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medical and biological sciences
UNIWERSYTET MIKOŁAJA KOPERNIKA w TORUNIU
COLLEGIUM MEDICUM im. LUDWIKA RYDYGIERA
W BYDGOSZCZY
MEDICAL
AND BIOLOGICAL
SCIENCES
(dawniej
ANNALES ACADEMIAE MEDICAE BYDGOSTIENSIS)
TOM XXVI/2
kwiecień – czerwiec
ROCZNIK 2012
REDAKTOR NACZELNY
Editor-in-Chief
Grażyna Odrowąż-Sypniewska
ZASTĘPCA
REDAKTORA NACZELNEGO
Co-editor
Jacek Manitius
SEKRETARZ REDAKCJI
Secretary
Beata Augustyńska
REDAKTORZY DZIAŁÓW
Associate Editors
Mieczysława Czerwionka-Szaflarska, Stanisław Betlejewski,
Roman Junik, Józef Kałużny, Jacek Kubica, Wiesław Szymański
KOMITET REDAKCYJNY
Editorial Board
Aleksander Araszkiewicz, Beata Augustyńska, Michał Caputa, Stanisław Dąbrowiecki, Gerard Drewa, Eugenia Gospodarek,
Bronisław Grzegorzewski, Waldemar Halota, Olga Haus, Marek Jackowski, Henryk Kaźmierczak, Alicja Kędzia,
Michał Komoszyński, Wiesław Kozak, Konrad Misiura, Ryszard Oliński, Danuta Rość, Karol Śliwka, Eugenia Tęgowska,
Bogdana Wilczyńska, Zbigniew Wolski, Zdzisława Wrzosek, Mariusz Wysocki
KOMITET DORADCZY
Advisory Board
Gerd Buntkowsky (Berlin, Germany), Giovanni Gambaro (Padova, Italy), Edward Johns (Cork, Ireland),
Massimo Morandi (Chicago, USA), Vladimir Palička (Praha, Czech Republic)
Adres redakcji
Address of Editorial Office
Redakcja Medical and Biological Sciences
ul. Powstańców Wielkopolskich 44/22, 85-090 Bydgoszcz
Polska – Poland
e-mail: [email protected], [email protected]
tel. (52) 585-3326
www.medical.cm.umk.pl
Informacje w sprawie prenumeraty: tel. (52) 585-33 26
e-mail: [email protected], [email protected]
ISSN 1734-591X
UNIWERSYTET MIKOŁAJA KOPERNIKA W TORUNIU
COLLEGIUM MEDICUM im. LUDWIKA RYDYGIERA
BYDGOSZCZ 2012
Medical and Biological Sciences, 2012, 26/2
CONTENTS
p.
ORIGINAL ARTICLES
Julia Feit, Edward Jacek Gorzelańczyk, Ewa Mrówczyńska, Ewelina
N o w i ń s k a , K a t a r z y n a P a s g r e t a – Effect of a single dose of methadone on the
functioning of visuo-spatial working memory in opiate dependent individuals with HIV(+)
treated with methadone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
Elżbieta Grześk, Sylwia Kołtan, Grzegorz Grześk, Barbara Tejza,
Robert Dębski, Andrzej Kołtan, Mariusz Wysocki, Aldona Katarzyna
J a n k o w s k a , S ł a w o m i r M a n y s i a k , G r a ż y n a O d r o w ą ż - S y p n i e w s k a – Value
of erythrocyte sedimentation rate, C-reactive protein and procalcitonin concentration versus
multimarker strategy in management of bronchiolitis in pediatric emergency . . . . . . . . . . . . . . . . . . . . .
11
Magdalena Hagner-Derengowska, Michał Dylewski, Joanna Dawidziuk,
W o j c i e c h H a g n e r – Changeability of spatial and temporal gait parameters measured
on a treadmill with the use of a 3D ultrasound-based movement measuring system . . . . . . . . . . . . . . . .
19
Magdalena Hagner-Derengowska, Monika Dylewska, Michał Dylewski
– Intrarater repeatability of manual testing of first muscle movement resistance . . . . . . . . . . . . . . . . . .
25
Bożenna Mazalska, Bożena Kiziewicz, Elżbieta Muszyńska,
A n n a G o d l e w s k a , E w a Z d r o j k o w s k a – Fungi and straminipilous organisms found
at bathing sites in the vicinity of Białystok . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
33
Katarzyna Strojek, Irena Bułatowicz, Agata Czechowska, Agnieszka
Radzimińska, Urszula Kaźmierczak, Grzegorz Srokowski, Marcin
S i e d l a c z e k – The assessment of influence of thermoplastic foot pads on the body stability
in patients with foot dysfunctions – piloty study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
41
Beata Kuryło-Rafińska, Beata Kołodziej, Małgorzata Kubicka, Mariusz
W y s o c k i , J a n S t y c z y ń s k i – Differential ex vivo drug resistance profile in first and
subsequent relapsed childhood acute myeloid leukemia in comparison to initial diagnosis . . . . . . . . . .
47
A n e t a Z r e d a - P i k i e s , A n d r z e j K u r y l a k – Social functioning of children who have
completed acute lymphoblastic leukemia treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
53
CASE REPORT
Adrian Reśliński, Agnieszka Mikucka, Jakub Szmytkowski, Katarzyna
Głowacka, Eugenia Gospodarek, Wojciech Szczęsny, Stanisław
D ą b r o w i e c k i – Asymptomatic infection of a surgical mesh implant – a case report . . . . . . . . . . . .
59
Medical and Biological Sciences, 2012, 26/2
SPIS TREŚCI
str.
PRACE POGLĄDOWE
Julia Feit, Edward Jacek Gorzelańczyk, Ewa Mrówczyńska, Ewelina
N o w i ń s k a , K a t a r z y n a P a s g r e t a – Wpływ pojedynczej dawki metadonu
na funkcjonowanie wzrokowo-przestrzennej pamięci operacyjnej osób HIV(+) uzależnionych
od opioidów leczonych metadonem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
Elżbieta Grześk, Sylwia Kołtan, Grzegorz Grześk, Barbara Tejza,
Robert Dębski, Andrzej Kołtan, Mariusz Wysocki, Aldona Katarzyna
Jankowska, Sławomir Manysiak, Grażyna Odrowąż-Sypniewska
– Wartość diagnostyczna OB, CRP oraz stężenia prokalcytoniny w różnicowaniu infekcji bakteryjnych
i wirusowych u dzieci z zapaleniem oskrzelików w pediatrycznej izbie przyjęć . . . . . . . . . . . . . . . . . . .
11
Magdalena Hagner-Derengowska, Michał Dylewski, Joanna Dawidziuk,
W o j c i e c h H a g n e r – Zmienność przestrzennych i czasowych parametrów chodu mierzona
na bieżni z użyciem systemu pomiaru ruchu 3-D USG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
19
Magdalena Hagner-Derengowska, Monika Dylewska, Michał Dylewski
– Powtarzalność intrarater manualnego badania oporu tkankowego dla mięśnia trójgłowego łydki . . .
25
Bożenna Mazalska, Bożena Kiziewicz, Elżbieta Muszyńska,
A n n a G o d l e w s k a , E w a Z d r o j k o w s k a – Grzyby i straminipile występujące
w kąpieliskach okolic Białegostoku . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
33
Katarzyna Strojek, Irena Bułatowicz, Agata Czechowska, Agnieszka
Radzimińska, Urszula Kaźmierczak, Grzegorz Srokowski, Marcin
S i e d l a c z e k – Ocena wpływu wkładek termoplastycznych na stabilność ciała u pacjentów
z dysfunkcjami stopy – badania wstępne . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
41
Beata Kuryło-Rafińska, Beata Kołodziej, Małgorzata Kubicka, Mariusz
W y s o c k i , J a n S t y c z y ń s k i – Zróżnicowany profil oporności ex vivo na cytostatyki
w pierwszej i kolejnych wznowach ostrej białaczki mieloblastycznej u dzieci w porównaniu
z pierwszym rozpoznaniem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
47
A n e t a Z r e d a - P i k i e s , A n d r z e j K u r y l a k – Społeczne funkcjonowanie dzieci po zakończonym
leczeniu ostrej białaczki limfoblastycznej . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
53
PRACA KAZUISTYCZNA
Adrian Reśliński, Agnieszka Mikucka, Jakub Szmytkowski, Katarzyna
Głowacka, Eugenia Gospodarek, Wojciech Szczęsny, Stanisław
D ą b r o w i e c k i – Bezobjawowe zakażenie siatki chirurgicznej – opis przypadku . . . . . . . . . . . . . .
59
Regulamin ogłaszania prac w Medical and Biological Sciences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
141
Medical and Biological Sciences, 2012, 26/2, 5-9
ORIGINAL ARTICLE / PRACA ORYGINALNA
Julia Feit1,2, Edward Jacek Gorzelańczyk1,2,3, Ewa Mrówczyńska2, Ewelina Nowińska1, Katarzyna Pasgreta1
EFFECT OF A SINGLE DOSE OF METHADONE ON THE FUNCTIONING
OF VISUO-SPATIAL WORKING MEMORY IN OPIATE DEPENDENT INDIVIDUALS
WITH HIV(+) TREATED WITH METHADONE
WPŁYW POJEDYNCZEJ DAWKI METADONU NA FUNKCJONOWANIE
WZROKOWO-PRZESTRZENNEJ PAMIĘCI OPERACYJNEJ OSÓB HIV(+)
UZALEŻNIONYCH OD OPIOIDÓW LECZONYCH METADONEM
1
Department of Theoretical Basis of Bio-Medical Sciences and Medical Informatics,
Nicolaus Copernicus University in Toruń, Collegium Medicum in Bydgoszcz
Head: prof. Krzysztof Stefański, PhD
2
Non-public Health Care Center Sue Ryder Home in Bydgoszcz,
Scientific Research Department
Head: Assoc. prof. Edward Jacek Gorzelańczyk, MD, PhD
3
Polish Academy of Sciences, Institute of Psychology
Head: Assoc. prof. Urszula Jakubowska, PhD
Summary
I n t r o d u c t i o n . Subclinical measurements of
psychomotor functions are being used for assessment of
mental functions by finding relations with these functions.
This study aims to assess the influence of a therapeutic dose
of methadone on psychomotor speed in HIV(+) and HIV(-)
subjects treated in substitution therapy.
M a t e r i a l s a n d m e t h o d s . 73 patients [32
HIV(-) and 41 HIV(+)]treated with methadone for an average
of 54 months, were examined. The assessment was
conducted twice: before and about 1.5 hours after the
administration of a therapeutic dose of methadone. Trail
Making Test A (TMT A) was completed. The test sheet was
placed on a graphic tablet. Execution time was measured in
both parts of the test.
R e s u l t s . It was found that the average time of TMT
A test completion before methadone administration in HIV(-)
subjects is statically significantly shorter than in HIV(+)
ones. However, after methadone administration psychomotor
speed, measured by the TMT A test, is not statistically
significantly different in HIV(-) subjects treated in
substitution therapy as compared to HIV(+) individuals.
Subjects with HIV (+) performed TMTA test statistically
significantly faster after a single dose of methadone.
C o n c l u s i o n . A therapeutic dose of methadone in
subjects infected with HIV virus can have an effect on the
improvement in psychomotor performance. Interactions of
antiretroviral drugs and methadone can lead to changes in the
concentration of methadone in the body influencing the
regulation of psychomotor activity at the same time.
Streszczenie
W s t ę p . Subkliniczne pomiary funkcji psychomotorycznych mają na celu ocenę funkcji psychicznych
poprzez znalezienie powiązania tych funkcji z funkcjami
psychomotorycznymi.
C e l e m b a d a n i a jest ocena wpływu leczniczej
dawki metadonu na szybkość psychomotoryczną u osób
HIV(+) oraz HIV(-) leczonych w programie substytucyjnym.
M a t e r i a ł y i m e t o d y . Zbadano 73 pacjentów
programu substytucyjnego, 32 osoby HIV(-) i 41 osób
HIV(+) leczonych metadonem średnio przez 54 miesiące.
6
Julia Feit et. al.
Badanie przeprowadzono dwukrotnie: przed podaniem oraz
około 1,5 godziny po podaniu leczniczej dawki metadonu.
Wykonano Test Łączenia Punktów Reitana A. Arkusz
testowy umieszczano na tablecie graficznym. W obu
częściach testu zmierzono czas wykonania.
W y n i k i . Stwierdzono, że średni czas wykonania
testu TMT A przed podaniem metadonu u osób HIV(-) jest
istotnie statycznie mniejszy niż u osób HIV(+). Natomiast po
podaniu metadonu szybkość psychomotoryczna mierzona za
pomocą Testu Łączenia Punktów TMT A nie jest istotna
statystycznie u osób HIV(-) leczonych w programie
substytucyjnym w porównaniu z osobami HIV(+). Osoby
z grupy HIV (+) istotnie statystycznie szybciej wykonują test
TMTA po podaniu pojedynczej dawki metadonu.
W n i o s k i . Przyjęcie leczniczej dawki metadonu
przez osoby zakażone wirusem HIV może mieć wpływ na
zwiększenie sprawności psychomotorycznej. Wchodzenie
leków antyretrowirusowych w interakcje farmakokinetyczne
z metadonem może prowadzić do zmiany stężeń metadonu
w ustroju i tym samym powodować zmiany w regulacji
czynności psychomotorycznych.
Key words: opiates, methadone, TMT A, HIV
Słowa kluczowe: opioidy, metadon, TMT A, HIV
INTRODUCTION
Addiction to opioids is one of the strongest forms
of addiction [1, 2]. Using opioids is connected with
adaptive changes in the nervous system [3, 4]. Opioids
affect cerebral neurotransmitters which transmit
information among nerve cells. [5] Psychoactive
substances can cause a release of a bigger or smaller
amount of neurotransmitters into the synaptic cleft or
inhibit the return transport or block its action [6]. Most
of the dysfunctions and deregulations associated with
the intake of opioids affect the brain reward system,
which is probably responsible for the homeostasis of
behavior [7]. It was proven that addiction is linked to
disturbances not only in the reward system, but also in
other major functional systems of the brain [8]. In
particular, it relates to the system associated with the
regulation of cognitive and emotional functions [8].
Structural and functional changes in these structures
are associated with the development of dependence to
psychoactive compounds [8]. Morphological and
functional changes in the striatum, especially in the
ventral striatum (and its main structure - nucleus
accumbens), have been found in addicted individuals.
It is the central structure of the limbic system and the
reward system. According to the current knowledge, a
cortico-subcortical loop is important in the processing
of sensory (visual and auditory perception), cognitive
(attention, executive functions, visual and auditory
memory, spatial memory), emotional (mood) and
motor stimuli (extraocular movements, other skeletal
muscle movements, such as upper limb muscles) [9,
10, 11].
Methadone is a synthetic opioid used in the
substitution therapy of opioid addicts. Substitution
treatment is the most effective method of treatment in
this type of addiction. It lowers the risk of transmitting
viruses: human immunodeficiency virus, hepatitis C
virus, hepatitis B virus (HIV, HCV, HBV) and other
infectious agents causing blood-borne diseases, thus
reducing the mortality rate among drug addicts [12].
Substitution therapy is the administration of a
substitute agent [15]. Blockage of opioid receptors
prevents mental and somatic symptoms of withdrawal
state. The purpose of the therapy is delivering a
controlled dose of a substitute agent, which will enable
normal functioning, rebuilding, preserving health and
reducing or eliminating criminal behaviours [16].
Alterations of the functioning of cortico-subcortical
loops occur in patients infected with HIV which is a
neurotropic virus. Features of subcortical stupor are
found [17]. As a result of the activity of HIV most
likely a damage of the striatum takes place.
Psychomotor (oculomotor, upper limb movements)
disturbances are the expected effect of the HIV virus.
Additionally, emotional (which can be measured by
changes in the functioning of the autonomic nervous
system) and cognitive (disturbances in processing of
information from the external and internal
environment) impairments are seen [10, 11].
In order to assess the impact of a therapeutic dose
of methadone on psychomotor performance of HIV(+)
subjects and HIV(-) subjects treated with the
substitution therapy, a graphomotor test was used. The
time of test completion was measured in subjects from
both groups.
MATERIAL AND METHODS
The study was conducted in the group of 73
participants of substitution program addicted to opioids
and included 32 HIV(-) and 41 HIV(+) subjects.
Twenty eight women and 45 men, participating in
methadone substitution program for an average of 53
Effect of a single dose of methadone on the functioning of visuo-spatial working memory in opiate dependent individuals...
months, were qualified for the study. The assessment
was conducted twice: before and about 1.5 hours after
the administration of a therapeutic dose of methadone.
The A TMT test evaluates visual-spatial functioning of
the working memory and the ability to combine two
principles of action. To perform the test visuomotor
coordination (eye-hand) is crucial. The test evaluates
the functioning of the area placed on the border of
frontal, temporal, parietal and frontal lobes
(particularly the right side). The test consists of two
parts: A and B. In part A mainly psychomotor speed
was evaluated. Subjects are to link circles with a
continuous line, arranged irregularly on an A4 sheet
and labeled by numbers from 1 to 25, in a proper
sequence and as soon as possible [13]. The time of
completion longer than 41 seconds is considered
abnormal. [14]. The test sheet is placed on the graphic
tablet. In both parts of the test execution time was
measured. In the study Intuos2 graphic tablet
connected to a computer was used to collect and
process biomechanical signals.
RESULTS
7
statistically significantly (t=2.1083, p=0.0385) in
HIV(-) patients treated with the substitution compared
to those being HIV(+).
Fig. 1. The comparison of mean execution time of TMT A test
before the administration of methadone in both
groups
Ryc. 1. Porównanie średniego czas wykonania testu TMT A
przed podaniem metadonu w obu grupach
Difference of the motor speed in the HIV(-) and
HIV(+) group after administration of therapeutic doses
of methadone for TMT A t-test value is not statistically
significant and is: t=1.6157, p=0.1106.
73 subjects, being in the substitution therapy for 2240 weeks, receiving the mean methadone dose of 76.1
± (34) mg, were qualified for the study.
Table. I. Characteristics of study groups
Tabela I. Charakterystyka grup badanych
Groups
HIV(-)
HIV(+)
The mean dose of
methadone (mg)
73.6±(28)
79.1±(38)
The mean duration
of treatment (weeks)
36.3±(39)
66.1±(54)
It was found that the duration of treatment in the
group of individuals with HIV(+) subjects is
statistically significantly longer (t=2.6232, p=0.0107)
in comparison to the group of HIV(-) individuals.
However, the size of the average dose of methadone
taken by the subjects from both groups is not
statistically significantly different.
In the group of HIV(-) individuals mean time of
TMT A performance test before administration of
methadone was 40.2 ± (12) s and in the HIV(+) group 50.6 ± (25.7) s After the administration of methadone
TMT A test execution time in HIV(-) group was 36.4 ±
(10.2) s and 42.4 ± (18.8) s in HIV(+) group. The
statistical analysis shows that psychomotor speed
measured by the Test Points Joining TMT A before
administration of therapeutic doses of methadone differ
Fig. 2. The comparison of mean execution time of TMT A test
after the administration of a therapeutic dose of
methadone in both groups
Ryc. 2. Porównanie średniego czas wykonania testu TMT A
po podaniu metadonu w obu grupach
Test execution time TMT in A the group with HIV
(+) before and after the administration of a single dose
of methadone statistically significantly different (p =
0.0113, p = 2.6547). There was no statistical
significance in the group of HIV (-) before and after
a single dose of methadone (p = 0.0710, p = 1.8694).
In HIV-positive patients, before methadone
administration, efficiency of motor function is reduced
in comparison to the efficiency after the administration
of methadone. After methadone administration,
psychomotor performance in opioid dependent
Julia Feit et. al.
8
individuals, who are not carriers of the virus, does not
differ statistically significantly from drug addicts who
are HIV positive.
Fig. 3. The comparison of execution time TMT A test before
and after the administration of a single dose of
methadone in the group of HIV(+)
Ryc. 3. Porównanie czasu wykonania testu TMT A przed i po
podaniu metadonu w grupie osób HIV(+)
DISCUSSION
The study aimed to verify the effect of a single dose
of methadone on the motor skills of HIV(+) persons
addicted to opioids in comparison to HIV(-) ones. In
addition, the TMT test examined whether its values
depend on the dose of methadone taken and the
duration of treatment.
It was found that there are statistically significant
differences both in the speed of TMT A test
completion and in the duration of methadone
treatment.
However, this does not mean that there is
a correlation between these results, because the
duration of the treatment may be associated with a
virus carrier status, which is associated with the risk of
loss of life, and what therefore motivates people in this
group for a systematic substitution therapy.
The time of completion of the TMT A test in
subjects from both groups may be related to the
influence of psychoactive substances in the nervous
centers [18,9]. It was found that in people addicted to
psychoactive substances, structural and functional
changes take place in the ventral striatum. The major
part of which is the nucleus accumbens anatomically a
part of the striatum (including caudate nucleus and
putamen) and functionally being a central structure of
the limbic system and reward system [19].
However, increasing the motor performance of
HIV(+) individuals may be influenced by many
pharmacokinetic factors.
Antiviral medicines often interact with methadone
due to the complex metabolism which may lead to
intensified adverse events including reduction or
potentiating of the effectiveness of methadone.
The pharmacokinetic properties of the same drug
can vary considerably between patients due to genetic
factors or comorbidities including liver damage
associated with HCV and HBV infection. Those are
very common in this group of patients. All of these
medications interact with methadone and antiviral
drugs [20, 21, 22, 23].
CONCLUSION
Based on the analysis of the test results in opioid
addicted subjects, who are participants of the
methadone program, before and after the
administration of a therapeutic dose of methadone, it
can be concluded that the adoption of a therapeutic
dose of methadone statistically significantly increases
psychomotor performance.
The size of methadone dose does not influence the
study results. The duration of treatment, which is
statistically significantly longer in HIV(+) individuals,
can be determined by a life-threatening risk in this
group. A single dose of methadone statistically
significantly affects motor functions of HIV(+)
subjects.
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Address for correspondence:
Julia Feit
NZOZ Dom Sue Ryder
ul. Roentgena 3
85-796 Bydgoszcz
tel.: 608-639-983
fax 52 320 61 85
e-mail: [email protected]
Received: 7.02.2012
Accepted for publication: 12.04.2012
Medical and Biological Sciences, 2012, 26/2, 11-17
ORIGINAL ARTICLE / PRACA ORYGINALNA
Elżbieta Grześk1, Sylwia Kołtan1, Grzegorz Grześk2, Barbara Tejza1, Robert Dębski1, Andrzej Kołtan1,
Mariusz Wysocki1, Aldona Katarzyna Jankowska1, Sławomir Manysiak3, Grażyna Odrowąż-Sypniewska3
VALUE OF ERYTHROCYTE SEDIMENTATION RATE, C-REACTIVE PROTEIN
AND PROCALCITONIN CONCENTRATION VERSUS MULTIMARKER STRATEGY
IN MANAGEMENT OF BRONCHIOLITIS IN PEDIATRIC EMERGENCY
WARTOŚĆ DIAGNOSTYCZNA OB, CRP ORAZ STĘŻENIA PROKALCYTONINY
W RÓŻNICOWANIU INFEKCJI BAKTERYJNYCH I WIRUSOWYCH
U DZIECI Z ZAPALENIEM OSKRZELIKÓW W PEDIATRYCZNEJ IZBIE PRZYJĘĆ
Departments of Pediatrics, Hematology and Oncology1, Pharmacology and Therapeutics2, Laboratory Medicine3,
Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun
Summary
B a c k g r o u n d . Accurate discrimination between viral
and bacterial infection is important in children with
bronchiolitis. During the viral infection the symptomatic
treatment is the most important but in the presence of
bacterial infection or co-infection the use of guided
antibiotics should be started as soon as possible to avoid
complications.
M a t e r i a l s a n d m e t h o d s . The efficacy of CRP,
PCT and ESR tests was analyzed in 149 children with
clinical symptoms of viral (group A) or bacterial co-infection
(group B).
R e s u l t s . In the whole group the normal values of
CRP, PCT and ESR were found in 75% of children. In group
A normal values of all markers were found in 95%, whereas
only in 42% of those in group B. The area under the receiver
operating characteristic (ROC) curve (AUC) for
distinguishing groups CRP was 0.63 (SE 0.059, 95% CI 0.51
to 0.75). AUC calculated for PCT was 0.67 (SE 0.06, 95% CI
0.55 to 0.79) and for ESR it was 0.71 (SE 0.058, 95% CI
0.60 to 0.83). P values calculated for AUCs’ in comparison
to CRP, PCT and ESR CRPxPCT were 0.2862, 0.5564 and
0.9047, respectively, for CRPxESR 0.2311, 0.4487 and
0.7418, respectively and for PCTxESR - 0.3157, 0.5492 and
0.8398, respectively.
C o n c l u s i o n s . Results suggest that value of multimarker strategy with the use of CRP, ESR, PCT is comparable
to single test in distinguishing bacterial co-infection from viral
etiology, thus single biochemical tests may help to make
decisions about antibiotic therapy in children with
bronchiolitis in pediatric emergency.
Streszczenie
Wstęp.
Prawidłowe
różnicowanie
infekcji
wirusowych i bakteryjnych jest bardzo ważne u dzieci z
zapaleniem oskrzelików. W przypadku infekcji wirusowej
najistotniejsze jest leczenie objawowe, natomiast podczas
infekcji bakteryjnej należy jak najszybciej wdrożyć
antybiotykoterapię celowaną.
M a t e r i a ł i m e t o d y . Oznaczenia CRP, PCT oraz
OB wykonano u 149 dzieci z klinicznymi objawami infekcji
wirusowej (grupa A), oraz współistniejącej infekcji
bakteryjnej (grupa B).
W y n i k i . W badanej grupie prawidłowe wartości
CRP, PCT i OB stwierdzono u 75% dzieci. W grupie A
prawidłowe wartości wszystkich wskaźników stwierdzono
u 95%, natomiast w grupie B tylko u 42% dzieci. Wydajność
diagnostyczną oceniono na podstawie obszaru pod krzywą
ROC.
AUC dla CRP wynosiło 0,63 (SE 0.059, 95% CI 0,51 do
0,75), dla PCT 0,67 (SE 0,06, 95% CI 0,55 do 0,79),
natomiast dla OB 0,71 (SE 0,058, 95% CI 0,60 do 0,83).
Istotność statystyczna obliczona dla AUC w porównaniu
12
Elżbieta Grześk et. al.
z CRP, PCT i OB, dla CRPxPCT wynosiły odpowiednio
0,2862, 0,5564 i 0,9047, dla CRPxOB odpowiednio 0,2311,
0,4487 i 0,7418, dla PCTxOB odpowiednio – 0,3157, 0,5492
i 0.8398.
W n i o s k i . Otrzymane wyniki sugerują, że oznaczenie
CRP, OB oraz PCT stanowią porównywalną wartość
diagnostyczną do pojedynczych testów stosowanych
w różnicowaniu infekcji wirusowych i bakteryjnych, tak więc
mogą być pomocne podczas podejmowania decyzji
o rozpoczęciu antybiotykoterapii u pacjentów z zapaleniem
oskrzelików.
Key words: erythrocyte sedimentation rate, C-reactive protein, procalcytonin, bronchiolitis
Słowa kluczowe: OB, białko ostrej fazy (CRP), prokalcytonina, zapalenie oskrzelików
INTRODUCTION
Bronchiolitis in children is a serious self-limited
disease of respiratory tract infections. The presence of
swelling and destruction of bronchial epithelial cells
without the spasm of bronchial smooth muscle cells is
a common histological sign of bronchiolitis [1, 2]. The
main clinical symptoms of bronchiolitis are wheezing,
cough and dyspnea. The leading causes of bronchiolitis
are viral infections, among them the respiratory
syncytial virus infection is the most frequent (60-80%
of cases) [3,4].
There are two strategies in the treatment of
bronchiolitis: etiological and symptomatic. During the
viral infection the symptomatic treatment is the most
important but in the presence of bacterial infection or
co-infection, etiological treatment with the use of
antibiotics should be started as soon as possible. On the
other hand, the unnecessary use of antibiotics may
cause many different complications.
In this condition, the possibility of the most
accurate and early distinguishing between viral and
bacterial infection is extremely important. The use of
single marker strategy may not be adequate, thus the
use of multi marker strategy should be considered. The
best widely available markers used in differentiation
between viral and bacterial infection etiology are Creactive protein and procalcitonin [5].
C-reactive protein (CRP) has proven to be a reliable
marker for infectious diseases thus measurements of
CRP concentration are routinely used in the clinical
practice for diagnosis and monitoring of infectious
diseases such as bronchitis, pneumonia, sepsis etc. [6,
7]. CRP is an acute phase protein produced by
hepatocytes as a response to the inflammatory
conditions. The transcription of CRP gene is upregulated by interleukin-6, interleukin-8 and tumor
necrosis factor, thus CRP concentration reflects the
severity of inflammation [7]. During inflammation the
concentration of CRP increases significantly. Normally
CRP is present in the blood in the concentration below
5 mg/L. It is generally accepted that serum CRP levels
below 10 mg/L suggest minor viral infections, whereas
level of CRP between 10 and 20 mg/L suggests serious
viral infection. Serum CRP levels above 20-30 mg/L
are observed during bacterial infections in children; in
adults this level is usually beyond 50 mg/L [5, 6, 8].
The concentration of procalcitonin (PCT) increases
significantly in bacterial infections. High plasma
concentrations of PCT typically occur in children with
severe bacterial infections especially sepsis, meningitis
and infections of lower respiratory tract. In viral
infections PCT concentration remains normal, thus
PCT is one of the best inflammatory markers in
differentiation between viral and bacterial infections
[9].
According to the Westergren method, erythrocytes
sedimentation rate (ESR), is commonly used for years
as an index of inflammation process [10]. However, in
children CRP appears to be more useful than WBC or
ESR [11]. There has been limited investigation into the
role of CRP measurement in distinguishing bacterial
from viral lower respiratory tract infection [12].
In our study we analyzed the efficacy of use the
CRP, PCT and ESR tests in comparison to routinely
evaluated examinations in children with clinical
symptoms of viral bronchiolitis and bacterial coinfection.
PATIENTS AND METHODS
The study included 149 children hospitalized
because of bronchiolitis. The main criterion of
inclusion was the clinical presentation of bronchiolitis
thus typical clinical presentation including presence of
seasonal viral illness characterized by fever, nasal
discharge and dry, wheezy cough and in physical
examination inspiratory cracles and/or high pitched
expiratory wheeze should be present [12]. Of these
children aged 1-24 months (102 boys – median age 8.2
months and 47 girls – median age 10.5 months) that
presented clinical signs of lower respiratory tract
infection, pathogens were identified in 16 children.
Value of erythrocyte sedimentation rate, C-reactive protein and procalcitonin concentration versus multimarker strategy...
To get the homogeneous group of patients, the
children with the presence of bronchial asthma, cystic
fibrosis, pulmonary bronchodysplasts, congenital heart
diseases, abnormalities of chest and lungs, children
treated with bronchodilatators and anti-inflammatory
drugs, children with gastroesophageal reflux were
excluded from the study. The agreement of parent(s)
for participation in the study was obligatory.
According to the results of physical examination in
pediatric emergency department and during first two
days of hospitalization at the pediatric department,
children were included into one of two subgroups:
children with clinical presentation of viral infection
(group A) and children with respiratory tract bacterial
co-infection (group B). In the study group of children
the concentrations of CRP, PCT and ESR were
analyzed. Additionally, in the suspicion of bacterial
infection, in some cases, according to the results of
physician examination chest X ray (CXR) was
performed. To classify a child into the group A the
chest X-ray (if performed) had to be without
inflammatory changes but the presence of peripheral
oedema or atelectasis should be present. The CXR
examination was performed in 130 children in total.
WBC count of 12 M/L or more in the presence of
clinical symptoms suggested possibility of bacterial coinfection [5,9,10]. Characteristics of the whole group
of children with bronchiolitis and subgroups A and B
are presented in Table I.
Table I. Age and sex of children hospitalized because of
bronchiolitis
Total
Number of
children
Sex
Age [months]
Age ♂ [months]
Age ♀ [months]
149 (100%)
♂ 102
(68.5%)
♀ 47
(31.5%)
7 (1-24)
Group A
Group B
91 (61.1%) 58 (38.9%)
p=0,0003
♂ 62
♂ 40
(68.1%)
(69,0%)
♀ 29
♀ 18
(31,9%)
(31%)
p=0,0001
8 (1-24)
5 (1-24)
p=0.001
6,5 (1-24)
7 (1-24)
5 (1-24)
p=0.0043
10 (1-24)
11 (1-24)
6 (1-24)
p=0.0559
♂ - boys, ♀ - girls
Presented data are median and (minimal – maximal values).
Statistical significance was calculated for data in group A and B.
Etiology was identified with the Directigen RSV
test kit (RSV detection set) (Becton-Dickinson) and
13
Euroimmun Pneumo – FIDE M (RTP1) (Lencomm),
detecting viruses such as RS virus, adenovirus,
influenza and parainfluenza viruses and bacterial
pathogens such as Bordetella, Mycoplasma, Legionella
and Chlamydia. [5,11,13,14]. We found respiratory
syncytial virus in 3 cases, in 1 case - adenovirus
infection, in 8 cases - mycoplasma pneumoniae
infection and in 4 - Bordetella pertusis infection.
In the study group of children the concentrations of
inflammatory biomarkers such as CRP, PCT and ESR
were analyzed. CRP was assayed in the serum using
high-sensitivity assay (BN II Dade Behring). The assay
detection limit is 0.15 mg/L and CV is 5% for
concentration of 0.35 and 0.5 mg/L. PCT was assayed
using chemiluminescent immunoassay (Liaison-Byk),
ESR was measured with Sedisystem (BectonDickinson).
Border line values suggesting the presence of
bacterial infection were: for ESR – 15mm/h, CRP 15
mg/L and PCT 1.0 ng/ml [5,6,7,9,10].
Study was approved by the Ethics Committee of the
Collegium Medicum of Nicolaus Copernicus
University.
STATISTICAL METHODS
Calculations were performed using Statistica PL
6.0 and Analyse-it for Microsoft Excel (version 2.12)
[15].
Quantitative data from patients of groups A and B,
after confirmation of normal distribution, were
compared using Student’s T test, whereas qualitative
parameters were compared with χ2 test with Yaets
correction when necessary.
Receiver operating curves (ROC) analysis was used
to define the value of CRP, PCT and ESR better in the
distinguishing viral from viral coexisting with bacterial
infection. The area under the curve calculated for CRP
PCT and ESR alone and in different combination was
compared using two-tailed Student’s t test.
RESULTS
Mean ESR in the study group was 14.1 ± 20.4
mm/1h. Mean CRP concentration was 4.94 ± 4.92
mg/L and PCT concentration was 0.48 ± 1.50 ng/ml.
Mean ESR was 7.5 ± 5.4 mm/1h in the group A and
significantly higher in the group B 25.5 ± 27.5 mm/1h
(p<0.0001). In 87 children (96%) of group A ESR was
14
below borderline value of 15
mm/1h. In group B ESR was
over 15 mm/1h in 25 out of
58 cases (42%).
Concentration of CRP in
group A was 3.70±1.3 mg/L.
In the group A concentration
of CRP was ≤5 mg/L in 89
out of 91 cases (97%) and in 2
cases (2%) CRP concentration
was between 5 and 15 mg/L.
In group B mean CRP
concentration was 6.82 ± 7.30
mg/L and was significantly
higher than in group A
(p=0.0001). In group B
concentration of CRP was ≤5
mg/L in 37 out of 58 cases
(64%), in 16 cases (28%)
CRP
concentration
was
between 5 and 15 mg/L and in
5 cases (9%) was over 15
mg/L.
Elżbieta Grześk et. al.
Fig. 1. Number of consecutively increased inflammatory markers (CRP, PCT, ESR) in
the whole group of children with bronchiolitis, in groups with viral infection
(group A) and with bacterial infection or co-infection (group B)
0.5 and 1.0 ng/ml and in 2 cases
(3%) PCT concentration was over 1
ng/ml. PCT was lower in group A
than in group B - 0.27 ± 0.12 ng/ml
vs. 0.75 ± 2.34 ng/ml, respectively.
However, the difference was not
statistically significant between the
groups (p=0.0523) although a
tendency to statistical significance
was present.
In group B the increase beyond
borderline occurred for ESR in 25
cases (42%), for CRP - in 21 cases
(35%) and for PCT - in 6 cases
(10%).
Statistically
significant
differences in concentration of
markers were found for ESR and
CRP.
Analyzing the number of
Fig. 2. Empirical test of area under the receiver operating curve (ROC) curve for
CRP, PCT and ESR in group A and B
consecutively increased inflammatory markers, we found that in the
PCT concentration was normal in the group A,
whole group of children with lower respiratory tract
moreover in 90 out of 91 cases (99%) mean PCT
infections, the normal values of CRP, PCT and ESR
concentration was below 0.5 ng/ml. Only in 1 case
were found in 75% of children, but normal values of all
(1%) PCT concentration was between 0.5 and 1 ng/ml.
markers were found in 97% of children from group A,
In group B concentration of PCT was ≤0.5 ng/ml in 52
whereas only in 40% of those from group B. 1 out of 3
out of 58 cases (90%), in 4 cases (7%) it was between
Value of erythrocyte sedimentation rate, C-reactive protein and procalcitonin concentration versus multimarker strategy...
markers was increased in 2% and 2 out of 3 markers
were increased in 1% of children from group A. In
group B the values of 1, 2 or 3 of 3 markers of
inflammation beyond significant for bacterial infection
were present in 38%, 19% and 3 % of children,
respectively (Figure 1).
The area under the receiver operating characteristic
(ROC) curve (area under curve – AUC) for
distinguishing viral infection (group A) from viral
infection with the presence of bacterial co-infection
(group B) for CRP was 0.63 (SE 0.059, 95% CI 0.51 to
0.75). AUC calculated for PCT was 0.67 (SE 0.06,
95% CI 0.55 to 0.79) and for ESR was 0.71 (SE 0.058,
95% CI 0.60 to 0.83). The differences between AUC
calculated for CRP, PCT and ESR were not statistically
significant (Figure 2). AUC calculated for CRP and
PCT was 0.72 (SE 0.06, 95% CI 0.60 to 0.84), for CRP
and ESR it was 0.74 (SE 0.07, 95% CI 0.60 to 0.88),
and for PCT and ESR it was 0.73 (SE 0.08, 95% CI
0.57 to 0.89). AUC of ROC calculated for double
marker strategy in comparison to AUC calculated for
single markers did not differ significantly. P values
calculated for AUCs’ in comparison to CRP, PCT and
ESR CRPxPCT were 0.2862, 0.5564 and 0.9047,
respectively; for CRPxESR - 0.2311, 0.4487 and
0.7418, respectively and for PCTxESR - 0.3157,
0.5492 and 0.8398, respectively.
DISCUSSION
Early diagnosis of respiratory tract infection is
difficult, especially when differentiation between viral
and bacterial infection is necessary to begin a safe and
effective method of treatment. In most cases, the
physical examination is not sufficient and we have to
make additional laboratory tests. In the recent years
markers of inflammation, such as CRP and PCT, have
been widely used as a single test or as a part of
multimarker strategy [5]. Early studies suggested that
in the diagnosis of bacterial infections PCT is better
than WBC count or CRP concentration [9]. PCT is also
a better marker of sepsis than CRP. The increase of
PCT shows a closer correlation than that of CRP with
the severity of infection and organ dysfunction [16]. In
critically ill children PCT is a better diagnostic marker
of sepsis than CRP. Moreover, CRP, and especially
PCT, may become a helpful clinical tool to stratify
patients with SIRS according to the disease severity
[17]. Some authors suggest that there is relationship
between severity of bronchiolitis and concentration of
15
CRP, thus CRP value on admission might be a marker
of disease severity and have prognostic significance in
patients with bronchiolitis [18]. Moulin et al. analyzed
the predictive value of PCT in differentiating bacterial
and viral causes of pneumonia [19]. PCT concentration
was compared to CRP concentration and WBC count,
and, if samples were available, to interleukin 6 (IL-6)
concentration. In conclusion the authors suggested that
PCT concentration, with a threshold of 1 µg/L (1
ng/ml), is more sensitive and specific and has greater
positive and negative predictive values than CRP, IL-6,
or white blood cell count for differentiating bacterial
and viral causes of community pneumonia in untreated
children admitted to hospital as emergency cases [19].
Other results were presented by Saijo [20]. There were
no significant differences in the WBC counts, the CRP
concentrations and ESR levels between the
bronchiolitis and bronchopneumonia cases. These
results suggested that the RSV lobar pneumonia cases
are co-infected with some bacterial organisms more
heavily than in the RSV bronchiolitis and
bronchopneumonia cases [20]. Ahn et al. [21]
suggested that PCT and CRP alone and their
combination had a moderate ability to detect
pneumonia of mixed bacterial infection during the
2009 H1N1 pandemic.
Our results suggested an increase in investigated
markers, but the more important was that the normal
values of CRP, PCT, ESR with normal WBC and
without clinical or radiological symptoms of bacterial
infection suggested the presence of viral bronchiolitis.
In a group B (42% of cases) the CRP, PCT and ESR
were normal only in 25 children, whereas in group A
all markers were normal in 88 children (95%). Thus, an
increase in one or more markers suggests presence of
bacterial infection or co-infection. The lack of
significant differences in PCT between the investigated
groups may result from including in the study children
with mild to moderate bronchiolitis in the first days of
disease. The best effect in differentiation between viral
and bacterial infection seems to be obtained in the
groups of children with serious infection.
Similar results were presented by Korpi [22]. The
aim of the study was to determine if the combination of
these four host response markers and chest radiograph
findings were suitable for differentiating pneumococcal
from viral etiology of pneumonia. In this study CRP,
WBC count, PCT and ESR were measured in 132
children
hospitalized
for
community-acquired
pneumonia. The main conclusion was that CRP, PCT,
16
Elżbieta Grześk et. al.
WBC and ESR have only limited meaning in
differentiating pneumococcal or other bacterial
pneumonia from viral pneumonia. A high value in at
least one of the markers had been high (CRP > 80
mg/L, PCT > 1.8 µg/L, WBC > 22 x 10(9)/L or ESR >
60 mm/h), viral infections were rare [22].
Ip analyzed the value of CRP, PCT and neopterin
tests in differentiation bacterial from viral etiology in
patients with lower respiratory tract infections. Authors
observed statistically significant increase in AUC of
ROC when the multimarker strategy was used [23]. In
our study the significant increase of AUC was not
observed, probably because of characteristics of study
group. Children with clinical symptoms of
bronchiolitis, were included in our study. Children with
bacterial co-infection were included to the group B,
children with viral infection were in group A. Children
with serious bacterial infection and with clinical
symptoms of bacterial infection as a main disease were
excluded, thus the differences were not significant.
In many recent studies the authors suggest the use
of new markers such as cytokines [24-27] but the
routine use of these markers needs additional clinical
studies.
6.
7.
8.
9.
10.
11.
12.
13.
CONCLUSION
Our results suggest that value of multi-marker
strategy with the use of CRP, ESR, PCT is comparable
to single tests in distinguishing bacterial co-infection
from viral etiology, thus single biochemical tests may
help to make decisions about antibiotic therapy in
children with bronchiolitis in pediatric emergency.
14.
15.
16.
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M., Jimenez O., Gali N., Ausina V.: Procalcitonin, Creactive protein and leucocyte count in children with
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Rey C, Los Arcos M, Concha A, Medina A, Prieto S,
Martinez P, Prieto B.: Procalcitonin and C-reactive
protein as markers of systemic inflammatory response
syndrome severity in critically ill children. Intensive Care
Med. 2007;33:477-484.
Costa S, Rocha R, Tavares M, Bonito-Vítor A, GuedesVaz L.: C Reactive protein and disease severity in
bronchiolitis.Rev Port Pneumol. 2009;15:55-65.
Moulin F, Raymond J, Lorrot M, Marc E, Coste J,
Iniguez JL, Kalifa G, Bohuon C, Gendrel D.:
Procalcitonin in children admitted to hospital with
community acquired pneumonia. Arch Dis Child.
2001;84:332-336.
Saijo M, Ishii T, Kokubo M, Murono K, Takimoto M,
Fujita K.: White blood cell count, C-reactive protein and
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Ahn S, Kim WY, Kim SH, Hong S, Lim CM, Koh Y,
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protein in differentiation of mixed bacterial infection
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Viruses. 2011 Mar 30. doi: 10.1111/j.17502659.2011.00244.x
Korppi M.: Non-specific host response markers in the
differentiation between pneumococcal and viral
pneumonia: what is the most accurate combination?
Pediatr Int. 2004;46:545-550.
Ip M, Rainer TH, Lee N, Chan C, Chau SS, Leung W,
Leung MF, Tam TK, Antonio GE, Lui G, Lau TK, Hui
DS, Fuchs D, Renneberg R, Chan PK.: Value of serum
procalcitonin, neopterin, and C-reactive protein in
differentiating bacterial from viral etiologies in patients
presenting with lower respiratory tract infections. Diagn
Microbiol Infect Dis. 2007;59:131-136.
Kurylak A, Kurylak D, Dylewska K, Kubicka M, Grześk
E, Wysocki M, Wojak I: Stężenia prokalcytoniny,
interleukiny 6, TNF-Alfa, IFN-Gamma oraz interleukiny
10 w przebiegu zakażeń o etiologii bakteryjnej lub
wirusowej u niemowląt. Ann. Acad. Med. Bydg. 2004;
18(4):85-90.
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Leinonen M, Ruuskanen O.: Serum procalcitonin, Creactive protein and interleukin-6 for distinguishing
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17
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Ausina V, Domínguez J.: Value of procalcitonin, Creactive protein, and neopterin in exacerbations of
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Ferra C, Blanco S, Lacoma A, Ribera JM, Ausina V.:
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Address for correspondence:
Elżbieta Grześk
Department of Pediatrics, Hematology and Oncology,
Collegium Medicum
Sklodowskiej-Curie 9
85-094 Bydgoszcz, Poland
phone: +48 52 5854860
fax: +48 52 5854867
e-mail: [email protected]
Received: 6.12.2011
Accepted for publication: 1.03.2012
Medical and Biological Sciences, 2012, 26/2, 19-23
ORIGINAL ARTICLE / PRACA ORYGINALNA
Magdalena Hagner-Derengowska1, Michał Dylewski2, Joanna Dawidziuk2, Wojciech Hagner1
CHANGEABILITY OF SPATIAL AND TEMPORAL GAIT PARAMETERS
MEASURED ON A TREADMILL WITH THE USE
OF A 3D ULTRASOUND-BASED MOVEMENT MEASURING SYSTEM
ZMIENNOŚĆ PRZESTRZENNYCH I CZASOWYCH PARAMETRÓW CHODU
MIERZONA NA BIEŻNI Z UŻYCIEM SYSTEMU POMIARU RUCHU 3-D USG
1
Chair, Department of Rehabilitation Medicine of Collegium Medicum in Bydgoszcz
Nicolaus Copernicus University in Toruń
Head: prof. dr hab. Wojciech Hagner
2
Pod Tężniami’ Health Clinic named after John Paul II, Health Services Cooperative, Research and Development
Laboratory under the auspices of Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University
Summary
I n t r o d u c t i o n . Gait is one of the most often
analysed forms of movement not only when it comes to
supporting a diagnosis or controlling treatment, but also as
far as evaluating the progress of a disease at a clinic or in
research is concerned. There are many ways of assessing the
above. They include simple questionnaires and visual
control, as well as sophisticated, high technology equipment.
The latter comprise mainly high speed cameras and infrared
radiation or ultrasound microphones and transmitters.
Regardless of the used methods, the reproduction of gait
itself in stable conditions is considered to be constant with
reference to a single person. This paper presents an attempt
to assess the changeability of spatial and temporal parameters
of gait.
M a t e r i a l s a n d m e t h o d s . 29 randomly chosen
records of gait on a treadmill were used in this paper. Each
record was analysed three times, at different time points, i.e.
5th, 25th, 45th second of gait, and consisted of 10 steps. Spatial
and temporal parameters, obtained through report for every
record, were compared with the use of standard statistical
tools. All measurements were taken with an ultrasound-based
system used for a 3D motion analysis, i.e. ZEBRIS, with a
CMS-HS main unit, WinGait software and a ‘15 markers’
measuring protocol.
R e s u l t s . The obtained results show a very high
(almost perfect) correlation between all probes, i.e. 0.92-1 for
temporal parameters (arithmetic mean: 0.97) and 0.94-1 for
spatial parameters (arithmetic mean: 0.98). While average
differences, as far as spatial parameters were concerned,
amounted to 0.7 degrees, maximum difference for a single
movement equalled 1.3 degrees. Additionally, average
difference presented as a percentage value for posture and
swing phases equaled 0.8. Average difference in the length of
steps, on the other hand, equaled 10.5 mm.
C o n c l u s i o n . A very high correlation between the
obtained results and a small difference between spatial and
temporal parameters show that the analysis of gait,
performed with the use of an ultrasound-based system, could
be used for clinical and research-related purposes. It also
shows that an analysis concerning a part of obtained records
is representative with reference to the entire measurement.
Streszczenie
W s t ę p . Chód jest jednym z najczęściej analizowanych
ruchów zarówno jako badanie dodatkowe w praktyce
klinicznej oraz w pracach naukowych. Jest wiele sposobów
wykonania takiej analizy – od prostego kwestionariusza
i kontroli wzrokowej do bardzo wyrafinowanych, zaawanso-
wanych technologicznie urządzeń. Te ostatnie oparte są
głównie na kamerach o dużej prędkości i promieniowaniu
podczerwonym lub mikrofonach i ultradźwiękowych nadajnikach. Niezależnie od stosowanych metod i ich powtarzalności,
chód postrzegany jest jako stały dla tej samej osoby
20
Magdalena Hagner-Derengowska et. al.
w stabilnych warunkach. W niniejszej pracy podjęto próbę
oceny zmienności przestrzennych i czasowych parametrów
chodu.
M a t e r i a ł i m e t o d y . W pracy wykorzystano 29
losowo wybranych zapisów chodu na bieżni. Każdy zapis
analizowano trzy razy w różnych punktach czasowych –
zaczynając od 5., 25. i 45. sekundy chodu. Każda analiza
obejmowała 10 kroków i była wykonywana przez tę samą
osobę. Przestrzenne i czasowe parametry z otrzymanych
analiz dla każdego zapisu zostały porównane przy użyciu
standardowych narzędzi statystycznych. Cały pomiar i zapis
zostały wykonane przy użyciu opartego na ultradźwiękach
systemu do przestrzennej analizy ruchu – ZEBRIS, z jednostką główną CMS-HS, oprogramowaniem WinGait i protokołem pomiarowym „15 markers”.
W y n i k i . Uzyskane wyniki wskazują bardzo wysoka
(prawie idealną) korelację (od 0,92 do 1, średnia 0,97 i od 0,94
do 1, średnia 0,98) odpowiednio dla czasowych i przestrzennnch parametrów pomiędzy wszystkimi analizami.
Średnia różnica w parametrach przestrzennych wynosi 0,7
stopnia, przy maksymalnej różnicy dla jednego ruchu równej
1,3 stopnia. Średnia różnica w wartości procentowej faz
podporu i przenoszenia wynosi 0,8%, a średnia różnica w
długości kroku wynosi 10,5 mm.
Wnioski.
Bardzo wysoka korelacja między
uzyskanymi wynikami i niewielkie różnice w parametrach
przestrzennych i czasowych pokazują, że analiza chodu za
pomocą systemu opartego na ultradźwiękach może być
uzywana do celów tak klinicznych, jak i badawczych.
Pokazuje również, że analiza na części otrzymanego zapisu w
dowolnym miejscu na osi czasu jest reprezentatywna dla
całego pomiaru.
Key words: gait, 3D movement analysis, gait parameters
Słowa kluczowe: chód, trójwymiarowa analiza ruchu, parametry chodu
INTRODUCTION
Gait is one of the most often analysed forms of
movement not only when it comes to supporting a
diagnosis or controlling treatment, but also as far as
evaluating the progress of a disease at a clinic or in
research is concerned. There are many ways of
assessing the above. They include simple
questionnaires and visual control, as well as
sophisticated, high technology equipment. The latter
comprise mainly high speed cameras and infrared
radiation or ultrasound microphones and transmitters.
Regardless of methodology used, assessing the
changeability of gait parameters in order to decide
whether changes observed with respect to various
measurements or gait disturbances could be considered
as significant or not of great importance. This
changeability is not only characteristic for a given
parameter, but also depends on the measuring system
and the number of gait cycles that are used for an
analysis. Methodology itself matters as well.
In this paper the authors try to assess the usefulness
of a 3D ultrasound-based motion analysis system
manufactured by ZEBRIS GmbH, Germany, and of
methods concerning data analysis based on 10 cycles
of gait.
MATERIALS AND METHODS:
Materials
The study was carried out with the use of 29
records of gait measurements taken in a group
consisting of women aged 22-66 (x=45.4, S.D. 15.6).
All measurements were taken within a standard
diagnosis procedure in the ‘Pod Tężniami’ Health
Clinic in Ciechocinek from March to September 2009.
The research included records of at least 70-second
recordings that showed no visible technical
disturbances or no serious gait disorders. The
recordings used during the research were chosen from
a number of measurements taken from January to July
2009.
Methods
All measurements of gait were taken with the use
of a 3D ultrasound-based motion analysis system,
ZEBRIS, equipped with a main unit – CMS HS – and
two measuring units (one for each side of the body), as
well as WinGait software designed for gait analysis.
During the test, patients were walking on a standard
Kettler treadmill, the inclination of which was 1 degree
(a minimum for this type of treadmill). The speed was
constant and set to a value that suited each participant.
All recordings were taken with the use of a ‘15
markers’ measuring protocol which assesses pelvic,
hip, knee and foot movement. Before a recording took
place a patient had been walking on a treadmill, the
speed of which was selected beforehand, for 3 minutes
and stated that he/she felt comfortable and was walking
in a natural manner. Every record was analysed three
times. The method used for data processing was fully
manual (3 markers) and produced three standard
reports, each based on 10 steps, starting at different
time points, i.e. 5th, 25th and 45th second of recording
Changeability of spatial and temporal gait parameters measured on a treadmill with the use of a 3D ultrasound-based...
The obtained correlation value between spatial
parameters is presented below (Figure 1 and 2).
1,00
0,99
Correlation rank
0,98
0,97
0,96
1 to 2
1 to 3
2 to 3
0,95
0,94
0,93
0,92
0,91
0,90
Knee
flexion
Ankle
flexion
Foot
rotation
Pelvis
obliquity
Pelvis
rotation
1 to 2
Hip
flexion
1,00
Hip
Hip
adduction rotation
0,99
0,99
0,98
0,96
0,99
1,00
0,99
1,00
0,99
1 to 3
0,99
0,99
0,99
0,97
0,94
0,98
0,99
0,98
0,99
0,98
2 to 3
0,99
0,99
0,99
0,97
0,97
0,98
1,00
0,98
1,00
0,99
Pelvis tilt Average
Fig. 2. Average degree of correlation between spatial
parameters obtained with respect to separate
analyses
Average correlation degree obtained for temporal
parameters is shown below in Figure 3 and 4.
1,00
0,99
0,98
Correlation rank
gait. All three analyses concerning single patients were
performed by the same person. Then, temporal and
spatial parameters from the obtained reports were
analysed.
Repeatability was calculated with the use of the
Pearson Correlation Rank as far as single parameters
were concerned. Additionally, differences between
single parameters were calculated.
An evaluation of the following parameters obtained
from the report took place:
•
minimum and maximum values concerning hip
flexion, hip adduction, hip rotation, knee
flexion, ankle flexion, foot rotation, pelvis
obliquity, pelvis rotation and pelvis tilt,
•
percentage value of posture and swing phases,
•
the length of stride and steps,
•
the duration of double support phases, posture
and swing phases, steps to the left, steps to the
right, time of deflection between the left and
right leg.
All of these parameters were calculated
automatically through the WinGait software and
widely described in the software’s manual. As far as all
ten steps are concerned, an arithmetic mean was
calculated on the basis of the obtained data.
RESULTS
21
0,97
0,96
0,95
0,94
0,93
0,92
0,91
0,90
Serie1
Stance
Phase,
%
0,92
Swing
Double
Stride
Step
Stance
Offset
Stride
Step
Phase,
support, duration, duration, phase,
right
Average
lenght, m lenght, m
%
sec
sec
sec
sec
from left,
0,92
1,00
0,99
0,96
0,99
0,99
0,99
0,98
0,97
Fig. 3. Average correlation degree for temporal parameters
1,02
1,00
Correlation Rank
1,00
0,99
0,98
Correlation rank
0,97
0,96
0,98
1 to 2
1 to 3
2 to 3
0,96
0,94
0,92
0,95
0,90
0,94
0,93
Double
Stance
Swing
Stride
Step
support,
Phase, % Phase, % lenght, m lenght, m
sec
Stride
Step
duration, duration,
sec
sec
Stance
phase,
sec
Offset
right from Average
left, sec
0,92
1 to 2
0,93
0,93
1,00
0,99
0,96
0,99
0,99
0,99
0,99
0,97
1 to 3
0,92
0,92
1,00
0,99
0,96
0,99
0,99
0,99
0,98
0,97
0,91
2 to 3
0,93
0,93
1,00
1,00
0,97
1,00
1,00
0,99
0,99
0,98
0,90
Hip
flexion
Hip
Hip
adduction rotation
Knee
flexion
Ankle
flexion
Foot
rotation
Pelvis
obliquity
Pelvis
rotation
0,97
0,95
0,98
1,00
0,98
Fig. 1. Average correlation degree for spatial parameters
Fig. 4. Average correlation degree between spatial
parameters obtained with respect to separate
analyses
When taking into consideration both average
coefficients and data presented in Figure 1 and 2 one
can see that the highest correlation degree applies to
pelvis and hip measurement. The lowest values, on the
other hand, apply to ankle flexion. Nevertheless, even
the minimum correlation degree that was achieved
(r=0.94) with respect to ankle flexion, in the period
from the first to third analysis, is still significantly
high.
A very high correlation degree is also obtained
when it comes to temporal parameters. The lowest
values of the correlation degree can be noted in the
stance and swing phase (r=0.92). What is interesting is
that the values characteristic for the stance phase
(measured in seconds) reveal a much higher correlation
degree (r=0.99).
The correlation degree for all parameters, temporal
or spatial, are not lower than r=0.9, and the average
Correlation Rank
0,99
0,99
0,99
Pelvis tilt Average
1,00
0,98
Magdalena Hagner-Derengowska et. al.
22
value amounts to r=0.98 and r=0.97 for spatial and
temporal parameters respectively.
Apart from the degree, also the average differences
for separate temporal and spatial parameters were
assessed. Their arithmetic mean values are shown in
Figure 5 and 6 below.
When analysing parameters, it is clearly visible that
parameters characterised by a lower correlation degree
are also characterised by more significant difference
between analysed aspects, i.e. parameters regarding
foot and knee motion, the maximum difference of
which between the first and third analysis equals 1.17º
for foot rotation. Moreover, as for correlation, the best
results (smaller differences) are achieved for pelvis and
hip motion. The average difference value for all spatial
parameters equals 0.67º.
In order to show all temporal parameters in one
graph, some degrees visible in Figure 6 were changed
with respect to the SI system, i.e. while time is
presented in 10 millisecond units and not in seconds,
length is presented in centimetres instead of meters.
Averag edifference (degrees)
1,40
1,20
1,00
Average
1 to 2
1 to 3
2 to 3
0,80
0,60
0,40
0,20
0,00
Hip
flexion
Hip
adductio
n
Hip
rotation
Knee
flexion
Ankle
flexion
Foot
rotation
Pelvis
obliquity
Average
0,57
0,34
0,63
0,91
0,90
1,05
0,23
0,56
0,44
0,67
1 to 2
0,53
0,32
0,57
0,83
0,87
0,91
0,23
0,53
0,38
0,61
1 to 3
0,63
0,36
0,70
1,00
1,07
1,17
0,25
0,61
0,54
0,75
2 to 3
0,54
0,33
0,61
0,89
0,75
1,06
0,21
0,55
0,41
0,64
Pelvis
Pelvis tilt Average
rotation
Fig. 5. Average differences between spatial parameters
obtained with respect to separate analyses
differences between time parameters range from 10 to
13 ms.
DISCUSSION
High correlation degree for both spatial and
temporal parameters, as well as small difference
values, show that the ZEBRIS system for gait analysis
and the manual analysis based on a 10 gait cycle are
useful for clinical and research-related purposes.
Worse outcomes concerning the foot and anklerelated parameter may be connected with the
measurement protocol in which a foot is considered to
be a rigid segment 2, 3. However, it should be noticed
that the ‘15 markers’ protocol used for this purpose is
not specifically designed for foot and ankle analyses.
The differences that arose with connection to
specific movements may be a result of characteristic
internal reasons, an error in the analysis or a
combination of both. Regardless of the reason,
differences in values may be used as possible
insignificant changes, yet only for the measurement
methodology used in this paper. Similar reasons and
possible applications concern temporal parameters.
It is worth noticing that the intrarater repeatability
obtained for chosen temporal parameters in the other
paper (r=0.96, difference in the percentage value of
phases 0.8, the average difference in the length of steps
= 4.9 mm)4 is comparable with the results obtained in
this research. This indicates that at least a part of those
differences, if not all, are caused by an error in
analyses.
CONCLUSIONS
1,80
Average differences
1,60
1,40
1,20
Average
1 to 2
1 to 3
2 to 3
1,00
0,80
0,60
0,40
0,20
0,00
Double
Stance
Swing
Stride
Step
support,
Phase, % Phase, % lenght, cm lenght, cm
sec/100
Stride
duration,
sec/100
Step
duration,
sec/100
Stance
phase,
sec/100
Offset
right from
left,
Average
0,78
0,78
1,25
1,06
1,02
1,27
1,27
1,29
0,98
1 to 2
0,69
0,69
1,19
1,01
1,05
1,32
1,32
1,15
0,87
1 to 3
0,84
0,84
1,64
1,27
1,06
1,59
1,59
1,50
1,11
2 to 3
0,83
0,83
0,93
0,90
0,94
0,89
0,89
1,23
0,97
Fig. 6. Average differences between temporal parameters
obtained with respect to separate analyses
The obtained results show that the average
difference between the percentage values of stance and
swing phases is lower than 0.8 percent (maximum 0.84
percent). What is more, the differences between the
length of a step and a stride equal 0.9 – 1.6 cm, and the
The very high correlation between all three probes
in all parameters and very small differences between
each and every parameter allow us to state that gait
measured with the use of a 3D ultrasound-based
motion analysis is characterised by very low
changeability. It means that the described method of
gait analysis could be useful for clinical and researchrelated purposes. It also shows that the method
involving an analysis of data and based on ten steps
only is sufficient in order to be used for clinical and
research-related purposes.
Changeability of spatial and temporal gait parameters measured on a treadmill with the use of a 3D ultrasound-based...
REFERENCES
1.
2.
3.
4.
Dennis S., Reynolds R.A.K, Kay R., Tolo V.T. ‘Are
gait analysis studies medically necessary?’ Gait &
Posture, Volume 7, Issue 2, Page 160
Kidder, S.; Abuzzahab, F.; Dow, A.; Ortiz, T.; Harris,
G.; Johnson, J. ‘Repeatability of Kinematic Data in
Normal Foot and Ankle Motion’ Gait & Posture
Volume: 4, Issue: 2, April, 1996, pp. 180
‘WinGait3.x for Windows. User Manual’. Isny am
Allgau, 2006.
Dylewski M., Trzcińska P., Lorens A., WagnerDerengowska M., Wagner. W. ‘Ocena powtarzalności
inter i intrarater manualnej obróbki danych podczas
badania chodu z użyciem systemu ZEBRIS’ – Postępy
Rehab. 2009 &. 23 nr 2 s. 170-171.
Address for correspondence:
doc. dr hab. Magdalena Hagner-Derengowska
Katedra i Klinika Rehabilitacji
UMK w Toruniu
Collegium Medicum im. L. Rydygiera
ul. M. Curie Skłodowskiej 9
85-094 Bydgoszcz
Received: 24.11.2011
Accepted for publication: 31.05.2012
23
Medical and Biological Sciences, 2012, 26/2, 25-31
ORIGINAL ARTICLE / PRACA ORYGINALNA
Magdalena Hagner-Derengowska1, Monika Dylewska1, Michał Dylewski1,2
INTRARATER REPEATABILITY OF MANUAL TESTING
OF FIRST MUSCLE MOVEMENT RESISTANCE
POWTARZALNOŚĆ INTRARATER MANUALNEGO BADANIA OPORU TKANKOWEGO
DLA MIĘŚNIA TRÓJGŁOWEGO ŁYDKI
1
Bydgoska Szkoła Wyższa
2
Klinika Uzdrowiskowa „Pod Tężniami” im. Jana Pawła II, Spółdzielnia Usług Medycznych w Ciechocinku,
Laboratorium Badawczo-Rozwojowe pod patronatem CM UMK w Bydgoszczy
Koordynator: prof. dr hab. Wojciech Hagner
Summary
First resistance in passive muscle lengthening is very
important in both diagnosis and treatment in many muscle
disorders. Many therapeutic methods use this muscle length
as a point of reference. All of them assume that a therapist is
able to feel this moment during manual muscle testing in
precise and repeatable way. In this paper assumption
regarding repeatability of such test is verified.
The study included 34 tests conducted on 17
participants, both men and women, aged 35.6 (±8.5). Every
test consisted of three trials on passive ankle dorsiflexion,
performed by a single, skilled therapist. Joint angle and
estimated length of triceps surae muscle was recorded in realtime measurement using ZEBRIS system and set of four
active ultrasound markers. Results of that test shows that
standard deviation and range of results between minimal and
maximal in each trial for both ankle joint and muscle length
were below 1 degree and millimeter respectively. Standard
error of this measurement for joint and muscle length were
below 0.5 degree and millimeter, respectively. This lead to
conclusion that manual testing of first resistance in manual
muscle lengthening performed by skilled therapist has a very
good repeatability.
Streszczenie
Pierwszy opór podczas biernego wydłużania mięśni jest
bardzo istotnym czynnikiem zarówno w diagnostyce, jak i w
terapii wielu schorzeń układu ruchu. Wiele metod
terapeutycznych wykorzystuje tą specyficzna długość
mięśnia jako punkt odniesienia w wykonywanych
technikach. Wszystkie one zakładają że terapeuta jest w
stanie wyczuć moment pierwszego oporu podczas
manualnego testowania mięśni w sposób dokładny i powtarzalny. W przedstawianej pracy to założenie w części
powtarzalności oceny poddane zostanie weryfikacji. W pracy
wykorzystano wyniki 34 badań, przeprowadzonych na 17
uczestnikach, zarówno kobietach jak i mężczyznach, o średniej wieku 35,6 (±8,5). Każdy test składał się trzech prób
wykonania biernego zgięcia grzbietowego stopy, wykonywanych przez jednego terapeutę, doświadczonego w pracy
z pacjentami z zaburzeniami ruchu. Kąt w stawie skokowym
oraz szacowana długość mięśnia trójgłowego łydki była
zapisywana w czasie rzeczywistym przez system ZEBRIS
wyposażony w zestaw 4 aktywnych markerów ultradźwiękowych. Wyniki badania pokazują że zarówno odchylenie
standardowe jak i rozbieżność między skrajnymi wynikami
w poszczególnych testach zarówno dla zgięcia w stawie, jak
i długości mięśnia wyniosło poniżej odpowiednio 1 stopnia i
1 milimetra. Wartość średnia błędu standardowego podczas
pomiaru
poszczególnych testach zarówno dla zgięcia
w stawie jak i długości mięśnia wyniosła poniżej
26
Magdalena Hagner-Derengowska et. al.
odpowiednio 0,5 stopnia i 0,5 milimetra. To prowadzi do
wniosku że manualne testowanie pierwszego oporu mięśnia
podczas biernego ruchu wykonywane przez doświadczonego
terapeutę cechuje się bardzo dobrą powtarzalnością.
Key words: muscle movement resistance
Słowa kluczowe: opór mięśni
First resistance in passive muscle lengthening, so
called tissue resistance, is very important in
physiotherapy used nowadays. Possibility to find this
moment in muscle stretching is a main important skill
of every therapist dealing with musculoskeletal
disorders [1,2,3]. In examination of muscle, reaching
this point allows assessing its tension and flexibility
[1,2,4]. In tension test of nerves this moment of first
resistance allows therapist to perform such
examination and avoid patient’s pain and nerve
irritation [1,5]. From that point in range of movement
therapist try to sense an ‘end feel’ and differentiate it
[1,2,3,5,6] . Also in examination of joints, a point of
first tissue resistance is a reference point in procedure
of joint play testing, even though it concerns rather
joint capsule and translatoric movements, such as
glides and traction than muscle itself and physiological
movement [1,7]. Nevertheless, skill of sensing this
moment remains the same. That skill concerning more
superficial tissues is also widely used for diagnosis in
therapeutic methods such as Kinesiology Taping or
different form of fascia assessment and therapy [8,9].
Exact feeling of first resistance is even more
important in therapeutic than in testing procedures.
There are many techniques using point of first
resistance as a reference point, including muscles,
peripheral nerves, joint capsule or other soft tissue,
such as fascia [4,8,9,10,11,12]. Moreover, it is often
stated that physiological reaction and therapeutic
effects could be different depending on force used to
lengthening this tissues in relation to point of first
mechanical resistance, i.e. length and force is lower,
equal or higher than that point [4,8].
In Post Isometric Relaxation of muscles (PIR), the
isometric voluntary muscle contraction has to be done
specifically at the moment of tissue resistance – first
resistance in passive movement which lengthens the
muscle. On one hand, precise localization allows a
possibility of muscle relaxation, on the other hand it
does not cause pain or other unwanted effects.
Performing these techniques on greater stretch of the
muscle than point of first resistance is considered as
mistake [4,8,10]. In joint capsule mobilization, the
moment of first resistance for passive movement is a
dividing point between first grade mobilization, used
for relaxation, joint surface nutrition and analgesic
action, and third grade mobilization, which is used in
joint capsule stretching [1,3,7,11]. In these techniques,
like in many others, feeling of first resistance is of
great importance to achieve desired results.
In muscles, described above point of first resistance
is related mainly with myofibrils, contractile part of
muscle belly, namely with their initial, resting tension,
called tonus [13,14]. Sensing that moment during
passive muscle stretching connected with standard
linear or angular measurement techniques could be
then considered as examination of muscle tonus. For
this application, even more than for described earlier,
accuracy and repeatability between tests and between
investigators are required. Only when these conditions
are satisfied, manual testing of muscle first resistance
could be used for measurement.
The goal of this paper is to determine the
repeatability of calf muscle first stretch resistance
assessment (the tissue resistance) of test results
obtained by the same therapist - intrarater repeatability.
MATERIALS
The study included 34 tests conducted on 17
participants, both men and women, patients of the Spa
Clinic “Pod Tężniami” named after John Paul II in
Ciechocinek. Mean age of this group was 35.6 (±8.5).
The group consisted of 6 men and 11 women.
All participants had signs of shortening triceps
surae muscles in clinical examination and for all of
them the post isometric relaxation technique for that
muscle were used as a therapy of choice. In any case
conducted measurement did not disturb or affect
treatment based on clinical reasoning.
The exclusion criteria for this study were as follows:
• Injury of the ankle joint
• Degeneration of the ankle joint grade III or IV
• Occurring pain during ankle flexion
• Limitation of knee extension
• Straight Leg Raise test below 30 degrees
• Lumbar pain with radiation below the knee
• Lack of cooperation with therapist
• Neurological diseases affecting muscle
tension
Existed trigger points (unless in acute phase) were
not considered as contraindication. In general, all
Intrarater repeatability of manual testing of first muscle movement resistance
participants had increased muscle tension, i.e.
functional problem, rather than structural contraction.
METHOD
The test was conducted using three-dimensional
movement measuring system based on active
ultrasound markers, ZEBRIS, manufactured in
Germany by ZEBRIS Medical GmbH. In that case
system consists of ZEBRIS CMS-HS main unit,
measuring unit (MU), and set of four single ultrasound
markers (transmitter).
The main unit collects the signal from the
measurement unit and provides control and
coordination between single ultrasound markers,
initializing signal sent by them. Main unit collects and
initially processes acquired data in real time
measurement.
The measuring unit consists of three single
receivers (microphones), fixed on a solid frame in
established position to each other. Each microphone
calculates simultaneously distance from the ultrasound
marker or markers. This allows, when using
triangulation rules, to define coordinates of each
transmitter in three dimensional coordinate system
referred to measuring unit. Calibration allows
determining the MU towards the frontal, sagittal and
transversal plane [15].
Single ultrasound markers are small transmitters,
which could be placed on patients’ skin using adhesive
tape or Velcro strips. The frequency of signal emitting
is set in software used and can be changed depending
on measurement requirements and equipment
capabilities. Placement of transmitters can be dictated
by a software and protocol used, or freely chosen by
user. The precision of marker localization in optimal
condition can be very high, and reaches values below
0.14 mm for linear and 0.16 degrees for angular
movement [16].
In this study WinData (ZEBRIS Medical GmbH,
Germany) software were used. This software has no
rigid protocols of measurement, and provides
possibility of construction complete and individual
measurement protocols which fits best to the specific
requirements of a particular study [17].
In order to assess manual testing of triceps surae
(TS) first mechanical resistance repeatability, authors
measured angular position of the ankle and calf muscle
length at the moment when the therapist felt that
27
resistance. To achieve this, the single markers were
placed on:
• Lateral femoral condyle
• Posterior part of calcaneal tuberosity at the
attachment of the Achilles tendon
• Above lateral ankle, at the axis of
flexion/extension movement
• Lateral side of 5-th metatarsal bone base
Based on this markers placement, following
parameters were calculated:
1. Ankle flexion, described as Angle between
vector of the fibula, connecting marker on lateral
femoral condyle and lateral ankle, and line built of
markers on lateral ankle and 5-th metatarsal bone.
2. Length of the Triceps Surae muscle, and
actual length of lateral head of gastrocnemius
muscle. That was calculated as a distance between
a marker placed on insertion and origin of that
muscle, i.e. on lateral femoral condyle and on
calcaneal tuberosity.
The frequency of signal transmission for each
marker was 20 Hz.
The test was executed by a skilled and experienced
in manual therapy therapist. Patient was lying supine
on a couch, in comfortable position, with both legs
extended. After placing markers on the right positions,
the therapist asked the patient to relax and try not to
make any movement. Then the therapist made three
attempts to flex patient’s ankle to dorsal flexion till he
felt first mechanical resistance of stretched Triceps
Surae muscle. The therapist was asked to stop for
about two three to five seconds after reaching this
‘destination point’. Spatial position of all four markers
was recorded from the beginning to the end of the test.
The knee of the patient was still fixed in extension. The
therapist performing manual testing was not allowed to
see the monitor screen with graphical exposition of
measured angular parameters till the test was over.
Obtained data were then analyzed using standard
statistical tools, such as mean, standard deviation,
relative values
and standard error of mean in
Microsoft Office software.
RESULTS
For every test there were three values of angular
position of foot and lower limb collected, each of every
trial. Based on these results, Standard Deviation
Magdalena Hagner-Derengowska et. al.
parameter was calculated for each of thirty four of the
conducted examinations separately. The mean value of
standard deviation as well as the greatest one for
angular movement is shown below on Fig. 1.
Average and maximal values of range between the
highest and lowest results obtained in every test
separately for angular movements are also presented on
Fig. 1.
Repeatability - Muscle lenght in mm
2,5
2,16
2
Standard Deviation
1,5
mm
28
1,21
1
0,5
Difference between maximal
and minimal result
0,97
0,55
0
Mean
Maximum
Repeatability - angular values in degrees
Fig. 2. Standard deviation and range of obtained results for
muscle length – average and maximal values
2
1,8
1,2
Standard Deviation
0,98
0,96
0,8
0,4
Difference between maximal and
minimal result
0,54
0
Mean
Maximum
Fig. 1. Standard deviation and range of obtained results for
angular movement – average and maximal values
Very low values of average and maximal standard
deviation (both below one degree) and low range in
obtained results for single test (average below one
degrees and maximal below two degrees) are worth
noting. This indicates very high repeatability of such
testing.
Unlike the angular values, which were defined and
calculated in WinData software automatically, the
length of the calf muscle had to be counted from raw
coordinates in three-dimensional coordinates system in
excel sheet. When values of muscle length were once
obtained, also for them standard deviation parameter
were calculated for each of thirty four tests separately.
The average value of standard deviation for all tests,
together with greatest received result for muscle length
is shown in Fig. 2.
Similarly to angular values, ranges between
extreme results for every test were calculated for
muscle length. Mean and maximal of obtained results
are shown together with standard deviation of the test
on Fig. 2.
It is significant that both standard deviation and
range between results in single test are very small,
amounts to less than one millimeter for average values.
Even the greatest observed differences between results
in single, three-trial test amounts to about one
millimeter for standard deviation and two millimeters
for scope of results in single test.
Values of standard deviation calculation shown in
Fig. 1 and Fig. 2 above in relation to measured angle
and assessed Triceps Surae muscle length, respectively
are shown in Fig. 3 in percentage values.
As it can be seen on mentioned figure, all of
calculated results are far below five percent, which is
an accepted level of measurement error in medical
sciences. Also when it comes to values related to
muscle length, both average and maximal values are
far below one percent.
Relative values of S.D. in percent
3
2,78
2,5
Percentage (%)
o
Degrees ( )
1,6
2
1,55
1,5
Mean
Maximum
1
0,5
0,13
0,29
0
Lenght
Angle
Fig. 3. Relative values of standard deviation for angular and
linear movement – average and maximal values
Intrarater repeatability of manual testing of first muscle movement resistance
Mean and maximal values for Standard Error for measurement
0,8
0,75
0,7
0,6
0,55
0,5
0,4
0,3
0,31
0,33
Mean SE
Maximal SE
0,2
0,1
0
Ankle Flexion (º)
Muscle lenght (mm)
Fig. 4. Standard error for angular and linear movement –
average and maximal values
Another possibility of evaluation of the
examination method is standard error of mean. In this
case, because every test was conducted on different
sample, each could have had a different actual result,
there was no possibility to calculate standard error of
mean (SE) for whole methodology of measurement. So
in this paper, standard error was assessed for every test
separately, and then average and maximal outcome has
been calculated. These results of SE for both linear and
angular measurement are shown in Fig. 4.
It must be noted that results observed in Fig. 4,
actually very good, far below one millimeter and one
degree respectively for linear and angular movement,
could be considered only in discussion about
repeatability, not accuracy. The reason is the fact that
actual true values of spatial position of ankle or muscle
length while first mechanical resistance occurs were
unknown.
DISCUSSION
Manual testing of the muscles and joints is
considered as a major skill in testing and treating
musculoskeletal patients in many methods of manual
therapy [3, 5, 10, 12]. Ability to feel and differentiate
quality of movement, especially from its first
resistance to the end of passive range of movement is
considered crucial for testing in manual therapy [1, 2,
11]. In fact, this is what makes the difference between
manual therapy and physiotherapy in general.
Supporting the idea, the general assumption is made
that a therapist is able to gain ability to feel in recurrent
manner both first mechanical resistance and quality of
changes in elasticity of the movement. It is called end
feel or joint play examination, respectively for
physiological and additional movements [1, 3, 11].
Nevertheless, there is visible lack of research works
29
that confirm or deny that possibility among manual
therapist. One of the reason of the small amount of
research works in that subject is that described
phenomenon itself is very subtle and dependent on
many factors. It is very hard to assess in objective
manner when this first mechanical resistance occurs in
a living human being. Theoretically, first mechanical
resistance (or tissue resistance) of muscle occurs when
during passive movement myofibrils, fascia, tendon
and other part of muscle as a whole, reach its resting
length [8, 13, 14]. It is the moment from which
stretching of the muscle-tendon unit could occur. So,
physically, from that moment force needed to increase
muscle length and range of movement rises, dependent
on parameter called muscle stiffness [13, 18]. But it is
not easy to perform objective evaluation of that
moment on a living person, due to both technical
problems and great amount of factors influencing that
parameter. One of the technical problems is that
passive movement does not produce electric activity of
the muscles, so EMG is not valid for such examination
[13, 18].
The moment in which first resistance occurs is
dependent mainly on muscle tonus, so the first group
of factors influencing tissue resistance are
neurophysiologic factors, such as mood, emotions,
apprehension or reliance to therapist, but also spatial
position of other part of the body causing stress to the
nervous system – i.e. rotation in cervical spine
[2,8,10,19,20].
Other group of influencing factors is of mechanical
nature. The most prominent in this group seems to be
velocity of movement and number of repetition –
especially if a test movement exceeds moment of first
resistance [13, 14]. The importance of velocity is
associated
with
viscoelasticity,
mechanical
characteristic of human soft tissues that is responsible
for different reactions of forces acting with different
speed, but also with physiologic protective reaction of
a muscle [8, 13, 18]. The high amount of repetition
could lead to a change of mechanical characteristic of
the muscles, moving point of first resistance further in
the range of movement [8, 10, 13]
Third group of factors could be named technical.
Inappropriate, uncomfortable position of both patient
and therapist could affect both muscle tonus and make
patient relaxation impossible. We also must not forget
that movement in which tissue resistance is assessed
must be passive. In clinical test, it is impossible to
30
Magdalena Hagner-Derengowska et. al.
move patient’s limb in passive way without patients’
relaxation and confidence to the therapist [1,2,8].
But all objections mentioned above concern mainly
problem with determination of accuracy of the testing
and interrater reliability. In both cases problem with
objective evaluation of true value of measured
characteristic and possibility of its changes between the
tests makes such research hard to perform.
Focusing on intrarater repeatability and limiting
number of test movement repetition authors hoped to
avoid majority of threats mentioned above.
What is the outcome of obtained results? However,
it is important to clearly mark what the come of these
results is.
We know that a skilled, experienced therapist could
test first muscle resistance in passive movement in
very repeatable way – so he feels the mechanical
resistance in almost the same muscle length in every
trial. But we do not know if the result obtained by the
therapist is the true result.
This implicates that the therapist could use that
kind of examination as a reference point in different
therapeutic techniques, what gives him good
repeatability of performing them. But obtained results
could not prove that it is the best way to do them, as
we do not know if the points that therapist feels is the
right one. However, the good repeatability of
performing therapeutic techniques gives strong basis
for research which assesses clinical outcomes of
therapy.
The last application is using the manual test of
muscle first mechanical resistance as a test performed
during therapy session to assess immediate effect of
performed treatment technique. Obtained results show
that such manual testing of tissue resistance could be
valuable for medical purposes, if joint spatial position
or muscle length is measured and recorded in more
traditional or sophisticated way. It was not a goal of
this paper to evaluate therapist’s possibility to
differentiation different joint position during manual
testing. That would require tests including assessment
of not only proprioceptive skills, but also capabilities
of memory related to movement task. Because in this
paper such examination was not performed, that, based
on obtained results, could not be stated whether a
therapist is or is not able to use such manual testing
without additional equipment or not.
CONCLUSIONS
On the basis of obtained results following
conclusions could be made:
1. Manual testing of muscle first mechanical
resistance
during
passive
movement
is
characterized by very high intrarater repeatability
when performing by an experience of therapist. It
makes this suitable for clinical use as a test and in
treatment techniques as a reference point.
2. The high intrarater repeatability allows comparison
of the obtained results between tests when another
instrumentation is used for recording ankle position
or muscle length.
3. In this paper the possibility of differentiation of two
different positions was not assessed, so it is not
known, based on described results, if a therapist is
able to differentiate changes after therapy
concerning position when first manual resistance
occurs without additional equipment.
4. Accuracy of manual testing was not the subject of
this work so it can not be assessed based on
obtained results. However, research in that
direction could be very interesting and valuable,
although not easy.
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Address for correspondence:
doc. dr hab. Magdalena Hagner-Derengowska
Katedra i Klinika Rehabilitacji
UMK w Toruniu
Collegium Medicum im. L. Rydygiera
ul. M. Curie Skłodowskiej 9
85-094 Bydgoszcz
Received: 15.11.2011
Accepted for publication: 14.02.2012
Medical and Biological Sciences, 2012, 26/2, 33-39
ORIGINAL ARTICLE / PRACA ORYGINALNA
Bożenna Mazalska, Bożena Kiziewicz*, Elżbieta Muszyńska, Anna Godlewska, Ewa Zdrojkowska**
FUNGI AND STRAMINIPILOUS ORGANISMS FOUND AT BATHING SITES
IN THE VICINITY OF BIAŁYSTOK
GRZYBY I STRAMINIPILE WYSTĘPUJĄCE W KĄPIELISKACH OKOLIC BIAŁEGOSTOKU
*Department of General Biology, Medical University, Białystok
**PhD student
Head: dr hab. Bożena Kiziewicz
Summary
I n t r o d u c t i o n . Fungi and straminipilous organisms play a
significant role in aquatic ecosystems as a food source for many
invertebrates and in the process of mineralization of organic matter.
Research on the occurrence of fungi and straminipila at bathing sites
has a major sanitary and epidemiological significance since it allows
registration of fungi that can be potentially pathogenic to man.
T h e a i m of the present study was to establish species diversity
of fungi and straminipila found in four bathing sites in the vicinity of
Białystok, to determine or exclude potential etiological factors of
mycotic infections, and to determine the effect of physicochemical
parameters of the waters examined on the growth of this group of
destruents in the spring and autumn of 2006/2007.
M a t e r i a l a n d m e t h o d s . The baiting method was used to
isolate fungi from water samples collected at the respective bathing
sites. Fungi and straminipilous organisms were trapped using
amphipod crustacean Gammarus pulex, grass snake skin, onion skin,
buckwheat seeds, as well as seeds of clover and cannabis.
R e s u l t s. Forty-two species were identified, with the
predominance of saprothrophic fungi, particularly species Aspergillus
fumigatus - a potential etiologic agent factor for aspergillosis. Most
species were found in the water of the bathing site in Supraśl
and Jurowce -26 (RF-63.41%), the fewest in Korycin -16
(RF-39.02%).
C o n c l u s i o n. Species diversity of the fungal and straminipilous
organisms at the investigated bathing sites depended on characteristics of
a given ecosystem, biotic and abiotic factors.
Streszczenie
W s t ę p. Grzyby i straminipile pełnią znacząca rolę w
wodnych ekosystemach, są źródłem pożywienia dla licznych
bezkręgowców i mineralizują materię organiczną. Badanie
występowania grzybów i straminipili w kąpieliskach ma duże
znaczenie w aspekcie sanitarnym i epidemiologicznym,
ponieważ umożliwia rejestrowanie grzybów potencjalnie
patogenicznych dla człowieka.
C e l e m b a d a ń było ustalenie występowania
grzybów i straminipili, w tym gatunków potencjalnie chorobotwórczych, w czterech kąpieliskach okolic Białegostoku
oraz wpływu na ich rozwój czynników fizykochemicznych
wiosną i jesienią w 2006 i w 2007 roku.
M a t e r i a ł i m e t o d y. Do izolowania grzybów
i straminipili w próbach wody zastosowano metodę przynęt.
Pułapkami grzybów był kiełż zdrojowy Gammarus pulex,
wylinka skóry węża, łuska okrywowa cebuli, nasiona gryki,
także nasiona koniczyny i konopi.
W y n i k i. Oznaczono łącznie 41 gatunków, dominowały saprotrofy, wśród nich Aspergillus fumigatus potencjalny
czynnik etiologiczny aspergiloz.. Największa liczba gatunków
wystąpiła w kąpielisku Supraśl i Jurowce - 26 (względna częstotliwość
– 63,41%), najmniejsza w kąpielisku Korycin – 16 (względna
częstotliwość – 39,02%).
W n i o s k i. Zróżnicowanie gatunkowe grzybów i straminipili
badanych kąpielisk warunkują czynniki biotyczne i abiotyczne tych
ekosystemów.
Key words: fungi, straminipilous organisms, bathing sites, Podlasie Province
Słowa kluczowe: grzyby, straminipile, kąpieliska, województwo podlaskie
34
Bożenna Mazalska et. al.
INTRODUCTION
Fungi and straminipilous organisms exhibit a
specific activity, colonizing cellulose, lignin, chitin and
keratin, i.e. the organic material of complex
polymerized structure difficult to access by other
microorganism [1]. These important destruents use the
organic matter for the growth and spread of species,
considerably contributing to self-purification of water
reservoirs. During decomposition of dead plants and
animals, gradual mineralization occurs with release of
elements that pass into the circulation. Partly
decomposed biomass is included in the trophic chain
consisting of subsequent consumers [2,3].
The study objective was to establish species
diversity of fungi and straminipila in water samples
collected from a few bathing sites in the vicinity of
Białystok, to identify or exclude potential etiologic
factors for mycotic infections affecting humans and
animals, and to determine the effect of
physicochemical parameters of the waters examined on
the growth of this group of destruents.
MATERIAL AND METHODS
Description of study area
Mycological investigations were conducted in
2006-2007 in two seasons - spring and autumn and
involved four bathing sites:
- bathing site in Dojlidy localized near Białystok:
area 34.2 ha, max. depth 2.85 m, its south shore
bordered by coniferous woods and its western part with
the town of Białystok; the samples were collected from
the western end of this pond, which is used by the
inhabitants of the town as a beach;
- bathing site in Korycin situated in the west
Korycin Reservoir, covering an area of 6.8 ha, mean
depth 1.35 m. fed by the river Kumiałka;
- two bathing sites on the river Supraśl in the town
of Supraśl (41 km of its middle course) and in Jurowce
(19 km of the middle course). The river Supraśl, 93.8
km long, covering an area of 1844.4 km 2 is a right
tributary of the river Narew and its surface intake is a
source of drinking water supply for inhabitants of
Białystok and its vicinity. The river, due to the unique
landscape assets of the Knyszyńska Forest (boreal
forest resembling southern taiga) is a recreational place
for the region inhabitants and tourists visiting Podlasie
[4].
Mycological investigations
For the analysis of fungi and straminipilous
organisms 3 samples were collected from each
sampling site. The water collected from the respective
reservoir was poured in sterile conditions into beakers,
0.6 l capacity, and placed in the laboratory in
conditions resembling those of the natural
environment. Baiting method described by Fuller and
Jaworski [5], Kiziewicz and Czeczuga [6] was used to
isolate the fungi from the water. The following baits
were used: amphipod crustacean Gammarus pulex,
snake skin Natrix natrix, clover seeds of Trifolium
repens, hemp seeds Cannabis sativa and buckwheat
seeds Fagopyrum esculentum, and onion skin Alium
cepa. Prior to being added to water samples all the
substrates were boiled and rinsed with distilled water a
few times. The baits were successively observed under
an optic microscope (100 and 400x magnification)
every 3-5 days, starting from day 3 of the culture.
Next, several microscope preparations were prepared
from each sample. The samples were stored for about a
month to detect fungal physiology associated with
sexual and asexual reproduction.
Fungi were identified, taking into consideration the
following morphological features: the shape and size of
the tallum, the shape of sporangium and spores, the
structure of the oogonium, antheridium and oospora.
Works of many authors were used to determine the
fungi [7-11].
Physicochemical investigation
Water samples were collected at each study site at a
depth of 0.20 m, by means of a Ruttner’s apparatus
(vol. 2.0 dm3). Physicochemical analyses of
temperature, pH, ammonium nitrogen, nitrite nitrogen
and nitrate nitrogen, phosphates, chlorides and
sulphates were performed. Standard methods as
described by [12, 13] were employed for
physicochemical investigations.
RESULTS
The physicochemical analysis of water used for the
experiments revealed that the highest temperature was
recorded in the water in bath Dojlidy (13.2°C),
whereas the lowest in the bath Korycin (11.5°C)
(Fig. 1).
The highest pH was in the baths Jurowce (7.90),
whereas the lowest in the baths Korycin (6.67) (Fig.2).
Fungi and straminipilous organisms found at bathing sites in the vicinity of Białystok
The concentration of ammonium nitrogen in the
baths Korycin, Jurowce and Supraśl (0.04 mg dm3)
stayed on the same level in samples of water. In bath
Dojlidy this content was lower (0.07 mg dm3) (Fig. 3).
temperature oC
0.025
0.02
0.015
0.01
13
0.005
12.5
0
12
Dojlidy
11.5
10.5
Dojlidy
Korycin
Jurowce
Jurowce
Supraśl
Supraśl
Fig. 1. The temperature of water from the particular bathing
sites
Ryc. 1. Temperatura wody na poszczególnych kąpieliskach
8
Fig. 4. Value of the N-NO2 of water from the particular
bathing sites
Ryc. 4. Wartość N-NO2 wody na poszczególnych
kąpieliskach
Table I. Physicochemical parameters of water from the
particular bathing sites
Tabela I. Fizykochemiczne parametry wody w poszczególnych kąpieliskach
7.8
7.6
7.4
7.2
7
6.8
6.6
6.4
6.2
6
Dojlidy
Korycin
Jurowce
Supraśl
Fig. 2. Value of the pH of water from the particular bathing
sites
Ryc.2. Wartość pH wody na poszczególnych kąpieliskach
0.08
0.07
0.06
N-NH4
Korycin
The water used in our experiment varied with
respect to the abundance in biogenic compounds
(Table I).
11
pH
0.03
N-NO2
13.5
35
0.05
0.04
Specification
Parametry
Temperature
(◦C)
pH
N-NH4
(mg dm3)
N-NO2
(mg dm3)
N-NO3
(mg dm3)
P-PO4
(mg dm3)
Chlorides
(mg dm3)
Sulphates
(mg dm3)
Watering places
Stanowiska pobierania prób wody
Dojlidy
Korycin
Jurowce
Supraśl
13.2
11.5
13.0
12.0
6.82
0.070
6.67
0.040
7.90
0.040
7.82
0.040
0.026
0.013
0.017
0.021
0.070
1.200
1.200
1.200
0.300
0.300
0.600
0.400
4.11
7.00
5.00
19.00
9.00
21.0
13.00
29.00
0.03
0.02
0.01
0
Dojlidy
Korycin
Jurowce
Supraśl
Fig. 3. Value of the N- NH4 of water from the particular
bathing sites
Ryc. 3. Wartość N-NH4 wody na poszczególnych
kąpieliskach
The highest N-NO2 concentration was found in the
bath Dojlidy (0.026 mg dm3). The lowest N-NO2
concentration was found in the bath Korycin (0.013 mg
dm3) (Fig. 4).
The concentration of nitrate nitrogen in the baths
Korycin, Jurowce and Supraśl (1.2 mg dm3) stayed on
the same level. In the bath Dojlidy this content was
lower (0.70 mg dm3) (Fig. 5).
The highest concentration of phosphates was
recorded in the water in bath Jurowce (0.6 mg dm3). In
the bath Dojlidy and Korycin the concentration
continued on the similar level and was half lower than
in remaining baths (Fig. 6).
The concentration of chlorides and sulphates was
revealed similarly in samples of water in all baths. The
highest value was noted in bath Supraśl, the lowest in
the bath Dojlidy (Fig. 7, Fig. 8).
Bożenna Mazalska et. al.
36
belonging to the Peronosporomycetes and 9 species of
fungi proper belonging to the Chytridiomycetes (7) and
Ascomycetes (2) (Table II, Fig.9, 10).
1.4
35
1.2
30
1
25
Sulphates
N-NO3
The number of species found in the water was the
highest in the bathing sites in Supraśl and Jurowce – 26
(RF-63.41%), whereas the fewest fungus species were
noted in Korycin 16 (RF-39.02%) (Table II).
0.8
0.6
20
15
10
0.4
5
0.2
0
0
Dojlidy
Dojlidy
Korycin
Jurowce
Korycin
Jurowce
Supraśl
Supraśl
Fig. 5. Value of the N-NO3 of water from the particular
bathing sites
Ryc. 5. Wartość N-NO3 wody na poszczególnych kąpieliskach
Fig. 8. Value of the sulphates of water from the particular
bathing sites
Ryc. 8. Wartość siarczanów w wodzie na poszczególnych
kąpieliskach
0.7
0.6
P-PO4
0.5
0.4
0.3
0.2
0.1
0
Dojlidy
Korycin
Jurowce
Supraśl
Fig. 6. Value of the P- PO4 of water from the particular
bathing sites
Ryc. 6. Wartość P-PO4wody na poszczególnych kąpieliskach
20
18
Fig. 9. Dictyuchus monosporus – sexual stage; oogonium
showing oospora and merging anteridium
Ryc. 9. Dictyuchus monosporus stadium płciowe; oogonium
z widoczną oosporą i łączące się anteridium
16
Chlorides
14
12
10
8
6
4
2
0
Dojlidy
Korycin
Jurowce
Supraśl
Fig. 7. Value of the chlorides of water from the particular
bathing sites
Ryc. 7. Wartość chlorków w wodzie na poszczególnych
kąpieliskach
The study conducted in the four bathing sites in the
vicinity of Białystok showed the occurrence of 41
species, including 32 straminipilous organisms
Fig. 10. Saprolegnia torulosa - gametangium in mature
mycelium
Ryc. 10. Saprolegnia torulosa – dojrzałe gametangium
grzybni
Scale bar = 50 µm
Fungi and straminipilous organisms found at bathing sites in the vicinity of Białystok
37
Table II. Fungi and straminipilous organisms found in water from the respective bathing sites 2006-2007
(s – spring, a – autumn)
Tabela II. Grzyby i straminipile stwierdzone w wodzie badanych kąpielisk 2006-2007 (wiosna, jesień)
Kingdom, class, order and species
Królestwo, klasa, rząd i gatunek
Dojlidy
Korycin
2006
2007
2006
s
a
s
a
s
a
Eurotiales
1. Aspergillus fumigatus Fresenius
2. Penicillium chrysogenum Thom
Lagenidiales
1. Lagenidium humanum Karling
Leptomitales
12. Apodachlya pyrifera Zopft
13. Leptomitus lacteus (Roth) Agardh
Pythiales
14. Pythium aquatile Höhnk
15. Py. butleri Subramaniam
16. Py. debaryanum Hesse
17. Py. inflatum Matthews
18. Py. myriotylum Drechsler
19. Py. rostratum Butler
20. Py. tenue Gobi
Saprolegniales
21. Achlya americana Humphrey
22. Ac. flagellata Coker
23. Ac. klebsiana Pieters
24. Ac. oligacantha de Bary
25. Ac. polyandra Hildebrand
26. Ac. racemosa Hildebrand
27. Ac. treleaseana (Humphrey) Kauffman
28. Aphanomyces irregularis Scott
29. Ap. stellatus de Bary
30. Ap. leavis de Bary
31. Dictyuchus monosporus Leitgeb
32. Isoachlya monilifera (de Bary) Kauffman
33. Saprolegnia anisospora de Bary
34. S. diclina Humphrey
35. S. ferax (Gruith) Thruet
36. S. glomerata (Thiesenthausen) Lund
37. S. litoralis Coker
38. S. parasitica Coker
39. S. torulosa de Bary
40. S. unispora Coker et Couch
41. Scoliolegnia asterophora (de Bary)
M.W.Dick
Total number of species in seasons
Total number
Relative frequency (RF %)
Supraśl
2006
2007
s
a
s
a
x
Blastocladiales
3. Catenophlyctis variabilis (Karling) x
Karling
Chytridiales
4. Chytridium xylophilum Cornu
5. Nowakowskiella elegans (Nowakowski)
x
Schröter
6. Phlyctochytrium aureliae Ajello
7. Rhizophydium keratinophilum Karling
Spizellomycetales
8. Rhizophlyctis rosea (deBary etWoronin)
x
A. Fischer
Zoopagales
9. Zoophagus insidians Sommerstorff
Olpidiopsidales
10. Olpidiopsis saprolegniae Cornu
Site
Stanowiska
Jurowce
2007
2006
2007
s
a
s
a
s
a
FUNGI
Ascomycetes
x
Chytridiomycetes
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
Straminipila
Hyphochytriomycetes
x
x
x
Peronosporomycetes
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
12
12
10
25
60.97
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
12
10
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
14
26
63.41
12
x
10
6
7
6
16
39.02
6
10
12
10
26
63.41
11
38
Bożenna Mazalska et. al.
Taxons identified in all the bathing sites included
Catenophlyctis variabilis, Nowakowskiella elegans,
Rhizophlyctis rosea, Saprolegnia ferax and S.
parasitica.
Among them potentially pathogenic and
allergogenic for humans fungi genera Aspergillus,
Penicilium and Lagenidium have already been
described.
Presence of fungi such as Leptomitus lacteus in the
water of the bath Korycin offers the possibility of using
them as indicator of water quality.
DISCUSSION
The water in Korycin exhibited the smallest
diversity of fungal and straminipilous species, as
compared to the remaining bathing sites, in which the
number of identified taxons was on a similar level. The
Korycin reservoir is a relatively new ecosystem,
originating in 2002 as the result of water lifting on the
river Kumiałka at a distance of 3 km from the
Brzozówka river mouth (right tributary of the Biebrza
river), and thus fungal and straminipilous species
composition was investigated there for the first time.
Mycological and physicochemical investigations of the
other water reservoirs had been previously conducted
as part of surface water monitoring in the region of
Podlasie Province[14, 15].
The water in bath Korycin showed the lower pH
than in other baths (6.65), whereas the level of nitrate
nitrogen was much higher than in the water the bath
Dojlidy and developed on the similar level as in baths
Jurowce and Supraśl. The concentration of phosphates
in the Korycin bath was similar like in Dojlidy bath
and lower than in the water of Supraśl and Jurowce.
The level of chlorides and sulphates achieved the lower
value in bath Dojlidy and Jurowce and a little bit
higher in the bath Korycin.
Saprotrophic species of the family Saprolegniaceae
belonging to the genus Achlya, Aphanomyces,
Dictyuchus and Saprolegnia were also isolated. Such
species as Achlya americana, Aphanomyces leavis,
Dictyuchus monosporus, Saprolegnia ferax, S. diclina
and S. parasitica may lead a parasitic mode of life,
attacking fish skin and inducing mycotic infections
[16].
An important role in colonizing dead fragments of
plants – leaves, stems, flowers, fruits and seeds can be
ascribed to phytosaprophytes which are able to
synthesize a number of enzymes, both the cellulolytic
and pectinolytic ones [17,18]. In the investigated water
reservoirs, Rhizophlyctis rosea, i.e. soil species
exhibiting strong cellulolytic properties in the aquatic
environment, was a very common phytosaprophyte
[19].
The analysis also showed the presence of such
phytopathogens as Pythium butleri attacking tobacco
and potato seedlings, Py. debaryanum and Py.
myriotylum, known as soil pathogens of cotton, peas,
cabbage, tomatoes and tobacco [20].
In the water samples from Korycin, Leptomitus
lacteus was detected, which is a nitrogen loving
indicator spacies of waters polluted with municipal
wastes. This species does not require a solid medium
for growth, but develops intensively in surface waters
willingly colonizing fish eggs [21].
The presence of Zoophagus insidians, a predacious
fungus fed on rotifers, was observed in the water
collected from two bathing sites – Dojlidy and Supraśl.
This species belongs to a small group of fungi which
equipped in a catching apparatus attack their prey to
use it as the source of nitrogen [2,6,22].
The analysis also revealed the presence of two
species of keratinophilic saprotrophic fungi, known to
grow on human skin and hair, namely Lagenidium
humanum
and
Rhizophydium
keratinophylum.
Keratinophilic fungi have been reported from water
reservoirs by [23-26].
The region of Podlasie is rich in natural assets:
picturesque landscape, the abundance of meadows and
forests, natural habitats of undestroyed valleys. This
perfect advantage could be used to promote the
development of tourism and water recreation.
However, due to the effects of pollution and strong
anthropopression this unspoilt nature becomes
impoverished and species diversity reduced. Research
into the occurrence of fungi and straminipila at bathing
sites has a major sanitary and epidemiological
significance since it allows registration of fungi that
can be potentially pathogenic to man.
In autumn 2006, at the bathing site of Dojlidy,
Aspergillus fumigatus, a potential etiologic agent factor
for aspergillosis was identified. This species shows a
particular affinity with the respiratory system.
Cancerogenicity of mycotoxins produced by
filamentous fungi, especially of the genus Aspergillus,
has been known. Aflatoxins, fumonisins, ochratoxins,
zearalenone are causally linked with cancers of the
breast, liver, oesophagus and prostate. These
compounds, as well as mould spores can act as strong
Fungi and straminipilous organisms found at bathing sites in the vicinity of Białystok
allergens [27]. In Poland, in surface waters, potentially
pathogenic fungi have been identified [28, 29].
15.
CONCLUSION
16.
The number of fungal species in every water reservoir is
determined by a complex of abiotic and biotic factors present
at a respective stage of reservoir development.
In the water samples from Korycin, Leptomitus
lacteus was detected, which is a nitrogen-loving
indicator species of waters polluted with municipal
wastes.
17.
18.
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Address for correspondence:
e-mail: [email protected]
Received: 6.12.2011
Accepted for publication: 13.02.2012
Medical and Biological Sciences, 2012, 26/2, 41-46
ORIGINAL ARTICLE / PRACA ORYGINALNA
Katarzyna Strojek, Irena Bułatowicz, Agata Czechowska, Agnieszka Radzimińska, Urszula Kaźmierczak,
Grzegorz Srokowski, Marcin Siedlaczek
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OCENA WPŁYWU WKŁADEK TERMOPLASTYCZNYCH NA STABILNOŚĆ CIAŁA
U PACJENTÓW Z DYSFUNKCJAMI STOPY – BADANIA WSTĘPNE
Departament of Kinezytherapy and Medical Massage Collegium Medicum in Bydgoszcz Nicolaus Copernicus
University in Torun
Head of the Chair – Doctor of Medical Sciences Irena Bułatowicz
Urszula Kaźmierczak - Doctor of Medical Sciences
Grzegorz Srokowski – Doctor of Medical Sciences
Katarzyna Strojek – Doctor of Medical Sciences
Agnieszka Radzimińska - Doctor of Medical Sciences
Urszula Kaźmierczak - Doctor of Medical Sciences
Grzegorz Srokowski – Doctor of Medical Sciences
Marcin Siedlaczek – Master of Physiotherapy
Agata Czechowska - Master of Physiotherapy
Summary
Nowadays, we can observe a tendency to reduce the
efficiency of the musculoskeletal system. Currently, the
majority of the population is dominated by a sedentary
lifestyle. The lower limbs are deprived of systematic
locomotion training and this is one of the main reasons for
reduction of feet functional efficiency. A sedentary lifestyle
more and more often leads to muscles and ligaments
inefficiency, which often contributes to the foot dysfunctions.
The aim of this study was to assess the influence of a
thermoform insole on body stability improvement in patients
with foot dysfunctions. The research included 20 people with
one or both feet dysfunctions, qualified to apply modeled
thermoform insole in order to correct the musculo-skeletal
imbalance of a foot. The following foot defects appeared the
most frequently among the people examined: hollow foot,
abducted foot, adducted foot, longitudinal and transversal flat
foot. The study was conducted in the Municipal
Rehabilitation Center for Children and Youth in Torun, and
started on the first day of giving an insole to a patient. An
assessment of foot structure and functions, and lower ankle
joint stability based on static and dynamic test on podoscope
were carried out. The height and weight were measured. The
BMI, characterizing height-weight ratios, was calculated.
Lower limb lengths were measured in order to detect a
possible asymmetry of limbs, affecting the feeling of a body
stability. After the application of thermoform insoles, a worse
outcome of the final assessment appears in overweight and
obese people . The size of the insole has no significant effect
on improving the results of the final assessment. In more than
half of the patients, the standing on one leg test stage of the
diagnostic part was an objective overall examination of body
stability using an electronic platform Freeman Easy Tech
LIBRA®.On the basis of the analysis of the studies, we have
formulated the following conclusions: 1) The use of
thermoform insoles individually tailored to the foot
dysfunctions affects overall improvement in the stability of
the body in patients in all age groups. 2) Patients aged 21
obtained a greater improvement of the parameters researched
than patients aged 22-65. 3) The use of thermoform insoles
had a positive impact on improving the overall surface
deflections in all age groups; in patients aged 22-65 the
improvement was smaller by half of the value. 4) After using
42
Katarzyna Strojek et. al.
insoles, the response time for both limbs improved by the
value of 0.3 s for patients aged 11-21, while in the other
groups it was slightly worse. 5) Assessment of reaction time
needs to be completed due to too small group of subjects.
6) The use of an electronic platform Freeman Easy Tech
LIBRA® makes it possible to objectify these studies. 7) The
correct height-weight ratios influence positively achieving a
greater improvement of the final evaluation.
Streszczenie
W dzisiejszych czasach można zaobserwować tendencję
do obniżania się wydolności narządu ruchu. Aktualnie wśród
większości populacji dominuje siedzący tryb życia.
Kończyny dolne pozbawione są systematycznego treningu
lokomocyjnego i jest to jedna z głównych przyczyn
obniżenia wydolności funkcjonalnej stóp. Siedzący tryb
życia prowadzi coraz częściej do niewydolności mięśniowowięzadłowej, która niejednokrotnie przyczynia się do
powstawania dysfunkcji stóp.
Celem pracy była ocena wpływu zastosowanej wkładki
termoplastycznej na poprawę stabilności ciała u pacjentów
z dysfunkcjami stopy. Badaniami objęliśmy 20 osób
z dysfunkcjami stopy lub obu stóp, kwalifikujących się do
zastosowania modelowanej wkładki termoplastycznej w celu
korekcji zaburzeń równowagi mięśniowo-szkieletowej stóp.
Wśród badanych najczęstszymi wadami stopy były: stopa
wydrążona, stopa koślawa, stopa szpotawa, stopa płaska
podłużnie i płaska poprzecznie.
Badanie przeprowadziliśmy w Miejskim Ośrodku
Rehabilitacji Dzieci i Młodzieży w Toruniu w pierwszym
dniu otrzymania przez pacjenta wkładki. Dokonano oceny
budowy i funkcji stopy, oraz stabilności stawu skokowego
dolnego opartej na badaniu statycznym i dynamicznym na
podoskopie. Dokonano pomiaru wysokości i masy ciała.
Obliczono wskaźnik masy ciała BMI charakteryzujący
proporcje wzrostowo-wagowe. Wykonano badanie długości
kończyn dolnych w celu wykrycia ewentualnej asymetrii
kończyn, rzutującej na poczucie stabilności ciała. Kolejnym
etapem części diagnostycznej było obiektywne badanie
ogólnej stabilności ciała przy użyciu elektronicznej platformy
Freemana Easy Tech LIBRA®. Na podstawie analizy
przeprowadzonych badań sformułowaliśmy następujące
wnioski:
1. Zastosowanie wkładek termoplastycznych dostosowanych indywidualnie do dysfunkcji stopy wpływa na ogólną
poprawę stabilności ciała u pacjentów we wszystkich
grupach wiekowych.
2. Pacjenci w przedziale wiekowym do 21 roku życia
uzyskali większą poprawę badanych parametrów niż pacjenci
w przedziale wiekowym 22-65 lat.
3. Zastosowanie wkładki termoplastycznej wpłynęło
korzystnie na poprawę całkowitej powierzchni wychyleń we
wszystkich grupach wiekowych, u pacjentów w wieku 22-65
lat poprawa była o połowę wartości niższa.
4. Po zastosowaniu wkładki czas reakcji dla obu kończyn
poprawił się o wartość 0,3s u pacjentów w przedziale
wiekowym 11-21 lat, zaś w pozostałych grupach uległ
nieznacznemu pogorszeniu.
5. Ocena czasu reakcji wymaga uzupełnienia badań ze
względu na zbyt małą grupę osób badanych.
6. Zastosowanie elektronicznej platformy Freemana Easy
Tech LIBRA® daje możliwość obiektywizacji powyższych
badań.
7. Prawidłowe proporcje wzrostowo-wagowe wpływają
korzystnie na uzyskanie większej poprawy oceny końcowej
po zastosowaniu wkładek termoplastycznych, gorszy wynik
oceny końcowej jest u osób z nadwagą i otyłością.
8. Wielkość wkładki nie ma istotnego wpływu na
poprawę wyników oceny końcowej.
9. U ponad połowy pacjentów wynik testu stania na
jednej nodze uległ poprawie po zastosowaniu wkładki
termoplastycznej.
Key words: physiotherapy, thermoform insoles, body stability, foot dysfunctions
Słowa kluczowe: fizjoterapia, wkładki termoplastyczne, stabilność ciała, dysfunkcje stopy
INTRODUCTION
Nowadays, we can observe a tendency to reduce
the efficiency of the musculoskeletal system.
Currently, the majority of the population is dominated
by a sedentary lifestyle. The lower limbs are deprived
of systematic locomotion training and this is one of the
main reasons for reduction of feet functional
efficiency. A sedentary lifestyle more and more often
leads to muscles and ligaments inefficiency, which
often contributes to the foot dysfunctions. In addition,
a number of diseases is raising due to occasional use of
increased physical activity acts, without prior body
efficiency preparation. These behaviours can lead to
dysfunctions and deepening of already existing
diseases [1]. Disturbances occurring in the foot area
cause changes in the spatial shape of the joints. This
condition negatively affects the coordination of
movement patterns, muscle balance and may contribute
to problems with static and dynamic proprioception in
the legs area [2]. Muscle imbalance of dysfunctional
foot includes not only the muscle tension, but also
leads to changes in correct muscle activity in motor
acts in the way of compensation. The activity of
muscles stabilizing ankle joint plays the key role in the
body stability control [3]. Disorders of a locomotive
apparatus fitness and dysfunction of postural control
contribute to the instability of the posture. In addition,
The assessment of influence of thermoplastic foot pads on the body stability in patients with foot dysfunctions...
the body stability is influenced by variables such as
body weight, height and the size of the body base field
[4, 5]. Improper footwear, prolonged external load,
obesity, weakened musculo-ligament apparatus, and
other factors could lead to an acquired deformity that
reduces motor skills and over time can cause pain [6].
Due to muscles weakness, the whole body weight is
transferred to the ligament, which stretches as a result
of disability to cope with too much effort. This
overload causes irreversible changes in the
osteoarticular system, which leads to inflammation and
distortion [7]. In literature, the term ‘static defect or
distortion; is used and relates to defects in the
developing osteoarticular system due to imbalance
between endurance and load of the system in gravity
conditions [8]. Foot dysfunctions are caused by muscle
imbalance and dysesthesia. Congenital foot
dysfunctions occur frequently in the course of
neuromuscular disorders [5]. The study paid particular
attention to the selection of appropriate orthopedic
supply for patients with foot dysfunction. We
presented applying thermoform insole as a way of
correction and prevention of dysfunctional feet. The
main feature of the thermally modeled insoles is the
ability to make them individually for each foot of the
patient. Insoles of this type are biomechanically
designed to shape a foot naturally, support its side
surfaces and help to correct and control the instability
of the foot. The main purpose of functional orthopedic
insoles is to stabilize the lower ankle joint, to set a foot
in the shoe properly and treat pain in the foot area.
Proper positioning of the foot by an insole helps other
locomotive components (joints of lower limbs and
spine) to increase operational efficiency and prevents
from the formation of pathological changes in the
adjacent joints of dysfunctional feet. An insole also
helps to reduce the feeling of congested muscle fatigue.
The manufacturer of this type of insoles lists a number
of features which positively improve a foot comfort:
secure the optimal distribution of pressing the ground,
support the vaulted feet, reduce the risk of ankle and
knee joint injuries, protect the Achilles tendon, provide
an accurate foot keeping in the axis of motion, prevent
limbs fatigue, are anti-static, hygienic, easy to clean,
comfortable and lightweight - insulate from the cold
and overheating of the foot. The insoles of this type are
made of polyethylene foam, which makes them
lightweight, waterproof, shock-absorbing, antibacterial
and antifungal, which provides a hygienic maintenance
of feet. The implementation of a thermally modeled
43
insole is preceded by a diagnostic system based on a
podoscope study, which enables to assess the shape
and function of a foot. The diagnosis is followed by the
insole creation process: an insole placed in a shoe is
heated to an appropriate temperature, after that the
shoe with the insole is worn on the foot. Under the
influence of self-weight, the process of forming the
insole to the present shape of the foot begins. The
insole is then cut and adjusted to the shoes, as it should
in fact form wholeness with the shoe. Then, the
pressure force on different parts of the foot changes
with the use of wedges and pads; it is also possible to
use elements equalizing the length of a shortened limb.
In each phase of the treatment, a thermoform insole
can be remodeled, depending on the current therapeutic
needs, which gives the patient and therapist a full
opportunity to control and adjust the insole at a given
stage of treatment. The correct setting and functioning
of the lower limbs significantly influence the proper
posture maintenance. Untreated feet defects are often
the cause of pain in the foot, leg, knee, hip and spine
areas. Functional orthopedic insole influences the
reduction of pain. However, it should be remembered
that only a comprehensive treatment, which consists of
a precise diagnosis, treatment of dysfunctional tissues,
correction of muscular-skeletal imbalances and
rehabilitation carried out properly, is the key to an
appropriate therapy [9].
AIM
The aim of this study was to assess the influence of a
thermoform insole on body stability improvement in
patients with foot dysfunctions.
To obtain the evaluation, it is necessary to answer
the following questions: 1) What is the improvement of
stability after the application of a thermoform insole,
on the basis of research conducted by an electronic
platform Freeman Easy Tech LIBRA® 2) What was
the influence of the variables, such as age, BMI
(depending on height and weight), a foot size of a
patient, on the above results 3) What is the assessment
of the influence of an individually tailored thermoform
insole on the stability of standing on one leg?
MATERIAL
The research included 20 subjects with one or both feet
dysfunctions, qualified to apply modeled thermoform
insole in order to correct the musculo-skeletal
44
Katarzyna Strojek et. al.
imbalance of a foot. The study was conducted in the
Municipal Rehabilitation Center for Children and
Youth in Torun, and started on the first day of giving
an insole to a patient. The condition for taking part in
the study was a patient's aware and written consent to
participate in the study, the age of subjects between
5-65 years old, a mental condition allowing
examination on the balance platform, no
contraindications to exercise, or diseases that may
affect the falsification of test results (e.g. the peripheral
system damage). The following food defects appeared
the most frequently among the people examined:
hollow foot, abducted foot, adducted foot, longitudinal
and transversal flat foot. The age of the respondents
ranged from five to sixty five years old. The average
age in the study group was 20.4 years. The patients
were divided into 3 age groups: group I - 5-10 years,
group II - 11-20 years, group III - 21-65 years. Age
ranges were based on the stages of growth and
remodeling of the body according to Martin. In the
study group aged 5-10 years were 8 patients (5M, 3F).
The group accounted for 40% of all the respondents,
the average age was 8.4 years. The group 11-21 years
consisted of 6 individuals (5M, 1F), which was 30% of
the total. The average age in this group was 13.8 years.
The last group within the range of 22-65 years
consisted of 6 individuals (1M, 5F), which was 30% of
respondents. The average age was 43.2 years.
As far as the sex criteria are concerned, the
structure of the patients in the test groups was the
following: men 55% (11 people) and women 45% (9
people).
METHODS
A medical history was collected from each patient. The
interview was to determine whether there is pain in the
lower limbs area, and what is its location. This allowed
the initial exclusion of patients whose medical history
could affect the accuracy of test results.
Romberg test which was to exclude imbalances
caused by peripheral somatosensory damage was
carried out. Romberg test is used to evaluate the
posture of the patient in a standing position with feet
together and eyes closed. A healthy person maintains a
correct posture. In case of balance system damage, the
patient is unable to stay upright, swaying on all sides,
or toward the damaged labyrinth. An assessment of a
foot structure and functions, and lower ankle joint
stability based on static and dynamic test on podoscope
were carried out. The height and weight were
measured. The BMI, characterizing height-weight
ratios, was calculated.
Lower limb lengths were measured in order to
detect a possible asymmetry of limbs, affecting the
feeling of a body stability. The next stage of the
diagnostic part was an objective overall examination of
body stability using an electronic platform Freeman
Easy Tech LIBRA®.
There were three tests in one’s own shoes, and
three in the shoes with a thermoform insole adapted
individually to the dysfunctions of a patient's foot. The
tests were performed on the first day of applying a
thermoform insole. The study required from a patient
to maintain a maximum healthy balance with a varied
support surface for 30 seconds of effective time. The
study was conducted in an upright position, relaxed,
with feet set in parallel. The study was conducted using
a profile - a straight line, the degree of amplitude of
oscillation set at level 3, while the diameter of the
excursion was 40 cm. Before the right measurement, a
respondent had the possibility to make a preliminary
test in order to become familiar with measuring
equipment. The above test was performed three times
in patients’ own shoes and three times in the shoes
with a thermoform insole. Three parameters were
evaluated: the total area of deflections and response
times for both legs and an assessment of the overall
(final). The respondent was able to use a visual
biofeedback.
In order to capture functional changes after the
application of thermoform insoles, the modified test of
standing on one leg was performed. During the test, a
patient had to maintain balance while standing on one
leg and keeping an upright posture, with hands freely
abandoned along the body within 15 seconds. The
study was performed in patients’ own shoes and in the
shoes with a thermoform insole [10, 11, 12, 13].
Edition and analysis of results was done using
STATISTICA 9.0. In this work, we used statistical
tests: t-Student test for dependent variables
(significance level = 0.05) and correlation r-Persona. I.
RESULTS
The average value of the final assessment for the
group aged 5-10 years and 11-21 years has
significantly improved by the value of 1.3. The average
improvement value in the group 22-65 years was
slightly lower than in other groups, reaching the value
The assessment of influence of thermoplastic foot pads on the body stability in patients with foot dysfunctions...
of 0.41. A significant difference was noted in the
evaluation parameter of the total surface deflections,
which has improved in all groups. Average
improvement of this parameter for both limbs was
similar in the group 5-10 years (9.03) and 11-21 years
(8.29), while the results improvement in respondents
aged 22-65 years was smaller by about half (4.73). The
response time for both legs has improved, in relation to
the result obtained before using a thermoform insole;
only in the group 11-21 years, while in the other
groups, it has deteriorated. It should be noted that the
study was conducted on the first day of receiving the
insole, which creates new proprioceptive conditions for
the foot and changes the anatomical relations due to the
foot’s correct settings. Such changes could have
affected the deterioration of the response time
parameter.
Analyzing the results of the groups formed on the
basis of determining the height-weight ratios (BMI),
the relationship of weight and improved results of the
tested parameters is visible. The final evaluation has
improved the most in patients with underweight, while
the lowest value of the improvement was achieved by
overweight and obese patients. The same trend was
observed in the evaluation of improvement of the total
surface deflections parameter for both limbs and
reaction time parameter. On the basis of the research
results, it appears that the size of the patient’s foot does
not significantly affect the results improvement of the
researched parameters. The results of the final
evaluation ranged between the lowest values of
improvement of 0.72 for the group with insole "S" and
the higher of 1.3 for the group with insole "XS". It can
be assumed that the differences between the groups
were not significant. The improvement of the total
surface deflection parameter improved significantly in
the groups with insoles size "Kids", "XS", "L",
reaching values in the range of 7.49-8.25. Only a group
of patients with insole "S" has reached the lower
average result of 4.83. The average response time in
groups with insoles size Kids, XS, S, has minimally
improved by the value of 0.06 - 0.07 s. In the group,
which used insole size L, the overall value of the
response time for both legs worsened by the value of 2.98. Standing on one leg test showed that in 14 cases,
patients who do not have the skills to stand on one leg
(left or right) in their own shoes, after using the insole
could maintain balance within a given time. This
means that in 63% of cases insoles positively
45
influenced the improvement of the ability to maintain
balance in standing on one leg.
DISCUSSION
Non-physiological conditions accompanying the
growth as well as feet functional failure resulting from
a sedentary lifestyle show that currently, an increasing
proportion of the population requires a treatment of
disorders of abnormally shaped foot. The universality
of this problem causes the growing interest in Podiatry
- a science dealing with the subject of physiology,
pathology and feet therapy [14]. There is a more often
necessity to use orthopedic equipment, which is aimed
at correction of developing feet deformities and
protection of the musculo-ligamentous apparatus from
overloads, arising due to change of normal muscle
activity changes in the way of compensation appears
more often [3]. When considering the influence of
disturbances in the foot area on maintaining a stable
posture, it can be assumed that feet dysfunctions
contribute to the deterioration of the body statics,
which significantly limits the ability to maintain
balance. In addition, the stability of the body depends
on variable factors, hence the research included the
division of the patients based on age, height-weight
ratios and the foot size. Analysis of issues related to
assessment of the influence of thermoform insoles on
the body stability improvement in patients with foot
dysfunctions is a new issue, which results from the fact
that the available literature lacks in research of similar
nature. The above research used thermoform insoles,
which are different from ‘standard’ insoles available in
stores. Increasingly, insoles are treated as a serial
industrial product, which, in our opinion, is an
erroneous assumption. Insoles should be performed
according to individual needs, hence the main aim of
thermoform insoles is the ability to make them on each
foot of the patient, adjusting an insole individually to
the needs of disorders in both right and left foot. The
use of thermoform insoles individually tailored to the
disorders aims at functional improvement of feet
efficiency, the correction of feet settings in the shoe
and the reduction of pain [9]. The possibility to select
insoles on each foot of a patient individually helps the
right correction of the foot anatomical structures and
restoring normal activity of muscles stabilizing the
ankle joint, which has a significant impact on control
of body stability.
46
Katarzyna Strojek et. al.
As indicated by the results obtained in this study,
the use of thermoform insoles in patients with foot
dysfunctions influenced the overall improvement of
balance in all patients in an objective research of the
general body stability, using an electronic platform
Freeman East Tech LIBRA ®. The research of the
influence of thermoform insoles on the body stability
improvement in patients with foot dysfunctions on a
large scale have not been carried out so far, and
therefore other work devoted to this subject cannot be
found. It should also be noted that the idea of insoles is
accepted by doctors and physiotherapists, who are
increasingly using this type of orthopedic supplies in
Poland as part of therapy. The presented results
indicate that the thermoform insole, adapted to
individual needs of a patient, has a positive influence
on the body stability improvement. It is proved by
objective using an electronic platform, as well as a
functional test of standing on one leg, which shows an
immediate opportunity to acquire skills to maintain a
balance in this test. The results seem to be encouraging
to continue and expand the research in this area.
CONCLUSIONS
On the basis of the analysis of the studies, we have
formulated the following conclusions:
1) The use of thermoform insoles individually
tailored to the foot dysfunction affects overall
improvement in the stability of the body in patients in
all age groups.
2) Patients aged 21 obtained a greater improvement
of the parameters researched than patients aged 22-65.
3) The use of thermoform insoles had a positive
impact on improving the overall surface deflections in
all age groups; in patients aged 22-65 the improvement
was smaller by half of the value.
4) After using insoles, the response time for both
limbs improved by the value of 0.3 s for patients aged
11-21, while in the other groups it was slightly worse.
5) Assessment of reaction time needs to be
completed due to too small group of subjects. 6) The
use of an electronic platform Freeman Easy Tech
LIBRA® makes it possible to objectify these studies.
7) The correct height-weight ratios influence
positively achieving a greater improvement of the final
evaluation after the application of thermoform insoles,
a worse outcome of the final assessment appears in
overweight and obese people.
8) The size of the insole has no significant effect on
improving the results of the final assessment.
9) In more than half of the patients, standing on one
leg test has improved after using a thermoform insole.
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Address for correspondence:
Departament of Kinezytherapy and Medical Massage
Collegium Medicum in Bydgoszcz Nicolaus
Copernicus University in Torun
Curie-Skłodowskiej 9
85-094 Bydgoszcz
Tel. 48 52 585 43 64
Fax. 48 52 585 43 64
e-mail:[email protected]
Received: 3.12.2011
Accepted for publication: 1.03.2012
Medical and Biological Sciences, 2012, 26/2, 47-52
ORIGINAL ARTICLE / PRACA ORYGINALNA
Beata Kuryło-Rafińska, Beata Kołodziej, Małgorzata Kubicka, Mariusz Wysocki, Jan Styczyński
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IN COMPARISON TO INITIAL DIAGNOSIS
ZRÓŻNICOWANY PROFIL OPORNOŚCI EX VIVO NA CYTOSTATYKI W PIERWSZEJ
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Kierownik: prof. dr hab. n. med. Mariusz Wysocki
Szpital Uniwersytecki nr 1 im. Jurasza w Bydgoszczy
Dyrektor: Jarosław Kozera
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(AML). In spite of continuous progress in therapy of AML,
relapses still occur frequently in both children and
adolescents. The aim of this study was the analysis of the ex
vivo drug resistance profile first and subsequent relapse in
childhood AML in comparison to newly diagnosed AML.
M e t h o d s . The results of 76 pediatric AML samples
tested for drug resistance by the MTT assay were analyzed.
Up to 22 drugs were tested for each patient.
R e s u l t s . No significant differences between ex vivo
drug resistance at first and subsequent relapse of childhood
AML were found, and no drug was found for which
significantly higher resistance of myeloblasts was observed
at subsequent relapse, when compared to first relapse of
AML. For most tested drugs, relapsed patients had higher ex
vivo drug resistance profile than de novo AML patients. The
median RR (relative resistance between relapsed and de novo
diagnosed patients) value of all 22 drugs tested was 1.6. For
five drugs, RR was significantly higher at relapse: idarubicin
(1.8-fold), etoposide (5.9-fold), cytarabine (1.7-fold),
fludarabine (3.7-fold) and busulfan (4.3-fold). For other four
drugs, a trend for higher resistance at relapse was observed:
for daunorubicin, mitoxantrone, L-asparaginase and
cladribine.
C o n c l u s i o n . Ex vivo drug resistance profile in
relapsed childhood AML is higher in comparison to initial
diagnosis, however we did not find differences in ex vivo
drug resistance between first and subsequent relapse of
AML.
Streszczenie
W s t ę p . Aktualne wyniki leczenia w ostrej białaczce
mieloblastycznej (AML) u dzieci sięgają 50-60%. Pomimo
ciągłego postępu, nadal często występują wznowy choroby,
zarówno u dzieci i u młodzieży. Celem pracy była ocena
profilu oporności ex vivo na cytostatyki w trakcie pierwszej
i kolejnej wznowy w stosunku do pierwszego rozpoznania
w AML u dzieci.
M e t o d y k a . Analizie poddano wyniki badań oporności na cytostatyki wykonanych przy użyciu testu MTT
u 76 dzieci z AML. Badania przeprowadzono z użyciem 22
leków.
48
Beata Kuryło-Rafińska et. al.
W y n i k i . Nie stwierdzono istotnych różnic w
oporności ex vivo na cytostatyki pomiędzy pierwszą i kolejną
wznową choroby. Dla żadnego leku nie zaobserwowano
większej oporności mieloblastów w trakcie kolejnej wznowy
w porównaniu do pierwszego nawrotu. Dla większości
leków, pacjenci we wznowie wykazywali większą oporność
ex vivo, niż pacjenci z AML de novo. Względna oporność na
cytostatyki dla pacjentów we wznowie w stosunku do
pacjentów AML de novo wynosiła dla poszczególnych
cytostatyków: idarubicyna (wyższa 1,8-krotnie), etopozyd
(5,9-krotnie), cytarabina (1,7-krotnie), fludarabina (3,7-krotnie) i busulfan (4,3-krotnie). Jednocześnie, dla 4 kolejnych
leków: daunorubicyny, mitoksantronu, L-asparaginazy
i kladrybiny, różnice były bliskie znamienności statystycznej.
W n i o s k i . Oporność ex vivo na cytostatyki we
wznowie AML u dzieci jest wyższa niż podczas pierwszego
rozpoznania. Nie stwierdzono natomiast istotnych różnic
w oporności pomiędzy pierwszą i kolejną wznową choroby.
Key words: acute myeloid leukemia, relapse, multiple relapse, drug resistance
Słowa kluczowe: ostra białaczka szpikowa, wznowa, wielokrotna wznowa, oporność na cytostatyki
INTRODUCTION
Current cure rate reach 80% of long-term survival
in childhood acute lymphoblastic leukemia (ALL) and
50-60% in acute myeloblastic leukemia (AML) [1-3].
In spite of continuous progress in therapy of acute
leukemias, relapses still occur frequently in both
children and adults. The results of therapy in childhood
relapsed AML do not exceed 30% and are very poor in
subsequent relapses [2,3]. Failure in the therapy is
dependent on three factors: pharmacokinetic resistance,
cellular drug resistance and minimal residual disease
[4]. Cellular drug resistance can be defined as cellular
insensitivity to drug reaching the cell.
Leukemic cells of children with de novo AML
show higher in vitro resistance to most drugs, when
compared to the cells of ALL at diagnosis [5, 6].
However, still little is known about drug resistance in
relapsed AML children. There is only a limited number
of studies published so far [7,8]. It has been shown that
children with relapsed AML were in vitro median
3-fold more resistant to cytarabine than the initial
AML group, however the group of patients was
relatively small; in the group of poor responders to
chemotherapy, 3-fold higher resistance to cytarabine
was observed in comparison to the group of good
responders [5]. In our study we aimed to compare in
vitro drug resistance at diagnosis and at first and
subsequent relapses in the group of patients with AML.
MATERIAL AND METHODS
Patient samples
A total number of 76 leukemic samples were
included into the study, including 44 samples obtained
from patients at initial AML diagnosis, 22 at first
relapse of leukemia, and 10 obtained at subsequent
leukemic relapse. Detailed patients characteristics with
respect to phase of the disease are presented in Table I.
Table I. Patients characteristics
Tabela I. Charakterystyka pacjentów
Initial AML First relapse
Subsequent
AML de
AML
relapse AML
novo
Pierwsza Kolejna wznowa
wznowa
44
22
10
23/21
14/8
6/4
12 (0.3-19) 12.5 (2-19)
13.5 (5-18)
Number of patients
Gender (male/female)
Median age (range)
FAB types
M0
3
1
M1
12
7
M2
20
9
M3
1
M4
4
1
M5
5
2
M6
1
Down syndrome
3
Median WBC count
20.3
3,5
(range) [G/L]
(1.2-341.0) (0.7-186.0)
1
4
5
2
6.1
(2.7-10.4)
The distribution of patients between these three
groups was comparable. All de novo, 10 firstly
relapsed and all subsequently relapsed patients were
diagnosed in our Department. This cohort was
supplemented by 12 firstly relapsed patients from
previously published study [9].
The MTT assay
Ex vivo drug resistance profile was estimated by
means of the MTT assay, as described previously [6].
Briefly, 80 µl of the cell suspension containing 2 x 106
vital cells/ml was incubated with each drug
concentration in 20 µl RPMI in duplicate wells of a 96well round-bottomed microtiter plate. Six wells
containing only cells in a drug-free medium served as
controls for cell survival, while six other wells
containing only culture medium blanked the
spectrophotometer. Plates were incubated for 4 days
(96 hours) at 37°C in humidified air containing 5%
CO2. After 4 days, 50 µg (10 µl of a solution of 5
mg/ml) of 3-[4.5-dimethylthiazol-2-yl]-2.5-diphenyl
tetrazoliumbromide (MTT, Serva, Heidelberg,
Germany) was added to each well (final concentration
0.45 mg/ml); plates were shaken and incubated for
another 4 hours at 37°C. In such an exposure yellow
Differential ex vivo drug resistance profile in first and subsequent relapsed childhood acute myeloid leukemia...
MTT was reduced into purple formazan by viable but
not dead cells. The formazan crystals were dissolved
with 100 µl of acidified (0.04 N HCl) 2-isopropanolol
(Chemia, Bydgoszcz, Poland) and the quantity of
reduced product was measured by an ELISA EL-312
microplate spectrophotometer at 570 nm (Asys Hitech
GmbH, Eugendorf, Austria). Cytospin slides from
control wells, stained with May-Grunwald-Giemsa,
were used to determine the percentage of blasts after
96-hours incubation. Samples with more than 70%
leukemic cells in the control wells without drug after 4
days of culture and with an OD higher than 0.050
arbitrary units (adjusted for blank values) were suitable
for evaluation. The leukemic cell survival was
calculated by the equation: (OD drug well / mean OD
control wells) x 100%. The OD of both control and
tested wells were adjusted by OD of blank wells.
The LC50, the concentration of drugs, which was
lethal to 50% of the cells, was used as a measure for
the ex vivo drug cytotoxicity in each sample. Relative
resistance (RR) between the groups of patients for each
drug was calculated as a ratio of median values of
LC50. Only samples with successful outcome of the
assay were included into the study, however in most
cases only part of drugs was tested for each patient.
DRUGS
Following 22 drugs and their concentrations were
used: prednisolone (Fenicort, Jelfa, Jelenia Góra,
Poland; tested concentration range 0.007–250 µg/ml),
dexamethasone (Dexamethasone, Jelfa, Jelenia Góra,
Poland; 0.0002–6 µg/ml), vincristine (Vincristine, EliLilly, Indianapolis, USA; 0.019–20 µg/ml), idarubicin
(Zavedos, Farmitalia, Milan, Italy; 0.0019–2 µg/ml),
daunorubicin (Daunorubicin, Rhone-Poulenc-Rhorer,
Paris, France; 0.0019–2 µg/ml), doxorubicin
(Doxorubicin, Farmitalia, Milan, Italy; 0.0078–8
µg/ml), epirubicin (Farmorubicin, Pharmacia &
Upjohn, Kalamazoo, USA; 0.002–2 µg/ml),
mitoxantrone (Mitoxantrone, Jelfa, Jelenia Gora,
Poland; 0.001–1 µg/ml), etoposide (Vepeside, Bristol–
Myers Squibb, Princeton, USA; 0.048–50 µg/ml), Lasparaginase (Medac, Medac, Hamburg, Germany;
0.0032–10 IU/ml), cytarabine (Cytosar, Pharmacia &
Upjohn, Kalamazoo, USA; 0.0097–10 µg/ml),
fludarabine (Fludara, Schering, Berlin, Germany;
0.019–20 µg/ml), cladribine (Biodribin, Bioton,
Warsaw, Poland; 0.0004–40 µg/ml), treosulfan
(Ovastat, Medac, Hamburg, Germany; 0.0005–1
µg/ml), thiotepa (Thiotepa, Lederle, Greifswald,
Germany; 0.032–100 µg/ml), melphalan (Alkeran,
Glaxo, Parma, Italy; 0.038-40 µg/ml), 4-HOO-
49
cyclophosphamide
(Asta
Medica,
Hamburg,
Geramany; 0.096–100 µg/ml), 4-HOO-ifosfamide
(Asta Medica, Hamburg, Germany; 0.096–100 µg/ml),
bortezomib (Velcade, Janssen Pharmaceutica N.V.,
Beerse, Belgium; 19-2000 nM), busulfan (Busilvex,
Pierre-Fabre Medicament, Boulogne, France, 1.171200 µg/ml), 6-mercaptopurine (Sigma, nr M7000, St.
Louis, USA; 15.6–500 µg/ml), 6-Thioguanine (Sigma,
nr A4882, St. Louis, USA; 1.56–50 µg/ml).
STATISTICAL METHODS
Observed differences in proportions were tested for
statistical significance using the appropriate chi-square
statistic. For small sample sizes, the Fisher exact test
was used. Differences in the distribution of the LC50
values between two groups were analyzed using the
Mann-Whitney U test. Using the 2-tailed test, p<0.05
was considered statistically significant. The study was
approved by the Local Bioethical Committee.
RESULTS
No significant differences between ex vivo drug
resistance at first and subsequent relapse of childhood
AML were found. The results of the MTT assay are
shown in Table II. Of the 22 drugs analyzed, no drug
was found for which significantly higher resistance of
myeloblasts was observed at subsequent relapse, when
compared to first relapse of AML. The median RR
(relative resistance between second and first relapse)
value of all tested drugs was 1.0; for 10 drugs RR it
was below 1 (i.e. assumed better sensitivity on
subsequent relapse) and for other 11 drugs RR value
was above 1 (i.e. higher drug resistance on subsequent
relapse). As the characteristics of patients at first and at
subsequent relapse were similar, these features
probably did not influence the overall results.
Virtually, no drug showed a trend towards better
cellular sensitivity at first versus subsequent relapse as
the differences were not significant for each tested
drug.
Since ex vivo drug resistance profile in children
with firstly versus subsequently relapsed AML is
comparable, we pooled all relapsed patients into one
group for further analysis in order to compare drug
resistance between relapsed and initially diagnosed
AML patients.
For most tested drugs, relapsed patients had higher
ex vivo drug resistance profile (Table III). The median
RR (relative resistance between relapsed and de novo
diagnosed patients) value of all tested drugs was 1.6.
For five drugs RR was significantly higher at relapse:
idarubicin (1.8-fold), etoposide (5.9-fold), cytarabine
Beata Kuryło-Rafińska et. al.
50
Table II. Comparison of ex vivo drug resistance profile between first and subsequent relapse of childhood acute myeloid
leukemia
Tabela II. Porównanie profile oporności ex vivo na cytostatyki u pacjentów z pierwszą i kolejnymi wznowami ostrej białaczki
mieloblastycznej
DRUG
Lek
FIRST RELAPSE
Pierwsza wznowa
SUBSEQUENT RELAPSE
Kolejna wznowa
RR
p
N
Median
Minimum
Maximum
N
Median
Minimum
Maximum
Prednisolone
17
95.10
3.40
250.00
7
112.36
36.07
147.50
1.2
0.924
Dexamethasone
12
6.00
0.03
6.00
6
6.00
6.00
6.00
1.0
0.303
Vincristine
17
4.27
0.13
20.00
7
2.59
0.57
10.47
0.6
0.775
Idarubicin
17
0.39
0.03
2.00
9
0.26
0.12
2.00
0.7
0.725
Daunorubicin
17
0.55
0.03
2.00
7
0.55
0.24
1.59
1.0
0.727
Doxorubicin
13
5.00
0.34
8.00
6
1.06
0.64
8.00
0.2
0.472
Epirubicin
8
0.87
0.28
2.00
4
0.79
0.48
0.92
0.9
0.732
Mitoxantrone
12
0.55
0.01
1.00
6
0.61
0.10
1.00
1.1
0.772
Etoposide
18
20.14
0.30
50.00
6
22.03
15.75
50.00
1.1
0.662
L-asparaginase
15
1.40
0.01
10.00
7
1.49
0.20
10.00
1.2
0.800
Cytarabine
16
0.81
0.22
10.00
8
0.64
0.14
10.00
0.8
0.478
Fludarabine
13
1.46
0.06
20.00
6
1.19
0.17
20.00
0.8
0.929
Cladribine
17
10.00
0.00
40.00
8
0.09
0.00
40.00
0.1
0.438
Treosulfan
9
0.60
0.00
1.00
6
0.58
0.00
2.11
1.0
0.903
Thiotepa
9
1.59
0.03
12.11
5
1.96
0.59
4.00
1.2
0.947
Melfalan
8
5.27
0.91
34.45
3
6.65
1.35
15.06
1.3
0.838
4-HOO-cyclophosphamide
10
2.74
0.38
17.41
6
1.29
0.39
3.13
0.5
0.193
4-HOO-ifosfamide
3
16.82
8.17
96.90
3
9.72
1.19
32.05
0.6
0.513
Bortezomib
3
1044.27
261.82
2000.00
2
1199.43
398.85
2000.00
1.1
0.767
Busulfan
3
64.65
33.53
1200.00
2
488.06
24.12
952.00
7.5
0.564
6-Thiguanine
10
21.25
1.56
50.00
5
6.25
4.42
18.95
0.3
0.141
6-Mercaptopurine
9
308.72
141.01
500.00
4
63.55
31.25
81.39
0.2
0.105
Median and range of LC50, as the value of in vitro resistance is provided given in IU/ml for L-asparaginase, nM for bortezomib, µM for
clofarabine and in µg/ml for the remaining drugs; n – number of patients; RR – relative resistance = median LC50 (subsequent relapse) / median
LC50 (first relapse); n, number of patients; p-value, Mann-Whitney U-test.
(1.7-fold), fludarabine (3.7-fold) and busulfan (4.3fold). For other four drugs, a trend for higher resistance
at relapse was observed: for daunorubicin,
mitoxantrone, L-asparaginase and cladribine.
DISCUSSION
In this study we have shown that drug resistance of
myeloblasts in relapsed patients is higher than that of
de novo ones. Still, relapse remains a significant
problem for all children with AML. In the study of
Dutch-German group, no significant differences in
drug resistance were reported in a large cohort of
childhood AML samples taken at diagnosis between
patients remaining in continuous complete remission
versus refractory/relapsed patients [10]. In general,
relapsed AML has a dismal prognosis mainly related to
the time-interval between initial diagnosis and relapse,
and possibly cellular drug resistance can play a key
role in therapy failure of relapsed childhood AML. It is
important, as relapsed patients had myeloblasts more
resistant to basic drugs used in the therapy of
childhood acute myeloid leukemia, such as: cytarabine,
idarubicin, daunorubicin, mitoxantrone and etoposide.
Relapsed leukemic blasts were also more resistant to
drugs commonly used in the therapy of relapsed AML:
fludarabine, cytarabine and idarubicin. High ex vivo
drug resistance in childhood acute myeloid leukemia
might partially explain worse clinical results of
therapy, when compared to acute lymphoblastic
Differential ex vivo drug resistance profile in first and subsequent relapsed childhood acute myeloid leukemia...
51
Table III. Comparison of ex vivo drug resistance profile between relapsed and de novo childhood acute myeloid leukemia
Tabela III. Porównanie profile oporności ex vivo na cytostatyki u pacjentów z ostrą białaczką mieloblastyczną
i jej wznowami
DRUG
Lek
INITIAL AML
AML de novo
RELAPSED AML
Wznowa AML
RR
P
250.00
1.1
0.295
0.03
6.00
1.0
0.664
n
Median
Min
Max
n
Median
Min
Max
Prednisolone
38
94.65
0.40
250.00
24
100.65
3.40
Dexamethasone
18
6.00
0.01
8.00
18
6.00
Vincristine
38
2.73
0.02
16.09
24
4.08
0.13
20.00
1.5
0.435
Idarubicin
40
0.22
0.01
2.00
26
0.38
0.03
2.00
1.8
0.041
Daunorubicin
37
0.27
0.01
2.00
24
0.55
0.03
2.00
2.0
0.052
Doxorubicin
33
1.69
0.24
8.00
19
1.41
0.34
8.00
0.8
0.870
Epirubicin
17
0.90
0.13
2.00
12
0.80
0.28
2.00
0.9
0.790
Mitoxantrone
34
0.23
0.00
13.28
18
0.61
0.01
1.00
2.6
0.077
Etoposide
36
3.44
0.05
50.00
24
20.14
0.30
50.00
5.9
0.007
L-asparaginase
33
0.68
0.03
10.00
22
1.35
0.01
10.00
2.0
0.058
Cytarabine
40
0.47
0.01
12.19
24
0.78
0.14
10.00
1.7
0.050
Fludarabine
35
0.40
0.02
15.54
19
1.46
0.06
20.00
3.7
0.022
Cladribine
32
0.04
0.00
40.00
25
0.75
0.00
40.00
21.2
0.072
Treosulfan
31
0.32
0.00
1.00
15
0.60
0.00
2.11
1.9
0.572
Thiotepa
31
1.88
0.12
100.00
14
1.94
0.03
12.11
1.0
0.787
Melfalan
25
4.65
0.10
40.00
11
6.57
0.91
34.45
1.4
0.973
4-HOO-cyclophosphamide
30
1.68
0.24
9.35
16
2.16
0.38
17.41
1.3
0.890
4-HOO-ifosfamide
13
1.98
0.35
34.74
6
13.27
1.19
96.90
6.7
0.136
Bortezomib
16
353.74
191.50
1096.83
5
1044.27
261.82
2000.00
3.0
0.137
Busulfan
14
15.19
1.17
42.30
5
64.65
24.12
1200.00
4.3
0.004
6-Thiguanine
17
14.63
1.36
50.00
15
14.79
1.56
50.00
1.0
0.533
6-Mercaptopurine
18
106.15
15.63
500.00
13
229.25
31.25
500.00
2.2
0.118
Median and range of LC50, as the value of in vitro resistance is provided given in IU/ml for L-asparaginase, nM for bortezomib, µM for
clofarabine and in µg/ml for the remaining drugs; n – number of patients; RR – relative resistance = median LC50 (initial AML) / median
LC50 (relapsed AML); n, number of patients; p-value, Mann-Whitney U-test.
leukemia. It is commonly assumed that relapsed
patients are more drug resistant than those diagnosed
de novo, and it was shown in this analysis for relapsed
AML samples. No conclusive results were obtained for
stem cell transplant teams, as relapsed patients were
highly resistant to busulfan, which is a key compound
used in conditioning of AML patients before
hematopoietic stem cell transplantation. On the other
hand, no significant differences were found between de
novo and relapsed patients for cyclophosphamide and
treosulfan. In current therapeutic regimens, based on
reduced intensity conditioning, these drugs play an
important role.
Unlike ALL, the role of individual in vitro tumor
response testing in childhood AML has not been
established yet. Several groups reported possible
prognostic value of in vitro drug sensitivity in pediatric
AML, showing a good correlation between in vitro
drug resistance and short-term clinical outcome after
chemotherapy [7,11-14]. These findings were related
mainly to cytarabine [7] and cyclophosphamide [14].
Part of these studies included both children and adults.
Newer, large studies showed no correlation between in
vitro drug resistance to individual drugs and long-term
clinical outcome in childhood AML [15-17]. So far, no
data exist to support the prognostic value of any in
vitro drug resistance profile in childhood AML, while
this relationship has been confirmed in adult AML
[18]. In our previous preliminary report of our group,
we showed the possible prognostic value of a
combined fludarabine, treosulfan and mitoxantrone
resistance profile in children with AML [8]. Recently,
Beata Kuryło-Rafińska et. al.
52
new compounds were shown to have good
antileukemic activity in childhood AML [19,20]. There
are still large hopes in results obtained in microarray
studies [21].
In conclusion, ex vivo drug resistance profile in
relapsed childhood AML is higher in comparison to
initial diagnosis, however we did not find differences
in ex vivo drug resistance between first and subsequent
relapse of AML.
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Address for correspondence:
prof. dr hab. n. med. Jan Styczyński
Katedra i Klinika Pediatrii, Hematologii i Onkologii
Collegium Medicum im. L. Rydygiera w Bydgoszczy
Uniwersytet im. Mikołaja Kopernika
ul. Curie-Skłodowskiej 9
85-094 Bydgoszcz
e-mail: [email protected]
tel.: 52 585 4860
fax: 52 585 4867
Received: 7.02.2012
Accepted for publication: 1.03.2012
Medical and Biological Sciences, 2012, 26/2, 53-58
ORIGINAL ARTICLE / PRACA ORYGINALNA
Aneta Zreda-Pikies, Andrzej Kurylak
SOCIAL FUNCTIONING OF CHILDREN WHO HAVE COMPLETED
ACUTE LYMPHOBLASTIC LEUKEMIA TREATMENT
SPOŁECZNE FUNKCJONOWANIE DZIECI PO ZAKOŃCZONYM LECZENIU
OSTREJ BIAŁACZKI LIMFOBLASTYCZNEJ
Department of Paediatric Nursing, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń
Head: prof. dr hab. n. med. Andrzej Kurylak
Summary
I n t r o d u c t i o n . A progress in acute lymphoblastic
leukemia treatment led to an increased number of recoveries.
This fact forces us to look closely at the functioning of
patients after completed treatment. Learning a subjective
evaluation of functioning may indicate existence of nonperceived needs of patients who require specialist care and
help outside the hospital environment.
M a t e r i a l s a n d m e t h o d s . The research was
conducted among patients treated in the Chair and Clinic of
Pediatrics, Hematology and Oncology of
Nicolaus
Copernicus University Collegium Medicum in Bydgoszcz,
who have completed acute lymphoblastic leukemia
treatment. The final group of patients who participated in the
research consisted of 64 persons. Research referring to
healthy children was carried out among students of primary
schools, junior high schools and kindergartens from
Bydgoszcz. Only children who have never undergone
hospital treatment and did not suffer from chronic diseases
were qualified for the said research. The comparative group
consisted of 70 healthy children. In order to evaluate the
quality of life of children who had completed ALL treatment
and of healthy children James W. Varni’s standardized
research instrument was used.
R e s u l t s . The subjective evaluation of social
functioning is quite high in all age groups and comprises 8588 points. The highest rated item is maintaining good
relationships with peers. The most problematic aspects are
connected with an inability to perform all activities that peers
can perform. As far as indirect evaluation is concerned, the
lowest amount of points pertaining to social functioning was
given within the group of children aged 2-4. When analysing
social functioning, an essential statistical difference in its
evaluation, both direct and indirect, was observed in favour
of healthy children. As far as statistics is concerned a general
evaluation of functioning at school differs significantly
between children who have completed ALL treatment and
healthy children (69.57 vs. 81.27; p=0.001).
C o n c l u s i o n . The quality of life within the sphere of
social functioning of children and teens who have completed
treatment is significantly lower than among healthy children.
Streszczenie
W s t ę p . Postęp w leczeniu ostrej białaczki limfoblastycznej spowodował wzrost liczby osób wyleczonych, fakt
ten wymusza spojrzenie na funkcjonowanie pacjenta po
zakończonym leczeniu. Poznanie subiektywnej oceny
funkcjonowania może wskazywać na istnienie niedostrzeganych potrzeb pacjentów wymagających zapewnienia
fachowej opieki i pomocy poza środowiskiem szpitalnym.
M a t e r i a ł i m e t o d y . Badania przeprowadzono
wśród pacjentów leczonych w Katedrze i Klinice Pediatrii,
Hematologii i Onkologii Collegium Medicum Uniwersytetu
Mikołaja Kopernika w Bydgoszczy, którzy zakończyli
leczenie ostrej białaczki limfoblastycznej. Ostateczna liczba
osób, biorących udział w badaniu wynosiła 64. Badania
wśród dzieci zdrowych przeprowadzono wśród uczniów
szkoły podstawowej, gimnazjum oraz przedszkola na terenie
Bydgoszczy. Do badania zakwalifikowano dzieci, które
nigdy nie były poddane leczeniu szpitalnemu oraz nie
chorują
na choroby przewlekłe. Grupę porównawczą
54
Aneta Zreda-Pikies, Andrzej Kurylak
stanowiło 70 dzieci zdrowych. Do oceny jakości życia dzieci
po zakończonym leczeniu ALL oraz dzieci zdrowych użyto
standaryzowanego narzędzia badawczego autorstwa Jamesa
W. Varni.
Wyniki.
Subiektywna ocena funkcjonowania
społecznego we wszystkich grupach wiekowych jest dość
wysoka i mieści się w granicach 85-88 punktów. Najwyżej
oceniane jest utrzymywanie dobrych kontaktów z
rówieśnikami. Najwięcej problemów związanych jest z
brakiem możliwości wykonywania wszystkich czynności,
które mogą robić ich rówieśnicy. W ocenie pośredniej
najmniej punktów dla funkcjonowania społecznego
przyznanych jest w grupie dzieci od 2 do 4 lat. Podczas
analizy funkcjonowania społecznego zaobserwowano istotną
statystycznie różnice w jego ocenie na korzyść dzieci
zdrowych, zarówno w ocenie bezpośredniej, jak i pośredniej.
Ogólna ocena funkcjonowania w szkole różni się istotnie
statystycznie pomiędzy dziećmi po zakończonym leczeniu
ALL, a dziećmi zdrowymi (69,57 vs 81,27; p=0,001).
W n i o s e k . Jakość życia w sferze funkcjonowania
społecznego dzieci i młodzieży po zakończonym leczeniu
jest znamiennie niższa niż wśród dzieci zdrowych.
Key words: social functioning of children, acute lymphoblastic leukemia
Słowa kluczowe: funkcjonowanie społeczne dzieci, ostra białaczka limfoblastyczna
INTRODUCTION
A progress in treatment of life-threatening diseases,
which led to an increased number of cured persons,
forces us to look closely at the functioning of patients
after completed treatment. ALL treatment results
which apply to children have been improving
systematically for the past years. At present, over 80
percent of children are considered to be cured;
therefore, it is justified to evaluate the quality of their
life. Learning a subjective evaluation of the quality of
life may be a source of information which often differs
from the evaluation made by medical staff or sick
children’s parents. The information might indicate
existence of non-perceived needs of patients who
require specialist care and help outside the hospital
environment.
The purpose of this paper is to evaluate the quality
of life of children suffering from ALL as far as social
functioning is concerned.
MATERIALS AND METHODS
The research was conducted among patients treated
in the Chair and Clinic of Pediatrics, Hematology and
Oncology of Nicolaus Copernicus University
Collegium Medicum in Bydgoszcz, who have
completed acute lymphoblastic leukemia treatment. It
comprised children whose ALL treatment had finished
at least 6 months prior to the research. The final group
of patients who participated in the research consisted
of 64 persons. The number of boys and girls was
comparable and amounted to 33 and 31, respectively.
The average age of children at the moment of the
research was 11.3 (4-18 years old, median - 11) and at
the moment of diagnosis - 6 (1-17 years old, median 5).
Research referring to healthy children was carried
out among students of primary schools, junior high
schools and kindergartens from Bydgoszcz. Only
children who had never undergone hospital treatment
and did not suffer from chronic diseases were qualified
for the said research. The comparative group included
70 healthy children: 31 girls and 39 boys. The children
were aged from 2 to 17, with the average age of 10.98
(median – 12).
In order to evaluate the quality of life of children
who have undergone ALL treatment and of healthy
children, James W. Varni’s standardized research
instrument was used [1, 2, 3, 4, 5, 6]. Permission to use
the questionnaire was granted by the Mapi Research
Trust Institute in Lyon.
The Paediatric Quality of Life Questionnaire PedsQL 4.0. Generic Core Scale is a general use tool
which has a Polish version. It is used to evaluate the
quality of life as well as physical, emotional, social and
school functioning.
The respondents were giving answers according to
a five-item scale by choosing one out of five answers.
Evaluation of particular aspects of functioning took
place by answering how often a child has problems
with aspects of everyday life mentioned in the
questionnaire.
In order to enable self-dependent evaluation among
children aged 5-7, a three-item scale was used.
Additionally, the scale was presented in a graphic
form.
All answers were assigned following points: 0=100
pts, 1=75 pts, 2=50 pts, 3=25 pts, 4=0 pts. The scores
obtained through particular scales as well as the final
score were calculated as an arithmetic mean presented
as points from 0-100. The higher the calculated value,
the better the quality of life is.
Social functioning of children who have completed acute lymphoblastic leukemia treatment
RESULTS
The evaluation of social functioning took place
based on answers given to questions connected with
maintaining
good
relationships
with
peers,
unwillingness of peers to be friends, inability to
perform all activities that peers can perform as well as
keeping up with peers.
The subjective evaluation of social functioning is
quite high in all age groups and comprises 85-88
points. The highest evaluated item is maintaining good
relationships with peers (average of 88.56 pts).
The children/teens who completed ALL treatment
and were participating in the research did not mention
peers’ unwillingness to be friends or being teased by
them as elements that decrease the quality of social
functioning. The most problematic situations are
connected with an inability to perform all activities that
peers can perform (average of 77.54 pts).
As far as indirect evaluation is concerned, the
smallest amount of points for social functioning was
given within the group of children aged 2-4 (70.00).
The factors that decrease the quality of life within the
said sphere include unwillingness of peers to play with
the sick child (65.00) and keeping up with other
children while playing (65.00). The evaluation
obtained in other age groups is similar and amounts to
82-83 points. The lowest evaluated aspects are keeping
up with peers (an average of 76.56 pts) and inability to
perform all activities that peers can perform (an
average of 77.73 pts).
Parents of children who have completed ALL
treatment evaluate the quality of life within the social
sphere lower than their children. Whereas the biggest
difference pertains to children aged 5-7 (88 vs. 83), the
smallest one refers to teens (85.19 vs. 82.31).
The evaluation of social functioning performed by
children/teens shows profound statistical discrepancies
between the groups and is in favour of healthy children
as far as inability to perform all activities that peers can
perform (77.54 vs. 93.65; p<0.001) and keeping up
with peers (80.51 vs. 95.63; p<0.001) are concerned.
While analysing social functioning, it was observed
that the least problems pertain to peers’ unwillingness
to be friends (92.80 vs. 90.08) or being teased by them
(88.98 vs. 86.51).
With regard to parents’ evaluation, the significant
statistical differences, in favour of the comparative
group, are connected with maintaining good
relationships with peers (79.69 vs. 89.29; p=0.018),
55
inability to perform all activities that peers can perform
(77.73 vs. 92.50; p<0.001) and keeping up with peers
(76.56 vs. 87.14; p=0.40).
When analysing social functioning, an essential
statistical difference in its evaluation was observed in
favour of healthy children, not only in direct evaluation
(85.68 vs. 91.98; p=0.012), but also in the indirect one
(81.33 vs. 88.21; p=0.013).
Fig. 1. Average evaluation of social functioning within
groups covered by the research
Ryc. 1. Średnia ocena funkcjonowania społecznego w badanych grupach
Functioning at school/kindergarten is evaluated by
children/teens in a similar way, i.e. 69-70 points. The
factor that decreases the quality of life within this
sphere is being absent from classes due to
appointments at doctors’ or a hospital stay (an average
of 61.21). As far as children aged 5-7 are concerned, it
was problematic to keep up with studying at school and
at home (50.00). The least problems are connected
with being absent from classes due to not feeling well
(an average of 75.86).
Parents of children who have completed ALL
treatment name being absent from classes due to
appointments at doctors’ or a hospital stay (an average
of 58.62), keeping up with studying at school and at
home (65.95) and forgetting about various things
(63.02) as the biggest problems related to functioning
at school. Similarly to a direct evaluation, according to
parents, children have the least problems in connection
with being absent from classes due to not feeling well
(75.86).
The group of children/teens who completed ALL
treatment evaluated functioning at school statistically
lower than their healthy peers (69.57 vs. 81.27;
p=0.001). An essential statistical difference in favour
of the comparative group was connected with all
56
Aneta Zreda-Pikies, Andrzej Kurylak
variables mentioned in the questionnaire, apart from
problems with forgetting about various things.
As far as indirect evaluation is concerned, profound
statistical discrepancies in favour of healthy children
concern problems with keeping up with studying
(65.95 vs. 79.76; p=0.008), being absent from classes
due to not feeling well (72.41 vs. 82.54; p=0.018) and
appointments at doctors’ (58.62 vs. 73.81; p<0.001).
As far as statistics is concerned, a general
evaluation of functioning at school differs significantly
between children who have completed ALL treatment
and healthy children (69.57 vs. 81.27; p=0.001).
Evaluation performed by parents in both groups is
lower than children’s evaluation.
Fig. 2. Average evaluation of school functioning within
groups covered by the research
Ryc. 2. Średnia ocena funkcjonowania szkolnego w badanych grupach
DISCUSSION
Exclusion of a child from normal life and the
accompanying feeling of social isolation contribute to
problems with readapting to the lifestyle from before
the illness [7]. An important goal in oncological
treatment is preparing a child and its family for
‘normal’ life after the completion of treatment. Contact
with peers is an inseparable element of a support
treatment. It lets a child/teen draw happiness from
everyday life and helps to fight the fear of being
rejected by peers due to appearance changes or healthy
children’s fear of a fatal disease.
Research carried out by E. Mess shows that patients
who had completed ALL treatment are scared of
contacts with peers and lack of acceptance in a group.
Some respondents spoke of problems with interacting
with peers [8].
While evaluating direct social functioning in own
research, a significant difference between healthy
children and children who have completed oncological
treatment was noticed as far as inability to perform all
activities that peers can perform (77.54 vs. 93.65) and
keeping up with peers (80.51 vs. 95.63) are concerned.
A general evaluation of social functioning among
children who have completed oncological treatment is
lower than among healthy children (85.68 vs. 91.98)
and the obtained difference is essential as far as
statistics is concerned (p=0.012).
Research carried out by E. Mess & Co. indicates
that almost all children treated due to ALL have friends
and that 60 percent of respondents arrange meetings
with them [9]. The above conforms to the results of
own research, according to which maintaining good
relationships with peers and no antipathy were the
highest rated elements of social functioning in direct
evaluation.
Social rejection of children who have completed
oncological treatment is more than once caused by
their fixed demanding attitude which manifests itself in
expecting privileged treatment and/or other persons
‘going easy on them’ [10]. During oncological
treatment such attitudes of children towards persons
surrounding them can be observed quite often and they
are accepted to some extent. Nevertheless, the same
attitudes are an obstacle in interpersonal contacts once
treatment is completed and they raise social objections.
When taking care of a child it is important not to
strengthen its demanding attitude. Once treatment is
completed a child should not want to remain in the role
of a patient.
Parents of children who have completed ALL
treatment evaluate their children’s functioning lower
than the children themselves (81.33 vs. 85.68).
According to parents, it is children aged 2-4 who have
the biggest problems with maintaining good
interpersonal relationships with peers (50.00), which is
undoubtedly a result of some sort of social isolation of
these children. None of the evaluated children in the
said age group went to day care or participated in
kindergarten classes. They were taken care of by their
mothers who were on maternity leave. Furthermore,
the parents were of the opinion that the least problems
connected with maintaining good relationships with
peers were experienced by teens aged 13-18 (85.58).
Normal child’s development requires contact with
peers. At school/kindergarten a child learns how to
coexist with other children, understand social
situations, cooperate and conform to set out rules. All
Social functioning of children who have completed acute lymphoblastic leukemia treatment
these skills are indispensable for functioning within a
society [11, 12, 13, 14].
Children who have completed ALL treatment are
often directed to individual teaching which, on the one
hand, protects a child, but, on the other hand, deprives
it from an opportunity to acquire the above mentioned
skills. While individual work with a teacher offers a
chance of developing interests of a particular child and
leads to better grades and results, it can become the
cause of problems with social functioning.
Involving a child in normal school obligations is an
essential element of psychotherapy. It provides a child
with a feeling of being equal to healthy peers and lets it
forget about the past differences [15]. In another article
Zdebska S. highlights the significant role of a form
master of the class a child attends to. It is important
that a teacher encourages and involves a child in active
class cooperation so that the child feels like a rightful
member of the peer group [14].
Problems with making interpersonal contacts and
functioning within social norms are an indication for
returning to school as soon as ALL treatment is
completed [16]. The SIOP Psychological Committee
advises providing continuity of studying and
integration at school. This should be done by securing
operations of a hospital school and fluent incorporation
of a child in classes at its original school once
treatment is finished [17, 18, 19].
According to own research, children who have
experienced oncological treatment evaluate their
functioning at school lower than healthy children
(69.57 vs. 81.27). Considerable differences between
their evaluations concern difficulties with in-class
concentration (71.98 vs. 84.13), studying at school and
at home (69.40 vs. 88.89), problems connected with
being absent from classes due to not feeling well
(75.86 vs. 84.13) and due to appointments at doctors’
(61.21 vs. 76.59). Whereas the majority of problems
with concentration are experienced by teens aged 1318, most problems with studying at school and at home
concern children aged 5-7 (50.00) while
most
problems with being absent from classes due to
appointments at doctors’ refer to children aged 8-12
(60.71).
Regardless of difficulties faced by children after
completion of ALL treatment, one should remember
that by participating in school activities a child
becomes independent, searches for its own place in the
society and undertakes new tasks and social roles.
Moreover, a child forms its norms and system of
57
values and develops self-evaluation skills which
increase with success and decrease with failures. A
young person aims at finding the meaning of his/her
life [20]. Consequently, resignation from active
participation in school life after completion of
treatment and choosing individual teaching instead
deprives a child of a chance for normal development
and ‘normal’ functioning within a society.
CONCLUSIONS
The quality of life of children and teens who have
completed treatment is significantly lower than among
healthy children.
As far as social functioning is concerned, being
able to keep up with peers and an inability to perform
all activities that children in a similar age can perform
received fewer points.
Worse school functioning results from difficulties
with in-class concentration, problems with keeping up
with studying as well as being absent from classes due
to not feeling well or appointments at doctors’.
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Address for correspondence:
Aneta Zreda-Pikies
ul. Osiedlowa 6/12
85-794 Bydgoszcz
e-mail: [email protected]
Received: 6.12.2011
Accepted for publication: 12.04.2012
Medical and Biological Sciences, 2012, 26/2, 59-63
CASE REPORT / PRACA KAZUISTYCZNA
Adrian Reśliński1, Agnieszka Mikucka2, Jakub Szmytkowski1, Katarzyna Głowacka3, Eugenia Gospodarek2,
Wojciech Szczęsny1, Stanisław Dąbrowiecki1
ASYMPTOMATIC INFECTION OF A SURGICAL MESH IMPLANT – A CASE REPORT
BEZOBJAWOWE ZAKAŻENIE SIATKI CHIRURGICZNEJ – OPIS PRZYPADKU
1
Department of General and Endocrine Surgery, Ludwik Rydygier Collegium Medicum in Bydgoszcz
of the Nicolaus Copernicus University in Torun, Poland
Head: Stanisław Dąbrowiecki D.Sc., assoc. prof.
2
Department of Microbiology, Ludwik Rydygier Collegium Medicum in Bydgoszcz of the Nicolaus Copernicus
University in Torun, Poland
Head: Eugenia Gospodarek D.Sc., assoc. prof.
3
Department of Plant Physiology and Biotechnology, Warmia-Mazury University, Olsztyn, Poland
Head: Ryszard Górecki D.Sc., prof.
Summary
Infection involving a surgical implant is one of the most
serious complications associated with the use of biomaterials
in hernia surgery. Implant infection may manifest clinically in
a number of ways. The authors present a case of asymptomatic
infection of a mesh implant which had been used to repair a
paraumbilical hernia. The infection was diagnosed
accidentally during surgery for recurrence. The presence of a
biofilm on the surface of the old implant was confirmed by a
quantitative method based on 2,3,5-triphenyltetrazolium
chloride (TTC) and by scanning electron microscopy (SEM).
The biofilm served to protect the microorganisms from the
activity of the patient’s immune system, resulting in an
asymptomatic clinical course of the infection. It is the authors’
opinion that all implants which are removed during surgery for
recurrent hernias should be routinely evaluated for the
presence of microorganisms even if no apparent signs of
infection can be observed. The TTC method should be
included in the diagnostic tools in order to limit the percentage
of false negative results.
Streszczenie
Zakażenie obejmujące implantat jest jednym z najpoważniejszych powikłań towarzyszących stosowaniu
biomateriałów w chirurgii przepuklin. Zakażenie implantatu
może mieć różny przebieg kliniczny. W pracy przedstawiono
przypadek bezobjawowego zakażenia siatki chirurgicznej
zastosowanej do zaopatrzenia przepukliny okołopępkowej.
Zakażenie zostało rozpoznane przypadkowo podczas operacji
z powodu nawrotu przepukliny. Badania metodą jakościową
z użyciem chlorku 2,3,5-trójfenylotetrazoliowego (TTC),
metodą ilościową oraz z użyciem skaningowego mikroskopu
elektronowego wykazały obecność biofilmu bakteryjnego na
Key words: hernia, surgical mesh , biofilm, TTC
Słowa kluczowe: przepuklina, siatka chirurgiczna, biofilm, TTC
powierzchni implantatu zastosowanego do pierwotnego
zaopatrzenia przepukliny. Jego obecność na powierzchni
implantatu uchroniła drobnoustroje przez działaniem układu
odpornościowego pacjenta i była odpowiedzialna za bezobjawowy przebieg zakażenia biomateriału. Zdaniem autorów
wszystkie implantaty usuwane podczas operacji z powodu
nawrotu przepukliny należy poddać badaniu mikrobiologicznemu, nawet gdy nie stwierdza się makroskopowych
cech zakażenia. Do badań diagnostycznych powinna zostać
włączona metoda redukcji TTC, co pozwala ograniczyć
liczbę wyników fałszywie ujemnych.
60
Adrian Reśliński et. al.
INTRODUCTION
A serious complication of tension-free mesh
hernioplasty is deep surgical site infection (SSI)
involving the implant (mesh infection) [1]. The
microorganisms colonizing the biomaterial may form a
biofilm on its surface. This structure serves their
protection from the host’s immune system and
antimicrobial agents [2].
Implant infection may present clinically in a
number of ways. Typical symptoms include: local
erythema, edema and increased temperature of the skin
overlying the infected implant, and generalized
symptoms of infection such as fever or shivering. In
some patients with implant infection a cutaneous
fistula and / or intraabdominal abscess [3,4].
Osteomyelitis is a rare presentation [5].
The authors’ experience indicates that implant
infection may follow an asymptomatic course, making
it difficult to diagnose and initiate appropriate
treatment. Moreover, the biofilm present on the surface
of the biomaterial may fragment and detach, giving
raise to secondary infection foci, which poses another
threat for the patient [2].
CASE REPORT
A 39-year-old Caucasian male patient was admitted
to the Department of General and Endocrine Surgery in
May 2009 for an elective repair of a recurrent
paraumbilical hernia.
In June 2008 the patient had undergone a primary
umbilical hernia repair in another center. A
polypropylene mesh implant had been used. The
postoperative course had been uneventful and the
patient had been discharged on the second
postoperative day. A recurrence of the hernia had been
diagnosed in December, 2008.
Upon admission the patient presented in good
overall condition, and no abnormalities aside from the
hernial bulge were observed upon physical
examination. The standard laboratory results were all
normal.
An elective surgery was performed. After resecting
the scar from the previous operation, at the border
between the fascia and subcutaneous tissue the old
polypropylene implant was found in a rolled
configuration, with evidence of an inflammatory
response in the surrounding tissues. No pus was
observed. The implant was completely removed and
referred for microbiological evaluation. The inflamed
tissues were excised with a wide margin. The
adhesions between the greater omentum and the hernial
defect were liberated and the hernia was repaired by
implantation of a new polypropylene mesh into the
retromuscular space.
A biochemical method utilizing the property of
metabolically active microorganisms to reduce
colorless 2,3,5-triphenyltetrazolium chloride (TTC) to
red formazan was used to detect biofilm on the
biomaterial surface [6]. Fragments of the implant (1 x
1 cm) were incubated in 4 ml of tryptic soy broth
(TSB, Becton Dickinson) containing 50 µl of 1% TTC
solution (POCH, Gliwice, Poland). The samples were
then incubated at 37ºC and the appearance of red
formazan was first observed after approximately 70
minutes, with the intensity of the red hue increasing
over time.
A quantitative analysis of the biofilm present on the
removed implants was then performed. The biofilm
was detached from the surface of the biomaterial
samples (1x1cm) by shaking in 0.5% saponin (Fluka,
Steinheim, Germany). Serial 10-fold dilutions of the
suspension thus obtained were performed with
subsequent inoculation on trypticase soy agar (Tryptic
Soy Agar, TSA, Becton Dickinson). After 24 hours of
incubation of the implant fragments at 37ºC, the result
of 4.8 x 107 colony-forming units (CFU’s) per one
milliliter of suspension (CFU/ml) of the biofilm
present on one implant sample was recorded (average
of three measurements).
The results of the qualitative and quantitative
evaluation were confirmed by scanning electron
microscopy. The implant fragments were fixed in a
2.5% glutaraldehyde solution (POCH, Gliwice,
Poland) in a 0.1 M phosphate buffer at a pH of 7.4 for
24-48 hours at 40C. After fixation, the material was
rinsed for 2 x 20 min in phosphate buffer at room
temperature. The samples were then dehydrated in a
graded series of ethanol concentrations: 30, 50, 70, 80,
96%, 10 minutes in each solution, and twice for 30
minutes in 99,8% ethanol (POCH, Gliwice, Poland) at
room temperature. After dehydration, the samples were
transferred to the dryer chamber (Critical Point Dryer CDP 030, Bal-Tec, Balzers, Lichtenstein) filled with
amyl acetate (Sigma-Aldrich, Steinheim, Germany)
and dried at the critical point of CO2. The dried
material was placed on copper tables and sputter –
coated with gold in an atmosphere of argon in an ionic
coater (Fine Coater, JCF-1200, JEOL, Tokyo, Japan).
Asymptomatic infection of a surgical mesh implant - a case report
The sputter – coated material was placed in a SEM
column (JSM-5310LV, JEOL, Tokyo, Japan) and
analyzed at a voltage of 25 kV. The results were
recorded on black – and-white ILFORD FP4 PLUS
125 photographic film (Fig. 1).
Fig. 1. Biofilm on the surface of a polypropylene mesh
implant (polymicrobial biofilm); scanning electron
microscopy (magnification 3500x)
Ryc. 1. Biofilm na powierzchni siatki polipropylenowej
(biofilm
wielogatunkowy);
skaningowa
mikroskopia elektronowa (powiększenie 3500x)
Initial identification of the cultures was based on
colony morphology on Columbia Agar with 5% sheep
blood (Becton Dickinson) and selective differential
media; specific tests were also performed, including:
ID32 Staph (bioMérieux S.A. RCS Lyon, France) test
for staphylococci and Rapid ID32 Strep (bioMérieux
S.A. RCS Lyon, France) ID32 E (bioMérieux S.A.
RCS Lyon, France) for streptococci. Based on the
above, the etiological factors of implant infection were
identified as: Staphylococcus warneri, Staphylococcus
epidermidis and Streptococcus oralis.
Drug susceptibility was tested in accordance with
the guidelines of the National Reference Center for
Microbial Drug Sensitivity [7], and the results were
interpreted according to the Clinical Laboratory
Standards Institute (CLSI) guidelines [8].
The postoperative course was uneventful. The
patient was discharged on the 5th postoperative day
and the treatment was continued in outpatient care.
During follow – up visits which took place 1, 6, 12 and
22 months after surgery neither signs of SSI nor hernia
recurrence were observed (Fig. 2).
Due to a suspicion of immune deficiency the
patient was subjected to a series of initial tests, i.e.
serum IgG, IgM and IgA levels, peripheral blood
morphology and smear, C3 and C4 complement
61
component levels, in order to evaluate the functional
components of the immune system. No abnormalities
were found in the humoral, cellular response,
phagocytic cell or component systems
Fig. 2. Status after 22 months upon discharge from hospital
Ryc. 2. Stan po 22 miesiącach od wypisu
DISCUSSION
This report presents a case of an asymptomatic
infection of a surgical implant in a patient after
paraumbilical mesh hernioplasty. The infection was
diagnosed accidentally during surgery for hernia
recurrence. Qualitative TTC assay, quantitative
evaluation and scanning electron microscopy have all
confirmed the presence of a bacterial biofilm on the
surface of the implant which had been used to repair
the primary hernia. Its presence probably protected the
microorganisms from the host’s immune system, as
any immune deficiencies which could have hindered
the elimination of bacteria colonizing the mesh implant
had been ruled out.
In the case presented here, implant infection was
diagnosed one year after the initial operation. We
cannot rule out the possibility that the asymptomatic
course of the disease was due to the presence of a
biofilm on its surface. Biofilm is probably responsible
for the late clinical manifestation of many biomaterials
used in hernia surgery – there have been reports on
mesh infections manifesting as late as 4.5 [3] or even 8
years after surgery [9].
Intraoperatively, the primary implant was found in
a rolled configuration. The appearance of the mesh was
due to biomaterial shrinkage. The pathophysiology of
62
this phenomenon has not yet been fully explained. It is
assumed to have resulted from an inflammatory
reaction an implant evokes, as well as abnormal
integration of the implant into the host’s tissues [10].
According to Mamy et al. [11] bacterial colonization of
the surface of the mesh is an independent risk factor
for its shrinkage. The shrinking of the implant in our
patient could have been due to the formation of a
biofilm on its surface. This biofilm may have interfered
with the ingrowth of the host’s tissues through the
implant. Bacteria growing as a biofilm decrease
adhesion of the connective tissue cells to the surface of
the biomaterial [12]. Moreover, microorganisms have
the ability to inhibit fibroblast proliferation [13] and
induce the death of these cells [14]. It is the opinion of
the authors that the poor integration of the biomaterial
and its deformation were responsible for the recurrence
of the hernia.
In spite of the contamination of the surgical field,
the recurrent hernia was repaired using a monofilament
polypropylene mesh. This approach has been
documented to be safe even in patients receiving
immunosuppressive therapy [15]. An alternative
technique for hernia repair in an infected field may be
using a biological implant [16]. In the case presented
here, biomaterial implantation was preceded by a
thorough debridement of the wound, which resulted
from the fact that bacteria are able to colonize the
tissues adjacent to a synthetic implant, thus gaining an
environment in which they can thrive despite
antimicrobial therapy [17, 18].
Another significant clinical problem arises from
false negative microbiology findings. According to
Delikoukos et al. [3], microbiological evaluation of a
removed implant may yield a negative result despite
the presence of the typical signs of SSI. In our opinion,
every implant which is removed during surgery for
recurrent hernia must be evaluated for biofilm presence
with the use of the TTC method, even if no apparent
signs of infection are present. The sensitivity of the
TTC reduction method may surpass that of the
traditional culture – based methods, allowing for the
detection of bacteria on the surface of an implant even
if their number is below the detection threshold of the
culture method [20]. This could decrease the number of
false negative results which delay the introduction of
appropriate treatment of surgical site infections.
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Address for correspondence:
Adrian Reslinski MD
Department of General and Endocrine Surgery
Nicolaus Copernicus University of Torun
Collegium Medicum in Bydgoszcz
M. Skłodowskiej-Curie 9 Str.
85-094 Bydgoszcz, Poland
tel. 00 48 52 585-47-30, fax. 00 48 52 585-40-16
email: [email protected]
Received: 7.02.2012
Accepted for publication: 12.04.2012
63
Medical and Biological Sciences, 2012, 26/2
Selected articles presented during
the 2nd International Conference
„Europejski Wymiar Nauk o Zdrowiu”
organized on the occasion of the XVth Anniversary
of Faculty of Health Sciences
at Collegium Medicum, Nicolaus Copernicus University
BYDGOSZCZ, March 19-20, 2012
GUEST EDITOR: PROFESSOR ZBIGNIEW BARTUZI
Medical and Biological Sciences, 2012, 26/2
Medical and Biological Sciences, 2012, 26/2
CONTENTS
p.
Anna Bitner, Paweł Zalewski, Jacek J. Klawe, Krzysztof Goryński,
M o n i k a Z a w a d k a , J o a n n a P a w l a k – Heat exposure effects and kinds of illnesses
among firefighters – review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
69
Anetta Cubała, Tomasz Jurkiewicz, Maciej Dzierżanowski, Jarosław
H o f f m a n , D o r o t a R a t u s z e k – Functional evaluation of the lumbosacral spine among
athletes practising grappling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
73
Grażyna Gebuza, Marzena Kaźmierczak, Małgorzata Gierszewska, Estera
M i e c z k o w s k a , M a ł g o r z a t a B a n n a c h , R o m a n K o t z b a c h – Standard of maternal
postpartum haemorrhage care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
79
Izabela Glaza, Katarzyna Pietkun, Rafał Szadujkis-Szadurski, Krystyna
Nowacka, Magdalena Hagner-Derengowska, Maciej Nowacki
– Probiotics in food. Important preventive factor in children allergy, or a controversial add-on?
Review of the literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
85
Andrzej Kuźmiński, Michał Przybyszewski, Małgorzata Graczyk,
M a g d a l e n a Ż b i k o w s k a - G o t z , E w a S o c h a , Z b i g n i e w B a r t u z i – Composition
of inflammatory infiltrate in the gastric mucosa of patients with food and airborne allergies . . . . . . . . .
89
I w o n a Ł o p a c i ń s k a , M a ł g o r z a t a W o j c i e c h o w s k a – Nurses vs ISO in hospital . . . . . . . . .
95
Katarzyna Napiórkowska, Krzysztof Pałgan, Ewa Gawrońska-Ukleja,
Magdalena Żbikowska-Gotz, Joanna Kołodziejczyk, Milena
Wojciechowska, Małgorzata Graczyk, Ewa Szynkiewicz, Robert
Z a c n i e w s k i , Z b i g n i e w B a r t u z i – The role of skin prick test in diagnosis of food allergy
in patients with birch pollinosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
101
K a t a r z y n a O b ł o z a , A l e k s a n d r a C z e r w , U r s z u l a R e l i g i o n i – The role of media
in creating the health care units’ image in Poland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
105
Joanna Pawlak, Paweł Zalewski, Jacek J. Klawe, Monika Zawadka,
A n n a B i t n e r , M a ł g o r z a t a T a f i l - K l a w e – Core body temperature changes after sauna
exposition in healthy subjects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
111
D o r o t a S i w c z y ń s k a , M a g d a l e n a M i ń k o – The functioning of health systems in Poland
and the Netherlands in patients’ opinions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
115
B ł a ż e j S t a n k i e w i c z , M i r o s ł a w a C i e ś l i c k a – Detailed analysis of a 240-second cycle
ergometric test in midlle-distance runners aged 16-19 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
121
E w a J o a n n a S z y m e l f e j n i k , A n n a C h i b a – The interdependence of nutritional status
and blood pressure in female students . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
129
Magdalena Żbikowska-Gotz, Krzysztof Pałgan, Ewa Socha, Michał
P r z y b y s z e w s k i , A n d r z e j K u ź m i ń s k i , Z b i g n i e w B a r t u z i – Metabolic activity
of neutrophilic granulocytes measured with chemiluminescence test (CL) in patients with allergic
hypersensitivity to food . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
135
Medical and Biological Sciences, 2012, 26/2
SPIS TREŚCI
str.
Anna Bitner, Paweł Zalewski, Jacek J. Klawe, Krzysztof Goryński,
M o n i k a Z a w a d k a , J o a n n a P a w l a k – Skutki ekspozycji na ciepło i rodzaje chorób
wśród strażaków – przegląd literatury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
69
Anetta Cubała, Tomasz Jurkiewicz, Maciej Dzierżanowski, Jarosław
H o f f m a n , D o r o t a R a t u s z e k – Ocena funkcjonalna kręgosłupa lędźwiowo-krzyżowego
u zawodników trenujących grappling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
73
Grażyna Gebuza, Marzena Kaźmierczak, Małgorzata Gierszewska, Estera
M i e c z k o w s k a , M a ł g o r z a t a B a n n a c h , R o m a n K o t z b a c h – Standard opieki
nad położnicą z krwotokiem poporodowym . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
79
Izabela Glaza, Katarzyna Pietkun, Rafał Szadujkis-Szadurski, Krystyna
Nowacka, Magdalena Hagner-Derengowska, Maciej Nowacki
– Probiotyki w żywności. Istotny czynnik prewencyjny w alergologii dziecięcej czy kontrowersyjny
dodatek? Przegląd piśmiennictwa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
85
Andrzej Kuźmiński, Michał Przybyszewski, Małgorzata Graczyk,
M a g d a l e n a Ż b i k o w s k a - G o t z , E w a S o c h a , Z b i g n i e w B a r t u z i – Skład nacieku
zapalnego błony śluzowej żołądka u chorych z alergią pokarmową i powietrznopochodną . . . . . . . . . . .
89
I w o n a Ł o p a c i ń s k a , M a ł g o r z a t a W o j c i e c h o w s k a – Pielęgniarki wobec ISO w szpitalu . .
95
Katarzyna Napiórkowska, Krzysztof Pałgan, Ewa Gawrońska-Ukleja,
Magdalena Żbikowska-Gotz, Joanna Kołodziejczyk, Milena
Wojciechowska, Małgorzata Graczyk, Ewa Szynkiewicz, Robert
Z a c n i e w s k i , Z b i g n i e w B a r t u z i – Rola testów skórnych w diagnostyce alergii
pokarmowej u pacjentów uczulonych na pyłki brzozy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
101
K a t a r z y n a O b ł o z a , A l e k s a n d r a C z e r w , U r s z u l a R e l i g i o n i – Rola mediów
w kreowaniu postrzegania wizerunku placówek ochrony zdrowia w Polsce . . . . . . . . . . . . . . . . . . . . . . .
105
Joanna Pawlak, Paweł Zalewski, Jacek J. Klawe, Monika Zawadka,
A n n a B i t n e r , M a ł g o r z a t a T a f i l - K l a w e – Zmiany temperatury głębokiej ciała
po zabiegu sauny suchej u osób zdrowych . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
111
D o r o t a S i w c z y ń s k a , M a g d a l e n a M i ń k o – Funkcjonowanie systemów opieki zdrowotnej
w Polsce i Holandii w opinii pacjentów . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
115
B ł a ż e j S t a n k i e w i c z , M i r o s ł a w a C i e ś l i c k a – Szczegółowa analiza 240-sekundowej próby
cykloergometrycznej przeprowadzonej wśród biegaczy na średnich dystansach w wieku 16-19 lat . . . .
121
E w a J o a n n a S z y m e l f e j n i k , A n n a C h i b a – Współzależność między stanem odżywienia
a ciśnieniem tętniczym u studentek . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
129
Magdalena Żbikowska-Gotz, Krzysztof Pałgan, Ewa Socha, Michał
P r z y b y s z e w s k i , A n d r z e j K u ź m i ń s k i , Z b i g n i e w B a r t u z i – Aktywność
metaboliczna granulocytów obojętnochłonnych mierzona testem chemiluminescencji u pacjentów
z nadwrażliwością alergiczną na pokarmy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
135
Medical and Biological Sciences, 2012, 26/2, 69-72
Anna Bitner1, Paweł Zalewski1, Jacek J. Klawe1, Krzysztof Goryński2, Monika Zawadka1, Joanna Pawlak1
HEAT EXPOSURE EFFECTS AND KINDS OF ILLNESSES
AMONG FIREFIGHTERS – REVIEW
SKUTKI EKSPOZYCJI NA CIEPŁO I RODZAJE CHORÓB
WŚRÓD STRAŻAKÓW – PRZEGLĄD LITERATURY
1
Chair and Department of Hygiene and Epidemiology, Collegium Medicum in Bydgoszcz
Nicolaus Copernicus University in Toruń
Head: dr hab. n. med. Jacek J. Klawe, prof. UMK
2
Department of Biopharmacy, Collegium Medicum in Bydgoszcz
Nicolaus Copernicus University in Toruń
Head: prof. dr hab. Adam Buciński
Summary
Based on the review of literature which has been
published within the last 20 years it was stated that
occupational hazard connected with work at the fire service is
significant. Character of the work of firefighters is connected
with exposure to the serious injury during the firefighting and
with thermal stress which can cause dehydration and heat
stroke. Moreover, scientists noticed that firefighters are
exposed to stress situations which can take lead to serious
psychological disorders.
Exhibition to high temperatures and substances such as
carbon monoxide, benzene, asbestos, vinyl chloride or other
substances produced in the course of the fire can probably
cause a number of illnesses such as bronchial asthma,
bronchial hyperactivity, arterial hypertension, coronary heart
disease or other cardiovascular and respiratory diseases in
older age. It is not fully explained whether above factors affect
cancer incidence in firefighters.
Streszczenie
Na podstawie przeglądu piśmiennictwa, które pojawiło
się w okresie ostatnich dwudziestu lat stwierdzono, że ryzyko
zawodowe związane z praca w straży pożarnej jest znaczące.
Charakter pracy strażaków związany jest z narażaniem na
poważne obrażenia ciała w czasie gaszenia pożarów oraz
stresem cieplnym, który może być przyczyną odwodnienia
oraz udaru cieplnego. Ponadto zauważono, że strażacy
narażeni są na sytuacje stresowe, które mogą doprowadzić do
poważnych zaburzeń psychologicznych. Ekspozycja na
wysokie temperatury oraz związki chemiczne jak tlenek
węgla, benzyna, azbest, chlorek winylu czy inne substancje
powstałe w trakcie pożaru prawdopodobnie mogą być
przyczyną wystąpienia u strażaków w późniejszym okresie
wielu chorób jak: astma oskrzelowa, nadwrażliwość oskrzeli,
nadciśnienie tętnicze, choroba niedokrwienna serca czy inne
choroby układu sercowo-naczyniowego i oddechowego. Nie
jest do końca wyjaśnione czy wyżej wymienione czynniki
mają wpływ na występowanie u strażaków nowotworów.
Key words: firefighters, stress, cardiovascular diseases, cancers, respiratory diseases
Słowa kluczowe: strażacy, stres, choroby układu sercowo-naczyniowego, nowotwory, choroby układu oddechowego
1. INTRODUCTION
Firefighting is a very dangerous career. Every year
fires destroy a lot of buildings and take many lives
away. Unfortunately, firefighters extinguishing the
fires are exposed to high temperatures, flames burning
and carcinogens substances such as: benzene, dioxins,
asbestos, chlorophenols or vinyl chloride, which could
70
Heat exposure effects and kinds of illnesses among firefighters - review
be a trigger for some cancers. Moreover, most
firefighters experience a lot of stress in their work
settings.
Firefighters are required to work in temperatures
well over the normal body core temperature (from
36.50 to 37.50 C). Persons exposed to an extreme
environmental heat are often diagnosed with
cardiovascular and pulmonary diseases. High heat
conditions combined with stressful situations at work
can lead to rapid body core temperature increases,
which can be very dangerous to the human organism.
2. OBJECTIVE
The aim of this work was to analyze scientific
papers which describe heat exposure effects and types
of illnesses among firefighters.
3. MATERIALS AND METHODS
A Medline search was performed to identify studies
problems of kinds of illnesses among firefighters and
heat exposure effects in their work. Searched terms
included words such as: heat stress, respiratory
symptoms, cancer incidence, cardiovascular disease
and chronic stress among firefighting.
4. RESULTS
The study describes the research articles describing
frequent illnesses and other hazards among firefighters.
Occupational hazards may be categorized as chemical,
psychological and physical. There are many chemical
and physical dangers in firefighting (for example
thermal stress), but physiological and biochemical
indicators of stress have shown that firefighters are
also exposed on stress situation all the time in their
work.
4.1. Chronic stress among firefighters
Stress is a term describing condition of our
organism under the influence of a stressor. We
experience stress every day, but it could have a
negative impact on the human organism. The problem
of the chronic stress among firefighters is presented on
the basis of a literature review. Firefighters are exposed
on stress situation all the time. On the basis of the
studies, scientists stated that traumatic incidents during
working hours of firefighters may be a cause of
depression, lack of sleep, loss of appetite. Moreover,
this situation may be a consequence of heart
conditions, diabetes, disabilities and other diseases.
The fact that firefighters may experience physical and
emotional problems after return home is discussed in
available literature. Also, lack of regular meals,
interrupted sleep and absences from home worsen this
situation [1, 2].
Reasons responsible of chronic stress can be
different among firefighters. We distinguish:
individualistic factors like negative feelings or
traumatic events, organizational factors like low pay or
a sense of high responsibility, and demographic factors
(job seniority) [1].
4.2. Respiratory symptoms among firefighters
The literature reviews included also studies, in
which firefighters reported respiratory symptoms (itchy
throat, cough, running nose, dyspnoea, bronchial
asthma) more often than general population.
Firefighters are exposed on various chemical
substances like carbon monoxide, nitrogen dioxide,
hydrogen cyanide, hydrogen chloride, aldehydes and
sulfur dioxide during their working hours. A number of
studies describe pulmonary diseases associated with
inhalation of toxic constituents of smoke products and
very hot air. The chronic effects of this situation can
cause lung cancer and chronic obstructive pulmonary
disease [3, 4, 5].
To sum up, firefighters experience more respiratory
symptoms at work compared with control group and
they suffer from more bronchial hyperactivity and
atopy more often than other people [3].
4.3. Cancer incidence among firefighters
The retrospective cohort studies demonstrated
strong relationship between firefighters and cancer.
Epidemiologic studies suggested that multiple
myeloma, leukemia, brain and bladder cancer appear
more often. Another evidence association with
firefighters is prostate, colon, rectal and stomach
cancer [6,7,8,9].
Firefighters are exposed to various carcinogenic
substances which can be associated with a specific type
of cancer. Other recent studies show that geographic
differences in building materials might affect the type
of cancer, because various substances are transmitted
into the environment during the fire. Scientists stated
Anna Bitner et. al.
that the protective equipment, firefighters use at work
does not
protect them enough from chemical
substances come across [6,7,8,9].
4.4. Cardiovascular disease among firefighters
Cardiovascular disorders may be a very serious
problem among firefighters. The first reason why
firefighters are prone to cardiovascular disease is a
stress situation in their work settings, irregular physical
exertion and heat during extinguishing the fire
[10,11,12,13]. The second reason is exposure to
chemical substances like carbon monoxide, hydrogen
sulfide and hydrogen cyanide. It causes dangerous
situation related to fatal coronary heart events such as:
sudden death, fatal arrhythmia or myocardial
infarction, resulting from the influence of the gases
[14,15,16,17,18].
Scientists conducted the examination including all
cases of heart attacks and other coronary syndromes
among firefighters. They discovered that the risk of
death due to heart disease at firefighters was over 100
times higher compared with general population
[19,20,21,22,23]. It clearly shows that the work in the
fire service can carry the crucial inducer the coronary
disease [24,25,26,27].
4.5. Thermal stress
Heat stress may result in local or generalized heat
stress, with the risk of dehydration, heat stroke and
cardiovascular diseases. Heat stress is compounded in
firefighting by physical exertion and by insulating
properties of the protective clothing.
5. SUMMARY
The literature review shows that the acute hazards
of firefighting include: thermal injury, smoke
inhalation and trauma. The type of the work
firefighters have brings an elevated risk of diseases
such as: ischemic heart disease, hypertension,
bronchial hyperactivity and psychological problems
more often than among other people of different
professions.
6. REFERENCES
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With Stress. J. Soc. Change 2009; 3: 38-56.
71
2. Baker S, Williams K.: Short Communications: Relation
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3. Miedinger D., Chhajed P.N., Stolz D. et al.: Respiratory
symptoms, atopy and bronchial hyperreactivity in
professional firefighters. Eur. Respir. J. 2007; 30: 538–
544.
4. Prezant D.J., Weiden M., Banauch G.I. et al.: Cough and
Bronchial Responsiveness in Firefighters at The World
Trade Center Site. N. Engl. J. Med. 2002; 347: 806-815.
5. Rosenstock L., Demers P., Heyer N.J. et al.: Respiratory
mortality among firefighters. Br. J. Ind. Med. 1990; 47:
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6. Guidotti T.L., Clough V.M.: Occupational health
concerns of firefighting. Annu. Rev. Publ. Health. 1992;
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Florida professional firefighters, 1981 to 1999. J. Occup.
Environ. Med. 2006; 48(9): 883-888.
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mortality in US firefighters: 1984-1993. J. Occup.
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pressure in firefighters, police officers, and other
emergency responders. Am. J. Hypertens. 2009; 22(1):
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12. Baxter C.S., Ross C.S., Fabian T et al.: Ultrafine particle
exposure during fire suppression - is it an important
contributory factor for coronary heart disease in
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13. Kales S.N., Soteriades E.S., Christoph C.A. et al.:
Emergency Duties and Deaths from Heart Disease among
Firefighters in the United States. N. Engl. J. Med. 2007;
356: 1207-1215.
14. Hansen E. A cohort study on the mortality of firefighters.
British Journal of Industrial Medicine 1990; (47): 805809.
15. Soteriades E.S., Smith D.L., Tsismenakis A.J. et al.:
Cardiovascular disease in US firefighters: a systematic
review. Cardiol. Rev. 2011; 4: 202-215.
16. Soteriades E.S., Hauser R., Kawachi I. et al.: Obesity
and cardiovascular disease risk factors in firefighters: a
prospective cohort study. Obes. Res.: 2005; 13(10):
1756-1763.
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Cardiovascular risk factors among career firefighters.
AAOHN J. 2009; 57(10): 415-422.
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body weight on arterial structure, function, and blood
pressure in firefighters. Am. J. Cardiol. 2009; 104(10):
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72
Heat exposure effects and kinds of illnesses among firefighters - review
19. Soteriades E.S., Kales S.N., Liarokapis D. et al.:
Prospective surveillance of hypertension in firefighters..
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disease risk factors in volunteer firefighters. J. Occup.
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and nutritional indices as cardiovascular risk factors
among Iranian firefighters. Ann. Clin. Biochem. 2009;
46(Pt 5): 385-389.
22. Fahs C.A., Smith D.L., Horn G.P. et al.: Impact of
excess body weight on arterial structure, function, and
blood pressure in firefighters. Am. J. Cardiol. 2009;
104(10): 1441-1445.
23. Kales S.N., Soteriades E.S., Christoudias S.G. et al.:
Firefighters' blood pressure and employment status on
hazardous materials teams in Massachusetts: a
prospective study. J. Occup. Environ. Med. 2002; 44(7):
669-676.
24. Mbanu I., Wellenius G.A., Mittleman M.A. et al.:
Seasonality and coronary heart disease deaths in United
States firefighters. Chronobiol. Int. 2007; 24(4): 715-726.
25. de Mattos C.E., de Mattos M.A., Toledo D.G. et al.:
Using ambulatory blood pressure monitoring to assess
blood pressure of firefighters with parental history of
hypertension. Arq. Bras. Cardiol. 2006; 87(6): 741-746
26. Byczek L., Walton S.M., Conrad K.M. et al.:
Cardiovascular risks in firefighters: implications for
occupational health nurse practice. AAOHN J. 2004;
52(2): 66-76.
27. Kales S.N., Soteriades E.S., Christoudias S.G. et al.:
Firefighters and on-duty deaths from coronary heart
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2(1): 14.
Address for correspondence:
Chair and Department of Hygiene and Epidemiology
ul. M. Curie Skłodowskiej 9
85-094 Bydgoszcz
tel. 52 585-36-15, 52 585-36-16, 52 585-36-17
e-mail: [email protected], [email protected]
Received: 10.01.2012
Accepted for publication: 6.03.2012
Medical and Biological Sciences, 2012, 26/2, 73-77
Anetta Cubała1, Tomasz Jurkiewicz2, Maciej Dzierżanowski2, Jarosław Hoffman3,4, Dorota Ratuszek4
FUNCTIONAL EVALUATION OF THE LUMBOSACRAL SPINE
AMONG ATHLETES PRACTISING GRAPPLING
OCENA FUNKCJONALNA KRĘGOSŁUPA LĘDŹWIOWO-KRZYŻOWEGO
U ZAWODNIKÓW TRENUJĄCYCH GRAPPLING
Chair and Department of Manual Therapy Nicolaus Copernicus University Collegium Medicum in Bydgoszcz
Head: dr Maciej Dzierżanowski
1
Department of Neurosurgery and Neurotraumatology, Nicolaus Copernicus University,
Collegium Medicum in Bydgoszcz, Poland
2
Department of Manual Therapy Nicolaus Copernicus University Collegium Medicum in Bydgoszcz,Poland
3
Gdansk Management College, Poland
4
Department of Rehabilitation, Nicolaus Copernicus University, Collegium Medicum in Bydgoszcz, Poland
Summary
I n t r o d u c t i o n . The lumbosacral spine pain
syndromes have become a global problem which transcends
the strictly medical sphere. Increased physical activity
predisposes in particular the lumbar to overexploitation and
exposure to heavy loads and pressures in various planes. In a
classic case, a competitor’s injury occurs in the summation of
microtraumas and the accelerated wear of tissues, which
leads to serious consequences, is the highest price for the
intensive improvement of the athlete’s movements.
A i m o f t h e s t u d y . The aim of the thesis is to
investigate the frequency and intensity of pain of the LS
spine among people who practice grappling at various levels.
On the basis of the survey, we answer the question whether
the intense, specific activity of the athlete has an influence on
the occurrence of pain and the motion range of the
lumbosacral spine.
M a t e r i a l a n d m e t h o d o l o g y . The study
involved the total of 20 subjects, including 10 selected
national team competitors in grappling and 10 amateur
grapplers from the Association of Brazilian Jiu-Jitsu "Gracie
Barra" Toruń. The entire study consisted of: questionnaires,
measurements of mobility of the LS spine and exercises done
by athletes according to the FMS method.
R e s u l t s . 75% of all respondents felt pain in the LS
spine (N = 8 amateurs, N = 7 members of national team). The
intensity of symptoms was similar in both groups, but
frequency was significantly higher in the amateurs. No
correlation between the occurrence of pain and limited range
of the LS spine motion was found. No functional
abnormalities within that segment were found.
C o n c l u s i o n s . 1. Despite the greater intensity and
frequency of training, members of the national grappling
team feel the pain in the LS spine less often than amateurs. A
complementary training played a significant role in reducing
the symptoms. 2. The occurrence of a lower spine pain of the
respondents does not have any effect on the limitation of
motion range in the LS spine. This risk increases with age
and the training duration. 3. The grappling trainings
predispose to occurrence of pain complaints among athletes.
Streszczenie
W s t ę p . Zespoły bólowe odcinka lędźwiowokrzyżowego kręgosłupa stały się problemem globalnym
wykraczającym poza sferę stricte medyczną. Zwiększony
wysiłek fizyczny szczególnie usposabia odcinek lędźwiowy
na nadmierną eksploatację oraz ekspozycję na duże
obciążenia i naciski w różnych płaszczyznach.
W klasycznym przypadku kontuzja zawodnika następuje
w wyniku sumowania się mikrourazów, a przyśpieszone
zużycie tkanek, prowadzące do poważnych konsekwencji,
jest największą ceną za intensywne doskonalenie ruchów
sportowca.
74
Anetta Cubała et. al.
Celem
p r a c y było zbadanie częstotliwości
i intensywności występowania dolegliwości bólowych
w odcinku L-S kręgosłupa u osób trenujących grappling na
różnych poziomach zaawansowania. Na podstawie
przeprowadzonych badań odpowiem na pytanie, czy
intensywna, specyficzna aktywność sportowca ma wpływ na
występowanie dolegliwości bólowych i zakres ruchomości
odcinka L-S kręgosłupa.
M a t e r i a ł i m e t o d y k a b a d a ń . W badaniu
wzięło udział łącznie 20 osób, w tym: 10 wybranych
zawodników kadry narodowej w grapplingu oraz 10 osób
amatorsko trenujących grappling ze Stowarzyszenia
Brazylijskiego Jiu Jitsu „Gracie Barra” Toruń. Na cały
proces badawczy złożyły się: ankiety, pomiary ruchomości
kręgosłupów w odcinku L-S oraz wykonane przez
zawodników ćwiczenia wg metody FMS.
W y n i k i . 75% wszystkich badanych posiadało
dolegliwości bólowe odcinka L-S kręgosłupa (amatorzy N=8,
członkowie kadry N=7). Intensywność dolegliwości była
podobna w obu grupach badawczych, a częstotliwość
znacznie większa u amatorów. Nie stwierdzono związku
między występowaniem dolegliwości bólowych a ograniczeniem zakresu ruchomości kręgosłupa w odcinku L-S.
Nie stwierdzono również nieprawidłowości funkcjonalnych
w obrębie interesującego odcinka kręgosłupa.
W n i o s k i . 1. Członkowie kadry narodowej grapplingu
pomimo większej intensywności i częstotliwości treningowej
odczuwają dolegliwości bólowe kręgosłupa w odcinku L-S
rzadziej niż amatorzy. Duże znaczenie w zmniejszeniu
dolegliwości odegrały treningi uzupełniające. 2. Występowanie dolegliwości bólowych kręgosłupa u badanych nie
wpływa na ograniczenie zakresu ruchomości w odcinku L-S
kręgosłupa. Ryzyko to rośnie wraz z wiekiem i stażem
treningowym. 3. Treningi grapplingu predysponują do
wystąpienia dolegliwości bólowych u ćwiczących.
Key words: grappling
Słowa kluczowe: grappling
INTRODUCTION
Lumbosacral spine, in sport, is subjected to
extensive stresses and loads acting on all planes. Sports
injuries, along with overload syndromes result from
practicing sport of every kind and are a frequent
consequence of intense physical exercise. According to
the data, the problem of spinal overload encompasses
5-10% of all sports injuries. As a rule, they are serious
and lead to the occurrence of spinal pain syndromes.
The mechanism of their formation is the same as for
osteoarthritis of the spine, with the difference that
natural degenerative processes are significantly
accelerated by extreme loads. In both general
comprehensive and specialized targeted training,
intensive spine exploitation is inevitable. Therefore,
highly qualified coaching team and constant
supervision of a doctor or physiotherapist would be
necessary, which, unfortunately, is often missing in
sports clubs. [1,] These factors, i.e. the lack of
knowledge of coaches in the field of biomechanics and
anatomy and constant medical care are also indicated
as causes of spinal pain complaints. [2, 3, 4, 5, 6, 7]
Grappling is defined as a group of sports and martial
arts based on maneuvers. Hitting is not allowed, and
the allowed techniques include throws, takedowns,
joint locks and chokes. The most popular martial arts
included in grappling are Brazilian Jiu Jitsu, wrestling,
judo and sambo. Grappling is also a fighting formula
created several years ago, in which Polish players gain
excellent results worldwide. In 2009, the Polish
Wrestling Federation appointed grappling national
team which has won several World and European
Team Champion titles.
MATERIALS AND METHODS
The study involved 20 men who practiced
grappling at various levels and who were assigned to
one of two research groups. The first group consisted
of individuals competing at the highest sports level,
and who were part of the Polish national grappling
senior team (N=10), treating the sport as a priority in
their life. The second group included people who
practiced amateur grappling (N=10), for whom it was a
hobby and a form of recreation. The table below shows
the characteristics of both groups.
Table I. Research groups characteristics
Tabela I. Charakterystyka badanej grupy
The national team
(Kadra narodowa)
Standard
Average
deviation
(Średnia) (Odchylenie
standardowe)
Age
(years)
(Wiek)
Height
(cm)
(Wzrost)
Weight
(kg)
(Waga)
Length
of
training
(years)
(Lata
treningu)
Amateurs
(Amatorzy)
Standard
Average
deviation
(Średnia)
(Odchylenie
standardowe)
26.8
5.73
29.6
5.5
179.4
5.99
180.2
3.77
79.55
10.71
84.2
7.69
8.2
2.62
5.85
3.33
Functional evaluation of the lumbosacral spine among athletes practising grappling
The study of the participants included: filling out
the questionnaire on the frequency and intensity of
pain in an LS spine and complementary training,
Saunders inclinometer measurement of the range of
mobility in an extension motion, maximum and
isolated flexion in the same segment and an analysis of
tests performed with the Functional Movement Screen
method.
FMS is a screening method which, by means of 7
tests, verifies the correctness and efficiency of the
locomotors pattern according to clear criteria. Proper
performance of the motor act according to its pattern
reduces the risk of overload or an injury. This method
can be applied to every person, whether it is a patient
who undergoes treatment, a professional athlete, or a
person who just wants to start an adventure with sport.
Each of the seven tests is scored on a scale of 0 to 3,
which clearly shows the motor deficit. On this basis,
you can successfully plan the treatment or functional
training, predict and provide medical or training
guidance. The FMS includes the following tests: a deep
squat, moving the leg over the hurdle, a lunge squat,
assessing the shoulder girdle mobility, active straight
leg elevation, trunk stability in front support and
rotational stability of the trunk. These tests include the
entire body, but most of them, directly or indirectly,
assess the function of lumbosacral spine. [8, 9]
75
activity for at least 8 weeks. Ranges of motion for all
studied movements spoke in favor of the members of
the team. On average, they amounted to:
- For the motion of the maximum flexion - 86.1°
(SD ± 14.8o for members of the team and 65.6°
(SD ± 5.13° for amateurs,
Fig. 1. Range of maximum flexion motion
Ryc. 1. Zakres ruchu maksymalnego zgięcia
- For an isolated flexion motion (to the first pelvis
movement) - 29.7° (SD ± 9.63°) for the members
of the team and 24.4° (SD ± 8.62°) for amateurs,
THE RESULTS
75% of respondents (Amateurs N=8, National team
N=7) felt the pain. The frequency of symptoms was
higher in amateurs (the most common answer: ‘a few
times a week’, while in the national team members
group: ‘once a month’). The intensity was determined
in the VAS scale as an average of 4.57 (SD ± 0.98) in
the national team members, and 4.12 (SD ± 1.36) in the
amateurs. All team members (N=10) also performed
regular additional exercises focused on lumbosacral
spine in the form of stretching, strengthening with the
use of your own body weight, and weight training with
the use of external weight. In the amateur group
(N=10), 7 of them performed additional exercises with
the
predominant
stretching
activity
(N=5).
Strengthening exercises with your own body weight
were performed by two amateurs, and with external
weight - by 3 people. It is worth mentioning that in 3 of
the respondents (2 amateurs and 1 member of the
national team) a painful incident occurred in the past
which had excluded the competitors from physical
Fig. 2. Range of isolated flexion motion
Ryc. 2. Zakres ruchu wyizolowanego zgięcia
- For the extension movement - 18.8° (SD ±
12.81°) for the members of the team and 12.6°
(SD ± 5.5°) for the amateurs.
Fig. 3. Range of extension
Ryc. 3. Zakres ruchu wyprostu
76
Anetta Cubała et. al.
Average performance obtained by two research
groups are slightly different over three points. The
members of the team achieved an average score of 25.7
points. (SD ± 4 pts.), and the amateurs 22.4 points (SD
± 3.58 pts.) out of possible 36 points. There was a
significant difference in the quality of execution of
individual tests. The vast majority of national team
members performed exercises with a stable position
and a considerable motion control, while the amateurs’
position was often unsteady, and the movements were
sometimes violent and imprecise.
DISCUSSION
The specificity of our spines transfers the greatest
load on the lumbar segments during physical activity.
The modern form of the sport tends to cause spinal
overload and deformity. This means that increased
physical activity predisposes the lumbar section to
over-exploitation and exposure to heavy loads and
pressures on different planes. The most common
causes of spinal pain complaints in those sports
primarily include excessive intensity of training and
organizational-methodological errors, but also posture,
structural defects in locomotor organs and innate
predispositions. [4, 10] Accelerated tissue wear is the
largest price for intensive movements’ improvement of
the athlete. In a classic case, a player is injured as a
result of summation of microtraumas. It should be
noted that as far as the locomotor organ is concerned,
even a single microtrauma does not heal without
leaving trace. Damaged high-quality and specialized
tissue is replaced by a defective one. [3] A large
number of rapid extension, flexion and rotation
movements combined with huge muscle tone and
additional external load in the form of a partner or an
opponent who resists pose a high risk of damage to the
lumbosacral spine. Psychological factors such as the
will to fight, ambition and desire to win of the players
fighting against each other are also a major cause of
sports injury. Pappas defines wrestling (which is a
grappling sport), as one of the most injury-causing
contact sports, where the most common injuries
include stretching and sprains (36.4%), particularly in
the upper limbs (44.3%). [11]
The study shows that the members of the national
team do a lot of exercises that supplement the
grappling training such as stretching, strengthening and
aggressive weight training of the lower spine, while the
amateurs performed only stretching exercises,
sometimes strengthening ones in the form of a warmup before training. It is the key to the results obtained.
Intensity of prevalence of pain complaints in both
groups was similar, but their frequency in the group of
the team members was much lower. The national team
members also gained greater ranges in every
movement. Comparing the results of maximum flexion
which, apart from the mobility of the spine itself, also
comprises the flexibility of ischiotibial muscles and the
mobility of the hip joint with isolated flexion in the LS
section, numerous causes of pain may be discerned.
Namely, for example, Lennard [5] closely relates the
lack of hamstring stretch to the occurrence of
lumbosacral pain. On the basis of exercises performed
by the study participants according to the Functional
Movement Screen test, no functional abnormalities of
the LS spine section were detected. Other observed
abnormalities did not concern the subject of the
research. Average results obtained by two research
groups in the total FMS were as follows: 25.7 points
(SD ± 4 pts.) for the members of the national team and
22.4 points (SD ± 3.58 points) for the amateurs out of
possible 36 points. Results do not differ considerably;
however, they do not reflect the quality of tests
performance, which varied between groups. Cofounder of the method, Gray Cook [12] believes that
‘the most common error in today's sport lies in
improving the locomotor pattern before obtaining a full
range of mobility and stability of this movement’. This
means that the emphasis should be put on the correct
technique of motion, mobility and stability and those
elements should be placed before the strength, stamina,
and specific ability training assigned to a given
discipline.
CONCLUSIONS
1. Despite the greater intensity and frequency of
training, members of the national grappling team
feel the pain in the LS spine less often than
amateurs. A complementary training played a
significant role in reducing the symptoms.
2. The occurrence of a lower spine pain of the
respondents does not have any effect on the
limitation of motion range in the LS spine. This
risk increases with the age and the training
duration.
3. The grappling trainings predispose to occurrence of
pain complaints among athletes.
Functional evaluation of the lumbosacral spine among athletes practising grappling
REFERENCES
1. Garlicki J., Bielecki A., Kuś W. M.: Urazy sportowe u
progu trzeciego tysiąclecia. Medycyna Sportowa, nr 114
Traumatologia sportowa; 2001; 01.
2. Cypress B.: Characteristics of physician visits for back
symptoms: a national perspective. An. J. Public. Health.,
1983; 73: 389-395.
3. Dziak A., Tayara S.: Urazy i uszkodzenia w sporcie,
Wydawnictwo Kasper, Kraków 2000.
4. Dziak A.: Bolesny krzyż. Medicina Sportiva, Kraków
2003.
5. Lennard T., A. Crabtree M. H.: Spine In Sports. Elsevier
2005.
6. Zajączkowski Z.: Medycyna Sportowa w praktyce.
PZWL, Warszawa 1984.
7. Żytkowski A.: Etiopatogeneza bólowych zespołów
kręgosłupa lędźwiowo-krzyżowego. Balneologia Polska,
2001; 1: 81-87.
8. Cook G., Burton L., Hoogenboom B.: Pre-participation
screening: The use of fundamental movements as an
assessment of function – part 1. North American Journal
of Sports Physical Therapy, 2(1): 62-72, 2006.
77
9. Cook G., Burton L., Hoogenboom B.: Pre-participation
screening: The use of fundamental movements as an
assessment of function – part 2. North American Journal
of Sports Physical Therapy, 2(1): 132-139, 2006.
10. Starosta W.: Kształt kręgosłupa z punktu widzenia
motoryki człowieka i motoryki sportowej. Postępy
rehabilitacji, Vol. VII 1993; 4: 19-32.
11. Pappas E.: Boxing, wrestling, and martial arts related
injuries treated in emergency departments in the United
States, 2002-2005. Journal of Sports Science and
Medicine, 6: 58-61, 2007.
12. Cook G.: Baseline sports-fitness testing. In: Foran B, ed.
High-performance sports conditioning. Champaign, IL:
Human Kinetics; 2001:19–55.
Address for correspondence:
mgr Anetta Cubała
Departament of Neurosurgery and Neurotraumatology,
Nicolaus Copernicus University
Collegium Medicum in Bydgoszcz
e-mail: [email protected]
Received: 10.01.2012
Accepted for publication: 6.03.2012
Medical and Biological Sciences, 2012, 26/2, 79-84
Grażyna Gebuza¹, Marzena Kaźmierczak ¹, Małgorzata Gierszewska¹, Estera Mieczkowska ¹, Małgorzata Bannach 2,
Roman Kotzbach³
STANDARD OF MATERNAL POSTPARTUM HAEMORRHAGE CARE
STANDARD OPIEKI NAD POŁOŻNICĄ Z KRWOTOKIEM POPORODOWYM
1
M.Sc. Grażyna Gebuza, The Department of Obstetric Care Basics
Nicolaus Copernicus University, Collegium Medicum in Bydgoszcz
1
M.Sc. Marzena Kaźmierczak, The Department of Obstetric Care Basics
Nicolaus Copernicus University, Collegium Medicum in Bydgoszcz
1
M.Sc. Estera Mieczkowska, The Department of Obstetric Care Basics
Nicolaus Copernicus University, Collegium Medicum in Bydgoszcz
1
M.D. Małgorzata Gierszewska, Head of Department of Obstetric Care Basics
Nicolaus Copernicus University, Collegium Medicum in Bydgoszcz
2
M.Sc. Małgorzata Bannach, Department of the Obstetric Nursing
Nicolaus Copernicus University, Collegium Medicum in Bydgoszcz
3
D.Sc. Roman Kotzbach, Professor. NCU, Head of the Department of Nursing and Midwifery
Nicolaus Copernicus University, Collegium Medicum in Bydgoszcz
Summary
Haemorrhage represents 38.7% of all direct causes of
maternal deaths and remains the most common cause. The
official definition of postpartum haemorrhage by the World
Health Organization (WHO) is the loss of more than 500 ml or
more blood from the reproductive tract within 24 hours after
birth. Blood loss in the first 24 hours after birth is called the
early postpartum haemorrhage, while in the period from 24
hours to 6 weeks after birth - late postpartum haemorrhage.
Due to the dynamism of haemorrhage, actions must be
oriented at protecting women in childbirth from lifethreatening conditions. Haemorrhage is the most common
state of urgency in obstetrics, which is why it is important that
the midwifery team knows and understands the rules of
conduct in this severe complication of labour. Therefore, it is
necessary to create and implement standards to ensure a high
level of maternity care.
Streszczenie
Krwotoki stanowią 38,7% wszystkich bezpośrednich
przyczyn zgonów matek i pozostają ich najczęstszą
przyczyną. Oficjalną definicją krwotoku poporodowego
według Światowej Organizacji Zdrowia (WHO) jest utrata
ponad 500 ml lub więcej krwi z dróg rodnych w ciągu
24 godzin od narodzin dziecka. Utratę krwi w pierwszych
24 godzinach po porodzie nazywamy wczesnym krwotokiem
poporodowym, a w okresie od 24 godzin do 6 tygodni po
porodzie, późnym krwotokiem poporodowym. Ze względu
Key words: postpartum haemorrhage, standard care
Słowa kluczowe: krwotok poporodowy, standard opieki
na dynamiczność krwotoku podejmowane działania muszą
być ukierunkowane na ochronę położnic przed stanem
zagrożenia życia. Krwotok to najczęstszy stan naglący
w położnictwie, dlatego ważne jest, aby cały zespół
położniczy znał i rozumiał zasady postępowania w tym
ciężkim powikłaniu porodu. W związku z tym należy
tworzyć i wdrażać standardy, aby zapewnić wysoki poziom
opieki położniczej.
Standard of maternal postpartum haemorrhage care
80
AIM OF THE STUDY
Presentation of the most common risk factors
associated
with
the
occurrence
of
haemorrhage in the postnatal period
- Acquainted with the standard care for
maternal postpartum blood loss of 500-1000
ml of blood without symptoms of shock
(protocol A),
- Acquainted with the standard care for
maternal postpartum blood loss of 500-1000
ml of blood at the existing symptoms of
hemorrhagic shock (protocol B),
- An indication of a significant role of
midwives in the prevention of post-natal
haemorrhage.
Subject:
Life-threatening
conditions
in
obstetrics
Group care: Mother with postpartum haemorrhage
with the loss of more than 500-1000 ml of blood
without signs of hemorrhagic shock (protocol A).
Mother with postpartum haemorrhage with loss of
more than 1000-1500 ml of blood or with existing
symptoms of hemorrhagic shock (protocol B).
Standard Statement: Mother is ensured with
intensive supervision and care aimed at preventing
severe and irreversible haemorrhage complications.
Justification:
One of the major causes of morbidity and maternal
mortality is a massive obstetric haemorrhage.
According to data from the years 1991-2000, in Poland
from 402 maternal deaths due to obstetric causes, 135
(33.5%) were caused by haemorrhages. Similarly, in
2001-2004, among the 132 deaths, 41 (31.06%) were
because of haemorrhage [1]. According to recent data
from 2010, a postpartum haemorrhage in Poland, is
still one of the most common causes of maternal
deaths, represents 38.7% of them. [2].
The official definition of postpartum haemorrhage
according to the World Health Organisation (WHO) is
the loss of more than 500 ml of blood from the
reproductive tract within 24 hours of birth. Average
blood loss during labour by forces of nature is 500 ml
of blood and more than 1000 ml during caesarean
section [3]. Blood loss in the first 24 hours after birth is
called the early postpartum haemorrhage, while in the
period from 24 hours to 6 weeks after birth, late
postpartum haemorrhage. Definition of massive
(severe) bleeding: blood loss of more than 150ml/min
(causes a loss of more than 50% of blood volume
-
within 20 min), sudden loss of more than 1500-2000ml
(uterine atony, loss of 25-35% of blood volume) [3, 4,
5]. Determining the volume of blood lost is often
subjective and inaccurate. Lowering the level of
haematocrit of 10% allows the identification of
postpartum haemorrhage, but the level of haemoglobin
or haematocrit may not reflect the current hematologic
state [6].
Prenatal risk factors for postpartum haemorrhage
include:
• antenatal bleeding,
• risk of premature separation of placenta,
• placenta praevia,
• multiple pregnancy,
• hypertension in pregnancy (preeclampsia,
eclampsia, HELLP), chorionamnionitis,
• polyhydramnios,
• fetal death,
• anaemia Hb <5, 8 mmol / l),
• multipara > 5 pregnancies
• fibroids
• haemorrhage in an interview,
• obese.
Birth risk factors:
• Caesarean section (especially in a matter of
urgency),
• placental retention, uterine weakness (atony)
• operational completion of delivery (tick,
vacuum extractor)
• lack of progress in labour (extending over 12
hours, particularly in the second period of
more than 1 hour in multiparous, over 2 hours
in the primipara),
• induction of parturition, a large fetus (more
than 4000G),
• genital tract trauma in childbirth (rupture,
hematomas, eversion of the uterus),
• fever,
• method of anaesthesia,
• DIC.
Causes of obstetric haemorrhage can be divided
into antenatal and intrapartum, among which there are:
placenta previa, placental abruption and uterine rupture
and postpartum causes such as uterine atony, placenta
ingrown, the remains of the placenta, damage of
cervix, vagina and perineum [7 ]. Excessive blood loss
after childbirth may be due to: the method of
conducting labour, abnormal separation of the
placenta, injuries of cervix, corpus of uterus, vaginal or
Grażyna Gebuza et. al.
perineal; also abnormal uterus contraction [4], which is
the most common cause, and disorders of haemostasis.
A specific group consist of patients with preeclampsia
and HELLP syndrome [7,8,9]. Therefore, each of the
parturient with emerging risk factors should ensure an
expert supervision [4].
Postpartum haemorrhage can lead to shock, which
is a clinical syndrome arising when autoregulation
system mechanisms are not able to ensure proper blood
flow to organs and tissues important for living. Direct
threat to the mother's life is not only a hypovolemic
shock induced by haemorrhage, but also other
complications such as blood coagulation disorders
(DIC) or uteroplacental stroke [1].
Proceedings with postpartum haemorrhage usually
include a series of actions intending to stop the
bleeding. Due to the dynamism, actions must be
focused on maternal protection against severe,
prolonged shock, which can become irreversible.
Therefore, it is important to urgently contact the
supervisor, place in a state of readiness obstetric team,
the operating block, anaesthesiologist, Blood Donation
Station. The cooperation of the whole team can
contribute to reducing maternal mortality.
Criteria for the structure
1. Highly specialized medical and obstetrical
staff providing professional treatment and
care is employed on the ward.
2. Midwife, as a member of the therapeutic team,
works with obstetrician, anaesthesiologist,
staff of laboratory, operating block, Blood
Donation Station, Pharmacy.
3. Midwife knows:
• etiology, risk factors and symptoms
of postpartum haemorrhage,
• algorithm of conduct with a
haemorrhage,
• type of fluid used to restore blood
volume crystalloids, colloids, blood),
• procedures for the transfusion of
blood and its preparations,
• type and method of collecting
material for testing,
• methods of monitoring the state of
mothers,
• medications which may be given in a
life-threatening situation without a
doctor's orders,
• algorithms, procedures and standards
of the department,
81
•
•
4.
5.
6.
7.
8.
9.
can take resuscitation action.
knows the advantages of breast
feeding.
Providing care, the midwife acts in
accordance with the principles of aseptic
techniques, provides sense of security and
intimacy to mothers.
The midwife knows and follows the Patients'
Rights Chart.
Midwife has the opportunity to development:
self-study, participation in conferences and
symposia, improvement in the ward, bachelor
and master’s degree, specialization.
Midwife has the authority to administer
medicines, blood and blood products,
intravenous infusion fluids.
The intensive care is provided in lifethreatening situation.
Ward, equipped with equipment to achieve
curative and care tasks at the highest level,
has:
• necessary resuscitation equipment (Ambu
device, intubation set) and drugs
• oxygen therapy equipment, access to a
central source of oxygen and suction,
• Devices for measuring blood pressure,
ECG monitor, pulse oximeter, body
temperature (equipment for electronic
monitoring of body temperature), hourly
and daily urine output, blood glucometers,
• needles and syringes, test tubes,
transfusion sets, infusion pumps, cannulas
into peripheral veins and central venous
catheters, vacuum blood collection sets
type BD Vacutainer, medications and
intravenous fluids, Foley catheters,
dressing material, personal protective
equipment, antiseptics ,
• procedure: collection of material for tests,
the establishment and care of the
peripheral and central intravenous line,
maternal care after physiological birth and
caesarean section, blood transfusion and
blood products, bleeding procedure;
• algorithm of conduct with a haemorrhage,
resuscitation activities algorithms,
• documentation enabling the registration of
diagnostic activities, nursing care,
rehabilitation and healing done by
midwives.
82
Standard of maternal postpartum haemorrhage care
Criteria for the process:
For transparency of the activities specified two
protocols to the proceedings:
Protocol A
In order to ensure optimal care to mothers with
postpartum haemorrhage with blood loss estimated at
500-1000 ml, with no signs of shock, the midwife takes
the following actions:
1. Recognizes
the
core
symptoms
of
haemorrhage: heavy vaginal bleeding, a
decrease in systolic blood pressure (<90
mmHg) and blood pressure amplitude,
thready pulse, heart rate, body pallor,
clammy-cold skin, the occurrence of cyanosis
on the fingers of the upper extremities, lower
extremities and lips, weakness, ringing in the
ears, spots before eyes, anxiety [11].
2. Performs fundus massage in order to achieve
strong and sustained contraction [4].
3. Foley catheter is assumed into the bladder
(patient consent).
4. Ensures blood supply to vital organs, lower
limbs placed above 15 0, the anti-shock
position [11].
5. Specifies the path of blood loss based on
observations and obtained information.
6. Provides access to a peripheral vein (1x14 G brown or 16 G - gray).
7. Takes the blood to the test in accordance with
a medical order to: determination of
morphology,
cross-matching
blood,
coagulation (PT, aPTT, fibrinogen). Securing
2 units of RBC concentrate [3] in Blood
Donation Station.
8. Participates in treatment (acting in accordance
with the physician order's), which aims to
• stop the bleeding, increased uterine
smooth muscle tension (Oxytocin 20-40
IU in bolus followed by 40 IU in 0.9%
NaCl [4], dinoprost, (Enzaprost, PGE 2),
sulproston, misoprostol (PGE 1, Cytotec)
• increase the circulating blood volume gives heated crystalline fluids 0, 9%:
NaCl, Ringer's fluid, multielectrolyte
fluid).
9. Administers humidified oxygen - 6-8 l / min
[3] (blood oxygenation).
10. Reduces demand for oxygen to maintain
proper body temperature (warm mother).
11. Conducts
monitoring,
analyzing
and
documenting: pulse rate, blood pressure by
cardiomonitor or by the indirect method (noninvasive peripheral sphygmomanometry,
using cuff whose width should be adjusted to
arm circumference), body temperature
(estimated temperature of peripheral parts of
the body and differentiate between the
temperature of the trunk and toe), the
frequency and character of respiration and
blood gases, renal function by controlling the
hourly diuresis (restoration of urine excretion
0.5-1 ml / kg / h) [5], state of consciousness,
results of laboratory tests, medications given.
12. Provides a sense of security and reduces
anxiety to mother by constant presence,
calming and supervision.
13. Participates in preparation for surgical
operations. If the methods described above do
not bring the expected improvement of the
control of bleeding, prepares mother to
surgical procedure:
• control of the genital tract injuries
• control of the uterus [3].
Protocol B
In order to ensure optimal care to mothers with
postpartum haemorrhage when blood loss is assessed
over of 1000-1500 ml or signs of hemorrhagic shock
(Tachycardia / bradycardia, hypotension, tachypnoea,
oligo / anuria) [4], the midwife will take the following
actions:
1. Recognizes the basic symptoms of
haemorrhage and hypovolemic shock: severe
vaginal bleeding, a decrease in systolic blood
pressure (<90 mmHg or a reduction of 3040% compared to baseline) and amplitude of
blood pressure, thready pulse (much less
noticeable at the periphery than central pulse),
tachycardia,
tachypnea,
respiratory
dysfunction (acceleration and shortness of
breath), restlessness, pallor of the body, the
moist-cold skin, the occurrence of cyanosis on
the fingers of the upper extremities, lower
extremities and the lips, weakness, vision
dimmed , tinnitus, impaired consciousness,
loss of consciousness, decrease of urine
output to less than 20-30 ml / hr. (oliguria),
sometimes no urine output (anuria) [11].
Grażyna Gebuza et. al.
2.
3.
4.
5.
6.
7.
8.
•
•
•
•
•
a.
Determines the type and severity of blood loss
based on observations and obtained
information.
Performs massage of fundus until a strong and
sustained contraction.
Foley catheter is assumed into the bladder [4]
(the patient's consent).
Provides access to a peripheral vein (2 x 14
G-brown or 16 G-gray).
Takes blood to the test in accordance with a
medical order to: determination of
morphology, (takes blood to cross-matching
before the transfusion of colloid), coagulation
(PT, aPTT, fibrinogen), blood gases,
electrolytes. Secure 5-6 units of PRBCs [4] in
Blood Donation Station.
Prepares and transfuses infusion fluids in
accordance with a medical order to fill
deficiencies in circulating blood volume and
restore the flow of tissue, respecting the
existing rules in this area, complies with the
principles of safe blood transfusion in
accordance with established procedure in the
ward, observes the patient when connecting
the blood (the performance of the bioassay),
transfusion and after the infusion.
Participates in treatment (acting in accordance
with the medical order's), which aims to save
lives:
stop the bleeding, increase uterine muscle
tension (Oxytocin 10-20 IU in bolus [1] and
then infusion of 40 IU in 500ml of 0, 9 NaCl infusion at 125 ml / h), dinoprost, (Enzaprost,
PGE 2), sulproston, misoprostol (PGE 1,
Cytotec)
prohaemostatic drugs - recombinant factor
VIIa (rFVIIa)
antifibrinolytic agents epsilon-aminocapronic
acid (EACA), tranexamic acid (TXA),
aprotinin, significantly reduce bleeding,
Desmopressin (vasopressin derivative - works
by increasing levels of coagulation factors
VIII and Von Willebrand factor and by direct
activation of platelets;
increase in circulating blood volume (if blood
loss 1000-1500 ml of blood and signs of
shock):
crystalline liquid to a volume of 2000ml
(heated),
b.
83
colloidal fluids (hydroxyethylated starch,
gelatin, 4.5% albumin) to a volume
1500ml/day,
c. PRBCs transfusion (as soon as possible). If
there is no cross-matched, group compatible
blood, transfusion of compatible by the group
of patients without a cross-match (on the
order of a physician !!!). In any case, the
urgent need for blood transfusions gives
group "0" Rh negative.
d. If bleeding does not stop, and (or) there is no
coagulation control, it is recommended to
transfuse 4-5 units of FFP, 10 units of KP
• oxygenation of blood - the supply of oxygen6-8 l / min [4],
• reduce the need for oxygen, maintaining the
correct temperature (heating patients)
• ensure the blood supply to vital organs, lays
lower limbs above, anti-shock position,
• conduct strict monitoring and documenting
actions taken diagnosis, treatment and care.
14. Conducts
strict
supervision
and
documentation of the diagnosis, treatment and
care activities: pulse rate, blood pressure
(systolic, diastolic) using the indirect method
(non-invasive peripheral sphygmomanometry,
using cuff whose width should be adjusted to
arm circumference), body temperature
(estimated temperature of peripheral parts of
the body and differentiate between the
temperature of the trunk and toe), ), the
frequency and character of respiration and
blood gases, renal function by controlling the
hourly diuresis (restoration of urine excretion
0.5-1 ml / kg / h) [5], state of consciousness,
results of laboratory tests, medications given,
the water balance chart; state of
consciousness, results of laboratory tests,
administered drugs.
15. Provides a sense of security and reduces
anxiety to mother by constant presence,
calming and supervision.
16. Participates in preparation for surgical
operations. If the methods described above do
not bring the expected improvement of the
control of bleeding, prepares mother to
surgical procedure:
• control of the genital tract injuries
• control of the uterus [3]
• tamponade of the uterus
84
Standard of maternal postpartum haemorrhage care
• laparotomy [4]
Outcome Criteria
Mother with postpartum haemorrhage during the
hospitalization was properly taken care of if the
following conditions were provided:
1. A patients was subject to intense maternal
care by midwife and multidisciplinary team to
rapidly identify the cause of haemorrhage and
control bleeding.
2. All the taken actions were adequately
matched to the patient's hemodynamic status.
3. Nursing problems were recognized and dealt
with by a midwife and a cooperating team.
4. The patient's condition is stable. Smooth
peripheral circulation (heart rate 60-100 min,
blood pressure is maintained at 110-100/60-50
mmHg, distal parts of limbs are warm. Mother
condition - shrunk uterus, vaginal bleeding mediocre, bloody.
5. Lack of systemic organ failure and lifethreatening multiorgan failure. Diuresis above
40 ml/h, hematocrit above 30%.
6. The patient is safe and feels no fear.
ABBREVIATIONS USED IN THIS STUDY
APTT - activated partial thromboplastin time
activation
FFP - fresh frozen plasma
Hb - haemoglobin
im - intramuscular administration of the drug
iv - intravenous administration of the drug
PRBCs - red blood cell concentrate (packed red blood
cells)
KP - cryoprecipitate
PC - platelet concentrate
PPH - postpartum hemorrhage (postpartum
haemorrhage)
PT - Prothrombin time
rFVIIa - recombinant activated factor VII (factor VIIa
Recombinant)
REFERENCES
1. Reroń A., Jaworowski A., Ossowski P. : Krwotoki
okołoporodowe - sposoby postępowania: Ginekologia i
położnictwo - medical project, 2009 (3): 33-40.
2. Szamotulska K.: Stan zdrowia matek i dzieci w okresie
okołoporodowym w Polsce na tle krajów Unii
Europejskiej. Opracowanie na podstawie wskaźników
Euro-Peristat. Medycyna Wieku Rozwojowego, 2010,
XIV, 2: 113-128.
3. Ramanathan G. Arulkumaran S.: Krwotok poporodowy,
Położnictwo, Ginekologia, Medycyna Rozrodu, 2007,
tom 1(1) XII: 2-5.
4. Sobieszczyk S. Bręborowicz G.H : Rekomendacje
postępowania w krwotokach poporodowych, Cz.I,
Protokół
postępowania,
Kliniczna
Perinatologia
i Ginekologia, 2004, tom 40, zeszyt 2: 60-63.
5. Sobieszczyk S. Bręborowicz G.H.: Propozycja zaleceń
stosowania rekombinowanego aktywnego czynnika VII
[rFVIIa] w ciężkich krwotokach położniczych
i
ginekologicznych,
Perinatologia,
Neonatologia
i Ginekologia, 2008, tom1, zeszyt 1: 78-80.
6. Oszukowski P. Pięta-Dolińska A. : Krwotok poporodowy
– kliniczna etiopatogeneza. Przegląd Menopauzalny,
2010, 4: 247–251.
7. Bręborowicz G. Sobieszczyk S. : Krwawienia w II i III
trymestrze ciąży. W: Bręborowicz G. (red.): Położnictwo
i ginekologia. PZWL, Warszawa: 2006.
8. ACOG. Postpartum haemorrhage, Practise Bulletin:
Obstet Gynecol, 2006, 108 (4): 1039-47.
9. Cunningham FG. Leveno KJ. Bloom SL. et al.: Obstetric
hemorrhage. In: Williams Obstetrics. New York:
McGraw-Hill, 2005: 809-52.
10. Czajkowski K.: Krwawienia poporodowe. W: Spaczyński
M. (red.): Postępy w ginekologii i położnictwie, Polskie
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Med.Wrocław, 2003:48.
Address for correspondence:
M.Sc. Gebuza Grażyna
Toruń, ul. Niesiołowskiego 2B/30
[email protected]
tel.: +48 796061139
Received: 10.01.2012
Accepted for publication: 6.03.2012
Medical and Biological Sciences, 2012, 26/2, 85-88
Izabela Glaza1, Katarzyna Pietkun2, Rafał Szadujkis-Szadurski1, Krystyna Nowacka2,
Magdalena Hagner-Derengowska1, Maciej Nowacki3
PROBIOTICS IN FOOD. IMPORTANT PREVENTIVE FACTOR IN CHILDREN ALLERGY,
OR A CONTROVERSIAL ADD-ON? REVIEW OF THE LITERATURE
PROBIOTYKI W ŻYWNOŚCI. ISTOTNY CZYNNIK PREWENCYJNY
W ALERGOLOGII DZIECIĘCEJ CZY KONTROWERSYJNY DODATEK?
PRZEGLĄD PIŚMIENNICTWA
1
Department of Pharmacology and Therapy, Collegium Medicum in Bydgoszcz
Nicolaus Copernicus University in Toruń
Head: dr hab. n. med. Grzegorz Grześk, prof. UMK
2
Department and Clinic of Rehabilitation, Collegium Medicum in Bydgoszcz
Nicolaus Copernicus University in Toruń
Head: prof. dr hab. n. med. Wojciech Hagner
3
Tissue Engineering Department, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń
Head: dr hab. n. med. Tomasz Drewa, prof. UMK
Summary
Currently, one of the most frequently discussed topics
related to the problem of child allergy are food allergies.
Statistical data on the number of children burdened with this
type of allergy are divergent according to reports of the
individual authors. But invariably publications and scientific
reports point to the upward trend in the number of newly
identified various forms of food allergy. According to the
data (AAAAI), in the years of 1997-2007 the number of
diagnoses in children under 18 years of age increased by
18%.
The European Data included in the reports (EFA) also
confirm a growing trend in this respect in the recent years. In
addition to significant development of diagnostics and
therapy of various forms of childhood food allergy attention
has been drawn to factors that affect the development of a
preventive of this disease. In this type of factors, probiotics
are also included .
Streszczenie
Jednym z częściej poruszanych obecnie tematów
problemowych w współczesnej alergologii dziecięcej są
alergie pokarmowe. Dane statystyczne na temat liczby dzieci
obarczonych tym typem alergii są rozbieżne według
doniesień poszczególnych autorów. Jednak niezmiennie od
kilku lat w publikacjach i doniesieniach naukowych
wskazuje się na tendencję wzrostową w ilości nowo
rozpoznanych różnych form alergii pokarmowej. Według
danych (AAAAI) w latach 1997-2007 liczba rozpoznań u
dzieci poniżej 18 roku życia wzrosła o 18%. Dane
Europejskie zawarte w raportach (EFA) potwierdzają także
tendencję wzrostową w tym aspekcie. Obok znacznego
rozwoju diagnostyki i różnych form terapii dziecięcej alergii
pokarmowej, istotnie zwraca się na przestrzeni ostatnich lat,
także uwagę na czynniki mogące wpływać prewencyjnie na
rozwój tej choroby. Do tego typu czynników zalicza się także
probiotyki.
Key words: probiotic, probiotic bacteria, food allergy, allergy
Słowa kluczowe: probiotyk, bakterie probiotyczne, alergia pokarmowa, alergologia
86
Izabela Glaza et al.
INTRODUCTION
Food allergies are one of the most common
problems of modern allergology. The cause of food
allergy is the most common, genetic and direct damage
of the intestinal barrier by bacteria and viruses. The
most common allergy symptoms occur after eating
foods that are a source of allergen. Very often, they
cause a direct increase in the production of IgE
stimulates mast cells to induce inflammatory processes.
The highest percentage of allergic reactions occur after
ingestion of milk, especially in infants and young
children, eggs, fish, seafood, peanuts. The most
common allergy symptoms include shortness of breath,
diarrhea, hives, stomach pain [1, 2, 3, 4, 5].
PROBIOTICS
Probiotics are bacterial cultures, usually lactic acid
bacteria that have a positive, protective effect on the
gastrointestinal mucosa. Their beneficial effect is to
improve and restore the normal bacterial flora. The
best known are L. acidophilus, L. casei, L. fermentum,
L. gasseri, L. Johnson, L. lactis, L. bulgaricus,
L. plantarum, L. salivarius, L. rhamnosus, L. reuteri
and Bifidobacterium: B. bifidum, B.longum, B.infantis.
Probiotic bacteria not only strengthen the body's
bacterial flora, but also inhibit the adhesion of
pathogenic microorganisms, so that there is an increase
in immunity. Probiotic bacteria are found primarily in
fermented milk drinks. This group includes: yogurt,
buttermilk, kefir, milk, and curdled milk acidophilous.
It is noteworthy that the nutritional value of fermented
dairy products is as high as milk, while the value of
fermented beverages care is much higher than milk.
This is connected mainly with the biological activity of
living lactic acid bacteria. Dairy products with
probiotics strengthen the content and stimulate the
human immune system. In addition, carcinogenic
compounds decompose and form one of the factors
preventing osteoporosis. Due to the presence of
probiotics, yogurt and kefir are rich in protein, fat,
lactose and mineral salts. In people who suffer from
lactose intolerance, regular consumption of fermented
milk drinks alleviates the symptoms of intolerance.
Probiotic bacteria contain the enzyme betagalactosidase, which breaks down lactose into simple
sugars [1, 4, 6, 7, 8, 9].
Additional benefits of consuming milk fermented
beverages are:
•
•
improvement of the processes of digestion,
improvement of the lipid profile in people
with high cholesterol,
•
destruction of pathogenic and putrefactive
faecal microflora in the large intestine of man,
• prevention of intestinal infections,
• therapeutic treatment for diarrhea in children,
• prevention of relapse of fungal and bacterial
infections of the vagina.
Regular consumption of fermented beverages seems to
be an important factor. It has proven to improve human
body's natural resistance to infections. A necessary
condition to obtain good results is diet rich in viable
bacteria (100 million in 1 ml of the drink) [2, 3, 10,
11].
THE BENEFITS OF PROBIOTICS
IN FOOD ALLERGY IN CHILDREN
Michalkiewicz et al. thought that lactic acid
bacteria provide many health benefits, including
improved resistance to bacterial physiological
microflora to antibiotics and have anticancer
properties. Important is the fact that this work
addresses the impact of probiotics on allergic reactions
weakness. An increasing number of reports confirm
many positive effects of probiotics in prevention and
treatment of food allergies. [12]
Isoluri et al. reported the ability of probiotics to
inhibit the early stages of allergic inflammation and
atopic eczema through observation carried among
infants with atopic eczema fed with mothers’ milk [the
effects of inclusion of probiotics (mainly
Bifidobacterium lactis, Lactobacillus GG) to reduce
eczema in infants]. The original value of SCORE
points (severity of eczema), which was 16, decreased
after supplementation with Bifidobacterium lactis Bb
to 0 and Lactobacillus GG to 1 It is important that in
the control group SCORAD score was 13.4, indicating
the positive role of probiotics in allergic reactions.
Furrie et al. reported an impact of pro biotic therapy
on the prevention of allergic diseases and the effects of
Lactobacillus rhamnosus GG on atopic eczema
reduction in newborns. Pessi et al. who claimed that
supplementation with Lactobacillus rhamnosus inhibits
inflammation in the mucosal inflammation of the
gastrointestinal tract and also relieves the symptoms of
atopic dermatitis [13].
Probiotics in food. Important preventive factor in children allergy, or a controversial add-on? Review of the literature
According to Kalliomaki et al. Lactobacillus GG
supplementation is an effective method of preventing
atopic disease in children with risk factors.
Detailed study by Kukkonen et al. reported that
preventing atopic dermatitis in infants at high risk is
possible by modulating probiotic intestinal microflora
of the child. In addition, there was no effect on the
incidence of food allergy in children up to 2 years old,
and a significant proportion of prevention of atopic
eczema was observed. [8]
According to Del Giudice et al. probiotics are
involved in interaction with the mucosal immune
system as a commensal bacterium of the system. The
study showed that probiotic bacteria in vivo cause an
increase in IL-10 and IgA in children with a
predisposition to allergies. [1]
However, research conducted in Warsaw by
Szajewska et al. proved the efficacy of probiotics in the
treatment of antibiotics, in particular strains of
Lactobacillus GG supplementation or Bifidobacterium
lactis Bb-12 as the symptoms of atopic dermatitis in
infants fed artificially and naturally. In addition, one
case reported a preventive effect of Lactobacillus GG
as it reduced the risk of incidence of atopic dermatitis
in infants with a history of allergy. [14]
Majamaa et al. have shown that use of probiotics
in infants with atopic dermatitis in the course of allergy
to cow's milk proteins results in significantly lower
SCORAD index and the decrease in TNF-α, and α-1AT. The corresponding data is given by Isolauri et al.;
their studies showed reduction of SCORAD score in
infants fed human milk with symptoms of atopic
dermatitis after taking probiotics supplemented by
hydrolysed protein.
CONCLUSION
Probiotics, which are often used as an addition to
the milk products are regarded as a controversial media
supplement but there is no reference in publications on
nutrition in the food allergies. Probiotics are a very
good method to increase the natural immunity. Many
sources report that supplementation with probiotics
plays an important role in the prevention of food
allergy and the symptoms of atopic dermatitis.
[15,16,17,18] Many clinical studies report significant
benefits of supplementation of probiotics in the
prevention and management of food allergy, but not
everyone agrees on their effectiveness. A significant
development in this branch of medicine, particularly in
87
the pediatrics and pediatric allergology, provides
a large number of probiotics as a drug or dietary
supplement products, specially dedicated for children,
such as chewable tablets or strawberry-flavored
droplets [19,20].
REFERENCES
1. Del Giudice MM, Leonardi S, Maiello N, Brunese FP.
Food allergy and probiotics in childhood. J Clin
Gastroenterol. 2010 Sep;44 Suppl 1:S22-5.
2. Furrie E. Probiotics and allergy. Proc Nutr Soc. 2005
Nov;64(4):465-9.
3. He F. et al.: Comparion of mucosal adhesion and species
identification of bifidobacteria isolated from healthy and
allergic infants; FEMS Immunol. Med. Microbiol., 2001;
30:43-47.
4. Host A., Koletzko B., Dreborg S. i wsp.: Dietary
products in infants for treatment and prevention of food
allergy. Joint statement of the European Society for
Paediatric Allergology and Clinical Immunology
(ESPACI) Committee on Hypoallergenic Formulas and
the European Society for Paediatric Gastroenterology,
Hepatology and Nutrition (ESPGHAN) Committee on
Nutrition. Arch. Dis. Child., 1999, 81, 80-84.
5. Isolauri E. et al.: Probiotics in the management of atopic
eczema, Clin. Exp. Allergy., 2000; 30: 1604-1610.
6. Kalliomaki M, et al.: Probiotics in primary prevention of
atopic disease. a randomised placebo-controlled trial.
Lancet 2001, 357(9262):1076-9. Clin Immunol 2007,
119(1):192-8.
7. Kirjavainen P.V., Apostolou E., et all: New aspects of
probiotics – a novel approach in the management of food
allergy. Allergy, 1999, 54, 909-915.
8. Kukkonen K, et al.: Probiotics and prebiotic galactooligosaccharides in the prevention of allergic diseases. a
randomized, double-blind, placebo-controlled trial. J
Allergy Clin Immunol 2007, 119(1):192-8.
9. Majama H, Isolauri E. Probiotics: a novel approach in the
management of food allergy. J Allergy Clin Immunol
1997;99:179-185.
10. Wysocka M.: Probiotyki – nowe, obiecujące
zastosowania w terapii. Nowa Pediatria 3/2001, s. 19-24.
11. Vliagoftis H, Kouranos VD, Betsi GI, Falagas ME.:
Probiotics for the treatment of allergic rhinitis and
asthma: systematic review of randomized controlled
trials. Ann Allergy Asthma Immunol. 2008
Dec;101(6):570-9.
12. Michałkiewicz
J.:
lmmunomodulujący
wpływ
probiotyków na reakcje odpornościowe. Standardy Med.
2003 T. 5 nr 9 s. 1270-1280.
13. Pessi T. et al.: Interleukin-10 generation in atopic
children following oral Lactobacillus rhamnosus GG;
Clin. Exp. Allergy., 2000; 30: 1804-1808
14. Szajewska H.: Rola probiotykóww zapobieganiu
i leczeniu chorób przewodu pokarmowego.: Pediatria
współczesna, Gastroenterologia, Hepatologia i żywienie
dziecka 2005, 7,1, 53-60.
88
Izabela Glaza et al.
15. Saavedra M.: Clinical applications of probiotic agents.
American Journal of Clinical Nutrition, Vol. 73, No. 6,
1147S-1151S.
16. Savilahti E, Kuitunen M, Vaarala O.: Pre and probiotics
in the prevention and treatment of food allergy. Curr
Opin Allergy Clin Immunol. 2008 Jun;8(3):243-8.
17. Von der Weid T, Ibnou-Zekri N, Pfeifer A.: Novel
probiotics for the management of allergic inflammation.
Dig Liver Dis. 2002 Sep;34 Suppl 2:S25-8.
18. Pelto, Isolauri, Lilius, Nuutila, Salminen: Probiotic
bacteria down-regulate the milk-induced inflammatory
response in milk-hypersensitive subjects but have an
immunostimulatory effect in healthy subjects. Clinical &
Experimental Allergy 1998, 28,12, 1474–1479.
19. Martens U, Enck P, Zieseniss E. Probiotic treatment of
irritable bowel syndrome in children. Ger Med Sci. 2010
Mar 2;8
20. Press Release 21th of September 2011 BioGaia signs
agreement with the largest pharmaceutical company in
the Philippines for its probiotic chewable tablets.
Address for correspondence:
I. Glaza
[email protected]
Coresponding Author:
K. Pietkun
[email protected]
ul. M. Curie Skłodowskiej 9
85-094 Bydgoszcz
Szpital Uniwersytecki nr 1 im. dr. A. Jurasza
tel.: prywatny: 506 766 509, tel kliniki: 52 585-43-30
R. Szadujkis-Szadurski
[email protected]
K. Nowacka
[email protected]
M. Hagner-Derengowska
[email protected]
M. Nowacki
[email protected]
Received: 10.02.2012
Accepted for publication: 6.03.2012
Medical and Biological Sciences, 2012, 26/2, 89-94
Andrzej Kuźmiński, Michał Przybyszewski, Małgorzata Graczyk, Magdalena Żbikowska-Gotz, Ewa Socha,
Zbigniew Bartuzi
COMPOSITION OF INFLAMMATORY INFILTRATE IN THE GASTRIC MUCOSA
OF PATIENTS WITH FOOD AND AIRBORNE ALLERGIES
SKŁAD NACIEKU ZAPALNEGO BŁONY ŚLUZOWEJ ŻOŁĄDKA U CHORYCH
Z ALERGIĄ POKARMOWĄ I POWIETRZNOPOCHODNĄ
Department of Nutrition and Dietetics of the Collegium Medicum in Bydgoszcz
Nicolaus Copernicus University of Toruń
Head: prof. dr hab. Roman Cichon
Summary
I n t r o d u c t i o n . The aim of this study was to analyze
the composition of inflammatory infiltrate in the gastric
mucosa of patients with food and airborne allergies.
P a t i e n t s a n d m e t h o d s . This study included 80
subjects: 30 patients with food allergy, 30 patients with
airborne allergy, as well as 20 healthy, allergy-free
individuals. Gastroscopy was performed in all patients and
gastric mucosal biopsies were taken for histopathological
examination that included the assessment of Helicobacter
pylori infection status and the presence of eosinophils within
the inflammatory infiltrate.
R e s u l t s . Eosinophils were revealed in the biopsies of
gastric mucosa originating from 12 (40%) food allergy
patients, eight (27%) individuals with airborne allergy, and
two controls. Compared to the controls, patients with food
allergies were characterized by significantly higher
prevalence of eosinophilic infiltrates (p=0.0206); there were
no other significant intergroup differences in regards to this
parameter.
Colonization with Helicobacter pylori was confirmed in
9 (30%) subjects with food allergy, 6 (20%) individuals with
airborne allergy, and in 10 (50%) controls. These three
groups did not differ significantly in terms of HP
colonization rates.
C o n c l u s i o n s . Compared to the controls, patients
with food allergy were characterized by a significantly higher
prevalence of eosinophils within inflammatory infiltrate. No
significant differences in regards to this parameter were
documented between food and airborne allergy patients as
well as between individuals with airborne allergy and the
controls.
Colonization of gastric mucosa with Helicobacter pylori
was less frequent amongst airborne (20%) and food allergy
patients (30%) than the controls (50%).
Streszczenie
W s t ę p . Celem pracy była ocena składu nacieku
zapalnego błony śluzowej żołądka u pacjentów z alergią
pokarmową oraz powietrznopochodną.
P a c j e n c i i m e t o d y . Do badania zakwalifikowano 80 pacjentów, w tym 30 badanych z alergią pokarmową, 30 z alergią powietrznopochodną oraz 20 zdrowych bez
alergii pokarmowej. U wszystkich badanych wykonano
gastroskopię oraz pobrano wycinki błony śluzowej żołądka
do weryfikacji histopatologicznej z uwzględnieniem obecności w nacieku zapalnym żołądka eozynofilów oraz
kolonizacji Helicobacter pylori.
Wyniki.
Obecność komórek kwasochłonnych
w ocenie histopatologicznej wycinków błony śluzowej
żołądka wykazano u 12 (40%) badanych chorych z alergią
pokarmową; u 8 (27%) badanych w grupie z alergią
powietrznopochodną oraz u 2 pacjentów w grupie kontrolnej.
Wykazano istotną statystycznie różnicę w częstości występowania nacieków komórek eozynochłonnych pomiędzy grupą
z alergią pokarmową a grupą kontrolną (p=0,0206). Między
pozostałymi grupami nie wykazano różnic istotnych
statystycznie.
Kolonizację Helicobacter pylori wykazano u 9 (30%)
badanych z alergią pokarmową, u 6 (20%) z alergią
90
Andrzej Kuźmiński et. al.
powietrznopochodną oraz u 10 (50%) badanych w grupie
kontrolnej. Nie wykazano istotnych statystycznie różnic
w częstości kolonizacji HP pomiędzy badanymi grupami.
W n i o s k i . W grupie chorych z alergią pokarmową
stwierdzono statystycznie istotny wzrost liczby komórek
kwasochłonnych w nacieku zapalnym w porównaniu z grupą
kontrolną. Nie było statystycznie istotnych różnic w tym
zakresie pomiędzy grupą pacjentów z alergią pokarmową
i powietrznopochodną, a także pomiędzy grupą pacjentów
z alergią powietrznopochodną a grupą kontrolną.
Kolonizacja błony śluzowej przez bakterię Helicobacter
pylori występowała w mniejszym odsetku wśród badanych
z alergią powietrznopochodną (20%) i alergią pokarmową
(30%) w porównaniu z grupą kontrolną (50% badanych).
Key words: allergy, gastritis, eosinophil, Helicobacter pylori
Słowa kluczowe: alergia, zapalenie żołądka, eozynofil, Helicobacter pylori
INTRODUCTION
The last three decades have been associated with a
rapid increase in the prevalence of allergic diseases,
including both sensitivity to food allergens and
airborne allergies [1]. According to the European
Allergy White Paper, 35% of population is currently
affected by allergic conditions [2]. The authors of
multicenter ECAP study, results of which were
published in 2008, estimate that 45-52% of Polish
population suffered from an allergy at least once in a
lifetime; the most frequent conditions include allergic
rhinitis, followed by bronchial asthma and food allergy
[3,4].
It is widely known, food allergens interact with the
gastric mucosa predisposing it to the development of
chronic inflammatory lesions; however, such lesions
can also result from an airborne allergy [5,6,7].
Chronic gastritis is a polyetiological condition that can
present with a variety of macroscopic changes; it lasts
years and can lead to gastric ulceration, autoimmune
lesions, mucosal atrophy, or even cancer [8].
Gastrointestinal barrier plays a crucial role in the
prevention of allergic processes in the alimentary tract.
It is composed of the appropriate acidity of the gastric
juice, proteolytic enzymes, lysozyme, lactoferrin,
defensins, mucus, and the proper motility of the
alimentary tract. Any injury to this barrier is reflected
by enhanced contact between allergens and the
immune system of alimentary mucosa, and
consequently by the development of food allergy [9].
The stomach of predisposed individuals can be
involved in immune reactions and, therefore, constitute
a target organ for IgE-dependent allergic processes
initiated by exogenous allergens, but probably also by
H. pylori (HP) infection [10]. IgE-dependent allergic
reaction is initiated by allergen-antibody interaction
that may be of systemic or local character leading to
chronic inflammation of tissues, including gastric
mucosa. In such cases, in addition to lymphocytes and
plasmatic cells, macrophages, mast cells and a small
number of granulocytes may be observed in the
mucosal lamina propria [11]. Initially, degranulation of
mast cells along with the release of inflammatory
mediators takes place; this is followed by the activation
of mast cell-cytokine cascade, and finally by the
inflammatory cell infiltration of the mucosa.
Eosinophils constitute the principal component of this
infiltrate [12].
The aim of this study was to analyze the
composition of inflammatory infiltrate in the gastric
mucosa of patients with food and airborne allergies.
MATERIAL AND METHODS
This study included 60 patients: 30 with airborne
allergy and 30 with food allergy, as well as 20 healthy,
allergy-free individuals. The patients were hospitalized
at the Clinic of Allergology, Clinical Immunology and
Internal Diseases of the L. Rydygier Collegium
Medicum in Bydgoszcz at Nicolaus Copernicus
University (NCU) in Torun due to the exacerbation of
an allergic condition. The controls (healthy volunteers)
were not allergic and did not report any dyspeptic
symptoms. The group of allergy patients included 38
women and 22 men aged between 18 and 65 years
(mean of 37.3 years). The control group was comprised
of 12 women and 8 men aged between 20 and 65 years
(mean of 42.2 years).
The study’s basic inclusion criterion included
dyspeptic symptoms reported in individuals aged
between 18 and 65 years and co-existing with the
exacerbation of an allergic condition.
The exclusion criteria included the presence of
severe chronic organic disorders such as necrotic
colitis, Crohn’s disease, intestinal fistulas, coeliac
disease, bacterial and fungal enteritis, disaccharide
intolerance, colorectal tumors, malignant diseases,
states after the resection of the stomach or intestines,
parasitic infections, hyperthyroidism, acute and chronic
leukemia, lymphoma, urinary tract infections,
tuberculosis, administration of oncological treatment,
Composition of inflammatory infiltrate in the gastric mucosa of patients with food and airborne allergies
immunotherapy or other agents that could potentially
modulate studied immunological parameters.
Medical history was collected from all patients
qualified to this study with particular attention paid to
the signs of allergic disorders and their association
with exposure to airborne and alimentary allergens.
Subsequently, routine physical examination focusing
on the alimentary tract function was performed.
Additionally, skin prick tests with alimentary and
airborne allergens were carried out using standard
allergen kits (Allergopharma). The result of the test
was considered positive if the reaction to the tested
allergen (blister diameter) was equal to or greater than
the reaction to histamine. The tests were performed at
the Allergology Clinic Skin Tests Laboratory in
Bydgoszcz.
Finally, the participants were subjected to
endoscopic examination of the upper alimentary tract
that evaluated the macroscopic appearance of the
gastric mucosa, its motility, and the secretory activity
of the stomach. Additionally, mucosal biopsies were
taken for histopathological examination and testing for
H. pylori infection. Histopathological examination was
performed at the Department of Pathomorphology of
the Dr. J. Biziel University Hospital No. 2 in
Bydgoszcz. The degree of gastric mucosa
inflammation was graded using the Sydney system
with the Houston modification. Special attention was
paid to the composition of cellular infiltrate, in
particular to the presence and count of eosinophils.
These parameters were assessed with 10HPFx250
method (sum of the cells in 10 high-power fields 250
x; divided by 10). Colonization with H. pylori was
analyzed histopathologically using hematoxilin, eosin,
and Giemsa’s staining. Presence of colonization was
expressed as (+), while the lack of the bacterium was
designated as (–).
Statistical analysis
The Mann-Whitney U test was used to study
intergroup difference in analyzed parameters.
Quantitative variables were presented as arithmetic (x)
and geometric means (g), and their standard deviations
(s).
RESULTS
Endoscopy of the upper alimentary tract was
performed in all the participants; specimens from the
antrum and body of the stomach were collected. The
91
histopathological examination of antral biopsy
specimens revealed chronic gastritis in 26 (87%)
patients from the food allergy group, in 20 (67%)
individuals with an airborne allergy, and in 9 (45%)
controls. Corporal specimens showed chronic gastritis
in 14 subjects (47%) from the food allergy group, in 12
patients (40%) with an airborne allergy, and in 6
individuals (30%) from the control group.
Eosinophils were found in the biopsies of gastric
mucosa originating from 12 (40%) food allergy
patients (including 5 patients [17%] with eosinophilia;
≥ 10 cells per field of view [FOV]), 8 (27%)
individuals with airborne allergy (2 cases with ≥ 10
cells per FOV), and two controls (none with ≥ 10 cells
per FOV). Compared to the controls, patients with food
allergies were characterized by significantly higher
prevalence of eosinophilic infiltrates (p=0.0206); there
were no other significant intergroup differences in
regards to this parameter.
Colonization with Helicobacter pylori was
confirmed in 9 (30%) subjects with food allergy, 6
(20%) individuals with airborne allergy, and in 10
(50%) controls. These three groups did not differ
significantly in terms of HP colonization rates.
DISCUSSION
Nutrition is a basic physiological need. During the
entire life, an average human ingests approximately 60
tons of food and drinks about 400 hectoliters of fluids
[13]. Since the largest accumulation of lymphatic
tissue lies within the alimentary tract, consuming such
vast quantities of food, containing high amounts of
potential allergens, suggests that this vital function is
possible solely due to the elimination of improper
immune response to ingested products, i.e. the
development of specific tolerance status [14]. The
gastrointestinal barrier plays a key role in this process;
its injury is associated with an enhanced interaction
between allergens and the immune system of the
alimentary mucosa [15,16]. Food allergy is associated
with the improper uptake of antigens and secondary
synthesis of IL-4 by Th2 cells. IL-4 is a cytokine
necessary both in the process of lymphocyte B
differentiation into IgE producing cells, as well as
during the synthesis IL-5, which subsequently is
responsible for the activation of eosinophils [17].
Repeated exposure of predisposed individuals to food
allergens can cause local allergic reaction in the form
of gastritis; eosinophils play a vital role in the
92
Andrzej Kuźmiński et. al.
inflammatory infiltrate observed in such cases [11].
Moreover, eosinophils are important in the induction
and maintenance of gastritis as suggested by elevated
serum levels of IL-5 observed in food-sensitive
patients [19].
While the involvement of eosinophils in the allergic
conditions of respiratory tract is well established, their
role in the alimentary allergies was recognized quite
recently [20], in spite of the fact that patients with food
allergies constitute a group where the association
between tissue eosinophilia and allergy is particularly
evident [21]. This relationship has been a subject of
several interesting studies. Graczyk et al. observed the
presence of eosinophils in 42% of patients with food
allergy.
In
those
patients,
histopathological
examination of the gastric mucosa biopsy specimens
revealed that as many as 20% of cases exhibited
eosinophilia exceeding 10 cells per FOV.
Corresponding values in individuals without the
allergy amounted to 30% and 6.67%, respectively [11].
Our study of patients with food allergy produced
similar results. In contrast, higher eosinophil
prevalence rate in gastric mucosal biopsies was
reported by Bartuzi. He revealed eosinophils in all
analyzed biopsies of gastric mucosa from 34 food
allergy patients, and in only 3 out of 10 controls with
dyspeptic symptoms [22].
The reasons behind the higher prevalence of
eosinophils in the alimentary tract mucosa of patients
with food allergies remain unclear. The recruitment
and presence of eosinophils in the alimentary tract are
closely regulated by cytokines (IL-5, IL-3, IL-13, and
GM-CSF) and chemokines (eotaxin, RANTES) [23].
IL-5 is considered the most important eosinophiliapromoting cytokine, and its levels are well correlated
with the presence of eosinophils in the inflammatory
infiltrate of patients with chronic gastritis and food
allergy [19]. Eosinophil recruitment into the alimentary
tract is also modulated by IL-13 and locally released
chemokines: predominantly by eotaxin-1, expression
of which is most pronounced in the lamina propria.
The lack of eotaxin-1, or its eosinophil receptor
(CCR3), is reflected by the absence of eosinophils in
the alimentary tract wall. Other factors that can induce
selective migration of eosinophils into the alimentary
tract wall include α4β7 integrin, present on the surface
of eosinophils, and its ligand MAdCAM-1 expressed
on the endothelial surface of venous vessels of the
intestinal lamina propria. Eosinophils with α4β7
integrin expression are postulated to undergo selective
accumulation in the lumen of small intestine; while the
recruitment of eosinophils to the colonic wall is
predominantly modulated by ICAM-1 adhesion
molecule [24].
Maintenance of the intestinal barrier is postulated
to be the principal function of the alimentary tract
eosinophils. On the one hand, eosinophils can be
activated by the cytokines released by Th lymphocytes;
on the other, they can also present antigens to T
lymphocytes modulating their function in this way.
Furthermore, eosinophils can influence the intestinal
nervous system by means of VIP, substance P,
serotonin, histamine and leukotriene secretion; this is
reflected by the remodeling of nerve fiber network and
changes in their activity as well as by an enhanced
transcription of neurotransmitter genes. These changes
seem particularly important in the context of
eosinophilic disorders of the gastrointestinal tract that
are associated with higher „sensitivity” of involved
organs and the impairment of their motility.
Furthermore, eosinophils can participate in the repair
of injured gastrointestinal epithelium, releasing TGF-β
and fibroblast growth factor. However, it is likely that,
depending on signaling, eosinophils can be involved
both in the destruction and repair of the epithelial cells
[24].
Besides physiological conditions, eosinophils can
also be involved in the pathological processes of the
gastrointestinal tract. Increasing prevalence of
eosinophilic gastrointestinal disorders (EGID):
eosinophilic esophagitis, gastritis, gastroenteritis,
enteritis, and colitis, has been pointed out in literature
published in the last two decades. While the reason
remains unclear, potential involvement of allergic
factors is being postulated, particularly in children with
atopy [20]. T cell activation by such food allergens as
the proteins present in cow’s milk, eggs, wheat, nuts,
and pork can play the principal role in this setting [25].
Almansa noticed the seasonal character of this
condition in adults and suggested that its pathogenesis
may involve the potential involvement of inhalatory
allergens [26]. Moreover, as revealed by Mishra,
aeroallergens may possibly play an important role in
the induction of eosinophilic esophagitis [27]. Recent
studies have documented an association of eosinophilic
duodenal infiltration with asthma and allergic rhinitis
(AR), as well as between the esophageal infiltration
and AR, and the colonic infiltration and atopic
dermatitis [24]. However, despite extensive research it
is still unclear why eosinophils migrate into specific
Composition of inflammatory infiltrate in the gastric mucosa of patients with food and airborne allergies
parts of the gastrointestinal organs without
simultaneous involvement of the other segments. The
results of some studies point to possible stimulation of
immune system by various allergens, including
inhalatory and food allergens. Perhaps this stimulation
causes the activation of pro-inflammatory cytokines,
mainly IL-3, IL-5, IL-13, and GM-CSF, constituting
the essence of the inflammatory process and being
responsible for the formation of clinical signs [28].
As previously mentioned, the association between
eosinophilia and allergy is particularly evident in
patients with allergic conditions of the gastrointestinal
tract [29]. Our study showed significant differences in
the eosinophil prevalence rate in the biopsies of gastric
mucosa: eosinophils were found in 40% of patients
with food allergies, but in only 27% of subjects with
airborne allergies, and in 10% of the controls.
Eosinophil count ≥10 per FOV was assumed as the
significant cut-off value during histopathological
examination of gastric mucosal biopsies. Such high
eosinophil count was observed in 17% of patients with
food allergies and in 10% of individuals with airborne
allergies; in contrast, eosinophil count did not exceed
10 cells per FOV in any of the controls.
Helicobacter pylori is the most frequent etiological
factor in chronic gastritis. Inflammation caused by HP
infection is characterized by a diffuse, superficial or
deep, infiltration of lamina propria with mononuclear
cells and neutrophils [30]. The results of previous
studies
examining
the
association
between
Helicobacter pylori infection and allergic processes of
the alimentary tract suggested a possible correlation
between these two factors in the development of
pathological gastrointestinal lesions. Mucosal injury
resulting from infection with this microorganism is
postulated to facilitate the transepithelial penetration of
food allergens. Moreover, it was revealed that
Helicobacter pylori can induce the migration of
eosinophils, being an important component of allergic
inflammatory infiltrate, to the alimentary tract tissues
[31]. In this study, the colonization of gastric mucosa
with HP was considerably more frequent in healthy
controls without concomitant allergic disorders and
alimentary complaints (50%) than in patients with
established food or airborne allergy, whose
colonization rates amounted to 30% and 20%,
respectively.
93
CONCLUSIONS
1.
2.
Compared to the controls, patients with food
sensitivity of allergic origin were characterized by
significantly higher prevalence of eosinophils
within inflammatory infiltrate. No significant
differences in regards to this parameter were
documented between food and airborne allergy
patients as well as between individuals with
airborne allergy and the controls. These findings
confirm the importance of eosinophils in the
development of gastritis in atopic patients.
Colonization of gastric mucosa with Helicobacter
pylori was less frequent amongst airborne (20%)
and food allergy patients (30%) than in the
controls (50%); this suggests a potential
preventative role of the infection in allergy
development.
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Address for correspondence:
Szpital Uniwersytecki nr 2
ul. Ujejskiego 75
85-168 Bydgoszcz
tel./fax: 052 3655416
e-mail: [email protected]
Received: 10.01.2012
Accepted for publication: 6.03.2012
Medical and Biological Sciences, 2012, 26/2, 95-100
Iwona Łopacińska¹, Małgorzata Wojciechowska²
NURSES VS ISO IN A HOSPITAL
PIELĘGNIARKI WOBEC ISO W SZPITALU
¹Clinical Nursing Faculty
University of Humanities and Economics in Łódź
Head of the Faculty: Zbigniew Tokarski, PhD
²Collegium Masoviense Nursing Institute
Wyższa Szkoła Nauk o Zdrowiu
Head of the Institute: Małgorzata Wojciechowska, PhD
Summary
ISO based Quality Management System in healthcare
facilities in Poland is no longer a novelty. Its implementation,
however, requires medical personnel to expand their
knowledge and accept the fact that medical service is a
medical product. In order for a medical service to be of high
quality, personnel should be familiar with medical services
marketing. Processes used as a result of standards’
implementation are a significant change for healthcare
workers but having a quality management system certificate
became a standard.
The aim of this work was to present the state of
knowledge concerning nursing personnel readiness to
implement the standards.
In this work a diagnostic survey method was used,
questionnaire was the technique used and as a research tool
– the authors’ own survey questionnaire consisting of both
closed and open questions.
The study was conducted among nursing personnel
working in hospital wards before and after the introduction of
ISO 9001 based Quality Management System.
Own studies revealed that before the implementation of
ISO the nursing personnel was apprehensive about the
changes related to it (53.22%), with only 28.65%
unconcerned about it and 18.13% unable to decide. The
research showed that the nurses surveyed were likely to
claim that their work organization improved after the
introduction of the Standards (48.54%), with only 19.30%
thinking it did not change, and 32.16% claiming it improved
to a small degree. According to the nurses, implementation of
the standards in hospitals encourages people to pursue
education or learn by themselves (67.84%), with 18.71%
respondents saying it does not encourage them and 13.45%
were undecided. The respondents most often thought that
implementation of standards will contribute to increase of
customer satisfaction with the quality of the offered services
(82.46%), while 17.54% respondents thought the opposite.
Streszczenie
System Zarządzania Jakością wg ISO w zakładach opieki
zdrowotnej w Polsce nie jest już nowością. Jednak jego
wdrożenie wymaga od personelu medycznego poszerzenia
wiedzy z tego zakresu, zaakceptowania faktu, że usługa
medyczna jest produktem medycznym. Aby usługa
medyczna była wysokiej jakości personel powinien
legitymować się
wiedzą z zakresu marketingu usług
medycznych. Dla pracowników ochrony zdrowia znaczącą
zmianą są procesy zachodzące
w wyniku wdrażania
normalizacji, jednak legitymowanie się certyfikatem systemu
zarządzania jakością stało się powszechnie obowiązującym
standardem.
Celem pracy było ukazanie wiedzy na temat
rzygotowania personelu pielęgniarskiego do wdrożenia
normalizacji.
W pracy zastosowano metodę sondażu diagnostycznego,
techniką była ankieta, narzędziem badawczym był autorski
96
Iwona Łopacińska, Małgorzata Wojciechowska
kwestionariusz ankiety składający się z pytań mających
charakter zamknięty i otwarty.
Badania
przeprowadzono
wśród
personelu
pielęgniarskiego pracującego na oddziałach szpitalnych
przed i po wprowadzeniu Systemu Zarządzania Jakością wg
Normy ISO 9001.
Z przeprowadzonych badań własnych wynika, iż przed
wdrożeniem ISO personel pielęgniarski obawiał się
związanych z tym procesem zmian (53,22%), nie miało obaw
tylko (28.65%) nie potrafiło jednoznacznie odpowiedzieć
(18.13%). Badania wykazały, że ankietowane pielęgniarki
częściej twierdziły, że ich organizacja pracy po
wprowadzeniu Norm poprawiła się (48,54%), nie uległa
zmianie ( 19.30%) oraz poprawiła się w niewielkim stopniu
(32,16%). Pielęgniarki uważały, że wdrożenie normalizacji w
szpitalu zachęca do kształcenia i samokształcenia, (67,84%)
nie zachęca (18,71%) nie miało zdania (13,45%). Najczęściej
respondenci uważali, że wdrożenie normalizacji przyczyni
się do wzrostu zadowolenia klienta z jakości oferowanych
usług (82.46%) inne, przeciwne zdanie miało (17,54%)
badanych.
Key words: hospital, organisation, service, quality management system
Słowa kluczowe: szpital, organizacja, usługa, system zarządzania jakością
INTRODUCTION
Requirements of the ISO 9001 standard, which is
the basis of quality systems certification as well as the
requirements listed in accreditation standards, are
today a well known tool for managing the quality of
services provided in healthcare. These processes,
despite being so popular, when introduced in medical
organisations are opposed to and criticised by both
personnel and patients. The former oppose the
excessive red tape required in order to prepare the
procedures. However, this is the case only if the set of
specification guidelines is excessively complex. Both
the ISO 9001-2000 standard and its amendment from
2008 require six documented procedures: control of
documents, control of records, internal audit, control of
nonconforming product and corrective and preventive
measures procedure. Patients always assess the quality
of healthcare services provided by all healthcare
workers in the process of diagnostics, treatment and
rehabilitation in a subjective way. Subject to their
assessment is not only the work of doctors, nurses,
rehabilitators but also the pharmacy facility, food
facility, the registration queue. There are quite many
negative comments from patients related to certain
parts of the whole medical service only.
Accreditation means that an authorised body issues
a formal certificate confirming that the unit providing
health care is competent to provide such services,
meeting the accreditation standards. The Polish
medical facilities accreditation system complies with
the Act of 6th November 2008 on accreditation in
health care, the Act of 30th August 2002 on conformity
assessment system, as well as the Ordinance of the
Minister of Health of 31st August 2009 on the
procedure assessing meeting by the healthcare
providing unit the accreditation standards and the
amount charged for their introduction [1, 2, 3]. The
starting point in accreditation proceedings is preparing
self-assessment, including the report and then
implementing the defined standards. The central unit
within the Ministry of Health established in order to
inspire, support and develop activities aiming at
improvement of the quality of healthcare services in
medical organisations is Krakow based Centrum
Monitorowania Jakości w Ochronie Zdrowia (Centre
for Quality Monitoring in Healthcare). Presently, the
Centre in a systemic beneficiary carrying out a project
co-funded by the European Union within the
framework of European Social Fund, which is a part of
Human Capital Operational Programme, activity 2.3
Strengthening the health potential of the working
persons and quality improvement of healthcare system
functioning, Sub-measure 2.3.3 Enhancement of the
healthcare management quality. The aim of the project
is obtaining the accreditation certificate by 188
hospitals in years 2009-2014 [4]. The certification
process, according to ISO regulations, involves
designing a quality system project and launching it.
The system is specified in documents, the key part of
which is the Quality Manual containing: the policy of
an organisation, quality aims, organisational structure,
responsibility, a general quality system inventory,
quality system documentation structure and
distribution. The second stage constitutes the
procedures describing the objective and the scope of
activities as well as the method of operation [5,6].
Accreditation of facilities offering health services is
well rooted in the healthcare system and the standards
of conduct are defined by medical professionals. The
ISO system encounters various barriers in the process
of implementation, one of them being non-medical
terminology, a specific language unrelated to medical
industry. The prototype for ISO standards of 9000
Nurses vs ISO in a hospital
series was the BS 5750 series designed in Great
Britain. In 1987 the International Organisation for
Standardization (ISO) approved it for use. The
standards of ISO 9000 family series were amended in
1994, then in 2000 the structure of quality assurance
standards was simplified, which resulted in
replacement of three standards (ISO 9001-1994, ISO
9002-1994, ISO 9003-1994) with one, for
documentation of companies’ quality system
credibility: ISO 9001-2000 Requirements. This is a
universal standard which can be used by any
organization, regardless for their type, size, and
delivered product.
ISO standards have gradually encompassed more
and more fields, which necessitated another
amendment in 2008, when PN-EN ISO 9001-2009
standard was established. An obligation resulting from
the standardization is use of PDCA method to all the
processes occurring in the organisation:
• P – Plan; means planning, i.e. specifying
goals and processes necessary to provide
results compliant with the organisation’s
policy and the requirements of a recipient.
• D – Do; means being active, i.e. completing
processes to get the result.
• C – Check; by use of measurement tools
monitor the processes and products in relation
to the organisational policy, goals of the
organisation and customer’s requirements.
• A – Action; be active in the field of
continuous improvement and functioning of
processes [6,7].
In the ISO implementation process in an
organisation it is important for every member of the
organisation implementing the change to have the
same knowledge regarding the quality management
system and understand the priorities and the ways to
achieve them in the same way. The result of work of
a multidisciplinary medical team is patient’s health
improvement. Healthcare, and especially reparative
medicine, always finds a service buyer. Polish
society is aging. According to GUS, (Central
Statistical Office) in 2000 the percentage of elderly
people was 12.4%. The percentage of people in postproductive age increased to 17% in 2010, while
average life expectancy in Poland in 2009 was over
70 for men, and 80 for women. The estimates of the
Central Statistical Office are quite frightening – in
2020 every fifth Pole will be a senior [8,9]. The fact
is confirmed both by the GUS data and long waiting
97
lists for an appointment with a specialist and distant
dates of treatments. Introduction of a quality
management system does not bring immediate
financial benefits. However, the main reason for
service providers to take interest in quality
management systems compliant with ISO standards
are customers that require them to provide certified
management system services. Another reason for
implementation of ISO standards is thinking of a
quality management system as of a tool for arranging
and improving the service-related processes [6]. If
one analyses the ISO 9001 standard and Centre for
Quality Monitoring in Health Care accreditation
requirements carefully and without any bias, it may
be concluded that their proper use results in order, it
lays out the paths to follow in order to reduce the
risk of errors, and should they occur – suggests the
proper way of dealing with them. Implementation of
ISO standards in an enterprise makes it possible to
arrange and formalise the company management
system. According to the reference books, an
implemented system introduces the structure of
responsibility, it clearly defines the rules of company
functioning, making possible improvement of its
internal operations; it also gives the employees
possibility to get a full picture of their facility
development [6]. When implementing the quality
management system according to ISO standards, one
should devote considerable amount of time to
content-related interpretation of the specific
standards in the medical context. With respect to a
common practice of leaving documents such as
temperature chart by patients’ beds one should refer
to section 4 of the Standard: “Control of documents”
and its subsections. The provision of this standard
refers to the procedure of control of documents,
control of records, as well as rules of preparing
quality records, the way to identify, protect, store
and update the documents. This issue is also dealt
with in accreditation requirements which clearly
specify information management (IM). Fulfilment of
this condition means that a hospital must develop a
system for storing and processing data. The last two
subsections that need emphasising are the rules of
making the data within the hospital and outside it, as
well as the rules for communication with the
personnel, patients, local community, external
partners, the media available. All newly introduced
things need to pass through the stages of learning
98
Iwona Łopacińska, Małgorzata Wojciechowska
and approval. Before implementation of system
documents employees should undergo training.
The subject of the training should include: basic
terminology in relation to quality systems, the
standard requirements, quality management system
documents. It should also include the methods
employed by a quality management system such as
audit, types of improvement activities, and most of
all the role of employees in the quality management
system. In face of hardly any reforms, healthcare
facilities should pay special attention to forming
proper attitudes and behaviour of their staff, which
can be achieved by engaging the staff in company
management [10].
OBJECTIVE OF THE WORK
The aim of the work was to present the state of
knowledge concerning preparation of nursing
personnel to implement standards.
This includes especially:
1. Taking into consideration the feelings of nursing
staff.
2. Presenting opinions on system implementation.
3. Getting opinions on whether standards’
implementation in hospitals encourages nurses to
pursue education or self-education.
4. Getting
opinions
concerning
whether
standardization will contribute to greater
customer satisfaction with the quality of services
offered.
were unconcerned, 18% could not decide. This may
mean that the nursing personnel were unprepared for
system implementation (Table I). The conducted
research revealed that the nurses surveyed were more
likely to say that organisation of their work after the
standardisation improved (48%), while according to
19% it did not change and according to 32% it slightly
improved (Table II). According to the research, nurses
thought that implementation of the standards in a
hospital encourages them to pursue education and selfeducation (68%), with 19% claiming it did not
encourage them and 13% having no opinion (Table
III). Respondents most often claimed that
implementation of the standards would contribute to
greater customer satisfaction with the quality of offered
services (82%), while 18% of respondents thought to
the contrary (Table IV).
Table I. Opinion on whether implementation of the standards
in hospitals raised concerns in relation to changes at
the nurse’s workplace.
Tabela I. Opinia na temat, czy wdrożenie normalizacji w
szpitalu spowodowało obawy związane ze
zmianami na stanowisku pracy pielęgniarki
Job position
Stanowisko
pracy
Nurses
Pielęgniarki
Yes/tak
No/nie
Don’t
know
/nie
wiem
n%
n%
n%
n%
91
49
31
171
53.22%
28.65%
18.13%
100.00%
Total
Razem
2
Statistical analysis: Chi =1.09; p=0.58
Analiza statystyczna: Chi2=1.09; p=0.58
THE METHOD AND MATERIAL
In this work a diagnostic survey method was used,
questionnaire was the technique used, the research tool
– the authors’ own survey questionnaire consisting of
both closed and open questions.
The study was conducted among nursing personnel
working in hospital wards before and after the
introduction of ISO 9001 based Quality Management
System. The surveyed group consisted of 171 people,
163 of them being women, 8 – men. The respondents
were aged between 25 and 50.
RESULTS
The results of the research show that before the
implementation of ISO, 53% of the nursing personnel
were apprehensive about the changes it involved, 29%
Table II. Opinion on whether the organization of nurses’
work changed after the introduction of standards
Tabela II. Opinia na temat, czy po wprowadzeniu normalizacji organizacja na stanowisku pielęgniarki
uległa zmianie
Job position
Stanowisko
pracy
Nurses
Pielęgniarki
Improved
Poprawiła
się
didn’t
change
Nie
uległa
zmianie
slightly
improved
Poprawiła
się w
niewielkim
stopniu
Total
Razem
n%
n%
n%
n%
83
33
55
171
48.54%
19.30%
32.16%
100.00%
Statistical analysis: Chi2=9.57; p=0.008*
Analiza statystyczna: Chi2=9.57; p=0.008*
Nurses vs ISO in a hospital
Table III. Opinion on whether the standards’ implementation
in hospitals encourages nurses to pursue education
and self-education
Tabela III. Opinia na temat, czy wdrożenie normalizacji
w szpitalu zachęca pielęgniarki do kształcenia
i samokształcenia
Job Position
Stanowisko
pracy
Nurses
Pielęgniarki
Yes
Tak
No
Nie
Don’t
know
Nie wiem
Total
Razem
n%
n%
n%
n%
116
32
23
171
67.84%
18.71%
13.45%
100.00%
Statistical analysis: Chi2=4.65; p=0.10
Analiza statystyczna: Chi2=4.65; p=0.10
Table IV. Opinion of nurses on whether standards’
implementation will contribute to increased
customer satisfaction with the services offered
Tabela IV. Opinia pielęgniarek na temat, czy wdrożenie
normalizacji przyczyni się do wzrostu zadowolenia klienta z jakości oferowanych usług
Job Position
Stanowisko pracy
Nurses
Pielęgniarki
No/tak
No/ don’t
know
Nie/nie
wiem
n%
n%
n%
141
30
171
17.54%
100.00%
82.46%
Total
Razem
2
Statistical analysis: Chi =13.65; p=0.0002*
Analiza statystyczna: Chi2=13.65; p=0.0002*
DISCUSSION
A few years ago companies that applied for ISO
Standard certificate wanted to function in a better way
on the market and improve their chances of getting
subsidies. Nowadays, apart from the marketing aspect
of the quality certificate, there is also the issue of
company operations optimisation, eagerness to predict
risks and any adverse phenomena as well as taking
such effective measures as to prevent them. The
attempts to reform the Polish healthcare system do not
bring any visible results. This is especially difficult for
patients who have no access to certain medical
services, and also for personnel who notice the
growing debts that the healthcare facilities gradually
incur. A major problem that becomes noticeable on
Polish streets is the fact of ageing of the society. In
face of such an unfavourable situation of the healthcare
industry, the modifier of the possibility to impact on
the hospital staff and on the society – the patients in the
99
hospital, was standardisation. The research shows that
over a half of nursing personnel were concerned about
the changes involved in the change process, while only
one third of the respondents were unconcerned. This
may mean that the personnel were unprepared for
system implementation. A prerequisite to get
employee's support for the introduced changes is to use
the right arguments for presenting advantages and
disadvantages resulting from such changes. Part of the
preparation to system implementation, as explained by
the authors of ‘System Zarządzania Jakością według
ISO 9001-2008’ (ISO 9001-2008 Quality Management
System) brochure, are: clear formulation of objectives,
aims of the organisation, and tasks assigned the staff as
well as transparent flow of information. 18% of
respondents were unable to provide a straightforward
opinion on the changes involved in implementation of
the standards. Also ISO 9001 standard in section 6.2
forces employers to actively train their employees [5].
The conducted research confirmed that the
organisation of work after the introduction of the
Standards improved according to half of the
respondents. 19% of respondents claimed the work
organisation did not change, and 32% perceived a
slight improvement. This may indicate that employees
do not have current data concerning the system and
they are burdened with more work than they can cope
with in relation to preparing documents. An analysis of
the results allows us to presume that for with many
employees adapting to and accepting the changes may
take more time than for the others. In recent years it
has been noticeable how nursing personnel increased
their skills. Persons that are regarded authorities in the
field of healthcare claim that improvement of skills
allows breaking through a barrier between particular
teams of employees and between employees and
managers. Employees that are involved in their own
education become advisors for those in charge [11].
The majority (68%) of respondents thought that
standards implementation in hospitals encourages them
to pursue education and self-education, while 19% said
they were not encouraged and 13% did not have any
opinion. Each staff member in their job position should
display knowledge, skills and competences, so in order
to keep up with the new developments in all the fields
of science and economy it is necessary to continuously
raise qualifications. The awareness of processes
undergoing in the organisation strengthens the
employees’ motivation and results in satisfied
customers. Majority of the respondents thought that
100
Iwona Łopacińska, Małgorzata Wojciechowska
implementation of the standards would contribute to
increase of customer satisfaction with the quality of
services offered (82%). However, the co-responsibility
for building the organisational/hospital culture is not
shared by every nurse surveyed as 18% of respondents
were of different opinion. One may suppose that those
people feel comfortable within the former structures
and may take some time before they become advocates
of the standards’ implementation.
CONCLUSIONS
The conducted research and its analysis allow the
following conclusions:
1. The standards’ implementation in hospitals
raised some concerns among 53% nurses in
relation to the changes in their workplace,
while 29% remained unconcerned and 18%
were unable to say.
2. Nursing personnel was likely to admit that
their work organisation improved after the
introduction of the Standards (48%), while
19% were of opposite opinion and 33%
thought it only improved slightly.
3. Majority of the respondents (68%) claimed
that the standards’ implementation in their
hospital encouraged them to pursue education
and self-education, while 19% were not
encouraged and 13% were of no opinion.
4. The standards’ implementation will contribute
to greater customer satisfaction with the
quality of services offered according to 82%
of respondents, while 18% were of different
opinion.
REFERENCES
1. Act of 6th November 2008 on accreditation in
healthcare. Dz. U. (Official Law Journal) of 2009 no.
52, item 418, no. 76, item 641.
2. Act of 30th August 2002 on compliance assessment
system Dz.U. (Official Law Journal) of 2002 no. 166,
item 1360, of 2003 no. 80, item 718, no. 130, item
1188, no. 170, item 1652, no. 229, item 2275.
3. Ordinance of the Minister of Health of 31st August
2009 on the procedure assessing meeting by the health
care providing entity the accreditation standards and
the amount of fees for their introduction.
4. www.cmj.org.pl 06.01.2012
5. PN-EN ISO 9001-2009.
6. Urbaniak M.: Zarządzanie jakością środowiskiem oraz
bezpieczeństwem w praktyce gospodarczej. DIFIN,
Warszawa 2007
7. www.iso.org/iso/homel 06.01.2012
8. www.stat.gov.pl/gus 06.01.2012
9. Płotek W.: Starzenie się ośrodkowego układu
nerwowego i anestezja. “Anestezjologia i Ratownictwo” 2008. no. 1. p. 35-43.
10. Opolski K, Dykowska G, Możdzonek M.: Zarządzanie
przez jakość w usługach zdrowotnych. Warszawa,
CeDeWu 2009.
11. Lewandowski R., Preus A., Ochyra I. i wsp.: System
Zarządzania Jakością według ISO 9001-2008 –
wdrażanie i organizacja. Wiedza i Praktyka, Warszawa
2010.
Address for correspondence:
Clinical Nursing Faculty
University of Humanities and Economics in Łódź
90-222 Łódź
ul. Rewolucji 1905 roku nr 52 i 64
Head of the Faculty
Zbigniew Tokarski, PhD
tel.: +48 42 299 55 73
fax: +48 42 299 56 74
Collegium Masoviense Nursing Institute
Wyższa Szkoła Nauk o Zdrowiu
96-300 Żyrardów, ul. G. Narutowicza 35
Head of the Institute
Małgorzata Wojciechowska, PhD
tel.: 601 24 11 25, fax: 46 855 46 64
e-mail: [email protected]
Received: 10.01.2012
Accepted for publication: 6.03.2012
Medical and Biological Sciences, 2012, 26/2, 101-104
Katarzyna Napiórkowska, Krzysztof Pałgan, Ewa Gawrońska-Ukleja, Magdalena Żbikowska-Gotz,
Joanna Kołodziejczyk, Milena Wojciechowska, Małgorzata Graczyk, Ewa Szynkiewicz, Robert Zacniewski,
Zbigniew Bartuzi
THE ROLE OF SKIN PRICK TEST IN DIAGNOSIS OF FOOD ALLERGY
IN PATIENTS WITH BIRCH POLLINOSIS
ROLA TESTÓW SKÓRNYCH W DIAGNOSTYCE ALERGII POKARMOWEJ
U PACJENTÓW UCZULONYCH NA PYŁKI BRZOZY
Department and Clinic of Allergology, Clinical Immunology and Internal Diseases
Collegium Medicum in Bydgoszcz, UMK in Toruń
Head: prof. dr hab. n. med. Zbigniew Bartuzi
Summary
I n t r o d u c t i o n . The incidence of food allergy is
constantly growing. Particularly high percentage of patients
is allergic to pollens - even 70 % of patients with a pollen
allergy suffer from undesirable symptoms that appear after
eating plant foods. It is connected mainly with crossreactivity between allergens. The fact that manifestations of
food allergy concern different systems and organs is a
problem and it causes diagnosing food allergy difficult and
often underestimated.
T h e a i m o f t h i s s t u d y was to determine the
role of skin prick tests in the diagnosis of food allergy in
patients with birch pollinosis.
M a t h e r i a l a n d m e t h o d s . 35 patients with
birch pollinosis suffering after eating apple, celery, carrot,
tomato, banana, peach, peanut and hazelnut were included
to the study. The skin prick tests with applying extracts of
allergens mentioned above were determined for all
individuals.
R e s u l t s . The analysis of the results of positive skin
prick tests in patients reporting manifestations was as
follows: celery 100 %, hazelnut 65.4 %, peanut 40 %, carrot
30.8 %, peach 20 %, tomato 14.3 %, apple 3.7 % and banana
0 %. In the skin prick tests, negative results were also
achieved, although patients reported appearance of
symptoms of sensitivity to given allergens: apple (74.3 % of
persons), peach (34.3 % of persons), the hazelnut and the
carrot (25.5 % for each of allergens), the tomato and the
peanut (17.1 % for each of allergens) and banana (11.4 %). It
is interesting that some of the patients had positive test
results for the celery (22.8 %), although they did not report
symptoms of oversensitivity to this kind of food.
C o n c l u s i o n s . Although skin prick tests are
a universally used diagnostic method but in case of food
allergy, the negative result cannot be a criterion which results
in excluding this diagnosis .
Streszczenie
W s t ę p . Częstość alergii pokarmowej stale wzrasta.
Szczególnie wysoki odsetek dotyczy pacjentów uczulonych
na pyłki roślin - nawet u 70 % pacjentów z alergią na pyłki
roślin występują objawy niepożądane po spożyciu pokarmów
pochodzenia roślinnego. Związane jest to głównie
z występowaniem reakcji krzyżowych między alergenami.
Problemem jest fakt, że objawy te dotyczą różnych układów
i narządów, co sprawia, że rozpoznanie alergii pokarmowej
jest utrudnione i często niedoszacowane.
C e l e m p r a c y było określenie roli testów skórnych
w diagnostyce alergii pokarmowej u pacjentów uczulonych
na pyłki brzozy.
M a t e r i a ł i m e t o d y . Do badania zakwalifikowano 35 pacjentów uczulonych na pyłek brzozy, którzy
zgłaszali jednocześnie objawy niepożądane po spożyciu
102
Katarzyna Napiórkowska et. al.
jabłka, selera, marchwi, pomidora, banana, brzoskwini,
orzechów laskowych i orzeszków ziemnych. U wszystkich
pacjentów wykonano testy skórne z zastosowaniem
wyciągów wyżej wymienionych alergenów.
W y n i k i . Analiza wyników dodatnich testów skórnych
u pacjentów zgłaszających objawy przedstawiała się
następująco: seler 100%, orzech laskowy 65,4%, orzeszek
ziemny 40%, marchew 30,8%, brzoskwinia 20%, pomidor
14,3%, jabłko3,7% oraz banan 0%. W testach skórnych
uzyskano również wyniki ujemne, pomimo, że pacjenci
zgłaszali objawy na dane alergeny. Przedstawiały się one
następująco: jabłko (74,3% osób), brzoskwinia (34,3% osób),
orzech laskowy i marchew (25,5% dla każdego z alergenów),
pomidor i orzeszek ziemny (17,1% dla każdego z alergenów)
oraz banan (11,4%). Interesujący jest fakt, że u części
pacjentów uzyskano dodatni wynik testu dla selera (22,8%),
pomimo że osoby te nie zgłaszały objawów nadwrażliwości
na ten pokarm.
W n i o s k i . Choć testy skórne są powszechnie
stosowaną metodą diagnostyczną, w przypadku alergii
pokarmowej ujemny wynik nie może być kryterium
wykluczającym to rozpoznanie.
Key words: food allergy, birch allergy, skin prick tests
Słowa kluczowe: alergia pokarmowa, alergia na pyłki brzozy, testy skórne
INTRODUCTION
Food allergy is a serious and often uderestimated
problem. It might have different symptoms which
result in the fact that before a patient comes to an
allergologist, he/she visits a lot of other specialists
including gastroenterologists. It might be caused by the
fact that very often the only symptoms of allergy are
the stomach ache, constipation and diarrhea. What is
more, the first symptoms appear a long time after
eating the food. In case of immediate reaction the
symptoms might appear after a few minutes but it may
appear even after a few hours when it is the immune
complex allergic reaction [1].
The literature raises also the problem of correlation
between food allergy and the irritable bowel syndrome
(IBS). The research proves that inpatient with irritable
bowel syndrome the incidence of atopy is more
frequent than with general population. Adverse
reaction to specific kind of food occurs in 25-65 % of
patients with IBS. However, the food allergy affects it
more rarely but it does not change the fact that it is
higher in comparison with the population without IBS.
There was also some improvement after following the
elimination diet and applying the sodium
cromoglycate. What is more, patients notice also the
relationship between the food they consume and
occurring disorders. According to some research, 2060% of patients with IBS think that their adverse
reactions result from the food they eat [2, 3].
The incidence of allergy is constantly growing. The
highest percentage of patients is allergic to plant pollen
which is associated with the occurrence of crossreactions between allergens. According to some
authors, even 70% of patients with pollen allergy suffer
because of symptoms appearing in the oral cavity,
after eating vegetable food [1]. That is why the
knowledge of this topic, and especially the symptoms
and useful diagnostic methods, will facilitate the
correct diagnosis and treatment.
MATERIALS AND METHODS
35 patients, over 16 years old, with pollinosis
caused by allergens birch, who were patients of
Allergy Outpatient Clinic of the Cathedral Clinic of
Allergy and Clinical Immunology and Internal diseases
of the Collegium Medicum in Bydgoszcz , were
qualified to the survey . Additionally, they reported
occurrence of adverse symptoms after eating such food
as apple, carrot, celery, tomato, peach, banana,
hazelnuts and peanuts . They were enrolled if they had
pollinosis confirmed by prick skin tests and it was also
suspected that they additionally suffer from food
allergy (subjective test). The group consisted of 22
women and 13 men , at the average age of 35.1± 10.9
years. Prick skin tests, applying allergen extracts
(apple, carrot, celery, tomato, banana, peach, peanuts
and hazelnuts) of the Company Allergopharma were
performed in each of the patients. The technique of the
test was based on the revised Pepys and Bernstein’s
prick method. The Scandinavian method, accepted by
European Academy of Allergology and Clinical
Immunology (EAACI) and commonly used in a
number of clinical centers in Europe and in Poland,
was used to evaluate the tests.
RESULTS
Most patients did not tolerate more than one kind of
food. The greatest number of people (22.8%) from the
test group reported adverse symptoms because 4
different kinds of food, while one patient reported
adverse symptoms after eating 8 different kinds of
food. Table I shows the percentage of people who
The role of skin prick test in diagnosis of food allergy in patients with birich pollinosis
reported adverse symptoms after eating specific kind
of food.
Table I. Percentage of people reporting adverse symptoms
after eating specific kind of food
Tabela I. Odsetek osób zgłaszających objawy niepożądane w
zależności od spożytego pokarmu
Food
The number of people reporting adverse symptoms
Apple
77.1%
Hazelnuts
74.3%
Peach
42.8%
Carrot
37.1%
Celery
34.3%
Peanuts
28.6%
Tomato
20.0%
Banana
11.4%
The analysis of positive skin tests in patient
reporting adverse symptoms ( the ‘true positive’
results) was as follows: celery 100%, hazelnuts 65.4%,
peanuts 40%, carrot 30%, peach 20%, tomato 14.3%,
apple 3.7%, banana 0%. In some cases, despite
adverse symptoms caused by some allergens, the prick
tests gave negative results. The percentage was as
follows: apple ( 74.3% people), beach (34.3%) and
hazelnuts and carrot (both 25.5%), tomato and peanuts
(17.1% for which of these allergens) and banana
(11.4%). Additionally ,in some cases there was a
positive test result for the celery (22.8%) but the
patient did not report any adverse symptoms
(hypersensitivity to this kind of food).
DISCUSSION
In patients allergic to birch pollen there was a
concomitant food allergy because of apples, hazelnuts
and peaches and less often because of carrots, celery,
peanuts, bananas and tomatoes. The adverse symptoms
appeared most often within the oral cavity, lips and
eyes and caused swelling, itching and burning. One
exception was the celery which mainly caused adverse
symptoms in gastrointestinal tract. The other one was
the banana, after eating of which the symptoms
appeared on the skin. The detailed analysis of skin
prick test was shown in table II.
Table II. The analysis of skin prick tests
Tabela II. Analiza wyników testów skórnych prick
Allergen
103
Patients
The number The number of The number of
of people people reporting people, reporting
with the
adverse
adverse
positive test
symptoms
symptoms, with
positive test
result
results
Apple
1
27
3.7%
Celery
20
12
100%
Carrot
4
13
30.8%
Tomato
1
7
14.3%
Banana
0
4
0%
Peach
3
15
20%
Peanuts
4
10
40%
Hazelnuts
17
26
65.4%
The skin prick tests are in fact the basis of modern
allergy diagnostics . They are cheap and easy to apply
and the risk of anaphylaxis is low. What’s more, if
there is such a need, they might be stopped at any time.
They may be treated as a dermal provocative test.
However, we should bear in mind that they are tests
which facilitate diagnosis of allergy, the base of which
are IgE-dependent mechanisms [5, 6].
However, we should remember that, as each of
other methods, skin prick tests have some limitations.
33-64% people from general population have positive
skin test results. In fact, from this number of cases only
15-25% of people suffer from asthma and rhinitis. It
proves that there is a number of people with positive
skin test results who do not have any clinical
symptoms. However, we should remember that
positive results of tests may precede the appearance of
disease that may develop even a few years later. What
is more, there is also a group of patients (10-15%) with
allergy symptoms but with negative prick skin tests [6].
A lot of factors influence the skin tests. False
negative results might result from the fact that the
penetration of the tool in the skin was not sufficient
(application not deep enough), the dilution of the drop
was too high or it had been wiped off before the prick
was performed, which made it impossible to introduce
the allergen into the skin. What is more false negative
results might be caused by some other factors:
improper and too long storage of the allergen extract,
reduced skin reactivity (elderly people and infants),
pathological skin lesion, taking medicines before the
test (e.g. antihistamine, glucocorticoid, and even
antidepressants), and also performing the test
104
Katarzyna Napiórkowska et. al.
immediately after anaphylactic shock, too low dose of
allergen that could cause the reaction ( inter-individual
differences). Sometimes false negative results might be
caused by the mechanisms which are not dependent on
IgE, while false positive results of tests might be
caused by the fact of bleeding in the point of prick, too
high concentration of glycerol in the extract used for
the test , drugs taken by the patient that may increase
the release of the histamine , eating food that might be
the potential allergen or food that contains a lot of
histamine or its precursors (tuna, cheese, cabbage,
spinach, sausages).They are also false positive because
of the active dermographia or acute nettle rash,
application of too high dose of allergen ( high
concentration), cross reaction between homologus
epitopes( substances similar to mediators in their
actions) that emerge during the process of degradation
of allergens , or between non-specific factors
degranulating mast cells. [5, 6, 7].
We have to remember that skin tests allow only
identification IgE –dependent allergy. The negative
result of the test does not exclude the presence of IgE independent allergy. What is more, some symptoms
might be caused by non - allergic oversensitivity to
some additives contained in food or biogenic amines
like histamine.
CONCLUSIONS
Food allergy has a lot of symptoms. When the only
symptom of allergy is chronic rhinitis, hoarseness or
inflammation of the ear the patients turn to the
laryngologist. Symptoms appearing in the digestive
tract (stomach aches, nausea, vomiting, heartburn ,
diarrhea or constipation) with patients having delayed
reactions cause that patients turn to the
gastroenterologist. That is why it is very important to
raise the issue not only with GPs but also with different
specialists . We should remember that when we cannot
find any reasons for the symptoms appearing in a
specific organ or system and the patient does not
respond to the treatment he/she should consult the
allergist. Performed analysis proved that skin tests do
not confirm the diagnosis of allergy in 100%. Their
usefulness in food allergy diagnosis is much lower
than for diagnosis of symptoms caused by allergens
contained in the air. These tests are only the
supplementary analysis which verifies but does not
exclude the disease. Despite of the fact that there are
other diagnostic methods such as patch tests,
determining the level of general and allergen-specific
IgE or provocation test which help to give a proper
diagnosis, the only method of successful treatment of
food allergy is following the diet that excludes food
causing allergy. That is why so much depends on the
doctor to whom the patient turns in the first place.
REFERENCES
1. Jarosz M, Dzieniszewski J, Alergie pokarmowe. Porady
lekarzy i dietetyków. Wydawnictwo lekarskie PZWL,
Warszawa 2004
2. Park MI., Camilleri M. Is there a role of food allergy in
irritable bowel syndrome and functional dyspepsia? A
systematic review. Neurogastroenterol Motil (2006) 18,
595–607
3. Monsbakken KW, Vandvik PO, Farup PG. Perceived
food intolerance in subjects with irritable bowel
syndrome – etiology, prevalence and consequences.
European Journal of Clinical Nutrition (2006) 60, 667–
672
4. Anhoej C, Backer V, Nolte H: Diagnostic evaluation of
grass- and birch-allergic patients with oral allergy
syndrome. Allergy 2001; 56 (6): 548-552
5. Wiśniewska-Barcz B., Orłowska E.: Testy skórne w
diagnostyce alergologicznej. Alergologia Współczesna
2001; 4 (09): 15-23
6. Białek S, Białek-Gosk K. Udział laboratorium w
rozpoznawaniu alergii. Artykuł dostępny na stronie
http://www.alergia.org.pl/pacjent/diagnostyka/laboratoriu
m.htm
7. Kruszewski J i wsp.: Testy skórne. Standardy w
alergologii – część I. Stanowisko ekspertów Zarządu
Głównego PTA. Dom Wydawniczy Benkowski 2003
8. Małolepszy J: Testy skórne, oznaczanie przeciwciał IgE i
próby prowokacji wargowej w rozpoznaniu alergii
pokarmowej towarzyszącej pyłkowicy. Rozprawa
doktorska. PAM w Szczecinie, 2001
Address for correspondence:
Małgorzata Graczyk
Klinika Alergologii, Immunologii Klinicznej
i Chorób Wewnętrznych
Szpital Uniwersytecki Nr 2 im. dr J. Biziela
ul. Ujejskiego 75
85-168 Bydgoszcz
tel. 052-3655416
fax 052-3655416
e-mail: [email protected]
Received: 10.01.2012
Accepted for publication: 6.03.2012
Medical and Biological Sciences, 2012, 26/2, 105-109
Katarzyna Obłoza1, Aleksandra Czerw1, Urszula Religioni1
THE ROLE OF MEDIA IN CREATING THE HEALTH CARE UNITS’ IMAGE IN POLAND
ROLA MEDIÓW W KREOWANIU POSTRZEGANIA WIZERUNKU PLACÓWEK
OCHRONY ZDROWIA W POLSCE
1
Department of Public Health, Medical University of Warsaw
prof. dr hab. n. med. Janusz Ślusarczyk
Summary
I n t r o d u c t i o n . The media have an enormous set of
various tools and techniques, which allow the creation of a
social reality. Nowadays, there are some stormy discussions
on unfavourable situation in health care. The aim of this
study was to determine the role of the media in creating
perceptions of the image of health care centres in Poland.
M a t e r i a l a n d m e t h o d s . Students and graduates of
the biggest Polish universities were the target group for the
following study. The surveyed group consisted of 1160
people (75% women and 25% men). 38% of the surveyed
live in a city of more than 500 thousand inhabitants and 16%
in village. An anonymous questionnaire was used to achieve
the aim of this study. The questionnaire consisted of 32
questions posted on the website.
R e s u l t s . 16.44% of respondents considered the media
a reliable source of information about health care. There was
no correlation between the assessment of the credibility of
the media and the place of residence of respondents.
According to 71% of respondents, the way in which the
media present information about health care has an impact on
their attitude towards the health system. The feature that
determines the assessment of the impact of the media on
attitudes towards health care system is sex.
C o n c l u s i o n s . The results obtained in this study
suggest that the media play a significant role in creating the
image of healthcare facilities in Poland. Therefore, shaping
correct relations with the media should become a part of the
activity of each health care organisation.
Streszczenie
Wstęp.
Media dysponują potężnym zbiorem
różnorodnych technik i narzędzi, pozwalających na
kreowanie pewnej rzeczywistości społecznej. Obecnie w
mediach wciąż toczą się burzliwe dyskusje na temat
niekorzystnej sytuacji w ochronie zdrowia. Celem niniejszej
pracy było więc określenie roli mediów w kreowaniu
postrzegania wizerunku placówek ochrony zdrowia w Polsce.
M a t e r i a ł i m e t o d y . Badaniem objęto losowo
wybranych studentów oraz absolwentów największych
polskich uczelni wyższych. Badana grupa liczyła 1160 osób
(75% kobiet oraz 25% mężczyzn). Miejscem zamieszkania
38% respondentów jest miasto powyżej 500 tys.
mieszkańców, a 16% uczestników badania to mieszkańcy
wsi. W realizacji celu badania wykorzystano anonimową
ankietę, składającą się z 32 pytań, zamieszczoną na stronie
internetowej.
W y n i k i . 16,44% respondentów uznało, iż media są
wiarygodnym źródłem informacji o ochronie zdrowia. Nie
stwierdzono zależności pomiędzy oceną wiarygodności
mediów a miejscem zamieszkania respondentów. Według
71% ankietowanych, sposób w jaki media przedstawiają
informacje dotyczące służby zdrowia ma wpływ na ich ocenę
i nastawienie do systemu ochrony zdrowia. Cechą, która
determinuje ocenę wpływu mediów na nastawienie do
systemu ochrony zdrowia jest płeć.
W n i o s k i . Wyniki uzyskane w niniejszej pracy sugerują,
że media odgrywają znaczącą rolę w kreowaniu wizerunku
placówek ochrony zdrowia w Polsce. Z tego względu,
kształtowanie prawidłowych relacji z mediami powinno stać
się częścią aktywności każdej organizacji ochrony zdrowia.
Key words: image of the hospital, media relations, cooperation with the media, the media
Słowa kluczowe: wizerunek szpitala, media relations, współpraca z mediami, media
106
Katarzyna Obłoza et. al.
INTRODUCTION
Present times surprise us with the variety of
information. Newspapers, radio and television are
constant attributes of everyday life. Ubiquitous media
dictate the latest trends to us, inform about current
events in the world, spread a new lifestyle
and customs. The huge popularity of the media leads to
reflection and research on the strength of their
influence and role in contemporary society.
The media have a huge collection of various
techniques and tools for creating a social reality [1].
This is due to the fact that they are commonplace and
generally available for almost everyone. They are now
the primary source of information in any modern
society. Each message has admittedly a different
impact on an individual [2,3], and therefore you should
not overestimate the power of the media, equally
dangerous may be underestimating their power.
The media continues to roll quite a lively
discussion on unfavourable situation in health care
system. Public opinion is constantly informed about
the growing indebtedness of public health practitioners,
payroll problems and lack of funding for health
services. The recent media reports were dominated by
information about the exhaustion of the limits of
admission of patients to various institutions,
the limitations of parties, ever-growing queues and
long waiting period for benefits, as well as the protests
of doctors, the new reimbursement rules and plans for
health care transformation in the company, the
introduction of supplementary health insurance and
partial charges for medical services. There arose
numerous social apprehensions that patients would be
denied the access to medical care. The continuing
atmosphere of uncertainty, anxiety and insecurity,
certainly has an impact on the negative opinions on the
health care system [4,5].
A natural consequence of this social-media debate was
the question what is the role of the media in shaping
perceptions of the image of health care centres in Poland.
MATERIAL AND METHODS
For two months (November - December) of 2010 a
study on the media image of healthcare facilities in
Poland was conducted. This study was carried out
by using a questionnaire specially prepared for this
purpose, conducted among 1160 people, predominantly
women (75%). The questionnaire covered randomly
selected students of the biggest Polish universities:
Medical University of Warsaw, Warsaw University of
Technology, Warsaw University, Maritime University,
AGH University of Science and Technology,
Jagiellonian University, Catholic University of Lublin,
Medical University of Silesia, Wrocław University
of Economics, National School of Film, Television and
Theatre in Łódź. Students of these schools represented
approximately 91% of all respondents. People who had
already completed their studies constituted the
remaining part.
Among those surveyed, there were 75% of women
and 25% of men. 38% of the surveyed lived in a city of
more than 500 thousand inhabitants and 16% in village. 6% of the surveyed residents of small towns
and cities of 10 thousand inhabitants, while 18% of the
filling the survey are urban residents of cities of 10-50
thousand inhabitants. The remaining respondents are
urban residents of cities of 50-100 thousand inhabitants
(10%) and 100-500 thousand inhabitants (12%).
Research technique was anonymous questionnaire
which used a website with a questionnaire to conduct
research via the Internet (www.ankietka.pl). The
questionnaire contained 32 questions with different
schema design. After analyzing the survey it was found
that 100% of the returned questionnaires were filled in
correctly.
The present study focuses on issues concerning the
media image of healthcare facilities in Poland: interest
information on the situation in the health care system,
the degree to inform about current medical topics,
sources of information about the health care system.
The survey also takes into account such issues
as the evaluation of the time the media spend on
information about the health care system, health care
picture created by the media and subject matter of
information most often encountered in the media, as
well as those individually looking for. Respondents
were asked about the credibility of the media as a
source of information about health care, assessment of
the media image of hospitals in Poland and the impact
of the media on opinion and attitude towards the health
system.
The results were statistically analyzed.
RESULTS
As the main source of information about the health
care system, more than 71% of respondents chose the
Internet, and 65% of them - the television. For almost
one third of respondents (32%) source of such
The role of media in creating the health care units' image in Poland
information are doctors, nurses, pharmacists and other
health professionals. 35% of respondents chose the
press, 28% the family, and every fifth of them - the
radio. For 19% of study participants source of
information about the health care system are
neighbours or friends, while 12% pointed to
conferences, symposia, scientific meetings and
professional trainings. Leaflets, pamphlets, brochures,
posters and professional publications are a source
of information for 12% and 11% of respondents
respectively (Fig. 1). In the present question,
respondents had the opportunity to select up to three
answers.
107
Fig. 2. Picture of health service presented in the media (n =
1058)
Ryc. 2. Obraz służby zdrowia przedstawiany w mediach (n =
1058)
Fig. 3. The media as a reliable source of information about
the health care system (n = 1058)
Ryc. 3. Media jako wiarygodne źródło informacji o systemie
ochrony zdrowia (n = 1058)
Fig. 1. Sources of information on the health care system (n =
1058)
Ryc. 1. Źródła informacji o systemie ochrony zdrowia (n =
1058)
Respondents participating in the survey feel that the
health picture shown in the media is negative - 68%. For
about 17% of them the media image of the health care
system is presented objectively and only slightly more
than 1% of respondents believe that it is positive. 14% of
people do not have an opinion on this subject (Fig. 2).
Figure 3 shows that for 44% of respondents of the
survey the media are not a reliable source of
information on the health care system. Only 16% of
respondents replied in the affirmative. As many as 40%
of the study group did not have an opinion on this
subject.
It was also found that the size of the place of
residence has no significant influence on the
assessment of the credibility of the media as a source
of information about the health care system (p > 0.05)
– Table I.
Table I. Place of residence and the assessment of the
credibility of the media as a source of information
on the health care system (n = 1058)
Tabela I. Miejsce zamieszkania a ocena wiarygodności
mediów jako źródła informacji o systemie
ochrony zdrowia (n = 1058)
73% of respondents evaluate the media image of
the health care centres in Poland negatively. One
108
Katarzyna Obłoza et. al.
quarter of people who fill out the questionnaire did not
have an opinion on this subject. Only 2% of the
respondents assess the media's image of healthcare
institutions in our country positively (Fig. 4).
media and presented information influence the attitude
of the health care system (p < 0.05).
Table II. The sex and influence information presents in the
media on the assessment of and attitude to health
system (n = 1058)
Tabela II. Płeć a ocena wpływu informacji prezentowanych
przez media na nastawienie do systemu ochrony
zdrowia (n = 1058)
Fig. 4. Evaluation of the media image of healthcare facilities
in Poland (n = 1058)
Ryc. 4. Ocena wizerunku medialnego placówek ochrony zdrowia
w Polsce (n = 1058)
According to 71% of respondents, the way the media
present information on health care has an impact on their
assessment of and attitude towards the health system (Fig.
5). One fifth of the participants believe that the media do
not affect their opinions and attitudes to health care. 9% of
people expressed no opinion on this subject.
Fig. 5. Influence the way the media presents information
about health care on the assessment of and attitude
to health system (n = 1058)
Ryc. 5. Wpływ sposobu w jaki media przedstawiają
informacje dotyczące służby zdrowia na ocenę
i nastawienie do systemu ochrony zdrowia (n =
1058)
Table II indicates that the feature that determines
the assessment of the impact of the media on attitudes
towards health care system is the sex. Women
significantly more often than men believe that the
DISCUSSION
In the assessment of healthcare facilities essential
role for the patient plays a personal experience. A
satisfied patient exhibits an increased level of loyalty
to the hospital, and has a particular impact on its
opinion in the environment. One of the largest medical
centres in the United States is the Mayo Clinic. The
hospital boasts a huge number of positive reviews in
the environment. How does it work in practice? There
are about 520 000 patients treated annually, of which
90% are satisfied with the provided medical services,
which gives approximately 470 000 positive opinions.
According to estimates of experts from the Mayo
Clinic, an average patient shares information and
conducts an assessment of its treatment with 39
persons. If you multiply this by the number of positive
reviews, you get an incredible score of 18 million
people who encounter the opinion of the facility [6].
However, based on the information presented in the
mass media, the public are able, under their influence, to
change their assessment of and beliefs about the health
care facility. Information presented in the media is
highly selected, and not always consistent with the
actual course of events, their cause and the resulting
effect.
CONCLUSIONS
The results obtained in this study suggest that the
media play a significant role in shaping the image of
The role of media in creating the health care units' image in Poland
healthcare facilities in Poland. The strength and nature
of the impact of the media on the perception of the
image of healthcare facilities is very diverse and
depends on many factors.
According to the theory of the media, presented
information is simplified, one-sided, schematic and not
devoid of a subjective point of view of the journalist.
Having a relatively limited time, the media are not able
to pass on all messages.
Given the above, the formation of normal relations
with the media (the media relations) should become
part of the activity of each health care organisation.
However, it is important to realise that media relations
is not only the transmission of press releases. It
consists of arduous building databases and networks
between individual editorial teams, organising events
that are attractive from the media's standpoint,
researching and creating interesting pieces of
information and disseminating them in a suitable form.
REFERENCES
1.
2.
3.
Budzyński W.: Public relations, strategia i nowe
techniki kreowania wizerunku. Poltex. Warszawa,
2008: 26-28, 81-88, 147-152.
Rozwadowska B.: Public relations w teorii, praktyce,
perspektywie. Studio EMKA, Warszawa, 2002: 25.
Staszewski R.: Media relations w szpitalu – czyli jak
nas widzą, tak nas piszą. Profesjonalizm w Instytucjach
Opieki Zdrowotnej – poradnik dla pracowników,
Publikacja współfinansowana ze środków Unii
Europejskiej i budżetu Państwa w ramach projektu:
Podnoszenie kompetencji i kwalifikacji kadry
medycznej na rzecz profesjonalizmu w ochronie
zdrowia, Poznań, 2008: 85-107.
109
4. Stępień W.: Kto, co i jak kształtuje opinię publiczną
dotyczącą ochrony zdrowia w Polsce? Procesy
przekształceń
w
ochronie
zdrowia:
bariery
i możliwości. Putz J. (red.), IPIS, Warszawa, 2002: 10196.
5. Samardakiewicz M.: Postrzeganie systemu ochrony
zdrowia w świetle ostatnich doniesień medialnych.
Onkologia polska 11/2008: 45-48.
6. Baum E., Staszewski R.: Wyzwania ochrony zdrowia.
Pielęgniarstwo, geriatria, sekretariat medyczny w
aspekcie etyki, opieki medycznej i zarządzania,
Publikacja współfinansowana ze środków Unii
Europejskiej w ramach Europejskiego Funduszu
Społecznego, Poznań, 2009: 73-89.
Address for correspondence:
Aleksandra Czerw, Ph.D.
Medical University of Warsaw
Department of Public Health
1a Banacha St.
02-097 Warsaw
tel.: (0-22) 599 21 80
e-mail: [email protected]
Received: 10.01.2012
Accepted for publication: 6.03.2012
Medical and Biological Sciences, 2012, 26/2, 111-114
Joanna Pawlak1, Paweł Zalewski1, Jacek J. Klawe1, ,Monika Zawadka1, Anna Bitner1, Małgorzata Tafil-Klawe2
CORE BODY TEMPERATURE CHANGES AFTER SAUNA EXPOSITION
IN HEALTHY SUBJECTS
ZMIANY TEMPERATURY GŁĘBOKIEJ CIAŁA PO ZABIEGU SAUNY SUCHEJ
U OSÓB ZDROWYCH
1
Department of Hygiene and Epidemiology, Nicolaus Copernicus University, Toruń
Ludwik Rydygier Collegium Medicum, Bydgoszcz
Head: dr hab. n. med. Jacek J. Klawe, prof. UMK
2
Department of Physiology, Nicolaus Copernicus University, Toruń
Ludwik Rydygier Collegium Medicum, Bydgoszcz
Summary
I n t r o d u c t i o n . Sauna therapy has been used for
hundreds of years in the Scandinavian region as a standard
health activity and, during the past decades, it has also
become a widely practiced wellness form in many central
European countries. Sauna bathing is a special form of heat
exposure characterized by a short-term exposure to
exceptionally high environmental temperatures. Human body
exposure to extreme environmental conditions e.g. wholebody dry sauna may modulate thermoregulation processes.
Aim of this study was to analyze changes in core temperature
after sauna bathing.
Material
and
methods.
Nine males
volunteered for the study. Each of the subjects had a 15minutes exposure in a sauna (air temperature: 100 ± 10oC,
humidity 34-45%).
Core body temperature measurements were done by
ingestible telemetric sensor- Vital Sense system.
R e s u l t s Observed changes were statistically
significant (p<0.05). Mean BCT values registered before
WBS was 37.05oC; after WBS 37.71 oC; 45-60 minutes after
37.3 oC; 2 hours after 37.31oC; 3 hours after 37.26oC;
4 hours after WBS was 37.35oC; 5 hours after 37.26oC;
6 hours after 37.37 oC.
C o n c l u s i o n s . Sauna bathing causes a core body
temperature changes despite the very strong stability of that
physiological mechanism. Obtained results of changes in core
body temperature revealed that WBS caused an increase in
core body temperature which may be sustained up to 6 hours
after the procedure.
Streszczenie
W s t ę p . Sauna sucha (fińska) jest zabiegiem
stosowanym powszechnie w krajach skandynawskich. Od
kilkunastu lat znajduje zastosowanie również w krajach
Europy Centralnej. Sauna jest zabiegiem termoterapii,
charakteryzującym się naprzemiennym przegrzewaniem ciała
gorącym, suchym powietrzem oraz ochładzaniem ciała za
pomocą zimnych zabiegów wodoleczniczych Celem pracy
była analiza zmian temperatury głębokiej ciała po zabiegu
sauny fińskiej u osób zdrowych.
M a t e r i a ł i m e t o d y Grupę badaną stanowiło
9 mężczyzn. Osoby badane zostały poddane jednokrotnemu
zabiegowi sauny suchej (czas ekspozycji 15 minut,
temperatura: 100 ± 10oC, wilgotność powietrza 34-45%).
Pomiary temperatury głębokiej ciała były wykonywane przy
użyciu telemetrycznego systemu pomiarowego Vital Sense.
W y n i k i Obserwowane zmiany temperatury głębokiej
ciała po zabiegu sauny suchej były istotne statystycznie
(p<0,05). Średnia wartość temperatury głębokiej ciała przed
zabiegiem sauny wynosiła 37,05 oC; po zabiegu 37,71oC; 4560 minut po zabiegu 37,3 oC; 2 godziny po zabiegu 37,31oC;
3 godziny po zabiegu 37,26 oC; 4 godziny po zabiegu
37,35oC; 5 godzin po zabiegu 37,26 oC; 6 godzin po zabiegu
37,37oC.
W n i o s k i . Zabieg sauny suchej ma istotny wpływ na
przebieg procesu termoregulacji u osób zdrowych. Powoduje
wzrost temperatury głębokiej ciała, który może utrzymać się
do czasu 6 godzin od zabiegu sauny suchej.
Key words: sauna bathing, core body temperature, thermoregulation
Słowa kluczowe: sauna, temperatura głęboka ciała, termoregulacja
112
Joanna Pawlak et. al.
INTRODUCTION
MATERIAL AND METHODS
Sauna therapy has been used for hundreds of years
in the Scandinavian region as a standard health
activity, and during the past decades, it has also
become a widely practiced wellness form in many
central European countries. Sauna bathing is a special
form of heat exposure characterized by a short-term
exposure to exceptionally high environmental
temperatures.
The basic modern sauna is an unpainted, woodpaneled room with wooden platforms and a rock-filled
electric heater. The hot room air temperature falls
within the range of 70 to 100 °C, optimally between 80
and 90 °C at the face level of the bathers. The air
should have a relative humidity of 10% to 20%. The
sauna bath consists of repeated cycles of exposure to
heat and cold. The length of stay in the hot room
depends on each bather’s own sensations of comfort;
the duration usually falls between 5 and 20 minutes.
This is followed by a cool-off (shower, swim, or a
period at room temperature), the length of which also
depends on personal sensations. A sufficient recovery
period (usually about one half of an hour) following a
few hot/cold cycles allows normalizing the body
temperature and cessation of sweating.
The acute reaction for sauna bathing is the
expression of active thermoregulation: hormonal
changes, sweating with loss of body water and
electrolytes, skin vasodilatation with an increase in
heart rate and cardiac output resulting in a slight drop
of blood pressure, hyperventilation [1,2,3].
There is a growing body of evidence on the clinical
use of saunas for therapeutic purposes. Evidence
suggests that sauna therapy is an effective and
underutilized treatment for a variety of cardiovascular
problems [4, 5, 6].
Body temperature regulation is controlled almost
exclusively by intricate nervous system feedback
mechanisms located in the hypothalamus. Normally,
thermoregulation is highly efficient, keeping the
internal temperature within a narrow range of 0.5–0.9
°C. The normal deep body temperature (core body
temperature) at rest is between 36-37.5 oC. Human
body exposure to extreme environmental conditions
e.g. whole-body dry sauna, may modulate
thermoregulation processes [1, 3, 7].
The aim of this study was to analyze changes in
core temperature after sauna bathing.
Nine males volunteered for the study. They all gave
written consent after being informed of the minor risks
involved. All were healthy adults ranging in age from
24 to 31 years, with a mean age of 26.7 years (Table I).
Table I. Subject characteristics
Tabela I. Charakterystka ogólna badanych osób
study group (n=9; only men)
grupa badana
(n=9; tylko mężczyźni)
mean
wartości
SD
średnie
Age, years
Wiek, lata
Height,[ m]
Wzrost [m]
Weight, [kg]
Waga [kg]
BMI, [kg/m2]
wskaźnik masy ciała [kg/m2]
BSA, [m2]
wskaźnik powierzchni ciała [m2]
sBP, [mmHg]
ciśnienie skurczowe [mmHg]
dBP, [mmHg]
ciśnienie rozkurczowe [mmHg]
26.78
3.03
1.79
0.02
81.56
11.09
25.22
2.72
2.00
0.13
129
8
78
7
Each of the subjects undertook a 15-minutes
exposure in a sauna (air temperature: 100 ± 10oC,
humidity 34-45%).
Core body temperature measurements were done by
ingestible telemetric sensor- Vital Sense System. It
consists of a monitor and a thermistor-based ingestible
capsule for core body temperature measurement. All
data were collected 40 minutes prior to exposure up to
six hours, minute-by-minute and mean values were
calculated from 5 minutes epochs divide by 15 minutes
gaps, and statistically analyzed. Core body temperature
measurements were done in unchanging thermal and
humidity conditions.
RESULTS
Core body temperature changes were analyzed
using a Friedman test. Changes of core body
temperature (BCT) values observed in time duration
after sauna (WBS) exposure were statistically
significant (p<0.05).The mean values of diagnosed
variables are presented in table II.
Mean BCT values registered before WBS was
37.05oC, the lowest BCT was 36.67oC , the highest
37.61oC. Mean BCT values registered after WBS was
37.71oC , (min was 37.46oC , max 37.91oC). After
WBS core body temperature increased very rapidly for
Core body temperature changes after sauna exposition in healthy subjects
a couple of minutes, after which the increase was
slower.
Table II. Basic statistic of core body temperature changes
Tabela II. Podstawowe parametry statystyczne dotyczące
zmian temperatury głębokiej ciała
before WBS
przed sauną
after WBS
po saunie
45-60 min after WBS
45-60 min po saunie
2 h after WBS
2 h po saunie
3 h after WBS
3h po saunie
4 h after WBS
4h po saunie
5 h after WBS
5h po saunie
6 h after WBS
6h po saunie
Mean
value
wartości
średnie
37.05
Mediana
Minimum
Maximum
SD
36.91
36.67
37.61
0.31
37.71
37.73
37.46
37.91
0.19
37.30
37.22
36.99
37.86
0.27
37.31
37.33
36.82
37.79
0.32
37.26
37.30
36.94
37.57
0.23
37.35
37.20
37.05
37.74
0.31
37.26
37.26
36.92
37.63
0.27
37.37
37.40
37.16
37.52
0.11
Mean BCT values registered 45-60 minutes after
WBS were 37.3oC (min 36.99oC, max 37.86oC). Mean
BCT values registered 2 hours after WBS were
37.31oC (min 36.82oC, max 37.79oC). Mean BCT
values registered 3 hours after WBS were 37.26oC
(min 36.94oC, max 37.57oC). Mean BCT values
registered 4 hours after WBS were 37.35oC (min
37.05oC, 37.74oC). Mean BCT values registered 5
hours after WBS were 37.26oC (min 36.92oC, max
37.63oC). Mean BCT values registered 6 hours after
WBS were 37.37 oC (min 37.16oC, max 37.52oC).
113
(p=0.0000), 2 hours after WBS (p= 0.0430), 4 hours
after WBS (p=0.0241) and 6 hours after WBS
(p=0.0145).
There were no statistically significant differences
between mean temperature before WBS and mean
temperature recorded 45-60 minutes after WBS
(p=0.0591), 3 hours after WBS (p=0.0980) and 5 hours
after WBS (p=0.1027) found.
Fig. 2. Box-and-whisker plot of mean core body temperature
before WBS (01), after WBS (02), 1 h after WBS (05),
2 h after WBS (09), 3 h after WBS (13), 4h after WBS
(17), 5 h after (21), 6 h after WBS (25)
Ryc. 2. Wykres ramka-wąsy dla średniej temperatury
głębokiej ciała przed WBS (01), po WBS (02), 1 h
po WBS (05), 2 h po WBS (09), 3 h po WBS (13),
4h po WBS (17), 5 h po (21), 6 h po WBS (25)
DISCUSSION
Fig. 1. Box-and-whisker plot of mean core body temperature
during successive measurement periods; all (n=25)
measurement periods are included; p<0.05
Ryc. 1. Wykres ramka-wąsy dla średnich wartości
temperatury głębokiej ciała na przebiegu
kolejnych odcinków pomiarowych, uwzględniono
wszystkie (n=25) odcinki pomiarowe; p<0.05
As a consequence of body overheating we found
statistically significant differences between mean BCT
before WBS and mean temperature after WBS
Core body temperature changes in extreme
environmental conditions were assessed by many
authors. Humans are homeothermic, which means they
must maintain body temperature within a narrow range
in varying environmental conditions. In humans the
temperature of blood in the pulmonary artery (PA) is
considered the ‘true’ core body temperature [7,8].
Temperature measurements from an esophageal site at
the level of the heart have been shown to correlate with
PA readings (mean difference -0.1 ˚C ± 0.5˚C) [7,9].
Rectal temperature has been found to track esophageal
and pulmonary artery temperature quite closely. A
rectal probe connected to a body-worn data logger is
often used to measure the circadian rhythm of core
temperature over extended periods.
Our results suggest that whole-body dry sauna
causes thermoregulation changes, which are
manifested by increasing core body temperature. There
is a characteristic feature arising after dry sauna bath,
Joanna Pawlak et. al.
114
mainly the body core temperature oscillations, which
emerge from an attempt to normalize the
thermoregulation system after exposure.
Several studies on core body temperature measures
also confirm our findings. Kukkonen-Harjula et al.
reported that the core temperature, as measured from
the esophagus, is more stable, rising in the hot room at
an average rate of 0,07°C × min-1 up to 38°C, then
accelerating to 0.4°C × min-1 up to 39°C, and
returning to initial values rapidly after the exposure [1].
Hannuksela et al. observed that increase in rectal
temperature depends on heat exposure: by 0.2 ˚C at 72
˚C for 15 minutes, by 0.4 ˚C at 92 ˚C for 20 minutes,
by 1.0 ˚C at 80 ˚C for 30 minutes [3, 10, 11, 12].
Other authors described infant’s thermoregulatory
response to short heat stress during sauna bath. Study
included 47 infants (age 3 - 14 month). Before taking a
short sauna bath lasting 3 minutes, the infants stayed in
a swimming pool for 15 minutes. Under these
conditions sauna bathing did not increase the rectal
temperature. Unexpectedly rectal temperature even
decreased by 0.2 oC (p < 0.05) probably due to
redistribution of cold peripheral blood into the core of
the body [13].
CONCLUSIONS
1. Sauna bathing cause a core body temperature
changes despite the very strong stability of
thermoregulation mechanism.
2. Obtained results of changes in core body
temperature revealed that WBS caused an increase in
core body temperature which may be sustained up to 6
hours after the procedure.
3. Dry sauna bath causes temperature oscillations
differing from the natural circadian temperature course,
which emerge from an attempt to normalize the
thermoregulation system after exposure.
REFERENCES
1.
2.
3.
Kukkonen-Harjula K., Kauppinen K.: Health effects
and risks of sauna bathing. Int J Circumpolar Health.
2006 Jun;65(3):195-205.
Biro S, Masuda A, Kihara T, Tei C. Clinical
implications of thermal therapy in lifestyle-related
diseases. Exp Biol Med (Maywood) 2003;228:12451249.
Minna L. Hannuksel, Samer Ellahham: Benefits and
Risks of Sauna Bathing. The American Journal of
Medicine; 2001:1 (110)
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Crinnion WJ: Sauna as a Valuable Clinical Tool for
Cardiovascular, Autoimmune, Toxicantinduced and
other Chronic Health Problems. Alternative Medicine
Review 2011:16(3)
Blum N., Blum A.: Beneficial effects of sauna bathing
for heart failure patients. Exp Clin Cardiol. 2007
Spring; 12(1): 29–32.
Nguyen Y, Naseer N, Frishman WH.: Sauna as a
therapeutic option for cardiovascular disease. Cardiol
Rev. 2004 Nov-Dec;12(6):321-4.
McKenzie JE, Osgood DW: Validation of a new
telemetric core temperature monitor. Journal of
Thermal Biology 29 (2004) 605–611
Giuliano, K.K., Scott, S.S., Elliot, S., Giuliano, A.J.,
1999: Temperature measurement in critically ill orally
intubated adults: a comparison of pulmonary artery
core, tympanic, and oral methods. Crit. Care Med. 27
(10), 2188–2193.
Robinson, J., Charlton, J., Seal, R., Spady, D., Joffres,
M.R.,1998. Oesophageal, rectal, axillary, tympanic and
pulmonary artery temperatures during cardiac surgery.
Can. J. Anaesth. 45 (4), 317–323.
Leppaluoto J, Tapanainen P, Knip M. :Heat exposure
elevates plasma immunoreactive growth hormonereleasing hormone levels in man. J Clin Endocrinol
Metab. 1987; 65:1035–1038.
Leppaluoto J, Arjamaa O, Vuolteenaho O, Ruskoaho
O.: Passive heat exposure leads to delayed increase in
plasma levels of atrial natriuretic peptide in humans. J
Appl Physiol. 1991;71:716 –720.
Leppaluoto J, Tuominen M, Vaananen A, et al.: Some
cardiovascular and metabolic effects of repeated sauna
bathing. Acta Physiol Scand. 1986;128:77– 81.
Rissmann A, Al-Karawi J, Jorch G: Infant's
physiological response to short heat stress during sauna
bath. Klinische Pädiatrie2002; 214 (3).
Address for correspondence:
Uniwersytet Mikołaja Kopernika w Toruniu
Collegium Medicum im. Ludwika Rydygiera
w Bydgoszczy
Katedra i Zakład Higieny i Epidemiologii
ul. M. Skłodowskiej-Curie 9
85-094 Bydgoszcz
tel. 52 585 36 16
e-mail: [email protected]
Received: 10.01.2012
Accepted for publication: 6.03.2012
Medical and Biological Sciences, 2012, 26/2, 115-120
Dorota Siwczyńska1, Magdalena Mińko2
THE FUNCTIONING OF HEALTH SYSTEMS IN POLAND AND THE NETHERLANDS
IN PATIENTS’ OPINIONS
FUNKCJONOWANIE SYSTEMÓW OPIEKI ZDROWOTNEJ W POLSCE I HOLANDII
W OPINII PACJENTÓW
1
Students Research Group of Public Health Department
Medical University of Lublin
Prof. dr hab. n. med. Teresa B. Kulik
2
Medical University of Warsaw
Summary
I n t r o d u c t i o n a n d p u r p o s e o f w o r k . The
health system aims is to safeguard the health needs and
improve the health of the individual and in the community.
Using the experiences of countries that achieve positive
effects of the system functioning, exchange of knowledge
and analysis of current results allows us to assess how the
health care system can fulfill its potential. The aim of the
work is to obtain information useful for health policymaking and implementation of effective solutions in health
care by comparing the opinion of patients on the functioning
of two health care systems in Europe - Polish and Dutch.
M a t e r i a l a n d m e t h o d . The examination
covered 133 persons living in Poland and 106 people living
in the Netherlands. The applied testing method was a
diagnostic survey. The tool used to conduct the study was the
author's questionnaire.
R e s u l t s a n d d i s c u s s i o n . The study indicates
large inequalities in access to medical services, waiting time
for a GP and specialist appointment, the treatment of
patients. Test results also indicate disparities between health
care in Poland and the Netherlands, as well as the lack of
cohesion of public and private sector in the Polish health care
system.
C o n c l u s i o n s . Competitiveness of the market of
medical services promotes improving the quality of services,
ensuring a high standard of treatment as well as empathic and
individual approach to each patient. So there is a need to
further improvement and reforming the health care system in
Poland to follow the changing market for health services.
Streszczenie
W s t ę p i c e l p r a c y . System opieki zdrowotnej
ma na celu zabezpieczenie potrzeb zdrowotnych i poprawę
stanu zdrowia jednostki i zbiorowości. Korzystanie
z doświadczeń krajów, które osiągają pozytywne efekty
funkcjonowania systemu, wymiana wiedzy i analiza
bieżących wyników pozwala ocenić, w jaki sposób system
opieki zdrowotnej może wykorzystać swój potencjał.
C e l e m p r a c y , dzięki porównaniu opinii pacjentów
na temat funkcjonowania dwóch europejskich systemów
opieki zdrowotnej – polskiego i holenderskiego, jest
uzyskanie informacji przydatnych przy kreowaniu polityki
zdrowotnej
i wprowadzaniu
efektywnych
rozwiązań
w ochronie zdrowia.
M a t e r i a ł i m e t o d a Badaniem zostały objęte 133
osoby mieszkające w Polsce i 106 osób zamieszkujących
Holandię. Zastosowaną metodą badawczą był sondaż
diagnostyczny. Narzędziem wykorzystanym do przeprowadzenia badania był autorski kwestionariusz ankiety.
W y n i k i i o m ó w i e n i e . Przeprowadzone badanie
wskazuje na występowanie dużych nierówności w dostępie
do usług medycznych, czasie oczekiwania na porady lekarza
rodzinnego i specjalistów, sposobie traktowania pacjentów.
Wyniki badania wskazują również na występowanie dyspro-
116
Dorota Siwczyńska, Magdalena Mińko
porcji pomiędzy opieką zdrowotną w Polsce i Holandii,
a także na brak spójności sektora publicznego i prywatnego
w polskim systemie zdrowotnym.
W n i o s k i . Konkurencyjność na rynku usług medycznych sprzyja podnoszeniu jakości świadczeń, zapewnieniu
wysokiego standardu warunków leczenia oraz empatycznego
i indywidualnego podejścia do każdego pacjenta. Toteż
istnieje potrzeba dalszego udoskonalania i reformowania
systemu opieki zdrowotnej w Polsce, tak by odpowiadał
zmieniającemu się rynkowi usług zdrowotnych.
Key words: health care system, health system functioning, medical services market
Słowa kluczowe: system opieki zdrowotnej, funkcjonowanie systemu zdrowotnego, rynek usług medycznych
INTRODUCTION
The health system is defined as an organized and
coordinated set of activities, regardless of the country
in which its functions, and aims at improving the
health and protection of the health needs of individuals
and communities [1]. The socio-demographic context,
cultural factors, life style and history have the impact
on the shape of the system in different countries around
the world have: These elements also determine the
direction of the state health policy and management.
The international cooperation is necessary in order to
minimize disparities between the systems, as well as
internal between health and other sectors of the state.
Using the experiences of countries that achieve
positive effects of the system functioning, exchange
knowledge and analysis of current results allow us to
assess how the health care system can fulfill its
potential.
Health insurance
In Poland, the foundation for the health care system
is the principles contained in the Articles. 68 of the
Polish Constitution of 1997, according to which
"everyone has the right to health" and to equal access
to benefits of public funds [2]. On 27 August 2004 a
law concerning healthcare services financed from
public funds was announced. The Act defines health
benefits provided to the patient and the so-called
"negative basket" that is, benefits which are not funded
by the country.
Under the law guaranteed provisions are:
- primary health care, outpatient specialist care,
hospital care;
- mental health and addiction treatment, medical
rehabilitation;
- care and welfare benefits in the long-term care;
- dental treatment;
- health resort;
- orthopedic and supply aids;
- medical emergency;
- palliative care and hospice;
- highly specialized provisions;
- health programs;
- medicines [3].
According to the Act, in the Polish health care
system the payer is the National Health Fund (NFZ),
which manages the funds paid by the insured and
concludes contracts with providers. The insured pays
periodic premiums for health insurance in the amount
of the percentage specified by the insurance law. Every
insured person has the right to choose providers from
among those who have signed a contract with the NFZ
[4].
In the Netherlands in 2006, new Health Protection
Act (Zorgverzekeringswet) abolished the distinction
between statutory health insurance (SHI) and private
health insurance (PHI), creating a single competitive
market of medical insurance. The new system of
covering the costs of health care is characterized by a
balance between solid foundation for the social system
and the dynamic development of the medical services
market. The new Dutch system also assumes a limited
state interference. The authorities only provide access
to medical care, make up the acts and regulations
providing for the operation of the system. They are not
directly involved in providing health care. This is done
by private providers, such as individual practices and
institutions of care.
The new law on health insurance ensures
a sustainable future of Dutch health care system.
According to the letter of the law, medical insurance is
mandatory for all people living in the Netherlands. The
key solutions that include the Act of 1 January 2006
are:
- a new standard of security for all;
- the ability to change insurer every year;
- competition among insurers;
- stimulation of suppliers to increase quality by patients
and insurers [5].
This "basic package" (Basisverzekering) is the
minimum level of health insurance, which must be
offered by all insurers. It determined by the
government and its composition includes:
- medical care: family doctor, some specialists;
- hospitalization;
The functioning of health systems in Poland and the Netherlands in patients' opinions
- dental services (up to 18 years old, over 18 years of
age in a range of specialist services include dental care
and prosthesis);
- some medications, aids;
- ambulance and medical transportation;
- midwife care and postnatal care
- health rehabilitation (physiotherapy, occupational
therapy, dietary advice) [4,6].
Other medical services not covered by the "basic
package" are offered by insurance companies under the
supplementary insurance. Their scope and the price are
determined individually by the insurers and citizens
may also purchase the appropriate package for
themselves [6].
There is also a narrow range of medical services
that are funded from tax revenues and include all
persons having a "basic package" health insurance.
They are defined by Emergency Treatment Costs Act
(AWBZ) and they include:
- admission to the hospital for a period longer than
1 year;
- care in social care homes;
- psychiatric care;
- care for the mentally and physically disabled;
- preventive actions such as vaccination [7].
Financial outlays
According to recent figures from the World Health
Organization (WHO), the total expenditure on health in
Poland amounts 6.6%, in the Netherlands - 9.1% gross
domestic product (GDP) in 2008 [8]. In comparison to
previous years, health fundings in Poland have
increased from 6.2% to 7% of GDP. However, in the
Netherlands after 1% growth at the turn of 2002/2003,
expenditures are at a similar level for several years
within the limits of 9.7-10% [9].
Financial outlays per capita in Poland are among
the lowest in Europe and amount 1 213 U.S. dollars.
However, the Netherlands spend 4 063 U.S for health
care per capita dollars and this is one of the highest
rates among European countries [10].
PURPOSE
The aim of the work is a detailed examination of
the level of satisfaction within various sectors of the
health care system by comparing the opinion of
patients on the functioning of two health care systems
in Europe - Polish and Dutch. This will help to obtain
information relevant to health policy-making and
implementation of effective solutions in health care,
affecting the interests of a patient, provider and payer.
117
MATERIAL
The examination covered persons living in Poland
and in the Netherlands. In Poland study was conducted
among the inhabitants of Lublin province, while in the
Netherlands people living in the province of North
Brabant took part in the study. Among all respondents
- 133 respondents were Polish, while the population
studied in the Netherlands was 106 people. The
detailed characteristics by sex, age, residence,
education and material status of respondents are
presented in Table I.
Table I. Comparison of the Polish and Netherlands studied
population by sex, age, residence, education and
material status
Tabela I. Porównanie w postaci liczbowej i procentowej
badanej populacji mieszkańców Polski i Holandii
według płci, wieku, miejsca zamieszkania,
wykształcenia i statusu materialnego
LICZBA I PROCENT
BADANYCH OSÓB
NUMBER AND
PERCENTAGE OF
CECHA
RESPONDENTS
CHARACTERISTIC
POLSKA HOLANDIA
POLAND
HOLLAND
liczba
liczba
%
%
(number)
(number)
kobieta (woman)
78
59
63
59
PŁEĆ
mężczyzna
SEX
55
41
43
41
(man)
18-24
33
25
40
38
25-34
28
22
13
12
35-44
18
14
14
13
WIEK
45-54
26
19
27
26
AGE
55-64
22
16
8
7
65 i więcej
6
4
4
4
(65 and more)
wieś (village)
15
12
20
19
miasto <200 tys.
MIEJSCE
59
44
50
47
ZAMIESZKANIA (town <200
thous.)
PLACE OF
miasto >200 tys.
RESIDENCE
(town >200
59
44
36
34
thous.)
student (student)
18
13
34
32
podstawowe
0
0
0
0
(primary)
WYKSZTAŁCENIE zawodowe
9
6
3
3
EDUCATION
(vocational)
średnie
43
33
28
26
(secondary)
wyższe (higher)
63
48
41
39
bardzo niski
2
1
0
0
(very low)
STATUS
niski (low)
18
13
4
4
MATEIALNY
średni (average)
47
36
20
19
MATERIAL
dobry (good)
48
36
54
51
STATUS
bardzo dobry
18
14
28
26
(very good)
Source: Authorial based on data from the questionnaire
Źródło: Opracowanie własne na podstawie danych z przeprowadzonego kwestionariusza ankiety
118
Dorota Siwczyńska, Magdalena Mińko
RESEARCH METHOD
The applied testing method was a diagnostic
survey. Research technique was interview. The tool
utilized to conduct the study was the authorial,
anonymous questionnaire. The study was conducted
during the period from January to May 2011.
RESULTS
Among survey respondents in Poland 60%
identified their health as good or very good, and only 4
people as bad and very bad. The population in the
Netherlands also determined their health as excellent,
good or average (97%) the most frequently.
Another survey question concerned the usage of
health services. The results show that Poles usually
receive provisions from both public and private
practice (78%). Only a small part of them use only a
private health care (2%), whereas 20% use health care
financed by the NFZ. In the Netherlands, the vast
majority of people use only the compulsory insurance
package (91%) and only 9% of the surveyed
respondents have an additional, optional health
insurance.
Among all respondents, there are large differences
between the Poles and the Dutch in the frequency of
medical visits and hospitalizations. As many as 28% of
Polish respondents and only 13% of the Dutch were
hospitalized last year . Similar trends apply to the
number of medical visits. Only 1% of Poles had a
doctor’s appointment within the past three years , 37%
of them visited a doctor from 1-3 times, 26% 4-6
times, and remaining - above 6 times. More than 87%
of respondents from the Netherlands reported
frequency of physician visits in the range of 1-6 times,
and only 8% more than 6 times.
The results of a detailed assessment of the
availability of specific services, patient rights, quality
and cost of care, as well as problems associated with
obtaining medical assistance are presented in Charts 1
to 6.
In one of the questions of the questionnaire,
respondents were asked to assess whether they faced
any problems in obtaining medical provisions. As it
turned out, this problem affects mainly people using
health services under the compulsory insurance in
Poland (30%). The most common problems, the
respondents indicated were long waiting times for
medical consultation and the necessary tests, especially
at the end of the year; difficulties in using the
rehabilitation, the inability to continue treatment with
the same specialist at the next year due to the absence
of a contract with the NFZ, the problems associated
with acceptance at the emergency room when
appropriate. Definitely fewer people (10%)
experienced various problems in the private services
than the population of Dutch respondents (5%). Most
emerging problem was too long waiting times for a
specialist appointment and a long waiting time for
antitumor therapy and to perform certain tests.
Figure 1. The percentage of patients who reported that it is
easy to get GP, specialist and dentist medical
provision
Wykres 1. Procentowy wskaźnik liczby pacjentów, którzy
stwierdzili, że łatwo jest uzyskać poradę u lekarzy: rodzinnego, specjalisty i stomatologa
Figure 2. Assessment of the ease of obtaining home nursing
assistance
Wykres 2. Ocena łatwości uzyskania domowej pomocy
pielęgniarskiej
Figure 3. Assessment whether the patient was treated with
care and kindness by the staff of medical
institutions
Wykres 3. Określenie przez pacjenta czy był traktowany
z troską i życzliwością przez personel placówek
medycznych
The functioning of health systems in Poland and the Netherlands in patients' opinions
119
DISCUSSION
Figure 4. Percentage ratio of the number of patients who
reported that all patients are treated equally, that
service quality is high and that patients' rights are
respected
Wykres 4. Procentowy wskaźnik liczby pacjentów, którzy
stwierdzili, że wszyscy pacjenci są traktowani
równo, że jakość usług jest wysoka i, że prawa
pacjenta są respektowane
Polish respondents had also negative feedback as to
the amount of contributions for mandatory health
insurance and high prices for private services. Half of
respondents think that the insurance premium is too
high, 14% - adequate, 10% - too low, and 26% have no
opinion. The charges for private services were assumed
as too high by as much as 74% of respondents, by 18%
as appropriate, and the rest had no opinion. Most of the
study population from the Netherlands (78%) believes
that the price of the primary insurance is adequate,
only 5% of people think that it is too low or too high,
while others have no opinion. The Dutch have a similar
opinion on additional packages. Nearly 69% of them
think that the price of packages is appropriate and 12%
believe that is too high.
Figure 5. Determining whether the patient is satisfied with
medical care
Wykres 5. Określenie przez pacjenta czy jest zadowolony z
opieki medycznej
Figure 6. Evaluation of the health care system by patients
Wykres 6. Ocena funkcjonowania systemu opieki zdrowotnej
przez pacjentów
The study showed large disparities in terms of
access to medical services between the Polish health
system and the Dutchone. Problems with specialist
care in Poland have existed for a long time and still
remains. This is confirmed by results of the studies
conducted in 2001 in Lublin on the availability of
medical services [11]. Another study published in 2007
also indicates a lack of equality in access to medical
services in Poland. As many as 35% of the survey
respondents confirmed the existence of inequalities
[12].
These trends also confirm the results of studies
conducted in Europe and worldwide. Examination of
the 2003 - World Health Survey – indicates that almost
78% of patients were satisfied using the Dutch health
care [13]. Precise analysis of the European health
systems in the Euro Health Consumer Index 2009 also
confirms the results of our audit. In this study, the
Netherlands was ranked first, while the Polish health
care system has been evaluated and found significantly
worse on 26 position compared with 33 systems [14].
CONCLUSIONS
The results of the study on the functioning of health
systems in Poland and the Netherlands in the opinion
of patients, allow us to draw the following conclusions:
1. There is a need to further improvement and
reform of the health care system in Poland, so as
to suit the changing market for health services.
2. Both Poland and the Netherlands should look for
new solutions in order to facilitate the availability
and shortening the waiting time for a GP and
specialists.
3. Due to the difficulties of access and the lack of
knowledge about the provisions of nursing home
care in Poland, this form of patient care is still not
sufficiently widespread in Poland. The emphasis
on the gradual development would allow savings
in the system.
4. Large differences in access to medical services,
treatment of the patient between state and private
medical care in Poland reflect the lack of a
coherent system.
5. Competitiveness in the market of medical
services promotes improving the quality of
services, ensuring a high standard of treatment
120
Dorota Siwczyńska, Magdalena Mińko
and empathic and individual approach to each
patient in his view.
6. Rational management and optimization in
spending public funds on health care is a right
direction in health economics.
7. The study indicated the need for further
development of the health care system in Poland,
taking into account additional sources of funding
and the principles of efficiency and optimization
REFERENCES
1. Poździoch S., System zdrowotny [w:] Zdrowie publiczne.
Wybrane zagadnienia. Tom I, pod red. Czupryna A.,
Poździoch S. i inni, Vesalius, Kraków 2000, s. 127.
2. Por. art. 68., ust. 1. i ust. 2. Konstytucji RP z 2 kwietnia
1997 r. (DzU nr 78, poz. 483).
3. Por. art. 15, ust. 2 Ustawy o świadczeniach opieki
zdrowotnej finansowanych ze środków publicznych z 27
sierpnia 2004 r. (DzU nr 210, poz. 2135).
4. Daley C., Gubb J., Health reform in the Netherlands,
Civitas Institute for the Study of Civil Society 2007, s. 24 (www.civitas.org.uk, dostęp 20.09.2011).
5. The new care system in the Netherlands. Durability,
solidarity, choice, quality, efficiency; Ministry of Health,
Welfare and Sport 2006, (www.minvws.nl, dostęp
20.03.2011)
6. Klazinga N., The Dutch Health Care System, Academic
Medical Centre, University of Amsterdam 2008,
(www.commonwealthfund.org, dostęp 20.09.2011).
7. AWBZ – General Exceptional Medical Expenses Act,
Euraxess – Research in motion 2009, (www. euraxess.nl,
dostęp 20.09.2011).
8. Total health expenditure as % of gross domestic product
(GDP), WHO estimates [w:] European health for all
database (HFA-DB) 2011, World Health Organization,
Regional Office for Europe, (www.data.euro.who.int,
dostęp 10.01.2012).
9. Total expenditure on health as a percentage of gross
domestic product [w:] OECD iLibrary 2011, (www.oecdilibrary.org, dostep 13.05.2011).
10. Total expenditure on health per capita at current prices
and PPPs [w:] OECD iLibrary 2011, (www.oecdilibrary,org, dostęp 13.05.2011).
11. Kalinowski P., Jędrzejewska B.: Dostępność usług
medycznych po reformie służby zdrowia w Polsce:
opinie pacjentów, Zdr Publ 2004, 114 (1), s. 8-11.
12. Gruszczak A., Dudzińska M., Piątkowski W. i inni: The
accessibility to medical services in patients’ opinions,
Zdr Publ 2007, 117 (4), s. 440-443.
13. Bleich S.N., Özaltin E., Murray C.J.L.: How does
satisfaction with the health-care system relate to patient
experience?, Bull World Health Organ 2009, 87, s. 271278.
14. Bjornberg A., Cebolla Garrofe B., Lindblad S.: Euro
Health Consumer Index 2009, Health Consumer
Powerhouse 2009.
Address for correspondence:
Dorota Siwczyńska
ul. Akacjowa 7/27
21-040 Świdnik
+48 605 833 715
e-mail: [email protected]
Received: 10.01.2012
Accepted for publication: 6.03.2012
Medical and Biological Sciences, 2012, 26/2, 121-127
Błażej Stankiewicz, Mirosława Cieślicka
DETAILED ANALYSIS OF A 240-SECOND CYCLE ERGOMETRIC TEST
IN MIDDLE-DISTANCE RUNNERS AGED 16-19
SZCZEGÓŁOWA ANALIZA 240-SEKUNDOWEJ PRÓBY CYKLOERGOMETRYCZNEJ
PRZEPROWADZONEJ WŚRÓD BIEGACZY NA ŚREDNICH DYSTANSACH W WIEKU 16-19 LAT
Faculty of Physical Education, Kazimierz Wielki University, Bydgoszcz
Head: dr. hab. Mariusz Zasada
Summary
I n t r o d u c t i o n . Middle-distance runs are endurance
events that include the distances from 600 m up to 1609 m.
The objective of the research is to determine work
capabilities in acid and lactic conditions, measured by means
of a 240-second test in young junior (16-17 years of age) and
junior (18-19 years of age) runners at middle distances and to
compare maximum lactate concentrations and maximum
heart rate after 60-second and 240-second tests of the
subjects.
M e t h o d s . The research included 20 competitors aged
16-17 and 12 competitors aged 18-19. During the test period
all subjects were training in the Kujawsko-Pomorskie
province sport clubs. In order to determine work capabilities
in acid-lactic conditions, a 240-second cycle ergometric
laboratory test was applied. The obtained results were
worked out using basic descriptive statistics: arithmetic
average (M), standard deviation (± δ), minimum (min) and
maximum values and coefficient of variation (V%).
R e s u l t s . The results obtained made it possible to
characterize the subjects in terms of work capabilities at a
high level of lactic acid in blood during middle-long effort.
An in-depth investigation of the collected material might
prove useful when planning training loads for work on
special stamina.
C o n c l u s i o n s . A set of criteria presented in the
paper, detailing work and power obtained during a 240second cycle ergometer might be used by trainers in a sport
training process to assess individual function predisposition.
Streszczenie
W s t ę p . Biegi średnie to konkurencje wytrzymałościowe, wśród których wymienić możemy dystanse od
600 m do 1609 m. Celem pracy jest określenie zdolności do
pracy w warunkach kwaso-mleczanowych, mierzonych
testem 240-sekundowym u biegaczy na średnich dystansach
w kategorii juniora młodszego (16-17 lat) i juniora (18-19
lat). Porównanie maksymalnych stężeń mleczanu oraz
maksy-malnej ilości skurczów serca po próbie 60 sek. i 240
sek. u badanych zawodników.
M a t e r i a ł i m e t o d y . W badaniach wzięło udział
20. zawodników w wieku 16-17 lat oraz 12. biegaczy w
wieku 18-19 lat. W trakcie testów wszyscy zrzeszeni byli w
klubach województwa kujawsko-pomorskiego. Do określenia
zdolności pracy w warunkach kwaso-mleczanowych
zastosowano próbę laboratoryjną: test cykloergometryczny 240s. Uzyskane wyniki opracowano za pomocą
podstawowej statystyki opisowej: średniej arytmetycznej
(M), odchylenia standardowego (± δ), wartości minimalnej
Key words: training, exercise stress tests, middle-distance running
Słowa kluczowe: trening, próby wysiłkowe, biegi średnie
(min) i maksymalnej (max) oraz współczynnika zmienności
(V%).
W y n i k i . Uzyskane wyniki pozwoliły scharakteryzować badanych w zakresie możliwości pracy w warunkach
wysokiego poziomu kwasu mlekowego we krwi przy średnio
długim wysiłku. Głęboka analiza zebranego materiału może
być pomocna w planowaniu obciążeń treningowych
w zakresie pracy nad wytrzymałością specjalną.
W n i o s k i . Zaprezentowany w pracy zestaw kryteriów
opisujących pracę i moc uzyskaną podczas 240-sekundowego
testu cykloergometrycznego, może być wykorzystany przez
szkoleniowców w praktyce szkolenia sportowego do oceny
indywidualnych predyspozycji wydolnościowych. Uzyskane
wyniki pozwoliły scharakteryzować badanych w zakresie
możliwości pracy w warunkach kwaso-mlekowych. Pomoże
to w planowaniu obciążeń treningowych właśnie w tym
zakresie.
122
Błażej Stankiewicz, Mirosława Cieślicka
INTRODUCTION
Middle-distance runs are endurance events that
include the distances from 600 m up to 1609 m.
Determining the share of individual systems providing
energy during middle-distance running is of crucial
importance when planning a training process. It is a
well-known fact that the sole direct source of energy
for muscle activity is ATP (adenosine triphosphate)
that undergoes hydrolysis in a reaction catalyzed by
myosinic ATP. Yet, its reserve is sufficient only for a
few seconds work. On that account, a competitor’s
body must provide energy in resynthesis. From a
physiological viewpoint, there are five methods of
reconstructing ATP [1]. In short efforts lasting up to 12
seconds maximum phosphagen emerges (ATP and
phosphocreatine), and the longer the effort, the greater
the significance of glycogen and free fatty acids [2].
The efforts above the lactic threshold (LT), i.e. middle
distance runs, cause an increase in lactic acid (LA) in
blood up to over 20 mmol/l, and for that reason the
main substrate in the ATP resynthesis process becomes
glycogen [3]. Middle distance running, where the share
of individual motor capabilities (stamina, strength,
speed) is evenly distributed, can be divided into two
subgroups, i.e. distances up to 1000 m and above. In
the first group, anaerobic processes comprise,
according to different sources, from 31% to 50% of all
processes and in runs at the distances 1000-1609 m,
where the share of anaerobic processes drops to 1735%, and the remaining part are aerobic processes
[4,5]. Factors conditioning good results in middledistance runs are: physical fitness, resistance of
muscle-tendom and skeleton systems to high loads
during trainings and competitions, resistance to fatigue
during efforts taking place in different environmental
conditions, low reactivity to stress caused by training
and starting stimuli [6,7,8,9].
The objective of the research is to determine work
capabilities in acid and lactic conditions, measured by
means of a 240-second test in young junior (16-17
years of age) and junior (18-19 years of age) runners at
middle distances and to compare maximum lactate
concentrations and maximum heart rate after 60second and 240-second tests of the subjects.
The research material collected during exercises
stress tests, observations and measurements taken
before, during and after the test, makes the following
questions emerge:
1. Will a higher level of lactic acid occur in
sportsmen subjected to a 60-second test
corresponding to the effort on the borderline of
maximum and submaximum phases, or will it
occur during a 240-second test that all authors
seem to be in a submaximum phase because of its
duration? [10,11]?
2. In which of the two tests will a greater mean and
maximum heart rate occur?
3. Do the results obtained in a 240-second test allow
determining the level of exercise test skills of
individual subjects and do these outcomes
correlate with the results achieved at sport
competitions?
The review of national and foreign literature,
experience gained during numerous tests and research,
along with trainers’ and competitors’ opinions allow
conducting cycle ergometric tests with submaximum
intensity among middle-distance runners aged 16-17
(young juniors) and 18-19 (juniors) years of age.
RESEARCH MATERIAL AND METHOD
The research included 20 competitors aged 16-17
and 12 competitors aged 18-19. During the test period
all subjects were training in the Kujawsko-Pomorskie
province sport clubs. Training seniority among the
competitors did not exceed 2 years in 11 cases, and the
remaining ones had 3-5 year seniority. In this group 2
competitors did not have any sport class, 7 competitors
were Class IV, 7 were Class III, and 4 young juniors
were Class II.
In order to determine work capabilities in acidlactic conditions, a 240-second cycle ergometric
laboratory test was applied. A ‘Monark 834 E’ cycle
ergometer was used in the test. For research purposes,
the ergometer was equipped with sensors connected to
a PC application. The MCE 5.1 is an application for
measuring and analysing physical effort on ergometers
developed by ‘JBA’ Zb. Staniak. The tests consisted in
each subject carrying out a test with the load selected
individually and comprising 7.5% of the subject’s body
mass. The subjects were weighted directly prior to the
test using a ‘Tanita’ BF-556 balance scales. The level
of lactic acid was measured directly before the test and
approximately 2-3 minutes after the test. ‘Accusport’
type 1488767 and “Roche” BM-Lactate strips were
utilized in the test. Additionally, a competitor’s heart
rate was measured prior to and after the test by means
of a Polar heart rate analyzer, models S610i and S810i.
Detailed analysis of a 240-second cycle ergometric test in middle-distance runners aged 16-19
123
Each test was carried out from a halt in a
200
start position just by the first sensor. All
194
190
subjects received instructions and were
183
182
181
motivated to carry out the tests at their
180
175
175
175
174
174
173
maximum capabilities. The remaining
young juniors
171
170
juniors
168
168
168
167
participants cheered on the subject under
165
164
161
161
161
160
158
test in order to create conditions as close
157 157
156 157 157 156
153
153
153
151
as possible to that of a real-life
150
150
competition. All competitors took part in
140
0
5
10
15
20
25
tests with at least a 2-day break in
higher-intensity trainings, therefore they
Fig. 1. Results of a 1000 m run (seconds) of both groups of runners under
were relaxed and after a light meal
research
around 2 hours before the test. The
Ryc. 1. Wyniki biegu na 1000m (sek.) obu badanych grup biegaczy
obtained results were worked out using
terms of duration. This allows obtaining the highest
basic descriptive statistics: arithmetic average (M),
possible level of lactic acid, which literature confirms
standard deviation (± δ), minimum (min) and
[15,3]. For middle-distance runners, a 240-second test
maximum values and coefficient of variation (V%).
reflects a competition effort and, as a consequence, it
illustrates capabilities to work when subjected to
ANALYSIS OF TEST RESULTS
acidosis.
Table No. I. shows a set of indicators obtained
It is owing to the research [12,13,14] and trainers’
throughout tests, including both somatic build, values
and competitors’ experience that the concentration of
of a sport result in a 1000m run, basic parameters of
lactic acid in blood after middle-distance running is
work and power obtained during a 240-second test, as
known to exceed threshold value several times. In
well as basic parameters of physiology of effort
relation with the above, it is indispensable to control a
describing a number of systoles before and after the
training process in such a manner so that their
test, and concentration of lactic acid before and after
constituents would prepare competitor’s body to work
the test in both age groups.
under acidosis. This is undoubtedly one of the factors
When analysing a somatic build of the runners in
optimizing a training process. It is know that the
both age groups, similarity in body height and
greatest LA concentration in blood occurs after about
significant divergence in body weight emerged. A
3-4 minutes of submaximum work; this being related
glimpse at individual sportsmen and minimum and
to a 2-3 minute delay in lactate diffusion outside the
maximum values clarifies this situation. A minimum
cell [2]. A 1500m distance run is held in such time
value in the younger group is just less than 40 kg, and
frames. A 240-second test corresponds to this event in
for older competitors it is 60 kg. The situation is
comparable
when
Table I. A set of indicators obtained in the tests
considering
maximum
Tabela I. Kompleks wskaźników uzyskanych w trakcie badań
value, where the heaviest
M
min
max
V%
±δ
young junior weighed 72
Indicators
kg, and his older
y.jun. junior y.jun. junior y.jun. junior y.jun. junior y. jun. junior
colleague’s body weight
Body height [cm]
176
178
7
5,6
155
172
186
191
4
3,2
exceeded 87 kg.
Body weight [kg]
61,9
70,2
8,1
8,5
39,2
56,6
71,8
87,1
13,1
12,1
Significant
Result in 1000m run [s]
169
158
11,5
6,3
153
150
194
168
6,8
4
discrepancies can be
Specific energy [J/kg]
951,1 1002 93,1
154
789
705
1122 1220
9,8
15,4
observed in the results of
Specific power [W/kg]
3,96
4,2
0,4
0,6
3,29
2,94
4,68
5,08
9,9
15,2
a 1000 m run that are
analysed in Figure 1.
Hr before effort [bpm]
99
92
12,1
21,1
77
62
120
137
12,2
23
The
arrangement
Hr after effort [bpm]
188
185
7,7
8,3
175
174
201
204
4,1
4,5
above
is
fully
LA before effort [mmol/l] 2,9
2,8
0,5
0,3
2,1
2,3
3,9
3,2
17,2
11,4
understandable
and
LA after effort [mmol/l]
14,2
14,6
2,5
2,9
10,5
11,7
20,9
21
17,6
19,9
supported with greater
124
Błażej Stankiewicz, Mirosława Cieślicka
and a maximum result is over 100 J/kg difference in
favour of older runners. In case of 4 juniors, the
indicators exceeded 1100 J/kg and only in three cases it
oscillated around 900 J/kg. About 40% of younger
competitors oscillated around 1000 J/kg. Only one
exceeded the limit of 1100 J/kg, and six of them did
not exceed the limit of 900 J/kg.
Similar discrepancies are illustrated in Figure 3 that
shows power indicators per a kilogram of body weight
obtained during the test. Both indicators correlate
significantly,
hence
similar
1300
disproportions.
1220
The best achievements in a junior
1200
1160
group oscillated around 5 W/kg of
1125
1122
1101
1100
body weight, and four competitors
1053
1046
1046
1041
102210311022
1022
young juniors
1013
1000
999
obtained mean power over 4.5 W/kg.
992
983
juniors
932 930
However, in a group of young juniors
923
920
908
909
900
888
875
864
only one competitor (3) worked with
856
849
828
802
800
789
mean power over 45 W/kg. Again, the
lowest power in the junior group was
705
700
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21
noted for the competitor (no. 4) who
was the only one who did not exceed 3
Fig. 2. Work (J/kg) carried out by the subjects during a 240-second cycle
W/kg. Three juniors did not attain the
ergometric test
threshold of 4 W/kg; three obtained
Ryc. 2. Praca (J/kg) wykonana przez badanych biegaczy podczas 240mean power between 4 W/kg and 4.5
sekundowej próby cykloergometrycznej
W/kg of body weight. The most
numerous (9) group of competitors
5,5
in the younger age group worked
5,08
with mean power between 4 W/kg
5
4,84
4,69
4,68
and 4.5W/kg, eight young juniors
4,59
4,5
4,39
4,36
4,36
4,34
obtained results below 4W/kg, and
4,29
4,26
4,26
4,26
4,22
4,16
4,13
4,1
young juniors
4
three of them a bit below 3.5 W/kg
3,91 3,87
juniors
3,85
3,83
3,79
3,78
3,7
3,64
of their body weight.
3,6
3,57
3,54
3,5
3,45
3,34
3,29
In Fig. IV a record of heart rate
3
2,94
monitor of subjects before the test
and after its completion can be
2,5
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20 21
found.
Mean values in competition in
Fig. 3. Mean power (W/kg) obtained by tested runners during a 240-second cycle
both groups are similar and within
ergometric test
the limits of between 90 and 100
Ryc. 3. Moc średnia (W/kg) uzyskana przez badanych biegaczy podczas 240bpm. In the case of mean maximum
sekundowej próby cykloergometrycznej
values it is only a difference of 3
heart beats. In both age groups maximum values
In both groups minimal values oscillate around 800
exceeded 200 bpm, which is standard bodily reaction at
J/kg – 850 J/kg. A junior no. 4 who falls behind his
this age. Only 6 competitors did not exceed the
peers but also behind his younger colleagues is an
threshold of 180 bpm, four of whom were young
exception here. The result of 705 J/kg most probably
juniors and two of them were their older colleagues.
stems from poor commitment of the subject when
For another 7 competitors a maximum heart rate was
carrying out the test, or from lack of adaptation of
between 180 bpm and 190 bpm. The most numerous
muscular apparatus to the cycle ergometer test. A mean
group (10) are the runners who exceeded 190 bpm.
result obtained by juniors is higher by over 50 J/kg,
seniority of juniors and their age. In the older group, 7
competitors obtained results exceeding 2’40”, and only
4 of them were in between 160 sec. and 170 sec. This
is quite different among younger runners, where 5
competitors obtained results below 160 sec. and 5 of
them below 170 sec. Yet, over 50% of younger juniors
obtained the results about 3 minutes.
The figure below shows work indicators expressed
in J/kg of body weight, obtained by the subjects during
a 240-second test.
Detailed analysis of a 240-second cycle ergometric test in middle-distance runners aged 16-19
125
Subjects in both groups were
characterized
by
significant
190
180
discrepancies between the lowest and the
170
160
highest exercise-induced concentration.
150
young juniors
140
In both cases the difference was
juniors
young juniors
130
approximately 10 mmol/l. Two results of
juniors
120
110
21 mmol/l were recorded, being very
100
90
high and corresponding to the research
80
70
of Hollmann and Hettinger [15] that
60
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20 21
furnishes these values for a 1500 m run.
In the majority of competitors an
Fig. 4. Heart rate before and after a 240-second cycle ergometric test in the
acidosis was observed with 13-17
subjects
mmol/l.
Ryc. 4. Liczba skurczów serca przed i po 240-sekundowej,
A correlation analysis was also
cykloergometrycznej próbie wśród badanych zawodników
carried
out
between
individual
parameters obtained in the test, the
results of which are provided in Table II
21
and III.
19
17
When analysing Table II, a
15
correlation between the work performed
young juniors
13
and power yielded emerges, yet this is
juniors
11
young juniors
self-evident. Aside from that, the
juniors
9
strongest correlating factors are work
7
and power altogether with the level of
5
3
lactic acid after the exercise and, to a
1
lesser degree, work with heart beats per
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21
minute after the exercise. The absence of
correlation of such factors as heart rate
Fig. 5. Lactic acid level in subjects before and after a 240 second cycle
after the exercise and the level of lactic
ergometric test
acid after the exercise or a fairly poor
Ryc. 5. Poziom kwasu mlekowego u badanych zawodników przed i po 240correlation between work performed and
sekundowej próbie cykloergometrycznej
power obtained in terms of a competition
High indications before starting the test are also
result in a 1000 m run is surprising.
interesting, i.e. only three competitors’ heart beat rate
In the Table below a similar summary for the junior
was below 80, and one of them approached 60 bpm.
group has been provided.
This fact comes as a surprise given that the majority of
In the junior group more significant correlations
subjects’ training seniority exceeded 2 years, thus
between a greater number of indicators emerged. The
bradycardia should have already manifested itself in a
highest correlation is certainly observed between work
slower resting heart rate. On the other hand, however,
performed and power output in the test. Yet, in this
participation in such a demanding test might have
group, unlike in the group of younger competitors, a
caused a stress reaction and a quickened heart rate.
significant relation between of work performed and
The Figure below illustrates the level of lactic acid
power obtained to the result of a 1000 m run emerges,
before and after a 240-second test on the cycle
which is highly significant in terms of confirming the
ergometer.
rightness of cycle ergometric tests in runners.
The concentration of lactic acid in almost all
Different correlations in both age groups are most
subjects before the test oscillated around 2-3 mmol/l,
probably caused by a greater spread of results in the
which is a relatively high value, yet commonplace in
younger group and a reverse phenomenon in juniors,
everyday trainer practice recorded at this time of the
which also provides a hint as to the organisation of
day and in these age groups. Maximum values are
tests in relation to the level the runners present.
noteworthy, as their mean was 14.2 mmol/l in a
younger group and 14.6 mmol/l in the junior group.
210
200
Błażej Stankiewicz, Mirosława Cieślicka
126
Table II. Correlation analysis of selected indicators in the
young junior group
Tabela II. Analiza korelacyjna wybranych wskaźników w
grupie juniorów młodszych
.
Specific Specific
energy power
Specific
energy
1
Specific
power
1000m
Hr
LA
Hr after
LA after
before
before
-0.14
0.07
-0.26
-0.04
0.36
-0.14
0.07
-0.26
-0.04
0.36
-0.12
0.22
-0.09
-0.003
0.3
0.05
-0.19
-0.13
-0.06
1000m
Hr before
Hr after
LA before
0.1
LA after
Table III. Correlation analysis of selected indicators in the
junior group
Tabela III. Analiza korelacyjna wybranych wskaźników w
grupie juniorów
Specific
energy
Specific
energy
Specific
Hr
1000m
Hr after
power
before
1
Specific
power
1000m
LA
before
LA after
-0.58
-0.46
-0.46
0.2
0.45
-0.58
-0.46
-0.46
0.21
0.46
0.41
0.48
-0.46
-0.53
0.86
0.26
-0.2
0.01
-0.2
Hr before
Hr after
LA
before
0.32
LA after
Table IV. Maximum heart beats and maximum lactic acid
concentration in blood in subjects during a 60second test
Tabela IV. Maksymalna liczba skurczów serca i maksymalne
stężenie kwasu mlekowego we krwi wśród
badanych zawodników podczas próby 60sekundowej
M
±δ
min
max
V%
Indicators
60 s
240
240
240
240
240
60 s
60 s
60 s
60 s
s
s
s
s
s
Hr after exercise [bpm]
182
188 9.4 7.7 167 175 197 201 0.05 4.1
LA after exercise [mmol/l]
12.2
14.2 2.3 2.5 7.2 10.5 17.8 20.9 19 17.6
DISCUSSION
The research conducted proved fruitful as valuable
material was gathered that can be further utilized in
more effective training management of middle-distance
runners. The obtained results allow confirming the
rightness of organizing tests among middle-distance
young junior and junior runners.
A 240-second cycle ergometric test is rarely
applied, even though it is well-adjusted to work
conditions at middle-distance running. It is particularly
suitable for a 1500 m run, where an increase in lactic
acid in blood over 20mmol/l is often observed after the
exercise. Based on a 240-second test, competitors’
capability to high-intensity effort and extended
duration were determined [16]. The data on the results
of the tests with such duration are beyond the reach.
An exception is an unpublished doctoral dissertation of
Grzywocz (1998) who carried out similar research in a
group of female competitors specializing in 400 m runs
and 400 m hurdle runs. Yet, the results of the
abovementioned are not feasible to be compared with
those of middle-distance runners. In the paper by
Prusik and Mroczyński [17] who investigated middledistance runners, numeric values obtained in a 240second test are not provided.
It is worthwhile to examine earlier studies carried
out in the same group of young juniors. Example
results can be found in Table IV.
The parameters above are lower than those of
young juniors in a 240-second test. Mean heart rate
throughout a 4-minute test was 188 bpm, and mean
lactic acid concentration reached 14.2 mmol/l. This
unequivocally proves that a higher acidosis level and
higher heart rate were characteristic of competitors
after a submaximum-type test, which validates the data
in literature [2], and own hypothesis. The results
obtained differ from those Hollman and Hettinger
came up with in 1980 that mention the highest increase
of lactic acid levels after a 400 m run, yet it should not
be neglected that their research was conducted among
master class competitors. On the other hand, however,
the results obtained in own research, as well as
awareness that each competitor is an individual and
their reactions to a wide array of exercises vary,
welcome future research and tests that would further
unravel a sportsman’s organism with an ultimate goal
to optimize a training process.
Detailed analysis of a 240-second cycle ergometric test in middle-distance runners aged 16-19
CONCLUSIONS
Upon analysing the results of own study, and
bearing in mind the questions posed, the following
conclusions emerge:
1. A set of criteria presented in the paper,
detailing work and power obtained during a
240-second cycle ergometer might be used by
trainers in a sport training process to assess
individual function predisposition.
2. The essential criteria for assessing
competitors’ effort capability proved to be the
work performed during the test, expressed in
joule per kilogram of body weight and mean
power expressed per one kilogram of body
weight.
3. The results obtained allowed to characterize
the subjects in terms of work capabilities in
acid and lactic conditions. This will help
when planning training loads in this particular
scope.
4. Ability to exercise under acid and lactic
conditions is not the sole indicator of middledistance runners’ preparedness. Aerobic and
anaerobic functions need to be considered as
well.
5. The results obtained in a 240-second cycle
ergometric test cannot be taken as a forecast
of results in running events; they might
nonetheless point at those individuals who are
best accommodated to exercises when
subjected to acidosis.
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wysiłku wytrzymałościowego, czyli od Holloszy’ego
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2. Sobczyk G.: Energetyczny trening w biegach średnich.
Trening, 1, 2000, 65-82.
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3. Górski J.: (red.) Fizjologiczne podstawy wysiłku
fizycznego. Warszawa, 2001, 553.
4. Newsholme E., Leech T., Duester G.: Keep on Running.
The Science of Training and Performance. Crystal
Dreams Pub, 1994, 462.
5. Kozłowski S., Nazar K. (red.): Wprowadzenie do
fizjologii klinicznej. PZWL Warszawa, 1999, 649.
6. Zaremba Z.: Nowoczesny trening biegów średnich i
długich. Warszawa. Sport i Turystyka, 1976, 207.
7. Socha S., Ważny T. (red.): Lekkoatletyka. Katowice
AWF, 1986, 500.
8. Naglak Z.:Metodyka trenowania sportowca. AWF
Wrocław, 1991, 205.
9. Mroczyński Z. (red.): Lekkoatletyka. Biegi. AWF
Gdańsk, 1995, 311.
10. Bompa T.: Teoria i metodyka treningu. RCMSKFiS
Warszawa, 1990, 260.
11. Sozański H., Zaporożanow W. A.: Kierowanie jako
czynnik optymalizacji treningu. Biblioteka Trenera.
RCMSzKFiS, Warszawa, 1993, 120.
12. Janssen P.: Training lactate-plus rate. Polar Electro Oy,
Helsinki, 1993, 173.
13. Wołkow N.: Bioenergetyczne podstawy i oceny
wytrzymałości. Sport Wyczynowy, 1989, 7-8, 7-18.
14. Miszczenko W. (red.): Mechanizmy rozwijania
wynosliwosti. KGHIFK, Kijów, 1993, 62.
15. Hollmann W., Hetinger T.: Sportmedizin Arbeite und
Trainingsgrundlagen. Stuttgart- New York, 1980, 773.
16. Prusik K., Ratkowski W.: Kierowanie procesem
treningowym na podstawie indywidualnej adaptacji do
wysiłku fizycznego. Trening, 1998, 2-3, 239-255.
17. Prusik K., Mroczyński Z.: Indywidualizacja procesu
treningowego biegaczy na średnim dystansie. Rocznik
naukowy, AWF Gdańsk, IX, 2000, 257-289
Address for correspondence:
Modrzewiowa 2/49
Bydgoszcz 85-631
e-mail: [email protected], [email protected]
Received: 10.01.2012
Accepted for publication: 6.03.2012
Medical and Biological Sciences, 2012, 26/2, 129-134
Ewa Joanna Szymelfejnik, Anna Chiba
THE INTERDEPENDENCE OF NUTRITIONAL STATUS AND BLOOD PRESSURE
IN FEMALE STUDENTS
WSPÓŁZALEŻNOŚĆ MIĘDZY STANEM ODŻYWIENIA A CIŚNIENIEM TĘTNICZYM
U STUDENTEK
Department of Nutrition and Dietetics of the Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University of Toruń
Head: prof. dr hab. Roman Cichon
Summary
I n t r o d u c t i o n : The value of blood pressure is
affected by a number of factors, nutritional status being of
utmost importance.
T h e a i m o f t h e s t u d y was an assessment of the
interdependence between the nutritional status and systolic
blood pressure (SBP) as well as diastolic blood pressure
(DBP) in female students.
M a t e r i a l a n d m e t h o d : The research included 66
women aged 20.5±0.71, studying in Bydgoszcz. The systolic
and diastolic blood pressure was measured. The nutritional
status of the students was estimated with the use of
anthropometric parameters. To assess the status, nutritional
indexes such as the BMI and %FM were applied.
R e s u l t s : The mean systolic and diastolic pressure of
the female students was optimal. Hypertension was identified
only in 1.5% of the students and high normal blood pressure in 12% of the students. The mean nutritional status of female
students was adequate (BMI=20.3±2.75 kg/m2). However,
low body mass was found in every 5th person and
undernutrition in every 3rd person. The percentage of body
fat was high (31.1±2.75%), and obesity was identified in
about 60% of the students. A significant correlation was
observed between systolic pressure and body mass (r=0.4
p<0.001), %FM (r=0.5 p<0.001) and BMI (r=0.4 p=0.002).
A significantly higher systolic pressure (121 vs. 111 mmHg
p<0,001) and diastolic pressure (77 vs. 73 mmHg p=0.013)
was observed in the obese female students compared to the
non-obese students.
Conclusions:
1. Disorders in nutritional status were identified in over
a half of the students.
2. An interdependence between body mass, body mass
index, body fat in female students and systolic pressure was
shown.
3. A significantly higher blood pressure and more
frequent occurrence of higher blood pressure categories were
observed in obese female students.
Streszczenie
W s t ę p Na wartość ciśnienia tętniczego krwi wpływa
szereg czynników, spośród których duże znaczenia ma stan
odżywienia.
C e l e m p r a c y było określenie współzależności
między ciśnieniem tętniczym skurczowym (SBP) i
rozkurczowego (DBP) u studentek a ich stanem odżywienia.
M a t e r i a ł a n d m e t o d y : Badaniami objęto 66
kobiet w wieku
20,5±071 lat z bydgoskich uczelni
wyższych. U studentek dokonano pomiaru ciśnienia
tętniczego krwi i pomiarów antropometrycznych. Do oceny
stanu odżywienia wykorzystani wskaźniki stanu odżywienia
m.in. BMI, %FM.
W y n i k i : U studentek średnie ciśnienie tętnicze
skurczowe i rozkurczowe było optymalne (117/75 mmHg).
Nadciśnienie tętnicze odnotowano jedynie u 1,5% studentek,
a wysokie prawidłowe u 12% badanych. Odnotowano
prawidłowy
średni
stan
odżywienia
studentek
(BMI=20,3±2,75 kg/m2). Jednak u co 5 osoby wykazano
niską masę ciała, a u co 3 niedożywienie. Procentowa
zawartości tłuszczu w ciele była wysoka (31,1±2,75%),
a nadmierne otłuszczenie odnotowano aż u ok.60%
studentek. Odnotowano istotną korelację pomiędzy
ciśnieniem skurczowym oraz masą ciała (r=0,4 p<0,001),
%FM (r=0,5 p<0,001) i BMI (r=0,4 p=0,002). U studentek
130
Ewa Joanna Szymelfejnik, Anna Chiba
z nadmierną ilością tłuszczu odnotowano istotnie wyższe
ciśnienie skurczowe (121 vs 111 mmHg p<0,001)
i rozkurczowe (77 vs 73 mmHg p=0,013) w porównaniu
z osobami z prawidłową zawartością tłuszczu w ciele.
Wnioski:
1. Występowanie zaburzeń w stanie odżywienia
wykazano u ponad połowy studentek.
2. Wykazano zależność między masą ciała, wskaźnikiem
masy ciała i zawartością tłuszczu w ciele studentek
a skurczowym ciśnieniem tętniczym.
3. U studentek z wyższą zawartością tłuszczu w ciele
odnotowano istotnie wyższe wartości ciśnienia tętniczego
i częstsze występowanie wyższych kategorii ciśnienia.
Key words: female students, blood pressure, nutritional status, body mass, BMI, % FM
Słowa kluczowe: studentki, ciśnienie tętnicze, stan odżywienia, masa ciała, BMI, %FM
INTRODUCTION
The value of blood pressure is affected by a number
of factors, nutritional status being of utmost
importance [1,2,3,4,5,6,7,8,9,10,11]. Appropriate body
weight and body composition is very important for
maintaining good health.
The development of
hypertension can be prevented primarily by certain
impact on the environmental conditions, and in
particular the lifestyle of the patient (diet, physical
activity) [1,2,12,13,14,15,16]. Prevention (prophylaxis)
should be addressed in particular to children and young
people, in whom a development of the disease
(hypertension) has not yet occurred [2, 3, 10].
THE AIM
The aim of the study was an assessment of the
interdependence between the nutritional status and
systolic blood pressure (SBP) as well as diastolic blood
pressure (DBP) in female students.
MATERIAL AND METHOD
The research included 66 women aged 20.5±0.71,
studying in Bydgoszcz as first or second year students.
The research was conducted from November 2010 to
May 2011, on the basis of an agreement of the
Bioethics Commission of the Nicolaus Copernicus
University in Toruń Collegium Medicum in
Bydgoszcz. The systolic and diastolic blood pressure
(SBP and DBP) and anthropometric measurements
were taken. Anthropometric measurements included
the specification of body mass (kg) and height (cm),
arm circumference (cm) and 4 skinfold thicknesses:
triceps skinfold (TSF, mm), biceps skinfold (BSF,
mm), subscapular skinfold (SCSF, mm) and suprailiac
skinfold (SISF, mm) measurements. The nutritional
status of the students was estimated with the use of
anthropometric parameters. To assess the status,
nutritional indexes such as the BMI, %FM, waist to hip
ratio (WHR) and arm muscle circumference (AMC)
were applied. The value of indicators underwent
classification according to the following criteria: the
BMI-WHO (2003), waist circumference (<80cm vs.
≥80 cm), % FM (non–obesity<30% vs. obesity >30%).
The classification of blood pressure was made in
accordance with the guidelines of the Polish Society of
Hypertension [1], the guidelines of the ESH and ESC
[2].
The statistical analysis was carried out with the
STATISTICA PL v.9.0 computer program of the
StatSoft where the significance level was ≤0.05. The
blood pressure, anthropometric parameters and
indicators of nutritional status were displayed as mean
value (x), standard deviation (SD), median (Me),
minimum (Min) and maximum (Max). In order to
determine the correlation of pressure and nutritional
status parameters, the Pearson correlation coefficient
was calculated. Evaluation of the variation in pressure
between students of different nutritional status was
carried out using the student's t-distribution test or the
Kruskal-Wallis test. The evaluation of population
distribution in the classes: obesity/non-obesity
(according to the % FM) was carried out using Chisquare test.
RESULTS
The mean systolic pressure (SBP) of the female
students in Bydgoszcz was at 117.2 ± 9.8 mm Hg, and
the diastolic pressure (DBP) was 75.4 ± 7.7 mm Hg.
The mean heart rate was 74.9 ±11.1 beats/minute
(Tab. I).
The optimum arterial SBP and DBP pressure was
found respectively in 59.1% and 69.7% of students
(Tab.II). The normal value of the systolic blood
pressure occurred in nearly one-third of all the students
(31.8%), and the normal value of diastolic pressure - in
16.7% of the population. High normal SBP and DBP
pressure was identified in 9.1% and 12.1% of the
students respectively. Among all the students, the SBP
value does not show hypertension. Only in 1.5% of the
students an increase in the value of DBP above the
The interdependence of nutritional status and blood pressure in female students
limit was observed and hypertension was found (Tab.
II).
Tabela.I. Średnia wartość ciśnienia tętniczego skurczowego
(SBP), rozkurczowego (DBP) i tętna studentek
Table.I. Average value of systolic blood pressure (SBP),
diastolic blood pressure (DBP) and pulse in female
students
Parametr/ parameter
x± SD
Me
Min
Max
SBP [mm Hg]
117.2±9.8
117.5
92.0
137.0
DBP [mm Hg]
75.4±7.7
75.0
57.0
90.0
Tętno [uderzeń/min]
/ Heart rate
74.9±11.1
72.0
57.0
120.0
[beats/minute]
x – średnia, SD - odchylenie standardowe, Me – mediana, Min –
minimum, Max – maximum
x – mean, SD - standard deviation, Me – median, Min – minimum,
Max – maximum
Tabela. II. Klasyfikacja ciśnienia tętniczego wśród studentek
Table. II. Classification of blood pressure in female students
Kategoria / Category
N=66
%N
Optymalne / Optimal
39
59.1
SBP
Normalne / Normal
21
31.8
[mm Hg]
Wysokie prawidłowe / High normal
6
9.1
Nadciśnienie / Hypertension
0
0
Optymalne / Optimal
46
69.7
DBP
Normalne / Normal
11
16.7
[mm Hg]
Wysokie prawidłowe / High normal
8
12.1
Nadciśnienie / Hypertension
1
1.5
SBP – ciśnienie tętnicze skurczowe, DBP – ciśnienie tętnicze
rozkurczowe, N – liczebność, %N - odsetek populacji,
SBP - systolic blood pressure, DBP - diastolic blood pressure, N –
number, %N – percentage of population
Tabela. III. Średnie wartości parametrów antropometrycznych i wskaźników stanu odżywienia
wśród studentek
Table. III. The average value of the anthropometric
parameter measurements and nutritional status
in female students
Parametr/ parameter
x±
SD
Min
Max
Wysokość/Weight [cm]
166.5 ± 5.1
152.0
181.0
Masa ciała/Body mass [kg]
56.6 ±
10.1
42.4
98.0
A [cm]
24.4 ±
3.0
20.0
30.5
W [cm]
73.9 ±
6.3
64.0
96.0
H [cm]
90.8 ±
5.0
82.5
107.5
TSF [mm]
20.7 ±
7.7
9.7
37.6
BSF [mm]
15.6 ±
7.7
4.0
35.1
SCSF [mm]
14.8 ±
5.5
8.2
31.5
SISF [mm]
20.7 ±
7.5
6.4
36.1
% FM [%]
31.1 ±
4.6
19.6
40.1
WHR
0.8 ±
0.1
0.7
1.0
2
BMI [BMI kg/m ]
20.3 ±
2.7
17.0
29.9
AMC [cm]
17.9 ±
2.6
10.7
25.6
x - średnia; SD - odchylenie standardowe; Min - minimum; Max maximum; A – obwód ramienia, W – obwód talii, H – obwód
bioder; grubość fałdu skórno-tłuszczowego nad: TSF – tricepsem,
BSF - bicepsem; SCSF - dolnym kątem łopatki; SISF - grzebieniem
kości biodrowej; % FM - procentowa zawartość tłuszczu w ciele;
WHR - wskaźnik talia -biodro; BMI - wskaźnik masy ciała; AMC obwód mięśni ramienia
x – mean, SD - standard deviation, Me – median, Min – minimum,
Max – maximum; A - Arm circumference, W - Waist circumference,
H – Hip circumference,TSF- triceps skinfold thickness, BSF- biceps
skinfold thickness; SCSF- subscapular skinfold thickness; SISFsuprailiac skinfold thickness; % FM - the percentage of fat in the
body; WHR- Waist to Hip Ratio; BMI- Body Mass Index; AMCarm muscle circumference
131
The characteristics of the anthropometric
parameters and indicators of nutritional status were
shown in the Tab. III. Statistical analysis showed no
statistically significant differences between blood
pressure among students with waist circumferences
<80 cm vs. ≥80 cm (Tab.IV). Statistical analysis
showed a statistically significant difference between
blood pressure values according to the percentage of
body fat (%FM). In obese female students the mean
value of systolic pressure was 121±8.0 mm Hg and
was higher compared to the non-obese students
(111±9.2 mm Hg, Tab.IV), while the average value of
diastolic pressure among non-obese students amounted
to 77±8.0 mm Hg and was lower than in the group
without obesity (73±6.3 mm Hg, Tab.IV).
Tabela. IV. Ciśnienie tętnicze i tętna studentek w zależności
od stanu odżywienia
Table. IV. Blood pressure and pulse of the students
depending on nutritional status
Tętno
SBP
DBP [uderz./min.] /
Kategoria/Category
N %N [mm Hg] [mm Hg] Heart rate
(beats/minute)
x± SD
x± SD
x± SD
Obwód talii (cm) / Waist circumference (cm)
<80 cm
56 84.8 117±10,2 76±7,3
75±11,4
≥80 cm
10 15.2 119±1,0
75±9,7
72±29,3
p=0,501 p=0.815
p=0.401
2
BMI [kg/m ]
0
0
<16.0 – niedożywienie 3o /
underweight 3 o
o
121#
83
57
16.0-16.9 – niedożywienie 2 1 1.5
/ underweight 2 o
75±12.4
17.0-18.4 – niedożywienie 1o 22 33.3 113±2.5* 75±7.5
underweight 1 o
18.5-19.9 – niska masa
13 19.7 117±2.2
75±7.6
73±10.9
ciała/low
20.0-24.9 –
28 42.4 120±1.5 * 75±7.6
77±10.2
prawidłowa/normal
25.0-29.9 – nadwaga
2 3.0 128±0.0# 88±0.7
70±2.1
/overweight
>30.0 – otyłość /obesity
0 0.0
p=0.012 0=0.074
p=0.435
%FM
<30% brak otyłości / no
27 40.9 111±9.2
73±6.3
72±12.4
obesity
>30% otyłość / obesity
39 59.1 121±8.0
77±8.0
77±9.8
p<0.001 p=0.014
p=0.525
SBP - ciśnienie tętnicze skurczowe; DBP - ciśnienie tętnicze
rozkurczowe; x - średnia;
SD - odchylenie standardowe; BMI – wskaźnik masy ciała, % FM procentowa zawartość tłuszczu w ciele; p - poziom istotności testu tStudenta lub Kruskala-Wallisa, # wykluczono z analizy statystycznej
(zbyt mała liczebność)
SBP - systolic blood pressure, DBP - diastolic blood pressure, x –
mean, SD - standard deviation, BMI- Body Mass Index; %FM - the
percentage of fat in the body; p - significant level of the t-Students
test or the Kruskal-Wallis test, #excluded from the analysis (to small
size)
Analysis of the diversity of blood pressure
according to the BMI was carried out for all the
students with normal body mass and first degree
malnutrition (other categories were excluded from the
analysis due to small sample sizes). Statistical analysis
132
Ewa Joanna Szymelfejnik, Anna Chiba
showed statistically significant differences in systolic
pressure values between the students with first degree
malnutrition and the students with correct weight. The
average value of systolic pressure in the normal BMI
students was 120±1.5 mm Hg and was lower by 7 mm
Hg compared to the students with first degree
malnutrition (113±2.5 mm Hg) (Tab.IV, p=0.012).
An analysis of the interdependence between blood
pressure and body mass showed a positive correlation
between the systolic pressure and body mass in the
female students (Fig.1). The analysis showed no
relationship between the diastolic pressure and body
mass (Tab.V). A significant correlation was observed
between the students’ systolic pressure and the BMI
(r=0.4 p=0.002, Fig. 2). A significant correlation was
not observed between the diastolic pressure (DBP) and
the BMI in the student population (Tab.V). No
correlation was observed between either the systolic or
diastolic pressure (DBP) and waist circumference or
hip circumference of the examined population of
Bydgoszcz female students (Tab.V).
(r=0.5 p<0.001, Fig.3) and a weak positive correlation
between diastolic pressure and body fat in the female
students (r=0.3 p=0.019, Fig.4).
Ryc. 2. Zależność między ciśnieniem skurczowym (SBP) a
wskaźnikiem masy ciała (BMI)
Fig. 2. Correlation between systolic blood pressure and body
mass index (BMI)
Tabela V. Korelacja ciśnienia i parametrów stanu odżywienia
Table V. Correlation between blood pressure and
parameters of nutritional status
SBP
DBP
Masa ciała
r=0.4 p<0.001
r=0.2 p=0.177
BMI
r=0.4 p=0.002
r=0.1 p=0.347
Obwód talii
r=0.2 p=0.110
r=0.0 p=0.852
Obwód bioder
r=0.2 p=0.095
r=0.2 p=0.075
%FM
r=0.5 p<0.001
r=0.3 p=0.019
r – współczynnik korelacji, r – the correlation coefficient
Ryc. 3. Zależność między ciśnieniem skurczowym (SBP) a
procentową zawartością tkanki tłuszczowej (%FM)
Fig. 3. Correlation between systolic blood pressure and body
fat percentage (%FM)
Ryc. 1. Zależność między ciśnieniem skurczowym (SBP) a
masą ciała
Fig. 1. Correlation between systolic blood pressure and body
mass
The analysis of interdependence between blood
pressure and body fat showed a high positive
correlation between systolic pressure and body fat
Ryc. 4. Zależność między ciśnieniem rozkurczowym (DBP) a
procentową zawartością tkanki tłuszczowej (%FM)
Fig. 4. Correlation between diastolic blood pressure and
body fat percentage (%FM)
The interdependence of nutritional status and blood pressure in female students
Statistical analysis showed the existence of
substantial variations in the distribution of the
population in terms of systolic pressure depending on
the percentage of body fat (% FM). Among the
students with optimal systolic pressure only just over a
half (53.9%) had a valid amount of fat in the body. The
others were obese. For all those with normal systolic
pressure, the presence of obesity was observed in more
than 70% of the persons (71.4%), and all those with a
high normal systolic pressure were obese (Tab.VI).
Statistical analysis did not show the existence of
substantial variations in the distribution of population
in terms of diastolic pressure depending on the
percentage of body fat (% FM). However, there has
been a trend of increase in the percentage of obese
people in subsequent diastolic pressure classes (from
optimum and normal to high normal). In the group
with normal diastolic pressure, almost ¾ of the
subpopulation was obese. Among all those with a high
normal pressure, the percentage of obese people was
close to 90%. Hypertension was shown in one obese
student (Tab.VI).
Tabela. VI. Rozkład studentek w kategoriach ciśnienia w
zależności od zawartości tłuszczu w ciele
(%FM)
Table VI. Distribution of female students in terms of blood
pressure depending on the percentage of fat in
the body (%FM)
Otyłość/brak
Ciśnienie / Blood pressure
otyłości wg % optymalne/ normalne / wysokie nadciśnienie/
FM
optimal
normal prawidłowe / hypertension
Obesity/nonhigh normal
obesity wg %
N N% N N% N
N%
N
N%
FM
Ciśnienie skurczowe / systolic blood pressure
Brak otyłości /
21 53.9 6 28.6 0
0.0
0
0.0
non-obesity
Otyłość / obesity 18 46.2 15 71.4 6 100.0 0
0.0
Ciśnienie rozkurczowe / diastolic blood pressure
Brak otyłości /
23 50.0 3 27.3 1
12.5
0
0.0
non-obesity
Otyłość / obesity 23 50.0 8 72.7 7
87.5
1
100
p
0.017
0.080
N - liczebność populacji; N% - odsetek populacji; p - poziom
istotności testu chi2, brak otyłości - %FM<30%, otyłość %FM>30%
N – number ; N% - percentage of population; p – significant level of
chi2 test, non- obesity - %FM<30%, obesity - %FM>30%
DISCUSSION
The mean systolic and diastolic pressure of
Bydgoszcz female students was optimal (117/75
mmHg). Recorded values were comparable to those
observed in the work of Krzych [3,4,5]. ParadowskaStankiewicz and Grzybowski [7] have slightly lower
average systolic and diastolic pressure values than in
the test group from Bydgoszcz. However, in Nowicki
133
is work [6], among all the students in Bydgoszcz, the
mean systolic and diastolic pressure values derogated
both from the results obtained in the test and from
those of the other authors (138.4 mm Hg and 88.7 mm
Hg).
Hypertension was identified only in 1.5% of
Bydgoszcz students and the result is similar to the one
recorded by Nowicki [6], whereas the highest
percentage of students with hypertension was reported
among the students of School of Medicine (9-10%).
The results of research among Polish adults
LIPIDOGRAM [8], WOBASZ [13] and the NATPOLPLUS [15,16] indicated a significant prevalence of
hypertension (29-42%) and a significant percentage of
people at risk of its development (11-30%).
The mean nutritional status of female students
from Bydgoszcz according to the BMI was adequate
(BMI=20.3±2.75 kg/m2). However, the analysis of
distribution in nutritional status classes showed low
body mass in every 5th person and malnutrition in
every 3rd person. Despite the malnutrition and low
body weight, the concern was body composition of
young women, as the average percentage of fat tissue
in the body was very high indeed (31.1±2.75%).
Obesity was identified in about 60% of the students.
High content of fat in the body of students with a low
or normal BMI was observed in research [17,18,19],
and the authors suggest the presence of metabolic
hazards is similar to the one in obese people.
The assessment of interdependence between
blood pressure and nutritional status showed a
significant relationship between the systolic pressure
and body mass, the % FM and the BMI. The strongest
correlation was found between the content of fat in the
body and the systolic pressure (r=0.5 p<0.001). In
female students with the proper content of fat in the
body (<30%), the SBP and DBP was optimal. A
significantly higher systolic and diastolic blood
pressure was observed in obese female students
compared to the non-obese students. The systolic
pressure was up to 10 mm Hg higher in obese students,
and despite their young age it already reached the high
normal value. These results indicate the presence of
risks of the development of hypertension in all those
young students. The basic preventive treatment for this
group should include, among others, moderate amount
of daily physical activity and diet modification [1,2].
134
Ewa Joanna Szymelfejnik, Anna Chiba
CONCLUSIONS
10.
11.
1. Disorders in nutritional status were identified in over
a half of the students.
2. An interdependence between body mass, body mass
index, body fat in female students and systolic pressure
was shown.
3. A significantly higher blood pressure and more
frequent occurrences of higher blood pressure
categories were observed in obese female students.
12.
13.
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14.
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Address for correspondence:
dr inż. Ewa Joanna Szymelfejnik
Katedra i Zakład Żywienia i Dietetyki
UMK w Toruniu
Collegium Medicum im. L. Rydygiera
ul. Dębowa 3
85-626 Bydgoszcz
tel.: 52 585 54 01 w.45
e-mail: [email protected]
Received: 10.01.2012
Accepted for publication: 6.03.2012
Medical and Biological Sciences, 2012, 26/2, 135-140
Magdalena Żbikowska-Gotz, Krzysztof Pałgan, Ewa Socha, Michał Przybyszewski, Andrzej Kuźmiński,
Zbigniew Bartuzi
METABOLIC ACTIVITY OF NEUTROPHILIC GRANULOCYTES MEASURED
WITH CHEMILUMINESCENCE TEST (CL)
IN PATIENTS WITH ALLERGIC HYPERSENSITIVITY TO FOOD
AKTYWNOŚĆ METABOLICZNA GRANULOCYTÓW OBOJĘTNOCHŁONNYCH
MIERZONA TESTEM CHEMILUMINESCENCJI
U PACJENTÓW Z NADWRAŻLIWOŚCIĄ ALERGICZNĄ NA POKARMY
The Chair and Department of Allergology, Clinical Immunology and Internal Diseases, Ludwik Rydygier
Collegium Medicum in Bydgoszcz, Nicholas Kopernik University in Toruń, 75, Ujejski Street, Bydgoszcz, Poland
The Head of the Chair and Department: Prof. Z. Bartuzi, M.D., Ph.D.
Summary
Introduction.
Neutrophilic
granulocytes
(neutrophils) are the most important cells of non-specific
immune response. These cells have capability of chemotaxis
and phagocytosis and also participate in inflammatory
processes. Stimulated neutrophils release reactive oxygen
species (ROS) important mediators of inflammatory process
responsible for tissues injury.
T h e a i m o f t h e s t u d y was assessment of
oxygenic metabolism as one of representatives regarding
metabolic activity of neutrophilic granulocytes measured
with chemiluminescence test (CL) in patients with allergic
type of hypersensitivity to food.
M a t e r i a l a n d m e t h o d s . The study contained
30 patients with diagnosed food allergy on the base of
medical history, clinical symptoms, positive prick tests and
the presence of allergen-specific IgE against selected food
allergens in the serum. The control group contained 10
healthy volunteers. Chemiluminescence of basal and
stimulated during 40 minutes neutrophils (fMLP, PMA, OZ)
was assessed with kinetic luminol-dependent method using
luminometer LUMINOSCAN – LABSYSTEM.
Results.
Mean
values
of
obtained
chemiluminescence from basal and stimulated neutrophils
were statistically significantly higher in patients with allergic
hypersensitivity to food than values in group of healthy
persons.
C o n c l u s i o n s . The results of performed analyses
indicate that neutrophils participate and have increased
activity in the process of allergic inflammation in patients
with food allergy.
Streszczenie
W s t ę p . Granulocyty obojętnochłonne – neutrofile to
najważniejsze komórki nieswoistej odpowiedzi immunologicznej posiadają zdolności chemotaksji i fagocytozy, biorą
udział w procesach zapalnych. Pobudzone neutrofile
wydzielają reaktywne formy tlenu (RFT) ważne mediatory
procesu zapalnego odpowiedzialne za uszkodzenie tkanek.
Cel
p r a c y . Ocena aktywności metabolicznej
neutrofilów mierzona testem chemiluminescencji (CL)
u pacjentów z alergią na pokarmy.
M a t e r i a ł i m e t o d y . Badaniem objęto 30 pacjentów ze zdiagnozowaną alergią pokarmową na podstawie
wywiadu, objawów klinicznych, dodatnich testów skórnych
i obecnością alergenowoswoistych IgE w surowicy krwi
przeciwko wybranym alergenom pokarmowym. Grupę
kontrolną stanowiło 10 zdrowych ochotników. Oceniano
metodą kinetyczną luminolozależną chemiluminescencję
neutrofili spoczynkowych i stymulowanych (fMLP, PMA,
Oz) w czasie 40 minut przy pomocy luminometru
LUMINOSCAN – LABSYSTEM.
W y n i k i . Wartości uzyskanej CL przez spoczynkowe
i stymulowane neutrofile były istotnie statystycznie wyższe
136
Magdalena Żbikowska-Gotz et. al.
u pacjentów z alergiczną nadwrażliwością na pokarmy niż
wartości w grupie osób zdrowych.
Wnioski.
Wyniki
przeprowadzonych
badań
potwierdzają udział i zwiększoną aktywność neutrofilów
w procesie zapalenia alergicznego u badanych pacjentów.
Key words: food allergy, chemiluminescence, neutrophils
Słowa kluczowe: alergia pokarmowa, chemiluminescencja, neutrofile
INTRODUCTION
AIM OF THE STUDY
Incidence of allergic reactions has significantly
increased during last several years. This problem also
concerns allergic hypersensitivity to food both in
children, young people and adult persons [1, 2].
ECAP Studies (Epidemiology of Allergic Diseases
in Poland) reveal that about 9% children at the age of
6-7 years and about 4% of adult persons at the age of
22-44 years present symptoms after consumption of
sensitizing food [3].
Diverse
clinical
symptoms
triggered
by
consumption of sensitizing food can be a result of
various, already well known immune pathogenic
mechanisms and can concern various organs and
systems. Examinations regarding immune system
function concentrate first of all on evaluation of
adaptive response indicators in patients with allergic
type of food hypersensitivity. It is also worth to pay
attention to participation of innate immunity system
that not only initiates, but also influences and forms
further specific response. It is known that complicated
interactions among various cells constitute the basis of
allergic inflammatory process. Besides already
confirmed participation of eosinophilic cells (Eo), also
neutrophils (Ne) can substantially participate in this
process that is emphasized more and more often.
Proinflammatory properties of Ne depend on their
ability to produce and release many important
mediators of inflammatory processes. These cells are
the most important source of reactive oxygen species
(ROS) in human organism [4, 5]. Membranous and
intracellular chemical reactions that are held in the cell
under the influence of various stimulators constitute
the source of emitted light. The range of oxygenic
metabolism that constitutes one of components of
neutrophil metabolic activity can be assessed with
chemiluminescence test (CL). Increased ROS
generation can happen in case of increased neutrophils
activation. This fact results in destructive effect of
these mediators on tissues when tissue defensive
mechanisms are unsatisfactorily efficient [6, 7, 8, 9] .
The aim of the study was an assessment of
oxygenic metabolism as one of representatives
regarding metabolic activity of neutrophilic
granulocytes measured with chemiluminescence test
(CL) in patients with allergic type of hypersensitivity
to food.
PATIENTS AND METHODS
Analysed group included 30 adult patients, 18
women and 12 men (mean age 41± 8.7 years), in
whom detailed diagnostics was performed to exclude
other diseases than allergic diseases.
Food allergy was diagnosed on the basis on medical
history, physical examination and performed
laboratory diagnostic and also double-blind placebo
controlled oral provocative test. Most often bloating,
abdominal pains, nausea and diarrhoeas occurred in the
analysed patients. All patients showed incidents of
acute urticaria in past medical history. Patients with
exacerbated complaints associated with food allergy
were qualified for analyses. The following food most
often caused allergy: peanuts, celery, apple, eggs and
fish. Allergy concerned more than one allergen in 8
patients. Patients with increased concentration of
allergen-specific IgE (sIgE) - class ≥2 (0.70 KU/I)
were qualified for the analysed group.
Reference group consisted of 10 healthy volunteers
5 women and 5 men (mean age 37±6.3) with negative
atopic past history, without symptoms of infection and
who did not take any medications.
The blood for the analyses was taken from ulnar
vein with use of closed system Vacutainer into testtube with lithium heparin with final concentration of
10 U/ml and also as clot into test-tube that did not
contain anticoagulants. Additionally, basic parameters
of the blood cell count were measured in all analysed
patients.
(sIgE) measurement was performed with fluoroenzyme-immune FEIA method on the UNICAP100
system using kits of Phadia company. Concentrations
Metabolic activity of neutrophilic granulocytes measured with chemiluminescence test (CL)...
of sIgE antibodies in class ≥2 were regarded as a
positive result.
Evaluation of neutrophil oxygenic metabolism was
performed with chemiluminescence method (CL)
intensified with luminol (5amino-2.3dihydroftalazyno1.4-dion), Sigma; dissolved in 0.4% NaOH solution up
to the concentration 28 µmol/ml. Luminol is
a compound that evolves into arousal state during
the process of oxidation and this fact allows significant
increase of light effects. The analyses were performed
with the use of LUMINOSCAN Ascent system
(Thermo
Labsystems
Helsinki,
Finland).
Measurements were performed with kinetic method for
40 minutes in temperature 37ºC ± 1ºC with CL
measurement of 2-minutes intervals. Results were
presented as integration CL values, it means surface
area under emission curve in time function measured
for 40 minutes and presented in units RLU (Relative
Light Units).
We evaluated not stimulated BS cells and cells
stimulated with fMLP (formyl-methionyl-leucylphenylalanine) 2x10¯6 M, PMA (phorbol myristate
acetate) 200ng/ml and OZ (opsonized zymosane)
0.33mg/ml.
Every analysed sample contained the whole blood,
stimulator, but in case of measurement of spontaneous
chemiluminescence without stimulator – luminol and
was also filled in with PBS for fixed volume. The
blood was added directly before reading. The readings
were performed at latest during 2 hours from the
moment of material collection. Every measurement
was repeated twice and mean value was calculated.
Chemiluminescence values were corrected in
accordance with values of hemoglobin concentration
and absolute neutrophils number and were expressed as
RLU according to the formula:
CL calculated = CL measured x{Hb[%] / (WBC
[thousands/µL] x PMN [%])}
Obtained result (RLU) was related to 1000 cells.
This fact allowed elimination of influence of diverse
number of neutrophilic granulocytes in the sample, but
thereby greater optimilization of obtained results.
The following statistical methods were applied to
draw up the data: arithmetical mean estimations (x);
estimations of standard deviation for mean (s).
Analysis of distribution form concerning analysed
characteristics was performed with use of ShapiroWilk test. U Mann-Whitney test was used to analyse
137
differences’ significance among groups which
distribution differed significantly from normal
distribution (Shapiro-Wilk test p<0.05). Spearman
correlation was used to prove interdependence among
analysed variables. STATISTICA v. 6.0 of StatSoft
company software was used in statistical analysis.
Studies were performed with consent of University
Bioethical Committee of Collegium Medicum in
Bydgoszcz, Nicolaus Copernicus University [consent
number KB 683/2009].
RESULTS
Results of the studies assessing basal and
stimulated state of neutrophils activation on the base of
ORF were presented in table 1 and graphically on the
figures (together with probability values). Analysis of
the obtained studies results showed in patients with
allergic hypersensitivity to food higher mean values of
CL test both by not stimulated and activated with
stimulators: fMLP, PMA and Oz in relation to persons
from reference group. There were statistically
significantly higher CL values of basal neutrophils and
chemiluminescence after PMA and OZ stimulators
application in the analysed patients in comparison with
the group of healthy persons proved. However,
significant differences were not found in CL quantity
among the analysed groups in case of use of
chemotactic peptide (fMLP).
Table I. Results of measurements and chemiluminescence
ranges of blood granulocytes depending on used
stimulators
Tabela I. Wyniki badań i zakresy chemiluminescencji
granulocytów
krwi
w
zależności
od
zastosowanych stymulatorów
Analysed
patients
BS
Chemiluminescence CL
[RLU total (40 min.)]
fMLP
PMA
OZ
Analysed group
n=30
x=1.24
SD=0.76
x=1.69
SD=0.79
x=2.44
SD=0.86
x=15.94
SD=8.65
Reference group
n=10
x=0.34
SD=0.14
x=1.14
SD=0.64
x=1.47
SD=0.61
x=8.61
SD=2.21
Magdalena Żbikowska-Gotz et. al.
138
4,5
p=0,00001
40
4,0
p=0,0142
35
30
3,0
OZ [RLU total (40 min.)]
BS [RLU total (40 min.)]
3,5
2,5
2,0
1,5
25
20
15
1,0
10
0,5
0,0
Grupa badana
Grupa kontrolna
Analysed group
Control group
Median
Mediana
25%
- 75%
25%-75%
Min-Maks
Min
- Max
5
0
Grupa badana
Analysed group
Fig. 1. Stimulated with BS neutrophils chemi-luminescence in
analysed groups
Rys. 1. Chemiluminescencja neutrofilów stymulowanych BS
w badanych grupach
Grupa kontrolna
Control group
Median
Mediana
25%
- 75%
25%-75%
Min-Maks
Min
- Max
Fig. 4. Stimulated with OZ neutrophils chemiluminescence in
analysed groups
Rys. 4. Chemiluminescencja neutrofilów stymulowanych OZ
w badanych grupach
4,5
DISCUSSION
p=0,0277
4,0
fMLP [RLU total (40 min.)]
3,5
3,0
2,5
2,0
1,5
1,0
0,5
0,0
Grupa badana
Grupa kontrolna
Analysed group
Control group
Median
Mediana
25%
- 75%
25%-75%
Min-Maks
Min
- Max
Fig. 2. Stimulated with fMLP neutrophils chemiluminescence
in analysed groups
Rys. 2. Chemiluminescencja neutrofilów stymulowanych
fMLP w badanych grupach
4,5
p=0,0011
4,0
PMA [RLU total (40 min.)]
3,5
3,0
2,5
2,0
1,5
1,0
0,5
0,0
Grupa badana
Analysed group
Grupa kontrolna
Control group
Median
Mediana
25%
- 75%
25%-75%
Min-Maks
Min
- Max
Fig. 3. Stimulated with PMA neutrophils chemiluminescence
in analysed groups
Rys. 3. Chemiluminescencja neutrofilów stymulowanych
PMA w badanych grupach
Despite intensive studies, pathogenesis of food
allergy is still not completely explained. More and
more often analyses undertake the subject regarding
possibility that neutrophils participate especially in
allergic reactions to food. Neutrophilic granulocytes
are the cells of basic significance in fight against
pathogens. The condition of neutrophils’ efficiency is a
normal course of their metabolic transformations.
Process of intracellular damage is associated with
activation of series of important enzymes and its
consequence consists among all in production and
release of active oxygen derivatives. This phenomenon
is called oxygenic explosion (‘respiratory burst’) [10,
11]. This reaction is accompanied by light emission –
chemiluminescence. The number of formed photons
can be measured with the use of luminometer.
Neutrophils circulating in the blood are not much
metabolically active till the moment of contact with
stimulating factors. Only signals transduced by many
stimulators regardless of the way of their transmission
can cause intensification of oxygenic metabolism [12,
13, 14].
Produced oxygenic compounds can disturb
metabolism of main cells elements, influence nuclear
transcription factors and stimulate synthesis of
proinflammatory cytokines. They also can cause
inactivation of important proteinases inhibitors and
result significant increase of proteolytic enzymes effect
on tissues.
Chemiluminescence in neutrophilic cells can be
induced via many ways: via chemotactic receptor
Metabolic activity of neutrophilic granulocytes measured with chemiluminescence test (CL)...
(fMLP), via receptor for Fc fragment of antibody and
complement (OZ), but also via direct activation way of
PKC (protein kinase C) via specific activator (PMA)
[11, 15].
Assessment of cells ability for chemiluminescence
was performed by evaluation regarding spontaneous
basal chemiluminescence as well as after addition of
stimulating factors.
We proved in the presented study increased ROS
production both by basal and stimulated neutrophils of
peripheral blood in patients with food allergy and
clinical symptoms from various organs. Obtained CL
values were significantly higher than values in the
group of healthy persons.
Our previous studies in asthmatic patients allergic
to allergens of house dust mite also proved
significantly higher ROS production made by
granulocytes in basal and activated by stimulants
circumstances [16, 17]. Participation and importance of
these mediators in inflammatory processes are also
shown by studies of other authors, performed in the
group of adults and children [18, 19, 20, 21, 22, 23].
It was noted that neutrophils of asthmatic patients
are characterized by increased ability to generate
reactive oxygen metabolites that can be associated with
the phenomenon of pre-reactivation of these cells in
circumstances in vivo. Triggering neutrophils priming
can be caused by many inflammatory mediators
released during allergic reactions. The result of such
influence can be excessive functional response to
stimulating factors in comparison with cells that did
not undergo earlier reactivation [24, 25, 26]. It seems
that this situation can occur also in described own
studies.
Interesting studies were performed by Monteseirini
et al. who proved that anti IgE class antibodies and
specific inhalatory antigens conditioning clinical
symptoms in selected patients with asthma, can be
responsible for increased oxygenic metabolism of
granulocytes and its range can be modulated by
specific immunotherapy [27].
Similarly to our studies, excessive ROS production
by basal Ne and Ne induced by stimulators was noted
in large group of children with well documented food
allergy [12]. The same authors in subsequent reports
also emphasize participation of TLR4 receptors present
in neutrophilic cells, suggesting involvement of the
system of innate immunity in mechanisms of allergy
development. TLR receptors activation constitutes
signal activating mechanisms of non-specific
139
immunity. It causes increased synthesis of antibacterial
factors and proinflammatory cytokines, dendritic cells
maturation (increased expression of co-stimulating
molecules and MHC) that obtain higher ability to
present antigens and proper activation of acquired
(specific) immunity as a result.
Wiktorowicz et al. direct attention to unknown till
then potential of proteins of lupine seeds for excessive
induction of oxygenic transformations in human
neutrophillic cells. Studies performed with use of flow
cytometry confirm this feature, but the fact that studies
were performed in healthy persons are significant and
worth emphasizing, because it is well known that
lupine seeds are more and more used in human
nutrition [28].
Studies of Wallaert et al. showed that in patients
with allergic hypersensitivity to food and without
symptoms of bronchial asthma, neutrophilic infiltration
occurs in the airways and is associated with increased
IL-8 concentration. Result of this study can be
confirmed by the conception that intends similar
immune response to allergic factor for all mucous
membranes, though cells and mediators responsible for
this process still remain unknown [29].
To sum up, it can be supposed that reactive
oxygenic metabolites released from neutrophilic
granulocytes play an important role in diseases with
active inflammation caused by allergic stimulation in
patients with allergic type of hypersensitivity to food.
Great part of literature is devoted to participation of
eosinophilic cells in allergic reactions to food, but on
the base of own studies it is also possible to indicate
increased activity of neutrophilic granulocytes and
indirect involvement of non-specific mechanisms of
organism defence. It is confirmed by analysis of
indicators of effector functions of peripheral blood
neutrophils.
CONCLUSIONS
1.
2.
Basal and stimulated neutrophils in patients with
food allergy show significantly higher ability to
generate reactive oxygenic metabolites.
Proved increased neutrophils activity can play
significant role in inflammatory process caused by
allergenic stimulation in patient with food allergy,
indicating indirectly that non-specific mechanisms
of organism defence participate in these reactions.
Magdalena Żbikowska-Gotz et. al.
140
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Address for correspondence:
Magdalena Żbikowska-Gotz
The Chair and Department of Allergology,
Clinical Immunology and Internal Diseases
Ludwik Rydygier Collegium Medicum
in Bydgoszcz
Nicholas Kopernik University in Toruń
75, Ujejski Street, Bydgoszcz, Poland
e-mail: [email protected]
Received: 10.01.2012
Accepted for publication: 6.03.2012
Medical and Biological Sciences, 2012, 26/2
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