medical and biological sciences

Transkrypt

UNIWERSYTET MIKOŁAJA KOPERNIKA w TORUNIU
COLLEGIUM MEDICUM im. LUDWIKA RYDYGIERA
W BYDGOSZCZY
MEDICAL
AND BIOLOGICAL
SCIENCES
(dawniej
ANNALES ACADEMIAE MEDICAE BYDGOSTIENSIS)
TOM XXV/1
styczeń – marzec
ROCZNIK 2011
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
BYDGOSZCZ 2011
Medical and Biological Sciences, 2011, 25/1
CONTENT
p.
REVIEWS
Alicja Krakowska, Magdalena Hagner-Derengowska, Lidia Ludwikowska,
W o j c i e c h Hagner – The influence of cardiological rehabilitation on the orthostatic tolerance
increase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
Anna Studzińska-Czyszka, Monika Skorupa, Agata Biełucha, Andrzej
T r e t y n – The correlation between cervical cancer and human papilloma virus infection . . . . . . . . . .
11
ORIGINAL ARTICLES
Anna Klimaszewska, Magdalena Izdebska, Maciej Gagat, Dariusz Grzanka,
A l i n a G r z a n k a – The influence of arsenic trioxide on the reorganization of the tubulin protein
in CHO AA8 cell line . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
17
J a n i n a B r u d n y , N a t a l i a P a w l i k , J a r o s ł a w K o z a , M a c i e j Ś w i ą t k o w s k i – The estimation of volunteer blood donors motivation factors on example of donors who applied to Regional
Blood Donation and Blood Treatment Center in Bydgoszcz . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
25
M a ł g o r z a t a Ł u k o w i c z , K a m i l a M a r s z a ł e k , M a g d a l e n a W e b e r - R a j e k – Endogenous cognitive potential P300 in TIA patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
31
Magdalena Mackiewicz-Milewska, Sabina Lach-Inszczak, Magdalena Kuligowska-Prusińska, Wojciech Hagner, Grażyna Odrowąż-Sypniewska
– Neurogenic heterotopic ossification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
37
L i d i a S i e r p i ń s k a , A n n a K s y k i e w i c z - D o r o t a , R a f a ł G o r c z y c a – Polish adaptation
of patient satisfaction with nursing care quality questionnaire (PSNCQQ) . . . . . . . . . . . . . . . . . . . . . . . .
43
Ewa Smoleń, Lucyna Gazdowicz, Monika Wilusz, Joanna Zacharska,
M a ł g o r z a t a G a w l i k – The significance of nursing interview (nursing assessment) in malignant
disease prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
51
Magdalena Weber-Rajek, Joanna Pawlak, Paweł Zalewski, Małgorzata
Ł u k o w i c z , J a c e k J . K l a w e , A n n a J a s k u l s k a – Assessment of kinesiology taping
therapy efficiency in lumbosacral pain syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
59
SPIS TREŚCI
str.
PRACA POGLĄDOWA
Alicja Krakowska, Magdalena Hagner-Derengowska, Lidia Ludwikowska,
W o j c i e c h Hagner – Wpływ rehabilitacji kardiologicznej na zwiększenie tolerancji ortostatycznej . .
5
Anna Studzińska-Czyszka, Monika Skorupa, Agata Biełucha, Andrzej
T r e t y n – Korelacja między rozwojem raka szyjki macicy a zakażeniem wirusa brodawczaka
ludzkiego . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11
ORIGINAL ARTICLES
Anna Klimaszewska, Magdalena Izdebska, Maciej Gagat, Dariusz Grzanka,
A l i n a G r z a n k a – Wpływ trójtlenku arsenu na reorganizację białka tubuliny w linii komórkowej
CHO AA8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
17
J a n i n a B r u d n y , N a t a l i a P a w l i k , J a r o s ł a w K o z a , M a c i e j Ś w i ą t k o w s k i – Ocena
czynników motywacyjnych wśród honorowych dawców krwi Regionalnego Centrum Krwiodawstwa
i Krwiolecznictwa w Bydgoszczy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
25
M a ł g o r z a t a Ł u k o w i c z , K a m i l a M a r s z a ł e k , M a g d a l e n a W e b e r - R a j e k – Badanie
endogennego poznawczego potencjału P300 u chorych po TIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
31
Magdalena Mackiewicz-Milewska, Sabina Lach-Inszczak, Magdalena Kuligowska-Prusińska, Wojciech Hagner, Grażyna Odrowąż-Sypniewska
– Neurogenne skostnienia pozaszkieletowe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
37
L i d i a S i e r p i ń s k a , A n n a K s y k i e w i c z - D o r o t a , R a f a ł G o r c z y c a – Polska adaptacja
kwestionariusza oceny poziomu satysfakcji pacjentów z opieki pielęgniarskiej (PSNCQQ) . . . . . . . . .
43
Ewa Smoleń, Lucyna Gazdowicz, Monika Wilusz, Joanna Zacharska,
M a ł g o r z a t a G a w l i k – Znaczenie wywiadu pielęgniarskiego w profilaktyce chorób
nowotworowych . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
51
Magdalena Weber-Rajek, Joanna Pawlak, Paweł Zalewski, Małgorzata
Ł u k o w i c z , J a c e k J . K l a w e , A n n a J a s k u l s k a – Ocena skuteczności kinesiotapingu
w terapii dolegliwości bólowych lędźwiowo-krzyżowego odcinka kręgosłupa . . . . . . . . . . . . . . . . . . . .
59
Regulamin ogłaszania prac w Medical and Biological Sciences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
65
Medical and Biological Sciences, 2011, 25/1, 5-9
REVIEW / PRACA POGLĄDOWA
Alicja Krakowska, Magdalena Hagner-Derengowska, Lidia Ludwikowska, Wojciech Hagner
THE INFLUENCE OF CARDIOLOGICAL REHABILITATION
ON THE ORTHOSTATIC TOLERANCE INCREASE
WPŁYW REHABILITACJI KARDIOLOGICZNEJ
NA ZWIĘKSZENIE TOLERANCJI ORTOSTATYCZNEJ
Chair and Clinic of Rehabilitation, Nicolaus Copernicus University in Toruń, Collegium Medicum in Bydgoszcz
Head: dr hab. n. med. Wojciech Hagner, prof. UMK
Summary
Circulatory system diseases are the most common reason
of death in Poland. Primary prevention should start as early as
possible and be realised in the constant manner in order to
lower the risk of disease development to minimum. An
inseparable element of actions as far as circulatory system
diseases are concerned, is rehabilitation which concerns not
only conservative therapy, but also an invasive one.
Nowadays, cardiological rehabilitation is introduced right after
life-threatening factors are eliminated. With respect to patients
who have been immobilised for a longer period of time it
becomes problematic to tilt them to erect position due to
orthostatic disorders. Regular physical activity may be one of
the factors lowering the risk of abrupt drop in arterial blood
pressure.
Streszczenie
Choroby układu krążenia są najczęstszą przyczyną
zgonów w Polsce. Prewencja pierwotna zawałów mięśnia
sercowego powinna rozpocząć się możliwie wcześnie i być
konsekwentnie realizowana, tak aby obniżyć do minimum
ryzyko rozwoju choroby. Nieodłącznym elementem
postępowania w chorobach układu krążenia jest rehabilitacja,
która dotyczy zarówno leczenia zachowawczego, jak
i inwazyjnego.
Obecnie rehabilitację kardiologiczną wdraża się
bezpośrednio po opanowaniu zagrożenia życia. U pacjentów
unieruchomionych przea dłuższy czas poważnym problemem
staje się pionizacja z powodu zaburzeń ortostatycznych.
Systematyczna aktywność fizyczna staje się zatem
czynnikiem zmniejszającym ryzyko nagłego spadku ciśnienia
krwi.
Key words: circulatory system diseases, cardiological rehabilitation, orthostatic tolerance
Słowa kluczowe: choroby układu krążenia, rehabilitacja kardiologiczna, tolerancja ortostatyczna
Circulatory system diseases are the most common
reason of death in Poland. Approximately 100,000.00
Polish citizens suffer from myocardial infarction every
year and every second inhabitant of our country dies
due to cardiovascular diseases [14].
These diseases arise due to risk factors of the
ischemic heart disease. Persons who are at the highest
risk of the above are those who suffer from several
factors simultaneously. We do not have any influence
on such risk factors as age, sex and genetic load.
However, we may fight obesity, lack of systematic
physical exercise, arterial hypertension, diabetes type 2
and a high level of cholesterol in an effective way.
As far as primary prophylaxis is concerned, one
should evaluate the health state, identify risk factors
and work out a prevention plan with an attending
6
Alicja Krakowska et al.
doctor. In the case of lipid disorders, one should
evaluate and modify the diet, and, when it comes to
overweight and obese patients, aim at lowering the
body weight. With reference to persons suffering from
diabetes it is significant not only to modify and control
the diet, but also to evaluate the oral drug or insulin
therapy. Optimal pressure values (± 120 mmHg) are
achieved through systematic blood pressure
measurement and pharmacological therapy. Regular
physical activity lowers the risk of ischemic disease
occurrence [3].
Primary prevention should start as early as possible
and be realised in a constant manner in order to lower
the risk of disease development to minimum. It is also
important to be aware of the fact that simultaneous and
constant actions against risk factors enable full success
in treatment [24, 25].
Modern diagnostic methods, development of
invasive cardiology and the use of new surgery
techniques contribute to a decreasing number of
mortality caused by diseases of the circulatory system.
Increasing the number of intervention procedures,
especially when it comes to elderly persons who were
earlier disqualified due to a procedure’s high risk,
results in a rising number of patients who require
comprehensive rehabilitation [9].
Comprehensive cardiological rehabilitation is
understood as actions that are meant to achieve
optimum physical, mental and social efficiency of a
patient suffering from a circulatory system disease and
actions that allow a patient to achieve satisfactory and
independent participation in everyday, social life, as
well as eliminate risk factors and decrease disease
symptoms [21].
An inseparable element of actions, as far as
circulatory system diseases are concerned, is
rehabilitation which concerns not only conservative
therapy, but also an invasive one.
Rehabilitation has positive results as it modifies the
following factors:
- it inhibits the development of atheromatosis
- it improves the efficiency of the circulatory system
- it improves the efficiency of the respiratory system
- it increases motor efficiency
- it improves the psychophysical form
- it encourages patients to cooperate in the process of
rehabilitation [18].
The improvement in treating circulatory system
diseases broadened the indications for
rehabilitation onto a larger number of patients. The
most numerous group of patients includes:
- patients who have suffered from myocardial
infarction
- patients who have undergone coronary artery
bypass graft procedures
- patients who have undergone procedures involving
an implantation of a stimulator or a cardioverterdefibrillator
- patients who have undergone procedures connected
with organic heart diseases
- patients who have undergone a heart transplantation
procedure
- patients who suffer from an ischemic heart disease,
without myocardial infarction
- patients who suffer from arterial hypertension
- patients who suffer from heart failure
- patients who suffer from dilated cardiomyopathy
- patients who suffer from respiratory system
diseases
- patients who suffer from diabetes
- patients who suffer from dysrrhythmia
- patients who suffer from atrial fibrillation [9].
The main aim of rehabilitation of patients in states
that were earlier considered a contradiction against the
above, to lower mortality caused by circulatory system
diseases. The time of hospitalisation after acute
coronary syndrome is shorter – this enables a quick
return to normal functioning in a family, vocational
activity and preventing disability [6, 26].
Quick physical rehabilitation of patients suffering
from a non-complicated myocardial infarction is a fully
safe part of treatment just like invasive and
pharmacological therapy. However, it has to include a
detailed psychophysical observation of a patient, be
based on an evaluation of clinical parameters and
include a patient’s attitude towards rehabilitation. It is
extremely important that the process of rehabilitation
takes place in close cooperation with the entire
rehabilitation team and a patient’s family [1].
Nowadays,
cardiological
rehabilitation
is
introduced right after life-threatening factors are
eliminated; 24 hours after percutaneous artery
angioplasty. Its main aim is to prevent clinical
complications and eliminate stress caused by
myocardial infarction. Early rehabilitation of patients
allows eliminating the risk of:
- orthostatis hypotonia
- embolic/thrombolic complications
- atelectasis
The influence of cardiological rehabilitation on the orthostatic tolerance increase
- inflammatory changes
- weakened blood flow in lower extremities
- weight and contractility loss on skeletal muscles
- demineralisation of bones
- consequences of long inactivity [2, 16, 17].
Early active rehabilitation should include all
patients who have suffered from an acute coronary
syndrome, aggravation of a coronary heart disease,
regardless of implemented treatment (conservative,
invasive). Active rehabilitation depends on the course
of myocardial infarction (complicated, noncomplicated) and the clinical state of a patient. If there
are no contraindications one may start gradual
rehabilitation supervised by a physiotherapeutists [11].
As far as non-complicated myocardial infarction is
concerned, usually on the 2nd or 3rd day (while the
patient is still in the Intensive Cardiological
Supervision room), rehabilitation should be started
from lessons on correct breathing, exercises preventing
embolic/thrombolic complications, exercises involving
small muscle groups, isometric and relaxation
exercises. The first time when a patient is fully tilted
on a tilting table to erect position should take place in
the Intensive Cardiological Supervision room, always
in the presence of a physiotherapeutists. Every patient
who is being tilted to erect position should be
supervised and his/her heart rate and ECG should be
observed in order to evaluate the cardiac rhythm,
conduction and a possibility of coronary ailments
occurrence [17, 22, 27].
The first step in the procedure of tilting a patient on
a tilting table to erect position is usually connected
with a drop in arterial blood pressure. Orthostatic
hypotonia is a consequence of abnormal functions of
the
autonomous
system,
expressed
through
maladjustment of the cardiovascular system to a
sudden body position change. It is usually defined as a
drop in systolic arterial blood pressure by a minimum
of 20 mmHg during the first three minutes of tilting.
Orthostatic hypotonia occurs only occasionally and
does not seem dangerous when it comes to young and
middle-aged persons. Yet, it is a source of anxiety with
respect to elderly persons and patients suffering from
arterial hypertension. Hypertension in the elderly is
connected with an increased stiffness of vessels,
decreased sensitivity of baroreceptors and stimulations
of the sympathetic system. Pressure variability
increases with age. Arterial hypertension causes autoregulation of cerebral circulation. Consequently,
7
hypotonia connected with a loss of consciousness [7,
13] may occur more easily.
With reference to the above, rehabilitation
procedures should be implemented as early as possible
and they should be adjusted to the current clinical state
of a patient and applied in a way accepted by him/her.
Early rehabilitation is the first step in preventing
circulatory system diseases and hypotensive
complications [8].
Longer rehabilitation should be applied in case of
patients:
- with a complicated course of disease (postinfarction
complications,
after-procedure
bleeding, pneumonia, cerebral stroke)
- with an extensive myocardial infarction
(persisting ischaemia features, heart failure,
dysrrhythmia, exercise intolerance)
- with incorrect hemodynamic reactions to
physical strain (excessive increase or drop in
arterial blood pressure during physical strain,
significant increase of heart rate)
- with a low physical efficiency before
myocardial infarction
- with cachexia
- after a longer period of reduced physical
activity [1, 2].
With respect to patients who have been
immobilised for a longer period of time it becomes
problematic to tilt them to erect position due to
orthostatic disorders. They arise when reflex
mechanisms preventing blood cumulation in the lowest
parts of the vascular system in an extensory position
[20] do not work. Such drop in blood pressure is most
often observed when it comes to persons suffering
from arterial hypertension and diabetes. Both groups of
patients constitute a risk group of circulatory system
diseases [7, 13].
Maintaining an extensory position is possible due
to continual adaptation of the cardiovascular system
which mainly depends on the influence of the
autonomous system. As far as healthy persons are
concerned, the drop in arterial blood pressure, after
change of position from a recumbent to a standing one,
is caused by a decreased venous return. An increased
activity of the sympathetic system and a decreased
stroke volume are caused by blood accumulation in the
lower extremities of a standing person. This increases
contractility of the cardiac muscle and stimulates
mechanoreceptors, leading to a drop in arterial blood
pressure and slower cardiac activity. The pathogenesis
8
Alicja Krakowska et al.
of fainting is based on disorders in the reflex arch.
Standing in an extensory position results in a decreased
heart output, decreased activity of mechanoreceptors,
and, consequently, a decreased vagus muscle tone.
Such reaction triggers an increase of vascular
resistance, heart rate and its contractile force. A correct
reaction following changing one’s position into an
extensory one should be as follows:
- a drop in heart rate
- a drop in systolic blood pressure
- a slight increase in diastolic pressure
- an invariable average value of arterial blood
pressure [5, 10, 12, 15].
Persons who are not very active as well as elderly
persons are more prone to a drop in arterial pressure
during the process of tilting to erect position than
persons who lead an active lifestyle [7]. A well
managed hypertensive pharmacological therapy is also
of great importance.
Apart from hypotensive drugs used in arterial
hypertension treatment, one should
include
pharmacological therapy used with reference to the
majority of patients undergoing post-infarction
rehabilitation, which changes the reaction of the
circulatory system to physical effort. Hypotensive
drugs include the following:
- anticoagulant drugs
- antiarrhythmic drugs
- drugs increasing the rate of myocardial
contractions (nitrate drugs, thyroid hormones,
psychotropic drugs)
- drugs decreasing the rate of myocardial
contractions
(beta
blockers,
fox-glove
preparations)
- drugs influencing physical efficiency (beta
blockers, fox-glove preparations, ACE inhibitors)
- drugs influencing the occurrence of ischaemia
symptoms (beta blockers, nitrate drugs) [6, 19,
24].
The new generation drugs, an ability to conduct a
twenty-four hour control of arterial blood pressure and
an effective control of blood pressure in home
conditions influence the lower frequency of orthostatic
hypotonia occurrence [4, 19].
Regular physical activity may be one of the factors
lowering the risk of abrupt drop in arterial blood
pressure. Moderate physical exercises have a positive
influence on reducing the risk factors of the ischemic
disease [3, 8, 23, 26]. Physical exercises used in
cardiological prophylaxis ought to be dynamic, involve
big groups of muscles and be intertwined with
breathing exercises [9]. Physical exercises may take a
form of systematic trainings or recreational activities
such as walking, marching, riding a bicycle, dancing or
playing games. An optimum number of trainings is 3-5
times a week, each one 30-45 minutes long. Persons
who are not well-trained or who suffer from at least
one main risk factor of the ischemic disease are
advised to do less intense physical exercises that are
less likely to cause cardiological complications [25].
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17. Piotrowicz R., Wolszakiewicz J. Rehabilitacja
kardiologiczna pacjentów po zawale serca. Folia
Cardiologica Excerpta 2008; 3: 559-565.
18. Piotrowicz R., Wolszakiewicz J. Rehabilitacja
kardiologiczna pacjentów z chorobą wieńcową.
Kardiologia dla lekarzy rodzinnych. Medipress Medical
Update 2003; 6: 3-9.
19. Rosendodorff C., Black H.R., Cannon C.P. i wsp.
Leczenie nadciśnienia tętniczego w prewencji i leczeniu
choroby niedokrwiennej serca. Stanowisko American
Heart Association 2007. Medycyna Praktyczna 2007; 9:
31-46.
20. Rosławski A. Wytyczne fizjoterapii kardiologicznej.
Pytania i odpowiedzi. Wydawnictwo AWF, Wrocław
2001.
21. Salabura B., Klimek-Piskorz E., Sokół B. Wpływ
szpitalnej rehabilitacji kardiologicznej na zmiany własnej
choroby u pacjentów po zawale mięśnia sercowego.
Postępy Rehabilitacji 2006; 2: 17-22.
22. Sobiczewski W., Gruchała M., Wirtwein M. i wsp.
Dobowy rozkład ciśnienia tętniczego wśród chorych z
nadciśnieniem
tętniczym
i
koronarograficznie
potwierdzoną chorobą wieńcową. Nadciśnienie Tętnicze
2007; 11: 37-45.
9
23. Stephard G., Balady G. Exercise as Cardiovascular
Therapy. Circulation 1999; 99: 963-972.
24. Szczęch R., Narkiewicz K. Czynniki ryzyka chorób
układu krążenia. Choroby serca i naczyń 2008; 5: 55-56.
25. Szostak W.B., Cybulska B. Prewencja chorób sercowo naczyniowych - Postępy 2007. Medycyna Praktyczna
2008; 6: 33-50.
26. Williams M., Fleg J., Ades P. i wsp. Secondary
prewention of coronary heart disease in the elderly (with
emphasis on patients >or = 75 years of age): on
American Hearth Association Scientific statement from
the Council on Clinical Cardiology Subcommitte on
Exercise Cardiac Rehabilitation and Prevention.
Circulation 2002; 105: 1735.
27. Wytyczne European Society of Cardiology 2008.
Postępowanie w świeżym zawale serca z uniesieniem
odcinków ST. Medycyna Praktyczna 2009; 2: 39-64.
Address for correspondence:
dr n. med. Alicja Krakowska
Katedra i Klinika Rehabilitacji
UMK w Toruniu
Collegium Medicum im. Ludwika Rydygiera
ul. M. Curie Skłodowskiej 9
85-094 Bydgoszcz
tel. (52) 585-43-30
e-mail: [email protected]
Received: 29.06.2010
Accepted for publication: 21.12.2010
REVIEW / PRACA POGLĄDOWA
Anna Studzińska-Czyszka1, Monika Skorupa1, Agata Białucha2, Andrzej Tretyn1
THE CORRELATION BETWEEN CERVICAL CANCER
AND HUMAN PAPILLOMA VIRUS INFECTION
KORELACJA MIĘDZY ROZWOJEM RAKA SZYJKI MACICY
A ZAKAŻENIEM WIRUSA BRODAWCZAKA LUDZKIEGO
1
Chair of Plant Physiology and Biotechnology Nicolaus Copernicus University in Toruń
Faculty Biology and Earth Sciences
Head: prof. dr hab. Andrzej Tretyn
2
Chair and Department of Microbiology Ludwik Rydygier Collegium Medicum in Bydgoszcz
Nicolaus Copernicus University in Toruń
Head: dr hab. Eugenia Gospodarek, prof. UMK
Summary
Cervical cancer is one of the most common cancers in
Polish women. The factors conducive to the development of
this disease are mainly smoking, use of steroid hormones
(found in oral contraceptive pills), use of immunosuppression, and infection with human papilloma virus (HPV).
Human papilloma virus belongs to the Papillomavirus
genus in Papovaviridae family. Nowadays, scientists know
more than 100 types of HPV that have specific numbers
depending on the order of identification. Among them,
depending on the degree of tumor growth risk, three groups
can be identified: low, medium and high risk. HPV types 16
and 18 are now detected in 90% of cervical cancer cases.
The microorganism’s virion has an icosahedrall capsid (55
nm diameter) composed of 72 capsomeres. The HPV’s
genome is approximately 8 kb long, circular double-stranded
DNA. The genome has been also functionally divided into
three regions: E, L and the noncoding LCR sequence. There is
no doubt that HPV infection plays an important role in the
development of cervical cancer. In the process of
carcinogenesis, the E6 and E7 proteins of the virus lead to cell
cycle disorder and uncontrolled cell growth. Further studies of
the correlation between HPV infection and the development of
cervical cancer may contribute to the creation of more
effective prevention and treatment of this type of cancer.
Streszczenie
Jednym z najczęściej występujących nowotworów
u kobiet w Polsce jest rak szyjki macicy. Do czynników
sprzyjających rozwojowi tej choroby należą przede
wszystkim: palenie papierosów, stosowanie hormonów
steroidowych (występujących w doustnych tabletkach
antykoncepcyjnych), stosowanie immunosupresji oraz
infekcja wirusem brodawczaka ludzkiego (ang. human
papilloma virus; HPV).
Wirus brodawczaka ludzkiego należy do rodzaju
Papillomavirus, do rodziny Papovaviridae. Obecnie znanych
jest już ponad 100 typów HPV, które posiadają określoną
numerację zależną od kolejności identyfikacji. Wśród nich,
w zależności od stopnia zagrożenia rozwojem nowotworu,
wyodrębniono trzy grupy: niskiego, średniego i wysokiego
ryzyka. HPV typu 16 i 18 wykrywany jest obecnie w 90%
przypadków raka szyjki macicy.
Wirion omawianego drobnoustroju otoczony jest
ikozaedralnym kapsydem mającym średnicę 55 nm i zawierającym 72 kapsomery. Genom wirusa jest niewielkim (ok. 8
kb), kolistym, dwuniciowym DNA. Podzielony jest na 3
regiony (w których znajdują się geny odpowiedzialne za
ekspresję poszczególnych białek wirusa): region E, region L,
sekwencja niekodująca LCR.
Nie ma wątpliwości, że zakażenie powyższym drobnoustrojem odgrywa istotną rolę w rozwoju nowotworu szyjki
macicy. W procesie nowotworzenia biorą udział białka E6
i E7 wirusa, prowadzące do zaburzenia cyklu komórkowego
i niekontrolowanego wzrostu komórek. Dalsze badania
12
Anna Studzińska-Czyszka et al.
korelacji między zakażeniem omawianym wirusem a
rozwojem raka szyjki macicy mogą przyczynić się do
stworzenia skuteczniejszej profilaktyki i leczenia tego
nowotworu.
Key words: HPV virus, the cervical cancer, cancerogenesis process
Słowa kluczowe: wirus HPV, rak szyjki macicy, procesy nowotworzenia
INTRODUCTION
One of the most common cancers in Polish women
is cervical cancer [1 - 6]. The factors conducive to the
development of this disease are mainly smoking, use of
steroid hormones (found in oral contraceptive pills),
use of immunosuppression, early sexual initiation,
having multiple sexual partners and HPV infection [1,
3, 5 - 9]. HPV is undoubtedly a factor initiating the
process of carcinogenesis, because it causes mutations
in the host cells [2, 3, 6, 10]. This relationship was
eventually confirmed by zur Hausen’s studies [3, 7, 6].
Also, men infected with HPV can be more predisposed
to urethral cancer [7, 11].
It is now recognized that there are groups with an
increased risk of developing cancer associated with
HPV infection. In the Papillomavirus genus there are
certain types of this microorganism, which - if marked
properly - enable the assignment of the infected to the
low, average or high risk groups [8].
HPV infection belongs to the diseases that are
transmitted sexually through a direct contact [4, 5, 12].
Among the factors that contribute to HPV infection
there are also those that predispose to the development
of cervical cancer [12].
CHARACTERISTICS OF THE HPV VIRUS
HPV belongs to the Papillomavirus genus in
Papovaviridae family [3-5, 8, 12, 13]. Currently there
are about 150 types of HPV known, and another 100
are being identified and studied [9]. They have specific
numbers depending on the order of identification [1, 35, 12, 13]. Depending on the cancer risk degree, there
are the three groups:
• low risk: HPV 6, HPV 11, HPV 42, HPV 43,
HPV 44 (these viruses predominate only in
benign hyperplastic changes);
• average risk: HPV 31, HPV 33, HPV 35, HPV
39, HPV 45, HPV 51, HPV 52, HPV 56, HPV
58, HPV 59, HPV 68 (their presence
correlates with dysplasia of small and
intermediate-level);
•
high risk: HPV 16, HPV 18, (these viruses are
referred to as oncogenic) [1, 3 - 5, 8, 9, 12 14].
HPV types 16, 18 and 45 are detected in over 70%
of all cervical cancer cases. So far HPV 16 has been
the dominant type causing more than 50% of tumors,
while HPV 18 10-14% and HPV 45 2-8% [15]. HPV
infection varies in different regions of the world,
nevertheless type 16 dominates in Europe, America,
Africa and Asia [3, 6, 8].
HPV virion has an icosahedrall capsid (55 nm
diameter), which is composed from 72 capsomeres [11,
13, 14, 16]. Each of them has 360 copies of the main
structural protein L1 and 12 copies of a structural
protein L2. Disulfide bonds between L1 molecules
stabilize its structure. The fully mature capsids show
increased regularity and resistance to proteolytic
degradation [17]. The internal side of the HPV capsid
is smooth and it is 2 nm from nucleoproteins. The
capsomeres have 90 small holes, occurring in rows of
three, with one central hole in accordance with the dual
axis of symmetry [18]. HPV capsids undergo
morphological maturation prior to cell lysis [17]. They
play a key role in the initiation of infection by the
virus, providing space for interaction with host cells
[16].
The genome of this virus is a small (approximately
8 kb), circular, double-stranded DNA [5, 8, 9, 11]. It is
divided into three regions in which genes responsible
for protein expression are:
• region E (Early): containing genes: E1, E2,
E4, E5, E6, E7 (they encode proteins involved
in the replication of virus’ nucleic acid, its
transcription, and malignant transformation of
cells);
• region L (Late): containing L1 and L2 genes
(they encode proteins that build HPV
capsids);
• non-coding LCR sequence (Long Control
Region): containing sequences responsible for
replication control and gene expression [1 - 3,
5, 8, 11, 12, 14, 19].
The correlation between cervical cancer and human papilloma virus infection
In the genome of this virus there are also signal
sequences (LCR or ULR) which control the replication
of this microorganism and its gene expression [3].
E1 gene’s product is an enzymatic protein involved
in DNA replication of the virus. It has a helicase
activity that separates the double-stranded DNA [1].
As a result of E2 expression, a protein built from 360
aminoacids, which is able to bind itself to DNA and
help to regulate other HPV genes expression, is created
[1]. E1 and E2 genes’ products are expressed in the
basic layers of the epidermis and are responsible for
the extra-chromosomal reproduction of the virus
genome [9, 13]. The protein, resulting from the E4
gene expression, plays an important role during
replication and maturation of this organism [1, 13]. E7
protein (composed of 98 aminoacids encoded by the
E7 gene) is responsible for the initiation of
uncontrolled growth of epithelial cells, while E6 (E6
gene product consisting of 158 amino acids) shows no
enzymatic activity on its own - its cell transformation
properties result from the interaction with p53 protein
(which regulates the cell cycle) [1, 5, 9, 12, 13, 19]. As
shown by recent studies, this protein may affect the
cell cycle by activating telomerase and allowing
uncontrolled cell division [13, 19].
HPV capsid is build from the proteins, which are
the products of L1 and L2 genes. The main role in its
formation is played by the L1 gene, which contains the
genetic information about the majority of the large
proteins of viral envelope [1, 2]. L genes subject to the
expression mostly in the deeply situated and more
diverse epidermis layers [13]. LCR region is localized
between the E and L regions (precisely between L1 and
L6 genes). Its role is mostly to control other HPV
genes which take part in viral transcription and
replication [2, 8]. All of the open reading frames
(ORF) are in one of the HPV nucleic acid chains and
code the information needed for replication [8]. The
division of this virus into types and subtypes is made
on the basis of the comparison and alignment of
nucleotides within late region ORF 1 [8]. 90%
compliance of analyzed ORF classifies the viruses to
subtypes [4, 8, 12].
The incidence of HPV infection depends primarily
on age and sex, and is significantly higher in women
under 30 years of age [13]. Although the exact course
of papilloma virus infection has not been fully
elucidated yet, it is known, however, that it attacks the
reproductive cell layers of the skin and mucous
membranes [4, 8].
13
Infection caused by this microorganism can result
from trauma or microdamages to the epidermis, which
favor the penetration of the virus to the basal layer of
reproductive cells [3, 8, 12]. In these cells, human
papilloma virus begins its life cycle, its genome
replicates and is transferred to daughter cells [20].
Most of the HPV virus types that have been tested,
probably enter the host cells through a clathrindependent mechanism, although this has not been fully
explored [16].
HPV can reproduce only in the self-differentiating
keratinocytes. If other cells are infected, the
carcinogenesis starts [4]. HPV infection can be
asymptomatic or can cause neoplastic changes [12].
The course of the replication is connected with
epithelial and epidermis cells differentiation process [3,
4, 11]. There are probably two types of viral
replication, which course depends on the type of the
infected cells and the quantity of E1 protein present in
the host cell. Immediately after the infection, the viral
genetic material increases to about 50-400 copies. This
stage is fast and transient. Then, the quantity of DNA
stays on the same level. After the cell differentiation
process, there comes another amplification, which
increases the number of nucleic acid copies to several
hundred. After that, the stage when the genetic
material is packed in daughter virions starts [12].
The cellular mechanisms of immune response are
primarily responsible for eliminating the HPV
infection in human organism. In patients with cellular
immune deficiency (primarily in people with AIDS and
people after transplants), there is no capacity for selfelimination of HPV infection [13].
At first after infection the immune system shows
antigens through the specific cells (APC): monocytes,
macrophags, Langerhans’s cells, etc. T-helper
lymphocytes, cytotoxic T lymphocytes and B
lymphocytes also participate in the organism’s
response [19]. In the executive phase of immune
response transformated or HPV infected cells are
eliminated. At this stage, human organism starts to
produce specific antibodies, which identify
nondenaturating epitops L1 and L2 proteins of human
papillomaviral envelope; or it generates the cytotoxic T
lymphocytes clones, which identify the viral E6 and E7
fragments of protein [19].
14
THE PARTICIPATION OF HPV IN THE CANCER
DEVELOPMENT
In 1978 first oncogenic viruses in humans were
detected. Characterizing genital viruses by a group of
German scientists caused a huge boom in science and
research of these microorganisms and their
pathogenicity. One of this type of microorganism is
human papillomavirus [11].
Both the development and course of cancer
developing on the ground of HPV infection depend on
several factors, including the proper functioning of the
immune system, which is confirmed by the high rate of
infection and the percentage of cancer in patients with
immunosuppression [13].
The time between infection with human papilloma
virus and the development of cancer (including
cervical cancer) is extremely long (can range from 20
to 40 years), since this virus has a very long latency
period [13].
Oncogenic effect of HPV infection is a
consequence of the influence of viral gene products on
cell cycle regulators [21].
The stages of the viral development are:
• infection;
• elimination of the virus or its appearance in
the host’s cells (so-called low-advanced
cervical intraepithelial neoplasia - CIN I);
• elimination of the infection or the viral genes
expression
(high-advanced
cervical
intraepithelial neoplasia - CIN II, CIN III);
• integration and /or intra-viral gene
modifications (case of an invasive cancer);
• mutations in host’s other genes and the
influence of viral proteins on p53
differentiation process (the occurrence of an
invasive growth and metastases) [13].
In the changes which lead to the cancer
development, viral DNA is usually in an
extrachromosomal forms. Its integration to the human
chromosome is within E1 and E2 open reading frames.
Then, a disorder of regulation of HPV viral promoters
occurs, and at the same time the E6 and E7 genes
expression increases [13, 19, 22, 23]. Their products
are small, oncogenic proteins, which are interacting
complementairly with the molecules regulating the cell
cycle. In the regular cells the p53 protein recognizes
damages, binds with DNA and takes part in the
repression of cell cycle before the beginning of
replication or - if the changes are so large that repair
process is impossible - the p53 promotes apoptosis
[24].
The E6 protein reacts with p53 protein and this
causes its degradation through ubiquitination, which
initiates carcinogenesis. The E6 oncoprotein is
multifunctional and can disturb the action of many
regulator proteins. It takes part in the activation of
telomerase and represses the shortening of telomeres,
which can be observed in cells’ aging process. It
represses the apoptosis process and enables the
uncontrolled cell division [23, 24, 26]. E7 protein
reacts with pRb protein, which is a critical regulator of
cell cycle in the G1 phase. E7, after the direct pRb
binding, inactivates it, which leads to a constant
expression of cellular transcription factor - E2F. In the
G0/G1 phase of cell cycle the pRB is in nonphosphorylation form and creates complexes with the
transcription factor E2F. This causes the repression of
the replication process [23, 26, 27]. As the result of cell
signals stimulating mitotic division, a transcription of
D-type cyclins encoding genes is initiated. This leads
to the activation of cyclin-dependent 4 and 6 kinase
(CDK4 and CDK6).
They phosphorylate pRBG1 and it causes the
release of E2F [28]. This factor stimulates the
transcription of a group of genes, which encode
proteins essential to further cell cycle [23, 26, 27]. The
interaction of E7 with pRB causes the release of E2F
stimulating the cell to enter the S phase of cell cycle;
even if there are no active CDK7 or CDK6 [28].
Additionally, E7 interacts with other proteins taking
part in the regulation of cell cycle, which causes a
disturbance and uncontrolled cellular proliferation [4,
5, 19, 25]. As a result of E6 and E7 expression, cells
causing genetic disorders (i.e. aneuploidy) can be
immortalized, which leads to carcinogenesis [5, 19].
The amount of the virus’ nucleic acid decreases with
an increase of dysplasia and neoplasia in patients [3].
DIAGNOSIS OF HPV
Among the most common methods of diagnosing
the human papilloma virus infection there are:
• serological diagnostic - in this case the antiHPV antibodies are the marker (i.e. ELISA
test);
• detection of viral DNA - a method widely used,
in which it is possible to determine the type of
virus (e.g. PCR, amplification of the sought
DNA’s signal - Hybrid Capture II test - which is
The correlation between cervical cancer and human papilloma virus infection
a simple test serving 13 types of virus detection
and is used in difficult to verify pre-plastic and
neoplastic changes associated with HPV);
• electron microscopy - expensive and timeconsuming, does not identify the type of virus,
but nevertheless allows its detection at a very
early stage of dysplasia;
• detection of specific antigen - allows only the
assignment of the microorganism to the genus;
• methods of histology, histopathology and
cytology - only indirectly help to confirm the
HPV infection and to determine the degree of
histopathological changes in the cells;
• isolation of virus in cell culture - a method that
uses a combination of organ culture with the
technique of transplantation of infected tissue in
the thymus deprived animals [3, 5, 6, 8, 11].
Currently, the most appropriate combination of
methods is the use of physical, cytological and
histological examination, along with molecular tests
[8]. These techniques form the basis of screening tests
to detect cervical cancer [8].
TREATMENT OF INFECTIONS
Treatment of HPV infection relies primarily on
epidermis-exfoliating accelerators. A very effective
means of destructing the infected cells are: laser
therapy, cryotherapy, electrocoagulation, and surgical
treatment [3, 5, 8, 12]. Among the substances used to
fight infection with human papilloma virus, which can
be used independently by the patient, there are:
Podophyllotoxin (0.5% solution, gel) and Imiquimod
(5% cream) [5, 12]. The factors which improve the
patient’s overall health during the treatment of diseases
associated with HPV are: vitamins (including vitamin
A responsible for the proper functioning of the
epithelium), micronutrients and the reduction or
complete elimination of all drugs which might impair
the immune potential [3, 5, 8].
The discovery of the relation between the development
of cervical cancer and HPV infection has enabled the
development of vaccines reducing the risk of
developing this type of cancer. Instead of a viral DNA,
vaccines contain a virus-like particle (VLP) and a viral
capsid protein L1.
At present there are two vaccines:
• quadrivalent
HPV
(Silgard/Gardasil)
containing virus’ L1 protein type 6, 11, 16 and
18; registered in order to prevent the cervical,
15
vulva and vagina cancers and pre-cancerous
changes;
• bivalent HPV (Cervarix) - inducing the
production of antibodies against HPV viral L1
protein types 16 and 18; registered in order to
prevent cancer and pre-cancerous states of the
cervix [6, 10, 22].
These vaccines have a typically prophylactic effect
and are suitable for women who never had contact with
this virus [22].
CONCLUSIONS
Although in Poland within 30 years the incidence
of cervical cancer has decreased markedly, this type of
cancer remains a significant cause of mortality among
women [5]. Human papillomavirus is detected in cases
of:
- 69-100 % various degrees of neoplasia (CIN-1,
CIN-2, CIN-3)
- 80-100 % squamous cell carcinoma
- 67-95 % cervical adenocarcinomas [5, 7].
There is no doubt that HPV infection plays an
important role in the development of cervical cancer
[11, 20]. The following are a clear evidence of this
association:
• positive correlation between the presence of
highly oncogenic HPV types, and a very
advanced dysplastic changes, which are a
premalignant stage;
• integration of the highly oncogenic HPV types
genomes with the chromosomal DNA of
human epithelial cells;
• presence of low-oncogenic HPV’s DNA
outside the nucleus;
• lack of this virus in mutated cells [5].
Future studies of this correlation can contribute to
creation of effective prevention and treatment of
cervical cancer. Serological tests that measure antibody
titers of anti-HPV, allow to predict the cervical cancer
development, estimate the size of the primary tumor
and lymph node involvement and obtain the
information about effective treatment and prognosis
[2].
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dr. Anna Studzińska-Czyszka
Chair of Plant Physiology and Biotechnology
ul. Gagarina 9
87-100 Toruń
tel./fax 56 611 45 59
Received: 1.06.2010
ORIGINAL ARTICLE / PRACA ORYGINALNA
Anna Klimaszewska1, Magdalena Izdebska1, Maciej Gagat1, Dariusz Grzanka2, Alina Grzanka1
THE INFLUENCE OF ARSENIC TRIOXIDE ON THE REORGANIZATION
OF THE TUBULIN PROTEIN IN CHO AA8 CELL LINE
WPŁYW TRÓJTLENKU ARSENU NA REORGANIZACJĘ BIAŁKA TUBULINY
W LINII KOMÓRKOWEJ CHO AA8
1
Department of Histology and Embryology, Nicolaus Copernicus University in Toruń, Collegium Medicum in
Bydgoszcz, Karłowicza 24, 85-092 Bydgoszcz, Poland
Head: Assoc. Prof. Alina Grzanka, Ph.D.
2
Department of Clinical Pathology, Nicolaus Copernicus University in Toruń, Collegium Medicum in Bydgoszcz,
Curie Skłodowskiej 9, 85-094 Bydgoszcz, Poland
Head: Assoc. Prof. Andrzej Marszałek, Ph.D.
Summary
I n t r o d u c t i o n . Arsenic trioxide proved effective in
patients with relapsed or refractory acute promyelocytic
leukemia (APL). It also has promising results for the
treatment of other hematologic and solid tumors. The
proapoptotic and antyproliferative effect of As2O3 has been
displayed in many cell lines but the precise mechanism of
ATO-action is still unknown. The aim of this investigation
was to determine the influence of arsenic trioxide on the
tubulin protein organization and distribution and also the type
of ATO-activated cell death in the CHO AA8 cells.
M a t e r i a l a n d m e t h o d s . The Chinese Hamster
Ovary AA8 cell line constituted the experimental material. In
order to determine the number of dead cells, the trypan blue
dye exclusion method was used. Morphological and
ultrastructural changes in the CHO AA8 cells were evaluated
by using light and electron microscope, respectively.
Reorganization of the tubulin protein was determined by
using fluorescence microscope.
R e s u l t s . The performed experiments revealed a dosedependent decrease in the cell survival. The morphological
and ultrastructural features acquired by the cells after ATOtreatment were considered typical for apoptosis, mitotic
catastrophe or autophagy. The changes in the rearrangement
and distribution of the tubulin protein were also observed.
C o n c l u s i o n s . The results obtained here showed
that arsenic trioxide influences organization of tubulin
cytoskeleton, presumably by promoting its polymerization
process. Moreover, the data presented here suggest that ATO
induces the cell death with at least three mechanisms:
apoptosis, mitotic catastrophe and autophagy.
Streszczenie
W s t ę p . Trójtlenek arsenu okazał się skutecznym
lekiem w nawrotowej lub opornej postaci białaczki
promielocytowej, a także dobrze rokującym w innych
nowotworach hematologicznych oraz guzach litych.
Zablokowanie cyklu komórkowego, z następczą apoptozą
jest powszechnie obserwowanym skutkiem działania ATO na
różne linie komórkowe, jednakże dokładny mechanizm jego
działania pozostaje nierozwiązany i wymaga dalszych badań.
Celem niniejszej pracy była ocena wpływu ATO na
organizację i rozmieszczenie białka tubuliny w linii
komórkowej CHO AA8. Za zasadne uznano również
zbadanie zmian morfologicznych i ultrastrukturalnych
indukowanych przez ATO, celem określenia rodzaju
uruchamianej śmierci zachodzącej w badanej linii.
18
Anna Klimaszewska et al.
M a t e r i a ł i m e t o d y . Materiał doświadczalny
stanowiły fibroblasty chomika chińskiego linii komórkowej
CHO AA8. W celu określenia ilości martwych komórek
zastosowano barwienie błękitem trypanu. Morfologiczne i
ultrastrukturalne
zmiany
w
komórkach
oceniono
odpowiednio, przy użyciu mikroskopu świetlnego i
mikroskopu elektronowego. Reorganizację białka tubuliny
zbadano przy pomocy mikroskopu fluorescencyjnego.
W y n i k i . Przeprowadzone doświadczenia wykazały,
zależny od dawki arszeniku spadek przeżycia komórek linii
CHO AA8. Ponadto ATO indukował pojawienie się komórek
o fenotypie apoptozy, katastrofy mitotycznej i autofagii. Pod
wpływem arszeniku obserwowano także zmiany w
organizacji i rozmieszczeniu białka tubuliny w komórkach
badanej linii.
W n i o s k i . Wyniki uzyskane w niniejszej pracy
sugerują, że arszenik wpływa na organizację cytoszkieletu
tubulinowego,
prawdopodobnie
promując
proces
polimeryzacji tubuliny. Ponadto, z przeprowadzonych
obserwacji wynika, że indukcja śmierci przez ATO w linii
komórkowej CHO AA8 zachodzi co najmniej trzema
niezależnymi drogami.
Key words: arsenic trioxide, tubulin, CHO AA8 cell line, apoptosis, mitotic catastrophe, autophagy
Słowa kluczowe: trójtlenek arsenu, tubulina, linia komórkowa CHO AA8, apoptoza, katastrofa mitotyczna, autofagia
INTRODUCTION
Arsenic trioxide (As2O3, ATO), the anti-cancer
drug proved effective in patients with relapsed or
refractory acute promyelocytic leukemia (APL). It also
has promising results for the treatment of other
hematologic and solid tumors [1]. Arsenic trioxide acts
by a variety of mechanisms which affect numerous
intracellular signal transduction pathways and promote
different response from the cancer cells [1,2]. These
cellular effects include increased level of apoptosis,
inhibition of growth, induction or inhibition of
differentiation, but also inhibition of angiogenesis [3].
Moreover, it has been shown that cellular responses to
ATO appear to vary according to a cell type, dose, and
duration of treatment [4]. Specifically, ATO triggers
apoptosis in many types of cancer cells through
inhibition of NFκB, activation of caspase cascade,
induction of oxidative stress, and disruption of
mitochondrial membrane potential [2,5]. Furthermore,
activation of JNK kinase, inhibition of telomerase, and
changes in expression of bcl-2 may also contribute to
the induction of cell death by arsenic trioxide [1].
In recent years, the attention of many researchers
has been focused on tubulin as a potential cellular
target for arsenic trioxide [6]. It is known that the
cytoskeleton plays an important role not only in
regulation of cell growth, differentiation and cell
survival, but also in neoplastic transformation [7].
Tubulin is a cysteine-rich protein which has critical for
microtubule polymerization sulfhydryl groups (SH)
[8,9]. Modification of critical cysteine groups in
cellular proteins appears to be a typical mechanism of
ATO-action. Mitotic arrest followed by apoptotic cell
death is a commonly observed result of ATO in a
number of myeloid cell lines (e.g. NB4, HL-60, K562,
U937) [4]. However, it has not been determined yet if
antimitotic properties of As2O3 result from its ability to
promote or inhibit tubulin polymerization. Moreover,
the antimitotic features have not been related to the
influence of ATO on tubulin organization at all. Thus,
the exact mechanism of ATO-induced mitotic arrest
related to apoptosis is not fully understood and requires
further investigation [6].
The aim of the present study was to determine the
changes in the rearrangement and distribution of
tubulin protein in the CHO AA8 cell line after a
treatment with arsenic trioxide. The choice of p53-lack
cell line in present investigation in the manner of
determination of cell death type seems justified.
Presented study is based on the influence of ATO
on tubulin rearrangement in CHO AA8 cell line and
can be useful for better understanding of molecular
mechanism of ATO action.
MATERIAL AND METHODS
Cell culture and treatment
The Chinese hamster ovary cell line, CHO AA8,
used in this study was a gift from Prof. M. Zdzienicka
(Department of Molecular Cell Genetics, Collegium
Medicum in Bydgoszcz, Nicolaus Copernicus
University, Poland). CHO AA8 cells were grown at
37°C in an atmosphere of 5% CO2 in minimum
essential medium eagle (Sigma-Aldrich) supplemented
with 10% fetal bovine serum (FBS, Gibco) and mixture
of penicillin and streptomycin (Sigma-Aldrich) in
concentration of 1ml/100ml medium. After 24 h of
culture the cells were incubated with arsenic trioxide
(ATO, Trisenox). ATO was added at doses of 0.6
µg/ml and 1.2 µg/ml for 24 h. Control cells were
cultured identically without ATO treatment.
Cell viability assay
Cell viability was assessed by the trypan blue dye
exclusion assay. Freshly prepared 2% solution of
The influence of arsenic trioxide on the reorganization of the tubulin protein in CHO AA8 cell line
trypan blue in 0.9% NaCl (1:1) were added to 10 µl of
cell suspension in culture medium . The percentage of
trypan blue negative cells was evaluated using the
Eclipse E800 light microscope (Nikon).
Mayer’s hematoxylin staining
The CHO AA8 cells grown on coverslips were
fixed in 4% paraformaldehyde (20 min, RT) and then
rinsed with PBS (3x 5 min). Afterwards, the cells were
incubated with 0.1M glycine solution (5 min, RT) and
treated with 0.1% Triton X-100 solution. Followed by
a double rinsing with PBS, the cells were stained with
Mayer's hematoxylin (5 min, RT) and rinsed for 20
minutes under running tap water. After that, the cells
were stained with 0.1M eosin solution, washed in
distilled water, and dehydrated in graded series of
alcohols and xylenes. The preparations were observed
using the Eclipse E800 microscope (Nikon) with NISElements image analysis system and CCD camera (DS5Mc-U1; Nikon).
Fluorescence microscopy
For immunofluorescence labeling of tubulin, the
cells were prefixed with bifunctional protein
crosslinking reagent DTSP ([di(N-succinimidyl) 3'3dithiodipropionate dithiobis(succinimidyl propionate)])
in HBSS (Hank's balanced salt solution; SigmaAldrich) for 10 minutes at 37°C. Then, the cells were
extracted in Tsb (0.5% Triton X-100 in MTSB
containing DTSP) for 10 minutes at 37°C (dilution
1:50). Afterwards, the cells were fixed in 4%
paraformaldehyde in MTSB (15 min, 37°C), washed
with PBS (3x5 min), and embedded in 0.1 M glycine
solution (5 min, RT). Nonspecific binding sites were
blocked with 1% BSA-TBS (2x5 min, RT). Labeling
of β-tubulin was performed using a mouse monoclonal
antibody specific for β-tubulin (Sigma-Aldrich; 45
min, 37°C, humidity chamber, dilution 1:65 in 1%
BSA/TBS). Then, the cells were treated with goat antimouse IgG-TRITC secondary antibody (SigmaAldrich; 45 min, 37°C, humidity chamber, diluted 1:85
in PBS). Nuclei of the cells were labeled with DAPI
(Sigma-Aldrich). Finally, coverslips were mounted in
Aqua-Poly/Mount (Polysciences) and analysed by the
Eclipse E800 microscope with the Y-FL fluorescence
attachment (Nikon), NIS-Elements 3.30 image analysis
system and CCD camera (DS-5Mc-U1; Nikon).
19
Electron microscopy
In ultrastructural analysis of CHO AA8 cells
electron microscope was used. The cells were fixed
with 3.6% glutaraldehyde (60 min) and moved to 0.1M
cacodylate buffer (pH 7.4). Afterwards, the cells were
postfixed with 2% osmium tetroxide (60 min),
dehydrated with an ascending series of alcohols and
acetones, and embedded in Epon 812. The
polymerization of the resin occurred at 37°C for 24 h,
and then at 65°C for 120 h. Selected parts of material
were cut into ultra-thin sections by using the Reichert
OmU3 ultramicrotome and then counterstained with
uranyl acetate and lead citrate. The material was
examined using the JEM 100 CX electron microscope
(JEOL).
Statistical analysis
STATISTICA 9 for Windows (StatSoft software)
was used for estimation of arithmetic mean, standard
deviation, median, minimum and maximum. To assess
the statistically significant differences between ATO
doses used, the nonparametric Mann-Whitney U test
was performed by using GraphPad Prism 5.0
(GraphPad Software). Results were considered at
p<0.05.
RESULTS
CHO AA8 cell line viability after ATO treatment
The trypan bule staining showed an increase in the
mean percentage of trypan positive CHO AA8 cells
after arsenic trioxide treatment. Moreover, the
percentage of surviving cells decreased together with
ATO dose used (Fig. 1, Table I). Statistical analysis
showed statistically significant differences (p<0.05) in
the average percentage of surviving cells in
comparison to the controls (Ctrl: 97.79%; ATO 0.6:
92.03%; ATO 1.2: 85.48%) (Fig. 1).
Table I. The effect of ATO doses on the survival of CHO AA8
cells
Tabela I. Wpływ dawek ATO na przeżycie komórek linii CHO
AA8
Dose Mean Standard Median Minimum Maximum
[µg/ml] [%]
deviation Mediana Minimum Maksimum
Dawka Średnia Odchylenie
[µg/ml] [%] standardowe
0.0
97.79
1.26
98
95
100
0.6
92.03
5.31
93
76
98
1.2
85.48
9.63
88
58
98
20
Fig. 1. The influence of ATO doses on the average
percentage of surviving CHO AA8 cells. Asterisks
indicate statistically significant differences
Ryc. 1. Wpływ ATO na średni procent przeżywających
komórek linii CHO AA8. Różnice istotne
statystycznie zaznaczono gwiazdką
Morphological changes of CHO AA8 cells after
ATO treatment
The light microscopy studies revealed ATO dosedependent changes in cell shape and size of CHO AA8
cells. The control cells demonstrated spindle-like
morphology typical for fibroblasts, only a few cells
were morphologically changed (Fig. 2A). After low
ATO concentration treatment (0.6 µg/ml) we observed
cell shrinkage with surface blebbing positively stained
with Mayer’s hematoxylin (Fig. 2B,C). A few cells
with the appearance of multi-nucleated and mononucleated giant cells were noticed (Fig. 2B,C). At a
higher concentration of ATO (1.2 µg/ml) the numerous
multi-nucleated and mono-nucleated giant cells were
noted (Fig. 2D).
Fig. 2. Light microscopy studies of ATO-treated CHO AA8
cells; The multi-nucleated (arrows C,D) and mononucleated (triangles B,D) giant cells. A- control, B,C0.6 µg/ml, D- 1.2 µg/ml
Ryc. 2. Analiza komórek linii CHO AA8 w mikroskopie
świetlnym; Olbrzymie komórki zawierające liczne
mikrojądra (strzałki C,D) lub jedno duże jądro
(trójkąty B,D). A- kontrola, B,C- 0.6 µg/ml, D- 1.2
µg/ml
Ultrastructural changes of CHO AA8 cells after
arsenic trioxide incubation
At the electron microscopic level regular shape and
intact nuclei of control cells were shown (Fig. 3A).
After arsenic trioxide treatment at a concentration of
0.6 and 1.2 µg/ml, the shrunken cells with undulating
surface were observed. These cells exhibited
deformation of the nuclei and margination of
chromatin (Fig. 3B). Besides, the incubation of CHO
AA8 cells with ATO resulted in occurring of enlarged
cells with nuclear fragmentation and chromatin
condensation (Fig. 3C). Furthermore, vacuoles in the
cytoplasm of CHO AA8 cells exposed to both
concentrations of ATO were observed. These
autophagic vacuoles contained cellular organelles that
were at various stages of degradation (Fig. 3D).
Fig. 3. The electron microscopy studies of ATO-treated CHO
AA8 cells; The autophagic vacuoles contained
damage cell structures (arrow D). A- control,
magnification x 3750, B- 1.2 µg/ml, magnification x
4524, C- 1.2 µg/ml, magnification x 2475, D- 0.6
µg/ml, magnification x 4138
elektronowym; Widoczne wakuole autofagiczne
zawierające uszkodzone organella komórkowe
(strzałka D). A- kontrola, pow. x 3750, B- 1.2
µg/ml, pow. x 4524, C- 1.2 µg/ml pow. x 2475, D0.6 µg/ml, pow. x 4138
Analysis of β-tubulin reorganization after treatment
of CHO AA8 cells with arsenic trioxide
The observations at the fluorescence microscopic
level revealed that arsenic trioxide induced changes in
the distribution and organization of tubulin in the CHO
AA8 cells, in the dose-dependent manner. In the
control cells, the tubulin was located throughout the
cytoplasm, more strongly marked at the cell periphery
in form of densifications or aggregations under the
plasma membrane (Fig. 4A). There were no
morphological changes in nuclei of these cells (Fig.
4A'). The small population of control cells was in the
stage of mitosis. In the dividing cells, the
immunolabeling of tubulin showed the structure of the
mitotic spindle. There were also cells with the
microtubule bundles radiating from the microtubuleorganizing centers (MTOCs) observed.
After the treatment of CHO AA8 cells with ATO at
a concentration of 0.6 µg/ml there were no alterations
in the distribution and organization of the tubulin in
comparison to the control (Fig. 4B) observed.
Occasionally, there were enlarged cells with
fragmented nuclei resembling micronuclei with
expanded microtubular network (Fig. 4B') seen. Only a
few dividing cells with visible mitotic spindle were
observed.
Fig. 4. The fluorescence microscopy studies of ATO-treated
CHO AA8 cells; β-tubulin is labelled in apoptotic
body (arrow E'). A- control TRITC, A'- control
DAPI/TRITC, B- 0.6 µg/ml TRITC, B'- 0.6 µg/ml
DAPI/TRITC, C,D,E- 1.2 µg/ml TRITC, C',D',E'- 1.2
µg/ml DAPI/TRITC
fluorescencyjnym; znakowanie β-tubuliny w ciałku
apoptotycznym (strzałka E'). A- kontrola TRITC, A'kontrola DAPI/TRITC, B- 0.6 µg/ml TRITC, B'- 0.6
µg/ml DAPI/TRITC, C,D,E- 1.2 µg/ml TRITC,
C',D',E'- 1.2 µg/ml DAPI/TRITC
21
After 1.2 µg/ml of ATO, the cells were shrunken
and the tubulin was located at their periphery, in the
form of larger agglomerations or ring-like structures
surrounding the nucleus (Fig. 4C,E). In some cells
treated with 1.2 µg/ml of ATO, the tubulin formed
thick bundles or aggregations localized within the
cytoplasm (Fig. 4D). Moreover, numerous multinucleated and mono-nucleated giant cells with strongly
expanded microtubular cytoskeleton were observed
(Fig. 4C',E'). In a few dividing cells the mitotic spindle
was noticed.
DISCUSSION
Apart from inhibition of cancer cells proliferation
the purpose of novel anticancer therapy is targeting
them at the pathways of apoptosis [10]. The
proapoptotic and antyproliferative effect of As2O3 has
been displayed in many cell lines [11]. As showed by
Taylor et al. the mechanism through which arsenic
trioxide leads to mitotic arrest before cell death
induction is still a subject of open intensive research
and discussion [6]. In recent years the attention of
many investigators has been focused on cysteine-rich
cytoskeletal proteins as a potential cellular target for
arsenic trioxide [4,12,13]. Li and Chou observed
changes in the cytoskeleton of Swiss 3T3 mouse cells
treated with sodium arsenite (NaAsO2) and suggested
that AsIII might interact directly with the cytoskeleton
through actin [14]. Furthermore, Qian et al. showed
that the stimulation with arsenic compounds induces
reorganization of actin filaments to form lamellipodia
and filopodia structures in SVEC4-10 endothelial cells
[15]. Izdebska et al. revealed that ATO affects
cytoplasmic and nuclear F-actin reorganization in the
HL-60 and K-562 cell lines [11,16]. Moreover, Binet et
al. suggested that intermediate filaments are another
molecular target of ATO action [12].
The proposed mechanism of arsenic-induced cell
cycle arrest is based on the inhibition of GTP-induced
tubulin polymerization [6,9]. Li and Brome found that
β-tubulin includes two adjacent cysteine residues (Cys12 and Cys-213), which are situated near the GTPbinding site and essential for the process of
microtubule formation. These authors suggested that
trivalent arsenic is a noncompetitive inhibitor of
binding of GTP to tubulin [17]. Carré et al. observed
that the binding of arsenic trioxide on tubulin cysteine
residues results in conformational changes of this
protein and consequently inhibition the process of its
22
polymerization [18]. The ATO is described not only as
a factor inhibiting tubulin polymerization, but also
promoting its depolimeryzation [9,13]. However, the
results presented in our study showed giant cells filled
with long, thick bundles of microtubules radiating from
the center of the cell, probably from MTOC. Moreover,
the dividing cells with microtubules arranged in the
mitotic spindle were observed. The higher dose of the
drug caused thickening of microtubules in comparison
to the controls. Additionally, in cells treated with ATO
in concentration of 1.2 µg/ml, the tubulin formed thick
bundles or intensively labeled aggregates in the area of
cytoplasm. The obtained results allow an assumption
that arsenic trioxide promotes the polymerization of
microtubules in the CHO AA8 cell line. These results
are consistent with the conclusion of Ling et al. that
arsenic trioxide induces tubulin polymerization and
prevents microtubules depolymerization in human
tumor cell lines [19].
In present work the Chinese Hamster Ovary cell
line with defect in p53 tumor suppressor gene was
used. It can be useful for the studies on the p53independent cell death pathways but also can be
significant because p53 is the mostly mutated gene in
human cancers.
In our studies on CHO AA8 cells treated with
different concentration of ATO both p53-independent
apoptotic and numerous multi-nucleated and mononucleated giant cells with a phenotype of mitotic
catastrophe were observed. In the literature a lot of
examples of ATO-induced apoptosis and mitotic
catastrophe were described [6,20,21]. Izdebska et al.
observed in ATO-treated HL-60 cells the formation of
apoptotic bodies and characteristic for apoptosis
features [16]. The similar changes in the morphology
of HL-60 cells under the influence of arsenic
compounds were reported by Charoensuk et al. [22].
There are also numerous reports on As(III)-induced
apoptosis and mitotic catastrophe in solid tumor cell
lines [6,23]. Yih et al. observed in arsenite-treated
CGL-2 cells the centrosome amplification, spindle
multipolarity and chromosome missegregation that
lead to mitotic cell death [21]. Additionally, the same
authors showed that sodium arsenite induces
multinucleation, endoreduplication and aneuploidy in
human fibroblasts [24].
The results obtained in the present work also
suggest that autophagy is another way of cell death
induced by arsenic trioxide in CHO AA8 cells. The
electron microscopy studies revealed that ATO
promotes the formation of autophagic vacuoles
containing cellular organelles at various stages of
degradation. Bolt et al. reported that autophagy was the
predominant form of cell death in human
lymphoblastoid cell lines exposed to sodium arsenite
[25]. In studies conducted on ATO-treated leukemia
cells, Quian et al. observed both apoptotic cells and
cells with a large number of autophagic vacuoles. It
was also shown that ATO induces a time-dependent
increase in Beclin-1 protein expression, involved in the
process of autophagy and considered its specific
marker [26]. Moreover, Kanzawa et al. found that the
glioma cells accumulate acidic vesicular organelles
(AVOs) in the response to arsenic trioxide, which are
characteristic of autophagy [27].
In conclusion, the data presented here suggest that
ATO induces the cell death through at least three
mechanisms: apoptosis, mitotic catastrophe and
autophagy. The ability of As2O3 to trigger the different
types of cell death indicates its great potential as an
anticancer agent. Moreover, based on the results of
these experiments, it may be assumed that ATO, in
contrast to many chemotherapeutic drugs, induces the
p53-independent apoptosis.
Additionally, this study showed that arsenic
trioxide
influences
organization
of
tubulin
cytoskeleton,
presumably
by
promoting
its
polymerization process. However, further studies using
additional investigation methods are required to
confirm this result.
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Ling Y.HE., Jiang J.D., Holland J.F. et al.: Arsenic
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Assoc. Prof. Alina Grzanka, Ph.D.
Collegium Medicum in Bydgoszcz
Department of Histology and Embryology
24 Karłowicza St.
85-092 Bydgoszcz,
tel.: +48525853725
fax: +48525853734
Janina Brudny, Natalia Pawlik, Jarosław Koza, Maciej Świątkowski
THE ESTIMATION OF VOLUNTEER BLOOD DONORS MOTIVATION FACTORS
ON EXAMPLE OF DONORS WHO APPLIED TO REGIONAL BLOOD DONATION
AND BLOOD TREATMENT CENTER IN BYDGOSZCZ
OCENA CZYNNIKÓW MOTYWACYJNYCH WŚRÓD HONOROWYCH DAWCÓW KRWI
REGIONALNEGO CENTRUM KRWIODAWSTWA I KRWIOLECZNICTWA W BYDGOSZCZY
Clinic of Gastroenterology, Vascular Diseases and Internal Diseases Nicolaus Copernicus University in Toruń,
Head: prof. Maciej Świątkowski, MD
Summary
I n t r o d u c t i o n . Honorary blood donation is
considered to be a form of voluntary help in saving people's
lives. Despite a considerable development of biomedical
sciences it is impossible to artificially create the majority of
blood derivatives outside of a living organism. Blood
donations do not satisfy the demand completely, thus means
of promoting such actions and increasing the number of
people willing to donate are of utmost importance. The aim
of this thesis is to define main factors which might motivate
people to donate their blood.
M a t e r i a l s a n d m e t h o d s . Blood donors from
the Regional Blood Donation and Blood Treatment Centre,
who had donated their blood within a period of 2 months,
were the target group for the following study. A survey in
which donors answered questions concerning different
factors motivating them to donate blood was conducted.
R e s u l t s . The surveyed group consisted of 85 people
(55 men and 30 women). 49.4% of the surveyed were under
25 years old. Most people had secondary education (54.1%).
100% of women stated that they had donated blood mainly
because of altruistic factors, whereas 14.5% of men marked
personal benefit as the most important reason for the
donation.
C o n c l u s i o n s . Most of the honorary donors were
people 18 to 25 yearsof age. Men constituting the majority (in
general as well as in each age group). Helping others proved
to be the most crucial factor motivating the donors.
Streszczenie
W s t ę p . Honorowe krwiodawstwo jest uważane za
bezinteresowne działanie w ratowaniu zdrowia i życia. Mimo
znacznego postępu w rozwoju nauk biomedycznych,
większości preparatów krwiopochodnych nadal nie można
uzyskać poza żywym ustrojem. Donacje ciągle pozostają na
poziomie niewystarczającym względem zapotrzebowania,
dlatego istotne jest podejmowanie działań mających na celu
zwiększenie liczby osób oddających honorowo krew.
Za cel pracy przyjęto określenie głównych czynników
motywujących do honorowego krwiodawstwa.
Materiał
i
metody.
Badaniem objęto
krwiodawców z Regionalnego Centrum Krwiodawstwa
i Krwiolecznictwa, którzy zgłaszali się celem donacji
w okresie 2 miesięcy. W tym celu wykorzystano formularz
ankiety składający się z pytań dotyczących czynników
motywujących do oddawania krwi.
W y n i k i . Badana grupa liczyła 85 osób (55 mężczyzn
i 30 kobiet). 49,4% badanych było poniżej 25 roku życia.
Osoby ze średnim wykształceniem przeważały wśród
dawców (54,1%). 100% kobiet deklarowało chęć oddawania
26
Janina Brudny et al.
krwi głównie w oparciu o przesłanki altruistyczne, podczas
gdy 14,5% badanych mężczyzn jako najistotniejszy czynnik
podaje osiągnięcie własnych korzyści.
Wnioski.
Wśród honorowych krwiodawców
dominują osoby młode w wieku 18-25 lat. Zarówno
całościowo, jak i w każdym z analizowanych przedziałów
wiekowych jest więcej mężczyzn niż kobiet. Kluczowym
czynnikiem motywującym jest chęć niesienia pomocy innym.
Key words: blood donors, honorary blood donation, motivation
Słowa kluczowe: dawcy krwi, honorowe krwiodawstwo, motywacja
INTRODUCTION
AIM
Honorary blood donation is considered to be a
noble and voluntary act which helps in saving people's
lives. Donors provide the state with most of its blood
and blood preparations supply. Because of the
significant demand and donation disproportion, certain
efforts which aim at attracting attention to blood
donation are made [1]. In spite of the fact that
contemporary medicine, biotechnology, and genetic
engineering allow the creation of plasma coagulation
factors, no alternative for morphotic elements
production has been found so far. That is why blood
preparations obtained from donors are the only solution
when a transfusion for patients who need to have their
essential bodily functions stabilised is necessary. They
are commonly used in clinical medicine, some
examples
include:
injury
treatment,
when
complications are liable to occur because of excessive
blood loss, significant surgeries, haematological
conditions. When patients suffer from bone marrow
damaging conditions, which may secondarily cause
ineffective haematopoesis, an erythrocyte concentrate
transfusion is one of the treatments often applied.
Taking into account epidemiologic aspects of patients
with haematological conditions, who live longer as the
result of the development of medical science, the
demand for such treatments has considerably increased
[2, 3].
Regional Blood Donation and Blood Treatment
Centres (RCKiK) in Poland organise promotional
campaigns to increase the number of people donating
blood. The centres usually aim at people of a particular
group, for example university students or general adult
population of a region. Sometimes these are
nationwide projects, for example ‘Motokrew’ [4]. The
problem of insufficient blood supply is also a topic of
mass media coverage. TV and radio stations as well as
press publishers nationwide conduct campaigns
encouraging people to donate blood.
Because of the significant demand and donation
disproportion, the authors of this study have tried to
analyse factors motivating people to donate blood. It is
likely that an analysis of this kind may help in
choosing resources and designing appropriate methods
which might motivate would-be donors.
MATERIALS AND METHODS
A survey conducted among honorary donors who
came to the Regional Blood Donation and Blood
Treatment Centre in Bydgoszcz was used as study
material.
The questionnaire had been designed to analyse
motivational factors. The survey was voluntary and
anonymous. In the first part, respondents were to
choose the most important motivational factor, which
had influenced their decision of donating blood. In the
second part, they had to list all factors which they
considered essential and motivating. The answers were
analysed taking gender, age, and education into
account.
Respondents were chosen according to their
spontaneous appearance in the RCKiK facility,
providing that they had come there to donate blood.
The survey was taking place from May to June 2009.
Statistics data assessment was done via the Fisher
Exact Test. Statistical variable was set to p<0.05.
The board of RCKiK and the appropriate bioethics
committee have both given their consent to the study.
RESULTS
The surveyed group consisted of 85 people (55 men
and 30 women). The average age of women amounted
to 24.9 ± 7.75 years (between 18 and 54 years), and
29.2 ± 10.28 years among men (from 18 to 57 years).
Majority of the people surveyed were between 18
and 25 years old (42 respondents), which constituted
about 50% of all surveyed people. In this age group
there were no statistically significant differences
The estimation of volunteer blood bonors motivation factors on example of donors who applied to Regional Blood Donation...
liczba krwiodawców
30
25
kobiety
24
19
mężczyźni
15
20
15
8
10
8
1
5
3
2
1
0
40-46
47-53
1
and mood improvement) as the main reason for
donating. 8 men (14.5%) stated that the benefit of free
blood tests, a day off, and revitalising meal were the
most important factors (p<0.05). Detailed data have
been included in Table I.
30
liczba dawców krwi
between men and women as far as the number of
donations was concerned. If the age range taken into
consideration is increased to 32, the discrepancies
between the genders become noticeable. Fig 1 shows
that only 3 out of 30 women (10%) were older than 32,
whereas there were 16 out of 55 men (29.1%) in the
same age group (p<0.05).
25
25
17
20
15
10
5
11
8
8
3
5
3
2 3
0
3
0
27
od lekarza
od znajom ych
z med iów
z plakatów
i nne
sposób uzy sk ania inform acji o kr wiodas twie
kobiety
mężczyźni
<25
25-32
33-39
>54
wiek krwiodawców
Fig. 3. Sources of information about the blood donation
Ryc. 3. Sposób uzyskania informacji o krwiodawstwie
Fig. 1. Number of blood donors depending on sex and age
Ryc 1. Liczba krwiodawców w zależności od płci i wieku
Respondents of secondary education, both men and
women, constituted the majority (54%) of the people
surveyed (Fig 2). No statistically significant relation
between the donors' education and their gender was
noted.
30
Mass
media
campaigns
Kampanie
medialne
Blood tests
free of
charge
Bezpłatne
badanie
krwi
Helping
others
Pomoc
innym
0
0
25
5
0
4
42
5
kobiety
26
Mood of mind
improvement
(through good
deeds)
Poprawa
samopoczucia
z powodu
dobrego
uczynku
mężczyźni
25
liczba krwiodawców
Table I. Main motivational factor influencing the decision to
donate blood (only one response allowed)
Tabela I. Decydujący czynnik motywacyjny do oddawania
krwi (ankietowani zaznaczali tylko 1 odpowiedź)
20
20
13
15
Woman
Kobiety
Man
Mężczyźni
Additional
Other
benefits, such as: factors
a day off and
Inne
receiving a
regenerative meal
Korzyści
dodatkowe pod
postacią dnia
wolnego od pracy
i posiłku
regeneracyjnego
0
0
4
0
10
10
0
6
5
5
0
1
podstaw ow e
2
gimnazjalne
2
zaw odow e
średnie
w yższe
wykształcenie krwiodawców
Fig. 2. Number of blood donors depending on education level
Ryc. 2. Liczba krwiodawców w zależności od poziomu
wykształcenia
Fig 3 presents respective information sources
concerning the donation process gained by the
respondents prior to their first donation. Almost 50%
of the first - time donors stated that they had received
some information from their friends, from media
campaigns (29%), and finally from doctors (15%).
After careful analysis of the factors responsible for
people donating blood the results show that all women
declared altruistic factors (willingness to help others
Table II contains a breakdown of factors
influencing the respondents' decision concerning
donating blood. Distinctive answers included
willingness to help others, mood improvement, free
blood tests.
Table II. Motivational factors influencing the decision to
donate blood (more than one response allowed)
Tabela II. Czynniki motywacyjne mające wpływ na fakt
oddawania krwi (gdy ankietowani mogli
zaznaczyć więcej niż jedną odpowiedź)
Woman
Kobiety
Man
Mężczyźni
Mass
media
campaigns
Kampanie
medialne
Blood
tests free
of charge
Bezpłatne
badanie
krwi
Helping
others
Pomoc
innym
6
7
29
Mood of
mind
improvement
(through good
deeds)
Poprawa
samopoczucia
z powodu
dobrego
uczynku
22
7
23
47
32
Additional benefits, Other
such as:
factors
a day off and
Inne
receiving a
regenerative meal
Korzyści dodatkowe
pod postacią dnia
wolnego od pracy i
posiłku
regeneracyjnego
4
0
10
0
28
role. Although they do not considerably influence the
donors' decision, they are a relatively indispensable
source of information about the donation process as
such (Fig 4). The fact that altruistic reasons play such a
significant role as
Table III. Main motivational factor for women in relation to their level of education
motivational factors
Tabela III. Decydujący czynnik motywacyjny dla kobiet w zależności od poziomu wykształcenia
might be helpful
Education
Blood tests free of charge Helping others Mood of mind improvement Additional benefits, such as: a day off
when
designing
Wykształcenie Bezpłatne badanie krwi Pomoc innym (through good deeds)
and receiving a regenerative meal
Poprawa samopoczucia
Korzyści dodatkowe pod postacią
campaigns
z powodu
dnia wolnego od pracy i posiłku
dobrego uczynku
regeneracyjnego
encouraging people
Basic
0
0
0
0
to donate blood.
Podstawowe
After junior
0
2
0
0
Data gathered
high school
Gimnazjalne
as the result of the
Vocational
0
2
0
0
survey
and
Zawodowe
Secondary
0
16
4
0
information
gained
Średnie
Higher
0
5
1
0
from
academic
Wyższe
sources
allow
indicating the most
Table IV. Main motivational factor for men in relation to their level of education
important factors
Tabela IV. Decydujący czynnik motywacyjny dla mężczyzn w zależności od poziomu wykształcenia
motivating people
Education
Blood tests free
Helping others
Mood of mind improvement Additional benefits, such as:
to donate blood,
Wykształcenie
of charge
Pomoc innym
(through good deeds)
a day off and receiving a
which include the
Bezpłatne badanie
Poprawa samopoczucia
regenerative meal
krwi
z powodu dobrego uczynku Korzyści dodatkowe pod postacią
following:
pro
dnia wolnego od pracy
i posiłku regeneracyjnego
social
behaviour
Basic
0
1
0
0
Podstawowe
(altruism)
and
After junior
0
4
0
1
willingness to help
high school
Gimnazjalne
others, as well as
Vocational
0
8
0
2
Zawodowe
personal
mood
Secondary
3
19
3
1
improvement
Średnie
Higher
1
10
2
0
through
good
Wyższe
deeds. Nonetheless,
both sources (academic materials and data gathered)
DISCUSSION
suggest that many people treat blood donation as
means of obtaining certain benefits, such as: a day off,
The authors of the study represent an internal
blood tests free of charge, and regenerative meal [1, 5,
medicine clinic and are familiar with many nosological
6, 7, 8].
entities, which require the supply of blood derivatives.
On one hand, it stands as an inconsistency with the
The problem of discrepancy between the demand and
principles of honorary donation as voluntary activity.
number of donations, especially of rare blood groups,
On the other hand, it motivates people, thus increases
is noticeable during routine medical practice.
the number and frequency of donations. This example
Cooperation with the "RCKiK" in Bydgoszcz has
might be treated as alarming because 8 men stated that
resulted in the analysis of factors motivating the blood
personal benefit is the only reason why they had
donors. Comparing the results has shown that men
decided to donate blood (Table II). It is commonly
donate blood more often than women. Half of the
believed that people donating blood because of
donors were people under 25 years old. The
altruistic reasons are more unlikely to spread infective
willingness to help others proved to be the decisive
conditions. Research suggests that honorary blood
factor regardless of the respondents' gender and
donation is the safest means of obtaining blood and its
education. Gaining additional personal benefits has
derivatives. Introducing additional material incentives,
also been found to be a factor, albeit a minor one,
especially financial ones, might increase potential risk
motivating the donors. Both mass media coverage and
for a blood recipient [9].
promotional campaigns serve an auxiliary motivational
Tables III and IV compare the motivational factors
to the respondents' level of education. No relation
between education and any of the particular factor has
been found.
The estimation of volunteer blood bonors motivation factors on example of donors who applied to Regional Blood Donation...
Based on the results of the research and general
observations, it seems sound to postulate a change of
attitude towards blood treatment of health care
employees, especially practising doctors. It is not
uncommon to meet health professionals with a passive
attitude towards encouraging or convincing people
(e.g. the family and friends of patients in need of blood
derivatives) to donate blood. The analysis proved that
willingness to help others is a significant factor
influencing the donors' decision. Thus, providing
relatives and friends of patients who receive blood
constituents with the most basic information about the
reasons for honorary blood donation (its possibilities
and rules as well), would noticeably improve the
frequency of donations. Therefore, convincing people
about the merits of blood donation would be a great
form of encouragement.
Answers given to three questions concerning the
donors' general knowledge of the organisational and
legal rules applying to the blood service in Poland,
might prove the insufficient level thereof.
Nevertheless, the lack of knowledge (of the rules and
types of honorary titles granted to the donors) confirms
that the benefits of long term, multiple donations are of
no importance to the donors. Almost one third of them,
however, do not know that they should not be driving a
car directly after a blood donation. Taking into account
possible grave consequences of such an act, the
number of people oblivious to this fact is astounding.
First - time donors have to be aware of all the rules and
regulations concerning the right behaviour before, and
after donation as well as benefits connected to the
donation itself and regular participation in the state
blood service. One peculiarity which might be noted
after carefully analysing the research data, is the fact
that half of first - time donors, who were surveyed, had
indicated their friends as the basic source of
information about the process. Providing that young
people who donate their blood for the first time often
decide to continue doing it systematically, and become
source of information for others, the Regional Blood
Donation and Blood Treatment Centres have an
opportunity to instruct the donors (during a several
hours' procedure) on the blood donating process.
Moreover, a sort of reminding campaigns might be
introduced, which would aim at providing updates and
concise remainder of the most important information.
This can be done by means of mail or its electronic
counterpart.
29
CONCLUSIONS
Most of the honorary blood donors are people of 18
to 25 years old. Men constitute the majority (in general
as well as in each age group). A key motivational
factor is the willingness to help others. As the number
of donations is insufficient in relation to demand,
different forms of encouragement are to be employed,
and providing information (updated accordingly) to the
first - time donors is of significant importance.
Consequently, the health professionals’ participation in
the processes of motivating the potential donors and
informing them of the necessity of donating blood is
essential.
ACKNOWLEDGEMENTS
Authors of the thesis would like to acknowledge the
board of the Regional Blood Donation and Blood
Treatment Centre in Bydgoszcz for all their help and
cooperation.
REFERENCES
1. Rosiek A., Rzymkiewicz L., Owczarska K., Łętowska
M.: Charakterystyka osób oddających krew honorowo w
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demograficznych, motywacji i wybranych badań. Acta
Haematologica Polonica, 2005; 36 (2): 197-206.
2. Sabliński J.: Jeśli chodzi o rozwój krwiodawstwa
jesteśmy na dobrej drodze. Magazyn Medyczny, 1994;
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3. Sabliński J. Problemy współczesnego krwiodawstwa
i krwiolecznictwa. Acta Haematologica Polonica, 1995;
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4. Zakres działań regionalnych centrów krwiodawstwa Regionalne Centrum Krwiodawstwa i Krwiolecznictwa
w Bydgoszczy - www.rckik-bydgoszcz.com.pl/start/onas,
2009.
5. Buciuniene I., Stobien L.,Blazeviciene A., Kazlauskaite
R., Skudiene V.: Blood donors' motivation and attitude to
non-remunerated blood donation in Lithuania. BMC
Public Health., 2006; 6: 166.
6. Chiavetta J., Ennis M., Gula C., Baker A., Chambers T.:
Test-seeking as motivation in volunteer blood donors.
Transfus. Med Rev 2000; 14: 205-215.
7. Glynn SA., Kleinmann SH., Schreiber GB., Zuck T.,
McCombs S., Bethel J., Garratty G., Williams
AE.Motivation to donate blood: demographics
comparisons. Retrovirus epidemiology donor study.
Transfusion, 2002; 42: 216-225
8. Nguyen D., DeVita D., Hirschler N., Murphy E.: Blood
donor satisfaction and intention of future donation. Blood
30
donor and blood collection. Transfusion, 2008; 48(4):
742-74.
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Jarosław Koza
Clinic of Gastroenterology, Vascular Diseases and
Internal Diseases Collegium Medicum Nicolaus
Copernicus University
Ujejskiego 75
85-168 Bydgoszcz
tel. (+48 52) 365 52 84
fax (+48 52) 371 49 12
Małgorzata Łukowicz, Kamila Marszałek, Magdalena Weber-Rajek
ENDOGENOUS COGNITIVE POTENTIAL P300 IN TIA PATIENTS
BADANIE ENDOGENNEGO POZNAWCZEGO POTENCJAŁU P300 U CHORYCH PO TI A
Chair and Departament of Lasertherapy and Physiology Nicolaus Copernicus University in Toruń,
Acting Head: dr n. med. Małgorzata Łukowicz
Summary
O b j e c t i v e s . Long latency event-related potentials
(ERPs)
and, among them, endogenous auditory-evoked
potential are a reflection of cognitive functions – memory,
attention and decision making . Potential P300 is the complex
of potentials produced by brain during the process of
recognizing different stimulus. It has a great clinical meaning
and has been widely testedrecently . The aim of this paper
was to combine parameters of P300 potential in patients after
TIA with a control group.
M a t e r i a l a n d m e t h o d s . Subjects were tested in
two groups: 1) 10 young subjects in the control group and 2)
10 subjects after TIA. In order to record P300 potential,
subjects were stimulated with two different kinds of auditory
stimulus (two frequencies). Subjects were asked to recognize
these two different stimulus and pay attention during the whole
test. The results were calculated statistically.
R e s u l t s . We found that latency of potential P300 is
slightly prolonged in the tested group but it correlated with
age. We also found that amplitudes of potential P300 were
reduced in the group of patients after TIA. These findings
correlated with neuropsychological tests and confirmed the
disturbances in cognitive functions.
C o n c l u s i o n . We observed the correlation between
age and the latency of endogenous auditory-evoked potentials.
The decrease of amplitude of potential P300 confirms the
results of neuropsychological test of cognitive functions.
Recurrent TIA can disturb cognitive functions and have an
influence on parameters of P300 potential: its amplitude and
latency, sometimes its absence. Long latency- auditory
potentials are very fragile in neurophysiologic disturbances.
Streszczenie
W s t ę p . Potencjały o długiej latencji związane
z wydarzeniem (ERPs), a wśród nich endogenny potencjał
słuchowy, są odbiciem funkcji poznawczych – pamięci, uwagi
i podejmowania decyzji. Potencjał P300 jest kompleksem
potencjałów generowanych przez mózg podczas procesu
rozróżniania różnych bodźców. Ma to istotne znaczenie
kliniczne i w ostatnim czasie pojawiło się wiele doniesień
naukowych na ten temat.
M a t e r i a ł i m e t o d a . Badanych podzielono na dwie
grupy: 1) 10 osób zdrowych w młodym wieku – grupa
kontrolna oraz 2) 10 osób po przebytym incydencie TIA.
W celu zarejestrowania potencjału P300 badanych
stymulowano dwoma bodźcami słuchowymi o różnych
parametrach
(dwie
różne
częstotliwości).
Proszono
o rozróżnienie tych dwóch bodźców i o skupienie podczas
całego testu. Wykonano ocenę podstawowych funkcji
poznawczych. Wyniki badań opracowano statystycznie.
W y n i k i . Wykazano, że potencjał P300 ma nieco
dłuższą latencję w grupie badanej I i jest skorelowany
z wiekiem. Zaobserwowano również zmniejszenie amplitudy
potencjału p300 w grupie pacjentów po incydencie TIA.
Badania te korelują z wynikami uzyskanymi przez pacjentów
w testach neuropsychologicznych.
W n i o s k i . Zaobserwowano korelację między wiekiem
a latencją endogennego potencjału wywołanego. Obniżenie
amplitudy potencjału P300 koreluje z wynikami testów
neuropsychologicznych funkcji poznawczych. Nawracające
incydenty TIA wpływają na funkcje poznawcze oraz mają
Małgorzata Łukowicz et al.
32
wpływ na parametry potencjału P300: latencję oraz amplitudę,
a czasami jego brak. Potencjały o długiej latencji związane
z wydarzeniem są bardzo
neuropsychologicznych.
czułym
testem
zaburzeń
Key words: neurophysiologic studies, evoked potentials (EP), long latency event-related potentials (ERPs), P300 component,
TIA, cognitive functions
Słowa kluczowe: badania neuropsychologiczne, potencjały wywołane (PW), potencjały o długiej latencji związane
z wydarzeniem (ERPs), komponent P300, TIA, funkcje poznawcze
INTRODUCTION
P300 is an endogenous long-latency potential,
elicited by the complex of acoustic stimuli. It reflexes
the cognitive functions of memory, attention as well as
decision making . The problem of neuronal sources
location based on each wave component has not been
well-known yet. Nowadays, it is said there are
cortical/subcortical areas of both cerebral hemispheres
responsible for P300 complex production, which are:
central part of temporal lobe, hippocampus, temporalparietal junction, prefrontal area, inferior parietal lobe,
mesencephalon, thalamus as well as subcortical nuclei
[1].
P300 component appears, when applied to data
processing, controlled by the instruction and is an
expression of activity connected with attracting one’s
attention to the introduced task [2,3]. It can be registered
mostly within parietal leads by patients, which pay
attention and respond to stimulus in a way suggested by
investigator. P300 response is independent of physical
stimulus so it is rated among endogenous potentials.
P300 component presents the positive wave
characterized by the latency time of 250 to 600 ms [4]. It
is mainly registered by stimulating with visual or
acoustic stimuli. The recording is registered by means of
electrodes disposed within a head in accordance with 1020 system recommended by International Society for
Clinical Neurophysiology. Determination of correlation
between P300 potential parameters changes and the
specific diseases causing the cognitive functions
disorders can be achieved taking into consideration the
standards as well as the factors affecting the result.
The biological factors are following: age, sex, body
temperature, extent of concentration, extent of difficulty
with the stimulus distinguishing from the background as
well as drugs administration. Among technical factors
the significant are: sort of stimulation, physical
properties of distinguished stimulus, the probability of
distinguish stimulus appearance. The variations of
amplitude values as well as the latency of registered
P300 complex were noticed in case of patients suffering
from neurological and psychical disorders: parkin-
sonism, multiple sclerosis, headaches, epilepsy,
schizophrenia, dementia syndromes – atherosclerotic,
posttraumatic (OUN) as well as multi-infract dementia
[2, 5, 6, 7, 8].
The following purposes are introduced:
1. Evaluation of latency and P300 potential amplitude
value in patients after TIA and within the control
group.
2. Evaluation
of
interrelationship
between
neuropsychological tests and result of P300 potential.
3. Evaluation of the influence of cerebral ischaemia on
P300 component – its presence and possible
deviations.
4. Demonstration of correlation between the latency
and the age.
MATERIALS AND METHODS
Patients subjected to examination were divided into
two groups: first – 10 diseased after TIA, the group
consisted of 6 men (range: 49-78 years) and 4 women
(range: 40-80 years). The preliminary auditory threshold
analysis of each patient was performed. The transient
cerebral ischaemia attack that had taken place in the past
was recognized in case of each person. The shortest time
interval between the attack and examination amounted to
8 days – the longest time: 15. The patients did not reveal
neurological disorders within the course of examination.
All of them recognized the stimulus. The control group
consisted of 10 young, health volunteers, 6 women and 4
men within the age range of 18-25 year old (mean age:
23.4). Each volunteer of comparative group revealed a
comparable intelligence level, did not disclose
inattention or lack of comprehension, what was
confirmed by neuropsychological tests. In order to
register P300 endogenous potential, the examinations of
auditory-evoked potential were carried out. The
examined person was subjected to two different sorts of
acoustic stimuli characterized by various frequencies.
The high tone frequencies of 1000 Hz appeared
frequently in contrast to the low tone characterized by
Endogenous cognitive potential P300 in TIA patients
33
latencja
subjected to statistical analysis.
frequency of 2000 Hz. The stimuli of 2000 Hz occurred
randomly and made up only 20% of frequent stimuli.
RESULTS
The stimulus duration amounted to 50 ms, intervals
between consecutive impulse – 1 second and the sound
The results of neuropsychological tests as well as the
volume – 75 dB. The filter value of low frequency
registered parameters of endogenous auditory-evoked
amounted 0,1 Hz, high frequency – 50 Hz. The notch
potential are presented below.
filter was used. The patient was to pay attention to and
count the noticed, rarely occurring stimuli (distinguished
1. Neuropsychological tests
from the background). The examination was carried out
Each participant of both control and study group
in a soundproofed room, comfort zone. The record was
was subjected to neuropsychological tests. The results
registered by means of four electrodes. Fz, Cz, Pz, O1
of Token Tests of health persons (control group)
electrodes were connected to the A1 reference electrode,
revealed the correct understanding of verbal
located at the left ear lobe. The electrodes located on the
statements, ability of concentration and memorizing
head were localized within the central sulcus: Fz in the
(Each achieved result of 39/39 points). The results of
frontal region, Cz in the central region, Pz in the parietal
the Test of Attention confirmed the correctness of
region. The eye movement was monitored by means of
cognitive processes within the control group.
O1 electrode, located below the left eye, in order to
The Token Test results of patients after TIA did
eliminate the artifacts of excessive motions. The
not reveal the significant cognitive disorders,
impedance of all electrodes (passive, active, reference)
however, it needs to be mentioned that the mean value
was lower than 4Ω. The locations of electrodes are
of achieved points within the study group was
consistent with 10-20 system recommended by the
decreased with reference to the control group. The
International Society for Clinical Neurophysiology
execution of directives required more attention as well
(IFCN). The value of P300 potential was estimated: the
as sustained thought (mean value 37.2/39 points).
latency as well as the amplitude.
Results of the Test of Attention were also
The latency was evaluated by means of extrapolation
decreased with reference to the control group. Time
of decreasing / increasing part of wave. The place of
needed for task execution was prolonged significantly
intersection of these lines assigns the latency. The results
(mean value of control group: 62 min, 112 min in the
were referred to the age norms. The amplitude was
study group). None of the participants executed all
assigned using a peak to peak principle. The research
tasks properly. The results of neuropsychological tests
method was based on IFCN recommendations [9].
show a decreased ability of correct understanding of
Before the stimulation, each participant of the
examinations was subjected to
350
the following tests:
Test
of
Attention
300
(Pąchalska, MacQueen,
250
1998) [10].
The
Token
Test,
200
Fz
elaborated
by
Cz
Pz
neurologists D. De Renzi
150
and L.A. Vingolo in 1962
100
[11].
The tests serve a purpose
50
of examination of ability to
0
verbal
statement
N1 kontrola
N1 TIA
P2 kontrola
P2 TIA
N2 kontrola
N2 TIA
P3 kontrola
P3 TIA
111,1
121,2
173,2
182,5
227,7
244,8
313,6
325,4
Fz
understanding, attention and
98,9
117,3
162,2
178,6
207,8
231
304,6
324,3
Cz
91,4
114,6
165,3
176,2
205
232
306,3
329,7
Pz
concentration to evaluate if
załamki
the participant understands
Fig. 1. Mean latency values of particular endogenous potential complexes within the control
the directive and is able to
and studygroup
focus his attention on
Ryc. 1. Wartości średnie latencji poszczególnych załamków potencjałów endogennych
w grupie kontrolnej i badanej
examination. The results were
34
verbal statements, attention, concentration and
memory in case of patients after TIA, which is also
reflected in P300 potential.
2.The evaluation of P300 potential
The P300 potential was not noticed (in one lead) in
two cases within the control group. The greatest
values of latency were registered from central sulcus:
(Fz) in the frontal region. The latency from parietal
region (Cz) and occiput region (Pz) revealed mostly
similar values. The mean value of N1 complex
latency, within the control group, amounted to 100.4
ms, what testifies to correct stimulus recognition. P2
wave appeared after the mean latency time of 166.9
ms. N2 complex revealed the mean latency value of
213.5 ms. The endogenous response – P300 potential
– had its place after the latency time of 308.3 ms. The
latencies of the particular complexes are included
within the range of norm determined for specific age
group, what testifies to correct cognitive functions of
health participants. The endogenous potential was no
achieved in case of two patients after TIA. One of
them revealed N1 complex, despite the fact the patient
heard and recognized the stimulus. The further
diagnostics of auditory-evoked brain stem potentials
was suggested in order to evaluate the auditory
pathway. The latency mean value of N1 complex
amounted to 117.7 ms and was significantly
statistically greater with reference to the control group
in Pz lead only, by the lowest confidence level of p≤
0,05. Mean latency values of all components within
the group of patients after TIA were slightly increased
with reference to this age group (growth of latency
connected with the age). The results of latency show
the correct functions of cognitive processes within the
group of patients after TIA (fig. 1).
The results revealed decrease of P300 potential
according to patients after TIA with reference to the
control group, what was closely connected with the
results of neuropsychological tests (fig. 2).
The statistical analysis included the calculation of
arithmetic mean as well as standard deviation. The
confidence level was calculated by means of t-Student
test. The following table presents the statistical analysis
of the achieved results.
Table I. Statistical analysis of parameters values of
endogenous potential
Tabela I. Analiza statystyczna wartości parametrów potencjałów endogennych
P300
Fz (mean value) Cz (mean value) Pz (mean value)
Parameter Control TIA
Control TIA
Control TIA
N1
111.1
121.25 99..8
117.33 91.4*
111.66*
latency[ms]
178.62* 165.3
P2 latency 173.22 182.57 162.2*
176.25
[ms]
N2 latency 227.7* 244.85* 207.8*** 231*** 205*** 236.37***
[ms]
325.42 304.6
324.37 306.4** 329.75**
latency P3 313.6
[ms]
N1-P2
8.75
9.08
14.88
10.97
11.01
9.47
Amplitude
[µV]
N2-P3
13.07** 8.38** 18.06** 10.1** 19.9** 13.65**
Amplitude
[µV]
(confidence level * - alfa=0.05, ** - alfa=0.01, ***-alfa=0.001)
DISCUSSION
wartości średnie amplitud
P. Calton, who discovered brain's electrical activity
observed as oscillations of the galvanometer needle in
1895 was one of the first
researchers considering a
25
problem
of
bioelectric
activity
of
brain.
In
Poland, at
20
the turn of the XIX and XX
century the issue of cerebral
15
cortex response for external
Fz
Cz
Pz
visual,
acoustic
and
10
somatosensory stimulus was
taken into consideration by
5
Napoleon Cybulski [12]. In
1965 Sutton described the
0
positive wave afterwards
N1-P2 kontrola
N1-P2 TIA
N2-P3 kontrola
N2-P3 TIA
8,75
9,08
13,07
8,3
Fz
featured by P300 potential
14,88
10,9
18,06
10,1
Cz
11,01
9,4
19,9
13,6
Pz
[4]. The variations of
Odprowadzenie
amplitude as well as the
Fig. 2. Mean amplitude lead values within the control and study group
latency values of P300
Ryc. 2. Wartości średnie amplitud odprowadzeń w grupie kontrolnej oraz badanej
Endogenous cognitive potential P300 in TIA patients
complex are usually registered. Barret noticed the
amplitudes reduction after brain injuries, ininsomnia,
various stupefactions and alcoholism [2].
So far, the influence of cerebral circulation on P300
potential has not been discovered. Mochizuki, Oishi and
Takasu [1,13] carried out examinations concerning the
connection of P300 component and the regional cerebral
blood circulation. The negative correlation between
P300 component and blood circulation within cerebral
cortex as well as thalamus was noticed. Kawamura et al.
[14] confirmed that the blood circulation within putamen
and thalamus is significantly decreased after multiply
brain infarction and in the course of mild dementia.
Thalamus equipped with numerous nerve fibres is
connected with the cerebral cortex, limbic system and
nuclei. That is why the decrease of blood circulation
within this structure can be connected with cognitive
dysfunction. Sakai et al. [15] investigated PET compared
to P300 in various neurological dysfunctions and stated
that the blood flow in the right parietal lobe, bilateral
thalamus and temporal lobes is related to the
prolongation of P300 latency. Tachibana et al [16]
reported the significant negative correlation between the
P300 latency and cerebral blood flow in examinations
using 133Xe inhalation in multiple cerebral infarction.
Other neurological diseases like Alzheimer’s Disease
[17], alcoholism [18], mild brain injury [19] may
influence P300 latency. Goodin et al. [20] compared
differences between the results of P300 potential
parameters based on examinations of patient suffering
from cortical/subcortical dementia. An example of
cortical dementia is presented by Alzheimer's disease,
subcortical dementia – parkinsonism and Huntington’s
disease. Different results allow differentiation of
diseases of cortical and subcortical regions on the basis
of extent of the latency deviation.
Goodin et al.[19] stated that the age of the examined
person presents another factor evoking the changes of
P300 parameters, especially the latency. Brown et al.
[21] proved the breaking point of the relation of the
linear dependence of latency and the age is at the age of
45. In accordance with Gordon et al. [22] the breaking
point apperas at the age of 63, according to Homberg
[23] at the age of 50. The examinations were carried out
based on the latency variation [2].
The consistent results of examinations of the above
authors proved that the latency extension for older
persons is twice as big as for the young.
In the present study the control group consisted of
persons aged 18 to 25 years. The latency has not
35
changed significantly within this age group. Another
group consisted of patients after TIA (age: 40-80). The
deviations of P300 potential of the young were not as
big as the values achieved in case of older persons.
The P300 potential was not noticed in case of the two
oldest persons. It confirms the correlation between the
latency extension and the age. The results introduced
in the present research work proved the decrease of
P300 complex amplitude in case of the diseased after
TIA. Goodin [19] notices similar features in patients
suffering from dementia.
CONCLUSIONS
The correlation between P300 potential latency
and the age was noticed. The latency deviation was
more significant in case of older persons in
comparison with young, healthy participants of the
examination. The significant decrease of P300
potential amplitude in case of the diseased after TIA
was registered. The variations of the potential
parameters may determine the cognitive functions
disorders. The correlation between neuropsychological
tests results and P300 potential parameters was
registered. The significant problems concerning the
tests were noticed in persons without P300 potential.
The results confirmed the cognitive processes
disorders: decrease of attention, concentration and
memory. The examinations of long-latency auditory
potential can be useful in evaluation of cognitive
functions disorders. The recurrent TIA incidents
change the values of P300 potential (early after
attack), evoke the latency and amplitude deviations or
even eliminate the potential. The changes of P300
potential parameters take place, despite the lack of
significant disorders of cognitive functions in case of
patients after TIA, what testifies to sensitivity of the
examination.
The future of endogenous potentials examinations
connected with cognitive function requires the
comprehensive approach and new methods of
stimulation using linguistic functions, which
contributes to cognition of the nervous system activity
in normal as well as pathological cases.
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Małgorzata Łukowicz
UMK w Toruniu
Collegium Medicum im. Ludwika Rydygiera
Katedra i Zakład Laseroterapii i Fizjoterapii
ul. Marii Skłodowskiej-Curie 9
85-094 Bydgoszcz
tel. 752 585-34-85
Magdalena Mackiewicz-Milewska1, Sabina Lach-Inszczak1, Magdalena Kuligowska-Prusińska2, Wojciech Hagner1,
Grażyna Odrowąż-Sypniewska2
NEUROGENIC HETEROTOPIC OSSIFICATION
NEUROGENNE SKOSTNIENIA POZASZKIELETOWE
1
Chair and Clinic of Rehabilitaion Nicolaus Copernicus University in Toruń,
Head: prof. dr. hab. Wojciech Hagner
2
Chair and Departament of Laboratory Medicine Nicolaus Copernicus University in Toruń,
Head: prof. dr. hab. Grażyna Odrowąż-Sypniewska
Summary
Heterotopic ossification is the formation of osseous
masses in the soft tissues where it does not normally occur.
The aetiology may be posttraumatic, neurogenic or genetic.
Neurogenic heterotopic ossification is generally
associated with brain and spinal cord injury, intracerebral
haematoma.
We examined 61 patients with heterotopic ossification
who were admitted to the rehabilitation unit between 2007
and 2010.
The diagnosis was confirmed by physical examination
(movement restriction in the joints), increased alkaline
phosphatase and X-ray. 36 patients were diagnosed with active
process of heterotopic ossification creation in average 5,.
months from injury.
Among the most common, there were hip, knee and
quadriceps muscles localization. Multijoints localization was
observed in half of the patients. Difficulty in diagnosing
neurogenic heterotopic ossification is caused by clinical
problems such as rehabilitation or nursing care hindrance.
Streszczenie
Skostnienia pozaszkieletowe polegają na tworzeniu
dodatkowej tkanki kostnej w miejscach, w których
fizjologicznie ona nie występuje. Przyczyną powstawania
skostnień mogą być urazy, uszkodzenie układu nerwowego
lub mogą mieć podłoże genetyczne. Neurogenne skostnienia
pozaszkieletowe występują najczęściej po urazach
czaszkowo-mózgowych, krwawieniach śródczaszkowych czy
po urazach kręgosłupa.
W latach 2007-2010 hospitalizowano 61 pacjentów
w średnim wieku 33 lata z obecnością skostnień
pozaszkieletowych. Rozpoznania dokonano na podstawie
badania przedmiotowego (ograniczenie ruchomości w sta-
wach), obrazu radiologicznego oraz podwyższonej
aktywności fosfatazy alkalicznej całkowitej. U 36 chorych
stwierdzono występowanie aktywnego procesu tworzenia
skostnień pozaszkieletowych w średnim czasie po urazie 5,4
miesiąca. Najczęściej znaleziona przez nas lokalizacja to
stawy biodrowe, kolanowe, okolica mięśni czworogłowych.
U połowy pacjentów występowała lokalizacja wielostawowa.
Neurogenne skostnienia pozaszkieletowe stanowią duży
problem kliniczny z powodu trudności w ich rozpoznaniu
w tej grupie chorych. Ponadto utrudniają rehabilitację
i pielęgnację chorych po ciężkich uszkodzeniach rdzenia
kręgowego i mózgu.
Key words: heterotopic ossification, brain injury, spinal cord injury
Słowa kluczowe: skostnienia pozaszkieletowe, urazy czaszkowo-mózgowe, urazy kręgosłupa
38
Magdalena Mackiewicz-Milewska et al.
INTRODUCTION
Heterotopic ossification is the formation of osseous
masses in the soft tissues where it does not normally
occur.[1, 2] The aetiology may be posttraumatic,
neurogenic or genetic [3].
Post traumatic heterotopic ossification is associated
with fractures, muscle injuries, burns and surgical
intervention, and particularly joint replacement. It may
affect 43-90% of patients following total hip
replacement [3, 4, 5]. Neurogenic heterotopic
ossification follows mostly brain injury [7] and spine
trauma [5, 9, 10] Less often it can be caused by
ischaemic
episodes,
subarachnoid
bleeding,
malignancy, Guillain-Barre syndrome, encephalitis or
meningitis.[1, 2, 4, 5]. Genetic causes are rare and
include progressive osseous fibrodysplasia, [11]
progressive osseous heteroplasty and Albright’s
disease [4].
Development of heterotopic ossification can be
accompanied by swelling, redness and heat around the
joint. Inflammatory markers and alkaline phosphatase
may be raised [2, 4, 12].
Heterotopic ossification may cause restriction in
movements of joints and occasionally severe stiffness.
They are causes of rehabilitation process hindrance.
The hip, knee, elbow and shoulder joint are most
commonly affected.[2, 3, 13].
PATIENTS AND METHODS
Between 2007 and 2010, we identified 61 patients
with HO. These patients were admitted to the
Rehabilitation Department of University Hospital in
Bydgoszcz, Poland. Mean age was 33 (from 15 to 63).
Authors accepted the following reference ranges for
alkaline phosphatase activity:
- 0-12 years old 1-500 U/l,
- adults 40-150 U/l.
Patients hospitalized with different kind of injuries
were characterized in Table I.
Patients with HO and spine injury were
characterized in Table II.
5 patients had both spine and brain injury. All
patients were examined; authors observed swelling,
redness and heat around the joint. In patients with
restricted or painful movements of joints, X rays were
performed. Alkaline phosphatise was measured in the
serum. CT evaluation of heterotopic bone was
performed in patients with positive results.
The activity of enzyme was analysed by the
Architect
ci8200.
Authors
established
the
recommended upper limit at 150 U/l.
Table I. Injuries and patients characteristic
Tabela I. Charakterystyka pacjentów ze względu na przebyte
schorzenie
Brain
Spine
Anoxemic Haemorrhagic Ischaemic
injury
injury
brain damage
stoke
stroke
Uraz
Uraz
after cardiac
Udar
Udar
czaszkowo- kręgosłupa
arrest
krwotoczny niedokrwienny
mózgowy
Anoksemiczne
uszkodzenie
mózgu po NZ
Number
33
21
7
5
0
of
patients
Liczba
pacjentów
Table II. Spine injury and HO patients characteristic
Tabela II. Charakterystyka pacjentów z HO i urazem
kręgosłupa
Cervical spine
injury
Uraz kręgosłupa
odc. szyjnego
14
Number of
patients
Liczba
pacjentów
Thoracic spine
injury
Uraz kręgosłupa
odc. piersiowy
6
Lumbar-sacral
spine injury
Uraz kręgosłupa
odc. L-S
1
RESULTS
Among the patients there were 49 men and 12
women.
The active phase of HO creation has been
diagnosed in 25 patients. There were 36 patients with
HO diagnosed before the hospitalization. In the first
group we usually observed increased of alkaline
phosphatase activity, swelling and redness around the
affected joint. X rays were performed in all patients.
Movement restrictions were usually difficult to
evaluate because of spasticity.
HO localization is presented in Table IV.
30 patients had multijoints HO and it most
commonly affected both hips.
33 patients had multijoints type of HO and 28 monojoint type. This correlation is presented in Fig. 1.
Table III. Mean alkaline phosphatase activity in serum
Tabela III. Średnia wartość fosfatazy alkalicznej w surowicy
Mean alkaline phosphatase activity in
active phase of HO patients
Wartość ALP u pacjentów ze
skostnieniami w fazie aktywnej [U/l]
262 ± 26
Mean alkaline phosphatase activity in
patients with HO made earlier
Wartość ALP u pacjentów ze
skostnieniami dawniej dokonanymi
[U/l]
171 ± 24
p<0,05
Neurogenic heterotopic ossification
Table IV. HO localization in examined group of patients
Tabela IV. Lokalizacja skostnień pozaszkieletowych w badanej grupie
HO
Hip
locakization Staw
Lokalizacja biodrowy
skostnień
Liczba
Number
16
Both
Knee
Elbow Shoulder Quadriceps Multijoints
hips
Staw
Staw
Staw
muscle
Okolica
Oba
kolanowy łokciowy barkowy
Mięsień
kilku
stawy
czworogłowy stawów
biodrowe
24
4
2
2
7
9
39
symptoms like swelling and redness can be dismissed
with deep vein thrombosis which increases the HO risk
[7, 8].
The most frequent place to create the HO were hip,
knee, elbow and shoulder (Figure 2, 3, 4). These
localizations are also present in literature [15].
Fig. 1. HO localization analysis
Ryc. 1. Analiza występowania HO
Among patients with active phase of HO creation,
the mean time from the injury to diagnosis was 5.4
months (from 1 to 18 months). In patients diagnosed
before the admission to the rehabilitation unit, the
authors were not able to established the mean time of
HO creation.
Fig. 2. Both hip HO in X ray
Ryc. 2. Zdjęcie radiologiczne skostnień pozaszkieletowych
stawów biodrowych
DISCUSSION
Neurogenic heterotopic ossification follows mostly
brain injury, spine trauma, ischaemic episodes,
subarachnoid bleeding, malignancy or encephalitis or
meningitis [2].
HO frequency after severe brain injury is between
11 and 73% [6], while after spine trauma 16-78% [10].
The occurance of heterotopic ossification after other
kinds of brain injuries is more rare. Functional
disorders are diagnosed in around 10-20% of patients
with HO [6,7].
Authors in their research estimated mean time of
HO creation which was 5.4 months. We also observed
this process from 1 to 18 months from the injury. E.
Vlasta determined mean time to HO occurance as 3
months from brain damages [1], while it is from 4 to
12 weeks according to J. Johns’a [4]. Filin in his
research examined 86 patients after severe brain injury
and observed HO creation from 2 weeks to 4 months
[14]. K. Chua observed this process after 18 months
from a stroke [7]. This discrepancy may be explained
by problems with diagnosis connected with increased
muscle tone affecting joint examination and that the
patients are unable to complain of symptoms. The
Fig. 3. Elbow HO in X ray
Ryc. 3. Zdjęcie radiologiczne skostnień pozaszkieletowych
w obrębie stawu łokciowego prawego
Fig. 4. Both hip heterotopic ossification in CT 3D
Ryc. 4. TK 3D skostnień pozaszkieletowych w obrębie
stawów biodrowych
40
Magdalena Mackiewicz-Milewska et al.
The active phase coincided with intensive
rehabilitation process. The connection with
kinesiotherapy was mentioned by Chan [7].
Experimental
studies
in
rabbits
showed
development of heterotopic ossification in previously
immobilised limbs 2-5 weeks after passive exercises
had started [16] although the dominated aetiology in
this case was rather traumatic than neurogenic. Iour
emphasized that there is a connection between
spasticity, improper exercises and HO creation [15].
Therefore, the development may be related to the
awkward movement of limbs with increased muscle
tone rather than the brain injury itself. However, there
also have been reports that early physiotherapy and
mobilisation may decrease the development of
heterotopic ossification [12,16]. The intensive passive
exercises are not recommended during the active HO
phase [1].
The underlying pathology of neurogenic
heterotopic ossification remains unknown. It is thought
that mesenchymal cells and osteoblasts play a crucial
role [7,11,12]. Unknown factors involved in the
cascade may include various systemic or pancreatic
hormones [11].
Therefore, the development may be related to the
awkward movement of limbs with increased muscle
tone rather than the brain injury itself. However, there
have also been reports that immobilisation, vegetative
state, inflammation, may decrease the development of
heterotopic ossification [11,12,17, 18].
The alkaline phosphatase activity is one of the HO
biochemical markers, while the most important one is
osseous isoenzyme [2]. Authors marked only alkaline
phosphatase activity, what is the research restriction.
Clinical examination and anamnesis excluded the liver
isoenzym influence. Authors observed increased
alkaline phosphatase activity in active HO phase. The
alkaline phosphatase activity was statistically higher in
HO patients than in another group of patients.
CONCLUSIONS
1. The accurate examination and alkaline phosphatase
monitoring are the main factors which allow an
early heterotopic ossification diagnosis after
nervous system injuries.
2. The heterotopic ossification may hinder the
rehabilitation process and nursing care.
3. The heterotopic ossification diagnosis may be
missed because of pain sensitivity disorders and
spasticity.
REFERENCES
1. Vlasta E. Hajek: Heterotopic ossification in hemiplegia
following stroke Arch Phys Med Reabil 1987, 68, 313314
2. Trentz Oana, A. Handschin, L. Bestmann, S. Hoerstrup:
Influence of brain injury on early posttraumatic bone
metabolism. Crit Care medicine 2005 ; 32(2) 399-406
3. T A. Balboni, R. Gobezie, H.: Mamon heterotopic
ossification : pathophysiology, clinical feathers and the
role of radiotherapy for prophylaxis International Journal
of
radiation
aOncology,
Biology,
Physics
2006;65,(5)1289-1299.
4. J. Johns, D. X Cifu, P.r. Jolles, M j.Fratkin: Impact of
clinically significant heterotopic ossification on
functional outcome after traumatic brain injury J Head
Trauma Rehabil. 1999;14(3)269-276
5. N. Namazi, K. Mozaffarian: Leothyroxin inhibits
heterotopic ossification: an experimental study in rabbits
J.Trauma 2008, 65,4,849-51.
6. L. Lau Simonensen, S. Sonne-Holm, M. Kraseninnikoff,
A. Engberg: Symptomatic heterotopic ossification after
very sever traumatic brain injury in 114 patients.
Incidence and risk factors. Int.J.Care Injured
2007,38;1146-1150.
7. K.G. Chua, K.H. Kong: Acquired heterotopic ossification
in the settings of cerebral anoxia and alternative therapy:
two cases brain Injury , 2003; 17, (6)535-544.
8. C. Riklin, M. Baumberger, L. Wick, D. Michel et all.:
Deep vein thrombosis and heterotopic ossification an
spinal cord injury: a 3 year experience at the Swiss
Paraplegic Center Nottwil Spinal Cord 2003, 41, 192198.
9. J. Andermahr, A. Elsner, A. Brings, T. Hensler, H.
Gerbershagen, A. Jubel: Reduced collagen degradation in
polytraumas with traumatic brain injuryncauses enhanced
osteogenesis. Journal of Neurotrauma, 2006, 23,5:708720.
10. K. Banovac. JM. Williams, LD Patrick, YM Haniff:
Preventio of heterotopic ossification after spinal cord
injury with indomthacin. Spinal Cord 2001,39; 370-374.
11. G. Kluger, A. Kochs, H. Holthausen: Heterotopic
ossification in childhood and adolescences. Journal of
Child neurology 2000,15,;406-413.
12. S.J. Hudson, S.J. Brett hetetopic ossification-a long term
consequence of prolonged immobility. Crit.Care 2006,
10,6;174-179.
13. E. Malamed, D. Robinson, N. Halperin and all.: Brain
injury-related heterotopic bone formation: treatment
strategy and results. Am.J Phys med Rebil, 2002, 81, 99),
670-674.
14. A. Toffoli, O. Gautschi, S. Frey, L. Filguleira, R.
Zellweger: From brain to bone;evidence to the release of
Neurogenic heterotopic ossification
15.
16.
17.
18.
osteogenic humoral factors after traumatic brain injury.
Brain Injury 2008, 22(7-8);511-518.
J. Michelsson, W. Rauschining: Pathogenesis of
experimental heterotopic bone formation following
temporary forcible exercising of immoblised limbs.
Clincal Orthopedics, 1993,176;265-272.
A. Iour, L. Sazbon, M. Lotem: Relationship between
muscular tone, movement and periarticular new bone
formation in post comaunaware patients. Brain Injury
1996, 10;259-262.
C. Filin, H. Curalucci, A. Duocelle, J.M. Viton:
Paraosteoarthropathies neurogenes et traumatisme
cranien severe.Annales dr Readaptation et de Medicine
Physique 2002,45;517-520.
A.B. Taly, K.P. Nair, P.N. Jayakumar, D. Ravishankar et
all.: Neurogenic heterotopic ossification: a diagnostic and
therapeutic challenge in neurorehabilitation. Neurol.
India, 2001,49,1;37-40.
Research to the publication was financed by UMK nr
55/2009 grant.
Magdalena Mackiewicz-Milewska
Katedra i Klinika Rehabilitacji
ul. M. Skłodowska-Curie 9
85-094 Bydgoszcz
tel. 600785633
41
Lidia Sierpińska1, Anna Ksykiewicz-Dorota2, Rafał Gorczyca3
POLISH ADAPTATION OF PATIENT SATISFACTION
WITH NURSING CARE QUALITY QUESTIONNAIRE (PSNCQQ)
POLSKA ADAPTACJA KWESTIONARIUSZA OCENY POZIOMU SATYSFAKCJI PACJENTÓW
Z OPIEKI PIELĘGNIARSKIEJ (PSNCQQ)
1
No. 1 Military Hospital with Outpatient Department Independent Public Health Care Unit, Lublin
Commander: colonel dr n. med. Zbigniew Kędzierski
2
Chair and Department of Management in Nursing, Faculty of Nursing and Health Sciences,
Medical University, Lublin
Head: prof. dr hab. n. med. Anna Ksykiewicz-Dorota
3
Department of Public Health, Institute of Agricultural Medicine, Lublin
Head: prof. dr hab. n. med. Jerzy Zagórski
Summary
I n t r o d u c t i o n . Patient Satisfaction with Nursing
Care Quality Questionnaire (PSNCQQ) developed by
Laschinger et al. at the School of Nursing, University of
Western Ontario, Canada, is a standardized instrument
designed for the evaluation of the level of patient satisfaction
with nursing care.
T h e o b j e c t i v e of the study was adaptation of the
PSNCQQ to the Polish conditions, including its linguistic
and psychometric validation.
Material and methods.
After obtaining
consent from the authors of the original version, the linguistic
validation of the questionnaire was performed. The text of
the PSNCQQ was translated into Polish, and then the Polish
version of the questionnaire was translated back into English
in order to determine the compliance between the Polish
version of the instrument and the version applied in Canada.
The questionnaire was completed by a group of 85 patients
treated in 6 hospitals in the regions of Lublin, Warsaw and
Łódź. Psychometric validation covered the evaluation of the
reliability of the Polish version, its construct and predictive
validity. The results of analyses were compared with the
results obtained by the authors of validation studies
conducted by means of the original Canadian version of the
questionnaire.
R e s u l t s . A high degree of linguistic compliance
between the Polish and original versions and a good level of
understandability of the PSNCQQ items for Polish patients
were confirmed. The measure of reliability of the Polish
version was Cronbach’s alpha coefficient of 0.96, which
means a high reliability of the method.
C o n c l u s i o n s . The Polish version of the PSNCQQ
satisfies psychometric criteria from the aspect of reliability
and validity and may be applied for the evaluation of the level
of patient satisfaction with nursing care in hospital wards in
Poland.
Streszczenie
W s t ę p . Kwestionariusz Patient Satisfaction with
Nursing Care Quality Questionnaire (PSNCQQ) opracowany
przez Laschinger i jej zespół na Wydziale Pielęgniarskim
Uniwersytetu w Ontario w Kanadzie jest wystandaryzowanym narzędziem przeznaczonym do oceny poziomu
satysfakcji pacjenta z opieki pielęgniarskiej.
C e l e m b a d a ń była adaptacja PSNCQQ do
warunków polskich, obejmująca jego walidację językową
i psychometryczną.
M a t e r i a ł i m e t o d y . Po uzyskaniu zgody
autorów wersji oryginalnej, dokonano walidacji językowej
kwestionariusza. W jej ramach przetłumaczono tekst
PSNCQQ na język polski a następnie polska wersja
kwestionariusza została przetłumaczona z powrotem na język
44
Lidia Sierpińska et al.
angielski w celu określenia zgodności polskiej wersji
narzędzia
z
wersją
stosowaną
w
Kanadzie.
Kwestionariuszem zbadano grupę 85 pacjentów leczonych
w 6 szpitalach na terenie województw: lubelskiego,
mazowieckiego i łódzkiego. W ramach walidacji
psychometrycznej, oceniono rzetelność polskiej wersji, jej
trafność teoretyczną i prognostyczną. Porównano rezultaty
analiz z uzyskanymi przez autorów badań walidacyjnych
oryginalnej wersji kanadyjskiej.
W y n i k i . Wykazano wysoki stopień zbieżności
językowej wersji polskiej z oryginałem, oraz dobry poziom
zrozumiałości pytań PSNCQQ dla polskich pacjentów. Miarą
rzetelności polskiej wersji był współczynnik spójności
wewnętrznej alfa Cronbacha, który wynosił 0,96, co oznacza
wysoką rzetelność metody.
W n i o s k i . Polska wersja Kwestionariusza PSNCQQ
spełnia kryteria psychometryczne pod względem rzetelności i
trafności i może być stosowana do oceny poziomu satysfakcji
pacjentów z jakości opieki pielęgniarskiej wśród chorych
leczonych w krajowych oddziałach szpitalnych.
Key words: quality of care, PSNCQQ, patient satisfaction
Słowa kluczowe: jakość opieki, kwestionariusz PSNCQQ, satysfakcja pacjenta
INTRODUCTION
According to the recommendations of the World
Health Organization, systems for the provision of the
quality of health services were introduced in many
countries. The methods of implementation of these
systems and evaluation of the level of services and
patient satisfaction vary. It becomes necessary for the
nursing subsystem to determine authoritative criteria,
indicators and instruments for quality measurement,
because a nurse plays an important role in the
provision of the complex care of patients.
Patient satisfaction with nursing care depends on to
what extent the services provided and approach to
patients satisfy their expectations. The evaluation of
satisfaction with nursing care among patients and the
recognition of their demands are important in the
process of managing health care facilities. An
introduction of the quality management system in
health care institutions provides opportunities for the
improvement of services and satisfaction of clients’
demands. The above-mentioned goals may be achieved
by means of efficient methods, techniques and
instruments. An example of recognizing patients’
expectations by a nurse during hospitalization is the
examination of the level of patient satisfaction by
means of a questionnaire [1,2,3].
The review of instruments for the evaluation of the
level of patient satisfaction with nursing care indicates
that the PSNCQQ is an optimum instrument. The
questionnaire was applied for the studies in 14
hospitals, among 100 patients, in Ontario, Canada, in
2002. The results of the studies on satisfaction with
nursing care among patients qualified for the study by
means of random sampling conducted in various
hospitals were authoritative, and concerned satisfaction
with the quality of care received during hospitalization.
According to the authors of the instrument, the
results of the studies show the directions of
improvement of the quality of hospital care, provide
valuable conclusions with respect to the patient-nurse
relationship, and help to establish priorities in the area
of management of the quality of nursing care in a
hospital [4].
In Polish literature, no reports concerning the
application of the above-mentioned instrument were
found. Therefore, it became necessary to perform the
process of validation of the PSNCQQ.
The objective of the study was Polish adaptation of
the PSNCQQ to the needs of the evaluation of patient
satisfaction with nursing care in the wards of Polish
hospitals.
Polish adaptation of the questionnaire required its
linguistic and psychometric validation. The process of
linguistic validation was carried out according to the
international requirements [5]. In this process, special
attention was paid to the consistency of translation,
with simultaneous consideration of cultural specificity
when using some terms and expressions. Linguistic
validation started from obtaining a written consent
from the author of the instrument to use it. Then, the
original version of the instrument was translated into
Polish, and then back from Polish to English. Both
versions were compared and necessary corrections
made before designing the final version of the text.
The PSNCQQ contains 19 items pertaining to
individual criteria of nursing care. A patient evaluates
the level of his/her satisfaction with nursing care
according to a 5-degree Likert-type scale within each
criterion. The assessment of the level of care is as
Polish adaptation of patient satisfaction with nursing care quality questionnaire (PSNCQQ)
follows: excellent (5 points), very good (4 points),
good (3 points), satisfactory (2 points), and poor (1
point).
Psychometric validation of the questionnaire
covered the determination of its reliability and
construct and predictive validity. The results of the
analyses were compared with the results of validation
studies of the original version.
than the Polish population (p < 0.0001), their mean age
was 62.9±16.351. The large majority of respondents, as
many as 92%, were married, 3 were unmarried and 4 –
widowed (Tab. I).
Table I. Demographic characteristics of the population in the
study
Variables
n(%)
STATISTICAL ANALYSES
The collected research material was entered into the
computer, then data control and correction were carried
out. The calculations were performed by means of a
statistical package SPSS PL v12. T-Student test was
applied to compare the significance of the differences
between the results of the Canadian and Polish
versions. The methods and strategies applied for the
evaluation of reliability and validity of the
questionnaire were the same as those used by the
authors of validation studies of the original version.
The assessment of reliability consisted of
the
calculation of Cronbach’s alpha coefficient for internal
consistency and the analysis of Pearson correlation
coefficients between questionnaire items, and
correlation between individual items and the total
score. The confirmation of a single-factor character of
the questionnaire by the method of exploratory factor
analysis was used for verifying the construct validity
[6]. Predictive validity of the questionnaire was
evaluated by the method of multiple regression
analysis [7].
COURSE OF STUDY AND STUDY POPULATION
The Polish version of the PSNCQQ was used to
examine a group of 100 randomly selected patients
treated in 18 wards of various profiles in 6 hospitals in
the Regions of Lublin, Warsaw and Łódź, who
voluntarily expressed their consent to participate in the
study. Qualified responses were provided by 85
respondents. The study group covered 31 males
(36.5%), and 54 females (63.5%) (p < 0.05). The
structure of the Polish population by gender differed
from the validation structure of the Canadian
population, where the percentage contribution of both
genders was nearly equal: males – 46.9%, and females
- 54.1%. The mean age of the patients in the survey
was 55 – males were aged 57, while females - 53. The
difference in age between males and females was not
statistically significant. Canadian patients were older
45
Age A
Marital
status B
unmarried
married
widowed
Males
31 (36.5)
Mean
(SD)
56.8
(10,97)
Females
54
(63.5)
53.4
(9.45)
n(%)
n(%)
n(%)
2 (6.5)
28 (90.3)
1 (3.2)
1(1.9)
50(92.6)
3(5.6)
TOTAL
85
(100)
54.7
(10.10)
3 (3.5)
78 (91.8)
4 (4.7)
A
Evaluation of the difference between males and females based on
age: Mann-Whitney test; Z = -1.50; p = 0.14.
B
In the adapted questionnaire the category of ‘concubinate’ was not
included due to the slightly pejorative meaning of this category in
Polish society. Respondents possessing this category were qualified
as married.
RESULTS
In the analysis of items in the PSNCQQ
questionnaire the results for Polish and Canadian
populations were considered (Tab. II).
Table 2 presents the full version of individual items
in the questionnaire. Short verbal definitions of
individual items are in capital letters; while after a
colon, a word-for-word quotation of the question
directed to a respondent is given. The subsequent
columns show mean scores and standard deviations of
evaluations obtained in the population of Polish
patients and in the population in original Canadian
studies.
For the majority of items, mean scores of Polish
patients did not differ from the evaluations expressed
by patients in the original studies. With respect to 5
criteria, the evaluations by Polish patients were
significantly higher than in the original studies. These
were items 6, 9, 13, 14 and 16.
1
The difference between Polish and Canadian populations based on
age was evaluated by t-Student test. t = 4.56; df= 1053; p < 0.0001.
46
Table II. Individual items of the PSNCQ, mean scores and
standard deviations in Polish and Canadian
populations
Item
No.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
Contents
Polish
population
n = 85
Mean Score
(SD)
INFORMATION
YOU
WERE 3.9 (0.76)
GIVEN: How clear and complete the
nurses’ explanations about tests,
treatments, and what to expect were.
INSTRUCTIONS: How well nurses
4 (0.79)
explained how to prepare for
examinations and operations.
EASE
OF
GETTING
4 (1.04)
INFORMATION:
Willingness
of
nurses to answer your questions.
INFORMATION
GIVEN
BY 3.8 (0.74)
NURSES:
How
well
nurses
communicated with patients, families
and doctors.
INFORMING FAMILY OR FRIENDS: 3.6 (0.86)
How well the nurses kept them
informed about your condition and
needs.
INVOLVING FAMILY OR FRIENDS 4 (0.76)*
IN YOUR CARE: How much they
were allowed to help in your care.
CONCERN AND CARING BY 4.4 (0.69)
NURSES: Courtesy and respect you
were given; friendliness and kindness.
ATTENTION OF NURSES TO YOUR 4.2 (0.79)
CONDITION: How often nurses
checked on you and how well they kept
track of how you were doing.
RECOGNITION
OF
YOUR 3.7 (0.84)*
OPINIONS: How much nurses asked
you what you think is important and
give choices.
CONSIDERATION
OF
YOUR 3.9 (0.77)
NEEDS: Willingness of the nurses to be
flexibile in meeting your needs.
THE DAILY ROUTINE OF THE 3.8 (0.82)
NURSES: How well they adjusted their
schedules to your needs?
HELPFULNESS: Ability of the nurses 4.1 (0.76)
to make you comfortable and reassure
you.
NURISNG STAFF RESPONSE TO 4.3 (0.77)***
YOUR CALLS: How quick they were
to help.
SKILLS AND COMPETENCES OF 4.4 (0.62)***
NURSES: How well things were done,
like giving medicine and handling IVs.
COORDINATION OF CARE: The 3.9(1.08)
teamwork between nurses and other
hospital staff who took care of you.
RESTFUL
ATMOSPHERE 4.2 (0.91)***
PROVIDED BY NURSES: Amount of
peace and quiet.
PRIVACY: Provisions for your privacy
4 (0.77)
by nurses..
DISCHARGE INSTRUCTIONS: How 3.8 (0.82)
clearly and completely the nurses told
you what to do and what to expect
when you left the hospital.
COORDINATION OF CARE AFTER
3.5 (1.08)
DISCHARGE: Nurses’ efforts to
provide for your needs after you left the
hospital.
Canadian
population A
n = 970
Mean Score
(SD)
3.9 (0.99)
3.9 (1)
3.9 (1.04)
3.8 (1.05)
3.6 (1.1)
3.7 (1.02)
4.2 (1.1)
4 (1.07)
3.4 (1.17)
4 (1.11)
3.6 (1.12)
4 (1.11)
3.7 (1.14)
4(1.02)
3.9 (1.07)
3.7 (1.12)
3.9 (1.01)
3.8 (1.18)
3.6 (1.25)
Tab. III. Mean scores and standard deviations of patient
satisfaction indicators in Polish and Canadian
populations
Variable A
Polish
population
n = 85
Mean
SD
3.97
0.64
4.06
0.81
4.22
0.78
4.45
0.91
Canadian
population
n = 970
Mean
SD
3.81
0.89
4.04
1.02
4.06
1.02
4.30
1.08
PNSCQQ
Overall quality of care and
services
Overall quality of nursing
care in the ward
Would the hospital be
recommended to your
family and friends?
A
Mean results of studies of Canadian and Polish populations did not
significantly differ with respect to all 4 satisfaction indicators (The
results of own studies were compared with the results of the original
studies by means of t-Student test)
Table III presents the compilation of the results of
patient satisfaction measurement in own studies and
among the Canadian population. Mean level of
satisfaction with care were considered as measured by
the PSNCQQ, and the results of evaluation of 3 items
supplementing the questionnaire, and measuring
satisfaction with the following: (1) quality of care and
services provided during hospitalization in the ward,
(2) quality of nursing care, and (3) satisfaction
manifested by willingness for recommending the
services provided by an individual hospital to own
family and friends.
Satisfaction indicators obtained in both populations
were high and did not significantly differ statistically.
The level of patient satisfaction measured by the Polish
version of the PSNCQQ was 3.97, whereas among
Canadian patients examined by the original version of
the questionnaire this level was only slightly lower 3.81. The evaluations concerning the general quality of
care and services in both populations were nearly the
same – in the Polish population – 4.06, in the Canadian
population – 4.02. General quality of nursing care in
the ward was evaluated non-significantly higher by the
Polish than the Canadian patients (4.22 and 4.06,
respectively). In both populations, the question
concerning the willingness for recommending the
hospital to family and friends obtained relatively the
highest indicators (4.45 and 4.30, respectively).
A
Source: Laschinger H.S., McGillis Hall L., Pedersen Ch., Almost
J.: A psychometric analysis of the Patient Satisfaction with Nursing
Care Quality Questionnaire. Journal of Nursing Care Quality 2005;
20(30): 220 - 230 -Table 1, p. 224
The results of own studies with the original studies were preformed
by means of t-Student test.
* p < 0.05; *** p < 0.001.
RELIABILITY OF THE POLISH VERSION OF THE
PSNCQQ
The indicator of reliability of the questionnaire was
Cronbach’s alpha coefficient, which is a measure of its
internal consistency. In own studies, this coefficient
was 0.96 which evidenced a very high reliability of the
47
Polish version of the questionnaire. This coefficient
value was nearly identical with the value reported by
the authors of the PSNCQQ, which was 0.97 [5].
High consistency of the instrument is evidence that
the individual items ‘work well’ for the total score.
While measuring various manifestations of satisfaction
with nursing care, these items provide a stable, reliable
measure of this satisfaction as a general theoretical
construct. The analysis of the correlation between
individual items and the correlation between individual
items and the total score provide detailed information
concerning the values of individual items for the total
score (Tab. IV).
remaining items of the scale: 36% for the item 6, and
51% for the item 18. Reliability of the scale calculated
without the participation of the two items discussed
would also be slightly higher than that actually
obtained (column 4). However, the fact of a relatively
lower usefulness of the items 6 and 18, with respect to
their contribution to the total score, was not a sufficient
basis for their deletion. These items, similarly to other
items, although to a lower degree, positively correlated
with the total score; benefits resulting from their
deletion would be minimum, while the reduction of the
scale to 16 items would be a considerable discrepancy
from the original version.
Tab. IV. Summing up of statistics for items of the PSNCQQ
Table V. Correlation between questionnaire items and total
correlation, squared multiple correlation, and
values of Cronbach’s alpha if item deleted
No.of Mean MinimumMaximum RangeMaximum/ Variance
Items score
Minimum
19 3.970 3.476
4.405 0.929 1.267
0.062
of 19 0.569 0.231
0.773 0.542 3.335
0.019
Mean
score
items
Correlation
between
items
Mean scores of individual criteria were very similar
and remained within the range from 3.5 - 4.4.
Evaluations of each item by patients were consistent
with the direction assumed: from low towards high
satisfaction, and a lack of consistency was not noted
between evaluations of individual items. The items
mutually correlated with the moderate degree on
average — r = 0.57. All of them correlated positively
with each other, the lowest value was r = 0.23 (low
correlation) and the highest value — r = 0.77 (high
correlation).
Data in Table V provide further information
concerning the value of individual items from the
aspect of the contents measured by the whole scale.
A valuable item should participate in the contents
of the measured construct, but at the same time not
fully identify with this construct. It is therefore
anticipated that items in the scale will significantly and
positively correlate with its total score; however,
correlate not too high (correlation coefficients of the
values higher than 0.90, evidencing collinearity of the
variables are undesirable). Correlation coefficients
between individual items and the total score (Tab. III,
column 2) remained within the ranges from moderate
to high (from 0.43 – 0.84). Only the coefficients of two
items: 6 and 18, were relatively lower than the
remaining ones. These items also obtained lower
percentage values of variability shared with the
Item
No.
Corrected Item –
Total Correlation A
1
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
2
0.815
0.798
0.814
0.734
0.790
0.430
0.699
0.841
0.702
0.832
0.766
0.809
0.809
0.571
0.820
0.843
0.713
0.498
0.782
Squared
Multiple
Correlation
3
0.782
0.770
0.790
0.704
0.716
0.359
0.650
0.798
0.717
0.829
0.786
0.803
0.798
0.544
0.781
0.815
0.748
0.505
0.747
Cronbach’s
Alpha if Item
Deleted
4
0.958
0.958
0.958
0.959
0.958
0.963
0.960
0.958
0.959
0.958
0.959
0.958
0.958
0.961
0.958
0.957
0.959
0.962
0.959
A
For each item total correlation was calculated without participation
of this item.
CONSTRUCT VALIDITY
The authors of the original version analyzed the
results obtained by means of factor analysis by
performing both exploratory factor analysis and
confirmatory factor analysis in the structural equations
model. The results of exploratory factor analysis
among the Polish population, based on Kaiser’s2
criterion, provided an opportunity to consider two
factors (with eigenvalues of 11.46 and 1.04). However,
simultaneously, based on the scree plot, a single-factor
2
The starting point for factor analysis are single standardized
variables, with variance equal 1. The Kaiser criterion suggests the
extraction of only those factors, the explaining power of which is
greater than that of single variables, i.e. eigenvalues greater than 1.
The second factor, which, ultimately, was not retained, slightly
exceeded the critical eigenvalue [6].
48
model should have been chosen, which was finally
performed [6]. This one factor explained 60.3% of
variability of individual items. This was less than that
by the authors of the original version who reported
values from 75% - 89%.
PREDICTIVE VALIDITY
In order to measure this type of validity, the authors
of the questionnaire used three additional scales which
have been discussed in the previous sections of the
article. These variables were the probe of the degree to
which the measurement by the PSNCQQ allowed
foreseeing patients’ evaluations within other
dimensions of satisfaction with hospital services.
Multiple regression analysis was applied, considering
among the explanatory variables, apart from the
PSNCQQ result, potentially significant intervening
variables: age, gender, number of hospitalization days
(in the analysis of the Polish population – number of
hospitalizations), self-reported state of health at
admission to hospital (Tab. VI).
Table VI. Results of regression analysis for three models
considering, as response variables, three scales
of satisfaction with care and hospital services
Model of analysis
Response variable: General quality of
care and services
age, gender, number of hospitalization
days/number of hospitalizations, selfreported state of health at admission
PSNCQQ
Final model
Response variable: General quality of
nursing care in the ward
PSNCQQ
Final model
Response variable: Would the
hospital be recommended to family
and friends?
PSNCQQ
Final model
R2 x 100A
Polish
Canadian
population
population
0.087
0.680
0.708
0.017
0.640
0.657
0.071
0.566
0.586
0.016
0.731
0.746
0.097
0.247
0.312
0.018
0.552
0.570
Source: Laschinger H.S., McGillis Hall L., Pedersen Ch., Almost J.:
A psychometric analysis of the Patient Satisfaction with Nursing
Care Quality Questionnaire. Journal of Nursing Care Quality 2005;
20(30): 220 - 230 -Tab. 5, s. 227.
A
The formula R2 x 100 (where R2 is coefficient of determination)
informs, what percentage of response variability is the explained by
the model.
The PSNCQQ results in own studies explained
68% of total variability of evaluation of the quality of
care and services, i.e. to a degree similar to that in the
original studies (64%). Assessments concerning the
quality of nursing care in the ward participated in 57%
of their total variability, i.e. to the degree lower than in
the original studies (73%), however highly significant.
To the relatively lowest degree – 25% of total
variability of the assessments explained the willingness
of the examined patients to recommending the hospital
to family and friends – in Canadian studies this was
55%.
DISCUSSION
The studies conducted among the Polish population
revealed a considerable similarity of the majority of the
obtained results to the results of the Canadian
researchers. Mean scores of the majority of the
questionnaire items, and especially the mean total
score of the PSNCQQ and three additional satisfaction
indicators, were very similar in both populations,
despite geographical distance, cultural differences and
varied level of medical services provided.
Inter-cultural similarity of patients with respect to
their satisfaction with the contact with health services
is evidenced by the results of another survey carried
out among 4,000 respondents from 4 countries: United
States, United Kingdom, France and Spain. In this
survey, among other things, the respondents who used
health services in 2008 were asked whether their
experiences from these contacts were or had been of a
positive, negative or neutral character. Irrespectively of
the country, the respondents almost did not differ with
respect to the structure of evaluations. For example, the
percentages of positive/negative evaluations in the
above-mentioned countries were as follows: United
Kingdom — 48%/10%, USA — 47%/11%, France
47%/13%, Spain — 56%/13% [8].
A certain dissimilarity of the results obtained for
Polish patients with respect to predictive validity of the
PSNCQQ is noteworthy. Its result, to a significantly
lower degree, affected their willingness for
recommending the given facility to family and friends
than among Canadian patients. Possibly, this was due
to the more modest offers from which the patients have
to choose in Poland.
Significant differences were observed between the
examined Polish and Canadian populations with
respect to the structure by gender and age. As
previously mentioned, among the Polish patients there
were more females and fewer males than among the
Canadian patients, and they were younger than the
latter. Nevertheless, the similarity of the results of
analyses obtained in both populations allows the
presumption that the differences reported did not
significantly affect the results.
CONCLUSIONS
1. The Polish version of the PSNCQQ satisfies the
psychometric criteria with respect to reliability and
validity.
2. The indicators of reliability and validity in the
Polish version were similar to those obtained in
validation studies of the original Canadian version
of the questionnaire.
3. The Polish version of the PSNCQQ may be applied
for the evaluation of the level of patient satisfaction
with the quality of nursing care among patients
treated in Polish hospital wards.
REFERENCES
1. Blenkiron P., Hammil C.A.: What determines patients`
satisfaction with their mental health care and quality of
life? Postgraduate Medical Journal 2003; 79(932), 337 –
340.
2. Coulter A.: Can patients assess the quality of health care?
British Medical Journal 2006; 333, 1 – 2.
3. Davis B.A., Bush H.A.: Patient satisfaction of emergency
nursing care in the United States, Slovenia and Australia.
Journal of Nursing Care Quality 2003; 18(4), 267 – 274.
4. Laschinger H.S., McGillis Hall L., Pedersen Ch., Almost
J.: A psychometric analysis of the Patient Satisfaction
With Nursing Care Quality Questionnaire. Journal of
Nursing Care Quality 2005, Vol. 20, 30, 220 – 230.
49
5. Chassany O., Sangnier P., Marquis P.(i in.): Patient –
reported outcomes: The example of health – related
quality of life – A European guidance document for the
improved integration of health – related quality of life
assessment in the drug regulatory process. Drug
Information Journal 2002, 36, 209 – 238.
6. Wieczorkowska G., Wierzbiński J.: Statystyka. Analiza
badań
społecznych,
Wydawnictwo
Naukowe
SCHOLAR, Warszawa 2007.
7. Ferguson G.A., Takane Y.: Analiza statystyczna w
psychologii i pedagogice. PWN, Warszawa 1999
8. http://www.ehealthnews.eu/picis/1381-patientsatisfaction-with-healthcare
systems-do-differentfunding-models-lead-to-different-results).
1 Military Hospital with Outpatient Department
Independent Public Health Care Unit
Al. Racławickie 23
20-950 Lublin
phone.: 507-810 339, fax: 81 718 32 77
Ewa Smoleń1,2, Lucyna Gazdowicz1, Monika Wilusz1, Joanna Zacharska1, Małgorzata Gawlik3
THE SIGNIFICANCE OF NURSING INTERVIEW (NURSING ASSESSMENT)
IN MALIGNANT DISEASE PREVENTION
ZNACZENIE WYWIADU PIELĘGNIARSKIEGO
W PROFILAKTYCE CHORÓB NOWOTWOROWYCH
1
PWSZ im. Jana Grodka w Sanoku, Instytut Pielęgniarstwa. Dyrektor Instytutu Pielęgniarstwa
Head: dr n. med. Anna Bednarek
2
Uniwersytet Medyczny w Lublinie, Katedra i Zakład Zarządzania w Pielęgniarstwie
3
Oddział Kliniczny Kliniki Onkologii Szpitala Uniwersyteckiego w Krakowie
Summary
I n t r o d u c t i o n . Malignant diseases are the second
most frequent cause of death in Poland. According to the
official statistical data (GUS, 2010) 26% of all deaths were
due to cancer. Early detection of alarming symptoms based
on a nursing interview makes the diagnosis of cancer in its
early stage possible. Screening examinations concern large
populations and aim at decreasing mortality rate related to
malignant diseases. Early detection of worrying symptoms
gives a possibility of effective treatment leading to the
recovery from cancer in preclinical stage.
T h e o b j e c t i v e of this work was to evaluate the
significance of nursing interview (nursing assessment) when
diagnosing alarming symptoms as well as risk factors, which
may indicate possible threat of malignant disease in patients
visiting a medical specialist during the open days.
M a t e r i a l a n d m e t h o d s . A population of 101
respondents, who came for examinations during the open
days organised by the Specialist Hospital in Sanok,
comprised the study group.
R e s u l t s . According to respondents the main reasons
for them to participate in preventive examinations included:
easy access (42.0%), free access to examinations (40.5%),
and desire to undergo examinations and check their health
status (45.5%). Every third respondent had a family history
of cancer among their closest relatives (parents, siblings)
which meant significant hereditary-genetic risk. The most
frequent malignant diseases recorded among women included
breast and cervical cancer, whereas lung and larynx cancer
were the most frequent male malignancies.
C o n c l u s i o n s . Data recorded during nursing
interviews made it possible to single out symptom, which
may indicate the beginning of malignant disease. Therefore,
the group of patients with these clinical symptoms should
undergo further diagnostics and be referred to additional
screening examinations. The analysis of data indicated a need
for regular organisation of the open days aiming at early
detection of alarming changes in functioning of systems and
organs, which may signal the development of cancer in its
subclinical stage without any external symptoms.
Streszczenie
W s t ę p . W Polsce choroby nowotworowe stanowią
drugą w kolejności przyczynę zgonów. Przyjmuje się
(według danych GUS 2010), że 26% ogółu zgonów
spowodowana jest nowotworami. Wczesne wykrycie
niepokojących objawów choroby na podstawie wywiadu
pielęgniarskiego, pozwala na rozpoznanie choroby w fazie
niezaawansowanej. Przeprowadzanie badań przesiewowych
(screning) na dużej grupie osób ma na celu zmniejszenie
umieralności z powodu chorób nowotworowych. Wczesne
wykrycie niepokojących symptomów daje możliwość
52
Ewa Smoleń et al.
skutecznego leczenia choroby nowotworowej w stadium
przedklinicznym.
C e l e m p r a c y była ocena znaczenia wywiadu
pielęgniarskiego w rozpoznawaniu niepokojących objawów
oraz czynników ryzyka mogących wskazywać na zagrożenie
rozwojem chorób nowotworowych u osób korzystających
z wizyty u lekarza specjalisty w czasie dni otwartych.
M a t e r i a ł i m e t o d y . Badaniami objęto 101 osób,
które zgłosiły się na badania podczas dni otwartych
zorganizowanych przez Samodzielny Publiczny Zakład
Opieki Zdrowotnej Szpital Specjalistyczny w Sanoku.
W y n i k i . Łatwość dostępu (42,0%), bezpłatny dostęp
do badań (40,5%) oraz chęć wykonania badań i sprawdzenia
swojego stanu zdrowia (45,5%) to główne przyczyny
korzystania z badań profilaktycznych. U co trzeciego
badanego w pierwszym pokoleniu (rodzice, rodzeństwo)
wystąpiła choroba nowotworowa, co stanowi znaczne
obciążenie rodowodowo-dziedziczne. Najczęściej występującymi nowotworami u kobiet były: rak piersi i rak szyjki
macicy, a u mężczyzn rak płuc i rak krtani.
W n i o s k i . Dane uzyskane z zebranego wywiadu
pielęgniarskiego pozwoliły wyodrębnić objawy mogące
wskazywać na pierwsze symptomy rozwoju choroby
nowotworowej.
Z tego względu tę grupę osób z objawami klinicznymi
należy objąć dalszą diagnostyką i skierować na
specjalistyczne skriningowe badania dodatkowe. Analiza
badań wskazuje na potrzebę cyklicznego organizowania
przedsięwzięcia dni otwartych celem wczesnego wykrycia
niepokojących zmian w funkcjonowaniu układów
i narządów, mogących wskazywać na rozwój choroby
nowotworowej w stadium bezobjawowym – subklinicznym.
Key words: malignant diseases, nursing interview, prevention, risk factors
Słowa kluczowe: choroby nowotworowe, wywiad pielęgniarski, profilaktyka, czynniki ryzyka
INTRODUCTION
In Poland malignant diseases present a significant
cause of mortality among both men and women. The
number of deaths because of cancer and malignant
tumours increases constantly. According to the data
from 2001 for Poland, almost every fourth man
(26.4%) and every fifth woman (22.8%) died of cancer
[2, 8, 14]. Old people comprise the majority of this
group since the risk of developing malignant disease as
well as poor prognosis significantly increase after the
age of 50.
Time, during which cancer develops, from the
moment of the exposure to an adverse factor to the
onset of symptoms and finally death, depends on the
type of malignancy, its localisation, the type of adverse
factor, and time of exposure. Multiple studies and
observations confirm that early detection of disturbing
symptoms, which may indicate developing cancer, is
very important as far as early diagnostics and adequate
effective therapeutic actions are concerned [6, 12, 15].
A nursing interview (nursing assessment) is one of
the methods of recording information about patients
during the diagnostic and therapeutic processes since it
provides data about patient’s bio-psycho-social status.
As a result a nursing diagnosis is given, which
becomes the basis for planning and providing care for a
patient. Information gathered during the interview
(assessment) is used by clinicians during the process of
disease recognition and diagnosis [7].
An interview is one of the assessment methods in
epidemiological studies, applied alone or before a
physical examination performed by a nurse or a
clinician [4]. During this interview special attention
should be paid to those features and symptoms, which
increase the risk of cancer development or accompany
the disease. It is helpful when determining the
diagnosis and patient prognosis. The nurse must be
familiar with the symptoms, which are major and
typical for carcinogenic processes. The assessment
concerns the status and functioning of particular
systems and organs and the nurse is able to distinguish
symptoms suggesting the progression of malignant
disease. These include: difficulties with swallowing,
the sense of being full in upper abdomen, dyspeptic
symptoms, fresh blood in stool, defecation disorders,
long-lasting hoarseness, haematuria, abnormal
bleeding from the reproductive organs, haemoptysis,
persistent cough or its changing character, appearance
of alarming nodules, discoloration and ulceration,
enlarged lymph nodes, pain of unexplained aetiology,
weakness and weight loss [6, 7, 9].
Almost 70% of all malignant tumours is determined
by harmful conditions related to one’s lifestyle, dietary
habits, physical, environmental , and professional
factors [2, 16].
The nursing interview (assessment) is of a great
significance when worrying symptoms are recognised
as well as risk factors, which may indicate the threat of
cancer development in patients attending specialist
appointments.
The significance of nursing interview (nursing assessment) in malignant disease prevention
The study was performed among Sanok District
inhabitants in 2009 during the open days organised by
the Specialist Hospital in Sanok. It included 101
patients attending free specialist appointments in the
following fields: cardiology, urology, neurology,
surgery, otolaryngology, ophthalmology, nephrology,
and radiology.
Selected risk factors in malignant diseases were
assessed using a questionnaire developed by the
authors. The questionnaire was based on current
standards and methods regarding data collection when
describing bio-psycho-social status of subjects.
All interviews were conducted in similar conditions
i.e. at the same time during one day. In order to
participate in the study, every patient attending a
specialist appointment was asked to express his/ her
consent for the nursing interview. Every respondent
was informed that the survey was anonymous. The
nursing assessment included the questionnaire and the
measurement of basic life functions i.e. blood pressure,
heart rate, and glucose concentration in blood. All
participants had their appointments refunded by the
National Health Fund (NFZ).
RESULTS
The majority of respondents were women (70.3%),
whereas men comprised only 29.7% of the study
population i.e. individuals attending specialist
appointments during the open day (Fig. 1).
53
vocational, university, and primary education
comprised 23.8%, 21.8%, and 9.9%, respectively
(Fig. 2).
4,1%
6,8%
18,8%
70,3%
panna/kawaler
mężatka/żonaty
wdowa / wdowiec
rozwiedziona / rozwiedziony
Fig. 2. Respondents’ marital status
Ryc. 2. Stan cywilny badanych
The youngest respondent attending the specialist
appointment was 13 and the oldest was 80. The most
numerous age subgroup was between 60 and 74 years
old –comprising 45.5% of the study population. Two
extreme age subgroups i.e. from 19 to 29 and between
75 and 80 years old included the same number of
respondents i.e. 8.9%. Individuals aged between 45 and
59 comprised 21.8% of all participants whereas
patients between 30 and 44 represented half of that
number i.e. 12.9%. Respondents younger than 18
constituted only 2% of the study population (Fig. 3).
45,5%
50,0%
45,0%
40,0%
35,0%
30,0%
21,8%
25,0%
29,7%
20,0%
12,9%
15,0%
8,9%
8,9%
10,0%
5,0%
2,0%
0,0%
70,3%
Kobiety
Mężczyźni
Fig. 1. Respondents’ gender profile
Ryc. 1. Płeć badanych
Most participants were married (70.3%). Singles
comprised 29.7% of patients attending the open day in
the Specialist Hospital in Sanok. (Fig.2) As far as
respondents’ education was concerned, patients with
secondary (high-school) education constituted the
biggest subgroup (44.5%), whereas those with
<18
19-29
30-44
45-59
60-74
75-80
Fig. 3. Age profile of patients attending the open days in
hospital
Ryc. 3. Przedział wiekowy osób korzystających z dni
otwartych
Respondents living in the urban environment
constituted a vast majority (78.2%) of the study
population, whereas patients from rural areas
comprised only 21.8% of the group.
The majority of respondents (52.5%) assessed their
economic status as good, 37.6% of participants
believed it was sufficient. According to 6.9% of
patients their financial situation was poor, whereas
Ewa Smoleń et al.
54
only 3% of the study population declared their
economic status as very good.
More than half of the study group (63.4%)
underwent preventive examinations before. The
remaining group (36.6% of respondents) participated in
that type of medical program for the first time. When
asked about major factors determining participation in
preventive examinations, respondents named the
following ones: desire to do medical tests and check
one’s health status – 45.5%, easy access – 42.5%, and
free examinations – 40.5%. Short time of waiting for a
specialist appointment and confirmation of previously
given diagnosis were mentioned less frequently by
34.6% and 7.9% respondents, respectively (Fig. 4).
45,5%
50,0%
45,0%
42,0%
40,5%
34,6%
40,0%
35,0%
30,0%
25,0%
20,0%
15,0%
7,9%
10,0%
In the opinion of respondents, more than half of the
study population (59.4%) led healthy lifestyle.
Participants, who believed their lifestyle was not
beneficial for their health and didn’t have any specified
opinion about it presented similar number i.e. 19.8%
and 20.8%, respectively.
Almost half of the study population (47.5%) had a
history of cancer in their family. Smaller group of
respondent (41.6%) didn’t recall any malignant disease
in their family (first generation). Four percent of
patients were unable to answer the question about
cancer history in their family, whereas 6.8% of
respondents could not specify the type of malignancy
which occurred among their closest relatives.
Respondents were also asked to indicate symptoms,
which may suggest malignant disease. Wounds, which
didn’t heal for a long time, and ulcerations were the
most frequent answer (44.5%). Urination and/ or
defecation disorders were pointed by 23.8% of patients
attending the open day, whereas 20.8% of them
believed skin papillae suggested cancer. Every tenth
respondent had a history of bleeding from
physiological body cavities.
5,0%
0,0%
łatwość dostępu
bezpłatny dostep do
chęć wykonania
krótki okes
badań
badań i sprawdzenbia oczekiwania na i
swojego stanu
wizytę specjalisty
zdrowia
uzyskanie
potwierdzenia
wcześniej szej
diagnozy
Fig. 4. The reason why respondents attended specialist
appointments during the hospital open day
Ryc. 4. Przyczyna korzystania z wizyt lekarza specjalisty
podczas dni otwartych szpitala
When asked which factors had the biggest
influence on health status, respondents gave the
following answers: lifestyle – 79.2%, hereditary genetic factors – 27.7%, environmental factors –
15.8%, and health care – only 6.9%.
Most patients (73.3%) attending specialist
appointment had
never smoked. Every sixth
respondent used to smoke in the past but gave it up.
Few (6.9%) participants admitted to be active smokers.
A small group of patients (3%) did not answer the
question regarding smoking. Only 5 respondents
(5.0%) specified the number of cigarettes smoked per
day (between 8 and 25). Mean time since last cigarette
taken by patients, who used to smoke in the past and
had given up smoking, was 13.5 years (between 1 and
25 years). Before giving up this addiction, respondents
used to smoke for 10 to 30 years. Mean period of
smoking in this group of patients was 19.3 years.
DISCUSSION
Malignant diseases represent an increasing health
and economical problem in Polish society. At the
beginning of the XXI century, 138 500 new cancer
cases and over 91 500 deaths caused by malignancies
were recorded. Cancer mortality rate increased from
23% to 26% between 2003 and 2009 [3]. In 2010 in
Poland, the incidence and type of malignant diseases
varied in relation to patient gender. The most frequent
male malignancies included lung cancer (25.1%),
prostate tumours (10%), and urinary bladder
malignancies (6.6%). Breast cancer was the most
common female malignancy (20.5%) followed by lung
cancer (7.8%) and uterine cancer (7.1%). According to
the statistical data from 2004, cancer was the cause of
death of 62 442 men and 58 858 women. Study
outcomes showed that malignant diseases were
observed more frequently among men than women (24
cases vs. 22 cases), however the difference was not
significant. Breast cancer had the biggest incidence
rate among women followed by cervical and colorectal
cancer. No lung cancer cases were recorded among
women at that time, whereas it was the most frequent
malignancy among men. Larynx cancer was the second
most common male malignancy followed by prostate
and colorectal cancer [14, 15, 17].
Education determined attitudes and behaviours
regarding lifestyle, i.e. individuals with higher
education (university degree) paid greater attention to
issues related with health, led pro-health lifestyle and
benefited from health services more frequently. The
study population comprised visibly bigger number of
respondents with university and high-school education
(66.3%) when compared with individuals with
primary and vocational education (33.7%) [11].
Almost 70% of general population received
medical help in outpatient settings in 2004. It means
that almost 26.5 million people had appointments with
physicians at least once a year, however women sought
medical advice more frequently than men. During the
open day in the Sanok Specialist Hospital women
constituted significantly bigger subgroup when
compared with men i.e. 70.3% vs. 27.9%, respectively
[11].
As far as patient’s age is concerned, two age
subgroups required medical assistance more often. The
first one comprised children between 0 and 4 years old
whereas mature adults and people older than 50 years
constituted the second subgroup. Almost half of the
study population (45.5%) were between 60 and 74
years old. Individuals aged between 45 and 59
comprised 21.8% of all respondents [3,11].
When analysing health status of patients, who saw
their physician, it is noticeable that individuals
suffering from diseases and those with poor health
status required medical advice more frequently than
people reporting no health problems. Only every tenth
person from the first subgroup did not look for medical
help, whereas in the subgroup of healthy individuals,
who did not report any complaints, this rate was lower
than 50%.
Rural inhabitants saw their physician significantly
less frequently than urban ones. The rate of medical
advice counted per an individual per year is 3.3 for the
urban area and over four for the urban settings. Every
fourth medical appointment was related with treatment
in chronic diseases, every fifth – other diseases or
health status check whereas the objective of every sixth
appointment was to obtain a prescription for
medicines. As far as the open day in the Sanok
Specialist Hospital was concerned, the majority of
patients wanted to undergo free medical examinations
and have their health status checked without long
55
waiting time, which was related with easier access to
medical tests and appointments with clinicians [11].
Almost 90% of all medical appointments in Poland
are free i.e. financed by the National Health Fund
(NFZ) and only 6% are paid by patients themselves.
However, almost every sixth adult stated that the lack
of money was the most common reason why they
cancelled the appointment (every fourth individual
resigning from medical appointment). The following
most frequent causes of giving up the visit included:
long list of patient waiting for the appointment, lack of
time, decision that there was no hurry and maybe
symptoms would disappear with time. Lack of time
and postponing a medical appointment were motives
typical for men, whereas women more often pointed to
long waiting lists and lack of money. The fact that sick
people and disabled patients gave up medical
appointment more frequently than healthy individuals,
usually because of long waiting time and the lack of
financial resources, is very disturbing. When
considering the study population of individuals
undergoing medical tests and requiring specialist
advice during the open days, over 80% of the group
suffered from chronic condition and reported to receive
treatment for at least one chronic disease. Individuals,
who did not report any disease, comprised significantly
smaller group i.e. 20.0% [3, 11].
In 2004 Polish patients most frequently required
medical assistance/ advice from gynaecologists,
ophthalmologists, and
dentists. Oncologists,
rheumatologists, and orthopaedists were attended less
often. Patients attending the open day expected to
receive medical advice from the following specialists:
cardiologist, laryngologist, urologist, ophthalmologist,
gastroenterologist, and neurologist [11].
Smoking, next to cardiovascular and respiratory
diseases, is the cause of cancer development (oral
cavity, throat, oesophagus, larynx, lungs, kidneys,
bladder, pancreas, stomach, liver, nasal sinus and
cervix). In Poland, 60% of deaths among men between
35 and 69 years old is due to smoking. Increased
mortality of middle-aged men is mainly determined by
the increasing number of deaths caused by tobaccorelated diseases. One of the priorities of primary
prophylaxis in health care in Poland is to eliminate
smoking. Deaths due to cancer are mainly recorded
among older people above the age of 50 with the
mortality peak between 75 and 85 years old. Only
6.9% of individuals attending the open day in the
Sanok Hospital were smokers. The group of
56
Ewa Smoleń et al.
respondents who used to smoke but gave up the habit
and were non-smokers for 14 years (mean value) was
much more numerous. However, almost every three
out of four participants did not ever smoke (73.3%) [3,
12, 15].
It is possible to influence the development and
progress of cancer in its subclinical stage through
prevention and early detection of symptoms [12, 13,
18].
Diagnosing a malignant disease characterised by
hereditary and genetic features indicates that a given
family is burdened with a possibility of cancer
incidence among their members – especially in singlegene mutations. Therefore, a family is described as
“cancer family” if the following is observed:
- Three or more cases of malignant diseases were
recorded in two or more generations;
- At least one of these individuals is a first-degree
relative to the other two family members;
- At least one case of cancer occurred before the age
of 50;
- An association between specified types of
malignancies are observed (e.g. breast, ovary,
large bowel) [1, p. 39]
Medical history (obtained through the interview)
together with screening examinations comprise
interventions aiming at cancer detection in its
preclinical (asymptomatic) stage.
Early detection of disturbing symptoms determines
lower morbidity and mortality in a given type of
malignant disease in a given population. It allows early
and effective therapy decreasing financial burden at the
same time [6, 9, 13].
Subjective examination (assessment) – interview
increases detection rate to the level of 80 to 90 % of all
morbidities [3]. Nursing assessment is one of methods
used for recording data about a patient, care subject,
allowing medical professionals to obtain necessary
information for further planning and realisation of
preventive actions [7].
Prophylaxis is a field of medicine describing all
activities aiming at disease prevention. Its objectives
include keeping and strengthening health status of an
individual as well as population. Primary prophylaxis
is a set of interventions preventing diseases from
developing through a possible early detection and
starting the therapy as soon as it is possible [5, 9].
Prevention focuses on individuals from the risk
populations threatened by a given disease. Nurse tasks
in that field include participation in screening
programmes, promoting adequate attitudes among
individuals at risk of diagnosed heath threats as well as
diagnosed morbidity [5, 18].
Prevention of phenomena dangerous to human
health is more effective and economic than fighting
their effects of social and health character [9, 18].
CONCLUSIONS
Information obtained during nursing assessments
(interviews) allowed the extraction of symptoms,
which may be first indicators of malignant disease
development. Respondents gave the following
symptoms – indicators of possible cancer development:
- Wounds and ulcerations that did not heal for a
long time – 44.5%,
- Long-lasting urination/defecation disorders –
23.8%,
- Changes in shape, size, or colour of nipples, skin
stigmas, and skin papillae– 20.8%,
- Bleeding from physiological body cavities –
10.9%.
Individuals with those symptoms should undergo
further diagnostics and be referred to additional
specialist screening examinations. A review of studies
indicates the need for regular organisation of open days
in hospitals in order to detect disturbing changes in
systems and organs’ functioning, which may point to
carcinogenic
processes
in
their
preclinical
asymptomatic stage.
REFERENCES
1. Asendrych A., Deptała A.: Badania przesiewowe w
onkologii. W: Deptała A. (red.). Onkologia w praktyce
Wyd. PZWL, Warszawa 2006.
2. Deptała A.: Podstawy epidemiologii nowotworów.
Środowiskowe i genetyczne uwarunkowania rozwoju
nowotworów. W: Deptała A. (red.). Onkologia w
praktyce. Wyd. PZWL, Warszawa 2006.
3. Główny Urząd Statystyczny: Stan zdrowia ludności w
2004 r., Informacje i opracowania statystyczne,
Warszawa 2006.
4. Jabłońska-Chmielewska A.: Wywiad standaryzowany.
W: Jabłoński L (red.). Epidemiologia. Wyd. Folium,
Lublin 1999.
5. Jachimowicz-Wołoszynek D.: Profilaktyka jako element
promocji
zdrowia.
W:
Andruszkiewicz
A.,
Banaszkiewicz M (red.). Promocja zdrowia. t. I. Wyd.
Czelej, Lublin 2008.
6. Kordek R., Piekarski J.: Wczesna wykrywalności
nowotworów. W: Kordek R. (red.). Onkologia. Via
Medica, Gdańsk 2007.
7. Marć M.: Gromadzenie informacji o pacjencie i jego
rodzinie. W: Podstawy pielęgniarstwa Ślusarska B,
Zarzycka D., Zahradniczek K. red. t I. Wyd. Czelej,
Lublin 2004.
8. Narodowy Program Zdrowia na lata 2007 – 2015.
Załącznik
do
Uchwały
nr 90/2007 Rady Ministrów z dn. 15 maja 2007.
9. Niwińska
A.:
Masowe
badania
przesiewowe
(skyningowe). W: Kułakowski A., Skowrońska – Gardas
A. (red.). Onkologia. Wyd. PZWL, Warszawa 2003.
10. Olszewski W.T.: Badania przesiewowe w kierunku
nowotworów.
W: Krzakowski M. (red.). Onkologia kliniczna. t. I. Wyd.
Borgis, Warszawa 2006.
11. Pączkowska M.: Dostępność świadczeń zdrowotnych w
opinii Polaków. Raport z badań. Centrum Systemów
Informacyjnych Ochrony Zdrowia. Zakład Analiz
Socjologicznych, Warszawa 2006.
12. Pająk A., Topór Mądry R.: Ocena stanu zdrowia
populacji. W: Czupryna A., Poździoch S., Ryś A.,
Włodarczyk W.C. (red.). Zdrowie Publiczne wybrane
zagadnienia. t. I. Wyd. Vesalius, Kraków 2000.
13. Pasz – Walczak G.: Zapobieganie W: Kordek R. (red.).
Onkologia. Via Medica, Gdańsk 2007.
14. Pawlęga J.: Częstość występowania nowotworów
złośliwych W: Kordek R. (red.). Onkologia. Via Medica,
Gdańsk 2007.
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15. Tyczyński J.E.: Epidemiologia nowotworów złośliwych
W: Kułakowski A., Skowrońska – Gardas A. (red.).
Onkologia. Wyd. PZWL, Warszawa 2003.
16. Tyczyński J.E.: Środowiskowe przyczyny chorób
nowotworowych i możliwości zapobiegania (profilaktyka
pierwotna). W: Kułakowski A., Skowrońska – Gardas A.
(red.): Onkologia. Wyd. PZWL, Warszawa 2003.
17. Zatoński W.A., Didkowska J.: Epidemiologia złośliwych
nowotworów. W: Krzakowski M. (red.). Onkologia
kliniczna. t. I. Wyd. Borgis, Warszawa 2006.
18. Żołnierczyk-Kieliszek D.: Zachowania zdrowotne i ich
związek ze zdrowiem. W: Kulik T.B., Latalski M. (red.).
Zdrowie publiczne. Wyd. Czelej, Lublin 2002.
Ewa Smoleń
Instytut Pielęgniarstwa
PWSZ im. J. Grodka w Sanoku
Ul. Mickiewicza 21
38-500 Sanok
tel. (13) 465 59 60
fax (13) 465 59 59
Received: 9.09.2010
Magdalena Weber-Rajek1, Joanna Pawlak2, Paweł Zalewski 2, Małgorzata Łukowicz1, Jacek J. Klawe2,
Anna Jaskulska3
ASSESSMENT OF KINESIOLOGY TAPING THERAPY EFFICIENCY
IN LUMBOSACRAL PAIN SYNDROME
OCENA SKUTECZNOŚCI KINESIOTAPINGU W TERAPII DOLEGLIWOŚCI BÓLOWYCH
LĘDŹWIOWO-KRZYŻOWEGO ODCINKA KRĘGOSŁUPA
1
Katedra i Zakład Laseroterapii i Fizjoterapii, Collegium Medicum w Bydgoszczy
Head: dr Małgorzata Łukowicz
2
Katedra i Zakład Higieny i Epidemiologii Collegium Medicum w Bydgoszczy
Head: dr hab. Jacek Jan Klawe, prof. UMK
3
Studentka Wydziału Nauk o Zdrowiu Collegium Medicum w Bydgoszczy
Summary
I n t r o d u c t i o n . Spinal pain syndromes are very
serious health problems of modern societies. Nearly 55% of
adult population of the developed countries suffers from
long-lasting rachialgia . The aim of the work was to evaluate
the efficiency of kinesio taping in treatment of low back pain.
M a t e r i a l a n d m e t h o d s . 20 patients aged from
30 to 51 with diagnosed lumbosacral rachialgia were
subjected to examination. The K-active strips were applied
within the area of lumbosacral spine of patients. On the first
and the last day of therapy, pain ailments of all patients were
evaluated with Visual Analogue Scale – VAS and a modified
Laitinen questionnaire was used as well. The following
functional tests for evaluation of spinal mobility were also
carried out: fingers-floor test, Schober’s test, Angular
evaluation of spinal mobility with Saunders inclinometer.
R e s u l t s . Statistically significant differences in Visual
Analogue Scale and Leitinen Scale were noticed within the
group of patients between the therapy and after its
termination (p<0,05). Mobility of L4 –L5 , L5 –S1 segments
increased after the treatment, what confirms the effectiveness
of the therapy. Results of tests for evaluation of spinal
mobility prove the improvement of complete spinal mobility
range within the lumbosacral segment.
C o n c l u s i o n s . The analysis of achieved results
revealed that K-active strips prove analgesic activity. Most
probably, the limitation of pain ailments, improved the
mobility of the individual segments of spine.
Streszczenie
W s t ę p . Zespoły bólowe kręgosłupa stanowią poważny
problem zdrowotny nowoczesnego społeczeństwa. Blisko
55% populacji dorosłych osób w krajach wysoko
rozwiniętych odczuwa przewlekłe dolegliwości bólowe
kręgosłupa.
Celem
niniejszej
pracy
była ocena
skuteczności metody kinesiotapingu w terapii dolegliwości
bólowych lędźwiowo-krzyżowego odcinka kręgosłupa.
M a t e r i a ł i m e t o d y . Do badań zakwalifikowano
20 pacjentów w wieku od 30 do 51 lat, u których
zdiagnozowano zespół bólowy lędźwiowo-krzyżowego
odcinka kręgosłupa. Wszystkim pacjentom na okolicę
lędźwiowo-krzyżową kręgosłupa zostały przyklejone plastry
K-active używane w terapii Kinesiology Taping. Pierwszego
i ostatniego dnia terapii u wszystkich pacjentów oceniano:
dolegliwości bólowe przy użyciu wzrokowo-analogowej
skali bólu – VAS (Visual Analogue Scale) oraz
60
Magdalena Weber-Rajek et al.
zmodyfikowanego kwestionariusza oceny dolegliwości
bólowych Laitinena, wykonano testy funkcjonalne
oceniające ruchomość kręgosłupa: test „palce-podłoga”, test
Schobera, kątową ocenę ruchomości kręgosłupa z zastosowaniem inklinometru Saundersa.
W y n i k i . Stwierdzono występowanie statystycznie
istotnych różnic (p<0,05) wartości skali oceny dolegliwości
bólowych VAS i Laitinena w badanej grupie pacjentów przed
rozpoczęciem i po zakończeniu terapii. Po zakończeniu
terapii poprawie uległa ruchomość segmentów L4 – L5,L5 –S1
, co potwierdza skuteczność stosowanej terapii. Ponadto
wyniki zastosowanych testów ruchomości kręgosłupa
świadczą o poprawie ruchomości całkowitej kręgosłupa
w odcinku lędźwiowo-krzyżowym.
W n i o s k i . Analiza uzyskanych wyników niniejszych
badań wykazała, iż plastry K-active wykazują działanie
przeciwbólowe. Najprawdopodobniej zmniejszenie odczuwania dolegliwości bólowych spowodowało poprawę
ruchomości poszczególnych segmentów kręgosłupa.
Key words: Kinesio Tex Tape, spine pain syndrome, musculoskeletal system
Słowa kluczowe: kinesiotaping, dolegliwości bólowe kręgosłupa, narząd ruchu
INTRODUCTION
Spinal pain syndromes are very serious health
problems of modern societies. Nearly 55% of adult
population of the developed countries suffers from
long-lasting rachialgia [1-4]. Spinal pain syndrome
appears usually between the 25th and 65th year of life,
in both women and men. Reports confirm the decrease
of age limits of people afflicted with this problem [57]. The pathomechanism of spinal pain is usually
multifactorial. The overload changes of spinal
structures are said to determine the main reason of this
chronic illness. The lesions arisen as a result of this
process are recognized as: discopathy, myalgia,
degenerative changes of vertebral bodies and joints, as
well as herniated nucleus pulposus with paresis or
muscular paralysis of limbs. The secondary
disturbances of proprioception, increased muscular
tone, as well as asymmetry of muscular tone, are also
noticed, which directly influence the limitation of
backbone mobility [8-11].
Due to widespread backbone pain ailments, the
examinations aimed at efficient treatment manners are
constantly being elaborated.
The aim of the work was evaluation of efficiency of
kinesio taping in treatment of low back pain. Kinesio
taping is a therapeutic method which uses strips with
an adhesive to treat overused muscles. Physical
features of K-active strips suit biomechanical
parameters of skin tissues. Elasticity of the bands
reaches 140%, they are water-repellent, permeable to
air, do not disturb heat exchange between skin surface
and environment. The adhesive acrylic layer is
characterized by hypoallergic properties, what
significantly limit the allergy or skin irritation.
Kinesio taping, as a therapeutic method, is based on
various techniques of strips application:
muscular application – the most physiological;
the strip is applied without stretching, by the maximal
muscular extension,
ligamentous application – stimulates mechanoreceptors, as well as increase proprioceptive pathways
for normalization of ligament and tendons tension;
strips stretch: 25-50%,
fascial application – decreases excessive fasciae
tension; strips stretch: 25-50%,
lymphatic application – prophylaxis and therapy
of lymphatic oedemas; compound cutting of strips is
applied, whereas the base is administered within the
area of lymph nodes and tails are applied circularly at
the limb; strips stretch: 0-15%,
functional application – therapy counteracting the
mobility limitation and irregular body segments
position [12, 14-16].
The selection of K-active strips application depends
inter alia on the dimension of muscle, as well as
anticipated therapeutic effects. One of the most popular
and universal method of K-active strips application is
V-type method, which either increases or decreases
muscular tone, depending on the need [14, 17].
20 patients aged from 30 to 51 with diagnosed
lumbosacral rachialgia were subjected to examination.
Before the research, each person was interviewed in
detail concerning the pain ailments. The K-active strips
were applied within the area of lumbosacral spine of
patients. The participants were not subjected to any
other physical procedures or kinesitherapy in the same
time. The application of strips was performed in
accordance with V-method and recommended
standards.
Assessment of kinesiology taping therapy efficiency in lumbosacral pain syndrome
On the first and the last day of therapy, all patients
were evaluated concerning pain ailments, with Visual
Analogue Scale – VAS, as well as modified Laitinen
questionnaire (pain intensity and frequency,
administered analgesics and limitation of motor
activity).
61
Assessment of pain ailments
The statistically significant differences in Visual
Analogue Scale and Leitinen Scale were noticed within
the group of patients between the therapy and after its
termination (p<0,05).
Before the therapy, mean values in VAS scale were
assessed at 6 points. The lowest level remained at 3
points, and the highest at 9 points. After the treatment
mean value of pain sensation decreased to 3 points.
Minimal value was assessed at 0 and maximal at 9
points.
Before the therapy, mean values in Laitinen scale
were assessed at 5 points. The lowest level remained at
1 points, and the highest at 9 points. After the
treatment mean value of pain sensation decreased to 3
points. Minimal value was assessed at 0 and maximal
at 6 points.
Wykres ramka-wąsy
10
Fig. 1. Muscular application of K-active tapes – lumbarsacral segments of vertebra column
Ryc. 1. Aplikacja mięśniowa plastrów K-active – odcinek
lędźwiowo-krzyżowy kręgosłupa
8
6
4
The following functional tests for evaluation of
spinal mobility were also carried out:
• fingers-floor test,
• Schober’s test,
• Angular evaluation of spinal mobility with
application of Saunders inclinometer
RESULTS
For statistical purposes the indexes below were
used:
01 – before the treatment
02 – after the treatment
2
0
-2
GR_BAD_VAS01
GR_BAD_VAS02
Średnia
Średnia±Odch.std
Średnia±1,96*Odch.std
Fig. 2. Box-and-whisker plot for changes of mean values of
VAS, before (01) and after the treatment (02)
Ryc. 2. Wykres ramka-wąsy dla średniej zmiany dolegliwości
bólowych ocenianych przy użyciu skali VAS przed
terapią (01) i po terapii (02), p<0,05
Angular mobility measurements
Before the treatment, mean value of spinal mobility
within L4-L5 segment amounted 420. The lowest
Table 1. Basic statistics for all functional tests and scales measured value was 180 and the highest was 680. After
performed in the experimental group – comparison of the therapy the mobility of the same segment
outcome val
increased, what is confirmed by the effectiveness of
Tabela 1 Wartości statystyki testowej skal i testów
applied therapy. Mean value of mobility evaluation
przeprowadzonych w grupie osób badanych –
was 630. The lowest rate was assessed at the level of
porównanie różnic wartości wyników przed
300 and the highest at the level of 980.
terapią (01) i po terapii (02), α=0,05
Before the therapy, mean value of L5-S1 segment
Skala/ocena czynnościowa
p
mobility, measured by means of Saunders inclinometer
VAS
0.0001
amounted 450. The lowest measured value was 150 and
Laitinen
0.0004
the highest 710. After the treatment the mobility of this
L4-L5
0.0000
segment increased, what is confirmed by the
L5-S1
0.0001
effectiveness of the therapy. After the treatment, mean
p-p
0.0006
Schober - zgięcie
0.0006
value of mobility assessment amounted 600. The
62
lowest rate was assessed at the level of 300 and the
highest at the level of 880.
Wykres ramka-wąsy
10
8
6
observed at the level of 11.5 cm, and the highest
amounted 16 cm. After termination of the procedures,
mean value of test was 15 cm. The lowest value was
11.8 cm, whereas the highest reached 18 cm. The
increase of mean value of the test carried out after the
therapy, proves the improvement of complete spinal
mobility range within the lumbosacral segment.
4
2
Wykres ramka-wąsy
100
0
90
80
-2
GR_BAD_LAIT01
GR_BAD_LAIT02
Średnia
Średnia±Odch.std
Laitinen scale, before (01) and after the treatment
(02)
Ryc. 3. Wykres ramka-wąsy dla średniej zmiany dolegliwości
bólowych ocenianych przy użyciu skali Laitinena
przed terapią (01) i po terapii (02), p<0,05
70
60
50
40
30
20
10
GR_BAD_L5-S101
GR_BAD_L5-S102
Before the treatment, mean value of the applied test
amounted -150 mm. The lowest measured value was
observed at the -350 mm level, and the highest
amounted 49 mm. After termination of the procedures,
mean value of fingers-floor test was -100 mm. The
lowest value was -180 mm, whereas the highest
reached 70 mm. The increase of mean value of the test
carried out after the therapy, proves the improvement
of spinal mobility range within the lumbosacral
segment.
Wykres ramka-wąsy
Średnia
Średnia±Odch.std
L5-S1 segmental mobility, before treatment (01), after
treatment (02)
Ryc. 5. Wykres ramka-wąsy dla średnich zmian ruchomości
segmentu L5-S1 ocenianych przed terapią (01) i po
terapii (02), p<0,05
Wykres ramka-wąsy
200
100
0
110
100
-100
90
80
-200
70
60
-300
50
-400
40
GR_BAD_P-P01
GR_BAD_P-P02
30
Średnia
Średnia±Odch.std
20
10
GR_BAD_L4-L501
GR_BAD_L4-L502
Średnia
Średnia±Odch.std
L4-L5 segmental mobility, before treatment (01), after
treatment (02)
Ryc. 4. Wykres ramka-wąsy dla średnich zmian ruchomości
segmentu L4-L5 ocenianych przed terapią (01) i po
terapii (02), p<0,05
Before the treatment, mean value of the applied test
amounted 13,7 cm. The lowest measured value was
toe-touch test, before treatment (01), after treatment
(02)
Ryc. 6. Wykres ramka-wąsy dla średnich zmian wartości
testu „palec-podłoga” przed terapią (01) i po terapii
(02), p<0,05
Assessment of kinesiology taping therapy efficiency in lumbosacral pain syndrome
order to adjust the patella, was observed. In each case
the ailments decreased, as well as the functionality of
joint improved.
Quily B et al observed the decrease of pain ailments
and the improvement of results in WOMAC scale in
patients with degenerative changes of knee joints after
a 10-week kinesio taping therapy. However, after 12
months the difference between group of patients
treated with strips and kinesiotherapy was not noticed
[12].
Wykres ramka-wąsy
19
18
17
16
15
14
13
12
11
GR_BAD_SCH-ZG01
GR_BAD_SCH-ZG02
63
Średnia
Średnia±Odch.std
toe-touch test, before treatment (01), after treatment
(02)
Ryc. 7. Wykres ramka-wąsy dla średnich zmian wartości
testu Schobera przed terapią (01) i po terapii (02),
p<0,05
DISCUSSION
The evaluation of kinesio taping effectiveness in
treatment of various diseases was assessed by many
authors. Zajt-Kwiatkowska et all [18] applied this
method to patients suffering from pain ailments of the
lower part of a spine (muscular and ligamentous
methods applied), rotator cuff syndrome (ligamentous
and corrective methods), as well as knee pain
syndrome (muscular, ligamentous and corrective
methods). The analysis of achieved results proved a
significant decrease of pain ailments after application
of kinesio taping therapy, which maintained up to 3
months after termination of the treatment. However,
after another 12 months, no differences between
patients subjected to kinesio taping and the reference
group were observed.
Other authors [19] studied a group of 87 patients
with degenerative changes of knee joints. The patients
were divided into 3 groups. Kinesio taping was applied
in case of two groups – first one subjected to hard
strips for correction of joint position, second group was
treated with elastic strips. Third group represented the
reference one. After a 6-week therapy, the decrease of
pain was noticed in 73% of patients of the first group.
In the second group, limitation of pain was achieved by
49% of subjects. Only 10% of patients representing
third group reported decrease of pain ailments. Similar
examinations concerning the influence of kinesio
taping on pain ailments within knee joints were
performed by Salsich et al. [20]. A group of 10 people
suffering from knee ache, subjected to kinesio taping in
CONCLUSIONS
The analysis of the achieved results revealed that Kactive strips prove analgesic activity. The significant
decrease of pain within a lower part of spine after the
therapy was noticed. The limitation of pain ailments
most probably improved the mobility of the individual
segments of a spine.
REFERENCES
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Balneologia Polska, 1998, 40 (3): 76-82.
3. Kujawa J., Pyszczek I., Talar J., Janiszewski M.:
Porównawcza ocena skuteczności przeciwbólowej
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bólowym dolnego odcinka kręgosłupa. Fizjoterapia
Polska, 2001, 3: 271-279.
4. Wahlgren D.R., Atkinson J.H., Epping- Jordan J.E.:
One- year follow- up of first onset low back pain. Pain,
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5. Lisiński P., Małgowska M.: Jakość życia a zespół
bólowy kręgosłupa na tle przeciążeniowym. Chirurgia
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lędźwiowo- krzyżowego. Kwartalnik Ortopedyczny,
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leczenie. Przewodnik Lekarski, 2006, 9(2): 86-98.
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Terapia, 2003, 11(4): 39-42.
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2001, 4(11): 104-110.
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zastosowanie
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wybranych
przypadkach
ortopedycznych,AWF, Warszawa 2005
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profilaktyce, leczeniu i rehabilitacji schorzeń i urazów
narządów ruchu, Warszawa, Agencja Wydaw.
MedSport Press 1997.
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Bakuła S.: Kinesio taping metoda wspomagająca proces
usprawniania fizjoterapeutycznego - wybrane aplikacje
kliniczne, : Nowiny Lek. 2005: 74 (2) s.190-194.
15. Tiffert M.: Nowe trendy fizjoterapii, Świat Lekarza nr
3/2009.
16. Żuk B.: Księżopolska-Orłowska K., Przydatność
metody Kinesio Taping w chorobach zapalnych układu
ruchu u dzieci.
17. Kase K.,Wallis J.,Kase T.: Clinical Therapeutic
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18. Zajt-Kwiatkowska J., Rajkowska-Labon E., Skrobot W.,
Bakuła S.: Kinesio taping metoda wspomagająca proces
usprawniania fizjoterapeutycznego - wybrane aplikacje
kliniczne, : Nowiny Lek. 2005: 74 (2) s.190-194.
19. Herbert R.: Exercise, not taping, improves outcomes for
patients with anterior knee pain. Aust. J. Physiother.,
2001, 47, 66.
20. Salsich G, Brechter J, Farwell D, Powers C. The effects
of patellar taping on knee kinetics, kinematics, and
vastus lateralis muscle activity during stair ambulation
in individuals with patellofemoral pain. J Orthop Sports
Phys Ther 2002; 32: 3-10
21. Quily B., Trucker M., Campbell R., Dieppe P.:
Physiotherapy, including quadriceps exercises and
patellar taping, for knee osteoarthritis with predominant
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involvement:
randomized
controlled trial. J. Rheum., 2003, 30, 1311–7.
mgr Magdalena Weber-Rajek
Katedra i Zakład Laseroterapii i Fizjoterapii
Collegium Medicum im. Ludwika Rydygiera w
Bydgoszczy UMK,
ul. M. Skłodowskiej-Curie 9
85-094 Bydgoszcz
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