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ðñùôïâÜèìéá Ôüìïò 15, Ôåý÷ïò 2, Áðñßëéïò - Éïýíéïò 2003

öñïíôßäá õãåßáò

Primary Health Care Ôñéìçíéáßá ¸êäïóç ôçò ÅëëçíéêÞò Åôáéñåßáò ÃåíéêÞò ÉáôñéêÞò Quarterly edited by the Greek Association of General Practitioners ÐåñéëáìâÜíåôáé óôçí çëåêôñïíéêÞ âÜóç Index Copernicus. Included in Index Copernicus electronic data base Ôüìïò 15, Ôåý÷ïò 2, Áðñßëéïò - Éïýíéïò 2003, Volume 15, Number 2, April - June 2003

Ôçò Óýíôáîçò 54

Å.Á. Èçñáßïò: 15o ÐáíåëëÞíéï ÓõíÝäñéï ÃåíéêÞò ÉáôñéêÞò Âñáâåõèåßóá åñãáóßá óôï Äéáãùíéóìü "Ä. ºêêïõ"

57

Á. ÆåúìðÝêçò, ×. Ðßôóáâïò, Ä. ÐáíáãéùôÜêïò, ×. ×ñõóï÷üïõ, É. Óêïýìáò, Ì. Ôïýôïõæá, Ð. Ôïýôïõæáò, ×. ÓôåöáíÜäçò: Óôåöáíéáßá íüóïò êáé ðáñÜãïíôåò êáñäéáããåéáêïý êéíäýíïõ óå ôõ÷áßï äåßãìá ôïõ ðëçèõóìïý: ÅðéäçìéïëïãéêÞ ìåëÝôç “ÁÔÔÉÊÇ” Åðáéíåèåßóá åñãáóßá óôï Äéáãùíéóìü "Ä. ºêêïõ"

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Å. ÂåêñÞ, ×. Ëçîïõñéþôçò, Á. Ìáñéüëçò, Å. ÌåóóÜñçò, Í. ÐáñáñÜò, Â. Âïõãéïýêáò, Æ. ÁëìÜæ, Á. Ìïíáóôçñéþôçò, Í. Áëåîáíäñüðïõëïò, Á. ÌïõëáêÜêçò: Ìðïñåß ç C-Áíôéäñþóá ÐñùôåÀíç íá áðïôåëÝóåé ðñïãíùóôéêü äåßêôç óôá ÁããåéáêÜ ÅãêåöáëéêÜ Åðåéóüäéá óôçí ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò;

ÐÑÙÔÏÂÁÈÌÉÁ ÖÑÏÍÔÉÄÁ ÕÃÅÉÁÓ – Primary Health Care

Âñáâåõèåßóåò åëåýèåñåò áíáêïéíþóåéò 73

Á. Ìáñéüëçò, ×. ÊáëáúôæÞ, Á. ÆåúìðÝêçò, Áéêáôåñßíç ÖïõôóéôæÞ-Äáíßêá, Í. Áëåîáíäñüðïõëïò, Ã. ÃåùñãéÜäçò: Ç ìÝôñçóç ôçò áñôçñéáêÞò ðßåóçò óôï óðßôé êáé ç óõìâïëÞ ôçò óôçí êáëýôåñç èåñáðåõôéêÞ áíôéìåôþðéóç ôùí õðåñôáóéêþí áôüìùí óôçí ðåñéï÷Þ åõèýíçò KÝíôñïõ Yãåßáò Âýñùíá

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Á. Ìðáôßêáò, Ê. Óôåöáíïðïýëïõ, É. ÄñõãéáííÜêçò, Á. ÐåôñÜêç, Í. ÐáðáäÜêçò: KáôáíÜëùóç áëêïüë áðü åöÞâïõò: Mßá åðéêßíäõíç ðñáãìáôéêüôçôá

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Ê. Óõñéáíüò, Â. ËÝôôá, Ä. ÊáêëáìÜíïõ: Ïé ôñïðïðïéÞóéìïé ðáñÜãïíôåò ðïõ êáèïñßæïõí ôçí ðéèáíüôçôá åðéâßùóçò áóèåíþí ìå åîùíïóïêïìåéáêÞ êáñäéáêÞ áíáêïðÞ Êåßìåío ïìïöùíßáò

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ÂÞìáôá ãéá ôçí áíÜðôõîç êáôåõèõíôÞñéùí ïäçãéþí óôç ÃåíéêÞ ÉáôñéêÞ óôçí ÅëëÜäá: Ýíá êåßìåíï ïìïöùíßáò Áíôáðüêñéóç áðü ôçí ÊñÞôç

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2ç Åëëçíï-ÏëëáíäéêÞ ÓõíÜíôçóç ãéá ôéò ÊáôåõèõíôÞñéåò Ïäçãßåò óôç ÃåíéêÞ ÉáôñéêÞ

ÐËÇÑÙÌÅÍÏ ÔÅËÏÓ Ôá÷. Ãñáöåßï Ê. Ä. Áèçíþí Áñéèìüò ¢äåéáò 451/91

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. (2310) 910342

Äéïéêçôéêü Óõìâïýëéï ôçò ÅëëçíéêÞò Åôáéñåßáò ÃåíéêÞò ÉáôñéêÞò Ðñüåäñïò ÌðïäïóÜêçò-Ðñüäñïìïò Ìåñêïýñçò Áíôéðñüåäñïò Á ×ñÞóôïò ËéoíÞò Áíôéðñüåäñïò  Áíôþíçò Êáñüôóçò Ãåíéêüò ÃñáììáôÝáò-Ôáìßáò ÁèáíÜóéïò Óõìåùíßäçò Åéäéêüò ÃñáììáôÝáò ÓôÝëëá ÁñãõñéÜäïõ ÌÝëç ÁíÜñãõñïò Ìáñéüëçò Áíôþíçò Ìðáôßêáò Executive Board of the Greek Association of General Practitioners President Bodosakis-Prodromos Merkouris Vice-President A Christos Lionis Vice-President B Antonis Karotsis General Secretary Treasurer Athanasios Symeonidis Special Secretary Stella Argiriadou Members Anargiros Margiolis Antonis Batikas Ãñáììáôåßá Óýíôáîçò: Áíáóôáóßá Ñùìáíßäïõ Ôçë.: (2810) 394615, (28310) 25833 Åêôýðùóç: ÔÅ×ÍÏÃÑÁÌÌÁ Ì. ÁõãÝñç 12, 153 43 Áã. ÐáñáóêåõÞ Ôçë.: 210.60.00.643, Fax: 210.6002295 E-mail: techn@hol.gr

ISSN 1105-7432

ÄéåõèõíôÞò Óýíôáîçò

Editor-in-Chief:

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

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

ÁíáðëçñùôÝò Ä/íôÝò Óýíôáîçò

Associate Editors

Íßêïò ÁíôùíÜêçò (ÇñÜêëåéïí) ÅëåõèÝñéïò Èçñáßïò (ÁèÞíá)

Nick Antonakis (Heraklion) Åleftherios Thireos (Athens)

Åðßêïõñïé Ä/íôÝò Óýíôáîçò

Assistant Editors

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

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

ÌÝëç ÓõíôáêôéêÞò ÅðéôñïðÞò

Members of Editorial Board

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

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

ÁíôáðïêñéôÝò Óýíôáîçò

Corresponding Editors

Êýðñïò ¸ëåíá ÅõáããåëÜêç Èåïäþñá Æá÷áñéÜäïõ Áëâáíßá Llukan Rrumbullaku

Cyprus Elena Evaggelaki 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

M. ÓãÜíôæïò, ËÝêôïñáò Áíáôïìßáò Ðáí/ìßïõ Èåó/ëßáò

M. Syantzos, Lector of Anatomy in University of Thessalia

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 ÐåñéëáìâÜíåôáé óôçí çëåêôñïíéêÞ âÜóç Index Copernicus. Included in Index Copernicus electronic data base Ôüìïò 15, Ôåý÷ïò 2, Áðñßëéïò - Éïýíéïò 2003, Volume 15, Number 2, April - June 2003

ÐÅÑÉÅ×ÏÌÅÍÁ Ôçò Óýíôáîçò Å.A. Èçñáßïò: 15o ÐáíåëëÞíéï ÓõíÝäñéï ÃåíéêÞò ÉáôñéêÞò ........................................................................................................................................... 54 Âñáâåõèåßóá åñãáóßá óôï Äéáãùíéóìü "Ä. ºêêïõ" Á. ÆåúìðÝêçò, ×. Ðßôóáâïò, Ä. ÐáíáãéùôÜêïò, ×. ×ñõóï÷üïõ, É. Óêïýìáò, Ì. Ôïýôïõæá, Ð. Ôïýôïõæáò, ×. ÓôåöáíÜäçò: Óôåöáíéáßá íüóïò êáé ðáñÜãïíôåò êáñäéáããåéáêïý êéíäýíïõ óå ôõ÷áßï äåßãìá ôïõ ðëçèõóìïý: ÅðéäçìéïëïãéêÞ ìåëÝôç “ÁÔÔÉÊÇ” ................................................................................................................................................................................................... 57 Åðáéíåèåßóá åñãáóßá óôï Äéáãùíéóìü "Ä. ºêêïõ" Å. ÂåêñÞ, ×. Ëçîïõñéþôçò, Á. Ìáñéüëçò, Å. ÌåóóÜñçò, Í. ÐáñáñÜò, Â. Âïõãéïýêáò, Æ. ÁëìÜæ, Á. Ìïíáóôçñéþôçò, Í. Áëåîáíäñüðïõëïò, Á. ÌïõëáêÜêçò: Ìðïñåß ç C-Áíôéäñþóá ÐñùôåÀíç íá áðïôåëÝóåé ðñïãíùóôéêü äåßêôç óôá ÁããåéáêÜ ÅãêåöáëéêÜ Åðåéóüäéá óôçí ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò; .............................................................................................................. 68 Âñáâåõèåßóåò åëåýèåñåò áíáêïéíþóåéò Á. Ìáñéüëçò, ×. ÊáëáúôæÞ, Á. ÆåúìðÝêçò, Áéêáôåñßíç ÖïõôóéôæÞ-Äáíßêá, Í. Áëåîáíäñüðïõëïò, Ã. ÃåùñãéÜäçò: Ç ìÝôñçóç ôçò áñôçñéáêÞò ðßåóçò óôï óðßôé êáé ç óõìâïëÞ ôçò óôçí êáëýôåñç èåñáðåõôéêÞ áíôéìåôþðéóç ôùí õðåñôáóéêþí áôüìùí óôçí ðåñéï÷Þ åõèýíçò KÝíôñïõ Yãåßáò Âýñùíá ..................................................................................................... 73 Á. Ìðáôßêáò, Ê. Óôåöáíïðïýëïõ, É. ÄñõãéáííÜêçò, Á. ÐåôñÜêç, Í. ÐáðáäÜêçò: KáôáíÜëùóç áëêïüë áðü åöÞâïõò: Mßá åðéêßíäõíç ðñáãìáôéêüôçôá ..................................................................................................................................................................................................... 79 Ê. Óõñéáíüò, Â. ËÝôôá, Ä. ÊáêëáìÜíïõ: Ïé ôñïðïðïéÞóéìïé ðáñÜãïíôåò ðïõ êáèïñßæïõí ôçí ðéèáíüôçôá åðéâßùóçò áóèåíþí ìå åîùíïóïêïìåéáêÞ êáñäéáêÞ áíáêïðÞ .............................................................................................................................................................. 84 Êåßìåío ïìïöùíßáò ÂÞìáôá ãéá ôçí áíÜðôõîç êáôåõèõíôÞñéùí ïäçãéþí óôç ÃåíéêÞ ÉáôñéêÞ óôçí ÅëëÜäá: Ýíá êåßìåíï ïìïöùíßáò ................... 91 Áíôáðüêñéóç áðü ôçí ÊñÞôç 2ç Åëëçíï-ÏëëáíäéêÞ ÓõíÜíôçóç ãéá ôéò ÊáôåõèõíôÞñéåò Ïäçãßåò óôç ÃåíéêÞ ÉáôñéêÞ ........................................................................ 94

CONTENTS Editorial E.A. Thireos: 15th National Congress of General Practice ............................................................................................................................................. 54 Awarded paper in the memory of Prof. D. Ikkou A Zeibekis, C. Pitsavos, D.B. Panagiotakos, C. Chrysohoou, J. Skoumas, M. Toutouza, P. Toutouzas, C. Stefanadis: Coronary heart disease and cardiovascular risk factors, in a random sample of males and females of Attica county: The “ATTICA STUDY” ........................................................................................................................................................................................................... 57 The second awarded paper in the memory of Prof. D. Ikkou I. Vekri, Ch. Lixuriotis, A. Mariolis, E. Mesaris, N. Pararas, V. Vougioukas, Z. Almaz, A. Monastiriotis, N. Alexandropoulos, A. Moulakakis: Can C-Reactive Protein be considered as marker in cerebral vascular stroke in the primary health care setting? ............................................................................................................................................................................................... 68 Awarded Freestanding Papers A. Mariolis, C. Kalaitzi, A. Zeimbekis, A. Foutsitzi-Danika, N. Alexandropoulos, G. Georgiadis: Blood pressure mesurement in the patient’s home and it’s contribution in the better therapeutic approach of hypertensive patients in the catchment area of the Vyronas Health Centre ....................................................................................................................................................... 73 A. Batikas, K. Stefanopoulou, I. Drygjannakis, A. Petraki, N. Papadakis: Alcohol consumption by adolescents: A dangerous reality .................................................................................................................................................................................................................................. 79 K. Syrianos, V. Letta, D. Kaklamanou: The modifiable factors that determine the survival probability of petients with out-of-hospital cardiac arrest ................................................................................................................................................................................................. 84 Consensus Report Steps in developing guidelines in General Practice in Greece: a consensus report ................................................................................... 91 Correspondence from Crete 2nd Dutch-Greek Meeting “On Guidelines in General Practice” ................................................................................................................................ 94


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Å.Á. Èçñáßïò

ÔÇÓ ÓÕÍÔÁÎÇÓ EDITORIAL Primary Heatlh Care, Volume 15, Number 2, 54-56, 2003 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 15, Ôåý÷ïò 2, 54-56, 2003

15ï ÐáíåëëÞíéï ÓõíÝäñéï ÃåíéêÞò ÉáôñéêÞò Óéèùíßá ×áëêéäéêÞò, 30 Áðñéëßïõ – 4 ÌáÀïõ 2003 Å.Á. Èçñáßïò

Ôï 15ï ÐáíåëëÞíéï ÓõíÝäñéï ÃåíéêÞò ÉáôñéêÞò ðñáãìáôïðïéÞèçêå óôç Óéèùíßá ôçò ×áëêéäéêÞò áðü 30 Áðñéëßïõ Ýùò 4 ÌáÀïõ 2003. Äõóôõ÷þò ç åðéëïãÞ ôïõ îåíïäï÷åéáêïý óõãêñïôÞìáôïò Porto Carras ãéá ôç äéåîáãùãÞ ôùí åñãáóéþí ôïõ óõíåäñßïõ äåí Þôáí ç êáëýôåñç äõíáôÞ, ìéáò êáé áíáêáôáóêåõáæüôáí ãéá ôéò áíÜãêåò ôçò ÅõñùðáúêÞò Óõíüäïõ ÊïñõöÞò, ãåãïíüò ðïõ äçìéïýñãçóå ðïëëÜ ðñïâëÞìáôá óôçí ÏñãáíùôéêÞ ÅðéôñïðÞ ôïõ óõíåäñßïõ êáé óôïõò óõììåôÝ÷ïíôåò óõíÝäñïõò. Ïé åñãáóßåò ðÜíôùò ôïõ Óõíåäñßïõ ïëïêëçñþèçêáí ìå åðéôõ÷ßá êáé ç ëÞîç ôïõ âñÞêå ôçí ÅËÅÃÅÉÁ ìå íÝï Ä.Ó., ôï ïðïßï èá åðùìéóèåß êáé ôçí åõèýíç ôçò äéïñãÜíùóçò ôïõ Åõñùðáúêïý Óõíåäñßïõ ôçò WONCA óôçí ÁèÞíá óôéò 3-7 Óåðôåìâñßïõ 2005. Áðü ôçí åíáñêôÞñéá óõíåäñßáóç êáé ôï óôñïããõëü ôñáðÝæé ìå èÝìá “Áíáóõãêñüôçóç ôïõ ÅÓÕ: åñùôÞìáôá, ðñïâëçìáôéóìïß êáé ðñïïðôéêÞ” ìå óõíôïíéóôÞ ôïí Ðñüåäñï ôçò ÅëëçíéêÞò Åôáéñåßáò ÃåíéêÞò ÉáôñéêÞò ê. Ì.Ð. Ìåñêïýñç, óôï ïðïßï êáôÝèåóáí ôéò áðüøåéò ôïõò ïé ê. Ê. ÊáëëÝñãçò Ðñüåäñïò ´ Ðå.Ó.Õ.Ð. ÊåíôñéêÞò Ìáêåäïíßáò, Å. Êáëïêáéñéíüò Ðñüåäñïò ÐáíåëëÞíéïõ Éáôñéêïý Óõëëüãïõ, Ê. Êéëôßäçò ÂïõëåõôÞò ÍÝáò Äçìïêñáôßáò êáé Ì ÓðõñéäÜêçò Íïìáñ÷éáêüò Óýìâïõëïò Èåó/íßêçò åêðñüóùðïò ôïõ Ê.Ê.Å., íá óôáèïýìå óôçí åéóÞãçóç ôïõ ê. Ê. Óïõëéþôç Åðéóôçìïíéêïý Óõìâïýëïõ Õðïõñãåßïõ Õãåßáò êáé Ðñüíïéáò ìå ôßôëï “Ç ðïëéôéêÞ õãåßáò óôçí ÅëëÜäá ìåôÜ ôç èåóìïèÝôçóç ôïõ ÅÓÕ: ðñïêëÞóåéò êáé ðñïâëçìáôéóìïß ãéá ôçí áíáóõãêñüôçóç ôçò ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò”. Êáßñéåò ïé 54

åðéóçìÜíóåéò ôïõ ãéá ôï õöéóôÜìåíï ÷ñçìáôïäïôéêü ðëáßóéï: ñáãäáßá áýîçóç ôùí äáðáíþí õãåßáò (êáôÜ 9.1% åðß ôïõ ÁÅÐ ôç äåêáåôßá 19912000, ðïóïóôü ðïõ õðåñâáßíåé ôï ìÝóï üñï ôùí ÷ùñþí-ìåëþí ôïõ ÏÏÓÁ), áýîçóç ôçò éäéùôéêÞò äáðÜíçò (ïé éäéùôéêÝò äáðÜíåò áðïôåëïýí ôï 42% ôùí óõíïëéêþí äáðáíþí õãåßáò, ìå ôçí ðáñáïéêïíïìßá íá áíÝñ÷åôáé óôï 20% ðåñßðïõ, ãåãïíüò ôï ïðïßï óçìáßíåé üôé ðñáêôéêÜ ôï ÷ñçìáôïäïôéêü âÜñïò ôùí õðçñåóéþí õãåßáò ìåôáêõëýåôå óôá íïéêïêõñéÜ áêõñþíïíôáò Ýôóé óå ìåãÜëï âáèìü ôï äéêáßùìá ôçò áóöáëéóôéêÞò êÜëõøçò), ðñïóáíáôïëéóìüò ôùí äçìïóßùí äáðáíþí óôç íïóïêïìåéáêÞ ðåñßèáëøç (ðïõ áðïññïöÜ ôï 55% ðåñßðïõ) êáé ôùí éäéùôéêþí äáðáíþí óôçí åîùíïóïêïìåéáêÞ ðñùôïâÜèìéá ðåñßèáëøç (63% ðåñßðïõ). Ïé õöéóôÜìåíåò äïìÝò ôïõ ÉÊÁ óõíèÝôïõí ôçí ðëáôöüñìá ðÜíù óôçí ïðïßá Ý÷åé ïéêïäïìçèåß ôï óýóôçìá ðáñï÷Þò Ð.Ö.Õ. óôá áóôéêÜ êÝíôñá, åíþ ç ýðáñîç äýï êÝíôñùí åõèýíçò êáé ðáñï÷Þò ôùí õðçñåóéþí áõôþí (ÉÊÁ/ÅÓÕ) èåùñåßôáé õðåýèõíç ãéá ôéò äéáöïñïðïéÞóåéò óôéò ðáñå÷üìåíåò õðçñåóßåò, ôç óðáôÜëç ðüñùí êáé ôçí áóõíÝ÷åéá ôçò öñïíôßäáò. Ìéá óåéñÜ åñùôçìÜôùí áðáéôïýí áðáíôÞóåéò ðñïêåéìÝíïõ íá åöáñìïóôåß ï èåóìüò ôïõ “ðñïóùðéêïý” ïéêïãåíåéáêïý éáôñïý: Ðïéïò åßíáé ï áñéèìüò ôùí ãåíéêþí ãéáôñþí ï ïðïßïò áðáéôåßôáé ãéá ôç óõãêñüôçóç åíüò óõóôÞìáôïò âáóéóìÝíïõ óôï èåóìü êáé ðüóïò ÷ñüíï áðáéôåßôáé ãéá ôçí ðáñáãùãÞ ôïõ áñéèìïý áõôïý; Ðïéåò åßíáé ïé äéáèÝóåéò ôïõ éáôñéêïý óþìáôïò áëëÜ êáé ïé äéáèÝóåéò-ðñïóäïêßåò ôùí ÷ñçóôþí; Äýï ðñïôÜóåéò Ý÷ïõí êáôáôåèåß, ìå ôá ðëåïíåêôÞìá-


Ôüìïò 15, Ôåý÷ïò 2, 2003

Å.Á. Èçñáßïò

ôá êáé ôá ìåéïíåêôÞìáôá ôïõò ç êÜèå ìéá. Ç ðñþôç ðñïâëÝðåé äéïéêçôéêÞ, ïñãáíùôéêÞ êáé ëåéôïõñãéêÞ ïìïãåíïðïéÞóåé ôçò äÝóìçò ôùí ðáñï÷þí, õðü êñáôéêü Ýëåã÷ï êáé óõíôïíéóìü. Áõôü ðñáêôéêÜ óçìáßíåé õðáãùãÞ üëùí ôùí õöéóôÜìåíùí äïìþí óå åíéáßï ó÷Þìá óôá ðëáßóéá ôïõ ÅÓÕ. Óôï ó÷Þìá áõôü, ç äçìéïõñãßá êïìâéêþí óçìåßùí (ð.÷. Ïéêïãåíåéáêüò Éáôñüò) êáé ç õéïèÝôçóç åíáëëáêôéêþí ìç÷áíéóìþí áðïæçìßùóçò åßíáé åðéâåâëçìÝíá. Ìå ôçí õéïèÝôçóç áõôÞò ôçò ðñüôáóçò åîáóöáëßæåôáé ðëÞñçò êñáôéêüò Ýëåã÷ïò óôï óýóôçìá êáé ìáêñïðñüèåóìá ìðïñåß íá óõìâÜëëåé óôïí Ýëåã÷ï ôùí äáðáíþí, áëëÜ ðåñéïñßæåé ôçí åëåõèåñßá åðéëïãÞò ôùí ÷ñçóôþí, ðñïûðïèÝôåé áëëáãÞ ôïõ åñãáóéáêïý êáèåóôþôïò ôùí óõìâáóéïý÷ùí éáôñþí ôïõ ÉÊÁ êáé Ý÷åé õøçëü êüóôïò ìåôÜâáóçò. Ç äåýôåñç ðñüôáóç ðñïôåßíåé ôç äéáôÞñçóç ôïõ õöéóôÜìåíïõ ôñüðïõ êÜëõøçò óôéò áóôéêÝò ðåñéï÷Ýò êáé åíßó÷õóç ôçò õðïäïìÞò ôïõ ÉÊÁ, áðü ôï ïðïßï èá ìðïñïýí íá “áãïñÜæïõí” õðçñåóßåò õãåßáò ôá Üëëá áóöáëéóôéêÜ ôáìåßá. Óôá ðëáßóéá áõôÜ, ç äçìéïõñãßá ðïëõúáôñåßùí ôá ïðïßá èá óôåëå÷þíïíôáé áðü ïìÜäåò éáôñþí (group practices) ìðïñåß íá óõìðëçñþóåé ôï èåóìü ôïõ ïéêïãåíåéáêïý éáôñïý ìÝóá áðü äéáäéêáóßåò ïñéïèÝôçóçò ôïõ ðëçèõóìïý åõèýíçò ìå ìéá óåéñÜ áðü êñéôÞñéá. Ç ðñüôáóç áõôÞ ìïéÜæåé íá áðïôåëåß ìéá ðéï ñåáëéóôéêÞ åêäï÷Þ ìå ðéï Üìåóá áðïôåëÝóìáôá êáé ìå ìéêñüôåñï äéïéêçôéêü êüóôïò, ï Ýëåã÷ïò üìùò ôçò êåíôñéêÞò äéïßêçóçò èåùñåßôáé ðåñéïñéóìÝíïò êáé ùò åê ôïýôïõ äåí äéáóöáëßæåé ôçí ôÞñçóç ôùí äåóìåýóåùí ôùí ôáìåßùí. Ï ãüíéìïò áõôüò ðñïâëçìáôéóìüò óõíå÷ßóôçêå êáé óå äýï Üëëá åíäéáöÝñïíôá óôñïããõëÜ ôñáðÝæéá: · “ÁóôéêÜ ÊÝíôñá Õãåßáò: ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò êáé Ãåíéêüò Éáôñüò” ìå óõíôïíéóôÞ ôïí ê. ×. ËéïíÞ ÁíáðëçñùôÞ ÊáèçãçôÞ Ðáí/ìßïõ ÊñÞôçò êáé ïìéëçôÝò ôïõò Á. ÌðÝíï ÁíáðëçñùôÞ ÊáèçãçôÞ Ðáí/ìßïõ Èåó/íßêçò, É. ×áôæçãéÜííç Ä/íôñéá Õðçñåóéþí Õãåßáò ÉÊÁ, êáé Ì. ÊáëïåéäÜ Ãåíéêü Éáôñü. · “Ï ñüëïò ôïõ Ãåíéêïý Éáôñïý óå Åõñþðç êáé ÅëëÜäá. Ðáñüí êáé ìÝëëïí” ìå óõíôïíéóôÞ ôïí ê. Á. ÖéëáëÞèç ÁíáðëçñùôÞ ÊáèçãçôÞ Ðáí/ìßïõ ÊñÞôçò êáé ïìéëçôÝò äõï óçìáíôéêÝò ðñïóùðéêüôçôåò ôçò ÃåíéêÞò ÉáôñéêÞò óôçí Åõñþðç ôïõò P. Evans Ðñüåäñï ôçò ÅõñùðáúêÞò Åôáéñåßáò ÃåíéêÞò ÉáôñéêÞò êáé I. Pisco Ðñüåäñï ôçò ÐïñôïãáëéêÞò Åôáéñåßáò Ãåíé-

êÞò ÉáôñéêÞò, êáèþò êáé ôïí Ä. Ìðïýìðá ÊáèçãçôÞ Ðáí/ìßïõ ÊñÞôçò. Ôï õðüëïéðï åðéóôçìïíéêü ðñüãñáììá ôïõ óõíåäñßïõ ðåñéåëÜìâáíå 12 óôñïããõëÝò ôñÜðåæåò, 10 äéáëÝîåéò, 324 åëåýèåñåò áíáêïéíþóåéò, 80 áíáñôçìÝíåò áíáêïéíþóåéò (poster) êáé ôñßá êëéíéêÜ öñïíôéóôÞñéá.

ÊëéíéêÜ ÖñïíôéóôÞñéá · “Áíôéìåôþðéóç áóèåíþí ìå ðïëëáðëïýò êéíäýíïõò ãéá êáñäéáããåéáêÞ íüóï óå åðßðåäï ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò”. ÏìéëçôÝò: Ì. ÅëéóÜö ÊáèçãçôÞò Ðáèïëïãßáò Ðáí/ìßïõ Éùáííßíùí, Â. ÊáñáìÜíïò ÁíáðëçñùôÞò êáèçãçôÞò Ðáí/ìßïõ Áèçíþí, Ã. Óôåñãßïõ Åðßêïõñïò ÊáèçãçôÞò Ðáí/ìßïõ Áèçíþí · “Ç êáôÜèëéøç óôçí ÐñùôïâÜèìéá Ðåñßèáëøç. Ç óïâáñüôçôá ôïõ ðñïâëÞìáôïò êáé ç äéÜãíùóç. Ç öáñìáêåõôéêÞ áíôéìåôþðéóç”. ÏìéëçôÞò: É. ÐáñÜó÷ïò Øõ÷ßáôñïò · “Ç ðñáêôéêÞ êëéíéêÞ áíôéìåôþðéóç ôïõ ïóôåïðïñùôéêïý áóèåíïýò óå åðßðåäï ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò”. ÏìéëçôÝò: Ã. ÓêáñáíôÜâïò Ñåõìáôïëüãïò, Á. Ëïõôñéþôçò Ïñèïðáéäéêüò, Ã. ÓðáèáñÜêçò Ãåíéêüò Éáôñüò

ÓôñïããõëÝò ôñÜðåæåò · Ôï ãåíéêåõìÝíï Üã÷ïò óôçí ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò · Ç ÷ñÞóç êáé áîéïëüãçóç ôùí êáôåõèõíôçñßùí ïäçãéþí óôçí ÃåíéêÞ ÉáôñéêÞ · Áíôéìåôþðéóç åðåéãüíôùí ðåñéóôáôéêþí áðü ôïí Ãåíéêü Éáôñü · Óýã÷ñïíåò óôñáôçãéêÝò áíôéìåôþðéóçò áóèåíþí ìå ìåãÜëï êáñäéáããåéáêü êßíäõíï · Áèçñïèñüìâùóç: ìéá óõóôçìáôéêÞ íüóïò – ÄéÜãíùóç êáé èåñáðåßá · ÊáñäéáããåéáêÞ íüóïò êáé äõóëéðéäáéìßá. Íåüôåñåò áðüøåéò ãéá ôçí ðñüëçøç êáé ôçí áíôéìåôþðéóÞ ôçò · ÈåñáðåõôéêÞ ðñïóÝããéóç ôçò öëåãìïíÞò. Ðñïóäïêßåò êáé åðéöõëÜîåéò · ÍÝá äåäïìÝíá óôçí ðáèïãÝíåéá êáé èåñáðåßá ôïõ óáê÷áñþäç äéáâÞôç · ÊáëïÞèçò õðåñðëáóßá ôïõ ðñïóôÜôç. ÄéÜãíùóç êáé öáñìáêåõôéêÞ áíôéìåôþðéóç óôçí 55


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò · ÊáôÜèëéøç êáé ÷ñüíéá íïóÞìáôá · ×ñüíéá áðïöñáêôéêÞ ðíåõìïíïðÜèåéá: ìéá ðïëõðáñáãïíôéêÞ íüóïò – Óýã÷ñïíç èåñáðåõôéêÞ áíôéìåôþðéóç · Ç åéóáãùãÞ ôïõ âéâëéáñßïõ åéäéêåõïìÝíïõ óôçí åêðáßäåõóç ôùí Ãåíéêþí Éáôñþí. ¸íá ÷ñÞóéìï åñãáëåßï ãéá ôçí áíáâÜèìéóç ôçò åêðáßäåõóçò – Ðñïôåéíüìåíç âéâëéïãñáößá ãéá êÜèå Ãåíéêü Éáôñü

ÄéáëÝîåéò · ÏëõìðéáêÞ óõíäñïìéêÞ åðéôÞñçóç · ÁíôéâéïôéêÜ 2003: ðüôå, ðïéá êáé ãéáôß · Óáê÷áñþäçò äéáâÞôçò: íåüôåñåò åîåëßîåéò óôçí áíôéìåôþðéóÞ ôïõ · Óõíå÷éæüìåíç éáôñéêÞ åêðáßäåõóç ìå ÷ñÞóç ðïëõìÝóùí · Áíôéìåôþðéóç ëïéìþîåùí ôïõ áíáðíåõóôéêïý · Äõóðåøßá – Íõ÷ôåñéíÞ õðåñïîýôçôá · ×ñüíéá çðáôßôéäá  – Áðü ôç äéÜãíùóç óôç èåñáðåßá · Ìåôáâïëßôåò ôçò âéôáìßíçò D. Ïé ãíùóôïßÜãíùóôïé óôçí áíôéìåôþðéóç ôçò ïóôåïðüñùóçò · ¸ñåõíá óôç ÃåíéêÞ ÉáôñéêÞ: ïñãÜíùóç, äõóêïëßåò, äõíáôüôçôåò · Ç óçìáóßá ôçò ëåéôïõñãéêÞò áðïêáôÜóôáóçò óôéò ÷ñüíéåò ðáèÞóåéò

Å.Á. Èçñáßïò

ôåëÝóåé ðñïãíùóôéêü äåßêôç óôá áããåéáêÞ åãêåöáëéêÜ åðåéóüäéá óôçí ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò”, ôùí óõíáäÝëöùí Å. ÂåêñÞ, ×. Ëçîïõñéþôç, Á. Ìáñéüëç, Å. ÌåóóÜñç, Í. ÐáñáñÜ, Â. Âïõãéïýêá, Æ. ÁëìÜæ, Á. Ìïíáóôçñéþôç, Í. Áëåîáíäñüðïõëïõ, Á. ÌïõëáêÜêç. “Åðßäñáóç ôùí ìç óôåñïåéäþí áíôéöëåãìïíùäþí öáñìÜêùí óôçí áñôçñéáêÞ ðßåóç ôùí åíçëßêùí”, ôùí óõíáäÝëöùí Áè. ÂÞôá, Å. ÍåñáíôæÜêç, Áíä. ÂÞôá, ×. Óåìåñôæßäç.

Âñáâåßá åëåõèÝñùí áíáêïéíþóåùí “Ç ìÝôñçóç ôçò áñôçñéáêÞò ðßåóçò óôï óðßôé êáé ç óõìâïëÞ ôçò óôçí êáëýôåñç èåñáðåõôéêÞ áíôéìåôþðéóç ôùí õðåñôáóéêþí áôüìùí óôçí ðåñéï÷Þ åõèýíçò ÊÝíôñïõ Õãåßáò Âýñùíá”, ôùí óõíáäÝëöùí Á. Ìáñéüëç, ×. ÊáëáúôæÞ, Á. ÆåúìðÝêç. Á. ÖïõôæéôæÞ-Äáíßêá, Í. Áëåîáíäñüðïõëïõ, Ã. ÃåùñãéÜäç. “ÊáôáíÜëùóç áëêïüë áðü åöÞâïõò: ìéá åðéêßíäõíç ðñáãìáôéêüôçôá”, ôùí óõíáäÝëöùí Á. Ìðáôßêá, Ê. Óôåöáíïðïýëïõ, É. ÄñõãéáííÜêç, Á. ÐåôñÜêç, Í. ÐáðáäÜêç. “Ïé ôñïðïðïéÞóéìïé ðáñÜãïíôåò ðïõ êáèïñßæïõí ôçí ðéèáíüôçôá åðéâßùóçò áóèåíþí ìå åîùíïóïêïìåéáêÞ êáñäéáêÞ áíáêïðÞ”, ôùí óõíáäÝëöùí Ê. Óõñéáíïý, Â. ËÝôôá, Ä. ÊáêëáìÜíïõ.

¸ðáéíïé åëåõèÝñùí áíáêïéíþóåùí Ïé åñãáóßåò ôïõ óõíåäñßïõ Ýêëåéóáí ìå ôçí áðïíïìÞ ôùí âñáâåßùí “Ä. ºêêïõ” êáé åëåõèÝñùí áíáêïéíþóåùí, ôá ïðïßá Ýëáâáí:

Âñáâåßï Êáèçãçôïý “Ä. ºêêïõ” “Óôåöáíéáßá íüóïò êáé ðáñÜãïíôåò êáñäéáããåéáêïý êéíäýíïõ óå ôõ÷áßï äåßãìá ðëçèõóìïý: åðéäçìéïëïãéêÞ ìåëÝôç “ÁÔÔÉÊÇ””, ôùí óõíáäÝëöùí Á. ÆåúìðÝêç, ×. Ðßôóáâï, Ä. ÐáíáãéùôÜêïõ, ×. ×ñõóï÷üïõ, É. Óêïýìá, Ì. Ôïýôïõæá, Ð. Ôïýôïõæá, ×. ÓôåöáíÜäç.

¸ðáéíïé Êáèçãçôïý “Ä. ºêêïõ” “Ìðïñåß ç C-áíôéäñþóá ðñùôåÀíç íá áðï56

“Åêôßìçóç ôçò áíáãêáéüôçôáò æçôïõìÝíùí ìéêñïâéïëïãéêþí åîåôÜóåùí óå êÝíôñï ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò”, ôùí óõíáäÝëöùí Ä. Æþãá, Â. Æþãá, ×. Ôóéþëç, Ó. Ðáíáãéùôßäïõ, É. ÔóéÜëéïõ, Ê. Äéáìáíôüðïõëïõ, Í. Åëåõèåñßïõ. “ËåéôïõñãéêÞ äéáóýíäåóç êáé óõíåñãáóßá ôïõ ðñïóùðéêïý ôùí ÊÝíôñùí Õãåßáò ôïõ ´ Ðå.Ó.Õ.Ð. ÁôôéêÞò”, ôùí óõíáäÝëöùí Å. Èçñáßïõ, Í. ÃéáìáëÜêçò, Å. Ëýêïõ, Ì. Ðýëëç, Ã. ÌðÝëïõ, ×. Ïéêïíïìïðïýëïõ, Å. ÌùñáÀôç. “¸ðáéíïò Ã. ÐáðáäÜêç” “Äéá÷ñïíéêÞ åîÝëéîç ôçò èíçóéìüôçôáò áðü êáêïÞèç íåïðëÜóìáôá óôçí ðåñéï÷Þ åõèýíçò åíüò Ðåñéöåñåéáêïý Éáôñåßïõ ôçò ÊñÞôçò”, ôïõ óõíáäÝëöïõ Ê. ÊáôñéôæéäÜêç.


Ôüìïò 15, Ôåý÷ïò 2, 2003

Á. ÆåúìðÝêçò êáé óõí.

ÂÑÁÂÅÕÈÅÉÓÁ ÅÑÃÁÓÉÁ ÓÔÏ ÄÉÁÃÙÍÉÓÌÏ Ä. ÉÊÊÏÕ AWARDED PAPER IN THE MEMORY OF PROF. D. IKKOY Primary Heatlh Care, Volume 15, Number 2, 57-67, 2003 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 15, Ôåý÷ïò 2, 57-67, 2003

Óôåöáíéáßá íüóïò êáé ðáñÜãïíôåò êáñäéáããåéáêïý êéíäýíïõ óå ôõ÷áßï äåßãìá ôïõ ðëçèõóìïý: ÅðéäçìéïëïãéêÞ ìåëÝôç “ÁÔÔÉÊÇ” Á. ÆåúìðÝêçò1, ×. Ðßôóáâïò2, Ä. ÐáíáãéùôÜêïò2, ×. ×ñõóï÷üïõ2, É. Óêïýìáò2, Ì. Ôïýôïõæá2, Ð. Ôïýôïõæáò1, ×. ÓôåöáíÜäçò2

Ðåñßëçøç Óêïðüò: Óôçí ðáñïýóá åñãáóßá ðáñïõóéÜæïíôáé áðïôåëÝóìáôá ôçò åðéäçìéïëïãéêÞò ìåëÝôçò “ÁÔÔÉÊÇ” ìå óêïðü ôç ìåëÝôç ôçò ó÷Ýóçò êëáóéêþí êáé íåüôåñùí ðáñáãüíôùí êéíäýíïõ ìå ôçí êáñäéáããåéáêÞ íüóï óå äéÜóôçìá 10 åôþí ðáñáêïëïýèçóçò. Õëéêü: Ç ìåëÝôç “ÁÔÔÉÊÇ” èá óõìðåñéëÜâåé (óôçí ôåëéêÞ ôçò öÜóç) 3075 Üôïìá (48% Üíäñåò êáé 52% ãõíáßêåò) ôïõ ãåíéêïý ðëçèõóìïý, çëéêßáò Üíù ôùí 18 åôþí. Ôï äåßãìá ôçò ðáñïýóáò áíÜëõóçò åßíáé ôá ðñþôá 1660 ôõ÷áßá åðéëåãìÝíá Üôïìá ðïõ åíôÜ÷èçêáí óôç ìåëÝôç. Ïé ðáñÜìåôñïé ðïõ ðáñïõóéÜæïíôáé åßíáé ïé ôéìÝò ïëéêÞò ÷ïëçóôåñüëçò, HDL-÷ïëçóôåñüëçò, ôñéãëõêåñéäßùí, ãëõêüæçò ïñïý, áñôçñéáêÞò ðßåóçò, ïìïêõóôåÀíçò, éíùäïãüíïõ, C-áíôéäñþóáò ðñùôåÀíçò, êáèþò åðßóçò êáé, áäñÝò, äéáôñïöéêÝò óõíÞèåéåò ôùí áôüìùí ôçò ìåëÝôçò. ÁðïôåëÝóìáôá: Ï ðñïóáñìïóìÝíïò êáôÜ çëéêßá åðéðïëáóìüò ôçò óôåöáíéáßáò íüóïõ âñÝèçêå ßóïò óôïõò Üíäñåò ìå 620 / 10000 Üôïìá (6,2%) êáé óôéò ãõíáßêåò 400 / 10000 Üôïìá (4,0%), åíþ ï åðéðïëáóìüò ôùí áããåéáêþí åãêåöáëéêþí åðåéóïäßùí, ôüóï óôïõò Üíäñåò üóï êáé óôéò ãõíáßêåò âñÝèçêå ßóïò ìå 110 / 10000 Üôïìá (1,1%). Ç áíÜëõóç ôùí óôïé÷åßùí Ýäåéîå üôé: 38,5% ôùí áíäñþí êáé 24,1% ôùí ãõíáéêþí åß÷áí õðÝñôáóç, 39% ôùí áíäñþí êáé 37% ôùí ãõíáéêþí åß÷áí õðåñ÷ïëçóôåñïëáéìßá, 8% ôùí áíäñþí êáé 7% ôùí ãõíáéêþí åß÷áí óáê÷áñþäç äéáâÞôç. Åðßóçò, 64,6% ôùí áíäñþí êáé 40,5% ôùí ãõíáéêþí äÞëùóáí åíåñãïß Þ ðñþçí êáðíéóôÝò, åíþ 55,3% ôùí áíäñþí êáé 62,8% ôùí ãõíáéêþí äÞëùóáí üôé äåí ãõìíÜæïíôáé ïýôå ìéá öïñÜ ôçí åâäïìÜäá. ÔÝëïò, 44% ôùí áíäñþí êáé 25% ôùí ãõíáéêþí åß÷áí ôïõëÜ÷éóôïí 3 áðü ôïõò ðñïáíáöåñèÝíôåò ðáñÜãïíôåò êéíäýíïõ. ÓõìðåñÜóìáôá: Óå éäéáßôåñá óçìáíôéêü ðïóïóôü ôïõ ãåíéêïý ðëçèõóìïý öáßíåôáé íá åðéðïëÜæïõí ðåñéóóüôåñïé áðü ôñåéò ðáñÜãïíôåò êéíäýíïõ. Ç áíÜãêç ëÞøçò ìÝôñùí êáôÜ ôçí ðñùôïâÜèìéá öñïíôßäá õãåßáò, êñßíåôáé åðéôáêôéêÞ, ðåñéóóüôåñï áðü ðïôÝ Üëëïôå.

1 Ãåíéêüò Éáôñüò, 2ÉððïêñÜôåéï Íïóïêïìåßï Áèçíþí, ÊáñäéïëïãéêÞ ÊëéíéêÞ É.Ã.Í.Á., ÉáôñéêÞ Ó÷ïëÞ Ðáíåðéóôçìßïõ Áèçíþí

ÅéóáãùãÞ Ôá ìÝ÷ñé óÞìåñá óôïé÷åßá áðü ìåëÝôåò ðïõ íá áíáöÝñïíôáé ôüóï óôïõò êëáóéêïýò (êÜðíéóìá, óùìáôéêü âÜñïò, öõóéêÞ Üóêçóç, äéáôñïöÞ, áñôçñéáêÞ ðßåóç ê.ëð.)1-4 üóï êáé óôïõò íåüôåñïõò êáñäéïáããåéáêïýò ðáñÜãïíôåò êéíäýíïõ (ïìïêõóôåÀíç, éíùäïãüíï, C-áíôéäñþóá ðñùôåÀíç ê.ëð.) óå ìåãÜëá äåßãìáôá ôïõ ãåíéêïý ðëçèõóìïý, óôç ÷þñá ìáò åßíáé åëÜ÷éóôá. Åßíáé åðßóçò ãåãïíüò üôé ôá ôåëåõôáßá ÷ñüíéá Ý÷ïõí óõíôåëåóèåß óçìáíôéêÝò áëëáãÝò óôéò äéÜöïñåò óõíÞèåéåò ôïõ ðëçèõóìïý ðïõ ðéèáíüí íá åðçñåÜæïõí ôéò ôéìÝò ôùí ðáñáãüíôùí êéíäýíïõ êáé íá áõîÜíïõí ôá ðïóïóôÜ ôùí áôüìùí ðïõ áíÞêïõí óôéò ïìÜäåò õøçëïý êéíäýíïõ óå ó÷Ýóç ìå ôï ðáñåëèüí. Óôçí ðñïóðÜèåéá íá êáëõöèåß ôï ËÝîåéò ÊëåéäéÜ: ÊáñäéáããåéáêÞ íüóïò, Êáñäéáããåéáêïß ðáñÜãïíôåò êéíäýíïõ, ÐñùôïâÜèìéá öñïíôßäá Õãåßáò ÕðïâëÞèçêå: Ç åñãáóßá õðïâëÞèçêå óôï äéáãùíéóìü "Ä. ºêêïõ" óôá ðëáßóéá ôïõ 15ïõ ÐáíåëëÞíéïõ Óõíåäñßïõ ÃåíéêÞò ÉáôñéêÞò (×áëêéäéêÞ 30 Áðñéëßïõ - 4 ÌáÀïõ 2003) êáé âñáâåýôçêå áðü ôçí ÅðéôñïðÞ Êñßóçò. Äçìïóéåýåôáé ìå êïéíÞ áðüöáóç ôçò ÓõíôáêôéêÞò ÅðéôñïðÞò ôïõ ðåñéïäéêïý êáé ôçò ÏñãáíùôéêÞò ÅðéôñïðÞò ôïõ Óõíåäñßïõ. Õðåýèõíïò áëëçëïãñáößáò: ÄçìïóèÝíçò  ÐáíáãéùôÜêïò, ×ßïõ 48-50, ÃëõöÜäá 165 61, ÁèÞíá, Tçë. (210)9603116, Fax. (210)9600719, E-mail: d.b.panagiotakos@usa.net 57


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Á. ÆåúìðÝêçò êáé óõí.

Coronary heart disease and cardiovascular risk factors,in a random sample of males and females of Attica county: The “ATTICA STUDY” A Zeibekis, C. Pitsavos, D.B. Panagiotakos, C. Chrysohoou, J. Skoumas, M. Toutouza, P. Toutouzas, C. Stefanadis. Summary Aim: In this work we present results from the “ATTICA” epidemiological study, in order to evaluate the association between established or emerging cardiovascular risk factors and the cardiovascular disease. Design and settings: The population analyzed in this work is consisted by 1660 randomly selected males and females, from several regions of Attica province. The parameters presented in this work are the serum values of total cholesterol, HDL-cholesterol, triglycerides, glucose, hs CRP, homocysteine, fibrinogen, and blood pressure levels. Additionally we evaluated the nutrition habits of the population of this study. The age adjusted prevalence of coronary heart disease was equal to 599 / 10000 persons (6%)in men and 400 / 10000 persons (4 %)in women, and the prevalence of vascular brain episodes was 110 / 10000 persons (1.1%) both in men and women. The 38.5% of the male population and 24.1% of the females had elevated blood pressure levels, 39% of the men’s and 37% of the women’s had hypercholesterolaemia, while 8% of the males and 7% of the females had diabetes mellitus. Additionally, 64.6% of the males and 40.5% of the females were defined as current smokers, and 55.3% of the males and 62.8% of the females reported physical inactivity (less than once per week). Finally, 44% of the males and 25% of the females had at least three of the referred above risk factors. Conclusions: The presented data are preliminary, but the increased prevalence of the common cardiovascular risk factors leads to the thought that actions for primary health care have become more essential than ever. Key words: Primary health care, Cardiovascular disease, Cardiovascular risk factors

êåíü ó÷åôéêÜ ìå ôçí êáñäéáããåéáêÞ íüóï óôç ÷þñá ìáò, ç êáñäéïëïãéêÞ êëéíéêÞ ôïõ Ðáíåðéóôçìßïõ Áèçíþí äéïñãÜíùóå óôéò áñ÷Ýò ôïõ 2001 ìéá äéá÷ñïíéêÞ åðéäçìéïëïãéêÞ ìåëÝôç ìå ôçí åðùíõìßá ìåëÝôç “ÁÔÔÉÊÇ”. Ç ìåëÝôç áõôÞ Ý÷åé óáí óêïðü íá êáôáãñÜøåé, íá áðïôéìÞóåé, íá ïìáäïðïéÞóåé, íá éåñáñ÷Þóåé êáé íá óõó÷åôßóåé ìå ôïí 10åôÞ êßíäõíï åêäÞëùóçò êáñäéáããåéáêÞò íüóïõ ôéò ôéìÝò äéáöüñùí êëáóéêþí ðáñáãüíôùí êéíäýíïõ, óå Ýíá áíôéðñïóùðåõôéêü, óôñùìáôïðïéçìÝíï êáé ôõ÷áßá åðéëåãìÝíï äåßãìá ôïõ ãåíéêïý ðëçèõóìïý ôïõ íïìïý ÁôôéêÞò. ÐáñÜëëçëá, èá åêôéìçèåß ï åðéðïëáóìüò êáé ç åðßðôùóç ôçò óôåöáíéáßáò íüóïõ, ôùí áããåéáêþí åãêåöáëéêþí êáé êáñêßíïõ êáé Üëëùí ìïñöþí áèçñïóêëçñõíôéêÞò íüóïõ (áíåõñýóìáôá áïñôÞò, áðïöñáêôéêÞ áñôçñéïðÜèåéá Üêñùí). Ôåëéêüò óôü÷ïò ôçò ìåëÝôçò èá åßíáé ç äçìéïõñãßá “ìïíôÝëïõ” êáñäéáããåéáêïý êéíäýíïõ ãéá ôïí Åëëçíéêü ðëçèõóìü ìå âÜóç ôï ïðïßï èá ìðïñåß íá áîéïëïãçèåß ï ó÷åôéêüò êßíäõíïò åìöÜíéóçò êáñäéáããåéáêïý åðåéóïäßïõ êáôÜ ôá ðñüôõðá äçìéïõñãßáò ðáñüìïéùí ìïíôÝëùí äéåèíþí ìåëåôþí (ìåëÝôç Framingham). Áðþôåñïò óôü÷ïò åßíáé ç ìåôÜ-áíÜëõóç ôùí åõñçìÜ58

ôùí ôçò ìåëÝôçò “ÁÔÔÉÊÇ” ìå Üëëåò äéåèíåßò ìåëÝôåò, ãéá ôçí åîáãùãÞ óõíïëéêþí óõìðåñáóìÜôùí. Óôçí ðáñïýóá åñãáóßá ðáñïõóéÜæåôáé ï ó÷åäéáóìüò êáé ç ìåèïäïëïãßá ôçò ìåëÝôçò áõôÞò (óõíïðôéêÜ), êáèþò åðßóçò êáé ôá ðñþôá ðåñéãñáöéêÜ áðïôåëÝóìáôÜ ôçò ðïõ áöïñïýí äéÜöïñïõò äçìïãñáöéêïýò, âéï÷çìéêïýò êáé êëéíéêïýò äåßêôåò ðïõ ó÷åôßæïíôáé ìå ôçí êáñäéáããåéáêÞ íïóçñüôçôá êáé èíçóéìüôçôá.

Ðëçèõóìüò ìåëÝôçò - ÌÝèïäïò Óõíïðôéêüò ó÷åäéáóìüò

Ç ìåëÝôç “ÁÔÔÉÊÇ” åßíáé ìéá äéá÷ñïíéêÞ ìåëÝôç ðáñáêïëïýèçóçò äåßãìáôïò ôïõ ãåíéêïý ðëçèõóìïý. ¼ðùò ðñïáíáöÝñèçêå ç ìåëÝôç Ý÷åé óáí áñ÷éêü óôü÷ï íá êáôáãñÜøåé ôéò ôéìÝò äéáöüñùí äçìïãñáöéêþí, âéï÷çìéêþí, êëéíéêþí, ãåíåôéêþí, äéáôñïöéêþí êáé øõ÷ïëïãéêþí ðáñáìÝôñùí óå ôõ÷áßá åðéëåãìÝíï äåßãìá ôïõ íïìïý ÁôôéêÞò. Ï ðëçèõóìüò áõôüò ðåñéëáìâÜíåé ôïõò êõñéüôåñïõò ôýðïõò ôïõ óýã÷ñïíïõ ¸ëëçíá ìéá êáé áðïôåëåßôáé áðü Üôïìá áóôéêþí, çìéáóôéêþí êáé áãñïôéêþí ðåñéï÷þí. ÐáñÜëëçëá áðïôåëåß ôï 40% ôïõ ãåíéêïý ðëçèõóìïý ôçò ÷þñáò (ÐçãÞ Å.Ó.Õ.Å. 2001). Ìå ôç 10åôÞ äéá÷ñïíéêÞ ðáñáêïëïýèçóç ôùí áôüìùí èá áðïôéìçèåß ï ñüëïò ðïõ Ý÷ïõí ïé äéåñåõíïýìåíïé ðáñÜãïíôåò óôïí êßíäõíï èáíáôçöüñáò Þ ìç, åêäÞëùóçò êáñäéáããåéáêÞò íüóïõ êáé êáñêßíïõ, óôïí ðëçèõóìü ôçò ìåëÝôçò. Ôï ôåëéêü äåßãìá èá ðåñéëáìâÜíåé 3075 Üôïìá. Åî áõôþí 1476 èá åßíáé Üíäñåò (48%) êáé ïé 1599 ãõíáßêåò (52%). Ôï ôåëéêü ìÝãåèïò ôïõ äåßãìáôïò ðñïÝêõøå Ýðåéôá áðü áíÜëõóç óôáôéóôéêÞò éó÷ýïò ìå âÜóç ôçí áðïôßìçóç äéáöïñþí óôïí åêôéìïýìåíï ó÷åôéêü êßíäõíï (hazard ratio) ãéá ðñïïðôéêÞ ðáñáêïëïýèçóç 10 åôþí ìåãáëýôåñùí áðü 10%, óå åðßðåäï óôáôéóôéêÞò óçìáíôéêüôçôáò < 5% êáé ìå óôáôéóôéêÞ éó÷ý (1 - óöÜëìá ôýðïõ ÉÉ) > 80% ãéá äßðëåõñïõò åëÝã÷ïõò. Ç äåéãìáôïëçøßá åßíáé ôõ÷áßá, ðïëõóôáäéáêÞ (áíÜ ðüëç), óôñùìáôïðïéçìÝíç (áíÜ çëéêéáêÞ êáôçãïñßá êáé öýëï), êáé áíáëïãéêÞ (ìå âÜóç ôïí ðëçèõóìü ôùí ÄÞìùí


Ôüìïò 15, Ôåý÷ïò 2, 2003

Á. ÆåúìðÝêçò êáé óõí.

êáé ÊïéíïôÞôùí ôçò ÕðÝñ-íïìáñ÷ßáò ÁôôéêÞò êáèþò åðßóçò êáé ôùí íïìáñ÷éþí ÁíáôïëéêÞò êáé ÄõôéêÞò ÁôôéêÞò). Ç óõíåéóöïñÜ ôùí åõñýôåñùí ðåñéï÷þí ôçò ÁôôéêÞò óôï ôåëéêü äåßãìá ôçò ìåëÝôçò èá åßíáé ç áêüëïõèç: ÄÞìïò Áèçíáßùí (20%), ÄÞìïò Ðåéñáéþò (8%), åõñýôåñç ðåñéöÝñåéá ðñùôåõïýóçò (41%), “õðüëïéðï” ÁôôéêÞò (29%) êáé íÞóïé (2%). Ìå âÜóç ôï ó÷åäéáóìü åðéëÝãïíôáí ôõ÷áßá åñãáóéáêïß ÷þñïé (Äçìüóéïé êáé Éäéùôéêïß), êÝíôñá óõãêÝíôñùóçò çëéêéùìÝíùí, êáèþò åðßóçò äçìïôéêïß ÷þñïé üðïõ åöáñìüóôçêå ôõ÷áßá åðéëïãÞ óôéò ëßóôåò ôùí áôüìùí (äõáäéêÞ áêïëïõèßá ôõ÷áßùí áñéèìþí, 1 = Ýíôáîç óôç ìåëÝôç, 0 = ìç Ýíôáîç óôç ìåëÝôç). Ìå ôïí ôñüðï áõôü åëá÷éóôïðïéåßôáé ç óõììåôï÷Þ åèåëïíôþí óôçí ìåëÝôç êáé ôïõ óõóôçìáôéêïý óöÜëìáôïò êáôÜ ôçí åðéëïãÞ. Ôï ðñùôüêïëëï ðñïâëÝðåé íá åðéëÝãåôáé Ýíá Üôïìï áíÜ ïéêïãÝíåéá, ïéêïäïìéêü óõãêñüôçìá êáé ôåôñÜãùíï. Ôá óôïé÷åßá èá óõãêåíôñþíïíôáé óå åéäéêü åñùôçìáôïëüãéï áðü ôïõò åñåõíçôÝò ôçò ìåëÝôçò “ÁÔÔÉÊÇ” êáé Ýðåéôá èá êùäéêïðïéïýíôáé óå âÜóç äåäïìÝíùí ðïõ ó÷åäéÜóèçêå ãéá ôï óêïðü áõôü. Ôá åñùôçìáôïëüãéá ôçò ìåëÝôçò åßíáé åìðéóôåõôéêÜ, áðëÜ êáé ãñÞãïñá ðñïóðåëÜóéìá. ¼ëá ôá Üôïìá åíçìåñþíïíôáé ãéá ôïõò óêïðïýò ôçò ìåëÝôçò êáé óõìöùíïýí óôï íá óõììåôÜó÷ïõí.

Áñ÷éêÜ ðñáãìáôïðïéåßôáé êáñäéïëïãéêÞ åîÝôáóç ðïõ ðåñéëáìâÜíåé ëÞøç áñôçñéáêÞò ðßåóçò êáé çëåêôñïêáñäéïãñÜöçìá 12-áðáãùãþí. ÌåôÜ ëáìâÜíåôáé áßìá, áöïý Ý÷åé ðñïçãçèåß 12ùñç íçóôåßá ôùí åîåôáæïìÝíùí áôüìùí, ãéá: (á) ãåíéêÞ åîÝôáóç áßìáôïò ìå ÷ñÞóç áõôüìáôïõ áéìáôïëïãéêïý áíáëõôÞ Ç1 Þ Ç2 ôçò Medicon, (â) âéï÷çìéêü Ýëåã÷ï ðïõ ðåñéëáìâÜíåé ïõñßá, ïõñéêü ïîý, ïëéêÞ ÷ïëåñõèñßíç- Üìåóç, êñåáôéíßíç (Cr), SGOT, SGPT, ãGT, áëêáëéêÞ öùóöáôÜóç, CPK, óÜê÷áñï, ïëéêÞ ÷ïëçóôåñüëç ïñïý (TC), HDL ÷ïëçóôåñüëç, LDL ÷ïëçóôåñüëç, ôñéãëõêåñßäéá (TG), ìå ôç ÷ñÞóç áõôüìáôïõ âéï÷çìéêïý áíáëõôÞ RA 1000 ôçò Techikon (÷ñùìáôïìåôñéêÞ åíæõìáôéêÞ ìÝèïäïò), (ã) ðñïóäéïñéóìü áðïëéðñùôåÀíçò (Ápo) A1 êáé Â, ëéðïðñùôåÀíçò (Lp) a, õøçëÞò åõáéóèçóßáò (hs) C – áíôéäñþóáò ðñùôåÀíçò (CRP), éíùäïãüíïõ, ìå áõôüìáôï íåöåëüìåôñï ÂÍÉÉ ôçò Dade Behring, êáé (ä) ðñïóäéïñéóìü ïìïêõóôåÀíçò ìå áõôüìáôï áíïóïëïãéêü áíáëõôÞ Axsym ôçò Abott (ôå÷íïëïãßá ôïõ ðïëùìÝíïõ áíïóïöèïñéóìïý, FPIA), ïîåéäùìÝíçò LDL, ïëéêïý èñïìâùôéêïý ðáñÜãïíôá, êáé áìõëïåéäïýò Á ïñïý. ÐáñÜëëçëá ãßíåôáé öýëáîç äåßãìáôïò óôïõò -80 ï C ãéá ìåëëïíôéêÞ ÷ñÞóç êáé ãåíåôéêü Ýëåã÷ï (ìåôÜ áðü áðïìüíùóç ôïõ DNA).

ÊëéíéêÝò ðáñÜìåôñïé Äéåñåõíïýìåíïé ðáñÜãïíôåò Ïé ðáñÜãïíôåò ðïõ äéåñåõíïýíôáé åßíáé ðáñÜìåôñïé ðïõ åêöñÜæïõí ôïí êáèçìåñéíü ôñüðï æùÞò, üðùò ïé êáðíéóôéêÝò óõíÞèåéåò, ç óùìáôéêÞ Üóêçóç, äéáôñïöéêÝò óõíÞèåéåò, ðáñïõóßá Üã÷ïõò - êáôÜèëéøçò êáèþò åðßóçò êáôáãñáöÞ óùìáôïìåôñéêþí êáé êïéíùíéêü-ïéêïíïìéêþí ÷áñáêôçñéóôéêþí (ïéêïãåíåéáêÞ êáôÜóôáóç, ìïñöùôéêü åðßðåäï, ïéêïíïìéêÞ êáé åðáããåëìáôéêÞ êáôÜóôáóç), ïéêïãåíåéáêïý éóôïñéêïý óôåöáíéáßáò íüóïõ êáé ðáñáãüíôùí êéíäýíïõ. Èá êáôáãñÜöåôáé, åðßóçò, ç ðáñïõóßá êáé ç ôõ÷üí èåñáðåßá áñôçñéáêÞò õðÝñôáóçò, óáê÷áñþäç äéáâÞôç, êáé õðåñëéðéäáéìßáò. Åðßóçò åëÝã÷åôáé ç ãíþóç ôùí áíþôåñùí öõóéïëïãéêþí åðéðÝäùí ÷ïëçóôåñüëçò êáé ç óõ÷íüôçôá ðáñáêïëïýèçóçò ôïõò. ¼ëç ç äéáäéêáóßá ðñáãìáôïðïéåßôáé áðü ôçí ïìÜäá ôùí åñåõíçôþí (êáñäéïëüãïé, ðáèïëüãïé,ãåíéêïß éáôñïß, øõ÷ßáôñïé, ìéêñïâéïëüãïé, êáé äéáôñïöïëüãïé) ôçò ìåëÝôçò “ÁÔÔÉÊÇ”.

Ç áñôçñéáêÞ ðßåóç ìåôñÜôáé óôï áñéóôåñü ÷Ýñé (ãéá ôïõò äåîéü÷åéñåò) Ý÷ïíôáò ôá Üôïìá óå êáèéóôÞ èÝóç êáé óå Þñåìç êáôÜóôáóç. Ãßíïíôáé ôñåéò ìåôñÞóåéò êáé õðïëïãßæåôáé ï ìÝóïò üñïò ôïõò. Áí ãéá êÜðïéï ëüãï ç ìÝôñçóç ãßíåé óôï äåîß ÷Ýñé áõôü óçìåéþíåôáé óôï åñùôçìáôïëüãéï ôïõ áôüìïõ. Åðßóçò óçìåéþíåôáé áí øçëáöþíôáò êáé ôéò äýï êåñêéäéêÝò áñôçñßåò, äéáðéóôþèçêå äéáöïñÜ óôï óöõãìü óôá äõï ÷Ýñéá, ïðüôå ìåôñÞèçêå ç áñôçñéáêÞ ðßåóç êáé óôï äåîß ÷Ýñé. Ç ôéìÞ ôçò óõóôïëéêÞò ðßåóçò áíôéóôïé÷åß óôçí ôéìÞ ðïõ äåß÷íåé ôï ðéåóüìåôñï üôáí áêïõóôåß ï ðñþôïò Þ÷ïò. Ç ôéìÞ ôçò äéáóôïëéêÞò ðßåóçò êáèïñßæåôáé üôáí ï Þ÷ïò óôáìáôÞóåé íá áêïýãåôáé ñõèìéêüò êáé áêïýãåôáé óõíå÷üìåíïò.

ÁíèñùðïìåôñéêÝò ðáñÜìåôñïé Ôï ýøïò ôùí áôüìùí ìåôñÜôáé ìéá öïñÜ, ÷ùñßò 59


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Á. ÆåúìðÝêçò êáé óõí.

ðáðïýôóéá êáé ïé ìåôñÞóåéò óôñïããõëïðïéïýíôáé óôï ðëçóéÝóôåñï 0,5 cm ôïõ ìÝôñïõ. Ôï âÜñïò ôùí áôüìùí åðßóçò ìåôñÜôáé ìéá öïñÜ, ÷ùñßò ðáðïýôóéá êáé ìå åëáöñÜ åóùôåñéêÞ Ýíäõóç. Ïé ìåôñÞóåéò óôñïããõëïðïéïýíôáé óôçí ðëçóéÝóôåñç åêáôïíôÜäá ãñáììáñßùí. Ï äåßêôçò ìÜæáò óþìáôïò (ÄÌÓ) õðïëïãßæåôáé óáí âÜñïò (Kg) / ýøïò2 (m).

Ïé Ýëåã÷ïé ìåôáîý ôùí êáôçãïñéêþí ìåôáâëçôþí Ýãéíáí ìå ôç ÷ñÞóç ôïõ êñéôçñßïõ ×2, ÷ùñßò äéüñèùóç óõíÝ÷åéáò. Óõó÷åôßóåéò ìåôáîý óõíå÷þí ìåôáâëçôþí Ýãéíáí ìå ôç ÷ñÞóç ôïõ óõíôåëåóôÞ óõó÷Ýôéóçò ôïõ Pearson. ¼ëïé ïé óôáôéóôéêïß õðïëïãéóìïß ðñáãìáôïðïéÞèçêáí ìå ôï ðñüãñáììá SPSS 10,0 (SPSS Inc., Illinois, USA).

Áðïôßìçóç ôïõ ôñüðïõ æùÞò

ÁðïôåëÝóìáôá

Ôá Üôïìá ïìáäïðïéïýíôáé ìå âÜóç ôç óùìáôéêÞ ôïõò äñáóôçñéüôçôá óå ôñåéò êáôçãïñßåò. Óôçí êáôçãïñßá É óõìðåñéëáìâÜíïíôáé Üôïìá ðïõ äåí áóêïýíôáé êáèüëïõ (êáèéóôéêÞ æùÞ), óôçí êáôçãïñßá ÉÉ áõôÜ ðïõ áóêïýíôáé ëßãï êáé óôçí êáôçãïñßá ÉÉÉ áõôÜ ðïõ áóêïýíôáé óõóôçìáôéêÜ. Ç êáôÜôáîç ãßíåôáé ìå âÜóç ôéò áðáíôÞóåéò ôùí áôüìùí óå áíÜëïãåò åñùôÞóåéò ó÷åôéêÝò ãéá ïðïéáäÞðïôå ìïñöÞ óùìáôéêÞò Üóêçóçò ðïõ äåí ó÷åôßæïíôáé ìå ôï êýñéï åðÜããåëìá. Ïé ðëçñïöïñßåò ó÷åôéêÜ ìå ôéò êáðíéóôéêÝò óõíÞèåéåò óõëëÝãïíôáé ìå âÜóç ôõðïðïéçìÝíï åñùôçìáôïëüãéï ðïõ ó÷åäéÜóôçêå ãéá ôç ìåëÝôç êáé ôï ïðïßï äéåñåõíÜ ôá Ýôç êáðíßóìáôïò, ôïí çìåñÞóéï áñéèìü ôóéãÜñùí, ôá áßôéá äéáêïðÞò êáèþò åðßóçò êáé ôçí Ýêèåóç óå ðáèçôéêü êÜðíéóìá.

Óôçí ðáñïýóá áíáöïñÜ ðáñïõóéÜæïíôáé ôá áðïôåëÝóìáôá áðü ôá ðñþôá 1660 Üôïìá ðïõ åéóÞ÷èçóáí óôç ìåëÝôç (ôï 87% åê ôùí áôüìùí ðïõ ôïõò æçôÞèçêå íá óõììåôÜó÷ïõí óôç ìåëÝôç). Óýìöùíá ìå ôïõò åñåõíçôÝò ôçò ìåëÝôçò “ÁÔÔÉÊÇ” äåí ðáñáôçñÞèçêå êáìéÜ äéáöïñÜ, üóïí áöïñÜ ôï êïéíùíéêü-ïéêïíïìéêü åðßðåäï, ìåôáîý ôùí óõììåôå÷üíôùí êáé áõôþí ðïõ áñíÞèçêáí íá óõììåôÜó÷ïõí (Ðßíáêáò 1). Åê ôùí 1660 áôüìùí ïé 804 (48,4%) åßíáé Üíäñåò ìÝóçò çëéêßáò 49 ± 14 åôþí (áðü 18 Ýùò 89 åôþí) êáé ïé 856 (51,6%) åßíáé ãõíáßêåò ìÝóçò çëéêßáò 48 ± 14 åôþí (áðü 18 Ýùò 90 åôþí). Ôï 73% ôùí åñùôçèÝíôùí äÞëùóáí Ýããáìïé, ôï 17% Üãáìïé êáé ïé õðüëïéðïé Þôáí äéáæåõãìÝíïé (4%) Þ ÷Þñïé (6%). Ï ìÝóïò áñéèìüò ðáéäéþí Þôáí äýï áíÜ ïéêïãÝíåéá. Ï ðñïóáñìïóìÝíïò êáôÜ çëéêßá åðéðïëáóìüò ôçò óôåöáíéáßáò íüóïõ (üðùò áõôÞ ïñßæåôáé áðü ðáñïõóßá äéáôáñá÷þí éó÷áéìéêïý ôýðïõ Þ ïõëÞò ðáëáéïý åìöñÜãìáôïò óôï çëåêôñïêáñäéïãñÜöçìá, Þ / êáé áíáöïñÜ êëéíéêïý óõíäñüìïõ ïìïéÜæïíôá ìå óôçèÜã÷ç Þ áíÜëïãü ôçò êáôÜ ôç ëÞøç ëåðôïìåñïýò éáôñéêïý éóôïñéêïý) âñÝèçêå ßóïò ìå 620 áíÜ 10000 Üíäñåò (6,2%) êáé 400 / 10000 ãõíáßêåò (4,0%), åíþ ï ðñïóáñìïóìÝíïò êáôÜ çëéêßá åðéðïëáóìüò ôùí áããåéáêþí åãêåöáëéêþí åðåéóïäßùí âñÝèçêå ßóïò ìå 100 / 10000 Üíäñåò (1,0%) êáé 110 / 10000 ãõíáßêåò (1,1%). Ôï 31% ôùí åñùôçèÝíôùí äÞëùóå üôé Ý÷åé ïéêïãåíåéáêü éóôïñéêü ðñþéìçò åêäÞëùóçò óôåöáíéáßáò íüóïõ óå óõããåíåßò ðñþôïõ Þ äåýôåñïõ âáèìïý < 55 åôþí ãéá Üíäñåò êáé < 65 åôþí ãéá ãõíáßêåò. Ïé êáðíéóôéêÝò óõíÞèåéåò üðùò áðïôõðþèçêáí êáôÜ äÞëùóç ôùí óõììåôå÷üíôùí óôç ìåëÝôç ðáñïõóéÜæïíôáé óôïí Ðßíáêá 2 êáé áöïñïýí ôçí êáôáíÜëùóç ôïõëÜ÷éóôïí åíüò ôóéãÜñïõ çìåñçóßùò (ôþñá Þ óôï ðáñåëèüí) êáé ãéá ÷ñïíéêü äéÜóôçìá ôïõëÜ÷éóôïí åíüò Ýôïõò. Ðáñáôçñïýìå üôé ôï

ÄéáôñïöéêÞ áðïôßìçóç ×ñçóéìïðïéåßôáé ôï åñùôçìáôïëüãéï ôïõ Åõñùðáúêïý ÐñïãñÜììáôïò Óõíåñãáóßáò ÉáôñéêÞò êáé Êïéíùíßáò (ÅÐÉÊ) áðü ôï åñãáóôÞñéï ÕãéåéíÞò êáé Åðéäçìéïëïãßáò ôçò ÉáôñéêÞò Ó÷ïëÞò ôïõ Ðáíåðéóôçìßïõ Áèçíþí.

ÓôáôéóôéêÞ áíÜëõóç Óôçí ðáñïýóá åñãáóßá ïé óõíå÷åßò ìåôáâëçôÝò ðáñïõóéÜæïíôáé óáí ìÝóç ôéìÞ ± ôõðéêÞ áðüêëéóç, åíþ óôá ãñáöÞìáôá ðáñïõóéÜæïíôáé óáí ìÝóç ôéìÞ êáé 95% äéÜóôçìá åìðéóôïóýíçò (ÄÅ). Ïé ðïéïôéêÝò - êáôçãïñéêÝò ìåôáâëçôÝò ðáñïõóéÜæïíôáé óáí áðüëõôåò êáé ó÷åôéêÝò (%) óõ÷íüôçôåò. Ïé Ýëåã÷ïé ìåôáîý óõíå÷þí êáé êáôçãïñéêþí ìåôáâëçôþí Ýãéíáí ìå ôç ÷ñÞóç ôïõ t-êñéôçñßïõ ôïõ Student Þ ôïõ åëÝã÷ïõ áíÜëõóçò äéáóðïñÜò (ANOVA), áöïý ðñïçãÞèçêå Ýëåã÷ïò êáíïíéêüôçôáò. 60


Ôüìïò 15, Ôåý÷ïò 2, 2003

Á. ÆåúìðÝêçò êáé óõí.

Ðßíáêáò 1. Óôñùìáôïðïßçóç, óôï ìÝ÷ñé ôþñá äåßãìá ôçò ìåëÝôçò (í = 1660 Üôïìá), áíÜ öýëï, çëéêßá êáé ãåùãñáöéêÞ ðåñéï÷Þ ÄÞìïò Áèçíáßùí 20 -29 30 -39 40 -49 50 -59 60 -69 70 -79 80+ Óýíïëï

¢íäñåò 60 57 48 52 44 25 14 300

¢íäñåò 20 -29 30 -39 40 -49 50 -59 60 -69 70 -79 80+ Óýíïëï

Ãõíáßêåò 23 22 18 20 17 9 5 114

Ãõíáßêåò 65 62 52 57 47 28 15 326

Õðüëïéðï ÁôôéêÞò Óýíïëï 125 119 100 109 91 53 29 626

20 -29 30 -39 40 -49 50 -59 60 -69 70 -79 80+ Óýíïëï

¢íäñåò 42 40 34 37 31 18 9 211

47 45 37 41 34 19 11 234

¢íäñåò 20 -29 30 -39 40 -49 50 -59 60 -69 70 -79 80+ Óýíïëï

Ãõíáßêåò 36 34 29 31 26 15 8 179

ÄÞìïò Ðåéñáéþò Óýíïëï 24 23 19 21 17 10 6 120

Ãõíáßêåò 44 42 36 39 32 19 10 222

Óýíïëï 86 82 70 76 63 37 19 433

ÐåñéöÝñåéá Ðåéñáéþò Óýíïëï 37 36 30 33 27 16 9 188

73 70 59 64 53 31 17 367

Ðßíáêáò 2. ÊáðíéóôéêÝò óõíÞèåéåò (åíåñãïß Þ ðñþçí êáðíéóôÝò) êáé êáèéóôéêÞ æùÞ óôï äåßãìá ôçò ìåëÝôçò, áíÜ öýëï êáé çëéêßá ÇëéêéáêÞ êáôçãïñßá ÊÜðíéóìá 20 – 29

30 – 39

40 – 49

50 – 59

60 – 69

70 – 79

80 +

Óýíïëï

¢íäñåò

62,1% 95/153 53,4% 87/163

75,2% 97/129 49,6% 68/137

72,9% 102/140 42,7% 64/150

64,4% 76/118 34,1% 42/123

55,2% 37/67 9,5% 7/73

50% 18/36 0% 0/40

64,7% 520/804 40,5% 347/856

60,1% 92/153 62,0% 101/163

72,1% 93/129 70,8% 97/137

56,4% 79/140 60,7% 91/150

51,7% 61/118 62,6% 77/123

40,3% 27/67 59,9% 43/73

38,9% 14/36 57,5% 23/40

55,3% 445/804 62,8% 538/856

Ãõíáßêåò

59% 95/161 46,5% 79/170

ÊáèéóôéêÞ æùÞ ¢íäñåò

49,1% 79/161 Ãõíáßêåò 62,4% 106/170

64,6% (520/804) ôùí áíäñþí êáé ôï 40,5% (347/ 856) ôùí ãõíáéêþí äÞëùóáí üôé åßíáé Þ õðÞñîáí êáðíéóôÝò (p < 0,01). To 55,3% (445/804) ôùí áíäñþí êáé ôï 62,8% (538/856) ôùí ãõíáéêþí äÞëùóáí üôé äåí ãõìíÜæïíôáé ïýôå ìéá öïñÜ ôçí åâäïìÜäá (p < 0,01) (Ðßíáêáò 2). Ôï ÄéÜãñáììá 1 ðáñïõóéÜæåé ôçí êáôáíïìÞ ôïõ äåßêôç ìÜæáò óþìáôïò óôïõò Üíäñåò êáé óôéò ãõíáßêåò ôïõ äåßãìáôïò. Óôï ãñÜöçìá áõôü öáßíåôáé ç êáìðõëïåéäÞò ó÷Ýóç ôïõ ÄÌÓ ìå ôçí çëéêßá, ôüóï óôïõò Üíäñåò üóï êáé óôéò ãõíáßêåò. Óôéò ìéêñÝò êáé ìÝóåò çëéêéáêÝò ïìÜäåò åðéâåâáéþíåôáé ç äéáöïñÜ ìåôáîý áíäñþí êáé ãõíáéêþí óôçí ðñïóáñìïóìÝíç óùìáôéêÞ ìÜæá, ãåãï-

íüò ðïõ öáßíåôáé íá áíáéñåßôáé óôéò ìåãáëýôåñåò çëéêßåò. ¸íá Üëëï ìÝôñï áíèñùðïìåôñéêþí ÷áñáêôçñéóôéêþí åßíáé ï ëüãïò ôçò ðåñéöÝñåéáò ìÝóçò ðñïò ôçí ðåñéöÝñåéá ôùí ãïöþí, êáé ï ïðïßïò ðåñéãñÜöåôáé óôï ÄéÜãñáììá 2. Ï åðéðïëáóìüò ôçò áñôçñéáêÞò õðÝñôáóçò (ÓÁÐ / ÄÁÐ > 140 / 90 mm Hg Þ åéäéêÞ áíôéõðåñôáóéêÞ áãùãÞ) Þôáí 38,5% óôïõò Üíäñåò êáé 24,1% óôéò ãõíáßêåò ôçò ìåëÝôçò (p < 0,05). Åê ôùí õðåñôáóéêþí ôï 38% áêïëïõèåß åéäéêÞ äéáéôçôéêÞ áãùãÞ êáé ôï 74% ðáßñíåé åéäéêÜ áíôéõðåñôáóéêÜ öÜñìáêá. Óôï ÃñÜöçìá 3 ðáñïõóéÜæïíôáé ïé ìÝóåò ôéìÝò óõóôïëéêÞò êáé äéáóôïëéêÞò áñôçñéáêÞò ðßåóçò. Áðü ôá ãñáöÞìáôá ãßíåôáé 61


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Á. ÆåúìðÝêçò êáé óõí.

31 30

ÄÌÓ (Kg/m2) - 95% ÄÅ

29 28 27 26 25 24 23 ¢íäñåò

22 21

Ãõíáßêåò

< 35

35 - 45

45 - 55

55 - 65

65 - 75

> 75

Çëéêßá (Ýôç)

ÄéÜãñáììá 1. Äåßêôçò ìÜæáò óþìáôïò (Kg / m2) áíÜ öýëï êáé çëéêßá.

Waist-to-hip (95% ÄÅ)

1,0

,9

,8

¢íäñåò

,7

Ãõíáßêåò

< 35

35 - 45

45 - 55

55 - 65

65 - 75

> 75

Çëéêßá (Ýôç)

ÄéÜãñáììá 2. Ëüãïò ðåñéöÝñåéáò ìÝóçò – ðåñéöÝñåéáò ãïöþí áíÜ öýëï êáé çëéêßá.

åìöáíÞò ç èåôéêÞ ó÷Ýóç ìå ôçí çëéêßá (p < 0,01), êáèþò åðßóçò êáé ç äéáöïñÜ ìåôáîý ôùí äýï öýëùí, êõñßùò, ìÝ÷ñé ôçí çëéêßá ôùí 55 åôþí (ÄéÜãñáììá 3). Ï óáê÷áñþäçò äéáâÞôçò åðéðüëáæå óå ðïóïóôü 8% åê ôùí áíäñþí êáé 7% åê ôùí ãõíáéêþí ôçò ìåëÝôçò (p = 0,43). Åðßóçò, ôï 6% ôùí áíäñþí êáé ôï 7% ôùí ãõíáéêþí åß÷áí äéáôáñá÷Þ ôçò ãëõêüæçò íçóôåßáò (ãëõêüæç ïñïý 110 – 125 mg/dl). Ôá äéáâçôéêÜ Üôïìá ñýèìéæáí ôï óÜê÷áñï ôïõò ìå åéäéêÞ äéáôñïöÞ (70%), ëÞøç äéóêßùí (64%) Þ / êáé ÷ïñÞãçóç éíóïõëßíçò (16%). Ôï 27% ôùí äéáâçôéêþí åß÷å ïéêïãåíåéáêü éóôïñéêü óáê÷áñþäïõò äéáâÞôç (p < 0,001). Ôï 39% ôùí áíäñþí êáé 37% ôùí ãõíáéêþí åß÷áí õðåñ÷ïëçóôåñïëáéìßá (ïëéêÞ ÷ïëçóôåñüëç ïñïý > 220 mg/ dl Þ åéäéêÞ õðïëéðéäáéìéêÞ áãùãÞ) (p = 0,15). ÔÝëïò, áîéïóçìåßùôï åßíáé üôé 44% ôùí áíäñþí êáé 25% ôùí ãõíáéêþí åß÷áí ôïõëÜ÷éóôïí ôñåéò áðü ôïõò êëáóóéêïýò ðáñÜãïíôåò êéíäýíïõ (õðÝñôáóç, õðåñ÷ïëçóôåñïëáéìßá, óáê÷áñþäç äéáâÞôç, êáðíéóôéêÝò óõíÞèåéåò êáé êáèéóôéêÞ æùÞ)). Ïé ìÝóåò ôéìÝò ôùí äéåñåõíïýìåíùí âéï÷çìéêþí äåéêôþí, üðùò áõôÝò ìåôñÞèçêáí êáôÜ ôïí åñãáóôçñéáêü Ýëåã÷ï, ðáñïõóéÜæïíôáé óôïí Ðßíáêá 3. Ç óôáôéóôéêÞ áíÜëõóç Ýäåéîå üôé ïé ôéìÝò ôùí ôñéãëõêåñéäßùí, ôçò ãëõêüæçò ïñïý êáé ôùí áðïëéðïðñùôåúíþí äéÝöåñáí óçìáíôéêÜ ìåôáîý ôùí öýëùí (p < 0,01). Åðßóçò ÷áñáêôçñéóôéêü åßíáé üôé ôï 45% ôùí åñùôçèÝíôùí äåí ãíþñéæå ðïéåò ðñÝðåé íá åßíáé ïé öõóéïëïãéêÝò ôéìÝò ôçò ÷ïëçóôåñüëçò, åíþ ôï 21% áðÜíôçóå ëáíèáóìÝíá óôçí áíôßóôïé÷ç åñþôçóç ðïõ ôïõò ôÝèçêå (>220 mg/ 100

ÄÁÐ (95% ÄÅ)

90

80

70 ¢íäñåò

¢íäñåò

Ãõíáßêåò

< 35

35 - 45

45 - 55

55 - 65

Çëéêßá (Ýôç)

65 - 75

> 75

60

Ãõíáßêåò < 35

35 - 45

45 - 55

55 - 65

Çëéêßá (Ýôç)

ÄéÜãñáììá 3. ÓõóôïëéêÞ êáé äéáóôïëéêÞ áñôçñéáêÞ ðßåóç (mm Hg) áíÜ öýëï êáé çëéêßá. 62

65 - 75

> 75


Ôüìïò 15, Ôåý÷ïò 2, 2003

Á. ÆåúìðÝêçò êáé óõí.

Ðßíáêáò 3. Äåßêôåò êåíôñéêÞò ôÜóçò êáé äéáóðïñÜò ôùí âáóéêþí ëéðéäßùí êáé óáê÷Üñïõ, êáèþò åðßóçò êáé äåéêôþí öëåãìïíÞò êáé èñüìâùóçò óôï äåßãìá ôçò ìåëÝôçò ÌÝóç ôéìÞ

ÔõðéêÞ áðüêëéóç

Ôåôáñôçìüñéá 25%

ÄéÜìåóïò

75%

¢íäñåò ÏëéêÞ ÷ïëçóôåñüëç ïñïý (mg/dl) Ôñéãëõêåñßäéá (mg/dl) Ãëõêüæç ïñïý (mg/dl) HDL – ÷ïëçóôåñüëç (mg/dl) Lp (a) APO-Á1 APO-B Éíùäïãüíï (mg/dl) Ïìïêõóôåßíç (ìMol/l) hs -CRP (mg/dl)

215,5 157,1** 96,7** 44,3** 18,3** 141,3** 118,6** 306,4** 14,8** 2,3

46,9 116,8 38,4 18,0 22,3 26,4 30,8 74,3 6,8 3,5

181,0 92,0 82,0 35,0 4,5 128,0 95,2 258,0 11,1 0,6

213,8 127,0 91,0 41,0 10,6 140,0 119,0 297,0 13,1 1,2

243,8 188,0 101,0 50,0 22,5 154,0 141,0 348,0 16,5 2,5

213,9 111,4 90,6 52,3 20,2 160,1 109,0 341,2 10,5 2,3

44,0 62,0 21,1 14,7 26,5 59,2 53,8 214,3 3,4 3,2

182,9 71,5 79,0 42,0 4,5 142,0 85,9 279,0 8,3 0,4

211,1 100,0 86,0 52,0 11,4 158,0 106,0 318,0 10,1 1,2

241,1 137,0 96,2 61,0 23,9 174,0 125,0 367,0 12,5 2,8

Ãõíáßêåò ÏëéêÞ ÷ïëçóôåñüëç ïñïý (mg/dl) Ôñéãëõêåñßäéá (mg/dl) Ãëõêüæç ïñïý (mg/dl) HDL – ÷ïëçóôåñüëç (mg/dl) Lp (a) APO-Á1 APO-B Éíùäïãüíï (mg/dl) Ïìïêõóôåßíç (ìMol/l) hs - CRP (mg/dl)

dl). Ôï 58% ôùí áôüìùí äÞëùóå üôé ðáñáêïëïõèåß ôéò ôéìÝò ôùí ëéðéäßùí ôïõ ìå ôáêôéêÝò åðéóêÝøåéò (åôÞóéåò Þ áíÜ äéåôßá) óôá ìéêñïâéïëïãéêÜ éáôñåßá. Óôï ÄéÜãñáììá 4 ðáñïõóéÜæåôáé ç ó÷Ýóç ôçò ïëéêÞò ÷ïëçóôåñüëçò, ôùí ôñéãëõêåñéäßùí, ôïõ óáê÷Üñïõ êáé ôçò Lp(a) ìå ôçí çëéêßá ôùí áôüìùí ôçò ìåëÝôçò (p < 0,01) (ÄéÜãñáììá 4). ÔÝëïò, ï Ðßíáêáò 4 ðáñïõóéÜæåé ìéá áäñÞ åéêüíá ôùí äéáôñïöéêþí óõíçèåéþí ôùí áíäñþí êáé ãõíáéêþí ôçò ìåëÝôçò. Ç óõíôñéðôéêÞ ðëåéïøçößá ôùí åñùôçèÝíôùí (95%) äÞëùóå üôé ÷ñçóéìïðïéåß åëáéüëáäï óôçí êáèçìåñéíÞ ìáãåéñéêÞ åíþ 41% ôùí áíäñþí êáé 12% ôùí ãõíáéêþí êáôáíáëþíïõí ìéêñÝò ðïóüôçôåò êñáóéïý, óõíÞèùò ìáæß ìå ôá ãåýìáôá. ÔÝëïò ôï 84% ôùí áíäñþí êáé ôï 55% ôùí ãõíáéêþí ÷ñçóéìïðïéïýí Ýôïéìï öáãçôü (fast food, øçôïðùëåßá ê.ë.ð) ôïõëÜ÷éóôïí ìéá öïñÜ ôçí åâäïìÜäá.

ÓõæÞôçóç Óôçí åñãáóßá áõôÞ ðáñïõóéÜóèçêáí ï ó÷å-

äéáóìüò êáé ôá ðñþôá áðïôåëÝóìáôá ôçò åðéäçìéïëïãéêÞò ìåëÝôçò “ÁÔÔÉÊÇ” ó÷åôéêÜ ìå äéÜöïñïõò ôåêìçñéùìÝíïõò áëëÜ êáé áíáäõüìåíïõò ðáñÜãïíôåò êáñäéáããåéáêïý êéíäýíïõ. Áîéïóçìåßùôï åßíáé üôé 44% ôùí áíäñþí êáé 25% ôùí ãõíáéêþí åß÷áí ôïõëÜ÷éóôïí ôñåéò áðü ôïõò êëáóéêïýò ðáñÜãïíôåò êéíäýíïõ (õðÝñôáóç, õðåñ÷ïëçóôåñïëáéìßá, óáê÷áñþäç äéáâÞôç, êáðíéóôéêÝò óõíÞèåéåò êáé êáèéóôéêÞ æùÞ). Åßíáé ôåêìçñéùìÝíïò ï ñüëïò ôïõ êáðíßóìáôïò óôçí êáñäéáããåéáêÞ íüóï áðü ðïëëÝò ðëçèõóìéáêÝò ìåëÝôåò ðáñáôÞñçóçò, åíþ óõíå÷þò ðëçèáßíïõí ïé åíäåßîåéò ãéá ôç óõììåôï÷Þ êáé ôïõ ðáèçôéêïý êáðíßóìáôïò óôïí êßíäõíï óôåöáíéáßáò íüóïõ êáé ãåíéêüôåñá áèçñïóêëçñõíôéêÞò íüóïõ5-7. Ç óõ÷íüôçôá ôïõ åíåñãïý êáðíßóìáôïò âñÝèçêå êáé óôç ìåëÝôç ìáò åîáéñåôéêÜ õøçëÞ åðéâåâáéþíïíôáò ðñüóöáôç åðéäçìéïëïãéêÞ ìåëÝôç8, áëëÜ êáé óôïé÷åßá Üëëùí öïñÝùí, üðùò ôçò ÅëëçíéêÞò ÁíôéêáñêéíéêÞò Åôáéñåßáò, ôá ïðïßá öÝñíïõí ôç ÷þñá ìáò óôéò ðñþôåò èÝóåéò óôçí êáôáíÜëùóç ôóéãÜñùí óôçí Åõñþðç. ¸ôóé ç äéáêïðÞ ôïõ êáðíßóìáôïò, áëëÜ êáé ç ðñïóôáóßá áðü ôçí Ýê63


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Á. ÆåúìðÝêçò êáé óõí. 400

500

r = 0.23, 0.33, , p < 0.001 , 400

300 200

Ôñéãëõêåñßäéá

200

100

0 0

20

40

60

80

0

100

0

20

Çëéêßá (Ýôç)

40

60

80

100

Çëéêßá (Ýôç)

200

200

0.06, 0.003 , pp<=0.001 , rr==0.22,

175 150

150

125 100

100

75 50

Lp(a)

50

0 0

20

40

60

80

100

25 0 0

20

40

60

80

100

Çëéêßá (Ýôç)

Çëéêßá (Ýôç)

ÄéÜãñáììá 4. ÔéìÝò ïëéêÞò ÷ïëçóôåñüëçò (mg/dl), ôñéãëõêåñéäßùí (mg/dl), óáê÷Üñïõ (mg/dl) êáé Lp(a) (mg/dl), êáé çëéêßá ôùí áôüìùí ôçò ìåëÝôçò.

Ðßíáêáò 4. ÌÝóç åâäïìáäéáßá êáôáíÜëùóç (ãåýìáôá) äéáöüñùí ôñïöþí, áíÜ öýëï ¢íäñåò Êüêêéíï êñÝáò Êïôüðïõëï ØÜñé ¼óðñéá Ëá÷áíéêÜ ÆõìáñéêÜ ÓáëÜôåò Öñïýôá (çìåñçóßùò)

2,1 1,3 1,3 1,4 2,1 1,8 5,5 2,0

± ± ± ± ± ± ± ±

1.4 0.8 0.9 0.9 1.6 1.7 2.0 1.9

Ãõíáßêåò 1,7 1,3 1,4 1,3 2,3 1,7 5,6 2,1

± ± ± ± ± ± ± ±

1,2 0,8 1,0 1,0 1,7 1,3 2,1 1,8

èåóç óå êáðíü ôïõ ðåñéâÜëëïíôïò, ðñÝðåé íá áðïôåëÝóåé åðéôáêôéêü óôü÷ï ðáñÝìâáóçò ôùí ãéáôñþí ðñïò ôïõò áóèåíåßò, åßôå óå åðßðåäï ðñùôïãåíïýò åßôå äåõôåñïãåíïýò ðñüëçøçò. Áîßæåé éäéáßôåñçò ðñïóï÷Þò ç áõîçìÝíç óõ÷íüôçôá åíåñãïý 64

êáðíßóìáôïò óôéò íåáñÝò ãõíáßêåò (Ðßíáêáò 2). Ç âëáðôéêÞ åðßäñáóç ôïõ êáðíßóìáôïò ó÷åôßæåôáé âÝâáéá ìå ôïí áñéèìü ôùí ôóéãÜñùí êáé ôçí ÷ñïíéêÞ äéÜñêåéá ôïõ êáðíßóìáôïò, åíäå÷ïìÝíùò üìùò ðñÝðåé íá áíáìÝíåôáé áýîçóç ôçò åðßðôùóçò ôçò óôåöáíéáßáò íüóïõ ôá åðüìåíá ÷ñüíéá, éäéáßôåñá óôéò ãõíáßêåò ìÝóçò çëéêßáò, ôüôå äçëáäÞ ðïõ äåí èá õößóôáôáé ç ó÷åôéêÞ ðñïóôáóßá ôïõ ãõíáéêåßïõ öýëïõ áðü ôç óôåöáíéáßá íüóï ëüãù ôçò åììçíüðáõóçò8. Åßíáé ãíùóôüò ï ñüëïò ôçò ðá÷õóáñêßáò – êåíôñéêïý ôýðïõ - óôïí êáñäéáããåéáêü êßíäõíï9- 11, áíåîÜñôçôá áðü Üëëïõò ðáñÜãïíôåò êéíäýíïõ. Óå íåüôåñåò çëéêßåò ç áýîçóç ôïõ âÜñïõò õðïäçëþíåé áíèõãéåéíÝò óõíÞèåéåò óôïí ôñüðï æùÞò ôùí áôüìùí, üðùò êÜðíéóìá êáé êáèéóôéêÞ æùÞ12–14. Ç õéïèÝôçóç áêüìá êáé Þðéáò óùìáôéêÞò äñá-


Ôüìïò 15, Ôåý÷ïò 2, 2003

Á. ÆåúìðÝêçò êáé óõí.

óôçñéüôçôáò áðü Üôïìá ìåãÜëùí çëéêéþí öáßíåôáé íá Ý÷åé åõíïúêÜ áðïôåëÝóìáôá óôç ìåßùóç ôïõ óùìáôéêïý âÜñïõò (åëÜôôùóç äåßêôç ìÜæáò óþìáôïò êáé åëÜôôùóç ëüãïõ ìÝóç ðñïò ðåñéöÝñåéá), óôçí åëÜôôùóç ôçò ïëéêÞò ÷ïëçóôåñüëçò êáé óôçí ñýèìéóç ôçò áñôçñéáêÞò õðÝñôáóçò êáé óôá äýï öýëá12. Ôá ðáñáðÜíù áðïôõðþíïíôáé óáöÝóôåñá óôéò çëéêéáêÝò ïìÜäåò ìå õøçëü åðßðåäï óùìáôéêÞò äñáóôçñéüôçôáò. Äõóôõ÷þò êáé óôçí åëëçíéêÞ êïéíùíßá ðëÝïí, åëÜ÷éóôá åßíáé ôá åðáããÝëìáôá ðïõ óõíïäåýïíôáé Þ êáé áðáéôïýí óùìáôéêÞ äñáóôçñéüôçôá. ¼ðùò öáßíåôáé áðü ôïí Ðßíáêá 2 óçìáíôéêüôáôï ðïóïóôü áíäñþí êáé ãõíáéêþí, áêüìá êáé íÝùí, äÞëùóå áðïõóßá óùìáôéêÞò äñáóôçñéüôçôáò. ¸ôóé ç ìüíç ëýóç åßíáé ç áîéïðïßçóç ôïõ åëåýèåñïõ ÷ñüíïõ, ìå ðñïãñÜììáôá áåñïâéêÞò Üóêçóçò ðñïóáñìïóìÝíá, öõóéêÜ, óôçí çëéêßá, óôï öýëï êáé óôï áôïìéêü éóôïñéêü ôùí áôüìùí. Ç óçìáóßá ôçò áñôçñéáêÞò õðÝñôáóçò ùò ðáñÜãùí êéíäýíïõ óôåöáíéáßáò íüóïõ óå Üíäñåò êáé ãõíáßêåò åßíáé Þäç ãíùóôÞ áðü ðïëëÝò åðéäçìéïëïãéêÝò ìåëÝôåò15–17. ÐáñÜ ôéò ðñïüäïõò ðïõ Ý÷ïõí ãßíåé ôá ôåëåõôáßá ÷ñüíéá óôç öáñìáêåõôéêÞ áíôéìåôþðéóç ôçò õðÝñôáóçò, äéáðéóôþíåôáé äõóêïëßá óôç óùóôÞ ñýèìéóç ôùí áóèåíþí, åíþ ç õãéåéíï-äéáéôçôéêÞ áãùãÞ õðïëåßðåôáé óçìáíôéêÜ17–19. Åðßóçò ðáñüëç ôçí ðñïóðÜèåéá ãéá åíçìÝñùóç, ðïëëïß Üíèñùðïé äåí ãíùñßæïõí üôé ðÜó÷ïõí áðü õðÝñôáóç, êáé áðü áõôïýò ðïõ ôï ãíùñßæïõí ðïëý ëßãïé ôç ñõèìßæïõí ôåëéêÜ17. Ðáñüìïéá óôïé÷åßá ðñïÝêõøáí êáé áðü ôï äåßãìá ôçò ìåëÝôçò ìáò. ÕðÜñ÷ïõí ðëçèõóìéáêÝò ìåôááíáëýóåéò êáé åðéäçìéïëïãéêÝò ìåëÝôåò ðïõ êáèïñßæïõí ìå éêáíïðïéçôéêü ôñüðï ôçí õðåñ-ôñéãëõêåñéäáéìßá óáí ðáñÜãïíôá óôåöáíéáßïõ êéíäýíïõ20,21 áí êáé äå ëåßðïõí êáé ìåëÝôåò êõñßùò ðïëõðáñáãïíôéêÝò ðïõ äåí äåß÷íïõí óáöÞ óõó÷Ýôéóç22,23. Ç ìÝóç ôéìÞ ïëéêÞò ÷ïëçóôåñüëçò êáé ôñéãëõêåñéäßùí ôùí áôüìùí ôçò ìåëÝôçò ìáò åßíáé óáöÝóôáôá õøçëüôåñåò ôùí áíôßóôïé÷ùí Áìåñéêáíþí åíçëßêùí24, ãåãïíüò ðïõ äýóêïëá åîçãåßôáé áðü ôéò äéáöïñåôéêÝò äéáôñïöéêÝò óõíÞèåéåò ìåôáîý ôùí ðëçèõóìþí. Åðßóçò, ïé ãõíáßêåò ôïõ äåßãìáôïò åìöáíßæïõí õøçëüôåñåò ôéìÝò Apo A-1 êáé ÷áìçëüôåñåò Apo-B áðü ôïõò Üíäñåò, óôïé÷åßá ðïõ óõíçãïñïýí óå ÷áìçëüôåñï êßíäõíï ôùí ãõíáéêþí ãéá êáñäéáããåéáêÝò ðáèÞóåéò14. ÔÝëïò, üðùò ðáñáôçñÞèçêå êáé áðü ôçí ðáñïýóá ìåëÝôç áëëÜ êáé ôç äéåèíÞ âéâëéïãñáößá, ðá-

ñáôçñåßôáé áýîçóç ôçò áñôçñéáêÞò õðÝñôáóçò êáé ôçò ÷ïëçóôåñßíçò áðü ôçí çëéêßá ôçò åììçíüðáõóçò äçë. ôï 45 Ýôïò êáé Ýðåéôá. Óôéò Ç.Ð.Á Üíù ôïõ 50% ôùí ãõíáéêþí ìåãáëýôåñùí ôùí 55 åôþí Ý÷ïõí åðßðåäá ÷ïëçóôåñüëçò ìåãáëýôåñá ôùí 240 mg/dl30. Ôá ôåëåõôáßá ÷ñüíéá ôåêìçñéþíåôáé óõíå÷þò, áí êáé õðÜñ÷ïõí êáé áíôßèåôåò áðüøåéò, ï ñüëïò ôçò ïìïêõóôåÀíçò óáí áíåîÜñôçôïò êáé éó÷õñüò ðáñÜãïíôáò êáñäéáããåéáêïý êéíäýíïõ25-30. ÕðÜñ÷ïõí ðåéñáìáôéêÜ äåäïìÝíá ãéá ôïõò ðéèáíïýò ìç÷áíéóìïýò äñÜóçò ôçò óôçí áèçñùìáôéêÞ ðëÜêá, åíþ ïé åñåõíçôÝò öáßíåôáé íá óõìöùíïýí óå öõóéïëïãéêÝò ôéìÝò ôçò êÜôù ôùí 10ìMol/lt25. Áðü ôá ìÝ÷ñé ôþñá äåäïìÝíá ôçò ìåëÝôçò “ÁÔÔÉÊÇ”31 ðñïêýðôïõí õøçëÝò ôéìÝò ïìïêõóôåÀíçò, óôïé÷åßï ðïõ åßíáé ðåñéóóüôåñï ðéèáíü íá ïöåßëåôáé óå áðïõóßá âéôáìßíçò B12 êáé öõëëéêïý ïîÝïò áðü ôç äéáôñïöÞ ôïõ ðëçèõóìïý ôçò ìåëÝôçò, ðáñÜ óå ãåíåôéêü õðüâáèñï. Óôïõò áíáäõüìåíïõò ðáñÜãïíôåò áíÞêïõí êáé ïé ôéìÝò ôçò C – áíôéäñþóáò ðñùôåÀíçò êáé ôïõ éíùäïãüíïõ. Óôçí ðáñïýóá åñãáóßá ðáñáôçñïýíôáé áõîçìÝíåò ôéìÝò CRP óå ó÷Ýóç ìå Üëëåò äéåèíåßò ìåëÝôåò. Áõôü èá ðñÝðåé íá åîåôáóèåß ðåñáéôÝñù, êáé ìå ôçí ïëïêëÞñùóç ôïõ äåßãìáôïò, ãéá ðéèáíÝò ãåíåôéêÝò, äéáôñïöéêÝò, Þ êáé Üëëåò óõó÷åôßóåéò ìå ôéò ôéìÝò ôçò CRP Þ ôïõ éíùäïãüíïõ. Ôá óôïé÷åßá ðïõ ðáñïõóéÜóèçêáí áðïôåëïýí ôá ðñþôá ôçò ìåëÝôçò “ÁÔÔÉÊÇ” êáé åíäå÷ïìÝíùò íá ôñïðïðïéçèïýí, ìåñéêþò, ìÝ÷ñé ôçí ïëïêëÞñùóç ôçò äåéãìáôïëçðôéêÞò äéáäéêáóßáò. Ðáñüëá áõôÜ, ôï ãåãïíüò üôé ôï 44% ôùí áíäñþí êáé ôï 25% ôùí ãõíáéêþí åß÷áí ôïõëÜ÷éóôïí ôñåéò áðü ôïõò êëáóéêïýò ðáñÜãïíôåò êéíäýíïõ, êáèþò åðßóçò êáé ç óçìáíôéêÞ Ýëëåéøç êáôÜëëçëçò áãùãÞò, ðñÝðåé íá áíçóõ÷Þóïõí éäéáßôåñá ôïõò öïñåßò ðïõ åìðëÝêïíôáé óôá ðñïãñÜììáôá ðñüëçøçò ôçò äçìüóéáò õãåßáò.

Åõ÷áñéóôßåò Ïé óõããñáöåßò åðéèõìïýí íá åõ÷áñéóôÞóïõí ôá õðüëïéðá óôåëÝ÷ç ôçò ïìÜäáò “ÁÔÔÉÊÇ” (Åöç ÔóåôóÝêïõ, Óðýñï Âåëëßá, ËÜìðñï Ðáðáäçìçôñßïõ, Êáôåñßíá Ãéáííáêïðïýëïõ, Ãéþñãï Ìðåëåãñßíï, Íôßíá Ìáóïýñïõ, Áíáóôáóßá Êáôçíéþôç, ÅììáíïõÞë Ïéêïíüìïõ, ÊÜñìåí ÂáóéëåéÜäïõ, Óßá Ðïõëïðïýëïõ, ×ñõóïýëá Ôóåëßêá, Ìáíþëç ÊÜ65


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

ìðáîç, Êùíóôáíôßíá ÐÜëéïõ, êáé Ìáñßá Ôïýôïõæá) ãéá ôçí ïõóéáóôéêÞ êáé áíåêôßìçôç óõìâïëÞ ôïõò óôç ìÝ÷ñé ôþñá äéåîáãùãÞ ôçò ìåëÝôçò.

Âéâëéïãñáößá 1. Keys A. Seven Countries: A multivariate analysis of death and coronary heart disease. Cambridge, MA, Harvard University Press, 1980. 2. Moulopoulos SD, Adamopoulos PN, Diamantopoulos EI, Nanas SN, Anthopoulos LN, IliadiAlexandrou M. Coronary heart diseas risk factors in a random sample of Athenian adults. The Athens Study. Am J Epidemiod, 126:882892, 1987. 3. Kalandidi A, Tzonou A, Toupadaki N, Lan SJ, Koutis C, Drogari P, Notara V, Hsieh CC, Toutouzas P, Trichopoulos D. A case-control study of coronary heart disease in Athens, Greece. Int J Epidemiol, 21:1074-1080, 1992. 4. Pitsavos C, Skoumas J, Dernellis J, Doulalas A, Stefanadis C, Toutouzas P. Influence of biological factors on lipid and fibrinogen measurements in young men. An epidemiological study in 2009 recruits. Eur Heart J, 19:1642-1647, 1998. 5. Dwyer JH :Exposure to environmental tobacco smoke and coronary risk. Circulation, 96:14031407, 1997. 6. Liam TH, He Y. Passive smoking and coronary heart disease: a brief review. Clin Exp Pharmacol Physiol, 24:993-996, 1997. 7. Panagiotakos D.B., Chrysohoou C, Pitsavos C, Papaioannou I, Skoumas J, Stefanadis C, Toutouzas P.K.. The association between secondhand smoke and the risk of developing acute coronary syndromes, among non-smokers, under the presence of several cardiovascular risk factors: the CARDIO2000 case-control study. BMC Public Health, 2:9, 2002. 8. Panagiotakos DB, Pitsavos C, Chrysohoou C, Stefanadis C, Toutouzas PK. Risk Stratification of Coronary Heart Disease through Established and Emerging Lifestyle Factors, In A Mediterranean Population: CARDIO2000 Epidemiological Study. J Cardiovasc Risk, 8:6: 329-335, 2001. 9. Rimm EB, Stampfer MJ, Giovanucci E. et al. Body size and fat distribution as predictors of coronary heart disease among middle-aged and older US men.Am J Epidemiol, 141:1117-1127, 1995. 66

Á. ÆåúìðÝêçò êáé óõí.

10. Folsom AR, Kaye SA, Sellers TA, et al. Body fat distribution and 5-year risk of death in older women. JAMA, 269:483-487 1993. 11. Larsson B. Obesity and body fat distribution as predictors of coronary heart disease. In : Marmot M, Elliot P, Eds. Coronary heart disease epidemiology. From aetiology to public health. Oxford University Press, 1992, pp 233-241. 12. Paffenbarger Jr R, Hyde RT, Wing Al, Lee IMlu, Jung DL, Kampert JB: The association of changes in physical activity level and other lifestyle characteristics with mortality among men. N Engl Med, 328:538-545, 1993. 13. Blair SN. Changes in physical fitness and all cause mortality: a prospective study of health and unhealthy men. JAMA, 73:1093-1098, 1995. 14. Labarthe D. Epidemiology and Prevention of Cardiovascular disease. A global challenge. Maryland, An Aspen Publications, 1998, 167367. 15. Prevention of coronary heart disease in clinical practice. European Heart Journal, 19, 14341503, 1998. 16. Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure. The fifth report of the joint National Committee on Detection. Evaluation and Treatment of High Blood Pressure (JNC-V). Arch Intern Med, 153:154-183, 1993. 17. Burt VL, Culter JA, Higgins MN. Trends in prevalence, awareness, treatment and control of hypertension in the adult US population: data from the health examination surveys, 1960 to 1991. Hypertension, 26:60-69, 1995. 18. Williams GH. Assessing Patient Wellness: New Perspectives on Quality of Life and Compliance. Am J Hypertens, 11:186S-191S 1998. 19. Panagiotakos DB, Chrysohoou C, Pitsavos C, Tzioumis K, Papaioannou I, Stefanadis C, Toutouzas PK. The Association Of Mediterranean Diet With Lower Risk Of Acute Coronary Syndromes, In Hypertensive Subjects. Int J Cardiol, 82:141-147, 2002. 20. Bainton D, Miller NE, Bolton CH, Yarnell JWG, Sweetnam PM, Baker IA, Lewis R, Elwood PC. Plasma triglyceride and high-density lipoprotein cholesterol as predictors of ischaemic heart disease in British men. Br Heart J, 68:6066, 1992 21. Stampfer MJ, Krauss RM, Ma J et al. A prospective study of triglycerides, LDL particle diameter and risk of myocardial infarction. J Am Med Assoc, 276:882-888, 1996. 22. Jeppesen J, Hein HO, Suadicani P, Gyntelberg


Ôüìïò 15, Ôåý÷ïò 2, 2003

Á. ÆåúìðÝêçò êáé óõí.

23.

24.

25.

26.

F. Triglyceride concentration and ischemic heart disease. An eight –year follow –up in the Copenhagen Male Study. Circulation, 97:1029-1036, 1998. US Department of Health and Human Services, Public Health Service, The lipid research clinics population studies: the prevalence study, data book, vol.1, 1980 Bethesda. (Report No USDHHS/NIH/ 80-1527). Austin MA. Plasma triglycerides as a risk factor for coronary heart disease: the epidemiologic evidence and beyond. Am J Epidemiol, 129:249-259, 1989. Boushey CJ, Beresford SAA, Omenn GS, et al. A quantitative assessment of plasma homocysteine as a risk factor for vascular disease probable benefits of increasing folic acid intakes. JAMA, 274:1049-1057, 1995. McCully KS. Vascular pathology of homocys-

27. 28.

29. 30.

31.

teinemia: implications for the pathogenesis of arteriosclerosis. Am J Pathol, 56:111-128, 1969. Berger PB. Homocysteine and coronary artery disease. ACC Educational Highlights, 1-5, 1998. Folson AR, Nieto FJ, McGovern PG. Prospective study of coronary heart disease incidence in relation to fasting total homocysteine related genetic polymorphisms and vitamins D. The Atherosclerosis Risk in Communities (ARIC) Study. Circulation, 98:204-210, 1998. Wong N, Black H, Gardin J. Preventive Cardiology. Mc Graw-Hill Co 2000. Miller NH, Hill M, Kottke T, et al. The multilevel compliance challenge: recommendations for a call to action. Circulation 1997: 95:10851090. Pitsavos C.E., Toutouzas P.K. Cardiovascular Risk Factors Profile. in Greece: Results from CARDIO2000 and ATTICA epidemiological studies. Current Med Res Opinion 2000.

ÊÁÔÁ×ÙÑÇÓÅÉÓ ÔÙÍ ÅÑÃÁÓÉÙÍ ÔÏÕ ÐÅÑÉÏÄÉÊÏÕ "ÐÑÙÔÏÂÁÈÌÉÁ ÖÑÏÍÔÉÄÁ ÕÃÅÉÁÓ" Ôá ðåñéå÷üìåíá ôïõ Ðåñéïäéêïý "ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò" Êáôá÷ùñïýíôáé óôçí çëåêôñïíéêÞ âÜóç äåäïìÝíùí Index Copernicus http://indexcopernicus.org. Ç "ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò" åðßóçò óõãêáôáëÝãåôáé óôá ÅëëçíéêÜ ÐåñéïäéêÜ ìå "ÅèíéêÞ Áíáãíþñéóç" (Õð. Áðüö. ÖÅÊ áñ. öýëëïõ 972/27 Íïåìâñßïõ 1999 Ô.´) ðïõ ëáìâÜíïíôáé õðüøç áðü ôá ÐåñéöåñåéáêÜ Óõìâïýëéá ÅðéëïãÞò Åðéìåëçôþí Éáôñþí êáé ÏäïíôéÜôñùí ôïõ ÅÓÕ êáé ôá Óõìâïýëéá ÅðéëïãÞò Äéåõèõíôþí ÅÓÕ.

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ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Å. ÂåêñÞ êáé óõí.

ÅÐÁÉÍÅÈÅÉÓÁ ÅÑÃÁÓÉÁ ÓÔÏ ÄÉÁÃÙÍÉÓÌÏ "Ä. ÉÊÊÏÕ" THE SECOND AWARDED PAPER IN THE MEMORY OF PROF. "D. IKKOY" Primary Heatlh Care, Volume 15, Number 2, 68-72, 2003 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 15, Ôåý÷ïò 2, 68-72, 2003

Ìðïñåß ç C-Áíôéäñþóá ÐñùôåÀíç íá áðïôåëÝóåé ðñïãíùóôéêü äåßêôç óôá ÁããåéáêÜ ÅãêåöáëéêÜ Åðåéóüäéá óôçí ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò; Å. ÂåêñÞ3, ×. Ëçîïõñéþôçò3, Á. Ìáñéüëçò3, Å. ÌåóóÜñçò2, Í. ÐáñáñÜò², Â. Âïõãéïýêáò5, Æ. ÁëìÜæ5, Á. Ìïíáóôçñéþôçò³, Í. Áëåîáíäñüðïõëïò1, Á. ÌïõëáêÜêçò4

Ðåñßëçøç Óêïðüò ôçò ðáñïýóáò ìåëÝôçò åßíáé íá åêôéìÞóåé ôçí ðñïãíùóôéêÞ óçìáóßá ôçò CRP óôá áããåéáêÜ åãêåöáëéêÜ åðåéóüäéá (ÁÅÅ) óå ðñùôïâÜèìéï åðßðåäï ðåñßèáëøçò. Ðëçèõóìüò ìåëÝôçò êáé ìÝèïäïò: Ç ìåëÝôç Þôáí ðñïïðôéêÞ êáé áöïñïýóå 50 äéáäï÷éêÝò åéóáãùãÝò éó÷áéìéêþí ÁÅÅ óôï ÉððïêñÜôåéï íïóïêïìåßï, ìå åëåýèåñï éóôïñéêü ÷ñüíéùí ðáèÞóåùí. Åéäéêåõüìåíïò Ãåíéêüò Éáôñüò åêôåëïýóå ðëÞñç íåõñïëïãéêÞ åîÝôáóç êáé åêôßìçóç ôçò âáñýôçôáò ôçò íåõñïëïãéêÞò âëÜâçò ìå ôçí Êëßìáêá Ãëáóêþâçò êáé ôçí êëßìáêá ôïõ Åèíéêïý Éíóôéôïýôïõ Õãåßáò ôùí ÇíùìÝíùí Ðïëéôåéþí (ÍÉÇ). ÁíÜ áóèåíÞ ãéíüôáí ìÝôñçóç ôùí åðéðÝäùí CRP óôïí ïñü ìÝóá óå 6 þñåò áðü ôçí Ýíáñîç ôïõ åðåéóïäßïõ êáé ç ìÝôñçóç åðáíáëáìâáíüôáí óôéò 12 þñåò. ÁðïôåëÝóìáôá: Ç ìÝóç ôéìÞ ôçò CRP óå ÷ñïíéêü äéÜóôçìá ìéêñüôåñï ôùí 6 ùñþí áðü ôçí Ýíáñîç ôïõ ÁÅÅ âñÝèçêå 2,1±0,3 mg/l, åíþ ç ìÝóç ôéìÞ ôçò CRP 12 þñåò ìåôÜ ôï ÁÅÅ Þôáí 3,1±0,5 mg/l êáé âñÝèçêå óçìáíôéêÜ áõîçìÝíç óå óýãêñéóç ìå ôçí ðñþôç ìÝôñçóç (p=0,012). Ç Üíïäïò ôùí ôéìþí ôçò CRP 12 þñåò ìåôÜ ôï ÁÅÅ âñÝèçêå íá óõíïäåýåôáé ìå ìåßùóç ôùí ôéìþí ôçò Êëßìáêáò Ãëáóêþâçò óôéò 6 (p=0,036) êáé 12 þñåò (p=0,026) áðü ôï ÁÅÅ êáèþò êáé ìå áýîçóç ôùí ôéìþí ôçò ÍÉÇ óôéò 6 (p=0,006) êáé 12 þñåò (p=0,0011) áðü ôï ÁÅÅ. Ôá õøçëÜ åðßðåäá CRP óõó÷åôßóôçêáí ìå åìöÜíéóç áõîçìÝíùí åðéðëïêþí êáé äõóìåíÞ ðñüãíùóç (p<0,05) óôïõò áóèåíåßò ìå ÁÅÅ.

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Âéï÷çìéêü ÔìÞìá, ÉððïêñÜôåéï Íïóïêïìåßï, ÁèÞíá, 2ÅñãáóôÞñéï ×åéñïõñãéêÞò ¸ñåõíáò, Á’ ÐñïðáéäåõôéêÞ ×åéñïõñãéêÞ ÊëéíéêÞ, ÐáíåðéóôÞìéï Áèçíþí, ÉððïêñÜôåéï Íïóïêïìåßï, 3ÔìÞìá ÃåíéêÞò ÉáôñéêÞò, ÉððïêñÜôåéï Íïóïêïìåßï, ÁèÞíá, 4ÁíáðëçñùôÞò Ä/íôÞò ÐáèïëïãéêÞò ÊëéíéêÞò ÉððïêñÜôåéïõ Íïóïêïìåßïõ Áèçíþí, 5Éáôñïß

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ÅéóáãùãÞ Ðåñéóóüôåñá áðü 700.000 áããåéáêÜ åãêåöáëéêÜ åðåéóüäéá (ÁÅÅ) êáôáãñÜöïíôáé åôçóßùò óôéò ÇíùìÝíåò Ðïëéôåßåò1.Ôï óýã÷ñïíï åñåõíçôéêü ðåäßï óôïí ôïìÝá ôùí áããåéáêþí åãêåöáëéêþí åðåéóïäßùí åíôïðßæåôáé óå èÝìáôá ðñüëçøçò, ìÝóù ôçò áíáãíþñéóçò ðáñáãüíôùí êéíäýíïõ êáé ðñüãíùóçò. Ôá éó÷áéìéêÜ áããåéáêÜ åãêåöáëéêÜ åðåéóüäéá áíôéóôïé÷ïýí óôçí ðëåéïøçößá ôùí óõìâáìÜôùí. Áí êáé ç Üìåóç áéôßá ôïõ åãêåöáëéêïý åìöñÜêôïõ åßíáé ç äçìéïõñãßá áñôçñéáêïý èñüìâïõ, ï âáóéêüò ðáñÜãùí ãéá ôç äçìéïõñãßá áõôïý åßíáé ç áèçñïóêëÞñõíóç. Ç áíÜðôõîç ôçò áèçñùìÜôùóçò óôá áããåßá ôïõ áíèñþðéíïõ ïñãáíéóìïý ïäçãåß óôç óôÝíùóç êáé

ËÝîåéò ÊëåéäéÜ: CRP, ÁããåéáêÜ ÅãêåöáëéêÜ Åðåéóüäéá ÐñùôïâÜèìéá Öñïíôßäá õãåßáò ÕðïâëÞèçêå: Ç åñãáóßá õðïâëÞèçêå óôï äéáãùíéóìü "Ä. ºêêïõ" óôá ðëáßóéá ôïõ 15ïõ ÐáíåëëÞíéïõ Óõíåäñßïõ ÃåíéêÞò ÉáôñéêÞò (×áëêéäéêÞ 30 Áðñéëßïõ - 4 ÌáÀïõ 2003) êáé Ýëáâå Ýðáéíï áðü ôçí ÅðéôñïðÞ Êñßóçò. Äçìïóéåýåôáé ìå êïéíÞ áðüöáóç ôçò ÓõíôáêôéêÞò ÅðéôñïðÞò ôïõ ðåñéïäéêïý êáé ôçò ÏñãáíùôéêÞò ÅðéôñïðÞò ôïõ Óõíåäñßïõ. Õðåýèõíïò áëëçëïãñáößáò: Å. ÂåêñÞ, ÉððïêñÜôåéï Íïóïêïìåßï Áèçíþí, Ôçë. (6972)217396, (210)2224393


Å. ÂåêñÞ êáé óõí.

Ôüìïò 15, Ôåý÷ïò 2, 2003

íåßò ìå éó÷áéìéêü áããåéáêü åãêåöáëéêü åðåéóüäéï, ïé ïðïßïé áíôéìåôùðßóôçêáí óôï ÉððïêñÜôåéï Íïóïêïìåßï Áèçíþí. Ôá êñéôÞñéá åéóüäïõ óôç ìåëÝôç áðïôÝëåóáí: ç äéÜãíùóç ôïõ éó÷áéSummary Aim: The aim of this study is to appreciate the prognostic role of C-Reactive ìéêïý ÁÅÅ ðñüôåñá ôùí 6 ùñþí áðü Protein in Primary Health Care level. Study population and methods: The ôçí Ýíáñîç ôïõ åðåéóïäßïõ, ç çëéêßá study was preoptic. The study population consisted of 50 patients, recovered in ôïõ áóèåíïýò ìåôáîý 18 êáé 90 åôþí Hippokrateion Hospital of Athens, with ischemic strokes. The patients haven’t êáé ç ðáñïõóßá óõããåíþí ãéá ôç ëÞøç other illness. Resident, General practitioner was executing a complete NeurologóõãêáôÜèåóçò. Ôá êñéôÞñéá áðïêëåéical examination. He also was estimating the gravity of the situation with the Glasgow Scale and the NIH Stroke Scale. In each patient was estimated the óìïý áðü ôç ìåëÝôç áðïôÝëåóáí: ï level of CRP in the plasma 6 hour after the beginning of the event. Result: 6 èÜíáôïò åíôüò 12 ùñþí áðü ôçí åéóáhour after the beginning of stroke, the media value of CRP was 2.1±0.32 mg/l ãùãÞ, ç ðáñïõóßá êáêïÞèåéáò, ç äéÜand 12 hour after was 3.1±0.55 mg/l. This deference is statistically important ãíùóç óõíõðÜñ÷ïõóáò ëïßìùîçò, ñåõ(p=0.012).The increase of CRP values 12 hour after stroke, was found to be ìáôïëïãéêïý íïóÞìáôïò, íåöñéêÞò áíåaccompanied with a decrease of Glasgow scale, 6 hour (p=0.036) and 12 hours (p=0.026) after stroke also with an increase of value of NIH stroke scale 6 hour ðÜñêåéáò, áíïóïêáôáóôïëÞò Þ áíïóïá(p=0.006) and 12 hour (p=0.001) after stroke. The high value of CRP was íåðÜñêåéáò, ç ëÞøç ìç óôåñïåéäþí related with appearance complications and poor prognosis (p<0.05) in patients áíôéöëåãìïíùäþí öáñìÜêùí, êïñôéêïwith stroke. Conclusion: The first hours of stroke the increment of CRP value óôåñïåéäþí, êõôôáñïóôáôéêþí ÷çìåéïrelated poor prognosis and clinical situation get worse. So CRP value can be èåñáðåõôéêþí, ç ðñüóöáôç ìåôÜããéused as a marker, in patients no other illness. Key word: CRP, cerebral ischemic stroke, Primary Health Care. óç, ïé ðñüóöáôåò åðåìâÜóåéò (<1 ìçíüò), ôï ôñáýìá (<1 ìçíüò), ï ðõñåôüò áðüöñáîç áõôþí ìå ôåëéêü áðïôÝëåóìá ôçí åê- áãíþóôïõ áéôéïëïãßáò êáé ç ýðáñîç éóôïñéêïý äÞëùóç áããåéáêþí óõìâáìÜôùí, üðùò ôï Ýìöñáã- íåõñïëïãéêïý åëëåßììáôïò. Ôñåéò áóèåíåßò áðïìá ôïõ ìõïêáñäßïõ êáé ôá áããåéáêÜ åãêåöáëéêÜ êëåßóôçêáí áðü ôç ìåëÝôç ëüãù ðáñïõóßáò ñåõåðåéóüäéá2. ÐëÝïí ç áèçñùìÜôùóç èåùñåßôáé ìéá ìáôïëïãéêïý íïóÞìáôïò êáé Ýíáò áóèåíÞò äå óõöëåãìïíþäçò íüóïò. Ç CRP áðïôåëåß ðñùôåÀíç íáßíåóå ãéá ôç óõììåôï÷Þ ôïõ óôï åñåõíçôéêü ïîåßáò öÜóçò ôçò ðñïöëåãìïíþäïõò äéåñãáóßáò3. ðñùôüêïëëï. Ôçí ïìÜäá ìåëÝôçò áðïôÝëåóáí ôå¸÷åé ðáñáôçñçèåß ìéá éó÷õñÞ óõó÷Ýôéóç ìåôáîý ëéêÜ 46 áóèåíåßò ìÝóçò çëéêßáò 79,1±1,3 åôþí ôùí êëéíéêþí åêäçëþóåùí ôçò áèçñùìáôéêÞò íü- (ÄéÜìåóïò: 80 Ýôç), åê ôùí ïðïßùí 19 (41,3%) óïõ êáé ôùí åðéðÝäùí ôçò CRP óôï áßìá óå Þôáí Üíäñåò êáé 27 (58,7%) Þôáí ãõíáßêåò. áóèåíåßò ìå ïîý Ýìöñáãìá ôïõ ìõïêáñäßïõ, óôáÌåôÜ ôçí åéóáãùãÞ ôïõò óôï ÔìÞìá ÅðåéèåñÞ êáé áóôáèÞ óôçèÜã÷ç êáé ïîÝá óôåöáíéáßá ãüíôùí Ðåñéóôáôéêþí, ïé áóèåíåßò õðïâÜëëïíôáí óýíäñïìá4,5. ÌåãÜëåò ðñïïðôéêÝò ìåëÝôåò óå õãéåßò óå ëåðôïìåñÞ íåõñïëïãéêÞ åêôßìçóç áðü åéäéáíèñþðïõò åðéâåâáßùóáí ôçí ðñïãíùóôéêÞ áîßá êåõüìåíï Ãåíéêü Éáôñü êáé Ýíáí ÅéäéêåõìÝíï Ðáôçò CRP ãéá ôçí åêôßìçóç ôïõ êáñäéáããåéáêïý èïëüãï. Ç íåõñïëïãéêÞ åêôßìçóç ðåñéåëÜìâáíå êéíäýíïõ. ¼ìùò ëßãá óôïé÷åßá õðÜñ÷ïõí ãéá ôçí êáé ôçí áíáëõôéêÞ êáôáãñáöÞ ôùí êëéíéêþí åõðéèáíÞ ó÷Ýóç ôùí åðéðÝäùí ôçò CRP óôï áßìá ñçìÜôùí, ôá ïðïßá åßíáé áðáñáßôçôá ãéá ôïí êáé ôçí ðñüãíùóç ôùí éó÷áéìéêþí áããåéáêþí åãêå- õðïëïãéóìü ôçò Êëßìáêáò Ãëáóêþâçò êáé ôçò öáëéêþí åðåéóïäßùí6,7. Êëßìáêáò Åãêåöáëéêþí ôïõ Åèíéêïý ÉíóôéôïýÓêïðüò ôçò ðáñïýóáò ìåëÝôçò åßíáé ç ìÝôñç- ôïõ Õãåßáò ôùí ÇíùìÝíùí Ðïëéôåéþí. Ðñïêåéóç ôùí åðéðÝäùí CRP óôï áßìá áóèåíþí êáôÜ ìÝíïõ íá áðïêëåéóôåß ôï áéìïññáãéêü ÁÅÅ êÜèå ôçí ïîåßá öÜóç ôùí éó÷áéìéêþí åãêåöáëéêþí åðåé- áóèåíÞò õðïâáëëüôáí óå áîïíéêÞ ôïìïãñáößá. óïäßùí êáé ç åêôßìçóç ôçò ðñïãíùóôéêÞò ôïõò Óå êÜèå áóèåíÞ åðéðëÝïí ôïõ óõíÞèç åñãáóôçóçìáóßáò. ñéáêïý åëÝã÷ïõ (ÃåíéêÞ áßìáôïò, ÓÜê÷áñï, Ïõñßá, Êñåáôéíßíç, SGOT, SGPT, ã-gt, ALP, Na, K, HDL, LDL, LDH, CPK, ÔÊÅ, Ro Èþñáêïò) ãéíüôáí ìÝôñçóç ôùí åðéðÝäùí CRP (ÂéïÐëçèõóìüò ìåëÝôçò - ÌÝèïäïò ÷çìéêü ÅñãáóôÞñéï, ÉððïêñÜôåéï Íïóïêïìåßï) Óôç ìåëÝôç åéóÞ÷èçóáí 50 äéáäï÷éêïß áóèå- óôï áßìá êáôÜ ôçí åéóáãùãÞ ôïõ óôá ÔÅÐ êáé Can C-Reactive Protein be considered as marker in cerebral vascular strokes in primary health care? I. Vekri, Ch. Lixuriotis, A. Mariolis, E. Mesaris, N. Pararas, V. Vougioukas, Z. Almaz, A.Monastiriotis, N. Alexandropoulos, A. Moulakakis

69


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Å. ÂåêñÞ êáé óõí.

ïðùóäÞðïôå óå ëéãüôåñï áðü 6 þñåò áðü ôçí Ýíáñîç ôïõ åðåéóïäßïõ. Óôéò 12 þñåò ìåôÜ ôçí åãêáôÜóôáóç ôïõ ÁÅÅ ãéíüôáí íÝá êëéíéêÞ åîÝôáóç ôïõ áóèåíïýò ìå Ýìöáóç óôç íåõñïëïãéêÞ óçìåéïëïãßá êáé åê íÝïõ åñãáóôçñéáêüò Ýëåã÷ïò, óõìðåñéëáìâáíïìÝíçò ôçò ìÝôñçóçò ôùí åðéðÝäùí ôçò CRP. Áóèåíåßò ïé ïðïßïé åìöÜíéæáí êëéíéêÜ óçìåßá Þ åñãáóôçñéáêÜ åõñÞìáôá ëïéìþîåùò ìÝóá óôéò 12 þñåò áðü ôçí åéóáãùãÞ ôïõò áðïêëåßïíôáí áðü ôç ìåëÝôç.

ðñþôç ìÝôñçóç (p=0,012). ÅðéðëÝïí ç Êëßìáêá Åãêåöáëéêþí ôïõ Åèíéêïý Éíóôéôïýôïõ Õãåßáò ôùí ÇíùìÝíùí Ðïëéôåéþí åìöÜíéóå óôáôéóôéêþò óçìáíôéêÞ ìåßùóç ôùí ôéìþí ôçò áðü 7,6±0,9 (<6 þñåò) óå 7±0,9 (12 þñåò) (p=0,006). Áíôßèåôá äåí ðáñáôçñÞèçêáí óçìáíôéêÝò ìåôáâïëÝò óôçí Êëßìáêá Ãëáóêþâçò (<6 þñåò:13,5±0,2, Ýíáíôé 12 þñåò: 13,6±0,3, p=0,68). ÐáñáôçñÞèçêå ìßá óôáèåñÞ óõó÷Ýôéóç ìåôáîý ôçò ôéìÞò ôçò CRP 12 þñåò ìåôÜ ôçí åãêáôÜóôáóç ôïõ ÁÅÅ êáé ôùí êëéíéêþí âáèìßäùí áîéïëüãçóçò: Êëßìáêá Ãëáóêþâçò êáé Êëßìáêá Åãêåöáëéêþí ôïõ Åèíéêïý Éíóôéôïýôïõ Õãåßáò ôùí ÇíùìÝíùí Ðïëéôåéþí. Ç Üíïäïò ôùí ôéìþí ôçò CRP 12 þñåò ìåôÜ ôï ÁÅÅ âñÝèçêå íá óõíïäåýåôáé ìå ìåßùóç ôùí ôéìþí ôçò Êëßìáêáò Ãëáóêþâçò (ÄõóìåíÞò Ðñüãíùóç) óôéò 6 (p=0,036) êáé 12 þñåò (p=0,026) áðü ôï ÁÅÅ êáèþò êáé ìå áýîçóç ôùí ôéìþí ôçò Êëßìáêáò Åãêåöáëéêþí ôïõ Åèíéêïý Éíóôéôïýôïõ Õãåßáò ôùí ÇíùìÝíùí Ðïëéôåéþí (ÄõóìåíÞò Ðñüãíùóç) óôéò 6 (p=0,006) êáé 12 þñåò (p=0,0011) áðü ôï ÁÅÅ. ÔÝóóåñéò áóèåíåßò (8,7%) êáôÝëçîáí ôïõëÜ÷éóôïí 12 þñåò ìåôÜ ôçí åãêáôÜóôáóç ôïõ ÁÅÅ, åíþ 13 (28,3%) åìöÜíéóáí åðéðëïêÝò ìåôÜ ôçí åãêáôÜóôáóç ôïõ ÁÅÅ (åéóñüöçóç, ðíåõìïíßá). Ôá åðßðåäá CRP óôï áßìá áóèåíþí ìå ÁÅÅ âñÝèçêáí íá Ý÷ïõí ðñïãíùóôéêÞ óçìáóßá ôüóï ãéá ôçí ôåëéêÞ Ýêâáóç ôùí áóèåíþí, üóï êáé ãéá ôçí åìöÜíéóç åðéðëïêþí. Ç ðñïãíùóôéêÞ áîßá ôçò CRP óôá ÁÅÅ ðáñïõóéÜæåôáé óôïí Ðßíáêá 1 êáé ôçí ÄéÜãñáììá 1.

ÓôáôéóôéêÞ ÁíÜëõóç Ãéá ôç óýãêñéóç ðïóïôéêþí ìåôáâëçôþí óå äéÜöïñåò äéáäï÷éêÝò ÷ñïíéêÝò óôéãìÝò åöáñìüóèçêå ç ìç ðáñáìåôñéêÞ äïêéìáóßá Wilcoxon. Ãéá ôç óõó÷Ýôéóç ðïóïôéêþí ìåôáâëçôþí ìåôáîý ôïõò åöáñìüóèçêå ç äïêéìáóßá Spearman. Ãéá ôç ìåëÝôç ôçò åðßäñáóçò ôùí ôéìþí ðïóïôéêþí ìåôáâëçôþí óôçí ðñüãíùóç ôùí áóèåíþí ÷ñçóéìïðïéÞèçêå ðáëßíäñïìç áíÜëõóç (regression analysis). ¼ëåò ïé äïêéìáóßåò ìå ôéìÞ p<0.05 èåùñÞèçêáí ùò óôáôéóôéêþò óçìáíôéêÝò.

ÁðïôåëÝóìáôá Ç ìÝóç ôéìÞ ôçò CRP óôï áßìá óå ÷ñïíéêü äéÜóôçìá ìéêñüôåñï ôùí 6 ùñþí áðü ôçí Ýíáñîç ôïõ ÁÅÅ âñÝèçêå íá åßíáé 2,1±0,3 mg/l (ÄéÜìåóïò:1,6), åíþ ç ìÝóç ôéìÞ ôçò CRP 12 þñåò ìåôÜ ôï ÁÅÅ Þôáí 3,1±0,55 mg/l (ÄéÜìåóïò: 1,9) êáé âñÝèçêå óçìáíôéêÜ áõîçìÝíç óå óýãêñéóç ìå ôçí

Ðßíáêáò 1. Ç CRP ùò ðñïãíùóôéêüò äåßêôçò óôá ÁÅÅ ÌÝôñçóç

Åðéâßùóç

ÔéìÞ p

ÅðéðëïêÝò

ÔéìÞ p

CRP (<6 þñåò)

Íåêñïß: 5,8±2,4 Æùíôáíïß: 1,8±0,2 Íåêñïß: 11±4 Æùíôáíïß: 2,3±0,3 Íåêñïß: 11±0,7 Æùíôáíïß: 13,8±0,2 Íåêñïß: 9,7±0,8 Æùíôáíïß: 14±0,3 Íåêñïß: 15±3 Æùíôáíïß: 7,4±0,9 Íåêñïß: 16±2,8 Æùíôáíïß: 6,8±0,9

0,008*

¢íåõ: 1,4±0,2 ÅðéðëåãìÝíïé: 3,8±0,9 ¢íåõ: 1,8±0,2 ÅðéðëåãìÝíïé: 6,1±1,5 ¢íåõ: 14±0,2 ÅðéðëåãìÝíïé: 12,2±0,7 ¢íåõ: 14,2±0,2 ÅðéðëåãìÝíïé: 11,6±0,9 ¢íåõ: 6.5±0.9 ÅðéðëåãìÝíïé: 11,7±3 ¢íåõ: 5.9±0.8 ÅðéðëåãìÝíïé: 11,6±3,1

0,001*

CRP (12 þñåò) GCS (<6 þñåò) GCS (12 þñåò) ÍÉÇ (<6 þñåò) ÍÉÇ (12 þñåò)

*Óôáôéóôéêþò óçìáíôéêÞ äéáöïñÜ 70

0,005* 0,007* 0,001* 0,56 0,3

0,0001* 0,0024* 0,007* 0,025* 0,024*


Ôüìïò 15, Ôåý÷ïò 2, 2003

Å. ÂåêñÞ êáé óõí. 16 14 12 10 8 6 4 2 0 6 P (< CR

) ) ) ò) ò) ò) ñåò ñåò ñåò þñå þñå þñå 6þ 2þ 2þ (12 (< 6 P (1 S (< S (1 ÍÉÇ ÍÉÇ CR GC GC Íåêñïß

Æùíôáíïß

ÄéÜãñáììá 1. Ôá åðßðåäá CRP <6 þñåò êáé 12 þñåò ìåôÜ ôï ÁÅÅ Ý÷ïõí ðñïãíùóôéêÞ óçìáóßá.

ÓõæÞôçóç Ôï ÁÅÅ åßíáé ôï ðéï óõ÷íÜ åìöáíéæüìåíï íåõñïëïãéêü íüóçìá óôïõò åíçëßêïõò. ¸÷åé õðïëïãéóôåß üôé ðáñáðÜíù áðü 700.000 áããåéáêÜ åãêåöáëéêÜ åðåéóüäéá êáôáãñÜöïíôáé åôçóßùò óôéò ÇíùìÝíåò Ðïëéôåßåò êáé åßíáé ç ôñßôç áéôßá èáíÜôïõ ìåôÜ ôá êáñäéáêÜ íïóÞìáôá êáé üëïõò ôïõò ôýðïõò íåïðëáóìÜôùí. Ôá éó÷áéìéêÜ áããåéáêÜ åãêåöáëéêÜ åðåéóüäéá áíôéóôïé÷ïýí óôçí ðëåéïøçößá ôùí óõìâáìÜôùí. ÊáôÜ ôç äéÜñêåéá ôçò ôåëåõôáßáò äåêáåôßáò óçìáíôéêÞ ðñüïäïò Ý÷åé åðéôåõ÷èåß óôïí ôïìÝá ôçò èåñáðåßáò ôùí éó÷áéìéêþí áããåéáêþí åãêåöáëéêþí åðåéóïäßùí8,9. ÐáñáìÝíåé üìùò ï êßíäõíïò èáíÜôïõ Þ êáéíïýñãéïõ áããåéáêïý åðåéóïäßïõ. Ãéá ôï ëüãï áõôü ç áíåýñåóç êáéíïýñãéùí ðñïãíùóôéêþí äåéêôþí èá âïçèïýóå óçìáíôéêÜ óôçí áíáãíþñéóç áôüìùí õøçëïý êéíäýíïõ êáé ôçí ðåñáéôÝñù êáôáíüçóç ôçò ðáèïöõóéïëïãßáò ôçò íüóïõ. Óôçí ðáñïýóá ìåëÝôç åîåôÜæåôáé ï ðñïãíùóôéêüò ñüëïò ôçò CRP óå áóèåíåßò ðïõ Ý÷ïõí õðïóôåß éó÷áéìéêü ÁÅÅ. ¸÷åé ðáñáôçñçèåß ìéá éó÷õñÞ óõó÷Ýôéóç ìåôáîý ôùí êëéíéêþí åêäçëþóåùí ôçò áèçñùìáôéêÞò íüóïõ êáé ôùí åðéðÝäùí ôçò CRP óôï áßìá óå áóèåíåßò ìå ïîý Ýìöñáãìá ôïõ ìõïêáñäßïõ, óôáèåñÞ êáé áóôáèÞ óôçèÜã÷ç êáé ïîÝá óôåöáíéáßá óýíäñïìá12,13. ¢ëëåò ìåëÝôåò êáôáãñÜöïõí ôçí ðñïãíùóôéêÞ óçìáóßá ôùí åðéðÝäùí ôçò CRP óå õãéåßò ìÜñôõñåò, ïé ïðïßïé óå óõãêåêñéìÝíç óôéãìÞ ôçò æùÞò ôïõò õößóôáíôáé ÁÅÅ. Ëßãá

óôïé÷åßá õðÜñ÷ïõí óôç âéâëéïãñáößá ãéá ôïí ðñïãíùóôéêü ñüëï ôçò CRP ìåôÜ áðü ôçí åêäÞëùóç ôïõ ÁÅÅ. Áðü ôá åõñÞìáôá ôçò ðáñïýóáò ìåëÝôçò ðñïêýðôåé üôé ç CRP åßíáé áíåîÜñôçôïò ðñïãíùóôéêüò ðáñÜãïíôáò üóïí áöïñÜ ôçí Ýêâáóç óôá éó÷áéìéêÜ ÁÅÅ êáé üôé ç Üíïäïò ôùí ôéìþí ôçò óõó÷åôßæåôáé ìå äõóìåíÞ ðñüãíùóç. Ôá åðßðåäá CRP óôï áßìá áóèåíþí ìå ÁÅÅ âñÝèçêáí íá Ý÷ïõí ðñïãíùóôéêÞ óçìáóßá ôüóï ãéá ôçí ôåëéêÞ Ýêâáóç ôùí áóèåíþí, üóï êáé ãéá ôçí åìöÜíéóç åðéðëïêþí. Ôá áðïôåëÝóìáôá áõôÜ Ýñ÷ïíôáé óå óõìöùíßá ìå áíáöïñÝò Üëëùí åñåõíçôþí14-16. ÅðéðëÝïí, ïé Di Napoli êáé óõí. Ý÷ïõí óõó÷åôßóåé ôá åðßðåäá ôçò CRP óôï áßìá áóèåíþí ìå ÁÅÅ ìå ôï ìÝãåèïò ôçò åãêåöáëéêÞò âëÜâçò êáé áíáöÝñïõí üôé ôá åðßðåäá áõôÞò áõîÜíïõí ìå ôï ÷ñüíï áðü ôçí åãêáôÜóôáóç ôïõ åìöñÜêôïõ êáé ðáñÜëëçëá ìå ôçí áýîçóç ôïõ ìåãÝèïõò áõôïý. ×ñçóéìïðïéÞóáìå äýï, êïéíþò áðïäåêôÝò, êëßìáêåò áîéïëüãçóçò ôùí áóèåíþí ìáò (Êëßìáêá Ãëáóêþâçò êáé Êëßìáêá Åãêåöáëéêþí ôïõ Åèíéêïý Éíóôéôïýôïõ Õãåßáò ôùí ÇíùìÝíùí Ðïëéôåéþí), þóôå íá ðñïóäéïñéóôåß êëéíéêÜ ôï ìÝãåèïò ôçò åãêåöáëéêÞò âëÜâçò. ÂñÞêáìå üôé üóï áõîÜíïõí ôá åðßðåäá ôçò CRP 12 þñåò ìåôÜ ôçí Ýíáñîç ôïõ åãêåöáëéêïý, üðïõ ðëÝïí ôï Ýìöñáêôï Ý÷åé “ïñãáíùèåß”, ìåéþíïíôáé ïé ôéìÝò ôçò Êëßìáêáò Ãëáóêþâçò êáé ôçò Êëßìáêáò Åãêåöáëéêþí ôïõ Åèíéêïý Éíóôéôïýôïõ Õãåßáò ôùí ÇíùìÝíùí Ðïëéôåéþí (ÁëëáãÝò äõóìåíïýò ðñüãíùóçò). Ç Üíïäïò ôùí åðéðÝäùí ôçò CRP óôá ÁÅÅ Ý÷åé âñåèåß üôé ìðïñåß íá ïöåßëåôáé åßôå óôç íÝêñùóç, åßôå óôï ìÝãåèïò ôçò öëåãìïíþäïõò áíôßäñáóçò êáé ßóùò íá áðïôåëåß ôï äåßêôç ðïõ êáôáãñÜöåé ôçí áäõíáìßá åðáíáóçñáããïðïßçóçò ôïõ áðïöñá÷èÝíôïò áããåßïõ Þ ôçí åììÝíïõóá éó÷áéìßá. Ç CRP óôéò 12 þñåò ìðïñåß íá ÷ñçóéìïðïéçèåß ùò äåßêôçò ôüóï ôçò íÝêñùóçò, üóï êáé ôçò öëåãìïíþäïõò áíôßäñáóçò êáé íá êáôåõèýíåé ðñïò ìßá ðéï åðéèåôéêÞ èåñáðåõôéêÞ áãùãÞ êáôÜ ðåñßðôùóç17-19. ÓõìðåñáóìáôéêÜ, ç ÷ñÞóç ôçò CRP óôçí êáèçìåñéíÞ êëéíéêÞ ðñÜîç óôï åðßðåäï ôçò ÐñùôïâÜèìéáò öñïíôßäáò äßíåé ôç äõíáôüôçôá óôïí êëéíéêü éáôñü íá åêôéìÞóåé ôç âáñýôçôá ôïõ éó÷áéìéêïý ÁÅÅ. Óå áóèåíåßò ìå ÁÅÅ ôá áõîçìÝíá åðßðåäá CRP óôï áßìá óå óõíäõáóìü ìå ôá êëéíéêÜ åõñÞìáôá áðïôåëïýí Ýíá áóöáëÝò êñéôÞñéï åêôßìçóçò ôçò Ýêâáóçò ôïõ åðåéóïäßïõ.

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Âéâëéïãñáößá 1. Di Napoli M, Papa F. Clinical use of C-reactive protein for prognostic stratification in ischemic stroke: has the time come for including it in the patient risk profile? Stroke, 34:375-6, 2003. 2. Ridker PM, Buring JE, Cook NR, Rifai N. Creactive protein, the metabolic syndrome, and risk of incident cardiovascular events: an 8year follow-up of 14,719 initially healthy American women. Circulation, 107:391-397, 2003. 3. Iyigun I, Bakirci Y. Plasma concentrations of C-reactive protein and fibrinogen in ischaemic stroke. J Int Med Res, 30:591-6,2003. 4. Van Der Meer IM, De Maat MP, Hak AE, Kiliaan AJ, Del Sol AI, Van Der Kuip DA, Nijhuis RL, Hofman A, Witteman JC. C-reactive protein predicts progression of atherosclerosis measured at various sites in the arterial tree: the Rotterdam Study. Stroke, 3:2750-5, 2002. 5. Muir KW. Inflammation, blood pressure, and stroke: an opportunity to target primary prevention? Stroke, 33:2732-3, 2002. 6. Ridker PM, Rifai N, Rose L, Buring JE, Cook NR. Comparison of C-reactive protein and lowdensity lipoprotein cholesterol levels in the prediction of first cardiovascular events. N Engl J Med, 347:1557-65, 2002. 7. Marquardt L, Ruf A, Mansmann U, Winter R, Schuler M, Buggle F, Mayer H, Grau AJ. Course of platelet activation markers after ischemic stroke. Stroke, 33:2570-2574, 2002. 8. Park R, Detrano R, Xiang M, Fu P, Ibrahim Y, LaBree L, Azen S. Combined use of computed tomography coronary calcium scores and C-reactive protein levels in predicting cardiovascular events in nondiabetic individuals. Circulation, 106:2073-2077, 2002. 9. Iyigun I C-reactive protein in ischemic stroke. Stroke, 33:2146-2147, 2002.

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10. Blann AD, Ridker PM, Lip GY. Éinflammation, cell adhesion molecules, and stroke: tools in pathophysiology and epidemiology? Stroke, 33:2141-2143, 2002. 11. van Exel E, Gussekloo J, de Craen AJ, Bootsma-van er Wiel A, Frolich M, Westendorp RG. Énflammation and stroke: the Leiden 85-Plus Study. Stroke, 33:1135-1138, 2002. 12. Retterstol L, Eikvar L, Bohn M, Bakken A, Erikssen J, Berg K. C-reactive protein predicts death in patients with revious premature myocardial infarction-a 10 year follow-up study. Atherosclerosis, 160:433-440, 2002. 13. Tohgi H, Takahashi H, Tamura K, Konno S, Kawamorita, Nozaki Y Ischemic stroke among inpatients with preceding inflammatory response. Thromb Res, 104:375-377, 2001. 14. Rost NS, Wolf PA, Kase CS, Kelly-Hayes M, Silbershatz H, Massaro JM, D’Agostino RB, Franzblau C, Wilson PW. Plasma concentration of C-reactive protein and risk of ischemic stroke and transient ischemic attack: the Framingham study. Stroke, 32:2575-9, 2001 15. Di Napoli M, Papa F Inflammation, statins, and outcome after ischemic stroke. Stroke, 32:2446-7, 2001. 16. Di Napoli M. C reactive protein and acute phase of ischaemic stroke. ÂÌJ, 30;322:1605-6, 2001. 17. Di Napoli M, Papa F, Bocola V. Prognostic influence of increased C-reactive protein and fibrinogen levels in ischemic stroke. Stroke, 32:133-8, 2001. 18. Gussekloo J, Schaap MC, Frolich M, Blauw GJ, Westendorp RG. C-reactive protein is a strong but nonspecific risk factor of fatal stroke in elderly persons. Arterioscler. Thromb. Vasc Biol, 20:10, 47-1051, 2000. 19. Ridker PM, Hennekens CH, Buring JE, Rifai N.C-reactive protein and other markers of inflammation in the prediction of cardiovascular disease in women. N Engl J Med, 342:836-43, 2000.


Ôüìïò 15, Ôåý÷ïò 2, 2003

Á. Ìáñéüëçò êáé óõí

ÂÑÁÂÅÕÈÅÉÓÁ ÅËÅÕÈÅÑÇ ÁÍÁÊÏÉÍÙÓÇ AWARDED FREESTANDING PAPER Primary Heatlh Care, Volume 15, Number 2, 73-78, 2003 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 15, Ôåý÷ïò 2, 73-78, 2003

Ç ìÝôñçóç ôçò áñôçñéáêÞò ðßåóçò óôï óðßôé êáé ç óõìâïëÞ ôçò óôçí êáëýôåñç èåñáðåõôéêÞ áíôéìåôþðéóç ôùí õðåñôáóéêþí áôüìùí óôçí ðåñéï÷Þ åõèýíçò KÝíôñïõ Yãåßáò Âýñùíá Á. Ìáñéüëçò1, ×. ÊáëáúôæÞ3, Á. ÆåúìðÝêçò1, Áéêáôåñßíç ÖïõôóéôæÞ-Äáíßêá2, Í. Áëåîáíäñüðïõëïò4, Ã. ÃåùñãéÜäçò5 Ðåñßëçøç Óêïðüò: Íá åîåôáóèåß ç ÷ñçóéìüôçôá ôùí ìåôñÞóåùí ôçò áñôçñéáêÞò ðßåóçò (ÁÐ) óôï óðßôé óôçí åêôßìçóç ôçò ñýèìéóçò ôçò áñôçñéáêÞò õðÝñôáóçò (ÁÕ), ìå ôç óõíéóôþìåíç áãùãÞ (öáñìáêåõôéêÞ Þ õãéåéíïäéáéôçôéêÞ) óå õðåñôáóéêÜ Üôïìá ðåñéï÷Þò åõèýíçò ÊÝíôñïõ Õãåßáò Áóôéêïý Ôýðïõ. Ðëçèõóìüò ìåëÝôçò –ÌÝèïäïò: Óå 80 õðåñôáóéêÜ Üôïìá ðïõ ðñïóÞëèáí óôï ÊÝíôñï Õãåßáò Âýñùíá óå äéÜóôçìá 2 ìçíþí ãéá ìÝôñçóç ôçò ÁÐ Þ ãéá óõíôáãïãñÜöçóç áíôéõðåñôáóéêþí öáñìÜêùí êáôáãñÜöçêå ç çëéêßá, ôï öýëï, ôï ýøïò êáé ôï âÜñïò. Óôïõò áóèåíåßò áõôïýò, áöïý Ýãéíå åðáñêÞò åêðáßäåõóç óôçí ôå÷íéêÞ ìÝôñçóçò ôçò ÁÐ, óõíåóôÞèç íá ìåôñïýí ôçí ÁÐ óôï óðßôé äýï öïñÝò ôçí çìÝñá, ðñùß êáé âñÜäõ ìå ôï ðéåóüìåôñï ðïõ äéáèÝôïõí êáé íá êáôáãñÜöïõí ôéò ìåôñÞóåéò ôïõò ãéá äéÜóôçìá 4 åâäïìÜäùí. Áðáéôåßôï êÜèå öïñÜ Ýíá æåýãïò ìåôñÞóåùí ôçò ÁÐ ìå äéáöïñÜ 1 ëåðôïý ç ìßá áðü ôçí Üëëç ìå ôïí áóèåíÞ óå êáèåóôçêõßá èÝóç. Ïé ìåôñÞóåéò ãßíïíôáí ðåñßðïõ ôçí ßäéá þñá êÜèå çìÝñá ìå ôï ßäéï ðéåóüìåôñï êáé áðü ôï ßäéï Üôïìï. Ùò ÁÐ óôï óðßôé èåùñÞèçêå ï ìÝóïò üñïò ôùí âñáäéíþí êáé ðñùéíþí ìåôñÞóåùí. Ïé áóèåíåßò åðáíÝñ÷ïíôáí óôï ÊÝíôñï Õãåßáò ìåôÜ áðü Ýíá ìÞíá üðïõ åëÝã÷ïíôáí ìå õäñáñãõñéêü óöõãìïìáíüìåôñï ç ÁÐ ôñåéò öïñÝò êáé ëáìâÜíïíôáí ï ìÝóïò üñïò áõôþí ôùí ìåôñÞóåùí. ÑõèìéóìÝíç èåùñåßôï ç ÁÕ áí ç ìÝóç ôéìÞ ôùí ìåôñÞóåùí ôçò ÁÐ óôï éáôñåßï Þ óôï óðßôé Þôáí <140/ 90 mmHg. ÁðïôåëÝóìáôá: Áðü ôïõò 80 õðåñôáóéêïýò áóèåíåßò, óôç ìåëÝôç ôåëéêÜ óõìðåñéëÞöèçóáí 75 áóèåíåßò áöïý 5 áóèåíåßò áðïññßöèçêáí ëüãù áíåðáñêïýò áñéèìïý ìåôñÞóåùí ôçò ÁÐ óôï óðßôé. Ï ìÝóïò áñéèìüò ìåôñÞóåùí ôçò ÁÐ óôï óðßôé áíÜ Üôïìï Þôáí 85±12 (áðü 45-110 ìåôñÞóåéò). Ç ìÝóç çëéêßá ôùí áôüìùí Þôáí 72±9 (64-87 Ýôç), ï äåßêôçò ìÜæáò óþìáôïò Þôáí 27,9±6 Kg/ m2 êáé 71 Üôïìá ëÜìâáíáí áíôéõðåñôáóéêÞ áãùãÞ. Ç ÁÐ óôï éáôñåßï Þôáí óôáôéóôéêÜ óçìáíôéêÜ õøçëüôåñç óõãêñéôéêÜ ìå ôçí ÁÐ óôï óðßôé (15,2±17/81±10 Ýíáíôé 150±14/80±11 mmHg, p<0,05). Ïé ðñùéíÝò ôéìÝò ìÝôñçóçò ôçò ÁÐ óôï óðßôé Þôáí óôáôéóôéêÜ óçìáíôéêÜ õøçëüôåñåò óõãêñéôéêÜ ìå ôéò âñáäéíÝò ôéìÝò ôçò ÁÐ (155±13/81±12 Ýíáíôé 144±15/78±11 mmHg, p<0,05). Äéáðéóôþèçêå óôáôéóôéêÜ óçìáíôéêÞ óõó÷Ýôéóç áíÜìåóá óôçí ÁÐ éáôñåßïõ êáé óôçí ÁÐ óôï óðßôé (r=0,44, p<0,005). Âáóéæüìåíïé óôçí ÁÐ éáôñåßïõ ôï 24 % ôùí õðåñôáóéêþí åß÷å ñõèìéóìÝíç ôçí ÁÐ åíþ âáóéæüìåíïé óôçí ÁÐ óôï óðßôé ôï 32% åß÷å ñõèìéóìÝíç ôçí ÁÐ (p<0,005). ÓõìðåñÜóìáôá: Ç ìÝôñçóç ôçò ÁÐ óôï óðßôé öáßíåôáé íá áðïôåëåß ìßá êáëÞ åíáëëáêôéêÞ ðñáêôéêÞ óôçí ðñïóðÜèåéá åðßôåõîçò êáëýôåñçò ñýèìéóçò ôçò ÁÐ óôá õðåñôáóéêÜ Üôïìá. 1

Ãåíéêïß Éáôñïß - 2Íïóçëåýôñéá ÊÝíôñïõ Õãåßáò Âýñùíá ‘’ÉððïêñÜôåéï” Ã.Í.Á., 3Øõ÷ßáôñïò Ã.Í.Á. “Ã. ÃåííçìáôÜò”, 5ÓõíôïíéóôÞò êáé 4ÁíáðëçñùôÞò Åêðáßäåõóçò Ãåíéêþí Éáôñþí "ÉððïêñÜôåéï". Ã.Í.Á.

ÅéóáãùãÞ Ìå ôïí üñï áñôçñéáêÞ õðÝñôáóç åííïïýìå ôçí áýîçóç ôçò áñôçñéáêÞò ðéÝóåùò (ÁÐ) ðÜíù áðü ôá öõóéïëïãéêÜ üñéá, ðïõ Ý÷åé ùò óõíÝðåéá ôïí áõîçìÝíï êßíäõíï åìöÜíéóçò íïóçñüôçôáò êáé èíçôüôçôáò áðü êáñäéáããåéáêÜ êõñßùò íïóÞìáôá. Ïñßæåôáé ùò öõóéïëïãéêÞ ç ÁÐ, üôáí ç óõóôïëéêÞ áñôçñéáêÞ ðßåóç (ÓÁÐ) åßíáé ìéêñüôåñç áðü 140 mmHg êáé ç äéáóôïëéêÞ áñôçñéáêÞ ðßåóç (ÄÁÐ) ìéêñüôåñç áðü 90 mmHg. Ç åðßðôùóç ôçò áñôçñéáêÞò õðåñôÜóåùò (ðáñáôçñåßôáé óôï 20 – 30 % ôïõ ãåíéêïý ðëçèõóìïý ôùí åíçëßêùí), êáèþò êáé ïé óçìáíôéêÝò êëéíéêÝò åðéðôþóåéò ôçò (áããåéïåãêåöáëéêÝò, óôåöáíéáßåò, ðåñéöå-

ËÝîåéò ÊëåéäéÜ: ÁñôçñéáêÞ ðßåóç óôï óðßôé, áñôçñéáêÞ ðßåóç éáôñåßïõ, èåñáðåõôéêÞ áíôéìåôþðéóç õðÝñôáóçò ÕðïâëÞèçêå: Ç åñãáóßá õðïâëÞèçêå ùò åëåýèåñç áíáêïßíùóç óôï 15o ÐáíåëëÞíéï ÓõíÝäñéï ÃåíéêÞò ÉáôñéêÞò (×áëêéäéêÞ 30 Áðñéëßïõ - 4 ÌáÀïõ 2003) êáé âñáâåýôçêå áðü ôçí åðéôñïðÞ Êñßóçò. Äçìïóéåýåôáé ìå êïéíÞ áðüöáóç ôçò ÓõíôáêôéêÞò ÅðéôñïðÞò ôïõ ðåñéïäéêïý êáé ôçò ÏñãáíùôéêÞò ÅðéôñïðÞò ôïõ Óõíåäñßïõ. Õðåýèõíïò áëëçëïãñáößáò: ÁíÜñãõñïò Ä. Ìáñéüëçò, Ìáíïýóïõ Êïõíäïýñïõ 85, KáóôÝëëá - ÐåéñáéÜò 18533, Ôçë. (210)4129393, (6945)713380, e-mail: anargirosm@yahoo.gr 73


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Á. Ìáñéüëçò êáé óõí

ìïðïéåßôáé ç Ýììåóç óöõãìáíïìÝôñçóç, ç ðáëìéêÞ ìÝèïäïò ðïõ ÷ñçóéìïðïéåßôáé óôï óðßôé êáé óå óõóêåõÝò ðåñéðáôçôéêÞò êáôáãñáöÞò êáé õðåñç÷ïãñáöéêÝò ôå÷íéêÝò. Ç Ýììåóç ìÝSummary ôñçóç ôçò áñôçñéáêÞò ðéÝóåùò ðïõ Aim: Our purpose was to examine the usefulness of blood pressure measureåéóÞ÷èç ôï 1896 áðü ôïí Rocci áðïments in the patients’ home in treating blood pressure (with medications or ôåëåß ôç óõíÞèç ðñáêôéêÞ ãéá ôçí êábehavioral changes) in hypertensive patients residing in the sector of a Health ôáãñáöÞ ôçò ÁÐ ôüóï óôï éáôñåßï Center. Population- Method: We examined 80 hypertensive patients that came üóï êáé óôï óðßôé. to Byronas Health Center within a time period of 2 months for BP measurement or prescription of antihypertensive agents, keeping records of their age, gender, Ôá ôåëåõôáßá ÷ñüíéá ðáñáôçñÞèçheight and weight. After being sufficiently trained to self- measure their blood êå ìéá óçìáíôéêÞ áýîçóç óôç ÷ñÞóç pressure (BP), patients were recommended to measure their blood pressure in ôçò ðáñáêïëïõèÞóåùò ôçò áñôçñéáêÞò their home twice daily (morning and night) and to record these measurements ðéÝóåùò áðü ôïí áóèåíÞ óôï óðßôé ùò for the next 4 weeks. Patients had to be in a sitting position and measure their ìéá óõìðëçñùìáôéêÞ ðçãÞ ðëçñïöïñéþí blood pressure each time twice, with an one minute interval between measurements. Measurements were set to take place approximately the same time each óôç êëéíéêÞ ðñáêôéêÞ1,2. ÄéÜöïñåò éáday, with the same sphygmomanometer, by the same person. We considered as ôñéêÝò ïñãáíþóåéò åíèáññýíïõí ôç ðñáhome BP, the mean of morning and night measurements. Each month patients êôéêÞ ôçò ìÝôñçóçò ôçò áñôçñéáêÞò returned to Health Center, where they had their BP measured three times with ðéÝóåùò óôï óðßôé1,3,4. ¸ôóé, ç USA’s a mercurial sphygmomanometer, and we calculated the mean of these meaJoint National Committee on the Desurements. Blood pressure was considered regulated if the mean of blood pressure measurements at home or at health center was <140/90mmHg. tection, Evaluation, and Treatment of Results: From the initial 80 hypertesive patients, 75 were finally included in the High Blood Pressure3, ç World Health study, as 5 patients were excluded for insufficient home measurements. The Organization/International Society of mean number of home blood pressure measurements was 85±12 (45-110 Hypertension4 êáé ç World Hypertenmeasurements). sion League1 áðïäÝ÷ïíôáé ôçí êëéíéêÞ Patients’ mean age was 72±9 years (64-87 years), mean body mass index (BMI) was 27.9±6 Kg/m2. Of these patients, 71 were receiving antihypertensive óçìáóßá ôçò ìÝôñçóçò ôçò áñôçñéáêÞò treatment. Blood pressure measurements at Health Center were significantly ðéÝóåùò óôï óðßôé óôç äéÜãíùóç ôçò higher than those taken at home (152±17/81±10 vs 150±14/80±11 mmHg, áñôçñéáêÞò õðåñôÜóåùò êáé óôçí áîéïp<0.05). For measurements at home, morning blood pressure values were sigëüãçóç ôùí áðïôåëåóìÜôùí ôçò èåñánificantly higher than night ones (155±13/81±12 vs. 144±15/78±11 mmHg, ðåßáò. Ùóôüóï, êáìéÜ áðü áõôÝò ôéò p<0.05). There was a statistically significant difference between BP measured at the Health Center and BP measured at home (r=0.44, p<0.005). Based on BP áíáöïñÝò äåí äéáôýðùóå óõãêåêñéìÝmeasurements at the Health Center, 24% of hypertensive patients had their íåò êáôåõèõíôÞñéåò ãñáììÝò ãéá ôï ðþò blood pressure satisfactorily regulated, while based on home measurements, ç ìÝôñçóç ôçò áñôçñéáêÞò ðéÝóåùò óôï this percentage mounted to 32 (p<0.005). óðßôé ìðïñåß íá ÷ñçóéìïðïéçèåß óôçí Conclusions: Measuring blood pressure at home seems to be a good alternative in attempting to achieve a better regulation of BP in hypertensive patients. ðñÜîç. ¸íá áðü ôá ìåãÜëá èåùñçôéêÜ Key words: home blood pressure, office blood pressure, hypertensive treatðëåïíåêôÞìáôá ôçò ÷ñÞóçò ôçò ìÝôñçment. óçò ôçò áñôçñéáêÞò ðéÝóåùò óôï óðßôé Vyronas Health Centre, Athens’s Greece åßíáé ï ìåãÜëïò áñéèìüò ôùí êáôáãñáöþí ôçò ÁÐ ðïõ ìðïñïýí íá ëçöèïýí1,2. ñéêÝò áããåéáêÝò, íåöñáããåéáêÝò âëÜâåò êáé áìöé- ÕðÜñ÷ïõí äéáöïñÝò óôéò ôéìÝò ôùí ìåôñÞóåùí ôçò âëçóôñïåéäïðÜèåéá, õðåñôñïößá ôçò áñéóôåñÜò ÁÐ óôï óðßôé óå ó÷Ýóç ìå ôéò ôéìÝò ôçò ÁÐ ðïõ êïéëßáò êáé áõîçìÝíï ðïóïóôü äéáóôïëéêÞò êáé êáôáãñÜöïíôáé óôï éáôñåßï. Áðü ôçí åðï÷Þ ðïõ óõóôïëéêÞò äõóëåéôïõñãßáò), êáèéóôïýí áíáãêáßá äéáôõðþèçêå ç Üðïøç üôé ïé ôéìÝò ôçò ÁÐ óôï ôç äéÜãíùóç, äéåñåýíçóç êáé áíôéìåôþðéóç ôçò óðßôé åßíáé ìéêñüôåñåò ôùí ôéìþí ðïõ êáôáãñÜöïáñôçñéáêÞò õðåñôÜóåùò óôá ðëáßóéá ôçò Ðñùôï- íôáé óôï éáôñåßï (Ayman and Goldshine)5, ðïëëÝò âÜèìéáò Öñïíôßäáò Õãåßáò. Ãéá ôïí ðñïóäéïñéóìü ìåëÝôåò áíáöÝñïõí üôé ç åðßóêåøç óôï éáôñåßï ôçò áñôçñéáêÞò ðéÝóåùò, ðëçí ôçò ðñüôõðçò ìå- åðéöÝñåé ìéá áýîçóç ôçò ÁÐ ôïõ áóèåíïýò óå èüäïõ ôïõ åíäáñôçñéáêïý êáèåôçñéáóìïý, ìåèü- ó÷Ýóç ìå ôéò ôéìÝò ðïõ êáôáãñÜöïíôáé óôï óðßôé Þ äïõ öõóéêÜ ìç ðñáêôéêÞò ãéá ôéò ðåñéðôþóåéò ìç ìå ôçí 24ùñç ðåñéðáôçôéêÞ êáôáãñáöÞ-Holter íïóçëåõïìÝíùí Þ ðåñéðáôçôéêþí áóèåíþí, ÷ñçóé- 24ùñçò êáôáãñáöÞò ÁÐ (õðÝñôáóç ôçò ëåõêÞò Blood pressure mesurement in the patient’s home and it’s contribution in the better therapeutic approach of hypertensive patients in the catchment area of the Vyronas Health Centre A. Mariolis, C. Kalaitzi, A. Zeimbekis, A. Foutsitzi-Danika, N. Alexandropoulos, G. Georgiadis

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Ôüìïò 15, Ôåý÷ïò 2, 2003

Á. Ìáñéüëçò êáé óõí

ìðëïýæáò)6-12. Ç ìÝôñçóç ôçò ÁÐ óôï óðßôé ìðïñåß íá Ý÷åé èåôéêÞ åðßäñáóç óôçí êáôáíüçóç ôùí õðåñôáóéêþí “ðñïâëçìÜôùí” êáé óôç óõììüñöùóç ôïõ áóèåíïýò óôçí áíôéõðåñôáóéêÞ áãùãÞ, åíþ ç 24ùñç êáôáãñáöÞ ìðïñåß íá áðïôåëåß ôçí ðëÝïí áîéüðéóôç, áëëÜ ôáõôü÷ñïíá êáé ôçí ðåñéóóüôåñï äáðáíçñÞ êáé óðáíéüôåñá ÷ñçóéìïðïéïýìåíç ìÝèïäï13. Ç ðáñïýóá åñãáóßá áðïóêïðåß óôçí áîéïëüãçóç ôùí ìåôñÞóåùí ôçò áñôçñéáêÞò ðéÝóåùò óôï óðßôé ìå ôç ÷ñÞóç äéáöüñùí ôýðùí ðéåóüìåôñùí, ùò ðñïò ôçí åêôßìçóç ôçò ñýèìéóçò ôçò áñôçñéáêÞò ðéÝóåùò (ÁÕ) ìå ôç óõíéóôþìåíç öáñìáêåõôéêÞ Þ õãéåéíïäéáéôçôéêÞ áãùãÞ óå õðåñôáóéêÜ Üôïìá ôçò ðåñéï÷Þò åõèýíçò ÊÝíôñïõ Õãåßáò Áóôéêïý Ôýðïõ.

Ðëçèõóìüò ìåëÝôçò - ÌÝèïäïò Ðëçèõóìüò ôçò ìåëÝôçò Ðñüêåéôáé ãéá ìéá ìåëÝôç ðïõ ðñáãìáôïðïéÞèçêå óôï ÊÝíôñï Õãåßáò Áóôéêïý ôýðïõ ôïõ Âýñùíá. Ôïí ðëçèõóìü ôçò ìåëÝôçò áðïôåëïýóáí Üôïìá ôçò ðåñéï÷Þò åõèýíçò ôïõ Ê. Õ. Âýñùíá ìå éäéïðáèÞ áñôçñéáêÞ õðÝñôáóç õðü öáñìáêåõôéêÞ Þ õãéåéíïäéáéôçôéêÞ áãùãÞ, ðïõ ðñïóÞëèáí óå äéÜóôçìá äýï ìçíþí (Áðñßëéïò-ÌÜéïò 2002) ãéá ìÝôñçóç ôçò áñôçñéáêÞò ôïõò ðéÝóåùò Þ ãéá óõíôáãïãñáößá áíôéõðåñôáóéêþí öáñìÜêùí. Óôïõò áóèåíåßò áõôïýò êáôáãñÜöçêå ç çëéêßá, ôï ýøïò, ôï âÜñïò êáé ïé êáðíéóôéêÝò ôïõò óõíÞèåéåò. Ôá äçìïãñáöéêÜ êáé êëéíéêÜ ÷áñáêôçñéóôéêÜ ôùí áóèåíþí êáôáãñÜöïíôáé óôïí ðßíáêá 1. Ç áíôéõðåñôáóéêÞ áãùãÞ, áí õðÞñ÷å, óõíå÷éæüôáí áìåôÜâëçôç êáôÜ ôçí ðåñßïäï ôçò ìåëÝ-

Ðßíáêáò 1. ÄçìïãñáöéêÜ êáé êëéíéêÜ ÷áñáêôçñéóôéêÜ ôùí áóèåíþí ÐáñÜìåôñïé

Óõíïëéêüò Ðëçèõóìüò (n =75)

Çëéêßá (Ýôç) 72±9 Öýëï (Üíäñåò / ãõíáßêåò) 46/29 Äåßêôçò ìÜæáò óþìáôïò (Kgr/m²) 27,9±6 ÊáðíéóôÝò 24 (32%) ÄéÜñêåéá õðÝñôáóçò (Ýôç) 15±3 ÁÐ (Baseline – mmHg) 158±19 / 83±13 Êáñäéáêüò ñõèìüò 77±5 (Baseline-ðáëìïß/ ëåðôü) Áóèåíåßò õðü áãùãÞ 71 (95%)

ôçò. ÊñéôÞñéï áðïêëåéóìïý áðü ôç ìåëÝôç áðïôåëïýóå ïðïéáäÞðïôå áëëáãÞ ôçò öáñìáêåõôéêÞò áãùãÞò, ç ïðïßá èá åðçñÝáæå ôéò ôéìÝò ôçò Á.Ð., ôÝóóåñéò åâäïìÜäåò ðñéí êáé êáôÜ ôç äéÜñêåéá ôçò ìåëÝôçò. ¼ëïé ïé áóèåíåßò Ýäùóáí ôç óõãêáôÜèåóÞ ôïõò ãéá ôç óõììåôï÷Þ ôïõò óôç ìåëÝôç. Óôïõò áóèåíåßò áõôïýò (ðëçèõóìüò 80 áôüìùí), Ýãéíå åðáñêÞò åêðáßäåõóç óôçí ôå÷íéêÞ ìÝôñçóçò ôçò ÁÐ.

ÌÝôñçóç ôçò áñôçñéáêÞò ðéÝóåùò Óôïõò áóèåíåßò óõíåóôÞèç íá ìåôñïýí ôçí áñôçñéáêÞ ôïõò ðßåóç (ÁÐ) óôï óðßôé äýï öïñÝò ôçí çìÝñá, ðñùß êáé âñÜäõ, ìå ôï ðéåóüìåôñï ðïõ äéáèÝôïõí êáé íá êáôáãñÜöïõí ôéò ìåôñÞóåéò ôïõò ãéá ÷ñïíéêü äéÜóôçìá ôåóóÜñùí åâäïìÜäùí. Áðáéôåßôï êÜèå öïñÜ Ýíá æåýãïò ìåôñÞóåùí, ìåôÜ áðü äéÜóôçìá áíÜðáõóçò 5´ ëåðôþí, ìå äéáöïñÜ 1´ ëåðôïý ç ìßá áðü ôçí Üëëç êáé ìå ôïí áóèåíÞ óå êáèåóôçêõßá èÝóç. Ïé ìåôñÞóåéò ãßíïíôáí ôçí ßäéá ðåñßðïõ þñá êÜèå çìÝñá, ìå ôï ßäéï ðéåóüìåôñï êáé áðü ôï ßäéï Üôïìï. Ôï ðéåóüìåôñï ðïõ èá ÷ñçóéìïðïéïýóå êÜèå áóèåíÞò åëÝã÷èçêå þóôå íá åðéâåâáéùèåß üôé ç ÁÐ ðïõ êáôÝãñáöå, äåí äéÝöåñå ðåñéóóüôåñï áðü 5 mmHg áðü ôçí ÁÐ ðïõ êáôÝãñáöå Ýíá õäñáñãõñéêü óöõãìïìáíüìåôñï ôïõ éáôñåßïõ. Ùò ÁÐ óôï óðßôé èåùñÞèçêå ï ìÝóïò üñïò ôùí ðñùéíþí êáé âñáäéíþí ìåôñÞóåùí. Ïé áóèåíåßò åðáíÝñ÷ïíôáí óôï éáôñåßï ìåôÜ áðü ôÝóóåñéò åâäïìÜäåò, üðïõ åëÝã÷ïíôáí ìå õäñáñãõñéêü óöõãìïìáíüìåôñï ôïõ éáôñåßïõ ç áñôçñéáêÞ ôïõò ðßåóç. Ðñáãìáôïðïéïýíôáí ôñåéò ìåôñÞóåéò ôçò áñôçñéáêÞò ôïõò ðßåóçò ìå äéáöïñÜ 1´ ëåðôïý ç ìéá áðü ôçí Üëëç, óå êáèåóôçêõßá èÝóç êáé ìåôÜ áðü ðåñßïäï áíÜðáõóçò 5´ ëåðôþí êáé ëáìâÜíïíôáí ï ìÝóïò üñïò ôùí ìåôñÞóåùí áõôþí. Ôï õäñáñãõñéêü óöõãìïìáíüìåôñï Þôáí êïéíü ãéá üëïõò ôïõò áóèåíåßò ìå ìÝãåèïò ðåñé÷åéñßäïò 15 cm x 35 cm, åíþ ãéá ôçí êáôáãñáöÞ ôçò äéáóôïëéêÞò áñôçñéáêÞò ðéÝóåùò (ÄÁÐ) ãßíïíôáí ÷ñÞóç ôùí Þ÷ùí Korotkoff V. ÑõèìéóìÝíç èåùñåßôï ç áñôçñéáêÞ õðÝñôáóç (ÁÕ) áí ç ìÝóç ôéìÞ ôùí ìåôñÞóåùí ôçò ÁÐ óôï éáôñåßï Þ óôï óðßôé Þôáí ìéêñüôåñç áðü 140 mmHg ç óõóôïëéêÞ êáé ìéêñüôåñç áðü 90 mmHg ç äéáóôïëéêÞ áñôçñéáêÞ ðßåóç. Ôá áðïôåëÝóìáôá ôçò ìåëÝôçò åêöñÜóôçêáí ùò ìÝóïò üñïò ôùí ìåôñÞóåùí ± ôç óôáèåñÜ 75


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Á. Ìáñéüëçò êáé óõí

áðüêëéóç (SD). Ñ < 0,05 èåùñÞèçêå óôáôéóôéêÜ óçìáíôéêü.

ÁðïôåëÝóìáôá Áðü ôïõò 80 õðåñôáóéêïýò áóèåíåßò, óôç ìåëÝôç ôåëéêÜ óõìðåñéëÞöèçóáí 75 áóèåíåßò (46 Üíäñåò êáé 29 ãõíáßêåò, ìå ìÝóç äéÜñêåéá ÁÕ 15±3 Ýôç), áöïý 5 áóèåíåßò áðïññßöèçêáí ëüãù áíåðáñêïýò áñéèìïý ìåôñÞóåùí ôçò ÁÐ óôï óðßôé. Ï ìÝóïò áñéèìüò ìåôñÞóåùí ôçò ÁÐ óôï óðßôé áíÜ Üôïìï Þôáí 85±12 (áðü 45-110 ìåôñÞóåéò). ÇëåêôñïíéêÜ ðéåóüìåôñá ÷ñçóéìïðïßçóáí 30 áóèåíåßò, áíåñïåéäÞ ðéåóüìåôñá 39 áóèåíåßò êáé õäñáñãõñéêÜ ðéåóüìåôñá 6 áóèåíåßò. Ç ìÝóç çëéêßá ôùí áôüìùí Þôáí 72±9 (64-87 Ýôç), ï äåßêôçò ìÜæáò óþìáôïò Þôáí 27,9±6 Kg/m2, ïé 24 (32%) Þôáí êáðíéóôÝò êáé 71 áóèåíåßò (95%) ëÜìâáíáí áíôéõðåñôáóéêÞ áãùãÞ. Ç ÁÐ óôï éáôñåßï Þôáí óôáôéóôéêÜ óçìáíôéêÜ õøçëüôåñç óõãêñéôéêÜ ìå ôçí ÁÐ óôï óðßôé (152±17/81±10 Ýíáíôé 150±14/ 80±11 mmHg, p<0,05). Ïé ðñùéíÝò ôéìÝò ìÝôñçóçò ôçò ÁÐ óôï óðßôé Þôáí óôáôéóôéêÜ óçìáíôéêÜ õøçëüôåñåò óõãêñéôéêÜ ìå ôéò âñáäéíÝò ôéìÝò ôçò ÁÐ (155±13/81±12 Ýíáíôé 144±15/78±11 mmHg, p<0,05). Äéáðéóôþèçêå óôáôéóôéêÜ óçìáíôéêÞ óõó÷Ýôéóç áíÜìåóá óôçí ÁÐ éáôñåßïõ êáé óôçí ÁÐ óôï óðßôé (r=0,44, p<0,005). Âáóé-

æüìåíïé óôçí ÁÐ éáôñåßïõ ôï 24 % ôùí õðåñôáóéêþí åß÷å ñõèìéóìÝíç ôçí ÁÐ åíþ âáóéæüìåíïé óôçí ÁÐ óôï óðßôé ôï 32% åß÷å ñõèìéóìÝíç ôçí ÁÐ (p<0,005). Ïé ôéìÝò ôçò ÁÐ óôï éáôñåßï êáé óôï óðßôé öáßíïíôáé óôïí ðßíáêá 2, åíþ ôï ðïóïóôü ôùí áóèåíþí ìå ñõèìéóìÝíç ôçí áñôçñéáêÞ ôïõò ðßåóç óôïí ðßíáêá 3.

ÓõæÞôçóç Óôç ìåëÝôç áõôÞ åðé÷åéñÞèçêå ç äéåñåýíçóç ôçò óõìâïëÞò ôçò ìÝôñçóçò ôçò áñôçñéáêÞò ðßåóçò óôï óðßôé óôçí êáëýôåñç èåñáðåõôéêÞ áíôéìåôþðéóç ôùí õðåñôáóéêþí áôüìùí. Âáóéæüìåíïé óôç äéáðßóôùóç ôçò óôáôéóôéêÜ óçìáíôéêÞò óõó÷åôßóåùò áíÜìåóá óôçí ÁÐ ôïõ éáôñåßïõ êáé óôçí ÁÐ óôï óðßôé öáßíåôáé íá áðïôåëåß ìéá êáëÞ åíáëëáêôéêÞ ðñáêôéêÞ óôçí ðñïóðÜèåéá åðßôåõîçò êáëýôåñçò ñýèìéóçò ôçò ÁÐ óôá õðåñôáóéêÜ Üôïìá. Ç ìÝôñçóç ôçò ÁÐ óôï óðßôé áðü ôï ßäéï ôï Üôïìï Ý÷åé åíèáññõíèåß áðü äéåèíåßò ïñãáíéóìïýò êáé åöáñìüæåôáé üëï êáé ðåñéóóüôåñï óôçí êëéíéêÞ ðñÜîç1-4. ÁðïôÝëåóìá ìåëÝôçò ðïõ äéåñåõíïýóå ôïí áñéèìü ôùí ìåôñÞóåùí ðïõ áðáéôïýíôáé óôï óðßôé, þóôå íá åîáóöáëéóèåß ï áêñéâÞò ðñïóäéïñéóìüò ôùí åðéðÝäùí ôçò ÁÐ, Ýäåéîáí üôé ï ìÝóïò üñïò ôçò ÁÐ äýï çìåñþí ìå äýï

Ðßíáêáò 2. ÔéìÝò ÁÐ óôï éáôñåßï êáé óôï óðßôé ÓõóôïëéêÞ ÁÐ (mmHg)

ÄéáóôïëéêÞ ÁÐ (mmHg)

ÁÐ Éáôñåßïõ 1ç ìÝôñçóç 2ç ìÝôñçóç 3ç ìÝôñçóç ÌÝóïò üñïò

156±18 151±15 150±16 152±17

82±12 80±11 80±11 81±10

155±13 144±15 150±14*

81±12 78±11 80±11*

ÁÐ óôï óðßôé ÌÝóïò üñïò ðñùéíþí ìåôñÞóåùí ÌÝóïò üñïò âñáäõíþí ìåôñÞóåùí ÌÝóïò üñïò

*p<0,05 Ýíáíôé ôïõ ìÝóïõ üñïõ ôùí ìåôñÞóåùí ôçò ÁÐ óôï éáôñåßï

Ðßíáêáò 3. Ðïóïóôü õðåñôáóéêþí áóèåíþí ìå ñõèìéóìÝíç ôçí ÁÐ ÂÜóåé ÂÜóåé ÂÜóåé ÂÜóåé

ôùí ôùí ôùí ôùí

ìåôñÞóåùí ôçò ÁÐ óôï éáôñåßï ðñùéíþí êáé âñáäõíþí ìåôñÞóåùí ôçò ÁÐ óôï óðßôé ðñùéíþí ìåôñÞóåùí ôçò ÁÐ óôï óðßôé âñáäõíþí ìåôñÞóåùí ôçò ÁÐ óôï óðßôé

*p<0,05 Ýíáíôé ôùí ìåôñÞóåùí ôçò ÁÐ óôï éáôñåßï 76

24% 32%* 22% 38%*


Ôüìïò 15, Ôåý÷ïò 2, 2003

Á. Ìáñéüëçò êáé óõí

ðñùéíÝò êáé äýï áðïãåõìáôéíÝò ìåôñÞóåéò ôçò ÁÐ, ìå äéáöïñÜ 1´ ëåðôïý ìåôáîý ôùí ìåôñÞóåùí, öáßíåôáé üôé ìðïñåß íá õéïèåôçèåß, ìå ôçí ðñïûðüèåóç üôé åîáéñïýíôáé ïé ôéìÝò ôùí ìåôñÞóåùí ôçò áñ÷éêÞò “áóôáèïýò” ùò ðñïò ôçí ÁÐ çìÝñáò14. ÅðéðëÝïí, ï ìÝóïò üñïò ôùí ôéìþí ôùí ðñùéíþí ìåôñÞóåùí ôçò ÁÐ óôï óðßôé öáßíåôáé íá åßíáé óôáèåñÜ õøçëüôåñïò áðü üôé ï áíôßóôïé÷ïò ìÝóïò üñïò ôùí ôéìþí ôùí âñáäéíþí ìåôñÞóåùí ôçò ÁÐ. ÁõôÞ ç äéáöïñÜ ðïõ åðéôõã÷Üíåé óôáôéóôéêÜ óçìáíôéêÞ äéáöïñÜ, äåí ìðïñåß íá áðïäïèåß óôçí áíôéõðåñôáóéêÞ áãùãÞ, ìéá êáé Þôáí åìöáíÞò óôï ßäéï ìÝãåèïò ôüóï óå áóèåíåßò õðü èåñáðåõôéêÞ áãùãÞ üóï êáé óå áõôïýò ÷ùñßò áãùãÞ14. Óå êëéíéêÝò ìåëÝôåò üðùò ç ìåëÝôç PAMELA15 êáé ç ìåëÝôç SAMPLE16, óôéò ïðïßåò åëÞöèçóáí äýï ìüíï ìåôñÞóåéò ôçò ÁÐ óôï óðßôé óå ìßá ìüíï ìÝñá (ìßá ðñùéíÞ êáé ìßá âñáäéíÞ ìÝôñçóç ôçò ÁÐ), ôá áðïôåëÝóìáôá êáé ôá óõìðåñÜóìáôá öáßíåôáé íá åßíáé äéáöïñåôéêÜ áðü ôá áíôßóôïé÷á ðïõ ðñïêýðôïõí áðü ðåñéóóüôåñåò ìåôñÞóåéò ôçò ÁÐ óôï óðßôé, óå ðåñéóóüôåñåò áðü ìßá ìÝñåò. ÐáñÜëëçëá ï Ohkubo et al. ðáñáôÞñçóáí üôé ç ìÝôñçóç ôçò áñôçñéáêÞò ðéÝóåùò óôï óðßôé åßíáé ðåñéóóüôåñï ðñïãíùóôéêÞ ôçò ìåëëïíôéêÞò íïóçñüôçôáò ëüãù áñôçñéáêÞò õðåñôÜóåùò áðü üôé ç ìÝôñçóç ôçò ÁÐ óôï éáôñåßï17. Ðáñüôé ç ìéêñïý ìåãÝèïõò ìåëÝôç ôïõ Ohkubo (ðëçèõóìüò 1789 Éáðþíùí), åßíáé ç ìïíáäéêÞ ðïõ åîåôÜæåé ôç ó÷Ýóç ìåôáîý ôùí ôéìþí ôçò ÁÐ óôï óðßôé êáé ôçí ðñüãíùóç ôçò íïóçñüôçôáò áðü ôçí áñôçñéáêÞ õðÝñôáóç, öáßíåôáé üôé ïé ôéìÝò ôçò ÁÐ óôï óðßôé áðïôåëïýí óçìáíôéêü ðñïãíùóôéêü ðáñÜãïíôá. Áðü ôçí Üëëç ðëåõñÜ, ìéá óåéñÜ ìåëåôþí äåß÷íïõí üôé ï ìÝóïò üñïò ôùí ôéìþí ôùí ìåôñÞóåùí ôçò ÁÐ óôï óðßôé, ó÷åôßæåôáé Üìåóá ìå ôï ìÝóï üñï ôùí çìåñÞóéùí ôéìþí ôçò 24ùñçò ðåñéðáôçôéêÞò êáôáãñáöÞò ìå ìéá äéáöïñÜ ôéìþí ðïõ ðñïóäéïñßæïíôáé ìüëéò -1,7/+1,2 mmHg18,19,15. Ï ìÝóïò üñïò ôùí ìåôñÞóåùí ôçò 24ùñçò ðåñéðáôçôéêÞò êáôáãñáöÞò, öáßíåôáé íá åßíáé ìéêñüôåñïò ôüóï ôïõ ìÝóïõ üñïõ ôùí ôéìþí ôçò ðåñéðáôçôéêÞò êáôáãñáöÞò êáôÜ ôç äéÜñêåéá ôçò çìÝñáò (äéáöïñÜ -5/-4 mmHg), üóï êáé ôïõ ìÝóïõ üñïõ ôùí ìåôñÞóåùí ôçò ÁÐ óôï óðßôé15. Ç óõììüñöùóç ôùí áóèåíþí óôçí áíôéõðåñôáóéêÞ èåñáðåßá âåëôéþíåôáé ìå ôçí åöáñìïãÞ ôçò êáôáãñáöÞò ôçò ÁÐ óôï óðßôé. ÌåëÝôç áðü

ôïí Ashida et al. äåß÷íåé õøçëüôåñç óõììüñöùóç óôïõò áóèåíåßò ðïõ ðáñáêïëïõèïýóáí ôçí ÁÐ óôï óðßôé óå ó÷Ýóç ìå áõôïýò ðïõ äåí áêïëïõèïýóáí áõôÞ ôçí ðñáêôéêÞ21. ÕðÜñ÷ïõí Üñáãå “áíôåíäåßîåéò” ôçò ìÝôñçóçò ôçò ÁÐ óôï óðßôé; Ï Nordman äéáôýðùóå üôé ïé êáôáãñáöÝò ôçò ÁÐ áóèåíþí ìå ÷áìçëü åðßðåäï åêðáßäåõóçò, åßíáé áíáêñéâåßò22. Ïé äéáôáñá÷Ýò ôïõ êáñäéáêïý ñõèìïý êáèéóôïýí ôéò ìåôñÞóåéò óôï óðßôé ìç áêñéâåßò19,23, Ýôóé þóôå ç êïëðéêÞ ìáñìáñõãÞ íá áðïôåëåß ßóùò “áíôÝíäåéîç” ôçò ðñáêôéêÞò áõôÞò. Äåí õðÜñ÷ïõí äåäïìÝíá ãéá ôïí ôñüðï ðïõ ìðïñåß ç ÷ñÞóç ôçò ìÝôñçóçò ôçò ÁÐ óôï óðßôé íá ïäçãÞóåé óå áëëáãÝò ôçò öáñìáêåõôéêÞò áãùãÞò. Åðßóçò, äåí åßíáé ãíùóôü áí ïé áóèåíåßò ðñïôéìïýí ôçí ðñáêôéêÞ ôçò ìÝôñçóçò ôçò ÁÐ óôï óðßôé Þ ôéò ìåôñÞóåéò ôçò ÁÐ ôïõ éáôñåßïõ, üðùò êáé áí ïé áóèåíåßò ðïõ áêïëïõèïýí ôçí ðñáêôéêÞ ôçò êáôáãñáöÞò ôçò ÁÐ óôï óðßôé , åðéôõã÷Üíïõí êáëýôåñï Ýëåã÷ï ôçò áñôçñéáêÞò ôïõò ðßåóçò. ÐåñáéôÝñù Ýñåõíá áðáéôåßôáé ìå óôü÷ï ôçí áðÜíôçóç ôùí ðáñáðÜíù åñùôçìÜôùí.

Âéâëéïãñáößá 1. World Hypertension League. Self measurement of blood pressure: a statement by the World Hypertension League. J Hypertens, 6:257-261, 1998. 2. Pickering T, for an American Society of Hypertension ad hoc panel. Recommendations for the use of home (self) and ambulatory blood pressure monitoring. Am J Hypertens, 9:1-11, 1995. 3. Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure. The fifth report of the Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure (JNC V). Arch Intern Med, 153:154-183, 1993. 4. WHO/ISH. Guidelines for the management of mild hypertension: memorandum from a World Health Organization/International Society of Hypertension meeting. J Hypertens, 11:905-918, 1993. 5. Ayman D, Goldshine A. The differences between clinic and home readings before treatment. Am J Med Sci, 200:465-474, 1940. 6. Mancia G, Bertinieri G, Grassi G, Parati G, Pomidossi G, Ferrari A, et al. Effects of blood 77


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

7.

8.

9.

10.

11.

12.

13.

14.

78

pressure measurement by the doctor on patient’s blood pressure and hear rate. Lancet, 24;2:695-698, 1983. Pickering TG, James GD, Boddie C, Harshfield GA, Blank S, Laragh JH. How common is white coat hypertension. JAMA, 259:225-228, 1988. Mengden T, Battig B, Edmonds D, Jeck T, Huss R, Sachindis A, et al. Self measured blood pressures at home and during consulting hours: are there any differences. J Hypertens, 8:S1519, 1990. Verdecchia P, Schillaci G, Borgioni C, Ciucci A, Zampi I, Gattobigio R, et al. White coat hypertension and white coat effect similarities and differences. Am J Hypertens, 8:790-798, 1995. Khattar RS, Senior R, Lahiri A. Cardiovascular outcome in white-coat versus sustained mild hypertension: a 10-year follow-up study. Circulation, 98:1892-1897, 1998. Verdecchia P, Schillaci G, Borgioni C, Ciucci A, Porcellati C. Prognostic significance of the white-coat effect. Hyprtension, 29:1218-1224, 1997. Julius S, Mejia A, Jones K, Krause L, Schork N, Van de Ven C, et al. White coat versus sustained borderline hypertension in Tecumseh, Michigan. Hypertension, 16:617-623, 1990. Chalmers J and WHO_ISH Guidelines Committee. Committee, World Health OrganisationInternational Society of Hypertension Guidelines for the management of hypertension. J Hypertens, 17:151-185, 1999. Stergiou GS, Skeva II, Zourbaki AS, Mountokalakis TD. Self-monitoring of blood pressure at home: how many measurements are

Á. Ìáñéüëçò êáé óõí

needed. J Hypertens, 16:725-731, 1998. 15. Mancia G, Sega R, Bravi C, De Vito G, Valagussa F, Cesana G, et al. Ambulatory blood pressure normality: results from the PAMELA study. J Hypertens, 13:1377-1390, 1995. 16. Mancia G, Zanchetti A, Agebiti-Rosei E, Benemio G, De Cesaris R, Fogari R, et al. Ambulatory blood pressure is superior to clinic blood pressure in predicting treatment-induced regression of left ventricular hypertrophy. Circulation, 95:1464-1470, 1997. 17. Ohkubo T, Imai Y, Tsuji I, Nagai K, Kikuchi N, Nishiyama A, et al. Home blood pressure measurement has a stronger predictive power for mortality than does screening blood pressure measurement: a population-based observation in Ohasama, Japan. J Hypertens, 16: 971975, 1998. 18. Stergiou GS, Zourbaki AS, Skeva II, Mountokalakis TD. White coat effect detected using self-monitoring of blood pressure at home: comparison with ambulatory blood pressure. Am J Hypertens, 11:820-827, 1998. 19. Yarows SA, Julius S, Pickering TG. Home blood pressure monitoring. Arch Intern Med, 160:12511257, 2000. 20. Ashida T, Sugiyama T, Okuno S, Ebihara A, Fujii J. Relationship between home blood pressure measurement and medication compliance and name recognition of antihypertensive drugs. Hypertens Res Clin Exper, 23:21-24, 2000. 21. Nordmann A, Frach B, Walker T, Martina B, Battegay E. Reliability of patients measuring blood pressure at home: prospective observational study. BMJ, 319:1172, 1999.


Ôüìïò 15, Ôåý÷ïò 2, 2003

Á. Ìðáôßêáò êáé óõí.

ÂÑÁÂÅÕÈÅÉÓÁ ÅËÅÕÈÅÑÇ ÁÍÁÊÏÉÍÙÓÇ AWARDED FREESTANDING PAPER Primary Heatlh Care, Volume 15, Number 2, 79-83, 2003 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 15, Ôåý÷ïò 2, 79-83, 2003

KáôáíÜëùóç áëêïüë áðü åöÞâïõò: Mßá åðéêßíäõíç ðñáãìáôéêüôçôá Á. Ìðáôßêáò, Ê. Óôåöáíïðïýëïõ, É. ÄñõãéáííÜêçò, Á. ÐåôñÜêç, Í. ÐáðáäÜêçò

Ðåñßëçøç Óêïðüò: Ç áíß÷íåõóç åöÞâùí ÷ñçóôþí áëêïüë áíÜìåóá óôï ìáèçôéêü ðëçèõóìü ëõêåßïõ çìéáóôéêÞò ðåñéï÷Þò ôçò âüñåéáò ÊñÞôçò, áöïý åßíáé ðñïöáíÝò üôé ôá ðñïãñÜììáôá ðñüëçøçò ðñÝðåé íá îåêéíïýí Ýãêáéñá êáé íá åðéêåíôñþíïíôáß ü÷é ìüíï óôï Üôïìï áëëÜ êáé óôçí ïéêïãÝíåéá êáé ôï ó÷ïëåßï. Ðëçèõóìüò – ìÝèïäïò: Ôá óôïé÷åßá óõãêåíôñþèçêáí óôç äéÜñêåéá ôïõ ôåëåõôáßïõ ôñéìÞíïõ ôïõ 2002. Ïé óõììåôÝ÷ïíôåò Þôáí ï óõíïëéêüò áñéèìüò ôùí ìáèçôþí (Í=133) ôïõ ìïíáäéêïý ëõêåßïõ ôïõ ÄÞìïõ ÃåñïðïôÜìïõ. Ôá áãüñéá Þôáí 58/ 133 (43,6%) êáé ôá êïñßôóéá 75/133 (56,4%). Ç ìÝóç çëéêßá ôùí óõììåôå÷üíôùí Þôáí ôá 16,9 ÷ñüíéá. ×ñçóéìïðïéÞèçêáí ùò åñãáëåßá áíß÷íåõóçò ôá åñùôçìáôïëüãéá CRAFFT (Car Relax Alone Forget Family-Friends Trouble) ãéá åöÞâïõò êáé AUDIT (Alcohol Use Disorder Identification Test). Äüèçêå Ýìöáóç óôïí åèåëïíôéêü ÷áñáêôÞñá ôçò óõììåôï÷Þò óôçí áíùíõìßá êáé ôç äéáóöÜëéóç ôïõ áðïññÞôïõ. ÁðïôåëÝóìáôá: Áðü ôç âáèìïëüãçóç ôïõ CRAFFT test ç åêôßìçóç Þôáí èåôéêÞ (score ≥ 2) ãéá 28/58 áãüñéá (48,3%) êáé ãéá 14/75 êïñßôóéá (18,7%). Ôá áíôßóôïé÷á ðïóïóôÜ èåôéêþí áðïôåëåóìÜôùí áðü ôï AUDIT test (score > 8) Þôáí 17/58 (29,3%) ãéá ôá áãüñéá êáé 3/75 (0,04%) ãéá ôá êïñßôóéá. Ðáñáôçñåßôáé óôáôéóôéêÜ óçìáíôéêÞ äéáöïñÜ óôçí êáôáíÜëùóç áëêïüë ìåôáîý ôùí äõï öýëùí óôçí ßäéá çëéêßá (Person’s x 2: p<0,001) ¢îéï ðñïóï÷Þò êáé ðñïâëçìáôéóìïý åßíáé üôé 80/133 (60,2%) ðáéäßá áðÜíôçóáí èåôéêÜ óôï ðñþôï åñþôçìá ôïõ CRAFFT, ðïõ áöïñÜ óôçí ðáñïõóßá ôïõò óå áõôïêßíçôï ðïõ ïäçãïýóå êÜðïéïò ï ïðïßïò åß÷å êÜíåé êáôáíÜëùóç áëêïüë. ÓõìðåñÜóìáôá: Ôï ðñüâëçìá ôçò ÷ñÞóçò áëêïüë áíÜìåóá óå íåáñïýò åöÞâïõò ðáßñíåé åðéêßíäõíåò äéáóôÜóåéò. Ç ëåéôïõñãßá ðñïãñáììÜôùí Ýãêáéñçò ðáñÝìâáóçò ìðïñåß íá áíáêüøåé ôçí ðïñåßá ðñïò ôçí ðñïâëçìáôéêÞ ÷ñÞóç êáé ôçí åîÜñôçóç áðü ôï áëêïüë.

KÝíôñï Õãåßáò ÐåñÜìáôïò Ñåèýìíïõ

ÅéóáãùãÞ Ç ÷ñÞóç “ïõóéþí” åßíáé ðéá áñêåôÜ äéáäåäïìÝíç áíÜìåóá óôïõò åöÞâïõò êáé ç êáôÜ÷ñçóÞ ôïõò áðïôåëåß Ýíá óõíå÷þò ïîõíüìåíï ðñüâëçìá. Ï üñïò “ïõóßåò” ìðïñåß íá ÷ñçóéìïðïéçèåß ãéá ðïëëÝò øõ÷ïôñüðåò ïõóßåò, áðü ôïí êáðíü êáé ôï áëêïüë Ýùò ôçí êÜííáâç êáé ôçí çñùßíç, ôùí ïðïßùí ç ÷ñÞóç êáé ç êáôÜ÷ñçóç ìðïñåß íá åðçñåÜóåé óå ìåãÜëï âáèìü áñíçôéêÜ ôçí ðïéüôçôá æùÞò ôùí ÷ñçóôþí1. ÐñÜãìáôé, ç êáôáíÜëùóç ïéíïðíåõìáôùäþí ðïôþí áõîÜíåôáé êáôáêüñõöá óôçí åöçâåßá. Ç óõ÷íüôçôá ôçò ìÝèçò áõîÜíåôáé, åðßóçò, äñáìáôéêÜ. Óôç ÌåãÜëç Âñåôáíßá ç êáôÜ÷ñçóç áëêïüë áíÜìåóá óôïõò íÝïõò ËÝîåéò ÊëåéäéÜ: áëêïüë, Ýöçâïò, åîÜñôçóç, ðñüëçøç, ðñùôïâÜèìéá öñïíôßäá õãåßáò ÕðïâëÞèçêå: Ç åñãáóßá õðïâëÞèçêå ùò åëåýèåñç áíáêïßíùóç óôï 15o ÐáíåëëÞíéï ÓõíÝäñéï ÃåíéêÞò ÉáôñéêÞò (×áëêéäéêÞ 30 Áðñéëßïõ - 4 ÌáÀïõ 2003) êáé âñáâåýôçêå áðü ôçí åðéôñïðÞ Êñßóçò. Äçìïóéåýåôáé ìå êïéíÞ áðüöáóç ôçò ÓõíôáêôéêÞò ÅðéôñïðÞò ôïõ ðåñéïäéêïý êáé ôçò ÏñãáíùôéêÞò ÅðéôñïðÞò ôïõ Óõíåäñßïõ. Õðåýèõíïò áëëçëïãñáößáò: Áíôþíçò Ìðáôßêáò, ÊÝíôñï Õãåßáò ÐåñÜìáôïò Ñåèýìíïõ, Ôçë. (2834)023074, (6944)504898, Fax: (28340)23191, E-Mail: antbatika@hotmail.com 79


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Á. Ìðáôßêáò êáé óõí.

Alcohol consumption by adolescents: A dangerous reality A. Batikas, K. Stefanopoulou, I. Drygjannakis, A. Petraki, N. Papadakis

Tá óôïé÷åßá óõãêåíôñþèçêáí óôç äéÜñêåéá ôïõ ôåëåõôáßïõ ôñéìÞíïõ ôïõ 2002. Ç ìåëÝôç åãêñßèçêå áðü ôç Äéåýèõíóç ÄåõôåñïâÜèìéáò Åêðáßäåõóçò Ñåèýìíïõ, äåäïìÝíïõ üôé ïé óõììåôÝ÷ïíôåò Þôáí ï óõíïëéêüò áñéèìüò ôùí ìáèçôþí (Í=133) ôïõ ìïíáäéêïý ëõêåßïõ ôïõ ÄÞìïõ ÃåñïðïôÜìïõ Ñåèýìíïõ. Ôá áãüñéá Þôáí 58/133 (43,6%) êáé ôá êïñßôóéá 75/133 (56,4%). H ìÝóç çëéêßá ôùí ðáéäéþí ðïõ ðÞñáí ìÝñïò óôçí Ýñåõíá Þôáí ôá 16,9 ÷ñüíéá. ×ñçóéìïðïéÞèçêáí ùò åñãáëåßá áíß÷íåõóçò ôá åñùôçìáôïëüãéá CRAFFT (Car Relax Alone Forget Family-Friends Trouble) ãéá åöÞâïõò4 êáé AUDIÔ (Alcohol Use Disorder Identification Test)5, üðùò áõôÜ Ý÷ïõí áðïäïèåß óôá åëëçíéêÜ áðü ôï ÊÝíôñï ÅîÜñôçóçò êáé Èåñáðåßáò ÅîáñôçìÝíùí Áôüìùí (Ê.Å.È.Å.Á), ôï ïðïßï óå óõíåñãáóßá ìå ôï ôìÞìá øõ÷éáôñéêÞò ôïõ Ðáí/ìßïõ Óáí ÍôéÝãêï ôçò Êáëéöüñíéá, õðü ôçí áéãßäá ôïõ Ð.å.Ó.Õ.Ð. ÊñÞôçò, áíÝëáâå ôçí åêðáßäåõóç ëåéôïõñãþí ôçò ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò óôçí áíß÷íåõóç, áëëÜ êáé áñ÷éêÞ áíôéìåôþðéóç åîáñôçìÝíùí áôüìùí. Ôï CRAFFT test ðåñéëáìâÜíåé Ýîé åñùôÞóåéò (íáé/ü÷é), åßíáé êáôÜëëçëï ùò åñãáëåßï áíß÷íåõóçò êáôáíÜëùóçò áëêïüë óôïõò åöÞâïõò êáé Ý÷åé õøçëÞ åõáéóèçóßá êáé åéäéêüôçôá óå ðïóïóôü 92% êáé 82% áíôßóôïé÷á. Ôï AUDIT åßíáé Ýíá åñãáëåßï äéáëïãÞò ìå äÝêá åñùôÞóåéò ðïëëáðëÞò åðéëïãÞò, êáôÜëëçëï ãéá üëåò ôéò çëéêßåò. Ç åõáéóèçóßá (51-79%) êáé ç åéäéêüôçôá (78-96%) ôïõ äéáöÝñåé áíÜëïãá ìå ôçí êïõëôïýñá êáé ôçí åèíéêüôçôá. Äüèçêå éäéáßôåñç Ýìöáóç óôïí åèåëïíôéêü ÷áñáêôÞñá ôçò óõììåôï÷Þò, óôçí áíùíõìßá êáé ôç äéáóöÜëéóç ôïõ áðïññÞôïõ, áöïý ïé ìáèçôÝò äåí Ýðñåðå íá ãñÜøïõí ôï üíïìÜ ôïõò óôï Ýíôõðï, áëëÜ, ìüíï ôï öýëï êáé ôç ÷ñïíïëïãßá ãÝííçóÞò ôïõò, ïé äå êáèçãçôÝò äåí Þôáí ðáñüíôåò êáôÜ ôç äéÜñêåéá ôçò óõìðëÞñùóçò ôùí åñùôçìáôïëïãßùí. Ôá ìÝëç ôçò ïìÜäáò õãåßáò, ðïõ óõììåôåß÷áí óôçí Ýñåõíá, Ýäéíáí ãåíéêÝò ïäçãßåò

Summary Aim: The detection of adolescent alcohol consumers among the higher grades student population of a semi-urban region in nothern Crete, since it is evident that prevention programmes should start in time and focus not only on the individual but also on family and school. Population-methods: The data were gathered during the last trimester of 2002. The participants were the total number of students (N=133) of the only lyceum (three last grades of secondary education) of the municipality of Geropotamos.There were 58/133 boys (43.6%) and 75/133 girls (56.4%). The participants’ mean age were 16.9 years. As tools of detection, the CRAFFT (Car Relax Alone Forget Family-Friends Trouble) for teenagers and AUDIT (Alcohol Use Disorder Identification Test) inquiry tests were used. Voluntary participation as well as anonymity were emphasized. Results: Judging by CRAFFT test, the score was positive (score = 2) for 28/58 boys (48.3%) and for 14/75 girls (18.7%). Respective positive scores from AUDIT test (score > 8) were 17/58 (29.3%) for boys and 3/75 (0.04%) for girls. A statistically significant difference in alcohol consumption between the two sexes is noted (Person’s x2: p<0.001). It is worth noting that 80/133 (60.2%) children answered positively to the first CRAFFT question regarding their presence in a car driven by someone having previously consumed alcohol. Conclusions: the alcohol consumption problem among young teenagers is taking dangerous dimensions. Early intervention programs may inhibit the course towards alcohol dependence. Key Words: alcohol, adolescent, dependence, prevention, primary health care Health Centre of Perama

áðïôåëåß ðïëý ìåãáëýôåñï ðñüâëçìá áð’áõôü ôçò êáôÜ÷ñçóçò íáñêùôéêþí. Ïé ðáìð êáé ôá ìðáñ åëêýïõí ôïõò íÝïõò üëï êáé ðåñéóóüôåñï, åíþ ôï ðïôü óÞìåñá Ý÷åé ãßíåé óðïõäáßï êïììÜôé ôçò æùÞò ôïõò1. Åßíáé åíäéáöÝñïí, åðßóçò, üôé ç ÷ñÞóç áëêïüë óôçí åöçâåßá áðïôåëåß óçìáíôéêü ðáñÜãïíôá êéíäýíïõ ãéá ôçí Ýíáñîç ôçò ÷ñÞóçò ðáñÜíïìùí ïõóéþí2, åíþ ôá óùìáôéêÜ ôñáýìáôá êáé ç åðéêßíäõíç óåîïõáëéêÞ óõìðåñéöïñÜ, üôáí ôï Üôïìï âñßóêåôáé õðü ôçí åðÞñåéá áëêïüë åßíáé óõ÷íü öáéíüìåíï óôïõò åöÞâïõò. ÔÝëïò, ôï ìåãáëýôåñï ðïóïóôü ôùí åíçëßêùí áëêïïëéêþí îåêßíçóå áðü õðåñâïëéêÞ êáôáíÜëùóç áëêïüë óôçí åöçâåßá3. Óêïðüò ôçò ìåëÝôçò ìáò åßíáé ç áíß÷íåõóç åöÞâùí ÷ñçóôþí áëêïüë áíÜìåóá óôïí ìáèçôéêü ðëçèõóìü Ëõêåßïõ áãñïôéêÞò-çìéáóôéêÞò ðåñéï÷Þò ôçò Âüñåéáò ÊñÞôçò, áöïý åßíáé ðñïöáíÝò üôé ôá ðñïãñÜììáôá ðñüëçøçò ðñÝðåé íá îåêéíïýí ðñéí áðü ôçí çëéêßá áõôÞ êáé íá åðéêåíôñþíïíôáé ü÷é ìüíï óôï Üôïìï, áëëÜ êáé óôçí ïéêïãÝíåéá êáé ôï ó÷ïëåßï.

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Ðëçèõóìüò ìåëÝôçò - ÌÝèïäïò:


Ôüìïò 15, Ôåý÷ïò 2, 2003

Á. Ìðáôßêáò êáé óõí.

óôïõò ìáèçôÝò ðïõ Ýêáíáí åñùôÞóåéò, áëëÜ äåí ôïõò âïçèïýóáí óôç óõìðëÞñùóç ôùí åñùôçìáôïëïãßùí. Óôï ôÝëïò êÜèå óõíåäñßáò, ãéíüôáí ìéá áíáóêüðçóç áðü ôïõò ëåéôïõñãïýò ôçò ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò ìå óôü÷ï íá ìåôáöåñèåß ôï êáôÜëëçëï ãé’áõôÞ ôçí çëéêéáêÞ ïìÜäá ìÞíõìá åíÜíôéá óôç ÷ñÞóç ïõóéþí. Áêïëïýèçóå ç âáèìïëüãçóç ôùí åñùôçìáôïëïãßùí (âáèìïëüãçóç êÜèå åñþôçóçò ÷ùñéóôÜ êáé õðïëïãéóìüò ôïõ ôåëéêïý score) óýìöùíá ìå ôéò õðïäåéêíõüìåíåò áðü ôï åñùôçìáôïëüãéï-åñãáëåßï áíß÷íåõóçò ïäçãßåò. Ôï èåôéêü CRAFFT TEST ãéá åöÞâïõò (äýï Þ ðåñéóóüôåñåò èåôéêÝò áðáíôÞóåéò) öáíåñþíåé ìåãÜëç ðéèáíüôçôá Ýíáñîçò åðéêßíäõíçò êáé åðéâëáâïýò êáôáíÜëùóçò áëêïüë êáé õðïäåéêíýåé ôçí áíÜãêç ãéá ðåñáéôÝñù åêôßìçóç, åíçìÝñùóç, åõáéóèçôïðïßçóç êáé ðáñáêïëïýèçóç4. ¼óïí áöïñÜ óôï AUDIT test ôï åëÜ÷éóôï óêïñ ðïõ ìðïñåß íá åðéôåõ÷èåß (áðü Üôïìá ðïõ äåí êÜíïõí êáôáíÜëùóç áëêïüë) åßíáé 0 êáé ôï ìåãáëýôåñï äõíáôü ôï 40. Óêïñ õøçëüôåñï ôïõ 8 õðïäåéêíýåé ìåãÜëç ðéèáíüôçôá åðéêßíäõíçò Þ åðéâëáâïýò êáôáíÜëùóçò áëêïüë5. Ôá áðïôåëÝóìáôá êáôá÷ùñÞèçêáí óå âÜóç äåäïìÝíùí Excel êáé áíáëýèçêáí óôáôéóôéêÜ ìÝóù SPSS, Ver. 8.

ÁðïôåëÝóìáôá Áðü ôç âáèìïëüãçóç ôïõ CRAFFT ôåóô (ÄéÜãñáììá 1) ç åêôßìçóç Þôáí èåôéêÞ (score ≥

2) ãéá 28/58 áãüñéá (48,3%)êáé ãéá 14/75 êïñßôóéá (18,7%). Ôá áíôßóôïé÷á ðïóïóôÜ èåôéêþí áðïôåëåóìÜôùí áðü ôï AUDIT test (score>8) Þôáí17/58 äçë. ( 29,3%) ãéá ôá áãüñéá êáé 3/75 ( 0,04%) ãéá ôá êïñßôóéá (ÄéÜãñáììá 2). Ðáñáôçñåßôáé êáé ìå ôá äýï åñùôçìáôïëüãéá óôáôéóôéêÜ óçìáíôéêÞ äéáöïñÜ óôçí êáôáíÜëùóç áëêïüë ìåôáîý ôùí äýï öýëùí óôçí ßäéá çëéêßá (Pearson’s ÷2 : p<0,001). ¢îéï ðñïóï÷Þò áëëÜ êáé ðñïâëçìáôéóìïý åßíáé üôé 80 óôá 133 ðáéäéÜ (60,2%) áðÜíôçóáí èåôéêÜ óôï ðñþôï åñþôçìá ôïõ CRAFFT test: “¸÷åéò âñåèåß ðïôÝ óå áõôïêßíçôï (CAR) ôï ïðïßï ïäçãïýóå êÜðïéïò (óõìðåñéëáìâáíïìÝíïõ ôïõ åáõôïý óïõ) ï ïðïßïò Þôáí ¨öôéáãìÝíïò¨ Þ åß÷å êÜíåé êáôáíÜëùóç áëêïüë Þ ïõóéþí ”, äåäïìÝíïõ üôé ôá ôñï÷áßá áôõ÷Þìáôá áðïôåëïýí ôçí ðñþôç áéôßá èáíÜôïõ êáé áíáðçñßáò óôçí çëéêéáêÞ ïìÜäá 15-44 óôéò áíåðôõãìÝíåò ÷þñåò5.

ÓõìðåñÜóìáôá • ¼ðùò ðñïêýðôåé áðü ôá áðïôåëÝóìáôá ôçò ÝñåõíÜò ìáò ôï ðñüâëçìá ôçò ÷ñÞóçò áëêïüë áíÜìåóá óå íåáñïýò åöÞâïõò ðáßñíåé åðéêßíäõíåò äéáóôÜóåéò êáé óýìöùíá ìå áñêåôïýò ìåëåôçôÝò ìðïñåß íá ëåéôïõñãÞóåé ùò “ðýëç åéóüäïõ” óôá ðáñÜíïìá íáñêùôéêÜ7. Åéäéêüôåñá, ç óõììåôï÷Þ óå êáôáóôÜóåéò ÷ñÞóçò áëêïüë áðü áíçëßêïõò ìðïñåß íá ïäçãåß ôïõò åöÞâïõò ó’Ýíá ðåñéâÜëëïí ÷ñÞ-

90,00% 80,00% 70,00%

%

60,00% 50,00%

51,72%

48,28%

¢ññåí ÈÞëõ

40,00% 30,00% 20,00% 10,00% 0,00% èåôéêÞ åêôßìçóç

áñíçôéêÞ ÁðÜíôçóç

ÄéÜãñáììá 1. ÁðïôåëÝóìáôá CRAFFT áíÜ öýëï. 81


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0,03% èåôéêÞ åêôßìçóç

áñíçôéêÞ åêôßìçóç ÁðÜíôçóç

ÄéÜãñáììá 2. ÁðïôåëÝóìáôá AUDIT áíÜ öýëï.

óçò óôï ïðïßï åßíáé ðéï ðéèáíü íá ôïõò ðñïóöÝñïõí íáñêùôéêÜ Þ óôï ïðïßï åêôßèåíôáé ðåñéóóüôåñï óå óôÜóåéò êáé áðüøåéò öéëéêÝò ðñïò ôç ÷ñÞóç8. • Ç ëåéôïõñãßá ðñïãñáììÜôùí Ýãêáéñçò ðáñÝìâáóçò ìðïñåß íá áíáêüøåé ôçí ðïñåßá ôùí ÷ñçóôþí, ðïõ âñßóêïíôáé óå öÜóç ðåéñáìáôéóìïý Þ óå ðñþéìá óôÜäéá êáôÜ÷ñçóçò áëêïüë Þ Üëëùí ïõóéþí ðñïò ôçí ðñïâëçìáôéêÞ ÷ñÞóç êáé ôçí åîÜñôçóç.

ÓõæÞôçóç Ïé Ýöçâïé ìåãáëþíïõí óå ìéá êïéíùíßá, üðïõ ï êáðíüò êáé ôï áëêïüë, Þ ôï ÷áóßò êáé ïé áìöåôáìßíåò âñßóêïíôáé ðáíôïý êáé äå èá ðñÝðåé íá ìáò åêðëÞóóåé ôï ãåãïíüò üôé äåëåÜæïíôáé êáé èÝëïõí íá ðåéñáìáôéóèïýí ì’ áõôÜ. Ôá íáñêùôéêÜ ðáñïõóéÜæïíôáé ùò ïé èáõìáôïõñãÝò ïõóßåò ðïõ õðïôßèåôáé üôé ëýíïõí üëá ôá ðñïâëÞìáôá ôçò áíÜðôõîçò êáé ôçò æùÞò ó’ Ýíáí êüóìï ãåìÜôï Ýíôáóç1. Áðü Ýíá óçìåßï üìùò êé Ýðåéôá, ðáýïõí íá åßíáé ìéá óõíáñðáóôéêÞ åìðåéñßá êáé ãßíïíôáé Ýíá äåêáíßêé ÷ùñßò ôï ïðïßï äåí ìðïñåß íá êÜíåé âÞìá óôç æùÞ. Ìå ôïí ßäéï, áêñéâþò, ôñüðï ëåéôïõñãåß ôï ïéíüðíåõìá óôïõò áëêïïëéêïýò. Ôï áëêïüë ðñïóöÝñåé ìéá áðüäñáóç áðü ôç äõóÜñåóôç ðñáãìáôéêüôçôá, äçìéïõñãåß êÝöé, ìåéþíåé ôéò áíáóôïëÝò, åîáëåßöåé ôçí Ýíôáóç êáé äéåõ82

êïëýíåé ôéò êïéíùíéêÝò ó÷Ýóåéò. ÐñïóöÝñåé äçë. óôéãìÝò áíáêïýöéóçò áðü ôç óôåíï÷þñéá êáé ôç äõóôõ÷ßá1,9. Ç êáôÜ÷ñçóÞ ôïõ üìùò, ïäçãåß óõ÷íÜ óôéò ãíùóôÝò åíï÷ëçôéêÝò óêçíÝò ôùí ìåèõóìÝíùí, óå óåîïõáëéêÝò áðñÝðåéåò, óå êáâãÜäåò, áêüìá êáé óôï èÜíáôï óôç ìÝóç ôïõ äñüìïõ, åíþ äå èá ðñÝðåé íá ðáñáãíùñßóïõìå êáé ôï ìåãÜëï ðïóïóôü ôùí ôñï÷áßùí áôõ÷çìÜôùí ðïõ óõìâáßíïõí õðü ôçí åðÞñåéá ôïõ áëêïüë. Åðßóçò, åßíáé åíäéáöÝñïí ôï ãåãïíüò üôé ç êáôáíÜëùóç áëêïüë óå ìéêñÝò çëéêßåò óõíäÝåôáé ìå ôç ÷ñÞóç íüìéìùí êáé ðáñÜíïìùí ïõóéþí10. ¸÷åé áðïäåé÷èåß üôé äåí õðÜñ÷åé ó÷åäüí êáíÝíáò Ýöçâïò, ðïõ íá êÜíåé ôþñá ÷ñÞóç óêëçñþí íáñêùôéêþí êáé ðïõ íá ìçí Ý÷åé êÜíåé óôï ðáñåëèüí êáôÜ÷ñçóç áëêïüë, êáðíïý êáé ÷áóßò11. Áõôü äå óçìáßíåé, âÝâáéá, üôé ïé Ýöçâïé ðïõ ðñþôá êáðíßæïõí êáé ìåôÜ ðßíïõí, èá óõíå÷ßóïõí áíáãêáóôéêÜ ìå ìáñé÷ïõÜíá Þ “óêëçñÜ” íáñêùôéêÜ. Ï íÝïò ðïõ ðßíåé õðåñâïëéêÜ, öáßíåôáé ðùò Ý÷åé ìéá éäéáßôåñç áíÜãêç íá áéóèáíèåß äõíáôüò. Ôï ðïôü, ëïéðüí, áõîÜíåé ôï áßóèçìá ôçò äýíáìçò, ðïõ íéþèåé êáíåßò12. ÖõóéêÜ, õðÜñ÷ïõí êáé ôá áñíçôéêÜ ïéêïãåíåéáêÜ ðñüôõðá ðïõ ðñïäéáèÝôïõí êáôÜ êÜðïéïí ôñüðï ôïí Ýöçâï ãéá õðÝñìåôñç êáôáíÜëùóç áëêïüë. Óôçí ïéêïãÝíåéá åíüò åöÞâïõ ðïõ ðßíåé õðÜñ÷åé óõíÞèùò Ýíá “ãåñü ðïôÞñé” êé áõôüò ôéò ðå-


Ôüìïò 15, Ôåý÷ïò 2, 2003

Á. Ìðáôßêáò êáé óõí.

ñéóóüôåñåò öïñÝò åßíáé ï ðáôÝñáò13. Ï ðéï áðïôåëåóìáôéêüò ôñüðïò óõìðáñÜóôáóçò åßíáé íá âïçèÞóïõìå ôïõò åöÞâïõò íá áíôéìåôùðßóïõí ôá ðñïâëÞìáôá ðïõ ðëáéóéþíïõí ôçí êáôáíÜëùóç áëêïüë. Ï øõ÷ïëüãïò J.Ôravers õðïóôçñßæåé üôé ç ðéï äýóêïëç áðüöáóç ãéá Ýíáí Ýöçâï äåí åßíáé ôï íá äéáëÝîåé áí èá ðßíåé Þ ü÷é. Ï ðñáãìáôéêüò ãñßöïò åßíáé áí èá ìðïñÝóåé íá æÞóåé ìå ôçí áðüöáóÞ ôïõ üðïéá êé áí åßíáé áõôÞ14. Áò Ý÷ïõìå óôï íïõ ìáò üôé ðñÝðåé íá ðñïóÝ÷ïõìå ðïëý üôáí ìéëÜìå óôá ðáéäéÜ ãéá ôï áëêïüë Þ Üëëá íáñêùôéêÜ. Ìéá ëÜèïò êïõâÝíôá óå ìéá áêáôÜëëçëç óôéãìÞ ìðïñåß íá ôá êÜíåé íá åðáíáóôáôÞóïõí êé Ýôóé íá öÝñïõìå áíôßèåôá áðïôåëÝóìáôá. Ìéá óùóôÞ êïõâÝíôá êáôáíüçóçò, ðÜëé, ìðïñåß íá åíéó÷ýóåé ôçí êñõöÞ ôïõò áðüöáóç íá ìçí ðéïõí Þ íá ìç äïêéìÜóïõí ôá íáñêùôéêÜ. Ç ðñüëçøç êáé ç áíôéìåôþðéóç ôùí åîáñôÞóåùí ðñïûðïèÝôåé ôïí ãüíéìï äéÜëïãï êáé ôç óõíåñãáóßá áíÜìåóá óôïõò åðáããåëìáôßåò õãåßáò, ôçí áêáäçìáúêÞ êïéíüôçôá êáé ôïõò ðïëéôéêÜ õðåýèõíïõò ãéá ôá èÝìáôá áõôÜ.

5.

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Âéâëéïãñáößá 1. Herbert Ì., Øõ÷ïëïãéêÜ ðñïâëÞìáôá åöçâéêÞò çëéêßáò, êåö.7, óåë.171-198, åêäüóåéò ÅëëçíéêÜ ÃñÜììáôá, 1994. 2. Wilner P. A view through the gateway: expectancies as a possible pathway from alcohol to cannabis, Adiction, 96:5, 2001. 3. Bonomo Y, Colfey C, Wolfie R, Lynskey M, Bowes G, Patton G. Ïé áñíçôéêÝò óõíÝðåéåò ôçò ÷ñÞóçò áëêïüë áðü åöÞâïõò. Addiction, 96:10, 2001. 4. Knight JR, Shrier LA, Bravender TD, Farrell M, Vander Bilt J, Shaffer HJ. A new brief

12.

13.

14.

screen for adolescent substance abuse. Arch Pediatr Adolesc Med, 153:591-596, 1999. Babor TF, de la Fuente JR, Saunders J, Grant M.AUDIT: The Alcohol use disorders identification Tests: Guidelines for use in Primary health care. Geneva, Switzerland: World Health Organization, 1992. Murray CJL, Lopez AD. Evidence Based Health Policy-Lessons from the Global Burden of Disease Study. Science, 274:740, 2002. Kandel D.B, Yamaguchi K. Stages of progression in drug involvement from adolescence to adult hood: further evidence for the gateway theory. Journal of Studies on Alcohol, 53:447457, 1992. Welte JW Barnes G.M Alcohol: the gateway to other drug use among secondary school students. Journal of Youth and Adolescence, 14:487498 1981. Stefanis N.C, Kokkevi A.: “Depression and drug use“ Psychopathology, 19:S2:124-134, 1986. Kokkevi A. Stefanis N.C “Alcohol consumption among Creek Adolescents” Paper presented at the world Psychiatric association, Warsow, Poland 22-25-November, 11-16, 1987. Kandel D.B, Yamaguchi K. Stages of progression in drug involvement from adolescence to adult hood: further evidence for the gateway theory. Journal of Studies on Alcohol, 53:447457, 1992. Marlatt G.A., Baer, J.S. Quigley L.A. Self-efficacy and addictive behavior. In Bandura, A. (ed) Self-efficacy in changing societies. Cambridge University Press, Cambridge, 289-315, 1995. O”Malley S.S. Maisto, S.A. Effect off family drinking history and expectancies on responses to alcohol in men. Journal of Studies on Alcohol, 46:289-297, 1985. Travers J.F. The Growing child, New York, Wiley, 1977.

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Ê. Óõñéáíüò êáé óõí.

ÂÑÁÂÅÕÈÅÉÓÁ ÅËÅÕÈÅÑÇ ÁÍÁÊÏÉÍÙÓÇ AWARDED FREESTANDING PAPER Primary Heatlh Care, Volume 15, Number 2, 84-90, 2003 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 15, Ôåý÷ïò 2, 84-90, 2003

Ïé ôñïðïðïéÞóéìïé ðáñÜãïíôåò ðïõ êáèïñßæïõí ôçí ðéèáíüôçôá åðéâßùóçò áóèåíþí ìå åîùíïóïêïìåéáêÞ êáñäéáêÞ áíáêïðÞ Ê. Óõñéáíüò1, Â. ËÝôôá1, Ä. ÊáêëáìÜíïõ2

Ðåñßëçøç Óêïðüò ôçò ìåëÝôçò åßíáé ç áíáæÞôçóç ôùí ôñïðïðïéÞóéìùí ðáñáãüíôùí, ðïõ êáèïñßæïõí ôçí ðéèáíüôçôá åðéâßùóçò ôùí áóèåíþí, ðïõ Ý÷ïõí õðïóôåß êáñäéáêÞ áíáêïðÞ Ýîù áðü ôï íïóïêïìåßï êáé áíôéìåôùðßóèçêáí áðü ôéò õðçñåóßåò ðáñï÷Þò åðåßãïõóáò ðñïíïóïêïìåéáêÞò éáôñéêÞò. Õëéêü êáé ìÝèïäïò: ìåëåôÞèçêå ç Ýêâáóç ôùí ðåñéóôáôéêþí êáñäéáêÞò áíáêïðÞò, ðïõ áíôéìåôùðßóèçêáí áðü ôï ÅÊÁ ÊïæÜíçò, óå äéÜóôçìá 13 ìçíþí, áðü 1 Éáíïõáñßïõ 2002 Ýùò 28 Öåâñïõáñßïõ 2003. ¸ãéíå ôáîéíüìçóç, óýìöùíá ìå ôçí Ýêâáóç, óå ôñåéò êáôçãïñßåò, óå ðåñéóôáôéêÜ ìå áðïôõ÷çìÝíç ðñïóðÜèåéá áíÜôáîçò, óå ðåñéóôáôéêÜ ìå áñ÷éêÞ áíÜôáîç êáé áðïêáôÜóôáóç ôçò áõôüíïìçò êõêëïöïñßáò êáé óå ðåñéóôáôéêÜ ìå ôåëéêÞ åðéâßùóç, ðïõ ôáõôßæåôáé ìå ôçí Ýêäïóç åîéôçñßïõ áðü ôï íïóïêïìåßï. Õðïëïãßóáìå ôçí ðéèáíüôçôá åðéâßùóçò ôùí ðåñéóôáôéêþí, ìå âÜóç ôïí åìðåéñéêü ìáèçìáôéêü ôýðï ACLS (Score for Predicting Survival After Out-of-Hospital Cardiac Arrest) êáé êÜíáìå óýãêñéóç ìå ôéò ðñáãìáôéêÝò åêâÜóåéò. ÁðïôåëÝóìáôá: óôá ðåñéóôáôéêÜ ìå áðïôõ÷çìÝíç ðñïóðÜèåéá áíÜôáîçò (26 áðü 37) ç ìÝóç ôéìÞ ôçò ðéèáíüôçôáò åðéâßùóçò Þôáí 6,3%, óôá ðåñéóôáôéêÜ ìå áñ÷éêÞ áíÜôáîç (11 áðü 37) Þôáí 39,5% êáé óôá ðåñéóôáôéêÜ ìå ôåëéêÞ åðéâßùóç (5 áðü 37) Þôáí 49%. Ç õðïëïãéóìÝíç ðéèáíüôçôá äåß÷íåé óõó÷Ýôéóç ìå ôçí ðñáãìáôéêÞ Ýêâáóç ôùí ðåñéóôáôéêþí. Áðü ôçí áíÜëõóç ðñïêýðôåé üôé, ïé âáóéêïß ðáñÜãïíôåò, ðïõ êáèïñßæïõí ôçí ðéèáíüôçôá åðéâßùóçò, åßíáé ç ðñüùñç Ýíáñîç áíáæùïãüíçóçò êáé ï ÷ñüíïò Üöéîçò ôïõ áóèåíïöüñïõ. ÓõìðåñÜóìáôá: ïé äõï âáóéêïß ôñïðïðïéÞóéìïé ðáñÜãïíôåò, ðïõ êáèïñßæïõí ôçí ðéèáíüôçôá åðéâßùóçò áôüìùí ìå åîùíïóïêïìåéáêÞ êáñäéáêÞ áíáêïðÞ, åßíáé ç Ýíáñîç ôçò õðïóôÞñéîçò ôçò æùÞò áðü ôïõò ìÜñôõñåò ôçò áíáêïðÞò êáé ç ôá÷åßá áíôáðüêñéóç ôïõ áóèåíïöüñïõ. Ç ôñïðïðïßçóç ìðïñåß íá ãßíåé ìå ôçí áðïêÝíôñùóç ôùí õðçñåóéþí åðåßãïõóáò éáôñéêÞò êáé ìå ôçí åêðáßäåõóç êáé åíçìÝñùóç ôùí ðïëéôþí óôá èÝìáôá õðïóôÞñéîçò ôçò æùÞò êáé ÷ñÞóçò ôïõ áõôüìáôïõ áðéíéäùôÞ.

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ÊÝíôñï Õãåßáò ÓéÜôéóôáò, 2ÐáñÜñôçìá ÊïæÜíçò ôïõ ÅÊÁÂ

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ÅéóáãùãÞ Ç åîùíïóïêïìåéáêÞ êáñäéáêÞ áíáêïðÞ åßíáé óõ÷íÜ ç ðñþôç åêäÞëùóç ôçò éó÷áéìéêÞò íüóïõ ôçò êáñäéÜò. Óôéò ÇíùìÝíåò Ðïëéôåßåò ç åðßðôùóç ôçò êáñäéáêÞò áíáêïðÞò õðïëïãßæåôáé ðåñßðïõ óôï 1/1000 ôïõ ðëçèõóìïý áíÜ Ýôïò (15%-20% üëùí ôùí èáíÜôùí)1,2. Ïé ìç áíáóôñÝøéìåò åãêåöáëéêÝò âëÜâåò åìöáíßæïíôáé ìÝóá óå äéÜóôçìá 4 ëåðôþí áðü ôçí Ýíáñîç ôçò êáñäéáêÞò áíáêïðÞò êáé ï åãêåöáëéêüò èÜíáôïò åìöáíßæåôáé óå 12 ëåðôÜ, åÜí ï áóèåíÞò ðáñáìÝíåé ÷ùñßò êáìéÜ õðïóôÞñéîç3,4. Ç ðéèáíüôçôá åðéâßùóçò ìåôÜ áðü êáñäéáêÞ áíáêïðÞ êõìáßíåôáé áðü 30% Ýùò 70%, êáé åîáñôÜôáé áðü ôçí åîáóöÜëéóç óôïí ðÜó÷ïíôá ôçò áëõËÝîåéò ÊëåéäéÜ: Áóõóôïëßá, ÂáóéêÞ õðïóôÞñéîç ôçò æùÞò, Åðåßãïõóá éáôñéêÞ, ÊáñäéáêÞ áíáêïðÞ, ÊïéëéáêÞ ìáñìáñõãÞ, ÊïéëéáêÞ ôá÷õêáñäßá ÕðïâëÞèçêå: Ç åñãáóßá õðïâëÞèçêå ùò åëåýèåñç áíáêïßíùóç óôï 15o ÐáíåëëÞíéï ÓõíÝäñéï ÃåíéêÞò ÉáôñéêÞò (×áëêéäéêÞ 30 Áðñéëßïõ - 4 ÌáÀïõ 2003) êáé âñáâåýôçêå áðü ôçí åðéôñïðÞ Êñßóçò. Äçìïóéåýåôáé ìå êïéíÞ áðüöáóç ôçò ÓõíôáêôéêÞò ÅðéôñïðÞò ôïõ ðåñéïäéêïý êáé ôçò ÏñãáíùôéêÞò ÅðéôñïðÞò ôïõ Óõíåäñßïõ. Õðåýèõíïò áëëçëïãñáößáò: Êá÷ëÜí Óõñéáíüò, Áãßáò ÐáñáóêåõÞò 23, ÊïæÜíç, 50100 Ôçë. (24610)21065, (24610)32988, (6972)307740.


Ê. Óõñéáíüò êáé óõí.

Ôüìïò 15, Ôåý÷ïò 2, 2003

íáé 60-70% óå üëïõò ôïõò áóèåíåßò ìå êáñäéáêÞ áíáêïðÞ16,17 êáé ç âáóéêÞ õðïóôÞñéîç ôçò æùÞò ìðïñåß íá åðéâñáäýíåé óçìáíôéêÜ ôç ãñÞãïñç ìåôÜSummary ðôùóÞ ôçò óå áóõóôïëßá15. Aim: study of modifiable factors that determine the chance of survival from outof-hospital cardiac arrest that treated by emergency medical services. Ïé õðçñåóßåò ðáñï÷Þò åðåßãïõóáò Methods: retrospective study on the outcomes of out-of-hospital cardiac arrests ðñïíïóïêïìåéáêÞò éáôñéêÞò êáëïýíôáé between January 1, 2002, and February 28, 2003, who were treated by emeróõ÷íÜ ãéá áíôéìåôþðéóç ðåñéóôáôéêþí gency medical services in the city of Kozani. The outcomes of the incidents åîùíïóïêïìåéáêÞò êáñäéáêÞò áíáêïhave been classified in three categories, in incidents with unsuccessful resusðÞò. Ó’ áõôÝò ôéò ðåñéðôþóåéò åßíáé citation, incidents with successful initial resuscitation, defined as return of spontaneous circulation and incidents with survival to hospital discharge. The survivëßãá ôá áêáôáìÜ÷çôá êñéôÞñéá, ðïõ al rate of every category has been compared with the ACLS score (Score for ìðïñïýí íá âïçèÞóïõí, áðü ôçí ðñþPredicting Survival After Out-of-Hospital Cardiac Arrest). Results: in the inciôç åðáöÞ ìå ôïí áóèåíÞ, óôçí ðñüdents with failed resuscitation (26 from 37) the ACLS was 6,3%, in the incidents âëåøç ôçò ìáôáéüôçôáò ôçò ðñïóðÜwith successful initial resuscitation (11 from 37) the ACLS was 39,5% and in èåéáò áíáæùïãüíçóçò Þ ôçò ðéèáíüôçthe incidents with survival to hospital discharge (5 from 37) the ACLS was 49%. The calculated probability shows cross-correlation with the outcomes of the ôáò åðéâßùóçò ðïõ Ý÷åé ï áóèåíÞò êáé incidents. The analysis of results shows that the basic factors that determine ç ãåíéêÞ ôÜóç åßíáé ç ðñïóðÜèåéá áíáthe chance of survival from out-of-hospital cardiac arrest is the early initiation æùïãüíçóçò üëùí ôùí áóèåíþí, åí of CPR and the interval between collapse and arrival of the ambulance. Conáðïõóßá ôçò ðôùìáôéêÞò áêáìøßáò êáé clusions: the two basic modifiable factors that determine the chance of survival ôçò íåêñéêÞò ðåëéäíüôçôáò18. Ùóôüóï from out-of-hospital cardiac arrest are the beginning of support of life from the witnesses and the rapid response of ambulance. The modification can become Ý÷ïõí ãßíåé ðïëëÝò ìåëÝôåò ìå óêïðü with the decentralisation of emergency medical services, with an aggressive ôïí êáèïñéóìü ôùí êñéôçñßùí ãéá ôçí citizen CPR training program and with the public education on the use of Ýíáñîç Þ ìç ôùí ðñïóðáèåéþí áíáautomated external defibrillators (AEDs). æùïãüíçóçò êáé ãéá ôç ìåôáöïñÜ ôïõ Key Words: Asystole, Basic Life Support, Cardiac Arrest, Emergency Medical ðÜó÷ïíôïò êáé ôç óõíÝ÷éóç ôùí ðñïServices, ventricular fibrillation, ventricular tachycardia óðáèåéþí åíôüò ôïõ íïóïêïìåßïõ19-23. Health Centre of Siatista, Kozani Óôçí ðáñïýóá ìåëÝôç ãßíåôáé áíáæÞôçóç ôùí ôñïðïðïéÞóéìùí ðáñáãüóßäáò åðéâßùóçò3, ç ïðïßá ðåñéëáìâÜíåé ôçí Üìå- íôùí, ðïõ êáèïñßæïõí ôçí ðéèáíüôçôá åðéâßùóçò óç ðñüóâáóç êáé êéíçôïðïßçóç ôùí õðçñåóéþí ôùí áóèåíþí ìå åîùíïóïêïìåéáêÞ êáñäéáêÞ áíáåðåßãïõóáò éáôñéêÞò, ôçí ðñþéìç âáóéêÞ õðïóôÞ- êïðÞ, ìå óêïðü ôïí êáëýôåñï ó÷åäéáóìü ôçò áíôéñéîç ôçò æùÞò, ôçí ðñþéìç áðéíßäùóç êáé ôçí ìåôþðéóçò áõôþí ôùí ðåñéóôáôéêþí. ðñþéìç åîåéäéêåõìÝíç õðïóôÞñéîç ôçò æùÞò2,5-11. Ç ðñüãíùóç åßíáé åîáéñåôéêÜ öôù÷Þ üôáí ç êáñäéáêÞ áíáêïðÞ åìöáíßæåôáé ÷ùñßò ðáñïõóßá ìÜñ- Ðëõèõóìüò ìåëÝôçò - ÌÝèïäïò ôõñá Þ üôáí êáèõóôåñåß ç Ýíáñîç ôçò âáóéêÞò õðïóôÞñéîçò ôçò æùÞò (ÊÁÑÐÁ) ðÝñá áðü 6 ëåðôÜ ÌåëåôÞèçêáí ôá ðåñéóôáôéêÜ åîùíïóïêïìåéáêáé ç áðéíßäùóç ðÝñá áðü 8 ëåðôÜ12. êÞò áíáêïðÞò ðïõ áíôéìåôùðßóèçêáí áðü ôï Ç ðéï óõ÷íÞ áññõèìßá ðïõ ðñïêáëåß ôçí ðáñÜñôçìá ÊïæÜíçò ôïõ ÅÊÁÂ, óå äéÜóôçìá 13 êáñäéáêÞ áíáêïðÞ åßíáé ç êïéëéáêÞ ìáñìáñõãÞ ìçíþí áðü ÉáíïõÜñéï 2002 Ýùò ôï ÖåâñïõÜñéï (ÊÌ), ðïõ Ý÷åé êáé êáëýôåñç ðñüãíùóç áðü ôéò 2003. Óôç ìåëÝôç óõìðåñéëÞöèçóáí ôá ðåñéóôáÜëëåò áññõèìßåò (áóõóôïëßá, Üóöõãìç çëåêôñéêÞ ôéêÜ ðïõ áíôéìåôùðßóèçêáí áðü ôçí êéíçôÞ ìïäñáóôçñéüôçôá ê.ëð.)13,14. Ç ðéèáíüôçôá åðéâßù- íÜäá ôïõ ÅÊÁÂ, ìå ðáñïõóßá éáôñéêïý ðñïóùóçò óôçí êïéëéáêÞ ìáñìáñõãÞ åßíáé ìÝ÷ñé äÝêá ðéêïý êáé äõíáôüôçôá åðéôüðéáò äéáóùëÞíùóçò, öïñÝò õøçëüôåñç áðü åêåßíç, ðïõ áíáìÝíåôáé óôéò áðéíßäùóçò êáé ÷ïñÞãçóçò öáñìÜêùí. ÁðïêëåßÜëëåò áññõèìßåò ôçò áíáêïðÞò. ÁõôÞ ç ðéèáíüôç- óôçêáí ôá ðåñéóôáôéêÜ ðïõ åß÷áí åìöáíßóåé óçôá ìåéþíåôáé ìå ôçí ðôþóç ôùí çëåêôñéêþí äõ- ìåßá áìåôÜêëçôïõ èáíÜôïõ (ð.÷. íåêñéêÞ áêáìíáìéêþí ôçò êïéëéáêÞò ìáñìáñõãÞò ìå ôçí ðÜñï- øßá), ôá ðåñéóôáôéêÜ ìå áíáêïðÞ ôñáõìáôïëïãéäï ôïõ ÷ñüíïõ ìÝ÷ñé ôçí åðéêñÜôçóç ôçò áóõóôï- êÞò áéôéïëïãßáò êáé ôá ðåñéóôáôéêÜ óôá ïðïßá ëßáò15. Ç åðßðôùóç ôçò ÊÌ õðïëïãßæåôáé üôé åß- äåí Þôáí äõíáôÞ ç ðñüóâáóç óå ëéãüôåñá áðü 20 The modifiable factors that determine the survival probability of petients with out-of-hospital cardiac arrest K. Syrianos, V. Letta, D. Kaklamanou

85


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Ê. Óõñéáíüò êáé óõí.

ëåðôÜ, åöüóïí äåí õðÞñ÷å êáìéÜ õðïóôÞñéîç óôïí ðÜó÷ïíôá ó’ áõôü ôï äéÜóôçìá. ¸ãéíå êáôáãñáöÞ ôçò ðñþôçò áññõèìßáò ðïõ åíôïðßóèçêå ìå ôï ìüíéôïñ, ôéò óõíèÞêåò ôçò áíáêïðÞò, áí Ýãéíå ðáñïõóßá ìÜñôõñá êáé áí Ýãéíå ðñïóðÜèåéá âáóéêÞò ÊÁÑÐÁ áðü ôïõò ðáñåõñéóêïìÝíïõò óôï óçìåßï ôïõ óõìâÜíôïò. Óå üëá ôá ðåñéóôáôéêÜ õðÞñîå ïñéóôéêÞ åîáóöÜëéóç ôïõ áåñáãùãïý, ÷ïñçãÞèçêáí öÜñìáêá êáé Ýãéíáí áðéíéäþóåéò üðïõ õðÞñ÷áí åíäåßîåéò. Ôá ðåñéóôáôéêÜ ôáîéíïìÞèçêáí óå ôñåéò êáôçãïñßåò, óýìöùíá ìå ôçí Ýêâáóç, óå ðåñéóôáôéêÜ ìå áñ÷éêÞ áíÜôáîç êáé áðïêáôÜóôáóç ôçò áõôüíïìçò êõêëïöïñßáò ãéá ôïõëÜ÷éóôïí 20 ëåðôÜ, óå ðåñéóôáôéêÜ ìå ôåëéêÞ åðéâßùóç, ðïõ ôáõôßæåôáé ìå ôçí Ýêäïóç åîéôçñßïõ áðü ôï íïóïêïìåßï êáé óå ðåñéóôáôéêÜ ìå áðïôõ÷çìÝíç ðñïóðÜèåéá áíÜôáîçò. ¸ãéíå õðïëïãéóìüò ôçò áíáìåíüìåíçò ðéèáíüôçôáò åðéâßùóçò, ìå âÜóç ôïí åìðåéñéêü ìáèçìáôéêü ôýðï (ACLS Score for Predicting Survival After Out-of-Hospital Cardiac Arrest), ðïõ åß÷å ðñïôáèåß áðü ôïí Eisenberg êáé óõí. ôï 198124: Ðéèáíüôçôá åðéâßùóçò = ACLS score = 80-A-C-L-S ¼ðïõ A = ðáñïõóßá ìÜñôõñá (Arrest witnessed) êáé ðáßñíåé ôéìÞ (ìçäÝí) ãéá ôçí ðåñßðôùóç ýðáñîçò ìÜñôõñá ôçò áíáêïðÞò êáé ôéìÞ (40) ãéá ôçí ðåñßðôùóç áíáêïðÞò ÷ùñßò ôçí ðáñïõóßá ìÜñôõñá, C = êáñäéáêüò ñõèìüò ôçò áíáêïðÞò (Cardiac rhythm) êáé ðáßñíåé ôéìÞ (ìçäÝí) ãéá ôçí êïéëéáêÞ ìáñìáñõãÞ Þ Üóöõãìç êïéëéáêÞ ôá÷õêáñäßá êáé ôéìÞ (40) ãéá ïðïéïíäÞðïôå Üëëï êáñäéáêü ñõèìü, L = ç ðáñï÷Þ Þ ìç ÊÁÑÐÁ áðü ôïõò ðáñåõñéóêüìåíïõò (Lay bystander initiates) êáé ðáßñíåé ôéìÞ (ìçäÝí) ãéá ôçí ðáñï÷Þ ÊÁÑÐÁ áðü ôïõò ðáñåõñéóêüìåíïõò êáé (20) ãéá ôçí ðåñßðôùóç Ýíáñîçò ÊÁÑÐÁ áðü ôï ðëÞ-

ñùìá áóèåíïöüñïõ, S = ôá÷ýôçôá áíôáðüêñéóçò áóèåíïöüñïõ (Speed of response by paramedic squad) êáé õðïëïãßæåôáé áðü ôïí ðïëëáðëáóéáóìü ôï ÷ñüíï óå ëåðôÜ ìå ôïí áñéèìü 5, üðùò öáßíåôáé êáé óôïí ðßíáêá 1. Ç ìéêñüôåñç ðéèáíüôçôá éóïýôáé ìå ìçäÝí (H ôéìÞ äåí ìðïñåß íá åßíáé áñíçôéêÞ) êáé ç ìåãáëýôåñç ðéèáíüôçôá éóïýôáé ìå 80. ÌåôÜ ôïí õðïëïãéóìü ôçò ðéèáíüôçôáò åðéâßùóçò, êÜíáìå óýãêñéóç ìå ôéò ðñáãìáôéêÝò åêâÜóåéò ôùí ðåñéóôáôéêþí áíáêïðÞò ðïõ áíôéìåôùðßóáìå, ðñïêåéìÝíïõ íá åîåôÜóïõìå ôçí áîéïðéóôßá ôùí ðáñáìÝôñùí, ðïõ åíóùìáôþíïíôáé óôïí ôñüðï õðïëïãéóìïý êáé íá áðïìïíþóïõìå åêåßíïõò ôïõò ðáñÜãïíôåò, ðïõ åßíáé ôñïðïðïéÞóéìïé.

ÁðïôåëÝóìáôá Óôï äéÜóôçìá ôùí 13 ìçíþí ôï ðáñÜñôçìá ÊïæÜíçò ôïõ ÅÊÁ êëÞèçêå ãéá ôçí áíôéìåôþðéóç 48 ðåñéóôáôéêþí åîùíïóïêïìåéáêÞò áíáêïðÞò, áðü ôá ïðïßá ôá 37 ðëçñïýí ôá êñéôÞñéá ôçò ìåëÝôçò. Ïé 27 ðáèüíôåò Þôáí Üíäñåò (73%) êáé ïé 10 Þôáí ãõíáßêåò (23%). Ç ìÝóç çëéêßá ôùí ðáèüíôùí Þôáí 62,8 åôþí. Ï ìÝóïò ÷ñüíïò áíôáðüêñéóçò ôïõ áóèåíïöüñïõ Þôáí 6,4 ëåðôÜ. Ï áñ÷éêüò êáôáãñáììÝíïò ñõèìüò Þôáí áðéíéäþóéìïò (êïéëéáêÞ ìáñìáñõãÞ Þ Üóöõãìç êïéëéáêÞ ôá÷õêáñäßá) óå 12 ðåñéóôáôéêÜ (32%) êáé óôá õðüëïéðá 25 ðåñéóôáôéêÜ (68%) Þôáí ìç áðéíéäþóéìïò (áóõóôïëßá). Ìüíï óå 4 ðåñéóôáôéêÜ (11%) õðÞñ÷å Üìåóç õðïóôÞñéîç ôçò æùÞò, áðü êÜðïéïí ðáñåõñéóêüìåíï óôï óçìåßï ôïõ óõìâÜíôïò. Óå 25 ðåñéóôáôéêÜ (68%) ç áíáêïðÞ åß÷å óõìâåß ðáñïõóßá ìÜñôõñá. Ç ðñïóðÜèåéá áíÜôáîçò Þôáí ÷ùñßò åðéôõ÷ßá óå 26 ðåñéóôáôéêÜ (70%) êáé ç

Ðßíáêáò 1. ÔéìÝò ôùí ðáñáìÝôñùí ãéá ôïí õðïëïãéóìü ôçò ðéèáíüôçôáò åðéâßùóçò ÐáñÜìåôñïò

ÐáñáëëáãÝò

A = ÊáñäéáêÞ áíáêïðÞ

Ðáñïõóßá ìÜñôõñá 0 ×ùñßò ìÜñôõñá 40 ÊïéëéáêÞ ìáñìáñõãÞ 0 ¢óöõãìç êïéëéáêÞ ôá÷õêáñäßá 0 ¢ëëïò ñõèìüò 40 ¸íáñîç áðü ôïõò ðáñåõñéóêüìåíïõò 0 ¸íáñîç áðü ôï ðëÞñùìá ôïõ 20 áóèåíïöüñïõ (÷ñüíïò óå ëåðôÜ) × 5

C = Êáñäéáêüò ñõèìüò

L = ÊÁÑÐÁ

S = Áíôáðüêñéóç ôïõ áóèåíïöüñïõ 86

ÔéìÞ


Ôüìïò 15, Ôåý÷ïò 2, 2003

Ê. Óõñéáíüò êáé óõí.

ìÝóç õðïëïãéóìÝíç ðéèáíüôçôáò åðéâßùóçò áõôþí ôùí ðåñéóôáôéêþí Þôáí 6,3%. Áñ÷éêÞ áíÜôáîç, ìå åðéóôñïöÞ ôçò áõôüíïìçò êõêëïöïñßáò õðÞñ÷å óå 11 ðåñéóôáôéêÜ (30%). Ç ìÝóç õðïëïãéóìÝíç ðéèáíüôçôá åðéâßùóçò ãé’ áõôÜ ôá ðåñéóôáôéêÜ Þôáí 39,5%. Ôá ðåñéóôáôéêÜ ìå ôåëéêÞ åðéâßùóç (åîéôÞñéï áðü ôï íïóïêïìåßï) Þôáí 5 (13,5%) êáé ç ìÝóç õðïëïãéóìÝíç ðéèáíüôçôá åðéâßùóçò áõôþí ôùí ðåñéóôáôéêþí Þôáí 49%. ÁíáëõôéêÜ ôá áðïôåëÝóìáôá öáßíïíôáé óôïí ðßíáêá 2. Ãéá ôçí åîÝôáóç ôçò ìåôáâïëÞò ôïõ ñõèìïý ôçò êáñäéáêÞò áíáêïðÞò, óå ó÷Ýóç ìå ôï ÷ñüíï,

áðïìïíþóáìå ôá 25 ðåñéóôáôéêÜ, üðïõ ç áíáêïðÞ åß÷å ãßíåé ðáñïõóßá ìÜñôõñá, åðåéäÞ ó’ áõôÜ ôá ðåñéóôáôéêÜ Þôáí åöéêôü íá êáôáãñáöåß, ìå ìåãáëýôåñç áêñßâåéá, ï ÷ñüíïò ðïõ ðÝñáóå áðü ôç óôéãìÞ ôçò Ýíáñîçò ôçò áíáêïðÞò. Äéáðéóôþóáìå ìåãáëýôåñç óõ÷íüôçôá åìöÜíéóçò ôçò êïéëéáêÞò ìáñìáñõãÞò, óôá ðñþôá ëåðôÜ ôçò áíáêïðÞò. ÁõôÞ ç óõ÷íüôçôá ìåéþíåôáé ãñÞãïñá ìå ôçí ðÜñïäï ôïõ ÷ñüíïõ, åíþ ôáõôü÷ñïíá áõîÜíåôáé ç óõ÷íüôçôá åìöÜíéóçò ôçò áóõóôïëßáò, üðùò öáßíåôáé óôïí ðßíáêá 3 êáé óôï ãñÜöçìá1. Óå ü,ôé áöïñÜ ôçí åðßäñáóç ôçò âáóéêÞò õðïóôÞñéîçò ôçò æùÞò, üôáí ðáñÝ÷åôáé Üìåóá áðü

Ðßíáêáò 2. ÁíáëõôéêÜ óôïé÷åßá ðåñéóôáôéêþí êáñäéáêÞò áíáêïðÞò Á/á

Öýëï

Çëéêßá

ÁíáêïðÞ ðáñïõóßá ìÜñôõñá

Áññõèìßá ðïõ êáôáãñÜöçêå

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37

Á È Á Á Á Á È Á Á È Á Á Á È Á È Á È È È Á È Á Á Á Á È Á È Á Á Á Á Á Á È Á

62 87 72 48 57 68 78 57 48 39 62 54 67 76 47 57 61 24 74 85 49 69 53 67 62 58 59 49 62 74 59 77 70 60 62 76 76

Íáé Íáé Íáé Íáé Íáé Íáé Íáé Íáé

KM KM Áóõóôïëßá ÊÌ ÊÌ ÊÌ Áóõóôïëßá Áóõóôïëßá Áóõóôïëßá Áóõóôïëßá Áóõóôïëßá ÊÌ Áóõóôïëßá Áóõóôïëßá ÊÌ Áóõóôïëßá Áóõóôïëßá ÊÌ ÊÌ Áóõóôïëßá Áóõóôïëßá Áóõóôïëßá Áóõóôïëßá ÊÌ ÊÌ Áóõóôïëßá Áóõóôïëßá Áóõóôïëßá Áóõóôïëßá ÊÌ Áóõóôïëßá Áóõóôïëßá Áóõóôïëßá Áóõóôïëßá Áóõóôïëßá Áóõóôïëßá Áóõóôïëßá

Íáé Íáé Íáé Íáé

Íáé Íáé Íáé Íáé Íáé Íáé Íáé Íáé Íáé Íáé Íáé Íáé Íáé

¢ìåóç ÊÁÑÐÁ

Íáé

Íáé

Íáé

Íáé

×ñüíïò áíôáðüêñéóçò áóèåíïöüñïõ

ÅðéóôñïöÞ áõôüíïìçò êõêëïöïñßáò

Åðéâßùóç

Ðéèáíüôçôá åðéâßùóçò ACLS score

2 2 2 3 3 3 3 3 3 3 3 4 4 4 4 4 4 5 5 5 5 5 5 6 6 6 6 6 8 9 10 13 13 16 17 18 19

Íáé

Íáé

Íáé Íáé Íáé Íáé

Íáé Íáé

50 50 30 65 45 45 5 5 5 5 5 40 0 0 40 0 0 55 35 0 15 0 0 30 30 10 0 0 0 15 0 0 0 0 0 0 0

Íáé

Íáé

Íáé Íáé

Íáé Íáé Íáé

Íáé

87


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Ê. Óõñéáíüò êáé óõí.

Ðßíáêáò 3. Ï êáñäéáêüò ñõèìüò ðïõ åíôïðßóèçêå óå ó÷Ýóç ìå ôï ÷ñüíï Óýíïëï ðåñéóôáôéêþí

ÊÌ

%

Áóõóôïëßá

%

2 3 4 5 6 > 7

3 5 4 5 5 3

2 3 2 2 2 1

0,7 0,6 0,5 0,4 0,4 0,3

1 2 2 3 3 2

0,3 0,4 0,5 0,6 0,6 0,7

Ðïóïóôü

×ñüíïò áðü ôçí Ýíáñîç ôçò áíáêïðÞò óå ëåðôÜ

0,70 0,60 0,50 0,40 0,30 0,20 0,10 0,00

Áóõóôïëßá ÊÌ

1

2

3

4

5

6

ËåðôÜ ÃñÜöçìá 1. Ï êáñäéáêüò ñõèìüò óå ó÷Ýóç ìå ôï ÷ñüíï áðü ôçí Ýíáñîç ôçò áíáêïðÞò.

ôïõò ðáñåõñéóêüìåíïõò óôï óçìåßï ôïõ óõìâÜíôïò, ï áñéèìüò ôùí ðåñéðôþóåùí Þôáí åîáéñåôéêÜ ìéêñüò (ìüíï 4 áðü 37). Ðáñüëï ðïõ õðÞñ÷å åðéóôñïöÞ ôçò áõôüíïìçò êõêëïöïñßáò óå 3 áðü ôá ôÝóóåñá ðåñéóôáôéêÜ, üðïõ åß÷å ãßíåé Üìåóç âáóéêÞ õðïóôÞñéîç ôïõ ðÜó÷ïíôïò êáé ïñéóôéêÞ áíÜôáîç óå äõï áð’ áõôÜ, ï ìéêñüò áñéèìüò äåí ìáò åðéôñÝðåé íá âãÜëïõìå óôáôéóôéêÜ óõìðåñÜóìáôá.

ÓõæÞôçóç Áðü ìéá áñ÷éêÞ åêôßìçóç ôùí áðïôåëåóìÜôùí ôçò ìåëÝôçò öáßíåôáé üôé ï õðïëïãéóìüò ôçò ðéèáíüôçôáò åðéâßùóçò, ìå âÜóç ôïí åìðåéñéêü ìáèçìáôéêü ôýðï ôïõ Eisenberg êáé óõí. ìðïñåß íá ðñïóåããßóåé ôçí ðñáãìáôéêüôçôá ìå ó÷åôéêÞ áêñßâåéá. Óôá ðåñéóôáôéêÜ ìå ïñéóôéêÞ áíÜôáîç ðïõ ðÞñáí åîéôÞñéï áðü ôï íïóïêïìåßï) õðÞñ÷å ó÷åôéêÜ õøçëÞ ðéèáíüôçôá åðéâßùóçò (49%), åíþ óôá ðåñéóôáôéêÜ ìå áðïôõ÷çìÝíç ðñïóðÜèåéá áíÜôáîçò ç ðéèáíüôçôá Þôáí åîáéñåôéêÜ ìéêñÞ (6,3%) êáé åíäéÜìåóç ðéèáíüôçôá åß÷áí ôá ðåñéóôáôéêÜ ìå áñ÷éêÞ áíÜôáîç êáé åðéóôñïöÞ ôçò áõôüíïìçò êõêëïöïñßáò (39,5). Áðü ôïõò ðáñÜãïíôåò, ðïõ åíóùìáôþíïíôáé 88

óôïí õðïëïãéóìü ôçò ðéèáíüôçôáò åðéâßùóçò, ïé ôñåéò åßíáé ôñïðïðïéÞóéìïé. Áõôïß åßíáé ï êáñäéáêüò ñõèìüò, ç Üìåóç âáóéêÞ õðïóôÞñéîç ôçò æùÞò áðü ôïõò ðáñåõñéóêüìåíïõò óôï óçìåßï ôïõ óõìâÜíôïò êáé ï ÷ñüíïò áíôáðüêñéóçò ôçò åðåßãïõóáò ðñïíïóïêïìåéáêÞò éáôñéêÞò. Ï êáñäéáêüò ñõèìüò ôçò áíáêïðÞò ìåôáâÜëëåôáé ãñÞãïñá ìå ôçí ðÜñïäï ôïõ ÷ñüíïõ, áðü áðéíéäþóéìï ñõèìü (êïéëéáêÞ ìáñìáñõãÞ Þ Üóöõãìç êïéëéáêÞ ôá÷õêáñäßá) óå ìç áðéíéäþóéìï (áóõóôïëßá). ÁõôÞ ç åîÝëéîç åðéâñáäýíåôáé ìå ôçí Üìåóç âáóéêÞ õðïóôÞñéîç ôçò æùÞò. Ç ôá÷åßá áíôáðüêñéóç ôçò åðåßãïõóáò ðñïíïóïêïìåéáêÞò éáôñéêÞò (áðéíßäùóç) ìðïñåß íá ðñïëÜâåé áõôÞ ôç ìåôáâïëÞ ôïõ êáñäéáêïý ñõèìïý. Ìüíï óå 4 ðåñéóôáôéêÜ áðü ôï äåßãìá ðïõ åîåôÜóáìå õðÞñ÷å Üìåóç ðáñï÷Þ âáóéêÞò ÊÁÑÐÁ (ðïóïóôü 11%). Áõôü ôï ðïóïóôü äéáöÝñåé áðü ÷þñá óå ÷þñá, áíÜëïãá ìå ôï åðßðåäï åíçìÝñùóçò êáé åêðáßäåõóçò ôùí ðïëéôþí. Óôç Óïõçäßá, ëüãïõ ÷Üñéí, ïé ìåëÝôåò áíáöÝñïõí Üìåóç ðáñï÷Þ âáóéêÞò ÊÁÑÐÁ áðü ôïõò ðáñåõñéóêüìåíïõò óå ðïóïóôü 36%25. Ç Üìåóç õðïóôÞñéîç ôçò æùÞò ìðïñåß íá åðéâñáäýíåé ôç ìåôÜðôùóç ôïõ áðéíéäþóéìïõ êáñäéáêïý ñõèìïý óå ìç áðéíéäþóéìï. Ôáõôü÷ñïíá êáèõóôåñåß ôçí åãêáôÜóôáóç ìç áíáóôñÝøéìùí âëáâþí ôïõ åãêåöÜëïõ, âåë-


Ôüìïò 15, Ôåý÷ïò 2, 2003

Ê. Óõñéáíüò êáé óõí.

ôéþíïíôáò Ýôóé óçìáíôéêÜ ôçí åðéâßùóç ôïõ ðÜó÷ïíôïò. Ï ÷ñüíïò áíôáðüêñéóçò áóèåíïöüñïõ åîáñôÜôáé áðü ôïí ôñüðï ïñãÜíùóçò êáé áíÜðôõîçò ôùí õðçñåóéþí ðáñï÷Þò åðåßãïõóáò ðñïíïóïêïìåéáêÞò éáôñéêÞò. Ç åõåñãåôéêÞ åðßäñáóç ôçò Üìåóçò áíôáðüêñéóçò ôçò åðåßãïõóáò ðñïíïóïêïìåéáêÞò éáôñéêÞò óôçí ðéèáíüôçôá åðéâßùóçò ìåôÜ áðü êáñäéáêÞ áíáêïðÞ, óõíßóôáôáé êõñßùò óôçí ðñþéìç åöáñìïãÞ ôçò áðéíßäùóçò, ðñéí ìåôáâëçèåß ï êáñäéáêüò ñõèìüò. Ç äéÜäïóç ôçò åõñåßáò ÷ñÞóçò ôïõ áõôüìáôïõ åîùôåñéêïý áðéíéäùôÞ áðü ôïõò ìç åðáããåëìáôßåò õãåßáò ìðïñåß íá äþóåé ôç ëýóç óôçí áäõíáìßá ôçò åðåßãïõóáò éáôñéêÞò íá áíôáðïêñéèåß ðÜíôá óå ôüóï óýíôïìï ÷ñüíï.

ÓõìðåñÜóìáôá Ç ðéèáíüôçôá åðéâßùóçò ìåôÜ áðü åîùíïóïêïìåéáêÞ êáñäéáêÞ áíáêïðÞ åîáñôÜôáé áðü ôçí Üìåóç ðáñï÷Þ âáóéêÞò õðïóôÞñéîçò ôçò æùÞò óôïí ðáèüíôá êáé áðü ôçí ðñþéìç áðéíßäùóç. Ãéá ôçí áýîçóç áõôÞò ôçò ðéèáíüôçôáò áðáéôåßôáé: 1. Ýíá åðéèåôéêü ðñüãñáììá åêðáßäåõóçò ôùí ðïëéôþí óôçí ðáñï÷Þ âáóéêÞò õðïóôÞñéîçò ôçò æùÞò, 2. ìéá êáëýôåñç ïñéæüíôéá ïñãÜíùóç ôùí õðçñåóéþí åðåßãïõóáò ðñïíïóïêïìåéáêÞò éáôñéêÞò (ÅÊÁÂ), âáóéóìÝíç óôéò ÷ñüíï-áðïóôÜóåéò, 3. ç Ýíôáîç ôùí êÝíôñùí õãåßáò óôéò õðçñåóßåò åðåßãïõóáò ðñïíïóïêïìåéáêÞò éáôñéêÞò ãéá ôçí åîáóöÜëéóç êáëýôåñçò ãåùãñáöéêÞò êÜëõøçò êáé 4. ç áíÜðôõîç ðñïãñáììÜôùí åéóáãùãÞò ôçò åõñåßáò ÷ñÞóçò ôùí åîùôåñéêþí áõôüìáôùí áðéíéäùôþí áðü ôïõò ìç åðáããåëìáôßåò õãåßáò (áðü ôçí áóôõíïìßá, ôçí ðõñïóâåóôéêÞ êáé ôïõò áðëïýò ðïëßôåò)

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

Âéâëéïãñáößá 15. 1. Becker LB, Smith DW, Rhodes KV. Incidence of cardiac arrest: a neglected factor in evaluating survival rates. Ann Emerg Med, 22:86-91, 1993. 2. Lindholm DJ, Campbell JP: Predicting survival

16.

from out-of-hospital cardiac arrest. Prehospital and Disaster Medicine, 13:126-129. Larson MP, Eisenberg MS, Cummins RO, et al. Predicting survival from out-of-hospital cardiac arrest. Ann Emerg Med, 22:1652-1658, 1993. American Heart Association. Emergency Cardiac Care Committee and Subcommittees. Guidelines for cardiopulmonary resuscitation and emergency care. JAMA, 268:2171, 1992. Aghababian RV, Mears G, Ornato JP, Kudenchuk PJ, Overton J. Cardiac arrest management. Prehosp Emerg Care, 5:237-46, 2001. Cummins RO, Ornato JP, Theis W, et al. Improving survival from cardiac arrest: the chain of survival concept. Circulation, 83:1832-1847, 1991. Maguire JE. Advances in cardiac life support: sorting the science from the dogma. Emerg Med, 9 Suppl:1-8, 1997. Callahan M, Madsen CD. Relationship of timeliness of paramedic Advanced Life Support interventions to outcome in out-of hospital cardiac arrest treated by first responders with defibrillators. Ann Emerg Med, 27:638-648, 1996. Weaver WD, Cobb LA, Hallstrom AP, et al. Considerations for improving survival from outof-hospital cardiac arrest. Ann Emerg Med, 10: 1181-1186, 1986. Eisenberg, M.S., Predicting Survival From Out of Hospital Cardiac Arrest ANN Emergency Med, 1652-1658, 1993. Kudenchuk, P J. Prehospital Treatment of Protracted Ventricular Tachycardia and Ventricular Fibrillation, Continuing Education Home, www.aacn.org Bailey ED, Wydro GC, Cone DC. Termination of resuscitation in the prehospital setting for adult patients suffering nontraumatic cardiac arrest. National Association of EMS Physicians Standards and Clinical Practice Committee. Prehosp Emerg Care, 4:190-5, 2000. Eisenberg MS, Horwood BT, Cummins RO, et al. Cardiac arrest and resuscitation: a tale of 29 cities. Ann Emerg Med, 19:179-186, 1990. Engdahl J, Holmberg M, Karlson BW, Luepker R, Herlitz J. The epidemiology of out-of-hospital ‘sudden’ cardiac arrest, Resuscitation, 52:23545, 2002. Waalewijn RA, Nijpels MA, Tijssen JG, Koster RW. Prevention of deterioration of ventricular fibrillation by basic life support during out-ofhospital cardiac arrest, Resuscitation, 54:31-6, 2002. Holmberg M, Holmberg S, Herlitz J. Incidence, 89


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

17.

18.

19.

20.

90

duration and survival of ventricular fibrillation in out-of-hospital cardiac arrest patients in Sweden, Resuscitation, 44:7-17, 2000. Kuisma M, Maatta T. Out-of-hospital cardiac arrests in Helsinki: Utstein style, Heart, 76:1823, 1996. Pepe PE, Swor RA, Ornato JP, Racht EM, Blanton DM, Griswell JK, Blackwell T, Dunford J; Turtle Creek Conference II. Resuscitation in the out-of-hospital setting: medical futility criteria for on-scene pronouncement of death, Prehosp Emerg Care, 5:79-87, 2001. Hick JL, Mahoney BD, Lappe M. Factors influencing hospital transport of patients in continuing cardiac arrest. Ann Emerg Med, 32:1925, 1998. Kellermann AL, Staves DR, Hackman BB. Inhospital resuscitation following unsuccessful prehospital advanced cardiac life support: ‘heroic efforts’ or an exercise in futility? Ann Emerg Med, 17:589-94, 1988.

Ê. Óõñéáíüò êáé óõí.

21. Van der Hoeven JG, Waanders H, Compier EA, van der Weyden PK, Meinders AE. Prolonged resuscitation efforts for cardiac arrest patients who cannot be resuscitated at the scene: who is likely to benefit? Ann Emerg Med, 22:165963, 1993. 22. Faine PG, Willoughby PJ, Koenigsberg M, Manczko TJ, Ward S. Implementation of an out-ofhospital termination of resuscitation policy. Prehosp Emerg Care, 1:246-52, 1997. 23. Smith JP, Bodai BI. Guidelines for discontinuing prehospital CPR in the emergency department—a review. Ann Emerg Med, 14:1093-98, 1985. 24. Eisenberg M, Hallstrom A, Bergner L. The ACLS score. Predicting survival from out-ofhospital cardiac arrest. JAMA, 246-50, 1981. 25. Holmberg M, Holmberg S, Herlitz J. Factors modifying the effect of bystander cardiopulmonary resuscitation on survival in out-of-hospital cardiac arrest patients in Sweden, Eur Heart J, 22:511-19, 2001.


Ôüìïò 15, Ôåý÷ïò 2, 2003

×. ËéïíÞò êáé óõí.

ÊÅÉÌÅÍÏ ÏÌÏÖÙÍÉÁÓ CONSENSUS REPORT Primary Heatlh Care, Volume 15, Number 2, 91-93, 2003 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 15, Ôåý÷ïò 2, 91-93, 2003

ÂÞìáôá ãéá ôçí áíÜðôõîç êáôåõèõíôÞñéùí ïäçãéþí óôç ÃåíéêÞ ÉáôñéêÞ óôçí ÅëëÜäá: ¸íá êåßìåíï ïìïöùíßáò ×. ËéïíÞò, Í. ÁíôùíÜêçò, Ì. Áíôùíïðïýëïõ, Ó. ÁñãõñéÜäïõ, E. Ãåùñãáêßëá, Í. ÃåùñãéÜííïò, N. ÄñáêùíÜêçò, Å. Èçñáßïò, Ä. ÊïõíáëÜêçò, Ê. ÌáêñÞ, Ã. Ìáíôæáâßíçò, Á. Ìáñéüëçò, Ì. ÌáñêÜêçò, Ì. ÌðáèéáíÜêç, Á Ìðáôßêáò, Ð. ÍéêçôÜêçò, Í. ÐáðáíéêïëÜïõ, Ì. Ñïâßèçò, Á. Ôáôóéþíç, Ì. Ôñiãþíç, É. ÔóéëéãéÜííç, Ì. ×áôæçáñóÝíçò, Á. ×ñéóôïöÝëç

Ïé êáôåõèõíôÞñéåò ïäçãßåò áðïôåëïýí åñãáëåßá ãéá ôç ëÞøç áðïöÜóåùí, ôüóï áðü ôïõò ãéáôñïýò ãéá ôïõò áóèåíåßò ôïõò ùò Üôïìá, üóï êáé áðü Oñãáíéóìïýò êáé ÅðéóôçìïíéêÝò Åôáéñåßåò. ÓçìáíôéêÝò óõæçôÞóåéò ó÷åôéêÜ ìå ôçí áðïôåëåóìáôéêüôçôÜ ôïõò êáé ôç ÷ñçóôéêÞ ôïõò áîßá ðáñïõóéÜæïíôáé óôç äéåèíÞ âéâëéïãñáößá Ïé ïäçãßåò áõôÝò áðáéôïýí óçìáíôéêÞ ðñïóðÜèåéá êáé éó÷õñÝò óõìöùíßåò ãéá íá áíáðôõ÷èïýí êáé íá åöáñìïóôïýí, üðùò õðïóôçñßæåôáé áðü åèíéêÝò êáé ôïðéêÝò ïìÜäåò áíÜðôõîçò êáôåõèõíôÞñéùí ïäçãéþí1-6. Ãéá ôçí áíÜðôõîÞ ôïõò Ý÷ïõí õéïèåôçèåß äýï ðñïóåããßóåéò, ç äçìéïõñãßá åîáñ÷Þò áõôïôåëþí ïäçãéþí Þ ç ÷ñçóéìïðïßçóç ôçò åìðåéñßáò Ïñãáíéóìþí Þ Åôáéñåéþí êáé ôçò ðñïóáñìïãÞ ôïõò óôéò ôïðéêÝò óõíÞèåéåò. Ç ôåëåõôáßá ðñïóÝããéóç öáßíåôáé íá Ý÷åé ìåéùìÝíï êüóôïò óå ðüñïõò êáé ÷ñüíï êáé ðëåïíåêôÞìáôá êáé ìåéïíåêôÞìáôá õðÜñ÷ïõí êáé ãéá ôéò äýï áõôÝò ðñïóåããßóåéò. Ç áíáãêáéüôçôá äçìéïõñãßáò êáôåõèõíôÞñéùí ïäçãéþí êáé óôçí ÅëëÜäá Ý÷åé áíáãíùñéóôåß ôá ôåëåõôáßá ÷ñüíéá êáèþò ç áðÞ÷çóç ôçò åéäéêüôçôáò ôçò ÃåíéêÞò ÉáôñéêÞò äéåõñýíåôáé ôá ôåëåõôáßá ÷ñüíéá. ¸ôóé, îåêßíçóå ìßá óõíåñãáóßá ìåôáîý ôïõ Ïëëáíäéêïý Êïëåãßïõ Ãåíéêþí Ãéáôñþí êáé ìéáò ÏìÜäáò Ðñùôïâïõëßáò ôçò ÊëéíéêÞò ÊïéíùíéêÞò êáé ÏéêïãåíåéáêÞò ÉáôñéêÞò ôïõ Ðáíåðéóôçìßïõ ÊñÞôçò ãéá ôçí ÁíÜðôõîç ÊáôåõèõíôÞñéùí Ïäçãéþí óôçí ÅëëÜäá. Óêïðüò ôçò óõíåñãáóßáò áõôÞò åßíáé ç ÷ñçóéìïðïßçóç ôçò ÏëëáíäéêÞò åìðåéñßáò ãéá ôçí êáèéÝñùóç êáôåõèõíôçñßùí ïäçãéþí ãéá

ôç ÃåíéêÞ ÉáôñéêÞ óôçí ÅëëÜäá. ÌåôÜ ôçí ðñþôç óõíÜíôçóç óôçí ÁèÞíá ôï ÌÜñôéï ôïõ 20017 áêïëïýèçóå ìßá äåýôåñç óõíÜíôçóç óôá ×áíéÜ ôï ÌÜéï ôïõ 2003. Óôç äåýôåñç áõôÞ óõíÜíôçóç, ïé ¸ëëçíåò óõììåôÝ÷ïíôåò óõìöþíçóáí ïìüöùíá ãéá ôç äçìéïõñãßá åíüò ðñùôïêüëëïõ ãéá ôçí áíÜðôõîç êáôåõèõíôÞñéùí ïäçãéþí óôçí ÅëëÜäá. Ôï ðñùôüêïëëï âáóßæåôáé óôçí ÏëëáíäéêÞ åìðåéñßá êáé óõíßóôáôáé áðü 8 âÞìáôá ôá ïðïßá ðåñéãñÜöïíôáé óôï Üñèñï áõôü. Óêïðüò ôïõ êåéìÝíïõ ïìïöùíßáò áõôïý åßíáé íá ðáñïõóéÜóåé ôéò èÝóåéò êáé ôá âÞìáôá Þ äéáäéêáóßåò ðïõ óõæçôÞèçêáí óôçí Åëëçíï-ÏëëáíäéêÞ ÓõíÜíôçóç ôïõ Ìáúïõ 2003, ôá ïðïßá áðïôåëïýí óõã÷ñüíùò êáé ìéá ðñüôáóç óôçí ÅëëçíéêÞ Åôáéñåßá ÃåíéêÞò ÉáôñéêÞò.

ÂÞìáôá/Äéáäéêáóßåò ãéá ôçí áíÜðôõîç êáôåõèõíôÞñéùí ïäçãéþí óôçí ÃåíéêÞ ÉáôñéêÞ óôçí ÅëëÜäá ÂÞìá 1: ÅðéëïãÞ ôïõ êëéíéêïý èÝìáôïò êáé êáèïñéóìüò ôçò óðïõäáéüôçôÜò ôïõ óôç ÃåíéêÞ ÉáôñéêÞ Ç åðéëïãÞ ôïõ èÝìáôïò èá ðñÝðåé íá ãßíåé ìå âÜóç ïñéóìÝíá êñéôÞñéá, ðïõ óõìðåñéëáìâÜíïõí: - ôç âáñýôçôá ôïõ ðñïâëÞìáôïò ìå âÜóç ôïõò åðéäçìéïëïãéêïýò äåßêôåò, - ôç óõ÷íüôçôá ðáñïõóßáò ôïõ ðñïâëÞìáôïò óôï éáôñåßï ôùí ãåíéêþí ãéáôñþí. Ôï ó÷Ýäéï áõôü èá ìðïñïýóå íá áðïôåëÝóåé Ýíá ìÝôñï ãéá ôçí åíßó÷õóç ôçò ðïéüôçôáò êáé ôçí åëÜôôùóç ôùí äéáêõìÜíóåùí óôéò õðçñåóßåò õãåßáò. ºóùò áõôü 91


ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

íá åßíáé Ýíá ó÷Ýäéï ãéá ôï ìÝëëïí. - ôçí åðßäñáóÞ ôïõ óôçí ðïéüôçôá æùÞò ôùí áíèñþðùí ðïõ ðÜó÷ïõí áðü áõôü - ôçí åðßäñáóÞ ôïõ óôï êüóôïò ðïõ äáðáíÜôáé áðü ôéò äïìÝò ãéá ôçí ðñùôïâÜèìéá öñïíôßäá õãåßáò êáé ôá íïóïêïìåßá Ç åðéëïãÞ ôïõ èÝìáôïò èá ðñÝðåé íá ãßíåé áðü ìßá ïñéóìÝíç ïìÜäá ãéá ôï óêïðü áõôü. Ç ïìÜäá áõôÞ ìðïñåß íá áðïôåëåßôáé áðü 2-3 ãåíéêïýò ãéáôñïýò, êáé ç ïðïßá èá Ý÷åé ðñïêýøåé áðü ìßá åõñýôåñç ïìÜäá 20-25 ãåíéêþí ãéáôñþí. Ç åõñýôåñç áõôÞ ïìÜäá èá áðïôåëåßôáé áðü ãåíéêïýò ãéáôñïýò ìå éäéáßôåñï åíäéáöÝñïí óôçí áíÜðôõîç ôùí êáôåõèõíôÞñéùí ïäçãéþí êáèþò åðßóçò êáé áðü ãåíéêïýò ãéáôñïýò – ìÝëç ôïõ äéïéêçôéêïý óõìâïõëßïõ êáé ôùí Åðéôñïðþí ôçò ÅëëçíéêÞò Åôáéñåßáò ÃåíéêÞò ÉáôñéêÞò (ÅËÅÃÅÉÁ). ÂÞìá 2: ÅöáñìïãÞ ìéáò óõóôçìáôéêÞò áíáóêüðçóçò ôçò âéâëéïãñáößáò êáé áíáæÞôçóç ôùí äçìïóéåõìÝíùí êáôåõèõíôÞñéùí ïäçãéþí Ç äéáäéêáóßá ãéá ôçí åíôüðéóç ôùí äçìïóéåõìÝíùí êáôåõèõíôÞñéùí ïäçãéþí èá ðñÝðåé íá ãßíåé áðü 10-15 ãåíéêïýò ãéáôñïýò ïé ïðïßïé èá åßíáé åîïéêåéùìÝíïé ìå ôéò ìåèüäïõò áíáæÞôçóçò óôç âéâëéïãñáößá, ïé ïðïßïé èá ðñï÷ùñÞóïõí óå ìßá óõóôçìáôéêÞ áíáóêüðçóç âáóéóìÝíç ôüóï óå äåäïìÝíá çëåêôñïíéêÞò ìïñöÞò üóï êáé óå äåäïìÝíá ðïõ áíáóýñèçêáí ÷ùñßò çëåêôñïíéêÞ áíáæÞôçóç êáé ìå êáèïñéóìÝíá êñéôÞñéá ãéá ôçí áíáóêüðçóç. Ï óêïðüò áõôïý ôïõ âÞìáôïò èá åßíáé íá åíôïðéóôåß ç äçìïóéåõìÝíç âéâëéïãñáößá, ç ó÷åôéêÞ ìå ôéò êáôåõèõíôÞñéåò ïäçãßåò ðïõ åíäéáöÝñïõí ôç ãåíéêÞ éáôñéêÞ. ÂÞìá 3: Áîéïëüãçóç ôçò ðïéüôçôáò ôùí êáôåõèõíôçñßùí ïäçãéþí ðïõ èá åíôïðéóôïýí Ç áîéïëüãçóç ôçò ðïéüôçôáò ôùí êáôåõèõíôÞñéùí ïäçãéþí èá ðñÝðåé íá ãßíåé áðü 3-4 ãåíéêïýò ãéáôñïýò, ðïõ Ý÷ïõí åêðáéäåõôåß óôç ÷ñÞóç åñãáëåßùí ãéá ôçí áîéïëüãçóç ôçò ðïéüôçôáò êáôåõèõíôÞñéùí ïäçãéþí, ìå ôç ÷ñçóéìïðïßçóç åíüò êáôÜëëçëïõ êáé Ýãêõñïõ åñãáëåßïõ, ôï ïðïßï èá áîéïëïãåß ôçí ðïéüôçôá ôùí êáôåõèõíôçñßùí ïäçãéþí8-12. Ôçí áîéïëüãçóç ôçò ðïéüôçôáò ìéáò êáôåõèõíôÞñéáò ïäçãßáò èá ðñÝðåé íá áêïëïõèÞóåé ç åêôßìçóç ãéá ôï áí áõôÞ ç ïäçãßá åßíáé åöéêôü íá åöáñìïóôåß óôç ãåíéêÞ éáôñéêÞ (feasibility) 92

×. ËéïíÞò êáé óõí.

Ãéá ôï ôåëåõôáßï áõôü óôÜäéï, èá Þôáí óêüðéìç ç áíÜðôõîç åíüò åñãáëåßïõ, ðïõ èá åêôéìÜ áí ìßá êáôåõèõíôÞñéá ïäçãßá åßíáé êáôÜëëçëç ãéá ôç ãåíéêÞ éáôñéêÞ. ÂÞìá 4: ÔïðïèÝôçóç ôùí åðéëåãìÝíùí êáôåõèõíôÞñéùí ïäçãéþí óôá åëëçíéêÜ äåäïìÝíá Åäþ ðåñéëáìâÜíåôáé óõæÞôçóç ðÜíù óôéò åðéëåãìÝíåò êáôåõèõíôÞñéåò ïäçãßåò, ëáìâÜíïíôáò õðüøç ôéò åëëçíéêÝò ôïðéêÝò óõíèÞêåò êáé ôçí êáèçìåñéíÞ ðñáêôéêÞ ãéá ôçí åöáñìïãÞ ôçò êáôåõèõíôÞñéáò ïäçãßáò. Ôï âÞìá áõôü ìðïñåß íá õëïðïéçèåß áðü ôçí ïìÜäá ôçí õðåýèõíç ãéá ôçí õëïðïßçóç ôïõ âÞìáôïò 3. ÂÞìá 5: ÓõæÞôçóç êáé áíÜðôõîç ìéáò åõñýôåñçò óõìöùíßáò ãéá ôç äéÜäïóç ðñáêôéêþí ïäçãéþí ãéá ôçí ÅëëÜäá. Ôï âÞìá áõôü ðåñéëáìâÜíåé ìéá äéáäéêáóßá ïìïöùíßáò ðïõ èá ðñÝðåé íá óõììåôÝ÷ïõí - 2-3 åéäéêåõìÝíïé áðü åéäéêüôçôåò ðïõ áöïñïýí ôï êëéíéêü ðåäßï ôçò êáôåõèõíôÞñéáò ïäçãßáò ðïõ áíáðôýóóåôáé - 3-4 ãåíéêïß ãéáôñïß – ìÝëç ôçò óõíôïíéóôéêÞò ïìÜäáò ãéá ôçí áíÜðôõîç ôçò êáôåõèõíôÞñéáò ïäçãßáò - 2-3 åêðñüóùðïé ôùí éáôñéêþí ïñãáíþóåùí - 2-3 åêðñüóùðïé Üëëùí éáôñéêþí åðáããåëìÜôùí - 2-3 åêðñüóùðïé áðü ôéò ïñãáíþóåéò ôùí áóèåíþí ÂÞìá 6: ¸ãêñéóç ôùí êáôåõèõíôÞñéùí ïäçãéþí Ç Ýãêñéóç ôïõ ôåëéêïý êåéìÝíïõ èá ãßíåôáé áðü ôï Äéïéêçôéêü Óõìâïýëéï ôçò ÅËÅÃÅÉÁ ÂÞìá 7: Äçìïóßåõóç ôùí êáôåõèõíôÞñéùí ïäçãéþí Ïé åãêåêñéìÝíåò êáôåõèõíôÞñéåò ïäçãßåò èá äçìïóéåýïíôáé óôï åëëçíéêü ðåñéïäéêü “ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò”, ôï ïðïßï åêäßäåôáé áðü ôçí ÅëëçíéêÞ Åôáéñåßá ÃåíéêÞò ÉáôñéêÞò. ÂÞìá 8: ÄéÜäïóç ôùí êáôåõèõíôÞñéùí ïäçãéþí Ç äéÜäïóç ôùí äçìïóéåõìÝíùí êáôåõèõíôÞñéùí ïäçãéþí, èá ãßíåé áðü ôçí ÅëëçíéêÞ Åôáéñåßá ÃåíéêÞò ÉáôñéêÞò (ÅËÅÃÅÉÁ) ìÝóù ôùí ôïðéêþí ôçò ôìçìÜôùí óå óõíåñãáóßá ìå ôçí ÏìÜäá ôçò ÊñÞôçò ãéá ôçí Áíáóêüðçóç ôùí ÊáôåõèõíôÞñéùí Ïäçãéþí (Cretan Guidelines Review Group), ðïõ èá ðñÝðåé íá ìåôïíïìáóèåß óå ÅëëçíéêÞ ÏìÜäá Áíáóêüðçóçò ôùí ÊáôåõèõíôÞñéùí Ïäçãéþí (Greek Guidelines Review Group).


Ôüìïò 15, Ôåý÷ïò 2, 2003

×. ËéïíÞò êáé óõí.

Åðßëïãïò Ç êáèéÝñùóç ìéáò äéáäéêáóßáò ãéá ôçí áíÜðôõîç êáôåõèõíôÞñéùí ïäçãéþí áðïôåëåß âáóéêÞ ðñïûðüèåóç ãéá ôç äçìéïõñãßá óõóôÜóåùí ðïõ èá óõìâÜëëïõí óôçí âåëôßùóç ôçò ðïéüôçôáò ôùí õðçñåóéþí óôçí ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò. Ôï êåßìåíï ãéá ôá âÞìáôá áíÜðôõîçò êáôåõèõíôÞñéùí ïäçãéþí óôçí ÅëëÜäá, áíáìÝíåôáé íá ðáñÝîåé ôï ðëáßóéï ãéá ôçí ðëÞñç óõëëïãÞ áíôéêåéìåíéêþí äåäïìÝíùí, ìå óêïðü ôç äçìéïõñãßá êëéíéêþí ðñáêôéêþí ïäçãéþí óôç ãåíéêÞ éáôñéêÞ êáé ôçí ðåñáéôÝñù äéÜäïóç ôïõò. Ôï ðñùôüêïëëï áõôü èá êáôáôåèåß ãéá Ýãêñéóç óôï äéïéêçôéêü óõìâïýëéï ôçò ÅËÅÃÅÉÁ êáé åíôÜóóåôáé óôá ðëáßóéá ôçò óõæÞôçóçò ãéá ôçí äçìéïõñãßá ìéáò ÏìÜäáò Åñãáóßáò (Task Force) ãéá ôç äéá÷åßñéóç ôçò öñïíôßäáò óôçí êáèçìåñéíÞ ðñÜîç. ÌåôÜ ôç ëåéôïõñãßá ôïõ ðñùôïêüëëïõ, ôç äçìéïõñãßá êáé äéÜäïóç ôùí êáôåõèõíôÞñéùí ïäçãéþí, êáèßóôáôáé áíáãêáßá ç áíÜðôõîç åíüò ðëáéóßïõ ãéá ôçí åöáñìïãÞ êáé ôç ÷ñÞóç ôùí ïäçãéþí áõôþí. Óôï ÷þñï ôçò õãåßáò åìöáíßæïíôáé äõóêïëßåò, ðïõ åìðïäßæïõí ðïëëÝò öïñÝò ôéò óõóôÜóåéò êáé ôéò ðñáêôéêÝò ïäçãßåò íá ãßíïõí ðñÜîç13. ¸ôóé öáßíåôáé íá åßíáé áðáñáßôçôï Ýíá ó÷Ýäéï ðïõ: - èá êáèïñßæåé åèíéêïýò óôü÷ïõò êáé èá åíôïðßæåé êïìâéêÝò ðáñåìâÜóåéò ãéá ìßá óõãêåêñéìÝíç õðçñåóßá Þ ïìÜäá öñïíôßäáò - èá áíáðôýóóåé óôñáôçãéêÝò ãéá ôçí õðïóôÞñéîç åöáñìïãÞò ôùí êáôåõèõíôçñßùí ïäçãéþí óõóôÜóåùí, êáé Ðßíáêáò. ÂÞìáôá ãéá ôçí áíÜðôõîç êáôåõèõíôÞñéùí ïäçãéþí ÂÞìá 1: ÅðéëïãÞ ôïõ êëéíéêïý èÝìáôïò êáé êáèïñéóìüò ôçò óðïõäáéüôçôÜò ôïõ óôç ÃåíéêÞ ÉáôñéêÞ ÂÞìá 2: ÅöáñìïãÞ ìéáò óõóôçìáôéêÞò áíáóêüðçóçò ôçò âéâëéïãñáößáò êáé áíáæÞôçóç ôùí äçìïóéåõìÝíùí êáôåõèõíôÞñéùí ïäçãéþí ÂÞìá 3: Áîéïëüãçóç ôçò ðïéüôçôáò ôùí êáôåõèõíôçñßùí ïäçãéþí ðïõ èá åíôïðéóôïýí ÂÞìá 4: ÔïðïèÝôçóç ôùí åðéëåãìÝíùí êáôåõèõíôÞñéùí ïäçãéþí óôá åëëçíéêÜ äåäïìÝíá ÂÞìá 5: ÓõæÞôçóç êáé áíÜðôõîç ìéáò åõñýôåñçò óõìöùíßáò ãéá ôçí äéÜäïóç ôùí ðñáêôéêþí ïäçãéþí ãéá ôçí ÅëëÜäá ÂÞìá 6: ¸ãêñéóç ôùí êáôåõèõíôÞñéùí ïäçãéþí ÂÞìá 7: Äçìïóßåõóç ôùí êáôåõèõíôÞñéùí ïäçãéþí ÂÞìá 8: ÄéÜäïóç ôùí êáôåõèõíôÞñéùí ïäçãéþí

- èá åäñáéþíåé ôñüðïõò ãéá íá äéáóöáëßóïõí ôçí ðñüïäï ìÝóá óå ðñïêáèïñéóìÝíá ÷ñïíéêÜ üñéá

Âéâëéïãñáößá 1. National Guideline Clearinghouse, United States: -http//www.guideline.gov./index.asp. 2. National Health and Medical Research Council (NHMRC), Australia: http://www.health.gov.au/ hfs/nhmrc 3. Dutch College of General Practitioners, The Netherlands: http://www.artsen.net. 4. New Zealand Guidelines Group (NZGG),New Zealand: http://www.nzgg.org.nz. 5. Scottish Intercollegiate Network (SIGN), Scotland: http://www.show.scot.nhs.uk/sign/ index.html: 6. Guidelines Advisory Committee, Canada: http:/ /www.gacguidelines.ca. 7. ËéïíÞò ×, Ôáôóéþíç Á, Heurberger P., MuijdenKarssen E van, H van der Schaaf, ÐáðáæÞóçò Ç., ÄÜóêïò Ã, ÌïíÝäáò É, ÊïõíáëÜêçò Ä, ÔæáãêáñÜêçò Ä, ÔóéëéãéÜííç É, Ôóéôßíç Å. ÊáôåõèõíôÞñéåò ïäçãßåò óôçí ðñùôïâÜèìéá öñïíôßäá õãåßáò: Ýíá êåßìåíï âáóéóìÝíï óôç óõíÜíôçóç åñãáóßáò ÅëëÞíùí êáé Ïëëáíäþí åñåõíçôþí êáé ãåíéêþí ãéáôñþí. ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, 13:214-21, 2001. 8. Lohr KN, Field MJ. A provisional instrument for assessing clinical practice guidelines. In: Field MJ, Lohr KN (eds). Guidelines for clinical practice. From development to use. Washington D.C. National Academy Press, 1992. 9. Cluzeau F, Littlejohns P, Grimshaw J, Feder G, Moran S. Development and application of a generic methodology to assess the quality of clinical guidelines. International Journal for Quality in Health Care, 11:21-28, 1999. 10. Grol R, Dalhuijzen J, Mokkink H, Thomas S, Veld C, Rutten G. Attributes of clinical guidelines that influence use of guidelines in general practice: observational study BMJ, 317:858861, 1998. 11. Lohr KN. The quality of practice guidelines and the quality of health care. In: Guidelines in health care. Report of a WHO Conference. January 1997, Baden-Baden: Nomos Verlagsgesellschaft 1998. 12. Appraisal of Guidelines Research and Evaluation (AGREE), http://www.agreecollaboration.org

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ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

Å.A. Èçñáßïò

ÁÍÔÁÐÏÊÑÉÓÇ ÁÐÏ ÔÇÍ ÊÑÇÔÇ CORRESPONDENCE FROM CRETE Primary Heatlh Care, Volume 15, Number 2, 94-95, 2003 ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 15, Ôåý÷ïò 2, 94-95, 2003

2ç Åëëçíï-ÏëëáíäéêÞ ÓõíÜíôçóç ãéá ôéò ÊáôåõèõíôÞñéåò Ïäçãßåò óôç ÃåíéêÞ ÉáôñéêÞ Ôïí ÌÜéï ôïõ 2001 ðñáãìáôïðïéÞèçêå óôçí ÁèÞíá ç ðñþôç óõíÜíôçóç óõíåñãáóßáò ìåôáîý ÅëëÞíùí êáé Ïëëáíäþí åñåõíçôþí êáé ãåíéêþí éáôñþí, ç ïðïßá åß÷å ùò óêïðü ôç óõæÞôçóç êáé áíôáëëáãÞ ãíþóåùí êáé åìðåéñéþí üóïí áöïñÜ óôçí áíÜðôõîç, åöáñìïãÞ êáé áîéïëüãçóç ôùí êáôåõèõíôçñßùí ãñáììþí (Guidelines) óôç ÃåíéêÞ ÉáôñéêÞ. Ôá óõìðåñÜóìáôá áõôÞò ôçò óõíÜíôçóçò ðáñïõóéÜóôçêáí óå ó÷åôéêÞ äçìïóßåõóç óôï ðåñéïäéêü “ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò”1. Ç äåýôåñç Åëëçíï-ÏëëáíäéêÞ óõíÜíôçóç åñãáóßáò ðñáãìáôïðïéÞèçêå óôçí ÊñÞôç áðü 24 Ýùò 28 ÌáÀïõ óôï îåíïäï÷åßï Santa Marina óôá ×áíéÜ. Ïñãáíþèçêå áðü ôçí ÊëéíéêÞ ÊïéíùíéêÞò êáé ÏéêïãåíåéáêÞò ÉáôñéêÞò ôïõ Ðáíåðéóôçìßïõ ÊñÞôçò, óå óõíåñãáóßá ìå ôçí ÅëëçíéêÞ Åôáéñåßá ÃåíéêÞò ÉáôñéêÞò êáé ôï Ïëëáíäéêü ÊïëÝãéï Ãåíéêþí Éáôñþí, åíþ ç üëç åêäÞëùóç ôåëïýóå õðü ôçí áéãßäá ôïõ ÐåÓÕÐ ÊñÞôçò. Óõììåôåß÷áí óõíïëéêÜ 17 Ïëëáíäïß êáé 20 ¸ëëçíåò ãåíéêïß éáôñïß êáé åñåõíçôÝò. Ôçí ðñþôç çìÝñá ôçò óõíÜíôçóçò Ýãéíáí ïé åíáñêôÞñéåò ïìéëßåò. Ï ê. ×. ËéïíÞò, ÁíáðëçñùôÞò ÊáèçãçôÞò ôïõ Ðáíåðéóôçìßïõ ÊñÞôçò êáé ÁíáðëçñùôÞò Ãåíéêüò ÄéåõèõíôÞò ôïõ Ðå.Ó.Õ.Ð. ÊñÞôçò óôçí äéêÞ ôïõ åéóÞãçóç áíáöÝñèçêå óôéò óôñáôçãéêÝò áíÜðôõîçò ôùí êáôåõèõíôçñßùí ïäçãéþí êáé ðáñïõóßáóå ôçí åëëçíéêÞ åìðåéñßá. Ï ê. Á. ÖéëáëÞèçò, ÁíáðëçñùôÞò ÊáèçãçôÞò ôïõ Ðáíåðéóôçìßïõ ÊñÞôçò êáé Ä/íôÞò ôçò ÊëéíéêÞò ÊïéíùíéêÞò êáé ÏéêïãåíåéáêÞò ÉáôñéêÞò Ýêáíå ìéá ðáñïõóßáóç ôïõ ÓõóôÞìáôïò ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò óôçí ÅëëÜäá, åíþ ï ê. Paul Heuberger Ýêáíå ìéá áíáöïñÜ óôçí ÏëëáíäéêÞ åìðåéñßá ó÷åôéêÜ ìå ôç äéáìüñöùóç êáôåõèõíôçñßùí ïäçãéþí êáé standards. Ôçí åêäÞëùóç ÷áéñÝôéóå 94

ï ÄéïéêçôÞò ôïõ Ãåíéêïý Íïóïêïìåßïõ ×áíßùí ê. ×. ÄïõëãåñÜêçò. Ç ÓõíÜíôçóç Åñãáóßáò ðåñéåëÜìâáíå ðáñÜëëçëåò óõíåäñéÜóåéò ôùí äýï åñåõíçôéêþí ïìÜäùí (Workshops) ðïõ åðåîåñãÜóôçêáí ôá èÝìáôá ôçò êáñäéáêÞò áíåðÜñêåéáò êáé ôïõ óáê÷áñþäïõò äéáâÞôç, êïéíÝò óõíåäñéÜóåéò üðïõ ðáñïõóéÜóôçêáí ôá óõìðåñÜóìáôá ôçò åñãáóßáò ôùí ïìÜäùí êáé åíôïðßóôçêáí ïé äéáöïñÝò êáé ïé ïìïéüôçôåò óôç äéá÷åßñéóç áõôþí ôùí íïóçìÜôùí êáé äéáëÝîåéò áðü óõììåôÝ÷ïíôåò åñåõíçôÝò. Ïé äéáëÝîåéò ôùí ÅëëÞíùí ïìéëçôþí áöïñïýóáí ôç äéá÷åßñéóç ôçò êáôÜèëéøçò (ïìéëÞôñéá ç êá ÓôÝëëá ÁñãõñéÜäïõ), ôç äéá÷åßñéóç áóèåíþí ìå áõîçìÝíï êßíäõíï óôåöáíéáßáò íüóïõ (ïìéëçôÞò ï ê. ÅëåõèÝñéïò Èçñáßïò), ôçí ðáñïõóßáóç åíüò åñåõíçôéêïý ðñùôïêüëëïõ ãéá ôçí êáñäéáêÞ áíåðÜñêåéá áðü ôïí ê. ÌÜñéï ×áôæçáñóÝíç, ôç óõíôáãïãñáößá öáñìÜêùí (ïìéëçôÞò ï ê. Íßêïò ÁíôùíÜêçò), åíþ éäéáßôåñï åíäéáöÝñïí åß÷å ç åéóÞãçóç ôùí ×. ËéïíÞ êáé ÁèçíÜò Ôáôóéþíç ìå èÝìá ôçí åêôßìçóç ôçò ðïéüôçôáò ôùí êáôåõèõíôçñßùí ïäçãéþí. Ïé äéáëÝîåéò ôùí Ïëëáíäþí åñåõíçôþí áöïñïýóáí ôï ðñüâëçìá ôçò åîÜñôçóçò áðü ïõóßåò êáé éäéáßôåñá ôï áëêïüë (åéóçãÞôñéá ç êá Marijke Nielsen) êáé ôçí åðßäñáóç ôçò äéáöïñåôéêüôçôáò ôçò êïõëôïýñáò óôçí áíÜðôõîç ôùí êáôåõèõíôçñßùí ïäçãéþí (åéóçãçôÞò ï ê. Hans van der Schaaf). Ôï ðñüãñáììá ôçò ÓõíÜíôçóçò Åñãáóßáò ïëïêëçñþèçêå ìå ôçí åðßóêåøç ôùí Ïëëáíäþí åñåõíçôþí óôï ÊÝíôñï Õãåßáò ÊáíäÜíïõ ×áíßùí. Ãéá ôçí áíÜðôõîç ôùí êáôåõèõíôçñßùí ïäçãéþí Ý÷ïõí õéïèåôçèåß äýï óôñáôçãéêÝò, ç äçìéïõñãßá åîáñ÷Þò áõôïôåëþí ïäçãéþí Þ ç ÷ñçóéìïðïßçóç ôçò åìðåéñßáò Ïñãáíéóìþí Þ Åôáéñåéþí


Ôüìïò 15, Ôåý÷ïò 2, 2003

Å.A. Èçñáßïò

êáé ç ðñïóáñìïãÞ ôïõò óôéò ôïðéêÝò óõíÞèåéåò. Óôá ðëáßóéá ôçò ôåëåõôáßáò óôñáôçãéêÞò åíôÜóóåôáé êáé áõôÞ ç Åëëçíï-ÏëëáíäéêÞ ÓõíÜíôçóç Åñãáóßáò. Óôá èåôéêÜ áðïôåëÝóìáôá áõôÞò íá óôáèïýìå éäéáßôåñá óôçí óõìöùíßá ôùí ÅëëÞíùí óõììåôå÷üíôùí ãéá ôç äçìéïõñãßá åíüò ðñùôïêüëëïõ ãéá ôçí áíÜðôõîç êáôåõèõíôÞñéùí ïäçãéþí óôçí ÅëëÜäá, óôï ïðïßï èá ðáñïõóéÜæïíôáé ïé èÝóåéò êáé ôá âÞìáôá Þ äéáäéêáóßåò ðïõ óõæçôÞèçêáí óôç óõíÜíôçóç, ôá ïðïßá áðïôåëïýí óõã÷ñüíùò êáé ðñüôáóç óôçí ÅëëçíéêÞ Åôáéñåßá ÃåíéêÞò ÉáôñéêÞò. ÅëåõèÝñéïò Èçñáßïò Ãåíéêüò Éáôñüò

Âéâëéïãñáößá 1. ËéïíÞò ×., Ôáôóéþíç Á., Heuberger P., Van Muijden-Karssen E., Van der Schaaf H., ÐáðáæÞóçò Ç., ÄÜóêïò Ã., ÌïíÝäáò É., ÊïõíáëÜêçò Ä., ÔæáãêáñÜêçò Å., ÔóéëéãéÜííç É., Ôóéôßíç Å. ÊáôåõèõíôÞñéåò ïäçãßåò óôçí ðñùôïâÜèìéá öñïíôßäá õãåßáò: Ýíá êåßìåíï âáóéóìÝíï óôç óõíÜíôçóç åñãáóßáò ÅëëÞíùí êáé Ïëëáíäþí åñåõíçôþí êáé ãåíéêþí éáôñþí. ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, 13:214-221, 2001

´ ÐåÓÕÐ ÁÔÔÉÊÇÓ ÃÅÍÉÊÏ ÍÏÓÏÊÏÌÅÉÏ ÁÈÇÍÙÍ "Ã. ÃÅÍÍÇÌÁÔÁÓ" ÊÅÍÔÑÏ ÅÐÁÃÃÅËÌÁÔÉÊÇÓ ÊÁÔÁÑÔÉÓÇÓ ÐÑÏÓÊËÇÓÇ ÅÊÄÇËÙÓÇÓ ÅÍÄÉÁÖÅÑÏÍÔÏÓ Ãíùóôïðïéåßôáé üôé óôï ÊÝíôñï ÅðáããåëìáôéêÞò ÊáôÜñôéóçò ôïõ Ã.Í. Áèçíþí "Ã. ÃÅÍÍÇÌÁÔÁÓ" áðü 8.9.2003 ìÝ÷ñé 20.10.2003 èá õëïðïéçèåß åðéäïôïýìåíï ðñüãñáììá åðáããåëìáôéêÞò êáôÜñôéóçò 200 ùñþí, ãéá 25 åñãáæüìåíïõò, Éáôñéêü Ðñïóùðéêü ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò, ôùí Íïóïêïìåßùí, Ê.Õ., Ðåñ. Éáôñåßùí, ôïõ ÅÓÕ, ÅÊÁÂ, ÐåÓÕÐ êáé Õ.Õ.Ð. ìå ôßôëï "Åêðáßäåõóç Êëéíéêþí Åêðáéäåõôþí" êáé Êùä. ÅíÝñãåéáò Õ.02 - Õ.04 - ÕÅ/Å 302. Ôï ðñüãñáììá èá õëïðïéçèåß óôï ðëáßóéï ôïõ Å.Ð. "ÕÃÅÉÁ - ÐÑÏÍÏÉÁ" 2000-2006 ôïõ Ã' ÊÐÓ, ìå óõã÷ñçìáôïäïôÞóåé êáôÜ 75% ôïõ Åõñùðáúêïý Êïéíïôéêïý Ôáìåßïõ êáé 25% ôïõ Åëëçíéêïý Äçìïóßïõ. Êáëïýíôáé ïé åíäéáöåñüìåíïé íá õðïâÜëïõí ìÝ÷ñé êáé ôçí 25.8.2003 áßôçóç óõììåôï÷Þò ãéá ôï ðñüãñáììá óôï ÊÝíôñï ÅðáããåëìáôéêÞò ÊáôÜñôéóçò ôïõ Ã.Í. Áèçíþí "Ã. ÃÅÍÍÇÌÁÔÁÓ", Ôá÷. Ä/íóç Ìåóïãåßùí 154 Ô.Ê. 115 27. Ï ÄéïéêçôÞò ÁËÅÎÁÍÄÑÏÓ ×ÏËÅÂÁÓ

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

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68 Å. ÂåêñÞ, ×. Ëçîïõñéþôçò, Á. Ìáñéüëçò, Å. ÌåóóÜñçò, Í. ÐáñáñÜò, Â. Âïõãéïýêáò, Æ. ÁëìÜæ, Á. Ìïíáóôçñéþôçò, Í. Áëåîáíäñüðïõëïò, Á. ÌïõëáêÜ...