Πρωτοβάθμια Φροντίδα Υγείας

öñïíôßäáPrimary Health Care

ðñùôïâÜèìéáðñùôïâÜèìéáöñïíôßäáõãåßáòõãåßáò

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Ôñéìçíéáßá ̧ êäïóç ôçò ÅëëçíéêÞò Åôáéñåßáò ÃåíéêÞò ÉáôñéêÞò

Quarterly edited by the Greek Association of General Practitioners

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

Cited in Index CopernicusRecognised by the Greek Ministry of Health and Welfare

ISSN 1105-7432

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Ôçò Óýíôáîçò

54 Á. Ìáñéüëçò, ×. ËéïíÞò: 16ï ÐáíåëëÞíéï ÓõíÝäñéï ÃåíéêÞò ÉáôñéêÞò:Áöåôçñßá ãéá ìéá íÝá åðï÷Þ óôç ÃåíéêÞ ÉáôñéêÞ;

Âñáâåõèåßóá Åñãáóßá óôï Äéáãùíéóìü "Ä. ºêêïõ"

56 Á. ÂÞôáò, ×. Óåìåñôæßäçò, Åõáããåëßá ÍåñáíôæÜêç: ÄéÜãíùóç ôçò åëÜóóïíïòâ-èáëáóóáíáéìßáò áðü ôïõò äåßêôåò ôùí åñõèñþí áéìïóöáéñßùí ôïõ áßìáôïò

Âñáâåõèåßóåò Åëåýèåñåò Áíáêïéíþóåéò

62 É. ÄñõãéáííÜêçò, Á. Ëáëéþôçò, Á. Ìåëéäïíéþôçò, Êáëëéüðç Óôåöáíïðïýëïõ,Ä. ÄñõãéáííÜêçò, Í. ÐáðáäÜêçò, Á. Ìðáôßêáò: Ç åêôßìçóç ôçò ïñèÞòóõíôáãïãñÜöçóçò áíôáãùíéóôþí ôùí õðïäï÷Ýùí-2 éóôáìßíçò (Ç2-RAs)êáé áíôáãùíéóôþí ôçò áíôëßáò ðñùôïíßùí (PPIs) óôçí ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

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

87 Ê. Óïõëéþôçò, Á. Ìáñéüëçò: Ç äéáìüñöùóç åíüò ÏëïêëçñùìÝíïõ ÓõóôÞìáôïòÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò óôçí ÅëëÜäá

Áíáóêüðçóç

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

öñïíôßäáðñùôïâÜèìéáðñùôïâÜèìéá

õãåßáòõãåßáòISSN 1105-7432

ÅÊÄÏÔÇÓ:ÌðïäïóÜêçò-Ðñüäñïìïò ÌåñêïýñçòÌ. ×ïõñìïýæç 28 Ê. Ôïýìðá544 53 ÈåóóáëïíßêçÔçë. (2310) 910342

Primary Health Care

öñïíôßäá

ÄéåõèõíôÞò Óýíôáîçò

×ñÞóôïò ËéïíÞòAíáðëçñùôÞò ÊáèçãçôÞò

ÔìÞìá ÉáôñéêÞòÐáíåðéóôÞìéï ÊñÞôçòÔ.È. 2208, ÇñÜêëåéïÔçë. (2810) 394621Fax. (2810) 394606

E-mail: [email protected]

ÁíáðëçñùôÝò Ä/íôÝò Óýíôáîçò

Íßêïò ÁíôùíÜêçò (ÇñÜêëåéï)ÅëåõèÝñéïò Èçñáßïò (ÁèÞíá)

Åðßêïõñïé Ä/íôÝò Óýíôáîçò

ÈùìÜò Áããåëüðïõëïò (Èåóóáëïíßêç)Ðáýëïò ÈåïäùñÜêçò (ÉùÜííéíá)

Êïñíçëßá ÌáêñÞ (ÇñÜêëåéï)ÁíÜñãõñoò Ìáñéüëçò (ÁèÞíá)

ÌÝëç ÓõíôáêôéêÞò ÅðéôñïðÞò

ÓôÝëéïò ÅõáããÝëïõ (ÁèÞíá)ÃéÜííçò ÌïíÝäáò (KÝñêõñá)

Íßêïò ÐáðáíéêïëÜïõ (ÊáñðåíÞóé)ÐçãÞ ÐåñäéêÜêç (´Áóôñïò)ÁèçíÜ Ôáôóéþíç (ÉùÜííéíá)×ñýóá ×áôæüãëïõ (ËÜñéóá)

Áíáóôáóßá ×ñéóôïöÝëç (Áëßáñôïò)¸öç Öñáãêïýëç (ËÞìíïò)

ÁíôáðïêñéôÝò Óýíôáîçò

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

ÓõìâïõëåõôéêÞ ÅðéôñïðÞ

Ð. ÂÜñäáò,ÊáèçãçôÞò Êáñäéïëïãßáò Ðáí/ìßïõ ÊñÞôçò

Ä. ÃëÜñïò,ÊáèçãçôÞò ÉáôñéêÞò ÖõóéêÞò Ðáí/ìßïõ Éùáííßíùí

É. Êõñéüðïõëïò,ÊáèçãçôÞò ÅèíéêÞò Ó÷ïëÞò Äçìüóéáò Õãåßáò

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

M. ÓãÜíôæïò,ËÝêôïñáò Áíáôïìßáò Ðáí/ìßïõ Èåóóáëßáò

K. Óéáìüðïõëïò,ÊáèçãçôÞò Íåöñïëïãßáò Ðáí/ìßïõ Éùáííßíùí

Í. ÓéáöÜêáò,ÊáèçãçôÞò Ðíåõìïíïëïãßáò Ðáí/ìßïõ ÊñÞôçò

K. ÓïõëéþôçòÄéäÜêôùñ Ïéêïíïìéêþí êáé ÐïëéôéêÞò Õãåßáò

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

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

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

Editor-in-Chief

Christos LionisÁssociate ProfessorFaculty of MedicineUniversity of Crete

P.O. Box 2208, HeraklioTel: +30 2810 394621Fax: +30 2810 394606

E-mail: [email protected]

Associate Editors

Nick Antonakis (Heraklio)Åleftherios Thireos (Athens)

Assistant Editors

Thomas Aggelopoulos (Thessaloniki)Pavlos Theodorakis (Ioannina)

Kornilia Makri (Heraklio)Anargiros Mariolis (Athens)

Members of Editorial Board

Stelios Evagelou (Athens)Ioannis Monedas (Corfu)

Nikos Papanikolau (Êarpenisi)Pigi Perdikaki (Astros)Atina Tatsioni (Ioannina)

Chrysa Chatzoglou (Larissa)Anastasia Christofeli (Aliartos)

Efi Fragouli (Limnos)

Corresponding Editors

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

Advisory Board

P. Vardas,Professor of University of Crete

D. Glaros,Professor of University of Ioannina

J. Kyriopoulos,Professor of National School of Public Health

V. Mavreas,Professor of University of Ioannina

M. Sgantzos,Lector of Anatomy in University of Thessalia

K. Siamopoulos,Professor of University of Ioannina

N. Siafakas,Professor of University of Crete

K. Souliotis,PhD, Health Policy and Economics

L. Sparos,Åmeritus Professor of University of Athens

A. Philalithis,Associate Professor of University of Crete

G. Christodoulou,Professor of University of Athens

Äéïéêçôéêü Óõìâïýëéïôçò ÅëëçíéêÞò Åôáéñåßáò

ÃåíéêÞò ÉáôñéêÞò

ÐñüåäñïòÌðïäïóÜêçò-ÐñüäñïìïòÌåñêïýñçò

Áíôéðñüåäñïò Á×ñÞóôïò ËéoíÞò

Áíôéðñüåäñïò ÂÁíôþíçò Êáñüôóçò

Ãåíéêüò ÃñáììáôÝáò-ÔáìßáòÁèáíÜóéïò Óõìåùíßäçò

Åéäéêüò ÃñáììáôÝáòÓôÝëëá ÁñãõñéÜäïõ

ÌÝëçÁíÜñãõñïò ÌáñéüëçòÁíôþíçò Ìðáôßêáò

Executive Boardof the Greek Associationof General Practitioners

PresidentBodosakis-ProdromosMerkouris

Vice-President AChristos Lionis

Vice-President BAntonis Karotsis

General SecretaryTreasurerAthanasios Symeonidis

Special SecretaryStella Argiriadou

MembersAnargiros MariolisAntonis Batikas

Åêôýðùóç:

ÔÅ×ÍÏÃÑÁÌÌÁÌ. ÁõãÝñç 12, 15343 Áã. ÐáñáóêåõÞÔçë.: 210.60.00.643, Fax: 210.6002295E-mail: [email protected]

Ãñáììáôåßá Óýíôáîçò:

Áíáóôáóßá ÑùìáíßäïõÔçë.: (2810) 394615, (28310) 25833e-mail: [email protected]

öñïíôßäáPrimary Health Care

ðñùôïâÜèìéáðñùôïâÜèìéáöñïíôßäáõãåßáòõãåßáò

ÐÅÑÉÅ×ÏÌÅÍÁ

Ôçò Óýíôáîçò

Á. Ìáñéüëçò, ×. ËéïíÞò: 16ï ÐáíåëëÞíéï ÓõíÝäñéï ÃåíéêÞò ÉáôñéêÞò:Áöåôçñßá ãéá ìéá íÝá åðï÷Þ óôç ÃåíéêÞ ÉáôñéêÞ; ................................................................................................................................................................ 54

Âñáâåõèåßóá Åñãáóßá óôï Äéáãùíéóìü "Ä. ºêêïõ"

Á. ÂÞôáò, ×. Óåìåñôæßäçò, Åõáããåëßá ÍåñáíôæÜêç: ÄéÜãíùóç ôçò åëÜóóïíïò â-èáëáóóáíáéìßáòáðü ôïõò äåßêôåò ôùí åñõèñþí áéìïóöáéñßùí ôïõ áßìáôïò ......................................................................................................................................... 56

Âñáâåõèåßóåò Åëåýèåñåò Áíáêïéíþóåéò

É. ÄñõãéáííÜêçò, Á. Ëáëéþôçò, Á. Ìåëéäïíéþôçò, Êáëëéüðç Óôåöáíïðïýëïõ, Ä. ÄñõãéáííÜêçò, Í. ÐáðáäÜêçò,Á. Ìðáôßêáò: Ç åêôßìçóç ôçò ïñèÞò óõíôáãïãñÜöçóçò áíôáãùíéóôþí ôùí õðïäï÷Ýùí-2 éóôáìßíçò (Ç2-RAs)êáé áíôáãùíéóôþí ôçò áíôëßáò ðñùôïíßùí (PPIs) óôçí ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò. ........................................................................ 62

Ê. Óõñéáíüò, Âéêôùñßá ËÝôôá, ÊëåïðÜôñá ÊïõñÜêç, ÄÞìçôñá ÊáêëáìÜíïõ-Âñåôôïý:Ïé áíáêñßâåéåò óôçí ðéóôïðïßçóç ôçò áéôßáò èáíÜôïõ .................................................................................................................................................... 80

Ê. Óïõëéþôçò, Á. Ìáñéüëçò: Ç äéáìüñöùóç åíüò ÏëïêëçñùìÝíïõ ÓõóôÞìáôïò ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáòóôçí ÅëëÜäá ................................................................................................................................................................................................................................................. 87

ÁíáóêïðÞóç

ÁèçíÜ Ñüäç, Ðáíáãéþôá ÓïõñôæÞ, Å. ÂåëïíÜêçò: Ç ÷ñçóéìüôçôá ôçò óôáôéóôéêÞò åðåîåñãáóßáòôùí Ðéóôïðïéçôéêþí ÈáíÜôïõ óôçí åêðüíçóç ìåëåôþí èíçóéìüôçôáò ................................................................................................................ 94

CONTENTS

Editorial

A. Mariolis, C. Lionis: 16th National Congress of General Practice: Is it a staring point? ....................................................................... 54

Awarded Paper in the Memory of Prof. “D. Ikkos”

A. Vitas, C. Semertzidis, Evaggelia Nerantzaki: Diagnosis of heterozygous (minor) beta-thalassemia basedon blood erythrocyte indexes ............................................................................................................................................................................................................ 56

Awarded Freestanding Papers

I. Drygiannakis, A. Laliotis, A. Melidoniotis, Kalliopi Stefanopoulou, D. Drygiannakis, N. Papadakis, A. Batikas:Assessing rational prescription of histamine-2 receptor antagonists (Ç2-RAs) and proton pump inhibitors (PPIs)in Primary Health Care .......................................................................................................................................................................................................................... 62

K. Syrianos, Victoria Letta, Kleopatra Kouraki, Dimitra Kaklamanou-Vrettou: The inaccuracies in the certificationof cause of death ...................................................................................................................................................................................................................................... 80

K. Souliotis, A. Mariolis: The development of an Intergrading Primary Health Care System in Greece ......................................... 87

Review

Athina Rodi, Panagiota Sourtzi, E. Velonakis: The importance of Death Certificate�s in the mortality statistics ..................... 94

Ôñéìçíéáßá ̧ êäïóç ôçò ÅëëçíéêÞò Åôáéñåßáò ÃåíéêÞò ÉáôñéêÞò

Quarterly edited by the Greek Association of General Practitioners

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

ÁÍÁÓÊÏÐÇÓÇ

REVIEW

ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

54

Á. Ìáñéüëçò, ×. ËéïíÞò

THÓ ÓÕÍÔÁÎÇÓ

ÅDITORIALPrimary Heatlh Care, Volume 16, Number 2, 54-55, 2004ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 16, Ôåý÷ïò 2, 54-55, 2004

16ï ÐáíåëëÞíéï ÓõíÝäñéï ÃåíéêÞò ÉáôñéêÞò:Áöåôçñßá ãéá ìéá íÝá åðï÷Þ óôç ÃåíéêÞ ÉáôñéêÞ;

Ôï ÅôÞóéï ÓõíÝäñéï ôçò ÅëëçíéêÞò ÅôáéñåßáòÃåíéêÞò ÉáôñéêÞò áðïôåëåß åäþ êáé äåêáÝîé ÷ñü-íéá Ýíá óçìáíôéêü óôáèìü ãéá ôçí êïéíïðïßçóçôùí èÝóåùí ôçò ÅËÅÃÅÉÁ ãéá ôçí åêðáßäåõóç,ôçí Ýñåõíá, ôçí ðïéüôçôá ôùí õðçñåóéþí óôïðåäßï ôçò ÃåíéêÞò/ÏéêïãåíåéáêÞò ÉáôñéêÞò, áëëÜêáé ôç óõæÞôçóç ôùí óçìáíôéêüôåñùí åîåëßîåùíóôçí Åõñþðç êáé ôïí êüóìï.

Ôï 16ï ÐáíåëëÞíéï ÓõíÝäñéï ÃåíéêÞò Éáôñé-êÞò ðñáãìáôïðïéÞèçêå óôçí Êù, óôï Óõíåäñéá-êü ÊÝíôñï “KICC” áðü 14 ùò 18 Áðñéëßïõ 2004,êáé ôéò åñãáóßåò ôïõ ðáñáêïëïýèçóáí ðÜíù áðü1350 óýíåäñïé áðü üëç ôçí ÅëëÜäá, ìå ìåãÜëçóõììåôï÷Þ ôüóï åéäéêåõìÝíùí üóï êáé åéäéêåõïìÝ-íùí éáôñþí ÃåíéêÞò ÉáôñéêÞò, êáèþò êáé éáôñþíÜëëùí åéäéêïôÞôùí. Ôçí Ýíáñîç ôïõ óõíåäñßïõêÞñõîå ï Õðïõñãüò Õãåßáò êáé ÊïéíùíéêÞò Áëëç-ëåããýçò ê. Í. ÊáêëáìÜíçò, óõììåôÝ÷ïíôáò ó’ Ýíáóôñïããõëü ôñáðÝæé, ôï ïðïßï õðïãñÜììéóå ôïíóçìáíôéêü ñüëï ôïõ Ãåíéêïý Éáôñïý óôçí åäñáßù-óç ôçò ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò óôç ÷þñáìáò.

Ðïéü Þôáí ôï êáéíïýñãéï ôïõ Óõíåäñßïõ áõ-ôïý, åêôüò áðü ôï ðëïýóéï åðéóôçìïíéêü ðñü-ãñáììá ðïõ ðåñéåëÜìâáíå 15 óôñïããõëÝò ôñÜðå-æåò, 8 äéáëÝîåéò, 5 êëéíéêÜ öñïíôéóôÞñéá, 3 óõíá-íôÞóåéò ìå ôïí åéäéêü, êáèþò åðßóçò êáé 514 áíá-êïéíþóåéò åñãáóéþí (353 åëåýèåñåò – 161 áíáñ-ôçìÝíåò);

ÁñêåôÝò êáéíïôïìßåò ðïõ åéóÞ÷èçêáí óôïöåôéíü óõíÝäñéï óêéáãñáöïýí ôç ìåôÜâáóÞ ôïõóå ìéá íÝá åðï÷Þ. Ç ïñãÜíùóç óõæçôÞóåùí õðüìïñöÞ óôñïããõëþí ôñáðåæéþí óå åðßêáéñá èÝìá-ôá, üðùò ç “ÄéïéêçôéêÞ êáé ïñãáíùôéêÞ áõôïôÝ-ëåéá êáé áõôïäõíáìßá ôùí ÊÝíôñùí Õãåßáò”, ï“ÍÝïò åõñùðáúêüò ïñéóìüò ôçò ÃåíéêÞò/Ïéêïãå-íåéáêÞò ÉáôñéêÞò. ÁëëÜæåé êÜôé;” áëëÜ êáé ç ðá-

ñïõóßáóç óçìáíôéêþí óõíåñãáóéþí óå äéåèíÝòåðßðåäï, üðùò áõôÞ ìå ôçí ÔïõñêéêÞ ÅôáéñåßáÃåíéêÞò ÉáôñéêÞò ìå èÝìá “Towards to the devel-opment of a mutual collaboration between Greekand Turkish general practice/family medicine:The first experiences learnt”, äéåýñõíáí ôï èå-ìáôéêü ðåäßï ôïõ Óõíåäñßïõ êáé áíÝäåéîáí ôéòäõíáôüôçôÝò ôïõ óôç óõæÞôçóç ôïõ íÝïõ. Ç ïñ-ãÜíùóç êëéíéêþí öñïíôéóôçñßùí ðïõ êÜëõøáíäõíáôüôçôåò Ýêèåóçò êáé åêðáßäåõóçò ôùí óõíÝ-äñùí óå êëéíéêÜ áíôéêåßìåíá, ãéá ôçí áðüêôçóçü÷é ìüíï ãíþóåùí, áëëÜ êáé äåîéïôÞôùí, ÞôáíêÜôé ðïõ áðïõóßáæå áðü ôá ðñïçãïýìåíá óõíÝ-äñéá.

ÔÝëïò, óôéò êáéíïôïìßåò ôïõ óõíåäñßïõ óõ-ãêáôáëÝãåôáé ç óõíÜíôçóç üëùí ôùí Ðåñéöåñåéá-êþí ÔìçìÜôùí ÅËÅÃÅÉÁ (5ìåëåßò ÄéïéêïýóåòÅðéôñïðÝò), üðïõ áíáðôý÷èçêå óçìáíôéêüò äéÜ-ëïãïò ãéá ôïí ôñüðï ëåéôïõñãßáò ôïõò áëëÜ êáéôçí äéáóýíäåóÞ ôïõò ìå ôéò åðéôñïðÝò åêðáßäåõ-óçò, Ýñåõíáò, ðïéïôéêÞò åîáóöÜëéóçò êáé ôï Ðå-ñéïäéêü “ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò”. Ç óõ-íÜíôçóç èá ðñáãìáôïðïéåßôáé óå êÜèå óõíÝäñéïêáé öéëïäïîåß íá áðïôåëÝóåé ðåäßï ðáñïõóßáóçòôïõ Ýñãïõ ðïõ åðéôåëåßôáé óå êÜèå ðåñéöåñåéáêüôìÞìá, áëëÜ êáé áíôáëëáãÞò éäåþí êáé áðüøåùíãéá ôï ìÝëëïí ôçò ÃåíéêÞò ÉáôñéêÞò.

Åßíáé áëÞèåéá üôé ìÝíïõí ðïëëÜ áêüìç íáóõæçôçèïýí êáé éäéáßôåñá èÝìáôá ó÷åôéêÜ ìå ôïíôñüðï ðáñïõóßáóçò ôùí åñãáóéþí êáé ôç óõæÞôç-óÞ ôïõò. Ôçí ðåñßïäï ðïõ ç Ðáãêüóìéá ÅôáéñåßáÃåíéêÞò ÉáôñéêÞò (WONCA World) äçìïóéåýåéóõóôÜóåéò ãéá ôçí áíÜðôõîç õðïäïìþí óôçí Ýñåõíáóôç ÃåíéêÞ ÉáôñéêÞ1 êáé õðïãñáììßæåôáé ç áíÜ-ãêç áíÜðôõîçò ôçò áêáäçìáúêÞò óôáäéïäñïìßáòóôï áíôéêåßìåíï áõôü óôç Íüôéá Åõñþðç2, ôï äåÓõíÝäñéï ôçò ÃåíéêÞò ÉáôñéêÞò áíáæçôÜ ôç èÝóç

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Ôüìïò 16, Ôåý÷ïò 2, 2004Á. Ìáñéüëçò, ×. ËéïíÞò

óôç óõæÞôçóç ôïõ state of the art óôç ÃåíéêÞÉáôñéêÞ óôç ÷þñá ìáò, ôï 16ï ÐáíåëëÞíéï ÓõíÝ-äñéï ÃåíéêÞò ÉáôñéêÞò ßóùò áðïôåëÝóåé ôçí áöå-ôçñßá ãéá ìéá íÝá åðï÷Þ óôçí åéäéêüôçôá ôçòÃåíéêÞò ÉáôñéêÞò óôçí ÅëëÜäá.

Á. Ìáñéüëçò, ×. ËéïíÞò,Éáôñüò ÃåíéêÞò ÉáôñéêÞò, Áí. ÊáèçãçôÞò,

Ê. Õ. Âýñùíá Áíôéðñüåäñïò Ä.Ó.ÌÝëïò Ä.Ó. ÅËÅÃÅÉÁ ÅËÅÃÅÉÁ

Âéâëéïãñáößá

1. Van Weel C, Rosser WW. Improving HealthCare Globally: A Critical Review of the Neces-sity of Family Medicine Research and Recom-mendations to Build Research Capacity. AnnFam Med 2:S5-S16, 2004.

2. Lionis C, Carelli F, Soler JK. Developing aca-demic career in family medicine within theMediterranean setting. Fam Pract 21; 5 (in press).

European Section

of the International Journal

of Rural and Remote Health

ü Ôï íÝï äéåèíÝò çëåêôñïíéêü ðåñéïäéêüãéá ôïõò õãåéïíïìéêïýòðïõ åñãÜæïíôáé óå áãñïôéêÝò ðåñéï÷Ýò

ü Ôï åðßóçìï ðåñéïäéêü ôïõ EURIPA

Åðéóêåöèåßôå ôï óôç äéåýèõíóç

http://rrh.deakin.edu.au

êáé åããñáöåßôå äùñåÜí


56

Áè.Ã. ÂÞôáò êáé óõí.

ÂÑÁÂÅÕÈÅÉÓÁ ÅÑÃÁÓÉÁ ÓÔÏ ÄÉÁÃÙÍÉÓÌÏ ÔÏÕ "Ä. IKÊOY"

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

ÅéóáãùãÞ

Óôá èáëáóóáíáéìéêÜ óýíäñïìáõðÜãåôáé ìéá ïìÜäá êëçñïíïìéêþíäéáôáñá÷þí ìå êýñéï ÷áñáêôçñéóôéêüôç ìåßùóç, óå ðïéêßëï âáèìü, ôçò ðá-ñáãùãÞò ìéáò Þ/êáé ðåñéóóïôÝñùíóöáéñéíéêþí áëõóßäùí. Ï üñïò èáëáó-óáíáéìßá ÷ñçóéìïðïéÞèçêå áñ÷éêÜ ãéáíá äçëþóåé ôçí áíáéìßá ðïõ åìöáíé-æüôáí óôïõò ëáïýò ðïõ êáôïéêïýóáíóå ðáñáèáëÜóóéåò ðåñéï÷Ýò. ÓÞìåñá ïüñïò ÷ñçóéìïðïéåßôáé ãéá ôçí áíáöï-ñÜ óôéò ðïóïôéêÝò êëçñïíïìéêÝò äéá-ôáñá÷Ýò ôçò âéïóýíèåóçò ôùí óöáéñé-íéêþí áëõóßäùí.

Ç ìïñéáêÞ âëÜâç óôç â-ìåóïãåéá-êÞ áíáéìßá ðñïêáëåßôáé ìå áðëÞ áíôé-êáôÜóôáóç ìéáò âÜóçò DNA áðü Üëëç(óçìåéáêÞ ìåôÜëëáîç) Þ ìå Ýëëåéøç(deletion) Þ ìå ðñïóèÞêç (insertion)

ÐåñßëçøçÓôçí ðáñïýóá óõã÷ñïíéêÞ åñãáóßá ìåëåôÞèçêå ç åîåýñåóç åíüò ãñÞãïñïõ,áðëïý, áóöáëïýò êáé åý÷ñçóôïõ äéáãíùóôéêïý ìÝóïõ, âáóéæüìåíïõ óôçí ðáñá-ôÞñçóç ôùí åñõèñïêõôôáñéêþí äåéêôþí ôïõ áßìáôïò, ãéá ôïí ðñïóäéïñéóìü ôïõóôßãìáôïò ôçò â-ìåóïãåéáêÞò áíáéìßáò (Óâ-ÌÁ). Ãéá ôï óêïðü áõôü äéåíåñãÞèç-êå screening test óå 784 Âïñåéïåëëáäßôåò ðïõ ðåñéëÜìâáíå ëÞøç éóôïñéêïý,áéìáôïëïãéêü Ýëåã÷ï êáé êëéíéêÞ åîÝôáóç. ÁîéïëïãÞèçêáí Ýîé äéáãíùóôéêÜ åñãá-ëåßá, (formulas). ¾ðáñîç Óâ-ÌÁ åðéâåâáéþèçêå óå 62 (7,9%) áóèåíåßò. Ïé ôýðïéôùí Green-King, ôùí Shine-Lal êáé ç ó÷Ýóç RDW/RBC öÜíçêå üôé áðïôåëïýíáîéüðéóôá åñãáëåßá äéáëïãÞò ãéá ôïí åíôïðéóìü ôïõ Óâ-ÌÁ, óôïí ðëçèõóìüðïõ åîåôÜóôçêå. Óõæçôþíôáé áêüìç, ç åõáéóèçóßá êáé ç åéäéêüôçôá ôçò êÜèåäïêéìáóßáò êáèþò êáé ôá áðïôåëÝóìáôá ðáñüìïéùí ìåëåôþí áðü ôçí ðáãêüóìéáâéâëéïãñáößá.

1ÅÊÁÂ ÊïæÜíçò, 2ÊÝíôñï Õãåßáò ÓéÜôéóôáò ÊïæÜíçò, 3Ã.Í. ÊïæÜíçò

Diagnosis of heterozygous (minor) beta-thalassemia basedon blood erythrocyte indexesA. Vitas, C. Semertzidis, Evaggelia Nerantzaki

SummaryTo evaluate the determination of a fast, simple, cheap, sure and functionaldiagnostic model, based in blood erythrocyte indexes for the localization ofheterozygous (minor) beta-thalassemia (HBT), in primary health care ambiance.In order to achieve this screening tests were held in northern Greece. Theparticipants were 784 in number. A clinical examination took place; personalhistory and blood tests were taken. Six diagnostic modes were evaluated. Thediagnosis of HBT was confirmed in 62 (7.9%) patients. The Green-King andShine-Lal formulas with RDW/RBC ratio appeared that they constitute awfulscreening instrument for the location of HBT, in northland Greek population.Discussed the sensitivity and the specificity of each assay as well as theresults of similar studies by the international bibliography.

Key Words: Heterozygous (minor) Beta-Thalassemia, Diagnosis, Screening Test,Validation of Screening Instruments.

ÄéÜãíùóç ôçò åëÜóóïíïò â-èáëáóóáíáéìßáò áðü ôïõò äåßêôåòôùí åñõèñþí áéìïóöáéñßùí ôïõ áßìáôïò

ÁèáíÜóéïò Ã. ÂÞôáò1, ×ñÞóôïò Ë. Óåìåñôæßäçò2, Åõáããåëßá É. ÍåñáíôæÜêç3

ËÝîåéò êëåéäéÜ: Óôßãìá â-ÌåóïãåéáêÞò Áíáéìßáò, ÄéÜ-ãíùóç, Ìáæéêüò Ðñïóõìðôùìáôéêüò ¸ëåã÷ïò, Áîéï-ëüãçóç ôùí Åñãáëåßùí ÄéáëïãÞò.ÕðïâëÞèçêå: Ç åñãáóßá õðïâëÞèçêå óôï äéáãùíé-óìü "Ä. ºêêïõ" óôá ðëáßóéá ôïõ 16ïõ ÐáíåëëçíßïõÓõíåäñßïõ ÃåíéêÞò ÉáôñéêÞò (Êùò, 14-18 Áðñéëßïõ2004) êáé âñáâåýèçêå áðü ôçí ÅðéôñïðÞ Êñßóçò,Äçìïóéåýåôáé ìå êïéíÞ áðüöáóç ôçò ÓõíôáêôéêÞòÅðéôñïðÞò ôïõ Ðåñéïäéêïý êáé ôçò ÏñãáíùôéêÞòÅðéôñïðÞò ôïõ ÓõíåäñßïõÕðåýèõíïò áëëçëïãñáößáò: ÁèáíÜóéïò Ã. ÂÞôáò,Náõáñßíïõ 7, 661 00 ÄñÜìá, Ôçë.: (25210) 32009,e-mail: [email protected]

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Áè.Ã. ÂÞôáò êáé óõí. Ôüìïò 16, Ôåý÷ïò 2, 2004

ìéêñïý âáèìïý âÜóåùí êáé óðáíéüôåñá ìå åîÜëåé-øç âÜóåùí óå ìåãáëýôåñç Ýêôáóç ôïõ DNA. Óôçâ-ìåóïãåéáêÞ áíáéìßá õðÜñ÷åé ìåñéêÞ Þ ïëéêÞ Ýë-ëåéøç ôçò â áëõóßäáò, åíþ ç áëõóßäá á ðáñÜãå-ôáé óå öõóéïëïãéêÜ åðßðåäá. Ç ìåéùìÝíç óýíèåóçôçò â áëõóßäáò óõíåðÜãåôáé ìåßùóç ôçò óýíèåóçòôçò áéìïóöáéñßíçò (Hb), ìå áðïôÝëåóìá ðáñïõ-óßá Ýíôïíçò õðï÷ñùìßáò êáé ìéêñïêõôôÜñùóçò1.

Ç åëÜóóùí â-ìåóïãåéáêÞ áíáéìßá, áíáöÝñå-ôáé óôç âéâëéïãñáößá êáé ùò óôßãìá â-ìåóïãåéá-êÞò áíáéìßáò (Óâ-ÌÁ). Ç äéÜãíùóç ôßèåôáé ãåíé-êÜ óå áóèåíåßò ðïõ áîéïëïãïýíôáé ãéá Þðéá áíáé-ìßá Þ óå ðáñáêïëïýèçóç áíùìáëéþí ðïõ âñÝèç-êáí óôï óõíÞèç áéìáôïëïãéêü Ýëåã÷ï. Ç çëå-êôñïöüñçóç ôçò Hb åßíáé ðïëý ÷ñÞóéìç óôç äéÜ-ãíùóç ôïõ Óâ-ÌÁ. ¼ìùò, ôá ðåñéóóüôåñá Üôï-ìá ìå Óâ-ÌÁ äéáöåýãïõí ôçò äéÜãíùóçò, ìåïëÝèñéåò óõíÝðåéåò2.

Óêïðüò ôçò ðáñïýóáò óõã÷ñïíéêÞò åñãáóßáòÞôáí ç áíáæÞôçóç êáé ç åðéëïãÞ åíüò ãñÞãïñïõ,öèçíïý, áóöáëïýò êáé åý÷ñçóôïõ äéáãíùóôéêïýìÝóïõ, ãéá ôïí ðñïóäéïñéóìü ôïõ Óâ-ÌÁ, óå ðå-ñéâÜëëïí ðñùôïâÜèìéáò ðåñßèáëøçò.

Ðëçèõóìüò ìåëÝôçò – ÌÝèïäïò

Óôéò áñ÷Ýò ôïõ ðñïçãïýìåíïõ Ýôïõò äéåíåñ-ãÞèçêå ðñïóõìðôùìáôéêüò Ýëåã÷ïò ãéá ôïí åíôï-ðéóìü ôïõ Óâ-ÌÁ óå 784 êáôïßêïõò (üìïéáòöõëåôéêÞò ìïñöïëïãßáò) ôçò Âïñåßïõ ÅëëÜäïò,çëéêßáò áðü 12-75 åôþí (Ì.Ç.: 44±11,7). Ç äéá-äéêáóßá äéáëïãÞò ðåñéëÜìâáíå ðëÞñåò áôïìéêüéóôïñéêü, êëéíéêÞ åîÝôáóç êáé áéìáôïëïãéêü Ýëåã-÷ï. Áðü ôç ãåíéêÞ åîÝôáóç ôïõ áßìáôïò êáôá-ãñáöüôáí: 1) Ï áéìáôïêñßôçò (Ht – Ö.Ô.: Üíäñåò40-54%, ãõíáßêåò 36-48%). 2) Ç Hb (Ö.Ô.: Üí-äñåò 14-18g/dl, ãõíáßêåò 12-14g/dl). 3) Ï áñéè-ìüò ôùí åñõèñþí áéìïóöáéñßùí ôïõ áßìáôïò (RBCX 106/ìL – Ö.Ô.: Üíäñåò 4,5-6M/ul, ãõíáßêåò3,8-5,8M/ul). 4) Ï ìÝóïò üãêïò åñõèñþí áéìï-óöáéñßùí (MCV – Ö.Ô.: 80-95fl). 5) Ç ìÝóç ðå-ñéåêôéêüôçôá Hb êáôÜ åñõèñü (MCH – Ö.Ô.: 27-34pg) êáé 6) Ôï åýñïò êáôáíïìÞò ôùí åñõèñþí(RDW – Ö.Ô.: 11,5-14,5%).

Ôï ðñüãñáììá äéáëïãÞò, âáóßóôçêå êõñßùò,óôïõò ðáñáêÜôù Ýîé (6) ôýðïõò, (formulas):

· Green-King: MCV2 X RDW/Hb X 100.Õðüíïéá Óâ-ÌÁ åÜí <72.3

· Shine-Lal: MCV2 X MCH/100. Õðüíïéá

Óâ-ÌÁ åÜí <1.5304.· Mentzler: MCV/RBC. Õðüíïéá Óâ-ÌÁ åÜí<135.

· MCH\RBC ratio. Õðüíïéá Óâ-ÌÁ åÜí <4,46.· RDW\RBC ratio. Õðüíïéá Óâ-ÌÁ åÜí <3,37.· England-Fraser: MCV – 5 X Hb + RBC +K (óôáèåñÜ ðïõ ëáìâÜíåé ôéìÞ 3,4 üôáí ïHt åßíáé åíôüò öõóéïëïãéêþí ïñßùí êáé 8,4üôáí åßíáé ÷áìçëüò êáé áðáéôåßôáé äéüñèù-óç). Õðüíïéá Óâ-ÌÁ åÜí <08.Óôá Üôïìá ìå èåôéêü åýñçìá Þ óçìáíôéêÞ

ìéêñïêõôôÜñùóç, äõóáíÜëïãç ôçò öõóéïëïãéêÞòHb Þ ôçò Þðéáò áíáéìßáò, åîåôáæüôáí ï óßäçñïòôïõ ïñïý êáé åðéðëÝïí ãéíüôáí çëåêôñïöüñçóçHb (åöüóïí äåí åß÷áí õðïâëçèåß óå çëåêôñïöü-ñçóç Hb óôï ðáñåëèüí), þóôå íá ôåêìçñéùèåß çäéÜãíùóç.

Áðïêëåßóôçêáí áðü ôç ìåëÝôç áóèåíåßò õðüóéäçñïèåñáðåßá, üóïé áíÝöåñáí ðñüóöáôç ìåôÜã-ãéóç áßìáôïò Þ ðåñéðôþóåéò üðïõ äéáðéóôùíüôáíóõíýðáñîç Ýíäåéáò óéäÞñïõ êáé Óâ-ÌÁ.

Ïé óõíå÷åßò ðáñÜìåôñïé åêöñÜóèçêáí ùòìÝóåò ôéìÝò (mean values), ìå ìéá óôáèåñÞ áðü-êëéóç (±SD). Ç ðñáãìáôïðïßçóç ôùí õðïëïãé-óìþí, ç áíÜëõóç ôùí ðëçñïöïñéþí êáèþò êáé çåêôßìçóç ôçò åõáéóèçóßáò êáé ôçò åéäéêüôçôáòêÜèå äïêéìáóßáò, äéåíåñãÞèçêáí ìå ôï MicrosoftExcel. Ãéá ôç óôáôéóôéêÞ áíÜëõóç ôùí äéáèÝóé-ìùí äåäïìÝíùí ÷ñçóéìïðïéÞèçêå ôï ëïãéóìéêüStatistical Package for the Social Sciences (S.P.S.S.v.11). ¼ñéï óôáôéóôéêÞò óçìáíôéêüôçôáò èåùñÞ-èçêå ôï p£0,05 (p£5%), êÜèå Üëëç ðéèáíüôçôáèåùñÞèçêå ìç óçìáíôéêÞ (Not Significant - NS).

ÁðïôåëÝóìáôá

Áðü ôïõò 784 åîåôáæüìåíïõò ïé 431 (54,9%)Þôáí Üññåíåò êáé ïé 353 (45%) èÞëåéò. ÅâäïìÞ-íôá ôÝóóåñéò (9,4%) Þôáí Ýöçâïé 12-18 åôþí (Ì.Ç:14,5+3,1), 398 (50,7%) åíÞëéêåò 19-60 åôþí (Ì.Ç:34,9+11,2) êáé 312 (39,7%) çëéêéùìÝíïé 61-75åôþí (Ì.Ç: 69,8±3,4).

Åðéâåâáéþèçêå Óâ-ÌÁ óå 62 (7,9%) áóèå-íåßò, 29 (46,7%) Þôáí Üññåíåò êáé 33 (53,2%)èÞëåéò. Ïé 3 (4,8%) Þôáí Ýöçâïé, ïé 29 (46,7%)åíÞëéêåò êáé ïé õðüëïéðïé 30 (48,3%) çëéêéùìÝ-íïé. Áðü áõôïýò ïé 41 (66%) ãíþñéæáí ôç íüóïôïõò, åíþ ïé õðüëïéðïé 21 (33,8%) öÜíçêå üôéôçí áãíïïýóáí.


58


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

er= 4,7±2,1 (p <0,004).Ïé ìÝóåò ôéìÝò ôïõ áéìáôïëïãéêïý åëÝã÷ïõ ôùí

ðáó÷üíôùí áðü ôï Óâ-ÌÁ Þôáí: Ht= 35,1±3,9%,Hb= 10,2±3,1g/dl, MCV= 66,9±2,1fl, MCH=21,5±1,6pg, RBC= 5,3±0,2M/ì, RDW= 12,4±0,9%.Ïé áíôßóôïé÷åò ôéìÝò óôï õðüëïéðï äåßãìá ðëçèõ-óìïý Þôáí: Ht= 36,7±11,8% (p NS), Hb= 13,2±4,3g/dl (p=0,05), MCV= 85,1±13,3fl (p <0,006), MCH=27,6±5,2pg (p <0,02), RBC= 3,5±1,09M/ì (p<0,05), RDW= 15,6±2,1% (p=0,05).

H åõáéóèçóßá êáé ç åéäéêüôçôá êÜèå äïêéìá-

Ðßíáêáò 1. Ç åõáéóèçóßá êáé ç åéäéêüôçôá ôùí ÷ñçóéìïðïéçèÝíôùí äéáãíùóôéêþí ìåèüäùí ðñïóäéïñéóìïý ôïõÓâ-ÌÁ

Ôýðïò ôùí Green-King (Óâ-ÌÁ <72) ÏñèÜ èåôéêÜ ÅóöáëìÝíá èåôéêÜ Óýíïëï

60 1 62

ÅóöáëìÝíá áñíçôéêÜ ÏñèÜ áñíçôéêÜ

2 721 723Óýíïëï 62 722 n=784

Åõáéóèçóßá= 96%, Åéäéêüôçôá=99%

Ôýðïò ôùí Shine-Lal (Óâ-ÌÁ <1530) ÏñèÜ èåôéêÜ ÅóöáëìÝíá èåôéêÜ Óýíïëï

60 11 71


2 711 713Óýíïëï 62 722 n=784

Åõáéóèçóßá= 96%, Åéäéêüôçôá= 98%.

Ôýðïò ôïõ Mentzler (Óâ-ÌÁ <13) ÏñèÜ èåôéêÜ ÅóöáëìÝíá èåôéêÜ Óýíïëï

58 9 67


4 713 717Óýíïëï 62 722 n=784


ÁñéèìçôéêÞ ó÷Ýóç MCH\RBC (Óâ-ÌÁ <4.4) ÏñèÜ èåôéêÜ ÅóöáëìÝíá èåôéêÜ Óýíïëï

57 12 69


5 710 715Óýíïëï 62 722 n=784


ÁñéèìçôéêÞ ó÷Ýóç RDW\RBC (Óâ-ÌÁ <3.3) ÏñèÜ èåôéêÜ ÅóöáëìÝíá èåôéêÜ Óýíïëï

59 5 64


3 717 720Óýíïëï 62 722 n=784


Ôýðïò ôùí England-Fraser (Óâ-ÌÁ <0) ÏñèÜ èåôéêÜ ÅóöáëìÝíá èåôéêÜ Óýíïëï

49 8 57


13 714 727Óýíïëï 62 722 n=784


59


óßáò ðáñáôßèåíôáé óôïí Ðßíáêá 1.ºêôåñïò (êëéíéêÞ ðáñïõóßá êßôñéíçò ÷ñïéÜò

äÝñìáôïò, åðéðåöõêüôùí êáé âëåííïãüíùí) ðá-ñáôçñÞèçêå óå 5 (8,1%) ðÜó÷ïíôåò. ÌÝôñéá ÞìéêñÞ óðëçíéêÞ äéüãêùóç äéáðéóôþèçêå óå 13(20,9%) óõíïëéêÜ áóèåíåßò.

ÓõæÞôçóç

ÊáôÜ ôç äéåèíÞ âéâëéïãñáößá, ï üñïò èáëáó-óáíáéìßá áíáöÝñèçêå ãéá ðñþôç öïñÜ ôï 1925óôç âüñåéï ÁìåñéêÞ, áðü ôïí Thomas Cooleyêáé áðïäüèçêå óå ðáéäéÜ Éôáëþí êáé ÅëëÞíùíìåôáíáóôþí. Ëüãù ãåùãñáöéêÞò êáôáíïìÞò ëÝ-ãåôáé êáé ÌåóïãåéáêÞ áíáéìßá. ÓõíáíôÜôáé, êõ-ñßùò, óå ðëçèõóìïýò Ìåóïãåéáêþí ÷ùñþí: ÅëëÜ-äá, Éôáëßá, Íüôéá Ãáëëßá, ÌÜëôá, Êýðñï, Ôïõñ-êßá êáé óôéò ÷þñåò ôçò Âüñåéáò ÁöñéêÞò. ¸÷åéðåñéãñáöåß üìùò óå üëá ôá ìÝñç ôïõ êüóìïõ êáéóå üëåò ôéò öõëÝò. Óôç ÷þñá ìáò ç óõ÷íüôçôáôïõ Óâ-ÌÁ õðïëïãßæåôáé ðåñßðïõ 7,5%9.

Ç èáëáóóáíáéìßá áðïäåß÷ôçêå üôé åßíáé êëç-ñïíïìéêÞ ðÜèçóç êáé äéáêñßíåôáé ìå âÜóç ôçâáñýôçôÜ ôçò óå ôñåéò êáôçãïñßåò: á) Ìåßæùíèáëáóóáíáéìßá (íüóïò ôïõ Cooley), â) ÅëÜóóùíèáëáóóáíáéìßá (íüóïò ôùí Rietti – Greppi –Micheli) êáé ã) ÅëÜ÷éóôç èáëáóóáíáéìßá.

Ôï Óâ-ÌÁ áíáðôýóóåôáé ìåôáîý 3ïõ êáé 10ïõ

Ýôïõò ôçò æùÞò êáé óõíÞèùò ôüôå äåí ðáñïõóéÜ-æåé êëéíéêÝò åêäçëþóåéò. Óôç ãåíéêÞ åîÝôáóç ôïõáßìáôïò áíåõñßóêåôáé áýîçóç ôïõ áñéèìïý ôùíRBC ðïõ åßíáé ìéêñüôåñá óå ìÝãåèïò êáé Ý÷ïõí÷áìçëüôåñç ðåñéåêôéêüôçôá óå Hb (ôéìÝò MCV –MCH ìéêñüôåñåò ôïõ öõóéïëïãéêïý). Ï óßäçñïòôïõ ïñïý åßíáé öõóéïëïãéêüò Þ áõîçìÝíïò. Óôïåðß÷ñéóìá ôïõ ðåñéöåñéêïý áßìáôïò áíåõñßóêåôáéõðï÷ñùìßá, ìéêñïêõôôÜñùóç, áíéóïêõôôÜñùóç,óôï÷ïêõôôÜñùóç êáé ðïéêéëïêõôôÜñùóç. ÓðÜíéáðáñáôçñåßôáé Þðéá ìéêñïêõôôáñéêÞ áíáéìßá, óõ-÷íÜ óõíõðÜñ÷åé óéäçñïðåíéêÞ áíáéìßá êáé ç ÷ï-ñÞãçóç óéäÞñïõ Þ/êáé öõëëéêïý ïîÝïò, âåëôéþíåé,áëëÜ ü÷é ðëÞñùò ôçí áíáéìßá. ÊáôÜ ôçí çëå-êôñïöüñçóç Hb âñßóêåôáé áýîçóç ôçò Hb A

2

(ðåñéóóüôåñï áðü 3,5%), åíþ ç Hb F åßíáé óõíÞ-èùò öõóéïëïãéêÞ.

Ç Hb óáí ðñùôåÀíç êéíåßôáé óå Ýíá çëåêôñé-êü ðåäßï ðñïò ìéá êáôåýèõíóç êáé ìéá áðüóôáóçáíÜëïãá ìå ôï çëåêôñéêü öïñôßï ôïõ ìïñßïõ ôçò(åîáñôÜôáé áðü ôï éóïçëåêôñéêü óçìåßï ôçò ðñù-

ôåÀíçò êáé ôï pH ôïõ äéáëýìáôïò). Óå áëêáëéêüpH ç Hb Ý÷åé êáèáñÜ áñíçôéêü öïñôßï êáé êéíåß-ôáé ðñïò ôï èåôéêü ðüëï, åíþ óå üîéíï äéÜëõìáÝ÷åé èåôéêü öïñôßï êáé êéíåßôáé ðñïò ôïí áñíçôé-êü ðüëï. Ç çëåêôñïöüñçóç óå ïîåéêÞ êõôôáñßíçóå pH 8,9 åßíáé ç êáëýôåñç ìÝèïäïò ðïóïôéêïýðñïóäéïñéóìïý ôùí áéìïóöáéñéíþí ðáñÜ óáí ìÝ-èïäïò screening êáé ÷ñçóéìïðïéåßôáé éäéáßôåñáãéá ôçí ðïóïôéêÞ ìÝôñçóç ôçò Hb A

2 (äéÜãíùóç

öïñÝùí â-ìåóïãåéáêÞò áíáéìßáò)10.Ç ðñüëçøç ðåñéëáìâÜíåé: á) ôçí åíçìÝñùóç

ôïõ êïéíïý, â) ôçí áíåýñåóç ôùí åôåñïæõãùôþí(öïñÝùí), ã) ôç ãåííçôéêÞ êáèïäÞãçóç ôùí æåõ-ãáñéþí (åÜí êáé ôá äýï ìÝëç ôïõ æåýãïõò ðÜ-ó÷ïõí áðü åëÜóóïíá â-èáëáóóáíáéìßá èåùñåßôáéüôé õðÜñ÷åé êßíäõíïò 25%, Þ êáô’ Üëëïõò ðåñéó-óüôåñï, ôùí ðáéäéþí ôïõò íá ðñïóâëçèïýí áðüâáñéÜ ïìüæõãï èáëáóóáíáéìßá) êáé ä) ôçí ðñï-ãåííçôéêÞ äéÜãíùóç ôçò íüóïõ. ÁõôÞ ãßíåôáé óôïðñþôï ôñßìçíï ôçò åãêõìïóýíçò ìå ôç ìåëÝôçôïõ åìâñõúêïý DNA ðïõ ãéíüôáí áñ÷éêÜ ìåôÜáðü äéáêïëðéêÞ âéïøßá ôñïöïâëÜóôçò êáé óôçóõíÝ÷åéá äéáêïéëéáêÜ êáôÜ ôçí 10ç-12ç åâäïìÜ-äá ôçò êýçóçò11.

Ï ðñïãáìéáßïò Ýëåã÷ïò ãéá ôçí áíß÷íåõóçôïõ Óâ-ÌÁ åßíáé áíáãêáßïò ãéá íá áðïöåõ÷èåßç ôõ÷üí ãÝííçóç ðáéäéþí ìå ìåóïãåéáêÞ áíáéìßá.

Ôï Õðïõñãåßï Õãåßáò êáôáâÜëåé óçìáíôéêÝòðñïóðÜèåéåò ìå ôï ðñüãñáììá “äéáöþôéóçò ðñï-ãáìéáßïõ åëÝã÷ïõ – áíáãíþñéóçò öïñÝùí êáéðñïãåííçôéêÞò äéÜãíùóçò”, ó÷åôéêÜ ìå ôç ìåóï-ãåéáêÞ áíáéìßá. Ïé ìïíÜäåò ðñüëçøçò êáé íïóç-ëåßáò ôçò ìåóïãåéáêÞò áíáéìßáò óôá íïóïêïìåßáôçò ÅëëÜäáò, áõôÞ ôç óôéãìÞ åßíáé ðåñéóóüôåñåòáðü ôñéÜíôá, åê ôùí ïðïßùí ìüíï ïé ìéóÝò êáëý-ðôïõí ôéò áíÜãêåò ôçò åðáñ÷ßáò. Åýêïëá áíôé-ëáìâÜíåôáé êÜèå ëåéôïõñãüò ðñùôïâÜèìéáò ðåñß-èáëøçò ôï üöåëïò áëëÜ êáé ôçí áíáãêáéüôçôáðñüóêôçóçò åíüò áîéüðéóôïõ åñãáëåßïõ ãéá ôçíáíß÷íåõóç ôïõ Óâ-ÌÁ. Åäþ èá ðñÝðåé íá ôïíß-óïõìå üôé óôç ÷þñá ìáò, ç çëåêôñïöüñçóç Hbóôá ðëáßóéá ôïõ ðñïãáìéáßïõ Þ ðñïãåííçôéêïýåëÝã÷ïõ, óýìöùíá ìå ôç ó÷åôéêÞ õðïõñãéêÞ áðü-öáóç áñ. Ö7/ïéê. 1624, èá ðñÝðåé íá äßíåôáéìüíï “åö’ üóïí õðÜñ÷ïõí óõãêåêñéìÝíåò åíäåß-îåéò” êáé ü÷é ùò åîÝôáóç ñïõôßíáò Þ screening.ÓõãêåêñéìÝíá, óýìöùíá ìå ôçí õð’ áñéè. 5803/98 (1178/Â) êïéíÞ áðüöáóç ôïõ Ðñùèõðïõñãïýêáé ôïõ Õðïõñãïý Õãåßáò & Ðñüíïéáò áðïöáóß-æåôáé, ìåôáîý Üëëùí, üôé: “...Ìå óêïðü ôçí Ýãêáé-


60


ñç äéÜãíùóç êáé ôç ëÞøç ìÝôñùí ãéá ôçí ðñüëç-øç ôçò åêäÞëùóçò Þ ôçí áðïôñïðÞ åìöÜíéóçòíïóçñþí êáôáóôÜóåùí êáèéåñþíïíôáé ãéá ôïõòáóöáëéóìÝíïõò ôïõ äçìïóßïõ êáé ôùí Üëëùí áóöá-ëéóôéêþí ïñãáíéóìþí êáèþò êáé ãéá ôá ìÝëç ôùíïéêïãåíåéþí ôïõò, ïé õðï÷ñåùôéêÝò ðáñï÷Ýò ðñï-ëçðôéêÞò éáôñéêÞò ðïõ Ý÷ïõí ùò åîÞò: “...2. Åîå-ôÜóåéò ðñïãåííçôéêïý åëÝã÷ïõ, óå ãõíáßêåò êáéÜíäñåò ìå óêïðü ôç ãÝííçóç õãéþí ðáéäéþí. Åéäé-êüôåñá: á) áéìáôïëïãéêÝò åîåôÜóåéò (ãåíéêÞ áßìá-ôïò, öåñéôßíçò êáé åãêëßóôùí) ãéá ôç äéáðßóôùóçôùí åôåñïæõãùôþí ôçò ìåóïãåéáêÞò áíáéìßáò êáéâ) çëåêôñïöüñçóç Hb, åöüóïí ðñïêýøïõí åíäåß-îåéò áðü ôéò ðáñáðÜíù åîåôÜóåéò”12.

Áðü ôá Ýîé åñãáëåßá äéáëïãÞò ôïõ Óâ-ÌÁðïõ ìåëåôÞèçêáí, ôçí õøçëüôåñç åõáéóèçóßá êáéåéäéêüôçôá åß÷áí: 1) ï ôýðïò ôùí Green-King(96%-99% áíôßóôïé÷á), 2) ç ó÷Ýóç RDW/RBC(95%-99%) êáé 3) ï ôýðïò ôùí Shine-Lal (96%-98%). Ç ìåãáëýôåñç èåôéêÞ äéáãíùóôéêÞ áîßááíÞêå óôç äïêéìáóßá ôùí Green-King: 96% êáéáêïëïõèïýóáí ç áíáëïãßá RDW/RBC: 92% êáéï ôýðïò ôùí Shine-Lal: 84%. Ç áñíçôéêÞ äéá-ãíùóôéêÞ áîßá âñÝèçêå 99% êáé ãéá ôéò ôñåéòäïêéìáóßåò.

Óçìáíôéêüôáôç Þôáí åðßóçò ç óõìâïëÞ ôïõòóôç äéáöïñéêÞ äéÜãíùóç ôïõ Óâ-ÌÁ áðü ôá ÜëëááíáéìéêÜ óýíäñïìá. Óå Üôïìá ðïõ ðñüêåéôáé íáåëåã÷èïýí ãéá ôï Óâ-ÌÁ ìå ôá ðñïáíáöåñèÝíôáäéáãíùóôéêÜ åñãáëåßá êáé óõìâáßíåé íá Ý÷ïõí÷áìçëü Ht, ïðïéáóäÞðïôå áéôéïëïãßáò, èá ðñÝðåéíá åëÝã÷ïíôáé ìå ôïí ôýðï ôùí England-Fraser(Ý÷åé ôç ìåãáëýôåñç äéáãíùóôéêÞ áîßá óôïõò áóèå-íåßò ìå ÷áìçëü Ht)13,14. Áêüìç, üôáí ôï áðïôÝëå-óìá áðü ôç ó÷Ýóç RDW\RBC åßíáé >3,3, Þ áðüôïí ôýðï ôïõ Mentzler >13, Þ ôçò ó÷Ýóçò MCH/RBC >4,4, ôüôå óõíÞèùò ðñüêåéôáé ãéá ÝëëåéøçóéäÞñïõ. Ó’ áõôÝò ôéò ðåñéðôþóåéò, ïé ðéèáíÝòåëëåßøåéò óéäÞñïõ ìðïñïýí íá åíôïðéóôïýí “ðñþé-ìá” (ðñéí ôïí åñãáóôçñéáêü Ýëåã÷ï), ìå ôïõò åîÞòôýðïõò: MCV – (5 × Hb) – RBC – 8,4 Þ 0,01 ×MCH × MCV2 Þ MCV/RBC ratio15,16.

ÁñêåôÝò äéåèíïýò êýñïõò åñãáóßåò, ðïõ ìåëÝ-ôçóáí ôç äéáêýìáíóç ôùí åñõèñïêõôôáñéêþí äåé-êôþí ðáãêïóìßùò óå äéáöïñåôéêÞò öõëåôéêÞòìïñöïëïãßáò Üôïìá, óõìöùíïýí üôé ïé óõãêåêñé-ìÝíåò ôñåéò äïêéìáóßåò áðïôåëïýí ðïëýôéìá åñ-ãáëåßá äéáëïãÞò ôïõ Óâ-ÌÁ. ÌÜëéóôá ôïíßæåôáéôï óçìáíôéêü ðëåïíÝêôçìá ôïõ êüóôïõò áëëÜ êáéôçò äõíáôüôçôáò äéåîáãùãÞò åíüò Üìåóïõ óõìðå-

ñÜóìáôïò áðü ôïí Ýëåã÷ï ôùí äåéêôþí ôùí åñõ-èñþí áéìïóöáéñßùí ôïõ áßìáôïò ìßáò êáé ìüíïåîÝôáóçò ç ïðïßá ìðïñåß íá äéåíåñãÞèçêå áêüìçêáé óôï ðáñåëèüí (ü÷é üìùò íùñßôåñá áðü ôçíçëéêßá ôùí äþäåêá åôþí)17-19.

Óå ìéá Üëëç ìåëÝôç ðïõ åêðïíÞèçêå óôéòáñ÷Ýò ôçò ðñïçãïýìåíçò äåêáåôßáò áðü Åõñù-ðáßïõò åñåõíçôÝò êáé ðïõ åîåôÜóôçêáí äéáêüóéåòðåñéðôþóåéò áóèåíþí ìå óïâáñÝò êáé ðïéêßëåòáíáéìßåò, öÜíçêå üôé ï ôýðïò ôùí England-Fras-er êáé ç ó÷Ýóç RDW/RBC áðïôåëïýí áñêåôÜáêñéâåßò äïêéìáóßåò ãéá ôïí ðñïóäéïñéóìü ôïõÓâ-ÌÁ óôïí éôáëéêü áëëÜ êáé ôï ãåñìáíéêü ãåíé-êü ðëçèõóìü20.

ÔÝëïò, åìåßò èá èÝëáìå íá âïçèÞóïõìå ìåêÜèå ôñüðï óôçí åêðüíçóç êáé Üëëùí ðáñüìïéùíåñãáóéþí, áðü óõíáäÝëöïõò ðïõ áóêïýí ðñùôï-âÜèìéá öñïíôßäá õãåßáò óå äéÜöïñåò ðåñéï÷Ýò ôçò÷þñáò ìáò, þóôå íá óõíåêôéìÞóïõìå åíäåëå÷þò,óå ðáíåëëÞíéï åðßðåäï, ôçí áðïôåëåóìáôéêüôçôáêáé ôï üöåëïò ôùí óõãêåêñéìÝíùí åñãáëåßùí äéá-ëïãÞò. ÄåäïìÝíïõ üôé ç ÅëëçíéêÞ âéâëéïãñáößáóôåñåßôáé ðáñüìïéùí ìåëåôþí.

ÓõìðåñÜóìáôá

Ï åðéðïëáóìüò ôïõ Óâ-ÌÁ óôï áíôéðñïóù-ðåõôéêü äåßãìá ðëçèõóìïý ôçò óõãêåêñéìÝíçòãåùãñáöéêÞò æþíçò ðïõ ìåëåôÞèçêå, êáôÜ ôï Ýôïò2003, Þôáí (62/784 ×100) 7,9%.

Ïé ôýðïé (formulas) ôùí Green-King, ôùíShine-Lal êáé ç ó÷Ýóç RDW\RBC öÜíçêå üôéáðïôåëïýí áîéüðéóôá åñãáëåßá äéáëïãÞò ãéá ôïíåíôïðéóìü ôïõ Óâ-ÌÁ (áëëÜ êáé ãéá ôç äéáöï-ñïäéÜãíùóÞ ôïõ áðü ôá Üëëá åßäç ôùí áíáé-ìéþí), óôï óõãêåêñéìÝíï åëëçíéêü ðëçèõóìü.

Äå âñÝèçêå óôï äåßãìá ðëçèõóìïý ðïõ åîå-ôÜóôçêå êáíÝíáò áóèåíÞò ìå Óâ-ÌÁ êáé MCV>70fl.

Ïé êëéíéêÝò åêäçëþóåéò ôïõ Óâ-ÌÁ (áíåîáñ-ôÞôùò ôçò çëéêéáêÞò ïìÜäáò áóèåíþí), üôáí õðÞñ-÷áí Þôáí åëÜ÷éóôåò êáé äåí ìðïñïýóáí áðü ìü-íåò ôïõò íá èÝóïõí âÜóéìåò õðïøßåò ãéá ôçí ýðáñ-îç Þ ôïí áðïêëåéóìü ôçò íüóïõ.


1. Ðáðáäçìçôñßïõ Ì, Éùáííßäïõ – ÐáðáãéáííÜêç

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Å. ÅóùôåñéêÞ Ðáèïëïãßá. ÐïóïôéêÝò Äéáôáñá-÷Ýò ôçò Óýíèåóçò ôçò Áéìïóöáéñßíçò – Èáëáó-óáíáéìéêÜ Óýíäñïìá Þ ÌåóïãåéáêÞ Áíáéìßá. Èåó-óáëïíßêç 1998. University Studio Press. 2ïò Ôü-ìïò. Óåë. 1097-1220.

2. Harrison.ÅóùôåñéêÞ Ðáèïëïãßá. Äéáôáñá÷Ýò ôçòÄïìÞò, ôçò Ëåéôïõñãßáò êáé ôçò ÓõíèÝóåùò ôçòÁéìïóöáéñßíçò. ÁèÞíá 1998. Ôüìïò Ã. 10ç ̧ êäïóç.Êåö. 330. Óåë. 2489-2492.

3. Green R, King R. A New Red Cell Discrimi-nate Incorporating Volume Dispersion for Dif-ferentiating Iron Deficiency Anaemia fromThalassemia Minor. Blood Cells, 15:481-495,1989.

4. Shine I, Lal S. A Strategy to Detect Beta-thalas-semia Minor. Lancet, 1:692-694, 1977.

5. Mentzler W. Differentiation of Iron Deficiencyfrom Thalassemia Trait. Lancet, 1:882, 1973.

6. D’ Onofrio G. Automated Measurement of RedBlood Cell Microcytosis and Hypochromia inIron Deficiency and Beta-thalassemia trait. ArchPathol Lab Med, 116:84-89, 1992.

7. Ricerca B, Storti S, D’ Onofrio G. Differentia-tion of Iron Deficiency from Thalassemia Trait:A New Approach. Haematologica, 72:409-413,1987.

8. England J, Fraser P. Differentiation of IronDeficiency from Thalassemia Trait by RoutineBlood Count. Lancet, 1:449-452, 1973.

9. Áäáìüðïõëïò Ð. Ç Ðáèïëïãßá óôçí ÉáôñéêÞÐñÜîç. ÍïóÞìáôá ôïõ Áßìáôïò. ÁèÞíá, 1998.ÌÝñïò 10o, 2ïò Ôüìïò, Óåë. 823-882.

10. ÌåëÝôçò É. Áðü ôï Áéìáôïëïãéêü Åýñçìá óôçÄéÜãíùóç. Áíáéìßåò - ÌåóïãåéáêÜ Óýíäñïìá.ÁèÞíá. 1996. 3ç ¸êäïóç. Óåë. 185-196.

11. Êáôñéïý Ä, Êñåìåíüðïõëïò Ã, Ðáíôåëßäçò ×,Áèáíáóßïõ-ÌåôáîÜ Ì. ÐáéäéáôñéêÞ. Áéìïðïéçôé-êü Óýóôçìá. ÌåóïãåéáêÜ Óýíäñïìá. Èåóóáëïíß-êç. 1997. Óåë. 441-449.

12. ÕðïõñãéêÝò ÁðïöÜóåéò Ö.Å.Ê.: Ôåý÷ïò Â’ – Áñ.Öýëëïõ 2053/24-11-99. ÁèÞíá 04 Íïåìâñßïõ1999.

13. D’Onofrio G. Automated Measurement of redBlood Cell Microcytosis and Hypochromia inIron Deficiency and Beta-thalassemia Trait. ArchPathol Lab Med, 116:84-89, 1992.

14. Lafferty J, Crowther M. The Evaluation of Var-ious Mathematical RBC Indices and their Effi-cacy in Discriminating Between Thalassemic andNon-Thalassemic Microcytosis. Am J Clin Pathol,106:201-205, 1996.

15. Johnson C, Tegos C, Beutler E. ThalassemiaÌinor: Ñoutine Erythrocyte Measurements andDifferentiation from Iron Deficiency. Am J ClinPathol, 80:31-36, 1983.

16. Wallach J. Interpretation of Laboratory Tests 6th

Edition. Little Brown and Company, 1996, pp:334-356.

17. Rowley P. The Diagnosis of Beta-thalassemiaTrait: A Review. American Journal of Haema-tology, 1:129-37, 1976.

18. Thool A, Walde M, Shrikhande A, Talib V. ASimple Screening Test for the Detection of Het-erozygous Beta-thalassemia. Indian Journal ofPathology & Microbiology, 4:423-6, 1998.

19. Soffritti E, Bernardoni R, Pelizzola D, Scaglian-ti G. Value of Various Haematological IndexesProposed for Identifying Healthy Carriers ofthe Beta-thalassemia Trait. Quad Sclavo Diagn,4:447-54, 1985.

20. Junca J, Flores A, Roy C, Alberti R, Milla F.Red Cell Distribution Width, Free ErythrocyteProtoporphyrin, and England-Fraser Index in theDifferential Diagnosis of Microcytosis due toIron Deficiency or Beta-thalassemia Trait. AStudy of 200 Cases of Microcytic Anaemia.Haematology & Pathology Journal, 1:33-6, 1991.


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ÂÑÁÂÅÕÈÅÉÓÁ ÅËÅÕÈÅÑÇ ÁÍÁÊÏÉÍÙÓÇ

AWARDED FREESTANDING PAPERPrimary Heatlh Care, Volume 16, Number 2, 62-79, 2004ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, Ôüìïò 16, Ôåý÷ïò 2, 109-114, 2004

ÅéóáãùãÞ

Óôçí ðáñïýóá ÝñåõíÜ ìáò þèçóåç áäñÞ êáé âáóéóìÝíç óôçí åìðåéñßáìáò äéáðßóôùóç ôçò õðåñ-óõíôáãïãñÜ-öçóçò Áíôáãùíéóôþí ôùí Õðïäï÷Ýùí2 ôçò Éóôáìßíçò (Histamine2 Recep-tor Antagonists - H2-RAs) êáé Áíá-óôïëÝùí ôçò Áíôëßáò Ðñùôïíßùí (Pro-ton Pump Inhibitors - PPIs) óôçíÐñùôïâÜèìéá Öñïíôßäá Õãåßáò (ÐÖÕ),êáèþò êáé ç ðáñáôÞñçóç üôé óõíôá-ãïãñáöïýíôáé PPIs åîáñ÷Þò, ÷ùñßò íáðñïçãçèåß äïêéìÞ ôùí H2-RAs, üôéëáìâÜíïíôáé ùò ìüíéìç áãùãÞ, áíôßãéá óõãêåêñéìÝíï ÷ñïíéêü äéÜóôçìá,óõ÷íÜ óå ëáíèáóìÝíç äüóç êáé üôé äåíãßíåôáé ðáñáðïìðÞ ãéá åíäïóêüðçóç,(ïéóïöáãïóêüðçóç êáé ãáóñïóêüðçóç),ìå ôïí êßíäõíï êëéíéêÞò êÜëõøçò íåï-

Ç åêôßìçóç ôçò ïñèÞò óõíôáãïãñÜöçóçò áíôáãùíéóôþíôùí õðïäï÷Ýùí-2 éóôáìßíçò (H

2-RAs) êáé áíôáãùíéóôþí

ôçò áíôëßáò ðñùôïíßùí (PPIs) óôçí ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò

É. ÄñõãéáííÜêçò1, Á. Ëáëéþôçò2, Á. Ìåëéäïíéþôçò1, Êáëëéüðç Óôåöáíïðïýëïõ1,Ä. ÄñõãéáííÜêçò1, Í. ÐáðáäÜêçò1, Á. Ìðáôßêáò1

ÐåñßëçøçÓêïðüò: Ç äéåñåýíçóç ôçò ïñèüôçôáò ôçò äéÜãíùóçò êáé ôçò èåñáðåßáò ôùííïóçìÜôùí ôïõ óôïìÜ÷ïõ êáé ôïõ ïéóïöÜãïõ, ìå ôçí per os ÷ïñÞãçóç H2-RAsêáé PPIs, óå ó÷Ýóç ìå ôéò äéåèíåßò ïäçãßåò.Õëéêü- ÌÝèïäïò: Äéáìïñöþèçêå åñùôçìáôïëüãéï ãéá ôçí êáôáãñáöÞ ôçò áé-ôßáò ëÞøçò ôùí H2-RAs êáé PPIs (ÃáóôñïïéóïöáãéêÞ Ðáëéíäñüìçóç- ÃÏÐ, Ãá-óôñßôéäá, Ðåðôéêü ¸ëêïò- ÐÅ, ×ñÞóç ìç óôåñïåéäþí áíôéöëåãìïíùäþí öáñìÜ-êùí- NSAIDs), êáèþò êáé ôïõ êëéíéêïý êáé åñãáóôçñéáêïý éóôïñéêïý ôùí õðüåîÝôáóç áóèåíþí. Ôá åñùôçìáôïëüãéá óõìðëçñþèçêáí áðü ôïí ãéáôñü ìÝóùáôïìéêÞò óõíÝíôåõîçò.ÁðïôåëÝóìáôá:· Óõìðëçñþèçêáí åñùôçìáôïëüãéá, ðïõ áöïñïýóáí óå 182 áóèåíåßò, 66 Üí-

äñåò (36,3%) êáé 116 ãõíáßêåò (63,7%), ìå ìÝóï üñï çëéêßáò ôá 70,8 Ýôç.· Ôï (75,8%) ôùí áóèåíþí, äçë. 138/182, öáßíåôáé üôé åß÷áí êÜðïéá áíé÷íåý-

óéìç áéôßá ëÞøçò H2-RAs Þ PPIs.· Ïé 123 áðü ôïõò 182 áóèåíåßò, (67,6%), äåí ëÜìâáíáí ôçí åíäåäåéãìÝíç

èåñáðåßá.· Äéáðéóôþèçêå éó÷õñÞ óõó÷Ýôéóç ôçò ïñèÞò Þ ëáíèáóìÝíçò ëÞøçò áãùãÞò

óå ó÷Ýóç ìå ôç íüóï (÷2=6,8x10-8). Ç ðñïôåéíüìåíç èåñáðåõôéêÞ áãùãÞ ãéáôçí ðñïóôáóßá ôïõ ãáóôñéêïý âëåííïãüíïõ áðü NSAIDs öáßíåôáé üôé Þôáíïñèüôåñç óå áíôßèåóç ìå ôéò èåñáðåßåò ãéá ôéò ÃÏÐ, ÐÅ, ËåéôïõñãéêÞ Ãá-óôñßôéäá.

· Ãéá ôçí áãïñÜ ôùí H2-RÁs êáé ôùí PPIs ç äáðÜíç åêôéìÞèçêå óôá 319,63�áíÜ Üíèñùðï-Ýôïò. Ôï êüóôïò ôçò ìç åíäåäåéãìÝíçò èåñáðåßáò áíåñ÷üôáíóôá 258,55� áíÜ Üíèñùðï-Ýôïò, (80,9%).

· Ìüíï ïé 14 (7,7%) áðü ôïõò 73 (40,1%), ðïõ Ýðñåðå íá åíäïóêïðçèïýí(40,1%), åíäïóêïðÞèçêáí.

ÓõìðåñÜóìáôá: Óôéò ðåñéï÷Ýò ôçò ìåëÝôçò ç óõíôáãïãñÜöçóç H2-RAs êáéPPIs óå ìåãÜëï ðïóïóôü (67,6%) äåí ãßíåôáé óýìöùíá ìå ôéò äéåèíåßò ïäçãßåòêáé äáðáíþíôáé ìåãÜëá ðïóÜ ÷ùñßò ôï åðéèõìçôü èåñáðåõôéêü áðïôÝëåóìá. Ç÷ñÞóç ôçò åíäïóêüðçóçò åßíáé åëëéðÞò êáé ðåñéïñßæåôáé óôï 19,2% üóùí èáÝðñåðå íá åíäïóêïðçèïýí, óýìöùíá ìå ôéò êáôåõèõíôÞñéåò ïäçãßåò.Ïé éáôñïß ôçò ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò ðñÝðåé íá åíçìåñþíïíôáé ãéáôéò äéåèíþò áíáãíùñéóìÝíåò ïäçãßåò êáé íá óõììïñöþíïíôáé ìå áõôÝò Ýôóéþóôå íá ðáñÝ÷ïõí áðïôåëåóìáôéêÞ äéá÷åßñéóç ôùí íïóçìÜôùí ôïõ ðåðôéêïýóõóôÞìáôïò.

1ÊÝíôñï Õãåßáò (Ê.Õ.) ÐåñÜìáôïò Ñåèýìíçò, 2Ê.Õ. Ìïéñþí Çñáêëåßïõ

ËÝîåéò êëåéäéÜ: ÓõíôáãïãñÜöçóç, ÁíôáãùíéóôÝòõðïäï÷Ýùí-2 éóôáìßíçò, ÁíôáãùíéóôÝò áíôëßáò ðñù-ôïíßùí, ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò.ÕðïâëÞèçêå: Ç åñãáóßá õðåâëÞèçêå ùò åëåýèåñçáíáêïßíùóç óôï 16ï ÐáíåëëÞíéï ÓõíÝäñéï ÃåíéêÞòÉáôñéêÞò (Êùò, 14-18 Áðñéëßïõ 2004) êáé âñáâåýèç-êå áðü ôçí ÅðéôñïðÞ ÊñÞóçò. Äçìïóéåýåôáé ìå êïé-íÞ áðüöáóç ôçò ÓõíôáêôéêÞò ÅðéôñïðÞò ôïõ Ðåñéï-äéêïý êáé ôçò ÏñãáíùôéêÞò ÅðéôñïðÞò ôïõ Óõíå-äñßïõÕðåýèõíïò áëëçëïãñáößáò: Áíôþíçò Ìðáôßêáò,ÊÝíôñï Õãåßáò ÐåñÜìáôïò Ñåèýìíïõ, Ôçë.: (28340)23074, e-mail: [email protected]

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ãçóç PPIs Þ H2-RÁs, èá ìðïñïýóáííá äéï÷åôåõèïýí óôçí ïñèÞ äéåñåýíç-óç ôùí ðåñéðôþóåùí ìå êýñéï óêïðüôçí Ýãêáéñç äéÜãíùóç íåïðëáóéþí êáéôçí ïñèÞ áíôéìåôþðéóç ôçò ëåéôïõñãé-êÞò ãáóôñßôéäáò ðÝñá áðü ôç ÷ïñÞãç-óç öáñìáêåõôéêÞò áãùãÞò.

Ðëõèõóìüò ìåëÝôçò - ÌÝèïäïò

Õëéêü

Ðñüêåéôáé ãéá ìéá áíáäñïìéêÞðëçèõóìéáêÞ ìåëÝôç, ðïõ ðñáãìáôï-ðïéÞèçêå êáôÜ ôç äéÜñêåéá 13,5 ìç-íþí (áðü 01-01-2003 Ýùò êáé 16-02-2004). ÌåëåôÞèçêáí 182 Üôïìá, áðüôá ïðïßá 66 Þôáí Üíäñåò (36,3%) êáé116 Þôáí ãõíáßêåò (63,7%). Ç çëéêßáôïõò Þôáí êáôÜ ìÝóï üñï ôá 70,8 Ýôçìå óôáèåñÜ áðüêëéóçò (SD) ôá 12,8Ýôç êáé åýñïò 69 Ýôç (29-98). Ïé ðå-ñéóóüôåñïé, 179/182 (98,4%) äéÝìåíáíìüíéìá óå áãñïôéêÝò ðåñéï÷Ýò (ðëçèõ-óìüò <5.000 êÜôïéêïé), åíþ, ìüëéò 3,(1,6%), Þôáí ìüíéìïé êÜôïéêïé çìéá-óôéêþí ðåñéï÷þí (ðëçèõóìüò 5.000-10.000 êÜôïéêïé) êáé êáíåßò (0%) áóôé-êþí ðåñéï÷þí (>10.000 êÜôïéêïé). Ïé153 (84,1%) Þôáí êÜôïéêïé ôïõ íïìïýÇñáêëåßïõ êáé ïé 29 (15,9%) ôïõ íï-

Assessing rational prescription of histamine 2 receptor antagonists(H2-RAs) and proton pump inhibitors (PPIs) in Primary Health CareI. Drygiannakis, A. Laliotis, A. Melidoniotis, Kalliopi Stefanopoulou,D. Drygiannakis, N. Papadakis, A. Batikas

SummaryAim: Propriety investigation of diagnosis and treatment of gastrointestinal dis-eases by administering per os H2-RAs and PPIs in view of international guide-lines.Study population-Method: A questionnaire was formed on the recording ofH2-RAs and PPIs administration cause (Gastroesophageal Reflux Disease- GERD,Gastritis, Peptic Ulcer- PU, Use of Non-Steroidal Anti-Inflammatory Drugs- NS-AIDs) and clinical and laboratorial evaluation. A physician via interview compl-eted the questionnaires.Results:· Questionnaires were completed for 182 patients, 66 men (36,3%) and 116

women (63,7%) with a mean age of 70,8 years.· 138/182 (75,8%) appeared to have a detectable cause of H2-RAs’ or PPIs’

administration.· A powerful correlation between suitable or erroneous drug reception and

disease was detected (÷2= 6,8x10-8). The proposed treatment for the prote-ction of gastric mucous against NSAIDs appears to be more suitable incontrast to treatments for GERD, PU, and Functional Dyspepsia.

· 123/182 (67,6%) did not receive the most appropriate treatment.· Expenses for H2-RAs and PPIs were estimated as 319,63 �/man-year, while

the cost of non-advisable treatment amounted in 258,55 �/man-year (80,9%).· Only 14 (7,7%) from those who should be evaluated by endoscopy (73-

40,1%) underwent endoscopy.Conclusions: Prescription of H2-RAs and PPIs does not follow guidelines in agreat percentage of patients (67,6%) and much money is spent without thedesirable therapeutic effect. The use of endoscopy is inadequate (19,2% ofthose who should undergo endoscopy according to the international guidelines).The PHC doctors should be educated for guidelines and comply with them soas to provide effective management of gastroesophageal diseases.

Key Words: Prescription, Histamine-2 receptor antagonists, Proton pump inhi-bitors. Primary Health Care

Ðßíáêáò 1. ÄçìïãñáöéêÜ óôïé÷åßá äåßãìáôïò

Óôïé÷åßï Í %

ÖýëïÃõíáßêåò 116 63,7¢íäñåò 66 36,3ÇëéêßáÌÝóïò ¼ñïò 70,8SD 12,8Åýñïò 69Ðåñéï÷Þ ÊáôïéêßáòÁãñïôéêÞ 179 98,4ÇìéáóôéêÞ 3 1,6Íïìüò ÊáôïéêßáòÇñáêëåßïõ 153 84,1Ñåèýìíïõ 29 15,9

ðëáóßáò, ï ïðïßïò åßíáé áõîçìÝíïò óå ðëçèõóìïýòìå áõîçìÝíï ìÝóï üñï çëéêßáò.

¢ëëç óçìáíôéêÞ ðáñÜìåôñïò, åßíáé ôï äõ-óâÜóôáêôï, ãéá ôï óýóôçìá õãåßáò, ïéêïíïìéêüêüóôïò ôçò ôüóï åêôåôáìÝíçò óõíôáãïãñÜöçóçòôùí åí ëüãù öáñìÜêùí, êáèþò ïé áíôßóôïé÷åòíüóïé Ý÷ïõí ìåãÜëï åðéðïëáóìü. Áðü äõóðåøßáåêôéìÜôáé üôé ðÜó÷åé ðåñßðïõ ôï 25% ôïõ ðëçèõ-óìïý6. Ç ËåéôïõñãéêÞ Ãáóôñßôéäá áðïôåëåß ôï áßôéïóôï 60% ôùí äõóðåðôéêþí åíï÷ëçìÜôùí, áëëÜ,óôéò êëéíéêÝò ìåëÝôåò, êáôáëáìâÜíåé ìéêñüôåñïðïóïóôü äéüôé ðïëý ìéêñüôåñï åßíáé êáé ôï ðïóï-óôü ôùí áóèåíþí, ðïõ ðñïóÝñ÷åôáé ãéá ôï ëüãïáõôü óôïí ãéáôñü88,89. Ç ÃáóôñïïéóïöáãéêÞ Ðá-ëéíäñüìçóç åìöáíßæåôáé óôï 33% ôïõ ãåíéêïýðëçèõóìïý90! Ç Ãáóôñßôéäá ðñïêáëåß ôï 15-25%ôùí äõóðåøéþí, åíþ ôï Ðåðôéêü ̧ ëêïò, ìüëéò ôï5-25%88,89. Ôá ðïóÜ ðïõ îïäåýïíôáé, ãéá ôç ÷ïñÞ-

ìïý Ñåèýìíïõ ôçò íÞóïõ ÊñÞôçò. Ôá ðáñáðÜíùóõíïøßæïíôáé óôïí ðßíáêá 1.


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áäéáöïñïðïßçôçò ÷ñÞóçò ôùí üñùí Ãáóôñïïéóï-öáãéêÞ Ðáëéíäñüìçóç (ÃÏÐ), Ãáóôñßôéò, Ðåðôé-êü ¸ëêïò (ÐÅ) êáé Ãáóôñïðñïóôáóßá êáôÜ ôçóõíôáãïãñÜöçóç. ÔÝôïéåò ðçãÝò Þôáí: åíõðüãñá-öåò éáôñéêÝò ãíùìáôåýóåéò áðü åéäéêåõìÝíï éá-ôñü, ôá áðïôåëÝóìáôá åîåôÜóåùí (áéìáôïëïãé-êþí, âéï÷çìéêþí, áêôéíïëïãéêþí êáé Üëëùí), çóõíÝíôåõîç êáé ç êëéíéêÞ åîÝôáóç.

ÅðåëÝãçóáí ìüíï ïé áóèåíåßò ìå ôïõò ïðïßïõòç óõíåííüçóç Þôáí åõ÷åñÞò êáé ìðïñïýóáí áîéü-ðéóôá íá äþóïõí ðëçñïöïñßåò ãéá ôá óõìðôþìá-ôá êáé ôï éóôïñéêü ôïõò. Áðïêëåßóèçêáí áðü ôçìåëÝôç áóèåíåßò ìå ðáèÞóåéò üðùò ç ãåñïíôéêÞÜíïéá, ç ó÷éæïöñÝíåéá, ïé óùìáôüìïñöåò êáé ïéäéðïëéêÝò óõíáéóèçìáôéêÝò äéáôáñá÷Ýò. Áêüìç,áðïêëåßóèçêáí ïé áóèåíåßò ìå ïîý Üëãïò ïðïéáó-äÞðïôå áéôéïëïãßáò, áöïý äå èá Þôáí üóï áíáëõ-ôéêÞ êáé áíôéêåéìåíéêÞ èá Ýðñåðå ç éáôñéêÞ óõíÝ-íôåõîç. Åðßóçò, áðïêëåßóèçêáí áóèåíåßò ìå ðñïå-îÜñ÷ïíôá óõìðôþìáôá áðü ôï áíþôåñï ðåðôéêü,ðïõ ïäçãïýí ôç äéáãíùóôéêÞ óêÝøç ðñïò äéáöï-ñåôéêÜ íïóÞìáôá. ÔÝôïéïé Þôáí áõôïß ìå äõóöá-ãßá (äéåñåýíçóç ðñùôßóôùò ãéá ðåðôéêÞ óôÝíùóç,äéáôáñá÷Ýò êéíçôéêüôçôáò ïéóïöÜãïõ, ïéóïöáãé-êïýò äáêôõëßïõò Þ ìåìâñÜíåò, ðëáêþäåò êáñêß-íùìá Þ áäåíïêáñêßíùìá êáôþôåñïõ ïéóïöÜ-ãïõ)24,25 êáé ïäõíïöáãßá (ëïéìþäåò Þ öáñìáêåõ-ôéêü áßôéï). Óôçí ðåñßðôùóç áõôÞ áðáéôåßôáé ÜìåóçåêôÝëåóç âáñéïý÷ïõ ãåýìáôïò Þ/êáé åíäïóêüðç-óçò, áíÜëïãá ìå ôï âáèìü õðïøßáò ôïõ êëéíéêïýéáôñïý ãéá á÷áëáóßá, ìå ôï âáñéïý÷ï ãåýìá íáåßíáé ðéï åõáßóèçôï óôçí ôåëåõôáßá ðÜèçóç38.

Ôï äåßãìá áðïôåëåßôáé áðü ôõ÷áßá åðéëåãìÝ-íïõò áóèåíåßò ðïõ åëÜìâáíáí H2-RAs Þ PPIsêáé ãéá äéÜöïñïõò ëüãïõò åðéóêÝöèçêáí ôïõòãéáôñïýò ðïõ óõììåôåß÷áí óôç ìåëÝôç.

Óôï ðñþôï ôìÞìá ôïõ åñùôçìáôïëïãßïõ, ðïõóõìðëÞñùíå ï éáôñüò, êáôáãñÜöïíôáí õðï÷ñåù-ôéêÜ ôï ïíïìáôåðþíõìï, ôï Ýôïò ãÝííçóçò, ï ôü-ðïò êáôïéêßáò ôïõ áóèåíïýò, ôá ëáìâáíüìåíá H2-RAs Þ/êáé PPIs, ï ÷ñüíïò ëÞøçò ôïõ êáèåíüòáðü áõôÜ, ôï áí ëáìâÜíïíôáí óõíå÷þò Þ äéáëåé-ðüíôùò êáèþò êáé ç óõìðôùìáôïëïãßá Þ êÜèåÜëëïò ëüãïò ãéá ôïí ïðïßï ðßóôåõå üôé ôá ëÜìâá-íå. ÐñïáéñåôéêÜ êáôáãñÜöïíôáí ôï ðáôñþíõìïôïõ áóèåíïýò êáé ï ôçëåöùíéêüò áñéèìüò ôïõ.

Ôï äåýôåñï ôìÞìá ôïõ åñùôçìáôïëïãßïõ ðñï-óðáèïýóå íá áíé÷íåýóåé áí ï áóèåíÞò ìðïñïýóåíá êáôçãïñéïðïéçèåß óå ìßá áðü ôéò ôÝóóåñéòâáóéêÝò áéôßåò ëÞøçò H2-RAs Þ/êáé PPIs: ôç ÃÏÐ,

ÌÝèïäïò

Äéáìïñöþèçêå åñùôçìáôïëüãéï ìåôÜ áðüåêôåíÞ áíáóêüðçóç, ìå ôç ÷ñÞóç ôïõ äéáäéêôýïõ,Üñèñùí äçìïóéåõìÝíùí óå éáôñéêÜ ðåñéïäéêÜ, ðïõåßíáé åíôáãìÝíá óôï Index Medicus áðü ôï 1980ìÝ÷ñé óÞìåñá. Åðßóçò, åëÞöèçóáí õðüøç ôá êåß-ìåíá ôùí ôåëåõôáßùí åêäüóåùí óýã÷ñïíùí óõã-ãñáììÜôùí Ðáèïëïãßáò êáé ïé ïäçãßåò ôçò Áìå-ñéêáíéêÞò ÃáóôñåíôåñïëïãéêÞò ¸íùóçò (AGA)6,ôçò ÂñåôáíéêÞò Åôáéñßáò Ãáóôñåíôåñïëïãßáò7 êáéôïõ Institute for Clinical System Improvement(ISCI)39. Ïé ôåëåõôáßåò åßíáé ïé ðéï ðñüóöáôåòêáé áðåõèýíïíôáé óôïõò áóêïýíôåò ÐÖÕ. ÃåíéêÜ,äåí õðÜñ÷ïõí ïìüöùíá áðïäåêôÝò êáôåõèõíôÞ-ñéåò ïäçãßåò ãéá ôï óýíïëï ôùí äõíáôþí êëéíé-êþí ðåñéðôþóåùí, ðïõ íá êáëýðôïõí ðëÞñùò ôïèÝìá ôïõ ðüôå ðñÝðåé íá ÷ïñçãïýíôáé H2-RAs,PPIs Þ ïðïéáäÞðïôå áðü ôéò äýï áãùãÝò.

Ùò ðñïò ôçí áêñéâÞ äéáôýðùóç ôùí åñùôç-ìÜôùí ðñïò ôïõò áóèåíåßò óõíåéóÝöåñå ïìÜäáãéáôñþí ìå ðåßñá ùò ðñïò ôï ãíùóôéêü åðßðåäïêáé ôï ãëùóóéêü éäßùìá ôïõ õðü ìåëÝôç ðëçèõ-óìïý. Åðßóçò, ç ïìÜäá áõôÞ äéÝèåôå ðåßñá óôç÷ïñÞãçóç ôÝôïéùí óêåõáóìÜôùí.

ÁêïëïõèÞèçêå ç ìÝèïäïò ôçò ðñïóùðéêÞòóõíÝíôåõîçò áðü Ýíáí ãéáôñü ÷ùñßò ôçí ðáñïõ-óßá Üëëïõ ðñïóþðïõ óå ÷þñï éáôñåßïõ (Ðåñéöå-ñåéáêÜ Éáôñåßá- ÊÝíôñá Õãåßáò) Þ óôï óðßôé ôïõáóèåíïýò. Ï ãéáôñüò áõôüò, óôéò ðåñéóóüôåñåòðåñéðôþóåéò, åß÷å êáé ðñïçãïýìåíç åðáöÞ ìå ôïíáóèåíÞ êáé åðñüêåéôï íá Ý÷åé êáé åðüìåíç, êá-èþò Þôáí õðåýèõíïò ãéá ôçí ðáñï÷Þ ÐÖÕ óåáõôüí. ×Üñç óôçí Þäç äïìçìÝíç ó÷Ýóç ìåôáîýôïõò åëÞöèçóáí ïé áêñéâÝóôåñåò äõíáôÝò ðëçñï-öïñßåò. Ï áóèåíÞò åíçìåñþèçêå ãéá ôïí óêïðüôçò ìåëÝôçò êáé äéáâåâáéþèçêå ãéá ôï áðüññçôïôçò óõíÝíôåõîçò êáé ôçò êëéíéêÞò åîÝôáóçò. Êá-ôüðéí æçôÞèçêå ç ðñïöïñéêÞ óõãêáôÜèåóÞ ôïõêáé ìüíï áí áõôÞ äéäüôáí ï áóèåíÞò óõììåôåß÷åóôç ìåëÝôç. Óå ìåñéêÝò ðåñéðôþóåéò æçôÞèçêå êáéäåýôåñç åðßóêåøç óôïí ßäéï ãéáôñü ãéá ôçí ðñï-óêïìéäÞ åããñÜöùí, åîåôÜóåùí Þ óõóêåõáóéþí ôùíóêåõáóìÜôùí ðïõ ðñáãìáôéêÜ êáôáíÜëùíå ìåóêïðü ôçí ðëçñÝóôåñç äéåñåýíçóç. Åðß ìç åðá-íüäïõ ï áóèåíÞò åîáéñïýôáí áðü ôç ìåëÝôç.

Ãéá ôá áßôéá ëÞøçò ôùí H2-RAs êáé ôùíPPIs ÷ñçóéìïðïéÞèçêå êÜèå Üëëç ðçãÞ, åêôüòáðü ôçí áíáãñáöüìåíç ðÜèçóç óôï óõíôáãïëü-ãéï ôïõ áóèåíïýò, ëüãù ôçò åíáëëáêôéêÞò êáé

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ôçí Ãáóôñßôéäá, ôï ÐÅ (Ãáóôñéêü Þ Äùäåêáäá-êôõëéêü) êáé ôç ËÞøç Ìç Óôåñïåéäþí Áíôéöëåã-ìïíùäþí ÖáñìÜêùí (NSAIDs). Ðáñå÷üôáí ÷þ-ñïò êáé åß÷å äïèåß ç ðáñüôñõíóç óôïõò éáôñïýòíá êñáôÞóïõí óçìåéþóåéò ãéá ôï ëïéðü éóôïñéêüôïõ áóèåíïýò, ôçí ëáìâáíüìåíç áãùãÞ, áëëÜ êáéôçí Üðïøç ôùí éäßùí êáèþò êáé ôùí áóèåíþíáõôþí ãéá ôá áßôéá ëÞøçò ôùí H2-RAs êáé PPIs.Ôï ôìÞìá áõôü ôçò óõíÝíôåõîçò êáé ôçò éáôñéêÞòåîÝôáóçò åß÷å ùò óôü÷ï íá áíé÷íåýóåé óõìðôþìá-ôá êáé óçìåßá Þ åîåôÜóåéò áðü ôéò ïðïßåò ðñïÝ-êõðôå ïðïéáäÞðïôå áðü ôéò ôÝóóåñéò ðñïáíáöåñ-èåßóåò áéôßåò ëÞøçò ôçò åí ëüãù áãùãÞò, êáèþòêáé ôç óõíýðáñîç êÜðïéáò áðü ôéò õðüëïéðåòôñåéò.

Óôïõò áëãïñßèìïõò ðïõ ðáñïõóéÜæïíôáé ðá-ñáêÜôù åííïåßôáé, ÷ùñßò íá áíáöÝñåôáé, üôé óôéòðåñéðôþóåéò ðïõ ï áóèåíÞò äåí ìðïñïýóå íá êá-ôçãïñéïðïéçèåß óå êÜðïéá áðü áõôÝò Þ óôéò ðåñé-ðôþóåéò ìåñéêÞò Þ ìçäåíéêÞò áíôáðüêñéóçò óôçíáãùãÞ, óôïõò ÷ñüíïõò ðïõ êÜèå öïñÜ ïñßæïíôáé,åêôåëåßôáé, ìåôÜ ôçí ðáñÝëåõóÞ ôïõò, áðåéêïíé-óôéêüò êáé åñãáóôçñéáêüò Ýëåã÷ïò, ìå áêñïãù-íéáßï ëßèï ôçí åíäïóêüðçóç. Áõôü äåí éó÷ýåé óôéòðåñéðôþóåéò ðïõ áðáéôïýí åîáñ÷Þò ôÝôïéï Ýëåã-÷ï6. Ç èíçôüôçôá áðü åíäïóêïðéêü Ýëåã÷ï åßíáé÷áìçëÞ êáé êõìáßíåôáé áðü 1/3300 ùò 1/400006.Ç íïóçñüôçôá áíáöÝñåôáé áðü 1/330 ùò 1/27006.

Ãéá ôç äéÜãíùóç ôçò ÃÏÐ óçìåéþíïíôáí Ö Þ× óôá áíôßóôïé÷á ôåôñáãùíßäéá, áí ï áóèåíÞòåìöÜíéæå êÜðïéá ôá áðü êýñéá óõìðôþìáôá (ïðé-óèïóôåñíéêüò êáýóïò, áíáãùãÝò, åñõãÝò) Þ äåõôå-ñåýïíôá óõìðôþìáôá (ðáñïîõóìéêÞ äýóðíïéá37,ðáñïîõóìéêüò âÞ÷áò37, ïðéóèïóôåñíéêü Üëãïò,âñÜã÷ïò öùíÞò, íáõôßá, ðñþéìïò êïñåóìüò ðåß-íáò), êáèþò êáé óõìðôþìáôá, óçìåßá Þ/êáé óôïé-÷åßá ôïõ éóôïñéêïý, ðïõ áðáéôïýí åðåßãïõóá ÞåðåìâáôéêÞ ðñï ôçò èåñáðåßáò äéåñåýíçóç Þ/êáéáíôéìåôþðéóç1 êáèþò êáé ôï áí áõôü Ýãéíå óôï÷ñüíï ðïõ Ýðñåðå. Áí õðÜñ÷ïõí ìüíï äåõôåñåýï-íôá óõìðôþìáôá êáé äåí áíåõñßóêåôáé Üëëï ðé-èáíüôåñï áßôéï, áðáéôåßôáé 24-ùñç pH-ìåôñßáïéóïöÜãïõ Üìåóá, ðñïò äéåñåýíçóç ôçò ÃÏÐ, ðñéíäïèåß ïðïéáäÞðïôå èåñáðåßá37.

Ãéá ôçí áíôéìåôþðéóç ôçò ÃÏÐ ôï ðñþôïâÞìá Þôáí ç êáôÜ ôïí éáôñü ôáîéíüìçóç ôçòíüóïõ óå: Þðéá, ìÝôñéá Þ óïâáñÞ ÃÏÐ. Óôçí Þðéá,áñêïýóáí ïé ðëÞñåéò êáé óùóôÝò óõóôÜóåéò ãéááðïöõãÞ êáôÜêëéóçò ðñéí áðü ôçí ðÜñïäï 3hìåôÜ ôï ãåýìá Þ ôï äåßðíï, áíýøùóç ôçò êåöá-

ëÞò óôï êñåâÜôé êáôÜ ôçí êáôÜêëéóç, áðïöõãÞêáôáíÜëùóçò ôïìÜôáò, üîéíùí öñïýôùí, üîéíùí÷õìþí, ðéêÜíôéêùí, êáöÝ, óïêïëÜôáò, ëéðþí,áëêïüë, áðïöõãÞ êáðíßóìáôïò êáé ëÞøç áíôéüîé-íùí êáé H2-RAs ðåñéóôáóéáêÜ. Óôç ìÝôñéá, åêôüòáðü ôá ðáñáðÜíù, èåùñåßôáé óêüðéìï íá óõíôá-ãïãñáöïýíôáé H2-RAs ãéá 6 åâäïìÜäåò êáé áíäåí õöåèïýí ôá óõìðôþìáôá íá áëëá÷èåß ç áãù-ãÞ óå PPI óå äüóç 1´1 ãéá 8-12 åâäïìÜäåò. Áíõöåèïýí, èåùñåßôáé óêüðéìï íá óõíå÷éóèïýí ãéáÜëëåò 2-6 åâäïìÜäåò ïé H2-RAs.

Óôç óïâáñÞ, ðñÝðåé íá äïèåß åîáñ÷Þò PPI óåäüóç 1´1 êáé áí ôá óõìðôþìáôá äåí õöåèïýí óå2-4 åâäïìÜäåò, íá áõîçèåß ç äüóç óå 1´2 êáé çèåñáðåßá íá ëçöèåß ãéá 8-12 åâäïìÜäåò óõíïëé-êÜ. ÓùóôÞ èåùñÞèçêå êáé áãùãÞ ãéá ìåãáëýôåñï÷ñïíéêü äéÜóôçìá áðü ôá ðáñáðÜíù, êáèþò áñ-êåôÝò Ýãêõñåò Ýñåõíåò Ý÷ïõí áðïäåßîåé ôçí ðïëýóõ÷íÞ õðïôñïðÞ ôçò ÃÏÐ, åéäéêÜ óôïõò 6 ìÞíåòìåôÜ ôçí ðáýóç 12 åâäïìÜäùí åðéôõ÷ïýò èåñá-ðåßáò91. Êáôáãñáöüôáí åðßóçò, áí åìöáíßóèçêåêÜðïéá áðü ôéò êýñéåò åðéðëïêÝò ôçò ÃÏÐ: ïéóï-öÜãïò Barrett (åíäïóêïðéêÞ äéÜãíùóç) êáé óôÝ-íùóç ïéóïöÜãïõ (êëéíéêÞ äéÜãíùóç ëüãù äõóêá-ôáðïóßáò Þ äéÜãíùóç åíäïóêïðéêÜ Þ ìå âáñéïý÷ïãåýìá)9-12,17.

Ãéá ôç äéÜãíùóç ôçò ãáóôñßôéäáò êáôáãñÜ-öïíôáí ìå Ö Þ × óôá áíôßóôïé÷á ôåôñáãùíßäéááí ï áóèåíÞò Ýðáó÷å áðü ïäçãÜ óõìðôþìáôá(áíïñåîßá, åðéãáóôñáëãßá, íáõôßá, åìÝôïõò, áßóèçìáðëçñüôçôáò, ìåôåùñéóìü) Þ êÜðùò ðéï óðÜíéáóõìðôþìáôá êáé êáôåõèýíïíôá ðñïò åðåßãïõóáäéåñåýíçóç Þ/êáé áíôéìåôþðéóç, üðùò áõôÜ ðñïá-íáöÝñèçêáí.

Ç áñ÷éêÞ áíôéìåôþðéóç äéáöÝñåé áíÜëïãáìå ôï áí ôá óõìðôþìáôá ïäçãïýí ðñïò ôç äéÜ-ãíùóç ôçò áéìïññáãéêÞò- äéáâñùôéêÞò ãáóôñßôé-äáò (åðéãáóôñáëãßá êõñßùò) Þ ôç äéÜãíùóç ôçòëåéôïõñãéêÞò ãáóôñßôéäáò (áßóèçìá ðëçñüôçôáò,ìåôåùñéóìüò) êáé áíáëüãùò ôïõ áéôßïõ áõôÞò êáéôùí äéáöüñùí óõíõðáñ÷ïõóþí óçìåßùí, óõìðôù-ìÜôùí êáé åðéâáñõíôéêþí ðáñáãüíôùí, üðùòöáßíåôáé óôïí áëãüñéèìï 1. Óçìåéþíåôáé üôé çäéÜãíùóç ëïßìùîçò áðü Helicobacter pylori ãß-íåôáé ìå ìç åðåìâáôéêü ôñüðï ìå ïñïëïãéêÝò ìå-

1×áñáêôÞñåò åðåßãïíôïò: áíáéìßá (7-10) çìÝñåò, åðéìÝíïíôåò Ýìåôïé(1 çìÝñá), áéìáôÝìåóç (7-10) çìÝñåò, ìÝëáéíåò êåíþóåéò (1 çìÝ-ñá), áðþëåéá âÜñïõò >5%, áêïýóéá (7-10 çìÝñåò), áéìáôï÷åóßá,çëéêßá >45 åôþí, ïîåßá äõóöáãßá (1 çìÝñá), åììÝíïíôá, óõíå÷ÞÞ äéáëåßðïíôá, ÷ñüíéá óõìðôþìáôá.


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á) ÄéáâñùôéêÞ- ÁéìïññáãéêÞ i) Stress H

2-RAs IV

ii) NSAIDs a) ×ùñßò ðñüóèåôïõò ðáñÜãïíôåò êéíäýíïõ (âëÝðå 2-Â-á-ii-b)

Ìåßùóç Äüóçò ÓõãêáôáíÜëùóç ìå ãåýìáôá Ðáýóç ÓõìðôùìÜôùí ® ÍÁÉ Ðáýóç

Ï×É

Åíäïóêüðçóç ® H2-RAs Þ PPIs

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

iii) Áëêïüë H2-RAs

â) Ìç äéáâñùôéêÞ-Ìç åéäéêÞ (ËåéôïõñãéêÞ) i) Ìå ³1 áðü ôïõò áêüëïõèïõò ðáñÜãïíôåò êéíäýíïõ:

- Ðñïçãïýìåíï Ðåðôéêü ¸ëêïò - MALT ËÝìöùìá ¸ëåã÷ïò ãéá H. pylori - Ïéêïãåíåéáêü Éóôïñéêü Ãáóôñéêïý ÍåïðëÜóìáôïò (ÁóéÜôåò éäéáßôåñá)

Áëãüñéèìïò 1

èüäïõò Þ ôç äïêéìáóßá åêðíïÞò ïõñßáò (UreaBreath Test), ìå ðñïôßìçóç óôç äåýôåñç ëüãùôçò ìåãáëýôåñçò åõáéóèçóßáò ôçò26. Áí ç äïêéìá-óßá áðïâåß èåôéêÞ, áðü ìåñéêïýò óõíéóôÜôáé, åéäé-êÜ óå ðëçèõóìïýò ìå õøçëü åðéðïëáóìü ãáóôñé-êþí íåïðëáóìÜôùí (ÁóéÜôåò, >45 åôþí) êáé Üìå-óç åíäïóêüðçóç6.

Ãéá ôç äéÜãíùóç ôïõ ðåðôéêïý Ýëêïõò, (ãá-óôñéêü Þ äùäåêáäáêôõëéêü), ôá áíáæçôïýìåíáóõìðôþìáôá Þôáí êõñßùò ç åðéãáóôñáëãßá, ìåïñéóìÝíïõò éäéáßôåñïõò ÷áñáêôÞñåò, (áìâëý Üë-ãïò, áöõðíßæïí Üëãïò, ñõèìéêü Üëãïò, Üëãïò ùòðåßíá) êáé äåõôåñåõüíôùò, ç íáõôßá êáé ç áíïñå-îßá. ÐåðôéêÜ Ýëêç âñßóêïíôáé óõ÷íÜ ìåôÜ áðüáðïôõ÷ßá ôùí áãùãþí ãéá ÃÏÐ êáé ãéá ãáóôñß-

ôéäá êáé áêüëïõèç åíäïóêüðçóç Þ êáé óôéò ðåñé-ðôþóåéò Üìåóçò, ðñéí ôç ëÞøç áãùãÞò, åíäïóêü-ðçóçò. Ç áíôéìåôþðéóç äéáöÝñåé áíÜëïãá ìå ôïáßôéï, üðùò öáßíåôáé óôïí áëãüñéèìï 2, (ôìÞìáôïõ åñùôçìáôïëïãßïõ).

ÔÝëïò, äéêáéïëïãçìÝíç èåùñåßôáé ç óõã÷ïñÞ-ãçóç PPIs (êáé ü÷é H2-RAs, ðïõ Ý÷ïõí áðïäåé-÷èåß áíåðáñêþò áðïôåëåóìáôéêÜ áêüìç êáé óåìåëÝôåò cost-effect) óå áóõìðôùìáôéêÜ Üôïìá,ðïõ ëáìâÜíïõí NSAIDs, (“ãáóôñïðñïóôáóßá”),ãéá üóï ÷ñïíéêü äéÜóôçìá ôá ëáìâÜíïõí, ìüíïáí óõíõðÜñ÷åé Ýíáò Þ ðåñéóóüôåñïé áðü ôïõò åîÞòðáñÜãïíôåò: çëéêßá >80 åôþí, ðåðôéêü Ýëêïò,êÜðíéóìá, óõ÷íÝò ãáóôñåíôåñéêÝò åðéðëïêÝò ìåNSAIDs, óôåñïåéäÞ, áíôéðçêôéêÜ, óïâáñÞ íüóïò,

Áëãüñéèìïò 2

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

Ï×É ×åéñïõñãéêÞ ÅðÝìâáóç

67


ëÞøç ðéñïîéêÜìçò Þ áæáðñïðáæüíçò. Ôá äýï ôå-ëåõôáßá åßíáé NSAIDs, ðïõ ðñïêáëïýí áõîçìÝíçóõ÷íüôçôá ãáóôñåíôåñéêþí åðéðëïêþí êáé äéêáéïý-ìáóôå íá óõíôáãïãñáöÞóïõìå PPIs, Ýóôù êáéáðïõóßá óõìðôùìÜôùí Þ Üëëùí áðü ôïõò ðéïðÜíù ðáñÜãïíôåò.

ÌåôÜ áðü ôçí ðáñáðÜíù äéåñåýíçóç áðá-íôÞèçêáí 5 åñùôÞìáôá- êëåéäéÜ ôçò ìåëÝôçò ãéáêÜèå áóèåíÞ:

· ¹ôáí ç áãùãÞ óùóôÞ (ïõóßá, äïóïëïãßá,÷ñüíïò ëÞøçò, áðïôåëåóìáôéêüôçôá);

· Ðïéá Þôáí ç ðñáãìáôéêÞ ðÜèçóç (åöüóïíôá óôïé÷åßá ðïõ ìáò ðáñÝ÷ïíôáí áñêïýóáíãéá ôç äéÜãíùóç);

· ¸ãéíå åíäïóêüðçóç;· Óõóôçíüôáí íá ãßíåé;· Ðïéï Þôáí ôï áðïôÝëåóìÜ ôçò;

ÓôáôéóôéêÞ ÁíÜëõóç

Ôá äåäïìÝíá ìåôáöÝñèçêáí óôï ðñüãñáììáóôáôéóôéêÞò åðåîåñãáóßáò äåäïìÝíùí SPSS, Ýêäï-óç 11.5 ìå êùäéêïðïßçóç ôùí äåäïìÝíùí, ðïõáíôéóôïé÷ïýóáí óå áñéèìïýò Þ êáôáóôÜóåéò, óåáêÝñáéïõò áñéèìïýò, ãéá äéåõêüëõíóç ôçò óôáôé-óôéêÞò åðåîåñãáóßáò. ÕðÞñ÷áí ìåôáâëçôÝò äýïåéäþí: êáôçãïñéêÝò êáé áñéèìçôéêÝò.

Áñ÷éêÜ ðñáãìáôïðïéÞèçêå ðåñéãñáöéêÞ óôá-ôéóôéêÞ áíÜëõóç åóôéÜæïíôáò êõñßùò óôá óôáôé-óôéêÜ ìåãÝèç ìÝóïò üñïò, äéÜìåóïò, êïñõöÞ, óôá-èåñÜ áðüêëéóçò, åëÜ÷éóôï, ìÝãéóôï, åýñïò, ãéáüóåò ìåôáâëçôÝò âÝâáéá åß÷å íüçìá ôï êáèÝíááðü áõôÜ. Áêïëïýèùò, äéåñåõíÞèçêáí ç åóùôåñé-êÞ óôÜèìéóç ôïõ äåßãìáôïò êáé ïé ðéèáíÝò óôáôé-óôéêÝò óõó÷åôßóåéò ìåôáîý ôùí äéáöüñùí ìåôá-âëçôþí ìå ôï Pearson’s ÷2 ãéá êáôçãïñéêÝò ìå-ôáâëçôÝò êáé ôï Independent Samples’ t test ãéááñéèìçôéêÞ ìå êáôçãïñéêÞ äé÷ïôïìéêÞ ìåôáâëçôÞ.Ìå áíÜëõóç One-Way ANOVA åðé÷åéñÞèçêå çóõó÷Ýôéóç áñéèìçôéêÞò ìå êáôçãïñéêÞ, ôñé÷ïôïìé-êÞ Þ ìå ðåñéóóüôåñåò ôéìÝò, ìåôáâëçôÞ.


ÐåñéãñáöéêÞ ÓôáôéóôéêÞ ÁíÜëõóç

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

ëç, 49 (26,9%) Ñáíéôéäßíç, 13 (7,1%) Ëáíóïðñá-æüëç, 12 (6,6%) Ðáíôïðñáæüëç, 7 (3,8%) Ñáìå-ðñáæüëç êáé 1 (0,5%) S-ïìåðñáæüëç. Óõãêåíôñù-ôéêÜ ïé 133 áðü ôïõò 182 , Þôïé ôï (73,1%) ôùíáóèåíþí ëáìâÜíïõí PPI (ðñáæüëåò), åíþ ïé 49(26,9%) ëáìâÜíïõí H2-RA (ñáíéôéäßíç). ¼ðùò åßíáéöáíåñü, ôç ìÝãéóôç êáôáíÜëùóç Ý÷åé ç Ïìåðñá-æüëç êáé áêïëïõèåß ç Ñáíéôéäßíç. Óôï ðáñåëèüí 3áóèåíåßò (1,6%) êáôáíÜëùíáí ñáíéôéäßíç áíôßðñáæüëçò.

Ç äüóç ôçò Ñáíéôéäßíçò åßíáé ç ïñèÞ óå 43/182, äçë. óôï (87,8%) ôùí áóèåíþí ðïõ ôç ëáì-âÜíïõí, åíþ åßíáé ëáíèáóìÝíç óå 6 (12,2%). Çäüóç 150 mg x 1, ëáìâáíüìåíç äéáëåéðüíôùò,åßíáé óùóôÞ ãéá áóèåíåßò ìå Þðéá ÃÏÐ êáé ÷ùñßòáíÜãêç ðåñáéôÝñù äéåñåýíçóçò, áëëÜ äåí åß÷áìåôÝôïéåò ðåñéðôþóåéò. Áêüìç, óôçí ÅëëÜäá äåíêõêëïöïñåß Ñáíéôéäßíç óå ìéêñüôåñç áðü ôçí åëÜ-÷éóôç èåñáðåõôéêÞ äüóç, ðïõ èåùñåßôáé ïñèÞ åðé-ëïãÞ ãéá èåñáðåßá ôÝôïéùí ðåñéðôþóåùí ëáìâá-íüìåíç åðß óõìðôùìÜôùí. ÔÝôïéá õðÜñ÷åé óå ÜëëáêñÜôç êáé ðùëåßôáé ÷ùñßò óõíôáãÞ éáôñïý. Çäüóç ôùí Ðñáæïëþí Þôáí ç åëÜ÷éóôç èåñáðåõôé-êÞ Üðáî çìåñçóßùò óå 125 (94%) ôùí áóèåíþí,äéò çìåñçóßùò óå 6 (4,5%) ôùí áóèåíþí êáé õðï-èåñáðåõôéêÞ óå 2 áóèåíåßò, (1,5%). Óõìðåñáßíïõ-ìå üôé ãåíéêÜ ç ëÞøç óùóôÞò äïóïëïãßáò äåíáðïôåëåß éäéáßôåñï ðñüâëçìá, ìå ìéá áóôï÷ßá ìüëéò4,4%.

Ï ìÝóïò ÷ñüíïò ëÞøçò ôçò ðáñáðÜíù áãù-ãÞò åßíáé 14,5 ìÞíåò, äçëáäÞ ðïëý ðåñéóóüôåñïáðü ïðïéïäÞðïôå áðïäåêôü äéÜóôçìá ëÞøçò ôçòåí ëüãù áãùãÞò. Ôï åëÜ÷éóôï åßíáé 0,07 ìÞíáò,ôï ìÝãéóôï 120 ìÞíåò êáé ç êïñõöÞ 0,5 ìÞíáò.

Ó÷Þìá 1. ÖáñìáêåõôéêÞ ïõóßá.


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Ðßíáêáò 2. Áíáöåñüìåíá áßôéá ëÞøçò H2-RAs Þ PPIs

Áßôéï Í %

Ãáóôñïðñïóôáóßá 78 42,9Åðéãáóôñáëãßá 54 29,7Ïðéóèïóôåñíéêü Êáýóïò 24 13,2Áßóèçìá Ðëçñüôçôáò 6 3,3Ðåðôéêü ¸ëêïò 6 3,3Åðéãáóôñáëãßá 4 2,2

+ Ïðéóèïóôåñíéêü ÊáýóïòÃáóôñßôéò 3 1,6Áßóèçìá Ðëçñüôçôáò 2 1,1

+ Ïðéóèïóôåñíéêü ÊáýóïòÃáóôñïðñïóôáóßá 2 1,1

+ Ïðéóèïóôåñíéêü ÊáýóïòÄåí ãíùñßæù 2 1,1Åðéãáóôñáëãßá + Ìåôåùñéóìüò 1 0,5Óýíïëï 182 100 Ó÷Þìá 3. ÏñèÞ áíôéìåôþðéóç;

Ó÷Þìá 2. ×ñüíïò ëÞøçò áãùãÞò.

163 áóèåíåßò, (89,6%), ëáìâÜíïõí ôçí áãùãÞóõíå÷þò êáé 19, (10,4%), äéáëåéðüíôùò. Áíáëõôé-êüôåñá ïé ÷ñüíïé ëÞøçò áãùãÞò öáßíïíôáé óôïó÷Þìá 2.

Ç óõìðôùìáôïëïãßá ðïõ ï êÜèå áóèåíÞòáíáöÝñåé ùò õðåýèõíç ãéá ôç ëÞøç ôçò áãùãÞòáõôÞò öáßíåôáé óôïí ðßíáêá 2. ÊáôáãñÜöåôáé çáéôéþìåíç íüóïò, áí ï áóèåíÞò äåí åßíáé óå èÝóçíá èõìçèåß ôá óõìðôþìáôá Þ áí ç áéôßá åßíáéðÝñá áðü êÜèå áìöéóâÞôçóç ëüãù åñãáóôçñéá-êÞò äéåñåýíçóçò. Åðéêñáôåß ç Ãáóôñïðñïóôáóßáìå 42,9% êáé áêïëïõèïýí ç Åðéãáóôñáëãßá ìå

29,7% êáé ï Ïðéóèïóôåñíéêüò Êáýóïò ìå 13,2 %.Ç ëáìâáíüìåíç áãùãÞ åßíáé ëáíèáóìÝíç, (åßôå

ùò öáñìáêåõôéêÞ ïõóßá, åßôå ùò äïóïëïãßá, åßôåùò ÷ñüíïò ëÞøçò, åßôå ëüãù áíáðïôåëåóìáôéêü-ôçôáò ìåôÜ áðü äéáöïñåôéêü ãéá êÜèå ðÜèçóç÷ñïíéêü äéÜóôçìá, åßôå åðåéäÞ ÷ñåéÜæåôáé ðñüôå-ñç äéåñåýíçóç (åíäïóêïðéêÜ, äïêéìáóßåò áíß÷íåõ-óçò Helicobacter pylori)), óå 123/182 áóèåíåßò,(67,6%), êáé ïñèÞ óå 59/182 áðü áõôïýò, (32,4%),(ó÷Þìá 3). ÅðáíáëáìâÜíïõìå åäþ ôçí åëáóôéêü-ôçôá ôùí êñéôçñßùí ðïõ ÷ñçóéìïðïéÞóáìå, åéäé-êÜ óôçí áãùãÞ ôçò ÃÏÐ, áëëÜ êáé óôéò Üëëåò 3

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êáôáóôÜóåéò, åéäéêÜ ùò ðñïò ôï ÷ñüíï ëÞøçò ôçòáãùãÞò.

Ïé áðüëõôïé áñéèìïß êáé ôá ðïóïóôÜ ôùíðáèÞóåùí ðïõ äéáãíþóôçêáí ìå ôç âïÞèåéá ôïõéóôïñéêïý, ôçò êëéíéêÞò åîÝôáóçò êáé ôùí åñãá-óôçñéáêþí åîåôÜóåùí öáßíïíôáé óôï ó÷Þìá 4.Åíôýðùóç ðñïêáëåß üôé ôï 25% ôùí áóèåíþíïõäÝðïôå ðáñïõóßáóáí êÜðïéï ëüãï ëÞøçò PPIsÞ H2-RAs. Õðïãñáììßæïõìå åäþ ôçí ðéèáíÞ õøç-ëüôåñç óõ÷íüôçôá, áðü ôçí êáôáãñáöüìåíç åäþ,ôïõ ðåðôéêïý Ýëêïõò, åéäéêÜ óôéò ðåñéðôþóåéòëÞøçò NSAIDs, ïðüôå êáé ôá óõìðôþìáôá åßíáéëéãüôåñï Ýíôïíá áðü ü,ôé óå ðåðôéêÜ Ýëêç Üëëçòáéôéïëïãßáò. Áõôü ìðïñåß íá äéáðéóôùèåß ìüíï ìååíäïóêüðçóç, ç ïðïßá Ýðñåðå íá Ý÷åé ðñáãìáôï-ðïéçèåß êáé äåí ðñáãìáôïðïéÞèçêå óå 59 (32,4%)

Ðßíáêáò 3. ÅõñÞìáôá åíäïóêüðçóçò

Åýñçìá Í %

Ãáóôñßôéò 4 28,6Åíåñãü ¸ëêïò 3 21,5ÃÏÐ 2 14,4Ãáóôñßôéò + H. Pylori 1 7,1ÅðïõëùèÝí ¸ëêïò 1 7,1Íåïðëáóßá ÓôïìÜ÷ïõ 1 7,1Ðåðôéêü ¸ëêïò + ÃÏÐ 1 7,1ÏõäÝí 1 7,1Óýíïëï 14 100

Ó÷Þìá 4. Íüóïé.

Ó÷Þìá 5. Óïâáñüôçôá ÃÏÐ.

áóèåíåßò. ¢óêïðá äåí Ýãéíå óå êáíÝíá áóèåíÞ,åíþ ïñèþò Ýãéíå óå 14 (7,7%)13. Ôá áðïôåëÝóìá-ôÜ ôçò öáßíïíôáé óôïí ðßíáêá 3.

ÅéäéêÜ ãéá ôç ÃÏÐ, ç ïðïßá áöïñïýóå 39Üôïìá (21,4%), ôá 38 áðü áõôÜ, (97,4%), åß÷áíêýñéá óõìðôþìáôá, 2 (5,1%) Üôõðá ìå ìïíáäéêüôï ïðéóèïóôåñíéêü Üëãïò, 1 äçëáäÞ (2,6%), ìüíïÜôõðá, åíþ ïé 33/39, (84,6%), Ýðñåðå íá äéåñåõ-íçèïýí åíäïóêïðéêÜ, äéüôé Þôáí >45 åôþí. Áíá-ëõôéêÜ, ç ðïéêéëßá ôùí êýñéùí óõìðôùìÜôùíöáßíåôáé óôïí ðßíáêá 4. Ç óïâáñüôçôá ôçò ÃÏÐöáßíåôáé óôï ó÷Þìá 5. Ïé áðáñáßôçôåò ïäçãßåòãéá áëëáãÞ óõìðåñéöïñÜò åß÷áí äïèåß ðëÞñùò óå25 áóèåíåßò (64,1%), ìåñéêþò óå 5 (12,8%) êáéêáèüëïõ óå 9 (23,1%). ÖáñìáêåõôéêÞ áãùãÞ ëÜì-âáíáí 36 (92,3%) êáé äåí ëÜìâáíáí 3 (7,7%).ÁõôÞ äåí Þôáí áðáñáßôçôç åîáñ÷Þò óå 10 (25,6%),äéüôé åß÷áí Þðéá ÃÏÐ. ÄçëáäÞ 7 Üôïìá (17,9%)ëÜìâáíáí öáñìáêåõôéêÞ áãùãÞ, åíþ äåí Ýðñåðå.Ìüíï óå 8, äçë. óôï (20,5%) ôùí áóèåíþí åß÷åáêïëïõèçèåß ï áëãüñéèìïò ôçò áíôéìåôþðéóÞò ôçò.

Ðßíáêáò 4. Êýñéá óõìðôþìáôá ÃáóôñïïéóïöáãéêÞò Ðá-ëéíäñüìçóçò

Óýìðôùìá Í %

Ïðéóèïóôåñíéêü êáýóïò 22 56,4Ïðéóèïóôåñíéêü êáýóïò + ÅñõãÝò 14 35,9Ïðéóèïóôåñíéêü Êáýóïò + ÁíáãùãÝò 2 5,1ÏõäÝí 1 2,6Óýíïëï 39 100


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äá êáé Þôáí 66/182, (36,3%) öáßíïíôáé óôï ó÷Þ-ìá 7. Ïé ãáóôñßôéäåò Þôáí åê ôçò óõìðôùìáôïëï-ãßáò êáôÜ 80,3% äéáâñùôéêÝò- áéìïññáãéêÝò êáéêáôÜ 19,7% ëåéôïõñãéêÝò. Ùò ðñïò ôïõò ðáñÜãï-íôåò ðïõ ôéò ðñïêÜëåóáí, 26 áðü áõôÝò, (39,4%),ðñïêëÞèçêáí áðü NSAIDs êáé óå 19, (73%),óõíõðÞñ÷å êáé Üëëïò ðáñÜãïíôáò. ÁíáëõôéêÜ ôïðïéïé Þôáí áõôïß ïé åðéðëÝïí ðáñÜãïíôåò öáßíå-ôáé óôïí ðßíáêá 5. Ï áëãüñéèìïò áíôéìåôþðéóçòôçò ãáóôñßôéäáò ôçñÞèçêå óôï 40,9% ôùí ðåñé-ðôþóåùí.

Ôá óõìðôþìáôá ðïõ ìáò ïäÞãçóáí óôçí éó÷õ-ñÞ ðåðïßèçóç üôé ðñüêåéôáé ãéá ðåðôéêü Ýëêïò(12 áóèåíåßò, 6,6%) öáßíïíôáé óôïí ðßíáêá 6. Ôïáßôéï ôïõ Ýëêïõò Þôáí ôá NSAIDs óå 4 áóèåíåßò(33,3%), åíþ Þôáí Üãíùóôï óå 8 (66,7%). Ìüíïóå 4 (33,3%) áêïëïõèÞèçêáí ïé áëãüñéèìïé äéå-ñåýíçóçò êáé èåñáðåßáò.

ÍSAIDs ëÜìâáíáí 61 Üôïìá (33,5%), åíþáõôÜ Þôáí ï ìüíïò ðáñÜãïíôáò ãéá ôç óõíôáãï-ãñÜöçóç PPIs (÷ùñßò êáìßá ðáñïýóá óõìðôùìá-ôïëïãßá) óå 33 áóèåíåßò, (18,13%), åíþ óõíõðÞñ-÷å êáé ÃÏÐ óå 1 áðü áõôïýò, (0,5%). Ïé 33óôïõò 34, (97%), ðáñïõóßáæáí ³1 ðáñÜãïíôåòêáé Ýôóé Þôáí äéêáéïëïãçìÝíç ç ÷ïñÞãçóç NSA-IDs. ÁíáëõôéêÜ ïé ðáñÜãïíôåò áõôïß öáßíïíôáéóôï ó÷Þìá 8.

Ðßíáêáò 6. Óõìðôùìáôïëïãßá ðåðôéêïý Ýëêïõò

ÐáñÜãïíôáò Í %

¸íôïíç êáé åíôïðéóìÝíç åðéãáóôñáëãßá 4 33,3Åðéãáóôñáëãßá ùò ðåßíá 2 16,7

êáé áöõðíßæïí ÜëãïòÅðéãáóôñáëãßá ùò áìâëý Üëãïò 2 16,7Åðéãáóôñáëãßá ùò ðåßíá êáé áìâëý Üëãïò 1 8,3Åðéãáóôñáëãßá ùò áöõðíßæïí Üëãïò 1 8,3ÑõèìéêÞ áöõðíßæïõóá åðéãáóôñáëãßá 1 8,3Åðéãáóôñáëãßá + ÌÝëáéíá êÝíùóç 1 8,3Óýíïëï 12 100

Ðßíáêáò 5. Åðéâáñõíôéêïß ðáñÜãïíôåò ãáóôñßôéäáò áðüNSAIDs

ÐáñÜãïíôáò Í %

>70 åôþí 8 42ÊïñôéêïóôåñïåéäÞ 5 26,3>70 åôþí + ÊïñôéêïóôåñïåéäÞ 3 15,8>70 åôþí + ÊÜðíéóìá 1 5,3ÊÜðíéóìá 1 5,3> 70 åôþí + ÁíôéðçêôéêÜ 1 5,3Óýíïëï 19 100

Óôï ðïóïóôü ðåñéëáìâÜíïíôáé êáé áãùãÝò ìåãá-ëýôåñçò äéÜñêåéáò áðü áõôÞ ðïõ ðñïâëÝðïõí ïéáëãüñéèìïé, ëüãù ôùí óõ÷íþí õðïôñïðþí ôçò ÃÏÐ(ùò >90% óôïõò 6 ìÞíåò åðß åíäïóêïðéêÜ äéáðé-óôùìÝíçò ïéóïöáãßôéäáò91). Óå 6 (15,4%) äå äéå-ñåõíÞèçêáí åíäïóêïðéêÜ ïé ðéèáíÝò åðéðëïêÝò ôçòÃÏÐ ëüãù åðéìïíÞò Ýóôù êáé ëéãüôåñùí Ýíôï-íùí óõìðôùìÜôùí ìåôÜ áðü 3 ìÞíåò èåñáðåßáò,åíþ áõôü Ýðñåðå íá ãßíåé. ÐáñÜ ôáýôá, ôï 74,4%ôùí áãùãþí Þôáí ðëÞñùò åðéôõ÷çìÝíåò, üðùòöáßíåôáé êáé óôï ó÷Þìá 6.

Ôá óõìðôþìáôá áõôþí ðïõ åß÷áí ãáóôñßôé-

Ó÷Þìá 7. Óõìðôþìáôá ãáóôñßôéäáò.

Ó÷Þìá 6. Áðïôåëåóìáôéêüôçôá èåñáðåßáò ÃÏÐ.

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ðôåé ìåôáîý ôïõ öýëïõ êáé ôïõ óõíïëéêïý ïéêï-íïìéêïý êüóôïõò ôçò èåñáðåßáò (÷2=0,608), üðùòêáé ìåôáîý öýëïõ êáé áíþöåëùí äáðáíþí(÷2=0,49). ÔÝëïò, óõó÷Ýôéóç äåí õðÜñ÷åé ìåôáîýöýëïõ êáé ðñáãìáôïðïßçóçò Þ ü÷é åíäïóêüðçóçò(÷2=0,108) Þ áðïôåëÝóìáôïò åíäïóêüðçóçò(÷2=0,641).

ÕðÜñ÷åé óáöÞò óõó÷Ýôéóç ìåôáîý ôïõ åßäïõòôçò öáñìáêåõôéêÞò áãùãÞò êáé ôïõ ÷ñüíïõ ëÞ-øçò (t-test=2,6x10-11), õðÝñ ôçò ðéï ìáêñï÷ñü-íéáò ëÞøçò H2-RAs, ìå ìÝóç äéáöïñÜ áðü ôçëÞøç PPIs, 22,26 ìÞíåò. Äåí õðÜñ÷åé óõó÷Ýôéóçìåôáîý åßäïõò öáñìáêåõôéêÞò áãùãÞò êáé óõíï-ëéêïý êüóôïõò (t-test=0,111), áëëÜ óõó÷Ýôéóçåìöáíßæåôáé ìåôáîý åßäïõò öáñìáêåõôéêÞò áãù-ãÞò êáé áíþöåëùí äáðáíþí (t-test=0,03), êáôá-äåéêíýïíôáò ôá ìåãáëýôåñá óðáôáëçèÝíôá ðïóÜóå H2-RAs, ðéèáíþò ëüãù ôïõ ìáêñïý ÷ñüíïõôçò áãùãÞò. Óõó÷Ýôéóç õðÜñ÷åé ìåôáîý ôïõ åß-äïõò ôçò áãùãÞò êáé ôïõ ôñüðïõ ëÞøçò áõôÞò(÷2=0,008), õðÝñ ôçò äéáëåßðïõóáò ëÞøçò ôùí H2-RAs. ÏñéáêÞ åìöáíßæåôáé ç óõó÷Ýôéóç ìåôáîýåßäïõò öáñìáêåõôéêÞò áãùãÞò êáé áíáöåñüìåíçòáéôßáò ëÞøçò (÷2=0,048). Óõó÷Ýôéóç õðÜñ÷åé ìå-ôáîý åßäïõò öáñìáêåõôéêÞò áãùãÞò êáé éó÷ýïòáõôÞò (÷2=0,002) õðÝñ ôçò ðåñéóóüôåñï ïñèÞòáãùãÞò, üôáí óõíôáãïãñáöïýíôáé PPIs, (39,1%),ðáñÜ üôáí óõíôáãïãñáöïýíôáé H2-RAs, (14,3%).Äåí õðÜñ÷åé óõó÷Ýôéóç ìåôáîý åßäïõò öáñìáêåõ-ôéêÞò áãùãÞò êáé íüóïõ (÷2=0,144). Óõó÷ÝôéóçõðÜñ÷åé ìåôáîý öáñìáêåõôéêÞò áãùãÞò êáé åíäï-óêüðçóçò (÷2=0,008), õðÝñ ôçò åíäïóêïðéêÞò äéå-ñåýíçóçò, ðéï óõ÷íÜ, ôùí ëáìâáíüíôùí PPIs,(26,9%), áðü ôïõò ëáìâÜíïíôåò H2-RAs, (0%).

Åìöáíßæåôáé óõó÷Ýôéóç ìåôáîý ÷ñüíïõ ëÞ-øçò áãùãÞò êáé óõíå÷ïýò Þ äéáëåßðïõóáò ëÞøçòôçò áãùãÞò (t-test=3,87x10-10), õðÝñ ôçò ðéï ìá-êñï÷ñüíéáò ëÞøçò äéáëåßðïõóáò áãùãÞò, ãåãïíüòáíáìåíüìåíï. Óõó÷Ýôéóç åìöáíßæåôáé ìåôáîý ôïõ÷ñüíïõ ëÞøçò áãùãÞò êáé ôçò áíáöåñüìåíçò áé-ôßáò ëÞøçò (one-way ANOVA significance=3,8x10-3), õðÝñ ôçò ìáêñü÷ñïíçò ëÞøçò áãùãÞò

Ðßíáêáò 5. ÓôÜèìéóç äåßãìáôïò ùò ðñïò ôá äçìïãñáöéêÜ ôïõ óôïé÷åßá

Öýëï Çëéêßá Ðåñéï÷Þ Êáôïéêßáò Íïìüò Êáôïéêßáò

Öýëï - t=0,192 ÷2=0,269 ÷2=0,295Çëéêßá t=0,192 - t=0,843 t=0,757Ðåñéï÷Þ Êáôïéêßáò ÷2=0,269 t=0,843 - ÷2=0,447Íïìüò Êáôïéêßáò ×2=0,295 t=0,757 ÷2=0,447 -

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

ÓôáôéóôéêÞ ÓôÜèìéóç Äåßãìáôïò

Ôï äåßãìá ìáò åßíáé åóùôåñéêÜ óôáèìéóìÝíï,êáèþò äåí ðñïêýðôïõí óôáôéóôéêÜ óçìáíôéêÝòäéáöïñÝò ìåôáîý ôùí ìåôáâëçôþí ðïõ áðïìÝ-íïõí, áí ïðïéáäÞðïôå áðü ôéò ìåôáâëçôÝò áõôÝò,(öýëï-çëéêßá-ðåñéï÷Þ êáôïéêßáò-íïìüò êáôïéêßáò),÷ñçóéìïðïéçèåß ãéá ôç äéÜôìçóç ôïõ äåßãìáôïò.Áõôü ðñïêýðôåé äéüôé óå üëåò ôéò ðåñéðôþóåéòóýãêñéóçò êáôçãïñéêþí ìåôáâëçôþí ç äïêéìáóßáPearson’s ÷2 åßíáé >0,05, åíþ óå üëåò ôéò ðåñé-ðôþóåéò óýãêñéóçò êáôçãïñéêÞò ìå áñéèìçôéêÞìåôáâëçôÞ ç äïêéìáóßá Independent Samples’ ttest åßíáé >0,05, üðùò öáßíåôáé óôïí ðßíáêá 7.

ÓôáôéóôéêÝò Óõó÷åôßóåéò

ÃåíéêÜ, ôï áí äßíåôáé óùóôÞ Þ ü÷é èåñáðåßáäåí öáßíåôáé íá óõó÷åôßæåôáé ìå ôï öýëï(÷2=0,597). Ôï ßäéï éó÷ýåé êáé ãéá ôï öýëï êáéôïí áíáöåñüìåíï ëüãï ëÞøçò (÷2=0,346), ôç íüóï(÷2=0,777), ôï åßäïò ôçò ÷ïñçãïýìåíçò áãùãÞò(÷2=0,173), ôçí êáôçãïñéïðïßçóç ëÞøçò PPIs ÞH2-RAs (÷2=0,936) êáé ôï ÷ñüíï ëÞøçò ôçò áãù-ãÞò (t-test=0,839). Áêüìç, óõó÷Ýôéóç äåí ðñïêý-


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áíôéìåôþðéóçò ôïõ ïðéóèïóôåñíéêïý êáýóïõò êáéôïõ áéóèÞìáôïò ðëçñüôçôáò. Ôï áðñüóöïñá äá-ðáíçèÝí ðïóü óõó÷åôßæåôáé ìå ôçí ïñèüôçôá Þü÷é ôçò èåñáðåßáò (t-test=1,16x10-7), öõóéêÜ õðÝñôùí ìåãáëõôÝñùí ðïóþí óôç ëáíèáóìÝíç áãùãÞ(ìÝóïò üñïò: 486,5 �/Üôïìï) êáé ôùí ìéêñüôåñùíóôçí ïñèÞ (ìÝóïò üñïò: 24,78 �/Üôïìï). Óçìáíôé-êÞ óôáôéóôéêÞ óõó÷Ýôéóç õðÜñ÷åé êáé ìåôáîýáðñüóöïñá äáðáíçèÝíôïò ðïóïý êáé íüóïõ (one-way ANOVA significance=0,003), õðÝñ ôïõ ìå-ãÜëïõ êüóôïõò áíôéìåôþðéóçò ôçò ëåéôïõñãéêÞòãáóôñßôéäáò êáé ôçò ÃÏÐ.

Óõó÷Ýôéóç äå öáßíåôáé íá õðÜñ÷åé ìåôáîýôçò óõíå÷ïýò Þ äéáëåßðïõóáò áãùãÞò êáé ôçòóõìðôùìáôïëïãßáò (÷2=0,307) Þ ôçò ïñèüôçôáòôçò èåñáðåßáò (÷2=0,102) Þ ôçò íüóïõ (÷2=0,125)Þ ôçò ðñáãìáôïðïßçóçò åíäïóêüðçóçò (÷2=0,356).

Óõó÷Ýôéóç åìöáíßæåôáé ìåôáîý áíáöåñüìåíïõóõìðôþìáôïò êáé ïñèüôçôáò áãùãÞò (÷2=0,017),êõñßùò õðÝñ ôçò ëáíèáóìÝíçò áíôéìåôþðéóçò ôïõïðéóèïóôåñíéêïý êáýóïõò (91,67%). ÓáöÞò óõ-ó÷Ýôéóç õðÜñ÷åé ìåôáîý áíáöåñüìåíïõ óõìðôþ-ìáôïò êáé åêôÝëåóçò åíäïóêüðçóçò Þ ü÷é(÷2=0,014), õðÝñ ôçò åêôÝëåóçò åíäïóêüðçóçò óååðéãáóôñáëãßåò (óôï 20% áõôþí).

ÅðéðñïóèÝôùò, äéáðéóôþèçêå, éó÷õñÞ óõó÷Ý-ôéóç ïñèÞò Þ ëáíèáóìÝíçò áíôéìåôþðéóçò óå ó÷Ý-óç ìå ôç íüóï (÷2=6,8x10-8). Ç ðñïôåéíüìåíç èå-ñáðåõôéêÞ áãùãÞ ãéá ôçí ðñïóôáóßá ôïõ ãáóôñé-êïý âëåííïãüíïõ áðü NSAIDs öáßíåôáé üôé Þôáíïñèüôåñç óå áíôßèåóç ìå ôéò èåñáðåßåò ãéá ôéòÃÏÐ, ÐÅ, ËåéôïõñãéêÞ Ãáóôñßôéäá. ÁíáëõôéêÜáõôÜ ðáñïõóéÜæïíôáé óôï ó÷Þìá 10.

ÔÝëïò äåí öáßíåôáé íá õðÜñ÷åé óõó÷Ýôéóçìåôáîý íüóïõ êáé åêôÝëåóçò åíäïóêüðçóçò Þ ü÷é(÷2=0,38).

ÓõæÞôçóç

Óå ìßá ìåëÝôç óôçí Áõóôñáëßá, ç ïðïßá èÝ-ëçóå íá åîåôÜóåé ôçí ïñèüôçôá óõíôáãïãñÜöç-óçò PPIs óå áóèåíåßò êáôÜ ôçí Ýîïäü ôïõò áðüôï íïóïêïìåßï, üðïõ íïóçëåýèçêáí, óôï 62,9%áõôÞ äåí õðÜêïõå óôéò äéáìïñöùìÝíåò ïäçãßåò1.Óýìöùíá ìå ôçí ßäéá ìåëÝôç, ôï 66,9% õðÝóôçåíäïóêüðçóç êáé ìüíï óôï 59,1% äïêéìÜóôçêáíåðáñêþò ðñéí ïé H2-RAs1. Ôï äéêÜ ìáò áíôßóôïé-÷á ðïóïóôÜ, ëáìâÜíïíôáò õðüøç ìüíï üóïõòëáìâÜíïõí PPIs, åßíáé: 60,9%, 10,5%, 14,3% êáé

Ó÷Þìá 9. Áíáöåñüìåíïò ëüãïò ëÞøçò.

óôéò ðåñéðôþóåéò áéóèÞìáôïò ðëçñüôçôáò êáéóõìðôùìÜôùí ÃÏÐ (ó÷Þìá 9), ãåãïíüò ðïõ öá-íåñþíåé ôï Üôïðï ôçò èåñáðåõôéêÞò áíôéìåôþðé-óçò ìüíï ìå PPIs Þ H2-RAs ôçò ëåéôïõñãéêÞòãáóôñßôéäáò. Áõôü, Üëëùóôå, åðéâåâáéþíåôáé êáéóõãêñßíïíôáò ìå ôçí ßäéá ìÝèïäï ÷ñüíï ëÞøçòáãùãÞò êáé íüóïõ (significance=8,6x10-4).

ÔÝëïò äåí õðÜñ÷åé óõó÷Ýôéóç ìåôáîý ÷ñüíïõëÞøçò áãùãÞò êáé ðñáãìáôïðïßçóçò Þ ü÷é åíäï-óêüðçóçò (t-test=0,131), êÜôé ðïõ åðßóçò öáíå-ñþíåé ôçí áóôï÷ßá ôçò äéáãíùóôéêÞò áíôéìåôþðé-óçò: áóèåíåßò ðïõ ðáñáðïíïýíôáé åðß ìáêñüí ãéáóõìðôùìáôïëïãßá äåí ðáñáðÝìðïíôáé ãéá åíäï-óêüðçóç, üðùò èá Ýðñåðå.

ÓçìáíôéêÞ óôáôéóôéêÞ óõó÷Ýôéóç õðÜñ÷åéìåôáîý êüóôïõò êáé óõìðôùìáôïëïãßáò (one-wayANOVA significance=7x10-4), õðÝñ ôïõ ìåãÜëïõêüóôïõò áíôéìåôþðéóçò ôçò ãáóôñßôéäáò. Ôï óõ-íïëéêü êüóôïò äåí öáßíåôáé íá óõó÷åôßæåôáé ìåôçí ïñèüôçôá Þ ü÷é ôçò èåñáðåßáò (t-test=0,482).ÓçìáíôéêÞ óôáôéóôéêÞ óõó÷Ýôéóç õðÜñ÷åé êáé ìå-ôáîý êüóôïõò êáé íüóïõ (one-way ANOVA signi-ficance=7,3x10-3), õðÝñ ôïõ ìåãÜëïõ êüóôïõòáíôéìåôþðéóçò ôçò ëåéôïõñãéêÞò ãáóôñßôéäáò êáéôçò ÃÏÐ.

Åðßóçò, óçìáíôéêÞ óôáôéóôéêÞ óõó÷ÝôéóçõðÜñ÷åé ìåôáîý áðñüóöïñá äáðáíçèÝíôùí ÷ñç-ìÜôùí êáé óõìðôùìáôïëïãßáò (one-way ANOVAsignificance=3,5x10-4), õðÝñ ôïõ ìåãÜëïõ êüóôïõò

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èá ìåßùíå êáôÜ 40-50 åêáôïììýñéá £ áíÜ Ýôïòôá öáñìáêåõôéêÜ Ýîïäá óå Áããëßá êáé Ïõáëëßá.ÐÜíôùò ç áëëáãÞ ôçò áãùãÞò óå H2-RAs öáßíå-ôáé åöéêôÞ, åéäéêÜ óôï ðåñéâÜëëïí ôçò ÐÖÕ óôéòáãñïôéêÝò êáé çìéáóôéêÝò ðåñéï÷Ýò ôçò ÅëëÜäáò,ëüãù ôçò ðñïóùðéêÞò åðáöÞò ôïõ éáôñïý ìå ôïíáóèåíÞ, åöüóïí êÜôé ôÝôïéï ðñáãìáôïðïéÞèçêåóå ìßá ìåëÝôç óôï Portland ôùí ÇíùìÝíùí Ðïëé-ôåéþí ôçò ÁìåñéêÞò. Ï ìÝóïò áñéèìüò óõíôáãþíPPIs áíÜ õðïøÞöéï áóèåíÞ ìåéþèçêå áðü 0,39óôïõò 9 ìÞíåò, ðñéí áðü ôçí åíçìÝñùóç ôùí éá-ôñþí, óå 0,27 óôïõò 9 ìÞíåò ìåôÜ áðü ôçí ðá-ñÝìâáóç20. Åðßóçò, èåìéôÞ, óýìöùíá ìå ôç âé-âëéïãñáößá, åßíáé êáé ç ðñïóðÜèåéá step-downèåñáðåßáò óôïõò áóèåíåßò ìå ÃÏÐ, ðïõ ëáìâÜ-íïõí èåñáðåõôéêÞ äüóç PPI äéò çìåñçóßùò, åöü-óïí äåí Ý÷ïõí ðëÝïí óõìðôþìáôá, êáèþò ôï 79,5%áõôþí äåí áíáöÝñïõí õðïôñïðÞ óôïõò 6 ìÞíåò21.ÂÝâáéá óôç äéêÞ ìáò ìåëÝôç ôÝôïéïé áóèåíåßò äåíõðÞñ÷áí. Áêüìç êáëýôåñá ðáñïõóéÜæïíôáé ôááðïôåëÝóìáôá ðáñüìïéáò ðáñÝìâáóçò óôï Hong-Kong23.

Ï ðëçèõóìüò ôçò õðáßèñïõ ôïí ïðïßï êõ-ñßùò ìåëåôÞóáìå (áãñïôéêüò- çìéáóôéêüò), ðéèá-íþò ëüãù ôçò áðüóôáóçò áðü ôá ìåãÜëá íïóï-êïìåßá êáé ôïõ åëëåßììáôïò åíçìÝñùóÞò ôïõ, äåíõößóôáôáé åíäïóêïðéêÞ ìåëÝôç ôïõ áíùôÝñïõðåðôéêïý ôïõ óõóôÞìáôïò, áí êáé áõôü óõíéóôÜ-ôáé óõ÷íÜ, (40,1%), ëüãù êõñßùò ôçò çëéêßáò ôïõêáé äåõôåñåõüíôùò ôçò óõìðôùìáôïëïãßáò. Áíôß-èåôá, äåí êáôáãñÜöçêå êáìéÜ ìç-áíáãêáßá åí-äïóêüðçóç. ÌÝíåé ìå íÝåò ìåëÝôåò íá áðïäåé÷èåßôï áí óõìâáßíåé ôï ßäéï óôïí áóôéêü ðëçèõóìü Þáí óå áõôüí óõìâáßíåé ôï áíôßóôñïöï. ÐÜíôùòóå ìßá ìåëÝôç óôçí Åëâåôßá, óå ðëçèõóìü ðïõåñ÷üôáí óå åðáöÞ ìå ôçí ÐÖÕ, ðñïÝêõøå üôé ôï49% ôùí åíäïóêïðÞóåùí ðïõ ðáñáããÝëëïíôáíÞôáí ìç áíáãêáßåò14,15. Áßôéá ãéá áõôü õðÞñîáí çëåéôïõñãéêÞ ãáóôñßôéò êáé ç áðïôõ÷çìÝíç Þ ìåñé-êþò ðåôõ÷çìÝíç ðñïçãïýìåíç áãùãÞ14,15. Áíôßèå-ôá, äåí ðáñáðÝìöèçêáí ãéá åíäïóêüðçóç ôï11,8% ôùí áóèåíþí êáé ôï ðïóïóôü áõôü áíÝâç-êå óôï 13,6% ãéá Üôïìá >65 åôþí14,15. Óå ÜëëçìåëÝôç ôï ôåëåõôáßï ðïóïóôü áíåñ÷üôáí óå 27,7%ãéá ôï óýíïëï ôùí áóèåíþí ôçò22.

O êßíäõíïò êëéíéêÞò åðéêÜëõøçò ãáóôñéêÞòíåïðëáóßáò óôéò ðåñéðôþóåéò ðïõ õößóôáíôáé åîáñ-÷Þò öáñìáêåõôéêÞ èåñáðåßá, ÷ùñßò ðñïçãïýìåíçåíäïóêüðçóç, åßíáé õðáñêôüò, åéäéêÜ üôáí ìéëÜìåãéá áóèåíåßò ôçò ôñßôçò çëéêßáò, üðùò ç ðëåéïíü-

Ó÷Þìá 10. ÏñèÞ Þ ëáíèáóìÝíç áíôéìåôþðéóç óå ó÷Ýóç ìå ôç âáóé-êÞ íüóï.

ôï ìåóáßï äéêáéïëïãåßôáé áðü ôçí áäõíáìßá åý-êïëçò ðñüóâáóçò óå åíäïóêïðéêü éáôñåßï. ÓôçíìåëÝôç áõôÞ ôï 17,1% ôùí óõíôáãïãñáöïýìåíùíPPIs áöïñïýóå ðåñéðôþóåéò Þðéáò Þ ìÝôñéáòÃÏÐ1, åíþ óôç äéêÞ ìáò Ýñåõíá, áí óõìðåñéëÜ-âïõìå ìüíï üóïõò ëáìâÜíïõí ôÝôïéá öÜñìáêá,ôï ðïóïóôü Þôáí 12%, ðéèáíþò ëüãù ôïõ üôé ïéáóèåíåßò ìáò ðñïÝñ÷ïíôáí áðü ôçí ÐÖÕ, åíþ çìåëÝôç áõôÞ áöïñïýóå êõñßùò íïóïêïìåéáêïýòáóèåíåßò1. Ôï ðïóïóôü ÷ïñÞãçóçò PPIs ÷ùñßòðñïçãïýìåíç åðáñêÞ äïêéìÞ H2-RAs (üðïõ áõôÞÞôáí äüêéìç) åßíáé 24% óýìöùíá ìå Üëëç ìåëÝ-ôç, ç ïðïßá üìùò åß÷å óôáôéóôéêÜ óçìáíôéêü ìå-ãáëýôåñï ðïóïóôü áóèåíþí ìå ÃÏÐ áðü ôç äéêÞìáò (55% ðñïò 15,4%)22.

Äéåèíþò, Üëëùóôå, ç Üóêïðç óõíôáãïãñÜöç-óç PPIs áðïôåëåß ìåßæïí èÝìá, ùò ðñïò ôçí ïéêï-íïìéêÞ ôïõ ðëåõñÜ, ùò ðñïò ôéò ìáêñï÷ñüíéåòäõíáôÝò ðáñåíÝñãåéåò ðïõ ìðïñïýí áõôïß íá Ý÷ïõíêáé ùò ðñïò ôçí ðáñÜëåéøç ôùí óõóôÜóåùí ìçöáñìáêåõôéêÞò èåñáðåßáò2,3. ÔÜóåéò áýîçóçò ðá-ñáôçñïýíôáé óå üëåò ôéò ÷þñåò, áíåðôõãìÝíåò êáéáíáðôõóóüìåíåò. Ãéá ðáñÜäåéãìá óôçí ÔáúâÜí áðüôï 1997 ùò ôï 2000 ç óõíôáãïãñÜöçóç ôùíPPIs, ðåñßðïõ, äéðëáóéÜóôçêå19. Ôï ÂñåôáíéêüÅèíéêü Éíóôéôïýôï ãéá ôçí ÊëéíéêÞ Áñéóôåßá(NICE) óõíéóôÜ ôïí åðáíÝëåã÷ï ôçò ÷ïñÞãçóçòüëùí ôùí PPIs êáé ðñïôåßíåé üôé ç êáôáíÜëùóÞôïõò èá ìðïñïýóå íá ìåéùèåß ùò 15% êáé áõôü


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ôçôá áõôþí ôçò ìåëÝôçò ìáò. Óå ìßá ìåëÝôç ôïðïóïóôü áõôü áíÞëèå óôï 35,5% óå áíôßèåóç ìåôï 1,9% óôçí ðåñßðôùóç ÷ñÞóçò áíôéüîéíùí Þêáìßáò èåñáðåßáò4. Óôï óçìåßï áõôü âïçèÜ ôï áíï áóèåíÞò åßíáé >45 åôþí Þ áí Ý÷åé êÜðïéï áðüôá ÷áñáêôçñéóôéêÜ ðïõ áðáéôïýí åðåßãïõóá áíôé-ìåôþðéóç, äéüôé, áí äåí óõìâáßíåé êÜôé áðü áõôÜ,ôá ðïóïóôÜ íåïðëáóéþí åßíáé ðïëý ÷áìçëÜ(<0,1%)5. ÐÜíôùò, óôï äéêü ìáò ðåñéâÜëëïí, çáðïäï÷Þ áðü ôïí áóèåíÞ ôçò ãáóôñïïéóïöáãï-óêüðçóçò ùò ìßáò åðåìâáôéêÞò äéáäéêáóßáò ðïõèá ôïí áíáêïýöéæå áðü ôçí áãùíßá ôçò áêñéâïýòäéÜãíùóçò, ðáñÜ ôç óùìáôéêÞ ôáëáéðùñßá ðïõáõôüò èá õößóôáôï, Þôáí ðïëý ðåñéïñéóìÝíç, áíôß-èåôá áðü Üëëåò ìåëÝôåò8.

ÅéäéêÜ, ùò ðñïò ôï èÝìá ôçò óõãêáôáíÜëù-óçò PPIs Þ H2-RAs ìå NSAIDs, ôï ðïóïóôüåðéãáóôñéêïý Üëãïõò áíÝñ÷åôáé óôï 36%27. Ç èíç-ôüôçôá áðü NSAIDs áíÝñ÷åôáé óå 0,22%/Ýôïòêáé ï ó÷åôéêüò êßíäõíïò óå ó÷Ýóç ìå ôïõò ìç÷ñÞóôåò óå 4,21, ìå ôá ìåãÝèç áõôÜ íá áöïñïýíêõñßùò áóèåíåßò ìå ÑåõìáôïåéäÞ Áñèñßôéäá êáéÏóôåïáñèñßôéäá28. Åëðéäïöüñïé áñ÷éêÜ öÜíçêáíïé åêëåêôéêïß COX-2 áíáóôïëåßò (ñïöåêïîßìðç,óåëåêïîßìðç -á’ ãåíåÜò êáé âáëäåêïîßìðç- â’ ãå-íåÜò) óôç ìåßùóç ôùí óïâáñþí åðéðëïêþí áðüôï áíþôåñï ãáóôñåíôåñéêü óýóôçìá, ìå ðáñü-ìïéá, áëëÜ ü÷é êáëýôåñç áðïôåëåóìáôéêüôçôá áðüôá êëáóéêÜ NSAIDs29-31. ÂÝâáéá, ãéá ôç óåëåêï-îßìðç, ç ïñéáêÜ óôáôéóôéêÜ óçìáíôéêÞ ìåßùóçôùí óïâáñþí åðéðëïêþí áðü ôï áíþôåñï ðåðôé-êü, áðü 1,27%/Ýôïò óå 0,44%/Ýôïò (p=0,04) óåáóèåíåßò, ðïõ äåí ëÜìâáíáí ÷áìçëÞ äüóç áóðéñß-íçò (£325mg), ãéíüôáí óôáôéóôéêÜ ìç óçìáíôéêÞãéá áóèåíåßò ðïõ åëÜìâáíáí ÷áìçëÞ äüóç áóðé-ñßíçò (2,12% ðñïò 2,01% ìå p=0,92) [ìåëÝôçCLASS]32. ¼ìùò, ôá ðáñáðÜíù áöïñïýóáí áöå-íüò õøçëÝò äüóåéò NSAIDs êáé áöåôÝñïõ äåíóõìðåñéëÜìâáíáí áðëÜ äõóðåðôéêÜ åíï÷ëÞìáôáêáé ïðéóèïóôåñíéêü êáýóï32. Ðáñüìïéá êñéôÞñéáåß÷å êáé ç ìåëÝôç VIGOR ãéá ôç ñïöåêïîßìðç,óôçí ïðïßá üìùò ç ìåßùóç áðïäåß÷èçêå óôáôé-óôéêÜ óçìáíôéêÞ (1,4 ðñïò 0,6%/Ýôïò ìå p<0,005)33. Óôç ìåëÝôç áõôÞ óôáôéóôéêÜ óçìáíôé-êÞ Þôáí êáé ç ìåßùóç ãåíéêÜ êÜèå êëéíéêÞò åðé-ðëïêÞò áðü ôï ãáóôñåíôåñéêü (4,5 ðñïò 2,1%/Ýôïò ìå p<0,001)33. ÅéäéêÜ ôï èÝìá ôçò ðñüêëç-óçò ëåéôïõñãéêÞò äõóðåøßáò áðü NSAIDs äåí Ý÷åéäéåñåõíçèåß ðëÞñùò, áëëÜ êáé åäþ ç èåñáðåßá ìåPPIs öáßíåôáé áðïåëåóìáôéêÞ85-87. ÐÜíôùò, åðåé-

äÞ íïóçëåýåôáé ãéá íüóï ôïõ áíþôåñïõ ãáóôñå-íôåñéêïý 1 óôïõò (80-300), ðïõ ëáìâÜíïõí NS-AIDs53-72, ç ÷ïñÞãçóç ãáóôñïðñïóôáóßáò óå üëïõòäåí èåùñåßôáé óùóôÞ ôáêôéêÞ. ÐÜíôùò, ç ðñáêôé-êÞ áõôÞ åßíáé óùóôÞ óßãïõñá ãéá áóèåíåßò ìåéóôïñéêü ðåðôéêïý Ýëêïõò, üðïõ ï êßíäõíïò ãéáðåðôéêü Ýëêïò ôåôñáðëáóéÜæåôáé62,73,74,76-84. Ôï ßäéïéó÷ýåé ãéá áóèåíåßò >80 åôþí êáé ãéá áóèåíåßò>60 åôþí, ðïõ ëáìâÜíïõí õøçëÝò äüóåéò Þ ëáì-âÜíïõí êáé êïñôéêïóôåñïåéäÞ52. Óýã÷õóç õðÜñ÷åéùò ðñïò ôç ÷ñÞóç áíôéðçêôéêþí, áëëÜ èåëÞóáìåíá ôá óõìðåñéëÜâïõìå óôïí áëãüñéèìü ìáò52. Ãå-íéêÜ, ùò ðñïò ôçí åêñßæùóç ôïõ Helicobacterpylori óôç ëÞøç NSAIDs, åðéêñáôïýí áíôéêñïõü-ìåíåò áðüøåéò52.

Ùò ðñïò ôçí ðñïóôáóßá áðü óõìâÜìáôá ôïõáíþôåñïõ ãáóôñåíôåñéêïý óõóôÞìáôïò óå áóèå-íåßò ðïõ ëáìâÜíïõí NSAIDs êáé Ý÷ïõí éóôïñéêüôÝôïéùí, óáöþò ïé PPIs ðñïóôáôåýïõí ðïëý êá-ëýôåñá áðü ôç ìéóïðñïóôüëç êáé ôïõò H2-RAs.Ãéá ðáñÜäåéãìá, ôá ðïóïóôÜ ðñïóôáóßáò áðüåðáíåîÝëêùóç ôïõ äùäåêáäáêôýëïõ, óå ôÝôïéåòðåñéðôþóåéò, åßíáé 3% ãéá ôçí ïìåðñáæüëç, 10%ãéá ôçí ìéóïðñïóôüëç êáé 12% ãéá ôçí ïìÜäáåëÝã÷ïõ óå äéðëÞ ôõöëÞ ìåëÝôç åëåã÷üìåíç ìåïìÜäá placebo34. Áêüìç, öÜíçêå óå Üëëç ðñïï-ðôéêÞ, ôõ÷áéïðïéçìÝíç, äéðëÞ ôõöëÞ ìåëÝôç üôé çóåëåêïîßìðç õðåñôåñåß ùò ðñïò ôá óõìâÜìáôááðü ôï áíþôåñï ãáóôñåíôåñéêü áðü ôï óõíäõá-óìü äéêëïöåíÜêçò êáé ïìåðñáæüëçò35. ÂÝâáéá, çäéêëïöåíÜêç ßóùò áðïôåëåß ó÷åôéêÜ áóöáëÝò ãéáôï ãáóôñåíôåñéêü NSAID êáé ôï áðïôÝëåóìá åîç-ãåßôáé Ýôóé36.

ÅéäéêÜ ç áìéãÞò ëåéôïõñãéêÞ äõóðåøßá92, ìåêýñéá óõìðôþìáôá ôïí ôõìðáíéóìü êáé ôï áß-óèçìá ðëçñüôçôáò ìåôÜ áðü êáôáíÜëùóç ìéêñÞòðïóüôçôáò ôñïöÞò, áðïôåëåß Ýíá èÝìá äýóêïëáäéåñåõíÞóéìï ìå ôá óõíÞèç åñãáóôçñéáêÜ ìÝóá52.Áðïôåëåß ôï áßôéï óôï 60% ôùí äõóðåøéþí, áëëÜóôéò ìåëÝôåò êáôáëáìâÜíåé ìéêñüôåñï ðïóïóôüäéüôé ðïëý ìéêñüôåñï ðïóïóôü ôùí áóèåíþí ðá-ñïõóéÜæåôáé ãéá ôï ëüãï áõôü óôïí éáôñü88-89.ÅðåéäÞ ç äéêÞ ìáò ìåëÝôç åß÷å ôõ÷áßï äåßãìááóèåíþí, áëëÜ ü÷é ãáóôñåíôåñïëïãéêþí áóèåíþí,èá áíáìÝíáìå ìéá õøçëüôåñç óõ÷íüôçôÜ ôçò áðüôï 15,4% ðïõ âñÞêáìå. H óõíÞèçò áãùãÞ ðåñé-ëáìâÜíåé ôá êïéíÜ áðïäåêôÜ ðñïêéíçôéêÜ44 öÜñ-ìáêá, ìå Þ ÷ùñßò H2-RAs. ÕðÜñ÷ïõí åíäåßîåéòüôé, ôá ìéêñÜ, óõ÷íÜ ãåýìáôá êáé ç áðïöõãÞëéðáñþí ôñïöþí âïçèïýí40,41. ÌéêñÜ ðëåïíåêôÞ-

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ìáôá öáßíïíôáé íá ðñïóöÝñïõí ïé PPIs êáé çèåñáðåßá åêñßæùóçò ôïõ H. Pylori. ¼ëá ôá ðáñá-ðÜíù öÜñìáêá Ý÷ïõí áðïäåé÷èåß áíþôåñá áðüôï placebo43. Óå åììÝíïíôá óõìðôþìáôá, öáßíå-ôáé íá âïçèÜ ç ÷ïñÞãçóç ôùí íåüôåñùí åêëåêôé-êþí áíáóôïëÝùí åðáíáðñüóëçøçò óåñïôïíßíçò(SSRIs), üðùò ç ðáñïîåôßíç45, Þ åêëåêôéêþí áãù-íéóôþí ôçò óåñïôïíßíçò óôïõò õðïäï÷åßò 1D46-49.Ç óéëíôåíáößëç (áíáóôïëÝáò ôçò öùóöïäéåóôå-ñÜóçò ôýðïõ 5)50 êáé ç êëïíéäßíç (êåíôñéêüò áãù-íéóôÞò á2 õðïäï÷Ýùí)51 ìåéþíïõí ôï ìõúêü ôüíïôïõ óôïìÜ÷ïõ êáé åßíáé öÜñìáêá ðïõ ßóùò óôïìÝëëïí áðïäåé÷èïýí ÷ñÞóéìá. Óôç äéêÞ ìáò ìåëÝ-ôç óå êáíÝíá áðü ôïõò ðÜó÷ïíôåò áðü ëåéôïõñãé-êÞ äõóðåøßá äåí åß÷å ðñïóôåèåß ðñïêéíçôéêÞ áãù-ãÞ. Ç ëåéôïõñãéêÞ äõóðåøßá óõíäõÜæåôáé óôï 46%ôùí áóèåíþí ìå óýíäñïìï åõåñÝèéóôïõ åíôÝñïõêáé áðáéôåßôáé ç õðïøßá ôïõ éáôñïý ôçò ÐÖÕãéá ôç äéÜãíùóç êáé ôïõ óõíäñüìïõ áõôïý ìáæßìå ôç ëåéôïõñãéêÞ äõóðåøßá42.

Ùò ðñïò ôï óõíïëéêü êüóôïò ôçò ÷ïñçãçèåß-óáò èåñáðåßáò áõôü áíÝñ÷åôáé óå 319,63 �/Üí-èñùðï-Ýôïò êáé åßíáé ìéêñüôåñï ìå ôçí êáôáíÜ-ëùóç Ñáíéôéäßíçò (205,6 �/Üíèñùðï-Ýôïò 34%)êáé õøçëüôåñï ìå ðñáæüëåò (525,78 �/Üíèñùðï-Ýôïò- 66%). Ãéá ôïõò áóèåíåßò ðïõ êáôáíáëþíïõíäéáëåéðüíôùò ôçí áãùãÞ ôïõò õðïëïãßóèçêå ôïêüóôïò ìå âÜóç ôçí êáôáíÜëùóç óôï 50% ôùíçìåñþí. Óáöþò óôïõò õðïëïãéóìïýò ìáò õðåéóÝñ-÷ïíôáé ôá óöÜëìáôá ôçò ìç óùóôÞò ìíÞìçò ôïõáêñéâïýò ÷ñüíïõ ëÞøçò ôçò áãùãÞò, ôçò èåþñç-óçò ôïõ óçìåñéíïý (êáé öèçíüôåñïõ) êüóôïõò êáéôïõ õðïëïãéóìïý ôïõ êüóôïõò áíÜ çìÝñá, ìå âÜóçôï ïéêïíïìéêÜ ðéï óõìöÝñïí óêåýáóìá áðü ðëåõ-ñÜò áñéèìïý äéóêßùí êáé ôéìÞò. ¼ëá áõôÜ ôåß-íïõí íá êïóôïëïãÞóïõí ëéãüôåñï ôç èåñáðåßá áðüôçí ðñáãìáôéêüôçôá.

Ç ïéêïíïìéêÞ æçìßá áíÝñ÷åôáé óôï óýíïëïôùí 60.328,46 � õðïëïãßæïíôáò ìüíï ôï ÷ñïíéêüäéÜóôçìá óôï ïðïßï ç ëÞøç Þôáí áðïëýôùò áäé-êáéïëüãçôç. Ôï ðïóü áõôü áðïôåëåß ôï 80,9%ôùí ÷ñçìÜôùí, ðïõ óõíïëéêÜ êüóôéóáí ïé öáñ-ìáêåõôéêÝò áãùãÝò (74.580,96 �) ôçò ìåëÝôçò.ÄéáöïñåôéêÜ, áõôü ìåôáöñÜæåôáé óå 258,55 �/Üíèñùðï-Ýôïò, ðïõ Ýñ÷åôáé óå åðáöÞ ìå ôçí ÐÖÕ.Ãéá ôç Ñáíéôéäßíç áõôü åßíáé 189,16 �/Üíèñùðï-Ýôïò êáé ãéá ôéò ðñáæüëåò 395,29 �/Üíèñùðï-Ýôïò. Ç åöéêôÞ ìåßùóç ôùí ïéêïíïìéêþí áðù-ëåéþí, èåùñþíôáò ôá ðáñáðÜíù ðïóÜ, îåðåñíÜêáôÜ ðïëý ôï óôü÷ï ôçò êáôÜ 15% ìåßùóçò ôçò

óõíôáãïãñÜöçóçò PPIs ðïõ èÝôåé ôï NICE93.


ÓõíïëéêÜ èá ðáñáôçñïýóáìå ôéò åîÞò áäõ-íáìßåò óôçí ðñáêôéêÞ ôùí éáôñþí:1) ÁíåðáñêÞò äéåñåýíçóç ðñéí ôçí Ýíáñîç áãù-

ãÞò,2) Ìç ôÞñçóç ôùí ïäçãéþí ãéá ôçí áíôéìåôþ-

ðéóç ôùí ðáñáðÜíù íüóùí,3) Õðåñ÷ñçóéìïðïßçóç ôùí PPIs,4) ÁíåðáñêÞò åðáíÝëåã÷ïò ôùí áóèåíþí óôï

÷ñüíï,5) ¢ãíïéá êáé ìç ðáñÝìâáóç ùò ðñïò ôç ëïéðÞ

áãùãÞ ôùí áóèåíþí, ðïõ óõ÷íÜ åðéâáñýíåéôéò íüóïõò áõôÝò.Ç äéáðßóôùóç äåí ìðïñåß íá åßíáé Üëëç áðü

ôçí åðéôáêôéêÞ áíÜãêç åíüò éáôñïý óõíôïíéóôÞêáé õðåýèõíïõ ãéá ôï óýíïëï ôùí ðñïâëçìÜôùíõãåßáò ôïõ áóèåíÞ, ìå ôïí ïðïßï ç åðáöÞ èáîåöåýãåé áðü ôç óõíÞèç -äõóôõ÷þò- ðåñéóôáóéá-êÞ êáé áðïóðáóìáôéêÞ1 áíôéìåôþðéóç.

Óôï äßëçììá áí ðñÝðåé íá ðáñáðÝìøïõìåãéá åíäïóêüðçóç Þ ü÷é ðÝñá áðü ôá ðáñáðÜíùáò óêåöèïýìå ôïí áõîçìÝíï êßíäõíï íåïðëáóßáòóå çëéêßåò ìåãáëýôåñåò ôùí 45 åôþí, ðïõ óõíÞ-èùò áöïñïýí ìåãÜëï ðïóïóôü ôçò åñãáóßáò ìáòêáé ôï üôé ï áóèåíÞò åßíáé ìßá éäéáßôåñç ìïíÜäáêáé ü÷é áðüëõôá ôìÞìá ìéáò óôáôéóôéêÞò ïìÜ-äáò16.

Ôï óðáôáëïýìåíï ðïóü óå öáñìáêåõôéêÝòáãùãÝò ìç êáôÜëëçëåò êáé óå ðïëëÝò ðåñéðôþ-óåéò åíôåëþò ðåñéôôÝò åßíáé éêáíü íá áíáäåßîåé ôïðñüâëçìá ôçò åóöáëìÝíçò óõíôáãïãñÜöçóçò ôÝ-ôïéùí ïõóéþí.

ÐÜíôùò, üðùò öáßíåôáé êáé áðü ôç óõíïëé-êÞ áíáóêüðçóç ìåëåôþí óå êáìéÜ ðåñßðôùóç äåíåßíáé ìå âåâáéüôçôá ãíùóôÞ ìßá áäéáìöéóâÞôçôááðïôåëåóìáôéêüôåñç èåñáðåßá ãéá ôéò ðáñáðÜíùíüóïõò. Ôá óõìðåñÜóìáôá åßíáé áêüìç ðéï áóá-öÞ üôáí óõíõðïëïãßóïõìå ôï ïéêïíïìéêü êüóôïòôùí íïóçìÜôùí áõôþí.18

Óå ãåíéêÝò ãñáììÝò äéáöáßíåôáé ôï ðüóï ìå-ãÜëç åßíáé ç áíÜãêç ïé éáôñïß ôçò ÐñùôïâÜèìéáòÖñïíôßäáò Õãåßáò íá åíçìåñþíïíôáé ãéá ôéò äéå-èíþò áíáãíùñéóìÝíåò ïäçãßåò êáé íá óõììïñöþ-íïíôáé ìå áõôÝò Ýôóé þóôå íá ðáñÝ÷ïõí áðïôåëå-óìáôéêÞ äéá÷åßñéóç ôùí ãáóôñïïéóïöáãéêþí íï-óçìÜôùí.


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1. Naunton M, Peterson GM; Bleasel MD. Over-use of proton pump inhibitors. J Clin PharmTher, 25:333-40, 2000.

2. Bashford JNR, Norwood J, Chapman SR. Whyare patients prescribed proton pump inhibitors?Retrospective analysis of link between morbid-ity and prescribing in the General PracticeResearch Database. British Medical Journal,317:452-456, 1998.

3. Bloath EH, Bleckinsopp A. The rise and rise ofproton pump inhibitor drugs: patients’ perspec-tives. Social Science & Medicine, 45:1571-1579,1997.

4. Bramble MG, Suvakovic Z, Hungin AP. Detec-tion of upper gastrointestinal cancer in patientstaking antisecretory therapy prior to gastrosco-py. Gut, 46:464-7, 2000.

5. Breslin NP, Thomson AB, Bailey RJ, BlusteinPK, Meddings J, Lalor E, et al. Gastric cancerand other endoscopic diagnoses in patients withbenign dyspepsia. Gut, 46:93-7, 2000.

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Ê. Óõñéáíüò êáé óõí.



ÅéóáãùãÞ

Ôá óôïé÷åßá ãéá ôç èíçóéìüôçôá,ðïõ áíôëïýíôáé áðü ôá ðéóôïðïéçôé-êÜ èáíÜôïõ áðïôåëïýí ôïí áêñïãù-íéáßï ëßèï ôùí åðéäçìéïëïãéêþí ìåëå-ôþí óå Ýíá ðëçèõóìü. Åêôüò áðü ôïíðñïóäéïñéóìü ôçò åðßðôùóçò ôùí äéÜ-öïñùí áéôéþí ôïõ èáíÜôïõ óå Ýíáíðëçèõóìü, áõôÜ ôá óôïé÷åßá ÷ñçóéìï-ðïéïýíôáé ãéá ôïí êáèïñéóìü óôñáôç-ãéêþí ðñüëçøçò, ãéá ôç äéáíïìÞ ôùíðüñùí ôçò õãåéïíïìéêÞò ðåñßèáëøçò,ãéá ôç ÷ñçìáôïäüôçóç ðñïãñáììÜôùíÝñåõíáò ôùí äéÜöïñùí íïóçìÜôùí êáéôÝëïò ãéá ôçí áîéïëüãçóç ôçò áðïôå-ëåóìáôéêüôçôáò ôùí äçìüóéùí ðñï-ãñáììÜôùí õãåßáò1,2.

Ï âáèìüò åãêõñüôçôáò ôùí óôïé-÷åßùí ðïõ áíôëïýíôáé áðü ôá ðéóôï-ðïéçôéêÜ èáíÜôïõ åîáñôÜôáé áðü ôçí

ÐåñßëçøçÔá ðéóôïðïéçôéêÜ èáíÜôïõ åßíáé óçìáíôéêÞ ðçãÞ ðëçñïöïñéþí êáé ïé óôáôéóôé-êÝò íïóçñüôçôáò êáé èíçóéìüôçôáò, ðïõ ÷ñçóéìïðïéïýíôáé ãéá ôçí áíÜðôõîçðñïãñáììÜôùí õãåßáò, âáóßæïíôáé ó’ áõôÝò ôéò ðëçñïöïñßåò. Óêïðüò ôçò ìåëÝ-ôçò åßíáé ç êáôáãñáöÞ ôçò óõ÷íüôçôáò åìöÜíéóçò ôõðéêþí êáé ïõóéáóôéêþíáíáêñéâåéþí óôá ðéóôïðïéçôéêÜ èáíÜôïõ êáé ç áîéïëüãçóç ôçò åðÜñêåéÜò ôïõòóôçí ðáñï÷Þ ðëçñïöïñéþí ãéá ôéò áéôßåò èáíÜôïõ. Õëéêü êáé ìÝèïäïò: êÜíáìåáíÜëõóç 86 ðéóôïðïéçôéêþí èáíÜôïõ, 49 áðü ôá êÝíôñá õãåßáò êáé 37 áðüíïóïêïìåéáêÝò ìïíÜäåò ôçò ÄõôéêÞò Ìáêåäïíßáò. Ïé ãéáôñïß ðïõ ðéóôïðïßçóáíôï èÜíáôï óôá êÝíôñá õãåßáò Þôáí Ãåíéêïß ãéáôñïß êáé áãñïôéêïß ãéáôñïß. ÔáðéóôïðïéçôéêÜ áðü ôéò íïóïêïìåéáêÝò ìïíÜäåò Þôáí áðü ãéáôñïýò äéÜöïñùíåéäéêïôÞôùí. Áñ÷éêÜ åîåôÜóáìå ôç óõììüñöùóç ôùí ãéáôñþí ìå ôéò ïäçãßåòðïõ áíáãñÜöïíôáé ðÜíù óôá Ýíôõðá ðéóôïðïßçóçò êáé óôç óõíÝ÷åéá êÜíáìåáíÜëõóç, âáóéóìÝíç óôéò ïäçãßåò ðéóôïðïßçóçò èáíÜôïõ ðïõ äçìïóéåýôçêáíóôï American Family Physician ôï 1997, åðåéäÞ ç ÅëëÜäá õéïèåôåß ôï áìåñéêÜ-íéêï ðñüôõðï ðéóôïðïßçóçò. ÁðïôåëÝóìáôá: Ôï ðéï óõ÷íü êïéíü óöÜëìá ðïõåíôïðßóáìå óôá ðéóôïðïéçôéêÜ èáíÜôïõ Þôáí ç ÷ñÞóç ôçò êáñäéáêÞò Þ ôçòêáñäéïáíáðíåõóôéêÞò áíáêïðÞò ùò áéôßá èáíÜôïõ. Áõôüò ï üñïò åßíáé ìéá ðåñé-ãñáöÞ ôçò ýðáñîçò íåêñïý êáé äåí ðáñÝ÷åé êáìéÜ ðëçñïöïñßá ùò ðñïò ôïíõðïêñõðôüìåíï ôñáõìáôéóìü Þ íüóï ç äéáäéêáóßá, áñìüäéá ãéá ôçí ðñüêëçóçôïõ èáíÜôïõ. Áõôüò ï üñïò ÷ñçóéìïðïéåßôáé ùò áéôßá èáíÜôïõ óå 32% ôùíðéóôïðïéçôéêþí ôùí ÊÕ êáé óå 58% ôùí ðéóôïðïéçôéêþí ôùí íïóïêïìåéáêþíìïíÜäùí. Åíôïðßóáìå åðßóçò óöÜëìáôá áëëçëïõ÷ßáò ùò ðñïò ôçí Üìåóç, ôçíåíäéÜìåóç êáé ôçí õðïêñõðôüìåíç áéôßá èáíÜôïõ óå 47% ôùí ðéóôïðïéçôéêþí,áíôáãùíéóôéêÝò áéôßåò èáíÜôïõ óå 19%, ìç êáôáãñáöÞ ôïõ ÷ñïíéêïý äéáóôÞìá-ôïò ìåôáîý Ýíáñîçò ôçò íüóïõ êáé ôïõ èáíÜôïõ óå 94% êáé Üëëåò áíáêñßâåéåò,ðïõ ðáñïõóéÜæïíôáé êáé áíáëýïíôáé. ÓõìðåñÜóìáôá: Ôá ðéóôïðïéçôéêÜ èáíÜôïõäåí ìðïñïýí, ìå ôïí ôñüðï üðùò óõìðëçñþíïíôáé óÞìåñá, íá áðïôåëïýíáîéüðéóôç ðçãÞ ãéá óôáôéóôéêÝò ìåëÝôåò. Áðáéôåßôáé ßóùò ìéá åðåîåñãáóßá åèíé-êþí êáôåõèõíôÞñéùí ïäçãéþí ãéá íá îåðåñáóôåß áõôÞ ç áäõíáìßá.

Ïé áíáêñßâåéåò óôçí ðéóôïðïßçóç ôçò áéôßáò èáíÜôïõ

Êá÷ëÜí Óõñéáíüò1, Âéêôùñßá ËÝôôá2, ÊëåïðÜôñá ÊïõñÜêç2, ÄÞìçôñá ÊáêëáìÜíïõ-Âñåôôïý3

1ÅÊÁÂ ÊïæÜíçò, 2ÊÝíôñï Õãåßáò ÓéÜôéóôáò ÊïæÜíçò, 3Ã.Í. ÊïæÜíçò

ËÝîåéò êëåéäéÜ: ¢ìåóç áéôßá èáíÜôïõ, Ìç÷áíéóìüòèáíÜôïõ, Ôñüðïò ôïõ èáíÜôïõ, Ðéóôïðïßçóç èáíÜ-ôïõ, Õðïêñõðôüìåíç áéôßá èáíÜôïõÕðïâëÞèçêå: Ç åñãáóßá õðïâëÞèçêå ùò åëåýèåñçáíáêïßíùóç óôï 16ï ÐáíåëëÞíéï ÓõíÝäñéï ÃåíéêÞòÉáôñéêÞò (Êùò, 14-18 Áðñéëßïõ 2004) êáé âñáâåýèç-êå áðü ôçí ÅðéôñïðÞ Êñßóçò, Äçìïóéåýåôáé ìå êïé-íÞ áðüöáóç ôçò ÓõíôáêôéêÞò ÅðéôñïðÞò ôïõ Ðåñéï-äéêïý êáé ôçò ÏñãáíùôéêÞò ÅðéôñïðÞò ôïõ Óõíå-äñßïõÕðåýèõíïò áëëçëïãñáößáò: Êá÷ëÜí Óõñéáíüò, ÁãßáòÐáñáóêåõÞò 23, 501 00, ÊïæÜíç, Ôçë.: (24610) 21065,(24610) 32988

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Ê. Óõñéáíüò êáé óõí. Ôüìïò 16, Ôåý÷ïò 2, 2004

óôï 0,90, åíþ ãéá ôï êáñäéáããåéáêüóýóôçìá åßíáé ðåñßðïõ 0,286. Ïé ìåëÝ-ôåò áðü ôç Óïõçäßá áíáöÝñïõí üôéáõôÞ ç åõáéóèçóßá åßíáé ìåéùìÝíç ãéááóèÝíåéåò, üðùò ï óáê÷áñþäçò äéáâÞ-ôçò êáé ç ñåõìáôéêÞ íüóïò ôçò êáñ-äéÜò7. Óôéò áíáêñßâåéåò ðïõ åìöáíßæï-íôáé óôá ðéóôïðïéçôéêÜ èáíÜôïõ áðï-äßäïíôáé ïé ðëáóìáôéêÝò áõîçôéêÝòôÜóåéò ôçò èíçóéìüôçôáò óôïí êáñêß-íï ôïõ ðñïóôÜôç8-10.

ÐïëëÜ óöÜëìáôá óôçí ðéóôïðïßç-óç ôïõ èáíÜôïõ ðñïÝñ÷ïíôáé áðü ôçóýã÷õóç ôùí üñùí “áéôßá” êáé “ôñü-ðïò” ôïõ èáíÜôïõ, áðü ôçí ðåñéãñá-öÞ ôçò áêïëïõèßáò ôùí íïóïëïãéêþíêáôáóôÜóåùí áðü ôçí õðïêñõðôüìå-íç Ýùò ôçí Üìåóç áéôßá ôïõ èáíÜôïõêáé áðü ôç óýã÷õóç ìåôáîý ôçò õðï-êñõðôüìåíçò êáé óõìâÜëëïõóáò ðÜèç-óçò3. Ïé ãéáôñïß ìå ðåñéóóüôåñç ðñï-óï÷Þ ìðïñïýí íá îåêáèáñßóïõí ôçíêÜèå Ýííïéá áð´ áõôÝò êáé íá óõìâÜë-ëïõí óôç âåëôßùóç ôùí åðéäçìéïëïãé-

The inaccuracies in the certification of cause of death.K. Syrianos, Victoria Letta, Kleopatra Kouraki, Dimitra Kaklamanou-Vrettou

SummaryAim: To study the frequency of essential inaccuracies in death certificates andthe evaluation of their sufficiency to provide information on the causes of death.Study population-Method: eighty-six death certificates were analysed, 49 fromhealth centres and 37 from hospitals of Western Macedonia. The doctors thatcertified the death in the centres of health were General Doctors and ruraldoctors. Doctors of different specialties completed the certificates from thehospitals. The assessment of the certificates was based on the directives ofcertification of death, published in the journal "American Family Physician" in1997, as a result of Greece adopting the American model of certification ofdeath. Results: The most frequent common error in death certificates was theuse of cardiac or cardio-respiratory arrest as a cause of death. This term isused as a cause of death in 32% of certificates from the health centres and in58% of certificates from hospitals. Sequence errors were identified in 47% ofcertificates, competitive causes of death in 19%, absence of time intervalsbetween the beginning of illness and death, in 94%. Other inaccuracies arepresented and analyzed. Conclusions: the way, in which death certificates arebeing completed today, cannot constitute a reliable source for statistical studi-es. Perhaps there is a need for national guidelines to improve the accuracy ofdeath certificates.Key Words: Death certificates, Cause of death, Immediate cause of death,Mechanism of death, Manner of Death, Underlying cause of death

êþí ìåëåôþí Üëëá êáé íá åêðëçñþóïõí ôï ÷ñÝïòðïõ Ý÷ïõí áðÝíáíôé óôéò ïéêïãÝíåéåò ôùí èáíü-íôùí, ðñïóöÝñïíôáò êáëýôåñç êáôáíüçóç, ôé åõ-èýíåôáé ãéá ôï èÜíáôï ôïõ áíèñþðïõ ôïõò1.

Ç ðáñïýóá ìåëÝôç ðñïóðáèåß íá áîéïëïãÞ-óåé ôçí åðÜñêåéá ôùí ðéóôïðïéçôéêþí èáíÜôïõ,ðïõ óõìðëçñþíïíôáé áðü ôïõò ãéáôñïýò ôùí õãåéï-íïìéêþí ìïíÜäùí, óôçí ðáñï÷Þ ðëçñïöïñéþí ãéáôéò áéôßåò èáíÜôïõ. ÅîåôÜæåé ôç óõ÷íüôçôá åìöÜ-íéóçò ôõðéêþí êáé ïõóéáóôéêþí áíáêñéâåéþí ó’áõôÜ ôá ðéóôïðïéçôéêÜ êáé ôç óõììüñöùóç ôùíãéáôñþí ìå ôéò ïäçãßåò, ðïõ áíáãñÜöïíôáé óôáÝíôõðá ðéóôïðïßçóçò.

Ðëçèõóìüò ìåëÝôçò - ÌÝèïäïò

Õëéêü ôçò ìåëÝôçò åßíáé 86 ðéóôïðïéçôéêÜèáíÜôïõ, ðïõ åðéëÝ÷èçêáí ôõ÷áßá áðü ôá ÊÝ-íôñá Õãåßáò êáé ôá Íïóïêïìåßá ôïõ Íïìïý Êï-æÜíçò. Ôá 49 ðéóôïðïéçôéêÜ åß÷áí óõìðëçñùèåßáðü ãåíéêïýò êáé áãñïôéêïýò ãéáôñïýò ôùí ÊÝ-íôñùí Õãåßáò êáé ôá õðüëïéðá 37 áðü íïóïêï-ìåéáêïýò ãéáôñïýò. Ç ìåëÝôç ðåñéïñßæåôáé óôçíåîÝôáóç ôùí ðéóôïðïéçôéêþí èáíÜôïõ, ÷ùñßò íááíáæçôÞóåé ðëçñïöïñßåò áðü ôïõò éáôñéêïýò öá-

áêñßâåéá ìå ôçí ïðïßá äéåíåñãåßôáé ç ðéóôïðïßç-óç, ç ïðïßá åßíáé áñìïäéüôçôá ôùí ãéáôñþí, çðëåéïøçößá ôùí ïðïßùí äåí ëáìâÜíåé åðßóçìçêáôÜñôéóç óôïí êáèïñéóìü ôçò áéôßáò êáé ôïõôñüðïõ ôïõ èáíÜôïõ3. Ïé Ýñåõíåò äåß÷íïõí üôéìüíï ôï 56% ôùí åéäéêåõïìÝíùí êáé 56,9% ôùíåéäéêåõìÝíùí ãéáôñþí åßíáé óå èÝóç íá äéáôõðþ-óïõí óùóôÜ ôçí áéôßá èáíÜôïõ2,3, ãé’ áõôü ïéåñåõíçôÝò ðñÝðåé íá åßíáé éäéáßôåñá ðñïóåêôéêïßóôç ÷ñÞóç ôùí ðéóôïðïéçôéêþí èáíÜôïõ ãéá ôéòáéôéïëïãéêÝò ìåëÝôåò ëüãù ôçò äõíáôüôçôáò óç-ìáíôéêÞò áðüêëéóçò áðü ôçí ðñáãìáôéêüôçôá.

ÐïëëÝò ìåëÝôåò áó÷ïëÞèçêáí ìå âáèìü åãêõ-ñüôçôáò ôùí ðéóôïðïéçôéêþí èáíÜôïõ óôçí ðá-ñï÷Þ ðëçñïöïñéþí ãéá ôéò åðéäçìéïëïãéêÝò ìåëÝ-ôåò. Óôéò ÇÐÁ ïé ìåëÝôåò áðÝäåéîáí üôé ôá ðé-óôïðïéçôéêÜ èáíÜôïõ áðïäßäïõí 24,3% ðåñéóóü-ôåñïõò èáíÜôïõò óôç óôåöáíéáßá íüóï óôï ãåíé-êü ðëçèõóìü êáé ðåñßðïõ ôï äéðëÜóéï ðïóïóôüóôïõò çëéêéùìÝíïõò4,5. Áðü ôç óýãêñéóç ôùí áé-ôéþí èáíÜôïõ ðïõ áíáãñÜöïíôáé óôá ðéóôïðïéç-ôéêÜ ìå ôá áðïôåëÝóìáôá ôçò íåêñïøßáò ðñïÝêõ-øå üôé ç åõáéóèçóßá áõôþí ôùí ðéóôïðïéçôéêþíóôïí åíôïðéóìü ôçò áéôßáò èáíÜôïõ åßíáé ãåíéêþòãýñù óôá 0,47 êáé êõìáßíåôáé áðü óýóôçìá óåóýóôçìá. Ãéá ôï íåõñïëïãéêü óýóôçìá åßíáé ãýñù


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êÝëïõò Þ áðü Üëëåò ðçãÝò. Äåí åîåôÜæåé ôç ó÷Ýóçôùí äåäïìÝíùí ìå ôïõò èáíüíôåò, áëëÜ ôç ó÷Ýóçôùí äåäïìÝíùí ìåôáîý ôïõò. Ãé áõôü ôï óêïðü÷ñçóéìïðïéåß êñéôÞñéá áîéïëüãçóçò âáóéóìÝíá óôéòðñïôÜóåéò ôïõ Ðáãêüóìéïõ Ïñãáíéóìïý Õãåßáò.ÁõôÜ ôá êñéôÞñéá áðïôåëïýíôáé áðü Ýîé åñùôÞ-ìáôá: 1) Áí õðÞñîå ìéá áðïäåêôÞ áéôßá ôïõ èá-íÜôïõ, 2) ÅÜí ïé ìç÷áíéóìïß ôïõ èáíÜôïõ ðïõêáôáãñÜöçêáí, åîçãÞèçêáí åðáñêþò áðü ìéá õðï-êñõðôüìåíç áéôßá ôïõ èáíÜôïõ, 3) Áí õðÞñîáíïðïéáäÞðïôå óöÜëìáôá áëëçëïõ÷ßáò, 4) Áí åì-öáíßóèçêáí óôç ëßóôá áíôáãùíéóôéêÝò áéôßåò ôïõèáíÜôïõ, 5) Áí êáôáãñÜöçêáí ôá ÷ñïíéêÜ äéá-óôÞìáôá ìåôáîý ôçò Ýíáñîçò ôçò ðÜèçóçò êáéôïõ èáíÜôïõ, êáé 6) Áí êáôáãñÜöçêáí ïðïéåó-äÞðïôå Üëëåò áêáôÜëëçëåò ðëçñïöïñßåò11.

ÅðåéäÞ ç ÅëëÜäá ÷ñçóéìïðïéåß ôï áìåñéêÜíé-êï ðñüôõðï ðéóôïðïßçóçò èáíÜôïõ ÷ñçóéìïðïéÞ-óáìå ôéò ïäçãßåò, ðïõ äçìïóéåýôçêáí óôï Amer-ican Family Physician ôï 1997 êáé Üëëåò âé-âëéïãñáöéêÝò áíáöïñÝò ãéá ôïí áêñéâÞ ïñéóìüôùí ÷ñçóéìïðïéçìÝíùí üñùí3,12. Ïé ÷ñçóéìïðïéç-ìÝíïé üñïé öáßíïíôáé óôï ðáñÜñôçìá óôïí ðßíá-êá 2. Ãéá ôçí ôáîéíüìçóç ôùí óöáëìÜôùí, ðïõåíôïðßóôçêáí ÷ñçóéìïðïéÞóáìå ôï óýóôçìá, ðïõ÷ñçóéìïðïßçóå ç Myers óôéò ìåëÝôåò ôçò ðïõ äéå-íÝñãçóå óôïí ÊáíáäÜ12. Ç ÷ñçóéìïðïéçìÝíç ïñï-ëïãßá êáé ç ôáîéíüìçóç ôùí óöáëìÜôùí öáßíï-íôáé óôïí ðßíáêá 2 êáé 3 ôïõ ðáñáñôÞìáôïò.

Ðåñéïñßóáìå ôçí åîÝôáóÞ ìáò óôïí åíôïðé-óìü ôñéþí ìåßæïíùí óöáëìÜôùí êáé ôñéþí åëÜó-óïíùí óöáëìÜôùí. Ùò ìåßæïíá óöÜëìáôá èåùñÞ-óáìå ôçí åìöÜíéóç ôïõ ìç÷áíéóìïý èáíÜôïõ, ùòáéôßá èáíÜôïõ, ÷ùñßò íá óõíïäåýåôáé áðü ìéáõðïêñõðôüìåíç áéôßá, ôá óöÜëìáôá áëëçëïõ÷ßáòêáé ôçí åìöÜíéóç, óôï ðñþôï ìÝñïò ôçò ëßóôáò,

äõï áíôáãùíéóôéêþí áéôéþí èáíÜôïõ êáé ùò åëÜó-óïíá óöÜëìáôá ôç ìç áíáãñáöÞ ôïõ ÷ñïíéêïýäéáóôÞìáôïò áðü ôçí åìöÜíéóç ôçò ðÜèçóçò ìÝ-÷ñé ôï èÜíáôï, ôç ÷ñÞóç óõíôïìåýóåùí êáé ôç÷ñÞóç ôïõ ìç÷áíéóìïý èáíÜôïõ, áëëÜ óõíïäåõü-ìåíïõ áðü ìéá ëïãéêÞ õðïêñõðôüìåíç áéôßá.

Ùò ìç÷áíéóìü èáíÜôïõ èåùñïýìå, ëüãïõ ÷Üñç,ôçí êáñäéáêÞ áíåðÜñêåéá, ôçí áíáðíåõóôéêÞ áíå-ðÜñêåéá ê.ëð. Äå èåùñïýìå ôçí êáñäéáêÞ áíáêï-ðÞ ìç÷áíéóìü èáíÜôïõ, äéüôé ðñüêåéôáé áðëþòãéá ìéá ðåñéãñáöÞ ôïõ èáíÜôïõ.


ÔïõëÜ÷éóôïí Ýíá ìåßæïí óöÜëìá åíôïðßóèç-êå óôï 58% ôïõ óõíüëïõ ôùí ðéóôïðïéçôéêþí,óôï 12 % åß÷å áíáöåñèåß ï ìç÷áíéóìüò èáíÜôïõùò áéôßá, óôï 47% õðÞñ÷å åóöáëìÝíç áëëçëïõ-÷ßá êáé óôï 19% åìöáíßóèçêáí ôïõëÜ÷éóôïí äõïáíôáãùíéóôéêÝò áéôßåò èáíÜôïõ óôï ðñþôï ìÝñïòôïõ ðéóôïðïéçôéêïý. Óå ü,ôé áöïñÜ ôá åëÜóóïíáóöÜëìáôá, Ýíá ôïõëÜ÷éóôïí åìöáíßæåôáé óôï 95%üëùí ôùí ðéóôïðïéçôéêþí, óôï 94% äåí õðÞñ÷áí÷ñïíéêÜ äéáóôÞìáôá, óôï 44% Ýãéíå ÷ñÞóç óõ-íôïìåýóåùí êáé óôï 19% åìöáíéæüôáí ï ìç÷áíé-óìüò èáíÜôïõ, ìáæß ìå ìéá ëïãéêÞ õðïêñõðôüìå-íç áéôßá. ÕðÞñ÷áí êÜðïéåò äéáöïñÝò óôç óõ÷íü-ôçôá åìöÜíéóçò óöáëìÜôùí ìåôáîý ôùí ãéáôñþíôùí êÝíôñùí õãåßáò êáé ôùí ãéáôñþí ôùí íïóï-êïìåßùí. Äåí ðñï÷ùñÞóáìå óå ìéá ëåðôïìåñÞóôáôéóôéêÞ áíÜëõóç áõôþí ôùí äéáöïñþí, äéüôéáõôü äåí Þôáí ï óêïðüò ôçò ìåëÝôçò, üìùò öáß-íåôáé ãåíéêÜ üôé ïé ãéáôñïß ôùí ÊÝíôñùí ÕãåßáòêÜíïõí ëéãüôåñá óöÜëìáôá óôçí ðéóôïðïßçóç ôïõèáíÜôïõ.

Ðßíáêáò 1. Ï áñéèìüò, ôï ðïóïóôü êáé ôï åßäïò ôùí óöáëìÜôùí ðïõ åíôïðßóèçêáí óôá ðéóôïðïéçôéêÜ èáíÜôïõ

ôùí Ê.Õ. êáé ôùí íïóïêïìåßùí

Åßäïò óöÜëìáôïò ÊÝíôñá Õãåßáò Íïóïêïìåßá Ãåíéêü Óýíïëï

Ìåßæïíá óöÜëìáôá Áñéèìüò Ðïóïóôü Áñéèìüò Ðïóïóôü Áñéèìüò Ðïóïóôü

Ìüíï ï ìç÷áíéóìüò 02 04% 08 22% 10 12%ÅóöáëìÝíç áëëçëïõ÷ßá 20 41% 20 54% 40 47%ÁíôáãùíéóôéêÝò áéôßåò 06 12% 10 27% 16 19%ÔïõëÜ÷éóôïí Ýíá 29 59% 21 57% 50 58%

ÅëÜóóïíá óöÜëìáôá

Äåí áíáöÝñïíôáé ÷ñïíéêÜ äéáóôÞìáôá 47 96% 34 92% 81 94%×ñÞóç óõíôïìåýóåùí 22 45% 16 43% 38 44%Ìç÷áíéóìüò + ËïãéêÞ õðïêñõðôüìåíç áéôßá 08 16% 08 22% 16 19%ÔïõëÜ÷éóôïí Ýíá 47 96% 35 95% 82 95%

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Ðßíáêáò 2. Ïñïëïãßá ôïõ ðéóôïðïéçôéêïý èáíÜôïõ12

¼ñïò Ïñéóìüò

ÄÞëùóç áéôßáò èáíÜôïõ ÓõìðëÞñùóç ôïõ ìÝñïõò É êáé ôïõ ìÝñïõò ÉÉ ôïõ ðéóôïðïéçôéêïý èáíÜôïõÇ Õðïêñõðôüìåíç áéôßá ôïõ èáíÜôïõ Ç êáôÜóôáóç Þ ç ðÜèçóç ðïõ ðñïêÜëåóå ôçí áëõóßäá ôùí ãåãïíüôùí ðïõ

ïäçãïýí óôï èÜíáôï. Ç ðéï áðüìáêñç ÷ñïíéêÜ, áëëÜ áéôéïëïãéêÜ õðåýèõíçêáôÜóôáóç.

Ç ¢ìåóç áéôßá ôïõ èáíÜôïõ Ç ôåëéêÞ åðéðëïêÞ ðïõ ðñïêëÞèçêå ùò áðïôÝëåóìá ôçò õðïêñõðôüìåíçòáéôßáò ôïõ èáíÜôïõ, ðïõ åìöáíßæåôáé íá óõíäÝåôáé óôåíÜ ìå ôç ÷ñïíéêÞóôéãìÞ ôïõ èáíÜôïõ êáé íá ôï ðñïêáëåß Üìåóá

ÅíäéÜìåóç áéôßá ôïõ èáíÜôïõ Ìéá ðÜèçóç Þ êáôÜóôáóç ðïõ åìöáíßóèçêå, ùò áðïôÝëåóìá ôçò õðïêñõ-ðôüìåíçò áéôßáò ôïõ èáíÜôïõ áëëÜ äåí Þôáí ç ôåëéêÞ åðéðëïêÞ Þ ç Üìåóçáéôßá ôïõ èáíÜôïõ

Ï ìç÷áíéóìüò ôïõ èáíÜôïõ Ìéá öõóéïëïãéêÞ Þ âéï÷çìéêÞ äéáôáñá÷Þ äéÜìåóùí ôçò ïðïßáò ç áéôßá ôïõèáíÜôïõ áóêåß ôç èáíáôçöüñá åðßäñáóÞ ôçò (ð.÷. ç êáñäéáêÞ Þ áíáðíåõ-óôéêÞ áíáêïðÞ) êáé äåí ðñÝðåé íá ÷ñçóéìïðïéçèåß ùò õðïêñõðôüìåíçáéôßá ôïõ èáíÜôïõ.

Ìç åéäéêÞ êáôÜóôáóç Ìéá áíáôïìéêÞ Þ ëåéôïõñãéêÞ äéáôáñá÷Þ ðïõ ìðïñåß íá Ý÷åé ðåñéóóüôåñåòáðü ìéá ðéèáíÞ áéôßá (ð.÷. ç óçøáéìßá, áéìïññáãßá, êáñäéáêÞ áíåðÜñêåéá,íåöñéêÞ áíåðÜñêåéá êëð.) êáé äåí ðñÝðåé íá ÷ñçóéìïðïéçèåß ùò õðïêñõ-ðôüìåíç áéôßá ôïõ èáíÜôïõ.

Ï ôñüðïò ôïõ èáíÜôïõ Ìéá ôáîéíüìçóç ôïõ èáíÜôïõ ðïõ âáóßæåôáé óôïí ôýðï ôùí êáôáóôÜóåùíðïõ ðñïêáëïýí ôï èÜíáôï êáé óôéò ðåñéóôÜóåéò êÜôù áðü ôéò ïðïßåò åìöá-íßóèçêáí (ð.÷. öõóéêüò èÜíáôïò, ðïõ ïöåßëåôáé ìüíï óå ìéá ðÜèçóç,áíèñùðïêôïíßá, áõôïêôïíßá, áôý÷çìá ôõ÷áßùí Þ Üãíùóôçò áéôéïëïãßáò)

Ðßíáêáò 3. Ïñéóìüò ôùí ìåßæïíùí êáé åëÜóóïíùí óöáëìÜôùí óôá ðéóôïðïéçôéêÜ èáíÜôïõ12

Ï ôýðïò ôïõ óöÜëìáôïò Ïñéóìüò

Ìåßæïíá óöÜëìáôá Åìöáíßæåôáé óôç ëßóôá ï ìç÷áíéóìüò ôïõ èáíÜôïõ Ï Ìç÷áíéóìüò ôïõ èáíÜôïõ Þ ìéá ìç åéäéêÞ êáôÜóôáóç÷ùñßò ìéá õðïêñõðôüìåíç áéôßá åìöáíßæïíôáé óôç ëßóôá ùò õðïêñõðôüìåíç áéôßá ôïõ èáíÜ-

ôïõÁíÜñìïóôç áëëçëïõ÷ßá Þ óöÜëìáôá áëëçëïõ÷ßáò Ç áêïëïõèßá ôùí ãåãïíüôùí äåí âãÜæåé íüçìá Þ ç õðïêñõ-

ðôüìåíç áéôßá ôïõ èáíÜôïõ äåí åìöáíßæåôáé óôç ëßóôá óôïôåëåõôáßï ðåäßï ôïõ ìÝñïõò É

ÁíôáãùíéóôéêÝò áéôßåò Äýï Þ ðåñéóóüôåñåò áéôéïëïãéêÜ áíåîÜñôçôåò, åéäéêÝò ðáèÞ-óåéò åìöáíßæïíôáé óôç ëßóôá óôï ìÝñïò É

ÅëÜóóïíá óöÜëìáôá ÓõíôìÞóåéò ×ñçóéìïðïéïýíôáé ÓõíôìÞóåéò ãéá ôïí ðñïóäéïñéóìü ôùí

ðáèÞóåùíÁðïõóßá ÷ñïíéêþí äéáóôçìÜôùí Äåí áíáãñÜöïíôáé ôá ÷ñïíéêÜ äéáóôÞìáôá óôï ìÝñïò É êáé ÉÉ

ôçò ëßóôáòÁíáöÝñåôáé ùò áéôßá ï ìç÷áíéóìüò ×ñÞóç ôïõ ìç÷áíéóìïý èáíÜôïõ ìáæß ìå ìéá áéôéïëïãéêÜôïõ èáíÜôïõ, áëëÜ áêïëïõèåßôáé áðü êáôÜëëçëç óõãêåêñéìÝíç áéôßá èáíÜôïõìéá ëïãéêÞ õðïêñõðôüìåíç áéôßá èáíÜôïõ

Ç ðñþôç åíôýðùóç ðïõ äçìéïõñãåßôáé áðüôçí åîÝôáóç ôùí ðéóôïðïéçôéêþí èáíÜôïõ åßíáé çðïëý ìåãÜëç ÷ñÞóç ôïõ üñïõ “êáñäéáêÞ áíáêï-ðÞ”, ùò áéôßá èáíÜôïõ êáé ìåñéêÝò öïñÝò ÷ùñßòáíáöïñÜ óå ìéá õðïêñõðôüìåíç áéôßá ðïõ ôçíðñïêáëåß. Ç êáñäéáêÞ áíáêïðÞ åìöáíßæåôáé óôï32% ôùí ðéóôïðïéçôéêþí áðü ôá ÊÝíôñá Õãåßáòêáé óôï 58% ôùí ðéóôïðïéçôéêþí ôùí íïóïêï-ìåßùí.

ÅíäéáöÝñïí åðßóçò ðáñïõóéÜæåé ç óõ÷íüôçôáåìöÜíéóçò ôïõ üñïõ “ãåñïíôéêüò ìáñáóìüò” óôáðéóôïðïéçôéêÜ èáíÜôïõ ôùí èáíüíôùí ìåãáëýôå-ñçò çëéêßáò. Áõôüò ï üñïò ÷ñçóéìïðïéåßôáé ðïëýðéï óõ÷íÜ áðü ôïõò ãéáôñïýò ôùí ÊÝíôñùí Õãåßáò(óôï 71% ôùí ðéóôïðïéçôéêþí èáíüíôùí çëéêßáòÜíù ôùí 85 åôþí).

ÁíáëõôéêÜ üëá ôá óöÜëìáôá ðïõ åíôïðßóèç-êáí åìöáíßæïíôáé óôïí ðßíáêá 1 êáé óôï ó÷Þìá


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1 êáé 2. Óôïõò ðßíáêåò 4, 5 êáé 6 ðáñïõóéÜæï-íôáé ÷áñáêôçñéóôéêÜ äåßãìáôá.

ÓõæÞôçóç

ÊÜíïíôáò ìéá áíáóêüðçóç óôç äéåèíÞ âéâëéï-ãñáößá äéáðéóôþíïõìå üôé ôï ðñüâëçìá ìå ôéòáíáêñßâåéåò óôçí ðéóôïðïßçóç ôïõ èáíÜôïõ åìöá-íßæåôáé óå üëåò ôéò ÷þñåò ìå äéáöïñåôéêÞ Ýíôáóç.Ïé ìåëÝôåò áíáöÝñïõí ðïóïóôü óöÜëìáôïò, ðïõêõìáßíåôáé áðü 29%13,14 Ýùò êáé 62,9%15-18. Óå ìéáìåëÝôç áíáöÝñèçêå üôé åíôïðßóèçêáí 55 óöÜë-ìáôá óå 45 ðéóôïðïéçôéêÜ èáíÜôïõ19. Ç óõ÷íüôç-

ôá åìöÜíéóçò óöáëìÜôùí ðïéêßëëåé êáé ìåôáîýôùí íïóçìÜôùí êáé çëéêéáêþí ïìÜäùí. ËéãüôåñáóöÜëìáôá åìöáíßæïíôáé óôéò êáêïÞèåéåò4,15, ðå-ñéóóüôåñá óôá êáñäéáããåéáêÜ4-6 êáé óôéò ìåãáëý-ôåñåò çëéêßåò1,20.

Ç óõ÷íüôçôá åìöÜíéóçò ôïõ ïñïý “ãåñïíôé-êüò ìáñáóìüò” óôï äåßãìá ìáò (71% óôá ÜôïìáÜíù ôùí 85 åôþí) åßíáé õðåñâïëéêÞ. Óå ìéá ìåëÝ-ôç ðïõ áó÷ïëÞèçêå ì’ áõôü ôï æÞôçìá áíáöÝñå-ôáé üôé ìüíï ôï 5% ôùí èáíÜôùí áôüìùí Üíùôùí 90 åôþí, ìðïñåß íá áðïäïèåß óå ãåñïíôéêüìáñáóìü êáé åêöñÜæåôáé ç Üðïøç üôé ç ÷ñÞóçáõôïý ôïõ üñïõ ó’ áõôÝò ôéò ðåñéðôþóåéò áíôé-óôïé÷åß óôïí üñï “Üãíùóôçò áéôéïëïãßáò”21.

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

ÐáñÜäåéãìá óõìðëÞñùóçò Åßäïò ôïõ óöÜëìáôïò

Áéôßá èáíÜôïõ ×ñïíéêü äéÜóôçìá Ìåßæïí ÅëÜóóïíáðü ôçí ÝíáñîçÝùò ôï èÜíáôï

É. Ðñþôï ìÝñïò: Áéôßá èáíÜôïõ (óùìáôéêÞ): Íüóïò ç íïóçñÜ êáôÜóôáóç ðñïêáëÝóáóá êáô’ åõèåßáí ôïèÜíáôïÁéôßá èáíÜôïõ(á) ÊáñäéáêÞ ÁíáêïðÞ — Ç êáñäéáêÞ áíáêïðÞ

áðïôåëåß ðåñéãñáöÞôïõ èáíÜôïõ êáé ü÷é ôçí áéôßá

Ïöåéëüìåíç óå Þ áðüôïêïò — ÁíáöÝñåôáé ï ìç÷áíéóìüò Äåí áíáöÝñåôáé(â) ÁíáðíåõóôéêÞ áíåðÜñêåéá ôïõ èáíÜôïõ ÷ùñßò ôçí áéôßá ôï ÷ñïíéêü äéÜóôçìá

áðü ôçí ÝíáñîçÝùò ôï èÜíáôï

Ïöåéëüìåíç óå Þ áðüôïêïò (ã) - - - - - - ÉÉ. Äåýôåñï ìÝñïò: ¢ëëåò áîéüëïãåò ðáèïëïãéêÝò åêäçëþóåéò:(á) Áéìïññáãßá Êáôþôåñïõ ðåðôéêïý(â) ÊÅÊ ×ñçóéìïðïéåßôáé

óõíôüìåõóç(ã) —

0%

10%

20%

30%

40%

50%

60%

ÔïõëÜ÷éóôïí

Ýíá óöÜëìá

ÅóöáëìÝíç

áëëçëïõ÷ßá

ÁíôáãùíéóôéêÝò

áéôßåò

ÁíáöÝñåôáé

ìüíï ï

ìç÷áíéóìüò

ÊÝíôñá õãåßáò Íïóïêïìåßá

0%

20%

40%

60%

80%

100%

¸íá ôïõëÜ÷éóôïí

óöÜëìá

×ùñßò ÷ñïíéêÜ

äéáóôÞìáôá

×ñÞóç

óõíôïìåýóåùí

Ìç÷áíéóìüò êáé

õðïêñõðôüìåíç

áéôßá

ÊÝíôñá õãåßáò Íïóïêïìåßá

Ó÷Þìá 1. Ç óõ÷íüôçôá åìöÜíéóçò ìåßæïíùí óöáëìÜôùí óôá ðéóôï-ðïéçôéêÜ èáíÜôïõ.

Ó÷Þìá 2. Ç óõ÷íüôçôá åìöÜíéóçò åëÜóóïíùí óöáëìÜôùí óôá ðé-óôïðïéçôéêÜ èáíÜôïõ.

Õ Õ

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Ç äéáöïñÜ óôç óõ÷íüôçôá åìöÜíéóçò óöáë-ìÜôùí ìåôáîý ôùí ãåíéêþí êáé íïóïêïìåéáêþíãéáôñþí Ý÷åé ðáñáôçñçèåß êáé óå ìåëÝôåò áðü ôïäéåèíÞ ÷þñï. Ïé ìåëÝôåò áðü ôç Âñåôáíßá áíáöÝ-ñïõí ìåãáëýôåñç óõ÷íüôçôá åìöÜíéóçò óöáëìÜ-ôùí ðéóôïðïßçóçò óôïõò íïóïêïìåéáêïýò ãéáôñïýò,üðïõ åíôïðßæïíôáé ëÜèç óôï 62% ôùí ðéóôïðïéç-ôéêþí ôùí íïóïêïìåéáêþí ãéáôñþí Ýíáíôé 38%ôùí ãåíéêþí ãéáôñþí22,23.

Ìå êáôÜëëçëåò ðáñåìâÜóåéò ìðïñåß ôï ðï-óïóôü óöáëìÜôùí íá ìåéùèåß óçìáíôéêÜ. Óå ìéáìåëÝôç ðáñÝìâáóçò óôïí ÊáíáäÜ, óå Ýíá ó÷åôéêÜìéêñü ÷ñïíéêü äéÜóôçìá, óçìåéþèçêå ìåßùóç ôçò

óõ÷íüôçôáò åìöÜíéóçò óöáëìÜôùí áðü 32,9% óå15,7%12.


Ç óõ÷íüôçôá åìöÜíéóçò óöáëìÜôùí óôá ðé-óôïðïéçôéêÜ èáíÜôïõ åìöáíßæåôáé óçìáíôéêÜ ìå-ãÜëç. Áõôü ôï ãåãïíüò ôá êÜíåé ëéãüôåñï áîéüðé-óôá ãéá ôçí ðáñï÷Þ ðëçñïöïñéþí ãéá óôáôéóôé-êÝò ìåëÝôåò, êÜôé ðïõ ðñÝðåé íá ëÜâïõìå óïâáñÜõðüøç. Áðü ôçí Üëëç ðëåõñÜ ðñÝðåé íá õðÜñ-÷ïõí ðáñåìâÜóåéò ãéá ôçí áíôéìåôþðéóç áõôÞò

Ðßíáêáò 6. ÐáñÜäåéãìá Ã ôùí óöáëìÜôùí óôç óõìðëÞñùóç ôùí ðéóôïðïéçôéêþí èáíÜôïõ


Áéôßá èáíÜôïõ ×ñïíéêü äéÜóôçìá Ìåßæïí ÅëÜóóùíáðü ôçí ÝíáñîçÝùò ôï èÜíáôï

É. Ðñþôï ìÝñïò: Áéôßá èáíÜôïõ (óùìáôéêÞ): Íüóïò ç íïóçñÜ êáôÜóôáóç ðñïêáëÝóáóá êáô’ åõèåßáí ôïíèÜíáôïÁéôßá èáíÜôïõ Äåí áíáöÝñåôáé(á) Óôåöáíéáßá Íüóïò — ôï ÷ñïíéêü äéÜóôçìá


Ïöåéëüìåíç óå Þ áðüôïêïò ÕðÜñ÷ïõí äõï ×ñçóéìïðïéåßôáé(â) ÁÅÅ - - áíôáãùíéóôéêÝò áéôßåò óõíôüìåõóçÏöåéëüìåíç óå Þ áðüôïêïò Äåí õðÜñ÷åé ëïãéêÞ(ã) Ãåñïíôéêüò Ìáñáóìüò — áëëçëïõ÷ßáÉÉ. Äåýôåñï ìÝñïò: ¢ëëåò áîéüëïãåò ðáèïëïãéêÝò åêäçëþóåéò:(á) —(â) —(ã) —

Ðßíáêáò 5. ÐáñÜäåéãìá Â ôùí óöáëìÜôùí óôç óõìðëÞñùóç ôùí ðéóôïðïéçôéêþí èáíÜôïõ


Áéôßá èáíÜôïõ ×ñïíéêü äéÜóôçìá Ìåßæïí ÅëÜóóùíáðü ôçí ÝíáñîçÝùò ôï èÜíáôï

É. Ðñþôï ìÝñïò: Áéôßá èáíÜôïõ (óùìáôéêÞ): Íüóïò ç íïóçñÜ êáôÜóôáóç ðñïêáëÝóáóá êáô’ åõèåßáí ôïíèÜíáôïÁéôßá èáíÜôïõ(á) Ãåñïíôéêüò Ìáñáóìüò —Ïöåéëüìåíç óå Þ áðüôïêïò Äåí áíáöÝñåôáé(â) Ôåôñáðëçãßá — ôï ÷ñïíéêü äéÜóôçìá


Ïöåéëüìåíç óå Þ áðüôïêïò Äåí õðÜñ÷åé(ã) ÃåñïíôéêÞ ¢íïéá — ëïãéêÞ áëëçëïõ÷ßáÉÉ. Äåýôåñï ìÝñïò: ¢ëëåò áîéüëïãåò ðáèïëïãéêÝò åêäçëþóåéò:(á) —(â) —(ã) —


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ôçò áäõíáìßáò.Ôï ðñþôï âÞìá ðñÝðåé íá ãßíåé áðü ôïõò

ßäéïõò ãéáôñïýò. Ç áðëÞ óõììüñöùóç ìå ôéò ïäç-ãßåò, ðïõ õðïóçìåéþíïíôáé óôá ßäéá ôá ðéóôïðïéç-ôéêÜ èáíÜôïõ, ìðïñåß íá âåëôéþóåé, óå óçìáíôéêüâáèìü, áõôÞ ôçí åéêüíá. ºóùò ÷ñåéÜæåôáé êáé ìéáðéï óõóôçìáôéêÞ ðñïóðÜèåéá, óå åèíéêü åðßðåäï,ëüãïõ ÷Üñç, ìÝóù êáôåõèõíôÞñéùí ïäçãéþí. ÓåêÜèå ðåñßðôùóç ðéóôåýïõìå üôé ç ðéóôïðïßçóçèáíÜôïõ äåí áðïôåëåß ìéá êáôþôåñçò óçìáóßáòéáôñéêÞ ðñÜîç. Áíôßèåôá, ðéóôåýïõìå üôé ç ïñèÞêáé ÷ùñßò áíáêñßâåéåò ðéóôïðïßçóç ôïõ èáíÜôïõáðïôåëåß ìéá Üëëç óçìáíôéêÞ éáôñéêÞ ðñïóöïñÜóôçí ðñïóôáóßá ôçò õãåßáò êáé ôçò æùÞò.


1. Lenfant C, Friedman L, Thom T. Fifty Years ofDeath Certificates, the Framingham Heart Study,Ann Intern Med, December 1998, Volume 129Issue 12, p.p. 1066-1067.

2. Huffman GB. Death Certificates: Why It Mat-ters How Your Patient Died, American FamilyPhysician, 56:5, 1997.

3. Magrane BP, Gilliland MGF, King DE. Certifi-cation of death by family physicians. Am FamPhysician, 56:1433-8, 1997.

4. Lloyd-Jones DM, Martin DO, Larson MG, LevyD. Accuracy of Death Certificates for CodingCoronary Heart Disease as the Cause of Death,Ann Intern Med, 129:1020-6, 1998.

5. Modelmog D, Rahlenbeck S, Trichopoulos D.Accuracy of death certificates: a population-based,complete-coverage, one-year autopsy study inEast Germany. Cancer Causes Control, 3:541-6, 1992.

6. Sington J D, Cottrell B J. Analysis of the sen-sitivity of death certificates in 440 hospitaldeaths: a comparison with necropsy findings,Journal of Clinical Pathology, 55:499-502, 2002.

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8. Penson D, Albertsen P, Nelson P, Barry M, Stan-ford J. Determining Cause of Death in ProstateCancer: Are Death Certificates Valid? Journalof the National Cancer Institute, 93, 23:1822-1823, 2001.

9. Grulich AE, Swerdlow AJ, dos Santos Silva I,

Beral V. Is the apparent rise in cancer mortal-ity in the elderly real? Analysis of changes incertification and coding of cause of death inEngland and Wales, 1970–1990. Int J Cancer,63:164-8, 1995.

10. Satariano WA, Ragland KE, Van Den Eeden SK.Cause of death in men diagnosed with prostatecarcinoma. Cancer, 83:1180-8, 1998.

11. Jordan JM, Bass MJ. Errors in death certificatecompletion in a teaching hospital, Clin InvestMed, 16:249-55, 1993.

12. Myers K, Farquhar D. Improving the accuracy ofdeath certification, CMAJ, 158:1317-23, 1998.

13. Slater DN. Certifying the cause of death: anaudit of wording inaccuracies, J Clin Pathol,46:232-4, 1993.

14. Vanatta PR, Petty CS. Limitations of the foren-sic external examination in determining the causeand manner of death, Hum Pathol, 18:170-4,1987.

15. Johansson L, Westerling R. Comparing Swedishhospital discharge records with death certificates:implications for mortality statistics, InternationalJournal of Epidemiology, 29:495-502, 2000.

16. Egnerova A, Slugen I. Reliability of data on themajor causes of death, Cesk Zdrav, 37:526-34,1989.

17. Swift B, West K. Death certification: an auditof practice entering the 21st century, J ClinPathol, 55:275-9, 2002.

18. James DS, Bull AD. Information on death cer-tificates: cause for concern? J R Coll PhysiciansLond. J Clin Pathol, 49:213-6, 1996.

19. Doyle YG, Harrison M, O’Malley F. A study ofselected death certificates from three Dublinteaching hospitals, J Public Health Med, 12:118-23, 1990.

20. Kohn RR. Cause of death in very old people.JAMA, 247:2793-7, 1982.

21. Koelmeyer J. The forensic pathology of nonage-narians and centenarians: do they die of oldage? (The Auckland experience), Am J ForensicMed Pathol, 22:150-4, 2001.

22. Armour A, Bharucha H. Nosological Inaccura-cies in death certification in Northern Ireland.A comparative study between hospital doctorsand general practitioners, Ulster Med J, 66:13-7, 1997.

23. James DS, Bull AD. Death certification: is cor-rect formulation of cause of death related toseniority or experience? J R Coll PhysiciansLond, 29:424-8, 1995.

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1. ÅéóáãùãéêÝò ðáñáôçñÞóåéò - Óêïðüò

Ç “ðåñéðÝôåéá” ôçò ìåôáññýèìé-óçò ôïõ Åèíéêïý ÓõóôÞìáôïò Õãåßáòóôçí ÅëëÜäá áðïôåëåß Ýíá åðßêáéñïêáé äéá÷ñïíéêü áíôéêåßìåíï ìåëÝôçò ôçòÝñåõíáò õðçñåóéþí õãåßáò, ëüãù ôùíéäéáéôåñïôÞôùí óôï åðßðåäï ôçò áñ÷é-êÞò óõãêñüôçóçò1, ôçò åîÝëéîçò, ôùíðïëëáðëþí äéïéêçôéêï-ïñãáíùôéêþíôïìþí êáé ôçò ðÜãéáò áäõíáìßáò ùòðñïò ôçí áíôéìåôþðéóç ôùí “åêêñå-ìïôÞôùí” ôçò ÷ñçìáôïäüôçóçò êáé ôçòðñùôïâÜèìéáò öñïíôßäáò õãåßáò. Çðáñïýóá åñãáóßá ðñïóåããßæåé ôá äå-äïìÝíá, ôéò åõêáéñßåò êáé ôéò ðñïïðôé-êÝò áíÜðôõîçò åíüò ïëïêëçñùìÝíïõóõóôÞìáôïò ðñùôïâÜèìéáò öñïíôßäáòõãåßáò, åðé÷åéñþíôáò ðáñÜëëçëá íááíáäåßîåé ôá ïöÝëç ôïõ óõóôÞìáôïòõãåßáò óôï óýíïëü ôïõ, áðü ìéá ôÝ-ôïéá ðñïïðôéêÞ.

ÐåñéëçøçÓêïðüò: Ç åñãáóßá áðïóêïðåß óôç ìåëÝôç êáé áîéïëüãçóç ôùí âáóéêþí ïñãá-íùôéêþí êáé ëåéôïõñãéêþí ÷áñáêôçñéóôéêþí, êáèþò êáé ôùí äåéêôþí åðÜñêåéáòêáé áðïäïôéêüôçôáò ôùí äïìþí ðñùôïâÜèìéáò öñïíôßäáò õãåßáò óôçí ÅëëÜäá,ðñïò ôçí êáôåýèõíóç ôçò äéáìüñöùóçò åíüò ïëïêëçñùìÝíïõ óõóôÞìáôïò. Õëéêüêáé ìÝèïäïò: Ç åñãáóßá âáóßæåôáé óå óôïé÷åßá ôçò ðñïóöïñÜò êáé ôçò æÞôçóçò,ìå óçìåßï áíáöïñÜò ôçí ðåñéöåñåéáêÞ óõãêñüôçóç ôïõ óõóôÞìáôïò õãåßáò.Óå ü,ôé áöïñÜ ôçí ðñïóöïñÜ, áîéïëïãïýíôáé ç äéÜñèñùóç êáé ç åðÜñêåéá ôùíõëéêþí êáé áíèñþðéíùí ðüñùí ôïõ óõóôÞìáôïò õãåßáò, õðü ôï ðñßóìá ôçòáðïêåíôñùôéêÞò ëïãéêÞò ðïõ äéÝðåé ôç ëåéôïõñãßá ôïõ. ËáìâÜíïíôáé õðüøçüëåò ïé äïìÝò, ìå êñéôÞñéï ôçí Ýíôáîç ôùí ðáñå÷ïìÝíùí õðçñåóéþí óôéòðáñï÷Ýò ðïõ ðñïêýðôïõí óôï ðëáßóéï ôùí êïéíùíéêï-áóöáëéóôéêþí äéêáéùìÜ-ôùí ôùí ðïëéôþí, áíåîáñôÞôùò äéïéêçôéêÞò õðáãùãÞò ôùí öïñÝùí. Ç ðïóïôé-êÞ áíÜëõóç óõíäÝåé ôç äéÜóôáóç áõôÞ ìå óôïé÷åßá áíáãêþí, üðùò áõôÝò ðñï-êýðôïõí áðü åðéäçìéïëïãéêÜ ðåñéöåñåéáêÜ äåäïìÝíá êáé äåäïìÝíá ãéá ôçæÞôçóç êáé ôç ÷ñçóéìïðïßçóç ôùí õðçñåóéþí. ÁðïôåëÝóìáôá: Ç ìåëÝôç ôùíäåäïìÝíùí áíáäåéêíýåé ìßá óçìáíôéêÞ áíôßöáóç ìåôáîý ôçò óõíïëéêÞò åðÜñ-êåéáò ôùí ðüñùí, ç ïðïßá Ý÷åé óå ìåãÜëï âáèìü åðéôåõ÷èåß, êáé ôçò ðåñéöå-ñåéáêÞò åðÜñêåéáò, ç ïðïßá ðñïêáëåß ìéá áíéóüôçôá óå âÜñïò ìÜëéóôá ôùíáóôéêþí ðåñéï÷þí, ïé ïðïßåò üìùò õðåñÝ÷ïõí óå Üëëåò ðåñéï÷Ýò ôïõ óõóôÞìá-ôïò õãåßáò, üðùò ð.÷. ïé äïìÝò íïóïêïìåéáêÞò ðåñßèáëøçò. Áðü ìßá ÜëëçïðôéêÞ, ôï áðïôÝëåóìá ôçò áíÜëõóçò ôùí äåäïìÝíùí áíôáíáêëÜ ôïõò ïñãáíù-ôéêïýò – ëåéôïõñãéêïýò ðåñéïñéóìïýò ðïõ êáôÝóôçóáí áíÝöéêôç ôç äéáìüñöù-óç åíüò ïëïêëçñùìÝíïõ êáé åíéáßïõ óõóôÞìáôïò ðñùôïâÜèìéáò öñïíôßäáò õãåßáòóôç ÷þñá ìáò. ÓõìðåñÜóìáôá: Ç åñãáóßá ëáìâÜíïíôáò õðüøç ôéò óõíïëéêÝòäõíáôüôçôåò ôïõ óõóôÞìáôïò õãåßáò óôçí ÅëëÜäá, ôçí Ýêôáóç êáé ôï ÷áñáêôÞ-ñá ôùí ðñïâëçìÜôùí ôçò ðñùôïâÜèìéáò öñïíôßäáò õãåßáò êáé ôï íÝï èåóìéêüðëáßóéï äéáìüñöùóÞò ôçò, êáôáëÞãåé óôç äéáôýðùóç ðñïôÜóåùí, ïé ïðïßåòáðïóêïðïýí óôï íá êáôáóôåß åöéêôÞ ç Ýíôáîç ëïãéêþí êáé ÷áñáêôçñéóôéêþí“óõóôÞìáôïò” óôçí ðñùôïâÜèìéá öñïíôßäá õãåßáò, åíþ ðáñÜëëçëá áíáäåéêíýåéôá ïöÝëç ôïõ óõóôÞìáôïò õãåßáò óôï óýíïëü ôïõ, áðü ìéá ôÝôïéá ðñïïðôéêÞ.

Ç äéáìüñöùóç åíüò ÏëïêëçñùìÝíïõ ÓõóôÞìáôïòÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò óôçí ÅëëÜäá

Ê. Óïõëéþôçò1, Á. Ìáñéüëçò2

1ÅèíéêÞ Ó÷ïëÞ Äçìüóéáò Õãåßáò, ÁèÞíá, 2ÊÝíôñï Õãåßáò Âýñùíá, ÁèÞíá

ËÝîåéò êëåéäéÜ: Åèíéêü Óýóôçìá Õãåßáò, ÐñùôïâÜè-ìéá Öñïíôßäá Õãåßáò, ÅëëÜäáÕðïâëÞèçêå: Ç åñãáóßá õðïâëÞèçêå ùò åëåýèåñçáíáêïßíùóç óôï 16ï ÐáíåëëÞíéï ÓõíÝäñéï ÃåíéêÞòÉáôñéêÞò (Êùò, 14-18 Áðñéëßïõ 2004) êáé âñáâåýèç-êå áðü ôçí ÅðéôñïðÞ Êñßóçò, Äçìïóéåýåôáé ìå êïé-íÞ áðüöáóç ôçò ÓõíôáêôéêÞò ÅðéôñïðÞò ôïõ Ðåñéï-äéêïý êáé ôçò ÏñãáíùôéêÞò ÅðéôñïðÞò ôïõ Óõíå-äñßïõÕðåýèõíïò áëëçëïãñáößáò: ÊõñéÜêïò Óïõëéþôçò,ÅèíéêÞ Ó÷ïëÞ Äçìüóéáò Õãåßáò, Ë. ÁëåîÜíäñáò 196,115 24, ÁèÞíá, Ôçë.: (210)6435328, e-mail: [email protected]


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Ê. Óïõëéþôçò, Á. Ìáñéüëçò

óôï óýóôçìá õãåßáò óå åðßðåäï áñ÷þí(éóüôçôá – áðïäïôéêüôçôá). Åéäéêüôå-ñá, ç èåóìéêÞ ìåôåîÝëéîç ôïõ ÅÓÕ ðå-ñéëáìâÜíåé ôÝóóåñéò ìåôáññõèìéóôéêÝòðñïóðÜèåéåò:

á) Íüìïò 2071/1992 - Åêóõã÷ñï-íéóìüò êáé ÏñãÜíùóç ôïõ ÓõóôÞìá-ôïò Õãåßáò: ÁëëáãÞ ôçò öéëïóïößáòôïõ óõóôÞìáôïò, Ýìöáóç óôçí áðïäï-ôéêüôçôá êáé ôç óõãêñÜôçóç ôïõ êü-óôïõò (ðåñéïñéóìÝíç åöáñìïãÞ).

â) Íüìïò 2194/1994 - ÁðïêáôÜ-óôáóç ôïõ Åèíéêïý ÓõóôÞìáôïò Õãåßáòêáé Üëëåò äéáôÜîåéò:

i. ÅðáíáöïñÜ ôùí áñ÷éêþí ÷áñá-êôçñéóôéêþí ôïõ ÅÓÕ (åöáñìïãÞ)

Ç Ýìöáóç óôçí ðñùôïâÜèìéá öñïíôßäá õãåßáòõðáãïñåýåôáé áðü äýï êõñßùò ëüãïõò: á) áðïôå-ëåß ôçí ðåñéï÷Þ ôïõ õãåéïíïìéêïý ôïìÝá óôç ÷þñáìáò áðü ôçí ïðïßá áðïõóéÜæåé ç ëïãéêÞ ôïõ “óõ-óôÞìáôïò”2 êáé â) äéá÷ñïíéêÜ, áðïôåëåß ôïí êý-ñéï ðáñÜãïíôá áêýñùóçò ôçò áóöáëéóôéêÞò êÜ-ëõøçò áðïññïöþíôáò ôï ìåãáëýôåñï ðïóïóôü ôùíéäéùôéêþí äáðáíþí õãåßáò3.

ÅðéðëÝïí, ôüóï ç äéåèíÞò üóï êáé ç åëëçíéêÞâéâëéïãñáößá Ý÷ïõí áíáäåßîåé ôï ñüëï ôçò ðñù-ôïâÜèìéáò öñïíôßäáò õãåßáò óôç äéáìüñöùóç åíüòðëáéóßïõ ïñéæüíôéáò êáé êÜèåôçò äéáóýíäåóçò ôùíäïìþí, ôçò åðßôåõîçò êáëýôåñçò áîéïðïßçóçò ôùíäéáèÝóéìùí ðüñùí êáé ôïõ ðåñéïñéóìïý ôïõ êü-óôïõò ôùí õðçñåóéþí õãåßáò4. Óõíåðþò, ç áíß-÷íåõóç ôùí âáóéêþí ïñãáíùôéêþí êáé ëåéôïõñãé-êþí ÷áñáêôçñéóôéêþí, êáèþò êáé ôùí äåéêôþíåðÜñêåéáò êáé áðïäïôéêüôçôáò ôùí äïìþí ðñù-ôïâÜèìéáò öñïíôßäáò õãåßáò óôçí ÅëëÜäá, ðñïòôçí êáôåýèõíóç ôçò äéáìüñöùóçò åíüò ïëïêëç-ñùìÝíïõ óõóôÞìáôïò, áðïôåëåß áêüìá Ýíá “áíïé-êôü” èÝìá, ôüóï óå åðßðåäï åðéóôçìïíéêþí ðñï-óåããßóåùí üóï êáé óå åðßðåäï ó÷åäéáóìïý êáéÜóêçóçò ðïëéôéêÞò õãåßáò.

2. Ç ðñùôïâÜèìéá öñïíôßäá õãåßáò óôçí ÅëëÜäá -ÄåäïìÝíá

ÌåôÜ ôï ðÝñáò ôçò äåýôåñçò äåêáåôßáò ëåé-ôïõñãßáò ôïõ ÅÓÕ óôç ÷þñá ìáò, ï áðïëïãéóìüòôçò èåóìéêÞò éóôïñßáò – “ðåñéðÝôåéáò” ôùí ìå-ôáññõèìßóåùí, îåêéíÜ áðü ôç äéáðßóôùóç ôçò äé-ëçììáôéêÞò ëïãéêÞò ðïõ äéÝðåé ôéò ðáñåìâÜóåéò

ii. Óõãêñüôçóç åðéôñïðÞò åìðåéñïãíùìüíùíãéá ôçí åðåîåñãáóßá ðïñßóìáôïò ìå óêïðü ôçíïñéïèÝôçóç åíüò íÝïõ ðëáéóßïõ ëåéôïõñãßáò ôïõÅÓÕ (ìç õëïðïßçóç)

ã) Íüìïò 2519/1997 - ÁíÜðôõîç êáé åêóõã-÷ñïíéóìüò ôïõ Åèíéêïý ÓõóôÞìáôïò Õãåßáò, ïñ-ãÜíùóç ôùí õãåéïíïìéêþí õðçñåóéþí, ñõèìßóåéòãéá ôï öÜñìáêï êáé Üëëåò äéáôÜîåéò:

ÊáéíïôïìéêÝò ñõèìßóåéò, Ýìöáóç óôç ëåéôïõñ-ãéêÞ áíáäéïñãÜíùóç ôïõ óõóôÞìáôïò êáé ôçíáðïäïôéêüôçôá (ðåñéïñéóìÝíç åöáñìïãÞ).

ä) Íüìïò 2889/2001 - Âåëôßùóç êáé Åêóõã-÷ñïíéóìüò ôïõ Åèíéêïý ÓõóôÞìáôïò Õãåßáò êáéÜëëåò äéáôÜîåéò:

ÑéæéêÞ ìåôáññõèìéóôéêÞ ëïãéêÞ, ðåñéöåñåéá-êÞ óõãêñüôçóç ôïõ óõóôÞìáôïò, äéïéêçôéêÞ ðá-ñÝìâáóç.

Óôéò ðáñåìâÜóåéò áõôÝò, ç ðñùôïâÜèìéá öñï-íôßäá õãåßáò äåí áðïôÝëåóå áíôéêåßìåíï åõñåßáòñýèìéóçò, ìå åîáßñåóç ôï ó÷åäéáóìü ôçò áíÜðôõ-îçò “äéêôýùí” ðñùôïâÜèìéáò öñïíôßäáò õãåßáòðïõ ðåñéëáìâÜíåôáé óôïí Í. 2519/1997, ï ïðïßïòüìùò äåí õëïðïéÞèçêå5. Óå áíôßóôïé÷ïõò ðñïóá-íáôïëéóìïýò – ðñïò ôçí êáôåýèõíóç ôçò ëåéôïõñ-ãéêÞò áíáóõãêñüôçóçò – êéíåßôáé êáé ç ôåëåõôáßáèåóìéêÞ ñýèìéóç, ìå íüìï ðïõ áöïñÜ áðïêëåéóôé-êÜ óôçí ðñùôïâÜèìéá öñïíôßäá õãåßáò (Í. 3235/2004)6.

Óå êÜèå ðÜíôùò ðåñßðôùóç êáé óýìöùíá êáéìå ôç äéåèíÞ åìðåéñßá ôùí ìåôáññõèìßóåùí êáéôïõ óôñáôçãéêïý ó÷åäéáóìïý, áíåîÜñôçôá áðü ôïðåñéå÷üìåíï ôïõ èåóìéêïý ðëáéóßïõ åßíáé áðáñáß-ôçôç ç äéáãíùóôéêÞ ðñïóÝããéóç ôïõ åõñýôåñïõðåäßïõ åöáñìïãÞò ôùí ìÝôñùí, ðñïêåéìÝíïõ íá

The development of an Intergrading Primary Health Care System inGreece.K. Souliotis, A. Mariolis

SummaryAim: To assess and evaluate the basic organizational and functional charac-teristics as well as the indicators of sufficiency and efficiency of primary carein Greece. Material-Method: The study is based on supply and demand datawith a reference point of regional organization of health system. Results: Thedata studies show significant contradictions between the total sufficiency ofresources and the regional one. This causes inequality in favor of rural areas.Data analysis reflects the organizational and functional limitations that renderunfeasible the construction of a complete and united primary care system inour country. Conclusions: The study takes into consideration the overall cap-abilities of the Greek Health System, the problems in primary care and the newframework, and as a result leads to the formulation of proposals regarding theprimary care system in Greece.

Key Words: Greek Health System, Primary Health Care

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êáôáóôåß åöéêôÞ ç ìåëÝôç ôçò åöéêôüôçôáò, ôïõ÷ñïíïäéáãñÜììáôïò õëïðïßçóçò êáé ôïõ êüóôïõòåöáñìïãÞò7. Õðü ôï ðñßóìá áõôü, ç ðñùôïâÜè-ìéá öñïíôßäá õãåßáò óôç ÷þñá ìáò, ðáñïõóéÜæåéôá åîÞò ãåíéêÜ ÷áñáêôçñéóôéêÜ:á) Ùò ðñïò ôçí ðáñï÷Þ ôùí õðçñåóéþí• Ç ðáñï÷Þ ôùí õðçñåóéþí âáóßæåôáé óôç ëåé-ôïõñãßá åíüò Üôõðïõ “äéêôýïõ” ôï ïðïßïáðïôåëåßôáé áðü 200 ðåñßðïõ êÝíôñá õãåßáòóôéò çìéáóôéêÝò êáé áãñïôéêÝò ðåñéï÷Ýò êáé250 ðåñßðïõ ðïëõúáôñåßá ôïõ ÉÊÁ óôéò áóôé-êÝò ðåñéï÷Ýò.

• Ïé äéêáéïý÷ïé ôùí áóöáëéóôéêþí öïñÝùí ðïõäåí äéáèÝôïõí äéêÝò ôïõò õðçñåóßåò õãåßáò,êáëýðôïíôáé ìÝóù óõìâÜóåùí ìå éäéùôéêÜó÷Þìáôá êáé ãéáôñïýò, ÷ùñßò üìùò íá äéá-óöáëßæåôáé ç åðÜñêåéá êáé ç ðïéüôçôá ôùíõðçñåóéþí, åíþ áðïõóéÜæïõí ç ðñïëçðôéêÞêáé ç ìåôáíïóïêïìåéáêÞ öñïíôßäá.

• Ôï êåíü ôçò ÷ñïíéêÞò äéáèåóéìüôçôáò ôùíðüñùí óôïõò ðïëßôåò ôï ïðïßï ÷áñáêôçñßæåéôç äçìüóéá ðáñáãùãÞ ÐÖÕ, åß÷å óáí áðï-ôÝëåóìá ôçí Ýíôïíç åðåíäõôéêÞ äñáóôçñéü-ôçôá ôïõ éäéùôéêïý ôïìÝá óôçí åîùíïóïêï-ìåéáêÞ ðåñßèáëøç, ìå ôçí ßäñõóç éäéùôéêþíäéáãíùóôéêþí êÝíôñùí, ôá ïðïßá õðåñâáß-íïõí ôá 400 êáé õðïëïãßæåôáé üôé åìöáíß-æïõí êýêëï åñãáóéþí ï ïðïßïò ôï 2000 îå-ðÝñáóå ôá 100 äéó. äñ÷.

â) Ùò ðñïò ôç ÷ñçìáôïäüôçóç ôùí õðçñåóéþí• Óå ü,ôé áöïñÜ ôéò äçìüóéåò äáðÜíåò õãåßáò,ç óýíèåóÞ ôïõò áíôáíáêëÜ ôçí Ýìöáóç óôçíïóïêïìåéáêÞ ðåñßèáëøç ç ïðïßá áðïññïöÜôï 55% ðåñßðïõ åðß ôïõ óõíüëïõ ôùí äçìï-óßùí äáðáíþí õãåßáò, Ýíáíôé 23,5% ðïõäáðáíÜôáé êõñßùò ãéá õðçñåóßåò éáôñþí (22%)êáé ðïëý ëéãüôåñï ãéá ïäïíôéáôñéêÞ ðåñßèáë-øç (1,5%).

• Óå ü,ôé áöïñÜ ôéò éäéùôéêÝò äáðÜíåò, ôï ìå-ãáëýôåñï ðïóïóôü áðïññïöÜôáé ãéá åîùíï-óïêïìåéáêÞ ðåñßèáëøç (63% ðåñßðïõ). Áõôüåðéìåñßæåôáé óå ðïóïóôü ðïõ áíÝñ÷åôáé óå33% ãéá ôçí ïäïíôéáôñéêÞ êáé 29% ãéá ôçíéáôñéêÞ ðåñßèáëøç. Áíôßèåôá, ç óõììåôï÷Þôçò äáðÜíçò ãéá íïóïêïìåéáêÞ ðåñßèáëøçóôéò éäéùôéêÝò äáðÜíåò õãåßáò, êõìáßíåôáé óå÷áìçëÜ åðßðåäá (14% ðåñßðïõ). Ç óýíèåóçáõôÞ áðïôõðþíåé ôçí áõôüìáôç õðïêáôÜ-óôáóç ìåôáîý äçìüóéáò êáé éäéùôéêÞò ÷ñç-ìáôïäüôçóçò, óôï ðëáßóéï ôçò ïðïßáò ïé ðï-

ëßôåò êáëýðôïõí ïéêïíïìéêÜ ôçí õðï÷ñçìá-ôïäüôçóç ôïõ äçìüóéïõ óõóôÞìáôïò ðñùôï-âÜèìéáò öñïíôßäáò õãåßáò8.Óôï óçìåßï áõôü, åßíáé áðáñáßôçôç ç åðéóÞ-

ìáíóç åíüò ðáñÜäïîïõ öáéíïìÝíïõ: åíþ ç õðï-êáôÜóôáóç óå åðßðåäï ÷ñçìáôïäüôçóçò åßíáéóáöÞò, óå ü,ôé áöïñÜ ôçí åðÜñêåéá ôùí ðñïóöå-ñïìÝíùí õðçñåóéþí, äåí ðñïêýðôåé áíôßóôïé÷çóõìðåñéöïñÜ ôùí ÷ñçóôþí. ÓõãêåêñéìÝíá, üðùòöáßíåôáé óôï ÄéÜãñáììá1, ôï ðïóïóôü ôçò éäéù-ôéêÞò äáðÜíçò õãåßáò ôï 2001 êéíåßôáé óôá ßäéáåðßðåäá ìå ôï 1980, áíåîÜñôçôá áðü ôç ñáãäáßááíÜðôõîç ôùí õðçñåóéþí ôïõ ÅÓÕ.

Áíôéóôïß÷ùò, óôá ßäéá åðßðåäá ìå ôçí ðñïÅÓÕ ðåñßïäï êéíåßôáé êáé ç óõììåôï÷Þ ôçò ðñù-ôïâÜèìéáò öñïíôßäáò õãåßáò óôéò éäéùôéêÝò äáðÜ-íåò õãåßáò (ÄéÜãñáììá 2), ãåãïíüò ôï ïðïßï áðï-ôõðþíåé ôïí ïñãáíùôéêï – ëåéôïõñãéêü ÷áñáêôÞ-ñá ôùí ðñïâëçìÜôùí ðïõ ùèïýí ôïõò ðïëßôåò óååðéâÜññõíóç ôùí áôïìéêþí ôïõò åéóïäçìÜôùí ãéáÝíá “ðñïúüí” ôï ïðïßï ôï äçìüóéï óýóôçìá ðá-ñÝ÷åé “äùñåÜí”.

Ìå äåäïìÝíá ôá ðáñáðÜíù, ôï åðßêåíôñïôïõ ðñïâëçìáôéóìïý ãýñù áðü ôç äéáìüñöùóçåíüò ïëïêëçñùìÝíïõ óõóôÞìáôïò ðñùôïâÜèìéáòöñïíôßäáò õãåßáò, ìåôáôßèåôáé óôçí áóöáëéóôéêÞæÞôçóç, ôï êüóôïò ÷ñüíïõ êáé ôçí ðïéüôçôá ôùíðáñå÷ïìÝíùí õðçñåóéþí. Åßíáé åíäåéêôéêü üôéðñüóöáôåò ó÷åôéêÝò ìåëÝôåò, êáôáãñÜöïõí õøç-ëÜ ðïóïóôÜ éêáíïðïßçóçò áðü ôá ÊÝíôñá Õãåßáòôïõ ÅÓÕ (79,3%), åíþ áíôßèåôá óôéò ìïíÜäåòôùí Áóöáëéóôéêþí ÖïñÝùí ðáñáôçñïýíôáé ÷á-ìçëüôåñá ðïóïóôÜ (52,5%). Áõôü ðéèáíüí áíôá-íáêëÜ ôç äõóáñÝóêåéá ôùí ðïëéôþí ùò ðñïò ôéòäéáäéêáóßåò åðéâåâáßùóçò ôïõ áóöáëéóôéêïý äé-êáéþìáôïò êáé ëéãüôåñï ôçí áñíçôéêÞ ôïõò ãíþ-ìç ãéá ôéò ðñïóöåñèåßóåò õðçñåóßåò9.

Óôï óçìåßï áõôü, ðñéí ôç äéáôýðùóç óêÝ-øåùí êáé ðñïâëçìáôéóìþí ãéá ôç äéáìüñöùóçìåôáññõèìéóôéêïý ó÷åäßïõ, ðñüôáóçò, Þ êáé åðé-ìÝñïõò ñõèìßóåùí, èåùñåßôáé éäéáßôåñá ÷ñÞóéìçìéá “åðé÷åéñçóéáêÞ ðñïóÝããéóç” ôçò õöéóôÜìåíçòðñáãìáôéêüôçôáò óôçí ÐÖÕ, ç ïðïßá ðáñïõóéÜ-æåôáé ó÷çìáôéêÜ ðáñáêÜôù:

Ç ðñïóÝããéóç áõôÞ åðéâåâáéþíåé ôçí áñ÷éêÞõðüèåóç üôé áíåîáñôÞôùò ôùí áäõíáìéþí ðïõÝ÷ïõí êáôáãñáöåß, ç ðïñåßá ôïõ Å.Ó.Õ. ôá ôåëåõ-ôáßá ÷ñüíéá Ý÷åé íá åðéäåßîåé óçìáíôéêÞ âåëôßù-óç óå áñêåôÝò ðôõ÷Ýò ôçò ëåéôïõñãßáò ôïõ. Ôçíßäéá óôéãìÞ åðéâåâáéþíïíôáé ïé “åêêñåìüôçôåò”


90


44,4

40,1

44

43,9

46,6

47,9

47,24748

49,8

45,5

45,4

46,6

46,3

44,1

45,9

0

10

20

30

40

50

60

1980 1987 1988 1989 199 0 1991 19 92 1993 1 994 1995 1996 1997 1998 1999 2000 2001

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

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

Å Ó Õ

Õ ð ïä ïì Þ Ð Ö Õ : 12 6

Õãåéï íï ìéê ïß Ó ôá è ì ïß êá é

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2 2 7 4 êÜ ôï éê ï é á íÜ ãéáôñ ü

Ð ÖÕ

Õð ïä ï ìÞ Ð ÖÕ : 17 0 Ê Ý íôñ á

Õãå ßá ò ê áé 13 1 1

Ð åñ éö åñ åéáê Ü É áô ñåßá

19 9 0 ê Ü ôïéê ïé á íÜ ã éáôñ ü

Ð ÖÕ

Õð ï äï ìÞ Ð ÖÕ : 2 0 1 Ê Ýíôñ á

Õã åßáò êá é 14 7 8

Ð å ñéö åñ åéá êÜ Éá ôñå ßá

~ 8 0 0 ê Üô ïéê ïé á íÜ ã éá ôñ ü

Ð ÖÕ

ÄéÜãñáììá 2.

63 ,38 67 ,83 62 ,24 64 ,35

0

10

20

30

40

50

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70

1981 1987 1993 2000

ÐÖÕ

Í ÏÓÏÊÏÌÅÉÁÊÇ

Ö ÁÑÌÁÊÅÕÔ ÉÊÇ

Ð ç ã Þ : Ó ï õ ë éþ ô ç ò Ê . ( 2 0 01 ) Ï Ñ ü ë ï ò ô ï õ É ä é ù ô éê ï ý Ô ï ì Ý á ó ôï Å ë ë ç í éê ü Ó ý ó ôç ì á Õ ã åß á ò , Ð á ð á æ Þ ó ç ò , Á è Þ í á .

Á Í Á Ë Õ Ó Ç Ô Ù Í É Ä É Ù Ô É Ê Ù Í Ä Á Ð Á Í Ù Í Õ Ã Å É Á Ó Ó Ô Ç Í Å Ë Ë Á Ä Á ( 1 9 8 1 - 2 0 0 0 )

ÄéÜãñáììá 1.

91


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ÐËÅÏÍÅÊÔÇÌÁÔÁ ÌÅÉÏÍÅÊÔÇÌÁÔÁ

ÅÕÊÁÉÑÉÅÓ ÁÐÅÉËÅÓ

?Å ðÜ ñ ê å éá õë éê þ í ê é á íè ñ þ ðéí ù í

ð ü ñ ù í

?Å ðá ñ ê Ý ò ðë á ßó éï ä ïì þ í ó ô éò

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

?Å õñ ý ä ßê ô õï éäé ù ô éê þ í ä ï ì þ í

? Á ð ïõ ó ßá ä ï ì þ í ó ôéò á ó ô éêÝ ò

ð åñ éï ÷ Ý ò

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

ð ëá éó ßï õ

?¸ ëë åé ø ç Ãå í éê þ í ã éá ôñ þ í

?Ð ñ ü âëç ì á ÷ ñï í éê Þò

ä éá èå ó éì üô ç ôá ò ô ù í õ ðç ñ å ó éþ í

?Õ ø ç ëÞ áô ï ì éêÞ åð éâ Ü ñ õ íó ç ó å

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

÷ ñ üí ï õ

?× Ü ñ ôç ò õ ã åßá ò ê á é á íÜ ëõ ó ç ôù í

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

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

?Åí ßó÷ õ ó ç ôù í ðå ñéö å ñ åéá ê þ í

ä ï ìþ í

?Ð ñ ù ôï âï õ ë ßå ò É Ê Á

?Åê ì åô Ü ëë å õ óç éä é ù ô éêÞ ò õ ð ï äï ì Þ ò

?Á ä õí á ì ßá åê ô ßìç ó ç ò ô çò

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

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

æ Þ ô ç óç ê ë ð)

?Á íå î Ýë åã ê ôç á ý î ç ó ç ôï õ ê ü ó ôï õ ò

?Á íå î Ýë åã ê ôç ä éå ýñ õ í ó ç ôï õ

éä éù ôéê ï ý ô ï ìÝ á

?× ñ çì á ô ïä ï ô éê ïß ðå ñéï ñ éó ì ï ß

ôçò ðïëéôéêÞò õãåßáò ãýñù áðü ôá áêáíèþäçæçôÞìáôá ôçò ÷ñçìáôïäüôçóçò (õøçëÞ éäéùôéêÞäáðÜíç) êáé ôçò Ýëëåéøçò êëéíþí óôá íïóïêï-ìåßá ôçò ÁôôéêÞò, êáôÜ ôç äéÜñêåéá ôùí åöçìå-ñéþí (ñÜíôæá). Êáé ôá äýï æçôÞìáôá óõíäÝïíôáéìå ôçí ðïëéôéêÞ ãéá ôçí ÐÖÕ, äåäïìÝíïõ üôé çáíáäéïñãÜíùóÞ ôçò èá åðÝôñåðå ôüóï ôïí Ýëåã÷ïôïõ êüóôïõò, üóï êáé ôïí ðåñéïñéóìü ôïõ öáéíï-ìÝíïõ ôçò Üóêïðçò ðñïóöõãÞò óôá íïóïêïìåßá,óôá ïðïßá ðïëëÝò öïñÝò êáé êõñßùò ëüãù ôçòåëëéðïýò ÷ñïíéêÞò äéáèåóéìüôçôáò ôùí õðçñåóéþíÐÖÕ, ðáñÝ÷ïíôáé öñïíôßäåò ãéá ôéò ïðïßåò äåíáðáéôïýíôáé íïóïêïìåéáêÝò äïìÝò.

3. ÓõæÞôçóç

Ï ÷áñáêôÞñáò ôùí ðñïâëçìÜôùí ôçò ðñù-ôïâÜèìéáò öñïíôßäáò õãåßáò óôçí ÅëëÜäá áðáé-ôåß ëýóåéò “éáôñïáóöáëéóôéêïý” ðåñéå÷ïìÝíïõ.ÏõóéáóôéêÜ, óå åðßðåäï õëïðïßçóçò, ìéá ìåôáñ-ñõèìéóôéêÞ ðñüôáóç èá ìðïñïýóå íá âáóéóôåß óôïðñüôõðï ôùí Ïñãáíéóìþí ÄéáôÞñçóçò ôçò Õãåßáòóôéò ÇÐÁ10-12, ìÝóù ôçò “åêìåôÜëëåõóçò” êáéâåëôßùóçò ôùí õðçñåóéþí ôïõ ÉÊÁ óôá áóôéêÜêÝíôñá, ôçò áîéïðïßçóçò ôçò éäéùôéêÞò õðïäïìÞòêáé ôçò äéáìüñöùóçò åíüò ðëáéóßïõ ëåéôïõñãßáòôçò áãïñÜò õðçñåóéþí õãåßáò, âáóéóìÝíïõ óå Ýíá


92


ðëÝãìá óõìâïëáßùí êáé óõìâÜóåùí13.Ôï óýóôçìá ôï ïðïßï èá ðñïêýøåé áðü ìéá

ôÝôïéá ëïãéêÞ èá (ðñÝðåé íá) éêáíïðïéåß ôéò áñ-÷Ýò ôçò óõíÝ÷åéáò êáé ôçò ïëïêëçñùìÝíçò öñï-íôßäáò êáé íá ðñïóáíáôïëßæåôáé óôïí ðïëßôç.Âáóéêü ðëåïíÝêôçìá ôïõ ó÷åäßïõ ãéá ôç ëåéôïõñ-ãéêÞ áíáäéïñãÜíùóç ôùí õðçñåóéþí ÐÖÕ, åßíáéüôé áíáìÝíåôáé íá ðñïóäþóåé Ýíáí ðëïõñáëéóôé-êü ÷áñáêôÞñá óôï óýóôçìá, åìðëïõôßæïíôáò ôïìåßãìá ôùí ðáñå÷üìåíùí öñïíôßäùí ìå õðçñå-óßåò ðÝñáí ôùí ðáñáäïóéáêþí êëéíéêïåñãáóôç-ñéáêþí äñáóôçñéïôÞôùí, äçëáäÞ ðñüëçøçò ôçòíüóïõ êáé ðñïáãùãÞò ôçò õãåßáò, äéá÷åßñéóçò ôùíìåéæüíùí ðáñáãüíôùí êéíäýíïõ14,15.

Åðéóçìáßíåôáé üôé ç ðñüôáóç áõôÞ ç ïðïßáïõóéáóôéêÜ áöïñÜ óôç ëåéôïõñãéêÞ åíóùìÜôùóçôùí õðçñåóéþí ôïõ ÉÊÁ óôï ðëÝãìá ôùí õðçñå-óéþí ôïõ ÅÓÕ, äåí Ýñ÷åôáé óå áíôéðáñÜèåóç ìåôï ó÷Ýäéï ôçò äéïéêçôéêÞò ìåôáññýèìéóçò êáé ôçòåíéáßáò ïñãáíùôéêÞò äïìÞò ôçò ðñùôïâÜèìéáòöñïíôßäáò õãåßáò, áëëÜ áíôßèåôá óõíéóôÜ áðá-ñáßôçôç ðñïûðüèåóç ãéá ôçí õëïðïßçóç êáé ôçíáëëáãÞ ôçò ïñãáíùôéêÞò öéëïóïößáò ôïõ óõóôÞ-ìáôïò. Ùò áðïôÝëåóìá ôçò ðñþôçò áõôÞò áðü-ðåéñáò äéáìüñöùóçò “äéêôýïõ” õðçñåóéþí, áíá-ìÝíåôáé íá åßíáé ç ïñèïëïãéêïðïßçóç óôç ÷ñÞóçôùí ðüñùí êáé ç âåëôßùóç ôçò áðïäïôéêüôçôáòôïõ óõóôÞìáôïò, åíþ óå áõôü áíáìÝíåôáé íá óõì-âÜëëïõí êáé ôá ìÝôñá åëÝã÷ïõ ôçò êëéíéêÞò áðï-ôåëåóìáôéêüôçôáò (ðñùôüêïëëá êëéíéêïý éáôñéêïýåëÝã÷ïõ-medical audit) ôá ïðïßá èá ìðïñïýí íáåöáñìüæïíôáé åíéáßá óå üëåò ôéò äïìÝò ÐÖÕ.

Âáóéêïß ðáñÜãïíôåò – ðñïûðïèÝóåéò ãéá ôçíåðéôõ÷ßá ôïõ åã÷åéñÞìáôïò, åßíáé ç áðïöõãÞ ðå-ñéïñéóôéêþí ëïãéêþí óôçí åíóùìÜôùóç èåóìþíüðùò ï ïéêïãåíåéáêüò éáôñüò (ð.÷. gate keeping),ç äéåýñõíóç ôïõ ÷ñüíïõ ëåéôïõñãßáò ôùí ìïíÜ-äùí ÐÖÕ, ç ïñãÜíùóç ôùí éáôñéêþí åéäéêïôÞ-ôùí ðïõ ëåéôïõñãïýí óå áõôÝò êáé ç åéóáãùãÞêéíÞôñùí ãéá ôçí áýîçóç ôçò ðáñáãùãéêüôçôáòôùí éáôñþí êáé ôç óõãêñÜôçóç ôïõ ðëçèõóìïýáíáöïñÜò åíôüò ôçò ìïíÜäáò ÐÖÕ. ÅðéðñïóèÝ-ôùò, ç äéáìüñöùóç ìéáò íÝáò ïñãáíùôéêÞò – äéïé-êçôéêÞò êïõëôïýñáò óôçí ÐÖÕ, åßíáé ôáõôüóçìçìå ôçí åîáóöÜëéóç ôùí ðñïûðïèÝóåùí ãéá ôçíôÞñçóç éáôñéêïý öáêÝëïõ, ï ïðïßïò áíáìÝíåôáéíá óõìâÜëåé óôçí åêôßìçóç ôùí áíáãêþí õãåßáòôùí ðïëéôþí êáé óôçí áõôïìáôïðïßçóç ôùí äéá-äéêáóéþí êáôáãñáöÞò ôùí êëéíéêþí êáé åñãá-óôçñéáêþí ðëçñïöïñéþí ðïõ åßíáé áðáñáßôçôåò

óå êÜèå åðáöÞ ôùí ðïëéôþí ìå ôéò õðçñåóßåòõãåßáò, áëëÜ êõñßùò óôçí åêôßìçóç ôçò áðïôåëå-óìáôéêüôçôáò ôïõ íÝïõ óõóôÞìáôïò. Ìå ôï ßäéïóêåðôéêü, âáóéêü óõóôáôéêü ôçò ëåéôïõñãßáò ôïõõðïäåßãìáôïò åßíáé ç ïëïêëÞñùóç ôïõ Õãåéïíïìé-êïý ×Üñôç, ï ïðïßïò èá åðéôñÝøåé ôçí åðßôåõîçôçò ìåãáëýôåñçò äõíáôÞò áíôáðïêñéóéìüôçôáò ôùííÝùí äïìþí óôéò áíÜãêåò ôùí ðïëéôþí.

ÔÝëïò, áí êáé üðùò ðñïáíáöÝñèçêå ç åíóù-ìÜôùóç ëïãéêÞò “óõóôÞìáôïò” óôçí ðñùôïâÜè-ìéá öñïíôßäá õãåßáò óôç ÷þñá ìáò áðïôåëåß ðÜãéá“åêêñåìüôçôá” ôçò ðïëéôéêÞò õãåßáò, åðéóçìáßíå-ôáé üôé óôçí ðáñïýóá óõãêõñßá ôçò èåóìéêÞòïëïêëÞñùóçò êáé ôçò ùñßìáíóçò ôùí åðéóôçìïíé-êþí ðñïóåããßóåùí ãéá ôç ëåéôïõñãéêÞ áíáóõãêñü-ôçóç ôçò ÐÖÕ, õðÜñ÷ïõí óõíèÞêåò ðïõ åõíïïýíðáñåìâÜóåéò ðñïò ôçí êáôåýèõíóç ôçò âåëôßùóçòôçò ÐÖÕ êáé êáô´ åðÝêôáóç ôçò ëåéôïõñãßáò ôïõóõóôÞìáôïò õãåßáò óôï óýíïëü ôïõ.


1. Óïõëéþôçò Ê. (2001) Ï Ñüëïò ôïõ ÉäéùôéêïýÔïìÝá óôï Åëëçíéêü Óýóôçìá Õãåßáò, ÐáðáæÞ-óçò, ÁèÞíá.

2. Souliotis K, Lionis C. Creating an IntegratedHealth Care System in Greece: A Primary CarePerspective, Journal of Medical Systems (inpress).

3. Souliotis K, Kyriopoulos J. The Hidden Econo-my and Health Expenditures in Greece: Mea-surement Problems and Policy Issues, AppliedHealth Economics and Health Policy, 3:129-134, 2003.

4. ËéïíÞò ×, Ìåñêïýñçò Ì-Ð. “Áðüøåéò ãéá ôçóçìåñéíÞ êáôÜóôáóç óôçí ÐñùôïâÜèìéá Öñï-íôßäá Õãåßáò êáé ðñïôÜóåéò ãéá ôç âåëôßùóÞ ôçò”,ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, 12:7-9, 2000.

5. Êõñéüðïõëïò Ã, ËéïíÞò ×, ÄçìïëéÜôçò Ã, êáéóõí.: Ç ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò ùò èåìÝ-ëéï ôçò õãåéïíïìéêÞò ìåôáññýèìéóçò, ÐñùôïâÜè-ìéá Öñïíôßäá Õãåßáò, 12:169-188, 2000.

6. Óïõëéþôçò Ê, ËéïíÞò ×. ËåéôïõñãéêÞ Áíáóõãêñü-ôçóç ôçò ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò: ÌéáÐñüôáóç ãéá ôçí ¢ñóç ôïõ Áäéåîüäïõ, Áñ÷åßáÅëëçíéêÞò ÉáôñéêÞò, 20:466-476, 2003.

7. Glied S. Chronic Condition: Why Health Re-form Fails? Harvard University Press, Cam-bridge, 1997.

8. Óïõëéþôçò Ê. ÁíÜëõóç ôùí Äáðáíþí Õãåßáò óôçíÅëëÜäá 1989-2000. ÌåèïäïëïãéêÝò Äéåõêñéíß-

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óåéò êáé Äéáðéóôþóåéò ãéá ôï Óýóôçìá Õãåßáò,óôï Êõñéüðïõëïò Ê., Óïõëéþôçò Ê. (åðéì.) ÏéÄáðÜíåò Õãåßáò óôçí ÅëëÜäá. ÌåèïäïëïãéêÜÐñïâëÞìáôá óôç ÌÝôñçóç êáé ÓõíÝðåéåò ãéáôéò ÐïëéôéêÝò Õãåßáò, ÐáðáæÞóçò, 2001, ÁèÞíá.

9. Óïõëéþôçò Ê., Äüëãåñáò Á., Êõñéüðïõëïò Ã. ÇÉêáíïðïßçóç ôùí ×ñçóôþí áðü ôéò ÕðçñåóßåòÕãåßáò: ÅñåõíçôéêÜ ÁðïôåëÝóìáôá áðü ôçí Ðå-ñéï÷Þ ôçò ÁèÞíáò, óåë. 279-296, óôï Êõñéüðïõ-ëïò Ã, ËéïíÞò ×, Óïõëéþôçò Ê, ÔóÜêïò Ã, (åðéì.):Ç Ðïéüôçôá óôéò Õðçñåóßåò Õãåßáò, ÈåìÝëéï,2003, ÁèÞíá.

10. Luft HS. “Health Maintenance Organizations:Dimensions and Performance, John Wiley andSons, New York, 1981.

11. Luft HS. “Translating the U.S. HMO Experi-ence to Other Health Systems”, Health Affairs,10: 172-186, 1991.

12. Lawrwnce D. From Chaos to Care: The prom-ise of Team-Based Medicine, Da Capo Press,Cambridge, 2002.

13. Flynn R, Williams G. “Contracting For Health.Quasi-Markets and the National Health Ser-vice”, Oxford University Press, New York, 1997.

14. Lionis C, Chatziarsenis M, Antonakis N, Gi-anoulis Y, Fioretos M. Assessment of vaccinecoverage of school children in three PrimaryHealth Care areas in rural Crete, Greece. Fam-ily Practice, 15: 443-448, 1998.

15. Chatziarsenis M, Miyakis S, Faresjö T, FioretosM, Vlachonicolis J, Trell E, Lionis C. Is thereroom for General Practice in Penitentiary In-stitutions: Screening and vaccinating high riskgroups against hepatitis. Family Practice, 16:366-368, 1999.

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94

Á. Ñüäç êáé óõí

ÁÍÁÓÊÏÐÇÓÇ

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

1. ÅéóáãùãÞ

Ïé ôáêôéêÝò óôáôéóôéêÝò óåéñÝòáðïôåëïýí óçìáíôéêÞ ðçãÞ ãéá ôç óõë-ëïãÞ åðéäçìéïëïãéêþí äåäïìÝíùí1-3. Ïéðåñéóóüôåñåò äçìéïõñãÞèçêáí ìå óêï-ðü ôçí êÜëõøç íïìéêþí, ìáêñïïéêï-íïìéêþí êáé äçìïãñáöéêþí áíáãêþí,üìùò Ýììåóá åîõðçñåôïýí êáé ôçíåðéäçìéïëïãßá4. Ôá äåäïìÝíá ðïõ áðïñ-ñÝïõí áðü ôéò ôáêôéêÝò óôáôéóôéêÝòóåéñÝò óõìâÜëëïõí óôçí áðïôýðùóç ôçòóõ÷íüôçôáò, ôçò êáôáíïìÞò êáé ôçòäéá÷ñïíéêÞò åîÝëéîçò ôùí íïóçìÜôùí2.

Ïé ôáêôéêÝò óôáôéóôéêÝò óåéñÝò äåíðñïóöÝñïíôáé ãéá ôïí Ýëåã÷ï óõãêå-êñéìÝíùí áéôéïëïãéêþí õðïèÝóåùí,Ý÷ïõí üìùò ôï ðëåïíÝêôçìá üôé åßíáéðñïóéôÝò êáé ìðïñïýí íá áíáíåþíï-íôáé ðåñéïäéêÜ, ÷ùñßò íá áðáéôåßôáééäéáßôåñç äáðÜíç Þ ðñïóðÜèåéá áðüôïõò åñåõíçôÝò. Áðü ôçí Üëëç ìåñéÜ,ðáñïõóéÜæïõí êáé óçìáíôéêÜ ìåéïíå-êôÞìáôá óå ó÷Ýóç ìå ôçí áêñßâåéá,ôçí ðïéüôçôá êáé ôçí ðëçñüôçôá ôùí

ÐåñßëçøçÓôçí åñãáóßá áõôÞ ìåëåôÞèçêå ç ÷ñçóéìüôçôá ôçò óôáôéóôéêÞò åðåîåñãáóßáòôïõ ðéóôïðïéçôéêïý èáíÜôïõ óôçí åêðüíçóç ìåëåôþí èíçóéìüôçôáò. ÁíáöÝñï-íôáé ç áîßá êáé ïé ðåñéïñéóìïß ôùí ìåëåôþí êáôÜ áéôßåò èíçóéìüôçôáò, ðáñáðÝ-ìðïíôáò óå åñãáóßåò ðïõ ìåëÝôçóáí íüóïõò êáé êáôáóôÜóåéò ðïõ åõèýíïíôáéãéá ôïõò ðåñéóóüôåñïõò èáíÜôïõò óôçí åðï÷Þ ìáò. ¸ãéíå áíÜëõóç ôïõ åßäïõòôùí ðëçñïöïñéþí ðïõ ðåñéÝ÷åé ôï ðéóôïðïéçôéêü èáíÜôïõ êáé áíáöÝñèçêáíóôïé÷åßá ðïõ áöïñïýí óôçí áîéïðéóôßá óõìðëÞñùóÞò ôïõ ôüóï óôçí ÅëëÜäá,üóï êáé óå Üëëåò ÷þñåò. ÐåñéãñÜöåôáé ç äéáäéêáóßá óõãêÝíôñùóçò êáé åðåîåñ-ãáóßáò ôùí äåäïìÝíùí, îåêéíþíôáò áðü ôç óõìðëÞñùóç ôïõ “Éáôñéêïý Ðéóôï-ðïéçôéêïý ÈáíÜôïõ” áðü ôï ãéáôñü Ýùò ôçí ôåëéêÞ äçìïóßåõóç ôùí óôïé÷åßùíêáé ôùí óôáôéóôéêþí èíçóéìüôçôáò áðü ôçí ÅèíéêÞ ÓôáôéóôéêÞ Õðçñåóßá ôçòÅëëÜäïò (ÅÓÕÅ). Åðéðñüóèåôá, ãßíåôáé áíáöïñÜ óôçí ðñïóâáóéìüôçôá óôéòðëçñïöïñßåò ôçò ÅÓÕÅ, êáèþò êáé ãéá ôï åßäïò ôùí äåäïìÝíùí ðïõ õðÜñ÷ïõíóôïõò Ïñãáíéóìïýò ÔïðéêÞò Áõôïäéïßêçóçò (ÏÔÁ) êáé ãéá ôïí ôñüðï ðïõ áõôÜôá äåäïìÝíá åðåîåñãÜæïíôáé êáé ÷ñçóéìïðïéïýíôáé áðü ôéò áíôßóôïé÷åò õðçñå-óßåò. ÔÝëïò, ãßíïíôáé ðñïôÜóåéò ïé ïðïßåò èá ìðïñïýóáí íá âåëôéþóïõí ôéòåëëåßøåéò êáé ðáñáëåßøåéò ôüóï óôï ðéóôïðïéçôéêü èáíÜôïõ, üóï êáé óôç äéáäé-êáóßá ôçò åðåîåñãáóßáò ôùí äåäïìÝíùí Ýôóé þóôå íá áõîçèåß ç áîéïðéóôßá ôùíäåäïìÝíùí ðïõ ðñïêýðôïõí áðü ôá ðéóôïðïéçôéêÜ èáíÜôïõ. Ç ×ñçóéìüôçôáôçò ÓôáôéóôéêÞò Åðåîåñãáóßáò ôùí Ðéóôïðïéçôéêþí ÈáíÜôïõ óôçí ÅêðüíçóçÌåëåôþí Èíçóéìüôçôáò.

Ç ÷ñçóéìüôçôá ôçò óôáôéóôéêÞò åðåîåñãáóßáò ôùí ÐéóôïðïéçôéêþíÈáíÜôïõ óôçí åêðüíçóç ìåëåôþí èíçóéìüôçôáò

ÁèçíÜ Ñüäç1, Ðáíáãéþôá ÓïõñôæÞ2, Å. ÂåëïíÜêçò3

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

ËÝîåéò êëåéäéÜ: Ðéóôïðïéçôéêü èáíÜôïõ, åðéäçìéïëï-ãßá, èíçóéìüôçôá, äçìïãñáößá, ôáêôéêÝò óôáôéóôéêÝòóåéñÝòÕðïâëÞèçêå: 16 Éáíïõáñßïõ 2004ÅðáíõðïâëÞèçêå: 2 Ìáñôßïõ 2004¸ãéíå äåêôÞ ãéá äçìïóßåõóç: 26 Ìáñôßïõ 2004Õðåýèõíïò áëëçëïãñáößáò: Ð. ÓïõñôæÞ, Ðáðáäéá-ìáíôïðïýëïõ 123, 11527, ÁèÞíá, Ôçë. 210-7461474,fax: 210-7461491, e-mail: [email protected]

95

Á. Ñüäç êáé óõí Ôüìïò 16, Ôåý÷ïò 2, 2004

The importance of Death Certificate's in the mortality statisticsÁthina Rodi, Panagiota Sourtzi, Å. Velonakis

SummaryTo assess the usefulness of statistic processing of the Death Certificate inmortality studies and the value and limitations of mortality studies according tothe cause of death as well as important studies, which are concerned withillnesses and circumstances responsible for most deaths today. Analysis of theinformation contained in the Death Certificate was made and facts were men-tioned which concern the reliability of its completion in Greece and in othercountries. The complete selection and processing of the data was described indetail beginning with the completion of the "Medical Death Certificate" by thedoctor to the final publication of the facts and the death-rate statistics by theNational Statistics Department of Greece (NSDG). In addition, a report of theability to gain access to the information of the NSDG was also made. A reportof the type of data that exist in the Local Municipal Organizations (LMO), wasmade as well as the way that this data are elaborated and used by the corre-sponding services. Finally, suggestions are mentioned, which could supplementthe deficiencies on the completion of the current Death Certificate and of thedata process procedure, which can contribute to the improvement of renderinginformation as well as the reliability of the Death Certificate.

Key Words: Death Certificate, Epidemiology, Mortality

ôßåò, êáé åðïìÝíùò óôçí ôá÷ýôåñçêáé áðïôåëåóìáôéêüôåñç áíôéìåôþ-ðéóÞ ôïõò2.

2. Ôï ðéóôïðïéçôéêü èáíÜôïõ ùò ðçãÞðëçñïöïñéþí

Ç êõñéüôåñç éáôñéêÞ óõìâïëÞ óôçäçìéïõñãßá ôùí óôáôéóôéêþí öõóéêÞòêßíçóçò ôïõ ðëçèõóìïý åßíáé ç óýíôá-îç ôïõ éáôñéêïý ðéóôïðïéçôéêïý èáíÜ-ôïõ. Ç éóôïñéêÞ åîÝëéîç ôçò äéáìüñ-öùóçò ôïõ ðéóôïðïéçôéêïý èáíÜôïõìÝ÷ñé ôç ìïñöÞ ðïõ Ý÷åé óÞìåñá áíá-êëÜ ôéò ðñïóðÜèåéåò âåëôßùóçò ôçòðëÞñïõò êáôáãñáöÞò ôùí èáíÜôùí êáéôçò áêñéâïýò äéÜãíùóçò ôçò áéôßáòèáíÜôïõ8.

Äõó÷Ýñåéåò óôçí ôáîéíüìçóç ôùíóôïé÷åßùí. ÅðéðëÝïí, ôá äåäïìÝíá ôùí ôáêôéêþíóôáôéóôéêþí óåéñþí óõíÞèùò äçìïóéåýïíôáé ìåêáèõóôÝñçóç êáé ÷ùñßò ëåðôïìÝñåéåò ðïõ èá éêá-íïðïéïýóáí üëïõò ôïõò åíäéáöåñüìåíïõò åñåõíç-ôÝò.

Ìå ôç âïÞèåéá ôùí óôïé÷åßùí ðïõ êáôáãñÜ-öïíôáé óôá ðéóôïðïéçôéêÜ èáíÜôïõ êáé ìåôÜ áðüìéá áêïëïõèßá óõãêÝíôñùóçò êáé åðåîåñãáóßáòôùí äåäïìÝíùí áðü ôéò ÓôáôéóôéêÝò ÕðçñåóßåòêÜèå ÷þñáò, äçìéïõñãïýíôáé äéÜöïñïé ðßíáêåò êáéóôáôéóôéêÝò èíçóéìüôçôáò. Ìå âÜóç áõôÝò ôéò óôá-ôéóôéêÝò åêðïíïýíôáé ìåëÝôåò ðïõ áöïñïýí ôçèíçóéìüôçôá êáé ðñïâÜëëïõí ôç öýóç ôùí õãåéï-íïìéêþí ðñïâëçìÜôùí ðïõ ðáñïõóéÜæïíôáé óôïóõãêåêñéìÝíï ðëçèõóìü êáé åêôéìÜôáé ç êáôÜ-óôáóç õãåßáò ôïõ5.

Åéäéêüôåñá ïé óôáôéóôéêÝò èíçóéìüôçôáò óõì-âÜëëïõí óôá åîÞò:Ø áîéïëüãçóç ôïõ ìåãÝèïõò ôùí ðñïâëçìÜôùí

õãåßáò óôïí ðëçèõóìü,Ø ó÷åäéáóìü êáé äçìéïõñãßá ðñïãñáììÜôùí

ðñüëçøçò êáé ðñùôïâÜèìéáò öñïíôßäáò õãåßáòáðü ôçí ðïëéôåßá5,

Ø Ýëåã÷ï êáé âåëôßùóç ôùí ðñïãñáììÜôùí ðñü-ëçøçò êáé ôùí õðçñåóéþí õãåßáò6,7,

Ø åêôßìçóç ôçò áðïôåëåóìáôéêüôçôáò êáé ôçâåëôßùóç ôùí èåñáðåõôéêþí ìåèüäùí áðü ôçíÜëëç6,7,

Ø Ýãêáéñç åðéóÞìáíóç åðéäçìéêþí åêñÞîåùí áðüãñßðç, áôìïóöáéñéêÞ ñýðáíóç Þ Üëëåò áé-

áéôéþí èáíÜôïõ äçìéïõñãïýíôáé üôáí äýï Þ ðå-ñéóóüôåñåò ðáèïëïãéêÝò êáôáóôÜóåéò óõìâÜëëïõíóôï èÜíáôï9. Ôüôå, èá ðñÝðåé íá åðéëÝîïõìå ìéááðü ôéò áéôßåò áõôÝò êáé ìÜëéóôá ôçí “áñ÷éêÞáéôßá èáíÜôïõ”, ðïõ èåùñåßôáé:á) ç íüóïò Þ ç êÜêùóç ðïõ ðñïêÜëåóå ôçí

áëõóßäá ôùí íïóçñþí öáéíïìÝíùí ðïõ ïäÞ-ãçóáí óôï èÜíáôï Þ,

â) ïé óõíèÞêåò êÜôù áðü ôéò ïðïßåò Ýëáâå ÷þñáôï áôý÷çìá Þ ç êÜêùóç ðïõ ðñïêÜëåóå èá-íáôçöüñï ôñáõìáôéóìü.Ï ãéáôñüò åßíáé õðåýèõíïò ãéá ôç óýíôáîç

ôïõ éáôñéêïý ðéóôïðïéçôéêïý áéôßáò èáíÜôïõ Ýôóé,þóôå íá äéåõêïëýíåôáé ç åðéëïãÞ ôçò “áñ÷éêÞòáéôßáò èáíÜôïõ”, üôáí åßíáé êáôá÷ùñçìÝíåò ðå-ñéóóüôåñåò áðü ìßá8.

Ôï éáôñéêü ðéóôïðïéçôéêü èáíÜôïõ áðïôåëåß-ôáé áðü äýï ìÝñç. Óôï ðñþôï ìÝñïò ðåñéÝ÷ïíôáéðñïóùðéêÜ ÷áñáêôçñéóôéêÜ ôïõ áðïèáíüíôïò, ïôüðïò èáíÜôïõ, êáèþò êáé áí ï ðéóôïðïéþí ãéá-ôñüò åßíáé ï èåñÜðùí Þ Üëëïò. Ôï äåýôåñï ìÝñïòôïõ éáôñéêïý ðéóôïðïéçôéêïý èáíÜôïõ âáóßæåôáéóôï áíôßóôïé÷ï õðüäåéãìá ôçò “Äéåèíïýò Ôáîéíü-ìçóçò ÍïóçìÜôùí” (International Classificationof Diseases - ICD) ôïõ Ðáãêüóìéïõ ÏñãáíéóìïýÕãåßáò (ÐÏÕ) êáé áöïñÜ ôéò íïóïëïãéêÝò óõíèÞ-êåò ðïõ ïäÞãçóáí óôï èÜíáôï9-11. Ôï äåýôåñï ìÝñïòôïðïèåôåßôáé óå ðåñßãñáììá êáé áðïôåëåßôáé áðüôñßá ôìÞìáôá: ôï É, ôï ÉÉ êáé ôï “åðß âéáßïõèáíÜôïõ”.


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Óôï ôìÞìá É öáßíåôáé ç áéôéïëïãéêÞ áêïëïõ-èßá ðïõ ïäÞãçóå óôï èÜíáôï. ÓõãêåêñéìÝíá, óôçèÝóç (á) óõìðëçñþíåôáé ç íüóïò Þ ç êáôÜóôáóçåêåßíç ðïõ áðïôÝëåóå ôçí Üìåóç áéôßá èáíÜôïõ.Ùò Üìåóç áéôßá èáíÜôïõ èåùñåßôáé ç ßäéá ç íü-óïò, ç êÜêùóç Þ ç åðéðëïêÞ ðïõ ðñïêÜëåóå ôïèÜíáôï, ü÷é üìùò ç ðáèïëåéôïõñãéêÞ äéáôáñá÷ÞÞ ï ìç÷áíéóìüò ôïõ èáíÜôïõ. Áí ç íüóïò Þ çêáôÜóôáóç ôçò èÝóçò (á) Þôáí óõíÝðåéá ìéáò Üëëçòíüóïõ Þ êáôÜóôáóçò, ôüôå áõôÞ ç Üëëç íüóïò ÞêáôÜóôáóç èá ãñáöôåß óôç èÝóç (â) êáé ïýôùêáè’ åîÞò.

Ç áñ÷éêÞ íüóïò Þ êáôÜóôáóç, ðïõ îåêßíçóåôçí áëëçëïõ÷ßá ôùí íïóçìÜôùí ðïõ ïäÞãçóå óôïèÜíáôï, üðùò åðßóçò êáé ïé ðåñéðôþóåéò áôõ÷Þ-ìáôïò Þ âßáò ðïõ åß÷áí ùò áðïôÝëåóìá ôç èáíá-ôçöüñï âëÜâç3 ïíïìÜæïíôáé “õðïêåßìåíç áéôßáèáíÜôïõ”, óýìöùíá ìå ôç óýóôáóç ôïõ ÐÏÕ9.Ôï óêåðôéêü ôçò óõãêåêñéìÝíçò áðüöáóçò Þôáíüôé áðü ôç ìéá ìåñéÜ ï êÜèå èÜíáôïò èá Ýðñåðåíá åß÷å ìßá ìüíï “ïíïìáóôéêÞ” áîßá (ãéáôß ôïáíôßèåôï áí êáé åßíáé âéïúáôñéêÜ ðéï óùóôü, èáðñïêáëïýóå ðïëý ìåãÜëç óýã÷õóç óôéò óôáôéóôé-êÝò èíçóéìüôçôáò). Áðü ôçí Üëëç ìåñéÜ, ç áíôé-ìåôþðéóç ôçò áñ÷éêÞò áéôßáò èáíÜôïõ áðïôåëåßêáé ôç ëïãéêüôåñç ôáêôéêÞ ãéá ôçí áíáêïðÞ ôçòèáíáôçöüñáò áëëçëïõ÷ßáò. Ç áíáãñáöÞ óôç äå-îéÜ ðëåõñÜ ôïõ ÷ñüíïõ ðïõ ðÝñáóå áðü ôçí Ýíáñîçôçò êÜèå íüóïõ Þ êáôÜóôáóçò ìÝ÷ñé ôç óôéãìÞôïõ èáíÜôïõ, äéåõêïëýíåé ôç ÷ñïíïëïãéêÞ éåñÜñ-÷çóç ôùí íïóçìÜôùí.

Áí ç õðïêåßìåíç áéôßá èáíÜôïõ åßíáé êÜêù-óç Þ äçëçôçñßáóç, ôüôå ç åîùôåñéêÞ áéôßá ðïõðñïêÜëåóå ôçí êÜêùóç ðåñéãñÜöåôáé áíáëõôéêÜóôï ôñßôï ôìÞìá ôïõ éáôñéêïý ðéóôïðïéçôéêïý,“åðß âéáßïõ èáíÜôïõ”. ÐáñÜëëçëá óçìåéþíåôáéáí ï èÜíáôïò ðïõ åðÞëèå ïöåßëåôáé óå áôý÷çìá,áõôïêôïíßá Þ áíèñùðïêôïíßá.

Óôï ôìÞìá ÉÉ áíáãñÜöïíôáé ìå öèßíïõóááîéïëïãéêÞ óåéñÜ üëåò ïé Üëëåò íüóïé Þ êáôáóôÜ-óåéò ðïõ Þôáí ðáñïýóåò êáôÜ ôï èÜíáôï êáé ïéïðïßåò ìðïñåß íá åðçñÝáóáí áñíçôéêÜ ôç íïóï-ëïãéêÞ åîÝëéîç. ÁõôÝò üìùò äåí áðïôåëïýí “êñß-êï” ôçò âáóéêÞò áéôéïëïãéêÞò áëëçëïõ÷ßáò. Äåíåßíáé ëßãåò ïé öïñÝò ðïõ åßíáé äýóêïëï íá áðï-öáóßóåé êáíåßò åÜí Ýíá íüóçìá ðñÝðåé íá ðåñéëç-öèåß óôï ôìÞìá É Þ óôï ôìÞìá ÉÉ ôïõ éáôñéêïýðéóôïðïéçôéêïý èáíÜôïõ.

3. Áîéïðéóôßá óõìðëÞñùóçò ôïõ ðéóôïðïéçôéêïýèáíÜôïõ

Åßíáé ãåãïíüò üôé ç êáôáãñáöÞ ôùí èáíÜ-ôùí óôéò ðåñéóóüôåñåò áíáðôõãìÝíåò ÷þñåò ôïõêüóìïõ åßíáé ó÷åäüí ðëÞñçò. Ôï ßäéï óõìâáßíåéêáé óôçí ÅëëÜäá. Åíþ üìùò ïé äåßêôåò ôçò áäñÞòèíçóéìüôçôáò, áëëÜ êáé ôçò êáôÜ öýëï êáé çëé-êßá èíçóéìüôçôáò õðïëïãßæïíôáé ìå áñêåôÞ áêñß-âåéá, äå óõìâáßíåé ôï ßäéï êáé ãéá ôïõò äåßêôåòôçò åéäéêÞò êáôÜ áéôßá èíçóéìüôçôáò12-14.

Ðïëëïß ðáñÜãïíôåò óõìâÜëëïõí óôç äçìéïõñ-ãßá áõôïý ôïõ öáéíïìÝíïõ:

É) åßíáé ðéèáíü ï ãéáôñüò ðïõ óõìðëçñþíåéôï ðéóôïðïéçôéêü èáíÜôïõ íá ìç ãíùñßæåé ôçíðñáãìáôéêÞ áéôßá èáíÜôïõ. Áõôü ìðïñåß íá óõì-âáßíåé ãéá äéÜöïñïõò ëüãïõò, üðùò:á) ç íüóïò áðü ôç öýóç ôçò åßíáé äõóäéÜãíù-

óôçâ) äåí æçôÞèçêå Þ äåí Ýãéíå íåêñïôïìÞã) äåí õðÞñ÷áí ôá êáôÜëëçëá äéáãíùóôéêÜ ôå-

÷íïëïãéêÜ ìÝóáä) ï ãéáôñüò ðïõ ðéóôïðïéåß ôï èÜíáôï äåí åß-

íáé ï èåñÜðùí ãéáôñüòå) ï ãéáôñüò ðïõ óõìðëçñþíåé ôï ðéóôïðïéçôé-

êü èáíÜôïõ äåí åßíáé áñêåôÜ êáôáñôéóìÝíïòÞ åíçìåñùìÝíïò

ÉÉ) ï ãéáôñüò ðïõ ðéóôïðïéåß ôï èÜíáôï ìðïñåßíá ãíùñßæåé ôçí ðñáãìáôéêÞ áéôßá ðïõ ôïíðñïêÜëåóå, üìùò äå ãíùñßæåé ìå ðïéï ôñüðïðñÝðåé íá óõìðëçñùèåß ôï ðéóôïðïéçôéêüèáíÜôïõ.

ÉÉÉ) ï ãéáôñüò ãíùñßæåé ôçí áéôßá èáíÜôïõ, áëëÜáäéáöïñåß ãéá ôç óõìðëÞñùóç ôïõ ðéóôïðïéç-ôéêïý èáíÜôïõ, ãéáôß ôï áíôéìåôùðßæåé óáíìéá åíï÷ëçôéêÞ ãñáöåéïêñáôéêÞ äéáäéêáóßá.

IV) åßíáé ðéèáíü íá ãßíïíôáé óöÜëìáôá êáôÜ ôçíêùäéêïðïßçóç ôùí áéôéþí èáíÜôïõ. Áõôüìðïñåß íá óõìâáßíåé ôüóï óôá Ëçîéáñ÷åßá,üóï êáé óôéò êåíôñéêÝò óôáôéóôéêÝò õðçñå-óßåò.ÁñêåôÝò öïñÝò óõìâáßíåé óôçí ðñüêëçóç ôïõ

èáíÜôïõ íá óõìâÜëëïõí ðåñéóóüôåñåò áðü ìßááéôßåò. Ôüôå äçìéïõñãåßôáé ðñüâëçìá ùò ðñïò ôçóõìðëÞñùóç ôïõ éáôñéêïý ðéóôïðïéçôéêïý èáíÜ-ôïõ2. Éäéáßôåñá óå ðåñéðôþóåéò ðïõ õðÜñ÷åé ôñáõ-ìáôéóìüò êáé ï áóèåíÞò äåí ðåèáßíåé áìÝóùò,áëëÜ êáôáëÞãåé áñãüôåñá áðü Üëëåò åðéðëïêÝò,áíáìåíüìåíåò Þ ü÷é. Åðßóçò, óå ðåñéðôþóåéò ðïõï èÜíáôïò åðÝñ÷åôáé êáôÜ ôç äéÜñêåéá ìéáò ÷åé-

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èáíÜôïõ äåí Þôáí óõìðëçñùìÝíá ðáñÜ ìüíï ôáâáóéêÜ óôïé÷åßá ôïõ èáíüíôïò, äçëáäÞ ôï ïíïìá-ôåðþíõìï êáé ç ìüíéìç êáôïéêßá ôïõ, êáèþò êáéôá óôïé÷åßá ôïõ ãéáôñïý ðïõ ðéóôïðïßçóå ôï èÜ-íáôï êáé ïé áéôßåò èáíÜôïõ. Óå ü,ôé áöïñÜ ôçóõìðëÞñùóç ôïõ åðáããÝëìáôïò, üôáí áõôÞ ãßíå-ôáé åßíáé ðïëý ãåíéêÞ (ð.÷. óõíôáîéïý÷ïò, äçìü-óéïò õðÜëëçëïò ê.ëð.), ðáñÜ ôéò óáöåßò ïäçãßåòáðü ôçí ÅÓÕÅ üôé ðñÝðåé íá áðïöåýãïíôáé ïéãåíéêüôçôåò êáé íá áíáãñÜöåôáé ç åéäéêüôçôáôçò áðáó÷üëçóçò êáé ôï åßäïò ôçò áôïìéêÞò åñ-ãáóßáò. Óôéò ìéóÝò ðåñßðïõ ðåñéðôþóåéò óõìðëç-ñþíåôáé êáé ôï ìÝñïò üðïõ óõíÝâç ï èÜíáôïò.Áðü ôá ðéóôïðïéçôéêÜ ðïõ åß÷áí óõìðëçñùìÝíïáõôü ôï åñþôçìá, ïé ðåñéóóüôåñïé èÜíáôïé óõíÝ-âçóáí åßôå óôá íïóïêïìåßá, åßôå óå éäéùôéêÝòêáôïéêßåò. Óôç óõìðëÞñùóç ôùí áéôéþí èáíÜôïõãßíåôáé ðñáãìáôéêÜ áíôéëçðôü áõôü ðïõ óôç âé-âëéïãñáößá áíáöÝñåôáé ùò óõìðëÞñùóç ôùí áé-ôéþí “êáôÜ ôï äïêïýí”. Åßíáé ÷áñáêôçñéóôéêüüôé áðü ôá 199 ðéóôïðïéçôéêÜ ðïõ åîåôÜóôçêáíìüíï ôá 17 Þôáí óùóôÜ êáé ðëÞñùò óõìðëçñù-ìÝíá. Óôéò õðüëïéðåò ðåñéðôþóåéò, ç ÷ñïíéêÞ äéÜñ-êåéá äåí Þôáí óõìðëçñùìÝíç êáé ïé áéôßåò åßôåäåí Þôáí ìå ôç óùóôÞ óåéñÜ (ç õðïêåßìåíç áéôßááíáöåñüôáí ðñþôç êáé ç êáôÜóôáóç ðïõ ðñïêÜ-ëåóå ôï èÜíáôï ôåëåõôáßá), åßôå ÷áñáêôçñéæüôáíáðü ãåíéêüôçôåò, åßôå êáôáãñáöüôáí ï ôñüðïòèáíÜôïõ êáé ü÷é ç êáôÜóôáóç ðïõ ôïí ðñïêÜëå-óå. Óå áñêåôÝò ðåñéðôþóåéò (29 [15%] ðéóôïðïéç-ôéêÜ) ôá ðéóôïðïéçôéêÜ äåí Þôáí åõáíÜãíùóôáìå áðïôÝëåóìá íá áðáéôïýíôáé äéåõêñéíßóåéò áðüôïõò ãéáôñïýò ðïõ ôá óõìðëÞñùóáí.

4. Áêïëïõèßá óõãêÝíôñùóçò êáé åðåîåñãáóßáòäåäïìÝíùí

Ï ãéáôñüò åßíáé åêåßíïò ðïõ ðéóôïðïéåß êáéêáôáãñÜöåé ôï óõìâÜí óôï “Éáôñéêü Ðéóôïðïéç-ôéêü ÈáíÜôïõ”. Ï èÜíáôïò êáôá÷ùñåßôáé, êáôÜêáíüíá, óôï Ëçîéáñ÷åßï ôïõ ÄÞìïõ ôçò ðåñéï÷Þòüðïõ óõíÝâç åíôüò 24 ùñþí, ìå âÜóç ôï ÉáôñéêüÐéóôïðïéçôéêü ÈáíÜôïõ êáé ôçí ôáõôüôçôá ôïõíåêñïý Þ õðåýèõíç äÞëùóç áðþëåéáò áõôÞò.

¼ôáí ôá ðáñáðÜíù ðñïóêïìéóèïýí ôüôååêäßäåôáé ç Âåâáßùóç ÈáíÜôïõ êáé ç ¢äåéá TáöÞòáðü ôï ÄÞìï óôïí ïðïßï èá ãßíåé ç ôáöÞ. ÔïðáñáðÜíù Ýíôõðï ðåñéÝ÷åé ôüóï ôçí õðïãñáöÞôïõ Ëçîßáñ÷ïõ, üóï êáé áõôÞí ôïõ ÄçìÜñ÷ïõ. Ç

ñïõñãéêÞò åðÝìâáóçò Þ ðåñéåã÷åéñçôéêÜ15.Ç áíáêñßâåéá êáôÜ ôç óõìðëÞñùóç ôïõ ðé-

óôïðïéçôéêïý èáíÜôïõ óõ÷íÜ ïöåßëåôáé óôç óýã-÷õóç ðïõ ðñïêáëåßôáé, üôáí óõã÷Ýåôáé ç “õðï-êåßìåíç áéôßá èáíÜôïõ” ìå ôçí “Üìåóç áéôßá èá-íÜôïõ”16. Ãéá ðáñÜäåéãìá, óå ìßá Ýñåõíá 68 óõ-ìðëçñùìÝíùí ðéóôïðïéçôéêþí, äåí õðÞñ÷å ïýôåÝíá ðïõ íá ðåñéÝ÷åé ôç óùóôÞ “õðïêåßìåíç áé-ôßá” áðü áõôÝò ðïõ åß÷áí áíáãñáöåß17, åíþ åîß-óïõ áíçóõ÷çôéêÜ åõñÞìáôá ðñïêýðôïõí êáé áðüÜëëåò ðñüóöáôåò ìåëÝôåò óôçí ÅëëÜäá êáé óôïåîùôåñéêü13,14,18.

Ç ðéóôïðïßçóç ôïõ èáíÜôïõ áðü Üôïìï Üëëï,åêôüò ôïõ ãéáôñïý, áðïôåëåß ëüãï ãéá ðéèáíÜóöÜëìáôá êáôÜ ôç óõìðëÞñùóç ôïõ ðéóôïðïéç-ôéêïý èáíÜôïõ. Óôç ÷þñá ìáò óÞìåñá ðñáêôéêÜäåí óõìâáßíåé, áöïý óå óýíïëï 102.668 èáíÜôùíôï 1998 ïé 102.323 (99,7%) ðéóôïðïéÞèçêáí áðüôï èåñÜðïíôá Þ Üëëï ãéáôñü4.

Ôá êõñéüôåñá óöÜëìáôá óôçí ÅëëÜäá öáß-íåôáé üôé Þôáí ç åëëéðÞò êáôáìÝôñçóç ôùí âñå-öéêþí èáíÜôùí êáé ôùí ãåííÞóåùí íåêñþí, êá-èþò êáé ôï ó÷åôéêÜ ìåãÜëï ðïóïóôü ôùí èáíÜ-ôùí ìå Üãíùóôç áéôßá, óýìöùíá ìå ôá óôïé÷åßáôïõ 1980 ôçò ÅÓÕÅ. Ôï ðïóïóôü áõôü ðáñïõ-óéÜæåé ìåßùóç êáé óõìâáäßæåé ìå ôçí áýîçóç ôïõðïóïóôïý ôùí èáíÜôùí ðïõ óõìâáßíïõí óå íïóï-êïìåßá êáé êëéíéêÝò êáé ìå ôçí Ýóôù êáé ìéêñÞâåëôßùóç ôçò êáôáíïìÞò ôùí êÝíôñùí õãåßáò óôéòäéÜöïñåò ðåñéï÷Ýò ôçò ÷þñáò16.

ÊáôÜ ðïëëïýò åðéóôÞìïíåò, ïé áíáêñßâåéåòóôá ðéóôïðïéçôéêÜ èáíÜôïõ äéåèíþò, äåí Ý÷ïõíðëÞñùò åêñéæùèåß, ìå áðïôÝëåóìá áõôÜ íá ìçíåßíáé ðëÞñùò áîéüðéóôá19,20. Óýìöùíá ìå Ýñåõíåòðïõ Ý÷ïõí ðñáãìáôïðïéçèåß, ìüíï ôï 35% ôïõðáãêüóìéïõ ðëçèõóìïý êáëýðôåôáé áðü åðáñêÝòóýóôçìá êáôáãñáöÞò êáé ðéóôïðïßçóçò ôùí èá-íÜôùí21. ÊáôÜ ðáñáäï÷Þ ôùí ßäéùí ôùí ãéáôñþí,ðïëëÝò öïñÝò ç óõìðëÞñùóç ôçò áéôßáò èáíÜôïõóôï ðéóôïðïéçôéêü èáíÜôïõ ãßíåôáé ìå âÜóç õðï-øßåò êáé õðïèÝóåéò22. Õðü áìöéóâÞôçóç ôßèåíôáéåðïìÝíùò êáé ïé óôáôéóôéêÝò ðïõ âáóßæïíôáé óôçíêáôÜ áéôßá èíçóéìüôçôá23-25.

Áðü ìéá ìéêñÞ ìåëÝôç ôùí “Éáôñéêþí Ðéóôï-ðïéçôéêþí ÈáíÜôïõ” (ðïõ óõìðëçñþèçêáí áðüôïí ÉáíïõÜñéï ìÝ÷ñé ôï ÓåðôÝìâñéï ôïõ 2001)ðïõ ðñáãìáôïðïéÞèçêå óå ÄÞìï ôçò ÄõôéêÞòÁôôéêÞò, äéáðéóôþèçêå üôé ç óõìðëÞñùóÞ ôïõòáðü ôïõò ãéáôñïýò åßíáé ôïõëÜ÷éóôïí áíåðáñêÞò26.Óôï 50% ðåñßðïõ áðü ôá 199 ðéóôïðïéçôéêÜ


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âåâáßùóç èáíÜôïõ êáé ç Üäåéá ôáöÞò áðïôåëåß-ôáé áðü ôñßá (3) ðáíïìïéüôõðá áðïêüììáôá: Ýíáãéá ôï ÄÞìï (íåêñïôáöåßï), Ýíá ãéá ôïí åíäéáöå-ñüìåíï (óõíÞèùò ç ïéêïãÝíåéá ôïõ íåêñïý) êáéÝíá ãéá ôïí éåñÝá ðïõ èá ôåëÝóåé ôç íåêñþóéìçáêïëïõèßá. Ìå ôïí ôñüðï áõôü áðïöåýãåôáé çðáñÜëåéøç êáôáãñáöÞò ôïõ èáíÜôïõ, áëëÜ êáé çäéðëÞ åããñáöÞ ôïõ.

Óå üëá ôá Ëçîéáñ÷åßá ç êáôá÷þñéóç ôçòËçîéáñ÷éêÞò ÐñÜîçò ÈáíÜôïõ ãßíåôáé óå åéäé-êïýò ôüìïõò êáé ü÷é çëåêôñïíéêÜ. Ôï Ëçîéáñ÷åßïåêäßäåé ôï Äåëôßï ÈáíÜôïõ ìå âÜóç ôï éáôñéêüðéóôïðïéçôéêü. ÁñêåôÜ áðü ôá óôïé÷åßá ðïõ äåíóõìðëçñþíïíôáé áðü ôï ãéáôñü óôï ðéóôïðïéçôé-êü èáíÜôïõ (üðùò ð.÷. ôüðïò ãÝííçóçò, åðßðåäïåêðáßäåõóçò, ïéêïãåíåéáêÞ êáôÜóôáóç ê.ëð.) êá-ôáãñÜöïíôáé áðü ôï Ëçîßáñ÷ï êáé ôïõò õðáëëÞ-ëïõò ôïõ Ëçîéáñ÷åßïõ êáôÜ ôç äÞëùóç ôïõ èáíÜ-ôïõ óôïí áíôßóôïé÷ï ÄÞìï ïýôùò þóôå ôï “Äåë-ôßï ÈáíÜôïõ” ðïõ áðïóôÝëëåôáé óôçí áñìüäéáÕðçñåóßá ÓôáôéóôéêÞò ôïõ Íïìïý íá åßíáé ðëÞ-ñùò óõìðëçñùìÝíï.

Ç Õðçñåóßá ÓôáôéóôéêÞò êÜèå Íïìïý, áöïýóõãêåíôñþóåé êáé åëÝãîåé ôá Äåëôßá ÈáíÜôïõ, ôááðïóôÝëëåé óôç “Äéåýèõíóç Ðëçèõóìïý êáé Áðï-ãñáöþí” ôçò ÅèíéêÞò ÓôáôéóôéêÞò Õðçñåóßáò(ÅÓÕÅ), üðïõ ãßíåôáé ç êùäéêïðïßçóç áðü ÷åéñé-óôÝò çëåêôñïíéêþí õðïëïãéóôþí. Óå ü,ôé áöïñÜôïí Ýëåã÷ï ãéá ôéò áéôßåò èáíÜôïõ åéäéêüôåñá,õðÜñ÷ïõí óôçí ÅÓÕÅ äýï Üôïìá ðïõ åñåõíïýíåðéðñüóèåôá Ýíá-Ýíá ôá áðïóôåëëüìåíá “ÄåëôßáÈáíÜôïõ” ãéá íá äéáðéóôþóïõí åÜí õðÜñ÷åé êÜ-ðïéï ëÜèïò êáôÜ ôç óõìðëÞñùóÞ ôïõò. Ôï ÝíáÜôïìï áó÷ïëåßôáé ìå ôçí ôáîéíüìçóç ôùí üãêùí,åíþ ôï Üëëï ìå üëåò ôéò õðüëïéðåò ðåñéðôþóåéòèáíÜôïõ. ¼ôáí ïëïêëçñùèåß ï áðáéôïýìåíïò Ýëåã-÷ïò, ôüôå ðñáãìáôïðïéåßôáé ç åðåîåñãáóßá ôùíäåäïìÝíùí çëåêôñïíéêÜ. ÁðïôÝëåóìá ôçò åðåîåñ-ãáóßáò åßíáé ç êáôÜñôéóç ðéíÜêùí áéôéþí, ðïõöèÜíïõí ôïí áñéèìü 130. Áðü áõôïýò äçìïóéåýï-íôáé ìüíï ïé 35, óôç “ÓôáôéóôéêÞ ôçò ÖõóéêÞòÊßíçóçò ôïõ Ðëçèõóìïý ôçò ÅëëÜäïò”, áí êáé ìåêáèõóôÝñçóç ôñéþí Ýùò ôåóóÜñùí åôþí4.

Ç êùäéêïðïßçóç ãéá ôéò áéôßåò èáíÜôïõ ãßíå-ôáé óýìöùíá ìå âÜóç ôç “ÄéåèíÞ ÔáîéíüìçóçÍïóçìÜôùí” (ICD) ôïõ ÐÏÕ, ãéá äå ôá åðáã-ãÝëìáôá ìå âÜóç ôç ÓôáôéóôéêÞ Ôáîéíüìçóç ôùíÅðáããåëìÜôùí ðïõ åêäüèçêå ôï 1992 (ÓÔÅÐ-92), ç ïðïßá âáóßæåôáé óôç ÄéåèíÞ ÔõðïðïéçìÝíçÔáîéíüìçóç ôùí ÅðáããåëìÜôùí (International

Classification of Occupations-ISCO)9,10,27,28. Áðüôá ðáñáðÜíù åßíáé åìöáíÝò üôé ç êùäéêïðïßçóçåßíáé ìéá äéáäéêáóßá áñêåôÜ ðïëýðëïêç, ãé’ áõôüêáé áðáéôåßôáé êáé éäéáßôåñç ðñïóï÷Þ üôáí áõôÞãßíåôáé.

5. Ðñïóâáóéìüôçôá óôéò ðëçñïöïñßåò ôçò ÅÓÕÅ

Ï üãêïò ôùí ðëçñïöïñéþí ðïõ åðåîåñãÜæå-ôáé ç ÅÓÕÅ åßíáé ôåñÜóôéïò. ÁíÜëïãçò äéÜóôá-óçò åßíáé êáé ïé ðëçñïöïñßåò ðïõ áðïññÝïõí áðüôçí ðáñáðÜíù åðåîåñãáóßá. Ïé óôáôéóôéêÝò ðïõäçìïóéåýïíôáé óôï ðëáßóéï ôïõ åèíéêïý óôáôéóôé-êïý ðñïãñÜììáôïò áðïôåëïýí äçìüóéï áãáèü,ðñïóéôü óôï êïéíü29. Ï ïðïéïóäÞðïôå åíäéáöåñü-ìåíïò ìðïñåß íá Ý÷åé ðñüóâáóç óôéò ðëçñïöïñßåòó÷åôéêÜ ìå ôï èÝìá ðïõ ôïí åíäéáöÝñåé, áöïýüëåò ïé åêäüóåéò (åëëçíéêÝò êáé ïé êõñéüôåñåò äéå-èíåßò) âñßóêïíôáé óôç ÂéâëéïèÞêç ôçò ÅÓÕÅ. Åêåßï åíäéáöåñüìåíïò ìðïñåß íá êÜíåé áßôçóç ãéáðáñï÷Þ áêüìç êáé óôïé÷åßùí ðïõ äåí åßíáé äçìï-óéåõìÝíá êáé íá åíçìåñùèåß ãéá ôï ðåäßï áíáöï-ñÜò êáé ôïí ôñüðï áðüêôçóçò ôùí óôáôéóôéêþíðëçñïöïñéþí ðïõ åðéèõìåß. Ç áßôçóÞ ôïõ ãßíåôáéäåêôÞ êáé éêáíïðïéåßôáé ìüíïí åöüóïí äåí ðñï-óâÜëëåé ôï áðüññçôï ôùí ðëçñïöïñéþí.

Óýìöùíá ìå ôïõò êáíüíåò ëåéôïõñãßáò ôçòÅÓÕÅ, üëåò ïé ðëçñïöïñßåò ðïõ óõëëÝãïíôáé ìÝóùáðïãñáöþí, åíäéÜìåóùí áðïãñáöþí, åñåõíþí êáéëïéðþí åñãáóéþí áðü êñáôéêÜ ìçôñþá êáé áñ-÷åßá (ÄÞìïé, Õðçñåóßåò ÓôáôéóôéêÞò ôùí Íïìþí,ÅÓÕÅ) ÷ñçóéìïðïéïýíôáé áðïêëåéóôéêÜ êáé ìüíïãéá óôáôéóôéêïýò óêïðïýò, èåùñïýíôáé åìðéóôåõ-ôéêÝò êáé äå äçìïóéåýïíôáé ùò Ý÷ïõí. ÄçëáäÞ, óåêáìßá ðåñßðôùóç äåí åðéôñÝðåôáé íá äçìïóéï-ðïéïýíôáé ôá óôïé÷åßá åíüò ðéóôïðïéçôéêïý èáíÜ-ôïõ, üðùò åêåßíï Ý÷åé óõìðëçñùèåß åßôå áðü ôïãéáôñü ðïõ ðéóôïðïßçóå ôï èÜíáôï, åßôå áðü ôïíáñìüäéï õðÜëëçëï ôïõ Ëçîéáñ÷åßïõ üðïõ äçëþ-èçêå26,27. Ôï ßäéï éó÷ýåé êáé óôçí ðåñßðôùóç ôùíÄÞìùí, äçëáäÞ åÜí êÜðïéïò åðéèõìåß íá óõëëÝîåéÞ íá åñåõíÞóåé óôïé÷åßá ó÷åôéêÜ ìå ôïõò èáíÜ-ôïõò ìðïñåß íá ôï êÜíåé îåöõëëßæïíôáò ôá ìç-ôñþá, áëëÜ äåí åðéôñÝðåôáé íá óçìåéþíåé êáé ôáïíüìáôá ìáæß ìå ôéò ëïéðÝò ðëçñïöïñßåò.

¼ôáí êÜðïéïò áíáæçôÞóåé óôïé÷åßá áðü ôçíÅÓÕÅ ðïõ èåùñïýíôáé åìðéóôåõôéêÜ, ôüôå óõíÝñ-÷åôáé åéäéêÞ åðéôñïðÞ, ðïõ ïíïìÜæåôáé “Åðéôñï-ðÞ Óôáôéóôéêïý ÁðïññÞôïõ”29 êáé êñßíåé åÜí åß-

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íáé óêüðéìï íá äïèïýí ôá áéôïýìåíá óôïé÷åßá.Óôïõò ÄÞìïõò, åßíáé áíáãêáßá ç åéóáããåëéêÞ Üäåéáãéá ôçí áíáæÞôçóç êáé äéåñåýíçóç ôùí æçôïýìå-íùí óôïé÷åßùí.

Ç äçìïóéïðïßçóç ôùí óôïé÷åßùí ðïõ ðñïêý-ðôïõí áðü ôçí åðåîåñãáóßá ôùí ðëçñïöïñéþíôçò ÅÓÕÅ óýìöùíá ìå ôï Üñèñï 7 ôïõ Í 2392/9629, åðéôñÝðåôáé íá ãßíåôáé ìüíï óå óõãêåíôñù-ôéêïýò ðßíáêåò, þóôå íá áðïêëåßåôáé ç Üìåóç ÞÝììåóç áðïêÜëõøç ôçò ôáõôüôçôáò åêåßíùí ôïõòïðïßïõò áöïñÜ ôï ðñùôïãåíÝò óôáôéóôéêü õëéêüêáé íá äéáóöáëßæåôáé ðëÞñùò ç åìðéóôåõôéêüôç-ôá ôùí óôïé÷åßùí.

6. ÐñïôÜóåéò óõìðëÞñùóçò-âåëôßùóçò

¸÷ïíôáò õðüøç ôéò äéáðéóôþóåéò ðïõ åêôß-èåíôáé ðéï ðÜíù, ðñïôåßíïíôáé ïé ðáñáêÜôù âåë-ôéþóåéò þóôå ôï ðñïôåéíüìåíï áðü ôïí ÐÏÕ ðé-óôïðïéçôéêü èáíÜôïõ íá óõìðëçñþíåôáé êáé íáêùäéêïðïéåßôáé ìå ìåãáëýôåñç áêñßâåéá, êáèþòêáé íá áíáëýåôáé ìå ôñüðï ðïõ ôá óôïé÷åßá íáåßíáé ÷ñÞóéìá óôïõò åñåõíçôÝò êáé ó’ üóïõò Ý÷ïõíåõèýíç ãéá ôïí ðñïãñáììáôéóìü ôùí õðçñåóéþíõãåßáò1-3,5,16,21-24,30. Ïé âåëôéþóåéò áõôÝò ìðïñåß íáðåñéëáìâÜíïõí:

• ×ñÞóç ôïõ åéäéêïý ðéóôïðïéçôéêïý íåêñïãÝí-íçóçò êáé èáíÜôïõ íåïãíïý, ðïõ ðñïôåßíåôáéáðü ôïí ÐÏÕ êáé Ý÷åé áðïäå÷ôåß ç ÷þñáìáò9,

• ÐëçñÝóôåñç åêðáßäåõóç ôùí öïéôçôþí ãéáôïí ôñüðï óõìðëÞñùóçò ôïõ ðéóôïðïéçôéêïýèáíÜôïõ êáé ãéá ôç óçìáóßá ôçò áêñéâïýòäéÜãíùóçò óýìöùíá ìå ôï ëåðôïìåñÞ êáôÜ-ëïãï ôçò ÄÔÍ, áëëÜ êáé áîéïëüãçóç ôùíãéáôñþí óôç óõìðëÞñùóç ôïõ ðéóôïðïéçôé-êïý èáíÜôïõ,

• óõìðëÞñùóç ôïõ ðéóôïðïéçôéêïý èáíÜôïõ áðüäýï Üôïìá îå÷ùñéóôÜ (äåýôåñï éáôñü Þ êáéíïóçëåõôÞ),

• ðáñáêïëïýèçóç åéäéêþí óåìéíáñßùí áðü ôïõòõðáëëÞëïõò ôùí Ëçîéáñ÷åßùí êáé ôçò ÅÓÕÅãéá ôïí ôñüðï óõìðëÞñùóçò êáé êùäéêïðïßç-óçò ôùí Äåëôßùí ÈáíÜôïõ,

• ÷ñçóéìïðïßçóç ðåñéóóïôÝñùí “äéêëåßäùíáóöáëåßáò” êáôÜ ôçí êùäéêïðïßçóç óôçíÅÓÕÅ,

• ôõ÷áßïò äåéãìáôïëçðôéêüò Ýëåã÷ïò áðü ôááñ÷åßá ôçò ÅÓÕÅ, þóôå íá äéáðéóôþíåôáé

åÜí Ý÷ïõí óõìðëçñùèåß êáé êùäéêïðïéçèåßóùóôÜ ôá Äåëôßá ÈáíÜôïõ,

• çëåêôñïíéêÞ êáôáãñáöÞ Þ êáé êùäéêïðïßç-óç óôá Ëçîéáñ÷åßá êáé áðïóôïëÞ óôçí ÅÓÕÅãéá ðåñáéôÝñù Ýëåã÷ï, ðéíáêïðïßçóç êáé åê-ðüíçóç óôáôéóôéêþí èíçóéìüôçôáò,

• åðéðñüóèåôç êáôá÷þñéóç óôï Äåëôßï ÈáíÜ-ôïõ êáé êùäéêïý áñéèìïý (ð.÷. ÁÖÌ), üðùòåðßóçò ôïõ ôüðïõ ãÝííçóçò, ôçò õðçêïüôç-ôáò êáé ôçò äéÜñêåéáò äéáìïíÞò óôç ìüíéìçêáôïéêßá, åðéðÝäïõ ìüñöùóçò êáé ïéêïíïìé-êÞò êáôÜóôáóçò,

• áíáëõôéêüôåñç êùäéêïðïßçóç óôï åðÜããåëìáôïõ èáíüíôá ìå âÜóç ôçí ôáîéíüìçóç åðáã-ãåëìÜôùí ôïõ Äéåèíïýò Ãñáöåßïõ Åñãáóßáò,

• êáôáãñáöÞ ãéá ôï åÜí Ý÷åé ãßíåé íåêñïôïìÞ,• ðåñéïñéóìüò ôùí åíôýðùí ðïõ áðáéôïýíôáéêáé óõìðëçñþíïíôáé óôá Ëçîéáñ÷åßá ôùíÄÞìùí (ð.÷. âåâáßùóç èáíÜôïõ, åíïðïßçóçÉáôñéêïý Ðéóôïðïéçôéêïý êáé Äåëôßïõ ÈáíÜ-ôïõ).

7. ÓõìðåñÜóìáôá

Ç óçìáóßá ôçò ïñèÞò óõìðëÞñùóçò ôïõ ðé-óôïðïéçôéêïý èáíÜôïõ åßíáé ìåãÜëç ãéá ôçí åîá-ãùãÞ ðïëýôéìùí åñåõíçôéêþí óõìðåñáóìÜôùí. Çâåëôßùóç ôïõ ôñüðïõ óõìðëÞñùóçò ôçò áéôßáòèáíÜôïõ óôï ðéóôïðïéçôéêü èáíÜôïõ áðü ôïõòéáôñïýò, óýìöùíá ìå ôéò ïäçãßåò ôïõ ÐÏÕ, åßíáéðñùôáñ÷éêÞò óçìáóßáò. Ï åìðëïõôéóìüò ôïõ åíôý-ðïõ ðïõ ÷ñçóéìïðïéåßôáé óÞìåñá ìå ðåñéóóüôåñåòðëçñïöïñßåò ãéá ôï èáíüíôá, èá ìðïñïýóå íááðïäåé÷ôåß ìáêñïðñüèåóìá ÷ñÞóéìç. ÔÝëïò çáðëïýóôåõóç ôçò äéáäéêáóßáò äÞëùóçò êáé êáôá-ãñáöÞò áðü ôï Ëçîéáñ÷åßï êáé ôçí ÅÓÕÅ èáðåñéïñßóåé ôçí ðéèáíüôçôá ëÜèïõò êáé èá êÜíåéåõ÷åñÝóôåñç ôçí åðåîåñãáóßá ôùí äåäïìÝíùí.


1. Êáôóïõãéáííüðïõëïò Â×. ÕãéåéíÞ êáé ÊïéíùíéêÞÉáôñéêÞ, ôüìïò 2ïò, Åêäïôéêüò ïßêïò Áöùí Êõ-ñéáêßäç Á.Å, 1997.

2. Ôñé÷üðïõëïò Ä. Åðéäçìéïëïãßá-áñ÷Ýò, ìÝèïäïé,åöáñìïãÝò. ÅðéóôçìïíéêÝò åêäüóåéò Ãñ. ÐáñéóéÜ-íïò, 1982.

3. ÄçìïëéÜôçò ÃÄ. ÂéïóôáôéóôéêÞ äéåñåýíçóç ôçòèíçóéìüôçôáò óôçí ÅëëÜäá, 1956-1982. Äéäá-


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êôïñéêÞ äéáôñéâÞ, ÉùÜííéíá 1988.4. ÓôáôéóôéêÞ ôçò ÖõóéêÞò Êßíçóçò ôïõ Ðëçèõ-

óìïý ôçò ÅëëÜäáò, Ýôïõò 1998. ÅÓÕÅ, 1999.5. ÐáðáåõáããÝëïõ Ã, Ôóßìðïò Ê. ÌåëÝôç ôçò åîå-

ëßîåùò ôçò èíçóéìüôçôáò áðü êáñäéáêÝò ðáèÞ-óåéò óôçí ÅëëÜäá. Áñ÷ Åëëçí ÉáôñéêÞò, 1:476-482, 1984.

6. Êïãåâßíáò Ì, ÊáôóïõãéÜííç Ê, Maisonneuve P,Ôñé÷üðïõëïò Ä. Èíçóéìüôçôá áðü êáêïÞèç íåï-ðëÜóìáôá óôéò ÷þñåò ôçò ÅÏÊ, 1955-1987.ÉáôñéêÞ 64:264-274, 1993.

7. Huffman GB. Death Certificates: Why it Mat-ters How Your Patient Died. Am Fam Physi-cian, 56:1287-1290, 1997.

8. ÐáðáåõáããÝëïõ Ã, Ôóßìðïò Ê. ÉáôñéêÞ Äçìï-ãñáößá êáé ïéêïãåíåéáêüò ðñïãñáììáôéóìüò.Åêäüóåéò ÂÇÔÁ, ÁèÞíá, 1993.

9. ICD-10. International Statistical Classificationof Diseases and Related Health Problems. TenthRevision. Volume 2. WHO, Geneva, 1993.

10. World Health Organization. Medical certifica-tion of cause of death. Instructions for physi-cians on use of international form of medicalcertificate of causes of death. Geneva, WHO,1979.

11. Õðïõñãåßï Åóùôåñéêþí. Íüìïé êáé ðñïåäñéêÜäéáôÜãìáôá ðåñß ëçîéáñ÷éêþí ðñÜîåùí. Ïäçãßåòãéá ôçí åöáñìïãÞ ôùí äéáôÜîåùí áõôþí. ÁèÞíá,Åèíéêü Ôõðïãñáöåßï, 1977.

12. Dallas RJ. Accuracy of death certification. N ZMed J, 113:385-6, 2000.

13. Lionis CD, Koutis AD, Antonakis N, IsacssonA, Lindholm LH, Fioretos M. Mortality ratesin a cardiovascular “low-risk” population in ruralCrete. Family Practice, 10:300-4, 1993.

14. Lionis C, Sasarolis S, Kasotakis GI, LapidakisGM, Stathopoulos AI. Investigation of accuracyof death certificate completion and implica-tions on mortality statistics in Greece. Letterto the editor. European Journal of Epidemiolo-gy, 16:1081, 2000.

15. Mason. Paediatric forensic Medicine and Pa-thology, Chapman and Hall Medical, London,pages 411-412, 414, 1989.

16. ÐáðáåõáããÝëïõ Ã, Ôóßìðïò Ê. ÊïéíùíéêÝò êáéõãåéïíïìéêÝò åðéðôþóåéò áðü ôéò äçìïãñáöéêÝòåîåëßîåéò ôïõ åëëçíéêïý ðëçèõóìïý: 1960- 2001,ÁèÞíá 1983.

17. Magrane BP, Gilliland MGF, King DE. Certifi-cation of death by family physicians. Am FamPhysician, 56:1433-8, 1997.

18. Cina SJ, Selby DM, Clark B. Accuracy of deathcertification in two tertiary care military hospi-tals. Mil Med., 164:897-9, 1999.

19. Messite J, Stellman SD. Accuracy of death cer-tificate completion: the need for formalizedphysician training. JAMA, 275:794-6, 1996.

20. Morton L, Omar R, Carroll S, Beirne M, Hal-liday D, Taylor KM. Incomplete and inaccuratedeath certification–the impact on research. JPublic Health Med., 22:133-7, 2000.

21. Ðïëõ÷ñïíüðïõëïò Ð, Ðáó÷Üëçò ×. Åðéäçìéïëï-ãéêÜ ÷áñáêôçñéóôéêÜ ôùí áããåéáêþí åãêåöáëé-êþí åðåéóïäßùí. ÉáôñéêÞ, 71:31-41, 1997.

22. Newman DM. Quality of death statistics. (let-ter) Am J Public Health, 77, 1230, 1987.

23. Moriyama IM. Problems in Measurement ofAccuracy of Cause-of-Death Statistics. Am JPublic Health, 79:1349-1350, 1989.

24. Hanzlick R, Parrish RG, Ing R. Classifyingunspecified and/or unexplained causes of death.Am J Public Health, 83:1492-3, 1993.

25. Chen L, Walker S, Tong S. The impact of thevariation in death certification and coding prac-tices on trends in mortality from ischaemicheart disease. Aust Health Rev, 25:189-97, 2002.

26. Ñüäç Á. Ç ÷ñçóéìüôçôá ôçò óôáôéóôéêÞò åðåîåñ-ãáóßáò ôùí ðéóôïðïéçôéêþí èáíÜôïõ óôçí åêðü-íçóç ìåëåôþí èíçóéìüôçôáò. Áäçìïóßåõôç Ì.Ä.Å.ÔìÞìá ÍïóçëåõôéêÞò, ÅÊÐÁ, 2001.

27. World Health Organization. International clas-sification of diseases for oncology. Geneva,WHO, 1990.

28. ÓôáôéóôéêÞ Ôáîéíüìçóç ôùí ÅðáããåëìÜôùíÓÔÅÐ-92, ÁèÞíá, ÅÓÕÅ, 1995.

29. N. 2392/96. Ðñüóâáóç ôçò ÃåíéêÞò Ãñáììáôåßáòôçò ÅèíéêÞò ÓôáôéóôéêÞò Õðçñåóßáò ôçò ÅëëÜ-äïò óå äéïéêçôéêÝò ðçãÝò êáé äéïéêçôéêÜ áñ÷åßá,ÅðéôñïðÞ Óôáôéóôéêïý ÁðïññÞôïõ, ñýèìéóç èå-ìÜôùí äéåíÝñãåéáò áðïãñáöþí êáé óôáôéóôéêþíåñãáóéþí, êáèþò êáé èåìÜôùí ôçò ÃåíéêÞò Ãñáì-ìáôåßáò ÅèíéêÞò Õðçñåóßáò ôçò ÅëëÜäïò(Ã.Ã.Å.Ó.Õ.Å.). ÖÅÊ Á60/1996.

30. Myers KA, Farquhar DR. Improving the accu-racy of death certification. CMAJ, 158:1317-23, 1998.

ÏÄÇÃÉÅÓ ÃÉÁ ÔÏÕÓ ÓÕÃÃÑÁÖÅÉÓ

INSTRUCTIONS FOR THE AUTHORS

Ç "ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò" äÝ÷åôáé ãéá äçìïóßåõóç êåßìåíá Åðéóôçìüíùí Õãåßáò, ôá ïðïßá êáôáôÜó-óïíôáé óôéò åîÞò êáôçãïñßåò: 1) ÅñåõíçôéêÝò åñãáóßåò Þ áíáóêïðÞóåéò (óýíôïìåò äçìïóéåýóåéò) Ýêôáóçò ìÝ÷ñé 7óåëßäåò 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 óõãêåêñéìÝíïãíùóôéêü ôïìÝá ôçò ÐñùôïâÜèìéáò Öñïíôßäáò Õãåßáò, ìðïñåß íá óõãêñïôåß ÁöéÝñùìá. Åêôüò ôùí êåéìÝíùí ðïõáíáöÝñïíôáé óôéò ðáñáðÜíù êáôçãïñßåò óôçí "ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò" äçìïóéåýïíôáé êáé Üñèñá ôçòÓõíôáêôéêÞò ÅðéôñïðÞò, êáèþò êáé êåßìåíá ðïõ áðïóêïðïýí óôçí ðáñïõóßáóç, ó÷ïëéáóìü êáé êñéôéêÞ áîéïëüãç-óç óõãêåêñéìÝíùí ãåãïíüôùí, Üñèñùí êáé åêäüóåùí ó÷åôéêþí ìå ôçí ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò, óôçíÅëëÜäá êáé óôï åîùôåñéêü. Ôçí åõèýíç ôçò óõããñáöÞò ôùí Üñèñùí áõôþí Þ êåéìÝíùí Ý÷ïõí ìüíï ôá ìÝëç ôçòÓõíôáêôéêÞò ÅðéôñïðÞò Þ åðéóôÞìïíåò ìåôÜ áðü åéäéêÞ ðñüóêëçóç. Åðßóçò óôçí "ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò"äçìïóéåýïíôáé êáé ãñÜììáôá ðïõ áðåõèýíïíôáé óôç ÓõíôáêôéêÞ ÅðéôñïðÞ, ôá ïðïßá áíáöÝñïíôáé óå ðáñáôçñÞ-óåéò, êëéíéêÝò êáé åñåõíçôéêÝò åìðåéñßåò Þ ó÷ïëéÜæïõí ôç äéåèíÞ êáé åëëçíéêÞ âéâëéïãñáößá. Ôçí åõèýíç ãéá ôçäçìïóßåõóç ôùí êåéìÝíùí áõôþí Ý÷åé ï ÄéåõèõíôÞò Óýíôáîçò êáé ç ÓõíôáêôéêÞ ÅðéôñïðÞ.

Ïé åñåõíçôéêÝò åñãáóßåò, ôá åíçìåñùôéêÜ Üñèñá, ïé óýíôïìåò äçìïóéåýóåéò êáé ïé áíáöïñÝò ðåñéóôáôéêþíãßíïíôáé äåêôÜ ãéá äçìïóßåõóç ìüíï ìåôÜ áðü èåôéêÞ êñßóç ôïõò áðü åðéóôÞìïíåò-êñéôÝò ìå ôïõò ïðïßïõòóõíåñãÜæåôáé ôï ðåñéïäéêü. ÊÜèå êåßìåíï ðïõ áðïóôÝëëåôáé óôçí "ÐñùôïâÜèìéá Öñïíôßäá Õãåßáò" äéáâéâÜæåôáéóôïõò êñéôÝò, ÷ùñßò íá ãíùóôïðïéïýíôáé ôá ïíüìáôá ôùí óõããñáöÝùí. Ôá ó÷üëéá êáé ïé ðáñáôçñÞóåéò ôùí êñéôþíóôç óõíÝ÷åéá, ìå ôçí åõèýíç ôçò Ãñáììáôåßáò Óýíôáîçò ôïõ ðåñéïäéêïý, åðéóôñÝöïíôáé óôïõò óõããñáöåßò, ðñïêåé-ìÝíïõ áõôïß íá ðñïóáñìüóïõí áíÜëïãá ôï êåßìåíü ôïõò ðñéí ôç äçìïóßåõóç. Óå ðåñßðôùóç áóõìöùíßáò ôùíêñéôþí, ôï êåßìåíï èá áîéïëïãåßôáé áðü ôçí ßäéá ôç ÓõíôáêôéêÞ ÅðéôñïðÞ. Ôá ïíüìáôá üëùí ôùí åðéóôçìüíùíðïõ 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 ðáñáêÜôùðñïäéáãñáöÝò.

• Íá åßíáé ãñáììÝíá óôçí åðßóçìç äçìïôéêÞ ãëþóóá êáé ìå ôï ìïíïôïíéêü óýóôçìá, äáêôõëïãñáöçìÝíá óôçìéá 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 ôùíóõããñáöÝùí (ìå êåöáëáßá ãñÜììáôá åíþ áíáãñÜöïíôáé ôá áñ÷éêÜ ôùí ïíïìÜôùí êáé ôá ðëÞñç åðþíõìá ìåáñéèìçôéêïýò åêèÝôåò ïé ïðïßïé óå õðïóçìåßùóç ðáñïõóéÜæïõí ôçí éäéüôçôá ôïõ êÜèå óõããñáöÝá), ã) ôïåðéóôçìïíéêü êÝíôñï óôï ïðïßï Ýãéíå ç åñãáóßá, ä) 3-5 ðñüóèåôïõò üñïõò ó÷åôéêÜ ìå ôï èÝìá êáé ïé ïðïßïéåßíáé õéïèåôçìÝíïé áðü ôï Medical Subject Headings (Bethesda Md, 1966), å) ôç äéåýèõíóç êáé ôï ôçëÝöùíïåíüò 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 ÝíäåéîçÐÅÑÉËÇØÇ), 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 äåèá ðñÝðåé íá Ý÷åé Ýêôáóç ìåãáëýôåñç ôùí 300 ëÝîåùí. Ðñïçãïýíôáé ç ëÝîç SUMMARY, ç áããëéêÞ ìåôÜöñá-óç ôïõ ôßôëïõ, ïé ëÝîåéò PRIMARY HEALTH CARE... êáé ôá ïíüìáôá ôùí óõããñáöÝùí ÷ùñßò ôßôëï Þéäéüôçôá.

• Ïé âéâëéïãñáöéêÝò ðáñáðïìðÝò, åëëçíéêÝò êáé îÝíåò, óôï êåßìåíï èá ðñÝðåé íá åßíáé ðñüóöáôåò, áðüáíáãíùñéóìÝíá ðåñéïäéêÜ Þ óõããñÜììáôá, íá åßíáé áñéèìçìÝíåò êáé í’ áíôáðïêñßíïíôáé óôï âéâëéïãñáöéêüêáôÜëïãï, 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 ðáñïõóéÜóôç-êáí óôï êåßìåíï. ÊáèåìéÜ áðü áõôÝò èá ðñÝðåé íá ðåñéÝ÷åé óôç óåéñÜ ôá áñ÷éêÜ ôùí ïíïìÜôùí êáé ôáåðþíõìá ôùí óõããñáöÝùí, ôïí ôßôëï ôçò åñãáóßáò, ôï üíïìá ôïõ ðåñéïäéêïý óýìöùíá ìå ôï óýóôçìá ôçòWHOCISO/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 ôïíôßôëï, ðñÝðåé íá ãñÜöïíôáé êáé ï áñéèìüò êáé ôá óôïé÷åßá Ýêäïóçò (åêäïôéêüò ïßêïò, ðüëç).(õðüäåéãìá âéâëéïãñáößáò: Biziagos E, Moschandrea J, Kouroumalis ÅÁ. Prevalence of hepatitis Â and Cmarkers 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 ôïõêåéìÝíïõ, êáèþò êáé ôéò áðáñáßôçôåò åðåîçãÞóåéò.

• 'Ïëá ôá êåßìåíá èá ðñÝðåé íá õðïâÜëëïíôáé êáôÜ ðñïôßìçóç ìå êåéìåíïãñÜöï word óå äýï áíôßôõðá êáé íááðïóôÝëëïíôáé 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:[email protected]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 êáéóå ðåñßðôùóç áðïäï÷Þò ôçò ãéá äçìïóßåõóç, ôá óõããñáöéêÜ äéêáéþìáôá åê÷ùñïýíôáé óôï ðåñéïäéêü. Ç Óõíôáêôé-êÞ ÅðéôñïðÞ äéáôçñåß ôï äéêáßùìá áðïóýñóåùò ìéáò åñãáóßáò åöüóïí áõôÞ Ý÷åé óôáëåß êáé ó' Üëëï ðåñéïäéêü.

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