2 nd Congress of Association of General Practice/Family Medicine of South East Europe (AGP/FM SEE)

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5 CONTENTS COMMITTEES 4 SCIENTIFIC PROGRAMME 6-3 LIST OF ORAL PRESENTATIONS 4-8 LIST OF POSTER PRESENTATIONS 9-29 FULL TEXTS OF INVITED FACULTY LECTURES 3 PLENARY LECTURES 33 PANELS 38 ROUND TABLES 6 MEET THE EXPERT SESSIONS 9 COURSES 3 WORKSHOPS 29 ABSTRACTS 4 ORAL PRES PRESENTATIONS 43 POSTER PRES PRESENTATIONS 6 AUTHORS INDEX

6 COMMITTEES CONGRESS CO-CHAIRS Ljubin SUKRIEV, President of AGP/FM SEE, Macedonia Okay BAfiAK, President of TAHUD, Turkey HONORARY BOARD Ayfle ÇAYLAN, Turkey Süleyman ÖMER, Macedonia ORGANIZING COMMITTEE President M. Mümtaz MAZICIO LU, Turkey Vice-Presidents Hakan ÖZDEM R, Turkey Katerina KOVACEVA, Macedonia Kurtulufl ÖNGEL, Turkey Svetlin MITEV, Bulgaria Members Dean KLANCIC, Slovenia Elif ALTUNBAfi, Turkey Fatih YÜKSEL, Turkey Lenka STOJANOVA, Macedonia Levent ÖZSEVEN, Turkey Ljiljana BALOS, Serbia Ljiljana ZOGOVIC, Montenegro Murat ÇEV K, Turkey Mustafa ÖZÜNAL, Turkey Melida HASANAGIC, FBIH Malijoka PETROVIC, Macedonia Nebi SÖKMEN, Turkey Radojka PERIC, Rebuplic of Srpska Reflat DABAK, Turkey Vjollka KONICA, Albania Zübeyde ANADOL, Turkey SCIENTIFIC COMMITTEE President lhami ÜNLÜO LU, Turkey Vice-Presidents Arzu UZUNER, Turkey Ljiljana KOCANKOVSKA, Macedonia Suzana STANKOVIC, Serbia Members Alis ÖZÇAKIR, Turkey Anesa SMAJLBEGOVIC, FBIH Ayça V TR NEL, Turkey Cahit ÖZER, Turkey Diana TCHINARSKA Dilek GÜLDAL, Turkey Ekrem ORBAY, Turkey Ergun ÖKSÜZ, Turkey Erhan SAYALI, Turkey Georgy IVANOV, Bulgaria Gorica ZAFIROVSKA-PIROVSKA, Macedonia Hasan Basri ÜSTÜNBAfi, Turkey Hüseyin Avni fiah N, Turkey smail Hamdi KARA, Turkey Janko KERSNIK, Slovenia Kamile MARAKO LU, Turkey Ksenija TUSEK-BUNC, Slovenia Lubomir KIROV, Bulgaria Maja RACIC, Rebuplic of Srpska Mehmet SARGIN, Turkey Mirjana MOJKOVIC, Serbia Muamera MUJCINAGIC-VRABAC, FBIH Murat ÜNALACAK, Turkey Nafiz BOZDEM R, Turkey Nazan B LGEL, Turkey Nejat DEM RCAN, Turkey Radmila STANISIC, Montenegro Recep Erol SEZER, Turkey Rengin ERDAL, Turkey Selma Ç V, Turkey Serpil NAN, Turkey Slavoljub ZIVANOVIC, Serbia Valentina MADJOVA, Bulgaria Zeynep TUZCULAR VURAL, Turkey - 4 -

7 Dear Colleagues, It is our great honor and privilege to welcome you in Antalya, Turkey for the 2nd Congress of Association of General Practice/Family Medicine of South-East Europe. This Congress, which is being organized with the collaboration of the Turkish Association of Family Physicians (TAHUD) and the Association of Family Medicine and General Practice of South-East Europe, is an opportunity to meet our colleagues from South-East Europe countries, to enhance communication between them for sharing information, developing continuing medical education and promoting research in the field of primary health care. The 2nd Congress of Association of General Practice/Family Medicine of South-East Europe will also help to build awareness about common and overwhelming problems in the region and to update current knowledge on the recent advances in the medical field. The scientific programme to be held in four parallel meeting halls, covers a lot of important topics of general practice/family medicine. It consists of 4 plenary sessions, 7 panels, 3 round table sessions, 3 courses, 3 workshops, 5 meet the expert sessions, 3 meetings, 42 oral presentations and 60 poster presentations in totally 35 sessions most of which are parallel. We wish all participants a fine, informative and unforgettable stay in Antalya. With our very best regards. Prof. Dr. Okay BAfiAK Turkish Association of Family Physicians President Prim. Dr. Ljubin SUKRIEV Association of General Practice/Family Medicine of South-East Europe President - 5 -

8 SCIENTIFIC PROGRAMME APRIL 22, :30 5:00 Registration & Check-in 5:00 6:20 COURSE, PART (Session in Turkish) (HALL A) Physical growth and development and thyroid hormone in physical growth (Büyüme geliflmenin takibi ve büyüme geliflmede tiroid hormonunun yeri) M. Mümtaz Maz c o lu; Brain storming: Physical growth and development; impressions (Beyin f rt nas : Büyüme geliflme; izlenimlerin toplanmas ) Servet Kesim; Development of tooth; development process of teeth according to the ages (Difl geliflimi; yafllara göre difllerin geliflim süreci) M. Mümtaz Maz c o lu; Methodology for following the physical growth; standards and methods of analysis (Büyümenin izlenmesinde metodoloji; standartlar ve analiz yöntemleri ) 6:20 6:30 Coffee Break 6:30 7:25 COURSE, PART 2 (Session in Turkish) (HALL A) Physical growth and development and thyroid hormone in physical growth (Büyüme geliflmenin takibi ve büyüme geliflmede tiroid hormonunun yeri) Selim Kurto lu; Discussion on growth curves (Büyüme e rileri üzerinde tart flma) Ahmet Öztürk; Statistical analysis for following physical growth; persentile calculation by a practical way (Büyümenin izlenmesinde istatistik analiz; pratik yolla persentil hesab yap lmas ) 7:25 7:35 Coffee Break 7:35 9:05 COURSE, PART 3 (Session in Turkish) (HALL A) Physical growth and development and thyroid hormone in physical growth (Büyüme geliflmenin takibi ve büyüme geliflmede tiroid hormonunun yeri) Selim Kurto lu; Following physical growth and development (Büyüme geliflmenin izlenmesi ) Selim Kurto lu; Thyroid hormones and physical growth and development (Tiroid hormonlar ve büyüme geliflme) Servet Kesim, Selim Kurto lu, M. Mümtaz Maz c o lu, Ahmet Öztürk; Course assessment (Seth rating scale) (Kursun de erlendirilmesi (Seth de erlendirme ölçe i) ) 9:00 2:00 SPECIAL SESSION Turkish Association of Family Physicians (TAHUD, Türkiye Aile Hekimleri Uzmanl k Derne i ) - 6 -

9 SCIENTIFIC PROGRAMME APRIL 23, :30 09:30 OPENING CEREMONY (HALL A) Master of Ceremony: Ifl k Gönenç Okay Baflak, Ljubin Sukriev, lhami Ünlüo lu, M. Mümtaz Mazicioglu, Seracettin Çom 09:30 0:5 PLENARY SESSION (HALL A) Association of General Practice and Family Medicine of South East Europe (Güneydo u Avrupa Aile Hekimleri ve Pratisyen Hekimler Birli i) Moderator : Erhan Sayal Ljubin Sukriev 0:5 0:45 Coffee Break 0:45 2:5 PANEL (HALL A) Violence in Family; the Europe and AGP/FM SEE (Aile içi fliddet; Avrupa ve Güneydo u Avrupa Aile Hekimleri ve Pratisyen Hekimler Birli i ) Moderators: Suzana Stankovic, Kurtulufl Öngel Leo Pas; Europe (Avrupa) Sabahat Tezcan; Turkey (Türkiye) Suzana Stankovic; SEE short report (Güneydo u Avrupa özet raporu) 0:45 2:5 SPECIAL SESSION (HALL B) Turkish Association of Family Physicians (TAHUD, Türkiye Aile Hekimleri Uzmanl k Derne i) 2:5 4:45 Lunch & Poster Session 4:45 6:5 ROUND TABLE (HALL A) Current health situation and health systems in South East Europe (Güney Do u Avrupa da mevcut sa l k durumu ve sa l k sistemleri) Moderators: Lubomir Kirov, lhami Ünlüo lu Ljiliana Kocankovska; Macedonia (Makedonya) Lubomir Kirov; Bulgaria (Bulgaristan) Ljiliana Zogovic-Vokovic; Montenegro (Karada ) Mirjana Mojkovic; Serbia (S rbistan) Murat Ünalacak; Turkey (Türkiye) Miro Popovic; Rebublika Srpska (S rp Cumhuriyeti), Vjolka Konica; Albania (Arnavutluk) Azijada Beganlic; Bosnia & Herzegovina (Bosna Hersek) Ksenija Tusek-Bunc; Slovenia (Slovenya) - 7 -

10 SCIENTIFIC PROGRAMME 4:45 6:5 ORAL PRESENTATIONS (HALL B) Moderators : Fisun Sözen, Katerina Kovaceva 4:45 6:5 PANEL 2 (HALL C) Type 2 DM advances in therapy insulin and new antidiabetic agents (Tip 2 Diabetes mellitus tedavisinde insülin ve yeni antidiabetik ajanlardaki son geliflmeler) Moderator: Reflat Dabak Zuhal Sa lam; Following up the patient (Hasta takibi) Ekrem Orbay; Insulin treatment ( nsülin tedavisi) Mehmet Sarg n; Innovations in treatments (Tedavide yenilikler) 4:45 6:5 WORKSHOP, PART (HALL D) Alternative medicine tabu and reality (Alternatif t p : Tabu ve gerçek) Moderator: Rengin Erdal Marco Ephraim 6:5 6:45 Coffee Break 6:45 8:5 ROUND TABLE 2 (HALL A) Reform in primary health care system (Birinci basamak sa l k sistemi reformu) Moderators: Lubomir Kirov, lhami Ünlüo lu Ljiliana Kocankovska; Macedonia (Makedonya) Lubomir Kirov; Bulgaria (Bulgaristan) Ljiliana Zogovic-Vokovic; Montenegro (Karada ) Mirjana Mojkovic; Serbia (S rbistan) Murat Ünalacak; Turkey (Türkiye) Miro Popovic; Rebublika Srpska (S rp Cumhuriyeti), Vjolka Konica; Albania (Arnavutluk) Azijada Beganlic; Bosnia & Herzegovina (Bosna Hersek) Ksenija Tusek-Bunc; Slovenia (Slovenya) 6:45 8:5 ORAL PRESENTATIONS 2 (HALL B) Moderators: Nazan Karao lu, Lenka Stojanova 6:45 8:5 PANEL 3 (HALL C) Journey from the sinuses to the Bronchi (Sinüslerden bronfllara yolculuk) Moderator: Dilek Güldal Dilek Güldal Sema Baflak Fad l Öztürk - 8 -

11 SCIENTIFIC PROGRAMME 6:45 8:5 WORKSHOP, PART 2 (HALL D) Alternative medicine tabu and reality (Alternatif t p : Tabu ve gerçek) Moderator: Rengin Erdal Marco Ephraim 8:5 9:5 WELCOME COCKTAIL APRIL 24, :30 09:5 PLENARY SESSION 2 (HALL A) CME and continuous professional development European experience and SEE (Sürekli T p E itimi ve sürekli mesleki geliflim, Avrupa deneyimi ve Güneydo u Avrupa) Moderator: Arzu Uzuner Marko Kolsek 09:5 0:45 PANEL 4 (HALL A) FM in SEE Management of FM Finance of the team need and reality (Güneydo u Avrupa da Aile Hekimli i, Aile Hekimli i ekibinin mali yönetimi, ihtiyaçlar ve gerçek durum) Moderators: Cahit Özer, Svetlin Mitev Azijada Beganlic Seracettin Çom Elif Altunbafl Slavoljub Zivanovic Gorica Zafirovska-Pirovska 09:5 0:45 ORAL PRESENTATIONS 3 (HALL B) Moderators: Pemra Ünalan, Anesa Smajlbegovic 09:5 0:45 PANEL 6 (HALL C) The new face of influenza, HN : The anatomy of a pandemic (Gribin yeni yüzü HN: Bir pandeminin anatomisi) Moderators: Hüseyin Avni fiahin Selim Badur; Growth of the pandemic-vaccines (Pandeminin geliflimi-afl lar) Gaye Usluer; Clinic of HN, treatment, usage of antivirals (HN klini i, tedavi, antivirallerin kullan m ) 09:5 0:45 WORKSHOP 2, PART (HALL D) Communication, communication skills and interactive way of work ( letiflim, iletiflim becerileri ve interaktif çal flma yollar ) Suzana Stankovic Valentina Madjova - 9 -

12 SCIENTIFIC PROGRAMME 0:45 :5 Coffee Break :5 2:5 ROUND TABLE 3 (HALL A) Management of FM Quality of/in FM (Aile hekimli inde kalite yönetimi) Moderator: Nejat Demircan Zekeriya Aktürk Melida Hasanagic Georgy Ivanov :5 2:5 ORAL PRESENTATIONS 4 (HALL B) Moderators: Levent Özseven, Radmila Stanisic :5 2:5 MEET THE EXPERT 2 (HALL C) Medical abortus (T bbi düflükler) Zeynep Tuzcular Vural Ifl k Gönenç Kenan Ertopçu :5 2:5 WORKSHOP 2, PART 2 (HALL D) Communication, communication skills and interactive way of work ( letiflim, iletiflim becerileri ve interaktif çal flma yollar ) Suzana Stankovic Valentina Madjova 2:5 4:45 Council Meeting of Association of General Practice / Family Medicine of South East Europe 2:5 4:45 Lunch & Poster Session 2 4:45 6:5 MEET THE EXPERT (HALL A) Management of the elderly patient (Yafll hastaya yaklafl m) Moderator: Ümit Aydo an Mladen Davidovic 4:45 6:5 ORAL PRESENTATIONS 5 (HALL B) Moderators : Zübeyde Anadol, Ljiljana Balos 4:45 6:5 MEET THE EXPERT 3 (HALL C) Pain management in chronical diseases (Kronik hastal klarda a r ya yaklafl m) Moderator: Nafiz Bozdemir Süleyman Özyalç n Osman Nuri Ayd n - 0 -

13 SCIENTIFIC PROGRAMME 4:45 6:5 WORKSHOP 3, PART (HALL D) ECG (EKG) Moderator: Hasan Basri Üstünbafl Ljiljana Kocanskova Ljubin Sukriev 6:5 6:45 Coffee Break 6:45 8:5 PANEL 5 (HALL A) Hypertension at goal in SEE new guidelines (Güneydo u Avrupa da hipertansiyon tedavisindeki hedefler ve yeni klavuzlar) Moderators: Murat Ünalacak, Dean Klancic smet Tamer; Introduction : How to make guidelines? (Girifl : Klavuzlar nas l haz rlanmal?) Suzana Stankovic; Comparison (Karfl laflt rma) Lubomir Kirov; Implementation (Uygulama) 6:45 8:5 MEETING (HALL B) Project Collaboration and Foundation in SEE Project Presentations (Güneydo u Avrupa da Proje flbirli i ve flletmesi Proje Sunumlar ) Moderator: Kurtulufl Öngel 6:45 8:5 MEET THE EXPERT 4 (HALL C) Management of tiroid disease (Tiroid hastal na yaklafl m) Alis Özçak r Hakan Özdemir 6:45 8:5 WORKSHOP 3, PART 2 (HALL D) ECG (EKG) Moderator: Hasan Basri Üstünbafl Ljiljana Kocanskova Ljubin Sukriev 20:00 23:30 GALA DINNER APRIL 25, :30 09:5 PLENARY SESSION 4 (HALL A) Family medicine : Do we have identity problem? (Aile hekimli i : Kimlik sorunumuz var m?) Moderator : Georgy Ivanov Okay Baflak - -

14 SCIENTIFIC PROGRAMME 09:5 0:45 PANEL 7 (HALL A) Artritis management (Artrite yaklafl m) Moderators: Murat Çevik, Muamera Mujcinagic-Vrabac Hüseyin Demir; Inflammatory artritis ( ltihapl artrit) P nar Borman; Osteoartritis (Osteoartrit) 09:5 0:45 MEETING 3 (HALL B) Vocational training in family medicine (Aile hekimli inde mesleki e itim) Moderators: Fatih Yüksel, Mustafa Özünal This meeting will bring the trainees of family medicine/general practice specialty training together, an opportunity to share common points regarding their programmes, their needs and problems. All the residents and the trainees of FM and GP s are invited to participate this meeting. 09:5 0:45 COURSE 2, PART (HALL C) Basic life support training (Temel yaflam deste i e itimi) Moderators: Nebi Sökmen Kurtulufl Öngel Mehmet Ali Karaca Bülent Erbil Nebi Sökmen 09:5 0:45 COURSE 3, PART (Session in Turkish) (HALL D) Course on epidemiology and statistics in primary care (Birinci basamakta epidemiyoloji ve istatistik kursu) Ahmet Öztürk; - Epidemiologic researches in general practice (Birinci basamakta epidemiyolojik araflt rmalar n yeri) - Variables and types (De iflkenler ve tipleri) - Which statistical test? (Hangi istatistik test daha uygundur?) - Introduction of statistical programs ( statistiksel paket programlar n tan t m ) 0:45 :5 Coffee Break :5 2:5 MEETING 2 (HALL A) Journals in SEE (Güneydo u Avrupa da yay nlanan dergiler) Moderators: Slavoljub Zivanovic, Zeynep Tuzcular Vural This meeting will provide a good opportunity to meet the colleagues interested in scientific periodic journals, especially the editors and the editorial boards of the journals from the SEE

15 SCIENTIFIC PROGRAMME :5 2:5 MEET THE EXPERT 5 (HALL B) Tobacco addiction (Tütün ba ml l ) Kamile Marako lu Recep Erol Sezer :5 2:5 COURSE 2, PART 2 (HALL C) Basic life support training (Temel yaflam deste i e itimi) Moderators: Nebi Sökmen Kurtulufl Öngel Mehmet Ali Karaca Bülent Erbil Nebi Sökmen :5 2:5 COURSE 3, PART 2 (Session in Turkish) (HALL D) Course on epidemiology and statistics in primary care (Birinci basamakta epidemiyoloji ve istatistik kursu) Ahmet Öztürk; Biostatistical analysis out of actual data (Gerçek veriler üzerinden biyoistatistik analizler) 2:5 3:5 CLOSING CEREMONY (HALL A) - 3 -

16 LIST OF ORAL PRESENTATIONS ORAL PRESENTATIONS April 23, 200 / 4:45-6:5 Each presentation is planned to be made in 0 minutes time which will be used as 7 minutes for presentation and 3 minutes for discussion. OP-9 EMPATHIC TENDENCY OF FAMILY PHYSICIANS COMPARED TO OTHER SPECIALTIES N. KARAOGLU, F. SIVRI OP-0 TAKING A STEP TO OUR FUTURE: AGE FRIENDLY PRIMARY HEALTH CENTRES B. PALA, F. YUKSEL, M. UNALACAK, I. UNLUOGLU OP- THE CHANGE IN THE SATISFACTION LEVEL OF FAMILY MEDICINE RESIDENTS BY TIME S. OZCAN, N. BOZDEMIR, E. SAATCI, H. KURDAK, E. AKPINAR OP-4 FAMILY DOCTOR AND WORKERS HEALTH L. CVEJANOV KEYUNPVOC, M. GRBOVIC, S.A. MICANOVIC OP-5 MONTENEGRO EXPERIENCE AT RETAINING ON FAMILY PRACTICE PROFESSIONALS L. CVEJANOV KEYUNPVOC, S.A. MICANOVIC, M. GRBOVIC OP-8 CHOSEN MEDICAL PRACTIOTIONERS FOR CHILDREN - WORK ANALYSIS D. OSTOJIC, S. MALOVIC, M. GRBOVIC OP-9 CHOSEN MEDICAL PRACTIOTIONERS FOR ADULTS - WORK ANALYSIS M. GRBOVIC, D. OSTOJIC, S. MALOVIC, OP-24 CHANGES IN HEALTH CARE INDICATORS AND HEALTH CARE SERVICES BEFORE AND AFTER A PILOT APPLICATION OF FAMILY MEDICINE CARE C. OZCAN, Y. CETINEL, E. TORE, M.G. EMINSOY, A. KUT OP-3 PRIMARY HEALTH CARE REFORM IN MONTENEGRO M. DOBROVIC-MILOSEVIC, S. VUKOTIC - 4 -

17 LIST OF ORAL PRESENTATIONS ORAL PRESENTATIONS 2 April 23, 200 / 6:45-8:5 Each presentation is planned to be made in 0 minutes time which will be used as 7 minutes for presentation and 3 minutes for discussion. OP-4 VENOUS THROMBOSIS - A PROSPECTIVE STUDY OF ETIOLOGICAL FACTORS J. DELIC, M. DELIC OP-3 URINARY INFECTIONS IN PATIENTS WITH DIABETES MELLITUS I. ILIC, J. STOJAKOVIC, B. JOKOVIC, L. BUNJAK, M. MILOSAVLJEVIC OP-22 RISK VALUATION OF DEVELOPING DM TYP II S. MICANOVIC, L. CVEJANOV-KEZUNOVIC, M. GRBOVIC OP-26 CONTROL AND PREVENTION OF EARLY DIABETIC COMPLICATIONS AMONG BULGARIAN ADO- LESCENTS IN GENERAL PRACTICE V. MADJOVA, V. TODOROVA, R. ASSENOVA, G. FOREVA OP-29 DENTISTS' SPINAL DISCOMFORTS AND PHYSICAL EXERCISE HABITS P.C. UNALAN, N. TOPSAKAL, M. KARAHAN, S. CIFCILI, G. YIGIT OP-35 THE FREQUENCY OF THE CARDIAL ARRHYTHMIES OF THE PATIENTS WHO SUFFER FROM THE CHRONIC OBSTRUCTIVE PULMONARY DISEASES D. V. NIKOLIC GROZDANOVIC, I.J. STOJKOVC, B. RAKIC, B. SARAC OP-36 DIABETES MELLITUS - THE MOST COMMON DISEASE OF OLDER AGE V. BANKOVIC, L. SIMONOVIC, B. SARAC, S.V. CEKIC OP-37 DIABETIC MELLITUS-METABOLIC SYNDROME V. VUKOVIC IGOV, S. PEJCIC, B. RAJKOVIC OP-39 BEHAVIOURS AND ATTITUDES OF FAMILY PHYSICIANS AGAINST PHYSICAL ACTIVITY I. KARATAS ERAY, E. ALTUNBAS, S. GUREL - 5 -

18 LIST OF ORAL PRESENTATIONS ORAL PRESENTATIONS 3 April 24, 200 / 09:5-0:45 Each presentation is planned to be made in 0 minutes time which will be used as 7 minutes for presentation and 3 minutes for discussion. OP-2 OBESITY AS A RISK FACTOR FOR MORBIDITY IN AMBULATORY CARE OF FAMILY DOCTOR S. MICANOVIC, Z. DAUTOVIC, M. GRBOVIC OP-23 COMPARISON OF BIOMEDICAL AND BIOPSYCHOSOCIAL APPROACHES IN THE TREATMENT OF OBESITY A. KUT, M.G. EMINSOY, M. SENAY, Y. CETINEL, H.S. AKGUN, A. GURSOY OP-25 PSYCHOSOCIAL AND CLINICAL EVALUATION OF PATIENTS WITH UNCONTROLLED BLOOD PRESSURE IN COMPARISON WITH THE EFFECT OF SSRI\'S ON BLOOD PRESSURE CONTROL A. KUT, M.G. EMINSOY, C. GOKTEKIN, Y. CETINEL, C. OZCAN, R. ERDAL OP-28 PROFILE OF 23 CASES INFECTED WITH INFLUENZA A (HN) IN EASTERN ANATOLIA S. VANCELIK, Z. AKTURK, R. CETIN SECKIN, H. ACEMOGLU OP-30 HYPERTENSION IN MONTENEGRO L. DRAGIC, L. DJUROVIC OP-32 ARTERY HYPERTENSION IN THE WORK OF CHOSEN DOCTOR V. PANTOVIC, T. CULAFIC, J. OBADOVIC, B. SCEKIC OP-38 PREVALANCE OF METABOLIC SYNDROME AND RELATED RISK FACTORS IN HYPERTENSIVE CHILDREN AND ADOLESCENTS D. YILDIZHAN, M. BAYAT, M.M. MAZICIOGLU, S. ISMAILOGULLARI, S. KURTOGLU, E. YILMAZ, H.B. USTUNBAS OP-42 THE INVESTIGATION OF METABOLIC DISORDERS IN NEWLY DIAGNOSED HYPERTENSION PATI- ENTS U. AYDOGAN, A. PARLAK, K. SAGLAM OP-43 THE EVALUATION OF KNOWLEDGE AND LIFE STYLES OF HYPERTENSIVE PATIENTS U. AYDOGAN, A. PARLAK, K. SAGLAM - 6 -

19 LIST OF ORAL PRESENTATIONS ORAL PRESENTATIONS 4 April 24, 200 / :5-2:5 Each presentation is planned to be made in 0 minutes time which will be used as 7 minutes for presentation and 3 minutes for discussion. OP-2 ADOLESCENT PREGNANCY: TRENDS, CHARACTERISTICS AND OUTCOMES IN EAST TURKEY T. EDIRNE, M. CAN, R. YILDIZHAN, A. KOLUSARI, E. ADALI, B. AKDAG OP-6 BENIGN PROSTATE HYPERPLASIA-IMPORTANCE OF ULTRASOUND DIAGNOSTICS IN PRIMARY HEALTH CARE N. PERISIC, S. ANDJELKOVIC, Z. STANKOVIC OP-6 BENIGN PROSTATIC HYPERPLASIA - ECHOSONOGRAPHIC DIAGNOSTICS IN PRIMARY HEALTH CARE N. PERISIC, S. ANDJELKOVIC, Z. STANKOVIC OP-27 SERUM PLASMA AND LEUKOCYTE ZINC LEVELS IN MOTHERS OF NORMAL AND LOW BIRTH WEIGHT INFANTS AND COMPARISON OF ITS EFFECT ON INFANT BIRTH WEIGHT A. KUT, Y. UCKARDES, H. GUNTURKUN, F. SOZEN, Y. CETINEL, R. ERDAL OP-34 BHP AND THE QUALITY OF LIFE D. MILOSEVIC, S. NIKOLIC OP-4 LOW DOSE ADMINISTRATION OF ORAL POWDER ANTIBOTICS DUE TO INAPPROPRIATE PREPA- RATION C. APAYDIN KAYA, S. CAGATAY, E. BUYUKKARA, O. OZLUK, A.I. CELIK, N. TOSUN - 7 -

20 LIST OF ORAL PRESENTATIONS ORAL PRESENTATIONS 5 April 24, 200 / 4:45-6:5 Each presentation is planned to be made in 0 minutes time which will be used as 7 minutes for presentation and 3 minutes for discussion. OP- WHAT DO PATIENTS KNOW ABOUT CANCER? N. OZCAKAR, M. KARTAL, C. ISIKLAR OP-3 A CASE-CONTROL STUDY EVALUATING DEPRESSION AND QUALITY OF LIFE IN HIGH-RISK PREGNANT WOMEN M.S. SAHSIVAR, K. MARAKOGLU OP-5 THE PRESENCE OF ANXIETY AND DEPRESSION IN THE ADULT POPULATION OF FAMILY PRACTICE PATIENTS WITH CHRONIC DISEASES K. TUSEK BUNC, Z. KLEMENC KETIS, J. KERSNIK, E. TRATNIK OP-7 OSTEOPOROSIS-METABOLIC ARTHROSIS D. PUNOSEVAC, A. KARAPANDZIC, M. ZIVIC OP-8 CASE REPORT OF ADULT STILL'S DISEASE M. VUCUREVIC, D. NIKOLIC, M. SOCIVICA, G. MARINKOVIC OP-2 PREVENTION OF MENTAL DISEASES BY GENERAL PRACTICE DOCTOR IN MONTENEGRO O. PRVULOVIC, S. STRAHINIC OP-7 THE COMPARATIVE EFFICIENCY OF DIFFERENT METHODS TREATMENT IN ESSENTIAL (CLASI- CAL) TRIGEMINAL NEURALGIA C. BUSNEAG, A. BUSNEAG OP-20 FALL RELATED FACTORS IN ELDERLY D. KARADENIZLI, T. ALIC, B. GULMAN, P. UNALAN OP-33 IPP-THE FIRST STEP IN TREATING FUNCTIONAL DYSPEPSIA D. MILOSEVIC, S. NIKOLIC - 8 -

21 LIST OF POSTER PRESENTATIONS There will be two Poster Sessions during the congress scientific programme. Presenters are responsible for setting up the posters in the morning of their presentation date and removing at the end of the day. At least one of the authors should be ready at the Posters Area during the related Poster Session. POSTER SESSION April 23, 200 / 2:5-4:45. Po- SMOKING AND DEPRESSION SYMPTOMS AMONG MEDICAL STUDENTS IN TURKEY K. MARAKOGLU, D. TOPRAK, S. OZDEMIR, D. ERDEM KOROGLU, S. SAHSIVAR Po-9 ANXIETY AND DEPRESSION LEVELS OF PRE- CLINICAL MEDICAL STUDENTS IN SELCUK UNIVERSITY N. KARAOGLU, M.SEKER Po-2 DEPRESSION AND RHEUMATOID ARTHRITIS CASE REPORT V. ILIC, N. ILIC Po-3 EVALUATION OF THE LEVELS OF OXIDATIVE STRESS FACTORS AND ISCHEMIA MODIFIED ALBUMIN IN THE CORD BLOOD OF SMOKER AND NON SMOKER PREGNANT WOMEN A.S. SAHINLI, K. MARAKOGLU, A. KIYICI Po-4 DEPRESSION AND ANXIETY WITH DOCTORS - PROVOCATIVE TOPIC, MISTAKE OR REALITY? N. ILIC, V. ILIC Po-0 XANTHOMA ERUPTIVUM AND DIABETES MEL- LITUS AT OUT- PATIENT VISIT AT POLIAMBULATORY OF SPECIALITIES NR 2 TIRANE, ALBANIA. B. GJONI, M. KELMENDI, N. DHALES, A. BITRI, V. KONICA Po- MORBIDITY OF DERMATOLOGICAL DISEASES OF THE PEDIATRIC AGE DURING AT HEALTH CLINIC OF SPECIALTIES NR 2 AND HEALTH CLINIC OF QUARTER NR 9,TIRANA, ALBANI B. GJONI, N. DHALES, M. KELMENDI, V. KON- ICA, A. BITRI, E. CUKANI Po-5 KNOWLEDGE AND ANTICIPATED ATTITUDES OF THE COMMUNITY ABOUT BIRD FLU OUT- BREAK IN TURKEY; A SURVEY-BASED DESCRIPTIVE STUDY T. EDIRNE,D. KUSASLAN, B. ATMACA, M. ASLAN Po-6 HAIR MESOTHERAPY IN TREATMENT OF ALOPECIA S. OZDOGAN, M. ERDAL Po-7 DERMATOLOGIC ANALYSIS IN ELDERLY PATIENTS DURING BALNEOTHERAPY S. OZDOGAN, E. KAYA, A.H. KAYAR, M. ERDAL Po-8 FAMILY PHYSICIANS CALENDER IN TURKEY SINCE 997: EVALUATION OF THE TURKISH JOURNAL OF FAMILY PRACTICE N. KARAOGLU,2M.A. KARAOGLU Po-2 DOES THE MOBING HAVE THE INFLUENCE ON THE TYPE OF PERSONALITY? A. BEGANLIC, O. BATIC-MUJANOVIC, S. HERENDA, M. HASANAGIC, A. BRKOVIC Po-3 POPULATION GROWING OLD - OLD PEOPLE S SOCIAL AND MEDICAL NEEDS Z. STANKOVIC, D. ANDJELKOVIC, N. PERISIC Po-4 CANCER IS NOT A DEATH SENTENCE, EARLY DETECTION SAVES LIFE Z. STANKOVIC, D. ANDJELKOVIC, N. PERISIC Po-5 ACUTE URTICARIA AT THE PEDIATRIC AGE, VISIT AT POLICLINIC OF SPECIALTIES NR 2 & HEALTH CLINIC NR 9 DURING JANUARY DECEMBER B. GJONI, M. HASANAJ, B. VACARRI, - 9 -

22 LIST OF POSTER PRESENTATIONS V. KONICA, M. KELMENDI, N. DHALES, A. BITRI, Po-6 ACCESS OF ELDERLY PATIENTS TO PRIMARY MEDICAL CARE L. GEORGIEVA, S. POPOVA, V. MADJOVA Po-7 WHY THEY DONT WANT TO BE A FAMILY PHYSICIAN? FAMILY MEDICINE FROM THE VIEW OF MEDICAL EDUCATION N. KARAOGLU, M.A. KARAOGLU Po-8 CONGENITAL STARDGARD\'S DISEASE, CASE REPORT N. BURDA, B. GJONI, M. KELMENDI, A. STOJKU Po-9 THE EVALUATION OF CASES OF DRUG INTOXICATION THAT ARE HOSPITALIZED O. ERDEM, I.H. KARA, O. AYYILDIZ Po-20 SERUM MAGNESIUM LEVELS IN GESTATION- AL DIABETES K. INCI, D. SUNAY, U. UCKAN Po-2 PREVALENCE OF HIPERTENSION IN NON TOXIC MULTINODULAR GOITRE AT THE OUT- PATIENT VISIT AT POLICLINIC OF SPECIALI- TIES NR 2 & POLICLINIC NR 9, TIRANE, ALBANIA M. KELMENDI, G. HYSI, A. BITRI, B. GJONI, A. VESELI, A. STOJKU Po-22 EVALUATION OF KNOWLEDGE, ATTITUDE AND BEHAVIOUR OF MEN ABOUT FAMILY PLANNING G. OZCEYLAN, K. ERTOPCU, S.H. KARAHAN, S. KELEKCI, A. DONMEZ, G. SOP Po-23 EVALUATION OF TEN YEARED FOLLOW UP OF NTERNAL AND POSTABORTIVE APPL ED CUT380A INTRAUTERINE DEV CES B. BULUT, K. ERTOPCU, A. DONMEZ, S. TINAR, I. OZELMAS, M. HELVACI, A. TASYURT Po-24 FREQUENCY OF PHYSICAL DEVELOPMENT DISORDERS IN CHILDREN FROM PRIMARY SCHOOL \"EDHEM MULABDIC\" IN ME?E?A S. BISANOVIC, S. SIVIC, O. BATIC-MUJANOVIC Po-25 PREVALENCE OF DIABETES FOOT IN OUT- PATIENT VISIT AT ENDOCRINOLOGIST AND DERMATOLOGICAL SERVICES OF THE HEALTH CENTER OF SPECIALTIES NR. 2, TIRANE, ALBANIA. M. KELMENDI, B. GJONI, G. HYSI, A. STOJKU, N. DHALES, A. BITRI, Po-26 TUBAL STERILIZATION VERSUS VASECTOMY (DEMOGRAPHIC EXAMINATION OF 3404 CASES) L. AKOGLU, K. ERTOPCU, S.H. KARAHAN, A. DONMEZ, M. OZEREN,M. HELVACI, I. OZEL- MAS, A. TASYURT Po-27 IMPLANON-SIDE EFFECTS,SAFETY,SATISFAC- TIONS,CONTINUITY S. KURNUC, K. ERTOPCU, Y. YILDIRIM, S.H. KARAHAN, G. SOP, A. TASYURT Po-28 THE DIAGNOSTICS OF DIABETIC POLYNEU- ROPATHY Z. DAUTOVIC, S. MICANOVIC Po-29 CARDIO-METABOLIC SYNDROME-INVASIVE TRATMENT OF PATIENTES L. ZOGOVIC VUKOVIC Po-30 HOW MANY PATIENTS WITH A STROKE HAS FULFILLED QUALITY INDICATORS OF CLINICAL PRACTICE? A. BEGANLIC, M. MUJCINAGIC-VRABAC, O. BATIC-MUJANOVIC, M. HASANAGIC, S. HERENDA

23 LIST OF POSTER PRESENTATIONS Po-3 RISC FACTORS FOR DEVELOPMENT OF DIA- BETIC RETINOPATHY E. RAMIC, A. BEGANLIC, E. ALIBASIC, E. KARIC, S. SELMANOVIC, O. BATIC-MUJANOVIC Po-32 NON-CONTAGIOUS DISEASES AS CAUSE OF TEMPORARY INCAPABILITY FOR WORK L. DELEVIC Po-33 DIABETES MELLITUS MONITORING REGIS- TERED PATIENTS FROM ASPECT OF PRIMARY HEALTH PROTECTION A. BAJRAMSPAHIC Po-34 ANTENATAL FOLLOW UP OF 00 WOMEN WHO GIVE BIRTH AT MINISTRY OF HEALTH,EGE TRAINING AND RESEARCH HOS- PITAL OF OBSTETRICS & GYNECOLOGY S.H. KARAHAN, K. ERTOPCU, T. GULEN, C.E. TANER, M. HELVACI, A. TASYURT, S. TINAR Po-35 PPD POSITIVITY IN HOSPITALIZED CHILDREN C. ONER, M.C. GUNERI Po-36 RISK FACTORS FOR ECTOPIC PREGNANCY C. ONER, M.C. GUNERI, O. UNAL, B. KARS Po-37 DIABETIC RETINOPATHY AND CLINIC PREDIS- POSING FACTORS TO THE PATIENTS WITH DIABETUS MELLITUS AT POLICLINIC OF SPE- CIALTIES NR 2 TIRANE, ALBANIA. N. BURDA, M. KELMENDI, B. GJONI, A. STO- JKU, E. XHOKAXHIU, A. VESELI Po-38 COMPARISON OF DEMOGRAPHIC CHARACTER- ISTICS OF WOMEN WHO APPLIED FOR CON- SULTING TO THE WOMEN APPLIED FOR ABORTION BECAUSE OF UNWANTED PREG- NANCIES I.A. ERCAN, K. ERTOPCU, S.H. KARAHAN, Y. YILDIRIM, A. DONMEZ, G. SOP, I. OZELMAS, A. TASYURT Po-39 COMPARISON OF DEMOGRAPHIC CHARACTER- ISTICS OF INTERVAL AND POSTABORTIVE TUBAL STERILIZATION (407 CASES) L. AKOGLU, K. ERTOPCU, B. TUNCAY, A. DONMEZ, I. OZELMAS, M. HELVACI, A. TASYURT Po-40 MONITORING OF CARDIOVASCULAR RISK FACTORS AMONG PATIENTS WITH STROKE IN FAMILY MEDICINE PRACTICE O. BATIC-MUJANOVIC, N. DAJANOVIC, H. DEMIC, L. GAVRAN, M. BECAREVIC, S. BISANOVIC, A. BEGANLIC, S. HERENDA, A. BRKOVIC, M. HASANAGIC Po-4 PAP SMEAR- SCREENING AND KNOWLEDGE ABOUT IT A. BEGANLIC, S. HERENDA, E. RAMIC, O. BATIC-MUJANOVIC, A. BRKOVIC Po-42 TAKING PILLS DOESN T MEAN THAT YOU HAVE CONTROLLED BLOOD PRESSURE! V. ALEKSOV, L. SUKRIEV, D. ALEKSOV Po-43 FOCUSING TO UNKNOWN WITH EVIDENCE BASED MEDICINE IN PRIMARY CARE F. YUKSEL, B. PALA, M. UNALACAK Po-44 ALCOHOL CONSUMPTION BEHAVIOUR OF STUDENTS OF A HIGH SCHOOL IN A SOUTH- ERN CITY OF TURKEY E. SAATCI, D. ANTEPUZUMU, Y. INCECIK, O.OZMEN, N. BOZDEMIR Po-45 THE EVALUATION OF NUTRITIONAL HABITS OF HYPERTENSION PATIENTS A. PARLAK, U. AYDOGAN, A. DIKILILER, K. SAGLAM - 2 -

24 LIST OF POSTER PRESENTATIONS Po-46 THE EVALUATION OF LIVER, KIDNEY AND THYROID FUNCTIONS OF NEWLY DIAGNOSED HYPERTENSION PATIENTS A. PARLAK, U. AYDOGAN, S. MUTLU, K. SAGLAM Po-47 THE EFFECT OF LABIAL FUSION ON CLINI- CAL OUTCOMES E. ALTUNBAS, N. TEKIN, I. KARATAS ERAY Po-48 FOLLOW UP RESULTS OF CHRONIC IDIOPATH- IC LOW BACK PAIN PATIENTS ACCORDING TO FAMILY MEDICINE PRINCIPLES I. TANYILDIZI, V. MEVSIM Po-49 AFFIRMATION OF PREVENTIVE PROGRAMS IN FAMILY MEDICINE R. AGIC, A. BAJRAMSPAHIC Po-50 THE HEALTH CONDITION OF GERIATRIC PATIENTS IN PETROVAC ON THE SEA K. RASKOCIC, M. VRANES-GRUJICIC, L. DJUROVIC, I. GALIC Po-5 ATTENDANCES IN FAMILY DOCTORS HEALTH CENTERS P. TSEKOVA Po-52 FREQUENCY OF RECOCNIZED DEPRESSION IN ERDERLY PATIENTS A. SOFTIC-OMEROVIC, J. EREIZ, A. BEGANLIC Po-53 THE RELATIONSHIP BETWEEN HYPERTENSION AND SLEEP DISORDER IN CHILDREN AND ADOLESCENTS R. PICAK, M. BAYAT, M.M. MAZICIOGLU, S. ISMAILOGULLARI, S. KURTOGLU, E. YILMAZ, D. YILDIZHAN, H.B. USTUNBAS Po-54 FREQUENCY OF UNRECOGNIZED DEPRESSION IN ERDERLY PATIENTS A. SOFTIC-OMEROVIC, J. EREIZ, A. BEGANLIC Po-55 THE USE OF TONOPEN APPLANATION TONOMETER IN HOME TREATMENT. T. PAVLOVIC, J. IVANCEVIC Po-56 THE USE OF ANTIBIOTICS FOR RESPIRATORY TRACT INFECTIONS J. IVANCEVIC, T. PAVLOVIC Po-57 ANXIETY AND DEPRESSION RELATED SOCIODEMOGRAPHIC FEATURES FOR DEN- TURED HEART FLAP PAT ENTS: PRELIMINARY STUDY Y. TURKER, K. ONGEL, M. OZAYDIN Po-58 OSTEOPOROSIS SCALE TO USE IN PRIMARY CARE SETTINGS: PRELIMINARY STUDY H. KAYACAN, K. ONGEL Po-59 WHAT DOES THE INCREASE OF PSA MEANS FOR THE GENERAL PRACTITIONER? B. STOJANOVSKI, V. GEORGIEV, O. IVANOVSKI Po-60 HELICOBACTER PYLORI PREVALENCE AND ERADICATION L. JANEVA, N. JANEV, L. ANGELOVSKA Po-6 HYPERLIPOPROTEINEMIA AND CARDIOVASCU- LAR DISEASES L. JANEVA, N. JANEV, L. ANGELOVSKA Po-62 CHRONIC COMPLICATIONS WITH PATIENTS SUFFERING FROM DIABETES MELLITUS TYPE II L. JANEVA, N. JANEV, L. ANGELOVSKA

25 Po-63 THE PREVALENCE OF CHRONICALLY NON- COMMUNICABLE DISEASES IN FAMILY PRAC- TICE TEAMS IN CANTON TUZLA S. SELMANOVIC, A. BEGANLIC, S. SRABOVIC, M. MUJCINAGIC-VRABAC, J. JASIC, A. SOFTIC LIST OF POSTER PRESENTATIONS Po-70 TREATMENT OF HYPOGLYCEMIC CONDITIONS AT THE EMERGENCY MEDICAL SERVICES OF THE CITY OF BELGRADE S. ZIVANOVIC, D. STEVOVIC GOJGIC, V. STE- FANOVIC Po-64 MODIFABLE CARDIOVASCULAR RISK FAC- TORS AMONG PATIENTS WITH STROKE IN FAMILY MEDICINE PRACTICE. BATIC-MUJANOVIC, S. BISANOVIC, L. GAVRAN, E. RAMIC, M. BECAREVIC, E. ALIBASIC Po-65 KNOWLEDGE AND ATTITUDES OF UNIVERSI- TY STUDENTS TOWARD PANDEMIC INFLUEN- ZA: A CROSSSECTIONAL STUDY FROM TURKEY H. AKAN, Y. GUROL, G. IZBIRAK, S. OZDATLI, G. YILMAZ, A. VITRINEL, O. HAYRAN Po-66 DEPRESSION IN THE ELDERLY AND FAMILY MEDICINE CLINICAL TRIAL S. GEORGETA, M. ARMASU, G. COSTINELA, P.C. CIUDIN, C. VORNICU Po-67 VIOLENCE AND THE FAMILY DOCTOR (CLINI- CAL TRIAL) S. GEORGETA, M. ARMASU, G. COSTINELA, R. TRACIUC, E. TRACIUC, C. VORNICU Po-68 INCREASED NUMBER OF DESEASED PATIENTS FROM PAROTITIS EPIDEMICA IN 2008 IN PRI- VATE HEALTH INSTITUTION, VITALIS,-STRU- MICA, R. MACEDONIA V. PEVKEVA, V. MANCHEV, L. MATKOVA, V. MANCHEVA Po-69 LIFESTYLE FACTORS IMPACT ON FERTILITY E. ALIBASIC, F. LJUCA, D. LJUCA, E. RAMIC, O. BATIC-MUJANOVIC, A. TULUMOVIC, A. BEGANLIC Po-7 THE IMPACT OF SMOKING ON THE CHANGES IN THE ORAL CAVITY D. TRIFUNOVIC BALANOVIC Po-72 URINARY BLADDER FUNCTION IN MEN WITH DIABETES TYPE 2 E. ALIBASIC, F. LJUCA, D. LJUCA, E. RAMIC, O. BATIC-MUJANOVIC, A. TULUMOVIC, A. BEGANLIC Po-73 CORONARY ARTERY DISEASE(CAD), SOCIODE- MOGRAPHIC FEATURES AND SEARCHING RISC FACTORS IN FAMILY A. PARLAK, H. AKBULUT, U. AYDOGAN, O. SARI, C. BARCIN, K. SAGLAM Po-74 COMPARISION OF HIPOCALSEMIA FREQUENCY AFTER THYROIDECTEMIA IN BENING OR MALIGN THYROID CANCERS O. SARI, U. AYDOGAN, H. DINCER, H. AKBU- LUT, S. KAVUK, K. SAGLAM Po-75 PARAMETRIC CHANGES IN RDW AND MCV FOR RADIATION HEALTH EMPLOYEES PERI- ODIC INSPECTIONS C. BOCUTOGLU, K. ONGEL Po-76 COMPARISON OF THE HAEMATOLOGIC PARA- METERS FOR THE DIAGNOSIS OF IRON DEFI- CIENCY ANEMIA BETWEEN PREGNANT AND NON-PREGNANT WOMEN C. BOCUTOGLU, K. ONGEL, M. Tamer MUNGAN

26 LIST OF POSTER PRESENTATIONS Po-77 LONELINESS OF FAMILY PHYSICIANS: A PRE- LIMINARY STUDY N. KARAOGLU, F. SIVRI Po-78 CELIC DISEASE - CASE STUDY M. STANISIC Po-79 MANAGEMENT OF PATIENT WITH CONSTIPA- TION COMPLAINT IN PRIMARY CARE M. KORKMAZ, F. YUKSEL, M.UNALACAK, I. UNLUOGLU Po-80 PREVALENCE OF CARDIOVASCULAR RISK FACTORS IN MENOPAUSES O. BATIC-MUJANOVIC, A. KURT, B. SENAIDA, G. LARISA, B. MUNEVERA POSTER SESSION 2 April 24, 200 / 2:5-4:45. Po-8 PRESENCE OF SPIROMETRY IN PRIMARY HEALTH CARE (PHC) IN SKOPJE. RECOMMEN- DATION FOR INTEGRATIVE APPROACH COPD CENTERS K. SOLESKI, F. LOKVENEC, D. ILIEV, M. MIHAJLOV, S. SOKOLSKA, S. KARALIESKI Po-82 THE EFFECTS OF SUPPLEMENTS IN HIPERLIPI- DEMY TREATMENT K. SOLESKI Po-83 SMOKING AS A RISK FACTOR IN GYPSY POP- ULATION T. PAVLOVIC, J. IVANCEVIC Po-84 THE EFFECT OF THYROID REPLACEMENT THERAPY TO LEVELS OF ANXIETY AND DEPRESSION IN SUBCLINICAL HYPOTHYROID PATIENTS M.Y. YARPUZ, U. AYDOGAN, O. SARI, A. AYDOGDU, G. UCKAYA, K. SAGLAM Po-85 DO THE FAMILY MEDICINE PRACTITIONERS TAKE CARE EQUALY OF PATIENTS WITH MENTAL DISORDERS? M. MUJCINAGIC-VRABAC, S. HERENDA, A. BEGANLIC, S. SELMANOVIC, O BATIC- MUJANOVIC, S. SRABOVIC Po-86 RESEARCHING PSYCHOLOGICAL SYMPTOMS IN YOUNG ADOLESCENT MALES ACCORDING TO THE SYMPTOM CHECKLIST-90-R (SCL-90-R) H. AKBULUT, U. AYDOGAN, O. SARI, S. MUTLU, M. CELIKTEPE, K. SAGLAM Po-87 COMPARING DIFFERENT DEMOGRAPHIC DATA TO THE SPREAD OF SMOKING AMONG YOUNG ADOLESCENT MALES IN OUR COUN- TRY U. AYDOGAN, O. SARI, H. AKBULUT, P. NERKIZ, O. GEVREK, K. SAGLAM Po-88 COMORBID PSYCHIATRIC DISORDERS IN PATIENTS WITH SOMATIZATION DISORDER ACCORDING TO THE SYMPTOM CHECKLIST- 90-R (SCL-90-R) O. SARI, U. AYDOGAN, H. AKBULUT, O. GEVREK, S. YUKSEL, K. SAGLAM Po-89 HYPERTENSION IN CONTEXT OF METABOLIC SYNDROME X S. MILOVANCEVIC, J. VUKOTIC Po-90 DETAILED ANALYSIS OF GERIATRIC PATIENTS VISITING THE EMERGENCY ROOM T. TAYMAZ

27 LIST OF POSTER PRESENTATIONS Po-9 THE CHARACTERISTIC OF MORBIDITY IN THE ELDERLY AREA MUNICIPALITIES SM.PALAN- KA D. NIKOLIC, G. COSIC, S. MAJSTOROVIC Po-92 INCIDENCE OF OBESITY AND GROWTH RETARDATION IN CHILDREN IN THREE DIF- FERENT REGIONS OF TURKEY T. TAYMAZ, N. MEMIOGLU, S.M. KAYIRAN, B. TAYMAZ Po-93 THE ELECTRONIC PRESCRIPTION (OUR EXPE- RIENCE IN 2009) S. SIMOVIC, O. KNEZEVIC, S. MARKOVIC Po-94 ABNORMAL REACTION ON ALCHOCOL IN PATIENTS WITH POST TRAUMATIC STRESS DISTURBANCE (PTSD) B. RANCIC Po-95 RELATIONSHIP BETWEEN HELICOBACTER PYLORI INFECTION AND HYPERLIPIDEMIA A.F. ERDOGAN, S. ASMA, C. GEREKLIOGLU Po-96 EVALUATION OF PATIENTS WHO APPLIED TO THE FAMILY MEDICINE CLINIC WITH OBESITY A.F. ERDOGAN, S. ASMA, C. GEREKLIOGLU Po-97 HEALTHY EATING IN OLD INDIVIDUALS AND SOME RECOMMENDATIONS ABOUT MICROELEMENTS V. MADJOVA, V. TODOROVA, L. SAVOV Po-98 EXOPHTALMIA REFERENCES OF TURKISH CHILDREN AGED 6-8 YEARS T. KARA, S. KURTOGLU, M.M. MAZICIOGLU, A. OZTURK, M. OZDOGRU, H.B. USTUNBAS Po-99 ULTRASOUND IN THE WORK OF A GP/FAMI- LY DOCTOR MY EXPERIENCE B. SEVO-ALEKSIC Po-00 HEALTHCARE AND PATIENT MANAGEMENT IN OUT-OF-OFFICE HOURS IN GENERAL PRAC- TICE A. ZABUNOV, V. MADJOVA, P. MANCHEVA, S. HRISTOVA Po-0 QUALITY OF LIFE EVALUATION IN PATIENTS WITH OSTEOARTHROSIS IN PRIMARY HEALTHCARE S. HRISTOVA, V. MADJOVA, A. ZABUNOV, P. MANCHEVA Po-02 ASSESSMENT OF THE PREDICTIVE VALUE OF OBESITY MARKERS FOR THE DIAGNOSIS OF METABOLIC SYNDROME IN GENERAL PRAC- TICE D. VANKOVA, D. GEROVA, D. IVANOVA, S. TOMCHEVA, V. MADJOVA Po-03 CONSULTING PATIENTS WITH CHRONIC MEN- TAL DISEASE IN GENERAL PRACTICE - INDIS- PENSABLE PART OF THEIR PSYCHO-SOCIAL REHABILITATION P. MANCHEVA, V. MADJOVA, A. ZABUNOV, S. HRISTOVA Po-04 FAMILY PHYSICIANS PERSPECTIVES ON IDENTIFYING THE PATIENTS FOR PALLIA- TIVE CARE - A STUDY AMONG BULGARIAN GPS G. FOREVA, R. ASSENOVA, V. MADJOVA Po-05 PSYCHOLOGICAL CO-MORBIDITIES IN OBESE CHILDREN R. ASSENOVA, G. FOREVA, V. MADJOVA

28 LIST OF POSTER PRESENTATIONS Po-06 ARE SECOND LINE HELICOBACTER PYLORI TREATMENTS ALARMING? A.F. ERDOGAN, S. ASMA, C. GEREKLIOGLU Po-07 PREVALENCE OF ADULT PATIENTS THAT INFLUENZA AND PNEUMOCOCCAL VACCINA- TION SHOULD BE RECOMMENDED IN FAMILY MEDICINE OUTPATIENT CLINIC A.F. ERDOGAN, S. ASMA, C. GEREKLIOGLU Po-08 DOMESTIC VIOLENCE L. MILJKOVIC, D. TRIFUNOVIC BALANOVIC, G. ZELJKOVIC Po-09 THE MOST FREQUENT CHRONIC NON-INFEC- TIONS DISEASES (HNO) IN ORDINATION OF GENERAL PRACTICE M. MILJESIC, L. NOZINIC-VILUS Po-0 PREVENTION OF COGNITIVE IMPAIRMENTS IN PRIMARY HEATH CARE M. RACIC, P. MIRA, K. SREBRENKA, K. LJILJA Po- PREMENSTRUAL SYNDROME AND ASSOCIAT- ED FACTORS AMONG UNIVERSITY GIRLS K. MARAKOGLU, M.S. SAHSIVAR, H. ULU, D. ERDEM KOROGLU, F. CEVIZCI Po-2 SMOKING BEHAVIOUR, KNOWLEDGE, ATTI- TUDES AND PRACTICE AMONG HEALTH CARE PROVIDERS IN KAHRAMANMARAS CITY, TURKEY M. CELIK, A. OZER, H.C. EKERBICER, F.O.ORHAN Po-3 EFFECTS OF PHARMACOLOGICAL TREATMENT OF HYPERLIPIDEMIA L. BUNJAK, B. GRUJIC, S. MILOVANCEVIC, J. VUKOTIC Po-4 STATIN THERAPY IN HYPERTENSIVE PATIENS WITH HYPERLIPIDEMIA B. GRUJIC, L. BUNJAK, S. MILOVANCEVIC, J. VUKOTIC Po-5 ECHINOCOCCOSIS HEPATIS IN PRIMARY HEALTH CARE D. JOKSIMOVIC STEVANOVIC, S. MILJKOVIC, V. ZDRAVKOVIC VASIC, M. MILJKOVIC Po-6 DOMESTIC VIOLENCE CASE INTRODUCTION L. MILJKOVIC, D. TRIFUNOVIC BALANOVIC, G. ZELJKOVIC Po-7 AFFECTS OF RISK FACTORS TO RESPIRATORY SYMPTOMS: A FIELD RESEARCH Z. GUNAYI, V. MEVSIM Po-8 SYMPTOMATIC ARTERIAL HYPERTENSION IN CHILDREN - CLINICAL OBSERVATION L. MARINOV, D. BLIZNAKOVA, P. SHIVACHEV Po-9 CARDIAC TUMORS AMONG CHILDREN TWO CASE REPORTS L. MARINOV, P. SHIVACHEV, S. LAZAROV Po-20 ASSOCIATION OF CUTANEOUS MANIFESTA- TIONS WITH BODY MASS INDEX AND HbAc LEVELS IN TYPE II DIABETES MELLITUS PATIENTS N. SENSOY, G. GENCOGLAN Po-2 VENOUS THROMBOEMBOLIC DISEASE COM- PLICATED WITH BRAIN THROMBOSIS AND ANTITHROMBIN III DEFICIENCY A CASE REPORT L. MARINOV, M. ZHELEVA, B. VARBANOVA, D. BLIZNAKOVA, P. SHIVACHEV

29 LIST OF POSTER PRESENTATIONS Po-22 CARDIAC COMPLICATIONS IN CHILDREN WITH ACUTE LYMPHOBLASTIC LEUKEMIA L. MARINOV, P. SHIVACHEV, M. BELCHEVA, E. PETEVA, V. KALEVA Po-23 REVIEW OF CONTEMPORARY POCT TESTING AND SYSTEMS. POSSIBILITIES OF THEIR APPLICATION TO PRIMARY MEDICAL SER- VICES S. KASHLOVA, M. BONCHEVA, V. MADJOVA Po-24 A WIDELY HEALTH SCREENING IN KOSOVO T. TAYMAZ, A. ERDIL, R. BAYAR, C. HICYIL- MAZ, B. TAYMAZ, A. OZGENECI, A. DURHAN, Y. SIVRIKAYA, U. POYRAZ Po-25 RESEARCH OF ANXIETY AND DEPRESSION SEVERITY AMONG CANCER PATIENTS Y.C. DOGANER, U. AYDOGAN, O. SARI, B. OZTURK, S. KOMURCU, K. SAGLAM Po-26 ASSOCIATION BETWEEN DOMESTIC VIOLENCE AND DEPRESSION IN TURKISH PREGNANT WOMEN T. EDIRNE, R. YILDIZHAN, A. KOLUSARI, E. ADALI, M. CAN, V. KARS Po-27 A KIND OF SMOKELESS TOBACCO IN TURKEY: MARAfi OTU (MARAS POWDER)-A REVIEW M. CELIK, H.C. EKERBICER, U.G. OZER, A. OZER, F.O. ORHAN Po-28 IMPORTANCE OF FAMILY PRACTITIONERS IN IMPLEMANTATION OF ISTANBUL PROTOCAL O. ELCIOGLU, A.T. KOKCU, N. KIRIMLIOGLU, M. UNALACAK, T. GUNDUZ Po-29 IMPORTANCE OF ACKNOWLEDGEMENT OF PATIENT IN PRIMARY CARE PHYSICIAN PER- FORMANCE IN TERMS OF VALUE OF HUMAN- ITY N. KIRIMLIOGLU, A.T. KOKCU, N. DEMIRSOY, I. UNLUOGLU Po-30 TREATMENT OF DIABETES MELLITUS TYPE 2 WITH METFORMIN AND GLIMEPIRID L. MAKSIMOVIC, K. MARKOVIC, S. RASOVIC Po-3 IMPORTANCE OF GERIATRIC PATIENTS INFORMED CONSENT IN PRIMARY CARE PHYSICIAN PERFORMANCE N. DEMIRSOY, A.T. KOKCU, O. ELCIOGLU, M. UNALACAK Po-32 COMORBID DISEASES IN PATIENTS DIAG- NOSED WITH ANXIETY DISORDER H. AKBULUT, U. AYDOGAN, A. PARLAK, Y.C. DOGANER, A. CUCELOGLU, K. SAGLAM Po-33 COMPLICATIONS AND COMORBID DISEASES IN TYPE 2 DIABETIC PATIENTS U. AYDOGAN, H. AKBULUT, A. AYDOGDU, Y.C. DOGANER, E. BOLU, K. SAGLAM Po-34 ANXIETY LEVELS IN PATIENTS DIAGNOSED WITH AND BEING TREATED FOR HYPOGO- NADISM A. AYDOGDU, U. AYDOGAN, H. AKBULUT, O. SARI, E. BOLU, K. SAGLAM Po-35 SEASONAL INFLUENZA VACCINATION RATES AND IMMUNIZATION AWARENESS OF ADULTS IN RISK GROUPS M. SAV AYDINLI, A.G. CEYHUN PEKER, A.S. TEKINER, Z. DAGLI, F. AK PARLAK, S. INAN

30 LIST OF POSTER PRESENTATIONS Po-36 OBESITY - RISK FACTOR FOR ARTERIAL HYPERTENSION IN ADULTS WITH INITIAL OPTIMAL BLOOD PRESSURE J. VUKOTIC, S. MILOVANCEVIC Po-37 A WIDELY HEALTH SCREENING IN AZERBAI- JAN T. TAYMAZ, A. ERDIL, I. YILDIZ, B. KARADAG Po-38 DISABILITY AND HEALTH S. INAN, A.G. CEYHUN PEKER, A.S. TEKINER, M.K. KOPUK Po-39 DETERMINATION OF THE AWARENESS LEVEL OF THE WOMEN IN TERMS OF URINARY INCONTINENCE N. SENSOY, N. DOGAN, B. OZEK, L. KARAASLAN Po-40 THE USE OF ANXIOLYTICS IN GENERAL PRACTITIONER S OFFICE B. JOVICEVIC, O. RADOSAVLJEVIC Po-4 HEALTH TOURISM IN ULCINJ G. KARAMANAGA Po-42 PULMONARY ECHINOCOCCOSIS G. KARAMANAGA Po-43 GERIATRIC SYNDROME L. DJUROVIC, V. OBORINA, K. RASKOVIC Po-44 Alternative Tradicional Medicine (CAM) L. DJUROVIC, K. RASKOVIC, J. DAMJANOVIC Po-45 ARTERIAL HYPERTENSION WITH DIABETICS L. MILOJKOVIC, L. NEDELJKOVIC Po-46 RISK FACTORS AND PREVENTIVE MEASURES WITH OBESITY L. MILOJKOVIC, L. NEDELJKOVIC Po-47 POSSIBILITIES OF RECOGNIZING THE INITIAL PHASE OF DIABETIC FOOT IN THE SELECTED DOCTOR S CLINIC M. DJUROVIC, L. MARKOVIC Po-48 THE QUALITY OF LIFE WITH EXTENSIVE POST-BURN SCARS L. MARKOVIC, M. DJUROVIC Po-49 EPIDEMIOLOGICAL CHARACTERISTICS AND THE IMPORTANCE OF THE PRESENCE OF HIPERTENSIVE DISEASES IN PATOLOGY AND EMERGENCY IN THE FORTH THREE - MONTH- LY PERIOD OF 200 M. RADOMIR MILENKOVIC, A. SPIRKOSKA, V. SPIRKOSKI, S. PECOVSKA, T. RISTESKI, V. MILENKOVIC, P. KARAGOZOV Po-50 ASPIRIN IN PREEKLAMPSIJA PREVENTION P. KOSTOVSKA, G. AVRAMOVSKI Po-5 ECONOMIC REASONS FOR PERFORMING LAPAROSCOPIC CHOLECYSTECTOMY AS A STANDARD SURGICAL PROCEDURE S. PEJCIC, V. PEJCIC, T. BOJIC, A. PRAZIC Po-52 RHEUMATOID ARTHRITIS-THE ROLE FOREIGN DEVELOPMENT AND COURSE OF DISEASE V. VUKOVIC IGOV, S. PEJCIC, B. RAJKOVIC

31 LIST OF POSTER PRESENTATIONS Po-53 WATER QUALITY AND HEALTH - HYGIENIC AND EPIDEMIOLOGICAL ASPECTS J. LUKIC Po-54 VALUE OF WBC AND SEDIMENTATION IN THE DIAGNOSE OF DIFFERENT DISEASES. G. CESUR, B. TURHAN, A. TUMERDEM, K. ONGEL Po-55 BURNOUT SYNDROME IN BUS DRIVERS IN ISTANBUL A. UZUNER, S. TUZUN, F. EKINCI, G. SAHOGLU, P. UNALAN Po-56 FOLLOW UP RESULTS OF CHRONIC IDIOPATH- IC LOW BACK PAIN PATIENTS ACCORDING TO FAMILY MEDICINE PRINCIPLES I. TANYILDIZI, V. MEVSIM Po-57 COMPARISON OF CERVICAL SMEAR CULTURE RESULTS OF WOMEN USING AND NOT USING THE INTRA UTERINE DEVICE S. GUNHER ARICA Po-58 THE ASSESSMENT OF BODY MASS INDEXES AND NUTRITIONAL HABITS OF THE STU- DENTS ATTENDING PRIMARY SCHOOL V. ARICA, S. GUNHER ARICA Po-59 PREVALENCE OF OBESITY AND ASSOCIATED FACTORS IN A KINDERGARDEN IN VAN S. GUNHER ARICA, V. ARICA Po-60 TREATMENT OF ACUTE SINUSITIS WITH INTERMITTENT AZITHROMYCIN AND CEFUROXIME: A COMPARATIVE STUDY V. ARICA, S. GUNHER ARICA, M. DOGAN

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35 PLENARY SESSION (Ple-) April 23, 200 / 09:30 0:5 / Hall A PLENARY SESSIONS Association of General Practice and Family Medicine of South East Europe (Güneydo u Avrupa Aile Hekimleri ve Pratisyen Hekimler Birli i) Moderator : Erhan Sayal Ljubin Sukriev Association of GP/FM SEE -bridge for collaboration and development- L. SUKRIEV Military Hospital, Skopje, R.of Macedonia Looking forward the identical problems of the region of South-East Europe in the Primary Health Care protection,an idea appeared to Form the Association of doctors of General Practice/Family Medicine of SEE in 2002.This idea was realized in 2003 in Ohrid,R.of Macedonia,where the Association was formed. From its constitutien till today,a lot of meetings were held,two studies in South-Eastern-Europe were conducted,and one Congress and Conferences of the Association were held. There were a lot of works published as well. The aim of the Association is the bring closer the opposites meanings, to change the experiences,to intense the collaboration between the country members of the Association,and all this in a way to afirmate General Practice/Family Medicine in the region and established its in the society through the institutions. Collaboration with other Associations,especially with Wonca World and Wonca Europe, is a necessity. A lot of countries are members in the Associations. Forming a Cathedra of Family Medicine in the country members of the Association and establish a permanent development of CME and CPD in order to provide the doctors with academic experiences in the field of medicine,is our primary goal and imperativ to achieve in the future. Coordination and mutual collaboration with the institutions should be enhance in the future and the problems should be solved in the frame of the institutions. PLENARY SESSION 2 (Ple-2) April 24, 200 / 08:30 09:5 / Hall A CME and continuous professional development European experience and SEE (Sürekli T p E itimi ve sürekli mesleki geliflim, Avrupa deneyimi ve Güneydo u Avrupa) Moderator: Arzu Uzuner Marko Kolsek CME and continuous professional development European experience and SEE M. KOLSEK Dept of Family Medicine, University of Ljubljana Medical Faculty, Slovenia General practice is the easiest job in the world to do badly, but the most difficult to do well. Professor Sir Denis Pereira Gray Learning is a life-long process. We start to learn some elements of a good general practitioner or family doctor already in our childhood. Medical school adds some specific elements. In the end, in Europe at least three

36 years of vocational training or specialization gives a doctor the right to work independently with patients in general practice or family medicine. It is important that already medical school start to teach family medicine or general practice all medical students to make them understand the importance of family medicine in health system, to understand our phylosophy and approach to health problems and to our patients. All medical students should get an overview of strength, advantages and possibilities of family medicine, but also our limitations. Family medicine is best learned in a GP-setting, although specific competences and skills can be learned in environments of other disciplines. After medical school postgraduate learning comes and after that practice with continuing learning. Countries of European Union are aiming to harmonize the content and the level of the training for GPs to reach common learning outcomes considering characteristics in 6 core competencies of a GP. Such postgraduate training should last at least three years and at least half of this should be taught in general practice settings. The first comptence is Primary care management which includes: first contact with unselected problems of the full range of health conditions, coordination of care with other health professionals and utilize health services effectively and appropriately. The second competence is Person-centred care which includes: an effective doctor-patient relationship and communication considering patient's circumstances and autonomy in longitudinal continuity of care. The third comptence is Specific problem solving skills which includes: ability to selectively gather, interpret and manage patient's information, selectively and effectively use of diagnostic and therapeutic interventions considering the prevalence of illnesses, effectively use of time and tolerate uncertainty. The forth competence is Comprehensive approach which includes: management of simultaneously multiple complaints and pathologies in the individual and co-ordination of health promotion, prevention, cure, care and palliation and rehabilitation. The fifth competence is Community orientation which includes: awareness and understanding of inequalities in health care, the impact of poverty, ethnicity and local epidemiology on health; considering issues on sick leave, referral system, co-payment and other legal issues for the management of the health needs of individual patients and of the community in balance with available resources which usualy are limited. And the last competence Holistic approach which means: caring for the whole person in the context of the person s subjective and sometimes mystical values, his family beliefs, the family system, and the culture and the socio-ecological situation in the larger community, and considering a range of therapies based on the evidence of their benefits and cost. All illnesses have both mental and physical components and that there is a dynamic relationship between biological, psychological and social components of system according to general systems theory. In other words, Holistic approach means use of a bio-psycho-social model of understanding ilnesses and patients. In applying these competences to the teaching, learning and practice of family medicine 3 essential features should be considered: contextual, attitudinal and scientific. These features determine GP's ability to apply the core competences in real life in the work setting. They consider the impact of the local community, culture, facilities, workload, financies, legislation on GP's work, the impact of GP's own professional capabilities, values and ethics, his attitudes and feelings, and also his private life, and finnaly these features include GP's critical approach to his work considering evidence based practice, his ability to assess medical literature and maintain continuing quality improvement. All these characteristics, 6 competences and 3 features are joined in EURACT Educational Agenda. But, when a trainee finishes his vocational training and passes the final exam this is not really the end but

37 it's the beginning of a continuous process of professional development. All medical specialists have to renovate, improve, upgrade and expand their knowledge, skills, attitudes and also relationships according to novelties, inovations and new approaches to different problems. This is especially true for us GPs/family doctors: we have to know»everything«. We would like this, our patients expect this, clinical specialists expect this, politicians and journalists as well. And this is the reason why we are here at this Conference. We used to call this long lasting learning»continous medical education CME«. Analyzing the content of this process European experts came to the conclusion that it is not the best expression: this learning is much more than that. So, we now call it»continuos professional development - CPD«. It means all doctor's activities which maintain and improve his professional competence and performance as close as possible to excellence. Doctor's excellent performance has clinical, managerial, social and personality elements to fulfil patients' needs, because good doctor cures also with his personality not only with guidelines. In many European countries such learning has been and is still now mandatory for doctors if they want to practice. With different learning activities that are approaved by an official professional body they have to collect a certain amount of so called»educational points«each year or in a period, e.g. in 7 years as to renew the working licence. All this in order to garantee quality of care and to stimulate doctors to endeavour toward excellence. In last decades it becomes clear that different learning activities are not equally effective: it is not the same sitting and listening a lecture or actively participate at a workshop or prepare a presentation. That is the reason why passive or active participation on a Congress should not be awarded by the same amount of»educational points«. In order to help doctors to maintain these learning activities professional associantions organize different educational events. To be more effective they combine different approaches, e.g. lectures, round tables, workshops, courses, practical training and work in small groups, oral presentations and posters prepared by participants, etc. If you look at the scientific programme of this Conference you can see that it is a good example of such a combination. There are also other learning activities that are effective, e.g. studying a literature, conducting audit procedure, making educational visits of colleague's practice, writing an article for a journal, preparing a protocol for management, analyzing an incident, preparing an information leaflet or guidelines for patients, preparing a case report or a family report for colleagues of a group practice, role playing, running a quality circle, participating in a Ballint group, using internet options for CME and CPD, etc. We are aware of the need to renovate our knowledge and skills on and on. But, what knowledge or skill should be renovate now, next month or this year? Many of us for years prefer to study a topic or to participate at an activity related to a topic which we like. Usualy we already know a lot on this issue and are familiar with it already. Sometimes we do not like to admit ourselves in which issues we feel a little unsecure where we are not very sure, and sometimes we try to avoid them, in a way we overlook them. I remember myself being a medical student: I didn't like the issue of vitamins different hyper and hypovitaminosis. Studying internal medicine I've just browsed vitamins chapter hoping that the professor would not ask me that. I was lucky then he didn't. I was lucky but under stress scared to be asked. But for everyday practice is this the best solution? In everyday practice we are under stress mostly if we are not really sure in what we are doing, if we are unsecure of our knowlegde and skills. There is a solution to avoid this challenge of overlooking some issues and being unsecure, being under unnecessary stress. The solution reflects in continuos learning continous professional development. I should think about my real educational needs, maybe discuss it with my colleagues. What do I need to renovate? Which topic I do not like so much and not know enough? Which of my skills is not good enough? Which clinical problems are difficult for me? Which patients I would like to be managed by somebody else? Were there any comments of my colleagues on my management? After thinking and considering my personality, my community, possibilities I will find my needs; than I can prepare my personal education plan

38 Personal education plan or personal development plan in continuos professional development - CPD is a process of planned and individually tailored learning in practice with a focus on the quality of care. It includes the identification of learning needs, construction of a learning agenda, drawing a concrete learning plan, and controlling this in an educational portfolio format. Exact plan should be realistic, relevant, feasible and time limited. For example: I realized I always have a problem when I suspect that a patient have problem because of alcohol drinking. I've never been sure what would be the best to do: how should I start our conversation, should I ask him directly about his drinking, should I just tell him not to drink, should I refer him, would he be offended, would this have an impact on our relationship? So, I've realized that the management of alcohol problems is my need. What now? I've prepared my personal plan: in this year I will improve my knowledge on alcohjol related issues and improve my skills to manage patients with alcohol drinking related problems. Next two months I will read»clinical guidelines on identification and brief interventions for primary health care on alcohool related problems«, in next four month I'll participate at the workshop on this topic organized by my association and then try to use these new knowledge and new skills in my practice. After 0 months I'll think over to evaluate if I feel more confident and competent when a patient with alcohol related problem comes to me. It is important having in mind that the competence is not enough it is not enough to know something how to show it if asked or assessed for it. The main thing is to use knowledge and skills and to do it in real practice at everyday work with patients to perform it. Let's go back from an individual doctor to national professional associations: they should have a lot of close contacts with us that are working in everyday practices to realize our needs and organize educational activities on topics we need and are relelvant to our practice, to our patients and to our country specific situation. They should also organize activities that promote new not enough known knowledge and skills or approaches for the management of old or new problems. Which countries are the most successful in continuos professional development of their GPs? Here are some of their common characteristics that enable or improve possibilities for good results: strong GPs' professional organisations with enthusiastic and altruistic leaders that are capable to listen to and coordinate different opinions professional dedication to quality of care shared responsibility for policy strong academic position (education, research) organized training opportunities are continuos, needs based and monitored, and teaching methods reflect learning needs good public image. Coming to the end, let me look at learning opportunities and possibilities from another side: what seem to be a kind of problem or a challenge already now and what problems or challenges may we face in future? farmaceutical industry: in many countries in a way enables continuos professional development by sponsorship of conference fees for individual doctors, for congress or workshop organizers, by donating funds for medical equipment, etc. But on the other hand farmaceutical industry can sometimes in a way force doctors to decide the opposite of guidelines, it can interfere with scientific content of a professional meeting, misuse congresses for own promotion multimorbidity: there is almost no patients any more with only one problem. Getting older problems are multiplying especially the chronic ones. There are more and more old people in Europe, so there is also more and more peolpe with multiple problems. GP is the main health professional that have to be able to coordinate the management of different problems at the same patient and to help patients to use health system in accordance with their needs and communitiy possibilities. As Chris van Weel has said. A GP has to be an

39 expert for the management of multimorbid chronic patients. medicalisation: in the last decades medicine is entering step by step in all parts of our life from the conception better already before the conception through pregnancy, delivery, childhood, adolescence, adult period, old age, death and even after that. Is there anybody or anything at all that is still complitely healthy, normally and doesn't need any help or support by a doctor, nurse or some kind of medicine? Should really all we, that we think are healthy, have to take the»polypill«to be more healthy now and in our old age? Should really we treat normal changes that come with ages? What should we learn, what should we teach? information overloading: already in 60th and 70th of the 20th century there was so many important professional journals that nobody could have an overview of what was happening in the scientific world of medicine. Next step was internet which brought an infinite pool of information of different quality. We already now have problems to orientate ourselves in this pool and it will be even worse in the next decades. Can we imagine our patients what they can do in this pool of information? Are we prepared to help them to orientate and to take over the responsibility in decision making process and for their health? information technology: in last decades we are slowly moving from paper to monitor, from paper medical record to computer based patients data set, to on-line exchange of information between medical professionals and also between doctor and patient. Are we prepared to overcome the danger of loosing the true and real interpersonal doctor patient relationship? Will we be able to keep eye contact, to notice those small changes in patients eyes, his face, or small moves of his fingers, to be empathic and communicate with him as a human being not only as an expert and not losing in all possible information on the monitor? overloaded doctors: health needs of population are growing each year and it looks that such trend is not going to stop in near future. Many GPs are overloaded already now, already now they think twice before they decide to take some days for learning or for holidays becasuse of their bad experience. When they come back to their practice they have to make up for the missing days. In many countries in West Europe there is also a lack of GPs, and also in some countries in South East Europe similar situation is coming already. Who knows what will be in ten years? This is followed with more overloading of the rest GPs. Supposing that we - GPs are also human beings with our families: how can we coordinate all these professional expectations with our private life, with our families, with our hobbies to fill our»life batteries«? All these factors can sometimes make doctor to be»lost in the space«let me finish: Where am I now? Each of us has to put this question to himself and give an answer. How often should I ask myself? For example: once a year. Where do I want to go to? The answer is preparation of my personal life plan and personal education plan that should consider step by step solutions. Professional plan should be prepared according to my needs on the way to excellence considering also my limitations and challenges that are coming. Next step is to follow this plan and after some time to make an audit or evaluation of the results. And then next year is here. And where Europe is now - where SEE countries are now and where they want to go to? All professional organizations in each country should put this question to themselves and answer it by analysing the situation and their members' needs. The direction should be EURACT Educational Agenda. Finding the needs, next step is to plan and organize different effective educational events in order to support and help their members to fulfil their personal education plans. This is the way to my (our) excellence which is expected by my (our) patients, colleagues, politicians and least but not last certainly by myself (ourselves)

40 PANEL (Pa-) April 23, 200 / 0:45 2:5 / Hall A PANELS Violence in Family; the Europe and AGP/FM SEE (Aile içi fliddet; Avrupa ve Güneydo u Avrupa Aile Hekimleri ve Pratisyen Hekimler Birli i ) Moderators: Suzana Stankovic, Kurtulufl Öngel Leo Pas; Europe (Avrupa) Sabahat Tezcan; Turkey (Türkiye) Suzana Stankovic; SEE short report (Güneydo u Avrupa özet raporu) Prevalence and characteristics of domestic violence against women in Turkey, 2008 S. TEZCAN, F.H. TUNCKANAT Director of Hacettepe University Institute of Population Studies, Ankara, Turkey 2 Research Asistant at Hacettepe University Institute of Population Studies, Ankara, Turkey Introduction: Domestic violence againts women is a widespread problem experienced by all women of the world in all societies and various social groups though some variations exists in its prevelance intensity and types. The issue of domestic violance againts women has taken place in the international agenda and especially in the developed countries, with the efforts of women s movements which has become effective since 960. In the last 30 years, domestic violence againts women is being considered as part of the violations of human rights. Women experience various types and degrees of violance in their homes, where they should feel safe, however they are exposed to violance by the people they rely on such as their fathers, brothers, and especially their husbands/partners with whom they share their lives. In addition to its physical harms on women, domestic violence againts women causes loss of self confidence and self-respect, which forms unpleasent model for next generations and destroys the pyhsical and mental health of women and children. That is why, it is an important public health problem that stems from strong social and cultural basis. In Turkey, the issue of violence againts women has entered the agenda of the country through the struggle of the women s movement in the late 980 s. Since the 990s institutionalization accelerated, the Directorate General on the Status of Women (DGSW) was established under the Prime Ministry, woman research centers were formed in universities and the number of women nongovermental organizations increased. The issue of domestic violence againts women in Turkey has stayed on the agenda through the collabration and activities of all these institutions. In Turkey, besides the various local studies on domestic violence few national studies were conducted in recent years. The lack of data and prevalence and causes of violence againts women and how its perceived by people has been one of the most important factors impeding the development and implementation of national programs to combat violence. Thus National Research on Domestic Violence Against Women in Turkey of which the DGSW is the beneficiary institution, has been conducted by a three partner consortium consisting of ICON- Institut Public Sector, Hacettepe University Institute of Population Studies and BNB Consulting. The research, of which the Central Finance and Contracting Unit is the contracting authority, has been realized with the financial support of the European Commission. The aim of this study is to present the prevelance of domestic violence againts women in differenet forms and health consequences by using the results of quatitative study of National Research on Domestic Violence Against Women in Turkey,

41 National Research on Domestic Violence against Women in Turkey, 2008: The National Research on Domestic Violence against Women in Turkey is the first most comprehensive survey carried out on the domestic violence against women with a nation-wide representativeness, and with the most wide range sample providing information about violence against women on urban and rural settlements, 2 regions and some basic characteristics. Among the surveys done in the world on this subject is also the biggest survey with regard to the sample size and in the context of the method employed (face to face interview technique). As the quantitative phase of the research has been realized by adapting the questionnaire, which WHO has applied in many countries, the results enable us to make international comparison. With the research both the prevalence of the different forms of domestic violence against women has been revealed through the quantitative survey, and information about how women as well as men and some professionals perceive violence has been obtained through the qualitative research. The target population of the research in the 5-59 age groups in Turkey. It meets the need of data with the information it presents about the prevalence of the domestic violence women experience, the forms of violence, the reasons and results, the determination of risk factors and the perception of violence. The methodology of Research on Domestic Violence against Women in Turkey is designed in a way to ensure the gathering of data in the most reliable way possible, which is one of the basic requirements of combating against the issue. In the research, information about physical and sexual violence against women from perpetrators other than husband or intimate partner(s), and childhood sexual abuse has been collected as well. Reliable estimates of prevalences of different forms of violence have been obtained for national level, urban and rural settlements and 2 Region* by utilizing quantitative research methodology. The sample design for Research on Domestic Violence Against Women in Turkey utilized a weighted, stratified and multi-staged cluster sample approach. The major aim of the sample design was to achieve estimates of indicators related to violence against women for the national level as well as the 2 regions and urban/rural strata. In the quantitative study of the research a household questionnaire and a woman questionnaire were used. They were designed according to the requirements of the country, taking the questionnaires of the World Health Organization s Multi-country Study on Women s Health and Domestic Violence against Women into consideration. Information on Household population and housing characteristics of the households, background characteristics of women and marriage histories of women, general health and reproductive health, behavioral problems of children, background characteristics and behavioral patterns of the husband/partner, physical and sexual violence, emotional and economic violence/abuse experienced by women during lifetime and in the last 2 months prior to interviews, perpetrated by husband or intimate partner, physical and sexual violence against women by perpetrators other than intimate partners, after 5 years of age, sexual abuse before 5 years of age, attitudes of women towards gender roles and violence, violence during pregnancy and injuries due to violence and the methods of coping with violence by women who experience domestic partner violence were collected. In addition to these, respondents were shown cards with one smiling and one crying face on, and were asked to mark the appropriate one in order to understand whether they been subjected to sexual abuse before the age of 5. In the qualitative stage of the research is to get detailed information about attitudes, beliefs and experiences of women and men. Information on institutions that provide counseling and service to women who have been subjected to domestic violence has also been gathered which could not be obtained from the quantitative component of the research. Information obtained through qualitative research has not only given directions on questionnaire wording, but also has been analyzed. A combination of in-depth and semi-structured interviews and focus groups has been used in the qualitative research. *2 Regions; The NUTS (Nomenclature of Territorial Units) system is a statistical region classification determined for Turkey s accession to the European Union. There are three different NUTS levels. The 2 regions represent the NUTS level composed of stanbul, West Marmara Aegean,East Marmara, West Anatolia, Mediterranean, Central Anatolia, West Black Sea, East Black Sea, Northeast Anatolia, Central East Anatolia Southeast Anatolia

42 During the interviews conducted in Research on Domestic Violence against Women in Turkey, women were asked whether they had experienced certain acts of violence in order to be able to measure the violence the women are experiencing. These acts are: Physical violence against women by husband or partner(s): He slapped her or threw something at her that could hurt her He pushed or shoved her or pulled her hair He hit her with his fist or something else that could hurt her He kicked her, dragged her or beat her up He choked or burnt her on purpose He threatened to use or actually used a gun, knife or other weapon against her Sexual violence against women by husband or partner(s): He physically forced her to have sexual intercourse when she did not want to He had sexual intercourse when she did not want to because she was afraid of what he might do He forced her to do something sexual that she found degrading or humiliating Emotional violence/abuse against women by husband or partner(s): He insulted her or cursed her He belittled or humiliated her in front of other people He scared or threatened her He threatened to hurt her or someone she cared about Economic violence/abuse against women by husband or partner(s): He prevented her from working or caused her to quit her job He was not giving money for household expenses He deprived her of her income Physical violence against women by non-partners: She was beaten or physically mistreated in any way by anyone other than husband or partner, since the age of 5 years Sexual violence against women by non-partners: She was forced to have sex when she did not want to or to perform a sexual act which she found humiliating or degrading, by anyone (other than husband or partner) since the age of 5 years Childhood sexual abuse: She was exposed to an unwanted sexual act or to sexually disturbing touching before the age of 5 years. The women, who confirmed having been exposed to any of the acts, were asked more detailed questions on when and how frequent the act had happened. Regarding the timing of the act, two different periods were considered: any period in their life and the last 2 months preceding the interview. Findings: According to results of the research, 39 percent of women reported to have experienced physical violence at any time in their lives. In other words, 4 out of 0 women have been exposed to physical violence by their husbands or intimate partner(s). Although there is not a significant variation between type of residence at national level, there is significant variation between regions with regards to experiencing physical violence. The proportions of women experiencing physical violence vary between 25 and 53 among regions. Nearly out of

43 women living in the Northeast Anatolia region reported having been exposed to physical violence. When looking at the 2 months prior to the interview, countrywide in 0 women report physical violence in this recent period. *Source: National Research on Domestic Violence against Women in Turkey, 2008 The prevalence of sexual violence, like physical violence, displays a significant variation between regions. While in the West Marmara region 9 percent of married women reported sexual violence at any time in their lives, in the Northeast Anatolia region this is 29 percent. For the remaining regions the prevalence varies between and 23 percent. When looking at sexual violence in the last 2 months prior to the interview, we find that nationwide almost half of these women who reported sexual violence ever in their life, do report a recent experience of sexual violence. *Source: National Research on Domestic Violence against Women in Turkey, 2008 Injuries due to violence: In the National Research on Domestic Violence Against Women in Turkey 2008, women who have experienced physical or sexual violence from their husbands or intimate partner(s) have been asked questions about the injuries occurred due to that violence, the number, severeness and types of the injuries. According to Table, one fourth of the ever-married women have reported to have been injured as a result of the physical or sexual violence experienced in Turkey. This ratio is also similar in urban or rural settlements. When regarded according to regions it is seen that the prevalence of injuries due to violence varies between 7.7 percent (East Marmara) and 32.9 percent (Central Anatolia). The prevalence of injuries due to violence among the women living in the Central Anatolia, West Anatolia, Mediterranean and Northeast Anatolia regions is higher compared to women living in other regions. Nearly one out of three women who has experienced violence from her husband or intimate partner, has been injured as a result of the violence experi

44 enced. Whereas the prevalence of injuries due to physical or sexual violence experienced lifetime is 9.5 percent among ever-married women between the ages 5-24, it is 26.8 among the women between the ages This finding is related with the cumulative increase of lifetime violence experiences from husbands or intimate partners among women in the higher age group. The women who reported to have been injured due to the lifetime physical or sexual violence experienced from husband or intimate partner(s), have been asked how many times they were injured until the date of the research. In addition, information of whether any of these injuries were severe enough to require treatment was also obtained. Turkey, 57.6 percent of the women injured due to violence have reported to have been injured 3 or more times. One out of 5 women who have been injured due to violence has reported to have been injured more than 5 times (Table 2). Four out of 0 women who have been injured due to violence have reported to have been injured severe enough to require treatment at least once. The findings reveal that injuries due to violence are not coincidental, on the contrary that injuries occur frequently and in severe levels

45 When regarding the number of injuries due to the violence experienced with respect to the basic characteristics of women, it is seen that the number of injuries is lower among women with higher education and wealth level. While 43.5 percent of the women with no education/ have not finished primary school who have been injured due to violence have reported to have been injured more than 5 times, the proportion of women with an injury number of more than 5 among the women who have high school or higher education is 9.2 percent (Table 2). For all that, except the women with highest education, injury severe enough to require treatment at least once does not vary according to the education and wealth level of the women. *Source: National Research on Domestic Violence against Women in Turkey,

46 The injuries occuring due to acts of physical or sexual violence experienced lifetime occur in different forms. When regarding these forms of injuries, it is seen that in the whole of Turkey the injuries occur most commonly as scratch, graze or bruise (66 percent) and tear of eardrum, injury or blackening of eye (60 percent) (Figure 3). 7 percent of the women who have been injured due to violence have reported to have been injured in the forms of cuts or grazes, twisting, dislocation and cracks or cuts in the bones. The high prevalence of severe injuries among the forms of injuries also overlaps with the information collected within the scope of the qualitative research. Women have reported the violence experienced from their husbands or intimate partner(s) to be experienced in severe level during this research as well. More than 7 out of 0 injured women living in the Mediterranean, Northeast Anatolia and Southeast Anatolia regions have reported to have been injured in the form of scratch, graze or bruise, nearly 6 out of 0 injured women living in the other regions have reported to have been injured in a similar way. In injuries in the form of scratch, graze or bruise, a certain variation is seen according to the education level of women and the wealth level of the household they live in. *Source: National Research on Domestic Violence against Women in Turkey, 2008 In the National Research on Domestic Violence Against Women in Turkey, women who have at least one child in school age (between 6-4 ages) were asked whether any of those children were displaying behavioural disorders. The questions asked in relation to the behaviour of the child, were asked before the questions related to domestic violence experienced from husbands or intimate partner(s) so as to ensure to obtain answers without being under effect. In Figure 4, the proportion of behavioural problems of children of women who have experienced physical or sexual violence is given in the whole of Turkey. According to this, behavioural problems are more prevalent in children of women who have experienced violence, than in children of women who have not experienced violence. For example, while in the children of 4 out of 0 women who have experienced violence the behaviour of being aggressive towards the mother or other children is seen, this proportion reduces to half among children of women who have not experienced violence. Conclusion: When we focused on physical or sexual violence and general health, it is possible to observe that in Turkey as a whole, mentioning of health condition as bad or very bad is twice as common among women who have experienced physical or sexual violence in their lifetime, than it is among women who have never experienced violence. It is seen that this difference exists among women living in urban and rural areas. When regarding in the aspect of region lived in, women who have experienced violence in Northeast Anatolia, Centraleast Anatolia and Southeast Anatolia make negative evaluations about their general health conditions in a higher ratio, than women in other regions. The research has revealed that violence experienced from husband or intimate partner(s) has direct and indi

47 rect negative effects in many aspects on the health of women. As this research is a cross section research, except the injuries, it is not possible to determine whether experiencing violence is the direct reason of women experiencing certain health problems. Nevertheless, when the research findings are studied, it is seen that there may be a strong relation between women experiencing violence and showing symptoms of some physical and mental health problems. Also when the findings are studied according to the settlements and basic characteristics of women, consistent results are revealed indicating the presence of such a relation. Regardless of the settlement and basic characteristics of women, negative reporting about physical and mental health conditions among women who have experienced violence is nearly 2 or 3 times more prevalent than among women have not experienced violence. Likewise, some mental behavioural problems of children between the ages 6-4 whose mothers have experienced violence is seen more prevalent compared to children of mothers who have not experienced violence. Reference: Kad n n Statüsü Genel Müdürlü ü, 2009, Domestic Violence Against Women in Turkey (Türkiye'de Kad na Yönelik Aile çi fiiddet) ISBN: , KSGM Press. *** Family violence and violence in the partner relationships in the Region of Southeast Europe S. STANKOVIC Family violence is a complex and socially conditioned phenomenon, which has very serious consequences for the individual and at the social level. Coordinated action of medical, governmental and social institutions, as well as permanent education of the general population through media about the appearance of violence in the family, its consequences and the system of legal protection against violence, present the starting point in designing appropriate prevention and repression strategies against family violence. There are no official statistics about the volume and prevalence of family violence, due to failure in registration and report of cases, as committed criminal acts. Family Violence is an endemic phenomenon, and violence against women by their partners is something that cuts all cultural, religious and regional boundaries. For these reasons, the research in the Association of General medical and Family physicians of South East Europe has been organized, with the objectives to observe the representation of violence against women in partner relationship in the countries the members of the Association. During this study an unequal number of registered cases of violence was recorded.the number of patients involved in the studies from different countries, members of the Association was uneven, which was of course affecting the structure of collected data, but the question was, whether this was the only reason of the different prevalence of family violence in these areas? Is the violence in some areas represented in greater percentage, or the population has been sensitive for this problem and there was a greater willingness to speak about this problem? Of course, due to uneven number of patients who were included into study, the possibility of making certain conclusions was not present, but the results of this study are still determined to encourage reflection, sharing experiences and suggestions for standardization of protocols on treatment of victims of violence. During the study, subjects were declared the existence of psychological violence in the majority of all communities, regardless of the number of patients that were surveyed, followed by physical violence, sexual violence and the fear of partner. Different is the readiness of the examinee, to talk about the problem of violence, regardless of them being the victims of violence or not. If in the areas where the women are in a small percentage have come out with the existence of family violence, and at the same time they are in much smaller percentage and are ready to report this problem, to talk to someone. There is a general lack of support and understanding from society, for women the victims of family violence, or maybe the readiness to speak about is connected with the intensity and prevalence of violence in some areas. These questions and the relevance of the given results have been discussed at the round table of representatives of all countries participating in the research. We came to conclusion, it still

48 seems insufficient what has been done in all areas about understanding this problem. There is a large area of ignorance, misconceptions and prejudices among professionals which, within their institutions, should deal with the problem of violence, as well as the whole range of shortcomings in understanding their own role, in the relations and procedures with victims of violence. Although a large number of professionals in institutions that deal with the problem of violence is considering, that the detection and documentation of violence, their scope of work, not in any institution at the local level exist insufficient education on a given topic, as well as specific or well-planned strategy for handling cases of violence, and the problem of violence is left only to the individuals. Such approach does not ensure the necessary support to victims and collection of evidence from the perspective of the potential of taking legal action without the additional application of psychological pain that is secondary victimization of victims. For these reasons it is necessary to provide an adequate professional training to as many employees in these institutions actively and properly involved in the fight against gender violence qualifying. Education of professionals return the confidence into institutions. Training should include the core of the problem-definition, forms and scale of violence, its consequences on victims, how the perpetrators deny and reject responsibility, financial and social costs of violence, specific guidelines for treatment in case of violence, safety assessment and safety planning for victims. It is best if there are no institutional barriers in one area, and if people from these institutions can be linked and if necessary can make personal contact. The multi-sectoral approaches are not automatic and efficient. The prevention of violence will be effective only if the relevant organizations cooperate and coordinate their interventions in an efficient manner. The mediation is a necessary condition for cooperation between institutions and organizations responsible for solving the problem of family violence, exchange of information about competencies and ways of action, knowledge in the responsibility domain (who is addressing whom and what is the issue) always and precise definition of the competence of other institutions and organizations, which in our environment does not exist, and which can be resolved by drafting and signing of cooperation protocols, in which development will participate all representatives from all relevant institutions that have the will and competence to change the existing practice. In all countries, is still widespread opinion that this form of family violence is a private matter and that the state should not interfere, that the woman that causes the tension in the family or relation, and that she therefore deserves violence that occurred, and since women are expected to remain silent about violence because it is her shame and failure, she should remain in the relationship and suffer the violence, according to these opinions, family obligations take priority over the personal rights of women. Such extreme beliefs are often reflected and argumented, that staying in a violent relation is a need for the "welfare" of children. The conclusion at the round table that other factors affect the willingness of women to continue maintaining silence abusive relationship? Economic dependence, concern for children, the fear of escalation of violence if they charge the partner with violence, or fear that the violent partner will become even worse after the police leave, because the state did not create a system that would provide support to victims and facilitate the search and adequate help? Thus, women victims of violence have little hope for the possibility of survival outside of a violent community, feel helpless and hopeless because they have been blacmailed by partners, oppressive environment and the state, so they chose to stay silent. Despite that in the most countries, family violence is regulated by law sanctioning, a small number of family violence cases has been processed. Usually the problem of violence speaks only when extreme situations occur, the problem of violence at that moment becomes current, then it is forgeten until the next extreme cases. The question that arises whether or not and which country the member of the Association or Europe has an adequate response to this social problem that can serve as a model for others?

49 PANEL 4 (Pa-4) April 24, 200 / 09:5 0:45 / Hall A FM in SEE Management of FM Finance of the team need and reality (Güneydo u Avrupa da Aile Hekimli i, Aile Hekimli i ekibinin mali yönetimi, ihtiyaçlar ve gerçek durum) Moderators: Cahit Özer, Svetlin Mitev Azijada Beganlic Seracettin Çom Elif Altunbafl Slavoljub Zivanovic, Gorica Zafirovska-Pirovska Primary health care management in Serbia Finance management S. ZIVANOVIC General Practice Specialist & Gerontologist, Serbia The Bismarck Model of Health Care System Pay as much as you can and use as much as you need. Contributions to health care and gross national income have been on the rise in Serbia in the period Compared to other European countries contributions per capita in our country have been 282 EUR whereas in Switzerland it is 7000 EUR. Relations: Insured Health care providers Health care institutions Contributors Health Insurance Plan Provider Our goal is to accomplish the following results in health care management: Specific Measurable Achievable Realistic Time bounding At present time, we have the following: Health care centres with no information technology implemented Health care centres that are partially using some applications for specific services only Health care centres that are currently in system development phase Health care centres with information systems up to the level of Electronic Medical Records (EMR) in most services and that are covering most of the business processes Serbian health insurance plan provider has offered help in implementing EMRs. They have indicated what their vision of EMRs would be, however they will rely heavily on the feedback from the profession on how that EMR works in practice, so changes to it will be likely. There will be an open bidding for the project of EMR in Serbia. Once this final version has been selected and approved, the former EMR will be nulled. Since year 2007, health care centres in Serbia have been using an application of the Health Insurance Plan

50 Provider of Serbia, i.e. the Software for electronic invoice generation, and since 2008 the application for patient registration with preferred general practitioners, all of which is in accordance with the process of per capita payment implementation. Implementation of these applications will necessarily lead to the need for EMR introduction into the health care system in Serbia. The EMRs would systematically indicate all information relating to patients health problems, activities and outcomes, patient demographic and administrative information, as well as all services provided and other information management according to the Law of mandatory reporting of activities of the Republic Health Insurance Plan Provider (RHIPP). Electronic invoice A simple application has been provided to all health care centres in Serbia in the year 2007 and is constantly being improved. It enables individual data collection and also reporting to the Republic Health Insurance Plan Provider about the services provided for all insured individuals. This, in fact, represents invoice specifications that are directed from health care centres to RHIPP. Development of the Unique database of all insured Central Information Service system Improvement of the Primary Health Care system software Software developed within Primary Health Care System project Not used in all Health Care Centres EU projects Ministry of Health /European agency for reconstruction: A. Electronic Medical Records No issues with bylaws. B. Project of Implementation of payment per capita In collision with current bylaws. In the process of defining the per capita formula, RHIPP has proposed four categories to be used for classification of selected general practitioners, i.e. respective Health Care Centres. These categories would later on represent elements for contract stipulation between RHIPP and Health care centres through annexed labour agreements, which would subsequently lead to bylaw changes if adopted by the government (which is a long and complicated procedure, as well as uncertain) It is unclear who the employer would be: RHIPP or the Ministry of Health? Capitation Participation in total: Rationality 40% Efficiency 0% Prevention quality 0% Total 00% 70% of total income is fixed and the rest of 30% is assigned from the four categories (of per capita formula) The variable part of the income represents the essence of capitation and differentiates between the ones who work more from the ones who work less and also who perform better or worse Patient registration Firstly, there began a registration process of insured with a preferred physician All physicians have to register all of their patients again There is a large number of medical records in physicians offices, however only those patients who have signed the new registration forms count in. Other patients who rarely come are considered to have passive medical records and therefore do not count. Serbian average number of patients per physician is around 000. If a physician has less patients than Rationalization The average monetary value of the drugs prescribed per physician/insured is established by the RHIPP. Drugs that are exempted from this are: neoplasm, HIV, hormone growth drugs and other expensive drugs

51 There is a limited list of drugs in this category (suggestion was to exempt all drugs that have the acquisition price of 7,5 EUR or more) According to the capitation formula if physicians surpass their limit allowed by the RHIPP, there is a repercussion in form of income reduction New physician ID numbers Every physician will be reimbursed according to contract stipulated with RHIPP and each physician has to have his/her own records archive or be associated with someone who has one. This introduces more practice order and work integrity. Evidence of number of patients will be retained at the RHIPP and every physician will have access to their Electronic database and the coefficient (calculated in the formula), however the ratio between income and performance will not be evident Efficiency Represents ratio between Completed to Agreed on Completed is the norm for the Institute for Public Health RHIPP calculates expenditure based on real number of working days and hours Prevention-Quality Number of preventative versus the total number of examinations at institution level, and also for every physician separately. This is the future! Lower limit of number of examinations will be established, there will be no credits awarded below this limit There is no upper limit for the number of examinations Corrective factor according to patient population: 0- year of age 3,00-6 years of age, years of age 0, years of age 0, years of age, years of age 2,20 over 75 years of age 3,00 Number of patients registered with a preferred physician is in accordance with article n. 24 of the Book of regulations on conditions and proceedings in mandatory health insurance. For ranking physicians with respect to patient registration, we have used the number of registered patients compared to number of health insurance cards issued in the community to which that specific health care centre belongs In general practice, there is a shortage of 4,5% physicians and surplus of 4,7% nurses. Every month we have: insured health care workers services provided prescriptions filled various data Literature:. Vukasin Radulovic, Mech.Eng., Republic Health Insurance Plan Provider, Capitation, first step (Republic Institute for Health Insurance ) 2. Patient s electronic medical record in primary health care - Serbia Recommendation for capitation formula in primary health care in the Republic of Serbia 4. Benefits of Electronic health care in Serbia 5. Book of regulations on conditions and proceedings in mandatory health insurance

52 PANEL 5 (Pa-5) April 24, 200 / 6:45 8:5 / Hall A Hypertension at goal in SEE new guidelines (Güneydo u Avrupa da hipertansiyon tedavisindeki hedefler ve yeni klavuzlar) Moderators: Murat Ünalacak, Dean Klancic smet Tamer; Introduction : How to make guidelines? (Girifl : Klavuzlar nas l haz rlanmal?) Suzana Stankovic; Comparison (Karfl laflt rma) Lubomir Kirov; Implementation (Uygulama) Recommendations for antihipertensive treatment S. STANKOVIC The importance of the risk profile assessment and determination of the range values of blood pressure. What are the values of blood pressure that will affect our decision to start pharmacological therapy? It was considered, in the beginning that the diastolic blood pressure, better indicator for the occurrence of cardiovascular disease and depending on the values of diastolic blood pressure the starting point for antihypertensive therapy was determined. Framingham Heart Study showed that systolic blood pressure is a better indicator of cardiovascular risk, and a number of researchers advocated that antihypertensive therapy should be started if the values of systolic or diastolic blood pressure, or both at the same time, were elevated above 40/90 mmhg. Today in diabetics, and people with cerebrovascular diseases, coronary or disease of peripheral arteries, the group with higher range values or normal values of arterial blood pressure, gets a higher importance, which is why the new criteria for the diagnosis of arterial hypertension, means continuous scrolling of borders of recommended values, which is very important primarily from the standpoint of the early start of the treatment and prevention of complications of the disease (diabetes <30/85, kidney disease with proteinuria <25/75). Lately, modern epidemiology has focused the research on early detection of predictors and risk factors for arterial hypertension, which independently or jointly, violate the general biological balance of the body, reduce the adaptive capacity and create conditions for the occurrence of the disease. In the world as well as here the numerous studies, have pointed out to the fact that by preventing or eliminating of one or more modified risk factors, can prevent or control this disease. Also, the literature data, indicate that the values of blood pressure, systolic and diastolic, depend on both the number and combination of risk factors, which creates the person with so-called risk profile for the occurrence of certain diseases, and that the presence of one can contribute to reducing or increasing the effects of another. According to the basis of this approach, a theory about risk factors for arterial hypertension has developed, because the results of numerous studies clearly showed that the length and quality of life is closely related to healthy lifestyles, actually with the elimination or reduction of risk factors, by the number and type. For these reasons, patients with these values of blood pressure on low or moderate risk requiring monitoring and reduction of other risk factors that may be present and may lead to the development of hypertension. The attitude of most researchers is that the non pharmacological treatment should be used, in individuals, who have not yet developed cardiovascular disease and other risk factors with higher normal rate of blood pressure or arterial hypertension. Timely application of non pharmacological therapy in risk groups may prevent the occurrence of arterial hyper

53 tension, and in individuals with high blood pressure reduced the number and dose of antihypertensive medication. If non pharmacological therapy does not regulate arterial blood pressure and hypertension exceeds into the higher category, the next step would be pharmacological therapy. The doctor makes decision when to start with pharmacological therapy. In the theory about risk factors, was precisely set forth the harmful habits that can affect, and how, and what factors are the subject to modification and therapeutic intervention. However, whether the non pharmacological therapy, elimination of the present modified risk factors can reach the desirable value, when they are found alone or in different combinations in people with these values of blood pressure? This question has been imposed during past years, because a group of patients with these values of blood pressure has been particularly interesting, because usually from that group, further on, are recruited people with hypertension. To get the answer to this question, on the territory of Serbia, the research has been conducted, which defined and ranged the blood pressure borders (blood pressure values that can be eliminated by the present modified risk factors and may lead to recommended limits). The guidelines have been provided in addition to high blood pressure and risk profiles of patients, taking into consideration the limits of blood pressure. Today, the decision to start antihypertensive therapy is based on two criteria: a levels of systolic and diastolic blood pressure as well as the total levels of overall cardiovascular risk, so the goal of antihypertensive therapy is to achieve good control of blood pressure and reduction of present risk factors in order to decrease cardiovascular risk. For these reasons, before making a decision about the way of treatment, all patients should be classified according to the values of blood pressure and overall cardiovascular risk, which comes from the coexistence of different risk factors, damage in target organs and added diseases. In all blood pressure degrees, should be recommended a healthy lifestyle and a way of life whether the hypertension has been diagnosed or suspected, while the introduction of pharmacological therapy depends on the level of total risk. In patients without a damage in targeted organs and without addition of other clinical serious illness (from the group of vascular diseases), in which, according to the current recommendations, the delay in use of pharmacological therapy or its intensification has been allowed, according to the border ranges of blood pressure (blood pressure values that can be eliminated by the present modified risk factors and may lead to recommended limits) that can be determined for each patient in Wirt-SAT program. When the decision about the beginning of pharmacological therapy has been made, treatment can start with any medicine from the antihypertensive group: thiazide diuretics, calcium, ACI, antagonists of angiothensin receptors or ß blocker, alone or in various combinations. ß blockers should not be used in combination with diuretics in patients with metabolic syndrome or patients with high risk for diabetes. In patients with heart failure use of alpha blockers is limited, and alpha blockers are no longer drugs of first choice because of complications - the development of cardiac weakness. Which the group or combination of drugs will be recommended depends on: previously used groups of drugs and therapeutic response, the presence of additional risk factors and drug effects on them, the damage of target organs (cardiovascular disease, kidney disease or diabetes), the presence of other diseases that can restricts the use of drugs, the possibility of interactions with other used drugs, the cost of the treatment, adverse effects of the drug and the degree of blood pressure reduction

54 PANEL 6 (Pa-6) April 24, 200 / 09:5 0:45 / Hall C The new face of influenza, HN : The anatomy of a pandemic (Gribin yeni yüzü HN: Bir pandeminin anatomisi) Moderators: Hüseyin Avni fiahin Selim Badur; Growth of the pandemic-vaccines (Pandeminin geliflimi-afl lar) Gaye Usluer; Clinic of HN, treatment, usage of antivirals (HN klini i, tedavi, antivirallerin kullan m ) Gribin yeni yüzü HN: Bir pandeminin anatomisi - Yaflananlardan ç kart lacak dersler S. BADUR Istanbul Üniversitesi stanbul T p Fakültesi, Mikrobiyoloji ve Klinik Mikrobiyoloji Anabilim Dal, stanbul, Türkiye 2009 y l n n nisan ay nda önce Meksika da, daha sonra ABD de yeni bir solunum yollar enfeksiyonu salg n n n ortaya ç kt bildirilmifl; k sa sürede söz konusu tablodan sorumlu olan etkenin insanlarda o güne dek saptanm fl olanlardan farkl bir antijenik yap ya sahip yeni bir Influenza alt-tipi oldu u belirlenmifltir (, 2). O dönemden günümüze dek geçen sürede, Dünya Sa l k Örgütü (DSÖ) Haziran 2009 tarihi itibar yla söz konusu pandeminin 6. evrede oldu unu ilan etmifl; enfeksiyonun birçok ülkede h zla yay ld görülmüfl; hastal ktan kaybedilenlerin say s binlerle ifade edilmeye bafllanm fl ve nihayet k sa sürede onay alan afl lar kullan ma girmifltir. Yeryüzünde tüm bu geliflmeler sürerken ülkemizde domuz gribi olarak tan mlanan salg n konusunda her önüne mikrofon uzat lan n yorum yapt na, bilimsellik d fl polemiklerin uzad kça uzad na ve bu önemli sa l k sorununun siyasi flova, magazinsel tart flmalara dönüfltü üne flahit olduk. Kimilerine göre söz konusu alarm ortam, DSÖ ile ilaç/afl üreticilerinin iflbirli i sonucu yarat lm fl yapay bir geliflmedir; bu tür yaklafl mlarda bulunanlar, savlar n, ben inanm yorum..., benim düflünceme göre... fleklinde bilimsellikle ba daflmayacak biçimde dile getirmektedirler. Bilimsel verilere dayan larak aktar lmas gereken do rular yerine, bireylerin kendi kiflisel inançlar n ya da düflüncelerini, konu ile ilgili do rular fleklinde dile getirmeleri sa l kl ve bilimsel sorumlulukla ba daflan bir yaklafl m de ildir. Ülkemizde bir süredir gözlenmekte olan ve bilgi kirlili ine yol açan tart flmalar n oda n pandemi kavram oluflturmaktad r. K saca k talar aras salg nlar olarak tan mlanan pandemiler, bir dizi nedene ba l olarak orta ya da fliddetli hastal k fleklinde seyredebilir, ölümlere yol açabilir ve fliddeti dinamik biçimde zaman içinde de iflim gösterebilir. Geçmifl deneyimler, pandemilere karfl al nacak önlemlerin en kötü senaryoya göre planlanmas n gerektirmektedir. Sonuçta pandeminin öngörülenden daha az hasar yaparak atlat lmas, gördünüz mü, ben demifltim, konu abart lm fl diyenlerin hakl l n de il, al nan bir dizi önlemin (afl laman n yan s ra bireysel hijyen önlemlerinin artt r lmas, gerekti inde okullar n tatil edilmesi gibi) ifle yarad n n göstergesi olarak kabul edilmelidir pandemisinin özellikleri 2009 pandemisinin ilk aylar nda olgular n büyük ço unlu unun hafif seyirli bir hastal k tablosu gösterdi i, genellikle bir hafta içersinde anti-viral tedavisi olmadan da iyileflmenin söz konusu oldu u gözlenmifl; bu durum nedeniyle DSÖ, temmuz 2009 döneminden bafllayarak olgular n say m n n ve tek tek dökümlerinin yap lmas n n gereksiz oldu unu duyurmufltur. Klinik belirtiler genel anlamda mevsimsel gribe benzemekte ve pandemik sufl ile enfekte olan hastalar n ço unda semptomlar hafif seyretmektedir. Nitekim.000 olgudan ancak 2-3 ünde yo un bak m gerektirecek flekilde tablonun a rlaflt hesaplanm flt r. Ancak pandemik grip için mortalite oran n gerçekçi biçimde hesaplamak kolay de ildir; bunun bafll ca nedeni, kontamine bireylerin bir bölümünde semptomlar n oluflmamas sonucu, enfekte birey say s n n tam olarak bilinmemesidir. Öte yandan, Influenza virüsleri ve genel anlamda pandemilerin özellikleri dikkate al nd nda, bafllang çta do ru kabul edilen baz bilgilerin k sa sürede süratle de iflmesi flafl rt c olmaz. Nitekim ilk günlerde daha masum olarak

55 stanbul T p Fakültesi-Viroloji ve Temel mmünoloji Bilim Dal -Ulusal Influenza Referans Laboratuar -Çapa, stanbul. de erlendirilen pandemik grip olgular n n en az ndan bir bölümünün, zaman içinde daha a r seyretme e iliminde olduklar gözlenmifltir. Özellikle hem ülkemizden hem de farkl co rafyalardan bildirilen bu tip olgular n ortalama %30 unda bilinen klasik risk özellikleri bulunmamaktad r. Bu durumda sa l kl görünen çocuklar n ani geliflen solunum yetmezli i tablosu ile hastaneye kald r lmalar na ve baz lar n n yaflamlar n yitirmelerine s kl kla rastlanmaktad r. Örne in ABD de yap lan hesaplamalara göre yo un bak m gerektiren olgular n %7 sinin (3), bir di er çal flmada ise hospitalize olgular n %6 s n n kaybedildi i saptanm flt r (4). Yaflam n yitiren hastalar n akci er patoloji bulgular nda, trakeabronfliyal epitelyum tabakas n n yan s ra, alveoler epitelyum hücreleri ve makrofajlarda da viral antijenin varl bildirilmifl; yayg n alveoler y k m, akci erlerde ödem ve hemoraji saptanm flt r (5). Bu tablo 98 pandemisindeki görüntülere çok benzemektedir. Pandemik HN virüsünün, mevsimsel grip etkenlerinden farkl olarak, buna karfl n kufl gribi etkeni olan H5N virüsünde görüldü ü gibi alt solunum yollar na yerleflti i; mevsimsel grip etkenlerinin, Influenza virüslerinin hücrelere tutunma bölgeleri olan sialik asit glikoproteinlerinden üst solunum yollar ndaki 2-6 y kullan rken, pandemik HN in alt solunum yollar nda bolca rastlan lan 2-3 yap s ndaki reseptöre ba land kan tlanm flt r (6). Patogenezde önemli olan bir di er önemli bulgu, grip sonras ortaya ç kan pnömonilerin özelli idir. Mevsimsel grip olgular n n %30 unda S. aureus ya da S. pneumoniae bakterilerinin etken oldu u sekonder enfeksiyonlar söz konusudur. Nitekim 98 spanyol pandemisinde gözlenen ölümlerin büyük k sm bu tip koenfeksiyonlara ba l d r. Buna karfl n pandemik HN olgular nda virüsün kendisinin de letal viral pnömoniye neden oldu u saptanm flt r. Gelinciklerde ve farelerde yap lan patogenez çal flmalar nda pandemik HN virüsünün mevsimsel grip etkeninden daha patojen oldu u; solunum yollar ndaki replikasyonunun daha güçlü oldu u; nazal kavite d fl nda trakea, bronfllar ve bronflioller gibi farkl akci er bölgelerinde de ço alabildi i ve nihayet virüs ç kar m n n daha yo un oldu u saptanm flt r (7). fiu an için insanlarda ba fl kl n bulunmad yeni bir virüs söz konusu oldu undan enfekte olacak kiflilerin say s n n fazla olmas do ald r. Bu durumda pandeminin boyutunu vurgulamak için sadece yaflam n yitirenlerin say s na bakmak yan lt c olabilir. Çok say da insan n hastalanmas sonucunda hastanelerin dolup taflmas, sa l k sisteminin bir anda kilitlenmesi, solunum cihazlar ve reanimasyon merkezlerinin yetersiz kalmas kaosa neden olabilir. Kanada verilerine bak ld nda bugüne dek geçen süreçte pandemik HN enfeksiyonlar için: ortalama inkübasyon süresi 4 gün, semptomlar n devam etti i süreç ise ortalama 7 gün olarak hesaplanm flt r. Ayr ca olgular n hastaneye kald r lma oran %4,5, olgu/ölüm oran %0,3 belirlenmifl ve simülasyon denklemlerine dayanarak Ro de eri,3 olarak hesaplanm flt r (8). Bu de erler flu an için salg n n l ml seyretti in göstergesi olmas na karfl n, virüsün de iflkenlik özelli i göz önüne al narak önlemlerin bir süre daha devam etmesi uygun bulunmaktad r. Asl nda yaflamakta oldu umuz pandemi sorununun gerçek boyutunu, büyük olas l kla pandemi sonland ktan sonra, ilkbahar aylar nda daha net biçimde de erlendirmek mümkün olacakt r. K sacas, gelecekte ne olaca n, gelecek günler bizlere gösterecektir. Tart flmalar n oda : pandemi kavram 2009 salg n n pandemi olarak tan mlamak uygunmudur? yoksa konu yapay biçimde abart lm flm d r? Bu sorular n yan t n ararken, asl nda bilim dünyas n n da pandemi tan m n tart flt n görmekteyiz. Baz kesimler salg n n yay l m sürati ve boyutunun pandemi ilan için belirleyici oldu unu söylerken; di erleri salg n s ras nda oluflacak hasar n boyutunun ve enfeksiyonun nas l seyir gösterdi inin, tan mlama için dikkate al nmas gerekti ini öne sürmüfllerdir. Ancak günümüzde, pandemi kavram için: etkenin farkl co rafi bölgelere süratle da lmay sa layacak bulaflt r c l a sahip olmas, patlar tarzda yüksek atak h z ile karakterize yay l m özelli inin varl, söz konusu etkenin yeni bir antijenik yap ya sahip olmas ve genelde bu yeni tipe karfl toplumda ba fl kl n bulunmamas gibi kriterler aranmaktad r (9). Bu durumda söz konusu salg n n oluflturaca hasar ve hastal n seyrinin tan mlama için gerekli bir özellik olmad görüflü a r basmaktad r. Böylece, genel anlamda insanlar n

56 ba fl k olmad ve 200 y l bafl nda toplam 207 ülkeden bildirildi i düflünüldü ünde, süratle yay l m özelli ine sahip 2009 salg n n pandemi olarak tan mlamak abart l ve yanl fl bir yaklafl m de ildir (0). Pandemi etkeni nas l ortaya ç kar? Pandemi etkeninin yeni bir virüs tipi olmas gerekti i noktas ndan hareketle, söz konusu yeni yap n n nas l ortaya ç kt birçok araflt r c taraf ndan irdelenmifltir. 20. yüzy lda üç önemli grip pandemisinin t p kay tlar na geçti i bilinmektedir: 98, 957 ve 968 pandemileri. Bunlar aras nda en büyük y k m n 98 y l nda görülen salg n süresince yafland ve bu nedenle baz araflt r c lar taraf ndan 98 pandemisinin, daha sonra görülenlerin kayna oldu u kabul edilmektedir (). Bugün 98 de ortaya ç kan etkenin nereden kaynakland, üç dalga halinde seyreden pandemi sürecinde hep ayn suflun etken olup olmad, etkenin insanlara hangi konaktan bulaflt, patojenitesinin mekanizmalar, neden özellikle genç eriflkinlerde ölümcül oldu u ve nihayet ayn etkenin tekrar sorun yarat p yaratamayaca sorular n n yan tlar n k smen de olsa biliyoruz. Kanatl lardan insana adapte oldu u kabul edilen ve bir Influenza A/HN alt-tipi oldu u saptanan 98 pandemisi etkeni, sonraki y llarda baflka bir kanatl suflu ile harmanlanarak üç yeni gen edinmifl ve 957 de etken olan H2N2 pandemisine neden olmufltur. ki farkl genin devreye girdi i baflka bir harmanlanma ise 968 y l n n H3N2 pandemisine yol açm flt r. Tüm bu geliflmeler, Influenza virüslerinin yo un de iflim yetenekleri ve kolayl kla harmanlanma özelliklerine ba l olarak ortaya ç kmaktad r. Bu özelliklerinin bilinmesine karfl n yeni bir pandeminin nas l, nereden, hangi özelliklerle ve ne zaman ortaya ç kaca n kestirmek mümkün de ildir. Üstelik hiçbir pandemi bir ötekini taklit etmez ve özellikleri birbirine benzemez. Nitekim 950 lerde pandemilerin her y lda bir ortaya ç kaca na inan l rken, 957 ve 968 pandemileri bu görüflün do ru olmad n kan tlam flt r. Sonuçta major Influenza salg nlar n n öngörülebilir bir döngüsel süreç izlemedi i anlafl lm fl; ayr ca bu tip salg nlar n nas l seyrettiklerini kestirmenin mümkün olmad kabul edilmifltir (2). Pandemi sonras olas geliflmeler Bu güne dek yaflananlar, pandemiyi izleyen dönemde söz konusu etkenin mevsimsel grip etkeni olarak varl n bir süre daha korudu unu göstermektedir. Elbette bu tip bir geliflme ilk salg n s ras nda toplumda oluflacak immünite oran ile ilintilidir. Ancak 20. yüzy lda yaflanan üç pandemi sonras nda, sorumlu etkenlerin interpandemik dönemlerde bir süre varl klar n koruduklar ve zaman içinde ortamdan çekildiklerini saptanm flt r (3). Bu deneyimlerden hareketle 2009 pandemisi etkeninin 200 y l nda mevsimsel grip olarak karfl m za ç kaca n söylemek flafl rt c olmamal d r. Bu yaklafl mdan hareketle 2009 pandemisinin prototipi olan A/California/7/2009 suflunun, 200/ sezonu mevsimsel grip afl s içine eklenmesi uygun görülmüfltür. Ancak bu geliflme d fl nda gelecek influenza sezonunda bizleri neyin bekledi ini, Influenza virüslerinin ne tür sürprizler haz rlad klar n öngörmenin mümkün olmad n biliyoruz. Bu arada tüm yaflananlar n deneyim kazanmam z ve eksikliklerimizi belirlememizi sa lad yads nmaz bir gerçektir. Pandemilere haz rl kl olmam z n en önemli aflamalar ndan birisi interpandemik dönemlerde sürdürülen sürveyans çal flmalar ndaki baflar d r (4). Ülkemizdeki iki referans laboratuar (Ankara-Refik Saydam H fz s hha Enstitüsü ve stanbul- stanbul T p Fakültesi) mevsimsel grip için sürdürdükleri sürveyans çal flmalar kapsam nda elde ettikleri deneyimlerden 2009 pandemisi sürecinde yararlanm fllar; etkenin izolasyonu, tan, mutasyon analizleri ve seroloji alanlar nda hizmet vererek pandeminin izlenmesinde önemli görevler üstlenmifllerdir. 200 ve gelinen nokta 200 y l ocak ay n n ilk günlerinde birçok Avrupa ülkesinde oldu u gibi, ülkemizde de pandemik HN olgular n n say s n n ani bir düflüfl gösterdi i yads nmaz bir gerçektir (5). Ancak etken virüslerin özelliklerine ve geçmifl pandemilere ait deneyimlere bakt m zda henüz son sözün söylenmedi ini öngörebiliriz (6). Mevsimsel-pandemik grip kavramlar n n k yaslanmas ve biri di erine göre daha m ölümcül sorusunun tart fl lmas, bilimsel aç dan do ru bir yaklafl m de ildir. Her iki salg n tipinin özellikleri farkl d r. Örne in mevsimsel grip kuzey yar mküredeki ülkeler için sonbahar aylar nda söz konusu olur iken, pandemik grip mevsimsel ay r m gözetmez. Nitekim umulan n aksine, HN yay l m kuzey yar mkürede yaz aylar nda da devam etmifl ve sonbahar n gelmesi ile ivme kazanm flt r. Öte yandan her iki grip türünün etkili oldu u yafl gruplar belirgin bir farkl l k göstermektedir; örne in mevsimsel grip için risk grubu olarak kabul edilen 65 yafl

57 üstü bireylerde pandemik gribin az görüldü ü; buna karfl n HN sorununun a rl kl olarak 5-35 yafl grubundan eriflkinlerde ve gençlerde ortaya ç kt görülmektedir. Ve nihayet pandemik grip nedeniyle yaflam n yitirenlerin yaklafl k %30 unda herhangi bir risk faktörü bulunmazken, böyle bir geliflme mevsimsel gripte gözlenmemektedir. Bugün gelinen noktada pandemik gripten yaflam n yitirenlerin say s laboratuar bulgular ile do rulanm fl olgular yans t rken, mevsimsel gripten kaybedilenlerin say s ancak belirli risk gruplar ndaki ölüm oranlar nda grip sezonu boyunca gözlenen art fllara bak larak yap lan hesaplamalara dayanmaktad r. Matematiksel olarak mevsimsel ve pandemik gribin mortalite oranlar çok farkl olmasa da, pandemi etkeninin çok daha fazla insan enfekte etmesi nedeniyle göreceli olarak ortaya ç kacak hasar daha a r olacakt r. Bu nedenle hangi tip salg nda kaç kifli öldü, hangisi hangisinden daha ölümcüldür hesaplamalar da do ru bir yaklafl m de ildir; bilim insanlar farkl salg n türlerini yar flt rmak yerine kan ta dayal verilerden hareketle bugün için sorun yaratan pandemiyi daha iyi anlamaya, ö renmeye ve çözüm üretmeye yönelik çal flmalar yapmal d r. Gelinen noktada pandeminin oldukça az hasarla atlat ld görülmektedir ve elbette bu durum sevindirici bir geliflmedir. Ancak konu ile ilgili bilimsellikten uzak tart flmalar n toplum genelinde uluslararas ve yerel sa l k otoritelerine karfl bir güvensizlik yaratm fl olaca ndan endifle edilmektedir. Sorumsuzca yap lan suçlamalara ilave olarak, sa l k otoritelerinin ald klar kararlarda afl üreticilerinin bask s n n etkili oldu u söylevleri, ya da ö rencilerin afl lanmas için velilerden onam formu istenmesi gibi uygulamalar afl lanma oranlar n n düflük düzeylerde kalmas na yol açm flt r. Sonuç olarak 2009 y l nda dünyada gerçek bir pandemi yaflanm flt r. Sa l k otoritelerince pandemiye karfl al nacak önlemler bellidir ve tüm ülkelerin sa l k yetkilileri olas bir kötü senaryoya karfl evrensel önlemleri uygulamak için yo un çaba göstermifllerdir. Pandeminin hafif atlat lmas al nan önlemlerin yersizli i olarak de erlendirilmemeli ve toplumda gelecekteki olas bir dizi sa l k sorununa karfl al nacak önlemler konusunda güvensizlik yarat lmamaya özen gösterilmelidir. Kaynaklar - Zimmer SM, Burke DS. Historical perspective-emergence of Influenza A (HN) viruses. N Engl J Med 2009;36: Trifonov V, Khiabanian H, Rabadan R. Geographic dependence, surveillance, and origins of the 2009 Influenza A (HN) virus. N Engl J Med 2009;36: Jain S, Kamimoto L, Bramley AM, et al. Hospitalized patients with 2009 HN Influenza in the United States, April-June N Engl J Med 2009;36: Reed C, Angulo FJ, Swerdlow DL, et al. Estimates of the prevalence of pandemic (HN) 2009, United States, April-July Emerg Infec Dis DOI:0.320/eid Gill JR, Sheng ZM, Ely SF et al. Pulmonary pathologic findings of fatal 2009 pandemic Influenza A/HN viral infections. Arch Pathol Lab Med 200;34: E. 6- Childs RA, Palma AS, Wharton S et al. Receptor-binding specificity of pandemic Influenza A (HN) 2009 virus determined by carbohydrate microarray. Nature Biotech 2009;27: Itoh Y, Shinya K, Kiso M et al. In vitro and in vivo characterization of the new swine-origin HN Influenza viruses. Nature 2009;460: Tuite AR, Greer AL, Whelan M et al. Estimated epidemiologic parameters and morbidity associated with pandemic HN influenza. CMAJ DOI:0.503/cmaj Morens DM, Folkers GK, Fauci A. What is pandemic? J Infect Dis 2009;200: McConnell J. Pandemic influenza: learning from the present. Public Health 200;24: 3. - Taubenberger JK, Morens DM. 98 Influenza: the mother of all pandemics. Emerg Infect dis 2006;2: Taubenberger JK, Morens DM, Fauci AS. The next influenza pandemic. Can it be predicted? JAMA 2007;297: Metgews JD, Chesson JM, McCaw JM, McVernon J. Understanding influenza transmission, immunity and pandemic threats. Influenza Other Res Viruses 2009; 3: Monto AS, Comanor L, Shay DK, Thompson WW. Epidemiology of pandemic influenza: use of surveil

58 lance and modeling for pandemic preparedness. J Infect Dis 2006;94(Suppl 2): S WHO. Pandemic (HN) 2009-update Jackson C, Vynnycky E, Mangtani P. Estimates of the transmissibility of the 968 (Hong Kong) influenza pandemic: evidence of increased transmissibility between successive waves. Am J Epidemiol 2009; DOI:0.093/aje/kwp394. *** Gribin yeni yüzü HN: Bir pandeminin anatomisi Gaye USLUER Eskiflehir Osmangazi Üniversitesi T p Fakültesi, Mikrobiyoloji Anabilim Dal, Eskiflehir, Türkiye Domuz influenza(hn) virusu yeni bir influenza A virusu olup, 4 farkl genetik element içermektedir. Bunlar domuz, insan, kufl ve Avrupa-Asya domuz (Eurasian swine) viruslar na ait genetik komponentlerdir. Meksika da bafllayan pandemi h zla ABD ne ve sonras nda tüm dünyaya yay lm flt r. Meksika da bafllang ç yay l m turistler ve ülkeler aras seyahatler arac l yla olmufltur. Di er influenza A pandemilerinde oldu u gibi, ilk dalgada herald wave (ilkbahar sonu ve yaz) çok say da kifli hastalanmas na ra men iliflkili ölüm say s az olmufltur. Letal seyirli domuz influenza (HN) pnömonisinden özellikle genç eriflkinler ve sa l kl kifliler etkilenmifltir. Epidemik influenzadan farkl olarak pandemideki ölümlerin ço unlu unun genç ve sa l kl eriflkinler olmas da dikkati çekmifltir. HN pandemisinde klinik bulgulara bak ld nda hafif ve orta fliddette seyreden olgularda di er solunum viruslar n n oluflturdu u hastal ktan farkl bulgular görülmemifltir. Kuzey yar m kürede influenza için pik insidans fiubat ay olmas na karfl n; pandemide influenza mevsiminin erken bafllamas nedeniyle k fl bafl nda salg n sona ermifltir. Pandemik influenzada da atak h z yüksek olmufltur. Mortalite ise daha düflük olup, özellikle patojenitesi daha fazla olan virulan sufllarla olufltu u dikkati çekmifltir. Pandemide eriflkin hastalarda, ciddi seyirli influenza A enfeksiyonu farkl klinik tablo oluflturmufltur. Pandemide görülen viral pnömoni di er etkenlerle kar flmayacak farkl bir flekilde karfl m za ç km flt r. Ayn SARS, hantavirus pulmoner sendromu (HPS), ve adenovirus enfeksiyonlar nda oldu u gibi, ciddi influenza A pnömonisi ani bafllang çl seyir göstermifltir. 39 C üzerinde atefl, ve titremeyle ciddi kas a r lar, hemoptizinin efllik etmedi i kuru öksürük bafll ca bulgular olmufltur. Bu bulgulara purulan balgam n ilave olmas durumunda ise toplum kökenli sekonder bakteriyel pnömoni düflünülmüfltür. Toplum kökenli pnömoni geliflen olgularda en s k rastlan lan etkenler MSSA/TK-MRSA, ile pnömokoklard r. Hastalar n bir bölümünde özellikle yafll hastalarda Streptococcus pneumoniae veya Haemophilus influenzae iliflkili TKP iyileflme döneminde 2 haftada ortaya ç km flt r. Pandemik influenza mevsimsel influenzadan farkl olarak çok genç yada yafll kifliler ile immündüflkün kifliler yerine sa l kl genç eriflkinleri etkilemifltir. Fatal olgular nda ço u bu grupta görülmüfltür. Pandemik influenzada özgül olmayan çeflitli laboratuvar test bozukluklar görülmüfltür. Çocuklarda lenfositoz daha s k görülürken, eriflkinlerde rölatif lenfopeni ile birlikte trombositopeni görülmüfltür. Özellikle uzun süreli lökopeni ve lenfopenisi olan hastalarda klinik seyir daha a r olmufltur. Radyolojik olarak bafllang çta minimal infiltrasyonu takiben, sonras nda (>48 saat) bilateral yama tarz nda interstisyal infiltrasyon görülmüfltür. Bafllang çta fokal segmental / lober infiltrasyon olan hastalarda efl zamanl bakteriyel TKP düflünülmüfltür. Bu hastalarda pürülan balgam, yüksek atefl ile birlikte s kl kla siyanoz / hipotansiyon görülmüfltür

59 Gastrointestinal semptomlar (bulant, kusma, veya ishal) s k görülmüfltür. Hastalar n bir bölümünde serum aspartat ve alanin transaminazlarda (AST/ALT) hafif ve geçici yükselmeler görülmüfltür. Di er önemli bir laboratuvar parametre kreatinin fosfokinaz (CPK) art fl d r. CPK düzeyleri çok yüksek olan hastalarda rhabdomyolizis görülmüfltür. Tedavi Günümüzde influenza tedavisinde kullan lan antiviral ilaçlar zanamivir ve oseltamivirdir. Her iki ilaç hastal n süresini k saltmakta, semptomlar n fliddetini azaltmaktad r. Oseltamivire karfl son y llarda artan direnç önem tafl makta olup, üzerinde durulmas gerekn bir konudur. nfluenza tedavisinde Oseltamivir genellikle 5 gün kullan lmaktad r. Ancak pandemide ciddi olgularda tedavi 0 güne kadar uzat lm flt r. Di er önemli bir husus süreçte antivirallerin özel gruplarda al fl lm fl dozlarda kullan ld klar nda etkinliklerinin düflük olmas d r. Bu nedenle özellikle fliflmanlarda, yüksek risk gruplar nda ve ciddi komplikasyonlar n oldu u hastalarda oseltamivirin çok daha yüksek dozlarda kullan lmas gerekmifltir. A r olgularda ve pnömoni geliflenlerde oral alamayan hastalarda oseltamivir kullan m sorun olmufltur. Bu dönemde ülkemizde olmamakla beraber CDC iv preparat n n olmas nedeniyle peramivir i önermifltir. Korunma 2009 pandemisinde en önemli avantaj m z HN afl s n n h zla gelifltirilmesi, test edilmesidir. Bununla birlikte tüm dünyada afl yla ilgili en önemli sorun afl n n da t m konusunda yaflanm flt r. Afl lamada öncelikli hedef olarak yüksek risk gruplar al nm flt r. Gebeler, 6 aydan küçük çocu u olanlar veya onlar n bak m n üstlenenler, sa l k personeli, 6ay-4 yafl aras çocuklar, 5-8 yafl aras nda olup yüksek risk gruplar öncelikli hedef gruplar olarak belirlenmifltir. Ancak en iyi afl lama programlar nda bile risk gruplar ancak /3 oran nda afl lanabilmifltir. Afl lama konusundaki olumsuz ve e itim eksikli ine ba l kampanyalar afl lanma oranlar n düflürmüfl ve yeterli afl lanman n yap lamamas sonucunu getirmifltir. Ancak burada toplumun tamam n n e itiminden daha önemli olan n sa l k personelinin e itimi oldu unu söylemek gerekmektedir. nfluenza enfeksiyonundan korunmada cerrahi maske yeterli olmas na karfl n, daha pahal olan N-95 maskelerinin çok miktarda gereksiz tüketimi e itim eksikli i nedeniyle olmufltur. Sonuç: Pandemi önecsinde yada pandeminin tan mlanmas yla birlikte haz rlanma ne kadar erken olursa hastal n olumsuz sonuçlar ile daha az karfl lafl lafl laca yads namaz bir gerçektir. H zl ve do ru tan testlerinden yararlan lmas büyük önem tafl maktad r. Korunmada ve pandemiyi kontrol alt na almada en etkin yöntemin afl lama oldu u bilinmelidir. 200 y l nda mevsimsel influenza etkenleri içinde dominant virus B viruslar ile birlikte bu y lki pandemi etkeni yeni HN virusu olacakt r. Bunun yan nda H3N2 virusunun da epidemilerde izlenebilece i aç klanm flt r. Ancak salg n nda ikinci dalgada virusun daha bulafl c ve patojen hale geldi i de unutulmamal d r. Bu nedenle pandemik HN in önümüzdeki k fl mevsiminde nas l bir yol izleyece ini flimdiden öngörmek çok kolay görülmemektedir. Bir baflka önemli sorun virusun mutasyona u ray p u ramayaca d r. Avrupa sürveyans sistemi içinde Norveç Halk Sa l Enstitüsü Mart 200 da 2009 pandemik HN enfeksiyonunda ciddi yada fatal enfeksiyon geliflen 6 viral örne in inde mutasyon bulduklar n belirtmifllerdir. Buna karfl n enfeksiyonun hafif seyretti i 205 olgunun hiçbirinde mutasyon görülmemifltir. Bu nedenle mutasyon önümüzdeki dönemde dikkatle izlenmesi gereken bir di er önemli konudur

60 PANEL 7 (Pa-7) April 25, 200 / 09:5 0:45 / Hall A Artritis management (Artrite yaklafl m) Moderators: Murat Çevik, Muamera Mujcinagic-Vrabac Hüseyin Demir; Inflammatory artritis ( ltihapl artrit) P nar Borman; Osteoartritis (Osteoartrit) Osteoarthritis P. BORMAN Ankara Training and Research Hospital, Clinic of Physical Medicine and Rehabilitation, Ankara, Turkey Osteoarthritis (OA), known as degenerative joint disease is the most common type of arthritis, affecting over 50 million people all over the world. Osteoarthritis is closely associated with the aging process, representing a growing public health cost, not only for the Western countries but worldwide. It is one of the most common disease, seen and treated by physiatrists, rheumatologists and general practitioners. Since there is no cure for this disease, the economical impact of OA on our health economy is an important concern in the context of an aging population. Indeed, this disease affects 0 to 5 percent of the world s population, and its frequency increases with aging; its incidence is higher than 60 percent in the population over 65 years of age. Before age 45, osteoarthritis occurs more frequently in males. After age 55 years, it occurs more frequently in females. Generally, all races appear equally affected. A higher incidence of osteoarthritis exists in the Japanese population, while South African blacks, East Indians, and Southern Chinese have lower rates. The aetiology of OA is multifactorial, yet this disease is characterized by a number of articular structural changes, including cartilage breakdown and alterations in synovial membrane and subcondral bone, which impair joint movement and cause pain. Cartilage destruction is associated with, and it is believed that it may even be preceded by, subcondral bone alterations. During the course of OA, intermittent flares, which reflect the presence of an inflammatory process, appear at the synovial membrane. There is a general consensus that synovial inflammation in OA, although not a primary phenomenon in this disease, contributes to its progression. Osteoarthritis commonly affects the hands, feet, spine and large weight-bearing joints, such as the hips and knees. Most cases of osteoarthritis have no known cause and are referred to as primary osteoarthritis. When the cause of the osteoarthritis is known, the condition is referred to as secondary osteoarthritis. Conditions that can lead to secondary osteoarthritis include obesity repeated trauma, surgery the joint structures, abnormal joints at birth (congenital abnormalities), gout, diabetes and other hormone disorders. Pathophysiology It is now well established that in OA, the earliest histopathological alteration that occurs in cartilage is a depletion of major matrix macromolecules including collagen and aggrecan. Collagen is of particular importance as its breakdown results in the loss of the structural integrity of the tissue. It appears that alterations of the collagen network, as well as the aggrecan, result from an increased level of proteolytic enzymes synthesized by chondrocytes. With aging, the water content of the cartilage increases, and the protein makeup of cartilage degenerates. Eventually, cartilage begins to degenerate by flaking or forming tiny crevasses. In advanced cases, there is a total loss of cartilage cushion between the bones of the joints. Repetitive use of the worn joints over the years can irritate and inflame the cartilage, causing joint pain and swelling. Loss of the cartilage cushion causes friction between the bones, leading to pain and limitation of joint mobility. Inflammation of the cartilage can also stimulate new bone outgrowths-osteophytes, to form around the joints. Osteoarthritis occasionally can develop in multiple members of the same family, implying a hereditary (genetic) basis for this condition

61 Considerable evidence has accumulated to indicate that the proinflammatory cytokines are crucial in mediating inflammation and tissue destruction in OA. OA is mediated by a multitude of complex autocrine and paracrine anabolic and catabolic factors that act upon diverse cells from articular tisues. Various pathways result in alterations in transcription factors that transduce signals intracellularly. The end result of these pathways is the production of proinflammatory cytokines in which multimatory mediators such as other cytokines and the factors NO, prostaglandins, leukotrienes and PARs. Symptoms and Physical Findings Osteoarthritis is the degenerative disease of the joints. Unlike many other forms of arthritis that are systemic illnesses, such as rheumatoid arthritis and seronegative spondyloarthropathies, osteoarthritis does not affect other organs of the body. The most common symptom of osteoarthritis is pain in the affected joints, especially after repetitive use. Joint pain is usually worse later in the day. There can be swelling, warmth, and creaking of the affected joints. Pain and stiffness of the joints can also occur after long periods of inactivity, as called sitting in a theater sign. In severe osteoarthritis, complete loss of cartilage, causes friction between bones, causing pain at rest or pain with limited motion. Symptoms of osteoarthritis vary greatly from patient to patient. Some patients can have disability due to their symptoms and functional loss. On the other hand, others may have remarkably few symptoms, although signs of degeneration of the joints apparent on X-rays. Symptoms also can be intermittent. It is common for patients with osteoarthritis of the finger joints of the hands and knees to have years of pain-free intervals between symptoms. Osteoarthritis of the knees is often associated with obesity, or a history of repeated injury, overuses and/or joint surgery. Progressive cartilage degeneration of the knee joints can lead to deformity which is called as "bowlegged." Patients with osteoarthritis of the weight-bearing joints (like the knees and hips) can develop a limp. Osteoarthritis of the cervical spine or lumbar spine cause pain in the neck or low back. Painful limitation of range of motion in the spine is common. Bony spurs, as called osteophytes, form along the arthritic spine and can irritate spinal nerves, causing severe pain, numbness, and tingling of the affected parts of the body. Osteoarthritis causes the formation of hard, bony enlargements of the small joints of the fingers. Classic bony enlargement of the small joint at DIP joints, is called Heberdan s node and at the PIP joints of the fingers in many patients with osteoarthritis is called a Bouchard's node. The characteristic appearances of these finger nodes can be helpful in diagnosing osteoarthritis. Osteoarthritis of the joint at the base of the big toe of the foot leads to the formation of a bunion. Osteoarthritis of the fingers and the toes may have a genetic basis and can be found in numerous female members of some families. Differential Diagnosis Differential diagnosis of OA includes inflammatory arthritis (e.g., rheumatoid arthritis, seronegative spondyloarthropthies, lyme disease, gout, psoriatic arthritis ),calcium pyrophosphate deposition disease, septic arthritis, systemic lupus erythematosus, scleroderma, and endocrine arthropathies. Diagnosis There is no laboratory or pathological definition of osteoarthritis, and therefore no accepted laboratory tests to diagnose it. Diagnosis of OA can be made with clinical examination and radiological assessment when needed. Blood tests and other imaging techniques may not be necessary for the differential diagnosis, unless the clinical picture is confusing. Confirmation can be done through radiological assessments. Subchondral sclerosis, subchondral cysts, narrowing of the joint space between the articulating bones, and osteophytes can be shown clearly on x-rays. Plain radiographs often do not correlate well with the findings of physical examination of the affected joints or with the degree of pain. An arthrocentesis can be a valuable test when encounteri,ng a patient with presumptive osteoarhritis. In OA the synovial fluid white blood cell count is <000 cells/mm3 suggest the possibility of an in inflammatory arhritis. In fluids from osteoarhritic joints, crystals visible by light microscopy are absent, but the presence of gout or pseudogout crystals provides diagnostic evidence of other forms of arhritis that occasionally are difficult to distinguish from osteoarthritis

62 Treatment The goals of medical therapy are to control pain, improve function, minimize disability, and enhance healthrelated quality of life. A further therapeutic priority is to minimize the risk of drug associated toxicity, particularly that which may result from NSAID therapy. Treatment of OA consists of education, exercise, physical modalities, lifestyle modification, medication and other interventions to alleviate pain. Therapeutic intervention for conservative, non-operative treatment of osteoarthritis begins with resting the involved joints. Activities that stress the joint should be identified and modified or discontinued. Instruction in joint protection and work simplification techniques is helpful, as well as encouraging the patient to perform routine tasks more proficiently and with less stress to the joints. When symptomatic medication does not stop the pain and if the pain worsens the quality of life of the patient with OA, surgery (total arthroplasy) is indicated. Education aims to enhance the knowledge of the patient about OA and lifestyle changes are recommended. Patient education has been shown to be helpful in the self-management of patients with arthritis in decreasing pain, improving function, reducing stiffness and fatigue, and reducing medical usage Conservative measures such as weight control, appropriate exercise and the use of mechanical support devices can be beneficial. In OA of the knees, taping and knee braces can be helpful. A cane, or a walker can reduce pressure on involved leg joints which can be helpful for walking and support. Splints for joints with hand osteoarthritis can be useful. Regular exercise such as walking, swimming and progressive resistive as well as isometric exercises for strengthening the muscles around the affected joint are encouraged. Physical modalities applying local heat with hot or cold packs, ultrasound, electrotherapy, paraffin and other modalities can be used for symptomatic medication. Functional, gait, and balance training can be recommended for the impairments of proprioception, balance, and strength in individuals with lower extremity arthritis. Medical Treatment Paracetamol (acetaminophen), is commonly used to treat the pain from OA, and was recommended in most of the guidelines. NSAIDs appear to be more potent, but can lead greater risk of side-effects. Most prominent drugs in the class include naproxen, piroxicam, diclofenac, ibuprofen, and ketoprofen. They can gastrointestinal and other systemic side effects especially in the elderly. Such systemic adverse side effects are normally not observed when using NSAIDs topically, therefore topical forms of NSAIDs can also be used. Oral steroids are not recommended in the treatment of OA because of their modest benefit and high rate of adverse effects. However intra - articular corticosteroid temporarily improve the symptoms. Injections are typically done no more than 2 to 3 times annually using a corticisteroid/ anesthetic preparation. As injectable medication hyaluronic acid as viscosupplementation, may also be useful in some patients but recent studies indicated a nonsignificant improvement with this viscosupplementation. For moderate to severe pain opioid analgesics may be useful. If the conservative management is ineffective, surgery may be required. Acupuncture, glucosamine/chondroitin, chondroitin sulfate supplementations can also be effective as alternative medicines. References. Dougados M. Clinical characteristics of osteoarthritis. In: Harris ED, Budd RC, Firestein GS, et al (eds). Kelley Rheumatology. 7th ed, Elsevier Saunders, Philadelphia, 2004, pp: Lozada CJ. Treatment of osteoarthritis. In: Harris ED, Budd RC, Firestein GS, et al (eds). Kelley Rheumatology. 7th ed, Elsevier Saunders, 2004, Philadelphia, pp: Felson DT. Degenerative joint Disease and Crystal-Inuced Arthritis. In: Imboden JB, Stone JH, Hellmann D (eds). Current Diagnosis and Treatment RHEUMATOLOGY. second edition 2004,Mc Graw-Hill Companies, pp:

63 ROUND TABLE (RTa-) April 23, 200 / 4:45 6:5 / Hall A ROUND TABLE SESSIONS Current health situation and health systems in South East Europe (Güney Do u Avrupa da mevcut sa l k durumu ve sa l k sistemleri) Moderators: Lubomir Kirov, lhami Ünlüo lu Ljiliana Kocankovska; Macedonia (Makedonya) Lubomir Kirov; Bulgaria (Bulgaristan) Ljiliana Zogovic-Vokovic; Montenegro (Karada ) Mirjana Mojkovic; Serbia (S rbistan) Murat Ünalacak; Turkey (Türkiye) Miro Popovic; Rebublika Srpska (S rp Cumhuriyeti ) Vjolka Konica; Albania (Arnavutluk) Azijada Beganlic; Bosnia & Herzegovina (Bosna Hersek) Ksenija Tusek-Bunc; Slovenia (Slovenya) Macedonia L. KOCANKOVSKA, L. SUKRIEV Every country has its own system of Primary Health Care which may encompass Conventional Medicine, Alternative Medicine and Traditional Medicine. No system is perfect and every system is evolving. This evolution must be guided to provide the best and most cost effective health delivery to the patient and to society in general. General practice is key element of all healthcare systems in Europe and is recognized by health service providers as being of ever increasing importance. International evidence indicates that health system based on effective primary care, with highly trained general physicians ( family doctors) practicing in the community, deliver care that is both more cost-effective and more clinically effective than in systems that place less emphasis on primary care. Society has altered over the last 30 years, and there has been an increasing role for the patient as a determining factor in health care and its provision. The expectation of patient, the interest of politicians and the media, the impact of new information system such as the internet and the increasing cost and complexity of healthcare delivery all have resulted in climate of continual change. Family doctors must continue to practice medicine as clinical generalists, applying the fundamental characteristics, but they also need to be involved in the continuing development of their healthcare system. As individual professionals they must adapt and grow in order to meet these new challenges. We should follow the six domains of core competences and essential features of the discipline described in the the WONCA 2005 definition and the learning outcomes developed by EURACT. The current situation is fulfill with understanding that the pillar of the Health care system has to be general practitioner (family physician). The position of the family medicine as a separate discipline is recognized within the professionals and Center for Family medicine is open. But some common problems related within clinical practice still remain:. Family doctor doesn t provide comprehensive health care according standards. 2. No rational referral system toward secondary and tertiary health care. 3. Irrational prescribing of drugs

64 4. Luck of time for preventive and educative health promotion programmes directed directed toward public. 5. Emphasis on treatment with medication instead of psycho social dimension 6. Members of the family have different family doctors. 7. Inclusion and exclusion of the patients with luck of criteria. 8. Too much administrative work. 9. Family physician are aware of a need of CME (economical and permission problems, standing as a obstacle against CME). The focus is on implementation of development strategy ( ) of the Ministry of Health of R.M. which recommends the adoption of the institution of family doctor to replace all another specialists in the provision of primary health care. According the strategy the health care system provides: * Public health services aimed at the community, as well as health services to individuals; * The generation of human and financial resources; * Proper financing of the health care sector: raising and pooling of sufficient financial resources, purchasing effective and quality services from health care providers, and proper methods for paying health care providers; * Stewardship: effective and efficient organization and management of the health care sector. Family Medicine as a discipline is not a collection of bits and pieces of established specialties. It is more than the provision of episodic care to the individual, it is primary, it is comprehensive, and it is continuing ongoing care. Family Physician is a independent practitioner who is not a mini-specialist in various specialties but one who relates to specialists and other health care professionals. The six domains of core competences:. Primary care management 2. Person-centered care 3. Specific problem-solving skills 4. A comprehensive approach 5. Community orientation 6. A holistic approach The essential features As a person-centered scientific discipline, the three essential features should be considered as fundamental. These are:. Contextual ( using the context of the person, the family, the community and their culture 2. Attitudinal ( based on the doctors professional capabilities, values and ethics 3. Scientific ( adopting a critical and research-based approach to practice, and maintaining this through continuing learning and quality improvement. Priorities of the strategy: The analysis of the health status of the population and of the functioning of the health care system leads to the following priorities that are to be achieved by the year 2020: * Improving the health status of the population, with special attention to vulnerable groups, and with emphasis on health promotion. * The effectiveness and efficiency of the health care system needs to be improved through the introduction of professional management in the institutions, and structural changes in the delivery of health care services, with emphasis on primary care

65 * Modernizing the system for protecting the public health according to the EU standards, with emphasis on the network of Institutes of Health Protection and occupational medicine services. * Improving the planning and management of human resources in the health care system according to the needs. * Establishing a total health care quality assurance system. * Improving the health system financing by way of establishing a sustainable mechanism of financing and resource allocation: - by providing a clearly defined and unique basic benefits package for all the citizens, covered by the compulsory health insurance; - by improved financial control mechanisms and improved collection of the health insurance premiums; - by contracting health care institutions; and - by providing a possibility for several forms of additional health insurance. Underlying principles and values of the health strategy are: * Equity, (whole population has financial and geographical access to a package of basic health services), * The citizens, the Government, all health care institutions providing health services, public and private enterprises, as well as non-governmental organizations, are responsible for the health. * Health insurance, creating mutuality and solidarity between sick and healthy, poor and rich, and young and old. The goal of better health for all will be achieved by: * Strengthening health promotion and disease prevention. * Reduction of inequalities in health and access to health services. * Strengthening of primary health care as the foundation of the health care system. * Reorganization and promotion of the secondary and tertiary health care. * Modernization of public health services. * Better planning and management of the human resources in health care. * Assurance of the quality and effectiveness of health services. * Achieving efficiency and financial sustainability of the health care sector. * Appropriate mix of public and private providers in the health care system. *** Republic Serbia M. MOJKOVIC DZ Vozdovac, Belgrad, Serbia According to the Primary Healthcare Development Plan, the scope and contents of health care are comprehensively defined and include measures for preserving and promotion of population health, prevention, control and early detection of diseases, injuries and other health disorders and timely and effective treatment and rehabilitation (health care law, paragraph 2). Serbian Health Care Law provides health care principles, as follows. Principle of health care accessibility (based on supplying proper health care, which is physically, geographically and economically accessible to all citizens of the Republic. Principle of equity (based on prohibition of any discrimination regarding race, sex, nationality, social origin, religion, political or any other conviction, wealth, culture, language, disease, psychical or physical handicap). Principle of comprehensive healthcare (connotes involvement of all citizens in healthcare system and implementation of conjoined healthcare measures and interventions, which comprise health promotion, prevention of disease, timely diagnosis, treatment and rehabilitation)

66 Principle of healthcare continuity (interconnection and harmonizing of healthcare system levels, from primary to tertiary, and uninterrupted healthcare for all ages of population of the Republic). Principle of permanent of healthcare improvement (accomplishes by measures and activities which in conformity with contemporary achievements of medical science and practice improve possibilities of favorable outcome, and decrease risk and other unfavorable consequences for individual and community health Principle of healthcare efficacy According to Healthcare Law (paragraph 99), chosen doctor is supposed to: According to Healthcare Law (paragraph 99), chose doctor is supposed to:. organizes and puts in effect the preservation of individual and family health 2. reveals and restrains disease risk factors 3. Determines diagnosis ant timely treats the patient 4. maintains urgent medical procedures 5. refers patient to proper medical institution, depending on medical indications, or to the specialist and coordinates medical opinions and suggestions for prolonged treatment 6. Maintains home care, medical support and palliative treatment, and treatment of patients which have no indication for hospitalization 7. Prescribes medicaments and remedies 8. Maintains healthcare in domain of the mental health 9. maintains other jobs according to law (refers patient to secondary and tertiary level of healthcare, manages medical documentation regarding patient's health condition Serbian Ministry of Health, with financial support of European Agency for reconstruction, carried out study for assesing Serbian burden of diseases in period from October 2002 till September Aim of the project was to determine priority of diseases endangered and neglected population groups insufficient medical services the most economical medical interventions medical trends for future Obtained results according to growing presence (. ischaemic heart disease; 2. cerebrovascular diseases; 3. lung cancer; 4. depression; 5. diabetes mellitus) indicate that primary and secondary disease prevention in work of chosen doctor represents the most effective recipe for supression of epidemic noninfectious diseases *** Management change of the primary health care sector in FBIH A. BEGANLIC Tuzla, Bosnia and Herzegovina Introduction In health care, the same events are constantly taking place: To improve the system, we are constantly changing events and people associated with it (directors, ministers, assistant ministers) or (the method of cost calculation for services rendered - by diagnosis, by procedure, using a point system, etc....) BUT, the overall state of the system remains unchanged. As a result, health care has not the early sixties of the last century

67 Why does the system remain unchanged? Any change in the system will most likely compromise and/or negatively affectthe status of at least some players in the system. In this system, everyone benefits in one way or another Any changes will in one way or another affect: Patients Physicians Health care leadership What is change? CHANGE is the process of transforming, changing or modifying something. Theories of change There are many theories of change, but most are modified derivatives of Kurt Lewin's 95 classical theory of change. Three stages of Change:. The need for Change is recognized 2. The Change is initiated after a careful planning process 3. The Change becomes operational Phase changes The need for Change was recognized (post-war public system in BiH). After much careful planning, Change was initiated (several years of planning primary care reforms) Change has become operational Categories of Change "adopters" Traditionalists - will never adopt change (6%) Late Majority skeptics, will only adopt change after seeing results (34%) Early Majority - motto: neither the first, nor the last Those who adopted changes in the early phases, (3.5%) Pioneers (2.5%) seeking change, often not understanding Barriers to change Not recognizing that a problem exists Resistance to change Fear of change Financial/personal reasons No motivation for change Rules within the system Implementation of changes Dramatic changes are proposed as part of the PHC reform Changes elicit reactions that are at times inappropriate and inadequate for the participants in the process Implementation of changes into any system is one of the greatest challenges to the system, as well as to every manager We are all stakeholders in MANAGING CHANGE! Intensive development of Family Medicine CMZ CRZ Private practice Short term development projects Market-operating institutions

68 Users do not accept responsibilities and obligations Health care system financing varies Insufficient funding for public health Quality indicators (on empty) Health care workers dissatisfied Institutions managed by founders Management is bounded by local politics Basic package for health care right Accreditation standards Public health laws What is happening? the Existing (or current) Stateneeds to be transitioned through a series of activities to A New Future State, and that the collective situation is governed as a whole, i.e. The characteristics of A Transitional State are recognized and properly reacted upon Management Changes In order to successfully carry out, it is necessary to know the techniques and processes of management of such changes. Necessary to have: A Vision for the future situation or state; Energy for support; Participants who will implement and successfully carry out the changes. Key participants can be divided into three groups: "Sponsors"-people who support the changes; Persons responsible for the changes; Persons who will benefit from the implemented changes For that, it is necessary to identify the Common Needs Defining common needs Ensure unity for the need of change: Common needs Ensure stronger arguments For versus Against changes Thoroughly explain the changes, Ensure and enable that everyone can support the change. Assessment process for health needs *Profiling population health *Identifying health needs *Selecting priorities *Planning the program *Implementation *Evaluation The process of assessment of health needs Profiling population health (What are the health issues plaguing the public at large?; What are the most important health problems?) Identifying health needs Selecting priorities Planning Program

69 Implementation Evaluation 2 nd Congress of Association of General Practice/Family Medicine Defining vision The most important step after recognizing the needs is defining the VISION achievements of the planned needs After that, energy is to be focused on the mobilization of all participants Statement on vision Vision is a statement about what your organization wants to become; Should reflect all members of the organization and help them feel proud, excited and part of something much bigger than themselves; Vision should increase the ability of the organization and its own image; Gives shape and direction to the future of the organization; Visions can be statements thatspan a few words to several pages in length; People will remember the short vision of your organization. "A computer on every desk in every home," Microsoft's early vision Mobilizing all participants Include those who support the changes Encourage those who are interested Identifywho and what may limit change and reduce their impact Participants need to be systematically coordinated in line with the vision and needs of all participants. For all elements of the system vital to the implementation of change and success of given objectives, it is necessary to: Shape, Adapt/customize, Activate Planning and implementation of changes Planning system is a form of project management. It is important to know all important elements of such management and cycle: Plan, set goals in accordance with the needs of users and plan how to achieve those goals Do, i.e. implement what you planned Check Act, based on the analysis, make changes in activity or project Development Map Problems typically occur when least expected Seemingly obvious problems often only show the tip of the iceberg. For more detailed causes of the problems, it is necessary to thoroughly work out and investigate the current situation and answer questions about the causes for the situation that we want to change (Who?What? When?How? How Much?) Defining the problem is not any easier It is necessary to define general and specific goals. Goals should be (SMART): Specific Measurable, Achievable (feasible)

70 Real, Placed in a manageable timeframe. After that, ensure the monitoring of activities, at the end, create a map to change, and plan the monitoring/review of all steps necessary to successfully install the planned changes, Evaluate the installed. Techniques in the implementation of changes Quality analysis to estimate the position in the implementation of changes SWOT analysis: STRENGTHS WEAKNESSES OPPORTUNITIES THREATS SWOT analysis Method of analysis and summary of key problems, in the business environment and the strategic capabilities of an organization, that can potentially impact the development strategy. SWOT analysis helps to: organization focuses on its strength, minimizes threats, using an efficacious strategy, that utilizes the best available opportunities to ensure a competitive advantage. The purpose of a SWOT analysis is: Identify the position and the values in one s own environment, Act by placing an increased importance on the environment NOW Strengths and weaknesses Internal determination ANTICIPATED Opportunities and threats Surrounding environment Problems of primary health care The population is impacted by serious chronic and degenerative diseases and has psychosocial needs Weak health care network within the community Medical education does not properly address the challenges Provision of more effective and successful care is prevented 35% of the population has more than a 5% risk of developing CV disease in the next 5 years Number of hospital admissions due to chronic diseases is 3X higher than in Europe HEALTH PROBLEMS TODAY - WHO -general health of the population is getting worse (life expectancy, standardized mortality rates from ischemic heart disease, rates of neoplasms, etc.). -care provided to patients with chronic degenerative diseases and people with special needs is in crisis, especially in regards to primary care. - noted is an increase of services provided by specialists, ancillary services and hospital care

71 -a problem of special concern is the sudden increase in costs of medicines prescribed, at the expense of the health insurance institution. CHALLENGE FOR THE FUTURE:HEALTH CRISIS OF THE CENTURY -changes in the structure of causes of illness and death -inability of modern medicine to provide all the answers, to all challenges presented, -sudden increase in development/use of high-technology - an enormous increase in health care costs - increased pressure on users to take a more active role in making decisions in regards to the public health system and the regulation of patient rights - Health care policy evolves from a narrow medical model to a better understanding of health and its contributors/determinants PLANS - BIH How to ensure that Family Medicine meets 70-80% of public healthneeds in terms of capitation? Are there services that should be paid for in addition to capitation? What are they and why should they not be coveredby the capitation? Does the quality of health care provided need to be taken into account when determining the amount of funds disbursed? How? How to ensure the focus of physicians on preventative medicine and the promotion/importance of general well-being? ROUND TABLE 2 (RTa-2) April 23, 200 / 6:45 8:5 / Hall A Reform in primary health care system (Birinci basamak sa l k sistemi reformu) Moderators: Lubomir Kirov, lhami Ünlüo lu Ljiliana Kocankovska; Macedonia (Makedonya) Lubomir Kirov; Bulgaria (Bulgaristan) Ljiliana Zogovic-Vokovic; Montenegro (Karada ) Mirjana Mojkovic; Serbia (S rbistan) Murat Ünalacak; Turkey (Türkiye) Miro Popovic; Rebublika Srpska (S rp Cumhuriyeti ) Vjolka Konica; Albania (Arnavutluk) Azijada Beganlic; Bosnia & Herzegovina (Bosna Hersek) Ksenija Tusek-Bunc; Slovenia (Slovenya) Macedonia L. KOCANKOVSKA, L. SUKRIEV Europe is characterized by diversity of all areas of society including the way health care is delivered. In the past 9 years, with the independence gained in 99, the health care system in Republic of Macedonia, went through huge political and economical changes and face with many positive effects as well as negative implication. The Ministry of Health, in cooperation with other governmental and non-governmental organizations, professional associations and the public, manage the modernization of the health care system. The Republic of Macedonia, inherited a large and well-established health care system with good geographical

72 and financial accessibility, long positive experience with health insurance covering nearly the whole population, qualified staff, good control of infectious diseases, and almost full coverage of the population with the national immunization programme. The health status of the population is similar as in the other countries of South- Eastern Europe, but is lagging behind the EU countries. However, the health care sector is faced with several challenges associated with the improvement of the health status of the population, the provision of basic benefits package, delivery of health services, public health, planning, management and development of human resources, quality assurance, health financing, and provision of a sustainable system of health care. The health gap between socio-economic groups should be reduced, thus substantially improving the level of health of disadvantaged groups. The analysis of the health status of the population in the Republic of Macedonia and in the world shows that priority health problems are and will continue to be the chronic noninfectious diseases, the new infectious diseases and the emergency cases. The Health Strategy of the Republic of Macedonia 2020 sets out the vision for improvement of the health and of the health care system, which will be responsive to the needs of the population. The achievement of the goals, objectives and guidelines included in this strategy will be ensured by way of adopting an Action plan and by the implementation there. Primary health care oriented towards the individual, the family and the community, with emphasis on the preventive health care and on satisfying the majority of the health needs of the population, will continue to be the basis of the health care system in the Republic of Macedonia. The hospital health care will be provided in a defined network of general and specialized hospitals. They will satisfy the needs of the local population in need of secondary health care, thus reducing the pressure on the tertiary health care. The specialized preventive health care of the population (public health) will be provided by way of strengthening and modernizing the Institutes for Health Protection and the occupational medicine services. Human resources are the core of the health care system. Staff expertise and competence will be improved through modernization of the under-graduation and post-graduation studies, implementation of different forms of continued education, and professional development. The assurance of the quality of health care will be a priority in the period to come, and this will be achieved through the implementation of accreditation and re-accreditation of health care institutions, health care workers, procedures and guidelines for treatment, implementation of internal and external assessment, and greater participation and influence of the consumers of health services. Human resources are the core of the health care system. Staff expertise and competence will be improved through modernization of the under-graduation and post-graduation studies, implementation of different forms of continued education, and professional development. The assurance of the quality of health care will be a priority in the period to come, and this will be achieved through the implementation of accreditation and re-accreditation of health care institutions, health care workers, procedures and guidelines for treatment, implementation of internal and external assessment, and greater participation and influence of the consumers of health services. Health care in the Republic of Macedonia is relatively easily accessible (geographically, economically and time-wise) for the population, because it is delivered within a widespread network of health care institutions. This makes it possible for around 90% of the population to get a health service in less than 30 minutes. Like in many other countries, the health care system in the Republic of Macedonia is oriented towards primary health care as the basis of the system, where the first contact with the health service is made and where the majority of the health care needs of the population are satisfied. Patients who need health care at higher level are referred by the primary health care doctor to ambulatory-policlinic treatment or hospital treatment. Despite the widespread network of different health care institutions, the system does not function as an integrated and coordinated system

73 There are several reasons for the lack of integration and co-ordination: The system is too fragmented and super-specialized. The chosen doctor usually does not provide comprehensive care and is not considered as the key player in the system. There are insufficient rules and incentives in place for proper gate keeping and referral to higher levels of the health care pyramid, as a result of what many patients are treated at inappropriate levels. Primary health care The population in the Republic of Macedonia will have better access to family- and community-oriented primary health care, supported by a flexible and responsive hospital. Primary health care in Macedonia is provided by different types of private and public health care organizations: doctor s offices, health stations and health houses. Preventive, promotional and curative services are provided in the primary health care. The latter is provided by many different types of health workers and co-workers: general physicians, specialists in general medicine, paediatricians, specialists in school age medicine, gynaecologists, and specialists in occupational medicine. The health workers mentioned above do not provide comprehensive primary health care except in villages with only one doctor. This system performs well in some areas (for example when providing immunisation and antenatal care) and less well in others (for example non-rational prescribing, high referral rates, lack of coordination between various treatments, and prevailing medicamentous treatment of the patients with mental health problems without paying sufficient attention to the psychosocial dimensions of the treatment). As in many other transition countries, widespread privatisation has taken place and many physicians have set up private practices. At present, 607 out of,722 primary health care physicians (most of them general physicians, paediatricians and gynaecologists) are working in private practice (source: Ministry of Health). Private primary care physicians do not provide comprehensive primary care including all preventive services and urgent care after office hours, i.e. they do not provide continued health care. The purpose of privatisation of the primary health care is to improve the quality of the health services, but its short-term and long-term consequences for service delivery have been insufficiently analysed. Citizens covered with the compulsory health insurance are obliged to choose a doctor in the primary health care sector - in a private or public health care institution. The principle of choosing a doctor in the primary health care in Macedonia has traditionally been fragmented and depends on the age and the sex of the users. Members of one family will usually have several chosen doctors (general practitioner, gynaecologist and paediatrician). A chosen doctor is not the same as family physician. In order to avoid fragmentation of the primary health care system, the Ministry of Health will aim at establishing multidisciplinary teams where the different doctors in one family will be in direct contact and cooperation. For medical doctors, dentists and pharmacists, a system of licensing and relicensing has been established, and it is implemented in the Medical, Dental and Pharmaceutical Chamber. Except for medical doctors, a system of compulsory and accredited continuing education courses required for relicensing has not been established yet. The financing of continuing educational activities is a problem in view of the low income of health care professionals. Another major bottleneck is the lack of access to Internet sources of information. Guidelines for primary health care have been developed, and clinical guidelines for specialist medical care, based on evidence-based medicine, have been prepared. The existing guidelines will need constant updating in the future. Guidelines are being used for the improvement of the treatment of patients, but also for educational purposes and for the formulation of the positive list of drugs and of the basic benefits package. A comprehensive system of co-ordination and monitoring of the responsibilities for provision and control of the quality of health care is missing

74 The further development of the primary health care with the introduction of family medicine by 2020 will take place according to the Action Plan for Primary Health Care that it is prepared. Additional training of a certain number of existing primary health care doctors and nurses will be carried out, and the remaining doctors and nurses as well as the new graduates that will choose to work in the PHC will follow residency and specialisation in family medicine according to the law. Doctors and nurses from the same family medicine practice will follow some modules of additional training together. The additional training and specialization in family medicine will be delivered by the Medical Faculty through the Centre and Department of Family Medicine, in accredited health care institutions and in the schools for nurses. They will develop curricula and syllabi and will provide an appropriate infrastructure for realization of the theoretical and practical training with trainers, patients and equipment. The Centre and The Department of Family Medicine was established in October The group of faculty member undertook a number of key tasks reviewing the literature; conducting a national survey of those involved in training; reviewing existing curriculum models; consulting on models and methods; and developing curriculum statements. It is the first national training curriculum for general practice and gives us a unique opportunity to reshape training for our discipline. Set within a framework for a structured educational programme, it is designed to address the wide ranging knowledge, competences, clinical and professional attitudes considered appropriate for a doctor intending to undertake practice in the contemporary National Health Service. The curriculum is a challenging and complex document that will change and develop as medicine changes and develops. 6 educators from the country is involved in the educational process of that center. The historical moment is that residents for family medicine attend the modules. Every citizen is guaranteed a right to health care. Citizens have the right and duty to protect and promote their own health and the health of others. The health care system of the Republic of Macedonia will be developed so that it becomes compatible with the EU system, thus providing for free movement of the health professionals, services and patients. *** Primary health care reform in Serbia M. MOJKOVIC DZ Vozdovac, Belgrade, Serbia Fundamental principles of health policy in Serbia are authority-based organization and financing of the health care together with state-regulated health insurance. Adoption of Resolution on Health Policy by the state government, in yr. is officially considered as the start of the primary health care reform in Serbia The healthcare reform action plan for the time period until 205 yr. was created, followed by adoption of system laws, as follows: The law on medicaments and non-official remedies The healthcare law The health insurance law The law on medical chambers The Health Council was formed (2009 yr.) The most important goals of the primary health care were defined The healthcare law offers better definition of the patient rights and obligations. These rights were promoted in the nation-wide campaign under the title "You Have the Right")

75 Development and planning of the healthcare personnel (Number of personnel in public health institutions was diminished) Financing of the healthcare system (Gross sum for healthcare was insignificantly increased) Management improvement in the all levels of the healthcare Better control mechanisms of the billing for services covered by insurance Increased responsibilities for needs and expectations of patients Improved communication and realization of the patient's rights in healthcare Introduction of chosen doctor in primary healthcare (doctor or specialist of general practice) who will be compensated according to the number of assigned patients. Financing per capitation is being introduced with the support of the World Bank and European Union Restriction of specialization - the planning is centralized Funds for education and trainings are increased Founding of medical chambers included regulation of licensing process Development of information systems Disease prevention becomes a cornerstone for improvement of health in Serbia Serbian Ministry of Health decided to implement model of heath care based on Health Centers, where patient makes the first contact with the healthcare system, i.e. with his chosen doctor in primary healthcare. Institution of chosen doctors exists in general medicine, gynecology, pediatrics and dental medicine. According to Law on Decentralization of 2005, founding rights of the health centers has been transferred to the municipality, which is enrolled in investments, while payment for the services exerts Republic Institute for health insurance. Project of the European Agency for Reconstruction is forcing payment realization by capitation, according to the effective legal regulations DILS (Delivery of Improved Local Services) project of the World Bank. Health minister introduced Rules on health care quality indicators, in the scope of the Healthcare law. Mandatory quality indicators that are monitored in the field of health care activities performed by the selected doctors are, as follows: The average number of visits per doctor The average number of prescriptions per doctor per 00 visits Average number of referred patients to lab, X-ray, echosonography, and specialist consultations for 00 visits (calculated as: total number of referrals divided by number of curative visits, multiplied by 00 Scope of influenza vaccination of persons older than 65 year 2. Recommended quality indicators that are monitored in the field of health care activities performed by chosen doctors are as follows Coverage of vaccination against influenza of patients with chronic non-infectious diseases The percentage of patients with coronary heart disease advised for smoking cessation and/or noted control of total cholesterol in last 2 months The percentage of patients with hypertension in whom the value of blood pressure measured in the last twelve months is noted in medical records, and percentage of patients in whom the last measurement of blood pressure amounted to 40/90 or less, in last twelve months Percentage of women aged 20 to 65 years included in targeted screening of the cervical cancer The percentage of the first visits with undefined diagnosis in relation to the total number of first visits Percentage of matching between referral diagnosis and specialist diagnosis

76 Students' healthcare is carried out through institute for students' healthcare Occupational healthcare through occupational medicine ward in health center or through Institute for occupational healthcare Healthcare of elderly population (more than 65 yrs.), through Institute of Gerontology Healthcare of patients suffering from TBC and pulmonary diseases through Institute for Pulmonary diseases and Tuberculosis Healthcare of patients suffering from sexually transmitted diseases and skin diseases, through Institute for Skin and Venereal diseases Emergency medical services, through department for Emergency Medical Services, belonging to Health centers and Medical Emergencies Centre In Serbia, institution of health centre exists in almost any city or municipality (57 health centers and subsidiaries) According to article 95 of the Healthcare Law, minimal scope of services in the health center comprises: Preventive healthcare General medicine Healthcare of women and children Domiciliary care Laboratory and other diagnostic procedures Emergency medical service If there are no other medical institutions in the area, a health center provides: Dental healthcare Occupational medicine Physiotherapy Rehabilitation Ambulance transport If health center is more than 20 kilometers away from the nearest hospital, and provides health care for population larger than , it also provide medical services in following specialties Internal medicine Pulmology Ophthalmology Otorhinolaryngology Mental health Patients rights in Serbian healthcare system are very broadly defined, and enable exaggerated utilization of specialist and hospital services. Chosen doctors in the Health centers work under great pressure induced primarily by quantity instead of quality of the services, maintaining dual medical records (in electronic form and writing), directed referring to different consultative examinations in order to provide therapy for the patient (medicaments ordered by specialist), and twofold testing ordered by consultative services Unfortunately, our professional association was allowed neither to present suggestions during drafting of legislation, nor to participate in realization of healthcare reform project ***

77 Strategic plan for the development of public health in the Federation of Bosnia and Herzegovina A. BEGANLIC Tuzla, Bosnia and Herzegovina Weaknesses in the public health system are a direct consequence of: the current organization of health systems poor governance insufficient commitment to further/continual development organization of human/technology resources series of problems in regards to insurance and fund raising External influences are also significant contributing factors: the socio-economic situation, demographic and epidemiological changes poor involvement of local communities insufficient awareness of the enormous importance and effect of public health on the country s economic and other developments weak cooperation between sectors CONSEQUENCES OF THESE WEAKNESSES inequality in access to health care among the cantons and different socio-economic and other excluded categories of the population insufficient efficacy and quality of the system and health services provided, affecting the general health of the population VISION Improved public health through an effective, accessible and transparent health care system oriented toward quality, based on the principles of solidarity and equality DIRECTING THE SYSTEM TOWARDS PRIMARY HEALTH CARE while not neglecting the development of other levels of health care: The basic principle is to assure the provision of health services that: protect and promote health, improve the quality of life, treat and prevent diseases, rehabilitate patients care for those who are suffering or are in the terminal phases of an illness Should strengthen the system joint decision making between customers and service providers, promotion of comprehensiveness and continuity of public health protection Reasons for the reform of primary health care. Unequal access to health care (the high rates of uninsured people, etc...) 2. Inefficient provision of services. 3. Current PHC is geared toward diseases and treatments, episodic protection of health and passive admission of patients, 4. Increased use of consults/specialists and diagnostic services, and in-patient treatments There is a fragmenting in ways of initial, first contacts of the public with the health care system, with a limited role of "gate-keepers," and

78 inadequate attention is paid to the continuity of health care provided. At the PHC level, services in most health centers are still provided on the basis of age, gender or type of illnesses in specialized dispensaries and services, and thus not the most effective use of available resources The ineffective arrangement of services provided is clearly visible when health care expenditures are reviewed, where to the detriment of PHC, the emphasis is still placed on secondary and tertiary health care The Medical Center (MC) function must be preserved Medical Center is the institutional form of organization in health care, It must be restructured to fit the model of Family Medicine and be a first-line provider of PHC Each MC should develop its own strategy for development The main, strategic goal is the development of PHC in which family medicine will play a central role and which will be based on the following: accessibility, efficacy, quality, and provision of beneficial health care services, interventions or programs. Changes Amending existing regulations in order to strengthen PHC; Establishing an effective service delivery system; Transformation of existing services rendered in Medical Centers and alignment with the model for family medicine Develop, test and implement new contracts, payment/reimbursement methods for health care providers; Creating an adequate profile of health care workers Introducing and implementing quality standards in order to improve, assure and monitor quality controls Development and implementation of information systems; Development and implementation of follow-up/evaluation systems Increasing the participation of local communities in terms of providing public health measures/phc Establishing necessary management/control mechanisms; In order to effectively transform Medical Centers and successfully implement the Family Medicine model throughout, it is necessary to develop educated and professional health care administrators, who then would capably supervise and direct the reform processes. (professionalization of the health care administrator occupation) Create favorable conditions for the education and training of management personnel with emphasis in health care administration; Plan, organize, and permanently implement and evaluate education and training of managers in health care administration/management; Extend the model of Family Medicine throughout the entire region In reforms of PHC, the role of Medical Centers is redefined Goal: no changes/development Changes: slow and defensive or reactive/fast and offensive or proactive Approach: follow the rules/create rules and modify as necessary Objectives: procedural, known methods/results and accomplishments

79 Leadership: autocratic/democratic Authority: formal hierarchy/participation and knowledge Problem Solving: experience/inventive Choices of People: formal criteria/knowledge and expertise Decisions: Majority vote, director/consensus New Ideas: negative attitude/positive attitude Key Resources: money or time/knowledge, ideas (human knowledge is amortized on average in 5 years) Organization: rigid and stable/flexible and dynamic Education: Narrow specialization/multidisciplinary Ideal Employee: obedient/independent, creative Evaluation/Quality Control: external, responsive/continuous self-evaluation/quality control Methods: "intuitive" changes/create conditions that will lead to positive changes How can all this be achieved? Establish a system that provides effectual services A PHC based on the Family Medicine model should establish an efficient system that serves as the first point of contact of citizens with the health care system and successfully achieves the most important principles of PHC: accessibility, comprehensiveness, continuity and harmonization What is expected from you? ADOPT NEW INFORMATION CONCERNING EFFECTIVE MANAGEMENT AND LEADERSHIP METHODS AND PUT THEM TO PRACTICE COMPREHENSIVELY ANALYZE THE EXPERIENCES OF OTHERS ROUND TABLE 3 (RTa-3) April 24, 200 / :5 2:5 / Hall A Management of FM Quality of/in FM (Aile hekimli inde kalite yönetimi) Moderator: Nejat Demircan Zekeriya Aktürk Melida Hasanagic Georgy Ivanov Management of Quality in Family Medicine in FBIH M. HASANAGIC, L. REDZEPAGIC, O. BATIC-MUJANOVIC Association of Family Physicians from the Federation of Bosnia and Herzegovina Agency for quality and accreditation in health care in the Federation of Bosnia and Herzegovina (AKAZ) and Agency for quality and accreditation in health care in the Republic srpska-aaqi ( are the competent authorities in the area of improving quality and safety of health services and accreditation of health institutions in Bosnia and Herzegovina. As I am coming from the Federational part of BH mostly I will talk about AKAZ.(More information on or AKAZ)-()

80 The Agency AKAZ was established on the basis of Law on Quality Improvement System, Security and Accreditation in Health (FBiH Official Gazette no. 59/07) which was adopted by the Parliament of the Federation of Bosnia and Herzegovina at the session of the House of Representatives from god. and the House of Peoples of year.(2) What are the main functions of a AKAZ? Development and revision of accreditation standards; Organizational and clinical, development of audit and clinical guideline based on evidence-based medicine; the definition, development and revision of Performance indicators; incentive funding for health care institutions, collection, processing and analysis of data from health institutions and disseminating information to health institutions for education and for comparative analysis (for example, performance indicators, incidents); resource center: AKAZ ensure access to appropriate databases, and professional " gray "literature, collecting information on good practices from the country and abroad, exchanges, and compares them with information from other countries; education: AKAZ organizes education and training in the field of quality and safety of health services and other health professionals; facilitation raise the system to improve quality and safety in health care institutions on request from the accreditation standards; External Feedback health institutions in order to Accreditation; domestic and international cooperation in the field of quality and safety of health services. Law on Quality Improvement System, Security and Accreditation in Health (FBiH Official Gazette no. 59/07) Health institutions shall establish the system of improvement of quality and safety of health services with an objective to achieve maximum healthcare quality. For the purpose of achieving the objective from paragraph of this Article, health institutions may get accredited in the manner, and under the conditions prescribed by this Law, and the regulations passed on the basis of this Law. Quality of Healthcare is a degree, to which an increase of expected health outcomes is foreseen in relation to defined healthcare standards; - Standard is a criterion that regulates a set of rules, protocols, requirements or statements of expected standard healthcare quality, which leads to better quality of healthcare in compliance with this Law, a) minimal standards are minimal criteria to be met for the purpose of protection and safety of patients, b) optimal standards are statements of expectations or requirements, which, once met, ensure provision of a good quality health service; - Internal Quality Control is a process of systemic control of expert activities in relation to prescribed standards; - External Quality Control is a process of external control of health services quality, through which health services provision in a health institution is compared with published standards, and in such manner, possibilities for improvement of health services quality are identified; - Clinical Guidelines are systemically developed, determined guidelines that help health workers, health associates and patients to bring decisions on appropriate health treatment in precisely defined clinical circumstances; ALPHA is an internationally recognized program for primary principles of accreditation in healthcare, i.e. accreditation of accreditors (the Agency), which is applied in the Federation; - Accreditation implies self-evaluation, and is a process of external collegiate examination applied by health institutions, with an aim to precisely check the extent of service provision in comparison with prescribed standards and methods of implementation of continuous health system & services improvement; - Accreditation user is a health institution, a citizen, patient and his family, who may actively participate in

81 evaluating the quality of health services at different levels, and in such manner influence a person who decides on accreditation, with an aim to achieve the top quality in health. Participants in the health services quality and safety improvement are the following:. health institutions 2. health workers and associates 3. health service users 4. public health institutes 5. health insurance funds 6. chambers and associations of health workers 7. health ministries. Health Insurance and Re-Insurance Fund of the Federation of Bosnia and Herzegovina, and cantonal health insurance funds (hereinafter: health insurance funds) determine methods of incentive financing of accredited health institutions and accredited private practices, provided that they have a status of a health institution under contract, i.e. private practice under contract, in the light of regulations on healthcare and regulations on health insurance. Health insurance funds base the financing from paragraph of this Article on the criteria of quality and safety of health services in the health institutions. The Agency recognizes ISO certificates for health institutions laboratory and radiological departments issued by the Accreditation Institute of Bosnia and Herzegovina, in accordance with accreditation regulations of Bosnia and Herzegovina, if there exists a proof of validity of such a certificate. The Agency performs the procedure of health institution accreditation through the team of competent evaluators from the List of Competent External Quality Control Evaluators of the Agency. In compliance with the external quality control of the health institution from paragraph 2 of this Article, the Agency, as a first-instance body, brings the decision on the health institution accreditation (hereinafter: accreditation), within 60 days from the day of performed external quality control of the health institution.the accreditation is issued with the specification of the duration period, which may not exceed three years. The accreditation includes the following elementary data: name and location of an accredited health institution, scope of surveyed activities of the health institution, designation of the main parameters that are critical in making a positive decision about accreditation; number of the accreditation decision; accreditation duration period; accreditation evaluation degree; method of use of the accreditation and the Agency s logo, and other data and conditions proposed by the Managerial Board. In each individual case, the Agency shall send to an accredited health institution / a health institution whose accreditation has been rejected, a report on the external quality control in the health institution, within three months from the day of the mentioned control. Six months prior to the expiry of the accreditation, an accredited health institution may initiate the procedure for the accreditation renewal, upon successfully performed external health service quality control in the health institution, in a manner and according to the procedure prescribed by this Law, and regulations passed on the basis of this Law. The standards(3) require patient/service user records to be current, complete, accurate and secure to assist the safety and continuity of care and treatment. In the case of both electronic and hard copy records,requirements may include, as relevant to the service being provided: a) legible, dated, timely and signed entries b) alert notations

82 c) progress notes, observations, consultation reports, diagnostic results d) all significant events such as alteration to patients /service users condition and responses to treatment and care e) any near misses, incidents or adverse events f) procedures for confidentiality, security and storage g) use of only recognised abbreviations h) procedures for retaining and destroying records. Standards(3) are based on:?current available research,evidence and experience?internationally recognised guidelines,?recommendations from WHO and national/international professional organisations and?input from technical experts and?legal requirements. Standards based on those of other organisations/countries could be adapted to local culture and health service requirements. Accreditation for family medicine teams have 8 goals():.assesment of quality and safety in health service; 2.assesment of health institution capacity for continious health service improvement, 3.suggestions for organisational improvement, 4.the effect on continious professional development; 5.health service management improvement; 6.improvement in health system management; 7.cost effectivenes 8.continious improvement of trust in health system. Accreditation of family medicine teams gives to health professionals as well as to community in general possibility of assesment and aknowledgement of quality in providing of health services by assesing development standards in that area. References:. Agency for quality and accreditation in health care in the Federation of Bosnia and Herzegovina (AKAZ)- 2.Law on Quality Improvement System, Security and Accreditation in Health ISQua s International Principles for Healthcare Standards Third Edition, 4.Accreditation of family medicine teams,akaz,

83 MEET THE EXPERT (MExp-) April 24, 200 / 4:45 6:5 / Hall A MEET THE EXPERT SESSIONS Management of the elderly patient (Yafll hastaya yaklafl m) Moderator: Ümit Aydo an Mladen Davidovic Is there such thinks as geriatric curricula in our education (South East Europe)? M. DAVIDOVIC, D.P. MILOSEVIC, N. DESPOTOVIC, P. ERCEG Dept of Gerontology, University of Belgrade Medical Faculty, Belgrade, Serbia Towards the end of 2003, 57.7 million people were living in the region of South-Eastern Europe, according to a demographic report prepared by the Council of Europe (Council of Europe, 2005). The report observed two main demographic trends in the region: low rate of population growth and an aging population. An average age of the population in South-East Europe has increased in the past 40 years. Current demographic picture of the region, as well as predictions for the future, shows similar trends to those observed in the rest of Europe. The existing education system in the field of gerontology and geriatrics will not be able to cope with the ever growing needs of the ageing population of the region. An effort must be made to improve the system and to provide education for all health care professionals engaged in providing care for elderly. It is further important to continue with research in geriatrics and gerontology which will lead to better understanding of the problems of age and ageing. It will not only bring better standards for medical treatment of old persons, but will also improve their overall position within the society. MEET THE EXPERT 2 (MExp-2) April 24, 200 / :5 2:5 / Hall C Medical abortus (T bbi düflükler) Zeynep Tuzcular Vural Ifl k Gönenç Kenan Ertopçu Medical methods for termination of first trimester pregnancy Z. TUZCULAR VURAL, I. GONENC Haydarpafla Numune Training and Research Hospital, Istanbul, Turkey Throughout ages, women have sought options to terminate unwanted pregnancies using both surgical and traditional methods. Termination of pregnancies are one of the major health concerns in developing countries for women in their reproductive ages. Approximately unwanted pregnancies are terminated daily, in the world. Each year, some 205 million women throughout the world become pregnant and nearly one in five - 8 -

84 (20%) chooses to terminate their pregnancy. One third of these terminations are done under illegal and unhealthy conditions causing morbidity and even mortality. Surgical abortions are very commonly performed worldwide and include manipulations such as vacuum aspiration, sharp curettage, and intra-uterine injections. However, medical abortion has also become a widely used alternative method of first trimester pregnancy termination for over twenty years. Medical abortion is a way of inducing termination of pregnancy with medicine (pills). It is a scientific adaptation of potions, teas, herbal remedies that women have sought for terminating unwanted pregnancies throughout centuries. A relatively new option for services and women, medical abortion has many advantages: It is highly effective (95-98%), safe, acceptable and is a no touch procedure. It is considered to be more private by many women. It lowers the risk of infection and trauma and is less costly than surgery. Moreover, it offers efficient use of clinic facilities and staff time and can be offered in more service settings, by less- skilled providers. It expands options of methods available and entitles women to all safe and effective treatment options. Medical abortion was first introduced in France in 989 and different regimens of an antiprogestin (mifepristone) used alone or in combination with a prostaglandin analogue (usually misoprostol), have provided an alternative to surgical abortion methods. Mifepristone antagonizes progesterone, the hormone needed to maintain pregnancy and misoprostol causes contractions of the smooth muscles lining the uterus, thus emptying the contents. Mifepristone is registered in over 35 countries, most of which are in the industrialized world, including Albania, Armenia, Azerbaijan, Belarus, China, Estonia, Georgia, Guyana, Hungary, India, Latvia, Moldova, Mongolia, South Africa, Tunisia, Uzbekistan, and Vietnam. Misoprostol is available in over 90 countries for the prevention and treatment of gastric ulcers and is widely used in reproductive health for a variety of reasons, such as: cervical softening, first and second trimester abortion, labor induction, missed abortion, intrauterine fetal death, incomplete abortion, prevention and treatment of postpartum hemorrhage. Together, the two drugs soften the cervix, increasing dilation and facilitating expulsion. Mifepristone + misoprostol which is highly effective (95-98%) and has proven to be safe and acceptable, is considered to be the gold standard by many authors. Studies show that, when given the choice, many women prefer medical abortion. Several trials have taken place in Turkey to investigate the effectiveness, safety and acceptability of medical abortion. The 3rd large trial: Randomized trial: 400 mcg sublingual vs oral misoprostol following 200 mg mifepristone up to 63 days gestation ( ), is being conducted in three of the largest cities of Turkey: Ankara, Istanbul and Izmir. Preliminary results show that when offered options for termination of pregnancy, many choose medical abortion. Reasons for preferring medical abortion are fear of the surgical procedure and pain, not wanting to have a pelvic exam and because they consider it to be more private. Success rates are high and complications minimal. Termination of unwanted pregnancies is a major health concern throughout the world. This procedure is both a mental and physical burden for women, depending on personality, religious beliefs, culture, social status, and psychological factors. Offering women options for this difficult decision prevents unnecessary morbidity and increases patient contentment. Medical abortion has become an important part of reproductive health services in many countries. Medical abortion provides women with a safe alternative to the complications of surgical abortion, such as infection and trauma, and is considered to be a more natural and private method by many women. Less costly than surgery, it can be offered in simpler settings, without need for specialized equipment and by lessskilled providers and therefore provides more efficient use of clinic facilities and providers trained in surgical procedures. We believe that including medical abortion alongside surgical methods for termination of unwanted pregnancies will help expanding women s safe abortion choices. Evidence from Turkey suggests that it can play an important role in termination of unwanted pregnancies. Family physicians should provide care for women in dificult situations such as unwanted pregnancies and be aware of the fact that women who receive no family planning counseling or services after abortion, often become pregnant again and offer family planning services /contraceptive options to avoid another abortion

85 References.Ashok PW, Penney GC, Flett GM, Templeton A. An effective regimen for early medical abortion: a report of 2,000 consecutive cases. Hum Reprod. 998;3: Aubeny E, Peyron R Turpin CL, et al. Termination of early pregnancy (up to 63 days of amenorrhea) with mifepristone and increasing doses of misoprostol. Int J Fertil Menopausal Studies 995; 40 Suppl 2: Bartley J, Brown A, Elton R, Baird DT. Double-blind randomized trial of mifepristone in combination with vaginal gemeprost or misoprostol for induction of abortion up to 63 days gestation. Human Reproduction 200; 6(0): Elul B, Hajri S, N.Ngoc, et al. Can women in less-developed countries use a simplified medical abortion regimen? The Lancet 200 ; 357: Guengant JP, Bangou J, Elul B, Ellertson C. Mifepristone-misoprostol medical abortion: Home administration of misoprostol in Guadeloupe. Contraception (3): Guest J, Chien PF, Thomson MA, Kosseim ML. Randomized controlled trial comparing the efficacy of sameday administration of mifepristone and misoprostol for termination of pregnancy with the standard 36 to 48 hour protocol. BJOG 2007; 4(2): Middleton T, Schaff E, Fielding SL, et al. Randomized trial of mifepristone and buccal or vaginal misoprostol for abortion through 56 days of last menstrual period. Contraception 2005; 72(5): Schaff EA, Eisinger SH, et al. Low-dose mifepristone 200mg and vaginal misoprostol for abortion. Contraception 999; 59:-6. 9.Schaff EA, Fielding SL, Westhoff C, et al. Vaginal misoprostol administered,2, or 3 days after mifepristone for early medical abortion: A randomized trial. JAMA 2000; 284(5): Schaff EA, Fielding SL, Eisinger SH, Stadalius LS, Fuller L. Low-dose mifepristone followed by vaginal misoprostol at 48 hours for abortion up to 63 days. Contraception. 2000;6:4-6..Winikoff B, Sivin I, Coyaji KJ, et al. Safety, efficacy and acceptability of medical abortion in China, Cuba, and India: A comparative trial of mifepristone-misoprostol versus surgical abortion. American Journal of Obstetrics and Gynecology 997; 76: Schaff EA, Fielding SL, Westhoff C. Randomized trial of oral versus vaginal misoprostol 2 days after mifepristone 200mg for abortion up to 63 days of pregnancy. Contraception 2002 ; 66(4): Shannon C, Wiebe E, Jacot F, et al. Regimens of misoprostol with mifepristone for early medical abortion: A randomized trial. BJOG 2006;3(6): Spitz IM, Bardin CW, Benton L, Robbins A. Early pregnancy termination with mifepristone and misoprostol in the United States. N Engl J Med 998 ; 338(8): Tang OS, Chan CC, Ng EH, Lee SW, Ho PC. A prospective, randomized, placebo-controlled trial on the use of mifepristone with sublingual or vaginal misoprostol for medical abortions of less than 9 weeks gestation. Hum Reprod 2003; 8(): WHO Task Force on Post-ovulatory Methods for Fertility Regulation. Comparison of two doses of mifepristone in combination with misoprostol for early medical abortion: A randomized trial. BJOG 2000;07: Turkish Demographic and Health Survey, 2008, Hacettepe University Institute of Population Studies, Turkish Republic Ministry of Health, Mother and Child Health and Family Planning Directorate, State Planning Organization and European Union, Ankara, UNDP/UNFPA/WHO/WORLD BANK. Special Programme of Research, Development and Research Training in Human Reproduction. Social Science and Operations Research in Sexual and Reproductive Health. Call for research proposals/concept papers on med cal abort on reached from 4.html on Akin A, Blum J, Özalp S, et al. Results and lessons learned from a small medical abortion clinical study in Turkey. Contraception 2004;70(5): ***

86 Mifepristone for medical abortion: overview and management of side effects and complications I. GONENC, Z. TUZCULAR VURAL Haydarpafla Numune Training and Research Hospital, Istanbul, Turkey Mifepristone, a synthetic steroid also known as RU-486, which blocks the actions of progesterone, was developed in France in 980. After undergoing clinical trials it was licensed for use in France in 988, the UK in 99, and the US in 2000 for the medial termination of pregnancies. Mifepristone is a safe, effective and economical alternative among abortion methods. It has access in many of the developed countries and underway of approval in many of the developing countries.,2 The possibility for privacy and the minimally invasive nature of the treatment resulted in high degrees of satisfaction with the method, with around 90% of women being satisfied or very satisfied.3,4 Literature reveals information about the administration, effectiveness as well as side effects and risks of mifepristone. Mifepristone is usually administered with a prostaglandin analogue to facilitate the expulsion of the uterine contents, when used for medical termination of pregnancy and most of the cases do not need any further surgical intervention. In a very small number of women, heavy vaginal bleeding necessitates hospital admission and very rarely transfusions. Infection of retained products of conception is a possibility, and antibiotics may be needed.,3,4 Pregnancy always has potential risks for any woman, but when compared with continuing the pregnancy, both surgical and medical abortions are reported to carry less than 0% of the risk of mortality.5 Medical termination can be performed as soon as intrauterine pregnancy is confirmed, usually with transvaginal ultrasound, approximately at 5 weeks of gestational age. A positive pregnancy test without the image of an intrauterine sac creates a dilemma for the providers. The patient may have either a very early pregnancy, a missed abortion, or an ectopic pregnancy; hence it is essential that an intrauterine pregnancy is confirmed at the follow-up visit in case the provider decides to carry out the medical termination.6 Side effects are an expected part of medical abortion. Some arise from the abortion process itself and some from the medication. Abdominal cramps, with the severity of pain varying from patient to patient affect 90% of women. Pain is modified by factors such as fear, anxiety and support during the procedure. Oral analgesics or NSAIDs are sufficient to control the pain in most women. In cases of severe persistent pain, it is important to exclude important causes such as ectopic pregnancy. 7-9 Bleeding is heaviest usually at the time of expulsion of the sac/fetus and is commonly more prolonged than after the surgical procedure. It is a normal consequence of the abortion process, but may exceed the woman s expectations due to previous experiences of bleeding. On-call evaluations of bleeding are sometimes needed with medical abortion and the presence of any symptoms such as dizziness, weakness or fatigue must be evaluated. As with pain management, informing the patient in advance of what to expect is essential. Surgical intervention for excessive bleeding is required in less than % of st trimester medical abortions. 0,

87 Subjective symptoms with persistent heavy bleeding unresponsive to medical treatment, symptoms or signs of orthostatic instability, a low Hb level, particularly if the patient continues to bleed, and the patient s preference for surgical aspiration are indications for surgical evacuation.7 As with surgical abortions, a small percentage of incomplete termination of pregnancy can be experienced. The clinical state of the patient determines the plans of monitoring or any type of intervention.2,3 Nausea and vomiting, which are also common nuisances at the early stages of pregnancy, can be increased also accompanied by diarrhea although usually self-limiting after misoprostol administration.4 Headache and dizziness are usually mild and self-limiting. Dizziness may be a side effect of any of the medications or a response to the abortion process. It is best managed with bed rest, hydration, slow position changes and assistance with ambulation unless associated with high volume loss 7. As a reaction to either mifepristone or misoprostol, hot flushes and sensations of warmth or fever are also fairly common side effects of medical abortion which are usually short-lived and resolve spontaneously. A temperature exceeding 38ºC that persists for more than 24 hours warrants evaluation for infection.5 Endometritis, especially in patients screened and treated for STI s, is a rare complication of medical abortion may present with persistent pelvic pain with or without irregular bleeding or fever in the days after the pregnancy. 7 No data exists to support routine prophylaxis for medical abortion. Mifepristone, not shown to be effective in treating ectopic pregnancy yields one of the most dangerous complications in case of an undiagnosed ectopic pregnancy. Every effort must be made before the medical abortion process in order not to miss an ectopic pregnancy. A pseudogestational sac which may mimic an early intrauterine gestational sac should always be kept in mind until the presence of a yolk sac or a fetal pole is depicted. 6,5 Previous allergic reaction to one of the drugs involved, documented history of familial porphyria, adrenal insufficiency, known or suspected ectopic pregnancy, clotting disorders or anticoagulant therapy, are the few absolute contraindications to medical abortion. Moreover caution is also required in a range of circumstances such as long-term corticosteroid therapy, an IUD in place and severe anemia. There is no evidence that age, anemia, breastfeeding, insulin-dependent diabetes or thyroid disease, multiple pregnancy, obesity, previous caesarean section, smoking, uterine malformations, previous cervical surgery represent any contraindications.6 Unwanted pregnancies will continue to occur as a consequence of human sexuality and the topic of abortion will always be a controversial one but women will continue to seek safe, legal abortion methods. References:. Dickerson V, American College of Obstetricians and Gynecologists. ACOG letter on safety of RU-486, 7 December 2004 [news release]. Available at: 04.cfm (accessed March 200)

88 2. Baulieu EE. Contraception by the progesterone antagonist RU 486: a novel approach to human fertility control. Res Reprod 987; 9: Schreiber CA, Creinin MD, Harwood B, Murthy AS. A pilot study of mifepristone and misoprostol administered at the same time for abortion in women with gestation from 50 to 63 days. Contraception 2005; 7: Faucher B, Baunot N, Madelenat P. The efficacy and acceptability of mifepristone medical abortion with home administration misoprostol provided by private providers linked to the hospital: a prospective study of 433 patients. Gynecol Obstet Fertil 2005; 33: Bartlett L, Berg C, Shulman H, Zane S, Green C, Whitebread S, et al. Risk factors for legal induced abortion-related mortality in the United States. Obstet Gynecol 2004; 03: Suzanne R. Trupin, MD, FACOG, Carey Moreno, BS. Medical Abortion: Overview and Management. 03/08/2002; Medscape General Medicine. 2002;4() 2002 Medscape. (accessed March 200). 7. Kruse B, Poppema S, Creinin MD, Paul M. Management of side effects and complications in medical abortion. Am J Obstet Gynecol 2000; 83(2 Suppl): S Spitz IM, Bardin CW, Benton L, Robbin A.Early Pregnancy termination with mifepristone and misoprostol in the United States. N Engl J Med 998; 338(8): Schaff EA, Eisinger SH, Stadalius LS, Franks P, Gore BZ, Poppema S. Contraception 999; 59 (): Harper C, Winikoff B, Ellertson C, Coyaji, K. Blood loss with mifepristone misoprostol abortion: measures from a trial in China, Cuba and India. Int J Gynaecol Obstet 998; 63(): Ashok PW, Penney GC, Flett GM, Templeton A. An effective regimen for early medical abortion: a report of 2000 consecutive cases. Hum Reprod 998; 3(O): Wolman I, Jaffa AJ, Pauzner D, Hartoov J, David MP, Amit A. Transvaginal sonohysterography: a new aid in the diagnosis of residual trophoblastic tissue. J Clin Ultrasound 996;24(5): Dillon EH, Case CQ, Ramos IM, Holland CK, Taylor. KJ. Endovaginal US and Doppler findings after first-trimester abortion. Radiology 993; 86(): El-Rafaey, H., D. Rajasekar, D, Abdalia M, Calder L, Templeton A. Induction of abortion with mifepristone (RU486) and oral or vaginal misoprostol. N Engl J Med 995; 332(5): Management of the side effects and complications of early medical abortion.(gestations <49 days). doc (accessed March 200). 6. The ICMA Information Package on Medical Abortion. Information for health care providers. March 200). MEET THE EXPERT 3 (MExp-3) April 24, 200 / 4:45 6:5 / Hall C Pain management in chronical diseases (Kronik hastal klarda a r ya yaklafl m) Moderator: Nafiz Bozdemir Süleyman Özyalç n Osman Nuri Ayd n A r ; tan m, s n flama, de erlendirme, hastaya yaklafl m, tedavi prensipleri, kronik a r l hastada t bbi ve invazif tedavi N.S. OZYALCIN stanbul Üniversitesi stanbul T p Fakültesi Algoloji Bilim Dal, stanbul, Türkiye A r var olan veya olas doku hasar na efllik eden veya bu hasar ile tan mlanabilen, hofla gitmeyen duyusal ve emosyonel deneyimdir. Bu deneyimi de erlendirirken hem fiziksel hem de fiziksel olmayan bileflenlerini birlikte de erlendirmek zorunday z. Farkl a r tür ve kaynaklar na yönelik, farkl tedavi modaliteleri bulunmaktad r

89 Genifl de erlendirme sonras nda hastalar öncelikle konvansiyonel yöntemler ile tedavi edilip yarar sa lanmad koflullarda giriflimsel yöntemler uygulan r. A RININ SINIFLAMASI A r ; süreye, nörofizyolojik mekanizmalara, etyolojiye ve kaynakland bölgeye göre s n fland r labilir. Süreye göre a r ; akut ve kronik a r olarak iki flekilde ele al n r. Akut ya da ivegen a r, ani olarak bafllayan ve k sa süren a r d r. Kronik a r ise kimi yazarlara göre üç ay; kimilerine göre alt ay aflk n süredir devam eden a r d r. Kronik a r içinde pek çok komponenti içeren kompleks bir yap d r ve bafll bafl na bir hastal k olarak de erlendirilir. Kronik a r l hastada a r n n duyumunun yan s ra, a r davran fl, emosyonel durum, a r n n ifl ve sosyal hayat üzerindeki etkileri gibi birçok faktör rol almaktad r. Bu özelliklerden yola ç karak IASP Taksonomi komitesi befl eksenli s n flamay ortaya atm flt r. Bu s n flamaya göre kronik a r genel olarak a) bölge, b) sistem, c) a r n n geçici özellikleri ve oluflum flekli, d) Hastan n fliddet de erlendirmesi ve bafllang çtan itibaren geçen zaman, e) etyoloji olarak befl eksene ayr lm flt r. Nörofizyolojik mekanizmalara göre a r : Nosiseptif a r ; a. Somatik a r b. Visseral a r Nosiseptif a r, fizyopatolojik olaylar n, a r reseptörlerini (nosiseptörler) uyarmas na ba l olarak ortaya ç kar. ki alt gruba ayr lmaktad r. Somatik sinirlerden kaynaklanan a r ani bafllar, keskindir ve iyi lokalize edilir. Tan s kolayd r. Buna karfl n visseral a r yavafl bafllar, künt ve s zlay c d r. Yerinin belirlenmesi zordur. Kolik ve kramp tarz nda olabilir. Baflka bölgelerde yans yan a r fleklinde ortaya ç kabilir. Nöropatik a r a- Santral - Spi nal kor d hastal klar (kon tüz yon, is ke mi, tü mör) - Be yin sa p, ta la mus (in farkt, tü mör, trav ma) b-periferik - Nö ro ma - Si nir komp res yo nu - Si nir ezil me si, avül si yo nu, ge ril mesi, ke sil mesi - Nö ro pa ti ler (di abe tik nö ro pa ti, rad yas yon nö ro pa ti si, al kol nö ro pa ti si, is ke mik nö ro pa ti, post her pe tik nev ral ji) Nöropatik a r, periferik sinirlerin travma veya metabolik bir hastal k sonucu malfonksiyonuna ba l olarak periferik, santral sinir sisteminden kaynaklanan nedenlerle ise santral olarak ortaya ç kar. Diabetik nöropati s ras nda ortaya ç kan a r lar periferik nöropatik a r ya, fantom a r s gibi deaferentasyon a r lar ise santral nöropatik a r ya örnek olarak verilebilir. Nöropatik a r da fizyopatolojik mekanizmalar periferik ve santral mekanizmalar olarak iki grupta de erlendirilebilmektedir. Periferik mekanizmalar içerisinde ektopik deflarj, nosiseptör sensitizasyonu, lifler aras anormal etkileflim, katekolaminlere artm fl duyarl l k gibi primer afferentlerde de iflikliklere sebep olan etkenler say labilir. Santral mekanizmalar ise duyusal yollar n irritasyonu, sempatik sistem irritasyonu, hipotalamik bozukluk, inici inhibitör mekanizmalar n kayb ve alternatif sekonder ç k c yollar n aktivasyonu olarak say labilir. Periferik sensitizasyon: Cerrahi giriflim veya travmadan sonra harap olan hücrelerden bir tak m intrasellüler maddeler sal n r. Makrofaj, lenfosit ve mast hücreleri de olaya ifltirak eder. Mast hücresi lenfosit ve makrofajlardan bradikinin ve serotonin salg lan r. Prostoglandinler ve lökotrienlerin yap m artar. Prostoglandinler sensitize olmufl sinir uçlar ndan a r y artt ran P Maddesi nin salg lanmas na neden olurlar. Bu da hasara komflu bölgelerdeki nosiseptörleri sensitize eder, sonuçta hiperaljezi meydana gelir. Yani düflük fliddetteki mekanik uyaran daha a r l olarak alg lan r. Buna primer hiperaljezi denir

90 Ektopik Deflarjlar: Sinir hasar sonras ortaya ç kan demiyelinizasyon nedeniyle sinir lifi boyunca ektopik uyar lar yay lmaya bafllar. Ayr ca, aksonun zedelendi i yerde membran hipereksitabilitesi oluflur. Bu durum da ektopik deflarjlar n oluflmas na yol açar. Santral Sensitizasyon: Periferik sinir hasar sonras afl r miktardaki sensoriyal uyar lar santral sinir sistemine ulaflarak dorsal boynuz reseptif alan nda de iflikliklere yol açar. Bu de ifliklikler sonucu hipereksitabl hale gelen nöronlar spontan aksiyon potansiyeli olufltururlar ve bu oluflan anormal yüksek frekansl aktivite a r ya katk da bulunur. Nöropatik a r n n hayvan modellerinden edinilen deneysel kan tlarda, NMDA (N-Metil-D-Aspartat) reseptörlerinin aktivasyonunun önemli bir rolünün oldu unu ve bir NMDA reseptör antagonisti olan ketaminin intravenöz infüzyonunun nöropatik a r l hastalarda a r n n fliddetinin azaltt gösterilmifltir. nhibitör kontrollerin kayb : Nöropatik a r oluflumunda korteksten spinal korda inen inhibitör kontrollerin kayb önemli yer tutar. Desenden yollar ile nosiseptif iletimi ayarlayan ana merkezler; somatosensoriyel korteks, talamus, hipotalamus, orta beyinde periakuaduktal gri madde, medullada rafe magnus çekirde i ve spinal kord arka boynuzdaki ara ba lant lard r. Nöropatik a r tedavisinde kullan lan antidepresanlar, serotonerjik ve noradrenerjik etkileri ile inen inhibitör yolara etkileri ile nöropatik a r y dindirirler. Eksitatör ve inhibitör inputlar periferden beyine bilginin gidiflini düzenlerler. nhibitör etkiler spinal korddaki inhibitör internöronlardan kaynaklan r ve bunlar gama amino bütirik asit (GABA) ve glisin gibi nörotransmitterler ile fonksiyon görürler. Bu inhibitör kontrollerden biri veya hepsinin bozulmas veya kayb ile dorsal boynuz nöronu afferent inputa cevap olarak abart l flekilde atefllenir ve hastada allodini ortaya ç kar. Nöropatik a r n n anormal duyular : Spontan a r : Bir uyaran olmadan oluflan zonklay c, yan c, keskin a r d r. Parestezi: Anormal a r l olmayan duyulard r. Kendili inden veya uyar ile meydana gelebilir ( kar ncalanma, uyuflukluk) ve duyu kayb efllik edebilir. Dizestezi: Kendili inden veya bir uyaranla meydana gelen anormal a r d r (hofl olmayan yanma ve kar ncalanma). Hiperaljezi: Zararl bir uyaran taraf ndan oluflturulan abart l bir a r cevab d r veya normalde a r l olan bir uyar ya verilen artm fl cevap olarak da tan mlanabilir. Hiperpati: Zararl veya zarars z uyaran taraf ndan oluflturulan abart l a r cevab d r. Allodini: Zarars z bir uyarana a r l cevapt r. Örne in vücuda pamuk de mesi ile a r n n ortaya ç kmas. Psikosomatik a r, psiflik ve psikososyal sorunlar n artt durumlarda a r olarak tan mlanan duygulard r. Somatizasyon ve hipokondriazis örneklerinde görüldü ü gibi. A RININ ÖLÇÜMÜ VE DE ERLEND R LMES Hastay hekime getiren nedenlerin bafl nda gelen ve insan hayat nda çok önemli olumsuz etkileri olabilen a r n n ortak bir dil ile ölçülebilmesi, a r n n kendisi ve tedavi yöntemlerinin de erlendirilmesi aç s ndan önemlidir. Ancak tamamen subjektif bir deneyim olan a r n n ölçümü oldukça güçtür. A r ölçümünde kullan lan tek boyutlu yöntemler;. Kategori skalalar : Bu tip skalalar n sözel yan tl olanlar nda hastadan a r s n n fliddetini tan mlayan kelimeleri seçmesi istenir. Hafif, can s k c, rahats z edici, berbat, çok fliddetli kelimeleri kullan labilinir. 2. Say sal skalalar: (Numerik Rating Skala (NRS): Subjektif a r de erlendirilmesinde en basit ve en s k kullan lan ölçüm fleklidir. Hastalar 0 n a r s zl 00 ün olabilecek en fliddetli a r y belirtti i (veya 0-0 aras nda) skalada ne fliddette a r duydu unu ifade eder. Bu tip skalalar hasta taraf ndan kolay anlafl l r. Yaz l veya sözlü olarak uygulan r. 3. Vizüel analog skala (VAS): Bir ucunda a r s zl k di er ucunda olabilecek en fliddetli a r yazan 0 cm lik bir cetvel üzerinde hasta kendi a r s n iflaretler. A r ölçümünde kullan lan çok boyutlu yöntemler; Bunlar içinde en çok kullan lan Mc Gill a r soru formu (MPQ), a r y sensoriyel, affektif ve de erlendirme yönünde inceleyen 20 tak m soru içerir. Hastalara a r lar na uyan tak m seçmeleri ve her tak m n içindeki a r y en iyi tarif eden kelimeyi iflaretlemeleri söylenir. Her bölüm a r n n fliddetini anlatan 2-6 kelimeden oluflur. lk

91 0 set sensoriyel kaliteyi, sonraki 5 tanesi affektif boyutu, 6 set de erlendirme seti, en son 4 set ise çok yönlü kelimelerden oluflur. Her tak m puanlay p sonunda toplam bir puan elde etmek mümkündür. Kronik a r l hastada a r günlü ü tutmak da faydal d r. A RILI HASTAYA YAKLAfiIM Kronik a r l bir hastada do ru tan ya ulaflmada en önemli faktör iyi bir anamnezin al nmas d r. Do ru tan, do ru tedavinin uygulanabilmesinin yegane yolu oldu una göre, a r l hastada anamnezin ne kadar önemli oldu u da ortaya ç kmaktad r. Önemli bir organik patolojinin ilk bulgusu olarak karfl m za ç kabilece i gibi, ortada hiçbir organik neden olmadan da a r l durumlarla karfl laflabiliriz. Bu nedenle a r l hastan n anamnezi, fizik muayene ve laboratuar bulgular kadar tan de erine sahiptir. A r l hastada genel olarak yap lan baz yanl fllar vard r. A r ya önem verilmemesi, a r de erlendirilmesinin yap lmamas ve ilaç farmakolojisi konusunda yeterli bilgi sahibi olunmamas bunlardan baz lar olarak say labilir. Ayr ca özellikle kanser a r lar nda büyük bir problem yaratan yanl fl, opioidlerin özellikle ba ml l k korkusu ile düzgün kullan lmamas d r. Kronik a r l hastalar n büyük bir ço unlu u say s z doktora gitmifl ve bu konuda ciddi ön yarg lar geliflmifltir. Daha önceki tedavilere ait baflar s zl klar nedeniyle, güvensiz, k rg n, hatta k zg n bir ruh halinde olabilir. Bu nedenle hekimin daha ilk karfl laflmada güven vermesi ve hasta ile iyi bir kooperasyon kurmas gerekmektedir. E er hasta baflka bir hekim taraf ndan gönderiliyorsa, hasta a r konusunda uzman ve deneyimli bir hekim ya da merkeze geldi i için daha bafllang çtan itibaren baz beklentileri olacakt r. lk görüflmede hekimin hastan n do ru yerde oldu u ve a r s n n kontrolü ile ilgili do ru giriflimlerin yap laca konusunda güven duymas n sa lamas gerekmektedir. A r ile ilgilenen bir hekimin bu aflamada yapaca en büyük yanl fl, bir meslektafl taraf ndan gönderilmifl olan hastan n gerekli de erlendirmesini yapmadan, tedaviyi planlamak olacakt r. De erlendirme s ras nda hastan n a r nedenini nas l tan mlad, a r n n etkisi konusunda duygular, a r kontrolunun hasta aç s ndan önemi ve sa l k ekibinden beklentileri ayr ca sorgulanmal d r. A r l hastan n anamnezini çeflitli bölümlere ay rabiliriz: - A r hikayesi 2- Geçmifl medikal hikaye 3- Fizik ve psikolojik hikaye 4- Aile anamnezi Tüm bu bölümlerin detayl ve dikkatli bir flekilde kaydedilmesi gerekmektedir. Bu nedenle a r kliniklerinin birço unda gelifltirilmifl anamnez formlar bulunmaktad r. Anamnez formunun bafllang c nda hastaya ait demografik bulgular yer almal d r. Ad -soyad, yafl, cinsiyeti, ev adresi, telefon numaras, medeni durumu, varsa çocuklar, mesle i ve e itim durumu kaydedilmelidir. Anamnez uzun sürece i için bafllang çta hastay bu konuda ayd nlatmak ve rahat edebilece i bir pozisyonda-gerekiyorsa yatar postürde, anamnez al nmal d r. Ancak hastan n hekimi manipüle etmesinin önüne geçilmelidir. Hastay hekime getiren neden elbette ki flu andaki a r s d r, ancak geçmiflteki a r hikayesi de hekime hasta ile ilgili de erli bilgiler verecektir. A r anamnezi; a r n n: a- Yeri, b- Yay l m, c- Süresi, d- S kl, e- Seyri, f- Niteli i, g- fiiddeti, h- Artt ran ve azaltan faktörler, i- A r n n beraberinde bulunan di er semptomlar, j- Daha önce uygulanan tedavi yöntemleri ve sonuçlar bölümlerini içermelidir. A r n n Yeri ve Yay l m A r n n lokalizasyonu ve yay l m a r n n tipi konusunda fikir verir. Lokalize a r, dermatomal a r, yans yan a r ya da psikolojik a r n n ay rt edilebilmesini sa lar. Lokalize a r ya bursit, tendinit ya da artrit a r s, dermatomal a r ya, radikülopatiler ve postherpetik nevralji, yans yan a r ya ise akut pankreatit a r s tipik örnektir. Somatizasyon a r s hiçbir nöroanatomik lokalizasyona ve da l ma uymaz. Hastalar n birço unda tüm vücudu saran ya da gezinen a r lar söz konusudur ve genellikle bir bölgedeki a r baflka bir yerin a r mas ile hafifleyebilir ya da unutulabilir

92 A r n n S kl, Süresi ve Seyri A r n n bafllang c n n ani olmas ya da giderek fliddetlenmesinin yan s ra, seyrinin epizodik mi sürekli mi oldu u da sorgulanmal d r. Örne in bafla r s olan bir hastada a r n n 0 y ld r sürekli olmas ile ayda -2 defa gelip -2 gün süren a r karakterinde olmas, ya da bel a r s olan bir hastada aktivite ile ortaya ç kan epizodlar n oluflu tan aç s ndan çok önemlidir. A r n n s kl ve süresi ile birlikte mutlaka seyri de irdelenmelidir. A r sürekli mi, intermittan m, dalgalanmalar gösteren bir karakteri mi var diye ay rt edilebilir. Günlük seyrin de tan da büyük önemi vard r. Örne in bel a r s olan bir hastada aktivite ile artan a r gece istirahatla azal rken, nöropatik a r lar genellikle geceleri fliddetlenirler. A r n n seyri konusunda tam bir fikir sahibi olabilmek için a r günlü ü önerilmektedir. A r n n Niteli i A r n n künt ya da keskin olmas n n yan s ra tipinin de belirlenmesi gerekmektedir. Hastaya a r nitelikleri bir liste halinde sunulabilece i gibi tek tek de sorulabilir Elektrik çarpmas fleklinde bir a r daha çok nevraljiyi düflündürürken, s zlama, yanma ya da üflüme nöropatik a r lehine bir bulgudur. diopatik trigeminal nevralji tan s n n anamnez ile konuldu u ve anamnezdeki en önemli bulgunun elektrik çarpmas niteli inde bir a r oldu u düflünülürse, a r n n niteli inin belirlenmesinin önemi ortaya ç km fl olur. A r n n fiiddeti A r subjektif oldu u ve kifliden kifliye de ifliklik gösterdi i için objektif ölçümü çok zordur. Ölçümde as l olan hastan n belirtti i a r fliddetine inanmakt r. A r fliddetinin ölçümünde genellikle kiflinin geçmiflteki deneyimlerinden yararlan l r. A r ölçümünde kullan lan çok çeflitli ölçüm yöntemleri bulunmaktad r. Genel olarak kronik a r l hastalarda çok boyutlu a r ölçüm yöntemlerinin, akut a r larda ise tek boyutlu yöntemlerin kullan lmas önerilmektedir. A r fliddeti takip ve tedavide en önemli parametredir ve s k aral klarla de erlendirilmelidir. A r n n aile ve ifl sorumluluklar, kiflisel bak m ve hijyen, sosyal ve cinsel yaflam gibi çeflitli aktiviteleri ne derece k s tlad saptanmal d r. A r y Artt ran ve Azaltan Faktörler Hastan n söylemeyi, hekimin ise sormay unutabilece i düflünülerek anamnez formuna sorgulanmas gerekli tüm faktörler önceden yaz larak tek tek sorgulanmal d r. Örne in bel a r s olan bir hastada a r n n pozisyonla olan iliflkisi bel a r s n n kayna ile ilgili de erli bilgiler verebilir. Bafla r l bir hastada ise a r n n menstrüel siklus, stres, alkol ve açl k gibi çeflitli faktörlerle olan iliflkisi de erlendirilmelidir. A r anamnezinde a r ya efllik eden semptomlar da belirlenmelidir. A r oluflturan organik bir patolojinin varl n ortaya koyabilmek aç s ndan semptomlar önem tafl maktad r. Hastada a r ile birlikte zay flama, ifltahs zl k gibi bulgular n varl malignite aç s ndan hekimi uyaracakt r. Belbacak a r s olan bir hastada a r ile birlikte baca nda güç kayb, uyuflukluk ya da inkontinans olup olmad, bafla r l bir hastada bafla r s na bulant -kusman n efllik edip etmedi inin bilinmesi tan aç s ndan çok önemlidir. Daha Önce Uygulanan Tedavi Yöntemleri ve Sonuçlar Kronik a r l hastalar n birço unda çeflitli a r kontrol yöntemleri uygulanm fl olabilir. Bu yöntemleri de erlendirirken hastan n flu anda kullanmakta oldu u ilaçlar ya da di er tedavi yöntemleri ile geçmiflte uygulananlar ayr bafll klar alt nda irdelenmelidir. Medikal tedavide kullan lan ajan n ne süre ile ne dozda kullan ld kaydedilmelidir. Özellikle hastada analjeziklerin yanl fl ya da kötü kullan m n n ortaya konabilmesi aç s ndan bu sorular önemlidir. Analjezikler d fl nda hastan n yak nmas na göre; a r kontrolü amac yla yap lm fl cerrahi giriflimler, sinir bloklar, fizik tedavi yöntemleri, malignite söz konusu ise, onkolojik tedavi yöntemleri de ayr ayr sorgulanmal d r. Bu bölümde ayr ca hastan n a r ile bafl etmede kendisinin kulland yöntemlere de yer verilmelidir

93 A r ya ait tüm özellikler geçmiflteki a r l durumlar için de sorgulanmal d r. Geçmiflte benzeri ya da baflka a r l bir hastal k nedeniyle hekime müracaat etmifl mi? Acil olarak a r l bir hastal k nedeniyle hastaneye gitmifl mi? sorular na yan t aranmal d r. Her hastan n anamnez formunda mutlaka geçmiflteki a r anamnezi bulunmal d r. Bu bölümde ayr ca, travma hikayesi, çal flt ifli ile ilgili aktiviteleri de sorgulanmal d r. Geçmifl Medikal Hikaye A r l hastada detayl bir a r anamnezinin al nmas tan için her zaman yeterli olmad gibi, tan s konmufl bir hastada tedavi düzenlenmesi s ras nda di er sistemik hastal klar konusunda bilgi sahibi olmak gerekmektedir. Bu nedenle anamnezde detayl bir medikal hikaye de bulunmal d r. Hastan n tan s konmufl ve tedavisi halen sürmekte olan kardiyovasküler, renal yada gastrointestinal hastal klar n n yan s ra; geçmiflte geçirdi i önemli hastal klar, ameliyatlar veya hastane yat fllar irdelenmelidir. Ayr ca henüz tan s konmam fl a r d fl ndaki semptomlar n n varl da araflt r lmal d r. Özellikle malignitelerin tan s nda medikal anamnezin büyük önemi bulunmaktad r. Hastan n kullanmakta oldu u ilaçlar da bu bölümde sorgulanmal d r. Sürekli kulland ilaçlar olan hastalarda tedavi düzenlenirken ilaç etkileflimleri göz önünde bulundurulmal d r. Bu nedenle hastan n kullanmakta oldu u ilaçlar, dozlar ve ne zamandan beri kullan ld klar ayr ayr not edilmelidir. Yine bu bölümde sigara ve içki gibi madde ba ml l klar bafllang çtan bu güne de in irdelenmelidir. Örne in; sigara içen bir hastada kaç y ld r bu al flkanl n sürdü ü kadar, günlük içilen miktar n da önemi vard r. Aile Anamnezi Kronik a r l hastan n anamnezinin son bölümünü aile anamnezi oluflturmal d r. Aile ve yak n akrabalarda görülen a r l durumlar ve ailede süregelen herhangi bir sistemik hastal k varl araflt r lmal d r. Bafla r s ile bize baflvuran ve migren tan s düflünülen bir hastada, ailede benzer bafla r lar n n oldu unun saptanmas tan aç s ndan de erli bir bulgu olabilir. Ailedeki a r anamnezi kadar sistemik hastal klar n da önemi vard r. Ailede kardiyovasküler hastal klar, diyabet, GIS hastal klar yada malignite olup olmad irdelenmeli ve ayr nt l olarak not edilmelidir. Kronik a r sendromlar n n bafll bafl na bir hastal k olarak kabul edilmesi ve tedavisinin özel bir disiplin çerçevesinde yap lmas n n gereklili i bilinen bir gerçektir. Bu çerçevede; subjektif bir duyu olan a r n n objektif de erlendirmesini yapabilmek ve ço u zaman objektif verileri bulunmayan baz kronik a r sendromlar na tan koyabilmek için elimizdeki en önemli silah anamnezdir. A r l hastadan al nacak detayl bir anamnez, fizik muayene ve laboratuar tetkiklerden önce ön tan konusunda bize fikir verecektir. A RI KONTROLÜ Kronik a r bir süre sonra hastal k gibi karakter kazan r. Depresyon, demoralizasyon, hareketsizlik, baflka kiflilere ba ml l k va afl r ilaç tüketimi bu hastalar n yaflam tarzlar n belirlemeye bafllar. Öte yandan sosyo-ekonomik sorunlar da artarak bunlara eklenir. A r kontrolünde tek bir modelden ziyade birçok tedavi fleklinin bir plan içinde belirlenmifl esaslara göre yap lmas son derece yararl d r. A RI TEDAV YÖNTEMLER A r n n ortadan kald r lmas ço u kez mümkün olabilmekte ancak, bazen a r tedaviye olan direncini sürdürmektedir. Amaç hastan n s k nt l, hayattan bezmifl görünümünü ve hayat kalitesini düzeltmeye yönelik olmal d r. Analjezikler ve Analjezik Kullan m lkeleri Analjezikler akut ve kronik a r sendromlar nda a r n n semptomatik kontrolünün sa lanmas nda kullan lan ajanlard r. Kronik a r l hastalarda tedavide uygulanan algoritmalar nedeniyle hastaya uygulanacak ilk a r kontrol yöntemi analjeziklerin verilmesidir. A r n n kontrolünde, a r n n fizyopatolojisine, alg lanmas na iliflkin bilgilerin yan s ra, kullan lacak analjeziklerin etkinliklerini de bilmek gereklidir

94 ANALJEZ K KULLANIM LKELER Analjezik kullan m nda önce oral yol tercih edilmelidir: Di er yollar ancak oral yol etkili olmad ya da etkisini yitirdi i takdirde seçilmelidir. Ancak oral yol tercih edilirken analjezik ilaçlar n yan etkileri de dikkate al nmal d r. Analjezik dozu hastaya göre ayarlan r: Analjeziklerin etki dozu hastadan hastaya farkl l k gösterir. Ayr ca a r n n niteli i ve fliddeti verilen analjezi in etkinli ini önemli ölçüde etkiler. Bu nedenle analjezik dozu her hasta için ayr ayr belirlenmelidir. Uygun doz, yeterli analjezi sa layan fakat yan etki oluflturmayan dozdur. Analjezikler belirli zaman aral klar ile verilmelidir: Analjezikler di er ilaçlar gibi kanda belirli yar lanma süresine sahiptirler. Bu nedenle etki süreleri belirlidir. Birçok hekim taraf ndan analjezikler yemek saatlerine göre verilmekte ve genellikle bu nedenle gece a r kontrolü daha güç olmaktad r. Analjezikler bölünmüfl dozlarda, doz atlanmadan ilac n yar lanma ömrüne göre verilmelidir. Örne in 3x (sabah-ö le-akflam) de il, 8 saatte bir verilmelidir. Analjezikler a r bafllamadan verilmelidir: Analjezikler belirli yar lanma süresine sahip ilaçlard r. Ço u kez analjezikler a r yeniden bafllay p dayan lmaz hale geldi inde verilmektedir. Bu da analjezik tedaviye her seferinde yeniden, s f r noktas ndan bafllan lmas anlam na gelmektedir. Kronik a r da hastan n fliddetli a r s olmadan, analjezikler bölünmüfl dozlarda saate göre verilmelidir. Analjezik kullan m ilkeleri tüm kronik a r sendromlar için geçerli olmakla birlikte, özellikle kanser a r lar nda kullan m nda bu ilkeler çok daha büyük öneme sahiptirler. Analjezikler flu flekilde s n flanabilir: A. Non-opioid analjezikler, B. Opioid analjezikler, C. Adjuvan (Sekonder) analjezikler NON-OP O D ANALJEZ KLER Nonsteroid antiinflamatuar ilaçlar (NSA ) d fl nda metamizol ve parasetamol da bu grupta incelenmektedir. NSAID, hafif-orta fliddette a r lar n, romatizmal atefl, romatoid artrit, osteoartrit gibi inflamatuar durumlar n; kronik a r n n ve kanser a r s n n (özellikle kemik metastazlar olan) semptomatik tedavisinde kullan l r. Nonsteroidlerin periferik ve merkezi etkileri vard r. Bafllang çta nonsteroid antiinflamatuarlar n etkisinin yaln zca periferik oldu u düflünülürken, son zamanlarda merkezi mekanizmalar üzerinde de durulmaktad r. Bundan yaklafl k 25 y l önce yap lan çal flmalar, aspirin ve antiinflamatuar ilaçlar n analjezik, antipiretik ve antiinflamatuar etkilerinin prostaglandin sentezinde yer alan siklooksijenaz COX enzimlerini inhibe ederek olufltuklar n göstermifltir. OP O D ANALJEZ KLER "Opiat" sözcü ü, morfinden kaynaklanan do al ve yar yapay ilaçlar, "opioid" sözcü ü tam yapay morfin benzeri ilaçlar için kullan lmaktad r. Opioidler kendilerine özgü befl tip (mü, kappa, sigma, delta, epsilon) reseptörlere ba lanarak etkilerini gösterir. S n fland rma Morfin, kodein ve yar yapay türevleri: (Hidromorfon, oksikodon, oksimorfon, eroin, levorfanol, rasemorfan): Morfin ve kodeinin afyon sak z nda do al olarak bulunmas na karfl n, di erleri morfin, kodein ya da tebainden türetilmifltir. Agonist özelliktedir. Yapay opioidler: (Meperidin, metadon, dekstromoramid, fentanil, dekstropropoksifen, sufentanil, alfentanil, tilidin,

95 anileridin, piminodin, femoperidin, alfaprodin, levo-alfa-asetil metadol): Tamamen yapay olan bu grup opioidler de agonist özelliktedir. Agonist-antagonist (karma etkili) opioidler: (Pentazosin, nalbufin, butorfanol, siklazosin, buprenorfin, meptazinol, dezosin, propriam, nalorfin): Bu grup droglarda hem agonist hem de antagonist aktivite bulunmaktad r. Antagonistler (Nalokson, naltrekson): Analjezik etkileri olmayan bu ilaçlar, opioidlerin afl r dozlar n n neden oldu u klinik durumlarda kullan l r. Farmakokinetik özellikleri Santral sinir sistemi: mü reseptörlerine ba lanarak etki oluflturur. Yan etkileri: Analjezi, öfori/disfori, tolerans, sedasyon, solunum depresyonu, öksürük refleksinin bask lanmas, miyozis, bulant -kusma, antidiüretik hormon, prolaktin ve somatotropin sal n m n n art m, ortostatik hipotansiyon (hatta bay lma), konstipasyon, üriner retansiyon, deride terleme ve kafl nt ile birlikte yanma ve k zarma, Analjezi, solunum depresyonu, sedasyon gibi depresan etkilerine karfl, miyozis gibi uyar c etkilerinden daha h zla tolerans geliflmektedir. Opioidler gastrointestinal yoldan kolayca emildikleri gibi, nazal mukoza ve akci erlerden de emilirler. ntramusküler ve cilt alt emilimleri de iyidir. Ancak morfin dahil opioidlerin ço u a z yolu ile al nd klar nda parenteral uygulamaya göre daha az etki gösterirler. Opioidler aras nda zay f etkili bir sentetik ajan olan Tramadol hidroklorid ve güçlü etkili transdermal fentanil son y llarda kullan m artan ajanlar olarak görülmektedir. Transdermal fentanilin özellikle oral yoldan ilaç uygulamas yap lamayan hastalarda tercih edilebilece i bildirilirken, 25 μg dan 00 μg a kadar de iflik doz seçenekleri bulunmaktad r saat etki süresi bu ajan n avantaj d r. Tramadol hidroklorid, serotonerjik sistem üzerinden etkilidr ve zay f mü reseptör affinitesi nedeniyle daha az yan etki avantajlar ile özellikle nöropatik a r larda önerilmektedir. ADJUVAN (Sekonder) ANALJEZ KLER Sekonder, adjuvan veya ko-analjezikler olarak adland r lan ilaçlar, esas kullan m alanlar a r d fl nda olan ancak analjezik özellikleri nedeniyle baz a r sendromlar nda yararl oldu u bilinen ajanlard r. Bu ilaçlar do rudan veya dolayl yoldan analjeziklerin etkisini artt rarak etki ederler. A r tedavisinde tek bafllar na veya kendi aralar nda ve di er analjezikler ile kombine edilerek kullan l rlar. Kronik a r tedavisinde hangi adjuvan analjezi in seçilece i hastaya, a r n n tipine, efllik eden semptomlara göre saptanabilir. Antidepresanlar: Antidepresanlar n pek ço u kullan lmaya baflland ktan sonra akut etki ile beyinde noradrenalin ve/veya serotonerjik sinapslarda nörotransmitter geri al m n inhibe ederler. Geri al m üzerine olan etki hemen bafllamakta, klinik etki ise ancak 2-3 haftal k latent bir sürenin sonunda bafllamaktad r. Çeflitli kronik a r sendromlar nda adjuvan analjezik amac yla antidepresan ilaçlar kullan lmaktad r. Trisiklik antidepresanlar (TSA) depresyon tedavisine göre daha düflük dozlarda kullan ld nda analjezi olufltururlar. TSA n bafllang ç dozu düflük olmal, yeterli analjezi sa lan ncaya veya yan etkiler ortaya ç k ncaya kadar doz artt r lmal d r. Sedasyon yan etki olarak s kl kla olufltu undan gece tek doz kullan m önerilir. Amitriptilin en s k kullan lan trisiklik antidepresand r mg kadar düflük dozlarda bafllanarak tolere edildikçe her 4-5 günde bir doz artt r l r. Nöroleptik ajanlar: Kronik a r tedavisinde genellikle antidepresan ilaçlarla kombine edilirler. Diyabetik nöropati, postherpetik nevralji ve trigeminal nevraljide s kl kla kullan lmaktad r

96 Antikonvülsanlar: Antikonvülsan ilaçlar n kronik a r daki esas endikasyonu nevraljiform a r lard r. Karbamazepin, trigeminal nevralji tedavisinde günde mg dozunda ilk seçilecek ilaçt r. GABA-A agonisti olarak üretilmifl ama etki mekanizmas henüz tam olarak aç klanamam fl olan Gabapentin, düflük toksisite ve daha olumlu yan etki profili ile nöropatik a r da s k kullan lan bir ajan haline gelmifltir. Önerilen bafllang ç dozu, günde 900 mg d r ve doz bölünmüfl dozlar halinde günde 3600 mg a kadar ç k labilir. Miyorelaksanlar: A r tedavisinde yayg n olarak kullan lmalar na ra men etkinlikleri tart flmal d r. Etkilerinin daha çok santral polisinaptik nöronal inhibisyon ile oluflur. Benzodiazepinler: Analjezik etkisi yoktur hatta hiperaljeziye neden olabilirler. Benzodiazepinlerin nosisepsiyon üzerindeki kazançlar çeliflkilidir. Akut a r durumlar nda özellikle postoperatif dönemde anksiyeteyi azaltmas nedeniyle yayg n olarak kullan lmaktad rlar. Kronik a r durumlar ndaki kullan mlar ise daha az baflar l d r. Kortikosteroidler: En s k kullan lan sekonder analjeziklerden birisidir. Antiinflamatuar etkisi ile inflamasyonu ve ödemi azalt r. Kemik metastaz, spinal kord bas s, yumuflak dokunun tümör infiltrasyonunda, kafa içi tümörlerde ve kanser a r lar nda kullan labilir. Kafein: Asetilsalisilik asit ve parasetamol gibi non-opioidlerle beraber kullan ld nda analjezik etkisi daha iyidir. Baklofen: Spinal kord hasar na ya da serebral hasara ba l kas spazmlar n n ve rijiditesinin neden oldu u a r larda kullan l r. Oral lokal anestezikler: Lokal anestezikler sistemik olarak uyguland klar nda periferik ve santral nöropatik a r larda etkili olabilirler. Postherpetik nevralji, diyabetik nöropati ve talamik a r tedavisinde intravenöz lidokain etkilidir. Topikal lidokain yama (% 5) a r kontrolünde etkilidir. Bu yamalar 2 saatten daha uzun süre uyguland nda hiçbir sistemik yan etki gözlenmez ve endikasyonu olan yafll hastalarda emniyetli ve etkili olabilirler. Kapsaisin: K rm z bibere tad n veren kapsaisinin yanma hissi oluflturdu u bilinmektedir. Etkilenen bölge üzerine kapsaisinin uzun süre uygulanmas sensoryal sinir uçlar ndan P-maddesinin azalmas yla sonuçlan r, bu da a r n n azalmas na neden olur. Alfa-2-adrenoreseptör agonistleri: Alfa-2-adrenoreseptör agonisti klonidin antihipertansif olarak kullan l r. Sistemik olarak oral, transdermal, intramüsküler ve intravenöz ve spinal yoldan: epidural ve spinal uyguland nda analjezik olarak etkindir. Alfa-2-reseptörleri aktive ederek noradrenerjik inhibisyonu stimüle etmesi ile analjezik etki oluflur. Kalsitonin: Analjezik etkiye de sahip olan kalsitonin parathormon ile vücuttaki kalsiyum dengesini düzenler. Kalsitonin hiperkalsemi, Paget hastal, akut pankreatit, migren profilaksisi, Sudeck atrofisi, romatoid artrit, osteoporoz tedavisinde ve metastaza ba l kanser a r lar nda kullan l r. Bifosfonatlar: Bifosfonatlar osteoklastik aktiviteyi inhibe ederek kemik y k m n önlerler ve hiperkalsemiyi azalt rlar. Meme, prostat kanseri ve multiple miyelomdaki kemik metastazlar na ba l a r larda, Paget hastal nda ve osteoporozda kullan l rlar. NMDA-reseptör agonistleri: N-metil-D-aspartat (NMDA) reseptörleri patolojik a r n n oluflumunda önemli rol oynarlar. NMDA reseptör antagonistlerinden ketamin ve dextromethorphan n postherpetik nevralji tedavisinde etkili olduklar bildirilmifl olmas na ra men, tolere edilemeyen yan etkilerinin s k görülmesi, kullan lmas na engel olmaktad r. Kalsiyum kanal blokerleri: Özellikle migrende koruyucu tedavide baflar l d r

97 Somatostatin: Analjezik etkisi de saptanan somatostatin ameliyat sonras ndaki a r tedavisinde ve kanser a r s nda epidural ve intratekal bölgeye verilmektedir. KRON K A RIDA NVAZ V G R fi MLER Sinir Bloklar : Kronik a r da sinir bloklar flu amaçlarla yap l r:. Diagnostik: A r n n nedenini ortaya ç karmada selektif bloklar yap l r. 2. Prognostik: Kal c bloktan önce lokal anesteziklerle geçici blok yap larak a r üzerine blo un etkinli i saptan r. 3. Terapötik: Tedavinin aktif yönünü oluflturur. Blok uygulamalar steril operasyon odas nda uygun ve yeterli materyel varl nda gerçeklefltirilmelidir. Tüm giriflimlerde C-kollu skopi cihaz ve skopinin oblik aç lardan görüntülemesine olanak sa layan operasyon masas kullan lmal d r. Bu uygulamalar temelde nöroablatif ve nöroogmentatif teknikler olarak iki gruba ayr l r. Nöroogmentatif tekniklerde sinir hasar oluflmaz. Tekniklerin etkisi uygulama sonland r ld nda kesilir. Bu yöntemler ilaç pompalar veya port sistemleri ile santral ilaç uygulamalar n ve spinal veya periferik sinir stimülasyon tekniklerini içerir. Nörolitik bloklarda sinir iletisinin geri dönüflümsüz olarak kesilmesi söz konusudur. Trigger nokta enjeksiyonlar Miyofasyal a r sendromlar nda a r adale kaynakl olup, bas nç uyguland nda afl r hassasiyet ve a r fliddetinde artma mevcuttur. Miyofasyal a r sendromuna özgün bir tan yöntemi ya da laboratuar bulgusu yoktur. Palpasyonla, adale liflerinde bantlar saptan r. Bu bölgeye lokal anestezik enjeksiyonu ile a r ve di er bulgular ortadan kald r labilir. Çeflitli araflt rmac lar taraf ndan, tetik nokta enjeksiyonlar nda serum fizyolojik, steroid, lokal anestezikler (% lidokain veya %0.25 bupivakain) ya da bunlar n kombinasyonlar n kullanm fllard r. Gunn taraf ndan gelifltirilen kuru-i neleme tekni i s k uygulanan tedavi yöntemlerindendir. Son y llarda tetik noktalara botilinismus toksini enjeksiyonu da uygulanmaktad r. Bu enjeksiyonlarla adale spazm n n azalt lmas sa lanarak hem hareket k s tlanmas hem de a r flikayetleri tedavi edilebilir. Epidural steroid uygulamalar Epidural steroid enjeksiyonu kaudal, interlaminar aral ktan veya transforaminal yoldan uygulanabilir. Epidural steroid enjeksiyonu a r l dermatoma en yak n kökün bulundu u seviyeden yap lmal d r. Epidural patolojinin bulundu u ve nöral a n yayg n oldu u anterior epidural alana en uygun ilaç enjeksiyonunun sa land transforaminal steroid uygulamas günümüzde giderek yayg nlaflmaktad r. Epidural nöroplasti Uygulamada a r n n yerleflimine göre uygun aral ktan giriflimle yerlefltirilen kateterden deposteroid ve 3 gün süreyle hipertonik salin uygulamas yap lmaktad r. Hipertonik serum sale kullan m yüz y l aflk n bir süredir uygulanmaktad r. Ayr ca hayvan araflt rmalar nda hipertonik serum salenin C-lifleri üzerine etkisi de gösterilmifltir. Eklem içi enjeksiyonlar Yafll hastalarda eklem içine steroid-lokal anestezik kombinasyonlar uygulamalar yayg nd r. Ayr ca son y llarda hiyaluronik asidin diz, ayak bile i, omuz, temporomandibüler eklem gibi baz eklemlere enjeksiyonu yayg n olarak uygulanmaktad r. Disk içi enjeksiyonlar Diske ba l a r n n ay r c tan s nda s k baflvurulan yöntemlerden birisi de diskografidir. Geleneksel yöntemlerin, diskojenik a r tedavisinde baflar l olmad durumlarda, cerrahi giriflimden önce, maliyetinin daha düflük olmas, komplikasyonlar n daha az olmas ve kolay uygulanabilmesi nedeni ile disk içi giriflimleri önerilmektedir. Amaç, a r oluflturan diskin stabilize edilmesi ve güçlendirilmesidir. Son y llarda disk içine Radyofrekans

98 Termokoagülasyon (RF) uygulamalar yayg nlaflm flt r. Hastalarda operasyon endikasyonu olmamal d r. Uygulamadan önce provakatif veya analjezik diskografi ile tan kesinlefltirilir. Nörolitik Ajanlar ve Nöroliz Uygulamalar Sinir iletisinde uzun süreli veya kal c kesinti oluflturmak amac yla kimyasal ajanlar ya da fiziksel uygulamalarla yap lan giriflimlere nöroliz ad verilir. Nöroliz uygulamalar daha çok kanser a r lar nda k smen de, diabetik nöropati, periferik vasküler hastal a ba l a r lar, trigeminal nevralji, küme bafla r s, atipik fasyal nevralji, faset eklem sendromuna ba l vertebral bölge a r lar gibi kanser d fl kronik a r larda uygulan r. Bu uygulamalarda, distile su, s cak/so uk serum fizyolojik, hipertonik sodyum klorür, serapin, amonium tuzlar, gümüfl nitrat, kloroform, osmik asit, fenol, alkol, alkol esterleri, gliserol, klorokresol kullan lm flt r. Somatik Sinir Bloklar A r l durumlarda somatik sinirlerin lokal anesteziklerle blo u yayg nd r. S kl kla kullan lan somatik sinir bloklar aras nda; interkostal blok, kranyal sinir bloklar, obturator sinir blo u, brakiyal pleksus blo u, kol ve bacaktaki de iflik sinir bloklar say labilir. Klinikte en s k kullan lan nörolitik ajanlar; fenol, gliserol ve etil alkoldür. Daha seyrek olarak, klorokrezol, amonyum sülfat, amonyum klorür ve so uk ya da hipertonik serum sale de kullan lmaktad r. RF ile veya kriyo probu ile dondurarak da sinirlerde lezyon yap labilir. Kronik a r tedavisinde en s k kullan lan somatik sinir blo u, trigeminal nevralji içindir. 970 li y llardan beri güncelli ini koruyan radofrekans termokoagülasyon yöntemi ile %95 lere ulaflan baflar l sonuçlar al nabilmektedir. Sempatik Sinir Bloklar Günümüzde sempatik kökenli a r lar Kompleks Bölgesel A r Sendromlar (CRPS I, II ) bafll alt nda toplanmaktad r. Periferik sempatik yollar; Subaraknoid bofllukta, epidural bofllukta, paravertebral bölgede, periferik sinirlerde ya da postganglionik aksonlarda, kesilebilir. Bafl, üst ekstremite ve torakal a r lar ile damar hastal klar için stellar ganglion ve torakal sempatik blok, bat n içi viseral organlardan kaynaklanan a r lar için çöliak pleksus blo u veya splanknik blok, alt ekstremite a r ve damar hastal klar için lomber sempatik blok; perine bölgesinde a r ve tenezm duygusunu gidermek için hipogastrik ve impar ganglion blo u uygulan r. Radyofrekans termokoagülasyon (RF) uygulamalar Radyofrekans s lezyonu, nöroablatif yöntemler içinde en güvenlisi, en etkini ve kolay uygulanan d r. S k olarak uygulanan RF giriflimleri; faset denervasyon, dorsal kök ganglion blo u, disk lezyonu, komunikan ramus blo u, sakroiliak eklem blo u, sempatik ganglion blo udur. Bu yöntemler, her biri için ayr belirlenmifl tedavi endikasyonlar n, s n rlar n ve teknik özelliklerini ayr nt l olarak bilen deneyimli kifliler taraf ndan uygulanmal d r. Son y llarda yeni bir yöntem olarak dikkati çeken Pulse-RF (PRF) uygulamas günümüzde giderek daha fazla klinisyen taraf ndan denenmektedir. Hasar oluflturmadan uygulanabilen yöntemin, nöropatik a r da etkili oldu u bildirilmifltir. Kriolezyon uygulamalar Kriolezyon uygulamas n n temeli, hedef dokuya skopi kontrolü alt nda yerlefltirilen bir probun ucunda, h zl so uma sa lanarak lezyon oluflturulmas d r. En yayg n endikasyonlar, a r l nöromalar, interkostal nevralji, faset artropati, ilioinguinal, genitofemoral ve iliohipogastrik nöropatidir. Koksikodinia, supraorbital, infraorbital, mandibüler sinirleri kapsayan kranyal a r larda daha az s kl kta uygulanabilir. Ayr ca yöntemin bir di er dezavantaj da, henüz tek kullan ml k krioproblar n bulunmamas d r

99 Spinal kord stimülasyonu (SKS) Stimülasyon uygulamas ile analjezik etkinin; spinal kord seviyesinde endojen opioid sistemin, serotonin gibi baz nöromodulatör nörotransmitterlerin artmas ve sinaptik kap sisteminin aktivasyonu ile olufltu u düflünülmektedir. Hastan n a r s n n organik bir nedeni bulunmal d r. A r flikayetleri çok s k ve fliddetli olmal, di er tedavi yöntemlerinden yeterli yan t al nmam fl olmal d r. SKS uygulanmas düflünülen hastalar psikiyatrik aç dan kontrol edilmeli ve majör psikiyatrik sorunlar n n veya ilaç ba ml l klar n n olmad ortaya konmal d r. Spinal kord lezyonu, fantom a r s, periferik nöropatiler, periferik vasküler hastal klar ve en s kl kla, baflar s z bel cerrahisi sendromuna ba l a r lar, SKS uygulamas n n özgün endikasyonlar d r. Spinal opioid uygulamalar A r kontrolünde opioid analjezik kullan m genellikle kanser a r s için kabul edilen bir yöntemdir. Günümüzde, kanser d fl a r da opioid kullan m giderek popülarite kazanmaktad r. Burada dikkat edilecek en önemli nokta, hasta seçimi kriterlerine uygunluktur. Daha önce uygulanan t bbi tedaviye ve daha az invazif uygulamalara yan ts z olan hastalar, oral opioid kullan m yetersiz olanlar veya kullan lan yüksek doz ilaç nedeniyle oluflan yan etkileri tolere edemeyen hastalar spinal opioid uygulamas için aday olabilir. Hastalarda geçici olarak sistemik veya spinal opioid uygulan r ve bu uygulamaya baflar l yan t al nmas halinde, bu hastalara kal c portpompa sistemleri, epidural veya intratekal olarak uygulanabilir. KAYNAKLAR. H. Breivik, PC Borchgrevink, SM. Allen, L, Rosseland, L. Romundstad, EK Breivik Hals, G Kvarstein, A Stubhaug. Assessment of pain. Br J Anesth 2008;0: Williamson A, Hoggart B. Pain: a review of three commonly used pain rating scales. J Clin Nurs 2005;4: Katz J, Melzack R. Measurement of pain. Surg Clin North Am 999;79: Salle JY, Ginies P, Perrouin-Verbe B, Ventura M. Pain management: what s the more efficient model?. Ann Phys Rehabil Med 2009;52: Wiffen PJ, Collins S, McQuay HJ, Carroll D, Jadad A, Moore RA. Anticonvulsant drugs for acute and chronic pain. Cochrane Database Syst Rav 200; 20:CD Haanpää ML, Backonja MM, Bennett MI, Bouhassira D, Cruccu G, Hansson PT, Jensen TS, Kauppila T, Rice AS, Smith BH, Treede RD, Baron R. Assessment of neuropathic pain in primary care. Am J Med 2009;22: Nelson L, Schwaner R. Transdermal fentanyl: pharmacology and toxicology. J Med Toxicol 2009;4: Kroenke K, Krebs EE, Bair MJ. Pharmacotherapy of chronic pain: a synthesis of recommendations from systematic reviews. Gen Hosp Psychiatry 2009;3: Berrocoso E, Sánchez-Blázquez P, Garzón J, Mico JA. Opiates as antidepressants. Curr Pharm Des 2009;5: Rothstein D, Zenz M. Chronic pain management. Internist (Berl) 2009; 50:6-8.. Nocom G, Ho KY, Perumal M. Interventional management of chronic pain. Ann Acad Med Singapore 2009;38: Jeoy Y, Huh BK. Spinal cord stimulation for chronic pain. Ann Acad Med Singapore 2009;38: *** Kronik A r Sendromlar Tan m ve Tedavileri; Bafla r s, Bel A r s, Myofasyal A r Sendromu, Kanser A r s O.N. AYDIN Adnan Menderes Üniversitesi T p Fakültesi Algoloji Bilim Dal, Ayd n, Türkiye BAfi A RILARI Günümüzde hastal klar n toplumlara getirdikleri ekonomik yük giderek daha çok önem tafl maktad r. Bu yükün bir k sm hastal klar n tan ve tedavi giderleri olarak kabul edilen her türlü doktor, inceleme, hastane, tedavi ve benzeri tutarlar olarak hesaplanan do rudan giderlerdir. Ancak ekonomik yükün daha önemli bölümü hastal a ba l ifle gidememe ve iflte verim düflüklü üne ba l ifl gücü kayb ndan kaynaklanan dolayl giderler olarak karfl m za ç kmaktad r

100 Sadece migren türü bafl a r s n n Amerika Birleflik Devletleri bütçesine getirdi i y ll k yükün,4 7,2 milyar dolar oldu u tahmin edilmektedir. ngiltere'de yap lan bir çal flmada migrenin ngiliz ekonomisine y ll k yükünün 280 milyon sterlin oldu u ve bunun sadece 30 milyonunun -doktor ve tedavi- gideri oldu u, geri kalan n n ifl gücü kayb na ba l dolayl giderler oldu u öne sürülmüfltür. Türkiye çal flmas nda son bir y l içinde Migren e ba l iflgücü kayb n n y lda ortalama 5,4 gün oldu u bulunmufltur. Bu iflgücü kayb n n, fiubat 2002 rakamlar na göre uyarlanm fl günlük asgari ücret üzerinden bütçeye getirdi i tahmini yük ise y lda yaklafl k 270 trilyon TL (200 milyon Dolar) olarak hesaplanmaktad r. Gerilim bafl a r s na ba l iflgücü kayb n n ise y lda ortalama 2,7 gün oldu u ve bütçeye getirdi i yükün y lda yaklafl k 270 trilyon TL d r (70 milyon Dolar). Hekimin en s k karfl laflt yak nmalar n bafl nda gelen bafl a r s, hem bir hastal k tablosu (birincil: primer bafl a r s ), hem de bir belirti (ikincil: sekonder) olarak ele al nmal d r. International Headache Society (IHS) (Uluslararas Bafl A r s Derne i) taraf ndan 2004 y l nda ikincisi yay nlanan s n flamaya göre tabloda yer alan ilk dört birincil bafl a r lar (. migren, 2. gerilim bafl a r s, 3. küme bafl a r s, 4. di er birincil bafl a r s ); sonrakiler ise ikincil bafl a r lar olarak adland r lm flt r. M GREN En s k rastlanan iki formu auras z (yayg n, adi) migren ve aural (klasik) migrendir Auras z Migren Tan m: 4 72 saat süren, ataklarla ortaya ç kan, idiopatik, tekrarlay c bafl a r s d r. Bafl a r s n n tipik özellikleri, tek yanl yerleflim, zonklay c nitelik, orta ya da fliddetli derecede a r, günlük fizik aktivite ile a rlaflma, bulant ve/veya fotofobi ve fonofobi efllik etmesidir. Tan kriterleri: 4 72 saat süren bafl a r s ataklar (tedavi edilmedi inde veya tedavi baflar s z oldu unda) Bafl a r s flu özelliklerden en az ikisine sahiptir: Tek tarafl yerleflim, zonklay c nitelik, orta veya fliddetli a r (günlük aktiviteleri bozar ya da ortadan kald r r), günlük fiziksel aktivite ile art fl ya da onlardan kaç nmaya neden olma. Bafl a r s s ras nda flunlardan en az birisi; Bulant ve/veya kusma, fotofobi ve fonofobi, baflka bir hastal a ba l olamama. Aural Migren Tan m: Aura, genellikle 5 20 dakika içinde basamakl olarak geliflen ve genellikle 60 dakikadan k sa süreli, geri dönüflümlü, serebral korteks veya beyin sap na ait fokal nörolojik belirtilerle seyreden yineleyici bozukluktur. Tan kriterleri: Belirtilerden en az birisini içeren fakat motor kuvvetsizli in olmad aura: Pozitif özellikleri (örn, yan p sönen fl klar, noktalar, çizgiler) ve/veya negatif özellikleri (örn, görme yitimi) içeren, tümüyle geri dönebilen görsel belirtiler, Pozitif özellikleri (örn, i nelenme) ve/veya negatif özellikleri (örn, uyuflukluk) içeren tümüyle geri dönebilen duyusal belirtiler, tümüyle geri dönebilen disfazik konuflma bozuklu u. fiunlardan en az ikisi, Homonim görsel belirtiler ve/veya duyusal belirtiler, en az bir aura semptomu 5 dakika veya daha uzun sürede yavafl geliflir ve/veya farkl aura belirtileri 5 dakika veya üzerindeki sürede art arda oluflur. Her belirti 5 dakika veya üzerinde ve 60 dakika veya daha alt nda sürer

101 M GREN N TEDAV S Davran flsal Terapi ve Yaflam Stili De iflikli i Bu tedavi grubu içinde yeterli uyku al m, düzenli yaflam, düzenli ö ünler, düzenli egzersiz yapma, alkollü içkilerden ve tütünden uzak durma, stres yönetimi, kafein ve teofilinden kaç nmak, monosodyum glutamat, tiramin içeren besinlerden (kabuklu yemifller..), süt ürünlerinden (eski peynirler..), turunçgillerden, çikolatadan uzak durmak gibi öneriler yer al r. Ataklar parlak fl klar ile indükleniyor ise fl engelleyici renkli gözlükler yararl olabilir.5 Davran flsal terapi baz hastalar da ataklarda belirgin düzelme yarat p koruyucu özellik gösterse de hastalar n ço unda medikal tedavi gerekir. Farmakolojik Tedavi Akut Tedavi (Atak Tedavisi) Akut tedavi, bafl a r s n durdurmay amaçlar. laç afl r kullan m na ba l bafl a r lar n n ortaya ç kmas na engellemek için, akut tedavinin haftada üç kereden az verilmelidir. Migrene özgü ilaçlar aras nda ergot türevleri ve triptanlar vard r. Spesifik olmayan ilaçlar; analjezikler, antiemetikler, anksiyolitikler, nonsteroid antienflamatuar ilaçlar (NSAI ), steroidler, major trankilizanlar ve opioidlerdir. Tedavi ata a ve hastaya göre biçimlendirilmelidir. Basit ve kombinasyon fleklinde analjezikler ve NSAI lar Hafif-orta fliddette bafl a r lar olan hastalarda ilk basamak basit ve kombine analjezikler (asetil salisilik asit, parasetamol ve bu ilaçlar n kafeinli kombinasyonlar ) ve NSAI lar olmal d r. Asetilsalisilik asit, parasetamol ve NSAI lar siklooksijenaz (COX) enzim inbisyonu ile prostoglandin sentezini engelleyerek, kafein ise COX 2 inhibisyonu, fosfodiesteraz enzim blokaj ile siklik adenozin monofosfat (camp) düzeylerinin artt r lmas.6 Ergotamin ve dihidroergotamin (DHE) Etki mekanizmas n n kan damarlar üzerine vazokonstriktör etki ve trigeminoservikal kompleks ile trigeminal ileti yollar üzerine inhibisyon mekanizmas oldu u kabul edilir.6 Triptanlar (selektif 5 HT agonistleri ) Bu ilaçlar etkilerini serebral ve dural damarlarda vazokonstriksiyon, trigeminoservikal kompleks ve ileti yollar nda inhibisyon, periferik trigeminal nöron aktivitesinde inhibisyon ve perivasküler enflamasyonu engelleyerek gösterirler. Opioidler Opioid d fl ndaki ilaçlar bafl a r s nda yeterli rahatlama sa lam yorsa, kodein, butalbital, meperidin, morfin, hidromorfin ve oksikodon gibi güçlü narkotik analjezikler tek bafl na veya basit analjeziklerle kombine halde kullan labilir.7 Magnezyum, Antiemetikler ve Kortikosteroidler de kullan labilir.8 9 Profilaktik (Önleyici) Tedavi Profilaktik tedavi, ataklar n s kl n, süresini ve fliddetini azaltmay amaçlar. Profilaktik tedavide, beta adrenerjik blokerler, antidepresanlar, kalsiyum kanal antagonistleri, serotonin (5HT2) antagonistleri ve antikonvulzanlar denenebilir. Tedavinin etkinli ine en erken 2 3 ay sonra karar verilmeli, tedavi etkili ise en az 6 ay sürdürülmelidir. Profilaktik tedavi atak s kl n %50 den fazla azaltabiliyorsa etkili say lmaktad r.0 GER L M BAfi A RISI Epizodik gerilim bafl a r s tan kriterleri:. Seyrek epizodik tip: her ay ortalama olarak bir günden az (y lda<2 gün) süreyle oluflan 2. S k epizodik tip: en az üç ay süreyle, her ay ortalama en az, en fazla 5 gün oluflan (Y lda>2 ve < 80 gün ) Kriterler; 30 dakika- 7 gün aras nda süren bafl a r s, bilateral yerleflim, s k flt r c /bas c nitelik (zonklay c de il), hafif veya orta fliddetteki a r, yürüme veya merdiven ç kma gibi rutin fizik aktivite ile fliddetlenmeme. Bulant veya kusma yoktur (ifltahs zl k olabilir), fotofobi ya da fonofobide sadece biri, baflka bir bozuklu a ba l olmama Fizyopatoloji Periferik mekanizmalar: Uygunsuz çal flma ve oturma pozisyonlar, afl r yorgunluk, fiziksel aktiviteler gibi bafl

102 boyun bölgesi kaslar nda zorlanmalar sonucu bu kaslardan kaynaklanan a r l uyaranlar n etkisiyle retikulospinal yol üzerinden bafl ve boyun bölgesi kaslar nda ortaya ç kan tonus art fl n n a r ya neden olabilece i ileri sürülmüfltür. Santral mekanizmalar: Psikososyal stres faktörü baflta olmak üzere çeflitli uyar lar n etkisiyle beyin sap nda bulunan ve a r n n alg lanmas n sa layan nöronlarda fasilitasyonun, buna karfl l k a r n n alg lanmas n kontrol eden antinosiseptif nöronlar n fonksiyonunda bask lanman n olmas yer almaktad r. Akut Tedavi Bu amaçla aspirin (000 mg), parasetamol (000 mg), metamizol (000 mg), naproksen ( mg), ibuprofen (800 mg), ketoprofen (50 mg), flurbiprofen (200 mg) kullan labilir.3 Proflaktik tedavi GBA da proflaktik tedavide en s k kullan lan ilaç grubu trisiklik antidepresanlard r. Bu gruptan amitriptilin 0 75 mg dozlarda en yayg n kullan l r. Di er antidepresanlar (maprotilin 75 mg, mianserin mg), noradrenarjik aktiviteye sahip mirtazapin, seratonin-noradrenalin sal n m geri al m inhibitörleri (SNRI) (özellikle venlafaksin ve milnasipran), seratonin geri al m inhibitörleri (fluoksetin 0 20 mg, paroksetin mg) di er tedavi edici ajanlard r.4 5 laç d fl tedavi uygulamalar Psikofizyolojik tedavi yöntemleri içinde gevfleme tedavileri, biofeedback uygulamalar, stresle mücadele yöntemleri, psikolojik destek gibi uygulamalar yer almaktad r. Tetik nokta enjeksiyonu, kuru i ne (dry-needling), oksipital sinir bloklar da kullan lmaktad r.5 BEL A RILARI Bel A r s epidemiyolojisi Tüm dünya nüfusunun % 85' n n, hayatlar nda en az bir defa bel a r s geçirmektedir. Akut bel a r s vakalar n n % 80'inde 6 8 hafta içinde tedaviye ba l olmaks z n iyileflme olmas na karfl l k, bunlar n % 38'inde bir y l içinde ikinci atak, subakut bel a r lar n n % 4'inde ve kronik bel a r l olanlar n % 8'inde bir y l içinde yeni atak geliflmektedir. Burada önemli olan ilk akut ata önleyebilmek ve bel a r s nda kronisite ve bunu izleyen sakatl a mani olmak için a r y bafllatan ve kroniklefltiren faktörleri tan mak ve önlem almakt r. S k bel a r s nedenleri Faset eklem osteoartriti Lomber bölgenin hareketinin sa lanmas nda görevli faset eklemin osteoartritinde bel ve tek veya çift tarafl bacak a r s görülmektedir. Uzun süreli oturmak, ayakta durmak, bel ekstansiyonu a r y artt r rken, istirahatle a r azal r. Muayenede faset eklemler basmakla a r l d r. Radyolojik bulgular klinikle her zaman uyumlu de ildir. Tan amaçl yap lan faset bloklar ile a r n n azalmas daha de erlidir.6 7 Bu hastalardaki a r vücut a rl n n kontrolü, istirahat, analjezikler veya NSAI ile ço u zaman kontrol alt na al nabilir. A r lomber ekstansiyonla artt için, amaç hiperekstansiyonu azaltmakt r. Fleksiyon egzersizleri ile abdominal kaslar güçlendirilmeli, lumbosakral korse ile a r azalt lmal d r. Faset eklem enjeksiyonunun baflar s ; Faset kapsülünün geçici olarak anestetize olmas Spazml bel kaslar n n gevflemesi Spazm n gevflemesi ile yer de ifltirmifl yap lar n yerine oturmas Devaml a r ya ba l sinir uyar s n n bu enjeksiyon sonucu kesilerek a r -spazm-a r k s r döngüsünün k r lmas ile aç klanabilir Faset eklemleri innerve eden mediyan sinirin lokal anestezikler ile blo undan fayda gören hastalarda radyofrekans termakoagulasyon (RF) uygulanabilir

103 Lomber disk hastal Disk hernisi, nukleus pulposus un anulus fibrosus liflerinden herniye olmas d r. Siyatik, diz alt na yay lan bir a r yla birlikte olan lomber a r sendromu olarak tan mlan r. Alt ekstremitede motor, duyu ve refleks bak lar, kord patolojilerindeki nörojenik defisitlerin saptanmas n sa lar. Tan görüntüleme yöntemlerinden ziyade anamnez ve fizik bak ile konur, hastan n tedavisi de semptomlar na göre planlan r.22 lk olarak olguyu rahatlatmak amac yla; a r -spazm-a r döngüsünü bir yerden k rmak için a r y gidermek, spazm azaltmak ve tekrar önlemek için kifliyi zorlamalardan korumak ve önlem almak fleklinde bir yol izlenir.23 Hastaya analjezik, NSAII, kas gevfletici ajanlar, epidural steroid uygulamas ve yatak istirahati verilebilir.24 Epidural steroid injeksiyonu baflta disk hernileri sonucu oluflan sinir kökü bas s ve iritasyonunda a r n n azalt lmas ve fonksiyonlar n geri dönmesi için uygulan r. Uygulama lomber bölgeden interlaminer ve transforaminal yoldan a r l dermatoma en yak n kökün bulundu u seviyeden uygulan r. nterlaminer yaklafl mla posterior epidural alana ulafl l rken, transforaminal yaklafl mda patolojinin bulundu u anterior epidural alana ulafl larak steroid ve lokal anestezik kar fl m verebilmek mümkün olmaktad r.25 Lomber spinal stenoz Spinal kanal n ve intervertebral foramenin konjenital veya edinsel olarak daralmas d r. Dejeneratif eklem hastal en s k nedenidir. Aktiviteyle oluflan intermitant a r, uyuflukluk ve baca a yay lan paresteziyle karekterize nörojenik kladikasyo ile baflvururlar. Semptomlar uzun süre ayakta durma, yürüme ve lomber ekstansiyon içeren pozisyonlarda artarken, oturma, uzanma, çömelme gibi lomber lordozu azaltan pozisyonlarla düzelir.26 E er hastan n mekanik, postural ve hareket de iflikli iyle artan, hafif yak nmalar varsa, hastan n hastal ile ilgili e itimi, egzersiz, korse kullan m ve NASII yeterli olabilir. Akut nörolojik kötüleflme veya kauda ekuina sendromu geliflimi olmad kça tüm olgular cerrahi olmayan bir yöntemle tedavi edilmelidir. Bu amaçla son 5 y l içerisinde epidural nöroplasti giriflimsel a r tedavi yöntemi olarak uygulanmaktad r. Bu amaçla yap lan uygulamalarda antiinflamatuar olarak kortikosteoid, ödem azaltmay hedefleyen hipertonik %0 salin ve steroid, nosiseptif bilginin beyine ulafl m n engellemek için lokal anestezik, bu maddelerin hedef dokuya ulaflabilmesinin önünde duran nedbe bariyerini y kmak amac yla da hyaluronidaz kullan labilmektedir.27 Epidural aral kta kanama, dura y rt lmas, subdural yerleflim, kateter y rt lmas, t kanmas, injeksiyon s ras nda a r, lokal anesteziklere ba l erken komplikasyonlar yan nda, kateter migrasyonu, parestezi, kauda ekuina sendromu, infeksiyon, epidural abse ve araknoidit gibi geç komplikasyonlar görülmektedir.28 Spondilozis ve Spondilolistezis Spondilolizis; Vertebran n nöral arkusunun stres k r d r. Spondiloliztezis; Bir vertebran n alt ndaki vertebraya göre yer de ifltirmesidir. Disk ve faset eklemdeki dejenerasyon sonucu öne do ru olan yer de ifltirme daha s k görülür. Hiçbir belirti vermeyebilece i gibi, inatç bel a r lar, hareket k s tl l, rijidite ve siyataljiye neden olabilir. Yafll larda konservatif tedavi önerilir. Is ve masaj a r ve sertli i azalt r. Ayr ca NSAII, korse kullan m ve izometrik bel güçlendirme egzersizleri verilir.29 Sakroiliyak Eklem Disfonksiyonu Sakroiliak eklem (S E) disfonksiyonu sonucu sakrum hareketleri azal r, lumbosakral diske binen yük artar ve buna ba l bel a r s meydana gelir. Bu kiflilerde a r öne e ilme hareketi sonras nda bafllar. A r SIE çevresinde en fazla olmakla birlikte, kalçan n arka d fl k sm na, uyluk ve baca n arka k sm na yay labilir. Akut veya kronik, tek tarafl ya da iki tarafl olabilir. Tan esas olarak fizik muayene ile konur.30 SIE disfonksiyonunda temel prensip a r n n hafifletilmesi ve disfonksiyona yönelik düzeltici egzersiz program d r. natç a r flikâyeti olan hastalara tan sal SIE blo u uygulanabilir. SIE içine steroid uygulanan veya diagnostik bloktan yarar gören hastalara RF ile denervasyon uygulanabilir.3-0 -

104 NÖROPAT K A RI Sinir sisteminin herhangi bir bölümünün hasar veya disfonksiyonundan kaynaklanan a r lara Nöropatik A r (NA) denir. NA periferik sinir sisteminden ya da santral sinir sisteminden kaynaklanabilir. Otonom sinir sisteminden kaynaklanan nöropatik a r lar CRPS olarak adland r lmaktad r.32 Keskin, yan c, bat c ya da elektrik çarpmas fleklinde a r ile beraber dizestezi, allodini, hiperaljezi, temporal sumasyon ve hiperpati gibi uyar lara karfl de iflmifl yan t hali bulunmaktad r. A r l alanda duysal kay p ya da bozukluk olabilir.33 Nöropatik kaynakl a r n n tedavisi oldukça zordur. Bu amaçla; Trisklik antidepresan ilaçlar (TCA): Antidepresanlar vücuttaki aminlerin etkisini artt rarak, ayr ca antikolinerjik ve antihistaminerjik etkiyle analjezik etki göstermektedir. Arka kök hücrelerinde seratonin ve noradrenalin geri al n m n inhibe ederler, sodyum kanal etkileri ve NMDA reseptör antagonisti etkileri de etkili olabilir. Özellikle de amitriptilin etkin bir analjezi sa lamaktad r. Klomipramin, Desipramin, mipramin kullan lan di er antidepresanlard r.34 Antikonvülzan ilaçlar: Karbamazepin, gabapentin, pregabalin, fenitoin kullan lmaktad r. Lokal anestezik, antiaritmik ilaçlar ve tramadol de kullan labilir.35 Kompleks Bölgesel A r Sendromlar (KBAS) Kompleks bölgesel a r sendromu (CRPS) vücudun bir bölgesinde (s kl kla bir ekstremitede) sempatik sinir sisteminin fonksiyon bozuklu u ve fliddetli nöropatik veya nosiseptif a r ile karakterize klinik bir durumdur. CRPS birbirinden farkl iki durumu içerir:36 CRPS tip I: Bir noksius uyar y takiben oluflan spontan a r veya allodini/hiperaljezi mevcuttur. A r ile birlikte duyusal de ifliklikler, s -sudamotor aktivite ve cilt rengi anormallikleri ve ödem görülebilir. CRPS tip II: Sinir yaralanmas n takiben oluflan bir sendromdur. Spontan a r veya allodini/hiperaljezi oluflur ve bu yaralanan sinirin bölgesi ile s n rl de ildir. A r ile birlikte ödem, ciltte kan ak m anormallikleri, anormal sudamotor aktivite vard r.37 Anamnezde en fazla önem verilmesi gereken nokta olay n bafllang c nda bir travman n olup olmad, semptomlar n travma ile iliflkisi, hastal n bafllang ç zaman ve süresidir. Tedavi esas olarak fonksiyonlar n geri kazand r lmas üzerine yo unlaflmaktad r. Farmakolojik ajanlar, sinir bloklar ve psikoterapinin uygun birlefliminden oluflur. Bu amaçla antiinflamatuar ajanlar (NSAII, oral veya IV steroidler), serbest radikal temizleyici ajanlar (dimetilsülfoksit, vitamin C), periferik ve santral sensitizasyon inhibitörleri (baklofen, kapsaisin, gabapentin, fenitoin, ketamin, lidokain,mofin), desendan a r kontrol deste i için ajanlar (amitriptilin, klonidin) ve sempatolitik ajanlar (guanidin, rezerpin, klonidin) kullan lmaktad r.38 Sempatik ganglion bloklar da (üst ekstremite için stellat ganglion blokaj, alt ekstremite için lumbar sempatik blok) a r tedavisi amac yla yap lmaktad r. Amputasyon sonras a r Cerrahi veya travmatik amputasyon sonras geliflen a r olarak tan mlanmaktad r. A r ampute ekstremitede (fantom a r s ) ya da amputasyon kökünde (güdük a r s ) duyulabilir. A r ya duysal bozukluklar, parestezi, dizestezi, hiperpati efllik edebilir. A r %70 oran nda amputasyondan sonra ilk bir hafta içinde ortaya ç kar. Yan c, kramp tarz nda, zonklay c, keskin a r fleklinde ifade edilir

105 Akut Herpes Zoster ve Postherpetik Nevralji (PHN) Herpes zoster, varisella zoster virüsünün spinal sinirlerin arka kök ganglionunu etkiledi i akut enfeksiyoz bir hastal kt r. Lezyon s kl kla torasik dermatomda yer al r. leri yafllarda ise trigeminal (oftalmik) zoster daha s k görülür. Etkilenen spinal kök ganglionun dermatomunda akut a r, parestezi ve dizesteziyle ortaya ç kar. 4 5 gün içinde vasküler erüpsiyonlar geliflir.40 Herpes zosterli hastalarda a r, veziküllerin iyileflmesinden sonra 4 6 hafta devam ediyorsa postherpetik nevraji (PHN) tan s verilmektedir. Sürekli yan c ve b çak saplan r fleklindeki a r ile birlikte parestezi ve dizestezi olabilir. Deri hiperestezik ve hiper aljeziktir. PHN de tedavi seçenekleri flunlard r: Opioid ve nonopioid analjezikler, trisklik antidepresanlar ve trankilizanlar, E ve B2 vitamini, kortikosteroidler, fenotiazinler, ergo deriveleri, baklofen, lokal anestezikler, TENS, omurilik veya derin beyin stimulasyonu, dorsal rizotomi, sempatektomi, dorsal kök girifl bölgesi (DREZ) lezyonu. Epidural blokla a r geçmekte, infeksiyon süresi k salmakta, lezyonlar daha h zl iyileflmektedir. M YOFASYAL A RI SENDROMU Miyofasyal a r sendromu (MAS) radikulopati yada eklem rahats zl olmaks z n kaslarda lokal ve yans yan kronik a r ya yol açan bir sendromdur. MAS kas lma sonucu k salm fl kaslarda hassasiyet ile karakterizedir. Bu k salm fl kas yap lar taut bantlar n oluflturur. Taut bant üzerinde yer alan tetik noktalar tipik biçimde fiziksel uyar ile (örne in i ne bat r lmas ) istemsiz olarak kas l r. Buna se irme (twitch) yan t ad verilir. Taut bantlar üzerindeki lokal se irme yan t, hareket k s tl l, güçsüzlük gibi motor bulgular n yan nda; MAS da tetik nokta hassasiyeti, yans yan a r varl gibi duyusal bulgular ve deride s de iflikli i, terleme, piloereksiyon gibi otonomik bulgular da görülmektedir.42 Spesifik tedavisi tetik nokta enjeksiyonu ve germe egzersizleridir. Myofasyal a r y tetikleyen postural ve ergonomik bozukluklar n düzeltilmesi önemlidir. Tedavide tetik noktalar n ortadan kald r lmas ve a r siklusunun k r lmas amaçlanmaktad r. Germe ve sprey tekni inde, a r l kas n bir noktas tutulup bas nç uygulan r. Ard ndan bu bölgeye 50 cm uzakl ktan 30 derece aç ile kas lifinin uzunlu u boyunca sprey uygulan r. So uk sprey refleks kas spazm n çözerek a r döngüsünün k r lmas n sa lar. skemik kompresyon, TENS, akupunktur, biofeedback de denenebilir.43 Tetik nokta (TN) enjeksiyonu ya da kuru i ne (dry-needling) yönteminde baflar l olmak için a r oluflturan tetik noktan n bulunmas ve uygulaman n buraya yap lmas gereklidir. Son y llarda tetik nokta üzerine botulinum toksini enjeksiyonu da yap lmaktad r.44 F BROM YALJ Primer fibromiyalji sendromu (FS) derin hassas noktalar n varl na genel kas a r s, tutukluk, yorgunluk ve düzensiz uyku gibi karakteristik bulgular n efllik etti i, s k rastlanan bir kronik a r durumudur. Genel populasyonda prevalans n %3,7 20 aras nda de iflti i bildirilmektedir. Tan da parmakla palpasyonda, 8 bilinen duyarl noktan n inde a r olmal d r. Tedavide TCAlar, özellikle amitriptilin ve siklobenzaprin, SSRI olan fluoksetin, 5-HT3 antagonisti ondansetron, opioidler, tramadol, ketamin, alfa-2 adrenerjik agonist tizanidin kullan lmaktad r. Nonfarmokolojik tedavide kognitif davran flsal terapi, fizik tedavi, EMG, biofeedback, TENS, masaj, yüzeysel s, buz gibi yöntemler denenebilir.45 KANSER A RISI Kanserde a r önemli bir sorun olarak karfl m za ç kmaktad r. Görülme s kl ilk tespit edildi inde % iken, ileri dönemdeki hastalarda % 80 dir. A r ile birlikte yaflam kalitesi bozulmaktad r

106 Kanser a r s nosiseptif ya da nöropatik mekanizmayla olabilir. Psikolojik ve davran fl bozukluklar ile psikiyatrik geliflim gösterebilir. Kanserli hastada a r sendromlar ;46 A r ya duyarl yap lar n tümörle invazyonu veya kompresyonu (%77); En s k nedenler ars nda kemi in invazyonu, sinir kökü ve pleksus kompresyonu, kan damar infiltrasyonu, içi bofl organlar n tümörle t kanmas say labilir. Kanser tedavisi s ras nda (%9); cerrahi (akut postop a r, insizyon a r s ), kemoterapi (eklem a r lar, mukozit, myalji, kardiyomyopati, pankreatit), radyoterapi (cilt yan klar, gastointestinal kramplar, proktit) gibi uygulamalara ba l Kanser d fl nedenlere ba l (%4); Kanser a r s nda analjezik olarak NSAII, parasetamol ve opioidler kombine olarak kullan l rlar. Adjuvan ilaç olarak TCA, antikonvülsanlar, meksiletin, bifosfonatlar (pamidronat), kortikosteroidler, ketamin, klonidin, lokal anstezikler, skopolamin kullan labilmektedir. Non farmakolojik yaklafl m sinir blo u, intraspinal infüzyon, cerrahi nörolitik lezyonlar, TENS, fizik tedavi, psikoterapi, akupunktur gibi yöntemleri kapsamaktad r. Dünya Sa l k Örgütü (WHO) nün basamak tedavisi ile kanser a r s tedavisi yap l r. Birinci basamakta nonopioidler ve adjuvan ilaçlar, ikinci basamakta nonopioidler, zay f opioidler ve adjuvan ilaçlar, üçüncü basamakta ise nonopioidler, kuvvetli opioidler ve adjuvanlar kullan l r. T bb tedavi ile kanser a r lar n n %75 sa alt labilir. T bb tedavi ile sa alt m yap lamayan hastalarda invazif a r yöntemleri kullan l r. KAYNAKLAR Siva A. Bafl a r s epidemiyolojisi. Erdine S (ed). A r, Üçüncü Bask. stanbul: Nobel Matbaac l k, 2007: Headache Classification Subcommittee of the International Headache Society. Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain, Second edition, Cephalalgia 2004;24: Russel MB, Olese J. A nasographic analysis of the migraine aura in a general papulation. Brain 996;9: Olesen J, Friberg L, Skyhoj-Olsen T. Timing and topography of cerebral blood flow, aura and headache during migraine attacks. Ann Neurol 990;28: Egilius L, Speirngs H. Migren sorular ve yan tlar. In: Migren. stanbul: Deomed Medikal Yay nc l k, 2002: Hansen PT, Saxena PR. Migraine:Acute drug treatment of the attack. Olesen J, Goadsby PJ, Ramadan NM et al (ed). In:The Headaches. 3rd edition. Philadelphia: Lippincott-Wilkins, 2006: Olsen J. Analgesic headache. BMJ 995;30: Peikert A, Wilimzig C, Kohne-Voland R. Prophylaxis of migraine with oral magnesium: results from a prospective, multi-center, placebo-controlled and double-blind randomized study. Cephalalgia 996,6: Olsen J. Analgesic headache. BMJ 995; 30: Ertafl M. Migren. Türkiye Klinikleri Nöroloji Bafla r s Özel Say s 2003; 2:6 23. Goadsby PJ. Chronic tension-type headache: Where are we? Brain 999;22: Bolay H, Dalkara T. Birincil bafl a r lar n n fizyopatolojisi. Türkiye Klinikleri Nöroloji 2003;2: Göksan B. Gerilim tipi bafl a r s. Erdine S(ed). A r, Üçüncü Bask. stanbul: Nobel Matbaac l k, 2007: Millea PJ, Brodie JJ. Tension-type headache. Am Fam Physician 2002;66(5): Schoenen J, Sandor PS (çeviri: Çimen A). Bafl A r s, In: Melzack R, Wall PD (ed). Wall and Melzack s Textbook of Pain (A r Tedavisi El Kitab, Erdine S(çeviri ed)). Ankara: Günefl Kitabevi, 2006: Alvarez DJ, Rockwell PG. Trigger points: diagnosis and management. Am Fam Physician 2002;65: Long DM (çeviri: Akyüz G). Kronik bel a r s. In: Melzack R, Wall PD (ed). Wall and Melzack s Textbook of Pain (A r Tedavisi El Kitab, Erdine S(çeviri ed)). Ankara: Günefl Kitabevi, 2006:

107 8 Öztürk C, Hepgüler S. Mekanik bel a r s ; Erdine S (ed). A r, Üçüncü Bask. stanbul: Nobel Matbaac l k, 2007: Zundert JV, Kleef MV. Low back pain: From algorithm to cost-effectiveness? Pain Practice 2006;6 : Manchikanti L, Pampati V, Rivera J, Fellows B, Beyer C, Damron K. Role of facet joints in chronic low back pain in the elderly: A controlled comparative prevalence study. Pain Practice 200;: Geurtz JWM, Lou L, Gauci CA. Newnham P. Radiofrequency treatments in low back pain. Pain Practice 2002; 2: Greenberg MS. ntervertebral disk herniasyonu. Bozbu a M (çeviri ed). Nöroflirurji el kitab, Üçüncü Bask. Nobel Kitabevi, 994: Öztürk C, Hepgüler S. Mekanik bel a r s. Erdine S (ed). A r, Üçüncü Bask. stanbul; Nobel Matbaac l k, 2007: Bozkufl H. Dejeneratif Disk Hastal. Siva A(ed). Bafl, Boyun, Bel A r lar. U Cerrahpafla T p Fakültesi Sürekli T p E itimi Etkinlikleri Sempozyum Dizisi, 2002; Güldo ufl F. Epidural steroid enjeksiyonu. Erdine S(ed). A r, Üçüncü Bask. stanbul; Nobel Matbaac l k, 2007: Greenberg MS. Spinal Stenoz. Bozbu a M(çeviri ed). Nöroflirurji El Kitab, Üçüncü bask. Nobel Kitabevi, 994: Pekel AF. Bel a r s nda tedavi: Algolojik yaklafl m. Siva A(ed). Bafl, Boyun, Bel A r lar. U Cerrahpafla T p Fakültesi Sürekli T p E itimi Etkinlikleri Sempozyum Dizisi.2002: Talu GK, Erdine S. Complications of epidural neuroplasty: A retrospective evaluation. Neuromodulation 2003;6: Greenberg MS. Spondilozis, spondilolizis, spondilolistezis. Bozbu a M (çeviri ed). Nöroflirurji El Kitab, Üçüncü Bask. Nobel Kitabevi, 994: SizerJr PS, Phelps V, Thompsen K. Disorders of the sacroiliac joint. Pain Practice 2002;2: Özyalç n NS. Kronik a r da radyofrekans termokoagulasyon (RF) uygulamalar. Erdine S(ed). A r, Üçüncü Bask. stanbul: Nobel Matbaac l k, 2007: Andrés JD, Garcia-Ribas G. Neurophatic pain treatment: the challenge. Pain Practice 2003;3: Köknel TG. Nöropatik a r. Erdine S(ed). A r, Üçüncü bask. stanbul: Nobel Matbaac l k, 2007: Jackson KC. Pharmacotherapy for neuropathic pain. Pain Practice 2006;6: Dworkin RH, O Connor AB, Backonja M et al. Pharmacologic management of neuropathic pain: Evidencebased recommendations. Pain 2007;32: Vranken JH, Dijkgraaf MG, Kruis MR, van der Vegt MH, Hollmann MW, Heesen M. Pregabalin in patients with central neuropathic pain: A randomized, double-blind, placebo-controlled trial of a flexible-dose regimen. Pain 2008;36: Harden RN. Complex regional pain syndrome. Br J Anaesth 200;87: Villanueva-Perez VL, Cerdá-Olmedo G, et al. Oral ketamine for the treatment of type I complex regional pain syndrome. Pain Practice 2007;7: Hartrick CT, Kovan JP, Naismith P. Outcome prediction following sympathetic block for complex regional pain syndrome. Pain Practice 2004;4: Dworkin RH, Gnann JW, Oaklander Al et al. Diagnosis and assessment of pain associated with herpes zoster and postherpetic neuralgia. The Journal of Pain 2008;9: Kumar V, Krone K, Mathieu A. Neuraxial and sympathetic blocks in herpes zoster and postherpetic neuralgia: An appraisal of current evidence. Regional Anesthesia and Pain Medicine 2004;29: Uyar M, Ayd n Ö. Miyofasyal a r sendromu ve di er muskuloskeletal kökenli a r lar. Erdine S (ed). A r, Üçüncü Bask. stanbul: Nobel Matbaac l k, 2007: Rickards LD. The effectiveness of non-invasive treatments for active myofascial trigger point pain: A systematic review of the literature. International Journal of Osteopathic Medicine 2006;9: Göbel H, Heinze A, Reichel G end all. Efficacy and safety of a single botulinum type A toxin complex treatment (Dysport ) for the relief of upper back myofascial pain syndrome: Results from a randomized double-blind placebo-controlled multicentre study. Pain 2006;25: Sarzi-Puttini P, Buskila D, Carrabba M, Doria A, Atzeni F. Treatment strategy in Fibromyalgia Syndrome: Where are we now? Seminars in Arthritis and Rheumatism 2008; 37: Önal A. Kanser a r s. Erdine S(ed). A r, Üçüncü Bask. stanbul: Nobel Matbaac l k, 2007:

108 MEET THE EXPERT 5 (MExp-5) April 25, 200 / :5 2:5 / Hall B Tobacco addiction (Tütün ba ml l ) Kamile Marako lu Recep Erol Sezer Pharmacologic Treatment of Smoking Cessation K. MARAKOGLU Selcuk University Selçuklu Medical Faculty, Department of Family Medicine, Konya, Turkey Tobacco use through cigarette smoking is the leading preventable cause of death in the world and kills nearly four million people annually (). According to the World Health Organization, 0 million smokers will die annually worldwide by the year The benefits of stopping cigarette smoking are undisputed. Smokers who quit reduce their risk of cardiovascular disease, lung disease, and cancer and prolong their lives substantially (2,3,4). An estimated 70 percent of persons who smoke have a desire to quit completely. Therefore, physicians should get involved in encouraging and facilitating smoking cessation. Studies have shown that even brief advice from physicians has a positive effect on cessation efforts. Pharmacologic treatment to support smoking cessation increases the likelihood of success, and the effectiveness of these medications is further increased by behavior therapy (5). Over the past 20 years, there have been significant advances in pharmacotherapy for treating tobacco dependence (6). The main purpose of the current drug therapy is to ameliorate the symptoms and signs of acute nicotine withdrawal (7). Pharmacotherapy is significantly more effective in achieving abstinence than placebo or cold turkey. Seven smoking cessation pharmacotherapies are currently approved by the US Food and Drug Adminstration (FDA). Five of these are nicotine replacement products (gum, patch, nasal spray, inhaler, and lozenge) (8). Each delivers nicotine, the agent that is responsible for the development of tobacco dependence, so that the nicotine withdrawal symptoms (Table ) and the craving for cigarettes are reduced while the patient is quitting smoking. Another approved smoking cessation therapy, bupropion sustained-release (SR), helps in smoking cessation by inhibiting dopamine reuptake in the central nervous systems. Table. The Nicotine Withdrawal Syndrome Symptom Incidence % (clinical assessment) Anxiety 87 Irritability, frustration, anger 87 Decreased heart rate 80 Difficulty concentrating 73 Increased appetite, weight gain 73 Restlessness 7 Craving for cigarettes 62 Depression, dysphoria (depends on the prior history of depression) Bupropion also antagonizes nicotinic acetylcholine receptor function. The primary mechanism of bupropion's effect on smoking cessation is not clear, but it appears to be via reduction of withdrawal symptoms by mimicking nicotine effects on dopamin and noradrenaline (9,0). It increases smoking cessation rates compared with both placebo and the nicotine patch (-2). Varenicline, a partial nicotine agonist, is the latest addition to the list of drugs approved by the FDA for smoking cessation (0)

109 NICOTINE REPLACEMENT THERAPY NRT was the first successful pharmacological intervention for nicotine dependency and is now widely employed. Recently, Alberg et al. reported that the use of NRT is common in the general population, particularly among heavy smokers (3,4). NRT refers to the administration of nicotine to substitute that obtained from tobacco. Nicotine replacement provides the smoker with lower, relatively safer dose of nicotine that is reported to attenuate withdrawal symptoms. The use of NRT allows the smoker to develop coping strategies for the behavioral aspects of their addiction with the physiologic component being addressed (4,5). NRT is supplied in several forms: patch, gum, inhaler, nasal spray and lozenges. When smokers use these products, they must cease all tobacco use before starting the NRT because of the possibility of nicotine toxicity with concurrent NTR and tobacco use. The faster acting formulation of NRT, such as nicotine gum, nasal spray or inhaler, appears to be helpful in satiating the positive effects of nicotine intake through smoking and reduce acute craving, while the slow acting transdermal nicotine patch supplies low but constant levels of nicotine, which, depending on the concentration, can relieve nicotine withdrawal symptoms (Fig.) (4). Studies have shown that NRT produces a.5 3-fold increase in smoking cessation rates compared to placebo (4,6). Nicotine Patch A number of transdermal nicotine replacement systems (Habitrol, Nicoderm CQ, Nicotrol) are available over the counter. The results of the Fagerstrom Test for Nicotine Dependence can be used to determine the appropriate starting patch strength for a patient (Table 2). However, the proper initial dose can be determined more quickly using the patient's score on the abbreviated Fagerstrom test: a score of 5 to 6 warrants use of the 2-mg nicotine patch; a score of 3 to 4 means that the 4-mg nicotine patch is appropriate for initial therapy; and a score of zero to 2 indicates initial use of the 7-mg nicotine patch (7)

110 Adverse reactions to transdermal nicotine replacement systems seldom cause discontinuation of therapy. From 30 to 50 percent of patients experience mild skin irritation under the patch. In most patients, this problem can be alleviated by rotating patch application sites. Sleep disruption is usually resolved by removing the patch at bedtime (7). It is important to discourage patients from smoking while they are using the nicotine patch. The combination of smoking and nicotine patch use results in discomfort from higher nicotine levels; more importantly, it increases the likelihood of relapse to virtually 00 percent. Concerns about sudden cardiac death as a result of concomitant smoking and nicotine patch use have been allayed by two clinical trials that showed no increase in morbidity or mortality associated with nicotine patch use in smokers with heart disease (7). Nicotine patches should be used for about eight to 2 weeks. Tapering to the next lowest dose (e.g., 2 mg to 4 mg) can be done after four to six weeks. The patient who starts with the 7-mg patch should continue using that patch for six weeks (7). Pregnancy: Pregnant smokers should be encouraged to quit without medication. The nicotine patch has not been shown to be effective for treating tobacco dependence treatment in pregnant smokers. (The nicotine patch is an FDA pregnancy Class D agent.) The nicotine patch has not been evaluated in breast-feeding patients (). Nicotine Gum Nicotine polacrilex (Nicorette) is available over the counter in 2-mg and 4-mg strengths. The gum is most effective in the 4-mg strength, with initial use of 0 to 5 pieces of gum per day. After two weeks, most patients can change to the 2-mg strength. The most important adverse events associated with nicotine gum appear to be gastrointestinal side effects from swallowing large amounts of nicotine when the gum is used improperly. Nicotine gum is intended to be parked in the buccal area and chewed once or twice every few minutes. If the gum is chewed too quickly, nicotine is swallowed with saliva, and nausea or dyspepsia can result (7). Pregnancy: Pregnant smokers should be encouraged to quit without medication. Nicotine gum has not been shown to be effective for treating tobacco dependence in pregnant smokers. (Nicotine gum is an FDA pregnancy Class D agent.) Nicotine gum has not been evaluated in breast-feeding patients (). Nicotine Inhaler A nicotine inhalation system (Nicotrol Inhaler) has recently become available by prescription. The nicotine is primarily absorbed through the oral cavity (36 percent) and the esophagus and stomach (36 percent), rather than through the lungs (4 percent). Currently, four inhalers a day must be used to achieve adequate nicotine

111 levels. Hence, frequent dosing is required, with each inhaler containing 500 puffs. Side effects include mouth and throat irritation (7,9-2). Pregnancy: Pregnant smokers should be encouraged to quit without medication. The nicotine inhaler has not been shown to be effective for treating tobacco dependence in pregnant smokers. (The nicotine inhaler is an FDA pregnancy Class D agent.) The nicotine inhaler has not been evaluated in breast-feeding patients (). Nicotine Nasal Spray Nicotine replacement can also be accomplished with a nasal spray (Nicotrol NS), which is available by prescription. Nicotine spray is administered in one or two doses (each dose is two 0.5 mg sprays, one in each nostril per hour initially).the dose may be increased as needed, not to exceed 5 doses per hour or 40 doses per day. ). Each bottle contains approximately 00 doses. The spray is used for eight weeks, then gradually tapered over four to six weeks. Recommended duration of therapy is 3-6 months. Nasal and throat irritation, rhinorrhea, and nausea are common side effects (7,22,23). Pregnancy: Pregnant smokers should be encouraged to quit without medication. Nicotine nasal spray has not been shown to be effective for treating tobacco dependence in pregnant smokers. (Nicotine nasal spray is an FDA pregnancy Class D agent.) Nicotine nasal spray has not been evaluated in breast-feeding patients (). Nicotine Lozenge Nicotine sublingual lozenge/tablet is available in 2-and 4mg dose. The pharmacokinetic properties of the lozenge are comparable to those of nicotine gum, where the nicotine is rapidly absorbed via the buccal mucosa providing a peak level of nicotine that declines with time. They are easy to use and deliver more (~25%) nicotine than nicotine gums. It was recently approved by the US-FDA as first-line medication (4). Pregnancy: Pregnant smokers should be encouraged to quit without medication. The nicotine lozenge has not been shown to be effective for treating tobacco dependence for pregnant smokers. The nicotine lozenge has not been evaluated in breast-feeding patients. Because the lozenge was approved as an over-the-counter agent, it was not evaluated by the FDA for teratogenicity (). Comparison of Delivery Systems Data are lacking on which nicotine delivery system is most effective. Because all four systems appear to be efficacious, patient preference usually determines the choice of nicotine replacement modality. For example, the patient who needs to be doing something with his or her hands may prefer the nicotine inhaler over the nicotine patch. The patient who is concerned about gaining weight may prefer to use nicotine gum, which has been shown to delay (but not prevent) weight gain associated with smoking cessation (20). BUPROPION Bupropion, the atypical antidepressant phenylaminoketone, is the first nonnicotine containing agent to be approved by the FDA for smoking cessation. Bupropion hydrochloride was introduced in the USA in 997, under the brand name of Zyban, and is now considered a first-line pharmacological treatment for nicotinedependent smokers (4). Bupropion inhibits the uptake of norepinephrine, serotonin, and dopamine. The mechanism by which bupropion enhances the ability of patients to abstain from smoking is unknown; however, the drug is believed to reduce the urge to smoke through its effect on the norepinephrine and dopamine neurotransmitter systems. Bupropion and nicotine replacement have been shown to have similar positive effects on quit rates. Combined use of these agents appears to be the most effective treatment for nicotine dependence. One controlled trial found that bupropion therapy resulted in a 2-month abstinence rate of 30 percent, compared with 6 percent for nicotine replacement therapy alone. Combination therapy using bupropion plus nicotine replacement resulted in an even higher 2-month quit rate (36 percent). Patients should begin with a dose of 50 mg every morning for 3 days, then increase to 50 mg twice daily. Dosage should not exceed 300 mg per day. Dosing at 50 mg twice daily should continue for 7-2 weeks. Bupropion therapy is usually continued for eight to 2 weeks after the patient has quit smoking (Prescribing

112 information for Bupropion Tablo 3.) (, 24). For long-term therapy, consider use of bupropion SR 50 mg for up to 6 months post-quit. Contraindications to the use of bupropion include a history of seizure disorder and the presence of eating disorders or uncontrolled hypertension. The most common side effects of the drug are dry mouth and sleep disturbance. Nicotine-dependent patients with comorbid depression may benefit from bupropion therapy (,4,7, 2,24) Table 3. Prescribing Information for Bupropion HCL SR 50 mg Tablets (Zyban). Contraindications Smokers under 8 years of age Pregnant women Hypersensitivity to bupropion A current or previous seizure disorder Tumour of the central nervous system A current or previous diagnosis of bulimia or anorexia nervosa Severe hepatic cirrhosis Concomitant use of bupropion and monoamine oxidase inhibitors A history of bipolar disorder Withdrawal from alcohol or benzodiazepines Precautions It is recommended that a risk benefit assessment be undertaken before prescribing bupropion to patients with other risk factors for seizures. Risk factors for seizures include the following: Medications that lower seizure threshold (e.g. antidepressants, antipsychotics, antimalarials, quinolones, sedating antihistamines, systemic corticosteroids, theophylline, tramadol) Current use of stimulants and anorectics Alcohol abuse History of head injury Dosage adjustments Elderly: 50 mg once daily is recommended. Hepatic/renal insufficiency: 50 mg once daily is recommended. Diabetes: If diet controlled, the standard dose can be prescribed. If well controlled with insulin or oral hypoglycaemics, prescribe 50 mg once daily. If poorly controlled use NRT Pregnancy Pregnant smokers should be encouraged to quit without medication. Bupropion has not been shown to be effective for tobacco dependence treatment in pregnant smokers. (Bupropion is an FDA pregnancy Class C agent.) Bupropion has not been evaluated in breast-feeding patients. Adverse effects Common (occurrence :00): dry mouth, insomnia, nausea, headache. Rare (occurrence :0,000 and :000): seizure, severe hypersensitivity reaction. VARENICLINE Originally developed by Pfizer, Inc. in 997, varenicline (Chantix, Champix) is structurally related to the plant alkaloid cytisine (discussed below), and one of only three smoking cessation therapeutics currently approved by the United States Food and Drug Administration (FDA). Initial in vivo binding studies found that varenicline has high affinity for the a4b2 nachr subtype with little affinity for other subtypes. Further, in rat brain slices, varenicline was found to release lower concentrations of DA (40 60% of that released by nicotine). Collectively, these findings suggested that varenicline is a partial agonist at 4 2* nachrs. However, studies report that varenicline also is expressed as a full agonist at 7 nachrs in cell systems. In humans, maximal - 0 -

113 absorption of varenicline occurs within 3 4 h of oral administration, and the drug has an elimination half-life of ~ 24 h, primarily through renal excretion. Further, steadystate conditions are established within 4 days of oral administration in healthy adults (2). The recommended dose of varenicline is mg BID after a -week titration period (starting with 0.5 mg QD, then 0.5 mg BID, and then mg BID). The initial dose titration reduced the incidence of nausea. Varenicline should be started 7 days before the date identified for smoking cessation (0). A recent multicenter, randomized, doubleblind placebo-controlled study found continuous abstinence rates of 44% for varenicline during 9 2 weeks after quitting, which was higher than the abstinence rates for patients treated with bupropion (30%) or placebo (8%) (22). Pregnancy: Pregnant smokers should be encouraged to quit without medication. Varenicline has not been shown to be effective for treating tobacco dependence in pregnant smokers. (Varenicline is an FDA pregnancy Class C agent.) Varenicline has not been evaluated in breast-feeding patients (). OTHER DRUGS Alprazolam (Xanax) and other benzodiazepines have been used to reduce the anxiety associated with nicotine withdrawal. However, treatment with benzodiazepines has not been shown to improve smoking cessation rates. Several other drugs including antidepressants (nortriptilyne, imipramine, doxepin, moclobemide), antihypertensives (clonidine, mecamylamine), anxiolytics (buspirone, diazepam, meprobamate and b- blockers), and sensory replacement therapy (silver acetate) have been used in smoking cessation. Among these Clonidine and Nortriptilyne are considered as second-line smoking cessation drugs (4,24). Dealing with Relapse Most patients relapse within the first six to 2 months of a smoking cessation attempt. If a patient relapses, the physician needs to encourage the patient to try again. It is useful to review the treatment plan to determine what did and did not work. A patient may not return immediately after a relapse and may smoke for months before another visit. At that point, the patient's readiness to change needs to be reevaluated, and the smoking cessation process must be repeated. Tobacco addiction is the commonest chronic and relapsing medical illness. Nicotine dependence is a tenacious and difficult addiction to treat successfully. Clearly, perseverance on the part of the patient and the physician is most effective for achieving permanent abstinence. The use of nicotine replacement, bupropion and varanicline can improve results, and the application of readiness-to-change strategies and motivational interviewing techniques are essential for success. Behavioral therapy and support in a group setting have been shown to improve quit rates. Individual counseling can also be effective. A supportive telephone call during the first few days of abstinence may help the patient who is trying to quit smoking (20-24). REFERENCES: - Fiore MC. Tobacco Use and Dependence: An Updated Review of Treatments. (0 March 200). 2- Pharmacological approaches to smoking cessation. Mitrouska I, Bouloukaki I, Siafakas NM. Pulm Pharmacol Ther. 2007;20(3): Epub 2006 Feb 23. Review. 3- Anthonisen NR, et al. The effects of a smoking cessation intervention on 4.5-year mortality: a randomized clinical trial. Ann Intern Med 2005;42(4): Pharmacological approaches to smoking cessation. Mitrouska I, Bouloukaki I, Siafakas NM. Pulm Pharmacol - -

114 Ther. 2007;20(3): Epub 2006 Feb 23. Review. 5- Mallin R. Smoking cessation: integration of behavioral and drug therapies. Am Fam Physician Mar 5;65(6): Frishman WH. Smoking cessation pharmacotherapy. Ther Adv Cardiovasc Dis Aug;3(4): Epub 2009 Jun 2. Review. 7- Lillington GA, Leonard CT, Sachs DP. Smoking cessation. Techniques and benefits. Clin Chest Med 2000;2(): Gonzales D, Rennard SI, Nides M, Oncken C, Azoulay S, Billing CB, Watsky EJ, Gong J, Williams KE, Reeves KR; Varenicline Phase 3 Study Group. Varenicline, an alpha4beta2 nicotinic acetylcholine receptor partial agonist, vs sustained-release bupropion and placebo for smoking cessation: a randomized controlled trial. JAMA Jul 5;296(): Warner C, Shoiab M. How does bupropion work as a smoking cessation aid? Addict BioI. 2005; Kaur K, Kaushal S,. Chopra CS. Varenicline for Smoking Cessation: A Review of the Literature. Current Therapeut c Research ():70. - Hurt RD, Sachs DP, Glover ED, et al. A comparison of sustained-release bupropion and placebo for smoking cessation. N Engl] Med. 997;337: Jorenby DE, Leischow SJ, Nides MA, et al. A controlled trial of sustained-release bupropion, a nicotine patch, or both for smoking cessation. N Engl] Med. 999;340: Alberg AJ, et al. Nicotine replacement therapy use among a cohort of smokers. J Addict Dis 2005;24(): Mitrouska I, Bouloukaki I, Siafakas N.M. Pharmacological approaches to smoking cessation. Pulmonary Pharmacology & Therapeutics 2007;20 : Lerman C, Patterson F, Berrettini W. Treating tobacco dependence: state of the science and new directions. J Clin Oncol 2005;23(2): Silagy C, et al. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev 2004(3):CD Malin R. Smoking cessation: integration of behavioral and drug therapies. Am Fam Physician Mar 5;65(6): Gourlay SG, Forbes A, Marriner T, Pethica D, McNeil JJ. Prospective study of factors predicting outcome of transdermal nicotine treatment in smoking cessation. BMJ 994;304: Fant RV, Owen LL, Henningfield JE. Nicotine replacement therapy. Prim Care 999;26: A clinical practice guideline for treating tobacco use and dependence: a US Public Health Service report. The Tobacco Use and Dependence Clinical Practice Guideline Panel, Staff, and Consortium Representatives. JAMA 2000;283: Dwoskin LP, Smith AM, Wooters TE, Zhang Z, Crooks PA, Bardo MT. Nicotinic receptor-based therapeutics and candidates for smoking cessation. Biochem Pharmacol Oct ;78(7): Epub 2009 Jun Gonzales D, Rennard SI, Nides M, Oncken C, Azoulay S, Billing CB, et al. Varenicline, an alpha4beta2 nicotinic acetylcholine receptor partial agonist, vs sustained-release bupropion and placebo for smoking cessation: a randomized controlled trial. JAMA 2006;296: Moore T. Treatment options for smoking cessation. Elseviler Science Inc. MEDICAL UPDATE FOR PSY- CHIATRISTS 997 2; : McRobbie H, Lee M, Juniper Z. Non-nicotine pharmacotherapies for smoking cessation. Respir Med Oct;99(0): Review

115 COURSES COURSE 2 (Co-2) April 25, 200 / 09:5 0:45 & :5 2:5 / Hall C Basic life support training (Temel yaflam deste i e itimi) Moderators: Nebi Sökmen Kurtulufl Öngel Mehmet Ali Karaca Bülent Erbil Nebi Sökmen Temel yaflam deste i ve otomatik eksternal defibrilatör kullan m e itimi N. SOKMEN Temel yaflam deste i koruyucu cihaz kullanmadan hava yolu aç kl n sa layarak solunum ve dolafl m desteklenmesini içerir. Bu bölümde yetiflkin TYD de kurtar c lar için rehber ve Otomatik Eksternal Defibrilatör (OED) kullan m rehberi bulunmaktad r. Ayr ca ani kardiyak arrest, recovary (derlenme pozisyonu) ve yabanc cisimle hava yolu t kan kl yönetimini içerir. Temel yaflam deste i ani kardiyak arrest, inme, yabanc cisimle havayolu t kan klar na ba l bulgular n saptanma becerisi, kardiyopulmoner resusitasyon (KPR), Otomatik Eksternal Defibrilatörle (OED) defibrilasyonu içerir. Girifl Ani kardiyak arrest Avrupa ve ABD de önde gelen ölüm nedenidir ve y lda Avrupa da kifliyi etkilemektedir. Ani kardiyak arrest olgular n n %40 da ilk ritim ventiküler fibrilasyondur. Arrest olgular nda ilk ritimler venriküler fibrilasyon (VF) veya h zl ventriküler taflikardi (VT) olsa da belirli bir zaman geçtikten sonra al nan ilk EKG kay tlar nda ritim asistol olarak görülmektedir. VF, ventrikülde kaotik olarak depolarizasyon ve repolarizasyon ile karakterizedir. Bunun sonucunda kalp koordineli olarak çal flma fonksiyonunu kaybeder ve etkili pompa ifllevi durur. Ani Kardiyak arrestli VF devam ederken yap lacak erken tedavi ile yaflam flans daha yüksek iken, bu ritim asistole döndü ünde baflar l resusitasyon flans azalmaktad r. VF ye ba l kardiyak arrestin optimum tedavisi KPR ( kardiyak masaj ve solunum kombinasyonu) ile erken elektriksel defibrilasyondur. Kardiyak arrest mekanizmalar travma, ilaç afl r doz al m, bo ulma ve birçok çocukta görülen asfiksi olgular nda kurtar c soluk resusitasyonda kritik role sahiptir. Afla da belirtilen yaflam zinciri baflar l resusitasyon için hayati basamaklard r. (Resim ) Afla daki basamaklar hem VF hem de asfiksi arresti kurbanlar için geçerlidir. Resim : Eriflkinde Yaflam Zinciri (Part 4: Adult Basic Life Support, Circulation. 2005;2:IV-8.) - Acil durumun erken saptanmas ve erken yard m isteme: Acil yard m sistemini aktive etmek. Örn: 2 aramak. Erken ve etkili yan t kardiyak arresti engelleyebilir

116 2- Erken KPR: Erken KPR, VF ye ba l ani kardiyak arrest olgular nda hayatta kal m 2 3 kat artt r r. 3- Erken defibrilasyon: KPR ve 3 5 dakika içinde yap lan defibrilasyon yaflam flans n %49 75 oran nda artt r r. Defibrilasyondaki her bir dakikal k gecikme yaflam flans nda %0 5 oran nda azalmaya neden olur. 4- Erken ileri yaflam deste i ve resusitasyon sonras bak m: Resusitasyon sonras bak m n kalitesi sonucu etkilemektedir. Birçok ülkede acil sa l k ekiplerinin ça r dan olguya eriflim kadar geçen zaman 8 dakikan n üzerindedir. Bu zaman içinde olgunun hayatta kalma flans yukar da belirtilen ilk basama n uygulan fl na ba l d r. Kardiyak arrest olgular nda hemen KPR bafllamak gereklidir. KPR küçük oranda fakat beyin ve kalp için kritik kan dolafl m na olanak sa lar. Ayr ca VF yi sonland rmada baflar flans n art r r. E er flok arrestten sonraki ilk 4 veya 5 dakika içinde uygulanamayacaksa gö üs kompresyonlar özellikle önem kazanmaktad r. Defibrilasyon, VF s ras ndaki miyokarddaki koordine olmayan depolarizasyon- repolarizayon sürecini durdurur. E er kalp dokusu canl l n devam ettiriyorsa daha sonra normal pacemaker fonksiyonu tekrar eline al r, etkili normal ritmi ve dolafl m n etkili olarak geri dönüflünü sa lar. Baflar l defibrilasyondan sonraki ilk birkaç dakikada ritim yavafl ve etkisiz olabilir; etkili kardiyak fonksiyon sa lanana kadar gö üs kompresyonuna devam edilmelidir. Kurtar c lar hastan n ritmini analiz edip VF varl nda elektriksel flok veren otomatik eksternal defibrilatör (OED) cihaz n kullanabilmesi için e itilmelidir. OED, kurtar c lar için sesli komut sistemine sahiptir. Cihaz EKG analizi yapar ve kurtar c ya flok verilmesi gerekli ise yönlendirir. OED cihaz VF varl n yüksek oranda do ru saptar. Bir sonraki konuda OED fonksiyonlar ve kullan m tart fl lm flt r. Baz çal flmalar erken bafllanan KPR nin, defibrilasyonun gecikmesinin zararl etkilerini azalt c flekilde yarar oldu unu göstermifllerdir. VF olgular nda KPR de her bir dakikal k gecikme hayatta kalma flans nda % 7-0 oran nda azalmaya neden olur. Erken bafllanan KPR, flahit olunan kardiyak arrest olgular n n yaflam oranlar nda 2-3 kat art fl sa lar. ER fik N TYD BASAMAKLARI (AKIfi fiemasi) TYD afla daki basamaklar içerir. TYD basamaklardan oluflur ve TYD algoritmas olarak adland r l r (Resim 2). Algoritma oluflturman n amac, bulunulan her basama mant kl ve ak lda kal c flekilde ö renmeyi ve uygulamay sa lamas d r. Kutu numaralar de inilecek olan Eriflkin TYD sa l k çal flanlar algoritmas n göstermektedir. Yaral ya yaklaflmadan önce kurtar c ortam n güvenli oldu undan emin olmal d r. Kurtar c lar yaral y ancak gerekli durumlarda hareket ettirmelidir. (örn: yanan bina gibi teklikeli bölge) Resim 2: Eriflkin temel yaflam deste i ak fl flemas (Sa l k Çal flan ) (Part 4: Adult Basic Life Support, Circulation. 2005;2:IV-2.) - 4 -

117 Cevab de erlendir. (Kutu ) Öncelikle kurtar c ortam güvenli inden emin olmal ve cevab de erlendirmelidir. Cevab de erlendirmek için yaral n n veya kazazedenin omzuna yaklafl p omzuna nazikce dokunulmal ve iyi misiniz? diye sorulmal d r. E er kazazede yan t verir, fakat yaral veya medikal yard m gerekli ise 2 aranmal d r. Sonra tekrar kazazedenin yan na h zla dönülmeli ve kazazedenin durumu s k kontrol edilmelidir. Acil Yard m sistemini aktive etme (Kutu 2) E er kurtar c yaln z olarak cevaps z eriflkinle karfl laflt nda (örn: hareketsiz veya uyar ya yan ts z) kurtar c acil yard m sistemini (2) aktive etmeli ve OED istemeli, sonra kazazedenin yan na dönüp KPR ve gerekli ise defibrilasyon yapmal d r. E er 2 veya daha fazla kurtar c varsa, bir kurtar c KPR basamaklar n bafllamal, ikinci kurtar c Acil yard m sistemini aktive etmeli ve OED istemelidir. Sa l k çal flanlar kurtarma giriflimlerinin basamaklar n arrestin olas nedenlerine göre planlamal d r. E er yaln z bir sa l k personeli eriflkin veya çocukta ani geliflen kollaps gördüyse ve kollaps büyük olas l kla kardiyak kökenli ise, kurtar c 2 aramal ve OED istemeli ve h zla kazazede yan na dönerek KPR ye bafllamal ve OED yi kullanmal d r. E er yaln z bir sa l k personeli bo ulan bir kifliye yard m ediyorsa veya yaral herhangi bir yaflta ve asfiksiye ba l arrest ise (primer solunumsal) kurtar c Acil servisi aktive etmeden önce 5 siklus ( yaklafl k 2 dakika) KPR uygulamal d r. Kurtar c 2 sistemini arad nda acil yard m sistemi taraf ndan sorulabilecek yer, ne oldu u, yaral say s, ne tür yard m yap ld fleklinde sorulara cevapland rabilmelidir. Kurtar c ancak bilgilendirmeyi yapt ktan/tamamlad ktan sonra telefonu kapat p kazazedenin yan na KPR ve gerekti inde defibrilasyonu yapmak için dönmelidir. Hava yolunu açma ve solunumu kontrol etme (Kutu 3) KPR ye bafllamadan önce kazazede sert ve düzgün bir yüzeye supin ( yüzü yukar gelecek flekilde) yat r lmal d r. E er yan ts z kazazede yüzüstü flekilde (prone) yat yorsa kazazede yüzü yukar gelecek flekilde döndürülmelidir. E er kazazede hospitalize ve ileri hava yoluna sahipse ( örn: endotrakeal tüp, laringeal mask airway (LMA) veya özefageal kombi tüp (Combitube)) ve supin pozisyona döndürülemeyecekse (örn: spinal cerrahi), sa l k çal flan KPR yi prone pozisyonda yapmal d r.(class IIb) Hava yolunu açma: sa l k personeli olmayan kurtar c Sa l k personeli olmayan kurtar c yaral ve yaral olmayan kazazedelerde bafl geriye-çene yukar manevras ile hava yolunu açmal d r (Class IIa). Jaw trust ( çeneyi yukar çekme) manevras sa l k personeli olmayan kurtar c lar için ö renmesi ve uygulamas zor oldu u, s kl kla etkili hava yolunu sa layamayaca ve spinal harekete neden olabilece i için önerilmemektedir (Class IIb). Hava yolunu açma: sa l k personeli Sa l k çal flan hava yolunu açmak için kazazedede bafl veya boyun yaralanma bulgular bulunmad durumlarda head tilt-chin lift (bafl geriye- çene yukar ) manevras n yapmal d r. Head tilt- chin lift (bafl geriye-çene yukar ) manevras bilinçsiz, paralize gönüllü yetiflkinlerde kullan lm fl ve kardiyak arrest olgularda çal fl lmam fl ve radyolojik olarak klinik kan tlar (LOE 3) bulunmasa da olgu serilerinde (LOE 5) etkili oldu u gösterilmifltir. Künt travmal hastalar n %2 de spinal yaralanma bulunmaktad r ve e er kazazedede kraniyofasiyal yaralanma bulunuyorsa, Glaskow Koma Skalas 8 den düflükse veya her ikisi mevcutsa bu oran üç kat artmaktad r. Sa l k çal flanlar servikal yaralanma olas l olan kazazedelerde hava yolunu açmak için bafl geriye itmeden jaw thrust (çeneyi yukar çekme) manevras n kullanmal d r (Class IIb). Hava yolunu açmak ve ventilasyonu sa lamak KPR de önceli e sahip olu u için (Class I) jaw-thrust manevras nda baflar s z olunursa hava yolunu açmak için head tilt- chin lift (bafl geriye- çene yukar ) manevras kullan lmal d r. Spinal yaralanmadan flüphelenilen olgularda manüel boyun hareketlerini s n rlayan cihazlar, immobilizasyon sa layan cihazlar tercih edilmelidir (Class IIb). Manüel boyun hareketlerini s n rlamak daha güvenlidir, immobilizasyon cihazlar hastan n hava yolunu engelleyebilir (LOE 3). Servikal collar ( boyunluk) KPR s ras nda havayolu yönetimi komplike hale getirebilir (LOE 3) ve kafa travmal hastalarda kafa içi bas nc n artmas na neden olabilir ( Class LOE 4, Class IIb). Fakat spinal sabitleyici cihazlar transport s ras nda gereklidir. Solunum Kontrolü Hava yolunu açarken solunum için bak, dinle, hisset yöntemi kullan l r. Sa l k personeli olmayan kurtar c 0 saniye içinde normal solunum tespit edemezse veya sa l k personeli 0 saniye içinde yeterli solunumu sapta

118 mazsa, 2 kurtar c soluk verilmelidir. Sa l k personeli olmayan kurtar c isteksizse veya kurtar c soluk vermeyi yapamazsa gö üs kompresyonuna bafllamal d r (Class IIb) Profesyoneller de sa l k personeli olmayan kurtar c lar gibi yan ts z hastalarda solunum yolu aç k olmad nda, hastan n ani kardiyak arrest sonras ilk dakikalarda s kl kla görülen gasping solunumu nedeniyle karars z kald nda, solunumun varl n veya yoklu unu, yeterli veya yetersiz oluflunu do ru olarak tespit edemeyebilir(loe 7). Gasping solunumu etkili bir solunum de ildir. Gasping solunumu olan hastada solunum yokmufl gibi davran lmal (Class I) ve kurtar c soluk verilmelidir. Kurtar c Soluk vermek ( Kutu 5 ve 5A) Her biri saniye olacak ve yeterli derecede gö üs kafesini kald racak flekilde 2 kurtar c soluk verilmedir. saniye süreli soluk verme, KPR süresincesi a zdan a za, balon maske ventilasyon ve ileri hava yolu ekipman ile oksijenli veya oksijensiz olarak her türlü ventilasyon ifllemi için geçerlidir (Class IIa). KPR s ras nda amaç yeterli oksijenizasyonu sa lamakt r fakat optimum tidal volüm, solunum h z ve inspire edilen oksijen konsantrasyonunun baflar l p baflar lmad tam olarak bilinmemektedir. Afla daki genel önerilere uyulmal d r: - VF ye ba l ani kardiyak arrest olgular nda kurtar c soluk gö üs kompresyonlar kadar önemli olmayabilir çünkü kardiyak arrestten sonraki ilk birkaç dakikada kandaki oksijen miktar hala yüksektir. Kardiyak arrestin erken döneminde miyokarda oksijen sunumu azalan kan ak m nedeniyle azalm flt r. KPR esnas nda kan ak m gö üs kompresyonlar ile sa lan r. Kurtar c lar etkili gö üs kompresyonu yapt ndan emin olmal d r. Kurtar c lar etkili kompresyon için gö üs kompresyonunu kesintisiz veya aralar n minimal oranda tutmal d r. 2- Uzam fl VF ye ba l kardiyak arrest olgular nda kandaki oksijen oran azald için ventilasyon ve kompresyon önemlidir. Ventilasyon ve kompresyonlar kardiyak arrest esnas nda hipoksemik olan çocuklar veya bo ulmaya ba l asfiksiye ba l arrestlerde de önemlidir. 3- KPR s ras nda akci erlere giden kan miktar azal r, bunun sonucunda ventilasyon/perfüzyon oran daha düflük tidal volüm ve yavafl solunum h z ile sa lan r. Kurtar c lar hiperventilasyon yapmamal d r (çok h zl solunum ya da çok fazla volüm). Afl r ventilasyon gereksiz hatta zararl d r çünkü intratorasik bas nc artt rarak kalbe venöz dünüflü azalt r ve kardiyak outpoutta ve hayatta kal mda azalmaya neden olur. 4- Çok fazla ve zorlu solutmadan kaç n lmal d r. Bu tür solutmalar gerekli de ildir ve gastrik dilatasyona ve onun komplikasyonlar na neden olur. Kardiyak arreste kurtar c soluk için rehberlerin önerileri: Her kurtar c solu u sn de ver. (Class Ia) Yeterli tidal volüm ver (a zdan a za, maske veya balon maske ile oksijenli veya oksijensiz) (Class IIa) H zl veya zorlu solutmadan kaç n leri hava yolu sa land nda KPR iki kifli ile yap l yorsa solutma dakikada 8-0 olacak flekilde ve kompresyonlar n aras nda olacak flekilde senkronize yap lmal d r. Ventilasyon için kompresyona ara verilmemelidir. (Class IIa) Anestezi alm fl eriflkinlerde yap lan çal flmalar (normal perfüzyonlu) 8-0 ml/kg hesaplanan tidal volümün normal oksijenizasyon ve CO2 eliminasyonu sa lamak için yeterli oldu unu göstermifltir. KPR esnas nda kardiyak output normalin %25 33 oran ndad r, bu nedenle akci er taraf ndan oksijen al m ve CO2 sal n m azalm flt r. Sonuç olarak düflük dakika ventilasyonu (normalden daha az tidal volüm ve solunum h z ) KPR s ras nda yeterli oksijenizasyon ve ventilasyonu sa lamaktad r. KPR s ras nda eriflkinde tidal volümün yaklafl k ml (6-7 ml/kg) olmas yeterlidir (Class IIa). E er solunum balon-maske ile sa lanacaksa eriflkin tip ventilasyon balonu kullan lmal d r (volüm -2 lt); pediyatrik balon maskeler eriflkinde yetersiz havalanma neden olur. Yeterli oranda verilen kurtar c soluk gö üs kafesinde gözle görülür yükselmeyi sa lar (LOE 6,7; Class IIa). Görünür gö üs kafesi yükselmesini sa layan tidal volüm ml olarak hesaplanm flt r (Class IIa). Asfiksik ve aritmik kardiyak arrestte de ayn tidal volüm kullan m mant kl d r (Class IIb)

119 Midenin hava ile distansiyonu ileri hava yolu sa lanmayan olgularda s kl kla geliflir. Bu diyafram n elevasyonu ile regurgitasyon ve aspirasyona neden olur, sonuçta akci er hareketi ve respiratuvar komplians azal r. Her kurtar c solukta verilen hava mideye gider ve sonuçta mide içinde bas nç alt özefagus sfinkterinin aç lmas na neden olur. Midenin havayla fliflmesi yüksek oranda proksimal hava yolu direncine neden olur. Midenin havayla doluflunu azaltmak için ileri hava yolu olsun veya olmas n her kurtar c soluk saniyede ve gö üs kafesini görünür flekilde yükselmeye neden olacak flekilde tidal volüm verilmelidir(class IIa). A zdan a za kurtar c solutma A zdan a za kurtar c solutma kazazedeye oksijen ve ventilasyon sa lar. A zdan a za solutma yapabilmek için kazazedenin a z aç lmal, burnu kapat lmal ve hava kaçmayacak flekilde a zdan a za solutulmal d r. sn de normal soluk verilmeli (derin de il) ve ikinci soluk sn de verilmelidir (Class IIb). Normal solutma kurtar c y bafl dönmesi ve kulak ç nlamas ndan korur. Ventilasyonu zorlaflt ran en s k neden iyi aç lmam fl hava yoludur, e er kazazedenin gö üs kafesi kurtar c soluk ile yükselmiyorsa head- tilt-chin lift ( bafl geriye- çene yukar ) manevras yap lmal ve ikinci kurtar c soluk verilmelidir. A zda bariyer cihaz ile solutma Güvenlik nedeniyle baz sa l k çal flanlar ve sa l k çal flan olmayan kurtar c lar a zdan a za solutmadan kaç nabilir ve bariyer cihaz kullan m tercih edebilirler. Bariyer cihazlar enfeksiyonun geçifl riskini azaltmamaktad r ve hava ak m n n direncini art rabilir. E er bariyer cihaz kullan yorsak kurtar c solu u geciktirmemeliyiz. Bariyer cihazlar iki flekildedir: yüz örtüleri ve yüz maskeleri. Yüz örtüleri temiz fleffaf plastik veya silikon örtülerdir ve kazazede ile kurtar c aras nda direkt temas azalt r fakat kurtar c taraf n n kontaminasyonunu engellemez. Görev olarak yapan kurtar c lar a zdan a za solutma için yüz örtülerini kullanmal d r. Bu kurtar c lar en k sa zamanda yüz maskesi ve balon maske ile ventilasyona geçmelidir. A zdan a za solutma için kullan lan maskeler tek yönlü valf mekanizmas na sahiptir; kurtar c n n nefesini hasta hava yoluna geçifline izin verirken hastan n nefesini kurtar c n hava yoluna gitmesini engeller. Baz maskeler oksijen girifline sahiptir. Sa l k çal flanlar oksijen uygun oldu unda 0-2 lt/dk oksijen vermelidir. A zdan buruna ve a z-stoma ventilasyonu Hastan n a z n n aç lamad ve a zdan a za solutman n imkans z oldu u, kazazedenin suyun içinde oldu u durumlarda a zdan buruna solutma tavsiye edilir (Class IIa). Olgu serileri a zdan buruna solutman n eriflkinlerde kullan fll, güvenli ve etkili oldu unu göstermifltir (LOE5). Kurtar c soluk gereken kazazedelerde a zdan stomaya solutma verilmelidir. S k hava kaç rmayan yuvarlak pediatrik maske kullan m bir alternatiftir (Class IIb). A zdan stoma solutman n güvenli i, etkili ini ve kullan labilirli ini gösteren yay nlanm fl kan t yoktur. Bir çal flmada larinjektomi yap lan hastalarda pediatrik maskenin standart balondan daha iyi peristomal s zd rmazl k sa lad n göstermifltir (LOE4) Balon maske ile ventilasyon Kurtar c lar balon maske ventilasyonunu oda havas yla veya oksijenle yapabilir. Balon maske ileri hava yolu sa lamadan pozitif bas nç sa lar, sonuçta gastrik hava dolmas na ve onun komplikasyonlar na neden olur. Balon maske kullan ld nda her solutma sn periyotta ve görünür gö üs kafesini sa layacak tidal volüm verilerek yap lmal d r. Balon maske Cihaz Balon maske cihaz afla dakilere sahip olmal d r; s k flmayan iç valf; bas nç oluflturmayan valf veya bas nc azaltan valf; standart olarak 5 mm/22 mm; yüksek yo unlukta oksijen verebilmek için oksijen rezervuar ; yabanc materyalle t kanmayan ve 30 L/dk ak mda s k flmayan d fl valf; normal do a koflullar nda ve afl r hava s s de iflimlerinde yeterli fonksiyona sahip olmal d r. Maske regurgitasyonu görülebilecek flekilde transparan materyalden olmal d r. Yüze oturdu unda s zd rmaz olmal, hem a z ve hem de burnu kapatmal d r. Maskelerde oksijen girifli olmal ve 55mm/22mm standart konnektore sahip olmal ve yetiflkin ve pediatrik ölçüleri bulunmal d r

120 Balon maske ventilasyonu Balon maske ventilasyonu beceri ve tecrübe gerektiren bir yöntemdir. Tek kurtar c lar balon maske kulland nda maskeyi hastan n yüzüne s k ca bast r nca kendili inden hava yolunu jaw thrust manevras n yaparak açm fl olurlar. Kurtar c lar ayn zamanda her solutmada gö üs kafesinin yükselmesini gözlemelidir. Balon maske 2 e itimli ve tecrübeli kurtar c taraf ndan kullan ld nda daha etkili olur. Bir kurtar c hava yolunu açar ve maskeyi s zd rmayacak flekilde yüze bast r r, di eri balonu s kar. Her iki kurtar c gö üs kafesinin yükselmesini gözlemelidir. Kurtar c lar gö üs kafesinde görünür yükselme ve yeterli tidal volümü sa lamak için eriflin tip (-2L) balon kullanmal d r (Class IIa). E er havayolu aç ksa, kaçak yoksa (örn: yüz ve maske aras nda s zma yok) L lik balonun yar s veya 2/3 ü s k larak veya 2 L lik balonun /3 ünün s k lmas yeterli olur. Hastan n ileri hava yolu sa lanana kadar kurtar c lar hastay 30 kompresyon ve 2 solutma flekilde siklusu sa lamal d r. Kurtar c lar solutmay kompresyonun gevfleme aflamas nda sn süre ile yapmal d r (Class IIa). Sa l k çal flanlar uygun oldu unda suplementer oksijen (O2 %40, minimum ak m h z 0-2 L/dk) verilmelidir. deal olarak balon oksijen rezervuar na ba l olmal ve %00 oksijen verebilmelidir. LMA ve Özefageal-trakeal kombitüp gibi ileri hava yolu cihazlar birçok alanda TYD prati inde kullan lmaktad r. Bu cihazlar iyi e itilmifl ve yeterli tecrübeye sahip sa l k çal flanlar için balon maske için kabul edilebilir bir alternatiftir (Class IIb). Bu cihazlar n balon maskeye göre daha fazla komplikasyona sahip olup olmad net de ildir; her ileri hava yolu sa layan bu iki cihaz ve balon maskenin için etkili ve güvenli kullan m için e itim gereklidir. leri havayolu ile ventilasyon KPR esnas nda hasta ileri hava yoluna sahipse 2 kurtar c KPR siklusuna devam etmek zorunda de ildir (örn: kompresyonlar ventilasyon için verilen arada kesintiye u rar). Bunun yerine kurtar c lar kesintisiz olarak dakikada 00 olacak flekilde gö üs kompresyonuna devam eder. Ventilasyonu sa layan kurtar c dakikada 8-0 solutma yapar. 2 kurtar c yaklafl k her iki dakikada kompresör ve ventilatör rollerini de iflerek yorgunlu u ve gö üs kompresyonlar nda kalite ve h z n azalmas n önlemifl olurlar. Çok say da kurtar c bulundu unda her iki dakikada kompresör rollerini de iflmelidir. Kurtar c lar önerilen h zlarda ve gö üs kafesini gözle görülür yükselme sa layacak flekilde tidal volümde devam ederek afl r ventilasyondan kaç nmal d r (Class IIa). Bir çal flmada KPR s ras nda dakikada 2 solutma intratorasik bas nçta artmaya, kalbe venöz dönüflte azalmaya neden olur. Azalan venöz dönüfl kardiyak outputta azalmaya buna ba l olarak koroner ve serebral perfüzyonda azalmaya neden olur. Bu nedenle KPR esnas nda ventilasyon h z n n dakikada 8-0 olmas ve afl r ventilasyondan kaç nma kritik öneme sahiptir. Otomatik transport ventilatörleri ve manuel ve ak m s n rl ventilatörler Otomatik transport ventilatörleri hem hastane hem de hastane d fl nda ileri hava yolu olan ve nabz al nan eriflkin hastalar için yararl d r (Class IIa). leri hava yolu olmayan kardiyak arrest hastalar nda PEEP olmaks z n kontrollü ak m sa lanarak tidal volümün oluflmas nda yararl olabilir. Manuel, oksijen kaynakl, kontrollü ak ml ventilatörler KPR s ras nda ileri havayolu olmayan maske ventilasyonu için düflünülebilir. Krikoid Bas Krikoid k k rda n üzerine bas trakenin posteriyora do ru yer de iflmesini sa layarak özefagusu servikal vertebralara do ru s k flt r r, midenin hava ile fliflmesini ve regurgitasyon riskini azalmas n sa lar. Krikoid bas uygulamas gö üs kompresyonu ve ventilasyondan sorumlu olmayan üçüncü kurtar c y gerektirir. Krikoid bas ancak kazazede bilinçsizse uygulanmal d r ( örn: öksürük veya gaga refleks)

121 Nab z Kontrolü ( sa l k çal flanlar için) (Kutu 5) Sa l k personeli olmayan kurtar c lar nab zs z hastalar n 5%0 da (kardiyak arrest için düflük sensitivite) ve nab zl hastalar n % 40 da nab z saptamada (düflük spesifite) baflar s z olmaktad r ECC Rehberlerinde nab z kontrolü sa l k personeli olmayanlarda kald r lm fl ve sa l k personelinde tekrar vurgulanm flt r. Yeterli kan t olmasa da, nefes kontrolü, öksürme veya hareket varl dolafl m n de erlendirmesi için nab z kontrolüne göre üstünlü e sahiptir. Sa l k personeli olmayanlar solunumu olmayan cevaps z hastada kardiyak arrest düflünmelidir. Sa l k çal flanlar nab z kontrolü için hala çok zaman harcamaktad r ve e er nab z yoksa veya varsa saptamada zorluk yaflamaktad r. Sa l k çal flanlar nab z kontrolü için 0 sn den fazla zaman harcamamal d r (Class IIa). E er nab z 0 sn içinde hissedilemezse gö üs kompresyonuna bafllanmal d r. Gö üs kompresyonu olmadan kurtar c soluk ( Sadede sa l k çal flanlar için) (Kutu 5A) E er eriflkin hastada spontan dolafl m varsa (örn. palpe edilen nab z) ve ventilasyon gerekli ise dakikada 0 2 veya her 5-6 sn de bir soluk verilmelidir (Class IIb). Her soluk ileri hava yolu olsun olmas n sn de verilmelidir. Her soluk gözle görülür flekilde gö üs kafesinde yükselme sa lamal d r. Kurtar c soluk verirken her 2 dakikada bir nab z de erlendirilmeli (Class IIa) fakat 0 sn den fazla zaman harcanmamal d r. Gö üs kompresyonu (Kutu 6) Gö üs kompresyonlar sternumun alt k sm na ritmik bas nç uygulama ifllemidir. Bu kompresyonlar intratorasik bas nçta art fl ve kalbi direkt s k flt rma ile kan ak m sa lar. Uygun yap lan gö üs kompresyonlar arteryal bas nc mmhg ç karabilir, nadiren karotis arterde 40 mmhg aflan ortalama (mean) arteryel bas nç sa lar. Gö üs kompresyonlar ile sa lanan küçük ama kritik miktardaki kan ak m, miyokard için kan ve besin sa lar. VF ye ba l ani kardiyak arrest olgular nda gö üs kompresyonlar elektiriksel flokun baflar flans n artt r r. Gö üs kompresyonlar özellikle arresten 4 dk ve sonras verilen elektiriksel flok için önemlidir. Gö üs kompresyonlar n n fizyolojisi, de iflen kompresyon oranlar, kompresyon-ventilasyon oranlar hayvan modelleri üzerinde yap lan çal flmalardan elde edilmifltir te toplanan Konferans Konsensüsünde araflt rmac lar en iyi kompresyon için;. KPR de kan ak m n sa lamak için etkili gö üs kompresyonu gereklidir(class I), 2. Etkili kompresyon için push hard ( sert bas ) ve push fast ( h zl bas ) sa lanmal d r. Eriflkin gö üs kafesine dakikada 00 bas uygulanmal, 4-5 cm derinlik sa lanmal d r. Her kompresyon sonras gögüs duvar tamamen gevflemeli ve yaklafl k olarak kompresyon ve relaksasyon zaman eflit olmal, 3. Gö üs kompresyonlar ndaki kesilme minimum olmal, 4. Hayatta kal m ve nörolojik sonuç için en iyi flekildeki koordine kompresyon ve ventilasyon metodunun saptanmas için ileri çal flmalar n gerekli oldu u sonucuna varm fllard r. Teknik Kompresyonun etkisi maksimum olmas için kazazede s rt üstü (supin) pozisyonda sert bir zemine yat r lmal ve kurtar c kazazedenin toraks n n yan nda dizleri üstüne çökmelidir. Kurtar c kazazedenin gö sünün orta yerinde, iki meme ucu arac ndaki sternumun alt yar s na kompresyon uygulamal d r. Kurtar c sternumun ortas na iki meme ucu aras na elinin ayas n koymal, di er elinin ayas n ilk elinin üzerine koymal ve parmaklar birbiri üstünde paralel olmal d r (LOE 6; Class IIa)

122 Sternum yaklafl k 4 5 cm çöktürülmeli ve gö üs kafesinin normal pozisyonuna dönmesine izin verilmelidir. Gö üs kafesinin kendi normal pozisyonuna dönmesi, kalbe venöz dönüflü ve etkili KPR sa layaca için e itimlerde özellikle vurgulanmal d r (Class IIb). Kompresyon ve gö üs kafesi relaksasyon zaman yaklafl k olarak eflit olmal d r (Class IIb). Çal flmalarda hastane d fl nda yap lan gö üs kompresyonlar n n %40 n n yetersiz oldu u saptanm flt r. Kurtar c lar iyi kompresyon için pratik yapmal d r. Optimum gö üs kompresyon h z için insan çal flmalar nda yetersiz kan t vard r. nsan çal flmalar dakikada 80 kompresyonun KPRda optimum kan ak m sa lad n desteklemektedir. TYD rehberi dakikada 00 kompresyonu önermektedir(class IIa). ki gözlemsel insan çal flmas nda gö üs kompresyonlar ndaki kesintilerin s k oldu u gösterilmifltir. Bu çal flmalarda KPR yi sa l k çal flanlar uygulam fl ve toplam arrest zamanlar n n %24 49 da gö üs kompresyonu uygulanmam flt r. Hayvan çal flmalar nda gö üs kompresyonlar ndaki kesintinin koroner arterlerde perfüzyon bas nc nda azalma, daha s k ve uzun kesintinin daha düflün ortalama koroner perfüzyon bas nc na neden oldu u gösterilmifltir. 3 hayvan çal flmas nda gö üs kompresyonunda s k ve uzun kesintinin spontan dolafl m n geri dönüflünde azalma, hayatta kal mda azalma, resusitasyon sonras miyokard fonksiyonunda azalma ile iliflkili oldu u gösterilmifltir (LO- E 6). Baz hayvan çal flmalar sürekli veya minimal kesintili gö üs kompresyonlar n n yüksek hayatta kal m oran sa lad n göstermifltir. TYD rehberi tüm kurtar c lara nab z kontrolü, ritim analizi veya di er aktiviteler için gö üs kompresyonunda minimal kesinti önerir (Class IIa). Sa l k çal flan olmayan kurtar c lara KPR ye OED gelene, hasta hareket edene veya Acil sa l k personeli hastay devir alana kadar devem ettirmesi önerilir (Class IIa). Sa l k personeli olmayan kurtar c lar nab z kontrolü veya cevap kontrolü için gö üs kompresyonlar na uzun süreli ara vermemelidir. Sa l k çal flanlar gö üs kompresyonlar na s k olmayacak flekilde ara vermeli ve olas ise ileri hava yolu sa lanmas ve defibrilatör kullar - m için ara 0 sn den daha uzun olmamal d r ( Class IIa). KPR s ras nda tehlikeli bir ortam yoksa veya travma hastalar nda acil cerrahi gerekmiyorsa hasta hareket ettirilmemelidir. KPR in hastan n bulundu u yerde ve daha az ara ile yap lmas en iyisidir. Her kompresyon sonras gö üs kafesinin tamamen relaksasyonuna izin verilmelidir. Yetersiz relaksasyon intratorasik bas nçta art fla, kalbe venöz dünüflte azalmaya ve koroner ve serebral perfüzyonda azalmaya neden olur (LOE 6). KPR talimatlar gö üs kafesinin gevflemesinin önemini vurgulamaktad r. Kurtar c n n yorulmas yetersiz kompresyon h z ve derinli ine neden olur. Kurtar c lar n KPR nin 5. dakikas nda geliflen yorgunlu u inkar etmesine karfl n belirgin yorgunluk ve yüzeysel kompresyon, KPR de dk sonra görülmeye bafllar (LOE6). 2 veya daha fazla kurtar c varl nda masaj yapan n yerini 2 dakikada bir de ifltirmesi mant kl d r(veya 5 siklus kompresyon-ventilasyon, oran 30:2). E er iki kurtar c hastan n ayn taraf nda ise gö üs kafesinin gevflemesi esnas nda her 2 dakikada bir yer de ifltirmelidir. Kompresyon-Ventilasyon Oran Kompresyon-ventilasyon oran 30:2 olarak tavsiye edilmektedir (Class IIa). nfant ve çocuklarda oran 5:2 (pediyatrik temel yaflam deste i).(class II b) Bu 30:2 oran net kan tlardan daha çok uzmanlar n deneyimlerine dayanmaktad r. Kompresyonun oran n artt rmak olarak düzenlenmifltir, bu flekilde hiperventilasyon azalmakta, ventilasyon için kompresyona verilen ara azalmakta, ö renme ve beceri kolaylaflt rmak için talimatlar basitlefltirmektedir. nsanlarda yap lan çal flmalarda 30:2 kompresyon-ventilasyon oran 5:2 oran na göre daha yorucu olmaktad r. Hayatta kal m ve nörolojik sonuçlar na göre ileri hava yolu olan veya olmayan hastalarda en iyi KPR yapabilmek için en uygun kom

123 presyon-ventilasyon oran n n saptanmas için ileri çal flmalar yap lmal d r. Hava yolu sa land nda, 2 kurtar c varl nda KPR siklusunu devam ettirmek gerekli de ildir. Bunun yerine kompresyon yapan kurtar c ventilasyonu için ara vermeden dakikada 00 olacak flekilde kompresyona devam etmelidir. Ventilasyonu yapan kurtar c dakikada 8 0 kez solutmal d r. 2 kurtar c n n, kompresör ve ventilatör rollerini her iki dakikada de iflmeli yapmas gö üs kompresyonu s ras nda yorgunluk ve gö üs kompresyonlar ndaki kalitenin azalmas n engellemifl olur. Çok say da kurtar c varl nda her iki dakika kompresyon yapan kurtar c de iflmelidir. Sadece kompresyon KPR Ventilasyon yapmadan sadece gö üs kompresyonu yapman n sonuçlar eriflkin kardiyak arrestte hiç KPR yapmamaya göre daha iyidir. Çal flmalarda sa l k çal flanlar ve sa l k çal flan olmayan kurtar c larda, sebebi bilinmeyen kardiyak arrest olgusunda a zdan-a z solunum yapmakta isteksiz olduklar saptanm flt r. Gözlemsel çal flmalarda sa l k çal flan olmayan kurtar c lar taraf ndan sadece gö üs kompresyonu yap lan kardiyak arrest olgular n n hayatta kal m oran hiç KPR yap lmayanlara göre daha yüksek saptan rken, kompresyon-ventilasyon yap lan olgularda bu oran en yüksek saptanm flt r (LOE3,4). Baz hayvan çal flmalar nda VF ye ba l ani kardiyak arrest olgular nda ilk 5 dakikada kurtar c solu un gerekli olmad saptanm flt r. E er hava yolu aç ksa, gasping ve pasif olarak gö üs duvar n n gevflemesi bir miktar havan n de iflimine olanak sa lar. Ek olarak, KPR de düflük dakika ventilasyonu normal ventilasyon-perfüzyon oran n devam ettirebilir. Sa l k çal flan olmayan kurtar c lar kurtar c soluk vermede isteksiz iseler en iyi metot koordineli kompresyonventilasyon metodu olmas na ra men sadece kompresyon yapmalar konusunda desteklenmelidir (Class IIa). Gö üs Kompresyonunda alternatif yaklafl mlar Cough ( Öksürük) KPR Öksürük KPR n sa l k personeli olmayan kurtar c varl nda ve yan ts z hastada rolü yoktur. Öksürük KPR sadece bilinci aç k ve monitörde VF veya VT ritmi saptanan hastalarda yap labilir. Prone (Yüzüstü) KPR Hastalar s rtüstü (supin) pozisyona al namad nda, hastanede ve ileri hava yolu sa lanan hastalarda kurtar c KPR yi hasta yüzüstü pozisyonundayken yapmay düflünmelidir (LOE5; Class IIb). 6 hastal k çal flmada (LOE3) ve 3 olgu sunumunda (LOE5), prone pozisyonunda yap lan KPR de supin pozisyona göre daha yüksek kan bas nc de erleri elde edilmifltir. Alt adet olgu sunumu serisinde 22 entübe olarak prone pozisyonda KPR yap lan hastalar n 0 tanesi hastaneden taburcu edilmifltir (LOE5). Defibrilasyon (Kutu 8, 9, 0) Tüm TYD kurtar c lar defibrilasyon yapabilecek flekilde e itilmelidir, çünkü eriflkinde nontravmatik flahitli kardiyak arrestlerde en s k rastlanan ritim VF dir. Bu hastalara erken KPR bafllanmas ve 3 5 dakikada defibrilasyon yap lmas, yaflam flans oldukça yükseltir. fiahitli ve k sa süre geçen VF ye ba l ani kardiyak arrestlerde erken defibrilasyon yap lmal d r(class I). VF ye ba l geliflen uzam fl ani kardiyak arrestlerde defibrilasyon öncesi KPR yap lmas olumludur. Bir randomize kontrollü çal flmada, acil sa l k ekibinin 4 5 dakikadan daha uzun zamanda ulaflt durumlarda, defibrilasyon öncesi k sa süreli (,5-3 dk) KPR uygulanmas n n spontan dolafl m n geri dönme olas l n ve eriflkinde hastane içi-d fl VF/VT ye ba l hayatta kal m oran n artt rd gösterilmifltir(loe3)

124 Bu nedenle sa l k ekibi taraf ndan flahit olunmayan hastane d fl kardiyak arrestlerde kurtar c ritmi kontrol etmeden ve defibrilasyon denemeden önce belirli bir süre (örn:5 siklus veya yaklas k 2 dk) KPR uygulamal d r (Class IIb). Sa l k personeli olmayan OED kullan c programlar nda (OED bulundu u ve uygun oldu u yerlerde) veya hastane içinde veya Acil sa l k hizmeti çal flanlar n n flahit oldu u arrestlerde, kurtar c mümkün olan en erken zamanda defibrilasyon yapmal d r (Class IIa). Resusitasyonda Özel Durumlar Bo ulma Bo ulma ölümün önlenebilir nedenidir. Bo ulmaya ba l hipoksinin süresi ve fliddeti sonuç için en önemli belirleyicidir. Kurtar c lar KPR a hemen bafllamal, kurtar c soluk vermeli ve yan ts z hasta hemen suyun d fl na ç kar lmal d r (Class IIa). Herhangi bir yafltaki bo ulan hasta varl nda, kurtar c yaln z ise Acil servis sistemini aktive etmeden önce 5 siklus (yaklafl k 2 dk) KPR yap lmal d r. E itimli kurtar c lar taraf ndan yap lan suda a zdan a za solunum yararl olabilir(loe 5;Class IIb). Suyun içinde gö üs kompresyonu etkili olmaz, hem kurtar c hem de kazazede için zararl olabilir. Suyun, t kay c yabanc cisim gibi davrand n gösteren kan t yoktur. Yabanc cisim aspirasyonu için yap lan manevralar gerekli de ildir hatta yaralanmaya, kusmaya ve KPR de gecikmeye neden olabilir. Kurtar c bo ulan hastay uygun olan araçlar ile en k sa zamanda sudan ç karmal ve en k sa zamanda KPR bafllamal d r (Class IIa). Yaralanma bulgular olan, alkol intoksikasyonu olan, dalma ve su kaya öyküsü olan veya travma öyküsü olan hastalar potansiyel servikal yaralanma varm fl gibi tedavi edilmeli, stabilizayon ve uygun servikal ve torakal vertebra immobilizasyonu yap lmal d r. Hipotermi Hipotermik yan ts z hastalarda, sa l k çal flanlar solunum arrestini saptamak için solunumu, kardiyak arrest veya bradikardi için nabz saniye de erlendirilmelidir, çünkü hipoterminin derecesine göre kalp h z ve solunum yavafllam fl olabilir. E er kurban solumuyorsa kurtar c hemen solutmaya bafllamal d r. E er hastada nab z yoksa gö üs kompresyonuna hemen bafllanmal d r. KPR e bafllamak için hastan n tekrar s t lmas beklenmemelidir. Daha fazla s kayb n engellemek için slak giysiler ç kart lmal, hasta rüzgardan, s dan veya so uktan korunmal, mümkünse kurban s cak nemli oksijen ile solutulmal d r. Kaba hareketlerden kaç n lmal ve hasta en k sa zamanda hastaneye transportu yap lmal d r. E er VF saptan rsa normotermik hastalara uygulanan protokol uygulan r. Hastane d fl nda aktif s tma sa lanana kadar pasif s tma kullan labilir (Class intermediate). Recovery (Derlenme) Pozisyonu Recovery (derlenme) pozisyonu normal solunumu (Class IIb) ve etkili dolafl m olan yan ts z hastalarda kullan l r. Bu pozisyon hava yolu aç kl n n devam n sa lar, aspirasyon ve havayolu t kan kl riskini azalt r. Hasta yan yat r larak ön kolu vücudun ön taraf na konur. Derlenme pozisyonunun de iflik varyasyonlar vard r ve her biri kendi avantajlar na sahiptir. Tek pozisyon tüm kazazedeler için mükemmel de ildir. Pozisyon stabil, gerçek lateral pozisyona yak n olmal, havayolu engelleyecek flekilde gö üs üzerine bas oluflturmamal d r. Yabanc cisimle havayolu t kan kl (Bo ulma, t kanma) Yabanc cisimle havayolu t kan kl nadir görülen fakat önlenebilir ölüm nedenidir. Eriflkinlerde en s k yabanc cisimle hava yolu t kan kl nedeni g daya ba l d r ve kazazede yemek yerken olur. Çocuklarda ve infantlarda t kanma, yemek esnas nda ve oyun s ras nda ebeveyn veya bak c yan nda olmaktad r. T kanma olgusu ile s kl kla karfl lafl lmaktad r ve kurtar c s kl kla kurban cevap veriyorken müdahale eder

125 Yabanc cisme ba l havayolu t kan kl n n tespiti Havayolu t kan kl n n fark edilmesi baflar l sonuç için anahtar noktad r, bu acil durumun bay lma, nöbet, bilinç kayb, siyanoz veya di er ani solunum s k nt s yapan nedenlerden ay rt edilmesi acildir. Yabanc cisimler hafif veya ciddi hava yolu t kan kl na neden olur. E er t kan kl k ciddi havayolu t kan kl na neden oluyorsa kurtar c hemen müdahale etmelidir. Bu zay f havayolu de iflimi bulgular n ve nefes almada artan zorluk, sessiz öksürük, siyanoz ve konuflma ve nefes almada zorluk içerir. Kazazede t kanma belirtisi olarak boynunu tutar. H zl ca hastaya t kan kl k m var? ve e er kazazede evet anlam nda bafl n sall yorsa ve konuflam yorsa bu kazazede ciddi hava yolu t kan kl n gösterir. Yabanc cisimle havayolu t kan kl n n tedavisi Ciddi havayolu t kan kl bulgular varl nda kurtar c hava yolu t kan kl n tedavisi için h zl hareket etmelidir. E er hafif düzeyde t kan kl k varsa ve kurban zorlukla öksürüyorsa hastan n spontan öksürme ve soluma çabas engellenmemelidir. Öksürük giderek azald nda, solunum s k nt s n n artt nda ve stridor veya hastada yan ts zl k geliflti inde giriflimde bulunulmal d r. Hasta nefes al p vermede zorluk yafl yorsa 2 aranmal d r. E er birden fazla kurtar c varsa bir kurtar c 2 ararken di er kurtar c hasta ile ilgilenmelidir. T kan kl kla ilgili klinik bilgiler ço unlukla retrospektif ve kiflilerin anlat m na ba l d r. Yan t veren eriflkin ve yafl ndan büyük çocuklarda ciddi yabanc cisimle t kan kl nda, olgu sunumlar s rta vurma, abdominal vuru ve gö üse vuru yapman n uygulanabilir oldu unu belirtmifllerdir. Olgu sunumu (LOE 5) ve genifl olgu serisinde 229 t kanma olgusunun %50 de hava yolu t kan kl n gidermede tek teknikle baflar l olunamad belirtilmifltir. S rta tokat atma veya vuru ile abdomene veya gö se vuru kombinasyonlar n n baflar olas l n artt raca düflünülmektedir. Gö se vuru, s rta vuru veya abdomen vuru tekniklerinin hepsi kullan labilir ve ciddi havayolu t kan kl nda bilinçli hastada ve yas ndan büyük çocuklarda etkili olabilse de ö retilmesi basit oldu undan dolay abdomene vuru tekni i t kan kl n giderilmesinde daha h zl olarak uygulanabilmektedir (Class IIb). E er abdomene vuru etkisiz olursa kurtar c gö se vuruyu denemelidir (Class IIb). Ak lda tutulmas gereken önemli nokta, kar na vuru yas ndan küçük infantlarda yaralanmalara neden olabilece i için kullan lmamal d r. Gö se vuru tekni i kurtar c n n ellerinin abdomeni çevreleyemedi i obez hastalarda denenmelidir (Class indeterminate). E er t kan kl k olan hasta gebeli in son haftalar nda ise kurtar c abdominal vuru yerine gö se vuru seçmelidir (Class indeterminate). Abdominal vuru yaralanmaya neden olabilece i için hava yolu t kan kl abdominal vuru ile tedavi edilen hastalar yaralanma riski aç s ndan doktor muayenesine al nmal d r (Class IIb). Epidemiyolojik veriler ilk giriflimde yan t veren ve ilk giriflimde yan ts z yabanc cisimle havayolu t kan kl n n fatalitesinin ay r m aç s ndan yeterli bilgi vermemektedir. Bunun yan nda flüphelenilmeyen yabanc cisme ba l yan ts zl k veya kardiyak arrest geliflimi olas l n n düflük oldu u düflünülmektedir. Yabanc cisim t kan kl sonucu hastada cevaps zl k geliflti inde kurtar c hastay yere yat rmal ve hemen acil yard m sistemini aktive etmeli ve sonra hemen KPR ye bafllamal d r. Kadavralarda havayolunu açmak için yap lan randomize bir çal flmada ve 2 adet anestezi alan gönüllülerde yap lan çal flmalarda gö üs vurusu ile abdominal vuruya göre daha yüksek oranda havayolu bas nc elde edilir( LOE 7). KPR esnas nda havayolunda her aç kl kta kurtar c hastan n a z nda yabanc cisimi aramal ve uzaklaflt rmal d r. A z içine basitçe bakma ventilasyon için zaman geciktirmemeli ve 30 gö üs kompresyonu ile devam etmelidir. Kurtar c cevaps z hastalarda yaln z yabanc cismi gördü ünde havayolu t kan kl na neden olan solid nesneleri ç karmak için a z içinde parma n ile s vama fleklinde hareket ettirmelidir (Class indeterminate). A z içinde görünür yabanc cisim olmad nda parmakla a z içine s vaman n rutin olarak kullan m n öneren hiçbir çal flma yoktur. Eski rehberlerdeki öneriler parma n a z içinde s vama tarz nda hareketini kiflilerin kendi deneyimler

126 ine göre yararl olabilece i düflünüldü ü için önerilmifltir. Fakat olgu sunumlar kurtar c ya veya kazazedeye zarar gelebildi ini göstermektedir (LOE7). Resim 3:Eriflkinde hava yolu t kan kl tedavisi algoritmas (Resuscitation (2005) 67S6) Özet: TYD Kalitesi Sa l k personeli ve sa l k personeli olmayan kurtar c lar taraf ndan yap lan KPR kalitesi artt rmak için metotlar gelifltirilmelidir. (Class IIa). Bu e itimi, biyomedikal cihazlar n yard m ve geri dönüflümünü, mekanik KPR ve elektronik monitörizasyonu içerir. KPR hemodinamiyi etkileyen komponentleri ventilasyon h z ve süresi, kompresyon derinli i, kompresyon h z ve say s, gö üs duvar n n tamamen gevsemesi/relaksasyonu, ve ellerin gö üs kafesine temas etmedi i süreyi içerir. Profesyonel KPR sistemleri, kardiyak arrestte KPR kalitesinin monitörizasyonu ve di er parametreleri (örn, bafllang ç ritmi, cevap aral klar n ) saptanmas nda yard mc d r (Class indeterminate). OTOMAT K EKSTERNAL DEF BR LATÖR KULLANIMI Bu bölümde otomatik eksternal defibrilatör (OED) ve manüel defibrilatörlerin kullan m anlat lacakt r. OED hem sa l k hem de sa l k personeli olmayan kullan c lar taraf ndan kullan labilir. Standart OED ler 8 yas ndan büyük çocuklarda kullan labilir. -8 yafl grubunda pediatrik padler veya varsa pediatrik modda kullan labilir. yafl alt çocuklarda OED kullan m önerilmemektedir. OED kullan m algoritmas Resim 3 bak n z. Resim 4: Otomatik eksternal defibrilatör kullan m algoritmas (Algorithm for use of an automated external defibrilatör. Resuscitation (2005) 67S9)

127 . Kurtar c, ifl arkadafl ve hasta güvenli ini sa la. 2. E er kurban yan ts z ve normal solumuyorsa, bir kifliyi OED almak için ve ambulans ça rmak yolla. 3. TYD rehberlerine göre KPR baflla 4. Defibrilatör gelince Defibrilatörü çal flt r ve elektrot pedleri yap flt r. E er birden fazla kurtar c varsa bu ifllemler s ras nda KPR a devam et Sözlü/görsel komutlar takip et OED ritmi analiz ederken hiç kimsenin hastaya dokunmamas n sa la 5.a.E er flok endike ise Hiç kimsenin hastayaa dokunmad ndan emin ol Komutlara göre flok butonuna bas ( tam OED ler floku otomatik olarak kendisi verir) Sözlü/görsel talimatlara göre devam et 5.b. E er flok endike de ilse Hemen KPR ye 30 kompresyon- 2 solutma oran na göre devam et Sözlü/görsel talimatlara göre devam et 6. OED komutlar na afla dakiler gerçekleflene kadar devam et Kalifiye sa l k personeli ulafl nca ve hastaya devir al ncaya kadar Hasta normal soluyana kadar Yorgunluktan tükenene kadar Defibrilasyon öncesi KPR Rehberlerde, OED gelince hemen defibrilasyon yap lmas hastan n VF ye ba l hayatta kal m belirlemede anahtar nokta olarak belirtilmifltir. Bu yaklafl m de iflmifltir, çünkü kan tlar ambulans ça r zaman ile ambulans gelene kadar geçen süre 5 dakikay aflacaksa defibrilasyon öncesi KPR yap lmas n önermektedir. Bir çal flma bunun yarar n onaylamam flt r fakat kan tlar n a rl defibrilasyon öncesi uzam fl kardiyak arrestte KPR uygulamas n desteklemektedir. Tüm bu çal flmalar paramedikler taraf ndan yap lm fl ve hastalar n hava yolu entübasyon ile korunmufl ve %00 oksijen verilmifltir. Bu yüksek kalitedeki resusitasyon a zdan a za solunum yapt ran sa l k d fl kurtar c lardan beklenmemelidir. kinci olarak, KPR yarar, sadece ça r zaman ile defibrilatör gelifl zaman aras ndaki sürenin 5 dakikan n üzerinde oldu unda geçerlidir, arrest zaman ile OED sahip kurtar c n n gelifl zaman aras ndaki süre ile ilgili kesin veriler yoktur. Üçüncü olarak, OED ulaflt nda flahitli olunan arreste KPR süreci devam etmektedir. Tüm bu nedenlerden dolay bu rehberler OED ulafl r ulaflmaz hemen flok verilmesini önermektedir. Erken ve kesintisiz gö üs kompresyonunun önemi özellikle vurgulanmaktad r. Sesli komutlar Baz yerlerde uygulamalar sesli görsel komutlar n s ras na göre yap l r. Bu komutlar s kl kla programlanabilir ve bu programlama KPR zaman na göre flok verilmesinin zaman uyarlanm flt r. Bunlar afla dakileri içermelidir:. E er flok verilen ritim saptan rsa tek flok verilmeli 2. Ritim saptanmad nda veya solunum veya nab z saptanmad nda flok verilmeli 3. Sesli komut, floktan hemen sonra KPR devam n önerir ( spontan dolafl m n oldu unda gö üs kompresyonu yap lmas zararl de ildir). 4. Komut, nab z, solunum veya ritim kontrolünden önce 2 dk KPR yap lmas n önerir Tam otomatik LED ler fiok verilen ritimler saptand nda tam otomatik OED ler kurtar c ek ifllem yapmadan flok verir. nsanlarda yap lan bir çal flmada, e itim almam fl hemflirelik ö rencileri tam otomatik defibrilatör kullan m nda yar otomatik defibrilatörlere göre daha az oranda güvenlikleriyle ilgili hata yapt saptam fllard r. Bu bilgilerin klinikte kullan m n destekleyecek insanlar üzerinde veri yoktur

128 Halk n eriflimine aç k defibrilasyon programlar Halka aç k alanlarda defibrilatör program ve ilk anda OED kullan m ani kardiyak arrest geliflen hastalar n erken dönemde KPR ve erken defibrilasyonu olanak sa layarak hastalar n hastaneden ç k flta hayatta kal m oranlar n artt rmaktad r. Bu programlar, kurtar c lar n e itimleri yap lm fl ve yeterli pratik sa lanm fl ve acil durumu alg lay p acil yard m sistemini aktive edecek flekilde ve uygun KPR yapacak ve OED kullanacak flekilde organize edilmelidir. Sa l k çal flan olmayan OED kurtar c programlar çok çabuk yan t verebilmektedir. Handley ve arkadafllar hava alan nda, uçakta, gazinoda polis birimlerinde çal flmalar n yapm fllar ve hayatta kal m oran n %49 74 olarak saptam fllard r. lk müdahale yapan kurtar c lar, yer sorunlar ndan dolay kurbana 5 6 dakikada ve acil yard m sisteminden hemen önce ulaflabilmekte, kardiyak arrestin elektriksel veya sirkulatuvar döneminde defibrilasyon ifllemini yapabilmektedir. Daha uzun gecikmeler, hayatta kal m e risini yass laflt rmakta, aramadan 0 dk sonra ulaflt nda kazan lan birkaç dakika daha az öneme sahip olmakta veya ilk kurtar c zaten h zl gelen acil yard m ekibinden farkl olarak ek yarar sa layamamaktad r. lk-kurtar c ekip programlar ile elde edilen ilk yan t zaman nda küçük azalmalar genifl yan t sistemine göre daha kullan fll ve etkili olmaktad r. Halk n eriflimine aç k defibrilasyon programlar afla daki elementlere sahip olmal d r: Planl ve prati i yap lm fl yan t Kurtar c lar n KPR ve OED kullan m konusunda e itilmesi Lokal acil yard m sistemi ile ba lant Program n sürekli denetimi Halka aç k defibrilasyon programlar n n flahitli kardiyak arrest olgular n büyük olas l kla gerçekleflece i yerlerde konumland r lmas kardiyak arrest olgular n n hayatta kal m nda önemli oranda ilerleme sa layabilir. Son iki y lda kardiyak arrest geliflen yerler bu ifllem için uygun yer olabilir. (örn; hava alan, gazinolar, spor alanlar ). Hastane d fl arrestlerin %80 i özel ve kiflisel yerleflim alanlar nda olabilir bu da hala aç k defibrilasyon programlar n n hayatta kal m üzerine etkisini s n rlamaktad r. Evlerde OED kullan m ile ilgili yay nlanm fl herhangi bir çal flma bulunmamaktad r

129 TYD Özeti Tablo : TYD Özeti (Summary of BLS ABCD Maneuvers Ffor Infants, Children, and Adults. Handbook of Emeregency Cardiovascular Care, American Heart Association.2008.P) * SÇOK: Sa l k personeli olmayan kurtar c *2 SP. Sa l k personeli

130 Kan ta Dayal Resusitasyon Rehberleri (Evidence Based Resussitation Guidelines) 2005 te tan mlanan Tavsiye derecesi s n flar Kan t Derecesi (Level of Evidence) Kan t (evidence) Tan m (Definition) Level Randomize klinik çal flmalar veya çok say da klinik çal flmalar n metaanalizler ile yarar gösterilmifl Level 2 Randomize klinik çal flmalar sonucuna göre daha az yarar gösterilmifl Level 3 Prospektif, kontrollü, randomize olmayan, kohort çal flmalar n n sonuçlar Level 4 Öyküye dayanan, randomize olmayan, kohort veya vaka-kontrol çal flmalar sonuçlar Level 5 Olgu serileri; derlenmifl hasta serileri, kontrol grubu yok Level 6 Hayvan veya mekanik model çal flmalar Level 7 Di er amaçlarla yap lan çal flmalar n sonuçlar ndan ç kar lanlar, teorik analizler Level 8 Rasyonel varsay mlar; pratik tecrübeler Kan t Düzeyi ve Tavsiyelerin S n fland r lmas : Class I Yarar >>> Risk Prosedür/ tedavi veya tan sal test/ inceleme, yap lmal /verilmeli Class IIa Yarar>>Risk Prosedür/tedaviyi vermek mankt kl veya tan sal test/inceleme Yap lmal Class IIb Yarar?Risk Prosedür/tedavi veya tan sal test/inceleme, düflünülebilir, yap labilir Class III Risk?Yarar Prosedür/tedavi veya tan sal test/inceleme, yap lmamal /verilmemeli. Yararl de ildir ve zararl olabilir. Class Indeterminate (Belirsiz) Çal flmalar yeni bafllam fl veya hala çal flmalar devam etti i alan leri çal flmalar sonuçlan ncaya kadar herhangi bir tavsiye olmayan (örn: tavsiye veya karfl görüfl bulunmayan)

131 WORKSHOP (Wo-) April 23, 200 / 4:45 6:5 & 6:45 8:5 / Hall D WORKSHOPS Alternative medicine tabu and reality (Alternatif t p : Tabu ve gerçek) Moderator: Rengin Erdal Marco Ephraim Alternative Medicine: Threat or Challenge? Ignore or Explore? 'Or' or 'and'? M. EPHRAIM Dept of Family Medicine, Primary Health Centre Therapeuticum Aurum, Zoetermeer, The Netherlands Patients and doctors worldwide show an increasing interest in 'complementary and alternative medicine' (CAM) or integrative medicine (IM). Mean streams are e.g.: natural medicine, acupuncture, anthroposophic medicine, neural therapy and homeopathy. CAM generally aims to recover health by supporting the self-healing capacities and by supporting personal develepment ( salutogenesis, Antonowsky). Patients report high patient satisfaction in CAM: Does this rely on specific treatments or specific attitudes? Can more research and integration avoid shopping behavour and delay of good treatment? Integration requires research, training and quality control. From a scientific approach the question should not be if a certain treatment is alternative or not, but if it is (on the way to be) evidence-based or not, and if it is save, applicable, payable. For some research results see e.g.: Examples: a Cochrane-study (2008) about the treatment of depression with extract of Hypericum (St.Johns wort) and a double cohort study about the anthroposophic vs. the conventional treatment of acute airway diseases (Hamre, 2005). Integration on an academic level: The Institute of Complementary Medicine (KIKOM, part of the University of Bern. Anthroposophic Medicine is one example of CAM which is well integrated in conventional medicine (international: practised in some hospitals (example: and in many primary health centres (example: How is it to work as GP in such a centre? The health centre in which I work as GP and GP-trainer will shortly be presented

132 WORKSHOP 2 (Wo-2) April 24, 200 / 09:5 0:45 & :5 2:5 / Hall D Communication, communication skills and interactive way of work ( letiflim, iletiflim becerileri ve interaktif çal flma yollar ) Suzana Stankovic Valentina Madjova Communication skills in medicine V. MADJOVA Department of Family Medicine, Varna Medical University, Bulgaria National Consultant of Family Medicine of Bulgaria What is the meaning of communication? Communicate = to impart, to share (Latin orig.) Communicating is imparting, conveying or exchanging ideas, knowledge etc. What does the communication mean in medicine? Communication is not an add on it is at the heart of patient care! Good communication is difficult: few can master it without special tuition and constant attention to its effectiveness (Fletcher CM, 973) The ability to communicate is by far the most precious skill that a doctor can learn. It is such a multifaceted art that it is difficult to define what exactly it means, but an aspect of prime importance is the ability to listen. Why is good communication important? Better care for our patients Accurate, relevant and comprehensive history-taking and diagnosis Doctors, trained in communication skills are more likely to diagnose patients psychiatric morbidity Detection emotional distress in patients Patients satisfaction with the care they ve received Patients compliance with their treatment plan and follow the advice given Positive effect on the patient s physical condition-bp

133 Factors influencing doctor-patient communications are divided into:. Patient-related factors: Physical symptoms Psychological factors related to illness and/or medical care (anxiety, depression, anger, denial) Previous experience of medical care Current experience of medical care 2. Doctor-related factors: Training in communication skills Self-confidence in ability to communicate Personality Physical factors (e.g. tiredness) Physiological factors (e.g. anxiety) 3. The interview setting (requirements): Privacy Comfortable surroundings An appropriate seating arrangement 4. Other factors: The patient s belief about health and illness The problem they wish to discuss Their expectations of what the doctor will do (often based on previous experience) How they perceive the role of the doctor Fig.. Developing a management plan for a patient Beginning the interview Make a comfortable seating Greet the patient by name and shake hands, if it seems appropriate Ask the patient sit down Explain the purpose of the interview Say how much time is available Explain the need to take notes and ask if this is accepted Main part of the interview Maintain a positive atmosphere, warm manner, good eye contact Use open questions at the beginning as often as possible (an easy first question) Listen carefully - 3 -

134 Be alert and response to verbal and non-verbal cues Facilitate the patient both verbally ( tell me more ) and non-verbally (using posture and head nods) Use specific (focused and closed) questions when appropriate Clarify what the patient has told you Encourage the patient to be relevant Basic rules in asking questions:. Do not: Ask too many questions and do not allow the patient to tell his (her) story in his (her) own words Ask questions which are too long, too complicated and confusing Ask questions in such a way that they may be bias the answers given Ignore questions which patients may ask 2. Use: Open questions at the beginning Focused and closed questions in obtaining specific information Probing questions to clarify, check accuracy and to help the patient expand on what he/her has said Simpler language when rephrase a question if the patient do not understand or if his/her answer is unclear 3. Avoid: Using leading questions Asking several questions at once: this is confusing Lack of time for answering the patient Open questions advantages: More relevant information can be obtained in a given time The patient feel more involved in the interview The patient can express all the concerns and anxieties about his/her problems (this can be missed in closed questions) Disadvantages The interview may take longer and be more difficult to control Some of the information may be not relevant Recording answers may be more difficult Closed questions- limitations: The information obtained is restricted to the questions asked The interview is controlled by the doctor who decides the content of the questions The interviewee has little opportunity to express his/her concerns and feelings This kind of conducting interview (with closed questions) may make the patient fell frustrated Questions to be avoided: COMPLEX QUESTIONS encompass several questions in one and are likely to confuse both the patient and the interviewer LEADING QUESTIONS encourage the patient responding to give the answer which the interviewer expects or wants. Listening: Listening is one of the core skills of good communication Allow patients to talk without interruption Effective listening means concentrating on what the patient says Be alert to verbal and non-verbal cues To demonstrate your attention use appropriate body language and facilitate comments

135 Active listening: Gathering and retaining the information accurately Understanding the implications for the patient of what is being said Responding to verbal and non-verbal signals or cues Demonstrating that you are paying attention and trying to understand What helps us to listen actively? Taking notes Asking the speaker to repeat or clarify parts which are not clear Checking that the information received is accurate by repeating or summarizing it How to demonstrate an active listening? Facilitation Clarification Reflection Helping the patient to be relevant Silence Summarising NON-VERBAL CUES (BODY LANGUAGE) The meaning of body language is how to read others thoughts by their gestures (A. Pease) Eye contact Difficulty in maintaining eye contact may indicate that the patient feels depressed, embarrassed about what he/she is saying, or uninterested in the conversation. Conversely, excessive eye contact may indicate anger and aggression. Posture The confident person will sit upright The patient who feels depressed may sit slouched with head bent forward The proper posture of the doctor is of great importance, too Gestures The angry patient may be with clenched fists The anxious patient wrings his/her hands or taps his/her feet continuously Voice Tone Timing Emphasis on certain words Ending the interview Summarize what the patient has told Ask the patient to check the accuracy of what you have said Ask the patient if you have left out any information which he/she feels is important Enquire if the patient would like to add anything important End by thanking the patient The importance of summarising Allows the doctor to check the accuracy of the patient s story by providing him/her with an opportunity to

136 correct any misunderstandings Enables the doctor to review the patient s story and deduce what else need to be explored. Allows the doctor to buy time, if he/she get stuck and can t think of what to ask next Gestures in Context NONVERBAL COMMUNICATION Dead fish and normal greetings Other factors affecting interpretation: A man who has a dead fish hand shake is likely to be accused of having a weak character. A man has arthritis in his hands, it is likely that he will use a dead fish hand shake to avoid the pain of a strong one. Persons like artists, musicians, surgeons and those in vocations, whose work is delicate and involves use of their hands, generally prefer not to shake hands, but, if they are forced to do so, they may use a dead fish to protect them. FOLDED ARMS GESTURES Standard Arm-Cross Gesture and Leg lock position

137 Defensive or Cold? Seated Body Formations The Co-operative Position (B-B2) CONCLUSION: KEY COMMUNICATIVE SKILLS IN EFFECTIVE INTERVIEW Questioning (ask appropriate questions) Listening (listen attentively and demonstrate interest) Facilitating (help the doctor to continue if you get stuck) Summerising *** Workshop - What is it about? S. STANKOVIC, V. MADJOVA, M. MOJKOVIC, L. BALOS The workshop means, the specific work method, which emphises the process and the way of work in the presence of the leader who directs the work.the workshops have clearly defined rules that explain it s working way, by having their own forms and working techniques, as well as the ways of checking the performance success, but what is the most common for each workshop? The workshop includes personal and active commitment of each participant, the communication diversity, respect for diversity, development of tolerance and mutual acceptance, as well as sharing personal experiences and the development of positive authority. Workshop

138 presents the various forms of group discussions, actions or meetings which main component is the self support or self affirmation way of work. Since the main goal of the educational workshop, is the knowledge, it is very clear, that talks, actually, about learning. Together with the active method (which means mental and motor activity of participants during the work), the experiential learning method has been used. Shaping personal experience is performed through exchange with the other participants and the group leader, so we talk about cooperative learning. In the workshops we meet learning by the model, because the participants have the opportunity to observe the other participants as well as the workshop leaders, in different situations and roles, and thus create a good assumption for correction and formation of your own behavior. Workshop activities usually present the problem solution, while combining convergent (the learning of desired solution) and divergent learning (by encouraging the search for different ways - ways of coming to the solution). When you pass the workshop training and when its basic characteristics are realized, it becomes a part of everyday thinking and it becomes easy applicable in the work. The workshops differ in their content, purpose and age that are intended, so therefore they can be classified. The number of participants that is recommended in a single workshop ranges between 5 and 25. Workshop, as a form of work, can be applied to all ages, with the issue volume, dynamics and organization of activities, adapts to all age differences. One workshop, which includes several activities, usually takes and a half to 2 hours. Workshop is guided by the two leaders at the same time, each sharing the role. Each workshop has a very clear and pre-defined plan - the script, which quality largely determines its success. The essence of the scenario consists: structured activities that occur as a result of specific requests which is introduced by the workshop leader, and are integrated into one theme. The scenario through the concrete requests, directs the personal involvement of participants. A good scenario encourages cooperation, not competition and discrimination. Each workshop runs through several basic stages: Evocation of personal experience - which in the context of cognitive workshop means bearing the new content throughout your own experience, Shaping your own personal experience - which is usually concretized through the words; Exchange - follows the shaping function and has the function of enrichment in personal experience. The exchange conditions have to be provided after each activity. Processing as the last phase in which the exchanged and enriched experience converse into knowledge. The role of the leader is especially important here, because it summarizes, generalizes, and meaningfully connects all that is given throughout the work, and ''returns'' to the participants (with an open space for their comment). WORKSHOP TECHN QUES AND FORMS OF WORK The workshop scenario should always specify precisely which forms of group work, for example techniques are predicted. Most common work methods in the workshop are: Exchange in the whole group is the basic form of work that begins and ends in each workshop. Regardless of the exchange form that is usually applied through the workshop the leader at the end summarizes the conversation. The most common forms of practice are the following: The talk in the circle - a structured exchange in which the participants speak by the sitting row; The group discussion - less structured exchange in which is very important to ensure that a large number of participants is involved, Brainstorming the most creative form of exchange in which participants feel free to associate to an existing topic. The leader encourages as many ideas as possible and records them on the board or panel without the selection and evaluation. The last phase is the organization and processing of what is produced. Working in pairs or small groups - sometimes it is desirable, and sometimes not, small group members know each other well, which will depend on the content of the activity itself. Keep in mind that during work the group does not interfere with one another, providing an optimal operational group with 3 to 5 members. It is best to use ''open minded'' questions (How? Why?), which develop the communication. Always be

139 aware of their reactions to the opinions of participants and ensure that all the different experiences are equally accepted (''OK'', ''good''). It is necessary to encourage new ideas and different opinions (''Is there anybody who has a different opinion?'', ''Does anyone wants anything else to add?''). Encourage passive and uninterested participants in the workshop with a note, that there is no right or wrong answer of solutions. Workshops are characterized by different techniques that aim to provoke deeper - personal experiences of participants, as well as the organization of these experiences into concrete units. The workshop techniques include: Guided fantasy - techniques in which participants, in a relaxed atmosphere, and directed by the leader, talk about the imaginary experience that is needed for further elaboration of new content in the workshop. Sculpture the media workshop in which participants should express their feelings or their vision problems by placing their partner in appropriate position which expresses his-her idea. Aquarium a technique in which, the scenario is in the middle of the circle - so that all participants can see, certain role takes place, that talks about the experience of actors who are in the "scene". It represents a transitional form of work between the small groups and the whole group. Role Play a technique that allows the assessment of the situation from another perspective. The participants play different roles and situations and thus they adopt new skills. Games - can be used independently of the workshop program. They round the whole of the dynamics of the group and must be thematically related to the objective of the workshop. The division of the games in general: Introductory games that can be divided into: Introduction Games - the participants has been given the chance to learn more about others in the interesting way; The relaxation games - introduce the participants to the relaxed state in which they will be ''open'' for the contents offered by the leader. Frequently used for ''warm ups'', for example, the workshop introduction. Games which divide participants in pairs or small groups - this is the way to avoid the same participant working together all the time. Since these games are often used to activate and wake up the participants, it is especially recommended after long verbal activity; Final game can be divided into: Relaxation Games - the main function of these games is relaxation of the participants, cheer them up and leave the workshop in a good mood; Games on '' closing workshop '' - these games have a function of summary on the workshop topic and settlement of the impression of the workshop; Evaluation Games - the objective of these games is that leader gives the information about how the participants liked certain activities in the workshop and how to assess them. Independent Games: These are the games that can be either opening or final games, as well as to serve as a framework for the main activity in the workshop. Workshop rules In any group work the rules are necessary because, they provide stability and "lighter" work in the group. Rules are being introduced at the beginning of the group work and they become the rules of all members. Presenter and participants refer to them whenever they break. The rules are always placed in a visible place so that all may become familiar with them, and must be formulated in a way that describes clear, desirable

140 behavior. Also, should clearly indicate, what will be the consequences, if one of the group members does not comply with the defined rules. Except basic rules, which are being introduced to participants by the leader, the leader can introduce the additional rules, depending on the objectives and content of each specific workshop. The rules may alter with the approval of all of the group members. Authority of the workshop Leader The leader of the workshop supports the development of the authority which main characteristics is the knowledge, which the participant posses in the relation to the topic and to the actual group. The basic question that arises is: "What is it that I want the participants to learn and how shall I accomplish that? The workshop leader controls the conditions and the environment in which the work takes place, but not the participants themselves, and develops self-discipline and responsibility versus obedience, as well as external motivation of the participants. The objective of the workshop leader is to achieve the participants do not do whatever they want, but that they want what they do. THE WORKSHOP LEADING SKILLS The workshop leading skills are all skills that enable a good atmosphere, acceptance and appreciation of all participants and expressions freedom in a way that suits them all. Since the main objective of the workshop is to encourage participants to personally engage in learning new, interesting ways. This goal can be achieved only in the relaxed acceptance and atmosphere of appreciation. The task of the workshop leader is to provide, an atmosphere in which participants will learn from one another, exchange experiences and where they all will feel comfortable. The leader does not pressure, does not offer pre-finished solution, but helps the participants by guiding them in their independent search for possible solutions. Each solution, no matter how incorrect, has been used as a new learning situation, for example; as a significant example, which may encourage further exchanges within the group. The leader fosters a positive approach and encourages each participant to present his/her own experiences and thoughts and thus the way of work within the group, to respect the participants resistance, if someone does not want to participate in an activity, by listening with particular attention and open mindedness. This is not an easy task and many workshop leaders because of that have higher expectations of themselves, which often leads to bad feelings in situations where the expectations are not fully met. COMMUNICATION SKILLS AS A PREREQUISITE OF EFFECTIVNESS IN WORKSHOP MANAGEMENT Communication that leads to dissatisfaction and conflict During workshop there are different situations in which participants do or say something that the leader of the workshop dislikes. In this situation the leader can react in many different devastating ways for the continuous communication. The safest way to achieve that is to send the YOU message: The solutions messages - offer ready solutions for problems that the other party should, or must accept. humiliating messages - show the other side in a negative light, challenging his/her character and have a bad influence on self-esteem. Indirect messages - this group includes jokes, sarcasm, teasing and distracting comments. Often not understandable and have no effect on change in behavior of the person which is addressed. No matter what kind of the YOU messages we speak about, these messages usually interrupt the communication with the person to whom they are communicated. The other person hears these messages as compulsory, ordering, labeling

141 COMMUNICATION THAT CONNECTS US WITH OTHERS In situations where the leader has a problem and wants to communicate, one way to do this is to clearly state what is in his mind, but in a way that is not accusing, or criticizing and labeling. I messages are a call to communication and attempt to resolve the problem and are consisting of four components: Perception - what we perceive that the other person does, or says, and what bothers us. In this step, it is important to distinguish between the description of the behavior that bothers us and our interpretation of that behavior; Feelings in relation to what we perceive; Needs - Recognizing and talking about the needs to communicate, is one of the fundamental difference between I and YOU messages. Through YOU message we announce that something is wrong with someone / others and therefore we feel bad. Through the I message we clearly communicate to the people what they do and what bothered us, how do we feel, but we talk about the need that was not satisfied which caused our bad feelings. Request - the concrete actions that we want to be undertaken so that our needs could be satisfied. Since the I messages are not accusatory, offensive and do not assess the other person, the better are the chances that the other side hears us and meet our request. WHEN THE I MESSAGES ARE USED IN THE WORKSHOP? The I messages are used when the leader has a problem, for example, when participants do something that endangers the leader. In these situations it is very important that leader sends the clear I message. Sometimes the problem arises when one participant talks a lot so the other participants do not have the opportunity to say something. In these situations the I message puts a clear knowledge to the presenter, to respect the need, of the participants, to talk about something important for him, but it is also important to hear others. In a situation of conflict of opinions, some of the participants can express their disagreement in a way to assess, label and disparage the opinion of others. The leader uses the I message to clarify that he dislikes this behavior. Sometimes it happens that the group is calm, not answering questions that leader asked. In these situations leader clearly expresses what is happening within himself as a reaction to the silence and seeks an explanation from the group. Listening Skills In situations when participants have the problem, the leader listens carefully to what happens within them, and thus shows the participants that he understands and accepts. Each person is unique, and has different motivations, experiences and knowledge. Active listening means the attempt to understand the feelings, needs and demands of others. The purpose of active listening is to help us with understanding of what the speaker wants to tell us, as well as to provide the feedback that we've heard and understood. In the process of active listening, we register the content of the messages and feelings that accompany it. Active listening means understanding, not necessarily agreement, or relaxation, perseverance of your own needs and requirements

142 Conflicts During workshop may be a conflict between participants or between leader and participants. Each of the above mentioned situations could result in deepening the conflict and it is important that the leader knows how to react in these situations. What is important to know about conflicts? Conflict provides us the opportunity to grow and develop - the conflicts are at the same time the risk, but the opportunity and challenge. There is unnecessarily a "right" solution to the conflict - through work with the conflicts; we learn how to deal with them in a successful manner, which means to test different possible solutions and to choose those which are most adequate in this situation. Often seen compromise, is the best possible outcome of the conflict, however, to compromise, each party thinks that maybe could get more, so that frustration often remains. How to come to the solution, in which both parties gain? The process of coming to solution, in which both parties will be satisfied, consists of six steps. Workshop Evaluation Detailed analyses of the scenario workshops, we will be able to determine: to what extent the workshops were taking place as expected the evaluation process and what are their effects compared with the set goals the effect evaluation. This way we shall better observe what is done with the goals for correction and improvement. No matter how much experience we have in the organization and conduction the workshop, the evaluation is necessary. Each workshop has pre - designed and pre - defined scenario. This, however, does not mean that the scenario is not subject to changes, if it has not been proved as good enough. On the other hand, some good workshops, does not have to cause equally good effects in various participants

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145 ORAL 2 nd Congress of Association of General Practice/Family Medicine OP- WHAT DO PATIENTS KNOW ABOUT CANCER? N. OZCAKAR, M. KARTAL, C. ISIKLAR Dept. of Family Medicine, Dokuz Eylul University Medical Faculty, Izmir, Turkey Cancer is a hard issue to discuss for both physicians and patients. However it is essential for patients to be informed about cancer prevention. Our aim was to determine characteristics and cancer prevention knowledge of the patients. The collected data with a questionnaire from 242 patients followed in a Family Medicine Department was analyzed as frequencies and chi-square test by using SPSS.0. Of the patients 62.0% were women, mean age was 39.7±.2 years (8-82). 40.9% of the patients had a family member with cancer. Although they wanted to be informed by their doctors/family physicians (64.5%) mostly had information from media (47.2%). They considered their knowledge low (58.3%) and didn t think that cancer substantially is a preventable disease (38.3%). After the exclusion of two cancer patients, early diagnosis (87.5%) and screening (86.2%) were generally well-known issues. Breast cancer occurrence in a family member is not an important risk factor, Vaccination can be used for prevention of cervix cancer and Early diagnosis of prostate cancer is not important statements were accepted by 54.5%, 4.2% and 34.6%. Although there was no gender difference for cancer knowledge level women had higher accurate answers for the first two statements (p=0.000). Patients having relatives with cancer remarkably noted higher risk for themselves (p=0.000), their answers for the statements didn t differ from the others (p values between ). Cancer prevention has to be discussed with patients to increase awareness and knowledge. Family physicians have a great role in patient education for prevention of cancer. OP-2 ADOLESCENT PREGNANCY: TRENDS, CHARACTERISTICS AND OUTCOMES IN EAST TURKEY T. EDIRNE, 2 M. CAN, 3 R. YILDIZHAN, 3 A. KOLUSARI, 3 E. ADALI, 4 B. AKDAG Dept. of Family Medicine, University of Pamukkale Medical Faculty, Denizli, Turkey Dept. of Forensic Medicine, University of Balikesir Medical Faculty, Balikesir, Turkey Dept. of Obstetrics and Gynecology, University of Yuzuncu Yil Medical Faculty, Van, Turkey Dept. of Statistics, University of Pamukkale, Denizli, Turkey Abstract Objective: To determine the proportion of adolescent births in Van, Turkey, and to identify characteristics and related outcomes. Methods: Mothers who gave birth at three maternity centers in Van, Turkey were chosen randomly and offered a faceto-face questionnaire. Participants were asked for demographic information and pregnancy history. Pregnancy outcomes were obtained from the birth records. Results: Of 872 mothers who completed the questionnaires, 2 (.3%) were younger than 9 years. Adolescent mothers showed significantly more inappropriate education for age (82.5% vs. 70., p<0.00) and were married to less educated partners (76.3% vs. 59.4%, p<0.00) by more unofficial matrimonies (25.6% vs. 0.7%, p<0.00) than older mothers, but there were no differences between the groups in rates of arranged marriages with relatives, income and household structure. Adolescent mothers reported higher rates of intimate partner violence (7.% vs. 0.8%, p=0.008) and inadequate prenatal care use (28.4% vs. 7.6%, p<0.00). Adolescent births were associated with an increased risk for preterm delivery (p<0.00) and low birth weight (p<0.00). Conclusions: Adolescent birth rate is very high in the east of Turkey, which results in inadequate education for age. Cultural factors rather than economical factors seem to be related with early age at marriage, and adolescent childbearing

146 OP-3 A CASE-CONTROL STUDY EVALUATING DEPRESSION AND QUALITY OF LIFE IN HIGH-RISK PREG- NANT WOMEN M.S. SAHSIVAR, 2 K. MARAKOGLU 2 Dept. of Family Medicine, Sarayonu Public Hospital, Turkey Dept. of Family Medicine, Selcuk University, Selcuklu Medical Faculty, Konya, Turkey Aim: To assess quality of life (QoL), presence of depressive symptomatology and their relationship in normal and high-risk pregnant women. Materials and Methods: Two hundred ninety seven pregnant women were screened using brief version of the World Health Organization Quality of Life in Turkish (WHOQOL-BREF TR) and Beck Depression Inventory (BDI). Results: BDI level was found as 7 and higher among 34.3% (n=02) of all women who took part in our study and 42.6% (n=49) among high-risk pregnants. The incidence of high-risk pregnancies among the pregnants who had 7 and higher BDI score was found significantly higher than the ones who took 6 and lower (p=0.07). High-risk pregnancies were 3 4 times higher among the pregnants whose husbands had education levels of primary, middle and high school than the level of university; times higher among the pregnants whose husbands were worker, unemployed and self-employed than the ones whose husbands were official;.8 times higher among the pregnants who had 7 and higher BDI score than the ones who had 6 and lower BDI score. High-risk pregnancies among the unemployed pregnant women were 3. times higher than the employed. QoL scores in the domains of physical health (p<0.00), psychological health (p=0.036), social relationships (p<0.00) and overall health (p<0.00) were significantly lower among high-risk pregnants than normal ones. Conclusions: In this study a substantial number of pregnant women, especially high-risk ones had depression symptoms and high-risk pregnancies diminished the quality of life. High-risk pregnant women may need more physical and psychological support. OP-5 THE PRESENCE OF ANXIETY AND DEPRESSION IN THE ADULT POPULATION OF FAMILY PRAC- TICE PATIENTS WITH CHRONIC DISEASES K. TUSEK BUNC, Z. KLEMENC KETIS, J. KERSNIK, 2 E. TRATNIK 2 Dept. of Family Medicine, Medical School University Maribor, Maribor, Slovenia HC, Helath Centra Kranj, Kranj, Slovenia The prevalence of multimorbidity in family practice is rising and psychiatric comorbidity presents a risk factor for premature mortality. The aim of this study was to determine the prevalence of anxiety and depression in the adult population of family practice patients with chronic somatic diseases, aged between 8 and 64 years old. We performed a cross sectional study in 500 consecutive patients from twelve family practices. Zung s selfassessment inventories for anxiety and depression were used to determine the presence of psychiatric comorbidity. The main outcome measures were depression and anxiety scores in patients with various comorbidities. Results: The response rate was 90.4 %. 8.4 % of family practice visitors suffered from anxiety symptoms and 5.2 % from depressive symptoms. At least one chronic disease was present in 40.7 % of the patients. Significantly higher rates of depression and anxiety were found among patients with chronic somatic disease (p=0.00, P<0.00, respectively; 2 test) or chronic pain (p<0.00, p<0.00, respectively; 2 test). Significantly more patients with rheumatic diseases had depression in comparison to those without them (p=0.08; 2 test). Significantly more patients with migraine or rheumatic diseases had anxiety in comparison to those

147 without them (p=0.00, p=0.030, respectively; 2 test). Chronic pain was present in significantly more patients with a particular chronic disease in comparison to the patients without it (p<0.050; 2 test). Family doctors should actively search and treat psychiatric comorbidity also in the population of patients with chronic somatic diseases, aged between 8 and 64 years old. OP-9 EMPATHIC TENDENCY OF FAMILY PHYSICIANS COMPARED TO OTHER SPECIALTIES N. KARAOGLU, 2 Fazilet SIVRI 2 Dept. of Medical Education and Informatics, Selcuk University, Meram Faculty of Medicine, Konya, Turkey Dept. of Family Medicine, Numune Education and Research Hospital, Turkey Aim: Empathy is defined as the capability of sharing and understanding another s emotion and feelings and is imperative for a good physician patient communication. It is known that a good communication is associated with improved health outcomes. The aim of this study was to compare empathic tendency (ET) of a group of family physicians and other specialties. Methods: An anonymous, voluntary questionnaire consisting of Empathic Tendency Scale (ETS) with some variables such as age, gender, civil status, academic career, specialty and years of experience was applied to the randomly selected physicians. Percentages, chi-square, student-t test and One-way ANOVA tests were used. Results: Among 53 voluntary physicians 37(24.2%) were family physicians and 0 (7.9%) were male. The mean age of the all group was 32.27±7.07 year (range: years). While 29 (84.3%) of the group were residents, 85 (55.9%) were married. The mean experience year was 6.83±6.73 year (range: -4 years). Although 84 (54.9%) of physicians ETS scores were about mean ETS of the all, when we added one standard deviation to the mean ETS of the all group only 3.% of the physicians were above the cut-off level. The difference of ETS in respect to specialty, gender, civil status, academic career and experience years was not significant (p>0.05). Conclusion: In this study empathic tendency of family physicians was not different from other specialties. One of the main claims of family physicians is being more patient-centered so during family physician education empathy in an academic approach should be given. OP-0 TAKING A STEP TO OUR FUTURE: AGE FRIENDLY PRIMARY HEALTH CENTRES B. PALA, F. YUKSEL, M. UNALACAK, I. UNLUOGLU Dept. of Family Medicine, Eskisehir Osmangazi University Medical Faculty, Eskisehir, Turkey Objectives: Primary health centers (PHC) play the critical role in the health of older people in all countries and the need for these centers must be adapted to the needs of older populations. Hence, all primary physicians should be well versed in the diagnosis and management of the chronic diseases. Aims: We aimed to emphasize the principles of an age-friendly primary health center and to aid the improving of primary health care response for older people. Methods: We scanned several research articles, reviews and WHO s Age Friendly PHC Toolkit to describe the true role model. Results: According to WHO, The Age-friendly Principles address three areas: Information, education, communication and training, Health care management systems, and The physical environment of the primary health care centre. Emphasis on a primary rather than a tertiary approach to care of older persons is needed. Based on these proposals; an age friendly PHC needs educated staffs about knowledge concerning communication with older people, screening and management of geriatric giants: memory loss, urinary incontinence, depression and falls/immobility.phcs must be designed to provide optimal physical conditions for privacy, secu

148 rity and safety for older people. Discussion: The older population is increasing all over the world and most of them live alone. As a result of prolonged human life; many of them will use these facilities more frequently than now. The care of older people will be tomorrow s challenge. A barrier-free PHC will be a milestone in that direction. OP- THE CHANGE IN THE SATISFACTION LEVEL OF FAMILY MEDICINE RESIDENTS BY TIME S. OZCAN, N. BOZDEMIR, E. SAATCI, H. KURDAK, E. AKPINAR Dept. of Family Medicine, Cukurova University Medical Faculty, Adana, Turkey Aim: To assess the change in the satisfaction level of family medicine residents by time. Subjects and Methods: The sample consisted of family medicine residents of a university department of family medicine in Turkey. An anonymous questionnaire was used to collect data. It was completed by every resident in February each year from 2005 to Satisfaction level was assessed by five- point Likert scale. Results: The numbers of residents in year 2005 to 2008 were 7, 5, 6 and 7, respectively. The changes in the mean scores of the satisfaction for being a family medicine resident by years (p < 0,05) were shown in Figure. The changes in the mean scores of satisfaction for being a family medicine resident by training years (p?0,05) were presented in Figure 2. Conclusion: The decrease in the satisfaction for being a family medicine resident by years may be due to The Pilot Practice of Family Medicine which started in 2005 and gave the graduates of medical school the opportunity of working as a family physician without specialization training. Nevertheless, the increase in the satisfaction for being a family medicine resident by training years may be related to learning the discipline better and having more self-confidence. Although the decrease in the satisfaction for being a family medicine resident by years was not significant, it should be taken into consideration for the improvement of the discipline in future. Fig 2.The changes in the mean scores by years Fig 2.The changes in the mean scores by training year

149 OP-3 URINARY INFECTIONS IN PATIENTS WITH DIABETES MELLITUS I. ILIC, J. STOJAKOVIC, B. JOKOVIC, L. BUNJAK, M. MILOSAVLJEVIC Dept. of General Practice, Helath Center Zvezdara, Belgrade, Serbia Introduction: Urinary infections in patients with diabetes mellitus are one of the most common complications. These infections more often develop as uncomplicated (cystitis and pyelonephritis) and more seldom are complicated that affect kidney parenchyma and are associated with functional or structural kidney anomalies (urine obstruction and stasis). Aim: Frequency of urinary tract infections and the most common causes of infection in patients with diabetes mellitus monitored over a six months period. Method: We monitored the frequency of infections in diabetics on the basis o clinical picture (urination frequency, pain, temperature), urine analyses (turbidity, leucocytes, nitrites, hemoglobin, proteins), microscopic examination of urine cast (erythrocytes, leucocytes, bacteria, cylinders) and urine culture results. Results: 40 patients were analyzed in all, 48 men and 92 women. We detected that infection developed in 59 (42.4%) of these patients, i.e. in 23 men (38.98%) and in 36 women (6.02%). Based on urine culture analysis, the most common cause of infection was E. coli (74%). Based on urine physicochemical analyses findings, in most cases urinary infections were uncomplicated (74.6% cystitis and 4.3% pyelonephritis) and. infections were complicated (presence of the renal epithelial cells and granulated cylinders). Conclusion: The obtained results indicate that diabetics are prone to urinary infections. OP-7 THE COMPARATIVE EFFICIENCY OF DIFFERENT METHODS TREATMENT IN ESSENTIAL (CLASI- CAL) TRIGEMINAL NEURALGIA C. BUSNEAG, 2 A. BUSNEAG 2 Dept. of Family Medicine Practice "dr. Busneag Carmen", Spiru Haret University, Bucharest, Romania National Institute of Sports Medicine, Spiru Haret University, Bucharest, Romania This study, realized in the area of medical practice from a family doctor cabinet, represented a part of the doctorate s tenet of the author. This work presents the comparative efficiency of different ways of treatment, which can be applied into a neurological disease, defined by an atrocious facial pain, such is the trigeminal neuralgia. The patients were divided in three study groups: the first group received medical treatment (which includes drugs), the second group was treated by stimulant methods : acupuncture, trancoutaneous electrical nerve stimulatation (TENS) and low level laser therapy (LLLT) and the third group suffered neurosurgical interventions: percoutaneous trigeminal rizotomy by radiofrequancy induction and compression of Gasser ganglion and his branches using a little balloon. The patients have been followed for five years. We present the study s results, based on the interpretation of pain s score, insisting on the influence over the patient s quality of life (especially over the anxiety and depression). Finally, we have realized a complex and original algorithm of diagnostic and treatment in the essential trigeminal neuralgia

150 OP-8 CHOSEN MEDICAL PRACTIOTIONERS FOR CHILDREN - WORK ANALYSIS D. OSTOJIC, S. MALOVIC, 2 M. GRBOVIC 2 Control Department, Health Insurance Fund, Podgorica, Montenegro CMP for Adults, Health Center, Podgorica, Montenegro The goal of this study has been the review of the informatic system implementation effects in Primary Health Care (PHC), which was applied on January, We have analysed daily work of chosen medical practitioners (CMP) as well as the electronic registration of medical documentation. Methods: We have analysed the work of CMP in 8 Health Centers in Montenegro in the period from january-december, 2009 following up the same parameters, from the basic informatic system Health Insurance Fund of Montenegro. Results: In the analysed period there was the increase of number registrated insured persons. On the date of 3 th of December, 2009 in Montenegro was registrated % insured persons on CMP for children and adults. During observed period every insurant person aged bellow 5 visited his CMP for children in average 5.7 times. The percentage of preventive checksums related to the total number of check-ups is 27.0%, which means that the plan of preventive check-ups was achieved at 83.26%. In one hour of his effective work every CMP for children have ministered 5.2 preventive and curative services and CMP team ministered 6.8 services. Conclusions: During observed period every insured aged bellow 5 visited his CMP for children in average 5.7 times. The percentage of the preventive checksums related to the total number of check ups is 27.0%, which means that the plan of preventive check-ups was achieved. OP-9 CHOSEN MEDICAL PRACTIOTIONERS FOR ADULTS - WORK ANALYSIS M. GRBOVIC, 2 D. OSTOJIC, 2 S. MALOVIC, 2 CMP for Adults, Health Center, Podgorica, Montenegro Control Department, Health Insurance Fund, Podgorica, Montenegro The goal of this study has been the review of the informatic system implementation effects in Primary Health Care (PHC) system, which was applied on January, We have analysed daily work of chosen medical practitioners (CMP) as well as the electronic registration of medical documentation. Methods: We have analysed the work of CMP in 8 Health Centers in Montenegro in the period from january-december, 2009 following up the same parameters, from the basic informatic system of the Health Insurance Fund of Montenegro. Results: In the analysed period there was the increase of number registrated insured persons. On the date of 3 th of December, 2009 in Montenegro was registrated % insured persons on CMP for children and adults. During observed period every adult insurant person visited his CMP for adults in average 3.5 times. The percentage of preventive checksums related to the total number of check-ups is 4.54, which means that the plan of preventive check-ups was not achieved. In one hour of his effective work every CMP for adults have ministered 4.65 preventive and curative services and CMP team ministered 6.57 services. Conclusions: During observed period every adult insured visited his CMP for adults in average 3.5 times. The percentage of preventive checksums related to the total number of check ups is 4.54%, which means that the plan of preventive check ups was not achieved

151 OP-20 FALL RELATED FACTORS IN ELDERLY D. KARADENIZLI, 2 T. ALIC, 2 B. GULMAN, 3 P. UNALAN 2 3 Dept. of Family Medicine, Baskent University Medical Faculty, Ankara, Turkey Dept. of Orthopedics, Ondokuz Mayis University Medical Faculty, Samsun, Turkey Dept. of Family Medicine, Marmara University Medical Faculty, Istanbul, Turkey Background: Falls increase with age and related with increase in hospitalizations and mortality. Previous fall is a predictor for recurrent falls and quality of life problems. Falls among the elderly are a significant problem regardless of the cause. They can result in musculoskeletal or neurological problems and death. Methods: This study included 63 patients who were admitted to an orthopedics clinic complaining of a fall between February and May The patients were administered a semi-structured questionnaire. Data was analysed with chi-square and linear regression analysis. Results: 59% of the study population was female. 8,% were living alone, 90.4% living with their children or spouse, and,6% in a hospice. 60,7% has nocturia but 72,5% fell during the day time, 93.4% were able to walk without assistance before their fall and 8.7% were independent throughout their daily activities before fall. The majority of the falls were attributed to home accidents (6%) With increasing age, falls were seen at home significantly rather than the outside of the house (rs: -0,39 P: 0,00). 90% incurred a fracture from the fall. Although 0% reported a fear of falling before the accident 95% have a fear of falling after the case. Conclusions: Known and improvable risk factors for falls in the elderly were obvious in this study and participants were afraid of new falls after the cases. As they were alert after the case all casualties should be consulted by a general physician for screening risk factors and preventive interventions should be introduced. OP-23 COMPARISON OF BIOMEDICAL AND BIOPSYCHOSOCIAL APPROACHES IN THE TREATMENT OF OBESITY A. KUT, M.G. EMINSOY, M. SENAY, Y. CETINEL, 2 H.S. AKGUN, 3 A. GURSOY 2 3 Dept. of Family Medicine, Baskent University Medical Faculty, Ankara, Turkey Dept. of Public Health, Baskent University Medical Faculty, Ankara, Turkey Dept. of Endocr nology, Baskent University Medical Faculty, Ankara, Turkey Obesity is more and more becoming one of the major health concerns of the upcoming decade worldwide. We aimed to separately evaluate the pharmacotherapy alone (group-) versus pharmacotherapy combined with lifestyle changes consisted of medical diet, physical activity, dietary education and behavioral changes (group-2) to determine the effectiveness of those two approaches. Among obese patients admitting to the outpatient clinics of a university hospital 48 patients were randomly added to the study group between September 2006 and April The TANITA device was used in the evaluation of the initial and final states of obese patients. Additional parameters were waist circumference, waist-hip ratio, and blood biochemistry analysis. Each subject in both groups underwent a treatment with sibutramine or orlistat. Group-2 additionally received a low calorie diet, physical activity program, and a cognitive behavioral approach to improve lifestyle changes. Both groups were followed up for six months after initiation of treatment. Compared to initial data group- achieved a mean weight loss of 8.8% while that of the group-2 was 4.9%. The mean waist-hip ratio, hyperlipidemia, fasting plasma glucose, HbAc, ALT levels and insulin resistance decrease was significantly higher in group-2. We strongly suggest an efficient and general use of the integrated biopsychosocial treatment approach in the medical management of obesity. For patients starting with anti-obesity therapy, we strongly suggest that lifestyle change treatment must be integrated to the drug treatment in order to achieve and maintain successful weight loss

152 OP-24 CHANGES IN HEALTH CARE INDICATORS AND HEALTH CARE SERVICES BEFORE AND AFTER A PILOT APPLICATION OF FAMILY MEDICINE CARE C. OZCAN, Y. CETINEL, E. TORE, M.G. EMINSOY, A. KUT Dept. of Family Medicine, Baskent University Medical Faculty, Ankara, Turkey The application of family medicine care is one of the largest health care reforms in the history of the Turkish Republic. This study aimed to compare the differences of health indicators and health care services before and after the initiation of the Pilot Application of Family Medicine in September 2005 in Düzce/Turkey, and to demonstrate the application basics. The periods to compare are defined as Period I ( ) and as Period II ( ). Data used are obtained from the Düzce City Health Directorate and regional visits to health care facilities. Outpatient services increased significantly in Period II. The mean physical investigation count per person/year increased from.70 to 3.60, and referral rates increased from 8.8% to.6%. The number of laboratory investigations and small surgical interventions decreased significantly. There was an overall increase in pregnancy, postpartum and infant screenings. While the number of childhood screenings in Period II decreased, the number of infant screenings increased yearly. In vaccinations we observed a significant increase for each vaccine. Whereas deliveries at hospitals increased in Period II, number of deliveries with or without any help of healthcare professionals decreased significantly. Rate of modern family planning methods and rate of nonuse of any family planning method increased. Especially the rate of intrauterine contraceptive devices decreased significantly. There were significant decreases in the number of total deaths and in infant deaths in Period II. We concluded that the implementation of family medicine in primary health care in Turkey improves health indicators. OP-25 PSYCHOSOCIAL AND CLINICAL EVALUATION OF PATIENTS WITH UNCONTROLLED BLOOD PRES- SURE IN COMPARISON WITH THE EFFECT OF SSRI\'S ON BLOOD PRESSURE CONTROL A. KUT, M.G. EMINSOY, C. GOKTEKIN, Y. CETINEL, C. OZCAN, R. ERDAL Dept. of Family Medicine, Baskent University Medical Faculty, Ankara, Turkey Blood pressure control is one of the major challenges in primary care settings in Turkey. This study aimed to identify psychiatric comorbidity in hypertensive patients, to investigate the changes in hypertension control after starting SSRI treatment, and to demonstrate the improvement in quality of life. The study was performed between June-September 2007 on 273 hypertensive patients treated at the cardiology outpatient clinics of a university hospital. The subjects filled out a sociodemographic form, SF-36 quality of life scale, Brief PHQ, and underwent an ambulatory blood pressure screening for 24 hours at the beginning of the study. These investigations defined the status of blood pressure, presence of psychiatric and systemic disorders, and quality of life level. All patients with a psychiatric disorder were prescribed with a SSRI. After 8 weeks of follow up all scales and questionnaires were repeated to demonstrate differences between patients using an SSRI and those not. In the study group, female-to-male ratio was :0.85 with a mean age of 60.43±0.62. Despite of sufficient antihypertensive therapy, insufficient blood pressure control was found in 26% of the subjects. Of these patients 9.6% had coexisting secondary diseases, 74.6% had psychiatric comorbidity, and poor quality of life. Adding a SSRI to the treatment of patients with uncontrolled blood pressure and coexisting psychiatric disorders improved blood pressure and quality of life in 8.% of the subjects. In conclusion, considering psychiatric comorbidity and adding a SSRI in treatment of patients with uncontrolled blood pressure may improve clinical outcomes and quality of life

153 OP-26 CONTROL AND PREVENTION OF EARLY DIABETIC COMPLICATIONS AMONG BULGARIAN ADOLESCENTS IN GENERAL PRACTICE V. MADJOVA, 2 V. TODOROVA, 3 R. ASSENOVA, 3 G. FOREVA 2 3 Dept. of Family Medicine, Varna Medical University, Varna, Bulgaria Medical College, Varna Medical University, Varna, Bulgaria Dept. of Family Medicine, Plovdiv Medical University, Bulgaria Background: Detection of early complications of diabetes is a marker of good control and prevention in general practice. Revealing microangiopathy in subclinical stages and correct management has a great impact on evolution and socio-economic significance of diabetes. Objectives: To assess the subclinical diabetic microangiopathy in 09 adolescents from 39 general practices in Varna district, North-eastern Bulgaria for a period of 0 years. Design and Methods: Using diagnostic methods for detection of early nephropathy (microalbuminuria, creatinine clearance and blood pressure), retinopathy (direct ophthalmoscopy and biomicroscopy) and polyneuropathy (electromyography and sympatic skin response) followed up the results in 0 years. Results: 2,% of diabetics had borderline albuminuria and /5 of them developed microalbuminuria after 5 years with annual cumulative index 0,9%. The most common complication was polyneuropathy, followed by nephropathy and nonproliferative retinopathy and the correlations are given on the table : Conclusions: we recommend early detection of diabetic microangiopathy in adolescents, especially in puberty girls for diabetic nephropathy. The best prevention of late complications is ACEIs treatment even in the stage of borderline albuminuria and normal blood pressure. Correlation between diabetic complications OP-27 SERUM PLASMA AND LEUKOCYTE ZINC LEVELS IN MOTHERS OF NORMAL AND LOW BIRTH WE- IGHT INFANTS AND COMPARISON OF ITS EFFECT ON INFANT BIRTH WEIGHT A. KUT, 2 Y. UCKARDES, H. GUNTURKUN, F. SOZEN, Y. CETINEL, R. ERDAL 2 Dept. of Family Medicine, Baskent University Medical Faculty, Ankara, Turkey Dept. of Pediatrics, Baskent University Medical Faculty, Ankara, Turkey Recently there are several studies claiming that zinc deficiency may lead to low birth weight infants. This study aimed to reveal the relationship between maternal zinc deficiency and low birth weight; to make a comparison between maternal serum and leukocyte zinc levels. The study included 70 normal and 70 low birth weight infants born at a state hospital and their mothers between March and April For each patient a forms containing socio-demographic information, general medical examination and serum, leukocyte zinc levels - 5 -

154 were filled out. Blood samples were taken from the mothers in the study and control groups for the measurements of serum and leukocyte zinc levels. The average age of the mothers was 25.6 ± 4.6 years. The prevalence of zinc deficiency in the mothers was determined as 0% (Zn <70 mcg/dl). Although there was no relationship between maternal serum zinc levels and low birth weight of infants, a significant relationship between maternal serum zinc levels and very low birth weight of infants was determined. Also there was a significant association between maternal age and low birth weight and between gestational week and low birth weight. Also, maternal serum zinc levels were determined to be strongly associated with apgar scores of infants and delivery method. The study indicates that, although there is no particular evidence that maternal zinc deficiency causes low birth weight, there may be an association that it has prenatal and postnatal outcomes for very low birth weight infants. OP-28 PROFILE OF 23 CASES INFECTED WITH INFLUENZA A (HN) IN EASTERN ANATOLIA S. VANCELIK, 2 Z. AKTURK, 3 R. CETIN SECKIN, 4 H. ACEMOGLU Director of Health, Erzurum Local Health Authority, Erzurum, Turkey Dept. of Family Medicine, Ataturk University Medical Faculty, Erzurum, Turkey Dept. of Communicable Diseases, Erzurum Local Health Authority, Erzurum, Turkey Dept. of Health Education, Ataturk University Medical Faculty, Erzurum, Turkey This study aimed to describe the profile of people diagnosed with the HN infection in Erzurum, a city with inhabitants at the North-East Turkey. All 445 patients suspected of HN infection between October 2009 and end of January 200 were referred to one of the five hospitals in the city. Blood was collected and sent for laboratory diagnosis by the Refik Saydam reference laboratory. Patients with positive test results were compared to the negative ones regarding the risk factors. 23 patients (47.9%) were proven to be HN positive. Mean age was 26.8 years. 55.5% were males. Of the HN positive cases, 89.7%(n=9) had high fever (>38.3 C), whereas this figure was 75.9%(n=22) for the negative group; also cough and runny nose were more common in the positive cases (p<0.05). Positive cases were further analyzed: 20(9.4%) died. 56.8%(n=2) were males. Median age was 9 years (0.2-83). Median duration of symptoms was 2 days (0-9). 43 patients received intensive care; 23 required ventilator support; 30 received antiviral therapy. There was no relationship between antiviral therapy and mortality (p>0.05). Mortality for HN vaccinated patients was 0%. In a logistic regression model, age (OR=.05), female sex (OR=6.), absence of headache (OR=2.20), absence of runny nose (OR=.), and presence of ARDS (OR=05.4) were significant variables predicting mortality (all p<0.05). This study supports the evidence that high grade fever and cough are major symptoms of patients infected with HN. The seemingly negative effect of symptoms such as headache and runny nose on mortality needs further investigation. Distribution of different factors vs. HN positivity %

155 Distribution of risk factors and mortality status. RDS: Respiratory Distress Syndrome. OP-29 DENTISTS\' SPINAL DISCOMFORTS AND PHYSICAL EXERCISE HABITS P.C. UNALAN, 2 N. TOPSAKAL, 3 M. KARAHAN, S. CIFCILI, G. YIGIT Dept. of Family Medicine, Marmara University Medical Faculty, Istanbul, Turkey 2 Dept. of Physical Education and Sports College, Marmara University, Istanbul, Turkey 3 Dept. of Orthopedics, Marmara University Medical Faculty, Istanbul, Turkey Background: The dentists expose to irrational posture and prolonged static muscle load during their profession. This causes discomfort related to musculoskeletal system. The aim of this study is to evaluate the frequency of the musculoskeletal discomfort with special reference to neck, low-back and knee pain and physical activity among the dentists. Method: This cross sectional study using a self report questionnaire which was completed by 647 dentists at their private offices who were randomly selected from the lists of the dentists association. Results: The mean age is 39.4±.7 and 62.8% are male. 264 dentists are overweight and obese (42.3%). Overweight and obese dentists are mainly male (84.2% vs 5.8%). Of the dentists 6.3% work for >5days/a week and men are more busy 5.5 days/week vs 5.4 (p 0.05). 38.9% make exercise regularly, but of them 32.5% can make exercise only day in a week. 33.2% report low back pain, 9% neck discomfort, 7.9% knee pain. The most common type of exercise is walking and jogging. As the years in profession advance, dentists who have at least 0 years of experience have more spinal discomfort (p=0.029) but they also make longer, frequent and heavier physical exercise (p=0.04, p=0.02 and p=0.02). Conclusion: Having a busy working schedule, getting older or having musculo-skeletal disorders are not barriers for physical exercise. Male dentists work longer hours, high in BMI, smoke more and do not exercise more than females. So the risks of male dentists may be overrated as they can be promoted

156 OP-30 HYPERTENSION IN MONTENEGRO L. DRAGIC, L. DJUROVIC Department of General Practice, Primary Health Center Podgorica, Podgorica, Montenegro Introduction: Hypertension is a major risk factor for cardiovascular disease target values are <40/90 mmhg, and diabetes mellitus 20/80mmHg. Goal: The aim of the presentation is to compare the past with the modern practice of family medicine practice. Method: Analysis of health cardboard from various cities of Montenegro (4 doctors). Every doctor is processed by 30 cardboard. Number of examined the cardboard 00. Total patients with hypertension: 420. Time of research: September 2009 year. Results: Of 420 patients 228 (54.2%) were women and 92 (45.7%) were man. Age structure:> 30 years was 5 (3.5%), from years 03 (24.5 %), <50 years, 302 (7.9%). Patients are processed by the risk factors for hypertension. Number of patients whose smoking status was recorded in a cardboard is 25 (29.7%), of which 07 were smokers (85, 6%), and non-smokers 8 (4.4%). -Number of patients with recorded BMI is 38 (9.0%), of which more than 25 BMI was 32 (84.2%) patients. Number of patients with recorded glucose was 280 (66.6%) than that with diabetes mellitus 89 (3.7%), and patients with cholesterol recorded in 283 (67.7%), than that are at risk (cholesterol> 5, 5mmol/l) was 82 (64.3%). Alcohol-drinking history recorded 28 (6.6%) patients, and of that drink large quantities of alcohol 26 (92.8%). Number of patients with family history recorded in the cardboard 66 (5.7%), and from this positive predisposition to hypertension is 38 (57.5%). Monotherapy is 7.%, 56.% combination of the two, and three patients medicine 25.4%,.% of patients not taking medicines. The most common drugs were ACE inhibitors 286 (68%), calcium channel blockers 69 (40.2%), and beta-blockers 53 (36.4%). Conclusion: The average blood pressure was 55/95, the gold standard was achieved in only 5.4%. OP-3 PRIMARY HEALTH CARE REFORM IN MONTENEGRO M. DOBROVIC-MILOSEVIC, S. VUKOTIC Health Center Podgorica, Podgorica, Montenegro Introduction: Implementation of a new model of organization of primary health care started on 28 March 2005, through institute of a chosen doctor that is, a team of a chosen doctor. Goal: Our goal is to determine the level of satisfaction of patients with so far accomplished results of the reform of primary health care in Podgorica, the capital of Montenegro. Method: Through method of random choice 050 patients have been interviewed, in the period between December 2008 and March Results of the pool: Random choice of patients for the pool included 638 women and 42 men age between 5 and 80 years. Average age in group of men was 53.6 years and in the group of women 49.. Results were obtained after citizens have anonymously filled-in the following questionnaire. Conclusion: Through analysis of this questionnaire we came to conclusion that the primary health care reform in Montenegro, that is, in Podgorica brought certain problems for the patients as well as for the doctors and other medical staff. Average grade of the primary health care reform given by questioned patients is

157 OP-33 IPP-THE FIRST STEP IN TREATING FUNCTIONAL DYSPEPSIA D. MILOSEVIC, S. NIKOLIC Primary Health Care Center Vozdovac, Belgrade, Serbia Introduction: One of the problems of today is also a problem of dyspepsia. Dyspepsia is the group of symptoms, or pain and uneasiness in stomach, which are present permanently or from time to time. Dyspepsia can be organic (in core of the disease-gerb, ulcer, stomach cancer) and functional (without the presence of organic diseases). The most common form is functional dyspepsia and it will last at least months. It is present in some 60% of the population and it is mainly by work active population between 20th and 40th year. Symptoms of the functional dyspepsia stomach pain, uneasiness, flatulence, nausea, a sense of early satiety, heart burn, pain behind chest bone. When you eliminate alarm symptoms (abruptly emerged anemia, undesired loss of BM more than 5%, disphagia, persistent vomiting, existence of palpable mass in belly), an adequate and very effective treatment can be activated. For the first step, in addition to change of hygienic-dietary regime, IPP (inhibitor proton stations) is included. TARGET -was to see, whether the IPP as the first step in therapy of functional dyspepsia is the right one. Patients are questioned over the first day when it was considered a detailed medical history and conducted clinical exam, 4th and 30th day when they are questioned about the presence or absence of symptoms of functional dyspepsia and it was evaluated their health condition. With detailed analysis it is determined the effect of IPP for medical treatment of functional dyspepsia. Method: in analytical study was included the 50 patients between 30 and 50 years of age, both sexes, working active. All have had symptoms of functional dyspepsia of weaker or stronger intensity. Symptoms were present back around 4 months. From all is considered a detailed medical history about way of life, impact of the stress on the workplace, hygienic-dietary regime, use of medicines, confirmed absence or presence alarm symptoms, the clinical exam, conducted blood tests, and by some abdominal echo and X-ray gastro duodenum. Study Results: Of the total number of patients, after 4th day from the beginning of therapy 60% did not have stomach pain, 80 % flatulence,, 90% nausea, 80% sense of early satiety, 0% heart burn and 4% pain behind chest bone.after 30 days 90% had no stomach pain, 90 % had no flatulence, by 00 % ceased the sense of nausea, 00% ceased the sense of early satiety, at 70% heart burn stopped, and by 6% there was no pain behind chest bone. 70% patients was not required further therapy, by 6% therapy has continued another 4 weeks, and 4 % of patients was sent for further investigation or sent to see specialist for gastroenterology. Evaluation of their general health situation was given from the patients themselves. From them after two weeks 65% said that they feel good, and 30% to till has occasionally some of the symptoms and 5 percent of the patients said that they feel the same as before the treatment. After four weeks 70% of the patients said that their health condition is excellent, while the 30 % said that they have occasionally some symptoms but in a much softer form. Conclusion: As we see functional dyspepsia is more represented by younger work active population.simptomatology is very different. In this study was demonstrated that doctors in primary health care, can provide IPP as the first step in the treatment of functional dyspepsia. Of course, this should be the approach without any fear, only after there were fully excluded alarm symptoms. With therapy it is very important to change way of life and hygienic-dietary regime. Early introducing IPP to patients it is possible to have high-quality life, as well as better productivity in business plan. Satisfaction is mutual -for patients and doctors

158 OP-34 BHP AND THE QUALITY OF LIFE D. MILOSEVIC, S. NIKOLIC Primary Health Care Center Vozdovac, Belgrade, Serbia Introduction: A very common problem in male population is benign prostate hyperplasia. BHP is a benign growth-prostate hyperplasia, which leads to many symptoms and sometimes severe complications. Disease is very often, so in many men, already at 30 years of life can be found the first signs of BHP. With age and the frequency increases, so BHP is most common between the 50th and 80th year. According to some researchers, it was found that 3/4 men, aged 50 years have symptoms of BHP, but there is significant number of the latent form of "silent prostatism". In puberty under the influence of androgens, there is a sudden increase in the prostate, which grows up to 30 years of life. After that the prostate gets smaller, unless there is hyperplasia. BHP occurs because of hormonal imbalance-reduction of testosterone and increase of estrogen. Symptoms of BHP are mainly proportionally enlarged prostate and weak stream of urine, difficulty urinating, incomplete emptying the bladder, irresistible urges to urinate (especially at night). The most common complications are frequent urinary tract infections, hematuria cessation of urination, kidney and bladder, intoxication, prostate cancer, as well as temporary or permanent phenomenon of impotence. Many epidemiological-clinical studies have shown the importance of racial and genetic factors as a basis for the development of endocrinopathia. Aim of Work: was that with the early detection of symptoms of BHP to prevent further progression hyperplasia, eliminate symptoms, prevent the complications, work to improve the quality of life and at the end as screening methods for early detection of prostate cancer. The emphasis was given on improving quality of life of our patients. Work Method: The study included 50 patients, aged years. They were controlled in period of 6 months. All were taken the detailed medical history, blood test, urine, an echo of the prostate, PSA / prostate-specific antigen /, free PSA and index PSA / fpsa. By taking the medical history, we learned about the frequency and nature of symptoms. Echo review showed the size of the prostate, homogeneity, calcification, the amount of residual urine, and kidney and urinary bladder condition Blood tests and urine confirmed the presence or the absence of urinary infection. PSA is a very important parameter, for BHP and for prostate cancer, but is not crucial. In men with BHP, the annual increase in PSA was 0.75 ng / ml, while with the cancer much higher. Results of the Study: From the total number of examined patients 20% had BHP, 40% had mild symptoms, 30% moderate, at 6% is revealed cancer, and 4% had BHP followed with complications. Based on the medical history: BHP was found in 80%, on the basis of repeated urinary infections 30%, and based on the value of PSA 60%. The feeling of incomplete emptying had 60%, discontinuous urination 70%, urinating at intervals of less than 2h 50%, weak stream of urine, 60% straining during urination 40%, need to wet during the night had 70%, a disorder of sexual function 30%. Conclusion: In addressing the problem of BHP, we came to the conclusion that early detection of symptoms significantly improves quality of life. It is very well known that men are reluctant to talk about their problems. Therefore, the selected doctor must be very careful and subtle in taking anamnesis and further advising. Every suspected echo, elevation of PSA values are the signposts for further research of prostate. After receiving adequate therapy / by the urologist / patients is allowed a better life, better sleep, without stress, again included in the social life, better results at work, prevent occurrence of urinary infections, improved sex life and many complications have been prevented

159 OP-37 DIABETIC MELLITUS-METABOLIC SYNDROME V. VUKOVIC IGOV, S. PEJCIC, B. RAJKOVIC Dept. of General Medicine, Health Nis, Nis Serbia Independent of the primary causes of lack of insulin or its reduced efficiency comes to the intermediary metabolism disorders and the occurrence of diabetes mellitus with hyperglycemia glycozuria, and in severe cases and ketone acidosis caused. Symptoms by metabolic disorders are expressed through: hyperglycemia long, disorder fat and protein catabolism, excretion and disorder action of insulin, creating a disorder of energy and chronic complications of diabetes (cardiovascular disease, cerebrovascular disease, diabetic nephropathy, angiopathy, neuropathy). GOAL: point to the frequency of occurrence of chronic complications of diabetes METHODS: Data were obtained by examining the medical records of patients clinics Nikola Tesla who have diagnosed diabetes mellitus already 0-5 years. Considered 00 patients, of which women 75 men 25th age> 65 years 80%, and <65 years 20%. In 80% of the patients morning glycemia was 7.2. Of the total number of 70% on oral therapy and regularly taken. 30% of patients on combined oral-insulin therapy. In 80% of cases occur in obesity, 20% without changes in body weight, 0% have a slight loss of body weight. A total number of 75% have a cardiovascular disease, 30% have a cerebrovascular disease 30%, nephropathy is at 30%, 50% of the angiopathy, neuropathy 80%. CONCLUSION: required early prevention of chronic complications of diabetes, through good regulation of glucose, body weight, fat, using medical nutritional therapy, applying medication, proper physical activity and raise health awareness among people. OP-38 PREVALANCE OF METABOLIC SYNDROME AND RELATED RISK FACTORS IN HYPERTENSIVE CHILDREN AND ADOLESCENTS D. YILDIZHAN, M. BAYAT, M.M. MAZICIOGLU, S. ISMAILOGULLARI, 2 S. KURTOGLU, E. YILMAZ, H.B. USTUNBAS 2 Dept. of Family Medicine, Erciyes University Faculty of Medicine, Kayseri, Turkey Dept. of Paediatrics, Erciyes University Faculty of Medicine, Kayseri, Turkey Introduction: Even though Metabolic Syndrome is a more common problem in adults rather than children, it is also seen as an important problem in adolescence and childhood. Aim: The aim of this study is to determine Metabolic Syndrome prevalence and related risk factors in hypertensive 6-8 years old children and adolescents. Method: The children and adolescents whose blood pressure is over than 95th percentile of their own age and gender in DAMTCA II study (Determination of antropometric measurement in Turkish children and adolescent) were included in this trial. According to IDF (International Diabetes Federation) criteria prevalence of Metabolic Syndrome will be determined and related factors would be checked. Results: The DAMTCA II study includes 4496 children and adolescents of whom 2496 were females and 2027 were males. Diastolic hypertension is found in 2.5 %,sistolic hypertension in 2.4 %,systolodiastolic hypertension in.6 % of samples. The prevalence of metabolic syndrome and related factors would be determined in these subjects. Conclusion: This study will provide the prevalence of metabolic syndrome and related risk factors with metabolic syndrome in hypertensive children and adolescents

160 OP-39 BEHAVIOURS AND ATTITUDES OF FAMILY PHYSICIANS AGAINST PHYSICAL ACTIVITY I. KARATAS ERAY, 2 E. ALTUNBAS, 3 S. GUREL 2 3 Dept. of Family Medicine, Bozok University Faculty of Medicine, Ankara, Turkey Mehmet Nurhan Kaynak Primary Health Care Center, Ankara, Turkey Turkish Ministry of Health Education and Trainning Consultant, Ankara, Turkey Introduction: In recent years many governments and health organizations started to work on encouraging activities and programs on attendance to the physical activity programs as their positive influence on physical and mental health of humans has been seen increasingly. Following are the common characteristics of the physical activity incentive programs that is for general population. In house programs, exercise with no trainer, close relations with professionals, medium frequency exercises and programs that chooses walking as exercise. It is thought that characteristics of the relation between health care professional and heath care beneficiary could be more important. Therefore we aimed to figure out the attitudes of those who are getting their training for their primary care physician specialization among their interrelations. Material and Methods: Twenty nine volunteer doctors from those Education and Research Hospitals in Ankara which has Family Physician program have been attended to this study. A questionnaire has been developed for testing the behaviours and attitudes of the doctors on physical activities. Surveyors utilizes a question format aiming to figure out demographic data of the participants, the individual behaviors in the physical activities and a scale for testing the appreciated value of the physical activities. SPSS.5 was used for descriptive statistical analysis of the survey outcome data. Besides utilizing the statistics for the analyze of the data some tests like chi-square, t-test and one way ANOVA has been performed. Results: Participants whose daily physical activity less than thirty minutes accepted as inactive, between thirty and sixty minutes activity as active, more than sixty minutes per day accepted as very active persons. Nine of the participants (3%) were inactive; fifteen (5,7%) were active; five (7,2%) were very active. The point for dietery behaviour was ranged minimum 52, maximum 96, average mean 78,58(SD 3,59); and physical activity behaviour point was between 60 and 80; mean 72,76 (SD 6.96). Conclusion: There was no significant difference for physical activity behaviours between physically active and inactive doctors. Inspite of all doctors have positive behaviours against physical activity, they can not achieve enough physical activity due to unsuccessfully usage of their sources. They need to be motivated to arrange their sources (time, money) correctly. OP-4 LOW DOSE ADMINISTRATION OF ORAL POWDER ANTIBOTICS DUE TO INAPPROPRIATE PREPARATION C. APAYDIN KAYA, 2 S. CAGATAY, 2 E. BUYUKKARA, 2 O. OZLUK, 2 A.I. CELIK, N. TOSUN Dept. of Family Medicine, Marmara University Medical Faculty, Istanbul, Turkey 2 Marmara University Medical Faculty, Istanbul, Turkey Aim: To evaluate the ability of mothers to measure and prepare oral powder antibiotics (OPA) for their children. Method: A descriptive and observational study was conducted with mothers who visit pharmacies in Istanbul to buy OPA for their children. After basic socio-demographic information, a questionnaire was applied about preparation of OPA were described or not. Then, mothers were asked to prepare the medicine with the same form and shape as the prescribed OPA in the same way they would do for children. A checklist was filled for how they prepared OPA. Later, the amount of the prepared suspension was measured with 0 ml glass pipettes. If measured dose was in ±0.ml range of the prescribed dose, we accepted it as correct dose. Frequency distribution and chi-square test was used for analysis. p <0.05 were considered as significant

161 Results: 99 mothers who have children 0-2 ages were included in the study. During the preparation of OPA, 96.3% of mothers didn t shake the bottle before adding water in the bottle, %42 of mothers couldn t align water to the marked line while adding water. When asked to scale the solution as in the prescription, 80.8% of mothers scaled the dose in less than the required amounts (p<0.00). Mothers\' educational status, number of children, age and doctors being a practitioner or a pediatrician were not related with appropriate preparation and correct scaling of OPA. Conclusion: We conclude that mothers aren t able to appropriately prepare OPA and they scale in low doses. OP-42 THE INVESTIGATION OF METABOLIC DISORDERS IN NEWLY DIAGNOSED HYPERTENSION PATIENTS U. AYDOGAN, A. PARLAK, 2 K. SAGLAM Dept. of Family Medicine, Gulhane Military Medical Academy, Ankara, Turkey 2 Dept. of Internal Medicine, Gulhane Military Medical Academy, Ankara, Turkey Objective: This study is aimed to evaluate the organ functions of newly diagnosed hypertensive patients. Material and method: This study is done with 200 patients including 00 newly diagnosed hypertensive patients consulted to internal medicine outpatient clinic and 00 healthy people with any diseases in sanitary controls as control group. Subjects with diabetes and chronic renal failure were not included to study. Results: The mean age of patients and control group was 55,48±2,28 (range:4-69) and 53,5±,5 (range:40-65) respectively. The mean glucose value of patients and healthy people were 94,0±7,49 and 92,33±9,37 respectively and there was no significant difference (p=0,25). Total cholesterol values in hypertension and control groups were 206,64±40,3 and 92,76±4,92 and there was statistically significant difference between two groups for two parameters (p=0,04). When LDL values were analysed, in hypertension group it was 34,48±32,76 and in control group 22,94±34,25, and there was significant difference between LDL values (p=0,03). AST and ALT values in patients and healthy were 23,6±6,03 and 8,07±0,87 ; 24,73±3,29 and 20,0±9,5 respectively and there were significant difference with control group for two parameters (p=0,035; p=0,04). HDL and trigliserid values have shown in table. Conclusion: It was found that although cholesterol, LDL, ALT and AST values were normal in patients, these parameters were higher than control group. As family phycians, we have to prevent patients enter chaotic process before systemic disorders occur, control hypertension as a component of metabolic syndrome, with existing treatment regimes and monitorize patients carefully in this period. The blood parameters evaluated in patients and control group

162 OP-43 THE EVALUATION OF KNOWLEDGE AND LIFE STYLES OF HYPERTENSIVE PATIENTS U. AYDOGAN, A. PARLAK, 2 K. SAGLAM Dept. of Family Medicine, Gulhane Military Medical Academy, Ankara, Turkey 2 Dept. of Internal Medicine, Gulhane Military Medical Academy, Ankara, Turkey Objective: This study is aimed to investigate the knowledge and life styles of patients monitorized for hypertension. Material and method: This study was performed using a questionnaire including 20 questions that interrogate the knowledge and life styles of patients with hypertension. SPSS 5.0 programme was used to evaluate data. Results: Seventy percent (n=40) of the patients were female and 30%(n=60) were male. The mean age of the patients was 56,22±4,73 (22-80). 84% (n=68) of the patients were non-smokers whereas 6% (n=32) were smokers. 8% (n=36) of the patients were aware of systolic and diastolic blood pressure (BP) values, 82% (n=64) were unaware. As they were asked about systolic BP values, it was found that 6% (n=32) had 50 mmhg, 6% (n=32) had 60 mmhg, 0% (n=20) had 70 mmhg and 8% (n=6) were unaware. When interrogated if hypertension caused other diseases or not, 64% (n=28) were unaware, 0 % (n=20) said it caused to brain hemorrhagia, 6% (n=2) to heart and eye diseases, 6% (n=2) to heart, stroke and renal diseases, 6% (n=2) to heart diseases and stroke, 4% (n=8) to heart disorders. 30% (n=60) of patients didnot know the normal values of BP, 8% (n=36) thought 20-70mmHg, 38% (n=76) thought mmhg. Regular sport and exercise were not performed by any proportion of the patients. Conlusions: According to the study, hypertensive patients didnot have enough knowledge about their conditions. we have lots of dealings as Family Pyhsicians and other health protectives have to inform society about hypertension disease

163 POSTERS Po- SMOKING AND DEPRESSION SYMPTOMS AMONG MEDICAL STUDENTS IN TURKEY K. MARAKOGLU, 2 D. TOPRAK, 3 S. OZDEMIR, 3 D. ERDEM KOROGLU, 3 S. SAHSIVAR 2 3 Dept.of Family Medicine, Selcuk University, Selcuklu Medical Faculty, Konya, Turkey Dept. of Family Medicine, Afyonkarahisar Kocatepe University, Medical Faculty, Afyonkarahisar, Turkey Dept.of Family Medicine, Selcuk University, Meram Medical Faculty, Konya, Turkey Objectives: The aim of this study was to evaluate the relationship between smoking status and the prevalence of depression among medical faculty students, and also to investigateere are differences in these factors between the classes. Methods: In this cross-sectional and descriptive research, a questionnaire to determine the sociodemograpic features and smoking status; and Beck Depression Inventory (BDI) for depression level were applied to three different medical faculty students in Turkey. Results: The mean age of the participants was 20.05±2.3 years. Smoking prevalence was found as 8.4%. Smoking prevalence (25.6%) was significantly higher in the fifth grade than the others (p=.00). BDI results were 7 and over in 3.4% of the students. Analysing the total BDI scores according to the classes, it was found that the frequency of depressive symptoms increased in the second class (22.2%) and decreased beginning from third class (p=.00). BDI symptomatology was 3.4 times higher among the smokers than nonsmokers (p=.000). Conclusions: Depression symptomatology in the second grade, when the medical courses especially begin in our country, was found higher among the current smokers than the nonsmokers. Giving psychological counselling services to the students by the related institutions, whose aims are to help them quit smoking and support them, will be beneficial in terms of bringing up future s healthier physicians. Po-3 EVALUATION OF THE LEVELS OF OXIDATIVE STRESS FACTORS AND ISCHEMIA MODIFIED ALBU- MIN IN THE CORD BLOOD OF SMOKER AND NON SMOKER PREGNANT WOMEN A.S. SAHINLI, 2 K. MARAKOGLU, 3 A. KIYICI 2 3 Cobanlar Health Center, Afyonkarahisar, Turkey Dept. of Family Medicine, Selcuk University, Selcuklu Medical Faculty, Konya, Turkey Dept. of Biochemistry, Selcuk University Meram Medical Faculty, Konya, Turkey The aim was to determine the levels of oxidative stress factors and ischemia modified albumin in the cord blood of smoker and non smoker pregnates and to establish if cigarette causes oxidative stress, and ischemia in the placenta. This study was performed on 30 smoker and 60 non smoker pregnant women who had normal spontaneous vaginal delivery at the 37th-40th gestational week. Age, parity and gestational weeks of both groups were similar. Malondialdehyde (MDA), vitamin A and E, total antioxidant capacity (TAC) and ischemia modified albumin (IMA) levels and superoxide dismutase activities were determined in the cord blood of the contributors. Student-t, Chi-square, Fisher s Exact analysis tests were performed as statistical significance tests. In the cord blood of the smoker women compared to the non smokers; MDA levels increased (5.7±0.25, 3.60±0.06, p=0.000), IMA levels increased (0.93±0.02, 0.830±0.0, p=0.050), SOD activities decreased (8.22±0.4, 8.63 ±0.4, p=0.045), Vit A (339.06±7.52, 454.9±6.56, p=0.000) and Vit E levels decreased (2.8±0.5, 7.58±0.38, p=0.000) and TAC levels decreased (3.25±0.5, 4.08 ± 0.09, p=0.000), and these differences were statistically significant. In conclusion; it was determined that smoking cigarette during gestation disturbed the balance between the oxidant and anti-oxidant system and caused oxidative stress. Increase in IMA levels caused by smoking during gestation makes us think that smoking cigarette during pregnancy causes placental ischemia

164 Po-5 KNOWLEDGE AND ANTICIPATED ATTITUDES OF THE COMMUNITY ABOUT BIRD FLU OUTBREAK IN TURKEY; A SURVEY-BASED DESCRIPTIVE STUDY T. EDIRNE, 2 D. KUSASLAN, 2 B. ATMACA, 2 M. ASLAN Dept of Family Medicine, University of Pamukkale Medical Faculty, Denizli, Turkey 2 Dept of Family Medicine, University of Yuzuncu Yil Medical Faculty, Van, Turkey Objective: To determine knowledge and anticipated preventive behavior responses to a foreseen serious bird flu outbreak in a high-risk population from a remote region. Methods: A random, cross-sectional face-to-face survey of 046 Turkish adults. Results: A low level of education and income was associated with a decrease in risk perception and preventive behaviors against bird flu disease and non-compliance with official regulations. In addition, persons who prefer on-site slaughter of poultry from backyard farming had a lower level of risk perception and use of preventive measures. Conclusions: Preparedness against bird flu endemic in remote regions could be hindered by factors such as low levels of education and economic dependence on small-scale backyard farming. The baseline data collected in this survey will be useful for monitoring changes over time in the population\'s perceptions of threat, and its preparedness to comply with specific public health behaviors. Po-6 HAIR MESOTHERAPY IN TREATMENT OF ALOPECIA S. OZDOGAN, 2 M. ERDAL Dept. of Dermatology, Bursa Military Hospital, Bursa, Turkey 2 Dept of Family Medicine, Etimesgut Military Hospital, Ankara, Turkey ntroduction: Hair mesotherapy, as broadly defined, represents a variety of minimally invasive techniques in which medications are directly injected into the scalp in order to improve alopecia. There are few clinical studies evaluating the efficacy and safety of mesotherapy in any form. Material and Method: In this study, we evaluate the clinical changes of mesotherapy formulation on 5 men and 8 women patients, which consists of minoxidil, biotin, dexpantenol, herbal complex and procain and which is applied for androgenetic alopecia in our clinic every week. Results: In the analysis done before and after the mesotherapy, when the hair quantity, hair thickness, scalp state and hair loss are compared, the difference between them was statistically meaningful(p<0,05). There was no side effect during and after the application. Discussion: In the hair mesotherapy, there is lack of mixture and application scheme whose effectiveness has been proved scientifically. We approve this study to be published that it supports the few issues. Comparison of Hair condition Before and After Hair Mesothera *Paired sample t test ** Wilcoxon sign rank test? Mean±S

165 Po-7 DERMATOLOGIC ANALYSIS IN ELDERLY PATIENTS DURING BALNEOTHERAPY S. OZDOGAN, 2 E. KAYA, 3 A.H. KAYAR, 4 M. ERDAL Dept. of Dermatology, Bursa Military Hospital, Bursa, Turkey 2 Dept. of Physiotheraphy, Bursa Military Hospital, Bursa, Turkey 3 Dept. of Physiotherapy, GATA Haydarpasa Hospital, Istanbul, Turkey 4 Dept of Family Medicine, Etimesgut Military Hospital, Ankara, Turkey Introduction: The aim of this study was to determine skin changes due to balneotherapy in elderly patients who were treated with termal therapy for rheumatismal pain. Material and methods: Older than 50 years old 5 patients with generalize ostoarthritis were treated with balneotherapy enrolled our study in October- November All patients treated 2 days with balneotherapy. Patient s skin analyses were done twice, at first day and 9th day of the treatment. Skin analyses were done at face region and fore arm flexor region. Moisturing, elasticity, pigmentation, fat ratio assessed in skin analysis. Results: 20 male and 3 female, totally 5 patients were enrolled our study. Before balneotherapy, mean moisturing was %67, after balneotherapy mean moisturing decreased %47 at fore arm region. After balneotherapy, mean moisturing at face decreased from %54 to %45. Fat ratio decreased from %28 to %20. Before balneotherapy and after balneotherapy elasticity and pigmentation differences were not significant statistically. Conclusions: By aging, skin becomes sensitive to environmental factors. Dry skin is a usual problem during balneotherapy. Patients with dry skin have pruritus and discomfort. We suggest patients treated with balneotherapy to use moisturing cream for protecting dry skin problems during balneotherapy. features of skin before and after Balneotherapy * : Mann Whitney-U **: Wilcoxon Signed Rank Po-8 FAMILY PHYSICIANS CALENDER IN TURKEY SINCE 997: EVALUATION OF THE TURKISH JOUR- NAL OF FAMILY PRACTICE N. KARAOGLU, 2 M.A. KARAOGLU Dept. of Medical Education and Informatics Department, Selcuk Univeristy Meram Faculty of Medicine, Konya, Turkey Dept. of Internal Medicine, Bilgi Hospital, Konya, Turkey Aim: Turkish Journal of Family Practice began to be published in 997 by Turkish Association of Family Physicians (TAHUD). The articles published in this journal may be the indicator of the interests of Turkish family physicians. The aim of this study is to analyze this journal as the main journal reflecting Turkey about family practice from the first issue in 997 to the last one printed in 2009 in a structural perspective. Material - Methods: We analyzed the Turkish Journal of Family Practice (TJFP) articles since 997 beginning with the first issue to the third issue of the 2009 in terms of number, content and topic of the studies. Results: There were 3 volumes and 43 issues printed in 3 years. Regularly 4 issues printed in each year

166 except 999 in which two combined issues and 2000 and 200 in which one combined issue printed. There were 44 articles in total but 298 (72.0%) were primarily in research, review, continuing medical education, case report and letter to the editor sections. Among these articles 46 (49.0%) were research articles, 7 (23.8%) were reviews and 38 (2.8%) were continuing medical education articles. The journal includes 6 (3.9%), 39 (9.4%) and 26 (6.3%) articles about family medicine in Turkey and the world, family physicians library and literature abstracts, respectively, among 44 articles. Conclusion: This study only shows the evaluation of TJFP during 3 years. Especially importance of continuing medical education is honourable. Po-9 ANXIETY AND DEPRESSION LEVELS OF PRECLINICAL MEDICAL STUDENTS IN SELCUK UNIVER- SITY N. KARAOGLU, M.SEKER Dept. of Medical Education and Informatics Department, Selcuk Univeristy Meram Faculty of Medicine, Konya, Turkey Aim: While training knowledgeable, competent and professional physicians for the nation s sick medical education distresses and sicken medical students. This conflict has given importance to the reasons of this distress. The aim of this study is to determine the anxiety and depression levels of medical students and related factors. Material - Methods: A self-administered questionnaire consisting of Hospital Anxiety and Depression Scale (HADS), demographic variables and questions about career selection was applied to the preclinical year students in a cross-sectional design. Results: There were 485 students representing 79.63% (n=609) of total number. Mean age was 9.49±.54. Above the half (n=272, 56.%) were male and 423 (87.2%) were from urban. While 46.2% (n=224) of mothers got primary school education, 5.3% (n=249) of fathers had university degree. In total 7.9% (n=87) students scores in anxiety and 28.0% (n=36) students scores in depression were above the cut-off levels. The mean anxiety and depression scores were 7.45±3.79 and 5.60±3.74, respectively. The difference was significant in terms of academic year, hometown, suicidal idea and being pleased with medical career both for anxiety and depression levels (p<0.05). In respect to gender, education of parents, current residency and reason of medical career selection there were significant difference in depression scores of students (p<0.05). Conclusion: Being male, second year student, being from rural areas, having illiterate parents, external effects in career decision and suicidal ideas, living with friends, and being not pleased with career decision were main factors determined for anxiety and depression and should be followed up carefully

167 Po-0 XANTHOMA ERUPTIVUM AND DIABETES MELLITUS AT OUT- PATIENT VISIT AT POLIAMBULA- TORY OF SPECIALITIES NR 2 TIRANE, ALBANIA. B. GJONI, 2 M. KELMENDI, 3 N. DHALES, 4 A. BITRI, 4 V. KONICA Dept. of Dermatology, Policlinic of Specialities Nr2, Tirane, Albania 2 Dept. of Endocrinology, Policlinic of Specialities Nr2, Tirane, Albania 3 Dept. of Ophtalmology, Policlinic of Specialities Nr 2, Tirane, Albania 4 Dept. of Family Medicine, Policlinic of Quorter Nr 9, Tirane, Albania Introduction: Cutaneous xanthomas result from deposition of lipids in the histiocytes in the dermis or subcutaneous tissue associated with a more sustained hyperlipidemia affecting plasma triglycerides and cholesterol, and hyperglycemia with glycosuria. Aim: To present a case of Xanthoma Eruptive and Diabetes Mellitus, in a 52 year old Type 2 patient who visited Poliambulatory of Specialties. Methods: The patient after recommendation of Family doctor presented to dermatology service. The clinical examination of the skin revealed the presence of numerous yellowish nodules on the trunk and extremities, followed by itching sensation. Patient was excessively overweight with body mass 20 kg. Results: At examination of the skin, the trunk and extremities were covered with numerous yellowish papules sized -5 mm, some of which are grouped in larger or smaller plaques. Laboratory examination: cholesterol 245 mg/dl, triglycerides 420mg/dl, glycaemia 260mg/dl. Pathohystological findings: Xanthoma. Endocrinological findings: non-insulin-dependent DM, hyperlipidemia. Ophthalmologist findings: without particularities. The treatment priority is body mass reduction and antidiabetic diet, antidiabetic, antilipemic. Skin marks have disappeared within two months. Level of cholesterol: 85mgl/dl, triglycerides: 90mg/dl and glycaemia: 40 mg/dl have progressively decreased under constant control, to attain following values after six months since the beginning of the treatment. Conclusion: Suffering from a lighter form of DM and hyperlipidemia most probably of the type IV, it was precisely the skin condition that enabled disease to be identified and adequate therapy to be established. Po- MORBIDITY OF DERMATOLOGICAL DISEASES OF THE PEDIATRIC AGE DURING AT HEALTH CLINIC OF SPECIALTIES NR 2 AND HEALTH CLINIC OF QUARTER NR 9,TIRANA, ALBANI B. GJONI, 2 N. DHALES, 3 M. KELMENDI, 4 V. KONICA, 4 A. BITRI, 5 E. CUKANI Dept. of Dermatology, Policlinic of Specialities Nr2, Tirane, Albania 2 Dept. of Ophtalmology, Policlinic of Specialities Nr 2, Tirane, Albania 3 Dept. of Endocrinology, Policlinic of Specialities Nr2, Tirane, Albania 4 Dept. of Family Medicine, Policlinic of Quorter Nr 9, Tirane, Albania 5 Dept. of General Practice, Faculty of Medicine, Tirane, Albania Introduction: Dermatological diseases of pediatric age 0-4 years old are the most common part of the general dermatological practice. Objectives: The main objectives of this retrospective study at the out-patients are : Evaluation of the morbidity of the dermatological and the identification of the most common dermatological pathology. Metodology: In this retrospective study year we examined the 3250 children at the age 0-4 years old. Results: 3250 patients were diagnosed for dermatological diseases. 890 of them or 58% were female children and 360 or 42 % were male children. We found out that eczematous diseases were present in 29.4%

168 of the children, Scabies in 9.2 and Alopecia 5.45%. We noticed that the year from 0- year old resulted more affected from eczema infantum localized mainly in the face, arms and forearms, accompanied with pyogenic infections. The most frequent pathology of the age group -5 years old resulted scabies because they had direct contact with the infected parents. Children living in rural areas presented more mycotic infections 3.46% due to their contact with the animals. We diagnosed 79 cases with psoriasis vulgaris and 42.2% of them had a family history for psoriasis. Conclusion: The prevalence of dermatological diseases of the pediatric age during the period is as above: Eczematous diseases 29.4% with their high frequency at the age group 0- years old. Scabies 9.2% with its high frequency at the group age -5 years old. Alopecia 5.45% with its frequency at the age 7-4 years old. Po-2 DOES THE MOBING HAVE THE INFLUENCE ON THE TYPE OF PERSONALITY? A. BEGANLIC, O. BATIC-MUJANOVIC, S. HERENDA, 2 M. HASANAGIC, A. BRKOVIC Family Medicine Teaching Center, Primary Health Care Center, Tuzla, Bosnia & Herzegovina 2 Family Medicine, Primary Health Care Center, Mostar, Bosnia & Herzegovina INTRODUCTION: mobbing presents the most common example of working stress. AIM: are the nurses of type A more often exposed to mobbing behavior than the nurses of type B? SUBJECT AND METHODS: we conducted a survey, a validated self/reported questionnaire among 274 nurses/medical technicians in Primary health care. The questionnaire covered experience of mobbing behavior and persons of type A or B. We used the questions from the questionnaire list about mobbing and on the standard questions about type of person A/B. For testing the statistical importance X2 test and t test has been used. RESULTS: Among participants, the females were more represented (239/ 274 or 87%). Most of the participants were persons of type A 47/ 274 (54%). During the last year there were reported 47/274 (54%) participants with mobbing experience. With mobbing experiences there are 83 (30%) persons of type A. The group of participants with mobbing experiences are statistically different than the group of participants without mobbing experiences according to the type of person A / B (P = 0.034). The risk of appearance of all stress symptoms is > 2 for persons of type A. CONCLUSION: mobbing is spread phenomenon between nurses. More than half of the nurses have been exposed to mobbing behavior in the last year. The persons of type A have often been exposed to mobbing. The persons of type A had twice the risk of appearance of all stress symptoms

169 Po-5 ACUTE URTICARIA AT THE PEDIATRIC AGE, VISIT AT POLICLINIC OF SPECIALTIES NR 2 & HE- ALTH CLINIC NR 9 DURING JANUARY DECEMBER B. GJONI, 2 M. HASANAJ, 2 B. VACARRI, 3 V. KONICA, 4 M. KELMENDI, 5 N. DHALES, 6 A. BITRI, Dept. of Dermatology, Policlinic of Specialities Nr2, Tirane, Albania 2 Dept. of Allergology, Policlinic of Specialities Nr2, Tirane, Albania 3 Dept. of Pediatrics, Health Clinic Nr9, Tirane, Albania 4 Dept. of Endocrinology, Policlinic of Specialities Nr2, Tirane, Albania 5 Dept. of Ophtalmology, Policlinic of Specialities Nr2, Tirane, Albania 6 Dept. of Family Medicine, Health Clinic Nr9, Tirane, Albania Introduction: Acute urticaria is caused by IgE Immunology mechanism, characterized by itching and 5% of the pediatric population develop pruritus during some time in its life. The diseases last for ashort period of time and responds effectively to the elimination of the responsible factor and at the usual antihistaminic therapy. Materials & Methods: In our study we examined the children from January 2009 until December 2009 in base of medical history, objective examination, basic and specific laboratory control. We recorded information according to age, sex, seasonal distribution and the cause of the diseases and the appearance of the accompanied angiomatic oedema. Results: We visit 228 children 0-4 age, 98 boys (42.9%) and 30 girls (57.%). Seasonal acute urticaria appeared in 46 children (20.%) during the autumn, in 78 children (34.2%) during the winter, 40 children (7.5%) during the spring, 64 and children (28 %) during the summer. The most commonly referred caused of urticaria were food( 5.0%), medicines(35.7%) and nygma of insects(3.3%). It was found out that 26 children (94.7%) who developed urticaria and only 2children ( 5.3%) with angiomatic oedema were hospitalized. Conclusion: The urticaria diagnosis is usually simple; medical history and physical examination most of the time are sufficient for the diagnosis. Urticaria is more often in winter and shows greater frequency in the females than the males. Food allergen is more frequent and direction should be given from specialists doctors to avoid and minimize the complications. Po-6 ACCESS OF ELDERLY PATIENTS TO PRIMARY MEDICAL CARE L. GEORGIEVA, S. POPOVA, 2 V. MADJOVA Dept of Social Medicine and Healthcare Organization, Medical University of Varna, Varna Bulgaria 2 Dept of Family Medicine, Medical University of Varna, Varna, Bulgaria Elderly people are a vulnerable group of the population mainly because of their low mobility and polymorbidity. That is why the access to general practitioner (GP) is a prerequisite that facilitates or impedes medical care for them. Access to primary medical care is investigated among 362 patients aged 65 years and over, discharged from therapeutic (internal and neurological) and surgical (surgical and orthopaedic) wards of two hospitals in northeastern Bulgaria. Information is obtained from patients via semi-structured interviews at their homes in 2 towns and 64 villages. For 93 (25.7%) elderly patients, GP s practices are located in settlements different from patients living places. This does not present a problem for some of them (such as patients living in villages after retirement but preferring their GPs in towns). For 56 (5.5%) patients in villages, where there is no GP practice, the access depends on availability of public transportation to GP s settlement: 46 - bus or train, train only, 9 lack of transportation. In 6 cases of bus availability, these are school buses that do not operate during weekends and holidays. Patients without transportation go from their villages to GPs settlements on foot, by car of relatives or do not visit a GP at all. Within 30 days after patients disc

170 harge from hospital, 6 GPs are denied home visits in villages because of lack of transportation. Results show that access to primary medical care is a serious problem for elderly people in some villages in Bulgaria. Po-7 WHY THEY DONT WANT TO BE A FAMILY PHYSICIAN? FAMILY MEDICINE FROM THE VIEW OF MEDICAL EDUCATION N. KARAOGLU, 2 M.A. KARAOGLU Dept. of Medical Education and Informatics Department, Selcuk Univeristy Meram Faculty of Medicine, Konya, Turkey Dept. of Internal Medicine, Bilgi Hospital, Konya, Turkey Aim: The decrease in the attraction of family medicine career in many countries is noteworthy. It is suggested that medical students preferences during education years is an indicative of their career choices after graduation. The aim of this study is to define Turkish medical students career preferences and the place of family medicine in this choice. Material - Methods: In the first week of 200 by a literature review from Turk Medline and Turkish Medline via student, career, medical student, medical faculty, family medicine, family physician terms studies showing medical students career preferences in Turkey evaluated. Career (3), medical student (57), student (942), medical faculty (2339), family medicine (23) family physician (22) and general practitioner (74) terms were screened. Medical faculty term had been eliminated because it was mostly depending on the authors institutions. Results: Among all abstracts scanned there were seven studies we aimed to evaluate. The studies were from Ondokuz May s, Ege, Uludag, Cerrahpafla, Hacettepe and Celal Bayar Universities. The percentage of students who wish to be specialized was between 58.8% and 97.%. While family medicine career was not noted as a specialization general practice was between 0.7% and 9.7% in student s career plans. There were some reasons students noted why they wanted to specialize but nothing known about why they don t want family medicine. Conclusion: Family medicine academicians should study about the reasons of unwillingness to family medicine and beginning from medical school family medicine as a specialty should have a management plan to be more attractive. Po-9 THE EVALUATION OF CASES OF DRUG INTOXICATION THAT ARE HOSPITALIZED O. ERDEM, 2 I.H. KARA, 3 O. AYYILDIZ Dept. of Family Medicine, Lice Halis Toprak Foundation Local Hospital, Diyarbakir, Turkey 2 Dept. of Family Medicine, Duzce University Medical Faculty, Duzce, Turkey 3 Dept. of Internal Medicine, Dicle University Medical Faculty, Diyarbakir, Turkey Aim: This study carried on with the aim of determine risk groups, socio demographic characteristics, and the drugs which had been taken by the cases that hospitalized. Material Method: The files of the cases that referred to Dicle University hospital with drug intoxication between January 2006 and December 2006 were analyzed retrospectively Conclusion: Most of the cases were young patients who attempted suicide by taking drug. It is observed that most of the people who attempt to suicide are housewives, students and house girls. It is thought that this is a behavior done by the people who have not got an adequate social status in society and they try to draw attention to themselves by attempting suicide

171 Po-20 SERUM MAGNESIUM LEVELS IN GESTATIONAL DIABETES K. INCI, D. SUNAY, U. UCKAN Dept of Family Medicine, Ankara Training and Reseach Hospital, Ministry of Health, Ankara, Turkey Aim: To assess the relation between gestational diabetes and daily magnesium intake and magnesium deficiency in pregnant women with gestational diabetes. Materials and Methods: Fifty-three patients pre-diagnosed as gestational diabetes and 49 healthy pregnant women who were admitted to Endocrinology and Obstetric clinics between April January 2009 were included into study. Obstetric history, body mass index, diabetes in family history of patients were asked and symptoms of magnesium deficiency were assessed. American Food and Nutrition Board s references were used to assess the nutrition status of patients. Serum magnesium, calcium, HbAc, kidney and liver function tests, amylase levels were measured and complete urinary analysis was performed to all patients. Data were tested by correlation and multiple linear regression analysis. Results: Mean age, gravida, parity and body mass index were significantly high in patient group (p<0,05). The rate of body mass index higher than 30 before pregnancy was 30.2% in patient group. No significant differences were found between groups in terms of daily magnesium intake and serum magnesium levels (p=0.234, p=0.337, respectively). Daily magnesium intake was significantly high in patients with nausea and vomiting (p=0.00, p=0.006). No significant difference was found between serum magnesium levels and HbAc and serum calcium levels (p=0.444, p=0.64, respectively). Conclusion: Although slight decreases were seen in serum magnesium levels during pregnancy, no differences were found in this study either in daily magnesium intake or serum magnesium levels between pregnant women with gestational diabetes and without gestational diabetes. Po-2 PREVALENCE OF HIPERTENSION IN NON TOXIC MULTINODULAR GOITRE AT THE OUT- PATIENT VISIT AT POLICLINIC OF SPECIALITIES NR 2 & POLICLINIC NR 9, TIRANE, ALBANIA M. KELMENDI, 2 G. HYSI, 3 A. BITRI, 4 B. GJONI, 5 A. VESELI, 6 A. STOJKU Dept. of Endocrinology, Policlinic of Specialities Nr2, Tirane, Albania 2 Dept. of Endocrinology, COUT Mother Theresa 3 Dept. of Family Medicine, Health Clinic Nr9, Tirane, Albania 4 Dept. of Dermatology, Policlinic of Specialities Nr2, Tirane, Albania 5 Dept. of Cardiology, Policlinic of Specialities Nr9, Tirane, Albania 6 Dept. of Nefrology, Policlinic of Specialities Nr2, Tirane, Albania We have recently observed a high prevalence of thyroid abnormalities and the particular non toxic multinopdular goitre, in the patient with primary aldosteronism. The aim of the study was to investigate the prevalence of hypertension in the patients with non toxic multinodular goitre. 05 patients with non toxic multinodular goitre (73 female and 32 male mean age 54 range 2-75 year) were investigated. In all the subjects the clinical data, the thyriod and adrenal function and thyroid ultrasonography were investigated. Blood pressure was measured three times in the sitting position. The normal value were under 20 mmhg ( diastolic) and 85 mmhg (sistolic). None of the patients does not have another disease that caused HTA.Control population was a group of 00 subjects with same characteristics (age, sex, BMI). Mean age was 52years. Results: The prevalence of sistolic hypertention was 70% in our out-patient visits and 40% in the controls group. Diastolic hypertension was 54% in the subject with multinodular goitre and 35% in the control group. The difference between two groups (multinodular goitre and control group) 0 was significant for both values. The pre

172 valence of hypertension was similar for both sex (695 male and 64 female) in the patient and in the controls. The prevalence of hypertension was correlated with the age of the subjects and the body mass index. Conclusion:The multinodular non toxic goitre patients diagnosted by specialists should be considered by the family doctor. Po-22 EVALUATION OF KNOWLEDGE, ATTITUDE AND BEHAVIOUR OF MEN ABOUT FAMILY PLANNING G. OZCEYLAN, 2K. ERTOPCU, S.H. KARAHAN, 2S. KELEKCI, 3A. DONMEZ, 4G. SOP Dept. of Family Medicine, Ministry of Health Education and Research Hospital, Izmir, Turkey 2 Dept. of Gyn&Obstetrics, Ministry of Health Education and Research Izmir Ege Maternity and Obstetrics Hospital, Izmir, Turkey 3 Dept. of Family Planning, Ministry of Health Education and Research Izmir Ege Maternity and Obstetrics Hospital, Izmir, Turkey 4 Dept. of Internal Medicine, Ministry of Health Education and Research Hospital, Izmir, Turkey Aim : In our study,unwanted pregnancies of women who were admitted to hospital for uterine evacuation,their partner about contraceptive methods,knowledge,attitudes and behaviour was evaluated. Material And Metnods : Between November 5,2009 and January 5,200 ; husbands of 60 women, who admitted for uterine evacuation to our clinic were included. Of men; age,educational status,marriage duration,number of children,such as target demographic characteristics were recorded.a questionnaire including 5 questions was applied to 30 men as validation test and later was applied to 60 men. Behaviour attitudes regarding family planning in the survey assessed the questions,including information about contraceptive methods were 40 questions found.the data were recorded with SPSS 3.0 and statistical analysis with chi-square methods were examined. Results: The mean age of patients were %of the cases graduated from elementary school. 4.7% were married between 3-0 years. 60 % of the cases wanted 2 children. Applicant men of 45% didn t use any method.8.3% of men used withdrawal method. 75% of men told they would support any method their wives choose. 76.7% of men answered 5 of 6 questions about condom,26.7% of men answered 5 of 7 questions about intrauterine contraceptive device,33.3% of men answered surgical sterilization of female questions,but only 23.3% of men answered questions about vasectomy correctly. Conclusion :As a result of our study,the spouses of women with unwanted pregnancies admitted ;they didn t have enough information about contraceptive methods except condoms.family planning education consultancy for the men on efficacy was emphasized

173 Po-23 EVALUATION OF TEN YEARED FOLLOW UP OF NTERNAL AND POSTABORTIVE APPL ED CUT380A INTRAUTERINE DEV CES B. BULUT, 2 K. ERTOPCU, 3 A. DONMEZ, 2 S. TINAR, 2 I. OZELMAS, 4 M. HELVACI, 2 A. TASYURT Dept. of Family Medicine, Ministry of Health Education and Research Hospital, Izmir, Turkey 2 Dept. of Gyn&Obstetrics, Ministry of Health Education and Research Izmir Ege Maternity and Obstetrics Hospital, Izmir, Turkey 3 Dept. of Family Planning, Ministry of Health Education and Research Izmir Ege Maternity and Obstetrics Hospital, Izmir, Turkey 4 Dept. of Pediatrics, Ministry of Health Education and Research Hospital Tepecik, Izmir, Turkey Aim : We purposed on determining effectiveness,reliability,contiousness, of CuT380A UD (intrauterine device) applied women in interval and postabortive period. Material And Methods: Woman applied CuT380A IUD between in our clinic,have been taken into our study, evaluated retrospectively. Women s demografic features such as age, number of abortion(spontaneous/voluntary), contraceptive method used before,etc are recorded. The complications in ten years period are evaluated. The data were recorded with SPSS 5.0 programme. Results : 722 women from 575 women CuT380A IUD applied have been taken into our study. IUD has been applied to 46 women in interval period, to 26 women in postabortive period. In interval applied group there are 3; postabortive applied group 2 IUD related pregnancy observed. There is only one ectopic pregnancy observed in interval group.dislocation is observed in 3 women (6.7%) in interval group, in postabortive group, there were dislocations(4.2%).in interval group, IUD has been taken out from 27(0.6%) women, because of bleeding and pain.in postabortive group, IUD has been taken out from women (4.2%), for bleeding and pain.in both groups, servical/fundal perforation isn t observed. Conclusion: CuT380A IUD is an effective, safe contraceptive method that can be applied in both interval period and postabortive period. In our study, it s determined that its effectiveness and safety don t change in ten years period. It s highlighted that ; counseling in controls is the most important factor that affects the continuousness of the use of IUD. Po-25 PREVALENCE OF DIABETES FOOT IN OUT-PATIENT VISIT AT ENDOCRINOLOGIST AND DERMA- TOLOGICAL SERVICES OF THE HEALTH CENTER OF SPECIALTIES NR. 2, TIRANE, ALBANIA. M. KELMENDI, 2 B. GJONI, 3 G. HYSI, 4 A. STOJKU, 5 N. DHALES, 6 A. BITRI, Dept. of Endocrinology, Policlinic of Specialities Nr2, Tirane, Albania 2 Dept. of Dermatology, Policlinic of Specialities Nr2, Tirane, Albania 3 Dept. of Endocrinology, COUT Mother Theresa, Albania 4 Dept. of Nefrology, Health Center of Speciality Nr2, Tirane, Albania 5 Dept. of Ophtalmology, Policlinic of Specialities Nr2, Tirane, Albania 6 Dept. of Family Medicine, Health Clinic Nr9, Tirane, Albania Introduction: It is well known that diabetic foot is the most serious complications of DM. Objectives: The aim is to present a short preliminary report on the diabetic foot in our services to know the situation and to undertake respective needs to prevent and to treat this invalid complication. Method and Materials: In our study we involved 580 patients diagnosed with diabetic tip & tip 2 (tip are 87, tip 2 are 93 ). Classification of diabetic foot was done in base of three clinic nozology: humid gangrene, sicca gangrene and ulcus plantaris

174 Results: We examined 580 patients with DM (tip and tip 2) Prevalence of diabetic foot resulted 6.2% in total. It was seen a predomination of diabetic foot at male patients 44 % versus 20 % at female patients. It was predominated by plantar ulcus in 42 patients (66%) versus sica gangrene in patients (7%) and humid gangrene in patients (7%). Complication of diabetic foot results: Diabetic neuropathies 00%, diabetic nephropathy 24 %, retinopathies 43 %, SAK 23 %. Bacterial culture resulted: staphylococcus areas 57%, pseudomonas 5 %, other negativ gram %, streptococcus b hemolytic %. Conclusions: From our data we can say that high prevalence diabetic foot is the great problem in the ambulatory that requires a tremendous effort in many directions to be reso. Po-26 TUBAL STERILIZATION VERSUS VASECTOMY ( DEMOGRAPHIC EXAMINATION OF 3404 CASES ) L. AKOGLU, 2 K. ERTOPCU, S.H. KARAHAN, 3 A. DONMEZ, 2 M. OZEREN, 4 M. HELVACI, 2 I. OZELMAS, 2 A. TASYURT Dept. of Family Medicine, Ministry of Health Education and Research Hospital, Izmir, Turkey 2 Dept. of Gyn&Obstetrics, Ministry of Health Education and Research Izmir Ege Maternity and Obstetrics Hospital, Izmir, Turkey 3 Dept. of Family Planning, Ministry of Health Education and Research Izmir Ege Maternity and Obstetrics Hospital, Izmir, Turkey 4 Dept. of Pediatrics, Ministry of Health Education and Research Hospital Tepecik, Izmir, Turkey Aim: To compare the demographic features of women with tubal sterilization and the men with vasectomy. Material & Methods: Women,had tubal sterilization at Family Planning Clinic of Ministry of Health Education and Research zmir Ege Maternity and Obstetrics Hospital between ;Men, had vasectomy at Urology Clinic of Ministry of Health Education and Research Hospital Tepecik, zmir between are included retrospectively in our study. In both groups age, education level, number of living children, last contraception method used before surgical sterilization are determined as demographic features.data is analyzed statistically by SPSS Findings: 2384 women with tubal sterilization from our Family Planning Clinic and 020 men with vasectomy from Urology Clinic are included in our study % of women with surgical sterilization was at the age of 3-40 and 47.64% of men with vasectomy was at % of women have primary school graduates while 0.25% have university graduates versus it is in turn 53.72% and 9.5 % for men with vasectomy. Women had 3 or more living children was 5.7% of all tubal sterilization cases while it was 42.5% of men with vasectomy.37.40% of women was using an effective method for contraception before surgical sterilization.the ratio of men using only condom for this purpose was 2.66 %. Conclusion : According to demographic features mentioned above we compared the two groups and no significant difference was observed between various demographic factors

175 Po-27 IMPLANON-SIDE EFFECTS,SAFETY,SATISFACTIONS,CONTINUITY S. KURNUC, 2 K. ERTOPCU, 2 Y. YILDIRIM, S.H. KARAHAN, 3 G. SOP, 2 A. TASYURT Dept. of Family Medicine, Ministry of Health Education and Research Hospital, Izmir, Turkey 2 Dept. of Gyn&Obstetrics, Ministry of Health Education and Research Izmir Ege Maternity and Obstetrics Hospital, Izmir, Turkey 3 Dept. of Internal Medicine, Ministry of Health Education and Research Hospital, Izmir, Turkey Aim: Evaluation of satisfaction, side effects, continuity, reasons for leaving of family planning methods as implanon. Materials And Methods: Women applied for implanon between the years are included in our study.demographic characteristics such as educational status,age,etc were determined.satisfaction levels, reasons for satisfaction were determined.method-related side effects were encountered,reasons for extraction of implanon and their preferred family planning methods were questioned. Findings: In our family planning clinic, 58 patients in the study group were applied Implanon. 48.3% of the patients 'age was % of the patients' was high school graduates. 25.9% of the patients' preferred method of implanon because of protective properties.58.6% of cases completed 3-year usage period. First 2 months, the proportion of patients,leave the method was 2.%.In the first 2 months, the most common side effect was amenorrhea (43%).versus 32.7% for all 3 years.although amenorrhea was seen, 64.2% of patients continued the method after follow up counseling.43.% of patients are satisfied.the leading causes of satisfaction is the easy usage by 24.%. 39.7%have said they will recommend the method of implanon.no pregnancies have been observed in our study group. Conclusion: Implanon is an effective, a reliable method of contraception. Most common side effects are amenorrhea and prolonged bleeding.side effects are observed in the first year but if adequate follow-up counseling of patients are given,they are sure to complete 3-year usage period.it's highlighted once again that follow up counseling after usage of a method is so important. Po-29 CARDIO-METABOLIC SYNDROME-INVASIVE TRATMENT OF PATIENTES L. ZOGOVIC VUKOVIC Dept. of General Practice, Health Centre Podgorica, Podgorica, Montenegro Cardio-metabolic syndrome is corelation of cardiovascular diseases caused by metabolic disorders metabolic syndrome.metabolic syndrome by definition of American heart assotiation (AHA) includes at least tree of five criteria: central obesity, high level of triglyceride more than,69,hdl less than,03,blood pressure more than mmhg,and sugar in blood more than 5,6 mmmol/l. Aim: to establish how much metabolic syndrome has influence on cardiovascular system. Method: we analysed medical card of patientes who were treated with invasive method. Results: 30 patients were treated with invasive method,average age of men is 59,69 and average age of women is 67,66. Z95.0 implementation of pace maker had 2 women. Z 95. implementation of by pass had 9 patients: woman and 8 men. Z95.2 implementation of valvula was done in 2 women and men. Z95.5 implementation of stent in 8 men, 2 men had electro. 24 patients had only one intervention and 5 of them had combined operation of implementation of stent or by pass. We analysed metabolic disorders and we found out that 0 patients suffered of hiperlipidemia before intervention it is 4,48%, after intervention 8 patients used therapy it is 62 %, 2 (6,8%) patients suffered of diabetes mellitus before intervention, 8 (27,8% ) patients were fat, 3 (44,82 %) had therapy for hipertension

176 Conclusion: we established that metabolic syndrome has enormous influence on cardiovascular system, stresfull lifestyle and heart stroke (30,67 %) also conrtibute the need for invasive methods Po-30 HOW MANY PATIENTS WITH A STROKE HAS FULFILLED QUALITY INDICATORS OF CLINICAL PRACTICE? A. BEGANLIC, 2 M. MUJCINAGIC-VRABAC, O. BATIC-MUJANOVIC, 3 M. HASANAGIC, S. HERENDA Family Medicine Teaching Center, Primary Health Care Center Tuzla, Bosnia and Herzagovina 2 Dept of Family Medicine, Primary Health Care Center Tuzla, Bosnia and Herzagovina 3 Dept of Family Medicine, Primary Health Care Center Mostar, Bosnia and Herzagovina INTRODUCTION: In standards, criteria and indicators for fulfilling of criteria of a good clinical practice are at least 25%. AIM: to set how well do we carry out the clinical management of patients with a stroke (ICV). SUBJECTS AND METHODS: With this revision, all the medical cards of patients with a stroke from Team of family medicine. The parameters used in the revision are values of indicators of a good clinical practice noted in the cards in last 5 months: blood pressure (BP) (targeted value <40/90 mmhg), total Cholesterol < 4,5 mmol/l), BMI, smoking status, counseling on quitting smoking, prescribed anticoagulant therapy, medical findings of CT and MRI. RESULTS: Out of 76 (4.06%), patients with ICV, the most are years old (55%). Values of BP in last 5 months were recorded in all patients, and the targeted value was achieved in 54 (72.98%) patients, the targeted values of total cholesterol had 28 (37.84%). Smoking status was recorded in 62 (82%) medical cards, 38 (6.28%) examinees are smokers. Conseling on quitting smoking were recorded in 7 medical cards. CT medical findings were recorded in 73 (99%) medical cards, and in all cards prescribed anticoagulant therapy was recorded. CONCLUSION: the Team is carrying out a good clinical practice of management of patients with ICV for more criterions, but and for criterion of quit smoking counseling we did not fulfill the indicator what can be seen on the quality. Po-3 RISC FACTORS FOR DEVELOPMENT OF DIABETIC RETINOPATHY E. RAMIC, A. BEGANLIC, 2 E. ALIBASIC, E. KARIC, S. SELMANOVIC, O. BATIC-MUJANOVIC Health Clinic Tuzla, Bosnia and Herzegovina 2 Health Clinic Kalesija, Bosnia and Herzegovina Background: Diabetic retinopathy is the most common micro-vascular complication of diabetes and one of the leading causes of blindness in the world. Duration of illness and long-term hyperglycemia are the most important risk factors for the development of diabetic retinopathy. Other risk factors are hypertension, hyperlipidemia, nephropathy, anemia, excessive body weight, pregnancy. Objective: To determine how many risk factors for the development of diabetic retinopathy have people who suffer from diabetes. Patients and Methods: 73 patients with diabetes mellitus and have been treated in family medicine centers in Simin Han, Health Center Tuzla, were examined. The data that were used as a risk factor are: the duration of diabetes mellitus, glycemic control method, high blood pressure, is blood sugar well regulated or varies, is there hyperlipidemia, time elapsed since the previous ophthalmological examination, smoker status. Results: interviewed persons are 39% men, 6% women. There were 27% of people who used insulin. High blood pressure has 55% of the respondents, 45% persons are obese, 65% women and 35% men. 33% of pa

177 tients have unsatisfactory blood glucose control. Hyperlipidemia is found in 53% of women and 29% of men. 55% of the respondents did not have ophthalmological examination in more than a year, 6% of respondents had no risk factor. Conclusion: The development of diabetic retinopathy can be slowed down, and the risk of diabetic blindness can be reduced if they reduce risk factors. The patient must know that there are risk factors to be avoided or reduced. Po-32 NON-CONTAGIOUS DISEASES AS CAUSE OF TEMPORARY INCAPABILITY FOR WORK L. DELEVIC Dept. of Family Medicine, Health Care Center, Bijelo Polje, Montenegro Temporary incapability for work we imply as every abnormal or sick condition of organism in which an employee is incapable for work at his workplace, and could appear as a consequence of an illness, injury, medical examination, care of ill family member and other reasons. The aim is to examine the connection between temporary incapability for work and non-contagious diseases. Materials and methods: the studied group consists of 235 employees of the Health-Care Center in Bijelo Polje. The analyzed period is from to Data sources: the reports of temporary incapability for work, record cards from the department for the health-care of working people, data from the personnel department. Method: epidemiological-retrospective. Results: Our results show that non-contagious diseases were the main cause of temporary incapability for work. Women are more often absent from work than men (80%:20%). The most frequent causes for absence from work are: pregnancy illnesses 20,3%, absence due to child care 7,5%, cardiovascular diseases 5,2% and mental disorders 2,7%%. The injuries at work as causes for absences from work are more frequent than other injuries (9,3%). 6,7 employees of the Health-Care Center were absent from work per day because of the sick leave. The rate of taking sick leave is 36,%. The number of lost working days per one sick leave is 48. The sick leave per employee is 7 days. Conclusion: Our results lead to the conclusion that the non-contagious diseases were the main or almost the only reason of temporary incapability for work. Po-33 DIABETES MELLITUS MONITORING REGISTERED PATIENTS FROM ASPECT OF PRIMARY HE- ALTH PROTECTION A. BAJRAMSPAHIC Dept. of Family Medicine, Health Care Center, Bijelo Polje, Montenegro Introduction: Diabetes mellitus is a set of metabolic irregularities that is characterized by significantly higher value of glucose in blood. Diabetes mellitus occurs due to the irregular secretion of insulin, its reduced activity or combination of the two factors. This illness reduces the quality of life, leads to many complications and increases mortality. Aim: To analyze the method of work in our ambulances with diabetic patients. Material and method: We used epidemiological-retrospective method. We used health data from chosen doctors at Health Center in Bijelo Polje. We analyzed the period to Results: Diabetes mellitus is diagnosed in 2 patients. Average age of our patients was 58 years, and compared to gender distribution, men amounted to 53.09%.The percentage of type 2 of diabetes mellitus was

178 72.5%. Average value of blood grlucose was 8.5mmol/l and HbAc was 6.3. Management of secondary complications points that it is necessary to pay more attention at controlling the complications of this disease. Patological analysis of urine: 76%, changes on ECG: 7%, fundoscopic changes-fou: 67%, examination of feet: 5%. Greatest number of our patients uses oral combination of 2 medicines (32%). Conclusion: Our results point to the importance of managing precise monitoring of patients with diabetes mellitus, early diagnostics and identification of persons with high risk of attaining such disease, modern therapy, prevention of complications of this disease and continuing education of health workers who work with diabetic patients. Po-34 ANTENATAL FOLLOW UP OF 00 WOMEN WHO GIVE BIRTH AT MINISTRY OF HEALTH,EGE TRAI- NING AND RESEARCH HOSPITAL OF OBSTETRICS & GYNECOLOGY S.H. KARAHAN, 2 K. ERTOPCU, T. GULEN, 2 C.E. TANER, 3 M. HELVACI, 2 A. TASYURT, 2 S. TINAR Dept. of Family Medicine, Ministry of Health Education and Research Hospital, Izmir, Turkey 2 Dept. of Gyn&Obstetrics, Ministry of Health Education and Research Izmir Ege Maternity and Obstetrics Hospital, Izmir, Turkey 3 Dept. of Pediatrics, Ministry of Health Education and Research Hospital Tepecik, Izmir, Turkey Aim: To determine the prenatal care usage of mother giving birth at the Ministry of Health, Ege Training and Research Hospital of Obstetrics and Gynecology and the influencing factors. Materials & Methods : Cross-sectional nature of this research in the Aegean Maternity and Women's Diseases Training and Research Hospital between January February 2008 within a month period 00 mothers who were giving birth. A questionnaire ; containing 25 questions about demographic characteristics, fertility characteristics, antenatal care of mothers was administered. Statistical analysis was done with SPSS 3.0. Findings: 72% of pregnant women were primary school graduates. 93% of pregnant women has been identified as not working.ultrasound at least once was made to 97% of pregnant women. Double and triple test were made to 46% of mothers. Tetanus vaccine ratio for pregnant women were 96%. Conclusions : Its found that the pregnant woman who have higher education level undergo double or triple test more than pregnants who have lower level of education and its found that the ratio of USG scanning and tetanus vaccination are less in pregnants who had lower income and checking for Hepatitis B is more common in women who have the first pregnancy or who have pregnancy intervals less than two years, than the women who have pregnancy intervals more than two years.the education level, the level of monthly income of family and the first pregnancy are important factors on the antenatal care

179 Po-38 COMPARISON OF DEMOGRAPHIC CHARACTERISTICS OF WOMEN WHO APPLIED FOR CONSUL- TING TO THE WOMEN APPLIED FOR ABORTION BECAUSE OF UNWANTED PREGNANCIES I.A. ERCAN, 2 K. ERTOPCU, S.H. KARAHAN, 2 Y. YILDIRIM, 3 A. DONMEZ, 4 G. SOP, 2 I. OZELMAS, 2 A. TASYURT Dept. of Family Medicine, Ministry of Health Education and Research Hospital, Izmir, Turkey 2 Dept. of Gyn&Obstetrics, Ministry of Health Education and Research Izmir Ege Maternity and Obstetrics Hospital, Izmir, Turkey 3 Dept. of Family Planning, Ministry of Health Education and Research Izmir Ege Maternity and Obstetrics Hospital, Izmir, Turkey 4 Dept. of Internal Medicine, Ministry of Health Education and Research Hospital, Izmir, Turkey Aim: To compare the patients who applied for uterine evacuation due to unwanted pregnancies to the ones applying only to prevent pregnancies who didn t have abortion because of unwanted pregnancies. Material & Methods: Between and The Ministry of Health Ege Maternity and Gynecology Family Planning Clinic study included women who admitted. We have reached the recordings like age, educational status, number of children, contraception methods they used within a year in both groups.both groups were selected after consulting contraception method were recorded. Demographic characteristics of patients and their chosen methods were compared retrospectively. Statistical evaluations were analyzed by SPSS 0.0 program. Findings: In the interval group 7083 patients, in postabortive group 8629 patients were evaluated. Demographic characteristics were analyzed according to the chosen method. Interval group admitted that they choose those methods; 4642 intrauterine device (IUD), 253 oral contraceptive (OC), 569 monthly injection, 492 threemonth injection, 28 condoms, 489 female surgical sterilization, 3 spouse vasectomy.in postabortive group, these rates were 097 for IUD, 3282 for OC and 386 month injection,42 three-month injection, 737 condoms, 489 female surgical sterilization, 30 spouse vasectomy. Conclusion: The differences and similarities were highlighted between the patients who applied for uterine evacuation due to unwanted pregnancies and the ones applying only to prevent pregnancies who didn t have abortion because of unwanted pregnancies. Po-39 COMPARISON OF DEMOGRAPHIC CHARACTERISTICS OF INTERVAL AND POSTABORTIVE TUBAL STERILIZATION (407 CASES) L. AKOGLU, 2 K. ERTOPCU, 3 B. TUNCAY, 4 A. DONMEZ, 2 I. OZELMAS, 5 M. HELVACI, 2 A. TASYURT Dept. of Family Medicine, Ministry of Health Education and Research Hospital, Izmir, Turkey 2 Dept. of Gyn&Obstetrics, Ministry of Health Education and Research Izmir Ege Maternity and Obstetrics Hospital, Izmir, Turkey 3 Dept. of General Practice, Ministry of Health Education and Research Hospital Tepecik, Izmir, Turkey 4 Dept. of Family Planning, Ministry of Health Education and Research Izmir Ege Maternity and Obstetrics Hospital, Izmir, Turkey 5 Dept. of Pediatrics, Ministry of Health Education and Research Hospital Tepecik, Izmir, Turkey Aim: To compare demographic characteristics between tubal sterilization in interval period and in post-abortive group. Materials and Methods : Between 99 and 998 demographic characteristics of women; who had surgical sterilization after abortion due to unwanted pregnancies and of whom applied to get a contraceptive method in interval period are compared.detailed individual counceling about all of the contraceptive methods and tubal

180 sterilization was given to both groups and their partners.mini laparatomy was performed as surgery.uterine evacuation method was performed for unwanted pregnancies. Age,education level,number of living children,number of abortions and last contraceptive method were determined as demographic features. Data was analyzed statistically by SPSS Objectives : 98 women in interval and 489 in post-abortive period were included in our study.49,23% of women in interval group was at the age of over 40 versus 46,2% in the post-abortive group.58,49% in interval group were primary school graduates versus 64,2% in the other group.women, had 3 or more children were 50,0% in interval group versus 63,07% in the other group.with the highest proportion of 6,43% women had no abortion in interval period group versus 5,2% in the post-abortive group.25,92% of interval group were using IUD (intrauterine device) for contraception and 45,60% of the post-abortive group were using coitus interruptus. Conclusion : According to demographic features mentioned above no significant difference was found among various characteristics in two groups. The table of main Demograhic Characteristics Po-40 MONITORING OF CARDIOVASCULAR RISK FACTORS AMONG PATIENTS WITH STROKE IN FAMILY MEDICINE PRACTICE O. BATIC-MUJANOVIC, 2 N. DAJANOVIC, 2 H. DEMIC, 3 L. GAVRAN, 4 M. BECAREVIC, 5 S. BISANOVIC, A. BEGANLIC, S. HERENDA, A. BRKOVIC, 6 M. HASANAGIC Family Medicine Teaching Centre, Health Centre Tuzla, Bosnia and Herzegovina 2 Family Medicine Department, Health Centre Tuzla, Bosnia and Herzegovina 3 Family Medicine Teaching Center, Health Center Zenica, Bosnia and Herzegovina 4 Department of Occupational Medicine, Health Centre Banovici, Bosnia and Herzegovina 5 Family Medicine Department, Health Centre Gradacac, Bosnia and Herzegovina 6 Family Medicine Department, Health Centre Mostar, Bosnia and Herzegovina Aim and purpose: Health promotion, disease prevention and the management of chronic uncommunicable diseases are the main goals in family medicine practice. The aim of this study was to assess the quality of care in patients with stroke provided by family medicine team through medical audit. Design&methods: This retrospective analysis included 05 medical records of patients with stroke treated by family medicine team 4 at Family Medicine Teaching Center Tuzla. Audit record form contained questions on sex, age, blood pressure, total cholesterol and triglyceride level, body mass index (BMI), blood glucose in patients with diabetes, smoking habits and family history. Results: We analyzed 99 medical records from team 4 and found that 05 patients (5,4%) had diagnosis of stroke: 64 women (60,95%) and 4 men (39,05%); P=0,005. Family medicine team showed poor compliance with established criteria of monitoring risk factors for stroke. Annual monitoring of blood pressure was recorded in 88 charts (83,8%), while 73 patients (69,52%) had total cholesterol and triglyceride level. Diabetes mellitus had 9 patients (8,%) with stroke and all of them had blood glucose level in their charts. BMI was recorded in 72 patients (68,57%), while no one had waist circumference. Smoking status had 87 patients (82,86%) and family history had 85 patients (80,95%). Conclusion: Results of this study showed a high prevalence of deficiencies in monitoring of cardiovascular

181 risk factors among patients with stroke in family medicine practice that indicates more effective intervention in primary health care in order to reduce cardiovascular morbidity and mortality. Po-4 PAP SMEAR- SCREENING AND KNOWLEDGE ABOUT IT A. BEGANLIC, S. HERENDA, E. RAMIC, O. BATIC-MUJANOVIC, A. BRKOVIC Family Medicine Teaching Center, Primary Health Care Center Tuzla, Bosnia and Herzegovina Introduction: In female population cervical cancer is the second prevalent and the third cause of all cancer deaths. In Bosnia and Herzegovina Pap smear test is done by gynecologists and incidence of this cancer is 33/ per year. Aim: To investigate how many of our female patients have had Pap smear in last year and to evaluate knowledge about reasons for doing this test. Method: Survey was run in Family Medicine Teaching Center Tuzla involving 40 female patients from 8-65 years. They were interviewed about last Pap smear and knowledge why it should be done in female population. Results: Our interviewed patients were 35 to 49 years (42%) and 33 (82.5%) of them had Pap smear in last year. Majority females (62.5%) knew that Pap smear screen cervical cancer. The most common reasons for not doing this test were: feeling uncomfortable (33%) or fear of result (6%). Among females who did not have Pap smear it was suggested to be provided either by family doctor (57.%) or by friends (28.6%). 92% of patients would like to do this test in family practice. Conclusion Majority of our female patients had Pap smear in last year but they still need education about importance of this screening test. Also, they would like Pap smear test to be performed in family practice by their family doctor. Po-42 TAKING PILLS DOESN T MEAN THAT YOU HAVE CONTROLLED BLOOD PRESSURE! V. ALEKSOV, 2 L. SUKRIEV, 3 D. ALEKSOV Al-medika, Macedonia 2 General practise, Military Hospital, Macedonia 3 General practise, Al-medika, Macedonia Aim: To show how much of the patients with hypertension already on medication has controlled blood pressure. Material and method: The data from 50 patients are analyzed during their regular examination at general practice. The blood pressure is taking after at least 5 minute rest. Hypertension is present minimum one year and all of them are taking therapy also minimum one year. Obtained results are classified by: gender, age, status of hypertension, the number of used medications and comorbidity. We use WHO 2007 classification of arterial blood pressure. Results: 84(56%) are male, 66(44%) are female. Controlled tension have 5(34%) and not controlled 99(66%) patients. High normal have 6(49% from normal tension). Grade one hypertension have 45(30% of all patients). Monotherapy is used in 53(35,33%), with two medications are 58(38,67%). The most used drugs are adenosin converting enzyme inhibitors 32(88%), calcium blockers 57(38%).Most used combination is just with these two medications, in nearly 40%. 36(24%) are with diabetes mellitus, and only 2(5,55%) patients have target tension-30/80mmhg. 8(54%) patients have at least one more disease what for they must use another drug that affect the hypertension regulation. With two disease comorbidity are 26(7,33%). Conclusion: 66% of the patients on medications for high blood pressure are not controlled. This correlate with world trends(60-70%) and only reminds us that this problem is a great challenge for doctors besides great variety of medications and new technologies

182 Po-43 FOCUSING TO UNKNOWN WITH EVIDENCE BASED MEDICINE IN PRIMARY CARE F. YUKSEL, B. PALA, M. UNALACAK Dept. of Family Medicine, Eskisehir Osmangazi University Medical Faculty, Eskisehir, Turkey Background: Lots of concepts emphasized and research articles published about how to reach the answer with strong evidence from the literature. This research and assessment concept became concrete with the new approach philosophy in recent years, called as the evidence based medicine. Hence, new website formats, types of journals and meetings appeared to make it easy to access to the necessary information for physicians. Aim: This evaluation study has been decided in order to support to the physicians in primary health care centers, based on the their reflection when they face with the computer at the floor of unknown; how to get the needed reliable, practically applicable and cost effective answers from the literature. Material and Methods: With this study, we assessed the literature about evidence based medical approach and computer based access to information study. We filtered the procedures of evidence based clinic practices and emerged practically applicable methods. Besides these, applied recent and reliable criteria for measuring the strength of the accessed evidence revealed. Conclusion: Assessment of updated knowledge and resources, selecting the applicable ones and overcoming these in a limited time in an intensive primary care practice would be progressively growing problem, unless physicians in primary care get educated about practical ways. So, education in evidence based practice should be take part in curriculum. Thus, research culture in primary care physicians would be improved too. Po-44 ALCOHOL CONSUMPTION BEHAVIOUR OF STUDENTS OF A HIGH SCHOOL IN A SOUTHERN CITY OF TURKEY E. SAATCI, D. ANTEPUZUMU, Y. INCECIK, O.OZMEN, N. BOZDEMIR Dept. of Family Medicine, Cukurova University Faculty of Medicine, Adana, Turkey Aim: To find out the prevalence of alcohol consumption behaviour and related factors in high school students. Material and Methods: All students (n=47) in a high school were included. A self-completed questionnaire with 26 items on demographic information and alcohol consumption behaviour was used. Data was analysed using statistical pocket program. Results: The response rate was 89.2%. Mean age was 6.04±0.92 years, 46.4% were male, 53.6% were female. Alcohol consumption behaviour was stated by 90 students out of 422 (2.3%). Of students, 2.2% (n=2) were every day drinkers,.% (n=) was frequent drinker (>2 times a week), and 96.7% (n=87) were social drinkers. The most preferred alcoholic beverage was beer (67.8%). Half of drinkers (53.2%) stated an alcohol consumption amount of <00 cc per time, 35.% stated an amount of cc and.7% >200 cc per time. The mean age of onset for alcohol consumption was 3.02±3.59 years (range: 5-7). Of students, 60% (n=54) declared that they did not drink alcohol during the last 30 days, 32.2% (n=29) drank -5 times and 7.8% (n=3) drank 6-0 times. Alcohol consumption behaviour was significantly related to father s occupation (p=0.000). Among risky behaviours, only carrying gun (p=0.005) and using illicit drugs (p=0.02) were significantly related to alcohol consumption behaviour of the student. Conclusion: Although alcohol consumption does not seem to be a major problem in adolescents living in Adana family physicians should provide consultancy on alcohol consumption and related risky behaviours. Text

183 Po-45 THE EVALUATION OF NUTRITIONAL HABITS OF HYPERTENSION PATIENTS A. PARLAK, U. AYDOGAN, A. DIKILILER, 2 K. SAGLAM Dept. of Family Medicine, Gulhane Military Medical Academy, Ankara, Turkey 2 Dept. of Internal Medicine, Gulhane Military Medical Academy, Ankara, Turkey Objective: This study is aimed to find out nutritional habits of patients with hypertension. Material and method: This study was performed using a questionnaire includes 5 questions interrogating nutritional habits. Results: The mean age of the patients was 54,22±5,43 (36-75) years. 52% (n=56) of the patients did not have any information about dietary cautions, 24% (n=72) of the patients declared that they are aware that they have to consume vegetables more, 22 % (n=48) of the patients thought vegetables and fruits have to take place as main courses in their diet, 2 % (n=6) of the patients stated that they have to stay away from salt. 42 % (n=26) of the patients had no idea how regular walking exercise affects BP whereas 52 % (n=56) thought it would detoriate the hypertension. Various BP measurement intervals practised by our patients; 0 % (n=30) of the patients measured once in three days, 4 % (n=2) once a week, 4 % (n=2) once a month, whereas 22% (n=66) not at all. 72% (n=26) of the patients were able to measure their BP themselves at home and 28% (n=84) were not. Conclusions: According to the results of the current study it can be argued that hypertension patients have not enough knowledge about how to regulate their diet and use other protective measures. It should be kept in mind that Family Physicians have much responsibility in terms of protecting the well-being of the society. Po-46 THE EVALUATION OF LIVER, KIDNEY AND THYROID FUNCTIONS OF NEWLY DIAGNOSED HYPER- TENSION PATIENTS A. PARLAK, U. AYDOGAN, S. MUTLU, K. SAGLAM Dept. of Family Medicine, Gulhane Military Medical Academy, Ankara, Turkey Objective: This study is aimed to evaluate the organ functions of newly diagnosed hypertension patients. Material and method: This study was performed with 28 patients including 5 newly diagnosed hypertensive patients consulted to internal medicine outpatient clinic and 03 healthy people with any diseases in sanitary controls as control group. Subject with diabetes and chronic renal failure were not included in study. Results: The mean age of the patients and control group was 52,44±,78 (40-65) and 50,45±9,5(39-6) respectively. T4 levels of patients and healthies were,37±0,43 and,27±0,34 and TSH levels were,72±0,79 and,93±,37 respectively. There were no statistically significant difference between two groups for two parameters (p=0,076, p=0,75). When ferritin values were analysed for both two groups, in hypertensive group 60,63 ±3,23 and in control group 59,64±5,45 (p=0,909). Folate values in hypertensive and control groups were 4,46±,92 and,78±6,98 (p=0,053). While Vitamin B-2 value was 238,8 ±3,4 in hypertensive group, it was 309,29±56,29 in control group and there was a statistically significant difference for these parameters (p<0,00). The urea, creatinine, AST and ALT values of patients are shown on table and there was only one significant difference between ALT values. Conclusions: At the end of this study, organ functions of hypertension patients without diabetes and chronic renal failure would have been evaluated at the time of diagnosis and it was understood that patients didnot have any health problems except their own diseases but they had to be followed up particularly

184 The blood parameters evaluated in patients and control group Po-47 THE EFFECT OF LABIAL FUSION ON CLINICAL OUTCOMES E. ALTUNBAS, 2 N. TEKIN, 3 I. KARATAS ERAY Mehmet Nurhan Kaynak Primary Health Care Center, Sincan, Ankara, Turkey 2 Narl dere Residental Nursing Home Care Facility, Izmir, Turkey 3 Department of Family Medicine, Bozok University Faculty of Medicine, Yozgat, Turkey Introduction: Labial fusion (LF) is a partial or complete central midline fusion of labium minora. It is the most common pediatric vulvovaginal disorders seen under six years. Generally it is asymptomatic. Lesions are related with local inflammation and hipoestrogenic condition. LF is one of the simplest treatable risk factors of urinary system disease. The purpose of this study was to determine the prevalence of LF in prepubertal children under 2 years old who admitted with different clinical diagnosis in our outpatient clinic. Material and Methods: The records of all patients aged month to 2 years seen at the outpatient clinic of Sincan Mehmet Nurhan Kaynak Health Care Center between 5th December 2009 and 5th February 200 were reviewed. Information on age, symptoms on admission and clinical diagnosis of each patient were recorded. Results: A total of 83 female patients aged to 24 months were seen during the 2-month period. Of these, 7 representing 8.4% of the total were diagnosed as LF. Mean age of the LF patients were 0.4±0.0 (range to 24) months. Four of seven admitted to the center with high fever, one with cough, one with constipation and one with irritability. Three of high fever patients were diagnosed as upper respiratory tract infection whereas the other was diagnosed as urinary infection. The others diagnosed as bronchiolitis, anal fissure and diaper dermatitis. Discussion: LF can be cause of recurrent vulvovaginitis, and urinary tract infections as a result of vagina full of urine. It is assigned that with treatment of one week usage of topical estrogen cream might be effective in more than 90% of the cases. Mechanical separation can be applied also. Labial fusion which is a rare bening disorder, can easily be diagnosed and treated in case of detailed physical examination made by clinician in different conditions. But once we have to check for it

185 Po-48 FOLLOW UP RESULTS OF CHRONIC IDIOPATHIC LOW BACK PAIN PATIENTS ACCORDING TO FA- MILY MEDICINE PRINCIPLES I. TANYILDIZI, V. MEVSIM Dept of Family Medicine, Dokuz Eylul University Medical Faculty, Izmir, Turkey Objective: The aim of this study was identifying the pain, physical disability, life quality and depression levels alteration with using approach of familiy medicine principles in chronic idiopathic low back pain (CIBP) patients for six months follow up period. Method: The study was finished with randomised 5 study and 5 control CIBP patients who were referred to department of physical treatment and rehabilitation. In study group, family medicine principles were applied, however in control group, no intervention were used. The alteration of life quality, depression, pain and physical disability of patients were evaluated by SF-36 life quality index, Beck depression inventory, visual analog scale and Oswestry disability index. SPSS.0 statistical program is used for data evaluation and descriptive analysis, chi-square, Wilcoxon T test and Mann-Whitney U tests. Results: In study group, the exercise adaptation (p=0.00) and decrease in pain scores (p=0.0) were higher than control group. Physical role limitations (p=0.03) and pain (p=0.00) subunits of life quality were significantly different in groups. There was no statistically difference in depression scores (p=0.24). Disability levels were significantly decreased (p=0.04) in study group. Conclusion: The result of this study show that the family medicine principles have been efficient in decreasing of pain severity, level of disability and efficient in increasing quality of physical life and exercise adaptation for CIBP patients. Po-49 AFFIRMATION OF PREVENTIVE PROGRAMS IN FAMILY MEDICINE R. AGIC, 2 A. BAJRAMSPAHIC Health Care Center, Bijelo Polje, Montenegro 2 Dept of Family Medicine, Health Care Center, Bijelo Polje, Montenegro Introduction: Chosen family doctor provides curative and preventive services to those insured. Specific illness is considered to be early diagnosed, when it is discovered before one spontaneously initiates in seeking services of the health sector. Aim: Analysis of preventive examinations. Results: Family doctor, who in the first six months does not accomplish 80% from the planned preventive examinations, will have his pay reduced by 0% for the duration of six following months. Program of health protection in 2009 deals with insured individuals who are older than 5, or 8.6% of all insured. Included in the same system of insurance are (4%) of those who are older than 65. Planned number of examinations is or 0.46 per insured. Health protection to insured who are older than 5 will be provided by 273 teams of chosen doctors who will be distributed based on density of populated areas (600 insurers for municipalities with lesser population density than 30 citizens per square km and 2000 insurers for other municipalities.) Discussion: Preventive examinations for matured are not shown in yearly statistics of the Institute for Public Health in years prior to reforming health protection and applying the model of chosen family doctor. Conclusion: Prior to reforms and application of chosen doctor model there were no preventive examinations conducted -preventive examinations are performed with high quality

186 Po-50 THE HEALTH CONDITION OF GERIATRIC PATIENTS IN PETROVAC ON THE SEA K. RASKOCIC, 2 M. VRANES-GRUJICIC, 3 L. DJUROVIC, 4 I. GALIC Dept. of Family Medicine, Primary Health Center Petrovac, Montenegro 2 Dept. of Occupational Medicine, Primary Health Center-Bar, Montenegro 3 Dept. of Family Medicine, Primary Healt Center-Podgorica, Montenegro 4 Dept. of Family Medicine, Primary Health Center-Bar, Montenegro Introduction: Our aim was to present the health condition of geriatric patients, the percentage of these patients in the owerall population treated by chosen doctor in Petrovac on the sea. Method: We have analysed the patients' cards. The total population included in this surway is 8 patients, of which 357 or 9,7% is older than 65. We have analysed the health condition data, main complaints, sex relations and general condition. Results: Most of the geriatric patients (357 or 9,7%) are over 80 years old i.e. 4 patient or 39,5%. There are 26% of 70 years old patients. There are 58,9% women and 4,% men. 9,8% of the patients are mobile while 8,2% are immobile. Most patients suffer from cardio-vascular problems mostly high blood pressure and artherosclerosis which presents 72 patients or 48%. Diabetes mellithus is found with 50 patiens or 4%, chronic obstructive pulmonary disease with 45 patients or 2,6% and degenerative diseases of bone-joint system with 40 patients or,2%. Conclusion: In our sample only 9,7% of patients were older than 65, which is suprisingly low number. Most of these patients are older than 80 (about 40%). The number of mobile patients is also very high ( 9,8%) and that is the result of previous way of living, influence of mediterranean climate and healthy diet, abscence of stress and better socio-economic status Po-52 FREQUENCY OF RECOCNIZED DEPRESSION IN ERDERLY PATIENTS A. SOFTIC-OMEROVIC, 2 J. EREIZ, 2 A. BEGANLIC Dept of Family Medicine, Primary Health Care Centre, Gracanica, Bosnia and Herzegovina 2 Dept of Family Medicine, Primary Health Care Centre, Tuzla, Bosnia and Herzegovina INTRODUCTION: Depression is on of the most common mental disorders of the modern age. Depressive disorders in general population on a high fourth illness. It represents the second most common female's health problem. Symptoms of depression are bad mood, indifference, apathy, anhedony, restlessness and irritabillity. According to the International Classification of Mental and Behavioral Disorders - ICD 0 depression may be described as mild, medium and serious. AIM: Examine the frequency of symptoms of unrecognized depression in elderly patients in the office of family practice. METODES: Testing conducted in Teaching centre of family medicine Tuzla, in the period from September to October Test used a sample of 50 respondents age grupe 60 and older. Used metod was random, but testing did not enter patients with a diagnosis of depression. Assessment of depression used Beck\'s questionnarre. RESULTS: Of the 50 subjects were 28 (56 %) female and 22 (44 %) male.of the 28 female subjects 3 (46,42 %) had mild, 2 (42,85 %)medium and 3 (0,7 %) serious degree of depresion. Of the 22 male subjects 2 (54,54 %) had mild, 9 (40,90 %) medium and (4,54 %) serious degree of depression. CONCLUSION: For all respondents faund depression different degree. It\'s unrecognizly depression, as a factor in excluding the earlier diagnosis of depression

187 Po-53 THE RELATIONSHIP BETWEEN HYPERTENSION AND SLEEP DISORDER IN CHILDREN AND ADO- LESCENTS R. PICAK, 2 M. BAYAT, M.M. MAZICIOGLU, 3 S. ISMAILOGULLARI, 4 S. KURTOGLU, 5 E. YILMAZ, D. YILDIZHAN, H.B. USTUNBAS Dept of Family Medicine, Erciyes University Medical Faculty, Kayseri, Turkey 2 Erciyes University, Ataturk Health Vocational College, Kayseri, Turkey 3 Dept of Neurology, Erciyes University Medical Faculty, Kayseri, Turkey 4 Dept of Paediatric Endocrinology, Erciyes University Medical Faculty, Kayseri, Turkey 5 Dept of Paediatrics, Erciyes University Medical Faculty, Kayseri, Turkey Introduction: It s shown that hypertension among children and adolescents is related with sleep disorders. Aim: The aim of this study is to determine the sleep disorders and related factors in 6-8 years old hypertensive children and adolescents. Method: We used DAMTCA II ( Determination of Antropometric Measurement in Turkish Children and Adolescents) study to determine the children whose blood pressure exceeds 95 percentile of their own age and gender are accepted as hypertensive. Pediatric Sleep Questionnaire (PSQ), the Children s Sleep Habits Questionnaire(CSHQ) will be used to determine sleep disorder in the children who are hypertensive. Results: A total of 2027 males and 2469 females were screened. The prevalence of high blood pressure for males were found to be as; 2 %,.7 %, and 2.3 % respectively for systolodiastolic, diastolic, and systolic. In females, systolodiastolic hypertensives were.2 %, systolic hypertensives were 2.6 %, and diastolic hpertensives were 3. %. Those children and adolescents who would found to be hypertensive would be evaluated for sleep disorder. Conclusion: In this study, we will try to find if hypertensive children or adolescents have coexisting sleep disorder. If such a relationship would be found than related factors will be evaluated. Po-54 FREQUENCY OF UNRECOGNIZED DEPRESSION IN ERDERLY PATIENTS A. SOFTIC-OMEROVIC, 2 J. EREIZ, 2 A. BEGANLIC Dept of Family Medicine, Primary Health Care Centre, Gracanica, Bosnia and Herzegovina 2 Dept of Family Medicine, Primary Health Care Centre, Tuzla, Bosnia and Herzegovina INTRODUCTION: Depression is on of the most common mental disorders of the modern age. Depressive disorders in general population on a high fourth illness. It represents the second most common female \'s health problem. Symptoms of depression are bad mood, indifference, apathy, anhedony, restlessness and irritabillity. According to the International Classification of Mental and Behavioral Disorders - ICD 0 depression may be described as mild, medium and serious. AIM: Examine the frequency of symptoms of unrecognized depression in elderly patients in the office of family practice. METHODS: Testing conducted in Teaching Centre of Family Medicine Tuzla, in the period from September to October Test used a sample of 50 respondents age group 60 and older. Used metod was random, but testing did not enter patients with a diagnosis of depression. Assessment of depression used Beck's questionnaire. RESULTS: Of the 50 subjects 28 were (56 %) female and 22 (44 %) male.of the 28 female subjects 3 (46,42 %) had mild, 2 (42,85 %) medium and 3 (0,7 %) serious degree of depresion. Of the 22 male subjects 2 (54,54 %) had mild, 9 (40,90 %) medium and (4,54 %) serious degree of depression. CONCLUSION: For all respondents different degree depression was found. It's unrecognized depression, as a factor in excluding the earlier diagnosis of depression

188 Po-55 THE USE OF TONOPEN APPLANATION TONOMETER IN HOME TREATMENT. T. PAVLOVIC, J. IVANCEVIC Opsta medicina, Dom Zdravlja, Leskovac, Serbia Introduction: The glaucoma green cataract is a harsh eye disease and one of the most frequent causes of blindness. A general practitioner should bear in mind in fifty people older than 40, one is prone to develop a glaucoma. In spite of all the efforts and technical progress, the disease has not been thoroughly explained. Aim. To show that by using the Tonopen applanation tonometer it is possible to diagnose glaucoma in home environment and to immobile patients, and then start with the treatment. Methodology: This research uses a survey questionnaire, an ophtalmoscope and a Tonopen applanation tonometer. Results: Case history: The patient R.M. is 83 years old. After she had suffered CVI in 999 the right part of her body remained paralysed. Further treatment was carried out by the Home Treatment Service. In May 2008 she suffered from splitting headaches in a part of her head and in the right eye. Examination without the ophtalmoscope discovered a grey nuclear cataract, which was later confirmed by the ophtalmoscope examination. Measuring the intraocular pressure we got the value of 44mmHg. for the right eye and 2mmHg for the left. The ophtamologist confirmed the secondary glaucoma diagnosis and the patient got an adequate teraphy. Conclusion: Thanks to the mobile Tonopen applanation tonometer, which can be used in the field, diagnosis was given without any difficulty and the pain which could not be removed with analgetics was released. Po-56 THE USE OF ANTIBIOTICS FOR RESPIRATORY TRACT INFECTIONS J. IVANCEVIC, T. PAVLOVIC Opsta medicina, Dom Zdravlja, Leskovac, Serbia Introduction: In order to treat rescpiratory tract infections with antibiotics in a rational manner, what is required are fair clinical estimate, familiarity with microbiological factors and the pharmacology of the medicine. Aim. To make evident that among patients there is a widespread practice of using antibiotics for respiratory tract infection treatment before they visit the doctor. Methodology: The data have been based on a survey questionnaire. The survey was carried out in the period between and in both village and town clinics. Results: The total number of eaminees was 0, 4 men (40.5 %) and 60 women (59.5%). Patients were between 9 and 8 years of age. 44 patients came from town and 57 from village. The number of patients who took antibiotics on their own initiative, without consulting their doctor, is 52, which makes 5.4% of the total number. It has been noted that the percentage of women who took antibiotics on thir own is larger (59.6%) than the percentage of men (40.3%). The most frequent groups of antibiotics used were penicillin (42.3%), then cephalosporin (26.9%), tetracyclic (3.4%), azithromicin (3.4%) and sulfonamides (3.8%). Before they contacted their doctor they had been usin antibiotics for -5 days. Conclusion: A great number of patients takes antibiotics on their own initiative because these are easy to get by. The task of primary medical care doctors is to teach their patients that the self use of antibiotics is not allowed

189 Po-57 ANXIETY AND DEPRESSION RELATED SOCIODEMOGRAPHIC FEATURES FOR DENTURED HEART FLAP PAT ENTS: PRELIMINARY STUDY Y. TURKER, K. ONGEL, 2 M. OZAYDIN Dept of Family Medicine, Suleyman Demirel University Medical Faculty, Isparta, Turkey 2 Dept of Cardiology, Suleyman Demirel University Medical Faculty, Isparta, Turkey Purpose: Previously surgery applied individuals consitute significant portion of the patients. According to the European Heart Survey, 28% of all patients who have heart valve disease are operated for heart valve surgery. Our aim was to determine sociodemographic features and their relation with depression and anxiety for the patients who were undergone prosthetic valve surgery. Material and method: This is a cross-sectional study which was planned for patients with prosthetic valve surgery who applied to Suleyman Demirel University Faculty of Medicine, Cardiology Policlinic between Prosthetic valve surgery assessment survey, hamilton assessment survey and Beck depression scale were applied. Results will be evaluated with SPSS.0 statistical programme. Results: Study was initiated on by applying questionnaires face to face. After obtaining informations, data were maintained with SPSS statistical programme and still evaluation of current data continues. Conclusion: Nowadays; mechanical prosthetic valves were widely used in the treatment of heart valve disease, to prolong life and promote life quality. Valve prosthesis patients need life-long policlinic controls with frequent intervals for INR detection and transthoracic echocardiography for follow-up. By the way; it is thought that these patients could have more complications due to their high prevalence of depression or anxiety. This study was estimated to be helpfull in the management of patients who have mechanical prosthetic valve. Po-58 OSTEOPOROSIS SCALE TO USE IN PRIMARY CARE SETTINGS: PRELIMINARY STUDY H. KAYACAN, K. ONGEL Dept of Family Medicine, Suleyman Demirel University Medical Faculty, Isparta, Turkey Aim: Osteoporosis is a metabolic bone disease characterized by decrease in bone mass and increase in bone fragility. Worldwide; osteoporosis is an important health problem because of the economical cost to society and the effects on the quality of life. It was aimed to create a scale that is related with risc factors, intended to identify patients with osteoporosis for primary care settings. Material-method: This descriptive, cross-sectional and case-control study was planned to be done in Suleyman Demirel University Faculty of Medicine, Nuclear Medicine and Family Medicine clinics in an eleven months period. During the study period; 8 patients who were admitted to the lumbar region-femoral bone mineral density measurements and has T-scores below -2.5 SD according to World Health Organization classification were evaluated as the case group. Equal number of patients who has femoral and lumbar bone mineral measurements with T scores above -,0 SD were admitted as control group. For the patients group and control group that were participated in the study; sociodemographic characteristics of the cases and risc factors for osteoporosis will be detected with a questionnaire. Results: By the review of the validity and reliability of a scale that can be used in primary care; it will be developed and attempted on a small sample. Conclusion: Scale to be obtained by measuring bone mineral in the diagnosis of osteoporosis will led us more cost-effective aproaches

190 Po-59 WHAT DOES THE INCREASE OF PSA MEANS FOR THE GENERAL PRACTITIONER? B. STOJANOVSKI, 2 V. GEORGIEV, 2 O. IVANOVSKI Dept of General Practice, Private Health Institution "Poliklinika Intermed", Skopje, Macedonia 2 University Clinic of Urology, Medical Faculty, University Ss Cyril and Methodius, Skopje, Macedonia Introduction: The introduction of prostate-specific antigen (PSA) for prostate cancer screening and detection has been used for over 20 years and has dramatically changed the face of prostate cancer. Although it is a highly sensitive serum test, its routine use has been the subject of continued controversy owing to its limited specificity. The aim of the present study is to evaluate the reasons for faus positive PSA results among men who present for the first time in the general medicine department. Patients and methods. PSA routine testing along with digital rectal examination and trans-abdominal prostate ultrasound has been performed in 203 men (mean age years). 24 among them (.25%) showed increase values of PSA ( ng/ml, referent value 0-4 ng/ml). All of them were treated with empiric fluoroquinolone antibiotic for 3 weeks. On the second control, only 3 patients (2.5%) showed constant increase of the PSA value ( ) and prostate biopsy was warranted. Conclusion: Our study is in agreement with the observation that men with a total PSA level greater than 0.0 ng/ml are at an increased risk for prostate cancer (more than a 67% chance, according to the American Cancer Society). Levels between 4.0 ng/ml and 0.0 ng/ml may indicate prostate cancer (about a 25% chance, according to the American Cancer Society), BPH, or prostatitis. These conditions are more common in the elderly, as is a general increase in PSA levels. Po-63 THE PREVALENCE OF CHRONICALLY NONCOMMUNICABLE DISEASES IN FAMILY PRACTICE TE- AMS IN CANTON TUZLA S. SELMANOVIC, A. BEGANLIC, S. SRABOVIC, M. MUJCINAGIC-VRABAC, 2 J. JASIC, 2 A. SOFTIC Dept of Family Practice, House of Public Health, Tuzla, Bosnia and Herzegovina 2 Dept of Family Practice, House of Public Health, Srebrenik, Bosnia and Herzegovina 3 Dept of Family Practice, House of Public Health, Granica, Bosnia and Herzegovina Introduction: Most of the registered patients in family practice teams (FPT) in Canton Tuzla (CT) have chronic noncommunicable diseases (CND). A great number of those patients are burdened with health care system in many ways. Aim: To determine the prevalence of leading CND with patients treated in family practice medicine in Canton Tuzla; by analysis of acquired results, to suggest the best possible model that will decrease the number of visits to the family practice office. Methods: Based on the crossectional study, information was being collected during three months period in the field. Representation of the whole canton was taken into consideration, so the collected information represents realistic situation in family practice. The acquired information were collected and analysed with analytic software. Results: 80 FPTs in CT were analysed (total of 37,956 patients). Prevalence of leading CND was analysed. The leading chronic disease (CD) is hypertension, of which 22.5% of patients are suffering. Next are: mental diseases with 5.86%, diabetes 5.85%, and ischemic heart disorder with 3 %. Strokes is involved with 2.6%, chronic obstructive disease.67%, and malign diseases with.36%. Conclusion. It is concerning that 42.85% of population registered in FPTs in CT are ill of 7 CNDs. Chronic patients are, because of the current health system, obliged to visit a doctor monthly to get a regular therapy, what is a burden for CNDs. A solution is to give a therapy to these patients for more than one month

191 Po-64 MODIFABLE CARDIOVASCULAR RISK FACTORS AMONG PATIENTS WITH STROKE IN FAMILY ME- DICINE PRACTICE O. BATIC-MUJANOVIC, 2 S. BISANOVIC, 3 L. GAVRAN, 4 E. RAMIC, 5 M. BECAREVIC, 6 E. ALIBASIC Family Medicine Teaching Center, Health Center, Tuzla, Bosnia and Herzegovina 2 Dept of Family Medicine, Health Center, Gradacac, Bosnia and Herzegovina 3 Family Medicine Teaching Center, Health Center, Zenica, Bosnia and Herzegovina 4 Dept of Family Medicine, Health Center, Tuzla, Bosnia and Herzegovina 5 Dept of Occupational Medicine, Health Center, Banovici, Bosnia and Herzegovina 6 Dept of Family Medicine, Health Center, Kalesija, Bosnia and Herzegovina Background/Aim: Extensive clinical and statistical studies have identified several factors that increase risk for stroke. Some of them can be modified, treated or controlled, and some can't. We evaluated the presence of modifable cardiovascular risk factors in patients with stroke related to gender. Design&methods: We analyzed 99 medical records from team 4 at Family Medicine Teaching Centre Tuzla and found that 05 patients (5,4%) had diagnosis of stroke. We evaluated presence of modifable cardiovascular risk factors: hyperlipidemia, hypertension, diabetes, smoking and obesity. Results: This trial included 05 patients with stroke: 64 women (60,95%) vs. 4 men (39,05%); p=0,005. Mean aged of participants was 68,24±7,69 years. High blood pressure was the most prevalent cardiovascular risk factor and 98 (93,33%) participants had hypertension: 57 women (58,6%) vs. 4 men (4,84); p= Hyperlipidemia was present in 89 (84.76%) participants: 54 (60,67%) women vs. 35 (39,33%) men; p=0,004. Diabetes mellitus had 9 (8,%) participants: 7 men and 2 women; p=0,74. We found that 2 patients (20%) were daily smokers: men (0,48%) and 0 women (9,52%); 7 (6,9%) patients were ex smokers: 8 men and 9 women; 49 (46,67%) patients had never smoked: 35 women (33.33%) vs. 4 men (3,33%); p=0,0396. Obesity was present in 33 (3,43%) patients: 26 women (24,76%) vs. 7 men (,4%); P=0,02). Conclusion: Results of this study showed a high prevalence of modifable risk factors for stroke, especially in women, that indicates more effective intervention in primary health care in order to reduce cardiovascular morbidity and mortality. Po-65 KNOWLEDGE AND ATTITUDES OF UNIVERSITY STUDENTS TOWARD PANDEMIC INFLUENZA: A CROSSSECTIONAL STUDY FROM TURKEY H. AKAN, 2 Y. GUROL, G. IZBIRAK, 3 S. OZDATLI, 2 G. YILMAZ, 4 A. VITRINEL, 5 O. HAYRAN Dept of Family Medicine, Yeditepe University Medical Faculty, Istanbul, Turkey 2 Dept of Microbiology and Clinical Microbiology, Yeditepe University Medical Faculty, Istanbul, Turkey 3 Yeditepe University Faculty of Pharmacy, Istanbul, Turkey 4 Dept of Pediatric Health and Diseases, Yeditepe University Medical Faculty, Istanbul, Turkey 5 Dept of Public Health, Yeditepe University Medical Faculty, Istanbul, Turkey BACKGROUND: In this study we aimed to examine university students knowledge about and attitudes toward the pandemic influenza A/ HN and vaccination. METHOD: A Cross-sectional, self-answered questionnaire survey was conducted among randomly chosen voluntary university students. RESULTS: Total 402 students of targeted 500 students, answered the questionnaire, 7 male and 23 female; mean age was ±2.90. The risk perception of HN was lower among males than females (p=0.004) and also was lower among the students of health sciences than the students attending other faculties (p=0.037)

192 But the risk perception was not significantly different between male and female students (p=0.058) of health sciences. The information sources of students were media (7.0%), internet (9.90%) and health personnel (8.00%). Students of health sciences used more internet as information source than the other students (p=0.05). The percentage of students not to be vaccinated against HN was 92.80%. The reasons were variable but mostly the students stated that the vaccination was not safe, unhealthy, and had a lot of side effects. Most of them believed that as a preventive measure hand washing, face mask or quarantina was effective. CONCLUSION: Among the university students, media is the most important source of information for HN pandemic. Although female students have higher risk perception than males, being acknowledged about the disease and health may eliminate this difference. All preventive measures were accepted well among university students, except vaccination. Po-69 LIFESTYLE FACTORS IMPACT ON FERTILITY E. ALIBASIC, 2 F. LJUCA, 3 D. LJUCA, 4 E. RAMIC, 4 O. BATIC-MUJANOVIC, 4 A. TULUMOVIC, 4 A. BE- GANLIC Dept of Family Medicine, Primary Health Care Center, Kalesija, Bosnia and Herzegovina 2 Dept of Physiology, University of Tuzla Faculty of Medicine, Tuzla, Bosnia and Herzegovina 3 Dept of Gynecology and Obstetrics, University Clinic Center, Tuzla, Bosnia and Herzegovina 4 Dept of Family Medicine, Primary Health Care Center and Polyclinics Dr. Mustafa Sehovic, Tuzla, Bosnia and Herzegovina Introduction: Potentially changeable factors including lifestyle, age, weight, smoking, diet, physical activity, psychological stress, alcohol, coffee, air pollution, adversely affecting both the general and reproductive health. Aims and purpose: To investigate the effects of lifestyle on fertility. Design and Methods: Retrospectively analyzed the impact of certain lifestyle factors on the outcome of infertility treatment in 3 of a total of 20 couples aged 8 to 39. The data on changing lifestyle factors as smoking, alcohol, physical activity, diet, body mass index (BMI), recorded in patient s documentation in the health care team of Family Medicine Health Center Kalesija, have been compared with data on the outcome of pharmacotherapy and/or surgery treatment of infertility. Information on the positive outcome of infertility treatment was information about conception and birth of healthy living child. Results: Parameters that differ in couples who have had a positive outcome of treatment from infertile couples are: BMI, lifestyle factors. 4 (30.7%) couples that are cured from infertility were non-smokers or former smokers aged 9-35 years of age, with BMI When infertile couples are analyzed, in 7 (53.8%) couples, women are active and long-time smokers, with a BMI of 28-32, and in 5 (38.4%) couples, men consume alcohol. Conclusions: Changing habits and ways of lifestyle can reduce the adverse effects on reproductive health. Continuous control of these risk factors on general health and fertility, is of great significance because it is noninvasive, the possibility of modification depends on the self-discipline and compliance of patients, and low cost

193 Representation of infertile couples among respondents Different BMI of recovering and infertile couples The difference between couples in relation to smoking - 9 -

194 Po-70 TREATMENT OF HYPOGLYCEMIC CONDITIONS AT THE EMERGENCY MEDICAL SERVICES OF THE CITY OF BELGRADE S. ZIVANOVIC, 2 D. STEVOVIC GOJGIC, 3 V. STEFANOVIC Dept of Emergency, EMS, Belgrade, Serbia 2 Dept of Eho, EMS, Belgrade, Serbia 3 Dept of Anestesia, KBC, Zvezdara, Serbia Hypoglycemic conditions are mostly caused by insulin or oral hypoglycemic drug use. Scope of study: is to show the frequency and causes of this condition as well as the way this is treated by the EMS Belgrade Method of study: One physician's retrospective analysis of his work at the EMS Belgrade in the period from to Results: In that period there were 79 cases of hypoglycemia with Glasgow coma scale scores from 3-5, out of which there were patients with hypoglycemia only and those with hypoglycemia and other conditions. There were hypoglycemic conditions caused by insulin use, caused by oral hypoglycemic drug use, and mixed. There were 6 patients with hypoglycemia only and 8 patients with hypoglycemia and other associated conditions. The treatment consisted in administering Glucose solution and, patients received other therapy, 5 patients were taken to hospital either because they had other associated conditions or illnesses, or because they were found in public places and there was nobody to observe their recovery (no family members there). Discussion and conclusion: EMS Belgrade treats these conditions in prehospital care, because these disorders happen suddenly and improve very quickly after the treatment. Patients that are taken to further hospital follow-up or observation are the ones with other associated illnesses or patients found in public places. Po-7 THE IMPACT OF SMOKING ON THE CHANGES IN THE ORAL CAVITY D. TRIFUNOVIC BALANOVIC Health Center Vozddovac, Belgrade, Serbia Smoking tobacco is one of the dependence diseases, but mainly it's a bad lifestyle habit. Objective: Overview of the representation of the smokers by sex, length of smoking, and the number of smoked cigarettes in the general population, with special emphasis on subjective problems and objective changes in the oral cavity, and the level of oral hygiene of active smokers. Methodology: The research included 7 patients, years. 7 of them agreed to answer questions on smoking, and to an exam of the oral cavity. We have registered subjective discomfort (data given by smokers), foetore ex ore and objective changes in the oral cavity. Results: From 7 examinees, 3% male, 69% female 45.3% are smokers. 67% are active smokers, aging from years, with over 20 cigarettes per day and an average length of a smoking of 32.8 years. Females smoke: 36%, aging from 35-44, with an average of -20 cigarettes per day and an average length of a smoking of 23.3 years. The most common symptom for smokers in the oral cavity is fetor ex ore (83%), taste disorder and mouth drying 20.7%, roughness of the oral mucous tissues (5%), tongue ache and sting (.3%).Objective findings in the oral cavity: inlay of the tongue (75.5%), discoloration of the teeth (73.6%), while xerostomia, opalescence of the oral mucous tissues, paradentopathia ulcer-necroticans is represented by 9.4%.Male smokers IOH = 75%, and female smokers 52%

195 Po-72 URINARY BLADDER FUNCTION IN MEN WITH DIABETES TYPE 2 E. ALIBASIC, 2 F. LJUCA, 3 D. LJUCA, 4 E. RAMIC, 4 O. BATIC-MUJANOVIC, 4 A. TULUMOVIC, 4 A. BEGANLIC Dept of Family Medicine, Primary Health Care Center, Kalesija, Bosnia and Herzegovina 2 Dept of Physiology, University of Tuzla Faculty of Medicine, Tuzla, Bosnia and Herzegovina 3 Dept of Gynecology and Obstetrics, University Clinic Center, Tuzla, Bosnia and Herzegovina 4 Dept of Family Medicine, Primary Health Care Center and Polyclinics Dr. Mustafa Sehovic, Tuzla, Bosnia and Herzegovina Introduction: Micro-vascular complications of diabetes in men damage urinary bladder function leading to changes in excitability detrusora and contractility damage, and myopathy appearance of urethral obstruction and irritation symptoms and other urological symptoms. Aims and purpose: To investigate the function of the urinary bladder, specific urological symptoms were analyzed in men with type 2 diabetes, comparing them with the symptoms of non-diabetics. Design and methods: During the in Health Care Kalesija several urological symptoms were analyzed in 34 men over the age of 50, diagnosed with type 2 diabetes and possible other accompanying diseases, including benign prostatic hypertrophy and/or urinary infection.the control group consisted of 32 men of similar age and comorbidity, except for diabetes mellitus type 2. Responses from a standardized questionnaire (International Prostate Symptom Score-IPSS) were used as urological symptoms for assessing urinary bladder function. Results: 8 men with diabetes responded that almost always have the majority of urological symptoms, and 6 of men with diabetes had symptoms or had them occasionally. From 8 men with diabetes who have almost always had symptoms, 3 men had a value of HbAc> 8%, and 5 the value of HbAc <8%. In the group of non-diabetics, 0 men almost always had the majority of urological symptoms, and 22 men had no symptoms, or they had them occasionally. Conclusions: In men with type 2 diabetes, urinary bladder function was significantly damaged compared to non-diabetics. Good glycemic control could reduce the risk of developing urinary bladder dysfunction in men with type 2 diabetes. Symptoms of men in relation to the presence of diabetes

196 Men with diabetes and present symptoms related to HbAc Predominant urological symptoms in men with diabetes Po-73 CORONARY ARTERY DISEASE(CAD), SOCIODEMOGRAPHIC FEATURES AND SEARCHING RISC FACTORS IN FAMILY A. PARLAK, H. AKBULUT, U. AYDOGAN, O. SARI, 2 C. BARCIN, K. SAGLAM Dept of Family Medicine, GATA-Gulhane Military Medical Academy, Ankara, Turkey 2 Dept of Cardiology, GATA-Gulhane Military Medical Academy, Ankara, Turkey Objective: In this study we wanted to investigate the possible diseases that play role at etiology in patients with CAD and existense of these diseases in their families. Material And Methods: This study is done in patients consulted to Cardiology Clinic in Age, body mass index, CAD patients parents and brothers existing diseases are investigated. Datas are analised by statistic programme. Result: 65 patients with CAD are included to the study. %29,2 (n=9) of patients were female, % 70,8 (n=46) were male. The avarage age of males and females were 57,73±3,43(9-79 age), 60,89±9,24 (40-79 age) years respectively. The body mass index of females was 27,36±4,08 kg/m2 and of males was 26,6±3,40 kg/m2. When patient s smoking stories is evaluated, %38,5(n=25) of patients did not smoke any more, %40(n=26) smoked but now they don t, %2,5(n=4) are still smoking. %49,2(n=32) of patients mothers did not have DM+HT+CAD, %6,9(n=) of patients mothers had CAD, %6,9(n=) of patients mothers had HT, %6,2(n=4) of patients mothers had DM. When their fathers diseases are investigated, in %60(n=39) DM+CAD+HT are not found, in %2,5(n=4) CAD is found, in %0,8(n=7) HT is found and in %,5(n=) DM is found. When their brothers diseases are investigated, in %49,2(n=32) DM+CAD+HT are not found, in %8,5(n=2) CAD is found, in %4,6(n=3) HT is found and in %0,8(n=7) DM is found. Conclusion: We understood that family physicians have to follow up patients children more carefully and closely with diseases DM, HT, CAD which have high rates of mortality and morbidity

197 Po-74 COMPARISION OF HIPOCALSEMIA FREQUENCY AFTER THYROIDECTEMIA IN BENING OR MA- LIGN THYROID CANCERS O. SARI, U. AYDOGAN, 2 H. DINCER, H. AKBULUT, S. KAVUK, K. SAGLAM Dept of Family Medicine, GATA-Gulhane Military Medical Academy, Ankara, Turkey 2 Dept of General Surgery, Erbaa Public Hospital, Tokat, Turkey Introduction: Hipocalcemia is one of the progressive complication after the operation of thyroid, threats the life, can couse a situation that demolish the quality of life even resultig death. In our study we compared the frequency of hipocalsemia after thyroidectemia in bening or malign cancers. Material And Method: 70 patients ( st group ) who have a thyroidectemia endication because of hyperthyroidea, retrosternal extend and multinoduler goitera and 50 patients ( 2 nd group ) have a malign diagnozis by thin needle aspiration byopsi were added to our study. The calsium levels of patients had been examined during two years periodicaly after the operation and compared with post operative calsium levels Results: Temporary hipocalsemia had been observed at 3 patients in first group and 4 patient in second group. Permanent hipocalsemia had been observed at one patient in both of groups. None of hipocalsemic patient were hyperthyroidic. There was no statistical diffirent between groups of patient about post operative hipocalsemia. Conclusion: Total hyperthyroidectemia may be applay to patient with appropriate endication. But they must be pursue nearly because of progressive hipocalsemia risk without looking at malignite situation. Po-75 PARAMETRIC CHANGES IN RDW AND MCV FOR RADIATION HEALTH EMPLOYEES PERIODIC INS- PECTIONS C. BOCUTOGLU, K. ONGEL Dept of Family Medicine, Suleyman Demirel University Medical Faculty, Isparta, Turkey Introduction: In this study, it was intended to show hematological parameter change in the blood test, in terms of RDW and MCV, for the radiology employees exposed to radiation with 6-month period. Material-method: The study was performed in the policlinic of Family Medicine in Suleyman Demirel University. 55 employees who were working in Radiodiagnostic and Nuclear Medicine Departments of the same university, were considered as the study group. Blood tests obtained from 55 employees within the 6-month intervals, in 2009, were carried out. The results were compared in SPSS statistical program with statistical t-test. Results: In the first period of 2009; avarage blood test levels for RDW and MCV were respectively, fl (min:63.40-max:96.40) and 3.29 % (min:.60-max:6.40). Whereas; in the second quarter of 2009, the control of blood analysis for MCV and RDW; respectively, fl (min:64.0-max:96.20) and 3:52% (min:.80- max:8.0). Between both periods, blood test comparison of the MCV values (p:0.5482) and RDW values (p:0.275) showed no significant relationship. Yet; in the first and second period, in the analysis of MCV and RDW values in themselves; a significant relationship was found between MCV and RDW values (p <0.000). Conclusion: Radiation exposure to the task under the control of health workers in the evaluation of blood tests, MCV and RDW values showed meaningful relationship. Whereas, during the follow check-up periods, MCV and RDW changes in direction did not reveal a significant relationship. Discussion: These findings show the need of MCV and RDW measurements in each periodic inspection for radiation health employees

198 Po-76 COMPARISON OF THE HAEMATOLOGIC PARAMETERS FOR THE DIAGNOSIS OF IRON DEFICI- ENCY ANEMIA BETWEEN PREGNANT AND NON-PREGNANT WOMEN C. BOCUTOGLU, K. ONGEL, 2 M. Tamer MUNGAN Dept of Family Medicine, Suleyman Demirel University Medical Faculty, Isparta, Turkey 2 Dept of Obstetric and Gynecology, Suleyman Demirel University Medical Faculty, Isparta, Turkey Introduction: This study was primarily planned to find out the efficacy of hematologic parameters for the diagnosis of iron deficiency anemia in pregnant women. Material method: This study was carried out in Suleyman Demirel University Faculty of Medicine Gynecology and Obstetrics Clinic between December February cases as the study group and 66 cases as the control group (total 3 patients) were included. To have diagnosed iron deficiency anemia and not using iron preparations were selected as the inclusion criterias. Results: The mean Hg, Htc, RDW, serum iron, serum iron binding capacity and ferritin levels for the patient group was found to be, respectively, 2.87 mg/dl, 36.23%, 4.43%, mg/dl, mg/dl, 2.68 ng/ml. Average Hg, Htc, RDW, serum iron, serum iron binding capacity and ferritin levels for the control group was found to be, respectively, 3.87 mg/dl, 39.24%, 3.6%, mg/dl, mg/dl, ng/ml. When the case and control groups were compared in terms of significance, Hg level (p<0.000), Htc level (p <0.000), RDW level (p:0.026) and serum iron (p:0.0440) were found statistical significance. Serum iron binding capacity (p:0.069) and ferritin level (p:0.342) did not reveal a significant relationship. Conclusion: In this study; Hg, Htc, RDW and serum iron level have proved to be feasible and reliable method for diagnosis of iron deficiency than iron binding capacity and serum ferritin levels. With these parameter values; for iron deficiency anemia in pregnant women, in early diagnosis, RDW parameter was found to have priority. Po-77 LONELINESS OF FAMILY PHYSICIANS: A PRELIMINARY STUDY N. KARAOGLU, 2 F. SIVRI Dept of Medical Education and Informatics, Selcuk University Meram Faculty of Medicine, Konya, Turkey 2 Dept of Family Medicine, Numune Education and Research Hospital, Konya, Turkey Aim: It is known that the survival of human depends on social abilities as communication and working with other individuals but approximately one third of people experience loneliness against this need. The wish to be lone and loneliness are defined as different situations while first one is a desired and the second is a undesired one with negative effects on mood and sociability. Family physicians are in a special position during residency and practice years and not much was known about their loneliness levels. The aim of this study was to compare loneliness of family physician with other specialties. Methods: In a group of doctors including family physicians and other specialties loneliness was assessed via questionnaire including 20-item R-UCLA scale which is a measure of general loneliness. Independent variables were also collected. Percentages, Chi-Square, Student t-test and one-way ANOVA analysis were used. Results: The participants were 0 physicians (77 male, 33 female) whose mean age was 3.7 ±6.07 years. Above half (n=59, 53.6%) were married and 87.3% (n=96) of all were residents. The loneliness levels of physicians were not different in respect to specialty, age, gender, civil status, career status and experience years (p>0.05). The mean loneliness level of physicians of other specialties and family physicians were 34.02±9.77 and 34.07±.25, respectively. Conclusion: The results of this preliminary study showed that family physicians were not lonelier than the physicians of other specialties

199 Po-79 MANAGEMENT OF PATIENT WITH CONSTIPATION COMPLAINT IN PRIMARY CARE M. KORKMAZ, F. YUKSEL, M.UNALACAK, I. UNLUOGLU Dept of Family Medicine, Eskisehir Osmangazi University Medical Faculty, Eskisehir, Turkey Background: Constipation is a common encountered symptom. That s a highly costing complaint as the result of prescribed medicines and admissions to health centers. In USA, more than 800 million dollars spent in a year for laxatives. In this country, every year 2,5 million people admitting to a physician with the complaint of constipation. Patients describe the constipation in several ways. Aim: The aim in our study is highlighting the importance of informing the patients about life style changes before medical treatment who admitted to hospital with the complaint of constipation, besides providing treatment algorithm by identifying the alarm symptoms and also highlighting the criteria of constipation. Material and Methods: In the study, description of constipation made by Rome III Diagnostic Criteria, Task Force Criteria and Bristol Stool Scale. In the light of current literature, management of patients with constipation reviewed and additionally the algorithms of WHO and North Devon Healthcare Trust given for daily use of physicians. Result: Management for constipation in between primary care physicians can be scattered in a wide range because of various descriptions of patients. Current studies and guidelines about patient oriented treatment standardization must be applied in clinic practice. It must be explained to patients with the constipation complaint in primary care, about the importance of the life style changes before the medical treatment. Patients with alarm symptoms must be identified and referred to secondary care. Current treatment algorithms must be taken into account in the treatment of patients. Po-83 SMOKING AS A RISK FACTOR IN GYPSY POPULATION T. PAVLOVIC, J. IVANCEVIC Opsta Medicina, Dom Zdravlja, Leskovac, Serbia Because of their way of life, noticeable cultural difference, their rejection and non-involvement in social spheres, smoking occurs as a mass phenomenon in Gypsy population. Aim of work: Showing to what extent smoking as the lead risk factor is present in Gypsy population on the territory of Leskovac community. Method of work: A survey questionnaire was used during the work. Results: The questioning included 55 Gypsies (07 women and 48 men) aged from 20 to 60 and older. It is concerning that 69% of those questioned smokes, i.e. 70% of the women and 66,6% of the men. The largest number of smokers is between 40 and 60 years of age, where 52% of those younger than 20 smokes as well as 45,7% of those over 20. What separates Gypsy population is that they start smoking very early, 74,7% of those questioned started before the age of 0. 45,7% of women and 25% of men smokers has got hypertension. Conclusion: It is obvious that smoking is highly present in Gypsy population, that they start smoking very early and that smoking is accompanied by other risk factors. Preventive examinations as well as health and educational work at all levels of health protection would surely lessen the number of those suffering from CV diseases

200 Po-84 THE EFFECT OF THYROID REPLACEMENT THERAPY TO LEVELS OF ANXIETY AND DEPRESSION IN SUBCLINICAL HYPOTHYROID PATIENTS M.Y. YARPUZ, U. AYDOGAN, O. SARI, 2 A. AYDOGDU, 2 G. UCKAYA, K. SAGLAM Dept of Family Medicine, GATA-Gulhane Military Medical Academy, Ankara, Turkey 2 Dept of Endocrinology, GATA-Gulhane Military Medical Academy, Ankara, Turkey Introduction and aim: In our study, we investigated that effectiveness of thyroxin replacement therapy and the levels of anxiety and depression in patients with subclinical hypothyroidisim. Method and material: Fresh diagnosed patients with subclinical hypothyroidisim and euthyroid control group with the same features were consisted of illustration of the study. Beck Anxiety and Beck Depression Scales were applied to participants. Levothyroxin therapy arrenged to patient group. Six weeks later thyroid hormones checked again. At the last of the study same psychologic scales were repeated. The obtained conclusions before and after therapy with sociodemogrphic features were enrolled to prepared pursuit form of patients. Findings: 66 patients were female and 8 patients were male, in control group there were 64 female and 8 male. Age average was 40,87±0,80 year in patients and 4,6±0,33 year in control group. In female group, there was a significant elevation (p<0,05) about both anxiety and depression according to control group. On depression scores in male patients, while a significant elevation has been found according to control group, no difference were found about to anxiety (p=0,88). In female group comparision of thyroid replacement therapy according to gender, a significant downfall were observed in both anxiety and depression scores after therapy (p<0,05). There wasn t any statistical difference in male (respectively p=0,68 and p=0,3). Conclusion: Subclinic hypothyroid related to Hashimoto thyroiditis may be risk factor for show up of anxiety and depression. Particularly thyroxin replacement therapy in subclinical hypothyroidism, may reduce anxiety and depression complaint. Po-85 DO THE FAMILY MEDICINE PRACTITIONERS TAKE CARE EQUALY OF PATIENTS WITH MENTAL DISORDERS? M. MUJCINAGIC-VRABAC, S. HERENDA, A. BEGANLIC, S. SELMANOVIC, O BATIC-MUJANOVIC, S. SRABOVIC Dept of Family Medicine, House of Health "Dr Mustafa Sehovic" Tuzla, Bosnia and Herzegovina Introduction: Family medicine practitioner is a person of the first contact for everyone who has a health issue, so persons with mental disorder too. In a team of family practice with patients registered, 4-3% are patients with mental disorders. Aim. To determine how well we take care of patients with mental disorders or do we those patients only send to psychiatrists. Do the registers of those patients consist all the essential information as the registers of the patients with other chronically noncommunicable diseases. Methods: Audit of the practice was done in 8 family practice teams in the area of the Municipality Tuzla. Data were collected retrospectively for 2008 and 2009 from health registers of patients suffering of schizophrenia, persistent delusional disorders, reaction to severe stress and adjustment disorders (The ICD-0 for Mental and Behavioural Disorders Diagnostic Criteria for Research: F20, F22 and F43). Data used in the study are blood pressure, body mass index, ECG description, laboratory findings and physical examinations. Results. Total of 203 patients in 8 family practice teams were analysed. It was found that in 79% of patients blood pressure was taken, in 74% BMI, in 44% ECG, physical examination in 76% and laboratory findings were recorded in 68% of patients. Conclusion: The aspect of a care for physical health of patients with mental disorder is not neglected. It is

201 required to improve the communication between family practitioners and patients with mental disorders, and to improve the prevention of chronically noncommunicable diseases. Po-86 RESEARCHING PSYCHOLOGICAL SYMPTOMS IN YOUNG ADOLESCENT MALES ACCORDING TO THE SYMPTOM CHECKLIST-90-R (SCL-90-R) H. AKBULUT, U. AYDOGAN, O. SARI, S. MUTLU, M. CELIKTEPE, K. SAGLAM Dept of Family Medicine, GATA-Gulhane Military Medical Academy, Ankara, Turkey Introduction: Adolescence in boys brings with it the onset of changes including sexual maturation, increased aggressiveness, responsibility, formation of one s own identity and trying to be socially accepted by one s peers. These changes can lead to psychiatric problems in some adolescents. In our study, we tried to determine the level of psychological symptoms in young adolescent boys and to determine the relationship between their demographic properties and the SCL-90-R. Method: SCL-90-R was applied to the participants of the study. The SCL-90-R consists of 90 questions related to psychological symptoms and complaints. Results: 3239 young adolescent boys participated in the study. The mean age of the participants was 9.5±.50 (9-32 years of age). The demographic data of the participants was examined to reveal that 0.7% (n=23) were illiterate, 96.7% (n=326) were single, 33.6% (n=073) had an income of 500 TL or under, 43.6% (n=403) lived in rural areas and 3.6% (n=438) smoked. Where the GSI was high there was a statistically significant increase in the number of smokers. There were no differences in the SCL-90-R results and the other demographic data. Conclusion: Stress encountered in our lives and psychological health, go hand in hand. It is important for adolescents to be able to deal with stress and to be equipped with the social skills necessary to communicate effectively in their social lives. Doing so will help them to have healthy relationships and to lead happy and balanced lives. Po-87 COMPARING DIFFERENT DEMOGRAPHIC DATA TO THE SPREAD OF SMOKING AMONG YOUNG ADOLESCENT MALES IN OUR COUNTRY U. AYDOGAN, O. SARI, H. AKBULUT, P. NERKIZ, O. GEVREK, K. SAGLAM Dept of Family Medicine, GATA-Gulhane Military Medical Academy, Ankara, Turkey Introduction: The most important factor in the smoking epidemic is the age at which smoking starts. Cigarette commercials, economic conditions, easy access to cigarettes, social circles and environmental factors and concerns over image can lead to smoking. Smoking is widespread in the world and plays an important role in etiopathogenesis. Materials and Method: In order for the study to be representative of a wider range of the population and in order to get a more general overview, young adolescent men from different regions in Turkey participated. Results: 3239 young adolescent men participated in the study. The mean age was 9.5± % had a history of smoking. Of these, 8.4%(n=595) smoked less than half a pack per day, 23.6%(n=764) smoked half a pack per day and.6%(n=52) smoked more than a pack per day. 80.7%(n=26) were elementary and high school graduates. Frequency of smoking in participants with higher levels of education was found to be statistically higher(p=0.005). About one third of the participants 32.7%(n=053) lived in rural areas. Frequency of smoking in participants who had a higher level of income and those who lived in the city were found to be statistically higher (p=0.000 and p=0.000 respectively). Conclusion: More than 80% of smokers started smoking before the age of 8. In some countries, the rate at which high school students experiment with smoking ranges from 70.4% to 78.0%

202 Po-88 COMORBID PSYCHIATRIC DISORDERS IN PATIENTS WITH SOMATIZATION DISORDER ACCOR- DING TO THE SYMPTOM CHECKLIST-90-R (SCL-90-R) O. SARI, U. AYDOGAN, H. AKBULUT, O. GEVREK, S. YUKSEL, K. SAGLAM Dept of Family Medicine, GATA-Gulhane Military Medical Academy, Ankara, Turkey Introduction: Somatization disorder can be easily mistaken for other medical disorders and is frequently encountered in polyclinics. Other disorders that are freqently seen in patients with somatization disorder included major depression (87.2%),panic disorder (44.9%),manic disorder (39.7%),phobias (38.5%),obsessive complusive disorder (26.9%) and skitzophrenia (26.9%). By administering SCL-90-R on our study group, we researched the frequency of other psychiatric disorders in patients with somatization disorder. Method: SCL-90-R was applied to the participants of the study. While keeping in mind their level of discomfort and irritability over the last three months, the participants were asked to answer 90 questions related to their psychological health. Results: 25 patients who yielded high values on the test indicating somatization were included in this study. The mean age of patients was 9.50 ±.29(9-25 years of age).45%(n=53) of patients had depression while 52.8%(n=65) of patients had signs indicating their anxiety levels were high. According to the index, of those patients who had depression,2(0.3%) of them had conditions that were severe while of those patients who had anxiety,8(8.%) of them had conditions that were severe.48.7%(n=59) of patients were obsessive,53.8%(n=65) were nonreceptive,55.6%(n=69) were aggressive,3.%(n=38) had a phobia,32.8%(n=4) had psychosis and 58.%(n=72) had sleep and appetitie disorders that were severe. Conclusion: Bearing in mind the complexity of somatization disorder, the difficulty in diagnosing the disorder and the fact that patients may have other underlying disorders, physicians must have a multidisiplinary approach when diagnosing and treating these patients Po-90 DETAILED ANALYSIS OF GERIATRIC PATIENTS VISITING THE EMERGENCY ROOM T. TAYMAZ Dept of Emergency, Istanbul American Hospital, Istanbul, Turkey Detailed analysis of geriatric patients visiting the emergency room Clinicians should devote more time to evaluating geriatric patients because of their age-specific features. In Turkey, the population above 65, which constitutes 7% of the overall population, is expected to rise to 2% in ten years. Geriatric population requires multi-disciplinary approach. Materials and Methods: Between January and May, 2009, 8,569 adult patients were seen in emergency service of our hospital. Out of these,,08 were hospitalized. Out of the latter, 36 were aged 65 and above. Out of the latter, 32 were cases of fall. Age,stay duration in the emergency, comorbidities,medicine they used,departments they hospitalized to, durations of hospitalization, fall cases on hospitalized patients were recorded and analyzed by Medcalc, a statistical program. Results: The average age of the above 65 patients was 78.26±7.24. From the point of comorbidity, the following was observed: %56 hypertension, %54 ischemic and/or other heart diseases, %23 diabetes, %2orthopedic,%3 neurologic diseaes... A geriatric patient was observed to have 2.95 comorbidity on average. The medicine they used:antiagregans:%54,acei/arb:%49,beta Blockers:%34,CalciumChannelBlockers:%32, Diuretics:%3, OAD/Insulin:%4,Antilipids:%4,respiratorial system medicine%28. Geriatric patients had on average 4.67 medicines. The duration of inpatient stay; for geriatric patients was5.74±0.47for geriatric patients with fall cases was 0.5±2.7and3.35±0.5 for non-geriatric patients(p<0.000)

203 Conclusion: One third of hospitalized patients were above theage of 65. When analyzing cases, we noticed comorbidity and multiple drug use. Detailed anamnesis and questioning of drugs used will favorably affect our diagnosis and treatment of geriatric patients Po-9 THE CHARACTERISTIC OF MORBIDITY IN THE ELDERLY AREA MUNICIPALITIES SM.PALANKA D. NIKOLIC, G. COSIC, S. MAJSTOROVIC Smed. Palanka, Dom Zdravlja, Serbia Aging is inevitable biological process whose beginning can not always be exactly determined, but there is a view that begins with the age of sixty fifth year. The aim of the research came down to examine the structure of morbidity in the old categories of population Sm.Palanci to customize our work to establish. Used a survey which included 82 respondents aged over 65 years, from the town and village. Note that most of the city suffering from myocardial insufficiency 50.4%, 49.6% hypertension, peripheral circulatory disorder 40%, rheumatism 38.7%, 3.9% diabetes mellitus renal diseases 2.4%, chronic bronchitis.6 %, 5.4% of tumors. The old village most affected by rheumatism 90.5%, peripheral disorder circulation 88.6%, hypertension 83%, heart disease 67.9%, chronic bronchitis 26.4%. Results show that people from the village poor health it is necessary to performing systematic reviews of elderly patients to early detection and treatment of these diseases. Po-92 INCIDENCE OF OBESITY AND GROWTH RETARDATION IN CHILDREN IN THREE DIFFERENT REGI- ONS OF TURKEY T. TAYMAZ, 2 N. MEMIOGLU, 2 S.M. KAYIRAN, 3 B. TAYMAZ Dept of Emergency Service, Istanbul American Hospital, Istanbul, Turkey 2 Pediatry Clinic, Istanbul American Hospital, Istanbul, Turkey 3 Dept of Anthropology, Yeditepe University, Istanbul, Turkey Purpose: To explore the incidence of obesity and growth retardation in three different regions of Turkey that exhibit different socioeconomic, geographical and cultural demographics. Materials and Method: This study was conducted in villages of I d r, Turkey s most eastern province, in the isolated periphery villages of Turkey s largest city, Istanbul, and at an elementary school in the district of Göcek, Mu la, southwestern Turkey. The height and weight of 208 children, ages 5-4, were measured to obtain body mass index (BMI). Obesity and growth retardation percentages were determined on the basis of official reference figures for Turkish children. Results were evaluated using the Medcalc statistical program. Findings: Evaluated by regions, BMI values indicated incidences of % in obesity, % in overweight and % in growth retardation. Distinctly significant differences were found in obesity rates and growth retardation between regions. Results: The study found that there were regional and cultural differences in the incidence of obesity and growth retardation in Turkish children. The number of obese and overweight children was seen to be higher in the southern region of Turkey, Growth retardation was more markedly seen in the east, in regions of the country exhibiting the features of a closed society and in particular, an aversion to contraception. The results suggest that environmental,cultural and economic factors rather than genetics have more of an impact on the development of obesity and growth retardation. Findings were shared with local administrations to ensure that children who needed guidance would be monitored at the appropriate medical centers

204 scanned regions Po-93 THE ELECTRONIC PRESCRIPTION (OUR EXPERIENCE IN 2009) S. SIMOVIC, O. KNEZEVIC, S. MARKOVIC Control Department, Health Insurance Fund, Podgorica, Montenegro Introduction: The application for Chosen Medical Practitioners have started applied since January,, 2009 in Montenegro as important part of project The Informatic support in reform of primary health care system (PHC). This application also enable prescribing therapy on electronic prescription.the main goal of this analysis is to determinate the dynamic of implementation of application by monitoring the number of contacts and number of prescribed prescription and relationship between number of contacts and number of prescribed prescriptions in Method: According to relevant datas from Informatic Technology sector of Health Insurance Fund of Montenegro this analysis includes 8 Health Centers with 262 Chosen Medical Practitioners for adults, 99 Chosen Medical Practitioners for children and 42 Chosen Medical Practitioners for women who were prescribing prescriptions during Results: prescriptions were prescribed in 8 Health Centers during 2009 which total value is ,24?. Aproximately,.09 prescriptions were prescribed during medical examination of one insured person which average value was 5.97?. In total electronic prescriptions were prescribed aproximately.06 prescriptions for one insured person. Conclusion: The beginning of presciribing electronic prescription is so well accepted that whole doctor s medical evidence, presciribing prescriptions and its realization in pharmacy are electronic. Po-97 HEALTHY EATING IN OLD INDIVIDUALS AND SOME RECOMMENDATIONS ABOUT MICROELE- MENTS V. MADJOVA, 2 V. TODOROVA, 3 L. SAVOV Dept of Family Medicine, Varna Medical University, Varna, Bulgaria 2 Medical College, Varna Medical University, Varna, Bulgaria 3 Dept of Internal Diseases, Varna Medical University, Varna, Bulgaria Introduction: Ageing is a global problem and WHO prognosis is 37% of European population will be over 60 years in % Óf Bulgarian population are pensioners nd 7% over 65 years. Physical, psychical and social changes in ageing are natural process, but nation s ageing put the question for specific health eating. Old people are more affected by unbalanced eating, initial and moderate deficits of organic and non-organic substances minerals and microelements. Many obstacles lead to deficiency even in healthy old people: economic restrictions, difficulties in exercise and food supply, chewing problems and alienation. Aim of the study: assessment of plasma and intraerythrocyte levels of Mg, Zn and Cu in healthy old individuals over 80 years

205 Methods and patients: Mg, Zn and Cu measurements by atomic-absorbent spectrophotometer ÄÄ-3030 Ç Perkin Elmer in healthy individuals over 80 years and a control group of healthy. Results and discussion: We found normal plasma and intraerythrocyte levels of Mg in healthy old individuals and difference in Cu - higher plasma level and significantly lower intraerythrocyte in the group years in comparison with controls. Zn also differs: plasma level is normal with a slight lowering tendency and intraerythrocyte - significantly lower in both groups in comparison with controls. Conclusions: intraerythrocyte microelement levels are more informative for their actual status. We found Cu and Zn deficiency in healthy old individuals and for their multifunctional effects in ageing processes, we recommend a diet, rich in Cu and Zn and nutritional supplies even in lack of disease. Po-98 EXOPHTALMIA REFERENCES OF TURKISH CHILDREN AGED 6-8 YEARS T. KARA, 2 S. KURTOGLU, M.M. MAZICIOGLU, 3 A. OZTURK, M. OZDOGRU, H.B. USTUNBAS Dept of Family Medicine, Erciyes University Medical Faculty, Erciyes, Turkey 2 Dept of Paediatric Endocrinology, Erciyes University Medical Faculty, Erciyes, Turkey 3 Dept of Biostatistics, Erciyes University, Erciyes, Turkey Purpose: To produce age and gender specific exophthalmia references for Turkish children aged 6-8 years old. Methods: This is a cross-sectional study. Data were obtained from the second study of the Determination of Anthropometric Measurements of Turkish Children and Adolescents (DAMTCA II).The study population was 456 primary and secondary school students aged 6 to 8 years (2525 girls, 2036 boys). Hertel exophthalmometer was used and age and gender specific standard deviations (SD) and percentiles were calculated for eye protrusion. Results: The 3rd, 5th, 0 th, 25 th, 50 th, 75 th, 80 th, 85 th, 90 th, 95 th, 97 th percentiles of right and left eye protrusion, the mean and SD for each age and gender was calculated. Difference between right and left eye was statistically significant looking at total data. Protrusion difference between right eye of the girls and boys was statistically significant. Protrusion difference between left eye of the girls and boys was statistically significant either. In both gender the protrusion difference between right and left eye were statistically significant. Exopthalmometric measurements were compared for pubertal periods by one-way analysis of variance and a significant difference for eye protrusion was found between pubertal periods for both eyes of girls and boys. Conclusions: Age and gender specific references for exophthalmia provides information both for clinical decision process and screening in describing abnormal or pathological conditions resulting with exophtalmos. This study provides the first exophtalmia references for Turkish children and most comprehensive data so far in the world. Figure. Comparison of right and left eye protrusion

206 Measurement with Hertel exophthalmometer Po-99 ULTRASOUND IN THE WORK OF A GP/FAMILY DOCTOR MY EXPERIENCE B. SEVO-ALEKSIC Dept of General Practice, DZ Zemun Health Centre, Belgrade, Serbia Introduction: As a consultant with the prior knowledge of the ultrasound diagnostic and examination techniques,for more than four years I used to spend a certain period of my hours working on the abdomen diseases ultrasound diagnosis.i want to point out the importance of the opportunity I was offered-to be able to give the diagnosis to the patient as a family doctor. Goal: I wanted to emphasise only a few of the key moments from my vast professional experience in the work on the abdomen diseases ultrasound diagnosis at the Zemun Health Centre ultrasound office.i am going to mention only a few examples of the patients I examined and diagnosed with something unexpected and unusual,that is,diagnoses which are mostly unavailable to the ultrasound diagnostics or which can seldom be given because they entail other diagnostic methods. Method: The retrospective-analytical study with the insight into the protocols of the examined patients at the Zemun Health Centre ultrasound office during the period I worked in the office and examined them there. Results: Some of these patients I would like to mention in this paper are of the utter importance to me for I contributed to their successful treatment in the way I gave the right diagnosis after a long period of time they had lost looking for the right diagnosis.in some other cases I recall as very important and inspiring, I put those where I gave the most unexpected diagnoses for the alternatives the ultrasound device offers. These are two male patients between 50 and 60 years of age I almost certainly diagnosed with the colon malign tumor. Nevertheless,they came with obscure symptoms and the clinic picture was implausible and my result interpreted as a daring one,additional diagnostic procedures confirmed my diagnoses and the patients were properly hospitalized.one more,almost unavailable diagnosis for the ultrasound device (especially for those performances that my device possesses) is the acute appendicitis. I diagnosed a man aged 49. I sent him as an urgent to the appropriate surgical institution where they suspected my diagnosis and spent 2 days exposing him to the unnecessary procedures which only confirmed my diagnosis. Conclusion: The ultrasound diagnostics is a non-invasive,available,elegant,comfortable and very reliable diagnostic method both for a doctor and a patient.as such,it should be used in every day work of a family doctorgeneral practicioner as an ordinary diagnostic method.and not only for abdominal organs diseases,but also for the thyroid and soft neck tissues

207 Po-00 HEALTHCARE AND PATIENT MANAGEMENT IN OUT-OF-OFFICE HOURS IN GENERAL PRACTICE A. ZABUNOV, V. MADJOVA, P. MANCHEVA, S. HRISTOVA Dept of Family Medicine, Varna Medical University, Varna, Bulgaria Introduction: Since 2000 the major criterion for good medical practice is the patient s evaluation of the healthcares provided by general practitioners. Out-of-office hours round the clock healthcare is still a problem in Bulgaria, especially in distant urban and rural regions. Objective and method: To study patients opinion about the quality of overall healthcare by an anonymous inquiry among 250 patients in 30 GP practices in Varna region, North-eastern Bulgaria for 0 months. We analyze patients satisfaction and their problems with the overall and out-of-office hours healthcare services using the 5-degree scale. Results: 78% of all estimated are very much satisfied with the opportunity to have a round the clock chance to consult their GP, including a telephone consultation, for a proper definition of the medical problem and an adequate decision making. Differences in satisfaction relate to specific characteristics of GP practice: type, number of patients and medical team. Conclusions: Good management of general practice requires a number of predisposing factors, most of them lacking for the time being. Despite current problems, a high level of satisfaction declare patients with GPs, showing good communication skills and attitude, even in cases of telephone consultations, and despite their prior expectations for an office consultation or a home visit. Patients management is a substantial point in running a GP practice. Relating traditions are still not available in Bulgaria and developing good communication skills for managing difficult patients is the proper approach, especially in practices with a prevailing part of elderly and chronically ill patients. Po-0 QUALITY OF LIFE EVALUATION IN PATIENTS WITH OSTEOARTHROSIS IN PRIMARY HEALTHCARE S. HRISTOVA, V. MADJOVA, A. ZABUNOV, P. MANCHEVA Dept of Family Medicine, Varna Medical University, Varna, Bulgaria Introduction: Advance in medicine results in life-expectancy increase and hence the number of people living with at least one chronic disease, affecting negatively their health and quality of life. Osteoarthrosis /OA/ and accompaning pain is the frequent reason to visit the general practitioner. Objective: Assessing quality of life in a cohort of symptomatic OA patients, consulted by their GPs, as well as the frequent OA co-morbidity. Method: A survey was carried out among 80, randomly selected OA patients from several GP practices in Varna, using VAS pain evaluation scale, HAQ quality of life questionnaire, EQ-5D health survey and WOMAC index statistically processed. Results: OA affects both sexes, but differs in localization - OA of the knee is more typical for women, while the hip joint is more vulnerable in men. Half of the patients were overweight or obese and practically all of them manifested at least one additional illness like hypertension and diabetes. Significant negative correlation between age and physical activity was observed, corresponding with the additional deterioration of their quality of life. Conclusion: OA patients indicate significant worsening of the quality of life due to chronic pain and disability. Depression and obesity are relatively more frequently observed. Chronic pain and OA s accompaning diseases motivate patients to visit the GP more often. Having knowledge of the particular problems, GPs could change for better their physical and mental health and the corresponding quality of life using the individual, patient-oriented approach, addressing not only the pain, but also the additional diseases

208 Po-02 ASSESSMENT OF THE PREDICTIVE VALUE OF OBESITY MARKERS FOR THE DIAGNOSIS OF META- BOLIC SYNDROME IN GENERAL PRACTICE D. VANKOVA, 2 D. GEROVA, D. IVANOVA, 2 S. TOMCHEVA, 2 V. MADJOVA Dept of Biochemistry, Molecular Medicine and Nutrigenomics, Varna Medical University, Varna, Bulgaria 2 Dept of Family Medicine and Clinical Laboratory, Varna Medical University, Varna, Bulgaria Obesity is a well known risk factor for the development of metabolic syndrome and could be assessed either by BMI or waist circumference. The aim of the present study was to assess which of the two markers of obesity had a greater predictive value for the diagnosis of metabolic syndrome in patients visiting general practitioners in the region of Varna, Bulgaria. A preliminary screening of seven markers of metabolic syndrome (waist circumference, BMI, triglycerides, HDL cholesterol, total cholesterol, glucose, blood pressure) was carried out in a group of 94 volunteers. The predictive value of waist circumference and BMI for the development of metabolic syndrome in accordance with the criteria published in the most recent joint scientific statement of International Diabetes Federation Task Force on Epidemiology and Prevention, National Heart, Lung, and Blood Institute, American Heart Association, World Heart Federation, International Atherosclerosis Society and International Association for the Study of Obesity was assessed. In women BMI > 25 and waist circumference > 80cm significantly correlated with elevated triglycerides, HDL cholesterol, glucose and blood pressure, while for men waist circumference > 94cm was a better discriminating criteria for metabolic syndrome as compared to BMI > 25. Po-03 CONSULTING PATIENTS WITH CHRONIC MENTAL DISEASE IN GENERAL PRACTICE - INDISPEN- SABLE PART OF THEIR PSYCHO-SOCIAL REHABILITATION P. MANCHEVA, V. MADJOVA, A. ZABUNOV, S. HRISTOVA Dept of Family Medicine, Varna Medical University, Varna, Bulgaria Abstract: Patients with chronic mental disease (CMD) represent a substantial problem in general practice in Bulgaria, because of the hampered psycho-social rehabilitation of the resulting disability. The healthcare reform still does not offer sufficient number of institutions for outpatient care, rehabilitation and social integration for patients with CMD. The problem deteriorates because of the lack of elaborated programs for giving psychological, emotional, financial and information support. Thus the patients are long-term dependant on various health and social services and still pose a heavy burden for their families and GPs. Psychological consulting as a form of short-term psycho-therapy, enables the family physicians with a team of psychiatrists to help in resolving these problems

209 Po-04 FAMILY PHYSICIANS PERSPECTIVES ON IDENTIFYING THE PATIENTS FOR PALLIATIVE CARE - A STUDY AMONG BULGARIAN GPS G. FOREVA, R. ASSENOVA, 2 V. MADJOVA Dept of Health Management, Economics and General Medicine, Plovdiv Medical University, Bulgaria 2 Dept of Family Medicine, Varna Medical University, Varna, Bulgaria Introduction: Palliative care (WHO, 2002) is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through prevention and relief of suffering by means of early identification and impeccable assessment, treatment of pain and other physical, psychosocial and spiritual problems. Because of the close relationship between GPs with patients, they are in unique position to provide palliative care. The aim of the study was to explore the indicators used by GPs to assess the patients for palliative care. Methods: A questionnaire survey was used and data were processing with statistical package SPSS The participants were 2,7% certificated GPs; 4,7% therapeutists or pediatricians and 45,6% in GP vocational training. Results: Almost? GPs provided care for over a ten palliative patients /yearly. GPs selected three criteria on identifying the patients for palliative care diagnosis (90,6%); symptoms, independent of it (83,7%) and time prognosis (79,5%) and 75% of them combined the criteria. Diagnostic related indicators were cancer with metastases (50%), CHF - NYHA III and IV (40,4%) and COPD (7,3%). The lead symptoms were pain (7,7%) and cachexia (53,3%). Almost? of the respondents selected one-year life expectancy indicator as a time prognostic criterion. Conclusion: Bulgarian family physicians perspectives on identifying patients for palliative care correspond to the current tendencies in providing palliative care: enlarging diagnostic criteria beyond cancer; reducing unnecessary suffering and applying palliative care approach in the early stage of the disease. Po-05 PSYCHOLOGICAL CO-MORBIDITIES IN OBESE CHILDREN R. ASSENOVA, G. FOREVA, 2 V. MADJOVA Dept of Health Management, Economics and General Medicine, Plovdiv Medical University, Bulgaria 2 Dept of Family Medicine, Varna Medical University, Varna, Bulgaria Background: The incidence of childhood obesity is rapidly rising thus obesity related co-morbidities are increasing in general practice, too. These diseases do not have immediate impact on the health of obese children, but also significantly increase the risk of morbidities in adulthood. Psychological and social consequences are prevalent but often overlooked. Children s obesity is not an individual child s problem, but a problem that involves the whole family and the community and GPs have a very important role in promoting preventive measures, identifying and treating obesity related psychological complication and co-morbidities. Aim: The study presents the prevalence, the different aspects of psychological co-morbidities in obese children and the general practitioners involvement in the assessment. Methods: PubMed, Embase, SCOPUS, ISI Web of Knowledge, ScienceDirect search for research and review papers on psychological complications of childhood obesity was performed for 5 years. Results: Psychological consequences in obese children are not established to the same degree as those connected with medical complications and co-morbidities. The relation between obesity and psychological problems in child obesity is bilateral - the obesity reveals conditions for arising of psychological problems and it could be a result of serious psychological problems in the family. Obese children were less socially competent, had more behaviour problems, poorer self-perception and the most prevalent problems were anxiety/depression and so

210 cial problems. A very few studies were correlated with general practitioners activities on psychological consequences in obese children. Conclusions: Psychological disorders are a real challenge for researches, especially in general practice. Po-08 DOMESTIC VIOLENCE L. MILJKOVIC, D. TRIFUNOVIC BALANOVIC, G. ZELJKOVIC Dept of General Practice, Health Center Vozdovac, Belgrade, Serbia Introduction: Domestic violence is a behaviour in which one family member threatens the physical integrity, mental health or the peace of another family member. Domestic violence is the term that usually refers to married couples, but also to the people who live together. Domestic violence is a global phenomen. Objective of the study: Incidence of domestic violence against women in relationships in the primary care practice. Exam method: A modified questionnaire for screening domestic violence is used in this study designed by?autonomni Ïenski centar?? Belgrade, Results: The research included 224 women, from 20 to 79 years old. The majority of the interviewed women were between 50 and 59 years old. (30.36%). Out of all these women, 70.54% suffered some kind of violence. Willingness to talk about the problem was shown by 4.52% of women. The highest willingness to talk about violence was shown by the youngest (77.78%) and the oldest respondents (57.4%). The most common form of violence is emotional abuse (2.43%), 9.64% were exposed to physical violence, 0.7% stated that their partner threatened to kill them, 9.82% was forced to have sexual relations and 8.93% were afraid of their partner. Conclusion: Domestic violence is engaging in all social and economic levels. The fact that concerns is that the majority of women are not ready to speak about this problem. Competent institutions in this area are: social work centres, police departments, courts. Health workers must also deal with this problem. Po-0 PREVENTION OF COGNITIVE IMPAIRMENTS IN PRIMARY HEATH CARE M. RACIC, P. MIRA, K. SREBRENKA, K. LJILJA Dept of Family medicine, Health Center, Sarajevo, Bosnia and Herzegovina Background: Dementia and mild cognitive impairments are disorders of aging populations and represent a significant economic burden for society, family practices and caregivers. There are numerous risk factors that can have direct and indirect effects on cognitive functions. Aim: The aim of this study is to look at the relationship between primary and secondary preventive strategies and cognitive impairments prevention. Method: From previously done study, we extracted a group of 96 elderly patients with different severity of cognitive impairments (69 with mild and 27 with moderate-severe cognitive decline) and estimated risk factors (cardiovascular risk factors, harmful drinking, depression, polypharmacy). All patients were included into National preventive program which offers identification and treatment of risk factors. In order to follow treatment result, comprehensive physical examination and MMSE have been done annually during three consecutive years. Results: Reaching the gold standards in the treatment of hypertension, diabetes, hyperlipidemia and depression led to the improvement in cognitive functions after three years in 76 % of participants. Smoking cessation let to the improvement of cognitive decline in 2 %, counselling toward alcohol consumption in 9 % and drug review in 32 % of the patients. Conclusion: Modification and treatment of risk factors in primary health care can be beneficial in the preven

211 tion of cognitive impairments of aging population. In order to prevent cognitive decline/dementia, primary health care physicians should provide effective management of cardiovascular risk factors, as well as other preventive strategies regarding head trauma, alcohol consumption and polypharmacy. Po- PREMENSTRUAL SYNDROME AND ASSOCIATED FACTORS AMONG UNIVERSITY GIRLS K. MARAKOGLU, 2 M.S. SAHSIVAR, H. ULU, 3 D. ERDEM KOROGLU, F. CEVIZCI Dept of Family Medicine, University of Selcuk, Medicine Faculty of Selçuk, Konya, Turkey 2 Dept of Family Medicine, Sarayonu Public Hospital, Konya, Turkey 3 Dept of Family Medicine, Centrum Village Clinic, Urfa, Turkey Aim: To investigate prevalence of premenstrual syndrome (PMS) and its associated factors among university girls. Materials and Methods: In this cross-sectional and descriptive research, we surveyed 695 young women enrolled in the medical educational programs at Selçuk university during subjects were interviewed at which time sociodemographic characteristics, and smoking status were examined. Beck Depression Inventory (BDI) was used to assess depression level. Additionally, these girls completed the premenstrual syndrome evaluation form (PMSEF). Data were evaluated using SPSS 3.0 (Scientific Packages for Social Sciences). Factors associated with PMS were analyzed using Student Chi-square test and Odds ratio. Results: The mean age of the participants was 2.72±2.09 years % (470) of university girls were suffering from PMS. After logistic regression analysis, the significant factors associated with PMS were smoking and depressive symptomatology; odds ratios (95% confidence interval) were (.398 to 2.948) and (2.45 to 6.677), respectively. Of the respondents, 30.4% (2) were current smokers, 5.8% (40) were former smokers, and 63.9% (444) were never smokers. The general mean BDI score was found as 0.87±8.5. The frequency of depression symptomatology (BDI 7 and higher) was 22% (53). Conclusions: Premenstrual syndrome is a significant disorder among reproductive aged young girls. The significant associated factors were smoking and depression. Patients with PMS and associated risk factors should be offered nonpharmacologic therapy and medication should be offered to patients with persistent symptoms of PMS. Po-2 SMOKING BEHAVIOUR, KNOWLEDGE, ATTITUDES AND PRACTICE AMONG HEALTH CARE PROVI- DERS IN KAHRAMANMARAS CITY, TURKEY M. CELIK, 2 A. OZER, 2 H.C. EKERBICER, 3 F.O.ORHAN Dept of Family Medicine, Kahramanmaras Sutcu Imam University Medical Faculty, Kahramanmaras, Turkey 2 Dept of Public Health, Kahramanmaras Sutcu Imam University Medical Faculty, Kahramanmaras, Turkey 3 Dept of Psychiatry, Kahramanmaras Sutcu Imam University Medical Faculty, Kahramanmaras, Turkey Aim: With the smoking epidemic in Turkey, the role that health care providers (HCPs) could play in tobacco control will be critical. This study identified smoking behaviour, knowledge, attitudes, and practice regarding smoking and smoking control among HCPs in Kahramanmaras city, Turkey. Material and Method: The study design was cross-sectional and conducted in primary health care canters of Kahramanmaras, Turkey. Data of PCPs (n=405) were collected by using a standard questionnaire. Results: Among the respondents, 24.5% were current smokers, which represented 34.8% of the physicians, 26.6% of the nurses, 5.2% of the midwives, 3.% of the health staffs and 46.9% of the males and 7.9% of the females. Knowledge regarding smoking s harmful effects and smoking-related respiratory system disea

212 ses was high. HCPs had same incorrect knowledge such as Filters make cigarettes safe (56.2%), Smoking is only harmful if you have smoked for over 20 years (62.%), and Quitting smoking is not difficult (26.9%). Attitudes of HCPs toward smoking and smoking control were excellent. Current smokers group compared to others groups received statistically higher knowledge scores. Ninety-seven percent approved their role in smoking control, but only 48.9% HCPs practically ask whether smoke or not and 66.2% of them informed patients about methods of smoking cessation. Conclusion: HCPs had some knowledge and positive attitudes regarding the cessation of smoking. Interventions for the cessation of smoking and continual education on smoking control for HCPs are indicated. Po-3 EFFECTS OF PHARMACOLOGICAL TREATMENT OF HYPERLIPIDEMIA L. BUNJAK, B. GRUJIC, S. MILOVANCEVIC, J. VUKOTIC Dept of General Practice, H C "Zvezdara", Belgrade, Serbia Aims: The prevention of atherosclerosis is closely related to duration and control of hyperlipidemia. The lipid status is important in primary prevention of the cardiovascular diseases. The aim was to observe the effects of six months of statin usag on cholesterol level. Design and methods: Prospective research included 25 patients aged 8-70 years. For all patients with elevated total cholesterol was recommended to control lipid parameters at check ups (n=4) and to take statin. Statistical analysis was performed using the SPSS program. Results: From 25 patients, 58 ( 73,4%) were analysed because of hyperlipidemia. At the first examination, average cholesterol value that men had vas 7,3 m mol/l, women had 7,9 m mol/l. LDL for men were 4,8 m mol/l, HDL,9 m mol/l, and for women LDL were4,7 m mol/l, HDL 2,6 m mol/l. At the ast examination, after the six months of statin usage, cholesterol level was lowered to normal in 69% of our patients total cholesterol was reduced 9,7% (5,2 m mol/l) for men and 2,% (5, m mol/l) for women. LDL was reduced by 6,4% (3,2 mmol/l)for men, and 7,8% (3, mmol/l) for women. HDL was better by 7,03%. Total cholesterol, HDL and LDL were scientifically reduced (statistical difference p<0.0 5). Conclusion: The six months of treatment confirmed positive results of statin usage in the regulation of the lipidstatus. Po-4 STATIN THERAPY IN HYPERTENSIVE PATIENS WITH HYPERLIPIDEMIA B. GRUJIC, L. BUNJAK, S. MILOVANCEVIC, J. VUKOTIC Dept of General Practice, H C "Zvezdara", Belgrade, Serbia AIMS AND PURPOSE: Hypertension is one of the most important risk factor for atherosclerosis and hyperlipidemia is established as the central factor coronary heart disease. The aim of this study was to recognize patients with hypertension and elevated cholesterol and to measure effects of therapy. Design and methods: Prospective research included 64 patients aged years (average age was 62,5 ± 8,7) with hypertension and hyperlipidemia. Blood pressure (BP) was measured and laboratory analyses were performed at check ups (n=4). Treatment steps were presented by medication therapy (angiotensin converting enzyme ACE) to reduce blood pressure and statin to reduce cholesterol. The treatment emphasized also the lifestyle changes. Statistical analysis was performed using the SPSS program. RESULTS: 64 patients (95 females and 69 males) elevated BP 55,69/92,03, the average cholesterol level was 7,62. At the end of the examined period we found statistically high difference for decreased systolic blood pressure (SBP), diastolic blood pressure and total cholesterol. For 09 patients the average SBP was 38,

213 (reduced of 2,36%), DBP 80,5 (reduced of 8,96%) and for 2 patients total cholesterol -5,53, was reduced by 2,7% (p<005). All groups of patients had shown risk reduction to below 5%. CONSLUSION: Antilipemic therapy, lifestyle modification and antihypertensive therapy have a great impact on reducing the risk for cardiovascular disease. Po-6 DOMESTIC VIOLENCE CASE INTRODUCTION L. MILJKOVIC, D. TRIFUNOVIC BALANOVIC, G. ZELJKOVIC Ambuloance, Health Center Vozdovac, Belgrade, Serbia Introduction: Domestic violence is a behaviour in which one family member threatens the physical integrity, mental health or the peace of another family member. Domestic violence is the term that usually refers to married couples, but also to the people who live together. Domestic violence is a global phenomen. Objective of the study: Incidence of domestic violence against women in relationships in the primary care practice. Exam method: A modified questionnaire for screening domestic violence is used in this study designed by Autonomni Ïenski centar Belgrade, Results: The research included 224 women, from 20 to 79 years old. The majority of the interviewed women were between 50 and 59 years old. (30.36%). Out of all these women, 70.54% suffered some kind of violence. Willingness to talk about the problem was shown by 4.52% of women. The highest willingness to talk about violence was shown by the youngest (77.78%) and the oldest respondents (57.4%). The most common form of violence is emotional abuse (2.43%), 9.64% were exposed to physical violence, 0.7% stated that their partner threatened to kill them, 9.82% was forced to have sexual relations and 8.93% were afraid of their partner. Conclusion: Domestic violence is engaging in all social and economic levels. The fact that concerns is that the majority of women are not ready to speak about this problem. Competent institutions in this area are: social work centres, police departments, courts. Health workers must also deal with this problem. Po-7 SOLUNUM SISTEMI HASTALIKLARINDA RISK FAKTÖRLERININ SEMPTOMLARA ETKISI: BIR ALAN ÇALIfiMASI Zeynep GÜNAYI, Ezine Merkez Sa l k Oca, Sa l k Bakanl Vildan MEVSIM, Aile Hekimli i, DÜTF Girifl: Sigara, mesleki toz ve kimyasallar, hava kirlili i, enfeksiyonlar, alfa- antitripsin eksikli i gibi genetik faktörler, akci er hastal klar için belirlenmifl risk faktörleridir. Öksürük, nefes darl ve balgam ç karma akci- er hastal klar nda görülen en önemli semptomlard r. Bu çal flmada; solunumsal semptomlara, belirlenmifl risk faktörlerinden, hangisinin, ne oranda etki etti inin saptanmas amaçlanm flt r. Yöntem: Kesitsel analitik olarak planlanan araflt rmaya; zmir de sanayi bölgesine yak n bir birinci basamak kurumuna baflvuran ve araflt rmaya kat lmay kabul eden 30 yafl ve üzeri hastalar al nm flt r. nhaler ilaç kullananlar, kalp yetmezli i olanlar ve akut hastal k saptananlar çal flma d fl b rak lm flt r. Standart fizik muayene, demografik özelliklerin ve risk faktörlerinin sorguland anket formu uygulanarak SPSS 2.0 ile tan mlay c analizler, ki-kare ve lojistik regresyon analizi yap lm flt r. Bulgular: Çal flmaya %46.0\' s kad n, %54,0\'ü erkek (yafl ort 50.38±4.) 450 kat l mc dahil edilmifltir. % 5.8 inin akci er hastal klar aç s ndan riskli bir meslek grubunda çal flt tespit edilmifltir. Kad nlarda daha s k olmak üzere (p<0.005), %2.7 ast m, %6.4 alerji, %8.9 pnömoni, %4. oran nda depresyon öyküsü bulunmaktad r. Sigaray b rakanlar n oran %20.4 iken %44.0 kat l mc n n halen sigara içti i saptanm flt r (ort 4.8 pk/y l). Sonuç: Solunumsal semptomlar incelendi inde; öksürük görülme riskinin pnömoni öyküsü olanlarda 2.39 kat, - 2 -

214 50 paket y l üzeri sigara içmifl olanlarda 5.44 kat; balgam ç karma riskinin pnomoni öyküsü olanlarda 2. kat ve 50 paket y l üzeri sigara içmifl olanlarda 3.6 kat; nefes darl görülme riskinin ise ast m öyküsü olanlarda 5.36 kat, 50 paket y l üzeri sigara içenlerde içmeyenlere oranla 5.47 kat artt tespit edilmifltir. Po-8 SYMPTOMATIC ARTERIAL HYPERTENSION IN CHILDREN - CLINICAL OBSERVATION L. MARINOV, D. BLIZNAKOVA, P. SHIVACHEV Second Pediatric Clinic, Varna Medical University, Varna, Bulgaria The Symptomatic Arterial Hypertension (SAH) is found rarely compared to the essential. Its incidence is approximately 5-20% of the whole frequency of the hypertension conditions. From age aspect, as lower is the age on which the high arterial blood pressure is observed, the probability that it is SAH is higher. SAH is a symptom of another already existing disease, which causes the rising of the blood pressure. Most often these are inherited or acquired diseases of the urinary system, of the cardiovascular system, of the endocrine and of the nervous system. The aim of this study is to specify the frequency and etiological belonging of SAH in hospitalized children. From the 34 children with high blood pressure, hospitalized for eight years, in 4,8% we found that this is a SAH. The highest is the number of children with renal parenchymal disease 4, with renal polycystosis 3, with stenosis of the renal arteries 2 and one child with suprarenal tumor. Two of the children with parenchymal disease were in advanced stages, with developed renal insufficiency, and in one of them we had to start haemodialysis. The children with SAH had high levels of blood pressure; some of them were hospitalized after hypertonic crisis, with signs of hypertonic encephalopathy, which were the initial signs of the high blood pressure. SAH, even rare during childhood, is a serious disease, leading to life threatening complications, requiring fast diagnosis and adequate treatment. Po-9 CARDIAC TUMORS AMONG CHILDREN TWO CASE REPORTS L. MARINOV, P. SHIVACHEV, 2 S. LAZAROV Second Pediatric Clinic, Varna Medical University, Varna, Bulgaria 2 Dept of Congenital Heart Malformation Surgery, National Heart Hospital, Sofia, Bulgaria We present to your attention two clinical cases of cardiac tumors - a newborn baby (20 days old) and a 5- years old boy. The reason for the hospitalization of the baby is cyanosis, cardiac noise and a suspected congenital heart malformation. The reason for the hospitalization of the infant is an attack of supraventricular paroxysmal tachycardia. During the clinical monitoring a tumor formation in the right atrium of the newborn and a tumor formation in the left ventricle of the infant were diagnosed via EchoCG. The implemented additional imagining examinations confirmed the presence of a cardiac tumor in both children. The last were transferred to National Heart Hospital in Sofia for surgical treatment

215 Po-20 ASSOCIATION OF CUTANEOUS MANIFESTATIONS WITH BODY MASS INDEX AND HbAc LEVELS IN TYPE II DIABETES MELLITUS PATIENTS N. SENSOY, 2 G. GENCOGLAN Dept of Family Medicine, Afyon Kocatepe University Medical Faculty, Afyonkarahisar, Turkey 2 Dept of Dermatology, Celal Bayar University Medical Faculty, Manisa, Turkey Objectives: Diabetes mellitus is a chronic metabolic disorder characterized by disturbance of the carbonhydrate and lipid metabolism. At least 30% of the diabetic patients have any type of cutaneous manifestation during the course of disease. Some skin conditions are specific to diabetes mellitus however, while most of them may also occur in nondiabetics. In this study, we aimed to investigate the type and frequency of skin lesions in type II diabetic patients, as well as their correlation with HbAc and body mass index (BMI). Material and Methods: One hundred nine consecutive type II diabetic outpatients were evaluated for their HbAc levels, BMI and Cutaneous Manifestations. Results: At least one skin condition was observed in 74,3% of the patients. Fungal infections (66 patients, 60,6% ), xerosis (58 patients, 53,2%), molluscum pendulum (43 patients, 39,4%) and plantar hyperkeratosis (40 patients, 36,7 %) were the mostly observed ones. There was no correlation between skin lesions and age, sex, HbAc levels and duration of diabetes. Only plantar hyperkeratosis was correlated with BMI (p=0,0). Conclusion: A type II diabetes mellitus is related with obesity and insuline resistance, we observed that plantar hyperkeratosis, skin tags and fungal infections in relation to these situations were frequent in our study group. There was no correlation between HbAc and skin findings. Cutaneous manifestations observed in diabetic patients are not spesific, but they have an important role in the diagnosis and therapy of the disorder. Table : Association of between body mass index and Hbac with skin lesions Po-2 VENOUS THROMBOEMBOLIC DISEASE COMPLICATED WITH BRAIN THROMBOSIS AND ANTIT- HROMBIN III DEFICIENCY A CASE REPORT L. MARINOV, M. ZHELEVA, B. VARBANOVA, D. BLIZNAKOVA, P. SHIVACHEV Second Pediaric Clinic, Varna University Hospital, Varna, Bulgaria The venous thromboembolic disease is a relatively rare disorder in childhood. Prerequisite for its occurrence are hereditary thrombophilia, gene defects, coagulation disorders associated with deficiency of natural anticoagulants, antiphospholipid syndrome, dysfibrinogenemia, etc. The frequency of brain phlebothrombosis among adult patients is approximately 3.5% of the thrombosis of cerebral vessels. It is more frequently seen among females. As for children, the share of thrombosis of cerebral veins is greater than the arterial ones. We present to your attention the following clinical case - a 7-year-old girl who is hospitalized because of pains in left abdominal half and inguinal area. The held laboratory tests brought data for abnormal coagulation status. The image and instrumental tests represented data on bilateral thrombosis of iliac veins. During the anticoagu

216 lant therapy a strong headache, nausea, vomiting and impaired vision accidents occurred. íhe IMR proved the presence of thrombosis in the left part of sigmoid and transversal sinuses and cerebral venous attack in the left temporal brain. The additional examinations on the cause of thromboembolic events proved Antithrombin III deficiency. We present this case as an exceptional casuistry in our practice - a combination of thrombosis of deep veins with thrombosis of cerebral veins and sinuses with cerebral venous infarction in a deficiency of one of the natural anticoagulants - Antithrombin III. Po-22 CARDIAC COMPLICATIONS IN CHILDREN WITH ACUTE LYMPHOBLASTIC LEUKEMIA L. MARINOV, P. SHIVACHEV, M. BELCHEVA, E. PETEVA, V. KALEVA Dept of Pediatrics and Medical Genetics, Varna Medical University, Varna, Bulgaria Cardio-vascular complications developed in children with malignant diseases during chemotherapy worsen the prognosis and increase the risk of early disability and mortality. The most frequent complications are hypertension, heart failure and pericardial effusions. The echocadiography is succesfully used for the documentation of the cardio-toxic changes and the disorders of the cardiac function. The Shorting fraction (FS) and the Ejection Fraction (EF) are used for assessment of left ventricular dysfunction. The aim of this study is to observe the cardio-vascular complications during the treatment of acute lymphoblastic leukemia (ALL) and assessment of the changes of the heart function. For a period of 5 years ( ) in the Pediatric clinic of Oncohematology, were hospitalized 66 children with ALL, aged to 7 years. 60 children were treated according ALL BFM 2000, and the other were treated according Dana Farber. When a relapse occurred the treatment was continued with ALL REZ BFM 96. The complications from the cardiovascular system that we have observed are hypertension in 7 children, pericardial effusions in 5 children and heart failure in 0 children. We had Exitus letalis in 9 children as the immediate cause for it was a resistant heart failure due to critically disturbed left-ventricular function. Po-23 REVIEW OF CONTEMPORARY POCT TESTING AND SYSTEMS. POSSIBILITIES OF THEIR APPLICA- TION TO PRIMARY MEDICAL SERVICES S. KASHLOVA, M. BONCHEVA, V. MADJOVA Dept of Family medicine and Clinical Laboratory, Varna Medical University, Varna, Bulgaria Clinical laboratory testing is an integral part of everyday doctor s work. POCT allows clinical testing to be done by trained paramedical staff in outpatient surgery or by the patient himself at his home. Objective: Research of contemporary POCT testing, the quality of their analytical reliability and the possibilities of their application to the primary medical services. Methods: Meta-analysis of literature for the 2 years period. Results: POCT tests were divided into several groups: ) related to emergency medical indications for patient s admittance to a hospital (troponin I, myoglobin, BNP, glucose, drugs); 2) related to medical indications for periodic control of appointed tests in monitoring of therapy (glucose, prothrombine index, urea, creatinine, hemoglobin); 3) related to patient s convenience during screening and diagnostic studies (urine analysis, cholesterol, glucose, triglycerides, HDL-cholesterol, PSA, pre-menopause, CRP, Streptoc A); 4) related to methodological principles; 5) related to their analytical reliability: limits of identification, accuracy, range of the testing method. Conclusion: Contemporary technologies offer POCT testing for a huge number of laboratory parameters with an application to prophylactics, diagnostics, differential diagnostics and therapy control of a great number of social significant diseases. Everywhere in the world, POCT testing is taking up a larger part of all laboratory testing

217 Po-24 A WIDELY HEALTH SCREENING IN KOSOVO T. TAYMAZ, 2 A. ERDIL, R. BAYAR, 3 C. HICYILMAZ, 4 B. TAYMAZ, 5 A. OZGENECI, 6 A. DURHAN, 5 Y. SIVRIKAYA, 7 U. POYRAZ Dept of Emergency, Istanbul American Hospital, Istanbul, Turkey 2 Dept of ENT, Istanbul American Hospital, Istanbul, Turkey 3 Dept of ENT, Istanbul Medamerican Clinic, Istanbul, Turkey 4 Dept of Anthropology, Yeditepe University, Istanbul, Turkey 5 Specialist of Family Medicine, Istanbul, Turkey 6 Dept of Pediatric Dental, Istanbul Marmara University, Istanbul, Turkey 7 Dept of Dermatology, Istanbul American Hospital, Istanbul, Turkey Kosovo s population is 2 million, 40% under 8 years-of-age. The infant-mortality rate: 35-49/,000, highest in Europe, under 5 mortality rate is estimated: 69/,000. Maternal mortality: 2-23/00,000 5% of children are considered malnourished 4% of women, 4% of men in rural areas are illiterate 57% of the available workforce is out-of-work. (for rural women reaching 99%) Primary Health services are provided by Family Medicine Centres, Secondary Health services are provided by five regional and one university hospital. Minority communities, poverty or rural people, the elderly, invalids, veterans have difficulty in accessing health services. The health sector is financed from the consolidated budget of Kosovo and donations from the international community. (*) Method: In 0 cities; 259 children were screened,27 adults were examined. 99 women were given information about breast cancer 2 newborn babies had hearing tested. Results: Vaxination have been performed in every village,chronic patologies were seen in 6 children(especially urologic,neurologic,cardiac) Dental caries and fluorosis are common. 99 children had lice problem. Most children have been to an opthalmologist 53 children were diagnosed with otitis/tonsilites A boy with severe visual impairment was diagnosed with hearing loss in both. We supplied the hearing aid. Families were informed to go to hospital for Children with genital disorders Conclusion To improve health conditions,fertile lands and dense youngpopulation should be utilized,and employment possibilities should be generated. Cardiac and neurologic problems of high percentage in Skenderay should be investigated in detail. Newborn Hearing Screening will be put into practice with WWH. (*)Data gathered from the Unicef -Kosovo ( and UNKosovo Team ( dental

218 Introduction: The diagnose and treatment of cancer types is a stressor condition for individuals. Psychiatric disorders, particularly anxiety disorder and depression, are common among cancer patients. Adapdation problems to the oncologic treatment, increase in duration of hospital stay, life quality disturbance can occur at untreated condition of the psychiatric disorders. In this study, we investigated the severity level of anxiety and depression among cancer patients. Materials and Methods: This prospective study was conducted among patients following different diagnosed cancer types. 68 patients were included to studty. Patients were evaluated according to Beck Anxiety Inventory(BA- I) and Beck Depression Inventory (BDI). According to sum of scores, severity levels are cathegorized in BAroman children audiologic tests pediatric examination regions where we have been Po-25 RESEARCH OF ANXIETY AND DEPRESSION SEVERITY AMONG CANCER PATIENTS Y.C. DOGANER, U. AYDOGAN, O. SARI, 2 B. OZTURK, 2 S. KOMURCU, K. SAGLAM Dept of Family Medicine, GATA - Gulhane Military Medical Academy, Ankara, Turkey 2 Dept of Medical Oncology, GATA - Gulhane Military Medical Academy, Ankara, Turkey

219 I.(0-7: minimal, 8-5: mild, 6-25: moderate, 26-63: severe anxiety). According to sum of scores, severity levels were cathegorized in BDI.(0-9: minimal,0-6:mild, 7-29:moderate, 30-63: severe depression). Results: 45(%66,7) patients were male, 23(%33,82) patients were female.average age was 36,27 (20-74) years. Average duration after diagnose was 2,5 months. 25(%36,76) patients had minimal anxiety, 9(%27,94) patients had mild anxiety, 8 (%26,47) patients had moderate anxiety, 6(%8,82) patients had severe anxiety. 35(%5,47) patients had minimal depression, 7(%25) patients had mild depression, 4(%20,58) patients had moderate depression, 2(%2,94) patients had severe depression. Conclusion: Depending on numerous of variables( nutritional habits, enviromental conditions etc.), cancer types and patients indicate rapidly rising rates. Despite the incredible improvement of treatment,psychiatric ruin is inevitable. Our study indicate the comordity and severity of anxiety disorder and depression with the cancer. Po-26 ASSOCIATION BETWEEN DOMESTIC VIOLENCE AND DEPRESSION IN TURKISH PREGNANT WO- MEN T. EDIRNE, 2 R. YILDIZHAN, 2 A. KOLUSARI, 2 E. ADALI, 3 M. CAN, 4 V. KARS Dept of Family Medicine, Pamukkale University Medical Faculty, Denizli, Turkey 2 Dept of Gynecology and Obstetrics, Yuzuncu Yil University Medical Faculty, Van, Turkey 3 Dept of Forensic Medicine, Yuzuncu Yil University Medical Faculty, Van, Turkey 4 Dept of Family Medicine, Yuzuncu Yil University Medical Faculty, Van, Turkey Background: Domestic violence is a major public health problem; surveys report that 3% 7% of pregnant women suffer from it during their pregnancy. First, we aim () to estimate the prevalence of domestic violence in women who had been admitted to the maternity unit of a tertiary care hospital, and (2) to identify risk factors for domestic violence. Second, we aim (3) to evaluate the association between violence and depression during pregnancy. Methods: For six consecutive months, 44 pregnant women were systematically interviewed and screened for domestic violence and depression. Results: 6.9% (70/44) of women were victims of violence during their recent pregnancy. These women and their husbands were less educated, living in more crowded households with less income than nonabused women and had experienced violence previously in their own family and in the family of their partners. Major depression was present in 24.4% (0/44) women. Depressed women were significantly more likely to have experienced physical abuse (odds ratio 2.6, 95% confidence interval ) and sexual abuse (odds ratio 4.3, 95% confidence interval ) than women who were not depressed. Conclusion: Physical and sexual abuse during pregnancy is strongly associated with depression in women attending maternity units. Doctors should screen for depression in pregnant women and interrogate domestic violence. Po-27 A KIND OF SMOKELESS TOBACCO IN TURKEY: MARAfi OTU (MARAS POWDER)-A REVIEW M. CELIK, 2 H.C. EKERBICER, 3 U.G. OZER, 2 A. OZER, 4 F.O. ORHAN Dept of Family Medicine, Kahramanmaras Sutcu Imam University Medical Faculty, Kahramanmaras, Turkey 2 Dept of Public Health, Kahramanmaras Sutcu Imam University Medical Faculty, Kahramanmaras, Turkey 3 Specialist of Family Medicine, Istanbul, Turkey 4 Dept of Pschiatry, Kahramanmaras Sutcu Imam University Medical Faculty, Kahramanmaras, Turkey Objective: A kind of smokeless tobacco called Maras powder (MP) are widely used by the addicts through buccal mucosa in the city of Kahramanmaras and its surroundings. The aim of this study is to review the ar

220 ticles in the literature and determine the effects of MP on human health. Method: The databases PubMed, ProQuest, Scopus and ScienceDirect and also Turkish databases such as ULAKB M, Türk Medline were screened by giving the keywords Marafl Otu and Maras Powder. Twenty articles were found and evaluated. Results: When the articles were evaluated, it was determined that MP had genotoxic effects on T-lymphocytes and buccal mucosal cells, led to three times higher urinary cotinine levels, did not lead bronchial obstruction, led to significantly higher serum total sialic acid concentrations, led to leukokeratosis in oral mucosal cells, might induce epithelial cell proliferation and Ki-67 expression, serum IgE levels were found to be remarkably higher, the IgM levels were lower in MP group and smoking group compared to the control group. Blood lead level was detected not to be affected by the use of Maras powder markedly. Conclusion: Although negative effects of MP could not yet be understood fully, many studies have shown that it has different harmful impacts on human health. Hence, further detailed studies are required to figure out the mechanisms of its effect. Moreover, the potential harms of MP should be explained to the public and emphasized that it is as much harmful as smoking. Po-28 IMPORTANCE OF FAMILY PRACTITIONERS IN IMPLEMANTATION OF ISTANBUL PROTOCAL O. ELCIOGLU, 2 A.T. KOKCU, N. KIRIMLIOGLU, 3 M. UNALACAK, 4 T. GUNDUZ Dept of Medical Ethics and History of Medicine, Eskisehir Osmangazi University Medical Faculty, Eskisehir, Turkey 2 st Gendarmerie Training Battalion Command, Kutahya, Turkey 3 Dept of Family Medicine, Eskisehir Osmangazi University Medical Faculty, Eskisehir, Turkey 4 Dept of Forensic Medicine, Eskisehir Osmangazi University Medical Faculty, Eskisehir, Turkey Istanbul Protocol is accepted and put into effect in 999 by United Nations. It anticipates effective investigation and documentation of torture and inhumane treatment and their punishment. Along with this topic, it emphasizes ethical values and rules as well. All health care staff should comply with the standards declared by professional associations. Within the context of ethical principals inside Istanbul Protocol, under the title of National Health Service Ethical Rules, basic responsibilities are defined as helping the patients, defending the undefended and not discriminating between patients unless medical emergency situations. Primary care physicians are the first contact points between patients and health service systems. Primary care physicians defend patients rights when necessary. They also have effective role in providing informed consent in order to make their patients own health decisions. Doctors have double responsibilities in both protecting patients rights and maintaining justice inside society. These responsibilities bring some ethical dilemmas along with. In this study, we aim to evaluate the ethical values, rules, approaches inside Istanbul Protocol in terms of primary care physician. Special attention is indicated for topics like doctor-patient confidentiality, informed consent, tender care and therapy during performance of primary care physician. Health care services should always be presented on the basis of medical ethics as a part of national law and protecting the patients favour and benefit

221 Po-29 IMPORTANCE OF ACKNOWLEDGEMENT OF PATIENT IN PRIMARY CARE PHYSICIAN PERFOR- MANCE IN TERMS OF VALUE OF HUMANITY N. KIRIMLIOGLU, 2 A.T. KOKCU, N. DEMIRSOY, 3 I. UNLUOGLU Dept of Medical Ethics and History of Medicine, Eskisehir Osmangazi University Medical Faculty, Eskisehir, Turkey 2 st Gendarmerie Training Battalion Command, Kutahya, Turkey 3 Dept of Family Medicine, Eskisehir Osmangazi University Medical Faculty, Eskisehir, Turkey It has been well recognized that human being is a biopsychosocial entity in modern medical comprehension. All the medical performances serve to a mutual objective: service of humanity and human health. The underlying cause of this is the value of being human. Human being is the unique entity who is valuable, has value in himself, and is the aim all by himself. Human being has a divine, essential value. Whole humanity or one individual are all independently accepted as valuable, their values are inside themselves. The reason of personal, uninterrupted and integrated health service regardless of the age, sex or disease is the acceptance of the divine, essential value of humanity. Primary care physician performes this service by handling individuals and their families as a part of the society. Primary care physician does not deal with non-personal pathologies or cases but actually deals with problems occuring in the living environment of people; patient is the origin of all procedures therefore doctors in this occupational field have to acknowledge the individual (patient) with all the aspects who has divine, essential value. With the acknowledgement of the patient by primary care physician, their continous relationship might be more stable, constant and strong. Thus every contact of doctor-patient will increase collaboration and recovery process will be shorter. Referral of patient from first-step to second or third step health institutions will decrease; unnecessary screenings, tests or treatments will be prevented by appropriate acknowledgement of patient as a whole. Po-30 TREATMENT OF DIABETES MELLITUS TYPE 2 WITH METFORMIN AND GLIMEPIRID L. MAKSIMOVIC, K. MARKOVIC, 2 S. RASOVIC Dept of General Practice, Health Center Krusevac, Krusevac, Serbia Dept of Biochemistry, Health Center Krusevac, Krusevac, Serbia Introduction: Diabetes mellitus is an ailment of a common man, which is becoming more and more epidemic like. The treatment of diabetes is complex, because there are applied several therapeutic procedures, individually, and chronically, or for life. Aim: The surveillance of the effectiveness of an applied combined oral therapy (METFORMIN + GLIMEPI- RID) by those suffering from diabetes mellitus, type 2. Method: This study involved 40 persons with diabetes mellitus type 2, where hasn t been achieved a satisfying glycoregulation with metfomin at a dose of 2000 mg/day. At all the patients before and after 2 weeks from introducing the therapy and a dose of 2 mg glimepirid in the morning there were evaluated parameters: fasting blood glucose, postprandial blood glucose (a glucose 2 after the main meal) and glicolisate hemoglobin- HbAc. Results: A group of 40 patients with diabetes mellitus type 2 was contained of 26(65%) women and 4(35%) men, of middle age and an average duration of diabetes years. The middle value of the fast blood glucose before introducing of glimepirid was 8.508±0.684mmol/l, and 2 weeks after introducing a combined therapy, 5.790±0.57mmol/l, which is statistically high significant difference (p<0.0). Comparing the middle value of a postprandial blood glucose which was 0.502±.48 before the treatment, and

222 after. We can see a statistically high significant difference (p<0.0). Conclusion: A combined therapy with metformin and glimepirid gave the expected results, because after 2 weeks of treatment 65% of patients had an optimal glycoregulation, HbAc 6.5%. Po-3 IMPORTANCE OF GERIATRIC PATIENTS INFORMED CONSENT IN PRIMARY CARE PHYSICIAN PERFORMANCE N. DEMIRSOY, 2 A.T. KOKCU, O. ELCIOGLU, 3 M. UNALACAK Dept of Medical Ethics and History of Medicine, Eskisehir Osmangazi University Medical Faculty, Eskisehir, Turkey 2 st Gendarmerie Training Battalion Command, Kutahya, Turkey 3 Dept of Family Medicine, Eskisehir Osmangazi University Medical Faculty, Eskisehir, Turkey In recent years, the ratio of elderly population in whole world is increasing in parallel to the lenghtening of the average lifetime durations. When the age of this geriatric group is considered, we should not ignore their difficulties in understanding and interpreting, and also acoustic losses, amnesia. These difficulties and losses should all be cared of and appropriately treated. Therefore treatment should be provided continously, expected benefit should be optimum, unnecessary time and monetory losses should be prevented. In addition, appropriate informed consent should be performed for every care and therapy procedures. The scope and content of each informed consent should be clear, understandible, unforgettable and planned for elderly population. Thus, their tendency to accept and maintain appropriate health care will improve, so elderly will be more collaborative. All of their health care should be provided by primary care physicians (family doctors). First-step health care service staff are responsible for providing adequate geriatric care at every point. The important aspects of primary care physician performance are as follows: being integrated and individualized, adoption of continous service with more time spent for elderly, supporting specific approaches for geriatric population. The group of doctors who provide various aspects of care should generate awareness in this field and all the relevant health-care staff should be included in a multi-disciplinary informative model to reach the best optimum. Po-32 COMORBID DISEASES IN PATIENTS DIAGNOSED WITH ANXIETY DISORDER H. AKBULUT, U. AYDOGAN, A. PARLAK, Y.C. DOGANER, 2 A. CUCELOGLU, K. SAGLAM 2 Dept of Family Medicine, GATA Gulhane Military Medical Academy, Ankara, Turkey Dept of Psychiatry, GATA Gulhane Military Medical Academy, Ankara, Turkey Aydin Introduction: With changes in life style and an increase in stress factors, we now see an increase in psychiatric disorders among society. According to the DSM-4 classification, generalized anxiety disorder(ad) is the most common among psychiatric disorders and is seen more frequently in females. Fatique, muscle stiffness, lack of concentration, anxiety and tremors are common symptoms of AD. However, these symptoms are non-spesific. Hyperthyroidism, vitamin B2 deficiency, anemia, intoxication and drug side effects can easily be misdiagnosed as AD. Methods: This study followed 42 patients diagnosed with AD in the GATA Psychiatry Clinic. Patients were diagnosed by psychiatrists using the Beck Anxiety Inventory. Comorbid diseases were later investigated through examination and laboratary parameters. Results: 9 patients were male, 33 patients were female. The average age of patients were 39,62±0,69(8-64 years). 6(%4,28) patients were diagnosed with vitamin B2 deficiency. After examining blood parameters 2(%4,76) patients were diagnosed with hyperthyroidism. 2(%4,76) patients were receiving levothyroxine treatment. 5(%,9) patients were diagnosed with anemia. None of the patients had any autoimmune diseases. 6(%4,28) patients had

223 coronary artery disease. Hypertension existed in 8(%9,05) patients receiving ARB treatment. Conclusion: AD is one of the most frequently encountered diseases in primary care and physcians must have enough knowledge of it in order to diagnose the disease properly. Anemia, vitamin B2 deficiency, hyperthyroidism, drug side effects and intoxications show similar symptoms as AD. Before diagnosing patients with anxiety disorder these should be taken into consideration. Po-33 COMPLICATIONS AND COMORBID DISEASES IN TYPE 2 DIABETIC PATIENTS U. AYDOGAN, H. AKBULUT, 2 A. AYDOGDU, Y.C. DOGANER, 2 E. BOLU, K. SAGLAM Dept of Family Medicine, GATA Gulhane Military Medical Academy, Ankara, Turkey 2 Dept of Endocrinology, GATA Gulhane Military Medical Academy, Ankara, Turkey Aydin Introduction: Diabetes Mellitus (DM) is a chronic multisystemic disease that effects approximately %7 of the general population. It can cause serious complications in chronic period including occlusion in peripherial vessels, renal failure, cataract, occlusion in coronary vessels and stroke. In this study, complications of the patients following by the diagnose of diabetes mellitus were investigated. Methods: This cross-sectional study followed 05 diabetic patients in the GATA Endocrinology polyclinic. Results: 25 patients were male, 80 patients were female. The average age of patients were 58,8±0,6 years. 70( % 66,6) were receiving antihypertensive treatment. According to the patients fundus examination, 24(%22.85) patients had signs related to DM. 9(%8,5) patients urea or creatinine levels were higher than normal. 49(%46,6) patients were suffering from numbness in their hands and feet. According to the physical examinations, some patients had decreased sensation in their skin on the hands and feet. After phsycially examining7(%6,66) patients, their A.dorsalis pedis pulsation could not be determined. 27(%25.7) patients had undergone myocardial infarction. Conclusion: Diabetes Mellitus is a significant public health problem. The most common reason of adulthood blindness is DM after than glaucoma. And also it s an important risk factor for chronic renal failure MI. Because of the morbidity during chronical period, it s a significant financial burden for both individuals and health system. Especially, well knowledge level about DM of the physicians, performing in primary care;training about complications(diabetic foot) caused by DM,is an effective strategy for prevention from complications. Furthermore,annual referral for fundus screening and 24-hour urine samples analysing is required. Po-34 ANXIETY LEVELS IN PATIENTS DIAGNOSED WITH AND BEING TREATED FOR HYPOGONADISM A. AYDOGDU, 2 U. AYDOGAN, 2 H. AKBULUT, 2 O. SARI, E. BOLU, 2 K. SAGLAM 2 Dept of Endocrinology, GATA Gulhane Military Medical Academy, Ankara, Turkey Dept of Family Medicine, GATA Gulhane Military Medical Academy, Ankara, Turkey Introduction: Hypogonadism can be defined as an inadequate gonadal function.hypogonadism can also result from testicular dysfunction.as a result of inadequate testosterone, symptoms including problems with secondary sex characteristics, below average testicular volume, infertility, decrease in muscle strength and anxiety disorder can be seen. Method: This study included 6 patients with Hypogonadism who were being treated at the GATA Endocrinology Clinic.With patient approval, the Beck Anxiety Scale was applied to each patient and the results were examined by a psychiatrist to assess the anxiety level in each patient. Results: The average age of patients was 20.4(20-25).Two of the patients (3.27%) were diagnosed with secondary Hypogonadism while the rest were diagnosed with primary Hypogonadism.57.37%(n=35) of patients had minimal anxiety,2.3%(n=3) of patients had mild anxiety,3.2%(n=8) of patients had moderate anxiety and 8.2%(n=5) of patients had severe anxiety. The patients were not diagnosed with a secondary disease

224 Conclusion: Anxiety disorders are frequently encountered in primary health care institutions.according to research conducted in primary health care institutions by Dönmez et al, 25.2% of patients were found to have an anxiety disorder. Hypogonadism is a disease that has a negative impact on patients psychological well being. In our study, 42.63% (n=26) of patients who were diagnosed with Hypogonadism also had an anxiety disorder. When compared with the results of previous studies, these results are much higher. In conclusion, diseases that can cause anxiety disorders should be well known by physicians and patients with these diseases should be carefully examined for anxiety and depression. Po-35 SEASONAL INFLUENZA VACCINATION RATES AND IMMUNIZATION AWARENESS OF ADULTS IN RISK GROUPS M. SAV AYDINLI, A.G. CEYHUN PEKER, A.S. TEKINER, Z. DAGLI, F. AK PARLAK, S. INAN Dept of Family Medicine, Ankara University Medical Faculty, Ankara, Turkey AIM: The aim of this study was to determine the status of influenza vaccination of adults in risk groups. METHODS: This cross-sectional study was conducted at Ankara University School of Medicine between September and November 2009 in 5 outpatient clinics. The study population comprised of 50 patients aged?8 and who should have influenza vaccination because of their risk factors. The questionnaire consisted of demographic characteristics, risk factors, status of immunization, knowledge about the necessity of the vaccine, immunization recommended by whom and immunization request after being informed. Following the interview individuals were informed about the necessity of the vaccine. SPSS 5 was used to interpret data. RESULTS: Twenty six percent of the group had their flu shots. There wasn t significant difference for immunization between departments. Also there was no significant difference between vaccinated and unvaccinated patients in terms of age, sex, marital status, health insurance and total number of risk factors. Patients with higher household income had higher vaccination rates (p=0,047). Patients who had graduated from university or college, had higher immunization rates, but there wasn t significant difference (p=0,083). There was significant difference between immunization status and knowledge of necessity of the vaccine. (p=0,00) After being informed about the necessity of the vaccine, 95% of the individuals decided for immunization. CONCLUSION: All health care professionals should be aware of the attitude and knowledge of the people with risk factors for immunization and create an athmosphere to overcome the resistance and illiteracy on influenza vaccination. Po-37 A WIDELY HEALTH SCREENING IN AZERBAIJAN T. TAYMAZ, 2 A. ERDIL, 3 I. YILDIZ, 4 B. KARADAG Dept of Emergency Services, Istanbul American Hospital, Istanbul, Turkey Dept of ENT, Istanbul American Hospital, Istanbul, Turkey Dept of Paediatrics, Istanbul American Hospital, Istanbul, Turkey Dept of Internal Medicine, Sisli Etfal Education and Research Hospital, Istanbul, Turkey Introduction: Population:8,629,900 Infant mortality 43-74/,000 Maternal mortality:36/00,000 Exclusive breastfeeding rate:2% Children aged 6-59 months with anaemia:39% Women aged 5-49 years with anaemia:37% Respiratory diseases are the main killer of the infants and the second is diarrhea. Children s poor nutritional status is the major underlying cause of child mortality, one fifth of children are stunted. Access of the rural population to safe drinking water appears to be a problem (58%). (*) Method: We screened and examined 398 children and 290 adults in 5 regions. Results: Universal access to basic healthcare services which existed during Soviet period, shows its influence

225 even today. Preschool education and 0 years of basic education are compulsory, vaccination coverage is high. However, access to second and third level healthcare services is not easy. There are serious problems with sewage systems in areas where we have been. Nevertheless infection rates are lower than could be expected. Laboratory services are limited, especially in first level services Drug standardization is necessary in treatment of chronic illnesses (hypertension,heart disease,respiratory diseases, etc) Because drug distributors are lacking, standardized drug availability is a problem. In peripheral areas, births don t take place under hygenic conditions. Birth traumas are common and circumcision errors have been observed frequently. Majority of neurological problems in children are called IICPS and treated as such. Conclusion: The improvement in hygenic and economic conditions will prevent many health problems in rural areas. Drug standardization will have favorable impact on the survival of chronic patients. The establishment of therapeutic standardized protocols nationally and routinization of educational seminars and meetings will take medicine in Azerbaijan to higher level. (*): regions where we have been for screening preschool children

226 ENT screening/examination pediatric examination/screening mountain roads and vehicles

227 Po-38 DISABILITY AND HEALTH S. INAN, A.G. CEYHUN PEKER, A.S. TEKINER, M.K. KOPUK Dept of Family Medicine, Ankara University Medical School, Ankara, Turkey Today there are 650 million disabled people around the world Population Survey of Turkey showed that 2.29% of the population were disabled. According to the Alma Ata Declaration in 978, the general structure of society- based rehabilitation was put forward which aimed that the disabled people should become independent and active individuals. In a study conducted in Canada, 2% of the research group declared that they didn t have a family doctor. In a study conducted in the USA, it was stated that the people with physical disabilities benefited less from primary protective care services. In 2008, Primary care for the disabled people was evaluated and all groups agreed that more education was needed on this subject. The insufficiency of the health care system were the factors that limited the provision of primary care. According to the 2002 Survey on The Disabled People in Turkey, 55,7% of them were able to reach health services. According to a study conducted in Konya, almost all of the primary health care organizations were found to be insufficient for the disabled. When we look at the health care systems from the perspective of the disabled people restructuring of the health care systems, the preparations of the educational programmes that will change the knowledge, skills and the perception of the health service providers and the designing of the surveys and projects are necessary. Po-39 DETERMINATION OF THE AWARENESS LEVEL OF THE WOMEN IN TERMS OF URINARY INCONTINENCE N. SENSOY, 2 N. DOGAN, 3 B. OZEK, 3 L. KARAASLAN Dept of Family Medicine, Afyon Kocatepe University Medical Faculty, Afyonkarahisar, Turkey 2 Dept of Biostatistics, Afyon Kocatepe University Medical Faculty, Afyonkarahisar, Turkey 3 Afyon Kocatepe University Medical Faculty 3rd Semester Students, Afyonkarahisar, Turkey Objective: This cross-sectional the aim of the study was planned to identify urinary incontinence (UI) symptoms and awareness level of women who applied to the outpatient polyclinics due to several problems at Ahmet Necdet Sezer Practising and Research Hospital. Material and Methods: The study was performed on 050 patients suitable for the study criteria and intended to attend the study between December 5, 2009 and January, 200. The data were obtained by face to face interviews with the patients. General poll form, ICIQ-SF (Incontinence Questionnaire-Short Form) poll form were interrogated. In general poll form; medical story about demographic data, UI risk factors, habits, additional diseases were interrogated. To evaluate the data collected 6.00 SPSS were used. Results : The mean age of patients was 48.80±.53, and urinary incontinence symptoms were determined in 44.6% of the patients. In conclusion 57.% of the patients felt urinary incontinence as a health problem, 63% of them had never admitted to a health institution for urinary incontinence and 64.7% of them had never got any necessary treatment for urinary incontinence Conclusion: Urinary incontinence is one of the most common health problems seen in women of nearly all ages and affects a wide aspect of daily life, including the social, psychological, occupational, domestic, physical, and sexual lives of women. Major portion of women consider this as a part of being woman and getting older, so they don t seek medical help. Determining this problem and associated risk factors are crucial for patients who applied to the polyclinic

228 Po-40 THE USE OF ANXIOLYTICS IN GENERAL PRACTITIONER S OFFICE B. JOVICEVIC, O. RADOSAVLJEVIC Dept of General Practice, Health Institute Zrenjanin, Zrenjanin, Serbia Introduction: The appearance of stress and stress related issues calls for the use of anxiolytics whose adequate use becomes one of the major problems in modern medicine. Aim of the study.frequency of anxiolytics usage in patients at general practitioners Method.The investigation has been conducted by general practitioners in everyday contact with patients. Results: The study included 207 patients, average age 57.6, 66 male and 4 female. All of them use anxiolytics in their therapy. Due to mental treatment 4 (68.%) patient uses anxiolytics, most of them use it because of anxiety depressive disorder 7 (34.3%); psychosomatic reaction 39 (27.6%) ; depressive syndrome 3 (9,2%); addiction diseases 9 (6,3%) and psychosis 9 patients (6,3%). In therapy of organ diseases, psychosomatic reaction are used by 66 patients (3,8%). Most of these use it for hypertension 3 (46,9%). Due to ischaeamic heart disease 0 (5,%), endocrine disease 8 (2,%), lumbar syndrome 8 (2,%), malignant disease 4 (6%). It has been concluded that anxiolytics are most used by patients between 50 and 70 years of age 05 patients (50,7%), then between 30 and 50 years of age 5 (24,6%), then from 70 to 90 3 (4,9%),and finally between 20 and 40 years of age 20 (9,6%). Conclusion: Results from this study show that there is a significant difference in use of anxiolytics for mental and somatic diseases. Furthermore it has been concluded that female patients used anxiolytics more as well as the older population. Every irrational and long-term therapy by anxiolytics is not recommended because of the high risk of addictiveness. Therefore the cooperation between physician and a patient is essential in terms of therapy conducting and fighting stress Po-4 HEALTH TOURISM IN ULCINJ G. KARAMANAGA Health Care Institute, Ulcinj, Montenegro Ulcinj is a world known natural sanatorium with it\'s special natural factors: the clear and clean blue sea, healing long sandy beaches, mineral sulfurous water, mud bath-peloid, sea salt and it's home base and the stimulating mediterranean climate. There are six healing factors on this territory (which cannot be found elsewhere as they do here): the optimal temperature of the sea water in the summer season, the sand slightly radioactive with healing thermic features, peloid mud bath, salty home base as well as a climate with the best insolation and suitable humidity and the air for natural aerosol therapy. A fairly exact survey of the construction of tourist objects has been given: the construction of hotels, resorts, camps and settlements, tourist agencies for both home and foreign tourism. These data are of great importance because, as Malic Sulejmanovic retired touristic worker said Health tourism preceded the development of other forms of tourism in Ulcinj. The pathology which can be cured by peloid, mineral sulfurous water, sand, the influence of tourism in Ulcinj. The pathology which can be cured by peloid, mineral sulfurous water, sand, the influence of the environment, has been processed. It has also been pointed out how certain diseases are treated nowadays as well as the possibilities of development of health-recreational tourism in Ulcinj

229 Po-42 PULMONARY ECHINOCOCCOSIS G. KARAMANAGA Health Care Institute, Ulcinj, Montenegro Introduction: Echinococcosis is a potentially fatal parasitic disease that can affect many animals, including wildlife, commercial livestock and humans. The disease results from infection by tapeworm larvae of the genus Echinococcus. The terminology dates back in 80, and it was introduced by Goetze and Rudolph. Researches, diagnosed and treated cases have shown that the Former Yugoslavia Region represents an endemic place notable for new species of endemic diseases. In Montenegro, Echinococcosis is regarded as a medical issue, but also as a socio-economic problem. Objective and method: The work tends to verify the existence of the Pulmonary Echinococcosis as a medical problem in Montenegro. Results: It will be proved that Pulmonary Echinococcosis is present even in the region of the municipality of Ulcinj. The disease is more frequent in Podgorica, Cetinje, Bar and Ulcinj. The number of patients affected with this disease is decreasing. The percentage of patients with chirurgical intervention during a 4O-year period: Liver 54,22%, Lungs 35,7%, other body organs 0,7%. Age: Young people are mostly affected by the disease. Hospitalization period: approximately 23 days. Conclusion: Echinococcosis still remains a medical and socio-economic problem in Montenegro. Usually, the diagnosis is easily made. However, new complications can develop during the treatment (as they occurred in two cases). The research on The role of a Doctor in Lung Deparment is still in development. The treatment is made by chirurgical intervention. Po-43 GERIATRIC SYNDROME L. DJUROVIC, 2 V. OBORINA, K. RASKOVIC Dept of General Practice, Health Center Podgorica, Podgorica, Montenegro 2 Dept of General Practice, Health Center Petrovac, Petrovac, Montenegro Introduction: The rapid growth of the elderly population has created a need for further understanding the aging process,as well as treatment of acute and chronic diseases in the elderly.decline in physiological capacity,biochemical disorders and increased tendency to illness and death accompany aging. One theory of aging states as a reason for oxidative stress.another theory refers to the programmed,genetically regulated aging. New researches indicate that psycho-physical activity significantly affect the aging process.the prevention in youth,physical and mental activity in late years,and adaptation to stress,affect the delay of the aging process. The aim:assessment of psycho-physical condition of elderly patients in outpatient clinic,by GP. Methods:Research instrument-questionnaire with questions. Results:Survey included 68 patients older then 65 years,who were observed by GP. 45 patients were men and 23 patients were women. Questionnaire included:.are you tense,anxious,forgetful?(60% of women said No,and 35,5% of men said No) 2.Are you able to create?( 69,5% of women said Yes,and 5,% of men said Yes) 3.Can you easily adjust to changes?(6,8% of women said Yes,and 3,% of men said Yes) 4.Are you able to include the news in your life?(56,5% of women said Yes,and 3,% of men said Yes) 5.Do you maintain a regular physical activity?(73,9% of women said Yes,and 40,0% of men said yes) 6.Do you enjoy alcohol moderately?(3% of women said Yes,and 24,4% of men said Yes) 7.Do you smoke?(2,7% of women said Yes,and 2,7% of men said Yes)

230 8.Do you sleep at least 7 hours a day?(78,2% of women said Yes,and 55,5% of men said Yes) 9.Do you have a breakfast usually?(52,% of women said Yes,and 3,% of men said Yes) 0.Do you maintain normal body weight?(73,9% of women said Yes,and 60% of men said Yes).do you have a habit of taking food between meals? (60,8% of women said Yes,and 20,2% of men said Yes) Conclusion:I was pleasantly surprised by results of this research.patients of the third age are in good psycho-physical condition.they are adapted to stress.they have a strong desire for life.this research confirmed that patients who are in better psycho-physical condition,who are active and foster healthy lifestyles;who are not inert and asleep,readily pass through the third age.they can also better distinguish biological aging from diseases that accompany the aging process.they have a happy third age. Po-44 Alternative Tradicional Medicine (CAM) L. DJUROVIC, K. RASKOVIC, J. DAMJANOVIC Dept of General Practice, Health Center Podgorica, Podgorica, Montenegro Introduction: Traditional medicine is a term that was introduced in the official use of the World Health Organization. This term includes health practices, knowledge and beliefs related to the preparations of plant, mineral or animal origin, spiritual therapy, as well as manual techniques and exercises. In 995 American Health Association took the attitude that alternative medicine is not quackery, and that doctors should be better acquainted with her. In Europe, according to data from 200 a high acceptance of alternative medicine is recorded. In Montenegro, there is a long history of traditional medicine. As ecological country, we have a wealth of medicinal plant species, which has always been used in treatment. The aim: To realize how often plants are used in treating our patients. Methods: The oral survey in our outpatient clinic (30 patients) Results: The majority of respondents treat themselves with medicinal herbs, teas and balsam inherited as family tradition. From 30 patients, 22 use plants(73%). 25% of patients collect herbs themselves, and 73% buy finished products. The most commonly used herbs are: Mint,Chamomile,Wart,Nettle,Sage,Plantain,Yarrow,Thyme. Wart is used for depression,and digestive problems;nettle is used for anemia;plantain for burned skin and wounds;thyme is used for bronchitis and coughing.yarrow is usually used for diabetes and diarrhea.one 6-year old girl said that she used phyto therapy combinated with peloid from Ulcinj,and she had wonderful results in acne treatment. Conclusion: Modern medicine has not rejected the values of traditional medicine,but it must be studied,scientifically defined and adequately used. When that happen,our country will take advantage of national resources,and join other European countries,where alternative medicine occupies an important place. Our patients use plants in their treatment; so physicians should support them, give their opinion and guidance

231 Po-47 POSSIBILITIES OF RECOGNIZING THE INITIAL PHASE OF DIABETIC FOOT IN THE SELECTED DOCTOR S CLINIC M. DJUROVIC, L. MARKOVIC KCCG, Dept of Dermatovenerologija, Podgorica, Montenegro The aim of this paper is to point out certain recognizable dermal signs of an early stage of diabetic foot. The aim of this paper is to point out certain recognizable dermal signs of an early stage of diabetic foot. Complicated pathophysiological mechanism of the small blood vessels and then larger create conditions for the development of numerous other complications, and in particular discussion of the creation of diabetic gangrene, which often ends up with amputation of the limbs parts. It is particularly important to recognize on time the change of skin on the feet of diabetics, in which case the therapeutic procedure is more effective because in the later stages vazoprotective drugs and HBO treatments remain with no effect. Since these patients turn to the selected physician it is important to recognize changes in the skin of the feet, which significantly delays the occurrence of complications and the life of such patients becomes better in quality. Intervention at an early stage is the most successful therapeutic procedure with the application of hiperbaric oxygen. For these reasons it is very simple in the selected doctor s clinic to make a small protocol to recognize the skin features, or skin protective protocol for diabetic foot. Nervous receptors in the skin do not have the full capacity of the perception of pain, and do not recognize the trauma and the small blood vessels visibly change the colour of the feet, which already represents occurrence of diabetic complication called diabetic foot. It is very important to treat the skin of a diabetic foot properly, and it is well known in the biological process that aging of the skin of a foot is faster than other parts of the body. Conclusion: This work should demonstrate how important the examination of the skin of feet in the selected doctor s clinic is, as well as the proper treatment and care of diabetic feet. Po-48 THE QUALITY OF LIFE WITH EXTENSIVE POST-BURN SCARS L. MARKOVIC, M. DJUROVIC KCCG, Dept of Dermatovenerologija, Podgorica, Montenegro Extensive burns are the cause of complex pathophysiological responses with more complex metabolic and pathophysiological changes than any other extensive injury. After the survival serious sequelae expressed at all ages remain present. These are: horrible appearance of a body, contractures of joint body parts of a serious degree and keloid scars with consequences. With children more than 5% of burned area and over 30% with adults qualify as extensive burns. All the patients in the treatment of a burned area and also in treatment of post-burn scar sequelae are treated for a long time. With these patients, surgery as well as conservative treatment of scars by physiotherapeutic procedure is performed. Through surgery functional and aesthetic corrections are made. Despite all the therapy functional and aesthetic results are those of limited possibilities. The essence of this paper is to demonstrate the quality of life with post-burn scars. In addition to objective deformational findings, a subjective perception of the appearance is also taken into consideration, expressed as quality of life. This review represents the assessment of quality of life and examines the correlation between the scores of quality of life with psycho-physical and clinical parameters. Previously verified cognitive disorders and psychiatric diseases were excluded from this analysis. For measuring the quality of life a special questionnaire was made and for examination of certain functions with extensive scars the following scales were used: Hamilton Scale for the assessment of depression and fatigue scale. Handicap compared with person s mental

232 disorder had a significant influence on the quality of life. The quality of life significantly corresponded with the length of treatment, surgical procedures, corrective procedures, occupation and marital status of monitored patients. Conclusion: This study showed that extensive scars significantly impair the quality of life of patients when speaking of depression and physical disability. Po-5 ECONOMIC REASONS FOR PERFORMING LAPAROSCOPIC CHOLECYSTECTOMY AS A STANDARD SURGICAL PROCEDURE S. PEJCIC, V. PEJCIC, T. BOJIC, A. PRAZIC Health Care Center Nis,Center For Minimally Invasive Surgery Clinical Center Nis, Serbia Aims and purpose: The aim of this study is to assess preference of economic reasons for performing laparoscopic cholecystectomy versus open cholecystectomy. Design and Methods: During 2008, 220 laparoscopic cholecystectomy and only 0 (4,5%) of open cholecystectomy were performed. All patients were preoperatively prepared in Health Care Center Nis by a general practitioner. We analyzed: operation price, time and price for hospitalization, time and price for sick leave, and total profit at laparoscopic procedure. IMAGE Results: 80 (82%) of patients were in permanent work employment. 0 (4,5%) patients were operated as urgent (open cholecystectomy). 7 (70%) patients to whom were performed open surgical procedure were in permanent work employment. After laparoscopic procedure 95 patients went to their home next day, 7 on the same day and 8 after two days postoperatively and 30 patients (72%) went back to their job after 2 days, then 38 patients (2%) after 5 days and after 20 days 2 patients (7%). After open cholecystectomy 6 patients (60%) went to their home after 5 days, 3 patients (39%) after 7 days and patient (%) after 0 days; then 4 patients went back to their job after 20 days and 3 patients after 30 days Price for laparoscopic and for open cholecystectomy is the same - 48?, price for one hospitalization day is 20? and the cost for one day for sick leave is 65% from the pay. Conclusions: The whole price for laparoscopic cholecystectomy was 0560? and for open cholecystectomy 480?. After laparoscopic cholecystectomy 80 patients were 2370 days on sick leave and were 43 days in hospital (8620?) and after open cholecystectomy 0 patients were 70 days on sick leave and they were 6 days in hospital (220?)

233 TABLE If all patients were operated with open surgical procedure, whole price would be about 40300? and 4000 days for sick leave (saving for 20000? and 500 days of seak leave) in year. TABLE 2 TABLE 3 Po-52 RHEUMATOID ARTHRITIS-THE ROLE FOREIGN DEVELOPMENT AND COURSE OF DISEASE V. VUKOVIC IGOV, S. PEJCIC, B. RAJKOVIC General Medicine Specialist, Nis, Serbia Rheumatoid arthritis is a chronic autoimmune inflammatory disease, which leads in most cases to the destruction of cartilage, bone erosion, joint damage and eventually to smaller or larger degree of disability. Causes are mostly unknown genetic predisposition for altered immune response has an important role in the etiology of the disease, the last time often speaks about some external factors in the etiology of the disease as follows: smoking, consumption of large quantities of coffee and alcohol, reduced entry of omega 3 fatty acids, minerals and vitamins, socio-economic conditions of life and work. GOAL: draw attention to the influence of external factors on the occurrence and course of rheumatoid arthritis. METHOD AND ANALYSIS: Listened of 20 patients at the Health Center in Nis, who had a diagnosed illness. By studying their living and working habits attempted to determine the possible impact there on their health. Data were obtained by interviewing the patients. Women were 8 males and 2nd Age of , And from 6 patients years and years from 4th The number of patients increases with age. Of the total number 90% were smokers, and 0% non-smokers. 00% of patients are consumers of coffee over 20 years and 70% of them occasionally consumed and alcohol. In 80% of patients in their menu is not used often fish, omega-3 fatty acids and foods rich in vitamins and oligo elements. In 90% of cases were noted poor socioeconomic conditions of life and work, and therefore the effect of infectious agents were larger and often. 20% of patients occasionally soft foods and this is in these patients it was concluded lighter form of the disease and less disability. In 75% of patients were in a smaller or greater degree of physically inactive and was noticed by the patient tends course of the disease compared to 25% of patients who were physically active. Conclusion: The task of general medicine doctors would accented to: medicament prevention and treatment of patients with rheumatoid arthritis, which means the mode and the healthy eating and raising the socio-economic conditions of life and work of people and thus prevent or delay the occurrence of disease and reduce rate of disability

234 Po-53 WATER QUALITY AND HEALTH - HYGIENIC AND EPIDEMIOLOGICAL ASPECTS J. LUKIC Department of Primary Care, Health Center, Valjevo, Serbia Safe and sufficient water supply is an important indicator of health status of a population. Physiological, hygienic, epidemiological, technical and economic importance of water are well known and depend on its physical, chemical and biological properties which are influenced by the circulation of water, self-purifing abilities of both water and soil, as well as their pollution with liquid and solid waste from households, industry, public and agricultural areas. Insufficient water supply and low quality of water can cause a number of communicable and noncommunicable diseases. Bacterial, viral and parasitic diseases are transmitted by water (cholera, typhus, dysentery, hepatitis, gastroenteritis, ascariasis, leptospirosis etc.). Shortage of water results in poor hygiene leading to various diseases (scabies and lice infestation). Protection of water resources, hygienic disposition of liquid and solid waste and rational use of water should be an imperative of any country, society and individuals. Water often flows through many countries, therefore administrative and political borders should not pose a problem in preserving its resources. Po-54 VALUE OF WBC AND SEDIMENTATION IN THE DIAGNOSE OF DIFFERENT DISEASES. G. CESUR, 2 B. TURHAN, 3 A. TUMERDEM, 4 K. ONGEL Dept of Sport Sciences, Suleyman Demirel University Faculty of Health Sciences, Isparta, Turkey 2 Dept of Biochemistry, Duzce Ataturk Govermental Hospital, Duzce, Turkey 3 Dept of Health Management, Marmara University Faculty of Health Sciences, Istanbul, Turkey 4 Dept of Family Medicine, Süleyman Demirel University Faculty of Medicine, Isparta, Turkey Introduction: Physician practices are formed of core routine physical examination and history research. However, diagnosis and treatment of many diseases with some laboratory tests that are performed with minimum cost-effective technological equipment; is guiding In this study, value of sedimentation and WBC in the diagnose of different diseases was investigated. Material and method: Study was carried out in Isparta E irdir Bone Diseases Hospital Biochemistry Service between September and December, A total of 93 outpatients who applied to the hospital for different reasons and have biochemical measurements of sedimentation with WBC were included in the study. Patients were classified according to diagnosis into 0 different groups; with SPSS program in terms of statistical significance were evaluated using ANOVA test. Results: 857 patients (44.4%) were male, 074 (55.6%) were female. Examined according to age groups 52.9% (n:022) were between 9-60 years. Diagnosis for patients were: 329 patients (7.0%) bronchial asthma, 8 patients (6.%) acute sinusitis, 66 patients (8.6%) unspecified pneumonia, 754 patients (39.0%) acute tonsillitis, 200 patients (0.4%) more than 5 acute upper respiratory tract infection, 49 patients (2.5%) arthritis, 7 patients (0.4%) primary gonarthros, 88 patients (9.7%) acute nasopharengitis, 40 patients (2.%) acute bronchiolitis, 35 patients (.8%) tenosynovitis, 3 patients (0.7%) acute lower respiratory tract infection and 32 patients (.7%) seropositive rheumatoid arthritis. The average WBC level was highest in lower respiratory tract infection, while gonarthros was the lowest. The average level of sedimentation was highest in lower respiratory tract infection, while the lowest was acute upper respiratory tract infection. Conclusion: In this study, WBC and sedimentation in the diagnosis of different patient groups were found to be as significant parameters

235 Po-55 BURNOUT SYNDROME IN BUS DRIVERS IN ISTANBUL A. UZUNER, S. TUZUN, F. EKINCI, G. SAHOGLU, P. UNALAN Dept. of Family Medicine, Marmara University, Medical Faculty, Istanbul, Turkey Introduction: Burnout is a psychological term for the experience of long-term exhaustion and diminished interest due to the workload especially for occupations that need close relation with a crowded population. Bus drivers work in a heavy traffic and are faced with many people. Aim: The aim of this study is to investigate frequency of burnout syndrome in bus drivers in Istanbul. Method: This is a cross sectional study, performed by using Maslach inventory in bus drivers working in the Anatolian side of Istanbul. The questionnaires were distributed equally to six main lines from the Anatolian central garage of the municipality (IETT). According to the inventory, Burnout syndrome is defined in three areas. The scores over 36 mean emotional exhaustion, >36 mean depersonalization and between 0 to 6 low personal accomplishment. Results: A total of 426 bus drivers filled in the questionnaire. All of the drivers were male. Mean age was 40.2±5.8, 96.8% were married, 99.8% had social insurance. Mean working year was 0.0±6.4; mean work hours was 8,7; 53.8% stated that they find time for rest, 99% for one day in a week. The main problems were in the health, economical and social security areas. Emotional burnout mean was 5.7±9.2 (>36); desensitization was 8.4±5.6 (>36); low personal success was 9.9±6.6. (-6) Conclusion: This study showed that despite the working conditions, Burnout syndrome was not frequent among bus drivers. Po-56 COMPARISON OF CERVICAL SMEAR CULTURE RESULTS OF WOMEN USING AND NOT USING THE INTRA UTERINE DEVICE S. GUNHER ARICA Hatay No. Primary Care Center, Hatay, Turkey Objective: Family planning continues to emerge as an important problem in the world as in Turkey. The intra uterine device (IUD) is among the most used family planning method following the oral contraceptives and withdrawal. We aimed to compare the prevalence of cervical infections in women using and not using IUD. Methods: We compared the results of vaginal swab cultures of 94 women using (study group) and 46 women not using (control group) IUD who visited the Mother Child Health and Family Planning Center (FPC) in Van, Turkey with vaginal discharge complaint between January and December Exclusion criteria included vaginal bleeding and pregnancy. Results: Mean age was 32 years for of the study group and 27 years for the control group. All patients were married. We determined positive culture results in 25.5% (24) in the study group including E. coli in 7% (6), for staphylococcus in 4.2% (4), for streptococcus in 3.2% (3) and for Candida.% (). The rate for positive cultures in the control group were 9.8% presenting E. coli in.6% (7), Staphylococcus in 4.% (6), Streptococcus in 2.8% (4) and Candida in.3% (2). The difference of positive culture rates was not statistically significant (p=0.68) for both groups. Conclusion: We conclude that IUD is not a risk factor for vaginal infection and is a safe contraceptive method

236 Po-57 THE ASSESSMENT OF BODY MASS INDEXES AND NUTRITIONAL HABITS OF THE STUDENTS ATTENDING PRIMARY SCHOOL V. ARICA, 2 S. GUNHER ARICA Dept of Paediatrics, Mustafa Kemal University Medical Faculty, Hatay, Turkey 2 Hatay No. Primary Care Center, Hatay, Turkey Objective: This study was performed to evaluate the body mass indexes and nutritional habits of the students attending to primary school. Material and methods: This study was out among 85 children attending Primary School between 5th February- 5th March After the anthropometric measurements of the students were computed, Body Mass Indexes based on an age and sex-specific were determined. Results: Of the 85 students, 97 were (52.5%) girls, 88 were (47.5%) boys and were aged between 7and 0 years old. The median age value of the students was 9 (min=7, max=0). Of the students, 79.4% (n=47) have had breakfast every day, 92.9 % (n=72) had lunch, 97.8% (n=8) had dinner regularly. Of the students, 72.4% (n=34) consumed milk and yoghurt, 49.7% (n=92) eggs, 64.3% (n=9) cheese, 95.6 % (n=77) bread, 6.4% (n=2) red meat, 24.8% (n=46) honey, 47.5% (n=88) jam, 23.2% (n=43) chocolate and 55.% (n=02) fresh fruit daily. There was no difference in the mean value of BKI between all age groups (p>0.05). Being the highest values, 5.8% of the girls aged 0 were underweight, 39.0% of the boys aged 8 were overweight and 27.3 % of the boys aged 0 were obese. Conclusion: In this study, the frequency of overweight and obesity were found higher than the malnutrition. It is necessary that the regulations of the nutrition and life habits should be taken into account during the school health programs. Po-58 PREVALENCE OF OBESITY AND ASSOCIATED FACTORS IN A KINDERGARDEN IN VAN S. GUNHER ARICA, 2 V. ARICA Hatay No. Primary Care Center, Hatay, Turkey 2 Dept of Paediatrics, Mustafa Kemal University Medical Faculty, Hatay, Turkey Objective: To determine point prevalence of obesity in preschool children and associated factors. Methods: This study was conducted with 55 children aged 5-6 years at a Kindergarten in Van, Turkey. In the first part, body weight, height, waist and back circumference were measured. Body mass index (BMI) was calculated and used as an indicator of overweight according to World Health Organization (WHO) 2007 criteria (?85 to <95 percentile overweight, 95 percentile obese). In the second part, an interview on weight perceptions and weight control practices was conducted with the parents. Results: Prevalence for being overweight was 7.74% (2) and prevalence for obesity was 3.5% (2). Prevalence for obesity was higher in girls compared with boys. Back and waist circumference were significantly greater in obese children (p<0.05). Daily exercise and exclusively breast feeding durations were negatively correlated (p<0.05) while body weight measures of the parents were positively correlated (p<0.0) with the body weights of the children. Conclusion: The prevalence of overweight in Turkish children in Van, and its attendant health and social consequences, are important public health concerns. Evaluation of children in the preschool period can help to analyze the current situation and future evolution in obesity

237 Po-59 TREATMENT OF ACUTE SINUSITIS WITH INTERMITTENT AZITHROMYCIN AND CEFUROXIME: A COMPARATIVE STUDY V. ARICA, 2 S. GUNHER ARICA, M. DOGAN Dept of Paediatrics, Mustafa Kemal University Medical Faculty, Hatay, Turkey 2 Hatay No. Primary Care Center, Hatay, Turkey 3 Special Region Hospital, Istanbul, Turkey Aim: To compare the side effects, adherence and outcomes of treatment with one daily dose Azithromycin and two daily doses of Cefuroxime in acute sinusitis in children. Methods: 50 children admitted to the Public hospital of Sariyer Istinye between November 2006 and March 2008 with clinical and radiological diagnosis of acute bacterial sinusitis were included in the study. 75 patients were treated in two periods with 0 mg/kg daily one dose Azithromycin for five days before and after a break of five days. Another 75 patient were treated with 20 mg/kg daily in two doses for 5 days consecutively. Results: 85 boys and 65 girls were included in the study with a mean age of 0 years (ranger 5-5 years). Symptom scores of Azithromycin group in the end of week one were significantly lower than the Cefuroxime group (p<0.05) which continued in a non-significant level at the end of week two. 95% of cases were cured in the Azithromycin group compared to 93% in the Cefuroxime group. Adherence to, acceptance and satisfaction with Azithromycin was significantly higher in the families. Results: We conclude that a five days intermittent treatment with Azithromycin is at least as effective as Cefuroxime and results in relieve in the symptoms earlier. Further investigation of intermittent Azithromycin treatment is necessary

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239 INDEX

240 ACEMOGLU H OP-28 ADALI E OP-2, Po-26 AGIC R Po-49 AK PARLAK F Po-35 AKAN H Po-65 AKBULUT H Po-73, Po-74, Po-86, Po-87, Po-88, Po-32, Po-33, Po-34 AKDAG B OP-2 AKGUN HS OP-23 AKOGLU L Po-26, Po-39 AKPINAR E OP- AKTURK Z OP-28 ALEKSOV D Po-42 ALEKSOV V Po-42 ALIBASIC E Po-3, Po-64, Po-69, Po-72 ALIC T OP-20 ALTUNBAS E OP-39, Po-47 ANTEPUZUMU D Po-44 APAYDIN KAYA C OP-4 ARICA V Po-57, Po-58, Po-59 ASLAN M Po-5 ASSENOVA R OP-26, Po-04, Po-05 ATMACA B Po-5 AYDIN ON MExp-3 AYDOGAN U OP-42, OP-43, Po-45, Po-46, Po-73, Po-74, Po-84, Po-86, Po-87, Po-88, Po-25, Po-32, Po-33, Po-34 AYDOGDU A Po-84, Po-33, Po-34 AYYILDIZ O Po-9 BADUR S Pa-6 BAJRAMSPAHIC A Po-33, Po-49 BALOS L Wo-2 BARCIN C Po-73 BATIC-MUJANOVIC O RTa-3, Po-2, Po-30, Po-3, Po-40, Po-4, Po-64, Po-69, Po-72, Po-85 BAYAR R Po-24 BAYAT M OP-38, Po-53 BECAREVIC M Po-40, Po-64 BEGANLIC A RTa-, RTa-2, Po-2, Po-30, Po-3, Po-40, Po-4, Po-52, Po-54, Po-63, Po-69, Po-72, Po-85 BELCHEVA M Po-22 BISANOVIC S Po-40, Po-64 BITRI A Po-0, Po-, Po-5, Po-2, Po-25 BLIZNAKOVA D Po-8, 2 BOCUTOGLU C Po-75, Po-76 BOJIC T Po-5 BOLU E Po-33, Po-34 BONCHEVA M Po-23 BORMAN P Pa-7 BOZDEMIR N OP-, Po-44 BRKOVIC A Po-2, Po-40, Po-4 BULUT B Po-23 BUNJAK L OP-3, Po-3, Po-4 BUSNEAG A OP-7 BUSNEAG C OP-7 BUYUKKARA E OP-4 CAGATAY S OP-4 CAN M OP-2, Po-26 CELIK AI OP-4 CELIK M Po-2, Po-27 CELIKTEPE M Po-86 CESUR G Po-54 CETIN SECKIN R OP-28 CETINEL Y OP-23, OP-24, OP-25, OP-27 CEVIZCI F Po- CEYHUN PEKER AG Po-35, Po-38 CIFCILI S OP-29 COSIC G Po-9 CUCELOGLU A Po-32 CUKANI E Po- DAGLI Z Po-35 DAJANOVIC N Po-40 DAMJANOVIC J Po-44 DAVIDOVIC M MExp- DELEVIC L Po-32 DEMIC H Po-40 DEMIRSOY N Po-29, Po-3 DESPOTOVIC N MExp- DHALES N Po-0, Po-, Po-5, Po-25 DIKILILER A Po-45 DINCER H Po-74 DJUROVIC L OP-30, Po-50, Po-43, Po-44 DJUROVIC M Po-47, Po-48 DOBROVIC-MILOSEVIC M OP-3 DOGAN M Po-59 DOGAN N Po-39 DOGANER YC Po-25, Po-32, Po-33 DONMEZ A Po-22, Po-23, Po-26, Po-38, Po-39 DRAGIC L OP-30 DURHAN A Po-24 EDIRNE T OP-2, Po-5, Po-26 EKERBICER HC Po-2, Po-27 EKINCI F Po-55 ELCIOGLU O Po-28, Po-3 EMINSOY MG OP-23, OP-24, OP-25 EPHRAIM M Wo- ERCAN IA Po-38 ERCEG P MExp- ERDAL M Po-6, Po-7 ERDAL R OP-25, OP-27 ERDEM KOROGLU D Po-, Po- ERDEM O Po-9 ERDIL A Po-24, Po-37 EREIZ J Po-52, Po-54 ERTOPCU K Po-22, Po-23, Po-26, Po-27, Po-34, Po-38, Po-39 FOREVA G OP-26, Po-04, Po-05 GALIC I Po-50 GAVRAN L Po-40, Po-64 GENCOGLAN G Po-20 GEORGIEV V Po-59 GEORGIEVA L Po-6 GEROVA D Po-02 GEVREK O Po-87, Po-88 GJONI B Po-0, Po-, Po-5, Po-2, Po-25 GOKTEKIN C OP-25 GONENC I MExp-2 GRBOVIC M OP-8, OP-9 GRUJIC B Po-3, Po-4 GULEN T Po-34 GULMAN OP-20 GUNAYI Z Po-7 GUNDUZ T Po-28 GUNHER ARICA S Po-56, Po-57, Po-58, Po-59 GUNTURKUN H OP-27 GUREL S OP-39 GUROL Y Po-65 GURSOY A OP

241 HASANAGIC M HASANAJ M HAYRAN O HELVACI M HERENDA S HICYILMAZ C HRISTOVA S HYSI G ILIC I INAN S INCECIK Y INCI K ISIKLAR C ISMAILOGULLARI S IVANCEVIC J IVANOVA D IVANOVSKI O IZBIRAK G JASIC J JOKOVIC B JOVICEVIC B KALEVA V KARA IH KARA T KARAASLAN L KARADAG B KARADENIZLI D KARAHAN M KARAHAN SH KARAMANAGA G KARAOGLU MA KARAOGLU N KARATAS ERAY I KARIC E KARS V KARTAL M KASHLOVA S KAVUK S KAYA E KAYACAN H KAYAR AH KAYIRAN SM KELEKCI S KELMENDI M KERSNIK J KIRIMLIOGLU N KIYICI A KLEMENC KETIS Z KNEZEVIC O KOCANKOVSKA L KOKCU AT KOLSEK M KOLUSARI A KOMURCU S KONICA V KOPUK MK KORKMAZ M KURDAK H KURNUC S KURTOGLU S KUSASLAN D KUT A LAZAROV S RTa-3, Po-2, Po-30, Po-40 Po-5 Po-65 Po-23, Po-26, Po-34, Po-39 Po-2, Po-30, Po-40, Po-4, Po-85 Po-24 Po-00, Po-0, Po-03 Po-2, Po-25 OP-3 Po-35, Po-38 Po-44 Po-20 OP- OP-38, Po-53 Po-55, Po-56, Po-83 Po-02 Po-59 Po-65 Po-63 OP-3 Po-40 Po-22 Po-9 Po-98 Po-39 Po-37 OP-20 OP-29 Po-22, Po-26, Po-27, Po-34, Po-38 Po-4, Po-42 Po-8, Po-7 OP-9, Po-8, Po-9, Po-7, Po-77 OP-39, Po-47 Po-3 Po-26 OP- Po-23 Po-74 Po-7 Po-58 Po-7 Po-92 Po-22 Po-0, Po-, Po-5, Po-2, Po-25 OP-5 Po-28, Po-29 Po-3 OP-5 Po-93 RTa-, RTa-2 Po-28, Po-29, Po-3 Ple-2 OP-2, Po-26 Po-25 Po-0, Po-, Po-5 Po-38 Po-79 OP- Po-27 OP-38, Po-53, Po-98 Po-5 OP-23, OP-24, OP-25, OP-27 Po-9 LJILJA K Po-0 LJUCA D Po-69, Po-72 LJUCA F Po-69, Po-72 LUKIC J Po-53 MADJOVA V Wo-2, OP-26, Po-6, Po-97, Po-00, Po-0, Po-02, Po-03, Po-04, Po-05, Po-23 MAJSTOROVIC S Po-9 MAKSIMOVIC L Po-30 MALOVIC S OP-8, OP-9 MANCHEVA P Po-00, Po-0, Po-03 MARAKOGLU K MExp-5, OP-3, Po-, Po-3, Po- MARINOV L Po-8, Po-9, Po-2, Po-22 MARKOVIC K Po-30 MARKOVIC L Po-47, Po-48 MARKOVIC S Po-93 MAZICIOGLU MM OP-38, Po-53, Po-98 MEMIOGLU N Po-92 MEVSIM V Po-48, Po-7 MICANOVIC S OP-28 MILJKOVIC L Po-08, Po-6 MILOSAVLJEVIC M OP-3 MILOSEVIC D OP-33, OP-34 MILOSEVIC DP MExp- MILOVANCEVIC S Po-3, Po-4 MIRA P Po-0 MOJKOVIC M RTa-, RTa-2, Wo-2 MUJCINAGIC-VRABAC M Po-30, Po-63, Po-85 MUNGAN MT Po-76 MUTLU S Po-46, Po-86 NERKIZ P Po-87 NIKOLIC D Po-9 NIKOLIC S OP-33, OP-34 OBORINA V Po-43 ONGEL Po-76 ONGEL K Po-57, Po-58, Po-75, Po-54 ORHAN FO Po-2, Po-27 OSTOJIC D OP-8, OP-9 OZAYDIN M Po-57 OZCAKAR N OP- OZCAN C OP-24, OP-25 OZCAN S OP- OZCEYLAN G Po-22 OZDATLI S Po-65 OZDEMIR S Po- OZDOGAN S Po-6, Po-7 OZDOGRU M Po-98 OZEK B Po-39 OZELMAS I Po-23, Po-26, Po-38, Po-39 OZER A Po-2, Po-27 OZER UG Po-27 OZEREN M Po-26 OZGENECI A Po-24 OZLUK O OP-4 OZMEN O Po-44 OZTURK A Po-98 OZTURK B Po-25 OZYALCIN S MExp-3 PALA B OP-0, Po-43 PARLAK A OP-42, OP-43, Po-45, Po-46, Po-73, Po-32 PAVLOVIC T Po-55, Po-56, Po-83 PEJCIC S OP-37, Po-5, Po-52 PEJCIC V Po-5 PETEVA E Po

242 PICAK R Po-53 POPOVA S Po-6 POYRAZ U Po-24 PRAZIC A Po-5 RACIC M Po-0 RADOSAVLJEVIC O Po-40 RAJKOVIC B OP-37, Po-52 RAMIC E Po-3, Po-4, Po-64, Po-69, Po-72 RASKOCIC K Po-50 RASKOVIC K Po-43, Po-44 RASOVIC S Po-30 REDZEPAGIC L RTa-3 SAATCI E OP-, Po-44 SAGLAM K OP-42, OP-43, Po-45, Po-46, Po-73, Po-74, Po-84, Po-86, Po-87, Po-88, Po-25, Po-32, Po-33, Po-34 SAHINLI AS Po-3 SAHOGLU G Po-55 SAHSIVAR MS OP-3, Po-, Po- SARI O Po-73, Po-74, Po-84, Po-86, Po-87, Po-88, Po-25, Po-34 SAV AYDINLI M Po-35 SAVOV L Po-97 SEKER M Po-9 SELMANOVIC S Po-3, Po-63, Po-85 SENAY M OP-23 SENSOY N Po-20, Po-39 SEVO-ALEKSIC B Po-99 SHIVACHEV P Po-8, Po-9, Po-2, Po-22 SIMOVIC S Po-93 SIVRI F OP-9, Po-77 SIVRIKAYA Y Po-24 SOFTIC A Po-63 SOFTIC-OMEROVIC A Po-52, Po-54 SOKMEN N Co-2 SOP G Po-22, Po-27, Po-38 SOZEN F OP-27 SRABOVIC S Po-63, Po-85 SREBRENKA K Po-0 STANKOVIC S Pa-, Pa-5, Wo-2 STEFANOVIC V Po-70 STEVOVIC GOJGIC D Po-70 STOJAKOVIC J OP-3 STOJANOVSKI B Po-59 STOJKU A Po-2, Po-25 SUKRIEV L Ple-, RTa-, RTa-2, Po-42 SUNAY D Po-20 TANER CE Po-34 TANYILDIZI I Po-48 TASYURT A Po-23, Po-26, Po-27, Po-34, Po-38, Po-39 TAYMAZ B Po-92, Po-24 TAYMAZ T Po-90, Po-92, Po-24, Po-37 TEKIN N Po-47 TEKINER AS Po-35, Po-38 TEZCAN S Pa- TINAR S Po-23, Po-34 TODOROVA V OP-26, Po-97 TOMCHEVA S Po-02 TOPRAK D Po- TOPSAKAL N OP-29 TORE E OP-24 TOSUN N OP-4 TRACIUC R Po-67 TRATNIK E OP-5 TRIFUNOVIC BALANOVIC D Po-7, Po-08, Po-6 TULUMOVIC A Po-69, Po-72 TUMERDEM A Po-54 TUNCAY B Po-39 TUNCKANAT Pa- TURHAN B Po-54 TURKER Y Po-57 TUSEK-BUNC K OP-5 TUZCULAR VURAL Z MExp-2 TUZUN S Po-55 UCKAN U Po-20 UCKARDES Y OP-27 UCKAYA G Po-84 ULU H Po- UNALACAK M OP-0, Po-43, Po-79, Po-28, Po-3 UNALAN P OP-20, Po-55 UNALAN PC OP-29 UNLUOGLU I OP-0, Po-79, Po-29 USLUER G Pa-6 USTUNBAS HB OP-38, Po-53, Po-98 UZUNER A Po-55 VACARRI B Po-5 VANCELIK S OP-28 VANKOVA D Po-02 VARBANOVA B Po-2 VESELI A Po-2 VITRINEL A Po-65 VRANES-GRUJICIC M Po-50 VUKOTIC J Po-3, Po-4 VUKOTIC S OP-3 VUKOVIC IGOV V OP-37, Po-52 YARPUZ MY Po-84 YIGIT G OP-29 YILDIRIM Y Po-27, Po-38 YILDIZ I Po-37 YILDIZHAN D OP-38, Po-53 YILDIZHAN R OP-2, Po-26 YILMAZ E OP-38, Po-53 YILMAZ G Po-65 YUKSEL F OP-0, Po-43, Po-79 YUKSEL S Po-88 ZABUNOV A Po-00, Po-0, Po-03 ZELJKOVIC G Po-08, Po-6 ZHELEVA M Po-2 ZIVANOVIC S Pa-4, Po-70 ZOGOVIC VUKOVIC L Po

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