Medical and Biological Sciences XXVI/1 - Collegium Medicum ...

Medical and Biological Sciences, 2012, 26/1, 5-9REVIEW / PRACA POGLĄDOWAMonika Kuczma¹ , ², Katarzyna Matuszak¹, Waldemar Kuczma¹, Wojciech Hagner¹, Barbara Książkiewicz²TREATMENT AND REHABILITATION OF PATIENTS WITH SCOLIOSISAT THE TURN OF THE CENTURYLECZENIE I REHABILITACJA PACJENTÓW ZE SKOLIOZĄ NA PRZEŁOMIE WIEKÓW1 Institute and University Department of RehabilitationNicolaus Copernicus University Collegium Medicum in BydgoszczHead: dr hab. Wojciech Hagner, prof. UMK2 Institute and University Department of NeurologyNicolaus Copernicus University Collegium Medicum in BydgoszczHead: dr hab. Barbara Książkiewicz, prof. UMKSummaryIdiopathic scoliosis is an illness commonly occurring inchildren and teenagers. During its development threedimensionaldeformities can be observed: in frontal plane –primary, lateral curvature, in sagittal plane - deepening orflattening of the natural curvature of the spine and intransversal, horizontal plane - rotation and torsion of thevertebraeScoliosis treatment and rehabilitation have been animportant and complex issue since the ancient times.The early methods, however, were very painful andhardly effective. At the turn of XVI - XVII centuries a fastdevelopment of scoliosis research and the first rehabilitationattempts were observed. In the following the use of corsetsbecame a popular way of treatment. In Poland, scoliosistreatment and patients’ rehabilitation gained new meaning atthe turn of XVII-XIX centuries, when new, fast developingrehabilitation/treatment centers in Krakow, Poznań andWarsaw were opened.StreszczenieSkolioza idiopatyczna jest chorobą dzieci i młodzieży.W trakcie jej rozwoju można obserwować u pacjenta zmianyzachodzące w trzech płaszczyznach. W płaszczyźnieczołowej występuje wyboczenie, w płaszczyźnie strzałkowejpogłębienie lub spłycenie krzywizn fizjologicznych, a wpłaszczyźnie poprzecznej notuje się rotację i torsję kręgów.Leczeniem i rehabilitacją pacjentów ze skoliozą zajmowalisię uczeni już w czasach starożytnych. Początkowo były tometody bardzo bolesne i mało skuteczne. Duży rozwójtechnik leczenia jak i początki rehabilitacji pacjentów zeskoliozą nastąpił na przełomie XVI-XVII w. W kolejnychlatach rozkwitły metody leczenia poprzez gorset. W Polsceduży rozwój technik leczenia i rehabilitacji pacjentów zeskoliozą datuje się na przełom XVIII-XIX w. kiedy topowstały prężne ośrodki rehabiltacyjno-lecznicze wKrakowie, Poznaniu i Warszawie.Key words: scoliosis, treatment, rehabilitationSłowa kluczowe: skolioza, leczenie, rehabilitacja

6Monika Kuczma et. al.INTRODUCTIONIdiopathic scoliosis is a typical, three-dimensionalillness of growing children and teenagers. During itsdevelopment the deformities can be observed in thefrontal plane, lateral or thoracic plane (in most casesdeepened chest kyphosis is also present) and horizontalplane with rotational deformity [1, 2, 3, 4].Another great physician, considered the father oforthopedic surgery in the United States, Lewis AlbertSayre treated scoliosis using a hoist (Picture 1)[6].WORLD HISTORY OF SCOLIOSIS TREATMENTIdiopathic scoliosis has been of interest of thegreatest scientists of our times, among othersHyppocrates or Galen, for a long time.Hippocrates of Kos (460-377 BC), considered thefather of Western medicine, presented a number ofvarious pioneer theories and descriptions, includinglateral curve, in a collection of medical works called:Hippocrates Corpus (‘Corpus Hippocraticum’). One ofthese was noticing the dependence between the level ofspine deformity and the age of the patient when thecurve became visible. However, it was a prominentRoman doctor - Galen (129-199) who introduced theterm ‘scoliosis’ into the world of medicine. In his greatwork ‘Ars Parva’ this scientist of Greek ethnicitypresented a handmade woodcut showing spine tractionand slide. Unfortunately, these early methods ofdeformities treatment were not only extremely crueland painful but also hardly effective [4].Avicenna (Persian physician and philosopher) inhis work entitled ‘Qanun’ completed in 1000 ADdescribed and pictured spine positioning. His treatmentmethods were widely applied until 1700s.The first clinical description of the lateral curveappeared in the sixteenth century works published by aFrench surgeon Ambroise Paré (1510-1590). This greatscientist did not only serve the French kings, treatingthem and describing various diseases, but alsopresented clinical descriptions of idiopathic scoliosisand its treatment using a metal corset [4,5].Francis Glisson (1599-1677), a British scientistand physician, was another doctor treating scoliosisusing innovative methods. In his work ‘Rachitis’Glisson published several theories and methods ofscoliosis treatment, nowadays considered the basis ofhandling with this illness. What is more, he was theinventor of the rehabilitation loop, known as ‘theGlisson’s loop’ which has been widely used inrehabilitation ever since. Its main aim is to stretch themuscles and ligaments along the spine and shoulders.Pic. 1. Spine traction in scoliosis treatmentRyc. 1. Trakcja kręgosłupa w leczeniu skoliozyPic. 2. Posture while learning. Date unknownRyc. 2. Postawa ciała podczas nauki. Data nieznanaNicolas Andry de Bois-Regard, a Frenchphysician and writer, who played a significant role inthe early history of orthopedics, was the inventor ofthe name ‘posture hygiene’, first used in his greatwork ‘Orthopédie’ (the name orthopedics derivedfrom it). In his discourse on biomechanics of scoliosis,Andry pointed out that the muscles changes may bethe etiological factor of the illness. He underlined theimportance of teaching the patients how to maintainthe correct posture habits. His approach was the

Treatment and rehabilitation of patients with scoliosis at the turn of the century 7beginning of postural reeducation, nowadays being thebasis of posture defects treatment (Picture 2) [6].Pic. 3. Prototype of orthesis used in scoliosis correction [7]Ryc. 3. Pierwowzór ortezy do korekcji skoliozy [7]Fast development of idiopathic scoliosisdiagnostics and treatment occurred between 1780 and1880s. The first rehabilitation centers were opened inFlorence, Bologna, Paris, Montpelier, Lozanne andBirmingham using innovative treatment methods aswell as various tools, equipment and corsets for posturecorrection (Pictere 3) [7].It was then, in 1772, that the prototype ofMilwaukee corset was designed in Paris by Lavarcher.A few years later, in 1780 a book entitled‘La gymnastique médicale et chirurgicale’ describingvarious methods of physical exercises for children withspine deformities, applied in surgery and orthopedicswas published by Tissot.In the XIX century a publication of the firstcatalogues with a variety of corsets appeared (Picture4,5) [7].Pic. 5. ‘Corsets for sale’, published by Sears, RoebuckCompany Incorporated in 1800s [7]Ryc. 5. „Gorsety na sprzedaż”, wydane przez Sears, RoebuckCompany Incorporated w latach 1800-tych [7]In 1894 corsets done up with laces were presented.(Picture 6,7) [7].Pic. 6. Corset, 1894, manufactured in Detroit PharmaceuticalCompanyRyc. 6. Gorset, 1894, zmontowany w Detroit PharmacalCompanyPic. 4. Various corsets presented by F.W. Braun and co. in1903 [7]Ryc. 4. Różne modele gorsetów zaprezentowane przez F.W.Braun i spółkę w 1903 [7]Pic. 7. Corsets presented by E.H. Bradford and E.G.Brackett in 1880Ryc. 7. Gorsety przedstawione w 1880 r przez E.H.Bradford and E.G. Brackett

8Monika Kuczma et. al.The flourish of corset production was at the turn ofXVIII and XIX centuries. A true supporter of apassive method of spine correction was Z.B. Adamswho designed the first laced corset (Picture 8) [7].Pic. 8. Corset designed in 1910 by Z. A. Adams as analternative to metal corsets. [7]Ryc. 8. Gorset zaprojektowany przez Z. A. Adamsa w 1910 r.Jako alternatywa dla gorsetów metalowych [7]One of the leading opponents of passive correctionof spine deformities was Shaw, who believed thatexercises were the only effective method of treatment.In his book ‘Curvature of the Spine’ (London, 1825)Shaw described a whole series of exercises correctingspine’s posture as well as hips and ribs’ placement.According to him, these exercises were to showtherapeutic properties, improving the overall posture(spine, ribs and limbs) and had to be followed by aseries of exercises strengthening the muscles of theback.Another French surgeon, Jacque Mathieu Delpechin his book ‘Orthomorphie’ (1829) advocated theimportance of the asymmetric growth of the spine andits influence on the curvature, and promoted using adisc placed between the vertebra as a successfultreatment method. His ideas were the first attempts ofcreating a theory explaining the source of scoliosis. Inhis treatment Delpech supported both passive andactive methods of posture correction, using variousequipment in order to relieve the pressure on spinewhen in horizontal position. He also recommendedswimming as a successful method of treatment and setup a rehabilitation centre for patients with scoliosis.In 1874 Sayre applied plaster cast in horizontalcurve correction. His approach was further developedby Bradford and Brackett, who put the cast on whenthe patient was lying on a special table, using thehorizontal hoist at the same time.Swedish school of scoliosis treatment andrehabilitation, led by Henry Ling (1776-1839)developed concurrently. The source of posturedeformities was searched for in the muscles structuredysfunction, therefore numerous dynamic exercises,aimed at proper symmetry reinforcement, wereintroduced. Even though they did not bring theexpected results, they surely played a significant role inscoliosis treatment, being one of the first of thepreventive measures undertaken to ensure correctposture habits.In 1886 Lorentz realized that in order tosuccessfully treat scoliosis, maximum muscles’strength had to be achieved, whereas regaining properspine line in the frontal layer and Swedish exerciseswere significant only as preventive measures.The beginning of the XX century and the yearsbetween the World Wars were dominated by the use ofvarious equipment in posture deformities’ correction.In 1911 Abbot designed a method of hunchbackcorrection by a de-rotation using a frame. This methodwas further developed by Cortel and then Risser (thefather of the so-called ‘Risser’s frame’) in the post waryears.In 1946 Boston orthesis and Milwaukee-Blountcorsets appeared and were soon popularized.POLISH HISTORYOne of the leading Polish scientists, a personaldoctor of Stefan Batory, Wojciech Oczko (1537-1599)based his theories of scoliosis treatment on Galen’s.In the XIX century a fast development ofrehabilitation centers in Krakow, Poznań and Warsawstarted, with gymnastic and orthopedic wards whererehabilitation of posture deformities was widelypracticed. Henry Ling’s methods found a number offollowers in Poland, among others Helena Kuczalska,who in 1892 set up the therapeutic and gymnasticcenter which developed into therapeutic and gymnasticand massage school 14 years later, training leadingfuture Polish therapists and instructors.

Treatment and rehabilitation of patients with scoliosis at the turn of the century 9Wiktor Dega, a pioneer in Polish orthopedics andrehabilitation of children was the first person toorganize therapeutic and gymnastic classes for pupilsin 1930. Seven years later the first department oftherapeutic rehabilitation was opened in Bydgoszcz[8].During 1990s further development of nationalrehabilitation centers treating posture deformities tookplace (e.g. ‘Konstancin’ managed by professor MarianWeiss [4].BIBLIOGRAPHYAddress for correspondence:mgr Monika KuczmaInstitute and University Department of RehabilitationNicolaus Copernicus University Collegium Medicumin Bydgoszczul. M. Curie Skłodowskiej 9,85-094 Bydgoszcztel. (52) 585-43-30, tel./fax (52) 585-40-42e-mail: monika_kuczma@tlen.plReceived: 18.05.2011Accepted for publication: 13.02.20121. Kasperczyk T.: Wady postawy ciała, leczenie idiagnostyka. Kraków 2001: 50-51.2. Nowakowski A., Łabaziewicz L.: Skoliozaidiopatyczna – epidemiologia i etiologia. ChirNarzadow Ruchu Ortop Pol 1998; 63(4): 317-320.3. Kwolek A.: Rehabilitacja medyczna, tom2. Wrocław2003: 250-256.4. Wilczyński J. Korekcja wad postawy człowieka.Starachowice 2001: 196-225.5. Milanowska K., Dega W.: Rehabilitacja medyczna.Warszawa 1999: 228-272.6. The Pediatric Spine: Principles and Practice New York1994: 556-557.Farrell-Beck J.: Medical andCommercial Supports for Scoliotic Patients;8. 1819-1935. Studies in Anatomy and Technology; 199511(3): 142-163.9. Dega W., Marciniak W.: Wiktora Degi ortopedia irehabilitacja, tom 2. Warszawa 2004: 66-68.

Medical and Biological Sciences, 2012, 26/1, 11-17ORIGINAL ARTICLE / PRACA ORYGINALNAMałgorzata Dabkowska¹, Tadeusz Pracki², Daria Pracka²THE OBJECTIVE MEASUREMENT OF MOVEMENTVS THE INTENSIFICATION OF ADHD SYMPTOMSIN ASSESSMENT OF PARENTS AND DOCTORSOBIEKTYWNY POMIAR RUCHU A NASILENIE OBJAWÓW ADHDW OCENIE RODZICÓW I LEKARZA¹Departament of Psychiatry Nicolaus Copernicus University in TorunCollegium Medium in BydgoszczHead: Prof. dr hab. Aleksander Araszkiewicz²Department of Physiology, Nicolaus Copernicus University in TorunCollegium Medium in BydgoszczHead: prof. dr hab. n. med. Małgorzata Tafil-KlaweSummaryThe purpose of this work was the objective actigraphicevaluation of movement at children with ADHD (AttentionDeficit Hyperactivity Disorder) in relation to the evaluationof symptom intensification according to their parents(ADHD-RS IV) and a medical qualification to a subtype ofADHD (DSM IV TR). The motor activity of a child wasevaluated by means of an actigraph - Actiwatch 4 producedby Cambridge Neurotechnology Ltd. The investigated groupconsisted of 37 children (32 boys, 5 girls). Results: therewere no differences in the activity between the group ofchildren with recognized ADHD combined subtype and thegroup of children with recognized ADHD predominantlyinattentive subtype observed. More serious attentiondisorders occur in case of children, who in later hours of theday have the maximum activity intensity. The scores of itemsevaluating the hyperactivity and impulsiveness did notcorrelate with the results of activity measurement. The resultsof actigraphic measurement did not correlate with theevaluation of the activity intensification according to parents.StreszczenieCelem pracy była obiektywna aktograficzna ocena ruchuu dzieci z rozpoznaniem ADHD w stosunku do ocenynasilenia objawów według rodziców i kwalifikacji lekarskiejdo podtypu ADHD. Diagnozę ADHD postawiono zgodnie zkryteriami badawczymi DSM IV TR. Nasilenieposzczególnych objawów ADHD opiekunowie oceniali zapomocą kwestionariusza ADHD Rating Scale-IV wersji dlarodziców. Aktywność ruchową dziecka oceniano za pomocąaktografu Actiwatch 4 firmy Cambridge NeurotechnologyLtd. Grupę badaną stanowiło 37 dzieci (32 chłopców, 5dziewcząt) w wieku od 7 do 14 lat, średnia wieku 10 lat(SD=2,3). Wyniki: Nie obserwowano różnicy w aktywnościmiędzy grupą dzieci z rozpoznaniem ADHD podtypumieszanego a grupą dzieci z rozpoznaniem ADHD podtypu zprzewagą deficytu uwagi. Większe zaburzenia uwagiwystępują u dzieci, które w późniejszych godzinach dobymają maksymalne nasilenie aktywności. Wyniki pomiaruaktograficznego nie korelowały z oceną nasilenia ruchliwościwedług rodziców.Key words: Attention Deficit Hyperactivity Disorder, actigraphy, motor activity, parent ratingsSłowa kluczowe: zaburzenie hiperkinetyczne, aktograf, aktywność ruchowa, ocena rodziców

12Małgorzata Dabkowska et. al.INTRODUCTIONAttention Deficit Hyperactivity Disorder (ADHD)is a multi-factor based disorder [1]. In children withADHD an increase of right hemisphere activation inresponse to both kinds of questions contrary to healthcontrols was observed [2]. In children with ADHD thedysfunctions of the frontal lobe were diagnosed [3].Motor hyperactivity is one of the core symptoms ofADHD [4]. Pathophysiologically, it can be understoodas a result of an abnormal motor facilitation orinhibition within cortical and subcortical motorcircuits.These children have serious problems with thecontrol of their moves, adjustment of the move strengthto the situation, limitation of moves in the socialsituations that require calm behavior. The utterances ofpeople with ADHD are accompanied by numeroushand gestures. The hyperactivity is particularly visiblein case of younger patients, but the increased motorreadiness still remains in adult life, negativelyinfluencing social functioning. In patients with ADHDsome deviations in the movement pattern in responseto electro-stimulation were observed [5]. Thepathophysiological basis of the motor disorders inpatients with ADHD can be deviations of thedopaminergic frontal-striatum circuit. The results provethat ADHD symptoms are significantly connected withneurophysiologic factors. Kids with ADHA havedysfunctions in the brain areas connected with bodymotor activity – in the temporal lobe, cerebellum, areaof sub-cortex [6]. In children with ADHD somedeviations in motor functions the basis of which isbrain immaturity are observed [7]. The intensificationof motor disorders in ADHD was evaluated by theevaluation of the presence of soft neurologicalsymptoms and general physical fitness [8]. In childrenwith ADHD higher intensity of syndrome symptoms isconnected with the weakening of the motor fitness.Motor dysfunctions are a significant factor of the riskof more serious or complicated ADHD and highernegative influence on social functioning.Irregularities in the motor activity can beconsidered factors responsible for interactions betweenthe biological aspect of the disorder and the level ofsocial and family functioning of those children [6].Sensor integration disorders occur much more oftenamong the patients with ADHD (84.3 %) than in thepopulation of school children (10.3 %) [9, 10]. Patientswith ADHD have weakened vestibular functions,worse performance of activities and movementplanning [11]. In children with ADHD, with the help ofobjective tests evaluating balance, the worsepossibilities of keeping the balance of the body wereconfirmed [12]. Hampering the activity and attentiondeficit visible in ADHD can be the results of disordersin the frontal-motor connections of the cortex [13].The Fourth Edition of the Diagnostic and StatisticalManual (DSM-IV) recognizes three subtypes ofADHD: the predominantly inattentive subtype, thepredominantly hyperactive/impulsive subtype, and thecombined subtype [14].A recent study suggested that deficits in responseinhibition may be related to inattentiveness rather thanhyperactive and impulsive behavior, suggesting adifferential neuropsychological profile associated withsubtypes of ADHD [15].The purpose of this work was the objectiveactigraphic evaluation of movement of children withrecognized ADHD in relation to the evaluation of theintensification of symptoms according to parents andmedical qualification to the sub-type of ADHD.METHODSI. Evaluation of presence and intensity of ADHDADHD was diagnosed by a child and youthpsychiatrics specialist in agreement with the DSM IVTR research criteria [16]. The parents evaluated theintensity of particular symptoms of the AttentionDeficit Hyperactivity Disorder by means of the ADHDRating Scale questionnaire – IV version for parents[17]. The questionnaire for parents - ADHD RatingScale-IV (ADHD-RS) was filled up during the parents’visits, most frequently mothers’ visits, at children andyouth psychiatrist. ADHD Rating Scale-IVquestionnaire (ADHD-RS) version for parents isdevoted to the evaluation of problems resulting fromADHD symptoms at children and youth at the age from4 do 20. It evaluates the ADHD symptoms from theperiod of last 6 months. It consists of 18 itemsdescribing behaviors resulting from the presence ofADHD symptoms. Each item is evaluated in a 4-gradescale describing the frequency of a given behavior –never, rarely, sometimes, often, very often(respectively from 0 to 3 points). The scale is dividedinto 2 sub-scales concerning separately the attentiondeficit symptoms and the hyperactivity and

The objective measurement of movement vs the intensification of ADHD symptoms in assessment of parents and doctors 13impulsiveness symptoms, and the sum of points of thesubscales constitutes the ADHD RS-IV questionnaireresult. The scale has a good reliability - test-retestassessed in big groups of children in the United States[17]. The scale norms are adjusted to boys and girlsseparately and to the age groups (5-7, 8-10, 11-13, 14-18) [18]. The interpretation of the results depends onthe type and number of symptoms and the intensity ofproblems. The percentile table serves the interpretation– separately for boys and girls, with the division intoage groups and the division into the symptoms ofattention deficit and hyperactivity and impulsiveness aswell as total score. The values equal to and over the 90percentile mean the high probability of ADHDdiagnosis. In the works of Korean researchers, inwhich the ADHD RS-IV score was equal to 90percentile and above, they qualified the patient toADHD diagnosis. DuPaul suggests that the scorebetween 80 and 90 percentile shows the possibility ofADHD diagnosis, while the score between 93 and 98percentile indicates ADHD diagnosis [18]. In theKorean researches, in case of using both versions ofADHDRS-IV – for parents and for teachers, the pointon 90 percentile had a high value confirming clinicaldiagnosis of ADHD [19].According to DSM IV-TR criteria, there were fourADHD subtypes (the combined subtype, thepredominantly inattentive subtype, the predominantlyhyperactive/impulsive subtype and unspecifiedsubtype) classified in the examined group.II. Motor activeness measurementThe motor activity of children was assessed withthe help of actigraph. For 72 hours all the examinedchildren wore digital recorders of the motor activity ontheir wrists - Actiwatch 4 actigraph produced byCambridge Neurotechnology Ltd. The motor activitywas calculated from 72 hours, from 2-minuteconsecutive measurement periods typical ofchronobiological examinations. The times of daily andnight activity were isolated. The peak time (an hour outof twenty-four hours) - maximum motor activity(cosine peak) was determined. The first miniatureelectronic digital actigraph in Poland was constructedin 1987 by the co-author of the research - TadeuszPracki [20].III. Study groupThe examined group was composed of 37 childrenat the age from 7 to 14, the average age in the groupwas 10 years (SD=2.3). The majority of children wereboys -32 and there were only 5 girls. The children wereoutpatients. Almost all children lived in a city with400000 inhabitants. In most cases the reasons forcoming with a child to the Clinic were teachers’suggestions about the need of diagnosing thedifficulties in school functioning. All children had aconfirmed intellectual norm. The children from a givengroup were at the moment of diagnosing, parents’ andteachers’ psycho-education, and before including intotherapeutic groups and possible pharmacotherapy.Among 37 children, the diagnosis of the combinedsubtype ADHD was the most frequent (86 %), whilethere was only 14 % of the predominantly inattentivesubtype.IV. Statistical analysisThe test results were subject to statistic evaluation.There was a packet of statistic tests - SPSS forWindows, version 13.0 used. Test for independentvariables: t-test and Pearson’s correlation coefficientwas used.RESULTSAccording to DSM IV TR, all examined childrenmet the diagnostic ADHD criteria. The total scoring ofthe ADHD RS-IV scale above the 90 percentile (93and 98), which shows undoubted ADHD diagnosis,was noted in case of 72 % children, and equal to the90 percentile or above the 80 percentile in case of 28%. In 80.5 % of children the scoring of the subscaleconcerning the attention deficit was over the 90percentile. The score of the subscale ofhyperactivity/impulsiveness in 66.6 % of the groupcorresponded to 93 or 98 percentiles. The averageintensity of scoring in the ADHD-RS questionnaireform for parents was 37.3 points (SD= 10.6), minimum18 points, and the maximum scoring amounted to 53points. The average intensity of the sum of the itemscorings concerning the attention deficit symptoms inthe group was 22 points (SD= 8.0), and the averageintensity of items concerning hyperactivity andimpulsiveness amounted to19.9 points (SD= 9.1). Theaverage intensity of scoring in the ADHD RS-IVquestionnaire form was significantly higher in thegroup of children with the combined subtype of ADHDthan in the group of children with the majority ofattention deficit symptoms (table I). The averageintensity of ADHD symptoms was similar in the group

14Małgorzata Dabkowska et. al.of younger children (below 10) in comparison to thegroup of older children (table I). There was nodifference in the intensity of average scoring of theADHD RS-IV scale at boys in comparison to girlsobserved (table I).Table I. Intensification of ADHD symptoms depending on thesub-type of the disorder, sex and ageADHD RS-IVpointsDifferenceMean SD t df PSubtypeCombined39.6 9.13.93 35 0.000*Inattentive 22.6 8.4Age 10 years 36.7 12.1 0.45735 0.651Boys 36.8 11.1 -Girls 40.8 6.3 0.77135 0.446Independent samples t-test, *- significant differenceAverage intensity of attention deficit was similar incase of boys (22.1points) and girls (21 points)(P=0.764); the intensity of hyperactivity andimpulsiveness in case of boys (19.8 points) and girls(19.8)(P=0.446; independent - sample test) was alsosimilar.No difference in the activity measured by means ofhand moves measurement was observed between thegroup of children with recognized ADHD of combinedsub-type and the group of children with recognizedADHD predominantly inattentive (table II). Betweenthe ADHD sub-types there were no differences in theresults of average 3-day activity, daily and nightactivity and in the relation of daily to night activity andcosine peak activity.Table II. Average results of activity measurement by meansof actigraph at children with ADHD diagnosistaking into account the ADHD sub-typeActigraphic Whole group ADHD subtype ADHD subtype DifferencemeasurementInattentive Combinedactivity Mean SD Mean SD Mean SD Paverage 145.5 98.3 139.2 124.0 152.2 96.3 0.767daily 206.5 148.5 203.6 185.5 214.2 146.0 0.874night 12.0 9.8 11.7 5.6 12.2 11.1 0.911daily/night 25.9 17.4 21.2 13.7 28.1 18.5 0.371cosine peak 13.9 1.4 12.9 1.6 14.1 1.3 0.075Independent samples t testAverage results of the boys’ and the girls’ activitymeasurement did not differ (table III).No differences between the intensity of averageactivity, daily activity and night activity were noticedin the group of younger children in comparison to thegroup of older children (below and over 10)(table IV).Table III. Average results of activity measurement dependingon sexMeasurement Boys Girls Differenceby actigraphactivity Mean SD Mean SD Paverage 146.6 102 138.4 78.5 0.866daily 206.9 154.4 203.4 117.8 0.961night 12.6 10.4 8.5 4.6 0.396daily/night 25.5 17.9 29.1 15.1 0.675cosine peak 13.7 1.4 14.2 1.1 0.462Independent samples t-testTable IV. Average values of activity in the group of youngerand older childrenMeasurement AgeAge Differencewith actigraph < 10 years >= 10 yearsActivity Mean SD Mean SD PAverage 170.5 122 127.6 75 0.201Daily 249.7 178 175.6 117 0.142Night 11.9 11.2 12.1 9.0 0.946Daily/night 28.3 14.5 24.3 19.4 0.507Cosine peak 14.0 0.88 13.7 1.7 0.566Independent samples t-testAlso the results of the objective measurement of the24-hour motor activity (P= 0.499), daily activity (P=0.329) and night activity (P= 0.659) did notconsiderably correlate with age (Pearson correlation).A The intensification of the total score of the ADHDRS-IV questionnaire for parents did not correlate withthe intensification of hand moves measured byactigraph (table V). The considerable positivecorrelation was observed between the intensification ofattention deficits evaluated in the middle of the ADHDRS-IV questionnaire for parents and the increase in thevalue of cosine peak (table V). The cosine peak valuein the actigraphic measurement shows the time oftwenty-four hour peak activity.The scorings of items evaluating hyperactivity andimpulsiveness did not correlate with the results of handmoves during three days of daily and night activity orthe measurement of cosine peak (table V).The correlations between the intensification ofparticular symptoms evaluated in 18 items of theADHD RS-IV questionnaire and the average twentyfourhour, daily, and night activity, the relation of thedaily activity to night-time activity and cosine peakactivity were studied. No significant correlationbetween the results of the activity measurement and theintensity of particular ADHD symptoms was found.No significant correlation between the results ofobjective movement measurement and itemsconcerning hyperactivity in relation to the symptoms ofattention disorders was noted (table VI).

The objective measurement of movement vs the intensification of ADHD symptoms in assessment of parents and doctors 15No difference in average measurements of 24-houractivity, daily activity or night activity at childrenhaving the total scores gained in ADHD RS-IV scaleover the 93 percentile, or in sub-scale concerningattention deficit as well as in the subscale describinghyperactivity was noted (table VII). The intensificationof symptoms in ADHD RS-IV scale over 93 percentileis connected with a reliable disorder diagnosis.Table V. The correlation between activity and theintensification of all ADHD symptoms, symptomsof hyperactivity and symptoms of attentiondisordersActigraphicmeasurementADHD RSAttention deficititemsADHD RSHyperactivity/impulsivenessitemsADHD RS-IVr P r P r Paverage activity -0.052 0.765 0.210 0.220 -0.075 0.665daily -0.091 0.596 0.192 0.261 -0.120 0.487night 0.158 0.359 0.119 0.491 0.071 0.681daily.night -0.144 0.402 -0.021 0.902 -0.087 0.616cosine peak 0.349 0.057* 0.211 0.216 0.311 0.065Pearson correlation test; r- correlation coefficient; * relevance on the0.05 levelTable VI. The correlation between the intensity of particularsymptoms of ADHD and the results of movementmeasurement by actigraphNumberof ItemADHDRS-IVaverage72-hour activitydaily activitynight activity1 r P r P r P2 -0.080 0.643 -0.119 0.491 0.014 0.9373 -0.12 0.487 -0.086 0.617 -0.220 0.1974 0.020 0.909 0.071 0.682 -0.090 0.6015 -0.081 0.637 -0.017 0.498 -0.024 0.8896 -0.031 0.858 -0.086 0.619 0.020 0.9067 -0.101 0.560 -0.136 0.428 -0.115 0.5048 -0.120 0.487 -0.160 0.350 -0.068 0.6969 -0.287 0.090 0.310 0.066 -0.266 0.11610 -0.157 0.361 -0.117 0.498 -0.145 0.39811 -0.142 0.409 -0.164 0.340 -0.192 0.26112 -0.060 0.727 -0.098 0.571 0.065 0.70713 -0.001 0.997 -0.048 0.783 0.042 0.80714 -0.031 0.856 -0.030 0.862 0.029 0.86715 -0.080 0.642 -0.080 0.642 0.121 0.48116 -0.120 0.487 -0.112 0.514 -0.074 0.66917 0.119 0.488 0.079 0.646 0.066 0.70418 -0.024 0.890 -0.054 0.756 -0.076 0.661Pearson correlation test; r- correlation coefficient; unevenitems concern attention deficit, even items concern thesymptoms of hyperactivity/impulsivenessTable VII. The average result of activity measurement in thegroup of children with the intensity of scoringover and below 93 percentileMeanactivity=93rd%ileMean(SD)P=93rd%ileMean(SD)P=93rd%ileMean(SD)158.4(97.4)P0.269(222.6 0.363(149.3)11,9(11.3)29.07(18.1)14.0(1.0)0.9640.1340.425Average scoring in the ADHD RS-IV questionnairewas significantly higher in the group of children withthe mixed subtype of ADHD than in the group ofchildren with the majority of attention deficitsymptoms. No difference in the activity evaluated withthe help of hand moves measurement between thegroup of children with recognized ADHD combinedtype and the group of children with recognized ADHDpredominantly inattentive was observed. Dane’s et al.compared subtypes of ADHD on an objective measureof activity level (actigraphy) and noted that there wereno significant group differences in activity level in themorning session. During the afternoon session,children with ADHD were significantly more activethan controls, but there were no differences betweenADHD subtypes [21].The results of the measurement of the boys’ and thegirls’ activity did not differ. Due to a gender unbalancein the study group (a very limited number of females)it was impossible to determine differences in severityof activity in girls and boys. According to someauthors, sex may not correlate with an ADHD subtype[22].In the actigraphic measurement no difference in theintensity of physical activity in the group of youngerchildren in comparison to older kids was observed. Insome works any no correlation of ADHD symptomswith age or motor dysfunctions was observed [6]. Asignificant positive correlation was observed betweenthe intensification of attention deficit evaluated in themiddle of the ADHD RS-IV questionnaire for parentsand the increase of the cosine peak value, i.e. the time

16Małgorzata Dabkowska et. al.of maximum activity during the measurement. Thelater time of the peak of 24-hour activity was, thebigger the attention deficit was.The ADHD subtype can have bigger influence onthe course of illness and co-morbidity than the sex orage of a child [22]. The evaluation of ADHD subtypesis based on the impression of surroundings (parents,teachers, doctor). The people evaluating the patient cansee problems resulting more from the attention deficitor hyperactivity. The objective actigraphicmeasurement shows that the intensification of handmoves is similar in both subtypes - in children inwhom attention disorders dominate and in those whoabove all show motor disturbances. The actigraphevaluates hand gesticulation which in the examinedgroup is similar in both subtypes, similar among boysand girls (males dominated in the group), similarly inyounger and older children. The literature proves thathyperactivity decreases with age, however thegesticulation remains on the similar level in case ofchildren at different ages in the examined group. Theexcessive gesticulation can disturb the performance ofcomplex activities (such as for example driving a car).CONCLUSIONSThe results of the actigraphic measurement did notcorrelate with the evaluation of activity intensityaccording to parents.In the studied group no differences in themovement intensity between the combined sub-typeand the attention deficit sub-type of ADHD wereobserved.More serious attention disorders occurred inchildren who in later hours (of 24-hours) had themaximum activity intensity.REFERENCES1. Dabkowska M (2002) Risk factors in attention deficithyperactivity disorder. Psychiatria i PsychologiaKliniczna 2:102-114.2. Dabkowska M, Borkowska A (2000a) Hemisphericactivation in children with ADHD (in Polish). In:Zaburzenia psychiczne dzieci i młodzieży: wybranezagadnienia (Namysłowska I, ed). Biblioteka PsychiatriiPolskiej, Kraków, Poland, 35-39.3. Dabkowska M, Borkowska A (2000b)Neuropsychological assessment of frontal dysfunction inchild and adolescent with ADHD (in Polish). In:Zaburzenia psychiczne dzieci i młodzieży: wybranezagadnienia (Namysłowska I, ed). Biblioteka PsychiatriiPolskiej, Krakow, 41-46.4. Biederman J (2005) Attention-deficit/hyperactivitydisorder: a selectiveoverview. Biol Psychiatry 57:1215–1220.5. Ben-Pazi H, Gross-Tsur V, Bergman H, Shalev RS(2003) Abnormal rhythmic motor response in childrenwith attention-deficit–hyperactivity disorder. Dev MedChild Neurol 45:743-745.6. Gustafsson P (2008) Bio-social aspects of AttentionDeficit Hyperactivity Disorder (ADHD):Neurophysiology, maturity, motor function and howsymptoms relate to family interaction. Lund University.7. Gustafsson P, Thernlund G, Besjakov J, Karlsson M,Ericsson I, Svedin CG (2008) ADHD symptoms andmaturity – a study in primary school children. ActaPaediatr 97: 233-238.8. Ericsson I (2008) Motor skills, attention and academicachievements - an intervention study in school year 1-3.Br Educ Res J 34:301-313.9. Guo P,Guo H,Yang CH, et al. (1999) SensoryIntegra-tion Therapyon Attention DeficitHyperactivityDis-order.Chinese J Behav Med Sci 8:306-306.10. Ren GY, Wang YF, Gu BM, et al.(1995) Investigation onprevalence of sensory integration dysfunction in1994school children in a Beijing urban area. Chinese J MentHealth 9:70-73.11. Mulligan S (1996) An analysis of score patterns ofchildren with attention disorders on the SensoryIntegration and Praxis Tests. Am J Occup Ther 50:647-654.12. Zang Y, Bomei Gu, Qian Q, Wang Y (2002) ObjectiveMeasurement of the Balance Dysfunction in AttentionDeficit Hyperactivity Disorder Children. Chin J ClinRehabil 6: 1372-1374.13. Niedermeyer E, Naidu SB (1997) Attention-deficithyper-activity disorder (ADHD) and frontal-motor cortexdisconnection. Clin Electroencephalogr 28:130-136.14. American Psychiatric Association (1994) Diagnostic andstatistical manual of mental disorders, 4th edition (DSM-IV) Washington DC.15. Chhabildas N, Pennington BF, Willcutt EG (2001) Acomparison of the neuropsychological profiles of theDSM-IV subtypes of ADHD. J Abnorm Child Psychol29:529 –540.16. American Psychiatric Association (2000) Diagnostic andstatistical manual of mental disorders: DSM-IV-TRFourth Edition Text Revision.17. DuPaul GJ, Anastopoulos AD, Power TJ, Reid R,McGoey MJ, McGoey KE (1998a) Parent Ratings ofAttention-Deficit/Hyperactivity Disorder Symptoms:Factor Structure and Normative Data. J PsychopatholBehav Assess 20:83-102.18. DuPaul GJ (1991) Parent and teacher ratings of ADHDsymptoms: psychometric properties in a communitybased sample. J Clin Child Psychol 20:245-53.19. Kim JW, Park KH, Cheon KA, Kim BN, Cho SC, HongKEM (2005) The Child Behavior Checklist Together

The objective measurement of movement vs the intensification of ADHD symptoms in assessment of parents and doctors 17With the ADHD Rating Scale Can Diagnose ADHD inKorean Community-Based Samples. Can J Psychiatry 50:802–805.20. Pracki T, Jurek K, Pracka D (1989) Aktograf - rejestratoraktywności ruchowej. Probl Techn Med. 20:93–98.21. Dane AV, Schachar RJ, Tannock R (2000) DoesActigraphy Differentiate ADHD Subtypes in a ClinicalResearch Setting? JAACA 39:752-760.22. Byun H, Yang J, Lee M, Jang W, Yang JW, Kim JH,Hong SD, Joung YS (2006) Comorbidity in KoreanChildren and Adolescents with Attention-DeficitHyperactivity Disorder: Psychopathology According toSubtype. Yonsei Med J 28:113–121.Address for correspondence:gosiadabkowska@yahoo.comtel.: 48 (52) 5854270fax: 48 52 5853766Received: 21.01.2011Accepted for publication: 6.12.2011

Medical and Biological Sciences, 2012, 26/1, 19-25ORIGINAL ARTICLE / PRACA ORYGINALNAJerzy Eksterowicz, Marek NapierałaMORPHOLOGICAL PARAMETERS OF PHYSICAL EDUCATION STUDENTSIN THE YEARS 2006-2010PARAMETRY MORFOLOGICZNE STUDENTÓW WYCHOWANIA FIZYCZNEGOW LATACH 2006-2010The Institute of Physical Education, Kazimierz Wielki University in BydgoszczHead: dr hab. Mariusz Zasada, prof. nadzw. UKWSummaryThe body construction of an adult person depends on avariety of factors. First of all, it is determined genetically – atthe moment of conception every human organism receives aset of an equal amount of chromosomes from the father andthe mother with genes that convey "instructions" about thedevelopmental features of the system. The human growth isnot a uniform process. It is characterised by a great diversityin terms of qualitative and quantitative changes and theintensity level of the processes in time. Ontogeneticdevelopment of a man is an ordered system of some specificdevelopmental changes leading to the formation of humanbeings adapted to living in particular conditions and able toextend the existence of mankind. The direction of theseprocesses is determined by inherited factors, surroundingenvironment and so-called behaviourism, which can bedescribed as the behaviour of an individual in particularconditions.The aim of this study was to determine the selected bodyparameters of 279 first-year students (179 men and 100women) of physical education (stationary studies) at theKazimierz Wielki University in Bydgoszcz. The research ofmorphological characteristics was conducted in the period of2006-2010 and its results were presented in tables. Theydocument the changes in morphological construction.StreszczenieBudowa ciała dorosłego człowieka zależy od wieluczynników. Przede wszystkim uwarunkowana jestgenetycznie, gdyż organizm w momencie poczęcia otrzymujew równym stopniu od ojca i matki zestaw chromosomów, wktórych rozmieszczone są geny zawierające „instrukcje” owłaściwościach rozwojowych ustroju. Rozwój konstytucjonalnyczłowieka nie jest procesem jednostajnym.Charakteryzuje go duża różnorodność pod względem zmianilościowych i jakościowych oraz stopnia natężeniazachodzących procesów w czasie. Ontogenetyczny rozwójczłowieka polega na uporządkowanym systemie przebiegupewnych specyficznych zmian rozwojowych zmierzającychdo ukształtowania się osobników przystosowanych do życiaw danych warunkach i zdolnych do przedłużenia istnieniagatunku. Kierunek tych procesów jest określony czynnikamidziedziczonymi, warunkami otaczającego środowiska oraztzw. behawioryzmem czyli postępowaniem, zachowaniem sięsamego osobnika w danych warunkach.Celem niniejszych badań było określenie wybranychparametrów ciała 279 studentów I roku (179 mężczyzn i 100kobiet) z kierunku wychowania fizycznego studiówstacjonarnych Uniwersytetu Kazimierza Wielkiego wBydgoszczy. Badania cech morfologicznych przeprowadzonood 2006-2010 roku, a wyniki przedstawionotabelarycznie. Dokumentują one zmiany budowymorfologicznej.Key words: morphological construction, physical education studentsSłowa kluczowe: budowa morfologiczna, studenci wychowania fizycznego

20Jerzy Eksterowicz, Marek NapierałaINTRODUCTIONThe body construction of an adult person dependson a variety of factors. First of all, it is determinedgenetically – at the moment of conception everyhuman organism receives a set of an equal amount ofchromosomes from the father and the mother withgenes that convey "instructions" about thedevelopment features of the system. The containedinformation shapes the growth of an individual; thegenetic factors and environmental conditions influencethe development in a comparable degree – initially, inthe prenatal life, when the external environment for thedeveloping embryo (and then foetus) is the uterus ofthe mother, and then during the post prenatal life aswidely understood environmental conditions.Moreover, there is a third factor affecting thedevelopment of an individual, which is calledbehaviourism – it can be described as a widelyunderstood behaviour of an individual. Its importancefor the organism development grows over time, as wellas with acquired experiences and knowledge. In theopinion of many researchers, these three factors shapeall somatic, functional and mental features of people(Eksterowicz, Napierała 2007; Wolański 2006;Malinowski 1994).Looking at the sizes of selected morphologicalfeatures among physical education students; bothretardation and excessive development of certainmorphological values in comparison with the averagevalues in the population can be observed. Theknowledge obtained from these researches allowsselecting appropriate didactic resources to supportstudents efforts aimed at maintaining good health, aswell as specifying risky areas in the somaticconstruction from the perspective of maintaining goodhealth of an individual and the whole population(obesity, lipohyperplasia, proneness to anorexia, etc.).The aim of this research was to specify the size ofselected morphological features and body compositionof physical education students at the Kazimierz WielkiUniversity in Bydgoszcz in the period of last fiveyears, separately for each year, and to compare theseparameters both in a one-year and a five-year scale.MATERIAL AND METHODSThe researches were carried out among 279stationary students of physical education (179 men and100 women) aged 19 - 26 years at the KazimierzWielki University in Bydgoszcz in the period from2006 to 2010. There was one research per year, carriedout in July during the summer sports camp. Allstudents were examined according to the followinganthropometric measurements (cm): body height (V -B), arm length (a - r), forearm length (r - sty), upperlimb length (a - da III), leg length (tro - B), foot length(ap - pte), shoulder width (a - a), hip width (ic - ic),pelvis width (is - is), arm width (mm - mu), hand width(mr - mu), foot width (mtt - mtf). Moreover, thecircumferences of the following body parts weremeasured (cm): chest at full inspiration and expiration,waist, flexed and unflexed arm, thigh and calf. Theproper body mass was specified as well (kg). Inaddition to that, the thickness of three skinfolds weremeasured (mm), which are located: over the tricepsmuscle (TSF) (triceps skinfold), vertical skinfold,under the lower angle of the shoulder blades (SCSF)(subscapular skinfold), horizontal skinfold, and overthe iliac crest (SISF) (suprailiac skinfold), obliqueskinfold. Based on those measurements, the followingindicators were calculated: BMI (Body Mass Index,kg/m 2 ), AMC (Arm Muscle Circumference), WHR(Waist to Hip Ratio), body fat mass (FM) (kg), percentbody fat (FM) (%) and lean body mass in kilogramsand percentage (FFM) (kg), (FFM) (%) (Drozdowski1998, 2002).For the indices interpretation the followingelements were calculated:- BMI (for women and men): below 19.0 – body massdeficit; between 19.0 and 25.0 – proper body mass;from 25.1 to 29.9 – overweight; over 30.0 – obesity;- it was assumed that the border value of the WHRindex, over which the obesity is observed, is: 0.95 formen and 0.85 for women;- the criteria of AMC evaluation: the degree ofaluminous nutrition was calculated according to theformula: arm circumference – (3.14 x the thickness ofthe dermal-aliphatic skinfold over the triceps), thefollowing values were assumed: good aluminousnutrition – men > 22.8, women > 20.9; slightmalnutrition – men: 22.7-20.2, women: 20.8-18.6;moderate malnutrition – men: 20,1-17,7, women: 18,5-16,2; heavy malnutrition – men < 17.7, women < 16.2;- the Rohrer index, specifying it with the Curtis Keyand the Kretschmer characteristics: x – 1.27leptosomatic type, 1.28 - 1.49 athletic type and 1.50 –x pyknic type;- the Pignet rate and the index values were ranked onthe basis of Polish materials and sources from the

Morphological parameters of physical education students in the years 2006-2010 21researches of candidates to the physical educationstudies (Drozdowski 2002, p. 118).The calculations were carried out according to theformula: I = the body height – (mass + chestcircumference). The following criteria were assumed:Criteria (Kryteria)men(mężczyźni)women(kobiety)Very strong construction (Budowabardzo mocna)x - 7.7 x - 18.8Strong construction (Budowa mocna) 7.8 - 12.5 18.9 - 22.5Medium construction (Budowaśrednia)12.6 - 22.1 22.6 - 30.0Weak construction (Budowa słaba) 22.2 - 26,9 30.1 - 33.8Very weak construction (Budowabardzo słaba)27 – x 33.9 - x- torso index: I = (torso length : body height) x body heightCriteria (Kryteria)men women(mężczyźni) (kobiety)Long torso (Długi tułów) 31.3 - x 30.8 – xMedium torso (Średni tułów) 29.6 - 31.2 29.5 - 30.7Short torso (Krótki tułów) x - 29.5 x . 29.4- shoulder index: I = (shoulder width : torso length) x 100Criteria (Kryteria)men women(mężczyźni) (kobiety)Narrow shoulders (Barki wąskie) x - 70.1 x - 72.6Medium shoulders (Barkiśrednioszerokie)70.2 - 76.5 72.7 - 77.2Broad shoulders (Barki szerokie) 76.6 - x 77.3 - x- pelvic index: I = (pelvis width : shoulders width) x 100Criteria (Kryteria)men women(mężczyźni) (kobiety)Narrow pelvis (Miednica wąska) x - 71.5 x - 79.3Medium pelvis (Miednicaśrednioszeroka)71.6 - 76.1 79.4 - 84.5Broad pelvis (Miednica szeroka) 76.2 - x 84.6 - x- arm musculature index: I = (circumference : length) x 100 –Men: slender arm > 77.1, stocky arm < 77.2, women: slenderarm > 76.0, stocky arm < 76.1 (Drozdowski 1998, 2002).The measurements were made using the portablemedical scale – model: TANITA BF 662M and theanthropometric tool-kit (anthropometer,anthropometric tape, skinfolds meter) produced by aSwiss company – Siber Hegner & Co. Ltd.(Drozdowski 1998, 2002).From these measurements the mean values andstandard deviations were calculated and the statisticalinference was conducted by comparing the testedparameters.TEST RESULTS ANALYSISThis paper is of diagnostic nature, so the researcheswere focusing on solving problems on the example ofspecified population and in the particular time horizon.Hence, no research hypothesis was formulated thatwould go beyond the factual materials. Theassumptions about the relative somatic homogeneity ofrespondents were made, which allows interpretingpossible developmental differences in the light of theenvironmental variety.Table I. Comparison of values of morphologicalmeasurements in men between 2006 and 2010Tabela I. Charakterystyka somatyczna (wielkości średnie iodchylenia standardowe) studentów (mężczyzn)na przestrzeni lat 2006=20102006N=412007N=372008N=322009N=432010N=26Tested featureX S X S X S X S X SBody height(Wysokość ciała) 180.58 6.07 180.5 7.79 181.0 8.01 `180,0 5,0 181.4 6.01(cm)Body mass (Masaciała) (kg)76,31 8.10 76.3 8.43 76.7 9.70 77.6 9.6 76.7 7.91Subscapularskinfold (Fałd pod 9,91 2.51 10.38 2.08 10.81 2.61 10.50 2.60 10.41 1.91łopatką) (mm)Skinfold overtriceps (Fałd nad 6.51 2.92 8.08 2.77 9.0 2.01 10.3 2.7 8.62 2.32tricepsem) (mm)Suprailiac skinfold(Fałd nad biodrem) 8.41 3.02 9.37 4.08 10.5 3.3 10.7 2.9 9.11 2.32(mm)Skinfolds in total(Suma fałdów) 27.5 6.10 27.83 5.34 30.3 6.70 31.5 7.6 28.01 5.34(mm)Arm length (Dł.ramienia) (a-r)30.48 2.87 30.10 3.13 32.51 2.51 32.40 2.78 32.52 1.63Forearm length(Dł. przedramienia) 25.85 1.62 26.75 2.05 27.43 1.86 25.86 2.49 27.84 2.33(r-sty)Upper limb length(Dł. kończyny 79.25 3.04 81.20 5.76 79.45 3.95 79.17 4.72 80.18 3.86górnej) (a-daIII)Leg length (Dł.kończyny dolnej) 90.86 3.88 96.00 5.68 91.88 3.89 91.08 4.72 90.77 4.69(tro-B)Foot length (Dł.stopy) (pte-ap)26.85 2.78 27.02 3.05 27.15 1.51 26.46 1.18 26.81 1.34Shoulders width(Szer. barków) (aa)40.40 2.26 43.15 2.05 43.07 1.89 43.19 2.48 42.43 2.14Hips width (Szer.bioder) (ic-ic)29.05 1.34 30.95 1.88 30.59 2.19 31.08 2.32 29.78 1.94Pelvis width (Szer.miednicy) (is-is)23.36 1.59 24.87 1.41 24.23 2.29 24.88 1.96 24.02 1.41Arm width (Szer.ręki) (mm-mu)10.77 0.99 10.92 1.12 10.93 0.64 10.75 0.64 11.14 0.63Palm width (Szer.dłoni) (mr-mu)8.77 0.54 8.86 0.61 8.78 0.64 8.57 0.55 8.62 0.42Foot width (Szer.stopy) (mtt-mtf)10.17 0.39 10.32 0.42 10.14 0.67 10.43 0.50 10.44 0.67Chestcircumference(inspiration) (Ob. 101.9 5.82 96.5 5.92 97.31 4.99 100.61 6.31 97.04 4.30klatki piersiowejwdech) (cm)Chestcircumference(expiration) (Ob. 94.08 5.33 90.55 6.02 91.82 5.53 93.62 3.03 91.15 3.90klatki piersiowejwydech) (cm)Waistcircumference (Ob. 80.96 3.54 81.2 5.76 78.02 5.32 82.69 6.78 79.35 4.62pasa) (cm)Hips circumference93.37 6.03 96.0 5.68 95.53 6.15 96.14 4.79 93.85 5.70(Ob. bioder) (cm)Arm circumference(flexed) (Ob.ramienia34.04 2.63 30.1 3.13 32.78 2.28 33.74 3.28 33.40 1.95napiętego) (cm)Arm circumference(unflexed) (Ob.ramienia bez30.04 1.61 29.05 0.65 29.93 2.67 29.85 2.83 29.74 1.70napięcia) (cm)Thighcircumference (Ob. 55.60 3.63 54.80 3.05 52.93 3.77 56.21 3.83 55.57 3.60uda)Calf circumference(Ob. łydki)37.42 2.11 36.95 3.08 36.78 2.82 38.22 2.45 37.30 2.45Torso length (Dł.tułowia) (tro-a)56.02 3.36 56.39 3.57 56.71 3.12 57.01 3.33 57.10 2.97N – numbers, X – average value, S – standard variation(source: own study) (źródło: opracowanie własne)This assumption is a reasonable condition due tothe similar sizes of the researched individuals thatoccur both within a one-year and a five-year scale.

22Jerzy Eksterowicz, Marek NapierałaTable II. Comparison of values of morphological measurementsin women between 2006 and 2010Tabela II. Charakterystyka somatyczna (wielkości średnie iodchylenia standardowe) studentek (kobiet) naprzestrzeni lat 2006 – 2010Tested featureBody height(Wysokośćciała) (cm)Body mass(Masa ciała)(kg)Subscapularskinfold (Fałdpod łopatką)(mm)Skinfold overtriceps (Fałdnad tricepsem)(mm)Suprailiacskinfold (Fałdnad biodrem)(mm)Skinfolds intotal (Sumafałdów) (mm)Arm length(Dł. ramienia)(a-r)Forearm length(Dł.przedramienia)(r-sty)Upper limblength (Dł.kończynygórnej) (adaIII)Leg length (Dł.kończynydolnej) (tro-B)Foot length(Dł. stopy)(pte-ap)Shoulderswidth (Szer.barków) (a-a)Hips width(Szer. bioder)(ic-ic)Pelvis width(Szer.miednicy) (isis)Arm width(Szer. ręki)(mm-mu)Palm width(Szer. dłoni)(mr-mu)Foot width(Szer. stopy)(mtt-mtf)Chestcircumference(inspiration)(Ob. klatkipiersiowej –wdech) (cm)Chestcircumference(expiration)(Ob. klatkipiersiowej –wydech) (cm)Waistcircumference(Ob. pasa) (cm)Hipscircumference(Ob. bioder)(cm)Armcircumference(flexed) (Ob.ramienianapiętego)(cm)Armcircumference(unflexed) (Ob.ramienia beznapięcia) (cm)Thighcircumference(Ob. uda)Calfcircumference(Ob. łydki)Torso length(Dł. tułowia)(tro-a)2006 2007 2008 2009 2010N=25 N=18 N=18 N=21 N=18X S X S X S X S X S169.83 4.80 170.0 4.97 170.017.02 169.06.0 167.4 8.0263.82 7.40 63.7 6.66 64.3 6.36 63.0 7.97 65.72 6.5212.10 4.00 12.78 4.33 14.20 5.55 13.75 6.1 11.81 2.9511.80 2.90 14.34 4.28 12.9 3.72 15.1 2.76 12.32 2.9912.40 3.30 13.71 4.45 10.21 2.71 12.0 2.82 12.31 3.1937.30 3.50 40.83 5.01 34.21 8.01 39.70 6.11 36.50 7.8028.25 2.25 26.0 2.27 29.04 1.65 32.09 3.47 30.82 2.6226.00 1.30 26.05 1.23 25.65 1.78 23.81 1.99 24.69 1.9671.38 3.95 74.30 4.02 72.48 3.64 74.13 4.24 72.79 3.9982.98 4.75 86.10 5.15 86.85 6.23 85.85 4.94 83.73 6.8724.68 1.20 24.70 1.18 25.19 1.30 24.45 1.37 24.23 1.3736.49 1.33 37.55 1.98 39.61 1.56 38.86 2.65 37.44 2.5329.39 1.75 31.80 2.88 32.62 3.32 30.51 1.95 30.56 1.9623.78 1.74 23.77 1.67 23.97 2.36 24.77 1.92 24.11 1.559.65 0.81 9.87 0.77 9.59 0.35 9.78 0.49 9.75 0.487.94 0.19 7.78 0.30 7.79 0.28 7.80 0.37 7.91 0.489.32 0.20 9.36 0.35 9.35 0.52 9.30 0.45 9.31 0.5090.44 4.59 93.80 4.93 91.81 5.22 93.38 5.17 94.73 4.2389.02 4.24 88.90 4.98 87.66 4.62 88.65 5.78 90.84 4.3372.59 5.23 75.2 6.64 71.57 3.45 76.03 6.50 74.89 6.0495.60 4.45 96.30 5.04 97.11 5.43 94.47 5.82 95.28 4.5728.61 2.15 28.01 1.90 28.35 1.71 28.49 2.31 28.11 1.7026.06 2.03 26.40 1.35 26.76 1.69 26.20 2.39 25.87 1.3856.38 3.74 55.10 4.08 54.70 3.04 53.05 3.66 53.02 2.3638.71 2.08 37.12 2.05 36.68 1.72 36.83 2.73 36.09 1.7252.01 3.22 52.36 3.63 52.45 2.89 52.32 2.77 51.44 2.64N – numbers, X – average value, S – standard variation(source: own study) (źródło: opracowanie własne)The average results of many somatic factors thatwere studied in different years do not differ too muchfrom each other. It may result from the specificuniformity of the researched group whose memberspractise sports from their early childhood and asstudents of physical education they still continue toparticipate actively in physical activities. Such alifestyle causes that they have slim and well-builtbodies, which are desirable in sport (mass orprofessional).The following tables present the somaticcharacteristics of the students who took part in theresearch. These results may be a material forcomparison for all people who deal with anthropology.The presented research results in men showed thatthe average BMI for all collated years was withinlimits for proper body mass. Also the average WHRdemonstrated that there was no example of obesity inthose years. The criteria of AMC evaluation indicatedthe medium/good nutrition. The average scores of bodyslenderness ratio defined by Rohrer index andKretschmer characteristics were within 1.28 - 1.33,which indicates the athletic types. The Pignet indexvalues proved that in 2006, 2008 and 2009 men hadstrong body construction, while in 2007 and 2001 itwas medium (Table III).In the years 2006 and 2007, the torso indexdemonstrated a medium body length, while in theremaining years it showed high body length among thestudents. The researched group of students hadmedium shoulders in 2006, 2007 and 2010, and broadshoulders in 2008 - 2009. When reading the calculatedaverage pelvis width, it can be concluded that in allthose years the students had narrow pelvis. In allresearched years the students had stocky arms (TableIII).Table III. Numerical characteristics of selected somaticindices of men (source: own studyTabela III. Charakterystyka liczbowa wybranych wskaźnikówsomatycznych mężczyzn) (źródło: opracowaniewłasne)Year ofstudy (RokBMI WHRAMC PignetaindexRohreraindexTorsoindexShoulderIndexbadań)(Wskaźnik (Wskaźnik (Wskaźnik (WskaźnikPigneta) Rohrera) tułowia) barków)Pelvic Armindex muscle(Wskaźnik indexmiednicy) (Wskaźnikumięśnieniaramienia)2006 23.3 0.85 27.20 10.19 1.30 31.02 72.12 57.82 98.562007 23.41 0.84 27.50 13.65 1.30 31.24 76.50 57.63 96.512008 23.40 0.82 27.11 12.48 1.28 31.33 77.48 56.26 92.062009 24.0 0.86 26.61 8.78 1.33 31.56 76.04 57.61 92.132010 23.6 0.84 29.46 13.55 1.31 31.70 74.20 56.61 91.40All23.54 0.84 27.58(Wszystkie)11.73 1.30 31.37 75.27 57.19 94.13

Morphological parameters of physical education students in the years 2006-2010 23The BMI values showed that during the researchwomen had proper body mass. There was also only asmall number of obese women and this is demonstratedby the WHR. When it comes to the AMC index, allresearched women had it over 20.9, which indicatesgood protein nutrition. When determining the averagevalues of the slenderness ratio, it can be stated that inall researched years both women and men representedthe athletic type. During the whole research, womenwere characterized by a very strong body construction(specified by the Pignet index). In the years 2007, 2008and 2009 the body length index demonstrated that theresearched women had long torso, while in theremaining years of the research they had medium bodylength. Narrow shoulders were observed among theresearched women in 2006 and 2007, while in theremaining years of the research they were medium. Inall observations, the researched women had narrowpelvises (pelvic index) and stocky arms (Table IV).Table IV. Numerical characteristics of selected somaticindices of women (source: own study)Tabela IV. Charakterystyki liczbowe wybranych wskaźnikówsomatycznych kobiet (źródło: opracowaniewłasne)Year ofstudy(Rokbadań)BMI WHR AMCPignetaindexRohreraindexTorsoindexShoulderIndexPelvicindexArmmuscle(Wskaźnik (Wskaźnik (Wskaźnik (Wskaźnik (Wskaźnik indexPigneta) Rohrera) tułowia) barków) miednicy) (Wskaźnikumięśnieniaramienia)2006 21.32 0.76 22.90 16.99 1.30 30.62 70.16 65.17 92.252007 22.0 0.78 21.50 17.43 1.30 30.80 71.69 63.30 101.532008 22.3 0.74 22.81 18.04 1.31 30.85 75.5 60.52 92.152009 22.2 0.81 21.45 17.35 1.31 30.96 74.26 63.74 81.642010 23.9 0.78 25.43 10.84 1.40 30.73 72.78 64.39 83.93All22.34 0.77 22.82(Wszystkie)16.13 1.32 30.79 72.88 63.42 90.3The presented average test results among men,including in particular the body mass, body fat andlean body mass in kilograms and percentages provethat these values were within the recommended limits,e.g. body fat (BF) from 12.79% in 2006 to 16.26% in2009. Similar observation was made concerning thelean body mass (FFM), which average value was thelowest in 2009 – 83.74% and the highest in 2006,87.20% (Table V).The researches carried out among women provedthat the smallest average value of body fat (BF) wasnoted in 2007 – 25.41%, while the highest in 2009 –30.49%. The latter parameters slightly exceed thenormative and recommended standards of body fat forwomen (25%).Lean body mass (FFM) was on average the lowestin 2009 amounting to 69.51%, while the highest FFMwas observed in 2007 – 74.60%. The recommendedaverage value of FFM is 75% (Table VI).Table V. The selected morphological body sizes of men(source: own study)Tabela V. Wybrane wielkości morfologiczne ciała mężczyzn(źródło: opracowanie własne)Year ofstudy(Rokbadań)20062007200820092010The average values Body fatLean body massand standard deviation (Tkanka tłuszczowa) (Beztłuszczowa masa ciała)(Wartości średniei odchylenie standardowe) (kg) (%) (kg) (%)X 9.21 12.79 67.10 87.20s 2.58 3.79 6.66 3.79X 10.64 13.7 63.02 85.6s 2.87 2.72 5.46 2.99X 12.23 15.73 64.48 84.27s 3.62 3.14 7.17 3.14X 12.76 16.26 64.63 83.74s 4.09 3.13 6.05 3.13X 11.41 14.74 65.27 85.26s 2.89 2.60 5.85 2.60AllX 11.25 14.65 64.90 85.21(Wszystkie) s 3.21 3.08 6.24 3.13Table VI. The selected morphological body sizes of women(source: own study)Tabela VI. Wybrane wielkości morfologiczne ciała kobiet(źródło: opracowanie własne)Year ofstudy (Rokbadań)2006200720082009The averagevalues andstandarddeviation(Wartości średniei odchyleniestandardowe)Body fat(Tkankatłuszczowa)Lean body massBeztłuszczowa masa ciała)(kg) (%) (kg) (%)X 19.21 29.45 44.6 70.55σ 3.94 3.44 4.08 3.43X 16.30 25.41 47.44 74.60σ 3.44 3.50 4.28 3.52X 18.34 28.38 45.93 71.62σ 3.25 2.80 3.66 2.80X 19.30 30.49 43.63 69.51σ 3.27 1.96 5.0 1.96X 19.23 29.23 46.46 70.772010σ 3.01 3.08 4.78 3.08All X 18.48 28.59 45.61 71.41(Wszystkie) σ 3.38 2.96 4.36 2.96CONCLUSIONSThe morphological construction differs and isunique for individuals. We can talk about thedifferentiation of body constitution. In the literature,there are divergent views on the characteristics of thehuman body (Roy, Shephard 1987; Andreasi andothers 2010). Drozdowski (2002) points out that eventhe terminology is not sufficiently uniform, because wetalk about a somatic, morphological andmorfofunctional body construction or the bodyconstitution of a man. The typology of the human body

24Jerzy Eksterowicz, Marek Napierałacould be understood as all characteristics of anorganism that are closely related to each other,interacting and conditioning its structural andfunctional unity (Drozdowski 2002, p. 94).The phenomenon of human diversification in termsof size and proportions of various body parts as well asthe types of reaction to environmental factors has beenknown for a long time (Wolański 2006).The differences between human forms appeared inrelatively early stages of their evolution. Variousgroups of people who occupied particular areas livedprobably in very diverse environments causing themorfofunctional characteristics to adopt to thesurrounding environmental conditions. It can beobserved that the construction of the human body is anexpression of adaptation to diverse naturalenvironment. Numerous studies show the diversitybetween human groups, which can be divided for theintercontinental and the intracontinental ones, isassociated with the formation of human races. Thepapers of many scientists point out that the formationprocess of various populations is influenced by theirgeographical location (Napierała 1999, 2008).Regional and environmental differences in terms ofbody composition can be observed also on the territoryof Poland, although it is an area inhabited by a veryhomogeneous society. One of the very distinctivecharacteristics of the human body is its height. It is ofpolygenic nature (shaped by multiple genes), thereforethe offspring may deviate in various directions fromthe value of particular characteristics of their parents.The final values for these characteristic show a highdependence on environmental conditions, especially onthe quality of nutrition during the progressivedevelopment (Malinowski 1994). The researchescarried out in Poland also demonstrate differences inheight, depending on the education and social position.Similar results were observed in longitudinal studies inthe Bydgoszcz area (Napierała, 1999).The results presented in this paper concerning thebasic morphological characteristics of physicaleducation students during a 5-year period do not showsignificant changes in the given body constitutionelements. The specificity of this particular field ofinterest gathers at the physical education studies anumber of young people with past or present interest insports. People practising sport differ from those whodo not exercise at all in terms of their constitutionalbody construction as it is influenced by systematicphysical exercises, the selection of sport disciplinesand maintaining a desired and well-muscled athleticbody.The research results bring the followingconclusions:1. The research carried out among women and menshowed that the average BMI in all collated years iswithin limits of proper body mass.2. The WHR demonstrated that there was no obesityin any year among the researched students; theAMC evaluation criteria showed good nutrition.3. The average results of the body slenderness amongmen and women defined by the Rohrer index andthe Kretschmer characteristics indicated the athletictypes.4. The Pignet index defined the body composition asmedium and strong in men, and as very strong inwomen in all researched years.5. The researched students (men and women) hadmedium or long torso. The shoulders were mediumand wide in men, and medium and narrow inwomen. In all years of the research both groups hadnarrow types of pelvis and stout arms.REFERENCES1. Drozdowski Z. (1998), Antropometria w wychowaniufizycznym, Podręczniki AWF, Poznań nr 242. Drozdowski Z. (2002), Antropologia dla nauczycieliwychowania fizycznego, AWF, Poznań3. Malinowski A. (1994), Wstęp do antropologii iekologii człowieka, Wydawnictwo UniwersytetuŁódzkiego4. Napierała M. (2008), Środowiskowe uwarunkowaniasomatyczne i motoryczne a wiek rozwojowy dzieci imłodzieży (na przykładzie województwa kujawsko –pomorskiego), Bydgoszcz, WydawnictwoUniwersytetu Kazimierza Wielkiego w Bydgoszczy5. Napierała M. (1999), Rozwój fizyczny i motorycznydzieci wiejskich i miejskich w województwie kujawsko– pomorskim, [w:] Uwarunkowania rozwojufizycznego dzieci i młodzieży wiejskiej, (red.) J.Zagórski i in., Instytut Wychowania Fizycznego iSportu, Biała Podlaska, Rocznik Naukowy Tom VISuplement nr 16. Eksterowicz J., Napierała M., (2007), Zmianymorfologiczne studentów z kierunku wychowaniafizycznego w trakcie letniego obozu sportowego,Medical and Biological Sciences, Tom21/3,Bydgoszcz, pp. 49-52.7. Roy J., Shephard M. D., (1987), Exercise physiology.BC Decker INC, Toronto, Philadelphia.8. Andreasi V, Michelin E, Rinaldi AE, Burini RC,(2010), Physical fitness and associations withanthropometric measurements in 7 to 15-year-older

Morphological parameters of physical education students in the years 2006-2010 25school children. Jornal De Pediatria [J Pediatr (Rio J)],Nov-Dec; Vol. 86 (6), pp. 497-502.9. Wolański N. (2006), Rozwój biologiczny człowieka,PZWL, Warszawa.Address for correspondence:Jerzy EksterowiczUniwersytet Kazimierza Wielkiego w BydgoszczyInstytut Kultury FizycznejBydgoszcz ul. Ogińskiego 16tel.: 601 63 91 81e-mail: jekster@interia.plReceived: 21.06.2011Accepted for publication: 30.08.2011

Medical and Biological Sciences, 2012, 26/1, 27-33Mariusz KlimczykSOMATIC BUILD VS SPORTS RESULTS OF POLE VAULT CONTESTANTS AGED 16-17BUDOWA SOMATYCZNA VS WYNIKI SPORTOWE ZAWODNIKÓW SKACZĄCYCH O TYCZCEW WIEKU 16-17 LATInstitute of Physical Culture, Kazimierz Wielki University in BydgoszczHeadmaster Senior Doctor Mariusz ZasadaSummaryExperimental researches conducted between 2005 and2009 included 20 sportsmen aged 16-17 pole vaulting at thesports club ‘Zawisza’ Bydgoszcz, TS ‘Olimpia’ Poznań, polevault centre Gdańsk, ‘Gwardia’ Piła, ‘Śląsk’ Wrocaław.The aim of the thesis was to define the relation betweensomatic parameters and sports results of pole vaulters ofjunior category (aged 16-17).The following methods and research tools were used inthe thesis: evaluation of physical development, testingphysical dexterity, recording sports results and statisticaldescription.The analysis of the research showed great diversity ofsomatic features and physical dexterity results of particularathletes.The relation which occurs between sports result of thepole vault and the body height (0.66), the length of upperlimb and lower limb (0.64, 0.54, respectively) are interesting.On the basis of the above analysis with regard to, amongmany, small number of the examined, it is not possible to drawfar-reaching conclusions concerning the relation which occursbetween somatic build and physical dexterity attempts andpole vault result.StreszczenieBadania eksperymentalne prowadzono w latach 2005-2009, którymi objęto 20 sportowców w wieku 16-17 latuprawiających skok o tyczce w klubie sportowym „Zawisza”Bydgoszcz, TS „Olimpia” Poznań, Ośrodek skoku o tyczceGdańsk, „Gwardia” Piła, „Śląsk” Wrocław.Celem pracy było określenie zależności międzyparametrami somatycznymi, a wynikiem sportowym w skokuo tyczce, tyczkarzy w kategorii junior młodszy (16-17 lat).W pracy wykorzystano następujące metody i narzędziabadań: ocena rozwoju fizycznego, testowanie sprawnościfizycznej, rejestracja wyników sportowych i metodystatystycznego opracowania.Analiza badań wykazała duże zróżnicowanie cechsomatycznych i wyników sprawności fizycznej uposzczególnych ćwiczących.Interesująco przedstawia się zależność, jaka występujepomiędzy wynikiem sportowym skoku o tyczce, awysokością ciała (0,66), długością kończyny górnej i dolnej(odpowiednio 0,64, 0,54).Na podstawie powyżej przeprowadzonej analizy zewzględu na między innymi małą liczbę badanych nie możnawysunąć daleko idące wnioski dotyczące relacji, jakazachodzi pomiędzy budową somatyczną, a próbamisprawności fizycznej i wynikiem w skoku o tyczce.Key words: somatic features, sports result, correlationSłowa kluczowe: cechy somatyczne, wynik sportowy, korelacja

28INTRODUCTIONMariusz KlimczykMETHODS OF RESEARCHThe history of men's pole vault shows that thebiggest sports achievements of this spectacular andcomplex athletic sports event are achieved by thecontestants of diverse somatic build [1]. Theachievement of the best results by the contestantdepends, among many, on: level, physical dexterity,somatic build, technical skills and other conditions [2].Numerous publications describe research results whichshow that the body type of every human being is theirbiological, to a high degree, determined geneticallyfeature, i.e. the feature with a great immutability in theperiod of life [3, 4, 5, 6]. That is why an accuratechoice in the aspect of children's body build to theproper sports events contributes to beneficial prognosisthat these individuals will meet, in the future, thesomatic requirements making sports competition on thehighest world level reachable for them.The external manifestation of the development of aparticular person is their body build and thepredispositions to execute particular physical activity.Because of that, somatic build and, most of all, some ofits proportions which have their own developmentcourse, are of great importance in the pole vault [4, 7].So far we have not been able to clearly state which ofthe parameters of somatic build are an exponent orrather a criterion for particular age categories of polevault contestants.The aim of the thesis was to define the relationbetween the somatic parameters and sports results ofthe pole vault jumpers of junior category (16 – 17).MATERIALS AND METHODSCognitive tests were conducted between 2005 and2009 and they included 20 sportsmen aged 16 – 17pole vaulting at the sports club ‘Zawisza’ Bydgoszcz,TS ‘Olimpia’ Poznań, pole vault centre Gdańsk,‘Gwardia’ Piła, ‘Śląsk’ Wrocław.The contestants participated in training classes atthe club 4-6 times a week. The training unit lasts for60-90 min., while at school they were followingPhysical Education programme in the amount of 3-445-minute units a week, with the emphasis oneducation of general physical dexterity.The following methods and research tools wereused in the thesis:•evaluation of physical development,•testing physical dexterity,•recording sports results,•methods of statistical description.In order to conduct the evaluation of physicaldevelopment, somatic build measurements includingthe following indexes were used.•body height (basis-vertex),•weight,•torso length (suprasternale-symphysiom),•lower limb length (basis-symphysion),•upper limb length (acromion-daktylion III),•shoulder width (acromion-acromion),•pelvis width (iliocristale-iriocristale),•thigh circumference,•shank circumference,•arm circumference,•volume of the chest during inhalation,•volume of the chest during exhalation,•chest breadth (the difference of the chest volumeduring inhalation and exhalation).Using the above parameters, somatic build indexaccording to Rohrer was calculated using the followingrelation:Body weight (g) x 100_________________Body height (cm) 3During the research a pair of large bow compasses,scales and measuring tape were used.During the construction of physical dexterityattempts the system of control indexes suitable forcompetition requirements of pole vault was taken intoaccount [8]:•running speed for 30-m distance - high start position(s),•running speed for 15-m distance with a 20-meter runup,•running speed for 15-m distance with a 20-meter runupwith a pole (s),•running speed for 15-m distance with a 20-meter runupwith setting a pole (s),•strength – measured by the long jump with a 20-meterrun-up (cm),

Somatic build vs sports results of pole vault contestants aged 16-17 29•explosive strength – measured by the long jump witha 20-meter run-up,•strength of back muscles and shoulder girdle –measured by lifting feet to the horizontal bar fromstraight arm overhang 5 times (time measured) (s),•strength of back muscles and shoulder girdle –measured by lifting feet to the horizontal bar fromstraight arm overhang (quantity),•strength of shoulder girdle and shoulders' muscles –measured by climbing 3-meter rope (s),•strength of shoulder girdle and shoulders' muscles,horizontal pull-ups (quantity),•strength of shoulder girdle and shoulders' muscles, 5horizontal pull-ups (time measured) (s),•pole vault test (cm),•coordination and explosive strength measured by“flying” over the crossbeam from back somersaultthrough a handstand (from the mattress) (cm),•strength – measured by 4-kg shot put thrown backover the head (m).The execution of the planned attempts waspreceded by a detailed instruction on a way of theirexecution and before their performance the coachconducted a 15-minute warm-up.To conduct the analysis of sports results the officialcompetition protocols were included. The collectedmaterial was analysed statistically using the minimum,maximum and average value, the variations of theexamined parameters and Pearson’s correlation factorswere considered as statistically significant for p

30Mariusz KlimczykComparing the body height of the examined polevault jumpers to the tests' results of M. Napierała(2008), who conducted researches within kujawskopomorskieprovince, shows that the examined polevault jumpers are taller than their peers (M. Napierała:16.5 years old – 175.64 cm). The relation between thebody height of the examined contestants and the bodyheight of the boys in Polish national tests of R.Przewęda and J. Dobosz (2003) looks similar: (16.5years old – 176.49 cm).Comparing the body weight of pole vault jumperswith the tests' results of M. Napierała (2008) withinkujawsko-pomorskie province and Polish national testsof R. Przewęda and J. Dobosz (2003) it is shown thatthe examined pole vault jumpers have greater averagebody weight. In the research of M. Napierała (2008)and R. Przewęda, J. Dobosz (2003)the results arefollowing: M. Napierała 16,5 years old – 65,27 kg; R.Przewęda, J. Dobosz 16,5 years old – 66,49 kg.The conducted analysis of biological developmentof pole vault jumpers contributed to showing therelations resulting from their above naturaldevelopment and, most of all, from the process oforganism's adaptation occurring because ofimplemented training factors used in their athleticsports discipline.In table 1 the parameters of somatic build of polevault jumpers of the junior category (aged 16-17) arepresented.The analysis of body slenderness, defined byRohrer index showed, on the basis of comparison oftests' results of the above index with the author'sprevious tests of the younger contestants doing the polevault [11], the tendency of growth. It can be anevidence of growth of their muscle mass caused bytraining loads and the period of biological developmentof the examined sportsmen, as well as shoulder widthand smaller dynamic of body height. The above indexachieved value of 1.14 (table 2)Table 2. Index of body built by RohrerTabela 2. Wskaźnik budowy ciała wg. RohreraNoRohrer indexAge16-171. 1,14The conducted analysis of physical dexterity tests'results showed significant fluctuation of standarddeviation from 0.03 (first /0-5m/ and second /5-10m/stage of the run for 15-m distance with setting a pole)to 49.48 in the pole vault in particular attempts. In therun for 30-m distance the average value was 4.05 s, theminimum value 3.71 s and the maximum value 4.31 s.In the run for 15-m distance, for 15-m distance with apole and for 15-m distance with setting a pole theaverage values of 1.79 s, 1.85 s and 1.95 s,respectively, were noted. The results of the long jumpat state and with a run-up are interesting. In bothattempts there is a great diversity of results (standarddeviation 25.92 and 31.63). The average of results ofthe long jump at state and with a run-up was 265.5 cmand 577.35 cm. The shortest long jump was 162 cmand the longest was 292 cm. In the long jump with arun-up the worst score was 528 cm and the best 631cm. The pole vault results present a greatest diversityand the difference between the worst and the best one -150 cm. The rest of the results of physical dexterityattempts are presented in Table 3.Correlative analysis of particular physical dexteritytests' results and somatic build of pole vault jumpersaged 16-17 showed numerous statistically significantrelations (table 4). Body height has statisticallysignificant relation with seven physical dexterityattempts; run for 15-m distance (0.46), climbing a rope(0.48), lifting feet to the horizontal bar 5 times (0.79),5 pull-ups on the horizontal bar (0.57), “flying” overthe crossbeam from back somersault (0.64), 4-kg shotput thrown back over the head (058) and pole vault(0.66). Statistically significant relations occur betweenbody weight and run for 15-m distance (0.52), firststage (0-5m), run for 15 m distance with setting a pole(0.49), climbing a rope (0.47) and lifting feet to thehorizontal bar 5 times (0.60). There is at least onestatistically significant relation between shoulderwidth, pelvis width (adequately with lifting feet to thehorizontal bar 5 times /0.52/ and the last stage /10-15m/ of the run for 15-m distance with setting a pole/0.45/). Interesting statistically significant relationsoccur between the length of lower and upper limb andlifting feet to the horizontal bar 5 times (0.68 and 0.72respectively), ‘flying’ over the crossbeam, 4-kg shotput throw back over the head and pole vault (0.60,0.52, 0.64 and 0.64 and 0.52, 0.54) and climbing a rope(0.52 and 0.52). We also found the relation betweenthigh circumference and 4-kg shot put thrown backover the head (0.59) and run for 15-m distance, shankcircumference (0.52).

Somatic build vs sports results of pole vault contestants aged 16-17 31Table 3. The results of physical dexterity of pole vaultjumpers aged 16-17Tabela 3. Wyniki sprawności fizycznej 16-17 letnichskoczków o tyczceNoDexterityStatistical Agetestsvalues 16-17 (n-20)1 run for 30 m (s) Average 4,05SD 0,16min 3,71max 4,312 run for 15 m (s) Average 1,79SD 0,07min 1,67max 1,983 run for 15 m with a Average 1,85pole (s) SD 0,11min 1,69max 2,054 run for 15 m with Averge 1,98setting a pole (s)SD 0,09min 1,81max 2,185 0 - 5 m (s) Average 0,64SD 0,03min 0,59max 0,736 5 - 10 m (s) Average 0,65SD 0,03min 0,60max 0,727 10 - 15 m (s) Average 0,70SD 0,04min 0,62max 0,778 long jump at state Average 265,50(cm) SD 25,92min 162,00max 292,009 long jum p with a Average 577,35Run-up (cm) SD 31,63min 528,00max 631,0010 climbing 3-m rope Average 5,84(s) SD 1,19min 3,31max 8,0211 Pull-ups on the Average 12,00horizontal barSD 3,08(quantity)min 7,00max 17,0012 lifting feet to the Aerage 4,70crossbeam -SD 2,13training stimulator min 1,00(quantity)max 10,0013 lifting feet to the Average 6,20horizontal barSD 0,935 times in goodmin 4,42time (s) max 7,5114 5 pull-ups on the Average 6,11horizontal barSD 1,01in good tim e (s)min 4,22max 7,5415 „ flying” over the crossbeam Average 70,40from back somersault SD 25,74through a handstand min 35,00from the m attress (cm ) max 120,0016 4-kg shot putAverage 14,73thrown back overSD 1,06the head (m ) m in 12,89max 16,2517 pole vault result Average 386,30(cm) SD 49,48min 330,00max 480,00Also many statistically significant relations occurbetween arm circumference, volume of the chestduring inhalation and exhalation and torso length andsome physical dexterity tests. The most interestingrelation occurs between arm circumference andclimbing a rope, lifting feet to the horizontal bar 5times and 5 pull-ups on the horizontal bar (0.51, 0.63,0.60, respectively). Statistically significant relations oftorso length and particular physical dexterity tests areon the level from 0.49 and 0.67. The chest breadth doesnot enter into statistically significant relations with anyphysical dexterity test. It is necessary to emphasise thatmost relations occur on the average and small level ofsignificance.In table 5 the relations of particular somaticfeatures with pole vault result are presented.Statistically significant correlation occurs between fiveout of 13 somatic build features. The relations betweensports result and body height (0.66), upper and lowerlimb length (0.64, 0.54 respectively) are also ofinterest. Interesting is that statistically significantrelation of pole vault occurs with the chest volumeduring inhalation and exhalation (0.45, 0.46).However, the relations of low and average relation arethe most common (table 5).

32Mariusz KlimczykTable 4. Values of correlative analysis of the results of particular physical dexterity tests and somatic build of pole vaultjumpers aged 16-17Tabela 4. Wartości analizy korelacyjnej wyników poszczególnych testów sprawności fizycznej i budowy somatycznej 16-17letnich skoczków o tyczceExamined features – somatic measurementsBody Body Shoulder Pelvis Lower Upper Thigh Shank Arm Chest Chest Chest TorsoExamined parameters height weight wdth width limb limb circum. circum. circum. volume volume breadth length(kg) (kg) (cm) (cm) length length (cm) (cm) (cm) inspiration exhalation (cm) (cm)(cm ) (cm) (cm ) (cm )Results of physical dexterity attem pts No A B C D E F G H I J K L Łrun for 30 m (s) 1 0,16 -0,11 0,08 0,20 0,28 0,50 0,02 -0,20 0,15 0,29 0,30 0,09 -0,28run for 15 m (s) 2 -0,46 -0,52 -0,34 0,24 -0,33 -0,23 -0,41 -0,52 -0,47 -0,31 -0,35 -0,19 -0,59run for 15 m with a pole (s)3 -0,30 -0,22 -0,36 0,19 -0,22 -0,54 -0,22 -0,13 -0,57 -0,44 -0,45 -0,30 -0,34run for 15 m with setting a pole (s)4 -0,35 -0,30 -0,27 0,25 -0,25 -0,39 -0,36 -0,25 -0,34 -0,29 -0,28 -0,10 -0,490 - 5 m (s) 5 -0,42 -0,49 -0,26 0,35 -0,47 -0,41 -0,08 -0,34 -0,26 -0,31 -0,42 -0,04 -0,075 - 10 m (s) 6 -0,41 -0,37 -0,37 0,21 -0,24 -0,43 -0,36 -0,24 -0,48 -0,39 -0,39 -0,29 -0,5410 - 15 m (s) 7 -0,41 -0,21 -0,07 0,45 -0,37 -0,30 -0,18 -0,19 -0,09 -0,17 -0,20 0,03 -0,32long jum p at state (cm )8 0,33 0,26 -0,10 0,07 0,12 0,00 0,10 0,15 0,09 0,09 0,08 -0,01 0,31long jump with a run-up (cm)9 0,09 0,01 -0,41 -0,35 0,21 -0,06 -0,31 -0,01 -0,01 -0,12 -0,10 -0,22 0,18climbing 3-m rope (s)10 -0,48 -0,47 -0,25 0,29 -0,52 -0,52 -0,04 -0,18 -0,51 -0,47 -0,55 -0,16 -0,33Pull-ups on horizontal bar (quantity)11 0,41 0,39 0,34 -0,17 0,19 0,15 0,36 0,25 0,34 0,28 0,24 -0,14 0,63Lifting-stim ulator-feet to the crossbeam (quantity) 12 0,22 0,02 0,11 -0,06 0,15 0,34 0,12 -0,01 0,25 0,27 0,21 -0,05 0,33lifting feet 5 tim es to the horizontal bar in good tim e (s) 13 -0,79 -0,60 -0,52 0,10 -0,68 -0,72 -0,42 -0,29 -0,63 -0,70 -0,76 -0,22 -0,505 pull-ups on the horizontal bar in good tim e (s) 14 -0,57 -0,35 -0,43 0,10 -0,38 -0,49 -0,45 -0,21 -0,60 -0,54 -0,51 -0,13 -0,67„ flying” over the crossbeam from back som ersault 15 0,64 0,26 0,27 0,05 0,60 0,64 0,39 0,09 0,22 0,56 0,54 -0,12 0,304-kg shot put thrown back over the head (m ) 16 0,58 0,28 0,29 0,16 0,52 0,52 0,59 0,32 0,52 0,49 0,45 0,03 0,58p

Somatic build vs sports results of pole vault contestants aged 16-17 33BIBLIOGRAPHY1. Kowalczuk G.I,, Wasniew I.A., Diagnostyka uzdolnieńskoczków o tyczce. W: Fiziczeskaja Kultura –Naukowo-Metodyczny Żurnal no 4. Moskwa[Moscow], 2002.2. Ważny Z., Współczesny system szkolenia w sporciewyczynowym. SiT, Warszawa [Warsaw], 1981.3. Drozdowski S., Dynamika przyrastania dzieciobciążonych różnym wysiłkiem fizycznym. W:Materiały. Konferencja – Biologia populacji ludzkichwspółczesnych pradziejowych. AWF, Poznań, 1993.4. Drozdowski Z., Antropologia sportowa. Morfologicznepodstawy wychowania fizycznego i sportu. Seria:Podręczniki nr 12. AWF, Poznań, 1984.5. Łaska-Mierzejewska T., Antropologia w sporcie iwychowaniu fizycznym. Biblioteka Trenera, COS,Warszawa [Warsaw], 1999.6. 6. Sawczyn S., Kochanowicz K., Kruczkowski D.,Dancewicz T., Cechy prognostyczne w budowiesomatycznej w doborze do gimnastyki sportowej. W:Trening, Kwartalnik Metodyczno Szkoleniowy nr 3PTNKF, Warszawa [Warsaw], 1997.7. Bril M. S., Princypy i mietodiczeskije osnowyaktiwnogo obora szkolnikow dla sportiwnogosowierszenstwowanija. Praca habilitacyjna. GCFK,Moskwa [Moscow], 1986.8. Klimczyk M. Special fitness and a sport result in 19-year-old pole vault jumpers. Medical and BiologicalSciences 2009, 23/3, p 61-67.9. Napierała M. (2008), Środowiskowe uwarunkowaniasomatyczne i motoryczne a wiek rozwojowy dzieci imłodzieży na przykładzie województwa kujawskopomorskiego.Wydawnictwo Uniwersytetu KazimierzaWielkiego, Bydgoszcz.10. 1Przewęda R., J. Dobosz (2003), Kondycja fizycznapolskiej młodzieży, Studia i Monografie nr 98, AWF,Warszawa [Warsaw].11. Klimczyk M. Kierowanie i kontrola szkoleniasportowego tyczkarzy na etapach wstępnym ipodstawowym. Bydgoszcz WydawnictwoUniwersytetu Kazimierza Wielkiego, 2008.12. Drozdowski Z. (1994): Filogenetyczny rozwójmotoryczności człowieka. W: Motorycznośćczłowieka – jak struktura, zmienność iuwarunkowania. Red. W. Osiński. Monografie,Podręczniki, Skrypty AWF, Poznań, no. 310.13. Osiński W. (2003): Antropomotoryka. AWF, Poznań. p367.Address for correspondence:Institute of Physical Culture, Kazimierz WielkiUniversity in BydgoszczHeadmaster Senior Doctor Mariusz Zasadaul. Ogińskiego 1685-092 Bydgoszczytel./fax: 663089733, 52 37 67 910e-mail: Klimczyk1956@poczta.onet.plReceived: 12.07.2011Accepted for publication: 6.12.2011

Medical and Biological Sciences, 2012, 26/1, 35-41ORIGINAL ARTICLE / PRACA ORYGINALNAAlicja Rzepka 1,2, Kornelia Kędziora-Kornatowska 1 , Marlena Jakubczyk 2 , Łukasz Sielski 2 , Krzysztof Kusza 2,3ASSESSMENT OF THE NEEDS AND EXPECTATIONS OF ELDERLY PATIENTSREGARDING PHYSIOTHERAPEUTICAL CARE IN POLANDOCENA ZAPOTRZEBOWANIA I OCZEKIWAŃ PACJENTÓW W STARSZYM WIEKUW ODNIESIENIU DO OPIEKI FIZJOTERAPEUTYCZNEJ W POLSCE1Department and Clinic of Geriatrics of the Nicolaus Copernicus University in ToruńCollegium Medicum in BydgoszczHead: Prof. Kornelia Kędziora –Kornatowska, PhD., M.D.2 Department and Clinic of Anesthesiology and Intensive Care of the Nicolaus Copernicus University in ToruńCollegium Medicum in BydgoszczHead: Prof of UMK Krzysztof Kusza, PhD., M.D.3 Department and Clinic of Anesthesiology and Intensive Care and a Pain Treatment of the Medical Universityin PoznańHead: Prof. Leon Drobnik, PhD., M.D.SummaryI n t r o d u c t i o n . The physiotherapeutic care is asensitive subject for the medical society, the elderly patientsand their carers.A i m . An assessment of the needs and expectation ofelderly patients in relation to physiotherapeutic care inPoland.M a t e r i a l s a n d m e t h o d s . 50 patients, aged61-91, under the care of the Department and Clinic ofGeriatrics of the University Hospital were qualified for thestudy. The study was based on a self-created anonymoussurvey. The questions concerned the needs and expectationsof the elderly regarding physiotherapeutic care. The resultswere analyzed in relation to sex, age, place of residence,marital status and education.R e s u l t s . (80%, n=40) of the patients pointed to theneed for improvement in the field of physiotherapeutic care.20% did not have an opinion on this topic. The need to adjustthe therapeutic services was equally voiced by men andwomen. Methods for improvement of this care would beadvertising the need for medical care in the field ofphysiotherapy (50%, n=25), education (22%, n=11) and morefunds (2%, n=1). 26% (n=13) do not believe any change ispossible while 70% (n=30) believe that in the coming 10years the state of physiotherapeutic care in Poland willimprove, 20% (n=10) - degrade and 10% (n=5) that it willnot change. The subjects expect that in the coming years thewaiting time for medical procedures will be shorter (42%,n=21), that there will be more physiotherapy centres (50%,n=25) and the qualification of the physiotherapeutic staff willimprove (8%, n=4).C o n c l u s i o n s . Elderly patients voice a need forphysiotherapeutic care and its improvement, regardless ofsex, age, marital status, place of residence and education.StreszczenieWstę p : Opieka fizjoterapeutyczna w Polsce stanowiproblem dla środowiska medycznego, starzejących siępacjentów oraz ich opiekunów.Celem pracy była ocena zapotrzebowaniai oczekiwań pacjentów w starszym wieku w odniesieniu doopieki fizjoterapeutycznej w Polsce.

36Alicja Rzepka et. al.Materiał i m e t o d y . Do badaniazakwalifikowano 50 pacjentów w wieku 61-91 lat będącychpod opieką Kliniki Geriatrii oraz Poradni GeriatrycznejSzpitala Uniwersyteckiego im. dr A. Jurasza. Badaniaprzeprowadzono na podstawie anonimowej ankietywłasnego autorstwa. Pytania dotyczyły oczekiwań orazzapotrzebowania na opiekę fizjoterapeutyczną u pacjentów wstarszym wieku. Wyniki przeanalizowano w zależności odpłci, wieku, miejsca zamieszkania, stanu cywilnego orazwykształcenia.Wyniki. Spośród 50 pacjentów (20%, n=40)opowiedziało się za koniecznością poprawy opiekifizjoterapeutycznej (20%, n=10) nie miało na powyższytemat zdania. Potrzebę dostosowania usług terapeutycznychw równym stopniu zgłaszali zarówno mężczyźni, jak ikobiety. Sposobami na poprawę w/w opieki byłobynagłośnienie/rozreklamowanie konieczności opiekizdrowotnej w zakresie fizjoterapii (50%, n=25), edukacjaśrodowiska (22%, n=11) oraz większe fundusze na ten cel(2%, n=1). Brak wiary w zmiany przewiduje (26%, n=13).Stan polskiej opieki fizjoterapeutycznej w najbliższych 10latach stanie się lepszy(70%, n=35) , gorszy (20%, n=10) ,nie zmieni się (10%, n=5). Badani oczekują w przeciągu 10lat skrócenia czasu oczekiwania na zabiegifizjoterapeutyczne (42%, n=21), zwiększenia liczbyośrodków fizjoterapeutycznych (50%, n=25) orazzwiększenia kwalifikacji personelu fizjoterapeutycznego(8%, n=4).W n i o s k i . Pacjenci w starszym wieku opowiadająsię za koniecznością poprawy oraz zapotrzebowaniem naopiekę fizjoterapeutyczną niezależnie od płci, wieku, stanucywilnego, miejsca zamieszkania i wykształcenia.Key words: care, physiotherapy, needs, elderly patients, survey questionnaireSłowa kluczowe: opieka, fizjoterapia, zapotrzebowanie, pacjenci w starszym wieku, badanie ankietoweINTRODUCTIONPhysiotherapy in Poland has been developingrapidly for the last couple of years, taking care ofpatients with locomotor organs’ ailments, neurologicalailments and patients after injuries [1]. However, thereis a lack of specialist physiotherapeutic care designedfor geriatric patients. Elderly patients are often underthe care of many specialists due to many organdysfunctions, often with complications arising frommany years of treatment and problems related withaging – anal incontinence, psychopathologicaldisorders, locomotion and balance dysfunction, falls,failing senses [2]. The need for physiotherapeutic carecatered for geriatric patients is steadily increasing dueto the growing number of people older than 60. This isconfirmed by the studies of the Central StatisticalOffice (Polish: GUS) which predicts that in 2030 therewill be 9.5% more people of 65 years of age, 12.9% -70 and up to 17.3% - 80 years old [3]. Developments inthe field of medicine as well as social care caused lifeexpectancy to increase by 5 years for men and 4.6years for women in the years 1999-2006 [3, 4]. That iswhy it is necessary to adjust physiotherapeutic care tothe needs of this group of patients. This care should beplanned individually and aim at the primary ailment ofa patient [5]. On the other hand, it should also preventphysical disability and dependency on family andcarers [5].AIM OF THE STUDYThe aim of the study was to assess the needs andexpectation of the elderly patients in relation tophysiotherapeutic care in Poland.MATERIALS AND METHODS50 patients over 60 years of age, under the care ofthe Department and Clinic of Geriatrics of the A.Jurasz University Hospital were qualified for the study.The group consisted of 19 men (38%) and 31 women(63%) aged 61-91. A detailed characteristic of thegroup is shown in table 2. The study was based on aself-created, anonymous survey. The questionsconcerned the needs and expectations of the elderlyregarding physiotherapeutic care. The results wereanalyzed in relation to sex, age, place of residence,marital status and education. The study was approvedby the Bioethical Committee.The data was analysed using Excel 2007 andStatistica for Windows 8.0 (created by StatSoft)software. A p

Assesment of the needs and expectations of elderly patients regarding physiotherapeutical care in Poland 37subgroup I (10%), 3 from subgroup II (6%) and 1 fromsubgroup IV (2) had no opinion on this topic [Fig 2].Liczba pacj/Number of patients(%)806040200Fig 1. The need for an improvement of physiotherapeuticcare for the elderly - in relation to sexRyc. 1. Konieczność poprawy opieki fizjoterapeutycznejwśród osób starszych w zależności od płciIn relation to the place of residence, 14 patients(28%) from cities with more than 100 000 residents, 23(46%) from cities below 50 000 residents and 3 (6%)from rural areas were for improving physiotherapeuticcare for the elderly. No resident of a city below 50 000residents nor rural area was against physiotherapeuticcare improvements. 3 patients from cities above100 000 residents (6%), 5 from cities below 50 000residents (10%) and 2 from rural areas (4%) did notvoice any opinion on this topic [Table I].Table I. The opinions of the elderly regarding theimprovement of physiotherapeutic care inrelation to the given characteristicTabela I Opinie osób starszych odnośnie poprawy opiekifizjoterapeutycznej wśród osób w starszym wieku wzależności od danej cechyCecha/ Characteristic Tak/Yes Nie/No Nie Razem/Sumwiem/DonotknowPłeć /Sex Kobiety/Women 17(34%) 0(0%) 14(28%) 31(62%)Mężczyźni/ Men 17 0(0%) 2(4%) 19(38%)(34%)Wiek /Age Podgrupa I/Subgroup I 21(42%) 0(0%) 5(10%) 26(52%)Podgr.II/Subgroup II 12(24%) 0(0%) 3(6%) 15(30%)Podgr.III/Subgroup III 8(16%) 0(0%) 0(0%) 8(16%)Podgr.IV/Subgroup IV 0(0%) 0(0%) 1(2%) 1(2%)Miejsce Pow.100tys./> 100k 14(28%) 0(0%) 3(6%) 17(34%)zamieszkania/ Do 50tys./< 50k 23(46%) 0(0%) 5(10%) 28(56%)Place ofresidenceWieś/Rural area 3(6%) 0(0%) 2(4%) 5(10%)Stan cywilny/Marital statusWykształcenie/EducationKobiety/WomenMężczyzni/MenTak/Yes Nie/No Nie wiem/Donot knowPotrzeba dostosowania opieki do osób starszych/A need to adjustphysiotherapy to the needs of the elderlyZamężny/Married 33(66%) 0(0%) 3(6%) 36(72%)Wdowiec/Widowed 6(12%) 0(0%) 4(8%) 10(20%)Wolny/Single 3(6%) 0(0%) 0(0%) 3(6%)Rozwiedziony/Divorced 1(2%) 0(0%) 0(0%) 1(2%)Podstawowe/Primary 4(8%) 0(0%) 1(2%) 5(10%)Zawodowe/Vocational 10(20%) 0(0%) 2(4%) 12(24%)Średnie/Secondary 14(28%) 0(0%) 3(6%) 17(34%)Wyższe/ Higher 12(24%) 0(0%) 4(8%) 16(32%)When analysing the need for physiotherapeuticcare improvement in relation to marital status it wasobserved that 33 (66%) married patients, 6 widowedpatients (12%), 3 single patients (6%) and 1 divorcedpatient (2%) were for the improvements. None of therespondents were against improving physiotherapeuticcare of the elderly. 3 married patients (6%) and 4widowed patients (8%) had no opinion in this regard[Table I].When analysing the need for physiotherapeuticcare improvement in relation to education 12 (24%)patients with higher education, 14 (28%) withsecondary education, 10 (20%) with vocationaleducation and 2 (8%) with primary education supportimproving physiotherapeutic care. No one was againstthe need for this development. No opinion was givenby 4 (8%) patients with higher education, 3 (6%) withsecondary education, 2 (4%) with vocational educationand 1 (2%) with primary education [ Table I].Fig. 2. The need for an improvement of physiotherapeuticcare for the elderly - in relation to ageRyc. 2. Konieczność poprawy opieki fizjoterapeutyczneju osób starszych w zależności od wiekuWhen analysing the opinion regarding the trendsin physiotherapeutic care in Poland for the next 10years in relation to sex it was observed that 25 (50%)women and 10 (20%) men believed that the changeswould be for the better. Changes for the worst werepredicted by 5 (10%) women and 5 men (10%). Nochanges were foreseen by 1 (2%) woman and 4 (8%)men [Fig 3; Table II].Fig 3. Changes in the Polish physiotherapeutic careproposed by the elderly for the next 10 years - inrelation to sexRyc. 3. Proponowane zmiany w polskiej opiecefizjoterapeutycznej na najbliższą dekadę w opiniiosób starszych zgodnie z płcią

38Alicja Rzepka et. al.Table II. Predictions of the elderly regardingphysiotherapeutic care in the next 10 years inrelation to the given characteristicTabela II. Prognozy na najbliższe 10 lat w opiecefizjoterapeutycznej w zależności od danej cechyCecha/CharacteristicPłeć/SexWiek/AgeNalepsze/For thebetterNagorsze/For theworseBrakzmian/NochangeBrakopinii/NoopinionRazem/TotalKobiety/Women 25(50%) 5(10%) 1(2%) 0(0%) 31 (62%)Mężczyźni/Men 10(20%) 5(10%) 4(8%) 0(0%) 19 (38%)PodgrupaI/ SubgroupI 9(18%) 0(0%) 12(24%) 5(10%) 26(52%)PodgrupaII/9(18%) 2(4%) 1(2%) 3(6%) 15 (30%)SubgroupIIPodgrupaIII/SubgroupIII4(8%) 3(6%) 1(2%) 0(0%) 8 (16%)PodgrupaIV/ Subgroup 0(0%) 0(0%) 1(2%) 0(0%) 1 (2%)IVMiejsce Pow.100tys.> 100k 7(14%) 1(2%) 4(8%) 0(0%) 17(34%)zamieszkania/ Do 50tys.< 50k 11(22%) 2(4%) 10(20%) 5(10%) 28(56%)Place of Wieś/Rural area 3(6%) 0(0%) 0(0%) 2(4%) 5(10%)residenceStan cywilny/ Zamężny/Married 12(24%) 2(4%) 0(0%) 7(14%) 36(76%)Marital statusWdowiec/Widowed 5(10%) 2(4%) 0(0%) 3(6%) 10(20%)Wykształcenie/EducationWolny/Single 2(4%) 1(2%) 0(0%) 2(4%) 5(10%)Rozwiedziony/Divorced 2(4%) 0(0%) 0(0%) 0(0%) 2 (4%)Podstawowy/Primary 0(0%) 2(4%) 3(60%) 0(0%) 5(10%)Zawodowy/Vocational 4(8%) 0(0%) 5(10%) 3(6%) 12(24%)Średnie/Secondary 4(8%) 2(4%) 5(10%) 5(10%) 16(32%)Wyższe/ Higher 10(20%) 3(6%) 2(4%) 2(4%) 17(34%)When analysing the opinion regarding the trendsin physiotherapeutic care in Poland for the next 10years in relation to age subgroup; 9 (18%) patientsfrom subgroup I, 9 (18%) patients from subgroup IIand 4 (8%) patients from subgroup III think that thesituation will improve. 2 patients from subgroup II(4%) and 3 from subgroup III (6%) predict changes forworse. No changes are predicted by 12 (24%)respondents from subgroup I, 1 (2%) from subgroup II,1 (2%) from subgroup III and 1 (2%) from subgroupIV. 5 (10%) patients from subgroup I and 3 (6%) fromsubgroup II gave no opinion [Fig 4, Table II ].Fig 4. Changes in the Polish physiotherapeutic careproposed by the elderly for the next 10 years - inrelation to ageRyc. 4. Proponowane zmiany w polskiej opiecefizjoterapeutycznej na przestrzeni najbliższej dekadyzgodnie z wiekiemAnalysing the opinion regarding the trends inphysiotherapeutic care in Poland for the next decade inrelation to the place of residence showed thataccording to 7 (14%) patients from cities with morethan 100 000 residents, 11 (22%) from cities below50 000 and 3 (6%) from rural areas believe that thiscare will develop. to 1 (2) patient from a city withmore than 100 000 residents and 2 (5%) from citiesbelow 50 000 believe that it will degrade.Respectively, 4 (8%) and 10 (20%) think it will notchange. No opinion was voiced by 5 (10%) patientsfrom cities with less than 50 000 residents and 2 (4)from rural areas [Table II].An analysis of the trends in physiotherapeutic carein Poland for the next decade in relation to maritalstatus showed that 12 (24%) married, 5 (10%)widowed, 2 (4%) single and 2 (4%) divorced patientsbelieve that the changes will be for the better. Changesfor the worse are predicted by 2 (4%) married, 2 (4%)widowed and 1 (2%) single patients. 7 (14%) married,3 (6%) widowed and 2 (4%) single patients did notstate any opinion on this matter [Table II].Opinions regarding changes in geriatric care forthe next decade were compared in relation toeducation. Changes for the better are predicted by 4(8%) patients with vocational education, 4 (8%) withsecondary education and 10 (20%) with highereducation. Changes for the worst are expected by 2(4%) patients with primary education, 2 (4%) withsecondary education and 3 (6%) with higher education.According to 3 (6%) patients with primary education,5 (10%) with vocational, 5 (10%) with secondary and 2(4%) with higher education no changes will happen.No opinion regarding this topic was stated by 3 (25%)patients with vocational education, 5 (31%) withsecondary education and 2 (4%) with higher education[ Table II].Methods for improving the aforementioned carecould be: advertising the need for physiotherapeutichealth care (25 patients, 50%), education in one’s ownsocial group (city, region) (11 patients, 22%) and morefunds (1 patient, 2%). 13 (26%) patients expressed nofaith in any positive changes. Opinions on the methodsfor improving physiotherapeutic care in relation to sex,age, place of residence, marital status and educationare shown in table III.The respondents were asked about what changesthey would like to see in the next 10 years. Theanswers were: shorter waiting time forphysiotherapeutic treatment (42%, n=21), morephysiotherapeutic centres for the elderly (50%, n=25)and an improvement in the qualification of thephysiotherapeutic staff (8%, n=4).

Assesment of the needs and expectations of elderly patients regarding physiotherapeutical care in Poland 39When analyzing the results based on therespondents’ sex, 16 (32%) women and 9 (18%) menvoted for an increase in the number ofphysiotherapeutic centres for the elderly. Shorterwaiting time was pointed out by 16 (32%) women and8 (16%) men. 2 women (4%) and 2 men (4%) wantedbetter qualified staff [Table IV]physiotherapy centres for the elderly. For 5 (10%)patients from cities above 100 000 residents and 9(18%) from cities below 50 000 residents the mostimportant issue is the shortening of waiting times.Physiotherapeutic staff with higher qualification is apriority for 1 (2%) person from a city above 100 000residents and 9 patients (18%) from cities below 50000residents [Table IV].Table III. Methods for improving physiotherapeutic care given by the elderly in relation to the given characteristicTabela III. Sposoby poprawienia opieki fizjoterapeutycznej wśród osób starszych w zależności od danej cechyCecha/ CharacteristicNagłośnieniekoniecznościopiekizdrowotnejwśródpacjentów wstarszymwieku/Promotingthe need forhealthcare forthe elderlyEdukacjaspołeczeństwa/Educating thesocietyAnalysing the opinion regarding the expectedchanges in physiotherapeutic care in Poland for thenext decade in relation to age subgroups showed that14 patients (28%) from subgroup I, 8 (16%) fromsubgroup II and 4 (8%) from subgroup III wanted thenumber of physiotherapeutic centres to increase. Ashorter waiting time was chosen by 1 (2%) person fromsubgroup I , 5 (10%) from subgroup II , and 4 (8%)from subgroup III. 1 patient (2%) from subgroup I, 2(4%) from subgroup II, none from subgroup III and1(2%) from subgroup IV wanted the staff to be betterqualified [Table IV].When analysing the expectations regardingphysiotherapeutic care for the next decade in relationto the place of residence it has been observed that 11(22%) respondents from cities above 100 000residents, 10 (20%) from cities below 50 000 residentsand 5 (10%) from rural areas wanted moreWiększefundusze/MorefundsBrak wiary wjakiekolwiekzmiany/Lack of faithin any changesRazem/TotalPłeć/Sex Kobiety/Women 14 (28%) 7 (14%) 10 (20%) 31 (62%)Mężczyźni/Men 11 (22%) 3 (6%) 1 (2%) 4 (8%) 19 (38%)Wiek/ PodgrupaI/20 (40%) 5 (10%) 1(2%) 26(52%)AgeSubgroup IPodgrupaII/ Subgroup 8 (16%) 4 (8%) 3 (6%) 15 (30%)IIPodgrupaIII/SubgroupIII5 (10%) 2 (4%) 1 (2%) 8 (16%)PodgrupaIV/1 (2%) 1 (2%)Subgroup IVMiejsce Pow.100 tys.> 100k 8 (16%) 5 (10%) 4 (8%) 17(34%)zamieszkania/ Do 50tys. < 50k 18 (36%) 2 (4%) 1(2%) 7 (14%) 28(56%)Place of Wieś/ Rural area 3 (6%) 2 (4%) 5(10%)residenceStanZamężny/Married 20 (40%) 5 (10%) 11 (22%) 36(76%)cywilny/Marital Wdowiec/Widowed 7 (14%) 2 (4%) 1 (2%) 10(20%)statusWolny/ Single 2 (4%) 2 (4%) 1 (2%) 5(10%)Rozwiedziony/Divorced1 (2%) 1(2%) 2 (4%)An analysis of the patients' expectations forphysiotherapeutic care in the next decade incomparison to marital status showed the followingresults. 18 (35%) married, 5 (10%) widowed, 3 (6%)divorced and 1 (2%) single patient wanted morephysiotherapeutic care centres for the elderly. Shorterwaiting times were expected by 15 (30%) married and5 (10%) widowed patients). 3 (6%) married patientswanted the physiotherapeutic staff to become morequalified [Table IV].When analysing the expectations regardingphysiotherapeutic care for the next decade in relationto education it has been observed that 2 (4%) patientswith primary education, 6 (12%) with vocationaleducation, 8 (16%) with secondary education and 9(18%) with higher education wanted morephysiotherapeutic centres for the elderly.

40Alicja Rzepka et. al.Table IV. Changes in the Polish physiotherapeutic care proposed by the elderly for the next10 years in relation to the given characteristicTabela IV. Proponowane zmiany na najbliższą dekadę w opiece fizjoterapeutycznej w opiniiosób starszych w zależności od cechyCecha/ CharacteristicPłeć/SexWiek/ AgeMiejscezamieszkania/Placeof residenceStan cywilny/Marital statusWykształcenie/EducationShorter waiting times are a priority for 1 (2%) ofthe respondents with primary education, 6 (12%) withvocation education, 9 (18%) with secondary educationand 5 (10%) with higher education. 2 (4%) patientswith primary education and 2 (4%) with highereducation would wish for more qualified staff [TableIV].DISCUSSIONWięcejośrodkówfizjoterapeutycznych/More physiotherapeuticcentresKrótszy czasoczekiwania nazabiegi/Shorterwaiting timesAccording to Kostka, the elderly are the largestsocial group benefiting from rehabilitation services.This is caused by a higher frequency of chronicdiseases, a decrease of functional fitness and growingdependency on others [5]. Despite these data the Polishnational health fund was planning to spend only onebillion PLN more on healthcare in 2011 than the yearbefore. Only 4% of this amount will be spent on healthresort care (a part of physiotherapeutic care) for theelderly. These amounts are about 3 times smaller thanin case of German and French healthcare.According to Kornatowska et al. physiotherapeuticcare for the elderly was neglected in the 20th century.This was connected with constant degradation of thevital energy of a person [9]. Patients from theDepartment and Clinic of Geriatrics of the UniversityHospital No. 1 in Bydgoszcz voice a need forimprovements in the field of Polish physiotherapeuticcare. They were mostly from the first age subgroup(between 60 and 70 years of age). This was probablyBardziej Razem/Totalwykwalifikowanypersonel/Betterqualified staffKobiety/Women 16(32%) 13(26%) 2(4%) 31(62%)Mężczyźni/Men 9(18%) 8(16%) 2(4%) 19(38%)Podgrupa I/Subgroup I 14(28%) 11(22%) 1(2%) 26(52%)PodgrupaII/Subgroup II 8(16%) 5(10%) 2(4%) 15(30%)PodgrupaIII/Subgroup III 4(8%) 4(8%) 0(0%) 8(16%)PodgrupaIV/Subgroup IV 0(0%) 0(0%) 1(2%) 1(2%)Pow.100tys./> 100k 11(22%) 5(10%) 1(2%) 17(34%)Do 50tys./< 50k 10(20%) 9(18%) 9(18%) 28(56%)Wieś/Rural area 5(10%) 0(0%) 0(0%) 5(10%)Zamężny/Married 18(36%) 15(30%) 3(6%) 36(72%)Wdowiec/Widowed 5(10%) 5(10%) 0(0%) 10(20%)Wolny/Single 3(6%) 0(0%) 0(0%) 3(6%)Rozwiedziony/Divorced 1(2%) 0(0%) 0(0%) 1(2%)Podstawowe/Primary 2(4%) 1(2%) 2(4%) 5(10%)Zawodowe/Vocational 6(12%) 6(12%) 0(0%) 12(24%)Średnie/Secondary 8(16%) 9(18%) 0(0%) 17(34%)Wyższe/Higher 9(18%) 5(10%) 2(4%) 16(32%)caused by worriesregarding their own healthand the fact that they willhave to start usingphysiotherapeutic servicesdue to disability growingwith age. This iscorroborated byBogowolska at al. studyentitled ‘Life conditions ofthe elderly from LowerSilesia’ which shows that21.3% of patients agedfrom 60-64 userehabilitation services -this percentage grows to24.26 in the 65-69 agegroup. It drastically dropsfor even older patients butnot due to a lack for thistreatment but because of the impossibility to make useof it. This study shows the need for physiotherapeuticcare and its current maladjustment to the elderly [10].The need is greatest amongst people living incities with a population below 50 000. This may beconnected with a small number of physiotherapeuticfacilities – this causes longer waiting times. What ismore, more than one fifth of the elderly from LowerSilesia complain about a lack of a health care centre intheir place of residence and this means no chance forany physiotherapeutic care [10, 11]. Bień confirmsthere results. According to her, health state as well asthe access to healthcare is much worse on rural areaswhen compared to cities. This applies to using medical,dentist and rehabilitation facilities [12]. Moscovice etal. share this view – according to them healthcare inthe rural areas of the USA is different from the one inthe cities. People face many challenges when it comesto accessing healthcare services [13]. These servicescan be improved by developing cost-effective andpractical standards for the healthcare centres. This is atask for the monitoring agencies, service providers andpeople buying medical insurance [13].Majority of married people voted for a need for animprovement of physiotherapeutic care. It must be saidthat this was the most numerous group. This need isprobably connected with the fact that a patient cares forhis/her health as well as the spouse’s health.Kalpakjian et al. say that marriage leads to improvedwelfare and the dissolution of marriage to

Assesment of the needs and expectations of elderly patients regarding physiotherapeutical care in Poland 41impoverishment. What is more, patients who sufferfrom spinal cord injuries and who are at the same timemarred, have a better frame of mind and are less proneto depression than divorced, single or widowedpatients. This study is also interesting as it shows thatwomen after divorce are more satisfied with life andjudge their health better than divorced men [14]. Thisis corroborated by DeVivo et al. According to them,people after such injuries rather stay married anddivorce more rarely. Increased divorce risk is true onlyfor the young, Afro-American and without children[15].Most people with secondary education wantedphysiotherapeutic care to improve. This was the mostpopulous group. Oztürk believes this to be otherwise.According to his study, there is no statisticallysignificant difference between education, sex, maritalstatus and the appearance of chronic diseases and theirtype amongst the elderly [16].According to most women, people from the firstand second age subgroup, residents of cities below50 000, married people and people with highereducation Polish physiotherapeutic care will improvein the coming decade. This may be connected with thefact that these groups are the most numerous and theyoungest – and consequently the most optimistic andhaving a stabilised personal life. The issues whichshould be addressed first in the coming years are longwaiting times for physiotherapy, not enoughphysiotherapy centres and an improvement of thequalification of the physiotherapy staff.According to the 2009 report, the MazovianCentre of Social Policies spent over 7 million PLN onphysiotherapeutic care. The money was spent onrehabilitation facilities, as well as and modernising theexisting social help centres [17].We have a similar situation in the Greater Polandvoivodeship where the Family, Social Issues andPublic Healthcare Commission of the Poznan CityCouncil spent 600 000 PLN for rehabilitation servicesfor Poznan citizens older than 60. The aim of thisinitiative was to ensure the elderly access torehabilitation (underfinanced by the National HealthFund) and, in consequence, to improve their health andstop further disabilities. However, this is only a smallpart of the physiotherapeutic need of the elderly inPoland [18].CONCLUSIONSElderly patients in Poland expectphysiotherapeutic care to improve. This is irrespectiveof age, sex, marital status, place of residence andeducation.REFERENCES1. Zembaty A. Kinezyterapia tom1 . Kraków 2002.Wydawnictwo Kasper S.p. z.o. o str. 9-14.2. Kędziora-Kornatowska K, Muszalik M. Kompendiumpielęgnowania pacjentów w starszym wieku.Wydawnictwo Czelej Lublin 2007 str 79-883. Prognoza ludności na lata 2008-2035, GUS Warszawa2009 tab. A6 str 2044. Wieczorowska-Tobis K, Kostka T, Borowicz A.M.Fizjoterapia w geriatrii, Wydawnictwo LekarskiePZWL. Warszawa 2011.5. Kostka T, Koziarska- Rościszewska M. Choroby wiekupodeszłego. Wydawnictwo Lekarskie PZWL.Warszawa 2009: 1646. Rosławski A. Wybrane zagadnienia z geriatrii. AWFWrocław 2008: 9-117. Wieczorowska-Tobis K., Talarska D. Geriatria ipielęgniarstwo geriatryczne. PZWL Warszawa 2008:335-3418. Uprawnienia kombatantów do korzystania zeświadczeń zdrowotnych bez kolejki [NarodowyFundusz Zdrowia]9. Adres: http:// www.nfzwarszawa.pl/index/pacjent/kom_1108201010. Kondycja życiowa dolnośląskich seniorów Raport zbadań. Część II. Analiza wyników badań.http://www.dops.wroc.pl/publikacje.php11. Kondycja życiowa dolnośląskich seniorów. Raport zbadań. Część I http://www.dops.wroc.pl/publikacje.php12. Bień B. Health care services for the elderly living in therural area of Poland13. Przegl Lek. 2002, 59(4-5): 211-215Address for correspondence:mgr Alicja RzepkaDepartament and Clinic of Geriatricsof the Nicolaus Copernicus University in ToruńCollegium Medicum in Bydgoszcz85-094 Bydgoszcz, M. Curie-Skłodowskiej 9 Streettel/fax (052) 585-49-00e-mail: Alicja_Rzepka@vp.plReceived: 18.05.2011Accepted for publication: 6.12.2011

Medical and Biological Sciences, 2012, 26/1, 43-49CASE REPORT / PRACA KAZUISTYCZNAMałgorzata Łukowicz 1 , Magdalena Mackiewicz-Milewska 2 , Sabina Lach-Inszczak 2 , Iwona Szymkuć 2 ,Wojciech Hagner 2TRANSPEDICULAR STABILIZATION COMPLICATIONS IN THORACIC REGIONOF THE SPINE AFTER SCI - THREE CASES REPORT AND LITERATURE REVIEWPOWIKŁANIA PO STABILIZACJI TRANSPEDIKULARNEJ ODCINKA PIERSIOWEGOKRĘGOSŁUPA U PACJENTÓW PO URAZIE RDZENIA KRĘGOWEGO– OPIS TRZECH PRZYPADKÓW I PRZEGLĄD LITERATURY1The Lasetherapy and Physical Therapy Department, Nicolaus Copernicus University in ToruńCollegium Medicum in BydgoszczHead: dr n. med. Małgorzata Łukowicz2 The Department of Rehabilitation, University Hospital in BydgoszczNicolaus Copernicus University in Toruń, Collegium Medicum in BydgoszczHead: prof. dr hab. Wojciech HagnerSummaryA case report of three cases of complications aftertranspedicular stabilization in thoracic part of the spine.O b j e c t i v e s . The aim of the study was to report thecomplications after surgical stabilization in thoracic level ofthe spine that could be very dangerous and cause manysymptoms. All patients were treated in The Department ofRehabilitation, University Hospital in Bydgoszcz, CollegiumMedicum of Nicolaus Copernicus University in Bydgoszcz,PolandC a s e r e p o r t 1 . The case of 24 year old patientafter spinal fracture within T9 as well as T12 level wasintroduced. The patient was subjected to transpedicularstabilization within the levels of T8-T10 and T11-L2. InASIA classification A, the lack of any sensation in sacralsegments, no anal sphincter motor activity was noticed.Complications manifested by dislocation of screws as well aspostoperative wound infection occurred, what caused thenecessity for the stabilizer removal. These complicationsexerted harmful effect on early rehabilitation process. Thepatient underwent three surgical procedures resulted fromdislocation of screws.C a s e r e p o r t 2 . 31 year old male patient after SCIin T6 region of the spine. He was treated with transpedicularstabilization within the levels of T5-T6. The complicationwas screw translocation in vertebral body T5 and connectingaortic aneurysm. He was successfully operated by thoracicsurgeons.C a s e r e p o r t 3 . 26 year old male patient afterfracture of T5 and T6 vertebra column. He was operated withtranspedicular stabilization. He had fever and respiratorytract infection symptoms; after radiological examination thediagnosis of pleuritis was stated and a dislocation of screw inT3 and T4 vertebral body. He was treated conventionallywithout operation.ConclusionsComplications prolong as well as disturb rehabilitationtreatment. The control radiographic examinations need to beperformed directly after operative treatment to evaluate thestabilization system during walking and assuming the erectposition. Increased pain ailments within spinal cord segmentthat was subjected to surgical procedure may signify thepossible dislocation of screws. Such dislocation, noticedwithin thoracic region, can be life-threatening, because of thenearness of the significant anatomical structures.

44Małgorzata Łukowicz et. al.StreszczenieOpisano trzy przypadki pacjentów, u których wystąpiłypowikłania po stabilizacji transpedikularnej odcinkapiersiowego kręgosłupa.Celem pracy było opisanie powikłań po stabilizacjiodcinka piersiowego kręgosłupa, które mogą byćniebezpieczne dla zdrowia i życia chorych oraz są przyczynąwystąpienia wielu dolegliwości.1 opis przypadku. 24-letnia chora po złamaniukręgosłupa z uszkodzeniem rdzenia kręgowego na poziomieT9 i T12. Została zakwalifikowana do wykonania stabilizacjitranspedikularnej na wysokości od T8 do T10 oraz od T11 doT12. W klasyfikacji ASIA A, bez czucia oddawania moczu istolca oraz czynności zwieraczy odbytu i cewki moczowej.Powikłaniem po stabilizacji było nieprawidłoweumieszczenie śruby transpedikularnej oraz zakażenie ranypooperacyjnej. Wskutek tych powikłań konieczne byłousunięcie całej stabilizacji transpedikularnej. Zdarzenia teznacznie spowolniły i ograniczyły cały proces rehabilitacji.Pacjentka łącznie została poddana trzem operacjomneurochirurgicznym wskutek nieprawidłowego umieszczeniaśrub transpedikularnych.2 opis przypadku. 31-letni mężczyzna po urazierdzenia kręgowego na wysokości T6. Wykonano stabilizacjetranspedikularną na poziomach od T5-T6. Powikłaniem byłonieprawidłowe umieszczenie w trzonie kręgu T5 śrubytranspedikularnej, co spowodowało powstanie tętniaka aorty.Ostatecznie chory ponownie był operowany przez zespółneurochirurgów i chirurgów naczyniowych z dobrymrezultatem.3 opis przypadku. 26-letni mężczyzna pozłamaniu kręgosłupa i uszkodzeniu rdzenia kręgowego nawysokości T5 i T6. Po wykonaniu stabilizacjitranspedikularnej wzrosły parametry stanu zapalnego tj.gorączka oraz cechy zapalenia dróg oddechowych.Wykonano zdjęcie radiologiczne płuc, które wykazałozapalenie opłucnej oraz nieprawidłowe położenie śrubtranspedikularnych w trzonach T3 i T4. Chorego leczonozachowawczo.Wnioski. Powikłania opóźniają oraz zaburzają całyproces rehabilitacji pacjenta. Kontrola radiologiczna powykonaniu stabilizacji transpedikularnej powinna byćwykonywana również po zabiegu operacyjnym, abyzapewnić choremu bezpieczną pionizację oraz naukę chodu.Wystąpienie dolegliwości bólowych wzdłuż dermatomówodpowiadających poziomom wykonanej stabilizacjitranspedikularnej może wskazywać na nieprawidłowepołożenie śrub transpedikularnych. W odcinku piersiowymtakie powikłanie może być groźne dla życia chorych, zpowodu bliskiego położenia ważnych strukturanatomicznych.Key words: spinal cord injury, thoracic injury, paraplegia, transpedicular stabilizationSłowa kluczowe: uraz rdzenia kręgowego, urazy odcinka piersiowego kręgosłupa, stabilizacja transpedikularnaINTRODUCTIONIt was estimated during the International SpinalCord Society Conference in 2001 that approximately17.2 people per million of the population in Europesuffer from traumatic SCI (spinal cord injury) everyyear. [1] Young people with average age of 40 yearsold suffer from these injuries. More often these aremen than women; it is approximately 5-6 times more.The cause of the spinal cord injuries are usuallycommunication accidents.Looking at the incidence of levels of the injury it isestimated that approximately 52% of cases are incervical region, 46% in thoracic, lumbar and sacralregion, remaining percentage is unrecorded.In complete paraplegia there was the evidence ofrecovery from flaccid muscle to antigravity grade in86% of the muscles, but if there was no activity, only26% of muscles can improve their activity toantigravity grade. The presence of sensation in thesacral region or voluntary anal sphincter motor activityis a good prognostic factor for neurological recoveryand whole rehabilitation process. [2]There are a lot of therapeutic indications toneurosurgery interventions after spinal cord injury.Without any doubts the most serious and obvious isinstability of the spine or/and neurovascular structurescompression. Immediate those structuresdecompression decreased the risk of neurologicaldeficits progression. The treatment of choice presentstranspedicular stabilization performed within the firsttwenty-four hours following injury and then – intensiverehabilitation. This procedure gives patients a chanceto improve their quality of life and achieve maximumprogress in rehabilitation process and treatment.The postoperative complications are very seldom.However, the most common are both generalpostoperative wound infections, especially thepostoperative wound infection, as well asextravertebral localization of transpedicular screws.Dislocation of the screws are the cause of vascularor/and neurological structures damage. However, forexample thoracic aorta aneurysm is a rare complicationafter transpedicular stabilization because of spinal cordinjury.

Transpedicular stabilization complications in thoracic region of the spine after SCI - three cases report and literature review 45CASE 1History data. Patient (female) sustained the fractionof T9 and L1 vertebral bodies along with spinal cordinjury within this level. Moreover, there werehaemothorax as well as bilateral rib fracture noticed.The transpedicular stabilization was applied at the dayof accident, at the level of T8 – L1. Twenty days aftersurgical procedure, the patient was subjected to another– the correction of localization (decompression ofspinal cord, removal of osteal fragments from duralsac, replacement of stabilization, introduction of titanplates).Examination. During the admission to a hospital,the patient notified intense pain ailments – root paintype. The examination revealed decreased muscle toneof lower limbs, decreased tendon and periostealreflexes, lack of active movements within lower limbsand trace movement in hip joint. Fecal and urinaryincontinence were observed.Evaluation:‐ ASIA (A)‐ WISCI II 7- The patient adapted to activewheelchairCourse of treatment. Girdle pain ailments withinthe thorax intensified while tilting the patient to erectposition and limited significantly the breathingexercises. That is why the imaging examination, whichrevealed incorrect localization of stabilization systemof T8-T10 – direct neighborhood of screw with aorta atthe left side, within T8 level (Fig. 1), as well asinfringement of vertebral body, was carried out.Another surgical procedure was carried out –repositioning of T11 screw, at the left side and T8, atthe same surface, due to excessive mobility and alsolimited location. The control CT examination revealedposition of T11 screw; T8 screw localized in a directcontact with vertebral canal but not clashing withvertebral column structures. There were antibioticsintroduced into the therapy.Persistent pain ailments, notified by the patientwithin the thorax, receded immediately after theprocedure. At the beginning the healing process ofpostoperative wound proceeded successfully, but then,the wound started dripping. The inoculation wasperformed. Unfortunately, the infection (Methicillin-Sensitive Staphylococcus Aureus) covered the wholestabilization region. The attempt of a treatment withguided antibiotic was taken. The whole stabilizingsystem was removed since the improvement had notbeen noticed.Fig. 1. NMR examination of the spinal column – the screwmodulates the abdominal aortaCASE 2History data. 31 year old patient (male) wasadmitted to the University Hospital in Bydgoszcz withdeep tetraparesis.Six weeks before admission, the patient sustainedmultiorgan injury (ski accident), including cranialtrauma (brain and brain stem contusion, secondarysubarachnoid bleeding) as well as the thoracic spinalcord injury. NMR examination revealed: compressionfracture of T6 vertebral body along with angularposition of spinal column, intervertebral stenosisbetween T5-T6 and T6-T7, some part of chondroosseousstructures translocated into the central canal,exerting pressure on spinal cord at the distance ofabout 15 mm.The neurosurgical procedure for thoracic spinalcord stabilization was delayed up to the fifth day, dueto the serious general condition (3 GCS).Transpedicular screws were introduced within the levelof T5-T7, using X-ray monitor. There wasdecompression laminectomy applied at the T6 level.The existing compression syndrome evoked byfragments of fractured bone from vertebral body wasnoticed within the dural sac. The posterior spinalarthrodesis was carried out by means of OMEGAinstrumentarium what made decompression within thelevel of fracture possible.Examination. Patient admitted to the rehabilitationdepartment within 6 weeks after the injury. Patient wasconscious, without verbal contact; serious paresis oflower limbs was observed, without arbitrary movement

46Małgorzata Łukowicz et. al.of lower limbs, upper limbs paresis, more significant atthe right side, paresis in regression, withoutdysesthesia.Evaluation:GCS 13ASIA BWISCI II 0 (at admission) and 7 (after therapy)Course of treatment. The arbitrary movement oflower limbs, flexion within hip, knee joints as well asfeet movement appeared in a course of hospitalization.Upper limbs paresis subsided completely. Because ofpain ailments within thoracic cord intensification, therewas guided X-ray imaging of T5-T7 carried out whichdisclosed extravertebral location of T5 screw (Fig. 2).Guided CT examination of T3-T8 thoracic cord levelwas performed and revealed posttraumatic-state of T6vertebral body fracture and postoperative state ofstabilization within T5-T7 level. The screwsincorporated at the level of T5 and T7, at the left side -laterally situated from the vertebral pedicles andbodies, and their extremities were localized withindirect neighbourhood of descending aorta.Fig. 3. The aorta aneurysm in angio-CT examinationA group of physicians consisting of neurosurgeon,vascular surgeon as well as cardiosurgeon decided toremove dislocated screw.The procedure was accompanied by vascularsurgeons because of the serious risk of surgicalintervention. Postoperative course was uncomplicated.As a result of stabilization removal from T5 regionand non-union of fragments of T6 vertebra, patient wasequipped with orthesis stabilizing thoracic cord,anticipated for the period of three months. CT controlexamination of aorta that was carried out directly afterthe procedure, 6 and 12 months after it, revealedaneurysmal bulge of descending aorta at the distance of7mm and diameter of 5 mm. The patient stays underregular supervision of vascular surgeon.Nowadays, the patient reveals satisfactoryneurological state (ASIA C), walks independently,with crutches at long distances (WISCI), went back towork.CASE 3Fig. 2. CT scan of T5 screw extravertebral locationAnother, CT angiography examination revealedaneurysmal bulge of thoracic aorta within a distance ofabout 5 mm and T5 screw extremity adhered to it. Thescrew applied to T7 vertebra at the left side modulatedthoracic aorta from medial side (Fig 3.).History data. 26 year old patient admitted to therehabilitation department with serious paraparesis, twoweeks after surgical operation of spinal fracture. Hesustained the fracture of T5 and T6 vertebral bodiesalong with the spinal cord injury, located at the samelevel, as a result of traffic accident. The transpedicularstabilization within the level of T3-T8 was carried out.There were screws applied to T3, T4, T6, T7 as well asT8 vertebral bodies.

Transpedicular stabilization complications in thoracic region of the spine after SCI - three cases report and literature review 47Examination. Patient suffering from paraparesis,none muscle tone, deep reflexes, superficial sensibility,deep pain and temperature sensitivity below T6 level.Fecal and urinary incontinence was observed.Evaluation:ASIA AWISCI II 0 (at admission), 1 (after therapy)Course of treatment. Patient demonstratedsubfebrile states, gradual increase of temperature aswell as inflammatory state indexes (CRP 163 mg/l,WBC 14 x 10 3 /ul), at the beginning the pleural rubover lung fields, then vesicular murmur lowered. Therewere X-ray examination of lungs and CT scan of spinalcolumn carried out within the region of stabilization tofind the source of inflammation. Dislocation of screwwithin T3 and T4 vertebral column was disclosed – itprotruded about 9mm in front of T3 and 6mm in frontof T4 vertebral body (Fig.4).Fig. 4. CT scan of T3 and T4 screw extravertebral locationInflammatory atelectasis connected with pleuralexudates. The pleurisy was diagnosed. Afterconsultation with neurosurgeon and thoracosurgeon, itwas decided to abandon the operative treatment andapply conservative therapy. Patient discharged fromhospital with improvement, tilted up.DISCUSSIONThe application of spinal column stabilizationincreased in frequency during the last few decades. It isconnected with development of knowledge concerningspinal column injuries, operative techniques as well asapplication of more and more advanced instruments[7].The precursor of currently applied transpedicularstabilization technique was King which introduced themethod in 1948. Roy-Camille improved it and spreadwithin the 70’s.Unfortunately, along with increased amount of thetranspedicular stabilization procedures, the problemsconnected with damages like: fractures or dislocationsof screws appear more often. In accordance withVanichkachorm, the value amounts to 3-19% and 4-8%- according to McAfee [7, 8].The diameter of spinal canal is of great significancein thoracic spine fractures. The canal diameter of thethoracic spine is narrower than that of the cervical andlumbar spine. At the T6 level, the long axis of thespinal canal is approximately 16 mm in diameter,whereas in the middle of cervical and lumbar spine, thelong axis is 23 mm and 26 mm, respectively. Thesmaller diameter may make fixation techniques such assublaminar wire fixation more difficult.Dislocation of screws may damage partially orcompletely the spinal cord, roots, liquorrhoea as wellas may cause the injury of main vessels [10, 11, 12].There was compression on spinal roots noticed,correlated with pain ailments of thorax, escalatedduring the motion. In case of the third patient,dislocated screw at the level of T3 and T4 vertebralbodies, modulated the pleura, what causedinflammatory reaction. In the second case, incorrectlocation of transpedicular screw caused aneurysmalbulge of thoracic aorta at a distance of about 5 mm,where Th5 screw extremity adhered to it. Theanatomical nearness of thoracic cord and the aortapresents increased danger of injury during theprocedure [13].Most of described injures of aorta, resulting fromcomplication after transpedicular stabilization, werecaused by the damage of wall due to interaction ofvascular wall and metal instruments. Metal causeserosion of vascular walls and finally the aortoclasia,which may be deadly [12, 13, 14].Another reason for damage of aorta is dislocationof transpedicular screws, what causes direct tremor ofvascular wall. This dislocation caused formation ofthoracic aorta false aneurysm in the first case report.Minor described similar case [14]; dislocation of screwwithin T5 segment caused aortic wall injury and it wasdiscovered within the routine CT examination.Dislocation of transpedicular screws, described inour cases as well as by Minor, had place despite the

48Małgorzata Łukowicz et. al.fact that the procedures were enhanced by X-rayimaging. Such control presents a standard [8].Nearness of thoracic spinal cord as well as aortarun the risk of vascular injury resulted from theprocedure of screws removal [14, 16]. In the secondcase, the procedure of screw removal was carried outby posterior-access surgical procedure, in a presence ofvascular surgeon and the operating room was preparedfor the possible thoracotomy. Minor assumed thesimilar pattern of procedure [14]. Vanichkachorndescribes difficulties of broken screw removal withinT12 segment, which translocated during the procedureand had direct contact with aorta [7]. The possibility ofaorta injury resulting from application oftranspedicular stabilization in thoracic region of thespine is caused by nearness of these structures.Especially, the anterior-access procedures bring a riskof complications [12, 13, 16].Iatrogenic false aneurysm of thoracic segmentsoccurs during the invasive cardiologic procedures orafter some time, as a postoperative complication (e.g.intraaortic counterpulsation) [13] or as a result ofcardiosurgical procedures (after coarctation of theaorta, direct vascular wall injury, aortic valvereplacement and others) [16, 17, 18]. Transpedicularstabilization presents rarely described etiology of suchaneurysms.It seems, the correctly performed supervision ofpatients after transpedicular stabilization located withinthoracic region, allows early detection of the possiblecomplications. In accordance with many authors, thecontrol should take place after 2, 8, 12, 26 and 52weeks [8, 11, 14, 19, 21]. There is no standardregarding the imaging method (X-ray or CT scan).Computer tomography examination seems to beindicated at least in case of the first supervision.The back pain can not be disregarded in case ofpatients subjected to procedures of spinal cord injuries,which may stay irrelevant; however, it can result fromdislocation of stabilization instruments, the presence ofaortic aneurysm or irritation of other structures that arelocated within direct neighbourhood [22, 23, 24, 25,26, 27, 28, 29].CONCLUSIONSComplications prolong as well as disturbrehabilitation treatment.The control radiographic examinations need to beperformed directly after operative treatment to evaluatethe stabilization system during walking and assuming oferect position. Increased pain ailments within spinalcord segment that was subjected to surgical proceduremay signify the possible dislocation of screws. Suchdislocation, noticed within thoracic region, can be lifethreatening,because of the nearness of the significantanatomical structures.REFERENCES1. Paddison S, Middleton F. Spinal Cord Injury. (in) StocesM. Physical Management in Neurological Rehabilitation.Edinburgh 2004: 125-152.2. Walters R.L., Adkins R.H., Yakura J.S. et al. Motor andsensory recovery following incomplete paraplegia. ArchPhys Med Rehab 1994a, 75:67-72.3. Collins W. Surgery in the acute treatment of spinal cordinjury: a review of the past forty years. J Spinal CordMed 1995, 18:3-8.4. American Spinal Injuries Association (ASIA)International Standards for Neurological and FunctionalClassification of Spinal Cord Injury. Chicago: ASIA;1992.5. Ditunno J.F., Young W., Donovan W.H. TheInternational Standards booklet for neurological andfunctional classification of spinal cord injury. Paraplegia1994, 32; 70-80.6. Ditunno J.F., Ditunno P.L., Graziani V. et al. WalkingIndex for Spinal cord injury (WISCI). An internationalmulti centre validity and reliability study, Spinal Cord2000, 38: 234-243. Revision: (WISCI II) Spinal Cord2001, 39:654-656.7. J.S. Vanichkachorn, A.R. Vaccaro, C.M. Cotler. Potentiallarge vessel injury during thoracolumbar pedicleremoval: a case report. Spine 1997, 22 (1); 110-113.8. J. Yue, A. Sossan, C. Selgrath, S.L. Deutsch, K. Wilkens,M. Testaiuti, P.J.Gabriel. The treatment of unstablethoracic spine fractures with transpedicular screwinstrumentation: a 3 year consecutive series. Spine 2002,27 (24), 15; 2782-2787.9. Leahy M. Thoracic Spine Fractures and Dislocations.www.emedicine.com/orthoped/topic567.htm10. R. A. Dickson Spinal cord injuries. Early surgicaltreatment. Paraplegia 1992; 30: 43-45.11. A. Vaccaro, S. Rizzolo, R.A. Balderston, T.J. Allardyce,S. R. Garfin, C. Dolinskas, H. S. Howard. Placement ofpedicle screws in the thoracic spine. The Journal of Boneand Joint Surgery 1995, 77, 8; 1200-1206.12. Tsutomu Ohnishi, Masashi Neo, Mutsumi Matsushita,Masashi Komeda, Tadaaki Koyama, Takashi Nakamura.Delayed aortic rupture caused by implanted anteriorspinal device. The Journal of Neurosurgery (Spine 2) 952001; 253-256.13. W Roy-Smythe, JP Carpenter. Upper abdominal aorticinjury during spinal surgery. The Journal of VascularSurgery 1997, 25; 774-777.

Transpedicular stabilization complications in thoracic region of the spine after SCI - three cases report and literature review 4914. M.E. Minor, N.J. Morrissey, R. Peress, A. Carroccio, S.Ellozy, G Agarwal, V. Teodorescu, L. Hollier, M.L.Marin. Endovascular treatment of an iatrogenic thoracicaortic injury after spinal instrumentation: case report. TheJournal of Vascular Surgery 2004, 39, 4; 893-897.15. W.C Sternbergh , Gonze M.D, C.L Garrard , S.R. Money. Abdominal and thoracoabdominal aortic aneurysm.Surg Clin North Am 1998;78:827-43.16. D W. Polly,J R.Orchowski, R G.Ellenbogen. Revisionpedicle screws: bigger,larger shims-what is best? Spine1998, 239 (12); 1374-1379.17. Mandak J, Lonsky V, Dominik J, Zacek P. Vascularcomplications of the intra-aortic ballon counterpulsation.Angiology 2005; 70:69-74.18. Ince H, Petzsch M, Rehders T, Kische S, Korber T,Weber F, et al. Percutaneous endovascular repair ofaneurysm after previous coarctation surgery. Circulation2004; 108 : 2967-70.19. R.F. Mclain, JK Burkus, D.R. Benson. Segmentalinstrumentation for thoracic and thoracolumbar fractures:prospective analysis of construct survival and five yearfollow-up. The Spine Journal 2000, 1; 310-323.20. Milas Z. L, Dodson T. F, Ricketts R. R. Pediatric blunttrauma resulting in major arterial injuries. The AmericanSurgeon 2004; 70: 443-447.21. Cook S. D., Salkeld S. L., Whitecloud T. S., Barbera J.Biomechanical testing and clinical experience with theOMEGA-21 spinal fixation system. The AmericanJournal of Orthopedics. 2001; 30 (5): 387-9422. Jendrisak M. Spontaneous abdominal aortic rupture fromerosion by lumbar spine fixation device: A case report.Surgery 1986, 99, 5; 631-63323. Heini P., Scholl E. Fatal cardiac tamponade associatedwith posterior spinal instrumentation. A case report.Spine 1998; 23(20): 2226-3024. Finkelmeier A., Mentzler R. M. Chronic traumaticthoracic aneurysm: report of two cases with the questionof timing for surgical intervention. The Journal ofCardiovascular Surgery; 1982, 84: 257-26625. Bacharach J. M., Garratt K. N., Rooke T. W. Chronictraumatic thoracic aneurysm: report of two cases with thequestion of timing for surgical intervention. The Journalof Vascular Surgery 1993; 17: 780-326. Coselli J. S., LeMaire S. A. Surgical techniques.Thoracoabdominal aorta. Cardiol Clin 1999; 17: 751-6527. Schnee Ch.L., Ansell L.W. Selection criteria andoutcome of operative approaches for thoracolumbar burstfracture. The Journal of Neurosurgery 1997; 86: 48-5628. Donovan W.H. Operative and nonoperative managementof spinal cord injury. A review. Paraplegia 1994; 32:375-38829. Alho A. Operative treatment as a part of thecomprehensive care for patients with injuries ofthoracolumbar spine. Paraplegia. 1994; 32: 509-516Address for correspondence:sabinalach-inszczak@wp.plReceived: 8.03.2011Accepted for publication: 5.07.2011

Medical and Biological Sciences, 2012, 26/1, 51-54CASE REPORT / PRACA KAZUISTYCZNAEdyta Sutkowska 1 , Anna Kołtowska 2 , Krzysztof Mastej 3 , Rajmund Adamiec 3TUBEROUS SCLEROSIS, LATE DIAGNOSIS: A CASE ANALYSISSTWARDNIENIE GUZOWATE, PÓŹNE ROZPOZNANIE: OPIS PRZYPADKU1 Department and Clinic of Orthopaedic and Traumatologic Surgery- Division of RehabilitationHead of the Department: Prof Szymon DraganHead of the Division of Rehabilitation: Prof Zdzisława Wrzosek2 General Radiology, Interventional Radiology and Neuroradiology Clinic of Wroclaw MedicalUniversity 3 Department of Angiology, Hypertension and Diabetology of Wroclaw Medical UniversitySummaryTuberous sclerosis (TS) is an uncommon, congenitaldisease, usually diagnosed during childhood. It is rare to findundiagnosed adult patient. The fundamental feature of TS isthe presence of multifocal malignant tumors. In this study wepresent a case of a 50-year-old woman with multiple tumors.The characteristic features e.g. on the brain and abdomen CThelped us diagnose this rare disease despite patient’s age. Weaimed at stressing the importance of careful medicalexamination because of oligosymptomatic patients with TS.StreszczenieStwardnienie guzowate jest rzadką chorobą wrodzoną,zazwyczaj diagnozowaną już w dzieciństwie. Wyjątkiem sąosoby dorosłe, u których diagnoza zapada w życiu dojrzałym.Typowo w tym schorzeniu występują liczne guzy, o bardzoróżnej lokalizacji. W poniższym opracowaniu prezentujemyprzypadek 50-letniej kobiety z późno zdiagnozowanymi,licznymi zmianami guzowatymi w narządach. Ze względu, jakwspomniano, na nietypowy dla rozpoznania stwardnieniaguzowatego, wiek pacjentki dopiero charakterystyczne zmianyw tomografii komputerowej głowy i jamy brzusznej pozwoliłyna postawienie diagnozy. Opisany przykład podkreśla wagędokładnych badań, także dodatkowych, u chorych zniejasnymi zmianami i konieczność uwzględnienia takżenietypowych dla wieku, rzadko występujących choróbwrodzonych.Key words: tuberous sclerosis, mutation, hamartoma, congenital diseaseSłowa kluczowe: stwardnienie guzowate, mutacja, hamartoma, choroba wrodzonaINTRODUCTIONTuberous sclerosis complex (TSC) is anuncommon, autosomal dominant disorder characterizedby multifocal tumors. The prevalence of TSC is 1:8000 to 1: 30 000 [1].Disease is caused by mutations in the TSC1 andTSC2 tumor suppressor genes on chromosomes 9q34and 16p13.3, respectively [2]. These mutations resultin uncontrolled cell growth and tumourigenesis.The main changes in TSC include hamartomas,hamartias, hamartoblastomas, or choriostomas [3].In TSC a number of organs are affected, includingthe skin (prevalence depends on the type ofdisturbances), eyes (approximately 40%) [4], heart(rare in adults) and liver (40%-50%) [5], lungs (26%-39%) [6,7], while the kidneys (75T-85%) [8] and brain

52Edyta Sutkowska et. al.(80%-95%) [9] are the two most frequently involvedorgans [10].Tuberous sclerosis (TS) is a disorder with avariable clinical presentation usually diagnosed duringchildhood. Mental retardation and seizures are themost frequent clinical problems that are manifestedduring infancy or childhood. The diagnosis is based onclinical criteria - a combination of signs classified asmajor or minor [11], is required to establish a clinicaldiagnosis.very small fatty tissue component); however,malignancy was not excluded. TSC was suggested.CASE REPORTThe study was approved by Commission ofBioethics of Wroclaw Medical University. A 50-year-old lady with left calf pain, originally diagnosedas a symptom of deep venous thrombosis (DVT), wasadmitted to the hospital.The laboratory test results, including D-dimer, werewithin norms except for a slight increase intriglycerides and a slight decrease in the magnesiumlevel. She denied any chronic diseases.She had 3 healthy, adult children and a 52-year-oldhealthy sister. Her mother died at 77 years of age fromcolon cancer and her father died at 57 years of agefrom a stroke.The physical examination showed a large, suppletumour in the left popliteal space-there was no swellingof the leg. An enlarged, heterogenic thyroid gland andmultiple, yellow-red papules on her nose and cheekswere noted. She confirmed that she had been diagnosedand treated for acne since the age of 5. . The remainderof the physical examination was normal.The history included several years of recurrentabdominal pain. The pain was independent of themenstrual cycle, bowel movements, or meals.An ultrasound study did not show venousthrombosis, but revealed a large (5x10 cm) Baker’scyst in the left popliteal space. A number ofirregularities were detected on abdominal echography,so a CT scan was ordered. The abdominal tomographyshowed a few cysts within both lobes of the liver up to3 cm in diameter, multiple nodular lesions within bothkidneys with heterogeneous densities andheterogeneous contrast enhancement with smallcalcifications ( Fig.1, Fig.2). There was an enlargedlymph node, measuring 1.5 cm in the short axis, withinthe retroperitoneal space. The diagnosis suggestedmultiple benign tumours within the kidneys, mostlikely atypical angiomyolipomas (with or without aFig. 1. Right renal tumour-abdomen CT no 1Ryc. 1. Guz prawej nerki-tomografia komputerowa jamybrzusznej nr 1Fig. 2. Right renal tumour-abdomen CT no 2Ryc. 2. Guz prawej nerki- tomografia komputerowa jamybrzusznej nr 2There were inhomogenous and normoechogenicnodules in the ultrasound study of the thyroid. Therewere no changes on the chest x-ray and ECG.A CT scan of the head (Fig.3, Fig.4) showedseveral tiny calcified nodules bilaterally along thecauodothalamic grooves in the caudate nuclei areas andone adjoining to the body of the right ventricle. Therewere several further cortical and subcortical whitematter calcified tubers in both the frontal and temporallobes. The appearance was classified as compatiblewith TS.A dermatologic consultation described the skinchanges as a high probability of angiofibromas.

Tuberous sclerosis, late diagnosis: a case analysis 53Fig. 3. Brain CT no 1Ryc. 3. Zmiany w tomografii komputerowej głowy- zdjęcie nr 1tumours. Epithelioid angiomyolipomas can also befound [14].For the brain, the most characteristic findings aresubependymal and cortical and subcortical tubers. Theprevalence of subependymal giant cell ependymomas(SEGAs) in patients with TSC is 6%-14% [15].In such cases we found few important featurescharacteristic of TSC, including facial angiofibromas,cortical tubers, subependymal nodules, 11 renalangiomyolipomas, and liver cysts.Our patient did not agree to further examination, orfor psychological testing. It was a very awkwardsituation because of the possibility of renal cancer.Two things could influence the patient decision.Firstly, the patient’s mental status seemed to be slightlydeficient and limited the comprehension of the problemand risk. Secondly, the course of the disease was nearlyasymptomatic. We offered patient diagnostic tests andtreatment wherever she decided for such care andinformed her about obligatory control.As we presented, even for adult patients, we shouldconsider the presence of rare congenital diseases. It isimportant especially if the patient’s clinical picture isnot consistent with our findings (e.g. ultrasound). Thebrain characteristic image can be helpful for TSCdetection even if there are no clear signs from nervoussystem. We aimed at stressing the importance ofcareful medical examination because of such kindoligosymptomatic patients.REFERENCESFig. 4. Brain CT no 2Ryc. 4. Zmiany w tomografii komputerowej głowy- zdjęcie nr 2The patient was referred to an urologist whorecommended surgery for probable renal carcinoma.The patient did not consent to surgery or any otherdiagnostic tests (e.g., thyroid biopsy, skin biopsy,colonoscopy, or genetic tests). She was informed ofthe risk and was discharged from the hospital with aninformation card.CONCLUSIONSRenal lesions associated with TS are serious, asthey are the second common cause of death afterlesions of the nervous system [12]. The most commonfindings are polycystic kidney disease, renal lipomata,or renal cancer [13], as a result of many benign1. Hong CH, Darling TN, Lee CH. Prevalence of TuberousSclerosis Complex in Taiwan: A National Population-Based Study. Neuroepidemiology 2009; 33:335-341.2. van Slegtenhorst M, de Hoogt R, Hermans C et al.Identification of the tuberous sclerosis gene TSC1 onchromosome 9q34. Science 1997; 277.5327:805-808.3. Napolioni V, Curatolo P. Genetics and molecular biologyof tuberous sclerosis complex. Curr Genomics 2008;9:475-487.4. Rowley SA, O’Callaghan FJ, Osborne JP. Ophthalmicmanifestations of tuberous sclerosis: a population basedstudy. Br J Ophthalmol 2001; 85:420-423.5. Jozwiak S, Michalowicz R, Pedich M et al. Hepatichamartoma in tuberous sclerosis. Lancet 1992; 339:180.6. Franz DN, Brody A, Meyer C et al. Mutational andradiographic analysis of pulmonary disease consistentwith lymphangioleiomyoma-tosis and micronodularpneumocyte hyperplasia in women with tuberoussclerosis. Am J respire Crit Care Med 2001; 164:661-668.7. Costello LC, Hartman TE, Ryu JH. High frequency ofpulmonary lymphangioleiomyomatosis in women with

54Edyta Sutkowska et. al.tuberous sclerosis complex. Mayo Clin Proc 2000;75:591-594.8. Roach ES, Sparagana SPJ. Diagnosis of tuberoussclerosis complex. Child Neurol 2004; 19:643-649;Review.9. Shepherd CW, Hoser OW, Gomez M. MR findings intuberous sclerosis complex and correlation with seizuredevelopment and mental impairment. Am J Neuroradiol1995; 16:149-155.10. Dumitrescu D, Georgescu EF, Niculescu M et al.Tuberous sclerosis complex: report of two intrafamilialcases, both in mother and daughter. Rom J MorpholEmbryol 2009; 50:119-124.11. Roach ES, Gomez MR, Northrup H. Tuberous sclerosiscomplex consensus conference: revised clinicaldiagnostic criteria. J Child Neurol 1998; 13:624-628.12. Sague LJ, Borrego PL, Salas CR et al. Urologicalconservative management of a patient with tuberoussclerosis complex (Bourneville disease). Arch Esp Urol2009; 62:596-599.13. Bonsib SM. Renal cystic disease and renal neoplasms: amini-review. Clin J Am Soc Nephrol 2009; 4:1998-2007.14. D’Antonio A, Caleo A, Caleo O et al. Monotypicepithelioid angiomyolipoma of the adrenal gland: anunusual site for a rare extrarenal tumor. Ann DiagnPathol 2009; 13:347-350.15. Adriaensen ME, Schaefer-Prokop CM, Stijnen T et al.Prevalence of subependymal giant cell tumors in patientswith tuberous sclerosis and a review of the literature. EurJ Neurol 2009; 16:691-696.Address for correspondence:tel.: 48 71 734 32 20; 48/503077016fax:48 71 734 32 09;e-mail: edytasutkowska@yahoo.comReceived: 10.01.2011Accepted for publication: 13.02.2012

Selected articles presented duringthe 2 nd International Conference„Europejski Wymiar Nauk o Zdrowiu”organized on the occasion of the XV th Anniversaryof Faculty of Health Sciencesat Collegium Medicum, Nicolaus Copernicus UniversityBYDGOSZCZ, March 19-20, 2012GUEST EDITOR: PROFESSOR ZBIGNIEW BARTUZI

Medical and Biological Sciences, 2012, 26/1CONTENTp.Ewa Barczykowska, Anna Burczyk, Iwona Sadowska-Krawczenko,M a r t a G r a b i n s k a , A n d r z e j K u r y l a k – Quality of life in children, adolescentsand young adults suffering from cystic fibrosis and in their parents . . . . . . . . . . . . . . . . . . . . . . . . . 61Graż yna Bą czek, Ewa Dmoch-Gajzlerska – Independent midwifery practicein Poland – legal considerations versus reality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69Bernadeta Cegł a, Mał gorzata Filanowicz, Aneta Dowbór-Dzwonka,E w a S z y n k i e w i c z – Does the character of hypertension and mode of therapy determinechanges in the quality of life? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77Kamila Faleń czyk, Agnieszka Pluta, Wiesł awa Kujawa, Halina Basiń ska,Maria Budnik-Szymoniuk, Alicja Marzec – Analysis of problems and theirdeterminants among family caregivers taking care of chronically ill people . . . . . . . . . . . . . . . . . . . 85Mirosł awa Felsmann, Agata Kosobucka – The influence of external, internal and artificialenvironment upon the occurrence of breast cancer and coping with this disease. The verificationof the systemic theory of Betty Neumann . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93Mirosł awa Felsmann, Barbara Futyma, Mariusz Zbigniew Felsmann,Marzena Anna Humań s k a , B e a t a H a o r – Quality of life in children with epilepsy,evaluated by the parents on the basis of QOLCE questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99Graż yna Franek, Marta Ć miel-Giergielewicz, Zofia Nowak-Kapusta,Marzena Zmysł o-Rogozik – Awareness of risk factors assessment among individualswith ischemic heart disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107Mał gorzata Graczyk, Michał Przybyszewski, Jacek Tlappa, Jacek Muć ka,Andrzej Kuź miń ski, Magdalena Ż bikowska-Gotz, Ewa Szynkiewicz,Katarzyna Napiórkowska, Joanna Koł odziejczyk, Robert Zacniewski,Anna Róż a l s k a , Z b i g n i e w B a r t u z i – Determination of ECP concentration in patientswith allergic type of food hypersensitivity and in subjects with dyspeptic symptoms not associatedwith food allergy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113Anna Grzanka-Tykwiń ska, Alicja Rzepka, Katarzyna Porzych, KrzysztofKusza, Kornelia Kę d z i o r a - K o r n a t o w s k a – The quality of life of patientsover 60 including demographic and environmental factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119Beata Haor, Kamila Korniluk , Mirosł awa Felsmann, Marzena Humań ska– Tasks of a nurse in seniors’ preparation for self-care in the course of type 2 diabetes . . . . . . . . . . 125Judyta Kutowska, Mał gorzata Gierszewska, Estera Mieczkowska,Graż yna Gebuza, Marzena Kaź m i e r c z a k – Quality of life among womenwith gestational diabetes mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133Magdalena Miń ko, Dorota Siwczyń s k a – Breast cancer prevention as a partof health policy activities in Lublin province . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139

Medical and Biological Sciences, 2012, 26/1Agnieszka Pluta, Magdalena Skrzeszewska, Halina Basiń ska,Maria Budnik-Szymoniuk, Kamila Faleń c z y k – The functionalefficiency in elderly patients treated with hemodialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143Iwona Sadowska-Krawczenko, Agata Staś kiewicz, Andrzej Kurylak,Barczykowska Ewa, Aldona Katarzyna Jankowska – The knowledgeof nurses working in pediatric wards of assessment and treatment of pain in children . . . . . . . . . . . 149Paweł Szczudł o, Marta Hreń c z u k – Variability of drugs with narrow therapeutic windowin transplantology – potential costs and clinical consequences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155Monika Zawadka, Paweł Zalewski, Jacek J. Klawe, Mał gorzataTafil-Klawe, Joanna Pawlak, Krzysztof Kunikowski, Anna Bitner– Cardiovascular autonomic regulation in response to orthostatic stress with Parkinson’sdisease – case report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161A 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 – Evaluation of the quality of life of childrenwho have completed acute lymphoblastic leukemia treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169

Medical and Biological Sciences, 2012, 26/1SPIS TREŚCIstr.Ewa Barczykowska, Anna Burczyk, Iwona Sadowska-Krawczenko,Marta Grabinska, Andrzej Kurylak – Jakość życia dzieci, młodzieżyi młodych dorosłych chorych na mukowiscydozę oraz ich rodziców . . . . . . . . . . . . . . . . . . . . . . . . . 61Graż yna Bą czek, Ewa Dmoch-Gajzlerska – Samodzielna praktyka położnejw Polsce – uwarunkowania prawne a rzeczywistość . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69Bernadeta Cegł a, Mał gorzata Filanowicz, Aneta Dowbór-Dzwonka,E w a S z y n k i e w i c z – Czy specyfika choroby nadciśnieniowej i sposób przyjmowania lekóww zastosowanej terapii są determinantami zmian w jakości życia chorych? . . . . . . . . . . . . . . . . . . . 77Kamila Faleń czyk, Agnieszka Pluta, Wiesł awa Kujawa, Halina Basiń ska,Maria Budnik-Szymoniuk, Alicja Marzec – Analiza problemów opiekunówrodzinnych osób przewlekle chorych oraz czynników wpływających na ich występowanie . . . . . . 85Mirosł awa Felsmann, Agata Kosobucka – Wpływ środowiska zewnętrznego,wewnętrznego i wykreowanego na występowanie raka piersi i radzenie sobie z chorobą.Weryfikacja teorii systemowej Betty Neumann . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93Mirosł awa Felsmann, Barbara Futyma, Mariusz Zbigniew Felsmann,Marzena Anna Humań ska, Beata Haor – Jakość życia dzieci z padaczkąw ocenie rodziców na podstawie kwestionariusza QOLCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99Graż yna Franek, Marta Ć miel-Giergielewicz, Zofia Nowak-Kapusta,Marzena Zmysł o-Rogozik – Ocena stanu wiedzy na temat czynników ryzykawśród chorych z niedokrwienną chorobą serca . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107Mał gorzata Graczyk, Michał Przybyszewski, Jacek Tlappa, Jacek Muć ka,Andrzej Kuź miń ski, Magdalena Ż bikowska-Gotz, Ewa Szynkiewicz,Katarzyna Napiórkowska, Joanna Koł odziejczyk, Robert Zacniewski,Anna Róż alska, Zbigniew Bartuzi – Ocena stężenia ECP u pacjentów z nadwrażliwościąpokarmową typu alergicznego i u pacjentów z objawami dyspeptycznymi bez alergiipokarmowej . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113Anna Grzanka-Tykwiń ska, Alicja Rzepka, Katarzyna Porzych, KrzysztofKusza, Kornelia Kę dziora-Kornatowska – Jakość życia pacjentów powyżej60 roku życia z uwzględnieniem czynników demograficzno-środowiskowych . . . . . . . . . . . . . . . . . 119Beata Haor, Kamila Korniluk , Mirosł awa Felsmann, Marzena Humań ska– Zadania pielęgniarki w przygotowaniu do samoopieki seniorów w przebiegu cukrzycy typu 2 . . 125Judyta Kutowska, Mał gorzata Gierszewska, Estera Mieczkowska,Graż yna Gebuza, Marzena Kaź mierczak – Jakość życia kobiet z cukrzycąciążową . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133

Medical and Biological Sciences, 2012, 26/1Magdalena Miń ko, Dorota Siwczyń s k a – Profilaktyka raka piersi jako elementdziałań z zakresu polityki zdrowotnej w województwie lubelskim . . . . . . . . . . . . . . . . . . . . . . . . . . 139Agnieszka Pluta, Magdalena Skrzeszewska, Halina Basiń ska,Maria Budnik-Szymoniuk, Kamila Faleń czyk – Sprawność funkcjonalnau pacjentów w wieku podeszłym leczonych hemodializą . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143Iwona Sadowska-Krawczenko, Agata Staś kiewicz, Andrzej Kurylak,Barczykowska Ewa, Aldona Katarzyna Jankowska – Wiedza pielęgniarekpracujących w oddziałach pediatrycznych w zakresie oceny i leczenia doznań bólowych u dzieci . . 149Paweł Szczudł o, Marta Hreń czuk – Zmienność leków o wąskim oknie terapeutycznymw transplantologii – potencjalne koszty I konsekwencje kliniczne . . . . . . . . . . . . . . . . . . . . . . . . . . 155Monika Zawadka, Paweł Zalewski, Jacek J. Klawe, Mał gorzataTafil-Klawe, Joanna Pawlak, Krzysztof Kunikowski, Anna Bitner– Autonomiczna regulacja sercowo-naczyniowa w odpowiedzi na pionizację u pacjentów z chorobąParkinsona – studium przypadku . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161Aneta Zreda-Pikies, Andrzej Kurylak – Ocena jakości życia dzieci po zakończonymleczeniu ostrej białaczki limfoblastycznej . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169

Medical and Biological Sciences, 2012, 26/1, 61-67Ewa Barczykowska 1 , Anna Burczyk 2 , Iwona Sadowska-Krawczenko 1 , Marta Grabinska 3 , Andrzej Kurylak 1QUALITY OF LIFE OF CHILDREN, ADOLESCENTS AND YOUNG ADULTSSUFFERING FROM CYSTIC FIBROSIS AND OF THEIR PARENTSJAKOŚĆ ŻYCIA DZIECI, MŁODZIEŻY I MŁODYCH DOROSŁYCHCHORYCH NA MUKOWISCYDOZĘ ORAZ ICH RODZICÓW1 Paediatric Nursing Research Institute Nicolaus Copernicus University in ToruńCollegium Medicum in Bydgoszcz2 Graduate from nursing, second level degree studies at , Nicolaus Copernicus University in Toruń CollegiumMedicum in Bydgoszcz, operating theatre ward at A. Jurasz University Hospital no. 1. in Bydgoszcz.3 Students' Paediatric Nursing Research Society, student of nursing research, first level degree full-time studies atNicolaus Copernicus University in Toruń Collegium Medicum in BydgoszczSummaryA i m . Assessment of quality of life of children,adolescents and adults suffering from cystic fibrosis and oftheir parents.Met h o d s . Examination involved 23 persons (16patients and 7 parents). Questionnaires CDQ-12-13, CFQ-14and CFQ-6-13 were used as research tools.R e s u l t s . Children between 12 and 13 years old, aswell as young adults and adolescents ranked their physicalaptitude and their food-related behaviours as highest, and theappearance of their bodies as lowest. Parents, on the otherhand, assessed eating as a difficult effort for their children. Adecisive majority of the parents claimed, that everydaytherapy was time-consuming, yet fulfilling the therapyrecommendations was not intensely difficult for the child.Also for adolescents and young adults, only minimally do thelimitations resulting from a prolonged systematic therapyobstruct everyday life.C o n c l u s i o n . The assessment of quality of life ofchildren suffering from cystic fibrosis is varied. The highestpatients' quality of life assessment is found in schoolchildrenaged 12 to 13. Patients assess their body image as very poor.StreszczenieC e l . Ocena jakości życia wśród dzieci, młodzieży idorosłych chorych na mukowiscydozę oraz ich rodziców.M e t o d y . Badaniu poddano 23 osoby (16 chorych i 7rodziców). Jako narzędzia badawcze wykorzystanokwestionariusze CFQ-12-13, CFQ-14 + oraz CFQ- 6-13.W y n i k i . Dzieci w wieku 12-13 lat oraz młodzidorośli i młodzież powyżej 14 lat najwyżej ocenilifunkcjonowanie fizyczne oraz zachowania związane zjedzeniem a najniżej wygląd własnego ciała. Natomiastrodzice najwyżej ocenili stan emocjonalny, a najniżej zakresdotyczący masy ciała chorego dziecka. Wśród chorych namukowiscydozę problemy związane z jedzeniem występująsporadycznie. Natomiast większość rodziców chorych dzieciocenia, że jedzenie jest dla dzieci trudne. Zdecydowanawiększość rodziców stwierdza, że codzienna terapia jestczasochłonna, jednak stosowanie się do zaleceńterapeutycznych nie sprawia dziecku dużych trudności.Także dla młodzieży i młodych dorosłych ograniczeniazwiązane z przewlekłym i systematycznym leczeniem wniewielkim stopniu utrudniają życie codzienne.W n i o s k i . Ocena jakości życia dzieci zmukowiscydozą jest zróżnicowana. Najwyższa ogólna ocena

62Ewa Barczykowska et. al.jakości życia wśród chorych występuje w grupie dzieciszkolnych w wieku 12-13 lat. Chorzy bardzo nisko oceniająwygląd własnego ciała.Key words: quality of life, children, cystic fibrosisSłowa kluczowe: jakość życia, dzieci, mukowiscydozaINTRODUCTIONCystic fibrosis (CF) is a genetically conditioned,multi-organ systemic disease [1, 2, 3]. The disease iscaused by mutation of a gene coding protein synthesis,CFTR (Cystic Fibrosis Transmembrane Regulator),which regulates transportation of ions within the cellmembrane. Due to disturbances in the transportation ofchloride ions, re-absorption of sodium ions and wateris increased, while mucus rises in density andviscosity. As a result, an irreversible and gradualdepletion of respiratory system occurs [1, 2, 4].Chronicinfections of respiratory tracts, as well as bronchitis,lead to a gradual respiratory failure [5]. In 85-90% ofcases exocrine pancreatic insufficiency and gastrointestinalproblems occur. The clinical picture isconditioned by the patient's age [1].Standard therapy in cystic fibrosis is multidirectionaland includes antibiotic therapy, chestphysiotherapy, bronchi-expanding and antiinflammatorymedicines, oxygen therapy and treatmentof late after-effects of the disease and its complications[6, 7, 8]. All patients receive pancreas enzymepreparations before each meal, pharmaceuticalsdecreasing hydrochloric acid secretion, preparations ofvitamin A, D, E and K. An intensive consumption ofcalories (130% of norm) is necessary [2, 9].An early beginning of treatment leads toprogression of changes and is a key to increasingquality of life in CF patients [10]. Progress in medicineover the years led to extension of cystic fibrosispatients' lifespan [2, 6, 7]. Average lifespan of thesepatients increased from 31 to 37 years over the lastdecade (30 years in 1999) [11, 12]. Average lifespanfor children born in the 21st century is estimated as 50years [13]. A well managed therapy effects in asatisfactory quality of life for most adult patients [7].The disease and its treatment have a considerableimpact on patient's everyday life [2, 9, 14]. Therefore,examining the influence of the disease on patient'squality of life has become very popular in recent years.Such examination aims, among other goals, atdetermining the impact of treatment on patient'sfunctioning, assessing benefits and losses ensuing fromintroduction of new forms of therapy, facilitatingclinical decision making [15, 16, 17].First results of cystic fibrosis patients' quality oflife examination were published in 1989. The researchconcentrated on assessing the physical mobility andsocial limitations in the context of respiratory system'sfunctioning and exercise-stress capacity [18, 19]. Laterresearch involved measuring the effect of differenttherapies, including lungs transplantation [20, 21].Valuable research compared cystic fibrosis patients'quality of life to the quality of life of patients sufferingfrom other chronic diseases of the respiratory system[22, 23].AIM OF THE RESEARCHThe research aimed at assessing the quality of lifein cystic fibrosis patients, including physical activity,roles played by the patient, vitality, social andemotional activity, perception of patient's owncondition, body image, digestion disturbances,Treatment Constrains, symptoms within the respiratoryand digestive systems.Research problems were formed into the followingquestions:1. Which of the areas covered by theexamination were ranked highest and lowest byadolescents and adults, by schoolchildren and parentsof children aged 6 to 13?2. What is the general quality of life rating incystic fibrosis patients in a group of adolescents andadults, schoolchildren and parents of children aged 6 to13?3. How do cystic fibrosis patients perceive theirown bodies?4. What was the rating of digestive behaviours inadolescents and adults, schoolchildren and parents ofchildren aged 6 to 13?5. How do patients perceive constrains related totheir treatment?PATIENTS AND METHODSResearch involved examining 23 persons: parentsof children aged 6-13, adolescents and young adultssuffering from cystic fibrosis, who were patients of

Quality of life of children, adolescents and young adults suffering from cystic fibrosis and of their parents 63Paediatrics, Pneumologic and Alergologic Ward withInfant Subward and of cystic fibrosis out-patient clinicat Children's Regional Hospital in Bydgoszcz.In the research conducted among parents, a decisivemajority of their children were aged between 12 and 13(42.9% and 28.6%). There were also two youngerchildren, aged 8 and 10 (14.3%). Questionnaires werefilled by mothers only (100%). The mothers were agedbetween 33-35 (42.9%) and 36-47 (57.1%). A decisivemajority of children came from married parents; onechild had parents living in concubinage. 42.9% of thewomen were graduates of high schools and the samepercentage graduated from vocational schools.Questioned about current occupation, 57% of themothers answered: „housekeeping”, while 28.6%worked full-time or part-time. Most children (71.4%)studied in schools.In case of questionnaire CFQ-14+, 61.5%respondents were persons between 14 and 17 years,while 38.5% are persons between 20 and 28 years. Adecisive majority of the respondents, 10 persons, werewomen (76.9%), while 3 were men (23.1%).Questioned about school and work, 53.8% of therespondents answered, they kept going to school asusual. 4 persons (30.8%) answered, they restrainedfrom going to school or work because of healthproblems. Among 13 respondents, only 1 was married,and 92.3% were single. Questioned about education,61.5% respondents confessed they graduated from ahigh school. Only 1 person had achieved a high schoolfinals diploma (7.7%), the same number completed ajunior college, 23.1% graduated from a vocationalschool. Answering the question about educational oroccupational situation, 38.5% responded they attendedclasses at school, while 30.8% learned at home. 1person (7.7%) worked full- or part-time, the samenumber was searching for a job. Only 1 personadmitted they did not go to school or work because oftheir health condition.Questionnaire CFQ-12-13 was filled by 3 personsonly. 66.7% were children aged 12, and 33.3% werechildren aged 13. Majority of the group consisted ofgirls (66.7%), boys forming 33.3%. 2 children (66.7%)attended classes at school as usual, the same numberwere 5th grade primary school pupils. Only 1 personhad an individual mode of education.Research was done using a polish version ofQuality of Life Questionnaire adapted for children andadults with cystic fibrosis, as well as for their parents(CFQ-R). The Questionnaire consisted of threeversions:- adolescents and parents (age 14 and older) - CFQ-14+,- older schoolchildren (age 12-13) - CFQ-12-13,- parents of children aged 6 to 13 - CFQ-6-13.The original version of the questionnaire wasassembled in France and became adapted in Germany,Netherlands, Brazil and United States. The Polishversion of the questionnaire originated from aninternational research and is adapted from theAmerican test. The questionnaires were adjusted toPolish conditions by D. Sands, Ph.D., and U.Borawska-Kowalczyk, MA at Mother and ChildInstitute in Warsaw [24].The aim of the statistic analysis was to determinequality of life in groups of patients for each domain,and to compare general quality of life levels in thesegroups. Parametric and non-parametric significancetests were used to verify hypotheses proposed.Respondents filled the questionnaires answeringquestions they contained. Questions demandedanswering with grades according to Likert's scale, from1 to 4. In several cases, grades in the questionnairedemanded an inversion, following the formula: grade=5-X, where X was a grade to be inverted.Standardized quality of life ratings (QoLR) of eachpatient in a given domain were calculated according tothe formula:sum of points − minimum possible sum of pointsQoLR=─────────────────────────────x 100maximum possible sum of points - minimum possiblesum of pointsAll QoLR values are situated within the range of 0to 100, a higher rating signifies a better quality of life.RESULTSIn the analysis and discussion of the results, asystem resulting from specific research problems ofthis paper was used.1. Areas ranked highest and lowest byadolescents and young adults, schoolchildren andparents of children aged 6 to 13.

64Ewa Barczykowska et. al.2. General CF patients' quality of life rating inthe group of adolescents and young adults,schoolchildren and parents of children aged 6 to 13.3. Body appearance rating.4. Digestive behaviours in adolescents andyoung adults, schoolchildren and parents of childrenaged 6 to 13.5. Treatment Constrains.1. Areas ranked highest and lowest byadolescents and young adults, schoolchildren andparents of children aged 6 to 13.Group 1. Parents/ legal guardians of children aged 6 to13.The following table contains quality of life ratings foreach of the 7 respondents in respective domains,calculated according to the foregoing formula, as wellas mean values (M) and standard deviations (SD) ineach domain. (table1)Table I. Means and standard deviations for respective areasof the CFQ-6-13 testAreasTable II. Means and standard deviations for respective areasof the CFQ-12-13 testRespondentsPhysical functioningEmotional conditionSocial limiationsBody imageAreasDigestive behavioursTreatment ConstrainsRespiratory systemfunctioningDigestive sytemfunctioning1 55.6 79.2 76.2 44.4 88.9 77.8 75.0 1002 88.9 58.3 71.4 22.2 44.4 55.6 91.7 66.73 94.4 83.3 85.7 77.8 33.3 88.9 58.3 33.3M 79.6 73.6 77.8 48.1 55.6 74.1 75.0 66.7SD 21.0 13.4 7.3 28.0 29.4 17.0 16.7 33.3Group 2. Children aged 12 and 13. The examinedgroup included 3 children at this age. Highest resultswere achieved in scales measuring physicalfunctioning (M=79.6) and social limitations (M=77.8).Lowest were the ratings related to body image(M=48.1) and digestive behaviours (M=55.6). Group 3.Adolescents and adults (patients aged over 14). (table3).RespondentsPhysical functioningVitalityEmotional conditionDigestive behavioursTreatment ConstrainsHealth perceptionSocial limiationsBody imageSchool performanceBody massRespiratory system functioning1 55.6 80.0 60.0 100.0 44.4 66.7 77.8 00.0 100 27.8 44.42 85.2 46.7 46.7 00.0 55.6 00.0 22.2 00.0 44.4 100.0 22.23 74.1 73.3 80.0 50.0 66.7 66.7 77.8 33.3 66.7 83.3 1004 40.7 66.7 66.7 83.3 22.2 33.3 33.3 33.3 11.1 66.7 77.85 88.9 73.3 60.0 50.0 44.4 55.6 77.8 33.3 77.8 55.6 44.46 70.4 86.7 60.0 100.0 77.8 100.0 44.4 66.7 66.7 77.8 88.97 81.5 93.3 80.0 50.0 55.6 77.8 77.8 66.7 77.8 88.9 88.9M 70.9 74.3 64.8 61.9 52.4 57.1 58.7 33.3 63.5 71.4 66.7SD 17.3 15.1 12.0 35.6 17.8 32.3 24.6 27.2 28.5 24.1 29.4Highest results were achieved in the areas related tothe emotional state (M=74.3) and functioning of therespiratory system (M=71.4), while the lowest resultwas achieved in the area of body mass (M=33.3).(table 2).Table III. Means and standard deviations for respectiveareas of the CFQ-14+ testRespondentsPhysical functioningVitalityEmotional conditionDigestive behavioursTreatment ConstrainsHealth perceptionAreasSocial limiationsBody imageRole limitationsBody massRespiratory systemfunctioningDigestive sytemfunctioning1 100 83.3 86.7 100 100 100 77.8 88.9 100 100 100 1002 37.5 33.3 6.7 66.7 44.4 33.3 50.0 33.3 25.0 66.7 55.6 88.93 50.0 83.3 66.777.8 66.7 88.9 83.3 66.7 75.0 100 94.4 100.04 33.3 33.3 53.333.3 33.3 44.4 50.0 55.6 58.3 33.3 0.0 22.25 79.2 33.3 6.7 77.8 88.9 55.6 55.6 0.0 66.7 33.3 83.3 66.76 4.2 50.0 46.766.7 33.3 22.2 44.4 33.3 50.0 0.0 61.1 77.87 66.7 25.0 100 100 55.6 77.8 66.7 100 58.3 100 27.8 66.78 70.8 66.7 86.7 100 44.4 77.8 77.8 55.6 66.7 66.7 44.4 88.99 91.7 66.7 100 100 88.9 77.8 88.9 100 83.3 100 88.9 88.910 70.8 33.3 46.788.9 66.7 44.4 61.1 0.0 50.0 33.3 72.2 44.411 62.5 58.3 66.7 100 33.3 66.7 55.6 66.7 50.0 0.0 22.2 66.712 66.7 83.3 100 100 66.7 88.9 66.7 11.1 100 0.0 72.2 88.913 79.2 75.0 86.7 100 66.7 44.4 88.9 33.3 83.3 66.7 50.0 88.9M 62.5 55.8 65.685.5 60.7 63.2 66.7 49.6 66.7 53.8 59.4 76.1SD 25.9 22.1 32.520.5 22.5 24.2 15.4 34.7 21.5 39.8 30.1 22.6

Quality of life of children, adolescents and young adults suffering from cystic fibrosis and of their parents 65The test for persona over 14 revealed highestresults in the scale for digestive behaviours (M=85.5)and functioning of the digestive system (M=76.1), andthe lowest results in the area related to body image (M-49.6) and body mass (M=53.8).2. quality of life rating among cystic fibrosispatients, in the group of adolescents and adults,schoolchildren and parents of children aged 6-13.The following table presents mean values andstandard deviations for quality of life ratings in thethree compared groups, as well as the result of testingdistribution normality in group 2 numbering less than50. ( table 4)Table IV. Mean values and standard deviations for quality oflife ratingsGroup 1 Group 2 Group 3n* 77 24 156Mean 61.4 68.8 63.8SD 25.8 21.5 27.5Shapiro-W - 0.940 -Wilk's testforW kr - 0.914 -normality normality n/a yes n/aAmong the three groups the highest quality of lifewas found in children aged 12 and 13.Shapiro-Wilk's test for normality did not reject ahypothesis that the distribution of quality of life ratingsin group 2 did not significantly differ from a normaldistribution.To compare mean values, a z-test was used, basedon a normal distribution and Student's t test. Z-test isused to compare mean values in two large (>50)groups, in this case groups 1 and 3.It was proved, that the distribution of quality of liferatings in group 2 did not significantly differ from thenormal. Snedecor's F test also did not detect significantdifferences between variances in groups 1-2 and 2-3(values of calculated F-statistics are lower than criticalvalues). This allowed using the Student's parametric ttest to compare mean values in these groups. Tocompare groups 1-3 the z-test was used.No significant difference between mean quality oflife ratings in the compared groups was detected. Allvalues received through statistic calculations are lowerthan critical values collected from respective tables atsignificance level p=0.05.3. Perception of body image.Body image received the lowest grade among alldomains ranked by the respondents. In one of thegroups it received a mean value M of 48.1, while in theother, 49.6.Questions about body mass appeared in twoversions of the test only, and also this domain was notranked high among CF patients and their parents. Theparents graded this domain very poor (M=33.3).4. Digestion-related behaviours amongadolescents and adults, schoolchildren and parents ofchildren aged 6-13.Rating digestion-related behaviours, patients withcystic fibrosis and their parents ranked high comparedto other domains. Adolescents and adults sufferingfrom cystic fibrosis received a high result in thisdomain (M=85.5).Questioned about difficulties related to eating, mostparents agreed, that eating was difficult for theirchildren.Over a half of adolescent and adult respondents(69.2%) claimed they always ate with pleasure.Ranking an answer about forcing themselves to eat,84.6% claimed it was untrue. Difficulties with eatingappeared occasionally or never in 92.3% ofrespondents.5. Limitations related to treatment.Answering questions about treatment-relatedlimitations, 85.7% of parents of children aged 6 to 13answered, that to follow therapy instructions dailycauses child little difficulty. Moreover, a large numberof parents (71.4%) claimed, that treatment did notobstruct child's everyday activities. A majority ofparents though, namely 85.8%, confirmed that medicalprocedures take a considerable amount of time everyday.84.6% of adolescents and adults answeringquestions about treatment-related limitations claimedthat treatment caused little or some difficulties for theireveryday life. Questioned about perception of everydaytreatment, 61.6% claimed, that treatment had causedthem little or no difficulty.DISCUSSIONAs research reveals, the age of the examined patientis one of the factors determining perception of qualityof life [19, 25]. Results of research undertaken bySands and Borawska-Kowalczyk on 128 persons (91cystic fibrosis patients and 37 parents) show, thatchildren aged 12-13 achieved the most points in scalesmeasuring emotional state (M=72.91) and functioningof the respiratory system (M=72.12), while the least

66Ewa Barczykowska et. al.points were achieved in the areas related to body image(M=65.38) and limitations associated with digestion(M=65.81) [24]. In our independent research, thehighest results for the same age group were achieved inthe scales measuring physical functioning and sociallimitations, while the lowest were achieved in areasrelated to body image and digestive limitations. Ininstances, body image as well as digestive limitationswas ranked poorest. In the test by Sands andBorawska-Kowalczyk for persons aged over 14,digestion-related behaviours ranked highest (M=84.23)and body mass perception ranked lowest (M=55.91)[24]. These results agree with the results of ourresearch.Subject literature suggests differences betweenquality of life perception by child patients [25] andtheir parents. In the parents' questionnaire Sands andBorawska-Kowalczyk received the highest ranks in thearea related to functioning of the digestive system(M=81.68), while the lowest ranks appeared in the arearelated to body mass (M=48.65) [24]. Our researchdoes not confirm this as for the highest ranks. Parentrespondents indicated the area related to emotionalstress and functioning of the respiratory system.However, we recorded agreement of the results in thelowest range, which is the child patient's body mass.Cystic fibrosis patients perceive their digestiveproblems as intermittent. Nevertheless, Polish researchon CF child patients' nutrition conducted by Brudzińskiand focusing on biological indicators, revealeddeficient body mass in relation to height in 35% ofchildren. L. Majek's research showed underweight in64% of respondents [26]. Analysis of our independentresearch's results indicates that a decisive majority ofcystic fibrosis patients are aware of the fact, that theyexperience problems with body mass and body imageas compared to their healthy peers. A majority of childpatients' parents define eating as difficult for children.A decisive majority of the parents claim, thateveryday therapy takes time, nevertheless followingtherapy recommendations does not cause significantdifficulties for the child. Hegarty notes, that “treatmentburden” is perceived as less significant by childpatients aged 6 to 13, than by their parents [25].Global quality of life factor achieved byrespondents varies between (M=61.4) and (M=68.8).In the research conducted by Sands and Borawska-Kowalczyk quality of life factor is higher than in ourresearch, and amounted to (M=70.21) in children aged12-13, (M=65.2) in parents, and (M=70.4) in patientsaged over 14 [24].Belgian research reveals that beginning educationor work by CF patients is closely connected with healthcondition. Decision to stop attending classes at schoolor quit work, is difficult and has impact on personal,social and financial quality of life [27]. In Majek'sresearch, the number of CF patients engaging inmarriages or employment is low. 36% had neverworked professionally, and 16% lived in formal orinformal relationships. One can notice a highpercentage of persons with high school education(about 88% of respondents graduated from a primaryschool) [26].Every chronic disease evokes strong negativeemotions. Many authors emphasise not only somaticsymptoms on patient's functioning, but also mentalburden as well [28, 29]. In Staab's research specialattention was focused on the demand to mentallysupport the patient with their adaptation and everydayfunctioning with a chronic disease like cystic fibrosis,and not only delivering medical service [30].CONCLUSION1. Quality of life assessment for children with cysticfibrosis is varied.2. Highest general ranking of quality of life amongpatients appears in a group of schoolchildren aged 12-13.3. Patients rank their body image very poor.BIBLIOGRAPHY1. Davies JC, Alton EW, Bush A, Cystic fibrosis. BMJ2007 Dec 15; 335(7632):1255-9.2. Ernst MM, MC Johnson, Stark LJ, Developmental andpsychosocial issues in cystic fibrosis. Child AdolescPsychiatr Clin N Am 2010 Apr; 19(2): 263-83.3. Program Badań Przesiewowych w Polsce na lata 2009-2014, www.mz.gov.pl [02.03.2011].4. Narasimhan M, Cohen R, New and investigationaltreatments in cystic fibrosis. Rher Ady Respir Dis 2011Mar 3 [PubMed 7.05.2011]5. Zemanick ET, Sagel SD, Harris JK, The airwaymicrobione in cystic fibrosis and implications fortreatment. Curr Opin Pediatr 2011 Apr 13[PubMed7.05.2011]6. O’Sullivan BP, Flume P, The clinical approach to lungdisease in patients with cystic fibrosis. Semin Respir CritCare Med 2009 Oct; 30(5): 505-13.

Quality of life of children, adolescents and young adults suffering from cystic fibrosis and of their parents 677. Dalcin T, Abreu e Silva, Cystic fibrosis in adults:diagnostic and therapeutic aspects. J Bras Pneumol 2008Feb; 34(2):107-17.8. Pressler T, Targeting airway inflammation in cysticfibrosis children: past, present, and future. Peadiatr Drugs2011 Jun 1; 13(3): 141-7.9. Jelalian E, Stark LJ, Reynolds L, et al., Nutritionintervention for weight gain in cystic fibrosis: a metaanalysis. J Pediatr 1998 Mar; 132(3Pt1): 486-92.10. McKay KO, Cystic fibrosis: benefis and clinicaloutcome. J Inherit Metab Dis 2007 Aug; 30(4): 544-55.11. Elborn JS, Hodson M, Bertram C, Implementation ofEuropean standards of care for cystic fibrosis —provision of care, Journal of Cystic Fibrosis 8(2009):348-355.12. O’Sullivan BP, Freedman SD; Cystic fibrosis. Lancet.2009 May 30; 373(9678): 1891-904.13. Dodge JA, Lewis PA, Stanton M, Wilsher J, Cysticfibrosis mortality and survival in the UK: 1947-2003. EurRespir J 2007; 29: 522-6.14. Pizzignacco TM, de Mello DF, de Lima RA, Stigma andcystic fibrosis. Rey Lat Am Enfermagem 2010 Jan-Feb;18(1): 139-42.15. Kochman D, Wybrane aspekty jakości życia dzieci imłodzieży. Pielęgniarstwo Polskie 2006; 2,22: 112-114.16. Uchmanowicz I, Łoboz-Grudzień K, Jakość życiadefinicjei narzędzia badawcze- przegląd literatury,Family Medicine & Primary Care Review 2008; 10,2:245-25217. Abbott J, Health-related quality of life measurement incystic fibrosis: advances and limitations. Chron RespirDis 2009; 6(1): 31-41.18. Orenstein D, The Quality of Well-Being In CysticFibrosis, Chest 1989;95:344-347.19. Cohen MA, Ribeiro MA, Ribeiro AF, Ribeiro JD,Morcillo AM; Quality of life assessment in patients withcystic fibrosis by means of the Cystic FibrosisQuestionnaire. J Bras Pneumol 2011 Apr; 37(2): 184-192.20. Jankaskas JR, Mallory GB, Lung transplantation in cysticfibrosis, Chest 1998; 113, 217- 226.21. Gomez C, Revnaud-Gaubert M; Long-term outcome oflung transplantation. Rev Pneumol Clin 2010 Feb; 67(1):64-73.22. Basa A, Pawlaczyk B (promotor), Jakość życia dzieci zmukowiscydozą i chorobą trzewną: praca doktorska,Akademia Medyczna im. Karola MarcinkowskiegoKatedra Pielęgniarstwa Pediatrycznego w Poznaniu,2004, GBL: 45/22725.23. Ziaian T, Sawyer M, Reynolds K, Carbone J., Clark J,Baghurst P, et al, Treatment burden and health-relatedquality of life of children with diabetes, cystic fibrosisand asthma. J Paediatr Child Health. 2006Oct;42(10):596-600.24. Sands D, Borawska-Kowalczyk U, Polska adaptacjaKwestionariusza Jakości Życia przeznaczonego dladzieci i dorosłych chorych na mukowiscydozę oraz ichrodziców (CFQ-R), Pediatria Polska 2009, 84,2, 165-172.25. Hegarty M, Macdonald J, Watter P, Wilson C, Quality oflive young people with cystic fibrosis: effects ofhospitalization, age and gender, and differences inparent/child perceptions, Child Care Health Dey 2009Jul; 35(4): 462-8.26. Dębska G, Jakość życia chorych na mukowiscydozę,Acta Pneumonologia et Allergologica Pediatrica 2003;6,3:39-42.27. Havermans T., Colpaert K., Vanharen L., Dupont L.J.;Health related quality of life in cystic fibrosis: To workor not to work?; Journal of Cystic Fibrosis 8 (2009), 218-22328. Kaplan SH, Greenfield S, Ware JE Jr, Assessing theEffects of Physician-Patient Interactions on theOutcomes of Chronic Disease, Med Care. 1989 Mar;27(3Suppl):S110-S127.29. Eiser C, Psychological Effects of Chronic Disease, J.Child Psychol Psychiatry, 1990 Jan; 31(1): 85-98.30. Staaba D, Wenningera K, Geberta N, Ruppratha K,Bissonb S, Trettinc M, et al, Quality of life in patientswith cystic fibrosis and their parents: what is importantbesides disease severity, Thorax 1998;53:727-731.Address for correspondence:Ewa BarczykowskaUMK w ToruniuCollegium Medicum im. L. Rydygieraul. Techników 385-801 Bydgoszcztel: 52 585 21 93e-mail: ebarczykowska@interia.plReceived: 10.01.2012Accepted for publication: 6.03.2012

Medical and Biological Sciences, 2012, 26/1, 69-76Grażyna Bączek, Ewa Dmoch-GajzlerskaINDEPENDENT MIDWIFERY PRACTICE IN POLAND– LEGAL CONSIDERATIONS VERSUS REALITYSAMODZIELNA PRAKTYKA POŁOŻNEJ W POLSCE– UWARUNKOWANIA PRAWNE A RZECZYWISTOŚĆDepartment of Gynecologic and Obstetrical Didactics, Warsaw Medical University, 00-424 Warsaw, PolandZakład Dydaktyki Ginekologiczno-PołożniczejKierownik: prof. dr hab. Ewa Dmoch-Gajzlerska, Wydział Nauki o Zdrowiu, Warszawski Uniwersytet MedycznySummaryO b j e c t i v e . To assess the readiness of midwives inregards to carrying out complex independent care forexpecting families during physiological pregnancy, deliveryand puerperium; to evaluate the role of midwifery practiceduring individual preparation of a woman (and her spouse)for childbirth; to define the elements of health educationincluded in preparation for childbirth.Material and method. Design - questionnairesurvey. Setting - eight types of hospitals located in andoutside of Warsaw. Participants - 291 practicing midwiveswith current or past practice in the delivery room.Findings. The majority of midwives (232; 80%)declared their readiness to provide complex care to expectingfamilies and offered individual preparation of women (andtheir spouses) for delivery. Most state obstacle is the lack ofpractice, the need to improve skills and prevent system. Themajority of midwives practice individual preparation ofwomen for childbirth (172; 59%).Midwives complementary education for masters, muchless frequently (72; 47%) operate this type of care than theother (76; 71%) - p = 0.001. This form of practice isimplemented by the midwives hot properties (25; 83%) - p =0.017. The most frequent components of prenatal healtheducation included: biological aspects of pregnancy, deliveryand puerperium, followed by psychological aspects, hygiene,diet, physical activity and prenatal communication with thechild.Conclusions and implications forpractice. Independent midwifery practice is not limitedby Polish law. The obstacles faced by independent midwivesare associated rather with the healthcare system and thementality of its workers. The profession of midwifery shouldbe strengthened by extensive media campaigns promoting thecompetency of this professional group, along with thecompletion of graduate and postgraduate education curriculain aspects useful for running independent practice.StreszczenieC e l e m p r a c y jest próba odpowiedzi na pytanie czypołożne mają możliwość podejmowania, gwarantowanejprzez ustawodawstwo, indywidualnej i samodzielnej praktykiw opiece nad zdrową kobietą oczekującą dziecka.Materiał i metoda. Badania przeprowadzonometodą sondażu diagnostycznego. Narzędziem badawczymbył samodzielnie skonstruowany dla celów pracykwestionariusz ankiety. Zbadano grupę 291 położnychpraktykujących obecnie lub w przeszłości w sali porodowej,zatrudnionych w ośmiu szpitalach warszawskich i pozaWarszawą.Wyniki. Większość badanych (232, 80%) uznała, żepołożne są przygotowane do objęcia całościową isamodzielną opieką rodziny oczekującej dziecka. Najczęściejwymienianą przeszkodą jest brak praktyki, koniecznośćpodnoszenia kwalifikacji oraz przeszkody systemowe.Większość położnych praktykuje indywidualneprzygotowanie kobiety do porodu (172, 59%). Położneuzupełniające wykształcenie na studiach magisterskichznacznie rzadziej (72, 47%) świadczą ten rodzaj opieki niżpozostałe (76, 71%) – istotność statystyczna p = 0,001.Znamiennie częściej ta forma praktyki realizowana jest przez

70Grażyna Bączek, Ewa Dmoch-Gajzlerskapołożne specjalistki (25, 83%) - istotność statystycznawynosi p = 0,017. Najczęściej realizowane elementy edukacjizdrowotnej w przygotowaniu do porodu dotyczyły:biologicznych aspektów ciąży, porodu, połogu, higieny,psychologicznych aspektów ciąży, porodu, połogu i diety,ruchu oraz komunikacji z dzieckiem.W n i o s k i . Prawodawstwo nie ogranicza samodzielnejpraktyki położnej w Polsce. Badane położne w większościuznały, że są gotowe do objęcia całościową opieką zdrowejrodziny oczekującej dziecka. Większość badanychpraktykuje indywidualne przygotowanie kobiety do poroduedukując swe podopieczne najczęściej w zakresiebiologicznych i psychologicznych aspektów ciąży, porodu,połogu. Konieczne jest wzmocnienie zawodu położnej orazuzupełnienie treści kształcenia przeddyplomowego ipodyplomowego w elementy samodzielnej praktyki.Key words: midwife, independent practice, legal aspectsSłowa kluczowe: położna, samodzielna praktyka, uwarunkowania prawneINTRODUCTIONThe internationally accepted definition ofmidwifery states: „A midwife is a person who, havingbeen regularly admitted to a midwifery educationalprogramme, duly recognized in the country in which itis located, has successfully completed the prescribedcourse of studies in midwifery and has acquired therequisite qualifications to be registered and/or legallylicensed to practice midwifery. The midwife isrecognized as a responsible and accountableprofessional who works in partnership with women togive the necessary support, care and advice duringpregnancy, labour and the postpartum period, toconduct births on the midwife’s own responsibility andto provide care for the newborn and the infant. Thiscare includes preventative measures, the promotion ofnormal birth, the detection of complications in motherand child, the accessing of medical care or otherappropriate assistance and the carrying out ofemergency measures. The midwife has an importanttask in health counseling and education, not only forthe woman, but also within the family and thecommunity.This work should involve antenatal education andpreparation for parenthood and may extend to women’shealth, sexual or reproductive health and child care. Amidwife may practice in any setting including thehome, community, hospitals, clinics or health units.”[1]The majority of Polish midwives belong to thePolish Midwives Association, a member organizationof the International Confederation of Midwives. Assuch, the aforementioned definition also encompassesthe role of midwifery practice in Poland. Poland, as amember state of the European Union, is obliged tofollow EU directives regulating various aspects of life.Midwifery practice is regulated by Directive80/155/EWG, particularly by article 4. According tothis article: „Member States shall ensure that midwivesare at least entitled to take up and pursue the followingactivities: 1) to provide sound family planninginformation and advice; 2) to diagnose pregnancies andmonitor normal pregnancies; to carry out theexaminations necessary for the monitoring of thedevelopment of normal pregnancies; 3) to prescribe oradvise on the examinations necessary for the earliestpossible diagnosis of pregnancies at risk; 4) to providea program of parenthood preparation and a completepreparation for childbirth including advice on hygieneand nutrition; 5) to care for and assist the motherduring labor and to monitor the condition of the fetusin utero by the appropriate clinical and technicalmeans; 6) to conduct spontaneous deliveries includingwhere required an episiotomy and in urgent cases abreech delivery; 7) to recognize the warning signs ofabnormality in the mother or infant which necessitatereferral to a doctor and to assist the latter whereappropriate; to take the necessary emergency measuresin the doctor's absence, in particular the manualremoval of the placenta, possibly followed by manualexamination of the uterus; 8) to examine and care forthe new-born infant; to take all initiatives which arenecessary in case of need and to carry out wherenecessary immediate resuscitation; 9) to care for andmonitor the progress of the mother in the post-natalperiod and to give all necessary advice to the motheron infant care to enable her to ensure the optimumprogress of the new-born infant; 10) to carry out thetreatment prescribed by a doctor; 11) to maintain allnecessary records.” [2]“The law on nurse and midwife profession” is alegally binding act in Poland. Specific considerationsregarding the practice of midwifery are included inarticle 5 of this act: „1) The profession of midwifery ispracticed by a person with the required qualifications,being confirmed by proper documents, and includesproviding healthcare services, particularly nursing,preventive, diagnostic, therapeutic and rehabilitativeservices as well as health promotion to women,including pregnant women, delivering women andwomen in puerperium as well as the neonates. 2) These

Independent midwifery practice in Poland - legal considerations versus reality 71aforementioned services are mostly provided by meansof: a) education in terms of preparation for parenthood,methods of family planning and protection of maternityand paternity, b) pregnancy detection, providing care topregnant women during physiologic pregnancy andperforming tests necessary in normal pregnancymonitoring, c) referral to examinations necessary forthe earliest possible detection of high-risk pregnancies,d) conducting spontaneous deliveries and monitoringof fetal welfare with the aid of medical devices, e)conducting spontaneous deliveries including perinealincisions and suturing, f) undertaking necessary actionsin emergency situations in the physician’s absence,conducting breech deliveries and manual removal ofthe placenta, g) care for future mothers and monitoringof them during the prenatal period, h) examination andcare of neonates, i) execution of physician’s ordersduring diagnostics, treatment and rehabilitation, j)independent, preventive, diagnostic, therapeutic andrehabilitative services to a limited extent, and k)prevention of gynecologic diseases and obstetricalpathologies.” [3]These aforementioned documents, along withongoing discussions within the Polish midwiferycommunity, prompt detailed competence analysis ofparticular members of the therapeutic team responsiblefor taking care of women during normal pregnancies,during physiological deliveries, and in puerperium.The hereby presented results constitute part of thisanalysis and in our opinion, will provide the basis forfuture discussion.The aim of this study was to verify if midwiveshave real possibilities for providing individual andindependent care to healthy expecting women, as isguaranteed to this profession by the aforementionedlaws. The detailed objectives of this study were: 1) toassess the readiness of midwives in regards to complexand independent care giving for expecting familiesduring physiological pregnancy, delivery andpuerperium, 2) to evaluate the role of midwiferypractice during individual preparation of woman (andher spouse) for childbirth, and 3) to define the elementsof health education included in preparations forchildbirth.MATERIAL AND METHODThe diagnostic survey was completed by 291practicing midwives. The inclusion criterion for thisstudy was current or past practice in the delivery room.The study included midwives employed at eight typesof hospitals located in and outside of Warsaw.Moreover, the study group included students ofweekend and complementary courses in midwifery atWarsaw Medical University.All participants were asked to complete thequestionnaire prepared by the authors for the purposeof this study. Grouping variables for further analysisincluded: participant’s age, place of residence,education level, current educational status, place ofwork, and work experience. The distributions ofanswers (in percentages) in the groups distinguishedbased on these variables were compared using the chisquaretest. Calculations were performed usingStatistica 7 (StatSoft ® , Poland) software, withstatistical significance defined as p≤0.05.FINDINGSThe first problem that was analyzed in this studywas the readiness of midwives to provide complexindependent care for expecting families duringphysiologic pregnancy, delivery and puerperium(Table I). Most of the study participants (n=232; 80%)declared their readiness for this type of caregiving.Twenty-seven out of 59 participants who answered thisquestion with a “no” gave their reasons for this answer.The most frequently declared reasons were: lack ofsufficient experience (n=14; 46%), need to improvequalifications (n=7; 23%), and systemic obstacles(n=5; 17%). Positive answers were observed mostfrequently (n=14; 88%) amongst midwives older than50 years of age. A relationship was observed betweenthe age of participants and the distribution of theiranswers – the younger the age of respondents, thelower the fraction of declared readiness for complexindependent caregiving to healthy women duringpregnancy, delivery and puerperium. This finding isundoubtedly related to the lack of sufficient experiencein younger midwives. Another association wasobserved between answer distributions and the place ofresidence. Nearly all respondents living in mediumsizedtowns (n=34; 92%) declared that they were readyto provide complex independent care – contrary toparticipants living in Warsaw (n=129; 75%) or in thecountryside (n=69; 83%). This finding is probablyrelated to the fact that midwives working in mediumsizedtown hospitals have more freedom and are moreindependent than their colleagues employed at clinicalhospitals in Warsaw. An interesting association was

72Grażyna Bączek, Ewa Dmoch-Gajzlerskaobserved between answer distributions and theeducation levels of participants.Table I. Readiness of midwives in regards to complex andindependent care giving for expecting familiesduring physiological pregnancy, delivery andpuerperiumTabela I. Gotowość położnych do świadczenia kompleksoweji samodzielnej opieki w zakresie fizjologicznejciąży, porodu i połoguGrouping variable/ Yes/ Tak No/ Nie p value*Grupa zmiennychTotal (n=291) 232 (80%) 59 (20%) -Age/ Wiek≤30 years / lat 39 (76%) 12 (24%) 0.626(n=51)31-50 years/ lat 179 (80%) 45 (20%)(n=224)>50 years/ lat (n=16) 14 (88%) 2 (12%)Place of residence/ Miejsce zamieszkaniaBig city/ Duże 129 (75%) 42 (25%) 0.052miasto (n=171)Medium-sized 34 (92%) 3 (8%)towns/ Średniemiasto (n=37)Countryside / Wieś(n=83)69 (83%) 14 (17%)Education/ WykształcenieSecondary/186 (81%) 44 (19%) 0.893Zawodowe (n=230)Higher/ Wyższe(n=61)46 (75%) 15 (25%)Studies/ Osoby aktualnie studiująceYes/ Tak (n=153) 115 (75%) 38 (25%) 0.033No/ Nie (n=107) 92 (86%) 15 (14%)Specialization/ SpecializacjaYes/ Tak (n=30) 28 (93%) 2 (7%) 0.08No/ Nie (n=261) 204 (78%) 57 (22%)Place of work/ Miejsce pracyClinical hospital/ 32 (74%) 11 (26%) 0.08Szpital kliniczny(n=43)Institute/ Instytut 28 (88%) 4 (12%)(n=32)City hospital/69 (81%) 16 (19%)Szpital miejski(n=85)Obstetricgynecologic30 (64%) 17 (36%)hospital/ Szpitalpołożniczo -ginekologiczny(n=47)Outpatient clinic/ 14 (78%) 4 (22%)Ambulatorium(n=18)Specialist hospital/ 17 (81%) 4 (19%)Szpitalspecjalistyczny(n=21)Voivodeshiphospital/ Szpitalwojewódzki (n=24)21 (88%) 3 (12%)Professional experience/ Staż pracy21 years/ lat (n=61) 53 (87%) 8 (13%)*chi-square testMidwives with secondary education gave positiveanswers more frequently (n=186, 81%) than theircolleagues with higher education (n=46, 75%).Presumably, the opinions of midwives with highereducation are more consciously and carefullyformulated. The aforementioned relationship wasconfirmed when answer distributions were comparedin relation to the current educational status ofparticipants: midwives who were completing theireducation at the time of this survey gave positiveanswers less frequently (n=115; 75%) than theircolleagues (n=92; 86%; p=0.033). An oppositerelationship, however, was observed in the group ofspecialized midwives. Therefore, it may be assumedthat specialization provides more useful skills thanuniversity education. No significant association wasobserved between the type of hospital the studyparticipants were employed at and their answerdistributions.Autonomy was most frequently declared by nurseswho worked at voivodeship hospitals or institutes(n=21; 88% and n=28; 88%, respectively). Negativeanswers were in turn most frequently observedamongst workers of specialist obstetric-gynecologichospitals (n=17; 36%). Midwives from voivodeshiphospitals declared organizational obstacles as theirmost frequent limitation in providing independent care.Midwives working for 20 years or longer (n=53; 87%)declared the highest readiness for complex andindependent care when the duration of professionalexperience was included in the analysis.Another analyzed question pertained to thereadiness of midwives for the individual preparation ofwomen (and their spouses) for delivery (Table II).More than half of the study participants (n=173; 59%)declared that they execute this task in their everydaypractice. Again, positive answers were most frequentamongst midwives older than 50 years of age (n=11;69%). Another association was observed in relation tothe participants’ place of residence. Most respondentsfrom medium-sized towns (n=29; 78%) declared theirreadiness for this type of care – contrary to midwivespracticing in Warsaw (n=101; 59%) or in thecountryside (n=42; 51%). Again, a higher degree offreedom and independence amongst midwives frommedium-sized town hospitals may be the potentialreason for this finding. Surprisingly, midwives whowere continuing their education at the time of thissurvey declared providing this type of care less

Independent midwifery practice in Poland - legal considerations versus reality 73frequently (n=72; 47%) than their colleagues (n=76;71%, p=0.001).Table II. Readiness of midwives in regards to individualpreparation of woman (and her spouse) forchildbirthTabela II. Gotowość położnych do świadczenia indywidualnegoprzygotowania kobiety (i jej małżonka) doporoduGrouping variable/ Yes/ Tak No/ Nie p value*Grupa zmiennychTotal (n=291) 173 (59%) 118 (41%) -Age/ Wiek≤30 years/ lat (n=51) 28 (55%) 23 (45%) 0.85931-50 years/ lat 134 (60%) 90 (40%)(n=224)>50 years/ lat (n=16) 11 (69%) 5 (31%)Place of residence/ Miejsce zamieszkaniaBig city/ Duże 101 (59%) 69 (41%) 0.063miasto (n=170)Medium sized 29 (78%) 8 (22%)towns/ Średniemiasto (n=37)Countryside/ Wieś(n=83)42 (51%) 41 (49%)Studies/ Osoby aktualnie studiująceYes/ Tak (n=152) 72 (47%) 80 (53%) 0.001No/ Nie (n=107) 76 (71%) 31 (29%)Specialization/ SpecjalizacjaYes/ Tak (n=30) 25 (83%) 5 (17%) 0.017No/ Nie (n=260) 147 (57%) 113 (43%)Place of work/ Miejsce pracyClinical hospital/ 19 (44%) 24 (56%) 0.23Szpital kliniczny(n=43)Institute/ Instytut 25 (78%) 7 (22%)(n=32)City hospital/47 (55%) 38 (45%)Szpital miejski(n=85)Obstetricgynecologic30 (65%) 16 (35%)hospital/ Szpitalpołożniczo -ginekologiczny(n=46)Outpatient clinic/ 8 (44%) 10 (56%)Ambulatorium(n=18)Specialist hospital/ 15 (71%) 6 (29%)Szpitalspecjalistyczny(n=21)Voivodeshiphospital/ Szpitalwojewódzki (n=24)16 (67%) 8 (33%)Professional experience/ Staż pracy21 years/ lat (n=60) 39 (65%) 21 (35%)*chi-square testOne reason for this discrepancy might be thatrespondents currently studying had less time, due tostudying, to provide this type of care. An oppositerelationship, however, was observed in the subgroup ofspecialized midwives who declared readiness for thistype of care more frequently than the other respondents(n=25, 83%; p=0.017). Considering the participants’place of work, individual preparation for delivery wasmost frequently provided by the midwives who workedat institutes (n=25; 78%) or specialist hospitals (n=15,71%).This form of care was declared least frequentlyamongst employees of academic hospitals (n=19,;44%) and outpatient clinics (n=8; 44%). Readiness forindividual preparation for delivery increasedproportionally along with the participants’ professionalexperience. This form of care was most frequentlydeclared by nurses whose professional experience wasgreater than 20 years (n=39; 65%).Describing the aspects of health education providedfor the preparation of expecting parents was the thirdobjective of this study. The most frequently declaredaspects were: biological aspects of pregnancy, deliveryand puerperium (n=150; 19%), followed by hygiene(n=145; 18%), psychological aspects of pregnancy,delivery and puerperium, and proper nutrition (eachn=131; 16%), physical activity (n=127; 16%), andprenatal communication with the child (n=106; 13%).Some respondents (n=14) proposed their own elementsin regards to the health education provided to parentsduring prenatal education. The most frequent answersin this category were: breastfeeding (n=8; 44%),preparation for the parental role, and childcare (eachn=4; 22%).DISCUSSIONThe question of providing complex andindependent midwifery care to healthy expectingwomen and women at the time of delivery or duringpuerperium is strongly associated with the continuityof healthcare. The selection of a midwife who willaccompany women on their way to maternity is ofcrucial importance. Analysis by Green et al. (2000)confirmed that women who experienced continuouscare during their pregnancies and deliveries were moresatisfied than those who did not experience this type ofcare. Consequently, these authors suggest organizingcenters of perinatal care in such a way as to ensure thatcontinuous care would be standard. Such an attitudewould follow patients’ expectations and strengthen therole of midwives amongst healthcare professionals. [4]Polish law in regards to the profession ofmidwifery does not prohibit practicing outpatient

74Grażyna Bączek, Ewa Dmoch-Gajzlerskamidwifery. Still, there is no room for such independentpractice in the Polish healthcare system.However, there is a group of independent midwiveswho provide care for pregnant women duringphysiologic pregnancies, conduct deliveries at homes,and take care of mothers and their neonates. Theirservices, however, are not refunded by the publichealthcare system.A study by Pollard (2010) [5] gives an interestinginsight into midwifery practice in Great Britain. Theaim of the study was to analyze if, and in what way,midwifery practices influenced maternity care andissues regarding the medicalization of childbirth. Theauthor was also interested in inter-relationships presentbetween the medical authority, gender, and the degreeof midwife professionalism. Qualitative methods wereused, including interviews and observations taken inneutral environments. The study revealed thatmidwives are often inconsistent and that systemicobstacles force them to perform activities differentfrom what they declare. Consequently, midwifeprofessionalism and a degree of delivery“medicalization” are mostly considered traditionally.These findings confirm the complexity of the situationfaced by midwives and the challenges faced by thisprofessional group.Our analysis revealed a wider context to thisproblem, identifying the reasons which inhibitmidwives from providing complex care to pregnantwomen, women during delivery, or in puerperium.One-fifth of our respondents declared that they werenot ready to provide this type of care due to the lack ofexperience and qualifications. Another declared reasonwas systemic obstacles faced during independentmidwifery practice.These aforementioned obstacles suggest the needfor the integration of therapeutic team members and amutual appreciation of competence. This hypothesiswas confirmed by Schmied et al. (2010) [6] whoanalyzed the role of integrated perinatal care. Theauthors highlighted the importance of cooperationbetween midwives, nurses and primary carephysicians. They also emphasized the role of anintegrated healthcare model for pregnant women,neonates and their families. The efficiency of thisintegrated care depends mostly on the quality ofcommunication within therapeutic teams along withmutual appreciation of competence.The appreciation of competence is still problematicin Poland. Even though laws pertaining to theprofession of midwifery state that these professionalsare competent to independently conduct spontaneousdeliveries, in most cases, such deliveries are stillconducted by physicians.An interesting example of midwifery care waspresented by Johnson et al. (2003). [7] Their model ofcare was geared towards women in low-riskpregnancies. Among numerous factors studied, theauthors analyzed practical considerations, elements ofcontinuity and patient satisfaction. The study includedpatients subjected to standard hospital care and womenwho received primary health care from midwives. Thequality and continuity of care experienced by womensubjected to midwifery care was better, resulting inbetter satisfaction when compared to hospitalizedpatients.Our study revealed that more than half of therespondents (59%) provide future parents withindividual preparations for delivery. It should be noted,however, that this form of practice is only a parasystemic(not refunded by the social insurance)element of perinatal care. Nonetheless, it is a substituteof aforementioned primary health midwifery care.Therefore, although not respected by the Polishhealthcare system, this type of activity constitutesproper direction of Polish midwifery development.According to Polish professional law, midwives areallowed to administer some drugs and may carry outindividual practice. Unfortunately, there are noregulations in regards to the purchasing of prescriptiondrugs necessary for the practice of midwifery (e.g.during childbirth at home or in a labor house).Therefore, Polish law paradoxically allows andsimultaneously disables carrying out individualpractice.In the curriculum of birthing schools in Poland,particular attention is paid to the promotion ofbreastfeeding. Questions pertaining to this aspect ofperinatal education were not included in ourquestionnaire on purpose, since breastfeeding is acompulsory subject in Polish birthing school curricula.Interesting research on the importance ofbreastfeeding promotion and public health was carriedout by Agampodi and Agampodi (2008) [8]. Theyanalyzed breastfeeding in a group of 336 mothers andobserved that the efficiency of breastfeeding increasedfrom 19% to 70% in women who participated in healthpromotion programs, Moreover, this study confirmedthe positive impact of educational intervention on theduration of breastfeeding (up to six months of life).

Independent midwifery practice in Poland - legal considerations versus reality 75In our study, none of the participants declared theuse of aromatherapy during preparations for delivery orduring delivery itself. However, we know fromunpublished information that this type of assistance isused by some midwives in Poland. Aromatherapy is amedical practice based on the use of plant oils. It hasbeen used for ages in female healthcare. The propercomposition of different plant-derived oils attenuatesthe woman’s feelings during delivery and puerperium.[9] Therefore, further research is needed on the use ofaromatherapy by Polish midwives.Birthing schools have for years been establishedareas for independent midwifery practice. Our studyconfirmed that this type of education is complex andincludes both physical, mental, and social aspects ofhealth. A separate problem pertains to the question offemale education in terms of decision making andparticipation in the delivery process. A Dutch studyanalyzed the opinions of midwives in regards todecision making by pregnant and delivering women.[10] Interestingly, decision making was more frequentamongst younger patients (below 29 years of age). Inthe author’s opinion, the increased “medicalization” ofdeliveries results from a conflict between the attitudesof midwives to delivery care and the freedom of choiceof pregnant women.Problems in the implementation of independentmidwifery practices in Poland suggest the necessity fordetailed analysis of the forms and extent of servicesprovided by midwives. Standardized tools, enablingcomparison between our own results and results fromother centers, allow for detailed evaluation ofmidwifery practices.An example of such studies was published byMurphy and Fullerton (2001). [11] According to theseauthors, studies on the effectiveness of midwifery careare complicated due to the lack of proper investigativetools. Therefore, they described their observations withthe use of an existing tool (Optimality Index-US)during the evaluation of midwifery practices in theUnited States. The results of preliminary studiessuggest that this tool could be used in the assessmentof perinatal care.Other results of midwifery practice assessments (interms of optimal care) were published by Cragin andKennedy (2006). [12] They analyzed a group of 375patients along with 179 physicians and 196 midwivesto compare the quality of care provided by the twolatter medical professions. After adjustment for actualrisk, the optimal model of care (low intervention and“medicalization” rates) was more frequently offered topatients who were subjected to midwifery care.The results of our study constitute a kind ofdiagnosis pertaining to the readiness of Polishmidwives for independent professional care of childexpectingwomen. These findings provide the basis forthe implementation of further proper procedures andtools.CONCLUSIONSIndependent midwifery practice is not limited byPolish law. The obstacles faced by independentmidwives are associated rather with the healthcaresystem and the mentality of its workers, who often donot appreciate the competence of midwives. Themajority of midwives (80%) declare their readiness inproviding complex care for expecting families.Additionally, most of the participants (59%) offer theindividual preparation of women (and their spouses)for delivery, even though this service is not refundedby social insurance. The biological aspects ofpregnancy, delivery and puerperium are the mostfrequent components of prenatal health education,followed by psychological aspects, hygiene, diet,physical activity and prenatal communication with thechild.The role of the midwife should be strengthened byextensive media campaigns promoting the competenceof this professional group, along with the completionof graduate and postgraduate education curricula inaspects useful for running independent practice.Perinatal care models and the methods of theirevaluation in different centers inspire Polish midwivesto search for ways to establish their professionalautonomy.REFERENCES1. Confederation of Midwives Council Meeting. 19 July2005, Brisbane, Australia. http://www.internationalmidwives.org. Accessed: 6.07.2006.2. Council Directive of 21 January 1980 concerning thecoordination of provisions laid down by law, regulationor administrative action relating to the taking up andpursuit of the activities of midwives (80/155/EEC)3. The law on nurse and midwife profession, 1996 (Dz. U.Nr 91, poz. 410)http://www.portalmed.pl/xml/prawo/medycyna/medycyna/r2005/051461u,18.04.2009

76Grażyna Bączek, Ewa Dmoch-Gajzlerska4. Green J.M., Renfrew M.J., Curtis P.A.,. Continuity ofcareer: what matters to women? A review of theevidence. Midwifery 2000,16, 186-196.5. Pollard K.C., How midwives' discursive practicescontribute to the maintenance of the status quo in Englishmaternity care. Midwifery 2010, 6 [Epub ahead of print]6. Schmied V., Mills A., Kruske S., at all.,. The nature andimpact of collaboration and integrated service deliveryfor pregnant women, children and families. Journal ofClinical Nursing 2010, 19, 3516-3526.7. Johnson M., Stewart H., Langdon R. at all. Womencentredcare and caseload models of midwifery.Collegian 2003, 10, 30-34.8. Agampodi, S.B., Agampodi T.C., Effect of low costpublic health staff training on exclusive breastfeeding.Indian Journal of Pediatrics 2008, 75, 1115-1119.9. Tillett J., Ames D., The uses of aromatherapy in women'shealth. Journal of Perinatal & Neonatal Nursing 2010, 24,238-245.10. van der Hulst L.A., van Teijlingen E.R., Bonsel G.J. atall. Dutch women's decision-making in pregnancy andlabour as seen through the eyes of their midwives.Midwifery 2007, 23, 279-286.11. Murphy P.A., Fullerton J.T., Measuring outcomes ofmidwifery care: development of an instrument to assessoptimality. Journal of Midwifery & Women’s Health2001, 46, 274-284.12. Cragin L., Kennedy H.P., Linking obstetric andmidwifery practice with optimal outcomes. Journal ofObstetric, Gynecologic, and Neonatal Nursing 2006,35,779-785.Address for correspondence:Grażyna Bączek PhDDepartment of Gynecologic and Obstetrical DidacticsWarsaw Medical Universityul. Solec 5700-424 Warsaw, Poland.Tel./fax +48 22 621 14 15;e-mail: gbaczek@wum.edu.pltel. 603 500 337Received: 10.01.2012Accepted for publication: 6.03.2012

Medical and Biological Sciences, 2012, 26/1, 77-83Bernadeta Cegła, Małgorzata Filanowicz, Aneta Dowbór-Dzwonka, Ewa SzynkiewiczDOES THE CHARACTER OF HYPERTENSION AND MODE OF THERAPYDETERMINE CHANGES IN THE QUALITY OF LIFE?CZY SPECYFIKA CHOROBY NADCIŚNIENIOWEJ I SPOSÓB PRZYJMOWANIA LEKÓWW ZASTOSOWANEJ TERAPII SĄ DETERMINANTAMI ZMIAN W JAKOŚCI ŻYCIA CHORYCH?Department of Health Sciences Division of Nursing in Internal DiseasesThe Nicolaus Copernicus University in Toruń Collegium Medicum named after Ludwik Rydygier in BydgoszczSummaryIntroduction. The study of factors whichdetermine changes of life quality in patients with arterialhypertension is crucial to relevancy and effectiveness ofsecondary activities which are implemented for patients’care. Does the character of hypertension and mode of therapydetermine changes in the quality of life? For many years, theimprovement in quality of life has been taken into account.Apart from activities eliminating the symptoms of diseaseand prolonging the duration of patient’s life, it is essential toimprove the quality of life. Conducting research aiming atdetermining factors allows taking proper preventive andreparative steps.The aim of the study is to determine:- what the level of quality of life in patients with arterialhypertension is,- if duration of illness influences changes in the quality oflife,- if differences in quality of life reflect severity ofhypertension,- if the type of leading symptom and its intensity changethe quality of life.M a t e r i a l s a n d m e t h o d s . The studied groupcomprised of 185 patients with arterial hypertension. Themean age of patients was 55.6±14.2 years. Diagnosticssurvey was applied as the analysis method. The selfdeveloped‘Quality of Life Questionnaire’ and ‘InterviewQuestionnaire’ were exploited. The study was performed inthe area of city of Bydgoszcz.T h e r e s u l t s showed that mean Quality of Life[QoL] in patients was 0.58, where 0 represented the lowestand 1.0 the highest level of QoL. The lowest level of QoL(0.54) was demonstrated by patients with long history ofhypertension. In patients with short duration of disease theQuality of Life was 0.69. The level of hypertension had themost important influence on the Quality of Life. Thedependence between the leading symptom and the quality oflife was not demonstrated. The level of intensity of theleading symptom of the disease revealed to be the moststrongly influencing factor.C o n c l u s i o n s . 1. The quality of life in patients witharterial hypertension is significantly low. 2. The duration ofthe disease influences the patients’ quality of life. 3. Themode of therapy is not a relevant factor causing changes oflife quality. 4. The intensity of the leading symptomdetermines the quality of life in patients.StreszczenieWstę p . Badanie czynników determinujących zmianyjakości życia chorych na nadciśnienie tętnicze jest istotne zpunktu widzenia trafności i skuteczności wtórnych działańwdrażanych do opieki nad pacjentem. Od wielu lat wleczeniu uwzględnia się poprawę jakości życia. Opróczdziałań likwidujących objawy choroby i przedłużania życiachorego istotna jest poprawa jego jakości. Prowadzeniebadań mających na celu poznanie czynnikówdeterminujących pogarszanie jakości życia pozwalapodejmować celowe działania prewencyjne i naprawcze.Cel badań- jaki jest poziom jakości życia chorych z nadciśnieniemtętniczym,- czy długość chorowania wpływa na zmiany w jakościżycia,

78Bernadeta Cegła et. al.- czy różnice w poziomie jakości życia związane są zciężkością nadciśnienia,- czy rodzaj wiodącego objawu i jego nasileniepowodują zmiany jakości życia.Materiał i metody. Grupę badaną stanowiło 185 osóbchorych na nadciśnienie tętnicze. Średni wiek pacjentówwynosił 55,6±14,2 lat. Do gromadzenia danychwykorzystano metodę sondażu diagnostycznego. Posłużonosię Kwestionariuszem Jakości Życia i KwestionariuszemWywiadu konstrukcji własnej. Badania przeprowadzono naterenie miasta Bydgoszczy.Wyniki badań wykazały, że średnia JŻ (jakośćżycia) chorych wynosi 0.58, przy czym 0 stanowi najniższą a1.0 najwyższą JŻ. Najniższą JŻ, 0.54 wykazywali pacjenci,chorujący długo na nadciśnienie. U pacjentów chorującychkrótko JŻ była na poziomie 0.69. Czynnikiem najsilniejwpływającym na JŻ był stopień ciężkości nadciśnienia. Niestwierdzono wpływu rodzaju, wiodącego w nadciśnieniuobjawu, na JŻ pacjentów. Zdecydowanie najsilniejwpływającym na zmiany jakości życia czynnikiem okazał sięstopień nasilenia głównego objawu choroby.W n i o s k i . 1. Jakość życia pacjentów znadciśnieniem tętniczym jest znacznie obniżona. 2. Czastrwania choroby wpływa na jakość życia chorych. 3. Sposóbprzyjmowania leków nie jest istotnym czynnikiempowodującym zmiany jakości życia. 4.Stopień nasileniawiodącego objawu choroby determinuje jakość życiachorych.Key words: hypertension, therapy, quality of lifeSłowa kluczowe: nadciśnienie tętnicze, terapia, jakość życiaINTRODUCTIONNine million Poles have been suffering fromarterial hypertension while the number of Americanswith the disease reached 50 millions [1]. Among all ofthem, about 15% in Poland and 50% in the U.S. havebeen effectively treated meaning not only the dose ortype of the prescribed medication but also grantingpriority to such factors as proper life style, adequateself-control, regularity and scrupulosity of drugadministration. Arterial hypertension belongs to thediseases which symptoms significantly burdeneveryday functions and decrease patients’ comfort [2,3]. Pain, vertigo and blurred vision worsenconcentration. The necessity of regular and continuousdrug administration, diet adjustment and quitting badhabits imply limitations which often result infrustration, discouragement and returning to negativeand hazardous behavior. On the other hand, the diseasecan be easily (in majority of cases) managed andcontrolled providing comfort and function on asatisfactory level. The above mentioned change of lifestyle, adequate self-control and diet are elementsdetermining improved Quality of Life and decreasinghypertension level. For example, a reduction in bodyweight of 5.1kg on average is related to a meandecrease of systolic pressure by 4.4 mm Hg anddiastolic pressure by 3.6 mm Hg [4]. It is obvious thatbeside elimination of disease symptoms and lifeprolongation of patients, an improvement in Quality ofLife plays an essential role and has been included inthe management of patients with hypertension formany years now. Without diagnosing specific reasonsfor worsening life quality, areas of better quality anddeterminants of changes, undertaken measures cannotlead to desired goals. The importance of explorationand confirmation of existing relations is essential as abasis and reference for recommended changes.This type of study is required when consideringpertinence and effectiveness of prospective activitieswhich will be implemented in patients care to helpreaching good preventive and reparative targets.The aimThe aim of this study was determining:- what a quality of life in patients with arterialhypertension is,- if duration of diseases influence changes life quality,- if differences in quality of life reflect severity ofhypertension,- if type of the leading symptom and its intensitychange the quality of life.MATERIAL AND METHODSThe studied group comprised 185 patients witharterial hypertension. Among them 104 were womenand 81 - men aged from 21 to 84 years. The mean ageof patients was 55.6±14.2 years. Patients diagnosedwith arterial hypertension, patients hospitalized due tovarious reasons in whom hypertension was aconcomitant disease and patients treated forhypertension under control of out-patient clinic wereenrolled into the study. The consent for participation inthe study was given by signing a consent form aftergetting information about the study. The detailedcharacteristic of the studied group is presented inTable I.

Does the character of hypertension and mode of therapy determine changes in the quality of life? 79Table I. The characteristics of the studied groupTabela I. Charakterystyka grupy badanejMarital statusStan cywilnyEducationWykształcenieResidenceZamieszkanieTable II. The quality of life in patients with arterialhypertensionTabela II. Poziom jakości życia chorych z nadciśnieniemtętniczymSingleWolnyMarriedŻonaty/ZamężnaUniversityElementary Professional CollegeRuralWyższePodstawowe Zawodowe ŚrednieWieśUrbanMiaston 48 137 30 43 80 32 36 149% 26% 74% 16.2% 23.2% 43.2% 17.3% 19.5% 80.5%Mean height średni wzrost168.2 ±9.2 cmMean weight średnia waga81.5 ±17.8 kgBMI 28.7 ±5.4 kg/m 2The study was performed in universitydepartments, wards and out-patient clinics in the areaof Bydgoszcz. In order to conduct the study, authorsobtained the approval of the Bioethics Board of theNicolaus Copernicus University Collegium Medicumin Bydgoszcz, (No. KB/44/2008). For the analysis themethod of diagnostic survey was used. The selfdevelopedQuality of Life questionnaire for Patientswith Arterial Hypertension and Interview and ActivityAssessment questionnaire were exploited.For gathering personal, physical activity and lifestyle data the Interview and Activity Assessmentquestionnaire was applied. In statistical analysis, asrelevant p=0.05 level of significance was assumed,for which critical values are given in the tables.RESULTSHereby presented results are a part of a morecomprehensive study which analyzed influence ofvarious life areas and modes of patient functioning onthe quality of life and the change determinants inobserved quality of life. The presented results compriseselected topics and concentrate on factors which arespecific to disease and patient’s self-control.The gathered data were subject to a quantitative andstatistical analysis. Firstly, data concerning patientswith arterial hypertension were analyzed. The analysisof data revealed the level of Quality of Life inparticular patients. For normalization of values in 0-1scale the linear conversion was applied; in result eachpatient received Quality of Life result in normalized 0-1 scale, where the worst possible Quality of Life wasrepresented by 0, while the best one by 1. The meanvalue of Quality of Life in the studied group wascalculated as 0.58 which is slightly higher than meanvalue of 0.5. The result allows concluding that Qualityof Life in patients with arterial hypertension issignificantly decreased by the disease and itsconsequences. The discussed results are presented inTable II.ParametersParametryQuality of life levelPoziom jakości życiaMin 0.04Max 0.99Median 0.60Mean 0.58SD 0.21Subsequently, the relation between Quality of Lifeand duration of illness was assessed. The levels ofobserved Quality of Life were compared in a subgroupbetween patients with a recently diagnosedhypertension (six months ago) and those with a longerhistory of hypertension (diagnosed ten years ago). Bothsubgroups had been treated since the diagnosis wasmade. The analysis revealed decreasing Quality of Lifealong with the duration of the disease. Patients withthe longest history of disease had the lowest Quality ofLife. An interesting result appeared in Quality of Lifeamong patients who have been treated for a year incomparison to a group of patients with a recentlydiagnosed hypertension (six months ago). It could beconcluded that significantly worsened Quality of Lifedoes not improve instantly with introducing treatment,whereas the longer the disease duration is, the more theQuality of Life decreases. The differences betweenmarginal values of Quality of Life are statisticallysignificant. It could be stated for certain that durationof disease determines Quality of Life in patients. Theresults suggest that this state is caused by patients’condition worsening along with disease duration orhealthy life style becoming neglected.The detailed data on the subject are presented inTable III.Table III. The duration of disease and quality of life inpatients with arterial hypertensionTabela III. Długość trwania choroby a poziom jakości życiachorych z nadciśnieniem tętniczymQuality oflifeJakośćŻyciaANOVAtest(F kr =2.42)Duration of disease (in years)Parame Długość trwania choroby (w latach)tersParametry 0.5 1 3 5 10n 15 15 36 35 81mean 0.58 0.69 0.64 0.56 0.54SD 0.20 0.15 0.23 0.22 0.20F 2.83p

80Bernadeta Cegła et. al.Another specific factor of hypertensioncharacteristics is its severity. According to ESHclassification, patients were grouped into mild,moderate and severe hypertension groups. 8 patientswere not able to determine the level of hypertensiondiagnosed by physician and blood pressure measureswere normal during treatment. In data analysis, thelevels of Quality of Life among three subgroups werecompared. Distinctly, the worst Quality of Life wasdemonstrated by patients with severe hypertension.The difference in Quality of Life in studied subgroupsreached the level of p=0.0006. The analyzed data arepresented in Table IV.Although significant influence of a type of leadingsymptoms on the Quality of Life was not stated, itsintensity determined the level of Quality of Life.Patients with the highest intensity of their mainsymptom in the VAS scale demonstrated the lowestQuality of Life. Based on the results, negativecorrelation between Quality of Life and intensity ofperceptible symptom was stated.Table IV. The level of hypertension and level of quality of lifeTabela IV. Stopień nadciśnienia a poziom, jakości życiachorych z nadciśnieniem tętniczymQuality oflifeJakośćŻyciaANOVAtest(F kr =2.65)ParametersParametryNormal*Prawidłowe*Level of hypertensionStopień nadciśnieniaMildŁagodneModerateUmiarkowaneSevereCiężkien 8 66 66 35mean 0.57 0.65 0.57 0.47SD 0.19 0.18 0.22 0.23F 6.02p 0.0006*patients with hypertension undergoing therapy with normalresults of blood pressure*pacjenci z nadciśnieniem, którzy biorą leki, a wynikipomiarów ciśnienia są prawidłoweHypertension is manifested by a number of specificsymptoms. The comparison of values and levels ofQuality of Life in patients with common leadingsymptom of hypertension allows stating that a type ofsymptom is not a significant determinant of Quality ofLife. Although absolute values showed that the lowestvalues of Quality of Life were demonstrated bypatients with hypertension and most aggravatingvertigo (0.52), and the highest value (0.62) in patientswith headache, the differences were not statisticallysignificant. The results are presented in Table V.Table V. The type of leading symptom and a level of qualityof life in patients with hypertensionTabela V. Rodzaj wiodącego objawu a poziom, jakości życiachorych z nadciśnieniem tętniczymQuality of lifeJakość ŻyciaParametersParametryHeadacheBól głowyType of leading symptomRodzaj wiodącego objawuBlurredVertigovisionZawrotyNiewyraźnegłowywidzenieTinnitusSzum wuszachOtherInnyn 66 40 31 29 12mean 0.62 0.52 0.55 0.56 0.62SD 0.20 0.18 0.21 0.24 0.25ANOVA test F 1.54(F kr =2.42) p 0.19 (ns)Pic. 1. Dependence between the quality of life and theintensity of the leading symptom experienced byhypertension patientsRyc. 1. Zależność poziomu jakości życia od nasileniawiodącego objawu odczuwanego przez chorych znadciśnieniemSubsequently, data on therapy compliance andmode of drug administration in particular wereanalyzed. With no regard to taking medicationregularly or only in case of discomfort, the levels ofQuality of Life were similar. It could be concludedthat mode of drug administration does not influenceQuality of Life. It is worth to note that more than 80%of patients declared regular medicines taking. Thediscussed results are presented in Table VI.Table VI. The mode of therapy and level of quality of life inpatients with arterial hypertensionTabela VI. Sposób przyjmowania leków a poziom jakościżycia chorych z nadciśnieniem tętniczymQuality oflifeJakośćŻyciaANOVAtest(F kr =2.66)ParametersParametryMode of therapySposób przyjmowania lekówIn case ofRegular discomfort SometimesRegularnie Gdy źle NiekiedyczujęNoNien 152 10 9 12mean 0.57 0.61 0.50 0.67SD 0.21 0.20 0.16 0.25F 1.35p0.26 (ns)According to subsequent data within RRmeasuring, regular self-control does not determine thelevel of Quality of Life. Although average Quality of

Does the character of hypertension and mode of therapy determine changes in the quality of life? 81Life levels are the higher when the measurements areless frequent, it is obvious that rarity or lack ofmeasurements cannot increase the Quality of Life. Thedifferences in Quality of Life levels in particularsubgroups of patients can confirm good condition andself-esteem or health status of patient. Lack ofsymptoms, quiet and comfort decrease alertness andstop the need for regular health status control. UnifactorialANOVA test of variance analysis revealeddifferences at least in marginal values. It could bestated that mean level of Quality of life in patients whodo not measure their blood pressure is significantlyhigher than in patients who take their blood pressuremeasurements on regular basis. The discussed resultsare presented in Table VII.Table VII. Self-control and level of quality of life in patientswith arterial hypertensionTabela VII. Samokontrola a poziom jakości życia chorych znadciśnieniem tętniczymQuality oflifeJakośćŻyciaANOVAtest(F kr =2.65)DISCUSSIONParametersParametryBlood pressure measurementsPomiar ciśnienia tętniczegoIn case ofRegular discomfort SometimesParametry Gdy źle NiekiedyczujęNoNien 91 53 30 11mean 0.53 0.59 0.64 0.68SD 0.20 0.22 0.20 0.20F 3.46p

82Bernadeta Cegła et. al.complications, Woźnicka et al. stated that in both menand women, the levels of quality of life is lowest inpatients with hypertension with complications [11]. Inown research, the quality of life in patients with severehypertension was observed at the lowest level incomparison to all other analyzed groups. Variety andintensity of the symptoms which constitute thecharacteristics of the disease are also the determinantsof quality of life in patients suffering fromhypertension.When studying the relation between symptoms andthe quality of life, Erickson et al. stated that symptomshave more influence on the quality of life than bloodpressure, taken medicine and other patients’characteristics [12]. Own study demonstrated that thelowest level of quality of life occurred in patients withvertigo as the most common and most severe symptomand reached the level below the mean value for thewhole studied group. In groups where headache orblurred vision was the leading symptom, the levels ofquality of life were comparable and differences werenot statistically significant. However, the intensity ofeach leading symptom already substantially influencedthe quality of life in patients. The basic element ofpharmacotherapy in hypertension management is aproper medicine administration. Taking medicine onregular basis and systematically should levelhypertension symptoms and assure life comfort in thisscope. Unfortunately, own studies did not demonstratesuch regularity. Patients, who took anti-hypertensionmedicines regularly, displayed low level of quality oflife, similarly to patients who took medicine from timeto time. A significantly higher quality of life wasobserved in patients who take medicine onlysometimes or when they feel well. Differences in levelsof quality of life were not statistically significant.Although obtained results show that the mode ofmedicine administration is not a relevant factor forchanges in quality of life, it cannot be suggested thatregular administration of drugs lowers the quality oflife. However it may be stated that it is the group ofpatients with the most severe hypertension who aremost determined to take medicine systematically andthe factor decreasing quality of life in this case isseverity of the disease or burden of this type oftreatment. Lack of regularity in adhering to treatmentguidelines, including not taking medicine, isconsidered an important reason for unsuccessfultreatment of hypertension. It concerns bothpharmacological as well as life style related course ofaction [13].Regular self-control is another element ofsuccessful hypertension therapy and related quality oflife improvement. Above quoted studies showed thatreminding and mobilizing fair compliance withtherapeutic (pharmacologic and related with life style)recommendation reduce systolic and diastolic pressurein a significant way. The studies were of observationaltype and were connected to an educational program[13]. Own studies demonstrated that patients whoregularly measure their blood pressure have distinctlylower quality of life than those who do not measure itat all or measure it only sometimes. This data confirmsan analogy to the previously discussed resultsconcerning regularity of medicine administration. Inthis case, the differences in levels of quality of lifewere statistically significant and it could be impliedthat the quality of life is related to self-control andregularity of blood pressure measurements. However,it cannot be concluded that regular measures contributeto lowering of quality of life exclusively. Resultsregarding precision of medicine administration andblood pressure control provide interesting informationnamely that patients with severe hypertension, whichsubstantially decreases quality of life, adhere totherapy recommendations more systematically andfaithfully. On the other hand, the fact that performanceof these activities, their burden and imposedfunctioning mode may be the causes of quality of lifedecreasing is of great importance. It can be concludedfrom the studies that characteristics of the disease andself-control determine the quality of life in patientswith arterial hypertension. There are also other crucialdeterminants such as psychological factors, e.g. anxietyand fear of stroke. Therefore, it should be studied towhat extent they contribute to changes in the quality oflife. Only then will implemented therapy and educationbe of purpose, performed in proper areas and, mostimportantly, effective. It is not anxiety and fear ofcomplications that should force proper behavior but abelief in their rightness and efficiency. The slogan ofSir George Pickering, an outstanding expert inhypertension, becomes even more true: ‘whatever wedo, most importantly let us not scare the patient’.

Does the character of hypertension and mode of therapy determine changes in the quality of life? 83CONCLUSIONS1. The quality if life in patients with arterialhypertension is significantly decreased by thedisease and its consequences.2. Duration of the disease considerably influences thequality of life in patients.3. The mode of therapy is not a relevant factorresulting in changes in the quality of life.4. Intensity of the leading symptom determines thequality of life in patients.LITERATURE1. Robinson JD., Segal R., Lopez LM. et al.: Impact of apharmaceutical care intervention on blood pressure in achain pharmacy practice. Annales of Pharmacotherapy,2010; 44(1): 88-96.2. Afsar B., Elsurer R., Sezer S., Ozdemir FN.: Nondippingphenomenon and quality of life: are they related inessential hypertensive patients? Clinical & ExperimentalHypertension, 2010; 32(2):105-12.3. Saboya PM., Zimmermann PR., Bodanese LC.:Association between anxiety or depressive symptoms andarterial hypertension, and their impact on the quality oflife. International Journal of Psychiatry in Medicine,2010; 40(3):307-20.4. Degl’Innocenti A., Elmfeldt D., Hofman A., Healthrealtedquality of life during treatment of elderly patientswith hypertension: results from the Study on Cognitionand Prognosis in the Elderly (SCOPE). J Hum Hypertens2004; 18: 239-245.5. Kucharska A., Jeznach-Steinhagen A., Sińska B.:Znaczenie diety w leczeniu nadciśnienia. Kardiol. na coDzień 2010; 5: 29-32.6. Gaciong Z., Wilczko J., Postępowanie w nadciśnieniutętniczym-aktualizacja zaleceń EuropejskiegoTowarzystwa Nadciśnienia Tętniczego Przew. Lek. 2010;4,13: 14-18.7. Widecka K., Grodzicki T., Narkiewicz K., Tykarski A.,Dziwura J. (zespół redakcyjny). Zasady postępowania wnadciśnieniu tętniczym - 2011 rok Wytyczne PolskiegoTowarzystwa Nadciśnienia Tętniczego. Nadciśn. Tętn.,2011; 15(2): 55-82.8. Kawecka-Jaszcz K., Klocek M., Jakość życia chorych nanadciśnienie tętnicze [w]: Andrzej Więcek (red.),Franciszek Kokot (red): Postępy w nefrologii inadciśnieniu tętniczym. Med. Prakt. 2007; 6: 154-156.9. Klocek M., Brzozowska-Kiszka M., Rajzer M.,Kawecka-Jaszcz K. Zmiany w jakości życia chorych nanadciśnienie tętnicze w czasie telemonitorowaniadomowych pomiarów ciśnienia. Nadciśn. Tętn., 2010;14(2): 120-127.10. Szczęch R., Szyndler A., Wierucki Ł. i wsp. Jakpoprawić skuteczność terapii nadciśnienia tętniczego?Doświadczenia z programu edukacji pacjentów w ramachPolskiego Projektu 400 Miast. Arterial Hypertension2006; 10(5): 350-361.11. Woźnicka L., Posadzy-Małaczyńska A., Leśkiewicz G.,Głuszek J. Ocena jakości życia pacjentów chorujących nanadciśnienie tętnicze według ankiety SF-36. Nadciśn.Tętn., 2008; 12(2): 109-117.12. Erickson S.R., Williams B.C., Gruppen L.D.Relationship between symptoms and health-relatedquality of life in patients treated for hypertension.Pharmacotherapy 2004; 24(3): 344-350.13. Wizner B., Gaciong Z., Narkiewicz K., Grodzicki T.Zwiększenie skuteczności terapii hipotensyjnej upacjentów z nadciśnieniem tętniczym dzięki edukacjiprzez SMS. Nadciśn. Tętn., 2009; 13(3): 147-157.Address for correspondence:B. CegłaDivision of Nursing in Internal DiseasesCM UMK85-801 Bydgoszczul. Techników 3tel. 600 482 836e-mail: bernadeta_cegla@tlen.plReceived: 10.01.2012Accepted for publication: 6.03.2012

Medical and Biological Sciences, 2012, 26/1, 85-91Kamila Faleńczyk, Agnieszka Pluta, Wiesława Kujawa, Halina Basińska, Maria Budnik-Szymoniuk, Alicja MarzecANALYSIS OF PROBLEMS AND THEIR DETERMINANTS AMONG FAMILY CAREGIVERSTAKING CARE OF CHRONICALLY ILL PEOPLEANALIZA PROBLEMÓW OPIEKUNÓW RODZINNYCH OSÓB PRZEWLEKLE CHORYCHORAZ CZYNNIKÓW WPŁYWAJĄCYCH NA ICH WYSTĘPOWANIEThe Department and Institute of Public NursingNicolaus Copernicus University of Toruń Collegium Medicum in Bydgoszczacting as the director: Ph. D. Kamila FaleńczykSummaryI n t r o d u c t i o n . All over the world, family caregiversconstitute the main pillar of the state care system.Nevertheless, they usually do not receive the sufficientinstitutional support. Therefore, an attempt has been made inorder to identify the most frequently appearing problemsamong the caregivers and to define factors which influencetheir behaviour.Materials and methods. The research wasconducted among 300 caregivers who take care of thechronically ill family members in domestic conditions. Theresearch was conducted with the use of the diagnostic poll. Inorder to collect data, four following diagnostic tools wereused: the modified Bartel's Scale, the Caregiver's StrainIndex, Beck's Depression Scale and the author'squestionnaire.R e s u l t s . Despite of the high self-evaluation inpreparation of the caregivers, most of them pointed outnumerous problems concerning the daily care of thechronically ill people. The respondents most frequentlypointed out the following: the difficulties with moving the illperson (55.7%), lack of time (50.0%), difficulties withhygienic activities (49.3%) and difficulties with obtainingfinancial support (38.7%). Majority of the caregivers (69.3%)suffered from a great level of strain, while 43.7% diagnosedthemselves with a gentle stage of depression. Occurrence ofstrain and depression and their intensity was strictlyconnected with the deficit level of ward's self-service,intensity of care and the level of caregiver's preparation.Functioning of the institutions responsible for supporting thechronically ill people and their families was assessednegatively by most of the caregivers (76%).C o n c l u s i o n s . Family caregivers of the chronicallyill people pointed out a number of problems connected withdaily care. They have also revealed a significant level ofstrain. The difficult situation of caregivers is affected bynumerous factors, one of which is lack of theinterdisciplinary support in fulfilling the caring function. Forthis reason, there is an urgent necessity of change in thecurrent state care system, which would enable effective caretakingin domestic conditions.StreszczenieWstę p. Na całym świecie opiekunowie rodzinnistanowią główny filar systemu opiekuńczego państwa, mimoto zazwyczaj nie otrzymują oni dostatecznego wsparciainstytucjonalnego w realizacji opieki wobec swoich bliskich.Stąd też podjęto próbę identyfikacji najczęściejwystępujących problemów u opiekunów oraz określeniaczynników mających wpływ na ich występowanie.Materiał i metody. Badania zostałyprzeprowadzone wśród 300 opiekunów sprawujących opiekęnad przewlekle chorymi członkami rodziny przebywającymiw środowisku domowym. Badanie przeprowadzono metodąsondażu diagnostycznego, natomiast do zebrania materiałubadawczego zostały wykorzystane 4 narzędzia badawcze:

86Kamila Faleńczyk et. al.zmodyfikowana Skala Bartel, Skala obciążenia opiekuna,Skala Depresji Becka oraz autorski kwestionariusz ankiety.W y n i k i . Mimo wysokiej samooceny badanych wzakresie przygotowania do sprawowania opieki większość znich zgłaszało liczne problemy związane z codzienną opiekąnad przewlekle chorym. Badani najczęściej wskazywali na:trudności w przemieszczaniu chorego (55,7%), brak czasu(50,0%), trudności w wykonywaniu czynności higienicznych(49,3%), a także problemy z pozyskaniem wsparciafinansowego (38,7%). Większość opiekunów (69,3%)wykazywało duży stopień poczucia obciążenia, a 43,7%badanych rozpoznało u siebie łagodną postać depresji.Występowanie poczucia obciążenia i depresji oraz ichnasilenie pozostawało w istotnym związku ze stopniemdeficytu w zakresie samoobsługi podopiecznego,intensywnością opieki oraz stopniem przygotowania dopełnienia roli opiekuna. Większość opiekunów (76%)negatywnie oceniło funkcjonowanie instytucji powołanychdo wspierania osób przewlekle chorych i ich rodzin.W n i o s k i . Opiekunowie rodzinni osób przewleklechorych wskazywali na liczne problemy związane zcodzienną opieką oraz wykazywali duży stopień obciążenia.Na trudną sytuację opiekunów wpływa wiele czynników,jednym z nich jest brak interdyscyplinarnego wsparcia wrealizacji funkcji opiekuńczej, stąd też istnieje pilna potrzebazmiany dotychczasowego systemu opieki państwa, któreumożliwiałyby skuteczne sprawowanie opieki w warunkachdomowych.Key words: family caregivers, problems of the caregivers, caregivers' strain, caregiver's depression, long-term careSłowa kluczowe: opiekunowie rodzinni, problemy opiekunów, obciążenie opiekunów, depresja opiekuna, opiekadługoterminowaINTRODUCTIONIn most of the countries, including Poland, afundamental part of caring responsibilities towards thechronically ill patients rests on family. Yet, the currentsocio-demographical determinants make the situationof family caregivers extremely difficult. First of all,the percentage of elderly, chronically ill and disabledpeople, who demand long-term care and support of therelatives, is systematically growing. This tendency is aresult of in lengthening of human life and ageing of thepopulation. In the developed countries, the highestpopulation growth pace concerns people older than 75years old [1]. Another factor involving family in caregiving is the growth of chronic illnesses incidence rate.Among Polish population, most frequently appearingdiseases are: cardiovascular diseases, cancer, spinediseases, inflammatory and degenerative diseases ofjoints, neurological diseases [2]. Most of the diseasesare of progressive character and lead towards gradualdeterioration of general condition and growth of theself-service deficit. Another unfavorable occurrence isa quick growth pace of the number of the disabled inPoland. In 1998, the disabled constituted 6.5% of thewhole of society, while in 2004; the percentage grewup to 16.3% of the whole population [3].The growing number of people demanding longtermcare is followed by the family caregiversproportion decrease. Among other things, theoccurrence is connected with a change in the familystructure, which transforms from a multigenerationalinto a nuclear one. In consequence there is a continuallygrowing number of the elderly living on their own,this might hinder taking daily care by the family. Polishfamilies evolve also when it comes to the number ofbrought up children. Nowadays, families with one ortwo children are a dominant pattern, which considerablylowers the family care potential. The forecast clearlypoints out a growth of demographical strain. By 2020,the child strain of the society will have decreased from44 to 33 on every 100 people in productive age. What ismore, the elderly strain will have risen from 24 up to 35on every 100 people in productive age [1].Apart from that, a difficult situation of familycaregivers is also influenced by an inefficient systemof institutional care, which is supposed to providesupport. Unfortunately, in most cases, familycaregivers’ need resulting from care responsibilities areunderestimated, not discerned nor realized by the state.On account of the presented tendencies, taking dailycare of an ill family member, substantially strains thefamily caregivers on various levels of life. For thisreason an attempt at identifying problems mostfrequently appearing among the caregivers together witha diagnose of factors influencing their behavior has beenmade.METHOD AND MATERIALThe research has been conducted among 300caregivers taking care of the chronically ill members offamily, who stay in domestic environment. Theanalysis embraced a group of the main caregivers, whosupported their relatives for at least 6 months. Womendominated the group constituting 89.3% of the

Analysis of problems and their determinants among family caregivers taking care of chronically ill people 87respondents. The average age in the group equaled50.2 years old (x ±SD 13.6 years). In most of the cases,the ward was taken care by their child (40.3%) andspouse (22%), rarely the responsibility belonged to aparent or a distant relative. Most of the caregivers(75%) were permanently living with the ill person,15.7% took care of the ill person living separately,while 9.7% declared to temporarily move in with theward, ex. in times of health deterioration. A significantpart of the respondents have been taking care of theirward for more than 5 years – 39.3%, and from 6months to 2 years – 35.0%. Almost half of therespondents (49.0%) provided care 24 hours a day,while every fifth respondent devoted half of a day orseveral hours a day (18.7%) for care taking.The research was conducted with the use of adiagnostic poll, while the diagnostic material wascollected with the use of the 4 following diagnostictools: Bartel's Scale, Caregiver Strain Index, Beck'sDepression Scale and the Author's Questionnaire. Themodified Bartel's Scale allowed evaluating of the selfsufficiencyabilities in case of people remaining underdirect care of the respondents. The Caregiver StrainIndex included 13 questions and enabled to define thestrains of the caregiver which are connected withphysical effort, finances and social life. Beck'sDepression Scale was used for self-evaluation ofpresence and intensification of depression symptomsamong the tested people. The Author's Questionnaireincluded questions concerning the sociodemographicaldata, problems resulting from caretakingand expectations in the field of social support.T-Student's test, r-Spearman's test of the rank corelationand r-Pearson's test of linear co-relation wasused in the statistical analysis. While verifying thehypothesis, the border level of relevance was agreed onp ≤ 0.05.RESULTSAnalysis of the research material collected on thebasis of The Caregiver Strain Index revealed asubstantial strain of the responding caregivers. Anaverage strain equalled 8.43 points, while the diversityin the tested group equalled Sd=2.6. A bearable levelof strain (up to 7 points inclusive) was pointed out by30.7% of the questioned people; however, the majorityof the caregivers were diagnosed with a great degree ofstrain. Most of the respondents obtained from 8 to 10points on a 13 points scale.The sense of strain usually results from specificproblems which accompany care taking of achronically ill family member. The following researchproved that the activities which cause the greatestdifficulties to the caregivers were: moving the illperson (55.7%), hygienic activities (49.3%) andconducting exercises (35.7%). Feeding the ill person(13.3%) and servicing the equipment (6.0%) were theleast problematic activities. Among the organizationalproblems, respondents most frequently pointed out lackof time (50%), difficulties with acquiring financialsupport (38.7%) and lack of information concerningthe rights and help opportunities for the ill (34%).Long-term care taking also causes a significantemotional strain, the consequence of which might bedepression. Conducted research allowed measuring theoccurrence of depression among the tested group ofcaregivers. 33.0% of the questioned caregivers did notshow any symptoms of depression. Symptoms ofgentle depression were stated in 43.7% of cases, whilemoderate depression was diagnosed by 22.0% of thecaregivers. Four of the questioned caregivers (1.4%)diagnosed themselves with heavy depression. Theaverage level of depressiveness in the diagnosed groupamounted to 18.34 points, which indicates a gentlestage of depression. Diversity in the questioned groupwas rather high (Sd=12.21).Another significant problem pointed by thecaregivers is lack of social support. A prevalentmajority of the questioned people – 76%, claimed thatthe institutions qualified to support the chronically illpeople and their families, do not fully implement theirtasks, therefore, relatives of the caregivers are theirmain source of support. When fulfilling activitiesconnected with direct care-taking, the main caregiversmay count on help of the closest family (84.7%), anurse (34%), neighbours and friends (15.3%). Therespondents received emotional support considerablyless often. In most of cases, it was granted by nurses(25.7%), neighbours, friends (21.7%) and family(20.7%). Only 4.3% could count on a psychologistsupport and 6.7% of the respondents did not receiveany emotional support.The research looked into the factors which mightinfluence the occurrence of caregivers’ problems. Thedata analysis proved that one of the most importantfactors determining strain of the caregivers is theirwards’ functional efficiency. The modified Bartel’sScale was used in order to assess the respondents’ward’s efficiency. Considering self-sufficiency of the

88Kamila Faleńczyk et. al.wards, it was proven that only 11.7% of ill peoplestaying in the custody of the questioned caregiversdemands slight help with the basic everyday activities(over 80 points on the Barthel Scale). Almost half ofthe wards (48.0%) were found in the range of 40-80points, which gives evidence to their significantinefficiency in self-service. 40.3% of the ill wereclassified under 40 points on Bartel's Scale, whichindicates full dependence on the caregivers. Theaverage degree of shortage in the examined groupequalled 44.7 points. The detailed analysis pointed outa relation between ward’s efficiency level and thefrequency of appearing problems - the greater theward’s inefficiency, the more difficulties concerningcare taking and organizational matters appear.The analysis disclosed a significant relationbetween the level of self-care deficiency and the strainlevel of the caregiver. The more efficient the patient is,the lesser the strain of the caregiver (p=0.0001)(Table I).Tab. I. Dependence between the deficiency level and thestrain indexTab. I. Zależność między stopniem deficytu a wskaźnikiemobciążeniar(X,Y) r 2 t pstopień deficytupodopiecznych a wskaźnik -0.22 0.05 -3.95 0.0001obciążenia badanychlevel of the wards' deficiencyin relation to the strain indexof the caregiversr(X,Y) - współczynniki korelacjir 2 – współczynnik determinacjit- wynik test t-Studenta badającego istotność siły związkup- poziom istotności statystycznejr(X,Y) – co-relation factorr 2 – determination factort - result of the t-Student test on the strength of therelationshipp - level of the statistic relevanceIt has been also proven that there is a relationshipbetween the level of deficiency and the level ofcaregiver's depressive inclinations. The more selfsufficientthe patient is, the less depressive thecaregiver is (Table II).The deficiency level of the ward's self-service isrelated to the intensity of care performed by thequestioned caregivers. In this aspect, analysis pointedat a statistically significant relation between theintensity of care, the level of depressive inclinations(p

Analysis of problems and their determinants among family caregivers taking care of chronically ill people 89statistically significant relation between these factors.The less prepared to fulfil the role of a caregiver therespondents were, the greater their strain was(p=0.001) and depressive inclinations (p=0.021) were(Tab. V). The low index of correlation is connectedwith a huge variation of the strain index anddepressiveness index results among the groups ofvarious preparation levels.Tab. V. Dependence between the care-taking preparationlevel, the depression level and the strain levelTab. V. Zależność między stopniem przygotowania dosprawowania opieki a wskaźnikiem depresji orazstopniem obciążeniastopień przygotowania a poziomdepresyjnościcare-taking preparation level in relationto depression levelstopień przygotowania a poziomobciążeniacare-taking preparation level in relationto the strain levelr t(N-2) p0.133 2.312 0.0210.187 3.278 0.001The research also looked into the influence offamily caregivers’ social support system on dealingwith problems resulting from care-taking. The detailedanalysis proved that there are no significant differenceson the level of strain and depressiveness between thecaregivers who received support in fulfilling careresponsibilities (regardless of the source) andcaregivers who did not receive such support. Therewere no significant differences found on the level ofdepressiveness and strain among the caregivers whoreceived emotional support (regardless of the source)and those who did not receive such support.DISCUSSIONConducted research confirmed that long-term careof an ill family member significantly influencescaregiver’s strain. One of the factors which determinethe strain level is the deficit level of ward’s selfefficiency.Most of the reports confirm that caregiver’sstrain significantly grows together with the decrease ofpatient’s efficiency. The research conducted as a partof EUROFAMCARE project, in which 6 Europeancountries took part (Poland, Greece, Germany,Sweden, Great Britain and Italy), proved thatcaregiver’s strain connected with caregivingsubstantially grows together with the decrease in an illperson’s state of health and efficiency [4]. Van Exel etal., with the use of various tools to assess the strainlevel of caregivers, also proved that independently onthe diagnostic tool, the strain level was significantlyhigher in the group taking care of the ill with a seriousefficiency deficit [5,6]. It was estimated that the ward’sinefficiency is one of the most important factorsdetermining caregivers’ strain.Analysis of this report’s results also pointed out arelation between the ward’s efficiency level and thenumber of appearing problems. The higher theefficiency deficit of a patient was, the more difficultiesin care activities and organizational difficultiesappeared. Among the most frequently reportedproblems there were: difficulties with relocating of theill person, lack of time, difficulties with hygienicactivities, conducting exercises and problemsconnected with obtaining financial support. Accordingto other reports focusing on examining the caregivers,the catalogue of problems and difficulties was quitesimilar. In the research conducted by Jaracz, familycaregivers who took care of people after a stroke, alsopointed out problems with moving an ill person (39%)and with fulfilling the sanitary activities (34%) [7].Kachaniuk et al. proved that the greatest difficulty wascaused by moving the ill person from the bed (38.2%)and changing patient's body position (33.1%), despitethe fact that most of the caregivers declared knowledgeof the proper relocation of an ill person [8].Authors of this research analysed also theemotional problems of caregivers, the consequence ofwhich may frequently lead towards depression. Theresearch revealed that only 33% of the respondentsremained untouched by the depression symptoms. Theaverage level of depressiveness in the group amountedto 18.34, which indicates the gentle stage ofdepression. Academic literature is dominated by thereports on fear and depression intensity among thecaregivers of patients with dementia. According toWitusik research, the depression intensity – on Beck'sScale – was greater in case of people taking care of aperson with dementia, than within the test group(18.00±7.90 regarding 13.12±10.49, p

90Kamila Faleńczyk et. al.The detailed analysis of the results of this researchproved that appearance of depression symptoms wereinfluenced by: the deficiency level in wards’ selfservice,care intensity and the preparation of caregiversto conduct caring functions. The dependence betweenthe depression level and ward’s functional deficiencylevel is also pointed out by other authors. Wade et al.confirmed that the lower the efficiency of a patientgets, the more possible it is for the caregiver to becomedepressed [12]. Some researches [13,14] prove that therisk of depression appearance grows together with thelengthening of care-taking time. While, in the researchconducted by the authors of this report, the dependencehas not been stated.Another significant factor influencing the conditionof caregivers is the support from the environment. Inthis report, it has been proved that the respondents maycount on help in daily care from the closest family,nurses, neighbours and friends. Caregivers receivedemotional support considerably less often. Results of agreat number of research point out that caregiversabove all receive help from the family [15,16,17,18].Unfortunately, caregivers assessed the institutionalhelp rather negatively, which was proved in thisresearch and other reports. For example, only fewcould count on psychologist's support [15,18]. In thereport on Alzheimer disease from 2009, lack ofeconomical, psychological and social support for theinformal caregivers was pointed out [19]. This veryreport has not stated any relation between the receivedsupport and the appearing problems; however, anumber of other reports point out the dependence. Forexample, support of the daily care centers is bringingpositive effects on the caregivers. Through herresearch, Wojcierowska proved that a significantevolution of certain behaviours, feelings and emotionsof the caregivers take place after placing the ward withAlzheimer disease in a daily care centre. The tension,helplessness, irritation and loss of emotional control inrelation with the ill person, as well as weepiness, havesignificantly weakened among the respondents [20].Despite the fact that the most favourable form of careis a family care model, the research proved that familycaregivers are not able to fulfil care duties efficientlyand effectively, since they are not receiving propersupport, neither from the welfare, nor from the socialservice.CONCLUSIONS1. A great level of strain is diagnosed amongmajority of caregivers. It strictly relates to thedeficiency level in ward's self-service, careintensity and preparation level of the caregiver.2. Despite high self-evaluation in preparation forcare taking, the majority of respondents point outnumerous problems connected with daily caretaken of a chronically ill person. The mostfrequently raised problems concern: difficultieswith moving the ill person, lack of time,difficulties with hygienic activities andconducting exercises as well as difficulties withobtaining financial support.3. More than a half of the respondents revealdepression symptoms, which are mostly of gentlenature. Depression symptoms are influenced by:the level of ward's deficiency in self-service, careintensity and the preparation level of thecaregiver.4. During everyday care-taking, the respondentsmay count on help from the closest relatives,nurses, neighbors and friends. The caregiversreceive emotional support significantly less often.Most of the caregivers negatively assess thefunctioning of institutions qualified to support thechronically ill people and their families.However, the research did not reveal anysubstantial relation between the caregivers’support system and appearance of the problemsconnected with looking after a chronically illfamily member.5. The difficult situation of family caregivers pointsout a necessity of change in current institutionalsupport system.BIBLIOGRAPHY1. Szczerbińska K.: Udział rodziny w realizacji opiekinad osobami starszymi. Zesz. Nauk. Ochr. Zdr., Zdr.Pub. Zarz. 2003, 1,1, 77-87.2. Główny Urząd Statystyczny:Stan zdrowia Polaków w2004,Warszawa2006: 24-26.3. Główny Urząd Statystyczny: Rocznik Demograficzny2008, Warszawa 2008: 58.4. Bień B., Wojszel Z., Doroszkiewicz H.: Poziomniesprawności osób w starszym wieku jako wskazaniepowspierania opiekunów rodzinnych. Gerontol. Pol.2008,16,1: 25-34.5. van Exel N.J.A. i wsp.: Burden of informal caregivingfor stroke patients. Cerebrovasc. Dis. 2005, 19: 11-17.

Analysis of problems and their determinants among family caregivers taking care of chronically ill people 916. van Exel N.J.A. i wsp.: Instruments for assessing theburden of informal caregiving for stroke patients inclinical practice: a comparison of CSI, CRA, CSQ andself-raterd burden. Clin.Rehabil. 2004, 18: 203-214.7. Jaracz K., Grabowska-Fudala B.: Źródła obciążeniaopiekunów nad chorymi po przebytym udarze mózgu –analiza jakościowa. Pielęg. Pol., 2007, 24-25, 2-3: 116-119.8. Kachaniuk H. i wsp.: Zakres działań podejmowanychprzez opiekunów na rzecz osób starszych. Probl.Pielęg. 2008, 16,3: 255-258.9. Witusik A., Pietras T.: Lęk i depresja u opiekunówosób chorych na otępienie - badanie pilotażowe.Psychogeriat. Pol. 2007, 4,1: 1-6.10. Cooper C, Katona C, Orrell M et al.: Coping strategies,anxiety and depression in caregivers of people withAlzheimer's disease. Int. J. Geriatr. Psychiatry 2008,23: 929-936.11. Haley W.E.: The family caregiver's role in Alzheimer'sdisease. Neurology 1997, 48 (suppl. 6): 25-29.12. Wade D.T., Legh-SmithJ., LangtonHewer R.: Effectsof living with and looking after survivors of a stroke.BMJ, 1986, 16: 418-420.13. Berg A. i wsp.: Depression among caregivers of strokesurvivors. Stroke, 2005, 36: 639-643.14. Morimoto T., Schreiner A.S., Asano H.: Caregiverburden and health-related quality of live amongJapanese stroke caregivers. Age Ageing, 2003, 32: 218-223.15. Gustaw K., Bełtowska K., Makara-Studzińska M.:Reakcje emocjonalne opiekunów z demencją –potrzeba pomocy społecznej. Przegl. Lek. 2008,65,6:304-307.16. Palczewska A.: System opieki długoterminowej azapotrzebowanie na ten rodzaj świadczeń. Probl.Pielęg. 2010, 18,2: 198-206.17. Kaczmarek M., Durda M., Skrzypczak M., Szwed A.:Ocena jakości życia opiekunów osób z chorobąAlzheimera. Gerontol. Pol. 2010,18,2:86-94.18. Morawska J.M., Gutysz-Wojnicka A.: Problemyopiekunów chorych po udarze mózgu. Udar Mózgu.2008,10,2: 83-90.19. World Alzheimer Report 2009 - Alzheimer’s DiseaseInternational. http://www.alz.co.uk/research/worldreport.20. Wojcierowska A.: Wpływ umieszczenia chorego zchorobą Alzheimera w ośrodku pobytu dziennego nasamopoczucie opiekuna. Probl, Pielęg. 2008,16,3: 269-272.Address for correspondence:dr n. med. Iwona Sadowska-KrawczenkoZakład Pielęgniarstwa PediatrycznegoWydział Nauk o Zdrowiu Collegium Medicum UMKul. Techników 385-801 Bydgoszcztel. (52) 3655262e-mail: sadowskakrawczenko@gmail.comReceived: 10.01.2012Accepted for publication: 6.03.2012

Medical and Biological Sciences, 2012, 26/1, 93-98Mirosława Felsmann, Agata KosobuckaTHE INFLUENCE OF EXTERNAL, INTERNAL AND ARTIFICIAL ENVIRONMENTUPON THE OCCURRENCE OF BREAST CANCER AND COPING WITH THE DISEASE.THE VERIFICATION OF THE SYSTEMIC THEORY OF BETTY NEUMANNWPŁYW ŚRODOWISKA ZEWNĘTRZNEGO, WEWNĘTRZNEGO I WYKREOWANEGONA WYSTĘPOWANIE RAKA PIERSI I RADZENIE SOBIE Z CHOROBĄ.WERYFIKACJA TEORII SYSTEMOWEJ BETTY NEUMANNDepartament of Pedagogy and Nursing Didactics, Nicolas Copernicus UniversityCollegium Medicum in BydgoszczHead: Mirosława Felsmann MD, PhDSummaryBetty Neumann makes an assumption that a human beingmay exert influence upon the environment, or be subjected tothe influence exerted upon him or her by the environment, inboth negative and positive manner. She enumerates threevarieties of environments, which act through so-called‘stressors’ and permeate each other. Apart from the externaland internal environment, she singles out an artificialenvironment as well.The qualitative analysis of the literature and also that ofcollected research material aimed at performing theclassification of environmental stressors, which may exertinfluence upon the occurrence of breast cancer. Aparticularly important task was that of conducting theassessment of the artificial environment, which is created byfemale patients in order to cope with the disease and itsconsequences. In the research, women suffering from breastcancer and without assessed genetic mutation, and womenwith a diagnosed mutation of the BRCA gene participated.It turns out that the development of the artificialenvironment, which means one’s own defense mechanisms,does not always have an appropriate course. Nurses ought tobe aware of the existence of such an environment and supportits positive development.StreszczenieBetty Neumann zakłada, że człowiek może oddziaływaćlub być poddawany oddziaływaniu środowiska zarówno wpozytywny, jak i negatywny sposób. Wymienia trzy rodzajeśrodowisk, które działają przez tzw. stresory i przenikają sięwzajemnie. Oprócz środowiska zewnętrznego iwewnętrznego wyróżnia również środowisko wykreowane.Analiza jakościowa literatury oraz zebranego materiałubadawczego miała na celu dokonanie klasyfikacji stresorówśrodowiskowych mogących mieć wpływ na wystąpienie rakapiersi. Szczególnie istotnym zadaniem była ocenaśrodowiska wykreowanego, które tworzą pacjentki by radzićsobie z chorobą i jej konsekwencjami. W badaniach wzięłyudział kobiety z rakiem piersi bez ocenionej mutacji genoweji kobiety z diagnozą mutacji genu BRCA.Okazuje się, że rozwój środowiska wykreowanego, czyliwłasnych mechanizmów obronnych nie zawsze przebiega wsposób prawidłowy. Pielęgniarki powinny mieć świadomośćistnienia takiego środowiska i wspierać jego pozytywnyrozwój.Key words: the systemic theory of Betty Neumann, breast cancerSłowa kluczowe: teoria systemowa Betty Neumann, rak piersi

94Mirosława Felsmann, Agata KosobuckaINTRODUCTIONBetty Neumann is the authoress of the systemictheory, the principal assumptions of which wereformulated upon the basis of the theory of stress ofSelye and the theory of systems of von Bertalanffy.The authoress indicated, first and foremost, thenecessity of understanding a human being as acreature, in constant interaction with the environment.She singled out the three kinds of environments, whichexert influence upon an organism. Among theenvironments singled out by the authoress particularattention, apart from the external and internalenvironments, is deserved by the artificialenvironment. The latter one of the three constitutes acertain defense mechanism of a human being. In theopinion of the authoress of this theory, it is activated inan unconscious manner at the times of danger, and itmobilizes all the areas of functioning of a humanbeing: physical, mental, social-cultural, developmentaland spiritual. The environments, enumerated byNeumann, exert influence upon the functioning of ahuman being with the use of stressors, and their impactmay be positive or negative. It is dependent upon theforce of the stressors and the number of stressorsexerting impact upon a human being at a given time,and upon the condition of the organism, alike.Characterizing a human organism, Neumann drawsattention to the so-called defense lines of it, which areformed in the course of a human being’s life. Theparticularly important ones are the immunologicallines, which the immunological system, which protectsus directly, and its imperfection may bring about adanger to our life [1]. Since the 1970s, we havewitnessed a number of studies which confirm themutuality of the impact exerted by three systems(nervous, hormonal and immunological) upon eachother. In that period, a branch of science calledpsychoneuroimmunology started developing in a moreintensive manner; the purpose of that is determiningthe influence which is exerted upon the immunologicalsystem by the psycho-social factors, which means thepersonality and the milieu of a human being. Therepresentatives of this branch of science point out thenecessity of appreciating the force of our psyche.Breast cancer is the neoplasm most frequentlyoccurring among women, and the cause of death incase of approximately 50% of female patients. Thedynamics of the increase in its incidence and deaths isan outcome not only of the improper health-relatedbehaviours, but it also results from many limitations,present in the organization of screening examinations,the insufficient knowledge of women in the field ofprophylaxis and the fact of adaptation disorders in caseof affected women frequently being neglected as well.The research proves that some of the women sufferingfrom breast cancer cope well with both the disease andits results. As the time passes, they becomeaccustomed to the new situation. However, a largegroup of these women cannot come to terms with thedisease and become adjusted to it. Such women requiresupport in the numerous spheres of life, early andappropriate assessment of the problems andappropriate therapy [2].MATERIAL AND METHODSThe research was carried out in the premises of theCenter of Oncology in Bydgoszcz, on a group of fivepatients diagnosed with breast cancer, without agenetic handicap being discovered, and five womenwith the positive outcome of family interview and thegenetic mutation of BRCA, remaining under care ofthe above-mentioned establishment and theProphylaxis and Promotion of Health Department ofGenetic Clinic. The patients had received informationabout the course of the research and maintaininganonymous character of the results, after which theysigned a document of acceptance of voluntaryparticipation in the research. What was also obtainedwas the approval of the Commission of Bioethics ofCollegium Medicum of Nicolas Copernicus Universityin Bydgoszcz.A typical feature of qualitative research is obtainingthe records of an interview. In the course of collectingthe material, a technique of individual structuralizedinterviews was utilized, with the use of NurseDiagnosis Data Collection Sheet [3]. This sheet makesit possible to conduct the detailed assessment of all theareas of the functioning of a human being which wereenumerated by B. Neumann, and that means: physical,psychic and social-cultural, developmental andspiritual spheres. What were also utilized werestandardized psychological tools, and that was done inorder to investigate the issue of the assessment ofprophylactic activities and the styles of coping with adisease or with a danger in a reliable manner. Amongthose tools, there were: Health-Related Behaviours

The influence of external, internal and artificial environment upon the occurrence of breast cancer and coping with the disease 95Inventory, the Mini MAC scale, indicating thestrategies used in the field of coping with a disease,and DS.-14, identifying the characteristics of stresspersonality.RESULTSThe analysis of individual cases was carried out inaccordance with the assumptions of B. Neumann. Firstof all, the environment and areas being the source ofstress were determined.Within the group of women in case of whom theBRCA gene had not been previously discovered,among the external stressors possibly capable ofexerting influence upon the disease, there were: thetoxic environment of work, smoking tobacco and usinghormone replacement therapy. The internal factorsincluded: age, menopause, arterial hypertension,general decrease in the functioning of theimmunological system, being overweight or obese.In case of women with the positive outcome ofBRCA, what was discovered, was the occurrence ofprincipally internal stressors, such as: the fact of theoccurrence of genetic mutation, mastopathic changes,age, and also positive family interview, which meansthe incidences of breast cancer and other neoplasms inthe closest family – those stressors may be treated asthe external ones as well. It is worth emphasizing thatsome of the elements of the internal and externalenvironment cannot exert influence upon by patients;nor is it possible for them to change or eliminate therisk factor, and they can only exert impact upon it insuch a manner so as to minimize its influence. Theanalysis of the outcomes gives rise to the conclusionthat a group of patients with a handicap and themutation of the BRCA gene more frequently undergoesprophylactic examinations and remains under theconstant care of specialists, still prior to the occurrenceof changes in their breast. Patients without geneticmutation generally did not tend to undergo a breastexamination and did not take advantage of screeningexaminations systematically. Prior to the discovery of aneoplasm, self-examination had been performed byonly as few as one patient within this group. Healthrelatedbehaviours, and, thus, life-style, is formed inthe process of mutual interaction of the internalenvironment and the individual patterns of behaviour,determined in particular by social-cultural factors andthe individual characteristic of a human being. Theresults of individual health-related behaviours indicatethat the health-related behaviours of the women with agenetic handicap are at a higher level, which meansbetter overall outcome of the ‘health-relatedbehaviours’. Health-related behaviours amount to 91.2in the stenic scale received 7 points, whereas in case ofwomen without a genetic handicap the overall outcomein terms of health-related behaviours amounts to 74.6,which means 4 points in the stenic scale. Similardifferences favouring women with the BRCA geneoccur in all categories of behaviours. The lowestoutcome in the group of women without the mutationwas discovered in the category of ‘health-relatedpractices’ (HRP). According to the assessment of theartificial environment in the psychic sphere, the MiniMAC scale was utilized; it makes it possible to becomeacquainted with the strategies of coping with thedisease used by women. Female patients with genetichandicap most frequently utilize the ‘fighting spirit’strategy, and least frequently the strategy, called‘hopelessness and helplessness’. A group of womenwithout discovered genetic mutation takes advantageof the ‘fighting spirit’ strategy most frequently as thatof a ‘positive revaluation’; these are strategies havingconstructive qualities. The assessment of the socialculturalsphere indicates that women with a genetichandicap take advantage of such actions fulfilling theirpassions, pursuing hobbies and doing various forms ofsports. In case of women without a genetic handicap, itrefers to home related activates and working in thegarden or meetings at the Associations of Amazons.Among the mechanisms facilitating coping with thedisease, there is also a spiritual sphere; that is mostfrequently connected with hope and faith. All patientswith genetic handicaps are religious and church-goingindividuals. Among the women without genetichandicaps two women defined themselves as atheists.The analysis of the D-14 scale showed that thegroup of women included in the research does notpossess the typical indicators of stress personality.Slightly elevated outcomes in the scale of ‘negativeemotionality’ were received by the patients withgenetic handicaps.The majority of the interviewed declared receivingsocial support in the form of family and friends’support. In one case, in the course of the disease, apartner left the woman, as he was unable to cope – inthe opinion of the patient – with the entire situation.The majority of the patients subjected to the analysisindicate a large number of infections and allergies, and

96Mirosława Felsmann, Agata Kosobuckaalso taking quite a lot of antibiotics whencharacterizing their immunological system.DISCUSSIONThe normal functioning of the organism is possiblethanks to the fact that approximately thirty billion ofthe cells of which it is composed live and proliferate ina controlled manner. Thanks to that, every tissuemaintains an appropriate structure and fulfills itsfunctions in dependence upon the needs of a givenorgan and the entire organism. Nevertheless, what alsohappens is that certain factors of both external andinternal origin contribute to an error occurring in thecourse of this process and the cells start proliferating inan uncontrolled manner. As one of the factors predisposingfor the incidence of various diseases,including neoplasms as well, stress, understood in avery broad manner, is regarded. H. Saley and R.Lazarus are the most frequently quoted authorities asfar as connection of stress and its influence upon theorganism and the state of health. Saley, researchingprincipally the issues connected with biological stress,proved that prolonged stress may bring about physicaldamage. He compared the functioning of the organismto that of the alarm clock, which keeps ringing until thebattery is flat. He proved that the reaction of thesystem, regardless of a causative factor, is similar [4].In turn, Lazarus arrived at the conclusion that wewitness stress when an individual assesses a situationin which he/she has found himself/herself as exceedinghis/her resources. The core characteristic of a stresssituation is the occurrence of external or internalrequirements making an individual reach the limit orexceed his/her capacity; most frequently, it isaccompanied by emotional strain, and the feelings offear and anger. An attempt to take action the outcomeof which is restoring an organism to the state of peaceand balance, which means overcoming a stressor, is aphenomenon natural in this situation. Currently, thereis a dominating tendency of devoting more attention inthe studies on stress to the ways of coping withstressful situations rather than with the factors causingthis phenomenon themselves. A human organism hasits own manner of coping with stress because it isbelieved that the outcomes of a confrontation aredetermined, to a greater degree, by an activity taken uprather than by the objective impact of the stressor [5].Similar conclusions drawn by Betty Neumann, too,presuming that the beginning of the disease isconnected not only with the activating of individualrisk factors, but principally with the impacts of coexistingstressors of various origins and degrees ofintensification, in connection with the individualcharacteristics of personality of a given human beingsubjected to the exposition of them. Enumerating in hertheory the third kind of the environment, the so-calledartificial environment, she ascertained that everyhuman being creates it for his/her own protection in anunconscious manner. Such a creation is connected withall the spheres of life: physical, mental social-cultural,developmental and spiritual.Taking under consideration the outcomes of theresearch, one may be of the opinion that the womenwho were aware of their handicaps were modifying, asfar as it was possible, the factors in their externalenvironment and created certain manners of copingwith this stressor, thus, protecting their organism. Theprincipal strategy of coping which was used by themwas ‘fighting spirit’. This strategy is connected withmobilization for the struggle against the disease.Existing common conviction says that strategiesconcentrated upon a problem, when an individual takesup active struggle with the problem and tries toeliminate or reduce the impact of stress, are superior tostrategies directed on emotions, consisting inwithdrawing oneself, denial and negation [6]. Womenwith the BRCA gene were also caring more about theirphysical and mental health, as it is indicated by theoutcomes of individual health-related behaviours. Itwas particularly revealed by correct heating habits,prophylactic behaviours and a positive mental attitude.The fundamental motivation for such behaviours wasfighting against what may not be possible to avoid, butthe outcomes of what may be minimized; it wasworking for strengthening one’s health. BettyNeumann calls such activities primary intervention,consisting in strengthening all the lines of defense. Atthis point, one ought to agree with the opinion of themajority of researchers stating that genetic clinicsproviding both medical and psychological careconstitute an important positive external environmentfor women with the diagnosed BRCA gene. Upon theconfirmation of the mutation, a patient receivesrecommendations relevant to the modification not onlyof her life style for a more pro-health one, but she isalso included into a detailed and comprehensiveprophylactic programme. Thanks to such action, it ispossible to reduce the risk of the development ofadvanced neoplasm within this group of patients from

The influence of external, internal and artificial environment upon the occurrence of breast cancer and coping with the disease 97the high 80% to only as few as 20%. One of veryimportant targets of such work is strengthening thefeeling of one’s own effectiveness of patients [7].According to Betty Neumann, the fundamentalsystem which protects our organism against dangerousstressor is the immunological system. For years, it hasbeen known that in case of individuals with thehandicapped immunological system there is anelevated tendency for the development of neoplasms. Itis assumed that in accordance with the theory ofimmunological supervision, which was explicated byThomas and Burnet for the first time ever, even healthyindividuals (in the clinical meaning of this term) havehad cancer many a time. However, it does not meanthat a neoplasm possible to be diagnosed developed intheir organisms. Appearing neoplastic cells wererapidly discovered and destroyed by the immunesystem. Another thesis, which was put forward,claimed that the increase of likelihood of the incidenceof cancer may be a result of tolerating stressorsprolonged in time. Those stressors exert influence uponthe change of hormonal reactions, and, as a result,suppress the activity of macrophages, T lymphocytesand the NK cells, which together participate in thedestruction of neoplastic cells.It was also proved that there is a connectionbetween the changes in tolerance occurring under theinfluence exerted by stressors to the defense system ofthe organism, and the passive style of coping withdifficulties and depression. There are more and moreoutcomes of research, principally in the field ofpsychology, which give rise to the conclusion thatneoplasm is mostly developed by individuals whotorment themselves all the time, who forgive others,but not themselves and who devote time to others; thistype of behaviours is termed by psychologists as thepattern of behavior C [8]. Female patients participatingin the research and without a discovered geneticmutation presented the attitude characteristic ofpositive revaluation. This is a strategy which isexpressed in the reorganization of the problem of one’sdisease in order to find hope and satisfaction with theyears already passed. This is the so-called ‘constructivestrategy of coping’, confirmed in the course of researchas the one thanks to which patients have betterprospects of recovery, live longer, and thanks to whichthere are fewer recurrences and the quality of patients’life is better [9].As it turns out, in case of approximately 20-40% ofwomen with breast cancer the incidence of variousdisorders of psycho-social character is discovered, theprincipal cause of which is – in the opinion ofresearchers – stress accompanying them. The mostfrequently quoted stressors include: fear of therecurrence of the disease, unwanted influence of themedication, limited ability, lack of self-acceptance,fear of the lack of acceptance of the milieu, inparticular, of spouses or common law spouses. Thelevel of fears being experienced is dependent upon thestages of the disease. The first stage is obtaininginformation about the diagnosis, which is accompaniedby shock, regardless of the fact, whether a womanknew about her genetic handicaps, or whether thediagnosis was unexpected. The following stressgeneratingstage is that of treatment, administeredmedications and their side-effects, an operationalprocedure and ailments connected with it. After theconclusion of the treatment, the feeling of the fear ofrecurrence remains for several years [10]. In case ofpatients with breast cancer, anxiety, insomnia, thefeeling of tiredness, and the fear of the following visitat the doctor’s are observed. It is disturbing that veryfrequently such reactions are treated as normalbehaviours, not requiring therapy. In case of some ofthe women, such a state passes, whereas in case ofsome of the other it does not; those latter womenundergo a mental break-down, which results indecrease in their activity, and also the occurrence offamily and social problems.A group of female patients participating in theresearch and not having a confirmed genetic handicapdid not take advantage of prophylactic examinations.As it turns out, in spite of the accessibility ofexaminations, many women do not take advantage ofthem. One of the most important causes of this fact, inthe opinion of the researchers, is the fear ofexamination. Among the demographic factors, age,education and dissatisfaction with the information arequoted. So-called situational stress is one of the factorslimiting the number of women taking advantage ofprophylactic examinations as well. Situational stressoccurs as a result of being unaware of the importanceand necessity of undergoing the examinations,inappropriate preparation to the examination, and theinaccurate reading of the information about the danger[11]. Many controversies are connected with theperformance of genetic tests within the groups ofwomen with a so-called ‘positive family interview’.Some of the women, out of fear of their emotionsconnected with the result, wonder, whether they ought

98Mirosława Felsmann, Agata Kosobuckato undergo the test at all. According to some of theauthors, these women have a high level of stress [12].Within the group of women included in the research,no stress personality was discovered, and that iscertainly where positive prophylactic behavioursoriginate from. Deciding to undergo genetic testing isdependent upon the decision of a patient, but, becausethey are of significant importance for prospects, oneought to take action in order to minimize the stressconnected with them.To conclude, in accordance with the theory ofNeumann, the fundamental activity of professionalindividuals looking after women suffering from breastcancer, or threatened by this disease, is identifying thekind and source of stressors, and, afterwards,assistance in activating the best defense mechanisms. Ifwe fail to take appropriate and timely actions togetherwith the patient and her milieu, then, in accordancewith the principles of psychoneuroimmunology, thesestressors may contribute to the incidence of the disease,or to its reoccurrence. Let us not forget that the state ofmind changes the state of body.CONCLUSIONS1. A human being is a system functioning in thegreat system of nature. Between thesesystems/environments, constant interactionsand transactions are in progress. Healthy andproper functioning consists of appropriateadaptation mechanisms and skillfully takingadvantage of all the resources of the external,internal and artificial environments.2. Nurses ought to be aware of the existence ofthe artificial environment of the patient andsupport the positive development of it.6. Wotson M., i inni: The Mini MAC: further developmentof the Mental Adjustment to Cancer Scale. Jurnal ofPsychosocial Oncology, 1994, 12,3, 38-467. Michałowska- Wieczorek.: Medical and psychologicalcare of patients in cancer genetic counseling clinic. ViaMedica 2006, 10,18. Umed Sing, Nidhi Verma: Psychopatology amongFemale Breast cancer Patients. Jornal of the IndianAcademy of Applied Psychology. 2007, Vol 33, 1:61-649. Salmon P.: Psychology in medicine, PsychologicalPublisher in Gdańsk. Gdańsk 2002.10. National Cancer Policy Bard. Meeting psychosocjalneeds of women with breast cancer. Hewitt M., HerdmanR., Holland J.(red) Nat. Acad. Press. Washington,D.C.2004;1012, 21-62.11. Wronkowski Z. inni.: Psychological aspects of breastcancer screening Sł. Zdr. 2000; 24-26.12. Lerman C., Hughes c., Lemon S,J i wsp. What You don´tknow can hurt you: adverse psychological effects inmembers of BRCA1 and BRCA2 – linked families whodecline testing. J. Clin. Oncol. 1998, 16, 5: 1650-1654Address for correspondence:e-mail: miroslawa.felsmann@cm.umk.pltel. 601-299-824Received: 10.01.2012Accepted for publication: 6.03.2012REFERENCES1. Górajek-Józwik J: Philosophy and theories of nursing,Czelej Publisher, Lublin 2004: 324-3342. Ślubowska M., Ślubowski T.: Psychosocial problems inbreast cancer. Psychooncology 2008, 12; 1:14-263. Felsmann M.: Data Collection Sheet for NursingDiagnoses developed by CM UMK, teaching material.4. Wrona- Polańska H.: Health, stress, illness,psychological dimension", Impuls Publisher, Cracow2008: 21-335. Dolińska- Zygmunt D.: Base of health psychology,Publisher of Wrocław's University, Wrocław 2001: 71-99

Medical and Biological Sciences, 2012, 26/1, 99-105Mirosława Felsmann 1 , Barbara Futyma 1 , Mariusz Zbigniew Felsmann 2 , Marzena Anna Humańska 1 , Beata Haor 1QUALITY OF LIFE IN CHILDREN WITH EPILEPSY, EVALUATED BY THE PARENTSON THE BASIS OF QOLCE QUESTIONNAIREJAKOŚĆ ŻYCIA DZIECI Z PADACZKĄ W OCENIE RODZICÓWNA PODSTAWIE KWESTIONARIUSZA QOLCE1 Department of Pedagogy and Nursing Didactics, Nicolaus Copernicus UniversityCollegium Medicum in BydgoszczHead: Mirosława Felsmann MD, PhDSummaryEpilepsy is a neurological chronic disease, which maynegatively influence physical, psychological and socialfunctioning. This problem mainly refers to children withepilepsy in whom, as the research proves, a number ofcommon problems appears, not only those related to epilepticseizures, but also problems connected with cognitive sphereand difficulties at school, as well as social stigma amongpeers.In the last years, the researches evaluating the quality oflife in children with epilepsy have been focused on itscomplex evaluation. Therefore, adequate measuring toolshave been looked for in order to make this evaluationpossible.In the research, evaluation of the quality of life wasmade in a group of 43 children with epilepsy, with the use ofQOLCE questionnaire, adapted to Polish conditions by ateam directed by K. Mathiak.Most of 16 subscales showed a high and very highreliability according to Cronbach’s α from 0.734 to 0.942.These results point to existence of significant dependencebetween individual spheres of children’s functioning. In theauthors’ opinion, it is worth to compare parents’ evaluationwith opinions of children, especially elder ones.StreszczeniePadaczka jest neurologicznym przewlekłymschorzeniem, które może negatywnie wpływać na fizyczne,psychologiczne i społeczne funkcjonowanie. Problem tendotyczy szczególnie dzieci z padaczką, u których, jakdonoszą badania, często występuje szereg problemów nietylko dotyczących napadów, ale związanych ze sferąpoznawczą i trudnościami szkolnymi a także piętnemspołecznym wśród rówieśników.Badania oceniające jakość życia dzieci z padaczkąnakierowane są w ostatnich latach na kompleksową jegoocenę. W związku z tym poszukuje się narzędzi pomiaru,które by tę ocenę umożliwiły.W badaniach dokonano oceny jakości życia w grupie 43dzieci z padaczką wykorzystując kwestionariusz QOLCEadaptowany na warunki polskie przez zespół pod kierunkiemK. Mathiak.Większość z 16 podskal wykazywała wysoką i bardzowysoką rzetelność według α Cronbacha od 0.734 – 0,941.Wyniki wskazują na istotnie statystyczną zależnośćpomiędzy poszczególnym sferami funkcjonowania dzieci.Potwierdziły się również wyniki innych badaczy o wpływiewieku i czasu choroby na funkcjonowanie poznawcze ispołeczne dzieci. Zdaniem autorów warto porównywaćoceny rodziców z opiniami dzieci, szczególnie tychstarszych.Key words: epilepsy in children, quality of life.Słowa kluczowe: padaczka u dzieci, jakość życia

100Mirosława Felsmann et. al.INTRODUCTIONEpilepsy in children is one of the most commonneurological diseases. It is chronic in character and ithas a multi-level influence on functioning of a childand its family. The researcher’s reports show that itmay often lead to inhibition of psycho-socialdevelopment [1]. Epilepsy is not a uniform diseaseentity; it is rather a number of variegated symptoms,starting with performance of automatic, repetitivemovements by the patient, through the individual fits,to strong epileptic seizures with the loss ofconsciousness. One should not omit or ignore alsoother disorders, which are behavioural, educational orcultural in character [2]. Epilepsy, due to the lack ofsocial knowledge on its reasons and appearance, isburdened with myths and stereotypes and thus, itdirectly influences the patient and his/her functioningin the society.In the end of the 20 th century, intensification of theresearch on the quality of life in patients was observed,also those with epilepsy. The tools were searched for,which would allow for evaluation of that quality in themost reliable way. In medical literature, most often wecan find reports on the research evaluating the qualityof life in patients with epilepsy; they mainly aim atverification of the efficiency of the newest therapies inthe aspect of minimisation or elimination of epilepticseizures or appearance of undesirable symptoms.Influence of various pharmacological therapies,chirurgical operations at patients with drug-resistanceor stimulation of a vagus nerve, as well as somecomplementary therapies e.g. diet-therapy has beenevaluated [3,4]. Unfortunately, each of therapies, apartfrom advantages, also adds to appearance of newproblems, which the patient is not prepared for andhe/she is not able to deal with. Still, we observe thelack of concentration of the chronic patient, i.e. thechild with epilepsy. There is a continuous insufficiencyof a complex evaluation of the quality of life and toolsmeasuring all life’s aspects with regard to taking careof man as a whole, together with his/her closestrelatives and surrounding society. One of tools testedin the last years, also in Poland is the Health-RelatedQuality of Life in Childhood Epilepsy QuestionnaireQOLCE. This questionnaire is directed to parents ofepileptic children in order to let them evaluatefunctioning of their children in various spheres.Adaptation of the tool for Polish conditions wasperformed by the team of researchers directed by K.Mathiak at Warsaw University. High reliability andtheoretical accuracy qualifies this questionnaire as areliable tool in scientific research and in individualdiagnostics.The research aimed at testing this questionnaire, aswell as determining and finding out those spheres oflife of an epileptic child, which may decrease itsquality and thus, they result in disfunctioning of a childand his/her family.MATERIALS AND METHODSThe research was made on 43 parents of childrenwith epilepsy. The questionnaire was filled in by16.28% of fathers, 79.07% of mothers and onecommittee. The average age of a person filling in thequestionnaire was 42. The youngest one was 30 andthe oldest – 64. Among the interviewees, there were16.28% of persons with primary education, the samenumber of persons after studies, 41.86% withprofessional education, and 25.58% with secondaryeducation.The average age of children that underwentevaluation was 11.8 ± 3.4. The time of lasting of thechild’s disease ranged within less, than one year to 14years.The research excluded children with co-existingchronic diseases different from epilepsy and mentallyhandicapped children.Parents of children that were qualified for theresearch received information on the aim and thecourse of the research, as well as the consent of theCommission of Bioethics at the Collegium Medicum ofNicolaus Copernicus University in Bydgoszcz forperforming the research.The research consisted of gathering informationfrom parents on the basis of socio-demographic andQOLCE questionnaires, while the latter was used uponthe consent of its authors.QOLCE questionnaire consists of 76 questionsgrouped in 5 scales and 16 subscales. Five basic scalesmake the functional category of a child in thefollowing fields: physical, cognitive, emotional, social,as well as manners of a child. In addition, the scaleevaluates health and the quality of life in generalmeaning. The individual subscales refer to suchaspects, as: physical limitations, tiredness,attention/concentration, memory, language, other

Quality of life in children with epilepsy, evaluated by the parents on the basis of QOLCE questionnaire 101cognitive, depression, anxiety, control/helplessness,self-evaluation, social interactions, social activity,stigmatization, behaviour, general health, the quality oflife.Parents provided their replies by marking one of thegiven options: very often, often, from time to time,seldom, never, does not apply. All replies werecalculated in such a way, that the high score reflectsgood functioning of a child in a given domain. Thetotal score of the individual subscales, as well as totalquality of life is received by calculating of thearithmetic average of all questions presented in a givensubscale. If parents decide, that some question does notrefer to their child, the score is calculated only on thebasis of all remaining questions.All statistical calculations were made with the useof the statistical program package STATISTICA 9.0.Most of 16 subscales showed high and very highreliability according to Cronbach’s α from 0.734 to0.941. Only the scale of depression shows too lowreliability and it is 0.407. In case of three subscales:stigmatisation, general health and the quality of life,the reliability cannot be calculated, because theyconsist of only one question. In the field of the generalquality of life, the co-efficient was 0.973.RESULTSThe average value received in the scale of thegeneral quality of life was 63.72. According to 44.19%of parents, in spite of the disease, their childrenfunction quite well, and 32.56% think, that evenperfectly. 23.26% of parents point to some difficultiesrelated to functioning in everyday life.In the functional scale in the field of physicallimitations, the average value is 56.48% points. Greatvariegation of evaluations can be observed here. 42%of parents think that they children are not limitedphysically, and 33% point to great limitations, whichinfluence physical functioning of their child. Usually,physical activity of a child depends on amount ofenergy and tiredness felt by a child. In that field, theaverage value is 55.23. More than 32% of parents pointto frequent and very frequent appearance of the lack ofenergy and tiredness at their children. At remainingchildren, according to their parents’ opinions, lack ofenergy and tiredness appear seldom or even never.Evaluation of cognitive functioning consists of 22questions, which are grouped into 4 subscales:attention/concentration, memory, language, and othercognitive. The questions refer to various cognitivedisorders which may result from structuralmalfunctions of the brain, epilepsy seizures or psychosocialproblems. In the field of concentration, the valueobtained in evaluated children was 64.07. Majority ofparents (44%) think that their children do not have anyproblems with concentration and focusing of theirattention on tasks imposed on them. 13% of parentsstate that difficulties of that type appear quite often incase of their children, and 6% of parents claim, thatthose problems are frequent. Memory makes the nextratio of the cognitive sphere. In that subscale, the scoreis 58.53. 27% of parents state, that their children do nothave any problems with memory, problems appearperiodically at 34%. 27% of parents notice somedisorders in the process of memorising at theirchildren. 44.18% of parents stated, that their childrendo not have any problems with understanding of texts,tracing the course of a conversation or understandingof instructions and orders given to them. 9% of parentsobserve these limitations in a very large part at theirchildren. In evaluation of the so-called other cognitivefunctions, the abilities of planning, solving problemsand time of reaction were taken into consideration. Theaverage numerical value of that subscale is 59.11points. More, than 39% of parents think, that theirchildren do not have problems with functions of thattype. Only in case of about 17% of children, parentsnotice some problems regarding analysed cognitivefunctions.Emotional functioning was evaluated on the basisof 19 questions making a subscale: depression, anxiety,control/helplessness, self-evaluation. Questions in thatsubscale refer to a general wellness of a child, withregard to some stated dysfunctions. Results of thesescales are 71.07points for depression and 65.27 pointsfor anxiety. Thus, they prove that at majority ofevaluated children, there is no presence of blues ordepression; they do not feel frustrated or worried.51.17% of parents think that way. The next large groupof parents (46.51%) does not observe such symptomsand attitudes nearly at all. In most of children(41.86%), anxiety states never appear, as well.However, 20.93% of parents state, that their childrenoften feel tense and anxious. Evaluations related tocontrol and helplessness seem to be a little worse, herethe average value is 61 points. According to 41.86% ofparents, this feeling does not appear at all and 30.23%think that it appears form time to time. However more,than 20% of parents believe, that their child has a

102Mirosława Felsmann et. al.problem with controlling his/her own life and someevents surpass them. 6.98% of parents think thatgenerally, their children do not cope with controllingtheir own life.In the subscale self-evaluation, the average valueobtained is 64.97 points. Parents think that theirchildren have the high self-respect, they are happy,self-confident and they feel that they can cope with thedisease and adversities. 51.16% of parents state so.Three subscales are made of a list of questionsevaluating functioning of a child in the society. Factorsevaluated are: social interactions, social activity andstigmatisation. The research questions focus on socialproblems at school, relations with peers and relatives,as well as limitations regarding free time and socialactivity. The average value obtained in evaluation ofsocial interactions is 76.49 points. According to62.79% of parents, their children never had to limittheir social interactions due to their disease, and intheir opinion, the disease did not influence thoseinteractions. However, 16.28% of parents think, thatthe disease had the inconvenient influence on relationsof their child with other persons in some situations,whereas 11.63% state, that epilepsy considerablylimited social interactions of the child and isolatedhim/her from the society.During analysis of the results evaluating socialactivity, the similar high scores were obtained. Theaverage value is 76.74 points. Evaluating the problemof stigmatisation in children with epilepsy in thesociety, majority of parents think that their children donot feel stigmatised or marked in any way due to theirdisease. The average value of points in that subscale is83.82.Behaviour is the next dimension that underwentevaluation. It includes typical functional disordersdescribed in many children with epilepsy. As opposedto previously-stated categories, the main assumption ofthis evaluation is to measure the manners of the childobserved directly. The average value of points obtainedin evaluation of children’s manners is 65.28.According to 37.21% of parents, the above-stateddisorders never appeared. 44.19% of parentssometimes observe such behaviour, in 11.63% theyappear often, and in case of 6.98% of children, they arevery frequent. Attitudes that make functioning reallydifficult are: aggression, anger or disobedience.The questionnaire also includes some questionsreferring to the general health condition and quality oflife. The average score evaluating general healthcondition in children is 41.86 points, whereas theaverage score referring to evaluation of the quality oflife – 59.88. In spite of the fact, that a large part ofparents evaluates the general health condition of theirchild as not very good one, as much as 48.84% ofparents believe, that the quality of life of their childrenis perfect, 41.86% think, that it is very good, and9.30% consider it to be average.In the comparative analysis, results and conclusionsgathered during adaptation of the tool for Polishconditions were considered. The fact of particularimportance is that none of the subscales showed a greatand statistically significant correlation with clinicalindexes, which advocates a good theoretical accuracyof the questionnaire. It also means, that clinical indexesexplain only a part of results.In the authors’ research, evaluation of the strengthof correlation between individual subscales and generalquality of life was discussed. The results show, that allcorrelations ire statistically significant. In theevaluation, r-Person correlation coefficient and t-Student test were used (Table I).Table I. Relations between criteria of functioning and thegeneral result of the quality of lifeTabela I. Związki kryteriów funkcjonowania z ogólnymwynikiem jakości życiaPhysical limitations*Ograniczenia fizyczneEnergy/tiredness*Energia/zmęczenieAttention/concentration*Uwaga/koncentracjaMemory*pamięćLanguage*językother cognitive*Inne poznawczeDepression*depresjaAnxiety*lękControl/helplessness*Kontrola/ bezradnośćSelf-evaluation*samoocenaSocial interactions*Interakcje społeczneSocial activity*Aktywność społecznaStigmatisation*stygmatyzacjaManners*zachowanieGeneral health*Zdrowie ogólneQuality of life*Jakość życia*statistically significantr r² t p0.687 0.472 5.981

Quality of life in children with epilepsy, evaluated by the parents on the basis of QOLCE questionnaire 103Moreover, evaluation of the influence of age andtime which passed from the beginning of the diseaseon the individual subscales was performed. It turns out,that the older the child is, the better functioning of thatchild is observed in the spheres described by subscales:attention/concentration, memory language, socialactivity, and behaviour (Table II). Also the time of thedisease has the influence on such subscales, as:control/resourcefulness and general health. The longerthe disease lasts, the lower quality of life in thatspheres is observed (Table III).Table II. Relation between age of a child and the criteria offunctioningTabela II. Związek wieku dziecka z kryteriamifunkcjonowaniaAGE OF A CHILDWiek dzieckaPhysical limitationsOgraniczenia fizyczneEnergy/tirednessEnergia/zmęczenieAttention/concentration*Uwaga/koncentracjaMemory*pamięćLanguage*językother cognitiveKontrola/bezradnośćDepressiondepresjaAnxietylękControl/helplessnessKontrola/bezradnośćSelf-evaluationsamoocenaSocial interactionsInterakcje społeczneSocial activity*Aktywność społecznaStigmatisationstygmatyzacjaManners*zachowaniaGeneral healthZdrowie ogólneQuality of lifeJakość życiaGeneral QOLCEOgólna QOLCE*statistically significantr(X,Y) r2 t p0.228 0.052 1.48 0.147-0.012 0 -0.07 0.9410.339 0.115 2.28 0.0280.356 0.127 2.41 0.0210.401 0.161 2.77 0.0080.264 0.07 1.73 0.092-0.293 0.086 -1.94 0.060.123 0.015 0.78 0.4390.058 0.003 0.36 0.7170.058 0.003 0.37 0.7150.242 0.059 1.58 0.1220.401 0.161 2.77 0.0080.110 0.012 0.624 0.5370.316 0.1 2.11 0.041-0.066 0.004 -0.42 0.6780.015 0 0.1 0.9240.249 0.062 1.62 0.112Table III. Relation between the time of lasting of the diseaseand the criteria of functioningTabela III. Związek czasu chorowania dziecka z kryteriamifunkcjonowaniaTIME OF LASTING OF r(X,Y) r2 t pTHE DISEASECzas chorowania dzieckaphysical limitations -0.299 0.09 -1.98 0.054Ograniczenia fizyczneEnergy/tiredness -0.089 0.008 -0.56 0.577Energia/zmęczenieAttention/concentration -0.168 0.028 -1.08 0.288Uwaga/koncentracjaMemory-0.091 0.008 -0.58 0.567pamięćLanguage-0.184 0.034 -1.18 0.244językother cognitive-0.215 0.046 -1.39 0.172Inne poznawczeDepression-0.224 0.05 -1.45 0.154depresjaAnxiety-0.224 0.05 -1.45 0.154lękControl/helplessness* -0.317 0.101 -2.12 0.041Kontrola/bezradnośćSelf-evaluation -0.195 0.038 -1.26 0.215samoocenaSocial interactions -0.215 0.046 -1.39 0.171Interakcje społeczneSocial activity-0.177 0.031 -1.14 0.261Aktywność społecznaStigmatisation-0.158 0.025 -0.905 0.372stygmatyzacjaMannerszachowania -0.129 0.017 -0.83 0.414General health*Zdrowie ogólneQuality of lifeJakość życiaGeneral QOLCEOgóne QOLCE*statistically significantDISCUSSION-0.325 0.106 -2.17 0.0360.048 0.002 0.3 0.763-0.259 0.067 -1.7 0.097Epilepsy belongs to the group of chronic diseases,which may negatively influence physical, psychicaland social functioning. Epileptic seizures make onlyone of the aspects of life of the child patient. Inscientific literature we can find some research-basedinformation, that e.g. in psycho-social aspect, epilepsyinfluences appearance of anxiety, depression, it lowersthe quality of life, it results in low self-evaluation, it isstigmatised. It also impairs such domains of activity, aseducation, professional work, family life, everydayactivities, social contacts and friendship relations. It isa chronic disease that considerably influences thequality of life of both the sick child and his /her wholefamily [6, 7].The authors’ research proves that each of theevaluated subscales with their constituents issignificant for the overall quality of life. In the

104Mirosława Felsmann et. al.evaluated group of children, the strongest relation, i.e.the influence on the general quality of life is observedin case of such subscales, as attention/concentration,language and other cognitive, whereas this relation isweaker in case of such subscales, as self-evaluationand stigmatisation. Most of results of the research onthe quality of life in epileptic children show, that thefactors, which considerably worsen the quality of lifeare disorders of cognitive functions [8].In opinion of parents taking part in the research, thebiggest problem in case of epileptic children is theirgeneral health condition, physical limitations andsimilar to what other researchers say, deficiencies ofcognitive functions, whereas the least number ofproblems is observed in the fields of social functioning,social interactions, social activity and stigmatisation.Similar results, pointing to simply good functioning insocial sphere of both the children and their relativeswere obtained by P. Hoere, and P. and M. Russel [9].By his/her parents, an epileptic child will always betreated as seriously ill or even handicapped. Healthcondition was also low-estimated by the parents underresearch. The research performed by Ch.B. Baca et al.prove, that cognitions of a child with epilepsy byhis/her parents can be distorted by conviction, that theirchild is yet ‘ill’. The author is afraid, that such feelingsof parents can lead to under-estimation of the child andhis/her quality of life. Such a negative evaluation ofparents often makes them lower their expectationstowards the child, as they claim, that the child must beprotected. Over-protectiveness, as well as taking overtotal control on the child can add to appearance of anumber of behavioural problems. The child becomesdependent, hypochondriac, and immature and he/shehas the low self-esteem. In this research, children withepilepsy evaluated their quality of life as equal to thatof their healthy siblings, whereas, the parents thoughtof it as much worse. The authors named thisphenomenon ‘a paradox of disability’ [10].Cognitive deficiencies refer both to intelligence andother selected deficiencies. The deficiency isinfluenced by existing brain defects, as well as those,which appeared in result of repeating seizures andpharmacotherapy. Environmental factors also influencethe scope and level of cognitive deficiencies. In theresearch done by Baker, Loring, and Talarska it isstated, that in comparison to their peers, the level ofintelligence in school children with epilepsy is withinnormal limits or it is only slightly handicapped in 80%of cases [11,12]. At 30% of children, partialdeficiencies of cognitive functions and disorders in thefield of sight and hearing abilities are observed. Age ofthe child in which the first symptoms of epilepsyappeared has a decisive influence on development ofcognitive functions. In those children, in whichepileptic seizures appeared very early, deficiencies inthe field of sight and movement correlation, memoryand attention were observed, also longer time ofattention and better dynamics of cognitive processesare seen. In the research performed by Mojs in theyears 2001 and 2007, the statistically significantcorrelation between the time of appearance of the firstseizure and the level of operational memory, learningability and the level of sight and movement integrationwas proved, as well. The authors’ research confirmsreports of the researchers on the significant influenceof the child’s age on attention and concentration,memory, as well as social activity and behaviour. Theperiod of disease considerably influences self-controland resourcefulness. Unfortunately, the longer theperiod of disease is, the lower the quality of life in thatsphere is.Most of all, epilepsy is characterised by seizures ofvarious frequency and strength. The most frequentsymptoms of the seizure are: loss of consciousness,body distortions during the fits, salivation, and urinaryincontinence. The seizures are unpredictable and theyoften cause injuries. It terrifies both the patient andabove all, the unaware observer. So, many people feelanxious while witnessing the seizure and dealing witha person, that suffers from epilepsy. Many research andreports in media points to the fact, that epilepsy issocially stigmatised and that sooner or later, theepileptic child will experience it. The results prove thatthe quality of life in children under research isevaluated on the average level of 59.88. 62.79% ofchildren got the highest scores in the scale of socialinteractions, social activity and stigmatisation.Therefore, it can be assumed that our society does notperceive epilepsy as something ignominious, thatchildren did not lose their self-esteem that they areopen to social interactions and the states of depressiondo not appear in their case. Certainly, these resultscome from their parents’ opinion. Maybe the childrenwould prove these aspects to be worse and maybe,better. We must remember that children may go bytheir own values. The authors of the presented researchthink that the next research on the quality of life inepileptic children should connect the parents’ andchildren’s opinions.

Quality of life in children with epilepsy, evaluated by the parents on the basis of QOLCE questionnaire 105CONCLUSIONS1. The tested tool shall be regarded as accurateand significant from the point of view of acomplex care of a child and his/her family.2. The research on the quality of life in childrenwith epilepsy shall compare evaluations ofchildren and their parents.3. The quality of life in epileptic children isseriously influenced by physical, cognitive,and emotional functioning, behaviour andgeneral health condition, so therapeuticprograms shall be complex in character.4. Age of the child significantly influenceshis/her cognitive functions, such asconcentration, attention, memory, but alsosocial activity. Worsening of cognitivefunctions considerably influences functioningin everyday life. A precise diagnosis oncognitive deficiencies becomes veryimportant in order to start activitiespreventing from further worsening of thesefunctions with the flow of time.5. The period of disease has a significantinfluence on the quality of life in childrenwith epilepsy. The more time passed since thefirst seizure, the worse the general healthcondition is and it refers also to functioning inemotional sphere and such indexes, as controland resourcefulness.Adaptation to life with epilepsy requires hardwork on the part of a child and his/herparents. It is crucial, that from the verybeginning, the child takes over control onhis/her life and health as early as possible. Ina normal development, each child tends to getindependence and esteem for himself/herselfand we shall enable him/her to achieve that. Inthe name of increased care, parents cannotisolate their ill children from activities, whichare performed by other healthy children.Extortionate mindfulness and limitation offreedom of a child often leads to developmentof a syndrome of learned helplessness. Then,the child fully accepts one basic role of ‘apatient’ and thus, he/she excludeshimself/herself from social life.REFERENCES1. Ronen G.M, Streiner D.L, Rosenbaum P.: Healthrelatedquality of life in childhood epilepsy: Movingbeyond ´seizure control with minimal adverse effects´.Health and Quality of life Outcomes. 2003,1,362. Służewski W.: Epilepsy in childhood – clinical viewand treatment. Guide for GPs 2001,4,3, 80-84.3. Jones M.W.: Consequences of epilepsy. Why do wetreat seizures? Can J Neurol Sci 1998, 25; 24-264. Schachster SC.: Epilepsy: Quality of life and cost ofcare. Epilepsy behaviour 2000, 1:120-1275. Mathiak K et al.: Questionnaire on the Quality of Lifein Child’s Epilepsy. Polish adaptation and validation ofthe questionnaire Heath–Related Quality of Life inChildhood Epilepsy Questionnaire. Polish Neurologyand Neurosurgery 2007, 41, 3: 203-2146. Tettenbaum B, Kramer G.: Total patient care inepilepsy. Epilepsy 1992,33(suppl1):S 28-327. Austin J.K., Shafer P.D., Dering J.B.: Epilepsyfamiliarity, knowledge, and perceptions of stigma:Report from survey of adolescents in the generalpopulation. Epilepsy Behavior 2002,3:368-3758. Mojs E., Głowacka M.D. Samborski Wł.: Appearanceof Cognitive Disorders and Emotions in Epilepsy andTheir Implications in Therapy. Annales AcademiaeMedicae Stetinensis. 2007, 53,3, 82-87.9. Hoare P, Russell M.: The quality of life of childrenwith chronic epilepsy and their families: PreliminaryFindings with a new assessment measure. Dev medChild Neurol 1995,37:689-696.10. Baker G.A. et al.: Quality of life of people withepilepsy: A European Study. Epilepsia, 1997,38 (3),353-362.11. Loring D.W. Kimford J.M.: Cognitive side effects ofantiepileptic drugs in children. Neurology, 2004, 62,872-877.12. Talarska D.: The Quality of Life in Children withEpilepsy on the Basis of QOLCE questionnaire. PolishFamily Practice Medicine, 2004, 6.Suppl.1, 42-44.13. Mojs E. Evaluation of cognitive functions at childrenand adolescents with epilepsy, treated with lamotrygineor vigabatrin in a system of mono- or poly-therapy.Epileptology, 2001,2, 143-167.Address for correspondence:e-mail: miroslawa.felsmann@cm.umk.pltel. 601-299-824Received: 10.01.2012Accepted for publication: 6.03.2012

Medical and Biological Sciences, 2012, 26/1, 107-111Grażyna Franek, Marta Ćmiel-Giergielewicz, Zofia Nowak-Kapusta, Marzena Zmysło-RogozikAWARENESS OF RISK FACTORS ASSESSMENT AMONG INDIVIDUALSWITH ISCHEMIC HEART DISEASEOCENA STANU WIEDZY NA TEMAT CZYNNIKÓW RYZYKA WŚRÓD CHORYCHZ NIEDOKRWIENNĄ CHOROBĄ SERCAThe Department of Health Care and Nursing of Silesian Medical University In KatowiceSenior M.D. Tomasz IrzyniecSummaryA i m . Awareness of risk factors assessment concerningpreventive measures to an ischemic heart disease dependingon socio-demographical factors such as: age, sex, education,place of residence and financial situation among hospitalisedindividuals.I n t r o d u c t i o n . The ischemic heart disease is themost frequent cause of death, hospitalisation and disability.The increasing number of the individuals suffering from thedisease underlines the importance of taking preventivemeasures among the whole population. Proper healtheducation and addressing the risk factors are one of the morecrucial parts of preventing the ischemic heart disease.M a t e r i a l a n d m e t h o d . A method of adiagnostic questionnaire along with the survey technique wasused in the work; an anonymous research was done among101 individuals with ischemic heart disease. The individualswere hospitalised in the Preventive Diagnostics andTelemedicine of Heart and Lungs Conditions of the JohnPaul II Hospital in Krakow. The questionnaire contained 47questions concerning the awareness of preventive measuresto ischemic heart disease and its use in everyday life.R e s u l t s . The obtained results pointed to the lack ofawareness among patients and their awareness of risk factors.The researched individuals were not aware of all the factors,did not know how to modify the risks in order not to developthe ischemic heart disease. The obtained results revealed thatthe higher the education, the improved the knowledge of therisk factors of ischemic heart disease (58.1% of correctanswers). The results also showed that sex was thedifferentiating factor in the knowledge about the condition.Only 33% of the individuals were educated on the ways ofmodifying the risk factors of the heart disease.C o n c l u s i o n s . The data from the research point tothe lack of education among patients with ischemic heartcondition as well as the necessity to address the preventivemeasures according to the education, sex and the age ofpatients.StreszczenieC e l . Ocena wiedzy pacjentów hospitalizowanych natemat czynników ryzyka w zakresie profilaktyki chorobyniedokrwiennej serca, w zależności od czynnikówsocjodemogaficznych, takich jak: wiek, płeć, wykształcenie,miejsce zamieszkania, sytuacja materialna.Wstę p . Choroba niedokrwienna serca od wielu latjest najczęstszą przyczyną zgonów, hospitalizacji orazniepełnosprawności. Wzrastająca wciąż liczba wykrywanychzachorowań wskazuje na potrzebę profilaktyki całejpopulacji. Właściwie prowadzona edukacja zdrowotna opartana przedstawianiu czynników ryzyka zachorowania, jestjednym z istotnych elementów profilaktyki chorobyniedokrwiennej serca.Materiał i m e t o d a . W pracy wykorzystanometodę sondażu diagnostycznego z użyciem techniki ankiety.Przeprowadzono anonimowe badanie wśród 101 osób zniedokrwienną chorobą serca hospitalizowanych wPododdziale Szybkiej Diagnostyki Prewencji iTelemedycyny Chorób Serca i Płuc SpecjalistycznegoSzpitala im. Jana Pawła II w Krakowie. Kwestionariuszzawierał 47 pytań dotyczących wiedzy o profilaktycechoroby niedokrwiennej serca i wykorzystania jej w życiucodziennym.

108Grażyna Franek et. al.W y n i k i . Uzyskane wyniki dowodzą, że stan wiedzypacjentów na temat czynników ryzyka jest niewystarczający.Pacjenci nie znają wszystkich czynników ryzyka, nie wiedzą,w jaki sposób można je modyfikować, aby nie doszło dorozwoju choroby niedokrwiennej serca. Wyniki badańpotwierdziły, że im wyższe wykształcenie, tym wyższypoziom wiedzy o czynnikach ryzyka choroby niedokrwiennejserca (58,1% poprawnych odpowiedzi). Z badań wynika, iżpłeć była czynnikiem, który różnicował badanych podwzględem ich wiedzy. Zaledwie 33% pacjentów do 39 rokużycia była edukowana na temat modyfikacji czynnikówryzyka choroby wieńcowej.W n i o s k i . Dane uzyskane w badaniu wskazują nadeficyt w edukacji pacjentów z chorobom niedokrwiennąserca oraz na celowość ukierunkowania działańprofilaktycznych z uwzględnieniem wykształcenia, płci orazwieku pacjentów.Key words: awareness of risk factors assessment among individuals with ischemic heart diseaseSłowa kluczowe: choroba niedokrwienna serca, czynniki ryzyka, profilaktykaINTRODUCTIONThe circulatory system ailments, and the ischemicheart disease as one of them, are one of the most fatalfor an individual and their health in today’s life. Thesediseases constitute the most often cause of morbidity,high number of deaths as well as disability in Polandand all over the world. The coronary atheromatosis hasbeen mostly responsible for such state of matters. [1]In 2002 the World Health Organization revealedthat due to the circulatory system ailments 16.7 millionof individuals were deceased, 4 million of them inEurope. The most frequent causes of death involve thecoronary disease (50%) and stroke (about 30%). [1]Comparing the number of deaths caused by cancer andheart diseases, we find out that the latter is responsiblefor a death of every second Pole. [2]The aetiology of circulatory and vascular diseasesis very complex, thus pointing to a single cause of thedisease is virtually impossible. One can merely addressthe risk factors, which contribute to the incidence ofthe ailment. [2] In the aftermath of the conceptiveintroduction of risk factors, which association with thedisease is well documented, the factors were dividedinto: alterable ones – closely linked with one’slifestyle, biochemical and physiological features, andunalterable ones – individual features. [2] The thirdgroup consists of risk factors defined as “new” - theyinclude inflammatory response indicators, homeostaticfactors and markers of endothelial dysfunction. [3]In Poland the promotion of health and its actionsaddress the issues of diseases of modern civilizationand are executed on the basis of the National HealthService Program from 2007 to 2015, as well as theNational Health Plan. The National Health Program2007-2015 points to actions which threaten man’shealth and life and is addressed to all nongovernmentalorganisations as well as the localgovernments. [4] The National Health Plan featuresbranches of preventive medicine and recoverysurgeries. The first goal of the National Health Plan isto decrease the number of deaths linked to thecirculatory system diseases, while the National HealthProgram concentrates on introducing early diagnosisand active care of individuals with the risk ofdeveloping an ischemic heart disease. [3, 4] Theestablished aims of the National Health Program andthe National Health Plan are executed throughnumerous actions aiming at preventing an ischemicheart disease. The following strategies are involved:1. Population strategy – involving changingone’s lifestyle and environmental factors ofthe whole population, also the social andeconomical conditions, which lead to the highprevalence of the heart disease;2. High risk strategy – separates the individualswith high risk of heart conditions andexecutes actions, which help modifying anyexisting risks in these individuals;3. Secondary preventive strategy – aims atpreventing heart disease prevalence, after theinitial one had occurred, as well asdiminishing the progress of the disease inindividuals with an identified ischemic heartdisease. [3]The researchers strongly appeal for and prioritisethe control of the heart conditions through masteringour knowledge of the risk factors linked with thedisease and the factors’ modification in individual’severyday life. Despite taking the actions on heartdisease prevention, this is not enough for someindividuals. [5] The aim of the research was to assessthe awareness among hospitalised individuals on riskfactors and prevention of ischemic heart disease,depending on socio-demographic factors such as: age,sex, education, place of residence and economicsituation. Due to the current state of medicine, today’sman needs to mature to be aware of their own health,

Awareness of risk factors assessment among individuals with ischemic heart disease 109realise the threats and make proper decisions, whichwould consequently prevent the threats. [5]MATERIAL AND METHODSThe research included the author’s questionnairesurvey, which featured 47 closed, open-closed andopen questions. The survey involved questionsassessing the individuals and their awareness of riskfactors of ischemic heart disease, information questionsand a metrics. The research was completed by 101individuals hospitalised in the Preventive Diagnosticsand Telemedicine of Heart and Lungs Conditions ofthe John Paul II Hospital in Krakow from the 14 thFebruary 2011 to 27 th April 2011. The patientsvolunteered to and were anonymous in the research.The obtained data was then analysed both statisticallyand descriptively, and was examined by the chi-2 test.The STATISTICA v, 9 computer software was used inthe calculation.55.5% of the researched individuals were females,while 44.5% - males; the age ranged from 22 to 80.The most popular group consisted of city residents(75%); the other (25%) came from the countryside.The majority of individuals completed a secondaryeducation degree (44%), then higher education (30%),vocational (21%) and basic (5%). 45% of theindividuals were still working, 33% were eitherpensioners or retired, while 22% remainedunemployed. As many as 54% marked their economicsituation as good, 41% as satisfactory, 4% asinsufficient and 1% as very good.RESULTSThe results were analysed statistically andexamined in relation to the sequence of answers onsocio-demographic data: sex, age and education.From the analysis we gather that 69% claimed toknew the risk factors of an ischemic heart disease,while 29% lacked such knowledge by choosing theanswer: not aware of and not able to describe theknowledge. Only 7% admitted not to know the riskfactors. The respondents chose: smoking (92.1%),improper diet (85.1%), alcohol abuse (82.2%), highlevel of cholesterol (81.2%), stress (80.2%), lowphysical activity (79.2%) and an increased bloodpressure (70.3%) as the most responsible factors forheart disease. The less common factors given were: age(25.7%), diabetes (39.6%) and genetic issues (47.5%).The difference between the answers given by bothsexes was statistically insignificant. As for the diet, wecan reveal that more correct answers were given byfemale (94.6%) than male individuals (64.1%). Somemen participants were not aware of the importance of adiet in heart disease (38.6%), with much fewer femalewho were not aware of it (5.4%). The BMI term wasfamiliar for 39.2% of female and 22.7% of maleparticipants. Nevertheless, men could calculate theirBMI twice as often (11.4%) as women. The queryabout the alcohol consumption provided us with thefollowing data: 70% of men and 47% of womenadmitted to have been drinking occasionally. As for thephysical activity, we can say that female individualswere less active (52.2%) than male ones (66%). Theresults also differed in preferences for physicalactivities. Male participants often chose walks (63.3%to 48.2% of female). Women participated more inswimming (10.7% to 9.1% of men). The subsequentpart of the research checked whether the individualshad followed their doctor’s advice on medicine use.From the analysis we can read that women were moredisciplined (96.2%) than men (63%). Another queryconcerned the behaviour in conflict situations wherethe individuals could choose between: turning toalcohol, housework, conversation, walk or consumingconfectionaries. The differences between given replieswere not statistically significant. However, two detailsbecame noticeable: women turned to alcohol moreoften than men (20% to 14%), while men chose walksand housework more often than women (51% to34.5% and 48.8% to 40%, respectively).Another part concerned the answers related to ageof respondents. Thus, they were divided into threegroups: - Group I included individuals not older than39, Group 2 – 40-59, Group III – 59 and above. Thefirst analysed question concerned the influence of ageon providing the correct answers on an ischemic heartdisease. The most knowledgeable was the secondgroup (aged 40-59). The two other groups had quitelimited knowledge of the subject. The subsequentquestion concerned blood pressure checks. Individualsaged 39 or younger did it rarely (55.6%), while somedid not do it at all (44.4%). As for the second group(aged 40-59), 33% did it every day, 47.2% - rarely,while 19.4% - not at all. Group III (aged 59 and above)included individuals who did it every day (56%), whilethose not controlling it at all were in minority (6%). Inthe aftermath of such analysis, we could observe anincreasing regularity in blood pressure control, whichcame with age. The following research featuredrelation between age and modifying actions on risk

110Grażyna Franek et. al.factors of the heart disease. There, we can observe thatyounger patients were twice less informed on themodification of risk factors than their above 60’scounterparts (33.3% to 79.6%). Out of every analysedsocio-demographic parameters, the level of educationwas the most important factor in providing answers byindividuals. The most correct answers were given bypatients with higher education (46.2%), secondaryeducation (37.6%), vocational (37.4%) and basiceducation (27.7%). From the analysis of education andits influence on health awareness in heart conditions,the following may be assumed: individuals with higherand secondary education (58.1% and 50%,respectively) possessed such awareness. However, only20% with basic education and 28.6% with vocationaleducation claimed to have been aware. Interestingly,66.7% with vocational education declared to have beenaware of only some of the health conducts, with only34.1% with secondary education admitting so. 15.9%with secondary education informed of their completelack of knowledge of the subject, with 4.8% withvocational education and none from basic educationdoing so. All things considered, we might state thatpatients with secondary education were less aware ofthe issues concerning the subject than the otherindividuals. The subsequent research analysed thecorrelation between the education and nutrition advicerelating to heart conditions. From the analysis we cangather that the diet awareness was quite limited. Only29% with higher education, 13.6% with secondaryeducation and 9.5% with vocational education chose acompletely correct answer. None with basic educationreplied properly on the accurate diet in heartconditions. Another question related to the knowledgeof approved values of cholesterol. The most correctreplies were given by the individuals with highereducation (25.8%), then basic education (20%) andvocational education (19%), whilst only 15.9% withsecondary education responded accurately. One of thelast issues to be analysed concerned the responsibilityof individuals for their own health. The researchedpatients could choose more than once between: me,patient, nurse, environment, family, and a doctor. Asmany as 92.8% felt their own responsibility for theirhealth. A doctor was responsible according to 43.3%,while 19.59% thought that it was the environment’sresponsibility, 12.37% - family’s and 2.1% - nurse’s.The respondents replied that the major source of theirknowledge about the disease came from: a doctor(75%), friends and relatives (24%), television (24%), anurse (15%), while 10% did not use any source ofknowledge.DISCUSSIONThe issue of heart conditions is crucial for thehealth care system and its work as well as in the socialaspect. This is, especially the case for politics, which iswhy numerous actions are taken to educate and thusdiminish the problem. [6] For the cooperation betweena patient and a doctor to be effective, it is the patientwho needs to have minimal knowledge of the healthissues hence, helping in understanding the actionwhich needs some effort or sacrifices (e.g. quittingsmoking, losing weight, regular physical activity ormodifying one’s diet). [7] Unfortunately, modifyingthe risk factors, which concentrates on healthy lifestyleis, on the one hand the most available method, but onthe other the most challenging one of preventing heartconditions. [8]Following the research made by A. Kubica on theawareness of the risk factors of the heart disease, wecan conclude that the knowledge about the risk factorsor the heart disease was higher among individuals aged65 or below (54.4%) than in the ones aged 65 or above(49%). [9] The similar results were obtained in thiswork – the most knowledgeable ones were aged 40-59,individuals aged 39 or below and 59 or above had alimited knowledge. According to the research made byKubica, sex was not a factor, which differentiated theindividuals between their awareness on the subject. Inthe subsequent part, A. Kubica focused on relationsbetween education and awareness. She noted thatindividuals with basic education and vocationaleducation had a very limited knowledge of the heartdisease (45% and 52.3%, respectively), while thosewith secondary and higher education differedpositively (61.2%). [9] The most correct answers onthe subject of an ischemic heart disease were given bythe individuals with higher education (46.2%), thensecondary education (37.6%), vocational education(37.4%) and basic education (27.7%). Nevertheless,the results were not satisfactory since more than a halfof individuals were not able to name half of the factorscausing the disease. The similar results were obtainedby G. Nowicki who analysed the risk factors of heartdisease among employed individuals. In his analysis,50% of the individuals had an average knowledge ofthe risk factors, while 30% - limited. The researchedgroup was well-educated on the diet used in heartconditions [6]; similar results were obtained in thiswork. Satisfyingly, a high proportion of respondentswas familiar with the diet in heart conditions andvalued its role in prevention and treatment of thedisease. Interestingly, 94.6% of women and 61.4% ofmen thought that diet had a high influence on the heartdisease. On the basis of the research done by E.

Awareness of risk factors assessment among individuals with ischemic heart disease 111Kawalec, it became evident that books or press are thepreferred source of knowledge about health (81.5%).More than a half (52.2%) thought a doctor or a nursewas a reliable source. [10] The results are only partlyconfirmed here, with 75% of the individuals thinkingof a doctor as a main source, 41% choosing theInternet, 35% - medical press, 24% - friends andrelatives, 24% - television and 15% - a nurse. The factthat only 15% chose a nurse as their main source ispuzzling. Is this due to the fact that nurse do notengage in health education? The confirmation of thishypothesis came in the subsequent reply whereindividuals claimed that a nurse plays alittlerole inbeing responsible for their health (2.06%), with thedoctor on the contrary (43.3%). The subsequent part ofthe research by E. Kawalec featured the analysis of thefemale replies to difficult situations. There we can readthat 30.6% found conversation with their female friendas helpful and 44.8% - housework [10]. The similaranswers were given in this work – 50.9% choosingconversation, 40% - housework. From the research wecan read that regularity of blood pressure checksincreases with age. The obtained results here can becompared with J. Kossak’s conclusions from theresearch on environmental risk factors and their rolesin secondary prevention of heart conditions. There itwas claimed that the frequency of blood pressurechecks depends on age and education. [11]The analysis points to the fact that education isclosely linked to awareness and healthy demeanour ofindividuals and that despite numerous campaigns ofhealthy lifestyle, the knowledge about the subject isstill limited. The research also showed a very crucialand, at the same time. Unenthusiastic informationabout the nurse care in that, the patients did notassociate nurses with educational functions whether inhospital or at individual’s place of living. Thus, actionsneed to be taken for the nurses to be involved in sucheducation.4. Doctors were considered the most reliablesource of knowledge about the disease.REFERENCES1. Ślusarska B., Pielęgniarstwo Kardiologiczne,Wydawnictwo Lekarskie PZWL, Warszawa 20102. Podolec P., Podręcznik Polskiego Forum Profilaktyki,Wydawnictwo Medycyna Praktyczna, Kraków 20073. Andruszkiewicz A. Banaszkiewicz M., Promocjazdrowia, Wydawnictwo Lekarskie PZWL, Warszawa20104. Narodowy Program Zdrowia na lata 2007-2015.Załącznik do uchwały nr 90/2007 Rady Ministrów z dnia15 maja 2007 r.5. Murynowicz-Hetka, Pedagogika społeczna,Wydawnictwo PWN, Warszawa 20076. Nowicki G., Ślusarska B., Brzezicka A., Analiza stanuwiedzy o czynnikach ryzyka chorób układu sercowonaczyniowegowśród osób pracujących, Probl. Piel.,2009, 17 (4), 321-3277. Kubica A., Koziński M., Sukiennik A., Skutecznaedukacja zdrowotna- utopia czy niewykorzystanemożliwości kardiologii, Cardiovascular Forum, 2007, 12,13-178. Ziółkowski M., Kubica A., Sienkiewicz W., MaciejewskiJ., Zmniejszenie umieralności na chorobę niedokrwiennąserca w Polsce- sukces terapii czy prozdrowotny stylżycia?, Folia Cardiologica Ex Cerpta, 2009, tom 4, 5,265-2729. Kubica A., Pufal J., Moczulska B., Koziński M., Ocenawiedzy dotyczącej profilaktyki i objawów chorobyniedokrwiennej serca u osób hospitalizowanych w klinicekardiologii, Psychiatria w Praktyce Ogólnolekarskiej,2004, 4 (3), 135-14110. Kawalec E., Gabryś T., Brzostek T., Reczek A., Czynnikiryzyka choroby niedokrwiennej serca u kobietpracujących umysłowo, Probl. Piel., 2008, 16 (4), 325-33011. Kossak J., Jędrzejczak M., Kossak D., Rola czynnikówśrodowiskowych w prewencji wtórnej chorób układukrążenia, Med. Rodz., 2004, 2, 78-85CONCLUSIONS1. Female individuals and their awareness of therisk factors and health conduct were muchsuperior to that of their male counterparts.2. Individuals aged 39 or below had very limitedknowledge of the risks of an ischemic heartdisease.3. Individuals with higher education were moreaware of the risk factors of heart conditionsand health conduct.Address for correspondence:The Department of Health Care and Nursingof Silesian Medical University In KatowiceMedyków 1240-752Katowicetel.: 32 208 86 35e-mail: pielrodz@sum.edu.plfax 32 208 86 35Received: 10.01.2012Accepted for publication: 6.03.2012

Medical and Biological Sciences, 2012, 26/1, 113-118Małgorzata Graczyk, Michał Przybyszewski, Jacek Tlappa, Jacek Mućka, Andrzej Kuźmiński, MagdalenaŻbikowska-Gotz, Ewa Szynkiewicz, Katarzyna Napiórkowska, Joanna Kołodziejczyk, Robert Zacniewski,Anna Różalska, Zbigniew BartuziDETERMINATION OF ECP CONCENTRATION IN PATIENTS WITH ALLERGIC TYPEOF FOOD HYPERSENSITIVITY AND IN PATIENTS WITH DYSPEPTIC SYMPTOMSNOT ASSOCIATED WITH FOOD ALLERGYOCENA STĘŻENIA ECP U PACJENTÓW Z NADWRAŻLIWOŚCIĄ POKARMOWĄ TYPU ALERGICZNEGOI U PACJENTÓW Z OBJAWAMI DYSPEPTYCZNYMI BEZ ALERGII POKARMOWEJDepartment and Clinic of Allergology, Clinical Immunology and Internal Diseases Collegium Medicum inBydgoszcz, UMK in ToruńHead of Clinic of Allergology, Clinical Immunology and Internal Diseases:prof. dr hab. n. med. Zbigniew BartuziSummaryI n t r o d u c t i o n . The results of many studies suggestthat the tendency towards the prevalence of food allergies isincreasing [1, 2, 3]. It is estimated that approximately 20% ofpopulation modifies their diet due to adverse reactionsobserved after ingestion of certain foods [2]. Still, the exactprevalence rate of food allergies in pediatric and adultpopulations cannot be satisfactorily estimated [4].T h e a i m o f t h i s s t u d y was to determineserum concentrations of eosinophil cationic protein (ECP) inpatients with allergic type of food sensitivity and to comparethem to data obtained from patients with dyspeptic disorderswithout a concomitant allergic condition.M a t e r i a l a n d m e t h o d s . This study included agroup of 80 patients; among them 50 individuals withdiagnosed food sensitivity based on existing standards, and30 subjects with dyspeptic symptoms without an associatedallergic condition. Venous blood was collected from eachparticipant and ECP concentration was determined by meansof fluoro-immunoenzyme assay (FIA) with UniCAP ECP test(Pharmacia Diagnostics).R e s u l t s . The arithmetic mean serum ECPconcentration in patients with food allergy was found to be24.604 ± 40.36 µg/l. In all individuals, serum ECPconcentrations were within the detection limit of the appliedmethod. The average concentration of ECP in a group ofsubjects without food allergy was determined to be 29.9±64.76 µg/l and did not exceed the lower or the upperdetection limit of the applied method.C o n c l u s i o n s . Patients with food allergy did notdiffer significantly from those with dyspeptic symptomswithout a concomitant allergy in terms of ECP concentration(Mann-Whitney U test, p=0.754218).StreszczenieWstę p . Jak wskazują wyniki wielu badań - częstośćwystępowania alergii pokarmowej wykazuje tendencjęwzrostową [1, 2, 3]. Szacuje się, że około 20% populacjimodyfikuje swoją dietę ze względu na spostrzeganeniepożądane reakcje po określonych pokarmach [2]. Jednakdokładne określenie częstości występowania alergii napokarmy wśród populacji dzieci i dorosłych pozostaje nadalniedostateczne [4].Celem niniejszego badania była ocenastężenia ECP w surowicy u pacjentów z nadwrażliwościąpokarmową typu alergicznego i porównanie wartości z grupąchorych z dolegliwościami dyspeptycznymi bezwspółistniejących schorzeń alergicznych.Materiał i m e t o d y . Badaniem objęto grupę 80chorych, wśród których wyodrębniono 50 pacjentów znadwrażliwością na pokarmy, rozpoznaną w oparciu o

114Małgorzata Graczyk et. al.obowiązujące standardy oraz 30 pacjentów z objawamidyspeptycznymi bez towarzyszących chorób alergicznych.Każdemu zakwalifikowanemu do badania pacjentowipobierano krew żylną w celu oznaczenia stężenia ECP, któreprzeprowadzono metodą fluoroimmunoenzymatyczną (FIA),testem UniCAP ECP, wyprodukowanym przez firmęPharmacia Diagnostics.Wyniki. Średnie arytmetyczne stężenie ECP wgrupie pacjentów z alergią pokarmową wynosiło 24,604 ±40,36 ug/l. U wszystkich badanych oznaczane stężenia ECPw surowicy mieściły się w granicach czułości stosowanejmetody. W grupie badanych pacjentów bez alergiipokarmowej średnie stężenie ECP wynosiło 29,9± 64,76 ug/li nie przekraczało dolnego i górnego zakresu czułościzastosowanej metody.W n i o s k i . Nie wykazano istotnej statystycznieróżnicy między stężeniami ECP u pacjentów z alergiąpokarmową i u pacjentów z objawami dyspeptycznymi bezalergii pokarmowej (Test U Manna-Whitneya, p=0,754218).Key words: food allergy, ECP, eosinophilSłowa kluczowe: alergia pokarmowa, ECP, eozynofilINTRODUCTIONThe results of many studies suggest that thetendency towards the prevalence of food allergies isincreasing worldwide [1,2,3]. An increase in theoccurrence of allergic disorders has been particularlyevident during the recent half-century, when anindisputable predominance of conditions with atopicbackground has been observed [5]. Currently, allergies,as one of the most common chronic disorders, arefrequently referred to as the epidemic of the 21stcentury and constitute a serious medical and socialproblem [6,7]. They are so widespread throughout thecontemporary world that some authors suggest thatmore than 30% of human population may be affectedby various disorders that can be classified as atopic orallergic. Allergic diseases are the 4 th or 5 th mostfrequent condition amongst United States citizens, afterneoplasms, cardiovascular and respiratory conditions,and AIDS [8]. Moreover, food allergies affectapproximately 3.7% of United States population and6% to 8% of small children. Food allergies have beenrevealed to affect the quality of life of patients andtheir families [2,9,10]. It is estimated thatapproximately 20% of population modifies their dietdue to adverse reactions observed after ingestion ofcertain foods [2]. Still, the exact prevalence rate offood allergies in pediatric and adult populations cannotbe satisfactorily estimated. The data that is availablederived from the studies of small populations, and thevariation in the results is considerable. The reasons forthis variation in the results include varied nutritionalconditions (dietary habits, cultural and ethnicbackground), the lack of standardized diagnosticmethods, and differences in nomenclature related tothis condition [4].It has been revealed that eosinophils are the centraleffector cells involved in chronic allergicinflammation. According to the current knowledge,they are the principal source of mediators releasedduring the chronic phase of allergic reaction and areresponsible for many symptoms associated with atopicreaction. Eosinophils express FcεRII surface receptors;still, the presence of FcεRI surface receptors for IgE iscontroversial, and it has not been confirmed if thesereceptors are involved in the process of eosinophildegranulation occurring during allergic conditions [11,12]. Activated eosinophils release cytotoxic proteins,such as major basic protein (MBP), eosinophil cationicprotein (ECP), and eosinophil protein X (EPX) [13].The aim of this study was to determine serumconcentrations of ECP in patients with allergic type offood sensitivity and to compare them to the dataobtained from patients with dyspeptic disorderswithout a concomitant allergic condition.MATERIAL AND METHODSThis study included a total number of 80 patientswho were hospitalized at the Clinic of Allergology,Clinical Immunology and Internal Diseases ofNicolaus Copernicus University (NCU) LudwikRydygier Collegium Medicum in Bydgoszcz, due todyspeptic disorders. This group was comprised of 56women and 24 men aged between 18 and 65 years(mean age of 37.575 years). A group of 50 subjectsdiagnosed with allergic type of food sensitivity wasselected from these patients. The principal inclusioncriterion for the study was the presence of dyspepticdisorders in patients aged between 18 and 65 years.The exclusion criteria included severe chronic organic

Determination of ECP concentration in patients with allergic type of food hypersensitivity and in patients with dyspeptic... 115conditions, such as status after stomach or intestineresection, necrotic colitis, Crohn’s disease, intestinalfistulas, coeliac disease, bacterial and fungal enteritis,parasitic infections, disaccharide intolerance, colorectaltumours, hyperthyroidism, acute or chronic leukaemia,lymphoma or other malignancies, ongoing oncologicaltherapy, urinary tract infections, and tuberculosis.Based on the established diagnosis, the patients weredivided into two groups.1. A group of 50 patients between 18 and 65years of age (mean of 38.36 years) withallergic type of food sensitivity diagnosedbased on existing standards, i.e. results ofphysical examination, skin prick tests withfood allergens, immunological tests as well asprovocation and elimination challenges;2. Control group comprised of 30 patientsbetween 18 and 54 years of age (mean of36.267 years) with dyspeptic symptomswithout the signs of atopy (negative personaland familial history, negative result of skinprick tests with food allergens, lowconcentration of total IgE and specific IgEclass antibodies).Concentrations of eosinophilic cationic proteinswere determined by means of fluoro-immunoenzymeassay (FIA) with UniCAP ECP test (PharmaciaDiagnostics). This method employed β-galactosidaseconjugated with anti-ECP mouse monoclonalantibodies (β-Galactosidase-anti-ECP) as a marker and4-metylumbelliferone-labeled β-D-galactose as thefluorescent substance. In this assay, anti-ECPantibodies interact with ECP present in patient’s serumsample. The sensitivity of the method was less than 0.5µg/l. According to the manufacturer, tests’ referencevalues were as follows:- 5.5 µg/l – for the geometric mean, or- 11.1 µg/l – for the 90 th -95 th percentile value, or- 13.3 µg/l – for the value between 90 th and 95 thpercentile, determined in a group of 95 healthyindividuals (44 men and 51 women between 18 and 76years of age).Table I. Concentration of ECP in patients with food allergyTabela I. Stężenie ECP u pacjentów z alergią pokarmowąECP (µg/l)Subjects with food allergySample size 50Arithmetic mean 24.604Standard deviation 40.36Geometric mean 13.6931Median 12.35Minimum 2.3Lower quartile 7.1Upper quartile 19.3Maximum 246.00The average concentration of ECP in the group ofsubjects without food allergy was determined to be29.9± 64.76 µg/l, and did not exceed the lower or theupper detection limit of the applied method.Table II. Concentration of ECP in patients without foodallergyTabela II. Stężęnie ECP u pacjentów bez alergii pokarmowejECP(µg/l)Subjects without food allergySample size 30Arithmetic mean 29.9Standard deviation 64.76Geometric mean 12.3968Median 13.00Minimum 1.18Lower quartile 8.5Upper quartile 22.3Maximum 315.00Patients with food allergy did not differedsignificantly from those with dyspeptic symptomswithout a concomitant allergy in terms of ECPconcentration (Mann-Whitney U test, p=0.754218).ECP [µg/ml]35030025020015010050p = 0.7542RESULTS0Group without food allergyGroup with food allergyMedian25%-75%RangeArithmetic mean of serum ECP concentration inpatients with food allergy was found to be 24.604 ±40.36 µg/l. In all individuals, serum ECPconcentrations were within the detection limit of theapplied method.Ryc. 1. Concentration of ECP in egzaminated patientsRyc. 1. Stężenie ECP u badanych pacjentów

116Małgorzata Graczyk et. al.DISCUSSIONThe tissue eosinophils count is known to be 100- to200-fold higher than in the peripheral blood. Thus,eosinophils constitute the principal tissue cells,showing particular predilection for skin, respiratorysystem, and alimentary tract [14]. Eosinophilinfiltration can be present in every part of thealimentary tract: eosinophilic inflammation has beenfound in the esophagus, stomach, and the smallintestine of individuals with food allergy, and in thelarge intestine of allergic and allergy-free subjects [15].The opinion on the role played by eosinophils in thepathomechanism of allergic disorders has beenchanged substantially during the recent several years.Previously, eosinophils were seen as the modulators ofinflammation. Presently, they are considered to be theeffector cells during inflammatory processes,possessing a regulatory function and a potential toxicinfluence on other cells present in theirmicroenvironment [16,17]. Allergic disorders areassociated with an enhanced migration of these cells(with the involvement of adhesion molecules) to targettissues, which is manifested by their elevatedperipheral blood count [16]. As a consequence,eosinophils were postulated to be the inflammatorycells involved in the pathogenesis of allergic conditions[18,19].It is widely believed that eosinophilic cationicprotein is a marker of inflammation in the course ofallergic conditions. ECP was isolated fromlymphoblastic leukaemia cells in 1971. In 1975, Olsonet al. identified eosinophils as the main source of thisprotein [15]. It is the principal, potentially cytotoxic,protein released as a result of eosinophil activation thatcan modulate systemic immune response [18,19]. Thiscationic toxin with 18-25 kDa molecular mass is storedin eosinophil granules [20]. ECP levels in biologicalfluids are currently used as specific markers inmonitoring and diagnosis of inflammatory conditions.Cytotoxic properties of ECP can also cause injury tohost’s epithelial cells, and eosinophils are consideredthe first leukocytes that respond to tissue injury duringinflammatory disorders [18]. The exact mechanism ofECP-mediated injury is still unclear. In 1986 Young etal. revealed that ECP can cause injury to artificial lipidmembranes in in vitro studies. ECP is known topossess RNAase (ribonuclease) activity [20]. Twoforms of ECP have been identified duringimmunochemical studies: ECP1 and ECP2. The firstcan be found in the granules of non-activatedeosinophils, while the second one is associated withactivated cells. The gene that encodes human ECP(RNS) was mapped to q24-q31 region of chromosome14, in a close neighbourhood of genes encoding otherproteins of endonuclease family: RNAse-4(pancreatic), and EPX/EDN. ECP is synthesized as aprecursor protein which is subsequently modifiedinside eosinophil granules [15]. GM-CSF, a factorrequired for eosinophil formation and maturation, doesnot influence the degranulation of mature eosinophils;it is IL-5 that stimulates these cells to release ECP.According to Venge, measurement of ECP level canconstitute a useful tool in the assessment of eosinophilactivation status and activity of inflammatory processin bronchial asthma patients [21]. Elevated levels ofECP were observed to be associated with more severeinjury to bronchial tissue in patients with inadequateanti-inflammatory treatment of bronchial asthma. Inthese cases, bronchial injury corresponded with anincreased density of basal membrane, injury toepithelial and glandular cells of the bronchi, and thehypertrophy of bronchial smooth muscles withresulting bronchial hyper responsiveness. Zapalka et al.revealed that serum ECP correlates with the results offunctional pulmonary tests (FEV1, FEF50).Furthermore, an increase is serum ECP was observedduring pollen season, and its concentrations werehigher in a group of patients with atopy [22]. Chung etal. observed an association between the concentrationof ECP in the mucosa and the degree of injury to smallintestinal mucosa. Furthermore, Hill et al. showed thateosinophils are involved in the intermediate phase ofantigen response (due to reaction time), while mastcells and lymphocytes play roles in the immediate andlate phase, respectively.Niggeman et al. studied the concentration of ECPprior to and after allergen challenge in children withatopic dermatitis. They observed that the positive resultof the challenge was associated with the decrease in thenumber of circulating eosinophils, and interpreted thisfinding as a consequence of their involvement at thereaction site. The serum concentration of ECP initiallydid not change (during the first eight hours), and thenincreased thereafter.Furthermore, involvement of ECP was reported inthe mechanism of mucosal membrane injury duringeosinophilic esophagitis [15].Czaja-Bulsa et al. verified if the accumulation andactivation of eosinophils during positive provocation

Determination of ECP concentration in patients with allergic type of food hypersensitivity and in patients with dyspeptic... 117challenge in children with IgE-dependent allergy tocereal protein can be monitored based on eosinophilcount and serum ECP concentration. Significantchanges in both parameters were detected duringimmediate adverse reaction observed as a result ofprovocation challenge. However, the increase in serumconcentrations did not occur simultaneously. Typically,a 2- to 3-fold, and sporadically even more pronounced(9-fold), decrease in eosinophil count was observedtwo hours after the provocation. This was followed byan increase to the levels higher than baseline values(most commonly 1.5- to 3-fold higher) one or two daysafter the challenge. Two- to three-fold increase in ECPconcentration was usually noted 2 hours after theprovocation in the same group of children, andpersisted, or even continued to grow up to 24 hoursafter the challenge [23].Osterlund et al. proved that the determination ofECP in the milk of lactating women can be used as anovel approach in the early detection of allergicdisorders. Based on the measurements of breast milkECP concentration and breast milk and peripheralblood leukocytes counts of 94 lactating women, ofwhich 58 had atopy and 36 did not, they observed thatthe presence of ECP in human milk is associated withthe development of allergy to β-lactoglobulin in cow’smilk and atopic dermatitis in breastfed children.However, no association was observed between thebreast milk ECP concentration and maternal atopy.In contrast, Maciorkowska and Kaczmarskirevealed that ECP concentration is not a reliableindicator of the degree of injury to the alimentary tractmucosa in the course of food allergy in children [24].Additionally, the role of eosinophils in gastritisassociated with Helicobacter pylori infection is notfully established. Aydemir et al. observed themigration of eosinophils to the infected regions and asubsequent release of ECP leading to considerableinjury of the gastric mucosa as a result of cytotoxiceffects of this protein [25].CONCLUSIONSThis study revealed that the concentration ofeosinophilic cationic protein was elevated in bothanalyzed groups, but the differences were notstatistically significant. Perhaps, this finding was theresult of the purposeful limitation of the exposure tocertain food allergens that are responsible forprovocation of clinical symptoms in a group of patientswith food allergy. The potential effects of H. pyloriinfection on eosinophil activation and resultingenhanced release of ECP in patients without foodallergy should be also considered.REFERENCES1. Bartuzi Z. „Alergia pokarmowa w praktycegastroenterologicznej- problem wciąż mało znany iniedoceniany”, Alergia 2003, 1/16 ;2. Mansueto P., Montalto G. and all.”Food allergy ingastroenterologic disease: Review of literature”,World J Gastroenerol 2006 December 28:12 (48):7744-7752;3. Samoliński B., Raciborski F., Tomaszewska A. i wsp.,“Częstość występowania alergii w Polsce –programECAP”, Alergoprofil 2007, Vol. 3, Nr 4, 26-28;4. Wysocka M., Jędrzejczak-Czechowicz M., KowalskiM. “Nadwrażliwość na pokarmy wśród dorosłychmieszkańców Łodzi- badanie ankietowe” AlergiaAstma Immunologia, 2007, 12 (4):191-199;5. Cochrane S., Beyer K., Clausen M., Wjst M., Hiller R.,Nicoletti C. and all “Factors influencing the incidenceand prevalence of food allergy”. Allergy 2009: 64:1246-1255 ;6. Kaczmarski M., Matuszewska E. “ Diagnostyka alergiii nietolerancji pokarmowej u dzieci “. Alergia Astmaimmunologia 2000, 5(2), 77-81;7. Kuźmiński A., Graczyk M., Przybyszewski M., BartuziZ. „ Alergia na pokarmy pochodzenia roślinnego –narastający problem współczesnej alergologii (część II)”. Współczesna Alergologia info 2009 , tom 4/nr 3(14); 105 – 111;8. Malinowska E., Kaczmarski M. ”Alergia pokarmowa udzieci i młodzieży”. Klinika 2001, 26 kwietnia- 7 maja,Nr 32-35(3027-3030);9. Ariana D.Buchanan, Todd D. Green, Stacie M. Jonesand All „Egg oral immunotherapy in nonanaphylacticchildren with egg allergy”, J Allergy Clin Immunology,January 2007, Volume 119, Number 1, 199-205;10. Ujwala Kaza, MD, Adina Kay Knight, MD, Sami L.Bahna, MD, DrPH „Czynniki ryzyka alergiipokarmowej”. Medycyna po Dyplomie 2008, Vol. 17/Nr 3 (144), 23-28.”Risk Factors for Development ofFood Allergy” Current Allergy and Asthma Reports2007, 7:182-186;11. Holgate S. T., Church M. K., Lichtenstein L. M.”Alergia” Wydawnictwo Czelej, Lublin 2003;12. Kowalski M. L.”Immunologia kliniczna” OficynaWydawnicza MEDITON, Łódź 2000;13. YQ Hsu, CYF Lo “A case of eosinophilicgastroenteritis”, HKMJ 1998;4:226-228;14. Kuziemski K., Jassem E. „ Eozynofilie płucne „Alergia, 2008, 2 : 24-27;15. Matusiewicz K., Mowszed K., Iwańczak B.,Matusiewicz M. „Eozynofilowe białko kationowe –znaczenie w patofizjologii i diagnostyce” , Adv ClinExp Med. 2006, 15, 4, 683-688;

118Małgorzata Graczyk et. al.16. Chazan R. „ Pneumonologia i alergologia praktyczna –badania diagnostyczne i terapia” Bielsko – Biała, α -medica press 2001/2003;17. Czarnobilska E., Olejarz P., Obtułowicz K. „ Rolaeozynofila w chorobach alergicznych i niealergicznych„Alergologia • Immunologia 2007, tom 4, numer 3-4,53 -57;18. Boix E., Carreras E., Nikolovski Z., Cuchillo C. M.,Nouges V. M. “ Identification and characterization ofhuman eosinophil cationic protein by an epitopespecificantibody” Journal of Leucocyte Biology, 2001June, Vol. 69: 1027- 1035;19. Woschnagg Ch., Rubin J., Venge P. “ EosinophilCationic Protein (ECP) is processed during sectretion1”The Journal of Immunology, 2009, 183, 3949- 3954;20. Rosenberg H. F. “ Recombinant human eosinophilcationic protein ribonuclease activity is not essential forcytotoxity “ The Journal of Biological Chemistry,1995, Issue April 7, Vol. 270, No. 14, 7876- 7881;21. Venge P. “ Monitoring of asthma inflammation byserum measurements of eosinophil cationic protein(ECP). A new clinical approach to asthma management“ Respiratory Medicine ( 1995 ), 89, 1- 2;22. Zapalka M., Kopriva Fr., Szotkowska J. “ Monitoringof serum eosinopil cationic protein (ECP) level and itsclinical value in paediatric practice” Acta Univ.Palacki.Olomuc., Fac. Med. 1998, Volume 141 ; 21-23;23. Czaja- Bulsa G., Małecka G. “ Równoczesna oceanstężenia eozynofilowego białka kationowego ieozynofilii krwi obwodowej w czasie dodatnich próbprowokacji pokarmowych „Pediatria Współczesna,Gastroenterologia, Hepatologia i Żywienie Dziecka2002, 4, 3, 225- 229 ;24. Rosińska A., Stajkowska I., Cichy W. „ Rolaalergenów pokarmowych w etiopatogenezie atopowegozapalenia skóry „ Post Dermatol Alergol 2007; XXIV,5: 224- 232;25. Nikoronow E., Godlewska R., Jagusztyn – Krynicka E.K. „ Oddziaływanie Helicobacter pylori na komórkisystemu odporności wrodzonej” Post. Mikrobiol. 2008,47, 2, 137- 148 ;Address for correspondence:Małgorzata GraczykKlinika AlergologiiSzpital Uniwersytecki nr 2 im. J. Bizielaul. Ujejskiego 7585-168 Bydgoszcztel. 052 3655416; fax 052 3655416e-mail: gosgra1@poczta.onet.plReceived: 10.01.2012Accepted for publication: 6.03.2012

Medical and Biological Sciences, 2012, 26/1, 119-123Anna Grzanka-Tykwińska 1 , Alicja Rzepka 1,2 , Katarzyna Porzych 1 , Krzysztof Kusza 2,3 ,Kornelia Kędziora-Kornatowska 1THE QUALITY OF LIFE OF PATIENTS OVER 60 INCLUDING DEMOGRAPHICAND ENVIRONMENTAL FACTORSJAKOŚĆ ŻYCIA PACJENTÓW POWYŻEJ 60 ROKU ŻYCIAZ UWZGLĘDNIENIEM CZYNNIKÓW DEMOGRAFICZNO-ŚRODOWISKOWYCH1 Department and Clinic of Geriatrics of the Nicolaus Copernicus University in ToruńCollegium Medicum in BydgoszczHead: Prof. Kornelia Kędziora-Kornatowska, PhD.,MD.2 Department and Clinic of Anesthesiology and Intensive Care of the Nicolaus Copernicus Universityin Toruń, Collegium Medicum in BydgoszczHead: Prof. of UMK Krzysztof Kusza, PhD., M.D.3 Department and Clinic of Anesthesiology, Intensive Care and Treatment of Pain Medical University in PoznańHead: Prof. Leon Drobnik, PhD., M.D.SummaryI n t r o d u c t i o n . The population of older people is adiversified community. It can be differentiated by sex,marital status or education. These factors may be alsoconnected with the assessment of older people’s lifestyle.Not only life extension but also taking care about its qualityprovides a challenge to contemporary medicine.P u r p o s e . The quality of life assessment in patientsover 60 including demographic and environmental factors.Material and methods. The study wasconducted by means of WHOQOL-BREF Questionnaire. 119patients of the Geriatric Outpatient Clinic at dr A. JuraszUniversity Hospital No. 1 in Bydgoszcz and patients ofdistrict outpatient clinics in Bydgoszcz were involved in it.R e s u l t s . Those involved in the study gave the worstassessment to their quality of life in the physical area (13.99± 2.13 points), whereas the psychological area was assessedmost favourably (15.32 ± 1.93 points). Statisticallysignificant differences were determined between women andmen (p=0.0421) as well as between the married and thewidowed (p=0.0185) in the area of social relations, andbetween people with vocational education and those withuniversity education (p=0.0015) in the area of environment.C o n c l u s i o n s . As far as social relations areconcerned, quality of life was assessed less favourably bywomen than by men and by the widowed than by themarried. Sex and marital status had an influence on quality oflife assessment in the field of social relations. As regardsquality of life assessment, the level of education wasinfluential. People with vocational education gave assessedquality of their life less favourably than those with universityeducation.StreszczenieWstę p . Populacja osób starszych jest zbiorowościązróżnicowaną. Indywidualizuje ją płeć, stan cywilny, czywykształcenie. Czynniki te mogą również wiązać się z ocenąjakości życia osób starszych. Wyzwaniem współczesnejmedycyny jest nie tylko przedłużanie życia, ale równieżdbałość o jego jakość.C e l . Ocena jakości życia pacjentów powyżej 60 rokużycia z uwzględnieniem czynników demograficznośrodowiskowych.Materiał i m e t o d y . Badania przeprowadzonoza pomocą Kwestionariusza WHOQOL-BREF. Wzięło wnich udział 119 pacjentów Poradni Geriatrycznej Szpitala

120Anna Grzanka-Tykwińska et. al.Uniwersyteckiego nr 1 im. dr A. Jurasza w Bydgoszczy ipacjentów bydgoskich poradni rejonowych.W y n i k i . Uczestnicy badania najniżej oceniali swojąjakość życia w dziedzinie fizycznej (13,99 ± 2,13 punkty), anajwyżej w dziedzinie psychologicznej (15,32 ± 1,93punkty). Istotne statystycznie różnice stwierdzono pomiędzykobietami a mężczyznami (p=0,0421) oraz pomiędzyosobami pozostającymi w związku a osobami owdowiałymi(p=0,0185) w dziedzinie relacji społecznych, a takżepomiędzy osobami z wykształceniem zawodowym a osobamiz wykształceniem wyższym (p=0,0015) w dziedzinieśrodowisko.W n i o s k i . W dziedzinie relacji społecznych niżejoceniały swoją jakość życia kobiety od mężczyzn oraz osobyowdowiałe od osób pozostających w związku. Płeć i stancywilny miały wpływ na ocenę jakości życia w dziedzinierelacji społecznych. W dziedzinie środowisko, na ocenęjakości życia wpływ miało wykształcenie. Osoby zwykształceniem zawodowym gorzej oceniały swoją jakośćżycia od osób z wykształceniem wyższym.Key words: quality of life, old ageSłowa kluczowe: jakość życia, wiek podeszłyINTRODUCTIONA growing share of the older population in thecommunity is a success of contemporary medicine andproves development of new technologies andimprovement in life conditions. At the same time thisprovides a challenge from the point of view ofeconomy and state social policy. Older people face oldage problems. A bigger number of older people meansa growing demand for medical, nursing and caringservices [1]. The issues related to growing old and oldage arouse interest of a range of scientific disciplines,therefore this period of life is perceived from differentperspectives. More and more often there are mentionedthe issues of independent functioning of older peoplein the contemporary environment, providing them withthe possibility of further development andaccomplishment of subsequent developmental tasksand an adaptation for new conditions [2]. Althougholder patients are provided with constant medicalassistance, their quality of life is an incredibly important and often considered problem. Not only lifeextension but also taking care about its qualityprovides a challenge to contemporary medicine.Numerous definitions of this term can be found inliterature. With reference to growing old and old ageissues, Rowe and Kahn’s definition is most frequentlyquoted. It involves three basic elements. The first oneis a low risk of disease and disability occurrence, thesecond one is a good physical and mental condition ofan individual whereas the last one is activeinvolvement in life problems [3].PURPOSE OF THE DISSERTATIONThe purpose of this dissertation was quality of lifeassessment in patients of district outpatient clinics inBydgoszcz including demographic and environmentalfactors.MATERIAL AND METHODS119 patients of the Geriatric Outpatient Clinic at drA. Jurasz University Hospital No. 1 in Bydgoszcz andpatients of district outpatient clinics in Bydgoszcz wereinvolved in the study. For the study there werequalified people aged between 60 – 80 living inKujawsko-Pomorskie Province, capable of independentfunctioning in everyday life in accordance with theLawton Instrumental Activities of Daily Living Scale,without mental dexterity disorders coexisting withstupor, according to Minimental State Examination[4,5]. Quality of life study was conducted by means ofWHOQOL-BREF Questionnaire in the Polish languageversion, developed under the supervision of LauraWałowicka and KrystynaJaracz [6]. WHOQOL-BREFQuestionnaire consists of 26 questions which providequality of life assessment in the following four fields oflife: physical health, psychological health, socialrelations and environment. A higher number of pointsobtained when using WHOQOL-BREF Questionnaireproves a better quality of life of those involved in thestudy.RESULTSThe study involved 119 people, including 81(68.1%) women and 38 (31.9%) men. The average ageof those involved in the study was 67.7 ± 5.6. Most ofthem came from the city (95%). 12.6% of the personsinvolved in the study had primary education, 27.7%had vocational education, 39.5% had secondaryeducation whereas 20.2% had university education. Asfar as marital status is concerned, 61.3% of thoseinvolved in the study were married, 31.9% werewidowed, and there were also 3.4% of the divorced andsimilarly 3.4% of singles. Among those involved in thestudy, 73.1% live with their family while 26.9% livedalone. For the purpose of cognitive functions

The quality of life of patients over 60 including demographic and environmental factors 121assessment there was applied a brief screening toolMini-Mental State Examination. The average numberof points obtained by the people involved in the studywas 28.09 ± 1.41. Cognitive disorders without stuporwere recognised in 16 people (13.4%). The rest ofthem (86.6%) achieved a correct result. The LawtonInstrumental Activities of Daily Living Scale wasapplied to make an assessment of possibilities ofindependent functioning in daily living. All the peopleinvolved in the study were independent in terms ofbeing able to perform complex everyday activities. Theaverage number of obtained points was 26.57 ± 0.95.The quality of life of those involved in the study wasestimated by means of WHOQOL-BREFQuestionnaire. The estimation was made within thefollowing four areas: physical health, psychologicalarea, social relations and environment. The best qualityof life among the individuals involved in the study wasobserved in the psychological area (15.32 ± 1.93points) whereas the worst quality of life was in thephysical area (13.99 ± 2.13 points). Average scoresobtained by those involved in the study in the physicaland psychological area, relations and environment canbe found in table 1. When assessing the influence ofdemographic and environmental factors on theoutcome of WHOQOL-BREF Questionnaire thefollowing were considered: sex, marital status,education, residence (alone, with family). Detailedresults can be found in tables 2, 3, 4 and 5. Sex, maritalstatus, education and residence do not affect the qualityof life of the individuals involved in the study asregards the physical and psychological area.Statistically significant differences were noticed in thefield of social relations between women and men(p=0.0421) as well as between married people andthose widowed (p=0.0185). As far as the area ofenvironment is concerned, statistically significantdifferences were observed between those withvocational education and those with universityeducation (p=0.0015).Table I. Average score in selected groups obtained accordingto the WHOQOL-BREF QuestionnaireTabela I. Średnia liczba punktów w poszczególnychdziedzinach uzyskana w kwestionariuszuWHOQOL-BREFFields of lifeDziedzinaŚrednia ± SDAverage ±SDStudy groupGrupa badanaMin. Maks.Minimum MaximumPhysicalFizyczna13,99 ± 2,13 8,00 19,43PsychologicalPsychologiczna15,32 ± 1,93 10,67 19,33Social relationsRelacje 14,41 ± 2,11 9,33 18,67społeczneEnvironmentŚrodowisko14,16 ± 2,15 8,50 18,00SD – standard deviationTable II. Average score in selected groups according toWHOQOL-BREF Questionnaire depending on sexTabela II. Średnia liczba punktów w poszczególnychdziedzinach kwestionariusza WHOQOL-BREFw zależności od płciWomenKobietyNPhysicaldisciplineDziedzinafizycznaŚrednia ± SDAverage±SDPsychologicaldisciplineDziedzinapsychologicznaŚrednia ± SDAverage±SDSocial relationsdiscipline EnvironmentdisciplineDziedzina relacji Dziedzina środowiskospołecznychŚrednia ± SDAverage±SDŚrednia ± SDAverage±SD81 13,90 ± 2,04 15,13 ± 1,98 14,14 1 ± 2,19 14,11 ± 2,18MenMężczyźni 38 14,18 ± 2,32 15,72 ± 1,76 14,982 ± 1,85 14,25 ± 2,12SD – standard deviation1-2 statistically significant difference p=0.04211-2 różnica istotna statystycznie p=0,0421Table III. Average score in selected groups according toWHOQOL-BREF Questionnaire depending onmarital statusTabela III. Średnia liczba punktów w poszczególnychdziedzinach kwestionariusza WHOQOL-BREFw zależności od stanu cywilnegoInconnectionW związkuWidowersWdowcyPhysicaldisciplineDziedzinafizycznaŚrednia ± SDNAverage±SDSocial relationsPsychologicaldiscipline disciplineDziedzina psychologiczna Dziedzina relacjispołecznychŚrednia ± SDAverage±SDŚrednia ± SDAverage±SDEnvironmentdisciplineDziedzina środowiskoŚrednia ± SDAverage±SD73 13,90 ± 2,07 15,47 ± 1,77 14,83 1 ± 2,02 13,98 ± 2,0238 14,26 ± 2,25 15,30 ± 2,16 13,86 2 ± 2,05 14,65 ± 2,19DivorcedRozwiedzeniUnmarriedStanuwolnego4 13,57 ± 2,40 14,17 ± 1,91 12,67 ± 3,17 12,38 ± 3,424 13,43 ± 2,40 13,83 ± 2,06 13,67 ± 1,68 14,50 ± 2,16SD – standard deviation1-2 statistically significant difference p=0.01851-2 różnica istotna statystycznie p=0,0185

122Anna Grzanka-Tykwińska et. al.Table IV. Average score in selected groups according toWHOQOL-BREF depending on educationTabela IV. Średnia liczba punktów w poszczególnychdziedzinach kwestionariusza WHOQOL-BREFw zależności od wykształceniaEducationWykształcenieBasicPodstawoweVocationalZawodoweMediumŚrednieNPhysicaldisciplineDziedzinafizycznaŚrednia ± SDAverage±SDPsychological SocialdisciplineDziedzinapsychologicznaŚrednia ± SDAverage±SDrelationsdisciplineDziedzina relacjispołecznychŚrednia ± SDAverage±SDEnvironmentdisciplineDziedzinaśrodowiskoŚrednia ± SDAverage±SD15 13,52 ± 2,24 15,42 ± 2,56 14,22 ± 2,18 14,83 ± 1,8533 13,94 ± 2,12 15,29 ± 1,78 14,87 ± 2,11 13,23 1 ± 2,0647 13,76 ± 2,00 15,09 ± 1,83 14,33 ± 2,20 13,94 ± 2,09Higher24 14,81 ± 2,22 15,72 ± 1,94 14,06 ± 1,93 15,44 2 ± 1,91WyższeSD – standard deviation1-2 różnicaistotnastatystycznie p=0,00151-2 statistically significant difference p=0.0015Table V. Average score in selected groups according toWHOQOL-BREF depending on residenceTabela V. Średnia liczba punktów w poszczególnychdziedzinach kwestionariusza WHOQOL-BREFw zależności od miejsca zamieszkaniaWihfamilyZ rodzinąNPhysicaldisciplineDziedzinafizycznaŚrednia ±SDAverage±SDPsychological SocialdisciplineDziedzinapsychologicznaŚrednia ± SDAverage±SDrelationsdisciplineDziedzina relacjispołecznychŚrednia ±SDAverage±SDEnvironmentdisciplineDziedzinaśrodowiskoŚrednia ±SDAverage±SD87 13,95 ± 2,09 15,30 ± 1,86 14,56 ± 2,10 14,05 ± 2,05Alone32 14,11 ± 2,25 15,38 ± 2,13 14,00 ± 2,14 14,44 ± 2,41SamotnieSD – standard deviationDISCOURSEThe population of older people does not comprise ahomogenous group. Pędich et al. divided thecommunity of older people according to their healthcondition and level of independence into four groups:independent and able-bodied individuals, individualswith minor diseases, chronically ill and bed-ridden [7].This study involved people able to function in theirdomestic environment on their own according to IADLLawton scale. However, the group of older people canbe distinguished not only by their health condition andindependence level but also marital status, sex oreducation. These factors may have influence on thequality of life assessment. Under this study the qualityof life was estimated in the physical and psychologicalareas, social relations and environment. Statisticallysignificant differences including demographic andenvironmental factors were determined only in the areaof social relations and environment. As regards socialrelations, statistically significant differences wereobserved between women and men (p=0.0421) andbetween those married and those widowed (p=0.0185).As far as environment is concerned, statisticallysignificant differences were recognized betweenindividuals with vocational education and withuniversity education (p=0.0015). The area ofenvironment consists of financial resources, recreationand relaxation, as well as access to information and thechance of gaining new skills. Thus, education mayaffect the general social position which is connectedwith a better economic situation, prestige or thepossibility of self-realizing. The study analysis in termsof demographic and environmental factors revealedthat widowed people achieved lower scores as regardsthe quality of life in the field of social relations thanthose married. According to other authors, the qualityof life and frame of mind in older people are affectedby marital status and close relations with family andfriends [8, 9, 10, and 11]. Meaningful as it appears tobe was sex in the quality of life as regards the area ofsocial relations. As opposed to men, women gaveworse assessment to quality of their life in the area ofsocial relations. Perhaps this results from social rolesperformed by women as well as their biggercontribution to close relations with others. As it resultsfrom the observation of other authors, older women aremore eager to participate in forms of activitiesconnected with frequent social contacts such asattending courses organized by the University of theThird Age [12, 13].CONCLUSIONS1. The highest assessment of the quality of lifewas observed in patients in the psychologicalarea whereas the lowest one was in thephysical area.2. Women assess the quality of life worse thanmen as regards social relations. This mightresult from their bigger need for interpersonalcontacts and membership in a group.3. As regards social relations, widowedindividuals assess their quality of life worsethan married individuals. Marital status mayhave an influence on quality of lifeassessment in the area of social relations.4. As far as environment is concerned, peoplewith university education give a morefavourable assessment of their quality of lifethan those with vocational education.

The quality of life of patients over 60 including demographic and environmental factors 123BIBLIOGRAPHY:1. Zarzeczna-Baran M., Słodkowska D.: Sytuacja społecznaseniorów a dostępność usług medycznych. ZdrPubl 2004;114: 502-507.2. Zielińska-Więczkowska H., Kędziora-Kornatowska K.:Starość jako wyzwanie. Gerontol Pol 2008; 16: 131-136.3. Depp C.A., Jeste D.V.: Definitions and predictors ofsuccessful aging: a comprehensive review of largerquantitative studies. Am J Geriatr Psychiatry 2006; 14: 6-20.4. Lawton M.P., Brody E.M.: Assessment of older people:Self-maintaining and instrumental activities of dailyliving. Gerontologist 1969; 9:179-186.5. Matczak A. (red.): Krótka Skala Oceny StanuUmysłowego. Przewodnik Kliniczny. Pracownia TestówPsychologicznych. Warszawa 2009: 7-16.6. Jaracz K., Wołowicka L.: Polska wersja WHOQOL-100 iWHOQOL BFER (red.): Jaracz K., Wołowicka L.:Jakość życia w naukach medycznych. WydawnictwoAkademii Medycznej w Poznaniu, Poznań 2001: 235-281.7. Błachnio A.: Pytanie o jakość życia w kontekścierozważań nad naturą starości. W: Obuchowski K. (red.):Starość i osobowość. Wyd. Akademii Bydgoskiej,Bydgoszcz 2002: 13-49.8. Antonucci T.C., Lansford J.E., Akiyama H.: Impact ofpositive and vegative aspects of marital relationships andfriendships on well-being of older adults. AppliedDevelopmental Science 2001; 5: 68-75.9. Makara-Studzińska M., Zaborska A.: Samotność wśródosób starszych. Porównanie międzykulturowe. ZdrPubl2006; 116: 619-622.10. Nocon A., Pearson M.: The roles of friends andneighbours in providing support for older people. Ageing& Society 2000; 20: 341-367.11. Peters A., Liefbroer A. C.: Beyond Marital Status:Partner History and Well-Being in Old Age. Journal ofMarriage and Family 1997; 59: 687-699.12. Lubryczyńska K.: Warszawskie uniwersytety trzeciegowieku. E-mentor 2005; 9: 89-92.13. Ziębińska B. Uniwersytety Trzeciego Wieku jakoinstytucje przeciwdziałające marginalizacji osóbstarszych.http:////www.sbc.org.pl/Content/7028/doktorat2757.pdf.Address for correspondence:mgr AlicjaRzepkaDepartment of and Clinic of Geriatricsof the Nicolaus Copernicus University in ToruńCollegium Medicum in Bydgoszcz85-094 BydgoszczM. Curie-Skłodowskiej 9 StreetTel/fax (052)-585-49-00e-mail:Alicja_Rzepka@vp.plReceived: 10.01.2012Accepted for publication: 6.03.2012Projekt jest współfinansowany przez UnięEuropejską z Europejskiego Funduszu Społecznegooraz Budżetu Państwa w ramach ZintegrowanegoProgramu Operacyjnego Rozwoju Regionalnego

Medical and Biological Sciences, 2012, 26/1, 125-131Beata Haor, Kamila Korniluk, Mirosława Felsmann, Marzena HumańskaTASKS OF A NURSE IN SENIORS’ PREPARATION FOR SELF-CAREIN THE COURSE OF TYPE 2 DIABETESZADANIA PIELĘGNIARKI W PRZYGOTOWANIU DO SAMOOPIEKI SENIORÓWW PRZEBIEGU CUKRZYCY TYPU 2Department of Pedagogy and Nursing Didactics, Nicolaus Copernicus University in ToruńCollegium Medicum in BydgoszczHead: Mirosława Felsmann, MD PhDSummaryI n t r o d u c t i o n . The key for a successful therapy ofthe diabetes is patients’education, aiming at optimisation ofthe patient’s quality of life and preparation for self-care. Anurse actively participates in that process.T h e t h e s i s aims at analysing tasks performed bynurses in preparation of seniors suffering from diabetes forself-care in the context of behaviour, they present in thecourse of the disease.Materials and methods. The research wasconducted in 2011 on a group of 60 persons at the age ≥65.The method of diagnostic sound with the use of aquestionnaire was applied. The statistical analysis was usedto check, if there were any differences or correlationsbetween behaviour of seniors with diabetes in the field ofself-care and their gender, age, place of residence, andeducation. The statistically significant results of theperformed tests were those results, in which co-efficient p

126Beata Haor et. al.INTRODUCTIONDiabetes is a metabolic disorder known as early asin the ancient times [1]. At present, it is among bothsocial and civilisation diseases. It refers to people of allraces, on all continents and it can appear at any age. Inthe last decades of the 20 th century and in thebeginning of 21century, a systematic increase innumber of new cases was registered. It has beenassumed that there are about 150 million peoplesuffering from diabetes in the world now. According toinformation from WHO, till 2025 the number ofpatients will have increased even to 380 millions. It isclosely related to the fact that the society is growingolder, obese, used to sedentary lifestyle and incorrectdietary habits [2,10]. Age makes an important factor ofthe risk of diabetes. Development peak of type 2diabetes is observed about the age of 60. In theresearchers’ opinion, per cent of patients in apopulation of people older than 65 oscillates between20% and 40% [3].In Poland, there are about 2 million peoplesuffering from diabetes, which makes about 5% of thepopulation [4]. In addition, about 10% of thepopulation, i.e. nearly 4 million people suffer fromimpaired glucose tolerance, whereas in older people,type 2 of the disease appears in every fifth or sixthperson. In Europe, diabetes appears in about 10-30% ofthe population in old age. Treatment of the disease andits complications makes one of the main problems ofhealth care in medical, as well as social and economicrespect [4,5].In spite of huge progress in therapy, at the time being,diabetes is still an incurable disease. The key forsuccess in therapy of this disease is diabetes education.Educating patients in the field of self-care andengagement in the process of curing makes the mostimportant part of the therapy [5]. According torecommendations of the Polish Diabetes Association,therapeutic education in regard to adult persons withdiabetes shall be realised during each visit [6]. Effectsof that therapy depend mainly on the completeengagement of the patient and his attitude toward thedisease. Within the course of the disease, the care isrendered by inter-disciplinary team of professionals.Specific tasks refer to the nurse, who, due to the fact offrequent contacts with the patient, plays a crucial rolein preparation of the patient for self-control and selfcare.Educating patients who suffer from diabetesimposes on her a duty of having substantial knowledgeof the subject. For that reason, she should take care ofher own professional development in order to gain orimprove her abilities in the field of preparing patientswith diabetes for care in the course of the disease. It isimportant to recognise the scope of deficiency of selfcarein a person under her care and prepare that personfor self-control and self-care by motivating them toacting for the benefit of one’s own health. Education ismainly aiming at e.g. preparation of the patient forimplementation of an appropriate diet and physicalactivity, evaluation of one’s own health throughobservation, measurements, registering andinterpretation of results [5,7]. Contents and a form ofhealth education shall be adjusted to both gender, age,and education of the patient [2]. Important informationshall be conveyed many times and verified during eachmeeting [7]. Also the family or curators of the patientshall be involved in educational program, especially incase of elder persons, which are not fully able tocontrol themselves at all times, [2,7].The survey aims at analysing tasks of nurses inpreparation of seniors with diabetes for self-care in thecontext of present manners which they present in thecourse of the disease.MATERIALS AND METHODSThe research was conducted in 2011 on a group of60 persons at the age ≥65, hospitalised in theDepartment of Internal Diseases of the Self-DependentPublic Heath Care Institution in Człuchów on a basisof a previous consent of the respondents and Directorof the above-mentioned institution, as well as theCommittee of Bioethics, of the Collegium Medicum inBydgoszcz. In the statistical analysis it was checked ifthere are any differences or correlations betweenseniors’ manners in the field of self-care in the courseof diabetes, and such socio-demographic variables, asgender, age, place of residence and education ofpatients under research. Comparing two independenttests (with regard to gender and place of residence ofthe respondents), Mann-Whitney U test was applied.When analysing results of the test in reference to theage and education of seniors, Spearman’s rankcorrelation test was used. The statistically significantresults of the performed tests were those of co-efficientp

Tasks of a nurse in seniors' preparation for self-care in the course of type 2 diabetes 127character. The basic part of the questionnaire consistedof 27 questions and it referred to manners in the fieldof self-care presented by seniors in the course of type 2diabetes.RESULTSAmong 60 respondents, women made 71.7%, andmen 28.3%. The biggest group consisted of seniorsaged between 71 and 80 (50% of persons underresearch). Persons at the age of 65-70 constituted 20%,and patients above 81 – 30% of the respondents. More,than a half of the researched persons (55%) lived incities, and 45% came from the countryside. Majority ofthe respondents (53.3%) had the professional educationand 18.3% - secondary education. 28.3% claimed tohave primary education. Among the researchedpersons, there were no university graduates. A largegroup of women (46.4%) and men (58.8%) claimedthat they had been suffering from diabetes for 6-10years whereas within the last 5 years, the disease wasrecognised at 39.5% of women, and 23.5% of men.Diabetes recognised within the last 11-20 yearsreferred to 17.6% of men and 11.6% of women. Only 1woman stated that the disease had been recognised inher case more than 21 years ago.Both gender and the place of residence did not havemuch influence on the self-evaluation of seniors in thefield of the preparation for self-care in the course ofdiabetes. More than a half of seniors (women- 53.5%,men -52.9%) determined their self-dependence in thefield of care rendered in relation to the disease atsatisfactory level. Men (70.6%) more often thanwomen (48.8%) stated that their family was alsoinvolved in the process of preparation for self-care.Seniors significantly more often pointed to theemployees of the hospital – the nurse and the doctor -as persons preparing them for self-dependent care inrelation to diagnosing diabetes, which is shown in tableI. Nevertheless, women more often stressedparticipation of the nurse in such activities (62.8%),whereas men – of the doctor (41.2%).Inhabitants of cities (57.6%) significantly moreoften (p=0.019) declared systematic visits of aspecialist in a diabetes outpatient clinic thaninhabitants of the countryside, who in a large part(77.8%) did not make use of such visits. Seniors fromcities also more often proved to have the knowledge ofthe usage of an injection pen and appropriate storage ofinsulin (p=0.047), as well as knowledge of reasons forhypo- and hyperglycaemia (p=0.023).Table I. Professionals preparing seniors for self-care inrelation to diagnosing diabetesTab. I. Profesjonaliści przygotowujący seniorów dosamoopieki w związku z rozpoznaniem cukrzycyProfessionalspreparing seniors forself-care in relationto diagnosing thediseaseProfesjonaliściprzygotowującyseniorów dosamoopieki wzwiązkuz rozpoznaniemchorobyFamily doctorLekarz rodzinnyDoctor in a hospitalLekarz w szpitaluNurse in a hospitalPielęgniarka wszpitaluFamily nursePielęgniarkarodzinnaTotalRazemWomenKobietyMenMężczyźnin % n %4 9.3 5 29.411 25.6 7 41.227 62.8 5 29.41 2.3 0 0.043 100.0 17 100.0p0.016Age significantly influenced the scope of selfdependenceof seniors in the field of care in the courseof diabetes. Majority of the respondents between age of65 and 70 (83.3%) evaluated their preparation for selfcareas good one, whereas the satisfactory evaluationof these abilities was stated most often (p=0.000) byolder persons between the age of 71 and 80 (60%) andmore than 81 (77.8%). In the age groups of 65-70(75%) and of 71-80 (50%), respondents more often(p=0.028) made use of preparation for self-care inresult of educational activities performed byprofessionals with the use of information brochures, aswell as presentations and exercises. Persons older than81 (66.7%) preferred individual conversations with adoctor/nurse, connected with analysis of informationmaterials. Respondents at the age of 65-70,significantly more often confirmed making use ofregular visits in the diabetes outpatient clinic(p=0.049). They also had more detailed knowledge onreasons and the substance of the disease (p=0.002),correct values of the contents of glucose in blood(p=0.017), reasons for hypo- and hyperglycaemia(p=0.024). They also more often declared to have theability to make the measurements of glucose with theuse of glucometer by themselves (p=0.001), theknowledge of rules for controlling and taking care of

128Beata Haor et. al.the condition of feet in the course of the disease(p=0.025), obeying to the dietary rules in diabetes(p=0.004), the knowledge of activity of oralantidiabetic medicines (p=0.008).Education significantly influenced the scope ofpreparation of seniors for self-care in the course ofdiabetes. In their preparation for self-care, olderpersons having secondary professional education ,apart from self-dependent analysis of educationalmaterials on diabetes, significantly more often thanthose with primary education (p=0.011) pointed toconsulting of problems with a nurse/doctor.Independent on a type of school they graduated from,respondents more often (p=0.007) pointed toemployees of the hospital – a nurse and a doctor aspersons who prepared them for self-dependent care asa result of diagnosing diabetes, which is presented intable II. Nevertheless, the researched graduates ofprofessional schools and secondary schools more oftenstressed the participation of a nurse in such activities,while seniors with primary education – of a doctor.Table II. Participation of professionals in preparation ofseniors for self-care in the course of diabetesTab. II. Udział profesjonalistów w przygotowaniu seniorówdo samoopieki w przebiegu cukrzycyProfessionalspreparing ofseniors for selfcarein relation todiagnosing of thediseaseProfesjonaliściprzygotowującyseniorów dosamoopiekiw związkuz rozpoznaniemchorobyFamily doctorLekarz rodzinnyDoctor in ahospitalLekarz w szpitaluNurse in ahospitalPielęgniarka wszpitaluFamily nursePielęgniarkarodzinnaTotalRazemEducationWykształceniePrimaryPodstawoweProfessionalZawodoweSecondaryŚrednien % n % n %5 29.4 4 12.5 0 0.06 35.3 11 34.4 1 9.15 29.4 17 53.1 10 90.91 5.9 0 0.0 0 0.017 100.0 32 100.0 11 100.0p0.007Seniors with secondary education significantlymore often, than persons who graduated fromprofessional and primary schools, declared: runningself-control diary (p=0,030), knowledge of reasons andthe substance of the disease (p=0.003), ability tomeasure the level of glucose in blood with the use ofglucometer (p=0.016) without assistance of any otherperson. Moreover, they more often presented theknowledge of the diet recommendations in diabetes(p=0.002), the mechanism of activity of oralantidiabetic medicines (p=0.001) and insulin(p=0.005), the rules for correct dosing and storage ofinsulin (p=0.003), as well as techniques of makinginjection with a pen (p=0.002). Graduates of secondaryschools (81.8%) determined their level of abilities inthe field of self-care in the course of the disease asgood in comparison with satisfactory evaluation whichwas made by seniors with primary (76.5%) andprofessional education (56.3%). Respondents withsecondary (81.8%) and professional (56.3%) educationpreferred individual educational activities offered byprofessionals with the use of information brochures, aswell as presentations and exercises. Persons whograduated from a primary school (82.4%) stated thatthey only made use of individual conversations with anurse/a doctor, connected with analysis of informationmaterials in their preparation for self-care. Allgraduates of secondary schools (100%) declaredsystematic use of consultations in diabetologicaloutpatient clinic, as opposed to those with professionaleducation (40.6%) and primary education (5.9%).In a large part, seniors did not participate in grouptrainings on self-care in the course of diabetes. Onlyone woman with secondary education in the agecategory of 71-80, living in a city declaredparticipating in such educational activities. Whentalking about preparation for self-care in relation to thedisease, older persons declared self-analysis ofbrochures, leaflets as used more often than looking forexplanation of problems by a nurse/doctor. Selfeducationwas declared by most of the respondents,independent on gender (women – 60.5%, men –52.9%), age category (65-70 years old – 50.0%, 71-80years old – 60.0%, more, than 81 – 61.1%) and theinhabitants of the countryside (74.1%). Only thosepersons, who lived in cities (54.5%) more often soughtfor explanation of problems by a nurse/doctor, as a partof educational activities.Preparation of seniors for self-care in the course ofdiabetes was also realised by members of theirfamilies. Participation of the relatives in activities inthe field of diabetological education was more oftenconfirmed by men (70.6%) than women (48.8%), andpersons in very old age (71-80 years old – 63.3%,more, than 81 years old – 55.6%) in comparison toseniors in the age between 65 and 70. Participation ofthe members of the family in preparation for self-care

Tasks of a nurse in seniors' preparation for self-care in the course of type 2 diabetes 129was also more often stressed by inhabitants of cities(63.3%) than the countryside (44.4%) and patients withprofessional (65.6%) and secondary education (45.5%)rather than primary education (41.2%).DISCUSSIONTherapy in the course of type 2 diabetes shall becomplex and multi-sided. While selecting forms oftherapy and diabetological education, the primary aimis to provide the patient with the best possible qualityof life. It mainly refers to elderly persons, who make avery variegated group regarding the time of lasting ofthe disease, complications as well as the degree ofintellectual and physical ability [8, 9, 10].Diabetological education aiming at preparation ofthe patient for self-care should be implemented byprofessionals, both in the hospital environment,outpatient clinic, and the place of residence of thepatient. In the present research, seniors stressed theparticipation of a nurse and a doctor in education,especially in the process of hospitalization. The basicrole of a nurse in educational activities in the course ofdiabetes is also confirmed by results of the research ofB. Kosicka, realised among patients of the outpatientclinic and hospital in Lublin [11]. Significance of theparticipation of a nurse and a doctor in preparation forself-care is also proved by the results of the research ofA. Bocian et al., made among the patients withdiabetes in Łódź [12].Chronic character of the disease predisposes forappearance of therapeutic and care neglects which mayresult from the fact of e.g. lack of strong will at thepatient, dejection, impoverishment, and insufficientphysical and mental proficiency. The above-mentionedfactors cannot be always controlled by a nurse inrelation to preparation of the patient for self-care.Then, support from the relatives and co-operation withthe family members in the process of health educationis just necessary [13]. In the current research, seniorspointed to participation of their relatives in educationalactivities. Respondents evaluated their abilities ofliving with the disease as satisfactory or good ones.Stronger engagement of the family in therapeuticeducation of older persons with diabetes could makethe basis for optimisation of their life in the course ofthe disease and encourage them to make higher selfevaluationof the preparation for self-care. Similarobservations referring to participation of the relativesin educational activities were cited by A. Bocian et al.in their research [12]. A number of the researches inthe field of family medicine and intensive developmentof family nursing provide arguments, which stress thenecessity of taking up educational activities in thecourse of a chronic disease in co-operation with thefamily [14]. However, in the current research seniorspointed to a slight participation of a family nurse intherapeutic education. Similar results were presented inthe research of A. Bocian et al. [12]. The research of A.Kołtuniuk et al. realised among environmental/familynurses in the area of Dolnośląskie Province show thatthey had insufficient preparation for rendering care tothe patient with diabetes. They also expected moreengagement from the patient and his/her family inactivities related to self-care in the course of thedisease [15]. Consequently, it can make a significantpremise for appropriate preparation of nurses forrealisation of tasks in the field of diabetologicaleducation for the benefit of the patient with chronicdisease in the environment of his/her place ofresidence, which would add to optimisation of his/herquality of life.In the research, depending on advancement in age,seniors presented worse and worse self-evaluation ofpreparation for self-care and controlling of the courseof the disease. It may result from the advancement ofthe process of growing old which substantiallyinfluences functional ability in older people. It leads,among others, to intellectual deficiencies, the ability toperform activities in the field of self-care, whichadditionally interfere with late complications ofdiabetes and other co-existing diseases [16]. In theresearch, older persons, depending on advancement inage, more often pointed to self-dependent usage ofinformation materials referring to the disease and theywere prompt to make use of individual conversationswith a nurse on the subject of preparation for self-care.Proceeding deficiency of recent memory at a seniorshall make the nurse to formulate simple,understandable recommendations in a written formduring educational activities, and thoserecommendations shall undergo systematicverification. It is also necessary to motivate a patientand his/her family to actively participate in preparationfor self-care.The current research proves that higher educationallevel is related to the higher level of knowledge andabilities in seniors in the field of self-care and selfcontrolin the course of diabetes. The influence ofeducation on the degree of preparation for self-care in

130Beata Haor et. al.the course of a chronic disease was also confirmed bythe research of M. Kadłubowska et al. [17].CONCLUSIONSAnalysis of references and results of the researchallowed drawing the following conclusions:1. A nurse who prepares the senior for self-carein the course of diabetes shall include in herprogram of therapeutic education a number offactors, e.g. age advancement, education of apatient, support from the patient’s family,presence of co-existing diseases, andcomplications related to diabetes, functionalability, availability of specialist services in thefield of diabetological care, motivation, andfinancial abilities of the patient.2. Education of seniors clearly influencespreparation for self-care in the course of type2 diabetes; the higher the education is, thehigher level of knowledge and abilities in thefield of self-control and self-care in thedisease are.3. Preparation for self-care in seniors in thecourse of diabetes is also considerablyinfluenced by age of the patients. Old agepersons show difficulties in acquiringknowledge and abilities regarding self-care.4. Both gender and place of residence of seniorsdo not have much influence on the degree ofpreparation for self-care in the course of thedisease.5. Due to frequent contacts, a nurse plays animportant role in preparation ofa patient for self-control and self-care in thecourse of diabetes.6. In order to optimise the quality of life in thecourse of a chronic disease, (diabetes), in theirenvironment, seniors require systematic andplanned activities in the field of diabetologicaleducation, realised by a family/environmentalnurse, who is prepared on the merits of thecase.7. In her activities in the field of educationregarding preparation of an old person withdiabetes for self-care, a nurse should payattention to formulating simple,understandable recommendations in a writtenform, which shall be systematically verified. Itis also necessary to motivateaREFERENCESpatient and his/her family to activelyparticipate in preparation for self-care.1. Marzec A., Muszalik M.: Nursing proceedings towardsthe patient with type 2 diabetes. W: Biercewicz M.,Szewczyk M., Ślusarz R. (edit..): Nursing in geriatrics.Selected issues on specialised nursing. Edited by Borgis,Warsaw 2006: 79-94.2. Kalota M., Kurpas D.: A role of a nurse in education ofpatients with type 2 diabetes. W: Steciwko A., WojtalM., Żurawicka D.(edit.): Caring and clinical aspects oftaking care of the patients. Selected issues. Edited byContinuo, Wrocław 2008: 77-83.3. Koziarska-Rościszewska M.: Diabetes in older persons.W: Kostka T., Koziarska-Rościszewska M.: Diseases inold age. Medical Publishing House NMPH, Warsaw2009: 110.4. Tatoń J.: Diabetology tailored to the needs. MetabolicMedicine 2008, 12, 3: 8-12.5. Kadłubowska M., Bąk M., Kolonko J.: Knowledge ofnurses on diabetes disease and participation in trainingsin the field of diabetology. Problems in Nursing 2008, 16(3): 293-298.6. Grzeszczak W.: Clinical recommendations referring toproceedings in case of diabetes. 2011.Diabetology inpractice 2011, 12, supl. A: 7.7. Ruxer M., Ruxer J., Markuszewski L.: Therapeuticeducation as a method of treatment of diabetes. Clinicaland Experimental Diabetology 2005, 5,4: 253-259.8. Koziarska-Rościszewska M.: Diabetes in older persons.Diagnosis, treatment, prevention from complications.Publishing House Aktis, Łódź 2005.9. Sieradzki J. et al.: Clinical regulations referring toproceedings in case of patients with diabetes in 2010.Diabetology in Practice 2010, 11, suppl. A.10. Szelachowska M.: Diabetes. W:Daniluk J., Jurkowska G.(edit.): Outline of internal diseases for students ofnursing. Publishing House Czelej, Lublin 2005:514-528.11. Kosicka B., Wrońska I.: A role of a nurse in education ofpatients with diabetes. Problems of Nursing 2007, 15,2,3.12. Bocian A., Borowiak E., Matuszewska M. : Importanceof education of a patient with diabetes for promotion ofsalutogenic behaviour. W: Krajewska – Kułak E. et al.(edit): Therapeutic and nursing problems: from theconception to the old age. Volume II. Medical Academyin Białystok, Białystok 2007: 391-399.13. Dubiel E., Sobczyńska P., Kłys J.: Medical care on thepatient with type 2 diabetes. W: Rosińczuk-Tonderys J.,Uchmanowicz I.: The patient with chronic disease –nursing, rehabilitation and therapeutic aspects.MeadPharm Poland, Wrocław, 2011:281-289.14. Abramczyk A., Łopatyński J., Pruska W.: Diabetes as thesocial problem. Medical Academy in Wrocław, Wrocław2002.

Tasks of a nurse in seniors' preparation for self-care in the course of type 2 diabetes 13115. Kołtuniuk A., Płatosz J., Abramczyk A.: Preparation andexpectations of environmental/family nurses in the fieldof care over the patient with diabetes. W: The patientwith chronic disease – nursing, rehabilitation andtherapeutic aspects. MeadPharm Poland, Wrocław 2011:349-356.16. Grodzicki T., Kocemba J., Skalska A. (edit.):Gerontology with elements of general gerontology. ViaMedica, Gdańsk 2007.17. Bąk E., Kadłubowska M., Fraś M.: Influence of selfcontrolin diabetes on the time of appearance of diabeticnephropathy. Problems in Nursing 2009, 17 (2): 105–109.Address for correspondence:Beata HaorDepartment of Pedagogy and Nursing DidacticsNicolaus Copernicus University in ToruńL. Rydygier Collegium Medicum in Bydgoszcz85-801 Bydgoszcz3 Techników streettel. 52 585 21 93e-mail: beata.haor@interia.plReceived: 10.01.2012Accepted for publication: 6.03.2012

Medical and Biological Sciences, 2012, 26/1, 133-138Judyta Kutowska 1 , Małgorzata Gierszewska 2 , Estera Mieczkowska 2 , Grażyna Gebuza 2 , Marzena Kaźmierczak 2QUALITY OF LIFE AMONG WOMEN WITH GESTATIONAL DIABETES MELLITUSJAKOŚĆ ŻYCIA KOBIET Z CUKRZYCĄ CIĄŻOWĄ1 student of Nicolaus Copernicus University, Collegium Medicum in Bydgoszcz2 Department of Obstetric Care Basics, Nicolaus Copernicus University, Collegium Medicum in BydgoszczSummaryT h e a i m of this study was to evaluate the life qualitylevel among women who had diabetes diagnosed during theirpregnancy, and to define any changes related to a medicaltreatment of the disease. Another purpose was to indicate anumber of factors which have a considerable impact on thequality of life in the study group.Materials and methodology. The researchwas performed among 100 patients of the PregnancyPathology Department of the Obstetrics and GynecologyClinic in the University Hospital No. 2 in Bydgoszcz. Therewas a subjective assessment of patient’s life quality used inthe study, with a 10-points scale, where 1 means very bad’and 10 - a ‘very good’ life quality.Results. Subjective assessment of pregnant patient’slife quality was good. The average score was 6.9 points in the1 – 10 scale. Majority (69%) of women with gestationaldiabetes require application of a diet and insulin therapysimultaneously. Adapting to a new diet seems to be the mostdifficult for the patients. The less the patients know about thedisease, the lower level of life quality they indicate. 174% ofpregnant women, who applied insulin a few times a day,were not aware of insulin's function in their body.Conclusions:1. Quality of life among pregnant womensignificantly decreased after they fell ill withdiabetes.2. High quality of life was more frequently indicatedby women with a high sense of influence on thecourse of disease.3. Women suffering from gestational diabetes needmental support and thorough information due totheir emotional condition.StreszczenieCel pracy. Zamysłem pracy była ocena poziomujakości życia kobiet, u których w czasie ciąży rozpoznanocukrzycę oraz określenie jak się ona zmienia po rozpoczęciuleczenia choroby, a także wyodrębnienie grupy czynnikówwarunkujących jakość życia kobiet chorujących na cukrzycęciążową.Materiał i metodyka. Badanieprzeprowadzono wśród 100 pacjentek Oddziału PatologiiCiąży Katedry i Kliniki Położnictwa, Chorób Kobiecych iGinekologii Onkologicznej Szpitala Uniwerysteckiego nr 2im. J. Bizela w Bydgoszczy. W badaniu wykorzystanosubiektywną ocenę jakości życia ciężarnych nadziesięciopunktowej skali, na której 1 oznaczało złą, a 10bardzo dobrą jakość życia.Wyniki. Subiektywna ocena jakości życia kobietchorujących na cukrzycę ciążową jest dobra, średni poziomjakości życia wyniósł 6,9 pkt. w skali od 1 do 10. Większośćbadanych kobiet (69%) chorujących na cukrzycę ciążowąwymagało jednoczesnego zastosowania dieto- iinsulinoterapii. Najwięcej trudności sprawia pacjentkomdostosowanie się do nowych zaleceń dietetycznych. Kobietynisko oceniające swój poziom wiedzy na temat cukrzycywskazywały też na niższe oceny jakości życia.17,4% kobietciężarnych stosujących kilka razy w ciągu dnia insulinę niezna jej roli w organizmie.Wnioski:1. Jakość życia kobiet w ciąży istotnie obniżyła się pozachorowaniu na cukrzycę.2. Wysokie oceny jakości życia częściej występowałyu kobiet z wysokim poczuciem wpływu naprzebieg choroby.3. Kobiety z cukrzycą ciążową potrzebująpsychicznego wsparcia oraz rzetelnej informacji zuwagi na przeżywany stan emocjonalny.Key words life quality, gestational diabetesSłowa kluczowe: jakość życia, cukrzyca ciążowa

134Judyta Kutowska et. al.INTRODUCTIONIn recent years there has been an increase in thenumber of pregnant women with diabetes, both inPoland and worldwide. This is related to increasingnumber of people with diabetes and prolonged periodof procreation. Despite the fact that pregnancy is ashort period in women’s life, it may be complicated byany of the types of diabetes. In this heterogeneousgroup, women with diagnosed disorders ofcarbohydrate metabolism during pregnancy(gestational diabetes mellitus, GDM) constitute vastmajority In Poland, on average 4 out of 100 pregnantwomen suffer from gestational diabetes [1]. Althoughthe biochemical abnormalities are often small, it is areal threat to the mother and fetus. The presenceof diabetes during pregnancy predisposes women andtheir children to reveal a disorder of carbohydratemetabolism in the future.Actually More and more attention is paid to thepsychological situation of patients with diabetes,especially their attitude towards the disease and howthe disease has changed their lives. Psychologicalsituation of women suffering from gestational diabetesis an extremely complex issue. Pregnant woman,expecting the birth of a child, who has been diagnosedwith diabetes, is accompanied by contradictoryfeelings: happiness and expectations on one hand,uncertainty and fear on the other. In women diagnosedwith diabetes, a feeling of fulfillment is interfered bythe fear of pregnancy and child health. The knowledgeabout diabetes that pregnant women have to get fromthe basics and providing satisfactory glycemic controlrequire strong commitment and many sacrifices.Suddenly, the woman who has diagnosed with diabetesis forced to follow the treatment in the form of:systematic and frequent measurements of blood sugar,following the recommendations regarding diet andexercise, and often - the insulin.The term, which is related to the assessment of thissituation, is the ‘quality of life’ (QoL). It determinesphysical and mental well-being, life satisfaction,realization of expectations and desires in relation toone’s own life. For the purposes of this article the mostuseful definition is that quality of life is an’individually perceived satisfaction due to meet theneeds of a given period’ [2]. The assessment of qualityof life includes: physical, mental and social well-being.Pregnant women have many difficulties in evaluationof the first two components of quality of life, due to thepresence of typical gestation period changes in theseareas. Physical and mental condition in pregnancy islargely determined by the period of pregnancy, inwhich currently a woman is. The dominant feature ofthe well-being during pregnancy, and therefore oftenperceived mental and physical [3], is very largevariability throughout the entire pregnancy.In the literature there are a number of generalconsiderations about the quality of life among patientswith diabetes, but there is still insufficient empiricalevidence reported in this area. There are no studies thatshow level of the quality of life of women withgestational diabetes mellitus. This is followed by thefact that the problems of women suffering from GDMare little known and rarely discussed; attention isfocused on the pregnancy and baby. According tosome, disease affects only the period of pregnancy; theproblems associated with it end at the time of birth orshortly afterwards, and the risk of complicationsoccurring later. In addition, symptoms of diabetesdiagnosed in pregnancy are smaller and intertwinedwith other ailments common in pregnant women.The intention of this study was to assess the qualityof life among women with diabetes diagnosed duringpregnancy, and to determine how it changes afterinitiation of treatment, as well as the indications offactors determining quality of life of women sufferingfrom gestational diabetes.MATERIAL AND METHODSThe study was conducted among 100 women withgestational diabetes residing in the Pathology ofPregnancy Department of J. Bizel Hospital inBydgoszcz. Patients were included to the study aftercompleting education on diet, physical activity,measurement of blood glucose, insulin administration(if necessary), not earlier than one week afterthe diagnosis of gestational diabetes, on average, in thetenth week of treatment of GDM. To determine thelevel of quality of life we used subjective assessmentof quality of life for pregnant women, the 10-pointscale where 1 meant a poor, and 10 – a very goodquality of life. For the analysis of factors determiningquality of life of women suffering from gestationaldiabetes we used Short Method of Assessment the

Quality of life among women with gestational diabetes mellitus 135Sense of Impact on Diseases Course, and a surveycourse of own design which takes into account thesituations of pregnancy that may correlate with thelevel of quality of life.RESULTSAssuming 5 points as the boundary level of bad andgood quality of life it can be concluded that the level ofQoL among women with gestational diabetes is good,because 71% of pregnant women rated the QoL withmore than 5 points on the 1-10 points scale. Everyfourth woman found that the quality of life is high byindicating 9 and 10 points on that scale. Table Icontains basic data about the studied population.treatment to the level of 6.9 points. 62 women reportedthat their quality of life decreased after diagnosis ofdiabetes and initiation of treatment, it was a largedecrease in most cases (an average of 2.55 points.).The number of high ratings of quality of life (9 and 10points) lowers drastically. Before the disease morethan a half of pregnant women (59%) assessed theirquality of life as high, while after the diagnosis thispercentage dropped to 25%. Therefore, the number oflow scores (≤ 5 pts.) rose from 9% to 29%. Summaryof QoL ratings before and after diagnosis of GDM isshown in the figure 1.Table I. Characteristics of the study groupTabela I. Charakterystyka badanej grupyPodstawowe dane populacji badanej (n=100)Basic data concerning the studied population (No.=100)30,9 lat /yearsWiek /age(min. 18, max.47)WykształcenieEducationMiejscezamieszkaniaPlace ofresidencewyższe /higher 38 %średnie /secondary 40 %zawodowe /vocational 18 %podstawowe /primary 4 %miasto >100 tys. /city >100thousand inhabitants35 %miasto

136Judyta Kutowska et. al.The difficulty level was calculated as the sum of thefive variables and then was subjected to normalization- brought to the scale of "0-1", where 0 indicatescomplete lack of difficulty (corresponding to a zerosum),and 1 - the highest level of difficulty (whichcorrespondent to sum of 25) (Fig. 2). From the analysisof variables in diabetes-related nuisance, the highestaverage numbers were given to the diet and mealplanning. It is the most troublesome element of thetherapy for either diet therapy alone and the combineddiet and insulin therapy. Self-monitoring of bloodglucose using a glucometer received the lowestaverage, showing the smallest nuisance. It should benoted that the assessment of the difficulty of measuringblood sugar levels, depending on the applied method oftreatment, varied significantly. For women treated withinsulin it was a bit more problematic task than forthose treated only with a diet. Probably the differenceobserved in the evaluation results from a number ofglucose measurements for patients treated with insulin;they also perform measurements during night.women suffering from gestational diabetes with a lowsense of influence on the course of the disease. This isa statistically significant relationship (p

Quality of life among women with gestational diabetes mellitus 137convinced of the need for only periodic injectionsbecause of the welfare of the child, have fewerproblems with the achievement of good control [5].Sense of security in nearly half the women (49%)declined after the diagnosis of GDM. Safety is afundamental human need, hollowness it makesimpossible the implementation of other needs, and alsohinders the development. In Maslow's hierarchy ofneeds, safety is the second most important humanneed, after the physiological needs like hunger andthirst. Security, in terms of a dictionary definition, is‘condition of no-threat, serenity, confidence’ [6].Pregnancy complicated by diabetes means three timesgreater risk of pregnancy complications than aphysiological process. Additionally, in the case ofabnormal metabolic control, risk of complicationsincreases tenfold [5]. Awareness of potentialcomplications threatening to women and their childrenentails anxiety and tension. According to Beisert andSęk, each hospitalization is stress. Particular care ofwomen with gestational diabetes may be understood asconfirmation of the risk. Assumption of failure canpotentiate anxiety, and this makes it difficult to treat.A sense of control over the disease is an importantfactor influencing the mood of patients and theirfunctioning. In the study of Langer et al. showed thatgood adaptation to the disease promotes wellcontrolleddiabetes [7]. However, Persily noted thatthe adaptation to the disease affects the way it isperceived by the patient. Women suffering fromgestational diabetes, as the disease affecting their lives,have problems to come to introduce the changesneeded to treat, and it is a simple way to complications[7].Adjustments to the new dietary recommendationsconstitute most difficulties to the patients. Statisticallysignificantly they, more often than other nuisance(measurement of blood glucose, frequent medicalchecks, treatment with insulin), indicated diet as themost troublesome. Similar results obtained Fałkowskaet al., conducted in 2004 among a group of 42 womenwith gestational diabetes. These studies indicate that asmall number of women with gestational diabetes,despite the existence of the disease, apply a diabeticdiet (7.14%) [8]. According to research conducted byBandurksą-Stankiewicz et al. in 2005 in a group of 81pregnant women with diabetes (both before pregnancyand gestational), difficulties in accepting the newdietary recommendations had especially those patients,which previous dietary habits differed considerablyfrom those recommended in diabetes, and morepregnant with abnormal body weight [5].To conclude, it must be emphasized that goodhealth does not guarantee a high level of quality of life.Quality of life among patients suffering from GDMshould always be closely related to pregnancy, itscourse and the past experience of women with previouspregnancies.CONCLUSIONS1. Subjective assessment of quality of life ofwomen suffering from gestational diabetes isgood.2. A small percentage (6%) of low opinion ofQoL in pregnant women with diabetesdiagnosed during pregnancy was observed.3. Quality of life of pregnant womensignificantly reduced after falling ill withdiabetes.4. An adjustment to the new dietaryrecommendations is most difficult for thepatients.5. The high quality of life occurs more commonin women with a high sense of influence onthe course of the disease.6. Women with gestational diabetes needpsychological support and reliableinformation because of their emotional state.REFERENCES1. Cypryk K.: Ocena klinicznej wartości dotychczasstosowanych metod i propozycja własnego modeludiagnostyki cukrzycy ciążowej. Diabetol. Pol. 2002, 1:3-642. Fałkowska J., Fórmaniak J., Gierszewska M. i wsp.:Jakość życia kobiet operowanych z powodu raka szyjkimacicy. w: Grabiec M. (red.) Intedyscyplinarnywymiar promocji zdrowia rodziny. Wyd. Scrypt,Bydgoszcz 2008, 287-3003. Sobol E. (red.) Mały słownik języka polskiego. Wyd.PWN, Warszawa 1996, 11974. Grabowska-Fudala B.: Samokontrola a jakość życiadzieci z cukrzycą typu I. Pielęgniarstwo Polskie2004,1-2: 83-915. Bandura- Stankiewicz E., Wańczyk A.: Edukacjaterapeutyczna kobiet z cukrzycą przedciążową iciężarnych leczona insuliną. Medycyna Metaboliczna,2006, 4: 40- 446. Szymczak M. (red.) Słownik języka polskiego T. I,Wyd. PWN, Warszawa 1978, s. 147

138Judyta Kutowska et. al.7. Bielawska- Batorowicz E., Cypryk K., Pawełczyk A:Cukrzyca ciążowa i jej wpływ na psychicznefunkcjonowanie kobiety. Diabetologia Polska. 1999, 3:227- 231Address for correspondence:Judyta Kutowskaul. Młyńska 17A86-122 Bukowiec,tel. 888 490 558e-mail: judytakutowska@wp.plReceived: 10.01.2012Accepted for publication: 6.03.2012

Medical and Biological Sciences, 2012, 26/1, 139-142Magdalena Mińko 1 , Dorota Siwczyńska 2BREAST CANCER PREVENTION AS A PART OF HEALTH POLICY ACTIVITIESIN LUBLIN PROVINCEPROFILAKTYKA RAKA PIERSI JAKO ELEMENT DZIAŁAŃ Z ZAKRESU POLITYKIZDROWOTNEJ W WOJEWÓDZTWIE LUBELSKIM1. Medical University of Warsaw2. Students Research Group of Public Health Department, Medical University of LublinProf. dr hab. n. med. Teresa B. KulikSummaryI n t r o d u c t i o n . Breast cancer is the most commonmalignancy tumour and it constitutes more than 20% of allcases of cancer among Polish women. Despite the prevalenceof many risk factors for breast cancer and negative statisticson morbidity and mortality of women in Poland, in the recentyears a number of actions, which have a positive influence onthis situation, have been observed. One of them is theprevention programs, which often save health and lives ofwomen.The aim of this study was to evaluate theeffectiveness of prevention programs for breast cancer in theLublin Macroregion.Material and method. Analysis of theprevention programs reports for breast cancer in 2007, 2008and 2010 provided by the Regional Centre of OccupationalMedicine in Lublin was the research method. Screening testscarried out during the above years covered a total of 3479women.R e s u l t s . The mostly studied group of women wasladies between 40-49 years old, who gave birth before theage of 30 years at least once. On average, 53% of the studiedwomen regularly performed breast self-examination. Duringmammography 64% of women were described as ‘in norm’,0.8% of women were diagnosed with suspected cancer, whilein the remaining participants of the study there were mildchanges found. They have been referred for further diagnosis.C o n c l u s i o n . There is still a request for continuedprevention programs, especially among women aged 40-49years. A request for education in the health prevention field(in theoretical and practical meaning) has also been observed.The percentage of morbidity and mortality from breast cancerin the Lublin Macroregion has decreased in the recent years.StreszczenieWstę p . Rak piersi jest najczęściej występującymnowotworem złośliwym u kobiet i stanowi aż 20%wszystkich zachorowań na nowotwory złośliwe wśród Polek.Pomimo występowania wielu czynników ryzyka raka piersi iniekorzystnych statystyk dotyczących zapadalnościi umieralności kobiet w Polsce, w ostatnich latach obserwujesię wiele działań wpływających pozytywnie na tę sytuację.Jednym z nich są programy profilaktyczne, któreniejednokrotnie ratują zdrowie i życie kobiet.Celem pracy było dokonanie oceny skutecznościrealizowanych programów profilaktycznych dotyczącychraka piersi w makroregionie lubelskim.Materiał i metoda. Metodą badawczą byłaanaliza sprawozdań z programów profilaktycznychdotyczących raka piersi w 2007, 2008 i 2010 r.udostępnionych przez Wojewódzki Ośrodek MedycynyPracy w Lublinie. Badaniami przesiewowymi na przestrzenitrzech badanych lat łącznie objęto 3479 kobiet.Wyniki. Najczęściej badaną grupą kobiet były paniepomiędzy 40-49 r.ż., które rodziły przynajmniej jeden razprzed ukończeniem 30 lat. Średnio 53% badanych kobietregularnie wykonywało samobadanie piersi. Normę wbadaniu mammograficznym uzyskało 64% kobiet, u 0,8%pań zdiagnozowano podejrzenie nowotworu, natomiast u

140Magdalena Mińko, Dorota Siwczyńskapozostałych uczestniczek badania wykryto łagodne zmiany izostały one skierowane do dalszej diagnostyki.Wnioski. Wciąż istnieje duże zapotrzebowanie nakontynuowanie programów profilaktycznych, szczególniewśród kobiet w wieku 40-49 lat. Obserwuje się również dużezapotrzebowanie na edukację prozdrowotną w zakresieteoretycznym i praktycznym. W ostatnich latachw makroregionie lubelskim odsetek zachorowań iumieralności z powodu raka piersi maleje.Key words: breast cancer, prevention, mammography, prevention programSłowa kluczowe: rak piersi, profilaktyka, mammografia, program profilaktycznyINTRODUCTIONOncological diseases are a main cause of themortality in the societies of developed countries. In thelast decade, their development has been particularlyintensified, causing the tumors to become a serioussocial problem [1]. In the population of women one ofthe major health problems is breast cancer. Themorbidity of this type of cancer is increasing onaverage by 3% per each year [2]. In the opinion theWorld Health Organization, Poland is on the 30th placeamong 46 countries according to the level of breastcancer. Nevertheless, the most worrying is the fact oflow survival rate (only 5-year survival in 40% ofwomen) after being diagnosed cancer, despite astatistically low level of morbidity [3].According to reports prepared on the basis of theOncology Centre in Warsaw, the number of reportedcases of breast cancer in the Lublin macro-regionincreased dramatically in 1999-2003. Only since 2007,a slight decrease in morbidity and mortality in the levelof this type of cancer has been noted [4,5].Persistently high rate of incidence and the relativelylate diagnosis of cancer, cause that every year there is alarge number of women requiring hospital care andburdensome treatment [6]. Therefore, a reduction themortality of women worldwide, including Poland ishighly influenced by knowledge about breast cancer,its causes, risk factors, methods of prevention and earlydetection of disease. Understanding the causes andconsequences greatly increases the chance to both toavoiding the disease and in case of occurrence,successful treatment. [7].Prevention programs, which often save the healthand lives of women, play an important role in illnessesrisk reduction and early detection of disease.AIM OF THE STUDYThe aim of this study was to evaluate theeffectiveness of prevention programs for breast cancerin the Lublin Macroregion.MATHERIAL AND METHODAccording to the data provided by the RegionalCentre of Occupational Medicine - Center forPrevention and Healing in Lublin, 1385 womenparticipated in the breast cancer prevention programsin 2007(in Lublin - 1085, Zamość - 300), 1100 women- in 2008 (Lublin - 800, Zamość - 300), and 994women - in 2010 - (Lublin - 646, Zamość - 300). Allstudied women were 40 to 69 years old. However,annually the largest percentage of women whoparticipated in the program, affected ladies between theages of 40 to 49.The analysis of reports prepared by the RegionalCentre of Occupational Medicine in Lublin was the heresearch method. The analyzed documents concernHealth Program for early detection of breast cancer forworking women (from 2007), Merits reports on theimplementation of the prevention programs forworkers in 2008 (from 2008) and Merits reports of theprograms prevention for workers in 2010 (from 2010).RESULTSThe etiopathology of breast cancer is influenced bymany factors. This group includes, e.g. childlessness orthe late age of first birth. In the majority of respondentsthere were women, who gave birth at least once beforeturning 30 years old. In 2007 it was 78% of women, in2008 - 83%, and in 2010 – 81%.Another factor which increases the possibility ofbreast cancer morbidity is the occurrence of mildchanges in women’s breasts. The appearance ofsymptoms such as chest pain, nipple discharge, nippleretraction, lump, thickening, or skin changes shouldmobilize women to have a mammography [8,9].Among women participating in the research in 2007,complaints described above were felt by 36% ofwomen, in the following year nearly 34%, and in 2010only among 31% of the studied population.

Breast cancer prevention as a part of health policy activities in Lublin province 14170%60%50%40%30%20%10%0%64% 66% 69% 34% 31%26%Without complaints - bezdolegliwosciWith complaints -dolegliwosciGraph 1. Existence of worrying complaintsRyc. 1. Występowanie niepokojących objawów2007200820100.63% (2008) and only 0.3% (2010). The decreasingtrend of suspected breast cancer, partially agree withthe declining number of mild changes, which werediagnosed in 42% of women in 2007, 30% in 2008 andalmost in 34% of women in 2010. The results ofmammography resulted in referral for additional testssuch as ultrasonography, targeted therapy, the repeat ofresearch the following year or referral to the BreastPathology Clinic in 32% of women in 2007, 34% - in2008 and 34.5% in 2010 of researched women.DISCUSSIONBesides the breast cancer risk factors, there arepreventive actions, which help to reduce theprobability of illness. These activities are a part ofhealthy lifestyle, which includes e.g. regular breastself-examination by women. This easy and painlessself-examination can help to detect cancer at theearliest possible stage, which considerably increasesthe chance for cure [7]. According to the data providedby WOMP, the systematic performance of breast selfexaminationin 2007 was declared by more than 52%of women, in 2008 – by about 61% of women, while in2010 by only 45% of respondents.Graph 2. Breast self-examinationRyc. 2. Samobadanie piersiAn important point of reference for the research,was the answer to the question about the last performedbreast mammography. Among women participating inthe study, the largest group in all the researched yearsconstituted the ladies, who had never had amammography performed. In 2007 it was about 52%of the studied population, in 2008 - 44%, and in 2010 -43% of women.The results of mammography of all analyzed yearsare quite diverse. In 2007 the norm was found in 56%of women, in 2008 at nearly 70%, in the last researchyear – (2010) the norm has reached by 66% of thestudied population. Suspected cancer detected fromyear to year was smaller and equaled 1.5% (2007),Breast cancer is the most common malignancytumor and it constitutes more than 20% of all cases ofcancer among Polish women [10]. Undoubtedly, it isalso the social problem, concerning in particular thedeveloped countries, including Poland.Genetics and age of women are still the maindeterminants of the existence of disease, but in therecent years, special attention has been also drawn tothe risk factors associated with lifestyle. These include:nutrition, decreased physical activity, adversereproductive factors, and use of hormones [10].Appropriate prophylaxis has a significant impact on theearly detection of mild changes. Its scope includeswomen's education, self-examination and screeningtest. The focus on prevention is justified by the resultsof subsequent treatment, which depend on thedetection of cancer at the earliest possible stage.Despite the prevalence of many risk factors forbreast cancer and negative statistics on morbidity andmortality of women in Poland, in the recent years theimprovement on this situation has been observed. Thepreventive program for early detection of breast canceramong working women, which is systematicallyorganized and carried by WOMP, plays an importantrole. It complements the National Program of CancerControl, an element of which is also fighting the breastcancer. The Ministry of Health program is aimed atwomen aged 50-69 years old. The breast cancerprevention programs, which are organized by WOMP,make possible to do a free mammography also foryounger women. Alike the WOMP reports, the largestgroup among the study population were women aged40-49 years.Nowadays, Lublin province is in the forefront interms of statistics on the number of women covered bythe breast cancer prevention programs in all Poland,with a score of 40.7%. The percentage of women living

142Magdalena Mińko, Dorota Siwczyńskain Lublin region, which took part in preventionprograms against breast cancer, slightly increases yearby year [11]. Prevalence of prevention programs has apositive effect. Consequently, the mortality of thebreast cancer by women in Lublin macro-regiondecreases. In this respect once again Lublin provincehas the satisfactory results in comparison to otherprovinces [12].The introduction of breast cancer preventionprograms resulted in positive changes not only inhealth-related behaviors among women, but alsoallowed for early detection of change in tumor. Theseprograms also helped to create a uniform andcontinuous monitoring of the prevention programsagainst the breast cancer morbidity. Currently, it ispossible to have a regular supervision over theepidemiological indicators relating to the declaration,detection and breast cancer mortality. It allows forefficient use of the potential of prevention programs.CONCLUSIONSThe analyzed reports of the breast cancer prevention inLublin macro-region allow formulating the followingconclusions:- there is huge need to perform mammography amongwomen aged 40-49 years; - demand for education inbreast self-examination and to emphasis of the role ofsystematic testing is observed;- referral of patients, in whose pathology was detected,for further diagnosis often contributed to saving theirhealth and even life;- prevention program could have had a direct impact ona slight decrease in breast cancer morbidity andmortality in Lublin province reported by the OncologyCentre in Warsaw;- there is a need to continue the prevention programsbecause of the large number of interested women.LITERATURE4. Liczba zachorowań w podziale na województwa i grupywiekowe, Raporty na podstawie Centrum Onkologii,(epid.coi.waw.pl, dostęp 10.04.2011 r.).5. Liczba zgonów w podziale na województwa i grupywiekowe, Raporty na podstawie Centrum Onkologii,(epid.coi.waw.pl, dostęp 10.04.2011 r.).6. Karwat I.D., Kołłątaj W., Kołłątaj B., Piecewicz-Szczęsna H., Ocena realizacji potrzeb informacyjnych iedukacyjnych kobiet w trakcie szpitalnego leczenia rakagruczołu piersiowego, Zdrowie Publiczne 2010120(4);351-355.7. Kochaniec I., Program zdrowotny w zakresie wczesnegowykrywania raka piersi dla kobiet pracujących, WOMP,Lublin 2007.8. Salomon B., Kochaniec I., Sprawozdanie merytoryczne zrealizacji programów profilaktycznych dla pracujących wroku 2008, WOMP, Lublin 2008.9. Kochaniec I., Sprawozdanie merytoryczne z realizacjiprogramów profilaktycznych dla pracujących w roku2010, WOMP, Lublin 2010.10. Program profilaktyki raka piersi – część administracyjnologistyczna(2005-2010), Ministerstwo Zdrowia,Departament Polityki Zdrowotnej, Warszawa 2005(www.mz.gov.pl, dostęp 15.04.2011 r.).11. Raport „Objęcie populacji programem profilaktyki rakapiersi”, Wojewódzki ośrodek koordynujący populacyjnyprogram wczesnego wykrywania raka piersi(www.onkologia.lublin.pl, dostęp 16.04.2011 r.).12. Sytuacja zdrowotna ludności Polski pod. red. WojtyniakB., Goryński P., Narodowy Instytut Zdrowia Publicznego– Państwowy Zakład Higieny, Warszawa 2008, s.59-60.Address for correspondence:Magdalena Mińkoul. Sarmacka 22A/5102-972 Warszawa+48 694 274 567mminko@onet.euReceived: 10.01.2012Accepted for publication: 6.03.20121. Grodzki L., Łangowska-Grodzka B., Ziółkowski M.,Ocena profilaktyki wtórnej raka piersi wśród mieszkanekTorunia, Zdrowie Publiczne 2004; 114(4):483-486.2. Waliłko E., Profilaktyka raka sutka, Pielęg i Położ 1995;6:7-11.3. Wabiszewska E., Ocena programu profilaktycznegowczesnego wykrywania raka piersi zrealizowanego wwojewództwie lubuskim w 2001 roku, ZdrowiePubliczne 2005 115(2);161-163.

Medical and Biological Sciences, 2012, 26/1, 143-148Agnieszka Pluta 1 , Magdalena Skrzeszewska 2 , Halina Basińska 1 , Maria Budnik -Szymoniuk 1 Kamila Faleńczyk 1THE FUNCTIONAL EFFICIENCY IN ELDERLY PATIENTS TREATEDWITH HEMODIALYSISSPRAWNOŚĆ FUNKCJONALNA U PACJENTÓW W WIEKU PODESZŁYMLECZONYCH HEMODIALIZĄ1 Katedra i Zakład Pielęgniarstwa Społecznego Collegium Medicum w Bydgoszczy Uniwersytetu MikołajaKopernika w ToruniuKierownik: dr n. med. Kamila Faleńczyk2 Katedra Nefrologii, Nadciśnienia Tętniczego i Chorób Wewnętrznych ze Stacją Dializ Szpitala UniwersyteckiegoCM w BydgoszczyKierownik: prof. dr hab. n. med. Jacek ManitiusSummaryB a c k g r o u n d . During the last few years in the worldas well as in Poland the number of patients with chronic renaldisease is observed to grow. Thanks to the great developmentthat was made in the field of dialysis therapy all the patientsdespite of their age are provided with a renal substitutiontherapy. Most of the dialyzed patients are constituted by elderpeople, not meeting the renal transplantation criteria. Theyhave to be treated with special care because of the coexistenceof many chronic diseases. Often the coexistence of manysomatic illnesses and the dialysis therapy influence thefunctional efficiency that remains restricted, especially withelder patients.O b j e c t i v e s . The aim of these studies was to evaluatethe functional efficiency in elderly patients treated withhemodialysis.M a t e r i a l a n d m e t h o d s . The study involved agroup of 48 respondents aged between 66 and 90 years.Standardized ADL and IADL scales were used and also thefinal part of the questionnaire containing the demographicinformation.C o n c l u s i o n s . From the undertaken research suchconclusions were made: 1. For the patients the biggest numberof problems among everyday tasks made taking a bath, thesmallest number of problems was made with nutrition. Inperforming complex everyday tasks the biggest problem forthe patients was connected with performing small homerepairs. 2. Together with the increase of the educationincreased the level of independence in the evaluation of thebasic everyday tasks. The biggest independence showed thepatients with higher education. Also in the evaluation of thecomplex everyday tasks the patients with higher educationshowed bigger independence. 3. The period of the dialysis didnot influence the functional efficiency of the respondents inthe range of evaluation of the basic as well as complexeveryday tasks.StreszczenieWprowadzenie. W ciągu ostatnich lat zarówno naświecie jak i w Polsce obserwuje się wzrost liczby pacjentówz przewlekłą chorobą nerek. Dzięki ogromnemu postępowijaki osiągnięto w dializoterapii wszyscy pacjenci niezależnieod wieku mają zapewnione leczenie nerkozastępcze.Większość dializowanych stanowią osoby w podeszłymwieku, niespełniający kryteriów do przeszczepienia nerki.Muszą oni zostać objęci szczególną opieką z powoduwspółwystępowania wielu chorób przewlekłych. Częstowspółistnienie wielu schorzeń somatycznych orazdializoterapia wpływa na sprawność funkcjonalną, którazostaje znacznie ograniczona, szczególnie u pacjentów wpodeszłym wieku.Celem niniejszych badań była ocenasprawności funkcjonalnej osób w podeszłym wiekuleczonych hemodializą.Materiał i m e t o d y . Badaniem objęto 48respondentów w wieku od 66 do 90 lat. Wykorzystano

144Agnieszka Pluta et. al.standaryzowane skale ADL i IADL oraz metryczkęzawierającą dane demograficzne.W n i o s k i . Z przeprowadzonych badań uzyskanonastępujące wnioski: 1.Najwięcej problemów wpodstawowych czynnościach dnia codziennego stwarzałabadanym kąpiel, najmniej problemów przejawiali przyodżywianiu się. W wykonywaniu złożonych czynności dniacodziennego najwięcej problemów stwarzało badanympacjentom samodzielne wykonywanie drobnych naprawdomowych. 2. Wraz ze wzrostem wykształcenia wzrastałstopień niezależności w ocenie podstawowych czynności wżyciu codziennym. Największą niezależność przejawialibadani z wykształceniem wyższym. Również w oceniezłożonych czynności codziennych badani z wykształceniemwyższym przejawiali najwyższą niezależność. 3. Okresdializowania nie wpłynął na sprawność funkcjonalnąrespondentów w zakresie oceny podstawowych jak izłożonych czynności dnia codziennego.Key words: elder, functional efficiency, hemodialysis, ADL scale, IADL scaleSłowa kluczowe: wiek podeszły, sprawność funkcjonalna, hemodializa, skala ADL, skala IADLINTRODUCTIONAccording to WHO data in the second half of theXX century the average length of life will be extendedby 20 years, and in the year 2030 about 30% of thepopulation in the developed countries will live longerthan 65 years. Actual demographic data, as well asprognosis for the future show the increasing problemof elder patients with chronic renal disease. 10 yearsago the availability of dialysis for elder patients withend-stage renal disease was limited in Poland. The ageof over 65 years was one of the factors disqualifying apatient from a renal replacement therapy. Currently, itis the largest group of patients starting dialysis.According to the data from the Report of the state ofthe renal replacement therapy, patients aged over 65constituted 55.5% [1]. The analysis of the mentionedabove report shows that the diabetic nephropathy isone of the main reasons of the end-stage renalinsufficiency. Old age, because of the natural course ofevents, and evolutionary changes predispose tochanges in both anatomy and renal function [2].Dialysis as a form of renal replacement therapy putspeople in a difficult situation, with which they have tostruggle. Because of the renal insufficiency theposition of the sick is special due to general lack ofpermanent treatment outcomes. Chronic renal diseaseis considered an incurable disease. The dialysis therapyis connected with a necessity of adjustment to new lifeconditions. The dissimilarity of this situation resultsamong all from frequent and long term hospitalization,and also the necessity of undergoing many diagnosticprocedures. As a result it leads to a change in a sickperson's functioning in the family, work and socialenvironment and limits the functional efficiency.Functional efficiency is the ability to be independentfrom other people in the field of basic life activities,such as: moving, eating, controlling physiologicalfunctions of the body and maintaining the body'shygiene.Many health (system and organ diseases) andsocio-demographical (age, sex, education, place ofresidence) factors have influence on functionalefficiency [3].OBJECTIVESEvaluation of the functional efficiency of elderpeople treated with hemodialysis. In this work weanalyzed the ability of elder people to self-functiondepending on their age, sex, education level andduration of the renal replacement therapy.MATERIAL AND METHODSThe research was carried out between September2010 and November 2010 in the Department andClinic of Nephrology, Hypertension and InternalMedicine with Dialysis Station of NCU CollegiumMedicum in Bydgoszcz. In order to undertake theresearch a grant was given by the BioethicalCommission at NCU Collegium Medicum inBydgoszcz. All the patients that took part in theresearch signed a consent form.The research involved 48 respondents agedbetween 66 and 90 years.The following research tools were used:-A survey questionnaire designed for the purpose ofthis study,-The ADL scale of everyday functioning;determining the ability to perform basic everydayactivities, such as using the toilet, ability to move (athome and outside), eating, bathing, foot care and nailcare, dressing and undressing, control of urine andstool excretion, which may be perform alone, an ability

The functional efficiency in elderly patients treated with hemodialysis 145to function without others’ help. The basic activitieswere evaluated on three levels: able to perform acertain activity alone – 3 points, ability to perform acertain activity under supervision or with small help –2 points, and lack of ability to perform activities alone– 1 point [4];-the IADL scale of complex everyday activitiesevaluating complex activities of daily living such asusing telephone, getting to places beyond walkingdistance, going out shopping, preparing meals,performing housework, home repairs, doing thelaundry, preparation and intake of drugs, andmanagement of funds.In the statistical analysis we used Statistica 6.0.software. In the study we used the Spearman'snonparametric test, Mann-Whitney test. Thesignificance of differences between the assessedgroups was evaluated with the use of analysis ofvariance and Student's t-test for dependent andindependent trials. Statistically significant level wasconsidered when p

146Agnieszka Pluta et. al.efficiency. The rest, constituting the largest group, arepeople partially dependent in the IADL manner.This work showed that along with the increase ofthe education level, the level of independence in theevaluation of basic daily activities increased. Thebiggest independence was noted among people withhigher education – average 8.0; the smallestindependence among the researched with primaryeducation – average 12.7. Patients with secondaryeducation and vocational education had a similaroutcome to the patients with higher education.Tabela 1. Korelacje skali oceny zagadnień ADL ze względuna wykształcenieTable 1. Correlation of the ADL scale of task evaluation dueto educationpunkty2826242220181614121086podstawowezawodoweśredniewyższewykształcenieŚrednia±Błąd std±Odch.stdFig. 1. IADL scale of evaluation with the consideration ofeducationRyc. 1. Skala oceny IADL z uwzględnieniem wykształceniaZmiennaVariableN R t(N-2)poziom pP levelKąpielBath48 -0,509583 -4,01682 0,000216Ubieranie sięDressing up48 -0,466335 -3,57541 0,000835Higiena osobistaPersonal hygiene48 -0,435484 -3,28106 0,001977Przemieszczanie sięMobility48 -0,372503 -2,72236 0,009125Czynności fizjologicznePhysiological activities48 -0,249066 -1,74422 0,087801Odżywianie sięNutrition48 -0,496381 -3,87812 0,000333N – numberR - Spearman correlation coefficientt(N-2) – distribution of t-Student of N-2 Levels of freedomLevel p – level of relevanceEvaluation of ADL scale in some particular issueswas found to be in a crucial correlation with theeducation (p

The functional efficiency in elderly patients treated with hemodialysis 147In this work the dependence of functionalefficiency was evaluated with the ADL scale and theduration of the dialysis did not reach a statisticalsignificance (p = 0.48).DISCUSSIONOld age brings a lot of limitations, the body'sfunctional capacity gets worse and functionalefficiency decreases gradually together with age.From the research it results that taking a bathconstitutes the biggest problem for dialyzed elderpatients, while nutrition – the smallest problem. Theseresearches correspond with Mazurkiwicz's researchundertaken among dialyzed patients at the UniversityHospital No.1 in Bydgoszcz [5]. In the research ofMuszalik et al. questioned people reported the largestproblem with performing housework; our research didnot confirm mentioned above outcomes, since smallhome repairs were the biggest difficulty for theresearched. This may be connected with the fact that83.3% of the researched lived with family and ran acommon household. Due to that fact that elder peoplewere dismissed from performing repair tasks or doingthe shopping, what limited their independence [6]. Inthe Mazurkiewicz’s research performance of smallhouse repairs as well as self-performance of houseworkcaused the most difficulty to the patients [5].From the researched made by Kachaniuk et al. [7] itresults that 31% is not able to self-do the shopping,14% needs help, 55% does the shoppingindependently. Our own results not correspond withthe outcomes of Kachaniuk et al., because 56.3% isentirely not able to do any shopping, 14.6% - with alittle help 29.2%. - without help. This may beconnected with the specificity of the disease (creationof arteriovenous fistula usually in the upper limb,saving this limb).In the research performed by Borowiak et al. [8] itis shown that the patients independent in the field ofeveryday activities also showed a high level offunctional efficiency in the range of instrumentalactivities. These researches correlate with our research,also in the field concerning independence in the IADLevaluation scale.The research performed by Muszalik et al. [9] showlack of influence of education on functional efficiencyof geriatric patients, while the results obtained byBorowiak et al. [8] and Fortuniak [10] show aninfluence of education on functional efficiency as wellas on quality of life. This may be related with the factthat people with lower education level more oftenexposed to harmful factors in their workplaces and hadbigger work load in the past were. The level ofeducation is often connected with patients' healthconsciousness and sets a lifestyle and pro-healthbehaviour. This may be the reason of lower functionalefficiency and some of the health problems presentamong people with lover education level.Our research corresponds with researches ofBorowiak et al. and Fortuniak M., because togetherwith the increase of education, the level ofindependence of elder patients treated withhemodialysis increases [8, 10, 9].From the research it results that the period ofdialysis does not have influence on functionalefficiency of the respondents in the range of evaluationof the basic as well as complex daily activities. Aboveresearches correspond with the research performed byMazurkiewicz [5]. This may result from the chronicdisease, long-term dialysis. Patients dialyzed for yearsaccepted their health state and do not show problems ineveryday life, despite the old age.Regular physical activity is the element of afunctional efficiency in everyday life of the dialyzedpatients as well as of the entire society is a [11].Physical rehabilitation leads to improvement ofphysical condition, increases the ability to performeveryday tasks with the end-stage renal disease andimproves quality of life rate. The problem of increasingphysical activity by patients chronically dialyzed wasshown in the orders of the U.S. National KidneyDisease Foundation – Performance ImprovementInitiative for Dialysis (NKF-K/ DOQI).The results of research performed [12] on the groupof 82 hemodialysis patients by Vischini et al. highlightthe importance of targeted rehabilitation, as well as ofpreventing and treatment of disability in the positiveinfluence on one of the sides of quality of life ofhemodialysed patients, while the other side on theworkload of the caregiver.CONCLUSIONS1. As it results from the undertaken research the mostproblems in the basic daily activities were made bytaking a bath, the least problems were made bynutrition. In the performance of complex dailyactivities the most problems were made by selfperformingsmall home repairs.

148Agnieszka Pluta et. al.2. Along with the increase of education increased thelevel of independence in the evaluation of the basiceveryday tasks. The biggest independence showedthe patients with higher education. Also in theevaluation of complex everyday tasks the patientswith higher education showed bigger independence.3. The duration of the dialysis did not have influenceon the functional efficiency of the respondents inthe range of evaluation of basic as well as complexeveryday activities.Address for correspondence:Agnieszka Plutae-mail agnieszkapluta@poczta.onet.pltel.6937169890Received: 10.01.2012Accepted for publication: 6.03.2012LITERATURERutkowski B., Lichodziejewska-Niemierko M., Grenda R.,Czekalski S., Durlik M., Bautembach S.: Raport ostanie leczenia nerkozastępczego w Polsce 2007.Drukonsul. Gdańsk. 2008: 7 - 34.Kokoszka- Paszkot J., Paszkot M.: Cukrzycowa chorobanerek. Geriatria 2009; 3: 214 – 218.Biercewicz M., Szewczyk M.T., Ślusarz R.:Pielęgniarstwo geriatryczne. BORGIS WydawnictwoMedyczne, Warszawa 2006: 7-11.Sosnowski M., Chmara –Pawlińska R.: Czynnościowaocena pacjentów skalą ADL w różnych typachotępienia . Medycyna Rodzinna. 2002, 5: 176-178.Mazurkiewicz S.: Zachowania zdrowotne a stanydepresyjne u chorych dializowanych w podeszłymwieku. Collegium Medicum im. LudwikaRydygiera w Bydgoszczy Uniwersytet MikołajaKopernika w Toruniu 2005. Praca magisterska.Muszalik M., Bartuzi Z., Kędziora-Kornatowska K.,Marzec A.: Jakość życia chorych przewlekle wbadaniu profili zdrowia. Ann. Universit. Mariae Curie-Skłodowska. Lublin 2004, vol.59. suppl XIV, 4: 158-163.Kachaniuk H., Droździe D., Fidecki i wsp.: Samodzielnośćosób starszych jako element jakości życia. Piel. XXIw., 2006; 4: 75-76.Borowiak E., Barylska A.: Problemy seniorówprzebywających w Domu Dziennego Pobytuwyzwaniem dla pielęgniarki. Problemy Pielęgniarstwa2007, tom 15, nr 1:13-15.Muszalik M., Ćwikła A., Kędziora-Kornatowska K.,Kornatowski T.: Ocena wpływu czynników socjodemograficznychi medycznych na poziom sprawnościfunkcjonalnej pacjentów geriatrycznych.Pielęgniarstwo XXI wieku 2010; 1: 2 - 9.Fortuniak M.: Problemy zdrowotne osób chorych w wiekupodeszłym.Pielęgniarstwo Polskie 2003, 1( 15 ), 54-56.Gołębiowski T., Wende W., Kusztal M. i wsp.: Ćwiczeniafizyczne w rehabilitacji chorych dializowanych.Postępy Hig. Med. Dośw. 2009; 63: 13 -22.Vischini G., Tendas A., Ferrannini M. et all.: Motordisability in end-stage renal failure: Anepidemiological study on Italian dialyzed patients.J. Kidney Dis Arabii transpl. 211; 22: 1236 – 7.

Medical and Biological Sciences, 2012, 26/1, 149-153Iwona Sadowska-Krawczenko 1 , Agata Staśkiewicz 2 , Andrzej Kurylak 1 , Barczykowska Ewa 1 ,Aldona Katarzyna Jankowska 3THE KNOWLEDGE OF NURSES WORKING IN PEDIATRIC WARDS OF ASSESSMENTAND TREATMENT OF PAIN IN CHILDRENWIEDZA PIELĘGNIAREK PRACUJĄCYCH W ODDZIAŁACH PEDIATRYCZNYCH W ZAKRESIEOCENY I LECZENIA DOZNAŃ BÓLOWYCH U DZIECI1 Department of Pediatric Nursing, Nicolaus Copernicus University in Toruń Collegium Medicum in BydgoszczHead: dr hab. n. med. Andrzej Kurylak, profesor UMK2 Graduate from nursing, second level degree studies at Nicolaus Copernicus University in ToruńCollegium Medicum in Bydgoszcz3 Department of Pediatric Hematology and Oncology, Nicolaus Copernicus University in ToruńCollegium Medicum in BydgoszczHead: Prof. Mariusz Wysocki, MDSummaryI n t r o d u c t i o n . Children's pain is often undiagnosedand wrongly treated. The skill of diagnostics andcounteraction of long-lasting pains is an extremely importantelement in the work of nursing staff. The knowledge of rulesof estimation and treatment of the pain in children is a basisof individualized care-giving for patient.T h e p u r p o s e of the research is to estimate theknowledge of the nurses working in pediatric wards in thefields of diagnostics, estimation and treatments of pain inchildren.M a t e r i a l a n d m e t h o d s . Evaluation based onquestionnaires filled out by 68 nurses working in neonatal,pediatric and pediatric surgery wards was conducted.R e s u l t s . Research shows that 79% of respondents -nurses, working in pediatric wards know the estimationscales of pain in children, and 59% of persons use theevaluation tools of pain experiences in their professional job.The results show that nurses possess a good knowledge aboutnon pharmacological treatment of pain, which was on a betterlevel than their knowledge about pharmacological treatment.82% of respondents consider non pharmacological methodsof treatment to be effective. 74% of respondents confirm theuse of pharmacological and non pharmacological methods ofpain alleviation in their professional job. 42% of nursesestimate their knowledge about treatment of pain as good.Conclusions:• Knowledge of nurses working in pediatric wardsconcerning estimation of pain experiences inchildren is not sufficient.• The level of nurses’ knowledge concerning nonpharmacological pain alleviation methods isaverage, but at the same time higher thanknowledge concerning pharmacological painalleviation methods.• Main factors determining pediatric nurses’knowledge about pain treatments in children are:their education, their practice in-service and theirparticipation in additional trainings for painalleviation.

150Iwona Sadowska-Krawczenko et. al.StreszczenieWstę p . Ból u noworodka i małego dziecka jest częstonie rozpoznawany i źle leczony. Umiejętność rozpoznawania,przeciwdziałania i leczenia bólu jest niezmiernie ważnymelementem pracy personelu pielęgniarskiego. Znajomośćzasad oceny i leczenia bólu u dzieci jest podstawą wzindywidualizowanej opiece świadczonej na rzecz pacjenta.Celem pracy była ocena wiedzy pielęgniarekpracujących w oddziałach pediatrycznych w zakresierozpoznawania, oceny i leczenia doznań bólowych u dzieci.Materiał i m e t o d y . Badanie ankietoweprzeprowadzono w grupie 68 pielęgniarek pracujących woddziałach pediatrycznych, neonatologicznych i chirurgiidziecięcejW y n i k i : . 79% respondentów- pielęgniarek,pracujących w oddziałach pediatrycznych zna skale ocenybólu u dzieci, a 59% osób wykorzystuje narzędzia ocenydoznań bólowych w pracy zawodowej. Ponadto wykazano,że wiedza ogólna badanych w zakresie metodfarmakologicznego leczenia bólu jest istotnie mniejsza niżwiedza w zakresie niefarmakologicznych metod uśmierzaniabólu. 82% badanych uważa niefarmakologiczne metodyleczenia za skuteczne. 74% badanych potwierdza, że w pracyzawodowej stosuje farmakologiczne i niefarmakologicznemetody leczenia bólu. 42% badanych ocenia swoją wiedzę natemat leczenia bólu jako dobrą.Wnioski:• Wiedza pielęgniarek pracujących w oddziałachpediatrycznych w zakresie oceny doznań bólowych udzieci jest niewystarczająca.• Stan wiedzy pielęgniarek w zakresieniefarmakologicznych metod leczenia jest średni ijednocześnie lepszy od stanu wiedzy pielęgniarek wzakresie farmakologicznych metod leczenia bólu udzieci.• Głównymi czynnikami determinującymi stan wiedzypielęgniarek pediatrycznych w zakresie leczenia bólu udzieci są wykształcenie, staż pracy oraz uczestnictwo wszkoleniach na temat bólu.Key words: nurse, knowledge, pain management, nonpharmacological, pharmacological, child, newbornSłowa kluczowe: pielęgniarka, wiedza, leczenie przeciwbólowe, niefarmakologiczne, farmakologiczne, dziecko, noworodekINTRODUCTIONPain is ‘an unpleasant sensory and emotionalexperience associated with actual or potential tissuedamage, or described in terms of such damage’ [1, 2].It is a subjective sensation, not always proportional tothe tissue damage level. Pain can be classifiedaccording to an assumed criterion, for example: thetime, the place or the mechanisms of its incidence.Untreated pain leads to adverse somatic bodyreactions, like: increased heart and breath rate, highblood pressure or an increased demand for oxygen.Unrelieved pain can also alter immune function [3].The purpose of the pain is to warn and protect againstdanger, expansion of the damaged area and illness. Inthe initial stage of sensing the pain, the reaction of thenervous system allows the body to adapt itself tostimulation for pain. Although pain stimuli have abeneficial influence on the body in the first stages, itscontinuation triggers a number of undesirable systemicreactions [4]. A loss of the ability to sense pain can bea distant after-effect of chronic pain stimulation. Thereare assumptions that late consequences of continuouspain can be: emotional and behavioral disorders andlearning disability [5].Estimation of pain in small children, especiallyinfants, is very hard due to a non-existent or limitedverbal communication. Small children cannot expresswhat they feel and usually cannot estimate the level ofpain. In consequence, children's pain is oftenundiagnosed and wrongly treated. Nurses play asignificant role in the process of estimating painexperiences in small children. Therefore, it is importantthat they have a proper level of knowledge aboutrecognizing and treating pain in children. A method ofestimating pain in children should be easy to conduct,estimate not only the child’s feelings but alsoefficiency of pain alleviation methods used at that time.The method should be adapted to: the child’sdevelopment period, the rate of severity and chronicityof the disease, type of conducted surgery and medicaltreatment and the hospital environment [6]. A lack ofpain management knowledge leads to inadequatemanagement and treatment of pain.THE OBJECTIVE OF THE STUDYThe objective of this study is estimating knowledgeof the nurses working in pediatric wards in the fields ofdiagnostics, estimation and treatments of pain inchildren.Following issues have been researched:1. What is the level of nurses’ knowledge aboutestimation of pain experiences in children?

The knowledge of nurses working in pediatric wards of assessment and treatment of pain in children 1512. What is the level of nurses’ knowledge aboutnon pharmacological methods of treating painin children?3. What is the level of nurses’ knowledge aboutpharmacological methods of treating pain inchildren?4. What factors determine the level of nurses’knowledge about estimation and treatment ofpain in children?MATERIAL AND METHODSThe research was conducted in the group of 153pediatric and neonatal nurses from wards: Departmentof Neonatology and Department of Pediatric Surgery,Dr J. Biziel University Hospital No. 2 in Bydgoszcz,Department of Pediatric Surgery, Department ofPediatrics, Allergy and Gastroenterology, Dr A. JuraszUniversity Hospital No. 1 in Bydgoszcz. The researchwas conducted between the 10 th and the 30 th of July2010. Consent KB 336 /2010 from BioethicalCommission of L. Rydygier Collegium Medicum inBydgoszcz was obtained.The research was conducted with the use of anopinion poll. Data was collected through aquestionnaire created on the basis of a researchconducted in the article: Nurses’ Knowledge AboutPharmacological and Nonpharmacological PainManagement in Children, published in the Journal ofPain and Symptom Management [7]. The questionnairecontained 4 sociodemographic questions and 45questions concerning the topic of the research,including 3 open-ended questions and 2 multiplechoicequestions. The questionnaires were anonymousand members of the researched group provided awritten consent of participation.Statistical analysis of the questionnaire was done.Questions from 18 to 49 were Likert-type questions,containing answers: agree, agree to some extent, don’tknow, disagree to some extent and disagree. Numericalvalue was attributed to these answers, 2 for correctanswers and -2 for incorrect answer, and calculationswere conducted. The differences between knowledgetypes were counted through t tests for dependentgroups. Differences between sexes were countedthrough t tests for independent groups. Differencesresulting from service in-practice, estimation of ownknowledge and level of education were estimatedthrough ANOVA test (variation test). All calculationswere done in the SPSS program for Windows 17.0.RESULTS AND DISCUSSIONOut of 153 nurses employed in wards listed above,68 persons declared agreement of participation in theresearch and answered the questions provided in thequestionnaire. Out of the researched group of 68, thereare 62 women. Average age of respondents is 38.2(median 39), the youngest person was 23 years old andthe oldest was 55 years old. The majority ofrespondents acquired high-school diploma – 49(72.1%) of respondents, 7 people (10.3%) had higherprofessional education, whereas 12 (17.6%) had amaster’s degree. 57 (83.8%) of respondents hadworked in-service for over 10 years.54 persons confirmed their acquaintance with painscales, out of which 32 respondents uses the scales intheir professional work. 84.4% of the group (27persons) uses the scales for pain estimation severaltimes during their shifts. The respondents list 15different pain estimation methods. The most often usedscales are Visual Analog Scale VAS and NumericalRating Scale NRS. All respondents using the pain scaleconsidered it to be a good method of pain estimation.21 people say that they use the scales in theirprofessional job because it is regulated by adequaterules and procedures used on the ward. 40 respondents(74.1%) say that at their workplace bothpharmacological and non pharmacological painalleviation methods are used, while 10 persons (18.5%)say that on their ward only pharmacological painalleviation methods are used. 56 people (82.4%)consider non pharmacological methods of treatment tobe effective. 29 of respondents (42.6%) think that theyhave a good knowledge about treating pain in children,7 (10.3%) think that their knowledge is bad, and 32(47.1%) cannot assess their knowledge about treatingpain. 20 nurses (29.4%) say that on their wardstrainings concerning pain estimation and alleviationmethods are conducted. 29 persons (42.6%) say thatthey had underwent training in pain alleviation duringlast two years.In order to estimate the nurses’ knowledge, theresults were divided into categories as following: nonpharmalogical methods of pain treatment, generalknowledge of pharmalogical pain treatment, rules ofnon-steroid anti-inflammatory drugs and paracetamoladministration, opioids administration and knowledgeabout regional anesthesia. Dependencies such aseducation, work experience and the examinees’

152Iwona Sadowska-Krawczenko et. al.opinion of their knowledge were used for obtainingproportions.The level of knowledge of the studied nurses wasvaried. Respondents scored on average 0.927 points(the maximum to acquire was 2 points – an average ofpoints for all answers), with deviation ±0.674. Theworst score was -0.255 points, and the best was 2. Itwas also the most frequently achieved score. Theresearched group of nurses was giving mainly correctanswers to the questions in the questionnaire.There is no significant statistic difference betweenthe nurses’ general level of knowledge about treatingpain in children and their education. There is, however,correlation between education and the level ofknowledge in the area of pain pharmacotherapy. Itshows that nurses with only a high school diplomahave the smallest knowledge in this particular area.Nurses with a master’s degree scored average, and thehighest score was that of nurses with bachelor’sdegree. In the correlation between education and thearea of non pharmacological methods of painalleviation, rules for administering non-steroid antiinflammatorydrugs and paracetamol, rules ofadministering opioids and the knowledge aboutregional anesthesia there are no statistically significantdifferences.In the correlation between the nurses’ generalknowledge and their seniority, the ones with seniorityin nursing of 10 to 15 years obtained the best results.There are no statistical differences in the correlationbetween the general knowledge of pharmalogical andnon-pharmalogical methods of pain treatment andnurses’ seniority. The knowledge of administering nonsteroidanti-inflammatory drugs and paracetamol is thehighest among nurses with 1 to 5 years of practice. Theknowledge about administering opiods and regionalanesthesia is the highest among nurses with 5 to 10years of work experience.The examinees’ general knowledge aboutpharmalogical pain treatment methods is indeed lowerthan their knowledge about non pharmalogical paintreatment methods. The general knowledge level aboutpharmalogical pain treatment is lower in the area ofadministering non-steroid anti-inflammatory drugs,paracetamol and opioids, with the knowledge levelbeing the highest for the last of these methods. Thereare no statistically significant differences between thenurses’ general knowledge about pharmalogicalmethods and local treatment – both are relatively low.The knowledge about non-steroid anti-inflammatorydrugs and paracetamol is significantly higher than theknowledge about regional anesthesia. There are nosignificant differences between the knowledge aboutnon-steroid anti-inflammatory drugs and paracetamoland the knowledge about opioids – both are relativelyhigh.DISCUSSIONThe above study was conducted among nurses fromfour wards in two university hospitals. Out of 153nurses working at these wards only 68 expressed thewillingness to take part in the study. The questionnaireused in the study had never been used in these centers.Own study showed that nurses working on thepediatric wards know the pain estimation scales anduse them in their work. The research by Tymecka et al.conducted in 2000 showed that nurses mainly use theobservation of the child’s behavior as a pain estimationmethod [8].The analysis of own research showed that thenurses’ knowledge about non pharmalogical andpharmalogical pain treatment in children is insufficient.The results are in accordance with the results of otherresearchers [7,9]. It was proven that the pediatricnurses’ knowledge about non pharmalogical paintreatment is higher than their knowledge aboutpharmalogical methods of pain treatment. Similarresults were obtained by Salanterä and Luri in 1999,and Twycross in 2004 [7,9].The nurses are aware of their knowledgedeficiencies in certain areas. It is confirmed by theestimation of their knowledge. Similar results wereshown in the study of the Finnish nurses [7].In own study the comparison between theknowledge of the nurses working at different centerswas omitted, due to too small number of respondentsfrom each particular centre and the examinees’objection. The study of Finnish nurses showedstatistically significant differences in correlationbetween the level of knowledge and the branches ofpediatrics in which the nurses worked [7].In own study the correlation between the nurses’education level and their knowledge level was shown.Nevertheless, it must be noted that a part of therespondents held a diploma in a different field thannursing. The questionnaire asked for the level ofeducation without specifying the field in which it wasobtained. It was proven by the research done bySalanterä that the level of education has a significant

The knowledge of nurses working in pediatric wards of assessment and treatment of pain in children 153influence on the nurses’ knowledge [7]. In a studyestimating the knowledge and attitude towards pain inchildren conducted in 2000, Manworren proved thatnurses with a higher education diploma obtainedsignificantly better results [22].In 2004 Twycross suggested that nurses’ seniorityhas no influence on their knowledge about painestimation and treatment [9]. The analysis of our ownresearch has shown that the best results in theestimation of pain treatment methods were obtained bynurses who worked professionally from 10 to 15 years.In the research conducted in 2007, Rieman et al.showed that nurses who were active in nursingorganizations obtained better results in the tests of theirknowledge about pain treatment in children [10]. Theanalysis of the nurses’ knowledge should be conductedin accordance with factors that have a direct influence.Own study did not take into consideration thefollowing factors: the nurses’ workstation, membershipin nursing organizations, the school’s curriculum,participation in scientific research.Our study indicated that more education is neededin the area of pain management. Further research isneeded to find the most effective way of educatingnurses in pain estimation and management field.CONCLUSIONSOn the basis of the conducted research thefollowing conclusions were drawn:• Knowledge of nurses working in pediatricwards concerning estimation of painexperiences in children is not sufficient.• The level of nurses’ knowledge concerningnon pharmacological pain alleviation methodsis average, but at the same time higher thanknowledge concerning pharmacological painalleviation methods.• Main factors determining pediatric nurses’knowledge about pain treatments in childrenare: their education, their practice in-serviceand their participation in additional trainingsfor pain alleviation.2. Wordliczek J., Dobrogowski J.: Leczenie bólupooperacyjnego. Zestaw szkoleniowy dla pielęgniarek.PERF 02/ 02/ 2009.3. Lynch, M.: Pain as the fifth vital sign. J Intraven Nurs,2001, 24, 85-93.4. Sokół- Kobielska E.: Leczenie bólu. Część I.Wprowadzenie: patofizjologia, klasyfikacja i ocenabólu. Pediatria i Medycyna Rodzinna, 2007, 3, 2, 95-100.5. Wytyczne Komisji ds. Płodu i Noworodka oraz SekcjaChirurgii American Academy of Pediatrics, Komisji ds.Płodu i Noworodka Canadian Paediatric Society.:Zapobieganie i leczenie bólu u noworodków:Uaktualnienie. Pediatria po Dyplomie, 2007, 11 , 3, 13-26.6. Morton N. S.: Zapobieganie i leczenie bólu u dzieci- Cz.I. Med Prakt Pediatr, 2000, 4, 56- 61.7. Salanterä S., Lauri S., Salami T. T. Helenius H.: Nurses’Knowledge About Pharmacological andNonpharmacological Pain Management in Children. JPain Symptom Manage, 18, 4 October 1999, 289- 299.8. Tymecka I., Flis E.: Rozpoznawanie bólu u dziecibadania pilotażowe.Anndes Universitis Mariae Curie- Skłodowska, 2000,LV, VII, 64.9. Twycross A., Dowden J. S.: Satatus of pediatric nurses’knowlegle about pain.Pediatric Pain Letter, 11, 3, December 2009.10. Rieman MT., Gordon M.: Pain managementcompetency evidenced by a survey of pediatric nurse’Knowledge and attitudes. Pediatr Nurs 2007, 33, 307-312.Address for correspondence:dr n. med. Iwona Sadowska-KrawczenkoZakład Pielęgniarstwa PediatrycznegoWydział Nauk o Zdrowiu Collegium Medicum UMKul. Techników 385-801 BydgoszczTel. (52) 3655262e-mail: sadowskakrawczenko@gmail.comReceived: 10.01.2012Accepted for publication: 6.03.2012REFERENCES1. International Association for the Study of PainSubcommittee on Taxonomy. Classification of chronicpain syndromes and definitions of pain terms. Pain,1986, 3 (Suppl. 3), S1-S226.

Medical and Biological Sciences, 2012, 26/1, 155-160Paweł Szczudło 1 , Marta Hreńczuk 2VARIABILITY OF DRUGS WITH NARROW THERAPEUTIC WINDOWIN TRANSPLANTOLOGY – POTENTIAL COSTS AND CLINICAL CONSEQUENCESZAMIENNOŚĆ LEKÓW O WĄSKIM OKNIE TERAPEUTYCZNYM W TRANSPLANTOLOGII– POTENCJALNE KOSZTY I KONSEKWENCJE KLINICZNE1 Astellas Pharma Sp. z o.o.2 Department of Surgical and Transplantation Nursing Medical University of WarsawHead: prof. dr hab. n. med. Piotr MałkowskiSummaryDemand for organ transplants is growing fast due to thesenescence of population and increased incidence of suchdiseases as diabetes mellitus and viral hepatitis. Resources ofhealth care providers are limited and steadily increasing.Transplant recipients require chronic medical managementand life-time immunosuppressant therapy. Patients must takemultiple drugs, such as immunosuppressants, anti-infectiveagents as well as drugs to treat comorbidities. A patient afterorgan transplantation may take an average of 11 differentdrugs daily. The aim of treatment of such patients is to avoidloss of a transplant through ensuring high safety level due tomonitoring of concentrations of drugs with narrowtherapeutic index (tacrolimus, cyclosporine). Potential costsof loss of a transplant include return to dialysis therapy, andin case of a liver or heart – retransplantation or death.Availability of generic immunosuppressants results inincreased availability of these drugs, improved quality ofcare and sometimes increased patient compliance. Genericformulations of cyclosporine, mycofenolate mofetil (MMF)and tacrolimus received marketing authorization in EU.Conclusions:Due to the fact that generic formulations of calcineurininhibitors are becoming available, both health care providersand health care payers must realize that their bioavailabilityis highly variable and depends on multiple factors that havenot yet been taken into account in studies of clinicalbioequivalence. Changes in systemic exposure may result inloss of transplant function or toxic effects of an administereddrug. Therefore, it is important for the transplant recipientand payer to evaluate evidence for safety and efficacy of anyapproved alternative formulation that contains a drug with anarrow therapeutic window used in transplantology.StreszczenieZapotrzebowanie na przeszczepy narządów szybkorośnie, z powodu starzenia się populacji i wzrostu częstościwystępowania takich chorób jak cukrzyca i wirusowezapalenie wątroby. Środki świadczeniodawców sąograniczone i stale rosną. Biorcy wymagają przewlekłegopostępowania medycznego, leczenia immunosupresyjnegostosowanego przez całe życie. Pacjenci muszą zażywać wieleleków jak immunosupresanty, leki przeciwzakażeniowe orazzwalczające choroby współistniejące. Pacjent poprzeszczepie może zażywać średnio 11 różnych lekówdziennie. Celem leczenia u takich pacjentów jest uniknięcieutraty przeszczepu poprzez zapewnienie wysokiego poziomubezpieczeństwa dzięki monitorowaniu stężenia leków oniskim indeksie terapeutycznym, (takrolimus, cyklosporyna).Potencjalne koszty utraty organu oznaczają powrót na dializya w przypadku wątroby lub serca retransplantację lub śmierć.Dostępność generycznych leków immunosupresyjnychoznacza zwiększenie ich dostępności, poprawienie jakościopieki, czasami zwiększenie stopnia stosowania siępacjentów do zaleceń dotyczących przyjmowania. Preparatygeneryczne cyklosporyny, mykofenolanu mofetylu (MMF) itakrolimusu, uzyskały pozwolenie na dopuszczenie do obrotuw UE.Wnioski:Ze względu na to, że generyczne preparaty inhibitorówkalcyneuryny stają się dostępne, świadczeniodawcy ipłatnicy usług zdrowotnych muszą być świadomi tego, że ichbiodostępność, jest wysoce zmienna i uzależniona od wieluczynników, które nie zostały jeszcze uwzględnione wbadaniach nad biorównoważnością kliniczną. Zmiany wekspozycji ogólnoustrojowej mogą prowadzić do utratyfunkcji przeszczepu lub efektów toksyczności podawanego

156Paweł Szczudło, Marta Hreńczukleku. W interesie biorcy organu i płatnika ważne jest zatemdokonanie oceny dowodów świadczących o bezpieczeństwiei skuteczności każdego zatwierdzonego preparatualternatywnego zawierającego lek o wąskim oknieterapeutycznym stosowanym w transplantologii.Key words: transplantation; tacrolimus; cyclosporineSłowa kluczowe: transplantacja; takrolimus; cyklosporynaINTRODUCTIONDemand for organ transplants in Europe isgrowing fast, largely due to the senescence ofpopulation and increased incidence of such diseases asdiabetes mellitus and viral hepatitis. Resources ofhealth care providers required for transplantation aresubstantial and are increasing steadily, although theyaccount only for a small fraction of total health carecosts. To meet this growing demand for organs, criteriafor organ donation for transplantation and their use arebeing expanded. For example, in many Europeancountries organs from elderly subjects, live donors andnon heart beating donors are increasingly used.Unfortunately, despite of these initiatives and efficacyof transplantology organisations that are responsiblefor organ procurement and distribution, we stillexperience imbalance between available organ poolversus patients who require transplantation. Therefore,organs are considered as valuable materials that shouldbe used appropriately.Transplant recipients require chronic medicalmanagement, including lifetime immunosuppressivetherapy, required to sustain function of a transplantedorgan, preventing return to dialysis therapy, anothertransplantation or death of the transplant recipient.Patients with a transplanted organ must take multipledrugs to control their chronic disease, includingimmunosuppressants, drugs that prevent infections anddrugs to treat comorbidities. A patient with atransplanted organ may take an average of 11 differentdrugs daily. Therefore, the aim of medical managementof the patients treated with immunosuppressants is toavoid loss of a transplanted organ through ensuringhigh safety level due to monitoring of clinicalcondition of the patient as well as monitoring ofconcentrations of drugs with narrow therapeutic indexrepresented by tacrolimus and cyclosporine).Availability of alternative generic drugs, when apatent for an original drug expires, is usuallywelcomed by payers and healthcare providers becausethey can provide better access to drugs and redistributesaved, limited health care resources. The need to stoprapidly increasing costs of health care is generallyaccepted and the development of generic drugs issupported. Government agencies and payer groupsincreasingly use legal regulations and incentives tosupport the use of generic drugs by pharmacists,doctors and patients. Generic alternatives for multipledrugs used by transplant recipients are also available inthe field of transplantology.The process of decision making with regard tosafe launching of tacrolimus based genericformulations must be based on detailed tacrolimusstudies and experience with other tacrolimus genericformulations approved outside of the European Union(EU). Authorities must take into considerationavailable evidence and expert opinions regarded asparticularly important for the interested parties(surgeons, doctors, pharmacists and payers) inproviding and funding transplantological care.Due to the fact that generic tacrolimusformulations are becoming available, health careproviders and health care payers must realize thatbioavailability of tacrolimus class member ofcalcineurin inhibitor, is highly variable and depends onmultiple factors that have not yet been included inbioequivalence studies and are currently required toapprove generic formulations. Bioavailability ofcalcineurin inhibitors is of particular importancebecause these drugs have narrow therapeutic index(NTI), and changes of drug exposure may depend onthe type of the formulation. Other factors affectingsystemic exposure includes clinical condition of thepatient, drug to drug interactions, patient geneticmaterial and concomitant food intake. Changes insystemic exposure may result in transplant loss or drugtoxicity. Therefore, in the best interest of both organrecipient and payer is to evaluate evidence supportingthe safety and effectiveness of any alternativetacrolimus formulation that has been approved.Previous experience with generic cyclosporineformulations, another calcineurin inhibitor, raisedconcerns over therapeutic equivalence of these genericalternative drugs, which were related to the evidenceindicating worse clinical outcomes obtained in certaincases. Therefore, caution must be exercised inprescribing or dispensing these drugs when alternativeformulations are available.

Variability of drugs with narrow therapeutic window in transplantology - potential costs and clinical consequences 157Practical aspects of switching tacrolimusformulations also have the highest priority with regardto ensuring full patient safety. Prograf (originaltacrolimus) should not be converted to other tacrolimusformulations and other tacrolimus formulations shouldnot be converted between them without monitoring ofblood levels of these drugs to ensure that systemicexposure for this drug (area under curve, AUC)remains unchanged. Furthermore, immunosuppressantsshould be converted only by transplantologists.Substitution of tacrolimus formulations requires carefulcooperation between subjects responsible for continuedcare – one has to be sure that errors related to use of adrug, e.g. wrong drug substitution, will not bedetrimental for the treatment effectiveness. Variousparties involved in organ transplantation – startingfrom decision makers, registration authorities andpayers to doctors, patients and manufacturers – sharethe responsibility and have a common interest inmaintaining transplant function after the procedure oftransplantation. Costs related to the treatment failureare enormous, both for patients and for the health caresystem. Evaluation of total costs of transplantationobviously demonstrates that effective treatment withimmunosuppressants to preserve normal function of atransplanted organ should remain priority. Relativelysmall reduction of costs of purchase that could resultfrom use of different tacrolimus formulations couldprove cost ineffective if clinical effectiveness and drugsafety are concomitantly reduced.Therefore a decision to use a generic formulation ofe.g. tacrolimus in a patient with a transplanted organ isof great importance. Health care providers and healthcare payers should carefully consider availableevidence and potential clinical and practicalconsequences of their decisions before they allowtreatment with alternative tacrolimus formulations ortheir uncontrolled substitution in pharmacies.Suggestions for safe combination of varioustacrolimus formulations in clinical practice• Changes in immunosuppressive therapy should bemade only by doctor experienced in this method oftreatment and in management of patients withtransplanted organs. Such changes should beaccompanied by proper monitoring of drugconcentration in patient’s blood.• Health care professionals who are responsible forcare of patients with transplanted organs should beaware of differences between tacrolimusformulations.• Doctors who want to be sure that their patientscontinue to receive the same tacrolimusformulation can:- decide to maintain control by prescribing thesame brand of the drug;- include specific instructions in protocols ofcommon patient care and in referrals.- prepare guidelines ensuring that the patient istreated with the same tacrolimus formulationunless clinical circumstances require drugswitching;- discuss relevant clinical evidence andguidelines with:• collaborators from the transplantationcenter,• hospital and regional pharmacists,• Drug and Therapy Committee,• primary care physicians.• Doctors should ensure that patients receivecomplete information explaining the use of thedrug with critical doses, so patients should beinformed and aware:- which formulation was prescribed by theirdoctor;- learn and recognize brand of the formulation;- understand the importance of consistentimmunosuppressive therapy;- those changes of immunosuppressive therapyshould be made only under strict supervision ofa transplantologist.LAUNCHING GENERIC DRUGS IN EU -INCREASED ROLE OF GENERIC DRUGSClearly, society benefits from generic drugs aremainly related to the reduced costs ofpharmacotherapy. European Generic MedicinesAssociation (EGA) estimates that use of generic drugsin EU results in annual 20 billion euro savings bypatients and health care systems [1] . Generic drugs arevery important for patients who cannot afford high feesrelated to co-payments for drugs in certain EU memberstates, in particular in new EU member states withdeveloping health care markets [2] .Proper substitution of original innovative drugswith generic drugs in the EU may result in reduction ofincreasing health care costs. Such policy maypotentially lead to substantial cost reduction.Importance of generic drugs for optimal use of limitedhealth care budgets is appreciated in all therapeutic

158Paweł Szczudło, Marta Hreńczukfields. In 2007 generic drugs accounted for 17.8% ofall drugs costs in the EU [3] .Availability of cheaper genericimmunosuppressants may lead to increased drugavailability and therefore to improvement of healthcare quality, may also result in increased patientcompliance where health care resources are limited [4,5] .Generic formulations of prednisone, azathioprine,cyclosporine and recently also mycofenolate mofetil(MMF) received marketing authorization. Since itsapproval, generic azathioprine became a commonlyused drug in the USA [6] and in Europe (for example,generic azathioprine accounted for 79% of sales ofazathioprine in the United Kingdom [7] ). Adoption ofgeneric cyclosporine, that, unlike azathioprine, has anarrow therapeutic index, was much more cautious.In 2007 immunosuppressants accounted for only1.4% of total drugs expenditures in the EU; thisnumber includes drugs used in the treatment ofrheumatoid arthritis and other indications unrelated toorgan transplantation [3] .Generic drugs expenditures accounted for 3.2% oftotal cost of immunosuppressive therapies. Fig. 1presents immunosuppressant expenditures in variousEuropean countries, as a function of total drug costs in2008 (from January to September) [3]IMS MIDAS-MAT, September 2008.* Only retail salesIMS MIDAS-MAT, wrzesień 2008r* sprzedaż aptecznaFig. 1. Immunosuppressant expenditures in various Europeancountries as a function of total drug expenditures in2008 (from January to September) [3]Ryc. 1. Wydatki na leki immunosupresyjne w różnych krajacheuropejskich w funkcji łącznych wydatków na leki wroku 2008 (od stycznia do września) [3]APPROVAL OF GENERIC DRUGS IN THE EUTo receive approval (marketing authorization) for ageneric drug, such drug must be proven bioequivalentto an innovative (reference) drug.To demonstrate bioequivalence, the manufacturermust prove that:• qualitative and quantitative composition of activeingredients of a generic drug are comparable to thatof an innovative drug with regard to pharmaceuticalcharacteristics and• relative bioavailabilities of these two drugs exhibitacceptable similarity.This is the base to assume that there is a therapeuticequivalence of a generic and innovative drug.There are three procedures to approve drugs in theEU. According to the first, “central” procedure, amarketing authorization application is submitted toEMA (to undergo scientific evaluation by its advisorycommittee, CHMP) and if it is approved, marketingauthorization granted by European Committee is validin all EU member states. “National” and “mutualrecognition” procedures allow the manufacturer togradually receive national approvals for the EUterritory basing on preliminary scientific evaluationperformed by a main office for registration ofmedicinal products in a member state (“referencemember state”). This evaluation will be the base forother EU member states (“interested member states”)to grant national marketing authorization.After approval, a generic drug may obtain identicalsummary product characteristics as the innovative drugand therefore may be used in the same indications andwith the same safety precautions, while themanufactured is not obliged to demonstrate clinicalefficacy and safety in the target patient population.Clinical efficacy and safety profile of a generic drugand innovative drug are assumed to be the same andthe same drug interactions are expected. Unless provedotherwise, bioavailability is also the basis to supportassumption of interchangeability of a generic drug andinnovative drug in stable patients. There is norequirement to demonstrate efficacy and safety of ageneric drug in patients; however in EU any office forregistration of medicinal products may requiresubmission of additional data to further explain issuesrelated to efficacy and safety of a generic drug if it isjustified by the patient safety and requirements ofpublic health.

Variability of drugs with narrow therapeutic window in transplantology - potential costs and clinical consequences 159DEVELOPMENT OF GENERIC DRUGS IN THE EUDue to lower costs of development, generic drugsare usually cheaper than innovative drugs and usuallyhave larger market share due to sales volume, but notsales value. Their market share largely differs indifferent EU member states [2] .Principles for establishing drug costsBasing on national principles for establishing drugcosts, usually price of an innovative drug is reducedafter expiration of patent protection. However, theseprinciples depend on whether an innovative drug isreimbursed in a national health care system.Regulations and principles of cost limitation also affectthe use of a generic drug, although they may beaffected by historical and economic circumstances inparticular countries. For each member state,reimbursement level may be defined by an initiallydetermined level or depend on market prices,established by free competition between its suppliers.Initiatives have been adopted, both with regard tosupply and demand, to increase the market share ofgeneric drugs, in particular in more advanced genericmarkets (e.g. Germany and United Kingdom) [8] .In countries with “free price establishment” (e.g.Germany, United Kingdom, Poland, the Netherlandsand Denmark), generic drugs usually have largermarket share, than in countries with tighter control ofdrug prices (e.g. Austria, Belgium, France, Italy,Portugal and Spain) [9] . In the latter group, differencesbetween prices of innovative and generic drugs aresmaller.Traditional rules of drug dispensing, legalregulations and incentivesTo reduce health care expenditures forpharmaceutical agents, several EU member states useprinciples of mandatory substitution of innovativedrugs with generic drugs, unless a doctor clearlyindicates otherwise. In other countries genericsubstitution by a pharmacist is allowed, but notmandatory, while some countries do not allow genericsubstitution. However, generic substitution of certaindrug classes, including immunosuppressive drugs withnarrow therapeutic index, is limited in certain memberstates, such as Denmark [10] and Spain [11] .According to an internal analysis prepared byEuropean Generic Medicines Association (EGA) in2006, despite the fact that prescription of generic drugsis mandatory only in 7% of EU member states,incentives for their prescribing are present in 50% ofmember states [12] . Physicians must consider bothpatient therapeutic needs as well as financialconsequences related to any prescription issued bythem, because not all drugs are reimbursed and incertain countries there may be some financialincentives to prescribe generic drugs (or penaltieswhen planned expenditures are exceeded whenphysicians have their budgets). In many countriesphysicians have tools and databases for electronic drugprescribing, guideline protocols and formularies.In many countries (e.g. in the United Kingdom)there are incentives to encourage physicians to enterinternational non-proprietary names (INN) on theirprescriptions. However, regulations differ with regardwhether such practice is obligatory and if this practiceis not preferred by a pharmacist’s remunerationsystem, it not universally results in dispensing genericdrugs [12] . In certain countries (e.g. in France),physicians are required to prescribe certain fraction ofgeneric drugs, while in another countries (such asLithuania) physicians must use international nonproprietarynames on their prescriptions for drugs to bereimbursed [12] . Only in Portugal physicians arerequired to use international non-proprietary names ontheir prescriptions if generic alternative is available [12] .Payer groupsPayer groups (e.g. insurance companies that offerhealth insurances and foundations) usually decidewhich drugs are prescribed and dispensed and they canimplement rules promoting the use of generic drugs, inparticular if the price difference between generic drugsand brand innovative drugs is substantial.Patient co-paymentThere are patient co-payment systems in majorityof countries where a patient contributes to the costs ofhis/her treatment [12] . When there is a differencebetween a price of a brand of innovative drug and ageneric drug, patient may be obliged to cover the pricedifference to be able to continue treatment withinnovative (original) drug. Therefore, patient ability orwillingness to contribute to the treatment costs maypartially affect the use of generic and innovative drugs.However, when there is a lump-sum (or constant) copaymentor when insurance companies fully reimbursecosts of co-payment for drugs, patients have smallermotivation to prefer therapies based on generic drugs.

160Paweł Szczudło, Marta HreńczukDifferent principles of establishment of drug prices anddrug reimbursement in the EU result in totally differentuse of generic drugs in various countries. Physiciansremain responsible for ensuring safe and cost-effectivetreatment of patients. However, options available forphysicians regarding the limitation of substitution ofinnovative drugs with generic alternative drugs alsodiffer in different countries.FUTURE TRENDSDemographic changes and increasing costs ofhealth care in EU countries clearly indicate that atendency to expand the use of generic drugs willcontinue. It is also probable that actions will be takento ensure more homogeneity in drug policy in the EU.The requirement for the reduction of health care costswill be increasing, but patient needs and safety shouldremain the priority.Traditional policy of launching and reimbursementof generic drugs may generally contribute to theintroduction of safe and effective drugs withconcurrent limitation of health care expenditures.Patients with transplanted organ require lifetimeimmunosuppressive therapy to prevent rejection of thetransplanted organ. Immunosuppressive treatment isindividualized only by transplantologists. Therefore itis important for decision makers and other persons whoare involved into decisions making related to drugprescription, to be aware that the presence of even verysmall differences between generic and innovativeformulations of immunosuppressants may establishrisks or benefits related to the conversion betweenalternative formulations in individual patients.6. Haroldson JA, Somerville KT, Carlson S, et al. Aretrospective assessment of safety, efficacy andpharmacoeconomics of generic azathioprine in hearttransplantrecipients. J Heart Lung Transplant 2001; 20:372-4.7. IMS Health, BPI/HPAI/MAT 12/2008.8. Simoens S, De Coster S. Sustaining generic medicinesmarkets in Europe; 2006. Available atwww.egagenerics.com/doc/simoens-report_2006-04.pdf. Last accessed on: 6 October 2008.9. Burgermeister J. Generic medicines could rescue EUgovernments’ spending. BMJ 2006; 332: 992.10. Danish Drug Agency. Bioequivalence and labelling ofmedicinal products with regard to generic substitution.Availableatwww.dkma.dk/1024/visUKLSArtikel.asp?artikelID=6437. Last accessed on: 15 October 2008..11. Agencia Española de Medicamentos y ProductosSanitarios. Ministerstry of Health and Consumer Issues,18994, regulation datek 12 November 2008.12. Perry G. The European generic pharmaceutical marketin review: 2006 and beyond. Journal of GenericMedicine 2006; 4: 4-14.Address for correspondence:M.D. Paweł SzczudłoAstellas Pharma Sp. z o.o. Poleczki 2102-822 Warsaw Polande-mail: pawel.szczudlo@gmail.commobile+48 608 336 159Received: 10.01.2012Accepted for publication: 6.03.2012REFERENCES1. European Generic Medicines Association. EGA factsheet on generic medicines. Available atwww.egagenerics.com/doc/ega_factsheet-01.pdf. Lastaccessed on: 6 October 2008.2. European Generic Medicines Association. Available atwww.egagenerics.com/gen-geneurope.htm. Lastaccessed on: 6 October 2008.3. IMS MIDAS-MAT, September 2008.4. Alloway RR, Isaacs R, Lake K, et al. Report of theAmerican Society of Transplantation conference onimmunosuppressive drugs and the use of genericimmunosuppressants. Am J Transplant 2003; 3: 1211–5.5. Sabatini S, Ferguson RM, Helderman JH, et al. Drugsubstitution in transplantation: a National KidneyFoundation White Paper. Am J Kidney Dis 1999; 33:389-97.

Medical and Biological Sciences, 2012, 26/1, 161-167ORIGINAL ARTICLE / PRACA ORYGINALNAMonika Zawadka 1 , Paweł Zalewski 1 , Jacek J. Klawe 1 , Małgorzata Tafil-Klawe 2 , Joanna Pawlak 1 ,Krzysztof Kunikowski 3 , Anna Bitner 1CARDIOVASCULAR AUTONOMIC REGULATION IN RESPONSETO ORTHOSTATIC STRESS WITH PARKINSON’S DISEASE – CASE REPORTAUTONOMICZNA REGULACJA SERCOWO-NACZYNIOWA W ODPOWIEDZINA PIONIZACJĘ U PACJENTÓW Z CHOROBĄ PARKINSONA – STUDIUM PRZYPADKU1 Chair and Department of Hygiene and Epidemiology Nicolaus Copernicus University in ToruńCollegium Medicum in BydgoszczHead: prof. dr hab. Jacek J. Klawe2 Chair of Physiology, Department of Human Physiology Nicolaus Copernicus University in ToruńCollegium Medicum in BydgoszczHead: prof. dr hab. n. med. Małgorzata Tafil-Klawe3ALAB Laboratory, Military Hospital, No 10, BydgoszczSummaryBackground and purpose. The mostcommonly reported disturbances of ANS function in PD arecardiovascular symptoms. The aim of the study was toevaluate hemodynamic parameters and heart rate variabilityin response to orthostatic stress in patient with Parkinson’sdisease.M a t e r i a l a n d m e t h o d s . In our study we usedTask Force Monitor System designed for non-invasivemeasurement of cardiovascular system and assessment offunctional autonomic nervous system. The device measuresand calculates hemodynamic parameters such as: cardiacoutput (CO), cardiac index (CI) stroke volume (SV), heartrate (HR), RR-Interval (RRI), Total Peripheral Resistance(TPR) and systolic (sBP), diastolic (dBP), mean (mBP)blood pressures [25;26]. Estimated parameters of heart ratevariability (HRV) spectral analysis: LFnu-RRI, HFnu-RRI,LF-RRI, HF-RRI, PSD-RRI, LF/HF.Results and conclusions. Parkinson’sdisease causes autonomic dysfunctions leading toabnormalities in cardiovascular regulation. Dysautonomia inParkinson’s disease patient is demonstrated by decreasedheart rate variability (HRV). The head up tilt test revealed adecreased LF/HF ratio and sympathovagal balance disordersStreszczenieWstę p i c e l p r a c y . W chorobie Parkinsonanajczęściej zgłaszanymi objawami uszkodzeniaautonomicznego układu nerwowego są zaburzenia sercowonaczyniowe.Celem badania była ocena parametrówhemodynamicznych krwi i zmienności rytmu serca wodpowiedzi na pionizację.Materiał i m e t o d y . W badaniu wykorzystanosystem Task Force Monitor służący do nieinwazyjnegobadania układu sercowo-naczyniowego czynnościowej ocenyautonomicznego układu nerwowego W sposób nieinwazyjnyokreślano: pojemność minutową (CO), wskaźnik sercowy(CI), objętość wyrzutową (SV), częstość pracy serca (HR),interwał RR (RRI) całkowity naczyniowy opór obwodowy(TPR) oraz skorygowane ciśnienie skurczowe(sBP),rozkurczowe (dBP), ciśnienie średnie (mBP) mierzonemetodą ciągłą. Oceniano następujące parametry zmiennościrytmu serca (HRV): LFnu-RRI, HFnu-RRI, LF-RRI, HF-RRI, PSD-RRI, LF/HF.Wyniki i wnioski. Choroba Parkinsonaprowadzi do zaburzeń w układzie sercowo-naczyniowym.

162Monika Zawadka et. al.Dysautonomia w chorobie Parkinsona manifestowana jestpoprzez zmniejszoną zmienność rytmu serca (HRV). Testpochyleniowy wykazał zmniejszenie współczynnika LF/HForaz zaburzoną równowagę współczulno-przywspółczulną.Key words: Parkinson’s disease, heart rate variability (HRV), cardiovascular regulationsSłowa kluczowe: choroba Parkinsona, zmienność rytmu serca (HRV), regulacja sercowo-naczyniowaINTRODUCTIONParkinson’s disease (PD) is a neurodegenerativedisorder associated not only with motor symptoms butalso with autonomic nervous system (ANS)dysfunction. The overall prevalence of autonomicsymptoms varies from 76% to 93% and may antedatemain motor symptoms by years [1;2;3;4,]. In idiopathiccases of PD these autonomic dysfunctions can beexplained by damage to neurological structures [7].Although mechanisms of their formation have not beenthoroughly known, they are probably related toaccumulation of Lewy bodies in the central andperipheral nervous system [9]. Lewy bodies can be alsoseen in autonomic regulatory region, includinghypothalamus, sympathetic (intermediolateral nucleusof the thoracic cord and sympathetic ganglia), andparasympathetic system (dorsal, vagal, and sacralparasympathetic nuclei) [10;11].Since PD involves postganglionic sympatheticnoradrenergic lesions, the disease seems to be not onlya movement disorder with dopamine loss in thenigrostriatal system of the brain, but also adysautonomia with norepinephrine loss in thesympathetic nervous system of the heart [7]. The mostcommonly reported disturbances of ANS functioningin PD are cardiovascular symptoms, i.e. orthostatichypotension, decreased heart rate variability, reversalof circardian rhythm [8,9]. Cardiovasculardysautonomia is an integral part of the disease and atleast 20% of PD patient suffer from orthostatichypotension (OH). Symptoms may be non specificwith generalized weakness and lethargy, dizziness mayalso occur [10].Most patients with Parkinson’s disease haveincreased heart rate and experience inversion of normaltrend 24-h blood pressure pattern, with highestpressures at night and lowest in the morning [4].Considering assessment methods (invasive/noninvasivemeasure) and patient groups (different stageof disease) with Parkinson’s disease, 24-h bloodpressure measurement revealed decreased, normal orincreased values [11]. Significance of cardiovascularregulation disorders among PD patients is not yet fullyknown. It is possible that the dysbalance of thesympathetic and the parasympathetic activity isconnected with arrhythmias and may cause ischaemicheart muscles [1].Presence of dysautonomia depended mainly onmethod of assessment. Analysis of heart rate variation(HRV) has become a popular noninvasive tool forassessing activities of the autonomic nervous system(ANS), which reflects the balance between thesympathetic and parasympathetic nervous system [12].Heart rate variability involves a complex interactionbetween several mechanisms working to maintain heartrate and blood pressure within normal limits [13].Many factors influence heart rate and displayenormous variability of measured parameters such asage, drugs, breathing frequency, physical exercise andorthostatic stress [12]. It is also presumed that there is aconnection between the autonomic dysbalance andhigh mortality among Parkinson’s disease patients [1].Additionally, aging is associated with decreased HRV,particularly HF component, reflecting a reducedcardiovascular autonomic control [14]. It is stillunclear whether the disease itself or its treatment is thecause of ANS failure. For the evaluation ofcardiovascular autonomic control, the current bedsidegolden standard is the study of cardiovascular reflexesand it has been suggested that these reflexes can evenreveal ANS dysfunction in untreated patients withearly Parkinson disease [7]. The aim of the study wasto evaluate hemodynamic parameters and heart ratevariability in response to orthostatic stress inParkinson’s disease patient.MATERIAL AND METHODWe report a case of an 84-year-old man with an 8-year history of Parkinson’s disease (BMI=26.6).Patient was in IV stage of Hoehn-Yahr (H-Y) scale50% in Schwab-England scale.

Cardiovascular autonomic regulation in response to orthostatis stres with Parkinson's disease - case report 163Table I. Characteristic of patient with Parkinson’s diseaseTabela I : Charakterystyka pacjenta z chorobą ParkinsonaAgeWiek[years][lata]WeightWaga[kg]HeightBMIWzrost[kg/m2][cm]Duration ofillnessH&YCzas trwaniachoroby [years][lata ]Activities ofdaily livingAktywnośćdniacodziennego84 75 168 26.6 8 IV 50%Medications[mg]LekiMadopar 750Madopar HBs1000H&Y scale is commonly used to assess disease’sseverity and symptom progress of PD, ranging betweenstages 1 to 5. [15,16]. The Schwab and England Testwas used to evaluate the daily living activities. [16]. Inour study we used Task Force Monitor Systemdesigned for non-invasive measurement ofcardiovascular system and assessment of functionalautonomic nervous system. Task Force Monitor® wasused for non-invasive beat-to-beat measurement of thepatient’s hemodynamic parameters and heart ratevariability (HRV). Tilt testing was chosen as the mostappropriate way of evaluating the patient’s symptomsafter normal findings on non-invasive assessment [13].System Task Force Monitor is composed of:impedance cardiography (ICG), electrocardiography(ECG), oscillometric BP (osc BP), continuous BP(cont BP) [11,17]. Six electrodes were placed on thethorax of the patient, one on the neck and one on theleg. Furthermore, one cuff for the oscillometric bloodpressure measurement was placed on upper arm of thepatient and the other cuff for the continuous bloodpressure was placed on the fingers. Task Force MonitorSystem measures and calculates hemodynamicparameters such as: cardiac output (CO), cardiac index(CI) stroke volume (SV), heart rate (HR), RR-Interval(RRI), Total Peripheral Resistance (TPR) and systolic(sBP), diastolic (dBP), mean (mBP) blood pressures[17, 11].Before the test, patient was informed about theprocedure of the study. Fasting was required for 2-3hour before the test. Study procedures were performedin a silent room with ambient temperature of 23 to 26C and stable humidity. The subject was studied in themorning and instructed to remain in resting position forat least 40 minutes. The study consisted of 3 phases:01- supine position before pionization, duration about:6 min; 02- upright position, duration: 5 min; 03-resting, supine position, duration: 5 min. Patient inphase 02 was tilted upright to angle 60° on an electricaltilt table with feet support and chest and knee straps.During the entire procedure blood pressure and heartrate were monitored continuously byelectrocardiography (ECG) and fingerplethysmography.Heart rate variability spectral analysisHeart rate variability (HRV) representscardiovascular control mediated by the autonomicnervous system and other mechanisms. In theestablished task, force HRV monitoring differentcardiovascular control mechanisms can approximatelybe identified at typical frequencies of heart rateoscillations by power spectral analysis [13, 14].Table II. Parameters of heart rate variability spectralanalysisTabela II. Parametry analizy widmowej zmienności rytmusercaParameter(parameter)LFnu-RRIHFnu-RRILF-RRIHF-RRIPSD-RRILF/HFParameters of heart rate variability spectral analysisParametry analizy widmowej zmienności rytmu sercaDescription (opis)Normalized unit In low frequency domain HRV(Znormalizowana składowa w zakresie niskichczęstotliwości HRV)Normalized unit In high frequency domain HRV(Znormalizowana składowa w zakresie wysokichczęstotliwości HRV)Heart rate variabilty LF(Składowa widmowa wysokiej częstotliwościwidma HRV)Heart rate variability HF(Składowa widmowa wysokiej częstotliwościwidma HRV)Power spectra density(Widmowa gęstość mocy HRV)Sympatho-vagal balance (LF_RRI/HF_RRI)(Współczynnik balansu współczulnoprzywspółczulnegoUnit(jednostka)[%][%][ms 2 ][ms 2 ][ms 2 ]Very low frequency (VLF) (below 0.03 Hz)describes activity of chemoreceptors, dependent onvasomotor, and thermoregulatory reflexes theparticipation of renin-angiotensin-aldosterone system.Low frequency (LF) ranged (0.04-0.15 Hz) is a resultof oscillatory alterations, R-R-intervals, andconcomitant pressure changes due to stimulation ofbaroreceptors. It corresponds with sympathetic activityof ANS. High frequency power (HF) (0.15 to 0.4 Hz);absolute values in milliseconds squared. The HFdetermines direct component related to activity ofnervus vagus and respiratory rhythm, and displaysactivity of parasympathetic parts of ANS. The LF/HFratio is considered, by a lot of investigators to mirrorsympatho-vagal balance or to reflect the sympatheticmodulations in numerous physiologic andpathophysiologic conditions. High values for the ratiosuggest a higher sympathetic nervous variability. The[1]

164Monika Zawadka et. al.results of LF, HF components are presented in absoluteunits [ms 2 ] of spectrum power as well as in normalizedunits, in this case percentage of [%] total spectrumpower without VLF component. According to availableliterature, components: LFnu-RRI, LF-RRI arecollerated with sympathetic activity of ANS, whereas:HFnu-RRI, HF-RRI connected with parasympathetic.Task Force Monitor System uses autoregressiveparameters uses adaptive algorithm [12, 13, 18].Description of heart rate variability spectral analysis ispresented in table II.RESULTSAnalysis of heart rate variability during tilt testshowed significant differences in all phases of thestudy. Obtained results are presented in mean values intable 2. Values of normalized units (LFnu-RRI, HFnu-RRI) in supine position (01) were following: LFnu-RRI 01 =80.635; HFnu-RRI 01 =19.365. Our studyrevealed decreased values of LFnu-RRI 02 (72.974) andincreased HFnu-RRI (27.026) in upright position.These results indicate an increase of parasympathetictone in response to head up tilt test. Power spectrum inthe low frequency domain (LF-RRI) in supine position(01) was 27.918, while in upright position (02) itincreased to 35.53. Power spectrum in high frequencydomain also underwent essential changes at particularphases of the study. In phase (01) HF-RRI was 5.193,in the upright position (02) the value increased to 9.29(HF-RRI). Time analysis of particular normalized unitsof HRV confirms stimulating effect of sympatheticnervous system. Values of spectral power density(PSD-RRI) were following: (01) PSD-RRI= 56.623,(02) PSD-RRI = 99.501, (03) PSD-RRI= 76.699. Ourstudy revealed increased values of PSD-RRI in uprightposition (02). The LF/HF power ratio decreased by50.6% compared with the supine value, (from 4.448 to2.248). Analysis of parameters of heart rate variabilityis presented in table III.We also measured hemodynamic response totilting. The analysis of hemodynamic parameters (SV,CO, TPR) in tilt test revealed no significant differencesthan those expected for patient’s age.At rest, from supine to upright position (02) valueof stroke volume (SV) and cardiac output (CO)typically decreased.Furthermore, return to supine position (03) showedincreased values of SV and CO but they were lowerthan in phase 01. Our study also revealed increasedvalues of total peripheral resistance (TPR) on tiltingand decreased after supine position. Upright position(02) resulted with the increase in sBP, dBP and mBPvalues. Our findings showed no significant increase ofheart rate in response to orthostatic stress. Value ofRR-Interval (RRI) in supine position (01) was794.868, in upright position (02) it decreased to782.013. Analysis of hemodynamic parameters ispresented in table IV, V. Normal (resting) results areplaced in brackets according to quoted literature- tableIV [17].Table III. Mean values of heart rate parameter.Tabela III. Średnie wartości parametrów zmienności rytmuserca (HRV)Parameter(Parametr)Unit(Jednostka)Meanvalues(Średniewartości)Supineposition(Leżenienaplecach)01Meanvalues(Średniewartości)Uprightposition(Pozycjapionowa)02Mean values(Średniewartości)Restingposition(Pozycjaspoczynkowa)03LFnu-RRI [%] 80.635 72.974 78.12HFnu-RRI[%] 19.365 27.026 21.88LF-RRI [ms 2 ] 27.918 35.53 42.495HF-RRI [ms 2 ] 5.193 9.29 6.014PSD-RRI [ms 2 ] 56.623 99.501 72.699LF/HF [1] 4.448 2.248 2.564Table IV. Basic statistics cardiovascular parameter and totalperipheral resistanceTabela IV. Statystyka podstawowych parametrów sercowonaczyniowychoraz całkowitego oporuobwodowegoMean(Średnia)Mean(Średnia)Mean(Średnia)Supine Upright RestingUnitParameterposition position position(jednostka)(Parametr)(Leżenie na (Pozycja (pozycjaplecach)01pionowa)02spoczynkowa)03SV [ml] 76.396 66.763 73.834CO [l/min] 5.769 5.125 5.55CI [l/(min*m 2 )] 3.071 2.728 2.954TPR [dyn*s/cm 5 ] 1141.124 1364.962 1054.481SV- stroke volume (objętość wyrzutowa) (60-120 ml)CO- cardiac output (pojemność minutowa) (4-8 L/min)CI- cardiac index (wskaźnik sercowy) (2.5-4.5 L/min/m 2)HR- heart rate (częstość akcji serca) (60-90 bpm)sBP- systolic blood pressure (skurczowe ciśnienie tętnicze) (90-129 mmHg)dBP- diastolic blood pressure (rozkurczowe ciśnienie tętnicze) (50-84 mmHg)mBP- mean blood pressure (średnie ciśnienie tętnicze) (

Cardiovascular autonomic regulation in response to orthostatis stres with Parkinson's disease - case report 165Table IV. Basic statistics of heart variability parameters such as:systolic, diastolic and corrected mean blond pressuremeasured constantlyTabela IV. Statystyka podstawowa parametrów zmienności rytmuserca, systolicznego, diastolicznego oraz skorygowanegociśnienia średniego krwi, mierzonego metodą ciągłąMean(Średnia)Mean(Średnia)SupineUprightParameter Unit positionposition(parameter) (jednostka) (Leżenie(Pozycjanapionowa)plecach0201RRI [ms] 794.868 782.013 800.282HR [1/min] 75.545 76.755 75.154sBP [mmHg] 116.001 120.058 104.46dBP [mmHg] 68.0017 73.946 59.355DISCUSSIONMean(Średnia)Restingposition(Pozycjaspoczynkowa)03MBP [mmHg] 85.214 90.282 75.508Spectral analysis of heart rate variability has beenused to explore dynamic mechanisms in thecardiovascular system and sympathovagal interactions.In normal subjects, the autonomic response to head uptilt test has been well documented. Increased LF powerand decreased HF power, as well as an increasedsympathovagal balance, reflect the normal response toupright tilt [13].Our study indicates that patients with Parkinson’sdisease have a different autonomic response toorthostatic stress. Head up tilt test revealed a declineLF/HF power ratio after they assumed the uprightposition. These results show an increase inparasympathetic tone and decrease in sympathetic.These findings agree with those of Mastrocola et al.who also reported increased low frequency powerdomain [19]. Our results confirm the sympathovagalbalance disturbances found in previous HRV studies.Furthermore, the heart rate variability abnormalitiesmight therefore present a cardiovascular mortality risk[12]. Additionally, decreased sympathetic tone is alsocharacteristic for healthy elderly. The results show thatthe heart rate variability decreases with aging.In our study we also measured hemodynamicresponse to tilting. On standing, the rapid migration ofblood from thorax to the lower parts of body results ina decrease in venous return and fall in cardiac output.These changes promptly activate compensatorymechanisms, with a consequent increase in heart rateand total peripheral resistance. The most importantcompensatory mechanism is an increase in sympatheticactivity, which results with a 25% acceleration of HRand increase in myocardial contractility [20, 13].Normal cardiac response to orthostatic stress isacceleration of HR by 5-20 bpm [21]. In our patientmean value of heart rate slightly increases. In phase 01HR was 75.55 bpm, HR in phase 02 was 76.75 bpm.Several studies on heart rate variability measures alsoconfirm our findings. In the study by Niehaus et al.,head up tilt test provoked smaller HR increases inParkinson’s patient than in healthy subjects [4].Parkinson's disease is known to affect the reflex ofcardiovascular control systems, resulting in asuppressed heart rate variability, which is apathological phenomenon indicating disorders inactivity of autonomic system (decreased activity ofparasympathetic system) [20]. Our results demonstratethat values of resting blood pressure (sBP, dBP, mBP)in our 84- old patient are lower than in his age group,probably as a consequence of diminished ability tosecrete rennin [22]. These findings agree with those ofBarbeau et al., Aminoff and Wilcox who also reportedresting blood pressure lower than expected for age andsex. Those disorders are due to baroreceptor reflexdamage, one of the main RR regulations [4]. Whileblood pressure responses during orthostatic stressdepend on the sympathetic activity and changes inperipheral vascular resistance, heart rate alterationsduring orthostatic stress are mainly vagally mediatedand contribute to a lesser extent to blood pressure. Thecontribution of heart rate to maintaining blood pressurebecomes more important in the elderly, especiallysince the sympathetic tone decreases with age [23].Additionally, these symptoms may be intensifiedby drugs used in PD treatment. It is still unclearwhether the disease itself or its treatment is the causeof ANS failure. In study of Goetz et al. and severalreports usage of levodopa did not show to affectcardiovascular reflexes, whereas Mesec et al.suggested that BP levels at rest are lower duringlevodopa treatment. Levodopa did not suppress theautonomic cardiovascular responses and thesympathetic BP response to tilting [4,24]. Van Dijk etal. have reported that age explained most of the HRvariability (HRV), whereas various PD medicationscontributed to only 7% of HR fluctuation [4]. Theresults of this study displayed that PD interferes notonly with the cardiovascular HR and BP reflexes, butalso with the tonic autonomic regulation of HRV.Assessment of heart rate variability (HRV) and

166Monika Zawadka et. al.hemodynamics parameters in response to tilt testprovide important information about sympathovagalbalance and autonomic regulation in patients withParkinson’s disease. It could be also a first step in theassessment of a possible cardiovascular risk marker[12]. Furthermore, our results demonstrate practicaluse of Task Force Monitor System as a device ofhemodynamic blood parameters measurement andcardiovascular autonomic regulation.CONCLUSIONS1. Parkinson’s disease causes autonomicdysfunctions leading to abnormalities incardiovascular regulation.2. Dysautonomia in a Parkinson’s disease patientis demonstrated by decreased heart ratevariability (HRV).3. The head up tilt test revealed a decreasedLF/HF ratio and sympathovagal balancedisorders.REFERENCES1. Szili-Török T, Dibö G, Kardos A et al.: Abnormalcardiovascular autonomic regulation in Parkinson’sdisease. Journal of clinical and Basic Cardiology.1999; (2): 245-247.2. Korchounov A, Kessler KR, Yakhno NM. Et all.:Determinants of autonomic dysfunction inidiopathic Parkinson’s disease. Journal ofNeurology. 2005; 252 (12): 1530–1536.3. Tykocki T, Mandat T, Nauman P.: Influence ofsubthalamic deep brain stimulation ondysautonomia observed in Parkinson’s disease.Neurologia i Neurochirurgia Polska 2010; 44, (3):277–284.4. Kallio M.: Cardiovascular autonomic dysfunctionin Parkinsonian syndromes. Faculty of Medicine,Department of Clinical Neurophysiology,University of Oulu, 2001.5. Kaufmann H, Goldstein DS.: Autonomicdysfunction in Parkinson's disease. Handbook ofClinical Neurology. 2007; 83: 343-63.6. Łabuz-Roszak B, Pierzchała K.: Selected methodsof autonomic dysfunction evaluation in Parkinson’sdisease. Postępy Psychiatrii I Neurologii. 2008;17(1): 23-28.7. Goldstein DS.: Dysautonomia in Parkinson'sdisease: neurocardiological abnormalities. TheLancet Neurology. 2003; 2 (11); 669 – 676.8. Turkka JT, Suominem K, Tolonen U, SotaniemiKA Myllylä VV.: Selegiline diminishescardiovascular autonomic responses in Parkinson’sdisease. Neurology. 1997; 48: 662-667.9. Krygowska-Wajs A.: Zaburzenia autonomiczne wchorobie Parkinsona. Polski PrzeglądNeurologiczny. 2008; (4A): 13-14.10. Martignoni E, Tassorelli C, Nappi, G.:Cardiovascular dysautonomia as a cause of falls inParkinson’s disease. Parkinsonism&RelatedDisorders. 2006; 12 (4): 195-204.11. Schwalm Torsten. Modern tilt Table Testing andNon-Invasive Monitoring-Traditional andInnovative Applications In Theory and Practise;ABW, Wissenschaftsverlag, 2007.12. Devos D, Kroumova M, Bordet R. et all.: Heartrate variability and Parkinson's disease severity. JNeural Transm. 2003, 110: 997-101113. Kouakam C., Lacroix D., Zghal N. et all.:Inadequate sympathovagal balance in response toorthostatism in patients with unexplained syncopeand a positive head up tilt test. Heart 1999, 82:312-31814. Albinet CT, Boucard G, Bouquet C.A et all.:Increased heart rate variability and executiveperformance after aerobic training in the elderly.Eur J Appl Physiol. 2010;109(4):617-24.15. Altug F, Acar F, Acar G et all.:. The influence ofsubthalamic nucleus Deep Brain Stimulation onPhysical, Emotional, Cognitive Functions andDaily Living Activities in Patients with Parkinson’sDisease. Turkish Neurosurgery 2011, 21, (2), 140-14616. Wolfgang Fries, Ingeborg Liebenstund.Rehabilitacja w chorobie Parkinsona; Elipsa-Jaim,Kraków, 2002.17. Zalewski P., K. Słomiński, Jacek J. Klawe,Małgorzata Tafil-Klawe.: Ocena czynnościowaautonomicznego układu nerwowego z użyciemsystemu Task Force Monitor. Acta Bio-Opt. Inf.Med., Inżynieria Biomedyczna, 2008 Vol. 14 nr 3s. 228-234.18. Fortin J, Klinger Th, Wagner Ch, Sterner H,MadriThe Task Force Monitor–A Non-invasiveBeat-to-beat Monitor for Hemodynamic andAutonomic Function of the Human Body.Proceedings of the 20 th annual InternationalConference of the IEEE Engineering in Medicineand Biology Society; 1998 29 Oct-1 Nov; HongKong.19. Mastrocola C, Vanacore N, Giovani A, et all.:Twenty-four-hour heart rate variability to assessautonomic function in Parkinson’s disease. ActaNeurol Scand 1999: 245-247.20. Dobosiewicz A, Puchalska L, Abramczyk P.:Występowanie atypowej odpowiedzi na aktywnąpionizację u osób z chorobami układu krążenia.Kardiologia Polska. 2009; 67 (6): 672-676.21. Diagnostyka autonomicznego układu nerwowego izaburzeń snu J. Jörg. red.nauk. Ryszard Podemski,Wydawnictwo Elselvier Urban&Partner, Wrocław2006.

Cardiovascular autonomic regulation in response to orthostatis stres with Parkinson's disease - case report 16722. Brevetti G, Bonaduce D, Breglio R. et all.:Parkinson’s Diesease and Hypotension: 24 –HourBlood Pressure Recording in Ambulatnt Patients.Clinical Cardiology. 1990; 13: 474-478.23. Czajkowska H, Tutaj M, Rudzińska M, Motyl M,Bryś M et all. Cardiac responses to orthostaticstress deteriotate in Parkinson disease patients whobegin to fall. Neurologia I Neurochirurgia Polska.2010; 44 (4): 339-349.24. McDowell FH, Lee JE.: Levodopa, Parkinson,sdisease and hypotension. Annals of InternalMedicine. 1970; 72: 751-752.Address for correspondence:Monika ZawadkaDepartment of Hygiene and Epidemiology,Collegium Medicum in BydgoszczM. Skłodowskiej-Curie 9 Street85-094 Bydgoszcze-mail: monikazawadka@poczta.onet.pltel: 504099619Received: 10.01.2012Accepted for publication: 6.03.2012

Medical and Biological Sciences, 2012, 26/1, 169-175Aneta Zreda-Pikies, Andrzej KurylakEVALUATION OF THE QUALITY OF LIFE OF CHILDREN WHO HAVE COMPLETEDACUTE LYMPHOBLASTIC LEUKAEMIA TREATMENTOCENA JAKOŚCI ŻYCIA DZIECI PO ZAKOŃCZONYM LECZENIUOSTREJ BIAŁACZKI LIMFOBLASTYCZNEJDepartment of Paediatric Nursing, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in ToruńHead: Aneta Zreda-Pikies, Andrzej KurylakSummaryI n t r o d u c t i o n . The progress in treating lifethreateningdiseases, which led to an increased number ofcured persons, forces us to look closely at the functioning ofpatients after completed treatment. The results of ALLtreatment which apply to children have been improvingsystematically for the past years. At present over 80 percentof children are considered to be cured; therefore, it isjustified to evaluate the quality of their life. Learning asubjective evaluation of the quality of life may be a source ofinformation which often differs from the evaluation made bymedical staff or sick children’s parents. The informationmight indicate existence of non-perceived needs of patientswho require specialist care and help outside the hospitalenvironment. As far as the following paper is concerned, anattempt was made to determine the connection betweenchosen factors (sex, age at the time of diagnosis, age at thetime of examination, time that passed from treatmentcompletion, family’s economic situation, parents’ education,place of residence, risk group, treatment program,implementation of CNS radiotherapy) and a subjectiveevaluation of the quality of life of children who haveundergone ALL treatment.M a t e r i a l a n d m e t h o d s . The research wasconducted among patients treated in the Chair and Clinic ofPaediatrics, Haematology and Oncology of CopernicusUniversity Collegium Medicum in Bydgoszcz, whocompleted acute lymphoblastic leukaemia treatment. Itcomprised children whose ALL treatment finished at least 6months prior to the research. The final group of patients whoparticipated in the research consisted of 64 persons. Thenumber of boys and girls was comparable and amounted to33 and 31, respectively. In order to evaluate the quality oflife of children who completed ALL treatment and of healthychildren James W. Varni’s standardized research instrumentwas used.R e s u l t s . The evaluation of general quality of life ofchildren who have completed ALL treatment does notdepend on: patient’s age at the time of diagnosis, age at thetime of examination, sex, place of residence, family’seconomic situation or being in the risk group. The quality oflife conditioned by the state of health depends on:implementation of radiotherapy, the time that passed fromcompleting treatment and parents’ education. The generalevaluation of the quality of life is significantly lower in thegroup of patients who have completed ALL treatment. Themost visible difference pertains to their functioning at school.As the time that passed from treatment completion goes by,the subjective evaluation of physical functioning decreases.Children’s fathers who have higher education evaluate thegeneral quality of life lower than fathers who have educationof a lower degree.StreszczenieWstę p. Postęp w leczeniu chorób zagrażającychżyciu, który spowodował wzrost liczby osób wyleczonychwymusza spojrzenie na funkcjonowanie pacjenta pozakończonym leczeniu. W przypadku dzieci w ostatnichlatach systematycznie poprawiają się wyniki leczenia ALL,obecnie ponad 80% dzieci uznaje się za wyleczone, zasadnąwięc jest ocena jakości ich życia. Poznanie subiektywnejoceny jakości życia może być źródłem informacji, które sąniejednokrotnie odmienne od oceny dokonywanej przezpersonel medyczny, a także rodziców chorych dzieci. Mogąone wskazywać na istnienie niedostrzeganych potrzebpacjentów, wymagających zapewnienia fachowej opieki i

170Aneta Zreda-Pikies, Andrzej Kurylakpomocy poza środowiskiem szpitalnym. W pracy podjętopróbę określenia zależności pomiędzy wybranymiczynnikami (płeć, wiek w chwili rozpoznania, wiek w chwilibadania, czas od zakończenia leczenia, sytuacja ekonomicznarodziny, wykształcenie rodziców, miejsce zamieszkania,grupa ryzyka, program leczenia, stosowanie radioterapiiOUN), a subiektywną oceną jakości życia dzieci pozakończonym leczeniu ALL.Materiał i m e t o d y . Badania przeprowadzonowśród pacjentów leczonych w Katedrze i Klinice Pediatrii,Hematologii i Onkologii Collegium Medicum UniwersytetuMikołaja Kopernika w Bydgoszczy, którzy zakończylileczenie ostrej białaczki limfoblastycznej. Badaniami objętodzieci, które zakończyły leczenie ALL przynajmniej 6miesięcy przed badaniem. Ostateczna liczba osób, biorącychudział w badaniu wynosiła 64. Liczba chłopców idziewczynek była porównywalna i wynosiła odpowiednio 33i 31 osób. Do oceny jakości życia dzieci po zakończonymleczeniu ALL oraz dzieci zdrowych użyto standaryzowanegonarzędzia badawczego autorstwa Jamesa W. Varni.W y n i k i . Ocena ogólnej jakości życia dzieci pozakończonym leczeniu ALL nie zależy od: wieku w chwilirozpoznania choroby, wieku pacjenta w chwili badania, płci,miejsca zamieszkania, sytuacji ekonomicznej rodziny orazprzynależności do grupy ryzyka. Jakość życia uwarunkowanastanem zdrowia jest uzależniona od: stosowania radioterapii,czasu od zakończenia leczenia oraz wykształcenia rodziców.Ogólna ocena jakości życia jest znamiennie niższa w grupiepacjentów u których stosowano radioterapię OUN,najbardziej widoczna różnica dotyczy funkcjonowania wszkole. Wraz z upływem czasu, który minął od zakończenialeczenia obniża się subiektywna ocena funkcjonowaniafizycznego. Ojcowie dzieci, którzy posiadają wyższewykształcenie oceniają ogólną jakość życia gorzej niżojcowie o niższym wykształceniu.Key words: acute lymphoblastic leukemia, quality of lifeSłowa kluczowe: ostra białaczka limfoblastyczna, jakość życiaINTRODUCTIONThe progress in treating life-threatening diseases,which led to an increased number of cured persons,forces us to look closely at the functioning of patientsafter completed treatment. The results of ALLtreatment which apply to children have been improvingsystematically for the past years. At present over 80percent of children are considered to be cured;therefore, it is justified to evaluate the quality of theirlife. Learning a subjective evaluation of the quality oflife may be a source of information which often differsfrom the evaluation made by medical staff or sickchildren’s parents. The information might indicateexistence of non-perceived needs of patients whorequire specialist care and help outside the hospitalenvironment.The purpose of this paper is to determine theconnection between chosen factors (sex, age at the timeof diagnosis, age at the time of examination, time thatpassed from treatment completion, family’s economicsituation, parents’ education, place of residence, riskgroup, treatment program, implementation of CNSradiotherapy) and a subjective evaluation of the qualityof life of children who completed ALL treatment.MATERIALS AND METHODSThe research was conducted among patients treatedin the Chair and Clinic of Paediatrics, Haematologyand Oncology of Nicolaus Copernicus UniversityCollegium Medicum in Bydgoszcz, who havecompleted acute lymphoblastic leukaemia treatment. Itcomprised children whose ALL treatment finished atleast 6 months prior to the research. The final group ofpatients who participated in the research consisted of64 persons. The number of boys and girls wascomparable and amounted to 33 and 31, respectively.The average age of children at the moment of theresearch was 11.3 (4-18 years old, median - 11) and atthe moment of diagnosis - 6 (1-17 years old, median -5). The average age at the moment of falling ill in theanalysed group of 64 children was 6 (median – 5). Thechildren’s age varied from 1 to 17. The majority ofpatients (53.12 percent) were qualified to the standardrisk (SR) group, whereas the intermediate risk (IR)group consisted of 21 patients, i.e. 32.8 percent of allpatients, the high risk group comprised 9 patients(14.05 percent). In order to evaluate the quality of lifeof children who have completed ALL treatment and ofhealthy children, James W. Varni’s standardizedresearch instrument was used [1, 2, 3, 4, 5, 6].Permission to use the questionnaire was granted by theMapi Research Trust Institute in Lyon.RESULTSAn analysis of the collected materials indicates thatthe quality of children’s lives is not affected by theirage at the moment of diagnosis or at the moment ofresearch.

Evaluation of the quality of life of children who have completed acute lymphoblastic leukaemia treatment 171However, there is a connection between the timethat passed from treatment completion and directevaluation of functioning in the physical sphere. Themore time passes from treatment completion, the betterthe results of an evaluation of the quality of life in thesaid sphere. Regardless of the time that passed fromthe treatment completion, the indirect quality of lifeevaluation was similar.Having observed the above correlation, an attemptwas made to evaluate, in detail, the quality of life in allspheres of functioning depending on the time thatpassed from treatment completion.lower than other patients (79.44 vs. 88.41). Thesmallest discrepancy between the groups was foundwithin the sphere of emotional functioning (66.11 vs.73.05).Fig. 2. Correlation between an evaluation of the generalquality of life and the time that passed from treatmentcompletionRyc. 2. Zależność pomiędzy oceną ogólnej jakości życia aczasem od zakończenia leczeniaFig. 1. Evaluation of specific spheres of functioningdepending on the time that passed from treatmentcompletionRyc. 1. Ocena poszczególnych sfer funkcjonowania wzależności od czasu, który upłynął od zakończenialeczeniaThe worst quality of life in all the spheres offunctioning was observed with respect to children whocompleted treatment 4-6 years before the research. Thequality of life of children/teens improved 6 years aftertreatment completion.When performing an analysis of the group ofchildren who completed acute lymphoblasticleukaemia treatment which took into considerationusing/not using CNS radiotherapy, significant statisticcorrelations between variables were found.The general evaluation of the quality of lifeperformed by children is lower in the group whereCNS irradiation was applied as compared with childrenwho did not undergo radiotherapy (71.08 vs. 79.96;p=0.023). The above evaluation was influenced bychildren’s functioning in all the analysed spheres;however, the biggest and, at the same time, statisticallysignificant difference was found in connection withfunctioning at school (60.00 vs. 73.88; p=0.01). Amajor, yet unimportant as far as statistics is concerned,difference pertained to social functioning. Childrenwho had undergone radiotherapy graded it 8.97 pointsWhen analysing the indirect evaluation, nostatistically significant differences between the twogroups were found. However, from the perspective ofparents whose children underwent CNS irradiation, theevaluation of children’s functioning is lower. The mostsignificant differences pertained to functioning atschool (59.72 vs. 69.78) and physical functioning(77.73 vs. 83.87). The smallest difference wasdiscovered in relation to evaluation of emotionalfunctioning (62.78 vs. 69.24).Fig. 3. Correlation between radiotherapy used duringtreatment and an evaluation of the quality of lifeRyc. 3. Zależność pomiędzy stosowaniem w trakcie leczeniaradioterapii a oceną, jakości życiaWhile analyzing the gathered materials, it wasnoticed that there is a correlation between the appliedtreatment program and evaluation of the quality of life.According to the evaluation, the best quality of life canbe observed among children who underwent BFM 90

172Aneta Zreda-Pikies, Andrzej Kurylaktreatment (79.10 pts. – direct evaluation; 79.34 pts. –indirect evaluation). The worst quality of life, on theother hand, is experienced by patients who were treatedas per the New York protocol (66.24 pts. – directevaluation; 67.09 pts. – indirect evaluation).A comparison of groups in relation to the appliedprogram of treatment, revealed a statistically essentialdifference between the indirect evaluation offunctioning at school, depending on the use of specifictreatment programs. However, children treated with theuse of the New York program (50 pts. – directevaluation; 48.75 pts. – indirect evaluation) have themost difficulty with functioning at school; the leastdifficulty is encountered by children treated accordingto the BFM 90 program (73 pts. – direct evaluation;75.5 pts. – indirect evaluation).Fig. 4. Correlation between programs applied duringtreatment and an evaluation of the quality of lifeRyc. 4. Zależność pomiędzy stosowanym programem leczeniaa oceną, jakości życiaDISCUSSIONOwn research has shown that an evaluation of thequality of life does not depend on patient’s age at thetime of diagnosis. This result is consistent with resultsobtained by Pemberg, S. et al. from Australia [7].The results of own research concerning theprevalence of the disease among boys and girlsindicate that the incidence of the disease is slightlyhigher with respect to boys (51.7 percent) (girls – 48.3percent). The above information is in agreement withthe general characteristics of the population of childrendiagnosed with acute lymphoblastic leukaemia. Theresearch carried out among 170 patients by Meeske, K.et al. reveals that boys are the dominant group ofpatients (59 percent) among children/teens who sufferfrom acute lymphoblastic leukaemia [8].According to own research, the number of childrenand teens living in cities (64.1 percent) was visiblyhigher than the number of children living in thecountry (35.8 percent). Based on the research carriedout in Lublin on a group of 44 children who completedALL treatment, one concludes that the environment, inwhich a child has been brought up, is differential withrespect to its intellectual functioning after thecompletion of treatment. Children living in cities had asignificantly higher intelligence quotient than childrenliving in the country [9].As far as the results of own research are concerned,children living in the country evaluated theirfunctioning in all the spheres covered by the researchslightly lower; however, the differences were notnoteworthy from the statistical point of view. Theevaluation performed by children’s parents was thesame as direct evaluation only with respect tofunctioning in the physical sphere. Their evaluation offunctioning in all other spheres was lower thanchildren’s evaluation.Own research has shown that the evaluation of thequality of life of children who completed ALLtreatment does not depend on: patient’s age at the timeof examination, age at the time of diagnosis, sex, placeof residence, family’s economic situation or mother’seducation.While analyzing the gathered materials, it wasnoticed that there are essential statistical correlationsbetween the evaluation of the quality of life and thetime that passed from completing treatment, usingCNS radiotherapy, treatment program and father’seducation.Due to small sizes of groups comprising patients,the carried out analysis of evaluating the quality of lifedepending on the treatment programs used does not letone draw binding conclusions. Nevertheless, it wasobserved that the lowest evaluation of functioning inthe emotional, social and school sphere pertained to thegroup of children who were treated with the use of theNew York program. The results of the said evaluationmight stem from a preventive CNS irradiation dosewhich is higher than with respect to other patients (18Gy vs. 12 Gy).According to the opinion of Constine, L.,deviations in the neuropsychological state connectedwith CNS irradiation start to show up not earlier than3-5 years after its completion [10].In connection with reports stating that CNSirradiation has a negative effect on the functioning ofchildren after treatment completion, an analysis of thequality of life in all spheres of functioning conditionedby using/not using CNS radiotherapy was carried out.

Evaluation of the quality of life of children who have completed acute lymphoblastic leukaemia treatment 173A general evaluation of the quality of life performed bychildren is lower in the group where CNS irradiationwas applied as compared with children who did notundergo radiotherapy (71.08 vs. 79.96; p=0.023). Theabove evaluation was influenced by children’sfunctioning in all the analysed spheres; however, thebiggest and, at the same time, statistically significantdifference was found in connection with functioning atschool (60.00 vs. 73.88; p=0.01). A major, yetinsignificant as far as statistics is concerned, differencepertained to social functioning (79.44 vs. 88.41). Thesmallest discrepancy between the groups was foundwithin the sphere of emotional functioning (66.11 vs.73.05). When analysing the indirect evaluation, nostatistically significant differences between the twogroups were found. However, from the perspective ofparents whose children have undergone CNSirradiation, the evaluation of children’s functioning islower in all spheres.The research carried out by Samardakiewicz, M.,Dudzińska, M. and Zdebska, S. did not reveal anysignificant differences between intelligence quotientsachieved by children with respect to whom variousirradiation doses were used [9, 11, 12]. Yet, Von derWeid, N. revealed that patients who had undergoneCNS irradiation had worse results in arithmetic, shorttermmemory, concentration and data processing speed[13].When examining the correlation between parents’education and evaluation of the quality of life, it wasnoticed that the evaluation of functioning at school waslower among children whose parents had highereducation. The lowest evaluation in the abovementioned sphere was demonstrated in the group ofchildren whose mothers had higher education.Additionally, a statistically important difference inevaluation was presented with respect to the educationof the father. Children whose fathers had highereducation evaluated their functioning at schoolnoticeably lower than children of fathers with highschool, vocational school and primary schooleducation. When looking at the indirect evaluation, onenotices that functioning in the physical sphere andfunctioning at school received the lowest evaluationfrom children whose fathers had higher education.Such evaluation probably stems from higherexpectations of parents with higher education towardstheir own children.Parents of children who have completed treatmentoften face a parenting dilemma. Do they have the rightto demand the same they would have demanded fromtheir child if the child had not fallen ill? Should they‘go easy’ on a child in connection with the pastdisease?In one of her articles Zdebska, S. stated that thedegree to which a child is privileged in a family as wellas the scope of requirements it is faced with as per itsage and abilities is a measure of parents’ hopes forpermanent recovery. In families where permanentrecovery is an option, the requirements are similar tousual ones [14].A long-lasting disease of a child modifies parents’attitude. As the formation of an attitude is distorted,negative attitudes such as rejection, avoidance,excessive protection or excessive requirements mayarise. As a consequence, a child’s needs may not besatisfied and its development might be disturbed [15,16, 17, 18].According to the research carried out by professorMess, E. et al., a demanding attitude is one of the leastformed attitudes towards a child suffering from ALL.A loving and protecting attitude dominates clearly;however, these attitudes bear the risk of limiting achild’s independence [19]. An evaluation of parents’attitudes did not take into account their education soone cannot exclude that they are also formed withrespect to parents who have higher education.The own research did not attempt to evaluate theattitude of parents towards children. Therefore, it isimpossible to determine the reason for a lowerevaluation of life quality of children of parents withhigher education in an explicit way.Having carried out research on intellectualfunctioning of children who have completed leukaemiatreatment, Samardkiewicz, M. and Kowalczyk, J. R.demonstrate that parents’ higher level of education hasa positive effect on children’s intellectual functioning,which might be connected with greater developmentstimulation in such families [9].As far as own research is concerned, it wasdemonstrated that there is a connection between thetime that passed from treatment completion and directevaluation of functioning in the physical sphere. Themore time passes from oncological treatmentcompletion, the lower the results of an evaluation ofphysical functioning. The above situation might beinfluenced by occurrence of late complications ofoncological treatment, which might limit formerpatients’ physical fitness. The own research was notaimed at evaluating complications occurring after the

174Aneta Zreda-Pikies, Andrzej Kurylaktreatment. Consequently, it is impossible to drawbinding conclusions in this matter. However, theobtained results indicate a necessity for furtherresearch that would answer the following question:why does functioning in the physical sphere decreaseas the time from treatment completion goes by?During a research carried out in Los Angeles andSan Diego, parents of children who completed ALLtreatment evaluated their children’s physicalfunctioning lower than in the own research (71.65 vs.82.14). The said evaluation differed for children whohave completed treatment 12months before the research (65.4 vs. 77.9) [8].CONCLUSIONS1. Evaluation of the general quality of life ofchildren who have completed ALL treatmentdoes not depend on: age at the time ofdiagnosis, age at the time of examination, sex,place of residence, family’s economicsituation or being in the risk group.2. The quality of life conditioned by the state ofhealth depends on: implementation ofradiotherapy, the time that passed fromfinishing treatment and parents’ education.2.1 The general evaluation of the quality oflife is significantly lower in the group ofpatients who have undergone CNS therapyand is the most visible as far asfunctioning at school is concerned.2.2 As the time which has passed fromtreatment completion goes by, thesubjective evaluation of physicalfunctioning decreases.2.3 Children’s fathers who have highereducation evaluate the general quality oflife lower than fathers with education of alower degree.REFERENCES1. Meeske K., Katz E., Palmer S., Burwinkle T., Varni J.Parent Proxy-Reported Health- Related Quality of Lifeand Fatigue in Pediatric Patients Diagnosed with BrainTumors and Acute Lymphoblastic Leukemia, Cancer2004, 101: 2116-21252. Varni J.W., Burwinkle T.M., Seid M. The PedsQL TM4.0 as a school population health measure: Feasibility,reliability and validity. Quality of Life Research 2006,15: 203-2153. Varni J.W., Limbers Ch.A., Burwinkle T.M. Impairedhealth- related quality of life in children and adolescentswith chronic conditions: a comparative analysis of 10disease cluster and 33 disease categories/ severitiesutilizing the PedsQL TM 4.0 Generic Core Scales. Healthand Quality of Life Outcomes 2007, 5: 43-584. Varni JW, Burwinkle TM, Seid M, Skarr D. The PedsQL4.0 as a pediatric population health measure: Feasibility,reliability and validity. Ambul Pediatr 2003; 3: 329-3415. Varni JW, Burwinkle TM, Seid M. The PedsQL 4.0 asschool population health measure: Feasibility, reliabilityand validity. Quality of Life Research 2006; 15: 203-2156. Varni, JW, Burwinkle TM, Katz ER et al. ThePedsQL in pediatric cancer: Reliability and validity ofthe Pediatric Quality of Life Inventory Generic CoreScales, Multidimensional Fatigue Scale, and CancerModule. Cancer 1994: 2090-2106.7. Pemberger S., Jagsch R., Frey E., Felder-Puig R., GadnerH., Kryspin-Exner J., Topf R. Quality of Life in longtermchildhood cancer survivors and the relation of lateeffects and subjective well-being. Support Care Cancer2005, 13: 49-568. Meeske K., Katz E., Palmer S., Burwinkle T., Varni J.Parent Proxy-Reported Health- Related Quality of Lifeand Fatigue in Pediatric Patients Diagnosed with BrainTumors and Acute Lymphoblastic Leukemia, Cancer2004, 101: 2116-21259. Samardakiewicz M., Kowalczyk J., R. Retrospektywnaocena intelektualnego funkcjonowania dzieci pozakończonym leczeniu białaczki, Przegląd Pediatryczny2005, vol 35, nr 4: 205-21010. Constine L. Late effectc of radiation therapy. Pediatrician1991, 18: 37-4811. Dudzińska M., Sońta-Jakimczyk D., Izydorczyk B.Ocena stanu neuropsychicznego dzieci żyjących wremisji ostrej białaczki limfoblastycznej, Pediatria Polska1994, LXIX, 9: 753-75812. Zdebska S., Armata J., Balwierz W. Wyniki kontrolnychbadań psychologicznych testem Wechslera leczonych zpowodu nowotworowych chorób krwi, Ped. Pol., 1987,62, 7: 490-49813. Von der Weid N. Late effects in long-term survivors ofALL in childhood: experiences from the SPOG lateeffects study. Swiss Med. Wkly 2001, 131 (13-14): 180-18714. Zdebska S., Armata J. Udział rodziców w leczeniu ichdziecka z chorobą nowotworową, Ped. Pol., 1978, 53:621-62715. Budziszewska B.K., Piusińska-Macoch R., Sułek K.,Stępień A. Psychologiczne problemy rodziny pacjentówz chorobami nowotworowymi krwi w koncepcjisystemowej. Acta Haematologica Polonica 2005; 36, 3:317-32516. Łatka J. Postawy rodzicielskie – uwarunkowania,Magazyn Pielęgniarki i Położnej 2005, nr 6: 22-2317. Yeh Ch-H., Lee T-T., Chen M-L. Adaptational process ofparents of pediatric oncology patients. PediatricHematology and Oncology 2000, 17: 119-131

Evaluation of the quality of life of children who have completed acute lymphoblastic leukaemia treatment 17518. Zdebska S., Armata J. Psychologiczne problemy wnowotworowych chorobach krwi u dzieci [w:] OchockaM. Hematologia kliniczna wieku dziecięcego. Warszawa1982. PZWL: 369-38119. Mess E., Wójcik D., Niedzielska E., wsp. Adaptacjaspołeczna dzieci leczonych na ostrą białaczkęlimfoblastyczną, Onkol. Pol. 2005, 8, 3: 166- 169List of abbreviationsRFS functioning at school, as evaluated by a child’sparentsfunkcjonowanie w szkole w ocenie dokonanej przezrodziców dzieckaRSE functioning in the emotional sphere, as evaluated bya child’s parentsfunkcjonowanie w sferze emocjonalnej w oceniedokonanej przez rodziców dzieckaRSF functioning in the physical sphere, as evaluated by achild’s parentsfunkcjonowanie w sferze fizycznej w oceniedokonanej przez rodziców dzieckaRSS functioning in the social sphere, as evaluated by achild’s parentsfunkcjonowanie w sferze społecznej w oceniedokonanej przez rodziców dzieckaSE functioning in the emotional sphere – directevaluationfunkcjonowanie w sferze emocjonalnej – ocenabezpośredniaSF functioning in the physical sphere – direct evaluationfunkcjonowanie w sferze fizycznej – ocenabezpośredniaSS functioning in the social sphere – direct evaluationfunkcjonowanie w sferze społecznej – ocenabezpośredniaAddress for correspondence:Aneta Zreda-Pikiesul. Osiedlowa 6/1285-794 Bydgoszcze-mail: aneta.zreda@wp.plReceived: 10.01.2012Accepted for publication: 6.03.2012

Medical and Biological Sciences, 2012, 26/1Regulamin ogłaszania prac w Medical and Biological Sciences1. Redakcja przyjmuje do druku wyłącznie pracepoprzednio niepublikowane i niezgłoszone dodruku w innych wydawnictwach.2. W Medical and Biological Sciences zamieszczasię:artykuły redakcyjnepracea) poglądowe,b) oryginalne eksperymentalne i kliniczne,c) kazuistyczne,które zostały napisane w języku angielskim.3. Objętość pracy wraz z materiałem ilustracyjnym,piśmiennictwem i streszczeniem nie powinnaprzekraczać 15 stron maszynopisu przypracach poglądowych oraz 12 stron przy pracachoryginalnych i kazuistycznych. Przekroczenieobjętości skutkuje opłatą 100 zł od dodatkowejstrony.4. Praca powinna być napisana jednostronniew programie Word (na jednej stronie może byćdo 32 wierszy, tj. 1800 znaków, margines z lewejstrony – 4 cm), czcionką 12 pkt., interlinia– 1,5.5. W nagłówku należy podać:a) imiona i nazwiska autorów oraz tytuły naukowe,b) tytuł pracy (również w j. pol.),c) nazwę kliniki (zakładu) lub innej instytucji,z której praca pochodzi, w j. ang.,d) tytuł naukowy, imię i nazwisko kierownikakliniki (zakładu), innej instytucji,e) adres do korespondencji, który powinienzawierać również e-mail, tel i faks.6. Każda praca powinna zawierać streszczeniew języku polskim i angielskim oraz słowa kluczowew j. polskim i angielskim, a także piśmiennictwo.7. Prace oryginalne powinny mieć następującyukład: streszczenie w języku polskim i angielskim,słowa kluczowe w j. polskim i angielskim,wstęp, materiał i metody, wyniki, dyskusja,wnioski, piśmiennictwo.8. Tabele i ryciny należy ograniczyć do niezbędnegominimum. Tabele numerujemy cyframirzymskimi. Tytuł tabeli w jęz. polskim i angielskimumieszczamy nad tabelą. Opisy wewnątrztabeli zamieszczamy w języku polskim i angielskim.9. Ryciny (fotografie, rysunki, wykresy itp.) numerujemycyframi arabskimi. Tytuł rycinyw jęz. polskim i angielskim umieszczamy podryciną. Opisy wewnątrz rycin zamieszczamyw języku polskim i angielskim.10. Odnośniki do piśmiennictwa zaznaczamyw tekście cyframi arabskimi i umieszczamyw nawiasie kwadratowym.11. Streszczenie powinno mieć charakter strukturalny,tzn. zachować podział na części, jak tekstgłówny. Objętość streszczenia zarówno w językupolskim jak i angielskim – ok. 250 wyrazów.12. Autor dostarcza pracę na płycie CD lub DVDoraz 3 egzemplarze, w tym 1 kompletny, zgodnyz płytą, zawierający nazwiska autorów i nazwęinstytucji, z której praca pochodzi (patrzpkt. 5 i 9) oraz 2 egz. przeznaczone dla recenzentówbez nazwisk autorów, nazwy instytucjii innych danych umożliwiających identyfikację.13. Na dyskietce w odrębnych plikach powinny byćumieszczone:a) tekst pracy,b) tabele,c) ryciny (fotografie w formacie BMP, TIF,JPG lub PCX; ryciny w formacie WMF,EPS lub CGM),d) podpisy pod ryciny i tabele w formacieMS Word lub RTF.14. Fotografie powinny mieć postać kontrastowychzdjęć czarno-białych na błyszczącym (ewentualniematowym) papierze. Na odwrocie należypodać imię i nazwisko autora, tytuł pracy, numeroraz oznaczyć górę i dół.15. Należy zaznaczyć w tekście miejsca, w którychmają być zamieszczone ryciny. Wielkość ryciny:podstawa nie powinna przekraczać 120 mm(z opisami).16. Piśmiennictwo – tylko prace cytowane w tekście(maksymalnie 30 pozycji) – powinno byćponumerowane i ułożone wg kolejności cytowania,każdy tytuł od nowego wiersza. Pozycjapiśmiennictwa dotycząca czasopisma musi zawieraćkolejno: nazwisko, inicjał imienia autora(ów) – maksymalnie trzech – tytuł pracy, tytułczasopisma wg skrótów stosowanych w „IndexMedicus”, rok, numer tomu i stron. Przy cytowaniupozycji książkowej (monografii, podręczników)należy podać nazwisko i inicjałyimion autorów, tytuł dzieła, wydawcę, miejscei rok wydania.17. Z pracą należy przesłać oświadczenie, iż niebyła ona dotąd publikowana, a także że nie zostałazłożona do innego wydawnictwa orazzgodę kierownika zakładu na publikację.

Medical and Biological Sciences, 2012, 26/118. Do każdej pracy należy dołączyć oświadczeniepodpisane przez wszystkich współautorów, żeaktywnie uczestniczyli w jej realizacji i przygotowaniudo druku oraz akceptują bez zastrzeżeńtekst pracy w formie przesłanej do redakcji.19. Prace niespełniające wymogów regulaminubędą zwracane autorom.20. Redakcja zastrzega sobie prawo poprawianiausterek stylistycznych oraz dokonywania skrótów.21. Za prace zamieszczone w Medical... autorzy nieotrzymują honorarium.22. Redakcja nie przekazuje autorom bezpłatnychegzemplarzy Medical...23. Prace publikowane w Medical... są ocenianeprzez dwóch recenzentów.24. Medical and Biological Sciences są punktowanezgodnie z listą czasopism Ministerstwa Naukii Szkodnictwa Wyższego i otrzymują 6punktów.Redakcja:Medical and Biological Sciencesul. Powstańców Wielkopolskich 44/2285-090 BydgoszczDyżury sekretarza Redakcji: wtorek 11.00-13.00tel.: (52) 585 33 26Opracowanie redakcyjne i realizacja wydawnicza:Redakcja w Bydgoszczyul. Powstańców Wielkopolskich 44/22, 85-090 Bydgoszcztel./faks: 52 585 33 25, e-mail: wydawnictwa@cm.umk.plCOLLEGIUM MEDICUM im. LUDWIKA RYDYGIERABYDGOSZCZ 2012Nakład: 100 egz.Druk i oprawa: Drukarnia cyfrowa UMK, ul. Gagarina 5, 87-100 Toruń, tel.: 56 611 22 15