EJFM 1(1) reduced

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EJFM 1(1) reduced

Euras J Fam Med
EURASIAN JOURNAL OF FAMILY MEDICINE
Avrasya Aile Hekimliği Dergisi
VOLUME 1 • YEAR 2012 • AUGUST • NUMBER 1
Euras J Fam Med
Avrasya Aile Hekimliği Dergisi
VOLUME 1 • YEAR 2012 • AUGUST • NUMBER 1
ISSN: 2147-3161
PUBLISHED THREE TIMES A YEAR
Editor
H. Nezih Dağdeviren
Editorial Board
Zekeriya Aktürk
Mehmet Ungan
Serdar Öztora
Ayşe Çaylan
Erdem Birgül
Necdet Süt (Statistics Editor)
INTERNATIONAL ADVISORY BOARD
Amanda Barnard (Australia)
Ayfer Gemalmaz (Türkiye)
Chris van Weel (Netherlands)
Christos Lionis (Greece)
Daniel M. Thuraiappah (Malaysia)
Davorina Petek (Slovenia)
Denis Puchain (France)
Dilek Toprak (Türkiye)
Esra Saatçi (Türkiye)
Faisal A. Latif Alnasir (Kingdom of Bahrain)
Ferdinando Petrazuoci (Italy)
Füsun Ersoy (Türkiye)
Howard Tandeter (Israel)
Iona Heath (UK)
İlhami Ünlüoğlu (Türkiye)
İsmail Hamdi Kara (Türkiye)
Johan Wens (Belgium)
John Murtagh (Australia)
José Miguel Bueno Ortiz (Spain)
Luc Martinez (France)
Marius Marginean (Romania)
Mehmet Uğurlu (Türkiye)
Michael Kidd (Australia)
Murat Ünalacak (Türkiye)
Mümtaz Mazıcıoğlu (Türkiye)
Nabil Alkurashi (Saudi Arabia)
Paul Van Royen (Belgium)
Peter Kotanyi (Hungary)
Pinar Topsever (Türkiye)
Richard Hobs (UK)
Richard Roberts (USA)
Sarah Larkins (Australia)
Süleyman Görpelioğlu (Türkiye)
Teresa Pawlikowska (UK)
Tuncay Müge Alvur (Türkiye)
Turan Set (Türkiye)
Valentina Madjova (Bulgaria)
Wesley Fabb (Australia)
Young-Sik Kim (Korea)
Zorayda E. Leopando (Philippines)
Owner
H. Nezih Dağdeviren
(On Behalf of ESFAM)
Responsible Managing Editor
Serdar Öztora
Editorial Office
Trakya University Medical Faculty, Department of Family Medicine (Aile Hekimligi), Balkan Campus, 22030, Edirne, Türkiye
EDITORIAL
Dear colleagues,
It is an honor for us to publish Eurasian Journal of
Family Medicine after a long time effort. Our journal
is on its way with the mission of sharing knowledge
among family physicians and contributing to
occupational improvement across the wide geography
of Eurasia. We hope that the repertoire from different
localizations, different medical traditions and
different health care systems around this geography
will improve the shared knowledge and ‘think
global-act local‘ ability of the family physicians.
Participation of the milestone names of the global
Family Medicine from all around the world as
Advisory Board Members is another prosperity of the
journal. I appreciate and thank our international
advisory board, which include the past, present and
future presidents of WONCA, for their agreement of
participation.
We dedicate our first issue to a great scientist Prof.
Dr. Barbara Starfield, who also agreed to participate
as an Advisory Board Member and passed away
before seeing the first issue and appreciate her great
contributions to the family medicine.
PROF. NEZIH DAGDEVIREN, MD
EDITOR IN CHIEF
Euras J Fam Med, 1(1),2012.
I N D E X / İÇ İN D E K İL E R
Title / Başlık
Authors / Yazarlar
1. Does Family Medicine Need Another Journal?
Richard Roberts
4. Evaluation of Daily Life Activities and Quality of Life Hasan Hüseyin Eker, Mustafa Taşdemir, Emel
Lüleci, Merve Kocaakman, Saime Şahinöz,
of the Elderly Living in Nursing Homes in Istanbul
Mehmet Akif Karan
11. Ailelerin Ateşli Çocuğa Yaklaşımı ve Ateş Bilinç
Durumu
Families’ Approach to Feverish Children and Fever
Awareness
Polat Nerkiz, Yusuf Çetin Doğaner, Ümit Aydoğan,
Tamer Onar, Faysal Gök, Kenan Sağlam, Okan
Özcan
17. Smoking, Alcohol Consumption and Exercise Habits Emel Lüleci, Hasan Hüseyin Eker, Mustafa
Taşdemir, Saime Şahinöz
of Elderly Living in Nursing Homes in Istanbul
23. Aile Hekimliğinde Kapsamlı Bakım Yeterliliği ve
Değerlendirilmesi
Zekeriya Aktürk, Hamit Acemoğlu
Comprehensive Care and its Evaluation in Family
Medicine
29. Family Medicine in Pre-clinical Years of Medical
School: Fruitful or Futile
Abdul Sattar Khan, Zekeriya Akturk
35. A Case with Skin Discoloration
Dilek Toprak, Esma Aksaç Adalı
2012
Does Family Medicine Need Another Journal?
AUTHOR
Richard Roberts
President of WONCA
Department of Family
Medicine, University of
Wisconsin School of
Medicine & Public
Health, USA
Using “Family Medicine” as a search term generates 82 journals in the National
Library of Medicine (NLM) catalog. After eliminating journals that have little to do
with Family Medicine, journals that are discontinued, and journals that are
duplicates, there remain about 40 current Family Medicine journals that are indexed
in NLM’s Medline.
It is estimated that there are about 14000 biomedical journals in publication with
about 40% of them, or 5800, approved for inclusion and indexed in Medline (1).
Family Medicine journals therefore represent less than 1% of indexed journals, or
about 40 out of 5800. The irony is that the proportion of all health system encounters
that occur in primary care ranges from about half (United States) to more than 9 out
of 10 (United Kingdom) (2,3). So, in effect, while primary care clinicians provide the
majority of health care services around the world, they are asked to do so with less
than 1% of the indexed knowledge base. We have a long way to go.
One barrier to research by and for family doctors is the difficulty in getting
published in indexed journals. Some might contend that Family Medicine does not
produce enough quality research to warrant more journals. This seems a bit like the
proverbial chicken and egg question: should more publication outlets come first or
should significant research results come first? Without a reasonable probability that
one’s research will be published, why bother to conduct the research? Therefore, an
important priority for our discipline should be to establish more journals that achieve
indexed status.
There are other barriers to research besides ease of publication. The daily work
of family doctors suggests that they prefer patient care over research, since that is
what they do most of the time. Some of their preference may reflect a sense of
greater satisfaction helping patients rather than performing research. On the other
hand, some of their preference may reflect the economic necessity of having to
maintain a financially viable practice. For many family doctors, participating in
research means earning less income or working longer hours or adding more
complexity to their lives than they are willing to take on.
As a result, most clinical research is done by sub-specialists working in academic
health centers. Many of those researchers see patients only a session or two a week.
They design research protocols to address issues of interest to them. To simplify the
analysis, their studies often limit research subjects to those without multiple
morbidities. To speed up the research, many studies are modeled along the same lines
as medication studies: 12 week double blind cross over placebo controlled trials.
Their research team is able to assure follow up visits and correct pill counts. They
can secure significant time and funding for their efforts because they are supported
by academic infrastructures that value research. Yet, when it comes to the health of
all people, we may be in a situation where the wrong people are asking the wrong
questions on the wrong patients in the wrong setting.
1
Roberts R. Does Family Medicine Need Another Journal?, Euras J Fam Med, 1(1):1-3,2012.
Although their studies were separated by 40 years,
White and Green and colleagues came to similar
conclusions when they looked at a typical United
States community of 1000 adults followed over a
month (4,5). During that time period, about 800 of the
1000 developed symptoms (cough, fracture, allergies,
depression, etc.), 217 sought consultation with a
doctor (slightly more than half of those were to
primary care doctors), 13 were seen in emergency
departments, 8 were admitted to a community
hospital, and less than 1 was hospitalized at an
academic health center. Given that the vast majority of
published studies are conducted in academic health
centers, one must conclude that the resulting literature
is not necessarily relevant to the care of most people.
More surprising is that the current literature may
not have much accuracy or durability for anyone, even
those in academic health centers. Ionnaides showed
that fewer than half of the most frequently cited
studies produce results that are accurate or durable (6).
Frustratingly, early research findings quickly get
converted into clinical practice guidelines, which take
on regulatory and financial importance when they are
reduced to performance measures.
A case in point is glycated hemoglobin. For a
number of years, the literature advised that a patient’s
glycated hemoglobin should be kept below 7%. Many
in the primary care community felt that was too low,
especially for older patients and those with multiple
morbidities. In the past several years, 3 studies
addressed this issue by including more typical patients
with type 2 diabetes mellitus – those who are middle
aged with other morbidities such as high blood
pressure, dyslipidemia, etc (7-9). Among these
patients, there was a higher mortality rate for those
with glycated hemoglobin levels less than 7%.
Frustratingly, once the target of less than 7% was set,
it has proved difficult to change it and allow less
intensive glucose control.
Imagine how different things might be if it were
easy for family doctors to do research. When needed,
there would be methodologists available to assist in
framing the research, statisticians to assist in analysis,
support teams to help conduct the research, and
financial support for the time away from patient care.
2
In fact, imagine for a moment that every family
doctor participated in research – some as principal
investigators, some as sources of data, and so on.
Further imagine that all the family doctors were able
to reach out to other family doctors around the world
to participate in their research and to quickly share
their findings. While these may seem like impossible
dreams today, electronic health records, practice-based
research networks, and mobile telephony are likely to
make this a reality in the next 2-3 decades.
The upshot of all this would be many more
research findings that are more likely to reflect the
typical patient in the typical setting. The number of
subjects studied, drawn from the billions cared for by
family doctors, could provide greater confidence that
the study is a better reflection of actual practice and
most patients.
Once all of this research has been conducted and
written up, there must be a place to publish it. Thus,
to go back to my opening question, we definitely need
more journals in Family Medicine. The Eurasian
Journal of Family Medicine will be unique because it
will cover a broad geographic expanse and focus on
studies drawn from practice networks. This should
excite all of us. I hope this journal will become an
indexed publication, publishing compelling research
which changes practice and improves patients’
outcomes.
Roberts R. Does Family Medicine Need Another Journal?, Euras J Fam Med, 1(1):1-3,2012.
References
1. National Library of Medicine.
Available at http://www.nlm.
nih.gov/tsd/serials/lsiou.html
2. National Center for Health
Statistics. Ambulatory
Medical Care Utilization
Estimates for 2007.
Bethesda, Maryland, USA:
April 2011. DHHS
Publication No. 2011-1740.
Available at http://www.
cdc.gov/nchs/data/series/sr_1
3/sr13_169.pdf .
3. Trends in consultation rates in
General Practice 1995/1996
to 2008/2009: Analysis of the
QResearch® database. Final
Report to the NHS
Information Centre and
Department of Health.
Hippisley-Cox
J,
Vinogradova Y. Published by
4.
5.
6.
7.
The NHS Information Centre
for Health and Social Care,
part of the Government
Statistical Service. September
2009. ISBN 978-1-84636-328
-3.
White KL, Williams TF,
Greenberg BG. The ecology
of medical care. N Engl J
Med 1961;265: 885-892.
Green LA, Yawn BP, Lanier
D, Dovey SM. The ecology
of medical care revisited. N
Engl J Med 2001;344:20212025.
Ionnaides JPA. Contradicted
and initially stronger effects
in highly cited clinical
research. JAMA 2005. July
13; 294(2): 218-228.
The Action Control
Cardiovascular Risk in
Diabetes Study Group.
Effects of intensive glucose
lowering in type 2 diabetes.
N Engl J Med 2008;358:
2545-2559.
8. The ADVANCE Collaborative Group. Intensive blood
glucose control and vascular
outcomes in patients with
type 2 diabetes. N Engl J Med
2008; 358:2560-2572.
9. Duckworth W, Abraira C,
Moritz T, et al. Glucose
control and vascular complications in veterans with
type 2 diabetes. N Engl J Med
2009;360: 129-139.
Corresponding author:
Prof. Richard Roberts, MD, JD
University of Wisconsin,
School of Medicine & Public Health,
Department of Family Medicine,
1100 Delaplaine Court, Madison WI 53715, USA
E-mail: [email protected]
3
2012
Evaluation of Daily Life Activities and Quality of Life of the Elderly
Living in Nursing Homes in Istanbul
AUTHORS
Hasan Hüseyin Eker
Department of Nursing,
Gümüşhane University
Health College,
Gümüşhane, Turkey
Mustafa Taşdemir
Department of Public
Health, Marmara
University School of
Medicine, Haydarpaşa,
Istanbul, Turkey
Emel Lüleci
Health, Marmara
Istanbul, Turkey
ABSTRACT
Aim: The aim of this study is to investigate the factors affecting DLA and QOLof elderly
living in public and private nursing homes.
Methods: This study is cross-sectional and it has been conducted in one public and six private
nursing homes. The evaluation of 161 elderly participants living in nursing homes was made by
Instrumental Daily Life Activities, KATZ daily life activities index and the WHOQOL – BREF
scale. Data were evaluated with the SPSS 11.5 package program.
Results: The mean age was 74.38 ± 9.59 years. 54.0% were in public and 46.0% in private
nursing homes. It was found that the elderly in private nursing homes were more dependent in all
daily life activities compared to those in public nursing homes (p<0.01). While the environmental
field score of the elderly in private nursing homes were higher; physical, mental and social field
scores of those in public nursing homes were higher (p <0.05). A positive correlation was found
between the score from face scale to evaluate satisfaction of living in a nursing home and
environmental, mental and social field scores (p<0.05).
Conclusion: It was found that elderly in private nursing homes were more dependent in all
DLA compared to elderly in public nursing homes. While the environmental field scores of elderly
in private nursing homes were higher; physical, mental and social field scores of those in public
nursing homes were higher.
Key words: Quality of life, Nursing home, Elderly
Merve Kocaakman
Istanbul Special
Provincial
Administration, Istanbul,
Turkey
Saime Şahinöz
Health College,
Mehmet Akif Karan
Department of Internal
Medicine, Istanbul
Medicine, Istanbul,
Turkey
4
Introduction
Senility is an important process in human life when physical and mental
capabilities are lost at different degrees and levels. In various references, senility is
described as “an inidividual transformation, physical and mental recession of an
individual", "A process when individuals loose beloved ones, transform from
productivity to consumption, when activity loss increase and they lead a life more
and more dependent on others” (1,2).
As in many countries senility process is gaining speed in Turkey too. While 3.4%
of population were 65 years or older in 1955 census, this ratio became 4.3% in 1990
census and 5.5% in 2000 census. In 2007, ratio of the population aged 65 years or
older was 6.8% in Turkey. It is estimated that this ratio will be approximately 10% in
2025 and 20% in 2050 (3,4).
With ageing and prolongation of life cycles of populations, quality of life and life
satisfaction have become important issues (5,6).
“Quality of life” can be described as “well being of individuals” or
“omnidirectional satisfaction from life”, in accordance with the description of
“health” by World Health Organisation (7,8).
This study was conducted to investigate the factors that affect the daily life
activities and quality of life of the elderly living in public and private sector nursing
homes.
Eker HH. Evaluation of Daily Life Activities and Quality of Life of the Elderly Living in Nursing Homes in İstanbul, Euras J Fam Med, 1(1):4-10,2012.
Methods
After approval by the local ethical committee,
this cross-sectional study was conducted in randomly
chosen nursing homes (one public and six private)
between November 2009 and January 2010.
Questionnaires were filled by face to face interview
with 87 volunteering participants of 132
communicable elders living in a public nursing home
and 74 volunteering participants of 98 communicable
elders living in private nursing homes. The survey
questionnaire included sociodemographic features,
state of handicap, state of using assistive apparatus
and prosthesis, kinds of assistive devices and diseases
diagnosed by the physician.
Instrumental Daily Life Activities and KATZ
Daily Life Activity Index have been used to evaluate
daily life activities. The World Health Organization
Quality of Life (WHOQOL – BREF) Scale has been
utilized to assess quality of life.
Daily life activity index has been developed by
Katz et al. (9). There are 8 questions included in the
index. These are eating-drinking, dressingundressing, combing, shaving, walking, going to
bed-rising from bed, fulfill lavatorial needs,
shopping- taking a walk and incontinence. All
questions other than incontinence are graded as 0 if
normal, as 1 slightly impaired and as 2 if totally
impaired. Incontinence is graded as 0 if negative, as 1
if it occurs once or twice a week and as 2 if it occurs
more than three times a week. Total grades range
between 0 (normal) and 16. Grade increases as
funcionality decreases.
Instrumental daily life activity scale has been
developed by Lawton and Brody (10). It consists of
seven questions. These include using a telephone,
travelling by car-taxi, shopping for food and clothes,
cooking, housework, recognition and usage of
medication and doing things related with money. If
the function is intact the grade is 0, if it is slightly
impaired the grade becomes 1 and in total impairment
the grade is 2. The total grade ranges between 0
(normal) and 14. Grade increases as functionality
decreases.
WHOQOL-BREF scale has four subsectional
scores. These are physical, mental, environmental and
social health domains. The sub-sectional scores and
not the total score are utilized. High scores indicate
higher quality of life.
Physical domain: Consists of pain and
disturbance, libido and fatigue, sleep and resting
phases.
Mental domain: Evaluates how often and how
much an individual experiences positive emotions
such as inner peace, stability, reconciliation,
happiness, hope, cheer, getting pleasure out of good
things in life as well as negative emotions such as
hopelessness, guilt, sadness, irritability, mopes and
lost taste of life; his/her concept of thinking, learning,
memory, focusing and making decision; feelings of
an individual about himself/herself and way of
looking to his/her external appearance.
Environmental domain: This section handles an
individual’s perception of physical security and
impact of milieu; individual’s assessment of material
sources, healthcare services nearby and social
support. In addition, it evaluates the way the
individual looks at desire and opportunities to
recognize and desire to obtain new knowledge to
maintain an opinion about things happening around,
individual’s opportunities to evaluate spare time and
his/her looking at the environment, his/her opinion on
how easy the individual can find vehicles to move
around and get advantage of them.
Social domain: It investigates what degree of
love and support an individual expects from relations
with others and how the individual evaluates the
support, consent and help from family. In addition, it
evaluates the state of an individual to express sexual
desires and fulfill them in an appropriate manner
(11).
Data have been analyzed with SPSS 11.5 package
program and Chi-Square, Kruskal-Wallis variance
analysis and Mann-Whitney U tests were used for
statistical analysis.
Results
Mean age of the participants was 74,4±9,6 years,
where the average age of those living in public
nursing homes was 70,25±7,69 and of those living in
private nursing homes was 79,19 ± 9,38 years.
Fiftyfour percent of participants were living in
public nursing homes while the rest (46%) were
5
living in private nursing homes. 58.4% of
participants were male and 41.6% of them were
female. High school graduates constituted the largest
group (31.7 %) while graduates of university make
the smallest group (5.6%). More than half of the
participants were widow/widower or divorced (Table
1).
When daily activities were examined considering
gender it was seen that females were more dependent
in hygiene, shopping, transportation, cooking and
bathing (p<0.005), (Table 2).
When daily activities were examined regarding
being residents of public or private nursing homes, it
was detected that elderly living in private nursing
homes were more dependent in all their daily
activities compared to those living in public nursing
homes (Table 3).
Table 1: Descriptive features of elderly
Features
n
%
Public
87
54
Private
74
46
Female
94
58.4
Male
67
41.6
Illiterate
16
9.9
Literate
28
17.4
Primary School
33
20.5
Secondary School
24
14.9
High School
51
31.7
Academy-College
9
5.6
Married
5
3.1
Single
60
37.3
Divorced
28
17.4
Widow-widower
67
41.6
Total
161
100
Nursing Home Type
Gender
Educational Level
Marital status
Table 2: Daily activity status and gender
Partially
dependent
Non dependent
n
%
n
%
n
%
Total
n
%
Significance
Hygiene
Male
Female
51
15
61.4
24.2
10
8
12.1
12.9
22
39
26.5
62.9
83
62
57.2
42.8
x²:22.01
p:0.000**
Shopping
Male
Female
56
18
65.1
27.3
12
11
14.1
16.7
18
37
20.9
56.1
86
66
56.6
43.4
x²:23.90
p:0.000**
Transportation
Male
Female
53
17
60.2
26.6
17
9
19.3
14.1
18
38
20.5
59.4
88
64
57.9
42.1
x²:24.95
p:0.000**
Cooking
Male
Female
47
20
23.2
31.3
15
11
17.2
17.2
25
33
28.7
51.6
87
64
57.6
42.4
x²:9.31
p:0.000**
Bathing
Male
Female
55
22
62.5
32.8
15
14
17.1
20.9
18
31
20.5
46.3
88
67
56.8
43.2
x²:15.05
p:0.001**
Dressing
Male
Female
57
33
63.3
36.7
13
12
52
48
18
21
46.2
53.8
88
66
57.1
42.9
x²:3.601
p:0.165
Lavatorial activities
Male
Female
69
43
61.6
38.4
14
13
51.9
48.1
6
11
35.3
64.7
89
67
57.1
42.9
x²:4.531
p:0.104
Sitting, Laying, Rising
Male
Female
69
41
62.7
37.3
7
11
38.9
61.1
10
13
43.5
56.5
86
65
57
43
x²:5.595
p:0.061
Incontinence
Male
Female
54
41
56.8
43.2
16
10
61.5
38.5
8
11
42.1
57.9
78
62
55.7
44.3
x²:1.833
p:0.400
Eating Food from
Dish, Oral Orientation
Male
Female
73
48
60.3
39.7
9
12
42.9
57.1
3
6
33.3
66.7
85
66
56.3
43.7
x²:4.271
p:0.118
**p<0.01
6
Dependent
Table 3: Daily Activity Status and Nursing
Non dependent
Partially dependent
Dependent
Total
Significance
Activity
Hygiene
Shopping
Transportation
Cooking
Bathing
Dressing
Lavatorial activities
Sitting, Laying
Rising
Incontinence
Eating Food from
Dish, Oral Orientation
n
%
n
%
Public
54
81.8
6
33.5
12
19.7
72
49.7
x²:51.16
Private
14
18.2
12
66.7
49
80.3
73
50.3
p:0.000**
Public
54
73
10
43.5
14
25.5
78
51.3
x²:29.18
Private
20
27
13
56.5
41
74.5
74
48.7
p:0.000**
Public
53
75.7
10
38.5
15
26.8
78
51.3
x²:31.88
Private
17
24.3
16
61.5
41
73.2
74
48.7
p:0.000**
Public
49
73.1
9
34.6
19
32.8
77
51.0
x²:23.65
Private
18
26.9
17
65.4
39
67.2
74
49.0
p:0.000**
Public
60
77.9
7
24.1
14
28.6
81
52.3
x²:40.53
Private
17
22.1
22
75.9
35
71.4
74
47.7
p:0.000**
Public
Private
63
27
70.0
30.0
6
19
24.0
76.0
11
28
28.2
71.8
80
74
51.9
48.1
x²:28.38
p:0.000**
Public
70
62.5
3
11.1
10
8.8
83
53.2
x²:23.31
Private
42
37.5
24
88.9
7
41.2
73
46.8
p:0.000**
Public
Private
68
42
61.8
38.2
4
14
22.2
77.8
8
15
34.8
65.2
80
71
53
47
x²:13.34
p:0.001**
Public
56
58.9
5
19.2
8
42.1
69
49.3
x²:13.33
Private
39
41.1
21
80.8
11
57.9
71
50.7
p:0.001**
Public
72
49
59.5
40.5
4
17
19
81
3
6
33.3
66.7
79
72
52.3
47.7
x²:13.12
p:0.001**
Private
n
%
n
%
**p<0.01
As the domain scores were evaluated regarding
title of nursing homes as whether being public or
private, while environmental domain scores of
elderly living in private nursing homes were higher,
the physical, mental and social domain scores of
those living in public nursing homes were higher
(Table 4).
Besides, the average lenght of stay in public
nursing homes (7.06±7.98 years) has been found to
be longer compared to that in private nursing homes
(3.01±3.34 years).
On the other hand, in those with any handicaps
the physical domain score has been lower and it was
concluded that being handicapped increases
dependence in daily activities (p<0.05).
A positive correlation has been detected between
scores of facial scale to evaluate satisfaction of living
in nursing home and scores of physical,
environmental, mental and social domains (for
physical domain (r=0.161, p=0.048); for mental
domain (r=0.275, p=0.001); for social domain
(r=0.297, p=0.000); and for environmental domain
(r=0.292, p=0.000).
7
Table 4: Quality of Life Domain Scores and Nursing Home Type
N
S.T.
S.O.
Public
82
86.38
7083.50
Private
71
66.16
4697.50
Public
83
87.86
7292.00
Private
72
66.64
4798.00
Public
82
85.45
7007.00
Private
72
68.44
4928.00
Environmental
Public
84
69.58
5845.00
Domain
Private
71
87.96
6245.00
U
Z
P
2141.5
-2.822
0.005**
2170
-2.946
0.003**
2300
-2.382
0.017*
2275
-2.549
0.011*
Physical Domain
Mental Domain
Social Domain
*p<0.05; **p<0.01
Discussion
Similar results were obtained in a study by
Berberoğlu et al conducted in Edirne (12). In
addition, Uçku et al in İzmir, Yardımcı et al and
Bircan et al separately in İstanbul, Ergün et al in
Adana have all found paralel and similar results in
their studies (13-16). In the study by Hays et al, it
was reported that dependence in daily life activities
are seen more in females (17).
That there is more dependence in hygiene,
shopping, transportation, cooking and bathing may
spring from the fact that these activities require more
movement and effort than the other activities.
Besides, the participants may feel enforced to inform
the investigators on these topics as there are certain
rules and restraints of nursing homes about
ingress-egress, bringing in food and etc.
The investigators have not detected any study
evaluating the title of nursing home status as public
or private in literature. That dependence is much
more encountered in private nursing homes can be
based on the fact that the average age of elderly
living in private nursing homes (79.18±9.38) is
bigger than the average age in public nursing homes
(70.25±7.69) and thus they are more dependent in
their daily life activities. Another reason for his can
be that the expectancy in private nursing homes is
8
greater and there is more effort to meet these
demands.
As public home care is regarded as permanent
and the shifts are more frequent in private nursing
homes, familiarity and long term relationships can
contribute to higher social and mental domain scores
in public sector. The socioeconomic status of those
living in private nursing homes can be considered as
high and thus receiving better healthcare, easy access
to activities outside the nursing home and acting
more independent can be factors contributing to
higher environmental domain scores (8).
There are various studies to show that chronic
diseases and functional limitations increase
dependence and reduce quality of life (18,19).
In those who are dependent for hygiene,
shopping, dressing, lavatory activities, sitting-layingrising, eating food from dish, all but environmental
quality of life scores have been found significantly
low (p<0.05). It is inevitable that physical, mental
and social dimension scores of such dependent
elderly are low and this finding is supported by a
variety of studies (15).
In the study by Yazgan et al., satisfaction status
has been found to be one of the leading factors
affecting physical, mental and social domain scores
(18).
Conclusion
It has been found that elderly living in private
nursing homes are more dependent in all daily
activities than those living in public nursing homes.
While environmental domain score is higher in
elderly living in private nursing homes, physical,
mental and social domain scores are higher in those
living in public nursing homes. A positive corelation
was found between scores of facial scale evaluating
satisfaction from staying in nursing homes and scores
of physical, environmental, mental and social
domains. We should help elderly in leading a life of
quality by taking measures to improve environmental
domain in public nursing homes and to reduce
limitations in physical, mental and social domains in
private nursing homes.
References
1. Bilgili N. Determination of
the Problems of the Families
Caring for the Elderly.
Doctoral Thesis, Hacettepe
University Institute of Health
Sciences, 2000.
2. Emiroğlu V. Senility and
Social Cohesion of the
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Matbaacılık, Ankara, 1995.
3. Ünalan T. The status of old
age population in Turkey.
Tu r k . J . P o p u l . S t u d . ,
Hacettepe Üniversitesi
Basımevi, 2002;22, 3-22.
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problems and suggestions for
improvement for the elderly
population in the world and in
Turkey. Turk. J. Geriatr 2004;
7(2): 105-110.
5. H a c e t t e p e
University
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and Application
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2002. Quality of Life Guide,
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6. Koçoğlu GO, Bilir N. Aging
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1969; 9:179-186.
11. Eser SY, Fidaner H, Fidaner
C, Elbi H, Eser E. Measuring
the quality of life,
WHOQOL-100 and
WHOQOL-BREF psychometric properties. 3P Journal
1997;7(Additional number 2):
5-13.
12. B e r b e r o ğ l u U , G ü l H ,
Eskiocak M, Ekuklu G, Saltık
A. Some socio-demographic
characteristics and daily life
13.
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activities according to Katz
Index of the elderly living in
Edirne Nursing Home. Turk.
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Uçku R, Ergin S, Erbay P.
Physical functions of the
elderly is changing rapidly. J
Health Soc Welf Found 1993;
3(2):20-23.
Yardımcı E, Tümerdem Y,
Yardımcı O. A medico-social
research on the elderly living
in nursing homes. 4. Ulusal
Halk Sağlığı Kongresi 1994;
Didim, 651-657.
Bircan B, Bindal A, Koçak
M, Kaya A, Güven S. Quality
of life and factors affecting
quality of life of the elderly
living in nursing homes.
M A S C O 2 0 0 6 , ( w w w.
marmaramedicaljournal.org/p
df/pdf_MMJ_404. pdf)
Ergün GÖ, Bozdemir N,
Uğuz Ş, Güzel R, Burgut R,
Saatçi E, Akpınar E.
Assessment of the medicosocial characteristics of the
elderly living in adana
nursing home and of the
elderly who have admitted to
the family medicine
9
polyclinic. Turk J Geriatr
2003;6(3):89-94.
17. Hays MK, Jette AM, Wolf
PA, D’Agostino RB, Odell
PM. Functional limitation and
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841-845.
18. Yazgan Ç, Kora K, Topçuoğlu
V, Kuşçu K. Factors affecting
quality of life of elderly
nursing home residents
without dementia. Turk J
Geriatr 2006;9(3):143-149.
19. Aylaz R, Güneş G, Karaoğlu
L. Evaluation of Social
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Elderly Living in Nursing
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University Med Faculty 2005;
12(3):177-183.
Dr. Mustafa Taşdemir
Marmara Üniversitesi Tıp Fakültesi Halk Sağlığı
Anabilim Dalı Haydarpaşa, İstanbul
Tel: +90 (532) 567 1023
Fax: +90 (216) 414 4731
10
2012
Ailelerin Ateşli Çocuğa Yaklaşımı ve Ateş Bilinç Durumu
Families’ Approach to Feverish Children and Fever Awareness
YAZARLAR
Polat Nerkiz
Aile Hekimliği Anabilim
Dalı, Gülhane Askeri Tıp
Fakültesi, Ankara
Yusuf Çetin Doğaner
Kara Harp Okulu Birinci
Basamak Muayene
Merkezi, Ankara
Ümit Aydoğan
Fakültesi, Ankara
Tamer Onar
Aile Sağlığı Merkezi
Kent Polikliniği, Gölcük
Asker Hastanesi,
Karamürsel
Faysal Gök
Çocuk Sağlığı ve
Hastalıkları Anabilim
Fakültesi, Ankara
Kenan Sağlam
İç Hastalıkları Bilim
Fakültesi, Ankara
Okan Özcan
Çocuk Sağlığı ve
Hastalıkları Anabilim
Dalı, Gülhane Askeri
Tıp Fakültesi, Ankara
ÖZET
Amaç: Çocuklardaki ateş yüksekliği, en sık karşılaşılan problemlerdendir ve acil servise
başvuruların en az yarısında nedenler arasında yer alır. Aileler tarafından bir semptom olarak değil
de bir hastalık olarak algılandığı için gereksiz endişelere yol açmaktadır. Bu çalışma, çocuklarını
ateş yüksekliği nedeniyle acil servise getiren ailelerin ateşle mücadele yöntemlerini ve ateş ile
ilgili bilgi düzeylerini saptamak için yapılmıştır.
Yöntemler: Çalışma, Ocak - Eylül 2010 tarihleri arasında yüksek ateş şikayetiyle çocuklarını
Gülhane Askeri Tıp Fakültesi (GATF) Çocuk Hastalıkları Acil Servisi’ne getiren ve çalışmaya
katılmayı kabul eden 747 aile ferdiyle gerçekleştirildi. Ebeveynlere 25 sorudan oluşan bir anket
formu uygulandı. Veriler değerlendirilirken SPSS 15.0 for Windows (Chicago-USA) paket
programı kullanılmıştır.
Bulgular: Çalışmamıza katılan annelerin %37.5’i ve babaların %63.3’ü üniversite
mezunuydu. Ateşin nedenlerini sorguladığımız anket sorusunda ailelerin %79.3’ü enfeksiyon,
%10.4’ü diş çıkarma, %9’u aşı cevabını verdi. Yüksek ateşin yol açabileceği zararları
sorduğumuzda ise havale şıkkına %90.4, beyin hasarı şıkkına %37.1 ve ölüm şıkkına %7 aile evet
cevabı verdi. Çocuklarına son verdikleri ateş düşürücü ise 442 çocukta parasetamol, 278 çocukta
ibuprofen ve 27 çocukta antigribal bir ilaçtı.
Sonuç: Çalışmamızda katılımcılar toplumun diğer kesimlerine oranla daha iyi eğitim
seviyesinde olmalarına karşın, ailelerin ateş ile ilgili eksik ve hatalı bilgileri ve uygulamaları
olduğunu tespit ettik. Çocuklarını muayeneye getirdiklerinde, ailelerine de zaman ayırarak
sorularını cevaplamak ve yanlış bilgi ve uygulamalarını düzeltmek ateşle ilgili bilinç düzeylerini
arttıracaktır.
Anahtar Kelimeler: Ateş, Aileler, Bilinç
ABSTRACT
Aim: Fever is one of the most common problems in children and it is among reasons in at
least half of admissions to the emergency services. It causes unnecessary anxiety because parents
perceive fever as an illness, not as a symptom. The aims of this study was to determine fever
control methods of parents and knowledge level about fever.
Methods: The study was conducted among 747 parents who brought their children to
Gulhane Military Medicine Faculty Pediatric emergency service due to fever and agreed to attend
study, between January and September 2010.
Results: In our study, 37.5% of mothers and 63.3% of fathers were graduate of college. When
we asked causes of fever, 79.3% of parents answered it as “infection”, 10.4% of parents “teethe”
and 9% of parents “vaccination”. Question about damages that fever could cause was answered as
90.4% “yes” for convulsion, 37.1% “yes” for brain damage and 7% “yes” for death. For 442
children, first choice drug for fever was acetaminophen, for 278 children it was ibuprofen, and for
27 children drugs for common cold was first choice.
Conclusion: We determined that parents have incomplete and inaccurate information and
applications related to the fever, ever so participants of our study are well educated rather than
other sectors of society. It will increase awareness of parents about fever, if we spare enough time
to families for answering questions and correcting inappropriate practices when they bring their
children for physical examination.
Key words: Fever, Parents, Awareness
11
Nerkiz P. Ailelerin Ateşli Çocuğa Yaklaşımı ve Ateş Bilinç Durumu, Euras J Fam Med, 1(1):11-16,2012.
Giriş
Çocuklardaki ateş yüksekliği en sık karşılaşılan
problemlerdendir. Aileleri fazlasıyla endişelendiren
ve acil servise başvuruların en az yarısını oluşturan
neden ya da nedenlerden olan bu durum, çoğunlukla
hastane acil servislerinin gereksiz meşgul edilmesine
ve uygunsuz tedavilerin verilmesine yol açmaktadır
(1,4,5,11,15). Vücudun doğal savunma mekanizmalarından olmasına karşın, aileler tarafından
ateşin yükselmesi bir semptom olarak değil bir
hastalık olarak algılanmakta ve ateşi düşürmek için
acele ve bazen de hatalı uygulamalar yapılabilmektedir (4,6,8,15).
30 yıl önce Barton Schmitt tarafından yapılan bir
çalışmada ailelerin çocuklarındaki ateş yüksekliği ile
ilgili birçok yanlış anlamaya sahip olduğu
gösterilmiştir. Örneğin çalışmaya katılanların %94’ü
ateşin zararlı yan etkilerinin olduğunu, %63’ü ise
ateşin ciddi hasara yol açabileceğini belirtmişlerdir.
En çok korktukları yan etkileri ise beyin hasarı ve
havale olarak açıklamışlardır (3,4,5,15). Yakın
zamanda yapılan pek çok çalışmada ise bu endişelerin
ve ateş korkusunun pek fazla da değişiklik
göstermediğini ortaya koymuştur (3,4,6,7,11,12,15).
Biz de bu çalışmamız ile ateş yüksekliği
şikayetiyle çocuklarını hastanemiz Çocuk Acil
Servisine getiren ailelerin ateşle mücadelede neler
yaptıklarını ve ateş ile ilgili bilinç durumlarını
belirlemeye çalıştık.
veriler kaydedilerek SPSS for Windows 15.0
programı yardımıyla analiz edildi.
Bulgular
Çalışmamızda toplam 747 ebeveyn ile görüşüldü.
Acil serviste değerlendirilen çocukların yaş ortancası
6 (1-17) yıldı. Çocuk hastaların %54.4’ü (n=406)
erkek, %45.6’sı (n=341) kızdı. Kardeş sayıları
sorgulandığında; 258 çocuğun kardeşi yoktu, 317
çocuğun bir, 120 çocuğun iki, 36 çocuğun üç ve 16
çocuğun dört ve üzeri kardeşi vardı.
Çocuklarını ateş nedeniyle acil servise getiren
aileler değerlendirildiğinde; %63.6 (n=475) çocuğun
anne-babası ile birlikte geldiğini, %17.8 (n=133)
çocuğun sadece annesi ile, %17.3 (n=129) çocuğun
ise sadece babası ile geldiğini, sadece %1.3 (n=10)
çocuğun ise başka bir aile bireyinin yardımı ile acil
servise getirildiği saptandı.
Ebeveynlerin eğitim durumu irdelendiğinde;
sağlık hizmeti verilen topluluğun özelliği nedeniyle
ülke ortalamalarının üzerinde bulgulara ulaşıldı.
Annelerin %10.7’si (n=80) ilkokul, %7.2’si (n=54)
ortaokul, %44.6’sı (n=333) lise ve %37.5’si (n=280)
anne üniversite ve yüksekokul mezunuydu. Babaların
ise %1.7’si (n=13) ilkokul, %3.6’sı (n=27) ortaokul,
%31.3’ü (n=234) lise ve %63.3’ü (n=473) üniversite
mezunuydu. Annelerin %28.9’u (n=216) çalıştığını
beyan etti.
Yöntemler
Çalışma Ocak – Eylül 2010 tarihleri arasında,
çocuklarını GATF Çocuk Hastalıkları Acil Servisi’ne;
ateş yüksekliği şikayeti ile getiren ebeveynler
arasında yapıldı. Çocuklarının gerekli tetkik ve
tedavileri yapıldıktan sonra çalışmaya katılmayı
kabul eden ve onamları alınan 747 kişiye yüz yüze
görüşme metodu kullanılarak 25 soruluk anket formu
uygulandı. Anket formunda sosyodemografik
özelliklere ilaveten; ateşin tanımı, ateşin belirlenmesi,
derece tipleri, düşürmek için yaptıkları ve zararları ile
ilgili sorular yer aldı. Çocuklarının rahatsızlığı
nedeniyle fazlasıyla endişeli olduğu için anketi
doldurmak istemeyen ve travma gibi ateş yüksekliği
dışı nedenlerle acil servise başvuran ebeveynler
çalışmamıza dahil edilmediler. Çalışmada elde edilen
12 Şekil 1: Anne eğitim düzeyi
Ateş yüksekliği şikayetiyle acil servisimize getirilen
çocukların Sağlık Bakanlığı onaylı kulaktan ateş
ölçer ile yapılan ölçümlerinde %74.3 (n=550)
çocuğun ateşi 37.5 °C ve üzerinde idi. Ailelere
çocuğunuzun ateşinin yükseldiğini nasıl anlarsınız
diye sorulduğunda %75,4 (n=563)’ü derece ile
c e v a b ı n ı v e r i r k e n % 2 4 . 6 ’s ı ( n = 1 8 4 ) e l l e
değerlendirdiğini söyledi. Çocuklarının neresine
dokunarak ateşini anlamaya çalıştıkları sorusuna ise
%78.6 (n=587) alın, %9.6 (n=72) ense, %7.6 (n=57)
yanak ve %4.1 (n=31) diğer (el, kol, bacak, göğüs
vb.) cevabını verdi. Diğer şıkkına en çok verilen
cevap göğüs bölgesi oldu. En çok tercih edilen derece
tipi %65.1 (n=486) ile dijital ateş ölçerdi. %23.0’ü
(n=172) civalı ateş ölçeri, %11.5’i (n=86) kulaktan
ateş ölçeri, %0.4 (n=3) ebeveyn de farklı tipte ateş
ölçeri kullanıyordu.
Şekil 2: Baba eğitim düzeyi
Çocukların ateş dışındaki şikayetleri
sorgulandığında %42.0’sinde (n=314) halsizlik,
%31.3’ünde (n=234) öksürük, %12.6’sında (n=94)
bulantı-kusma, %5.1’inde (n=38) ishal tespit
edilirken %9’unda (n=67) diğer şikayetler eşlik
ediyordu. Doktor tanılarına baktığımızda ise;
çocukların %40.8’ine (n=305) üst solunum yolu
enfeksiyonu, %22.1’ine (n=165) tonsillit, %6.6’sına
(n=49) farenjit, %5.8’ine (n=43) otit, %5.6’sına
(n=42) enterit ve %4.8’ine (n=36) sistit tanısı
konulurken, %3.6’sında (n=27) bronşiolit, %0.8’inde
(n=6) pnömoni teşhis edilmiştir. Diğer tanılarda ise
birer olgu olarak febril konvülsiyon, krup ve dermatit
hastalarına rastlanılmıştır.
“Ateş zararlı mı” sorusuna %98.9 (n=739)
oranında “evet” yanıtı veren ebeveynlere; ateşin
hangi nedenlerle yükselebildiğini sorduğumuzda;
%79.3 (n=592) enfeksiyon, %10.4 (n=78) diş
çıkarma, %9 (n=67) aşı olma ve %1.3 (n=10) diğer
nedenlerden kaynaklandığını ifade etti.
Hangi derecenin üstünü yüksek ateş olarak kabul
ettikleri sorusuna %10.7’si (n=80) 37 °C, %21.7’si
(n=162) 37.5 °C, %40.2’si (n=300) 38 °C, %17.8’i
(n=133) 38.5 °C, %7.1’i (n=53) 39 °C ve %2.5’u
(n=19) da 39.5 °C ve üzerini yüksek ateş olarak kabul
ettiklerini belirttiler. Vücut sıcaklığına müdahale
derecesi sorulduğunda; %4.6’sı (n=34) çocuklarının
Şekil 3: Ailelerin yüksek ateşle mücadelede yaptıkları ilk girişimlerin oranları
13
vücut sıcaklığı 37 °C’yi geçtiğinde, %15.3’ü (n=114)
37.5 °C, %43.9’u (n=328) 38 °C, %19.5’i (n=146)
38.5 °C, %15.1’i (n=113) 39 °C ve %1.6’sı (n=12)
39.5 °C ve üzeri değerleri sınır kabul ettiklerini
bildirdiler.
“Yüksek ateşle mücadele için yaptıkları ilk
müdahale” sorusuna da %68.5 (n=512) oranında ılık
duş, %12.4(n=93) parasetamol vermek, %6.8 (n=51)
ibuprofen vermek, %4.8 (n=36) sirkeli su uygulamak,
%3.6 (n=27) soğuk duş, %1.3 (n=10) alkollü bez
uygulaması ve %2.4 (n=18) de diğer uygulamalar ile
ateşle mücadele ettiklerini beyan ettiler. Ailelerin
ateşli çocuklarına verdikleri antipiretik tercihi
sorgulandığında %91.4’ü (n=683) ilk tercih olarak
şurup formunu %3.7’si (n=28) tablet formunu, %4.8’i
(n=36) fitil formunu verdiklerini belirttiler.
Hekime başvurmada, ebeveynlerin %9.2’si
(n=69) 37.5 °C üzerini, %28.4’ü (n=212) 38 °C,
%32.1’i (n=240) 38.5 °C, %24.8’i (n=185) 39 °C ve
%5.5’i (n=41) 39.5 °C ve üzerindeki değerleri sınır
kabul ettiklerini söylediler.
Çocuklarının ateşli durumlarını evde takip eden
ailelere ateş ölçüm sıklığı sorulduğunda; %28.8’inin
(n=215) yarım saatten daha sık aralıklarla ölçtüğü,
%52.2’sinin (n=390) yarım saatte bir, %17.3’ünün
(n=129) saatte bir ve sadece %1.7’sinin (n=13) saatte
birden seyrek ölçtüğü tespit edildi.
Ateşin zararlarını irdelemek için sorduğumuz
sorulardan “ateş havale yapar mı” sorusuna %90.4
(n=675) ebeveyn “evet” cevabını verdi. “Beyin hasarı
yapar mı” sorusunda bu oran %37.1 (n=277) iken
“ölüme sebep olur mu” sorusunda oran %7 (n=52)
oldu. “Diğer” şıkkını işaretleyen %0.9 (n=7) ebeveyn
de yüksek ateşin körlüğe yol açabileceğini belirtti.
Ateş düşürücüleri ne sıklıkla kullandıklarını
sorguladığımızda 6 saatte bir verdiğini söyleyenlerin
oranı %41.0 (n=306) idi. %29.2 (n=218) ebeveyn 4
saatte bir, %11.0 (n=82) ebeveyn 8 saatte bir, %2.7
(n=20) ebeveyn de 12 saatte bir ateş düşürücü
verilebileceğini söyledi. Çocuklarına ateş düşürücü
olarak verdikleri en son ilaç sorusuna da %59.1
(n=442) ebeveyn parasetamol, %37.2 (n=278)
ebeveyn ibuprofen ve %3.6 (n=27) ebeveyn
antigribal olarak kullanılan ilaçlardan birisini
verdiğini ifade etti. Ebeveynlerin %74.6’sı (n=557)
reçetesiz ilaç temin etmezken, %24.2’si (n=181)
14 eczacısına danışarak, %1.2’si (n=9) de çocuğu olan
yakınlarına danışarak ilaç temin ettiklerini belirtti.
Son olarak ateş konusundaki bilgilerini hangi
kaynaklardan öğrendiklerini sorguladığımızda; %61.0
(n=456) doktor, %16.3 (n=122) internet, %11.6
(n=87) yardımcı sağlık personeli, %7.5 (n=56)
televizyon ve %3.5 (n=26) gazetelerden faydalanarak
bilgi edindiklerini belirtti.
Tartışma
Çalışmamız, aileler için önemli bir endişe
kaynağı olan çocuklarda yüksek ateş hakkında bilinç
düzeylerini sorguladığımız tanımlayıcı bir çalışmadır.
Önceki çalışmalar ile benzer şekilde bizim
çalışmamızda da ailelerde ateş korkusuna sık
rastlandığı ve bu korku nedeniyle ailelerin
çocuklarının sağlığına zarar verebilecek hatalı
uygulamalarda bulunabildiği tespit edilmiştir
(3,4,5,15).
Çalışmamıza katılan ailelerin eğitim düzeyleri,
hizmet verdiğimiz popülasyonun özelliği nedeniyle,
diğer çalışmalardan daha yüksek bulundu. Annelerin
%37.5’i, babaların ise %63.3’ü üniversite
mezunuydu. Çocuklarını acil servise genellikle
(%63.6) anne babalar birlikte getirdiler. Yine
annelerin çalışma durumuna baktığımızda bizim
çalışmamızdaki annelerin %28.9’u çalışırken bu oran
Esenay ve arkadaşlarının çalışmasında %18.3’tü (15).
Saz ver arkadaşlarının yaptıkları çalışmada
ailelerin %20’si 37 ºC ve altındaki vücut ısılarını
yüksek ateş olarak kabul ettikleri görüldü. Esenay ve
arkadaşları 38 ºC ve altındaki aksiler ölçümleri ateş
olarak kabul edenlerin oranını %61 bulurken bizim
çalışmamızda 38 ºC altındaki değerleri yüksek kabul
eden ailelerin oranı %32.4 olarak bulundu (4,15).
Çalışmamızda ateş zararlı mı sorusuna evet
cevabı verenlerin oranı %98.9 gibi oldukça yüksek
bir orandaydı. Bu oran Saz ve arkadaşları tarafından
%88, Crocetti ve arkadaşlarınca %91, Betz ve
arkadaşlarınca %82 ve Esenay ve arkadaşları
tarafından da %82.7 olarak tespit edilmiştir
(3,4,5,15). Bizim çalışmamızda oranın bu kadar
yüksek çıkmasının nedeni soruyu soruş şeklimizden
k a y n a k l a n m ı ş o l a b i l i r. A t e ş i n z a r a r l a r ı
sorgulandığında; Esenay ve arkadaşları %82.6 nöbet,
%12.1 ölüm bildirirken, Crocetti ve arkadaşları %14
ölüm, %21 beyin hasarı, Betz ve arkadaşları %24
beyin hasarı, %19 havale ve %5 ölüm oranları
bildirmiştir. Bizim çalışmamızda ailelerin en büyük
endişesi %90.4 ile havaleydi. Bunu %37.1 ile beyin
hasarı ve %7 ile ölüm izledi (3,4,5,15). Toplumlar
arasında görülen sosyokültürel farklılıklar ve
ülkemizde febril konvülsiyonun sık görülüyor olması
yabancı çalışmalar ile aramızdaki farkı açıklayabilir.
Ebeveynleri bu kadar çok endişelendiren yüksek
ateş sonuç olarak davranışları da etkilemektedir.
Örneğim bizim çalışmamızda ailelerin %28.8’i
çocuklarının ateşi olduğunda yarım saatten daha sık
aralıklarla vücut sıcaklığı ölçümü yaptıklarını
bildirmişlerdir. Crocetti ve arkadaşlarının
çalışmasındaki ailelerin %52’si bir saatten daha sık
ölçüm yaptıklarını beyan ederken, Esenay ve
arkadaşlarının çalışmasına ailelerin %69.2’si yarım
saatten daha sık ölçüm yapmaktaydılar (3,15).
Yine bu aşırı korku ve endişenin bir sonucu
olarak aileler gereğinden sık ateş düşürücü ilaç
kullanmaktadırlar. Örneğin Crocetti ve arkadaşları
ailelerin çocuklarına %14 oranında parasetamolü ve
%44 oranında ibuprofeni yüksek sıklıkla verdiklerini
buldu. Betz ve arkadaşlarının yaptığı çalışmada ise
oran daha da ürkütücüydü; sırasıyla %27 ve %50. Biz
çalışmamızda ilaçları ayrı ayrı sorgulamadık, ancak 4
saat ve hatta daha sık aralıklara ateş düşürücü
verilebileceğini bildiren ailelerin oranını %33.9
bulduk (3,5,15).
Sonuç olarak, çalışmamıza katılan ebeveynlerin
ateş yüksekliği konusunda ciddi endişeleri olduğu ve
bu endişe nedeniyle gereksiz ve zararlı olabilecek
tutum ve davranışlar sergiledikleri görülmüştür. Bu
nedenle herhangi bir sebeple çocuğunu muayeneye
getiren ailelerin ateş ile ilgili bilgilendirilmesi yapılan
hataların azaltılmasında faydalı olacaktır.
Kaynaklar
1. Van der Jagt EW. Fever. In:
Hoekelman RA, ed. Primary
Pediatric Care. 3rd ed. St
Louis, Mo: Mosby;1997:
959-66.
2. Kara B. Çocuklukta ateşle
ilgili bilgilerin gözden
geçirilmesi. Sted 2003;12
(1):10-14
3. Crocetti M, Moghbeli N,
Serwint J. Fever phobia
revisited: have parenteral
misconceptions about fever
changed in 20 years?
Pediatrics 2001;107:1241-6.
4. Saz EU, Koturoğlu G, Duyu
M, Ozananar Y, Kurugöl Z,
Sever M. Türk ailelerinin
ateş yönetimi ile ilgili bilinç
düzeyi ve korkuları. Çocuk
Enf Derg 2009;3:161-4.
5. Betz MG, Grunfeld AF.
‘Fever phobia’ in the
emergency department: a
survey of children’s caregivers. Eur J Emerg Med
2006; 13: 129-33.
6. Taveras EM, Durousseau S,
Flores G. Parents’ beliefs and
practices regarding childhood
fever: a study of a multiethnic and socioeconomically
diverse sample of parents.
Pediatr Emerg Care 2004; 20:
579-87.
7. O'Neill-Murphy K, Liebman
M, Barnsteiner JH. Fever
education: does it reduce
parent fever anxiety? Pediatr
Emerg Care 2000; 17: 47-51.
8. H u f f m a n G B . P a r e n t a l
misconceptions about fever
9.
10.
11.
12.
in children. Am Fam
Physician 2002; 65: 482-3.
Blumenthal I. What parents
think of fever. Fam Pract
1998; 15: 513-8.
Wa l s h A , E d w a r d s H .
Management of childhood
fever by parents: literature
rewiev. J Adv Nurs 2006, 54:
217-27.
Kabakuş N, Açık Y, Aygün
AD. Annelerin çocuklarının
ateşli hastalıkları
konusundaki düşünce ve
davranışları. Çocuk Sağlığı
ve Hastalıkları Dergisi 2000;
43: 56-62.
Yiğit R, Esenay F, Şen E, ve
ark. Annelerin yüksek ateş
konusunda bilgi ve
uygulamaları. Atatürk
15
Üniversitesi Hemşirelik
Yüksekokulu Dergisi
2003;6:48-56.
13. Keleş S, Yavuz H, Bodur S.
Çocuk sağlığı ve hastalıkları
uzmanları ile pratisyen
hekimlerin ateşli havale hak-
kındaki görüş ve uygulamaları. Genel Tıp Derg 2006;
16(4): 169-174.
14. Vatansever Ü, Ekuklu G.
Olgu Sunumu: Birinci
basamakta ateşli çocuk
izlemi. Sted 2003;12(1):8-9.
15. Esenay FI, İşler A, Kurugöl
Z, Conk Z, Koturoğlu G.
Annelerin ateşli çocuğa
yaklaşımı ve ateş korkusu.
Türk Ped Arş 2007;42:57-60.
İletişim için
Polat NERKİZ
Gülhane Askeri Tıp Fakültesi
Aile Hekimliği Anabilim Dalı
06018 Etlik / Ankara
16 EURASIAN JOURNAL OF FAMILY MEDICINE
2012
Smoking, Alcohol Consumption and Exercise Habits of Elderly Living
in Nursing Homes in Istanbul
AUTHORS
Emel Lüleci
Health, Marmara
Istanbul, Turkey
Hasan Hüseyin Eker
Health College,
Mustafa Taşdemir
Health, Marmara
Istanbul, Turkey
Saime Şahinöz
Health College,
ABSTRACT
Aim: The aim of this study is to determine the life style of elderly’s living in nursing homes
and factors affecting on the issue.
Methods: This is a cross-sectional study conducted in seven nursing homes one being public
and the other six being private. An inventory form has been applied to 161 communicable elderly
living in nursing homes who have accepted to participate in the study. SPSS 11.5 package program
has been used to evaluate data.
Results: Mean age of elderly was 74.38±9.59 years. Among participants, 54.0% of elderly’s
were staying in public nursing home, 58,4% were males, 41,9% were widow/widowers and 37,5%
were single. 30.9% of males, 11.9% of females and 23.0% of all elderly living in nursing homes
have still been smoking. 63.9 of smoking elderly have stated that they were smoking one or more
than one package of cigarettes per day. The ratio of smokers have been found to be statistically
significantly higher among those staying in public nursing home, among males, among divorced,
among elementary school or higher educated and among handicapped (p<0.05). Among those
living in nursing homes, 91.9% of elderly have stated that they were not drinking alcohol, 6.9%
told that they have quit drinking, 1.9% told that they were still drinking alcohol and 18.5% have
stated that they were exercising regularly. 12.5% of elderly were obese. A significant correlation
between body mass index and the nursing home, gender, level of education has been detected
(p<0.05).
Conclusion: Ratio of smoking has been found significantly higher in males, in those living in
public nursing homes, those with high school education and those handicapped.
Key words: Senility, cigarettes, alcohol, exercise, nursing home
Introduction
The world is aging. Today, there are nearly 600 million elderly aged 60 and over
worldwide; this total will double by 2025 and will reach virtually two billion by
2050. The majority of older people will be living in developing countries that are
often the least prepared to confront the challenges of rapidly ageing societies (WHO,
1). As for the data derived from the Turkish Population and Health Research, while
elderly aged 65 and above constitutes 4% of total population by 1990, this ratio
turned to be 7% in 2008 and it is in an increasing trend (2).
Tobacco smoking is the initial preventable risk factor in 7 of 14 primary causes
of death in people aged 65 years and over (3). Older tobacco users have a mortality
ratio of nearly double the mortality rate of non-smokers (OR of 2.1 for men, 1.8 for
women) (4).
Though the rate of time dependent physical loss varies among elderly, tobacco
use is a major factor known to accelerate this rate (5). Research data reveal that
quitting smoking decreases the morbidity risk at any age. While the decrease in risk
is more significant among those who quit smoking at early ages, a decrease in lung
cancer risk has been found even in those who quit smoking after the age 60 (6,7).
17
Lüleci E. Smoking, Alcohol Consumption and Exercise Habits of Elderly Living in Nursing Homes in Istanbul. Euras J Fam Med, 1(1):17-22,2012.
The unfavorable effects of alcohol in elderly are
too many. Polypharmacia in elderly that could
interact with alcohol, increased frequency of
depression and relevant disorders that could relapse
with alcohol consumption, negative effects of alcohol
on bone density and increased pelvic fracture
frequency with falling of drunk elderly are examples
(8-11).
Regular exercise is essential for a healthy and
active aging process. At progressive ages, decreases
in physical capacity can affect negatively even daily
activities like efforts of rising from a chair. An
additional health issue can put a previously healthy
elderly into a fully dependent and immobile position.
The initial way to prevent these unwanted conditions
is to exercise regularly. Even in very advanced ages
physical capacity can be increased with regular
physical activity (12).
The aim of this study is to detect the status of
alcohol and tobacco consumption and exercising
habits of elderly living in nursing homes and to find
out factors affecting these entities.
Methods
This is a cross-sectional study. The study has
been conducted in randomly chosen seven nursing
homes one being public and the others private.
Necessary permissions have been taken from
institutions and the study has been done in January
2010.
Face to face inventories have been filled with 78
agreeing to participate out of communicable 132
elderly living in public nursing home and with 74
agreeing to participate out of communicable 98
elderly living in private nursing homes. SPSS 11,5
package program has been used to evaluate data.
Chi-square test has been used in interpretation of
data.
Results
Mean age of elderly was 74.38±9.59 years.
Among participants, 54.0% of elderly were staying in
public nursing home, 46.0% were living in private
nursing homes, 58.4% were males, 41.6% were
females, 41.9% were widow/widowers, 37.5% were
Table 1. Description of study population regarding smoking, drinking status and exercise
All subjects
Age
Smoking
Drinking
Regular Exercise
Total
Never
Past
Current
Never
Past
Current
Yes
No
55-64
66.7
20.0
13.3
96.7
0.0
3.3
76.7
23.3
18.8
65-74
36.5
50.0
13.5
88.2
3.9
7.8
84.6
15.4
32.5
75-84
78.0
10.0
12.0
89.8
2.0
8.2
90.0
10.0
31.3
≥85
85.7
0.0
14.3
92.9
0.0
7.1
67.9
32.1
17.5
Male
51.1
30.9
18.1
87.1
2.2
10.8
85.1
14.9
58.4
Female
82.1
11.9
6.0
97.0
1.5
1.5
77.6
22.4
41.6
Sex
Education
Illiteracy
62.5
18.8
18.8
100.0
.0
.0
81.3
18.8
9.9
<5 years
52.5
39.3
8.2
89.8
5.1
5.1
85.2
14.8
37.9
6–12 years
69.3
13.3
17.3
90.7
0.0
9.3
77.3
22.7
46.6
>12 years
100.0
0.0
0.0
88.9
0.0
11.1
100.0
0.0
5.6
Married
100.0
0.0
0.0
0.0
0.0
100.0
100.0
0.0
3.1
Single
68.3
11.7
20.0
0.0
8.3
91.7
81.7
18.3
37.5
Divorced
39.3
17.9
42.9
3.7
7.4
88.9
82.1
17.9
17.5
Widow/widower
67.2
13.4
19.4
3.0
6.1
90.9
80.6
19.4
41.9
Public
56.3
13.8
29.9
90.8
6.9
2.3
82.8
17.2
54.0
Private
73.0
12.2
14.9
91.7
6.9
1.4
81.1
18.9
46.0
Total
64.0
13.0
23.0
91.2
6.9
1.9
82.0
18.0
100.0
Marital Status
Nursing home
18 Lüleci E. Smoking, Alcohol Consumption and Exercise Habits of Elderly Living in Nursing Homes in Istanbul. Euras J Fam Med, 1(1):17-22,2012.
Table 2. Smoking Status of Elderly Regarding Some Features
Non-smokers and
quitters
n
%
Smokers
Total
Significance
n
%
n
%
Public
61
70.1
26
29.9
87
54.0
Private
63
85.1
11
14.9
74
46.0
Male
65
69.1
29
30.9
94
58.4
Female
59
88.1
8
11.9
67
41.6
Single
48
80.0
12
20.0
60
38.7
Divorced
16
57.1
12
42.9
28
18.1
54
80.6
13
19.4
67
43.2
50
64.9
27
35.1
77
47.8
Elementary school and
over
74
88.1
10
11.9
84
52.2
None
82
82.8
17
17.2
99
61.5
Yes
42
67.7
20
32.3
62
38.5
124
77.0
37
23.0
161
100.0
Title
Gender
Marital
Status
Education
Handicap
Total
Married
widower
or
Primary
below
school
widow
and
single, 17.5% were divorced and 3.1% were married
(Table 1).
Among those living in nursing homes 64.0%
have stated that they had never smoked, 91.2% that
they had never drank alcohol, 13.0% that they quit
smoking, 6.9% left alcohol, 23.0% told that they were
still smoking, 1.9% told that they were still drinking
alcohol and 18.0% stated that they were regularly
exercising (Table 1). Elderly who quit smoking told
that they had smoked for an average of 25.35±16.09
years while among smokers 14.8% said that they
were smoking 1–2 cigarettes per day, 21.3% that they
were smoking nearly 10 cigarettes per day, 63.9%
that they were smoking 20 or more cigarettes per day.
Males were smoking an average of 21.75±17.41
cigarettes per day while females were smoking an
average of 11.87±8.87 cigarettes per day.
The percentage of actual smokers compared to
actual non-smokers (sum of those who have never
smoked and those who have quit) is significantly
higher in those living in public nursing homes
compared to those living in private nursing homes; in
males compared to females; in divorced compared to
widow-widowers or singles; in elementary school or
x²: 5.097
p : 0.018*
x²: 7.904
p: 0.004*
x²: 8.618
p: 0.013
x²: 12.17*
p: 0.000
x²: 4.902*
p : 0.022*
over educated compared to primary school or below
educated; in handicapped compared to nonhandicapped (Table 2). 30.9% of males, 11.9% of
females and 23.0% of all elderly are actual smokers.
The percentage of actual smoking among elderly
who are dependent in shopping and transportation
activities has been found lower compared to those
who are partially or non dependent in such activities
(p<0.05). Among those elderly living in nursing
homes, the body mass index of 2.5% has been found
to be 18 and below, of 47.9% between 18.1 and 25, of
36.8 between 25,1and 30, of 12.5% over 30.1. A
significant correlation between body mass index and
the nursing home, gender, level of education (p<0.05)
has been found. While 17.1% of those living in
public nursing home were obese, this percentage
among those living in private nursing homes is 6.5%
(p=0.004). 18.2% of females and 9.0% of males have
been found obese (p=0.048). While 15.9% of those
educated in primary school or below were obese, only
9.3% of those educated in elementary school or over
were obese (p=0.028).
There has not been a significant correlation
between age, length of stay in nursing home,
19
smoking, alcohol drinking, regular exercise, presence
of a chronic disorder, presence of a handicap and
body mass index (BMI) (p>0.05).
There was a chronic disorder in 80.7% of elderly;
and among those with chronic disorders 56.9% had
hypertension, 16.2% had coronary artery disease,
13.1% cerebrovascular accident, 13.3% had
osteoporosis, 10.0% had osteoarthritis, 8.5% had
cardiac failure and 6.9% had chronic bronchitis.
Chronic bronchitis is more frequently seen in those
who have smoked previously compared to those nonsmokers or actual smokers (p=0.014).
Discussion
In some studies conducted in Turkey, it was
reported that smoking among 65 years or more
population ranges between 8% and 25.9%; and that
this range was between 19.2% and 38.6% in males,
between 6.3% and 13.4% in females (13–16). In
some foreign studies, smoking frequency has been
found nearly 19% in Finland; 26% in Italy and 30%
in Netherlands (17).
In a study conducted in Istanbul it was found that
90% of elderly had never drunk alcohol and 12%
were still smoking (18). In a community based study
conducted in Erzurum Pasinler this ratio has been
found 28.9% (19). In the study “Defining Quality Of
Life And Health Status In City Of Van Central
District” it was found that 25% of elderly over 65
years of age, 13.4% of females and 38.6 of males
were actual smokers (14). In this study the percentage
of actual smoking elderly is lower (23.0% of all
elderly, 11.9% of females and 30.9% of males were
actual smokers). But the average number of
cigarettes that females and males were smoking have
been found to be higher. In the study conducted in
Van, females were smoking an average of 6.56
(±6.89) cigarettes and males were smoking an
average of 19.4 (±10.4) cigarettes, while in our study
females were smoking an average of 11.87 (±8.87)
and males were smoking an average of
21.75(±17.41) cigarettes.
In this study 23% of elderly told that they were
actual smokers, 64.0% said that they had never
smoked and 13.0% stated that they had quit smoking.
In a study that was done by Huadong et al in China,
20 25.2% of elderly were actual smokers while 65.6%
said that they had never smoked and 9.2% told that
they had quit smoking (20).
Though similar results have been obtained about
smoking frequency in studies done in different
locations and different populations, we cannot predict
the same result for alcohol consumption. In the study
by Güleç et al. the rate of alcohol consumption
among retired army officers was 46.0% (21); this
ratio was found to be 7.9% (in the whole group) in
Mandıracıoğlu study (22); 5% in Oğuz study (males)
(23) and 17.1% in Yardımcı study (24). In a study
made in China it was reported that 32.0% of elderly
were drinking alcohol every day (20). In this study
only 1.9% have told that they were actual alcohol
drinkers.
Among elderly, significantly higher incidence of
chronic bronchitis in previous smokers compared to
non-smokers or actual smokers can be explained with
the reason that those who had suffered from chronic
bronchitis might have quit smoking.
In 1990s, it was stated that 30% of elderly 65
years and over in USA were regularly exercising and
to pull this ratio to 60% has been a social target (25).
In this study, the percentage of those who stated that
they were regularly exercising is 18%.
According to National Health and Nutrition
Epidemiology Survey III (NHANES- III) Analysis,
42.2% of American males between 60 and 69 years
and 42.5% of females were overweight (26). In this
study, 12.5% of all elderly has been found obese
while this ratio was 18.2% in females and 9.0% in
males.
Conclusions
23% of elderly living in nursing homes are still
actual smokers. Smoking frequency has been found
significantly higher in those living in public nursing
homes, in males, in divorced, in elementary school or
over educated and in handicapped. It was reported
that 1.9% of elderly living in nursing homes are still
drinkers and 18.5% of them are regularly exercising.
References
1. Older people and Primary
Health Care (PHC) http://
www.who.int/ageing/primary
_health_care/en/index.html
(Erişim tarihi: 12-Temmuz
2010).
2. Hacettepe Üniversitesi Nüfus
Etütleri Enstitüsü (2009)
Türkiye Nüfus ve Sağlık
Araştırması, 2008. Hacettepe
Üniversitesi Nüfus Etütleri
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Dr. Mustafa Taşdemir
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Anabilim Dalı Haydarpaşa, İstanbul
Tel: +90 (532) 567 1023
Fax: +90 (216) 414 4731
2012
Aile Hekimliğinde Kapsamlı Bakım Yeterliliği ve Değerlendirilmesi
Comprehensive Care and its Evaluation in Family Medicine
YAZARLAR
Zekeriya Aktürk
Dalı, Atatürk
Üniversitesi Tıp
Fakültesi, Erzurum
Hamit Acemoğlu
Tıp Eğitimi Anabilim
Dalı, Atatürk
Üniversitesi Tıp
Fakültesi, Erzurum
ÖZET
Kapsamlı bakım, yeterliliğe dayalı eğitim ve eğitimin değerlendirilmesi aile hekimlerinin
önem verdiği güncel konulardandır. Bu yazıda bu konuların aile hekimliği bakış açısıyla
değerlendirilmesi ve birbirleri ile ilişkisinin incelenmesi amaçlanmıştır. Dünya Aile Hekimleri
Birliği (Wonca) aile hekimleri için altı adet temel yeterlilik ve bunlarla ilişkili 11 özellik
tanımlamıştır. Bu özellikler bir ağaca benzetilirse, ağacın köklerinin Tutum, Bilim ve Ortam
olduğu söylenebilir. Bu yeterliliklerin hepsi aile hekimliğine özgün olmakla birlikte, hekimlik
uygulamaları için en vazgeçilmez olanın “Kapsamlı sağlık hizmeti” olduğunu söyleyebiliriz.
Yeterliliğe Dayalı Eğitim, toplumun ihtiyacına uygun eleman yetiştirmesi açısından önemlidir.
Yeterliliğe dayalı eğitim verilebilmesi için öncelikle yeterliliklerin neler olacağının iyi belirlenmesi
gerekir. Türkiye’de aile hekimlerinin yeterlilikleriyle ilgili bir çalışma Türkiye Aile Hekimleri
Yeterlilik Kurulu (TAHYK) tarafından yürütülmüş ve yayınlanmıştır. Bu çalışmada aile hekimliği
uzmanının sahip olması gereken yeterlilikler “Bilir”, “Uygular”, “Koruyucu hekimlik hizmeti
verir”, “Tanı koyar”, “Tanı koyup tedavi eder”, “Acil müdahalede bulunur” gibi başlıklar altında
ayrıntılı olarak belirtilmiştir Yeterliliklerin ölçme ve değerlendirilmesinde, objektif yapılandırılmış
sınavlar gibi yöntemler ve Çalışma Ortamında Ölçme yöntemleri kullanılabilir. Çalışma Ortamında
Ölçme diğer yöntemlere göre daha zor olmakla birlikte, kişinin gerçek performansını
değerlendirmesi açısından önemlidir ve dört bileşenden oluşmaktadır: İnceleme, Yönetim kayıtları,
Günlükler ve Gözlemler. Sonuç olarak, Aile hekimliği için son derece önemli olan kapsamlı bakım
hizmetinin etkin bir şekilde sunulması için öncelikle aile hekimliği uzmanlık eğitiminin
yeterliliklerinin iyi belirlenmesi, aile hekimi asistanlarının belirlenen yeterliliklere ulaşıp
ulaşmadıklarının değerlendirilmesi ve aile hekimliği asistanına eksik bulunan yeterlilikleri
tamamlaması için imkân ve fırsatların sağlanması gerekir.
Anahtar Kelimeler: aile hekimliği, kapsamlı bakım, yeterliliğe dayalı eğitim, ölçme
değerlendirme
ABSTRACT
Comprehensive care, competency based education, and evaluation of education are topics
with great importance for family physicians. In this article we aim to discuss the relationships of
these terms with each other in the context of family medicine. The World Organization of Family
Doctors (Wonca) has defined six core competencies and eleven related characteristics of family
medicine. If we resemble these features to a tree, attitude, science, and context would compose its
roots. Although all these competencies are important, we can claim that “comprehensive care” the
inevitable one for the practice of family medicine. Competency based education is important in
order to train professionals meeting the needs of the population. For this, the first step is to define
what will be the required competencies. The Turkish Board of Family Medicine (TAHYK)
published a set of competencies needed for Turkish family physicians. This document sub
categorizes the competencies into “Knows”, “Applies”, “Performs preventive tasks”, “Diagnoses”,
“Diagnoses and treats”, and “Applies emergency interventions”. Assessment methods such as the
objective structured clinical exams and work-based assessments can be used in the evaluation of
competencies. Although the work based assessment is more difficult, is more superior in the
evaluation of real performance and is composed of four components: audit, admin database, diary,
and observation. As a conclusion, in order to provide comprehensive care, which is of utmost
importance for family physicians, required competencies should be defined first, followed by
evaluation of whether the family medicine trainees are meeting these competencies or not, and
lastly a training atmosphere has to be established for the trainee with sufficient infrastructure and
opportunities to meet the lacking competencies.
Keywords: family medicine, comprehensive care, competency based education, assessment
and evaluation
23
Aktürk Z. Aile Hekimliğinde Kapsamlı Bakım Yeterliliği ve Değerlendirilmesi, Euras J Fam Med, 1(1):23-28,2012.
Giriş
Kapsamlı bakım, yeterliliğe dayalı eğitim ve
eğitimin değerlendirilmesi aile hekimlerinin önem
verdiği güncel konulardandır. Bu yazıda her birisi
önemli bir makale konusu olabilecek bu başlıkların
aile hekimliği bakış açısıyla değerlendirilmesi ve bir
arada, birbirleri ile ilişkisinin incelenmesi
amaçlanmıştır.
Kapsamlı Sağlık Hizmeti
Kapsamlı sağlık bakımı aile hekimliği disiplinin
en önemli özelliklerinden biridir. Saultz, aile
hekimliğini diğer disiplinlerden ayıran dört özellik
(continuity of care, comprehensivecare, coordination
of care, contextualcare) arasında kapsamlı bakıma
özel bir önem vermektedir (8). Dünya Aile Hekimleri
Birliği de (Wonca) 2005 yılında güncellediği
tanımlarında altı adet temel yeterlilik ve bunlarla
ilişkili 11 özellik belirlemiştir(1; 3). Bu tanımdaki
özellikler bir ağaca benzetilirse (Şekil 1), ağacın
köklerinin aile hekimliğinin kendine özgü
profesyonellik değerleri ve yaklaşımı (Tutum), kanıta
dayalı tıp uygulamaları ve kendi araştırma temeli
(Bilim) ve hizmetin sunulabilmesi için gerekli sistem,
donanım, altyapı vb. Ortamın sağlanması olduğu
söylenebilir. Ağacın dallarını ise altı adet temel
yeterlilik oluşturur. Bu yeterliliklerin hepsi aile
hekimliğine özgün olmakla birlikte, hekimlik
uygulamaları için en vazgeçilmez olanın “Kapsamlı
sağlık hizmeti” olduğunu söyleyebiliriz.
Şekil 1: Wonca ağacı (U. Grueninger – İsviçre Aile
Hekimliği Koleji).
24 Amerikan Aile Hekimliği Akademisi (AAFP)
kapsamlı bakımı ”Sürekli kapsamlı bakım hizmet
uygulaması, bir hastanın birden fazla fiziksel ve
ruhsal sağlık sorunlarını aile, yaşam olayları ve çevre
ilişkisi içinde belli bir sürede eşzamanlı olarak
önleme ve yönetmedir.” olarak tanımlamaktadır (7).
Dolayısıyla aile hekiminin gerek sağlık sorunlarının
yelpazesi olarak her çeşit sağlık sorununa yaklaşım
sunabilmesi, gerekse her bir sağlık sorunu için
koruyucu ve tedavi edici sağlık hizmetlerini bir arada
sunabilmesi “Kapsamlı Bakım” tanımının içerisinde
değerlendirilmelidir.
Yeterlilikler
Yeterlilikler ve yeterliliğe dayalı eğitim çağdaş
eğitim terminolojisinde önemli bir yer tutmaktadır.
Yeterliliğe dayalı eğitimin önemi daha 1970’li
yıllarda kavranmıştır. Schneck yeterliliğe dayalı
eğitimi “Sonuç temelli öğretimdir ve öğrenciler,
öğretmenler ve toplumun değişen ihtiyaçlarına göre
uyarlanabilir.” olarak tanımlamaktadır (9).
Yeterlilikler, öğrencilerin günlük hayatta sık
karşılaşılan durumlarda temel ve diğer becerileri
uygulama yeteneklerini tanımlar. Böylece Yeterliliğe
dayalı eğitim (YDE), öğrencilerin tipik olarak
yaşamdaki rollerinin analiz edilerek oluşturulmasına
dayanmaktadır.
YDE, toplumun ihtiyacına uygun eleman
yetiştirmesi açısından önemlidir. Bununla birlikte,
“işi yapabilmek” her zaman gerçekten bilmek
anlamına gelmemektedir. Bu açıdan yeterliliğe dayalı
eğitime bazı eleştiriler de getirilmiştir. Yeterliliğe
dayalı eğitimin iyi planlanmaması halinde bilgi
içeriği açısından zayıf yetişebileceği ve eğiticilere
gereksiz bürokratik yük yükleneceği bu eleştirile
arasındadır.
Yeterliliğe dayalı eğitim verilebilmesi için
öncelikle yeterlilik ifadelerinin iyi tanımlanması
gerekir. Ardından içeriğin öğrenen ihtiyacına göre
belirlenmesi, ustalaşana kadar eğitimine devam
etmesi ve eğitim programını ancak yeterliliğini ispat
ettikten sonra bitirebilmesi gibi standartlar
önerilmiştir (11).
Yeterliliklerin belirlenmesi Kern tarafından
önerilen müfredat geliştirme yaklaşımında da ilk
adımı oluşturur (4). Bu yaklaşıma göre öncelikle
Şekil 3: Yeterlilik haritasının çıkarılması (Weddel KS).
genel ihtiyaçlar iyi belirlenmeli, ardından öğrenende
var olan birikimlerle karşılaştırması yapılarak
müfredat içeriği tasarlanmalıdır (Şekil 2).
Yeterliliklerin alt başlıklara ayrılması ve öğrenme
ihtiyacı haritalarının çıkarılması önemlidir. Bu
amaçla Weddel’in örneği Şekil 3’te gösterilmiştir.
Türkiye’de aile hekimlerinin yeterlilikleriyle
ilgili bir çalışma Türkiye Aile Hekimleri Yeterlilik
Kurulu (TAHYK) tarafından yürütülmüş ve
yayınlanmıştır (10). Bu çalışmada aile hekimliği
uzmanının sahip olması gereken yeterlilikler “Bilir”,
“Uygular”, “Koruyucu hekimlik hizmeti verir”, “Tanı
koyar”, “Tanı koyup tedavi eder”, “Acil müdahalede
Şekil 2: Yeterliliğe dayalı öğrenme ihtiyacının
belirlenmesi
25
bulunur” gibi başlıklar altında ayrıntılı olarak
belirtilmiştir (Şekil 4).
dört bileşenden oluşmaktadır: İnceleme, Yönetim
kayıtları, Günlükler ve Gözlemler (Şekil 6).
Şekil 4: TAHYK Aile Hekimliği Uzmanlık Eğitimi
Programı – Kalp ve Damar Sistemi Hastalıkları.
TAHYK tarafından belirlenen iskemik kalp
hastalığı yeterliliğini cümleye dökecek olursak şu
şekilde bir ifade ortaya çıkabilir: “Aile hekimliği
uzmanı iskemik kalp hastalığında koruyucu hekimlik
yaklaşımı sunabilir, bu hastalığın tanısını koyup
tedavisini planlayabilir ve gerektiğinde acil
müdahalede bulunabilir.” Başarılı bir eğitim için bu
yeterliliğin alt başlıklarıyla ilgili yeterlilik haritasını
çıkarmalı ve öğrenenin eksik olduğu alanları saptayıp
uygun bir eğitim planı çıkarmalıyız.
Yeterliliğin Değerlendirilmesi
Eğitimde sıkça başvurulan bir değerlendirme
yaklaşım Miller’in 1990’da tanımladığı piramit
yaklaşımıdır (5). Bu yaklaşıma göre piramidin alt
kısmındaki bilgi ve becerileri çoktan seçmeli sınavlar,
sözlü sınavlar, objektif yapılandırılmış sınavlar gibi
yöntemlerle değerlendirmek mümkün iken kişinin
performansını gerçekten uyguladığını değerlendirmenin ancak çalışma ortamında değerlendirme
yöntemleriyle mümkün olduğu belirtilmektedir.
Ç a l ı ş m a o r t a m ı n d a ö l ç m e ( Wo r k b a s e d
assessment), diğer yöntemlere göre daha zor olmakla
birlikte, kişinin gerçek performansını değerlendirmesi
açısından önemlidir. Bununla birlikte, kişinin gerçek
performansı sadece kendi yeterliliğine bağlı değildir.
Sağlık sistemiyle ilgili faktörler ve kişinin o andaki
beden ve ruh sağlığı gibi bireysel faktörler de
performansta önemli belirleyicilerdir (2).
Çalışma ortamında ölçme ve değerlendirme
yapmak için Norcini tarafından önerilen yaklaşım (6)
26 Şekil 5: Miller Piramidi
Şekil 6: Çalışma ortamında değerlendirme.
Klinik Uygulama Kayıtları
Çıktılar, süreçler ve hacim hakkında en iyi bilgi
kaynaklarından birisi klinik uygulama kayıtlarıdır. Bu
kayıtların dış denetimi geçerli ve verilerin kaynağı
güvenilirdir. Ancak, kayıtların özetlenmesi, pahalı,
zaman alıcı ve genellikle eksik veya okunamaz
olduğu gerçeği bu uygulamayı elverişsiz kılmaktadır.
Bu sorunların çözümü elektronik tıbbi kayıtların
yaygınlaşması ile olabilir. Bu arada bazı doktorlar
kendi kayıtlarına güvenerek değerlendirme
yapmaktadırlar. Dış denetimle birlikte bu yöntem
güvenilir ve uygun bir alternatiftir.
Çıktılar
Bir doktor hastalarının sonuçları ile ilgili kararı
kendisi değerlendirebilir. Örneğin bir kardiyolog,
akut miyokard infarktüsü olan hastalarında 30 gün
içinde mortalite olasılığını değerlendirebilir. Tarihsel
olarak, mortalite ve morbidite sonuçları sınırlı
kalmıştır. Ancak son yıllarda, klinik uç noktaları
genişletilmiş oldu. Hasta memnuniyeti, fonksiyonel
durumu, maliyet-etkinlilik ve ara sonuçlar- örneğin,
diyabetik hastalarda HbA1c ve lipid düzeyleri-kabul
edilmiştir. İlgi yanlış tanı hataları çevresinde
toplanmakla birlikte, tüm bunlardan sonra, yukarıda
belirtilen pek çok alanlarda eğer doğru tanıya
dayanılıyorsa bu uygulama faydalıdır. Sadece
konjestif kalp yetmezliği çeken bir hasta, astım için
tüm tanı kriterlerini karşılayabilir.
Bakım süreci
Bakım süreci ile ilgili kararı bir aile hekimi verir.
Örneğin, 50 yaş üzeri bir hastanın kaç kez kolorektal
kanser taraması yapılması gerektiğini
değerlendirebilmelidir. Genel ölçme süreçleri;
koruyucu tarama hizmetleri, tanı, yönetim, reçete
yazma, hasta ve danışmanlık eğitimini içerir. Buna ek
olarak, doktorun, örneğin diyabetik hastalarının
HbA1c düzeyleri düzenli olarak izlenip izlenmediği
ve rutin ayak muayenesinin yapılıp yapılmadığı gibi
duruma özgü süreçler hakkında karar vermeleri de
temel bir hizmet olabilir.
Performans-Volüm
Hekimlerin çalışma performansını değerlendirmenin üçüncü bir yolu, yapılan belirli bir
aktivitenin katsayısı hakkında karar vermeleridir.
Örneğin, bir cerrahın kalite ölçümlerinden biri, belli
bir prosedürün kaç kez yapıldığının sayısı olabilir. Bu
tür bir değerlendirme için dayanak noktası, bakım
kalitesinin daha yüksek performans ile ilişkili
olduğunu belirten araştırmalardır. Sonuçlar ve
süreçler karşılaştırıldığında, performansa dayanan işe
dayalı değerlendirmenin problemlere atfedilen
önemin azalması, karmaşanın elimine edilmesi gibi
sebeplerle avantajları vardır. Ancak, tek başına
performansa dayalı bir değerlendirme, işin düzgün bir
şekilde yapıldığına dair bir güvence sunmamaktadır.
Günlükler
Doktorlar, özellikle de stajyerler, sık sık günlük
kullanırlar veya yaptıkları uygulamaların kaydını
tutarlar. Amaçlarına bağlı olarak, günlükler doktor
rolünün tanımlanması, endikasyonun doğru olup
olmadığı ve gözlemcinin adı ve komplikasyon
listesini içerebilir. Elektronik sağlık kaydı yapılıncaya
kadar performansa ait veri toplamak ve klinik
uygulamada kayıtlarının özetlenmesi için günlükler
kabul edilebilir alternatif bir yoldur.
Gözlem
Veri pek çok açıdan pratik gözlem yoluyla
toplanabilir, ama Miller'in iş tabanlı değerlendirmesi
tanımı ile tutarlı olması için, gözlemler rutin
olmalıdır. Bu gözlemler herhangi bir yolla ve
herhangi sayıda farklı gözlemci tarafından yapılabilir.
Gözlem tabanlı değerlendirmenin en yaygın biçimi
denetçiler, meslektaşlar ve hastaların yaptığı
değerlendirmedir, ancak, aynı zamanda hemşire ve
diğer yardımcı sağlık profesyonellerden de bir
doktorun performansı hakkında bilgi alınabilir. Çok
kaynaklı geribildirim araçlarının kombinasyonla
kullanımı değerlendirmeyi basitleştirir. Diğer gözlem
örnekleri, doktorların ameliyatları için standardize
hasta vizitesi ve ses veya video kasetlerini sayabiliriz.
Sonuç
Aile hekimliği için son derece önemli olan
kapsamlı bakım hizmetinin etkin bir şekilde
sunulması için öncelikle aile hekimliği uzmanlık
eğitiminin yeterliliklerinin yeniden gözden
geçirilmesi ve ayrıntılı yeterlilik haritalarının
çıkarılması gerekmektedir. Ardından aile hekimliği
asistanlarının ihtiyaçları doğru belirlenmeli ve bu
ihtiyaçları karşılayabilecek müfredat içerikleri ve
eğitim ortamı sağlanmalıdır. Aile hekimliği uzman
adaylarının TAHYK tarafından belirlenen yeterliliklere ulaşıp ulaşmadıklarının değerlendirilmesi
için aile hekimliği asistanı eğitimi boyunca değerlendirilmeli ve bir öğrenme portföyü oluşturulmalıdır.
Aile hekimliği asistanına eksik bulunan yeterlilikler
tamamlaması için imkân ve fırsatlar sağlanmalıdır.
27
Kaynaklar
1. Allen J. The European
Definition of General
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Wonca Europe, Barcelona,
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2. Cantillon PW, D. ABC of
Learning and Teaching in
Medicine. pp 48. Blackwell
Publishing Ltd; 2010.
3. Evans PEB, Aile Hekimliği /
Genel Pratisyenlik Avrupa
Tanımı. Basak O. (Çeviri
E d . ) Wo n c a E u r o p e ,
Barselona, 2002.
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Development for Medical
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clinical skills/competence/
performance. Acad Med
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and teaching in medicine.
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org/online/en/home/policy/po
licies/c/comprehensivecare2.
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8. Saultz JM. Textbook of
Family Medicine. New York:
McGraw-Hill Professional
Publishing; 1999. pp:17.
9. Schneck EA.. Approaches
and Methods in Language
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Identifying High School
Graduation Competencies:141. Portland: Northwest
Regional Educational
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10. TAHYK. Aile Hekimliği
Uzmanlık Eğitimi Programı.
2006. http://www.tahud.org.
tr/uploads/content/AHU_egiti
mi_mufredat.pdf
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Based Education and Content
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cde.state.co.us/cdeadult/down
load/pdf/CompetencyBasedE
ducation.pdf
İletişim için:
Prof. Dr. Zekeriya Aktürk,
Atatürk Üniversitesi Tıp Fakültesi Aile Hekimliği AD,
25240 Erzurum,
Tel: 05545409798, Faks: +904422360968,
e-posta: [email protected]
2012
Family Medicine in Pre-clinical Years of Medical School: Fruitful or
Futile
AUTHORS
Abdul Sattar Khan
Medicine, Atatürk
University Medical
Faculty, Erzurum,
Turkey
Zekeriya Akturk
Medicine, Atatürk
University Medical
Faculty, Erzurum,
Turkey
ABSTRACT
Family medicine is the one field that gives you full satisfaction and a sense of being the
complete physician because of taking care of the whole person and others around. However it is
not fully accepted by the medical students as an admiring medical specialty and different efforts
have been made to accept it at different stages of medical schools.
The family medicine introduced currently in different models and different shapes in different
parts of the world but mainly existing three models – resident trainings, on job trainings and
undergraduate teaching. Family medicine usually started in clinical period of undergraduate
medical education in many part of the world and found effective.
Ataturk University is one of those universities, which took a lead and established a family
medicine department in 2009. Nevertheless this department entered into curriculum and was able
to apply a new model of family medicine in first and second year of teaching. Although the family
medicine department is just two years old we are hopeful that it will continue to grow and even
will be very fruitful.
In this article, we emphasize the importance of family medicine in undergraduate medical
education by presenting the Atatürk University’s model as an example.
Key words: undergraduate medical education, medical education, medical curriculum
Introduction
This was a routine to blame or criticize universities in general or medical schools
in particular about their way of teaching and not to produce those physicians who
respond to the need of population. This was also an argument that the students usually
were not prepared to deal the health problems that they most likely to encounter when
they will go into practice (1, 2). So far there are several decisions have been made to
improve the curriculum at undergraduate level in many medical schools (3).
Nonetheless, the Royal College of General Practitioners (RCGP), who stressed
the importance of undergraduate medical education in inspiring, stimulating,
supporting, and training future doctors. It reminded us of the key role of the generalist
in medical education, and urged medical schools to ensure that all students have good
experience of general practice embedded in the curriculum (4).
One of the frequent interventions is to introduce family medicine as part of the
curriculum in order to give students the opportunity to get in contact with most
frequent problems, to integrate and apply their knowledge (5, 6). Turkey is one of
those countries, which tries very hard to produce as much as possible family
physicians and in this mission almost all universities that have medical colleges are
supporting government.
Some milestones of Medical Education in Turkey
Turkey has 50 Faculties of Medicine located in different areas. Some new medical
schools are being expected to develop and establish in the near future however now
46 are accepting students for undergraduate training. There is a 6-year curriculum in
29
Khan AS. Family Medicine in pre-clinical years of medical school: Fruitful or Futile, Euras J Fam Med, 1(1):29-34,2012.
all colleges. Students enter medical school after
passing a national entrance examination after
finishing their 12 years high school. In almost all
schools, the curriculum comprises of 6 years with the
distribution of 2 years of basic sciences, 3 years of
clinical sciences, and 1 year is devoted to family
practice as internship. The specialty of family
medicine was created in 1984 (7). In most of the
medical schools the problem-based education cannot
be implemented so far, if present then programs for
faculty development and improving teaching skills
are seen as volunteers’ activities (8). The Continuous
Medical Education (CME) activities are carried out
by the Ministry of Health, the Turkish Medical
Association and Turkish Association of Family
Physicians with the help of some universities (9).
Pre-clinical vs Clinical curriculum
A preclinical/clinical division was firmly
established as the norm in medical education a
century ago at a time when biomedical science was
proving its ability to explain disease and provide a
theoretical basis for treatment (10). Now, medical
schools in many parts of the world are ‘vertically
integrating’ various types of practical experience. A
recently published consensus survey suggested that
early experience might orientate medical curricula
towards the social context of practice, ease students’
transition to the clinical environment, motivate them,
make them more confident to approach patients, and
make them more aware of themselves and others
(11).
Medical curriculum & Family Medicine at
Atatürk University
The Ataturk University started in 1957 and
faculty of medicine has been developed within 5
years time. It is a government sector university
comprised of 19 faculties with a tertiary care 1200
bed hospital. The curriculum is based on committee
system (Table 1). Medical students at university need
to complete six years and public health, biostatistics
and family medicine teaching starts from the first
year in phases. The family medicine currently exists
in different models and different shapes in different
parts of the world but mainly existing three models –
resident trainings, on job trainings and undergraduate
30 teaching (12-14). The family medicine usually started
in clinical period and found effective (15).
Ataturk University is one of those universities
that took a lead and established a family medicine
department in 2009. Nevertheless this department
entered into curriculum and able to apply it in first
and second year of teaching (Table 2 & 3). Although
the family medicine department is just two years old
we are hopeful that it will continue growing and even
will be very fruitful.
Discussion
The family medicine teaching has gone through
several milestones in Turkey. Although the history of
family medicine goes back to several centuries (16),
however after accepting it as specialist discipline
going through many transition periods (17, 18),
recently it became a reality and need of health care
system in Turkey. So far in medical schools several
experiments have to be done to incorporate the family
medicine in the curriculum of medical faculty and
medical educationist are fully convinced that
community-based, comprehensive primary care
education given by the primary care team is
necessary for medical students (19).
New education models were developed to
integrate basic sciences with clinical problem solving
and to enable medical students contact with patients
in their own environment (20). In many European
countries family medicine programs are generally
affiliated with primary care centres and are placed in
later periods of the medical curriculum (21).
However mostly the family medicine training start
when clinical rotations start in many countries
including Turkey (16, 19, 22).
In our family medicine model we started the
curriculum at first and second year (Table 1 & 2) and
continue it up third year. We designed the curriculum
based on results of many studies concluding that
early clinical exposure to primary care has positive
impact on the educational quality and career choice
(23-26) while so far none of university dares to
modify the basic sciences timetable and incorporate
the family medicine in early years of medical schools
at least in Turkey. The concept of early exposure to
patients might be not a new idea but it was debated
Table 1. The six year undergraduate medical curriculum
Study Years
1st
2nd
3rd
4th
5th
6th (Internship)
Number of committees /
Rotations
6-Committees
Committees/ Rotations
Cell and Tissue Sciences Course – I
Cell and Tissue Sciences Course – II
Cell and Tissue Sciences Course – III
Cell and Tissue Sciences Course – IV
Cell and Tissue Sciences Course – V
Cell and Tissue Sciences Course – VI
1.
2.
3.
4.
5.
6.
Musculoskeletal system
Circulatory & Respiratory system
Digestive & Metabolism
Neurology
Endocrinology & Urogenital system
Biological bases of diseases
9-Committees
1.
2.
3.
4.
5.
6.
7.
8.
9.
Public health
Biological bases of diseases
Circulatory & Respiratory system
Digestive & Metabolism
Hemopoietic System
Locomotors
Genitourinary system
Neurology & Psychiatry
Endocrinology
4- Rotations
1.
2.
3.
4.
Internal medicine
General surgery
Obstetrics & Gynecology
Pediatrics
17- Rotations
Forensic medicine, Neurosurgery
Pediatric surgery, Dermatology
Infectious diseases, Physical therapy and rehabilitation,
Chest surgery
Chest diseases, Eye diseases
Cardiovascular surgery, Cardiology
ENT, Neurology, Orthopedics
Plastic and reconstructive surgery
Radiology, Psychiatry, and Urology
6-Committees
Internal medicine
Pediatrics
Emergency medicine
Public health
Family medicine
Gynecology and obstetrics
Psychiatry
31
Table 2: Family medicine in 1st & 2nd Year
Items
1st year MBBS
2nd year MBBS
13/782
15/686
4/166
0/220
Number of hours
Total theory classes (Contents)
Total practical classes
(Contents)
Assessment procedures
Every 6 months MCQs theory papers
Class participation
Report writing about hospital visit
during last whole decade that how it can apply to get
a good outcome without disturbing of curriculum of
pre-clinical or basic sciences subjects. Our whole
curriculum consists of total 948 hours in first year
and 906 hours in second year. We not only have
theory classes but also expose students to our primary
health care units as well as hospitals. Our rationale to
expose the students earlier make them more
confident, empathic and well oriented about the
holistic approach to the patients and will learn the
Every 6 months MCQs theory papers
Class participation
Report writing about hospital visit
basic sciences as an application science rather to
memorize the facts and expressed through the
different methods of assessments and then forget it.
Likewise a study shows that first-year medical
students who received structured and supervised
interview training with real patients, and followed up
a chronically ill patient over time, showed significant
increases in objective ratings of their ability to relate
to simulated patients in videotaped interviews. Their
self-reported ability to relate to patients and
Table 3. Objectives of Family medicine in 1st & 2nd Year
1st year MBBS
The students will be able to:
The students will be able to:
1. Describe terms used in primary care and
1. Discuss the basic principles of family
2. Explain terms related with quality and dis-
2. Related with the base of clinical family
explain stages of a family life cycle and its
effects on health.
cuss quality improvement methods
3. Accepts importance of medical records
and can discuss types of records
4. Explain types of communication and principles of effective communication
5. Explain features of different health units
and list their responsibilities
6. List common diseases encountered in family practice and discuss their effects on
health provision
32 2nd year MBBS
medicine such as comprehensive care,
contextual care, and coordination of care
medicine, explain consultation principles,
shared decision making, and biopsychosocial approach
3. Discuss the evidence base of family prac-
tice and how to use this knowledge in giving clinical decisions and prescribing
medications
4. Discuss ICD and ICPC coding principles
5. List principles of patient education and
factors related with patient adherence
communicate empathy increased greatly (27).
Another study portrays that first- and second-year
student participants in community interviewing
schemes reported improvements in their ability to
communicate, and valued being able to explore social
and psychological determinants of health and illness
through contact with real patients (28). Our
experiment is second by so many other studies
(23-26) in different other part of the world as well. So
far students are not raising any voice instead they are
happy and satisfied during class and give a positive
feedback. Indeed, in itself, has not been proved to be
a sufficient to believe that it is effective because it
requires follow up for further for at least up to their
workplaces.
In nutshell our hypothesis is that it can help
learners attain a number of affective outcomes,
including positive attitudes towards practice, build
self-awareness, and make students more satisfied
with their curriculum and confident to meet patients,
motivate them and reduce the stress of meeting
patients. Early experience can also benefit teachers,
healthcare organizations, individual patients and
population (29) in terms of enhancing skills for
handling patients holistically. Of course a successful
family medicine incorporation in basic sciences
curriculum needs institutional support, structured
curriculum, patients, clinical setting, evaluation
process, volunteer faculty, preceptors, and financial
support (30), which are fully provided by Ataturk
University. We suggest that medical schools should
renovate their curriculum and should try this model
and follow up and assess the effectiveness. We would
also recommend some comparative longitudinal
studies for assessment of long-term benefits for early
intervention of family medicine in medical school.
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Corresponding Author:
Dr. Abdul Sattar Khan
Assistant Professor, Family Medicine Department
Ataturk University- Erzurum
2012
A Case with Skin Discoloration
AUTHORS
Dilek Toprak
Family Medicine Clinics,
Sisli Etfal Education and
Research Hospital,
Istanbul
Esma Aksaç Adalı
Family Medicine Clinics,
Sisli Etfal Education and
Research Hospital,
Istanbul
ABSTRACT
Erythema ab igne is a pigmented reticular skin lesion with telangiectasias caused by
prolonged exposure to heat. In this report an 11-year-old adolescent boy with erythema ab igne
induced by a laptop computer was discussed.
Keywords: Erythema ab igne, skin discoloration, computers, radiation effects
Introduction
Erythema ab igne is a pigmented reticular skin lesion with telangiectasias caused
by prolonged exposure to heat. It is also known as erythema a calore.
The term is derived from Latin and means "redness from fire" (1). Although wide
use of Central Heating has reduced the incidence, it is still sometimes found in people
exposed to heat from other sources like heat packs, laptops, and hot water bottles
(1,2).
Case
11-year-old adolescent boy presented to the family medicine clinics with a
complaint of patch like pigmentation on the dorsal surface of his left thigh that had
been present for the past 2 months. The mother of the patient said that they did not
recognised this condition till that time and she did not see similar colour change even
in his childhood period. No medical care received before, for this compaint. On
physical examination, there was a fairly well-defined, brown, mildly erythematous,
reticulated patch on the left anterior thigh (Figure 1 and 2).
35
Toprak D. A Case with Skin Discoloration, Euras J Fam Med, 2012;1(1):35-38.
Although the rash in the patient had a vascular
net-like appearance, it did not blanch as would blood
vessels, and there was no superficial thrombophlebitis
on palpation of the skin. The lesion was so fade on
the right thigh. The patient was asymptomatic except
this colour change and we couldn’t determined any
other abnormal finding except BMI which was
28kg/m². The other tests carried out, including full
blood count, C-reactive protein (CRP) and
erythrocyte sedimentation rate (ESR), were all within
the normal range.
When questioned, the patient reported that
around 3-4 months previously he had bought a new
laptop and had developed the habit of using it on his
thighs several hours in a day.
Discussion
Erythema ab igne is a skin reaction caused by
exposure to heat. It was once commonly seen in the
elderly who stood or sat closely to open fires or
electric heaters. Prolonged and repeated exposure
causes a marked redness and colouring of the skin.
The temperature required to induce erythema ab igne
ranges from 43 to 47 ºC (2).
In this case the lesion was isolated to the left
anterior thigh, because the heat source (optical drive)
was located on the left base of the computer and it
caused exposure to heat for a long time.
Like our case aside from the skin discoloration,
erythema ab igne is usually asymptomatic. Erythema
ab igne also has been reported in individuals who use
hot water bottles for warmth in winter or repeated hot
compresses and in patients who strongly prefer warm
environments (heating pads applied for pain, car
heaters, hot baths, hot popcorn kernels applied for
arthritis relief (1,2). It is found more commonly on
women’s legs, but may also be seen on the buttocks
and thighs.
Erythema ab igne often begins as mild localized
erythema. Repeated exposures to moderate heat may
result in reticulate erythema, hyperpigmentation,
telangiectasia, scaling, and atrophy. Histopathological
changes include hyperkeratosis,
epidermal atrophy, squamous atypia,
and interface dermatitis with necrotic
keratinocytes (1).
Currently, the development of new
technology in the form of portable
computers and accessories means that
these devices may be in direct contact
with the user’s skin for prolonged
periods of time, consequently causing
damage to the skin (3). So we also have
to discuss how important it is for the
manufacturers of these devices to warn
consumers of the potential hazards that
could occur if the equipment is
misused. In laptop computers, as in the
vast majority of personal computers,
cooling is achieved through the use of
fans.
Treatment involves eliminating
direct contact between the skin and the
source of infrared radiation. Topical
treatment with tretinoin and
hydroquinone has been used for
persistent hyperpigmentation, and
36 Toprak D. A Case with Skin Discoloration, Euras J Fam Med, 2012;1(1):35-38.
epithelial atypia may respond to topical therapy with
5-fluorouracil. In severe cases in which the rash does
not resolve, laser treatment may be beneficial (4).
Our patient was advised not to place his laptop
computer directly on her thighs but had to use a table
or another type of support to diminish the possibility
of direct contact with the device and to use local
photoprotection.
Rarely, in the form of the Koebner phenomenon,
psoriasis, lichen planus and lupus may develop at the
site of erythema ab igne. Also in rare cases of
squamous cell carcinoma and Merkel cell carcinoma
arising in lesions of Erythema ab igne have been
reported (5). Therefore, it is prudent to monitor
patients periodically for changes in the appearance of
the rash. Our patient was reevaluated ten days later
and the brownish macules were found to be gradually
disappearing.
A biopsy should be performed if there is any
evidence of cutaneous malignancy. For the
confirmation of the diagnosis a punch biopsy can be
performed, which shows epidermal atrophy and
flattening of the dermo-epidermal junctions, collagen
(Drug information on collagen) degeneration, and an
increase in dermal elastic tissue (2).
Other skin lesions which cause skin discoloration
should be considered for differential diagnosis; like
poikiloderma (actinic keratosis), livedo reticularis,
vasculitis and cutis marmorata. A careful history
taking and physical diagnosis are the main points for
diagnosis. In Table 1, differential diagnosis of skin
discoloration was shown.
Table 1: Differential Diagnosis of skin discoloration
Condition
Characteristics
Eritema ab igne
Pigmented reticular skin lesion with telangiectasias caused by prolonged
exposure to heat.
Characterized by red coloured pigment on the skin that is commonly
associated with sun damage; mostly seen on the chest or neck.
Reddish blue mottling of the skin found usually on the extremities in a
reticular or fishnet pattern.
It is believed that the blanched areas of skin are secondary to a vasospasm of the perpendicular arterioles that perforate the skin from the
subcutaneous tissue.
Poikiloderma, sun damage (actinic
keratosis)
Livedo reticularis
Vasculitis
A general term for a group of uncommon diseases that feature inflammation of the blood vessels. Immune system abnormality is common but
can also accompany infections, exposure to chemicals, medications, cancers and rheumatic diseases.
Cutis marmorata
Reticular bluish discoloration of the skin.
It resolves with warming of the skin.
This marbled appearance occurs in 50% of young healthy children and is
frequently found in those with trisomy 21 syndrome.
37
Toprak D. A Case with Skin Discoloration, Euras J Fam Med, 2012;1(1):35-38.
References
1. Beleznay K, Humphrey S, Au
S (March 2010). "Erythema
ab igne". CMAJ: Canadian
Medical Association Journal=
Journal De l'Association
Medicale Canadienne 182
(5): E228.
2. Kennedy CTC, Burd DAR.
Effects of heat and infrared
radiation. In: Burns T,
Breathnach SB, Cox N,
Griffiths C. Rook's Textbook
of Dermatology. Hong Kong:
Blackwell, 2004. p.22.6422.65.
3. Giraldi S, Diettrich F, Abbage
KT, Carvalho VO, Marinoni
L P. E r y t h e m a a b i g n e
induced by a laptop computer
in an adolescent. An Bras
Dermatol 2011;86(1):128-30.
4. Tan S, Bertucci V. Erythema
ab igne: an old condition new
again. CMAJ 2000;162:77–8.
5. Iacocca MV, Abernethy JL,
Stefanato CM, Allan AE,
Bhawan J. Mixed Merkel cell
carcinoma and squamous cell
carcinoma of the skin. J Am
Acad Dermatol 1998;39:
882-7.
Corresponding Author
Assoc. Prof. Dr. Dilek Toprak
Sisli Etfal Education and Research Hospital
Family Medicine Clinics
Istanbul/TURKEY
GSM: +905323827836
Fax:+902722132907
38 Euras J Fam Med
INSTRUCTIONS FOR AUTHORS
Eurasian Journal of Family Medicine (EJFM) is an
international journal which publishes clinical and experimental
trials, interesting case reports, invited reviews, letters to the
Editor, meeting, news and bulletin, clinical news and abstracts of
interesting researches conducted in Family Medicine field. The
language of the journal is both Turkish and English. The journal
is based upon independent and unbiased double-blinded
peer-review principles. The Journal is the scientific publication
of the Eurasian Society of Family Medicine (ESFAM), and is
published three times per year.
The authors are responsible for the scientific content of the
material to be published.
Scientific Review and Acceptance
Manuscripts must only be submitted electronically through
the following website: www.ejfm.org.
Only the papers that have not previously been published in
any scientific publication are accepted for publication.
Manuscripts that have been presented orally or as a poster must
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The manuscript file should include title page, abstracts and
keywords, text, references, tables (each table on a separate page),
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as Introduction, Case(s) and Discussion following the titles and
abstracts. Author names and their institutional information,
figures and illustrations should not be present in the manuscript
file.
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ICMJE standards and numbered consecutively at the end of the
manuscript in the order in which they are mentioned in the text.
Journal abbreviations should be in Index Medicus style. If there
are more than six authors, it should be abbreviated with the use of
"et al.". Authors should only cite the articles that they have
directly used. Our journal does not approve the citations made
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authors against the original documents by sending the photocopy
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end of the main text. Tables, figures and graphics must be cited in
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Ethics
An approval of research protocols by ethics committee in
accordance with international agreements (Helsinki Declaration
of 1975, revised 2002 - available at http://
w w w. v m a . n e t / e / p o l i c y / b 3 . h t m < h t t p : / / w w w. v m a . n e t /
e/policy/b3.htm>, "Guide for the care and use of laboratory
animals"- www.nap.edu/ catalog/ 5140.html/) is required for
experimental, and clinical and drug trial studies.
Euras J Fam Med
YAZARLARA BİLGİ
Avrasya Aile Hekimliği Dergisi (EJFM), Aile Hekimliği
alanında yapılan klinik çalışmaları, ilginç olgu bildirimlerini,
davet edilmiş derlemeleri, Editöre mektupları, toplantı, haber ve
duyuruları, klinik haberleri ve ilginç araştırmaların özetlerini
yayınlayan; yayın dili Türkçe ve İngilizce olan, bağımsız ve
önyargısız çift-kör hakemlik (peer-review) ilkelerine dayanan
uluslararası bir dergidir. Dergi, Avrasya Aile Hekimliği
Derneği’nin (ESFAM) bilimsel içerikli yayın organı olup yılda 3
sayı yayınlanır.
Yazıların bilimsel sorumluluğu yazarlara aittir.
Bilimsel Değerlendirme ve Yayına Kabul
Yazılar sadece http://www.ejfm.org adresinden online olarak
gönderilmelidir. Gönderilen yazıların dergide yayınlanabilmesi
için daha önce başka bir bilimsel yayın organında yayınlanmamış
olması gerekir. Daha önce sözlü ya da poster olarak sunulmuş
çalışmalar, yazının başlık sayfasında tarihi ve yeri ile birlikte
belirtilmelidir.
Dergiye gönderilen yazılar, ilk olarak dergi standartları
açısından incelenir. Derginin formatına uymayan yazılar, daha
ileri bir incelemeye gerek görülmeksizin yazarına iade edilir. Bu
nedenle, gereksiz yere zaman ve emek kaybına yol açılmaması
için, yazı sahipleri dergi kurallarını dikkatli incelemek
zorundadır.
Derginin temel kurallarına uygunluğuna karar verilen yazılar
Danışma Kurulundan en az iki üyeye gönderilir ve bu üyelerden
yayına uygun olup olmadığı konusunda görüşleri alınır. Bu
incelemeden geçen yazılar, Yayın Kurulu tarafından tekrar
değerlendirilir ve basılacağı yer ve sayı kararlaştırılır.
Tüm yazarlar bilimsel katkılarını, sorumluluklarını ve çıkar
çatışması olmadığını bildiren toplu imza ile yayına katılmalıdır.
Araştırmalara yapılan kısmi de olsa nakdi ya da ayni yardımların
hangi kurum, kuruluş, ilaç-gereç firmalarınca yapıldığı dip not
olarak bildirilmelidir.
Makalelerin formatı ICMJE-Uniform Requirements for
Manuscripts Submitted to Biomedical Journals: Writing and
Editing for Biomedical Publication (www.icmje.org) kurallarına
göre düzenlenmelidir.
Danışma Kurulu, Yayın Kurulu ve Yayıncı dizgi ve kontrol
aşamasında, yazılarda düzeltme yapmak, biçiminde değişiklikler
istemek ve yazarları bilgilendirerek kısaltma yapmak yetkisine
sahiptir. Yazarlardan istenen değişiklik ve düzeltmeler yapılana
kadar, söz konusu yazılar yayın programına alınmayacaktır.
Makalenin Hazırlanması
Yazının gönderildiği metin dosyasının içinde sırasıyla, başlık
sayfası, Türkçe ve İngilizce özetler ve anahtar sözcükler,
makalenin metinleri, kaynaklar, her sayfaya bir tablo olmak üzere
tablolar ve son sayfada şekillerin (varsa) alt yazıları şeklinde
olmalıdır.
Başlık sayfası: Başlık sayfası yazının başlığını, yazar(lar)ın
isim ve çalıştıkları kurumları ve sorumlu yazarın telefon, adres ve
elektronik posta bilgilerini içermelidir.
Özetler: İkinci sayfada Türkçe ve İngilizce özetler yazı
başlığı ile birlikte verilmelidir. Araştırma makalelerinde özetler;
Amaç, Yöntemler, Bulgular, Sonuç bölümlerine ayrılmalı ve
toplamı 200 sözcüğü geçmemelidir. Olgu sunumlarının özetleri
ağırlıklı olarak mutlaka olgu hakkında bilgileri içermeli, kısa ve
tek para- graf olmalıdır.
Tam metin dosyası: Giriş, Yöntemler, Bulgular, Tartışma,
Çıkar Çatışması Beyanı, ve Kaynaklar şeklinde oluşturulmalıdır.
Metin dosyasında yazının hiçbir bölümünün ayrı sayfalarda
başlatılması zorunluluğu yoktur. Olgu sunumları da, başlık ve
özetlerden sonra Giriş, Olgu(lar) ve Tartışma şeklinde
düzenlenmelidir. Metin dosyasının içinde, yazar isimleri ve
kurumlara ait bilgi, makalede kullanılan şekil ve resimler
olmamalıdır.
Kaynaklar: Kaynak yazım stilleri ICMJE kurallarına göre
yapılmalı ve yazı içinde geçiş sırasına göre makale sonunda
listelenmelidir. Kullanılacak kısaltmalar Index Medicus'a uygun
olmalıdır. Yazar sayısı altıdan fazla ise Türkçe makalelerde "ve
ark." İngilizce makalelerde ise "et al." şeklinde kısaltılmalıdır.
Yazarlar yalnızca doğrudan yararlandıkları kaynakları yazılarında
gösterebilirler. Dergimiz, başka çalışmalarda bildirilen
kaynakların aktarma şeklinde kullanılmasını kesinlikle
benimsememektedir. Bir kaynağın aslından yararlanılmamış
olduğu düşünüldüğünde, yazarından söz konusu kaynak ya da
kaynakların ilk sayfalarının fotokopilerini göndermesi istenir.
Yayınlanmamış ve sayfa numaralarıyla verilemeyecek kaynak
(yayınlanmamış kongre, sempozyum, toplantı, vb. belgeleri)
kullanılamaz.
Tablo, Şekil, Grafik ve Fotoğraflar: Tablo, şekil ve
grafikler yazının içine yer- leştirilmiş halde gönderilmemelidir.
Tablolar her sayfaya bir tablo olmak üzere yazının gönderildiği
dosya içinde olmalı ancak yazıya ait şekil, grafik ve fotoğrafların
her biri ayrı bir imaj dosyası olarak yüksek çözünürlüklü jpeg
formatında gönderilmelidir. Tablo başlıkları ve şekil altyazıları
eksik bırakılmamalıdır. Şekillere ait açıklamalar yazının
gönderildiği dosyanın en sonuna yazılmalıdır. Tablo, şekil ve
grafiklerin yazıda nerede geçtiği belirtilmelidir.
Etik
Deneysel, klinik ve ilaç araştırmaları için ilgili uluslararası
anlaşmalara uygun (Helsinki Declaration of 1975, revised 2002 http://www.vma.net/e/policy/b3.htm, "Guide for the care and use
of laboratory animals - www.nap.edu/catalog/5140.html) etik
komisyon raporu gerekmektedir.

EJFM 1(1) reduced

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