Medical and Biological Sciences XXVI/2 - Collegium Medicum ...

UNIWERSYTET MIKOŁAJA KOPERNIKA w TORUNIU 

COLLEGIUM MEDICUM im. LUDWIKA RYDYGIERA 

W BYDGOSZCZY 

MEDICAL 

AND BIOLOGICAL 

SCIENCES 

(dawniej ANNALES ACADEMIAE MEDICAE BYDGOSTIENSIS) 

TOM XXVI/2 kwiecień – czerwiec ROCZNIK 2012

REDAKTOR NACZELNY 

Editor-in-Chief 

Grażyna Odrowąż-Sypniewska 

ZASTĘ PCA REDAKTORA NACZELNEGO 

Co-editor 

Jacek Manitius 

SEKRETARZ REDAKCJI 

Secretary 

Beata Augustyńska 

REDAKTORZY DZIAŁ ÓW 

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, 

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Bogdana Wilczyńska, Zbigniew Wolski, Zdzisława Wrzosek, Mariusz Wysocki 

KOMITET DORADCZY 

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ISSN 1734-591X 

UNIWERSYTET MIKOŁAJA KOPERNIKA W TORUNIU 


BYDGOSZCZ 2012

Medical and Biological Sciences, 2012, 26/2 

CONTENTS 

p. 

ORIGINAL ARTICLES 

Julia Feit, Edward Jacek Gorzelań czyk, Ewa Mrówczyń ska, Ewelina 

Nowiń ska, Katarzyna Pasgreta – Effect of a single dose of methadone on the 

functioning of visuo-spatial working memory in opiate dependent individuals with HIV(+) 

treated with methadone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 

Elż bieta Grześ k, Sylwia Koł tan, Grzegorz Grześ k, Barbara Tejza, 

Robert Dę bski, Andrzej Koł tan, Mariusz Wysocki, Aldona Katarzyna 

Jankowska, Sł awomir Manysiak, Graż yna Odrowąż-Sypniewska – Value 

of erythrocyte sedimentation rate, C-reactive protein and procalcitonin concentration versus 

multimarker strategy in management of bronchiolitis in pediatric emergency . . . . . . . . . . . . . . . . . . . . . 11 

Magdalena Hagner-Derengowska, Michał Dylewski, Joanna Dawidziuk, 

W o j c i e c h H a g n e r – Changeability of spatial and temporal gait parameters measured 

on a treadmill with the use of a 3D ultrasound-based movement measuring system . . . . . . . . . . . . . . . . 19 

Magdalena Hagner-Derengowska, Monika Dylewska, Michał Dylewski 

– Intrarater repeatability of manual testing of first muscle movement resistance . . . . . . . . . . . . . . . . . . 25 

Boż enna Mazalska, Boż ena Kiziewicz, Elż bieta Muszyń ska, 

A n n a G o d l e w s k a , E w a Z d r o j k o w s k a – Fungi and straminipilous organisms found 

at bathing sites in the vicinity of Białystok . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 

Katarzyna Strojek, Irena Buł atowicz, Agata Czechowska, Agnieszka 

Radzimiń ska, Urszula Kaź mierczak, Grzegorz Srokowski, Marcin 

Siedlaczek – The assessment of influence of thermoplastic foot pads on the body stability 

in patients with foot dysfunctions – piloty study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 

Beata Kurył o-Rafiń ska, Beata Koł odziej, Mał gorzata Kubicka, Mariusz 

Wysocki, Jan Styczyń s k i – Differential ex vivo drug resistance profile in first and 

subsequent relapsed childhood acute myeloid leukemia in comparison to initial diagnosis . . . . . . . . . . 47 

A n e t a Z r e d a - P i k i e s , A n d r z e j K u r y l a k – Social functioning of children who have 

completed acute lymphoblastic leukemia treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 

CASE REPORT 

Adrian Reś liń ski, Agnieszka Mikucka, Jakub Szmytkowski, Katarzyna 

G ł owacka, Eugenia Gospodarek, Wojciech Szczę sny, Stanisł aw 

D ą b r o w i e c k i – Asymptomatic infection of a surgical mesh implant – a case report . . . . . . . . . . . . 59


SPIS TREŚCI 

str. 

PRACE POGLĄDOWE 

Julia Feit, Edward Jacek Gorzelań czyk, Ewa Mrówczyń ska, Ewelina 

Nowiń ska, Katarzyna Pasgreta – Wpływ pojedynczej dawki metadonu 

na funkcjonowanie wzrokowo-przestrzennej pamięci operacyjnej osób HIV(+) uzależnionych 

od opioidów leczonych metadonem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 

Elż bieta Grześ k, Sylwia Koł tan, Grzegorz Grześ k, Barbara Tejza, 

Robert Dę bski, Andrzej Koł tan, Mariusz Wysocki, Aldona Katarzyna 

Jankowska, Sł awomir Manysiak, Graż yna Odrowąż-Sypniewska 

– Wartość diagnostyczna OB, CRP oraz stężenia prokalcytoniny w różnicowaniu infekcji bakteryjnych 

i wirusowych u dzieci z zapaleniem oskrzelików w pediatrycznej izbie przyjęć . . . . . . . . . . . . . . . . . . . 11 

Magdalena Hagner-Derengowska, Michał Dylewski, Joanna Dawidziuk, 

Wojciech Hagner – Zmienność przestrzennych i czasowych parametrów chodu mierzona 

na bieżni z użyciem systemu pomiaru ruchu 3-D USG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 

Magdalena Hagner-Derengowska, Monika Dylewska, Michał Dylewski 

– Powtarzalność intrarater manualnego badania oporu tkankowego dla mięśnia trójgłowego łydki . . . 25 

Boż enna Mazalska, Boż ena Kiziewicz, Elż bieta Muszyń ska, 

Anna Godlewska, Ewa Zdrojkowska – Grzyby i straminipile występujące 

w kąpieliskach okolic Białegostoku . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 

Katarzyna Strojek, Irena Buł atowicz, Agata Czechowska, Agnieszka 

Radzimiń ska, Urszula Kaź mierczak, Grzegorz Srokowski, Marcin 

Siedlaczek – Ocena wpływu wkładek termoplastycznych na stabilność ciała u pacjentów 

z dysfunkcjami stopy – badania wstępne . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 

Beata Kurył o-Rafiń ska, Beata Koł odziej, Mał gorzata Kubicka, Mariusz 

Wysocki, Jan Styczyń ski – Zróżnicowany profil oporności ex vivo na cytostatyki 

w pierwszej i kolejnych wznowach ostrej białaczki mieloblastycznej u dzieci w porównaniu 

z pierwszym rozpoznaniem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 

Aneta Zreda-Pikies, Andrzej Kurylak – Społeczne funkcjonowanie dzieci po zakończonym 

leczeniu ostrej białaczki limfoblastycznej . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 

PRACA KAZUISTYCZNA 

Adrian Reś liń ski, Agnieszka Mikucka, Jakub Szmytkowski, Katarzyna 

G ł owacka, Eugenia Gospodarek, Wojciech Szczę sny, Stanisł aw 

D ą b r o w i e c k i – Bezobjawowe zakażenie siatki chirurgicznej – opis przypadku . . . . . . . . . . . . . . 59 

Regulamin ogłaszania prac w Medical and Biological Sciences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141

Medical and Biological Sciences, 2012, 26/2, 5-9 

ORIGINAL ARTICLE / PRACA ORYGINALNA 

Julia Feit 1,2 , Edward Jacek Gorzelańczyk 1,2,3 , Ewa Mrówczyńska 2 , Ewelina Nowińska 1 , Katarzyna Pasgreta 1 

EFFECT OF A SINGLE DOSE OF METHADONE ON THE FUNCTIONING 

OF VISUO-SPATIAL WORKING MEMORY IN OPIATE DEPENDENT INDIVIDUALS 

WITH HIV(+) TREATED WITH METHADONE 

WPŁYW POJEDYNCZEJ DAWKI METADONU NA FUNKCJONOWANIE 

WZROKOWO-PRZESTRZENNEJ PAMIĘCI OPERACYJNEJ OSÓB HIV(+) 

UZALEŻNIONYCH OD OPIOIDÓW LECZONYCH METADONEM 

1 Department of Theoretical Basis of Bio-Medical Sciences and Medical Informatics, 

Nicolaus Copernicus University in Toruń, Collegium Medicum in Bydgoszcz 

Head: prof. Krzysztof Stefański, PhD 

2 Non-public Health Care Center Sue Ryder Home in Bydgoszcz, 

Scientific Research Department 

Head: Assoc. prof. Edward Jacek Gorzelańczyk, MD, PhD 

3 Polish Academy of Sciences, Institute of Psychology 

Head: Assoc. prof. Urszula Jakubowska, PhD 

Summary 

I n t r o d u c t i o n . Subclinical measurements of 

psychomotor functions are being used for assessment of 

mental functions by finding relations with these functions. 

This study aims to assess the influence of a therapeutic dose 

of methadone on psychomotor speed in HIV(+) and HIV(-) 

subjects treated in substitution therapy. 

M a t e r i a l s a n d m e t h o d s . 73 patients [32 

HIV(-) and 41 HIV(+)]treated with methadone for an average 

of 54 months, were examined. The assessment was 

conducted twice: before and about 1.5 hours after the 

administration of a therapeutic dose of methadone. Trail 

Making Test A (TMT A) was completed. The test sheet was 

placed on a graphic tablet. Execution time was measured in 

both parts of the test. 

R e s u l t s . It was found that the average time of TMT 

A test completion before methadone administration in HIV(-) 

subjects is statically significantly shorter than in HIV(+) 

ones. However, after methadone administration psychomotor 

speed, measured by the TMT A test, is not statistically 

significantly different in HIV(-) subjects treated in 

substitution therapy as compared to HIV(+) individuals. 

Subjects with HIV (+) performed TMTA test statistically 

significantly faster after a single dose of methadone. 

C o n c l u s i o n . A therapeutic dose of methadone in 

subjects infected with HIV virus can have an effect on the 

improvement in psychomotor performance. Interactions of 

antiretroviral drugs and methadone can lead to changes in the 

concentration of methadone in the body influencing the 

regulation of psychomotor activity at the same time. 

Streszczenie 

Wstę p . Subkliniczne pomiary funkcji psychomotorycznych 

mają na celu ocenę funkcji psychicznych 

poprzez znalezienie powiązania tych funkcji z funkcjami 

psychomotorycznymi. 

Celem badania jest ocena wpływu leczniczej 

dawki metadonu na szybkość psychomotoryczną u osób 

HIV(+) oraz HIV(-) leczonych w programie substytucyjnym. 

Materiał y i m e t o d y . Zbadano 73 pacjentów 

programu substytucyjnego, 32 osoby HIV(-) i 41 osób 

HIV(+) leczonych metadonem średnio przez 54 miesiące.

6 

Julia Feit et. al. 

Badanie przeprowadzono dwukrotnie: przed podaniem oraz 

około 1,5 godziny po podaniu leczniczej dawki metadonu. 

Wykonano Test Łączenia Punktów Reitana A. Arkusz 

testowy umieszczano na tablecie graficznym. W obu 

częściach testu zmierzono czas wykonania. 

W y n i k i . Stwierdzono, że średni czas wykonania 

testu TMT A przed podaniem metadonu u osób HIV(-) jest 

istotnie statycznie mniejszy niż u osób HIV(+). Natomiast po 

podaniu metadonu szybkość psychomotoryczna mierzona za 

pomocą Testu Łączenia Punktów TMT A nie jest istotna 

statystycznie u osób HIV(-) leczonych w programie 

substytucyjnym w porównaniu z osobami HIV(+). Osoby 

z grupy HIV (+) istotnie statystycznie szybciej wykonują test 

TMTA po podaniu pojedynczej dawki metadonu. 

Wnioski. Przyjęcie leczniczej dawki metadonu 

przez osoby zakażone wirusem HIV może mieć wpływ na 

zwiększenie sprawności psychomotorycznej. Wchodzenie 

leków antyretrowirusowych w interakcje farmakokinetyczne 

z metadonem może prowadzić do zmiany stężeń metadonu 

w ustroju i tym samym powodować zmiany w regulacji 

czynności psychomotorycznych. 

Key words: opiates, methadone, TMT A, HIV 

Słowa kluczowe: opioidy, metadon, TMT A, HIV 

INTRODUCTION 

Addiction to opioids is one of the strongest forms 

of addiction [1, 2]. Using opioids is connected with 

adaptive changes in the nervous system [3, 4]. Opioids 

affect cerebral neurotransmitters which transmit 

information among nerve cells. [5] Psychoactive 

substances can cause a release of a bigger or smaller 

amount of neurotransmitters into the synaptic cleft or 

inhibit the return transport or block its action [6]. Most 

of the dysfunctions and deregulations associated with 

the intake of opioids affect the brain reward system, 

which is probably responsible for the homeostasis of 

behavior [7]. It was proven that addiction is linked to 

disturbances not only in the reward system, but also in 

other major functional systems of the brain [8]. In 

particular, it relates to the system associated with the 

regulation of cognitive and emotional functions [8]. 

Structural and functional changes in these structures 

are associated with the development of dependence to 

psychoactive compounds [8]. Morphological and 

functional changes in the striatum, especially in the 

ventral striatum (and its main structure - nucleus 

accumbens), have been found in addicted individuals. 

It is the central structure of the limbic system and the 

reward system. According to the current knowledge, a 

cortico-subcortical loop is important in the processing 

of sensory (visual and auditory perception), cognitive 

(attention, executive functions, visual and auditory 

memory, spatial memory), emotional (mood) and 

motor stimuli (extraocular movements, other skeletal 

muscle movements, such as upper limb muscles) [9, 

10, 11]. 

Methadone is a synthetic opioid used in the 

substitution therapy of opioid addicts. Substitution 

treatment is the most effective method of treatment in 

this type of addiction. It lowers the risk of transmitting 

viruses: human immunodeficiency virus, hepatitis C 

virus, hepatitis B virus (HIV, HCV, HBV) and other 

infectious agents causing blood-borne diseases, thus 

reducing the mortality rate among drug addicts [12]. 

Substitution therapy is the administration of a 

substitute agent [15]. Blockage of opioid receptors 

prevents mental and somatic symptoms of withdrawal 

state. The purpose of the therapy is delivering a 

controlled dose of a substitute agent, which will enable 

normal functioning, rebuilding, preserving health and 

reducing or eliminating criminal behaviours [16]. 

Alterations of the functioning of cortico-subcortical 

loops occur in patients infected with HIV which is a 

neurotropic virus. Features of subcortical stupor are 

found [17]. As a result of the activity of HIV most 

likely a damage of the striatum takes place. 

Psychomotor (oculomotor, upper limb movements) 

disturbances are the expected effect of the HIV virus. 

Additionally, emotional (which can be measured by 

changes in the functioning of the autonomic nervous 

system) and cognitive (disturbances in processing of 

information from the external and internal 

environment) impairments are seen [10, 11]. 

In order to assess the impact of a therapeutic dose 

of methadone on psychomotor performance of HIV(+) 

subjects and HIV(-) subjects treated with the 

substitution therapy, a graphomotor test was used. The 

time of test completion was measured in subjects from 

both groups. 

MATERIAL AND METHODS 

The study was conducted in the group of 73 

participants of substitution program addicted to opioids 

and included 32 HIV(-) and 41 HIV(+) subjects. 

Twenty eight women and 45 men, participating in 

methadone substitution program for an average of 53

Effect of a single dose of methadone on the functioning of visuo-spatial working memory in opiate dependent individuals... 7 

months, were qualified for the study. The assessment 

was conducted twice: before and about 1.5 hours after 

the administration of a therapeutic dose of methadone. 

The A TMT test evaluates visual-spatial functioning of 

the working memory and the ability to combine two 

principles of action. To perform the test visuomotor 

coordination (eye-hand) is crucial. The test evaluates 

the functioning of the area placed on the border of 

frontal, temporal, parietal and frontal lobes 

(particularly the right side). The test consists of two 

parts: A and B. In part A mainly psychomotor speed 

was evaluated. Subjects are to link circles with a 

continuous line, arranged irregularly on an A4 sheet 

and labeled by numbers from 1 to 25, in a proper 

sequence and as soon as possible [13]. The time of 

completion longer than 41 seconds is considered 

abnormal. [14]. The test sheet is placed on the graphic 

tablet. In both parts of the test execution time was 

measured. In the study Intuos2 graphic tablet 

connected to a computer was used to collect and 

process biomechanical signals. 

RESULTS 

statistically significantly (t=2.1083, p=0.0385) in 

HIV(-) patients treated with the substitution compared 

to those being HIV(+). 

Fig. 1. The comparison of mean execution time of TMT A test 

before the administration of methadone in both 

groups 

Ryc. 1. Porównanie średniego czas wykonania testu TMT A 

przed podaniem metadonu w obu grupach 

Difference of the motor speed in the HIV(-) and 

HIV(+) group after administration of therapeutic doses 

of methadone for TMT A t-test value is not statistically 

significant and is: t=1.6157, p=0.1106. 

73 subjects, being in the substitution therapy for 2- 

240 weeks, receiving the mean methadone dose of 76.1 

± (34) mg, were qualified for the study. 

Table. I. Characteristics of study groups 

Tabela I. Charakterystyka grup badanych 

Groups 

The mean dose of 

methadone (mg) 

The mean duration 

of treatment (weeks) 

HIV(-) 73.6±(28) 36.3±(39) 

HIV(+) 79.1±(38) 66.1±(54) 

It was found that the duration of treatment in the 

group of individuals with HIV(+) subjects is 

statistically significantly longer (t=2.6232, p=0.0107) 

in comparison to the group of HIV(-) individuals. 

However, the size of the average dose of methadone 

taken by the subjects from both groups is not 

statistically significantly different. 

In the group of HIV(-) individuals mean time of 

TMT A performance test before administration of 

methadone was 40.2 ± (12) s and in the HIV(+) group - 

50.6 ± (25.7) s After the administration of methadone 

TMT A test execution time in HIV(-) group was 36.4 ± 

(10.2) s and 42.4 ± (18.8) s in HIV(+) group. The 

statistical analysis shows that psychomotor speed 

measured by the Test Points Joining TMT A before 

administration of therapeutic doses of methadone differ 

Fig. 2. The comparison of mean execution time of TMT A test 

after the administration of a therapeutic dose of 

methadone in both groups 

Ryc. 2. Porównanie średniego czas wykonania testu TMT A 

po podaniu metadonu w obu grupach 

Test execution time TMT in A the group with HIV 

(+) before and after the administration of a single dose 

of methadone statistically significantly different (p = 

0.0113, p = 2.6547). There was no statistical 

significance in the group of HIV (-) before and after 

a single dose of methadone (p = 0.0710, p = 1.8694). 

In HIV-positive patients, before methadone 

administration, efficiency of motor function is reduced 

in comparison to the efficiency after the administration 

of methadone. After methadone administration, 

psychomotor performance in opioid dependent

8 

Julia Feit et. al. 

individuals, who are not carriers of the virus, does not 

differ statistically significantly from drug addicts who 

are HIV positive. 

putamen) and functionally being a central structure of 

the limbic system and reward system [19]. 

However, increasing the motor performance of 

HIV(+) individuals may be influenced by many 

pharmacokinetic factors. 

Antiviral medicines often interact with methadone 

due to the complex metabolism which may lead to 

intensified adverse events including reduction or 

potentiating of the effectiveness of methadone. 

The pharmacokinetic properties of the same drug 

can vary considerably between patients due to genetic 

factors or comorbidities including liver damage 

associated with HCV and HBV infection. Those are 

very common in this group of patients. All of these 

medications interact with methadone and antiviral 

drugs [20, 21, 22, 23]. 

Fig. 3. The comparison of execution time TMT A test before 

and after the administration of a single dose of 

methadone in the group of HIV(+) 

Ryc. 3. Porównanie czasu wykonania testu TMT A przed i po 

podaniu metadonu w grupie osób HIV(+) 

DISCUSSION 

The study aimed to verify the effect of a single dose 

of methadone on the motor skills of HIV(+) persons 

addicted to opioids in comparison to HIV(-) ones. In 

addition, the TMT test examined whether its values 

depend on the dose of methadone taken and the 

duration of treatment. 

It was found that there are statistically significant 

differences both in the speed of TMT A test 

completion and in the duration of methadone 

treatment. 

However, this does not mean that there is 

a correlation between these results, because the 

duration of the treatment may be associated with a 

virus carrier status, which is associated with the risk of 

loss of life, and what therefore motivates people in this 

group for a systematic substitution therapy. 

The time of completion of the TMT A test in 

subjects from both groups may be related to the 

influence of psychoactive substances in the nervous 

centers [18,9]. It was found that in people addicted to 

psychoactive substances, structural and functional 

changes take place in the ventral striatum. The major 

part of which is the nucleus accumbens anatomically a 

part of the striatum (including caudate nucleus and 

CONCLUSION 

Based on the analysis of the test results in opioid 

addicted subjects, who are participants of the 

methadone program, before and after the 

administration of a therapeutic dose of methadone, it 

can be concluded that the adoption of a therapeutic 

dose of methadone statistically significantly increases 

psychomotor performance. 

The size of methadone dose does not influence the 

study results. The duration of treatment, which is 

statistically significantly longer in HIV(+) individuals, 

can be determined by a life-threatening risk in this 

group. A single dose of methadone statistically 

significantly affects motor functions of HIV(+) 

subjects. 

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management of opioid dependence: a systematic 

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Assess. 2007, 11, 1–171. 

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The motor evoked potential in AIDS and HAM/TSP, 

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18. Habrat B., et al. Odstęp QT w zapisie ekg u osób z 

uzależnieniem opioidowym leczonych substytucyjnie. 

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systems and networks of the limbic forebrain/limbic 

midbrain. Prog Neurobiol. 2005, 75, 143-160. 

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induced opiate withdrawal amonginjection drug users 

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Address for correspondence: 

Julia Feit 

NZOZ Dom Sue Ryder 

ul. Roentgena 3 

85-796 Bydgoszcz 

tel.: 608-639-983 

fax 52 320 61 85 

e-mail: j.feit@domsueryder.org.pl 

Received: 7.02.2012 

Accepted for publication: 12.04.2012



Elżbieta Grześk 1 , Sylwia Kołtan 1 , Grzegorz Grześk 2 , Barbara Tejza 1 , Robert Dębski 1 , Andrzej Kołtan 1 , 

Mariusz Wysocki 1 , Aldona Katarzyna Jankowska 1 , Sławomir Manysiak 3 , Grażyna Odrowąż-Sypniewska 3 

VALUE OF ERYTHROCYTE SEDIMENTATION RATE, C-REACTIVE PROTEIN 

AND PROCALCITONIN CONCENTRATION VERSUS MULTIMARKER STRATEGY 

IN MANAGEMENT OF BRONCHIOLITIS IN PEDIATRIC EMERGENCY 

WARTOŚĆ DIAGNOSTYCZNA OB, CRP ORAZ STĘŻENIA PROKALCYTONINY 

W RÓŻNICOWANIU INFEKCJI BAKTERYJNYCH I WIRUSOWYCH 

U DZIECI Z ZAPALENIEM OSKRZELIKÓW W PEDIATRYCZNEJ IZBIE PRZYJĘĆ 

Departments of Pediatrics, Hematology and Oncology 1 , Pharmacology and Therapeutics 2 , Laboratory Medicine 3, 

Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun 

Summary 

B a c k g r o u n d . Accurate discrimination between viral 

and bacterial infection is important in children with 

bronchiolitis. During the viral infection the symptomatic 

treatment is the most important but in the presence of 

bacterial infection or co-infection the use of guided 

antibiotics should be started as soon as possible to avoid 

complications. 

Materials and methods. The efficacy of CRP, 

PCT and ESR tests was analyzed in 149 children with 

clinical symptoms of viral (group A) or bacterial co-infection 

(group B). 

R e s u l t s . In the whole group the normal values of 

CRP, PCT and ESR were found in 75% of children. In group 

A normal values of all markers were found in 95%, whereas 

only in 42% of those in group B. The area under the receiver 

operating characteristic (ROC) curve (AUC) for 

distinguishing groups CRP was 0.63 (SE 0.059, 95% CI 0.51 

to 0.75). AUC calculated for PCT was 0.67 (SE 0.06, 95% CI 

0.55 to 0.79) and for ESR it was 0.71 (SE 0.058, 95% CI 

0.60 to 0.83). P values calculated for AUCs’ in comparison 

to CRP, PCT and ESR CRPxPCT were 0.2862, 0.5564 and 

0.9047, respectively, for CRPxESR 0.2311, 0.4487 and 

0.7418, respectively and for PCTxESR - 0.3157, 0.5492 and 

0.8398, respectively. 

C o n c l u s i o n s . Results suggest that value of multimarker 

strategy with the use of CRP, ESR, PCT is comparable 

to single test in distinguishing bacterial co-infection from viral 

etiology, thus single biochemical tests may help to make 

decisions about antibiotic therapy in children with 

bronchiolitis in pediatric emergency. 

Streszczenie 

Wstę p. Prawidłowe różnicowanie infekcji 

wirusowych i bakteryjnych jest bardzo ważne u dzieci z 

zapaleniem oskrzelików. W przypadku infekcji wirusowej 

najistotniejsze jest leczenie objawowe, natomiast podczas 

infekcji bakteryjnej należy jak najszybciej wdrożyć 

antybiotykoterapię celowaną. 

Materiał i m e t o d y . Oznaczenia CRP, PCT oraz 

OB wykonano u 149 dzieci z klinicznymi objawami infekcji 

wirusowej (grupa A), oraz współistniejącej infekcji 

bakteryjnej (grupa B). 

W y n i k i . W badanej grupie prawidłowe wartości 

CRP, PCT i OB stwierdzono u 75% dzieci. W grupie A 

prawidłowe wartości wszystkich wskaźników stwierdzono 

u 95%, natomiast w grupie B tylko u 42% dzieci. Wydajność 

diagnostyczną oceniono na podstawie obszaru pod krzywą 

ROC. 

AUC dla CRP wynosiło 0,63 (SE 0.059, 95% CI 0,51 do 

0,75), dla PCT 0,67 (SE 0,06, 95% CI 0,55 do 0,79), 

natomiast dla OB 0,71 (SE 0,058, 95% CI 0,60 do 0,83). 

Istotność statystyczna obliczona dla AUC w porównaniu

12 

Elżbieta Grześk et. al. 

z CRP, PCT i OB, dla CRPxPCT wynosiły odpowiednio 

0,2862, 0,5564 i 0,9047, dla CRPxOB odpowiednio 0,2311, 

0,4487 i 0,7418, dla PCTxOB odpowiednio – 0,3157, 0,5492 

i 0.8398. 

W n i o s k i . Otrzymane wyniki sugerują, że oznaczenie 

CRP, OB oraz PCT stanowią porównywalną wartość 

diagnostyczną do pojedynczych testów stosowanych 

w różnicowaniu infekcji wirusowych i bakteryjnych, tak więc 

mogą być pomocne podczas podejmowania decyzji 

o rozpoczęciu antybiotykoterapii u pacjentów z zapaleniem 

oskrzelików. 

Key words: erythrocyte sedimentation rate, C-reactive protein, procalcytonin, bronchiolitis 

Słowa kluczowe: OB, białko ostrej fazy (CRP), prokalcytonina, zapalenie oskrzelików 

INTRODUCTION 

Bronchiolitis in children is a serious self-limited 

disease of respiratory tract infections. The presence of 

swelling and destruction of bronchial epithelial cells 

without the spasm of bronchial smooth muscle cells is 

a common histological sign of bronchiolitis [1, 2]. The 

main clinical symptoms of bronchiolitis are wheezing, 

cough and dyspnea. The leading causes of bronchiolitis 

are viral infections, among them the respiratory 

syncytial virus infection is the most frequent (60-80% 

of cases) [3,4]. 

There are two strategies in the treatment of 

bronchiolitis: etiological and symptomatic. During the 

viral infection the symptomatic treatment is the most 

important but in the presence of bacterial infection or 

co-infection, etiological treatment with the use of 

antibiotics should be started as soon as possible. On the 

other hand, the unnecessary use of antibiotics may 

cause many different complications. 

In this condition, the possibility of the most 

accurate and early distinguishing between viral and 

bacterial infection is extremely important. The use of 

single marker strategy may not be adequate, thus the 

use of multi marker strategy should be considered. The 

best widely available markers used in differentiation 

between viral and bacterial infection etiology are C- 

reactive protein and procalcitonin [5]. 

C-reactive protein (CRP) has proven to be a reliable 

marker for infectious diseases thus measurements of 

CRP concentration are routinely used in the clinical 

practice for diagnosis and monitoring of infectious 

diseases such as bronchitis, pneumonia, sepsis etc. [6, 

7]. CRP is an acute phase protein produced by 

hepatocytes as a response to the inflammatory 

conditions. The transcription of CRP gene is upregulated 

by interleukin-6, interleukin-8 and tumor 

necrosis factor, thus CRP concentration reflects the 

severity of inflammation [7]. During inflammation the 

concentration of CRP increases significantly. Normally 

CRP is present in the blood in the concentration below 

5 mg/L. It is generally accepted that serum CRP levels 

below 10 mg/L suggest minor viral infections, whereas 

level of CRP between 10 and 20 mg/L suggests serious 

viral infection. Serum CRP levels above 20-30 mg/L 

are observed during bacterial infections in children; in 

adults this level is usually beyond 50 mg/L [5, 6, 8]. 

The concentration of procalcitonin (PCT) increases 

significantly in bacterial infections. High plasma 

concentrations of PCT typically occur in children with 

severe bacterial infections especially sepsis, meningitis 

and infections of lower respiratory tract. In viral 

infections PCT concentration remains normal, thus 

PCT is one of the best inflammatory markers in 

differentiation between viral and bacterial infections 

[9]. 

According to the Westergren method, erythrocytes 

sedimentation rate (ESR), is commonly used for years 

as an index of inflammation process [10]. However, in 

children CRP appears to be more useful than WBC or 

ESR [11]. There has been limited investigation into the 

role of CRP measurement in distinguishing bacterial 

from viral lower respiratory tract infection [12]. 

In our study we analyzed the efficacy of use the 

CRP, PCT and ESR tests in comparison to routinely 

evaluated examinations in children with clinical 

symptoms of viral bronchiolitis and bacterial coinfection. 

PATIENTS AND METHODS 

The study included 149 children hospitalized 

because of bronchiolitis. The main criterion of 

inclusion was the clinical presentation of bronchiolitis 

thus typical clinical presentation including presence of 

seasonal viral illness characterized by fever, nasal 

discharge and dry, wheezy cough and in physical 

examination inspiratory cracles and/or high pitched 

expiratory wheeze should be present [12]. Of these 

children aged 1-24 months (102 boys – median age 8.2 

months and 47 girls – median age 10.5 months) that 

presented clinical signs of lower respiratory tract 

infection, pathogens were identified in 16 children.

Value of erythrocyte sedimentation rate, C-reactive protein and procalcitonin concentration versus multimarker strategy... 13 

To get the homogeneous group of patients, the 

children with the presence of bronchial asthma, cystic 

fibrosis, pulmonary bronchodysplasts, congenital heart 

diseases, abnormalities of chest and lungs, children 

treated with bronchodilatators and anti-inflammatory 

drugs, children with gastroesophageal reflux were 

excluded from the study. The agreement of parent(s) 

for participation in the study was obligatory. 

According to the results of physical examination in 

pediatric emergency department and during first two 

days of hospitalization at the pediatric department, 

children were included into one of two subgroups: 

children with clinical presentation of viral infection 

(group A) and children with respiratory tract bacterial 

co-infection (group B). In the study group of children 

the concentrations of CRP, PCT and ESR were 

analyzed. Additionally, in the suspicion of bacterial 

infection, in some cases, according to the results of 

physician examination chest X ray (CXR) was 

performed. To classify a child into the group A the 

chest X-ray (if performed) had to be without 

inflammatory changes but the presence of peripheral 

oedema or atelectasis should be present. The CXR 

examination was performed in 130 children in total. 

WBC count of 12 M/L or more in the presence of 

clinical symptoms suggested possibility of bacterial coinfection 

[5,9,10]. Characteristics of the whole group 

of children with bronchiolitis and subgroups A and B 

are presented in Table I. 

Table I. Age and sex of children hospitalized because of 

bronchiolitis 

Number of 

children 

Sex 

Age [months] 

Age ♂ [months] 

Age ♀ [months] 

Total Group A Group B 

149 (100%) 

♂ 102 

(68.5%) 

♀ 47 

(31.5%) 

7 (1-24) 

6,5 (1-24) 

10 (1-24) 

91 (61.1%) 58 (38.9%) 

p=0,0003 

♂ 62 

(68.1%) 

♀ 29 

(31,9%) 

p=0,0001 

♂ 40 

(69,0%) 

♀ 18 

(31%) 

8 (1-24) 5 (1-24) 

p=0.001 

7 (1-24) 5 (1-24) 

p=0.0043 

11 (1-24) 6 (1-24) 

p=0.0559 

♂ - boys, ♀ - girls 

Presented data are median and (minimal – maximal values). 

Statistical significance was calculated for data in group A and B. 

Etiology was identified with the Directigen RSV 

test kit (RSV detection set) (Becton-Dickinson) and 

Euroimmun Pneumo – FIDE M (RTP1) (Lencomm), 

detecting viruses such as RS virus, adenovirus, 

influenza and parainfluenza viruses and bacterial 

pathogens such as Bordetella, Mycoplasma, Legionella 

and Chlamydia. [5,11,13,14]. We found respiratory 

syncytial virus in 3 cases, in 1 case - adenovirus 

infection, in 8 cases - mycoplasma pneumoniae 

infection and in 4 - Bordetella pertusis infection. 

In the study group of children the concentrations of 

inflammatory biomarkers such as CRP, PCT and ESR 

were analyzed. CRP was assayed in the serum using 

high-sensitivity assay (BN II Dade Behring). The assay 

detection limit is 0.15 mg/L and CV is 5% for 

concentration of 0.35 and 0.5 mg/L. PCT was assayed 

using chemiluminescent immunoassay (Liaison-Byk), 

ESR was measured with Sedisystem (Becton- 

Dickinson). 

Border line values suggesting the presence of 

bacterial infection were: for ESR – 15mm/h, CRP 15 

mg/L and PCT 1.0 ng/ml [5,6,7,9,10]. 

Study was approved by the Ethics Committee of the 

Collegium Medicum of Nicolaus Copernicus 

University. 

STATISTICAL METHODS 

Calculations were performed using Statistica PL 

6.0 and Analyse-it for Microsoft Excel (version 2.12) 

[15]. 

Quantitative data from patients of groups A and B, 

after confirmation of normal distribution, were 

compared using Student’s T test, whereas qualitative 

parameters were compared with χ 2 test with Yaets 

correction when necessary. 

Receiver operating curves (ROC) analysis was used 

to define the value of CRP, PCT and ESR better in the 

distinguishing viral from viral coexisting with bacterial 

infection. The area under the curve calculated for CRP 

PCT and ESR alone and in different combination was 

compared using two-tailed Student’s t test. 

RESULTS 

Mean ESR in the study group was 14.1 ± 20.4 

mm/1h. Mean CRP concentration was 4.94 ± 4.92 

mg/L and PCT concentration was 0.48 ± 1.50 ng/ml. 

Mean ESR was 7.5 ± 5.4 mm/1h in the group A and 

significantly higher in the group B 25.5 ± 27.5 mm/1h 

(p

14 

below borderline value of 15 

mm/1h. In group B ESR was 

over 15 mm/1h in 25 out of 

58 cases (42%). 

Concentration of CRP in 

group A was 3.70±1.3 mg/L. 

In the group A concentration 

of CRP was ≤5 mg/L in 89 

out of 91 cases (97%) and in 2 

cases (2%) CRP concentration 

was between 5 and 15 mg/L. 

In group B mean CRP 

concentration was 6.82 ± 7.30 

mg/L and was significantly 

higher than in group A 

(p=0.0001). In group B 

concentration of CRP was ≤5 

mg/L in 37 out of 58 cases 

(64%), in 16 cases (28%) 

CRP concentration was 

between 5 and 15 mg/L and in 

5 cases (9%) was over 15 

mg/L. 


Fig. 1. Number of consecutively increased inflammatory markers (CRP, PCT, ESR) in 

the whole group of children with bronchiolitis, in groups with viral infection 

(group A) and with bacterial infection or co-infection (group B) 

Fig. 2. Empirical test of area under the receiver operating curve (ROC) curve for 

CRP, PCT and ESR in group A and B 

PCT concentration was normal in the group A, 

moreover in 90 out of 91 cases (99%) mean PCT 

concentration was below 0.5 ng/ml. Only in 1 case 

(1%) PCT concentration was between 0.5 and 1 ng/ml. 

In group B concentration of PCT was ≤0.5 ng/ml in 52 

out of 58 cases (90%), in 4 cases (7%) it was between 

0.5 and 1.0 ng/ml and in 2 cases 

(3%) PCT concentration was over 1 

ng/ml. PCT was lower in group A 

than in group B - 0.27 ± 0.12 ng/ml 

vs. 0.75 ± 2.34 ng/ml, respectively. 

However, the difference was not 

statistically significant between the 

groups (p=0.0523) although a 

tendency to statistical significance 

was present. 

In group B the increase beyond 

borderline occurred for ESR in 25 

cases (42%), for CRP - in 21 cases 

(35%) and for PCT - in 6 cases 

(10%). Statistically significant 

differences in concentration of 

markers were found for ESR and 

CRP. 

Analyzing the number of 

consecutively increased inflammatory 

markers, we found that in the 

whole group of children with lower respiratory tract 

infections, the normal values of CRP, PCT and ESR 

were found in 75% of children, but normal values of all 

markers were found in 97% of children from group A, 

whereas only in 40% of those from group B. 1 out of 3


markers was increased in 2% and 2 out of 3 markers 

were increased in 1% of children from group A. In 

group B the values of 1, 2 or 3 of 3 markers of 

inflammation beyond significant for bacterial infection 

were present in 38%, 19% and 3 % of children, 

respectively (Figure 1). 

The area under the receiver operating characteristic 

(ROC) curve (area under curve – AUC) for 

distinguishing viral infection (group A) from viral 

infection with the presence of bacterial co-infection 

(group B) for CRP was 0.63 (SE 0.059, 95% CI 0.51 to 

0.75). AUC calculated for PCT was 0.67 (SE 0.06, 

95% CI 0.55 to 0.79) and for ESR was 0.71 (SE 0.058, 

95% CI 0.60 to 0.83). The differences between AUC 

calculated for CRP, PCT and ESR were not statistically 

significant (Figure 2). AUC calculated for CRP and 

PCT was 0.72 (SE 0.06, 95% CI 0.60 to 0.84), for CRP 

and ESR it was 0.74 (SE 0.07, 95% CI 0.60 to 0.88), 

and for PCT and ESR it was 0.73 (SE 0.08, 95% CI 

0.57 to 0.89). AUC of ROC calculated for double 

marker strategy in comparison to AUC calculated for 

single markers did not differ significantly. P values 

calculated for AUCs’ in comparison to CRP, PCT and 

ESR CRPxPCT were 0.2862, 0.5564 and 0.9047, 

respectively; for CRPxESR - 0.2311, 0.4487 and 

0.7418, respectively and for PCTxESR - 0.3157, 

0.5492 and 0.8398, respectively. 

DISCUSSION 

Early diagnosis of respiratory tract infection is 

difficult, especially when differentiation between viral 

and bacterial infection is necessary to begin a safe and 

effective method of treatment. In most cases, the 

physical examination is not sufficient and we have to 

make additional laboratory tests. In the recent years 

markers of inflammation, such as CRP and PCT, have 

been widely used as a single test or as a part of 

multimarker strategy [5]. Early studies suggested that 

in the diagnosis of bacterial infections PCT is better 

than WBC count or CRP concentration [9]. PCT is also 

a better marker of sepsis than CRP. The increase of 

PCT shows a closer correlation than that of CRP with 

the severity of infection and organ dysfunction [16]. In 

critically ill children PCT is a better diagnostic marker 

of sepsis than CRP. Moreover, CRP, and especially 

PCT, may become a helpful clinical tool to stratify 

patients with SIRS according to the disease severity 

[17]. Some authors suggest that there is relationship 

between severity of bronchiolitis and concentration of 

CRP, thus CRP value on admission might be a marker 

of disease severity and have prognostic significance in 

patients with bronchiolitis [18]. Moulin et al. analyzed 

the predictive value of PCT in differentiating bacterial 

and viral causes of pneumonia [19]. PCT concentration 

was compared to CRP concentration and WBC count, 

and, if samples were available, to interleukin 6 (IL-6) 

concentration. In conclusion the authors suggested that 

PCT concentration, with a threshold of 1 µg/L (1 

ng/ml), is more sensitive and specific and has greater 

positive and negative predictive values than CRP, IL-6, 

or white blood cell count for differentiating bacterial 

and viral causes of community pneumonia in untreated 

children admitted to hospital as emergency cases [19]. 

Other results were presented by Saijo [20]. There were 

no significant differences in the WBC counts, the CRP 

concentrations and ESR levels between the 

bronchiolitis and bronchopneumonia cases. These 

results suggested that the RSV lobar pneumonia cases 

are co-infected with some bacterial organisms more 

heavily than in the RSV bronchiolitis and 

bronchopneumonia cases [20]. Ahn et al. [21] 

suggested that PCT and CRP alone and their 

combination had a moderate ability to detect 

pneumonia of mixed bacterial infection during the 

2009 H1N1 pandemic. 

Our results suggested an increase in investigated 

markers, but the more important was that the normal 

values of CRP, PCT, ESR with normal WBC and 

without clinical or radiological symptoms of bacterial 

infection suggested the presence of viral bronchiolitis. 

In a group B (42% of cases) the CRP, PCT and ESR 

were normal only in 25 children, whereas in group A 

all markers were normal in 88 children (95%). Thus, an 

increase in one or more markers suggests presence of 

bacterial infection or co-infection. The lack of 

significant differences in PCT between the investigated 

groups may result from including in the study children 

with mild to moderate bronchiolitis in the first days of 

disease. The best effect in differentiation between viral 

and bacterial infection seems to be obtained in the 

groups of children with serious infection. 

Similar results were presented by Korpi [22]. The 

aim of the study was to determine if the combination of 

these four host response markers and chest radiograph 

findings were suitable for differentiating pneumococcal 

from viral etiology of pneumonia. In this study CRP, 

WBC count, PCT and ESR were measured in 132 

children hospitalized for community-acquired 

pneumonia. The main conclusion was that CRP, PCT,

16 


WBC and ESR have only limited meaning in 

differentiating pneumococcal or other bacterial 

pneumonia from viral pneumonia. A high value in at 

least one of the markers had been high (CRP > 80 

mg/L, PCT > 1.8 µg/L, WBC > 22 x 10(9)/L or ESR > 

60 mm/h), viral infections were rare [22]. 

Ip analyzed the value of CRP, PCT and neopterin 

tests in differentiation bacterial from viral etiology in 

patients with lower respiratory tract infections. Authors 

observed statistically significant increase in AUC of 

ROC when the multimarker strategy was used [23]. In 

our study the significant increase of AUC was not 

observed, probably because of characteristics of study 

group. Children with clinical symptoms of 

bronchiolitis, were included in our study. Children with 

bacterial co-infection were included to the group B, 

children with viral infection were in group A. Children 

with serious bacterial infection and with clinical 

symptoms of bacterial infection as a main disease were 

excluded, thus the differences were not significant. 

In many recent studies the authors suggest the use 

of new markers such as cytokines [24-27] but the 

routine use of these markers needs additional clinical 

studies. 

CONCLUSION 

Our results suggest that value of multi-marker 

strategy with the use of CRP, ESR, PCT is comparable 

to single tests in distinguishing bacterial co-infection 

from viral etiology, thus single biochemical tests may 

help to make decisions about antibiotic therapy in 

children with bronchiolitis in pediatric emergency. 

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21. Ahn S, Kim WY, Kim SH, Hong S, Lim CM, Koh Y, 

Lim KS, Kim W.: Role of procalcitonin and C-reactive 

protein in differentiation of mixed bacterial infection 

from 2009 H1N1 viral pneumonia. Influenza Other Respi 

Viruses. 2011 Mar 30. doi: 10.1111/j.1750- 

2659.2011.00244.x 

22. Korppi M.: Non-specific host response markers in the 

differentiation between pneumococcal and viral 

pneumonia: what is the most accurate combination? 

Pediatr Int. 2004;46:545-550. 

23. Ip M, Rainer TH, Lee N, Chan C, Chau SS, Leung W, 

Leung MF, Tam TK, Antonio GE, Lui G, Lau TK, Hui 

DS, Fuchs D, Renneberg R, Chan PK.: Value of serum 

procalcitonin, neopterin, and C-reactive protein in 

differentiating bacterial from viral etiologies in patients 

presenting with lower respiratory tract infections. Diagn 

Microbiol Infect Dis. 2007;59:131-136. 

24. Kurylak A, Kurylak D, Dylewska K, Kubicka M, Grześk 

E, Wysocki M, Wojak I: Stężenia prokalcytoniny, 

interleukiny 6, TNF-Alfa, IFN-Gamma oraz interleukiny 

10 w przebiegu zakażeń o etiologii bakteryjnej lub 

wirusowej u niemowląt. Ann. Acad. Med. Bydg. 2004; 

18(4):85-90. 

25. Toikka P, Irjala K, Juvén T, Virkki R, Mertsola J, 

Leinonen M, Ruuskanen O.: Serum procalcitonin, C- 

reactive protein and interleukin-6 for distinguishing 

bacterial and viral pneumonia in children. Pediatr Infect 

Dis J. 2000;19:598-602. 

26. Lacoma A, Prat C, Andreo F, Lores L, Ruiz-Manzano J, 

Ausina V, Domínguez J.: Value of procalcitonin, C- 

reactive protein, and neopterin in exacerbations of 

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Obstruct Pulmon Dis. 2011;6:157-69. 

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Ferra C, Blanco S, Lacoma A, Ribera JM, Ausina V.: 

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2008;49:1752-61. 


Elżbieta Grześk 

Department of Pediatrics, Hematology and Oncology, 

Collegium Medicum 

Sklodowskiej-Curie 9 

85-094 Bydgoszcz, Poland 

phone: +48 52 5854860 

fax: +48 52 5854867 

e-mail: ellag@cm.umk.pl 





Magdalena Hagner-Derengowska 1 , Michał Dylewski 2 , Joanna Dawidziuk 2 , Wojciech Hagner 1 

CHANGEABILITY OF SPATIAL AND TEMPORAL GAIT PARAMETERS 

MEASURED ON A TREADMILL WITH THE USE 

OF A 3D ULTRASOUND-BASED MOVEMENT MEASURING SYSTEM 

ZMIENNOŚĆ PRZESTRZENNYCH I CZASOWYCH PARAMETRÓW CHODU 

MIERZONA NA BIEŻNI Z UŻYCIEM SYSTEMU POMIARU RUCHU 3-D USG 

1 Chair, Department of Rehabilitation Medicine of Collegium Medicum in Bydgoszcz 

Nicolaus Copernicus University in Toruń 

Head: prof. dr hab. Wojciech Hagner 

2 Pod Tężniami’ Health Clinic named after John Paul II, Health Services Cooperative, Research and Development 

Laboratory under the auspices of Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University 

Summary 

I n t r o d u c t i o n . Gait is one of the most often 

analysed forms of movement not only when it comes to 

supporting a diagnosis or controlling treatment, but also as 

far as evaluating the progress of a disease at a clinic or in 

research is concerned. There are many ways of assessing the 

above. They include simple questionnaires and visual 

control, as well as sophisticated, high technology equipment. 

The latter comprise mainly high speed cameras and infrared 

radiation or ultrasound microphones and transmitters. 

Regardless of the used methods, the reproduction of gait 

itself in stable conditions is considered to be constant with 

reference to a single person. This paper presents an attempt 

to assess the changeability of spatial and temporal parameters 

of gait. 

M a t e r i a l s a n d m e t h o d s . 29 randomly chosen 

records of gait on a treadmill were used in this paper. Each 

record was analysed three times, at different time points, i.e. 

5 th , 25 th , 45 th second of gait, and consisted of 10 steps. Spatial 

and temporal parameters, obtained through report for every 

record, were compared with the use of standard statistical 

tools. All measurements were taken with an ultrasound-based 

system used for a 3D motion analysis, i.e. ZEBRIS, with a 

CMS-HS main unit, WinGait software and a ‘15 markers’ 

measuring protocol. 

R e s u l t s . The obtained results show a very high 

(almost perfect) correlation between all probes, i.e. 0.92-1 for 

temporal parameters (arithmetic mean: 0.97) and 0.94-1 for 

spatial parameters (arithmetic mean: 0.98). While average 

differences, as far as spatial parameters were concerned, 

amounted to 0.7 degrees, maximum difference for a single 

movement equalled 1.3 degrees. Additionally, average 

difference presented as a percentage value for posture and 

swing phases equaled 0.8. Average difference in the length of 

steps, on the other hand, equaled 10.5 mm. 

Conclusion. A very high correlation between the 

obtained results and a small difference between spatial and 

temporal parameters show that the analysis of gait, 

performed with the use of an ultrasound-based system, could 

be used for clinical and research-related purposes. It also 

shows that an analysis concerning a part of obtained records 

is representative with reference to the entire measurement. 

Streszczenie 

Wstę p . Chód jest jednym z najczęściej analizowanych 

ruchów zarówno jako badanie dodatkowe w praktyce 

klinicznej oraz w pracach naukowych. Jest wiele sposobów 

wykonania takiej analizy – od prostego kwestionariusza 

i kontroli wzrokowej do bardzo wyrafinowanych, zaawansowanych 

technologicznie urządzeń. Te ostatnie oparte są 

głównie na kamerach o dużej prędkości i promieniowaniu 

podczerwonym lub mikrofonach i ultradźwiękowych nadajnikach. 

Niezależnie od stosowanych metod i ich powtarzalności, 

chód postrzegany jest jako stały dla tej samej osoby

20 

Magdalena Hagner-Derengowska et. al. 

w stabilnych warunkach. W niniejszej pracy podjęto próbę 

oceny zmienności przestrzennych i czasowych parametrów 

chodu. 

Materiał i m e t o d y . W pracy wykorzystano 29 

losowo wybranych zapisów chodu na bieżni. Każdy zapis 

analizowano trzy razy w różnych punktach czasowych – 

zaczynając od 5., 25. i 45. sekundy chodu. Każda analiza 

obejmowała 10 kroków i była wykonywana przez tę samą 

osobę. Przestrzenne i czasowe parametry z otrzymanych 

analiz dla każdego zapisu zostały porównane przy użyciu 

standardowych narzędzi statystycznych. Cały pomiar i zapis 

zostały wykonane przy użyciu opartego na ultradźwiękach 

systemu do przestrzennej analizy ruchu – ZEBRIS, z jednostką 

główną CMS-HS, oprogramowaniem WinGait i protokołem 

pomiarowym „15 markers”. 

W y n i k i . Uzyskane wyniki wskazują bardzo wysoka 

(prawie idealną) korelację (od 0,92 do 1, średnia 0,97 i od 0,94 

do 1, średnia 0,98) odpowiednio dla czasowych i przestrzennnch 

parametrów pomiędzy wszystkimi analizami. 

Średnia różnica w parametrach przestrzennych wynosi 0,7 

stopnia, przy maksymalnej różnicy dla jednego ruchu równej 

1,3 stopnia. Średnia różnica w wartości procentowej faz 

podporu i przenoszenia wynosi 0,8%, a średnia różnica w 

długości kroku wynosi 10,5 mm. 

W n i o s k i . Bardzo wysoka korelacja między 

uzyskanymi wynikami i niewielkie różnice w parametrach 

przestrzennych i czasowych pokazują, że analiza chodu za 

pomocą systemu opartego na ultradźwiękach może być 

uzywana do celów tak klinicznych, jak i badawczych. 

Pokazuje również, że analiza na części otrzymanego zapisu w 

dowolnym miejscu na osi czasu jest reprezentatywna dla 

całego pomiaru. 

Key words: gait, 3D movement analysis, gait parameters 

Słowa kluczowe: chód, trójwymiarowa analiza ruchu, parametry chodu 

INTRODUCTION 

Gait is one of the most often analysed forms of 

movement not only when it comes to supporting a 

diagnosis or controlling treatment, but also as far as 

evaluating the progress of a disease at a clinic or in 

research is concerned. There are many ways of 

assessing the above. They include simple 

questionnaires and visual control, as well as 

sophisticated, high technology equipment. The latter 

comprise mainly high speed cameras and infrared 

radiation or ultrasound microphones and transmitters. 

Regardless of methodology used, assessing the 

changeability of gait parameters in order to decide 

whether changes observed with respect to various 

measurements or gait disturbances could be considered 

as significant or not of great importance. This 

changeability is not only characteristic for a given 

parameter, but also depends on the measuring system 

and the number of gait cycles that are used for an 

analysis. Methodology itself matters as well. 

In this paper the authors try to assess the usefulness 

of a 3D ultrasound-based motion analysis system 

manufactured by ZEBRIS GmbH, Germany, and of 

methods concerning data analysis based on 10 cycles 

of gait. 

MATERIALS AND METHODS: 

Materials 

The study was carried out with the use of 29 

records of gait measurements taken in a group 

consisting of women aged 22-66 (x=45.4, S.D. 15.6). 

All measurements were taken within a standard 

diagnosis procedure in the ‘Pod Tężniami’ Health 

Clinic in Ciechocinek from March to September 2009. 

The research included records of at least 70-second 

recordings that showed no visible technical 

disturbances or no serious gait disorders. The 

recordings used during the research were chosen from 

a number of measurements taken from January to July 

2009. 

Methods 

All measurements of gait were taken with the use 

of a 3D ultrasound-based motion analysis system, 

ZEBRIS, equipped with a main unit – CMS HS – and 

two measuring units (one for each side of the body), as 

well as WinGait software designed for gait analysis. 

During the test, patients were walking on a standard 

Kettler treadmill, the inclination of which was 1 degree 

(a minimum for this type of treadmill). The speed was 

constant and set to a value that suited each participant. 

All recordings were taken with the use of a ‘15 

markers’ measuring protocol which assesses pelvic, 

hip, knee and foot movement. Before a recording took 

place a patient had been walking on a treadmill, the 

speed of which was selected beforehand, for 3 minutes 

and stated that he/she felt comfortable and was walking 

in a natural manner. Every record was analysed three 

times. The method used for data processing was fully 

manual (3 markers) and produced three standard 

reports, each based on 10 steps, starting at different 

time points, i.e. 5 th , 25 th and 45 th second of recording

Changeability of spatial and temporal gait parameters measured on a treadmill with the use of a 3D ultrasound-based... 21 

gait. All three analyses concerning single patients were 

performed by the same person. Then, temporal and 

spatial parameters from the obtained reports were 

analysed. 

Repeatability was calculated with the use of the 

Pearson Correlation Rank as far as single parameters 

were concerned. Additionally, differences between 

single parameters were calculated. 

An evaluation of the following parameters obtained 

from the report took place: 

• minimum and maximum values concerning hip 

flexion, hip adduction, hip rotation, knee 

flexion, ankle flexion, foot rotation, pelvis 

obliquity, pelvis rotation and pelvis tilt, 

• percentage value of posture and swing phases, 

• the length of stride and steps, 

• the duration of double support phases, posture 

and swing phases, steps to the left, steps to the 

right, time of deflection between the left and 

right leg. 

All of these parameters were calculated 

automatically through the WinGait software and 

widely described in the software’s manual. As far as all 

ten steps are concerned, an arithmetic mean was 

calculated on the basis of the obtained data. 

RESULTS 

The obtained correlation value between spatial 

parameters is presented below (Figure 1 and 2). 

Correlation rank 

1,00 

0,99 

0,98 

0,97 

0,96 

0,95 

0,94 

0,93 

0,92 

0,91 

0,90 

Hip 

flexion 

Hip 

adduction 

Hip 

rotation 

Knee 

flexion 

Ankle 

flexion 

Foot 

rotation 

Pelvis 

obliquity 

Pelvis 

rotation 

Pelvis tilt 

Average 

1 to 2 1,00 0,99 0,99 0,98 0,96 0,99 1,00 0,99 1,00 0,99 

1 to 3 0,99 0,99 0,99 0,97 0,94 0,98 0,99 0,98 0,99 0,98 

2 to 3 0,99 0,99 0,99 0,97 0,97 0,98 1,00 0,98 1,00 0,99 

Fig. 2. Average degree of correlation between spatial 

parameters obtained with respect to separate 

analyses 

Average correlation degree obtained for temporal 

parameters is shown below in Figure 3 and 4. 


1,00 

0,99 

0,98 

0,97 

0,96 

0,95 

0,94 

0,93 

0,92 

0,91 

0,90 

Stance 

Phase, 

% 

Swing 

Phase, 

% 

Stride Step 

lenght, m lenght, m 

Double 

support, 

sec 

Stride 

duration, 

sec 

Step 

duration, 

sec 

Stance 

phase, 

sec 

Offset 

right Average 

from left, 

Serie1 0,92 0,92 1,00 0,99 0,96 0,99 0,99 0,99 0,98 0,97 

Fig. 3. Average correlation degree for temporal parameters 

1,02 

1 to 2 

1 to 3 

2 to 3 

1,00 


1,00 

0,99 

0,98 

0,97 

0,96 

0,95 

0,94 

0,93 

Correlation Rank 

0,98 

0,96 

0,94 

0,92 

0,90 

Double 

Stance Swing Stride Step 

support, 

Phase, % Phase, % lenght, m lenght, m 

sec 

Stride Step 

duration, duration, 

sec sec 

Stance 

phase, 

sec 

Offset 

right from Average 

left, sec 

1 to 2 

1 to 3 

2 to 3 

0,92 

0,91 

1 to 2 0,93 0,93 1,00 0,99 0,96 0,99 0,99 0,99 0,99 0,97 

1 to 3 0,92 0,92 1,00 0,99 0,96 0,99 0,99 0,99 0,98 0,97 

2 to 3 0,93 0,93 1,00 1,00 0,97 1,00 1,00 0,99 0,99 0,98 

0,90 

Hip Hip Hip Knee Ankle Foot Pelvis Pelvis 

Pelvis tilt Average 

flexion adduction rotation flexion flexion rotation obliquity rotation 

Correlation Rank 0,99 0,99 0,99 0,97 0,95 0,98 1,00 0,98 1,00 0,98 

Fig. 1. Average correlation degree for spatial parameters 

Fig. 4. Average correlation degree between spatial 

parameters obtained with respect to separate 

analyses 

When taking into consideration both average 

coefficients and data presented in Figure 1 and 2 one 

can see that the highest correlation degree applies to 

pelvis and hip measurement. The lowest values, on the 

other hand, apply to ankle flexion. Nevertheless, even 

the minimum correlation degree that was achieved 

(r=0.94) with respect to ankle flexion, in the period 

from the first to third analysis, is still significantly 

high. 

A very high correlation degree is also obtained 

when it comes to temporal parameters. The lowest 

values of the correlation degree can be noted in the 

stance and swing phase (r=0.92). What is interesting is 

that the values characteristic for the stance phase 

(measured in seconds) reveal a much higher correlation 

degree (r=0.99). 

The correlation degree for all parameters, temporal 

or spatial, are not lower than r=0.9, and the average

22 


value amounts to r=0.98 and r=0.97 for spatial and 

temporal parameters respectively. 

Apart from the degree, also the average differences 

for separate temporal and spatial parameters were 

assessed. Their arithmetic mean values are shown in 

Figure 5 and 6 below. 

When analysing parameters, it is clearly visible that 

parameters characterised by a lower correlation degree 

are also characterised by more significant difference 

between analysed aspects, i.e. parameters regarding 

foot and knee motion, the maximum difference of 

which between the first and third analysis equals 1.17º 

for foot rotation. Moreover, as for correlation, the best 

results (smaller differences) are achieved for pelvis and 

hip motion. The average difference value for all spatial 

parameters equals 0.67º. 

In order to show all temporal parameters in one 

graph, some degrees visible in Figure 6 were changed 

with respect to the SI system, i.e. while time is 

presented in 10 millisecond units and not in seconds, 

length is presented in centimetres instead of meters. 

Averag edifference (degrees) 

1,40 

1,20 

1,00 

0,80 

0,60 

0,40 

0,20 

0,00 

Hip 

flexion 

Hip 

adductio 

n 

Hip 

rotation 

Knee 

flexion 

Ankle 

flexion 

Foot 

rotation 

Pelvis 

obliquity 

Pelvis 

rotation 

Pelvis tilt Average 

Average 0,57 0,34 0,63 0,91 0,90 1,05 0,23 0,56 0,44 0,67 

1 to 2 0,53 0,32 0,57 0,83 0,87 0,91 0,23 0,53 0,38 0,61 

1 to 3 0,63 0,36 0,70 1,00 1,07 1,17 0,25 0,61 0,54 0,75 

2 to 3 0,54 0,33 0,61 0,89 0,75 1,06 0,21 0,55 0,41 0,64 

Fig. 5. Average differences between spatial parameters 

obtained with respect to separate analyses 

Average differences 

1,80 

1,60 

1,40 

1,20 

1,00 

0,80 

0,60 

0,40 

0,20 

0,00 

Stance 

Phase, % 

Swing 

Phase, % 

Stride 

lenght, cm 

Step 

lenght, cm 

Double 

support, 

sec/100 

Stride 

duration, 

sec/100 

Step 

duration, 

sec/100 

Stance 

phase, 

sec/100 

Offset 

right from 

left, 

Average 0,78 0,78 1,25 1,06 1,02 1,27 1,27 1,29 0,98 

1 to 2 0,69 0,69 1,19 1,01 1,05 1,32 1,32 1,15 0,87 

1 to 3 0,84 0,84 1,64 1,27 1,06 1,59 1,59 1,50 1,11 

2 to 3 0,83 0,83 0,93 0,90 0,94 0,89 0,89 1,23 0,97 

Fig. 6. Average differences between temporal parameters 

obtained with respect to separate analyses 

Average 

1 to 2 

1 to 3 

2 to 3 

Average 

The obtained results show that the average 

difference between the percentage values of stance and 

swing phases is lower than 0.8 percent (maximum 0.84 

percent). What is more, the differences between the 

length of a step and a stride equal 0.9 – 1.6 cm, and the 

1 to 2 

1 to 3 

2 to 3 

differences between time parameters range from 10 to 

13 ms. 

DISCUSSION 

High correlation degree for both spatial and 

temporal parameters, as well as small difference 

values, show that the ZEBRIS system for gait analysis 

and the manual analysis based on a 10 gait cycle are 

useful for clinical and research-related purposes. 

Worse outcomes concerning the foot and anklerelated 

parameter may be connected with the 

measurement protocol in which a foot is considered to 

be a rigid segment 2, 3 . However, it should be noticed 

that the ‘15 markers’ protocol used for this purpose is 

not specifically designed for foot and ankle analyses. 

The differences that arose with connection to 

specific movements may be a result of characteristic 

internal reasons, an error in the analysis or a 

combination of both. Regardless of the reason, 

differences in values may be used as possible 

insignificant changes, yet only for the measurement 

methodology used in this paper. Similar reasons and 

possible applications concern temporal parameters. 

It is worth noticing that the intrarater repeatability 

obtained for chosen temporal parameters in the other 

paper (r=0.96, difference in the percentage value of 

phases 0.8, the average difference in the length of steps 

= 4.9 mm) 4 is comparable with the results obtained in 

this research. This indicates that at least a part of those 

differences, if not all, are caused by an error in 

analyses. 

CONCLUSIONS 

The very high correlation between all three probes 

in all parameters and very small differences between 

each and every parameter allow us to state that gait 

measured with the use of a 3D ultrasound-based 

motion analysis is characterised by very low 

changeability. It means that the described method of 

gait analysis could be useful for clinical and researchrelated 

purposes. It also shows that the method 

involving an analysis of data and based on ten steps 

only is sufficient in order to be used for clinical and 

research-related purposes.

Changeability of spatial and temporal gait parameters measured on a treadmill with the use of a 3D ultrasound-based... 23 

REFERENCES 

1. Dennis S., Reynolds R.A.K, Kay R., Tolo V.T. ‘Are 

gait analysis studies medically necessary?’ Gait & 

Posture, Volume 7, Issue 2, Page 160 

2. Kidder, S.; Abuzzahab, F.; Dow, A.; Ortiz, T.; Harris, 

G.; Johnson, J. ‘Repeatability of Kinematic Data in 

Normal Foot and Ankle Motion’ Gait & Posture 

Volume: 4, Issue: 2, April, 1996, pp. 180 

3. ‘WinGait3.x for Windows. User Manual’. Isny am 

Allgau, 2006. 

4. Dylewski M., Trzcińska P., Lorens A., Wagner- 

Derengowska M., Wagner. W. ‘Ocena powtarzalności 

inter i intrarater manualnej obróbki danych podczas 

badania chodu z użyciem systemu ZEBRIS’ – Postępy 

Rehab. 2009 &. 23 nr 2 s. 170-171. 


doc. dr hab. Magdalena Hagner-Derengowska 

Katedra i Klinika Rehabilitacji 

UMK w Toruniu 

Collegium Medicum im. L. Rydygiera 

ul. M. Curie Skłodowskiej 9 


Received: 24.11.2011 




Magdalena Hagner-Derengowska 1 , Monika Dylewska 1 , Michał Dylewski 1,2 

INTRARATER REPEATABILITY OF MANUAL TESTING 

OF FIRST MUSCLE MOVEMENT RESISTANCE 

POWTARZALNOŚĆ INTRARATER MANUALNEGO BADANIA OPORU TKANKOWEGO 

DLA MIĘŚNIA TRÓJGŁOWEGO ŁYDKI 

1 Bydgoska Szkoła Wyższa 

2 Klinika Uzdrowiskowa „Pod Tężniami” im. Jana Pawła II, Spółdzielnia Usług Medycznych w Ciechocinku, 

Laboratorium Badawczo-Rozwojowe pod patronatem CM UMK w Bydgoszczy 

Koordynator: prof. dr hab. Wojciech Hagner 

Summary 

First resistance in passive muscle lengthening is very 

important in both diagnosis and treatment in many muscle 

disorders. Many therapeutic methods use this muscle length 

as a point of reference. All of them assume that a therapist is 

able to feel this moment during manual muscle testing in 

precise and repeatable way. In this paper assumption 

regarding repeatability of such test is verified. 

The study included 34 tests conducted on 17 

participants, both men and women, aged 35.6 (±8.5). Every 

test consisted of three trials on passive ankle dorsiflexion, 

performed by a single, skilled therapist. Joint angle and 

estimated length of triceps surae muscle was recorded in realtime 

measurement using ZEBRIS system and set of four 

active ultrasound markers. Results of that test shows that 

standard deviation and range of results between minimal and 

maximal in each trial for both ankle joint and muscle length 

were below 1 degree and millimeter respectively. Standard 

error of this measurement for joint and muscle length were 

below 0.5 degree and millimeter, respectively. This lead to 

conclusion that manual testing of first resistance in manual 

muscle lengthening performed by skilled therapist has a very 

good repeatability. 

Streszczenie 

Pierwszy opór podczas biernego wydłużania mięśni jest 

bardzo istotnym czynnikiem zarówno w diagnostyce, jak i w 

terapii wielu schorzeń układu ruchu. Wiele metod 

terapeutycznych wykorzystuje tą specyficzna długość 

mięśnia jako punkt odniesienia w wykonywanych 

technikach. Wszystkie one zakładają że terapeuta jest w 

stanie wyczuć moment pierwszego oporu podczas 

manualnego testowania mięśni w sposób dokładny i powtarzalny. 

W przedstawianej pracy to założenie w części 

powtarzalności oceny poddane zostanie weryfikacji. W pracy 

wykorzystano wyniki 34 badań, przeprowadzonych na 17 

uczestnikach, zarówno kobietach jak i mężczyznach, o średniej 

wieku 35,6 (±8,5). Każdy test składał się trzech prób 

wykonania biernego zgięcia grzbietowego stopy, wykonywanych 

przez jednego terapeutę, doświadczonego w pracy 

z pacjentami z zaburzeniami ruchu. Kąt w stawie skokowym 

oraz szacowana długość mięśnia trójgłowego łydki była 

zapisywana w czasie rzeczywistym przez system ZEBRIS 

wyposażony w zestaw 4 aktywnych markerów ultradźwiękowych. 

Wyniki badania pokazują że zarówno odchylenie 

standardowe jak i rozbieżność między skrajnymi wynikami 

w poszczególnych testach zarówno dla zgięcia w stawie, jak 

i długości mięśnia wyniosło poniżej odpowiednio 1 stopnia i 

1 milimetra. Wartość średnia błędu standardowego podczas 

pomiaru poszczególnych testach zarówno dla zgięcia 

w stawie jak i długości mięśnia wyniosła poniżej

26 


odpowiednio 0,5 stopnia i 0,5 milimetra. To prowadzi do 

wniosku że manualne testowanie pierwszego oporu mięśnia 

podczas biernego ruchu wykonywane przez doświadczonego 

terapeutę cechuje się bardzo dobrą powtarzalnością. 

Key words: muscle movement resistance 

Słowa kluczowe: opór mięśni 

First resistance in passive muscle lengthening, so 

called tissue resistance, is very important in 

physiotherapy used nowadays. Possibility to find this 

moment in muscle stretching is a main important skill 

of every therapist dealing with musculoskeletal 

disorders [1,2,3]. In examination of muscle, reaching 

this point allows assessing its tension and flexibility 

[1,2,4]. In tension test of nerves this moment of first 

resistance allows therapist to perform such 

examination and avoid patient’s pain and nerve 

irritation [1,5]. From that point in range of movement 

therapist try to sense an ‘end feel’ and differentiate it 

[1,2,3,5,6] . Also in examination of joints, a point of 

first tissue resistance is a reference point in procedure 

of joint play testing, even though it concerns rather 

joint capsule and translatoric movements, such as 

glides and traction than muscle itself and physiological 

movement [1,7]. Nevertheless, skill of sensing this 

moment remains the same. That skill concerning more 

superficial tissues is also widely used for diagnosis in 

therapeutic methods such as Kinesiology Taping or 

different form of fascia assessment and therapy [8,9]. 

Exact feeling of first resistance is even more 

important in therapeutic than in testing procedures. 

There are many techniques using point of first 

resistance as a reference point, including muscles, 

peripheral nerves, joint capsule or other soft tissue, 

such as fascia [4,8,9,10,11,12]. Moreover, it is often 

stated that physiological reaction and therapeutic 

effects could be different depending on force used to 

lengthening this tissues in relation to point of first 

mechanical resistance, i.e. length and force is lower, 

equal or higher than that point [4,8]. 

In Post Isometric Relaxation of muscles (PIR), the 

isometric voluntary muscle contraction has to be done 

specifically at the moment of tissue resistance – first 

resistance in passive movement which lengthens the 

muscle. On one hand, precise localization allows a 

possibility of muscle relaxation, on the other hand it 

does not cause pain or other unwanted effects. 

Performing these techniques on greater stretch of the 

muscle than point of first resistance is considered as 

mistake [4,8,10]. In joint capsule mobilization, the 

moment of first resistance for passive movement is a 

dividing point between first grade mobilization, used 

for relaxation, joint surface nutrition and analgesic 

action, and third grade mobilization, which is used in 

joint capsule stretching [1,3,7,11]. In these techniques, 

like in many others, feeling of first resistance is of 

great importance to achieve desired results. 

In muscles, described above point of first resistance 

is related mainly with myofibrils, contractile part of 

muscle belly, namely with their initial, resting tension, 

called tonus [13,14]. Sensing that moment during 

passive muscle stretching connected with standard 

linear or angular measurement techniques could be 

then considered as examination of muscle tonus. For 

this application, even more than for described earlier, 

accuracy and repeatability between tests and between 

investigators are required. Only when these conditions 

are satisfied, manual testing of muscle first resistance 

could be used for measurement. 

The goal of this paper is to determine the 

repeatability of calf muscle first stretch resistance 

assessment (the tissue resistance) of test results 

obtained by the same therapist - intrarater repeatability. 

MATERIALS 

The study included 34 tests conducted on 17 

participants, both men and women, patients of the Spa 

Clinic “Pod Tężniami” named after John Paul II in 

Ciechocinek. Mean age of this group was 35.6 (±8.5). 

The group consisted of 6 men and 11 women. 

All participants had signs of shortening triceps 

surae muscles in clinical examination and for all of 

them the post isometric relaxation technique for that 

muscle were used as a therapy of choice. In any case 

conducted measurement did not disturb or affect 

treatment based on clinical reasoning. 

The exclusion criteria for this study were as follows: 

• Injury of the ankle joint 

• Degeneration of the ankle joint grade III or IV 

• Occurring pain during ankle flexion 

• Limitation of knee extension 

• Straight Leg Raise test below 30 degrees 

• Lumbar pain with radiation below the knee 

• Lack of cooperation with therapist 

• Neurological diseases affecting muscle 

tension 

Existed trigger points (unless in acute phase) were 

not considered as contraindication. In general, all

Intrarater repeatability of manual testing of first muscle movement resistance 27 

participants had increased muscle tension, i.e. 

functional problem, rather than structural contraction. 

METHOD 

The test was conducted using three-dimensional 

movement measuring system based on active 

ultrasound markers, ZEBRIS, manufactured in 

Germany by ZEBRIS Medical GmbH. In that case 

system consists of ZEBRIS CMS-HS main unit, 

measuring unit (MU), and set of four single ultrasound 

markers (transmitter). 

The main unit collects the signal from the 

measurement unit and provides control and 

coordination between single ultrasound markers, 

initializing signal sent by them. Main unit collects and 

initially processes acquired data in real time 

measurement. 

The measuring unit consists of three single 

receivers (microphones), fixed on a solid frame in 

established position to each other. Each microphone 

calculates simultaneously distance from the ultrasound 

marker or markers. This allows, when using 

triangulation rules, to define coordinates of each 

transmitter in three dimensional coordinate system 

referred to measuring unit. Calibration allows 

determining the MU towards the frontal, sagittal and 

transversal plane [15]. 

Single ultrasound markers are small transmitters, 

which could be placed on patients’ skin using adhesive 

tape or Velcro strips. The frequency of signal emitting 

is set in software used and can be changed depending 

on measurement requirements and equipment 

capabilities. Placement of transmitters can be dictated 

by a software and protocol used, or freely chosen by 

user. The precision of marker localization in optimal 

condition can be very high, and reaches values below 

0.14 mm for linear and 0.16 degrees for angular 

movement [16]. 

In this study WinData (ZEBRIS Medical GmbH, 

Germany) software were used. This software has no 

rigid protocols of measurement, and provides 

possibility of construction complete and individual 

measurement protocols which fits best to the specific 

requirements of a particular study [17]. 

In order to assess manual testing of triceps surae 

(TS) first mechanical resistance repeatability, authors 

measured angular position of the ankle and calf muscle 

length at the moment when the therapist felt that 

resistance. To achieve this, the single markers were 

placed on: 

• Lateral femoral condyle 

• Posterior part of calcaneal tuberosity at the 

attachment of the Achilles tendon 

• Above lateral ankle, at the axis of 

flexion/extension movement 

• Lateral side of 5-th metatarsal bone base 

Based on this markers placement, following 

parameters were calculated: 

1. Ankle flexion, described as Angle between 

vector of the fibula, connecting marker on lateral 

femoral condyle and lateral ankle, and line built of 

markers on lateral ankle and 5-th metatarsal bone. 

2. Length of the Triceps Surae muscle, and 

actual length of lateral head of gastrocnemius 

muscle. That was calculated as a distance between 

a marker placed on insertion and origin of that 

muscle, i.e. on lateral femoral condyle and on 

calcaneal tuberosity. 

The frequency of signal transmission for each 

marker was 20 Hz. 

The test was executed by a skilled and experienced 

in manual therapy therapist. Patient was lying supine 

on a couch, in comfortable position, with both legs 

extended. After placing markers on the right positions, 

the therapist asked the patient to relax and try not to 

make any movement. Then the therapist made three 

attempts to flex patient’s ankle to dorsal flexion till he 

felt first mechanical resistance of stretched Triceps 

Surae muscle. The therapist was asked to stop for 

about two three to five seconds after reaching this 

‘destination point’. Spatial position of all four markers 

was recorded from the beginning to the end of the test. 

The knee of the patient was still fixed in extension. The 

therapist performing manual testing was not allowed to 

see the monitor screen with graphical exposition of 

measured angular parameters till the test was over. 

Obtained data were then analyzed using standard 

statistical tools, such as mean, standard deviation, 

relative values and standard error of mean in 

Microsoft Office software. 

RESULTS 

For every test there were three values of angular 

position of foot and lower limb collected, each of every 

trial. Based on these results, Standard Deviation

28 


parameter was calculated for each of thirty four of the 

conducted examinations separately. The mean value of 

standard deviation as well as the greatest one for 

angular movement is shown below on Fig. 1. 

Average and maximal values of range between the 

highest and lowest results obtained in every test 

separately for angular movements are also presented on 

Fig. 1. 

mm 

2,5 

2 

1,5 

1 

0,5 

0,55 

Repeatability - Muscle lenght in mm 

0,97 

1,21 

2,16 

Standard Deviation 

Difference between maximal 

and minimal result 

Repeatability - angular values in degrees 

0 

Mean 

Maximum 

Degrees ( o ) 

2 

1,6 

1,2 

0,8 

0,4 

0 

0,54 

Mean 

0,98 0,96 

Maximum 

1,8 

Standard Deviation 

Difference between maximal and 

minimal result 

Fig. 1. Standard deviation and range of obtained results for 

angular movement – average and maximal values 

Very low values of average and maximal standard 

deviation (both below one degree) and low range in 

obtained results for single test (average below one 

degrees and maximal below two degrees) are worth 

noting. This indicates very high repeatability of such 

testing. 

Unlike the angular values, which were defined and 

calculated in WinData software automatically, the 

length of the calf muscle had to be counted from raw 

coordinates in three-dimensional coordinates system in 

excel sheet. When values of muscle length were once 

obtained, also for them standard deviation parameter 

were calculated for each of thirty four tests separately. 

The average value of standard deviation for all tests, 

together with greatest received result for muscle length 

is shown in Fig. 2. 

Similarly to angular values, ranges between 

extreme results for every test were calculated for 

muscle length. Mean and maximal of obtained results 

are shown together with standard deviation of the test 

on Fig. 2. 

Fig. 2. Standard deviation and range of obtained results for 

muscle length – average and maximal values 

It is significant that both standard deviation and 

range between results in single test are very small, 

amounts to less than one millimeter for average values. 

Even the greatest observed differences between results 

in single, three-trial test amounts to about one 

millimeter for standard deviation and two millimeters 

for scope of results in single test. 

Values of standard deviation calculation shown in 

Fig. 1 and Fig. 2 above in relation to measured angle 

and assessed Triceps Surae muscle length, respectively 

are shown in Fig. 3 in percentage values. 

As it can be seen on mentioned figure, all of 

calculated results are far below five percent, which is 

an accepted level of measurement error in medical 

sciences. Also when it comes to values related to 

muscle length, both average and maximal values are 

far below one percent. 

Percentage (%) 

3 

2,5 

2 

1,5 

1 

0,5 

0 

0,13 

Lenght 

Relative values of S.D. in percent 

0,29 

1,55 

Angle 

2,78 

Mean 

Maximum 

Fig. 3. Relative values of standard deviation for angular and 

linear movement – average and maximal values


0,8 

0,7 

0,6 

0,5 

0,4 

0,3 

0,2 

0,1 

0 

Mean and maximal values for Standard Error for measurement 

0,31 

0,55 

Ankle Flexion (º) 

0,33 

0,75 

Muscle lenght (mm) 

Mean SE 

Maximal SE 

Fig. 4. Standard error for angular and linear movement – 

average and maximal values 

Another possibility of evaluation of the 

examination method is standard error of mean. In this 

case, because every test was conducted on different 

sample, each could have had a different actual result, 

there was no possibility to calculate standard error of 

mean (SE) for whole methodology of measurement. So 

in this paper, standard error was assessed for every test 

separately, and then average and maximal outcome has 

been calculated. These results of SE for both linear and 

angular measurement are shown in Fig. 4. 

It must be noted that results observed in Fig. 4, 

actually very good, far below one millimeter and one 

degree respectively for linear and angular movement, 

could be considered only in discussion about 

repeatability, not accuracy. The reason is the fact that 

actual true values of spatial position of ankle or muscle 

length while first mechanical resistance occurs were 

unknown. 

DISCUSSION 

Manual testing of the muscles and joints is 

considered as a major skill in testing and treating 

musculoskeletal patients in many methods of manual 

therapy [3, 5, 10, 12]. Ability to feel and differentiate 

quality of movement, especially from its first 

resistance to the end of passive range of movement is 

considered crucial for testing in manual therapy [1, 2, 

11]. In fact, this is what makes the difference between 

manual therapy and physiotherapy in general. 

Supporting the idea, the general assumption is made 

that a therapist is able to gain ability to feel in recurrent 

manner both first mechanical resistance and quality of 

changes in elasticity of the movement. It is called end 

feel or joint play examination, respectively for 

physiological and additional movements [1, 3, 11]. 

Nevertheless, there is visible lack of research works 

that confirm or deny that possibility among manual 

therapist. One of the reason of the small amount of 

research works in that subject is that described 

phenomenon itself is very subtle and dependent on 

many factors. It is very hard to assess in objective 

manner when this first mechanical resistance occurs in 

a living human being. Theoretically, first mechanical 

resistance (or tissue resistance) of muscle occurs when 

during passive movement myofibrils, fascia, tendon 

and other part of muscle as a whole, reach its resting 

length [8, 13, 14]. It is the moment from which 

stretching of the muscle-tendon unit could occur. So, 

physically, from that moment force needed to increase 

muscle length and range of movement rises, dependent 

on parameter called muscle stiffness [13, 18]. But it is 

not easy to perform objective evaluation of that 

moment on a living person, due to both technical 

problems and great amount of factors influencing that 

parameter. One of the technical problems is that 

passive movement does not produce electric activity of 

the muscles, so EMG is not valid for such examination 

[13, 18]. 

The moment in which first resistance occurs is 

dependent mainly on muscle tonus, so the first group 

of factors influencing tissue resistance are 

neurophysiologic factors, such as mood, emotions, 

apprehension or reliance to therapist, but also spatial 

position of other part of the body causing stress to the 

nervous system – i.e. rotation in cervical spine 

[2,8,10,19,20]. 

Other group of influencing factors is of mechanical 

nature. The most prominent in this group seems to be 

velocity of movement and number of repetition – 

especially if a test movement exceeds moment of first 

resistance [13, 14]. The importance of velocity is 

associated with viscoelasticity, mechanical 

characteristic of human soft tissues that is responsible 

for different reactions of forces acting with different 

speed, but also with physiologic protective reaction of 

a muscle [8, 13, 18]. The high amount of repetition 

could lead to a change of mechanical characteristic of 

the muscles, moving point of first resistance further in 

the range of movement [8, 10, 13] 

Third group of factors could be named technical. 

Inappropriate, uncomfortable position of both patient 

and therapist could affect both muscle tonus and make 

patient relaxation impossible. We also must not forget 

that movement in which tissue resistance is assessed 

must be passive. In clinical test, it is impossible to

30 


move patient’s limb in passive way without patients’ 

relaxation and confidence to the therapist [1,2,8]. 

But all objections mentioned above concern mainly 

problem with determination of accuracy of the testing 

and interrater reliability. In both cases problem with 

objective evaluation of true value of measured 

characteristic and possibility of its changes between the 

tests makes such research hard to perform. 

Focusing on intrarater repeatability and limiting 

number of test movement repetition authors hoped to 

avoid majority of threats mentioned above. 

What is the outcome of obtained results? However, 

it is important to clearly mark what the come of these 

results is. 

We know that a skilled, experienced therapist could 

test first muscle resistance in passive movement in 

very repeatable way – so he feels the mechanical 

resistance in almost the same muscle length in every 

trial. But we do not know if the result obtained by the 

therapist is the true result. 

This implicates that the therapist could use that 

kind of examination as a reference point in different 

therapeutic techniques, what gives him good 

repeatability of performing them. But obtained results 

could not prove that it is the best way to do them, as 

we do not know if the points that therapist feels is the 

right one. However, the good repeatability of 

performing therapeutic techniques gives strong basis 

for research which assesses clinical outcomes of 

therapy. 

The last application is using the manual test of 

muscle first mechanical resistance as a test performed 

during therapy session to assess immediate effect of 

performed treatment technique. Obtained results show 

that such manual testing of tissue resistance could be 

valuable for medical purposes, if joint spatial position 

or muscle length is measured and recorded in more 

traditional or sophisticated way. It was not a goal of 

this paper to evaluate therapist’s possibility to 

differentiation different joint position during manual 

testing. That would require tests including assessment 

of not only proprioceptive skills, but also capabilities 

of memory related to movement task. Because in this 

paper such examination was not performed, that, based 

on obtained results, could not be stated whether a 

therapist is or is not able to use such manual testing 

without additional equipment or not. 

CONCLUSIONS 

On the basis of obtained results following 

conclusions could be made: 

1. Manual testing of muscle first mechanical 

resistance during passive movement is 

characterized by very high intrarater repeatability 

when performing by an experience of therapist. It 

makes this suitable for clinical use as a test and in 

treatment techniques as a reference point. 

2. The high intrarater repeatability allows comparison 

of the obtained results between tests when another 

instrumentation is used for recording ankle position 

or muscle length. 

3. In this paper the possibility of differentiation of two 

different positions was not assessed, so it is not 

known, based on described results, if a therapist is 

able to differentiate changes after therapy 

concerning position when first manual resistance 

occurs without additional equipment. 

4. Accuracy of manual testing was not the subject of 

this work so it can not be assessed based on 

obtained results. However, research in that 

direction could be very interesting and valuable, 

although not easy. 

REFERENCES 

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3. Maitland G.D “Vertebral Manipulation” 6th Edition, 

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4. Lisowski J, Hagner W “Terapeutyczna moc rozciągania 

mięśni. Ćwiczenia w procesie autoterapii I profilaktyki 

najczęstszych dolegliwości I dysfunkcji narządu ruchu” 

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6. Magee DJ .Orthopedic Physical Assessment. Wyd IV. 

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8. Myers WT "Anatomy Trains" I ed. Churchill 

Livingstone, 2001 

9. Kase K, Wallis J, Kase T "Clinical therapeutic 

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Association, 2003. 

10. Rakowski A “Kręgosłup w stresie. Jak pokonać ból i jego 

przyczyny” III wyd, Gdańskie Wydawnictwo Psychologiczne, 

Gdańsk 2001.


11. Kaltenborn FM, Kaltenborn TB, Vollowitz E “Manual 

Mobilization of the Joints, Vol.III. Traction- 

Manipulation of the Extremities and Spine: Basic Thrust 

Techniques” Norli, 2008. 

12. Triano JJ (2001) Biomechanics of spinal manipulative 

therapy, The Spinal Journal vol. 1, Pp.121-130. 

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Lekarskie PZWL; Warszawa 2004. 

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człowieka” Wyd. 2. Wydawnictwo BK, Wrocław 2003 

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oceny postawy ciała z wykorzystaniem czynnych i 

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Biała, 75-84. 

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„Methodological considerations for using a kinematic 

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Wrocław 1997. 

19. Brumagne S, Cordo P, Lysens S, Verschueren S, 

Swinnen S. (2000) The role of paraspinal muscle spindles 

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Electromyogr Kinesiol 13:303-304. 


doc. dr hab. Magdalena Hagner-Derengowska 

Katedra i Klinika Rehabilitacji 

UMK w Toruniu 




Received: 15.11.2011 




Bożenna Mazalska , Bożena Kiziewicz*, Elżbieta Muszyńska , Anna Godlewska , Ewa Zdrojkowska** 

FUNGI AND STRAMINIPILOUS ORGANISMS FOUND AT BATHING SITES 

IN THE VICINITY OF BIAŁYSTOK 

GRZYBY I STRAMINIPILE WYSTĘPUJĄCE W KĄPIELISKACH OKOLIC BIAŁEGOSTOKU 

*Department of General Biology, Medical University, Białystok 

**PhD student 

Head: dr hab. Bożena Kiziewicz 

Summary 

I n t r o d u c t i o n . Fungi and straminipilous organisms play a 

significant role in aquatic ecosystems as a food source for many 

invertebrates and in the process of mineralization of organic matter. 

Research on the occurrence of fungi and straminipila at bathing sites 

has a major sanitary and epidemiological significance since it allows 

registration of fungi that can be potentially pathogenic to man. 

T h e a i m of the present study was to establish species diversity 

of fungi and straminipila found in four bathing sites in the vicinity of 

Białystok, to determine or exclude potential etiological factors of 

mycotic infections, and to determine the effect of physicochemical 

parameters of the waters examined on the growth of this group of 

destruents in the spring and autumn of 2006/2007. 

M a t e r i a l a n d m e t h o d s . The baiting method was used to 

isolate fungi from water samples collected at the respective bathing 

sites. Fungi and straminipilous organisms were trapped using 

amphipod crustacean Gammarus pulex, grass snake skin, onion skin, 

buckwheat seeds, as well as seeds of clover and cannabis. 

R e s u l t s. Forty-two species were identified, with the 

predominance of saprothrophic fungi, particularly species Aspergillus 

fumigatus - a potential etiologic agent factor for aspergillosis. Most 

species were found in the water of the bathing site in Supraśl 

and Jurowce -26 (RF-63.41%), the fewest in Korycin -16 

(RF-39.02%). 

C o n c l u s i o n. Species diversity of the fungal and straminipilous 

organisms at the investigated bathing sites depended on characteristics of 

a given ecosystem, biotic and abiotic factors. 

Streszczenie 

W s t ę p. Grzyby i straminipile pełnią znacząca rolę w 

wodnych ekosystemach, są źródłem pożywienia dla licznych 

bezkręgowców i mineralizują materię organiczną. Badanie 

występowania grzybów i straminipili w kąpieliskach ma duże 

znaczenie w aspekcie sanitarnym i epidemiologicznym, 

ponieważ umożliwia rejestrowanie grzybów potencjalnie 

patogenicznych dla człowieka. 

C e l e m b a d a ń było ustalenie występowania 

grzybów i straminipili, w tym gatunków potencjalnie chorobotwórczych, 

w czterech kąpieliskach okolic Białegostoku 

oraz wpływu na ich rozwój czynników fizykochemicznych 

wiosną i jesienią w 2006 i w 2007 roku. 

M a t e r i a ł i m e t o d y. Do izolowania grzybów 

i straminipili w próbach wody zastosowano metodę przynęt. 

Pułapkami grzybów był kiełż zdrojowy Gammarus pulex, 

wylinka skóry węża, łuska okrywowa cebuli, nasiona gryki, 

także nasiona koniczyny i konopi. 

W y n i k i. Oznaczono łącznie 41 gatunków, dominowały 

saprotrofy, wśród nich Aspergillus fumigatus potencjalny 

czynnik etiologiczny aspergiloz.. Największa liczba gatunków 

wystąpiła w kąpielisku Supraśl i Jurowce - 26 (względna częstotliwość 

– 63,41%), najmniejsza w kąpielisku Korycin – 16 (względna 

częstotliwość – 39,02%). 

W n i o s k i. Zróżnicowanie gatunkowe grzybów i straminipili 

badanych kąpielisk warunkują czynniki biotyczne i abiotyczne tych 

ekosystemów. 

Key words: fungi, straminipilous organisms, bathing sites, Podlasie Province 

Słowa kluczowe: grzyby, straminipile, kąpieliska, województwo podlaskie

34 

Bożenna Mazalska et. al. 

INTRODUCTION 

Fungi and straminipilous organisms exhibit a 

specific activity, colonizing cellulose, lignin, chitin and 

keratin, i.e. the organic material of complex 

polymerized structure difficult to access by other 

microorganism [1]. These important destruents use the 

organic matter for the growth and spread of species, 

considerably contributing to self-purification of water 

reservoirs. During decomposition of dead plants and 

animals, gradual mineralization occurs with release of 

elements that pass into the circulation. Partly 

decomposed biomass is included in the trophic chain 

consisting of subsequent consumers [2,3]. 

The study objective was to establish species 

diversity of fungi and straminipila in water samples 

collected from a few bathing sites in the vicinity of 

Białystok, to identify or exclude potential etiologic 

factors for mycotic infections affecting humans and 

animals, and to determine the effect of 

physicochemical parameters of the waters examined on 

the growth of this group of destruents. 


Description of study area 

Mycological investigations were conducted in 

2006-2007 in two seasons - spring and autumn and 

involved four bathing sites: 

- bathing site in Dojlidy localized near Białystok: 

area 34.2 ha, max. depth 2.85 m, its south shore 

bordered by coniferous woods and its western part with 

the town of Białystok; the samples were collected from 

the western end of this pond, which is used by the 

inhabitants of the town as a beach; 

- bathing site in Korycin situated in the west 

Korycin Reservoir, covering an area of 6.8 ha, mean 

depth 1.35 m. fed by the river Kumiałka; 

- two bathing sites on the river Supraśl in the town 

of Supraśl (41 km of its middle course) and in Jurowce 

(19 km of the middle course). The river Supraśl, 93.8 

km long, covering an area of 1844.4 km 2 is a right 

tributary of the river Narew and its surface intake is a 

source of drinking water supply for inhabitants of 

Białystok and its vicinity. The river, due to the unique 

landscape assets of the Knyszyńska Forest (boreal 

forest resembling southern taiga) is a recreational place 

for the region inhabitants and tourists visiting Podlasie 

[4]. 

Mycological investigations 

For the analysis of fungi and straminipilous 

organisms 3 samples were collected from each 

sampling site. The water collected from the respective 

reservoir was poured in sterile conditions into beakers, 

0.6 l capacity, and placed in the laboratory in 

conditions resembling those of the natural 

environment. Baiting method described by Fuller and 

Jaworski [5], Kiziewicz and Czeczuga [6] was used to 

isolate the fungi from the water. The following baits 

were used: amphipod crustacean Gammarus pulex, 

snake skin Natrix natrix, clover seeds of Trifolium 

repens, hemp seeds Cannabis sativa and buckwheat 

seeds Fagopyrum esculentum, and onion skin Alium 

cepa. Prior to being added to water samples all the 

substrates were boiled and rinsed with distilled water a 

few times. The baits were successively observed under 

an optic microscope (100 and 400x magnification) 

every 3-5 days, starting from day 3 of the culture. 

Next, several microscope preparations were prepared 

from each sample. The samples were stored for about a 

month to detect fungal physiology associated with 

sexual and asexual reproduction. 

Fungi were identified, taking into consideration the 

following morphological features: the shape and size of 

the tallum, the shape of sporangium and spores, the 

structure of the oogonium, antheridium and oospora. 

Works of many authors were used to determine the 

fungi [7-11]. 

Physicochemical investigation 

Water samples were collected at each study site at a 

depth of 0.20 m, by means of a Ruttner’s apparatus 

(vol. 2.0 dm 3 ). Physicochemical analyses of 

temperature, pH, ammonium nitrogen, nitrite nitrogen 

and nitrate nitrogen, phosphates, chlorides and 

sulphates were performed. Standard methods as 

described by [12, 13] were employed for 

physicochemical investigations. 

RESULTS 

The physicochemical analysis of water used for the 

experiments revealed that the highest temperature was 

recorded in the water in bath Dojlidy (13.2°C), 

whereas the lowest in the bath Korycin (11.5°C) 

(Fig. 1). 

The highest pH was in the baths Jurowce (7.90), 

whereas the lowest in the baths Korycin (6.67) (Fig.2).

Fungi and straminipilous organisms found at bathing sites in the vicinity of Białystok 35 

The concentration of ammonium nitrogen in the 

baths Korycin, Jurowce and Supraśl (0.04 mg dm 3 ) 

stayed on the same level in samples of water. In bath 

Dojlidy this content was lower (0.07 mg dm 3 ) (Fig. 3). 

Fig. 1. The temperature of water from the particular bathing 

sites 

Ryc. 1. Temperatura wody na poszczególnych kąpieliskach 

pH 

Fig. 2. Value of the pH of water from the particular bathing 

sites 

Ryc.2. Wartość pH wody na poszczególnych kąpieliskach 

N-NH4 

temperature o C 

8 

7.8 

7.6 

7.4 

7.2 

7 

6.8 

6.6 

6.4 

6.2 

6 

0.08 

0.07 

0.06 

0.05 

0.04 

0.03 

0.02 

0.01 

13.5 

13 

12.5 

12 

11.5 

11 

10.5 

0 

Dojlidy Korycin Jurowce Supraśl 



Fig. 3. Value of the N- NH 4 of water from the particular 

bathing sites 

Ryc. 3. Wartość N-NH 4 wody na poszczególnych 

kąpieliskach 

The highest N-NO 2 concentration was found in the 

bath Dojlidy (0.026 mg dm 3 ). The lowest N-NO 2 

concentration was found in the bath Korycin (0.013 mg 

dm 3 ) (Fig. 4). 

N-NO2 

0.03 

0.025 

0.02 

0.015 

0.01 

0.005 

0 


The water used in our experiment varied with 

respect to the abundance in biogenic compounds 

(Table I). 

Fig. 4. Value of the N-NO 2 of water from the particular 

bathing sites 

Ryc. 4. Wartość N-NO 2 wody na poszczególnych 

kąpieliskach 

Table I. Physicochemical parameters of water from the 

particular bathing sites 

Tabela I. Fizykochemiczne parametry wody w poszczególnych 

kąpieliskach 

Watering places 

Stanowiska pobierania prób wody 

Specification Dojlidy Korycin Jurowce Supraśl 

Parametry 

Temperature 13.2 11.5 13.0 12.0 

( ◦ C) 

pH 6.82 6.67 7.90 7.82 

N-NH 4 0.070 0.040 0.040 0.040 

(mg dm 3 ) 

N-NO 2 0.026 0.013 0.017 0.021 

(mg dm 3 ) 

N-NO 3 0.070 1.200 1.200 1.200 

(mg dm 3 ) 

P-PO 4 

0.300 0.300 0.600 0.400 

(mg dm 3 ) 

Chlorides 4.11 7.00 5.00 19.00 

(mg dm 3 ) 

Sulphates 

(mg dm 3 ) 

9.00 21.0 13.00 29.00 

The concentration of nitrate nitrogen in the baths 

Korycin, Jurowce and Supraśl (1.2 mg dm 3 ) stayed on 

the same level. In the bath Dojlidy this content was 

lower (0.70 mg dm 3 ) (Fig. 5). 

The highest concentration of phosphates was 

recorded in the water in bath Jurowce (0.6 mg dm 3 ). In 

the bath Dojlidy and Korycin the concentration 

continued on the similar level and was half lower than 

in remaining baths (Fig. 6). 

The concentration of chlorides and sulphates was 

revealed similarly in samples of water in all baths. The 

highest value was noted in bath Supraśl, the lowest in 

the bath Dojlidy (Fig. 7, Fig. 8).

36 


The number of species found in the water was the 

highest in the bathing sites in Supraśl and Jurowce – 26 

(RF-63.41%), whereas the fewest fungus species were 

noted in Korycin 16 (RF-39.02%) (Table II). 

belonging to the Peronosporomycetes and 9 species of 

fungi proper belonging to the Chytridiomycetes (7) and 

Ascomycetes (2) (Table II, Fig.9, 10). 

N-NO3 

1.4 

1.2 

1 

0.8 

0.6 

0.4 

0.2 

0 


Fig. 5. Value of the N-NO 3 of water from the particular 

bathing sites 

Ryc. 5. Wartość N-NO 3 wody na poszczególnych kąpieliskach 

Sulphates 

35 

30 

25 

20 

15 

10 

5 

0 


Fig. 8. Value of the sulphates of water from the particular 

bathing sites 

Ryc. 8. Wartość siarczanów w wodzie na poszczególnych 

kąpieliskach 

0.7 

0.6 

0.5 

P-PO4 

0.4 

0.3 

0.2 

0.1 

0 


Fig. 6. Value of the P- PO 4 of water from the particular 

bathing sites 

Ryc. 6. Wartość P-PO 4 wody na poszczególnych kąpieliskach 

Chlorides 

20 

18 

16 

14 

12 

10 

8 

6 

4 

2 

0 


Fig. 9. Dictyuchus monosporus – sexual stage; oogonium 

showing oospora and merging anteridium 

Ryc. 9. Dictyuchus monosporus stadium płciowe; oogonium 

z widoczną oosporą i łączące się anteridium 

Fig. 7. Value of the chlorides of water from the particular 

bathing sites 

Ryc. 7. Wartość chlorków w wodzie na poszczególnych 

kąpieliskach 

The study conducted in the four bathing sites in the 

vicinity of Białystok showed the occurrence of 41 

species, including 32 straminipilous organisms 

Fig. 10. Saprolegnia torulosa - gametangium in mature 

mycelium 

Ryc. 10. Saprolegnia torulosa – dojrzałe gametangium 

grzybni 

Scale bar = 50 µm


Table II. Fungi and straminipilous organisms found in water from the respective bathing sites 2006-2007 

(s – spring, a – autumn) 

Tabela II. Grzyby i straminipile stwierdzone w wodzie badanych kąpielisk 2006-2007 (wiosna, jesień) 

Kingdom, class, order and species 

Królestwo, klasa, rząd i gatunek 

Site 

Stanowiska 


2006 2007 2006 2007 2006 2007 2006 2007 

s a s a s a s a s a s a s a s a 

FUNGI 

Ascomycetes 

Eurotiales 

1. Aspergillus fumigatus Fresenius x 

2. Penicillium chrysogenum Thom x 

Chytridiomycetes 

Blastocladiales 

3. Catenophlyctis variabilis (Karling) 

Karling 

x x x x x x x x x x x 

Chytridiales 

4. Chytridium xylophilum Cornu x x x 

5. Nowakowskiella elegans (Nowakowski) x x x x x x x x x x x x 

Schröter 

6. Phlyctochytrium aureliae Ajello x x 

7. Rhizophydium keratinophilum Karling x 

Spizellomycetales 

8. Rhizophlyctis rosea (de Bary et Woronin) 

A. Fischer 

x x x x x x x x x x x x 

Zoopagales 

9. Zoophagus insidians Sommerstorff x x 

Straminipila 

Hyphochytriomycetes 

Olpidiopsidales 

10. Olpidiopsis saprolegniae Cornu x x x x x 

Peronosporomycetes 

Lagenidiales 

1. Lagenidium humanum Karling x x 

Leptomitales 

12. Apodachlya pyrifera Zopft x x 

13. Leptomitus lacteus (Roth) Agardh x x 

Pythiales 

14. Pythium aquatile Höhnk x x x 

15. Py. butleri Subramaniam x 

16. Py. debaryanum Hesse x x 

17. Py. inflatum Matthews x x x x 

18. Py. myriotylum Drechsler x x 

19. Py. rostratum Butler x x x x x x 

20. Py. tenue Gobi x 

Saprolegniales 

21. Achlya americana Humphrey x x x x x x x x 

22. Ac. flagellata Coker x 

23. Ac. klebsiana Pieters x x x x 

24. Ac. oligacantha de Bary x x 

25. Ac. polyandra Hildebrand x x x x x x x 

26. Ac. racemosa Hildebrand x x x 

27. Ac. treleaseana (Humphrey) Kauffman x x x 

28. Aphanomyces irregularis Scott x x x x x x x x x x 

29. Ap. stellatus de Bary x x 

30. Ap. leavis de Bary x x x 

31. Dictyuchus monosporus Leitgeb x 

32. Isoachlya monilifera (de Bary) Kauffman x x 

33. Saprolegnia anisospora de Bary x x 

34. S. diclina Humphrey x x 

35. S. ferax (Gruith) Thruet x x x x x x x x x x x x 

36. S. glomerata (Thiesenthausen) Lund x x x x x x x 

37. S. litoralis Coker x x 

38. S. parasitica Coker x x x x x x x x x 

39. S. torulosa de Bary x x x 

40. S. unispora Coker et Couch x 

41. Scoliolegnia asterophora (de Bary) 

M.W.Dick 

Total number of species in seasons 12 12 10 10 6 7 6 6 10 12 10 12 10 11 14 12 

Total number 25 16 26 26 

Relative frequency (RF %) 60.97 39.02 63.41 63.41 

x

38 


Taxons identified in all the bathing sites included 

Catenophlyctis variabilis, Nowakowskiella elegans, 

Rhizophlyctis rosea, Saprolegnia ferax and S. 

parasitica. 

Among them potentially pathogenic and 

allergogenic for humans fungi genera Aspergillus, 

Penicilium and Lagenidium have already been 

described. 

Presence of fungi such as Leptomitus lacteus in the 

water of the bath Korycin offers the possibility of using 

them as indicator of water quality. 

DISCUSSION 

The water in Korycin exhibited the smallest 

diversity of fungal and straminipilous species, as 

compared to the remaining bathing sites, in which the 

number of identified taxons was on a similar level. The 

Korycin reservoir is a relatively new ecosystem, 

originating in 2002 as the result of water lifting on the 

river Kumiałka at a distance of 3 km from the 

Brzozówka river mouth (right tributary of the Biebrza 

river), and thus fungal and straminipilous species 

composition was investigated there for the first time. 

Mycological and physicochemical investigations of the 

other water reservoirs had been previously conducted 

as part of surface water monitoring in the region of 

Podlasie Province[14, 15]. 

The water in bath Korycin showed the lower pH 

than in other baths (6.65), whereas the level of nitrate 

nitrogen was much higher than in the water the bath 

Dojlidy and developed on the similar level as in baths 

Jurowce and Supraśl. The concentration of phosphates 

in the Korycin bath was similar like in Dojlidy bath 

and lower than in the water of Supraśl and Jurowce. 

The level of chlorides and sulphates achieved the lower 

value in bath Dojlidy and Jurowce and a little bit 

higher in the bath Korycin. 

Saprotrophic species of the family Saprolegniaceae 

belonging to the genus Achlya, Aphanomyces, 

Dictyuchus and Saprolegnia were also isolated. Such 

species as Achlya americana, Aphanomyces leavis, 

Dictyuchus monosporus, Saprolegnia ferax, S. diclina 

and S. parasitica may lead a parasitic mode of life, 

attacking fish skin and inducing mycotic infections 

[16]. 

An important role in colonizing dead fragments of 

plants – leaves, stems, flowers, fruits and seeds can be 

ascribed to phytosaprophytes which are able to 

synthesize a number of enzymes, both the cellulolytic 

and pectinolytic ones [17,18]. In the investigated water 

reservoirs, Rhizophlyctis rosea, i.e. soil species 

exhibiting strong cellulolytic properties in the aquatic 

environment, was a very common phytosaprophyte 

[19]. 

The analysis also showed the presence of such 

phytopathogens as Pythium butleri attacking tobacco 

and potato seedlings, Py. debaryanum and Py. 

myriotylum, known as soil pathogens of cotton, peas, 

cabbage, tomatoes and tobacco [20]. 

In the water samples from Korycin, Leptomitus 

lacteus was detected, which is a nitrogen loving 

indicator spacies of waters polluted with municipal 

wastes. This species does not require a solid medium 

for growth, but develops intensively in surface waters 

willingly colonizing fish eggs [21]. 

The presence of Zoophagus insidians, a predacious 

fungus fed on rotifers, was observed in the water 

collected from two bathing sites – Dojlidy and Supraśl. 

This species belongs to a small group of fungi which 

equipped in a catching apparatus attack their prey to 

use it as the source of nitrogen [2,6,22]. 

The analysis also revealed the presence of two 

species of keratinophilic saprotrophic fungi, known to 

grow on human skin and hair, namely Lagenidium 

humanum and Rhizophydium keratinophylum. 

Keratinophilic fungi have been reported from water 

reservoirs by [23-26]. 

The region of Podlasie is rich in natural assets: 

picturesque landscape, the abundance of meadows and 

forests, natural habitats of undestroyed valleys. This 

perfect advantage could be used to promote the 

development of tourism and water recreation. 

However, due to the effects of pollution and strong 

anthropopression this unspoilt nature becomes 

impoverished and species diversity reduced. Research 

into the occurrence of fungi and straminipila at bathing 

sites has a major sanitary and epidemiological 

significance since it allows registration of fungi that 

can be potentially pathogenic to man. 

In autumn 2006, at the bathing site of Dojlidy, 

Aspergillus fumigatus, a potential etiologic agent factor 

for aspergillosis was identified. This species shows a 

particular affinity with the respiratory system. 

Cancerogenicity of mycotoxins produced by 

filamentous fungi, especially of the genus Aspergillus, 

has been known. Aflatoxins, fumonisins, ochratoxins, 

zearalenone are causally linked with cancers of the 

breast, liver, oesophagus and prostate. These 

compounds, as well as mould spores can act as strong


allergens [27]. In Poland, in surface waters, potentially 

pathogenic fungi have been identified [28, 29]. 

CONCLUSION 

The number of fungal species in every water reservoir is 

determined by a complex of abiotic and biotic factors present 

at a respective stage of reservoir development. 

In the water samples from Korycin, Leptomitus 

lacteus was detected, which is a nitrogen-loving 

indicator species of waters polluted with municipal 

wastes. 

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e-mail: bozena.kiziewicz@umb.edu.pl 





Katarzyna Strojek, Irena Bułatowicz, Agata Czechowska, Agnieszka Radzimińska, Urszula Kaźmierczak, 

Grzegorz Srokowski, Marcin Siedlaczek 

THE ASSESSMENT OF INFLUENCE OF THERMOPLASTIC FOOT PADS 

ON THE BODY STABILITY IN PATIENTS WITH FOOT DYSFUNCTIONS - PILOTY STUDY 

OCENA WPŁYWU WKŁADEK TERMOPLASTYCZNYCH NA STABILNOŚĆ CIAŁA 

U PACJENTÓW Z DYSFUNKCJAMI STOPY – BADANIA WSTĘPNE 

Departament of Kinezytherapy and Medical Massage Collegium Medicum in Bydgoszcz Nicolaus Copernicus 

University in Torun 

Head of the Chair – Doctor of Medical Sciences Irena Bułatowicz 

Urszula Kaźmierczak - Doctor of Medical Sciences 

Grzegorz Srokowski – Doctor of Medical Sciences 

Katarzyna Strojek – Doctor of Medical Sciences 

Agnieszka Radzimińska - Doctor of Medical Sciences 

Urszula Kaźmierczak - Doctor of Medical Sciences 

Grzegorz Srokowski – Doctor of Medical Sciences 

Marcin Siedlaczek – Master of Physiotherapy 

Agata Czechowska - Master of Physiotherapy 

Summary 

Nowadays, we can observe a tendency to reduce the 

efficiency of the musculoskeletal system. Currently, the 

majority of the population is dominated by a sedentary 

lifestyle. The lower limbs are deprived of systematic 

locomotion training and this is one of the main reasons for 

reduction of feet functional efficiency. A sedentary lifestyle 

more and more often leads to muscles and ligaments 

inefficiency, which often contributes to the foot dysfunctions. 

The aim of this study was to assess the influence of a 

thermoform insole on body stability improvement in patients 

with foot dysfunctions. The research included 20 people with 

one or both feet dysfunctions, qualified to apply modeled 

thermoform insole in order to correct the musculo-skeletal 

imbalance of a foot. The following foot defects appeared the 

most frequently among the people examined: hollow foot, 

abducted foot, adducted foot, longitudinal and transversal flat 

foot. The study was conducted in the Municipal 

Rehabilitation Center for Children and Youth in Torun, and 

started on the first day of giving an insole to a patient. An 

assessment of foot structure and functions, and lower ankle 

joint stability based on static and dynamic test on podoscope 

were carried out. The height and weight were measured. The 

BMI, characterizing height-weight ratios, was calculated. 

Lower limb lengths were measured in order to detect a 

possible asymmetry of limbs, affecting the feeling of a body 

stability. After the application of thermoform insoles, a worse 

outcome of the final assessment appears in overweight and 

obese people . The size of the insole has no significant effect 

on improving the results of the final assessment. In more than 

half of the patients, the standing on one leg test stage of the 

diagnostic part was an objective overall examination of body 

stability using an electronic platform Freeman Easy Tech 

LIBRA®.On the basis of the analysis of the studies, we have 

formulated the following conclusions: 1) The use of 

thermoform insoles individually tailored to the foot 

dysfunctions affects overall improvement in the stability of 

the body in patients in all age groups. 2) Patients aged 21 

obtained a greater improvement of the parameters researched 

than patients aged 22-65. 3) The use of thermoform insoles 

had a positive impact on improving the overall surface 

deflections in all age groups; in patients aged 22-65 the 

improvement was smaller by half of the value. 4) After using

42 

Katarzyna Strojek et. al. 

insoles, the response time for both limbs improved by the 

value of 0.3 s for patients aged 11-21, while in the other 

groups it was slightly worse. 5) Assessment of reaction time 

needs to be completed due to too small group of subjects. 

6) The use of an electronic platform Freeman Easy Tech 

LIBRA® makes it possible to objectify these studies. 7) The 

correct height-weight ratios influence positively achieving a 

greater improvement of the final evaluation. 

Streszczenie 

W dzisiejszych czasach można zaobserwować tendencję 

do obniżania się wydolności narządu ruchu. Aktualnie wśród 

większości populacji dominuje siedzący tryb życia. 

Kończyny dolne pozbawione są systematycznego treningu 

lokomocyjnego i jest to jedna z głównych przyczyn 

obniżenia wydolności funkcjonalnej stóp. Siedzący tryb 

życia prowadzi coraz częściej do niewydolności mięśniowowięzadłowej, 

która niejednokrotnie przyczynia się do 

powstawania dysfunkcji stóp. 

Celem pracy była ocena wpływu zastosowanej wkładki 

termoplastycznej na poprawę stabilności ciała u pacjentów 

z dysfunkcjami stopy. Badaniami objęliśmy 20 osób 

z dysfunkcjami stopy lub obu stóp, kwalifikujących się do 

zastosowania modelowanej wkładki termoplastycznej w celu 

korekcji zaburzeń równowagi mięśniowo-szkieletowej stóp. 

Wśród badanych najczęstszymi wadami stopy były: stopa 

wydrążona, stopa koślawa, stopa szpotawa, stopa płaska 

podłużnie i płaska poprzecznie. 

Badanie przeprowadziliśmy w Miejskim Ośrodku 

Rehabilitacji Dzieci i Młodzieży w Toruniu w pierwszym 

dniu otrzymania przez pacjenta wkładki. Dokonano oceny 

budowy i funkcji stopy, oraz stabilności stawu skokowego 

dolnego opartej na badaniu statycznym i dynamicznym na 

podoskopie. Dokonano pomiaru wysokości i masy ciała. 

Obliczono wskaźnik masy ciała BMI charakteryzujący 

proporcje wzrostowo-wagowe. Wykonano badanie długości 

kończyn dolnych w celu wykrycia ewentualnej asymetrii 

kończyn, rzutującej na poczucie stabilności ciała. Kolejnym 

etapem części diagnostycznej było obiektywne badanie 

ogólnej stabilności ciała przy użyciu elektronicznej platformy 

Freemana Easy Tech LIBRA®. Na podstawie analizy 

przeprowadzonych badań sformułowaliśmy następujące 

wnioski: 

1. Zastosowanie wkładek termoplastycznych dostosowanych 

indywidualnie do dysfunkcji stopy wpływa na ogólną 

poprawę stabilności ciała u pacjentów we wszystkich 

grupach wiekowych. 

2. Pacjenci w przedziale wiekowym do 21 roku życia 

uzyskali większą poprawę badanych parametrów niż pacjenci 

w przedziale wiekowym 22-65 lat. 

3. Zastosowanie wkładki termoplastycznej wpłynęło 

korzystnie na poprawę całkowitej powierzchni wychyleń we 

wszystkich grupach wiekowych, u pacjentów w wieku 22-65 

lat poprawa była o połowę wartości niższa. 

4. Po zastosowaniu wkładki czas reakcji dla obu kończyn 

poprawił się o wartość 0,3s u pacjentów w przedziale 

wiekowym 11-21 lat, zaś w pozostałych grupach uległ 

nieznacznemu pogorszeniu. 

5. Ocena czasu reakcji wymaga uzupełnienia badań ze 

względu na zbyt małą grupę osób badanych. 

6. Zastosowanie elektronicznej platformy Freemana Easy 

Tech LIBRA® daje możliwość obiektywizacji powyższych 

badań. 

7. Prawidłowe proporcje wzrostowo-wagowe wpływają 

korzystnie na uzyskanie większej poprawy oceny końcowej 

po zastosowaniu wkładek termoplastycznych, gorszy wynik 

oceny końcowej jest u osób z nadwagą i otyłością. 

8. Wielkość wkładki nie ma istotnego wpływu na 

poprawę wyników oceny końcowej. 

9. U ponad połowy pacjentów wynik testu stania na 

jednej nodze uległ poprawie po zastosowaniu wkładki 

termoplastycznej. 

Key words: physiotherapy, thermoform insoles, body stability, foot dysfunctions 

Słowa kluczowe: fizjoterapia, wkładki termoplastyczne, stabilność ciała, dysfunkcje stopy 

INTRODUCTION 

Nowadays, we can observe a tendency to reduce 

the efficiency of the musculoskeletal system. 

Currently, the majority of the population is dominated 

by a sedentary lifestyle. The lower limbs are deprived 

of systematic locomotion training and this is one of the 

main reasons for reduction of feet functional 

efficiency. A sedentary lifestyle more and more often 

leads to muscles and ligaments inefficiency, which 

often contributes to the foot dysfunctions. In addition, 

a number of diseases is raising due to occasional use of 

increased physical activity acts, without prior body 

efficiency preparation. These behaviours can lead to 

dysfunctions and deepening of already existing 

diseases [1]. Disturbances occurring in the foot area 

cause changes in the spatial shape of the joints. This 

condition negatively affects the coordination of 

movement patterns, muscle balance and may contribute 

to problems with static and dynamic proprioception in 

the legs area [2]. Muscle imbalance of dysfunctional 

foot includes not only the muscle tension, but also 

leads to changes in correct muscle activity in motor 

acts in the way of compensation. The activity of 

muscles stabilizing ankle joint plays the key role in the 

body stability control [3]. Disorders of a locomotive 

apparatus fitness and dysfunction of postural control 

contribute to the instability of the posture. In addition,

The assessment of influence of thermoplastic foot pads on the body stability in patients with foot dysfunctions... 43 

the body stability is influenced by variables such as 

body weight, height and the size of the body base field 

[4, 5]. Improper footwear, prolonged external load, 

obesity, weakened musculo-ligament apparatus, and 

other factors could lead to an acquired deformity that 

reduces motor skills and over time can cause pain [6]. 

Due to muscles weakness, the whole body weight is 

transferred to the ligament, which stretches as a result 

of disability to cope with too much effort. This 

overload causes irreversible changes in the 

osteoarticular system, which leads to inflammation and 

distortion [7]. In literature, the term ‘static defect or 

distortion; is used and relates to defects in the 

developing osteoarticular system due to imbalance 

between endurance and load of the system in gravity 

conditions [8]. Foot dysfunctions are caused by muscle 

imbalance and dysesthesia. Congenital foot 

dysfunctions occur frequently in the course of 

neuromuscular disorders [5]. The study paid particular 

attention to the selection of appropriate orthopedic 

supply for patients with foot dysfunction. We 

presented applying thermoform insole as a way of 

correction and prevention of dysfunctional feet. The 

main feature of the thermally modeled insoles is the 

ability to make them individually for each foot of the 

patient. Insoles of this type are biomechanically 

designed to shape a foot naturally, support its side 

surfaces and help to correct and control the instability 

of the foot. The main purpose of functional orthopedic 

insoles is to stabilize the lower ankle joint, to set a foot 

in the shoe properly and treat pain in the foot area. 

Proper positioning of the foot by an insole helps other 

locomotive components (joints of lower limbs and 

spine) to increase operational efficiency and prevents 

from the formation of pathological changes in the 

adjacent joints of dysfunctional feet. An insole also 

helps to reduce the feeling of congested muscle fatigue. 

The manufacturer of this type of insoles lists a number 

of features which positively improve a foot comfort: 

secure the optimal distribution of pressing the ground, 

support the vaulted feet, reduce the risk of ankle and 

knee joint injuries, protect the Achilles tendon, provide 

an accurate foot keeping in the axis of motion, prevent 

limbs fatigue, are anti-static, hygienic, easy to clean, 

comfortable and lightweight - insulate from the cold 

and overheating of the foot. The insoles of this type are 

made of polyethylene foam, which makes them 

lightweight, waterproof, shock-absorbing, antibacterial 

and antifungal, which provides a hygienic maintenance 

of feet. The implementation of a thermally modeled 

insole is preceded by a diagnostic system based on a 

podoscope study, which enables to assess the shape 

and function of a foot. The diagnosis is followed by the 

insole creation process: an insole placed in a shoe is 

heated to an appropriate temperature, after that the 

shoe with the insole is worn on the foot. Under the 

influence of self-weight, the process of forming the 

insole to the present shape of the foot begins. The 

insole is then cut and adjusted to the shoes, as it should 

in fact form wholeness with the shoe. Then, the 

pressure force on different parts of the foot changes 

with the use of wedges and pads; it is also possible to 

use elements equalizing the length of a shortened limb. 

In each phase of the treatment, a thermoform insole 

can be remodeled, depending on the current therapeutic 

needs, which gives the patient and therapist a full 

opportunity to control and adjust the insole at a given 

stage of treatment. The correct setting and functioning 

of the lower limbs significantly influence the proper 

posture maintenance. Untreated feet defects are often 

the cause of pain in the foot, leg, knee, hip and spine 

areas. Functional orthopedic insole influences the 

reduction of pain. However, it should be remembered 

that only a comprehensive treatment, which consists of 

a precise diagnosis, treatment of dysfunctional tissues, 

correction of muscular-skeletal imbalances and 

rehabilitation carried out properly, is the key to an 

appropriate therapy [9]. 

AIM 

The aim of this study was to assess the influence of a 

thermoform insole on body stability improvement in 

patients with foot dysfunctions. 

To obtain the evaluation, it is necessary to answer 

the following questions: 1) What is the improvement of 

stability after the application of a thermoform insole, 

on the basis of research conducted by an electronic 

platform Freeman Easy Tech LIBRA® 2) What was 

the influence of the variables, such as age, BMI 

(depending on height and weight), a foot size of a 

patient, on the above results 3) What is the assessment 

of the influence of an individually tailored thermoform 

insole on the stability of standing on one leg? 

MATERIAL 

The research included 20 subjects with one or both feet 

dysfunctions, qualified to apply modeled thermoform 

insole in order to correct the musculo-skeletal

44 


imbalance of a foot. The study was conducted in the 

Municipal Rehabilitation Center for Children and 

Youth in Torun, and started on the first day of giving 

an insole to a patient. The condition for taking part in 

the study was a patient's aware and written consent to 

participate in the study, the age of subjects between 

5-65 years old, a mental condition allowing 

examination on the balance platform, no 

contraindications to exercise, or diseases that may 

affect the falsification of test results (e.g. the peripheral 

system damage). The following food defects appeared 

the most frequently among the people examined: 

hollow foot, abducted foot, adducted foot, longitudinal 

and transversal flat foot. The age of the respondents 

ranged from five to sixty five years old. The average 

age in the study group was 20.4 years. The patients 

were divided into 3 age groups: group I - 5-10 years, 

group II - 11-20 years, group III - 21-65 years. Age 

ranges were based on the stages of growth and 

remodeling of the body according to Martin. In the 

study group aged 5-10 years were 8 patients (5M, 3F). 

The group accounted for 40% of all the respondents, 

the average age was 8.4 years. The group 11-21 years 

consisted of 6 individuals (5M, 1F), which was 30% of 

the total. The average age in this group was 13.8 years. 

The last group within the range of 22-65 years 

consisted of 6 individuals (1M, 5F), which was 30% of 

respondents. The average age was 43.2 years. 

As far as the sex criteria are concerned, the 

structure of the patients in the test groups was the 

following: men 55% (11 people) and women 45% (9 

people). 

METHODS 

A medical history was collected from each patient. The 

interview was to determine whether there is pain in the 

lower limbs area, and what is its location. This allowed 

the initial exclusion of patients whose medical history 

could affect the accuracy of test results. 

Romberg test which was to exclude imbalances 

caused by peripheral somatosensory damage was 

carried out. Romberg test is used to evaluate the 

posture of the patient in a standing position with feet 

together and eyes closed. A healthy person maintains a 

correct posture. In case of balance system damage, the 

patient is unable to stay upright, swaying on all sides, 

or toward the damaged labyrinth. An assessment of a 

foot structure and functions, and lower ankle joint 

stability based on static and dynamic test on podoscope 

were carried out. The height and weight were 

measured. The BMI, characterizing height-weight 

ratios, was calculated. 

Lower limb lengths were measured in order to 

detect a possible asymmetry of limbs, affecting the 

feeling of a body stability. The next stage of the 

diagnostic part was an objective overall examination of 

body stability using an electronic platform Freeman 

Easy Tech LIBRA®. 

There were three tests in one’s own shoes, and 

three in the shoes with a thermoform insole adapted 

individually to the dysfunctions of a patient's foot. The 

tests were performed on the first day of applying a 

thermoform insole. The study required from a patient 

to maintain a maximum healthy balance with a varied 

support surface for 30 seconds of effective time. The 

study was conducted in an upright position, relaxed, 

with feet set in parallel. The study was conducted using 

a profile - a straight line, the degree of amplitude of 

oscillation set at level 3, while the diameter of the 

excursion was 40 cm. Before the right measurement, a 

respondent had the possibility to make a preliminary 

test in order to become familiar with measuring 

equipment. The above test was performed three times 

in patients’ own shoes and three times in the shoes 

with a thermoform insole. Three parameters were 

evaluated: the total area of deflections and response 

times for both legs and an assessment of the overall 

(final). The respondent was able to use a visual 

biofeedback. 

In order to capture functional changes after the 

application of thermoform insoles, the modified test of 

standing on one leg was performed. During the test, a 

patient had to maintain balance while standing on one 

leg and keeping an upright posture, with hands freely 

abandoned along the body within 15 seconds. The 

study was performed in patients’ own shoes and in the 

shoes with a thermoform insole [10, 11, 12, 13]. 

Edition and analysis of results was done using 

STATISTICA 9.0. In this work, we used statistical 

tests: t-Student test for dependent variables 

(significance level = 0.05) and correlation r-Persona. I. 

RESULTS 

The average value of the final assessment for the 

group aged 5-10 years and 11-21 years has 

significantly improved by the value of 1.3. The average 

improvement value in the group 22-65 years was 

slightly lower than in other groups, reaching the value

The assessment of influence of thermoplastic foot pads on the body stability in patients with foot dysfunctions... 45 

of 0.41. A significant difference was noted in the 

evaluation parameter of the total surface deflections, 

which has improved in all groups. Average 

improvement of this parameter for both limbs was 

similar in the group 5-10 years (9.03) and 11-21 years 

(8.29), while the results improvement in respondents 

aged 22-65 years was smaller by about half (4.73). The 

response time for both legs has improved, in relation to 

the result obtained before using a thermoform insole; 

only in the group 11-21 years, while in the other 

groups, it has deteriorated. It should be noted that the 

study was conducted on the first day of receiving the 

insole, which creates new proprioceptive conditions for 

the foot and changes the anatomical relations due to the 

foot’s correct settings. Such changes could have 

affected the deterioration of the response time 

parameter. 

Analyzing the results of the groups formed on the 

basis of determining the height-weight ratios (BMI), 

the relationship of weight and improved results of the 

tested parameters is visible. The final evaluation has 

improved the most in patients with underweight, while 

the lowest value of the improvement was achieved by 

overweight and obese patients. The same trend was 

observed in the evaluation of improvement of the total 

surface deflections parameter for both limbs and 

reaction time parameter. On the basis of the research 

results, it appears that the size of the patient’s foot does 

not significantly affect the results improvement of the 

researched parameters. The results of the final 

evaluation ranged between the lowest values of 

improvement of 0.72 for the group with insole "S" and 

the higher of 1.3 for the group with insole "XS". It can 

be assumed that the differences between the groups 

were not significant. The improvement of the total 

surface deflection parameter improved significantly in 

the groups with insoles size "Kids", "XS", "L", 

reaching values in the range of 7.49-8.25. Only a group 

of patients with insole "S" has reached the lower 

average result of 4.83. The average response time in 

groups with insoles size Kids, XS, S, has minimally 

improved by the value of 0.06 - 0.07 s. In the group, 

which used insole size L, the overall value of the 

response time for both legs worsened by the value of - 

2.98. Standing on one leg test showed that in 14 cases, 

patients who do not have the skills to stand on one leg 

(left or right) in their own shoes, after using the insole 

could maintain balance within a given time. This 

means that in 63% of cases insoles positively 

influenced the improvement of the ability to maintain 

balance in standing on one leg. 

DISCUSSION 

Non-physiological conditions accompanying the 

growth as well as feet functional failure resulting from 

a sedentary lifestyle show that currently, an increasing 

proportion of the population requires a treatment of 

disorders of abnormally shaped foot. The universality 

of this problem causes the growing interest in Podiatry 

- a science dealing with the subject of physiology, 

pathology and feet therapy [14]. There is a more often 

necessity to use orthopedic equipment, which is aimed 

at correction of developing feet deformities and 

protection of the musculo-ligamentous apparatus from 

overloads, arising due to change of normal muscle 

activity changes in the way of compensation appears 

more often [3]. When considering the influence of 

disturbances in the foot area on maintaining a stable 

posture, it can be assumed that feet dysfunctions 

contribute to the deterioration of the body statics, 

which significantly limits the ability to maintain 

balance. In addition, the stability of the body depends 

on variable factors, hence the research included the 

division of the patients based on age, height-weight 

ratios and the foot size. Analysis of issues related to 

assessment of the influence of thermoform insoles on 

the body stability improvement in patients with foot 

dysfunctions is a new issue, which results from the fact 

that the available literature lacks in research of similar 

nature. The above research used thermoform insoles, 

which are different from ‘standard’ insoles available in 

stores. Increasingly, insoles are treated as a serial 

industrial product, which, in our opinion, is an 

erroneous assumption. Insoles should be performed 

according to individual needs, hence the main aim of 

thermoform insoles is the ability to make them on each 

foot of the patient, adjusting an insole individually to 

the needs of disorders in both right and left foot. The 

use of thermoform insoles individually tailored to the 

disorders aims at functional improvement of feet 

efficiency, the correction of feet settings in the shoe 

and the reduction of pain [9]. The possibility to select 

insoles on each foot of a patient individually helps the 

right correction of the foot anatomical structures and 

restoring normal activity of muscles stabilizing the 

ankle joint, which has a significant impact on control 

of body stability.

46 


As indicated by the results obtained in this study, 

the use of thermoform insoles in patients with foot 

dysfunctions influenced the overall improvement of 

balance in all patients in an objective research of the 

general body stability, using an electronic platform 

Freeman East Tech LIBRA ®. The research of the 

influence of thermoform insoles on the body stability 

improvement in patients with foot dysfunctions on a 

large scale have not been carried out so far, and 

therefore other work devoted to this subject cannot be 

found. It should also be noted that the idea of insoles is 

accepted by doctors and physiotherapists, who are 

increasingly using this type of orthopedic supplies in 

Poland as part of therapy. The presented results 

indicate that the thermoform insole, adapted to 

individual needs of a patient, has a positive influence 

on the body stability improvement. It is proved by 

objective using an electronic platform, as well as a 

functional test of standing on one leg, which shows an 

immediate opportunity to acquire skills to maintain a 

balance in this test. The results seem to be encouraging 

to continue and expand the research in this area. 

CONCLUSIONS 

On the basis of the analysis of the studies, we have 

formulated the following conclusions: 

1) The use of thermoform insoles individually 

tailored to the foot dysfunction affects overall 

improvement in the stability of the body in patients in 

all age groups. 

2) Patients aged 21 obtained a greater improvement 

of the parameters researched than patients aged 22-65. 

3) The use of thermoform insoles had a positive 

impact on improving the overall surface deflections in 

all age groups; in patients aged 22-65 the improvement 

was smaller by half of the value. 

4) After using insoles, the response time for both 

limbs improved by the value of 0.3 s for patients aged 

11-21, while in the other groups it was slightly worse. 

5) Assessment of reaction time needs to be 

completed due to too small group of subjects. 6) The 

use of an electronic platform Freeman Easy Tech 

LIBRA® makes it possible to objectify these studies. 

7) The correct height-weight ratios influence 

positively achieving a greater improvement of the final 

evaluation after the application of thermoform insoles, 

a worse outcome of the final assessment appears in 

overweight and obese people. 

8) The size of the insole has no significant effect on 

improving the results of the final assessment. 

9) In more than half of the patients, standing on one 

leg test has improved after using a thermoform insole. 

REFERENCES 

1. Perner R.T, Lipiński T.R. Stopy twojego dziecka. 

http://www.life-plus.pl/str/artykuly/2/. 

2. Lewit K., Stodolny J. Terapia Manualna w rehabilitacji 

chorób narządu ruchu. ZL Natura, Kielce 2001. 

3. Błaszczyk J.W.: Biomechanika kliniczna. PZWL, 

Warszawa 2004. 

4. Błaszczyk J.W.: Biomechanika kliniczna. PZWL, 


5. Aluisio F.V., Christensen C.P., Urbaniak J.R. Ortopedia. 

Urban & Partner, Wrocław 2000. 

6. Green W.B., Dziak A. Ortopedia Nettera. Urban & 

Partner, Wrocław 2007. 

7. Kutzner-Kozińska M. i wsp.: Proces korygowania wad 

postawy. AWM, Warszawa 2001. 

8. Nowotny J. Podstawy kliniczne fizjoterapii w 

dysfunkcjach narządów ruchu. Medipage, Warszawa 

2006. 

9. http://www.dynasplint.com.pl/ 

10. Ciejka, E., Daniszewska B., Janiszewski M. Analiza 

rozwoju i kształtu stopy dziecka w procesie ontogenezy, 

Med Man, Biomed, Głogów 2001, 5, 1 i 2. 

11. Syczewska M., Lebiedowski M., Kalinowska M.: analiza 

chodu w praktyce klinicznej. Biomechanika i inżynieria 

rehabilitacyjna. Akademicka Oficyna Wydawnicza Elit, 

Warszawa 2004, 5, 351-370. 

12. Mraz M., Sipko T., Anwajler J., Dąbrowska G, Skrzek 

A.: Ocena koordynacji ruchowej w utrzymaniu 

równowagi ciała osób młodych i starszych. Acta Bio- 

Optica et Informatica Medica, 2006 ,12, 3, 145-149. 

13. Octkiewicz T., Skalska A., Grodzicki T. Badanie 

równowagi przy użyciu platformy balansowej- ocena 

powtarzalności metody. Gerontologia Polska, 2006, 14, 

2, 144-148. 

14. Perner R.T.: Protetyka i ortotyka – Zarys. Uniwersytet 

Medyczny w Łodzi, Łódź 2003. 


Departament of Kinezytherapy and Medical Massage 

Collegium Medicum in Bydgoszcz Nicolaus 

Copernicus University in Torun 

Curie-Skłodowskiej 9 


Tel. 48 52 585 43 64 

Fax. 48 52 585 43 64 

e-mail:kizkinezy@cm.umk.pl 





Beata Kuryło-Rafińska, Beata Kołodziej, Małgorzata Kubicka, Mariusz Wysocki, Jan Styczyński 

DIFFERENTIAL EX VIVO DRUG RESISTANCE PROFILE IN FIRST 

AND SUBSEQUENT RELAPSED CHILDHOOD ACUTE MYELOID LEUKEMIA 

IN COMPARISON TO INITIAL DIAGNOSIS 

ZRÓŻNICOWANY PROFIL OPORNOŚCI EX VIVO NA CYTOSTATYKI W PIERWSZEJ 

I KOLEJNYCH WZNOWACH OSTREJ BIAŁACZKI MIELOBLASTYCZNEJ U DZIECI 

W PORÓWNANIU Z PIERWSZYM ROZPOZNANIEM 

Pracownia Onkologii Klinicznej i Eksperymentalnej, Katedra Pediatrii, Hematologii i Onkologii, Collegium 

Medicum im. L. Rydygiera w Bydgoszczy, Uniwersytet Mikołaja Kopernika 

Kierownik: prof. dr hab. n. med. Mariusz Wysocki 

Szpital Uniwersytecki nr 1 im. Jurasza w Bydgoszczy 

Dyrektor: Jarosław Kozera 

Summary 

B a c k g r o u n d . Current cure rate reach 50-60% of 

long-term survival in childhood acute myeloblastic leukemia 

(AML). In spite of continuous progress in therapy of AML, 

relapses still occur frequently in both children and 

adolescents. The aim of this study was the analysis of the ex 

vivo drug resistance profile first and subsequent relapse in 

childhood AML in comparison to newly diagnosed AML. 

M e t h o d s . The results of 76 pediatric AML samples 

tested for drug resistance by the MTT assay were analyzed. 

Up to 22 drugs were tested for each patient. 

R e s u l t s . No significant differences between ex vivo 

drug resistance at first and subsequent relapse of childhood 

AML were found, and no drug was found for which 

significantly higher resistance of myeloblasts was observed 

at subsequent relapse, when compared to first relapse of 

AML. For most tested drugs, relapsed patients had higher ex 

vivo drug resistance profile than de novo AML patients. The 

median RR (relative resistance between relapsed and de novo 

diagnosed patients) value of all 22 drugs tested was 1.6. For 

five drugs, RR was significantly higher at relapse: idarubicin 

(1.8-fold), etoposide (5.9-fold), cytarabine (1.7-fold), 

fludarabine (3.7-fold) and busulfan (4.3-fold). For other four 

drugs, a trend for higher resistance at relapse was observed: 

for daunorubicin, mitoxantrone, L-asparaginase and 

cladribine. 

Conclusion. Ex vivo drug resistance profile in 

relapsed childhood AML is higher in comparison to initial 

diagnosis, however we did not find differences in ex vivo 

drug resistance between first and subsequent relapse of 

AML. 

Streszczenie 

Wstę p . Aktualne wyniki leczenia w ostrej białaczce 

mieloblastycznej (AML) u dzieci sięgają 50-60%. Pomimo 

ciągłego postępu, nadal często występują wznowy choroby, 

zarówno u dzieci i u młodzieży. Celem pracy była ocena 

profilu oporności ex vivo na cytostatyki w trakcie pierwszej 

i kolejnej wznowy w stosunku do pierwszego rozpoznania 

w AML u dzieci. 

M e t o d y k a . Analizie poddano wyniki badań oporności 

na cytostatyki wykonanych przy użyciu testu MTT 

u 76 dzieci z AML. Badania przeprowadzono z użyciem 22 

leków.

48 

Beata Kuryło-Rafińska et. al. 

W y n i k i . Nie stwierdzono istotnych różnic w 

oporności ex vivo na cytostatyki pomiędzy pierwszą i kolejną 

wznową choroby. Dla żadnego leku nie zaobserwowano 

większej oporności mieloblastów w trakcie kolejnej wznowy 

w porównaniu do pierwszego nawrotu. Dla większości 

leków, pacjenci we wznowie wykazywali większą oporność 

ex vivo, niż pacjenci z AML de novo. Względna oporność na 

cytostatyki dla pacjentów we wznowie w stosunku do 

pacjentów AML de novo wynosiła dla poszczególnych 

cytostatyków: idarubicyna (wyższa 1,8-krotnie), etopozyd 

(5,9-krotnie), cytarabina (1,7-krotnie), fludarabina (3,7-krotnie) 

i busulfan (4,3-krotnie). Jednocześnie, dla 4 kolejnych 

leków: daunorubicyny, mitoksantronu, L-asparaginazy 

i kladrybiny, różnice były bliskie znamienności statystycznej. 

W n i o s k i . Oporność ex vivo na cytostatyki we 

wznowie AML u dzieci jest wyższa niż podczas pierwszego 

rozpoznania. Nie stwierdzono natomiast istotnych różnic 

w oporności pomiędzy pierwszą i kolejną wznową choroby. 

Key words: acute myeloid leukemia, relapse, multiple relapse, drug resistance 

Słowa kluczowe: ostra białaczka szpikowa, wznowa, wielokrotna wznowa, oporność na cytostatyki 

INTRODUCTION 

Current cure rate reach 80% of long-term survival 

in childhood acute lymphoblastic leukemia (ALL) and 

50-60% in acute myeloblastic leukemia (AML) [1-3]. 

In spite of continuous progress in therapy of acute 

leukemias, relapses still occur frequently in both 

children and adults. The results of therapy in childhood 

relapsed AML do not exceed 30% and are very poor in 

subsequent relapses [2,3]. Failure in the therapy is 

dependent on three factors: pharmacokinetic resistance, 

cellular drug resistance and minimal residual disease 

[4]. Cellular drug resistance can be defined as cellular 

insensitivity to drug reaching the cell. 

Leukemic cells of children with de novo AML 

show higher in vitro resistance to most drugs, when 

compared to the cells of ALL at diagnosis [5, 6]. 

However, still little is known about drug resistance in 

relapsed AML children. There is only a limited number 

of studies published so far [7,8]. It has been shown that 

children with relapsed AML were in vitro median 

3-fold more resistant to cytarabine than the initial 

AML group, however the group of patients was 

relatively small; in the group of poor responders to 

chemotherapy, 3-fold higher resistance to cytarabine 

was observed in comparison to the group of good 

responders [5]. In our study we aimed to compare in 

vitro drug resistance at diagnosis and at first and 

subsequent relapses in the group of patients with AML. 


Patient samples 

A total number of 76 leukemic samples were 

included into the study, including 44 samples obtained 

from patients at initial AML diagnosis, 22 at first 

relapse of leukemia, and 10 obtained at subsequent 

leukemic relapse. Detailed patients characteristics with 

respect to phase of the disease are presented in Table I. 

Table I. Patients characteristics 

Tabela I. Charakterystyka pacjentów 

Number of patients 

Gender (male/female) 

Median age (range) 

FAB types 

M0 

M1 

M2 

M3 

M4 

M5 

M6 

Down syndrome 

Median WBC count 

(range) [G/L] 

Initial AML 

AML de 

novo 

44 

23/21 

12 (0.3-19) 

3 

12 

20 

- 

4 

5 

- 

3 

20.3 

(1.2-341.0) 

First relapse 

AML 

Pierwsza 

wznowa 

22 

14/8 

12.5 (2-19) 

1 

7 

9 

1 

1 

2 

1 

- 

3,5 

(0.7-186.0) 

Subsequent 

relapse AML 

Kolejna wznowa 

10 

6/4 

13.5 (5-18) 

1 

4 

5 

2 

- 

- 

- 

- 

6.1 

(2.7-10.4) 

The distribution of patients between these three 

groups was comparable. All de novo, 10 firstly 

relapsed and all subsequently relapsed patients were 

diagnosed in our Department. This cohort was 

supplemented by 12 firstly relapsed patients from 

previously published study [9]. 

The MTT assay 

Ex vivo drug resistance profile was estimated by 

means of the MTT assay, as described previously [6]. 

Briefly, 80 µl of the cell suspension containing 2 x 10 6 

vital cells/ml was incubated with each drug 

concentration in 20 µl RPMI in duplicate wells of a 96- 

well round-bottomed microtiter plate. Six wells 

containing only cells in a drug-free medium served as 

controls for cell survival, while six other wells 

containing only culture medium blanked the 

spectrophotometer. Plates were incubated for 4 days 

(96 hours) at 37°C in humidified air containing 5% 

CO 2 . After 4 days, 50 µg (10 µl of a solution of 5 

mg/ml) of 3-[4.5-dimethylthiazol-2-yl]-2.5-diphenyl 

tetrazoliumbromide (MTT, Serva, Heidelberg, 

Germany) was added to each well (final concentration 

0.45 mg/ml); plates were shaken and incubated for 

another 4 hours at 37°C. In such an exposure yellow

Differential ex vivo drug resistance profile in first and subsequent relapsed childhood acute myeloid leukemia... 49 

MTT was reduced into purple formazan by viable but 

not dead cells. The formazan crystals were dissolved 

with 100 µl of acidified (0.04 N HCl) 2-isopropanolol 

(Chemia, Bydgoszcz, Poland) and the quantity of 

reduced product was measured by an ELISA EL-312 

microplate spectrophotometer at 570 nm (Asys Hitech 

GmbH, Eugendorf, Austria). Cytospin slides from 

control wells, stained with May-Grunwald-Giemsa, 

were used to determine the percentage of blasts after 

96-hours incubation. Samples with more than 70% 

leukemic cells in the control wells without drug after 4 

days of culture and with an OD higher than 0.050 

arbitrary units (adjusted for blank values) were suitable 

for evaluation. The leukemic cell survival was 

calculated by the equation: (OD drug well / mean OD 

control wells) x 100%. The OD of both control and 

tested wells were adjusted by OD of blank wells. 

The LC50, the concentration of drugs, which was 

lethal to 50% of the cells, was used as a measure for 

the ex vivo drug cytotoxicity in each sample. Relative 

resistance (RR) between the groups of patients for each 

drug was calculated as a ratio of median values of 

LC50. Only samples with successful outcome of the 

assay were included into the study, however in most 

cases only part of drugs was tested for each patient. 

DRUGS 

Following 22 drugs and their concentrations were 

used: prednisolone (Fenicort, Jelfa, Jelenia Góra, 

Poland; tested concentration range 0.007–250 µg/ml), 

dexamethasone (Dexamethasone, Jelfa, Jelenia Góra, 

Poland; 0.0002–6 µg/ml), vincristine (Vincristine, Eli- 

Lilly, Indianapolis, USA; 0.019–20 µg/ml), idarubicin 

(Zavedos, Farmitalia, Milan, Italy; 0.0019–2 µg/ml), 

daunorubicin (Daunorubicin, Rhone-Poulenc-Rhorer, 

Paris, France; 0.0019–2 µg/ml), doxorubicin 

(Doxorubicin, Farmitalia, Milan, Italy; 0.0078–8 

µg/ml), epirubicin (Farmorubicin, Pharmacia & 

Upjohn, Kalamazoo, USA; 0.002–2 µg/ml), 

mitoxantrone (Mitoxantrone, Jelfa, Jelenia Gora, 

Poland; 0.001–1 µg/ml), etoposide (Vepeside, Bristol– 

Myers Squibb, Princeton, USA; 0.048–50 µg/ml), L- 

asparaginase (Medac, Medac, Hamburg, Germany; 

0.0032–10 IU/ml), cytarabine (Cytosar, Pharmacia & 

Upjohn, Kalamazoo, USA; 0.0097–10 µg/ml), 

fludarabine (Fludara, Schering, Berlin, Germany; 

0.019–20 µg/ml), cladribine (Biodribin, Bioton, 

Warsaw, Poland; 0.0004–40 µg/ml), treosulfan 

(Ovastat, Medac, Hamburg, Germany; 0.0005–1 

µg/ml), thiotepa (Thiotepa, Lederle, Greifswald, 

Germany; 0.032–100 µg/ml), melphalan (Alkeran, 

Glaxo, Parma, Italy; 0.038-40 µg/ml), 4-HOOcyclophosphamide 

(Asta Medica, Hamburg, 

Geramany; 0.096–100 µg/ml), 4-HOO-ifosfamide 

(Asta Medica, Hamburg, Germany; 0.096–100 µg/ml), 

bortezomib (Velcade, Janssen Pharmaceutica N.V., 

Beerse, Belgium; 19-2000 nM), busulfan (Busilvex, 

Pierre-Fabre Medicament, Boulogne, France, 1.17- 

1200 µg/ml), 6-mercaptopurine (Sigma, nr M7000, St. 

Louis, USA; 15.6–500 µg/ml), 6-Thioguanine (Sigma, 

nr A4882, St. Louis, USA; 1.56–50 µg/ml). 

STATISTICAL METHODS 

Observed differences in proportions were tested for 

statistical significance using the appropriate chi-square 

statistic. For small sample sizes, the Fisher exact test 

was used. Differences in the distribution of the LC50 

values between two groups were analyzed using the 

Mann-Whitney U test. Using the 2-tailed test, p

50 


Table II. Comparison of ex vivo drug resistance profile between first and subsequent relapse of childhood acute myeloid 

leukemia 

Tabela II. Porównanie profile oporności ex vivo na cytostatyki u pacjentów z pierwszą i kolejnymi wznowami ostrej białaczki 

mieloblastycznej 

DRUG 

Lek 

FIRST RELAPSE 

Pierwsza wznowa 

SUBSEQUENT RELAPSE 

Kolejna wznowa 

N Median Minimum Maximum N Median Minimum Maximum 

Prednisolone 17 95.10 3.40 250.00 7 112.36 36.07 147.50 1.2 0.924 

Dexamethasone 12 6.00 0.03 6.00 6 6.00 6.00 6.00 1.0 0.303 

Vincristine 17 4.27 0.13 20.00 7 2.59 0.57 10.47 0.6 0.775 

Idarubicin 17 0.39 0.03 2.00 9 0.26 0.12 2.00 0.7 0.725 

Daunorubicin 17 0.55 0.03 2.00 7 0.55 0.24 1.59 1.0 0.727 

Doxorubicin 13 5.00 0.34 8.00 6 1.06 0.64 8.00 0.2 0.472 

Epirubicin 8 0.87 0.28 2.00 4 0.79 0.48 0.92 0.9 0.732 

Mitoxantrone 12 0.55 0.01 1.00 6 0.61 0.10 1.00 1.1 0.772 

Etoposide 18 20.14 0.30 50.00 6 22.03 15.75 50.00 1.1 0.662 

L-asparaginase 15 1.40 0.01 10.00 7 1.49 0.20 10.00 1.2 0.800 

Cytarabine 16 0.81 0.22 10.00 8 0.64 0.14 10.00 0.8 0.478 

Fludarabine 13 1.46 0.06 20.00 6 1.19 0.17 20.00 0.8 0.929 

Cladribine 17 10.00 0.00 40.00 8 0.09 0.00 40.00 0.1 0.438 

Treosulfan 9 0.60 0.00 1.00 6 0.58 0.00 2.11 1.0 0.903 

Thiotepa 9 1.59 0.03 12.11 5 1.96 0.59 4.00 1.2 0.947 

Melfalan 8 5.27 0.91 34.45 3 6.65 1.35 15.06 1.3 0.838 

4-HOO-cyclophosphamide 10 2.74 0.38 17.41 6 1.29 0.39 3.13 0.5 0.193 

4-HOO-ifosfamide 3 16.82 8.17 96.90 3 9.72 1.19 32.05 0.6 0.513 

Bortezomib 3 1044.27 261.82 2000.00 2 1199.43 398.85 2000.00 1.1 0.767 

Busulfan 3 64.65 33.53 1200.00 2 488.06 24.12 952.00 7.5 0.564 

6-Thiguanine 10 21.25 1.56 50.00 5 6.25 4.42 18.95 0.3 0.141 

6-Mercaptopurine 9 308.72 141.01 500.00 4 63.55 31.25 81.39 0.2 0.105 

RR 

p 

Median and range of LC50, as the value of in vitro resistance is provided given in IU/ml for L-asparaginase, nM for bortezomib, µM for 

clofarabine and in µg/ml for the remaining drugs; n – number of patients; RR – relative resistance = median LC50 (subsequent relapse) / median 

LC50 (first relapse); n, number of patients; p-value, Mann-Whitney U-test. 

(1.7-fold), fludarabine (3.7-fold) and busulfan (4.3- 

fold). For other four drugs, a trend for higher resistance 

at relapse was observed: for daunorubicin, 

mitoxantrone, L-asparaginase and cladribine. 

DISCUSSION 

In this study we have shown that drug resistance of 

myeloblasts in relapsed patients is higher than that of 

de novo ones. Still, relapse remains a significant 

problem for all children with AML. In the study of 

Dutch-German group, no significant differences in 

drug resistance were reported in a large cohort of 

childhood AML samples taken at diagnosis between 

patients remaining in continuous complete remission 

versus refractory/relapsed patients [10]. In general, 

relapsed AML has a dismal prognosis mainly related to 

the time-interval between initial diagnosis and relapse, 

and possibly cellular drug resistance can play a key 

role in therapy failure of relapsed childhood AML. It is 

important, as relapsed patients had myeloblasts more 

resistant to basic drugs used in the therapy of 

childhood acute myeloid leukemia, such as: cytarabine, 

idarubicin, daunorubicin, mitoxantrone and etoposide. 

Relapsed leukemic blasts were also more resistant to 

drugs commonly used in the therapy of relapsed AML: 

fludarabine, cytarabine and idarubicin. High ex vivo 

drug resistance in childhood acute myeloid leukemia 

might partially explain worse clinical results of 

therapy, when compared to acute lymphoblastic

Differential ex vivo drug resistance profile in first and subsequent relapsed childhood acute myeloid leukemia... 51 

Table III. Comparison of ex vivo drug resistance profile between relapsed and de novo childhood acute myeloid leukemia 

Tabela III. Porównanie profile oporności ex vivo na cytostatyki u pacjentów z ostrą białaczką mieloblastyczną 

i jej wznowami 

DRUG 

Lek 

INITIAL AML 

AML de novo 

RELAPSED AML 

Wznowa AML 

n Median Min Max n Median Min Max 

Prednisolone 38 94.65 0.40 250.00 24 100.65 3.40 250.00 1.1 0.295 

Dexamethasone 18 6.00 0.01 8.00 18 6.00 0.03 6.00 1.0 0.664 

Vincristine 38 2.73 0.02 16.09 24 4.08 0.13 20.00 1.5 0.435 

Idarubicin 40 0.22 0.01 2.00 26 0.38 0.03 2.00 1.8 0.041 

Daunorubicin 37 0.27 0.01 2.00 24 0.55 0.03 2.00 2.0 0.052 

Doxorubicin 33 1.69 0.24 8.00 19 1.41 0.34 8.00 0.8 0.870 

Epirubicin 17 0.90 0.13 2.00 12 0.80 0.28 2.00 0.9 0.790 

Mitoxantrone 34 0.23 0.00 13.28 18 0.61 0.01 1.00 2.6 0.077 

Etoposide 36 3.44 0.05 50.00 24 20.14 0.30 50.00 5.9 0.007 

L-asparaginase 33 0.68 0.03 10.00 22 1.35 0.01 10.00 2.0 0.058 

Cytarabine 40 0.47 0.01 12.19 24 0.78 0.14 10.00 1.7 0.050 

Fludarabine 35 0.40 0.02 15.54 19 1.46 0.06 20.00 3.7 0.022 

Cladribine 32 0.04 0.00 40.00 25 0.75 0.00 40.00 21.2 0.072 

Treosulfan 31 0.32 0.00 1.00 15 0.60 0.00 2.11 1.9 0.572 

Thiotepa 31 1.88 0.12 100.00 14 1.94 0.03 12.11 1.0 0.787 

Melfalan 25 4.65 0.10 40.00 11 6.57 0.91 34.45 1.4 0.973 

4-HOO-cyclophosphamide 30 1.68 0.24 9.35 16 2.16 0.38 17.41 1.3 0.890 

4-HOO-ifosfamide 13 1.98 0.35 34.74 6 13.27 1.19 96.90 6.7 0.136 

Bortezomib 16 353.74 191.50 1096.83 5 1044.27 261.82 2000.00 3.0 0.137 

Busulfan 14 15.19 1.17 42.30 5 64.65 24.12 1200.00 4.3 0.004 

6-Thiguanine 17 14.63 1.36 50.00 15 14.79 1.56 50.00 1.0 0.533 

6-Mercaptopurine 18 106.15 15.63 500.00 13 229.25 31.25 500.00 2.2 0.118 

RR 

P 

Median and range of LC50, as the value of in vitro resistance is provided given in IU/ml for L-asparaginase, nM for bortezomib, µM for 

clofarabine and in µg/ml for the remaining drugs; n – number of patients; RR – relative resistance = median LC50 (initial AML) / median 

LC50 (relapsed AML); n, number of patients; p-value, Mann-Whitney U-test. 

leukemia. It is commonly assumed that relapsed 

patients are more drug resistant than those diagnosed 

de novo, and it was shown in this analysis for relapsed 

AML samples. No conclusive results were obtained for 

stem cell transplant teams, as relapsed patients were 

highly resistant to busulfan, which is a key compound 

used in conditioning of AML patients before 

hematopoietic stem cell transplantation. On the other 

hand, no significant differences were found between de 

novo and relapsed patients for cyclophosphamide and 

treosulfan. In current therapeutic regimens, based on 

reduced intensity conditioning, these drugs play an 

important role. 

Unlike ALL, the role of individual in vitro tumor 

response testing in childhood AML has not been 

established yet. Several groups reported possible 

prognostic value of in vitro drug sensitivity in pediatric 

AML, showing a good correlation between in vitro 

drug resistance and short-term clinical outcome after 

chemotherapy [7,11-14]. These findings were related 

mainly to cytarabine [7] and cyclophosphamide [14]. 

Part of these studies included both children and adults. 

Newer, large studies showed no correlation between in 

vitro drug resistance to individual drugs and long-term 

clinical outcome in childhood AML [15-17]. So far, no 

data exist to support the prognostic value of any in 

vitro drug resistance profile in childhood AML, while 

this relationship has been confirmed in adult AML 

[18]. In our previous preliminary report of our group, 

we showed the possible prognostic value of a 

combined fludarabine, treosulfan and mitoxantrone 

resistance profile in children with AML [8]. Recently,

52 


new compounds were shown to have good 

antileukemic activity in childhood AML [19,20]. There 

are still large hopes in results obtained in microarray 

studies [21]. 

In conclusion, ex vivo drug resistance profile in 

relapsed childhood AML is higher in comparison to 

initial diagnosis, however we did not find differences 

in ex vivo drug resistance between first and subsequent 

relapse of AML. 

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1629-1632. 


prof. dr hab. n. med. Jan Styczyński 

Katedra i Klinika Pediatrii, Hematologii i Onkologii 

Collegium Medicum im. L. Rydygiera w Bydgoszczy 

Uniwersytet im. Mikołaja Kopernika 

ul. Curie-Skłodowskiej 9 


e-mail: jstyczynski@cm.umk.pl 

tel.: 52 585 4860 

fax: 52 585 4867 





Aneta Zreda-Pikies, Andrzej Kurylak 

SOCIAL FUNCTIONING OF CHILDREN WHO HAVE COMPLETED 

ACUTE LYMPHOBLASTIC LEUKEMIA TREATMENT 

SPOŁECZNE FUNKCJONOWANIE DZIECI PO ZAKOŃCZONYM LECZENIU 

OSTREJ BIAŁACZKI LIMFOBLASTYCZNEJ 

Department of Paediatric Nursing, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń 

Head: prof. dr hab. n. med. Andrzej Kurylak 

Summary 

I n t r o d u c t i o n . A progress in acute lymphoblastic 

leukemia treatment led to an increased number of recoveries. 

This fact forces us to look closely at the functioning of 

patients after completed treatment. Learning a subjective 

evaluation of functioning may indicate existence of nonperceived 

needs of patients who require specialist care and 

help outside the hospital environment. 

Materials and methods. The research was 

conducted among patients treated in the Chair and Clinic of 

Pediatrics, Hematology and Oncology of Nicolaus 

Copernicus University Collegium Medicum in Bydgoszcz, 

who have completed acute lymphoblastic leukemia 

treatment. The final group of patients who participated in the 

research consisted of 64 persons. Research referring to 

healthy children was carried out among students of primary 

schools, junior high schools and kindergartens from 

Bydgoszcz. Only children who have never undergone 

hospital treatment and did not suffer from chronic diseases 

were qualified for the said research. The comparative group 

consisted of 70 healthy children. In order to evaluate the 

quality of life of children who had completed ALL treatment 

and of healthy children James W. Varni’s standardized 

research instrument was used. 

R e s u l t s . The subjective evaluation of social 

functioning is quite high in all age groups and comprises 85- 

88 points. The highest rated item is maintaining good 

relationships with peers. The most problematic aspects are 

connected with an inability to perform all activities that peers 

can perform. As far as indirect evaluation is concerned, the 

lowest amount of points pertaining to social functioning was 

given within the group of children aged 2-4. When analysing 

social functioning, an essential statistical difference in its 

evaluation, both direct and indirect, was observed in favour 

of healthy children. As far as statistics is concerned a general 

evaluation of functioning at school differs significantly 

between children who have completed ALL treatment and 

healthy children (69.57 vs. 81.27; p=0.001). 

C o n c l u s i o n . The quality of life within the sphere of 

social functioning of children and teens who have completed 

treatment is significantly lower than among healthy children. 

Streszczenie 

Wstę p. Postęp w leczeniu ostrej białaczki limfoblastycznej 

spowodował wzrost liczby osób wyleczonych, fakt 

ten wymusza spojrzenie na funkcjonowanie pacjenta po 

zakończonym leczeniu. Poznanie subiektywnej oceny 

funkcjonowania może wskazywać na istnienie niedostrzeganych 

potrzeb pacjentów wymagających zapewnienia 

fachowej opieki i pomocy poza środowiskiem szpitalnym. 

Materiał i m e t o d y . Badania przeprowadzono 

wśród pacjentów leczonych w Katedrze i Klinice Pediatrii, 

Hematologii i Onkologii Collegium Medicum Uniwersytetu 

Mikołaja Kopernika w Bydgoszczy, którzy zakończyli 

leczenie ostrej białaczki limfoblastycznej. Ostateczna liczba 

osób, biorących udział w badaniu wynosiła 64. Badania 

wśród dzieci zdrowych przeprowadzono wśród uczniów 

szkoły podstawowej, gimnazjum oraz przedszkola na terenie 

Bydgoszczy. Do badania zakwalifikowano dzieci, które 

nigdy nie były poddane leczeniu szpitalnemu oraz nie 

chorują na choroby przewlekłe. Grupę porównawczą

54 


stanowiło 70 dzieci zdrowych. Do oceny jakości życia dzieci 

po zakończonym leczeniu ALL oraz dzieci zdrowych użyto 

standaryzowanego narzędzia badawczego autorstwa Jamesa 

W. Varni. 

W y n i k i . Subiektywna ocena funkcjonowania 

społecznego we wszystkich grupach wiekowych jest dość 

wysoka i mieści się w granicach 85-88 punktów. Najwyżej 

oceniane jest utrzymywanie dobrych kontaktów z 

rówieśnikami. Najwięcej problemów związanych jest z 

brakiem możliwości wykonywania wszystkich czynności, 

które mogą robić ich rówieśnicy. W ocenie pośredniej 

najmniej punktów dla funkcjonowania społecznego 

przyznanych jest w grupie dzieci od 2 do 4 lat. Podczas 

analizy funkcjonowania społecznego zaobserwowano istotną 

statystycznie różnice w jego ocenie na korzyść dzieci 

zdrowych, zarówno w ocenie bezpośredniej, jak i pośredniej. 

Ogólna ocena funkcjonowania w szkole różni się istotnie 

statystycznie pomiędzy dziećmi po zakończonym leczeniu 

ALL, a dziećmi zdrowymi (69,57 vs 81,27; p=0,001). 

Wniosek. Jakość życia w sferze funkcjonowania 

społecznego dzieci i młodzieży po zakończonym leczeniu 

jest znamiennie niższa niż wśród dzieci zdrowych. 

Key words: social functioning of children, acute lymphoblastic leukemia 

Słowa kluczowe: funkcjonowanie społeczne dzieci, ostra białaczka limfoblastyczna 

INTRODUCTION 

A progress in treatment of life-threatening diseases, 

which led to an increased number of cured persons, 

forces us to look closely at the functioning of patients 

after completed treatment. ALL treatment results 

which apply to children have been improving 

systematically for the past years. At present, over 80 

percent of children are considered to be cured; 

therefore, it is justified to evaluate the quality of their 

life. Learning a subjective evaluation of the quality of 

life may be a source of information which often differs 

from the evaluation made by medical staff or sick 

children’s parents. The information might indicate 

existence of non-perceived needs of patients who 

require specialist care and help outside the hospital 

environment. 

The purpose of this paper is to evaluate the quality 

of life of children suffering from ALL as far as social 

functioning is concerned. 

MATERIALS AND METHODS 

The research was conducted among patients treated 

in the Chair and Clinic of Pediatrics, Hematology and 

Oncology of Nicolaus Copernicus University 

Collegium Medicum in Bydgoszcz, who have 

completed acute lymphoblastic leukemia treatment. It 

comprised children whose ALL treatment had finished 

at least 6 months prior to the research. The final group 

of patients who participated in the research consisted 

of 64 persons. The number of boys and girls was 

comparable and amounted to 33 and 31, respectively. 

The average age of children at the moment of the 

research was 11.3 (4-18 years old, median - 11) and at 

the moment of diagnosis - 6 (1-17 years old, median - 

5). 

Research referring to healthy children was carried 

out among students of primary schools, junior high 

schools and kindergartens from Bydgoszcz. Only 

children who had never undergone hospital treatment 

and did not suffer from chronic diseases were qualified 

for the said research. The comparative group included 

70 healthy children: 31 girls and 39 boys. The children 

were aged from 2 to 17, with the average age of 10.98 

(median – 12). 

In order to evaluate the quality of life of children 

who have undergone ALL treatment and of healthy 

children, James W. Varni’s standardized research 

instrument was used [1, 2, 3, 4, 5, 6]. Permission to use 

the questionnaire was granted by the Mapi Research 

Trust Institute in Lyon. 

The Paediatric Quality of Life Questionnaire - 

PedsQL 4.0. Generic Core Scale is a general use tool 

which has a Polish version. It is used to evaluate the 

quality of life as well as physical, emotional, social and 

school functioning. 

The respondents were giving answers according to 

a five-item scale by choosing one out of five answers. 

Evaluation of particular aspects of functioning took 

place by answering how often a child has problems 

with aspects of everyday life mentioned in the 

questionnaire. 

In order to enable self-dependent evaluation among 

children aged 5-7, a three-item scale was used. 

Additionally, the scale was presented in a graphic 

form. 

All answers were assigned following points: 0=100 

pts, 1=75 pts, 2=50 pts, 3=25 pts, 4=0 pts. The scores 

obtained through particular scales as well as the final 

score were calculated as an arithmetic mean presented 

as points from 0-100. The higher the calculated value, 

the better the quality of life is.

Social functioning of children who have completed acute lymphoblastic leukemia treatment 55 

RESULTS 

The evaluation of social functioning took place 

based on answers given to questions connected with 

maintaining good relationships with peers, 

unwillingness of peers to be friends, inability to 

perform all activities that peers can perform as well as 

keeping up with peers. 

The subjective evaluation of social functioning is 

quite high in all age groups and comprises 85-88 

points. The highest evaluated item is maintaining good 

relationships with peers (average of 88.56 pts). 

The children/teens who completed ALL treatment 

and were participating in the research did not mention 

peers’ unwillingness to be friends or being teased by 

them as elements that decrease the quality of social 

functioning. The most problematic situations are 

connected with an inability to perform all activities that 

peers can perform (average of 77.54 pts). 

As far as indirect evaluation is concerned, the 

smallest amount of points for social functioning was 

given within the group of children aged 2-4 (70.00). 

The factors that decrease the quality of life within the 

said sphere include unwillingness of peers to play with 

the sick child (65.00) and keeping up with other 

children while playing (65.00). The evaluation 

obtained in other age groups is similar and amounts to 

82-83 points. The lowest evaluated aspects are keeping 

up with peers (an average of 76.56 pts) and inability to 

perform all activities that peers can perform (an 

average of 77.73 pts). 

Parents of children who have completed ALL 

treatment evaluate the quality of life within the social 

sphere lower than their children. Whereas the biggest 

difference pertains to children aged 5-7 (88 vs. 83), the 

smallest one refers to teens (85.19 vs. 82.31). 

The evaluation of social functioning performed by 

children/teens shows profound statistical discrepancies 

between the groups and is in favour of healthy children 

as far as inability to perform all activities that peers can 

perform (77.54 vs. 93.65; p

56 


variables mentioned in the questionnaire, apart from 

problems with forgetting about various things. 

As far as indirect evaluation is concerned, profound 

statistical discrepancies in favour of healthy children 

concern problems with keeping up with studying 

(65.95 vs. 79.76; p=0.008), being absent from classes 

due to not feeling well (72.41 vs. 82.54; p=0.018) and 

appointments at doctors’ (58.62 vs. 73.81; p

Social functioning of children who have completed acute lymphoblastic leukemia treatment 57 

these skills are indispensable for functioning within a 

society [11, 12, 13, 14]. 

Children who have completed ALL treatment are 

often directed to individual teaching which, on the one 

hand, protects a child, but, on the other hand, deprives 

it from an opportunity to acquire the above mentioned 

skills. While individual work with a teacher offers a 

chance of developing interests of a particular child and 

leads to better grades and results, it can become the 

cause of problems with social functioning. 

Involving a child in normal school obligations is an 

essential element of psychotherapy. It provides a child 

with a feeling of being equal to healthy peers and lets it 

forget about the past differences [15]. In another article 

Zdebska S. highlights the significant role of a form 

master of the class a child attends to. It is important 

that a teacher encourages and involves a child in active 

class cooperation so that the child feels like a rightful 

member of the peer group [14]. 

Problems with making interpersonal contacts and 

functioning within social norms are an indication for 

returning to school as soon as ALL treatment is 

completed [16]. The SIOP Psychological Committee 

advises providing continuity of studying and 

integration at school. This should be done by securing 

operations of a hospital school and fluent incorporation 

of a child in classes at its original school once 

treatment is finished [17, 18, 19]. 

According to own research, children who have 

experienced oncological treatment evaluate their 

functioning at school lower than healthy children 

(69.57 vs. 81.27). Considerable differences between 

their evaluations concern difficulties with in-class 

concentration (71.98 vs. 84.13), studying at school and 

at home (69.40 vs. 88.89), problems connected with 

being absent from classes due to not feeling well 

(75.86 vs. 84.13) and due to appointments at doctors’ 

(61.21 vs. 76.59). Whereas the majority of problems 

with concentration are experienced by teens aged 13- 

18, most problems with studying at school and at home 

concern children aged 5-7 (50.00) while most 

problems with being absent from classes due to 

appointments at doctors’ refer to children aged 8-12 

(60.71). 

Regardless of difficulties faced by children after 

completion of ALL treatment, one should remember 

that by participating in school activities a child 

becomes independent, searches for its own place in the 

society and undertakes new tasks and social roles. 

Moreover, a child forms its norms and system of 

values and develops self-evaluation skills which 

increase with success and decrease with failures. A 

young person aims at finding the meaning of his/her 

life [20]. Consequently, resignation from active 

participation in school life after completion of 

treatment and choosing individual teaching instead 

deprives a child of a chance for normal development 

and ‘normal’ functioning within a society. 

CONCLUSIONS 

The quality of life of children and teens who have 

completed treatment is significantly lower than among 

healthy children. 

As far as social functioning is concerned, being 

able to keep up with peers and an inability to perform 

all activities that children in a similar age can perform 

received fewer points. 

Worse school functioning results from difficulties 

with in-class concentration, problems with keeping up 

with studying as well as being absent from classes due 

to not feeling well or appointments at doctors’. 

REFERENCES 

1. Meeske K., Katz E., Palmer S., Burwinkle T., Varni J. 

Parent Proxy-Reported Health- Related Quality of Life 

and Fatigue in Pediatric Patients Diagnosed with Brain 

Tumors and Acute Lymphoblastic Leukemia, Cancer 

2004, 101: 2116-2125 

2. Varni J.W., Burwinkle T.M., Seid M. The PedsQL TM 

4.0 as a school population health measure: Feasibility, 

reliability and validity. Quality of Life Research 2006, 

15: 203-215 

3. Varni J.W., Limbers Ch.A., Burwinkle T.M. Impaired 

health- related quality of life in children and adolescents 

with chronic conditions: a comparative analysis of 10 

disease cluster and 33 disease categories/ severities 

utilizing the PedsQL TM 4.0 Generic Core Scales. Health 

and Quality of Life Outcomes 2007, 5: 43-58 

4. Varni JW, Burwinkle TM, Seid M, Skarr D. The PedsQL 

4.0 as a pediatric population health measure: Feasibility, 

reliability and validity. Ambul Pediatr 2003; 3: 329-341 

5. Varni JW, Burwinkle TM, Seid M. The PedsQL 4.0 as 

school population health measure: Feasibility, reliability 

and validity. Quality of Life Research 2006; 15: 203-215 

6. Varni, JW, Burwinkle TM, Katz ER et al. The PedsQL 

in pediatric cancer: Reliability and validity of the 

Pediatric Quality of Life Inventory Generic Core 

Scales, Multidimensional Fatigue Scale, and Cancer 

Module. Cancer 1994: 2090-2106. 

7. Ogińska-Bulik N., Izydorczyk K., Style radzenia sobie ze 

stresem a poczucie własnej wartości i umiejscowienie 

kontroli zdrowia u dzieci chorych na białaczkę, 

Psychoonkologia 2000, lipiec-grudzień nr7: 29-37

58 


8. Mess E. Ocena stanu psychicznego dzieci leczonych z 

powodu ostrej białaczki limfoblastycznej, Polska 

Medycyna Paliatywna 2002, tom 1, nr 2: 9-21 

9. Mess E., Wójcik D., Niedzielska E., wsp. Adaptacja 

społeczna dzieci leczonych na ostrą białaczkę 

limfoblastyczną, Onkol. Pol. 2005, 8, 3: 166- 169 

10. Armata J. Dzieci wyleczone z nowotworów szukają 

miejsca wśród ludzi, Przegl. Lek. 1992, 45:218-221 

11. Małkowska A., Mazur J., Woynarowska B. Poziom 

spostrzegania wsparcia społecznego a jakość życia dzieci 

i młodzieży 8-18- letniej, Med. Wieku Rozw. 2004, VIII, 

3 cz. I: 551-566 

12. Strecker D., Kaczmarek D., Strecker B., Czaja-Bulsa G., 

Edukacja szkolna dziecka chorego, Family Medicine & 

Primary Care Review 2006, 8, 2: 327- 331 

13. Zdebska S., Armata J. Psychologiczne problemy w 

nowotworowych chorobach krwi u dzieci [w:] Ochocka 

M. Hematologia kliniczna wieku dziecięcego. Warszawa 

1982. PZWL: 369-381 

14. Zdebska S., Armata J. Niektóre problemy 

psychologiczno-wychowawcze w opiece nad dzieckiem 

szkolnym z nowotworową chorobą krwi, Ped. Pol., 1979, 

54, Nr 8: 919- 924 

15. Zdebska S., Armata J. Udział dziecka i jego zadania w 

leczeniu nowotworowej choroby krwi, ped. Pol., 1979 

54: 911-914 

16. Kawalczyk J.R., Samardakiewicz M. Rola pediatry 

pierwszego kontaktu w opiece nad dzieckiem przewlekle 

chorym. Choroba nowotworowa. Med Prakt Pediatr 

2000, 2: 144-154 

17. Korzeniowska J. Psychoonkologia – psychologia we 

współczesnej onkologii dziecięcej, Pediatria Polska 2005, 

80, 1: 62-66 

18. Samardakiewicz M., Kowalczyk J., R. Rekomendacje 

dotyczące opieki psychospołecznej nad dziećmi z 

chorobami nowotworowymi, Pediatria Polska 2000, 

LXXV, 9: 729-736 

19. Szweda E. Psychologiczna opieka nad dziećmi 

chorującymi na nowotwory i ich rodzicami, Bioetyczne 

Zeszyty Pediatrii 1, 2003-2004: 45-52 

20. Krawczyński M., Dojrzewanie i dorastanie. Problemy i 

potrzeby zdrowotne i psychospołeczne. Pediatria Polska 

1994, LXIX, 8: 581-587 


Aneta Zreda-Pikies 

ul. Osiedlowa 6/12 


e-mail: aneta.zreda@wp.pl 




CASE REPORT / PRACA KAZUISTYCZNA 

Adrian Reśliński 1 , Agnieszka Mikucka 2 , Jakub Szmytkowski 1 , Katarzyna Głowacka 3 , Eugenia Gospodarek 2 , 

Wojciech Szczęsny 1 , Stanisław Dąbrowiecki 1 

ASYMPTOMATIC INFECTION OF A SURGICAL MESH IMPLANT – A CASE REPORT 

BEZOBJAWOWE ZAKAŻENIE SIATKI CHIRURGICZNEJ – OPIS PRZYPADKU 

1 Department of General and Endocrine Surgery, Ludwik Rydygier Collegium Medicum in Bydgoszcz 

of the Nicolaus Copernicus University in Torun, Poland 

Head: Stanisław Dąbrowiecki D.Sc., assoc. prof. 

2 Department of Microbiology, Ludwik Rydygier Collegium Medicum in Bydgoszcz of the Nicolaus Copernicus 

University in Torun, Poland 

Head: Eugenia Gospodarek D.Sc., assoc. prof. 

3 Department of Plant Physiology and Biotechnology, Warmia-Mazury University, Olsztyn, Poland 

Head: Ryszard Górecki D.Sc., prof. 

Summary 

Infection involving a surgical implant is one of the most 

serious complications associated with the use of biomaterials 

in hernia surgery. Implant infection may manifest clinically in 

a number of ways. The authors present a case of asymptomatic 

infection of a mesh implant which had been used to repair a 

paraumbilical hernia. The infection was diagnosed 

accidentally during surgery for recurrence. The presence of a 

biofilm on the surface of the old implant was confirmed by a 

quantitative method based on 2,3,5-triphenyltetrazolium 

chloride (TTC) and by scanning electron microscopy (SEM). 

The biofilm served to protect the microorganisms from the 

activity of the patient’s immune system, resulting in an 

asymptomatic clinical course of the infection. It is the authors’ 

opinion that all implants which are removed during surgery for 

recurrent hernias should be routinely evaluated for the 

presence of microorganisms even if no apparent signs of 

infection can be observed. The TTC method should be 

included in the diagnostic tools in order to limit the percentage 

of false negative results. 

Streszczenie 

Zakażenie obejmujące implantat jest jednym z najpoważniejszych 

powikłań towarzyszących stosowaniu 

biomateriałów w chirurgii przepuklin. Zakażenie implantatu 

może mieć różny przebieg kliniczny. W pracy przedstawiono 

przypadek bezobjawowego zakażenia siatki chirurgicznej 

zastosowanej do zaopatrzenia przepukliny okołopępkowej. 

Zakażenie zostało rozpoznane przypadkowo podczas operacji 

z powodu nawrotu przepukliny. Badania metodą jakościową 

z użyciem chlorku 2,3,5-trójfenylotetrazoliowego (TTC), 

metodą ilościową oraz z użyciem skaningowego mikroskopu 

elektronowego wykazały obecność biofilmu bakteryjnego na 

powierzchni implantatu zastosowanego do pierwotnego 

zaopatrzenia przepukliny. Jego obecność na powierzchni 

implantatu uchroniła drobnoustroje przez działaniem układu 

odpornościowego pacjenta i była odpowiedzialna za bezobjawowy 

przebieg zakażenia biomateriału. Zdaniem autorów 

wszystkie implantaty usuwane podczas operacji z powodu 

nawrotu przepukliny należy poddać badaniu mikrobiologicznemu, 

nawet gdy nie stwierdza się makroskopowych 

cech zakażenia. Do badań diagnostycznych powinna zostać 

włączona metoda redukcji TTC, co pozwala ograniczyć 

liczbę wyników fałszywie ujemnych. 

Key words: hernia, surgical mesh , biofilm, TTC 

Słowa kluczowe: przepuklina, siatka chirurgiczna, biofilm, TTC

60 

Adrian Reśliński et. al. 

INTRODUCTION 

A serious complication of tension-free mesh 

hernioplasty is deep surgical site infection (SSI) 

involving the implant (mesh infection) [1]. The 

microorganisms colonizing the biomaterial may form a 

biofilm on its surface. This structure serves their 

protection from the host’s immune system and 

antimicrobial agents [2]. 

Implant infection may present clinically in a 

number of ways. Typical symptoms include: local 

erythema, edema and increased temperature of the skin 

overlying the infected implant, and generalized 

symptoms of infection such as fever or shivering. In 

some patients with implant infection a cutaneous 

fistula and / or intraabdominal abscess [3,4]. 

Osteomyelitis is a rare presentation [5]. 

The authors’ experience indicates that implant 

infection may follow an asymptomatic course, making 

it difficult to diagnose and initiate appropriate 

treatment. Moreover, the biofilm present on the surface 

of the biomaterial may fragment and detach, giving 

raise to secondary infection foci, which poses another 

threat for the patient [2]. 

CASE REPORT 

A 39-year-old Caucasian male patient was admitted 

to the Department of General and Endocrine Surgery in 

May 2009 for an elective repair of a recurrent 

paraumbilical hernia. 

In June 2008 the patient had undergone a primary 

umbilical hernia repair in another center. A 

polypropylene mesh implant had been used. The 

postoperative course had been uneventful and the 

patient had been discharged on the second 

postoperative day. A recurrence of the hernia had been 

diagnosed in December, 2008. 

Upon admission the patient presented in good 

overall condition, and no abnormalities aside from the 

hernial bulge were observed upon physical 

examination. The standard laboratory results were all 

normal. 

An elective surgery was performed. After resecting 

the scar from the previous operation, at the border 

between the fascia and subcutaneous tissue the old 

polypropylene implant was found in a rolled 

configuration, with evidence of an inflammatory 

response in the surrounding tissues. No pus was 

observed. The implant was completely removed and 

referred for microbiological evaluation. The inflamed 

tissues were excised with a wide margin. The 

adhesions between the greater omentum and the hernial 

defect were liberated and the hernia was repaired by 

implantation of a new polypropylene mesh into the 

retromuscular space. 

A biochemical method utilizing the property of 

metabolically active microorganisms to reduce 

colorless 2,3,5-triphenyltetrazolium chloride (TTC) to 

red formazan was used to detect biofilm on the 

biomaterial surface [6]. Fragments of the implant (1 x 

1 cm) were incubated in 4 ml of tryptic soy broth 

(TSB, Becton Dickinson) containing 50 µl of 1% TTC 

solution (POCH, Gliwice, Poland). The samples were 

then incubated at 37ºC and the appearance of red 

formazan was first observed after approximately 70 

minutes, with the intensity of the red hue increasing 

over time. 

A quantitative analysis of the biofilm present on the 

removed implants was then performed. The biofilm 

was detached from the surface of the biomaterial 

samples (1x1cm) by shaking in 0.5% saponin (Fluka, 

Steinheim, Germany). Serial 10-fold dilutions of the 

suspension thus obtained were performed with 

subsequent inoculation on trypticase soy agar (Tryptic 

Soy Agar, TSA, Becton Dickinson). After 24 hours of 

incubation of the implant fragments at 37ºC, the result 

of 4.8 x 10 7 colony-forming units (CFU’s) per one 

milliliter of suspension (CFU/ml) of the biofilm 

present on one implant sample was recorded (average 

of three measurements). 

The results of the qualitative and quantitative 

evaluation were confirmed by scanning electron 

microscopy. The implant fragments were fixed in a 

2.5% glutaraldehyde solution (POCH, Gliwice, 

Poland) in a 0.1 M phosphate buffer at a pH of 7.4 for 

24-48 hours at 4 0 C. After fixation, the material was 

rinsed for 2 x 20 min in phosphate buffer at room 

temperature. The samples were then dehydrated in a 

graded series of ethanol concentrations: 30, 50, 70, 80, 

96%, 10 minutes in each solution, and twice for 30 

minutes in 99,8% ethanol (POCH, Gliwice, Poland) at 

room temperature. After dehydration, the samples were 

transferred to the dryer chamber (Critical Point Dryer - 

CDP 030, Bal-Tec, Balzers, Lichtenstein) filled with 

amyl acetate (Sigma-Aldrich, Steinheim, Germany) 

and dried at the critical point of CO2. The dried 

material was placed on copper tables and sputter – 

coated with gold in an atmosphere of argon in an ionic 

coater (Fine Coater, JCF-1200, JEOL, Tokyo, Japan).

Asymptomatic infection of a surgical mesh implant - a case report 61 

The sputter – coated material was placed in a SEM 

column (JSM-5310LV, JEOL, Tokyo, Japan) and 

analyzed at a voltage of 25 kV. The results were 

recorded on black – and-white ILFORD FP4 PLUS 

125 photographic film (Fig. 1). 

component levels, in order to evaluate the functional 

components of the immune system. No abnormalities 

were found in the humoral, cellular response, 

phagocytic cell or component systems 

Fig. 1. Biofilm on the surface of a polypropylene mesh 

implant (polymicrobial biofilm); scanning electron 

microscopy (magnification 3500x) 

Ryc. 1. Biofilm na powierzchni siatki polipropylenowej 

(biofilm wielogatunkowy); skaningowa 

mikroskopia elektronowa (powiększenie 3500x) 

Initial identification of the cultures was based on 

colony morphology on Columbia Agar with 5% sheep 

blood (Becton Dickinson) and selective differential 

media; specific tests were also performed, including: 

ID32 Staph (bioMérieux S.A. RCS Lyon, France) test 

for staphylococci and Rapid ID32 Strep (bioMérieux 

S.A. RCS Lyon, France) ID32 E (bioMérieux S.A. 

RCS Lyon, France) for streptococci. Based on the 

above, the etiological factors of implant infection were 

identified as: Staphylococcus warneri, Staphylococcus 

epidermidis and Streptococcus oralis. 

Drug susceptibility was tested in accordance with 

the guidelines of the National Reference Center for 

Microbial Drug Sensitivity [7], and the results were 

interpreted according to the Clinical Laboratory 

Standards Institute (CLSI) guidelines [8]. 

The postoperative course was uneventful. The 

patient was discharged on the 5th postoperative day 

and the treatment was continued in outpatient care. 

During follow – up visits which took place 1, 6, 12 and 

22 months after surgery neither signs of SSI nor hernia 

recurrence were observed (Fig. 2). 

Due to a suspicion of immune deficiency the 

patient was subjected to a series of initial tests, i.e. 

serum IgG, IgM and IgA levels, peripheral blood 

morphology and smear, C3 and C4 complement 

Fig. 2. Status after 22 months upon discharge from hospital 

Ryc. 2. Stan po 22 miesiącach od wypisu 

DISCUSSION 

This report presents a case of an asymptomatic 

infection of a surgical implant in a patient after 

paraumbilical mesh hernioplasty. The infection was 

diagnosed accidentally during surgery for hernia 

recurrence. Qualitative TTC assay, quantitative 

evaluation and scanning electron microscopy have all 

confirmed the presence of a bacterial biofilm on the 

surface of the implant which had been used to repair 

the primary hernia. Its presence probably protected the 

microorganisms from the host’s immune system, as 

any immune deficiencies which could have hindered 

the elimination of bacteria colonizing the mesh implant 

had been ruled out. 

In the case presented here, implant infection was 

diagnosed one year after the initial operation. We 

cannot rule out the possibility that the asymptomatic 

course of the disease was due to the presence of a 

biofilm on its surface. Biofilm is probably responsible 

for the late clinical manifestation of many biomaterials 

used in hernia surgery – there have been reports on 

mesh infections manifesting as late as 4.5 [3] or even 8 

years after surgery [9]. 

Intraoperatively, the primary implant was found in 

a rolled configuration. The appearance of the mesh was 

due to biomaterial shrinkage. The pathophysiology of

62 

this phenomenon has not yet been fully explained. It is 

assumed to have resulted from an inflammatory 

reaction an implant evokes, as well as abnormal 

integration of the implant into the host’s tissues [10]. 

According to Mamy et al. [11] bacterial colonization of 

the surface of the mesh is an independent risk factor 

for its shrinkage. The shrinking of the implant in our 

patient could have been due to the formation of a 

biofilm on its surface. This biofilm may have interfered 

with the ingrowth of the host’s tissues through the 

implant. Bacteria growing as a biofilm decrease 

adhesion of the connective tissue cells to the surface of 

the biomaterial [12]. Moreover, microorganisms have 

the ability to inhibit fibroblast proliferation [13] and 

induce the death of these cells [14]. It is the opinion of 

the authors that the poor integration of the biomaterial 

and its deformation were responsible for the recurrence 

of the hernia. 

In spite of the contamination of the surgical field, 

the recurrent hernia was repaired using a monofilament 

polypropylene mesh. This approach has been 

documented to be safe even in patients receiving 

immunosuppressive therapy [15]. An alternative 

technique for hernia repair in an infected field may be 

using a biological implant [16]. In the case presented 

here, biomaterial implantation was preceded by a 

thorough debridement of the wound, which resulted 

from the fact that bacteria are able to colonize the 

tissues adjacent to a synthetic implant, thus gaining an 

environment in which they can thrive despite 

antimicrobial therapy [17, 18]. 

Another significant clinical problem arises from 

false negative microbiology findings. According to 

Delikoukos et al. [3], microbiological evaluation of a 

removed implant may yield a negative result despite 

the presence of the typical signs of SSI. In our opinion, 

every implant which is removed during surgery for 

recurrent hernia must be evaluated for biofilm presence 

with the use of the TTC method, even if no apparent 

signs of infection are present. The sensitivity of the 

TTC reduction method may surpass that of the 

traditional culture – based methods, allowing for the 

detection of bacteria on the surface of an implant even 

if their number is below the detection threshold of the 

culture method [20]. This could decrease the number of 

false negative results which delay the introduction of 

appropriate treatment of surgical site infections. 

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hernia repair. Surgeon 2009; 7:316-318 

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between tissue ingrowth and mesh contraction. World J 

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11. Mamy L, Letouzey V, Lavigne JP et al. Correlation 

between shrinkage and infection of implanted synthetic 

meshes using an animal model of mesh infection. Int 

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12. Subbiandoss G, Grijpma DW, van der Mei HC et al. 

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prostheses. Biomaterials 2001; 22:2021-2024 

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ASAIO J 2000; 46:33-37 

15. Antonopoulos IM, Nahas WC, Mazzucchi E et al. Is 

polypropylene mesh safe and effective for repairing 

infected incisional hernia in renal transplant recipients? 

Urology 2005; 66: 874-877 

16. Diaz JJ, Conquest AM, Ferzoco SJ et al. Multiinstitutional 

experience using human acellular dermal 

matrix for ventral hernia repair in a compromised 

surgical field. Arch Surg 2009; 144: 209-15 

17. Broekhuizen CA, de Boer L, Schipper K et al. Periimplant 

tissue is an important niche for Staphylococcus

Asymptomatic infection of a surgical mesh implant - a case report 63 

epidermidis in experimental biomaterial-associated 

infection in mice. Infect Immun 2007; 75: 1129-36 

18. Broekhuizen CA, de Boer L, Schipper K et al. 

Staphylococcus epidermidis is cleared from biomaterial 

implants but persists in peri-implant tissue in mice 

despite rifampicin/vancomycin treatment. J Biomed 

Mater Res A 2008; 85: 498-505 

19. Yassien M, Khardori N. Interaction between biofilms 

formed by Staphylococcus epidermidis and quinolones. 

Diagn Microbiol Infect Dis 2001; 40: 79-89 

20. Jałoza D, Juda M, Malm A et al. The qualitative and 

quantitative detection of biofilm formation in vitro on the 

biomaterials. Sepsis, 2009; 2: 143-146 


Adrian Reslinski MD 

Department of General and Endocrine Surgery 

Nicolaus Copernicus University of Torun 

Collegium Medicum in Bydgoszcz 

M. Skłodowskiej-Curie 9 Str. 

85-094 Bydgoszcz, Poland 

tel. 00 48 52 585-47-30, fax. 00 48 52 585-40-16 

email: bigar@wp.pl 




Selected articles presented during 

the 2 nd International Conference 

„Europejski Wymiar Nauk o Zdrowiu” 

organized on the occasion of the XVth Anniversary 

of Faculty of Health Sciences 

at Collegium Medicum, Nicolaus Copernicus University 

BYDGOSZCZ, March 19-20, 2012 

GUEST EDITOR: PROFESSOR ZBIGNIEW BARTUZI

Medical and Biological Sciences, 2012, 26/2


CONTENTS 

p. 

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Anetta Cubał a, Tomasz Jurkiewicz, Maciej Dzierż anowski, Jarosł aw 

H o f f m a n , D o r o t a R a t u s z e k – Functional evaluation of the lumbosacral spine among 

athletes practising grappling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 

Graż yna Gebuza, Marzena Kaź mierczak, Mał gorzata Gierszewska, Estera 

Mieczkowska, Mał gorzata Bannach, Roman Kotzbach – Standard of maternal 

postpartum haemorrhage care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 

Izabela Glaza, Katarzyna Pietkun, Rafał Szadujkis-Szadurski, Krystyna 

Nowacka, Magdalena Hagner-Derengowska, Maciej Nowacki 

– Probiotics in food. Important preventive factor in children allergy, or a controversial add-on? 

Review of the literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 

Andrzej Kuź miń ski, Michał Przybyszewski, Mał gorzata Graczyk, 

Magdalena Ż b i k o w s k a - G o t z , E w a S o c h a , Z b i g n i e w B a r t u z i – Composition 

of inflammatory infiltrate in the gastric mucosa of patients with food and airborne allergies . . . . . . . . . 89 

Iwona Ł opaciń ska, Mał g o r z a t a W o j c i e c h o w s k a – Nurses vs ISO in hospital . . . . . . . . . 95 

Katarzyna Napiórkowska, Krzysztof Pał gan, Ewa Gawroń ska-Ukleja, 

Magdalena Ż bikowska-Gotz, Joanna Koł odziejczyk, Milena 

Wojciechowska, Mał gorzata Graczyk, Ewa Szynkiewicz, Robert 

Z a c n i e w s k i , Z b i g n i e w B a r t u z i – The role of skin prick test in diagnosis of food allergy 

in patients with birch pollinosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 

Katarzyna Obł oza, Aleksandra Czerw, Urszula Religioni – The role of media 

in creating the health care units’ image in Poland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 

Joanna Pawlak, Paweł Zalewski, Jacek J. Klawe, Monika Zawadka, 

Anna Bitner, Mał g o r z a t a T a f i l - K l a w e – Core body temperature changes after sauna 

exposition in healthy subjects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 

Dorota Siwczyń ska, Magdalena Miń k o – The functioning of health systems in Poland 

and the Netherlands in patients’ opinions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 

B ł a ż ej Stankiewicz, Mirosł awa Cieś l i c k a – Detailed analysis of a 240-second cycle 

ergometric test in midlle-distance runners aged 16-19 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 

E w a J o a n n a S z y m e l f e j n i k , A n n a C h i b a – The interdependence of nutritional status 

and blood pressure in female students . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 

Magdalena Ż bikowska-Gotz, Krzysztof Pał gan, Ewa Socha, Michał 

Przybyszewski, Andrzej Kuź miń s k i , Z b i g n i e w B a r t u z i – Metabolic activity 

of neutrophilic granulocytes measured with chemiluminescence test (CL) in patients with allergic 

hypersensitivity to food . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135


SPIS TREŚCI 

str. 

Anna Bitner, Paweł Zalewski, Jacek J. Klawe, Krzysztof Goryń ski, 

Monika Zawadka, Joanna Pawlak – Skutki ekspozycji na ciepło i rodzaje chorób 

wśród strażaków – przegląd literatury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 

Anetta Cubał a, Tomasz Jurkiewicz, Maciej Dzierż anowski, Jarosł aw 

H o f f m a n , D o r o t a R a t u s z e k – Ocena funkcjonalna kręgosłupa lędźwiowo-krzyżowego 

u zawodników trenujących grappling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 

Graż yna Gebuza, Marzena Kaź mierczak, Mał gorzata Gierszewska, Estera 

Mieczkowska, Mał gorzata Bannach, Roman Kotzbach – Standard opieki 

nad położnicą z krwotokiem poporodowym . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 

Izabela Glaza, Katarzyna Pietkun, Rafał Szadujkis-Szadurski, Krystyna 

Nowacka, Magdalena Hagner-Derengowska, Maciej Nowacki 

– Probiotyki w żywności. Istotny czynnik prewencyjny w alergologii dziecięcej czy kontrowersyjny 

dodatek? Przegląd piśmiennictwa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 

Andrzej Kuź miń ski, Michał Przybyszewski, Mał gorzata Graczyk, 

Magdalena Ż bikowska-Gotz, Ewa Socha, Zbigniew Bartuzi – Skład nacieku 

zapalnego błony śluzowej żołądka u chorych z alergią pokarmową i powietrznopochodną . . . . . . . . . . . 89 

Iwona Ł opaciń ska, Mał gorzata Wojciechowska – Pielęgniarki wobec ISO w szpitalu . . 95 

Katarzyna Napiórkowska, Krzysztof Pał gan, Ewa Gawroń ska-Ukleja, 

Magdalena Ż bikowska-Gotz, Joanna Koł odziejczyk, Milena 

Wojciechowska, Mał gorzata Graczyk, Ewa Szynkiewicz, Robert 

Zacniewski, Zbigniew Bartuzi – Rola testów skórnych w diagnostyce alergii 

pokarmowej u pacjentów uczulonych na pyłki brzozy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 

Katarzyna Obł oza, Aleksandra Czerw, Urszula Religioni – Rola mediów 

w kreowaniu postrzegania wizerunku placówek ochrony zdrowia w Polsce . . . . . . . . . . . . . . . . . . . . . . . 105 

Joanna Pawlak, Paweł Zalewski, Jacek J. Klawe, Monika Zawadka, 

Anna Bitner, Mał gorzata Tafil-Klawe – Zmiany temperatury głębokiej ciała 

po zabiegu sauny suchej u osób zdrowych . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 

Dorota Siwczyń ska, Magdalena Miń k o – Funkcjonowanie systemów opieki zdrowotnej 

w Polsce i Holandii w opinii pacjentów . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 

B ł a ż ej Stankiewicz, Mirosł awa Cieś l i c k a – Szczegółowa analiza 240-sekundowej próby 

cykloergometrycznej przeprowadzonej wśród biegaczy na średnich dystansach w wieku 16-19 lat . . . . 121 

Ewa Joanna Szymelfejnik, Anna Chiba – Współzależność między stanem odżywienia 

a ciśnieniem tętniczym u studentek . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 

Magdalena Ż bikowska-Gotz, Krzysztof Pał gan, Ewa Socha, Michał 

Przybyszewski, Andrzej Kuź miń ski, Zbigniew Bartuzi – Aktywność 

metaboliczna granulocytów obojętnochłonnych mierzona testem chemiluminescencji u pacjentów 

z nadwrażliwością alergiczną na pokarmy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135


Anna Bitner 1 , Paweł Zalewski 1 , Jacek J. Klawe 1 , Krzysztof Goryński 2 , Monika Zawadka 1 , Joanna Pawlak 1 

HEAT EXPOSURE EFFECTS AND KINDS OF ILLNESSES 

AMONG FIREFIGHTERS – REVIEW 

SKUTKI EKSPOZYCJI NA CIEPŁO I RODZAJE CHORÓB 

WŚRÓD STRAŻAKÓW – PRZEGLĄD LITERATURY 

1 Chair and Department of Hygiene and Epidemiology, Collegium Medicum in Bydgoszcz 


Head: dr hab. n. med. Jacek J. Klawe, prof. UMK 

2 Department of Biopharmacy, Collegium Medicum in Bydgoszcz 


Head: prof. dr hab. Adam Buciński 

Summary 

Based on the review of literature which has been 

published within the last 20 years it was stated that 

occupational hazard connected with work at the fire service is 

significant. Character of the work of firefighters is connected 

with exposure to the serious injury during the firefighting and 

with thermal stress which can cause dehydration and heat 

stroke. Moreover, scientists noticed that firefighters are 

exposed to stress situations which can take lead to serious 

psychological disorders. 

Exhibition to high temperatures and substances such as 

carbon monoxide, benzene, asbestos, vinyl chloride or other 

substances produced in the course of the fire can probably 

cause a number of illnesses such as bronchial asthma, 

bronchial hyperactivity, arterial hypertension, coronary heart 

disease or other cardiovascular and respiratory diseases in 

older age. It is not fully explained whether above factors affect 

cancer incidence in firefighters. 

Streszczenie 

Na podstawie przeglądu piśmiennictwa, które pojawiło 

się w okresie ostatnich dwudziestu lat stwierdzono, że ryzyko 

zawodowe związane z praca w straży pożarnej jest znaczące. 

Charakter pracy strażaków związany jest z narażaniem na 

poważne obrażenia ciała w czasie gaszenia pożarów oraz 

stresem cieplnym, który może być przyczyną odwodnienia 

oraz udaru cieplnego. Ponadto zauważono, że strażacy 

narażeni są na sytuacje stresowe, które mogą doprowadzić do 

poważnych zaburzeń psychologicznych. Ekspozycja na 

wysokie temperatury oraz związki chemiczne jak tlenek 

węgla, benzyna, azbest, chlorek winylu czy inne substancje 

powstałe w trakcie pożaru prawdopodobnie mogą być 

przyczyną wystąpienia u strażaków w późniejszym okresie 

wielu chorób jak: astma oskrzelowa, nadwrażliwość oskrzeli, 

nadciśnienie tętnicze, choroba niedokrwienna serca czy inne 

choroby układu sercowo-naczyniowego i oddechowego. Nie 

jest do końca wyjaśnione czy wyżej wymienione czynniki 

mają wpływ na występowanie u strażaków nowotworów. 

Key words: firefighters, stress, cardiovascular diseases, cancers, respiratory diseases 

Słowa kluczowe: strażacy, stres, choroby układu sercowo-naczyniowego, nowotwory, choroby układu oddechowego 

1. INTRODUCTION 

Firefighting is a very dangerous career. Every year 

fires destroy a lot of buildings and take many lives 

away. Unfortunately, firefighters extinguishing the 

fires are exposed to high temperatures, flames burning 

and carcinogens substances such as: benzene, dioxins, 

asbestos, chlorophenols or vinyl chloride, which could

70 

Heat exposure effects and kinds of illnesses among firefighters - review 

be a trigger for some cancers. Moreover, most 

firefighters experience a lot of stress in their work 

settings. 

Firefighters are required to work in temperatures 

well over the normal body core temperature (from 

36.5 0 to 37.5 0 C). Persons exposed to an extreme 

environmental heat are often diagnosed with 

cardiovascular and pulmonary diseases. High heat 

conditions combined with stressful situations at work 

can lead to rapid body core temperature increases, 

which can be very dangerous to the human organism. 

2. OBJECTIVE 

The aim of this work was to analyze scientific 

papers which describe heat exposure effects and types 

of illnesses among firefighters. 

3. MATERIALS AND METHODS 

A Medline search was performed to identify studies 

problems of kinds of illnesses among firefighters and 

heat exposure effects in their work. Searched terms 

included words such as: heat stress, respiratory 

symptoms, cancer incidence, cardiovascular disease 

and chronic stress among firefighting. 

4. RESULTS 

The study describes the research articles describing 

frequent illnesses and other hazards among firefighters. 

Occupational hazards may be categorized as chemical, 

psychological and physical. There are many chemical 

and physical dangers in firefighting (for example 

thermal stress), but physiological and biochemical 

indicators of stress have shown that firefighters are 

also exposed on stress situation all the time in their 

work. 

4.1. Chronic stress among firefighters 

Stress is a term describing condition of our 

organism under the influence of a stressor. We 

experience stress every day, but it could have a 

negative impact on the human organism. The problem 

of the chronic stress among firefighters is presented on 

the basis of a literature review. Firefighters are exposed 

on stress situation all the time. On the basis of the 

studies, scientists stated that traumatic incidents during 

working hours of firefighters may be a cause of 

depression, lack of sleep, loss of appetite. Moreover, 

this situation may be a consequence of heart 

conditions, diabetes, disabilities and other diseases. 

The fact that firefighters may experience physical and 

emotional problems after return home is discussed in 

available literature. Also, lack of regular meals, 

interrupted sleep and absences from home worsen this 

situation [1, 2]. 

Reasons responsible of chronic stress can be 

different among firefighters. We distinguish: 

individualistic factors like negative feelings or 

traumatic events, organizational factors like low pay or 

a sense of high responsibility, and demographic factors 

(job seniority) [1]. 

4.2. Respiratory symptoms among firefighters 

The literature reviews included also studies, in 

which firefighters reported respiratory symptoms (itchy 

throat, cough, running nose, dyspnoea, bronchial 

asthma) more often than general population. 

Firefighters are exposed on various chemical 

substances like carbon monoxide, nitrogen dioxide, 

hydrogen cyanide, hydrogen chloride, aldehydes and 

sulfur dioxide during their working hours. A number of 

studies describe pulmonary diseases associated with 

inhalation of toxic constituents of smoke products and 

very hot air. The chronic effects of this situation can 

cause lung cancer and chronic obstructive pulmonary 

disease [3, 4, 5]. 

To sum up, firefighters experience more respiratory 

symptoms at work compared with control group and 

they suffer from more bronchial hyperactivity and 

atopy more often than other people [3]. 

4.3. Cancer incidence among firefighters 

The retrospective cohort studies demonstrated 

strong relationship between firefighters and cancer. 

Epidemiologic studies suggested that multiple 

myeloma, leukemia, brain and bladder cancer appear 

more often. Another evidence association with 

firefighters is prostate, colon, rectal and stomach 

cancer [6,7,8,9]. 

Firefighters are exposed to various carcinogenic 

substances which can be associated with a specific type 

of cancer. Other recent studies show that geographic 

differences in building materials might affect the type 

of cancer, because various substances are transmitted 

into the environment during the fire. Scientists stated

Anna Bitner et. al. 71 

that the protective equipment, firefighters use at work 

does not protect them enough from chemical 

substances come across [6,7,8,9]. 

4.4. Cardiovascular disease among firefighters 

Cardiovascular disorders may be a very serious 

problem among firefighters. The first reason why 

firefighters are prone to cardiovascular disease is a 

stress situation in their work settings, irregular physical 

exertion and heat during extinguishing the fire 

[10,11,12,13]. The second reason is exposure to 

chemical substances like carbon monoxide, hydrogen 

sulfide and hydrogen cyanide. It causes dangerous 

situation related to fatal coronary heart events such as: 

sudden death, fatal arrhythmia or myocardial 

infarction, resulting from the influence of the gases 

[14,15,16,17,18]. 

Scientists conducted the examination including all 

cases of heart attacks and other coronary syndromes 

among firefighters. They discovered that the risk of 

death due to heart disease at firefighters was over 100 

times higher compared with general population 

[19,20,21,22,23]. It clearly shows that the work in the 

fire service can carry the crucial inducer the coronary 

disease [24,25,26,27]. 

4.5. Thermal stress 

Heat stress may result in local or generalized heat 

stress, with the risk of dehydration, heat stroke and 

cardiovascular diseases. Heat stress is compounded in 

firefighting by physical exertion and by insulating 

properties of the protective clothing. 

5. SUMMARY 

The literature review shows that the acute hazards 

of firefighting include: thermal injury, smoke 

inhalation and trauma. The type of the work 

firefighters have brings an elevated risk of diseases 

such as: ischemic heart disease, hypertension, 

bronchial hyperactivity and psychological problems 

more often than among other people of different 

professions. 

6. REFERENCES 

1. Milen D.: The Ability of Firefighting Personnel to Cope 

With Stress. J. Soc. Change 2009; 3: 38-56. 

2. Baker S, Williams K.: Short Communications: Relation 

between social problem solving, appraisals, work stress, 

and psychological distress in male firefighters. Stress and 

Health 2001; 17: 219-229. 

3. Miedinger D., Chhajed P.N., Stolz D. et al.: Respiratory 

symptoms, atopy and bronchial hyperreactivity in 

professional firefighters. Eur. Respir. J. 2007; 30: 538– 

544. 

4. Prezant D.J., Weiden M., Banauch G.I. et al.: Cough and 

Bronchial Responsiveness in Firefighters at The World 

Trade Center Site. N. Engl. J. Med. 2002; 347: 806-815. 

5. Rosenstock L., Demers P., Heyer N.J. et al.: Respiratory 

mortality among firefighters. Br. J. Ind. Med. 1990; 47: 

462-465. 

6. Guidotti T.L., Clough V.M.: Occupational health 

concerns of firefighting. Annu. Rev. Publ. Health. 1992; 

13: 151-171. 

7. Kang D., Davis L.K., Hunt P. et al: Cancer Incidence 

Among Male Massachusetts Firefighters, 1987–2003. 

Am. J. Ind. Med. 2008; 51: 329–335. 

8. Ma F., Fleming L.E., Lee D.J. et al.: Cancer incidence in 

Florida professional firefighters, 1981 to 1999. J. Occup. 

Environ. Med. 2006; 48(9): 883-888. 

9. Ma F., Lee D.J., Fleming L.E. et al.: Race-specific cancer 

mortality in US firefighters: 1984-1993. J. Occup. 

Environ. Med. 1998; 40(12): 1134-1138. 

10. Geibe J.R., Holder J., Peeples L. et al.: Predictors of onduty 

coronary events in male firefighters in the United 

States. Am. J. Cardiol. 2008; 101(5): 585-589. 

11. Kales S.N., Tsismenakis A.J., Zhang C et al.: Blood 

pressure in firefighters, police officers, and other 

emergency responders. Am. J. Hypertens. 2009; 22(1): 

11-20. 

12. Baxter C.S., Ross C.S., Fabian T et al.: Ultrafine particle 

exposure during fire suppression - is it an important 

contributory factor for coronary heart disease in 

firefighters? J. Occup. Environ. Med. 2010; 52(8): 791- 

796. 

13. Kales S.N., Soteriades E.S., Christoph C.A. et al.: 

Emergency Duties and Deaths from Heart Disease among 

Firefighters in the United States. N. Engl. J. Med. 2007; 

356: 1207-1215. 

14. Hansen E. A cohort study on the mortality of firefighters. 

British Journal of Industrial Medicine 1990; (47): 805- 

809. 

15. Soteriades E.S., Smith D.L., Tsismenakis A.J. et al.: 

Cardiovascular disease in US firefighters: a systematic 

review. Cardiol. Rev. 2011; 4: 202-215. 

16. Soteriades E.S., Hauser R., Kawachi I. et al.: Obesity 

and cardiovascular disease risk factors in firefighters: a 

prospective cohort study. Obes. Res.: 2005; 13(10): 

1756-1763. 

17. Drew-Nord D.C., Hong O., Froelicher E.S.: 

Cardiovascular risk factors among career firefighters. 

AAOHN J. 2009; 57(10): 415-422. 

18. Fahs C.A., Smith D.L., Horn G.P. et al.: Impact of excess 

body weight on arterial structure, function, and blood 

pressure in firefighters. Am. J. Cardiol. 2009; 104(10): 

1441-1445.

72 

Heat exposure effects and kinds of illnesses among firefighters - review 

19. Soteriades E.S., Kales S.N., Liarokapis D. et al.: 

Prospective surveillance of hypertension in firefighters.. 

J. Clin. Hypertens (Greenwich). 2003; 5: 315-320. 

20. Yoo H.L., Franke W.D.: Prevalence of cardiovascular 

disease risk factors in volunteer firefighters. J. Occup. 

Environ. Med. 2009; 51(8): 958-962. 

21. Azabdaftari N., Amani R., Taha Jalali M.: Biochemical 

and nutritional indices as cardiovascular risk factors 

among Iranian firefighters. Ann. Clin. Biochem. 2009; 

46(Pt 5): 385-389. 

22. Fahs C.A., Smith D.L., Horn G.P. et al.: Impact of 

excess body weight on arterial structure, function, and 

blood pressure in firefighters. Am. J. Cardiol. 2009; 

104(10): 1441-1445. 

23. Kales S.N., Soteriades E.S., Christoudias S.G. et al.: 

Firefighters' blood pressure and employment status on 

hazardous materials teams in Massachusetts: a 

prospective study. J. Occup. Environ. Med. 2002; 44(7): 

669-676. 

24. Mbanu I., Wellenius G.A., Mittleman M.A. et al.: 

Seasonality and coronary heart disease deaths in United 

States firefighters. Chronobiol. Int. 2007; 24(4): 715-726. 

25. de Mattos C.E., de Mattos M.A., Toledo D.G. et al.: 

Using ambulatory blood pressure monitoring to assess 

blood pressure of firefighters with parental history of 

hypertension. Arq. Bras. Cardiol. 2006; 87(6): 741-746 

26. Byczek L., Walton S.M., Conrad K.M. et al.: 

Cardiovascular risks in firefighters: implications for 

occupational health nurse practice. AAOHN J. 2004; 

52(2): 66-76. 

27. Kales S.N., Soteriades E.S., Christoudias S.G. et al.: 

Firefighters and on-duty deaths from coronary heart 

disease: a case control study. Environ. Health. 2003; 

2(1): 14. 


Chair and Department of Hygiene and Epidemiology 



tel. 52 585-36-15, 52 585-36-16, 52 585-36-17 

e-mail: kizhigieny@cm.umk.pl, jklawe@cm.umk.pl 

Received: 10.01.2012 



Anetta Cubała 1 , Tomasz Jurkiewicz 2 , Maciej Dzierżanowski 2 , Jarosław Hoffman 3,4 , Dorota Ratuszek 4 

FUNCTIONAL EVALUATION OF THE LUMBOSACRAL SPINE 

AMONG ATHLETES PRACTISING GRAPPLING 

OCENA FUNKCJONALNA KRĘGOSŁUPA LĘDŹWIOWO-KRZYŻOWEGO 

U ZAWODNIKÓW TRENUJĄCYCH GRAPPLING 

Chair and Department of Manual Therapy Nicolaus Copernicus University Collegium Medicum in Bydgoszcz 

Head: dr Maciej Dzierżanowski 

1 Department of Neurosurgery and Neurotraumatology, Nicolaus Copernicus University, 

Collegium Medicum in Bydgoszcz, Poland 

2 Department of Manual Therapy Nicolaus Copernicus University Collegium Medicum in Bydgoszcz,Poland 

3 Gdansk Management College, Poland 

4 Department of Rehabilitation, Nicolaus Copernicus University, Collegium Medicum in Bydgoszcz, Poland 

Summary 

I n t r o d u c t i o n . The lumbosacral spine pain 

syndromes have become a global problem which transcends 

the strictly medical sphere. Increased physical activity 

predisposes in particular the lumbar to overexploitation and 

exposure to heavy loads and pressures in various planes. In a 

classic case, a competitor’s injury occurs in the summation of 

microtraumas and the accelerated wear of tissues, which 

leads to serious consequences, is the highest price for the 

intensive improvement of the athlete’s movements. 

A i m o f t h e s t u d y . The aim of the thesis is to 

investigate the frequency and intensity of pain of the LS 

spine among people who practice grappling at various levels. 

On the basis of the survey, we answer the question whether 

the intense, specific activity of the athlete has an influence on 

the occurrence of pain and the motion range of the 

lumbosacral spine. 

Material and methodology. The study 

involved the total of 20 subjects, including 10 selected 

national team competitors in grappling and 10 amateur 

grapplers from the Association of Brazilian Jiu-Jitsu "Gracie 

Barra" Toruń. The entire study consisted of: questionnaires, 

measurements of mobility of the LS spine and exercises done 

by athletes according to the FMS method. 

R e s u l t s . 75% of all respondents felt pain in the LS 

spine (N = 8 amateurs, N = 7 members of national team). The 

intensity of symptoms was similar in both groups, but 

frequency was significantly higher in the amateurs. No 

correlation between the occurrence of pain and limited range 

of the LS spine motion was found. No functional 

abnormalities within that segment were found. 

C o n c l u s i o n s . 1. Despite the greater intensity and 

frequency of training, members of the national grappling 

team feel the pain in the LS spine less often than amateurs. A 

complementary training played a significant role in reducing 

the symptoms. 2. The occurrence of a lower spine pain of the 

respondents does not have any effect on the limitation of 

motion range in the LS spine. This risk increases with age 

and the training duration. 3. The grappling trainings 

predispose to occurrence of pain complaints among athletes. 

Streszczenie 

Wstę p. Zespoły bólowe odcinka lędźwiowokrzyżowego 

kręgosłupa stały się problemem globalnym 

wykraczającym poza sferę stricte medyczną. Zwiększony 

wysiłek fizyczny szczególnie usposabia odcinek lędźwiowy 

na nadmierną eksploatację oraz ekspozycję na duże 

obciążenia i naciski w różnych płaszczyznach. 

W klasycznym przypadku kontuzja zawodnika następuje 

w wyniku sumowania się mikrourazów, a przyśpieszone 

zużycie tkanek, prowadzące do poważnych konsekwencji, 

jest największą ceną za intensywne doskonalenie ruchów 

sportowca.

74 

Anetta Cubała et. al. 

Celem pracy było zbadanie częstotliwości 

i intensywności występowania dolegliwości bólowych 

w odcinku L-S kręgosłupa u osób trenujących grappling na 

różnych poziomach zaawansowania. Na podstawie 

przeprowadzonych badań odpowiem na pytanie, czy 

intensywna, specyficzna aktywność sportowca ma wpływ na 

występowanie dolegliwości bólowych i zakres ruchomości 

odcinka L-S kręgosłupa. 

Materiał i metodyka badań . W badaniu 

wzięło udział łącznie 20 osób, w tym: 10 wybranych 

zawodników kadry narodowej w grapplingu oraz 10 osób 

amatorsko trenujących grappling ze Stowarzyszenia 

Brazylijskiego Jiu Jitsu „Gracie Barra” Toruń. Na cały 

proces badawczy złożyły się: ankiety, pomiary ruchomości 

kręgosłupów w odcinku L-S oraz wykonane przez 

zawodników ćwiczenia wg metody FMS. 

W y n i k i . 75% wszystkich badanych posiadało 

dolegliwości bólowe odcinka L-S kręgosłupa (amatorzy N=8, 

członkowie kadry N=7). Intensywność dolegliwości była 

podobna w obu grupach badawczych, a częstotliwość 

znacznie większa u amatorów. Nie stwierdzono związku 

między występowaniem dolegliwości bólowych a ograniczeniem 

zakresu ruchomości kręgosłupa w odcinku L-S. 

Nie stwierdzono również nieprawidłowości funkcjonalnych 

w obrębie interesującego odcinka kręgosłupa. 

Wnioski. 1. Członkowie kadry narodowej grapplingu 

pomimo większej intensywności i częstotliwości treningowej 

odczuwają dolegliwości bólowe kręgosłupa w odcinku L-S 

rzadziej niż amatorzy. Duże znaczenie w zmniejszeniu 

dolegliwości odegrały treningi uzupełniające. 2. Występowanie 

dolegliwości bólowych kręgosłupa u badanych nie 

wpływa na ograniczenie zakresu ruchomości w odcinku L-S 

kręgosłupa. Ryzyko to rośnie wraz z wiekiem i stażem 

treningowym. 3. Treningi grapplingu predysponują do 

wystąpienia dolegliwości bólowych u ćwiczących. 

Key words: grappling 

Słowa kluczowe: grappling 

INTRODUCTION 

Lumbosacral spine, in sport, is subjected to 

extensive stresses and loads acting on all planes. Sports 

injuries, along with overload syndromes result from 

practicing sport of every kind and are a frequent 

consequence of intense physical exercise. According to 

the data, the problem of spinal overload encompasses 

5-10% of all sports injuries. As a rule, they are serious 

and lead to the occurrence of spinal pain syndromes. 

The mechanism of their formation is the same as for 

osteoarthritis of the spine, with the difference that 

natural degenerative processes are significantly 

accelerated by extreme loads. In both general 

comprehensive and specialized targeted training, 

intensive spine exploitation is inevitable. Therefore, 

highly qualified coaching team and constant 

supervision of a doctor or physiotherapist would be 

necessary, which, unfortunately, is often missing in 

sports clubs. [1,] These factors, i.e. the lack of 

knowledge of coaches in the field of biomechanics and 

anatomy and constant medical care are also indicated 

as causes of spinal pain complaints. [2, 3, 4, 5, 6, 7] 

Grappling is defined as a group of sports and martial 

arts based on maneuvers. Hitting is not allowed, and 

the allowed techniques include throws, takedowns, 

joint locks and chokes. The most popular martial arts 

included in grappling are Brazilian Jiu Jitsu, wrestling, 

judo and sambo. Grappling is also a fighting formula 

created several years ago, in which Polish players gain 

excellent results worldwide. In 2009, the Polish 

Wrestling Federation appointed grappling national 

team which has won several World and European 

Team Champion titles. 


The study involved 20 men who practiced 

grappling at various levels and who were assigned to 

one of two research groups. The first group consisted 

of individuals competing at the highest sports level, 

and who were part of the Polish national grappling 

senior team (N=10), treating the sport as a priority in 

their life. The second group included people who 

practiced amateur grappling (N=10), for whom it was a 

hobby and a form of recreation. The table below shows 

the characteristics of both groups. 

Table I. Research groups characteristics 

Tabela I. Charakterystyka badanej grupy 

Age 

(years) 

(Wiek) 

Height 

(cm) 

(Wzrost) 

Weight 

(kg) 

(Waga) 

Length 

of 

training 

(years) 

(Lata 

treningu) 

The national team 

(Kadra narodowa) 

Average 

(Średnia) 

Standard 

deviation 

(Odchylenie 

standardowe) 

Average 

(Średnia) 

Amateurs 

(Amatorzy) 

Standard 

deviation 

(Odchylenie 

standardowe) 

26.8 5.73 29.6 5.5 

179.4 5.99 180.2 3.77 

79.55 10.71 84.2 7.69 

8.2 2.62 5.85 3.33

Functional evaluation of the lumbosacral spine among athletes practising grappling 75 

The study of the participants included: filling out 

the questionnaire on the frequency and intensity of 

pain in an LS spine and complementary training, 

Saunders inclinometer measurement of the range of 

mobility in an extension motion, maximum and 

isolated flexion in the same segment and an analysis of 

tests performed with the Functional Movement Screen 

method. 

FMS is a screening method which, by means of 7 

tests, verifies the correctness and efficiency of the 

locomotors pattern according to clear criteria. Proper 

performance of the motor act according to its pattern 

reduces the risk of overload or an injury. This method 

can be applied to every person, whether it is a patient 

who undergoes treatment, a professional athlete, or a 

person who just wants to start an adventure with sport. 

Each of the seven tests is scored on a scale of 0 to 3, 

which clearly shows the motor deficit. On this basis, 

you can successfully plan the treatment or functional 

training, predict and provide medical or training 

guidance. The FMS includes the following tests: a deep 

squat, moving the leg over the hurdle, a lunge squat, 

assessing the shoulder girdle mobility, active straight 

leg elevation, trunk stability in front support and 

rotational stability of the trunk. These tests include the 

entire body, but most of them, directly or indirectly, 

assess the function of lumbosacral spine. [8, 9] 

activity for at least 8 weeks. Ranges of motion for all 

studied movements spoke in favor of the members of 

the team. On average, they amounted to: 

- For the motion of the maximum flexion - 86.1° 

(SD ± 14.8 o for members of the team and 65.6° 

(SD ± 5.13° for amateurs, 

Fig. 1. Range of maximum flexion motion 

Ryc. 1. Zakres ruchu maksymalnego zgięcia 

- For an isolated flexion motion (to the first pelvis 

movement) - 29.7° (SD ± 9.63°) for the members 

of the team and 24.4° (SD ± 8.62°) for amateurs, 

THE RESULTS 

75% of respondents (Amateurs N=8, National team 

N=7) felt the pain. The frequency of symptoms was 

higher in amateurs (the most common answer: ‘a few 

times a week’, while in the national team members 

group: ‘once a month’). The intensity was determined 

in the VAS scale as an average of 4.57 (SD ± 0.98) in 

the national team members, and 4.12 (SD ± 1.36) in the 

amateurs. All team members (N=10) also performed 

regular additional exercises focused on lumbosacral 

spine in the form of stretching, strengthening with the 

use of your own body weight, and weight training with 

the use of external weight. In the amateur group 

(N=10), 7 of them performed additional exercises with 

the predominant stretching activity (N=5). 

Strengthening exercises with your own body weight 

were performed by two amateurs, and with external 

weight - by 3 people. It is worth mentioning that in 3 of 

the respondents (2 amateurs and 1 member of the 

national team) a painful incident occurred in the past 

which had excluded the competitors from physical 

Fig. 2. Range of isolated flexion motion 

Ryc. 2. Zakres ruchu wyizolowanego zgięcia 

- For the extension movement - 18.8° (SD ± 

12.81°) for the members of the team and 12.6° 

(SD ± 5.5°) for the amateurs. 

Fig. 3. Range of extension 

Ryc. 3. Zakres ruchu wyprostu

76 

Anetta Cubała et. al. 

Average performance obtained by two research 

groups are slightly different over three points. The 

members of the team achieved an average score of 25.7 

points. (SD ± 4 pts.), and the amateurs 22.4 points (SD 

± 3.58 pts.) out of possible 36 points. There was a 

significant difference in the quality of execution of 

individual tests. The vast majority of national team 

members performed exercises with a stable position 

and a considerable motion control, while the amateurs’ 

position was often unsteady, and the movements were 

sometimes violent and imprecise. 

DISCUSSION 

The specificity of our spines transfers the greatest 

load on the lumbar segments during physical activity. 

The modern form of the sport tends to cause spinal 

overload and deformity. This means that increased 

physical activity predisposes the lumbar section to 

over-exploitation and exposure to heavy loads and 

pressures on different planes. The most common 

causes of spinal pain complaints in those sports 

primarily include excessive intensity of training and 

organizational-methodological errors, but also posture, 

structural defects in locomotor organs and innate 

predispositions. [4, 10] Accelerated tissue wear is the 

largest price for intensive movements’ improvement of 

the athlete. In a classic case, a player is injured as a 

result of summation of microtraumas. It should be 

noted that as far as the locomotor organ is concerned, 

even a single microtrauma does not heal without 

leaving trace. Damaged high-quality and specialized 

tissue is replaced by a defective one. [3] A large 

number of rapid extension, flexion and rotation 

movements combined with huge muscle tone and 

additional external load in the form of a partner or an 

opponent who resists pose a high risk of damage to the 

lumbosacral spine. Psychological factors such as the 

will to fight, ambition and desire to win of the players 

fighting against each other are also a major cause of 

sports injury. Pappas defines wrestling (which is a 

grappling sport), as one of the most injury-causing 

contact sports, where the most common injuries 

include stretching and sprains (36.4%), particularly in 

the upper limbs (44.3%). [11] 

The study shows that the members of the national 

team do a lot of exercises that supplement the 

grappling training such as stretching, strengthening and 

aggressive weight training of the lower spine, while the 

amateurs performed only stretching exercises, 

sometimes strengthening ones in the form of a warmup 

before training. It is the key to the results obtained. 

Intensity of prevalence of pain complaints in both 

groups was similar, but their frequency in the group of 

the team members was much lower. The national team 

members also gained greater ranges in every 

movement. Comparing the results of maximum flexion 

which, apart from the mobility of the spine itself, also 

comprises the flexibility of ischiotibial muscles and the 

mobility of the hip joint with isolated flexion in the LS 

section, numerous causes of pain may be discerned. 

Namely, for example, Lennard [5] closely relates the 

lack of hamstring stretch to the occurrence of 

lumbosacral pain. On the basis of exercises performed 

by the study participants according to the Functional 

Movement Screen test, no functional abnormalities of 

the LS spine section were detected. Other observed 

abnormalities did not concern the subject of the 

research. Average results obtained by two research 

groups in the total FMS were as follows: 25.7 points 

(SD ± 4 pts.) for the members of the national team and 

22.4 points (SD ± 3.58 points) for the amateurs out of 

possible 36 points. Results do not differ considerably; 

however, they do not reflect the quality of tests 

performance, which varied between groups. Cofounder 

of the method, Gray Cook [12] believes that 

‘the most common error in today's sport lies in 

improving the locomotor pattern before obtaining a full 

range of mobility and stability of this movement’. This 

means that the emphasis should be put on the correct 

technique of motion, mobility and stability and those 

elements should be placed before the strength, stamina, 

and specific ability training assigned to a given 

discipline. 

CONCLUSIONS 

1. Despite the greater intensity and frequency of 

training, members of the national grappling team 

feel the pain in the LS spine less often than 

amateurs. A complementary training played a 

significant role in reducing the symptoms. 

2. The occurrence of a lower spine pain of the 

respondents does not have any effect on the 

limitation of motion range in the LS spine. This 

risk increases with the age and the training 

duration. 

3. The grappling trainings predispose to occurrence of 

pain complaints among athletes.

Functional evaluation of the lumbosacral spine among athletes practising grappling 77 

REFERENCES 

1. Garlicki J., Bielecki A., Kuś W. M.: Urazy sportowe u 

progu trzeciego tysiąclecia. Medycyna Sportowa, nr 114 

Traumatologia sportowa; 2001; 01. 

2. Cypress B.: Characteristics of physician visits for back 

symptoms: a national perspective. An. J. Public. Health., 

1983; 73: 389-395. 

3. Dziak A., Tayara S.: Urazy i uszkodzenia w sporcie, 

Wydawnictwo Kasper, Kraków 2000. 

4. Dziak A.: Bolesny krzyż. Medicina Sportiva, Kraków 

2003. 

5. Lennard T., A. Crabtree M. H.: Spine In Sports. Elsevier 

2005. 

6. Zajączkowski Z.: Medycyna Sportowa w praktyce. 

PZWL, Warszawa 1984. 

7. Żytkowski A.: Etiopatogeneza bólowych zespołów 

kręgosłupa lędźwiowo-krzyżowego. Balneologia Polska, 

2001; 1: 81-87. 

8. Cook G., Burton L., Hoogenboom B.: Pre-participation 

screening: The use of fundamental movements as an 

assessment of function – part 1. North American Journal 

of Sports Physical Therapy, 2(1): 62-72, 2006. 

9. Cook G., Burton L., Hoogenboom B.: Pre-participation 

screening: The use of fundamental movements as an 

assessment of function – part 2. North American Journal 

of Sports Physical Therapy, 2(1): 132-139, 2006. 

10. Starosta W.: Kształt kręgosłupa z punktu widzenia 

motoryki człowieka i motoryki sportowej. Postępy 

rehabilitacji, Vol. VII 1993; 4: 19-32. 

11. Pappas E.: Boxing, wrestling, and martial arts related 

injuries treated in emergency departments in the United 

States, 2002-2005. Journal of Sports Science and 

Medicine, 6: 58-61, 2007. 

12. Cook G.: Baseline sports-fitness testing. In: Foran B, ed. 

High-performance sports conditioning. Champaign, IL: 

Human Kinetics; 2001:19–55. 


mgr Anetta Cubała 

Departament of Neurosurgery and Neurotraumatology, 

Nicolaus Copernicus University 

Collegium Medicum in Bydgoszcz 

e-mail: anettacubala@gmail.com 

Received: 10.01.2012 



Grażyna Gebuza¹, Marzena Kaźmierczak ¹, Małgorzata Gierszewska¹, Estera Mieczkowska ¹, Małgorzata Bannach 2 , 

Roman Kotzbach³ 

STANDARD OF MATERNAL POSTPARTUM HAEMORRHAGE CARE 

STANDARD OPIEKI NAD POŁOŻNICĄ Z KRWOTOKIEM POPORODOWYM 

1 M.Sc. Grażyna Gebuza, The Department of Obstetric Care Basics 

Nicolaus Copernicus University, Collegium Medicum in Bydgoszcz 

1 M.Sc. Marzena Kaźmierczak, The Department of Obstetric Care Basics 


1 M.Sc. Estera Mieczkowska, The Department of Obstetric Care Basics 


1 M.D. Małgorzata Gierszewska, Head of Department of Obstetric Care Basics 


2 M.Sc. Małgorzata Bannach, Department of the Obstetric Nursing 


3 D.Sc. Roman Kotzbach, Professor. NCU, Head of the Department of Nursing and Midwifery 


Summary 

Haemorrhage represents 38.7% of all direct causes of 

maternal deaths and remains the most common cause. The 

official definition of postpartum haemorrhage by the World 

Health Organization (WHO) is the loss of more than 500 ml or 

more blood from the reproductive tract within 24 hours after 

birth. Blood loss in the first 24 hours after birth is called the 

early postpartum haemorrhage, while in the period from 24 

hours to 6 weeks after birth - late postpartum haemorrhage. 

Due to the dynamism of haemorrhage, actions must be 

oriented at protecting women in childbirth from lifethreatening 

conditions. Haemorrhage is the most common 

state of urgency in obstetrics, which is why it is important that 

the midwifery team knows and understands the rules of 

conduct in this severe complication of labour. Therefore, it is 

necessary to create and implement standards to ensure a high 

level of maternity care. 

Streszczenie 

Krwotoki stanowią 38,7% wszystkich bezpośrednich 

przyczyn zgonów matek i pozostają ich najczęstszą 

przyczyną. Oficjalną definicją krwotoku poporodowego 

według Światowej Organizacji Zdrowia (WHO) jest utrata 

ponad 500 ml lub więcej krwi z dróg rodnych w ciągu 

24 godzin od narodzin dziecka. Utratę krwi w pierwszych 

24 godzinach po porodzie nazywamy wczesnym krwotokiem 

poporodowym, a w okresie od 24 godzin do 6 tygodni po 

porodzie, późnym krwotokiem poporodowym. Ze względu 

na dynamiczność krwotoku podejmowane działania muszą 

być ukierunkowane na ochronę położnic przed stanem 

zagrożenia życia. Krwotok to najczęstszy stan naglący 

w położnictwie, dlatego ważne jest, aby cały zespół 

położniczy znał i rozumiał zasady postępowania w tym 

ciężkim powikłaniu porodu. W związku z tym należy 

tworzyć i wdrażać standardy, aby zapewnić wysoki poziom 

opieki położniczej. 

Key words: postpartum haemorrhage, standard care 

Słowa kluczowe: krwotok poporodowy, standard opieki

80 

Standard of maternal postpartum haemorrhage care 

AIM OF THE STUDY 

- Presentation of the most common risk factors 

associated with the occurrence of 

haemorrhage in the postnatal period 

- Acquainted with the standard care for 

maternal postpartum blood loss of 500-1000 

ml of blood without symptoms of shock 

(protocol A), 

- Acquainted with the standard care for 

maternal postpartum blood loss of 500-1000 

ml of blood at the existing symptoms of 

hemorrhagic shock (protocol B), 

- An indication of a significant role of 

midwives in the prevention of post-natal 

haemorrhage. 

Subject: Life-threatening conditions in 

obstetrics 

Group care: Mother with postpartum haemorrhage 

with the loss of more than 500-1000 ml of blood 

without signs of hemorrhagic shock (protocol A). 

Mother with postpartum haemorrhage with loss of 

more than 1000-1500 ml of blood or with existing 

symptoms of hemorrhagic shock (protocol B). 

Standard Statement: Mother is ensured with 

intensive supervision and care aimed at preventing 

severe and irreversible haemorrhage complications. 

Justification: 

One of the major causes of morbidity and maternal 

mortality is a massive obstetric haemorrhage. 

According to data from the years 1991-2000, in Poland 

from 402 maternal deaths due to obstetric causes, 135 

(33.5%) were caused by haemorrhages. Similarly, in 

2001-2004, among the 132 deaths, 41 (31.06%) were 

because of haemorrhage [1]. According to recent data 

from 2010, a postpartum haemorrhage in Poland, is 

still one of the most common causes of maternal 

deaths, represents 38.7% of them. [2]. 

The official definition of postpartum haemorrhage 

according to the World Health Organisation (WHO) is 

the loss of more than 500 ml of blood from the 

reproductive tract within 24 hours of birth. Average 

blood loss during labour by forces of nature is 500 ml 

of blood and more than 1000 ml during caesarean 

section [3]. Blood loss in the first 24 hours after birth is 

called the early postpartum haemorrhage, while in the 

period from 24 hours to 6 weeks after birth, late 

postpartum haemorrhage. Definition of massive 

(severe) bleeding: blood loss of more than 150ml/min 

(causes a loss of more than 50% of blood volume 

within 20 min), sudden loss of more than 1500-2000ml 

(uterine atony, loss of 25-35% of blood volume) [3, 4, 

5]. Determining the volume of blood lost is often 

subjective and inaccurate. Lowering the level of 

haematocrit of 10% allows the identification of 

postpartum haemorrhage, but the level of haemoglobin 

or haematocrit may not reflect the current hematologic 

state [6]. 

Prenatal risk factors for postpartum haemorrhage 

include: 

• antenatal bleeding, 

• risk of premature separation of placenta, 

• placenta praevia, 

• multiple pregnancy, 

• hypertension in pregnancy (preeclampsia, 

eclampsia, HELLP), chorionamnionitis, 

• polyhydramnios, 

• fetal death, 

• anaemia Hb 5 pregnancies 

• fibroids 

• haemorrhage in an interview, 

• obese. 

Birth risk factors: 

• Caesarean section (especially in a matter of 

urgency), 

• placental retention, uterine weakness (atony) 

• operational completion of delivery (tick, 

vacuum extractor) 

• lack of progress in labour (extending over 12 

hours, particularly in the second period of 

more than 1 hour in multiparous, over 2 hours 

in the primipara), 

• induction of parturition, a large fetus (more 

than 4000G), 

• genital tract trauma in childbirth (rupture, 

hematomas, eversion of the uterus), 

• fever, 

• method of anaesthesia, 

• DIC. 

Causes of obstetric haemorrhage can be divided 

into antenatal and intrapartum, among which there are: 

placenta previa, placental abruption and uterine rupture 

and postpartum causes such as uterine atony, placenta 

ingrown, the remains of the placenta, damage of 

cervix, vagina and perineum [7 ]. Excessive blood loss 

after childbirth may be due to: the method of 

conducting labour, abnormal separation of the 

placenta, injuries of cervix, corpus of uterus, vaginal or

Grażyna Gebuza et. al. 81 

perineal; also abnormal uterus contraction [4], which is 

the most common cause, and disorders of haemostasis. 

A specific group consist of patients with preeclampsia 

and HELLP syndrome [7,8,9]. Therefore, each of the 

parturient with emerging risk factors should ensure an 

expert supervision [4]. 

Postpartum haemorrhage can lead to shock, which 

is a clinical syndrome arising when autoregulation 

system mechanisms are not able to ensure proper blood 

flow to organs and tissues important for living. Direct 

threat to the mother's life is not only a hypovolemic 

shock induced by haemorrhage, but also other 

complications such as blood coagulation disorders 

(DIC) or uteroplacental stroke [1]. 

Proceedings with postpartum haemorrhage usually 

include a series of actions intending to stop the 

bleeding. Due to the dynamism, actions must be 

focused on maternal protection against severe, 

prolonged shock, which can become irreversible. 

Therefore, it is important to urgently contact the 

supervisor, place in a state of readiness obstetric team, 

the operating block, anaesthesiologist, Blood Donation 

Station. The cooperation of the whole team can 

contribute to reducing maternal mortality. 

Criteria for the structure 

1. Highly specialized medical and obstetrical 

staff providing professional treatment and 

care is employed on the ward. 

2. Midwife, as a member of the therapeutic team, 

works with obstetrician, anaesthesiologist, 

staff of laboratory, operating block, Blood 

Donation Station, Pharmacy. 

3. Midwife knows: 

• etiology, risk factors and symptoms 

of postpartum haemorrhage, 

• algorithm of conduct with a 

haemorrhage, 

• type of fluid used to restore blood 

volume crystalloids, colloids, blood), 

• procedures for the transfusion of 

blood and its preparations, 

• type and method of collecting 

material for testing, 

• methods of monitoring the state of 

mothers, 

• medications which may be given in a 

life-threatening situation without a 

doctor's orders, 

• algorithms, procedures and standards 

of the department, 

• can take resuscitation action. 

• knows the advantages of breast 

feeding. 

4. Providing care, the midwife acts in 

accordance with the principles of aseptic 

techniques, provides sense of security and 

intimacy to mothers. 

5. The midwife knows and follows the Patients' 

Rights Chart. 

6. Midwife has the opportunity to development: 

self-study, participation in conferences and 

symposia, improvement in the ward, bachelor 

and master’s degree, specialization. 

7. Midwife has the authority to administer 

medicines, blood and blood products, 

intravenous infusion fluids. 

8. The intensive care is provided in lifethreatening 

situation. 

9. Ward, equipped with equipment to achieve 

curative and care tasks at the highest level, 

has: 

• necessary resuscitation equipment (Ambu 

device, intubation set) and drugs 

• oxygen therapy equipment, access to a 

central source of oxygen and suction, 

• Devices for measuring blood pressure, 

ECG monitor, pulse oximeter, body 

temperature (equipment for electronic 

monitoring of body temperature), hourly 

and daily urine output, blood glucometers, 

• needles and syringes, test tubes, 

transfusion sets, infusion pumps, cannulas 

into peripheral veins and central venous 

catheters, vacuum blood collection sets 

type BD Vacutainer, medications and 

intravenous fluids, Foley catheters, 

dressing material, personal protective 

equipment, antiseptics , 

• procedure: collection of material for tests, 

the establishment and care of the 

peripheral and central intravenous line, 

maternal care after physiological birth and 

caesarean section, blood transfusion and 

blood products, bleeding procedure; 

• algorithm of conduct with a haemorrhage, 

resuscitation activities algorithms, 

• documentation enabling the registration of 

diagnostic activities, nursing care, 

rehabilitation and healing done by 

midwives.

82 


Criteria for the process: 

For transparency of the activities specified two 

protocols to the proceedings: 

Protocol A 

In order to ensure optimal care to mothers with 

postpartum haemorrhage with blood loss estimated at 

500-1000 ml, with no signs of shock, the midwife takes 

the following actions: 

1. Recognizes the core symptoms of 

haemorrhage: heavy vaginal bleeding, a 

decrease in systolic blood pressure (

Grażyna Gebuza et. al. 83 

2. Determines the type and severity of blood loss 

based on observations and obtained 

information. 

3. Performs massage of fundus until a strong and 

sustained contraction. 

4. Foley catheter is assumed into the bladder [4] 

(the patient's consent). 

5. Provides access to a peripheral vein (2 x 14 

G-brown or 16 G-gray). 

6. Takes blood to the test in accordance with a 

medical order to: determination of 

morphology, (takes blood to cross-matching 

before the transfusion of colloid), coagulation 

(PT, aPTT, fibrinogen), blood gases, 

electrolytes. Secure 5-6 units of PRBCs [4] in 

Blood Donation Station. 

7. Prepares and transfuses infusion fluids in 

accordance with a medical order to fill 

deficiencies in circulating blood volume and 

restore the flow of tissue, respecting the 

existing rules in this area, complies with the 

principles of safe blood transfusion in 

accordance with established procedure in the 

ward, observes the patient when connecting 

the blood (the performance of the bioassay), 

transfusion and after the infusion. 

8. Participates in treatment (acting in accordance 

with the medical order's), which aims to save 

lives: 

• stop the bleeding, increase uterine muscle 

tension (Oxytocin 10-20 IU in bolus [1] and 

then infusion of 40 IU in 500ml of 0, 9 NaCl - 

infusion at 125 ml / h), dinoprost, (Enzaprost, 

PGE 2), sulproston, misoprostol (PGE 1, 

Cytotec) 

• prohaemostatic drugs - recombinant factor 

VIIa (rFVIIa) 

• antifibrinolytic agents epsilon-aminocapronic 

acid (EACA), tranexamic acid (TXA), 

aprotinin, significantly reduce bleeding, 

• Desmopressin (vasopressin derivative - works 

by increasing levels of coagulation factors 

VIII and Von Willebrand factor and by direct 

activation of platelets; 

• increase in circulating blood volume (if blood 

loss 1000-1500 ml of blood and signs of 

shock): 

a. crystalline liquid to a volume of 2000ml 

(heated), 

b. colloidal fluids (hydroxyethylated starch, 

gelatin, 4.5% albumin) to a volume 

1500ml/day, 

c. PRBCs transfusion (as soon as possible). If 

there is no cross-matched, group compatible 

blood, transfusion of compatible by the group 

of patients without a cross-match (on the 

order of a physician !!!). In any case, the 

urgent need for blood transfusions gives 

group "0" Rh negative. 

d. If bleeding does not stop, and (or) there is no 

coagulation control, it is recommended to 

transfuse 4-5 units of FFP, 10 units of KP 

• oxygenation of blood - the supply of oxygen- 

6-8 l / min [4], 

• reduce the need for oxygen, maintaining the 

correct temperature (heating patients) 

• ensure the blood supply to vital organs, lays 

lower limbs above, anti-shock position, 

• conduct strict monitoring and documenting 

actions taken diagnosis, treatment and care. 

14. Conducts strict supervision and 

documentation of the diagnosis, treatment and 

care activities: pulse rate, blood pressure 

(systolic, diastolic) using the indirect method 

(non-invasive peripheral sphygmomanometry, 

using cuff whose width should be adjusted to 

arm circumference), body temperature 

(estimated temperature of peripheral parts of 

the body and differentiate between the 

temperature of the trunk and toe), ), the 

frequency and character of respiration and 

blood gases, renal function by controlling the 

hourly diuresis (restoration of urine excretion 

0.5-1 ml / kg / h) [5], state of consciousness, 

results of laboratory tests, medications given, 

the water balance chart; state of 

consciousness, results of laboratory tests, 

administered drugs. 

15. Provides a sense of security and reduces 

anxiety to mother by constant presence, 

calming and supervision. 

16. Participates in preparation for surgical 

operations. If the methods described above do 

not bring the expected improvement of the 

control of bleeding, prepares mother to 

surgical procedure: 

• control of the genital tract injuries 

• control of the uterus [3] 

• tamponade of the uterus

84 


• laparotomy [4] 

Outcome Criteria 

Mother with postpartum haemorrhage during the 

hospitalization was properly taken care of if the 

following conditions were provided: 

1. A patients was subject to intense maternal 

care by midwife and multidisciplinary team to 

rapidly identify the cause of haemorrhage and 

control bleeding. 

2. All the taken actions were adequately 

matched to the patient's hemodynamic status. 

3. Nursing problems were recognized and dealt 

with by a midwife and a cooperating team. 

4. The patient's condition is stable. Smooth 

peripheral circulation (heart rate 60-100 min, 

blood pressure is maintained at 110-100/60-50 

mmHg, distal parts of limbs are warm. Mother 

condition - shrunk uterus, vaginal bleeding - 

mediocre, bloody. 

5. Lack of systemic organ failure and lifethreatening 

multiorgan failure. Diuresis above 

40 ml/h, hematocrit above 30%. 

6. The patient is safe and feels no fear. 

ABBREVIATIONS USED IN THIS STUDY 

APTT - activated partial thromboplastin time 

activation 

FFP - fresh frozen plasma 

Hb - haemoglobin 

im - intramuscular administration of the drug 

iv - intravenous administration of the drug 

PRBCs - red blood cell concentrate (packed red blood 

cells) 

KP - cryoprecipitate 

PC - platelet concentrate 

PPH - postpartum hemorrhage (postpartum 

haemorrhage) 

PT - Prothrombin time 

rFVIIa - recombinant activated factor VII (factor VIIa 

Recombinant) 

REFERENCES 

1. Reroń A., Jaworowski A., Ossowski P. : Krwotoki 

okołoporodowe - sposoby postępowania: Ginekologia i 

położnictwo - medical project, 2009 (3): 33-40. 

2. Szamotulska K.: Stan zdrowia matek i dzieci w okresie 

okołoporodowym w Polsce na tle krajów Unii 

Europejskiej. Opracowanie na podstawie wskaźników 

Euro-Peristat. Medycyna Wieku Rozwojowego, 2010, 

XIV, 2: 113-128. 

3. Ramanathan G. Arulkumaran S.: Krwotok poporodowy, 

Położnictwo, Ginekologia, Medycyna Rozrodu, 2007, 

tom 1(1) XII: 2-5. 

4. Sobieszczyk S. Bręborowicz G.H : Rekomendacje 

postępowania w krwotokach poporodowych, Cz.I, 

Protokół postępowania, Kliniczna Perinatologia 

i Ginekologia, 2004, tom 40, zeszyt 2: 60-63. 

5. Sobieszczyk S. Bręborowicz G.H.: Propozycja zaleceń 

stosowania rekombinowanego aktywnego czynnika VII 

[rFVIIa] w ciężkich krwotokach położniczych 

i ginekologicznych, Perinatologia, Neonatologia 

i Ginekologia, 2008, tom1, zeszyt 1: 78-80. 

6. Oszukowski P. Pięta-Dolińska A. : Krwotok poporodowy 

– kliniczna etiopatogeneza. Przegląd Menopauzalny, 

2010, 4: 247–251. 

7. Bręborowicz G. Sobieszczyk S. : Krwawienia w II i III 

trymestrze ciąży. W: Bręborowicz G. (red.): Położnictwo 

i ginekologia. PZWL, Warszawa: 2006. 

8. ACOG. Postpartum haemorrhage, Practise Bulletin: 

Obstet Gynecol, 2006, 108 (4): 1039-47. 

9. Cunningham FG. Leveno KJ. Bloom SL. et al.: Obstetric 

hemorrhage. In: Williams Obstetrics. New York: 

McGraw-Hill, 2005: 809-52. 

10. Czajkowski K.: Krwawienia poporodowe. W: Spaczyński 

M. (red.): Postępy w ginekologii i położnictwie, Polskie 

Towarzystwo Ginekologiczne, Warszawa, 2006: 391-9. 

11. Jakubaszko J.: Ratownik medyczny, Górnicki Wyd. 

Med.Wrocław, 2003:48. 


M.Sc. Gebuza Grażyna 

Toruń, ul. Niesiołowskiego 2B/30 

grazyna.gebuza@cm.umk.pl 

tel.: +48 796061139 

Received: 10.01.2012 



Izabela Glaza 1 , Katarzyna Pietkun 2 , Rafał Szadujkis-Szadurski 1 , Krystyna Nowacka 2 , 

Magdalena Hagner-Derengowska 1 , Maciej Nowacki 3 

PROBIOTICS IN FOOD. IMPORTANT PREVENTIVE FACTOR IN CHILDREN ALLERGY, 

OR A CONTROVERSIAL ADD-ON? REVIEW OF THE LITERATURE 

PROBIOTYKI W ŻYWNOŚCI. ISTOTNY CZYNNIK PREWENCYJNY 

W ALERGOLOGII DZIECIĘCEJ CZY KONTROWERSYJNY DODATEK? 

PRZEGLĄD PIŚMIENNICTWA 

1 Department of Pharmacology and Therapy, Collegium Medicum in Bydgoszcz 


Head: dr hab. n. med. Grzegorz Grześk, prof. UMK 

2 Department and Clinic of Rehabilitation, Collegium Medicum in Bydgoszcz 


Head: prof. dr hab. n. med. Wojciech Hagner 

3 Tissue Engineering Department, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń 

Head: dr hab. n. med. Tomasz Drewa, prof. UMK 

Summary 

Currently, one of the most frequently discussed topics 

related to the problem of child allergy are food allergies. 

Statistical data on the number of children burdened with this 

type of allergy are divergent according to reports of the 

individual authors. But invariably publications and scientific 

reports point to the upward trend in the number of newly 

identified various forms of food allergy. According to the 

data (AAAAI), in the years of 1997-2007 the number of 

diagnoses in children under 18 years of age increased by 

18%. 

The European Data included in the reports (EFA) also 

confirm a growing trend in this respect in the recent years. In 

addition to significant development of diagnostics and 

therapy of various forms of childhood food allergy attention 

has been drawn to factors that affect the development of a 

preventive of this disease. In this type of factors, probiotics 

are also included . 

Streszczenie 

Jednym z częściej poruszanych obecnie tematów 

problemowych w współczesnej alergologii dziecięcej są 

alergie pokarmowe. Dane statystyczne na temat liczby dzieci 

obarczonych tym typem alergii są rozbieżne według 

doniesień poszczególnych autorów. Jednak niezmiennie od 

kilku lat w publikacjach i doniesieniach naukowych 

wskazuje się na tendencję wzrostową w ilości nowo 

rozpoznanych różnych form alergii pokarmowej. Według 

danych (AAAAI) w latach 1997-2007 liczba rozpoznań u 

dzieci poniżej 18 roku życia wzrosła o 18%. Dane 

Europejskie zawarte w raportach (EFA) potwierdzają także 

tendencję wzrostową w tym aspekcie. Obok znacznego 

rozwoju diagnostyki i różnych form terapii dziecięcej alergii 

pokarmowej, istotnie zwraca się na przestrzeni ostatnich lat, 

także uwagę na czynniki mogące wpływać prewencyjnie na 

rozwój tej choroby. Do tego typu czynników zalicza się także 

probiotyki. 

Key words: probiotic, probiotic bacteria, food allergy, allergy 

Słowa kluczowe: probiotyk, bakterie probiotyczne, alergia pokarmowa, alergologia

86 

Izabela Glaza et al. 

INTRODUCTION 

Food allergies are one of the most common 

problems of modern allergology. The cause of food 

allergy is the most common, genetic and direct damage 

of the intestinal barrier by bacteria and viruses. The 

most common allergy symptoms occur after eating 

foods that are a source of allergen. Very often, they 

cause a direct increase in the production of IgE 

stimulates mast cells to induce inflammatory processes. 

The highest percentage of allergic reactions occur after 

ingestion of milk, especially in infants and young 

children, eggs, fish, seafood, peanuts. The most 

common allergy symptoms include shortness of breath, 

diarrhea, hives, stomach pain [1, 2, 3, 4, 5]. 

PROBIOTICS 

Probiotics are bacterial cultures, usually lactic acid 

bacteria that have a positive, protective effect on the 

gastrointestinal mucosa. Their beneficial effect is to 

improve and restore the normal bacterial flora. The 

best known are L. acidophilus, L. casei, L. fermentum, 

L. gasseri, L. Johnson, L. lactis, L. bulgaricus, 

L. plantarum, L. salivarius, L. rhamnosus, L. reuteri 

and Bifidobacterium: B. bifidum, B.longum, B.infantis. 

Probiotic bacteria not only strengthen the body's 

bacterial flora, but also inhibit the adhesion of 

pathogenic microorganisms, so that there is an increase 

in immunity. Probiotic bacteria are found primarily in 

fermented milk drinks. This group includes: yogurt, 

buttermilk, kefir, milk, and curdled milk acidophilous. 

It is noteworthy that the nutritional value of fermented 

dairy products is as high as milk, while the value of 

fermented beverages care is much higher than milk. 

This is connected mainly with the biological activity of 

living lactic acid bacteria. Dairy products with 

probiotics strengthen the content and stimulate the 

human immune system. In addition, carcinogenic 

compounds decompose and form one of the factors 

preventing osteoporosis. Due to the presence of 

probiotics, yogurt and kefir are rich in protein, fat, 

lactose and mineral salts. In people who suffer from 

lactose intolerance, regular consumption of fermented 

milk drinks alleviates the symptoms of intolerance. 

Probiotic bacteria contain the enzyme betagalactosidase, 

which breaks down lactose into simple 

sugars [1, 4, 6, 7, 8, 9]. 

Additional benefits of consuming milk fermented 

beverages are: 

• improvement of the processes of digestion, 

• improvement of the lipid profile in people 

with high cholesterol, 

• destruction of pathogenic and putrefactive 

faecal microflora in the large intestine of man, 

• prevention of intestinal infections, 

• therapeutic treatment for diarrhea in children, 

• prevention of relapse of fungal and bacterial 

infections of the vagina. 

Regular consumption of fermented beverages seems to 

be an important factor. It has proven to improve human 

body's natural resistance to infections. A necessary 

condition to obtain good results is diet rich in viable 

bacteria (100 million in 1 ml of the drink) [2, 3, 10, 

11]. 

THE BENEFITS OF PROBIOTICS 

IN FOOD ALLERGY IN CHILDREN 

Michalkiewicz et al. thought that lactic acid 

bacteria provide many health benefits, including 

improved resistance to bacterial physiological 

microflora to antibiotics and have anticancer 

properties. Important is the fact that this work 

addresses the impact of probiotics on allergic reactions 

weakness. An increasing number of reports confirm 

many positive effects of probiotics in prevention and 

treatment of food allergies. [12] 

Isoluri et al. reported the ability of probiotics to 

inhibit the early stages of allergic inflammation and 

atopic eczema through observation carried among 

infants with atopic eczema fed with mothers’ milk [the 

effects of inclusion of probiotics (mainly 

Bifidobacterium lactis, Lactobacillus GG) to reduce 

eczema in infants]. The original value of SCORE 

points (severity of eczema), which was 16, decreased 

after supplementation with Bifidobacterium lactis Bb 

to 0 and Lactobacillus GG to 1 It is important that in 

the control group SCORAD score was 13.4, indicating 

the positive role of probiotics in allergic reactions. 

Furrie et al. reported an impact of pro biotic therapy 

on the prevention of allergic diseases and the effects of 

Lactobacillus rhamnosus GG on atopic eczema 

reduction in newborns. Pessi et al. who claimed that 

supplementation with Lactobacillus rhamnosus inhibits 

inflammation in the mucosal inflammation of the 

gastrointestinal tract and also relieves the symptoms of 

atopic dermatitis [13].

Probiotics in food. Important preventive factor in children allergy, or a controversial add-on? Review of the literature 87 

According to Kalliomaki et al. Lactobacillus GG 

supplementation is an effective method of preventing 

atopic disease in children with risk factors. 

Detailed study by Kukkonen et al. reported that 

preventing atopic dermatitis in infants at high risk is 

possible by modulating probiotic intestinal microflora 

of the child. In addition, there was no effect on the 

incidence of food allergy in children up to 2 years old, 

and a significant proportion of prevention of atopic 

eczema was observed. [8] 

According to Del Giudice et al. probiotics are 

involved in interaction with the mucosal immune 

system as a commensal bacterium of the system. The 

study showed that probiotic bacteria in vivo cause an 

increase in IL-10 and IgA in children with a 

predisposition to allergies. [1] 

However, research conducted in Warsaw by 

Szajewska et al. proved the efficacy of probiotics in the 

treatment of antibiotics, in particular strains of 

Lactobacillus GG supplementation or Bifidobacterium 

lactis Bb-12 as the symptoms of atopic dermatitis in 

infants fed artificially and naturally. In addition, one 

case reported a preventive effect of Lactobacillus GG 

as it reduced the risk of incidence of atopic dermatitis 

in infants with a history of allergy. [14] 

Majamaa et al. have shown that use of probiotics 

in infants with atopic dermatitis in the course of allergy 

to cow's milk proteins results in significantly lower 

SCORAD index and the decrease in TNF-α, and α-1- 

AT. The corresponding data is given by Isolauri et al.; 

their studies showed reduction of SCORAD score in 

infants fed human milk with symptoms of atopic 

dermatitis after taking probiotics supplemented by 

hydrolysed protein. 

CONCLUSION 

Probiotics, which are often used as an addition to 

the milk products are regarded as a controversial media 

supplement but there is no reference in publications on 

nutrition in the food allergies. Probiotics are a very 

good method to increase the natural immunity. Many 

sources report that supplementation with probiotics 

plays an important role in the prevention of food 

allergy and the symptoms of atopic dermatitis. 

[15,16,17,18] Many clinical studies report significant 

benefits of supplementation of probiotics in the 

prevention and management of food allergy, but not 

everyone agrees on their effectiveness. A significant 

development in this branch of medicine, particularly in 

the pediatrics and pediatric allergology, provides 

a large number of probiotics as a drug or dietary 

supplement products, specially dedicated for children, 

such as chewable tablets or strawberry-flavored 

droplets [19,20]. 

REFERENCES 

1. Del Giudice MM, Leonardi S, Maiello N, Brunese FP. 

Food allergy and probiotics in childhood. J Clin 

Gastroenterol. 2010 Sep;44 Suppl 1:S22-5. 

2. Furrie E. Probiotics and allergy. Proc Nutr Soc. 2005 

Nov;64(4):465-9. 

3. He F. et al.: Comparion of mucosal adhesion and species 

identification of bifidobacteria isolated from healthy and 

allergic infants; FEMS Immunol. Med. Microbiol., 2001; 

30:43-47. 

4. Host A., Koletzko B., Dreborg S. i wsp.: Dietary 

products in infants for treatment and prevention of food 

allergy. Joint statement of the European Society for 

Paediatric Allergology and Clinical Immunology 

(ESPACI) Committee on Hypoallergenic Formulas and 

the European Society for Paediatric Gastroenterology, 

Hepatology and Nutrition (ESPGHAN) Committee on 

Nutrition. Arch. Dis. Child., 1999, 81, 80-84. 

5. Isolauri E. et al.: Probiotics in the management of atopic 

eczema, Clin. Exp. Allergy., 2000; 30: 1604-1610. 

6. Kalliomaki M, et al.: Probiotics in primary prevention of 

atopic disease. a randomised placebo-controlled trial. 

Lancet 2001, 357(9262):1076-9. Clin Immunol 2007, 

119(1):192-8. 

7. Kirjavainen P.V., Apostolou E., et all: New aspects of 

probiotics – a novel approach in the management of food 

allergy. Allergy, 1999, 54, 909-915. 

8. Kukkonen K, et al.: Probiotics and prebiotic galactooligosaccharides 

in the prevention of allergic diseases. a 

randomized, double-blind, placebo-controlled trial. J 

Allergy Clin Immunol 2007, 119(1):192-8. 

9. Majama H, Isolauri E. Probiotics: a novel approach in the 

management of food allergy. J Allergy Clin Immunol 

1997;99:179-185. 

10. Wysocka M.: Probiotyki – nowe, obiecujące 

zastosowania w terapii. Nowa Pediatria 3/2001, s. 19-24. 

11. Vliagoftis H, Kouranos VD, Betsi GI, Falagas ME.: 

Probiotics for the treatment of allergic rhinitis and 

asthma: systematic review of randomized controlled 

trials. Ann Allergy Asthma Immunol. 2008 

Dec;101(6):570-9. 

12. Michałkiewicz J.: lmmunomodulujący wpływ 

probiotyków na reakcje odpornościowe. Standardy Med. 

2003 T. 5 nr 9 s. 1270-1280. 

13. Pessi T. et al.: Interleukin-10 generation in atopic 

children following oral Lactobacillus rhamnosus GG; 

Clin. Exp. Allergy., 2000; 30: 1804-1808 

14. Szajewska H.: Rola probiotykóww zapobieganiu 

i leczeniu chorób przewodu pokarmowego.: Pediatria 

współczesna, Gastroenterologia, Hepatologia i żywienie 

dziecka 2005, 7,1, 53-60.

88 

Izabela Glaza et al. 

15. Saavedra M.: Clinical applications of probiotic agents. 

American Journal of Clinical Nutrition, Vol. 73, No. 6, 

1147S-1151S. 

16. Savilahti E, Kuitunen M, Vaarala O.: Pre and probiotics 

in the prevention and treatment of food allergy. Curr 

Opin Allergy Clin Immunol. 2008 Jun;8(3):243-8. 

17. Von der Weid T, Ibnou-Zekri N, Pfeifer A.: Novel 

probiotics for the management of allergic inflammation. 

Dig Liver Dis. 2002 Sep;34 Suppl 2:S25-8. 

18. Pelto, Isolauri, Lilius, Nuutila, Salminen: Probiotic 

bacteria down-regulate the milk-induced inflammatory 

response in milk-hypersensitive subjects but have an 

immunostimulatory effect in healthy subjects. Clinical & 

Experimental Allergy 1998, 28,12, 1474–1479. 

19. Martens U, Enck P, Zieseniss E. Probiotic treatment of 

irritable bowel syndrome in children. Ger Med Sci. 2010 

Mar 2;8 

20. Press Release 21th of September 2011 BioGaia signs 

agreement with the largest pharmaceutical company in 

the Philippines for its probiotic chewable tablets. 


I. Glaza 

izaglaza@gmail.com 

Coresponding Author: 

K. Pietkun 

pietkasia@wp.pl 



Szpital Uniwersytecki nr 1 im. dr. A. Jurasza 

tel.: prywatny: 506 766 509, tel kliniki: 52 585-43-30 

R. Szadujkis-Szadurski 

rszszadziu@gmail.com 

K. Nowacka 

k.nowacka1@o2.pl 

M. Hagner-Derengowska 

madzixhag@wp.pl 

M. Nowacki 

maciej.s.nowacki@gmail.com 

Received: 10.02.2012 



Andrzej Kuźmiński, Michał Przybyszewski, Małgorzata Graczyk, Magdalena Żbikowska-Gotz, Ewa Socha, 

Zbigniew Bartuzi 

COMPOSITION OF INFLAMMATORY INFILTRATE IN THE GASTRIC MUCOSA 

OF PATIENTS WITH FOOD AND AIRBORNE ALLERGIES 

SKŁAD NACIEKU ZAPALNEGO BŁONY ŚLUZOWEJ ŻOŁĄDKA U CHORYCH 

Z ALERGIĄ POKARMOWĄ I POWIETRZNOPOCHODNĄ 

Department of Nutrition and Dietetics of the Collegium Medicum in Bydgoszcz 

Nicolaus Copernicus University of Toruń 

Head: prof. dr hab. Roman Cichon 

Summary 

I n t r o d u c t i o n . The aim of this study was to analyze 

the composition of inflammatory infiltrate in the gastric 

mucosa of patients with food and airborne allergies. 

P a t i e n t s a n d m e t h o d s . This study included 80 

subjects: 30 patients with food allergy, 30 patients with 

airborne allergy, as well as 20 healthy, allergy-free 

individuals. Gastroscopy was performed in all patients and 

gastric mucosal biopsies were taken for histopathological 

examination that included the assessment of Helicobacter 

pylori infection status and the presence of eosinophils within 

the inflammatory infiltrate. 

R e s u l t s . Eosinophils were revealed in the biopsies of 

gastric mucosa originating from 12 (40%) food allergy 

patients, eight (27%) individuals with airborne allergy, and 

two controls. Compared to the controls, patients with food 

allergies were characterized by significantly higher 

prevalence of eosinophilic infiltrates (p=0.0206); there were 

no other significant intergroup differences in regards to this 

parameter. 

Colonization with Helicobacter pylori was confirmed in 

9 (30%) subjects with food allergy, 6 (20%) individuals with 

airborne allergy, and in 10 (50%) controls. These three 

groups did not differ significantly in terms of HP 

colonization rates. 

C o n c l u s i o n s . Compared to the controls, patients 

with food allergy were characterized by a significantly higher 

prevalence of eosinophils within inflammatory infiltrate. No 

significant differences in regards to this parameter were 

documented between food and airborne allergy patients as 

well as between individuals with airborne allergy and the 

controls. 

Colonization of gastric mucosa with Helicobacter pylori 

was less frequent amongst airborne (20%) and food allergy 

patients (30%) than the controls (50%). 

Streszczenie 

Wstę p. Celem pracy była ocena składu nacieku 

zapalnego błony śluzowej żołądka u pacjentów z alergią 

pokarmową oraz powietrznopochodną. 

P a c j e n c i i m e t o d y . Do badania zakwalifikowano 

80 pacjentów, w tym 30 badanych z alergią pokarmową, 

30 z alergią powietrznopochodną oraz 20 zdrowych bez 

alergii pokarmowej. U wszystkich badanych wykonano 

gastroskopię oraz pobrano wycinki błony śluzowej żołądka 

do weryfikacji histopatologicznej z uwzględnieniem obecności 

w nacieku zapalnym żołądka eozynofilów oraz 

kolonizacji Helicobacter pylori. 

Wyniki. Obecność komórek kwasochłonnych 

w ocenie histopatologicznej wycinków błony śluzowej 

żołądka wykazano u 12 (40%) badanych chorych z alergią 

pokarmową; u 8 (27%) badanych w grupie z alergią 

powietrznopochodną oraz u 2 pacjentów w grupie kontrolnej. 

Wykazano istotną statystycznie różnicę w częstości występowania 

nacieków komórek eozynochłonnych pomiędzy grupą 

z alergią pokarmową a grupą kontrolną (p=0,0206). Między 

pozostałymi grupami nie wykazano różnic istotnych 

statystycznie. 

Kolonizację Helicobacter pylori wykazano u 9 (30%) 

badanych z alergią pokarmową, u 6 (20%) z alergią

90 

Andrzej Kuźmiński et. al. 

powietrznopochodną oraz u 10 (50%) badanych w grupie 

kontrolnej. Nie wykazano istotnych statystycznie różnic 

w częstości kolonizacji HP pomiędzy badanymi grupami. 

W n i o s k i . W grupie chorych z alergią pokarmową 

stwierdzono statystycznie istotny wzrost liczby komórek 

kwasochłonnych w nacieku zapalnym w porównaniu z grupą 

kontrolną. Nie było statystycznie istotnych różnic w tym 

zakresie pomiędzy grupą pacjentów z alergią pokarmową 

i powietrznopochodną, a także pomiędzy grupą pacjentów 

z alergią powietrznopochodną a grupą kontrolną. 

Kolonizacja błony śluzowej przez bakterię Helicobacter 

pylori występowała w mniejszym odsetku wśród badanych 

z alergią powietrznopochodną (20%) i alergią pokarmową 

(30%) w porównaniu z grupą kontrolną (50% badanych). 

Key words: allergy, gastritis, eosinophil, Helicobacter pylori 

Słowa kluczowe: alergia, zapalenie żołądka, eozynofil, Helicobacter pylori 

INTRODUCTION 

The last three decades have been associated with a 

rapid increase in the prevalence of allergic diseases, 

including both sensitivity to food allergens and 

airborne allergies [1]. According to the European 

Allergy White Paper, 35% of population is currently 

affected by allergic conditions [2]. The authors of 

multicenter ECAP study, results of which were 

published in 2008, estimate that 45-52% of Polish 

population suffered from an allergy at least once in a 

lifetime; the most frequent conditions include allergic 

rhinitis, followed by bronchial asthma and food allergy 

[3,4]. 

It is widely known, food allergens interact with the 

gastric mucosa predisposing it to the development of 

chronic inflammatory lesions; however, such lesions 

can also result from an airborne allergy [5,6,7]. 

Chronic gastritis is a polyetiological condition that can 

present with a variety of macroscopic changes; it lasts 

years and can lead to gastric ulceration, autoimmune 

lesions, mucosal atrophy, or even cancer [8]. 

Gastrointestinal barrier plays a crucial role in the 

prevention of allergic processes in the alimentary tract. 

It is composed of the appropriate acidity of the gastric 

juice, proteolytic enzymes, lysozyme, lactoferrin, 

defensins, mucus, and the proper motility of the 

alimentary tract. Any injury to this barrier is reflected 

by enhanced contact between allergens and the 

immune system of alimentary mucosa, and 

consequently by the development of food allergy [9]. 

The stomach of predisposed individuals can be 

involved in immune reactions and, therefore, constitute 

a target organ for IgE-dependent allergic processes 

initiated by exogenous allergens, but probably also by 

H. pylori (HP) infection [10]. IgE-dependent allergic 

reaction is initiated by allergen-antibody interaction 

that may be of systemic or local character leading to 

chronic inflammation of tissues, including gastric 

mucosa. In such cases, in addition to lymphocytes and 

plasmatic cells, macrophages, mast cells and a small 

number of granulocytes may be observed in the 

mucosal lamina propria [11]. Initially, degranulation of 

mast cells along with the release of inflammatory 

mediators takes place; this is followed by the activation 

of mast cell-cytokine cascade, and finally by the 

inflammatory cell infiltration of the mucosa. 

Eosinophils constitute the principal component of this 

infiltrate [12]. 

The aim of this study was to analyze the 

composition of inflammatory infiltrate in the gastric 

mucosa of patients with food and airborne allergies. 


This study included 60 patients: 30 with airborne 

allergy and 30 with food allergy, as well as 20 healthy, 

allergy-free individuals. The patients were hospitalized 

at the Clinic of Allergology, Clinical Immunology and 

Internal Diseases of the L. Rydygier Collegium 

Medicum in Bydgoszcz at Nicolaus Copernicus 

University (NCU) in Torun due to the exacerbation of 

an allergic condition. The controls (healthy volunteers) 

were not allergic and did not report any dyspeptic 

symptoms. The group of allergy patients included 38 

women and 22 men aged between 18 and 65 years 

(mean of 37.3 years). The control group was comprised 

of 12 women and 8 men aged between 20 and 65 years 

(mean of 42.2 years). 

The study’s basic inclusion criterion included 

dyspeptic symptoms reported in individuals aged 

between 18 and 65 years and co-existing with the 

exacerbation of an allergic condition. 

The exclusion criteria included the presence of 

severe chronic organic disorders such as necrotic 

colitis, Crohn’s disease, intestinal fistulas, coeliac 

disease, bacterial and fungal enteritis, disaccharide 

intolerance, colorectal tumors, malignant diseases, 

states after the resection of the stomach or intestines, 

parasitic infections, hyperthyroidism, acute and chronic 

leukemia, lymphoma, urinary tract infections, 

tuberculosis, administration of oncological treatment,

Composition of inflammatory infiltrate in the gastric mucosa of patients with food and airborne allergies 91 

immunotherapy or other agents that could potentially 

modulate studied immunological parameters. 

Medical history was collected from all patients 

qualified to this study with particular attention paid to 

the signs of allergic disorders and their association 

with exposure to airborne and alimentary allergens. 

Subsequently, routine physical examination focusing 

on the alimentary tract function was performed. 

Additionally, skin prick tests with alimentary and 

airborne allergens were carried out using standard 

allergen kits (Allergopharma). The result of the test 

was considered positive if the reaction to the tested 

allergen (blister diameter) was equal to or greater than 

the reaction to histamine. The tests were performed at 

the Allergology Clinic Skin Tests Laboratory in 

Bydgoszcz. 

Finally, the participants were subjected to 

endoscopic examination of the upper alimentary tract 

that evaluated the macroscopic appearance of the 

gastric mucosa, its motility, and the secretory activity 

of the stomach. Additionally, mucosal biopsies were 

taken for histopathological examination and testing for 

H. pylori infection. Histopathological examination was 

performed at the Department of Pathomorphology of 

the Dr. J. Biziel University Hospital No. 2 in 

Bydgoszcz. The degree of gastric mucosa 

inflammation was graded using the Sydney system 

with the Houston modification. Special attention was 

paid to the composition of cellular infiltrate, in 

particular to the presence and count of eosinophils. 

These parameters were assessed with 10HPFx250 

method (sum of the cells in 10 high-power fields 250 

x; divided by 10). Colonization with H. pylori was 

analyzed histopathologically using hematoxilin, eosin, 

and Giemsa’s staining. Presence of colonization was 

expressed as (+), while the lack of the bacterium was 

designated as (–). 

Statistical analysis 

The Mann-Whitney U test was used to study 

intergroup difference in analyzed parameters. 

Quantitative variables were presented as arithmetic (x) 

and geometric means (g), and their standard deviations 

(s). 

RESULTS 

Endoscopy of the upper alimentary tract was 

performed in all the participants; specimens from the 

antrum and body of the stomach were collected. The 

histopathological examination of antral biopsy 

specimens revealed chronic gastritis in 26 (87%) 

patients from the food allergy group, in 20 (67%) 

individuals with an airborne allergy, and in 9 (45%) 

controls. Corporal specimens showed chronic gastritis 

in 14 subjects (47%) from the food allergy group, in 12 

patients (40%) with an airborne allergy, and in 6 

individuals (30%) from the control group. 

Eosinophils were found in the biopsies of gastric 

mucosa originating from 12 (40%) food allergy 

patients (including 5 patients [17%] with eosinophilia; 

≥ 10 cells per field of view [FOV]), 8 (27%) 

individuals with airborne allergy (2 cases with ≥ 10 

cells per FOV), and two controls (none with ≥ 10 cells 

per FOV). Compared to the controls, patients with food 

allergies were characterized by significantly higher 

prevalence of eosinophilic infiltrates (p=0.0206); there 

were no other significant intergroup differences in 

regards to this parameter. 

Colonization with Helicobacter pylori was 

confirmed in 9 (30%) subjects with food allergy, 6 

(20%) individuals with airborne allergy, and in 10 

(50%) controls. These three groups did not differ 

significantly in terms of HP colonization rates. 

DISCUSSION 

Nutrition is a basic physiological need. During the 

entire life, an average human ingests approximately 60 

tons of food and drinks about 400 hectoliters of fluids 

[13]. Since the largest accumulation of lymphatic 

tissue lies within the alimentary tract, consuming such 

vast quantities of food, containing high amounts of 

potential allergens, suggests that this vital function is 

possible solely due to the elimination of improper 

immune response to ingested products, i.e. the 

development of specific tolerance status [14]. The 

gastrointestinal barrier plays a key role in this process; 

its injury is associated with an enhanced interaction 

between allergens and the immune system of the 

alimentary mucosa [15,16]. Food allergy is associated 

with the improper uptake of antigens and secondary 

synthesis of IL-4 by Th2 cells. IL-4 is a cytokine 

necessary both in the process of lymphocyte B 

differentiation into IgE producing cells, as well as 

during the synthesis IL-5, which subsequently is 

responsible for the activation of eosinophils [17]. 

Repeated exposure of predisposed individuals to food 

allergens can cause local allergic reaction in the form 

of gastritis; eosinophils play a vital role in the

92 


inflammatory infiltrate observed in such cases [11]. 

Moreover, eosinophils are important in the induction 

and maintenance of gastritis as suggested by elevated 

serum levels of IL-5 observed in food-sensitive 

patients [19]. 

While the involvement of eosinophils in the allergic 

conditions of respiratory tract is well established, their 

role in the alimentary allergies was recognized quite 

recently [20], in spite of the fact that patients with food 

allergies constitute a group where the association 

between tissue eosinophilia and allergy is particularly 

evident [21]. This relationship has been a subject of 

several interesting studies. Graczyk et al. observed the 

presence of eosinophils in 42% of patients with food 

allergy. In those patients, histopathological 

examination of the gastric mucosa biopsy specimens 

revealed that as many as 20% of cases exhibited 

eosinophilia exceeding 10 cells per FOV. 

Corresponding values in individuals without the 

allergy amounted to 30% and 6.67%, respectively [11]. 

Our study of patients with food allergy produced 

similar results. In contrast, higher eosinophil 

prevalence rate in gastric mucosal biopsies was 

reported by Bartuzi. He revealed eosinophils in all 

analyzed biopsies of gastric mucosa from 34 food 

allergy patients, and in only 3 out of 10 controls with 

dyspeptic symptoms [22]. 

The reasons behind the higher prevalence of 

eosinophils in the alimentary tract mucosa of patients 

with food allergies remain unclear. The recruitment 

and presence of eosinophils in the alimentary tract are 

closely regulated by cytokines (IL-5, IL-3, IL-13, and 

GM-CSF) and chemokines (eotaxin, RANTES) [23]. 

IL-5 is considered the most important eosinophiliapromoting 

cytokine, and its levels are well correlated 

with the presence of eosinophils in the inflammatory 

infiltrate of patients with chronic gastritis and food 

allergy [19]. Eosinophil recruitment into the alimentary 

tract is also modulated by IL-13 and locally released 

chemokines: predominantly by eotaxin-1, expression 

of which is most pronounced in the lamina propria. 

The lack of eotaxin-1, or its eosinophil receptor 

(CCR3), is reflected by the absence of eosinophils in 

the alimentary tract wall. Other factors that can induce 

selective migration of eosinophils into the alimentary 

tract wall include α4β7 integrin, present on the surface 

of eosinophils, and its ligand MAdCAM-1 expressed 

on the endothelial surface of venous vessels of the 

intestinal lamina propria. Eosinophils with α4β7 

integrin expression are postulated to undergo selective 

accumulation in the lumen of small intestine; while the 

recruitment of eosinophils to the colonic wall is 

predominantly modulated by ICAM-1 adhesion 

molecule [24]. 

Maintenance of the intestinal barrier is postulated 

to be the principal function of the alimentary tract 

eosinophils. On the one hand, eosinophils can be 

activated by the cytokines released by Th lymphocytes; 

on the other, they can also present antigens to T 

lymphocytes modulating their function in this way. 

Furthermore, eosinophils can influence the intestinal 

nervous system by means of VIP, substance P, 

serotonin, histamine and leukotriene secretion; this is 

reflected by the remodeling of nerve fiber network and 

changes in their activity as well as by an enhanced 

transcription of neurotransmitter genes. These changes 

seem particularly important in the context of 

eosinophilic disorders of the gastrointestinal tract that 

are associated with higher „sensitivity” of involved 

organs and the impairment of their motility. 

Furthermore, eosinophils can participate in the repair 

of injured gastrointestinal epithelium, releasing TGF-β 

and fibroblast growth factor. However, it is likely that, 

depending on signaling, eosinophils can be involved 

both in the destruction and repair of the epithelial cells 

[24]. 

Besides physiological conditions, eosinophils can 

also be involved in the pathological processes of the 

gastrointestinal tract. Increasing prevalence of 

eosinophilic gastrointestinal disorders (EGID): 

eosinophilic esophagitis, gastritis, gastroenteritis, 

enteritis, and colitis, has been pointed out in literature 

published in the last two decades. While the reason 

remains unclear, potential involvement of allergic 

factors is being postulated, particularly in children with 

atopy [20]. T cell activation by such food allergens as 

the proteins present in cow’s milk, eggs, wheat, nuts, 

and pork can play the principal role in this setting [25]. 

Almansa noticed the seasonal character of this 

condition in adults and suggested that its pathogenesis 

may involve the potential involvement of inhalatory 

allergens [26]. Moreover, as revealed by Mishra, 

aeroallergens may possibly play an important role in 

the induction of eosinophilic esophagitis [27]. Recent 

studies have documented an association of eosinophilic 

duodenal infiltration with asthma and allergic rhinitis 

(AR), as well as between the esophageal infiltration 

and AR, and the colonic infiltration and atopic 

dermatitis [24]. However, despite extensive research it 

is still unclear why eosinophils migrate into specific

Composition of inflammatory infiltrate in the gastric mucosa of patients with food and airborne allergies 93 

parts of the gastrointestinal organs without 

simultaneous involvement of the other segments. The 

results of some studies point to possible stimulation of 

immune system by various allergens, including 

inhalatory and food allergens. Perhaps this stimulation 

causes the activation of pro-inflammatory cytokines, 

mainly IL-3, IL-5, IL-13, and GM-CSF, constituting 

the essence of the inflammatory process and being 

responsible for the formation of clinical signs [28]. 

As previously mentioned, the association between 

eosinophilia and allergy is particularly evident in 

patients with allergic conditions of the gastrointestinal 

tract [29]. Our study showed significant differences in 

the eosinophil prevalence rate in the biopsies of gastric 

mucosa: eosinophils were found in 40% of patients 

with food allergies, but in only 27% of subjects with 

airborne allergies, and in 10% of the controls. 

Eosinophil count ≥10 per FOV was assumed as the 

significant cut-off value during histopathological 

examination of gastric mucosal biopsies. Such high 

eosinophil count was observed in 17% of patients with 

food allergies and in 10% of individuals with airborne 

allergies; in contrast, eosinophil count did not exceed 

10 cells per FOV in any of the controls. 

Helicobacter pylori is the most frequent etiological 

factor in chronic gastritis. Inflammation caused by HP 

infection is characterized by a diffuse, superficial or 

deep, infiltration of lamina propria with mononuclear 

cells and neutrophils [30]. The results of previous 

studies examining the association between 

Helicobacter pylori infection and allergic processes of 

the alimentary tract suggested a possible correlation 

between these two factors in the development of 

pathological gastrointestinal lesions. Mucosal injury 

resulting from infection with this microorganism is 

postulated to facilitate the transepithelial penetration of 

food allergens. Moreover, it was revealed that 

Helicobacter pylori can induce the migration of 

eosinophils, being an important component of allergic 

inflammatory infiltrate, to the alimentary tract tissues 

[31]. In this study, the colonization of gastric mucosa 

with HP was considerably more frequent in healthy 

controls without concomitant allergic disorders and 

alimentary complaints (50%) than in patients with 

established food or airborne allergy, whose 

colonization rates amounted to 30% and 20%, 

respectively. 

CONCLUSIONS 

1. Compared to the controls, patients with food 

sensitivity of allergic origin were characterized by 

significantly higher prevalence of eosinophils 

within inflammatory infiltrate. No significant 

differences in regards to this parameter were 

documented between food and airborne allergy 

patients as well as between individuals with 

airborne allergy and the controls. These findings 

confirm the importance of eosinophils in the 

development of gastritis in atopic patients. 

2. Colonization of gastric mucosa with Helicobacter 

pylori was less frequent amongst airborne (20%) 

and food allergy patients (30%) than in the 

controls (50%); this suggests a potential 

preventative role of the infection in allergy 

development. 

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6): 367-371. 

31. Gocki J., Bartuzi Z.: Częstość występowania i 

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Szpital Uniwersytecki nr 2 

ul. Ujejskiego 75 


tel./fax: 052 3655416 

e-mail: jendrek75@interia.pl 

Received: 10.01.2012 



Iwona Łopacińska¹, Małgorzata Wojciechowska² 

NURSES VS ISO IN A HOSPITAL 

PIELĘGNIARKI WOBEC ISO W SZPITALU 

¹Clinical Nursing Faculty 

University of Humanities and Economics in Łódź 

Head of the Faculty: Zbigniew Tokarski, PhD 

²Collegium Masoviense Nursing Institute 

Wyższa Szkoła Nauk o Zdrowiu 

Head of the Institute: Małgorzata Wojciechowska, PhD 

Summary 

ISO based Quality Management System in healthcare 

facilities in Poland is no longer a novelty. Its implementation, 

however, requires medical personnel to expand their 

knowledge and accept the fact that medical service is a 

medical product. In order for a medical service to be of high 

quality, personnel should be familiar with medical services 

marketing. Processes used as a result of standards’ 

implementation are a significant change for healthcare 

workers but having a quality management system certificate 

became a standard. 

The aim of this work was to present the state of 

knowledge concerning nursing personnel readiness to 

implement the standards. 

In this work a diagnostic survey method was used, 

questionnaire was the technique used and as a research tool 

– the authors’ own survey questionnaire consisting of both 

closed and open questions. 

The study was conducted among nursing personnel 

working in hospital wards before and after the introduction of 

ISO 9001 based Quality Management System. 

Own studies revealed that before the implementation of 

ISO the nursing personnel was apprehensive about the 

changes related to it (53.22%), with only 28.65% 

unconcerned about it and 18.13% unable to decide. The 

research showed that the nurses surveyed were likely to 

claim that their work organization improved after the 

introduction of the Standards (48.54%), with only 19.30% 

thinking it did not change, and 32.16% claiming it improved 

to a small degree. According to the nurses, implementation of 

the standards in hospitals encourages people to pursue 

education or learn by themselves (67.84%), with 18.71% 

respondents saying it does not encourage them and 13.45% 

were undecided. The respondents most often thought that 

implementation of standards will contribute to increase of 

customer satisfaction with the quality of the offered services 

(82.46%), while 17.54% respondents thought the opposite. 

Streszczenie 

System Zarządzania Jakością wg ISO w zakładach opieki 

zdrowotnej w Polsce nie jest już nowością. Jednak jego 

wdrożenie wymaga od personelu medycznego poszerzenia 

wiedzy z tego zakresu, zaakceptowania faktu, że usługa 

medyczna jest produktem medycznym. Aby usługa 

medyczna była wysokiej jakości personel powinien 

legitymować się wiedzą z zakresu marketingu usług 

medycznych. Dla pracowników ochrony zdrowia znaczącą 

zmianą są procesy zachodzące w wyniku wdrażania 

normalizacji, jednak legitymowanie się certyfikatem systemu 

zarządzania jakością stało się powszechnie obowiązującym 

standardem. 

Celem pracy było ukazanie wiedzy na temat 

rzygotowania personelu pielęgniarskiego do wdrożenia 

normalizacji. 

W pracy zastosowano metodę sondażu diagnostycznego, 

techniką była ankieta, narzędziem badawczym był autorski

96 

Iwona Łopacińska, Małgorzata Wojciechowska 

kwestionariusz ankiety składający się z pytań mających 

charakter zamknięty i otwarty. 

Badania przeprowadzono wśród personelu 

pielęgniarskiego pracującego na oddziałach szpitalnych 

przed i po wprowadzeniu Systemu Zarządzania Jakością wg 

Normy ISO 9001. 

Z przeprowadzonych badań własnych wynika, iż przed 

wdrożeniem ISO personel pielęgniarski obawiał się 

związanych z tym procesem zmian (53,22%), nie miało obaw 

tylko (28.65%) nie potrafiło jednoznacznie odpowiedzieć 

(18.13%). Badania wykazały, że ankietowane pielęgniarki 

częściej twierdziły, że ich organizacja pracy po 

wprowadzeniu Norm poprawiła się (48,54%), nie uległa 

zmianie ( 19.30%) oraz poprawiła się w niewielkim stopniu 

(32,16%). Pielęgniarki uważały, że wdrożenie normalizacji w 

szpitalu zachęca do kształcenia i samokształcenia, (67,84%) 

nie zachęca (18,71%) nie miało zdania (13,45%). Najczęściej 

respondenci uważali, że wdrożenie normalizacji przyczyni 

się do wzrostu zadowolenia klienta z jakości oferowanych 

usług (82.46%) inne, przeciwne zdanie miało (17,54%) 

badanych. 

Key words: hospital, organisation, service, quality management system 

Słowa kluczowe: szpital, organizacja, usługa, system zarządzania jakością 

INTRODUCTION 

Requirements of the ISO 9001 standard, which is 

the basis of quality systems certification as well as the 

requirements listed in accreditation standards, are 

today a well known tool for managing the quality of 

services provided in healthcare. These processes, 

despite being so popular, when introduced in medical 

organisations are opposed to and criticised by both 

personnel and patients. The former oppose the 

excessive red tape required in order to prepare the 

procedures. However, this is the case only if the set of 

specification guidelines is excessively complex. Both 

the ISO 9001-2000 standard and its amendment from 

2008 require six documented procedures: control of 

documents, control of records, internal audit, control of 

nonconforming product and corrective and preventive 

measures procedure. Patients always assess the quality 

of healthcare services provided by all healthcare 

workers in the process of diagnostics, treatment and 

rehabilitation in a subjective way. Subject to their 

assessment is not only the work of doctors, nurses, 

rehabilitators but also the pharmacy facility, food 

facility, the registration queue. There are quite many 

negative comments from patients related to certain 

parts of the whole medical service only. 

Accreditation means that an authorised body issues 

a formal certificate confirming that the unit providing 

health care is competent to provide such services, 

meeting the accreditation standards. The Polish 

medical facilities accreditation system complies with 

the Act of 6 th November 2008 on accreditation in 

health care, the Act of 30 th August 2002 on conformity 

assessment system, as well as the Ordinance of the 

Minister of Health of 31 st August 2009 on the 

procedure assessing meeting by the healthcare 

providing unit the accreditation standards and the 

amount charged for their introduction [1, 2, 3]. The 

starting point in accreditation proceedings is preparing 

self-assessment, including the report and then 

implementing the defined standards. The central unit 

within the Ministry of Health established in order to 

inspire, support and develop activities aiming at 

improvement of the quality of healthcare services in 

medical organisations is Krakow based Centrum 

Monitorowania Jakości w Ochronie Zdrowia (Centre 

for Quality Monitoring in Healthcare). Presently, the 

Centre in a systemic beneficiary carrying out a project 

co-funded by the European Union within the 

framework of European Social Fund, which is a part of 

Human Capital Operational Programme, activity 2.3 

Strengthening the health potential of the working 

persons and quality improvement of healthcare system 

functioning, Sub-measure 2.3.3 Enhancement of the 

healthcare management quality. The aim of the project 

is obtaining the accreditation certificate by 188 

hospitals in years 2009-2014 [4]. The certification 

process, according to ISO regulations, involves 

designing a quality system project and launching it. 

The system is specified in documents, the key part of 

which is the Quality Manual containing: the policy of 

an organisation, quality aims, organisational structure, 

responsibility, a general quality system inventory, 

quality system documentation structure and 

distribution. The second stage constitutes the 

procedures describing the objective and the scope of 

activities as well as the method of operation [5,6]. 

Accreditation of facilities offering health services is 

well rooted in the healthcare system and the standards 

of conduct are defined by medical professionals. The 

ISO system encounters various barriers in the process 

of implementation, one of them being non-medical 

terminology, a specific language unrelated to medical 

industry. The prototype for ISO standards of 9000

Nurses vs ISO in a hospital 97 

series was the BS 5750 series designed in Great 

Britain. In 1987 the International Organisation for 

Standardization (ISO) approved it for use. The 

standards of ISO 9000 family series were amended in 

1994, then in 2000 the structure of quality assurance 

standards was simplified, which resulted in 

replacement of three standards (ISO 9001-1994, ISO 

9002-1994, ISO 9003-1994) with one, for 

documentation of companies’ quality system 

credibility: ISO 9001-2000 Requirements. This is a 

universal standard which can be used by any 

organization, regardless for their type, size, and 

delivered product. 

ISO standards have gradually encompassed more 

and more fields, which necessitated another 

amendment in 2008, when PN-EN ISO 9001-2009 

standard was established. An obligation resulting from 

the standardization is use of PDCA method to all the 

processes occurring in the organisation: 

• P – Plan; means planning, i.e. specifying 

goals and processes necessary to provide 

results compliant with the organisation’s 

policy and the requirements of a recipient. 

• D – Do; means being active, i.e. completing 

processes to get the result. 

• C – Check; by use of measurement tools 

monitor the processes and products in relation 

to the organisational policy, goals of the 

organisation and customer’s requirements. 

• A – Action; be active in the field of 

continuous improvement and functioning of 

processes [6,7]. 

In the ISO implementation process in an 

organisation it is important for every member of the 

organisation implementing the change to have the 

same knowledge regarding the quality management 

system and understand the priorities and the ways to 

achieve them in the same way. The result of work of 

a multidisciplinary medical team is patient’s health 

improvement. Healthcare, and especially reparative 

medicine, always finds a service buyer. Polish 

society is aging. According to GUS, (Central 

Statistical Office) in 2000 the percentage of elderly 

people was 12.4%. The percentage of people in postproductive 

age increased to 17% in 2010, while 

average life expectancy in Poland in 2009 was over 

70 for men, and 80 for women. The estimates of the 

Central Statistical Office are quite frightening – in 

2020 every fifth Pole will be a senior [8,9]. The fact 

is confirmed both by the GUS data and long waiting 

lists for an appointment with a specialist and distant 

dates of treatments. Introduction of a quality 

management system does not bring immediate 

financial benefits. However, the main reason for 

service providers to take interest in quality 

management systems compliant with ISO standards 

are customers that require them to provide certified 

management system services. Another reason for 

implementation of ISO standards is thinking of a 

quality management system as of a tool for arranging 

and improving the service-related processes [6]. If 

one analyses the ISO 9001 standard and Centre for 

Quality Monitoring in Health Care accreditation 

requirements carefully and without any bias, it may 

be concluded that their proper use results in order, it 

lays out the paths to follow in order to reduce the 

risk of errors, and should they occur – suggests the 

proper way of dealing with them. Implementation of 

ISO standards in an enterprise makes it possible to 

arrange and formalise the company management 

system. According to the reference books, an 

implemented system introduces the structure of 

responsibility, it clearly defines the rules of company 

functioning, making possible improvement of its 

internal operations; it also gives the employees 

possibility to get a full picture of their facility 

development [6]. When implementing the quality 

management system according to ISO standards, one 

should devote considerable amount of time to 

content-related interpretation of the specific 

standards in the medical context. With respect to a 

common practice of leaving documents such as 

temperature chart by patients’ beds one should refer 

to section 4 of the Standard: “Control of documents” 

and its subsections. The provision of this standard 

refers to the procedure of control of documents, 

control of records, as well as rules of preparing 

quality records, the way to identify, protect, store 

and update the documents. This issue is also dealt 

with in accreditation requirements which clearly 

specify information management (IM). Fulfilment of 

this condition means that a hospital must develop a 

system for storing and processing data. The last two 

subsections that need emphasising are the rules of 

making the data within the hospital and outside it, as 

well as the rules for communication with the 

personnel, patients, local community, external 

partners, the media available. All newly introduced 

things need to pass through the stages of learning

98 


and approval. Before implementation of system 

documents employees should undergo training. 

The subject of the training should include: basic 

terminology in relation to quality systems, the 

standard requirements, quality management system 

documents. It should also include the methods 

employed by a quality management system such as 

audit, types of improvement activities, and most of 

all the role of employees in the quality management 

system. In face of hardly any reforms, healthcare 

facilities should pay special attention to forming 

proper attitudes and behaviour of their staff, which 

can be achieved by engaging the staff in company 

management [10]. 

OBJECTIVE OF THE WORK 

The aim of the work was to present the state of 

knowledge concerning preparation of nursing 

personnel to implement standards. 

This includes especially: 

1. Taking into consideration the feelings of nursing 

staff. 

2. Presenting opinions on system implementation. 

3. Getting opinions on whether standards’ 

implementation in hospitals encourages nurses to 

pursue education or self-education. 

4. Getting opinions concerning whether 

standardization will contribute to greater 

customer satisfaction with the quality of services 

offered. 

THE METHOD AND MATERIAL 

In this work a diagnostic survey method was used, 

questionnaire was the technique used, the research tool 

– the authors’ own survey questionnaire consisting of 

both closed and open questions. 

The study was conducted among nursing personnel 

working in hospital wards before and after the 

introduction of ISO 9001 based Quality Management 

System. The surveyed group consisted of 171 people, 

163 of them being women, 8 – men. The respondents 

were aged between 25 and 50. 

RESULTS 

The results of the research show that before the 

implementation of ISO, 53% of the nursing personnel 

were apprehensive about the changes it involved, 29% 

were unconcerned, 18% could not decide. This may 

mean that the nursing personnel were unprepared for 

system implementation (Table I). The conducted 

research revealed that the nurses surveyed were more 

likely to say that organisation of their work after the 

standardisation improved (48%), while according to 

19% it did not change and according to 32% it slightly 

improved (Table II). According to the research, nurses 

thought that implementation of the standards in a 

hospital encourages them to pursue education and selfeducation 

(68%), with 19% claiming it did not 

encourage them and 13% having no opinion (Table 

III). Respondents most often claimed that 

implementation of the standards would contribute to 

greater customer satisfaction with the quality of offered 

services (82%), while 18% of respondents thought to 

the contrary (Table IV). 

Table I. Opinion on whether implementation of the standards 

in hospitals raised concerns in relation to changes at 

the nurse’s workplace. 

Tabela I. Opinia na temat, czy wdrożenie normalizacji w 

szpitalu spowodowało obawy związane ze 

zmianami na stanowisku pracy pielęgniarki 

Job position 

Stanowisko 

pracy 

Nurses 

Pielęgniarki 

Yes/tak 

No/nie 

Don’t 

know 

/nie 

wiem 

Total 

Razem 

n % n % n % n % 

91 49 31 171 

53.22% 28.65% 18.13% 100.00% 

Statistical analysis: Chi 2 =1.09; p=0.58 

Analiza statystyczna: Chi 2 =1.09; p=0.58 

Table II. Opinion on whether the organization of nurses’ 

work changed after the introduction of standards 

Tabela II. Opinia na temat, czy po wprowadzeniu normalizacji 

organizacja na stanowisku pielęgniarki 

uległa zmianie 

Job position 

Stanowisko 

pracy 

Nurses 

Pielęgniarki 

Improved 

Poprawiła 

się 

didn’t 

change 

Nie 

uległa 

zmianie 

slightly 

improved 

Poprawiła 

się w 

niewielkim 

stopniu 

Total 

Razem 

n % n % n % n % 

83 33 55 171 

48.54% 19.30% 32.16% 100.00% 

Statistical analysis: Chi 2 =9.57; p=0.008* 

Analiza statystyczna: Chi 2 =9.57; p=0.008*

Nurses vs ISO in a hospital 99 

Table III. Opinion on whether the standards’ implementation 

in hospitals encourages nurses to pursue education 

and self-education 

Tabela III. Opinia na temat, czy wdrożenie normalizacji 

w szpitalu zachęca pielęgniarki do kształcenia 

i samokształcenia 

Job Position 

Stanowisko 

pracy 

Nurses 

Pielęgniarki 

Yes 

Tak 

No 

Nie 

Don’t 

know 

Nie wiem 

Total 

Razem 

n % n % n % n % 

116 32 23 171 

67.84% 18.71% 13.45% 100.00% 

Statistical analysis: Chi 2 =4.65; p=0.10 

Analiza statystyczna: Chi 2 =4.65; p=0.10 

Table IV. Opinion of nurses on whether standards’ 

implementation will contribute to increased 

customer satisfaction with the services offered 

Tabela IV. Opinia pielęgniarek na temat, czy wdrożenie 

normalizacji przyczyni się do wzrostu zadowolenia 

klienta z jakości oferowanych usług 

Job Position 

Stanowisko pracy 

Nurses 

Pielęgniarki 

DISCUSSION 

No/tak 

No/ don’t 

know 

Nie/nie 

wiem 

Total 

Razem 

n % n % n % 

141 30 171 

82.46% 17.54% 100.00% 

Statistical analysis: Chi 2 =13.65; p=0.0002* 

Analiza statystyczna: Chi 2 =13.65; p=0.0002* 

A few years ago companies that applied for ISO 

Standard certificate wanted to function in a better way 

on the market and improve their chances of getting 

subsidies. Nowadays, apart from the marketing aspect 

of the quality certificate, there is also the issue of 

company operations optimisation, eagerness to predict 

risks and any adverse phenomena as well as taking 

such effective measures as to prevent them. The 

attempts to reform the Polish healthcare system do not 

bring any visible results. This is especially difficult for 

patients who have no access to certain medical 

services, and also for personnel who notice the 

growing debts that the healthcare facilities gradually 

incur. A major problem that becomes noticeable on 

Polish streets is the fact of ageing of the society. In 

face of such an unfavourable situation of the healthcare 

industry, the modifier of the possibility to impact on 

the hospital staff and on the society – the patients in the 

hospital, was standardisation. The research shows that 

over a half of nursing personnel were concerned about 

the changes involved in the change process, while only 

one third of the respondents were unconcerned. This 

may mean that the personnel were unprepared for 

system implementation. A prerequisite to get 

employee's support for the introduced changes is to use 

the right arguments for presenting advantages and 

disadvantages resulting from such changes. Part of the 

preparation to system implementation, as explained by 

the authors of ‘System Zarządzania Jakością według 

ISO 9001-2008’ (ISO 9001-2008 Quality Management 

System) brochure, are: clear formulation of objectives, 

aims of the organisation, and tasks assigned the staff as 

well as transparent flow of information. 18% of 

respondents were unable to provide a straightforward 

opinion on the changes involved in implementation of 

the standards. Also ISO 9001 standard in section 6.2 

forces employers to actively train their employees [5]. 

The conducted research confirmed that the 

organisation of work after the introduction of the 

Standards improved according to half of the 

respondents. 19% of respondents claimed the work 

organisation did not change, and 32% perceived a 

slight improvement. This may indicate that employees 

do not have current data concerning the system and 

they are burdened with more work than they can cope 

with in relation to preparing documents. An analysis of 

the results allows us to presume that for with many 

employees adapting to and accepting the changes may 

take more time than for the others. In recent years it 

has been noticeable how nursing personnel increased 

their skills. Persons that are regarded authorities in the 

field of healthcare claim that improvement of skills 

allows breaking through a barrier between particular 

teams of employees and between employees and 

managers. Employees that are involved in their own 

education become advisors for those in charge [11]. 

The majority (68%) of respondents thought that 

standards implementation in hospitals encourages them 

to pursue education and self-education, while 19% said 

they were not encouraged and 13% did not have any 

opinion. Each staff member in their job position should 

display knowledge, skills and competences, so in order 

to keep up with the new developments in all the fields 

of science and economy it is necessary to continuously 

raise qualifications. The awareness of processes 

undergoing in the organisation strengthens the 

employees’ motivation and results in satisfied 

customers. Majority of the respondents thought that

100 


implementation of the standards would contribute to 

increase of customer satisfaction with the quality of 

services offered (82%). However, the co-responsibility 

for building the organisational/hospital culture is not 

shared by every nurse surveyed as 18% of respondents 

were of different opinion. One may suppose that those 

people feel comfortable within the former structures 

and may take some time before they become advocates 

of the standards’ implementation. 

CONCLUSIONS 

The conducted research and its analysis allow the 

following conclusions: 

1. The standards’ implementation in hospitals 

raised some concerns among 53% nurses in 

relation to the changes in their workplace, 

while 29% remained unconcerned and 18% 

were unable to say. 

2. Nursing personnel was likely to admit that 

their work organisation improved after the 

introduction of the Standards (48%), while 

19% were of opposite opinion and 33% 

thought it only improved slightly. 

3. Majority of the respondents (68%) claimed 

that the standards’ implementation in their 

hospital encouraged them to pursue education 

and self-education, while 19% were not 

encouraged and 13% were of no opinion. 

4. The standards’ implementation will contribute 

to greater customer satisfaction with the 

quality of services offered according to 82% 

of respondents, while 18% were of different 

opinion. 

REFERENCES 

3. Ordinance of the Minister of Health of 31 st August 

2009 on the procedure assessing meeting by the health 

care providing entity the accreditation standards and 

the amount of fees for their introduction. 

4. www.cmj.org.pl 06.01.2012 

5. PN-EN ISO 9001-2009. 

6. Urbaniak M.: Zarządzanie jakością środowiskiem oraz 

bezpieczeństwem w praktyce gospodarczej. DIFIN, 

Warszawa 2007 

7. www.iso.org/iso/homel 06.01.2012 

8. www.stat.gov.pl/gus 06.01.2012 

9. Płotek W.: Starzenie się ośrodkowego układu 

nerwowego i anestezja. “Anestezjologia i Ratownictwo” 

2008. no. 1. p. 35-43. 

10. Opolski K, Dykowska G, Możdzonek M.: Zarządzanie 

przez jakość w usługach zdrowotnych. Warszawa, 

CeDeWu 2009. 

11. Lewandowski R., Preus A., Ochyra I. i wsp.: System 

Zarządzania Jakością według ISO 9001-2008 – 

wdrażanie i organizacja. Wiedza i Praktyka, Warszawa 

2010. 


Clinical Nursing Faculty 

University of Humanities and Economics in Łódź 

90-222 Łódź 

ul. Rewolucji 1905 roku nr 52 i 64 

Head of the Faculty 

Zbigniew Tokarski, PhD 

tel.: +48 42 299 55 73 

fax: +48 42 299 56 74 

Collegium Masoviense Nursing Institute 

Wyższa Szkoła Nauk o Zdrowiu 

96-300 Żyrardów, ul. G. Narutowicza 35 

Head of the Institute 

Małgorzata Wojciechowska, PhD 

tel.: 601 24 11 25, fax: 46 855 46 64 

e-mail: malgorzataw62@gmail.com 

1. Act of 6 th November 2008 on accreditation in 

healthcare. Dz. U. (Official Law Journal) of 2009 no. 

52, item 418, no. 76, item 641. 

2. Act of 30 th August 2002 on compliance assessment 

system Dz.U. (Official Law Journal) of 2002 no. 166, 

item 1360, of 2003 no. 80, item 718, no. 130, item 

1188, no. 170, item 1652, no. 229, item 2275. 

Received: 10.01.2012 



Katarzyna Napiórkowska, Krzysztof Pałgan, Ewa Gawrońska-Ukleja, Magdalena Żbikowska-Gotz, 

Joanna Kołodziejczyk, Milena Wojciechowska, Małgorzata Graczyk, Ewa Szynkiewicz, Robert Zacniewski, 


THE ROLE OF SKIN PRICK TEST IN DIAGNOSIS OF FOOD ALLERGY 

IN PATIENTS WITH BIRCH POLLINOSIS 

ROLA TESTÓW SKÓRNYCH W DIAGNOSTYCE ALERGII POKARMOWEJ 

U PACJENTÓW UCZULONYCH NA PYŁKI BRZOZY 

Department and Clinic of Allergology, Clinical Immunology and Internal Diseases 

Collegium Medicum in Bydgoszcz, UMK in Toruń 

Head: prof. dr hab. n. med. Zbigniew Bartuzi 

Summary 

I n t r o d u c t i o n . The incidence of food allergy is 

constantly growing. Particularly high percentage of patients 

is allergic to pollens - even 70 % of patients with a pollen 

allergy suffer from undesirable symptoms that appear after 

eating plant foods. It is connected mainly with crossreactivity 

between allergens. The fact that manifestations of 

food allergy concern different systems and organs is a 

problem and it causes diagnosing food allergy difficult and 

often underestimated. 

T h e a i m o f t h i s s t u d y was to determine the 

role of skin prick tests in the diagnosis of food allergy in 

patients with birch pollinosis. 

Matherial and methods. 35 patients with 

birch pollinosis suffering after eating apple, celery, carrot, 

tomato, banana, peach, peanut and hazelnut were included 

to the study. The skin prick tests with applying extracts of 

allergens mentioned above were determined for all 

individuals. 

R e s u l t s . The analysis of the results of positive skin 

prick tests in patients reporting manifestations was as 

follows: celery 100 %, hazelnut 65.4 %, peanut 40 %, carrot 

30.8 %, peach 20 %, tomato 14.3 %, apple 3.7 % and banana 

0 %. In the skin prick tests, negative results were also 

achieved, although patients reported appearance of 

symptoms of sensitivity to given allergens: apple (74.3 % of 

persons), peach (34.3 % of persons), the hazelnut and the 

carrot (25.5 % for each of allergens), the tomato and the 

peanut (17.1 % for each of allergens) and banana (11.4 %). It 

is interesting that some of the patients had positive test 

results for the celery (22.8 %), although they did not report 

symptoms of oversensitivity to this kind of food. 

Conclusions. Although skin prick tests are 

a universally used diagnostic method but in case of food 

allergy, the negative result cannot be a criterion which results 

in excluding this diagnosis . 

Streszczenie 

Wstę p. Częstość alergii pokarmowej stale wzrasta. 

Szczególnie wysoki odsetek dotyczy pacjentów uczulonych 

na pyłki roślin - nawet u 70 % pacjentów z alergią na pyłki 

roślin występują objawy niepożądane po spożyciu pokarmów 

pochodzenia roślinnego. Związane jest to głównie 

z występowaniem reakcji krzyżowych między alergenami. 

Problemem jest fakt, że objawy te dotyczą różnych układów 

i narządów, co sprawia, że rozpoznanie alergii pokarmowej 

jest utrudnione i często niedoszacowane. 

Celem pracy było określenie roli testów skórnych 

w diagnostyce alergii pokarmowej u pacjentów uczulonych 

na pyłki brzozy. 

Materiał i m e t o d y . Do badania zakwalifikowano 

35 pacjentów uczulonych na pyłek brzozy, którzy 

zgłaszali jednocześnie objawy niepożądane po spożyciu

102 

Katarzyna Napiórkowska et. al. 

jabłka, selera, marchwi, pomidora, banana, brzoskwini, 

orzechów laskowych i orzeszków ziemnych. U wszystkich 

pacjentów wykonano testy skórne z zastosowaniem 

wyciągów wyżej wymienionych alergenów. 

W y n i k i . Analiza wyników dodatnich testów skórnych 

u pacjentów zgłaszających objawy przedstawiała się 

następująco: seler 100%, orzech laskowy 65,4%, orzeszek 

ziemny 40%, marchew 30,8%, brzoskwinia 20%, pomidor 

14,3%, jabłko3,7% oraz banan 0%. W testach skórnych 

uzyskano również wyniki ujemne, pomimo, że pacjenci 

zgłaszali objawy na dane alergeny. Przedstawiały się one 

następująco: jabłko (74,3% osób), brzoskwinia (34,3% osób), 

orzech laskowy i marchew (25,5% dla każdego z alergenów), 

pomidor i orzeszek ziemny (17,1% dla każdego z alergenów) 

oraz banan (11,4%). Interesujący jest fakt, że u części 

pacjentów uzyskano dodatni wynik testu dla selera (22,8%), 

pomimo że osoby te nie zgłaszały objawów nadwrażliwości 

na ten pokarm. 

Wnioski. Choć testy skórne są powszechnie 

stosowaną metodą diagnostyczną, w przypadku alergii 

pokarmowej ujemny wynik nie może być kryterium 

wykluczającym to rozpoznanie. 

Key words: food allergy, birch allergy, skin prick tests 

Słowa kluczowe: alergia pokarmowa, alergia na pyłki brzozy, testy skórne 

INTRODUCTION 

Food allergy is a serious and often uderestimated 

problem. It might have different symptoms which 

result in the fact that before a patient comes to an 

allergologist, he/she visits a lot of other specialists 

including gastroenterologists. It might be caused by the 

fact that very often the only symptoms of allergy are 

the stomach ache, constipation and diarrhea. What is 

more, the first symptoms appear a long time after 

eating the food. In case of immediate reaction the 

symptoms might appear after a few minutes but it may 

appear even after a few hours when it is the immune 

complex allergic reaction [1]. 

The literature raises also the problem of correlation 

between food allergy and the irritable bowel syndrome 

(IBS). The research proves that inpatient with irritable 

bowel syndrome the incidence of atopy is more 

frequent than with general population. Adverse 

reaction to specific kind of food occurs in 25-65 % of 

patients with IBS. However, the food allergy affects it 

more rarely but it does not change the fact that it is 

higher in comparison with the population without IBS. 

There was also some improvement after following the 

elimination diet and applying the sodium 

cromoglycate. What is more, patients notice also the 

relationship between the food they consume and 

occurring disorders. According to some research, 20- 

60% of patients with IBS think that their adverse 

reactions result from the food they eat [2, 3]. 

The incidence of allergy is constantly growing. The 

highest percentage of patients is allergic to plant pollen 

which is associated with the occurrence of crossreactions 

between allergens. According to some 

authors, even 70% of patients with pollen allergy suffer 

because of symptoms appearing in the oral cavity, 

after eating vegetable food [1]. That is why the 

knowledge of this topic, and especially the symptoms 

and useful diagnostic methods, will facilitate the 

correct diagnosis and treatment. 


35 patients, over 16 years old, with pollinosis 

caused by allergens birch, who were patients of 

Allergy Outpatient Clinic of the Cathedral Clinic of 

Allergy and Clinical Immunology and Internal diseases 

of the Collegium Medicum in Bydgoszcz , were 

qualified to the survey . Additionally, they reported 

occurrence of adverse symptoms after eating such food 

as apple, carrot, celery, tomato, peach, banana, 

hazelnuts and peanuts . They were enrolled if they had 

pollinosis confirmed by prick skin tests and it was also 

suspected that they additionally suffer from food 

allergy (subjective test). The group consisted of 22 

women and 13 men , at the average age of 35.1± 10.9 

years. Prick skin tests, applying allergen extracts 

(apple, carrot, celery, tomato, banana, peach, peanuts 

and hazelnuts) of the Company Allergopharma were 

performed in each of the patients. The technique of the 

test was based on the revised Pepys and Bernstein’s 

prick method. The Scandinavian method, accepted by 

European Academy of Allergology and Clinical 

Immunology (EAACI) and commonly used in a 

number of clinical centers in Europe and in Poland, 

was used to evaluate the tests. 

RESULTS 

Most patients did not tolerate more than one kind of 

food. The greatest number of people (22.8%) from the 

test group reported adverse symptoms because 4 

different kinds of food, while one patient reported 

adverse symptoms after eating 8 different kinds of 

food. Table I shows the percentage of people who

The role of skin prick test in diagnosis of food allergy in patients with birich pollinosis 103 

reported adverse symptoms after eating specific kind 

of food. 

Table I. Percentage of people reporting adverse symptoms 

after eating specific kind of food 

Tabela I. Odsetek osób zgłaszających objawy niepożądane w 

zależności od spożytego pokarmu 

Food 

The number of people reporting adverse symptoms 

Apple 77.1% 

Hazelnuts 74.3% 

Peach 42.8% 

Carrot 37.1% 

Celery 34.3% 

Peanuts 28.6% 

Tomato 20.0% 

Banana 11.4% 

In patients allergic to birch pollen there was a 

concomitant food allergy because of apples, hazelnuts 

and peaches and less often because of carrots, celery, 

peanuts, bananas and tomatoes. The adverse symptoms 

appeared most often within the oral cavity, lips and 

eyes and caused swelling, itching and burning. One 

exception was the celery which mainly caused adverse 

symptoms in gastrointestinal tract. The other one was 

the banana, after eating of which the symptoms 

appeared on the skin. The detailed analysis of skin 

prick test was shown in table II. 

Table II. The analysis of skin prick tests 

Tabela II. Analiza wyników testów skórnych prick 

Allergen 

The number 

of people 

with the 

positive test 

result 

Patients 

The number of 

people reporting 

adverse 

symptoms 

The number of 

people, reporting 

adverse 

symptoms, with 

positive test 

results 

Apple 1 27 3.7% 

Celery 20 12 100% 

Carrot 4 13 30.8% 

Tomato 1 7 14.3% 

Banana 0 4 0% 

Peach 3 15 20% 

Peanuts 4 10 40% 

Hazelnuts 17 26 65.4% 

The analysis of positive skin tests in patient 

reporting adverse symptoms ( the ‘true positive’ 

results) was as follows: celery 100%, hazelnuts 65.4%, 

peanuts 40%, carrot 30%, peach 20%, tomato 14.3%, 

apple 3.7%, banana 0%. In some cases, despite 

adverse symptoms caused by some allergens, the prick 

tests gave negative results. The percentage was as 

follows: apple ( 74.3% people), beach (34.3%) and 

hazelnuts and carrot (both 25.5%), tomato and peanuts 

(17.1% for which of these allergens) and banana 

(11.4%). Additionally ,in some cases there was a 

positive test result for the celery (22.8%) but the 

patient did not report any adverse symptoms 

(hypersensitivity to this kind of food). 

DISCUSSION 

The skin prick tests are in fact the basis of modern 

allergy diagnostics . They are cheap and easy to apply 

and the risk of anaphylaxis is low. What’s more, if 

there is such a need, they might be stopped at any time. 

They may be treated as a dermal provocative test. 

However, we should bear in mind that they are tests 

which facilitate diagnosis of allergy, the base of which 

are IgE-dependent mechanisms [5, 6]. 

However, we should remember that, as each of 

other methods, skin prick tests have some limitations. 

33-64% people from general population have positive 

skin test results. In fact, from this number of cases only 

15-25% of people suffer from asthma and rhinitis. It 

proves that there is a number of people with positive 

skin test results who do not have any clinical 

symptoms. However, we should remember that 

positive results of tests may precede the appearance of 

disease that may develop even a few years later. What 

is more, there is also a group of patients (10-15%) with 

allergy symptoms but with negative prick skin tests [6]. 

A lot of factors influence the skin tests. False 

negative results might result from the fact that the 

penetration of the tool in the skin was not sufficient 

(application not deep enough), the dilution of the drop 

was too high or it had been wiped off before the prick 

was performed, which made it impossible to introduce 

the allergen into the skin. What is more false negative 

results might be caused by some other factors: 

improper and too long storage of the allergen extract, 

reduced skin reactivity (elderly people and infants), 

pathological skin lesion, taking medicines before the 

test (e.g. antihistamine, glucocorticoid, and even 

antidepressants), and also performing the test

104 

Katarzyna Napiórkowska et. al. 

immediately after anaphylactic shock, too low dose of 

allergen that could cause the reaction ( inter-individual 

differences). Sometimes false negative results might be 

caused by the mechanisms which are not dependent on 

IgE, while false positive results of tests might be 

caused by the fact of bleeding in the point of prick, too 

high concentration of glycerol in the extract used for 

the test , drugs taken by the patient that may increase 

the release of the histamine , eating food that might be 

the potential allergen or food that contains a lot of 

histamine or its precursors (tuna, cheese, cabbage, 

spinach, sausages).They are also false positive because 

of the active dermographia or acute nettle rash, 

application of too high dose of allergen ( high 

concentration), cross reaction between homologus 

epitopes( substances similar to mediators in their 

actions) that emerge during the process of degradation 

of allergens , or between non-specific factors 

degranulating mast cells. [5, 6, 7]. 

We have to remember that skin tests allow only 

identification IgE –dependent allergy. The negative 

result of the test does not exclude the presence of IgE - 

independent allergy. What is more, some symptoms 

might be caused by non - allergic oversensitivity to 

some additives contained in food or biogenic amines 

like histamine. 

CONCLUSIONS 

Food allergy has a lot of symptoms. When the only 

symptom of allergy is chronic rhinitis, hoarseness or 

inflammation of the ear the patients turn to the 

laryngologist. Symptoms appearing in the digestive 

tract (stomach aches, nausea, vomiting, heartburn , 

diarrhea or constipation) with patients having delayed 

reactions cause that patients turn to the 

gastroenterologist. That is why it is very important to 

raise the issue not only with GPs but also with different 

specialists . We should remember that when we cannot 

find any reasons for the symptoms appearing in a 

specific organ or system and the patient does not 

respond to the treatment he/she should consult the 

allergist. Performed analysis proved that skin tests do 

not confirm the diagnosis of allergy in 100%. Their 

usefulness in food allergy diagnosis is much lower 

than for diagnosis of symptoms caused by allergens 

contained in the air. These tests are only the 

supplementary analysis which verifies but does not 

exclude the disease. Despite of the fact that there are 

other diagnostic methods such as patch tests, 

determining the level of general and allergen-specific 

IgE or provocation test which help to give a proper 

diagnosis, the only method of successful treatment of 

food allergy is following the diet that excludes food 

causing allergy. That is why so much depends on the 

doctor to whom the patient turns in the first place. 

REFERENCES 

1. Jarosz M, Dzieniszewski J, Alergie pokarmowe. Porady 

lekarzy i dietetyków. Wydawnictwo lekarskie PZWL, 

Warszawa 2004 

2. Park MI., Camilleri M. Is there a role of food allergy in 

irritable bowel syndrome and functional dyspepsia? A 

systematic review. Neurogastroenterol Motil (2006) 18, 

595–607 

3. Monsbakken KW, Vandvik PO, Farup PG. Perceived 

food intolerance in subjects with irritable bowel 

syndrome – etiology, prevalence and consequences. 

European Journal of Clinical Nutrition (2006) 60, 667– 

672 

4. Anhoej C, Backer V, Nolte H: Diagnostic evaluation of 

grass- and birch-allergic patients with oral allergy 

syndrome. Allergy 2001; 56 (6): 548-552 

5. Wiśniewska-Barcz B., Orłowska E.: Testy skórne w 

diagnostyce alergologicznej. Alergologia Współczesna 

2001; 4 (09): 15-23 

6. Białek S, Białek-Gosk K. Udział laboratorium w 

rozpoznawaniu alergii. Artykuł dostępny na stronie 

http://www.alergia.org.pl/pacjent/diagnostyka/laboratoriu 

m.htm 

7. Kruszewski J i wsp.: Testy skórne. Standardy w 

alergologii – część I. Stanowisko ekspertów Zarządu 

Głównego PTA. Dom Wydawniczy Benkowski 2003 

8. Małolepszy J: Testy skórne, oznaczanie przeciwciał IgE i 

próby prowokacji wargowej w rozpoznaniu alergii 

pokarmowej towarzyszącej pyłkowicy. Rozprawa 

doktorska. PAM w Szczecinie, 2001 


Małgorzata Graczyk 

Klinika Alergologii, Immunologii Klinicznej 

i Chorób Wewnętrznych 

Szpital Uniwersytecki Nr 2 im. dr J. Biziela 

ul. Ujejskiego 75 


tel. 052-3655416 

fax 052-3655416 

e-mail: gosgra1@poczta.onet.pl 

Received: 10.01.2012 



Katarzyna Obłoza 1 , Aleksandra Czerw 1 , Urszula Religioni 1 

THE ROLE OF MEDIA IN CREATING THE HEALTH CARE UNITS’ IMAGE IN POLAND 

ROLA MEDIÓW W KREOWANIU POSTRZEGANIA WIZERUNKU PLACÓWEK 

OCHRONY ZDROWIA W POLSCE 

1 Department of Public Health, Medical University of Warsaw 

prof. dr hab. n. med. Janusz Ślusarczyk 

Summary 

Introduction. The media have an enormous set of 

various tools and techniques, which allow the creation of a 

social reality. Nowadays, there are some stormy discussions 

on unfavourable situation in health care. The aim of this 

study was to determine the role of the media in creating 

perceptions of the image of health care centres in Poland. 

Material and methods. Students and graduates of 

the biggest Polish universities were the target group for the 

following study. The surveyed group consisted of 1160 

people (75% women and 25% men). 38% of the surveyed 

live in a city of more than 500 thousand inhabitants and 16% 

in village. An anonymous questionnaire was used to achieve 

the aim of this study. The questionnaire consisted of 32 

questions posted on the website. 

Results. 16.44% of respondents considered the media 

a reliable source of information about health care. There was 

no correlation between the assessment of the credibility of 

the media and the place of residence of respondents. 

According to 71% of respondents, the way in which the 

media present information about health care has an impact on 

their attitude towards the health system. The feature that 

determines the assessment of the impact of the media on 

attitudes towards health care system is sex. 

Conclusions. The results obtained in this study 

suggest that the media play a significant role in creating the 

image of healthcare facilities in Poland. Therefore, shaping 

correct relations with the media should become a part of the 

activity of each health care organisation. 

Streszczenie 

Wstęp. Media dysponują potężnym zbiorem 

różnorodnych technik i narzędzi, pozwalających na 

kreowanie pewnej rzeczywistości społecznej. Obecnie w 

mediach wciąż toczą się burzliwe dyskusje na temat 

niekorzystnej sytuacji w ochronie zdrowia. Celem niniejszej 

pracy było więc określenie roli mediów w kreowaniu 

postrzegania wizerunku placówek ochrony zdrowia w Polsce. 

Materiał i metody. Badaniem objęto losowo 

wybranych studentów oraz absolwentów największych 

polskich uczelni wyższych. Badana grupa liczyła 1160 osób 

(75% kobiet oraz 25% mężczyzn). Miejscem zamieszkania 

38% respondentów jest miasto powyżej 500 tys. 

mieszkańców, a 16% uczestników badania to mieszkańcy 

wsi. W realizacji celu badania wykorzystano anonimową 

ankietę, składającą się z 32 pytań, zamieszczoną na stronie 

internetowej. 

Wy niki. 16,44% respondentów uznało, iż media są 

wiarygodnym źródłem informacji o ochronie zdrowia. Nie 

stwierdzono zależności pomiędzy oceną wiarygodności 

mediów a miejscem zamieszkania respondentów. Według 

71% ankietowanych, sposób w jaki media przedstawiają 

informacje dotyczące służby zdrowia ma wpływ na ich ocenę 

i nastawienie do systemu ochrony zdrowia. Cechą, która 

determinuje ocenę wpływu mediów na nastawienie do 

systemu ochrony zdrowia jest płeć. 

Wnioski. Wyniki uzyskane w niniejszej pracy sugerują, 

że media odgrywają znaczącą rolę w kreowaniu wizerunku 

placówek ochrony zdrowia w Polsce. Z tego względu, 

kształtowanie prawidłowych relacji z mediami powinno stać 

się częścią aktywności każdej organizacji ochrony zdrowia. 

Key words: image of the hospital, media relations, cooperation with the media, the media 

Słowa kluczowe: wizerunek szpitala, media relations, współpraca z mediami, media

106 

Katarzyna Obłoza et. al. 

INTRODUCTION 

Present times surprise us with the variety of 

information. Newspapers, radio and television are 

constant attributes of everyday life. Ubiquitous media 

dictate the latest trends to us, inform about current 

events in the world, spread a new lifestyle 

and customs. The huge popularity of the media leads to 

reflection and research on the strength of their 

influence and role in contemporary society. 

The media have a huge collection of various 

techniques and tools for creating a social reality [1]. 

This is due to the fact that they are commonplace and 

generally available for almost everyone. They are now 

the primary source of information in any modern 

society. Each message has admittedly a different 

impact on an individual [2,3], and therefore you should 

not overestimate the power of the media, equally 

dangerous may be underestimating their power. 

The media continues to roll quite a lively 

discussion on unfavourable situation in health care 

system. Public opinion is constantly informed about 

the growing indebtedness of public health practitioners, 

payroll problems and lack of funding for health 

services. The recent media reports were dominated by 

information about the exhaustion of the limits of 

admission of patients to various institutions, 

the limitations of parties, ever-growing queues and 

long waiting period for benefits, as well as the protests 

of doctors, the new reimbursement rules and plans for 

health care transformation in the company, the 

introduction of supplementary health insurance and 

partial charges for medical services. There arose 

numerous social apprehensions that patients would be 

denied the access to medical care. The continuing 

atmosphere of uncertainty, anxiety and insecurity, 

certainly has an impact on the negative opinions on the 

health care system [4,5]. 

A natural consequence of this social-media debate was 

the question what is the role of the media in shaping 

perceptions of the image of health care centres in Poland. 


For two months (November - December) of 2010 a 

study on the media image of healthcare facilities in 

Poland was conducted. This study was carried out 

by using a questionnaire specially prepared for this 

purpose, conducted among 1160 people, predominantly 

women (75%). The questionnaire covered randomly 

selected students of the biggest Polish universities: 

Medical University of Warsaw, Warsaw University of 

Technology, Warsaw University, Maritime University, 

AGH University of Science and Technology, 

Jagiellonian University, Catholic University of Lublin, 

Medical University of Silesia, Wrocław University 

of Economics, National School of Film, Television and 

Theatre in Łódź. Students of these schools represented 

approximately 91% of all respondents. People who had 

already completed their studies constituted the 

remaining part. 

Among those surveyed, there were 75% of women 

and 25% of men. 38% of the surveyed lived in a city of 

more than 500 thousand inhabitants and 16% - 

in village. 6% of the surveyed residents of small towns 

and cities of 10 thousand inhabitants, while 18% of the 

filling the survey are urban residents of cities of 10-50 

thousand inhabitants. The remaining respondents are 

urban residents of cities of 50-100 thousand inhabitants 

(10%) and 100-500 thousand inhabitants (12%). 

Research technique was anonymous questionnaire 

which used a website with a questionnaire to conduct 

research via the Internet (www.ankietka.pl). The 

questionnaire contained 32 questions with different 

schema design. After analyzing the survey it was found 

that 100% of the returned questionnaires were filled in 

correctly. 

The present study focuses on issues concerning the 

media image of healthcare facilities in Poland: interest 

information on the situation in the health care system, 

the degree to inform about current medical topics, 

sources of information about the health care system. 

The survey also takes into account such issues 

as the evaluation of the time the media spend on 

information about the health care system, health care 

picture created by the media and subject matter of 

information most often encountered in the media, as 

well as those individually looking for. Respondents 

were asked about the credibility of the media as a 

source of information about health care, assessment of 

the media image of hospitals in Poland and the impact 

of the media on opinion and attitude towards the health 

system. 

The results were statistically analyzed. 

RESULTS 

As the main source of information about the health 

care system, more than 71% of respondents chose the 

Internet, and 65% of them - the television. For almost 

one third of respondents (32%) source of such

The role of media in creating the health care units' image in Poland 107 

information are doctors, nurses, pharmacists and other 

health professionals. 35% of respondents chose the 

press, 28% the family, and every fifth of them - the 

radio. For 19% of study participants source of 

information about the health care system are 

neighbours or friends, while 12% pointed to 

conferences, symposia, scientific meetings and 

professional trainings. Leaflets, pamphlets, brochures, 

posters and professional publications are a source 

of information for 12% and 11% of respondents 

respectively (Fig. 1). In the present question, 

respondents had the opportunity to select up to three 

answers. 

Fig. 2. Picture of health service presented in the media (n = 

1058) 

Ryc. 2. Obraz służby zdrowia przedstawiany w mediach (n = 

1058) 

Fig. 3. The media as a reliable source of information about 

the health care system (n = 1058) 

Ryc. 3. Media jako wiarygodne źródło informacji o systemie 

ochrony zdrowia (n = 1058) 

Fig. 1. Sources of information on the health care system (n = 

1058) 

Ryc. 1. Źródła informacji o systemie ochrony zdrowia (n = 

1058) 

Respondents participating in the survey feel that the 

health picture shown in the media is negative - 68%. For 

about 17% of them the media image of the health care 

system is presented objectively and only slightly more 

than 1% of respondents believe that it is positive. 14% of 

people do not have an opinion on this subject (Fig. 2). 

Figure 3 shows that for 44% of respondents of the 

survey the media are not a reliable source of 

information on the health care system. Only 16% of 

respondents replied in the affirmative. As many as 40% 

of the study group did not have an opinion on this 

subject. 

It was also found that the size of the place of 

residence has no significant influence on the 

assessment of the credibility of the media as a source 

of information about the health care system (p > 0.05) 

– Table I. 

Table I. Place of residence and the assessment of the 

credibility of the media as a source of information 

on the health care system (n = 1058) 

Tabela I. Miejsce zamieszkania a ocena wiarygodności 

mediów jako źródła informacji o systemie 

ochrony zdrowia (n = 1058) 

73% of respondents evaluate the media image of 

the health care centres in Poland negatively. One

108 

Katarzyna Obłoza et. al. 

quarter of people who fill out the questionnaire did not 

have an opinion on this subject. Only 2% of the 

respondents assess the media's image of healthcare 

institutions in our country positively (Fig. 4). 

media and presented information influence the attitude 

of the health care system (p < 0.05). 

Table II. The sex and influence information presents in the 

media on the assessment of and attitude to health 

system (n = 1058) 

Tabela II. Płeć a ocena wpływu informacji prezentowanych 

przez media na nastawienie do systemu ochrony 

zdrowia (n = 1058) 

Fig. 4. Evaluation of the media image of healthcare facilities 

in Poland (n = 1058) 

Ryc. 4. Ocena wizerunku medialnego placówek ochrony zdrowia 

w Polsce (n = 1058) 

According to 71% of respondents, the way the media 

present information on health care has an impact on their 

assessment of and attitude towards the health system (Fig. 

5). One fifth of the participants believe that the media do 

not affect their opinions and attitudes to health care. 9% of 

people expressed no opinion on this subject. 

Fig. 5. Influence the way the media presents information 

about health care on the assessment of and attitude 

to health system (n = 1058) 

Ryc. 5. Wpływ sposobu w jaki media przedstawiają 

informacje dotyczące służby zdrowia na ocenę 

i nastawienie do systemu ochrony zdrowia (n = 

1058) 

Table II indicates that the feature that determines 

the assessment of the impact of the media on attitudes 

towards health care system is the sex. Women 

significantly more often than men believe that the 

DISCUSSION 

In the assessment of healthcare facilities essential 

role for the patient plays a personal experience. A 

satisfied patient exhibits an increased level of loyalty 

to the hospital, and has a particular impact on its 

opinion in the environment. One of the largest medical 

centres in the United States is the Mayo Clinic. The 

hospital boasts a huge number of positive reviews in 

the environment. How does it work in practice? There 

are about 520 000 patients treated annually, of which 

90% are satisfied with the provided medical services, 

which gives approximately 470 000 positive opinions. 

According to estimates of experts from the Mayo 

Clinic, an average patient shares information and 

conducts an assessment of its treatment with 39 

persons. If you multiply this by the number of positive 

reviews, you get an incredible score of 18 million 

people who encounter the opinion of the facility [6]. 

However, based on the information presented in the 

mass media, the public are able, under their influence, to 

change their assessment of and beliefs about the health 

care facility. Information presented in the media is 

highly selected, and not always consistent with the 

actual course of events, their cause and the resulting 

effect. 

CONCLUSIONS 

The results obtained in this study suggest that the 

media play a significant role in shaping the image of

The role of media in creating the health care units' image in Poland 109 

healthcare facilities in Poland. The strength and nature 

of the impact of the media on the perception of the 

image of healthcare facilities is very diverse and 

depends on many factors. 

According to the theory of the media, presented 

information is simplified, one-sided, schematic and not 

devoid of a subjective point of view of the journalist. 

Having a relatively limited time, the media are not able 

to pass on all messages. 

Given the above, the formation of normal relations 

with the media (the media relations) should become 

part of the activity of each health care organisation. 

However, it is important to realise that media relations 

is not only the transmission of press releases. It 

consists of arduous building databases and networks 

between individual editorial teams, organising events 

that are attractive from the media's standpoint, 

researching and creating interesting pieces of 

information and disseminating them in a suitable form. 

REFERENCES 

1. Budzyński W.: Public relations, strategia i nowe 

techniki kreowania wizerunku. Poltex. Warszawa, 

2008: 26-28, 81-88, 147-152. 

2. Rozwadowska B.: Public relations w teorii, praktyce, 

perspektywie. Studio EMKA, Warszawa, 2002: 25. 

3. Staszewski R.: Media relations w szpitalu – czyli jak 

nas widzą, tak nas piszą. Profesjonalizm w Instytucjach 

Opieki Zdrowotnej – poradnik dla pracowników, 

Publikacja współfinansowana ze środków Unii 

Europejskiej i budżetu Państwa w ramach projektu: 

Podnoszenie kompetencji i kwalifikacji kadry 

medycznej na rzecz profesjonalizmu w ochronie 

zdrowia, Poznań, 2008: 85-107. 

4. Stępień W.: Kto, co i jak kształtuje opinię publiczną 

dotyczącą ochrony zdrowia w Polsce? Procesy 

przekształceń w ochronie zdrowia: bariery 

i możliwości. Putz J. (red.), IPIS, Warszawa, 2002: 10- 

196. 

5. Samardakiewicz M.: Postrzeganie systemu ochrony 

zdrowia w świetle ostatnich doniesień medialnych. 

Onkologia polska 11/2008: 45-48. 

6. Baum E., Staszewski R.: Wyzwania ochrony zdrowia. 

Pielęgniarstwo, geriatria, sekretariat medyczny w 

aspekcie etyki, opieki medycznej i zarządzania, 

Publikacja współfinansowana ze środków Unii 

Europejskiej w ramach Europejskiego Funduszu 

Społecznego, Poznań, 2009: 73-89. 


Aleksandra Czerw, Ph.D. 

Medical University of Warsaw 

Department of Public Health 

1a Banacha St. 

02-097 Warsaw 

tel.: (0-22) 599 21 80 

e-mail: aleksandra.czerw@wum.edu.pl 

Received: 10.01.2012 



Joanna Pawlak 1 , Paweł Zalewski 1 , Jacek J. Klawe 1 , ,Monika Zawadka 1 , Anna Bitner 1 , Małgorzata Tafil-Klawe 2 

CORE BODY TEMPERATURE CHANGES AFTER SAUNA EXPOSITION 

IN HEALTHY SUBJECTS 

ZMIANY TEMPERATURY GŁĘBOKIEJ CIAŁA PO ZABIEGU SAUNY SUCHEJ 

U OSÓB ZDROWYCH 

1 Department of Hygiene and Epidemiology, Nicolaus Copernicus University, Toruń 

Ludwik Rydygier Collegium Medicum, Bydgoszcz 

Head: dr hab. n. med. Jacek J. Klawe, prof. UMK 

2 Department of Physiology, Nicolaus Copernicus University, Toruń 

Ludwik Rydygier Collegium Medicum, Bydgoszcz 

Summary 

I n t r o d u c t i o n . Sauna therapy has been used for 

hundreds of years in the Scandinavian region as a standard 

health activity and, during the past decades, it has also 

become a widely practiced wellness form in many central 

European countries. Sauna bathing is a special form of heat 

exposure characterized by a short-term exposure to 

exceptionally high environmental temperatures. Human body 

exposure to extreme environmental conditions e.g. wholebody 

dry sauna may modulate thermoregulation processes. 

Aim of this study was to analyze changes in core temperature 

after sauna bathing. 

Material and methods. Nine males 

volunteered for the study. Each of the subjects had a 15- 

minutes exposure in a sauna (air temperature: 100 ± 10 o C, 

humidity 34-45%). 

Core body temperature measurements were done by 

ingestible telemetric sensor- Vital Sense system. 

R e s u l t s Observed changes were statistically 

significant (p

112 

INTRODUCTION 

Joanna Pawlak et. al. 


Sauna therapy has been used for hundreds of years 

in the Scandinavian region as a standard health 

activity, and during the past decades, it has also 

become a widely practiced wellness form in many 

central European countries. Sauna bathing is a special 

form of heat exposure characterized by a short-term 

exposure to exceptionally high environmental 

temperatures. 

The basic modern sauna is an unpainted, woodpaneled 

room with wooden platforms and a rock-filled 

electric heater. The hot room air temperature falls 

within the range of 70 to 100 °C, optimally between 80 

and 90 °C at the face level of the bathers. The air 

should have a relative humidity of 10% to 20%. The 

sauna bath consists of repeated cycles of exposure to 

heat and cold. The length of stay in the hot room 

depends on each bather’s own sensations of comfort; 

the duration usually falls between 5 and 20 minutes. 

This is followed by a cool-off (shower, swim, or a 

period at room temperature), the length of which also 

depends on personal sensations. A sufficient recovery 

period (usually about one half of an hour) following a 

few hot/cold cycles allows normalizing the body 

temperature and cessation of sweating. 

The acute reaction for sauna bathing is the 

expression of active thermoregulation: hormonal 

changes, sweating with loss of body water and 

electrolytes, skin vasodilatation with an increase in 

heart rate and cardiac output resulting in a slight drop 

of blood pressure, hyperventilation [1,2,3]. 

There is a growing body of evidence on the clinical 

use of saunas for therapeutic purposes. Evidence 

suggests that sauna therapy is an effective and 

underutilized treatment for a variety of cardiovascular 

problems [4, 5, 6]. 

Body temperature regulation is controlled almost 

exclusively by intricate nervous system feedback 

mechanisms located in the hypothalamus. Normally, 

thermoregulation is highly efficient, keeping the 

internal temperature within a narrow range of 0.5–0.9 

°C. The normal deep body temperature (core body 

temperature) at rest is between 36-37.5 o C. Human 

body exposure to extreme environmental conditions 

e.g. whole-body dry sauna, may modulate 

thermoregulation processes [1, 3, 7]. 

The aim of this study was to analyze changes in 

core temperature after sauna bathing. 

Nine males volunteered for the study. They all gave 

written consent after being informed of the minor risks 

involved. All were healthy adults ranging in age from 

24 to 31 years, with a mean age of 26.7 years (Table I). 

Table I. Subject characteristics 

Tabela I. Charakterystka ogólna badanych osób 

Age, years 

Wiek, lata 

Height,[ m] 

Wzrost [m] 

Weight, [kg] 

Waga [kg] 

BMI, [kg/m 2 ] 

wskaźnik masy ciała [kg/m 2 ] 

BSA, [m 2 ] 

wskaźnik powierzchni ciała [m 2 ] 

sBP, [mmHg] 

ciśnienie skurczowe [mmHg] 

dBP, [mmHg] 

ciśnienie rozkurczowe [mmHg] 

study group (n=9; only men) 

grupa badana 

(n=9; tylko mężczyźni) 

mean 

wartości SD 

średnie 

26.78 3.03 

1.79 0.02 

81.56 11.09 

25.22 2.72 

2.00 0.13 

129 8 

78 7 

Each of the subjects undertook a 15-minutes 

exposure in a sauna (air temperature: 100 ± 10 o C, 

humidity 34-45%). 

Core body temperature measurements were done by 

ingestible telemetric sensor- Vital Sense System. It 

consists of a monitor and a thermistor-based ingestible 

capsule for core body temperature measurement. All 

data were collected 40 minutes prior to exposure up to 

six hours, minute-by-minute and mean values were 

calculated from 5 minutes epochs divide by 15 minutes 

gaps, and statistically analyzed. Core body temperature 

measurements were done in unchanging thermal and 

humidity conditions. 

RESULTS 

Core body temperature changes were analyzed 

using a Friedman test. Changes of core body 

temperature (BCT) values observed in time duration 

after sauna (WBS) exposure were statistically 

significant (p

Core body temperature changes after sauna exposition in healthy subjects 113 

a couple of minutes, after which the increase was 

slower. 

Table II. Basic statistic of core body temperature changes 

Tabela II. Podstawowe parametry statystyczne dotyczące 

zmian temperatury głębokiej ciała 

before WBS 

przed sauną 

after WBS 

po saunie 

45-60 min after WBS 

45-60 min po saunie 

2 h after WBS 

2 h po saunie 

3 h after WBS 

3h po saunie 

4 h after WBS 

4h po saunie 

5 h after WBS 

5h po saunie 

6 h after WBS 

6h po saunie 

Mean 

value 

wartości 

średnie 

Mediana Minimum Maximum SD 

37.05 36.91 36.67 37.61 0.31 

37.71 37.73 37.46 37.91 0.19 

37.30 37.22 36.99 37.86 0.27 

37.31 37.33 36.82 37.79 0.32 

37.26 37.30 36.94 37.57 0.23 

37.35 37.20 37.05 37.74 0.31 

37.26 37.26 36.92 37.63 0.27 

37.37 37.40 37.16 37.52 0.11 

(p=0.0000), 2 hours after WBS (p= 0.0430), 4 hours 

after WBS (p=0.0241) and 6 hours after WBS 

(p=0.0145). 

There were no statistically significant differences 

between mean temperature before WBS and mean 

temperature recorded 45-60 minutes after WBS 

(p=0.0591), 3 hours after WBS (p=0.0980) and 5 hours 

after WBS (p=0.1027) found. 

Mean BCT values registered 45-60 minutes after 

WBS were 37.3 o C (min 36.99 o C, max 37.86 o C). Mean 

BCT values registered 2 hours after WBS were 

37.31 o C (min 36.82 o C, max 37.79 o C). Mean BCT 

values registered 3 hours after WBS were 37.26 o C 

(min 36.94 o C, max 37.57 o C). Mean BCT values 

registered 4 hours after WBS were 37.35 o C (min 

37.05 o C, 37.74 o C). Mean BCT values registered 5 

hours after WBS were 37.26 o C (min 36.92 o C, max 

37.63 o C). Mean BCT values registered 6 hours after 

WBS were 37.37 o C (min 37.16 o C, max 37.52 o C). 

Fig. 2. Box-and-whisker plot of mean core body temperature 

before WBS (01), after WBS (02), 1 h after WBS (05), 

2 h after WBS (09), 3 h after WBS (13), 4h after WBS 

(17), 5 h after (21), 6 h after WBS (25) 

Ryc. 2. Wykres ramka-wąsy dla średniej temperatury 

głębokiej ciała przed WBS (01), po WBS (02), 1 h 

po WBS (05), 2 h po WBS (09), 3 h po WBS (13), 

4h po WBS (17), 5 h po (21), 6 h po WBS (25) 

DISCUSSION 

Fig. 1. Box-and-whisker plot of mean core body temperature 

during successive measurement periods; all (n=25) 

measurement periods are included; p

114 

Joanna Pawlak et. al. 

mainly the body core temperature oscillations, which 

emerge from an attempt to normalize the 

thermoregulation system after exposure. 

Several studies on core body temperature measures 

also confirm our findings. Kukkonen-Harjula et al. 

reported that the core temperature, as measured from 

the esophagus, is more stable, rising in the hot room at 

an average rate of 0,07°C × min-1 up to 38°C, then 

accelerating to 0.4°C × min-1 up to 39°C, and 

returning to initial values rapidly after the exposure [1]. 

Hannuksela et al. observed that increase in rectal 

temperature depends on heat exposure: by 0.2 ˚C at 72 

˚C for 15 minutes, by 0.4 ˚C at 92 ˚C for 20 minutes, 

by 1.0 ˚C at 80 ˚C for 30 minutes [3, 10, 11, 12]. 

Other authors described infant’s thermoregulatory 

response to short heat stress during sauna bath. Study 

included 47 infants (age 3 - 14 month). Before taking a 

short sauna bath lasting 3 minutes, the infants stayed in 

a swimming pool for 15 minutes. Under these 

conditions sauna bathing did not increase the rectal 

temperature. Unexpectedly rectal temperature even 

decreased by 0.2 o C (p < 0.05) probably due to 

redistribution of cold peripheral blood into the core of 

the body [13]. 

CONCLUSIONS 

1. Sauna bathing cause a core body temperature 

changes despite the very strong stability of 

thermoregulation mechanism. 

2. Obtained results of changes in core body 

temperature revealed that WBS caused an increase in 

core body temperature which may be sustained up to 6 

hours after the procedure. 

3. Dry sauna bath causes temperature oscillations 

differing from the natural circadian temperature course, 

which emerge from an attempt to normalize the 

thermoregulation system after exposure. 

REFERENCES 

1. Kukkonen-Harjula K., Kauppinen K.: Health effects 

and risks of sauna bathing. Int J Circumpolar Health. 

2006 Jun;65(3):195-205. 

2. Biro S, Masuda A, Kihara T, Tei C. Clinical 

implications of thermal therapy in lifestyle-related 

diseases. Exp Biol Med (Maywood) 2003;228:1245- 

1249. 

3. Minna L. Hannuksel, Samer Ellahham: Benefits and 

Risks of Sauna Bathing. The American Journal of 

Medicine; 2001:1 (110) 

4. Crinnion WJ: Sauna as a Valuable Clinical Tool for 

Cardiovascular, Autoimmune, Toxicantinduced and 

other Chronic Health Problems. Alternative Medicine 

Review 2011:16(3) 

5. Blum N., Blum A.: Beneficial effects of sauna bathing 

for heart failure patients. Exp Clin Cardiol. 2007 

Spring; 12(1): 29–32. 

6. Nguyen Y, Naseer N, Frishman WH.: Sauna as a 

therapeutic option for cardiovascular disease. Cardiol 

Rev. 2004 Nov-Dec;12(6):321-4. 

7. McKenzie JE, Osgood DW: Validation of a new 

telemetric core temperature monitor. Journal of 

Thermal Biology 29 (2004) 605–611 

8. Giuliano, K.K., Scott, S.S., Elliot, S., Giuliano, A.J., 

1999: Temperature measurement in critically ill orally 

intubated adults: a comparison of pulmonary artery 

core, tympanic, and oral methods. Crit. Care Med. 27 

(10), 2188–2193. 

9. Robinson, J., Charlton, J., Seal, R., Spady, D., Joffres, 

M.R.,1998. Oesophageal, rectal, axillary, tympanic and 

pulmonary artery temperatures during cardiac surgery. 

Can. J. Anaesth. 45 (4), 317–323. 

10. Leppaluoto J, Tapanainen P, Knip M. :Heat exposure 

elevates plasma immunoreactive growth hormonereleasing 

hormone levels in man. J Clin Endocrinol 

Metab. 1987; 65:1035–1038. 

11. Leppaluoto J, Arjamaa O, Vuolteenaho O, Ruskoaho 

O.: Passive heat exposure leads to delayed increase in 

plasma levels of atrial natriuretic peptide in humans. J 

Appl Physiol. 1991;71:716 –720. 

12. Leppaluoto J, Tuominen M, Vaananen A, et al.: Some 

cardiovascular and metabolic effects of repeated sauna 

bathing. Acta Physiol Scand. 1986;128:77– 81. 

13. Rissmann A, Al-Karawi J, Jorch G: Infant's 

physiological response to short heat stress during sauna 

bath. Klinische Pädiatrie2002; 214 (3). 


Uniwersytet Mikołaja Kopernika w Toruniu 

Collegium Medicum im. Ludwika Rydygiera 

w Bydgoszczy 

Katedra i Zakład Higieny i Epidemiologii 

ul. M. Skłodowskiej-Curie 9 


tel. 52 585 36 16 

e-mail: j.pawlak@doktorant.umk.pl 

Received: 10.01.2012 



Dorota Siwczyńska 1 , Magdalena Mińko 2 

THE FUNCTIONING OF HEALTH SYSTEMS IN POLAND AND THE NETHERLANDS 

IN PATIENTS’ OPINIONS 

FUNKCJONOWANIE SYSTEMÓW OPIEKI ZDROWOTNEJ W POLSCE I HOLANDII 

W OPINII PACJENTÓW 

1 Students Research Group of Public Health Department 

Medical University of Lublin 

Prof. dr hab. n. med. Teresa B. Kulik 

2 Medical University of Warsaw 

Summary 

Introduction and purpose of work. The 

health system aims is to safeguard the health needs and 

improve the health of the individual and in the community. 

Using the experiences of countries that achieve positive 

effects of the system functioning, exchange of knowledge 

and analysis of current results allows us to assess how the 

health care system can fulfill its potential. The aim of the 

work is to obtain information useful for health policymaking 

and implementation of effective solutions in health 

care by comparing the opinion of patients on the functioning 

of two health care systems in Europe - Polish and Dutch. 

M a t e r i a l a n d m e t h o d . The examination 

covered 133 persons living in Poland and 106 people living 

in the Netherlands. The applied testing method was a 

diagnostic survey. The tool used to conduct the study was the 

author's questionnaire. 

Results and discussion. The study indicates 

large inequalities in access to medical services, waiting time 

for a GP and specialist appointment, the treatment of 

patients. Test results also indicate disparities between health 

care in Poland and the Netherlands, as well as the lack of 

cohesion of public and private sector in the Polish health care 

system. 

C o n c l u s i o n s . Competitiveness of the market of 

medical services promotes improving the quality of services, 

ensuring a high standard of treatment as well as empathic and 

individual approach to each patient. So there is a need to 

further improvement and reforming the health care system in 

Poland to follow the changing market for health services. 

Streszczenie 

Wstę p i c e l p r a c y . System opieki zdrowotnej 

ma na celu zabezpieczenie potrzeb zdrowotnych i poprawę 

stanu zdrowia jednostki i zbiorowości. Korzystanie 

z doświadczeń krajów, które osiągają pozytywne efekty 

funkcjonowania systemu, wymiana wiedzy i analiza 

bieżących wyników pozwala ocenić, w jaki sposób system 

opieki zdrowotnej może wykorzystać swój potencjał. 

C e l e m p r a c y , dzięki porównaniu opinii pacjentów 

na temat funkcjonowania dwóch europejskich systemów 

opieki zdrowotnej – polskiego i holenderskiego, jest 

uzyskanie informacji przydatnych przy kreowaniu polityki 

zdrowotnej i wprowadzaniu efektywnych rozwiązań 

w ochronie zdrowia. 

Materiał i m e t o d a Badaniem zostały objęte 133 

osoby mieszkające w Polsce i 106 osób zamieszkujących 

Holandię. Zastosowaną metodą badawczą był sondaż 

diagnostyczny. Narzędziem wykorzystanym do przeprowadzenia 

badania był autorski kwestionariusz ankiety. 

W y n i k i i o m ó w i e n i e . Przeprowadzone badanie 

wskazuje na występowanie dużych nierówności w dostępie 

do usług medycznych, czasie oczekiwania na porady lekarza 

rodzinnego i specjalistów, sposobie traktowania pacjentów. 

Wyniki badania wskazują również na występowanie dyspro-

116 

Dorota Siwczyńska, Magdalena Mińko 

porcji pomiędzy opieką zdrowotną w Polsce i Holandii, 

a także na brak spójności sektora publicznego i prywatnego 

w polskim systemie zdrowotnym. 

W n i o s k i . Konkurencyjność na rynku usług medycznych 

sprzyja podnoszeniu jakości świadczeń, zapewnieniu 

wysokiego standardu warunków leczenia oraz empatycznego 

i indywidualnego podejścia do każdego pacjenta. Toteż 

istnieje potrzeba dalszego udoskonalania i reformowania 

systemu opieki zdrowotnej w Polsce, tak by odpowiadał 

zmieniającemu się rynkowi usług zdrowotnych. 

Key words: health care system, health system functioning, medical services market 

Słowa kluczowe: system opieki zdrowotnej, funkcjonowanie systemu zdrowotnego, rynek usług medycznych 

INTRODUCTION 

The health system is defined as an organized and 

coordinated set of activities, regardless of the country 

in which its functions, and aims at improving the 

health and protection of the health needs of individuals 

and communities [1]. The socio-demographic context, 

cultural factors, life style and history have the impact 

on the shape of the system in different countries around 

the world have: These elements also determine the 

direction of the state health policy and management. 

The international cooperation is necessary in order to 

minimize disparities between the systems, as well as 

internal between health and other sectors of the state. 

Using the experiences of countries that achieve 

positive effects of the system functioning, exchange 

knowledge and analysis of current results allow us to 

assess how the health care system can fulfill its 

potential. 

Health insurance 

In Poland, the foundation for the health care system 

is the principles contained in the Articles. 68 of the 

Polish Constitution of 1997, according to which 

"everyone has the right to health" and to equal access 

to benefits of public funds [2]. On 27 August 2004 a 

law concerning healthcare services financed from 

public funds was announced. The Act defines health 

benefits provided to the patient and the so-called 

"negative basket" that is, benefits which are not funded 

by the country. 

Under the law guaranteed provisions are: 

- primary health care, outpatient specialist care, 

hospital care; 

- mental health and addiction treatment, medical 

rehabilitation; 

- care and welfare benefits in the long-term care; 

- dental treatment; 

- health resort; 

- orthopedic and supply aids; 

- medical emergency; 

- palliative care and hospice; 

- highly specialized provisions; 

- health programs; 

- medicines [3]. 

According to the Act, in the Polish health care 

system the payer is the National Health Fund (NFZ), 

which manages the funds paid by the insured and 

concludes contracts with providers. The insured pays 

periodic premiums for health insurance in the amount 

of the percentage specified by the insurance law. Every 

insured person has the right to choose providers from 

among those who have signed a contract with the NFZ 

[4]. 

In the Netherlands in 2006, new Health Protection 

Act (Zorgverzekeringswet) abolished the distinction 

between statutory health insurance (SHI) and private 

health insurance (PHI), creating a single competitive 

market of medical insurance. The new system of 

covering the costs of health care is characterized by a 

balance between solid foundation for the social system 

and the dynamic development of the medical services 

market. The new Dutch system also assumes a limited 

state interference. The authorities only provide access 

to medical care, make up the acts and regulations 

providing for the operation of the system. They are not 

directly involved in providing health care. This is done 

by private providers, such as individual practices and 

institutions of care. 

The new law on health insurance ensures 

a sustainable future of Dutch health care system. 

According to the letter of the law, medical insurance is 

mandatory for all people living in the Netherlands. The 

key solutions that include the Act of 1 January 2006 

are: 

- a new standard of security for all; 

- the ability to change insurer every year; 

- competition among insurers; 

- stimulation of suppliers to increase quality by patients 

and insurers [5]. 

This "basic package" (Basisverzekering) is the 

minimum level of health insurance, which must be 

offered by all insurers. It determined by the 

government and its composition includes: 

- medical care: family doctor, some specialists; 

- hospitalization;

The functioning of health systems in Poland and the Netherlands in patients' opinions 117 

- dental services (up to 18 years old, over 18 years of 

age in a range of specialist services include dental care 

and prosthesis); 

- some medications, aids; 

- ambulance and medical transportation; 

- midwife care and postnatal care 

- health rehabilitation (physiotherapy, occupational 

therapy, dietary advice) [4,6]. 

Other medical services not covered by the "basic 

package" are offered by insurance companies under the 

supplementary insurance. Their scope and the price are 

determined individually by the insurers and citizens 

may also purchase the appropriate package for 

themselves [6]. 

There is also a narrow range of medical services 

that are funded from tax revenues and include all 

persons having a "basic package" health insurance. 

They are defined by Emergency Treatment Costs Act 

(AWBZ) and they include: 

- admission to the hospital for a period longer than 

1 year; 

- care in social care homes; 

- psychiatric care; 

- care for the mentally and physically disabled; 

- preventive actions such as vaccination [7]. 

Financial outlays 

According to recent figures from the World Health 

Organization (WHO), the total expenditure on health in 

Poland amounts 6.6%, in the Netherlands - 9.1% gross 

domestic product (GDP) in 2008 [8]. In comparison to 

previous years, health fundings in Poland have 

increased from 6.2% to 7% of GDP. However, in the 

Netherlands after 1% growth at the turn of 2002/2003, 

expenditures are at a similar level for several years 

within the limits of 9.7-10% [9]. 

Financial outlays per capita in Poland are among 

the lowest in Europe and amount 1 213 U.S. dollars. 

However, the Netherlands spend 4 063 U.S for health 

care per capita dollars and this is one of the highest 

rates among European countries [10]. 

PURPOSE 

The aim of the work is a detailed examination of 

the level of satisfaction within various sectors of the 

health care system by comparing the opinion of 

patients on the functioning of two health care systems 

in Europe - Polish and Dutch. This will help to obtain 

information relevant to health policy-making and 

implementation of effective solutions in health care, 

affecting the interests of a patient, provider and payer. 

MATERIAL 

The examination covered persons living in Poland 

and in the Netherlands. In Poland study was conducted 

among the inhabitants of Lublin province, while in the 

Netherlands people living in the province of North 

Brabant took part in the study. Among all respondents 

- 133 respondents were Polish, while the population 

studied in the Netherlands was 106 people. The 

detailed characteristics by sex, age, residence, 

education and material status of respondents are 

presented in Table I. 

Table I. Comparison of the Polish and Netherlands studied 

population by sex, age, residence, education and 

material status 

Tabela I. Porównanie w postaci liczbowej i procentowej 

badanej populacji mieszkańców Polski i Holandii 

według płci, wieku, miejsca zamieszkania, 

wykształcenia i statusu materialnego 

CECHA 

CHARACTERISTIC 

PŁEĆ 

SEX 

WIEK 

AGE 

MIEJSCE 

ZAMIESZKANIA 

PLACE OF 

RESIDENCE 

WYKSZTAŁCENIE 

EDUCATION 

STATUS 

MATEIALNY 

MATERIAL 

STATUS 

LICZBA I PROCENT 

BADANYCH OSÓB 

NUMBER AND 

PERCENTAGE OF 

RESPONDENTS 

POLSKA HOLANDIA 

POLAND HOLLAND 

liczba 

(number) % liczba 

% 

(number) 

kobieta (woman) 78 59 63 59 

mężczyzna 

(man) 

55 41 43 41 

18-24 33 25 40 38 

25-34 28 22 13 12 

35-44 18 14 14 13 

45-54 26 19 27 26 

55-64 22 16 8 7 

65 i więcej 

(65 and more) 

6 4 4 4 

wieś (village) 15 12 20 19 

miasto 200 

thous.) 

59 44 36 34 

student (student) 18 13 34 32 

podstawowe 

(primary) 

0 0 0 0 

zawodowe 

(vocational) 

9 6 3 3 

średnie 

(secondary) 

43 33 28 26 

wyższe (higher) 63 48 41 39 

bardzo niski 

(very low) 

2 1 0 0 

niski (low) 18 13 4 4 

średni (average) 47 36 20 19 

dobry (good) 48 36 54 51 

bardzo dobry 

18 14 28 26 

(very good) 

Source: Authorial based on data from the questionnaire 

Źródło: Opracowanie własne na podstawie danych z przeprowadzonego 

kwestionariusza ankiety

118 


RESEARCH METHOD 

The applied testing method was a diagnostic 

survey. Research technique was interview. The tool 

utilized to conduct the study was the authorial, 

anonymous questionnaire. The study was conducted 

during the period from January to May 2011. 

RESULTS 

Among survey respondents in Poland 60% 

identified their health as good or very good, and only 4 

people as bad and very bad. The population in the 

Netherlands also determined their health as excellent, 

good or average (97%) the most frequently. 

Another survey question concerned the usage of 

health services. The results show that Poles usually 

receive provisions from both public and private 

practice (78%). Only a small part of them use only a 

private health care (2%), whereas 20% use health care 

financed by the NFZ. In the Netherlands, the vast 

majority of people use only the compulsory insurance 

package (91%) and only 9% of the surveyed 

respondents have an additional, optional health 

insurance. 

Among all respondents, there are large differences 

between the Poles and the Dutch in the frequency of 

medical visits and hospitalizations. As many as 28% of 

Polish respondents and only 13% of the Dutch were 

hospitalized last year . Similar trends apply to the 

number of medical visits. Only 1% of Poles had a 

doctor’s appointment within the past three years , 37% 

of them visited a doctor from 1-3 times, 26% 4-6 

times, and remaining - above 6 times. More than 87% 

of respondents from the Netherlands reported 

frequency of physician visits in the range of 1-6 times, 

and only 8% more than 6 times. 

The results of a detailed assessment of the 

availability of specific services, patient rights, quality 

and cost of care, as well as problems associated with 

obtaining medical assistance are presented in Charts 1 

to 6. 

In one of the questions of the questionnaire, 

respondents were asked to assess whether they faced 

any problems in obtaining medical provisions. As it 

turned out, this problem affects mainly people using 

health services under the compulsory insurance in 

Poland (30%). The most common problems, the 

respondents indicated were long waiting times for 

medical consultation and the necessary tests, especially 

at the end of the year; difficulties in using the 

rehabilitation, the inability to continue treatment with 

the same specialist at the next year due to the absence 

of a contract with the NFZ, the problems associated 

with acceptance at the emergency room when 

appropriate. Definitely fewer people (10%) 

experienced various problems in the private services 

than the population of Dutch respondents (5%). Most 

emerging problem was too long waiting times for a 

specialist appointment and a long waiting time for 

antitumor therapy and to perform certain tests. 

Figure 1. The percentage of patients who reported that it is 

easy to get GP, specialist and dentist medical 

provision 

Wykres 1. Procentowy wskaźnik liczby pacjentów, którzy 

stwierdzili, że łatwo jest uzyskać poradę u lekarzy: 

rodzinnego, specjalisty i stomatologa 

Figure 2. Assessment of the ease of obtaining home nursing 

assistance 

Wykres 2. Ocena łatwości uzyskania domowej pomocy 

pielęgniarskiej 

Figure 3. Assessment whether the patient was treated with 

care and kindness by the staff of medical 

institutions 

Wykres 3. Określenie przez pacjenta czy był traktowany 

z troską i życzliwością przez personel placówek 

medycznych

The functioning of health systems in Poland and the Netherlands in patients' opinions 119 

DISCUSSION 

Figure 4. Percentage ratio of the number of patients who 

reported that all patients are treated equally, that 

service quality is high and that patients' rights are 

respected 

Wykres 4. Procentowy wskaźnik liczby pacjentów, którzy 

stwierdzili, że wszyscy pacjenci są traktowani 

równo, że jakość usług jest wysoka i, że prawa 

pacjenta są respektowane 

Polish respondents had also negative feedback as to 

the amount of contributions for mandatory health 

insurance and high prices for private services. Half of 

respondents think that the insurance premium is too 

high, 14% - adequate, 10% - too low, and 26% have no 

opinion. The charges for private services were assumed 

as too high by as much as 74% of respondents, by 18% 

as appropriate, and the rest had no opinion. Most of the 

study population from the Netherlands (78%) believes 

that the price of the primary insurance is adequate, 

only 5% of people think that it is too low or too high, 

while others have no opinion. The Dutch have a similar 

opinion on additional packages. Nearly 69% of them 

think that the price of packages is appropriate and 12% 

believe that is too high. 

Figure 5. Determining whether the patient is satisfied with 

medical care 

Wykres 5. Określenie przez pacjenta czy jest zadowolony z 

opieki medycznej 

Figure 6. Evaluation of the health care system by patients 

Wykres 6. Ocena funkcjonowania systemu opieki zdrowotnej 

przez pacjentów 

The study showed large disparities in terms of 

access to medical services between the Polish health 

system and the Dutchone. Problems with specialist 

care in Poland have existed for a long time and still 

remains. This is confirmed by results of the studies 

conducted in 2001 in Lublin on the availability of 

medical services [11]. Another study published in 2007 

also indicates a lack of equality in access to medical 

services in Poland. As many as 35% of the survey 

respondents confirmed the existence of inequalities 

[12]. 

These trends also confirm the results of studies 

conducted in Europe and worldwide. Examination of 

the 2003 - World Health Survey – indicates that almost 

78% of patients were satisfied using the Dutch health 

care [13]. Precise analysis of the European health 

systems in the Euro Health Consumer Index 2009 also 

confirms the results of our audit. In this study, the 

Netherlands was ranked first, while the Polish health 

care system has been evaluated and found significantly 

worse on 26 position compared with 33 systems [14]. 

CONCLUSIONS 

The results of the study on the functioning of health 

systems in Poland and the Netherlands in the opinion 

of patients, allow us to draw the following conclusions: 

1. There is a need to further improvement and 

reform of the health care system in Poland, so as 

to suit the changing market for health services. 

2. Both Poland and the Netherlands should look for 

new solutions in order to facilitate the availability 

and shortening the waiting time for a GP and 

specialists. 

3. Due to the difficulties of access and the lack of 

knowledge about the provisions of nursing home 

care in Poland, this form of patient care is still not 

sufficiently widespread in Poland. The emphasis 

on the gradual development would allow savings 

in the system. 

4. Large differences in access to medical services, 

treatment of the patient between state and private 

medical care in Poland reflect the lack of a 

coherent system. 

5. Competitiveness in the market of medical 

services promotes improving the quality of 

services, ensuring a high standard of treatment

120 


and empathic and individual approach to each 

patient in his view. 

6. Rational management and optimization in 

spending public funds on health care is a right 

direction in health economics. 

7. The study indicated the need for further 

development of the health care system in Poland, 

taking into account additional sources of funding 

and the principles of efficiency and optimization 

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1. Poździoch S., System zdrowotny [w:] Zdrowie publiczne. 

Wybrane zagadnienia. Tom I, pod red. Czupryna A., 

Poździoch S. i inni, Vesalius, Kraków 2000, s. 127. 

2. Por. art. 68., ust. 1. i ust. 2. Konstytucji RP z 2 kwietnia 

1997 r. (DzU nr 78, poz. 483). 

3. Por. art. 15, ust. 2 Ustawy o świadczeniach opieki 

zdrowotnej finansowanych ze środków publicznych z 27 

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database (HFA-DB) 2011, World Health Organization, 

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dostęp 13.05.2011). 

11. Kalinowski P., Jędrzejewska B.: Dostępność usług 

medycznych po reformie służby zdrowia w Polsce: 

opinie pacjentów, Zdr Publ 2004, 114 (1), s. 8-11. 

12. Gruszczak A., Dudzińska M., Piątkowski W. i inni: The 

accessibility to medical services in patients’ opinions, 

Zdr Publ 2007, 117 (4), s. 440-443. 

13. Bleich S.N., Özaltin E., Murray C.J.L.: How does 

satisfaction with the health-care system relate to patient 

experience?, Bull World Health Organ 2009, 87, s. 271- 

278. 

14. Bjornberg A., Cebolla Garrofe B., Lindblad S.: Euro 

Health Consumer Index 2009, Health Consumer 

Powerhouse 2009. 


Dorota Siwczyńska 

ul. Akacjowa 7/27 

21-040 Świdnik 

+48 605 833 715 

e-mail: d.siwczynska@gmail.com 

Received: 10.01.2012 



Błażej Stankiewicz, Mirosława Cieślicka 

DETAILED ANALYSIS OF A 240-SECOND CYCLE ERGOMETRIC TEST 

IN MIDDLE-DISTANCE RUNNERS AGED 16-19 

SZCZEGÓŁOWA ANALIZA 240-SEKUNDOWEJ PRÓBY CYKLOERGOMETRYCZNEJ 

PRZEPROWADZONEJ WŚRÓD BIEGACZY NA ŚREDNICH DYSTANSACH W WIEKU 16-19 LAT 

Faculty of Physical Education, Kazimierz Wielki University, Bydgoszcz 

Head: dr. hab. Mariusz Zasada 

Summary 

I n t r o d u c t i o n . Middle-distance runs are endurance 

events that include the distances from 600 m up to 1609 m. 

The objective of the research is to determine work 

capabilities in acid and lactic conditions, measured by means 

of a 240-second test in young junior (16-17 years of age) and 

junior (18-19 years of age) runners at middle distances and to 

compare maximum lactate concentrations and maximum 

heart rate after 60-second and 240-second tests of the 

subjects. 

M e t h o d s . The research included 20 competitors aged 

16-17 and 12 competitors aged 18-19. During the test period 

all subjects were training in the Kujawsko-Pomorskie 

province sport clubs. In order to determine work capabilities 

in acid-lactic conditions, a 240-second cycle ergometric 

laboratory test was applied. The obtained results were 

worked out using basic descriptive statistics: arithmetic 

average (M), standard deviation (± δ), minimum (min) and 

maximum values and coefficient of variation (V%). 

R e s u l t s . The results obtained made it possible to 

characterize the subjects in terms of work capabilities at a 

high level of lactic acid in blood during middle-long effort. 

An in-depth investigation of the collected material might 

prove useful when planning training loads for work on 

special stamina. 

C o n c l u s i o n s . A set of criteria presented in the 

paper, detailing work and power obtained during a 240- 

second cycle ergometer might be used by trainers in a sport 

training process to assess individual function predisposition. 

Streszczenie 

Wstę p. Biegi średnie to konkurencje wytrzymałościowe, 

wśród których wymienić możemy dystanse od 

600 m do 1609 m. Celem pracy jest określenie zdolności do 

pracy w warunkach kwaso-mleczanowych, mierzonych 

testem 240-sekundowym u biegaczy na średnich dystansach 

w kategorii juniora młodszego (16-17 lat) i juniora (18-19 

lat). Porównanie maksymalnych stężeń mleczanu oraz 

maksy-malnej ilości skurczów serca po próbie 60 sek. i 240 

sek. u badanych zawodników. 

Materiał i m e t o d y . W badaniach wzięło udział 

20. zawodników w wieku 16-17 lat oraz 12. biegaczy w 

wieku 18-19 lat. W trakcie testów wszyscy zrzeszeni byli w 

klubach województwa kujawsko-pomorskiego. Do określenia 

zdolności pracy w warunkach kwaso-mleczanowych 

zastosowano próbę laboratoryjną: test cykloergometryczny - 

240s. Uzyskane wyniki opracowano za pomocą 

podstawowej statystyki opisowej: średniej arytmetycznej 

(M), odchylenia standardowego (± δ), wartości minimalnej 

(min) i maksymalnej (max) oraz współczynnika zmienności 

(V%). 

W y n i k i . Uzyskane wyniki pozwoliły scharakteryzować 

badanych w zakresie możliwości pracy w warunkach 

wysokiego poziomu kwasu mlekowego we krwi przy średnio 

długim wysiłku. Głęboka analiza zebranego materiału może 

być pomocna w planowaniu obciążeń treningowych 

w zakresie pracy nad wytrzymałością specjalną. 

W n i o s k i . Zaprezentowany w pracy zestaw kryteriów 

opisujących pracę i moc uzyskaną podczas 240-sekundowego 

testu cykloergometrycznego, może być wykorzystany przez 

szkoleniowców w praktyce szkolenia sportowego do oceny 

indywidualnych predyspozycji wydolnościowych. Uzyskane 

wyniki pozwoliły scharakteryzować badanych w zakresie 

możliwości pracy w warunkach kwaso-mlekowych. Pomoże 

to w planowaniu obciążeń treningowych właśnie w tym 

zakresie. 

Key words: training, exercise stress tests, middle-distance running 

Słowa kluczowe: trening, próby wysiłkowe, biegi średnie

122 


INTRODUCTION 

Middle-distance runs are endurance events that 

include the distances from 600 m up to 1609 m. 

Determining the share of individual systems providing 

energy during middle-distance running is of crucial 

importance when planning a training process. It is a 

well-known fact that the sole direct source of energy 

for muscle activity is ATP (adenosine triphosphate) 

that undergoes hydrolysis in a reaction catalyzed by 

myosinic ATP. Yet, its reserve is sufficient only for a 

few seconds work. On that account, a competitor’s 

body must provide energy in resynthesis. From a 

physiological viewpoint, there are five methods of 

reconstructing ATP [1]. In short efforts lasting up to 12 

seconds maximum phosphagen emerges (ATP and 

phosphocreatine), and the longer the effort, the greater 

the significance of glycogen and free fatty acids [2]. 

The efforts above the lactic threshold (LT), i.e. middle 

distance runs, cause an increase in lactic acid (LA) in 

blood up to over 20 mmol/l, and for that reason the 

main substrate in the ATP resynthesis process becomes 

glycogen [3]. Middle distance running, where the share 

of individual motor capabilities (stamina, strength, 

speed) is evenly distributed, can be divided into two 

subgroups, i.e. distances up to 1000 m and above. In 

the first group, anaerobic processes comprise, 

according to different sources, from 31% to 50% of all 

processes and in runs at the distances 1000-1609 m, 

where the share of anaerobic processes drops to 17- 

35%, and the remaining part are aerobic processes 

[4,5]. Factors conditioning good results in middledistance 

runs are: physical fitness, resistance of 

muscle-tendom and skeleton systems to high loads 

during trainings and competitions, resistance to fatigue 

during efforts taking place in different environmental 

conditions, low reactivity to stress caused by training 

and starting stimuli [6,7,8,9]. 

The objective of the research is to determine work 

capabilities in acid and lactic conditions, measured by 

means of a 240-second test in young junior (16-17 

years of age) and junior (18-19 years of age) runners at 

middle distances and to compare maximum lactate 

concentrations and maximum heart rate after 60- 

second and 240-second tests of the subjects. 

The research material collected during exercises 

stress tests, observations and measurements taken 

before, during and after the test, makes the following 

questions emerge: 

1. Will a higher level of lactic acid occur in 

sportsmen subjected to a 60-second test 

corresponding to the effort on the borderline of 

maximum and submaximum phases, or will it 

occur during a 240-second test that all authors 

seem to be in a submaximum phase because of its 

duration? [10,11]? 

2. In which of the two tests will a greater mean and 

maximum heart rate occur? 

3. Do the results obtained in a 240-second test allow 

determining the level of exercise test skills of 

individual subjects and do these outcomes 

correlate with the results achieved at sport 

competitions? 

The review of national and foreign literature, 

experience gained during numerous tests and research, 

along with trainers’ and competitors’ opinions allow 

conducting cycle ergometric tests with submaximum 

intensity among middle-distance runners aged 16-17 

(young juniors) and 18-19 (juniors) years of age. 

RESEARCH MATERIAL AND METHOD 

The research included 20 competitors aged 16-17 

and 12 competitors aged 18-19. During the test period 

all subjects were training in the Kujawsko-Pomorskie 

province sport clubs. Training seniority among the 

competitors did not exceed 2 years in 11 cases, and the 

remaining ones had 3-5 year seniority. In this group 2 

competitors did not have any sport class, 7 competitors 

were Class IV, 7 were Class III, and 4 young juniors 

were Class II. 

In order to determine work capabilities in acidlactic 

conditions, a 240-second cycle ergometric 

laboratory test was applied. A ‘Monark 834 E’ cycle 

ergometer was used in the test. For research purposes, 

the ergometer was equipped with sensors connected to 

a PC application. The MCE 5.1 is an application for 

measuring and analysing physical effort on ergometers 

developed by ‘JBA’ Zb. Staniak. The tests consisted in 

each subject carrying out a test with the load selected 

individually and comprising 7.5% of the subject’s body 

mass. The subjects were weighted directly prior to the 

test using a ‘Tanita’ BF-556 balance scales. The level 

of lactic acid was measured directly before the test and 

approximately 2-3 minutes after the test. ‘Accusport’ 

type 1488767 and “Roche” BM-Lactate strips were 

utilized in the test. Additionally, a competitor’s heart 

rate was measured prior to and after the test by means 

of a Polar heart rate analyzer, models S610i and S810i.

Detailed analysis of a 240-second cycle ergometric test in middle-distance runners aged 16-19 123 

Each test was carried out from a halt in a 

start position just by the first sensor. All 

subjects received instructions and were 

motivated to carry out the tests at their 

maximum capabilities. The remaining 

participants cheered on the subject under 

test in order to create conditions as close 

as possible to that of a real-life 

competition. All competitors took part in 

tests with at least a 2-day break in 

higher-intensity trainings, therefore they 

were relaxed and after a light meal 

around 2 hours before the test. The 

obtained results were worked out using 

basic descriptive statistics: arithmetic average (M), 

standard deviation (± δ), minimum (min) and 

maximum values and coefficient of variation (V%). 

ANALYSIS OF TEST RESULTS 

It is owing to the research [12,13,14] and trainers’ 

and competitors’ experience that the concentration of 

lactic acid in blood after middle-distance running is 

known to exceed threshold value several times. In 

relation with the above, it is indispensable to control a 

training process in such a manner so that their 

constituents would prepare competitor’s body to work 

under acidosis. This is undoubtedly one of the factors 

optimizing a training process. It is know that the 

greatest LA concentration in blood occurs after about 

3-4 minutes of submaximum work; this being related 

to a 2-3 minute delay in lactate diffusion outside the 

cell [2]. A 1500m distance run is held in such time 

frames. A 240-second test corresponds to this event in 

Table I. A set of indicators obtained in the tests 

Tabela I. Kompleks wskaźników uzyskanych w trakcie badań 

Indicators 

M ±δ min max V% 

y.jun. junior y.jun. junior y.jun. junior y.jun. junior y. jun. junior 

Body height [cm] 176 178 7 5,6 155 172 186 191 4 3,2 

Body weight [kg] 61,9 70,2 8,1 8,5 39,2 56,6 71,8 87,1 13,1 12,1 

Result in 1000m run [s] 169 158 11,5 6,3 153 150 194 168 6,8 4 

Specific energy [J/kg] 951,1 1002 93,1 154 789 705 1122 1220 9,8 15,4 

Specific power [W/kg] 3,96 4,2 0,4 0,6 3,29 2,94 4,68 5,08 9,9 15,2 

Hr before effort [bpm] 99 92 12,1 21,1 77 62 120 137 12,2 23 

Hr after effort [bpm] 188 185 7,7 8,3 175 174 201 204 4,1 4,5 

LA before effort [mmol/l] 2,9 2,8 0,5 0,3 2,1 2,3 3,9 3,2 17,2 11,4 

LA after effort [mmol/l] 14,2 14,6 2,5 2,9 10,5 11,7 20,9 21 17,6 19,9 

200 

190 

180 

170 

160 

150 

175 

173 

181 

174 

194 

183 

175 

168 168 167 

164 

161 161 

157 

158 

156 

157 156 

157 157 

153 

153 

150 

151 

140 

0 5 10 15 20 25 

182 

165 

terms of duration. This allows obtaining the highest 

possible level of lactic acid, which literature confirms 

[15,3]. For middle-distance runners, a 240-second test 

reflects a competition effort and, as a consequence, it 

illustrates capabilities to work when subjected to 

acidosis. 

Table No. I. shows a set of indicators obtained 

throughout tests, including both somatic build, values 

of a sport result in a 1000m run, basic parameters of 

work and power obtained during a 240-second test, as 

well as basic parameters of physiology of effort 

describing a number of systoles before and after the 

test, and concentration of lactic acid before and after 

the test in both age groups. 

When analysing a somatic build of the runners in 

both age groups, similarity in body height and 

significant divergence in body weight emerged. A 

glimpse at individual sportsmen and minimum and 

maximum values clarifies this situation. A minimum 

value in the younger group is just less than 40 kg, and 

for older competitors it is 60 kg. The situation is 

comparable when 

considering maximum 

value, where the heaviest 

young junior weighed 72 

kg, and his older 

colleague’s body weight 

exceeded 87 kg. 

Significant 

discrepancies can be 

observed in the results of 

a 1000 m run that are 

analysed in Figure 1. 

The arrangement 

above is fully 

understandable and 

supported with greater 

171 

161 

174 

153 

175 

168 

young juniors 

juniors 

Fig. 1. Results of a 1000 m run (seconds) of both groups of runners under 

research 

Ryc. 1. Wyniki biegu na 1000m (sek.) obu badanych grup biegaczy

124 


seniority of juniors and their age. In the older group, 7 

competitors obtained results exceeding 2’40”, and only 

4 of them were in between 160 sec. and 170 sec. This 

is quite different among younger runners, where 5 

competitors obtained results below 160 sec. and 5 of 

them below 170 sec. Yet, over 50% of younger juniors 

obtained the results about 3 minutes. 

The figure below shows work indicators expressed 

in J/kg of body weight, obtained by the subjects during 

a 240-second test. 

1300 

1200 

1100 

1000 

900 

800 

700 

1053 

1013 

1220 

849 

1122 

932 930 

908 

705 

864 

1046 

1160 

999 

983 

856 

828 

102210311022 1046 1022 

In both groups minimal values oscillate around 800 

J/kg – 850 J/kg. A junior no. 4 who falls behind his 

peers but also behind his younger colleagues is an 

exception here. The result of 705 J/kg most probably 

stems from poor commitment of the subject when 

carrying out the test, or from lack of adaptation of 

muscular apparatus to the cycle ergometer test. A mean 

result obtained by juniors is higher by over 50 J/kg, 

1101 

888 

1125 

923 

909 

875 

992 

920 

789 802 1041 

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 

and a maximum result is over 100 J/kg difference in 

favour of older runners. In case of 4 juniors, the 

indicators exceeded 1100 J/kg and only in three cases it 

oscillated around 900 J/kg. About 40% of younger 

competitors oscillated around 1000 J/kg. Only one 

exceeded the limit of 1100 J/kg, and six of them did 

not exceed the limit of 900 J/kg. 

Similar discrepancies are illustrated in Figure 3 that 

shows power indicators per a kilogram of body weight 

obtained during the test. Both indicators correlate 

significantly, hence similar 

disproportions. 

The best achievements in a junior 

group oscillated around 5 W/kg of 

body weight, and four competitors 

young juniors 

juniors 

Fig. 2. Work (J/kg) carried out by the subjects during a 240-second cycle 

ergometric test 

Ryc. 2. Praca (J/kg) wykonana przez badanych biegaczy podczas 240- 

sekundowej próby cykloergometrycznej 

5,5 

5 

4,5 

4 

3,5 

3 

2,5 

4,39 

4,22 

5,08 

3,54 

4,68 

3,91 3,87 

3,78 

2,94 

3,6 

4,36 

4,84 

4,16 

4,1 

3,57 

3,45 

4,59 

4,26 4,29 4,26 4,36 4,26 

3,7 

4,69 

3,85 

3,79 

3,64 

4,13 

3,83 

3,29 3,34 4,34 

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 

young juniors 

Fig. 3. Mean power (W/kg) obtained by tested runners during a 240-second cycle 


Ryc. 3. Moc średnia (W/kg) uzyskana przez badanych biegaczy podczas 240- 

sekundowej próby cykloergometrycznej 

juniors 

obtained mean power over 4.5 W/kg. 

However, in a group of young juniors 

only one competitor (3) worked with 

mean power over 45 W/kg. Again, the 

lowest power in the junior group was 

noted for the competitor (no. 4) who 

was the only one who did not exceed 3 

W/kg. Three juniors did not attain the 

threshold of 4 W/kg; three obtained 

mean power between 4 W/kg and 4.5 

W/kg of body weight. The most 

numerous (9) group of competitors 

in the younger age group worked 

with mean power between 4 W/kg 

and 4.5W/kg, eight young juniors 

obtained results below 4W/kg, and 

three of them a bit below 3.5 W/kg 

of their body weight. 

In Fig. IV a record of heart rate 

monitor of subjects before the test 

and after its completion can be 

found. 

Mean values in competition in 

both groups are similar and within 

the limits of between 90 and 100 

bpm. In the case of mean maximum 

values it is only a difference of 3 

heart beats. In both age groups maximum values 

exceeded 200 bpm, which is standard bodily reaction at 

this age. Only 6 competitors did not exceed the 

threshold of 180 bpm, four of whom were young 

juniors and two of them were their older colleagues. 

For another 7 competitors a maximum heart rate was 

between 180 bpm and 190 bpm. The most numerous 

group (10) are the runners who exceeded 190 bpm.


210 

200 

190 

180 

170 

160 

150 

140 

130 

120 

110 

100 

90 

80 

70 

60 

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 

High indications before starting the test are also 

interesting, i.e. only three competitors’ heart beat rate 

was below 80, and one of them approached 60 bpm. 

This fact comes as a surprise given that the majority of 

subjects’ training seniority exceeded 2 years, thus 

bradycardia should have already manifested itself in a 

slower resting heart rate. On the other hand, however, 

participation in such a demanding test might have 

caused a stress reaction and a quickened heart rate. 

The Figure below illustrates the level of lactic acid 

before and after a 240-second test on the cycle 

ergometer. 

The concentration of lactic acid in almost all 

subjects before the test oscillated around 2-3 mmol/l, 

which is a relatively high value, yet commonplace in 

everyday trainer practice recorded at this time of the 

day and in these age groups. Maximum values are 

noteworthy, as their mean was 14.2 mmol/l in a 

younger group and 14.6 mmol/l in the junior group. 

young juniors 

juniors 

young juniors 

Fig. 4. Heart rate before and after a 240-second cycle ergometric test in the 

subjects 

Ryc. 4. Liczba skurczów serca przed i po 240-sekundowej, 

cykloergometrycznej próbie wśród badanych zawodników 

21 

19 

17 

15 

13 

11 

9 

7 

5 

3 

1 

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 

juniors 

young juniors 

juniors 

young juniors 

Fig. 5. Lactic acid level in subjects before and after a 240 second cycle 


Ryc. 5. Poziom kwasu mlekowego u badanych zawodników przed i po 240- 

sekundowej próbie cykloergometrycznej 

juniors 

Subjects in both groups were 

characterized by significant 

discrepancies between the lowest and the 

highest exercise-induced concentration. 

In both cases the difference was 

approximately 10 mmol/l. Two results of 

21 mmol/l were recorded, being very 

high and corresponding to the research 

of Hollmann and Hettinger [15] that 

furnishes these values for a 1500 m run. 

In the majority of competitors an 

acidosis was observed with 13-17 

mmol/l. 

A correlation analysis was also 

carried out between individual 

parameters obtained in the test, the 

results of which are provided in Table II 

and III. 

When analysing Table II, a 

correlation between the work performed 

and power yielded emerges, yet this is 

self-evident. Aside from that, the 

strongest correlating factors are work 

and power altogether with the level of 

lactic acid after the exercise and, to a 

lesser degree, work with heart beats per 

minute after the exercise. The absence of 

correlation of such factors as heart rate 

after the exercise and the level of lactic 

acid after the exercise or a fairly poor 

correlation between work performed and 

power obtained in terms of a competition 

result in a 1000 m run is surprising. 

In the Table below a similar summary for the junior 

group has been provided. 

In the junior group more significant correlations 

between a greater number of indicators emerged. The 

highest correlation is certainly observed between work 

performed and power output in the test. Yet, in this 

group, unlike in the group of younger competitors, a 

significant relation between of work performed and 

power obtained to the result of a 1000 m run emerges, 

which is highly significant in terms of confirming the 

rightness of cycle ergometric tests in runners. 

Different correlations in both age groups are most 

probably caused by a greater spread of results in the 

younger group and a reverse phenomenon in juniors, 

which also provides a hint as to the organisation of 

tests in relation to the level the runners present.

126 


Table II. Correlation analysis of selected indicators in the 

young junior group 

Tabela II. Analiza korelacyjna wybranych wskaźników w 

grupie juniorów młodszych 

. 

Specific 

energy 

Specific 

power 

Specific 

energy 

Specific 

power 

1000m 

Hr 

before 

Hr after 

LA 

before 

LA after 

1 -0.14 0.07 -0.26 -0.04 0.36 

-0.14 0.07 -0.26 -0.04 0.36 

1000m -0.12 0.22 -0.09 -0.003 

Hr before 0.3 0.05 -0.19 

Hr after -0.13 -0.06 

LA before 0.1 

LA after 

Table III. Correlation analysis of selected indicators in the 

junior group 

Tabela III. Analiza korelacyjna wybranych wskaźników w 

grupie juniorów 

Specific 

energy 

Specific 

power 

Specific 

energy 

Specific 

power 

1000m 

Hr 

before 

Hr after 

LA 

before 

LA after 

1 -0.58 -0.46 -0.46 0.2 0.45 

-0.58 -0.46 -0.46 0.21 0.46 

1000m 0.41 0.48 -0.46 -0.53 

Hr before 0.86 0.26 -0.2 

Hr after 0.01 -0.2 

LA 

before 

LA after 

0.32 

Table IV. Maximum heart beats and maximum lactic acid 

concentration in blood in subjects during a 60- 

second test 

Tabela IV. Maksymalna liczba skurczów serca i maksymalne 

stężenie kwasu mlekowego we krwi wśród 

badanych zawodników podczas próby 60- 

sekundowej 

Indicators 

60 s 

M ±δ min max V% 

240 

s 

60 s 240 

s 

60 s 240 

s 

60 s 240 

s 

60 s 240 

s 

Hr after exercise [bpm] 182 188 9.4 7.7 167 175 197 201 0.05 4.1 

DISCUSSION 

The research conducted proved fruitful as valuable 

material was gathered that can be further utilized in 

more effective training management of middle-distance 

runners. The obtained results allow confirming the 

rightness of organizing tests among middle-distance 

young junior and junior runners. 

A 240-second cycle ergometric test is rarely 

applied, even though it is well-adjusted to work 

conditions at middle-distance running. It is particularly 

suitable for a 1500 m run, where an increase in lactic 

acid in blood over 20mmol/l is often observed after the 

exercise. Based on a 240-second test, competitors’ 

capability to high-intensity effort and extended 

duration were determined [16]. The data on the results 

of the tests with such duration are beyond the reach. 

An exception is an unpublished doctoral dissertation of 

Grzywocz (1998) who carried out similar research in a 

group of female competitors specializing in 400 m runs 

and 400 m hurdle runs. Yet, the results of the 

abovementioned are not feasible to be compared with 

those of middle-distance runners. In the paper by 

Prusik and Mroczyński [17] who investigated middledistance 

runners, numeric values obtained in a 240- 

second test are not provided. 

It is worthwhile to examine earlier studies carried 

out in the same group of young juniors. Example 

results can be found in Table IV. 

The parameters above are lower than those of 

young juniors in a 240-second test. Mean heart rate 

throughout a 4-minute test was 188 bpm, and mean 

lactic acid concentration reached 14.2 mmol/l. This 

unequivocally proves that a higher acidosis level and 

higher heart rate were characteristic of competitors 

after a submaximum-type test, which validates the data 

in literature [2], and own hypothesis. The results 

obtained differ from those Hollman and Hettinger 

came up with in 1980 that mention the highest increase 

of lactic acid levels after a 400 m run, yet it should not 

be neglected that their research was conducted among 

master class competitors. On the other hand, however, 

the results obtained in own research, as well as 

awareness that each competitor is an individual and 

their reactions to a wide array of exercises vary, 

welcome future research and tests that would further 

unravel a sportsman’s organism with an ultimate goal 

to optimize a training process. 

LA after exercise [mmol/l] 12.2 14.2 2.3 2.5 7.2 10.5 17.8 20.9 19 17.6


CONCLUSIONS 

Upon analysing the results of own study, and 

bearing in mind the questions posed, the following 

conclusions emerge: 

1. A set of criteria presented in the paper, 

detailing work and power obtained during a 

240-second cycle ergometer might be used by 

trainers in a sport training process to assess 

individual function predisposition. 

2. The essential criteria for assessing 

competitors’ effort capability proved to be the 

work performed during the test, expressed in 

joule per kilogram of body weight and mean 

power expressed per one kilogram of body 

weight. 

3. The results obtained allowed to characterize 

the subjects in terms of work capabilities in 

acid and lactic conditions. This will help 

when planning training loads in this particular 

scope. 

4. Ability to exercise under acid and lactic 

conditions is not the sole indicator of middledistance 

runners’ preparedness. Aerobic and 

anaerobic functions need to be considered as 

well. 

5. The results obtained in a 240-second cycle 

ergometric test cannot be taken as a forecast 

of results in running events; they might 

nonetheless point at those individuals who are 

best accommodated to exercises when 

subjected to acidosis. 

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AWF, 1986, 500. 

8. Naglak Z.:Metodyka trenowania sportowca. AWF 

Wrocław, 1991, 205. 

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Gdańsk, 1995, 311. 

10. Bompa T.: Teoria i metodyka treningu. RCMSKFiS 

Warszawa, 1990, 260. 

11. Sozański H., Zaporożanow W. A.: Kierowanie jako 

czynnik optymalizacji treningu. Biblioteka Trenera. 

RCMSzKFiS, Warszawa, 1993, 120. 

12. Janssen P.: Training lactate-plus rate. Polar Electro Oy, 

Helsinki, 1993, 173. 

13. Wołkow N.: Bioenergetyczne podstawy i oceny 

wytrzymałości. Sport Wyczynowy, 1989, 7-8, 7-18. 

14. Miszczenko W. (red.): Mechanizmy rozwijania 

wynosliwosti. KGHIFK, Kijów, 1993, 62. 

15. Hollmann W., Hetinger T.: Sportmedizin Arbeite und 

Trainingsgrundlagen. Stuttgart- New York, 1980, 773. 

16. Prusik K., Ratkowski W.: Kierowanie procesem 

treningowym na podstawie indywidualnej adaptacji do 

wysiłku fizycznego. Trening, 1998, 2-3, 239-255. 

17. Prusik K., Mroczyński Z.: Indywidualizacja procesu 

treningowego biegaczy na średnim dystansie. Rocznik 

naukowy, AWF Gdańsk, IX, 2000, 257-289 


Modrzewiowa 2/49 

Bydgoszcz 85-631 

e-mail: cudaki@op.pl, blazej1975@interia.pl 

Received: 10.01.2012 



Ewa Joanna Szymelfejnik, Anna Chiba 

THE INTERDEPENDENCE OF NUTRITIONAL STATUS AND BLOOD PRESSURE 

IN FEMALE STUDENTS 

WSPÓŁZALEŻNOŚĆ MIĘDZY STANEM ODŻYWIENIA A CIŚNIENIEM TĘTNICZYM 

U STUDENTEK 

Department of Nutrition and Dietetics of the Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University of Toruń 

Head: prof. dr hab. Roman Cichon 

Summary 

Introduction: The value of blood pressure is 

affected by a number of factors, nutritional status being of 

utmost importance. 

T h e a i m o f t h e s t u d y was an assessment of the 

interdependence between the nutritional status and systolic 

blood pressure (SBP) as well as diastolic blood pressure 

(DBP) in female students. 

Material and method: The research included 66 

women aged 20.5±0.71, studying in Bydgoszcz. The systolic 

and diastolic blood pressure was measured. The nutritional 

status of the students was estimated with the use of 

anthropometric parameters. To assess the status, nutritional 

indexes such as the BMI and %FM were applied. 

R e s u l t s : The mean systolic and diastolic pressure of 

the female students was optimal. Hypertension was identified 

only in 1.5% of the students and high normal blood pressure - 

in 12% of the students. The mean nutritional status of female 

students was adequate (BMI=20.3±2.75 kg/m 2 ). However, 

low body mass was found in every 5th person and 

undernutrition in every 3rd person. The percentage of body 

fat was high (31.1±2.75%), and obesity was identified in 

about 60% of the students. A significant correlation was 

observed between systolic pressure and body mass (r=0.4 

p

130 


z nadmierną ilością tłuszczu odnotowano istotnie wyższe 

ciśnienie skurczowe (121 vs 111 mmHg p

The interdependence of nutritional status and blood pressure in female students 131 

limit was observed and hypertension was found (Tab. 

II). 

Tabela.I. Średnia wartość ciśnienia tętniczego skurczowego 

(SBP), rozkurczowego (DBP) i tętna studentek 

Table.I. Average value of systolic blood pressure (SBP), 

diastolic blood pressure (DBP) and pulse in female 

students 

Parametr/ parameter x± SD Me Min Max 

SBP [mm Hg] 117.2±9.8 117.5 92.0 137.0 

DBP [mm Hg] 75.4±7.7 75.0 57.0 90.0 

Tętno [uderzeń/min] 

/ Heart rate 

74.9±11.1 72.0 57.0 120.0 

[beats/minute] 

x – średnia, SD - odchylenie standardowe, Me – mediana, Min – 

minimum, Max – maximum 

x – mean, SD - standard deviation, Me – median, Min – minimum, 

Max – maximum 

Tabela. II. Klasyfikacja ciśnienia tętniczego wśród studentek 

Table. II. Classification of blood pressure in female students 

Kategoria / Category N=66 %N 

Optymalne / Optimal 39 59.1 

SBP Normalne / Normal 21 31.8 

[mm Hg] Wysokie prawidłowe / High normal 6 9.1 

DBP 

[mm Hg] 

Nadciśnienie / Hypertension 0 0 

Optymalne / Optimal 46 69.7 

Normalne / Normal 11 16.7 

Wysokie prawidłowe / High normal 8 12.1 

Nadciśnienie / Hypertension 1 1.5 

SBP – ciśnienie tętnicze skurczowe, DBP – ciśnienie tętnicze 

rozkurczowe, N – liczebność, %N - odsetek populacji, 

SBP - systolic blood pressure, DBP - diastolic blood pressure, N – 

number, %N – percentage of population 

Tabela. III. Średnie wartości parametrów antropometrycznych 

i wskaźników stanu odżywienia 

wśród studentek 

Table. III. The average value of the anthropometric 

parameter measurements and nutritional status 

in female students 

Parametr/ parameter x± SD Min Max 

Wysokość/Weight [cm] 166.5 ± 5.1 152.0 181.0 

Masa ciała/Body mass [kg] 56.6 ± 10.1 42.4 98.0 

A [cm] 24.4 ± 3.0 20.0 30.5 

W [cm] 73.9 ± 6.3 64.0 96.0 

H [cm] 90.8 ± 5.0 82.5 107.5 

TSF [mm] 20.7 ± 7.7 9.7 37.6 

BSF [mm] 15.6 ± 7.7 4.0 35.1 

SCSF [mm] 14.8 ± 5.5 8.2 31.5 

SISF [mm] 20.7 ± 7.5 6.4 36.1 

% FM [%] 31.1 ± 4.6 19.6 40.1 

WHR 0.8 ± 0.1 0.7 1.0 

BMI [BMI kg/m 2 ] 20.3 ± 2.7 17.0 29.9 

AMC [cm] 17.9 ± 2.6 10.7 25.6 

x - średnia; SD - odchylenie standardowe; Min - minimum; Max - 

maximum; A – obwód ramienia, W – obwód talii, H – obwód 

bioder; grubość fałdu skórno-tłuszczowego nad: TSF – tricepsem, 

BSF - bicepsem; SCSF - dolnym kątem łopatki; SISF - grzebieniem 

kości biodrowej; % FM - procentowa zawartość tłuszczu w ciele; 

WHR - wskaźnik talia -biodro; BMI - wskaźnik masy ciała; AMC - 

obwód mięśni ramienia 

x – mean, SD - standard deviation, Me – median, Min – minimum, 

Max – maximum; A - Arm circumference, W - Waist circumference, 

H – Hip circumference,TSF- triceps skinfold thickness, BSF- biceps 

skinfold thickness; SCSF- subscapular skinfold thickness; SISFsuprailiac 

skinfold thickness; % FM - the percentage of fat in the 

body; WHR- Waist to Hip Ratio; BMI- Body Mass Index; AMCarm 

muscle circumference 

The characteristics of the anthropometric 

parameters and indicators of nutritional status were 

shown in the Tab. III. Statistical analysis showed no 

statistically significant differences between blood 

pressure among students with waist circumferences 

132 


showed statistically significant differences in systolic 

pressure values between the students with first degree 

malnutrition and the students with correct weight. The 

average value of systolic pressure in the normal BMI 

students was 120±1.5 mm Hg and was lower by 7 mm 

Hg compared to the students with first degree 

malnutrition (113±2.5 mm Hg) (Tab.IV, p=0.012). 

An analysis of the interdependence between blood 

pressure and body mass showed a positive correlation 

between the systolic pressure and body mass in the 

female students (Fig.1). The analysis showed no 

relationship between the diastolic pressure and body 

mass (Tab.V). A significant correlation was observed 

between the students’ systolic pressure and the BMI 

(r=0.4 p=0.002, Fig. 2). A significant correlation was 

not observed between the diastolic pressure (DBP) and 

the BMI in the student population (Tab.V). No 

correlation was observed between either the systolic or 

diastolic pressure (DBP) and waist circumference or 

hip circumference of the examined population of 

Bydgoszcz female students (Tab.V). 

(r=0.5 p

The interdependence of nutritional status and blood pressure in female students 133 

Statistical analysis showed the existence of 

substantial variations in the distribution of the 

population in terms of systolic pressure depending on 

the percentage of body fat (% FM). Among the 

students with optimal systolic pressure only just over a 

half (53.9%) had a valid amount of fat in the body. The 

others were obese. For all those with normal systolic 

pressure, the presence of obesity was observed in more 

than 70% of the persons (71.4%), and all those with a 

high normal systolic pressure were obese (Tab.VI). 

Statistical analysis did not show the existence of 

substantial variations in the distribution of population 

in terms of diastolic pressure depending on the 

percentage of body fat (% FM). However, there has 

been a trend of increase in the percentage of obese 

people in subsequent diastolic pressure classes (from 

optimum and normal to high normal). In the group 

with normal diastolic pressure, almost ¾ of the 

subpopulation was obese. Among all those with a high 

normal pressure, the percentage of obese people was 

close to 90%. Hypertension was shown in one obese 

student (Tab.VI). 

Tabela. VI. Rozkład studentek w kategoriach ciśnienia w 

zależności od zawartości tłuszczu w ciele 

(%FM) 

Table VI. Distribution of female students in terms of blood 

pressure depending on the percentage of fat in 

the body (%FM) 

Otyłość/brak 

otyłości wg % 

FM 

Obesity/nonobesity 

wg % 

FM 

optymalne/ 

optimal 

Ciśnienie / Blood pressure 

normalne / wysokie nadciśnienie/ 

normal prawidłowe / hypertension 

high normal 

N N% N N% N N% N N% 

Ciśnienie skurczowe / systolic blood pressure 

Brak otyłości / 21 53.9 6 28.6 0 0.0 0 0.0 0.017 

non-obesity 

Otyłość / obesity 18 46.2 15 71.4 6 100.0 0 0.0 

Ciśnienie rozkurczowe / diastolic blood pressure 

Brak otyłości / 23 50.0 3 27.3 1 12.5 0 0.0 0.080 

non-obesity 

Otyłość / obesity 23 50.0 8 72.7 7 87.5 1 100 

N - liczebność populacji; N% - odsetek populacji; p - poziom 

istotności testu chi 2 , brak otyłości - %FM30% 

N – number ; N% - percentage of population; p – significant level of 

chi 2 test, non- obesity - %FM30% 

DISCUSSION 

The mean systolic and diastolic pressure of 

Bydgoszcz female students was optimal (117/75 

mmHg). Recorded values were comparable to those 

observed in the work of Krzych [3,4,5]. Paradowska- 

Stankiewicz and Grzybowski [7] have slightly lower 

average systolic and diastolic pressure values than in 

the test group from Bydgoszcz. However, in Nowicki 

p 

is work [6], among all the students in Bydgoszcz, the 

mean systolic and diastolic pressure values derogated 

both from the results obtained in the test and from 

those of the other authors (138.4 mm Hg and 88.7 mm 

Hg). 

Hypertension was identified only in 1.5% of 

Bydgoszcz students and the result is similar to the one 

recorded by Nowicki [6], whereas the highest 

percentage of students with hypertension was reported 

among the students of School of Medicine (9-10%). 

The results of research among Polish adults 

LIPIDOGRAM [8], WOBASZ [13] and the NATPOL- 

PLUS [15,16] indicated a significant prevalence of 

hypertension (29-42%) and a significant percentage of 

people at risk of its development (11-30%). 

The mean nutritional status of female students 

from Bydgoszcz according to the BMI was adequate 

(BMI=20.3±2.75 kg/m2). However, the analysis of 

distribution in nutritional status classes showed low 

body mass in every 5th person and malnutrition in 

every 3rd person. Despite the malnutrition and low 

body weight, the concern was body composition of 

young women, as the average percentage of fat tissue 

in the body was very high indeed (31.1±2.75%). 

Obesity was identified in about 60% of the students. 

High content of fat in the body of students with a low 

or normal BMI was observed in research [17,18,19], 

and the authors suggest the presence of metabolic 

hazards is similar to the one in obese people. 

The assessment of interdependence between 

blood pressure and nutritional status showed a 

significant relationship between the systolic pressure 

and body mass, the % FM and the BMI. The strongest 

correlation was found between the content of fat in the 

body and the systolic pressure (r=0.5 p

134 


CONCLUSIONS 

1. Disorders in nutritional status were identified in over 

a half of the students. 

2. An interdependence between body mass, body mass 

index, body fat in female students and systolic pressure 

was shown. 

3. A significantly higher blood pressure and more 

frequent occurrences of higher blood pressure 

categories were observed in obese female students. 

REFERENCES 

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Polsce, Buczkowski K., Chudziak K., Czachowski S. , et 

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osób dorosłych z podwyższonymi wartościami ciśnienia 

tętniczego. Arterial Hypertension, 2006a, tom10, nr 6, 

524-531 

4. Krzych Ł., Zejda J.E.: Ciśnienie tętnicze krwi u 

zdrowych, młodych osób dorosłych w obserwacji 12- 

miesięcznej. Pol Przegl Kardiol, 2007, 9,6, 409-416 

5. Krzych Ł., Kowalska M., Zejda J.E.: Czynniki ryzyka i 

częstość nadciśnienia tętniczego u młodych dorosłych 

osób. Nad tętn, 2006b, tom 10, nr 2, 136-141 

6. Nowicki G., Łosiakowska A.: Ryzyko zachorowania na 

nadciśnienie tętnicze u studentów Kujawsko- 

Pomorskiej Szkoły Wyższej w Bydgoszczy w świetle 

badań ilościowych. Rocz Nauk KPSW w Bydgoszczy. 

Nauki o edukacji, 2007, 2, 105-109 

7. Paradowska-Stankiewicz I., Grzybowski A.: Ocena 

stanu odżywienia w grupie młodzieży szkół 

ponadgimnazjalnych i studentów UM w Łodzi. Żyw 

Człow i Met 2007, XXXIV, nr ¾, 933-937 

8. Szczepaniak-Chicheł L., Mastej M., Jóźwiak J., et al.: 

Występowanie nadciśnienia tętniczego w zależności od 

masy ciała w populacji polskiej – badanie 

LIPIDOGRAM 2004. Nad Tętn, 2007, tom 11, nr 3, 

195-204 

9. Poręba R., Gać P., Zawadzki M., et al.: Styl życia i 

czynniki ryzyka chorób układu krążenia wśród 

studentów uczelni Wrocławia. Pol Arch Med Wewn., 

2008, 118, 3, 1-9. 

10. Chrostowska M., Szczęch R.: Nadciśnienie związane z 

otyłością. Kardiol na co dzień, 2007, 3,2,106-112 

11. Czyżewski Ł.: Nadwaga i otyłość jako czynniki 

wystąpienia nadciśnienia tętniczego. Probl Piel, 2008, 

tom16, zeszyt nr 1, 2, 128-135 

12. Małaczyńska-Rajpold K., Woźnicka L., Kuczmarska 

A., et al.: Aktywność fizyczna jako czynnik redukujący 

ryzyko sercowo-naczyniowe w populacji badanej w 

programie Kobiety w czerwieni. Nad Tętn, 2009, tom 

13, nr 1,42-47 

13. Tykarski A., Posadzy Małaczyńska A., Wyrzykowski 

B., et al.: Rozpowszechnienie nadciśnienia tętniczego 

oraz skuteczność jego leczenia u dorosłych 

mieszkańców naszego kraju. Wyniki programu 

WOBASZ. Kardiol Pol, 2005, 63, 6 (supl.4), 614-619 

14. Zdrojewski T.: Nadciśnienie tętnicze w Polsce. 

Terapia, 2002,10,7/8, 4-7 

15. Zdrojewski T.: Rozpowszechnienie głównych 

czynników ryzyka chorób układu sercowonaczyniowego 

w Polsce. Wyniki badania NATPOL 

PLUS. Kardiol Pol, 2004, 61, IV-5-IV-19 

16. Zdrojewski T., Bandosz P., Szpakowski P., et al.: 

Rozpowszechnienie głównych czynników ryzyka 

chorób układu sercowo-naczyniowego w Polsce. 

Wyniki Badania NATPOL PLUS. Kardiol Pol, 2004, 

61,IV-5. 

17. Szczepańska J., Wądołowska l., Słowińska M.A., et al., 

Badanie wpływu częstości spożycia wybranych źródeł 

błonnika na skład ciała studentek. Probl Hig Epidemiol 

2011, 92(1): 103-109. 

18. Conus F, Alisson DB, Rabasa-Lhoret R., et al.. 

Metabolic and behavioral characteristics of 

metabolically obsese but normalweight women. JCEM 

2004, 89(10): 5013-5020. 

19. Conus F, Rabasa-Lhoret R, Peronnet F. Characteristics 

of metabolically obese normal weight (MONW) 

subjects. Appl Physiol Nutr Metab 2007, 32: 4-12. 


dr inż. Ewa Joanna Szymelfejnik 

Katedra i Zakład Żywienia i Dietetyki 

UMK w Toruniu 


ul. Dębowa 3 


tel.: 52 585 54 01 w.45 

e-mail: szymelfejnik@wp.pl 

Received: 10.01.2012 



Magdalena Żbikowska-Gotz, Krzysztof Pałgan, Ewa Socha, Michał Przybyszewski, Andrzej Kuźmiński, 


METABOLIC ACTIVITY OF NEUTROPHILIC GRANULOCYTES MEASURED 

WITH CHEMILUMINESCENCE TEST (CL) 

IN PATIENTS WITH ALLERGIC HYPERSENSITIVITY TO FOOD 

AKTYWNOŚĆ METABOLICZNA GRANULOCYTÓW OBOJĘTNOCHŁONNYCH 

MIERZONA TESTEM CHEMILUMINESCENCJI 

U PACJENTÓW Z NADWRAŻLIWOŚCIĄ ALERGICZNĄ NA POKARMY 

The Chair and Department of Allergology, Clinical Immunology and Internal Diseases, Ludwik Rydygier 

Collegium Medicum in Bydgoszcz, Nicholas Kopernik University in Toruń, 75, Ujejski Street, Bydgoszcz, Poland 

The Head of the Chair and Department: Prof. Z. Bartuzi, M.D., Ph.D. 

Summary 

I n t r o d u c t i o n . Neutrophilic granulocytes 

(neutrophils) are the most important cells of non-specific 

immune response. These cells have capability of chemotaxis 

and phagocytosis and also participate in inflammatory 

processes. Stimulated neutrophils release reactive oxygen 

species (ROS) important mediators of inflammatory process 

responsible for tissues injury. 

T h e a i m o f t h e s t u d y was assessment of 

oxygenic metabolism as one of representatives regarding 

metabolic activity of neutrophilic granulocytes measured 

with chemiluminescence test (CL) in patients with allergic 

type of hypersensitivity to food. 

Material and methods. The study contained 

30 patients with diagnosed food allergy on the base of 

medical history, clinical symptoms, positive prick tests and 

the presence of allergen-specific IgE against selected food 

allergens in the serum. The control group contained 10 

healthy volunteers. Chemiluminescence of basal and 

stimulated during 40 minutes neutrophils (fMLP, PMA, OZ) 

was assessed with kinetic luminol-dependent method using 

luminometer LUMINOSCAN – LABSYSTEM. 

R e s u l t s . Mean values of obtained 

chemiluminescence from basal and stimulated neutrophils 

were statistically significantly higher in patients with allergic 

hypersensitivity to food than values in group of healthy 

persons. 

C o n c l u s i o n s . The results of performed analyses 

indicate that neutrophils participate and have increased 

activity in the process of allergic inflammation in patients 

with food allergy. 

Streszczenie 

Wstę p . Granulocyty obojętnochłonne – neutrofile to 

najważniejsze komórki nieswoistej odpowiedzi immunologicznej 

posiadają zdolności chemotaksji i fagocytozy, biorą 

udział w procesach zapalnych. Pobudzone neutrofile 

wydzielają reaktywne formy tlenu (RFT) ważne mediatory 

procesu zapalnego odpowiedzialne za uszkodzenie tkanek. 

C e l p r a c y . Ocena aktywności metabolicznej 

neutrofilów mierzona testem chemiluminescencji (CL) 

u pacjentów z alergią na pokarmy. 

Materiał i m e t o d y . Badaniem objęto 30 pacjentów 

ze zdiagnozowaną alergią pokarmową na podstawie 

wywiadu, objawów klinicznych, dodatnich testów skórnych 

i obecnością alergenowoswoistych IgE w surowicy krwi 

przeciwko wybranym alergenom pokarmowym. Grupę 

kontrolną stanowiło 10 zdrowych ochotników. Oceniano 

metodą kinetyczną luminolozależną chemiluminescencję 

neutrofili spoczynkowych i stymulowanych (fMLP, PMA, 

Oz) w czasie 40 minut przy pomocy luminometru 

LUMINOSCAN – LABSYSTEM. 

Wyniki. Wartości uzyskanej CL przez spoczynkowe 

i stymulowane neutrofile były istotnie statystycznie wyższe

136 

Magdalena Żbikowska-Gotz et. al. 

u pacjentów z alergiczną nadwrażliwością na pokarmy niż 

wartości w grupie osób zdrowych. 

W n i o s k i . Wyniki przeprowadzonych badań 

potwierdzają udział i zwiększoną aktywność neutrofilów 

w procesie zapalenia alergicznego u badanych pacjentów. 

Key words: food allergy, chemiluminescence, neutrophils 

Słowa kluczowe: alergia pokarmowa, chemiluminescencja, neutrofile 

INTRODUCTION 

Incidence of allergic reactions has significantly 

increased during last several years. This problem also 

concerns allergic hypersensitivity to food both in 

children, young people and adult persons [1, 2]. 

ECAP Studies (Epidemiology of Allergic Diseases 

in Poland) reveal that about 9% children at the age of 

6-7 years and about 4% of adult persons at the age of 

22-44 years present symptoms after consumption of 

sensitizing food [3]. 

Diverse clinical symptoms triggered by 

consumption of sensitizing food can be a result of 

various, already well known immune pathogenic 

mechanisms and can concern various organs and 

systems. Examinations regarding immune system 

function concentrate first of all on evaluation of 

adaptive response indicators in patients with allergic 

type of food hypersensitivity. It is also worth to pay 

attention to participation of innate immunity system 

that not only initiates, but also influences and forms 

further specific response. It is known that complicated 

interactions among various cells constitute the basis of 

allergic inflammatory process. Besides already 

confirmed participation of eosinophilic cells (Eo), also 

neutrophils (Ne) can substantially participate in this 

process that is emphasized more and more often. 

Proinflammatory properties of Ne depend on their 

ability to produce and release many important 

mediators of inflammatory processes. These cells are 

the most important source of reactive oxygen species 

(ROS) in human organism [4, 5]. Membranous and 

intracellular chemical reactions that are held in the cell 

under the influence of various stimulators constitute 

the source of emitted light. The range of oxygenic 

metabolism that constitutes one of components of 

neutrophil metabolic activity can be assessed with 

chemiluminescence test (CL). Increased ROS 

generation can happen in case of increased neutrophils 

activation. This fact results in destructive effect of 

these mediators on tissues when tissue defensive 

mechanisms are unsatisfactorily efficient [6, 7, 8, 9] . 

AIM OF THE STUDY 

The aim of the study was an assessment of 

oxygenic metabolism as one of representatives 

regarding metabolic activity of neutrophilic 

granulocytes measured with chemiluminescence test 

(CL) in patients with allergic type of hypersensitivity 

to food. 

PATIENTS AND METHODS 

Analysed group included 30 adult patients, 18 

women and 12 men (mean age 41± 8.7 years), in 

whom detailed diagnostics was performed to exclude 

other diseases than allergic diseases. 

Food allergy was diagnosed on the basis on medical 

history, physical examination and performed 

laboratory diagnostic and also double-blind placebo 

controlled oral provocative test. Most often bloating, 

abdominal pains, nausea and diarrhoeas occurred in the 

analysed patients. All patients showed incidents of 

acute urticaria in past medical history. Patients with 

exacerbated complaints associated with food allergy 

were qualified for analyses. The following food most 

often caused allergy: peanuts, celery, apple, eggs and 

fish. Allergy concerned more than one allergen in 8 

patients. Patients with increased concentration of 

allergen-specific IgE (sIgE) - class ≥2 (0.70 KU/I) 

were qualified for the analysed group. 

Reference group consisted of 10 healthy volunteers 

5 women and 5 men (mean age 37±6.3) with negative 

atopic past history, without symptoms of infection and 

who did not take any medications. 

The blood for the analyses was taken from ulnar 

vein with use of closed system Vacutainer into testtube 

with lithium heparin with final concentration of 

10 U/ml and also as clot into test-tube that did not 

contain anticoagulants. Additionally, basic parameters 

of the blood cell count were measured in all analysed 

patients. 

(sIgE) measurement was performed with fluoroenzyme-immune 

FEIA method on the UNICAP100 

system using kits of Phadia company. Concentrations

Metabolic activity of neutrophilic granulocytes measured with chemiluminescence test (CL)... 137 

of sIgE antibodies in class ≥2 were regarded as a 

positive result. 

Evaluation of neutrophil oxygenic metabolism was 

performed with chemiluminescence method (CL) 

intensified with luminol (5amino-2.3dihydroftalazyno- 

1.4-dion), Sigma; dissolved in 0.4% NaOH solution up 

to the concentration 28 µmol/ml. Luminol is 

a compound that evolves into arousal state during 

the process of oxidation and this fact allows significant 

increase of light effects. The analyses were performed 

with the use of LUMINOSCAN Ascent system 

(Thermo Labsystems Helsinki, Finland). 

Measurements were performed with kinetic method for 

40 minutes in temperature 37ºC ± 1ºC with CL 

measurement of 2-minutes intervals. Results were 

presented as integration CL values, it means surface 

area under emission curve in time function measured 

for 40 minutes and presented in units RLU (Relative 

Light Units). 

We evaluated not stimulated BS cells and cells 

stimulated with fMLP (formyl-methionyl-leucylphenylalanine) 

2x10¯6 

M, PMA (phorbol myristate 

acetate) 200ng/ml and OZ (opsonized zymosane) 

0.33mg/ml. 

Every analysed sample contained the whole blood, 

stimulator, but in case of measurement of spontaneous 

chemiluminescence without stimulator – luminol and 

was also filled in with PBS for fixed volume. The 

blood was added directly before reading. The readings 

were performed at latest during 2 hours from the 

moment of material collection. Every measurement 

was repeated twice and mean value was calculated. 

Chemiluminescence values were corrected in 

accordance with values of hemoglobin concentration 

and absolute neutrophils number and were expressed as 

RLU according to the formula: 

CL calculated = CL measured x{Hb[%] / (WBC 

[thousands/µL] x PMN [%])} 

Obtained result (RLU) was related to 1000 cells. 

This fact allowed elimination of influence of diverse 

number of neutrophilic granulocytes in the sample, but 

thereby greater optimilization of obtained results. 

The following statistical methods were applied to 

draw up the data: arithmetical mean estimations (x); 

estimations of standard deviation for mean (s). 

Analysis of distribution form concerning analysed 

characteristics was performed with use of Shapiro- 

Wilk test. U Mann-Whitney test was used to analyse 

differences’ significance among groups which 

distribution differed significantly from normal 

distribution (Shapiro-Wilk test p

138 


4,5 

4,0 

p=0,00001 

40 

p=0,0142 

3,5 

35 

BS [RLU total (40 min.)] 

3,0 

2,5 

2,0 

1,5 

1,0 

OZ [RLU total (40 min.)] 

30 

25 

20 

15 

10 

0,5 

0,0 

Grupa badana 

Analysed group 

Grupa kontrolna 

Control group 

Median 

Mediana 

25% 25%-75% - 75% 

Min-Maks - Max 

Fig. 1. Stimulated with BS neutrophils chemi-luminescence in 

analysed groups 

Rys. 1. Chemiluminescencja neutrofilów stymulowanych BS 

w badanych grupach 

5 

0 

Grupa badana 



Control group 

Median 

Mediana 

25% 25%-75% - 75% 


Fig. 4. Stimulated with OZ neutrophils chemiluminescence in 

analysed groups 

Rys. 4. Chemiluminescencja neutrofilów stymulowanych OZ 

w badanych grupach 

4,5 

4,0 

p=0,0277 

DISCUSSION 

fMLP [RLU total (40 min.)] 

3,5 

3,0 

2,5 

2,0 

1,5 

1,0 

0,5 

0,0 

Grupa badana 



Control group 

Median 

Mediana 

25% 25%-75% - 75% 


Fig. 2. Stimulated with fMLP neutrophils chemiluminescence 

in analysed groups 

Rys. 2. Chemiluminescencja neutrofilów stymulowanych 

fMLP w badanych grupach 

PMA [RLU total (40 min.)] 

4,5 

4,0 

3,5 

3,0 

2,5 

2,0 

1,5 

1,0 

0,5 

0,0 

Grupa badana 


p=0,0011 


Control group 

Median 

Mediana 

25% 25%-75% - 75% 


Fig. 3. Stimulated with PMA neutrophils chemiluminescence 

in analysed groups 

Rys. 3. Chemiluminescencja neutrofilów stymulowanych 

PMA w badanych grupach 

Despite intensive studies, pathogenesis of food 

allergy is still not completely explained. More and 

more often analyses undertake the subject regarding 

possibility that neutrophils participate especially in 

allergic reactions to food. Neutrophilic granulocytes 

are the cells of basic significance in fight against 

pathogens. The condition of neutrophils’ efficiency is a 

normal course of their metabolic transformations. 

Process of intracellular damage is associated with 

activation of series of important enzymes and its 

consequence consists among all in production and 

release of active oxygen derivatives. This phenomenon 

is called oxygenic explosion (‘respiratory burst’) [10, 

11]. This reaction is accompanied by light emission – 

chemiluminescence. The number of formed photons 

can be measured with the use of luminometer. 

Neutrophils circulating in the blood are not much 

metabolically active till the moment of contact with 

stimulating factors. Only signals transduced by many 

stimulators regardless of the way of their transmission 

can cause intensification of oxygenic metabolism [12, 

13, 14]. 

Produced oxygenic compounds can disturb 

metabolism of main cells elements, influence nuclear 

transcription factors and stimulate synthesis of 

proinflammatory cytokines. They also can cause 

inactivation of important proteinases inhibitors and 

result significant increase of proteolytic enzymes effect 

on tissues. 

Chemiluminescence in neutrophilic cells can be 

induced via many ways: via chemotactic receptor

Metabolic activity of neutrophilic granulocytes measured with chemiluminescence test (CL)... 139 

(fMLP), via receptor for Fc fragment of antibody and 

complement (OZ), but also via direct activation way of 

PKC (protein kinase C) via specific activator (PMA) 

[11, 15]. 

Assessment of cells ability for chemiluminescence 

was performed by evaluation regarding spontaneous 

basal chemiluminescence as well as after addition of 

stimulating factors. 

We proved in the presented study increased ROS 

production both by basal and stimulated neutrophils of 

peripheral blood in patients with food allergy and 

clinical symptoms from various organs. Obtained CL 

values were significantly higher than values in the 

group of healthy persons. 

Our previous studies in asthmatic patients allergic 

to allergens of house dust mite also proved 

significantly higher ROS production made by 

granulocytes in basal and activated by stimulants 

circumstances [16, 17]. Participation and importance of 

these mediators in inflammatory processes are also 

shown by studies of other authors, performed in the 

group of adults and children [18, 19, 20, 21, 22, 23]. 

It was noted that neutrophils of asthmatic patients 

are characterized by increased ability to generate 

reactive oxygen metabolites that can be associated with 

the phenomenon of pre-reactivation of these cells in 

circumstances in vivo. Triggering neutrophils priming 

can be caused by many inflammatory mediators 

released during allergic reactions. The result of such 

influence can be excessive functional response to 

stimulating factors in comparison with cells that did 

not undergo earlier reactivation [24, 25, 26]. It seems 

that this situation can occur also in described own 

studies. 

Interesting studies were performed by Monteseirini 

et al. who proved that anti IgE class antibodies and 

specific inhalatory antigens conditioning clinical 

symptoms in selected patients with asthma, can be 

responsible for increased oxygenic metabolism of 

granulocytes and its range can be modulated by 

specific immunotherapy [27]. 

Similarly to our studies, excessive ROS production 

by basal Ne and Ne induced by stimulators was noted 

in large group of children with well documented food 

allergy [12]. The same authors in subsequent reports 

also emphasize participation of TLR4 receptors present 

in neutrophilic cells, suggesting involvement of the 

system of innate immunity in mechanisms of allergy 

development. TLR receptors activation constitutes 

signal activating mechanisms of non-specific 

immunity. It causes increased synthesis of antibacterial 

factors and proinflammatory cytokines, dendritic cells 

maturation (increased expression of co-stimulating 

molecules and MHC) that obtain higher ability to 

present antigens and proper activation of acquired 

(specific) immunity as a result. 

Wiktorowicz et al. direct attention to unknown till 

then potential of proteins of lupine seeds for excessive 

induction of oxygenic transformations in human 

neutrophillic cells. Studies performed with use of flow 

cytometry confirm this feature, but the fact that studies 

were performed in healthy persons are significant and 

worth emphasizing, because it is well known that 

lupine seeds are more and more used in human 

nutrition [28]. 

Studies of Wallaert et al. showed that in patients 

with allergic hypersensitivity to food and without 

symptoms of bronchial asthma, neutrophilic infiltration 

occurs in the airways and is associated with increased 

IL-8 concentration. Result of this study can be 

confirmed by the conception that intends similar 

immune response to allergic factor for all mucous 

membranes, though cells and mediators responsible for 

this process still remain unknown [29]. 

To sum up, it can be supposed that reactive 

oxygenic metabolites released from neutrophilic 

granulocytes play an important role in diseases with 

active inflammation caused by allergic stimulation in 

patients with allergic type of hypersensitivity to food. 

Great part of literature is devoted to participation of 

eosinophilic cells in allergic reactions to food, but on 

the base of own studies it is also possible to indicate 

increased activity of neutrophilic granulocytes and 

indirect involvement of non-specific mechanisms of 

organism defence. It is confirmed by analysis of 

indicators of effector functions of peripheral blood 

neutrophils. 

CONCLUSIONS 

1. Basal and stimulated neutrophils in patients with 

food allergy show significantly higher ability to 

generate reactive oxygenic metabolites. 

2. Proved increased neutrophils activity can play 

significant role in inflammatory process caused by 

allergenic stimulation in patient with food allergy, 

indicating indirectly that non-specific mechanisms 

of organism defence participate in these reactions.

140 


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Magdalena Żbikowska-Gotz 

The Chair and Department of Allergology, 

Clinical Immunology and Internal Diseases 

Ludwik Rydygier Collegium Medicum 

in Bydgoszcz 

Nicholas Kopernik University in Toruń 

75, Ujejski Street, Bydgoszcz, Poland 

e-mail: magda.zb@wp.pl 

Received: 10.01.2012 



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