Lw 03 215 book fin 12 11 2015 en by Medycyna Praktyczna

MILITARY PHYSICIAN Military Physician

Program Council Members

Quarterly

Chairman Grzegorz Gielerak – Head of the Military Institute of Medicine

Official Organ of the Section of Military Physicians of the Polish Medical Society Oficjalny Organ Sekcji Lekarzy Wojskowych Polskiego Towarzystwa Lekarskiego Scientific Journal of the Military Institute of Medicine Pismo Naukowe Wojskowego Instytutu Medycznego Published since 3 January 1920 Number of points assigned by the Polish Ministry of Science and Higher Education (MNiSW) – 4

Editorial Board Editor-in-Chief Jerzy Kruszewski MD, PhD

Members Massimo Barozzi (Italy) Nihad El-Ghoul (Palestine) Claudia E. Frey (Germany) Anna Hauska-Jung (Poland) Wiesław W. Jędrzejczak (Poland) Dariusz Jurkiewicz (Poland) Paweł Kaliński (USA) Frederick C. Lough (USA) Marc Morillon (Belgium) Arnon Nagler (Israel) Stanisław Niemczyk (Poland) Krzysztof Paśnik (Poland) Francis J. Ring (UK) Tomasz Rozmysłowicz (USA) Daniel Schneditz (Austria) Zofia Wańkowicz (Poland) Piotr Zaborowski (Poland)

Deputy Editors-in-Chief Krzysztof Korzeniewski, Marek Maruszyński, Piotr Rapiejko Secretary Ewa Jędrzejczak Editorial Office Military Institute of Medicine 128 Szaserów St., 04-141 Warsaw 44 telephone/fax: +48 261 817 380 e-mail: lekarzwojskowy@wim.mil.pl www.lekarzwojskowy.pl © Copyright by Military Institute of Medicine Practical Medicine Publishing House / Medycyna Praktyczna 2 Rejtana St. 30-510 Kraków telephone: +48 12 29 34 020, fax: +48 12 29 34 030 e-mail: listy@mp.pl Managing Editor Lidia Miczyńska Proofreading Dariusz Rywczak, Iwona Żurek Cover Design Krzysztof Gontarski Typesetting Łukasz Łukasiewicz DTP Katarzyna Opiela Advertising Piotr Lorens MD telephone +48 663 430 191; e-mail: piotr.lorens@mp.pl Print TECHNET, Kraków Circulation: 700 copies Price PLN 14

For many years, “Military Physician” has been indexed in the Polish Medical Bibliography (Polska Bibliografia Lekarska), the oldest Polish bibliographic database. The original version of "Military Physician" is the electronic version (www.lekarzwojskowy.pl). The journal is financed by the Military Medical Chamber

ISSN 0024-0745

Tanslation, proofreading and DTP of the English version by Skrivanek Sp. z o.o.

GUIDELINES FOR MANUSCRIPT SUBMISSION

Background "Military Physician" has been published continuously since 1920, currently as a quarterly of the Military Institute of Medicine in Warsaw, Poland. 1. “Military Physician” publishes original articles (research and clinical), reviews, reports on military issues, deontological papers, interesting case reports, articles on the history of medicine, descriptions of rationalization results, posthumous memoirs, letters to the editor, book reviews, article summaries (reviews) from international journals particularly on the military health service, reports on meetings and scientific conferences, and announcements of events. 2. Before publication, each article is reviewed by 2 independent reviewers while maintaining anonymity. 3. "Military Physician" is indexed in the Polish Ministry of Science and Higher Education, number of points - 4. 4. With respect to the fact that unsolicited articles submitted to our Editorial Board are royalty-free, manuscript submission with a request for publishing will be understood as the implied consent of the Author(s) not to receive any royalty and to transfer copyright to the Military Institute of Medicine. 5. A clinical article for submission should be in accordance with the requirements of the Declaration of Helsinki. The chapter "Material and methods" should contain both the information on the approval of the Bioethical Committee and patients' informed consent to participate in the study. In case of using the results of studies conducted by other centers, such information should appear either in the text or in the acknowledgements. 6. Authors of clinical studies on medications (international name) and medical procedures should provide a description of the research funding and the influence of the sponsor on the content of the publication. 7. The Author must provide the Editorial Board with the consent of the owner of an image to use the image in an article. 8. Please submit your article to: Editorial Board of "Military Physician", 128 Szaserów St. 04-141 Warsaw 44 or by e-mail: lekarzwojskowy@wim.mil.pl

row. Figures (including maps) and images should be saved in a separate file. Digital images should have a resolution of 300 dpi and be saved in TIFF format. Good quality traditional images should be delivered on photographic paper. The reverse side of each image delivered on paper should contain the author's last name, the title of the contribution, a consecutive number and a marking indicating the top of the image. 5. Papers should be prepared carefully, in accordance with Polish spelling and with special attention to communicativeness and Polish medical nomenclature. Abstracts, keywords and figure captions translated into English should be identical with the Polish version and show an appropriate language level. Manuscripts that do not meet the criteria will be sent back to the authors for revision. 6. Each article should include the following: 1) On the first page: main title in Polish and English, Author's or Authors' (max. 10 people) first and last names, including academic degrees, full name of affiliated institute (institutes), head of the institute (academic degree, first and last name), followed by an abstract (up to 15 lines) with keywords in Polish and another abstract with keywords in English, corresponding author, his/her postal address with postal code, telephone (fax) and e-mail address. 2) Main text Original articles should be prepared according to the following structure: introduction, aim, material and methods, results, discussion, conclusions, references; case reports: introduction, case description, discussion, summary (conclusions), and references. Abbreviations and acronyms should be defined when first mentioned in the text and consequently used in the paper. 3) References should be presented according to the order they appear in the text. If the article has no more than four authors, all of them should be named. If there are more then give the first three, followed by "et al.". References should be numbered using the keyboard: please do not use automatic numbering. Examples of citations:

9. All Authors who wish to publish their papers in "Military Physician" are asked to carefully read and strictly follow the guidelines listed below. Failure to follow the requirements of the Editorial Board makes editing more difficult, increases costs and delays publication. Manuscripts not meeting the requirements will not be published, and those considered inadequately prepared will be returned to the Authors for revision.

Journal articles:

Manuscript

Rudzki E. Alergia na leki: z uwzględnieniem odczynów anafilaktycznych i idiosynkrazji. Lublin, Wydawnictwo Czelej, 2002: 338-340

1. Manuscripts should be prepared using the MS Word text editor and sent by e-mail or by post on a 3.5" floppy disk or a CD.

Chapter of a book:

2. The number of pages of the manuscript (including tables, figures and references) cannot exceed 30 pages for original articles, 30 for review articles, 20 for reports, 30 for articles on the history of medicine and 15 for rationalization articles. Reports on meetings and conferences should be concise (up to 5 pages) and discuss only significant issues. 3. An original publication may also take the form of a short temporary report. 4. Materials for printing 1) Text (with references, tables and figure captions) should be uploaded as a separate file. One page of the manuscript should contain 30 lines, about 60 characters each (a total of about 1,800 characters). The text must be written in Times New Roman 12 point font and double spaced (this also applies to references, tables, captions etc.), with 2.5 cm left margin, and no right margin, i.e. with the 'flag'. Authors are asked not to format the titles, i.e., not to center or justify them, as well as not to use the tabulator or automatic numbering (both within the text and references). A new paragraph should be started from the left margin without paragraph indentation. Please do not insert blank lines between paragraphs or enumerations. From typefaces, bold (semi-bold) and italics for foreign phrases may be used. 2) Please do not insert any graphics into the Word manuscript. Figures and tables should be referenced in the body of the text as follows: "in Figure 1" or "(Table 1)". The number of tables should be kept to a minimum. Each table should be provided with captions in Polish and in English in bold in the first

218

Calpin C, Macarthur C, Stephens D, et al. Effectiveness of prophylactic inhaled steroids in childhood asthma: a systemic review of the literature. J Allergy Clin Immunol, 1997; 114 (100): 452-457 Books:

Wantz GE. Groin hernia. In: Cameron JJ, ed. Current surgical therapy. St Louis: Mosby, 1998: 557-561 The list of references should include only those publications that were used by the Author and should be reduced to 20. All references should be cited in the text and the numbers of references should be put in square brackets. In order to avoid errors, titles should be copied from medical databases. 7. The paper should be accompanied by: a) author's request to publish the paper with a declaration that the article has not been published before and has not been simultaneously submitted to any other journal; b) approval of the head of the clinic, head of the department or head of the institute in which the study has been conducted, and, in the case of a study carried out in several centers, the approval of all of them; c) Declaration of Conflict of Interest; and d) acknowledgements, if applicable. 8. The Editorial Board reserves the right to correct nomenclature and stylistic errors as well as to introduce abbreviations without consultation with the Author. 9. The Author receives 1 free copy of the issue in which his or her article has been published. For further copies, contact the Editor. 10. If the manuscript is not accepted for publication, the Editorial Board will return the submitted article to the Author.

MILITARY PHYSICIAN 3/2015

SPIS TREŚCI

2015, vol. 93, no. 3

ORIGINAL ARTICLES 223

Energy expenditure by tank crews during field training exercises J. Bertrandt, A. Kłoś, R. Łakomy

227

Life satisfaction and self-efficacy in multiple myeloma patients before and after treatment E. Wasińska, W. Skrzyński

231

Levels of self-esteem in multiple myeloma patients W. Skrzyński, E. Wasińska, A. Torska

236

Evaluation of selected early multiorgan dysfunction symptoms in forecasted survival rates for patients with burns A. Surowiecka-Pastewka, M. Kawecki, W. Witkowski

244

Hemodynamic conditions related to exercise capacity in patients with arterial hypertension – a preliminary report M. Kurpaska, P. Krzesiński, G. Gielerak, A. Stańczyk, K. Piotrowicz, B. Uziębto-Życzkowska, M. PotapowiczKrysztofiak, A. Skrobowski

CASE REPORTS 253

The usefulness of applying the FEEL ultrasound protocol during CPR W. Wierzejski, R. Górecki, R. Brzozowski

256

REVIEW ARTICLES 259

The clinical aspects of abdominal compartment syndrome J. Włodarski

219

CONTENTS

HISTORY OF MEDICINE 262

70 anniversary of the Regional Military Medical Board in Żagań - an outline history of its establishment and development K. Kopociński, Z. Kopociński, Cz. Jeśman

269

Lt. Col. Ludwik Tomasz Zieliński PhD (1888-1956) – the unusual life of a military internal specialist from Grodno K. Kopociński, Z. Kopociński, Cz. Jeśman

How to subscribe to MP (Practical Medicine / Medycyna Praktyczna) publications Methods of placing orders  By telephone (Mon-Fri, 08:00-18:00): +48 800 888 000 (landline, toll-free hotline) +48 12 293 40 80 (mobile and landline)  At our website ksiegarnia.mp.pl  By e-mail at zamowienia@mp.pl (please specify titles of the ordered items or their catalogue numbers, an address for correspondence, details for the invoice and the payment method of your choice)  by completing a Direct Debit Mandate Form (direct debit) available at ksiegarnia.mp.pl Payment methods  Bank transfer / postal transfer: Medycyna Praktyczna Spółka z ograniczoną odpowiedzialnością sp. k., 2 Rejtana St. 30-510 Kraków Account Number: 35 1600 1039 0002 0033 3552 6001  Credit Card  Cash on Delivery  Direct Debit (Direct Debit Form available at ksiegarnia.mp.pl)

220

Shipping fees  The shipping fee for ordered books and the one-time shipping fee charged for subscriptions is PLN 12. These prices are valid only in Poland. Additional information Subscribers to our journals are entitled to a discount on a single copy of each book and special edition. The address label includes the information on:  Parcel contents  Possible overpayment or underpayment in relation to the order  Issue of each journal that has been recently paid or ordered Contact  By telephone (Mon-Fri, 08:00-18:00): +48 800 888 000 (landline, toll-free hotline) +48 12 293 40 80 (mobile and landline)  By e-mail (zamowienia@mp.pl)

MILITARY PHYSICIAN 3/2015

SPIS TREŚCI

2015, tom 93, nr 3

PRACE ORYGINALNE 223

Wydatek energetyczny czołgistów w trakcie szkolenia poligonowego J. Bertrandt, A. Kłoś, R. Łakomy

227

Satysfakcja z życia i poczucie własnej skuteczności chorych z rozpoznaniem szpiczaka plazmocytowego przed leczeniem i po nim E. Wasińska, W. Skrzyński

231

Poczucie własnej wartości pacjentów z rozpoznaniem szpiczaka plazmocytowego W. Skrzyński, E. Wasińska, A. Torska

236

Ocena wartości wybranych wczesnych objawów zaburzeń ogólnoustrojowych w prognozowaniu przeżycia oparzonych A. Surowiecka-Pastewka, M. Kawecki, W. Witkowski

244

Hemodynamiczne uwarunkowania wydolności fizycznej chorych na nadciśnienie tętnicze - doniesienie wstępne M. Kurpaska, P. Krzesiński, G. Gielerak, A. Stańczyk, K. Piotrowicz, B. Uziębto-Życzkowska, M. PotapowiczKrysztofiak, A. Skrobowski

PRACE KAZUISTYCZNE 253

Przydatność zastosowania ultrasonografii według protokołu FEEL w trakcie resuscytacji krążeniowo-oddechowej -opis przypadku W. Wierzejski, R. Górecki, R. Brzozowski

256

Resekcja guza przestrzeni zaotrzewnowej z fragmentem żyły głównej dolnej z jednoczasową jej rekonstrukcją u chorego po orchidektomii prawostronnej z powodu raka jądra - opis przypadku D. Żak, J. Włodarski, M. Pawelczyk, M. Dziekiewicz, M. Maruszyński

PRACE POGLĄDOWE 259

Zespół wzmożonego ciśnienia wewnątrzbrzusznego w aspekcie klinicznym J. Włodarski

221

SPIS TREŚCI

HISTORIA MEDYCYNY 262

70-lecie Rejonowej Wojskowej Komisji Lekarskiej w Żaganiu -zarys historii powstania i rozwoju K. Kopociński, Z. Kopociński, Cz. Jeśman

269

Ppłk dr Ludwik Tomasz Zieliński (1888-1956) – nietypowy żywot wojskowego internisty z Grodna K. Kopociński, Z. Kopociński, Cz. Jeśman

Subscribe to Military Physician! Yearly subscription fee - PLN 56 Subscription with Compendium for Practical Medicine (Kompendium MP) - PLN 116 You can place an order:  by calling the toll-free number 800 888 000  by calling +48 12 293 40 80 (mobile)  online at www.ksiegarnia.mp.pl You can also make a payment of PLN 56 / PLN 116 to the account: 35 1600 1039 0002 0033 3552 6001

222

MILITARY PHYSICIAN 3/2015

ORIGINAL ARTICLES

Energy expenditure by tank crews during field training exercises Wydatek energetyczny czołgistów w trakcie szkolenia poligonowego Jerzy Bertrandt, Anna Kłoś, Roman Łakomy Department of Hygiene and Physiology, Gen. K. Kaczkowski Military Institute of Hygiene and Epidemiology in Warsaw; head: Prof. Jerzy Bertrandt Pharm.D Gen. K. Kaczkowski Military Institute of Hygiene and Epidemiology

Abstract. The amount of energy expended due to different training activities undertaken by soldiers is an important determinant describing the daily energy expenditure. An understanding of these parameters allows the determination of the optimal daily energy requirement for each soldier as well as creating the possibility of adjusting those requirements during training. The aim of the work was to assess the energy load of soldiers serving in armored divisions while carrying out scheduled tasks during field training exercises (FTX). Measurements of energy expenditure were made during typical activities included in the training schedule using POLAR RC3 GPS heart rate monitors. The results were then statistically analyzed. The duration of individual exercises and activities varied considerably, ranging from 5 to 12 hours. The field training schedule included days at different levels of energy expenditure. By considering the differences and intensity of activities on individual training days, it was demonstrated that the daily energy expenditure was diverse and ranged from 3187.3 kcal (13.3 MJ) to 4808.5 kcal (20.1 MJ). The daily energy expenditure of soldiers participating in training exercises was diverse and dependent on the type of activities. The greatest daily energy expenditure, classified as extremely hard work, occurred during training periods involving night shooting. Key words: energy expenditure, tank crew training, work load

Streszczenie. Wstęp. Wielkość wydatków energetycznych związanych z wykonywaniem przez żołnierzy różnych czynności szkoleniowych jest ważną determinantą określającą wysokość całodobowych wydatków energetycznych. Znajomość tych parametrów z jednej strony umożliwia wyznaczenie optymalnego dla każdego żołnierza dobowego zapotrzebowania energetycznego, z drugiej stwarza możliwość jego dozowania w tracie szkolenia. Cel pracy. Celem pracy była ocena obciążenia energetycznego żołnierzy wojsk pancernych podczas wykonywania planowych zadań szkoleniowych w warunkach poligonowych. Materiał i metody. Pomiarów wydatku energetycznego dokonywano podczas typowych czynności ujętych w planie szkolenia poligonowego, używając pulsometrów POLAR RC3 GPS. Uzyskane wyniki poddano analizie statystycznej. Wyniki. Czasokres trwania poszczególnych ćwiczeń i czynności był bardzo zróżnicowany i wahał się od 5 do 12 godzin. W programie szkolenia wojska na poligonie są dni o zróżnicowanym natężeniu wydatku energetycznego. Uwzględniając różnice i natężenie zajęć w poszczególnych dniach szkoleniowych, wykazano, że całodobowy wydatek energetyczny był zróżnicowany i kształtował się w granicach od 3187,3 kcal (13,3 MJ) do 4808,5 kcal (20,1 MJ). Wnioski. Dobowy wydatek energetyczny żołnierzy szkolonych na poligonie był zróżnicowany w zależności od rodzaju prowadzonych zajęć. Największy dobowy wydatek energetyczny, zaliczany do prac o charakterze bardzo ciężkim, stwierdzono w dniach szkolenia obejmującego strzelanie nocne z czołgów. Słowa kluczowe: wydatek energetyczny, szkolenie czołgistów, ciężkość pracy Delivered: 09/03/2015 Approved for print: 01/06/2015 No conflicts of interest were declared. Mil. Phys., 2015; 93 (3): 223-226 Copyright by Military Institute of Medicine

The human body derives its energy from food, and this energy is released in the organism as a result of the oxidation of macronutrients. Energy is essential to ensure the appropriate levels of physical and mental development, control of the biochemical processes inside the body, and to maintain normal bodily functions. Energy expenditure by tank crews during field training

Corresponding author: Prof. Jerzy Bertrandt Pharm. D. Gen. K. Kaczkowski Military Institute of Hygiene and Epidemiology 4 Kozielska St., 01-163 Warsaw, Poland Telephone: +48 22685 31 34 e-mail: j.bertrandt@wihe.waw.pl

It is also necessary for the human body to grow and for people to engage in many types of physical activity, including job-related, sporting, recreational and leisure. To grow, stay healthy, and remain physically and intellectually fit, people need a well-balanced diet consisting of a range of nutrients. 223

ORIGINAL ARTICLES

Table 1. Average value of energy expenditure for typical activities performed during the training of armor-based troops during FTX Tabela 1. Średnia wartość wydatków energetycznych typowych czynności wykonywanych podczas szkolenia żołnierzy wojsk pancernych na poligonie No. Activity Energy Heart rate expenditure [kcal/min.] Min. Max. Average 1. watchtower patrol

2.39 ±0.86

2. observation (static 2.92 ±1.04 observation post)

63.0 ±0.6 54.5 ±0.7

136.0 ±1.2 152.0 ±1.4

84 ±7.2 78.0 ±7.7

3. maintenance

3.19 ±1.44

51.0 ±14.0

141 ±30.8

80.0 ±10.1

4. vehicle driving

3.53 ±1.05

49.0 ±13.9

151.0 ±23.2

85.0 ±9.0

5. tank driving

3.77 ±0.89

49.0 ±19.0

152.0 ±13.7

89.0 ±5.5

6. sapper training (in 3.79 ±0.75 full gear)

53.0 ±11.0

160.0 ±27.4

88.0 ±6.6

7. weather service command

3.89 ±0.8

53.0 ±9.2

203.0 ±25.4

80.0 ±3.6

8. infantry tactics – 37.2 kgheavy gear

4.10 ±0.99

62.0 ±9.9

151.0 ±21.9

90.1 ±7.4

8. loading ammunition boxes

4.24 ±1.22

66.0 ±12.2

141.0 ±24.6

85.0 ±3.2

9. tactics

4.26 ±1.48

55.0 ±12.6

206.0 ±28.9

90.0 ±11.0

10. running in full gear

4.61 ±1.52

62.0 ±18.4

185.0 ±34.3

96.0 ±12.9

11. grenade launcher 4.81 ±1.05 shooting 12. night-vision tank 5.38 ±2.1 fire exercises 13. patrol marching 6.12 ±2.46 in full gear

70.0 ±5.8 68.0 ±11.1 62.0 ±9.9

165.0 ±36.2 145.0 ±20.6 180.0 ±25.4

94.0 ±3.4 94.0 ±12.4 102.0 ±13.9

14. putting up tents 7.63 ±2.92 and setting up power generating units

72.0 ±10.0

174 ±19.82

111 ±18.8

224

According to the law of conservation of energy, the amount of energy taken in by the human body equals the sum of the energy accumulated in the body and energy expended. The energy expenditure involved in physical activity depends on the lifestyle and many environmental factors, such as working conditions as well as economic and social conditions [1]. To assess and classify physical effort, the following methods of measuring energy expenditure are primarily used:  time study;  blood gas analysis;  heart rate measurement [2]. Underlying the heart rate-based method is the assumption that work causes adaptive changes in the circulatory and respiratory systems. The heart -rate analysis takes into account the cardiac e nergy expenditure involved in certain types of work in the sense of the total number of myocardial contractions above the resting heart rate. Heart rate depends on a number of endogenous and exogenous factors. Dynamic effort and heat stress are the primary factors that influence heart rate, as well as static effort, mental strain, noise, and the general health of the body. As physical activity increases, so does the heart rate, and there is also a linear link between increased heart rate and increased oxyge n consumption. Heart rate monitoring can be used to indirectly determine oxygen uptake and, consequently, to calculate the energy expenditure [2, 4]. The energy expenditures involved in the various training activities of soldiers is an important determinant of the soldier's daily energy expenditures. Once these parameters are known, the optimum daily energy requirements can be defined for individual soldiers and appropriately supplied during field training exercises (FTX) [5]. To achieve a high level of professional training, soldiers require constant training and exercise. Field training programs include, therefore, many hours of exercise involving great physical effort and stamina.

Aim of the study The aim of the study is to assess the energy demand of armed troops during scheduled field training activities.

MILITARY PHYSICIAN 3/2015

ORIGINAL ARTICLES

Table 2. Timetable of activities on individual days Tabela 2. Porządek dnia w poszczególnych dniach zajęć Type of activity

Days with night fire exercise

Days after night fire exercise

Sundays or holidays

Wake-up

Days without night fire exercise 5.00

5.00

6.00

Personal hygiene and area clean-up

5.00-5.20

6.00-6.20

Breakfast

5.20-6.00

6.20-7.00

6.30-7.30

Pick-up equipment, ammunition and rations for training

6.00-6.15

7.00-7.15

Free time

Morning roll call

6.15-6.30

7.15-7.30

Free time

March to the training area for a morning 6.30-7.30 warm-up

6.30-7.30

7.30-8.30

Organized cultural, educational, recreational and sporting activities

Organization of activities in training facilities

7.30-8.00

8.30-9.00

Training time (including time for breakfast and dinner)

8.00-18.00

9.00-18.00

Dinner

14.00-15.00

Supper

18.00-19.00

Free time

19.00-20.30

Evening roll call

20.30-20.40

Night fire exercise

18.00-18.50

18.50-19.00

18.00-19.00

19.00-20.30

Free time

20.30-20.40

19.00-23.00

Personal hygiene and area clean-up

20.40-21.00

Last call

21.00-5.00

20.40-21.00 23.00-5.00

Material and Methods The study of the energy expenditure during military training involved 111 soldiers. To determine the energy expenditure during field training activities, the study employed heart rate monitoring based on POLAR RC3, GPS heart rate monitors [6]. Energy expenditure was measured during typical, scheduled field training activities.

Results and discussion The average age of the studied soldiers was 29.9 ±5.4 (22-47), and their average body height and weight were 177.7 ±5.7 cm (161.5-198.0 cm) and 86.0 ±11.1 kg (65.2-118.5 kg), respectively. The average energy expenditures for selected training activities are listed in Table 1. Individual exercises and activities had significantly different durations, ranging from 5 to 12 hours, and the energy expenditure during field training activities varied

Energy expenditure by tank crews during field training

21.00-6.00

21.00-5.00

substantially. Based on Christensen's classification, the energy expenditure (expressed in kcal/min) for activities 1-11 should be defined as light physical effort (energy expenditure within 2.5-5.0 kcal/min). The physical effort of tank crewmen, including night-vision fire exercises and screening patrols, should be classified as moderate (energy expenditure within 5.0-7.5 kcal/min.). The physical effort involved in putting up tents and setting up power generating units should be defined as heavy (energy expenditure >7.5 kcal/min) [8]. Individual days in the training program for tank crewmen involve different rates of physical effort, which is attributable to the nature of the activities. Also, there were no training activities on holidays. Table 2 shows the daily schedule of field training activities. With these differences in mind, the study showed that the daily energy expenditure varied from day to day within the range of 3,187-4,808.5 kcal (13.3-20.1 MJ). Table 3 shows the daily energy expenditures during training on individual days.

225

ORIGINAL ARTICLES

Table 3. Daily energy expenditure of soldiers resulting from FTX activities Tabela 3. Dobowy wydatek energetyczny żołnierzy wynikający z realizacji zadań szkoleniowych na poligonie Training day type

Energy expenditure (kcal)

4291.4

17.9

Field training exercises with 4808.5 night fire exercises

20.1

Following night fire exercise 4157.7

17.4

Sundays and holidays

13.3

Field training exercises without night fire exercises

3187.2

According to Lehman's classification of physical effort [9], the soldiers' energy expenditure during days with night fire exercises should be defined as very heavy physical effort. Those days without night fire exercises and days after night fire exercises involved energy expenditures that could be defined as heavy physical effort. The least energy expenditure, typical for light physical effort, was recorded on free days (Sundays and holidays). Existing studies show that for the chemical corps, the daily energy expenditure involved in field training activities is 4,335.6 kcal (18.15 kJ). This means their physical effort could be defined as very light [10]. In comparison, the average daily energy expenditure involved in field training activities for the third-year students of the Main School of the Fire Service was 4,745 kcal (19.87 kJ) [11], and the energy expenditure (while on duty) for the students at a Fire and Rescue Unit was 3,081.6 kcal [12]. Studies of energy expenditure of soldiers in winter and summer showed that the daily energy expenditure was similar for both seasons, ranging from 3,937, 159±kcal to 4,281, ±170 kcal for men, and from 2,360, ±124 kcal to 2,781, ±311 kcal for women [13]. The energy expenditure involved in the training of the infantry soldiers of the Israeli Army was 4,249, ±174 kcal (17.8, ±2.7 MJ) [14], while field training activities of soldiers of the American Army involved the large energy expenditure of 5,185, ±668 kcal (21.7, ±2.8 MJ). Tharion et al. demonstrated that the daily energy expenditure of military personnel from various branches (army, navy, and air forces) was within 3,1097,131 kcal (13-29.8 MJ) [14].

4,500 kcal of energy.

Literature 1.

Jarosz M, Traczyk I, Rychlik E., Energia [Energy]. In: Jarosz M, (eds) Normy żywienia dla populacji polskiej – nowelizacja IŻŻ [Nutrition norms for Polish population – an amendment of the Food and Nutrition Institute]. Warsaw, 2012: 18-21 Bugajska J. Ocena obciążenia pracą fizyczną dynamiczną na stanowisku pracy [An assessment of dynamic occupational physical effort]. In: Koradecka D. Nauka a praca, bezpieczeństwo, higiena, ergonomia – pakiet edukacyjny dla uczelni wyższych [Science and work, health, safety and ergonomics – an educational package for higher education institutions]. Warsaw, Central Institute for Labour Protection, 2000

3. 4.

6. 7. 8.

9. 10.

11.

12.

13.

14.

Wróblewska M. Ergonomia-skrypt dla studentów [Ergonomics – a script for students]. Opole 2004: 179-194 Jeszka J. Potrzeby energetyczne organizmu. [The energy needs of the human body]. In: Gawęcki J, Hryniewiecki L, (eds) Żywienie człowieka [Human Nutrition] Podstawy nauki o żywieniu [The Basics of Nutritional Science]. Warsaw, PZWL, 2000: 114-129 Jeszka J, Wawrzyniak T, Bojarska J. Wydatki energetyczne słuchaczy wyższej szkoły oficerskiej w trakcie wybranych zajęć szkoleniowych [The energy expenditures of the students of military academies during selected training activities]. Żyw Czlow Metab [Polish Journal of Human Nutrition and Metabolism], 2001;28:215-219 POLAR RC3 GPS. User manual Petri A., Sabin C. Medical Statistics at a Glance. Warsaw, PZWL, 2006 Christensen CG, Frey HM, Foenstein EA. A critical evaluation of energy expenditure estimates based on individual 02 consumption / heart rate curves and average daily heart rate. Am J Clin Pathol, 1983; 37: 468-472 Lehman G. Praktyczna fizjologia pracy [Practical Occupational Physiology]. Warsaw, PZWL, 1966 135-160 Bertrandt J, Łakomy R, Kłos A. Dobowy wydatek energetyczny żołnierzy wojsk chemicznych podczas szkolenia na poligonie [The daily energy expenditure involved in the field training activities of the chemical corps]. Mil. Phys., 2012; 1: 4 16-19 Bertrandt J, Kłos A, Szymańska W. Obciążenie energetyczne studentów III roku Szkoły Głównej Służby Pożarniczej w trakcie szkolenia poligonowego [The average daily energy expenditure involved in field training activities of the 3rd-year students of the Main School of the Fire Service]. Bezpieczeństwo i Technika Pożarnicza [Safety and Fire Technology], 2013; 29: 61-65 Bertrandt J, Kłos A, Szymańska W. Wydatek energetyczny słuchaczy Szkoły Głównej Służby Pożarniczej podczas pełnienia 24-godzinnego dyżuru w jednostce Ratowniczo-Gaśniczej [The energy expenditure of the students of the Main School of Fire Service while on 24-hour duty at a Fire and Rescue Service]. Mil. Phys., 2012; 3: 4 244-247 Burnstein R, Coward AW, Askew WE, et al. Energy expenditure variations in soldiers performing military activities under cold and hot climate conditions. Military Medicine, 1996; 177 (161): 750-764 Tharion WJ, Liebermann HR, Montain SJ, et al. Energy requirements of military personnel. Appetite, 2005, 44: 47-65

Conclusions 



226

Daily energy expenditures of tank crewmen involved in field training activities varied depending on the type of activities. The largest daily energy expenditure, defined as very heavy physical effort, occurred on those days with night tank fire exercises. On days with intensive field training activities, tank crewmen should receive rations that provide at least MILITARY PHYSICIAN 3/2015

ORIGINAL ARTICLES

Life satisfaction and self-efficacy in multiple myeloma patients before and after treatment Satysfakcja z życia i poczucie własnej skuteczności chorych z rozpoznaniem szpiczaka plazmocytowego przed leczeniem i po nim 1

Ewa Wasińska , Wiesław Skrzyński

Department of Haematology, Świętokrzyskie Centre of Oncology in Kielce; head: Marcin Pasiarski MD, PhD. Department of Internal Diseases and Haematology, Central Clinical Hospital of the Ministry of National Defence, Military Institute of Medicine in Warsaw; head: Prof. Piotr Rzepecki MD, PhD 2

Abstract. During the treatment of any patient, especially those who are chronically ill, one should consider the subjective evaluation of condition, the emotional effects of the disease and also adaptive behaviors. The most important factor appears to be the discussion of existing possibilities and objectives together with the patient as the new situation may have the nature of a constructive confrontation with reality. It is worth working with the patient in seeking those particular fields where those goals important for the patient may be achieved. Apart from the limitations, there are also strong points, both in personality structure and in the current situation. One purpose of this study was to define the quality of life as general satisfaction of life and selfefficacy in chronically ill patients diagnosed with myeloma (n=72). The study was conducted both six months before treatment (the first one or a subsequent one) and after the treatment. Key words: quality of life, self-efficacy, multiple myeloma, personal resources Streszczenie. W leczeniu każdego pacjenta, a zwłaszcza przewlekle chorego, należy uwzględniać subiektywną ocenę stanu zdrowia oraz skutki emocjonalne choroby i zachowania adaptacyjne. Najważniejsze wydaje się wspólne z pacjentem odkrywanie nadal istniejących realnych możliwości i zadań. Nowa sytuacja może mieć charakter konstruktywnej konfrontacji z rzeczywistością. Warto wspólnie poszukiwać tych konkretnych dziedzin, w których możliwa jest realizacja celów ważnych dla chorego. Obok ograniczeń istnieją zwykle mocne strony zarówno w strukturze osobowości, jak i w aktualnej sytuacji. Celem prezentowanych badań było określenie jakości życia przewlekle chorych pacjentów z rozpoznaniem szpiczaka (N = 72) w wymiarze ogólnej satysfakcji z życia (SWLS) oraz poczucia własnej skuteczności (GSES). Badania zostały przeprowadzone przed podjęciem leczenia (pierwszego lub kolejnego) oraz po 6 miesiącach jego trwania. Słowa kluczowe: jakość życia, poczucie własnej skuteczności, szpiczak plazmocytowy, zasoby osobiste Received: 17/03/2015 Approved for printing: 01/06/2015 No conflicts of interest were declared. Mil. Phys., 2015; 93 (3): 227-230 Copyright by Military Institute of Medicine

Introduction The questions of quality of life and satisfaction with life have been explored extensively for various reasons: people are interested in more than mere survival, and satisfaction with life is a universal and democratic category as it concerns everybody to a similar extent, as well as reflecting the increasing tendency towards individualism. People who are ill are interested in their own evaluations and experiences, not only those of others, regardless of their professionalism and objectivity. People need more than the simple removal of their shortcomings; th ey want to be satisfied with themselves, as well as with their

Corresponding author: Wiesław Skrzyński, PhD Department of Internal Diseases and Haematology, Central Clinical Hospital of the Ministry of National Defence, Military Institute of Medicine 128 Szaserów St., 04-141 Warsaw, Poland e-mail: skrzynski@poczta.onet.pl

lives [1]. Moreover, the development and improvement of suitable tools significantly increases the research potential. Numerous authors indicate (in Poland the problem has been emphasized parti cularly by that excellent physician, Andrzej Szczeklik [2,3]) the need to consider all the dimensions of a patient's functioning: the physical dimension (somatic condition), the psychological aspect (primarily cognitive and emotional functioning, and perso nal resources), the social dimension (social relations, social roles, and social support), and the spiritual dimension - the latter receiving more emphasis recently in helping to explain the coexistence of life satisfaction with suffering [5-8].

Life satisfaction and self-efficacy in multiple myeloma patients before and after the treatment

227

ORIGINAL ARTICLES

For this r eason the patients with myeloma in the study were considered not just in terms of the somatic condition but also certain aspects of other dimensions that help determine the quality of life : general satisfaction with life and the sense of self efficacy.

Aims of the study 



To determine whether experience related to hospitalization and aggressive treatment (cytostatics) contributes to changes in such stable dimensions of human existence as general satisfaction with life. W hether helplessness, typically experien ced by patients with neoplastic disease, is reflected in an increased sense of self -efficacy in patients with myeloma in the period before and after treatment.

Material and methods The study involved 44 females and 38 males diagnosed with multiple myeloma. The study was conducted individually, at six months before and after the treatment in the Department of Haematology at the Świętokrzyskie Centre of Oncology in Kielce. The group characteristics are presented in Table 1. Only six of the patients involved in the study were professionally active, while the others were in receipt of social benefits. Most of the study subjects were married or in some kind of informal relationship (48 patients). The most frequently used method of analyzing satisfaction with life is the Satisfaction with Life Scale (SW LS), consisting of five statements. So far, several million people on all continents have been tested using this method [9]. The authors of the scale are: Diener, Emmons, Larson and Griffin [10], and it has been adapted by Juczyński [11]. Using the SW LS scale, the patients evaluated each statement regarding their lives , on a scale from 1 to 7. The ultimate result indicates the level of life satisfaction, and it ranges from 5 to 35 points. The higher the score, th e greater the life satisfaction it expresses. The scale is intended for adults, whether ill or healthy, and the test only takes a few minutes.

228

Table 1. Age, education, time from diagnosis and number of chemotherapy courses Tabela 1. Wiek badanych, wykształcenie, czas od ustalenia rozpoznania oraz liczba kursów chemioterapii Age Education Time since the Number of diagnosis chemotherapy courses 8 0 8 50-60 13 elementary 19 first diagnosis 61-70

29 vocational 18

<12 months 20

71-80

27 secondary 20

<24 months 10

<12

>80

3 higher 15

>24 months 34

>12

Another questionnaire used in this study was the Generalized Self-Efficacy Scale (GSES). The authors of the Polish version are Schwarzer, Jerusalem and Juczyński [8]. The scale is used to measure the level of expected efficacy related to the sense of control over one's actions. The method is based on Bandura's concept of expectations and self-efficacy [12]. Perceived efficacy may refer to specific partial areas of activity, but it may also express a general belief in self-efficacy in any situation, even an unexpected and difficult one [13]. Beliefs related to self-efficacy affect the assessment of an individual's personal resources in a stressful situation; people aim higher, and their engagement in undertaken actions is stronger, even when facing difficulties and obstacles [14]. The GSES reliability criteria determined in the study analysis were satisfactory (Cronbach's alpha of 0.85, and stability coefficient of 0.78). The scale comprises 10 statements and is designed for adults. The sense of self-efficacy allows one to predict motivation and behaviors in various areas of functioning, including behaviors related to one's health [11]. The general score is between 10 and 40 points: the higher the score, the greater the sense of self-efficacy. The test usually takes approximately 5 minutes. The study was conducted individually within a 6 month period in late 2013 and early 2014.

MILITARY PHYSICIAN 3/2015

ORIGINAL ARTICLES

Table 2. Evaluation of life satisfaction in multiple myeloma patients before and after treatment Tabela 2. Ocena ogólnej satysfakcji z życia badanych pacjentów (N = 72) z rozpoznaniem szpiczaka przed podjęciem leczenia i po jego zakończeniu

Table 3. Self-efficacy in a study group of multiple myeloma patients (n=72) before and after treatment Tabela 3. Poczucie własnej skuteczności badanych pacjentów z rozpoznaniem szpiczaka (N = 72) przed podjęciem leczenia oraz po jego zakończeniu Self-efficacy

SWLS scale

Before treatment

After treatment

Item 1

3.18

1.62

3.89

1.44

2.89

0.005

Item 2

3.54

1.57

4.35

1.32

3.61

0.001

Item 3

4.38

1.50

4.57

1.23

0.88

0.380

Item 4

4.21

1.38

4.76

1.29

2.81

0.006

Item 3

3.82

1.83

3.67

1.53

0.53

0.596

General score

19.31

6.43

20.96

5.86

1.63

0.107

Results Quality of life assessment result in patients diagnosed with myeloma We all differ to a greater or lesser extent; however, we share a strong and stable need to be satisfied with our lives. Satisfaction is a summary evaluation, a balance that expresses acceptance or disapproval of what is already in the past, what we are experiencing at the moment, and what we expect in the future. Every disease, chronic diseases in particular, forms a threat to one's life satisfaction. The scores obtained in the study subjects are presented in Table 2. The global result of the study subjects regarding general satisfaction with life, both before and after the treatment, is slightly lower in comparison to the scores obtained in healthy individuals (M = 20.37; SD = 5.32 [7]), without any statistical significance. The level of quality of life is similar to that obtained in other clinical groups (oncological, dialysis, and diabetic) [11]. The results are interesting for items 2 and 4, where the patients assess the conditions of their lives after treatment much better (the signific ance of the difference in assessments is >0.001), and that they achieved the most important aims to a higher degree than before the treatment, although this satisfaction is rather moderate (it only slightly exceeds the neutral level on the seven-point scale [M = 4.76, SD = 1.29]). Therefore, the expected change in general satisfaction with life has not been confirmed. General satisfaction with life is such a stable dimension that even a difficult situation, such as a chronic neoplastic disease, does not affect the quality of life assessment.

Before treatment

After treatment

Statement 1.

2.83

0.89

2.64

0.83

1.41

0.163

Statement 2.

2.53

0.82

2.51

0.75

0.12

0.907

Statement 3.

2.65

0.87

2.61

0.90

0.31

0.758

Statement 4.

2.44

0.79

2.56

0.95

0.91

0.369

Statement 5.

2.63

0.91

2.54

0.93

0.62

0.540

Statement 6.

2.82

0.86

2.60

0.87

1.84

0.070

Statement 7.

2.65

0.89

2.69

0.96

0.29

0.774

Statement 8.

2.74

0.82

2.83

0.98

0.69

0.494

Statement 9.

2.79

0.80

2.61

0.86

1.47

0.145

Statement 10.

2.72

0.86

2.64

0.97

0.61

0.544

General score

26.85

7.26

26.19

7.88

0.58

0.563

Self-efficacy assessment in the study subjects Disease does not change the basic needs and essential characteristics of a person. A dominant, strong, almost genetically encoded need for competence remains [14, 15]; therefore the need for self-efficacy and control is very strong. Table 3 presents how the study patients assessed this need. The general score obtained from the study subjects diagnosed with myeloma is typical for the average scores obtained by patients in other clinical groups [11]. However, the score obtained from the study patients in statement no. 6 is interesting. ("I can solve most problems if I invest the necessary effort"). Although the significance of the differences between the mean scores is close to 0.05, in the context of other scores it seems to be rather specific. The scores obtained after the treatment, often including multiple hospitalizations and chemotherapy courses, are lower than the assessment before the treatment. Therefore, do the experiences, side effects of chemotherapy and greater knowledge about one's disease create a set of factors that reduces the belief in one's potential and hope for complete recovery?

Conclusions 

The present study evaluated important dimensions of the quality of life. In compliance with numerous previous study outcomes regarding general satisfaction with life [8, 9], it appears that in this aspect the study group does not differ significantly from other clinical groups or from healthy study subjects. However, a significant sense of improvement of living conditions after the treatment was visible (item 2.), as well as a specific increase in contentment with the therapy results (item 4.).

Life satisfaction and self-efficacy in multiple myeloma patients before and after the treatment

229

ORIGINAL ARTICLES



The study patients obtained rather low scores in the area of self-efficacy. Those results are typical for other groups of chronically ill patients. Unexpectedly, the after-thetreatment scores were lower in the majority of statements on the Efficacy Scale used in the study. This may be due to an increased level of awareness of one's disease, greater knowledge about the course and the prognosis for the disease gained from the medical personnel and their own observations, as well as from other patients and their own research (of particular significance is the Internet). Therefore, before the treatment the patients' belief in their own contribution to their recovery was slightly higher than after the treatment. This should be considered in the process of treatment, by physicians and, to a greater extent, by clinical psychologists or psycho-oncologists. Finally, the strong adaptive mechanisms of the study patients in a difficult health situation should be emphasized, as well as the decrease in personal resources in the form of a poorer assessment of one's own participation in the treatment process and general dealing with difficult situations.

Literature 1. 2.

3. 4. 5.

8. 9. 10. 11.

12. 13. 14.

15.

230

Franki VE. Homo patiens. Warsaw, Pax, 1976 Szczeklik A. Korę. 0 chorych, chorobach i poszukiwaniu duszy medycyny. [On patients, diseases, and searching for the soul of medicine] Cracow, Znak, 2007 Szczeklik A. Słuch absolutny. [Absolute hearing] Krakow, Znak, 2014 Antonovsky A. The sense of coherence: an historical and future perspective. Israeli J Med Science, 1996; 32: 170-178 Oginska-Bulik N, ed. Zasoby osobiste i społeczne sprzyjające zdrowiu jednostki. [Personal and social resources contributing to the health of an individual] Łódź, Wydawnictwo Uniwersytetu Łódzkiego, 2003 Schumacher J, Gunzelmann T, Braehler E. Lebenszufriedenheit im Alter – Differentielle Aspekte und Einflussfaktoren, Zeitschrifft fur Gerontopsychologieund Psychiatrie, 1996; 9: 1-17 Heszen-Niejodek I. Wymiar duchowy człowieka a zdrowie. [Man's piritual dimension and health] In: Juczyński Z, Oginska-Bulik N, eds. Zasoby osobiste i społeczne sprzyjające zdrowiu jednostki. [Personal and social resources contributing to the health of an individual] Łódź, Wydawnictwo Uniwersytetu Łódzkiego, 2003: 136 Myers DG, Diener E. Who is happy? Psychological Science, 2006; 1: 1019 Ahuvia A. Well-being in cultures-of-choice: A cross cultural perspective. American Psychologist, 2001; 56: 77-78 Diene E, Emmons RA, Larsen RJ, Griffin S. The satisfaction with life scale. J Personal Assess, 1985; 49: 71-75 Juczyński Z. Narzędzia pomiaru w promocji i psychologii zdrowia. [Measuring tools in health promotion and psychology] Warsaw, PTP, 2001 Bandura A. Self-efficacy: Toward a unifying theory of behavioral change. Psychol Rev, 1977; 84: 191-215 Aronson E, Wilson TD, Akert R.M. Psychologia społeczna. [Social psychology] Poznań, Zysk i S-ka, 1997 Schwarzer R. Poczucie własnej skuteczności w podejmowaniu i kontynuacji zachowań zdrowotnych. [Self-efficacy in undertaking and continuation of health-related actions] In: Heszen-Niejodek I, Sęk H, eds. Psychologia zdrowia. [Psychology of health] Warsaw, PWN, 1998 Seligman MP, Csikszentmihalyi M. Positive psychology. Am Psychologist, 2000; 55: 5-14

MILITARY PHYSICIAN 3/2015

ORIGINAL ARTICLES

Levels of self-esteem in multiple myeloma patients Poczucie własnej wartości pacjentów z rozpoznaniem szpiczaka plazmocytowego 1

Wiesław Skrzyński , Ewa Wasińska , Anna Torska

Department of Internal Diseases and Haematology, Central Clinical Hospital of the Ministry of National Defence, Military Institute of Medicine in Warsaw; head: Prof. Piotr Rzepecki MD, PhD 2 Department of Haematology, Świętokrzyskie Centre of Oncology in Kielce; head: Marcin Pasiarski MD, PhD

Abstract. While one purpose of this study was to define real self-assessment in chronically ill patients with multiple myeloma, another significant one was the diagnosis of potential change in self-assessment after several months of chemotherapy. It appears that the analysis of the relation between real self-assessment and the ideal image of oneself is extremely important. Increasing evaluation differences are an indicator of internal tension, the acceptance of oneself and one's life. In order to achieve the purpose of the study, a group of patients (n = 72) with multiple myeloma was tested using adjectival rating for semantic differential analysis. The tool allows the precise determination of selected aspects of the real and ideal self-image (12 adjectival ratings) in respect of values, activity and strength. This can form a base for recognition of not only the current cognitive and emotional condition of a chronically ill patient, but also the determination of their ability to cooperate in the treatment process by means of defining their most basic personal resources, which constitute an extremely significant prognostic factor indicating not only the duration of life but also its quality. Key words: self-esteem, multiple myeloma, real and ideal self-assessment Streszczenie. Celem prezentowanych badań jest nie tylko określenie wymiaru realnego własnej samooceny pacjentów z rozpoznanym szpiczakiem plazmocytowym, ale przede wszystkim diagnoza ewentualnej zmiany samooceny po kilkumiesięcznym okresie chemioterapii. Niezwykle istotna wydaje się również analiza odniesienia ocen realnych do idealnego obrazu siebie. Nasilenie rozbieżności ocen jest bowiem wyznacznikiem wewnętrznego napięcia i równocześnie akceptacji siebie oraz swojego życia. Aby zrealizować ten cel, grupę pacjentów ze szpiczakiem (N = 72) przebadano za pomocą skal przymiotnikowych dyferencjału semantycznego. Narzędzie to pozwala w dokładny sposób określić wybrane aspekty obrazu realnego i idealnego (12 skal przymiotnikowych) w wymiarze wartości, aktywności i siły. Tego typu badanie stanowi podstawę rozpoznania nie tylko aktualnego stanu poznawczego i emocjonalnego pacjenta przewlekle chorego, ale także określenia jego możliwości współpracy w procesie leczenia poprzez określenie najbardziej podstawowych zasobów osobistych, które stanowią niezmiernie istotny czynnik rokowniczy decydujący nie tylko o czasie przeżycia, ale i jego jakości. Słowa kluczowe: poczucie własnej wartości, samoocena realna i idealna, szpiczak plazmocytowy

Received: 17/03/2015 Accepted for print: 01/06/2015 No conflicts of interest were declared. Mil. Phys., 2015; 93 (3): 231-235 Copyright by Military Institute of Medicine

Introduction Self-assessment is not limited to the understanding of oneself, it is a set of experiences that determine not only how to deal with success or problems, but also expectations about the course of one's own life and that of other people [1, 2]. Most of us have a strong need to perceive ourselves as a smart, decent and healthy people. We also tend Self-esteem in multiple myeloma patients

Corresponding author: Wiesław Skrzyński PhD Department of Internal Diseases and Haematology, Central Clinical Hospital of the Ministry of National Defence, Military Institute of Medicine 128 Szaserów St., 04-141 Warsaw, Poland e-mail: skrzynski@poczta.onet.pl

to improve continuously the results of our evaluation, and, in order to achieve this, we are ready to distort reality. Distorting reality and our own experiences results in an inadequate image of reality, as well as the inability to learn from our own mistakes or to use previous experiences, particularly in coping with difficult situations. The need to perceive oneself as good and intelligent is very strong; therefore the need to trivialize or ignore one's shortcomings (and any 231

ORIGINAL ARTICLES

alarming symptoms), with simultaneous overemphasizing our strengths is highly intense [3, 4]. We believe success to be our own achievement, whereas in failure we notice numerous aspects beyond our control. Therefore, disease is associated with the experience of an unfair threa t (why me?). This especially effects terminally ill patients, their sense of self-esteem and expectations towards themselves and their future [5, 6].

Research questions 1. What is the level of self-acceptance in a patient with hematological chronic diseas e? 2. If, and to what extent, does the sense of self esteem change before and after the treatment (the first or the next one) in patients with multiple myeloma?

Material and methods The study involved 72 patients: 44 females and 38 males, diagnosed with multiple myeloma. The study was conducted individually, 6 months before treatment and then again after completion of the treatment at the Department of Haematology at the Świętokrzyskie Centre of Oncology in Kielce. The group characteristics are presented in Table 1. Only six patients involved in the study were professionally active, while the others received social benefits. Most study subjects were either married or in some kind of informal relationship (48 patients). Table 1. Age, education, time since diagnosis and number of chemotherapy courses Tabela 1. Wiek badanych, wykształcenie, czas od ustalenia rozpoznania oraz liczba kursów chemioterapii

Age

Education

Time since the diagnosis

Number of chemotherapy courses

50-60

13 elementary 19

first 8 diagnosis

61-70

29 vocational 18

<12 months 20

71-80

27 secondary 20

<24 months 10

<12

>80

3 higher 15

<24 months 34

>12

232

The semantic differential – possible uses for studies in health psychology and medical science Theoretical grounds The theoretical premises for the semantic differential were presented in 1952 by Ch. E. Osgood [7]. The aim of this technique is to measure connotative meaning, here denoting a set of features collectively described by a given name, but without the unambiguous determination of the scope of that name. This understanding of connotative meaning can be referred to as psychological meaning, as it i s a form of personal preference, a presentation of a personal attitude not just on a cognitive level but also an emotional one [8]. The semantic differential technique is based on the concept of the representational mediation process and the model of seman tic space created by a set of mediation processes. Each term has a multidimensional space in which it has a beginning (zero point), and an n -dimensional character created by epithets used to describe it, usually mono - (good) or bi -polar (good – bad) adjectives.

Use The semantic differential is not a tool used to analyze a given aspect of personality, it is a technique that needs to be prepared and adjusted for each study by the appropriate selection of the concepts to be studied and their scope. This gives the tool many possible uses in evaluating self assessment, as well as that of people, phenomena and experiences. The semantic differential is often used in psychological diagnosis and therapy, as well as in medical sciences involving the study of holistic change. It allows one to follow precisely any changes in self -esteem or relations with significant people, giving a scale to the scope and intensity of emotional experiences, both positive and negative, associated with the treatment and personal beliefs re garding the prognosis. In this study, twelve adjectivals were used, selected as intended by their authors: active, good, attractive, smart, hard -working, friendly, cheerful, strong, calm, emotional, valuable and healthy. The assessments were made using a s even -point continuous rating scale, and involved the following self -assessment by the patients: "I am" and "I want to be" before the treatment, and then the same dimensions (real and ideal) following the treatment.

MILITARY PHYSICIAN 3/2015

ORIGINAL ARTICLES

Table 2. Self-esteem in multiple myeloma patients in the real and ideal dimensions prior to treatment Table 2. Self-esteem in multiple myeloma patients in the real and ideal dimensions prior to treatment Tabela 2. Poczucie własnej wartości pacjentów z rozpoznaniem szpiczaka w wymiarze realnym i idealnym przed podjęciem leczenia Before treatment

I am

I want to be

Table 4. Self-esteem in the real dimension prior to and following treatment Tabela 4. Poczucie własnej wartości pacjentów w wymiarze realnym przed leczeniem hematologicznym i po leczeniu

I am

Before treatment

After treatment

active

3.35

1.60

2.99

1.44

1.71

0.092

active

3.35

1.60

5.86

1.07

11.60

<0.001 good

4.13

1.42

4.28

1.12

0.88

0.384

good

4.13

1.42

5.67

0.90

8.00

<0.001

attractive

3.50

1.51

3.33

1.21

0.78

0.441

attractive

3.50

1.51

5.42

1.16

10.65

<0.001

smart

4.17

1.22

4.06

0.92

0.69

0.493

smart

4.17

1.22

5.75

0.87

11.58

<0.001

hard-working

4.88

1.26

4.24

1.29

3.77

0.000

hard-working

4.88

1.26

5.35

0.83

2.85

0.006

friendly

4.99

1.28

4.76

1.03

1.18

0.241

friendly

4.99

1.28

5.64

1.13

4.37

<0.001

cheerful

3.88

1.55

3.76

1.34

0.55

0.586

strong

3.21

1.56

2.78

1.37

2.09

0.041

cheerful

3.88

1.55

5.81

0.93

11.25

<0.001 calm

4.31

1.41

4.15

1.41

0.72

0.477

emotional

5.29

1.17

5.32

1.14

0.15

0.883

valuable

4.67

1.26

4.14

1.19

2.74

0.008

healthy

2.75

1.22

2.29

1.08

2.71

0.008

strong

3.21

1.56

5.82

1.07

14.99

<0.001

calm

4.31

1.41

5.71

1.03

7.66

<0.001

emotional

5.29

1.17

5.25

1.23

0.27

0.791

valuable

4.67

1.26

6.03

0.98

7.73

<0.001

healthy

2.75

1.22

6.17

1.30

17.47

<0.001

Table 3. Self-esteem in the study group patients following treatment Tabela 3. Poczucie własnej wartości badanych pacjentów po przebytym leczeniu After treatment

I am

I want to be

active

2.99

1.44

5.92

0.84

16.13

0.001

good

4.28

1.12

5.44

0.63

10.12

0.001

attractive

3.33

1.21

5.33

0.73

14.91

0.001

smart

4.06

0.92

5.64

0.63

15.48

0.001

hard-working

4.24

1.29

5.38

0.66

7.67

0.001

friendly

4.76

1.03

5.51

0.75

6.01

0.001

cheerful

3.76

1.34

5.69

0.74

11.98

0.001

strong

2.78

1.37

6.01

0.70

19.08

0.001

calm

4.15

1.41

5.54

0.71

7.92

0.001

emotional

5.32

1.14

5.47

0.73

1.03

0.308

valuable

4.14

1.19

6.17

0.77

12.34

0.001

healthy

2.29

1.08

6.39

0.78

25.86

0.001

Self-esteem in multiple myeloma patients

Results The obtained results are presented in the basic descriptive data (M, SD), and the significance of differences between the mean test (t-Student) results are compared. It is clear from Table 1 that the scores regarding the real self-assessment were significantly lower, with the impression "I am not healthy" (M = 2.75; SD = 1.22) clearly dominating. Next, a low self-assessment applied to the statement "I am weak (M = 3.21; SD = 1.56), and therefore not very active" (M = 3.25; SD = 1.60), and "My appearance is not attractive", as the scores on the "attractive" scale (M = 3.50; SD = 1.51) were significantly below the average self -assessment. Relatively positive assessments occurred for the following categories in the real dimension: "I am emotional" (M = 5.29; SD = 1.17), "I am friendly" (M = 4.99; SD = 1.28), "I am hard-working" (M = 4.88; SD = 1.26) and "I am quite valuable" (M = 4.67; SD = 1.26). The expectations of the patients treated for multiple myeloma were similar to those of healthy people, so the discrepancy in the ideal self-assessment scores drastically and dramatically differed from the real assessments. In as many as 10 out of the 12 scales used in the study the significance of difference was above 0.001, which was not only very high but definitely too high. Such a considerable discrepancy between the real and ideal assessments often 233

ORIGINAL ARTICLES

becomes a source of frustration and negative emotions associated with the inability to meet one's own expectations. Instead of the first question related to the shock after the diagnosis, which is usually "why me?", a disappointment or grudge appeared in the form of the statement: "It was not supposed to be like this! This is not how I planned my life". After the treatment, the self-esteem in the real dimension was rather low. For five self -assessment scales the scores were significantly lower than the average: "I still don't feel healthy" (M = 2.29; SD = 1.08), "I don't feel strong" (M = 2.78; SD = 1.37), "I can't be active" (M = 2.99; SD = 1.44), "I do not perceive myself as attractive" (M = 3.33; SD = 1.21) or "cheerful person" (M = 3.76; SD = 1.34). Similarly to before the treatment, patie nts saw themselves as: emotional (M = 5.32; SD = 1.14), friendly (M = 4.76; SD = 1.03), rather good (M = 4.28; SD = 1.12) and rather hard-working (M = 4.24; SD = 1.29). In eleven of the self-assessment categories, those patients diagnosed with myeloma afte r the treatment wanted to be different. In all the cases the significance of difference exceeded the confidence interval of 0.001. Only on the "emotional" scale did they not express a need for change. At this stage, the difference was analyzed between self-esteem in the study patients in the real dimension before and after the treatment. The obtained scores were surprising, because for ten scales the mean self assessment was lower after the treatment than before. Patients after the treatment perceived thems elves as less able to work (p <0.001), less valuable (p <0.01), as well as less healthy (p <0.01) and weaker (p <0.05). A question should be posed here: to what extent do the expectations of myeloma patients regarding themselves and the future change? The answer is provided in the analysis shown in Table 5.

Table 5. Self-esteem in the ideal dimension in multiple myeloma patients Tabela 5. Poczucie własnej wartości w wymiarze idealnym badanych pacjentów z rozpoznaniem szpiczaka I want to be

Before treatment

After treatment

active

5.86

1.07

5.92

good

5.67

0.90

5.44

0.84

0.38

0.703

0.63

1.82

0.073

attractive

5.42

1.16

5.33

0.73

0.55

0.584

smart

5.75

0.87

5.64

0.63

1.03

0.305

hard-working

5.35

0.83

5.38

0.66

0.24

0.810

friendly

5.64

1.13

5.51

0.75

0.87

0.388

cheerful

5.81

0.93

5.69

0.74

0.91

0.369

strong

5.82

1.07

6.01

0.70

1.44

0.154

calm

5.71

1.03

5.54

0.71

1.15

0.255

emotional

5.25

1.23

5.47

0.73

1.50

0.139

valuable

6.03

0.98

6.17

0.77

0.92

0.361

healthy

6.17

1.30

6.39

0.78

1.28

0.205



Conclusions 



The analysis of scores regarding self-esteem reveals the significant decrease in selfassessment in the most significant dimension, the real one. The most striking observation is the greatest decrease in self-assessment before the treatment in the "healthy" category, together with increased lowering of self-assessment after the treatment. The patients feel very ill before admission to the hospital, and after the treatment they feel even more unwell. Moreover, the self-assessment of the patients decreases even more after the treatment for the majority of the ratings, particularly in the assessment of the ability to undertake any effort or activity, or the sense of fitness. This aspect should als o be considered during the therapy process so that it is not limited to the treatment of the disease but also constitutes a comprehensive, holistic approach to the patients and their lifestyles.



Literature 1. 2.

234

The process of lowering self-esteem is very detrimental to the quality of life, as in the ideal self-assessment dimension (I want to be) in almost all the studied categories the ideal assessments differed considerably from the real ones, which may result in deepening and destructive frustration due to the inability to fulfil one's desires and expectations. The consequences of this frustration not only considerably limit life satisfaction, perceived sense and value of life, but also becomes an important destructive component regarding motivation for treatment and belief in its effectiveness. This, in turn, may ( and often does) increase apathy, as well as limit one's confidence in the suggested treatment, reducing the hope for an improvement in health, and significantly decreasing the quality of life. Human expectations and needs remain significant, despite such a negative and traumatic experience as chronic and health- or life-threatening disease such as multiple myeloma. No significant differences occurred in any of the twelve self assessment ratings. Ideas and expectations towards functioning in the future, despite what has happened, are very stable and rather high, especially when compared to the considerably lowered real self-assessments.

Strack M, Argyle M, Schwartz N. Subjective well -being. An Interdysc yplinary Perspective. London, Pergamon Pr ess, 1991 Silvia PJ, Gendolla GHE. On introspection and self -perception: Does self-focused attention enable accurate self -knowledge? Review of General Psychology, 2001; 5 (3): 241 -269 Trzebińska E. Psychologia pozytywna. [Positive ps ychology] W arsaw, W ydawnictwa Akademickie i Profesjonalne, 2008

MILITARY PHYSICIAN 3/2015

ORIGINAL ARTICLES

4. 5.

W egscheider-Cruse S. Poczucie własnej wartości. [Learning to love yourself] Gdańsk, GW P, 2007 Stolar GE, MacEntee ML, Hill P. Senio r's assessment of their health and life satisfaction. International Journal of Aging and Human Development, 1992; 35:305-317 Carr A. Psychologia pozytywna. Nauka o szczęściu i ludzkich

Self-esteem in multiple myeloma patients

7. 8.

silach. [Positive Ps ychology: The Science of Happiness and Human Strengths] Poznań, W ydawnictwo Zysk i S -ka, 2009 Osgood Ch E. The nature and measurement of meaning. Psychological Bulletin, 1952; 49,197 -237 Osgood ChE, Suci GJ, Tannenbaum PH. The measurement of meaning. University of Illinois Press, 1957

235

ORIGINAL ARTICLES

Evaluation of selected early multiorgan dysfunction symptoms in forecasted survival rates for patients with burns Ocena wartości wybranych wczesnych objawów zaburzeń ogólnoustrojowych w prognozowaniu przeżycia oparzonych 1

2-3

Agnieszka Surowiecka-Pastewka , Marek Kawecki , Wojciech Witkowski

Clinical Department of Plastic Surgery, Reconstruction Surgery and Burn Treatment, Dialysis Therapy, Central Clinical Hospital of the Ministry of National Defence, Military Institute of Medicine in Warsaw; head: Wojciech Witkowski MD, PhD 2 Centre for Burn Treatment in Siemianowice Śląskie; medical head: Prof. Marek Kawecki MD, PhD 3 Emergency Medicine Division, Faculty of Life Sciences, University of Bielsko Biała; dean of the faculty: Prof. Monika Mikulska MD, PhD. Abstract. In order to predict organ disorders early for severely burned patients as part of the clinical examination and selected laboratory tests performed on admission to the hospital, a retrospective analysis and comparison of selected parameters was carried out for three subgroups: >25%TBSA, 15-25% TBSA and <15%TBSA. The group consisted of 842 burned patients who were treated at the Burn Treatment Centre in Siemianowice Śląskie and in the Clinical Department of Plastic and Reconstructive Surgery and Burns Unit of the Military Institute of Medicine in Warsaw, admitted in 2012 and 2013. Statistically significant (p<0.05) differences between the three subgroups were found. The severe burns group (>25% TBSA) was characterized by low arterial pressure, low pH in arterial blood gas analysis, elevated white blood cell count, hypoproteinemia and/or hypoalbuminemia, and hyperglycemia. These deviations could be important in predicting multiorgan dysfunction and failure, especially in burned patients at increased risk of death. Key words: mortality rates in burns, multiorgan failure in burns, severe burns Streszczenie. W celu przewidywania wczesnych zaburzeń ogólnoustrojowych u ciężko oparzonych, ujawniających się w badaniu klinicznym i w wybranych badaniach laboratoryjnych wykonywanych w chwili przyjęcia do szpitala, dokonano retrospektywnej analizy wybranych parametrów i porównania ich w trzech podgrupach: oparzeń ciężkich, średnich i lekkich (>25%, 15-25%, <15% całkowitej powierzchni ciała). Grupę badaną stanowiło 842 oparzonych z dwóch ośrodków: Centrum Leczenia Oparzeń w Siemianowicach Śląskich (CLO) oraz Oddziału Klinicznego Chirurgii Plastycznej, Rekonstrukcyjnej i Leczenia Oparzeń Wojskowego Instytutu Medycznego w Warszawie (WIM), przyjętych w latach 2012 i 2013. W badanym materiale stwierdzono istotne statystycznie (p <0,05) różnice między trzema podgrupami. W podgrupie ciężko oparzonych (>25% całkowitej powierzchni ciała) przy przyjęciu do szpitala obserwowano niskie ciśnienie tętnicze, małe pH krwi w gazometrii, zwiększenie liczby leukocytów, małe stężenie białka całkowitego i/lub albuminy oraz zwiększone stężenie glukozy we krwi. Stwierdzone odchylenia mogą mieć wartość w przewidywaniu możliwości wystąpienia dysfunkcji lub niewydolności wielu narządów, zwłaszcza u osób ze zwiększonym ryzykiem zgonu. Słowa kluczowe: ciężkie oparzenia, śmiertelność w oparzeniach, niewydolność wielonarządowa w oparzeniach Received: 08/04/2015 Approved for printing: 01/06/2015 No conflict of interest was reported. Mil. Phys., 2015; 93 (3): 236-243 Copyright by Military Institute of Medicine

236

Corresponding author: Agnieszka Surowiecka-Pastewka MD Clinical Department of Plastic Surgery, Reconstruction Surgery and Burn Treatment, Dialysis Therapy, Central Clinical Hospital of the Ministry of National Defence, Military Institute of Medicine 128 Szaserów St., 04-141 Warsaw, Poland telephone +48 261 817 219, telephone/fax: +48 226 100 164 e-mail: wojwit@wim.mil.pl

MILITARY PHYSICIAN 3/2015

ORIGINAL ARTICLES

Introduction Severe burn treatment is a multidisciplinary and highly specialized task. In severely burned patients, immediate implementation of intensive systemic treatment (fluid resuscitation) is necessary as early as possible in order to prevent the clinical symptoms of burn shock. The surgical treatment chosen depends on the patient's general condition (cardiopulmonary stabilization) and on the area and depth of the burns. Severe burns, which are considered to those covering over 25% of the total body surface area (TBSA), regardless of their depth, especially if accompanied by burns of the respiratory tract and other injuries, are associated per se with high mortality. One of the most serious complications of a burn injury is multiorgan failure (MOF)[1]. Therefore, the aim of severe burn therapy is a multifaceted action to prevent multiorgan insufficiency occurring early after the burn.

Aim of the study This study attempts to assess the value of basic life parameters and selected laboratory tests in severely burned patients, compared to patients with moderate or mild burns, in order to determine the role of early symptoms of impaired organism functions in the prognosis for patient survival.

Material and methods A retrospective analysis was carried out for selected parameters related to the patient, injury and laboratory test results in patients admitted to the Centre for Burn Treatment in Siemianowice Śląskie (CLO) and to the Clinical Department of Plastic Surgery, Reconstruction Surgery and Burn Treatment, Military Institute of Medicine in Warsaw (WIM) in the years 2012 and 2013. The group of patients with burns (842 patients) was divided into three subgroups, according to the total surface area of the burn: >25% TBSA, 15-25% TBSA and <15% TBSA. The division was based on the criteria adapted by the American Burn Association (ABA) [2]. The inclusion criterion was a burn caused by fire, boiling water or watersteam. Electrical, chemical and mixed burns were excluded. The first subgroup comprised the 238 most severely burned patients (78% males), with a mean age of 50 years (SD ±17, range 18-92 years). Mean total surface area of the burn was 50% TB SA (SD ±20), and 25% in case of a deep burn (SD ±25, range 0-100). The second subgroup comprised patients with moderate burns, consisting of 138 subjects. Males formed 69% of the subgroup, with a mean age lower than in the first group, at 49 years (SD ±18, range 18 – 87 years). Total burn surface area in this subgroup was estimated at an average of 19% (SD ±3), and for third degree deep burns at 5% (SD ±6, range 0 – 23). The third subgroup comprised 454 patients with mild

burns. The majority of the subjects (71%) were again males, with a mean age of 47 years (SD ±17, range 18 – 96 years). Total burn surface area in this subgroup was estimated at an average of 8% (SD ±4), and in case of deep burns at 2% (SD ±3, range of 0 – 13). The factors considered in the analysis were the patient's clinical condition and test results at admission to CLO and WIM. A number of parameters collected on admission were assessed: age, sex, total burn surface area, surface area of deep burns, coexisting respiratory tract burns and time from the burn to hospital admission (CLO and WIM) expressed in days. Moreover, several life parameters were analyzed: consciousness disorders according to the Glasgow Coma Scale (GCS), body temperature, number of breaths per minute, arterial pressure and heart rate. The results of the laboratory tests on admission were also collected: arterial blood gasometry (for patients in danger of respiratory failure), complete blood count (leukocytes, reticulocytes, blood platelets, hemoglobin, and hematocrit), coagulogram (APTT, INR), and selected biochemical markers (concentration of sodium, potassium, glucose, creatinine, protein and albumin). Next, prognostic scales were calculated for each subgroup individually, and the survival -death ratio was analyzed. Basic descriptive statistics were used to describe the parameters studied. The statistical analyses were performed with the use of StatSoft, Inc. (2011) software: STATISTICA (data analysis software system) version 12. The Kruskall-Wallis test was used to analyze the statistical significance of variance of characteristics. If the test results suggested statistical significance between the studied groups, a post hoc analysis using the Nemenyi method was performed to determine between which groups the statistical ly significant difference occurred. If the observation values were within the nominal scale, the data were analyzed using the chi-square test (independent test).

Results Patients from the most severely burned group (>25% TBSA) were admitted on average to CLO and WIM 24 hours following the thermal injury (SD ±3.5, range of 0 – 31), that is on the second day. Patients with moderate burns were admitted after 72 hours (SD ±7, range of 0 – 50), and with mild burns on day 4 (SD 8, range of 0 – 60). P value obtained in the KruskalWallis test was <0.05. The post hoc evaluation of selected early multiorgan dysfunction symptoms in the survival prognosis rates for patients with burns revealed a statistical difference between the subgroup of patients with severe burns and those with mild burns (p = 0.000), and between those with severe burns and moderate burns (p = 0.003).

Evaluation of selected early multiorgan dysfunction symptoms in survival prognosis rates for patients with burns

237

ORIGINAL ARTICLES

Table 1. Life parameter values of patients in the three burns subgroups estimated on admission to hospital Tabela 1. Wartości parametrów życiowych oparzonych z trzech podgrup ocenianych w chwili przyjęcia do ośrodka Descriptive statistics inclusion condition: (%TBSA >25)

Descriptive statistics inclusion condition: (%TBSA <25) exclusion condition (%TBSA <15)

Descriptive statistics inclusion condition (%TBSA <15)

Mean

Min.

Max.

Mean

Min.

Max.

Mean

Min.

Max.

92.182

26.00

145.00

19.16

84.47

52.00

130.00

12.09

82.19

40.00

134.00

12.25

temperature

36.31

26.60

38.40

0.92

36.51

35.80

37.20

0.25

36.58

32.60

39.00

0.38

breaths

14.90

8.00

24.00

2.45

15.77

10.00

23.00

2.34

14.74

8.00

20.00

2.25

GCS

8.00

18.00

3.42

8.00

18.00

1.45

8.00

15.00

1.08

MAP

90.30

0.00

146.7

21.90

99.74

66.66

145.33

14.21

99.69

53.33

150.00

14.33

TBSA – Total Body Surface Area, HR – heart rate, GCS – Glasgow Coma Scale, MAP – mean arterial pressure, min – minimum, max. – maximum, SD – Standard Deviation

Table 2. Analysis of arterial blood gas in patients requiring intubation or presenting symptoms of respiratory failure Tabela 2. Wyniki badań gazometrii krwi tętniczej pobranej u pacjentów zaintubowanych lub z niewydolnością oddechową Descriptive statistics inclusion condition: (%TBSA >25)

Descriptive statistics inclusion condition: (%TBSA <25), exclusion condition: (%TBSA <15)

Descriptive statistics inclusion condition: (%TBSA <15)

Mean

Min.

Max.

Mean

Min.

Max.

Mean

Min.

Max.

PH (7.35 – 7.45)

7.239

7.000

7.620

0.108

7.333

7.077

7.432

0.095

7.324

6.957

7.481

0.133

02 (80.0 – 100.0)

94.92

23.10

465.20

90.22

160.84

23.90

414.50

148.42

127.45

28.80

526.00

147.80

In the severe burn subgroup, comorbid respiratory burns occurred in 70% of cases, while in the moderate burn subgroup inhalatory injury was found in 40% of patients, and 30% in the mild burn subgroup. The statistical result revealed a significant variance between respiratory tract burns and the burn area, with a p value <0.05. In the subgroup of severely burned patients the mean heart rate was 92/min. (SD ±19, range of 26 – 145), with average arterial pressure of 90 mm Hg (SD ±22, range indeterminate – 147) (Tab. 1.). A statistically significant difference in distributions of a given characteristic was obtained in the Kruskal-Wallis test, and in the post hoc test the p value was <0.05 (p = 0.0000) between the subgroups of severely and mildly burned patients, and between the subgroups of severely and moderately burned patients. Consciousness disorders occurred most frequently in the subgroup of patients with severe burns, and the differences between the severe and mild burn subgroups, and the severe and moderate burn subgroups in the Nemenyi test were statistically significant, with a p value of <0.05. Mean GCS score in the >25% TBSA group was 12, with the methodological assumption that intubated and analgosedated patients had GCS <8 (patients with

238

pharmacologically induced loss of consciousness – pharmacological coma). For the two remaining groups (patients with moderate and mild burns) the mean Glasgow Coma Scale score was approximately 15. Mean body temperature at admission did not differ between the subgroups, at 36°C (Tab. 1.). In each analyzed subgroup the mean breath rate was 15/min., and no significant differences between the subgroups were observed. A gasometric test from the arterial line was performed not only in the intubated patients with burns but also in those with suspected respiratory failure (Tab. 2.). Gasometric testing of arterial blood in the subgroup of patients with severe burns was performed in 47% of patients. Mean blood pH in the gasometric test in the severely burned patient subgroup was 7.239 (SD ±0.108, range of 7 – 7.62) with pO2 95 (SD ±90, range of 23 – 465). In the two other subgroups (patients with moderate and mild burns) it was 7.33 on average, with normal pO2 >100, most frequently in patients undergoing respiratory therapy and oxygen therapy.

MILITARY PHYSICIAN 3/2015

ORIGINAL ARTICLES

Table 3. Blood count values in three study subgroups Tabela 3. Wyniki morfologii krwi obwodowej w trzech badanych podgrupach

WBC 10.0)

(4.0

Descriptive statistics inclusion condition: (%TBSA >25)

Descriptive statistics inclusion condition: (%TBSA <25) exclusion condition: (%TBSA <15)

Descriptive statistics and inclusion condition: (%TBSA <15)

Mean

Min.

Max.

Mean

Min.

Max.

Mean

Min.

Max.

– 17.45

3.10

55.06

8.20

14.10

7.70

18.80

1.92

9.49

3.20

29.20

3.54

RBC (3.5 – 5.5)

4.76

2.23

7.42

0.87

4.58

2.37

6.54

0.67

4.60

2.71

7.78

0.62

HCT (35 – 55)

43.96

25.00

62.00

7.13

41.83

24.70

52.80

5.15

41.75

28.00

51.40

4.53

7.80

21.40

2.56

14.10

7.70

18.800

1.917

13.99

4.99

17.90

1.73

35.00

1372.00

184.18 240.72

10.00

608.00

92.76

249.2

13.60

1273

106.8

HGB 18.0)

(11.0

– 14.77

PLT (150 – 400) 293.31

Table 4. Results of coagulogram in three subgroups Tabela 4. Wyniki badań krzepliwości krwi w trzech podgrupach Descriptive statistics inclusion condition: (%TBSA >25)

Descriptive statistics inclusion condition: (%TBSA <25) exclusion condition: (%TBSA <15)

Descriptive statistics inclusion condition: (%TBSA<15)

Mean

Min.

Max.

Mean Min.

Max.

Mean

Min.

Max.

APTT N (23.0 – 35.0)

29.2

12.9

78.60

7.09

28.64 19.90

56.90

5.48

30.29

17.10

327.60

15.53

INR

1.09

0.72

3.27

0.34

1.02

6.33

0.49

0.97

0.75

11.80

0.56

0.76

Blood oxygen pressure did not show any statistical differences between the subgroups, unlike pH where the value distribution was statistically significantly different in all the subgroups (Kruskal-Wallis test, p <0.05). In the subgroup of severely burned patients the white 3 blood cell count in the peripheral blood was 17.45 x 10 /l (SD ±8, range of 1 – 55), the highest of all the study groups (Tab. 3.). The distribution of leukocyte count values between the three subgroups was statistically significantly different, with p = 0.000. Mean erythrocyte counts, hemoglobin and hematocrit concentrations did not differ significantly between the subgroups. The highest blood platelet count was observed in the subgroup of patients with >25% body surface area burns (severely burned), but the platelet number was not statistically significantly different between the study subgroups (Kruskal-Wallis test, p = 0.07). Mean results of selected coagulation indicators (APTT, INR) in all the subgroups did not reveal any statistically significant differences (Tab. 4.). In the severely burned patients subgroup, total protein was reduced to 5.33 g/l (SD ±1, range of 0.54 – 7.8), and albumin to 2.86 g/l (SD ±0.88, range of 0.9 – 4.7) (Tab. 5.). In the two other subgroups the mean protein and albumin concentrations were normal. The observed differences were statistically significant (Nemenyi test, p <0.05). The severely and moderately burned patients demonstrated increased blood glucose concentrations

(glycemia), significantly different in comparison to the subgroup of patients with mild burns (Nemenyi test, p < 0.05). No significant abnormalities were observed in mean ion concentrations (sodium, potassium) or blood creatinine. The highest mortality was found in the subgroup of severely burned patients (chi-square test, p <0.05 [Tab. 6.]). In this group 48% of patients died, with a mean survival of 28 days (SD ±29, range of 0 – 216). In the moderate and mild burn subgroups the mortality rate was 6% and 1%, respectively. The severely burn subgroup was characterized by the highest death risk, according to commonly used systems and prognostic tables (Kruskal-Wallis test, p < 0.05 [Tab. 7.]).

Discussion Multiorgan dysfunction is one of the principal causes of death in patients with severe burns [1, 2]. According to the American Burn Association report, it causes approximately 28% of deaths among patients admitted to burn centers [2], and according to European data it may be the cause of death in 25% or even 65% of patients with burns [3]. In the last 30 years in Europe the mortality due to thermal injuries has been decreasing [3]. However, for >20% TBSA burns, this risk should not be excluded [3].

Evaluation of selected early multiorgan dysfunction symptoms in survival prognosis rates for patients with burns

239

ORIGINAL ARTICLES

Table 5. Selected biochemical results, estimated on admission to the Center Tabela 5. Wyniki wybranych parametrów biochemicznych, ocenianych przy przyjęciu do ośrodka Descriptive statistics inclusion condition: Descriptive statistics (%TBSA >25) inclusion condition: (%TBSA <25) exclusion condition: (%TBSA <15)

Descriptive statistics inclusion condition: (%TBSA <15)

Mean

Min.

Max.

Mean

Min.

Max.

Mean

Min.

Max.

0.90

4.70

0.88

3.74

2.50

5.38

0.78

3.84

2.4

5.4

0.61

sodium (137 – 139.6 145) potassium (3.5 4.35 – 5.1) glucose (74 – 134.0 106)

121.00

155.00

4.98

139.7

125.00

153.00

4.44

140.4

125.0

152

3.49

2.20

6.70

0.66

4.20

2.90

5.90

0.55

4.30

2.70

8.70

0.55

59.00

490.00

57.32

113.4

63.00

390.00

46.05

100.3

48.00

448

37.31

creatinine (0.7 – 0.94 1.2)

0.31

3.20

0.40

0.83

0.40

3.50

0.31

0.80

0.22

3.09

0.24

total protein 6.4-8.3

0.54

7.82

1.21

6.34

4.40

8.09

0.73

6.56

4.10

8.40

0.63

– 2.86

albumin (3.5 5.2)

5.33

Table 6. Mortality rate and days of survival in individual subgroups Tabela 6. Zgony i dni przeżycia w poszczególnych podgrupach Descriptive statistics inclusion condition: (%TBSA >25)

death days survival

Descriptive statistics inclusion condition: (%TBSA <25) exclusion condition: (%TBSA <15)

Descriptive statistics inclusion condition: (%TBSA <15)

Mean

Min.

Max.

Mean

Min.

Max.

Mean

Min.

Max.

0.48

0.0

1.00

0.50

0.06

0.0

1.00

0.24

0.01

0.0

1.00

0.11

of 28.5

0.0

216.0

28.85

23.26

0.0

114.00

17.77

16.54

0.0

258.0

16.72

Table 7. Prognostic scales for the three study subgroups Tabela 7. Skale prognostyczne dla trzech badanych podgrup Descriptive statistics inclusion condition: (%TBSA >25)

Descriptive statistics inclusion condition: (%TBSA <25) exclusion condition: (%TBSA <15)

Descriptive statistics inclusion condition: (%TBSA <15)

Mean

Baux

99.39

25.44

67.54

17.90

55.02

18.09

Osier

110.98

28.08

74.42

18.81

60.24

19.57

Bull-Fisher

0.79

0.27

0.32

0.31

0.10

0.18

Schwartz

0.61

0.37

0.18

0.26

0.07

0.15

Watson-Sachs

125.28

90.97

32.67

17.78

13.36

9.60

ABSI

9.87

2.90

5.75

1.88

4.14

1.81

FLAMES

17.50

5.46

11.90

3.16

9.62

3.18

BEAMS

0.79

0.29

0.95

0.10

0.97

0.06

240

MILITARY PHYSICIAN 3/2015

ORIGINAL ARTICLES

In the group of severely burned patients, the first subgroup was characterized by the highest mortality rate compared to the other subgroups, p <0.05. These patients were more often diagnosed and treated for inhalatory burns of the respiratory tract, p <0.05. Statistically significant parameters that distinguished the extensive burn subgroups from the other subgroups on the first day after admission to CLO and WIM were as follows: low systolic pressure, consciousness disorders associated or not with intubation, low pH in the gasometric test (acidosis), leukocytosis, low concentrations of total protein and/or albumin, and hyperglycemia. The scales for proper functioning of the vital organs are used to assess organ impairment in the intensive therapy of burns. There is not one recognized, standardized and universally usable prognostic method, and those methods that are in use analyze various parameter numbers and values. Moreover, there is no scale for early detection of multiorgan dysfunction that is both highly specific and sensitive [4]. The method proposed by Goris evaluates seven organs (respiratory organ, circulatory system, kidneys, liver, bone marrow, intestines, and CNS), with three grades of dysfunctions being distinguished: 0 - no dysfunctions, 1 dysfunction, 2 - insufficiency [4]. Another scale is APACHE II, which provides a basis for more advanced prognostic scales, specifically for burns: BEAMS and FLAMES [5, 6]. Another assessment tool, SOFA (Sequential Organ Failure Assessment), is used to evaluate intensive care unit patients suffering from sepsis and organ hypoperfusion [7]. Ngujen et al. used this scale to assess the development of multiorgan failure in patients with severe burns of surface area >40% TBSA. They noticed that MOF usually develops 7 days after the burn; however, they did not investigate any early (1-2 day) premises that could predict MOF or justify a credible expectation of the condition. Respiratory failure was the most frequent disorder, followed by renal failure [8]. The mortality rate in the entire population in the Nguyen et al. study was approx. 42%, which is in compliance with our results. In another study by Alama et al., the most frequent independent organ dysfunction was renal failure [9]. Mace et al. used the Marshall scale for assessment of multiorgan failure intensity, which evaluates not only the respiratory system, kidneys, liver, circulatory system and CNS, but also the coagulatory system, to demonstrate that the degree of organ dysfunction in patients with severe burns increases with time from the time of burn; according to the assessment parameters in the form of points, the degree is the lowest on the day of hospital admission, regardless of the day of the burn incident [10]. Our study investigated the possibility to assess early the probability of dysfunction or failure from days 1-2. Comparing mortality rates in burns between various centers is difficult and poses many problems. This is primarily due to the differing systems of patient classification to the group with severe burns, time of observation and assessment of the risk of death using various prognostic systems and tables. Often the parameters and criteria of evaluation of the thermal injury also vary. In Europe, burn centers admit patients with a mean total burn area of 11-25% [3]; however, an increasing volume of data indicates that the admission criteria to referential burn centers should be much higher, reaching 30-55% of the total body surface area [3]. In the Pavoni study, involving patients with a burn surface area

>40% TBSA, admitted to a specialist burn treatment center, the mortality rate among the patients with mean burn area of 54% TBSA (SD ±18.1), with a Baux index of 108.4 (SD ±21.3), was 44% [11]. In our study, the subgroups of patients with severe burns comprised those with a burn area of over 25% TBSA and 50% TBSA on average, with a Baux index of 99, and 48% mortality rate. Similar inclusion criteria as in our study were adopted by Lavrentieva et al.; however, the study assessed survival within 28 days from the burn, with a mortality rate of 33% [12]. In our observation, the mean survival of patients with severe burns was 28 days (range of 0 – 216). The primary task in the first day from the burn incident is adequate fluid resuscitation. Burn shock on the first day from the burn incident, if untreated or inadequately treated, results in death. Prolonged hemoconcentration, hypoxia, hypoxemia, acidosis, hypotony, ischemia and microcirculatory rheological disorders, and uncontrolled perspiratio insensibilis result in organ damage on a cellular and tissue level [13]. As a consequence of hypoxia, numerous inflammatory and proinflammatory cytokines are released [13]. Equally harmful is increasing reperfusion damage due to the release of active oxygen forms [14]. A study by Sahib et al. demonstrated that early use of antioxidants such as vitamin C or melatonin in patients with severe burns precipitates the healing of wounds and improves survival, even in groups at high risk of death [14, 15]. Melatonin reduces the risk of gastrointestinal hemorrhage due to hemorrhaging gastritis and duodenitis or Curling's ulcer by the antioxidative mechanism and inactivation of free radicals [16]. The protective effect of melatonin on the hepatic function and regenerative potential was assessed on an animal model and confirmed [17]. Properly performed fluid resuscitation in the shortest time from the burn prevents ischemic complications in organs and the development of multiorgan failure, or even sepsis [18]. In our centers (CLO, WIM) the Parkland formula is routinely applied on the first day from the burn incident, using 3-4 ml of crystalloid solutions per 1% of burned body area per kilogram of body weight, estimated using a 50% TBSA if the burn area is larger [19]. On the next day the estimated fluid requirement decreases by about half, and resuscitation is continued according to the patient's clinical condition, the effectiveness of the vascular bed filling, and monitoring of arterial pressure, central venous pressure (CVP), hourly duresis and hematocrit, with dehydration or hyperhydration treatment applied accordingly. In the analyzed material, mean arterial pressure (MAP) in patients with severe burns admitted to the centers was 90 ±21.9, heart rate (HR) was 92 ±19, pH was 7.239 and hematocrit was 44% ±7. Holm et al. analyzed the effectiveness of a Baxter transfusion using the Baxter formula [20]. The study involved patients with burns of >20% TBSA, with mean ABSI indicator of 8.8 (in our subgroup of patients with severe burns ABSI was 9.9), and 36% mortality rate in the study group. In the Holm study, mean arterial pressure (MAP) on the first day in the study population was 78 mmHg, heart rate was 94, pH was 7.28, hematocrit was 42.4%, while, in the group receiving Baxter formula treatment, MAP was 74 mmHg, heart rate was 94, pH was 7.27, and hematocrit was 42.7%. Aggressive fluid therapy in the first days from the burn incident on the one hand ensures compensation of losses and proper filling of the vascular bed,

Evaluation of selected early multiorgan dysfunction symptoms in survival prognosis rates for patients with burns

241

ORIGINAL ARTICLES

prevents deepening of necrosis by mobilizing the stagnation site, and prevents early renal damage. On the other hand, it is also associated with the risk of hyperhydration and the development of edema in tissues. Therefore, it is necessary to constantly monitor laboratory indicators, including through the use of invasive methods, as well as the vital functions of the patient. The significance of white blood cells for the diagnosis and assessment of multiorgan failure is now better understood. It has been observed that dynamic changes in the white cell system are associated with the increased risk of respiratory failure [21]. However, the mechanisms by which leukocytes affect organ dysfunction have not yet been fully evaluated. A study by Johansson et al. assessed the level of expression of leukocyte and monocyte receptors [22]. Increased concentrations of these receptors were observed on the first day after the burn incident, and the increase correlated with the size of the deep burn. In our study material, higher laukocytosis on admission was found in the severe burn subgroup, which may confirm the correlation between the size of a thermal injury and the intensity of systemic inflammatory response syndrome (SIRS). Blood coagulation disorders and disseminated intravascular coagulation (DICE) are important factors deteriorating the prognosis and increasing the possibility of MOF. In a study by Lavrentieva et al. DICE was found in 91.1% of patients with severe burns [12]. To assess the risk of DICE, parameters related to the plasmatic coagulation were used, including the factors regulating the coagulation process, e.g. t-PA, PAI-1, AT, INR, PTT, fibrinogen concentration and blood platelet count. Mean blood platelet count in the group of patients who died was higher than in the recovery group (270 ±127 vs 210 ±97) [12]. Similarly, INR was higher in patients with lethal burns (1.5 ±0.5 vs 1.3 ±0.37). In our study material, increased blood platelet count was also specific for the group of patients with the most severe burns, and was associated with a higher mortality rate. In the subgroup of patients with burns of >25% TBSA mean blood platelet count was the highest, compared to the other two subgroups (293 [range of 35 – 1372] vs 240 for patients with moderate burns, and 249 for those with mild burns). In the group of patients with severe burns INR was also the highest (1.09 ±0.34 vs 1.02 ±0.49 and 0.97 ±0.56). Protein and/or albumin concentration is believed to be one of the factors increasing the risk of death and acute kidney injury (AKI) [23]. In a study by Kim et al., albumin <2.5 g/dl at hospital admission increased the risk of death 2.7 fold. Two forms of renal damage due to burns are distinguished: early kidney injury, i.e. up to 6th day after the incident, and late kidney injury. Early acute non-inflammatory kidney injury (AKI) may also be associated with damage due to catabolic processes, muscular decay and myoglobinuria [24]. Intensive fluid resuscitation in the first hours after the burn incident prevents renal ischemia [24, 25]. Kidney failure usually develops two weeks after the thermal injury [24, 25], and is related to numerous factors, most frequently with septic shock [26], hypovolemia, myoglobinuria, hemoglobinuria [27], rhabdomyolysis [28], and use of nephrotoxic medications [24, 27, 28]. In patients with burns covering >25% of the body surface 242

area, abnormalities in standard clinical and laboratory tests are detected early. Compared to the patients with less severe burns, they more often experience altered consciousness states, hypotonia and serious dysfunctions in the form of hemoconcentration, coagulatory system disorders and leukocytosis. Usually the most severe burns are those associated with burns of the respiratory tract or other injuries. Compared to patients with moderate and mild burns, those with severe burns are still characterized by high mortality rates. Patients with extensive burns quickly present general symptoms of burn shock. Early implementation of adequate fluid resuscitation, diagnosis and treatment of multiorgan dysfunctions, or addressing the risk of their development, are equally important as treating the burn wound.

Conclusions 



In the study material low arterial pressure, low blood pH in the gasometric test, increased leukocyte count, low total protein and/or albumin concentration and increased blood glucose concentration found on admission to the hospital could have value in predicting possible multiorgan dysfunctions or failures, particularly in patients at increased risk of death, including the group of patients with the most severe burns. In the group of patients with moderate or mild burns, where mortality rates are much lower, the studied parameters are also of significant value and reproducible in patients who died despite a smaller burn size. Further research needs to be conducted to find reliable methods of predicting multiorgan dysfunctions and failures due to burns. Adequate, professional resuscitation and modern, advanced treatment of the burn wound are of key importance in reducing mortality rates due to multiorgan dysfunction or failure.

Literature 1.

Sheridan RL, Ryan CM, Yin ILM, et al. Death in the burn unit: sterile multiple organ failure. Burns, 1998; 24: 307-311 2. American Burn Association National Burn Repository, National Burn Repository 2005 Report 2006. Version 2.0 3. Brusselaers N, Monstrey S, Vogelaers D, et al. Severe burn injury in Europe: a systematic review of the incidence, etiology, morbidity, and mortality. Crit Care, 2010; 14(5): R188 4. El-Menyar A, Al Thani H, Zakaria ER, et al. Multiple organ dysfunction syndrome (MODS): Is it preventable or inevitable? Int J Clin Med, 2012; 3: 722-730 5. Gomez M, Wong DT, Stewart TE, et al. The FLAMES score accurately predicts mortality risk in burn patients. J. Trauma, 2008; 65 (3): 636-645 6. Moore EC, Pilcher DV, Bailey MJ, et al. The Burns Evaluation and Mortality Study (BEAMS): Predicting deaths in Australian and new Zealand burn patients admitted to intensive care with burns. J Trauma Acute Care Surg, 2013; 75 (2): 298-303 7. Jones AE, Trzeciak S, Kline JA. The Sequential Organ Failure Assessment score for predicting outcome in patients with severe sepsis and evidence of hypoperfusion at the time of emergency department presentation. Crit Care Med, 2009; 37 (5): 1649-1654 8. Nguyen LN, Nguyen TG. Characteristics and outcomes of multiple organ dysfunction syndrome among severe-burn patients. Burns, 2009; 35: 937941 9. Alam MS, Begum SH. Multiple organ dysfunction syndrome in major burns patients. Medicine Today, 2010; 02: 75-79 10. Mace JE, Park MS, Mora GA, et al. Differential expression of the immunoinflammatory response in trauma patients: Burn vs non-burn. Burns, 2012; 38: 599-606

MILITARY PHYSICIAN 3/2015

ORIGINAL ARTICLES

11. Pavoni V, Gianesello L, Paparella L, et al. Original research: Outcome predictors and quality of life of severe burn patients admitted to intensive care unit. Scand J Trauma, Resuscitation Emerg Med, 2010; 18: 24 12. Lavrentieva A, Kontakiotis T, Bitzani M, et al. Early coagulation disorders after severe burn injury: impact on mortality. Intensive Care Med, 2008; 34 (4): 700-706 13. Hawkins HK. The burn problem: a pathologist's perspective. In: Total burn care. Saunders Elsevier, 2012: 483-493 14. Sahib AS, Al-Jawad FH, Alkaisy AA. Effect of antioxidants on the incidence of wound infection in burn patients. Annals of Burns and Fire Disasters, 2010; 23(4):199-205 15. Al-Jawad FH, Sahib AS, Al-Kaisy AA. Role of antioxidants in the treatment of burn lesions. Annals of Burns and Fire Disasters, 2008; 21 (4): 186-191 16. Maldonado MD, Murillo-Cabeza F, et al. Melatonin as pharmacologic support in burn patients: A proposed solution to thermal injury-related lymphocytopenia and oxidative damage. Crit Care Med, 2007; 4: 11771185 17. Bekyarova G, Bratchkova Y, Tancheva S, Hristova M. Effective melatonin protection of burn-induced hepatic disorders in rats. Cent Eur J Med, 2012; 7 (4): 533-538 18. Guo F, Chen XL, Wang YJ, et al. Management of burns of over 80% of total body surface area: A comparative study. Burns, 2009; 35: 210-214 19. Alvarado R, Chung KK, Cancio LC, Wolf SE. Burn resuscitation. Burns, 2009; 5: 4-14 20. Holm C, Mayr M, Tegeler J, et al. A clinical randomized study on the effects of invasive monitoring on burn shock resuscitation. Burns, 2004; 30: 798-807 21. Steinvall I, BakZ, Sjoberg F. Acute kidney injury is common, parallels organ dysfunction or failure, and carries appreciable mortality in patients with major burns: a prospective exploratory cohort study. Crit Care, 2008; 12: R124 22. Johansson J, Sjogren F, Bodelsson M, Sjoberg F. Dynamics of leukocyte receptors after severe burns: An exploratory study 2011. Burns, 2011; 37 (2): 227-233 23. KimGH, Oh KH, Yoon JW, et al. Impact of burn size and initial serum albumin level on acute renal failure occurring in major burn. Am J Nephrol, 2003; 23: 55-60 24. Holm C, Horbrant F, von Donnersmarck GH, Muhlbauer W. Acute renal failure in severely burned patients. Burns, 1999; 25: 171-178 25. Tremblay R, Ethier J, Queerin S, et al. Veno-venous continuous renal replacement therapy for burned patients with acute renal failure. Burns, 2000; 26: 638-643 26. Coca SG, Bauling P, Schifftner T, et al. Contribution of acute kidney injury toward morbidity and mortality in burns: a contemporary analysis. Am J Kidney Dis, 2007; 49 (4): 517-523 27. Leblanc M, Thibeault Y, Querin S. Continuous haemofiltration and haemodiafiltration for acute renal failure in severely burned patients. Burns, 1997; 23:160-165 28. Stollwerck PL, Namdar T, Stang FH, et al. Rhabdomyolysis and acute renal failure in severely burned patients. Burns, 2011; 37: 240-248

Evaluation of selected early multiorgan dysfunction symptoms in survival prognosis rates for patients with burns

243

ORIGINAL ARTICLES

Hemodynamic conditions related to exercise capacity in patients with arterial hypertension – a preliminary report Hemodynamiczne uwarunkowania wydolności fizycznej chorych na nadciśnienie tętnicze – doniesienie wstępne Małgorzata Kurpaska, Paweł Krzesiński, Grzegorz Gielerak, Adam Stańczyk, Katarzyna Piotrowicz, Beata Uziębło-Życzkowska, Magdalena Potapowicz-Krysztofiak, Andrzej Skrobowski Department of Cardiology and Internal Diseases, Central Clinical Hospital of the Ministry of National Defence, Military Institute of Medicine, Warsaw, Poland; head: Prof. Andrzej Skrobowski MD, PhD Abstract. It is expected that the resting hemodynamic profile substantiates the adaptability of the circulatory system in response to exercise training in patients with arterial hypertension (AH). The relationship between exercise capacity and selected clinical and hemodynamic parameters was assessed in patients with AH. The exercise capacity of 139 subjects with AH (mean age: 45.6) was examined using a six-minute walk test (6-MWT). The hemodynamic profile was assessed by non-invasive methods such as impedance cardiography, applanation tonometry and echocardiography. The average 6-MWT distance in the group was significantly greater for males than females. Correlation analysis showed a strong association between the achieved 6-MWT distance and age, TAC, Al, and E/e'. The comparative analysis in subgroups of patients who covered the shortest and the longest 6-MWT distances confirmed that its most important determinants were: age, CI, Al, CPP and, in particular, TAC. Univariable logistic regression analysis gave the following variables related to the hazard of the shortest 6-MWT distance: sex (female), age, Al, CPP and TAC. However, all of these were independent in the multivariable analysis. Limited exercise capacity is related to vascular stiffness, as well as lower CI. It reflects the influence of vascular remodeling of the left ventricular function, advancing with age. Key words: impedance cardiography, applanation tonometry, arterial hypertension, left ventricular diastolic dysfunction

Streszczenie. Wstęp. Można się spodziewać, że spoczynkowy profil hemodynamiczny warunkuje zdolność adaptacji układu krążenia do wysiłku fizycznego u pacjentów z nadciśnieniem tętniczym (NT). Cel pracy. Ocena powiązania wydolności fizycznej z wybranymi parametrami klinicznymi i hemodynamicznymi u chorych na NT. Metody. U 139 chorych na NT (średni wiek: 45,6 roku) wydolność fizyczną oszacowano na podstawie dystansu testu 6-minutowego marszu (6-MWT). Profil hemodynamiczny oceniono z wykorzystaniem metod nieinwazyjnych, takich jak kardiografia impedancyjna, tonometria aplanacyjna i echokardiografia. Wyniki. Średni dystans 6-MWT w badanej grupie był istotnie większy u mężczyzn niż u kobiet. W analizie korelacji najwyraźniejsze powiązanie dystansu 6-MWT zaobserwowano z wiekiem, TAC, Al oraz wskaźnikiem E/e'. W analizie porównawczej między podgrupami badanych, którzy pokonali najkrótszy i najdłuższy dystans 6-MWT, potwierdzono, że najistotniejszymi jego determinantami są: wiek. Cl, Al, CPP, a zwłaszcza TAC. W analizie metodą regresji logistycznej jednoczynnikowej zmiennymi wpływającymi na prawdopodobieństwo osiągnięcia najkrótszego dystansu 6-MWT były: płeć żeńska, wiek, Al, CPP oraz TAC, choć żadna z nich nie okazała się zmienną niezależną w analizie wieloczynnikowej. Wnioski. Ograniczona wydolność fizyczna wykazuje związek z większą sztywnością naczyń tętniczych i mniejszym rzutem serca. Odzwierciedla to wpływ postępującego z wiekiem remodelingu naczyniowego na morfologię i funkcję lewej komory. Słowa kluczowe: kardiografia impedancyjna, tonometria aplanacyjna, nadciśnienie tętnicze, dysfunkcja rozkurczowa lewej komory Received: 28/05/2015 Approved for printing: 01/06/2015 No conflicts of interest were declared. Mil. Phys., 2015; 93 (3): 244-252 Copyright by Military Institute of Medicine

244

Corresponding author Małgorzata Kurpaska MD Department of Cardiology and Internal Diseases, Central Clinical Hospital of the Ministry of National Defence, Military Institute of Medicine 128 Szaserów St., 04-141 Warsaw, Poland telephone/fax: +48 261 816389 e-mail: mkurpaska@wim.mil.pl

MILITARY PHYSICIAN 3/2015

ORIGINAL ARTICLES

Introduction Arterial hypertension (AH) is one of the main risk factors in heart failure (HF). Remodeling of the left ventricle (LV) associated with increased blood pressure (BP) results in left ventricular hypertrophy (LVH) and left ventricular diastolic dysfunction (LVDP) [1, 2]. Cardiac remodeling is associated with arterial stiffness (AS), which is a consequence of adaptation of the vessels to non-physiological hemodynamic conditions, as well as being a cause of increased BP. Adaptive mechanisms of the circulatory system determine the organism's effort capacity. These include modulation of heart rate and blood pressure, ejection fraction and cardiac output, arteriovenous oxygen difference, and blood flow redistribution [3]. Maintaining a functional balance between LV and the vascular system, referred to as ventricular-vascular coupling, is necessary for preservation of the LV ejection fraction [4]. Already by the early stage of AH, this adaptation is associated with a reduction in exercise reserves, increased oxygen requirement and the risk of coronary hypoperfusion, even if the epicardial artery structure is normal [5, 6]. Impairment of LV diastole, which increases during exercise, may result in pressure overload of the pulmonary circulation, manifested by dyspnea [7]. At the beginning of AH development, hemodynamic disorders are not reflected in the structural or functional abnormalities assessed in the echocardiographic examination. Patients usually do not notice these symptoms, or identify them as some nonspecific limitation of exercise tolerance, a nd this may delay proper diagnosis and treatment of diastolic HF, associated with a significant deterioration in the long term prognosis [8, 9]. Therefore, it seems justified to investigate those hemodynamic indicators related to exercise capacity, particularly at the asymptomatic stage. Non -invasive methods for the assessment of circulatory system function include impedance cardiography (ICG), which enables the assessment of cardiac output, vascular resistance and arterial compliance, as well as applanation tonometry (AT), used to estimate central pressure [10-13]. Simultaneous use of all the above diagnostic methods increases the probability of correct assessment of a disturbed cardiac -coronary interaction. As evaluation of exercise capacity is not possibl e on the basis of the medical history alone, it seems reasonable to complete the clinical assessment with a six-minute walk test (6-MWT). This is a simple and safe tool, well-tolerated by patients, used to assess exercise capacity and adaptation to everyda y activities. It is used not only in patients with cardiac [14, 15], lung [16] or musculoskeletal system [17, 18] diseases, but also in healthy individuals [19, 20, 26]. It has been demonstrated that even in patients without a chronic disease burden, and who do not report any symptoms or limited exercise tolerance, significant differences can be observed in the distance covered during the test [19-21]. Age and sex are indicated as

some of the factors that determine the final result of the tests; however, the pathophysiological mechanisms responsible for these differences have not been explained. Based on previous clinical experience with the hemodynamic assessment of patients with AH and HF, a study hypothesis was adapted so that exercise capacity depends on the resting hemodynamic profile.

Aim of the study The aim of this analysis was to assess any correlation between exercise capacity in patients with AH, determined by 6-MW T, and selected clinical and hemodynamic parameters.

Methods Study group The study involved 139 patients (96 males) with untreated AH (BP elevated for >3 months). The exclusion criteria were as follows:  confirmed secondary AH,  confirmed chronic renal failure at stage III or higher 2 – GFR <60 mL/min/1.73 m , according to the MDRD formula,  other serious comorbidities: systolic HF, cardiomyopathy, significant arrhythmias, significant valvular disease, chronic obstructive pulmonary disease (COPD), previously diagnosed diabetes, polyneuropathy, or peripheral vascular disease,  age < 18 years and > 75 years, 2  body mass index (BMI) > 40 kg/m ,  mental diseases that prevent full cooperation with the patient,  cardiac rhythm other than sinus rhythm (including permanent cardiac pacing). The study protocol was approved by the Bioethics Committee at the Military Institute of Medicine (Agreement No. 3/WIM/2008), and all participants gave their written informed consent to participate in the study. The study was conducted as part of the statutory project of the Military Institute of Medicine (ID 148) implemented at the Department of Cardiology and Internal Diseases, Military Institute of Medicine, registered with the ClinicalTrials.gov database (NCT01 996085).

Clinical study The clinical study was performed with a pa rticular focus on the medical history concerning cardiovascular risk factors (e.g. family history of cardiovascular disease, smoking, etc.) and the assessment of the body constitution (height, weight, and BMI). Metabolic syndrome (MS) was defined according to current IDF guidelines [22].

Echocardiography An echocardiographic examination was performed using a Vivid S6 device (GE Medical System,

Hemodynamic conditions of exercise capacity in patients with arterial hypertension - preliminary report

245

ORIGINAL ARTICLES

Wauwatosa, Wl, USA). The following measurements were evaluated: size of the heart chambers, contractility and thickness of the left ventricular wall, ejection fraction as well as morphology and function of the heart valves. LVH was diagnosed in accordance with the current recommendations, based on the assessment of the left ventricular mass, indexed to 2 the body surface area (LVMI > 95 g/m for women and 2 115 g/m for men). Calculations of LVM were made according to the following formula: 3 3 0.8 x (1.04 x [LVEDD + PWTd + SWTd] -[LVEDD] ) + 0.6 [g]. The parameters required for calculation were: left ventricular end-diastolic diameter (LVEDD), diastolic posterior wall thickness (PW Td), and diastolic septal wall thickness (SW Td). These were assessed in the parasternal long axis, using the M-mode technique, based on two-dimensional imaging (2D). Also in this projection, the left ventricular enlargement (LVEDD index - dimension indexed to the body surface area) was estimated: over 3.2 cm/m2 for men and over 3.1 cm/m2 for women. Left ventricular diastolic dysfunction (LVDD) was diagnosed according to the applicable guidelines [23]. Blood flow through the mitral valve was assessed using a pulsed wave Doppler in the four chamber apical projection with the gate positioned in the left ventricle, on top of the open cusps of the mitral valve, evaluating the ratio of the early to late ventr icular filling velocities (E/A), as well as the E -wave deceleration time. Using tissue Doppler imaging (TDI), the diastolic velocity of the mitral annulus and the early diastolic mitral annulus velocity (e') were measured, and the E/e' ratio was calculated . The five chamber apical projection enabled single -stage assessment of the flow wave through the aortic and mitral valves, as well as calculation of the isovolumetric relaxation time (IVRT). The following values were considered as diagnostic factors in LV DD (in the study group the condition was found only in a mild form – impaired relaxation): left atrial diameter >40 mm for males and >38 for females, E/A <0.8, deceleration time >200 ms, IVRT >100 ms, e' <8 cm/s, and E/e' ratio >8.

Impedance cardiography Hemodynamic parameters were examined with the ICG method during a 10-minute resting test in the supine position, using a Niccomo™ device (Medis, llmenau, Germany). Based on 10-minute ICG test records, a detailed analysis of mean hemodynamic indicators was performed (Niccomo Software), including the following: systolic blood pressure (SBP), mean blood pressure (MBP), diastolic blood pressure (DBP), arterial pressure, pulse pressure (PP), heart rate (HR), stroke volume (SV), stroke index (SI) (mL), 2 cardiac output (CO), cardiac index (CI) (ml x m x 1 min ), systemic vascular resistance (SVR) (dyn x s x 5 cm ), systemic vascular resistance index (SVRI) (dyn 5 2 x s x cm x m ), total arterial compliance (TAC) (ml x -1 mm Hg ): TAC = SV x PP-1), velocity index (VI) 246

(1,000 x ZO x s1]: VI = 1000 x dZmax x Z01), presenting peak blood flow in the aorta, acceleration index (ACI) (100 x Z0 x s2): ACI = 100 x dZmax x dt1, describing the peak acceleration of the blood flow in the aorta, and Heather index (HI) (Ohm x s2): HI = dZmax x TRC, which is derived by dividing peak cardiac ejection velocity by the time from peak Q/R wave in ECG to peak ICG wave, and which adequately characterizes the ionotropic function of the heart.

Measurement of central blood pressure A non-invasive assessment of central blood pressure (CBP) and associated parameters was performed with the use of applanation tonometry (SphygmoCor Px Aortic BP Profile System, AtCor Medical Pty Ltd, Australia). The measurement was made in a supine position, on the left radial artery, using a micromanometer (Millar Instruments, Houston, Texas), following the resting ICG examination. The pulse wave in the aorta was reconstructed according to the last brachial measurement of systolic blood pressure (SBP) and diastolic blood pressure (DBP), using the oscillometric module of the Niccomo™ device. The wave form was analyzed with the use of SphygmoCor 2000 software (version 7.01, AtCor Medical). The assessment involved parameters derived from the aortic blood pressure waveform analysi s, including central systolic blood pressure (CSBP) (mm Hg), central diastolic blood pressure (CDBP) (mm Hg), central pulse pressure (CPP) (mm Hg), and augmentation index (AI), which is derived by dividing augmentation pressure (AP) (mm Hg) by CPP (an indicator independent of the absolute blood pressure value)

6-minute walk test Exercise capacity was assessed by a 6 -minute walk test (6-MW T). Patients walked along a 25-metre-long corridor, marked every 5 meters, at a free and comfortable pace, as fast as they could. The distance covered by the 6th minute was recorded, and rounded to the nearest 5 meters. All the patients were assessed for dyspnea, chest pains and palpitations during the test.

Statistical analysis The statistical analysis of the results was p erformed using Microsoft Office Excel 2007 and Statistica 10.0 (StatSoft Inc.). The results were expressed as a mean ± standard deviation (SD) for quantitative variables, and numbers and percentages for qualitative variables. Distribution of variables was assessed visually and using the Kolmogorov-Smirnov test. Relations between the clinical and hemodynamic parameters and the 6-MWT distance were evaluated using the Pearson correlation coefficient for normal distribution of variables, and Spearman's rank correlation coefficient for abnormal distribution of variables. To assess co-dependence of the variables MILITARY PHYSICIAN 3/2015

ORIGINAL ARTICLES

correlated with the 6-MW T distance, the most representative ones (age, sex, SI, VI, TAC, Al, E/e') were introduced to the multiple regression model. For differentiation of the clinical and hemodynamic parameters according to the 6-MW T distance, quartile boundaries were set for the variable, and then the extreme subgroups of patients (from the lower and upper quartile) were compared, with the use of tStudent and Mann-Whitney U test. Next, the most representative variables were analyzed using the logistic regression method (with one or many variables), adopting the shortest achieved 6 -MWT distance as the dependent variable (lower quartile). Statistical significance was set at p <0.05.

Results The final analysis involved the results of testing 139 subjects (96 males) who took the 6-MWT according to the methodological assumptions (mean age of 45.6 years). The characteristics of the clinical group are presented in Table 1. The majority of subjects were patients with mild AH (systolic pressure of 140-159 mm Hg and diastolic pressure of 90-99 mm Hg), while coexisting MS was found in half of the group members.

Figure 1. Correlations between 6-MWT distance and total arterial compliance and augmentation index Rycina 1. Korelacje pomiędzy dystansem 6-MWT a całkowitą podatnością tętnic (TAC) oraz wskaźnikiem wzmocnienia (Al)

Hemodynamic conditions of exercise capacity in patients with arterial hypertension - preliminary report

247

ORIGINAL ARTICLES

Table 1. Basic characteristics of the study group Tabela 1. Podstawowa charakterystyka badanej grupy Study group (n = 139) Age (years), mean ± SD

45.6 ± 10.3

Males, n (%)

96 69.1)

Mild AH, n (%)

112 (79.2)

Moderate AH, n (%)

27 (19.4)

SBP (mmHg), mean ±SD

141 ± 13

DBP (mmHg), mean ±SD

90 ± 9

Table 2. Correlations between 6-MWT distance and selected clinical and hemodynamic parameters Tabela 2. Korelacje pomiędzy dystansem 6-MWT a wybranymi parametrami klinicznymi i hemodynamicznymi 6-MWT distance vs R P Clinical parameters 0.002 Age 0.27 SBP 0.13

0.122

DBP 0.03

0.658

PP 0.16

0.062

HR 0.10

0.225

BMI 0.16

0.059

HR (bpm), mean ± SD

72 ± 10

BMI [kg/m2], mean ±SD

29.0 ± 4.2

LVH, n (%)

15 (10.8)

Hemodynamic parameters Impedance cardiography

LVDD, n (%)

35 (25.2)

SI 0.23

0.017

MS, n (%)

81 (58.3)

CI 0.19

0.029

VI 0.20

0.017

ACI 0.21

0.016

HI 0.01

0.893

SVRI 0.14

0.108

TAC 0.35

<0.0001

SBP – systolic blood pressure, DBP – diastolic blood pressure, HR – heart rate, BMI – body mass index, AH – arterial hypertension, LVH – left ventricular hypertrophy, LVDD – left ventricular diastolic dysfunction, MS – metabolic syndrome

Correlation between 6-MWT distance and clinical and hemodynamic parameters Mean 6-MWT distance achieved in the study group was 592 m (median of 600 m, minimum of 400 m, maximum of 750 m), and it was significantly longer for males than females (604 ±69 m vs 565 ±72 m). None of the patients reported significant symptoms related to the walk. Analysis of correlations revealed correlation between the 6-MWT distance achieved with age and hemodynamic parameters, although the correlation was not strong (Table 2.). In the multiple regression analysis (R2 = 0.17), independent factors affecting the 6-MWT distance were age (p = 0.022), sex (p = 0.0006) and velocity indicator (p = 0.014).

Differentiation of clinical and hemodynamic parameters according to 6-MWT distance Based on the "6-MWT distance" variable, the boundaries of its lower and upper quartile were determined, and the following subgroups were distinguished:  patients who covered the shortest distances – group S_6-MWT (short distance 6-MWT <530 m),  patients who covered the longest distances – group L_6-MWT (long distance 6-MWT <650 m). Comparative analysis of the subgroups (Table 3) confirmed that statistically significant determinants of 6-MWT distance include: age, CI, AI and TAC. One variable logistic regression analysis revealed that the variables affecting the probability of achieving the shortest 6MWT distance were: sex – female (OR 1.81; 95% Cl: 1.20-2.72; p = 0.004), age (OR 1.05; 95% Cl: 1.01-1.09; p = 0.019), Al (OR 1.05; 95% Cl 1.01-1.09; p = 0.006), CPP (OR 1.05; 95% Cl: 1.01-1.09; p = 0.026) and TAC (OR 0.39; 95% Cl 0.17-0.84; p = 0.026). At the same time, none of the above indicators were identified as an independent variable in the multi-variable analysis. 248

Applanation tonometry CSBP 0.01

0.888

CDBP 0.09

0.318

CPP 0.15

0.087

Al 0.22

0.010

Echocardiography LVEDD 0.21

0.011

LA 0.0

0.975

LVMI 0.3

0.142

E/A 0.5

0.075

e' 0.5

0.087

E/e' 0.0

0.024

A – maximum atrial systolic velocity, ACI - acceleration index, Al – augmentation index, BMI – body mass index, CDBP – central diastolic blood pressure, Cl – cardiac input, CPP – central pulse pressure, CSBP – central systolic blood pressure, DBP – diastolic blood pressure, E – maximum velocity of E-wave in early mitral inflow, e' – maximum velocity of the mitral valve ring, HI – Heather index, HR– heart rate, LA – left atrial diameter, LVEDD – left ventricular end diastolic diameter, LVMI – left ventricular mass index, LVDD – left ventricular diastolic dysfunction, PP – pulse pressure, SBP – systolic blood pressure, SI – stroke index, SVRI – systemic vascular resistance index, TAC – total arterial compliance, VI – velocity index

MILITARY PHYSICIAN 3/2015

ORIGINAL ARTICLES

Table 3. Comparison of subgroups based on 6-MWT distance Tabela 3. Porównanie podgrup wyróżnionych na podstawie dystansu 6-MWT S_6MWT (n=33)

L_6MWT (n=29)

Age (years), mean ± SD

49.4 ± 9.6

42.6 ± 9.1

0.002

Males, n (%)

16(48.5)

24(82.8)

0.005

SBP, mean ± SD

145 ± 15

141 ± 14

0.357

DBP, mean ± SD

91 ± 10

0.861

PP, mean ± SD

53.9 ± 9.1

50.0 ± 11.8

0.051

HR, mean ± SD

73 ± 9

72 ± 9

0.661

BMI, mean ± SD

30.6 ± 4.8

28.5 ± 3.4

0.051

MS, n (%)

19(57.6)

19(65.5)

0.522

SI, mean ± SD

48.3 ± 14.6

53.6 ± 10.8

0.049

Cl, mean ± SD

3.34 ± 0.61

3.78 ± 0.65

0.002

VI, mean ± SD

44.6 ± 12.6

52.2 ± 15.8

0.052

ACI, mean ± SD

65.5 ± 29.0

83.8 ± 36.2

0.054

HI, mean ± SD

13.4 ± 4.1

13.1 ± 5.1

0.433

SVRI, mean ± SD

2355 ± 561

2112 ± 335

0.121

TAC, mean ± SD

1.89 ± 0.57

2.41 ± 0.642

0.0005

CSBP, mean ± SD

126.8 ± 15.8

125.2 ± 13.5

0.671

CDBP, mean ± SD

87.8 ± 9.5

91.1 ± 10.8

0.209

CPP, mean ± SD

39.1 ± 10.2

34.1 ± 9.0

0.046

Al, mean ± SD

27.7 ± 12.1

20.3 ± 10.9

0.014

LVEDD, mean ± SD

48.2 ± 4.1

50.1 ± 3.8

0.642

LA, mean ± SD

37.3 ± 2.9

37.1 ± 3.2

0.181

LVMI, mean ± SD

88.9 ± 16.4

92.8 ± 16.6

0.943

E/A, mean ± SD

0.98 ± 0.29

1.11 ± 0.36

0.191

e', mean ± SD

9.40 ± 2.55

10.24 ± 2.57

0.361

E/e', mean ± SD

7.46 ± 1.87

6.57 ± 1.24

0.089

LVH, n (%)

5(15.2)

6(20.7)

0.573

LVDD, n (%)

6(18.2)

6(20.7)

0.897

Clinical parameters

Hemodynamic parameters Impedance cardiography

Applanation tonometry

Echocardiography

A – maximum atrial systolic velocity, ACI – acceleration index, Al – augmentation index, BMI – body mass index, CDBP – central diastolic blood pressure, Cl – cardiac input, CPP – central pulse pressure, CSBP – central systolic blood pressure, DBP – diastolic blood pressure, E – maximum velocity of E-wave in early mitral inflow, e' – maximum velocity of the mitral valve annulus motion, HI – Heather index, HR– heart rate, LA – left atrial diameter, LVEDD – left ventricular end diastolic diameter, LVMI – left ventricular mass index, LVDD – left ventricular diastolic dysfunction, PP – pulse pressure, SBP – systolic blood pressure, SI – stroke index, SVRI – systemic vascular resistance index, TAC – total arterial compliance, VI – velocity index

Hemodynamic conditions of exercise capacity in patients with arterial hypertension - preliminary report

249

ORIGINAL ARTICLES

Discussion

Th e p r e s e n t e d o u t c o m e s i n d i c a t e t h a t t h e e xe r c i s e c a p a c i t y o f p a t i e n t s wi t h A H a s s e s s e d b y 6 - MW T i s r e l a t e d t o a g e , s e x a n d t h e r e s t i n g h e m o d yn a m i c p r o f i l e . A m o n g t h e m o r p h o l o g i c a l a n d h e m o d yn a m i c i n d i c a t o r s , t h e m o s t i m p o r t a n t were the parameters describing va s c u l a r stiffness (TAC, AI, CPP) and the pumping f u n c t i o n o f t h e l e f t ve n t r i c l e ( S I , C I ) . A s l i g h t l y l o we r d i s c r i m i n a t i ve va l u e wa s p r e s e n t e d b y t h e parameters assessed in echocardiographic e xa m i n a t i o n . Th e o b s e r va t i o n s s u g g e s t t h a t m o d e r n n o n - i n va s i ve d i a g n o s t i c m e t h o d s m a y b e u s e f u l i n t h e a s s e s s m e n t o f e a r l y h e m o d yn a m i c d i s o r d e r s t h a t a r e n o t ye t c l e a r l y vi s i b l e i n echocardiographic tests. Th e 6 - MW T d i s t a n c e s a c h i e ve d i n t h e s t u d y g r o u p we r e r a t h e r va r i e d ( 4 0 0 - 7 5 0 m ) , b u t d i d n o t d i f f e r f r o m t h e d i s t r i b u t i o n o f t h i s va r i a b l e i n t h e g e n e r a l p o p u l a t i o n [ 2 4 ] . Th e s a m e a p p l i e d t o the differences depending on sex and age. Chetta et al. [25] demonstrated in a study of a g r o u p o f h e a l t h y vo l u n t e e r s a g e d 2 0 - 5 0 ye a r s o l d t h a t m a l e s a c h i e ve d a 6 - MW T d i s t a n c e o f a b ou t 45 meters further than females. Other r e s e a r c h e r s o b s e r ve d t h a t i n a g r o u p o f h e a l t h y m a l e s o ve r 6 8 ye a r s o l d , m e a n 6 - MW T d i s t a n c e w a s 4 0 0 m e t e r s , w h e r e a s f o r wo m e n i t w a s 3 6 7 meters [26]. Th e c o r r e l a t i o n o f h e m o d yn a m i c p a r a m e t e r s a s s e s s e d b y I C G a n d A T wi t h t h e a c h i e ve d 6 MW T d i s t a n c e o b s e r v e d i n o u r s t u d y w a s p r i m a r i l y d e r i ve d f r o m d i f f e r e n c e s i n a g e a n d s e x. Th e m a i n r o l e c o u l d b e a t t r i b u t e d t o i n c r e a s e d v a s c u l a r s t i f f n e s s e xp r e s s e d i n h i g h e r A I , C P P a n d TA C va l u e s . L e s s p r o n o u n c e d difference in SVRI indicates that the functional c o n d i t i o n o f l a r g e ve s s e l s ( e s p e c i a l l y t h e a o r t a ) , a n d n o t m e d i u m o r s m a l l ve s s e l s i s o f m o r e i m p o r t a n c e f o r e xe r c i s e t o l e r a n c e [ 2 7 , 2 8 ] . Simultaneous reduction of SI and CI is probably a sign of LV adaptation to increased afterload. I n c r e a s e d s t i f f n e s s o f t h e va s c u l a r s ys t e m i s a l s o r e f l e c t e d i n t h e dyn a m i c s o f b l o o d o u t p u t from LV to the less compliant aorta (lower VI and A C I va l u e s ) . Th e p r e s e n t e d p h e n o m e n o n i s c o e xi s t e n t w i t h i m p a i r e d d i a s t o l i c f u n c t i o n a n d p r e s s u r e b u r d e n o n L V , wh i c h i n o u r s t u d y wa s i n d i r e c t l y c o n f i r m e d b y a n e g a t i ve c o r r e l a t i o n o f 6 - MW T distance wi t h E/e', and echocardiographic indicator demonstrating filling p r e s s u r e i n L V . I n p a t i e n t s wi t h m o r e a d va n c e d LV remodeling, then such a configuration of h e m o d yn a m i c p a r a m e t e r s m a y b e r e s p o n s i b l e f o r i n c r e a s e d p r e s s u r e i n t h e l e f t ve n t r i c l e a n d p u l m o n a r y ve i n s d u e t o e xe r c i s e , r e s u l t i n g i n d ys p n e a a n d h e n c e r e d u c e d e xe r c i s e c a p a c i t y [29, 30]. Th e u s e f u l n e s s o f I C G i n t h e h e m o d yn a m i c 250

a s s e s s m e n t o f p a t i e n t s wi t h A H i s c o n f i r m e d i n numerous scientific reports [10 -12, 31]. It appears that reduced arterial compliance may o c c u r e ve n b e f o r e a s i g n i f i c a n t i n c r e a s e o f r e s i s t a n c e o c c u r s [ 3 2 , 3 3 ] . Th i s va l u e m a y b e independent of BP, and may rise even before the clinical manifestation of AH [ 33]. Similar o b s e r va t i o n s a p p l y t o t h e u s e o f a p p l a n a t i o n t o n o m e t r y i n t h e a s s e s sm e n t o f c a r d i a c - va s c u l a r interaction. Kim et al. [34] demonstrated that AI is a strong predictor of LV diastolic function i m p a i r m e n t . Th e r e a r e a l s o r e p o r t s i n d i c a t i n g t h e u s e f u l n e s s o f t h e h e mo d yn a m i c f a c t o r i n t h e assessment of treatment outcomes affecting the 6 - MW T d i s t a n c e [ 3 5 ] . Th e 6 - MW T a s p e r f o r m e d i n o u r s t u d y a l s o a p p e a r e d t o b e u s e f u l i n t h e e va l u a t i o n o f e xe r c i s e c a p a c i t y i n A H p a t i e n t s . A l t h o u g h t h e s u b j e c t s d i d n o t r e p o r t a n y s i g n i f i c a n t s ym p t o m s associated wi t h effort, the test r e ve a l e d c o n s i d e r a b l e d i f f e r e n c e s i n e xe r c i s e t o l e r a n c e . Th i s s i m p l e a n d s a f e d i a g n o s t i c t e s t i s no t f r e q u e n t l y u s e d i n e ve r y d a y p r a c t i c e , a l t h o u g h i t m a y b e u s e d t o a s s e s s t r e a t m e n t e f f e c t i ve n e s s and prognosis [14, 24]. Our study was performed i n a h o m o g e n e o u s g r o u p o f p a t i e n t s , h a vi n g e xc l u d e d a n y s i g n i f i c a n t c o m o r b i d i t i e s t h a t c o u l d a f f e c t t h e a c h i e ve d 6 - MW T d i s t a n c e ( e . g . respiratory or musculoskeletal diseases) [24, 26, 3 6 - 3 8 ] . H o w e ve r , i t s h o u l d b e n o t e d t h a t c o m p a r i s o n o f 6 - MW T r e s u l t s i n t h e s a m e p a t i e n t i s o f m o r e va l u e t h a n c o m p a r i n g t h e r e s u l t s o f different patients.

Clinical implications Th e o b s e r ve d r e l a t i o n b e t we e n e xe r c i s e c a p a c i t y and h e m o d yn a m i c profile suggests that implementation of treatment correcting h e m o d yn a m i c d i s o r d e r s a s s o c i a t e d wi t h A H m a y contribute to higher e xe r c i s e capacity. I d e n t i f i c a t i o n o f p a t i e n t s wi t h a s i g n i f i c a n t l y e l e va t e d a f t e r l o a d a s s o c i a t e d wi t h va s c u l a r s t i f f n e s s i s o f p a r t i c u l a r va l u e . T h i s p r e m i s e i s a n o t h e r r e a s o n t o u s e I C G a n d A T i n e ve r yd a y clinical practice. Th e r e s u l t s o f o u r s t u d y e n c o u r a g e t h e u s e o f m o d e r n n o n - i n va s i ve m e t h o d s o f h e m o d yn a m i c a s s e s s m e n t t o e va l u a t e t h e e xe r c i s e c a p a c i t y o f AH patients. Progress in technology enables t h e i r u s e n o t o n l y i n r e s t i n g a s s e s s m e n t b u t a l so d u r i n g p h ys i c a l e f f o r t . A c c e s s t o a p o r t a b l e i m p e d a n c e c a r d i o g r a p h y s ys t e m wi t h w i r e l e s s data transmission [39] and fully automated central pressure measurement [40] increases the opportunity of using these methods d uring m o n i t o r e d e xe r c i s e , n o t o n l y i n A H p a t i e n t s .

MILITARY PHYSICIAN 3/2015

ORIGINAL ARTICLES

Study limitations Our study was limited by the number of study subjects and the relatively low rate of patients wi t h L V H a n d L V D D . I n c l u d i n g p a t i e n t s wi t h A H a n d wi t h o u t o t h e r s i g n i f i c a n t c o m o r b i d i t i e s i n t h e a n a l ys i s e l i m i n a t e d t h e e f f e c t o f c o n f o u n d i n g f a c t o r s ; h o we ve r , i t p r e ve n t e d e xt r a p o l a t i o n o f the results to the general population. Another m e t h o d o l o g i c a l l i m i t a t i o n wa s t h e c o - d e p e n d e n c e of certain cardioimpedance parameters due to the mathematical formulas used to compute t h e m , wh i c h wa s c o n s i d e r e d wh i l e p l a n n i n g t h e m u l t i - va r i a b l e a n a l ys i s . I t s h o u l d a l s o be e m p h a s i ze d t h a t t h e p o t e n t i a l m e c h a n i s m s correlating e xe r c i s e capacity wi t h resting h e m o d yn a m i c p r o f i l e , a s d i s c u s s e d a b o ve , n e ed t o b e ve r i f i e d i n f u r t h e r r e s e a r c h i n vo l vi n g h e m o d yn a m i c monitoring during e xe r c i s e . H o we ve r , i t i s o u r b e l i e f t h a t t h o s e l i m i t a t i o n s d i d n o t a f f e c t s i g n i f i c a n t l y t h e c o g n i t i ve va l u e o f the study.

4. 5.

10.

11.

Conclusions I n t h e g r o u p o f A H p a t i e n t s wi t h o u t o t h e r s i g n i f i c a n t c a r d i o va s c u l a r d i s e a s e s t h e 6 - MW T d i s t a n c e d e p e n d s p r i m a r i l y o n a g e a n d s e x. A s h o r t e r 6 - MW T d i s t a n c e i s r e l a t e d t o g r e a t e r va s c u l a r s t i f f n e s s , l o w e r s t r o k e vo l u m e a n d c a r d i a c o u t p u t . Th e r e s u l t s c o n f i r m t h e e f f e c t o f i m p a i r e d c o m p l i a n c e o f l a r g e ve s s e l s , a d va n c i n g wi t h a g e , a n d o f m o r p h o l o g y a n d l e f t ve n t r i c u l a r f u n c t i o n , wh i c h m a y a f f e c t e xe r c i s e c a p a c i t y i n t h e e a r l y s t a g e s o f a r t e r i a l h yp e r t e n s i o n . Mo d e r n methods of n o n - i n va s i ve h e m o d yn a m i c assessment may be useful in the detailed e va l u a t i o n o f a d a p t a t i o n o f t h e c a r d i o va s c u l a r s ys t e m t o e xe r c i s e .

Financi al support Th e s t u d y wa s c o n d u c t e d a s p a r t o f a s t a t u t o r y p r o j e c t ( MN i SW /W I M 1 4 8 ) . Th e S t a t i s t i c a 1 0 . 0 ( S t a t S o f t I n c . ) s o f t w a r e wa s p u r c h a s e d u n d e r project no. POIG.02.03.00 -00-042/09 " Te l e Me d N e t - s c i e n t i f i c a n d d i a g n o s t i c m e d i c a l platform".

12.

13.

14.

15.

16.

17.

18.

19.

20.

Literature 1.

Lewartowski B. P atofi zj ol ogi a rozk urczowej ni ew ydolności serca. [P atophysi ol ogy of di astoli c heart insufficiency] K ardiol P ol, 2008; 66 (10): 1096 -1101 McMurray JJ, Adamopoulos S, Anker SD, et al. ESC Committee for Practice Guidelines. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the E uropean S oci et y of Cardi ol ogy. D evel oped i n collaboration with the Heart Failure Association (HFA) of the ESC. Eur Heart J, 2012; 33: 1787 -1847 Górski J. Fi zj ol ogi czne podstaw y w ysi łku fi zycznego. [P hysiological basis of physi cal effort] W arsaw, W yd a w n i c t w o L e k a r s k i e P ZW L, 2 0 0 1

21.

22.

W an SH, V og el MW , Ch en HH. P r e -cl i nic al di as t oli c dysfuncti on. J Am C oll C ardi ol, 2014; 5: 407 -416 Mahfouz RA, Elawady W, Abdu M, Salem A. Associations of fractional pulse pressure to aortic stiffness and their impact on diastolic function and coronary flow reserve in asymptomatic diabetic patients with norm al coronary angiograph y. C ardi ol J, 2013; 20 (6): 605-611 Brilla CG, Janicki JS, W eber KT. Impaired diastolic functi on and coronar y reserve i n genetic h ypertensi on. Role of interstitial fibrosis and medial thickening of intram yocardi al coronary arteri es. C irc Res, 1991; 69 (1): 107-115 Ziele MR, Lewinter MM. Left ventricular end -diastolic volum e is norm al in patients with heart failure and a normal ejection fraction. J Am Coll Cardiol, 2007; 49:982-985 Alj aroudi W , Alrai es MC , H all e y C , et al. Im pac t of progression of diastolic dysfunction on mortali ty in patients with normal ejection fraction. Circulation, 2012; 125 (6): 782-788 Ha ll e y C M, Ho u g ht al in g P L, Kh ali l MK , e t a l. Mo r ta li t y rate i n pati ents wi th di astol i c d ysfunction and norm al systoli c functi on. A rch Intern Med, 2011; 171:1082 -1087 Taler SJ, Textor SC, Augustine JE. Resistant hypertensi on: compari ng hemod ynam ic m anagem ent to speci ali st care. H ypertensi on, 2002; 39 (5): 982 -988 Smith RD, Levy P, Ferrario CM. Consideration of Noninvasive H emod ynami c Monitoring to Target Reduction of Blood Pressure Levels Study Group: Value of Noninvasive H emod ynamics to Achieve Blood Pressure Control in H yp ertensi ve Subjects (The CONTR OL T ri al ). H ypertensi on, 2006; 47: 769 -775 Ferrario CM, Flack JM, Strobeck JE, et al. Indi vi duali zi ng h ypertens i on treatm ent wi th im pedance cardi ography: a meta-anal ysi s of published tri als. Ther Adv Cardiovasc Dis, 2010; 4 (1): 5 -16 Siebert J, Molisz A. Centralne ciśnienie tętnicze tonom etri a apl anac yj na. [C entral arterial pressure – applanati on tonom etry] F orum Medyc yn y Rodzi nnej, 2010; 4 (2): 141-148 ATS Committee of Proficiency Standards for Clinical Pulmonary Function Laboratories. ATS statement for the six-minute walk test. Am J Respir Crit Care Med, 2002; 166:111-117 W olszakiewicz J. The 6-minute walking test clinical usefulness and limitations, Kardiol Pol, 2010; 68 (2): 237-240 Haji ro T , Ni shimura K, T suki no M, et al. A nal ysi s of cli ni cal m ethods used to eval uate dyspnea i n pati ents with chronic obstructive pulmonary disease. Am J Respir Crit Care Med, 1998; 158 (4): 1185-1189 King S, W essel J, Bhambhani Y, et al. The effects of exercise and education, individually or combined, in women with fi brom yalgia. J Rheumatol, 2002; 29(12):2620-2627 Focht B, Rejeski W J, Ambrosius W , et al. Exercise, self-effi cacy, and mobi li ty performance i n overwei ght and obese older adults with knee osteoarthritis. Arthritis and Rheumatism, 2005; 53 (5): 659 -665 Troosters T, Gosselink R, Decramer M. Six minute walking distance in healthy elderly subjects. Eur Respir J, 1999; 14 (2): 270-274 Enright PL, Sherril DL. Reference equations for the six-minute walk in healthy adults. Am J Respir Crit Care Med, 1998; 158: 1384-1387 Casanova C, Celli BR, Barria P, et al. The 6 -min walk distance in healthy subjects: reference standards from seven countries. Six Minute W alk Distance Project (ALAT). Eur Respir J, 2011; 37 (1): 150 -156 Alberti K G, Zimm et P, Shaw J. Metabolic s yndrom e

–

a new world -wide definition. A Consensus S tatement from the International Diabetes Federation. Diabet Med, 2006; 23 (5): 469-480 23. Nagueh SF, Appleton CP, Gillebert TC, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiograph y. Eur J Echocardiogr, 2009; 10: 165 -193 24. Enright PL. The six minute walk test. Respir Care, 2003; 48: 783-785

Hemodynamic conditions of exercise capacity in patients with arterial hypertension - preliminary report

251

ORIGINAL ARTICLES

25.

26.

27.

28.

29.

30.

31.

32.

33.

34.

35.

36.

37.

38.

39. 40.

252

Chetta A, Zanini A, Pisi G, et al. Reference values for the 6 -mi n walk test in heal th y subj ects 20 -50 years old. Respir Med, 2006; 100: 1573 -1578 Enright P, McBurnie M, Bittner V , et al. The 6-min walk test: a quick measure of functional status in elderly adults. Chest, 2003; 123: 387 -398 Safar ME, Boudier HS. Vascular development, pulse pressure, and the m echani sms of hypertensi on. H ypertension, 2005; 46 (1): 205 -209 Kass DA. Ventricular arterial stiffening: integrating the pathoph ysiolog y. H ypertension, 2005; 46 (1): 185 193 Andersen MJ, Ersball M, Bro -Jeppesen J, et al. E xerci se hem odynamics i n pati ents with and without di astolic d ysfunction and preserved ejection fraction after m yocardial infarction. Circ Heart Fail, 2012; 5 (4): 444-451 Ambrosi P, Oddoze C, Habib G. Utility of B natri ureti c pepti de in detecting di astoli c d ysfunction: comparison with Doppler velocity recordings. Circulation, 2002; 8: 106 (15) KrzesiĹ&#x201E;ski P, Gielerak GG, Kowal JJ. A "patient tailored" treatment of hypertension with use of impedance cardiograph y: a random i zed, prospective and controlled trial. Med Sci Monit, 2013; 19: 242 -250 Ventura HO, T al er SJ, S trobeck JE . H ypertensi o n as a hem od ynam ic disease: the role of im pedance cardiography in diagnostic, prognostic, and therapeutic deci si on m aki ng. Am J H ypertens, 2005; 18: 26 -43 Abdelhammed Al, Smith RD, Levy P, et al. Noni nvasi ve hem odynami c profil es i n h ypertensive subj ects. Am J H ypertens, 2005; 18 (2): 51 -59 Kim G, Kim JH, Moon KW , et al T he clinical usefulness of central hemod ynam ics to evaluate di astoli c dysfuncti on i n subj ects wi thout hypertensi on. Clin Interv Aging, 2014; 9: 527 -233 Ahimastos AA, Dart AM, L awler A, etal. Reduced arterial stiffness may contribute to angiotensin converting enzym e inhibitor induced im provem ents in walking time in peripheral arterial disease patients. J H ypertens, 2008; 26 (5): 1037 -1042 Opasich C, De Feo S, Pinna GD, et al . Distance walked i n the 6 -mi nute test soon after cardi ac surger y. Chest, 2004; 126: 1796 -1801 Sciurba F, Criner GJ, Lee SM, et al. Six-minute walk distance in chronic obstructive pulmonary disease: reproduci bi lit y and effect of walking course la yout and length. Am J Respir Crit Care Med, 2003; 167: 1522 1527 W u G, Sanderson B, Bittner V. The 6 -minute walk test: how important is the learning effect? Am Heart J, 2003; 146: 129-133 http://ww w.physi oflow.com/products_ph ysiofl ow.php http://ww w.atcormedi cal.com/sph ygm ocor_xcel.html

MILITARY PHYSICIAN 3/2015

CASE REPORTS

The usefulness of applying the FEEL ultrasound protocol during CPR Przydatność zastosowania ultrasonografii według protokołu FEEL w trakcie resuscytacji krążeniowo-oddechowej - opis przypadku

Wojciech Wierzejski , Rafał Górecki , Robert Brzozowski

Institute of Tactical Combat Care, Military Institute of Medicine in Warsaw; head: Lt. Col. Robert Brzozowski MD, PhD Emergency Unit, Central Clinical Hospital of the Ministry of National Defence, Military Institute of Medicine in Warsaw; head: Włodzimierz Janda MD, PhD Abstract. The ultrasound type of examination is increasingly used as a decision support tool when assessing sudden lifethreatening conditions and monitoring patients who require intensive care [6]. It is considered to be a modern non-invasive diagnostic tool, available at the patient's bedside, cost-effective and capable of providing repeatable results. This article discusses an example application of the ultrasound point-of-care protocol in a female patient in a life-threatening condition with cardiac arrest caused by massive thrombosis, and the procedures intended to neutralize the causes of cardiac arrest and restore spontaneous circulation. Key words: ultrasound point of care, resuscitation, pulmonary thrombosis, fibrinolysis 2

Streszczenie. Badanie ultrasonograficzne jest coraz częściej wykorzystywane jako wspomaganie decyzyjne dla oceny stanów nagłego zagrożenia życia oraz monitorowania pacjentów wymagających intensywnej opieki medycznej [6]. Uznane zostało za nowoczesne nieinwazyjne narzędzie diagnostyczne, dostępne przy łóżku chorego, a przy tym tanie i powtarzalne w zastosowaniu. W artykule omówiono przykład zastosowania protokołu ultrasonograficznego point of care u chorej w stanie zagrożenia życia po zatrzymaniu krążenia spowodowanym masywną zatorowością, a także sekwencję działań ratowniczych zmierzających do neutralizacji przyczyny zatrzymania krążenia i powrotu spontanicznej czynności serca. Słowa kluczowe: ultrasonografia point of care, resuscytacja, zatorowość płucna, fibrynoliza Corresponding author: Sent on: 05/05/2015 Accepted for print: 01/06/2015 Wojciech Wierzejski No conflicts of interest were declared. Institute of Tactical Combat Care, Military Institute of Medicine Mil. Phys., 2015; 93 (3): 253-255 128 Szaserów St., Warsaw Copyright by Military Institute of Medicine e-mail: wierzej1@o2.pl

Introduction

The ultrasound examination is becoming a common diagnostic technique for life -threatening conditions, meaning that it is seeing increased use in everyday practice in intensive care and emergency units. The recommendations for assessment of the heart and lungs extend the scope of applying ultrasound by giving the opportunity to differentiate between the causes of acute cardiopulmonary failure [1,2]. In order to simplify the use of ultrasound , protocols for specified clinical situations have been developed. Thanks to this, on the basis of the clinical image and the use of special configurations of the ultrasound device, the physician can search for specific pathologies and hence not only reduc e the length of the examination but also enable quicker Usefulness of ultrasound FEEL protocol application during CPR - case study

application of appropriate treatment algorithms [3]. In the case study of a female patient with cardiac arrest, the application of the FEEL (Focused Echocardiographic Evaluation in Life Support) [4] protocol enabled faster administration of causative treatment, with the cause of the cardiac arrest being located within a few minutes of beginning the resuscitation.

Case report A 59 -year-old woman was transported by a medical rescue team to the Emergency Unit of the Military Institute of Medicine in W arsaw due to dyspnea. According to her interview, she was recently diagnosed and treated for deep vein thrombosis, and three days earlier had withdrawn from antithrombotic medications. On admission, the 253

CASE REPORTS

patient was conscious with partially maintained logical contact. She complained about the increasing dyspnea. The physical examination revealed respiratory failure (orthopnea and tachypnea), RR approx. 30/min, SpO2 80% accompanied by circulatory problems (NIBP 85/35 mm Hg and HR 55/min). It was impossible to conduct a full interview as, shortly after the patient was admitted, she lost consciousness and suffered a cardiac arrest. Cardiopulmonary resuscitation was initiated and the patient was intubated and put on a ventilator. After five cycles of compression, during a break for pulse assessment, an ultrasound assessment of the heart in the subcostal four-chamber view was performed, in accordance with the protocol proposed by Beitkreutz [5]. During further chest c ompressions, the registered video material from the ultrasound examination was analyzed. The material showed real PEA (pulseless electrical activity) consisting of a lack of any systolic activity by the cardiac muscle with maintained electrical activity in ECG; furthermore, an organized thrombus filling almost the whole lumen of the right atrium was revealed. Massive pulmonary embolism was diagnosed, and a decision was made concerning thrombolytic treatment. Intravenous alteplase (Actilyse, Boehringer Ingel -heim) in a bolus was administered in a scheme adapted due to suit the critical condition of the patient: 50 mg in a bolus and then an intravenous infusion of 50 mg of alteplase in 50 ml of 0.9% NaCI solution, at the speed of 25 mL/h. W ithin 2 minutes from the administration of the initial alteplase dose, the ultrasound image changed from real PEA to apparent PEA, registering a slight systolic function of the left chamber. An intravenous infusion of noradrenaline and dobutamine was introduced and the resusc itation was continued to the twentieth minute, when spontaneous circulation returned (HR 115/ min, NIBP 110/70 mm Hg). The patient was referred to the Cardiology Clinic of the Military Institute of Medicine. She was mechanically ventilated and stabilized cardiovascularly with a catecholamine infusion.

Discussion This case of the use of ultrasound in cardiac arrest illustrates the benefits of point -of-care ultrasound in the differentiation of the causes of sudden cardiac arrest (SCA).

254

Figure 1. Heart without any systolic function. Many hyperechogenic artifacts in the right atrium and in the right ventricle, proving no blood flow. Rycina 1. Serce bez czynności skurczowej. W prawym przedsionku i prawej komorze liczne hiperechogeniczne artefakty świadczące o braku przepływu krwi.

Figure 2. Heart after mild systolic function appeared. The hyperechogenic shape of the embolus can be seen in the right atrium. Rycina 2. Serce po pojawieniu się śladowej czynności skurczowej. W prawym przedsionku widać hiperechogeniczny cień materiału zatorowego.

Use of ultrasound to explain a clinical situation enables rapid and certain determination of a number of potentially reversible causes of SCA, such as acute left ventricular failure, pulmonary embolism, pneumothorax, cardiac tamponade and hypovolemia caused by a hemorrhage.

MILITARY PHYSICIAN 3/2015

CASE REPORTS

ultrasound assisted interventions (UAI), such as vessel cannulation, thoracocentesis or laparocentesis. In the everyday assessment of patients it extends and supplements the physical examination (ultrasound assisted examination UAE). Video material: https://www.youtube.com/ watch?v=jnA1IOqlnEo

Literature 1.

Figure 3. Heart image on restoration of spontaneous circulation. Right atrium filled with free-floating embolic material. Rycina 3. Obrazserca po przywróceniu spontanicznego krążenia. Prawy przedsionek wypełniony balotującym materiatem zatorowym.

Apart from cardiac arrest, the use of point-of-care protocols in ultrasound examinations enables quick diagnosis of shock (Focused Assessment with Transthoracic Echocardiography - FATE protocol), differentiation of the causes of dyspnea (Bedside Lung Ultrasound in Emergency - BLUE protocol) or

Usefulness of ultrasound FEEL protocol application during CPR - case study

Jensen MB, Sloth E, Larsen KM, Schmidt MB. Transthoracic echocardiography for cardiopulmonary monitoring in intensive care. Eur J Anaesthesiol, 2004; 21: 700-707 Lichtenstein DA, Meziere GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest, 2008; 134: 117-125; erratum in: Chest, 2013; 144: 721 Wierzejski W. Nowakowski P. Drobiński D. Rozpoznanie rozwarstwienia aorty wstępującej dzięki wykorzystaniu ultrasonograficznej oceny point-ofcare [Diagnosis of ascending aortic dissection thanks to point-of-care ultrasound evaluation]. Case report J Ultrason, 2014; 14: 428-434 Breitkreutz R, Price S, Steiger HV, et al. Focused echocardiographic evaluation in life support and peri-resuscitation of emergency patients: a prospective trial. Resuscitation, 2010; 81 (11): 1527-1533 Breitkreutz R, Walcher F, Seeger FH. Focused echocardiographic evaluation in resuscitation management: Concept of an advanced life support-conformed algorithm. Crit Care Med, 2007; 35: 5 Manno E, Navarra M, Faccio L, et al. Deep impact of ultrasound in the intensive care unit The "ICU-sound" Protocol. Anesthesiology, 2012; 117:801-809

255

CASE REPORTS

Resection of a retriperitoneal tumor including part of the inferior vena cava, with its simultaneous reconstruction, in a patient undergoing a right-sided orchidectomy due to testicular carcinoma - a case report Resekcja guza przestrzeni zaotrzewnowej z fragmentem żyły głównej dolnej z jednoczasową jej rekonstrukcją u chorego po orchidektomii prawostronnej z powodu raka jądra - opis przypadku

Dariusz Żak, Jakub Włodarski, Małgorzata Pawelczyk, Mirosław Dziekiewicz, Marek Maruszyński Department of Vascular and Endovascular Surgery, Central Clinical Hospital of the Ministry of National Defence, Military Institute of Medicine in Warsaw; head: Prof. Marek M. Maruszyński MD, PhD Abstract. The paper presents a case report of a 27-year-old patient, with a biopsy-proved, mixed non-seminomatous germ cell tumor, who underwent right-sided orchidectomy. Later post-operative observation revealed a massive, slow-growing retroperitoneal tumor (15 x 12 x 12 cm) on the right side. The retroperitoneal mass involved an 8 cm section of the inferior vena cava and renal vein, causing obstruction of the right urinary tract, compressing the right liver lobe, right kidney and shifting the abdominal aorta to the left, and reaching the right hip bone. An almost complete resection of the tumor was performed with removal of a section of the inferior vena cava and the simultaneous reconstruction of the VCI with a 20 mm end to end Uni-Graft to form an arteriovenous saphenofemoral fistula. Key words: testicular cancer, inferior vena cava reconstruction, retroperitoneal tumor.

Streszczenie. Przedstawiono przypadek 27-letniego chorego z rozpoznanym rakiem jądra o typie mieszanego nienasieniaka, który przeszedł orchidektomię prawostronną. W późniejszym okresie pooperacyjnym wykryto u niego sukcesywnie powiększający się guz przestrzeni zaotrzewnowej olbrzymich rozmiarów (15 x 12 x 12 cm) po prawej stronie, naciekający 8 cm odcinek żyty głównej dolnej z żyłą nerkową oraz moczowód, uciskający górnym biegunem prawy płat wątroby, spychający prawą nerkę, przemieszczający aortę na lewo i sięgający talerza kości biodrowej. Wykonano prawie całkowite wycięcie guza z fragmentem żyły głównej dolnej z jednoczasową rekonstrukcją VCI protezą Uni-Graft 20 mm koniec do końca oraz wytworzeniem przetoki tętniczo-żylnej koniec do boku kikuta żyły odpiszczelowej wielkiej do tętnicy udowej wspólnej. Słowa kluczowe: rak jądra, guz przestrzeni zaotrzewnowej, rekonstrukcja żyły głównej dolnej Sent on: 30/04/2015 Accepted for print: 01.06.2015 No conflicts of interest were declared. Mil. Phys., 2015; 93 (3): 256-258 Copyright by Military Institute of Medicine

256

Corresponding author: Jakub Włodarski MD Department of Vascular and Endovascular Surgery Central Clinical Hospital of the Ministry of National Defence, Military Institute of Medicine 128 Szaserów St., 04-141 Warsaw Telephone: +48 502 538895 E-mail: kwlodarski@vp.pl

MILITARY PHYSICIAN 3/2015

CASE REPORTS

Introduction Testicular cancer is one of the most common neoplasms in young men aged 15-35 years [1]. Neoplasms affecting the testes constitute about 1% of all malignant neoplasms in men. According to the American Cancer Society (ACS), testicular cancer now affects 1 in 270 men, and the mortality rate is estimated at 1 in 5000. Since the Second World War, the number of cases of testicular cancer has been on the increase in almost all European countries, while in some countries (e.g. France) it has doubled. The highest incidence is reported in Denmark and Germany [2]. In Poland, in 2010 there were 1094 new cases of malignant testicular neoplasm [ICD-10: C62], concerning all age groups, with the group having the most cases (as many as 242) being men aged 25 to 29 years. The number of deaths in the same year was 123, giving a mortality rate of approximately 11.3%. In comparison, according to the American Cancer Society, in 2010 in the USA there were 8,480 new cases while the number of deaths was 350, giving a mortality rate of about 4.13%. This means that in Poland the risk of death from a malignant testicular neoplasm is almost three times higher than in the USA, resulting mainly from the late diagnosis of this neoplasm. In most of the cases, cancer was detected by accident by those patients who felt some anomalies in one of their testes. The most important risk factors include:  cryptorchidism (undescended testes) - orchiopexy, surgical shifting of the testicle to the scrotum, if it is done before the puberty period, the risk of cancer in the future significantly decreases [3],  testicular cancer in the family, especially in the father or brother,  age, usually 15-35 years, but it can occur at any age,  race - usually in white men, with an incidence rate almost 5 times higher than in black men [4],  infertility,  genetic burdens, such as Klinefelter syndrome or Down syndrome,  cancer of the other testicle,  HIV infection,  controversial and not significantly confirmed: previous injury of the scrotum, height - greater risk in tall men, smoking marihuana in the interview.

Case report A 27-year-old patient was operated on in the Department of General, Oncologic and Vascular Surgery of the Central Clinical Hospital of the Ministry of National Defence, Military Institute of Medicine in October 2006. In April 2000, a rightside orchidectomy was performed due to a testicular tumor, size 53x40 mm, covering 2/3 of the volume of the testicle, without infiltration to the tunicae, stage IIC, mixed nonseminoma (immature teratoma, embryonal carcinoma, seminoma). The AFP concentration before surgery was 203.0 IU/ml. During the hospitalization, an abdominal ultrasound was performed, which revealed a hypoechogenic lesion in the epigastrium region, in the periotic space, which was thought to correspond to an enlarged lymph node. An abdominal CT revealed a focus located between the vena cava inferior and the aorta, with a diameter of 15-20 mm. In Resection of retriperitoneal tumor with a part of inferior vena cava...

May of the same year, the check-up AFP concentration was 215.5 IU/ml. The patient was scheduled for first line chemotherapy. He received 4 courses of PVB (cisplatin, vinblastine, and bleomycin). The AFP concentration dropped to 2.97 IU/ml but the scans revealed growth of the solid lesion in the retroperitoneal space to 6 cm. No cancerous cells were found in the BAC. The patient was then not scheduled for removal of retroperitoneal lymph nodes. Approximately four years later, a check-up scan revealed the progression of the tumor to 8 cm in diameter. The patient was scheduled for an exploratory laparotomy, which showed a tumor infiltrating the vena cava inferior and aorta posteriorly, of 12 cm in diameter. The tumor was considered inoperable and a specimen was collected - size 2.3 x 0.7 x 0.3 cm. The histopathological examination of a fragment of the scirrhous connective tissue showed no cancerous infiltrations. The patient was left without treatment until December 2005, when further progression of the retroperitoneal tumor was observed. The value of beta HCG increased to 41.26 mIU/ml; CEA to 10.42 n/ml, while AFP remained within the norm. The patient was scheduled for a second laparotomy, in which new specimens from the tumor were collected. Histopathological diagnosis: mixed-type tumor - teratocarcinoma and seminoma. The patient received four courses of VIP chemotherapy, after which in March 2006, the levels of the markers returned to normal values, but there were no traits of regression of the tumor in the retroperitoneal space. The patient was not assessed as suitable for a new operation. The check-up abdominal CT scan in August 2006 revealed progression in the tumor size to 12.5x9.5 cm and the increase of beta-HCG concentration to 46.6 and CEA to 32.18. In September 2006, further growth of CEA to 64.09 was observed. In October, it was decided that the patient would undergo another operation. The laparotomy was performed in our center. It revealed an enormous (15x12x12 cm) polycyclic cancerous tumor on the right side of the retroperitoneal space. The tumor pressed the right hepatic lobe with its upper side, pushed the right kidney to the right and back, shifted the aorta to the left, stretched the vena cava inferior and its tributaries on its anterior surface and reached the wing of ilium at the bottom. No infiltration to the mesenteric vessels was found. The VCI and right renal vein were dissected in those segments not infiltrated by the neoplasm. The obstructed right renal vein was cut and dressed. The whole tumor was dissected. The almost total dissection involved an approximately 5-cm-long segment of the right ureter surrounded by the infiltration and an 8-cm-long segment of the VCI infiltrated posteriorly. The tumor solidly adhered to the duodenum and, in order not to damage it, a piece of the adhering fibrous capsule of the tumor was left. The site on the tumor was additionally marked (underpinned) to perform an additional locoregional histological assessment. The continuity of the ICU was obtained with a 20 mm Uni-Graft prosthesis sutured to both ends of the vein. The superior anastomosis was located 2 cm below the right renal vein and the inferior one 2 cm above the common iliac veins. Before clamping the VCI, 3000 units of unfractionated heparin were administered systemically. The VCI remained clamped for 38 minutes. A massive edema of the legs occurred, but it subdued after the flow was restored and the vascular clamps were removed. The ends of the right 257

CASE REPORTS

ureter were mobilized and sutured on an "S" catheter. In order to ensure dynamic flow, an arteriovenous fistula was created through the right armpit, by stitching end-to-side a narrowed stump of the great saphenous vein to the common femoral artery. Total surgery time was 5 hours and 15 minutes. There were no post-surgical complications. The patient left the hospital in good general and local condition seven days after the operation. About two weeks after the operation, he received rescue TIP chemotherapy (paclitaxel, ifosfamide and cisplatin), in three courses. After a month, the arteriovenous fistula was coagulated, with conservation of normal blood flow through the graft, and with no traits of ischemia of the lower limbs. In the postoperative tests the marker concentrations were as follows AFP - 2.78, beta-HCG - 17.71, and CEA - 4.08. A month after the surgery, the concentrations of AFP and betaHCG had further decreased. In the six-month period after the operation, the patient received a further three courses of TIP. During the last course, further chemotherapy was suspended due to intensifying neutropenia. During the check-up abdominal CT performed in March 2007, the image was described as stable, with lesions in the adipose tissue surrounding the vena cava inferior and located anteriorly to it, towards the hepatic hilum. In May 2007, an analogous blood marrow transplant was performed, while further autologous blood marrow transplants in September 2007 were complicated by candidemia and left-sided fungal pneumonia. In November, the patient was again hospitalized in the Department of Oncology for check-up examinations. The chest CT revealed a progression of the inflammatory lesions and a cyst (80 x 64 mm) in the inferior lobe of the left lung. The patient was scheduled for thoracotomy, and in 2007 the resection of the inferior lobe of the left lung with the cyst was performed. The image corresponded to an abscess. A year after the resection of the tumor in the retroperitoneal space and VCI reconstruction, no relapse was observed.

A total of 95-99% of testicular neoplasms stem from germ cells. There is an important clinical division of germ cell tumors (GCTs) into two main groups differing in their therapy - radiosensitivity and curing rate: seminomas (about 25%) and non-seminomas (about 75%). In both groups, the therapy starts from hemicastration, aimed at the removal of the primary focus and obtaining material for the biopsy. Seminomas are characterized by higher radio- and chemosensitivity, so the results of combined treatments are good and reach 100% of total cures in the early stages of cancer and 60-70% in later stages [5,6]. In non-seminomas, during the initial stage, a correctly performed lymphadenectomy and chemotherapy guarantee a total cure in almost 100% of the patients, while in later stages the values range from 20 to 80% [7]. In our patient with stage IIC mixed non-seminoma, it is worth noting that the retroperitoneal lymph node dissection (RLPND) was performed too late, which significantly worsened the prognosis. Although there are many controversies related to the performance of RLPND during stage IA, when the postsurgical risk of relapse is approximately 20-30%, in later stages it becomes obligatory and must be combined with chemotherapy [8].

Literature 1. 2. 3.

6. 7.

Discussion Such aggressive and radical surgery is possible and justified for those neoplasms characterized by high vulnerability to chemotherapy, as in such cases extensive cytoreduction improves the treatment effects and survival rate.

258

Huyghe E, Matsuda T, Thonneau P. Increasing incidence of testicular cancer worldwide: a review. J Urol, 2003; 170: 5 Huyghe E, Plante P, Thonneau PF. Testicular cancer variations in time and space in Europe Eur Urol. 2007; 51 (3): 621-628 Pettersson A, Richiardi L, Nordenskjold A, et al. Age at surgery for undescended testis and risk of testicular cancer. N Engl J Med, 2007; 356 (18): 1835-1841 Spitz M, Sider J, Pollack E, et a I. Incidence and descriptive features of testicular cancer among United States Whites, Blacks, and Hispanics, 1973-1982. Cancer, 1986; 58: 1785-1790 Fossa SD, Aass N, Kaalhus 0. Radiotherapy for testicular seminoma stage I: treatment results and long term postirradiation morbidity in 365 patients. Int J Radiat Oncol Biol Phys, 1989; 16: 383 Duncan W, Munro AJ. The management of testicular seminoma: Edinburgh 1970-1981. Br J Cancer, 1987; 55: 443 Ptużański A. Chemioterapia w przypadkach nienasieniakowatych nowotworów zarodkowych jądra [Chemotherapy in non-semitomatous testicular germ cell tumors]. Urol Pol, 2007; 60: 3 Heidenreich A, Albers P, Hartmann M, et al. Complications of primary nerve sparing retroperitoneal lymph node dissection for clinical stage I nonsemino-matous germ cell tumors of the testis: experience of the German Testicular Cancer Study Group. J Urol, 2003; 169 (5): 1710-1714

MILITARY PHYSICIAN 3/2015

REVIEW ARTICLES

The clinical aspects of abdominal compartment syndrome Zespół wzmożonego ciśnienia wewnątrzbrzusznego w aspekcie klinicznym Jakub Włodarski 1 Department of Vascular and Endovascular Surgery, Central Clinical Hospital of the Ministry of National Defence, Military Institute of Medicine in Warsaw; head: Prof. Marek Maruszyński MD, PhD Abstract. Since the 1930s many physicians, especially surgeons, have been concerned about intra-abdominal hypertension (IAH), in particular its postoperative impact on the patient's general state and related systemic complications. Circulatory, respiratory and renal disorders resulting from IAH were defined as abdominal compartment syndrome (ACS). Following the rising interest in ACS, efforts were made to investigate its causes and consequences, and to determine standards of treatment. Due to the different systemic disorders causing IAH and previously mentioned factors compromising IAH, qualification for laparotomy is still conducted on the basis of the general clinical picture. Nevertheless, IAP is becoming a prognostic factor when considering decompressing laparotomy. The paper tries to present the causes of ACS, its severity scale and methods of IAP measurement. Although ACS is not well researched it still remains a topic of frequent debates and a cause of controversies, and as such is still a notable question encouraging further research towards eliminating the related uncertainties. Key words: abdominal compartment syndrome, intra-abdominal hypertension, intra-abdominal pressure, decompressing laparotomy

Streszczenie. Od lat 30. XX wieku lekarzy, a zwłaszcza chirurgów i anestezjologów, niepokoi wzrost ciśnienia śródbrzusznego (IAH) u chorych, a zwłaszcza jego pooperacyjny wpływ na stan ogólny i związane z nim powikłania ogólnoustrojowe. Zespół wzmożonego ciśnienia wewnątrzbrzusznego (ACS) zdefiniowano jako zaburzenia krążeniowo-oddechowe oraz nerkowe wynikające z IAH. Z powodu coraz większego zainteresowania problemem ASC starano się lepiej poznać jego przyczyny i skutki oraz opracować standardy postępowania. Ze względu na wielokierunkowość zarówno zaburzeń ogólnoustrojowych powodujących IAH, jak i wcześniej wspomnianych czynników wchodzących w skład ACS, chirurg w dalszym ciągu będzie kwalifikował chorych do laparotomii na podstawie całokształtu obrazu klinicznego. Nie umniejsza to jednak faktu, iż wartość ciśnienia wewnątrzbrzusznego (IAP) staje się jednym z czynników rokowniczych co do konieczności wykonania laparotomii odbarczającej. W artykule starano się przedstawić przyczyny ACS, skalę oceny i metody pomiaru IAP. ACS jest zagadnieniem nie do końca poznanym, często wywołującym dyskusje i kontrowersje, ale godnym uwagi i zachęcającym do prowadzenia dalszych badań w celu wyeliminowania wszystkich związanych z nim niejasności. Słowa kluczowe: zespół wzmożonego ciśnienia wewnątrzbrzusznego, nadciśnienie wewnątrzbrzuszne, ciśnienie wewnątrzbrzuszne, laparotomia odbarczająca Sent on: 30/04/2015 Accepted for print: 01/06/2015 No conflicts of interest were declared. Mil. Phys., 2015; 93 (3): 259-261 Copyright by Military Institute of Medicine

Abdominal compartment syndrome (ACS) consists of circulatory, respiratory and renal function disorders caused by intra-abdominal hypertension (IAH). Some authors include brain function disorders in ACS. It is assumed that ACS may be diagnosed if the value of intra-abdominal pressure (IAP) equals or exceeds 20 mm Hg, when flow disorders in the organs begin to be reflected in the clinical condition of the patient [12]. Normal intra-abdominal pressure is 0-5 mm Hg. IAP >13 mm Hg may cause disruptions in visceral flow, gradually Abdominal compartment syndrome in clinical aspect

leading to organ perfusion disorders and damage to the organs. IAP >25 mm Hg, which cannot be lowered with conservative methods, requires the consideration of surgical decompression [6]. Cardiovascular disorders caused by IAH are related to lowered heart ejection and pressure to the inferior vena cava, which in turn decreases blood return to the heart. Cardiac output is decreased as a result of the higher central venous pressure, constriction of the pulmonary arteries and increased systemic vascular resistance. IAH leads to 259

REVIEW ARTICLES

pressure on the diaphragm, which in turn increases the peak respiratory pressure, causing restrictive ventilatory defects, and pressure in the chest, which results in a lower venous return to the heart. A sudden pressure increase in the pleural cavities may lead to a pressure injury, and, as a consequence, to acute respiratory distress syndrome (ARDS). Urinary system disorders lead to oliguria and anuria, stemming from the pressure on the renal vessels and parenchyma. The renal flow and glomerular filtration rate decrease in parallel to the increase in resistance of the renal vessels [2,17,24,25]. Both IAH and chest pressure increase lead to an increase of central venous pressure, which hinders venous return from the brain and potentially to an increase of intercranial pressure and cerebral edema. Other life-threatening consequences of ACS are progressive acidosis and hypothermia, which slow down the metabolism and have a harmful influence on coagulation factors, and may cause the deformation (disk-like shape) of thrombocytes and coagulation disorders. Due to the impaired blood supply to the intestines, the intestinal villi and walls become increasingly permeable to bacterial toxins, for example, which may later cause septic complications through contamination [5,11]. IAP should be measured in the case of suspected IAH. As the examination is of a non-invasive character, it can be done without harm to the patient. IAP is usually measured in patients with multiple injuries, intensifying symptoms of gastrointestinal obstruction, burns covering over 60% of the body surface or after transplants. Maxwell et al. state that IAP should be routinely measured in patients who received 10 l of crystalloids or 10 PRBCs in the resuscitation process [3,21]. According to the literature, the most frequent causes of ACS are internal injuries, usually to parenchymal organs located intra- or extraperitoneally. They are related to the edema of the organs or surrounding tissue, or to their rupture and blood extravasation to the peritoneal cavity or extraperitoneal space, resulting in IAH. Among the causes of ACS, we can identify:  multiple body injuries  extensive burns  organ transplants  acute pancreatitis  peritonitis  gastrointestinal obstruction  hemorrhage to the peritoneum or digestive tract  coagulopathies  ischemia, embolism or thrombosis of mesenteric vessels  intraoperative packing  ruptured abdominal aortic aneurysm,  metabolic disorders  ascites  peritoneal dialysis with complications  shock [22,23] Division of ACS into stages of advancement: Grade I 12-15 mm Hg, Grade II 16-20 mm Hg, Grade III 21-25 mm Hg, Grade IV >25 mm Hg. 260

Due to the need to monitor IAP, attempts were made to develop more precise, non-invasive and easier measurement methods reflecting the actual IAP. In 1987, Lacey et al. measured the pressure in the stomach, rectum, urinary bladder, superior and inferior vena cava, femoral and radial artery and peritoneal cavity and concluded that the best correspondence with IAP can be observed for the urinary bladder and inferior vena cava. Due to the close results of the measurement, as well as the non-invasive and simple measuring process, it was decided to measure IAP on a broader scale in the urinary bladder. With time, the technique of IAP measurement in the urinary bladder was modified, and finally the method described below became the standard [1,7,20]. All that is required to measure IAP in the urinary bladder is:  Foley catheter with two or (better) three tubes,  sensor for invasive blood pressure measurement and a set of drains (fluid transfusion set),  monitor (with the option of invasive blood pressure measurement),  syringes: 10 ml and 100 ml. After positioning the patient, the Foley catheter is inserted into the urinary bladder. After filling of the stabilizing and tightening balloon with 10 ml of 0.9 NaCl solution, all urine should be removed from the bladder. The catheter is then connected to the sensor used for invasive blood pressure measurement by means of a fluid transfusion set. The sensor is located on the level of symphysis pubis and connected to the monitor. The whole system is then filled with a 0.9% NaCl solution or distilled water. The urinary bladder is then filled with 100 mL of 0.9% NaCl solution, so that the opening of the catheter is below the fluid surface [4, 16]. If the catheter has three tubes, it is enough to administer an appropriate amount of fluids into the bladder without disconnecting the drains, and it is easy to achieve each measurement using or with the same amount of fluid in the bladder. The measuring tools must be sterile. After two calibrations of the system, measurements can be started [10,13]. Measurements in patients with ACS should be made every 2-4 hours. Due to the varying systemic disorders causing IAH and the previously mentioned factors compromising IAH, qualification for laparotomy will still be conducted on the basis of the general clinical picture. Nevertheless, IAP is becoming a prognostic factor when considering decompressing laparotomy. The majority of the experts of the American Association for the Surgery of Trauma hold the position that if ACS requires a laparotomy and the cause of the ACS cannot be removed surgically, the abdomen should be left open. After the removal of the cause and normalization of IAP, the abdomen may be closed, but IAP should still be monitored. The minority thinks that the decision concerning abdomen closure should be postponed until it is certain that the symptoms will not return [1,9,10,14,18,19,24]. In order to avoid ACS in patients in a high risk group, the abdomen may be closed with MASH, foil and zippers (for temporary protection, but requiring reoperation) [4,8].

MILITARY PHYSICIAN 3/2015

REVIEW ARTICLES

Literature 1.

6. 7. 8.

9. 10.

11. 12.

13.

Mayberry JC, Goldman RK, Mullins RJ, et al. Surveyed opinion of American trauma surgeons on the prevention of the abdominal compartment syndrome. J Trauma, 1999; 47:509-514 Williams M, Simms HH. Abdominal compartment syndrome case reports and implications for management in critically ill patients. Am Surg, 1997; 63: 555-558 Meldrum DR, Moore FA, Moore EE, et al. Prospective characterization and selective management of the abdominal compartment syndrome. J Vase Surg, 1997; 174: 667-672 Mayberry JC, Mullins RJ, Crass RA, Trunkey DD. Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure. Arch Surg, 1997; 132:957-961 Sugerman HJ, Bloomfield GL, Saggi BW. Multisystem organ failure secondary to increased intraabdominal pressure. Infection, 1999; 27: 6166 Pottecher T, Segura P, Launoy A. Abdominal compartment syndrome. Ann Chir, 2001; 126: 192-200 Sanchez NC, Tenofsky PL, Dort JM, et al. What is normal intra-abdominal pressure? Am Surg, 2001; 67: 243-248 Balogh Z, McKinley BA, Holcomb JB, et al. Both primary and secondary abdominal compartment syndrome can be predicted early and are harbingers of multiple organ failure. J Trauma, 2003; 54: 848-859 Sugure M. Intra-abdominal pressure: time for clinical practice guidelines? Intensive Care Med, 2003; 28: 389-391 Kirkpatrick AW, Brenneman FD, McLean RF, et al. Is clinical examination an accurate indicator of raised intra-abdominal pressure in critically injured patients? Can J Surg, 2000; 43: 207-211 Gracia VH, Braslow B, Johnson J, et al. Abdominal compartment syndrome in the open abdomen. Arch Surg, 2003; 137: 1298-1300 Schein M. Abdominal compartment syndrome: historical background. In: Ivatury R, Cheatham M, Malbrain M, Sugrue M, (eds). Abdominal compartment syndrome. Georgetown, Landes Bioscience, 2006: 1-7 Malbrain ML, Cheatham ML, Kirkpatrick A, et al. Results from the International Conference of Experts on Intra-abdominal Hypertension and Abdominal Compartment Syndrome. I. Definitions. Intensive Care Med, 2006; 32: 1722-1732

Abdominal compartment syndrome in clinical aspect

14. Malbrain ML, Cheatham ML, Kirkpatrick A, et al. Abdominal compartment syndrome: it's time to pay attention! Intensive Care Med, 2006; 32: 1912â&#x20AC;&#x201D; 1914 15. Ivatury RR. Abdominal compartment syndrome: a century later, isn't it time to accept and promulgate? Crit Care Med, 2006; 34: 2494-2495 16. Malbrain ML. Different techniques to measure intra-abdominal pressure (IAP): time for a critical re-appraisal. Intensive Care Med, 2004; 30: 357371 17. Malbrain M, Jones F. Intra-abdominal pressure measurement techniques. In: Ivatury R, Cheatham M, Malbrain M, Sugrue M, (eds). Abdominal compartment syndrome. Georgetown, Landes Bioscience, 2006: 19-68 18. Davis PJ, Koottayi S, Taylor A, Butt WW. Comparison of indirect methods of measuring intra-abdominal pressure in children. Int. Care Med., 2005; 31: 471-475 19. De Potter TJ, Dits H, Malbrain ML. Intra-and interobserver variability during in vitro validation of two novel methods for intra-abdominal pressure monitoring. Intensive Care Med, 2005; 31: 747-751 20. Cheatham ML, White MW, Sagraves SG, et al. Abdominal perfusion pressure: a superior parameter in the assessment of intra-abdominal hypertension. J Trauma, 2000; 49: 621-626; discussion 6-7 21. Malbrain ML, Deeren D, De Potter TJ. Intra-abdominal hypertension in the critically ill: it is time to pay attention. Curr Opin Crit Care, 2005; 11: 156171 22. Cheatham M, Malbrain M. Cardiovascular implications of elevated intraabdominal pressure. In: Ivatury R, Cheatham M, Malbrain M, Sugrue M, (eds). Abdominal compartment syndrome. Georgetown, Landes Bioscience, 2006: 89-104 23. Dellinger RP, Carlet JM, Masur H, et al. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Intensive Care Med, 2004; 30: 536-355 24. Sugrue M, D'Amours S. The problems with positive end expiratory pressure (PEEP) in association with abdominal compartment syndrome (ACS). J Trauma, 2001; 51:419-420 25. Gattinoni L, Pelosi P, Suter PM, et al. Acute respiratory distress syndrome caused by pulmonary and extrapulmonary disease. Different syndromes? Am J Respir Crit Care Med, 1998; 158: 3-11 26. Malbrain ML, Chiumello D, Pelosi, et al. Incidence and prognosis of intraabdominal hypertension in a mixed population of critically ill patients: a multiple-center epidemiological study. Crit Care Med, 2005; 33: 315-322

261

HISTORY OF MEDICINE AND MILITARY MEDICAL SERVICES

70th anniversary of the Regional Military Medical Board in Żagań - an outline history of its establishment and development 70-lecie Rejonowej Wojskowej Komisji Lekarskiej w Żaganiu - zarys historii powstania i rozwoju Krzysztof Kopociński, Zbigniew Kopociński, Czesław Jeśman Department of the History of Medicine, Pharmacy and Military Medicine of the Medical University in Łódź; head: Prof. Czesław Jeśman MD, PhD Abstract. In 2015 we celebrated 70th anniversary of the Regional Military Medical Board in Żagań. It was formed in January 1945 in Leszczyny as the Medical Board of the 8th Mobile Field Surgical Hospital of the 2nd Polish Army. With this hospital the Board followed the combat trail from Leszczyny to Ruszów. In 1945, it was transformed into the Garrison Military Medical Board at the Garrison Hospital in Iłowa, and then in May 1946 it arrived in Żary. On 1 March 2015, the Regional Military Medical Board left Żary and moved to Żagań, finally parted from the hospital. Key words: military medical board, military physician. Sagan, Sorau, Żagań, Żary Streszczenie. W 2015 r. obchodzimy 70. rocznicę powstania Rejonowej Wojskowej Komisji Lekarskiej w Żaganiu. Została ona sformowana w styczniu 1945 r. w miejscowości Leszczyny jako Komisja Lekarska 8. Polowego Ruchomego Szpitala Chirurgicznego w składzie II Armii Wojska Polskiego. Ze szpitalem tym przeszła cały szlak bojowy z Leszczyn do Ruszowa. W 1945 r. została przekształcona w Garnizonową Wojskową Komisję Lekarską przy Szpitalu Garnizonowym w Iłowej. W maju 1946 r. przybyła wraz ze swoim szpitalem do miasta Żary. 1 marca 2015 r. Rejonowa Wojskowa Komisja Lekarska opuściła swoje miasto i przeniosła się do Żagania. Słowa kluczowe: wojskowa komisja lekarska, lekarz wojskowy, Sorau, Sagan, Żagań, Żary Delivered: 26/03/2015 Approved for print: 01/06/2015 No conflicts of interest were declared. Mil. Phys., 2015; 93 (3): 262-268 Copyright by Military Institute of Medicine

Introduction

2015 coincides with the 70th anniversary of establishment of the Regional Military Medical Board (RMMB) in Żagań, which currently forms one of the pillars of the military medical examination division in Poland. This division is often omitted when any prizes or distinctions are awarded, as medical examiners perform no spectacular operations to save the health or lives of patients, nor do they capture important enemy points of resistance. However, anyone who is aware of the functioning of the armed forces knows well that it is on their professionalism and medical skills that the level of every army depends. The main tasks of the Military Medical Boards (MMB) include the selection of suitable candidates for military service, in accordance with th e current 262

Corresponding author: Zbigniew Kopociński MD, PhD 105th Kresy Military Hospital with Outpatient Clinic, Subdepartment of Ophthalmology 2 Domańskiego St., 68-200 Żary telephone: +48 68 470 78 62 e-mail: zkopocinski@wp.pl

level of medical knowledge and the health requirements for a particular position. Owing to the reliable efforts of the medical examiners our soldiers are selected in accordance with the highest health standards applicable in most NATO member states. Military service has always been a real challenge for young men, and in more recent times also for women. Much attention was once focused on the most physically fit and bravest individuals becoming warriors, and nowadays we can only speculate how the selection and draft to the armed forces might look if modern healthcare and treatment were still provided by barber -surgeons and healers. As a rule, in the past it was limited to a superficial assessment of the physical qualities of a person, such as height , body mass, physical strength and age. The life experience of older soldiers, who knew what a MILITARY PHYSICIAN 3/2015

HISTORY OF MEDICINE AND MILITARY MEDICAL SERVICES

particular recruit was fit for after a short observation period, was not without meaning either. This is, for example, how a reti nue was formed during a mass levy, and noblemen were very interested in having the fittest and strongest people among their servants, as in time of war their lives could depend on it. Therefore, it took on a certain form of natural selection based on an as sessment of the skills of the subject. Significant progress was made in military medical examinations in Poland at the turn of the 18th century when a set of provisions was published, entitled: “Rules of Camp and Garrison Service for the entire army of th e Polish–Lithuanian Commonwealth”. This specified the duties of a 'feldsher', who should: “...examine and review all the recruits kept by the company for any disability, or any defect that would make them unfit for military service, and report it to the 'F euerwerk' and the Officer...”. Conscripting criminals, vagabonds and the sickly was officially prohibited, and the Constitution of 1789 specified that “...a recruit should be healthy, disabled in no part of the body, at least sixty inches tall, and not you nger than eighteen years of age or older than thirty -five”. Three criteria were therefore taken into account during enlistment into the military service: age, general health condition and height. The general draft was introduced in the Duchy of W arsaw unde r a decree of 9 May 1808 by Duke Frederick August II. It was conducted by enrolment councils, as draft boards were referred to then, composed of: two department councilors, two surgeons (civilian and military), one officer and a secretary. Three groups of conscripts were distinguished:  men aged 21-28, who were all drafted, except for teachers, civil servants and clergymen.  men aged 28-50, i.e. remaining in the reserve,  'laid-off people', i.e. not subject to draft. Napoleon's defeat meant that the draft to t he army of the then Kingdom of Poland was conducted in accordance with the regulations in force in Russia (“Selection of laws, acts and ukases”), published in Polish in Grodno as early as in 1803. Three groups of illnesses were defined on their basis:  faked, i.e. feigned illnesses,  latent illnesses,  illnesses rendering recruits unfit. The main task of the medics taking part in the draft was to examine the recruit, identify possible illnesses and deem the conscript fit or unfit for service [1-4]. In the period of the Partitions, the rules governing military medical examinations relevant to the particular partitioning countries applied in the territory of the former Poland. After the regaining of independence in 1918, during the rebirth of the Polish Army, mil itary boards were forced to use translations of the rules of the partitioning countries due to the lack of Polish military medical examination laws. In the following years Polish medical examiners developed original Polish rules 70th anniversary of the Regional Military Medical Commission in Żagań

to determine fitness for mi litary service, which were revised several times in the interwar period. The last rules of military medical examination for officers in force in the Second Polish Republic were contained in the instruction of 1 January 1933: “Examination and assessment of physical and mental fitness of officers for military service, San 5/32”. Three categories of health were defined on its basis:  “I” – fit for military service,  “C” and “D” – fit for service in a mass levy,  “E” – completely and permanently unfit for military service. The last regulations for privates and non commissioned officers of the Polish Army applicable before the Second W orld W ar were contained in instruction “San 5/37”, specifying five health categories:  “A” – fit for mandatory military service,  “B” – temporarily unfit for military service ,  “C” – fit for service in a mass levy,  “D” – fit for auxiliary military service,  “E” – completely unfit for military service. During that period, decisions were issued by the military medical boards in the p articular District Corps Commands (DCC). These consisted of: a chairman (a military physician with the rank of lieutenant colonel), two military physicians, a representative of the commissariat and a representative of the military district staff. Decisions concerning generals and senior officers (positions of heads of departments, sections of general staff, and heads of services at the DCC) were made by a special board of the Ministry of Military Affairs. The main tasks of the medical examiners included, ap art from evaluation of fitness for military service, identification of the causal link between a particular illness and military service, assessment of the degree of loss of earning capacity and determining the necessity for continuous care [5,6].

Establishment of the Medical Board of the 8th Mobile Field Surgical Hospital (MFSH) and its battle trail Pursuant to the Order of the Commander -in-Chief of the Polish Armed Forces, No. 8 of 20 August 1944, in the region of Czemierniki -Kock-Siedlce, the 3rd Field Evacuation Point (PEP in Russian) commanded by Major Leon Gecow MD established thirteen field hospitals, including the 8th Mobile Field Surgical Hospital in Kock. The first location of this facility was Jabłonowski Palace in Kock, where on 5 October 1939 the commander of the “Polesie” Independent Operational Group (the last of the Polish Army troops to fight the Germans and Russians) Brig. Gen. Franciszek Kleeberg signed the surrender. For the soldiers of the Second Polish Army it almost symbolically meant they were resuming the battle initiated b y that virtuous general during the September campaign. The first three months for the new facility did not

– an outline history of its establishment and development

263

HISTORY OF MEDICINE AND MILITARY MEDICAL SERVICES

bring any need for examination activities as the hospital was still being organized and the flow of the sick and injured was yet small. It should be noted that the Polish Army established in the east was to a major extent based on the models of the Red Army, duplicating its structure, organization and tactics. This was certainly not the choice of the Polish soldiers but the result of the treaties signe d in Tehran and Yalta, according to which our allies (the USA and Great Britain) gave Poland into the sphere of influence of the Soviet Union, which meant radical changes in the political and economic system, as well as changes concerning the entire Polish Army, which was to a large extent commanded by Russian officers transferred to serve in a Polish uniform, including the military medical examination. On 26 April 1944 Gen. Karol Świerczewski established at the Formation Centre in Sumy a Main Medical Board, the duties of which included establishing the lower (district and garrison) levels of military medical examinations. The latter were formed at field hospitals, although this was not immediate as initially there was no need for them in the new hospitals. In the 8th Mobile Field Surgical Hospital this took place as late as 16 January 1945, when a real situation necessitated decisions concerning the future of the treated soldiers, and the commander of the hospital formed a medical board in Leszczyny (distric t of Garwolin) consisting of three people: a chairman and two members. The position of chairman was taken by the commander of the hospital, Maj. Karol Rumeld MD (Tab.), and he appointed two physicians as the other members: Lt. Chaim Scharage and Cpt. W iesł aw Hołobut (graduates of the Faculty of Medicine of the Jan Kazimierz University in Lviv). Table. Chairmen of the Militar y M edical Board in the ye ars 1945-2015 Tabela. Przewodnicząc y W ojskow ej Komisji Lekarskiej w latach 1945-2015

Rank, full name Maj. Karol Rumeld, MD

Period duties performed 16.01.1945-15.02.1945

Lt. Col. Andrzej Szkwara MD

15.02.1945-06.05.1945

Lt. Mieczysław Mel MD

06.05.1945-29.08.1945

Cpt. Maksymilian Mościsker MD 29.08.1945-23.10.1945 Cpt. Adam Browar Paszkowski

01.11.1945-22.05.1946

Maj. Salom on Riegelhaupt MD

06.1946 - 12.01.1947

Maj. Jerzy Rowiński MD

12.01.1947-01.12.1950

Acting Cpt. W łodzimierz 02.12.1950-01.1951 Pietkiewicz MD Maj./Lt. Col. Stanisław Andrzej 01.1951 - 21.08.1957 Bonikowski MD Acting Cpt. Ludomir Bien ias MD 01.03.1957-01.08.1957 264

Cpt./Lt. Col. W iktor 28.08.1957-29.05.1971 Jędrzejkiewicz MD Lt. Col./Col. W alenty W asiński 29.05.1971-09.1990 MD Lt. Col. Ludwik Kotecki MD 09.1990 - 13.04.2001 Cpt./Maj. Janusz Jasiński MD

23.08.2001-30.11.2010

Cpt./Lt. Col. Marek Jędrzejczyk 04.2011MD

Sources: AB: T. Andrzejewski; AB: J. Jasiński; AB: M. Jędrzejczyk; AB: W . Jędrzejkiewicz; AB: W . Pietkiewicz; AB: W . W asiński; Archive of the 105th Military Hospital with Public Outpatient Clinic: KSG: 1 -78; KRD PF29/2000, PF-6/2001, PF-8/2001; AW O: Set 214, Garrison Hospital in Żary, file nos. 12230/65/64, 12319/65/50, 12320/65/55, 12321/42/65, 12309/65/28, 12310/65/20, 12312/65/46, 12313/65/52; CAW : TAP 1164/66/4

This mode of examination division at the hospital was then copied by the four successive commanders of the facility: Lt. Col. Andrzej Szkwara MD, Lt. Mieczysław Mel MD, Cpt. Maksymilian Mościsker MD and Cpt. Adam Browar Paszkowski. They held the position of chairman and the duties of the members were performed by those physicians least burdened with other tasks at that particular moment. During this period this position was often held by two physicians: Cpt. Arnold Sinkower and Cpt. Artur Reich. The medical examination was performed on the basis of the regulati ons introduced by the Order of the General Headquarters of the Polish Army of 22 January 1945, which were really Soviet rules of medical examination translated into Polish. They defined the following health categories for officers and non -commissioned officers:  fit for military service,  fit for military service with 1st or 2nd degree restrictions,  convalescent leave or exemption from activities for a specified period,  unfit for military service with removal from the register or re-examination at a later, specified date. In the case of conscripts and privates the following three categories applied:  fit for front-line service,  fit for non-combatant service,  temporarily unfit for military service. It is worth mentioning that there was a characteristic depa rture from the typical Polish nomenclature of marking health categories with letters of the alphabet. This tradition was only revived some six years later. It should be noted that in the period of front -line operations the Medical Board of the 8th Mobile Field Surgical Hospital was an integral part of this facility and the physicians who formed it primarily performed duties related to helping the sick and wounded soldiers. The location changed several times, until in the second half of January 1945 the faci lity arrived in Koło on the MILITARY PHYSICIAN 3/2015

HISTORY OF MEDICINE AND MILITARY MEDICAL SERVICES

W arta River. About a month later it moved to Złotów (German: Flatów) to provide aid to the medical subunits of the First Polish Army and the Red Army, fighting difficult battles at the Pomeranian W all. In March, the hospital was delegated to support the actions of the Second Polish Army in the area of W rocław fortress (in German: Festung Breslau), being stationed in Oleśnica (German: Oels) and then in Skarszyn (German: Sauerbrunn). However, it performed its greatest military oper ation after relocating to Ruszów (German: Rauscha), where in April 1945 it took active part in providing medical aid for the crossing of the Lusatian Neisse. It should be strongly emphasized that the number of admitted wounded exceeded the capacity of the facility ten times, which best confirms the devotion and engagement of the entire staff, including the members of the Medical Board [7 -9].

Transformation of the Medical Board of the 8th Mobile Field Surgical Hospital into the Garrison Military Medical Boar d (GMMB) at the stationary Garrison Hospital The end of war necessitated the adaptation of the structures of military healthcare to peaceful conditions. As a result, on 22 September 1945, the 8th Mobile Field Surgical Hospital of the Second Polish Army was transformed into the stationary Garrison Hospital in Iłowa (German: Halbau, location of the hospital from August 1945). Next, by order of the General Headquarters of the Polish Army, No. 41 of 29 October 1945, the commander of the hospital, Cpt. Adam Browar Paszkowski appointed and approved the Garrison Military Medical Board at the Garrison Hospital in Iłowa on 1 November 1945. The composition of the board was modelled on its predecessors: the chairman was commander Cpt. Adam Browar Paszkowski and its members were Cpt. Salomon Riegelhaupt MD (head of the General Unit) and Lt. W endelin Stanek MD (head of the Surgical Unit), whereas the secretary was a newly drafted physician, a W arsaw insurgent, Zbigniew Badowski (radiologist). It should be noted that military medical examinations were performed by physicians holding other positions at the hospital, and any activity in this field was therefore an additional duty for the medical staff. It was an incredibly important task and required concentration, with the e xtra time required having to be found, as well as the energy and strength. It must be mentioned that these physicians were truly remarkable figures. A very important date in the history of the entire hospital and its medical examination division was 15 May 1946 – when it moved to Żary (German: Sorau, present day: Żary). The hospital occupied the buildings of the former German mental hospital (Brandenburg Psychiatric Institution – BPI), where during W orld W ar II, within the framework of 'Action 70th anniversary of the Regional Military Medical Commission in Żagań

T4', German psychiatrists practised non-voluntary euthanasia on the mentally ill. The premises of the division of medical examination were located in building No. 7 (former men's ward no. 2 of the German BPI), and the board took over its long standing seat in the loft of building No. 23 (form er women's ward no.6 of the German BPI) in 1953, where it remained for the next 62 years. On 1 March 2015 the Regional Military Medical Board finally left its historical seat and moved to nearby Żagań, where it was stationed in the former barracks at Żarska St. It was while based in Żary that the functions of the commander of the hospital and the chairman of the Garrison Military Medical Board were divided for the first time in the history of the facility; the duties of the latter being accepted on an ad -hoc basis by Maj. Salomon Riegelhaupt MD - head of the General Unit. In the following years several other officers would perform such additional duties, until in 1951 when Maj. Stanisław And rzej Bonikowski MD became the first ever full-time chairman of the Regional Military Medical Board in history. This was a landmark event that sanctioned the individuality of the division of military medical examination, which was becoming an independent structure directed by a physician who performed no other function in the hospital. The other two members of the board were still appointed by the commander of the hospital from among the physicians who were least burdened with official duties at that particular moment. W orking with constantly changing colleagues was not easy, especially since all of the ad -hoc members had their own duties at the department or in the clinic and treated examination work as an undeserved punishment. This situation did not improv e until 1957, when an additional position of member of the Garrison Military Medical Board was created at the 105th Garrison Military Hospital (this name being adopted by the military clinic in Żary in 1951). From that time on there were two full -time medical examiners working at the hospital, which significantly improved its efficiency. No significant changes occurred in the structure of the examination division for the next 20 years, two officer physicians holding the position of chairman during that period: Cpt./Lt. Col. W iktor Jędrzejkiewicz and Lt. Col./Col. W alenty W asiński. In October 1978 the Garrison Military Medical Board at the 105th Garrison Military Hospital was transformed into the Regional Military Medical Hospital in Żary, which was then sepa rated from the structure of the hospital, under the Regulation of the Ministry of National Defence, No. 29 of 30 June 1981, and became subordinate to the District Medical Board in W rocław. The best testimony to the workload of just two full -time physicians of the examination division (the third one was appointed ad-hoc by the commander of the hospital) is the number of decisions issued, which had increased from 2376 in 1956 to 4016 in 1990. Having noticed

– an outline history of its establishment and development

265

HISTORY OF MEDICINE AND MILITARY MEDICAL SERVICES

this trend, the superiors decided to increase the full-time staff by adding the position of deputy chairman of the Regional Military Medical Board, effectively increasing the number of medical examiners to three. The political transformation at the end of the 1980s brought further significant changes to mil itary medical examinations in Żary. In 1990 the former chairman, W alenty W asiński MD, took a well deserved retirement, and was replaced by Lt. Col. Ludwik Kołecki MD. This was a period of huge transformations throughout the Polish Army , resulting from the liquidation of the W arsaw Pact and the endeavors to be accepted by NATO. The very large reduction in the army resulted in a reform of the structures of the military medical examination boards, which meant a degradation for the Regional Military Medical Boa rd in Żary. The order of the Ministry of National Defence, No. 29/Org/P-5 of 2 April 2001 and § 1 of the Order of the Chief of the General Staff of the Polish Army No. 0/161/Org/P-5 of 13 April 2001 determined that the Regional Military Medical Board shoul d be disbanded and a new structure, namely the Local Military Medical Board (LMMB), established in its place. As of 23 August 2001 Maj. Janusz Jasiński MD was appointed its new chairman. The new millennium brought the engagement of the Polish Armed Forces in operations outside the borders of the country, something unheard of since W orld W ar II. The medical examiners in Żary accepted the burden of responsibility for the health based selection of the soldiers of the contingents organized by the 11th Lubusz Ar moured Cavalry Division, named after Jan III Sobieski, to participate in missions in Kosovo, Iraq, Afghanistan and Chad, duties which they fulfilled in an exemplary manner. The last serious structural changes consisted of the transformation of the Local Mi litary Medical Board into a Regional Military Medical Board, which followed the Regulation of the Ministry of National Defence of 24 August 2012 on establishing military medical boards and defining their locations, territorial scope and competences. Simult aneously, the seat of the board was ordered to be moved from building No. 23 at the 105th Kresy Military Hospital with Outpatient Clinic in Żary (where it had functioned continuously from 1953) to the barracks on Żarska Street in Żagań. The territorial sco pe of the then-established Regional Military Medical Boards covered the Lubuskie province and four districts of the Dolnośląskie province: Bolesław, Głogów, Polkowice and Zgorzelec. Today, the position of the chairman of the medical board is held by Lt. Col. Marek Jędrzejczyk MD [4,7,10 -13].

266

Figure 1. The combat trail of the Medical Board of 8 t h Mobile Field Surgical Hospital Rycina 1. Szlak bojowy Komisji Lekarskiej 8. Polowego Ruchomego Szpitala Chirurgicznego

Conclusions During the 70 years of its exi stence, the Regional Military Medical Board in Żagań (it left its former headquarters in Żary on 1 March 2015) went through numerous changes in terms of organization and structure, and also in terms of its location during the period of military operations. As the Medical Board of the 8th Mobile Field Surgical Hospital of the Second Polish Army it followed the combat trail from Leszczyny to Ruszów (Fig. 1.), changing its location several times. Its members participated in the largest combat operation of the hospital, i.e. providing support while crossing the Lusatian Neisse. After the end of the war, the Board was stationed in Iłowa for a short time, and then from 1946 for the next 69 years continuously at the military clinic in Żary. During that long period, it managed to gradually make its long way through the reforms in the modes of operation, from ad -hoc appointments of physicians (burdened by current work in their parent departments) to perform the additional duties of medical examination, to the establishment of an independent team of experienced medical examiners. Both the structure and the name of the division of medical examination at the hospital underwent certain changes: Garrison Military Medical Board, Regional Military Medical Board, Local Militar y Medical Board, and then Regional Military Medical Board. Until 1981 the board formed an integral part of the 105th Military Hospital in Żary, before departing to become an independent structure subordinate to the Central Military Medical Board (earlier t he Regional Military Medical Board). MILITARY PHYSICIAN 3/2015

HISTORY OF MEDICINE AND MILITARY MEDICAL SERVICES

Figure 2. Staff of the Regional Military Medical Board, Żary, 2013 Rycina 2. Personel Rejonowej Wojskowej Komisji Lekarskiej, Żary, 2013 r.

It was related to the military clinic in Żary by means of its location, which, according to all the previous chairmen, met the necessary criteria for proper operation. Its major advantage was the location in the area of the Specialist Clinic of the 105th Kresy Military Hospital with Outpatient Clinic, where specialist doctors were available to interview the examined patients. This allowed for immediate consultations in disputable and unclear situations, including the possibility of holding a quick case conference in the presence of the medical examiners. Unfortunately, operations in Żagań, a dozen or so kilometers from the hospital, excludes direct contact with medical examiners and specialist doctors, and it should be noted that most of the employees of the military clinic in Żary are former military physicians, well aware of the rules of medical examination and the specificity of military service. They provide the most professional and reliable opinions possible regarding professional soldiers and candidates for military service. At a time of unprecedented commercialization and the significant lowering of standards in different institutions of general healthcare, which results from the tendency to cut costs (low quality equipment, poorly qualified staff, etc.), the Ministry of National Defence should take care to maintain the hi ghest 70th anniversary of the Regional Military Medical Commission in Żagań

quality of the operations of the military medical examination division. The simplest way is to provide continuous support to the hospitals established by the Ministry of National Defence and to introduce the rule of obligatory examinations for the ne eds of military medical boards in such facilities. In this way certain situations can be avoided, such as those where a small company is awarded a contract for the provision of services (medical consultations and examinations), offering an understated price before performing its “examinations” at a very questionable level. The result only becomes clear after some time, such as during an operation in Iraq or in Afghanistan, for example, where a responsible position may be held by a person who, due to poor health condition, puts himself and other people at risk. By means of the reinforcement of military hospitals established by the Ministry of National Defence (a large part currently deprived of military positions) it is possible to simultaneously reinforce and create a system of reserve hospitals in the case of a military conflict, which in the long years of blissful peace has already been forgotten. In these uncertain times it would rather be a shame to waste the huge potential and experience of former milita ry physicians. Through all the years, the medical examiners in Żary

– an outline history of its establishment and development

267

HISTORY OF MEDICINE AND MILITARY MEDICAL SERVICES

have also created an excellent system of teaching the profession through the “master-apprentice” scheme, with a natural rotation in the managerial positions. This good practice was initiated by Lt. Col. W. Jędrzejkiewicz MD, succeeded in the position of the chairman by his subordinate and apprentice in the field of medical examination - Lt. Col. W. Wasiński MD. Afterwards, the work of the board was managed by Lt. Col. L. Kołecki MD, who also had been an apprentice in the field of medical examination under his previous superior. A similar case occurred with Maj. J. Jasiński MD. The current chairman of the Regional Military Medical Board in Żagań, Lt. Col. M. Jędrzejczyk MD, “apprenticed” in a lower position for over ten years, which allowed him to gain the knowledge and experience necessary to manage one of the best Regional Military Medical Boards in Poland. The longest-serving chairmen of the MMB in Żary in history were: Lt. Col. W. Wasiński MD - 19 years and Lt. Col. W. Jędrzejkiewicz MD - 14 years, while the longest-serving physicians included: Lt. Col. W. Wasiński MD - 25 years, Lt. Col. L. Kołecki MD 21 years, and Maj. J. Jasiński MD - 20 years. In the past 70 years, there have been six full -time chairmen and eleven full-time members, and for many years they were assisted by physicians appointed ad -hoc to perform medical examination duties. It is particularly worth mentioning that, regardless of the very modest staffing, the number of the decisions iss ued constantly increased, oscillating between 2360 and 8790, which is undeniable proof of the great work organization, engagement and dedication of the entire staff. The civilian employees have also taken part in building the excellent position of the Regional Military Medical Board, including the independent clerk, Elżbieta Kozikowska, who deserves special credit as being a true legend of medical examination in Żary, remaining faithful to “her” board for 39 years. Throughout the 69 years stationed in Żary, the Regional Military Medical Board became an inherent part of the history of the town, and the fact that it celebrates its 70th anniversary in a new location, Żagań, is a source of some regret. The connection between the board and the capital of the Polish part of Lusatia is signified by the informal Memorial Badge containing the coat of arms of Żary.

268

References 1. Baranowski K. Krótki rys historyczny orzecznictwa wojskowo lekarskiego w dawnej Polsce [Short historical overview of military medical examination in Poland]. Mil. Phys., 1967; 8: 720 -725 2. Dąbrowski S. Z dziejów szpitalnictwa wojskowego [The history of military hospitals]. Mil. Phys., 1956; 12: 1280-1285 3. Papliński R. Organizacja szpitali polowych W ojska Polskiego w drugiej polowie XVIII w. [Organisation of field hospitals of the Polish Army in the second half of the 18th century]. Mil. Phys., 1961; 10: 985-987 4. Szymański P, W ilmowska-Pietruszyńska A., W ojskowe orzecznictwo lekarskie - rys historyczny. [The Military Medical Examination – A Historical Outline] Orzecznictwo Lekarskie 2008: 5 (2): 114-117 5. Baranowski K. Kryteria badania zdolności do służby wojskowej w II Rzeczypospolitej [Criteria for examining fitness for military service in the Second Polish Republic]. Mil. Phys., 1986; 1 -2: 106107 6. Dział Urzędowy. Komisje wojskowo -lekarskie dla zawodowych wojskowych. [Official Division. Military medical boards for professional soldiers]. Mil. Phys., 1924; 5 (8): 765 -766 7. Archive of the 105th Military Hospital with an Independent Public Health Care Clinic: KSG: p. 1 -69 8. Killar M, Zabłotniak R. Niektóre uwagi o zabezpieczeniu medycznym forsowania Nys y w 1945 r. [Certain remarks on medical protection while crossing the Lusatian Neisse in 1945] Lek. W ojsk., 1966; 3: 239-245 9. Płoński K. W Szeregach Służby Zdrowia 2 AW P [In the ranks of the Health Care of the 2nd Polish Army]. W arsaw, 1969: 51 -52 10. Central Military Archive (CAW ) in W arsaw: TAP 1573/75/276; TAP 1256/67/160; TAP 990/64/199 11. Military Archive in Oleśnica: Set 214, Garriso n Hospital in Żary, file No. 1417/5/51, 0810/21/56,12322/65/8 12. Jasiński J, Jędrzejczyk M, Marcinkowski J, et al. 60 lat orzecznictwa wojskowo-lekarskiego na Ziemi Żarskiej. [60 years of military medical examination in the Land of Żary] Żary 2005: 14 -21 13. Journal of Laws of the Republic of Poland, W arsaw, 12 September 2012, item 1013

MILITARY PHYSICIAN 3/2015

HISTORY OF MEDICINE AND THE MILITARY MEDICAL SERVICES

Lt. Col. Ludwik Tomasz Zieliński PhD (18881956) – the unusual life of a military internal specialist from Grodno Ppłk dr Ludwik Tomasz Zieliński (1888-1956) – nietypowy żywot wojskowego internisty z Grodna Krzysztof Kopociński, Zbigniew Kopociński, Czesław Jeśman Department of the History of Medicine, Pharmacy and Military Medicine of the Medical University in Łódź; head: Prof. Czesław Jeśman MD, PhD Abstract. This article presents a Polish military physician who was long bound to the town of Grodno. He was born in Poryck, on 1 January 1888, and in 1918 he graduated from the Saint Włodzimierz University in Kiev. During the Great War he served in the Russian Army before, in 1920, becoming a Polish soldier and taking part in the war against Russia in the same year. In the interwar period, he worked as the head of internal diseases department of the 3rd Regional Hospital in Grodno. He was a very popular and respected man among the patients, recognized in the whole town of Grodno. He often served as the commandant of the Military Seasonal Hospital in Druskininkai. He was one of very few doctors from the 3rd Regional Hospital in Grodno to survive World War II. Key words: physician, officer, military hospital, Grodno Streszczenie. W artykule przedstawiono sylwetkę polskiego lekarza wojskowego przez wiele lat związanego z Grodnem. Urodził się 1 stycznia 1888 roku w Porycku. W 1918 roku ukończył Uniwersytet św. Włodzimierza w Kijowie. W czasie I wojny światowej służył w armii rosyjskiej. W 1920 roku został polskim żołnierzem i wziął udział w wojnie przeciwko Rosji. W okresie międzywojennym pełnił funkcję starszego ordynatora oddziału chorób wewnętrznych w 3. Szpitalu Okręgowym w Grodnie. Był lubiany i ceniony przez pacjentów, znany w całym Grodnie. Wielokrotnie był komendantem Wojskowego Szpitala Sezonowego w Druskiennikach. Jako jeden z nielicznych lekarzy z 3. Szpitala Okręgowego przeżył II wojnę światową. Słowa kluczowe: lekarz, oficer, szpital wojskowy, Grodno

Delivered: 19.02.2015. Approved for print: 01/06/2015 No conflicts of interest were declared. Mil. Phys., 2015; 93 (3): 269-274 Copyright by Military Institute of Medicine

Lt. Col. Ludwik Tomasz Zieliński, PhD, was born on 2 January 1888 in Poryck, in the Russian partition of Poland. He attended a high school in Zhytomyr, where he passed his school graduation examination in 1904. Being interested in medicine, he decided to continue his education at the Faculty of Medicine of the University of Saint Vladimir in Kiev, where he received his medical diploma in 1918. His life, however, was not free from the problems and difficulties caused by the outbreak of World War I, helping to complicate his life plans. As a subject of the tsar, Zieliński was conscripted into the Russian army, where he initially served as a junior medical officer in the District Medical Office in Kiev. On 10 December 1914, he was assigned to a post of a junior medical officer on Ambulance Train no. 229, where he

worked until 15 December 1915. The doctor's last known post in the tsarist army was the position of Chief Medical Officer for the 9th Engineering Squadron [1]. After Poland regained its independence, he became part of the newly reborn Polish Army. This was a time of utmost importance for Poland and the Polish people: there was a constant struggle to establish the borders of this new nation, especially in the war with Soviet Russia and the raging, contagious and dangerous diseases that were wreaking havoc mostly in the Eastern Borderlands. All these factors contributed greatly to the Polish Army's demand for medical personnel, especially for physicians - in this respect the situation for the modern Polish Army is undoubtedly very similar.

Lt. col. Ludwik Tomasz Zieliński PhD (1888-1956) – an unusual life of a military internal specialist from Grodno

269

HISTORY OF MEDICINE AND THE MILITARY MEDICAL SERVICES

Figure 1. Capt. Ludwik Tomasz Zieliński PhD with his wife Maria, 1926 Rycina 1. Kpt. dr Ludwik Tomasz Zieliński z żoną Marią, 1926 rok

Dr. Zieliński was inducted into the Polish Army on 25 May 1920, during the most intense period of warfare on the Polish-Bolshevik front. Initially, he served as the medical director of field hospital no. 605 and then no. 905, where he was serving at the time of the Battle of W arsaw and the Niemen operation [1,2]. After the warfare had come to an end, on 1 May 1921 he was assigned to a post in the city where he was to spend a considerable part of his life, becoming a symbol of the military medical service of this garrison, located in a former residence of Polish kings: Grodno on the Niemen. He lived not far from his place of work, at 12 Zamkowa Street. In the beginning he was a junior medical officer for the 3rd Reserve Medical Company in Grodno, but later he became the medical director of the 3rd Regional Hospital. He worked at this hospital throughout the entire interwar period, with the exception of a short period between 15 March and 19 September 1924 when he was the commandant of the Regional Hospital in Lida. After 270

returning from Lida, he became the senior medical director of the department of internal medicine at the 3rd Regional Hospital in Grodno, which was located in the New Castle, the former residence of King Stanisław August Poniatowski (and where this unfortunate king of Poland signed his famous act of abdication), and which had 80-100 hospital beds [16]. The main health problems of the patients under the care of Dr. Zieliński and his subordinates were diseases of the respiratory tract (most frequently fatal tuberculosis), diseases of the digestive and vascular systems, as well as metabolic disorders. The subdepartment of infectious diseases, which initially operated within the department of internal diseases, was later separated and became an independent department. What is noteworthy is that antibiotics had not yet been invented and the doctors that had contact with patients afflicted with infectious diseases risked their own health and life; although this did not prevent them from performing their duties diligently and with dedication. Undoubtedly one such doctor was Lt. Col. L. T. Zieliński PhD, who saw while working in Grodno, as well as in the entire Eastern Borderlands, a massive expansion of often fatal infectious diseases like typhoid, typhus, dysentery, smallpox, etc. The death of one of Dr. Zieliński's colleagues, an assistant physician, Lt. Bolesław Eborowicz, who died in a typhus epidemic while devotedly helping his patients, bears testimony to the gravity of the danger that the doctors were exposed to at that time [1,2]. All these difficult moments strengthened the senior medical director of the 3rd Regional Hospital and equipped him with the necessary experience to l ead one of the biggest departments of the hospital. It had considerably contributed to the good opinion of this military facility in Grodno, which was highly popular among its patients, despite its proximity to the clinics of the Stefan Batory University in Vilnius. Dr. Zieliński's organizational skills were the reason why his department functioned efficiently like a Swiss watch, even during the short absences of the senior medical director. These absences were due to the fact that the Medical Service Offic e of the 3rd Corps District decided to utilize the knowledge, experience and the organizational skills of Dr. Zieliński, who was a major at that time, by appointing him commandant of the Seasonal Hospital in Druskininkai – a branch of the 3rd Regional Hospital. Druskininkai had long been known as a health resort, and the first scientific research of the local mineral waters was commissioned by King Stanisław August Poniatowski. It was also Marshal Józef Piłsudski's favorite leisure place, which most probably was a contributing factor in the decision to establish a seasonal branch of the 3rd Regional Hospital there in 1926. Maj./Lt. col. L. T. Zieliński PhD served as the commandant multiple times: 1927, 1928, 1931, 1934, 1936 and 1937.

MILITARY PHYSICIAN 3/2015

HISTORY OF MEDICINE AND THE MILITARY MEDICAL SERVICES

Figure 2. Staff and patients of the Military Seasonal Hospital in Druskininkai, 1936, Maj. Ludwik Tomasz Zieliński PhD is seated in the center Rycina 2. Kadra i kuracjusze Wojskowego Szpitala Sezonowego w Druskiennikach, 1936 rok, w środku siedzi major dr Ludwik Tomasz Zieliński

As an excellent internal specialist and an experienced individual, he was able to provide his patients with optimal conditions for treatment and recuperation. This is evident from the constant shortage of beds for patients at the branch of the 3rd Regional Hospital in Druskininkai, although the number of hospital beds had increased from 40 in 1926 to 200 in 1938. The work of L. T. Zieliński PhD was highly 1 valued by Brig. Gen. Józef Olszyna-Wilczyński , Commander of the 3rd Corps District at that time, who wrote the following in his official opinion: "... He demonstrated remarkable organizational skills also as the commandant of the Seasonal Military Hospital in Druskininkai..." It is noteworthy that his versatility was appreciated by his military superiors as well, which, unfortunately, is not particularly commonplace. This was reflected in his promotions to higher military ranks – in the 3rd Regional Hospital, Dr. Zieliński was promoted from captain to lieutenant colonel. He was decorated with the Medal of the Decade of Regained Independence (Polish: Medal Dziesięciolecia Odzyskanej Niepodległości), among others [1,5,6]. Despite his hard work at the hospital, he also found time for academic research and wrote a paper entitled "Pleural empyema on the basis of materials form military regional hospitals from the years 1932-1936," co-authored by R. Puszkiewicz, PhD, and presented at the 3rd Academic Convention of Medical Service Officers [7]. The crowning 1

Brig. Gen. Józef Konstanty Olszyna-Wilczyński (1890-1939), the last commander of the 3rd Corps District, killed by the Russians on 22 September 1939 near the town of Sapotskin.

achievement of the military and medical career of Lt. Col. L. T. Zieliński PhD was his appointment as the commandant of the Garrison Hospital in Rivne on 3 April 1938. However, he did not hold this post long because the German and Soviet invasion of Poland in 1939 ended perhaps the best period in the life of this doctor from Grodno. During the German occupation, he was a member of the staff of the Ujazdów Hospital in Warsaw (the legendary "Rzeczpospolita Ujazdowska") and a soldier of the Home Army. After the outbreak of the Warsaw Uprising, he worked at the Health Authorities Office in Subdistrict V in Mokotów and served as the commandant of the field hospital at 57 Morszyńska Street [1,2,4]. He survived the war and, after the warfare had come to an end, he worked at the Tuberculosis Sanatorium in Kowanówko near Oborniki Wielkopolskie (1948-1949), and later at the hospital in Tuszyn. He died on 1 January 1956 and was buried at Górczyński Cemetery, section IV P, row 2, plot 18. He was married twice and the family medical tradition was continued by his daughter Irena (1926-2013) who was a pediatrician [4,5]. Being one of the few doctors from the 3rd Regional Hospital in Grodno not to be killed by the NKVD or Gestapo makes the life of Dr. Zieliński unusual in comparison to other military doctors from the city of Stefan Batory. His survival might have been due to the fact that more than a year before the outbreak of World War II he left Grodno, a city that was to fight so bravely against Soviet aggression in 1939. If not, then he would probably have suffered the same fate as most of his colleagues, who failed to survive the Second World War. Pursuant to the decision made by the participants of the

Lt. col. Ludwik Tomasz Zieliński PhD (1888-1956) – an unusual life of a military internal specialist from Grodno

271

HISTORY OF MEDICINE AND THE MILITARY MEDICAL SERVICES

Yalta Conference, his 3rd Regional Hospital in Grodno ceased to exist. Since most of the staff were dead, only the fortunate few who managed to survive could recount the story of the hospital.

References 1. 2.

4. 5. 6. 7.

272

CAW: AP-8681 Jeśman Cz. Choroby zakaźne w Wojsku Polskim w latach 1918-1939 jako zagadnienie epidemiologiczne i profilaktyczno-lecznicze. [Infectious diseases in the Polish Army in the years 1918-1939 as an epidemiological, prophylactic and medicinal issue] Habilitation thesis. Łódź 1997 Lista starszeństwa oficerów zawodowych korpusu sanitarnego. [The list of the seniority of career officers of the medical corps] Ministerstwo Spraw Wojskowych, Departament Zdrowia, Warsaw 1934: 13 The account of R. Augustowska from 25 May 2004. The account of T. Zajdel from 15 May 2004. Rocznik oficerski 1924. Warsaw 1924: 1010 Zieliński L, Puszkiewicz R. Ropne zapalenie opłucnej na podstawie materiału wojskowych szpitali okręgowych za lata 1932-1936 [Pleural empyema on the basis of materials from military regional hospitals from the years 1932-1936], Mil. Phys., 1936, vol. 27, no. 11, 664-669

MILITARY PHYSICIAN 3/2015