáöåñèåß óôï Õðïõñ- ôç äéÜñêåéá íïóçëåßáò ôïõò. Ôá ÊÝíôñá Õãåßáò ôïõ Íïìïý åßíáé ðÝíôå ãåßï Õãåßáò ôçò ÅëëÜäáò, ìå õøçëüôåñá ðïóïóôÜ åðßðôùóçò óôéò áãñïôéêÝò ðåñéï÷Ýò. Êáèþò üìùò óõíïëéêÜ. ÌåôÜ áðü ôç óõíåííüçóç ðïõ Ýãéíå ìå åßíáé ãíùóôü üôé ç âñïõêÝëëùóç üðùò êáé ïé ôïõò äéåõèõíôÝò ôïõò êáé óå óõíåñãáóßá ìå ôçí Üëëåò ëïéìþäåéò íüóïé, õðïäçëþíåôáé, ï áñéèìüò Õðçñåóßá Åðéóêåðôþí Õãåßáò, óõëëÝ÷èçêáí óôïéôùí êñïõóìÜôùí óå áõôÞí ôç äåêáåôßá èåùñåßôáé ÷åßá ãéá ôá êñïýóìáôá ðïõ êáôÜ ôç äéÜñêåéá ôïõ Ýôïõò 1999 äéáãíþóôçêáí êáé ðáñáêïëïõóßãïõñï üôé åßíáé ðïëý ìåãáëýôåñïò3. Ç ðáñïýóá åñãáóßá áðïóêïðåß óôïí õðïëï- èÞèçêáí óôá éáôñåßá ôïõò. ãéóìü ôïõ ðïóïóôïý ôùí íÝùí êñïõóìÜôùí ìåëéÇ äéÜãíùóç ôùí íÝùí êñïõóìÜôùí ìåëéôáßïõ ôáßïõ ðõñåôïý ðïõ äçëþíïíôáé åðéóÞìùò êáè'üôé ðõñåôïý, ôüóï óôéò ÊëéíéêÝò üóï êáé óôá ÊÝíôñá åíþ åßíáé ãíùóôü üôé ç íüóïò õðïäçëþíåôáé, äåí Õãåßáò, åß÷å âáóéóôåß óôçí êëéíéêÞ åéêüíá êáé óå Ý÷åé êáôáãñáöåß óå ôé âáèìü áõôü éó÷ýåé êáé Üñá áíïóïäéáãíùóôéêÝò ìåèüäïõò. Ùò ãíùóôüí ç äéÜäåí åßíáé ãíùóôÞ ç áëçèéíÞ åðßðôùóç ôçò íüóïõ. ãíùóç ôßèåôáé áðü ôçí êëéíéêÞ åéêüíá, ôï åðéäçÇ Ýëëåéøç ôùí óôïé÷åßùí áõôþí äåí åðéôñÝðåé ìéïëïãéêü éóôïñéêü êáé ôçí åñãáóôçñéáêÞ åðéâåôçí åöáñìïãÞ ôùí êáôÜëëçëùí ìÝôñùí ðñüëç- âáßùóç, ç ïðïßá ðåñéëáìâÜíåé ôéò êáëëéÝñãåéåò øçò. êáé ôéò ïñïëïãéêÝò áíôéäñÜóåéò -óõ÷íüôåñá äå ç äéÜãíùóç âáóßæåôáé ìüíï óôéò ïñïáíôéäñÜóåéò êáé ü÷é óôéò êáëëéÝñãåéåò4,5 Ôï Êôçíéáôñéêü ÅñãáóôÞñéï äéáèÝôåé áíïóïÐëçèõóìüò ÌåëÝôçò - ÌÝèïäïò äéáãíùóôéêÝò ìåèüäïõò ôÝôïéåò, ðïõ åðéôñÝðïõí Ðñüêåéôáé ãéá ìéá áíáäñïìéêÞ ìåëÝôç ðïõ ôçí åîáãùãÞ ðïëý áîéüðéóôùí áðïôåëåóìÜôùí êáé ðñáãìáôïðïéÞèçêå óôï íïìü ËÜñéóáò êáé ôá óôïé- ãé’ áõôü ôï ëüãï óõãêåíôñþíåé ìåãÜëï áñéèìü äåéãìÜôùí áßìáôïò ðñïò Ýëåã÷ï -ü÷é ìüíï æþùí ÷åßá áíáöÝñïíôáé óôï Ýôïò 1999. ÐçãÝò ðëçñïöïñéþí Þôáí ôá âéâëßá ìçôñþïõ áëëÜ êáé áíèñþðùí. ÓõãêåêñéìÝíá, áðïóôÝëëïáóèåíþí ôùí Êëéíéêþí ôïõ Ãåíéêïý Íïóïêïìåßïõ íôáé äåßãìáôá áðü ôéò ÊëéíéêÝò ôïõ Íïóïêïìåßïõ, ËÜñéóáò, ôùí ÊÝíôñùí Õãåßáò ôïõ Íïìïý, ôï áðü ôá ÊÝíôñá Õãåßáò êáé áðü éäéþôåò ãéáôñïýò. Êôçíéáôñéêü ÅñãáóôÞñéï, ç Äéåýèõíóç ÕãéåéíÞò ¸ôóé, ôï Êôçíéáôñéêü åñãáóôÞñéï áðïôÝëåóå ôç ôçò Íïìáñ÷ßáò ËÜñéóáò êáé ôá óôïé÷åßá ðïõ äéá- óçìáíôéêüôåñç ðçãÞ ðëçñïöïñéþí êáèþò åêåß Þôáí èÝôåé ï åðßóçìïò öïñÝáò ôïõ Õðïõñãåßïõ Õãåßáò óõãêåíôñùìÝíá óôïé÷åßá ãéá ìåãÜëï áñéèìü íÝùí êáé Ðñüíïéáò, ôï ÊÅÅË (ÊÝíôñï ÅëÝã÷ïõ Åéäé- êñïõóìÜôùí. Ç ôáõôïðïßçóç ôùí íÝùí êñïõóìÜEvaluation of the report of the new cases of brucellosis in a region of central Greece (Larissa) V. Roka, E. Koutsoukou-Hartona, M. Vevizelos

57


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

ôùí ìåëéôáßïõ ðõñåôïý âáóßóôçêå óôéò èåôéêÝò ïñïëïãéêÝò äïêéìáóßåò ìå áíåýñåóç õøçëþí Þ óõíå÷þò áõîáíüìåíùí ôßôëùí áíôéóùìÜôùí ìå ôéò ìåèüäïõò Rose-Bengal, Wright êáé óýíäåóçò óõìðëçñþìáôïò. Ôßôëïé ôçò ïñïáíôßäñáóçò Wright >1/160 åßíáé äéáãíùóôéêïß, åíþ åðß áìöéâïëßáò óõíéóôÜôáé ç ôÝëåóç êáé Üëëùí ïñïáíôéäñÜóåùí üðùò ç óýíäåóç óõìðëçñþìáôïò óôçí ïðïßá ôßôëïé 1/16 êáé Üíù åßíáé èåôéêïß4,5. Óôç Äéåýèõíóç ÕãéåéíÞò ãßíåôáé äÞëùóç ôùí íÝùí êñïõóìÜôùí ìåëéôáßïõ ðõñåôïý ôïõ íïìïý áðü ôïõò ãéáôñïýò êáé ôïõò Üëëïõò õðåýèõíïõò ãéá ôï óêïðü áõôü öïñåßò åôçóßùò. Ôï ÊÅÅË ëáìâÜíåé óôïé÷åßá ãéá íÝá êñïýóìáôá ìåëéôáßïõ ðõñåôïý áðü ôç Äéåýèõíóç ÕãéåéíÞò, ôï Íïóïêïìåßï êáé ôá ÊÝíôñá Õãåßáò ôïõ åêÜóôïôå íïìïý. Ôüóï óôï Õðïõñãåßï Õãåßáò üóï êáé óôç Äéåýèõíóç ÕãéåéíÞò äçëþíïíôáé åôçóßùò üëá ôá íÝá êñïýóìáôá ìåëéôáßïõ ðõñåôïý ðïõ ðñùôïäéáãíþóôçêáí ôï óõãêåêñéìÝíï Ýôïò áíåîáñôÞôùò ìïñöÞò: ïîåßáò åìðýñåôçò, ìå Þ ÷ùñßò åíôïðßóåéò. Áíôéóôïß÷ùò, äåí ãßíåôáé ôÝôïéïò äéá÷ùñéóìüò óôá íÝá êñïýóìáôá ðïõ êáôáãñÜöçêáí áðü ôï Íïóïêïìåßï, ôá ÊÝíôñá Õãåßáò êáé ôï Êôçíéáôñéêü ÅñãáóôÞñéï. Ç óõëëïãÞ óôïé÷åßùí áðü ôïõò éäéþôåò ãéáôñïýò óôÜèçêå áäýíáôç êáèþò êáôÜ ãåíéêÞ ïìïëïãßá äåí êñáôïýóáí áñ÷åßá ôïõ Ýôïõò 1999. Ôá óôïé÷åßá ðïõ óõëëÝ÷èçêáí áðü ôéò ôñåéò ðñþôåò ðçãÝò áíôéðáñáâëÞèçêáí ìåôáîý ôïõò ðñïêåéìÝíïõ íá áðïöåõ÷èïýí ïé åðáíáëÞøåéò ïíïìÜôùí óôçí êáôáìÝôñçóç ôùí êñïõóìÜôùí, êÜôé ðïõ èá ìðïñïýóå íá óõìâåß ãéá êÜðïéïí áðü ôïõò ðáñáêÜôù ëüãïõò. ¼ðùò ðáñáôçñÞèçêå, õðÞñîáí ìåôáöïñÝò ôïõ ßäéïõ áóèåíïýò áðü ôç ìßá êëéíéêÞ óå Üëëç ìåôÜ ôçí åðéâåâáßùóç ôçò äéÜãíùóçò, ãéá ðáñÜäåéãìá áðü ôçí ÐáèïëïãéêÞ óôçí ÏñèïðáéäéêÞ. ÅðéðëÝïí, ôï ßäéï Üôïìï ìðïñïýóå íá åßíáé êáôáãåãñáììÝíï ôüóï óôá âéâëßá ìçôñþïõ áóèåíþí åíüò ÊÝíôñïõ Õãåßáò üóï êáé êÜðïéáò ÐáèïëïãéêÞò ÊëéíéêÞò, êáèþò êáôÜ ôçí ðïñåßá ôçò íüóïõ êñßèçêå áðáñáßôçôç ç íïóçëåßá ôïõ, åíþ åðÝóôñåøå êáé ðÜëé óôï ÊÝíôñï Õãåßáò ãéá ðáñáêïëïýèçóç. Ï óõíïëéêüò áñéèìüò êñïõóìÜôùí áðü ôï Íïóïêïìåßï, ôá ÊÝíôñá Õãåßáò êáé ôï Êôçíéáôñéêü åñãáóôÞñéï óõãêñßèçêå ìå ôá êñïýóìáôá ðïõ åß÷áí äçëùèåß óôç Äéåýèõíóç ÕãéåéíÞò êáé ìå ôá óôïé÷åßá ôïõ åðßóçìïõ öïñÝá ôïõ Õðïõñãåßïõ Õãåßáò, ôïõ ÊÅÅË ãéá ôï Ýôïò 1999 óôï Íïìü 58

Â. ÑïêÜ êáé óõí.

ËÜñéóáò.

ÁðïôåëÝóìáôá Óôïí Ðßíáêá 1, öáßíåôáé áíáëõôéêÜ ãéá êÜèå êëéíéêÞ ôïõ Ãåíéêïý Íïóïêïìåßïõ ËÜñéóáò ï áñéèìüò ôùí íÝùí êñïõóìÜôùí ìåëéôáßïõ ðõñåôïý ðïõ Þôáí êáôáãåãñáììÝíá óôá âéâëßá ìçôñþïõ áóèåíþí ôïõò. Ïé äýï ðáèïëïãéêÝò êëéíéêÝò íïóÞëåõóáí óõíïëéêÜ êáôÜ ôï Ýôïò 1999, 28 áóèåíåßò ðïõ ðñïóâëÞèçêáí áðü âñïõêÝëëùóç, åíþ óôçí ÏñèïðáéäéêÞ êáé óôçí ÐáéäéáôñéêÞ ï áñéèìüò ôïõò Þôáí áíôßóôïé÷á 1 êáé 3 áóèåíåßò. Ôá óôïé÷åßá ðïõ óõãêåíôñþóáìå áðü ôá ÊÝíôñá Õãåßáò ôïõ Íïìïý ðáñïõóéÜæïíôáé óôïí Ðßíáêá 2. Áðü ôá ðÝíôå ÊÝíôñá Õãåßáò, óå áõôü ôçò ÁãéÜò áíáöÝñåôáé 1 ìüíï íÝï êñïýóìá âñïõêÝëëùóçò, óôï ÊÝíôñï Õãåßáò Åëáóóüíáò 36, óôï ÊÝíôñï Õãåßáò ÖáñóÜëùí 5, óôï ÊÝíôñï Õãåßáò ÔõñíÜâïõ 15 êáé 6 óôï ÊÝíôñï Õãåßáò Ãüííùí. Ï óõíïëéêüò áñéèìüò åßíáé 63 íÝá êñïýóìáôá. Óôï Êôçíéáôñéêü ÅñãáóôÞñéï 162 äåßãìáôá áßìáôïò Þôáí èåôéêÜ ìå õøçëïýò Þ óõíå÷þò áõîáíüìåíïõò ôßôëïõò áíôéóùìÜôùí. Ïé ïñïëïãéêÝò äïêéìáóßåò, ïé ïðïßåò ÷ñçóéìïðïéïýíôáé, åßíáé ç Ðßíáêáò 1. Ï áñéèìüò íÝùí êñïõóìÜôùí ìåëéôáßïõ ðõñåôïý ðïõ Þôáí êáôá÷ùñçìÝíá óôá âéâëßá ìçôñþïõ áóèåíþí ôùí êëéíéêþí ôïõ Ãåíéêïý Íïóïêïìåßïõ ËÜñéóáò êáôÜ ôï Ýôïò 1999 ÊëéíéêÝò Ãåíéêïý Íïóïêïìåßïõ ËÜñéóáò Á´ ÐáèïëïãéêÞ Â´ ÐáèïëïãéêÞ ÏñèïðáéäéêÞ ÐáéäéáôñéêÞ Óýíïëï

Áñéèìüò ÍÝùí ÊñïõóìÜôùí 17 11 1 3 32

Ðßíáêáò 2. Ï áñéèìüò íÝùí êñïõóìÜôùí ìåëéôáßïõ ðõñåôïý ðïõ Þôáí êáôá÷ùñçìÝíá óôá âéâëßá ìçôñþïõ áóèåíþí ôùí ÊÝíôñùí Õãåßáò ôïõ Íïìïý êáôÜ ôï Ýôïò 1999 ÊÝíôñá Õãåßáò íïìïý ËÜñéóáò ÁÃÉÁÓ Åëáóóüíáò ÖáñóÜëùí ÔõñíÜâïõ Ãüííùí Óýíïëï

Áñéèìüò ÍÝùí ÊñïõóìÜôùí 1 36 5 15 6 63


Ôüìïò 14, Ôåý÷ïò 2, 2002

Â. ÑïêÜ êáé óõí.

áíôßäñáóç Rose-Bengal, ç óýíäåóç óõìðëçñþìáôïò êáé ç óõãêïëëçôéíïáíôßäñáóç Wright. Ï óõíïëéêüò áñéèìüò íÝùí êñïõóìÜôùí ðïõ ðñïêýðôåé áðü ôçí Üèñïéóç ôùí áíùôÝñù åßíáé 257 (Ðßíáêáò 3). Áðü ôçí áíôéðáñÜèåóç ôùí ïíïìÜôùí ôùí áóèåíþí äéáðéóôþèçêå ç ýðáñîç 38 êïéíþí ðåñéóôáôéêþí ðïõ áíáöÝñïíôáé óå ðåñéóóüôåñåò áðü ìßá ðçãÝò. Ùò åê ôïýôïõ, ìåôÜ áðü ôçí áöáßñåóç áõôþí ðñïÝêõøå ï áñéèìüò ôùí 219 íÝùí êñïõóìÜôùí. Áõôüò åßíáé êáé ï áñéèìüò ðïõ óõãêñßèçêå ìå ôá óôïé÷åßá ôçò Äéåýèõíóçò ÕãéåéíÞò êáé ôïõ Õðïõñãåßïõ Õãåßáò. Óôç Äéåýèõíóç ÕãéåéíÞò åß÷áí äçëùèåß 33 íÝá êñïýóìáôá ôï Ýôïò 1999. Ç ðñïÝëåõóç ôùí óôïé÷åßùí áõôþí, üðùò öáßíåôáé êáé óôïí Ðßíáêá 4, Þôáí 26 áðü ôï ÊÝíôñï Õãåßáò Åëáóóüíáò, 4 áðü ôï Ãåíéêü Íïóïêïìåßï ËÜñéóáò, 1 áðü ôï Óôñáôéùôéêü Íïóïêïìåßï êáé 2 áðü ôç Äéåýèõíóç ÕãéåéíÞò ôçò Èåóóáëïíßêçò. Óýìöùíá ìå ôá óôïé÷åßá ôïõ ÊÅÅË ï áñéèìüò êñïõóìÜôùí ðïõ åß÷áí äçëùèåß óôï Õðïõñãåßï Õãåßáò Þôáí 44 áðü ôï íïìü ËÜñéóáò, åíþ

Ðßíáêáò 3. Ï áñéèìüò íÝùí êñïõóìÜôùí ìåëéôáßïõ ðõñåôïý ðïõ áíôéóôïé÷åß óå êáèåìéÜ áðü ôéò ðçãÝò óõëëïãÞò ðëçñïöïñéþí êáé ï ôåëéêüò áñéèìüò ðïõ ðñïêýðôåé ìåôÜ áðü ôçí áöáßñåóç ôùí êïéíþí ðåñéóôáôéêþí þóôå íá ìçí ðñïóìåôñÜôáé ðåñéóóüôåñåò áðü ìßá öïñÝò ôï ßäéï êñïýóìá üôáí áõôü áíáöÝñåôáé óå äýï Þ ðåñéóóüôåñåò ðçãÝò ÐçãÞ ÐñïÝëåõóçò ôçò ðëçñïöïñßáò Ãåíéêü Íïêïóïìåßï ËÜñéóáò ÊÝíôñá Õãåßáò íïìïý Êôçíéáôñéêü ÅñãáóôÞñéï Óýíïëï

Ôåëéêüò Áñéèìüò

Áñéèìüò ÍÝùí ÊñïõóìÜôùí 32 63 162 251 -38 (áñéèìüò êïéíþí ðåñéóôáôéêþí) 219

Ðßíáêáò 4. Ï áñéèìüò íÝùí êñïõóìÜôùí ìåëéôáßïõ ðõñåôïý ðïõ äçëþèçêáí óôç Äéåýèõíóç ÕãéåéíÞò êáôÜ ôï Ýôïò 1999 êáé ïé ðçãÝò ðáñï÷Þò ôùí áíôßóôïé÷ùí ðëçñïöïñéþí ÐçãÞ Ðáñï÷Þò Ðëçñïöïñéþí ðñïò ôç Äéåýèõíóç ÕãéåéíÞò ÊÝíôñá Õãåßáò Åëáóóüíáò Ãåíéêü Íïêïóïìåßï ËÜñéóáò Óôñáôéùôéêü Íïóïêïìåßï 404 Äéåýèõíóç ÕãéåéíÞò Èåóóáëïíßêçò Óýíïëï

Áñéèìüò ÍÝùí ÊñïõóìÜôùí 26 4 1 2 33

ôï óýíïëï ôùí íÝùí êñïõóìÜôùí ãéá ôçí ÅëëÜäá Þôáí 538. ¢ñá ç åôÞóéá åðßðôùóç ôçò íüóïõ ãéá ôï 1999 óôï íïìü ËÜñéóáò Þôáí 16,26 áíÜ 100000 êáôïßêïõò, åíþ óå ðáíåëëÞíéï åðßðåäï ç åðßðôùóç õðïëïãßæåôáé óå 5,24 áíÜ 100000 êáôïßêïõò6. Ôï ðïóïóôü ôùí íÝùí êñïõóìÜôùí ìåëéôáßïõ ðõñåôïý ðïõ, ìå âÜóç ôá óôïé÷åßá áõôÞò ôçò ìåëÝôçò, äçëþíïíôáé åðßóçìá åßíáé 15% áí ãßíåé óýãêñéóç ìå ôá óôïé÷åßá ôçò Äéåýèõíóçò ÕãéåéíÞò êáé 20% áí ãßíåé óýãêñéóç ìå ôá óôïé÷åßá ôïõ ÊÅÅË.

ÓõæÞôçóç Óôç ìåëÝôç áõôÞ åðé÷åéñÞèçêå ï õðïëïãéóìüò ôïõ ðñáãìáôéêïý áñéèìïý ôùí íÝùí êñïõóìÜôùí ìåëéôáßïõ ðõñåôïý ðïõ åêäçëþèçêáí êáôÜ ôï Ýôïò 1999 óôï íïìü ËÜñéóáò, ìå óêïðü íá êáôáäåé÷èåß óå ðïéï ðïóïóôü áõôÜ äçëþíïíôáé åðßóçìá. Óôçí ðñïóðÜèåéÜ áõôÞ ðñïÝêõøå Ýíáò ôåëéêüò áñéèìüò 219 íÝùí êñïõóìÜôùí åê ôùí ïðïßùí ìüíï 44, ðïóïóôü ðåñßðïõ 20%, åß÷áí äçëùèåß åðßóçìá. Ùóôüóï êáôÜ ôç äéåíÝñãåéá ôçò Ýñåõíáò ðñïÝêõøáí êÜðïéåò ðáñÜìåôñïé ðïõ êÜíïõí âÜóéìç ôçí õðïøßá üôé ï ðñáãìáôéêüò áñéèìüò ôùí íÝùí êñïõóìÜôùí åßíáé áêüìç ìåãáëýôåñïò êáé Üñá ôï ðïóïóôü ìéêñüôåñï ôïõ 20%. Ïé ðáñÜìåôñïé áõôÝò åßíáé: - Äå óõëëÝ÷èçêáí óôïé÷åßá áðü ôïõò éäéþôåò ãéáôñïýò åðåéäÞ äåí êñáôïýí óôçí ðëåéïøçößá ôïõò áñ÷åßá ðåñáóìÝíùí åôþí. ¢ñá ï áñéèìüò ôùí áóèåíþí ìå ìåëéôáßï ðõñåôü ðïõ áõôïß ðåñéÝèáëøáí äå óõíõðïëïãßæåôáé. - Áðü ôï íïóïêïìåßï ëÞöèçêáí üóá óôïé÷åßá Þôáí êáôáãåãñáììÝíá óôá âéâëßá ìçôñþïõ áóèåíþí ôùí êëéíéêþí. Êáé åäþ üìùò õðÜñ÷åé äéáöõãÞ ðåñéóôáôéêþí êáèþò ðïëëïß åßíáé ïé áóèåíåßò ðïõ åîÝñ÷ïíôáí ÷ùñßò ôçí ôåëéêÞ äéÜãíùóç êáé óå áíáìïíÞ ôùí áðïôåëåóìÜôùí êÜðïéùí åñãáóôçñéáêþí åîåôÜóåùí. Ãíùñßæïõìå ëïéðüí, ìüíï ôç äéÜãíùóç åîüäïõ ôïõò ðïõ óå êÜðïéåò ðåñéðôþóåéò ðåñéïñßæåôáé óôçí ðåñéãñáöÞ ôùí óõìðôùìÜôùí, ð.÷. ðáñáôåéíüìåíï åìðýñåôï, åßíáé ðïëý ðéèáíü íá äéÝöõãáí êÜðïéá ðåñéóôáôéêÜ ôçò êáôáãñáöÞò. - ¼óïé åê ôùí áóèåíþí ðáñáêïëïõèïýíôáí óôá ÅîùôåñéêÜ Éáôñåßá ôïõ Íïóïêïìåßïõ äå óõíõðïëïãßæïíôáé ãéáôß äåí Þôáí êáôáãåãñáììÝíïé 59


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

óôá áíôßóôïé÷á áñ÷åßá. Êáèþò ëïéðüí ãíùñßæïõìå üôé Ýíá ìéêñü ðïóïóôü ðáó÷üíôùí ÷ñÞæåé íïóçëåßáò êáé ç ðëåéïøçößá áõôþí áíôéìåôùðßæïíôáé ùò åîùôåñéêïß áóèåíåßò óõìðåñáßíïõìå üôé Ýíáò óçìáíôéêüò áñéèìüò ðáó÷üíôùí äéáöåýãåé ôçò êáôáãñáöÞò. - Ôá óôïé÷åßá ôùí ÊÝíôñùí Õãåßáò åßíáé ðéèáíüôáôá åëëéðÞ, êáèþò êáôÜ ãåíéêÞ ïìïëïãßá äåí ãßíåôáé óõóôçìáôéêÞ êáôáãñáöÞ ôùí ðåñéóôáôéêþí óôá Áñ÷åßá ôïõò. Áðü ôçí Üëëç ðëåõñÜ, ï áñéèìüò íÝùí êñïõóìÜôùí ìåëéôáßïõ ðõñåôïý ðïõ Þôáí êáôáãåãñáììÝíá óôï Êôçíéáôñéêü ÅñãáóôÞñéï, êáèþò Þôáí óçìáíôéêÜ ìåãáëýôåñïò áðü ôùí Üëëùí ðçãþí, Ýðñåðå íá äéáóöáëéóôåß ç áîéïðéóôßá ôïõ áñéèìïý áõôïý. ÕðÞñ÷å ôï åñþôçìá áí ðñüêåéôáé ãéá íÝá êñïýóìáôá Þ ãéá åðáíåëÝã÷ïõò. Ãéá ôï ëüãï áõôü áíôéðáñáôÝèçêáí ôá ïíüìáôá üëùí üóùí åß÷áí âñåèåß èåôéêïß óôï ÅñãáóôÞñéï êáôÜ ôá Ýôç 1997-1999 êáèþò ùò ãíùóôüí áíôéóþìáôá ìðïñïýí íá áíé÷íåõèïýí ãéá 2-3 ÷ñüíéá ìåôÜ ôç ìüëõíóç7. Áðü ôïí Ýëåã÷ï áõôü ðñïÝêõøå ï áñéèìüò 162. Áðü ôçí áíÜëõóç ôùí óôïé÷åßùí ðïõ óõëëÝ÷èçêáí áðü ôá ÊÝíôñá Õãåßáò, áëëÜ êáé áðü åêåßíá ôçò Äéåýèõíóçò ÕãéåéíÞò, ãßíåôáé öáíåñü üôé ç ðåñéï÷Þ ôçò Åëáóóüíáò ðáñïõóéÜæåé óçìáíôéêÜ ìåãáëýôåñï áñéèìü íÝùí êñïõóìÜôùí ìåëéôáßïõ ðõñåôïý óå ó÷Ýóç ìå ôïí õðüëïéðï íïìü. Ç Åëáóóüíá åßíáé ìéá áãñïôïêôçíïôñïöéêÞ ðåñéï÷Þ ìå áõîçìÝíç åðßðôùóç ôçò íüóïõ, üðùò Ý÷ïõí êáôáäåßîåé êáé ðáëáéüôåñåò ìåëÝôåò ôçò ðåñéï÷Þò8. Ôï ãåãïíüò áõôü öáßíåôáé üôé Ý÷åé åõáéóèçôïðïéÞóåé ôïõò áñìüäéïõò öïñåßò þóôå íá ãßíåôáé êáëýôåñç êáôáãñáöÞ ôùí êñïõóìÜôùí êáé äÞëùóç áõôþí óôç Äéåýèõíóç ÕãéåéíÞò êáé óôï Õðïõñãåßï Õãåßáò. Ç ìåëÝôç áõôÞ Ýäåéîå üôé ìüëéò óå ðïóïóôü 20% äçëþíïíôáé ôá íÝá êñïýóìáôá ìåëéôáßïõ ðõñåôïý. Ôï ðïóïóôü áõôü ìå ôçí ðéèáíüôçôá, üðùò ðñïáíáöÝñèçêå, íá åßíáé áêüìç ìéêñüôåñï äåí äéáöÝñåé óçìáíôéêÜ áðü ôá ðïóïóôÜ ðïõ áíáöÝñïíôáé ðáãêïóìßùò. ¸ôóé óôéò ÇÐÁ, áí êáé åßíáé óðÜíéá íüóïò, åðéäçìéïëïãéêÝò ìåëÝôåò äåß÷íïõí üôé ìüíï ôï 4-10% ôùí ðåñéóôáôéêþí áíáãíùñßæïíôáé êáé äçëþíïíôáé9. Åíþ áêüìç êáé óôéò áíáðôõãìÝíåò ÷þñåò ç áëçèéíÞ åðßðôùóç ìðïñåß íá åßíáé áêüìç êáé 26 öïñÝò õøçëüôåñç áðü ôá åðßóçìá óôïé÷åßá9. ÄåäïìÝíá áðü ôéò ÷þñåò ôçò Ìåóïãåßïõ, éäéáßôåñá ôçò ÌÝóçò ÁíáôïëÞò, 60

Â. ÑïêÜ êáé óõí.

áíáöÝñïõí åðéðïëáóìü ðïõ êõìáßíåôáé áðü 2,2% óå åíçëßêïõò êáé ðáéäéÜ ôùí ÷ùñéþí ôïõ ÓïõäÜí10, ùò 19,2% óôç ÓáïõäéêÞ Áñáâßá11,12. Áêüìç ìåãáëýôåñïò åðéðïëáóìüò áíáöÝñåôáé óôéò ÁöñéêáíéêÝò ÷þñåò êÜôù áðü ôçí Ýñçìï Óá÷Üñá ìå ðïóïóôü 18-24% óôçí ÏõãêÜíôá13 êáé 9-11% óôç Íéãçñßá14. Ç åðßðôùóç ôçò âñïõêÝëëùóçò óôçí éôáëéêÞ ðüëç Campania ôï 1990 Þôáí 8,4 áíÜ 100000 êáôïßêïõò14. Ìåôáîý ôùí óôïé÷åßùí ðïõ åðéóçìÜíèçêáí åßíáé üôé ïé ãéáôñïß ôïõ äçìüóéïõ ôïìÝá, êõñßùò üìùò ïé ãéáôñïß ôïõ éäéùôéêïý ôïìÝá, äåí äçëþíïõí ôá ðåñéóôáôéêÜ âñïõêÝëëùóçò óôéò áñìüäéåò õãåéïíïìéêÝò õðçñåóßåò. Ùóôüóï åßíáé ãíùóôü üôé âÜóåé ôïõ Âáóéëéêïý ÄéáôÜãìáôïò ôçò 3/11/195015 ï ìåëéôáßïò ðõñåôüò áíÞêåé óôá õðï÷ñåùôéêþò äçëïýìåíá ëïéìþäç íïóÞìáôá. Ôï ÄéÜôáãìá áõôü áíáöÝñåé üôé üëïé ïé ãéáôñïß üëùí ôùí åéäéêïôÞôùí åßíáé õðï÷ñåùìÝíïé íá äçëþíïõí êÜèå íÝï êñïýóìá óôéò ÕãåéïíïìéêÝò Õðçñåóßåò, ÷ùñßò üìùò íá äéåõêñéíßæïíôáé ïé êõñþóåéò ðïõ ðñïâëÝðïíôáé óå ðåñßðôùóç ìç ôÞñçóÞò ôïõ. ÃåííÜôáé ëïéðüí ôï åñþôçìá ãéáôß åðéêñáôåß ç ðáñïýóá êáôÜóôáóç. Ôï Êôçíéáôñéêü ÅñãáóôÞñéï áðïôåëåß óçìáíôéêüôáôç ðçãÞ ðëçñïöïñéþí ãéá ôá íÝá êñïýóìáôá ìåëéôáßïõ ðõñåôïý. Ôï åí ëüãù åñãáóôÞñéï îåêßíçóå áðü ôïí Ýëåã÷ï ôùí æþùí ôçò ðåñéï÷Þò êáé óýíôïìá åðåêôÜèçêå êáé óôïí Ýëåã÷ï äåéãìÜôùí áßìáôïò áðü áíèñþðïõò. Ìå ôç ìåëÝôç áõôÞ ãßíåôáé óáöÝò üôé ï ìåëéôáßïò ðõñåôüò, üðùò êáé Üëëá ëïéìþäç íïóÞìáôá, õðïäçëþíåôáé êáé ìÜëéóôá Ýíá ìéêñü ðïóïóôü êáôáãñÜöåôáé åðßóçìá. ËáìâÜíïíôáò õðüøç üôé ç âñïõêÝëëùóç åßíáé åíäçìéêÞ êáé áðïôåëåß óïâáñü ðñüâëçìá õãåßáò óå óõãêåêñéìÝíåò áãñïôéêÝò ðåñéï÷Ýò ôçò ÅëëÜäáò, üðùò Ý÷ïõí êáôáäåßîåé êáé ïñïëïãéêÝò åðéäçìéïëïãéêÝò ìåëÝôåò16, ãßíåôáé êáôáíïçôü üôé ðñïêåéìÝíïõ íá åëåã÷èåß êáé íá åîáëåéöèåß ç âñïõêÝëëùóç, êáèþò äåí õðÜñ÷åé áóöáëÝò êáé áðïôåëåóìáôéêü åìâüëéï ðñïò ôï ðáñüí ãéá ôïõò áíèñþðïõò, ðñÝðåé ïé ÕãåéïíïìéêÝò Õðçñåóßåò ôçò ÷þñáò íá åîáóöáëßóïõí ôç óùóôÞ ëåéôïõñãßá ôùí óõóôçìÜôùí áíáöïñÜò ôùí íÝùí êñïõóìÜôùí ôüóï óôïõò áíèñþðïõò üóï êáé óôá æþá, óõã÷ñüíùò ìå ôá ìÝôñá ãéá ôçí ðáóôåñßùóç ôïõ ãÜëáêôïò êáé ôùí ãáëáêôïêïìéêþí ðñïúüíôùí, êáé ôçí åêðáßäåõóç ãéá ôçí ôÞñçóç ôùí êáíüíùí õãéåéíÞò. Ç åìðåéñßá áðü Üëëåò ÷þñåò Ý÷åé äåßîåé üôé êÜôé ôÝôïéï åßíáé åöéêôü, âëÝðïíôáò ðþò ç âñïõêÝëëùóç ôùí âïïåéäþí åîá-


Ôüìïò 14, Ôåý÷ïò 2, 2002

Â. ÑïêÜ êáé óõí.

ëåßöèçêå, éäéáéôÝñùò óôéò ÓêáíäéíáâéêÝò ÷þñåò17.

Âéâëéïãñáößá 9. 1. Ð. ÓöçêÜêçò, Å. ÃéáìáñÝëïõ. Ëïéìþîåéò êáé ÁíôéìéêñïâéáêÞ ×çìåéïèåñáðåßá, 1991, óåë. 701707. 2. Ch. Hadjichristodoulou. Experience gained from the use of reporting systems. Report of the MZCR/WHO training course on the establishment of a human and animal brucellosis national surveillance system, 2:13-14 (DOC/MZCP/ 93.2) 1993. 3. Ch. Hadjichristodoulou. Epidemiological study of brucellosis in eight Greek villages using a computerized mapping programme. Eur. J. Epidemiol. 15:671-680, 1999. 4. Ó. ÑÜðôçò. ÅóùôåñéêÞ Ðáèïëïãßá óåë. 1571-1576, 1998. 5. E. Gotuzzo, C. Cellillo. Brucella In: Gorbach Sh, Bartlett JG, Blacklow NR (Eds): Infectious Diseases, WB Saunders Co, Philadelphia, 1992, pp 1513-1521. 6. ÊÝíôñï ÅëÝã÷ïõ Åéäéêþí Ëïéìþîåùí (ÊÅÅË). Åðéäçìéïëïãéêü Äåëôßï Ëïéìùäþí ÍïóçìÜôùí ÅëëÜäïò, Ôåý÷ïò 14, ÍïÝìâñéïò 1999. 7. A. Lopez-Merino, R. Lopez-Santiago. Imunology of brucellosis in humans. In: Monir Madkour M. (ed): Brucellosis. Cambridge: University Press, 244-249, 1989. 8. T. Tsikrikas, T. Karanis, D. Katsiafliakas, V.

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Alexandropoulou, C. Halkias, E. Kalymopoulos. Epidimiological, clinical, laboratory and other interesting observations from 157 cases of brucellosis. Hellenic Armed Forces Medical Review, 15:39-49, 1981. Harrison’s 15th edition. Principles of Internal Medicine pp 986-989. W. Sixl, F. Reinthalen, B. Sixl-Voigt, H. Withalm, D. Stunzner, W.D. Schneeweiss, H. Rosegger, G. Schuhmann, F. Mascher. Brucellosis in the upper Nile region-Melut district, Sudan. Geogr. Med, (Suppl. 1) 71-76, 1988. A. Hossain, T.F. Bakir, M.N. Chowdhury, E. Kurstake. Seroepidemiology of enteric fever and brucellosis in a developing country. J Hyg Epidemiol Microbiol. Immunol. 35:325-335, 1991. Alballa, S.R. Epidemiology of human brucellosis in southern Saudi Arabia. J. Trop. Med. Hyg., 98:185-189, 1995. D.G. Ndyabahinduka, I.H. Chu. Brucellosis in Uganda. Int. J. Zoonoses 11:59-64, 1984. M. Guerra, E. Tasselli, M.G. Fantini, Picotto. La brucellosi in Italia Fra il 1981 ed il 1992. Rivista Italiana di Igiene, 53:298-321, 1993. Âáóéëéêü ÄéÜôáãìá 3/11/1950 ÖÅÊ 262 Ôåý÷ïò Á´. S. Manetas, Y. Tselentis, A. Charvalos. Epidemiological investigation of human brucellosis in Greece. Italian J. Epidemiol. 6:393-396, 1989. A.F. Kaufmann, J.D. Wenger. Brucellosis. In: Last J.M., Wallace R.B. Rublic health and preventive medicine; 13th ed.Appleton and Lange, Norwalk, CT, 1992, pp. 263-264.

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ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Âáñ. Ðáðáãåùñãßïõ êáé óõí.

ÅÐÁÉÍÅÈÅÉÓÁ ÅÑÃÁÓÉÁ ÓÔÏ ÄÉÁÃÙÍÉÓÌÏ "Ä. ÉÊÊÏÕ" THE SECOND AWARDED PAPER IN THE MEMORY OF PROF. D. IKKOS Primary Heatlh Care, Volume 14, Number 2, 62-70, 2002 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 14, Ôåý÷ïò 2, 62-70, 2002

Åðéäçìéïëïãßá ôñï÷áßùí áôõ÷çìÜôùí óôï íïìü ×áëêéäéêÞò óôçí ðåñßïäï 1986 - 2001 Âáñ. Ðáðáãåùñãßïõ, Ð. ÓôáöõëÜò, Ìáñßá Æïýêá, Á. Âáñäáñéíüò, Â. Ðáðáãåùñãßïõ, Ä. Ðáñáóêåõüðïõëïò, Á. Ôóá÷ïõñßäçò

Ðåñßëçøç Óêïðüò ôçò ðáñïýóáò åðéäçìéïëïãéêÞò Ýñåõíáò åßíáé ç ëåðôïìåñÞò ðáñïõóßáóç ôùí ôñï÷áßùí áôõ÷çìÜôùí ðïõ óõíÝâçóáí óôï ïäéêü äßêôõï ôïõ Í. ×áëêéäéêÞò óôç ÷ñïíéêÞ ðåñßïäï 1986 – 2001. ÅñåõíÞèçêáí ï áñéèìüò, ôï åßäïò êáé ç óïâáñüôçôá ôùí ôñï÷áßùí áôõ÷çìÜôùí, ç êáôáíïìÞ ôïõò áíÜ þñá, çìÝñá êáé ìÞíá, ç áéôßá ðïõ ôá ðñïêÜëåóå êáé ç çëéêßá ôùí ïäçãþí ðïõ åíåðëÜêçóáí ó’ áõôÜ. Õëéêü êáé ìÝèïäïò. Ôï õëéêü ôçò Ýñåõíáò áíôëÞèçêå áðü ôá âéâëßá êßíçóçò ôïõ Íïóïêïìåßïõ êáé ôùí ÊÝíôñùí Õãåßáò ôïõ íïìïý, êáèþò êáé áðü ôá áñ÷åßá ôçò Äéåýèõíóçò Ôñï÷áßáò ôïõ íïìïý. ÁðïôåëÝóìáôá. Ç åðßðôùóç ôùí ôñï÷áßùí áôõ÷çìÜôùí óôï Íïìü ðáñïõóéÜæåôáé éäéáßôåñá õøçëÞ. Ùóôüóï, ìå âÜóç ôá óôïé÷åßá ôçò ôåëåõôáßáò 3åôßáò, ç ðáëáéüôåñá ðñïúïýóá áõîçôéêÞ ðïñåßá ôåßíåé íá áíáóôñáöåß. Óôá 16 Ýôç êáôáãñáöþí, óôï ïäéêü äßêôõï ôïõ íïìïý, óõíÝâçóáí 4.490 ôñï÷áßá áôõ÷Þìáôá, ìå 554 Üìåóá êáôáìåôñçìÝíïõò íåêñïýò êáé ðïëëáðëÜóéï áñéèìü ôñáõìáôéþí (7.270). Ôá ðåñéóóüôåñá êáé óïâáñüôåñá áôõ÷Þìáôá óõìâáßíïõí ôïõò èåñéíïýò ìÞíåò, ôéò çìÝñåò ôùí åïñôþí êáé ôá Óáââáôïêýñéáêá, ôüôå ðïõ óçìåéþíåôáé ìáæéêÞ ìåôáêßíçóç ðëçèõóìïý ðñïò ôï íïìü. ÓõìðåñÜóìáôá. Ôá ôñï÷áßá áôõ÷Þìáôá áðïôåëïýí Ýíá áðü ôá óçìáíôéêüôåñá óýã÷ñïíá ðñïâëÞìáôá äçìüóéáò õãåßáò ãéá ôç ÷þñá ìáò áëëÜ êáé ôï Í. ×áëêéäéêÞò êáé ôá ôåëåõôáßá ÷ñüíéá Ý÷ïõí ðÜñåé äéáóôÜóåéò åðéäçìßáò. Ç êïéíùíéêÞ åðéâÜñõíóç ìå ïðïéáäÞðïôå ìÝèïäï êé áí åðé÷åéñçèåß íá áðïôõðùèåß åßíáé éäéáßôåñá õøçëÞ. Ç óõíåéäçôïðïßçóç ôçò óïâáñüôçôáò ôïõ ðñïâëÞìáôïò áðïôåëåß åðåßãïõóá êïéíùíéêÞ áíÜãêç, áöïý ç áíôéìåôþðéóÞ ôïõ åßíáé åöéêôÞ óýìöùíá ìå ôçí åìðåéñßá Üëëùí ÷ùñþí. Ç áëëáãÞ íïïôñïðßáò êáé ç õéïèÝôçóç áóöáëÝóôåñùí ðñïôýðùí óõìðåñéöïñÜò, óå óõíäõáóìü ìå ðëçñÝóôåñç áóôõíüìåõóç, ëÞøç ìÝôñùí âåëôßùóçò ôïõ ïäéêïý äéêôýïõ, êáëýôåñåò ðñïäéáãñáöÝò áóöÜëåéáò ï÷çìÜôùí, áëëÜ êé Ýãêáéñç ðáñï÷Þ Á´ Âïçèåéþí ìåôÜ ôçí åðÝëåõóç ôïõ áôõ÷Þìáôïò, áðïôåëïýí ïëïêëçñùìÝíç ðñüôáóç ìÝôñùí ðïõ èá óõìâÜëëïõí áðïôåëåóìáôéêÜ óôç ìåßùóç êáé áíôéìåôþðéóç ôùí ôñï÷áßùí áôõ÷çìÜôùí.

Ê.Õ. Êáóóáíäñåßáò, Êáóóáíäñåßá Í. ×áëêéäéêÞò

62

ÅéóáãùãÞ Ôá ôñï÷áßá áôõ÷Þìáôá áðïôåëïýí óçìáíôéêü ðñüâëçìá äçìüóéáò õãåßáò ãéá ôç ÷þñá ìáò êáé ôá ôåëåõôáßá ÷ñüíéá Ý÷ïõí ðÜñåé äéáóôÜóåéò åðéäçìßáò ÷ùñßò ôÜóç áíÜêáìøçò. Åíþ óôéò õðüëïéðåò ÷þñåò ôçò ÅõñùðáúêÞò ¸íùóçò (Å.Å.) ðáñáôçñåßôáé ìéá óõíå÷Þò ìåßùóç ôçò åðßðôùóçò ôùí ôñï÷áßùí áôõ÷çìÜôùí, áðïôÝëåóìá ôçò ðïëéôéêÞò ðñüëçøçò êé ïäéêÞò áóöÜëåéáò ðïõ åöáñìüæåôáé óôéò ÷þñåò áõôÝò, ç ÅëëÜäá, ßóùò êáé ç Éñëáíäßá ìå ôçí Éóðáíßá, åßíáé ïé ÷þñåò ðïõ ðáñïõóéÜæïõí ìéá äéá÷ñïíéêÞ áýîçóç ôùí ôñï÷áßùí áôõ÷çìÜôùí Þ êáé óçìáíôéêÞ óôáóéìüôçôá óå õøçëÜ åðßðåäá1,2. ¼óïí áöïñÜ ôï Íïìü ×áëêéäéêÞò, ç åéêüíá ðïõ ðáñïõóéÜæåé áðü ðëåõñÜò ïäéêþí ôñï÷áßùí áôõ÷çìÜôùí, ËÝîåéò êëåéäéÜ: ôñï÷áßá áôõ÷Þìáôá, åðéäçìéïëïãßá, ÅëëÜò ÕðïâëÞèçêå: ÕðïâëÞèçêå: Ç åñãáóßá õðïâëÞèçêå óôï äéáãùíéóìü "Ä. ºêêïõ" óôá ðëáßóéá ôïõ 14ïõ Ðáíåëëçíßïõ Óõíåäñßïõ ÃåíéêÞò ÉáôñéêÞò (ÊñÞôç, 812 ÌáÀïõ 2002) êáé Ýëáâå Ýðáéíï áðü ôçí ÅðéôñïðÞ Êñßóçò. Äçìïóéåýåôáé ìå êïéíÞ áðüöáóç ôçò ÓõíôáêôéêÞò ÅðéôñïðÞò ôïõ ðåñéïäéêïý êáé ôçò ÏñãáíùôéêÞò ÅðéôñïðÞò ôïõ Óõíåäñßïõ. Õðåýèõíïò áëëçëïãñáößáò: ÑïêÜ ÂéïëÝôá, ÌÜíäñá ËÜñéóáò, Ô.Ê. 41500, ôçë.: 0410821342, e-mail: lavdas@med.uth.gr


Ôüìïò 14, Ôåý÷ïò 2, 2002

Âáñ. Ðáðáãåùñãßïõ êáé óõí.

Epidemiology of road accidents in the Prefecture of Chalkidiki during 1986 - 2001 Var. Papageorgiou, A. Vardarinos, Maria Zouka, V. Papageorgiou, D. Paraskevopoulos, P. Stafilas, A. Tsachourides Summary The purpose of this epidemiological study is the detailed presentation of road accidents in the Prefecture of Chalkidiki during the period 1986 - 2001. The parameters considered are the number, type and importance of the road accidents, the time of day, the day and month they occurred, and the cause, as well as the drivers' age. Although, the results show that the incidence of road accidents is especially high, there seems to be a minor decrease, according to the data of the last 3 years. During the 16 years of the study 4490 accidents occurred, causing 554 immediate deaths and 7270 multiple injuries. There is a crucial/significant increase in the frequency and severity of accidents not only during the summer period, but also national holidays and weekends. In conclusion, although road accidents are a major social problem in Greece, they appear even more so in the Prefecture of Chalkidiki. Finally, a number of measures have been presented which should be undertaken in order to prevent road accidents and reduce the casualties. Health Center of Kassandreia, Chalkidiki

åßíáé áíÜëïãç áõôÞò ðïõ ðáñáôçñåßôáé ãåíéêüôåñá óôç ÷þñá ìáò. Ôï ðñüâëçìá ôùí ôñï÷áßùí êáêþóåùí äåí åóôéÜæåôáé ìüíï óôïí áñéèìü ôùí èáíÜôùí ðïõ óçìåéþíïíôáé óõíåðåßá áõôþí. Óå êáèÝíá áðü ôïõò 2.500 ðåñßðïõ èáíÜôïõò ðïõ óõìâáßíïõí êáô’ Ýôïò áðü ôñï÷áßá áôõ÷Þìáôá, áíôéóôïé÷ïýí ôïõëÜ÷éóôï 17 ôñáõìáôßåò, åíþ ôá ÷áìÝíá ÷ñüíéá áíáìåíüìåíçò æùÞò3, åßíáé ðåñéóóüôåñá áðü êÜèå Üëëç áéôßá èáíÜôïõ ôüóï óå Üíäñåò üóï êáé óå ãõíáßêåò. Ôï åôÞóéï êüóôïò ãéá ôçí ðåñßèáëøç êé áðïêáôÜóôáóç ôùí ôñáõìáôéþí, êáèþò êáé ãéá ôçí êÜëõøç ôçò ÷áìÝíçò ðáñáãùãéêüôçôáò õðïëïãßæåôáé üôé õðåñâáßíåé ôá 3 äéóåêáôïììýñéá åõñþ4. ÊÜèå èÜíáôïò, óå ïðïéáäÞðïôå çëéêßá êé áí óõìâåß áðïôåëåß Ýíá äñÜìá, áëëÜ ïé èÜíáôïé áðü ôñï÷áßá áôõ÷Þìáôá Ý÷ïõí óõ÷íÜ ôá óôïé÷åßá ìéáò ãíÞóéáò ôñáãùäßáò, áöïý áöïñïýí êáôÜ êáíüíá õãéÞ Üôïìá íåáñÞò çëéêßáò, êõñßùò Üíäñåò. Óôçí ðáñïýóá áíáäñïìéêÞ Ýñåõíá åðé÷åéñåßôáé ìéá ëåðôïìåñÞò ó÷åôéêÜ ðáñïõóßáóç ôùí ôñï÷áßùí áôõ÷çìÜôùí ìå óêïðü íá áíáäåé÷ôïýí ïé ðñáãìáôéêÝò äéáóôÜóåéò ôïõ ðñïâëÞìáôïò êáé íá õðïóôçñé÷ôåß ç áíÜãêç Üóêçóçò ðïëéôéêÞò ðñüëçøçò êé ïäéêÞò áóöÜëåéáò. ÓõãêåêñéìÝíá, åñåõíÞèçêáí ï áñéèìüò, ôï åßäïò êáé ç óïâáñüôçôá ôùí ôñï÷áßùí áôõ÷çìÜôùí ðïõ óõíÝâçóáí óôçí áíùôÝñù ÷ñïíéêÞ ðåñßïäï, ç êáôáíïìÞ ôïõò áíÜ þñá, çìÝñá êáé ìÞíá,

ç áéôßá ðïõ ôá ðñïêÜëåóå êáé ç çëéêßá ôùí ïäçãþí ðïõ åíåðëÜêçóáí ó’ áõôÜ. Åðßóçò, åðéóçìáßíïíôáé ïé ðåñéï÷Ýò õøçëïý êéíäýíïõ ôïõ ïäéêïý äéêôýïõ ôïõ íïìïý, ðïõ ÷ñÞæïõí éäéáßôåñçò áóôõíüìåõóçò, ðñïóï÷Þò êáé âåëôßùóçò.

Ðëçèõóìüò ÌåëÝôçò - ÌÝèïäïò

Ôï õëéêü ôçò Ýñåõíáò áíôëÞèçêå áðü ôá ó÷åôéêÜ âéâëßá êßíçóçò áóèåíþí ôïõ Íïóïêïìåßïõ êáé ôùí ÊÝíôñùí Õãåßáò ôïõ íïìïý, êáèþò êáé áðü ôá áñ÷åßá ôçò Äéåýèõíóçò Ôñï÷áßáò ôïõ íïìïý. ÅñåõíÜôáé ç ðåñßïäïò 1986 – 2001. Ç Ýñåõíá îåêéíÜåé áðü ôï 1986 ãéáôß ôüôå Üñ÷éóáí ôç ëåéôïõñãßá ôïõò ôï íÝï Íïóïêïìåßï êáé ôá ðñþôá ÊÝíôñá Õãåßáò ôïõ íïìïý, ïðüôå ïé õðÜñ÷ïõóåò êáôáãñáöÝò ðïõ ó÷åôßæïíôáé ìå ôá ôñï÷áßá áôõ÷Þìáôá åßíáé ðéï ðëÞñåéò êáé ðéï áîéüðéóôåò.

ÁðïôåëÝóìáôá Óôïí Ðßíáêá 1 (êáé ÄéÜãñáììá 1) öáßíåôáé ï áñéèìüò ôùí ôñï÷áßùí áôõ÷çìÜôùí ðïõ óõíÝâçóáí óôï ïäéêü äßêôõï ôïõ Í. ×áëêéäéêÞò óôç ÷ñïíéêÞ ðåñßïäï 1986–2001, êáèþò êáé ï óõíïëéêüò áñéèìüò ôùí ðáèüíôùí (íåêñïß, ôñáõìáôßåò)5. Óôïí Ðßíáêá 2 (êáé ÄéÜãñáììá 2) ðáñïõóéÜæïíôáé ôï óýíïëï ôùí ôñï÷áßùí áôõ÷çìÜôùí êáé ôùí ôñáõìáôéþí óôçí åëëçíéêÞ åðéêñÜôåéá, óôç ÷ñïíéêÞ ðåñßïäï 1986–1992 êáé 2000–2001. Äåí âñÝèçêáí óôïé÷åßá ãéá ôá Ýôç 1993–19995-8. Óôïí Ðßíáêá 3 (êáé ÄéÜãñáììá 3) ðáñïõóéÜæïíôáé ïé íåêñïß áðü ôñï÷áßá áôõ÷Þìáôá óôçí åëëçíéêÞ åðéêñÜôåéá, óôç ÷ñïíéêÞ ðåñßïäï 1986 – 20016-8. Ï Ðßíáêáò 4 (êáé ÄéÜãñáììá 4) äåß÷íåé ôï åßäïò ôùí áôõ÷çìÜôùí5. Ïé Ðßíáêåò 5 êáé 6 (êáé ÄéáãñÜììáôá 5 êáé 6) äåß÷íïõí ôçí êáôáíïìÞ ôùí ôñï÷áßùí áôõ÷çìÜôùí óôç äéÜñêåéá ôïõ 24þñïõ êáé óôç äéÜñêåéá ôçò åâäïìÜäáò áíôßóôïé÷á5. Ï Ðßíáêáò 7 (êáé ÄéÜãñáììá 7) äåß÷íåé ôç 63


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Âáñ. Ðáðáãåùñãßïõ êáé óõí.

Ðßíáêáò 1. Áñéèìüò ôñï÷áßùí áôõ÷çìÜôùí êáé ðáèüíôùí óôï Í. ×áëêéäéêÞò óôç ÷ñïíéêÞ ðåñßïäï 1986 - 2001 ¸ôïò

Áñéèìüò Áôõ÷çìÜôùí

Áñéèìüò ðáèüíôùí

Áñéèìüò Íåêñþí

1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001

207 244 266 284 286 298 296 322 305 308 282 272 357 286 288 189

362 440 526 512 459 505 525 517 563 536 483 517 606 460 465 348

25 22 43 25 27 41 30 41 38 20 54 31 42 40 37 38

97 104 120 117 81 84 68 77 75 75 79 108 121 81 76 53

240 314 363 370 351 380 427 399 450 441 350 378 443 339 352 257

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Óýíïëï

Áñéèìüò Ôñáõìáôéþí ÂáñéÜ ÅëáöñÜ

7270

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Íåêñïß

ÂáñéÜ ôñáõìáôßåò

ÅëáöñÜ ôñáõìáôßåò

ÄéÜãñáììá 1. Áñéèìüò ôñï÷áßùí áôõ÷çìÜôùí êáé ðáèüíôùí óôï Í. ×áëêéäéêÞò óôç ÷ñïíéêÞ ðåñßïäï 1986 - 2001

Ðßíáêáò 2. Áñéèìüò ôñï÷áßùí áôõ÷çìÜôùí êáé ðáèüíôùí óôçí ÅëëÜäá óôç ÷ñïíéêÞ ðåñßïäï 1986 - 1992 êáé 2000 - 2001 ¸ôïò

Áôõ÷Þìáôá

Ðáèüíôåò

Íåêñïß

1986 1987 1988 1989 1990 1991 1992 2000 2001

19462 18966 23832 23737 22672 23230 24125 22952 19649

28953 27980 35132 35408 33389 33854 34781 32482 27889

1451 1502 1784 2016 1986 2013 1995 2103 1911

64

Ôñáõìáôßåò ÂáñéÜ ÅëáöñÜ 3490 3163 3902 4014 3888 3883 4000 4213 3250

24012 23315 29446 29378 27515 27958 28786 26166 22728


Ôüìïò 14, Ôåý÷ïò 2, 2002

Âáñ. Ðáðáãåùñãßïõ êáé óõí. 40000 35000 30000 25000 20000 15000 10000 5000 0

1986

1987

1988

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1990

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2000

2001

¸ôïò Áôõ÷Þìáôá

Ðáèüíôåò

ÂáñéÜ ôñáõìáôßåò

ÅëáöñÜ ôñáõìáôßåò

ÄéÜãñáììá 2. Áñéèìüò ôñï÷áßùí áôõ÷çìÜôùí êáé ðáèüíôùí óôçí ÅëëÜäá óôç ÷ñïíéêÞ ðåñßïäï 1986 - 1992 êáé 2000 - 2001

Ðßíáêáò 3. Íåêñïß áðü ôñï÷áßá óôçí ÅëëçíéêÞ åðéêñÜôåéá óôçí ðåñßïäï 1986 - 2001 ¸ôïò

Íåêñïß

¸ôïò

Íåêñïß

1986 1987 1988 1989 1990 1991 1992 1993

1451 1502 1784 2016 1986 2013 1995 2008

1994 1995 1996 1997 1998 1999 2000 2001

2149 2175 2141 2229 2181 2103 1911

Óýíïëï

31720

ìçíéáßá êáôáíïìÞ ôùí áôõ÷çìÜôùí êáèþò êáé ôïí áñéèìü ôùí íåêñþí óõíåðåßá áõôþí óôï Í. ×áëêéäéêÞò óôç ÷ñïíéêÞ ðåñßïäï 1986 – 20015. ÁíáöïñéêÜ ìå ôïõò åìðëåêüìåíïõò áéôéïëïãéêïýò ðáñÜãïíôåò óôá ôñï÷áßá áôõ÷Þìáôá, äéáêñßíïõìå áßôéá áíáöåñüìåíá óôïõò ïäçãïýò, ôï ü÷çìá, ôï äñüìï êáé ôéò êáéñéêÝò óõíèÞêåò. Åéäéêüôåñá ôá áßôéá ðïõ áíáöÝñïíôáé óôïõò ïäçãïýò, öáßíïíôáé êáôÜ óåéñÜ öèßíïõóáò óõ÷íüôçôáò óôïí Ðßíáêá 8 (êáé ÄéÜãñáììá 8)5. Óôá ëïéðÜ áßôéá ôïõ ðßíáêá ðåñéëáìâÜíïíôáé ç ïäÞ-

2500

2250

2000

1750

1500

1250

1000 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001

ÄéÜãñáììá 3. Íåêñïß áðü ôñï÷áßá áôõ÷Þìáôá óôçí ÅëëÜäá óôç ÷ñïíéêÞ ðåñßïäï 1986 - 2001. 65


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Âáñ. Ðáðáãåùñãßïõ êáé óõí. ÁíáôñïðÞ ï÷Þìáôïò 4,18%

ÅêôñïðÞ ï÷Þìáôïò 21,09%

ÐéíáêÜò 6. ÊáôáíïìÞ ôùí áôõ÷çìÜôùí óôç äéÜñêåéá ôçò åâäïìÜäáò

¢ëëï 0,36%

ÇìÝñá Óýãêñïõóç ìå ðåæü 13,45%

Ðñüóêñïõóç 4,36% Óýãêñïõóç ìå æþï 0,18%

Ðïóïóôü %

ÄåõôÝñá Ôñßôç ÔåôÜñôç ÐÝìðôç ÐáñáóêåõÞ ÓÜââáôï ÊõñéáêÞ

13,7 11,37 10,21 12,66 14,47 18,6 18,99

20 18

Óýãêñïõóç ìå ü÷çìá 56,37% Óýãêñïõóç ìå ðåæü ÅêôñïðÞ ï÷Þìáôïò

Óýãêñïõóç ìå ü÷çìá ÁíáôñïðÞ ï÷Þìáôïò

Óýãêñïõóç ìå æþï ¢ëëï

16

Ðñüóêñïõóç

14 12

ÄéÜãñáììá 4. Åßäïò ôñï÷áßùí áôõ÷çìÜôùí.

10 8 6

Ðßíáêáò 5. ÊáôáíïìÞ ôùí áôõ÷çìÜôùí óôç äéÜñêåéá ôïõ 24þñïõ ¿ñåò

Ðïóïóôü %

1.00 - 5.00 5.00 - 9.00 9.00 - 13.00 13.00 - 17.00 17.00 - 21.00 21.00 - 1.00

7,11 10,46 20,8 27,39 20,54 13,7

21.00-1.00 13,70% 17.00-21.00 20,54%

1.00-5.00 7,11%

4 2 0

ÄÅÕÔÅÑÁ

ÔÑÉÔÇ

ÔÅÔÁÑÔÇ

ÐÅÌÐÔÇ

ÐÁÑÁÓÊÅÕÇ ÓÁÂÂÁÔÏ

ÊÕÑÉÁÊÇ

ÄéÜãñáììá 6. ÊáôáíïìÞ ôñï÷áßùí áôõ÷çìÜôùí óôç äéÜñêåéá ôçò åâäïìÜäáò.

ðïõ ÷ñÞæïõí âåëôßùóçò êáé éäéáßôåñçò ðñïóï÷Þò êé áóôõíüìåõóçò5. ¹äç ðïëëÜ óçìåßá ôùí åðéìÝñïõò ïäéêþí áîüíùí Ý÷ïõí âåëôéùèåß Þ âñßóêïíôáé óôï óôÜäéï õëïðïßçóçò Ýñãùí âåëôßùóçò.

5.00-9.00 10,46% 9.00-13.00 20,80%

ÓõæÞôçóç – ÓõìðåñÜóìáôá Áðü ôçí áíÜëõóç ôùí áðïôåëåóìÜôùí ôçò 13.00-17.00 27,39%

ÄéÜãñáììá 5. ÊáôáíïìÞ ôñï÷áßùí áôõ÷çìÜôùí óôç äéÜñêåéá ôïõ 24þñïõ.

1000 900

Íåêñïß

Áôõ÷Þìáôá

800 700

66

600 500 400 300 200 100 ÍÏÅÌÂÑÉÏÓ

ÄÅÊÅÌÂÑÉÏÓ

ÏÊÔÙÂÑÉÏÓ

ÁÕÃÏÕÓÔÏÓ

ÓÅÐÔÅÌÂÑÉÏÓ

ÉÏÕËÉÏÓ

ÉÏÕÍÉÏÓ

ÌÁÉÏÓ

ÌÁÑÔÉÏÓ

ÁÐÑÉËÉÏÓ

Íåêñïß ÉÁÍÏÕÁÑÉÏÓ

0

ÖÅÂÑÏÕÁÑÉÏÓ

ãçóç óå êáôÜóôáóç ìÝèçò, ç ÷ñÞóç åêôõöëùôéêþí öþôùí, ç ðáñáâßáóç óçìáôïäüôç, ïé åðéäåéêôéêïß åëéãìïß, ç áäéêáéïëüãçôç ôñï÷ïðÝäçóç ê.ëð. ÔÝëïò, óå ü,ôé áöïñÜ ôçí çëéêßá ôùí õðáßôéùí ïäçãþí êáé ôùí ðáèüíôùí ðïõ åìðëÝêïíôáé óôá ôñï÷áßá áôõ÷Þìáôá, áõôÞ öáßíåôáé óôïí Ðßíáêá 9 (êáé ÄéÜãñáììá 9)5. Êëåßíïíôáò ôçí ðáñïõóßáóç ôùí áðïôåëåóìÜôùí, óôïí Ðßíáêá 10 åìöáíßæïíôáé ïé ðåñéï÷Ýò õøçëïý êéíäýíïõ ôïõ ïäéêïý äéêôýïõ ôïõ íïìïý

ÄéÜãñáììá 7. Ìçíéáßá êáôáíïìÞ áôõ÷çìÜôùí êáé íåêñþí áíÜ ìÞíá óôï Í. ×áëêéäéêÞò óôç ÷ñïíéêÞ ðåñßïäï 1986-2001.


¸ôïò

ÌÞíáò ÉáíïõÜñéïò Á Í

1986 6 0 1987 7 0 1988 10 1 1989 5 0 1990 12 0 1991 14 2 1992 14 0 1993 9 1 1994 7 0 1995 10 1 1996 12 2 1997 14 5 1998 8 6 1999 19 4 2000 13 1 2001 7 0 Óýíïëï 167 23

ÖåâñïõÜñéïò Á Í 3 7 6 11 15 9 7 13 8 10 8 13 12 10 7 7 146

0 0 1 0 0 1 3 4 1 0 1 0 1 1 1 8 22

ÌÜñôéïò Á Í 8 2 6 3 12 1 11 0 19 1 15 3 14 3 15 1 14 2 10 0 11 1 7 1 17 2 6 0 14 1 10 1 189 22

Áðñßëéïò Á Í 9 1 11 3 14 1 14 0 26 4 12 2 15 1 9 1 13 1 12 0 17 5 14 2 22 3 17 1 25 3 8 1 238 29

ÌÜéïò Á Í 10 22 17 24 26 26 20 22 33 30 35 19 22 22 25 9 362

Éïýíéïò Á Í

0 26 2 27 2 31 4 32 1 26 3 37 1 25 1 36 8 37 3 34 3 41 2 39 3 39 2 28 6 36 1 25 42 519

ÓÕÍÏËÉÊÁ

Éïýëéïò Áýãïõóôïò ÓåðôÝìâñéïò Á Í Á Í Á Í

2 51 9 4 58 2 4 61 14 4 60 4 0 48 8 2 66 5 2 65 6 2 71 7 6 72 11 4 66 3 10 55 14 3 55 3 3 64 5 4 56 10 7 59 5 6 43 12 63 950 118

45 6 49 4 47 8 68 8 59 8 50 11 69 5 71 11 60 3 57 0 43 8 45 7 92 15 65 10 68 8 31 6 919 118

13 18 26 24 15 25 34 23 29 32 22 26 31 17 18 20 373

1 1 5 1 1 6 6 7 3 3 2 3 0 2 0 0 41

Ïêôþâñéïò ÍïÝìâñéïò ÄåêÝìâñéïò Á Í Á Í Á Í 9 11 21 10 17 17 18 26 13 14 16 17 20 16 9 12 246

1 2 4 0 1 2 0 3 1 1 3 3 2 4 2 1 30

17 2 16 0 13 0 10 2 15 2 18 4 10 3 12 1 13 1 15 4 13 2 8 2 17 1 11 1 5 3 9 1 202 29

10 12 8 15 8 9 5 15 6 18 9 15 13 19 9 8 179

1 1 2 2 1 0 0 2 1 1 3 0 1 1 0 1 17

Á

Í

207 25 244 22 266 43 284 25 286 27 298 41 296 30 322 41 305 38 308 20 282 54 272 31 357 42 286 40 288 37 189 38 4490 554

Âáñ. Ðáðáãåùñãßïõ êáé óõí.

Ðßíáêáò 7. Ìçíéáßá êáôáíïìÞ áôõ÷çìÜôùí êáé íåêñþí áíÜ ìÞíá óôï Í. ×áëêéäéêÞ

Á: áôõ÷Þìáôá, Í: íåêñïß óõíåðåßá ôùí áôõ÷çìÜôùí

Ðïóïóôü %

¢ëëá 16,95%

24,58 17,32 11,92 8,38 8,00 6,89 5,96 16,95

ÅóöáëìÝíç áðïöåõêôéêÞ åíÝñãåéá 5,96%

Ôüìïò 14, Ôåý÷ïò 2, 2002

Ìç ôÞñçóç áðüóôáóçò áóöáëåßáò 6,89%

Ðßíáêáò 8. Áßôéá áôõ÷çìÜôùí ìå åõèýíç ôïõ ïäçãïý

Áßôéá áôõ÷çìÜôùí

Ðáñáâßáóç ðñïôåñáéüôçôáò 8,00%

ÕðåñâïëéêÞ ôá÷ýôçôá 24,58%

ÕðåñâïëéêÞ ôá÷ýôçôá Êßíçóç óôï áíôßèåôï ñåýìá Áíôéêáíïíéêü ðñïóðÝñáóìá Áðüóðáóç ðñïóï÷Þò ïäçãïý Ðáñáâßáóç ðñïôåñáéüôçôáò Ìç ôÞñçóç áðüóôáóçò áóöáëåßáò ÅóöáëìÝíç áðïöåõêôéêÞ åíÝñãåéá ¢ëëá

Áðüóðáóç ðñïóï÷Þò ïäçãïý 8,38%

Áíôéêáíïíéêü ðñïóðÝñáóìá 11,92%

Êßíçóç óôï áíôßèåôï ñåýìá 17,32%

Ðïóïóôü %

13,63 38,27 32,23 15,87

¢íù ôùí 50

ÄéÜãñáììá 8. Áßôéá ôñï÷áßùí áôõ÷çìÜôùí ìå õðáéôéüôçôá ôïõ ïäçãïý.

30-50

Ðßíáêáò 9. Çëéêßá õðáßôéùí ïäçãþí êáé ðáèüíôùí

18-30

Çëéêßá ïäçãþí - ðáèüíôùí

ÊÜôù ôùí 18

ÊÜôù ôùí 18 18-30 30-50 ¢íù ôùí 50

40

35

30

25

20

15

5

10

0

ÄéÜãñáììá 9. Çëéêßá õðáßôéùí ïäçãþí êáé ðáèüíôùí.

Ýñåõíáò ðñïêýðôïõí ôá ðáñáêÜôù óõìðåñÜóìáôá. Áðü ôá óôïé÷åßá ôïõ Ðßíáêá 1 äéáêñßíïíôáé êáèáñÜ ïé óôáèåñïðïéçôéêÝò äéá÷ñïíéêÝò ôÜóåéò ôùí ôñï÷áßùí áôõ÷çìÜôùí óôï Í. ×áëêéäéêÞò êáé ôùí áíôßóôïé÷ùí óõíåðåéþí ôïõò (íåêñïß, ôñáõìáôßåò).

67


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Âáñ. Ðáðáãåùñãßïõ êáé óõí.

Ðßíáêáò 10. Ðåñéï÷Ýò õøçëïý êéíäýíïõ óôï ïäéêü äßêôõï ôïõ Íïìïý ×áëêéäéêÞò Ïäüò ÅèíéêÞ Èåó/íßêçò – Ðïëõãýñïõ ÍÝá åèíéêÞ Èåó/íßêçò – Ìïõäáíéþí ÍÝá åèíéêÞ Èåó/íßêçò – Éåñéóóïý Åðáñ÷éáêÞ Ðïëõãýñïõ – ÃåñáêéíÞò Åðáñ÷éáêÞ Í.Ìïõäáíéþí – Êýêëùìá Êáóóáíäñåßáò Åðáñ÷éáêÞ Í.Ìïõäáíéþí – Êýêëùìá Óéèùíßáò

Óôç ÷ñïíéêÞ ðåñßïäï 1986 – 2001 óõíÝâçóáí óôï ïäéêü äßêôõï ôïõ íïìïý 4.490 ôñï÷áßá áôõ÷Þìáôá ìå èëéâåñü áðïëïãéóìü 554 íåêñïýò êáé 7.270 ôñáõìáôßåò, áðü ôïõò ïðïßïõò ïé 1.416 âáñéÜ êáé ïé 5.854 åëáöñÜ. ¸ôóé, ï íïìüò, ìå Ýíá ìÝóï üñï 280 ôñï÷áßùí áôõ÷çìÜôùí êáô’ Ýôïò êé áíôßóôïé÷ï áðïëïãéóìü 35 íåêñþí êáé 595 ðåñßðïõ ôñáõìáôéþí, ðáñïõóéÜæåé Ýíáí åîáéñåôéêÜ õøçëü äåßêôç ôñï÷áßùí áôõ÷çìÜôùí êáé ðáèüíôùí ðñïóþðùí. ÁíÜëïãç åéêüíá óå áðïëïãéóìü íåêñþí ãéá ôï óýíïëï ôçò åëëçíéêÞò åðéêñÜôåéáò ðñïêýðôåé áðü ôá óôïé÷åßá ôïõ Ðßíáêá 3. ÅíäéáöÝñïí ðáñïõóéÜæåé ç óõãêñéôéêÞ ðáñÜèåóç ôùí óôïé÷åßùí ôùí ÐéíÜêùí 1 êáé 2 (êáé ÄéáãñáììÜôùí 1 êáé 2). Ïé óáöþò ìéêñüôåñïé áñéèìïß ôñï÷áßùí áôõ÷çìÜôùí êáé ðáèüíôùí ôïõ Ýôïõò 2001 óå ó÷Ýóç ìå ôï Ýôïò 2000, ôüóï óå åðßðåäï íïìïý üóï êáé ðáíåëëáäéêÜ, ìðïñåß íá óçìáôïäïôïýí ôÜóåéò áñ÷üìåíçò ìåßùóçò ôùí ôñï÷áßùí, ìåôÜ ôçí õéïèÝôçóç êé åöáñìïãÞ áðü ôçí åðßóçìç ðïëéôåßá ôïõ íÝïõ ðñïãñÜììáôïò ïäéêÞò áóöÜëåéáò “Êáè’ ïäüí”6. Ç ðôþóç áõôÞ ôùí äåéêôþí êñßíåôáé éäéáßôåñá åíèáññõíôéêÞ êáé ìðïñåß íá áðïäïèåß óôçí áñìïíéêÞ, óõíåðÞ êáé óõíôïíéóìÝíç óõíåñãáóßá ìåôáîý óõíáñìüäéùí õðïõñãåßùí êáé öïñÝùí. ¼óïí áöïñÜ óôï åßäïò ôùí áôõ÷çìÜôùí (Ðßíáêáò 4 êáé ÄéÜãñáììá 4), èá ðñÝðåé íá åðéóçìáíèåß ôï ìåãÜëï ðïóïóôü ðáñÜóõñóçò ðåæþí (12,9%), ãåãïíüò ðïõ óçìáßíåé üôé áõôÞ ç êáôçãïñßá áôõ÷çìÜôùí óõìâáßíåé óå êáôïéêçìÝíåò ðåñéï÷Ýò. Ç åðéóÞìáíóç áõôÞ èá ðñÝðåé íá ðñïóáíáôïëßóåé ôçí åðßóçìç ðïëéôåßá óôç ëÞøç ðñüóèåôùí ìÝôñùí óå êáôïéêçìÝíåò ðåñéï÷Ýò, þóôå íá ìåéùèåß äñáóôéêÜ ï áñéèìüò ôùí áôõ÷çìÜôùí ðïõ óõìâáßíïõí ó’ áõôÝò. Áðü ôïõò Ðßíáêåò 5, 6 êáé 7 (êáé áíôßóôïé÷á ÄéáãñÜììáôá) öáßíåôáé êáèáñÜ üôé ôá ðåñéóóüôåñá êáé óïâáñüôåñá áôõ÷Þìáôá óõìâáßíïõí óå þñåò êõêëïöïñéáêÞò áé÷ìÞò, ôéò çìÝñåò ôùí 68

×éëéïìåôñéêÞ èÝóç 35, 47-49, 59-61 44-47, 52-64 93, 104 5, 10 29-33 6, 9, 12, 15, 18, 24, 28, 35

åïñôþí êáé ôá Óáââáôïêýñéáêá êáèþò êáé ôïõò èåñéíïýò ìÞíåò, ôüôå ðïõ óçìåéþíåôáé ìáæéêÞ Ýîïäïò áðü ôá ìåãÜëá áóôéêÜ êÝíôñá (Èåóóáëïíßêç) êé Üëëåò ðåñéï÷Ýò, ìå ðñïïñéóìü ôï íïìü ×áëêéäéêÞò (åðéäçìßá åîüäïõ)9. ¼óïí áöïñÜ ôïõò áéôéïëïãéêïýò ðáñÜãïíôåò ðñüêëçóçò ôñï÷áßùí áôõ÷çìÜôùí ðïõ áíáöÝñïíôáé óôïõò ïäçãïýò (Ðßíáêáò 8 êáé ÄéÜãñáììá 8), ç õðåñâïëéêÞ ôá÷ýôçôá åõèýíåôáé ãéá ôï ìåãáëýôåñï ðïóïóôü áôõ÷çìÜôùí (28,12%). Äõï áêüìç ðáñÜãïíôåò (áíôéêáíïíéêü ðñïóðÝñáóìá êáé êßíçóç óôï áíôßèåôï ñåýìá) ðïõ ó÷åôßæïíôáé ìå ôçí ìç ôÞñçóç ôïõ Êþäéêá ÏäéêÞò Êõêëïöïñßáò, åíÝ÷ïíôáé ìáæß ìå ôçí õðåñâïëéêÞ ôá÷ýôçôá óôç äéáìüñöùóç ôïõ ìåãÜëïõ ðïóïóôïý ôùí áôõ÷çìÜôùí (60% ðåñßðïõ). ÔÝëïò áðü ôá óôïé÷åßá ôïõ Ðßíáêá 9 (êáé ÄéÜãñáììá 9) öáßíåôáé üôé óôï âùìü ôçò áóöÜëôïõ èõóéÜæïíôáé êáôÜ êáíüíá íåáñÜ Üôïìá (53% ðåñßðïõ êÜôù ôùí 30 åôþí). Ìå âÜóç ôéò áíùôÝñù äéáðéóôþóåéò, ïé ïðïßåò áíáäåéêíýïõí ôç óïâáñüôçôá ôïõ ðñïâëÞìáôïò ôùí ôñï÷áßùí áôõ÷çìÜôùí, èá ðñÝðåé íá áíáöåñèïýìå äéá âñá÷Ýùí óôá ìÝôñá ðñüëçøçò áõôþí êáé ìåßùóçò ôùí óïâáñþí óõíåðåéþí ôïõò. Åí ðñþôïéò, èá ðñÝðåé íá óõíåéäçôïðïéÞóïõìå üôé ôá ôñï÷áßá áôõ÷Þìáôá, óýìöùíá ìå ôçí åìðåéñßá Üëëùí ÷ùñþí, åßíáé äõíáôü íá ðñïëçöèïýí êáé íá áíôéìåôùðéóôïýí. ÊáôÜ ôïí êáèçãçôÞ Ôñé÷üðïõëï ôá áôõ÷Þìáôá äåí áðïôåëïýí áðñüêëçôï ÷ôýðçìá ôçò ìïßñáò, áëëÜ ôçí áðÜíôçóÞ ôçò óå ìéá ðñüêëçóç ðïõ ôç äçìéïõñãåß ç áäéáöïñßá êáé ç ðåñéöñüíçóÞ ìáò – ðáñïäéêÜ Þ óõóôçìáôéêÜ, áôïìéêÜ Þ óõëëïãéêÜ – óôç óôï÷áóôéêÞ Ýííïéá ôïõ êéíäýíïõ. ¢ôïìá êáé ëáïß ðïõ óõíåéäçôïðïéïýí ôï âáóéêü áõôü áîßùìá ãßíïíôáé ãñÞãïñá äÝêôåò ìéáò áíôáðïäïôéêüôçôáò, ðïõ åêöñÜæåôáé ìå äñáóôéêÞ ìåßùóç ôçò ðéèáíüôçôáò åíüò ôñï÷áßïõ óõìâÜìáôïò, êáèþò êáé ôçò ðéèáíüôçôáò óïâáñÞò óùìáôéêÞò âëÜâçò Þ èáíÜôïõ åîáéôßáò ôïõ áôõ÷Þìáôïò. ÐáñÜäåéãìá, óå áôïìé-


Âáñ. Ðáðáãåùñãßïõ êáé óõí.

êü åðßðåäï, áðïôåëåß ç ìéêñüôåñç ðéèáíüôçôá ôñï÷áßïõ áôõ÷Þìáôïò êáé óõíáêüëïõèïõ èáíÜôïõ ôïõ åíÞëéêá óå ó÷Ýóç ìå íåáñü Üôïìï. ÐáñÜäåéãìá äåýôåñï, óå óõëëïãéêü åðßðåäï, áðïôåëåß ç äéá÷ñïíéêÞ ìåßùóç ôùí ôñï÷áßùí áôõ÷çìÜôùí êáé ôùí óõíáêüëïõèùí óõíåðåéþí óôéò óêáíäéíáâéêÝò ÷þñåò êáé óôéò Ç.Ð.Á. óå áíôéäéáóôïëÞ ìå ôéò ìåóïãåéáêÝò ÷þñåò êáé êáô’ åîï÷Þí ôçí ÅëëÜäá2,4. ÁíáöïñéêÜ ìå ôá ìÝôñá ðñüëçøçò èá ðñÝðåé íá åðéóçìÜíïõìå ôá åîÞò: Ïé ðáñÜãïíôåò ðïõ åìðëÝêïíôáé óå Ýíá ôñï÷áßï áôý÷çìá åßíáé ôñåéò: ï ïäçãüò, ôï ü÷çìá êáé ï äñüìïò. Áíáìößâïëá ï áíèñþðéíïò ðáñÜãïíôáò åßíáé ï ðëÝïí óçìáíôéêüò, áöïý ôá ï÷Þìáôá êéíïýíôáé ðÜíôá óýìöùíá ìå ôç âïýëçóç êáé ôç óõìðåñéöïñÜ ôùí ïäçãþí4,10. ÅðïìÝíùò, ç óùìáôéêÞ êáé øõ÷éêÞ õãåßá ôùí ïäçãþí, ç çëéêßá, ôï äéáíïçôéêü åðßðåäï, ç ïäçãçôéêÞ éêáíüôçôá êáé ï óåâáóìüò áðü ìÝñïõò ôïõò ôïõ Êþäéêá ÏäéêÞò Êõêëïöïñßáò ðáßæïõí óçìáíôéêü ñüëï óôçí ðñüëçøç ôùí ôñï÷áßùí áôõ÷çìÜôùí. Åäþ èá ðñÝðåé íá ó÷ïëéÜóïõìå éäéáßôåñá äýï åðéìÝñïõò ðáñáìÝôñïõò ðïõ Ý÷ïõí Üìåóç ó÷Ýóç ìå ôçí ðñüëçøç ôùí ôñï÷áßùí êáé ôéò óïâáñÝò óõíÝðåéÝò ôïõò. Ç ðñþôç áöïñÜ ôçí êáôáíÜëùóç ïéíïðíåõìáôùäþí ðïôþí áðü ôïõò ïäçãïýò. Óýìöùíá ìå ôïí êáèçãçôÞ Ôñé÷üðïõëï, ðåñéóóüôåñá áðü 25% ôùí èáíáôçöüñùí ôñï÷áßùí áðïäßäïíôáé óå ðñïçãçèåßóá ÷ñÞóç ïéíïðíåýìáôïò êáé äåäïìÝíïõ üôé ðõêíüôçôá áëêïüëçò óôï áßìá ðÜíù áðü 40mg/100ml (ðïõ åðéôõã÷Üíåôáé ìå 2–3 ðïôÞñéá êñáóß, üôáí ôï óôïìÜ÷é åßíáé êåíü) áõîÜíåé ôç ó÷åôéêÞ óõ÷íüôçôá ôùí áôõ÷çìÜôùí, êáôáäåéêíýåôáé ç Ýêôáóç êáé ç óïâáñüôçôá ôçò áéôéïëïãéêÞò ó÷Ýóçò ôùí ôñï÷áßùí ìå ôçí êáôáíÜëùóç áëêïüëçò11. Ç äåýôåñç ðáñÜìåôñïò áíáöÝñåôáé óôç ÷ñÞóç ôçò æþíçò áóöáëåßáò4,12. ÊáìéÜò ÷þñáò ï ëáüò äåí ðñüêåéôáé íá ùöåëçèåß ôüóï ðïëý áðü ôç óõóôçìáôéêÞ ÷ñÞóç æþíçò áóöáëåßáò üóï ïé ¸ëëçíåò, åðåéäÞ ôï ðïóïóôü ðïõ ôç ÷ñçóéìïðïéåß óÞìåñá åßíáé áðïãïçôåõôéêÜ ÷áìçëü áëëÜ êé åðåéäÞ ôï ïäéêü äßêôõï ôçò ÷þñáò ìáò åßíáé ìéêñü êé áíåðáñêÝò ó÷åôéêÜ ìå ôïí áñéèìü ôùí êõêëïöïñïýíôùí ï÷çìÜôùí, ôá ïðïßá óå ìåãÜëç áíáëïãßá åßíáé ìåãÜëçò çëéêßáò12. Õðïëïãßæåôáé üôé ç óõóôçìáôéêÞ êáé óùóôÞ ÷ñÞóç ôçò áëëÜ êáé ôùí ðáéäéêþí êáèéóìÜôùí, êáèþò êáé ôïõ êñÜíïõò áðü ôïõò äéêõêëéóôÝò, ìðïñïýí íá õðïäéðëáóéÜ-

Ôüìïò 14, Ôåý÷ïò 2, 2002

óïõí ôïí áñéèìü ôùí íåêñþí êáé âáñéÜ ôñáõìáôéóìÝíùí áíÜìåóá óôïõò ïäçãïýò êáé óôïõò åðéâÜôåò ôùí ï÷çìÜôùí óôç ÷þñá ìáò. Óôçí ÅëëÜäá ôá ðïóïóôÜ áõôÜ ìåôáöñÜæïíôáé óå ðåñéóóüôåñåò áðü 300 áíèñþðéíåò æùÝò êáé ðåñéóóüôåñïõò áðü 6.000 âáñéÜ ôñáõìáôéóìÝíïõò êÜèå ÷ñüíï. ÅîÜëëïõ ôï ïéêïíïìéêü êÝñäïò áðü ôç ãåíéêÞ êáé óõóôçìáôéêÞ ÷ñçóéìïðïßçóç ôçò æþíçò áóöáëåßáò õðïëïãßæåôáé ôïõëÜ÷éóôïí óå 735 åêáôïììýñéá åõñþ åôçóßùò, ðïóü ðïõ êÜëëéóôá èá ìðïñïýóå íá åðåíäõèåß ãéá ôçí áíáâÜèìéóç ôïõ óõóôÞìáôïò õãåßáò4. Ç åîáóöÜëéóç ôùí äõï áõôþí ðñïûðïèÝóåùí èá åðéôåõ÷èåß ìÝóá áðü ìéá ðëáôéÜ, óùóôÞ êáé óõíôïíéóìÝíç åêóôñáôåßá åíçìÝñùóçò (ðëçñïöüñçóç áðü ôá ìÝóá ìáæéêÞò åíçìÝñùóçò, õðï÷ñåùôéêÜ ìáèÞìáôá êõêëïöïñéáêÞò áãùãÞò óôá ó÷ïëåßá, åõñýôåñá êïéíùíéêÜ ðñïãñÜììáôá ïäéêÞò áóöÜëåéáò) êáé èá óõìðëçñùèåß ìå ìÝôñá ïõóéáóôéêüôåñïõ åëÝã÷ïõ (ð.÷. ìå êÜìåñåò – ñáíôÜñ) êé áõóôçñüôåñçò áíôéìåôþðéóçò ôùí ðáñáâáôþí. ÁíáöïñéêÜ ìå ôï ü÷çìá äéÜöïñåò ìç÷áíéêÝò ðáñÜìåôñïé áõôïý, üðùò ç ðïéüôçôá êáôáóêåõÞò êáé óõíôÞñçóçò ôïõ óõóôÞìáôïò ïäÞãçóçò êáé ðÝäçóçò, ôï áíÝíäïôï ôùí èõñþí, ç áíÜñôçóç, ç ðáëáéüôçôá ê.ëð. äéáäñáìáôßæïõí óïâáñü ñüëï óôç óõ÷íüôçôá êáé âáñýôçôá ôùí ôñï÷áßùí áôõ÷çìÜôùí, áëëÜ äåí õðüêåéíôáé óôçí éáôñéêÞ áñìïäéüôçôá. Åßíáé õðï÷ñÝùóç ôçò ðïëéôåßáò íá èåóðßóåé êáëýôåñåò ðñïäéáãñáöÝò áóöáëåßáò ôùí ï÷çìÜôùí ðïõ åéóÜãïíôáé óôçí êõêëïöïñßá. Óå ü,ôé áöïñÜ ôï ïäéêü äßêôõï, ç êáôáãñáöÞ ôùí åðéêßíäõíùí èÝóåùí áõôïý êáé ç âåëôßùóÞ ôïõò, ç óçìáôïäüôçóÞ ôïõ óå êáßñéá óçìåßá (ôïðïèÝôçóç êáôáêüñõöçò êé ïñéæüíôéáò óÞìáíóçò), ç åãêáôÜóôáóç öùôéóìïý üðïõ ÷ñåéÜæåôáé, ç ôïðïèÝôçóç óôçèáßùí êé áíôéïëéóèçôéêþí óôñþóåùí ê.ëð. èá âïçèÞóïõí ïõóéáóôéêÜ óôçí ðñüëçøç ôùí ôñï÷áßùí áôõ÷çìÜôùí. Áêüìç, ç áñôéüôåñç ïñãÜíùóç ôïõ Å.Ê.Á.Â. ìå ôçí áíÜðôõîç êáé ðýêíùóç êáôÜëëçëá åîïðëéóìÝíùí êáé óôåëå÷ùìÝíùí áóèåíïöüñùí, éäßùò ôéò ãéïñôÝò êáé ôïõò èåñéíïýò ìÞíåò, ìðïñåß íá óõíôåëÝóåé óôçí ôá÷ýôåñç êáé áðïôåëåóìáôéêüôåñç áíôéìåôþðéóç ôùí ôñáõìáôéþí. ÔÝëïò, ôïíßæåôáé üôé ç óõíåéäçôïðïßçóç ôïõ ðñïâëÞìáôïò ôùí ôñï÷áßùí áôõ÷çìÜôùí èá ðñÝðåé íá áðïôåëÝóåé åðåßãïõóá êïéíùíéêÞ áíÜãêç4 êáé ç ðñüëçøÞ ôïõ íá êáôáóôåß åèíéêüò óôü÷ïò, ìå áðþôåñï óêïðü íá ìåéùèåß ç ïäýíç ôïõ èáíÜ69


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

ôïõ êáé ôï äñÜìá ôçò áíáðçñßáò.

Âéâëéïãñáößá 1. ¸êèåóç ôçò ÄéáêïììáôéêÞò ÊïéíïâïõëåõôéêÞò ÅðéôñïðÞò ãéá ôç ìåëÝôç ôïõ ðñïâëÞìáôïò ôùí ôñï÷áßùí áôõ÷çìÜôùí, Ôüìïé É-ÉÉÉ, Áðñßëéïò 1996. 2. World Health Organization, World Health Statistics (Annual), Geneva: WHO, 1980-1994. 3. Ã. ÊïôóõöÜêçò, Ê. Ñåâßíèç, Â. ÖëõôæÜíç, Å. Ðåôñßäïõ, ×áìÝíá ÷ñüíéá áíáìåíüìåíçò æùÞò óå íÝïõò çëéêßáò 1-19 åôþí óôçí ÅëëÜäá. Óôá ÐñáêôéêÜ ôïõ 5ïõ Ðáíåëëçíßïõ Óõíåäñßïõ ÅëëçíéêÞò Åôáéñåßáò ÊïéíùíéêÞò ÐáéäéáôñéêÞò êáé ÐñïáãùãÞò ôçò Õãåßáò, ÁèÞíá 1994, óåë. 4446. 4. Å. Ðåôñßäïõ, Ä. Ôñé÷üðïõëïò, Ôï åèíéêü ðñüâëçìá õãåßáò ôçò ÅëëÜäáò: Ôñï÷áßá Áôõ÷Þìáôá,

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Âáñ. Ðáðáãåùñãßïõ êáé óõí.

ÐáéäéáôñéêÞ, 61:31-36, 1998. 5. Âáñ. Ðáðáãåùñãßïõ, Â. Ðáðáãåùñãßïõ, Åðéäçìéïëïãßá ôñï÷áßùí áôõ÷çìÜôùí óôï Íïìü ×áëêéäéêÞò óôç äåêáåôßá 1986-1995, ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, 8:106-111, 1996. 6. Ã. ÌáñíÝëëïõ, Ëéãüôåñï áßìá “Êáè’ ïäüí”, Åëåõèåñïôõðßá, 23/1/2002. 7. Å.Ó.Õ.Å., ÓôáôéóôéêÞ Åðåôçñßäá ôçò ÅëëÜäáò, Ýôç 1986-2000. 8. Å.Ó.Õ.Å., Äåëôßï Ìåôáöïñþí êáé Åðéêïéíùíéþí, Ýôç 1986-2000. 9. Â. Êáôóïõãéáííüðïõëïò. Åðéäçìéïëïãßá, Èåóóáëïíßêç, 1990. 10. L. Evans. Comment: The dominant role of driver behavior in traffic safety. Am. J. Public. Health, 86:784-786, 1996. 11. Á. Ôñé÷ïðïýëïõ, Ä. Ôñé÷üðïõëïò, ÐñïëçðôéêÞ ÉáôñéêÞ, Åêäüóåéò ÐáñéóéÜíïò, 1986. 12. European Transport Safety Council, Seat belts and child restraints: Increasing use and optimizing performance, Brussels 1996.


Ôüìïò 14, Ôåý÷ïò 2, 2002

Ã.Ôæáíßäçò êáé óõí.

BÑÁÂÅÕÈÅÉÓÁ ÅËÅÕÈÅÑÇ ÁÍÁÊÏÉÍÙÓÇ AWARDED FREESTANDING PAPER Primary Heatlh Care, Volume 14, Number 2, 71-80, 2002 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 14, Ôåý÷ïò 2, 71-80, 2002

Ìåéþíïíôáò ôïí ðüíï ôùí ðáéäéþí óå ìáæéêü åìâïëéáóìü. Ðïéá åßíáé ç áðïôåëåóìáôéêüôåñç ìÝèïäïò; Ã. Ôæáíßäçò1, Ð. ÓêáðéíÜêçò2, Áéêáôåñßíç Êáëýâá3, Óôáõñïýëá ÂïñãéÜ1, Áíäñïíßêç ÌáõñÜêç3, Ðáãþíá Ðáðáäçìçôñßïõ3, Áëåîßá Ôæáíßäïõ1, Å. Óêëçñüò4

Ðåñßëçøç Ðáñüôé ðïëëÝò ìç öáñìáêåõôéêÝò ìÝèïäïé Ý÷ïõí áðïäåé÷èåß áðïôåëåóìáôéêÝò óôç ìåßùóç ôïõ ðüíïõ ôùí ðáéäéþí êáôÜ ôç äéÜñêåéá ôáêôéêþí åìâïëéáóìþí óôï Éáôñåßï, êáìéÜ åñåõíçôéêÞ åñãáóßá äåí Ý÷åé óõãêñßíåé ôçí áðïôåëåóìáôéêüôçôÜ ôïõò êáôÜ ôç äéÜñêåéá ìáæéêïý åìâïëéáóìïý. Óêïðüò ôçò åñãáóßáò åßíáé íá óõãêñßíåé ôçí áðïôåëåóìáôéêüôçôá ôñéþí áðëþí êáé ÷ùñßò êüóôïò ðáñåìâÜóåùí, óôç ìåßùóç ôçò áíôßäñáóçò êáé ôïõ ðüíïõ ôùí ðáéäéþí êáôÜ ôïí åìâïëéáóìü ìå BCG. Ðëçèõóìüò ìåëÝôçò–ìÝèïäïò. Ç ìåëÝôç äéåîÞ÷èçêå óôçí ðåñéï÷Þ ôïõ Áãßïõ Äçìçôñßïõ êáôÜ ôç äéÜñêåéá ðñïãñÜììáôïò ìáæéêïý åìâïëéáóìïý ôçò Íïìáñ÷ßáò Áèçíþí. 235 ðáéäéÜ ôçò ðñþôçò ôÜîçò ôïõ Äçìïôéêïý, ôõ÷áéïðïéÞèçêáí óå ôÝóóåñéò ïìÜäåò. ÏìÜäá ãíùóéáêÞò ðáñÝìâáóçò: (ÃÐ-58 ðáéäéÜ), ôá ïðïßá ðáñáêïëïýèçóáí ïëéãüëåðôï ìÜèçìá óôçí ôÜîç, ìå óêïðü ôçí åíçìÝñùóç êáé ôçí åìøý÷ùóÞ ôïõò ëßãï ðñéí áðü ôïí åìâïëéáóìü. ÏìÜäá áðüóðáóçò ðñïóï÷Þò: (ÁÐ-60 ðáéäéÜ), áðü ôá ïðïßá æçôÞèçêå íá êáôïíïìÜóïõí ãñÞãïñá Ýã÷ñùìåò åéêüíåò áðü ðáñáìýèé óõã÷ñüíùò ìå ôïí åìâïëéáóìü. Óõíäõáóìüò êáé ôùí äýï ðáñåìâÜóåùí: (ÓÐ-60 ðáéäéÜ) êáé ôÝëïò, ïìÜäá åëÝã÷ïõ (ÏÅ-57 ðáéäéÜ). ×ñçóéìïðïéÞóáìå ôç óôáèìéóìÝíç êëßìáêá ôïõ Groningen (Groningen Distress Scale-GDS) êáèþò êáé ôçí êëßìáêá ìå ôá ðñüóùðá (Visual Analogue Scale–VAS) ãéá ôç ìÝôñçóç ôïõ Üëãïõò ôüóï êáôÜ ôç äåñìïáíôßäñáóç Mantoux, üóï êáé êáôÜ ôïí åìâïëéáóìü ìå BCG. ¼ëåò ïé ðáñåìâÜóåéò, Ýëáâáí ìÝñïò ëßãá ëåðôÜ ðñéí ôï BCG. ×ñçóéìïðïéÞóáìå ìéá ðïëõðáñáãïíôéêÞ ìÝèïäï ãéá íá óõãêñßíïõìå ôçí åëÜôôùóç ôïõ Üëãïõò áíÜìåóá óôéò ôÝóóåñéò ïìÜäåò. ÁðïôåëÝóìáôá. ÐáñáôçñÞèçêå åëÜôôùóç ôïõ Üëãïõò ôùí ðáéäéþí óå üëåò ôéò ïìÜäåò, êáôÜ ôïí åìâïëéáóìü ìå BCG, üðùò åêöñÜóôçêå ôüóï ìå ôçí GDS, üóï êáé ìå ôçí VAS (GDS/ÃÐ: 21,65% ìåßùóç, ÁÐ: 7,01%, ÓÐ: 15,28% êáé ÏÅ: 0,79%). ÐáñÜ ôáýôá, óôáôéóôéêÜ óçìáíôéêÞ ìåßùóç óå ó÷Ýóç ìå ôçí ïìÜäá åëÝã÷ïõ ðáñáôçñÞèçêå ìüíï óôçí ïìÜäá ôçò ãíùóéáêÞò ðáñÝìâáóçò (F=3.233, p=0.024). ÊáôáãñÜöçêå Ýíá óçìáíôéêÜ õøçëüôåñï ðïóïóôü õðïäüñéáò Ýê÷õóçò ôïõ BCG óôçí ïìÜäá åëÝã÷ïõ óå óýãêñéóç ìå ôéò Üëëåò ïìÜäåò (ÏÅ: 7.3%, ÁÐ:0%, ÃÐ: 1.7% êáé ÓÐ: 0% Chi square=9.565, p=0,023). ÓõìðÝñáóìá: Ìßá óýíôïìç êáé ÷ùñßò êüóôïò óõæÞôçóç ìå ôá ðáéäéÜ óôçí ôÜîç, ìðïñåß íá ìåéþóåé áðïôåëåóìáôéêÜ ôçí áíôßäñáóÞ ôïõò óôïí ðüíï êáé íá åðéôñÝøåé Ýíáí ðåñéóóüôåñï åðéôõ÷Þ åìâïëéáóìü ìå BCG. Ç ãíùóôïðïßçóç ôùí áðïôåëåóìÜôùí ìáò óôïõò Éáôñïýò ÐñùôïâÜèìéáò Öñïíôßäáò äõíáôüí íá áõîÞóåé ôçí áðïäï÷Þ ôùí ðñïãñáììÜôùí ìáæéêïý åìâïëéáóìïý áðü ôá ðáéäéÜ ó÷ïëéêÞò çëéêßáò. 1 4

Ãåíéêüò Éáôñüò, Ä/íôçò ÊÕ ÐÜñïõ, 2Øõ÷ßáôñïò, 3Ãåíéêüò Éáôñüò ÐÃÍ Íßêáéáò-Ðåéñáéþò, Ãåíéêüò Éáôñüò, Ä/íôçò ÊÕ ÍåìÝáò.

ÅéóáãùãÞ Ôá ôåëåõôáßá Ýôç, ï ìåãÜëïò åíèïõóéáóìüò áðü ôçí åéóáãùãÞ íÝùí åìâïëßùí óôï Åèíéêü ðñüãñáììá åìâïëéáóìþí, Ý÷åé ìåôñéáóôåß áðü ôïí ðñïâëçìáôéóìü ôùí ãïíÝùí êáé ôùí ðáéäéÜôñùí1, ãéá ôçí ðéèáíÞ áýîçóç ôïõ Üã÷ïõò êáé ôïõ ðüíïõ ðïõ óõíïäåýåôáé ìå ôéò ðïëëáðëÝò åíÝóåéò. Ïé ðñïâëçìáôéóìïß áõôïß åðéôåßíïíôáé áðü ôá áõîáíüìåíá âéâëéïãñáöéêÜ äåäïìÝíá ãéá áíåðéèýìçôåò åðéäñÜóåéò óôçí øõ÷ïóýíèåóç ôïõ ðáéäéïý êáé ôç ìåëëïíôéêÞ áíôßäñáóÞ ôïõ óôïí ðüíï åîáéôßáò åðþäõíùí åìðåéñéþí óôá ðñþôá Ýôç ôçò æùÞò.2,3 ÅðéðëÝïí, åßíáé ãíùóôü üôé ôï áõîáíüìåíï Üã÷ïò ôùí ãïíÝùí ãéá ôéò áíôéäñÜóåéò ôùí ðáéäéþí ôïõò óôïí ðüíï, ìðïñåß íá ïäçãÞóåé óå êáèõóôÝñçóç Þ êáé áðïöõãÞ ôïõ ðñïãñáììáôéóìÝíïõ åìâïëßïõ, áðïôåËÝîåéò êëåéäéÜ: ðüíïò, åìâüëéï, ðáéäß, ìáæéêüò åìâïëéáóìüò, Ãåíéêüò Éáôñüò, ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò ÕðïâëÞèçêå: Ç åñãáóßá õðïâëÞèçêå ùò åëåýèåñç áíáêïßíùóç óôï 14ï ÐáíåëëÞíéï ÓõíÝäñéï ÃåíéêÞò ÉáôñéêÞò (ÊñÞôç, 8-12 ÌáÀïõ 2002) êáé âñáâåýèçêå áðü ôçí ÅðéôñïðÞ Êñßóçò. Äçìïóéåýåôáé ìå êïéíÞ áðüöáóç ôçò ÓõíôáêôéêÞò ÅðéôñïðÞò ôïõ ðåñéïäéêïý êáé ôçò ÏñãáíùôéêÞò ÅðéôñïðÞò ôïõ Óõíåäñßïõ. Õðåýèõíïò áëëçëïãñáößáò: Ôæáíßäçò Ãåþñãéïò, Óïõëéùôþí 4, Ô.Ê. 16233 ÁèÞíá, Ôçë.: 0107652486, e-mail: janidis@yahoo.gr 71


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Ã.Ôæáíßäçò êáé óõí.

âïëéáóìþí üðùò ôïõ ðíåõìïíéüêïêêïõ, ôçò áíåìåõëïãéÜò Þ ôïõ ìçíéããéôéäüêïêêïõ. ¸íáò óçìáíôéêüò áñéèìüò áðü öáñìáêïëïãéêÝò êáé ìç ìåèüäïõò Ý÷ïõí Summary Although several non-pharmacological measures have been shown to reduce áðïäåé÷èåß áðïôåëåóìáôéêÝò óôç ìåßùóç children's distress associated with painful procedures, no study has compared ôïõ ðüíïõ ôùí ðáéäéþí êáôÜ ôïõò their effectiveness during mass vaccination. Aims: To evaluate two simple and ôáêôéêïýò åìâïëéáóìïýò7 (Ðßíáêáò 1). inexpensive interventions and their combined effect on children's reactions during ÌåñéêÝò áðü áõôÝò (öáñìáêåõôéêÝò vaccination. Design: Randomised, unblinded controlled study. Methods: The study ìÝèïäïé), áðáéôïýí êÜðïéá óôïé÷åéþwas conducted in the district of Agios Dimitrios during a massive anti-tuberculosis vaccination programme in Athens, Greece. The study consisted of 235 children äç õëéêïôå÷íéêÞ õðïäïìÞ (êñÝìåò, óôõbetween the ages of six and seven years who were randomly split into four ëü, óðñÝé), ç ïðïßá äåí åßíáé ðÜíôá groups. The cognitive intervention group (CIG); this group of 58 children were äéáèÝóéìç óôïí éáôñü ÐñùôïâÜèìéáò provided with information through discussions prior to their vaccination. The Öñïíôßäáò Õãåßáò (ÐÖÕ) ðïõ ìðïñåß distraction group (DG); these 60 children were asked to quickly describe images íá åñãÜæåôáé óå êÜðïéá áðïêåíôñùwhich were shown to them during their vaccination. The third group was a combination of both interventions BI with 60 children and the control group CG with 57 ìÝíç Þ êáé áðïìïíùìÝíç ðåñéï÷Þ. children. The Groningen distress scale (GDS) and the Visual analogue (VAS) were ÅðéðëÝïí ôï êüóôïò ôïõò ðáñüôé åìused to measure the level of distress during both the Mantoux test and the BCG öáíßæåôáé áñ÷éêÜ ìéêñü, äåí åßíáé áìåvaccination. All interventions were carried out a few minutes before the BCG. A ëçôÝï åÜí óêåöôåß êáíåßò ôïí ìåãÜëï multivariable statistical approach was used (GLM-repeated measures, SPSS Ver.9.0) áñéèìü ôùí åìâïëßùí óå ðåñßðôùóç to compare the decrease of distress among the different groups. Results: Both GDS and VAS scores decreased in all groups (CIG; 21,65% reduction, DG; 7,01%, ìáæéêþí åìâïëéáóìþí. ÔÝëïò Üëëåò ìÝBI; 15,28%, CG; 0,79%). However, compared to the control group, statistically èïäïé, üðùò ç ýðíùóç, áðáéôïýí åéäésignificant decrease occurred only in the GDS of the CIG (F=3,233 p=0,024). A êÞ åêðáßäåõóç ôïõ ðñïóùðéêïý ãéá significantly higher percentage of subcutaneous incision of BCG was noted in the ôçí åöáñìïãÞ ôïõò, åíþ Üëëåò êñßíïcontrol group (7,3%, versus 0% in DG, 1,7% in CIG, and 0% in BI respectively. Chi íôáé ùò ÷ñïíïâüñåò êáé ðñáêôéêÜ äýsquare=9,565 p=0,023). Conclusions: A simple and cost-free 10-15 minute discussion in the classroom before the vaccinations can significantly decrease the óêïëåò óôçí åöáñìïãÞ ôïõò áðü ðïchildren's distress and permit a more successful BCG vaccination outcome. DisëõÜó÷ïëïõò õãåéïíïìéêïýò. semination of our findings to GP's could possibly increase the acceptance of Ç åñåõíçôéêÞ äïõëåéÜ ðïõ Ý÷åé íá massive/mass vaccination programmes by children. åðéäåßîåé ç âéâëéïãñáößá óôï óõãêåKey words: Vaccines, massive vaccination, injection, pain, child, General PracêñéìÝíï ôïìÝá åßíáé ðåñéïñéóìÝíç, åëÜtice, Family Practice, Primary Health Care ÷éóôåò äå ôõ÷áéïðïéçìÝíåò åëåã÷üìåGeneral Hospital of Nikea, Nemea’s Health Center íåò äïêéìÝò Ý÷ïõí óõãêñßíåé ôéò äéÜöïñåò ìåèüäïõò ìåôáîý ôïõò8,9, êáìéÜ äå ëåß äå ìéá áðü ôéò óõ÷íüôåñåò áéôßåò ìç óõììüñ- äåí áíáöÝñåé ùò ðåäßï åöáñìïãÞò ôçò ôïí ìáæéêü öùóçò óôï ðñüãñáììá åìâïëéáóìþí4-6. Ôï ðñü- åìâïëéáóìü. Óêïðüò ôçò óõãêåêñéìÝíçò áõôÞò åñåõâëçìá áíáìÝíåôáé íá ëÜâåé áêüìç ìåãáëýôåñåò íçôéêÞò åñãáóßáò, åßíáé íá óõãêñßíåé ôçí áðïôåäéáóôÜóåéò ôá åðüìåíá Ýôç, áðü ôçí ðéèáíÞ åéóá- ëåóìáôéêüôçôá üëùí ôùí ãíùóôþí êáé åöáñìüóéãùãÞ íÝùí åìâïëßùí óôï Åèíéêü ðñüãñáììá åì- ìùí óå åðßðåäï ÐÖÕ ðáñåìâÜóåùí, êáèþò êáé Effects of a cognitive intervention versus distraction versus both on children's reactions during mass vaccination G. Janidis, P. Skapinakis, A. Kaliva, S. Voria, A. Mavraki, P. Papadimitriou, A. Janidou, E. Skliros

Ðßíáêáò 1. ÌÝèïäïé ìåßùóçò ôïõ ðüíïõ ôùí ðáéäéþí óå åìâïëéáóìü Ìç ÖáñìáêïëïãéêÝò

ÖáñìáêåõôéêÝò

ÊáôáóêåõÝò äß÷ùò âåëüíç

1. ÖõóéêÝò (physical) (ð.÷. åöáñìüæïíôáò ðßåóç óôï óçìåßï ôïõ ôñõðÞìáôïò) 2. Óõììåôï÷Þò - áëëçëåðßäñáóçò (interactional) (ð.÷. ï ãïíÝáò äßíåé ïäçãßåò ãéá âáèéÝò áíáðíïÝò ôçí þñá ôïõ åìâïëßïõ) 3. ÓõìðåñéöïñéïëïãéêÝò - ãíùóéáêÝò (cognitive-behavioral) (ð.÷. áðüóðáóç ðñïóï÷Þò ìå äéÜöïñá ìÝóá)

1. ØõêôéêÜ spray (Åthyl Chloride, Fluori-Methane) 2. ÊñÝìá EMLA (óõíäõáóìüò ôïðéêþí áíáéóèçôéêþí: ëéäïêáúíç - ðñéëïêáÀíç) 3. Éïíôïöüñçóç ìå ëéäïêáúíç

Óôõëü (Jet injectors)

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Ôüìïò 14, Ôåý÷ïò 2, 2002

Ã.Ôæáíßäçò êáé óõí.

ôïõ óõíäõáóìïý ôïõò, óôç ìåßùóç ôùí áíôéäñÜóåùí êáé ôïõ ðüíïõ ôùí ðáéäéþí ôçò ðñþôçò ó÷ïëéêÞò çëéêßáò (6,5-7 åôþí) êáôÜ ôç äéÜñêåéá ìáæéêïý åìâïëéáóìïý.

Ðëçèõóìüò ÌåëÝôçò – ÌÝèïäïò Ó÷åäéáóìüò ìåëÝôçò: Ôõ÷áéïðïéçìÝíç, åëåã÷üìåíç, ìç ôõöëÞ äïêéìÞ (Randomized, non blind, controlled trial)

OSBD, âëÝðå ðáñáêÜôù), åíþ ç ìÝóç ôéìÞ ôïõ åêäçëïýìåíïõ Üëãïõò âñßóêåôáé ðëçóßïí ôïõ 2,2 ôçò êëßìáêáò ôïõ Gronigen óå ðáéäéÜ 6-7 åôþí11,12, õðïëïãßóáìå üôé ÷ñåéáæüìáóôå ïìÜäåò ôùí ôïõëÜ÷éóôïí 40 ðáéäéþí ãéá íá ìðïñÝóïõìå íá ôåêìçñéþóïõìå óôáôéóôéêÜ óçìáíôéêÞ äéáöïñÜ áðü ôçí ïìÜäá åëÝã÷ïõ. H ôéìÞ ôïõ á (ðéèáíüôçôá áðüññéøçò ìçäåíéêÞò õðüèåóçò åíþ åßíáé áëçèéíÞ – óöÜëìá ôýðïõ 1) ïñßóôçêå óå 0,01, ôïõ â (ðéèáíüôçôá áðïäï÷Þò ôçò ìçäåíéêÞò õðüèåóçò, åíþ äåí éó÷ýåé – óöÜëìá ôýðïõ 2) óå 0,05, åíþ ïé êáôáíïìÝò èåùñÞèçêáí ìç êáíïíéêÝò, ìå Üãíùóôåò êáé ßóåò äéáêõìÜíóåéò.

Ðëçèõóìüò ìåëÝôçò Ç åñãáóßá Ýëáâå ìÝñïò óôï ÄÞìï ôïõ Áãßïõ Äçìçôñßïõ, êáôÜ ôç äéÜñêåéá ôïõ äéáíïóïêïìåéáêïý ðñïãñÜììáôïò “Åìâïëéáóìüò êáé åìøý÷ùóç ôùí ðáéäéþí Äçìïôéêïý êáé ô Ãõìíáóßïõ” ôçò Íïìáñ÷ßáò Áèçíþí. ÐñïçãÞèçêå áßôçóÞ ìáò êáé Ýêäïóç ãñáðôÞò Üäåéáò áðü ôï Õðïõñãåßï Ðáéäåßáò. Ç ðåñéï÷Þ ôïõ Áãßïõ Äçìçôñßïõ èåùñÞèçêå êáôÜ ðñïóÝããéóç ùò áíôéðñïóùðåõôéêÞ, áðü ðëåõñÜò êïéíùíéêïïéêïíïìéêïý åðéðÝäïõ, ôïõ Íüôéïõ ôïìÝá ôçò Íïìáñ÷ßáò Áèçíþí êáé ôïõ Íïìïý ÁôôéêÞò ãåíéêüôåñá. 240 ðáéäéÜ ôçò ðñþôçò ôÜîçò ôïõ Äçìïôéêïý Ó÷ïëåßïõ (çëéêßáò 6-7 åôþí), ôá ïðïßá åðñüêåéôï íá åìâïëéáóôïýí ìå ôï åìâüëéï BCG, ðåñéåëÞöèçóáí óôç ìåëÝôç. ÐñïçãÞèçêå ãñáðôÞ óõãêáôÜèåóç ôùí ãïíÝùí ãéá ôï åìâüëéï êáé ôç óõììåôï÷Þ óôçí åñãáóßá. Áðïêëåßóôçêáí ôá ðáéäéÜ ðïõ åß÷áí Þäç åìâïëéáóôåß (äýï ðáéäéÜ) Þ åß÷áí èåôéêÞ Mantoux (Ýíá ðáéäß), äåí åðéèõìïýóáí ôïí åìâïëéáóìü (äýï ðáéäéÜ) Þ ôç óõììåôï÷Þ óôçí Ýñåõíá, Þ ðáñïõóßáæáí áíôåíäåßîåéò óôïí åìâïëéáóìü (êáíÝíá ðáéäß –óýíïëï ðáéäéþí ðïõ áðïêëåßóôçêáí: ðÝíôå). Äåéãìáôïëçøßá. ¸ãéíå äåéãìáôïëçøßá êáôÜ óôñþìáôá (Äçìïôéêü ó÷ïëåßï, ôìÞìá), ìå äåéãìáôïëçðôéêÞ ìïíÜäá ôï ó÷ïëéêü ôìÞìá (ôÜîç). ×ñçóéìïðïéÞèçêáí ïé ðßíáêåò ôõ÷áßùí áñéèìþí. Ìå ôïí ßäéï ôñüðï Ýãéíå ç ôõ÷áéïðïßçóç óôéò ôÝóóåñéò ïìÜäåò, ìåôÜ ôïí áðïêëåéóìü ôùí ðáéäéþí ðïõ äåí ðëçñïýóáí ôá êñéôÞñéá åéóüäïõ óôçí Ýñåõíá. Õðïëïãéóìüò ìåãÝèïõò äåßãìáôïò. Ìå äåäïìÝíá ôá óôïé÷åßá áðü ôç âéâëéïãñáößá üôé ç áðüóðáóç ðñïóï÷Þò ìåéþíåé ôï Üëãïò êáé ôçí åðþäõíç áíôßäñáóç ôùí ðáéäéþí êáôÜ 17-20%, üðùò ìåôñÜôáé ìå óôáèìéóìÝíåò êëßìáêåò10 (GDS, VAS,

ÐáñåìâÜóåéò Ôá ðáéäéÜ ôõ÷áéïðïéÞèçêáí óå ôÝóóåñéò ïìÜäåò 1. ÏìÜäá áðüóðáóçò ðñïóï÷Þò - 60 ðáéäéÜ. Óôá ðáéäéÜ, ëßãï ðñéí ôï åìâüëéï BCG, æçôÞèçêå íá ðáßîïõí Ýíá “ðáé÷íßäé” êáôÜ ôç äéÜñêåéá ôïõ åìâïëéáóìïý. Ãéá íá ôï êåñäßóïõí èá Ýðñåðå íá êáôáíïìÜóïõí ðïëý ãñÞãïñá åéêüíåò áðü Ýíá Ýã÷ñùìï ðáñáìýèé. Åöüóïí áðáíôïýóáí ïñèÜ êáé ÷ùñßò êáèüëïõ êáèõóôÝñçóç, èá äÝ÷ïíôáí ìåôÜ ôï BCG Ýíá äþñï “Ýêðëçîç” (ìéá êïíêÜäñá ðïõ áíÝöåñå üôé åß÷áí áíïóßá). ÊáôÜ ôç äéÜñêåéá ôçò ðñïêáôáñôéêÞò öÜóçò êáé åíþ ôï ðáéäß áðáíôïýóå óôéò åñùôÞóåéò, ìéá ðáãïêýóôç åß÷å ôïðïèåôçèåß óôï óçìåßï ôïõ íõãìïý, åðß ôïõëÜ÷éóôïí 20 äåõôåñüëåðôá êáé ï åìâïëéáóìüò áêïëïõèïýóå áìÝóùò ìåôÜ. 2. ÏìÜäá ãíùóéáêÞò ðáñÝìâáóçò – 58 ðáéäéÜ. Óôá ðáéäéÜ áõôÜ ðñïçãÞèçêå ïëéãüëåðôï ìÜèçìá óôçí ôÜîç, äéÜñêåéáò ðåñßðïõ 10´15´, ìå óêïðü ôçí åíçìÝñùóÞ ôïõò ãéá ôçí áîßá ôùí åìâïëßùí êáé ôç óçìáóßá ôïõò óôçí ðñüëçøç Þ êáé ôç åîáöÜíéóç ïñéóìÝíùí ëïéìùäþí íïóçìÜôùí. Ôï ìÜèçìá ãéíüôáí ðÜíôá áðü ôïí ßäéï åñåõíçôÞ, êáôÜ ôñüðï áðüëõôá ïìïéüìïñöï óôá äéÜöïñá ôìÞìáôá, îåêéíïýóå äå ìå ôçí åñþôçóç: “... ðüóá ðáéäÜêéá áðü áõôÞ ôçí ôÜîç, Ý÷ïõí ðåñÜóåé ôçí éëáñÜ Þ ôçí åñõèñÜ; Áò óçêþóïõí ôï ÷Ýñé ôïõò... Ðåñßåñãï... êáíÝíá ðáéäÜêé äåí áññþóôçóå... Ðþò åßíáé üìùò äõíáôü êáé ï Éáôñüò êáé ç ÄáóêÜëá ìáò áëëÜ êáé üëá ôá ðáéäÜêéá íá áññþóôáéíáí ðáëáéüôåñá êáé åóåßò 73


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

êáèüëïõ;...”. ÔÝëïò, ãéíüôáí ðñïóðÜèåéá åìøý÷ùóçò ôùí ðáéäéþí ëßãï ðñéí ôïí åìâïëéáóìü êáé ç êïíêÜñäá äéíüôáí áðñïåéäïðïßçôá óôï ôÝëïò ôïõ åìâïëéáóìïý. 3. ÏìÜäá ôïõ óõíäõáóìïý êáé ôùí äýï ðñïáíáöåñèåéóþí ðáñåìâÜóåùí – 60 ðáéäéÜ. 4. ÏìÜäá åëÝã÷ïõ – 57 ðáéäéÜ.

ÌÝèïäïé ìÝôñçóçò ôïõ Üëãïõò Ç áíôßäñáóç ôùí ðáéäéþí óôïí ðüíï, ìåôñÞèçêå ìå ôñåéò äéáöïñåôéêÝò ìåèüäïõò: ÌÝôñçóç ôùí óöýîåùí. Ïé óöýîåéò ìåôñÞèçêáí óå ôñåéò äéáöïñåôéêÝò ÷ñïíéêÝò ðåñéüäïõò · Óöýîåéò çñåìßáò: ÌÝôñçóç ôïõ áñéèìïý ôùí óöýîåùí êáôÜ ôç äéÜñêåéá ôïõ ìáèÞìáôïò óôçí ôÜîç êáé åíþ ôï ðáéäß Þôáí ðëÞñùò áðïññïöçìÝíï óôï ìÜèçìá. ÅÜí ôï ðáéäß Ýäåé÷íå íá áíçóõ÷åß êáé íá öïâÜôáé, ï åñåõíçôÞò ðñï÷ùñïýóå óôï åðüìåíï êáé åðáíåñ÷üôáí óôï ßäéï ðáéäß üôáí åß÷å âåâáéùèåß üôé Þôáí ðëÞñùò ÷áëáñùìÝíï êáé áðïññïöçìÝíï óôï ìÜèçìá. · Óöýîåéò áíáìïíÞò (Ýêöñáóç ôïõ öüâïõ): ÅëÞöèçóáí ëßãï ðñéí áðü ôïí åìâïëéáóìü êáôÜ ôç äéÜñêåéá ôçò áíáìïíÞò. · Óöýîåéò åìâïëéáóìïý: ÌÝôñçóç ôùí óöýîåùí ôçí þñá ôçò åéóüäïõ ôçò âåëüíçò óôï äÝñìá ôïõ ðáéäéïý. Ï ÷ñüíïò ìÝôñçóçò Þôáí êáé óôéò ôñåéò ðåñéðôþóåéò 10 äåõôåñüëåðôá. Êëßìáêá ìå ôá ðñüóùðá (Visual Analogue Scale-VAS).14,15 Ðñüêåéôáé ãéá êëßìáêá áðïôåëïýìåíç áðü ðÝíôå ðñüóùðá (Åéêüíá 1), êáôÜëëçëç ãéá ôç ìÝôñçóç ôïõ öüâïõ êáé ôïõ Üëãïõò óå ðáéäéÜ ðñïó÷ïëéêÞò Þ ðñþôçò ó÷ïëéêÞò çëéêßáò. ÌåôñÞèçêå äýï öïñÝò: 1. Ëßãï ðñéí ôïí åìâïëéáóìü (ìÝôñçóç ôïõ öüâïõ ãéá ôï åìâüëéï). Ôï êÜèå ðáéäß åñùôÞèçêå, Ý÷ïíôáò ìðñïóôÜ ôïõ ôçí êëßìáêá, ðïéï ðñüóùðï åêöñÜæåé êáëýôåñá ôá óõíáéóèÞìáôÜ ôïõ (“...Óáí ðïéï ðáéäÜêé áéóèÜíåóáé;...”). 2. ÁìÝóùò ìåôÜ ôçí ïëïêëÞñùóç ôïõ åìâïëßïõ (ìÝôñçóç ôïõ êáè’ áõôïý Üëãïõò ôïõ åìâïëéáóìïý “...Óáí ðïéï ðáéäÜêé ðüíåóåò;...”). Ç áðÜíôçóç ôïõ ðáéäéïý êáôáãñáöüôáí áðü ôïõò åñåõíçôÝò êáé óôéò äýï ðåñéðôþóåéò, óå åéäéêÜ äéáìïñöùìÝíç “öüñìá” (Åéêüíá 2). Êëßìáêá stress ôïõ Groningen (Groningen 74

Ã.Ôæáíßäçò êáé óõí.

Distress Scale)12. Aðïôåëåß óôáèìéóìÝíç êëßìáêá ìÝôñçóçò ôçò áíôßäñáóçò ôùí ðáéäéþí óôïí ðüíï, ðïõ ðáñïõóéÜóôçêå ãéá ðñþôç öïñÜ áðü ôïõò Humphrey GB êáé óõíåñãÜôåò. ¸íáò áíôéêåéìåíéêüò ðáñáôçñçôÞò, êáôáôÜóóåé ôá ðáéäéÜ óå ðÝíôå ïìÜäåò, âáèìïëïãþíôáò ôéò áíôéäñÜóåéò ôïõò êáôÜ ôç äéÜñêåéá ôïõ åìâïëéáóìïý (Åéêüíá 2). Ï åñåõíçôÞò ðïõ åìâïëßáæå, áðïöáóßóôçêå üôé ðñÝðåé íá ðñïâåß êáé óôçí áîéïëüãçóç, áöïý Þôáí ôï Üôïìï ðïõ âñéóêüôáí êïíôýôåñá óôï åìâïëéáæüìåíï ðáéäß êáé ìðïñïýóå íá êáôáãñÜøåé ðëçñÝóôåñá ôéò áíôéäñÜóåéò ôïõ. Ïé ãïíåßò êáé ïé óõíïäïß åíçìåñþíïíôáí åõãåíéêÜ áìÝóùò ìåôÜ ôçí åßóïäü ôïõò óôï Ó÷ïëåßï, áëëÜ êáé ìÝóù åíçìåñùôéêïý åíôýðïõ, üôé äåí èá Ýðñåðå íá ðáñáìåßíïõí óôçí áßèïõóá, ôçí þñá ôïõ åìâïëéáóìïý.

Ó÷åäéáóìüò ôçò ÌåëÝôçò - ÓôáôéóôéêÞ ÁíÜëõóç Ï ó÷åäéáóìüò ôçò ìåëÝôçò, öáßíåôáé óôï ó÷Þìá 1. Ôï ßäéï ðáéäß áîéïëïãÞèçêå äýï öïñÝò, ôüóï êáôÜ ôç äåñìïáíôßäñáóç Mantoux, üóï êáé êáôÜ ôç äéÜñêåéá ôïõ åìâïëéáóìïý ìå BCG, äýï çìÝñåò áñãüôåñá. Ïé ìåéþóåéò óôéò êëßìáêåò ôïõ ðüíïõ óõãêñßèçêáí ìåôáîý ôùí ôñéþí ðáñåìâÜóåùí êáé ôçò ïìÜäáò åëÝã÷ïõ ÷ñçóéìïðïéþíôáò êáôÜëëçëï ãåíéêåõìÝíï ãñáììéêü ìïíôÝëï ðïëõðáñáãïíôéêÞò áíÜëõóçò, áöïý ëÞöèçêáí õðüøç ïé ðñïûðïèÝóåéò ôçò ÷ñÞóçò ôïõ (éóüôçôá äéáóðïñþí, êáôÜ ðñïóÝããéóç êáíïíéêüôçôá äåéãìÜôùí). Ðñéí áðü êÜèå áîéïëüãçóç, ðñïçãÞèçêå ïëéãüëåðôï ìÜèçìá óôçí ôÜîç üðïõ äßäïíôáí ïäçãßåò óôá ðáéäéÜ ãéá ôçí ïñèÞ ÷ñÞóç ôçò êëßìáêáò ìå ôá ðñüóùðá (VAS). Äýï áíåîÜñôçôïé åñåõíçôÝò êáôÝôáóóáí ôéò áíôéäñÜóåéò ôùí ðáéäéþí óýìöùíá ìå ôçí êëßìáêá ôïõ Groningen (GDS). Ç óõìðåñéöïñÜ êáèþò êáé ôï ëåîéëüãéï ôùí åñåõíçôþí áðÝíáíôé óôá ðáéäéÜ, Þôáí áðüëõôá ïìïéïãåíÞ óå üëá ôá óôÜäéá ôçò åñãáóßáò, êáìéÜ äå åðéðëÝïí ëåêôéêÞ Þ ìç ðáñÝìâáóç ðñïò ôá ðáéäéÜ äåí Þôáí áðïäå-

Eéêüíá 1. Ç êëßìáêá ìå ôá ðñüóùðá (Visual Analogue Scale)


Ôüìïò 14, Ôåý÷ïò 2, 2002

Ã.Ôæáíßäçò êáé óõí.

êôÞ, êáèþò èá ìðïñïýóå ðïëý åýêïëá íá åðçñåÜóåé ôçí áíôßäñáóÞ ôïõò, áöïý åßíáé ãíùóôü üôé åßíáé åîáéñåôéêÜ õðïâüëéìá. Ï ßäéïò ðÜíôá åñåõíçôÞò Ýêáíå ôç Mantoux, åìâïëßáæå êáé áîéïëïãïýóå ôï ßäéï ðáéäß êáé óôéò äýï öÜóåéò ôçò Ýñåõíáò ôüóï óôçí ïìÜäá ôùí ðáñåìâÜóåùí, üóï

êáé óôçí ïìÜäá åëÝã÷ïõ. ÐñïçãÞèçêå áðü êïéíïý åêðáßäåõóç ôùí äýï ðáñáôçñçôþí óôç ÷ñÞóç ôçò GDS ãéá ìåßùóç ôçò ìåôáâëçôüôçôáò ìåôáîý ôùí ðáñáôçñçôþí (between observers variation). Óå äïêéìáóôéêÞ áíåîÜñôçôç áîéïëüãçóç ïìÜäáò 21 ðáéäéþí, ðñéí áðü ôçí Ýíáñîç ôçò

MANTOUX BCG Ó×ÏËÅÉÏ____ ÔÌÇÌÁ_____ ____ *6=___ (1. ÓÖÕÎÅÉÓ ÇÑÅÌÉÁÓ ) 2. ÓÖÕÎÅÉÓ ÁÍÁÌÏÍÇÓ ____ *6=___ 3. ÓÖÕÎÅÉÓ ÅÌÂÏËÉÁÓÌÏÕ ____ *6=___

Ä1=(óýíïëï) =3-1= Ä2=(áíáìïíÞò) =2-1= Ä3=(åìâïëéáóìïý)=3-2=

ÊËÉÌÁÊÁ ÌÅ ÐÑÏÓÙÐÁ (VISUAL ANALOGUE SCALE ) 1.ÁÍÁÌÏÍÇÓ (ìÝôñçóç öüâïõ) ______ 2.ÌÅÔÁ ÔÏ ÅÌÂÏËÉÏ (ìÝôñçóç ðüíïõ)______

(1-5)

ÂÁÈÌÏÓ____ ÊËÉÌÁÊÁ STRESS ÔÏÕ GRONINGEN 1.ÐËÇÑÇÓ ÇÑÅÌÉÁ 2.ÄÅÉËÏ – ÍÅÕÑÉÊÏ – ÁÃ×ÙÄÅÓ 3.ÓÏÂÁÑÇ , ÅÍÔÏÍÇ ÍÅÕÑÉÊÏÔÇÔÁ- ÁÃ×ÏÓ ÁËËÁ ÕÐÏ ÅËÅÃ×Ï 4.ÅÍÔÏÍÏ ÁÃ×ÏÓ ÌÅ ÁÐÙËÅÉÁ ÅËÅÃ×ÏÕ 5.ÐÁÍÉÊÏÓ ÅÐÁÍÁËÇØÇ ÔÑÕÐÇÌÁÔÏÓ ÕÐÏÄÏÑÉÁ ÅÊ×ÕÓÇ

ÍÁÉ ÍÁÉ

ÏÍÏÌÁ______________________

Eéêüíá 2. Öüñìá êáôáãñáöÞò

ÌANTOUX

ÌÝôñçóç óöýîåùí çñåìßáòáíáìïíÞò-åìâïëßïõ Êëßìáêåò (ðñïçãÞèçêáí ïäçãßåò óôá ðáéäéÜ ãéá ôç ÷ñÞóç ôïõò)

BCG

ÐÁÑÅÌÂÁÓÇ (ðëçí ôçò ïìÜäáò åëÝã÷ïõ)

ÎáíÜ ìÝôñçóç óöýîåùí çñåìßáò-áíáìïíÞòåìâïëßïõ (óôï ßäéï ðáéäß) Êëßìáêåò (ðñïçãÞèçêáí ïäçãßåò óôá ðáéäéÜ ãéá ôç ÷ñÞóç ôïõò)

Ó÷Þìá 1. Ó÷åäéáóìüò ôçò ìåëÝôçò 75


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Ã.Ôæáíßäçò êáé óõí.

åñãáóßáò, ìåôñÞèçêå Ýíáò éêáíïðïéçôéêüò äåßêôçò óõìöùíßáò (kappa=0,653, p<0,005) ìåôáîý ôùí ðáñáôçñçôþí. Ç ìåëÝôç äåí Þôáí ôõöëÞ ïýôå ãéá ôá ðáéäéÜ (ìåèïäïëïãéêÜ áäýíáôï), ïýôå üìùò êáé ãéá ôïõò åñåõíçôÝò (áöïý ïé ßäéïé åöÜñìïæáí ôéò ðáñåìâÜóåéò). ÐáñÜ ôáýôá, ïé ðáñáôçñçôÝò äåí Þôáí óå èÝóç íá äéá÷ùñßóïõí ôçí ïìÜäá 2 áðü ôçí 4 (ïìÜäá åëÝã÷ïõ), ïýôå ôçí 1 áðü ôçí 3 (ôï óõíäõáóìü ôùí ðáñåìâÜóåùí), áöïý ç ãíùóéáêÞ ðáñÝìâáóç ðïõ åëÜìâáíå ìÝñïò óôçí áßèïõóá, ðñïçãïýíôáí ôïõ åìâïëéáóìïý êáé ðñáãìáôïðïéïýíôáí áðü äéáöïñåôéêÞ ïìÜäá åñåõíçôþí. ÅðéðëÝïí, êáôÜ ôçí áîéïëüãçóç ôïõ Üëãïõò êáôÜ ôïí åìâïëéáóìü ìå BCG, ïõäåßò åê ôùí ðáñáôçñçôþí åß÷å ãíþóç ôçò ðñïçãïýìåíçò áîéïëüãçóÞò ôïõ (ôçò äåñìïáíôßäñáóçò Mantoux).

ÁðïôåëÝóìáôá 235 ðáéäéÜ Ýëáâáí óõíïëéêÜ ìÝñïò óôç ìåëÝôç, 126 (ðïóïóôü 54%) Þôáí êïñßôóéá êáé 109 (46%) Þôáí áãüñéá. Ç êáôÜôáîç ôùí ðáéäéþí óýìöùíá ìå ôçí êëßìáêá GDS êáôÜ ôç äéÜñêåéá ôçò äåñìïáíôßäñáóçò Mantoux êáé ôçí ïìÜäá ôçò ðáñÝìâáóçò, öáßíåôáé óôïí ðßíáêá 2. Ïé ìÝóåò ôéìÝò üëùí ôùí êëéìÜêùí êáôÜ ôç äéÜñêåéá ôçò Mantoux (ðñéí ïðïéáäÞðïôå ðáñÝìâáóç), öáßíïíôáé óôïí ðßíáêá 3. Ïé áíôéäñÜóåéò ôùí ðáéäéþí óôïí ðüíï, äåí äéÝöåñáí óå óôáôéóôéêÜ óçìáíôéêü âáèìü ìåôáîý ôùí ôåóóÜñùí ïìÜäùí. Óôá ó÷Þìáôá 2, 4 êáé 5 öáßíïíôáé ïé ìåôáâïëÝò ôçò êëßìáêáò Groningen (GDS), êáèþò êáé ôçò êëßìáêáò ìå ôá ðñüóùðá (VAS) áíáìïíÞò êáé åìâïëéáóìïý (GDS/BCG ìåßoí GDS/Mantoux,

Ðßíáêáò 2. H Êëßìáêá stress ôïõ Groningen 1 (Mantoux) áíÜ ïìÜäá.

ÐëÞñçò çñåìßá

Êëßìáêá stress ôïõ Groningen 1 ÄåéëüÓïâáñü ¸íôïíï Üã÷ïò íåõñéêü Üã÷ïò áëëÜ ìå áðþëåéá áã÷þäåò õðü Ýëåã÷ï åëÝã÷ïõ Ðáíéêüò

Óýíïëï

ÏìÜäá åëÝã÷ïõ Áðüóðáóç Åßäïò ðñïóï÷Þò ðáñÝìâáóçò ÃíùóéáêÞ ðáñÝìâáóç Êáé ôá äýï

Óõ÷íüôçôá Ðïóïóôü Óõ÷íüôçôá Ðïóïóôü Óõ÷íüôçôá Ðïóïóôü Óõ÷íüôçôá Ðïóïóôü

17 29,8% 19 31,7% 13 22,4% 9 15,0%

23 40,4% 20 33,3% 27 46,6% 24 40,0%

11 19,3% 15 25,0% 15 25,9% 19 31,7%

4 7,0% 4 6,7% 2 3,4% 7 11,7%

2 3,5% 2 3,3% 1 1,7% 1 1,7%

57 100,0% 60 100,0% 58 100,0% 60 100,0%

Óýíïëï

Óõ÷íüôçôá Ðïóïóôü

58 24,7%

94 40,0%

60 25,5%

17 7,2%

6 2,6%

235 100,0%

Pearson Chi-Square= 10,745, p= 0,551

Ðßíáêáò 3. ÌÝóåò ôéìÝò ôùí GDS, VAS áíáìïíÞò êáé VAS åìâïëéáóìïý 1 (Mantoux).

ÏìÜäá åëÝã÷ïõ Áðüóðáóç ðñïóï÷Þò Åßäïò ÃíùóéáêÞ ðáñÝìâáóç ðáñÝìâáóçò Êáé ôá äýï Óýíïëï

MÝóç ôéìÞ Áñéèìüò ðáéäéþí MÝóç ôéìÞ Áñéèìüò ðáéäéþí MÝóç ôéìÞ Áñéèìüò ðáéäéþí MÝóç ôéìÞ Áñéèìüò ðáéäéþí MÝóç ôéìÞ Áñéèìüò ðáéäéþí

Êëßìáêá ìå ôá ðñüóùðá áíáìïíÞò 1

Êëßìáêá ìå ôá ðñüóùðá åìâïëéáóìïý 1

Êëßìáêá ìå ôá ðñüóùðá Groningen 1

2,04 57 2,28 60 2,12 58 2,27 60 2,18 235

1,86 56 2,22 60 2,16 58 2,31 59 2,14 233

2,14 57 2,17 60 2,16 58 2,45 60 2,23 235

ÁNOVA: F= 0,369, p= 0,775/F= 1.247, p= 0,294/F= 1.352, p= 0,258 áíôßóôïé÷á

76


Ã.Ôæáíßäçò êáé óõí.

VAS/BCG ìåßoí VAS/Mantoux ê.ï.ê.) áíÜìåóá óôéò ôÝóóåñéò ïìÜäåò ôùí ðáñåìâÜóåùí. ÐáñáôçñÞèçêå åëÜôôùóç ôïõ Üëãïõò ôùí ðáéäéþí óå üëåò ôéò ïìÜäåò, êáôÜ ôïí åìâïëéáóìü ìå BCG, üðùò åêöñÜóôçêå ôüóï ìå ôçí GDS, üóï êáé ìå ôç VAS (ÃíùóéáêÞ ðáñÝìâáóç: 21,65% ìåßùóç ôçò GDS, Áðüóðáóç ðñïóï÷Þò: 7,01%, Óõíäõá-

Ó÷Þìá 2. ÄéáöïñÜ êëßìáêáò Groningen

Ó÷Þìá 3. ÄéáöïñÜ êëßìáêáò Vas áíáìïíÞò

Ôüìïò 14, Ôåý÷ïò 2, 2002

óìüò ôïõò: 15,28% êáé ÏìÜäá åëÝã÷ïõ: 0,79%). ÊáôÜ ôçí åöáñìïãÞ ðïëõðáñáãïíôéêÞò áíÜëõóçò ìå åîáñôçìÝíç ìåôáâëçôÞ ôçí êëßìáêá GDS êáé áíåîÜñôçôåò ôçí åñåõíçôéêÞ ïìÜäá (ôïõò äýï áíåîÜñôçôïõò ðáñáôçñçôÝò), ôï öýëï ôïõ ðáéäéïý, ôï åßäïò ôçò ðáñÝìâáóçò, êáèþò êáé ôéò ðéèáíÝò áëëçëåðéäñÜóåéò ôùí ìåôáâëçôþí (ðáñÝìâáóç*öýëï, ðáñÝìâáóç*åñåõíçôéêÞ ïìÜäá êáé öýëï*åñåõíçôéêÞ ïìÜäá), ìüíï ôï åßäïò ôçò ðáñÝìâáóçò êáé óõãêåêñéìÝíá ç ãíùóéáêÞ öÜíçêå íá áóêåß óôáôéóôéêÜ óçìáíôéêÞ åðßäñáóç óôç ìåôáâïëÞ ôçò GDS. Óôï ó÷Þìá 5 öáßíåôáé ç ìåôáâïëÞ ôçò ìÝóçò GDS áíÜ ïìÜäá ðáñÝìâáóçò, äéïñèùìÝíç ãéá ôï öýëï êáé ôï åßäïò ôïõ ðáñáôçñçôÞ. Ç ìÝóç äéïñèùìÝíç ìåßùóç ôçò GDS áíÜ ïìÜäá, ìå ïìÜäá áíáöïñÜò ôçí ïìÜäá åëÝã÷ïõ, êáèþò êáé ôá äéáóôÞìáôá åìðéóôïóýíçò ôçò öáßíïíôáé óôïí ðßíáêá 4. Ïé êëßìáêåò VAS áíáìïíÞò êáé åìâïëéáóìïý, êáèþò êáé ï áñéèìüò ôùí óöýîåùí, ìåéþèçêáí åðßóçò óå üëåò ôéò ïìÜäåò, ç ìåßùóÞ ôïõò üìùò óå ó÷Ýóç ìå ôçí ïìÜäá åëÝã÷ïõ, äåí Þôáí óôáôéóôéêÜ óçìáíôéêÞ. ÊáôáãñÜøáìå Ýíá óçìáíôéêÜ õøçëüôåñï ðïóïóôü õðïäüñéáò Ýê÷õóçò ôïõ BCG óôçí ïìÜäá åëÝã÷ïõ óå óýãêñéóç ìå ôéò Üëëåò ïìÜäåò (ÏìÜäá åëÝã÷ïõ: 7.3%, áðüóðáóç ðñïóï÷Þò: 0%, ãíùóéáêÞ ðáñÝìâáóç: 1.7% êáé óõíäõáóìüò: 0%, Chi square=9.565, p=0,023). ÌåôÜ ôçí åöáñìïãÞ

Ó÷Þìá 4. ÄéáöïñÜ êëßìáêáò Vas åìâïëéáóìïý 77


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Ã.Ôæáíßäçò êáé óõí.

ÌÅÔÁÂÏËÇ ÔÇÓ GDS

ÓõæÞôçóç

2,4

ÐáñÜ ôï äéáñêþò áõîáíüìåíï åíäéáöÝñïí ãéá ôéò åðéðôþóåéò ôùí åðþäõíùí åìðåéñéþí ôçò ðáéäéêÞò çëéêßáò óôçí áíÜðôõîç êáé ôçí øõ÷ïóýíèåóç ôùí ðáéäéþí, ôá ðáéäéÜ, áêüìç êáé óÞìåñá, õðïèåñáðåýïíôáé ãéá ôï Üëãïò16. ÊÜðïéåò áðü ôéò åóöáëìÝíåò áíôéëÞøåéò ðïõ õéïèåôïýíôáé áðü ôïõò õãåéïíïìéêïýò åßíáé, üôé ôá ðáéäéÜ äåí áéóèÜíïíôáé Ýíôïíá ôï Üëãïò, ëüãù áíùñéìüôçôáò ôïõ ÊÍÓ, Þ üôé äåí èõìïýíôáé ôá áëãåéíÜ åñåèßóìáôá óôïí ßäéï âáèìü üðùò ïé åíÞëéêåò. Áíôßèåôá, ïé Taddio êáé óõíåñãÜôåò, âñÞêáí óôáôéóôéêÜ óçìáíôéêÞ áýîçóç óôçí áíôßäñáóç óôï Üëãïò ôïõ åìâïëéáóìïý óôá âñÝöç 4 Þ 6 ìçíþí ðïõ åß÷áí õðïóôåß ðåñéôïìÞ, óå ó÷Ýóç ìå ôçí ïìÜäá åëÝã÷ïõ.10 Ïé åíÝóåéò, áðïôåëïýí ôïí ìåãáëýôåñï ßóùò öüâï ôùí ìéêñþí ðáéäéþí17,18. Åöüóïí äåí ãßíïõí ðñïóðÜèåéåò ãéá íá áíôéìåôùðéóôåß áðïôåëåóìáôéêÜ ôï stress êáé ï öüâïò, ôï ðáéäß äõíáôüí íá áíôéäñÜ ìå äéáñêþò åíôïíüôåñï Üã÷ïò óå êÜèå åðßóêåøç, ÷ùñßò íá óõíçèßæåé ôï åðþäõíï åñÝèéóìá. Ï öüâïò ãéá ôçí âåëüíç êáé ôéò åíÝóåéò, óõ÷íÜ ìðïñåß íá åðçñåÜóåé áñíçôéêÜ ôçí ó÷Ýóç ôïõ éáôñïý ìå ôïí ìéêñü áóèåíÞ7. Ìßá åñþôçóç ðïõ óõ÷íÜ áêïýãåôáé áðü ðáéäéêÜ ÷åßëç óôïõò èáëÜìïõò áíáìïíÞò ôùí ÊÝíôñùí Õãåßáò êáé ôùí

Estimated Marginal Means

2,2

2,0

1,8

GDS 1,6

MANTOUX BCG

1,4 ÏìÜäá åëÝã÷ïõ

ÃíùóéáêÞ ðáñÝìâáóç Áðüóðáóç ðñïóï÷Þò

Êáé ôá äýï

Åéäïò ðáñåìâáóçò

Ó÷Þìá 5. ÌåôáâïëÞ ôçò gds áíÜ ïìÜäá ðáñÝìâáóçò. (ÄéïñèùìÝíç ãéá ôï åßäïò ôïõ ðáñáôçñçôÞ êáé ôï öýëï)

ìïíôÝëïõ ëïãáñéèìéêÞò ðáëéíäñüìçóçò ìå åîáñôçìÝíç ìåôáâëçôÞ ôçí ðéèáíüôçôá åðáíÜëçøçò ôïõ ôñõðÞìáôïò êáé áíåîÜñôçôåò ôïí ðáñáôçñçôÞ êáé ôçí åöáñìïãÞ Þ ìç êÜðïéáò ðáñÝìâáóçò, óõìðåñÜíáìå, üôé ï ó÷åôéêüò êßíäõíïò íá îáíáôñõðçèåß ôï ðáéäß ïêôáðëáóéÜæåôáé óôçí ïìÜäá åëÝã÷ïõ óå ó÷Ýóç ìå ôéò ïìÜäåò ôùí ðáñåìâÜóåùí, åíþ äåí åðçñåÜæåôáé óå óôáôéóôéêÜ óçìáíôéêü âáèìü, áðü ôï Üôïìï ðïõ åìâïëéÜæåé. Ôá áðïôåëÝóìáôá öáßíïíôáé áíáëõôéêÜ óôïí ðßíáêá 5.

Ðßíáêáò 4. ÌÝóç ìåôáâïëÞ ôçò gds áíÜ ïìÜäá (ÄéïñèùìÝíç ãéá ôï åßäïò ôïõ ðáñáôçñçôÞ êáé ôï öýëï) Åßäïò ðáñÝìâáóçò

ÌÝóç ìåßùóç ôçò gds**

Se

P

95% äéÜóôçìá åìðéóôïóýíçò ìåßùóçò

0,24 0,33* 0,22

0,169 0,162 0,162

0,159 0,045 0,21

-0.00947/+0,57 0.008/0,65 -0,011/0,34

Áðüóðáóç ðñïóï÷Þò ÃíùóéáêÞ ðáñÝìâáóç* Óõíäõáóìüò

*Óôáôéóôéêþò óçìáíôéêÞ äéáöïñÜ (äïêéìáóßá LSD ãéá ôéò ðïëëáðëÝò óõãêñßóåéò) ** Ìå ïìÜäá áíáöïñÜò ôçí ïìÜäá åëÝã÷ïõ

Ðßíáêáò 5. Êßíäõíïò õðïäüñéáò Ýê÷õóçò B

S.E.

P

Exp(B)

95% ÄéÜóôçìá åìðéóôïóýíçò

ÏìÜäá åëÝã÷ïõ (ìå ïìÜäá áíáöïñÜò ôçí ýðáñîç ïðïéáóäÞðïôå ðáñÝìâáóçò)

2,0099

1,080

0,052

8,161

0,98/67,74

ÐáñáôçñçôÞò 1 (Óå ó÷Ýóç ìå ôïí ðáñáôçñçôÞ 2)

0,428

1,13

0,705

1,534

0,16/14,06

ÓôáèåñÜ (constant)

-3,87

1,01

>0,005

0,021

78


Ã.Ôæáíßäçò êáé óõí.

éáôñåßùí, åßíáé: “Èá ìïõ êÜíïõí Ýíåóç; !!!”. Ïé ôõ÷áéïðïéçìÝíåò åëåã÷üìåíåò äïêéìÝò ðïõ óõãêñßíïõí ôéò ãíùóôÝò ðáñåìâÜóåéò ìåôáîý ôïõò, åßíáé åëÜ÷éóôåò,8,9,19 êáìßá äå, äåí áöïñÜ ìáæéêü åìâïëéáóìü. Ç ãåíßêåõóç ôùí óõìðåñáóìÜôùí áõôþí ôùí åñåõíþí óôï ðåäßï ôïõ ìáæéêïý åìâïëéáóìïý, äåí åßíáé ìåèïäïëïãéêÜ áäéÜâëçôç. Óôïí ÷þñï ôïõ éäéùôéêïý éáôñåßïõ Þ ôïõ ÊÝíôñïõ Õãåßáò, ï éáôñüò, ãíùñßæåôáé êáôÜ êáíüíá áðü ðñéí ìå ôïí ìéêñü áóèåíÞ, ìå áðïôÝëåóìá íá Ý÷åé, óôçí ðëåéïøçößá ôùí ðåñéðôþóåùí, Þäç åãêáôáóôáèåß ìßá ó÷Ýóç ïéêåéüôçôáò êáé áìïéâáßáò åìðéóôïóýíçò. Ç ôåëåõôáßá, áñêåß ðïëëÝò öïñÝò áðü ìüíç ôçò ãéá íá ðåñéïñßóåé ôï Üã÷ïò ôïõ åìâïëéáóìïý. ÅðéðëÝïí, ç ðáñïõóßá ôùí ãïíÝùí êáé éäéáßôåñá ôçò ìçôÝñáò, åßíáé ãíùóôü üôé ðáßæåé áðïöáóéóôéêü ñüëï (óõ÷íüôåñá èåôéêü, áëëÜ êáé óðáíéüôåñá áñíçôéêü) óôçí áíôßäñáóç ôïõ ðáéäéïý óôïí ðüíï. Ïé ãïíåßò üìùò, ðáñáâñßóêïíôáé óðÜíéá óå ðñïãñÜììáôá ìáæéêïý åìâïëéáóìïý, ðïõ ðñáãìáôïðïéïýíôáé êáôÜ êýñéï ëüãï ôéò ðñþôåò ðñùéíÝò þñåò. Óôçí åñãáóßá ìáò, ç ðáñïõóßá ôïõ ãïíÝá áðïôåëïýóå äõíçôéêÜ óõã÷õôéêü ðáñÜãïíôá êáé ãéá ôï ëüãï áõôü ïé óõíïäïß ôùí ðáéäéþí áðïêëåßóôçêáí åõãåíéêÜ áðü ôï ÷þñï ôïõ åìâïëéáóìïý. Ç ðáñïýóá åñãáóßá ôåêìçñéþíåé ôçí áîßá ôçò ãíùóéáêÞò ðáñÝìâáóçò óôç ìåßùóç ôçò áíôßäñáóçò ôùí ðáéäéþí êáôÜ ôç äéÜñêåéá ìáæéêïý åìâïëéáóìïý. ¸íá áðëü, óýíôïìï êáé ÷ùñßò êüóôïò ìÜèçìá óôçí áßèïõóá, ìðïñåß íá ìåéþóåé áðïôåëåóìáôéêÜ ôçí áíôßäñáóç ôùí ðáéäéþí óôïí ðüíï. Óõìðåñáßíïõìå üôé ôá ðáéäéÜ çëéêßáò 6-7 åôþí åßíáé ðíåõìáôéêÜ þñéìá ü÷é ìüíï íá áíôéëçöèïýí ôá ìçíýìáôá åíüò ôÝôïéïõ ìáèÞìáôïò, áëëÜ êáé íá ôá ÷ñçóéìïðïéÞóïõí áðïôåëåóìáôéêÜ óôç ìåßùóç ôïõ öüâïõ áðü ôï áëãåéíü åñÝèéóìá. Áðïôåëåß Üîéï ëüãïõ ôï ãåãïíüò, üôé êáíÝíá áðü ôá 58 ðáéäéÜ ôçò ãíùóéáêÞò ðáñÝìâáóçò äåí áðÜíôçóå ïñèÜ üôáí åñùôÞèçêå ãéá ðïéüí ëüãï äåí Ý÷åé íïóÞóåé áðü ôá êïéíÜ åîáíèçìáôéêÜ íïóÞìáôá ôçò ðáéäéêÞò çëéêßáò (éëáñÜ, åñõèñÜ). Öáßíåôáé üôé áêüìç êáé óÞìåñá, ôçí åðï÷Þ ôçò Üíèçóçò ôçò ðëçñïöïñéêÞò êáé ôçò ðëçèþñáò ôùí ìÝóùí ìáæéêÞò åíçìÝñùóçò, õðÜñ÷åé Ýëëåéøç ðëçñïöüñçóçò ðÜíù óå èÝìáôá õãåßáò, óôá ðáéäéÜ ó÷ïëéêÞò çëéêßáò. Ïé ëïéðÝò ðáñåìâÜóåéò, ðáñïõóßáóáí åðßóçò ìåßùóç ôïõ Üëãïõò, ìåãáëýôåñç ôçò ïìÜäáò åëÝã÷ïõ, ïé äéáöïñÝò üìùò, äåí Þôáí óôáôéóôéêþò

Ôüìïò 14, Ôåý÷ïò 2, 2002

óçìáíôéêÝò. Áõôü Ýñ÷åôáé óå áíôßèåóç ìå ìåñéêÝò ðáëáéüôåñåò åñãáóßåò,9,19 ðïõ Ý÷ïõí êáôáäåßîåé ôçí áðïôåëåóìáôéêüôçôÜ ôïõò. Ç Fowler-Kerry êáé óõíåñãÜôåò19, ôõ÷áéïðïßçóáí 200 ðáéäéÜ çëéêßáò 4.5-6.5 åôþí, óå ôÝóóåñéò ïìÜäåò: áðüóðáóç ðñïóï÷Þò, õðïâïëÞ, ôï óõíäõáóìü ôïõò, Þ ôßðïôå (ïìÜäá åëÝã÷ïõ). ÐáñáôÞñçóáí üôé ôá ðáéäéÜ ôçò áðüóðáóçò ðñïóï÷Þò ìå Þ ÷ùñßò õðïâïëÞ, ðáñïõóßáóáí óôáôéóôéêÜ óçìáíôéêÞ ìåßùóç ôçò VAS. Ïé Gonzalez JC êáé óõí9, ôõ÷áéïðïßçóáí 42 “äõÜäåò” ðáéäéþí 3-7 åôþí êáé ìçôÝñáò, óå ôñåéò ïìÜäåò: áðüóðáóçò ðñïóï÷Þò, êáèçóõ÷áóìïý êáé ïìÜäáò åëÝã÷ïõ. ¼ëåò ïé ðáñåìâÜóåéò Ýãéíáí áðü ôç ìçôÝñá. Ìüíï ôá ðáéäéÜ ôçò áðüóðáóçò ðñïóï÷Þò ðáñïõóßáóáí óôáôéóôéêÜ óçìáíôéêÞ ìåßùóç ôïõ Üëãïõò. ¸íáò ëüãïò ðïõ èá ìðïñïýóå íá åîçãÞóåé ôéò äéáöïñÝò, åßíáé ç çëéêßá. Ç ìÝóç çëéêßá (6,5-7 Ýôç) ôùí ðáéäéþí ôçò åñãáóßáò ìáò, åßíáé ìåãáëýôåñç áõôÞò ôùí ðñïçãïýìåíùí åñãáóéþí. Åßíáé ãíùóôü, üôé, áõîáíüìåíçò ôçò çëéêßáò êáé ôçò ðíåõìáôéêÞò ùñéìüôçôáò ôïõ ðáéäéïý, ïé ãíùóéáêÝò ðáñåìâÜóåéò êÜèå åßäïõò, õðåñôåñïýí ôçò áðüóðáóçò ôçò ðñïóï÷Þò (ðïõ óå Ýíá ìåãáëýôåñï ðáéäß åßíáé ðïëý äõóêïëüôåñï íá åðéôåõ÷èåß). Ç Fowler-Kerry êáé óõí.19, ðáñáôÞñçóáí üôé ï êáèïñéóôéêüôåñïò ðáñÜãïíôáò åðéôõ÷ßáò Þ ìç ôçò áðüóðáóçò ðñïóï÷Þò, åßíáé ç çëéêßá. Äåí åßíáé ãíùóôü ôï üñéï çëéêßáò, ðÝñá áðü ôï ïðïßï ç ôåëåõôáßá áñ÷ßæåé íá ÷Üíåé ôçí áðïôåëåóìáôéêüôçôÜ ôçò. Óýìöùíá ìå ôá åõñÞìáôÜ ìáò, ðñÝðåé íá âñßóêåôáé êïíôÜ óôçí çëéêßá ôùí 6 åôþí. ÅîÜëëïõ, ôá áðïôåëÝóìáôÜ ìáò Ýäåéîáí áíÜëïãç ìåôáâïëÞ êáé ôçò êëßìáêáò VAS áëëÜ êáé ôùí óöýîåùí, ãåãïíüò ðïõ êáèéóôÜ áðßèáíï ìéá ôÝôïéá ìåôáâïëÞ íá åßíáé ôõ÷áßá. Áêüìç ðéï åíôõðùóéáêü åßíáé ôï ãåãïíüò ôçò ìåßùóçò ôçò áðïôåëåóìáôéêüôçôáò ôçò ãíùóéáêÞò ðáñÝìâáóçò, åÜí áõôÞ óõíäõáóôåß ìå áðüóðáóç ðñïóï÷Þò. Ôï ãåãïíüò áõôü, Ýñ÷åôáé óå áíôßèåóç ìå ôçí áñ÷éêÞ åñåõíçôéêÞ ìáò õðüèåóç üôé äçëáäÞ ïé äýï ðáñåìâÜóåéò èá åß÷áí áèñïéóôéêÞ äñÜóç ðÜíù óôç ìåßùóç ôïõ ðüíïõ ôùí ðáéäéþí. Ìéá ðéèáíÞ åîÞãçóç ßóùò åßíáé, üôé, ï óõíäõáóìüò ôïõò äçìéïõñãåß ìéá áíôßöáóç óôç óêÝøç ôùí ìéêñþí ðáéäéþí. Ç ðñþôç (ãíùóéáêÞ), åóôéÜæåé ôç óêÝøç óôïí åðåñ÷üìåíï åìâïëéáóìü, êáé ôá êáëåß íá ôïí áíôéìåôùðßóïõí äß÷ùò öüâï, åíþ ç äåýôåñç Ý÷åé ùò óôü÷ï ôçí áðïìÜêñõíóç ôçò óêÝøçò áðü ôï åìâüëéï êáé ôïí åóôéáóìü óôï ðáé÷íßäé. 79


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

ÔÝëïò, ç ðéèáíüôçôá õðïäüñéáò Ýê÷õóçò ôïõ BCG êáé êáôÜ óõíÝðåéá êáé ç áðïôåëåóìáôéêüôçôá ôïõ åìâïëßïõ, öÜíçêå íá åîáñôþíôáé óå ìåãÜëï âáèìü áðü ôç óõíåñãáóßá êáé ôçí áíôßäñáóç ôïõ ðáéäéïý. Ç ðéèáíüôçôá õðïäüñéáò Ýê÷õóçò ôïõ BCG, Þôáí áõîçìÝíç êáôÜ 8,1 öïñÝò óôçí ïìÜäá åëÝã÷ïõ, óå ó÷Ýóç ìå ôçí ïìÜäá ïðïéáóäÞðïôå ðáñÝìâáóçò, Þôáí äå áíåîÜñôçôç áðü ôï Üôïìï ðïõ Ýêáíå ôïí åìâïëéáóìü. Öáßíåôáé, üôé êáé ïé ôñåéò ðáñåìâÜóåéò Ý÷ïõí åõåñãåôéêÞ åðßäñáóç óôçí áíôßäñáóç ôùí ðáéäéþí, Ýóôù êáé áí áõôÞ äåí åßíáé äõíáôü íá áðïêáëõöèåß ðëÞñùò ìå ôéò óôáèìéóìÝíåò ìåèüäïõò ðïõ ÷ñçóéìïðïéÞóáìå.

ÓõìðåñÜóìáôá Ìßá óýíôïìç êáé ÷ùñßò êüóôïò óõæÞôçóç ìå ôá ðáéäéÜ óôçí ôÜîç, ìðïñåß íá ìåéþóåé áðïôåëåóìáôéêÜ ôçí áíôßäñáóÞ ôïõò óôïí ðüíï êáé íá åðéôñÝøåé Ýíáí ðåñéóóüôåñï åðéôõ÷Þ åìâïëéáóìü ìå BCG. Ç ãíùóôïðïßçóç ôùí áðïôåëåóìÜôùí ìáò óôïõò Éáôñïýò ÐñùôïâÜèìéáò Öñïíôßäáò äõíáôüí íá áõîÞóåé ôçí áðïäï÷Þ ôùí ðñïãñáììÜôùí ìáæéêïý åìâïëéáóìïý áðü ôá ðáéäéÜ ó÷ïëéêÞò çëéêßáò. Åõ÷áñéóôßåò. Ïé óõããñáöåßò ôçò åñãáóßáò åõ÷áñéóôïýí èåñìÜ ôïí êáèçãçôÞ ôçò ÅèíéêÞò Ó÷ïëÞò Äçìüóéáò Õãåßáò ê. Èùìáúäç êáèþò êáé ôçí åðéóôçìïíéêÞ Äéåõèýíôñéá êáé åìðíåõóôÞ ôïõ ðñïãñÜììáôïò êõñßá ÂáóéëÜêïõ ÉùÜííá, ãéá ôç âïÞèåéá ðïõ ðñïóÝöåñáí óôçí ðñáãìáôïðïßçóç ôçò ðáñïýóáò åñãáóßáò. Âéâëéïãñáößá 1. K.A. Woodin, L.E. Rodewald, S.G. Humison, M.S. Carges, S.J. Schaffer, P.G. Szilagyi. Physician and parent options: Are children becoming pincushions from immunizations? Arch. Pediatr. Adolesc. Med., 149:845-849, 1995. 2. A. Taddio, M. Goldbach, M. Ipp, B. Stevens, G. Koren. Effect of neonatal circumcision on pain responses during vaccination in boys. Lancet, 345:291-2, 1995. 3. B. Stevens, M. Hunsberger, G. Browne. Pain in children; theoretical research and practice di-

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lemmas. J. Pediatr. Nurs., 2:154-160, 1987. 4. D.J. Madlon-Kay, P.G. Haper. Two many shots? Patient, nurse and physician attitudes toward multiple simultaneous childhood vaccines. Arch. Fam. Med., 3:610-613, 1994. 5. R.K. Zimmerman, J.J. Schlesselman, A.L. Baird, T.A. Mieczkowski. A national review to understand why physicians limit childhood immunizations. Arch. Pediatr. Adolesc. Med., 151:657664, 1997. 6. E.C. Reis. Multiple scheduled injections contribute to missed opportunities to immunize during well care visits. Ambulatory Child Çealth, 3:172, 1007. 7. E.R. Cohen, et al. Taking the sting out of shots: control of vaccination – associated pain and adverse reactions. Pediatric Annals, 6:375-386, 1998. 8. S.M. Jay, et al. Behavioral management of children’s distress during paiful medical procedures. Behav. Res. Ther., 23:513-520, 1985. 9. J.C. Gonzalez, D.K. Routh, F.D. Armstrong. Effects of maternal distraction versus reassurance on children’s reactions to injections. Journal Pediatr. Psychol., 18:593-604, 1993. 10. G.M. French, et al. Blowing away shot pain: A technique for pain management during immunization. Pediatrics, 93:384-388, 1994. 11. RM Jacobson, et al. Making vaccines more acceptable – methods to prevent and minimize pain and other common adverse events associated with vaccines Vaccine, 19:2418-2427, 2001. 12. G.B. Humphrey, et al. The occurrence of high levels o acute behavioral distress in children and adolescents undergoing routine venipunctures. Pediatrics, 90:87-91, 1992. 13. PASS/NCSS, August 2000, Utah, USA. 14. A.R. Lloyd-Thomas. Pain management in pediatric patients. British Journal of Anaesthesia, 64:85-104, 1990. 15. J.E. Beyer, N.D. Wells. The assessment of pain in children. Pediatric Clinics of North America, 36:837-854, 1989. 16. N.L. Schechter. The undertreatment of pain in children: An overview. Pediatric Clinics of North America, 36:781-794, 1989. 17. D. Fassler, N. Wallace Children’s fear of needles. Clin. Pediatr., 21:59-60, 1982. 18. D. Fassler. The fear of needles in children. Amer. J. Orthophychiat. 55:371-377, 1985. 19. S. Fowler-Kerry, J.R. Lander Management of injection pain in children. Pain, 30:169-75, 1987.


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ÖùôåéíÞ Ãåùñãïðïýëïõ êáé óõí.

BÑÁÂÅÕÈÅÉÓÁ ÅËÅÕÈÅÑÇ ÁÍÁÊÏÉÍÙÓÇ AWARDED FREESTANDING PAPER Primary Heatlh Care, Volume 14, Number 2, 81-91, 2002 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 14, Ôåý÷ïò 2, 81-91, 2002

Ç åêôßìçóç ôïõ âáèìïý ôçò ðéèáíÞò ðåñéöåñéêÞò íåõñïðÜèåéáò óå äéáâçôéêïýò áóèåíåßò ìå ôç ÷ñÞóç åíüò äéáãíùóôéêïý åñãáëåßïõ ÖùôåéíÞ Ãåùñãïðïýëïõ1, Å. Èçñáßïò1, Êáëëéüðç ÊáëáúôæÜêç1, Åýá ×ïõäåëïýäç2, ÁããåëéêÞ Áñþíç2, Í. Âëá÷ïãéÜííçò3, Ó. Ðïëïíýöçò4

Ðåñßëçøç Óêïðüò: Ç åêôßìçóç ôïõ âáèìïý ôçò ðéèáíÞò ðåñéöåñéêÞò íåõñïðÜèåéáò óå äéáâçôéêïýò áóèåíåßò ìå ôç ÷ñçóéìïðïßçóç åíüò äéáãíùóôéêïý åñãáëåßïõ, ôïõ Michigan Neuropathy Screening Instrument (MNSI). Ðëçèõóìüò ìåëÝôçò – ÌÝèïäïò: Óå 60 áóèåíåßò ìå óáê÷áñþäç äéáâÞôç ôýðïõ ÉÉ (27 Üíäñåò êáé 33 ãõíáßêåò, ìÝóç çëéêßá 66,35±6,39 Ýôç, ìÝóç äéÜñêåéá äéáâÞôç 9,13±7,87 Ýôç) ðïõ ðñïóÞëèáí óôï Äéáâçôïëïãéêü Éáôñåßï ôïõ Ê.Õ. Ëáõñßïõ óå ÷ñïíéêü äéÜóôçìá ôñéþí ìçíþí, êáôáãñÜöçêå ôï ðñïößë êÜèå áññþóôïõ (çëéêßá, öýëï, äéÜñêåéá äéáâÞôç, BMI, èåñáðåõôéêÞ áãùãÞ, âáèìüò ãëõ÷áéìéêÞò ñýèìéóçò, êÜðíéóìá, óõíõðÜñ÷ïõóá õðÝñôáóç êáé õðåñëéðéäáéìßá) êáé Ýãéíå åêôßìçóç ôïõ âáèìïý ðéèáíÞò ðåñéöåñéêÞò íåõñïðÜèåéáò ìå ôç ÷ñÞóç ôïõ MNSI (score>2). ÅêôéìÞèçêáí ôá á÷ßëëåéá áíôáíáêëáóôéêÜ êáé ç åõáéóèçóßá óôï áßóèçìá êñáäáóìþí [óôï Üêñï ôïõ ìåãÜëïõ äáêôýëïõ] ìå ôç ÷ñÞóç âéïèåóéïìÝôñïõ 128Hz. Áðïêëåßóôçêáí áðü ôç ìåëÝôç áóèåíåßò ìå ðåñéöåñéêÞ áããåéáêÞ íüóï, áìöéâëçóôñïåéäïðÜèåéá êáé éóôïñéêü áëêïïëéóìïý. Ãéá ìÜñôõñåò ÷ñçóéìïðïéÞèçêáí 10 õãéÞ ìç äéáâçôéêÜ Üôïìá. Ç óôáôéóôéêÞ áíÜëõóç Ýãéíå ìå ôç ÷ñÞóç ôïõ ðáêÝôïõ SPSS (ver. 10,0). ÁðïôåëÝóìáôá: ÓõìðôùìáôéêÞ äéáâçôéêÞ íåõñïðÜèåéá (ðüíïò, ðáñáéóèçóßá) ðáñïõóßáóáí 40 (66,6%) áóèåíåßò (ìÝóç ôéìÞ MNSIscore=2,67). 6 áðü ôïõò 20 (33.4%) áóõìðôùìáôéêïýò áóèåíåßò åß÷áí MNSIscore>2. Ôá êýñéá ðáèïëïãéêÜ íåõñïëïãéêÜ óçìåßá óôï MNSI Þôáí ç ìåßùóç Þ êáôÜñãçóç ôùí á÷ßëëåéùí áíôáíáêëáóôéêþí êáé ôçò ðáëëáéóèçóßáò. Ïé Üíäñåò åìöáíßæïõí óõ÷íüôåñá ôùí ãõíáéêþí óõìðôùìáôéêÞ äéáâçôéêÞ íåõñïðÜèåéá (p<0,01). Ç ðôù÷Þ ãëõ÷áéìéêÞ ñýèìéóç (p<0,01), ç ìåãÜëç äéÜñêåéá ôïõ äéáâÞôç (p<0,01) êáé ôï êÜðíéóìá (MNSIscore=2,64 ïé êáðíßæïíôåò Ýíáíôé MNSIscore=2,21 ïé ìç êáðíßæïíôåò, p=NS) åßíáé ðáñÜãïíôåò êéíäýíïõ ãéá óõìðôùìáôéêÞ äéáâçôéêÞ íåõñïðÜèåéá. ÓõìðåñÜóìáôá: Ï Ýëåã÷ïò ôùí äéáâçôéêþí áôüìùí ãéá ðåñéöåñéêÞ íåõñïðÜèåéá ïäçãåß óôïí åíôïðéóìü áôüìùí ðïõ Ý÷ïõí õøçëü êßíäõíï áíÜðôõîçò üøéìùí íåõñïðáèçôéêþí åðéðëïêþí (åîåëêþóåéò, ëïéìþîåéò). Ôï MNSI ìðïñåß íá åßíáé Ýíá áðëü, åý÷ñçóôï êáé áîéüðéóôï åñãáëåßï ãéá ôçí åêôßìçóç ôïõ âáèìïý ðåñéöåñéêÞò äéáâçôéêÞò íåõñïðÜèåéáò áðü ôïõò ãåíéêïýò éáôñïýò.

1 Ãåíéêüò Éáôñüò, 2Íïóçëåýôñéá, 3Ðáèïëüãïò, Õðåýèõíïò Äéáâçôïëïãéêïý Éáôñåßïõ, 4Êáñäéïëüãïò, Ä/íôÞò ÊÝíôñïõ Õãåßáò, ÊÝíôñï Õãåßáò Ëáõñßïõ

ÅéóáãùãÞ Ç äéáâçôéêÞ íåõñïðÜèåéá åßíáé ÷ñüíéá åðéðëïêÞ ôïõ óáê÷áñþäç äéáâÞôç ôçò ïðïßáò ç áéôéïëïãßá êáé ï ïñéóìüò ôçò åßíáé áóáöåßò. Ìåñéêïß õðïóôçñßæïõí üôé ðñüêåéôáé ãéá ìéêñïáããåéïðÜèåéá (éó÷áéìßá vasa nervorum) ôùí íåýñùí êáé Üëëïé üôé ïöåßëåôáé áðïêëåéóôéêÜ óå ìåôáâïëéêÞ äéáôáñá÷Þ õðü ôç ìïñöÞ åßôå óõóóþñåõóçò óïñâéôüëçò åßôå ôçò áíåðÜñêåéáò ìõïúíïóéôüëçò1. Ç ðïéêéëßá ôùí åêäçëþóåþí ôçò (êéíçôéêÞ, áéóèçôéêÞ, áõôüíïìç) êáèéóôÜ äõó÷åñÞ ôïí êáèïñéóìü äéáãíùóôéêþí êñéôçñßùí ìå áðïôÝëåóìá ï åðéðïëáóìüò êáé ç åðßðôùóç ôçò íüóïõ íá äéáöÝñïõí óçìáíôéêÜ ìåôáîý ôùí ìåëåôþí1. Óýìöùíá ìå ôçí Eurodiab Complications Study, ËÝîåéò êëåéäéÜ: Óáê÷áñþäçò äéáâÞôçò, ðåñéöåñéêÞ íåõñïðÜèåéá, ãåíéêÞ éáôñéêÞ, ðñùôïâÜèìéá öñïíôßäá õãåßáò ÕðïâëÞèçêå: Ç åñãáóßá õðïâëÞèçêå ùò åëåýèåñç áíáêïßíùóç óôï 14ï ÐáíåëëÞíéï ÓõíÝäñéï ÃåíéêÞò ÉáôñéêÞò (ÊñÞôç, 8-12 ÌáÀïõ 2002) êáé âñáâåýèçêå áðü ôçí ÅðéôñïðÞ Êñßóçò. Äçìïóéåýåôáé ìå êïéíÞ áðüöáóç ôçò ÓõíôáêôéêÞò ÅðéôñïðÞò ôïõ ðåñéïäéêïý êáé ôçò ÏñãáíùôéêÞò ÅðéôñïðÞò ôïõ Óõíåäñßïõ. Õðåýèõíïò áëëçëïãñáößáò: Èçñáßïò ÅëåõèÝñéïò, Âïõëãáñïêôüíïõ 8, ÁèÞíá Ô.Ê. 114 71, ôçë.: 0106425149, e-mail: ethireos@hol.gr 81


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

ÖùôåéíÞ Ãåùñãïðïýëïõ êáé óõí.

The Assessment and staging of possible peripheral neuropathy in diabetic patients: the usage/use of an instrument. Fotini Georgopoulou, E. Thireos, Kalliopi Kalaitzaki, Eva Houdeloudi, Angela Aroni, N. Vlahogiannis. Summary Objective: The aim of this study was to detect the prevalence and stage of possible diabetic neuropathy, a common complication of diabetes, by the use of a diagnostic test, the Michigan Neuropathy Screening Instrument (MNSI). Research design and methods: Neuropathy was diagnosed by using the MNSI, a standardised examination which was developed to be used in the outpatient setting. A total of 60 patients (27 men and 33 women, with an average age of 66.35± 6.39) with confirmed type II diabetes, were studied over a three month period in the Lavrio Health Centre. All of the patients were administered the MNSI by a general practitioner. Patients with peripheral vascular disease, retinopathy and alcoholism were excluded from the study. The control group consisted of 10 healthy non-diabetic individuals. Results: 40 (66.6%) * of the 60 patients had symptomatic diabetic neuropathy (pain, numbness) with an average value of MNSIscore=2.67. Of the remaining 20 asymptomatic patients 6 had a MNSIscore>2. The key clinical abnormal signs in MNSI were the decrease or absence of Ankle reflexes and vibration. Diabetic neuropathy is more common to men than women. (p<0.01).A long duration of diabetes (p<0.01), poor glycaemic control (p<0.01) and smoking (MNSIscore=2.64 for smokers, MNSIscore=2.21 for non-smokers, ps=NS) were all reported to be associated with an increased risk of diabetic neuropathy. Conclusions: An increased awareness of the prevalence of neuropathy can lead to an early therapeutic intervention and possible prevention of later neuropathic complications, such as infection and foot ulcers. The MNSI is a simple and reliable screening tool that can be used by heath care professionals in the outpatient setting to screen for possible diabetic neuropathy. Key words: diabetic mellitus, peripheral neuropathy, Michigan Neuropathy Screening Instrument, general practice, primary health care Lavrio Health Center

ðïõ ðñáãìáôïðïéÞèçêå óå 16 åõñùðáúêÝò ÷þñåò, ï åðéðïëáóìüò ôçò äéáâçôéêÞò íåõñïðÜèåéáò óå äéáâçôéêïýò ôýðïõ É êõìáßíåôáé ìåôáîý 15 êáé 60%2. Óå ìåëÝôç 4400 áóèåíþí äéáâçôïëïãéêïý éáôñåßïõ äéáðéóôþèçêå üôé ôï 10% ôùí áóèåíþí åß÷áí ðåñéöåñéêÞ íåõñïðÜèåéá êáôÜ ôç äéÜãíùóç ôïõ äéáâÞôç, åíþ Ýíá 50% áíáðôýóóåé íåõñïðÜèåéá ìåôÜ áðü 25 Ýôç3. Ó’ Üëëç ðïëõêåíôñéêÞ ìåëÝôç ìå 6.487 áóèåíåßò óôï ÇíùìÝíï Âáóßëåéï, ç åðßðôùóç ôçò ðåñéöåñéêÞò íåõñïðÜèåéáò Þôáí 44% óå äéáâçôéêïýò áóèåíåßò çëéêßáò 70 êáé 79 åôþí4. ÁíÜëïãåò ìåëÝôåò óôçí Éôáëßá, Ýäåéîáí üôé ôï 66% ôùí äéáâçôéêþí áóèåíþí åìöÜíéæå áíôéêåéìåíéêÜ åõñÞìáôá íåõñïðÜèåéáò5. Êïéíü óçìåßï üëùí ôùí ðáñáðÜíù ìåëåôþí åßíáé üôé ï åðéðïëáóìüò ôçò äéáâçôéêÞò íåõñïðÜèåéáò áõîÜíåé ìå ôçí çëéêßá ôïõ áóèåíÞ êáé ôç äéÜñêåéá ôïõ óáê÷áñþäç äéáâÞôç êáé ó÷åôßæåôáé ìå óçìáíôéêÞ íïóçñüôçôá ôùí áóèåíþí (åðþäõíåò ðáñáéóèçóßåò, áéóèçôéêÞ áôáîßá êáé ôåëéêÜ ôçí áíÜðôõîç íåõñïðáèçôéêþí åîåëêþóåùí) ðïõ ìðïñåß íá ïäçãÞóåé óå áêñùôçñéáóìïýò. Óôéò ÇíùìÝíåò Ðïëé82

ôåßåò ôçò ÁìåñéêÞò êáé ôï ÇíùìÝíï Âáóßëåéï ôï 50-70% ôùí ìç ôñáõìáôéêÞò áéôéïëïãßáò áêñùôçñéáóìþí ïöåßëïíôáé äåõôåñïðáèþò óå óáê÷áñþäç äéáâÞôç6. Ç äéáâçôéêÞ íåõñïðÜèåéá Ý÷åé âáèìéáßá Ýíáñîç ìå ðåñéöåñéêÝò óõììåôñéêÝò áéóèçôéêÝò äéáôáñá÷Ýò êáé åîåëéóóüìåíç ðïñåßá óôçí ïðïßá ðñïóôßèåíôáé äéáôáñá÷Ýò áðü ôï êéíçôéêü êáé ôï áõôüíïìï íåõñéêü óýóôçìá. Ïé ìÝèïäïé äéÜãíùóçò ôçò ðåñéöåñéêÞò íåõñïðÜèåéáò Ý÷ïõí áðïôåëÝóåé èÝìá áíôéðáñáèÝóåùí ìåôáîý ôùí åéäéêþí. ¸÷ïõí ÷ñçóéìïðïéçèåß áðëÝò ìÝèïäïé, üðùò ôá êëéíéêÜ óõìðôþìáôá êáé ôá íåõñïëïãéêÜ óçìåßá7 áëëÜ êáé ðëÝïí åéäéêÝò, üðùò ï çëåêôñïöõóéïëïãéêüò Ýëåã÷ïò ôçò ôá÷ýôçôáò áãùãéìüôçôáò, êéíçôéêÞò êáé áéóèçôéêÞò, óôá ðåñéöåñéêÜ íåýñá8. Ïé ðåñéóóüôåñïé õðïóôçñßæïõí üôé ï óõíäõáóìüò ôùí ðáñáðÜíù ìåèüäùí èÝôåé ìå âåâáéüôçôá ôç äéÜãíùóç, áöïý áóèåíåßò ìå óïâáñÜ óõìðôþìáôá äåí ðáñïõóéÜæïõí íåõñïëïãéêÜ óçìåßá êáé Üëëïé, åíþ åßíáé áóõìðôùìáôéêïß, Ý÷ïõí óïâáñÞ íåõñï-

ðÜèåéá. Óêïðüò ôçò ìåëÝôçò ìáò åßíáé ç áíß÷íåõóç êáé ç åêôßìçóç ôïõ âáèìïý ôçò ðéèáíÞò ðåñéöåñéêÞò íåõñïðÜèåéáò óå äéáâçôéêïýò áóèåíåßò ôýðïõ ÉÉ ôïõ ÊÝíôñïõ Õãåßáò Ëáõñßïõ ìå ôç ÷ñÞóç åíüò äéáãíùóôéêïý åñãáëåßïõ, ôïõ Ìichigan Neuropathy Screening Instrument (MNSI) (âëÝðå ÐáñÜñôçìá).

Ðëçèõóìüò ìåëÝôçò - ÌÝèïäïé Ç ìåëÝôç ðñáãìáôïðïéÞèçêå óôï äéáâçôïëïãéêü éáôñåßï ôïõ Ê.Õ. Ëáõñßïõ êáôÜ ôï ôåëåõôáßï ôñßìçíï ôïõ 2001. ÐåñéåëÜìâáíå 60 ìç åðéëåãìÝíïõò áóèåíåßò, ðïõ óýìöùíá ìå ôá êñéôÞñéá ôçò American Diabetes Association (ADA) Ýðáó÷áí áðü óáê÷áñþäç äéáâÞôç ôýðïõ 29. ÅîåôÜóôçêáí 27 Üíäñåò êáé 33 ãõíáßêåò ìå ìÝóç çëéêßá 66,35±6,39 Ýôç êáé ìÝóç äéÜñêåéá äéáâÞôç 9,13±7,87 Ýôç. Ïé áóèåíåßò äåí ãíþñéæáí áí Ýðáó÷áí áðü ðåñéöåñéêÞ íåõñïðÜèåéá. Áðïêëåßóèçêáí áðü ôçí ìåëÝôç ïé áóèåíåßò ðïõ åß÷áí äéá-


Ôüìïò 14, Ôåý÷ïò 2, 2002

ÖùôåéíÞ Ãåùñãïðïýëïõ êáé óõí.

ãíùóìÝíç äéáâçôéêÞ áìöéâëçóôñïåéäïðÜèåéá, ðåñéöåñåéáêÞ áããåéáêÞ íüóï êáé éóôïñéêü áëêïïëéóìïý. Ãéá ìÜñôõñåò ÷ñçóéìïðïéÞèçêáí 10 õãéÞ ìç äéáâçôéêÜ Üôïìá. ÊáôáãñÜöçêå ôï ðñïößë ôïõ êÜèå áññþóôïõ, ôï ïðïßï ðåñéåëÜìâáíå ôï öýëï, ôçí çëéêßá, ôç äéÜñêåéá ôïõ äéáâÞôç, ôï ÂÌÉ, ôç èåñáðåõôéêÞ áãùãÞ, ôï âáèìü ôçò ãëõ÷áéìéêÞò ñýèìéóçò, ôï êÜðíéóìá, êáèþò êáé ôç óõíõðÜñ÷ïõóá õðÝñôáóç êáé õðåñëéðéäáéìßá. Óå üëïõò ôïõò áóèåíåßò ÷ñçóéìïðïéÞèçêå ôï Ìichigan Neuropathy Screening Instrument (ÌÍSÉ), ôï ïðïßï áðïôåëåß ôï ðñþôï óôÜäéï ôïõ Michigan Neuropathy Program. Ôï óôÜäéï áõôü ðåñéëáìâÜíåé Ýíá åñùôçìáôïëüãéï 8 åñùôÞóåùí êáé ìéá óýíôïìç êëéíéêÞ åêôßìçóç. Ïé åñùôÞóåéò áíáöÝñïíôáé óôá óõíÞèç õðïêåéìåíéêÜ åíï÷ëÞìáôá ôçò ðåñéöåñéêÞò íåõñïðÜèåéáò (Üëãïò, ðáñáéóèçóßåò, áéìùäßåò, ìõñìçêéÜóåéò, êáõóáëãßåò, êñÜìðåò), ðáñÜãïíôåò ðïõ ôá åðçñåÜæïõí üðùò ç âÜäéóç (ãéá ôïí áðïêëåéóìü ðåñéöåñéêÞò áñôçñéïðÜèåéáò), åíôüðéóÞ ôïõò (êÜôù Üêñá Þ ðÝëìáôá, ãáóôñïêíçìßåò, ìçñïýò) ÷ñïíéêÞ äéÜñêåéá êáé ó÷Ýóç ìå ôïí ýðíï. Ç êëéíéêÞ åêôßìçóç ôçò íåõñïðÜèåéáò ðåñéëáìâÜíåé åðéóêüðçóç ôùí ðïäéþí, åêôßìçóç ôùí á÷ßëëåéùí áíôáíáêëáóôéêþí êáé ôçò áíôßëçøçò ôùí äïíÞóåùí óôï ìåãÜëï äÜêôõëï ôïõ Üêñïõ ðïäüò. ÊáôÜ ôçí åðéóêüðçóç åëÝã÷áìå ôçí îçñüôçôá ôïõ äÝñìáôïò, ôçí ýðáñîç õðåñêåñáôþóåùí (êÜëùí) êáé áíáôïìéêþí áíùìáëéþí, üðùò ï âëáéóüò Þ ñáéâüò ìÝãáò äÜêôõëïò êáèþò êáé ôçí ýðáñîç öëåãìïíþí, åîåëêþóåùí êáé áêñùôçñéáóìþí8. Ç åêôßìçóç ôïõ á÷ßëëåéïõ áíôáíáêëáóôéêïý Ýãéíå ìå Üìåóç ðëÞîç ôïõ ôÝíïíôá óå êáèéóôÞ èÝóç. Óå ðåñßðôùóç áðïõóßáò ôïõ, Ýãéíå ðñïóðÜèåéá ðñüêëçóçò áõôïý ìå õðïâïÞèçóç. Ï Ýëåã÷ïò ôçò åõáéóèçóßáò óôï áßóèçìá êñáäáóìþí ãéíüôáí ìå ôçí åöáñìïãÞ âéïèåóéïìÝôñïõ óõ÷íüôçôáò 128 Hz óôï ìåãÜëï äÜêôõëï ôïõ Üêñïõ ðïäüò óõììåôñéêÜ. ÐñïçãÞèçêå ðåñßïäïò åêðáßäåõóçò ôïõ áóèåíïýò ðñïêåéìÝíïõ íá áîéïëïãçèïýí ïñèÜ ô’ áðïôåëÝóìáôá ôçò äïêéìáóßáò. Ç äïêéìáóßá èåùñÞèçêå èåôéêÞ, üôáí ï áóèåíÞò äÞëùíå üôé äåí áéóèÜíåôáé ôçí ðáëëáéóèçóßá, åíþ ï åîåôáóôÞò óõíÝ÷éæå íá ôçí áéóèÜíåôáé ìåôÜ áðü 10 sec. Ç åðéóêüðçóç, êáèþò êáé ç åêôßìçóç ôïõ á÷ßëëåéïõ áíôáíáêëáóôéêïý êáé ôùí äéáôáñá÷þí ôçò áéóèçôéêüôçôáò áîéïëïãïýíôáí ìå ìéá 3âáè-

ìç êëßìáêá: 0=öõóéïëïãéêü, 0.5=ìåéùìÝíï êáé 1=êáôçñãçìÝíï. Áí ôï óõíïëéêü score Þôáí ìåãáëýôåñï ôïõ 2 åôßèåôï ç õðïøßá ðåñéöåñéêÞò íåõñïðÜèåéáò. Áêïëïýèçóå ôï äåýôåñï óôÜäéï ôïõ ðñïãñÜììáôïò, ôï Michigan Diabetic Neuropathy Score (MDNS), ôï ïðïßï ðåñéåëÜìâáíå åêôßìçóç ôùí áíôáíáêëáóôéêþí Üíù êáé êÜôù Üêñùí (äéêÝöáëïõ, ôñéêÝöáëïõ, ôåôñáêÝöáëïõ êáé á÷ßëëåéïõ) Ýëåã÷ï ôïõ áéóèÞìáôïò êñáäáóìþí ìå âéïèåóéüìåôñï 128 Hz, Ýëåã÷ï ôçò áöÞò ìå ìïíïúíßäéï 5.07 (filament 10gr), ôïõ ðüíïõ ìå íõãìü êáé ôÝëïò Ýëåã÷ï ôçò ìõúêÞò éó÷ýïò8. Êáé ôá äõï óôÜäéá ôïõ ðñïãñÜììáôïò ðñáãìáôïðïéÞèçêáí áðü ãåíéêïýò éáôñïýò. Óýìöùíá ìå ôï ðñüãñáììá èá ðñÝðåé íá ãßíåôáé åðáíåêôßìçóç ôïõ äåõôÝñïõ óôáäßïõ áðü íåõñïëüãï, óôçí ïðïßá ðåñéëáìâÜíåôáé êáé ï çëåêôñïöõóéïëïãéêüò Ýëåã÷ïò ôçò ôá÷ýôçôáò áãùãéìüôçôáò, êéíçôéêÞò êáé áéóèçôéêÞò, óôá ðåñéöåñéêÜ íåýñá8. Ç óôáôéóôéêÞ åðåîåñãáóßá ôùí áðïôåëåóìÜôùí Ýãéíå ìå ôç ÷ñÞóç ôïõ ðáêÝôïõ SPSS (ver. 10.0).

ÁðïôåëÝóìáôá Áðü ôïõò 60 äéáâçôéêïýò áóèåíåßò ìå Óáê÷áñþäç ÄéáâÞôç ôýðïõ ÉÉ ðïõ åëÝã÷èçêáí ãéá äéáâçôéêÞ íåõñïðÜèåéá óôï Äéáâçôïëïãéêü Éáôñåßï ôïõ ÊÝíôñïõ Õãåßáò Ëáõñßïõ, 8 (13,3%) Þôáí ìüíï óå äßáéôá, 44 (73,4%) óå áãùãÞ ìå áíôéäéáâçôéêÜ äéóêßá êáé 8 (13,3%) óå éíóïõëßíç. ÊáðíéóôÝò Þôáí 14 Üôïìá (23,3%), ç ìÝóç ôéìÞ ôïõ Äåßêôç ÌÜæáò Óþìáôïò (ÂÌÉ) Þôáí 28,9±4,65 êáé ç ìÝóç ôéìÞ ôçò ãëõêïæõëéïìÝíçò áéìïóöáéñßíçò (HBA1c) Þôáí 7,75±1,59. Ôá ÷áñáêôçñéóôéêÜ Ðßíáêáò 1. ×áñáêôçñéóôéêÜ ôùí 60 áóèåíþí ìå Óáê÷áñþäç ÄéáâÞôç ôýðïõ ÉÉ ðïõ åëÝã÷èçêáí ãéá äéáâçôéêÞ íåõñïðÜèåéá ¢íäñåò/Ãõíáßêåò ÌÝóç çëéêßá ÌÝóç äéÜñêåéá Ó.Ä. ÊáðíéóôÝò ÌÝóç ôéìÞ ÂÌÉ ÌÝóç ôéìÞ HBA1c Óå äßáéôá Óå áãùãÞ ìå äéóêßá Óå éíóïõëßíç

Áñéèìüò

Ðïóïóôü (%)

27/33 66.35±6.39 9.13±7.87 14 28.9±4.65 7.75±1.59 8 44 8

45/55

23.3

13.3 73.4 13.3 83


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

ÖùôåéíÞ Ãåùñãïðïýëïõ êáé óõí.

ôùí áóèåíþí ðáñïõóéÜæïíôáé óôïí Ðßíáêá 1. Ôá áèñïéóôéêÜ áðïôåëÝóìáôá áðü ôï åñùôçìáôïëüãéï óõìðôùìÜôùí ôïõ MNSI ìå ôçí åêôßìçóç ôçò ðéèáíÞò íåõñïðÜèåéáò ðáñïõóéÜæïíôáé óôïí Ðßíáêá 2. ×ùñßò õðüíïéá äéáâçôéêÞò íåõñïðÜèåéáò âñÝèçêáí 21 (35%) Üôïìá ìå ôéìÝò score 0-2, óå 11 (18,3%) êáé 16 (26,7%) áóèåíåßò åôÝèç õðïøßá åëáöñÜò êáé ìÝôñéáò äéáâçôéêÞò íåõñïðÜèåéáò, åíþ ãéá 12 (20%) Üôïìá åôÝèç ç õðüíïéá óïâáñÞò äéáâçôéêÞò íåõñïðÜèåéáò (ìå ôéìÝò score 7-9), óôï óýíïëï ôùí 39 (65%) áôüìùí, ãéá ôá ïðïßá ìå âÜóç ôá õðïêåéìåíéêÜ åíï÷ëÞìáôá Þôáí ðéèáíÞ ç äéáâçôéêÞ íåõñïðÜèåéá. Ôï ðñþôï óôÜäéï ôïõ Michigan Neuropathy Program ïëïêëçñþèçêå ìå ôçí êëéíéêÞ åêôßìçóç ôçò íåõñïðÜèåéáò (Ðßíáêáò 3). Óå 33 (55%) Üôïìá äåí åêñßèç áíáãêáßá ç ðáñáðïìðÞ ãéá íåõñïëïãéêÞ åîÝôáóç ìéá êáé åß÷áí MNSI score < 2 êáé ôïõò óõíåóôÞèç åîÝôáóç êáé åðáíåêôßìçóç ìåôÜ Ýíá ÷ñüíï. 27 (45%) Üôïìá ðáñáðÝìöèçêáí ãéá íåõñïëïãéêÞ åîÝôáóç êáé çëåêôñïìõïãñÜöçìá, åê ôùí ïðïßùí ìüíï 3 (5%) Üôïìá åß÷áí MNSI score >5. Ìåßùóç Þ êáôÜñãçóç ôïõ á÷ßëëåéïõ áíôáíáêëáóôéêïý åß÷áí 30 (50%) ôùí áóèåíþí, ðáèïëïãéêÞ áíôßëçøç áéóèçôéêüôçôáò, ìå ìåßùóç Þ êáôÜñãçóç ôçò áíôßëçøçò ôçò ðáë-

ëáéóèçóßáò, åß÷áí 41 (68,3%) áóèåíåßò, åíþ 14 (23,3%) Üôïìá äåí ðáñïõóßáóáí äéáôáñá÷Ýò Á÷ßëëåéïõ áíôáíáêëáóôéêïý Þ ôçò áéóèçôéêüôçôáò (Ðßíáêáò 4). ÕðïêåéìåíéêÜ óõìðôþìáôá (ðüíïò, ðáñáéóèçóßåò) ðïõ óõíçãïñïýí ãéá äéáâçôéêÞ íåõñïðÜèåéá ðáñïõóßáæáí 40 (66,6%) áóèåíåßò, ìå ìÝóç ôéìÞ MNSIscore= 2,67. Áðü ôïõò 20 (áóõìðôùìáôéêïýò áóèåíåßò, 6 áóèåíåßò (28,6%) åß÷áí MNSIscore>2. Ç óýãêñéóç ôùí áðáíôÞóåùí ôïõ åñùôçìáôïëïãßïõ óõìðôùìÜôùí ìå ôï áèñïéóôéêü MNSI score ôçò êëéíéêÞò åêôßìçóçò ôçò íåõñïðÜèåéáò ðáñïõóéÜæåôáé óôïí Ðßíáêá 5, åíþ ïé óõó÷åôßóåéò ôïõ MNSI score ìå ôéò äéÜöïñåò ðáñáìÝôñïõò ôïõ êëéíéêïý ðñïößë ôùí äéáâçôéêþí áóèåíþí (öýëï, ìÝóç çëéêßá, ìÝóç äéÜñêåéá óáê÷áñþäç äéáâÞôç, êÜðíéóìá, ìÝóç ôéìÞ ÂÌÉ êáé âáèìüò ãëõ÷áéìéêÞò ñýèìéóçò) ðáñïõóéÜæïíôáé óôïí Ðßíáêá 6.

Ðßíáêáò 2. Áèñïéóôéêü score áðü ôï åñùôçìáôïëüãéï óõìðôùìÜôùí ôïõ MNSI êáé åêôßìçóç ôçò ðéèáíÞò íåõñïðÜèåéáò

Ðßíáêáò 4. ÊëéíéêÞ åêôßìçóç íåõñïðÜèåéáò ìå ôï MNSI. ÍåõñïëïãéêÜ óçìåßá

Åêôßìçóç íåõñïðÜèåéáò

Ìåßùóç Þ êáôÜñãçóç 30 á÷ßëëåéïõ áíôáíáêëáóôéêïý Ìåßùóç Þ êáôÜñãçóç 41 ôçò áíôßëçøçò ðáëáéóèçóßáò ×ùñßò äéáôáñá÷Þ 14 (6 Üôïìá åß÷áí õðïêåéìåíéêÜ åíï÷ëÞìáôá ðáñáéóèçóßáò)

ÔéìÞ Áñéèìüò Ðïóïóôü score (n=60) (%)

Äåí õðÜñ÷åé íåõñïðÜèåéá ÅëáöñÜ ÌÝôñéá ÓïâáñÞ

0-2 3-4 5-6 7-9

21 11 16 12

35 18,3 26,7 20

Ðßíáêáò 3. Áèñïéóôéêü score áðü ôçí êëéíéêÞ åêôßìçóç ôçò äéáâçôéêÞò íåõñïðÜèåéáò ìå ôï MNSI. ÓõóôÜóåéò ðñïò ôïí áóèåíÞ Óýóôáóç ÅîÝôáóç ó’ Ýíá ÷ñüíï äåí ÷ñåéÜæåôáé íåõñïëïãéêÞ åîÝôáóç ÍåõñïëïãéêÞ åîÝôáóç>2 ÇëåêôñïìõïãñÜöçìá

84

ÔéìÞ score

Áñéèìüò (n=60)

Ðïóïóôü (%)

<2

33

55

27

45

3-3,5 4-4,5 5-5,5 6-6,5

12 6 0 3

20 10 0 5

ÓõæÞôçóç Ç äéáâçôéêÞ íåõñïðÜèåéá ìáæß ìå ôçí áìöéâëçóôñïåéäïðÜèåéá, ôç íåöñïðÜèåéá êáé ôç ìá-

ÍåõñïëïãéêÜ óçìåßá

Áñéèìüò

Ðïóïóôü (%) 50 68.3 23.3

Ðßíáêáò 5. ÕðïêåéìåíéêÜ óõìðôþìáôá áóèåíþí ðïõ óõíçãïñïýí ãéá äéáâçôéêÞ íåõñïðÜèåéá óå ó÷Ýóç ìå ôï MNSIscore Óõìðôþìáôá íåõñïðÜèåéáò

MNSI£2 Áñéèìüò (%)

Ðáñáéóèçóßåò 12 Åðþäõíåò 3 ðáñáéóèçóßåò ÊñÜìðåò 4 ¢íåõ óõìðôùìÜôùí 14

52.2 27.3 66.6 70

MNSI>2 Áñéèìüò (%) 11 8

47.8 72.7

2 33.4 6 30 (MNSI<3.5)


Ôüìïò 14, Ôåý÷ïò 2, 2002

ÖùôåéíÞ Ãåùñãïðïýëïõ êáé óõí. Ðßíáêáò 6. Óõó÷åôßóåéò ôïõ MNSIscore ìå äéÜöïñåò ðáñáìÝôñïõò ôùí äéáâçôéêþí áóèåíþí ÐáñÜìåôñïé äéáâçôéêþí áóèåíþí ÌÝóç äéÜñêåéá Ó.Ä. ÌÝóç çëéêßá áóèåíþí ÌÝóç ôéìÞ BMI ÌÝóç ôéìÞ HBA1c ¢íäñåò Ãõíáßêåò Êáðíßæïíôåò Ìç êáðíßæïíôåò

MNSI£2

MNSI>2

8.2±3.1 10.8±3.2 65.6±5.1 67.2±4.8 29.8±4.5 27.5±3.2 6.7±1.2 7.8±1.5 15 (55.5%) <0.01 12 (36.3%) MNSI=2.64 NS MNSI=2.21

p <0.01 NS NS <0.01

êñïáããåéïðÜèåéá áðïôåëïýí ôéò êõñéüôåñåò áðþôåñåò åðéðëïêÝò ôïõ óáê÷áñþäç äéáâÞôç. Áí êáé ç íåõñïðÜèåéá áðïôåëåß ìéá áðü ôéò ðéï óõ÷íÝò åðéðëïêÝò, ðïëý ëßãá ãéá ôçí ðáèïãÝíåéÜ ôçò ãíùñßæïõìå. Äåí õðÜñ÷ïõí óáöåßò ðëçñïöïñßåò ãéá ôïõò ðñïäéáèåóéêïýò ðáñÜãïíôåò ôçò íåõñïðÜèåéáò, áí åßíáé ðéï óõ÷íÞ, äéáöïñåôéêÞ Þ ðéï óïâáñÞ óôïí ôýðï É áð’ ü,ôé óôïí ôýðï ÉÉ10. Ç ðñïóâïëÞ ôùí íåýñùí óôï óáê÷áñþäç äéáâÞôç ãßíåôáé áðü ðßåóç, éó÷áéìßá Þ ìåôáâïëéêÝò äéáôáñá÷Ýò ðïõ áðïôåëïýí ôéò êýñéåò áéôßåò ôùí íåõñïðáèåéþí. Ôï ïéíüðíåõìá, ôï ïðïßï áðü ìüíï ôïõ ìðïñåß íá ðñïêáëÝóåé íåõñïðÜèåéá, ôåßíåé íá ÷åéñïôåñåýóåé õðÜñ÷ïõóá äéáâçôéêÞ íåõñïðÜèåéá11. Åîáéôßáò áõôïý áðïêëåßóôçêáí áðü ôç ìåëÝôç ìáò ïé áóèåíåßò ìå éóôïñéêü áëêïïëéóìïý, êáèþò êáé äéáãíùóìÝíç äéáâçôéêÞ áìöéâëçóôñïåéäïðÜèåéá Þ ðåñéöåñåéáêÞ áããåéáêÞ íüóï. Ïé äéÜöïñåò êëéíéêÝò åìöáíßóåéò êáé ôá åõñÞìáôá ôçò íåõñïðÜèåéáò ìåôáîý ôùí äéáâçôéêþí áíôáíáêëïýí óôçí åôåñïãÝíåéá áõôïý ôïõ ðñïâëÞìáôïò. Ðïëëïß èåùñïýí üôé åßíáé ðéï óùóôü íá ìéëÜìå ãéá “äéáâçôéêÝò íåõñïðÜèåéåò”, Ýôóé þóôå íá ãßíåôáé ðåñéóóüôåñï êáôáíïçôü üôé õðÜñ÷ïõí ðïëëÜ íåõñïëïãéêÜ óýíäñïìá, ðïõ êáèÝíá áð’ áõôÜ, ðéèáíþò íá ïöåßëåôáé åßôå óå äéáöïñåôéêïýò ðáñÜãïíôåò åßôå óå ðáñÜãïíôåò ðïõ åðéäñïýí êÜèå öïñÜ ìå äéáöïñåôéêü ôñüðï (Ðßíáêáò 7)11.

Ìå ôç äéÜãíùóç êáé ôç óôáäéïðïßçóÞ ôçò Ý÷ïõí áó÷ïëçèåß áñêåôïß åñåõíçôÝò. Ôï 1988 ç ÁìåñéêÜíéêç ÄéáâçôïëïãéêÞ Åôáéñåßá (San Antonio Consensus Statement), ðñüôåéíå, üôé ãéá ôç äéÜãíùóç ôçò äéáâçôéêÞò íåõñïðÜèåéáò áðáéôåßôáé äéåñåýíçóç ôùí êëéíéêþí óõìðôùìÜôùí, êëéíéêÞ åîÝôáóç, çëåêôñïöõóéïëïãéêÞ ìåëÝôç, êáèþò êáé ðïéïôéêÞ åîÝôáóç ôçò áéóèçôéêüôçôáò êáé ôçò áõôüíïìçò ëåéôïõñãßáò12. Ùóôüóï ç äéáäéêáóßá áõôÞ åßíáé ÷ñïíïâüñá, áðáéôåß åîåéäéêåõìÝíï ðñïóùðéêü êáé åîïðëéóìü, ìå áðïôÝëåóìá íá ìçí ìðïñåß íá åöáñìïóôåß óå êÝíôñá ðñùôïâÜèìéáò öñïíôßäáò õãåßáò. Ç ÅðéôñïðÞ Neurodiab ôçò ÅõñùðáúêÞò ÄéáâçôïëïãéêÞò Åôáéñåßáò13 ðñïôåßíåé üôé ç äéÜãíùóç ôçò äéáâçôéêÞò íåõñïðÜèåéáò ìðïñåß íá åßíáé êëéíéêÞ êáé íá âáóßæåôáé óôçí ýðáñîç ðáèïëïãéêþí åõñçìÜôùí óå ôïõëÜ÷éóôïí äýï áðü ôá åðüìåíá ôÝóóåñá êñéôÞñéá: · Óõìðôþìáôá · Óçìåßá äéáôáñá÷Þò ôçò áéóèçôéêüôçôáò (ðüíïõ, áöÞò, èåñìïý-øõ÷ñïý, äïíÞóåùí) êáé ðïóïôéêÞ åêôßìçóÞ ôïõò · Óçìåßá äéáôáñá÷Þò ôïõ êéíçôéêïý íåõñþíá (áíôáíáêëáóôéêÜ, áôñïößá ìéêñþí ìõþí ôùí Üêñùí) · ÇëåêôñïöõóéïëïãéêÞ ìåëÝôç ôçò ôá÷ýôçôáò áãùãéìüôçôáò, êéíçôéêÞò êáé áéóèçôéêÞò, óôá ðåñéöåñéêÜ íåýñá Óýìöùíá ìå ôçí ðáñáðÜíù ðñüôáóç ç äéÜãíùóç ìðïñåß íá ôåèåß êáé óå ìéêñÝò íïóïêïìåéáêÝò ìïíÜäåò êáé ÊÝíôñá Õãåßáò. Óå ìéá êáëÜ ó÷åäéáóìÝíç ìåëÝôç êáé ãéá Ýíá ðëçèõóìü 41.940 áôüìùí ìå óáê÷áñþäç äéáâÞôç ôýðïõ ÉÉ, ðïõ åëÝã÷èçêå ãéá Ýíá ÷ñüíï áðü 19 Ãåíéêïýò Éáôñïýò óôçí ðåñéï÷Þ Hoogeveen ôçò Ïëëáíäßáò, áíé÷íåýèçêå äéáâçôéêÞ íåõñïðÜèåéá óå ðïóïóôü 68%, ìåôáîý ôùí üøéìùí åðéðëïêþí ôïõ äéáâÞôç14. ¼ðùò åýóôï÷á ðáñáôçñåß óå áíÜëïãç åñåõíçôéêÞ åñãáóßá ç ïìÜäá ôïõ Óôáýñïõ ÐáððÜ áðü ôï Äéáâçôïëïãéêü Éáôñåßï óôï Ð.Ã.Í. Íßêáéáò-ÐåéñáéÜ15, ç Ýãêáéñç äéÜãíùóç ôçò äéáâç-

Ðßíáêáò 7. ÊëéíéêÝò ìïñöÝò íåõñïðÜèåéáò Åîåëéóóüìåíåò

ÁíáóôñÝøéìåò

· ÄéÜ÷õôç ðïëõíåõñïðÜèåéá ÓõììåôñéêÞ áéóèçôéêïêéíçôéêÞ íåõñïðÜèåéá ÍåõñïðÜèåéá ôïõ áõôüíïìïõ íåõñéêïý óõóôÞìáôïò

· ÌïíïíåõñïðÜèåéåò Åããýò êéíçôéêÞ (ìçñéáßá) ÑéæéôéêÜ óýíäñïìá (éäßùò êïñìïý) Ðáñáëýóåéò åãêåöáëéêþí óõæõãéþí · Ïîåßåò åðþäõíåò íåõñïðÜèåéåò 85


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

ôéêÞò íåõñïðÜèåéáò áðïôåëåß ðñüêëçóç êáé êáèÞêïí ãéá ôïí êëéíéêü éáôñü êáé éäéáßôåñá ãéá ôïí Ãåíéêü Éáôñü, äåäïìÝíïõ üôé ç êáôÜëëçëç èåñáðåõôéêÞ áíôéìåôþðéóç ðïõ óôï÷åýåé êýñéá óôçí åðßôåõîç êáëÞò ãëõ÷áéìéêÞò ñýèìéóçò, ïäçãåß óôç èåñáðåßá ôçò êáé ôåëéêÜ óôçí ðñüëçøç ôùí åëêþí óôá ðüäéá ôùí äéáâçôéêþí, ôçí áðïöõãÞ ôùí áêñùôçñéáóìþí êáé ôç ìåßùóç ôçò èíçóéìüôçôÜò ôïõò. Óôá ðëáßóéá áõôÜ ï Ãåíéêüò/ Ïéêïãåíåéáêüò Éáôñüò èá ðñÝðåé íá åßíáé éêáíüò íá ôçí áíé÷íåýåé ìå åýêïëåò êáé åý÷ñçóôåò ìåèüäïõò óôï åðßðåäï ôçò ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò. ÔÝôïéåò áðëÝò êáé áîéüðéóôåò äïêéìáóßåò åßíáé ç åîÝôáóç ôïõ ðüíïõ ìåôÜ áðü íõãìü Þ ôçò áöÞò ìå ìïíïúíßäéï 5,07, êáèþò êáé ôçò åõáéóèçóßáò óôï áßóèçìá êñáäáóìþí. Óå ìéá ðñüóöáôç ìåëÝôç 478 äéáâçôéêþí áóèåíþí åîåôÜóèçêå ç åõáéóèçóßá, ç åéäéêüôçôá êáé ç åðáíáëçðôüôçôá ôùí ðáñáðÜíù äïêéìáóéþí ìå óêïðü ôç ÷ñçóéìïðïßçóÞ ôïõò ùò äïêéìáóßåò äéáëïãÞò óôïí åôÞóéï ðñïóõìðùìáôéêü Ýëåã÷ï ôçò äéáâçôéêÞò íåõñïðÜèåéáò. Äéáðéóôþèçêå üôé ï Ýëåã÷ïò ôçò åõáéóèçóßáò ôùí êñáäáóìþí êáé ç äïêéìáóßá ôçò áöÞò Ý÷ïõí åéäéêüôçôá 92% êáé 97% áíôßóôïé÷á16. Ïé äïêéìáóßåò áõôÝò ðåñéëáìâÜíïíôáé êáé óôéò êáôåõèõíôÞñéåò ïäçãßåò ðïõ áöïñïýí óôçí áíß÷íåõóç êáé äéá÷åßñéóç ôçò äéáâçôéêÞò íåõñïðÜèåéáò óå åðßðåäï ðñùôïâÜèìéáò ðåñßèáëøçò. Óýìöùíá ìå ôéò êáôåõèõíôÞñéåò ïäçãßåò ï äéáâçôéêüò áóèåíÞò ðñÝðåé íá åîåôÜæåôáé åôçóßùò. Ç êëéíéêÞ åîÝôáóç áõôïý ðåñéëáìâÜíåé ôçí ðáñïõóßá Þ áðïõóßá óõìðôùìÜôùí, ôçí åðéóêüðçóç ôùí ðïäéþí, ôçí åêôßìçóç ôçò áéóèçôéêüôçôáò ìå ôéò äïêéìáóßåò ôçò áöÞò, ôïõ ðüíïõ êáé ôçò ðáëëáéóèçóßáò êáé ôçò êéíçôéêüôçôáò ìå ôï á÷ßëëåéï áíôáíáêëáóôéêü2. ¢ëëïé åñåõíçôÝò óôçí ðñïóðÜèåéÜ ôïõò íá óõìâÜëëïõí óôçí ðñþéìç äéÜãíùóç ôçò äéáâçôéêÞò íåõñïðÜèåéáò ðñïóðÜèçóáí íá áíôéêåéìåíïðïéÞóïõí ôá åõñÞìáôá ôçò êëéíéêÞò åîÝôáóçò ìå óýóôçìá âáèìïëüãçóçò, üðïõ åêôéìÜôáé êáé ï âáèìüò âáñýôçôáò ôçò íåõñïðÜèåéáò (8,17,18). Ìéá ôÝôïéá ðñïóðÜèåéá áðïôåëåß êáé ôï Michigan Neuropathy Program. Ôï ðñüãñáììá áõôü áîéïëüãçóçò ðñáãìáôïðïéåßôáé óå äõï óôÜäéá, ìå ôï Ìichigan Neuropathy Screening Instrument (ÌÍSÉ) êáé ôï Michigan Diabetic Neuropathy Score (MDNS). Ôï ðñþôï ðåñéëáìâÜíåé åðéóêüðçóç ôùí ðïäéþí, åêôßìçóç ôçò áíôßëçøçò äïíÞ86

ÖùôåéíÞ Ãåùñãïðïýëïõ êáé óõí.

óåùí óôï ìåãÜëï äÜêôõëï êáé Ýëåã÷ï ôùí á÷ßëëåéùí áíôáíáêëáóôéêþí. ÅÜí ôï ÌÍSÉ åßíáé ìåãáëýôåñï ôïõ 2, ôüôå ï áóèåíÞò õðïâÜëëåôáé óôï äåýôåñï óôÜäéï ðïõ ðåñéëáìâÜíåé ðñïóåêôéêÞ íåõñïëïãéêÞ åîÝôáóç ìå Ýëåã÷ï áéóèçôéêüôçôáò, áíôáíáêëáóôéêþí êáé ìõúêÞò éó÷ýïò, êáèþò êáé Ýëåã÷ï áãùãéìüôçôáò óå 2-3 íåýñá. ¼ëåò ïé åîåôÜóåéò âáèìïëïãïýíôáé ìå áíôéêåéìåíïðïéçìÝíç âáèìïëïãßá, ôï ôåëéêü äå score ðñïóäéïñßæåé êáé ôç âáñýôçôá ôçò íåõñïðÜèåéáò. Ðñüêåéôáé ãéá Ýíá áðëü óôáèìéóìÝíï ðñüãñáììá äéáëïãÞò êáé óôáäéïðïßçóçò, ìå åõáéóèçóßá 80%, åéäéêüôçôá 95% êáé åðáíáëçðôüôçôá 94%8,18. Óôç äéêÞ ìáò ìåëÝôç åöáñìüóôçêå ôï MNSI êáé äéáðéóôþèçêå üôé 27 (45%) áóèåíåßò åß÷áí áèñïéóôéêü score>2, åíþ áðü ôï åñùôçìáôïëüãéï óõìðôùìÜôùí ãéá 39 áóèåíåßò (65%) õðÞñ÷å õðüíïéá ðåñéöåñéêÞò áéóèçôéêïêéíçôéêÞò íåõñïðÜèåéáò. To score áõôü áðïäßäåé ôá ðáèïëïãéêÜ óçìåßá ôçò êëéíéêÞò åîÝôáóçò, üóï äå ìåãáëýôåñï åßíáé ôüóï âáñýôåñç åßíáé ç ðåñéöåñéêÞ íåõñïðÜèåéá. ¸ôóé, áðü ôá óôïé÷åßá ôçò ìåëÝôçò ìáò, åßíáé áîéïóçìåßùôï üôé ìüíï 3 Üôïìá (5%) åß÷áí MNSIscore>5, åíþ áðü ôç ìåëÝôç ôùí åñùôçìáôïëïãßùí óõìðôùìÜôùí ðñïÝêõðôå üôé ãéá 12 Üôïìá (20%) åôßèåôï ç õðüíïéá óïâáñÞò äéáâçôéêÞò íåõñïðÜèåéáò ìå ôéìÝò score 7-9. Áðü ôïõò 33 áóèåíåßò (55%) ìå MNSIscore<2, 19 Üôïìá (57,6%) åß÷áí óõìðôþìáôá ðïõ íá óõíçãïñïýí ãéá äéáâçôéêÞ íåõñïðÜèåéá (ðüíïò, ðáñáéóèçóßåò), åíþ áíôßèåôá, 6 áóèåíåßò (30%) áðü ôïõò 20 óõíïëéêÜ ÷ùñßò õðïêåéìåíéêÜ åíï÷ëÞìáôá åß÷áí MNSIscore>2, áí êáé üëùí ôùí score Þôáí <3.5. Áðü ôá ðáñáðÜíù åðéâåâáéþíåôáé, üôé ç õðïøßá ôçò äéáâçôéêÞò íåõñïðÜèåéáò ôßèåôáé ìå óõíäõáóìü íåõñïëïãéêþí óçìåßùí êáé êëéíéêþí óõìðôùìÜôùí. Ôá êýñéá ðáèïëïãéêÜ íåõñïëïãéêÜ óçìåßá óôï MNSI Þôáí ç ìåßùóç Þ êáôÜñãçóç ôùí á÷ßëëåéùí áíôáíáêëáóôéêþí êáé ôçò ðáëëáéóèçóßáò. 30 (50%) áóèåíåßò åß÷áí ìåßùóç Þ êáôÜñãçóç ôïõ á÷ßëëåéïõ áíôáíáêëáóôéêïý, 41 (68,3%) áóèåíåßò åß÷áí ðáèïëïãéêÞ áíôßëçøç áéóèçôéêüôçôáò, ìå ìåßùóç Þ êáôÜñãçóç ôçò áíôßëçøçò ôçò ðáëëáéóèçóßáò, åíþ áðü ôá 14 (23,3%) Üôïìá ðïõ äåí ðáñïõóßáóáí äéáôáñá÷Ýò á÷ßëëåéïõ áíôáíáêëáóôéêïý Þ ôçò áéóèçôéêüôçôáò, 6 áóèåíåßò åß÷áí õðïêåéìåíéêÜ åíï÷ëÞìáôá ðáñáéóèçóßáò (ìïýäéáóìá, ìõñìÞãêéáóìá). Áðü ôç ìåëÝôç ôùí óõó÷åôßóåùí ôïõ MNSI-


Ôüìïò 14, Ôåý÷ïò 2, 2002

ÖùôåéíÞ Ãåùñãïðïýëïõ êáé óõí.

score ìå ôéò äéÜöïñåò ðáñáìÝôñïõò ôïõ êëéíéêïý ðñïößë ôùí äéáâçôéêþí áóèåíþí (öýëï, ìÝóç çëéêßá, ìÝóç äéÜñêåéá óáê÷áñþäç äéáâÞôç, êÜðíéóìá, ìÝóç ôéìÞ ÂÌÉ êáé âáèìüò ãëõ÷áéìéêÞò ñýèìéóçò), ðñïêýðôåé üôé ïé Üíäñåò åìöáíßæïõí óõ÷íüôåñá ôùí ãõíáéêþí óõìðôùìáôéêÞ äéáâçôéêÞ íåõñïðÜèåéá (p<0,01). ¸÷åé áíáöåñèåß óôç âéâëéïãñáößá, üôé ïé ãõíáßêåò êáé ïé Ýöçâïé ðéèáíþò íá åìöáíßæïõí êÜðïéá ó÷åôéêÞ ðñïóôáóßá áð’ áõôÞ ôçí åðéðëïêÞ10. Ç ðôù÷Þ ãëõ÷áéìéêÞ ñýèìéóç (p<0,01), ç ìåãÜëç äéÜñêåéá ôïõ äéáâÞôç (p<0,01) êáé ôï êÜðíéóìá (MNSIscore=2,64 ïé êáðíßæïíôåò Ýíáíôé MNSIscore=2,21 ïé ìç êáðíßæïíôåò, p=NS) åßíáé ðáñÜãïíôåò êéíäýíïõ ãéá óõìðôùìáôéêÞ äéáâçôéêÞ íåõñïðÜèåéá. Ôá áðïôåëÝóìáôá áõôÜ åßíáé óýìöùíá ìå áíÜëïãåò ìåëÝôåò8,17-19. ¢ëëùóôå, ôüóï ç ìåëÝôç DCCT óå äéáâçôéêïýò ôýðïõ 1 üóï êáé ç UKPDS óå äéáâçôéêïýò ôýðïõ 2 åðéâåâáéþíïõí üôé ç ðñþéìç äéÜãíùóç êáé ç ïñèÞ ãëõ÷áéìéêÞ ñýèìéóç ìðïñïýí íá ðñïëÜâïõí ôçí Ýíáñîç êáé åîÝëéîç ôçò äéáâçôéêÞò íåõñïðÜèåéáò16,20. ÓõìðåñáóìáôéêÜ, ôï MNSI ìïéÜæåé íá ìðïñåß íá åßíáé Ýíá áðëü, åý÷ñçóôï êáé áîéüðéóôï åñãáëåßï ãéá ôçí åêôßìçóç ôïõ âáèìïý ôçò ðéèáíÞò ðåñéöåñéêÞò äéáâçôéêÞò íåõñïðÜèåéáò êáé íá ìðïñåß íá åöáñìïóôåß áðü ôïõò ãåíéêïýò éáôñïýò. ÅðåéäÞ âáóßæåôáé óå áðëÝò êëéíéêÝò äïêéìáóßåò ìðïñåß íá áðïôåëÝóåé Ýíá åñãáëåßï äéáëïãÞò êáé åëÝã÷ïõ äéáâçôéêþí áóèåíþí ãéá áíß÷íåõóç äéáâçôéêÞò íåõñïðÜèåéáò, ìå óêïðü ôïí åíôïðéóìü áôüìùí ìå áõîçìÝíï êßíäõíï áíÜðôõîçò üøéìùí íåõñïðáèçôéêþí åðéðëïêþí (åîåëêþóåéò, ëïéìþîåéò) êáé ôçí ðñþéìç èåñáðåõôéêÞ áíôéìåôþðéóçò ôïõò.

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Âéâëéïãñáößá 1. Â.Ã. ÊáñáìÜíïò. ÅôÞóéá ÌåôåêðáéäåõôéêÜ ÌáèÞìáôá ãéá ôïí Óáê÷áñþäç ÄéáâÞôç (23ï Ýôïò), óåë. 159, 2001. 2. I Illa. Diagnosis and management of diabetic peripheral neuropathy Eur. Neurol., 41(suppl 1):3-7, 1999. 3. J. Pirart. Diabetes mellitus and its degenerative complications; a prospective study of 4400 patients observed between 1947 and 1973 Diabetes Care, 1:168-188, 1978. 4. M.J. Young, A.J.M. Boulton, D.R.R Macleod Williams, PH Sonksen. A multicenter study of the

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sanio. A Multicenter Study on the prevelence of Diabetic Neuropathy in Italy. Italian Diabetic Neuropathy Committee. Diabetes Care, 20:836843, 1997. 18. M. Lunetta, R. Le Mori, G. Grasso, L. Sangiorgio. A simplified diagnostic test for ambulatory screening of peripheral diabetic neuropathy. Diabetes Res. Clin. Pract, 39:165-72, 1998.

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19. D.H. Akbar, S.A. Mira, T.H. Zawawi, H.M. Malibary. Subclinical diabetic neuropathy: a common complication in Saudi diabetics. Saudi Med. J, 21:433-437, 2000. 20. The DCCT Reasearch Group: The effect of intensive diabetes therapy on the development and progression of neuropathy. Ann. Intern, Med., 122: 561-568, 1995.

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BÑÁÂÅÕÈÅÉÓÁ ÅËÅÕÈÅÑÇ ÁÍÁÊÏÉÍÙÓÇ AWARDED FREESTANDING PAPER Primary Heatlh Care, Volume 14, Number 2, 92-98, 2002 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 14, Ôåý÷ïò 2, 92-98, 2002

Áíß÷íåõóç ôçò ðéèáíüôçôáò ðáéäéêÞò êáêïðïßçóçò êáé ðñïâëçìáôéêþí ðåñéðôþóåùí óôçí áíáôñïöÞ êáé öñïíôßäá ðáéäéþí Ýùò 14 åôþí ÅëÝíç Êñåììýäá1, Óð. Äåäåãêßêáò1, ÁñãõñÞ ÐÝôóá1, Ìé÷. Áíèñáêüðïõëïò3, ×ñõóÞ Ëõêïýñåóç1, Áöñïäßôç ÌÞôóéêá1, ¼ëãá ÐåñäéêÜêç2 êáé ÐçãÞ ÐåñäéêÜêç1

Ðåñßëçøç Ç ÷ñÞóç âßáò óôá ðáéäéÜ åßíáé Ýíá óõíå÷þò áõîáíüìåíï öáéíüìåíï ôçò óçìåñéíÞò êïéíùíßáò ðïõ üëï êáé ðåñéóóüôåñï âëÝðïõìå íá êáôáëáìâÜíåé äéáóôÜóåéò åðéäçìßáò. Óêïðüò áõôÞò ôçò åñãáóßáò åßíáé ç áíß÷íåõóç ôçò ðéèáíüôçôáò ðáéäéêÞò êáêïðïßçóçò êáé ðñïâëçìáôéêþí ðåñéðôþóåùí óôçí ðåñéï÷Þ åõèýíçò ôïõ ÊÝíôñïõ Õãåßáò ¢óôñïõò êáé êáôüðéí ç ðñïáãùãÞ ôçò äõíáôüôçôáò ðáñÝìâáóçò ôïõ ÊÝíôñïõ Õãåßáò óôçí ðñüëçøç ôçò êáêïðïßçóçò ôùí ðáéäéþí áðü ôïõò ãïíåßò. Ôï õëéêü áðïôÝëåóáí 261 ãïíåßò áíÞëéêùí ðáéäéþí óôïõò ïðïßïõò äüèçêå ðñïò óõìðëÞñùóç áíþíõìï åñùôçìáôïëüãéï êáé óôï ïðïßï áðÜíôçóáí. Ôá áðïôåëÝóìáôá êáôáäåéêíýïõí üôé ç óùìáôéêÞ êáêïðïßçóç ôùí ðáéäéþí äåí åßíáé óðÜíéï ïýôå áóõíÞèéóôï ãåãïíüò óôçí ôïðéêÞ êïéíùíßá ìáò. Ïé ìçôÝñåò ðåñéóóüôåñï êáé ïé Üíôñåò ëéãüôåñï, ÷ôõðïýí ôá ðáéäéÜ ôïõò ðïëëÝò öïñÝò êáé áíáßôéá üðùò ïé ßäéïé áíáöÝñïõí. Åíþ Ýíá ìéêñü ðïóïóôü ôùí ãïíÝùí ðéóôåýåé üôé ôï îýëï åßíáé áíáãêáßï ðáéäáãùãéêü ìÝóïí, ç óõíôñéðôéêÞ ðëåéïøçößá ÷ôõðÜ ìå ôá ÷Ýñéá Þ Üëëï áíôéêåßìåíï ôï ðáéäß ôïõ. ¸íá ìéêñü ðïóïóôü ãïíÝùí Ý÷åé áöÞóåé, ìåôÜ áðü îõëïäáñìü, áêüìá êáé óçìÜäéá óôï óþìá ôïõ ðáéäéïý, ÷ùñßò üìùò íá êáôáëÞîåé êáíÝíá ðáéäß óå Íïóïêïìåßï ãéá éáôñéêÞ ðåñßèáëøç. Ðïëëïß ãïíåßò ðïõ ÷ôõðïýí ôá ðáéäéÜ ôïõò, åß÷áí ðåñÜóåé äõóôõ÷éóìÝíç ðáéäéêÞ çëéêßá. ÓõìðåñáóìáôéêÜ ç Ýêèåóç ôùí ðáéäéþí óå êáèçìåñéíÞ âßá åßíáé ãåãïíüò ðïõ èá ðñÝðåé íá åëåã÷èåß êáé íá áíé÷íåõôåß óå åõñýôåñç êëßìáêá. Ôï éóôïñéêü êáêïðïßçóçò ôùí ßäéùí ôùí ãïíÝùí áõîÜíåé ôéò ðéèáíüôçôåò êáêïðïßçóçò ôùí ðáéäéþí ôïõò. Êáôáíïþíôáò ôç äéáäéêáóßá ðïõ ïäçãåß óôçí êáêïðïßçóç, ìðïñïýìå íá ðñïóäéïñßóïõìå ôïõò ðáñÜãïíôåò êáé ôéò óõíèÞêåò ðïõ áõîÜíïõí ôçí ðéèáíüôçôá êáêïðïßçóçò. Ç áðïôåëåóìáôéêÞ ðñüëçøç ìðïñåß íá áñ÷ßóåé ìüíï üôáí üëïé üóïé áó÷ïëïýíôáé ìå ôçí åõçìåñßá ôùí íÝùí ïéêïãåíåéþí, åßíáé Ýôïéìïé íá õéïèåôÞóïõí áõôÞ ôçí ïëéóôéêÞ ðñïóÝããéóç.

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ÊÝíôñï Õãåßáò ¢óôñïõò Êõíïõñßáò, 2ÊÝíôñï Õãåßáò ÍáõðÜêôïõ êáé 3ÐáéäïðíåõìïíïëïãéêÞ ÌïíÜäá ÐáéäéáôñéêÞò ÊëéíéêÞò Ðáíåðéóôçìßïõ Ðáôñþí.

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ÅéóáãùãÞ Ç âéâëéïãñáößá êáé ç éáôñéêÞ Ýñåõíá, ôüóï øõ÷éáôñéêÞ üóï êáé øõ÷ïëïãéêÞ, ãéá ðïëëÜ ÷ñüíéá äåí Ýäùóáí ôçí áðáéôïýìåíç Ýìöáóç óôï èÝìá ôçò êáêïðïßçóçò ôùí ðáéäéþí, óáí íá Þôáí Ýíá ôáìðïý ôï ãåãïíüò ôçò ýðáñîçò ôïõ ðñïâëÞìáôïò êáé ç ìåëÝôç ôùí áéôéþí êáé ôùí ðéèáíþí ëýóåùí. Ôï 1929 óôï ×É× ÓõíÝäñéï ÉáôñïäéêáóôéêÞò äýï ÃÜëëïé éáôñïß ðáñïõóßáóáí ìßá ìåëÝôç ðÜíù óôçí êáêïðïßçóç åéò âÜñïò ôùí ðáéäéþí áëëÜ ãéá ðïëëÜ ÷ñüíéá ç Üñíçóç ôïõ ðñïâëÞìáôïò ïäÞãçóå óôï íá âñåèïýí øåõäïáðáíôÞóåéò, ôüóï åðéóôçìïíéêÝò üóï êáé êïéíùíéêÝò, üðùò áõôÞ ôïõ éáôñïý R. Astley (1953) ï ïðïßïò áöïý åîÝôáóå áñêåôÜ ðáéäéÜ ðïõ äéáêïìßóèçêáí óôï íïóïêïìåßï ìå êáôÜãìáËÝîåéò êëåéäéÜ: ðáéäéêÞ êáêïðïßçóç, ãåíéêüò éáôñüò, ðñùôïâÜèìéá öñïíôßäá õãåßáò ÕðïâëÞèçêå: ðïâëÞèçêå: Ç åñãáóßá õðïâëÞèçêå ùò åëåýèåñç áíáêïßíùóç óôï 14ï ÐáíåëëÞíéï ÓõíÝäñéï ÃåíéêÞò ÉáôñéêÞò (ÊñÞôç, 8-12 ÌáÀïõ 2002) êáé âñáâåýèçêå áðü ôçí ÅðéôñïðÞ Êñßóçò. Äçìïóéåýåôáé ìå êïéíÞ áðüöáóç ôçò ÓõíôáêôéêÞò ÅðéôñïðÞò ôïõ ðåñéïäéêïý êáé ôçò ÏñãáíùôéêÞò ÅðéôñïðÞò ôïõ Óõíåäñßïõ. Õðåýèõíïò áëëçëïãñáößáò: ÐåñäéêÜêç ÐçãÞ, ÊÝíôñï Õãåßáò ¢óôñïõò, Ô.Ê. 22001, e-mail: vdaik@otenet.gr


ÅëÝíç Êñåììýäá êáé óõí.

Ôüìïò 14, Ôåý÷ïò 2, 2002

öõóéêïý, óôï íá åìðïäßóïõí Þ íá ðáñåêêëßíïõí ôçí ßäéá ôçí áíÜðôõîç3. Óôéò ðåñéóóüôåñåò ðåñéðôþóåéò ç êáêïðïßçóç åßíáé ôï áðïôÝëåóìá ðáèïëïãéêþí êáôáóôÜóåùí êáé óïâáñþí Summary Use of violence against children is an increasing phenomenon nowadays, which ïéêïãåíåéáêþí ðñïâëçìÜôùí. Áí áðü is reaching epidemic proportions. The aim of this survey is to screen the ôç ìéá ðëåõñÜ õðÜñ÷ïõí áôïìéêïß possibility of child abuse and difficult cases taking place in the area of the êïéíùíéêïß - ðïëéôéóìéêïß ðáñÜãïíôåò Astros health centre and the possibility of intervention and possible prevention ðïõ äéåõêïëýíïõí ôç âßá, åßíáé åðßóçò of these cases. The study population consisted of 261 parents of minors, ðñáãìáôéêüôçôá üôé êáé óôéò ïéêïãÝ(children under the age of 14/18 see above) to whom an anonymous questionnaire was administered. The results from this questionnaire showed that child íåéåò ðïõ èåùñïýíôáé öõóéïëïãéêÝò abuse is neither rare nor an unusual occurrence in the local society. Although õðÜñ÷åé ðÜíôá ìéá äõíáìéêÞ ðïõ ìðïthis abuse is mostly carried out by the mothers, some fathers have also done ñåß íá åðéöÝñåé êáêïðïßçóç. ÐïëëÝò so, but to a lesser degree. These parents reported that they hit their children, êáôáóôÜóåéò üìùò ìðïñïýí åõôõ÷þò many times without a reason, with the majority using either their hands or other íá äéïñèùèïýí äéüôé ôá ðáéäéÜ óôçí objects for the punishment. Some parents have left signs of their violence on the bodies of their children, but fortunately these children were taken to the áíáðôõîéáêÞ çëéêßá Ý÷ïõí ìåãÜëåò éêáHospital. There is also a small group of parents who believe that biting children íüôçôåò øõ÷éêÞò áðïêáôÜóôáóçò4. is a necessary part of their education. Many of the parents that bite their Óêïðüò ôçò åñãáóßáò ìáò Þôáí ç children, had a miserable childhood themselves. äéåñåýíçóç ôçò óõìðåñéöïñÜò ôùí ãïíÝùí ó÷åôéêÜ ìå ôçí Üóêçóç âßáò, ç áíß÷íåõóç ôõ÷üí êáêïðïéçìÝíùí ðáéAstros Health Center, Naupaktos Health Center, Pedopneumonal Unit of Pediatric Clinic of äéþí êáé ç ðáñïõóßá ðñïâëçìÜôùí ðïõ University of Patras. ðéèáíüí íá ðñïêýðôïõí áðü ìéá äéáôá óôï êñáíßï êáé/Þ óôá Üêñá, Ýöèáíå óôï óõ- ôáñáãìÝíç ó÷Ýóç ãïíÝùí - ðáéäéþí óôçí ðåñéï÷Þ ìðÝñáóìá ìéáò áðëÞò "ïóôéêÞò åõáéóèçóßáò" ôùí åõèýíçò ôïõ ÊÝíôñïõ Õãåßáò ¢óôñïõò. áóèåíþí ÷ùñßò íá äéåñùôçèåß ãéá ôéò ðñáãìáôéÌå ôïí üñï "óùìáôéêÞ êáêïðïßçóç" åííïïýìå êÝò áéôßåò ôçò öõóéêÞò êÜêùóçò. ôçí çèåëçìÝíç ÷ñçóéìïðïßçóç öõóéêÞò âßáò ôùí Ìüíï ìå ôçí áíáêÜëõøç ôùí áêôßíùí × ïé ãïíÝùí åíáíôßïí ôùí ðáéäéþí ôïõò. Ôï öáéíüìåíï ìåëÝôåò åìâÜèõíáí êáé ôï 1962 ïé Rezza, Silver- ôçò êáêïðïßçóçò êáé ðáñáìÝëçóçò ôïõ ðáéäéïý man êáé Kempe, áöïý ìåëÝôçóáí ðïëëÜ ðáéäéÜ åßíáé ãíùóôü äéáìÝóïõ ôùí áéþíùí êáé åêäçëþìå ôñáýìáôá óôï êñáíßï, êáôÜãìáôá óôá Üêñá, íåôáé ìå äéÜöïñåò ìïñöÝò. Åßíáé Üìåóá óõíäåäåáéìïññáãßåò êáé Üëëåò êáêþóåéò êáôÝëçîáí óôïí ìÝíï ìå ðïëéôéóìéêïýò êáé êïéíùíéêïýò ðáñÜãïïñéóìü ôïõ "óõíäñüìïõ ôïõ êáêïðïéçìÝíïõ ðáé- íôåò, åîáñôÜôáé äå êáé áðü ôá ðñüôõðá ôá ïðïßá äéïý"1. êÜèå êïéíùíßá åðéâÜëëåé óôïõò ãïíåßò ó÷åôéêÜ ìå Ïé ìåëÝôåò, áðü êáèáñÜ éáôñéêÞò ðëåõñÜò, ôïõò ôñüðïõò áíáôñïöÞò, ðåéèáñ÷ßáò êáé óõìðåóõãêåíôñþèçêáí áñ÷éêÜ óå óõãêåêñéìÝíåò ìïñ- ñéöïñÜò ôùí ðáéäéþí. Óôçí êïéíùíßá ðïõ æïýìå öÝò êáêïðïßçóçò, üðùò ç öõóéêÞ êáêïðïßçóç, äõóôõ÷þò êáèçìåñéíÜ äéáðéóôþíïõìå üôé ôá "èååíþ äåí õðÞñîáí ìåëÝôåò ó÷åôéêÝò ìå ôçí åãêá- ìÝëéÜ ôçò" ñáãßæïõí åíþ äéáñêþò ðåñéïñßæïíôáé ôÜëåéøç Þ ôçí Üóêçóç øõ÷ïëïãéêÞò âßáò, ìÝ÷ñéò ïé êÜèå åßäïõò çèéêÝò áíáóôïëÝò êáé ôá âáóéêÜ üôïõ áíáãíùñéóèåß ç ðáéäéêÞ çëéêßá, óáí öÜóç áíèñþðéíá äéêáéþìáôá êáôáðáôïýíôáé âÜíáõóá. áíÜðôõîçò óôç æùÞ ôïõ ðáéäéïý2. Äéáðéóôþíïõìå üôé ðïëëÝò öïñÝò óáí ìÝóï äéáÇ âïÞèåéá ôçò øõ÷áíÜëõóçò Þôáí óçìáíôéêÞ ðáéäáãþãçóçò ÷ñçóéìïðïéåßôáé ç âßá, øõ÷éêÞ êáé êáé Ýäùóå Ýìöáóç óôï ãåãïíüò üôé ç ðáéäéêÞ óùìáôéêÞ5. çëéêßá åßíáé ç ðåñßïäïò êáôÜ ôçí ïðïßá ìðáßíïõí ïé âÜóåéò ãéá ôçí êáôáóêåõÞ ìéáò õãéïýò Þ ìç ðñïóùðéêüôçôáò. Ç âïÞèåéá ôçò øõ÷áíÜëõóçò Ðëçèõóìüò ÌåëÝôçò - ÌÝèïäïò åðéêåíôñþèçêå óôçí ðñùôáñ÷éêÞ ó÷Ýóç ìçôÝñáò - ðáéäéïý, óôçí åðßäñáóç ôïõ áíèñþðéíïõ ðåñéÌåëåôÞèçêáí 261 åñùôçìáôïëüãéá ðïõ óõâÜëëïíôïò ðïõ óõíôåëåß óôçí áíÜðôõîç êáé óôçí ìðëçñþèçêáí áðü 194 ãõíáßêåò êáé 67 Üíäñåò, áîßá ôïõ ôñáýìáôïò, ôüóï øõ÷ïëïãéêïý üóï êáé çëéêßáò áðü 20 Ýùò 45 åôþí. Screening the possibility of child abuse and difficult cases in raising and caring for children up to 14 years of age Kremida Eleni, Dedegikas Sp., Petsa Argyri, Anthrakopoulos Michael, Likouresi Chrisi, Mitsika Afrodite, Perdikaki Olga, Perdikaki Pigi

93


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

ÊñéôÞñéï åðéëïãÞò ôùí åñùôçèÝíôùí Þôáí íá Ý÷ïõí ðáéäéÜ çëéêßáò ìÝ÷ñé 14 åôþí. Ç ìÝèïäïò ðïõ ÷ñçóéìïðïéÞèçêå ãéá ôç óõëëïãÞ ôùí ðëçñïöïñéþí Þôáí ç óõìðëÞñùóç åíüò áíþíõìïõ åñùôçìáôïëïãßïõ ðïõ Ýãéíå ìå ðñïóùðéêÞ óõíÝíôåõîç. Ôï åñùôçìáôïëüãéï ðåñéåëÜìâáíå 28 åñùôÞóåéò ðïõ áöïñïýóáí, ðÝñá áðü êÜðïéá ðñïóùðéêÜ äåäïìÝíá (öýëï, çëéêßá, äéáìïíÞ, ìïñöùôéêü åðßðåäï, ïéêïãåíåéáêÞ êáôÜóôáóç êáé áñéèìü ðáéäéþí), ôç óõíÞèç óõìðåñéöïñÜ ôùí ãïíÝùí óå ó÷Ýóç ìå ôç öõóéêÞ êáêïðïßçóç ôùí ðáéäéþí ôïõò (åÜí ôá Ý÷ïõí ÷ôõðÞóåé, ìå ðïéá óõ÷íüôçôá, åÜí ôá Ý÷ïõí ÷ôõðÞóåé ÷ùñßò ëüãï, åÜí Ý÷ïõí ìåßíåé óçìÜäéá êáé åÜí Ý÷ïõí ÷ñåéáóôåß éáôñéêÞ öñïíôßäá ìåôÜ áðü îýëï, åÜí ðéóôåýïõí üôé ôéìùñïýí äßêáéá ôá ðáéäéÜ, åÜí èåùñïýí ôï îýëï óáí áíáãêáßï ðáéäáãùãéêü ìÝóï, áí óõæçôïýí ìå ôá ðáéäéÜ ôá ðñïâëÞìáôÜ ôïõò, ôç óõìðåñéöïñÜ ôùí ðáéäéþí óå ó÷Ýóç ìå ôïõò ãïíåßò êáé ôá ðáéäéÜ ôçò çëéêßáò ôïõò). Áöïý óõãêåíôñþèçêáí ïé áðáíôÞóåéò, ÷ñçóéìïðïéÞèçêå ç ðåñéãñáöéêÞ óôáôéóôéêÞ ãéá ôçí ïñãÜíùóç êáé ðåñßëçøç ôùí äåäïìÝíùí ìÝóù ðéíÜêùí êáé ãñáöçìÜôùí ãéá ôïí ðñïóäéïñéóìü ôùí áíôéðñïóùðåõôéêþí ôéìþí. Ìå áõôÞ ôçí ôå÷íéêÞ åêôüò áðü ôçí ðáñï÷Þ ôïõ ðñïößë ôùí äåäïìÝíùí, Ýãéíå äõíáôÞ ç óýãêñéóç ôùí áðáíôÞóåùí áíäñþí êáé ãõíáéêþí, áëëÜ êáé ôùí åðéìÝñïõò åéäéêþí êáôçãïñéþí. Ãéá ôçí ðáñïõóßáóç ôçò Ýñåõíáò Ýãéíå ðñïóðÜèåéá óõìðýêíùóçò ìåãÜëùí óåéñþí äåäïìÝíùí óå åýêïëåò áöïìïéþóéìåò ìïñöÝò ðïõ åßíáé ïé ãñáöéêÝò ðáñáóôÜóåéò, þóôå íá ãßíïõí êáôáíïçôÝò ïé ðëçñïöïñßåò ðïõ óõãêåíôñþèçêáí.

ÁðïôåëÝóìáôá ¸íá ìåãÜëï ðïóïóôü ãõíáéêþí (90%) êáé áíäñþí (69%) ðáñáäÝ÷ïíôáé üôé ÷ôõðïýí ôá ðáéäéÜ ôïõò, ìå ôç äéáöïñÜ, üôé ïé ìåí Üíäñåò ôá ÷ôõðïýí ðéï óðÜíéá (57%) åíþ ïé ãõíáßêåò ðéï óõ÷íÜ (59%). ¼ðùò ðñïêýðôåé áðü ôçí Ýñåõíá ïé ðåñéóóüôåñåò ãõíáßêåò (87%) ÷ôõðïýí ôá ðáéäéÜ ôïõò ðéï óõ÷íÜ óôç âñåöïíçðéáêÞ çëéêßá (0-6 åôþí) êáé ëéãüôåñï (13%) óå ìåãáëýôåñç çëéêßá. Åíþ ðïëëïß Üíäñåò öáßíåôáé íá óõíå÷ßæïõí íá ÷ôõðïýí ôá ðáéäéÜ ôïõò êáé óå çëéêßá ìåãáëýôåñç ôùí 6 94

ÅëÝíç Êñåììýäá êáé óõí.

åôþí (35%). ¸íá óçìáíôéêü ðïóïóôü ôùí ãõíáéêþí (13%) êáé Ýíá ìéêñüôåñï ôùí áíäñþí (2%) ÷ôõðïýí ôá ðáéäéÜ ôïõò ÷ùñßò êáíÝíá ëüãï áëëÜ üëïé áíáöÝñïõí üôé ðïôÝ äåí ôá ÷ôýðçóáí óå ôÝôïéï âáèìü þóôå íá ÷ñåéáóôåß éáôñéêÞ öñïíôßäá. Ùóôüóï ìåñéêÝò ãõíáßêåò (14%) êáé Üíäñåò (4%) äçëþíïõí üôé êÜðïéá óôéãìÞ ðáñÝìåéíáí óçìÜäéá áðü ôï îýëï óôá ðáéäéÜ ôïõò. Ðéï ðïëý ïé Üíäñåò (85%) êáé ëéãüôåñï ïé ãõíáßêåò (76%) öáßíåôáé üôé ìðïñïýí íá åëÝãîïõí ôá íåýñá ôïõò. Åñ÷üìåíïé üìùò óå áíôßöáóç ìå åðüìåíç åñþôçóç ðïõ äçëþíïõí ïé Üíäñåò (72%) êáé ïé ãõíáßêåò (64%) üôé ìðïñïýí íá âëÜøïõí ôá ðáéäéÜ ôïõò ðÜíù óôá íåýñá ôïõò. Ï ôñüðïò ìå ôïí ïðïßï ÷ôõðïýí ôá ðáéäéÜ ôïõò ïé ãïíåßò åßíáé óõíÞèùò ìå ôá ÷Ýñéá (93%) êáé ëéãüôåñï ìå Üëëá áíôéêåßìåíá, üðùò åßíáé ç æþíç, ç âÝñãá êáé ç ìõãïóêïôþóôñá. Ïé ðéï ðïëëïß ãïíåßò (90%) áéóèÜíïíôáé Üó÷çìá ðïõ ÷ôõðïýí ôá ðáéäéÜ ôïõò êáé Ýíá ìéêñüôåñï ðïóïóôü (10%) äçëþíåé üôé äåí áéóèÜíåôáé ôßðïôá Þ áêüìç üôé áéóèÜíåôáé üìïñöá. Ïé ðåñéóóüôåñïé ãïíåßò (70%) óõæçôïýí óå êáèçìåñéíÞ âÜóç ìå ôá ðáéäéÜ ôïõò êáé áõôü ßóùò ïöåßëåôáé óôç öéëéêÞ ó÷Ýóç (45%) ðïõ äéáôçñïýí ìå áõôÜ. Óôç óõíÝ÷åéá ïé åñùôçèÝíôåò êáôçãïñéïðïéÞèçêáí ìå âÜóç ôï ìïñöùôéêü åðßðåäï (âáóéêÞ ìÝóç/áíþôåñç - áíþôáôç åêðáßäåõóç), ôïí áñéèìü ôùí ðáéäéþí (Ýíá - äýï - ôñßá Þ ðåñéóóüôåñá ðáéäéÜ) êáé ôÝëïò ôçí êáêïðïßçóç óôçí ðáéäéêÞ çëéêßá ôùí ßäéùí ôùí ãïíÝùí. ÅÜí ëÜâïõìå õðüøç ôï ìïñöùôéêü åðßðåäï ôùí ãïíÝùí ðáñáôçñïýìå üôé ôï ìåãáëýôåñï ðïóïóôü (90%) ôùí ãïíÝùí ðïõ ÷ôõðïýí ôá ðáéäéÜ ôïõò áíÞêïõí óôçí êáôçãïñßá ôçò ìÝóçò åêðáßäåõóçò, åíþ åêåßíïé ðïõ ôá ÷ôõðïýí óõ÷íÜ (2-3 öïñÝò ôçí åâäïìÜäá) Ý÷ïõí ìüíï âáóéêÞ åêðáßäåõóç (54%). Ôï ðïóïóôü ôùí ãïíÝùí ìå áíþôáôç åêðáßäåõóç ðïõ ÷ôõðïýí ôá ðáéäéÜ ôïõò åßíáé ìéêñüôåñï ìåí (65%) áëëÜ ç óõ÷íüôçôá ìå ôçí ïðïßá ôï êÜíïõí åßíáé ðïëý ìåãÜëç (ó÷åäüí êáèçìåñéíÜ 13%) óå ó÷Ýóç ìå ôéò Üëëåò êáôçãïñßåò (3%), (Ðßíáêáò 1). Âåëôéþíïíôáò ôï ìïñöùôéêü åðßðåäï ðáñáôçñåßôáé üôé áõîÜíåé ç áíôßëçøç ôçò äßêáéçò ôéìùñßáò ôïõ ðáéäéïý (80%), åíþ áíåîÜñôçôá áðü ôï ìïñöùôéêü åðßðåäï äéáôçñåßôáé õøçëÞ (63%) ç ðåðïßèçóç üôé ïé ãïíåßò èá ìðïñïýóáí íá êÜíïõí êáêü óôï ðáéäß ðÜíù óôá íåýñá ôïõò, (Ðßíáêáò 2).


Ôüìïò 14, Ôåý÷ïò 2, 2002

ÅëÝíç Êñåììýäá êáé óõí.

Ïé ãïíåßò åíäéáöÝñïíôáé êáé áíáæçôïýí ðçãÝò ðëçñïöüñçóçò ãéá ôç äéáðáéäáãþãçóç ôùí ðáéäéþí ôïõò áíÜëïãá ìå ôï ìïñöùôéêü ôïõò åðßðåäï: âáóéêÞ 56% - ìÝóç 81% - áíùôÜôç åêðáßäåõóç 96%, (Ðßíáêáò 2). ¼óï äå ãéá ôï ãíùìéêü "ôï îýëï âãÞêå áðü ôïí ðáñÜäåéóï" öáßíåôáé üôé ç áðïäï÷Þ ôïõ áðü ôïõò ãïíåßò Ý÷åé öèßíïõóá ðïñåßá óå ó÷Ýóç ìå ôï ìïñöùôéêü åðßðåäï (âáóéêÞ 40% - ìÝóç 38% êáé áíùôÜôç 26%), (Ðßíáêáò 2). Ïé ãïíåßò åêåßíïé ðïõ êáêïðïéÞèçêáí óôçí ðáéäéêÞ ôïõò çëéêßá, åßíáé åêåßíïé ðïõ êáêïðïéïýí ðåñéóóüôåñï ôá ðáéäéÜ ôïõò (75%) óå óýãêñéóç ìå åêåßíïõò ðïõ äåí êáêïðïéÞèçêáí (10%), (Ðßíáêáò 3), êáé åðßóçò åêåßíïé ïé ïðïßïé ðéóôåýïõí üôé ôéìùñïýí äßêáéá ôá ðáéäéÜ ôïõò (56%), (Ðßíáêáò 4). ËáìâÜíïíôáò õðüøç ôïí áñéèìü ôùí ðáéäéþí óôçí ïéêïãÝíåéá ðáñáôçñïýìå üôé ç ðëåéïøçößá ôùí ãïíÝùí ìå ðåñéóóüôåñá áðü äýï ðáéäéÜ åßíáé áõôïß ðïõ ôá ÷ôõðïýí (86%) êáé ìÜëéóôá óõ÷íÜ (52%), åíþ áõôïß ðïõ Ý÷ïõí Ýíá ìüíï ðáéäß äåí óõíçèßæïõí íá ôï ÷ôõðïýí, áëëÜ üôáí óõìâáßíåé ç óõ÷íüôçôá åßíáé ó÷åäüí êáèçìåñéíÞ

(7%). ¸íá óçìáíôéêü ðïóïóôü (44%) ðïëýôåêíùí ïéêïãåíåéþí ðéóôåýåé üôé äåí ôéìùñåß ôá ðáéäéÜ ðÜíôá äßêáéá. Ï áñéèìüò ôùí ðáéäéþí äåí åðçñåÜæåé ôçí áíáæÞôçóç ðçãþí ãéá ðëçñïöüñçóç ó÷åôéêÜ ìå ôç äéáðáéäáãþãçóç, áëëÜ ðáñáôçñåßôáé üôé áõôü óõìâáßíåé óå ìåãÜëï ðïóïóôü (75%). Áîéïóçìåßùôï äå åßíáé ôï ãåãïíüò üôé üóï áõîÜíåé ï áñéèìüò ôùí ðáéäéþí óôçí ïéêïãÝíåéá ôüóï ìåéþíåôáé ç áíôßëçøç üôé ôï "îýëï" åßíáé áíáãêáßï ðáéäáãùãéêü ìÝóïí, (Ðßíáêáò 5, 6).

Ðßíáêáò 3. Êáêïðïßçóç ãïíÝùí 80%

75%

êáêïðïéçìÝíïé ãïíåßò ìç êáêïðïéçìÝíïé ãïíåßò

70% 60% 50%

47%

38%

40% 30% 20%

10%

0%

÷ôõðïýí

÷ôõðïýí óðÜíéá

4%

5%

6%

10%

÷ôõðïýí óõ÷íÜ

÷ôõðïýí êáèçìåñéíÜ

Ðßíáêáò 1. Êáêïðïßçóç êáé óõ÷íüôçôá âáó éêÞ åêð áßäåõóç

90 80 70 60 50

Ðßíáêáò 4. Äßêáéç ôéìùñßá/äéáðáéäáãþãçóç

ìÝó ç/áíþ ôåñç åêð áßäåõó ç

90 82

ìç êá êï ð ï éç ì Ýí ï é ã ï í å ßò

áíþ ôáôç åêð áßäåõó ç 65 54

40 30 20 10 0

51 40

3

÷ôõð ïýí

58%

6%

ä ßêá éç ôéì ù ñ ßá

4 13

ó÷åäüí êÜèå

2-3/åâä.

56%

2-3/ìçíá

Ðßíáêáò 5. Êáêïðïßçóç óå ó÷Ýóç ìå ôïí áñéèìü ðáéäéþí 100%

Ðßíáêáò 2. Äßêáéç ôéìùñßá/äéáðáéäáãþãçóç âá ó éêÞ åêð á ßä åõó ç

80%

1 ðáéäß 86%

2 ðáéäéÜ > 2 ðáéäéÜ

86%

ìÝó ç/á íþ ôåñ ç åêð .

100

96

80

áíþ ôá ôç åêð á ßä åõó ç

60%

81

80 65 57

56 40

20%

38 26

20 ä ßê á éç ôéì ù ñ ßá

å í ç ì / ä éá ð á éä .

ã í ù ì éêü

0%

55%

50% 43%

40%

40

0

13%

ä éá ð á éä á ãþ ã ç ó ç

çìÝñá

60

4 2%

ð ëç ñ ï ö ü ñ ç ó ç

43 45 47

êá êï ð ï éç ì Ý í ï é ã ï í å ßò

24%

ã í ù ì éê ü

50% 47%

41%

30% 7%

÷ôõðïýí

ó÷åäüí êáè/íá

4%

2-3/åâä.

3%

2-3/ìÞíá

95


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

ÅëÝíç Êñåììýäá êáé óõí.

Ðßíáêáò 6. Äßêáéç ôéìùñßá/äéáðáéäáãþãçóç/ãíùìéêü äßêáéç ôéìùñßá / äéáðáéäáãþãçóç / ãíùìéêü 100% 80% 70%

1 ð áéäß 2ð áéäéÜ

90%

75% 67%

> 2 ðáéäéÜ

76% 68%

64% 56%

60% 50%

40%

40%

39%

36%

30% 20% 10% 0% äßêáéç ôéìùñßá

åíçìÝñùóç

ãíùìéêü

äéáð áéäáãþãçóç

ÓõæÞôçóç H ÷ñÞóç âßáò óôá ðáéäéÜ åßíáé Ýíá óõíå÷þò áõîáíüìåíï öáéíüìåíï ôçò óçìåñéíÞò êïéíùíßáò ðïõ üëï êáé ðåñéóóüôåñï âëÝðïõìå íá êáôáëáìâÜíåé äéáóôÜóåéò åðéäçìßáò. Ôï öáéíüìåíï ôçò êáêïðïßçóçò êáé ðáñáìÝëçóçò ôïõ ðáéäéïý åßíáé ãíùóôü äéáìÝóïõ ôùí áéþíùí êáé åêäçëþíåôáé ìå äéÜöïñåò ìïñöÝò. Åßíáé Üìåóá óõíäåäåìÝíï ìå ðïëéôéóìéêïýò êáé êïéíùíéêïýò ðáñÜãïíôåò, åîáñôÜôáé äå êáé áðü ôá ðñüôõðá ôá ïðïßá åðéâÜëëåé êÜèå êïéíùíßá óôïõò ãïíåßò ó÷åôéêÜ ìå ôïõò ôñüðïõò áíáôñïöÞò, ðåéèáñ÷ßáò êáé óõìðåñéöïñÜò ôùí ðáéäéþí6. Áîßæåé åðßóçò íá áíáöåñèåß ï ïñéóìüò ôïõ GIL ðïõ ïñßæåé ùò "óùìáôéêÞ êáêïðïßçóç ôùí ðáéäéþí" ôçí ìå ôç èÝëçóç ôùí ãïíÝùí ÷ñçóéìïðïßçóç óùìáôéêÞò âßáò åíáíôßïí ôùí ðáéäéþí ôïõò6,7. Åäþ åðßóçò óõìðåñéëáìâÜíåôáé ç êáêïðïßçóç ôùí ðáéäéþí áðü ôïõò ãïíåßò Þ Üëëï ðñüóùðï, ðïõ Ý÷åé áíáëÜâåé ôç öñïíôßäá ôïõ ðáéäéïý, ìå áðïôÝëåóìá ôçí ðñüêëçóç øõ÷éêïý ôñáýìáôïò êáé ôç ãåíéêüôåñç êáêïðïßçóÞ ôïõ6. ¼ðùò öáßíåôáé áðü ôïí ïñéóìü ðïõ äéáôõðþèçêå ðéï ðÜíù, ç êáêïðïßçóç åíüò ðáéäéïý ãßíåôáé áöïñìÞ ãéá íá äéáôáñá÷èåß óïâáñÜ ç ó÷Ýóç ôïõ ìå ôïõò ãïíåßò ôïõ. Óôçí êïéíùíßá ðïõ æïýìå äõóôõ÷þò êáèçìåñéíÜ äéáðéóôþíïõìå üôé ôá "èåìÝëéÜ" ôçò ñáãßæïõí åíþ äéáñêþò ðåñéïñßæïíôáé ïé êÜèå åßäïõò çèéêÝò áíáóôïëÝò êáé ôá âáóéêÜ áíèñþðéíá äéêáéþìáôá êáôáðáôïýíôáé âÜíáõóá. Ðïëëïß ãïíåßò ðïõ êáêïðïéïýí ôá ðáéäéÜ ôïõò ðáñÜëëçëá ôá áãáðïýí êáé ðñïóðáèïýí íá åíäéáöåñèïýí êáé íá ôá öñïíôßóïõí. Ìåñéêïß äõóôõ÷þò äåí ôá áãáðïýí, ïýôå ìðïñïýí íá åíäéáöåñèïýí ãé' áõôÜ, áëëÜ äýóêïëá ôï ðáñáäÝ÷ïíôáé. 96

Óôç óõìðåñéöïñÜ ôïõ áôüìïõ ðïõ êáêïðïéåß Ýíá ðáéäß âáóéêü ñüëï ðáßæåé ç ðåðïßèçóç, áóõíåßäçôá óôï ìåãáëýôåñï ìÝñïò ôçò, üôé ôá ðáéäéÜ ãßíïíôáé ãéá íá éêáíïðïéïýí ôéò áíÜãêåò ôùí ìåãÜëùí6,7. Ôá ðáéäéÜ ðïõ Ý÷ïõí êáêïðïéçèåß ìðïñåß íá åßíáé åðéññåðÞ óå áôõ÷Þìáôá, íá åìöáíßæïõí áõôïêáôáóôñïöéêÞ óõìðåñéöïñÜ Þ íá åäñáéþóïõí Ýíá ðñüôõðï óýìöùíá ìå ôï ïðïßï ðñïêáëïýí êÜðïéïí íá ôïõò êÜíåé êáêü êáé ðáßæïõí ôï ñüëï ôïõ èýìáôïò. Åðßóçò ôá ðáéäéÜ ôáõôßæïíôáé ìå ôïõò åðéèåôéêïýò ãïíåßò êáé áíôéãñÜöïõí ôï ðñüôõðï ôçò óõìðåñéöïñÜò ôïõò6. Áðü ôçí Ýñåõíá ìáò äåí áíáìÝíáìå íá äéáðéóôþóïõìå áêñáßåò êáôáóôÜóåéò êáêïðïßçóçò (Üãñéï îõëïäáñìü ìå ðñüêëçóç óùìáôéêÞò âëÜâçò ìÝ÷ñé ôç ìïñöÞ ôçò óêëçñÞò ôéìùñßáò). Ùóôüóï áðü ôá áðïôåëÝóìáôá ìáò ðñïêýðôïõí óôïé÷åßá ðïõ öáíåñþíïõí üôé ç Ýêèåóç ôùí ðáéäéþí óå êáèçìåñéíÞ âßá (óùìáôéêÞ, øõ÷éêÞ) åßíáé Ýíá ãåãïíüò ðïõ èá ðñÝðåé íá åëåã÷èåß êáé íá ìåëåôçèåß óå åõñýôåñç êëßìáêá. ¼ðùò åßíáé ãíùóôü áðü åñåõíçôéêÜ êáé êëéíéêÜ äåäïìÝíá ç êáêïðïßçóç óõìâáßíåé ðåñéóóüôåñï óôç âñåöïíçðéáêÞ çëéêßá, ãåãïíüò ðïõ äéáðéóôþíåôáé êáé áðü ôçí ðáñïýóá Ýñåõíá. Ç äéáôáñá÷Þ óôçí ðñþéìç ó÷Ýóç ãïíÝáðáéäéïý Þ ìçôÝñáò-ðáéäéïý (êáèþò üðùò åðßóçò öáßíåôáé ïé ìçôÝñåò åßíáé åêåßíåò ðïõ êáêïðïéïýí ðéï óõ÷íÜ ôá ðáéäéÜ ôïõò), Ý÷åé ùò áðïôÝëåóìá íá åðçñåÜæåôáé ç ïìáëÞ áíÜðôõîç ôïõ ðáéäéïý êáé ç öõóéïëïãéêÞ ùñßìáíóç ôçò ðñïóùðéêüôçôáò ôïõ óôï íïçôéêü, óõíáéóèçìáôéêü êáé êïéíùíéêü åðßðåäï10. Áí êáé åßíáé ìéêñü ôï ðïóïóôü ôùí ãõíáéêþí (14%) êáé ôùí áíäñþí (4%) ðïõ Ý÷ïõí äçëþóåé üôé êÜðïéá óôéãìÞ Ýìåéíáí óçìÜäéá áðü ôï îýëï óôá ðáéäéÜ ôïõò åßíáé ðéèáíü ôï øõ÷éêü ôñáýìá ðïõ Ý÷åé ðñïêëçèåß óôá ðáéäéÜ áõôÜ áðü ôï ðåñéâÜëëïí ôçò êáêïðïßçóçò íá Ý÷åé åðéðôþóåéò óôçí øõ÷éêÞ ôïõò õãåßá áëëÜ êáé óôï ìÝëëïí ôïõò ãåíéêüôåñá êáé íá óõíå÷éóôåß ï öáýëïò êýêëïò ìå ôá äéêÜ ôïõò ðéá ðáéäéÜ óå üëç ôïõò ôç æùÞ7,10. Ôï éóôïñéêü ôùí ßäéùí ôùí ãïíÝùí áõîÜíåé óõ÷íÜ ôéò ðéèáíüôçôåò êáêïðïßçóçò. Ðïëëïß áðü ôïõò ãïíåßò ðïõ êáêïðïéïýí ôá ðáéäéÜ ôïõò åß÷áí õðïóôåß êáé ïé ßäéïé êáêïðïßçóç Þ óõíáéóèçìáôéêÞ óôÝñçóç óôçí ðáéäéêÞ ôïõò çëéêßá, óõìðÝñáóìá ðïõ ôáõôßæåôáé ó÷åäüí áðüëõôá ìå ôá óôïé÷åßá ôçò Ýñåõíáò ðïõ äéåíåñãÞóáìå. Ç óùìáôéêÞ êáêïðïßçóç öáßíåôáé ðïëëÝò


Ôüìïò 14, Ôåý÷ïò 2, 2002

ÅëÝíç Êñåììýäá êáé óõí.

öïñÝò "íüìéìç" êáèþò ïé ðïëéôéóôéêïß êáíüíåò ãéá ôçí áíáôñïöÞ ôùí ðáéäéþí äåí áðïêëåßïõí ôç ÷ñÞóç ïñéóìÝíïõ âáèìïý óùìáôéêÞò âßáò áðü ôïõò ãïíåßò. Áíôßèåôá ôåßíåé ìÜëëïí íá åíèáññýíåôáé ìå äéáêñéôéêü Þ ìç ôñüðï ìÝóù äéáöüñùí ðáñïéìéþí, üðùò ð.÷. üðïõ äåí ðßðôåé ëüãïò ðßðôåé ñÜâäïò, ôï îýëï âãÞêå áðü ôïí ðáñÜäåéóï ê.á. ÐÜíù óå áõôü ôá óôïé÷åßá ðïõ ðñïêýðôïõí áðü ôçí Ýñåõíá, áíåîÜñôçôá áðü ôï ìïñöùôéêü åðßðåäï, ôïí áñéèìü ôùí ðáéäéþí êáé ôçí êáêïðïßçóç ôùí ßäéùí ôùí ãïíÝùí, öáíåñþíïõí üôé åßíáé áðáñáßôçôï íá èåùñÞóïõìå üôé Ý÷åé öôÜóåé ç óôéãìÞ íá áðÝ÷ïõìå áðü êÜèå ìïñöÞ öõóéêÞò âßáò ðñïò ôá ðáéäéÜ7.

ÓõìðåñÜóìáôá Ç êáêïðïßçóç ôïõ ðáéäéïý åßíáé Ýíá ðñüâëçìá ðïëýðëïêï êáé ìå ðïëëÝò äéáóôÜóåéò. Áñêåß êáé ìüíï íá åîåôÜóïõìå ôéò óõíèÞêåò êÜôù áðü ôéò ïðïßåò ðñáãìáôïðïéåßôáé, êáé íá äéáðéóôþóïõìå üôé ðñÝðåé íá áó÷ïëçèåß Ýíá åõñý öÜóìá åéäéêþí ãéá ôçí áíôéìåôþðéóÞ ôïõ. Äåí õðÜñ÷ïõí èýìáôá êáé èýôåò óå áõôÝò ôéò ðåñéðôþóåéò. ÂÝâáéá ôï ðáéäß åßíáé áõôü ðïõ ÷ñåéÜæåôáé ôçí ðñïóôáóßá êáé ôç âïÞèåéá áõôþí ðïõ áó÷ïëïýíôáé ìå ôçí êáêïðïßçóç. ÁëëÜ êáé ïé ãïíåßò óôéò ðåñéóóüôåñåò ðåñéðôþóåéò åßíáé èýìáôá ôùí åáõôþí ôïõò êáé ôùí ðåñéóôÜóåùí. Ãé' áõôü ÷ñåéÜæåôáé êáôáíüçóç êáé ü÷é áðüññéøç. Ãéá ôçí áíôéìåôþðéóç ôïõ ðñïâëÞìáôïò ðñÝðåé ôï âÜñïò íá äïèåß ðñïðÜíôùí óôçí ðñüëçøç8. Ç ðñùôïãåíÞò ðñüëçøç óôï÷åýåé óôç âåëôßùóç ôùí óõíèçêþí æùÞò ãéá üëï ôïí ðëçèõóìü, éäéáßôåñá äå ãéá ïéêïãÝíåéåò ìå ìéêñÜ ðáéäéÜ. Ç âåëôßùóç ôçò ãåíéêüôåñçò ðïéüôçôáò æùÞò üóïí áöïñÜ óå èÝìáôá áíáôñïöÞò ôùí ðáéäéþí åßíáé äõíáôüí íá åðéôåõ÷èåß ìÝóá áðü áíáâáèìéóìÝíá ðñïãñÜììáôá áãùãÞò õãåßáò êáé åêðáßäåõóçò ìå óôü÷ï ôçí ðáñï÷Þ ãíþóåùí, ôçí õéïèÝôçóç õãéþí óôÜóåùí êáé óõìðåñéöïñþí êáé ôçí ðñïáãùãÞ ôçò øõ÷éêÞò õãåßáò. Åðßóçò ç áíÜðôõîç ðñïãñáììÜôùí ìå óôü÷ï ôïí åíôïðéóìü ïéêïãåíåéþí êáé ðáéäéþí ðïõ áíÞêïõí óå ïìÜäåò "õøçëïý êéíäýíïõ", ìðïñåß íá ðñïëÜâåé óïâáñÜ ðñïâëÞìáôá äéáôáñá÷Þò äåóìïý ðïõ ìå åéäéêÞ ðáñÝìâáóç ìðïñïýí íá áðïêáôáóôáèïýí9,10.

ÓõíÞèùò ï Ýíáò Þ êáé ïé äýï ïé ãïíåßò åß÷áí ìéá óõíáéóèçìáôéêÜ óôåñçìÝíç ðáéäéêÞ çëéêßá Þ Ý÷ïõí ãéá ôï ðáéäß ìéá áñíçôéêÞ åéêüíá Þ åßíáé ðïëý áðáéôçôéêïß êáé ìå ðáñÜëïãåò ðñïóäïêßåò. Ãéá êÜèå ãïíÝá ðïõ êáêïðïéåß ôï ðáéäß ôïõ, õðÜñ÷åé Ýíáò óýæõãïò ðïõ åíèáññýíåé, áíÝ÷åôáé êáé êáëýðôåé ôçí êáêïðïßçóç. Ïé óýæõãïé Ý÷ïõí ôçí ôÜóç íá åßíáé ðïëý ðñïóôáôåõôéêïß ìåôáîý ôïõò. Óõ÷íÜ åßíáé êáé ïé äýï ðïëý óôåñçìÝíá Üôïìá, ðïõ ðñïóêïëëþíôáé ôï Ýíá óôï Üëëï, åîáéôßáò ôçò áíåðáñêïýò õðïóôÞñéîçò10. Ç ðéèáíüôçôá êáêïðïßçóçò ôïõ ðáéäéïý åßíáé ìåãáëýôåñç üôáí êáé ïé äýï ãïíåßò Ý÷ïõí óôåñçèåß ôç ìçôñéêÞ óôïñãÞ óôçí ðáéäéêÞ ôïõò çëéêßá. Ïé ãïíåßò áõôïß åðéæçôïýí õðÝñìåôñç áãÜðç, éêáíïðïßçóç êáé öñïíôßäá áêüìá êáé áðü ôá ðïëý ìéêñÜ ðáéäéÜ ôïõò. Ðïëëïß ãïíåßò ðïõ äÝñíïõí ôï ðáéäß ôïõò, äåí ôï âëÝðïõí üðùò åßíáé, áëëÜ üðùò Ýâëåðáí ôïõò ßäéïõò ïé ãïíåßò ôïõò óå ìéêñÞ çëéêßá - áñãïýò, êáêïýò, åãùéóôÝò, áíõðÜêïõïõò, áðåßèáñ÷ïõò. ×áñáêôçñéóôéêÜ ïé ãïíåßò åßíáé óõíÞèùò ìåëáã÷ïëéêïß êáé áðïìïíùìÝíïé êáé äåí Ý÷ïõí êáìéÜ õðïóôÞñéîç áðü êÜðïéïí ðïõ èá ìðïñïýóå íá âïçèÞóåé óå óôéãìÝò êñßóçò. ÏñéóìÝíá ðáéäéÜ ìðïñåß íá åßíáé ðéï êáêïðïéçìÝíá áðü Üëëá. Ìåôáîý áõôþí ðïëëÜ åßíáé åêåßíá ðïõ ðáñïõóéÜæïõí ðñüùñç áíÜðôõîç, ôá ðñüùñá, ôá õéïèåôçìÝíá êáé åêåßíá ðïõ Ý÷ïõí ìçôñéÜ Þ ðáôñéü10. Ç êáêïðïßçóç óáí åíÝñãåéá åßíáé ìéá ôåëéêÞ óõíçèéóìÝíç ðïñåßá. Ãéá ôçí ðñáãìÜôùóÞ ôçò ðñÝðåé íá õðÜñ÷ïõí (á) ôï äõíáìéêü ãéá êáêïðïßçóç, (â) ôá ÷áñáêôçñéóôéêÜ ôïõ óõãêåêñéìÝíïõ ðáéäéïý üðùò ôá âëÝðåé ï óõãêåêñéìÝíïò ãïíÝáò, êáé (ã) êÜðïéá êñßóç.

Âéâëéïãñáößá 1. http://www.vix.com/men/abuse/studies/childma.html 2. H. Agathonos, N. Stathakopoulou, H. Adam, S. Nakou. Child abuse and neglect in Greece. Sociomedical aspects. Child Ábuse and Íeglect 6: 307, 1982 3. J. Bowlby. Maternal care and mental health. WHO monograph series No 2, Gevena, 1951, WHO reprinted 1966, New York Schocken Books. 4. D.G. Gil. Violence against children. Én Dreitzel H.P. (ed) Children and Socialisation, New York, 97


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Macmillan, 1973, pp.114-32. 5. D.G. Gil. Viollence against children: Physical abuse in the United States Cambridge M.A., Harvard University Press, 1970. 6. M.A. Lynch. Child abuse: the critical path, Journal of Maternal and Child Health, 25-9, 1976. 7. R.K. OATES "Personality development after physical abuse". Archives of Disease in Children, 59, 2:147, 1984.

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8. B. Steele, C. Pollock. A phychiatric study of parents who abuse infants and small children" óôï Battered child åðéì. R. Helfer and C. Kembe, The University of Chicago Press, 1972. 9. M. Klaus, J. Kennel. Maternal - infant bonding. Saint Louis, 1976. 10. H.P. Martin et al. Behavioral observations of abused children. Dev. Ìedical. Child. Neurol., 19:373-387, 1984.


Ôüìïò 14, Ôåý÷ïò 2, 2002

É. ÌïíÝäáò êáé óõí.

ÅÐÁÉÍÅÈÅÉÓÁ ÅËÅÕÈÅÑÇ ÁÍÁÊÏÉÍÙÓÇ THE SECOND AWARDED FREESTANDING PAPER Primary Heatlh Care, Volume 14, Number 2, 95-97, 2002 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 14, Ôåý÷ïò 2, 94-97, 2002

Óõó÷åôéóìüò óùìáôïìåôñéêþí äåéêôþí êáé áñôçñéáêÞò ðßåóçò óå ìáèçôÝò áãñïôéêÞò ðåñéï÷Þò Íüôéáò ÊÝñêõñáò É. ÌïíÝäáò1, Á. Èáíïðïýëïõ2, Í. ÄçìçóéÜíïò1, È. ÄÜóéïò1, Ô. ÍôÜöçò1, Â. Óôáóéíüò1, Â. ÌÞëéá1, Í. Ðáôïýíçò1, E. ÑÝããéïõ

ÅéóáãùãÞ Ç ðá÷õóáñêßá áðïôåëåß óÞìåñá Ýíá ìåßæïí ðñüâëçìá äçìüóéáò õãåßáò, êõñßùò ãéá ôéò äõôéêïý ôýðïõ áíåðôõãìÝíåò êïéíùíßåò, êáé áöïñÜ óõíå÷þò ìåãáëýôåñï ðïóïóôü ôïõ ðáéäéêïý êáé åöçâéêïý ðëçèõóìïý, åíþ áõîÜíåé óôáäéáêÜ ìå ôçí ðÜñïäï ôçò çëéêßáò. Ðñüóöáôåò ìåëÝôåò äåß÷íïõí üôé ç áëëáãÞ ôïõ ôñüðïõ æùÞò ôá ôåëåõôáßá ÷ñüíéá êáé óôç ÷þñá ìáò Ý÷åé ðñïêáëÝóåé áýîçóç ôïõ åðéðïëáóìïý ôçò ðá÷õóáñêßáò, áëëÜ êáé êáñäéáããåéáêþí íïóçìÜôùí, ðïõ ôåßíïõí íá åîéóùèïýí ìå ôá åõñùðáúêÜ êáé áìåñéêáíéêÜ ðïóïóôÜ. Ç áñôçñéáêÞ õðÝñôáóç áðïôåëåß Ýíáí áðü ôïõò ìåßæïíåò ðáñÜãïíôåò êéíäýíïõ áíÜðôõîçò êáñäéáããåéáêÞò íüóïõ êáé ó÷åôßæåôáé óôåíÜ ìå ôçí ðá÷õóáñêßá, ìå áõîáíüìåíï åðéðïëáóìü ðïõ áðïäßäåôáé óôçí áëëáãÞ ôïõ ôñüðïõ æùÞò, ÷ùñþí üðùò ç ÷þñá ìáò. Ôï ãåãïíüò üôé ï ñüëïò ôçò áñôçñéáêÞò õðÝñôáóçò êáé êõñßùò ôçò åöçâéêÞò ðá÷õóáñêßáò åßíáé åîáéñåôéêÜ óçìáíôéêüò óôçí åìöÜíéóç êáñäéáããåéáêþí íïóçìÜôùí, ìáò þèçóå óôï íá ìåëåôÞóïõìå ôïí åðéðïëáóìü ôçò ðá÷õóáñêßáò êáé ôçò áñôçñéáêÞò õðÝñôáóçò óôï ìáèçôéêü ðëçèõóìü. ÅîåôÜóôçêáí ìáèçôÝò äåõôåñïâÜèìéáò åêðáßäåõóçò ìéáò áãñïôéêÞò ðåñéï÷Þò ðïõ äéáôçñåß áêü1

ÊÝíôñï Õãåßáò Ëåõêßììçò, 2ÓõíåñãÜôçò Äéáâçôïëïãéêïý ÊÝíôñïõ Éððïêñáôåßïõ Íïóïêïìåßïõ Áèçíþí

ìç åí ìÝñåé ÷áñáêôçñéóôéêÜ áãñïôéêÞò ðåñéï÷Þò, áëëÜ Ý÷åé õðïóôåß ôçí åðéññïÞ ôïõ äõôéêïý ôñüðïõ æùÞò êõñßùò óôïí ðáéäéêü êáé åöçâéêü ðëçèõóìü, êáé íá åêôéìÞóïõìå ôç ó÷Ýóç ðá÷õóáñêßáò êáé áñôçñéáêÞò õðÝñôáóçò.

Ðëçèõóìüò ìåëÝôçò - ÌÝèïäïò ÌåëåôÞèçêáí 224 ìáèçôÝò ãõìíáóßùí êáé ëõêåßùí ôùí ÄÞìùí Êïñéóóßùí êáé Ëåõêßììçò ôçò Íüôéáò ÊÝñêõñáò êáôÜ ôï ó÷ïëéêü Ýôïò 20012002. Óõìðëçñþèçêå äåëôßï êáôáãñáöÞò äçìïãñáöéêþí äåäïìÝíùí, áíèñùðïìåôñéêþí óôïé÷åßùí, óõóôïëéêÞò êáé äéáóôïëéêÞò áñôçñéáêÞò ðßåóçò êáé Üóêçóçò. Ï êáèïñéóìüò ôïõ äåßêôç ìÜæáò óþìáôïò (ÂÌÉ) ðñïóäéïñßóôçêå ìå ôïí ôýðï ôïõ Quetelet, áöïý êáôáãñÜöçêå ôï âÜñïò ôùí åîåôáæüìåíùí ìå ôá åóþñïõ÷á êáé ôï ýøïò ôïõò ìå æõãü SEGA êáé áíáóôçìüìåôñï ðñïóáñìïóìÝíï óôï æõãü. Ùò õðÝñâáñïé èåùñÞèçêáí ïé Ýöçâïé ìå ÂÌÉ >25kg/ m2, ùò ðá÷ýóáñêïé áõôïß ìå ÂÌÉ >30kg/m2, åíþ ùò åëëéðïâáñåßò áõôïß ìå ÂÌÉ <18kg/m2. ÊáôáãñÜöçêå åðßóçò ï äåßêôçò ðåñßìåôñïò ìÝóçò ÕðïâëÞèçêå: Ç åñãáóßá õðïâëÞèçêå ùò åëåýèåñç áíáêïßíùóç óôï 14ï ÐáíåëëÞíéï ÓõíÝäñéï ÃåíéêÞò ÉáôñéêÞò (ÊñÞôç, 8-12 ÌáÀïõ 2002) êáé Ýëáâå Ýðáéíï áðü ôçí ÅðéôñïðÞ Êñßóçò. Äçìïóéåýåôáé ìå êïéíÞ áðüöáóç ôçò ÓõíôáêôéêÞò ÅðéôñïðÞò ôïõ ðåñéïäéêïý êáé ôçò ÏñãáíùôéêÞò ÅðéôñïðÞò ôïõ Óõíåäñßïõ. Õðåýèõíïò áëëçëïãñáößáò: Ê. Óôåöáíïðïýëïõ, ÊÝíôñï Õãåßáò ÐåñÜìáôïò Ñåèýìíïõ, Ôçë.0834-0-23074, e-mail: serteda@otenet.gr 99


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

É. ÌïíÝäáò êáé óõí.

ðñïò ðåñßìåôñï éó÷ßùí (waist/hip ratio) ï ïðïßïò óõíäÝåôáé ìå áõîçìÝíç êáñäéáããåéáêÞ íïóçñüôçôá. Ç áñôçñéáêÞ ðßåóç ìåôñÞèçêå ìå õäñáñãõñéêü óöõãìïìáíüìåôñï óå êáèéóôÞ èÝóç. ¸ãéíáí ôñåéò ìåôñÞóåéò ìå ìåóïäéáóôÞìáôá äýï ëåðôþí êáé áöïý ðáñáëÞöèçêå ç ôéìÞ ôçò ðñþôçò ìÝôñçóçò êáôåãñÜöç ï ìÝóïò üñïò ôùí äýï åðïìÝíùí. Ç Üóêçóç åêôéìÞèçêå ìÝóù åñùôçìáôïëïãßïõ êáé êáôåãñÜöç ç ðñáãìáôïðïßçóç êÜðïéïõ áèëÞìáôïò áðü ôïí åîåôáæüìåíï êáé ïé þñåò Üèëçóçò áíÜ åâäïìÜäá. Ç óôáôéóôéêÞ åðåîåñãáóßá Ýãéíå ìå SPSS 10 êáé ç óôáôéóôéêÞ áíÜëõóç êáôÜ Pearson's x2 ìå ôç ìÝèïäï bivariate correlations.

22,7+3,8 kg/m2 êáé w/h ratio 0,85 åíþ ãéá ôá êïñßôóéá ÓÁÐ 114+13 mmHg, ÄÁÐ 73+9, ÂÌÉ 21,5+3,8 kg/m2 êáé w/h ratio 0,79. Ìå âÜóç ôï ÂÌÉ êáôáôÜ÷ôçêáí óå ôÝóóåñéò êáôçãïñßåò, üðùò öáßíåôáé óôïí ðßíáêá 1 óå åëëéðïâáñåßò ìå ÂÌÉ<18 31 ìáèçôÝò (9 áãüñéá êáé 22 êïñßôóéá), öõóéïëïãéêïß ìå 18<ÂÌÉ<25 148, õðÝñâáñïé ìå 25<ÂÌÉ<30 37 (23 áãüñéá êáé 14 êïñßôóéá) êáé ðá÷ýóáñêá ìå ÂÌÉ>30 8 (5 áãüñéá êáé 3 êïñßôóéá. Ïé åîåôáæüìåíïé êáôåôÜãçóáí óå äýï êáôçãïñßåò áíÜëïãá ìå ôï ëüãï waist/hip ratio. Ôá ìåí áãüñéá ìå w/h <1 êáé w/h>1 ôá äå êïñßôóéá ìå w/h<0,85 êáé w/h>0,85 üðùò öáßíåôáé óôïí ðßíáêá 2. ¼ðùò öáßíåôáé óôïí ðßíáêá 3, áðü ôï óýíïëï ôùí ìáèçôþí ôéìÝò áñôçñéáêÞò ðßåóçò ðïõ ÷áñáêôçñßæïíôáé õøçëÝò åß÷áí: 4 ÓÁÐ >140 mmHg, 3 ÄÁÐ >90 mmHg, åíþ 1 åß÷å ÓÁÐ >140 mmHg êáé ÄÁÐ >90 mmHg. Áðü ôç óôáôéóôéêÞ áíÜëõóç äéáðéóôþèçêå üôé ãéá ôï óýíïëï ôùí åîåôáóèÝíôùí ìáèçôþí õðÜñ÷åé óôáôéóôéêÜ óçìáíôéêÞ óõó÷Ýôéóç ôïõ ÂÌÉ ìå ôç ÓÁÐ r=0,296 êáé p<0,01, ôç ÄÁÐ r=0,258 êáé p<0,01 êáé ôï ëüãï waist/hip ratio r=0,216 êáé p<0,01. Áíáëýïíôáò ôéò ßäéåò ðáñáìÝôñïõò ãéá êÜèå öýëï îå÷ùñéóôÜ äéáðéóôþíïõìå üôé ãéá ôá áãüñéá ôï ÂÌÉ óõó÷åôßæåôáé óôáôéóôéêÜ óçìáíôéêÜ ìå ôç ÓÁÐ r=0,270 êáé p<0,01, ôç ÄÁÐ r=0,201 êáé p<0,05 êáé ôï ëüãï waist/hip ratio r=0,258 êáé p<0,01. Äåí õðÜñ÷åé óõó÷Ýôéóç ìå ôçí çëéêßá ç ïðïßá üìùò ó÷åôßæåôáé óôáôéóôéêÜ óçìáíôéêÜ ìå ôç ÓÁÐ r=0.264 êáé p<0,01 êáé ôç ÄÁÐ

ÁðïôåëÝóìáôá ÅîåôÜóôçêáí 224 ìáèçôÝò, 108 áãüñéá (48,2%) êáé 116 êïñßôóéá (51,8%). Ç ìÝóç çëéêßá ôïõ äåßãìáôïò Þôáí 15,13+1,90 Ýôç, ÷ùñßò íá õðÜñ÷åé óôáôéóôéêÜ óçìáíôéêÞ äéáöïñÜ ìåôáîý ôùí äýï öýëùí ìå ôéìÝò áíôßóôïé÷á ãéá ôá áãüñéá êáé ôá êïñßôóéá 15,4+1,9 êáé 14,9+1,9 Ýôç. Ç ìÝóç óõóôïëéêÞ áñôçñéáêÞ ðßåóç (ÓÁÐ) Þôáí 116+13 mmHg, ç ìÝóç äéáóôïëéêÞ áñôçñéáêÞ ðßåóç (ÄÁÐ) Þôáí 73+9 mmHg, ï ìÝóïò äåßêôçò ìÜæáò óþìáôïò (ÂÌÉ) Þôáí 21,5+3,8 kg/ m2 êáé ç ðåñßìåôñïò ìÝóçò ðñïò ðåñßìåôñï éó÷ßùí (w/h ratio) Þôáí 0,82. Ïé áíôßóôïé÷åò ôéìÝò ãéá ôá áãüñéá Þôáí ÓÁÐ 118+13 mmHg, ÄÁÐ 73+10 mmHg, ÂÌÉ Ðßíáêáò 1. ÂÌÉ ÂÌÉ <18 31 (13,8%) 9 áãüñ. - 22 êïñ.

18<ÂÌÉ<25 148 (66,0%) 71 áãïñ. - 77 êïñ.

25<ÂÌÉ<30 37 (16,5%) 23 áãüñ.- 14 êïñ.

ÂÌÉ>30 8 (3,6%) 5 áãïñ. - 3 êïñ.

Ðßíáêáò 2. Waist/hip ratio Áãüñéá w/h <1

Êïñßôóéá w/h<0,85

Áãüñéá w/h >1

Êïñßôóéá w/h>0,85

105

10

3

3 13

Ðßíáêáò 3. ÁñôçñéáêÞ ðßåóç ÓÁÐ>140

ÄÁÐ>90

ÓÁÐ>140 êáé ÄÁÐ>90

ÓÁÐ<140 êáé ÄÁÐ<90

4

3

1

216

100


Ôüìïò 14, Ôåý÷ïò 2, 2002

É. ÌïíÝäáò êáé óõí.

r=0.378 êáé p<0,01. Ãéá ôá êïñßôóéá ôï ÂÌÉ óõó÷åôßæåôáé óôáôéóôéêÜ óçìáíôéêÜ ìå ôç ÓÁÐ r=0.286 êáé p<0,01, ôç ÄÁÐ r=0.324 êáé p<0,01 áëëÜ ü÷é ôï ëüãï waist/hip ratio. Ç çëéêßá óôá êïñßôóéá åðßóçò äåí ó÷åôßæåôáé óôáôéóôéêÜ óçìáíôéêÜ ìå êáíÝíáí áðü ôïõò ðáñáðÜíù ðáñÜãïíôåò. Ç Üóêçóç óõó÷åôßæåôáé óôáôéóôéêÜ óçìáíôéêÜ ìå ôç ÓÁÐ r=0.146 êáé p<0.05 êáé ôç ÄÁÐ r=0.159 êáé p<0,05, åíþ äå óõó÷åôßæåôáé ìå ôï ÂÌÉ. Ôá áãüñéá áóêïýíôáé ðåñéóóüôåñï áðü ôá êïñßôóéá óå ðïóïóôü 82,4% vs 49,1%, r=0.349 êáé p<0,01.

ÓõæÞôçóç Áðü ôá áðïôåëÝóìáôá ôçò áíÜëõóçò ôùí äåäïìÝíùí ðñïêýðôåé üôé ôï ìÝóï ÂÌÉ ôùí åîåôáóèÝíôùí ìáèçôþí âñßóêåôáé åíôüò ôùí öõóéïëïãéêþí ïñßùí (21,5+3,8kg/m2) êáé áðÝ÷åé áñêåôÜ áðü ôéìÝò ðïõ ÷áñáêôçñßæïíôáé óáí õðåñâïëéêü âÜñïò. Ôï 3,6% (8) ôùí ìáèçôþí åßíáé ðá÷ýóáñêïé, ÂÌÉ>30, êáé ôï 16,5% (37) õðÝñâáñïé, 25 <ÂÌÉ<30, ðïóïóôÜ ÷áìçëüôåñá áðü áõôÜ Üëëùí åðéäçìéïëïãéêþí ìåëåôþí. Ôï 13,8% (31) åßíáé åëëéðïâáñåßò, ÂÌÉ<18. Óôçí õðïïìÜäá ôùí áãïñéþí ôï ÂÌÉ åßíáé 22,7+3,8kg/m 2 åíþ ó' áõôÞ ôùí êïñéôóéþí 21,5+3,8kg/m2, óôáôéóôéêÜ ìç óçìáíôéêÞ äéáöïñÜ. Áîéïóçìåßùôï åßíáé ôï ãåãïíüò üôé ï ëüãïò áãïñéþí/êïñéôóéþí ãéá ôéò ôñåéò êáôçãïñßåò ðá÷ýóáñêïé, õðÝñâáñïé, åëëéðïâáñåßò åßíáé áíôßóôïé÷á 1,67, 1,64 êáé 0,41, ðñÜãìá ðïõ óçìáßíåé üôé ç ðñïò ôá ðÜíù åêôñïðÞ ôïõ ÂÌÉ åßíáé óõ÷íüôåñç óôá áãüñéá, åíþ ç ðñïò ôá êÜôù óôá êïñßôóéá. Ï ëüãïò waist/hip ratio óôá áãüñéá åßíáé 0,85 êáé óôá êïñßôóéá 0,79, ôéìÝò èåìéôÝò ðïõ äå èåùñïýíôáé ðáñÜãïíôåò êéíäýíïõ. Ôï 7,14% (16) ôùí ìáèçôþí ÷áñáêôçñßæåôáé áðü ôéìÝò åêôüò ôùí öõóéïëïãéêþí ïñßùí, w/h ratio >1 ãéá ôá áãüñéá êáé >0,85 ãéá ôá êïñßôóéá, åõñÞìáôá ðïõ óõìðßðôïõí ìå áõôÜ Üëëùí ìåëåôþí. Ïé ôéìÝò ÓÁÐ êáé ÄÁÐ âñßóêïíôáé åíôüò öõóéïëïãéêþí ïñßùí áíôßóôïé÷á 116+13 mmHg êáé 73+9 mmHg êáé áðÝ÷ïõí áñêåôÜ áðü ôá áíþôåñá öõóéïëïãéêÜ üñéá. Ãéá ôéò äõï õðïïìÜäåò, áãïñéþí êáé êïñéôóéþí, ïé ôéìÝò ÓÁÐ êáé

ÄÁÐ åßíáé áíôßóôïé÷á 118+13 mmHg, 73+10 mmHg êáé 114+13 mmHg, 73+9 mmHg, óôáôéóôéêÜ ìç óçìáíôéêÞ äéáöïñÜ. Ôï 1,8% (4) ÷áñáêôçñßæåôáé áðü õøçëÝò ôéìÝò ÓÁÐ>140 mmHg, ôï 1,3% (3) áðü ôéìÝò ÄÁÐ>90 mmHg, åíþ Ýíáò ìüíï ìáèçôÞò áðü õøçëÝò ôéìÝò ÓÁÐ áëëÜ êáé ÄÁÐ. Ç Üóêçóç, íïïýìåíç óáí ðñáãìáôïðïßçóç êÜðïéïõ áèëÞìáôïò ôïõëÜ÷éóôïí ìéá çìÝñá ôçí åâäïìÜäá, åßíáé ÷áñáêôçñéóôéêü ôçò õðïïìÜäáò ôùí áãïñéþí óå ðïóïóôü 82,4%, åíþ ôá êïñßôóéá õðïëåßðïíôáé óôáôéóôéêÜ óçìáíôéêÜ ìå ðïóïóôü 49,1% êáé p<0,01. Áðü ôç óôáôéóôéêÞ áíÜëõóç äéáðéóôþíåôáé óôáôéóôéêÜ óçìáíôéêÞ óõó÷Ýôéóç (p<0,01) ôïõ ÂÌÉ ôüóï ìå ôç ÓÁÐ (r=0.296) üóï êáé ôç ÄÁÐ (r=0.258) ãéá ôï óýíïëï ôùí ìáèçôþí, áëëÜ êáé ãéá êÜèå õðïïìÜäá åîåôáæüìåíç îå÷ùñéóôÜ. Ç çëéêßá åðßóçò óõó÷åôßæåôáé óôáôéóôéêÜ óçìáíôéêÜ (p<0,01) ôüóï ìå ôç ÓÁÐ (r=0.264) üóï êáé ôç ÄÁÐ (r=0.378). ¸íáò Üëëïò ðáñÜãïíôáò ðïõ óõó÷åôßæåôáé åðßóçò óôáôéóôéêÜ óçìáíôéêÜ (p<0,05) ôüóï ìå ôç ÓÁÐ (r=0.146) üóï êáé ôç ÄÁÐ (r=0.159) åßíáé ç Üóêçóç. Áðü ôçí Ýñåõíá ðïõ ðñáãìáôïðïéÞóáìå óôïõò ìáèçôÝò ôçò äåõôåñïâÜèìéáò åêðáßäåõóçò ôçò íüôéáò ÊÝñêõñáò äéáðéóôþóáìå ó÷åôéêÜ ÷áìçëü åðéðïëáóìü õðåñâÜëëïíôïò âÜñïõò êáé ðá÷õóáñêßáò, ãåãïíüò ðïõ ðéèáíþò íá ïöåßëåôáé óôç äéáôÞñçóç ôñüðïõ æùÞò ìå ÷áñáêôçñéóôéêÜ áãñïôéêÞò ðåñéï÷Þò. Ç çëéêßá, ôï ÂÌÉ êáé ç Üóêçóç óõó÷åôßæïíôáé óôáôéóôéêÜ óçìáíôéêÜ, óáí áíåîÜñôçôïé ðáñÜãïíôåò, ìå ôç óõóôïëéêÞ áëëÜ êáé ôç äéáóôïëéêÞ áñôçñéáêÞ ðßåóç. Ìå äåäïìÝíï üôé ïé äõï ôåëåõôáßïé åßíáé ôñïðïðïéÞóéìïé ðáñÜãïíôåò, åßíáé óçìáíôéêü íá ðñïãñáììáôéóôïýí ðñïãñÜììáôá ðáñÝìâáóçò ãéá ôçí ôñïðïðïßçóÞ ôïõò, ìå óôü÷ï ôçí åðßôåõîç ôéìþí áñôçñéáêÞò ðßåóçò åíôüò ôùí åðéèõìçôþí ïñßùí.

Âéâëéïãñáößá: 1. A. Trichopoulou, P. Efstasiadis. Changes in nutrition patterns and health indicators at the population level in Greece. Am. J. Clin. Nutr., 49:1042-1047, 1989. 2. Å. ÃåùñãéÜäçò, Ë. ÐáðáíäñÝïõ, ×. Ìáíôæþñïò, 101


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4.

5.

6.

102

Ê. ÁëéöÝñçò, Ê. Êùíóôáíôßíïõ. Åðßäñáóç êïéíùíéêïïéêïíïìéêþí ðáñáãüíôùí óôï âÜñïò êáé óôçí ðá÷õóáñêßá ôùí íÝùí ÅëëÞíùí. ÉáôñéêÞ, 63:595601, 1993. G. Mamalakis, A. Kafatos. Prevalence of obesity in Greece. Inter. J. Obesity, 20:480-492, 1996. J.C. Seidell, K.M. Flegal. Assessing obesity: classification and epidemiology. Br. Med. Bull., 53:238-252, 1997. Obesity: Preventing and managing the global epidemic. Report of WHO Consultation on Obesity, 1997. 1999 WHO-International Society of Hypertension Guidelines for the management of hyper-

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tension, J. Hypert., 17:151-183, 1999. 7. M.M. Brueren, H. Petri, C. van Weel, J.W. van Ree. how many measurements are necessary in diagnosing mild to moderate hypertension. Fam. Pract., 14:130-135, 1997. 8. Â. Ðáðáãåùñãßïõ, Âáñ. Ðáðáãåùñãßïõ, Áñ. Ôóá÷ïõñßäçò, Ê. Ãñßâïõ. Åðéðïëáóìüò õðåñâÜëëïíôïò âÜñïõò (Þ êáé ðá÷õóáñêßáò), äéáôñïöéêÝò óõíÞèåéåò êáé äéáôñïöéêÞ áãùãÞ óå ìáèçôéêïýò ðëçèõóìïýò ôïõ íïìïý ×áëêéäéêÞò. Ðñùô. Öñ. Õãåßáò, 13:153-160, 2001. 9. ÓõóôÜóåéò ãéá ôç ÄéÜãíùóç êáé ôç Èåñáðåßá ôçò ÁñôçñéáêÞò ÕðÝñôáóçò áðü ôïí Êëéíéêü Ãéáôñü. Åíçìåñùôéêü öõëëÜäéï Õðïõñãåßïõ Õãåßáò êáé Ðñüíïéáò. ÁèÞíá ÄåêÝìâñéïò 2001.


Ôüìïò 14, Ôåý÷ïò 2, 2002

Ã. Ôóßñïò êáé óõí.

ÅÐÁÉÍÅÈÅÉÓÁ ÅËÅÕÈÅÑÇ ÁÍÁÊÏÉÍÙÓÇ THE SECOND AWARDED FREESTANDING PAPER Primary Heatlh Care, Volume 14, Number 2, 98-106, 2002 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 14, Ôåý÷ïò 2, 98-106, 2002

Ðñüëçøç, áíôéìåôþðéóç êáé óõìðåñéöïñÜ ôùí éáôñþí óå èÝìáôá õãåßáò ôïõò Ã. Ôóßñïò1, Ä. Êáëïãåñüðïõëïò1, Ðáí. ÂïÀëá2, ×ñ. Âüóóïõ3, Ã. ÊáñäÜôïò4, Ã. ÌïõæÜêçò5, Í. ÌáãêëÜñáò6, Ð. Áèáíáóüðïõëïò7, Áéê. Ãáôïðïýëïõ8

Ðåñßëçøç Óêïðüò: Ç ìåëÝôç ðñüëçøçò, óõìðåñéöïñÜò êáé áíôéìåôþðéóçò ðñïâëçìÜôùí õãåßáò éáôñþí, êáèþò êáé ï âáèìüò åìðéóôïóýíçò-óõììüñöùóÞò ôïõò óôéò óõìâïõëÝò êáé ïäçãßåò, ðáñå÷üìåíåò áðü åéäéêïýò-ùò ðñïò ôçí áíôßóôïé÷ç íüóï-óõíáäÝëöïõò. Õëéêü êáé ÌÝèïäïò: Óõìðëçñþèçêå áíþíõìï åñùôçìáôïëüãéï áðü 208 éáôñïýò äéáöüñùí åéäéêïôÞôùí, åñãáæüìåíïõò óå äýï íïóïêïìåßá ôçò ÁèÞíáò (Íáõôéêü Íïóïêïìåßï, Ï Åõáããåëéóìüò) êáé Ýíá ðåñéöåñåéáêü ðáíåðéóôçìéáêü (Ð.Ð.Ã.Í. Ðáôñþí). ¸ãéíå áîéïëüãçóç êáé ïìáäïðïßçóç ôùí áðáíôÞóåùí ãéá óõãêñßóåéò, êáôÜ öýëï êáé ôïìÝá åéäéêüôçôáò. ÁðïôåëÝóìáôá: Áðü 208 éáôñïýò (46% ðáèïëüãïé, 28% ÷åéñïõñãïß, 26% åñãáóôçñéáêïß), ìåëåôÞèçêáí 108 (51%) Üíäñåò êáé 100 (49%) ãõíáßêåò ìÝóçò çëéêßáò 32,2 êáé 31,3 åôþí áíôßóôïé÷á. Ðïóïóôü 64% áõôþí åìâïëéÜóèçêáí ìå ôá áðáñáßôçôá ãéá ôçí çëéêßá ôïõò åìâüëéá, áíåìâïëßáóôïé-9%, 27% äçëþíïõí Üãíïéá (êõñßùò ÷åéñïõñãïß-39%). 71% åðß óõíüëïõ ÷ñçóéìïðïéåß ìÝóá ðñïóôáóßáò, üôáí áðáéôåßôáé óôéò þñåò åñãáóßáò (÷åéñïõñãïß 77%, åñãáóôçñéáêïß 78%, ðáèïëüãïé 57%), åíþ óõ÷íÜ äçëþíïõí ÷ñÞóç 26%. ¸ãêáéñá áíôéìåôùðßæïõí êáôáóôÜóåéò áóèÝíåéÜò ôïõò 50% (ãõí. 62%, Üíäñ. 39%), áíáëüãùò êñßóåùò 39%, ìç-åãêáßñùò 11%. Áðåõèýíïíôáé óå åéäéêü 52% (ðáèïë. 60%, ÷åéñïõñã. 54%, åñãáóô. 42%), óõ÷íÜ 36% êáé ü÷é 12%. Óôéò ïäçãßåò åéäéêïý éáôñïý óõììïñöþíåôáé ôï 39% ôùí óõíáäÝëöùí (åñãáóô. 46%, ðáèïë. 42%, ÷åéñïõñã. 28%), óõ÷íÜ 54% êáé êáèüëïõ 7%. ÖáñìáêåõôéêÞ áãùãÞ óùóôÜ ëáìâÜíïõí 58% (ãõí. 66%, Üíäñ. 50%), åíþ ðëçììåëþò-34%. Áðïöåýãïõí ôçí ðïëõöáñìáêßá 66%, ôï 32% üìùò ëáìâÜíåé öÜñìáêá üôáí áðáéôåßôáé. 38% åìðéóôåýïíôáé óõíáäÝëöïõò ôïõò (êõñßùò ëüãù åìðåéñßáò), 28% ìå ìéêñÞ åðéöýëáîç, áðüëõôç åìðéóôïóýíç 20% êáé 11% óå ãíùóôïýò-óõíåñãÜôåò. ÓõìðåñÜóìáôá: Ç ðëåéïíüôçôá ôùí éáôñþí Ý÷åé åìâïëéáóèåß åðáñêþò, êñßíåôáé üìùò áðáñáßôçôï íá äåßîïõí åíäéáöÝñïí üóïé äçëþíïõí Üãíïéá. Ïé ðáèïëüãïé ÷ñçóéìïðïéïýí ëéãüôåñï ìÝóá ðñïóôáóßáò. Ôï Þìéóõ ôùí éáôñþí áíôéìåôùðßæåé Ýãêáéñá êáôáóôÜóåéò áóèåíåßáò ôïõò (êõñßùò ãõíáßêåò, ðïõ ëáìâÜíïõí ðéï óùóôÜ ôç öáñìáêåõôéêÞ ôïõò áãùãÞ) êáé ãåíéêüôåñá áðåõèýíïíôáé óå åéäéêü ãéá ôçí ðÜèçóÞ ôïõò éáôñü, óõììïñöþíïíôáé ìå ôéò ïäçãßåò ôïõ êáé ôïí åìðéóôåýïíôáé-êõñßùò ôïõò Ýìðåéñïõò êáé óõíåñãÜôåò ôïõò.

1

ÃåíéêÞ ÉáôñéêÞ Ð.Ð.Ã.Í. Ðáôñþí, 2Éáôñüò ÉáôñéêÞò Âéïðáèïëïãßáò, 3Éáôñüò Íïóïêïìåßïõ "Åõáããåëéóìüò", 4Éáôñüò Íáõôéêïý Íoó. Áèçíþí, 5Éáôñüò ÃåíéêÞò ÉáôñéêÞò, 6Öõóßáôñïò Ð.Ð.Ã.Í. Ðáôñþí, 7Ìéêñïâéïëüãïò, 8Áéìïäïóßá Êáñáìáíäáíåßïõ Íïóïêïìåßïõ Ðáôñþí

ÅéóáãùãÞ Ïé éáôñïß, ùò ëåéôïõñãïß ôçò õãåßáò ðñïóöÝñïõí ôéò õðçñåóßåò ôïõò óå êáôáóôÜóåéò áóèåíåßáò óõíáíèñþðùí ôïõò, êáèïäçãþíôáò ôïõò ãéá ôçí áðïôåëåóìáôéêüôåñç èåñáðåßá ôùí íüóùí ôïõò. ¼íôùò ùò Üíèñùðïé äéáôñÝ÷ïõí ðáñÜëëçëá êáé ïé ßäéïé êßíäõíï íüóçóçò êáé ìÜëéóôá áõîçìÝíï, áöïý åñãÜæïíôáé óôï ÷þñï ôçò õãåßáò-íïóïêïìåßá êáé “åêôßèåíôáé” óå ëïéìþäåéò ðáñÜãïíôåò êáé ìïëõóìÝíá âéïëïãéêÜ õãñÜ (éüò çðáôßôéäáò  & çðáôßôéäáò C, HIV ê.ëð.), þóôå íá áõîÜíïíôáé ïé ðéèáíüôçôåò ìüëõíóçò êáé íüóçóçò1-3. Áóðßäá-ðñüëçøç ó´ áõôÞ ôçí “Ýêèåóç” áðïôåëïýí: ç óùóôÞ åíçìÝñùóç, ïé áðáñáßôçôïé åìâïëéáóìïß êáé ìÜëéóôá ïé åðáíáëçðôéêÝò äüóåéò (üðùò çðáô. Â), ç ÷ñÞóç ìÝóùí ðñïóôáóßáò (ãÜíôéá, ìÜóêá ê.ëð.) üôáí áðáéôåßËÝîåéò êëåéäéÜ: éáôñéêÞ íïóçñüôçôá, Ðñüëçøç, Áíôéìåôþðéóç, ÓõìðåñéöïñÜ ÕðïâëÞèçêå: Ç åñãáóßá õðïâëÞèçêå ùò åëåýèåñç áíáêïßíùóç óôï 14ï ÐáíåëëÞíéï ÓõíÝäñéï ÃåíéêÞò ÉáôñéêÞò (ÊñÞôç, 8-12 ÌáÀïõ 2002) êáé Ýëáâå Ýðáéíï áðü ôçí ÅðéôñïðÞ Êñßóçò. Äçìïóéåýåôáé ìå êïéíÞ áðüöáóç ôçò ÓõíôáêôéêÞò ÅðéôñïðÞò ôïõ ðåñéïäéêïý êáé ôçò ÏñãáíùôéêÞò ÅðéôñïðÞò ôïõ Óõíåäñßïõ. Õðåýèõíïò áëëçëïãñáößáò: Ãåþñãéïò Ôóßñïò, ÓïöïêëÝïõò 29, Ô.Ê. 26442 ÐÜôñá, Ôçë. 0610 454667 103


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Ã. Ôóßñïò êáé óõí.

Doctors’ prevention, confrontation and behaviour in themes of their health G. Tsiros, D. Kalogeropoulos, P. Voila, Ch. Vossou, G. Kardatos, G. Mouzakis, N. Maglaras, P. Athanasopoulos, E. Gatopoulou Summury Aim: The study of prevention, behaviour and confrontation referring to doctors’ health problems, such as the degree of their confidence–compliance with the advices and guide-lines given by specialists – as concerning the corresponding disease- colleges. Material and Method: It was completed nameless questionnaire by 208 doctors of different specialties, who are working in two hospitals in Athens and in the Regional University Hospital of Patras. Took place appreciation and grouping of the answers for comparisons, per sex and sector of specialty. Results: From 208 doctors (46% pathologists, 28% surgeries, 26% laboratorians), were studied 108 (51%) males and 100 (49%) females with age average 32,2 and 31,3 correspondently. 64% of them were vaccinated with the appropriate for their age vaccines, 9% were unvaccinated, 27% declare ignorance (mainly surgeries-39%). Means of protection use the 71%, when it is demanded (surgeries-77%, laboratorians-78%, pathologists-57%), while often declare use 26%. In time face situations of their disease 50% (fem. 62%-mal. 39%), depending on their judgment 39%, not on time 11%. They appeal to specialist 52% (path.60%, surg. 54%, labor. 42%), often 36% and not at all-12%. At special doctor’s guide-lines are confronted 39% of the colleges (labor. 46%, path. 42%, surg. 28%), often 54% and not at all 7%. Treatment correctly receive 58% (fem. 66%, mal. 50%), as faulty-34%. Avoid polypharmacy 66%, but 32% take drugs when it is necessary. 38% have confidence to their colleges (especially because of experience), 28% with a small reservation, absolute confidence-20% and 11% to known collaborators. Conclusions: The majority of doctors are sufficiently vaccinated, but it is appreciated as necessary to care about these who declare ignorance. Pathologists use less means of protection. Half of doctors confront in time situations of their disease(mainly females, who receive more-correctly their treatment) and generally they apply to specialist for their disease doctor, comply with his instructions and they trust him-mainly the experts and collaborators. Keywords: Doctors’ diseases, Prevention, Confrontation, Behaviour.

ôáé, êáèþò ç Ýãêáéñç êáé óùóôÞ áíôéìåôþðéóç ãåíéêÜ êáôáóôÜóåùí áóèÝíåéÜò ôïõò4-7. Ïé ãíþóåéò êáé ç åìðåéñßá áíÜ åéäéêüôçôá ãéá êÜèå éáôñü óå óõíÜñôçóç ìå ôçí êáôÜëëçëç ðëçñïöüñçóç, áðïôåëïýí ðïëëÝò öïñÝò âáóéêÝò ðáñáìÝôñïõò þóôå íá áðåõèõíèïýí óôïí “åéäéêü” ãéá ôçí ðÜèçóÞ ôïõò óõíÜäåëöï, íá áêïëïõèÞóïõí ôéò óõìâïõëÝò ôïõ êáé ôçí ðñïôåéíüìåíç öáñìáêåõôéêÞ áãùãÞ. Ï åîåôÜæùí éáôñüò áðü ôç ìåñéÜ ôïõ ïöåßëåé íá ôçñåß ôï éáôñéêü áðüññçôï (éáôñéêÞ äåïíôïëïãßá), íá åíçìåñþíåé åðáñêþò ôïí åîåôáæüìåíï óõíÜäåëöü ôïõ ðñéí áðü êÜèå éáôñéêÞ ðñÜîç, êáèþò åðßóçò íá áêïëïõèåß ìÝèïäï óýã÷ñïíç êáé åðéóôçìïíéêÜ ôåêìçñéùìÝíç – ùò ïöåßëåé êáé ìå êÜèå áóèåíÞ – þóôå íá åðéôý÷åé ôçí êáëýôåñç äõíáôÞ åðéêïéíùíßá êáé ôç äçìéïõñãßá êëßìáôïò åìðéóôïóýíçò ìå ôïí ðÜó÷ïíôá. 104

Óêïðüò ôçò åñãáóßáò ìáò Þôáí ç ìåëÝôç ðñüëçøçò, óõìðåñéöïñÜò êáé áíôéìåôþðéóçò ðñïâëçìÜôùí õãåßáò éáôñþí, êáèþò êáé ï âáèìüò åìðéóôïóýíçò-óõììüñöùóÞò ôïõò óôéò óõìâïõëÝò êáé ïäçãßåò, ðáñå÷üìåíåò áðü åéäéêïýò-ùò ðñïò ôçí áíôßóôïé÷ç íüóïóõíáäÝëöïõò.

Ðëçèõóìüò ìåëÝôçò êáé ÌÝèïäïé

Óôçí ðáñïýóá åñãáóßá óõììåôåß÷áí 208 éáôñïß äéáöüñùí åéäéêïôÞôùí, ïé ïðïßïé åñãÜæïíôáé óå äýï íïóïêïìåßá ôçò ðñùôåýïõóáò (Ð.Ã.Í. “Ï Åõáããåëéóìüò”, Íáõôéêü Íïóïêïìåßï Áèçíþí) êáé Ýíá Ðåñéöåñåéáêü Ðáíåðéóôçìéáêü Íïóïêïìåßï (Ð.Ð.Ã.Í. Ðáôñþí). Óõìðëçñþèçêå áíþíõìï åñùôçìáôïëüãéï, åéäéêÜ äéáìïñöùìÝíï, ìå ôá ÷áñáêôçñéóôéêÜ óôïé÷åßá ôïõ éáôñïý (öýëï, çëéêßá, åéäéêüôçôá), þóôå íá äéåñåõíçèïýí ðáñÜãïíôåò ó÷åôéæüìåíïé ìå: · Ôïí áðáñáßôçôï ãéá ôçí çëéêßá ôïõò åìâïëéáóìü. · Ôç ÷ñÞóç óôéò þñåò åñãáóßáò ìÝóùí ðñïóôáóßáò (ãÜíôéá, ìÜóêá ê.ëð.) üôáí áðáéôåßôáé. · Ôçí Ýãêáéñç áíôéìåôþðéóç êáôáóôÜóåùí áóèÝíåéÜò ôïõò. · Ôï áí áðåõèýíïíôáé óôïí “åéäéêü” ãéá ôçí ðÜèçóÞ ôïõò éáôñü êáé áí óõììïñöþíïíôáé ìå ôéò ïäçãßåò – óõìâïõëÝò ôïõ. · Ôç óùóôÞ ëÞøç ôçò öáñìáêåõôéêÞ ôïõò áãùãÞ êáé áí ÷ñçóéìïðïéïýí ðïëëÜ öÜñìáêá (ðïëõöáñìáêßá). · Ôçí åìðéóôïóýíç óôïõò óõíáäÝëöïõò ôïõò óå êáôáóôÜóåéò áóèÝíåéÜò ôïõò. Áêïëïýèùò Ýãéíå áîéïëüãçóç êáé ïìáäïðïßçóç ôùí áðáíôÞóåùí ôïõ åñùôçìáôïëïãßïõ ãéá óýãêñéóç, êáôÜ: á) öýëï â) ôïìÝá åéäéêüôçôáò: ðáèïëïãéêüò, ÷åéñïõñãéêüò, åñãáóôçñéáêüò, êáé åðß óõíüëïõ. Äåí Ýãéíå äéÜêñéóç ìåôáîý åéäéêåõüìåíùí êáé åéäéêåõìÝíùí, áöïý ïé ðñþôïé (92%) áðïôåëïýí ôç óõíôñéðôéêÞ ðëåéïøçößá ôïõ äåßãìáôïò.


Ôüìïò 14, Ôåý÷ïò 2, 2002

Ã. Ôóßñïò êáé óõí.

¼ëá ôá óôïé÷åßá êáôá÷ùñÞèçêáí óå âÜóç äåäïìÝíùí (excel for windows), üðïõ êáé Ýãéíå ç åðåîåñãáóßá ôïõò.

ÁðïôåëÝóìáôá Åðß óõíüëïõ 208 éáôñþí, ìåëåôÞèçêáí 108 (51%) Üíäñåò êáé 100 (49%) ãõíáßêåò ìå ëüãï öýëïõ Üíäñåò/ãõíáßêåò: 1/0,93, åíþ ç ìÝóç çëéêßá ôïõ äåßãìáôïò Þôáí 32,2 êáé 31,3 åôþí áíôßóôïé÷á. ÁíÜ ôïìÝá äéáêñßíïõìå ôïõò éáôñïýò: 95 (46%) óôïí ðáèïëïãéêü (Üíäñ./ãõí.: 1/0,83), 59 (28%) óôïí ÷åéñïõñãéêü (Üíäñ./ãõí.: 1/0,64), 54 (26%) óôïí åñãáóôçñéáêü (Üíäñ./ãõí.: 1/1,7).

¸ãêáéñç áíôéìåôþðéóç êáôáóôÜóåùí áóèÝíåéáò Ïé áðáíôÞóåéò áíáöÝñïíôáé ùò åîÞò: Ýãêáéñç áíôéìåôþðéóç ôï 50% (39% Üíäñåò, 62% ãõíáßêåò), ìç Ýãêáéñç ôï 11% (16%, 6%) êáé ôÝëïò áíáëüãùò êñßóåùò ðáñïõóéÜæåôáé ôï 39% (45%, 32%) (Ðßíáêáò 3, ÄéÜãñáììá 3).

Áíôéìåôþðéóç ðñïâëçìÜôùí õãåßáò áðü ôïí “åéäéêü” éáôñü-óõíÜäåëöï Óôï åñþôçìá áí áðåõèýíïíôáé óôïí “åéäéêü” ãéá ôçí ðÜèçóÞ ôïõò óõíÜäåëöï, ïé éáôñïß áðÜíôçóáí: èåôéêÜ ôï 52% (55% Üíäñåò, 49% ãõíáßêåò), áñíçôéêÜ ôï 12% (13%, 11%), ìå óõ÷íÜ íá áðåõèýíåôáé ôï 36% (32%, 40%) (Ðßíáêáò 4, ÄéÜãñáììá 4).

Áðáñáßôçôïò ùò ðñïò ôçí çëéêßá åìâïëéáóìüò Åê ôùí 208 éáôñþí, áíáöÝñåôáé üôé: Ý÷ïõí åìâïëéáóèåß ôï 64% (56% Üíäñåò, 71% ãõíáßêåò), áíåìâïëßáóôïé ôï 9% (11%, 8%), åíþ Üãíïéá äçëþíåé ôï 27% (33%, 21%) (Ðßíáêáò 1, ÄéÜãñáììá 1).

×ñÞóç ìÝóùí ðñïóôáóßáò Áðü ôï óýíïëü ôïõò, ÷ñçóéìïðïéïýí ìÝóá ðñïóôáóßáò êáôÜ ôçí åñãáóßá ôïõò üôáí áðáéôåßôáé ôï 71% (63% Üíäñåò, 79% ãõíáßêåò), ìç ÷ñÞóç áíáöÝñåé ôï 3% (4%, 2%), åíþ óõ÷íÞ ÷ñÞóç äçëþíåé ôï 26% (33%, 19%) (Ðßíáêáò 2, ÄéÜãñáììá 2).

Óõììüñöùóç ìå ôéò éáôñéêÝò ïäçãßåò – óõìâïõëÝò ôïõ “åéäéêïý” Ôéò éáôñéêÝò ïäçãßåò áêïëïõèåß ôï 39% (38% Üíäñåò, 39% ãõíáßêåò) åê ôïõ óõíüëïõ ôùí éáôñþí, áíáöÝñåé ðùò äåí óõììïñöþíåôáé ôï 7% (11%, 3%), åíþ ôï 54% (51%, 58%) áêïëïõèåß ôéò óõìâïõëÝò ôïõ ôéò ðåñéóóüôåñåò öïñÝò (Ðßíáêáò 5, ÄéÜãñáììá 5).

ÓùóôÞ ëÞøç öáñìáêåõôéêÞò áãùãÞò ÓùóôÜ ëáìâÜíåé ôç öáñìáêåõôéêÞ ôïõ áãù-

Ðßíáêáò 1. Áðáñáßôçôïò ãéá ôçí çëéêßá åìâïëéáóìüò (%) ÔïìÝáò Éáôñïß

Ðáèïëïãßáò Óýí Áñ ÈÞë

×åéñïõñãéêÞò Óýí Áñ ÈÞë

Åñãáóôçñéáêüò Óýí Áñ ÈÞë

Óýí

ÍÁÉ Ï×É ÄÅ ÃÍÙÑÉÆÙ

66 11 23

52 9 39

73 8 19

64 9 27

56 13 31

75 9 16

42 14 44

61 4 35

70 5 25

76 12 12

Ìåéêôüò Áñ ÈÞë 56 11 33

71 8 21

Ðßíáêáò 2. ×ñÞóç ìÝóùí ðñïóôáóßáò óôéò þñåò åñãáóßáò (%) ÔïìÝáò Éáôñïß

Ðáèïëïãßáò Óýí Áñ ÈÞë

×åéñïõñãéêÞò Óýí Áñ ÈÞë

Åñãáóôçñéáêüò Óýí Áñ ÈÞë

Óýí

ÍÁÉ Ï×É ÓÕ×ÍÁ

57 8 35

77 2 21

78 0 22

71 3 26

54 8 38

60 7 33

64 3 33

91 0 9

70 0 30

85 0 15

Ìåéêôüò Áñ ÈÞë 63 4 33

79 2 19 105


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Ã. Ôóßñïò êáé óõí. ÓÕ×ÍÁ ÓÕ×ÍÁ 26%

ÄÅÍ ÃÍÙÑÉÆÙ ÄÅ ÃÍÙÑÉÆÙ 27%

ÍÁÉ 64%

O×É 9%

O×É 3%

ÄéÜãñáììá 1. Åê ôïõ óõíüëïõ éáôñþí, áðáñáßôçôïò ãéá ôçí çëéêßá ôïõò åìâïëéáóìüò.

ÍÁÉ 71%

ÄéÜãñáììá 2. Åê ôïõ óõíüëïõ éáôñþí, ÷ñÞóç ìÝóùí ðñïóôáóßáò óôéò þñåò åñãáóßáò

Ðßíáêáò 3. ¸ãêáéñç áíôéìåôþðéóç êáôáóôÜóåùí áóèÝíåéáò áðü ôïõò éáôñïýò (%) ÔïìÝáò Éáôñïß

Ðáèïëïãßáò Óýí Áñ ÈÞë

ÍÁÉ 50 Ï×É 10 ÊÑÉÍÙ ÁÍÁËÏÃÁ 40

35 17 48

65 2 33

×åéñïõñãéêÞò Óýí Áñ ÈÞë

Åñãáóôçñéáêüò Óýí Áñ ÈÞë

Óýí

50 16 34

50 8 42

50 11 39

36 22 42

65 9 26

45 10 45

56 6 38

Ìåéêôüò Áñ ÈÞë 39 16 45

62 6 32

Ðßíáêáò 4. Áíôéìåôþðéóç ðñïâëçìÜôùí õãåßáò áðü ôïí “åéäéêü” éáôñü-óõíÜäåëöï (%) ÔïìÝáò Éáôñïß

Ðáèïëïãßáò Óýí Áñ ÈÞë

×åéñïõñãéêÞò Óýí Áñ ÈÞë

Åñãáóôçñéáêüò Óýí Áñ ÈÞë

Óýí

ÍÁÉ Ï×É ÓÕ×ÍÁ

60 7 33

54 18 28

42 10 48

52 12 36

60 9 31

60 5 35

56 19 25

52 17 31

50 10 40

35 9 56

Ìåéêôüò Áñ ÈÞë 55 13 32

49 11 40

ÓÕ×ÍÁ 36%

ÊÑÉÍÙ ÁÍÁËÏÃÁ 39%

ÍÁÉ 50%

¼×É 11%

ÍÁÉ 52%

¼×É 12%

ÄéÜãñáììá 3. Åê ôïõ óõíüëïõ éáôñþí, Ýãêáéñç áíôéìåôþðéóç êáôáóôÜóåùí áóèÝíåéáò

ÄéÜãñáììá 4. Åê ôïõ óõíüëïõ éáôñþí, áíôéìåôþðéóç ðñïâëçìÜôùí õãåßáò ôïõò áðü ôïí “åéäéêü” éáôñü-óõíÜäåëöï

ãÞ ôï 58% (50% Üíäñåò, 66% ãõíáßêåò) ôùí éáôñþí, ðëçììåëÞò ëÞøç ôï 8% (14%, 2%), åíþ ôï 34% (36%, 32%) áíáöÝñåé “ôéò ðåñéóóüôåñåò öïñÝò” (Ðßíáêáò 6, ÄéÜãñáììá 6).

×ñÞóç ðïëëþí öáñìÜêùí (ðïëõöáñìáêßá)

106

Óôï óýíïëü ôïõò ïé éáôñïß äåí ÷ñçóéìïðïéïýí ãåíéêþò “ðïëëÜ ” öÜñìáêá óå ðïóïóôü 66% (69% Üíäñåò, 63% ãõíáßêåò), áõôïß ðïõ êÜíïõí ÷ñÞóç ðïëõöáñìáêßáò áíÝñ÷ïíôáé óôï 2% (3%, 1%), åíþ ÷ñÞóç üôáí áðáéôåßôáé, äçëþíåé ôï 32% (28%, 36%) (Ðßíáêáò 7, ÄéÜãñáììá 7).


Ôüìïò 14, Ôåý÷ïò 2, 2002

Ã. Ôóßñïò êáé óõí. Ðßíáêáò 5. Óõììüñöùóç ìå ôéò éáôñéêÝò ïäçãßåò – óõìâïõëÝò ôïõ “åéäéêïý” (%) ÔïìÝáò Éáôñïß

Ðáèïëïãßáò Óýí Áñ ÈÞë

×åéñïõñãéêÞò Óýí Áñ ÈÞë

Åñãáóôçñéáêüò Óýí Áñ ÈÞë

Óýí

ÍÁÉ Ï×É ÔÉÓ ÐÅÑIÓ. ÖÏÑÅÓ

42 9 49

28 7 65

46 6 48

39 7 54

38 10 52

47 8 47

25 14 61

30 0 70

50 10 40

41 3 56

Ìåéêôüò Áñ ÈÞë 38 11 51

39 3 58

Ðßíáêáò 6. ÓùóôÞ ëÞøç öáñìáêåõôéêÞò áãùãÞò (%) ÔïìÝáò Éáôñïß

Ðáèïëïãßáò Óýí Áñ ÈÞë

×åéñïõñãéêÞò Óýí Áñ ÈÞë

Åñãáóôçñéáêüò Óýí Áñ ÈÞë

Óýí

ÍÁÉ Ï×É ÔÉÓ ÐÅÑÉÓ. ÖÏÑÅÓ

61 5 34

60 10 30

53 8 39

58 8 34

54 10 36

68 0 32

47 20 33

ÍÁÉ 39%

ÔÉÓ ÐÅÑÉÓÓÏÔÅÑÅÓ ÖÏÑÅÓ 54%

¼×É 7%

74 0 26

50 10 40

ÔÉÓ ÐÅÑÉÓÓÏÔÅÑÅÓ ÖÏÑÅÓ 34%

56 6 38

Ìåéêôüò Áñ ÈÞë 50 14 36

66 2 32

ÍÁÉ 58%

¼×É 8%

ÄéÜãñáììá 5. Åê ôïõ óõíüëïõ éáôñþí, óõììüñöùóç ìå ôéò éáôñéêÝò ïäçãßåò – óõìâïõëÝò ôïõ “åéäéêïý”

ÄéÜãñáììá 6. Åê ôïõ óõíüëïõ éáôñþí, óùóôÞ ëÞøç öáñìáêåõôéêÞò áãùãÞò

Åìðéóôåýåóôå ôïõò óõíáäÝëöïõò óáò óå êáôáóôÜóåéò áóèÝíåéÜò óáò;

ôéò óçìáíôéêüôåñåò áíáêáëýøåéò óôçí éóôïñßá ôçò éáôñéêÞò. Ìå ôá ðñïãñÜììáôá åìâïëéáóìþí ðïõ Ý÷ïõí ôåèåß óå åöáñìïãÞ Ý÷åé ãßíåé åöéêôü íá óôáìáôÞóåé ç åîÝëéîç-ðáñïõóßá ðïëëþí áóèåíåéþí8,9. Ôá ðåñéóóüôåñá åìâüëéá óõíÞèùò ðñïëáìâÜíïõí ôç íüóï, åíþ ìåñéêÜ áðü áõôÜ ôçí ôñïðïðïéïýí, Ýôóé þóôå íá ìçí åìöáíßæåôáé óå âáñéÜ ìïñöÞ. Ãéá ôçí åðéôõ÷ßá ôùí åìâïëéáóìþí ðñÝðåé íá ôçñïýíôáé ïñéóìÝíïé êáíüíåò, üðùò ç óùóôÞ ìåôáöïñÜ êáé óõíôÞñçóç ôùí åìâïëßùí, ï óùóôüò ôñüðïò êáé ç çëéêßá åöáñìïãÞò ôïõò êáé ôï óðïõäáéüôåñï ßóùò ïé áíáìíçóôéêïß åìâïëéáóìïß. Ï åðáíáëçðôéêüò åìâïëéáóìüò áíáãêÜæåé ôïí ïñãáíéóìü íá “èõìçèåß” êáé íá îáíáöôéÜîåé ìåãÜëï áñéèìü áíôéóùìÜôùí, þóôå íá ìðïñåß íá áíôéìåôùðßæåé åðáñêþò ôçí åßóïäï óôï óþìá ôïõ ìéêñïâßùí Þ éþí. Ï óêïðüò ôùí åìâïëßùí åßíáé íá “ìéìçèïýí” ôçí ðñáãìáôéêÞ íüóï, þóôå üôáí ï ïñãáíéóìüò ÷ñåéáóôåß íá ôçí áíôéìåôùðßóåé íá Ý÷åé óôç äéÜèåóÞ ôïõ áñêåôÜ áíôéóþìáôá ãéá áõôü, ìå ôñüðï ðïõ íá ìçí ôïí âÜæåé óå êßíäõíï10-12. Åíèáññõíôéêü ðáñïõóéÜæåôáé ôï õøçëü ðï-

Ó’ áõôü ôï åñþôçìá ïé éáôñïß áðáíôïýí ùò åîÞò: áðüëõôá ôï 20% (20% Üíäñåò, 20% ãõíáßêåò), ü÷é ôï 3% (2%, 3%), ìå ìéêñÞ åðéöýëáîç (ôéò ðåñéóóüôåñåò öïñÝò) ôï 28% (27%, 28%), áíáëüãùò ôçí åìðåéñßá ôïõ ôï 38% (37%, 40%), êáé üôáí åßíáé ãíùóôïß-óõíåñãÜæïíôáé ôï 11% (14%, 9%) (Ðßíáêáò 8, ÄéÜãñáììá 8).

ÓõæÞôçóç Áí êáé ôï ìåãáëýôåñï ðïóïóôü ôùí éáôñþí Ý÷åé åìâïëéáóôåß ìå ô’ áðáñáßôçôá ãéá ôçí çëéêßá ôïõ åìâüëéá, åíôïýôïéò ôï 27% äçëþíåé Üãíïéá (ìå ôïõò ÷åéñïõñãïýò óôï 39%). ÁíÜ öýëï, óôïõò ãåíüìåíïõò åìâïëéáóìïýò õðåñÝ÷ïõí ïé ãõíáßêåò ó’ üëïõò ôïõò ôïìåßò åéäéêïôÞôùí, åíþ áíôßóôïé÷á õðåñï÷Þ ôùí áíäñþí ðáñïõóéÜæåôáé óôçí Üãíïéá/áìÝëåéá. Ôá åìâüëéá åßíáé óßãïõñá ìßá áðü

107


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Ã. Ôóßñïò êáé óõí.

Ðßíáêáò 7. ×ñçóéìïðïßçóç “áñêåôþí” öáñìÜêùí (ðïëõöáñìáêßá) (%) ÔïìÝáò Éáôñïß

Ðáèïëïãßáò Óýí Áñ ÈÞë

×åéñïõñãéêÞò Óýí Áñ ÈÞë

Åñãáóôçñéáêüò Óýí Áñ ÈÞë

Óýí

ÍÁÉ Ï×É ÏÔÁÍ ÁÐÁÉÔÅÉÔÁÉ

0 68 32

4 64 32

2 65 33

2 66 32

0 79 21

0 56 44

8 67 25

0 61 39

0 60 40

3 71 26

Ìåéêôüò Áñ ÈÞë 3 69 28

1 63 36

Ðßíáêáò 8. Åìðéóôïóýíç óå óõíáäÝëöïõò, óå êáôáóôÜóåéò áóèÝíåéÜò ôùí éáôñþí (%) ÔïìÝáò Éáôñïß

Ðáèïëïãßáò Óýí Áñ ÈÞë

×åéñïõñãéêÞò Óýí Áñ ÈÞë

Åñãáóôçñéáêüò Óýí Áñ ÈÞë

Óýí

ÍÁÉ Ï×É ÃÍÙÓÔÏÓ ÅÌÐÅÉÑÉÁ ÔÉÓ ÐÅÑIÓ. ÖÏÑÅÓ

20 2 13 36 29

30 6 8 31 25

9 0 13 48 30

20 3 11 38 28

18 4 21 32 25

21 0 76 39 34

39 3 7 32 19

22 9 9 30 30

ÍÁÉ 2%

0 0 15 45 40

ÃÍÙÓÔÏÓ 11%

¼ÔÁÍ ÁÐÁÉÔÅÉÔÁÉ 32% ¼×É 66%

ÅÌÐÅÉÑÉÁ 38%

18 0 11 51 20

Ìåéêôüò Áñ ÈÞë 20 2 14 37 27

20 3 9 40 28

ÍÁÉ 20% ¼×É 3% ÔÉÓ ÐÅÑÉÓÓÏÔÅÑÅÓ ÖÏÑÅÓ 28%

ÄéÜãñáììá 7. Åê ôïõ óõíüëïõ éáôñþí, ÷ñçóéìïðïßçóç “áñêåôþí” öáñìÜêùí (ðïëõöáñìáêßá)

ÄéÜãñáììá 8. Åê ôïõ óõíüëïõ éáôñþí, åìðéóôïóýíç óå óõíáäÝëöïõò, óå êáôáóôÜóåéò áóèÝíåéÜò ôïõò.

óïóôü 71% ôùí éáôñþí ðïõ ÷ñçóéìïðïéïýí ìÝóá ðñïóôáóßáò üôáí áðáéôåßôáé óå þñá åñãáóßáò, ìå áõîçìÝíï éäéáßôåñá óôéò ÷åéñïõñãéêÝò (77%) êáé åñãáóôçñéáêÝò (78%) åéäéêüôçôåò åöüóïí áõôïß ïé éáôñïß Ýñ÷ïíôáé óå ìåãáëýôåñç Ýêèåóç ìå ìïëõóìÝíá õãñÜ, áêôéíïâïëßåò ê.ô.ë. ÁíÜ öýëï, ðéï “ðñïóåêôéêÝò” ðáñïõóéÜæïíôáé ïé ãõíáßêåò éáôñïß ó’ üëïõò ôïõò ôïìåßò åéäéêïôÞôùí, êáé éäéáßôåñá óôïí ÷åéñïõñãéêü ìå ðïóïóôü 91%. ÊáèçìåñéíÜ Ýíáò óçìáíôéêüò áñéèìüò áôüìùí ôïõ íïóçëåõôéêïý ðñïóùðéêïý ðïõ Ýñ÷åôáé ó´ åðáöÞ ìå âéïëïãéêÜ õãñÜ ìïëõóìÝíá áðü ôïõò éïýò ôçò çðáôßôéäáò Â, C êáé ôïí éü ôïõ óõíäñüìïõ ôçò åðßêôçôçò áíïóïáíåðÜñêåéáò (HIV1-2), äéáôñÝ÷åé ôïí êßíäõíï íá ìïëõíèåß êáé íá íïóÞóåé13,14. Ç áíÜðôõîç ëïßìùîçò åîáñôÜôáé áðü ôï åßäïò êáé ôç ëïéìïãüíï éêáíüôçôá ôïõ éïý, ôçí ðõêíüôçôÜ ôïõ óôï âéïëïãéêü õãñü êáé ôï åßäïò ôçò åðáöÞò15,16. Ïé ëïéìþîåéò áõôÝò ìåôáäßäïíôáé óôï õãåéïíïìéêü

ðñïóùðéêü êõñßùò áðü ìéêñïôñáõìáôéóìïýò, áõôü üìùò óõìâáßíåé óå ÷áìçëü ðïóïóôü åíþ åîáéñåôéêÜ óðÜíéá ïöåßëïíôáé óå åðáöÞ âéïëïãéêþí õãñþí ìå âëåííïãüíïõò. Ï óõíçèÝóôåñïò ôñüðïò åðáöÞò óå ÷þñïõò üðïõ ãßíïíôáé ìéêñïåðåìâÜóåéò åßíáé ï ôñáõìáôéóìüò êáôÜ ôçí ðñïóðÜèåéá êÜëõøçò ôçò âåëüíçò ìå ôï êÜëõììÜ ôçò17,18. Ôá ìïëõóìÝíá áé÷ìçñÜ åñãáëåßá áðïññßðôïíôáé óå óôåñåÜ äï÷åßá åíþ ôá ìïëõóìÝíá âéïëïãéêÜ õãñÜ óå ðëáóôéêÝò óáêïýëåò. Áðáñáßôçôç åßíáé ç ðëÞñçò óõíåñãáóßá ôïõ ðñïóùðéêïý êáôÜ ôçí þñá ôùí åðåìâÜóåùí ìå óáöåßò ïäçãßåò ëåéôïõñãßáò. Ôï Þìéóõ ðåñßðïõ ôùí éáôñþí, ó’ üëïõò ôïõò ôïìåßò åéäéêïôÞôùí, áíôéìåôùðßæïõí Ýãêáéñá êáôáóôÜóåéò áóèÝíåéÜò ôïõò (éäéáßôåñá ïé ãõíáßêåò) êáé áðåõèýíïíôáé óôïí “åéäéêü” ãéá ôçí ðÜèçóÞ ôïõò óõíÜäåëöï, êõñßùò ïé ðáèïëïãéêÝò åéäéêüôçôåò óôï 60%. ÃåíéêÜ ìå ôéò ïäçãßåò ôïõ “åéäéêïý” óõììïñöþíïíôáé: ôéò ðåñéóóüôåñåò öïñÝò ôï 54%

108


Ôüìïò 14, Ôåý÷ïò 2, 2002

Ã. Ôóßñïò êáé óõí.

êáé áðüëõôá ôï 39%, ìå ôéò ÷åéñïõñãéêÝò åéäéêüôçôåò íá ìçí áêïëïõèïýí ôéò éáôñéêÝò óõìâïõëÝò áðüëõôá (28%) áëëÜ ôéò ðåñéóóüôåñåò öïñÝò (65%), åíþ ôï Þìéóõ ðåñßðïõ ôùí éáôñþí ôùí åñãáóôçñéáêþí åéäéêïôÞôùí, äåí áðåõèýíïíôáé ðÜíôïôå óôïí êáôÜëëçëï éáôñü. Ç ðëåéïøçößá ôùí éáôñþí (58%) ëáìâÜíåé óùóôÜ ôç öáñìáêåõôéêÞ ôïõ áãùãÞ (ìå õðåñï÷Þ ôùí ãõíáéêþí ó’ üëïõò ôïõò ôïìåßò åéäéêïôÞôùí), åíþ ðñïóðáèåß (ôéò ðåñéóóüôåñåò öïñÝò) ôï 34%. Áêüìá ôï 66% áðïöåýãåé ôçí ðïëõöáñìáêßá ìå ôï 32% íá ôç ÷ñçóéìïðïéåß üôáí áðáéôåßôáé, äåßãìá ôçò åðéóôçìïíéêÞò ãíþóçò ôùí áñíçôéêþí åðéðôþóåùí ôüóï ôçò ìç ÷ñÞóçò üóï êáé ôçò õðåñâïëéêÞò êáôáíÜëùóçò ôùí öáñìáêåõôéêþí éäéïóêåõáóìÜôùí19-23. Ôï öÜñìáêï åßíáé ðïëýôéìï ãéá ôç äéáóöÜëéóç ôçò õãåßáò, ôçí ðáñÜôáóç ôçò æùÞò êáé ôç âåëôßùóç ôçò ðïéüôçôÜò ôçò, ìðïñåß üìùò óå ëáèåìÝíç ÷ñÞóç Þ õðåñâïëéêÞ äüóç, íá áðïâåß åðéêßíäõíï24-27. Ï êÜèå áóèåíÞò áðïôåëåß ìéá îå÷ùñéóôÞ ðåñßðôùóç. ÁíÜëïãá ìå ôï éáôñéêü éóôïñéêü, ôçí çëéêßá, ôç óùìáôéêÞ ôïõ åðéöÜíåéá, ôïí øõ÷éóìü ôïõ, ôçí áíåýñåóç õðåñåõáéóèçóßáò (áëëåñãßåò), ôéò ðéèáíÝò áíôåíäåßîåéò Þ ôçí ôáõôü÷ñïíç ÷ñÞóç êáé Üëëùí öáñìÜêùí èá ðñÝðåé íá åöáñìïóôåß ôï êáôÜëëçëï èåñáðåõôéêü ó÷Þìá, óôç óùóôÞ äïóïëïãßá êáé ãéá óõãêåêñéìÝíï ÷ñïíéêü äéÜóôçìá28-31. ¸ñåõíåò åðéóçìáßíïõí (áíáöïñÜ óôï 6ï ÐáíåëëÞíéï ÓõíÝäñéï Ðáèïëïãßáò) üôé ç ðéèáíüôçôá íá ÷Üóåé êáíåßò ôç æùÞ ôïõ áðü ðáñåíÝñãåéåò êÜðïéïõ óêåõÜóìáôïò ãéá ÷ñüíéï íüóçìá åßíáé ìßá óôéò åêáôü, ôç óôéãìÞ ðïõ ï áíôßóôïé÷ïò êßíäõíïò íá óêïôùèåß êÜðïéïò óå ôñï÷áßï åßíáé ìßá óôéò ÷ßëéåò êáé óå áåñïðïñéêü äõóôý÷çìá ìßá óôéò äÝêá ÷éëéÜäåò. ÁíáöïñéêÜ ìå ôçí åìðéóôïóýíç, ãéá êáôáóôÜóåéò áóèÝíåéÜò ôïõò, óå óõíáäÝëöïõò ôïõò, ðñïâÜëëïõí êõñßùò ôçí åìðåéñßá (38%), ôç óõíåñãáóßá (11%), ôçí áðüëõôç åìðéóôïóýíç (20%) êáé ìéêñÞ åðéöýëáîç ôï 28%. Ç êáëýôåñç åêðáßäåõóç ôùí éáôñþí ôüóï êáôÜ ôéò ðáíåðéóôçìéáêÝò óðïõäÝò, üóï êáé êáôÜ ôçí ðåñßïäï ôçò åéäéêüôçôïò, ç äéÜ âßïõ åêðáßäåõóç, ç êáëýôåñç åðéêïéíùíßá-óõíåñãáóßá ìåôáîý ôùí éáôñþí, ç áíÜðôõîç éáôñéêÞò äåïíôïëïãßáò, ç åíçìÝñùóç ôùí ëåéôïõñãþí ôïõ Äéêáßïõ, áëëÜ êáé ôùí áóèåíþí üôé êÜèå ðáñÝêêëéóç áðü ôçí áíáìåíüìåíç Ýêâáóç äåí áðïôåëåß êáô’ áíÜãêçí éáôñéêÞ áìÝëåéá, áðïôåëïýí ßóùò ôìÞìá ôçò ëýóçò ôïõ “ëåðôïý” áõôïý æçôÞìáôïò32-34.

ÓõìðåñÜóìáôá – ÐñïôÜóåéò · Ç ðëåéïíüôçôá ôùí éáôñþí Ý÷åé åìâïëéáóèåß åðáñêþò, êñßíåôáé üìùò áðáñáßôçôï íá äåßîïõí åíäéáöÝñïí üóïé äçëþíïõí Üãíïéá, Þ äåí Ý÷ïõí åíçìåñùèåß êáôÜëëçëá. · ×ñçóéìïðïéïýí üôáí áðáéôåßôáé ìÝóá ðñïóôáóßáò óôéò þñåò åñãáóßáò, (êõñßùò ïé ÷åéñïõñãéêÝò êáé åñãáóôçñéáêÝò åéäéêüôçôåò). · Ôï Þìéóõ ôùí éáôñþí áíôéìåôùðßæåé Ýãêáéñá êáôáóôÜóåéò áóèåíåßáò ôïõò êáé êõñßùò ïé ãõíáßêåò, ðïõ ëáìâÜíïõí ðéï óùóôÜ ôç öáñìáêåõôéêÞ ôïõò áãùãÞ. · Ç ðëåéïíüôçôá ôùí éáôñþí êÜíåé ïñèïëïãéêÞ ÷ñÞóç ôùí öáñìÜêùí, áðïöåýãïíôáò ôçí ðïëõöáñìáêßá. · ÓõãêñéôéêÜ ìå ôïõò Üíäñåò, ïé ãõíáßêåò éáôñïß ðáñïõóéÜæïíôáé ðéï ðñïóåêôéêÝò êáé åõáéóèçôïðïéçìÝíåò ó÷åôéêÜ ìå ôçí ðñüëçøç êáé áíôéìåôþðéóç èåìÜôùí õãåßáò ôïõò. · ÃåíéêÜ ïé éáôñïß áðåõèýíïíôáé óå åéäéêïýò ãéá ôçí ðÜèçóÞ ôïõò óõíáäÝëöïõò êáé óõììïñöþíïíôáé ìå ôéò ïäçãßåò ôïõ. Åìðéóôåýïíôáé êõñßùò ôïõò ðéï Ýìðåéñïõò, ãíùóôïýò Þ óõíåñãÜôåò ôïõò. Ç óùóôÞ ðñüëçøç (åìâïëéáóìïß, Ýëåã÷ïò áíïóßáò, åíçìÝñùóç ôñüðùí ìåôÜäïóçò ëïéìùäþí íïóçìÜôùí), ç Ýãêáéñç êáé êáôÜëëçëç áíôéìåôþðéóç êáôáóôÜóåùí õãåßáò (óõììüñöùóç ìå ôéò ïäçãßåò ôïõ èåñÜðïíôá) ôïõ éáôñéêïý ðñïóùðéêïý, áðïôåëåß ýøéóôç õðï÷ñÝùóç êÜèå éáôñïý. Ï ðáñáìåñéóìüò ôùí áíùôÝñù, åêôüò ôïõ üôé åêèÝôåé óå Üìåóï êßíäõíï íüóçóçò Üëëïõò áóèåíåßò, åñãáæüìåíïõò Þ êáé ìÝëç ôçò ïéêïãÝíåéÜò ôïõ, áíôéðáñáôßèåôáé ìå ôç óýã÷ñïíç êáé åðéóôçìïíéêÜ ôåêìçñéùìÝíç ãíþóç, ç ïðïßá ëáìâÜíåôáé ìå ôç óõíå÷Þ åíçìÝñùóç êáé åêðáßäåõóç. ÅðéðñïóèÝôùò, ç ðñïóðÜèåéá ãéá ôçí êáëýôåñç äõíáôÞ åðéêïéíùíßá êáé óõíåñãáóßá ôùí éáôñþí, äçìéïõñãåß êëßìá åìðéóôïóýíçò ãéá ôïí ðÜó÷ïíôá óõíÜäåëöï, èåìåëéþíïíôáò Ýôóé óçìáíôéêÜ óôïé÷åßá áíÜðôõîçò êáé ëåéôïõñãßáò åíüò õðåýèõíïõ ðñïãñÜììáôïò õãåßáò.

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16. L.M. Robert, M.E. Chamberland, J.L. Cleveland. Investigations of patients of health care workers infected with HIV: the centers for Disease control and Prevention database. Ann. Intern. Med., 122:653-657, 1995. 17. J.L. Gerberding. Profylaxis for occupational exposure to HIV. Ann. Intern. Med., 125:497-501, 1996. 18. J.L. Tokars, R. Marcus, D. Culver, et al. Surveillance of HIV infection and Ziduvodine use among health care workers after occupational exposure to HIV-infected blood. Ann. Inter. Med., 118:913-919, 1993. 19. Ã. ÔåñæÞ, Ê. ÊáôóïõãéÜííç. Äéåñåýíçóç ðñïóäéïñéóôéêþí ðáñáãüíôùí ôçò êáôáíÜëùóçò öáñìÜêùí êáôÜ ãåùãñáöéêÞ ðåñéöÝñåéá óôçí ÅëëÜäá. Áñ÷åßá ÅëëçíéêÞò ÉáôñéêÞò, 3:88-9, 1986. 20. Ñ. ÂáëÝñç, Ä. Áëïýðç, Ä. Ìðáîåâáíßäïõ êáé óõí. Áõèáßñåôç ÷ñÞóç öáñìÜêùí. Óôá ÐñáêôéêÜ 7ïõ Âïñåéïåëëáäéêïý Óõíåäñßïõ, Èåóóáëïíßêç, óåë. 214-7, 1992. 21 Å. ÁíåõëáâÞò. ÊëéíéêÞ Ëïéìùîéïëïãßá. ÉáôñéêÝò åêäüóåéò Ð.×. Ðáó÷áëßäçò, 1997. 22. J.F. Vilarino, I.C. Soares, C.M. da Silveira et al. Self-medication profile in a city of south Brazil. Rev Saude ublica 32:43-9, 1998. 23. Å. ÃéáìáñÝëëïõ, Ê. Êáíåëëáêïðïýëïõ. Ïé ëïéìþîåéò ôçò Êïéíüôçôáò êáé ç èåñáðåßá ôïõò. ÁèÞíá, 1997. 24. G.S. Lau, K.K. Lee, C.T. Luk. Self-medication among university students in Hong Kong. Asta Pac. J. Public. Health, 8:153-7, 1995. 25. Å. ÃéáìáñÝëëïõ. Ôá íåþôåñá áíôéìéêñïâéáêÜ öÜñìáêá. ÐëåïíåêôÞìáôá, ìåéïíåêôÞìáôá êáé óõãêñéôéêÞ áîéïëüãçóç. ÉáôñéêÞ 55:258-263, 1989. 26. A. Orero Gonzalez, M.A. Ripoll Lozano, J. Gonzalez Nunez. Analysis of automedication with antibiotics in Spain. Enferm Infecc Microbiol Clin, 16:328-33, 1998. 27. C. Baum, D. Kennedy, D. Knapp, et al. Prescription drug use in 1984 and changes over time. Med. Care. 26:105-194, 1988. 28. P. Laure. Investigation on self-medication: from disease to performance. Therapic., 53:127-35, 1998. 29. C. Baum, D. Kennedy, M. Forges, J. Jones. Drug use in the United States in 1981. JAMA, 251:1293-1297, 1984. 30. Å. ÃéáìáñÝëëïõ. Áñ÷Ýò áíôéìéêñïâéáêÞò ÷çìåéïèåñáðåßáò ôùí ëïéìþîåùí. ÉáôñéêÞ, 53:631-636, 1988. 31. Á. ÐáñáäÝëëçò. ÁëëçëïåðéäñÜóåéò öáñìÜêùí, University Studio Press Á.Å. Èåóóáëïíßêç 1985. 32. P.J. Hoyte. Unsound practice ,the epidemiology of medical negligence. M.A. Thesis, 1993, Keele


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ÅÐÁÉÍÅÈÅÉÓÁ ÅËÅÕÈÅÑÇ ÁÍÁÊÏÉÍÙÓÇ THE SECOND AWARDED FREESTANDING PAPER Primary Heatlh Care, Volume 14, Number 2, 107-114, 2002 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 14, Ôåý÷ïò 2, 107-114, 2002

Aîéïëüãçóç ôùí áðïôåëåóìÜôùí ôçò ðáñÝìâáóçò ôïõ éáôñïý ðåñéöåñåéáêïý éáôñåßïõ óå ãíùóôü ðëçèõóìü óáê÷áñïäéáâçôéêþí ôçò ðåñéï÷Þò åõèýíçò ôïõ ìåôÜ ôçí ðáñÝëåõóç åíüò Ýôïõò Ê. Óôåöáíïðïýëïõ1, Ó. Ãêïíôüëéáò1, ×. ÓðõñÜêç1, Á. Ðáñáóýñç2, Á. ÐåôñÜêç2, Í. ÐáðáäÜêçò1, Á. Ðáôßêáò1

Ðåñßëçøç Óêïðüò: Ç áðïôýðùóç ôùí áðïôåëåóìÜôùí ôçò ðáñÝìâáóçò ôïõ É.Ð.É. óôïõò óáê÷áñï- äéáâçôéêïýò ôçò ðåñéï÷Þò ôïõ ìåôÜ ôçí ðáñÝëåõóç åíüò Ýôïõò, üðùò áõôÞ åêäçëþíåôáé ìå ôçí åêôßìçóç ôùí ìåôáâïëþí ôçò HbA1c, ôïõ ëéðéäáéìéêïý ðñïößë, áëëÜ êáé ôùí ìåôáâïëþí óôéò óõíÞèåéåò êáé ôïí ôñüðï æùÞò ôùí áóèåíþí áõôþí. Ðëçèõóìüò áíáöïñÜò - ÌÝèïäïò: ÌåëåôÞèçêáí 24 äéáãíùóìÝíïé óáê÷áñoäéáâçôéêïß åðß óõíüëïõ 870 êáôïßêùí óôá äçìïôéêÜ äéáìåñßóìáôá ÃáñÜæïõ, Ìïõñôæáíþí, ÅðéóêïðÞò êáé Êåöáëßïõ. ¼ëïé Ýðáó÷áí áðü óáê÷áñþäç äéáâÞôç (Ó.Ä.) ôýðïõ ÉÉ. Óôá Üôïìá áõôÜ, ìåôÜ ôçí áñ÷éêÞ åêôßìçóç ôïí Áýãïõóôï ôïõ 2000 ôùí ôéìþí ôçò HbA1c êáé ôïõ ëéðéäáéìéêïý ðñïößë, Ýãéíáí ïé áíÜëïãåò êáôÜ ðåñßðôùóç ôñïðïðïéÞóåéò êáé ðñïóáñìïãÝò ôçò öáñìáêåõôéêÞò áãùãÞò êáé óõíåóôÞèç ìåôáâïëÞ ôïõ ôñüðïõ æùÞò (åöáñìïãÞ óõãêåêñéìÝíïõ äéáéôïëïãßïõ, Üóêçóç, äéáêïðÞ êáðíßóìáôïò êáé ðåñéïñéóìüò ôïõ áëêïüë). Åðßóçò äéïñãáíþèçêáí åêðáéäåõôéêÜ ìáèÞìáôá ìå óõæçôÞóåéò êáé ðñïâïëÝò slides, üðïõ óõæçôÞèçêáí èÝìáôá ó÷åôéêÜ ìå ôïí ÓÄ (ðñüëçøç, ðáèïëïãßá, åðéðëïêÝò, áíôéìåôþðéóç). ÁðïôåëÝóìáôá: ÌåôÜ ôçí ðáñÝìâáóÞ ìáò äéáðéóôþèçêå üôé üëïé ó÷åäüí ïé áóèåíåßò (21/24) ìåßùóáí ôçí HbA1c Ýùò êáé 40% ôçò áñ÷éêÞò. Áðü ôïõò åîåôáóèÝíôåò áóèåíåßò 12 êáôüñèùóáí íá ìåéþóïõí ôï óùìáôéêü âÜñïò ôïõò Ýùò êáé 7 êéëÜ, åíþ 16/22 ðáñïõóßáóáí âåëôßùóç üóïí áöïñÜ óôï ëéðéäáéìéêü ðñïößë ðïõ óõíïäåýôçêå áðü áëëáãÞ óôéò óõíÞèåéåò êáé óôïí ôñüðï æùÞò (äéáêïðÞ êáðíßóìáôïò, ðåñéïñéóìüò áëêïüë). ÓõìðÝñáóìá: Ôá áðïôåëÝóìáôá ôçò ðáñÝìâáóÞò ìáò õðÞñîáí åíôõðùóéáêÜ, ùò áðüññïéá ôçò óõíôïíéóìÝíçò ðñïóðÜèåéáò ôïõ É.Ð.É êáé ôïõ ÊÝíôñïõ Õãåßáò ãéá åíçìÝñùóç êáé êéíçôïðïßçóç ôùí áóèåíþí ãéá èÝìáôá ó÷åôéêÜ ìå ôç íüóï ôïõ ÓÄ, äßíïíôáò éäéáßôåñç Ýìöáóç óôçí êáôáíüçóç áðü ðëåõñÜò ôïõò ôçò óðïõäáéüôçôáò ôçò áëëáãÞò ôùí õãéåéíïäéáéôçôéêþí óõíçèåéþí ôïõò.

1

Éáôñïß ÊÝíôñïõ Õãåßáò ÐåñÜìáôïò Ñåèýìíïõ, 2Íïóçëåõôéêü ðñïóùðéêü Ê.Õ. ÐåñÜìáôïò Ñåèýìíïõ, ÊÝíôñï Õãåßáò ÐåñÜìáôïò Ñåèýìíïõ

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ÅéóáãùãÞ O Óáê÷áñþäçò äéáâÞôçò ôýðïõ 2 áöïñÜ óôï 95% ôùí ðåñéðôþóåùí óáê÷áñþäç äéáâÞôç1 êáé áðïôåëåß óçìáíôéêü ðñüâëçìá äçìüóéáò õãåßáò, åîáéôßáò: 1) Ôçò õøçëÞò óõ÷íüôçôáò áíåýñåóÞò ôïõ óôïí åíÞëéêï ðëçèõóìü (Ç óõ÷íüôçôá ôïõ óáê÷áñþäç äéáâÞôç ôýðïõ 2 áõîÜíåôáé, üóï áõîÜíåôáé ç çëéêßá êáé ï äåßêôçò ìÜæáò2 óþìáôïò.) 2) ôçò ÷ñïíéüôçôÜò ôïõ êáé 3) ôçò óïâáñüôçôáò êáé ôçò óõ÷íÜ “ýðïõëçò” êáé “óéùðçëÞò” åîÝëéîçò ôùí åðéðëïêþí3,4 ðïõ ôïí óõíïäåýïõí êáé åßíáé: • ÌáêñïáããåéïðÜèåéá, ðïõ ïäçãåß óå áããåéáêÜ åãêåöáëéêÜ åðåéóüäéá, éó÷áéìéêÞ êáñäéïðÜèåéá êáé ðåñéöåñéêÞ áããåéïðÜèåéá5 ËÝîåéò êëåéäéÜ: Óáê÷áñþäçò äéáâÞôçò ôýðïõ 2,ðñùôïâÜèìéá öñïíôßäá õãåßáò. ÕðïâëÞèçêå: Ç åñãáóßá õðïâëÞèçêå ùò åëåýèåñç áíáêïßíùóç óôï 14ï ÐáíåëëÞíéï ÓõíÝäñéï ÃåíéêÞò ÉáôñéêÞò (ÊñÞôç, 8-12 ÌáÀïõ 2002) êáé Ýëáâå Ýðáéíï áðü ôçí ÅðéôñïðÞ Êñßóçò. Äçìïóéåýåôáé ìå êïéíÞ áðüöáóç ôçò ÓõíôáêôéêÞò ÅðéôñïðÞò ôïõ ðåñéïäéêïý êáé ôçò ÏñãáíùôéêÞò ÅðéôñïðÞò ôïõ Óõíåäñßïõ. Õðåýèõíïò áëëçëïãñáößáò: Ê. Óôåöáíïðïýëïõ, ÊÝíôñï Õãåßáò ÐåñÜìáôïò Ñåèýìíïõ, Ôçë.0834-023074, e-mail: serteda@otenet.gr


Ê. Óôåöáíïðïýëïõ êáé óõí.

Ôüìïò 14, Ôåý÷ïò 2, 2002

èíçóéìüôçôáò, ðïõ óõíäÝïíôáé ìå ôç íüóï,ç âåëôßùóç ôçò óõíïëéêÞò ðïéüôçôáò æùÞò ôùí äéáâçôéêþí áóèåíþí êáé ç ìåßùóç ôïõ êüóôïõò ðåñßèáëøçò. Summary ÅðïìÝíùò, åìöáíßæåôáé åðéôáêôéAim: To evaluate the results of the intervention program by the PMSP in the êÞ ç áíÜãêç óùóôÞò áíôéìåôþðéóçò diabetic patients of his/her area of responsibility after one year of the applicaôïõ óáê÷áñïäéáâçôéêïý áóèåíïýò, tion of the program. Evaluation was based on the following parameters: HbA1c ðñÜãìá ðïõ áðáéôåß, ü÷é ìüíï ôçí variation, lipid profile variation, changes in the patients' habits and lifestyle. êáôÜëëçëç öáñìáêåõôéêÞ áãùãÞ, áëëÜ Reference population-Methods: The study population consisted of 24 patients in whom the diagnosis of NIDDM type II was already established. They were êáé ôç óôåíÞ êáé äéáñêÞ åìðëïêÞ ôïõ inhabitants of the municipal areas of Garazo, Mourtzana, Episkopi and Kephali ãéáôñïý ðñùôïâÜèìéáò ðåñßèáëøçò, (total population: 870 inhabitants). After initial determination, in August 2000, of þóôå íá ìåãéóôïðïéçèåß ç óõììüñöùHbA1c levels and lipids profile, appropriate modifications and adjustments of óç ôïõ áóèåíïýò, ü÷é ìüíï ìå ôç öáñmedication in each patient were suggested. Patients were also advised to ìáêåõôéêÞ èåñáðåßá, áëëÜ ðñþôá change their lifestyle, to follow a specific dietary program, to exercise, to stop smoking and to limit their alcohol intake. Educational courses were organized, êáé êýñéá ìå ôï ðñïôåéíüìåíï ìïíôÝëï during which several aspects of NIDDM(prevention, pathology, complications, õãéåéíïäéáéôçôéêÞò áãùãÞò (áëëáãÞ ôïõ treatment) were discussed with the assistance of relevant audiovisual material. ôñüðïõ æùÞò ìå Ýìöáóç óôçí åöáñìïResults: One year after the initiation of the program, a decrease in HbA1c level ãÞ óõãêåêñéìÝíïõ äéáéôïëïãßïõ, óôçí up to 40% of the inital concentration was observed in almost all patients (21/ Üóêçóç, óôç äéáêïðÞ ôïõ êáðíßóìá24). Twelve patients managed to reduce their body weight up to 7 Kgr.Sixteen out of 22 patients presented an improved lipid profile accompanied by lifestyle ôïò êáé ôïí ðåñéïñéóìü ôïõ áëêïüë).12,13 and habits modification (reduced alcohol intake, giving up smoking). Óêïðüò ôçò óõãêåêñéìÝíçò ìåëÝConclusion: The combined effort of the PMSP and other health factors to ôçò åßíáé ç áîéïëüãçóç ôùí áðïôåëåinform the patients about NIDDM and to help them realize the importance of óìÜôùí ôçò ðáñÝìâáóçò ôïõ éáôñïý changes in diet and lifestyle for the course of the disease had really impressive ðåñéöåñåéáêïý éáôñåßïõ óå ãíùóôü results. ðëçèõóìü óáê÷áñïäéáâçôéêþí ôçò ðåHealth Center of Perama Rethymno ñéï÷Þò åõèýíçò ôïõ, üðùò áõôÞ åêäç• ÌéêñïáããåéïðÜèåéá, ðïõ ðñïêáëåß áìöéâëç- ëþíåôáé ìå ôçí åêôßìçóç ôùí ìåôáâïëþí ôçò Çba1C, ôïõ ëéðéäáéìéêïý ðñïößë, áëëÜ êáé ôéò óôñïåéäïðÜèåéá êáé íåöñïðÜèåéá5 êáé • ÍåõñïðÜèåéá5,6 ìåôáâïëÝò óôéò óõíÞèåéåò êáé ôïí ôñüðï æùÞò Áîéïóçìåßùôï åßíáé üôé ôá áããåéáêÜ åãêåöá- ôùí áóèåíþí áõôþí. ëéêÜ êáé ôá óôåöáíéáßá åðåéóüäéá, áðïôåëïýí ôçí êýñéá áéôßá èáíÜôïõ ôùí áóèåíþí ìå óáê÷áñþäç äéáâÞôç ôýðïõ 2.7-9 Õëéêü êáé ÌÝèïäïò Áí, åðéðñüóèåôá, åêôüò áðü ôïí óáê÷áñþäç äéáâÞôç ôýðïõ 2, ëÜâïõìå õðüøç ìáò êáé ôï MåëåôÞèçóáí, óõíïëéêÜ, 24 äéáãíùóìÝíïé ãåãïíüò üôé, ôï 65% ôùí áóèåíþí áõôþí Ý÷åé óáê÷áñïäéáâçôéêïß ôýðïõ 2, óå óýíïëï 870 êááõîçìÝíç áñôçñéáêÞ ðßåóç (>135/85 mmHg, ôïßêùí óôá äçìïôéêÜ äéáìåñßóìáôá ÃáñÜæïõ, óýìöùíá ìå ôá êñéôÞñéá ôçò JNC VI)10, åíþ ôï Ìïõñôæáíþí, ÅðéóêïðÞò êáé Êåöáëßïõ. 55% åìöáíßæåé óçìáíôéêÜ áõîçìÝíá åðßðåäá ëéÃéá üëïõò ôïõò áóèåíåßò, ðïõ ðåñéåëÞöèçóáí ðéäßùí11 óôï áßìá, ãßíåôáé öáíåñü, óå ôåëéêÞ áíÜ- óôç ìåëÝôç, óõìðëçñþèçêå, ôïí Áýãïõóôï ôïõ ëõóç, ðüóï áõîçìÝíïò êßíäõíïò õðÜñ÷åé ãéá ôç 2000, åéäéêü äåëôßï êáôáãñáöÞò ôùí äçìïãñáöéæùÞ ôùí áóèåíþí áõôþí12. êþí ôïõò óôïé÷åßùí, ôùí áíèñùðïìåôñéêþí ôïõò ÄåäïìÝíïõ, äå, êáé ôïõ ôåñÜóôéïõ êüóôïõò ÷áñáêôçñéóôéêþí êáé ôïõ áôïìéêïý éóôïñéêïý ôïõò. äéá÷åßñéóçò êáé íïóçëåßáò ëüãù ôùí åðéðëïêþí Ï êáèïñéóìüò ôïõ Äåßêôç ÌÜæáò Óþìáôïò (ãéá íá ìçí áíáöÝñïõìå ôïí ðüíï êáé ôçí ôáëáé- Ýãéíå ìå ôïí ðñïóäéïñéóìü ôïõ ýøïõò êáé ôç ìÝðùñßá ôùí áóèåíþí), ï êýñéïò óôü÷ïò ïðïéáóäÞ- ôñçóç ôïõ âÜñïõò, óýìöùíá ìå ôïí ôýðï Ä.ðïôå óôñáôçãéêÞò áíôéäéáâçôéêÞò èåñáðåßáò ðñÝ- Ì.Ó.= ÂÜñïò/(ýøïò)2. ðåé íá åßíáé ç ðñüëçøç Þ ç êáèõóôÝñçóç åìöÜíéÇ ýðáñîç óáê÷áñþäç äéáâÞôç äéáðéóôþèçóçò åðéðëïêþí, ç åëÜôôùóç ôçò íïóçñüôçôáò êáé êå åßôå áðü ôï éóôïñéêü ëÞøçò áíôéäéáâçôéêÞò Evaluation of an intervention program by the peripheral medical station physician (pmsp) in a known population of NIDDM patients in his/her area of responsibility after one year of its application Names ? ? ? ? ? ?

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ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

áãùãÞò (äéóêßá-éíóïõëßíç), åßôå áðü ôçí áíåýñåóç äõï äéáäï÷éêþí ôéìþí ãëõêüæçò íçóôåßáò >126mg/dl.14-21 Ïé áóèåíåßò, áíÜëïãá ìå ôç ÷ñÞóç êáðíïý, êáôçãïñéïðïéÞèçêáí óå ìç êáðíéóôÝò, ðñþçí êáðíéóôÝò êáé êáðíéóôÝò, åíþ áíÜëïãá ìå ôç ÷ñÞóç áëêïüë, êáôçãïñéïðïéÞèçêáí óå ìç ðüôåò (<10 ãñ. áëêïüëçò ôçí åâäïìÜäá), Þðéïõò ðüôåò (<150 ãñ. áëêïüëçò ôçí åâäïìÜäá), ìÝôñéïõò ðüôåò (<300 ãñ. áëêïüëçò ôçí åâäïìÜäá) êáé ðüôåò (>300 ãñ. áëêïüëçò ôçí åâäïìÜäá). Ç çìåñÞóéá êáôáíÜëùóç áëêïüë õðïëïãßóèçêå ìå âÜóç ôéò ðëçñïöïñßåò ãéá ôçí çìåñÞóéá êáôáíÜëùóç ìðßñáò, êñáóéïý, ëéêÝñ, óýìöùíá ìå ôïí ôýðï: áëêïüë=1/ 7*[(0,04Ì*12)+(0,15Ê*4)+(0,45Ë*1,5)+28,35)].22 ÐáñÜëëçëá, ðñáãìáôïðïéÞèçêå ìÝôñçóç ôçò áñôçñéáêÞò ðßåóçò, ìå õäñáñãõñéêü óöõãìïìáíüìåôñï, óå 3 äéáäï÷éêÝò, áíÜ äßëåðôï ìåôñÞóåéò. Ïé ìåôñÞóåéò Ýãéíáí óå êáèéóôÞ èÝóç, ìåôÜ áðü ðåíôÜëåðôç áíÜðáõóç êáé áöïý åß÷áí ðåñÜóåé, ôïõëÜ÷éóôïí 30 ëåðôÜ áðü ôçí ðüóç êáöåúíïý÷ïõ ñïöÞìáôïò Þ êáðíßóìáôïò. ÉêáíïðïéçôéêÞ ñýèìéóç ôçò áñôçñéáêÞò ðßåóçò ÷áñáêôçñßóèçêå ç ôéìÞ ôçò óõóôïëéêÞò áñôçñéáêÞò ðßåóçò <135 mmHg êáé ôçò äéáóôïëéêÞò áñôçñéáêÞò ðßåóçò <85 mmHg.23 ÌåôÜ ôïí áñ÷éêü ðñïóäéïñéóìü, ôïí Áýãïõóôï ôïõ 2000, ôùí ôéìþí ôïõ óáê÷Üñïõ íçóôåßáò óôï áßìá, ôçò ãëõêïæõëéùìÝíçò áéìïóöáéñßíçò (Hba1C), ôùí ôéìþí ôçò HDL êáé LDL ÷ïëçóôåñüëçò, ùò êáé ôùí ôñéãëõêåñéäßùí, êáèþò êáé ôïí õðïëïãéóìü ôïõ ÂÜñïõò, ôïõ Äåßêôç ÌÜæáò Óþìáôïò êáé ôçò áñôçñéáêÞò ðßåóçò, ïé ìåôñÞóåéò åðáíáëÞöèçêáí Üëëåò äõï öïñÝò, ðïõ áðåß÷áí ÷ñïíéêÜ ìåôáîý ôïõò Ýîé (6) ìÞíåò (äçë. ÖåâñïõÜñéï êáé Áýãïõóôï 2001). ÁðïäåêôÞ ôéìÞ ìåôáâïëéêïý åëÝã÷ïõ24-26, óýìöùíá ìå ôá äéåèíÞ äåäïìÝíá, üóïí áöïñÜ óôçí Hba1C èåùñåßôáé ôï 7%, åíþ ç ôéìÞ ôçò LDL ðñÝðåé íá äéáôçñåßôáé óå åðßðåäá £130mg/dl23. Óôá Üôïìá áõôÜ, ìåôÜ ôçí ðñþôç åêôßìçóç, Ýãéíáí ïé áíÜëïãåò, êáôÜ ðåñßðôùóç, ôñïðïðïéÞóåéò êáé ðñïóáñìïãÝò ôçò öáñìáêåõôéêÞò áãùãÞò êáé óõíåóôÞèç ìåôáâïëÞ ôïõ ôñüðïõ æùÞò24-25 (åéäéêüôåñá: åöáñìïãÞ óõãêåêñéìÝíïõ äéáéôïëïãßïõ13 ìå Ýìöáóç, ðÝñá áðü ôç ìåßùóç ôùí ðñïóëáìâáíïìÝíùí èåñìßäùí, óôçí áõîçìÝíç ðñüóëçøç öõôéêþí éíþí êáé óôç ìåéùìÝíç ðñüóëçøç ëßðïõò, óôçí Üóêçóç (æùçñü ðåñðÜôçìá ãéá ôïõëÜ÷éóôïí 30 ëåðôÜ, ôñåéò (3) öïñÝò ôçí åâäïìÜ114

Ê. Óôåöáíïðïýëïõ êáé óõí.

äá, óôç äéáêïðÞ ôïõ êáðíßóìáôïò êáé ôïí ðåñéïñéóìü ôïõ áëêïüë).23 ÐáñÜëëçëá, äéïñãáíþèçêáí åíçìåñùôéêÝò óõãêåíôñþóåéò ìå óõæçôÞóåéò êáé ðñïâïëÝò slides, ó÷åôéêÜ ìå ôïí óáê÷áñþäç äéáâÞôç ôýðïõ 2 (ðñüëçøç, ðáèïëïãßá, åðéðëïêÝò, áíôéìåôþðéóç).

ÓôáôéóôéêÞ áíÜëõóç Tá äåäïìÝíá êáôá÷ùñÞèçêáí óå âÜóç Excel 2000 êáé áðü åêåß áíáëýèçêáí. Ç ìÝóç ôéìÞ êÜèå äåßãìáôïò ðïóïôéêþí ðáñáôçñÞóåùí (ìåôñÞóåùí), õðïëïãßóèçêå ùò ôï áëãåâñéêü Üèñïéóìá üëùí ôùí ìåôñÞóåùí, äéáéñåìÝíï ìå ôï ðëÞèïò ôùí ìåôñÞóåùí áõôþí, åíþ, ùò ìÝôñï ôïõ âáèìïý äéáóðïñÜò ôùí ðáñáôçñÞóåùí ÷ñçóéìïðïéÞèçêå ç óôáèåñÞ áðüêëéóç S Þ SD (standard deviation). Ãéá ôç óýãêñéóç 2 ìÝóùí ôéìþí ðïóïôéêþí ðáñáôçñÞóåùí êáé ôçí áîéïëüãçóç ôçò óôáôéóôéêÞò óçìáíôéêüôçôáò ôçò äéáöïñÜò ôïõò ÷ñçóéìïðïéÞèçêå ç ôéìÞ ôïõ êñéôçñßïõ t (t-value), åíþ, ïé âáèìïß åëåõèåñßáò ãéá ôçí áîéïëüãçóç ôïõ êñéôçñßïõ (t), õðïëïãßóèçêáí ìå âÜóç ôïí ôýðï (n1+n22), üðïõ n1, n2 ôï ðëÞèïò ôùí ðáñáôçñÞóåùí êÜèå ïìÜäáò åëÝã÷ïõ.27

ÁðïôåëÝóìáôá ÌåëåôÞèçóáí, óõíïëéêÜ, 24 Üôïìá, 13 Üíäñåò (54,2%) êáé 11 ãõíáßêåò (45,8%). Ç ìÝóç çëéêßá ôïõ äåßãìáôïò Þôáí 69,4 Ýôç (±SD: 8,87 Ýôç). Äåí õðÞñîå óôáôéóôéêÜ óçìáíôéêÞ äéáöïñÜ, ìåôáîý ôçò çëéêßáò ôùí áíäñþí êáé ôùí ãõíáéêþí. ÁñôçñéáêÞ õðÝñôáóç åß÷áí 17/24 Üôïìá (70,8%), 9 Üíäñåò êáé 8 ãõíáßêåò. Ç ìÝóç ôéìÞ ôçò Ó.Á.Ð. Þôáí 147,1 (±13,8) mmHg, ìå ìÝóç ôéìÞ Ä.Á.Ð. 85,8 (±5,24) mmHg. Äåí âñÝèçêå óôáôéóôéêÜ óçìáíôéêÞ äéáöïñÜ óôçí áñôçñéáêÞ ðßåóç üóïí áöïñÜ ôï öýëï. ÌåôÜ ôçí ðáñÝëåõóç åíüò Ýôïõò ïé áíôßóôïé÷åò ìÝóåò ôéìÝò äéáìïñöþèçêáí ãéá ìåí ôç ÓÁÐ óôá 141,3 (±3,53) mmHg, åíþ ãéá ôç ÄÁÐ óôá 82,7 (±6,6) mmHg, ÷ùñßò, üìùò, ç öáéíïìåíéêÞ åëÜôôùóç íá åßíáé óôáôéóôéêÜ óçìáíôéêÞ óôï óõìâáôéêü åðßðåäï ôïõ 5% Þ ôïõëÜ÷éóôïí åíäåéêôéêÞ óôï åðßðåäï ôïõ 10%.


Ôüìïò 14, Ôåý÷ïò 2, 2002

Ê. Óôåöáíïðïýëïõ êáé óõí.

Ï ìÝóïò Äåßêôçò ÌÜæáò Óþìáôïò (Ä.Ì.Ó.) ôïõ äåßãìáôïò Þôáí 28,5 (±3,2) êáé äåí ðáñáôçñÞèçêå óôáôéóôéêÜ óçìáíôéêÞ äéáöïñÜ ìåôáîý áíäñþí êáé ãõíáéêþí. Öõóéïëïãéêü âÜñïò óå ó÷Ýóç ìå ôï ýøïò ôïõò (ÄÌÓ <25) åß÷áí ìüíï 2 Üôïìá (8,3%) (2 ãõíáßêåò), åíþ õðÝñâáñïé (ÄÌÓ: 25-30) êáé ðá÷ýóáñêïé (ÄÌÓ >30) Þôáí 22 Üôïìá (91,7%), 13 Üíäñåò êáé 9 ãõíáßêåò. Âåëôßùóç ôïõ ÄÌÓ ìåôÜ ôçí ðáñÝëåõóç åíüò Ýôïõò, ðáñïõóßáóáí 12 Üôïìá, ðïõ áðïôåëïýóáí ôï 50% ôùí áóèåíþí, Þôïé 7 Üíäñåò êáé 5 ãõíáßêåò. Ôá Üôïìá áõôÜ, êáôüñèùóáí íá ìåéþóïõí ôï óùìáôéêü âÜñïò ôïõò ìÝ÷ñé êáé 7 êéëÜ, ðáñ’ üëá áõôÜ ï ìÝóïò ÄÌÓ ðáñÝìåéíå, ïõóéáóôéêÜ óôáèåñüò (Ðßíáêåò 1, 2). Áññýèìéóôá, üóïí áöïñÜ óôá åðßðåäá ôïõ óáê÷Üñïõ óôï áßìá Þôáí 17Üôïìá (70,8%), 12 Üíäñåò êáé 7 ãõíáßêåò, ìå ìÝóç ôéìÞ óáê÷Üñïõ íçóôåßáò ôá 192,7 mg/dl êáé áðïäåêôÞ ôéìÞ ôá 140mg/dl23,28. Äåí âñÝèçêå óôáôéóôéêÜ óçìáíôéêÞ äéáöïñÜ óôéò ôéìÝò ôçò ãëõêüæçò óôï áßìá ìåôáîý áíäñþí êáé ãõíáéêþí. Êáô’ åðÝêôáóç äå, üóïí áöïñÜ óôéò ôéìÝò Ðßíáêáò 1. ÄÌÓ áôüìùí ìå ÓÄ 12

11

12

Ðßíáêáò 3. ÌåôáâïëÞ % HbA1c óå Üôïìá ìå ÓÄ

8

9

10

<25

7

8

25-28 28-35 35-40

6 4

2

2

0

0

2 0 0

Á

1

1

2

1

0

Ã

ôçò Hba1c óôï áßìá êáé óýìöùíá ìå ôéò äéåèíåßò ðáñáäï÷Ýò, ôéìÝò <7% (23) èåùñÞèçêáí éêáíïðïéçôéêÝò êáé ðáñáôçñÞèçêáí ôïí Áýãïõóôï ôïõ 2000 óå (6) Üôïìá, (25%), 3 Üíäñåò êáé 3 ãõíáßêåò, ôéìÝò ìåôáîý 7-8,5% èåùñÞèçêáí ùò ìÝôñéá éêáíïðïéçôéêÝò êáé äéáðéóôþèçêáí óå 3 Üôïìá (12,5%) (1 Üíäñá êáé 2 ãõíáßêåò), åíþ ôéìÝò >8,5% (ìç áðïäåêôÝò) âñÝèçêáí óå 15 Üôïìá (62,5%), 9 Üíäñåò êáé 6 ãõíáßêåò. ÌåôÜ ôçí ðáñÝìâáóÞ ìáò, äéáðéóôþèçêå üôé üëïé ó÷åäüí ïé áóèåíåßò, 21/24, äçëáäÞ ðïóïóôü (87,5%), ìåßùóáí ôç ãëõêïæõëéùìÝíç áéìïóöáéñßíç (Hba1c) ùò êáé 40% ôçò áñ÷éêÞò. ¸ôóé, åíþ ç ìÝóç ôéìÞ ôçò Hba1c Þôáí 9,2%, áõôÞ ìåéþèçêå óôï 7,6%, ôïí Áýãïõóôï ôïõ 2001 (Ðßíáêåò 3, 4). Ç äéáöïñÜ ôùí 2 ìÝóùí ôéìþí äåí åßíáé óôáôéóôéêÜ óçìáíôéêÞ óôï óõìâáôéêü åðßðåäï ôïõ 5% (Üñá p>0,05), åíþ, áíôßèåôá, êáëýðôåé ôï åíäåéêôéêü åðßðåäï ôïõ 10% (p<0,10). KáôÜ óõíÝðåéá, ÷ñåéÜæåôáé ìåãáëýôåñïò áñéèìüò ðáñáôçñÞóåùí ãéá ôç óôáôéóôéêÞ êáôï÷ýñùóç ôçò äéáöïñÜò. Áíáëõôéêüôåñá, ìåôÜ ôçí áñ÷éêÞ åêôßìçóç, ôéìÞ Hba1c <7% åß÷áí 9 Üôïìá (7 Üíäñåò êáé 2

>40 0

6 4

0-10% 10-20% 20-30% 30-40%

4 4

2 0

ÓÕÍ

7

6

2 ÂÅËÔÉÙÓÇ

0 0 0

ÅÐÉÄÅÉÍÙÓÇ

Ðßíáêáò 2. ÌåôáâïëÞ % ÄÌÓ áóèåíþí ìå ÓÄ 9 8 7 6 5 4 3 2 1 0

Ðßíáêáò 4. Óýãêñéóç ôéìþí HbA1c áôüìùí ìå ÓÄ ìåôÜ áðü äéÜóôçìá 1 Ýôïõò èåñáðåßáò 9

10 7

3

3 1

0-5%

4

5 10

ÂÅËÔÉÙÓÇ

à 2

2

5-10%

Á

0-5%

11 5-10%

ÅÐÉÄÅÉÍÙÓÇ

ÓÕÍ

14 12 10 8 6 4 2 0

15 9 6

8

7

3

ÁÕÃ.2000 ÁÕÃ.2001

ÊÁËÇ(<7) ÌÅÔÑÉÁ(7- ÊÁÊÇ(>8,5) 8,4)

115


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Ê. Óôåöáíïðïýëïõ êáé óõí.

ãõíáßêåò), ìåôáîý 7-8% 8 Üôïìá (2 Üíäñåò êáé 6 ãõíáßêåò), åíþ ðÜíù áðü 8,5%, 7 Üôïìá (4 Üíäñåò êáé 3 ãõíáßêåò). ÓôáôéóôéêÜ óçìáíôéêÞ äéáöïñÜ óôéò ôéìÝò ôçò Hba1c óôï áßìá ìåôáîý áíäñþí êáé ãõíáéêþí äåí âñÝèçêå. Áîéïóçìåßùôï åßíáé üôé ç åðéäçìéïëïãéêÞ ìåëÝôç ôïõ Wisconsin5 Ýäùóå éó÷õñÝò áðïäåßîåéò üôé óå áóèåíåßò ìå óáê÷áñþäç äéáâÞôç ôýðïõ 2, ðïõ õðïâëÞèçêáí óå ðáñáêïëïýèçóç åðß 10 Ýôç, ï âáèìüò êáé ç äéÜñêåéá ôçò õðåñãëõêáéìßáò, ðïõ áîéïëïãÞèçêáí ìå âÜóç ôç ãëõêïæõëéùìÝíç áéìïóöáéñßíç, áðïôÝëåóáí óçìáíôéêü ðáñÜãïíôá ðñüâëåøçò ôüóï ãéá ôéò ìéêñï- üóï êáé ôéò ìáêñïáããåéáêÝò åðéðëïêÝò. Ç âåëôßùóç ôïõ ãëõêáéìéêïý åëÝã÷ïõ ðñïëáìâÜíåé ôéò åðéðëïêÝò29-31. Ùò ðñïò ôï óõíåêôéìçèÝí ëéðéäáéìéêü profile, üðùò áõôü åêöñÜæåôáé, êõñßùò, ìå ôéò ôéìÝò ôçò LDL, ðïõ ðëÝïí åðéäéþêåôáé íá äéáôçñåßôáé óå åðßðåäá £130mg/dl óôï áßìá23,28, 16 áðü ôïõò 22 åíáðïìåßíáíôåò óôçí ïìÜäá åëÝã÷ïõ áóèåíåßò (2 áðåâßùóáí êáôÜ ôç äéÜñêåéá ôçò ìåëÝôçò), ðáñïõóßáóáí âåëôßùóç, ìÝ÷ñé êáé ðÜíù áðü 20% (Ðßíáêáò 5). ¸ôóé, ç ìÝóç ôéìÞ ôçò LDL åëáôôþèçêå áðü ôá 131 óå 121,5 mg/dl, óôï ÷ñïíéêü äéÜóôçìá ìåôáîý ôùí ìåôñÞóåùí áõôþí, ÷ùñßò, üìùò, íá ôåêìçñéùèåß ç óôáôéóôéêÞ óçìáíôéêüôçôá áõôÞò ôçò äéáöïñÜò óôï óõìâáôéêü åðßðåäï ôïõ 5%. ÐáñÜëëçëá, áîéïóçìåßùôï åßíáé üôé áíÜëïãï ðïóïóôü áóèåíþí ìå óáê÷áñþäç äéáâÞôç ôýðïõ 2, âåëôßùóáí ôéò óõíÞèåéåò êáé ôïí ôñüðï æùÞò ôïõò. ¸ôóé, óôáìÜôçóáí íá êáðíßæïõí 6 Üôïìá óå óýíïëï 8 êáðíéóôþí (75%), åíþ áðü ôïõò ìç êáðíßæïíôåò, êáíåßò äåí Üñ÷éóå ôï êÜðíéóìá. Åðßóçò, óôáìÜôçóáí íá ðßíïõí Þ ðåñéüñéóáí ôï áëêïüë 5 Üôïìá óå óýíïëï 10 áôüìùí (50%), Ðßíáêáò 5. ÌåôáâïëÞ LDL áóèåíþí ìå ÓÄ

10

10

8 6 4 2 0

116

ÂÅËÔÉÙÓÇ ÅÐÉÄÅÉÍÙÓÇ 4

3

0-10%

2 10-20%

2

1

>20%

ðïõ ðåñéåëÜìâáíå, Þðéïõò êáé ìÝôñéïõò ðüôåò.

ÓõìðåñÜóìáôá Ôá áðïôåëÝóìáôá ôçò ðáñÝìâáóÞò ìáò õðÞñîáí, êáô’ áñ÷Þí, éêáíïðïéçôéêÜ, ùò áðüññïéá ôçò óõíôïíéóìÝíçò ðñïóðÜèåéáò ôïõ éáôñïý ðåñéöåñåéáêïý éáôñåßïõ êáé ÊÝíôñïõ Õãåßáò, ãéá åíçìÝñùóç êáé êéíçôïðïßçóç ôùí áóèåíþí ãéá èÝìáôá ó÷åôéêÜ ìå ôç íüóï ôïõ óáê÷áñþäç äéáâÞôç, äßíïíôáò éäéáßôåñç Ýìöáóç óôçí êáôáíüçóç áðü ðëåõñÜò ôïõò ôçò óðïõäáéüôçôáò ôçò áëëáãÞò ôùí õãéåéíïäéáéôçôéêþí óõíçèåéþí ôïõò. ÂÝâáéá ï ìéêñüò áñéèìüò ôùí ðáñáôçñÞóåùí äåí ìáò åðÝôñåøå íá ôåêìçñéþóïõìå ôç óôáôéóôéêÞ óçìáíôéêüôçôá ôùí ðáñáôçñçèåéóþí ìåôáâïëþí.

ÓõæÞôçóç O ÓÄ Ý÷åé áíáãíùñéóèåß ðëÝïí ùò ðñüâëçìá, ðïõ áõîÜíåôáé óôéò äõôéêÝò êïéíùíßåò. Åßíáé åíäåéêôéêü üôé ôï 1985, ðåñßðïõ 30.000.000 Üíèñùðïé ó’ üëï ôïí êüóìï Ýðáó÷áí áðü óáê÷áñþäç äéáâÞôç, ôï 1998 ïé áóèåíåßò õðïëïãßóèçêáí óå 143.000.000 êáé ï áñéèìüò ôïõò áíáìÝíåôáé íá áíÝëèåé ôï 2025 óå, ðåñßðïõ, 300.000.00032-34. Óôéò ÇÐÁ ôï ðïóïóôü ôùí óáê÷áñïäéáâçôéêþí ôýðïõ 2 åããßæåé, ðëÝïí, ôï 7%2, åíþ, ðåñßðïõ, 1.000.000 ¸ëëçíåò ôáëáéðùñïýíôáé áðü óáê÷áñþäç äéáâÞôç êáé êéíäõíåýïõí áðü ôéò åðéðëïêÝò ôïõ. Ç íüóïò ðáñïõóéÜæåôáé ýðïõëá óå åíçëßêïõò35-37 (óõíÞèùò >40 åôþí, áí êáé óôçí âéâëéïãñáößá ðåñéãñÜöïíôáé êáé ðåñéðôþóåéò ðáéäéþí Þ åöÞâùí ìå óáê÷áñþäç äéáâÞôç ôýðïõ 2)34,35 êáé åìöáíßæåôáé ðåñéóóüôåñï óõ÷íÜ óå ðá÷ýóáñêá Üôïìá, ðïõ êÜíïõí êáèéóôéêÞ æùÞ, ðñïóëáìâÜíïõí ìå ôç äéáôñïöÞ ôïõò ðåñéóóüôåñá ëéðáñÜ êáé Ý÷ïõí èåôéêü ïéêïãåíåéáêü éóôïñéêü.40-43 Ôï óùìáôéêü âÜñïò åßíáé ï óçìáíôéêüôåñïò ðáñÜãïíôáò êéíäýíïõ ãéá ôï äéáâÞôç44-47, ï ïðïßïò ìðïñåß íá ôñïðïðïéçèåß, áöïý ï ðÜó÷ùí ìðïñåß, êáé åðéâÜëëåôáé, íá åëáôôþóåé ôï óùìáôéêü ôïõ âÜñïò, åöüóïí åßíáé ðá÷ýóáñêïò. Ç âáñýôçôá ôçò íüóïõ ôïõ óáê÷áñþäç äéáâÞôç ïöåßëåôáé óôéò äéÜöïñåò åðéðëïêÝò ôçò. Ôï 75% ôùí óáê÷áñïäéáâçôéêþí áóèåíþí ðåèáßíåé ùò áðïôÝëåóìá ôùí äéáöüñùí êáñäéáããåéáêþí


Ôüìïò 14, Ôåý÷ïò 2, 2002

Ê. Óôåöáíïðïýëïõ êáé óõí.

åðéðëïêþí.23 Ôï äéáâçôéêü ðüäé êáôÝ÷åé ëüãù ôïõ óõ÷íïý óõíäõáóìïý ôïõ ìå íåõñïðÜèåéá, éó÷áéìßá êáé ëïéìþîåéò ìéá åéäéêÞ èÝóç êáé áðïôåëåß ôçí êýñéá áéôßá áêñùôçñéáóìïý óôéò ÇÐÁ.48-50 Ç íåöñéêÞ áíåðÜñêåéá åßíáé ç äåýôåñç óõ÷íüôåñç áéôßá èáíÜôïõ êáé áíáðçñßáò êáé åìöáíßæåôáé ðåñßðïõ óôï 10% ôùí äéáâçôéêþí áóèåíþí.23 ÔÝëïò, ç äéáâçôéêÞ áìöéâëçóôñïåéäïðÜèåéá åßíáé ç ðéï óõ÷íÞ áéôßá íÝùí ðåñéðôþóåùí ôýöëùóçò óôïõò Áìåñéêáíïýò (20-74 åôþí) êáé öèÜíåé ôéò 20.000 íÝåò ðåñéðôþóåéò ôï ÷ñüíï.23 Óôü÷ïò ôïõ êëéíéêïý ãéáôñïý åßíáé íá ìÜèåé óôïõò áóèåíåßò ôïõ íá æïõí ìå ôï óáê÷áñþäç äéáâÞôç. Ç áíôéìåôþðéóç ôçò íüóïõ åðéêåíôñþíåôáé óôï óùóôü ìåôáâïëéêü Ýëåã÷ï, óôçí õðïóôÞñéîç ôçò áõôïöñïíôßäáò ôïõ áóèåíïýò êáé óôçí ðñüëçøç ôùí åðéðëïêþí. ÓõíÞèùò, ãéá ôïýôï, åßíáé æùôéêÞò óçìáóßáò ìéá ïìÜäá åéäéêþí, ðïõ èá ðñïóåããßóåé êáé èá öñïíôßóåé ôïí äéáâçôéêü áóèåíÞ. ¼ëïé ïé íÝïé áóèåíåßò, åöüóïí êáé ïé ßäéïé ôï åðéèõìïýí, ðñÝðåé íá Ý÷ïõí ëåðôïìåñÞ åíçìÝñùóç êáé åêðáßäåõóç23 ó÷åôéêÜ ìå ôç íüóï ôïõò, ôéò áëëáãÝò ðïõ åðéâÜëëïíôáé óôïí ôñüðï ôçò æùÞò ôïõò, êáèþò êáé ãéá ôá óõìðôþìáôá êáé óçìåßá ôçò õðÝñ- Þ õðï-ãëõêáéìßáò êáé ôéò óõíÞèåéò åðéðëïêÝò. Ôï ìÞíõìá, ðïõ ðñÝðåé íá ëÜâïõí åßíáé üôé: á) Ï óáê÷áñþäçò äéáâÞôçò åßíáé ìéá óïâáñÞ áóèÝíåéá êáé â) üôé ïé áëëáãÝò óôïí ôñüðï æùÞò (äéáéôçôéêÝò óõíÞèåéåò, êÜðíéóìá, åðßðåäï öõóéêÞò äñáóôçñéüôçôáò), ðáßæïõí ïõóéáóôéêü ñüëï óôçí áíôéìåôþðéóÞ ôçò. Áõôü, áêñéâþò, ðñïóðáèÞóáìå êáé ðéóôåýù üôé ðåôý÷áìå, óå éêáíïðïéçôéêü âáèìü, íá êÜíïõìå óôçí õðü Ýëåã÷ï ïìÜäá ôùí óá÷áñïäéáâçôéêþí áóèåíþí, óôçí ðåñéï÷Þ åõèýíçò ôïõ ðåñéöåñåéáêïý éáôñåßïõ ÃáñÜæïõ. ÂÝâáéá, ç áíôéìåôþðéóç åßíáé ðïëýðëïêç êáé áðáéôåß óõíÝ÷åéá óôç ó÷Ýóç ôïõ áóèåíïýò ìå ôïí ãéáôñü ðñùôïâÜèìéáò ðåñßèáëøçò. ÁõôÞ ç ó÷Ýóç ðñÝðåé íá åßíáé öéëéêÞ, þóôå íá ìåãéóôïðïéçèåß ç óõììüñöùóç ôïõ áóèåíïýò ìå ôçí ðñïôåéíüìåíç èåñáðåõôéêÞ áãùãÞ êáé óå ôåëéêÞ áíÜëõóç, ï ßäéïò ï ãéáôñüò èá Ý÷åé ôçí åõ÷Üñéóôç åìðåéñßá ôçò éêáíïðïßçóçò áðü ôçí ðñüëçøç ôñáãéêþí

åðéðëïêþí.

Âéâëéïãñáößá 1. National Diabetes Information clearinghouse. Diabetes Statistics. NIH publication no.96-3926. Washington, DC: US Department of Health and Human Services, Public Health Service, National Institutes of Health, 1995. 2. M.I. Harris. Undiagnosed NIDDM: clinical and public health issues. Diabetes care, 16:642652, 1993. 3. G.C. Gill. Type 2 diabetes-is it "mild diabetes"? Pract Diabetes, 3:280-282, 1986. 4. J. Pirart. Diabetes mellitus and its degenerative complications. A prospective study of 4,400 patients observed between 1947 and 1973. Diabetes Care, 1:168-188, 1978. 5. R. Klein. Hyperglycemia and microvascular and macrovascular disease in diabetes. Diabetes Care, 18:258-271, 1995. 6. J.W. Meijer, E. van Sonderen, E.E. Blaauwwiekel, A.J. Smit, J.W. Groothhoff. Diabetic neuropathy examination hierarchical scoring system to diagnose distal polyneuropathy in diabetes. Diabetes Care, 23:750-3, 2000. 7. M. Laakso. Glycemic control and the risk for coronary heart disease in-patients with noninsulin-dependent diabetes mellitus: the Finnish Studies. Ann. Intern. Med., 124:127-130, 1996. 8. B.L. Rodriguez, N.L. Lau, C.M. Burchfiel, et al. Glucose intolerance and 23-year risk of coronary heart disease and total mortality: The Honolulu Heart Program. Diabetes care, 22:1262-65, 1999. 9. E. Barrett-Connor, A. Ferrara. Isolated postchallenge hyperglycemia and the risk of fatal cardiovascular disease in older women and men. The rancho Bernardo study. Diabetes Care, 21:1236-39, 1998. 10. Joint National Committee. Detection, Evaluation and Treatment of high blood pressure. arch. Inter. Med. 1997, 24:2413-2446. 11. C.H. Hawks. Twin studies in diabetes mellitus. Diabetic Med. 347-352, 1997. 12. J.S. Yudkins. How can we prolong life? Benefits of coronary risk factors reduction in nondiabetic and diabetic subjects. BMJ, 306:13131318, 1993. 13. American Diabetes Association: nutritional recommendations and principles for individu117


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ISSN 1105-7432 Ôñéìçíéáßá ¸êäïóç ôçò ÅëëçíéêÞò Åôáéñåßáò ÃåíéêÞò ÉáôñéêÞò Quarterly edited by the Greek Association of General Practitioners...

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