medical and biological sciences
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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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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. 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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. REFERENCES 1. Kaltenborn FM „Kręgosłup. Badanie manualne i mobilizacja.“ Wydawnictwo Rolewski, Toruń, 1998. 2. Lewit K „Terapia manualna w rehabilitacji chorób narządu ruchu” III wyd. ZL Natura, 2001 3. Maitland G.D “Vertebral Manipulation” 6th Edition, Butterworths, London 2001 4. 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TractionManipulation of the Extremities and Spine: Basic Thrust Techniques” Norli, 2008. 12. Triano JJ (2001) Biomechanics of spinal manipulative therapy, The Spinal Journal vol. 1, Pp.121-130. 13. Błaszczyk JW „Biomechanika Kliniczna” Wydawnictwo Lekarskie PZWL; Warszawa 2004. 14. Bober T, Zawadzki J „Biomechanika układu ruchu człowieka” Wyd. 2. Wydawnictwo BK, Wrocław 2003 15. Dylewski M, Rzepka R (2009) “Możliwości obiektywnej oceny postawy ciała z wykorzystaniem czynnych i biernych markerów.” W: Nowotny J. (red.): Wady postawy ciała u dzieci i młodzieży. Wydawnictwo Wyższej Szkoły Administracji w Bielsku-Białej, BielskoBiała, 75-84. 16. Chateau H, Girard D, Degueurce C, Denoix J-M (2003) „Methodological considerations for using a kinematic analysis system based on ultrasonic triangulation” ITBMRBM Volume 24, Issue 2, Pages 69-78. 31 17. “WinData 2x for Windows. Operating instructions” ZEBRIS MEDICAL Gmbh Isny im Allgau, 2006. 18. Będziński R „Biomechanika Inżynierska. Zagadnienia wybrane” Oficyna Wydawnicza Politechniki Wrocławskiej, Wrocław 1997. 19. Brumagne S, Cordo P, Lysens S, Verschueren S, Swinnen S. (2000) The role of paraspinal muscle spindles in lumbosacral position sense in individuals with and without low back pain. Spine;25(8):989-94. 20. Cholewicki J, van Diee¨n JH, Arsenault AB (2003) Muscle function and dysfunction in the spine. J Electromyogr Kinesiol 13:303-304. 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. REFERENCES 1. Aleksander M.: Biodegradation and bioremediation, Academic Press. A Division of Harcourt Brace 7 Company, 1994. 2. Barron G. L.: Predatory fungi, wood decay, and carbon cycle. Biodiversity. 2003, 4, 3-9. 3. Czeczuga B., Kiziewicz B., Mazalska B.: Aquatic fungi growing on dead blades of certain representatives of emergent plants. Curr. Top. Plant Biol. 2003, 4, 175-191. 4. Kędzierzawski M.: The environment conditions of Podlasie Province in 2000-2001. Wydawnictwo i Drukarnia, Białystok. 2002. (In Polish) 5. Seymour R.L., Fuller M.S.: Collection and isolation of water molds (Saprolegniaceae) from water and soil.In: Fuller M. S., Jaworski A. (eds). Zoosporic fungi in teaching and research. Southeastern Publishing, Athens. 1987. 6. Kiziewicz B., Czeczuga B.: [Occurrence and morphology of some predatory fungi, amoebicidal, rotifericidal and nematodicidal, in the surface waters of Białystok region]. Wiad. Parazytol. 2003, 49, 281-291. ( In Polish) 7. Batko A.: [Hydromycology - an overview] PWN, Warszawa.1975.(In Polish) 8. Sparrow F. K.: Ecology of Freshwater Fungi. In: G.C. Ainsworth, A.S. Sussman (eds),The Fungi, III: 41-93. Academic Press, New York-London, 1968 9. Fassatiova O.: [The microscopic fungi in technical microbiology]. Wydawnictwo Naukowo-Techniczne, Warszawa 1983. (In Polisch) 10. Kowszyk-Gindifer Z., Sobiczewski W.: [Mycosis and ways of fighting against it]. PZWL, Warszawa 1986. ( In Polish) 11. Dick M.W.: Keys to Pythium. University of Reading Press, Reading 1990. 12. Greenberg A. E., Clesceri L.S., Eaton A.D.: Standard methods for the examination of water and waste-water. 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(In Polish) 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 THE ASSESSMENT OF INFLUENCE OF THERMOPLASTIC FOOT PADS ON THE BODY STABILITY IN PATIENTS WITH FOOT DYSFUNCTIONS - PILOTY STUDY 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. REFERENCES 1. Perner R.T, Lipiński T.R. Stopy twojego dziecka. http://www.life-plus.pl/str/artykuly/2/. 2. Lewit K., Stodolny J. Terapia Manualna w rehabilitacji chorób narządu ruchu. ZL Natura, Kielce 2001. 3. Błaszczyk J.W.: Biomechanika kliniczna. PZWL, Warszawa 2004. 4. Błaszczyk J.W.: Biomechanika kliniczna. PZWL, Warszawa 2011. 5. Aluisio F.V., Christensen C.P., Urbaniak J.R. Ortopedia. Urban & Partner, Wrocław 2000. 6. Green W.B., Dziak A. Ortopedia Nettera. Urban & Partner, Wrocław 2007. 7. Kutzner-Kozińska M. i wsp.: Proces korygowania wad postawy. AWM, Warszawa 2001. 8. Nowotny J. Podstawy kliniczne fizjoterapii w dysfunkcjach narządów ruchu. Medipage, Warszawa 2006. 9. http://www.dynasplint.com.pl/ 10. Ciejka, E., Daniszewska B., Janiszewski M. Analiza rozwoju i kształtu stopy dziecka w procesie ontogenezy, Med Man, Biomed, Głogów 2001, 5, 1 i 2. 11. Syczewska M., Lebiedowski M., Kalinowska M.: analiza chodu w praktyce klinicznej. Biomechanika i inżynieria rehabilitacyjna. Akademicka Oficyna Wydawnicza Elit, Warszawa 2004, 5, 351-370. 12. Mraz M., Sipko T., Anwajler J., Dąbrowska G, Skrzek A.: Ocena koordynacji ruchowej w utrzymaniu równowagi ciała osób młodych i starszych. Acta BioOptica et Informatica Medica, 2006 ,12, 3, 145-149. 13. Octkiewicz T., Skalska A., Grodzicki T. Badanie równowagi przy użyciu platformy balansowej- ocena powtarzalności metody. Gerontologia Polska, 2006, 14, 2, 144-148. 14. Perner R.T.: Protetyka i ortotyka – Zarys. Uniwersytet Medyczny w Łodzi, Łódź 2003. 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 DIFFERENTIAL EX VIVO DRUG RESISTANCE PROFILE IN FIRST AND SUBSEQUENT RELAPSED CHILDHOOD ACUTE MYELOID LEUKEMIA IN COMPARISON TO INITIAL DIAGNOSIS ZRÓŻNICOWANY PROFIL OPORNOŚCI EX VIVO NA CYTOSTATYKI W PIERWSZEJ I KOLEJNYCH WZNOWACH OSTREJ BIAŁACZKI MIELOBLASTYCZNEJ U DZIECI W PORÓWNANIU Z PIERWSZYM ROZPOZNANIEM Pracownia Onkologii Klinicznej i Eksperymentalnej, Katedra Pediatrii, Hematologii i Onkologii, Collegium Medicum im. L. Rydygiera w Bydgoszczy, Uniwersytet Mikołaja Kopernika Kierownik: prof. dr hab. n. med. Mariusz Wysocki Szpital Uniwersytecki nr 1 im. Jurasza w Bydgoszczy Dyrektor: Jarosław Kozera Summary B a c k g r o u n d . Current cure rate reach 50-60% of long-term survival in childhood acute myeloblastic leukemia (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. REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Pui CH, Robison LL, Look AT. Acute lymphoblastic leukaemia. Lancet 2008;371:1030-1043. Coenen EA, Raimondi SC, Harbott J i wsp. Prognostic significance of additional cytogenetic aberrations in 733 de novo pediatric 11q23/mll-rearranged AML patients: Results of an international study. Blood 2011;117:7102-7111. Creutzig U, Zimmermann M, Bourquin JP i wsp. Second induction with high-dose cytarabine and mitoxantrone: Different impact on pediatric AML patients with t(8;21) and with inv(16). Blood 2011;118:5409-5415. Pieters R, Huismans DR, Loonen AH i wsp. Relation of cellular drug resistance to long-term clinical outcome in childhood acute lymphoblastic leukaemia. Lancet 1991;338:399-403. 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Zwaan CM, Kaspers GJ, Pieters R i wsp. Different drug sensitivity profiles of acute myeloid and lymphoblastic leukemia and normal peripheral blood mononuclear cells in children with and without down syndrome. Blood 2002;99:245-251. Yamada S, Hongo T, Okada S i wsp. Clinical relevance of in vitro chemoresistance in childhood acute myeloid leukemia. Leukemia 2001;15:1892-1897. Staib P, Staltmeier E, Neurohr K i wsp. Prediction of individual response to chemotherapy in patients with acute myeloid leukaemia using the chemosensitivity index ci. Br J Haematol 2005;128:783-791. Homminga I, Zwaan CM, Manz CY i wsp. In vitro efficacy of forodesine and nelarabine (ara-g) in pediatric leukemia. Blood 2011;118:2184-2190. Wang Y, Li W, Chen S i wsp. Salvage chemotherapy with low-dose cytarabine and aclarubicin in combination with granulocyte colony-stimulating factor priming in patients with refractory or relapsed acute myeloid leukemia with translocation (8;21). Leuk Res 2011;35:604-607. Lamba JK. Pharmacogenomics of cytarabine in childhood leukemia. Pharmacogenomics 2011; 12: 1629-1632. 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’. REFERENCES 1. Meeske K., Katz E., Palmer S., Burwinkle T., Varni J. Parent Proxy-Reported Health- Related Quality of Life and Fatigue in Pediatric Patients Diagnosed with Brain Tumors and Acute Lymphoblastic Leukemia, Cancer 2004, 101: 2116-2125 2. Varni J.W., Burwinkle T.M., Seid M. The PedsQL TM 4.0 as a school population health measure: Feasibility, reliability and validity. Quality of Life Research 2006, 15: 203-215 3. Varni J.W., Limbers Ch.A., Burwinkle T.M. Impaired health- related quality of life in children and adolescents with chronic conditions: a comparative analysis of 10 disease cluster and 33 disease categories/ severities utilizing the PedsQL TM 4.0 Generic Core Scales. Health and Quality of Life Outcomes 2007, 5: 43-58 4. Varni JW, Burwinkle TM, Seid M, Skarr D. The PedsQL 4.0 as a pediatric population health measure: Feasibility, reliability and validity. Ambul Pediatr 2003; 3: 329-341 5. Varni JW, Burwinkle TM, Seid M. The PedsQL 4.0 as school population health measure: Feasibility, reliability and validity. Quality of Life Research 2006; 15: 203-215 6. Varni, JW, Burwinkle TM, Katz ER et al. The PedsQL in pediatric cancer: Reliability and validity of the Pediatric Quality of Life Inventory Generic Core Scales, Multidimensional Fatigue Scale, and Cancer Module. Cancer 1994: 2090-2106. 7. Ogińska-Bulik N., Izydorczyk K., Style radzenia sobie ze stresem a poczucie własnej wartości i umiejscowienie kontroli zdrowia u dzieci chorych na białaczkę, Psychoonkologia 2000, lipiec-grudzień nr7: 29-37 58 Aneta Zreda-Pikies, Andrzej Kurylak 8. Mess E. Ocena stanu psychicznego dzieci leczonych z powodu ostrej białaczki limfoblastycznej, Polska Medycyna Paliatywna 2002, tom 1, nr 2: 9-21 9. Mess E., Wójcik D., Niedzielska E., wsp. Adaptacja społeczna dzieci leczonych na ostrą białaczkę limfoblastyczną, Onkol. Pol. 2005, 8, 3: 166- 169 10. Armata J. Dzieci wyleczone z nowotworów szukają miejsca wśród ludzi, Przegl. Lek. 1992, 45:218-221 11. Małkowska A., Mazur J., Woynarowska B. Poziom spostrzegania wsparcia społecznego a jakość życia dzieci i młodzieży 8-18- letniej, Med. Wieku Rozw. 2004, VIII, 3 cz. I: 551-566 12. Strecker D., Kaczmarek D., Strecker B., Czaja-Bulsa G., Edukacja szkolna dziecka chorego, Family Medicine & Primary Care Review 2006, 8, 2: 327- 331 13. Zdebska S., Armata J. Psychologiczne problemy w nowotworowych chorobach krwi u dzieci [w:] Ochocka M. Hematologia kliniczna wieku dziecięcego. Warszawa 1982. PZWL: 369-381 14. Zdebska S., Armata J. Niektóre problemy psychologiczno-wychowawcze w opiece nad dzieckiem szkolnym z nowotworową chorobą krwi, Ped. Pol., 1979, 54, Nr 8: 919- 924 15. Zdebska S., Armata J. Udział dziecka i jego zadania w leczeniu nowotworowej choroby krwi, ped. Pol., 1979 54: 911-914 16. Kawalczyk J.R., Samardakiewicz M. Rola pediatry pierwszego kontaktu w opiece nad dzieckiem przewlekle chorym. Choroba nowotworowa. Med Prakt Pediatr 2000, 2: 144-154 17. Korzeniowska J. Psychoonkologia – psychologia we współczesnej onkologii dziecięcej, Pediatria Polska 2005, 80, 1: 62-66 18. Samardakiewicz M., Kowalczyk J., R. Rekomendacje dotyczące opieki psychospołecznej nad dziećmi z chorobami nowotworowymi, Pediatria Polska 2000, LXXV, 9: 729-736 19. Szweda E. Psychologiczna opieka nad dziećmi chorującymi na nowotwory i ich rodzicami, Bioetyczne Zeszyty Pediatrii 1, 2003-2004: 45-52 20. Krawczyński M., Dojrzewanie i dorastanie. Problemy i potrzeby zdrowotne i psychospołeczne. Pediatria Polska 1994, LXIX, 8: 581-587 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. REFERENCES 1. Tolino MJ, Tripoloni DE, Ratto R et al. Infections associated with prosthetic repairs of abdominal wall hernias: pathology, management and results. Hernia 2009; 13: 631-637 2. Bryers JD. Medical biofilms. Biotechnol Bioeng 2008; 100: 1-18 3. Delikoukos S, Tzovaras G, Liakou P et al. Late-onset deep mesh infection after inguinal hernia repair. Hernia 2007; 11: 15-17 4. Sohail MR, Smilack JD. Hernia repair mesh-associated Mycobacterium goodii infection. J Clin Microbiol 2004; 42: 2858-2860 5. Due SS, Billesbølle P, Hansen MB. Osteomyelitis. A rare and serious complication of inguinal hernia surgery. Ugeskr Laeger 2001; 163: 3230-3231 6. Gallimore B, Gagnon RF, Subang R et al. Natural history of chronic Staphylococcus epidermidis foreign body infection in a mouse model. J Infect Dis 1991; 164: 12201223 7. Hryniewicz W, Gniadkowski M, Łuczak-Kadłubowska A et al. Recommendations for susceptibility testing to antimicrobial agents of selected bacterial species 2006. Changes in text 2007 (in Polish). National Reference Center on Microbial Drug Susceptibility 8. Performance Standards for antimicrobial susceptibility testing; nineteenth informational supplement, Vol. 29, No. 3 (2009) 9. Tamhankar AP, Ravi K, Everitt NJ. Vacuum assisted closure therapy in the treatment of mesh infection after hernia repair. Surgeon 2009; 7:316-318 10. Gomzalez R, Fugate K, McClusky D et al. Relationship between tissue ingrowth and mesh contraction. World J Surg 2005; 29: 1038-1043 11. Mamy L, Letouzey V, Lavigne JP et al. Correlation between shrinkage and infection of implanted synthetic meshes using an animal model of mesh infection. Int Urogynecol J Pelvic Floor Dysfunct 2011; 22: 47-52 12. Subbiandoss G, Grijpma DW, van der Mei HC et al. Microbial biofilm growth versus tissue integration on biomaterials with different wettabilities and a polymerbrush coating. J Biomed Mater Res A 2010; 94: 533-538 13. Bellón JM, N G-Honduvilla, Jurado F et al. J In vitro interaction of bacteria with polypropylene/ePTFE prostheses. Biomaterials 2001; 22:2021-2024 14. Edds EM, Bergamini TM, Brittian KR. Bacterial components inhibit fibroblast proliferation in vitro. ASAIO J 2000; 46:33-37 15. Antonopoulos IM, Nahas WC, Mazzucchi E et al. Is polypropylene mesh safe and effective for repairing infected incisional hernia in renal transplant recipients? Urology 2005; 66: 874-877 16. Diaz JJ, Conquest AM, Ferzoco SJ et al. Multiinstitutional experience using human acellular dermal matrix for ventral hernia repair in a compromised surgical field. Arch Surg 2009; 144: 209-15 17. Broekhuizen CA, de Boer L, Schipper K et al. Periimplant tissue is an important niche for Staphylococcus Asymptomatic infection of a surgical mesh implant - a case report epidermidis in experimental biomaterial-associated infection in mice. Infect Immun 2007; 75: 1129-36 18. Broekhuizen CA, de Boer L, Schipper K et al. Staphylococcus epidermidis is cleared from biomaterial implants but persists in peri-implant tissue in mice despite rifampicin/vancomycin treatment. J Biomed Mater Res A 2008; 85: 498-505 19. Yassien M, Khardori N. Interaction between biofilms formed by Staphylococcus epidermidis and quinolones. Diagn Microbiol Infect Dis 2001; 40: 79-89 20. Jałoza D, Juda M, Malm A et al. The qualitative and quantitative detection of biofilm formation in vitro on the biomaterials. Sepsis, 2009; 2: 143-146 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 1. Milen D.: The Ability of Firefighting Personnel to Cope With Stress. J. Soc. Change 2009; 3: 38-56. 71 2. Baker S, Williams K.: Short Communications: Relation between social problem solving, appraisals, work stress, and psychological distress in male firefighters. Stress and Health 2001; 17: 219-229. 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: 462-465. 6. Guidotti T.L., Clough V.M.: Occupational health concerns of firefighting. Annu. Rev. Publ. Health. 1992; 13: 151-171. 7. Kang D., Davis L.K., Hunt P. et al: Cancer Incidence Among Male Massachusetts Firefighters, 1987–2003. Am. J. Ind. Med. 2008; 51: 329–335. 8. Ma F., Fleming L.E., Lee D.J. et al.: Cancer incidence in Florida professional firefighters, 1981 to 1999. J. Occup. Environ. Med. 2006; 48(9): 883-888. 9. Ma F., Lee D.J., Fleming L.E. et al.: Race-specific cancer mortality in US firefighters: 1984-1993. J. Occup. 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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. 17. Drew-Nord D.C., Hong O., Froelicher E.S.: Cardiovascular risk factors among career firefighters. AAOHN J. 2009; 57(10): 415-422. 18. 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. 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.. J. Clin. Hypertens (Greenwich). 2003; 5: 315-320. 20. Yoo H.L., Franke W.D.: Prevalence of cardiovascular disease risk factors in volunteer firefighters. J. Occup. Environ. Med. 2009; 51(8): 958-962. 21. Azabdaftari N., Amani R., Taha Jalali M.: Biochemical 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 disease: a case control study. Environ. Health. 2003; 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 Towarzystwo Ginekologiczne, Warszawa, 2006: 391-9. 11. Jakubaszko J.: Ratownik medyczny, Górnicki Wyd. 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. PREFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Jahnz-Różyk K.: Choroby alergiczne na początku XXI w. Przew Lek. 2007; 2: 155-159. European Allergy White Paper Summary. The UCB Institute of Allergy 2004. Samoliński B.: Epidemiologia alergii i astmy w Polsce – doniesienie wstępne badania ECAP. Terapia 2008; 04: 127-131. ECAP-Epidemiologia Chorób Alergicznych w Polsce. Raport z badań przeprowadzonych w latach 2006–2008 w oparciu o metodologię ECRHS II i ISAAC pod redakcją B. Samolińskiego Dixon M, Genta R, Yardley J.: Classification and grading of gastritis: the updated Sydney system. Am J Surg Pathol. 1996; 20: 1161-1181. Bartuzi Z.: Reakcje alergiczne w tkankach żołądka i dwunastnicy w przebiegu pyłkowicy. Pneum Allergol Pol. 1992; 59(2): 113. 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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) 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 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. REFERENCES 1. Popinigis J.: O tlenie, mitochondriach i adaptacji do wysiłku wytrzymałościowego, czyli od Holloszy’ego 1967 do Holloszy’ego 2002. Sport Wyczynowy, 2002, 9-10, 7-21. 2. Sobczyk G.: Energetyczny trening w biegach średnich. Trening, 1, 2000, 65-82. 127 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. 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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. REFERENCES 14. 1. Zasady postępowania w nadciśnieniu tętniczym. Wytyczne Polskiego Towarzystwa Nadciśnienia Tętniczego oraz Kolegium Lekarzy Rodzinnych w Polsce, Buczkowski K., Chudziak K., Czachowski S. , et al., Nadciśnienie tętnicze rok 2008, tom 12, nr 5, 317342. 2. 2007 Guidelines for the management of arterial hypertension The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC), Journal of Hypertension 2007, 25:1105–1187 http://eurheartj.oxfordjournals.org/content/ 28/12/1462.full (5.01.2010) 3. Krzych Ł., Kowalska M., Zejda J.E.: Styl życia młodych osób dorosłych z podwyższonymi wartościami ciśnienia tętniczego. Arterial Hypertension, 2006a, tom10, nr 6, 524-531 4. Krzych Ł., Zejda J.E.: Ciśnienie tętnicze krwi u zdrowych, młodych osób dorosłych w obserwacji 12miesięcznej. Pol Przegl Kardiol, 2007, 9,6, 409-416 5. Krzych Ł., Kowalska M., Zejda J.E.: Czynniki ryzyka i częstość nadciśnienia tętniczego u młodych dorosłych osób. Nad tętn, 2006b, tom 10, nr 2, 136-141 6. Nowicki G., Łosiakowska A.: Ryzyko zachorowania na nadciśnienie tętnicze u studentów KujawskoPomorskiej Szkoły Wyższej w Bydgoszczy w świetle badań ilościowych. Rocz Nauk KPSW w Bydgoszczy. Nauki o edukacji, 2007, 2, 105-109 7. Paradowska-Stankiewicz I., Grzybowski A.: Ocena stanu odżywienia w grupie młodzieży szkół ponadgimnazjalnych i studentów UM w Łodzi. Żyw Człow i Met 2007, XXXIV, nr ¾, 933-937 8. Szczepaniak-Chicheł L., Mastej M., Jóźwiak J., et al.: Występowanie nadciśnienia tętniczego w zależności od masy ciała w populacji polskiej – badanie LIPIDOGRAM 2004. Nad Tętn, 2007, tom 11, nr 3, 195-204 9. Poręba R., Gać P., Zawadzki M., et al.: Styl życia i czynniki ryzyka chorób układu krążenia wśród studentów uczelni Wrocławia. Pol Arch Med Wewn., 2008, 118, 3, 1-9. 15. 16. 17. 18. 19. Chrostowska M., Szczęch R.: Nadciśnienie związane z otyłością. Kardiol na co dzień, 2007, 3,2,106-112 Czyżewski Ł.: Nadwaga i otyłość jako czynniki wystąpienia nadciśnienia tętniczego. Probl Piel, 2008, tom16, zeszyt nr 1, 2, 128-135 Małaczyńska-Rajpold K., Woźnicka L., Kuczmarska A., et al.: Aktywność fizyczna jako czynnik redukujący ryzyko sercowo-naczyniowe w populacji badanej w programie Kobiety w czerwieni. Nad Tętn, 2009, tom 13, nr 1,42-47 Tykarski A., Posadzy Małaczyńska A., Wyrzykowski B., et al.: Rozpowszechnienie nadciśnienia tętniczego oraz skuteczność jego leczenia u dorosłych mieszkańców naszego kraju. Wyniki programu WOBASZ. Kardiol Pol, 2005, 63, 6 (supl.4), 614-619 Zdrojewski T.: Nadciśnienie tętnicze w Polsce. Terapia, 2002,10,7/8, 4-7 Zdrojewski T.: Rozpowszechnienie głównych czynników ryzyka chorób układu sercowonaczyniowego w Polsce. Wyniki badania NATPOL PLUS. Kardiol Pol, 2004, 61, IV-5-IV-19 Zdrojewski T., Bandosz P., Szpakowski P., et al.: Rozpowszechnienie głównych czynników ryzyka chorób układu sercowo-naczyniowego w Polsce. Wyniki Badania NATPOL PLUS. Kardiol Pol, 2004, 61,IV-5. Szczepańska J., Wądołowska l., Słowińska M.A., et al., Badanie wpływu częstości spożycia wybranych źródeł błonnika na skład ciała studentek. Probl Hig Epidemiol 2011, 92(1): 103-109. Conus F, Alisson DB, Rabasa-Lhoret R., et al.. Metabolic and behavioral characteristics of metabolically obsese but normalweight women. JCEM 2004, 89(10): 5013-5020. Conus F, Rabasa-Lhoret R, Peronnet F. Characteristics of metabolically obese normal weight (MONW) subjects. Appl Physiol Nutr Metab 2007, 32: 4-12. 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 REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. Bartuzi Z. Alergia na pokarmy u osób dorosłych problem wciąż mało znany i niedoceniany. 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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 Regulamin ogłaszania prac w Medical and Biological Sciences 1. 2. 3. 4. 5. 6. 7. 8. 9. Redakcja przyjmuje do druku wyłącznie prace poprzednio niepublikowane i niezgłoszone do druku w innych wydawnictwach. W Medical and Biological Sciences zamieszcza się: artykuły redakcyjne prace a) poglądowe, b) oryginalne eksperymentalne i kliniczne, c) kazuistyczne, które zostały napisane w języku angielskim. Objętość pracy wraz z materiałem ilustracyjnym, piśmiennictwem i streszczeniem nie powinna przekraczać 15 stron maszynopisu przy pracach poglądowych oraz 12 stron przy pracach oryginalnych i kazuistycznych. 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