Annual Reports of Education, Health and Sport 9781329893009

Radomska Szkoła Wyższa w Radomiu Radom University in Radom

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Iwona Czerwińska Pawluk Radosław Muszkieta Hanna Żukowska Wiesława Pilewska Mariusz Klimczyk Walery Zukow

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Open Access

Radom 2013 Radomska Szkoła Wyższa w Radomiu Radom University in Radom

Annual Reports of Education, Health and Sport 9781329893009

Edited by

Iwona Czerwińska Pawluk Radosław Muszkieta Hanna Żukowska Wiesława Pilewska Mariusz Klimczyk Walery Zukow

Open Access

Radom 2013

1 Scientific Council prof. zw dr hab. geo. Z. Babiński (Poland), prof. zw dr hab. med. T. Chumachenko (Ukraine), prof. zw. dr hab. techn. R. Cichon (Poland), prof. zw. dr hab med. N. Dragomiretskaya (Ukraine), prof. zw. dr hab. med. V Ezhov (Ukraine), prof. zw. dr hab. geo. J. Falkowski (Poland), prof. zw dr hab. med. A. Gozhenko (Ukraine), prof. zw dr hab. geo. M. Grodzynskyi (Ukraine), prof. zw. dr hab. I. Grygus (Ukraine), prof. zw. dr hab med. A. Gudyma (Ukraine), prof, zw dr hab. med. S. Gulyar (Ukraine), prof. zw dr hab. med. W. Hagner (Poland), prof. zw dr hab. med. I. Karwat (Poland), prof. zw. dr hab. med. M. Kyryliuk (Ukraine), prof. zw. dr hab. med. Y Limansky (Ukraine), prof. zw dr hab. geo. A. Melnik (Ukraine), prof. zw. dr hab. med. V. Mizin (Ukraine), prof. zw. dr hab. med. B. Nasibullin (Ukraine), prof. zw. dr hab. geo. O. Obodovskyi (Ukraine), prof. zw. dr hab. med. I. Samosiuk (Ukraine), prof. zw. dr hab. med. L. Shafran (Ukraine), prof. zw dr hab. med. I. Shmakova (Ukraine), prof. zw dr hab. med.A. Svirskiy (Ukraine), prof. zw. dr hab. O. Sokolov (Ukraine), prof. zw. dr hab. med. V Stebliuk (Ukraine), prof. zw. dr hab. S. Yermakov, (Ukraine), prof. dr hab. med. A. Avramenko, doc. PaedDr. Elena Bendikova, PhD. (Slovakia), prof. dr hab. K. Buśko (Poland), dr hab. med. E. Gozhenko (Ukraine), prof. dr hab. H. Knapik (Poland), dr hab. R Muszkieta (Poland), prof. dr hab. med. W. Myśliński (Poland), prof. dr hab. M. Napierała (Poland), prof. dr hab. M. Pastuszko (Poland), prof. dr hab. K. Prusik (Poland), prof. dr hab. M. Zasada (Poland), dr med. L. Butskaia (Ukraine), dr I. M. Batyk (Poland), dr M. Cieślicka (Poland), dr med. M. Charzynska-Gula (Poland), doc. dr n. med. V. Cherno (Ukraine), dr med. K. Cywinski (Poland), dr med. I. Czerwinska Pawluk (Poland), dr biol. S. Dolomatov (Ukraine), dr med. M. Dzierzanowski (Poland), dr med. M. Hagner-Derengowska (Poland), dr med. B. Jędrzejewska (Poland), dr med. U. Kazmierczak (Poland), dr med. K Kiczuk (Poland), dr Z. Kwaśnik (Poland), dr med. T. Madej (Poland), dr med. E. Mikolajewska (Poland), dr D. Mikolajewski (Poland), dr med. B. Muszynska (Poland), dr med. A. Nalazek (Poland), dr med. N. Novikov (Ukraine), dr med. K. Nowacka (Poland), dr med. G. Polak (Poland), dr med. P Prokopczyk (Poland), dr med. A. Radziminska (Poland), dr med. L. Sierpinska (Poland), dr Daves Sinch (Republic of India), doc. dr A. Skaliy (Ukraine), dr T. Skaliy (Ukraine), dr B. Stankiewicz (Poland), dr med. E. Trela (Poland) Editorial Board Stefan Adamcak (Slovakia), Pavol Bartik (Slovakia), Elena BendAkova (Czech Republic), Janusz Bielski (Poland), Krzysztof Buśko (Poland), Mirosława Cieślicka (Poland), Jerzy Eksterowicz (Poland), Włodzimierz Erdmann (Poland), Tomasz Frołowicz (Poland), Attila Gilanyi (Hungary), Igcr Grygus (Ukraine), Halina Guła-Kubiszewska (Poland), Paweł Izdebski (Poland), Sergii Iermakov (Ukraine), Tetyana Iermakova (Ukraine), Jana Jurikova (Czech Republic), Vlastimila Karaskova (Czech Republic), Jacek Klawe (Poland), Mariusz Klimczyk (Poland), Alicja Kostencka (Poland), Frantisek Langer (Czech Republic), Eligiusz Madejski (Poland), Jiri Michal (Slovakia), Ludmila Miklankova (Czech Republic), Emila Mikołajewska (Poland), Viktor Mishchenko (Ukraine), Stanisław Mocek (Poland), Mirosław Mrozkowiak (Poland), Radosław Muszkieta (Poland), Anna Nalazek (Poland), Marek Napierała (Poland), Jerzy Nowocień (Poland), Piotr Oleśniewicz (Poland), Władysław Pańczyk (Poland), Wiesława Pilewska (Poland), Miroslava Pridalova (Czech Republic), Krzysztof Prusik (Poland), Krzysztof Sas-Nowosielski (Poland), Aleksandr Skaliy (Ukraine), Tetyana Skaliy (Ukraine), Ewa Sokołowska (Poland), Błażej Stankiewicz (Poland), Robert Stępniak (Poland), Aleksander Stuła (Poland), Naoki Suzuki (Japan), Mirosława Szark-Eckardt (Poland), Maciej Świątkowski (Poland), Hrychoriy Tereschuk (Ukraine), Hryhoriy Vasjanovicz (Ukraine), Mariusz Zasada (Poland), Tetyana Zavhorodnya (Ukraine), Walery Żukow (Poland), Hanna Żukowska (Poland) Advisory Board Zygmunt Babiński (Poland), Yiriy Briskin (Ukraine), Laszló Csernoch (Hungary), Kazimierz Denek (Poland), Miroslav Dutchak (Ukraine), Karol Gorner (Slovakia), Kazimierz Kochanowicz (Poland), Jerzy Kosiewicz (Poland), Stanisław Kowalik (Poland), Tadeusz Maszczak (Poland), Mikolaj Nosko (Ukraine), Jerzy Pośpiech (Poland), Eugeniusz Prystupa (Ukraine), Robert Szeklicki (Poland), Jitka Ulrichova (Czech Republic). R e v ie w e rs : prof. zw. dr hab. geo. Z. Babiński (Poland), doc. PaedDr. Elena Bendikova, PhD. (Slovakia), prof. zw. dr hab. med. T. Chumachenko (Ukraine), prof. zw. dr hab. techn. R Cichon (Poland), prof. zw. dr hab. med. N. Dragomiretskaya (Ukraine), prof. zw. dr hab. med. V Ezhov (Ukraine), prof. zw. dr hab. geo. J. Falkowski (Poland), prof. zw dr hab. med. A. Gozhenko (Ukraine), prof. zw dr hab. geo. M. Grodzynskyi (Ukraine), prof. zw. I. Grygus (Ukraine), prof. zw A. Gudyma (Ukraine), prof. zw dr hab. med. S. Gulyar (Ukraine), prof. zw dr hab. med. W. Hagner (Poland), prof. zw. dr hab. med. I. Karwat (Poland), prof. zw dr hab. med. M. Kyryliuk (Ukraine), prof. zw. dr hab. med. Y Limansky (Ukraine), prof. zw dr hab. geo. A. Melnik (Ukraine), prof. zw. dr hab. med. V Mizin (Ukraine), prof. zw dr hab. med. B. Nasibullin (Ukraine), prof. zw. dr hab. geo. O. Obodovskyi (Ukraine), prof. zw. dr hab. med. I. Samosiuk (Ukraine), prof. zw dr hab. med. L. Shafran (Ukraine), prof. zw dr hab. med. I. Shmakova (Ukraine), prof. zw. dr hab. O. Sokolov (Ukraine), prof. zw dr hab. med. V Stebliuk (Ukraine), prof. zw. dr hab. S. Yermakov, (Ukraine), prof. dr hab. med. A. Avramenko, prof. dr hab. K. Buśko (Poland), dr hab. med. E. Gozhenko (Ukraine), prof. dr hab. H Knapik (Poland), prof. zw. dr hab. geo. A. Melnik (Ukraine), prof. dr hab. R. Muszkieta (Poland), prof. dr hab. med. W. Myśliński (Poland), prof. dr hab. M. Napierała (Poland), prof. dr hab. M. Pastuszko (Poland), prof. dr hab. K. Prusik (Poland), prof. dr hab. M. Zasada (Poland), prof. dr hab. med. W. Zukow (Poland), dr I. M. Batyk (Poland), dr med. L. Butskaia (Ukraine), doc. dr n. med. V Cherno (Ukraine), dr M. Cieślicka (Poland), dr med. I. Czerwinska Pawluk (Poland), dr biol. S. Dolomatov (Ukraine), dr med. N. Novikov (Ukraine), doc. dr A. Skaliy (Ukraine), dr T. Skaliy (Ukraine), dr B. Stankiewicz (Poland), dr med. E. Trela (Poland) E d i t o r s - i n - C h i e f Anatoliy Gozhenko Walery Zukow C o - e d i t o r s Radosław Muszkieta Marek Napierała A s s o c i a t e E d i t o r s Iwona Czerwinska Pawluk Mariusz Klimczyk Mirosława Cieślicka A d a m S zu lc S e c r e t a r y Bartłomiej Niespodziński

© The Author(s) 2013. This articles is published with Open Access at Annual Reports of Education, Health and Sport of Radomska Szkoła Wyższa w Radomiu, Poska, Radom University in Radom, Poland Open Access This articles is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.

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2 Content:

Introduction ...... 5

Babkina N. M., Chebotareva A. M., Shpak S.V. Количественное определение эмфиземы легких у пациентов с ВИЧ-инфекцией по данным компьютерно-томографической денситометрии: клинико-патофизиологические аспекты = Quantitative determination of lung emphysema in patients with HIV-infection according to the computer-tomography densitometry: clinical and pathophysiological aspects. [in] Czerwińska Pawluk Iwona Ed., Muszkieta Radosław Ed., Żukowska Hanna Ed., Pilewska Wiesława Ed., Klimczyk Mariusz Ed., Zukow Walery Ed. Annual Reports of Education, Health and Sport 9781329893009. RSW. Radom. 2013. 7-22. ISBN 9781329893009. © The Author(s) 2013. This articles is published with Open Access at Annual Reports of Education, Health and Sport. RSW. Radom. Poland.

Gozhenko AI, Gorobets OP, Goydyk VS, Mikhalchuk VN, Shukhtin VV, Fateh GP, Fateh H, Zukow W. Characteristic of anemia in patients with AIDS = Характеристика анемии у больных СПИДом. [in] Czerwińska Pawluk Iwona Ed., Muszkieta Radosław Ed., Żukowska Hanna Ed., Pilewska Wiesława Ed., Klimczyk Mariusz Ed., Zukow Walery Ed. Annual Reports of Education, Health and Sport 9781329893009. RSW. Radom. 2013. 23-34. ISBN 9781329893009. © The Author(s) 2013. This articles is published with Open Access at Annual Reports of Education, Health and Sport. RSW. Radom. Poland.

Samosiuk Ivan, Flomin Yuriy, Samosiuk Natalia, Zukow Walery. Cognitive violations of postinsult patients and modern methods of their treatment. [in] Czerwińska Pawluk Iwona Ed., Muszkieta Radosław Ed., Żukowska Hanna Ed., Pilewska Wiesława Ed., Klimczyk Mariusz Ed., Zukow Walery Ed. Annual Reports of Education, Health and Sport 9781329893009. RSW. Radom. 2013. 35-50. ISBN 9781329893009. © The Author(s) 2013. This articles is published with Open Access at Annual Reports of Education, Health and Sport. RSW. Radom. Poland.

Eksterowicz Jerzy, Napierała Marek, Zukow Walery. Size of the sex dimorphism of students from direction physical education of Kazimierz Wielki University in Bydgoszcz = Wielkość dymorfizmu płciowego studentów z kierunku wychowanie fizyczne Uniwersytetu Kazimierza Wielkiego w Bydgoszczy. [in] Czerwińska Pawluk Iwona Ed., Muszkieta Radosław Ed., Żukowska Hanna Ed., Pilewska Wiesława Ed., Klimczyk Mariusz Ed., Zukow Walery Ed. Annual Reports of Education, Health and Sport 9781329893009. RSW. Radom. 2013. 51-67. ISBN 9781329893009. © The Author(s) 2013. This articles is published with Open Access at Annual Reports of Education, Health and Sport. RSW. Radom. Poland.

Dolomatov Sergey, Zukow Walery, Hagner-Derengowska Magdalena, Kozestanska Monika, Iwona Jaworska, Nalazek Anna. Toxic and Physiological Aspects of Metabolism of Nitrites and Nitrates in the Fish Organism. [in] Czerwińska Pawluk Iwona Ed., Muszkieta Radosław Ed., Żukowska Hanna Ed., Pilewska Wiesława Ed., Klimczyk Mariusz Ed., Zukow Walery Ed. Annual Reports of Education, Health and Sport 9781329893009. RSW. Radom. 2013. 68-91. ISBN 9781329893009. © The Author(s) 2013. This articles is published with Open Access at Annual Reports of Education, Health and Sport. RSW. Radom. Poland.

Dolomatov Sergey, Zukow Walery, Novikov Nikolay, Hagner-Derengowska Magdalena, Jaworska Iwona, Kozestanska Monika, Napierała Marek, Muszkieta Radosław, Nalazek Anna, Trela Ewa, Eksterowicz Jerzy. Features of physiological mechanisms control fluid and electrolyte balance in fishes. [in] Czerwińska Pawluk Iwona Ed., Muszkieta Radosław Ed., Żukowska Hanna Ed., Pilewska Wiesława Ed., Klimczyk Mariusz Ed., Zukow Walery Ed. Annual Reports of Education, Health and Sport 9781329893009. RSW. Radom. 2013. 92-114. ISBN 9781329893009. © The Author(s) 2013. This articles is published with Open Access at Annual Reports of Education, Health and Sport. RSW. Radom. Poland.

Banaszak-Piechowska Agnieszka, Mreła Aleksandra, Sokołov Oleksandr. Expert systems - the help for vocational guidance of medical physics graduates. [in] Czerwińska Pawluk Iwona Ed., Muszkieta Radosław Ed., Żukowska Hanna Ed., Pilewska Wiesława Ed., Klimczyk Mariusz Ed., Zukow Walery Ed. Annual Reports of Education, Health and Sport 9781329893009. RSW. Radom. 2013. 115-129. ISBN 9781329893009. © The Author(s) 2013. This articles is published with Open Access at Annual Reports of Education, Health and Sport. RSW. Radom. Poland.

Hagner-Derengowska Magdalena, Trela Ewa, Kochański Bartosz, Kałużny Krystian, Konecki Kajetan, Gryckiewicz Szymon, Zukow Walery. Prevention of ACL injuries in skiing = Prewencja uszkodzeń ACL w narciarstwie. [in] Czerwińska Pawluk Iwona Ed., Muszkieta Radosław Ed., Żukowska Hanna Ed., Pilewska Wiesława Ed., Klimczyk Mariusz Ed., Zukow Walery Ed. Annual Reports of Education, Health and Sport 9781329893009. RSW. Radom. 2013. 120-141. ISBN 9781329893009. © The Author(s) 2013. This articles is published with Open Access at Annual Reports of Education, Health and Sport. RSW. Radom. Poland.

Gozhenko AI, Moskalenko AM, Zukow W. Renal complications in cancer patients in remote period after cisplatin chemotherapy = Почечные осложнения у онкобольных в отдалённом периоде после химиотерапии цисплатином. [in] Czerwińska Pawluk Iwona Ed., Muszkieta Radosław Ed., Żukowska Hanna Ed., Pilewska Wiesława Ed., Klimczyk Mariusz Ed., Zukow Walery Ed. Annual Reports of Education, Health and Sport 9781329893009. RSW. Radom. 2013. 142-148. ISBN 9781329893009. © The Author(s) 2013. This articles is published with Open Access at Annual Reports of Education, Health and Sport. RSW. Radom. Poland.

3 Butskaya L.V. Dynamics parameters of the functional state of physical fitness and morbidity in primary school children under the influence of health programs in swimming = Динамика показателей функционального состояния физической подготовленности и заболеваемости детей младшего школьного возраста под влиянием оздоровительных программ по плаванию. [in] Czerwińska Pawluk Iwona Ed., Muszkieta Radosław Ed., Żukowska Hanna Ed., Pilewska Wiesława Ed., Klimczyk Mariusz Ed., Zukow Walery Ed. Annual Reports of Education, Health and Sport 9781329893009. RSW. Radom. 2013. 149-173. ISBN 9781329893009. © The Author(s) 2013. This articles is published with Open Access at Annual Reports of Education, Health and Sport. RSW. Radom. Poland.

Yezhov VV, Subbotin FA. Оценка болевых и сенсорных пороговых ответов на электростимуляцию в оценке результативности лечения пациентов с хронической миофасциальной цервикалгией = Estimation of pain and sensory threshold responses to electrical stimulation in the measurement of the effectiveness of treatment of patients with chronic myofascial cervicalgia. [in] Czerwińska Pawluk Iwona Ed., Muszkieta Radosław Ed., Żukowska Hanna Ed., Pilewska Wiesława Ed., Klimczyk Mariusz Ed., Zukow Walery Ed. Annual Reports of Education, Health and Sport 9781329893009. RSW. Radom. 2013. 174-197. ISBN 9781329893009. © The Author(s) 2013. This articles is published with Open Access at Annual Reports of Education, Health and Sport. RSW. Radom. Poland.

Kolesnik K. A. The stomatologic status in children with maxillodental anomalies and concomitant diseases of the thyroid gland. [in] Czerwińska Pawluk Iwona Ed., Muszkieta Radosław Ed., Żukowska Hanna Ed., Pilewska Wiesława Ed., Klimczyk Mariusz Ed., Zukow Walery Ed. Annual Reports of Education, Health and Sport 9781329893009. RSW. Radom. 2013. 198-207. ISBN 9781329893009. © The Author(s) 2013. This articles is published with Open Access at Annual Reports of Education, Health and Sport. RSW. Radom. Poland.

Yezhov VV. Professor Aleksandr Szczerbak Uniwersytet Warszawski 1893-1911. Zaproszenie na konferencje fizjoterapia, balneologia, medycyna uzdrowiskowa Jalta Krym 10-11.10.2013 r. [in] CZerwińska Pawluk Iwona Ed., Muszkieta Radosław Ed., Żukowska Hanna Ed., Pilewska Wiesława Ed., Klimczyk Mariusz Ed., Zukow Walery Ed. Annual Reports of Education, Health and Sport 9781329893009. RSW. Radom. 2013. 208-213. ISBN 9781329893009. © The Author(s) 2013. This articles is published with Open Access at Annual Reports of Education, Health and Sport. RSW. Radom. Poland.

Korshnyak V.A., Gozhenko E.A., Nasibullin B.A., Zmiyevskiy A.V., Zukow W. Comparative evaluation of the effects of phyto-therapeutic and medical treatment factors on the cerebral hemodynamics in patients with syndrome of vegetative dystonia due to radiative forcing = Сравнительная оценка влияния фитотерапевтических и медикаментозных лечебных факторов на состояние мозговой гемодинамики у лиц с синдромом вегетативной дистонии вследствие радиационного воздействия. [in] Czerwińska Pawluk Iwona Ed., Muszkieta Radosław Ed., Żukowska Hanna Ed., Pilewska Wiesława Ed., Klimczyk Mariusz Ed., Zukow Walery Ed. Annual Reports of Education, Health and Sport 9781329893009. RSW. Radom. 2013. 214-233. ISBN 9781329893009. © The Author(s) 2013. This articles is published with Open Access at Annual Reports of Education, Health and Sport. RSW. Radom. Poland.

4 Introduction

We hope that a varied program of the Annual Reports of Education, Health and Sport will answer your expectations. We believe that the Annual Reports of Education, Health and

Sport will contribute to raising the knowledge, skills and abilities of doctors, therapists, physiotherapists, nurses, psychologists, biologists, researchers, practitioners and health workers interested in rehabilitation, physiotherapy, tourism and recreation.

Annual Reports of Education, Health and Sport, corresponding to the modern challenges of global health specialists collect articles from those areas of the leading centers of renowned foreign and domestic. Many of them present state of art in their field. This will be particularly valuable for young doctors in the specialization, and students.

Welcome to familiarize yourself with this issue all relevant hazards and health, life and safety at work in tourism, recreation, rehabilitation, physiotherapy, nursing organization to work safely and missions in these conditions, the influence of environmental conditions on public health.

Authors from abroad and the country will present an overview of contemporary challenges and solutions in these areas. The issue concerns the text of the wider work for human health, tourism, recreation, physiotherapy, nursing, wellness and rehabilitation, including the economics of health care.

5 © The Author(s) 2013. This articles is published with Open Access at Annual Reports of Education, Health and Sport. RSW. Radom. Poland Open Access This articles is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.

6 Journal of Health Sciences (J o H Ss) 2013; 3(1): 7-22 The journal has had 4 points in Ministry of Science and Higher Education of Poland parametric evaluation. List B item 683.

UDC 616.24-006.6:615.849]616-973.756.8(476)

Количественное определение эмфиземы легких у пациентов с ВИЧ- инфекцией по данным компьютерно-томографической денситометрии: клинико-патофизиологические аспекты Национальная медицинская академия последипломного образования имени П.Л. Шупика ООО «Ланжерон» Бабкина Т.М., Чеботарева А.М., Шпак С.В.

Эмфизема легких (ЭЛ) является конечным этапом развития многих заболеваний дыхательной системы, ведущих к прогрессирующей дыхательной недостаточности [1]. Прижизненная диагностика и определение степени выраженности ЭЛ позволяет оценить глубину патоморфологических и патофизиологических изменений легочной ткани, степень необратимости изменений в легких. Наиболее распространенной методикой прижизненной оценки эмфиземы является измерение рентгеновской плотности легочной ткани - денситометрия. Обзор отечественной и зарубежной литературы свидетельствует о пристальном внимании к денситометрии как методу, позволяющему освободиться от субъективизма при анализе рентгеновских изображений, количественно характеризовать патологические изменения органов грудной клетки [2, 3, 4]. Таким образом, актуальным является определение прикладного значения метода в оценке патоморфологических изменений легких на фоне различных заболеваний, в частности ВИЧ-инфекции, учитывая данные литературы о более частой встречаемости ЭЛ у этих больных. Так, известно, что риск эмфиземы у

7 ВИЧ-инфицированных курильщиков в несколько раз выше, в сравнении с курильщиками без ВИЧ-инфекции [5, 6 ]. ЭЛ хоть и не относится к СПИД- индикаторным заболеваниям, однако является состоянием, ухудшающим

прогноз и качество жизни пациента [1, 5, 6]. В оценке взаимосвязи ЭЛ с наличием ВИЧ-инфекции необходим комплексный подход, учитывая факт мультифакториальности в возникновении и развитии эмфиземы легких — доказана роль генетических факторов, иммуно- гуморальных особенностей гомеостаза [1] и т.п. Перспективным и практически легко осуществимым в решении данной задачи является учет выраженности лимфоаденопатии у больных с ВИЧ-инфекцией. С одной стороны, при рутинном компьютерно-томографическом (КТ) исследовании органов грудной клетки аксиллярные и медиастинальные лимфоузлы (ЛУ) хорошо визуализируются, их КТ-морфометрическая оценка достаточно точна и воспроизводима [2, 3], с другой стороны - лимфоаденопатия является одним из основных диагностических критериев синдрома приобретенного иммунодефицита человека, отражает активность процесса и степень патофизиологических расстройств на фоне заболевания [7, 8]. Цель работы: изучение клинико-патофизиологического значения количественной оценки эмфиземы легких у ВИЧ-инфицированных больных путем изучения взаимосвязи данных КТ-денситометрии легочной ткани с возрастом, полом, состоянием аксиллярных и медиастинальных лимфоузлов. Материалы и методы На протяжении 2010 - 2012 гг. обследовано 80 ВИЧ-инфицированных пациентов, среди которых мужчин было 36 (45%), женщин - 44 (55%). Средний возраст больных мужчин - 36,1±3,9 года, женщин - 36,4±7,1 года. Лабораторная верификация диагноза ВИЧ-инфекции выполнена на базе сертифицированной лаборатории Центральной иммуно-вирусологической лаборатории с диагностики СПИДа Госсанэпидслужбы Одесской области. Диагноз верифицирован путем обнаружения антител к ВИЧ в сыворотке пациента 8 методом ИФА, двукратно. Учитывались антитела к диагностическим белкам ВИЧ-1, а именно к гликопротеидам — структурным белкам оболочки гена (env) - gp160, gp120, gp41; ядра (gag) - p17, p24, p55. Положительным результатом являлось обнаружение антител к каким-либо двум гликопротеидам ВИЧ. Необходимым условием для включения пациентов в исследование было также отсутствие других СПИД индикаторных заболеваний. Отсутствие активной туберкулёзной инфекции верифицировалось общеклиническими методами и КТ органов грудной клетки. У всех пациентов посредством микроскопического исследования мазка слюны исключено наличие пневмоцистной, кандидозной, аспергиллезной и криптококковой инфекции. Контрольную группу составили 30 практически здоровых мужчин (n=15) и женщин (n=15), средний возраст которых составил соответственно 39,1±10,2 года, и 42,4±10,6 года. По результатам КТ исследования органов грудной клетки лиц КГ — патологических изменений не выявлено. КТ органов грудной клетки проведена с использованием 16-срезового томографа Phillips Mx8000 16 IDT (Филлипс, Голландия). Параметры сканирования: коллимация - 16x1.5 мм; толщина томографического слоя - 5 мм; инкремент реконструкции - 2,5 мм; время ротации рентгеновской трубки - 0,75 с; питч (отношение шаг стола/коллимация среза) - 1; наклон гентри - 0; матрица реконструкции изображений - 5122; разрешение - стандартное; фильтр - С; напряжение на рентгеновской трубке - 120 кВ; сила тока на рентгеновской трубке соответствовала параметру экспозиции 120 мАс/слайс; среднее произведение поглощенной дозы на длину исследуемой области (DLP) - 290 mGy - cm. Положение пациента - лежа на спине, с запрокинутыми за голову руками. Сканирование исследуемой области производили на фоне глубокого вдоха. Направление сканирования - каудо-краниальное. Компьютерная обработка полученных сканов проводилась на рабочей станции Extended Brilliance™ Workspace Release 2.1, Copyright 1998 - 2004, CT Mx8000 IDT, Version 3.2. Использовалась программа постпроцессорной 9 обработки и денситометрического анализа КТ — сканов «Lung Emphysema», посредством которой производилось построение и анализ гистограмм рентгеновской плотности легочной ткани. Плотность легочной ткани определялась в единицах Хаунсфилда. Рассчитывались среднее значение (Mean) и стандартное отклонение (SD) оптической плотности легочной ткани обоих легких (Total Lung). Определялся общий объем (Ул) легочной ткани обоих легких, а также объем эмфизематозно измененной легочной ткани при пороговых значениях плотности вокселей легочной ткани ниже - 910, Уэ(-910) и - 950, Уэ(-950). Удельный вес эмфиземы (Ro(-910) и Ro(-950)) рассчитывался как отношение объёмов эмфизематозно измененной легочной ткани при разных пороговых значениях плотности к общему объёму обоих легких. Рис. 1, 2 Пример результатов постпроцессорной обработки КТ-сканов представлен на рис. 1 и 2 . Для оценки состояния лимфатических узлов (ЛУ) измеряли длину (ДЛУ), ширину (ШЛУ) и толщину коркового слоя (ТЛУ) максимальных размеров аксиллярных и медиастинальных ЛУ. Определяли также отношение ТЛУ к ДЛУ (Т/ДЛУ). Морфометрические характеристики максимальных размеров подмышечных лимфоузлов слева и справа усредняли. Учитывались усредненные значения. Статистическую обработку данных проводили с помощью непараметрических статистических методов, в частности использован двухвыборочный W-критерий Уилкоксона, Н-критерий Краскелла-Уоллиса, а также коэффициент сопряженности качественных признаков СП Пирсона [9, 10]. Параметрические методы не использовались в связи с редкой встречаемостью нормального закона распределения в анализируемых вариационных рядах. Достоверными считали полученные результаты при вероятности альтернативной гипотезы р < 0,05. Результаты и их обсуждение 10 Табл. 1 Значения показателей эмфиземы легких у пациентов контрольной и основной групп представлены в табл. 1. Важно отметить, что в исследуемом возрастном диапазоне больных ВИЧ-инфекцией и здоровых лиц связи возраста с показателями эмфиземы не получено, однако, как уже было указано выше, пациенты пожилого и старческого возраста в исследование не включены. Половые различия достоверны (р<0,001) у лиц контрольной и опытной групп для объёма лёгких. Показатели эмфиземы Уэ(-910) и Уэ(-950) у больных женщин ОГ оказались достоверно ниже в сравнении с таковыми среди больных мужчин (р<0,05), а также среди лиц КГ. Последняя закономерность, возможно, обусловлена различным соотношением курящих женщин и мужчин среди больных, что в работе не проверялось. Не исключены и другие факторы, в частности случайное сочетание и разнородность больных в отношении иммунного статуса, длительности заболевания, а также генетических особенностей, что требует дополнительного исследования. Остальные показатели эмфиземы достоверно не различались между собой. Полученные данные противоречат литературным данным относительно связи эмфиземы легких с наличием ВИЧ-инфекции [5, 6], но это отнюдь не исключает ее наличие. Для определения условий проявления указанной связи представляет интерес анализ взаимосвязи комбинаций исследуемых параметров. Поскольку состояние ЛУ у пациентов с ВИЧ-инфекцией тесно связано с особенностями иммунного статуса и стадией заболевания, возможно, именно оно является отражением условий прогрессирования эмфиземы легких. Табл. 2 Результаты КТ-морфометрии аксиллярных и медиастинальных ЛУ представлены в таблице 2 . Исходя из представленных данных, все КТ-морфометрические характеристики аксиллярных ЛУ были достоверно выше у больных ВИЧ- инфекцией, в сравнении с таковыми у лиц КГ, что согласуется с положением о высокой частоте выявления лимфоаденопатии у ВИЧ-инфицированных пациентов [7, 8] и свидетельствует об адекватности использованной в работе 11 системы оценки состояния ЛУ. Наиболее достоверные различия между исследуемыми группами показала толщина коркового слоя аксиллярных ЛУ, что соответствует данным литературы о преобладании гиперплазированного коркового слоя над сердцевиной у функционально активных или пораженных ЛУ по данным ультразвукового исследования [11, 12, 13]. Табл. 3 В ходе последующей работы нами обнаружена взаимосвязь данных КТ- морфометрии аксиллярных ЛУ с показателями ЭЛ у пациентов опытной группы, что представлено в табл. 3. Достоверный непараметрический Н- критерий множественных сравнений Краскела-Уоллиса указывает на наличие минимум одного достоверного межгруппового отличия. КТ-морфометрические параметры медиастинальных ЛУ с показателями ЭЛ не коррелировали и поэтому нами не представлены. Исходя из полученных данных, наибольшие значения показателей ЭЛ при пороговом значении плотности легочной ткани -910 обнаружены у больных ВИЧ-инфекцией с длиной аксиллярных ЛУ менее 17 мм и ТЛУ более 4 мм, а также, более достоверно, с Т/ДЛУ более 0,33. Учитывая тот факт, что показатели эмфиземы легких у больных мужского пола были достоверно выше, в сравнении с таковыми у лиц женского пола, представляет интерес оценка влияния полового фактора на выявленную взаимосвязь. Так, при Т/Д >0,33 и длине ЛУ <17 мм количество больных мужчин было 15 из 32 (46,9%) и больных женщин - 17 из 32 (53,1%). Среди пациентов с другими соотношениями морфометрических характеристик ЛУ - соответственно 21 из 48 (43,8%) и 27 из 48 (56,3%). Таким образом, указанные различия во встречаемости лиц разного пола не достоверны, а морфометрическая характеристика ЛУ независимо связана с выраженностью эмфиземы легких у больных ВИЧ-инфекцией. Табл. 4 В отличие от показателей эмфиземы при пороговом значении плотности - 910, таковые при пороговом значении плотности -950 были достоверно связаны с относительной толщиной коркового слоя ЛУ (табл. 4). Связь Уэ(-950) и Яэ(- 12 950) с ДЛУ была менее достоверна р<0,03 и была заметной только при сравнении медиан групп сравнения. Так при ДЛУ <17 мм и >17 мм медианы Уэ(-950) равнялись соответственно 11,3 мл и 3,7 мл, а медианы Яэ(-950) - соответственно 0,16 и 0,06%. Табл. 5 В отличие от показателей эмфиземы легких у больных ВИЧ-инфекцией, таковые среди практически здоровых лиц были связаны только с ДЛУ, также с аналогичным критериальным значением 17 мм, причем достоверно при пороговом значении плотности легочной ткани -910 Ни, р<0,01 и практически достоверно при пороговом значении плотности -950 Ни, р<0,12 (табл. 5). Относительное утолщение коркового слоя аксиллярных ЛУ у здоровых испытуемых встречалось достоверно реже и не было связано с показателями эмфиземы легких. Таким образом, несмотря на меньшие значения показателей эмфиземы легких у ВИЧ-инфицированных пациентов в сравнении с практически здоровыми (достоверно - среди лиц женского пола), при строго определённом лимфатическом статусе больных денситометрические характеристики легочной ткани были хуже. Указанная закономерность подтверждает связь эмфиземы легких с ВИЧ-инфекцией, реализующуюся только при определенных условиях, маркером которых может быть состояние лимфоузлов. Важно также отметить, что длина аксиллярных ЛУ свыше 17 мм ассоциирована с наименьшими значениями эмфиземы легких, как у здоровых, так и у исследуемых ОГ. Причем характерная для больных ВИЧ-инфекцией высокая частота утолщения коркового слоя ЛУ не влияла на выявленную закономерность при длине ЛУ свыше 17 мм. Такое состояние лимфатического статуса по-видимому ассоциировано с индивидуальными генетическими особенностями организма, препятствующими развитию эмфизематозных изменений легочной ткани. Выводы Показатели эмфиземы Уэ(-910) и Rэ(-910) у больных женщин оказались достоверно ниже в сравнении с таковыми среди больных мужчин и лиц 13 контрольной группы. Указанная закономерность обусловлена случайным сочетанием и разнородностью больных мужчин и женщин в отношении фактора курения, иммунного статуса, длительности ВИЧ-инфекции, а также генетических особенностей, что требует дополнительного исследования. Остальные показатели эмфиземы легких достоверно не различались между исследуемыми группами. У ВИЧ-инфицированных пациентов относительное утолщение коркового вещества аксиллярных ЛУ (Т/ДЛУ >0,33) при ДЛУ <17 мм было ассоциировано с большими значениями показателей эмфиземы легких. У пациентов КГ зависимости последних от Т/ДЛУ не обнаружено. Длина аксиллярных ЛУ свыше 17 мм у здоровых и больных, независимо от значения Т/ДЛУ, была ассоциирована с меньшими значениями показателей эмфиземы легких. Такое состояние лимфатического статуса с наибольшей вероятностью ассоциировано с индивидуальными генетическими особенностями организма, препятствующими развитию эмфизематозных изменений легочной ткани.

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Babkina N. M., Chebotareva A. M., Shpak S.V.

National medical Academy of postgraduate education named after P.L.Shupyk LLC «Langeron»

The purpose of the quantitative lung emphysema assessment in HIV-infected patients by studying the relationship between lung tissue CT -densitometry data and age, sex, auxiliary and mediastinal lymph nodes condition. Materials and methods: CT scan of the chest in 80 HIV-infected patients and 30 practically healthy was performed using 16-slice computed tomograph Phillips Mx8000 16 of the IDT. Conclusions. The results of the work show the relationship between lung emphysema development in HIV-infected patients and the condition of the auxiliary and mediastinal lymph nodes.

Количественное определение эмфиземы легких у пациентов с ВИЧ- инфекцией по данным компьютерно-томографической денситометрии: клинико-патофизиологические аспекты

Национальная медицинская академия последипломного образования имени П.Л. Шупика ООО «Ланжерон» 17 Бабкина Т. М., Чеботарева А. М., Шпак С.В. Цель работы: изучение клинико-патофизиологического значения количественной оценки эмфиземы легких у ВИЧ-инфицированных больных путем изучения взаимосвязи данных КТ-денситометрии легочной ткани с возрастом, полом, состоянием аксиллярных и медиастинальных лимфоузлов. Материалы и методы. КТ органов грудной клетки у 80 ВИЧ- инфицированных пациентов и 30 практически здоровых проведена с использованием 16-срезового томографа Phillips Mx8000 16 IDT. Выводы. Результаты работы указывают на взаимосвязь развития эмфиземы легких у ВИЧ-инфицированных больных с состоянием аксиллярных лимфатических узлов.

18 Рис.1. Результаты постпроцессорной обработки КТ-сканов у группы контроля. Здесь и далее: красным цветом на объёмной реконструкции легких отмечены воксели эмфизематозно измененной легочной ткани, синим - воксели эмфизематозно измененной лёгочной ткани на аксикальных сканах. На диаграмме по оси ОУ отражено количество вокселей легочной ткани, по оси ОХ - градации плотности этих векселей.

000004110 РИШрэ М 11/18/11 10/11/80 13:57:43 ЭРОУ 403.0 т т '% I ПИ: 0.0 Ьедгееэ

кУ 120.0 120 тА э 3 2 0 сю

19 Рис.2 Результаты постпроцессорной обработки КТ-сканов у пациента с умеренно выраженной эмфиземой легких.

Таблица 1 Показатели эмфиземы легких у обследованных нами лиц Г руппы Показатели контрольная основная эмфиземы мужчины женщины мужчины женщины (п=15) (п=15) (п=36) (п=44) Ул 6383±748 4997±837 6901±1165 4687±899 Уэ(-910) 882±599 657±711 743±724 254±355 Rэ(-910) 13,5±8,6 12,0± 12,2 10,1±9,2 4,9±5,8 Уэ(-950) 19,2±24,3 16,4±17,3 23,5±23,3 15,6±35,3 Rэ(-950) 0,29±0,34 0,3±0,29 0,32±0,3 0,29±0,61 Меап -853±15 -844±28 -849±19 -831±24 8Б 75±3 73±3 74±2 74±3

Таблица 2 Данные КТ-морфометрии аксиллярных и медиастинальных лимфоузлов Отношение Группа ЛУ ДЛУ, мм ШЛУ, мм ТЛУ, мм Т/ДЛУ Аксиллярные лимфоузлы Контрольная группа 14,1±3,6 8,4±2,5 3,6±1,0 0,27±0,11 Основная группа 16,3±4,6 10,3±3,0 5,8±2,3 0,36±0,12 Достоверность различий р<0,04 р<0,003 р<0,00001 р<0,001 Медиастинальные лимфоузлы Контрольная группа 7,8±2,9 4,6±1,3 4,3±1,4 0,58±0,18 Основная группа 9,9±3,3 5,9±2,0 4,7±1,6 0,50±0,15 Достоверность различий р<0,002 р<0,001 р>0,2 р>0,2

20 Таблица 3 Показатели эмфиземы легких при пороговом значении плотности легочной ткани -910 Ни в зависимости от данных морфометрии ______аксиллярных ЛУ у исследуемых основной группы Уэ(-910) Яэ(-910) Значение Т/Д Длина ЛУ Длина ЛУ Длина ЛУ Длина ЛУ <17 мм >17 мм <17 мм >17 мм

334,9±377,4 277,7±518,5 5,8±5,8% 4,5±6,9% <0,33 (п=15) (п=19) (п=15) (п=19)

735,4±728,9 293,1±346,3 10,7±9,1% 4,5±4,9% >0,33 (п=32) (п=14) (п=32) (п=14)

Н-критерий 10,5; р<0,015 10,4; р<0,015

Таблица 4 Показатели эмфиземы легких при пороговом значении плотности легочной ткани -950 НИ в зависимости от данных морфометрии ______аксиллярных ЛУ у исследуемых основной группы Количество Значение обследован Уэ(-950), мл Яэ(-950), % Т/ДЛУ ных

<0,33 34 8,3±13,9 0,14±0,19%

>0,33 46 27,2±36,6 0,42±0,6%

Н-критерий 8,5; р<0,0035 6,9; р<0,009

21 Таблица 7 Показатели эмфиземы легких при пороговом значении плотности легочной ткани -910 НИ в зависимости от данных морфометрии аксиллярных ЛУ у исследуемых контрольной группы

Количество ДЛУ, мм обследован Уэ(-910), мл R3(-910), % Уэ(-950), мл Rэ(-950), % ных

<17 23 934±641 15,5±10,0 21,1±22,3 0,35±0,33

>17 7 229±361 3,6±5,2 7,1±8,8 0,12±0,14

Достоверность различий p<0,005 p<0,003 p<0,06 p<0,07

This is an open access article licensed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the work is properly cited.

Received: 15.12.2012. Revised: 25.12.2012. Accepted: 18.01.2013.

22 Journal of Health Sciences (J o H Ss) 2013; 3(2): 23-34 The journal has had 4 points in Ministry of Science and Higher Education of Poland parametric evaluation. List B item 683.

UDC 616.155.194.8-02:616.98:578.828.6

CHARACTERISTIC OF ANEMIA IN PATIENTS WITH AIDS

Характеристика анемии у больных СПИДом

AI Gozhenko, OP Gorobets, VS Goydyk, VN Mikhalchuk, VV Shukhtin, GP Fateh, H Fateh, W. Zukow

А.И. Г оженко, О.П. Г оробец, В.С. Г ойдык, В.Н. Михальчук, В.В. Шухтин, Г.П. Фатех, Х. Фатех, W. Zukow

State Enterprise Ukrainian Scientific-Research Institute of Medical Transport of the Ministry of Health of Ukraine, Odessa, Ukraine Odessa Regional Center for Prevention and Control of AIDS, Odessa, Ukraine Radom University, Radom, Poland

ГП «Украинский научно-исследовательский институт медицины транспорта Министерства здравоохранения Украины» Одесский областной Центр по профилактике и борьбе со СПИДом, г. Одесса, Украина Radomska Szkoła Wyższa, Radom, Polska

Keywords: anemia, patients with AIDS, immune deficiency, HAART.

Ключевые слова: анемия, больные СПИДом, иммунная недостаточность, ВААРТ.

Abstract

Studied the incidence, characteristics and perform the analysis of anemia in 119 HIV-infected patients in stages of AIDS. The data indicate that anemia is observed mostly in AIDS patients and is combined with thrombocytopenia, lakopenia, shift left in leukocyte formula and acceleration of Erythrocyte Sedimentation Rate. As a result of therapy going on improving red blood but at discharge from hospital patients anemia does have almost the same features as and when requested.

Резюме

Изучали распространенность, характеристику и проводили анализ течения анемии у 119 ВИЧ- инфицированных больных в стадии СПИДа. Полученные данные свидетельствуют о том, что анемия наблюдается в большинстве случаев у больных СПИДом и сочетается с тромбоцитопенией, лейкопенией, сдвигом лейкоцитарной формулы влево и ускорением СОЭ. В результате проведенной терапии происходит улучшение состояния красной крови, но при выписке больных из стационара анемия все же имеет почти такие же характеристики, как и при поступлении.

23 Introduction As is known, the problem of HIV / AIDS is relevant to the world communi ty. In today's world are more than 30 million people with HIV infection [1-3]. Ac cording to WHO, Ukraine is one of the most affected countries in Europe, the prevalence of HIV / AIDS. In the Odessa area every day there are nearly 10 new cases of HIV infection and the child is born to HIV infected women [5, 10]. HIV / AIDS - duration of the current disease, which is caused by infection with the human immunodeficiency virus (HIV) and is a severe disorders of the immune system in the absence of specific treatment with the same fatal outcome. [7] The development of the clinical picture in the course of HIV infection, the ini tial deep selective depletion of the population of CD4 + cells [4]. Of HIV infection at all clinical stages - from asymptomatic virus infection to clinical AIDS devel oped stage - has the character of systemic disease [6 , 9]. The severity of the course of HIV infection depends not only on the infection, but also on the presence of concomitant somatic pathology. According to some authors, it is possible to acti vate CD4 + T lymphocytes and induction of HIV-1 replication outside the lym phoid tissue - directly into the bloodstream. [13] Thus, it is believed that the AIDS than CD4 + T-lymphocytes, and suffer blood system. This is supported by the world literature, which contains descriptions of anemia in AIDS. [14] In our coun try, due to a set of causes has ample material for the study of changes of red blood cells, accompanied by profound immunosuppression. These results can be added to existing data, however, to adjust the approaches and tactics of HIV - infected patients with anemia. Therefore aim of this study was to investigate the prevalence, characteristics and analysis of anemia in HIV-infected patients with AIDS. Materials and methods

24 The objects of our study were 119 patients who were treated at the Odessa Regional Centre for Prevention and Control of AIDS. They have identified a group of AIDS patients with anemia, which amounted to 95 people. In the analysis of the material into account clinical diagnosis, clinical stage of HIV infection, these immunological studies, instrumental and laboratory examination. Defines the basic red blood and biochemical parameters were evaluated serum depending on the severity of anemia. All patients received appropriate treatment according to the protocol. Results and Discussion In a study of 119 patients with AIDS found that 95 of them had anemia, which was 79,8%. Subsequent analysis of patients with anemia allowed to charac terize features of anemia in patients with AIDS. General characteristics of the studied group of patients with anemia were as follows: of the 95 HIV-infected patients with AIDS were men 52 people, repre senting 54.74%, women - 43 (45.26%). The median age for men and 37.2 ± 1.17 in women 35.23 ± 1.06. 46 people died (48.4%) of whom are women - 18 (39.13%), men - 28 (60.87%). In the study group III clinical stage of HIV infec tion (according to WHO classification) was observed in 4 patients (4.21%), IV stage - in 91 (95.79%) patients. Extent immune deficiency assessed by the absolute number of CD4 +-T- lymphocyte. The level of CD4 from 500 to 301 ml-1 was in 8 patients (8.42%), from 300 to 201 mE in 11 (11.58%) patients, 200 - 101 mE - 21 (22 , 1%), 100 -

51 ml-1 - 14 (14.74%) and less than 50 ml-1 - 41 (43.16%) patients. Average CD4 +- T-lymphocytes was 127.84 ± 11.66 ml-1. Considering the absolute number of CD4 +-T-lymphocytes in the patients who died, found: CD4 count of 500 to 301 ml-1 - 2 people (4.35% ), from 300 to

201 ml-1 - 4 (8.7%) patients, 200 - 101 ml-1 - 11 (23.9%), 100 - 51 ml-1 - 8 people

(17.4%) and less than 50 ml-1 - 21 (45.65%) patients. Average CD4 +-T- lymphocytes 107.52 ± 13.28 ml-1. 25 Has also been an associated pathology: pneumonia - 45 (47.36%), pleural effusion - 8 (8.42%), pulmonary tuberculosis - 22 ( 23.16%), tuberculosis of lymph nodes - 11 (11.58%), prolonged fever - 21 (22.1%), left-sided adnexitis - 1 (1.05%), toxic myocarditis - 1 (1.05%) , duodenal ulcer - 1 (1.05%), gastrointesti nal bleeding - 1 (1.05%), hemorrhagic anemia - 1 (1.05%), cirrhosis of the liver - 1 (1.05%), sepsis - 1 (1.05%). Analyzing requirements sick complaints, found that the most common are: weakness - 95 patients (100%), malaise - 47 (49.47%), lethargy - 8 (8.42%), fever - 58 (61.1%), fatigue - 34 (35.79%), shortness of breath - 13 (13.68%), headache -

32 (33.68%), dizziness - 10 (10.53%), decrease 15 (15.79%), and anorexia 8 (8.42%). On examination, pale skin was determined in 76 patients (80%). General state of moderate severity was observed in 59 patients (62.1%), se vere - in 36 (37.89%) patients and extremely heavy - 2 (2.1%) patients. The nor mal level of body temperature was recorded in 8 patients (8.42%), low-grade fever - 63 persons (66.32%) and febrile - 23 (24.21%) patients. The study of red blood found that the average rate of hemoglobin in the total group of patients was 91.513 ± 4.84 g / l, erythrocyte - 2.363 ± 0.156 T / L, and serum iron levels - 10.9 ± 0.87 mmol / l. Characterization of anemia in the color index (CPU) was: hypochromic anemia was found in 49 patients, accounting for 51.58%, normochromic anemia - in 36 people (37.89%) and hyperchromic anemia - 10 (10.53%) patients. In this case, the lowest CPU has been in 30 (31.5%) pa tients and was within 0.6 - 0.8. Thrombocytopenia at admission was found in 53 patients (55.79%), in the course of the disease - 62 people (65.26%) and at dis charge - 41 (43.16%). Average mortality rate of erythrocyte sedimentation rate (ESR), depending on the absolute number of CD4 +-T-lymphocytes were: ESR in CD4 levels from 1 to 100 ml-1 - 50.0 ± 3.07 mm / h, 101 - 200 ml-1 -54.52 ± 5.57 mm / h, 201 - 300 ml-

1 - 60.0 ± 7.76 mm / h, from 301 to 400 ml-1 - 38.33 ± 23.76 mm / h and 401 to 500 ml-1 - 51,67 ± 10.83 mm / h. 26 Treatment given AIDS patients include: antibiotics, detoxication therapy, anti-fungal and anti-tuberculosis drugs, liver protecting, mucolytics, antipyretic drugs, vitamins, symptomatic treatment. As symptomatic treatment also used blood products, such as packed red blood cells - 9 people (20.0%), platelet leuco suspension - 2 people. (2.1%), plate let concetrat - 2 (2.1%), aktiferrin - 2 persons (2.1%), and albumin - 5 (5.26%) pa tients. Describing the general condition of patients at discharge, reported im provement in 44 patients, accounting for 46.32%. Analyzing hemoglobin levels in AIDS patients with anemia, calculated the minimum average rate of hemoglobin in the course of the disease, which was 78.63 ± 2.23 g / l. Depending on the floor calculated the average performance lev el of hemoglobin and red blood cells at admission and discharge from hospital (Table 1).

Table 1. Hemoglobin and red blood cells in AIDS patients with anemia. On admission, M ± m At discharge, M ± m Indicator Men (1) Women (2) Men (3) Women (4) Hemoglobin, g / l 87,7±2,8 93,1±2,85 82,3±3,66 96,2±2,95

P1-3<0,05 P2-4<0,05 P2-3 <0,01 P1-4<0,01 Erythrocytes, 2,86±0,097 3,15±0,114 2,57±0,12 3,15±0,09

1x1012 / l P1-3<0,05 P2-4<0,001 P2-3 <0,001 P1-4<0,01 Note: p1-3 - significance of the difference between men at admission and discharge, p2-4 - significant differences between women at admission and discharge, p^ - The significance of the difference between women and men on admission at discharge,

p1-4 - significance of the difference between men and women on admission at dis charge. Addition, we calculated the average performance level of platelets, white blood cells and blood sedimentation rate based on the data on admission, in course of the disease, and hospital discharge (Table 2).

27 Table 2. Some blood parameters in AIDS patients with anemia. On admission, In dynamics of, At discharge, Deceased, Indicator M ± m (1) M ± m (2) M ± m (3) M ± m (4) Platelets, 213,89±13,87 170,74±10,07 229,16±13,22 191,96±20,21

1x109 / l P1-2<0,01 P2-3<0,001 P1-3<0,05 P3-4<0,05 Leucocytes, 5,3±0,36 4,67±0,44 6,2±0,42 8,05±0,97

1x109 /l P1-2<0,05 P2-3<0,001 P1-3<0,01 P3-4<0,05

ESR, mm / h 48,6±2,4 40,36±2,75 47,52±2,37 52,33±3,49

P1-2<0,01 P2-3<0,05 P1-3<0,05 P3-4<0,05

Note: p 1-2 - significance of the difference of blood parameters at admission and in dynamics, p^ - significance of the difference at admission and discharge, p 2-3 - The significance of the difference in the dynamics and performance at discharge, p s-4 - reliability performance differences between the discharge and the dead. Of all AIDS patients with anemia highly active antiretroviral therapy (HAART) received 37 people, which accounted for 38.95%. Of them died 9 peo ple (24.32%). At the same time, those receiving HAART, the following red blood parameters (Table 3).

Table 3. Blood counts in AIDS patients with anemia receiving HAART. Indicator On admission, At discharge, P M±m M±m Erythrocytes, 1x1012 / l 2,94±0,09 2,97±0,1 p<0,05 Hemoglobin, g / l 100,86±2,6 101,14±2,58 p<0,05 Platelets, 1x109 /n 207,08±16,2 270,59±19,47 p<0,01

Leucocytes, 1x109 /n 4,45±0,39 5,58±0,86 p<0,05

ESR, mm / h 45,27±3,8 39,86±3,43 p<0,05 Note: p - reliability performance differences between admission and discharge.

According hemoglobin anemia subdivided according to severity: mild ane mia was observed in 37 people (38.95%), moderate anemia - 26 (27.37%) and se

28 vere anemia - 32 (33.68%) patients. Also analyzed separately in each group of pa tients with anemia of varying severity. Established that general characteristics of the study group of HIV - infected patients with mild anemia were as follows: of 37 (38.95%) male patients was 15 people, representing 40.54% of the total number of patients, women - 22 (59.46%). III stage of HIV infection was observed in one person. (2.7%), IV stage - in 36 (97.3%). By the degree of immune deficiency, according to the absolute number of CD4 +-T-lymphocytes found that CD4 counts of 500 to 301 ml-1 - 4

(10.81%), from 300 to 201 ml-1 - 6 (16.22 %) patients, 200 - 101 ml-1 - 8 (21.62%) and from 100 ml up to 1-1 - 19 people (51.35%). The average indicator of CD4 +- T-lymphocytes was 145.6 ± 20.12 ml-L The following were also calculated the av erage blood parameters in this group of patients: hemoglobin level in the blood was 99.26 ± 0.94 g / l, erythrocytes - 3.1 ± 0.07 x 1012/ l, leukocytes - 4.36 ± 0.36 x 109/ L, platelets - 220.6 ± 17.11 x 109 / l. Thrombocytopenia was observed in 17 patients (45.95%). Of all patients with mild anemia died 12 (32.43%). HAART re ceived 16 people, accounting for 43.24%. Characteristics of the study group of patients with moderate severity of anemia were as follows: of 26 (27.37%) patients were male 16 people, accounting for 61.54% of the total number of patients, women - 10 (38.46%). III stage of HIV infection was observed in 2 patients (7.7%), IV stage - in 24 people. (92.3%). By the degree of immune deficiency, according to the absolute number of CD4 +-T- lymphocytes found that CD4 counts of 500 to 301 ml-1 - was observed in 3 people (11.54%), from 300 to 201 ml-1 - 3 ( 11.54 %) patients, 200 - 101 ml-1 - 4 ( 15.3 8 %) and from 100 ml up to 1-1 - 16 (61.54%). The average indicator of CD4 +-T- lymphocytes was 131.77 ± 25.5 ml-L Were also calculated following blood parame ters in this group of patients: the level of hemoglobin in the blood was 82.1 ± 1.1 g / l, erythrocytes - 2.7 ± 0.11 x 1012/ L, white blood cells - 4.8 ± 0.84 x 109/ L, platelet count - 151 ± 18.6 x 109/ l. Thrombocytopenia was found in 20 patients

29 (76.92%). Of all AIDS patients with a mean severity of anemia died 12 (46.15%). HAART received 14 people, accounting for 53.8%. Characteristics of patients with severe anemia severity were as follows: of 32 (33.68%) of the men were 21 people, accounting for 65.63%, women - 11 (34.37%). III stage of HIV - infection - 1 patient (3%), IV stage - 31 people. (97%). By the degree of immune deficiency, according to the absolute number of

CD4 +-T-lymphocytes found that CD4 counts of 500 to 301 ml-1 was observed in 2 patients (6.2%), from 300 to 201 ml-1 - 3 (9.4%) patients, 200 - 101 ml-1 - 8 (25%) and from 100 ml up to 1-1 - 19 people (59.4%). The average indicator of CD4 +-T- lymphocytes was 116.6 ± 17.39 ml-1 The following were also calculated the aver age blood values: hemoglobin was 51.4 ± 2.33 g / l, erythrocyte - 1.85 ± 0.1 x 1012/ L, white blood cells - 2.8 ± 0.7 x 109/ l, platelets - 142.13 ± 17.5 x 109/ l. In 4 of the person identified in the blood reticulocytes, which were in the range of 6 to

28%o, while they have an average hemoglobin level was 47.5 ± 4.7 g / l. Throm bocytopenia was found in 24 patients (77.42%). Of all the patients died 22 (68.75%). 7 people receiving HAART, which was 21.9%. Considering other blood count results in the total group of patients with anemia have identified the following characteristics: young neutrophils were de tected in 43 people (45.26%), myelocytes - 9 (9.47% ) patients oxyphilic normo blasts - 5 (5.26%), neutrophils polisegmentednuclear - 1 (1.05%), neutrophils hipersegmentednuclear - 1 (1.05%), plasma cells - 1 (1.05%), wide plasma lym phocytes - 1 (1.05%), toxic granularity of neutrophils was detected in 16 (16.84%), erythrocyte anisocytosis - 9 (9.47%) expressed anisopoikilocytosis red blood cells - 19 (20%), erythrocyte hypochromia - 5 (5.26 %), degenerate vacuoli zation of the cytoplasm and nuclei of monocytes - 3 (3.16%). The average rates of blood neutrophils were: stab neutrophils - 9.56 ± 0.72, segmented neutrophils - 58.89 ± 1.57, young neutrophils - 2.56 ± 0.18.

Summarization 30 Thus, based on these data, we can judge that anemia occurs in 79.8% of pa tients with HIV - in the III and IV stages. Anemia is not dependent on age, but is dependent on gender: for men it is more severe, as evidenced by a significant de crease in red blood cells and hemoglobin compared to women. As a result of the therapy is improvement of red blood, but the discharge of patients from hospital anemia does have almost the same characteristics as the admission. Thus the general condition of the patients at discharge is noted as an improvement. In patients treated with HAART reduces mortality, but the severity of anemia is almost exactly the same as before the treatment. Consequently, severity of anemia is directly proportional to the degree of severity of AIDS and immune deficiency. In more than half of the patients anemia is hypochromic character, combined with a moderate decrease in the amount of serum iron. However, erythropoiesis occurs normoblast type, and the ability to re generate the bone marrow, is likely to continue, judging by the presence of nor moblasts and increase the number of reticulocytes in some of the patients. Howev er, the failure of erythropoiesis combined with thrombocytopenia and leukopenia, which may indicate depression of the bone marrow. However, the shift to the left leukocyte counts and the presence of reticulocytes suggest that the bone marrow has a clan of hematopoietic cells capable of regeneration. At the same time, the combination of reduction of peripheral blood cells with some signs of activation of blood red and white germ can be explained only by the decrease in the total num ber of blood stem cells, most likely at the level of pluripotent cells. However, some of the cells of hematopoietic tissue responds to regulatory signals (erythropoietin, leukopoetin), however, the total number of cells generated is not enough to ensure a normal peripheral blood cell count. It must be empha sized that, in the treatment of AIDS in a hospital even increases the severity of anemia, and discharge of patients, despite the normalization of the immune system and improving the overall condition, the severity of anemia is reduced slightly.

31 Based on the foregoing, it can be assumed that the anemia that developed in patients with AIDS, in turn, may adversely affect the general physical health of HIV-infected patients. On the other hand, even the successful use of HAART is not enough to treat anemia, exposure to which is necessary to improve therapy, which, apparently, is an important part of the treatment of AIDS.

Conclusions

1. Anemia occurs in most patients with AIDS (80%), and blood type is normo blast and is predominantly hypochromic character. 2. Frequency and severity of anemia depends on the sex of patients (most common in men and heavier), but does not depend on age. The severity of anemia under more severe AIDS and proportional to the degree of immune deficiency. 3. Anemia in AIDS patients combined with thrombocytopenia, leukopenia, leukocyte left shift and accelerated ESR. 4. Combined therapy of AIDS with HAART is effective in patients, but the majority of patients with hospital discharge anemia remains the same degree of severity.

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6 . Gozhenko A.I., Gorobec O.P., Gojdyk V.S. i dr. Mochevoj sindrom u VICh- inficirovannyh bol'nyh v stadii SPIDa. Nefrologija 2008; 12(4): 54-58. 7. Goliusova M.D., Ivanova L.A., Konnov D.S., Jurin O.G. Jeffektivnost' i bezopa- snost' anteretrovirusnoj terapii. Infekcionnye bolezni 2007; 5(2): 20-24.

8 . Makarova M.V, Bojchuk S.V., Mustafin I.G. Rol' jendotelial'nyh kletok i belka N ef v replikacii VICh-1. Infekcionnye bolezni 2009; 7(3): 18-24. 9. Men'shikov I.V, Beduleva L.V. Idiotip-antiidiotipicheskie vzaimodejstvija v pato- geneze SPIDa. Immunologija 2006; 27(5): 316-321. 10. Sadovnikova V.N. Zabolevaemost' i rasprostranennost' VICh-infekcii sredi zhenshhin i detej. Infekcionnye bolezni 2009; 7(3): 12-17. 11. Stepanova E.Ju., Hasanova G.R., Anohin V.A. i dr. Verojatnost' razvitija anemii u bol'nyh VICh-infekciej. Infekcionnye bolezni 2010; 8(3):9-12.

References in original 1. AIDS Epidemic Update: December 2006 /- UNAIDS/00/44R-WHO/. Geneva 2006; 23. 2. Aral S.O., Padian N.S., Holmes K.K. Advances in multilevel approaches to under standing the epidemiology and prevention of sexually transmitted infections and HIV: an overview. J. Infect Dis 2005; 191(1): 1-6. 33 3. Sexually transmitted infections/HIV/AIDS programme. WHO/Europe survey on HIV/AIDS and antiretroviral therapy: 31 December 2006. Copenhagen, WHO Re gional Office for Europe; 2007. 4. Бойчук С.В, Мустафин И.Г, Макарова М.В и др. Механизмы репликации ВИЧ-1 в С04+-лимфоцитах: роль антигенпрезентирующих клеток. Иммунология 2008; 28(4):196-199. 5. Бочкова Л.В., Немцов А.В. Розвиток етдемп ВШ-шфекцп/СНЩу в Одеськш областг Инфекционный контроль 2007; 4: 3-10. 6 . Гоженко А.И., Горобец О.П., Гойдык В.С. и др. Мочевой синдром у ВИЧ- инфицированных больных в стадии СПИДа. Нефрология 2008; 12(4): 54-58. 7. Голиусова М.Д., Иванова Л.А., Коннов Д.С., Юрин О.Г. Эффективность и безопасность антеретровирусной терапии. Инфекционные болезни 2007; 5(2): 20-24. 8 . Макарова М.В, Бойчук С.В., Мустафин И.Г. Роль эндотелиальных клеток и белка Nef в репликации ВИЧ-1. Инфекционные болезни 2009; 7(3):18-24. 9. Меньшиков И.В, Бедулева Л.В. Идиотип-антиидиотипические взаимодействия в патогенезе СПИДа. Иммунология 2006; 27(5): 316-321. 10. Садовникова В.Н. Заболеваемость и распространенность ВИЧ-инфекции среди женщин и детей. Инфекционные болезни 2009; 7(3): 12-17. 11. Степанова Е.Ю., Хасанова Г.Р., Анохин В.А. и др. Вероятность развития анемии у больных ВИЧ-инфекцией. Инфекционные болезни 2010; 8(3):9-12.

Received: 15.12.2012. Revised: 25.12.2012. Accepted: 19.01.2013.

34 Journal of Health Sciences (J o H Ss) 2013; 3(2): 35-50 The journal has had 4 points in Ministry of Science and Higher Education of Poland parametric evaluation. List B item 683.

COGNITIVE VIOLATIONS OF POSTINSULT PATIENTS AND MODERN METHODS OF THEIR TREATMENT

Ivan Samosiuk1, Yuriy Flomin2,3, Natalia Samosiuk1,3, Walery Zukow4

National Medical Academy of Postgraduate Education named PL Shupyk, Kiev, Ukraine 2Kharkov Medical Academy of Postgraduate education, Kharkov, Ukraine 3Medical Centrum Universal Clinic Oberig, Kiev, Ukraine 4University of Economy, Bydgoszcz, Poland

Keywords: cognitive violations; cognitive impairment; postinsult patients; treatment.

Słowa kluczowe: funkcje poznawcze człowieka; upośledzenie funkcji poznawczych, pacjenci postinsultne (po udarach mózgu); leczenie.

Abstract

Strokes are a powerful risk factor for cognitive impairment and dementia. Data on the prevalence of postinsult dementia vary depending on the time of study, location and size of infarct, methods of determination of dementia and other methodological features. Stroke increases the risk of dementia. Dementia after stroke dramatically increases the risk of death regardless of age, the functional status and comorbid conditions. The main directions for treatment of cognitive impairment in patients after stroke are active secondary prevention of stroke, including lifestyle modification and symptomatic treatment. Among the drugs for the symptomatic treatment of vascular cognitive impairment are usually used donepezil, galantamine, memantine, citicolina. Priority research areas should consider the development of rapid and reliable methods to diagnose post-stroke cognitive impairment and treat stroke to reduce the risk of cognitive impairment.

Streszczenie

Udary mózgu są potężnym czynnikiem ryzyka zaburzeń poznawczych i demencji. Dane dotyczące częstości występowania otępienia poudarowego różnią się w zależności od czasu badania, umiejscowienia i wielkości obszaru zawału, metody oznaczania demencji i innych cech metodologicznych. Udar zwiększa ryzyko demencji. Po udarze demencja gwałtownie zwiększa ryzyko zgonu niezależnie od wieku, od stanu funkcjonalnego i chorób współistniejących. Główne kierunki leczenia zaburzeń poznawczych u chorych po udarze są aktywna prewencja wtórna udaru mózgu, w tym modyfikacja stylu życia i leczenia objawowego. Spośród leków do objawowego leczenia naczyniowego zaburzeń poznawczych najczęściej są używane donepezil, galantamina, memantyna, citicolina. 35 Obszary badawcze priorytetowe powinny rozważyć opracowanie szybkich i niezawodnych metod, by po udarze zdiagnozować zaburzenia funkcji poznawczych i leczyć udar mózgu w celu zmniejszenia ryzyka wystąpienia zaburzeń poznawczych.

Strokes are a powerful risk factor for of development of cognitive the violation and of dementia. The frequency of postinsult cognitive violations of can reach 82% of [54]. After 2 of the week after a stroke one or another the degree of cognitive disorders had a a place in 91% of of patients [35]. The data about the frequency of post-stroke of dementia vary within the depending on the timing conduct a study, localization and the size of myocardial, techniques of definition dementia and other methodological of singularities. Prospective studies have demonstrated , that the stroke increases the risk of development of dementia of approximately in the 10 times, and of her the prevalence of postinsult patients amounts to 20-25% [7, 28, 72]. Post-stroke dementia sharply increases the risk of death regardless of age, of the functional state and the of concomitant diseases [69]. These data are underscore the importance of assessing cognitive functions and timely diagnosis of dementia for rendering aid to patients, suffered strokes, including the postinsult rehabilitation. Together with the fact, the development of dementia sharply makes it difficult to observation of the patient in scientific researches, which leads to an underestimation of both the prevalence of the vascular of dementia, the so-and her of influence on the livelihoods of patients [12]. Postinsult cognitive impairment, as a and about the any other consequences of stroke, has a sense to consider only the in survivors patients. It is logical to assume, that the decrease in case- fatality in stroke will be accompanied by an increase in the prevalence of post-stroke of cognitive dysfunction. Results of the study 42 thousand of persons at the age > 65 years of age, conducted in the framework of Nationwide the cutoff long-term care(National Long-Term Care Survey) in the U.S., have demonstrated, that in 1991-2000 yy. in comparison with the 1984-1990 yy. frequency (with the amendment on the age of the) of all types dementia has increased by 53%, while the postinsult dementia - on the 87%. It has occurred on the background of achieved in the this period reducing the indicator of mortality in the within 1 year after a stroke with the 65% of up to 53% [72]. These data indicate on the link between the increase in survival rate of and prevalence of cognitive violations of in patients after a stroke, as well as underscore the importance of prophylaxis, diagnosis, and of treatment post-stroke of cognitive dysfunction.

The spectrum of postinsult of cognitive of violations

36 On the connection of between the cerebrovascular diseases (CEH) and the dementia is well known has already a few decades [32 , 70]; however, to accurately set the pathobiological foundations of vascular cognitive violations do not manage to up to now pores [30, 36]. On the Way to understanding of the role of vascular of factors in the development of cognitive violations of there are a number of obstacles. One of the them is the heterogeneity of cerebrovascular pathology. From the point of view of risk cognitive violations of the most important type of a vascular the defeat of the brain are the infarcts. Cerebral infarcts represent a visible to the naked eye or by under a microscope discrete plots, in which the of pathologically changed or is absent parenchyma is the cerebral of the brain. Signs of old infarcts of the brain are detected y 1/3-1/2 of people an elderly-age [60, 64], then the is, their the prevalence of significantly more, than of strokes with the clinical manifestations. Heart attacks differ by size, to the quantity and of localization, may to have or to not to have of clinical manifestations and to develop as a on the background of preceding the cognitive impairment, the so-and without them [36, 60, 61, 64, 78]. In the clinico-of pathological studies it has been shown, that the increase in of quantity and the volume of of macroscopic infarcts is associated with an increased risk of dementia [60, 61, 64, 78]. Earlier, Tomlinson et al. (1970) pointed out, that in order to of development of of dementia a sufficiently losses of 100 cm3 tissue of the brain, however, regard, between the volume of and quantity of heart attacks and cognitive impairment were contradictory [78]. Multiple microscopic infarcts, which are encountered much more often of macroscopic can testify about the of hypoxia, inflammation, oxidative stress or damage of hematoencephalic of the barrier, play a more important the role of in the development of dementia, than large ones infarcts [64, 78]. If the, in addition to heart attacks, to take into account and other signs of cerebrovascular pathology, such as the microangiopathy and the changes in the white matter of the brain, her the frequency of in people an elderly-age reaches 75% [27]. Clinically vascular cognitive violations of fluctuate from mild dysfunction up to of dementia (which the define as expressed by violations in the of several of cognitive domains, including memory, which lead to a breach of of everyday vital activity of [15]). Hachinski, which is almost 40 years ago proposed the term «multi-infarct dementia» [32], later than the emphasized the, that vascular cognitive violations of should be regarded as a whole spectrum disorders with varying degrees of of vascular of changes in the parenchyma of of the brain and of varying the severity of cognitive deficits [31]. Adhering to of this approach, hereinafter we are let us consider, what factors predispose to the development cognitive dysfunction after a stroke and what are the main varieties of postinsult cognitive the violation.

Prerequisites of of development of of cognitive of violations of

Factors associated with the localization of and the sizes of stroke

37 Influence of stroke hotbeds of on cognitive function, according to-apparently, is determined by their the localization of, quantity and dimensions. For example, are described the consequences of so-called "strategic" infarcts, then the there are of single infarcts in certain zones the cerebral of the brain, which cause multiple cognitive or emotional violations of (Table 1) [29]. Traditionally, to portions of the brain, where the can arise "strategic» infarcts, carry an angular gyrus and the knee- deep the internal capsule on the left, low-medial departments of of the temporal lobes, medial departments of the frontal lobes, front and dorsomedial zone thalamus and caudate nucleus [27]. It was noted, is also, that the picture, reminiscent of defeat of the “strategic” zones, can be observed at lacunary infarctions in the basal ganglia, the thalamus, the hippocampus or a the medial portions of the frontal lobes [77]. In clinical practice, expressed by cognitive violations of more frequently are encountered when infarctions in the vertebrobasilar basin [3]. In other varieties of strokes, associated with cognitive dysfunction, are the multiple (symptomatic or asymptomatic) infarcts, rendering the total influence of on mental functions. The results of of the multidimensional analysis with the amended, at all the other the risk factors of dementia testify, that the total volume infarcts in the left and the right hemisphere (in particular, in the limbic and the of an associative's crust) is a predictor of of development of post-stroke of dementia [13, 53]. However, set the number of or volume of the heart attacks, which are the thresholds for the development of of dementia, until does not managed to.

The development of cognitive impairment, related with the personality of the patient's Among the of demographic factors with an increased risk post-stroke of dementia are associated Senior age of the and a low educational level, and also, possibly, male sex and belonging to a non-European race of [13, 73 ]. Risk factor for postinsult cognitive violations of is also a the severity of the preceding VNC, on what indicates the revealed connection between their the severity of and the migrated the previously stroke, in volume the defeat of white matter of the brain and the presence of vascular of risk factors (diabetes mellitus, smoking or elevated the level of cholesterol low-density lipoprotein) [13, 44, 73]. The risk of post-stroke of dementia increases in the case of of diabetes mellitus, of atrial fibrillation and especially the recurrent stroke [65]. These data are in good agree with the results population-based studies, which testify about the connection between the various vascular risk factors (arterial hypertension or hypercholesterinemia in the middle age, diabetes mellitus / hyperinsulinemia, hyperhomocysteinemia, smoking, metabolic syndrome and composite assessment of gravity of atherosclerosis) [11, 18, 38, 50, 55, 74]. On the other hand, the big cognitive reserve of may restrain the manifestation of cognitive violations of [17, 19]. One of the key of factors determining expressiveness of postinsult cognitive impairment, may be preceding the neurodegenerative changes in the brain. All the greater recognition receives a the

38 concept of, that the cerebrovascular and the neurodegenerative pathology of the exert synergistic the influence on cognitive function [21]. Was convincingly demonstrated connection between the presence of cognitive violations of in front stroke and the degree of post-stroke cognitive deficits [6]. In addition, the atrophy of the of medial of departments of the temporal lobes of the brain is a weighty predictor of post-stroke of dementia [5]. Thus, the situation, when the available violations of mental functions can be explained by a unit with myocardial of “strategic” of localization, is the exception rather, than the rule. Most often postinsult cognitive violations of arise as a result of cumulative effect of a infarcts (as a of fresh, the so and old) and the preceding the of pathological changes in the brain.

Characteristics of of cognitive of violations

It may seem, that all conditioned stroke cognitive violations must manifest itself immediately same after a stroke, however, the data researches testify about gradual the development of post stroke of dementia through the a few months and even the years of age. These observations is partly are explained by difficulty of of diagnostics of dementia at an early period of stroke, but, together with the same time, according-apparently, reflect the predisposition of the brain postinsult patients to take further vascular and the neurodegenerative the events of [29]. According to the data the study 154 patients without of the original post-stroke of dementia, the development of at them in a subsequent dementia was significantly above, the than the in the control group: 10% in the within 1 year, 15% in within 2 years and 22 of% on the throughout 3 years [68]. More than half of of cases of development of dementia in participants of the given studies have been are connected with Repeated strokes or a concomitant diseases, which could cause a hypoxia of the brain (epileptic bouts of, cardiac insufficiency, pneumonia). A similar the frequency of of development of cognitive violations in the post-stroke period the was documented in the of other prospective studies [62, 65]. The authors of a number of studies, comparing the profiles are cognitive violations of at illness Alzheimer's (BA) and of vascular dementia, have come to the conclusion that, if the at BA are more expressed disorders short-term memory, then the vascular diseased worse than the perform tasks, requiring of participation executive functions and operative memory (for example, sorting of pictures or assembly takes place of subjects of the parts of) [42]. However, in patients with stroke also meets decrease in short-term memory [56, 66]. Violations of the of memory in post-stroke period the may be a consequence of the defeat of of medial of structures of the temporal lobes, which play a an important role in storing of information [77]. Another potential mechanism may be damage to the ties of the temporal lobes, of participating in extracting of information, then the there is so-called uncoupling of. So, in the study of elderly of people without the cognitive violations of

39 with the use of functional magnetic-of the resonance tomography it was shown that hyperintensity white matter in the field of dorsal prefrontal of the cortex correlated with the the lowered the activation of of medial of departments of the temporal gyri and the worst the results of testing short term memory [46]. The most prevalent cognitive violations of after a stroke are the aphasia (from the 1/6 up to 1/3 of cases) and neglekt (violation of perception of incentives, of outgoing from the contralateral stroke than half of the space in the absence of touch-deficit). Also often are encountered decrease in of attention, disorders of operative memory, impaired the ability of to learning and the perception of of the space [28]. One of the domains, in which more frequently the entire are revealed postinsult violations of, are the the executive functions(executive function)[80]. The executive functions - this is not yet having a precise determination of block of of cognitive functions, who plays a key role in ensuring the of everyday of vital activity. They represent a complex of higher mental of skills of work with available information for the planning of and the implementation of complex of Action. The elements of cognitive functions are considered to the concentration of attention, the flexibility of the mind, the speed of processing information, the realization and change of strategy, operative memory and corrigendum of errors. An important step forward in the study of the executive of the functions y patients after a stroke was the introduction of category «vascular cognitive violations of without dementia» (vascularcognitive impairment, no dementia - CIND) [57]. The given category has allowed to allocate a group of patients with significant cognitive impairment, but without the denominated disorders of memory and functional limitations, of relevant the criteria of dementia [15]. cognitive impairment, which are characteristic for CIND,are the of deviation in the definition of the sequence, decrease of attention, of RAM and a the rate of mental processes [14]. Other domains are of cognitive functions in patients after a stroke been studied is not enough. All the more attention to the are attracted postinsult neuropsychiatric disorders, including the anxious-depressive disorders and psychomotor retardation [4, 45].

Detection and treatment of postinsult of cognitive of violations For today day of do not have any of the scale or batteries cognitive tests, which is would have became a part of standard protocol the study of cognitive functions in patients after a stroke. In standard of screening scales of, such as the Mini-investigation of of mental functions(Mini-Mental State Examination - MMSE) or a brief version of the of Cambridge of cognitive the study (Cambridge Cognitive Examination - CAMCOG),is practically absent investigation of executive functions, so the they are unlikely whether the may be deemed optimal tools for postinsult patients [29].

40 The Working Group on vascular cognitive violations of the National Institute neurological disorders and stroke the USA and the Canadian stroke the network (National Institute of Neurological Disorders and Stroke Network NINDS-CSN) - Stroke-Canadian proposed three study protocol of cognitive functions, which are used in the depending on the time available, (5 min., 30 min. or 60 min.) [30]. A set of tests, included in the most complete The 60-minute protocol, allows to investigate are four basic a domain: the executive functions, speech, visuo-spatial perception of and the memory - neuropsychiatric peculiarities of the patient. In the most a brief 5-minute protocol, which is intended, mainly, for screening, as well as for the study on the phone, inclusive testing of orientation, the immediate and of deferred playback of words, as well as the generation of words, beginning or after on a certain the letter. The authors of NINDS-CSN have reported that instructions (in English and in French languages) and the norms for the of this short the protocol free of charge are available for non-commercial use on the site www.mocatest.org. Although the protocols are NINDS-CSN does not have been developed (and so far have not passed the corresponding validation) for the of identifying and dynamic assessment postinsult of violations of, they are predstvlyayut themselves thoughtful set of of generally accepted instruments, which in the future has the chances to become a standard for the of clinical practice [29]. As soon as the established the presence of cognitive violations of, the question goes over into the plane of of their of treatment. Observance of diets according to the type of Mediterranean in old age associates with more than low-tempo of development of cognitive violations [67]. Similar the advantages of has the an increase in of physical activity [63]. Of special studies the effectiveness of these of interventions in patients after a stroke until the was not. One of the of widely used of approaches in the treatment of postinsult cognitive violations of is a cognitive rehabilitation [10]. Meanwhile, the studies in which has been studied this approach, until very little. Thus, the authors Cochrane the review of cognitive methods of treatment of of violations of memory in postinsult patients were able to find only the two studies, in which the have participated 18 patients [43]. In the a whole, until the is not enough of data for addition, the order to to draw a conclusion about the effectiveness of or inefficiency of cognitive rehabilitation and cognitive stimulation of the [9]. Pharmacotherapy of postinsult cognitive violations of has the two of the leading directions of: modification of flow of the disease, to slow the tempo of cognitive decline, the and the symptomatic treatment, directional on the improvement of the current state of of cognitive functions. Among the of the first group of interventions colossal importance has the a full-fledged secondary prevention of stroke, the so-as a repeated a stroke is a powerful risk factor for the appearance of cognitive deficits [65, 69, 75]. Current guidelines for secondary prevention of stroke underscore the importance of events such as blood pressure control (the greatest benefits are inhibitors of angiotensin-converting

41 enzyme inhibitors and diuretics), elimination of hyperglycemia and hyperlipidemia, treatment with anticoagulants or antiplatelet agents (with cardioembolic stroke) and lifestyle modification (waiver of smoking and alcohol abuse, regular exercise, good nutrition and normalization of body weight) [25]. The results of a large (N = 6105) randomized clinical trial of perindopril as a protection against recurrent stroke (Perindopril Protection Against Recurrent Stroke Study - PROGRESS) demonstrated that treatment with perindopril (± indapamide) significantly reduced the risk of cognitive decline and progression of pathological changes in white matter [16, 71]. These data suggest that this and similar combinations of antihypertensive drugs may be effective in preventing not only recurrent strokes, but the post-stroke cognitive impairment. In general, patients with stroke, lower blood pressure can reduce the risk of post-stroke dementia. [27] In clinical trials of drugs for the treatment of poststroke cognitive impairment have been studied mainly those funds previously demonstrated efficacy in the symptomatic treatment of asthma [27 , 29]. Based on the available scientific evidence American Heart Association / American Stroke Association has formulated the following recommendations [27]: - donepezil may be useful to enhance cognitive function in patients with vascular dementia (Class IIa); - galantamine treatment may have advantages in patients with mixed (AD + vascular) dementia (Class IIa); - the benefits of memantine and rivastigmine in vascular dementia is not proven (Class Iib).

Table 1. Drugs that have shown efficacy in clinical trials in vascular cognitive disorders. Drug Initial dose Titration scheme Effective dose The most common side effects Donepezil 5 mgonce Increasing the 5-10 mg per Nausea, vomiting, daily doseat 5 mg per day day diarrhea, dissomnia in 4-6 weeks. Galantamine 8 mg per day increase the dose of 16 -24 mg per Nausea, vomiting, in two divided 8 mg per day in 4-6 day diarrhea, anorexia doses weeks. Memantine 5 mg once a increase in dose to 5 20 mg per day Dizziness, day mg every week, in two divided disorientation, fatigue doses All of these interventions have a level a recommendations (based on data from several randomized clinical trials or meta-analyzes).

42 One of the most promising means for preventing and treating post-stroke cognitive impairment is citicoline [1, 26]. Cochrane review of 14 studies of elderly patients with cognitive impairment of varying severity testified about the positive effect of citicoline on memory and behavior, as well as a statistically significant improvement in the overall impression of the state compared with the placebo group [24]. The magnitude of the effect was significant (odds ratio 8.89, p<0.001), indicating a marked improvement in the active treatment group. Citicoline is very well tolerated (in the placebo group had documented more side effects than the citicoline group) [23, 24]. Alvarez-Sabin et al. (2011) demonstrated that treatment with citicoline, which began in the first 24 hours of onset and lasted 6 months. Was safe and reduced the risk of post-stroke cognitive impairment compared to placebo. Citicoline has helped improve the orientation in time, attention and executive functions. Prolonged treatment (12 months). Demonstrated excellent tolerability and a tendency to regress further post-stroke cognitive impairment [1]. Ortega et al. (2010) investigated the effect of citicoline on neurocognitive function after 6 weeks. and 6 months. after the first in the life of an ischemic stroke [49]. First, all patients (N = 347, mean age 67 years) were treated with citicoline (2000 mg daily) for 6 weeks., And then were randomly assigned to the group were further citicoline treatment (N = 172) up to 6 months from the onset of the disease or discontinuation of treatment group (N = 175). After 6 months. from the onset of the disease results of a study of cognitive functions (attention, executive function and orientation in time) in patients who discontinued treatment citicoline, were worse than those of patients in the active treatment group (p<0.05). Thus, treatment of citicoline for 6 months. after ischemic stroke is safe and reduces the severity of cognitive impairment. Our experience suggests that, given the optimal price-quality drug citicoline on the Ukrainian market is Somakson (Mili Healthcare). The treatment of post-stroke cognitive impairment is important to be screened for depression and appropriate treatment in case of detection [8]. In a randomized clinical trial showed that patients after stroke without depression medication escitalopram (5 mg in the morning in patients > 65 years and 10 mg in patients <65 years) was associated with improved global assessment of cognitive function (chiefly through verbal and visual memory) compared with the control group [37]. In addition, attention should be paid to the influence of the received treatment on cognitive function and to refrain from the use of resources, with adverse effects (eg, tranquilizers and anticholinergics). Other proposed approaches to the pharmacotherapy of cognitive impairment in patients after stroke, such as the use of stimulants (methylphenidate or modafinil) or antidepressants in the absence of the diagnosis of depression, but their effectiveness has not yet confirmed by large randomized clinical trials.

Conclusions

43 Thus, the main lines of treatment for patients with post-stroke cognitive impairment are aggressive secondary prevention of stroke, including lifestyle modification and symptomatic treatment. Of the drugs for the symptomatic treatment of vascular cognitive impairment most commonly used donepezil, galantamine and memantine, although the evidence is not registered in all countries (for example, are absent in the U.S.). Great hopes are connected with the research citicoline, which has a high safety. The priority areas for future research should consider the development of fast and reliable way to diagnose post-stroke cognitive impairment, and treatment of stroke to reduce the risk of cognitive impairment.

Open Access This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.

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Received: 05.05.2012. Revised: 25.12.2012. Accepted: 19.01.2013.

50 Journal of Health Sciences (J o H Ss) 2013; 3(2): 51-67 The journal has had 4 points in Ministry of Science and Higher Education of Poland parametric evaluation. List B item 683.

SIZE OF THE SEX DIMORPHISM OF STUDENTS FROM DIRECTION PHYSICAL EDUCATION OF KAZIMIERZ WIELKI UNIVERSITY IN BYDGOSZCZ

Wielkość dymorfizmu płciowego studentów z kierunku wychowanie fizyczne Uniwersytetu Kazimierza Wielkiego w Bydgoszczy

Jerzy Eksterowicz 1 , Marek Napierała 1, Walery 2 Zukow

1Kazimierz Wielki University, Bydgoszcz, Poland 2Radom University, Radom, Poland

Keywords: sex dimorphism; students; direction of physical education; Kazimierz Wielki University; Bydgoszcz.

Sowa kluczowe: dymorfizm płciowy; studenci; kierunek wychowanie fizyczne; Uniwersytet Kazimierza Wielkiego; Bydgoszcz

A bstract Phenomenon of the sex dimorphism in the physical culture particularly in the professional sport and recreational has a very great significance. Differences of the size of somatic features but later between men and women create functional features ground for diversifying the possibility forcing of both representatives of sex. Determining the size of differences of chosen somatic parameters at students and studying students was a purpose of this work physical education. Material and testing method They carried out research amongst 47 students of the II year of full-time studies (29 men and 18 women) in century 19 - 22 years from direction of the physical education of the University of Kazimierz Wielki in Bydgoszcz in June 2012 during the summer training camp. Results Dimorphic differences of basic parameters as somatic as the height and the body weight turned out statistically to be substantial (heights of the body on the level of the 5% and mass of the 1%). Mass of fat at examined women was greater than compared groups of men, but the difference are statistically substantial on the level of the 5%, and the percentage content of the fat-free body weight was larger at men (statistical difference on the level of the 1%). Sum of creases fat skin measured under the shovel, above the triceps and above the comb of the iliac bone appeared bigger at men (statistical difference on the level of the 5%). From measurements longish dimorphic differences turned out statistically to be substantial between bases and the length of the torso (1%) and with shoulders and forearms (5%). Men also towards women demonstrated the greater width of bars, the hand, the hand and the foot on the level of the 1% of the confidence. In measurements of circumferences (chest measurements, of the belt, the shoulder and the calf) differences were recorded statistically essential on levels of the 1% and the 5%. Conclusions 1. Dimorphic differences of basic parameters as somatic as the height and the body weight turned out statistically to be substantial (heights of the body on the level of the 5% and mass of the 1%). 51 2. Mass of fat at examined women was greater than groups of men, (on the level of the 5% of the confidence), and the percentage content of the fat-free body weight was larger at men (statistical difference on the level of the 1%). 3. The most he makes compared groups different (of Mollison indicator) width of the hand (1.85) percentage content of the fat-free body weight (1.59). 4. BMI measurements amongst examined men and women show that the majority of persons has a correct build. 5. Amongst examined men and women of persons above the border size of the indicator WHR, but the state of protein feeding up weren't noticed (AMC) is at everyone examined good. 6. Determining the build with Pignet indicator, it is possible to state, around both at men as well as women a very strong structure dominates, about the average torso at men and wide bars and the short torso at women and narrow bars. Most oftentimes at both of sex chunky shoulders appear.

Streszczenie Zjawisko dymorfizmu płciowego w kulturze fizycznej a szczególnie w sporcie wyczynowym i rekreacyjnym posiada bardzo duże znaczenie. Różnice wielkości cech somatycznych a w dalszej kolejności cech funkcjonalnych między mężczyznami a kobietami stwarzają podstawę do zróżnicowania możliwości wysiłkowych przedstawicieli obydwu płci. Celem niniejszej pracy było określenie wielkości różnic wybranych parametrów somatycznych u studentów i studentek studiujących wychowanie fizyczne. Materiał i metoda badań Badania prowadzono wśród 47 studentów II roku studiów stacjonarnych (29 mężczyzn i 18 kobiet) w wieku 19-22 lata z kierunku wychowania fizycznego Uniwersytetu Kazimierza Wielkiego w Bydgoszczy w czerwcu 2012 roku podczas letniego obozu szkoleniowego. U wszystkich dokonano następujących pomiarów antropometrycznych w (cm): wysokość ciała (V - B), długość ramienia (a - r), długość przedramienia (r - sty), długość kończyny górnej (a - da III), długość kończyny dolnej (tro - B), długość tułowia (a tro), długość stopy (ap - pte), szerokość barów (a - a), szerokość bioder (ic - ic), szerokość miednicy (is - is), szerokość ręki (mm - mu), szerokość dłoni (mr - mu) i szerokość stopy (mtt - mtf). Poza tym zmierzono (cm) obwód klatki piersiowej przy pełnym wdechu i wydechu, obwód talii, bioder, obwód napiętego i rozluźnionego ramienia, oraz obwód uda i łydki. W yniki Różnice dymorficzne podstawowych parametrów somatycznych jak wysokość i masa ciała okazały się statystycznie istotne (wysokości ciała na poziomie 5% i masa 1%). Masa tłuszczu u badanych kobiet była większa niż porównywanej grupy mężczyzn, a różnica jest statystycznie istotna na poziomie 5%, a procentowa zawartość beztłuszczowej masy ciała była większa u mężczyzn (różnica statystyczna na poziomie 1%). Suma fałdów tłuszczowo skórnych mierzona pod łopatką, nad mięśniem trójgłowym i nad grzebieniem kości biodrowej wystąpiła większa u mężczyzn (różnica statystyczna na poziomie 5%). Z pomiarów długościowych różnice dymorficzne okazały się statystycznie istotne pomiędzy stopami i długością tułowia (1%) oraz ramionami i przedramionami (5%). Również mężczyźni w stosunku do kobiet wykazali się większą szerokością barków, ręki, dłoni i stopy na poziomie 1% ufności. W pomiarach obwodów (obwody klatki piersiowej, pasa, ramienia i łydki) odnotowano różnice statystycznie istotne na poziomach 1% i 5%. Wnioski 1. Różnice dymorficzne podstawowych parametrów somatycznych jak wysokość i masa ciała okazały się statystycznie istotne (wysokości ciała na poziomie 5% i masa 1%).

52 2. Masa tłuszczu u badanych kobiet była większa niż grupy mężczyzn, (na poziomie 5% ufności), a procentowa zawartość beztłuszczowej masy ciała była większa u mężczyzn (różnica statystyczna na poziomie 1%). 3. Najbardziej różni porównywane grupy (wskaźnika Mollisona) szerokość ręki (1,85) procentowa zawartość beztłuszczowej masy ciała (1,59). 4. Pomiary BMI wśród badanych mężczyzn i kobiet wskazują, że większość osób posiada prawidłową budowę ciała. 5. Nie zauważono wśród badanych mężczyzn i kobiet osób powyżej granicznej wielkości wskaźnika WHR, a stan odżywienia białkowego (AMC) jest u wszystkich badanych dobry. 6. Określając budowę ciała wskaźnikiem Pigneta, można stwierdzić, ze zarówno u mężczyzn jak i kobiet dominuje budowa bardzo mocna, o tułowiu średnim u mężczyzn i szerokich barkach oraz krótkim tułowiu u kobiet i wąskich barkach. Najczęściej u obu płci występują ramiona krępe.

Introduction

Phenomenon of the sex dimorphism in the physical culture particularly in the professional sport and recreational has a very great significance. Differences of the size of somatic features but later between men and women create functional features ground for diversifying the possibility forcing of both representatives of sex. In the population understanding, trained men get good results, in tests forcing than practised women. It results above all from the majority of men towards women in sizes of such elements of the body as: the length and the body weight, length of lower limbs and upper, width of bars, volume of the fat-free body weight (LBM) (from Eng. Lean body mass) and the like However the male sex towards female a baulk is characteristic other with smaller content of the fatty tissue (BF) (from the Eng. body fat). Diversity of under construction males and female is an effect of the genetic, neurohormone dissimilarity, psychological setting, but the finally diversified lifestyle in it of feeding and keeping. It is worthwhile emphasizing that the size of the sex dimorphism isn't identical in the entire ontogenesis and changes in different lifespans. He results from tests [1], that biggest appears in the period of early mature years and smallest during the prenatal life and the advanced years.

Some exponents of the health peculiarly manifesting itself with the efficiency of arrangements are associated with the size of the fatty tissue: circulatory and respiratory. 53 Presented issues waited until numerous studies in Poland [1, 2, 3, 4]. Peculiarly tests concerning secondary school children are valuable and student, because based on it isn't possible to formulate the developmental and health prognosis of determined population. Quickly the changing living conditions of people in our country affects dynamics of changes of the size of somatic ripening generations. Therefore many researchers attentively keep up with this process, notices developmental conditioning, creates health recommendations. It is necessary to emphasize that this process isn't he exactly, after all recognised and requires further research.

Determining the size of differences of chosen somatic parameters at students and studying students was a purpose of this work physical education.

Material and the testing method

They carried out research amongst 47 students of the II year of full-time studies (29 men and 18 women) in century 19 - 22 years from direction of the physical education of the University of Kazimierz Wielki in Bydgoszcz in June 2012 during the summer training camp. At everyone they made the following measurements antropometric in (cm): height of the body (V - B), length of the shoulder (and - r), the length of the forearm (r - sty), length of the upper limb (and - will give III), length of a lower limb (tro - B), length of the torso (a-tro), length of the foot (ap - pte), width of bars (and - a), the width of hips (ic - ic), width of the pelvis (is - is), width of the hand (mm - for him), width of the hand (mr - for him) and width of the foot (mtt - mtf). Apart from that they measured (cm) chest measurement by full inhalation and exhalation, circumference of the pack, of hips, the size of the tensed and loosened shoulder, and the size of the thigh and calves. Additionally a body weight was appointed (kg). Apart from that they measured (mm) thickness of three skin-fatty creases located: above the triceps brachii (TSF) (triceps skinfold), vertical crease, under the bottom angle of shoulder blades (SCSF) (subscapular skinfold), horizontal crease, and above the comb of the iliac bone (SISF) (suprailiac skinfold), oblique crease. Based on above measurements they counted out: mass of fat in the body in the kg and in the per cent (FM) (kg), FM (%) and fat-free body weight in kilogrammes and the per cent (FFM) (from Eng. fat free mass) (FFM) (kg), (FFM) (%) according to algorithms Durnin and Womersley [5]. Apart from that the following somatic indicators were counted out: by weight-height indicator (BMI) (Eng. Body Mass Index, kg/m ), determining status of the body weight, rate of the size of muscles of the shoulder

54 (AMC) (Eng. Arm Muscle Circumference) (in the cm), indicator of the waist/hip (WHR) (Eng. Whist it hip Ratio).

They caught: - sizes of the BMI indicator (for women and men), below 19.0 - deficiency of the body weight, within the limits of from 19.0 to 25.0 - correct body weight, 25.1 to 29.9 - excess weight, 30.0 and above - obesity, - the border size of the WHR indicator, apart from which the obesity is seen takes out: 0.95 for men and 0.85 for women, - AMC evaluation criteria: the degree of protein feeding up was enumerated according to the pattern: size of the shoulder - (3.14 x thickness of the skin-fatty crease above the triceps), they caught: soundness of protein feeding up: men > 22.8, women > 20.9, slight undernourishment: men 22.7-20.2, women 20.8-18.6, moderate undernourishment: men 20.1 17.7, women 18.5-16.2 and heavy undernourishment: men < 17.7), women < 16.2). Based on above measurements they counted out additionally: - rate of the slenderness of the Rohrer body, determining it with the key of Curtis and characteristics of Kretschmer: x - 1.27 leptosomatic type, 1.27 - 1, 49 athletic type and 1.50 - x type picnic. - the Pignet indicator but sizes of the indicator were given marks based on Polish materials of candidates created from tests for studies of the physical education (Drozdowski 2002, p. 118). They effected the calculation according to the pattern and = height of the body - (mass + chest measurement). They caught:

Circuit races men women Very strong structure x - 7.7 x - 18.8 Strong structure 7.8 - 12.5 18.9 - 22.5 Average structure 12.6 - 22.1 22.6 - 30.0 Poor construction 22.2 - 26.9 30.1 - 33.8 Very poor construction 27 - x 33.9 - x indicator of the torso: and = (length of the torso: height of the b o d y )x 100 Circuit races men women Long torso 31.3 - x 30.8 - x Average torso 29.6 - 31.2 29.5 - 30.7 Short torso x - 29.5 x - 29.4 indicator of bars: and = (width of bars: length of the torso) x 100 Circuit races men women Narrow shoulders x - 70.1 x - 72.6 Barges midlewided 70.2 - 76.5 72.7 - 77.2 Wide barges 76.6 - x 77.3 - x 55 - indicator of the pelvis: and = (width of the pelvis: width of bars) x 100 Circuit races men women Narrow pelvis x - 71.5 x - 79.3 Pelvis midlewided 71.6 - 76.1 79.4 - 84.5 Wide pelvis 76.2 - x 84.6 - x - indicator of the musculature of the shoulder: and = (circumference: length) x 100; slender shoulder for men > 77.1, chunky < 77,2, for women, respectively > 76.0 and < 76.1. Measurements were performed exploiting the portable medical TANITA BF 662 weight range of the M and the toolkit antropometric (antropometr, arch-shaped compasses, tape, fold measure) of Swiss Siber Hegner company & Co. Ltd.

From conducted source measurements average values and standard deviations were counted out. Demonstrated somatic sizes of males were compared from female with the help of the t-Student test an existing degree of the gravity of differences in the examined subpopulation was established amongst sex.

Findings and discussing them

Dimorphic differences of basic parameters as somatic as the height and the body weight turned out statistically to be substantial (heights of the body on the level of the 5% and mass of the 1%). Mass of fat at examined women was greater than compared groups of men, but the difference are statistically substantial on the level of the 5%, and the percentage content of the fat-free body weight was larger at men (statistical difference on the level of the 1%). Sum of creases sheep skin measured under the shovel, above the triceps and above the comb of the iliac bone appeared bigger at men (statistical difference on the level of the 5%). From measurements longish dimorphic differences turned out statistically to be substantial between bases and the length of the torso (1%) and with shoulders and forearms (5%). Men also towards women demonstrated the greater width of bars, the hand, the hand and the foot on the level of the 1% of the confidence. In measurements of circumferences (chest measurements, of the belt, the shoulder and the calf) differences were recorded statistically essential on levels of the 1% and the 5%. A table presents the numerical detailed data I.

The dimorphic diversity was also specific with the help of the Mollisona indicator (table and and drawing 9). The most a width of the hand makes compared groups different (1.85) percentage content of the fat-free body weight (1.59).

56 Table I. Numerical characteristics of the tested somatic features of men and women

Studied trademark Men Women d u Tested feature Men Women 2012 (N-29) (N- 18) W m

^ 2 .X 1 X 2 Height of the body (body height) (cm) (B - V) 179.87 7.11 171.98 13.40 7.89 2.34 * 0.59 Body weight (kg) 76.48 8.13 63.88 16.22 12.6 3.11 * * 0.78 (body mass) Mass of fat in the FM body (kg) (fat mass) 11.18 3.10 14.67 6.39 3.49 2.20 * 0.55 The percentage fat content in the FM body (%) 14.45 2.95 22.78 5.24 8.33 1.58 1.59 (fat mass) Fat-free FFM body weight (kg) 65.30 5.96 49.21 10.79 16.09 5.92 * * 1 49 (fat free mass) Percentage content of the fat-free FFM body 85.55 2.95 77.22 5.24 8.33 6.29 * * 1 59 weight (%) (fat free mass) Sum of skin-fatty creases (mm) 27.57 6.18 21.94 9.57 5.63 2.28 * 0 59 (Of sums of skinhead - fat folds) - under the shovel - (mm) (subscap) 10.28 2.80 7.16 3.38 3.12 3.40 * * 1 09 - above the three-headed flat - (mm) (triceps) 8.28 1.69 6.58 3.11 1.70 2.17 * 0 55 - above the k.biodrowej- comb (mm) (suprial) 9.02 2.78 8.21 3.66 0.81 1.03 0 22 Measurements długościowe (cm): (length measurements) 30.90 2.17 30.39 5.64 0.51 0.37 0 09 - shoulder (a-r) arm 25.89 1.90 24.18 3.09 1.71 2.16 * 0 55 - forearm (r-sty) (fore arm) 78.07 3.98 73.28 7.32 4.79 2.60 * 0 65 - upper limb (and - will give III) (upper of aroll; 91.21 4.88 87.86 11.69 3.35 0.28 0 29 pines) 26.57 1.08 24.70 2.45 1.87 3.10 * * 0 76 - lower limb (tro-B) (lower of arolla pines) 55.73 4.79 50.62 5.69 5.11 3.30 * * 0 90 - foot (pte-ap) (foot) - length of the torso (tro-a) Measurements szerok. (cm): (width measurements) 42.72 1.93 37.32 4.50 5.40 5.37 * * 1 20 - of bars (cm) (a-a) (shoulder breadth) 31.03 2.67 31.57 7.17 0.54 0.31 0 07 - of hips (cm) (ic - ic) (hip) 24.88 1.74 24.28 4.06 0.60 0.60 0 15 - of pelvis (cm) (is - is) (pelvis) 11.18 0.88 9.66 0.82 1.52 6.32 * * 1 85 - of hand (cm) (mm-mu) (hand) 8.58 0.64 7.76 0.88 0.82 3.53 * * 0 93 - of hand (cm) (mr-mu) (of palms) 10.24 0.78 9.16 0.90 1.08 4.37 * * 1 2 - feet (cm) (mtt-mtf) (foot) Measurements of circumferences (cm): (lucasurements) 99.06 5.05 93.47 8.56 5.59 2.57 * 0 65 - of chest (inhalation) (cm) (chest measurement) (aspiration) 93.97 4.91 89.31 9.33 4.66 1.99 0 50 - of chest (exhalation) (cm) (chest measurement) (expiration) 79.31 3.95 70.39 9.70 8.92 3.76 * * 0 92 - of belt (cm) (waist measurement) 92.47 4.25 88.72 11.78 3.75 1.31 0 32 - of hips (cm) hip 33.48 3.52 28.07 3.69 5.41 5.20 * * 1 47 - of shoulder at stretching (cm) (arm measurement) (tensed) 30.01 3.47 26.28 3.62 3.73 3.64 * * 1 03 - of shoulder atonic (cm) (arm measurement) (relaxed) 55.17 3.04 51.27 6.15 3.90 1.53 0 63 - he will pretend (cm) (thigh measurement) 36.99 2.33 34.09 5.16 2.90 2.27 * 0 56 - calves (cm) (calf measurement) BMI 23.67 2.49 21.46 3.30 2.21 2.52 * 0.67 AMC indicator 27.41 3.54 24.21 3.30 3.20 3.31 * * 0.97 WHR indicator 0.86 0.04 0.79 0.06 0.07 4.50 * * 1.17 N - number (numbers), X - average value (average value), Sec. - standard deviation (variation standard), at - statistical gravity of differences * p < 0.05; * * p < 0.01; t (= 0.05 = 2.01; t (= 0.01 = 2.67, W m - Mollison indicator 57 SEC K> K> K) K> K> K) K> K) K> to - SO 00 Os LA LJ K> *1 SO 00 ^1 Os LA 4-* LJ K> o SO 00 Os LA 4^ LJ K> o 4^ - Lp. 179.87 7.11 00 ^1 00 00 Os ^1 SO ^1 00 ^1 00 ^1 00 SO ^1 ^1 ^1 ^1 ^1 00 ^1 00 SO ^1 ^1 00 ^1 ^1 00 Height of the u> 4-* 00 U> LJ Os O LJ u> 4-- 4-* 00 ^1 4-- 00 4-- LA LJ 4-- 4-* LJ K) O so ^1 ^1 Os 4-- SO body 76.48 76.7 68.7 77.0 67.8 74.3 66.1 76.8 74.9 78.2 65.1 68.4 65.8 66.5 79.0 67.2 76.9 70.3 86.9 81.7 8.13 85.1 83.5 85.5 83.3 98.7 84.7 84.0 £ 0 8 L\L LZL Body weight 23.67 22.9 28.6 23.0 20.5 24.8 23.6 22.2 27.6 24.2 21.3 24.7 21.5 22.3 28.0 29.1 22.2 25.5 21.0 25.5 22.0 24.0 23.5 19.5 'LZ 1 1 6VZ LZZ LZZ ¿TZ LZZ 6'1Z BMI 0.04 0.94 0.92 0.94 0.84 0.84 0.82 0.82 0.84 0.85 0.92 0.84 0.82 0.84 0.79 o o O O o o O o o O O 00 00 00 00 00 00 00 00 00 00 00 WHR indicator 1 6 0 £ 8 0 a l 2 Idctr o men of Indicators 2. Table Os 6 8 0 ^1 0 6 0 ^1 Os ^1 Os Os o 6 8 0 Os o o 28.49 40.43 25.27 25.49 29.49 24.74 29.74 25.17 24.24 25.46 28.43 26.11 23.80 24.93 23.83 25.14 25.96 28.05 27.56 24.96 25.15 24.86 31.06 31.04 32.21 32.39 3.54 AMC IV LZ IV £tL Z 9Z9Z LYLZ

LA 00 0.17 1.32 1.25 1.65 1.23 1.41 1.24 1.31 1.21 1.58 1.36 1.14 1.39 1.23 1.27 1.25 1.58 1.28 1.40 1.15 1.45 1.29 1.38 1.24 Rohrer indicator ZVl 9 9 1 9 0 1 ¿ 1 1 0 9 1 ¿ 1 1 ¿ 1 1 7.25 22.3 29.9 20.9 20.2 21.8 12.7 12.8 18.4 12.2 18.7 12.6 14.3 13.3 4^ 4-* 00 SO 4-* K > LA © Os Os U > SO LA K> 4-* 00 00 LA LJ Pignet indicator r o z 1X1 ¿1 1 2.35 28.2 29.5 29.8 27.6 29.8 25.2 28.6 30.9 31.7 33.2 30.7 31.4 31.6 30.6 31.7 36.3 32.6 31.8 30.4 LJ 30.1 30.8 30.7 30.3 30.2 30.6 32.4 U > LJ ^1 Indicator of the 4-* o to f ' l £ torso 102.4 79.4 79.9 78.9 78.6 62.9 68.9 75.2 79.8 75.9 76.9 70.1 82.6 ^1 86.4 85.2 83.2 82.1 83.9 00 U> ^1 Os K) LA O '9L Indicator of bars VZL 1'9A 00 ¿ ' t ¿ to ¿ ' t ¿ Z'LL V\L 9

^1 I'LL 58.20 61.5 45.1 63.7 68.5 60.5 65.5 61.3 62.3 63.9 5.01 50.6 53.9 56.8 51.5 54.4 59.4 Os 59.6 59.3 56.3 53.4 54.3 55.8 56.7 Indicator of the o Os LA LA LA LJ Os ^1 4-* pelvis 00 6 1 9 6 0 9

97.67 Indicator of the 13.07 104.2 134.6 106.4 108.7 109.6 103.3 116.7 107.7 103.3 120.1 89.6 81.8 97.3 92.6 80.2 93.8 84.4 92.3 97.9 94.2 92.1 82.3 94.3 80.7 o o o musculature of

o 6 0 8 9 1 8 1101 the shoulder Fig. 1. BMI of examined men (source: own study)

BMI measurements showed that there had been no men with the deficiency of the body weight (below 19.0), students constituted the largest number of people about the correct body weight (72%), the rest part is overweight persons (28%). They overlooked amongst examined men of persons above the border size of the WHR indicator, apart from which the obesity is seen (0.95). Also state of protein feeding up (AMC) is at all examined men good (above 22.8). Using with characteristics of Kretschmer, Curtius key and the rate of the slenderness of the Rohrer body, they characterised examined: a 51% is leptosomatic types, athletic types and the 21% constitute the 28% types picnic.

59 (source: own study)

Table 2. Indicators of women

J BMI torso AMC pelvis Height Body Body weight the the shoulder musculature musculature of WHR WHR indicator Indicator of the Indicator of the Indicator of the Pignet Pignet indicator Indicator Indicator of bars Rohrer Rohrer indicator

1 180 80.0 23.4 0.83 27.43 1.37 1 28.2 86.20 66.10 89.00 2 173 62.0 20.8 0.81 24.74 1.20 21 30.6 69.60 63.30 84.90 3 169 64.5 22.6 0.76 24.93 1.34 9.5 31.5 72.90 61.40 91.70 4 169 67.0 23.5 0.81 23.51 1.39 3 27.3 79.60 71.70 104.60 5 171 63.3 21.6 0.84 24.96 1.26 17.2 30.7 72.40 60.50 84.40 6 182 74.2 22.4 0.81 25.02 1.23 13.8 29 71.80 65.30 74.20 7 167 54.9 19.7 0.80 22.30 1.18 21.1 28.1 76.60 65.80 78.70 8 164 48.8 18.1 0.79 21.87 1.10 25.2 27.7 80.00 54.90 90.40 9 168 70.4 25.0 0.77 24.49 1.48 0.6 28.7 79.90 64.40 97.50 10 169 60.6 21.2 0.76 23.71 1.25 20.9 28.3 70.10 68.10 86.10 11 189 80.4 22.5 0.79 25.83 1.19 9.6 28.8 74.60 68.90 80.00 12 167 57.7 20.6 0.83 24.34 1.24 18.8 30.1 72.70 63.80 90.90 13 168 58.9 20.9 0.80 24.34 1.24 19.1 29.4 72.10 64.00 90.90 14 178 63.2 19.9 0.81 24.37 1.12 18.8 29.9 68.80 64.30 84.40 15 177 63.1 20.1 0.76 26.93 1.14 13.9 27.5 79.10 60.20 98.90 16 164 60.2 22.5 0.82 23.80 1.36 11.8 31.3 69.80 71.20 89.90 17 169 59.7 21.0 0.74 21.12 1.23 21.3 31.4 66.90 67.60 74.20 18 173 61.0 20.5 0.78 22.15 1.18 20.0 31.1 66.80 69.40 75.50 73.9 65.1 X 171.98 63.88 21.46 0.79 24.21 1.25 14.8 29.4 87.0 SEC 5.31 4.20 13.40 16.22 3.30 0.06 3.30 1.44 0.10 7.46 8.52 (source: own study)

BMI measurements amongst examined women: 6% of the person with the underweight, 94% of the person about the correct structure. Amongst examined women persons weren't recorded above the border size of the WHR indicator, apart from which the obesity is seen (0.85). As similarly as at men state of protein feeding up (AMC) is at all examined women good (above 22.8).

60 Rate of the slenderness of the Rohrer body, (determined by the Curtius key and the description of Kretschmer) demonstrated, that examined it is a 72% these are leptosomatic types, 28% athletic types.

Fig. 3. BMI of examined women (source: own study)

Fig. 4. Slenderness of the body of men (source: own study)

61 70

50 □ mężczyźni □ kobiety 40

0 JZZL Budowa bardzo Budowa mocna Budowa średnia Budowa słaba Budowa bardzo mocna słaba

Fig. 5. Build (Pignet indicator) (source: own study) Determining the build with Pignet indicator, it is possible to state, around both at men (about 50%) as well as of women (over the 60%) a very strong structure dominates. Women in over the 30% they represent types about a strong build, however in similar sizes men have a medium build. The build was described graphically on drawing 5.

□ mężczyźni 30 □ kobiety

0 1 1 1 ------Długi tułów Średni tułów Krótki tułów

Fig. 6. Indicator of the torso (source: own study) Most oftentimes at examined men an average torso appears (45%) and debts (about 40%), however at women in over the 55% a short torso appears, over the long and average 20% (drawing 6). 62 60

50 □ mężczyźni □ kobiety

0 Barki wąskie Barki średnioszerokie Bark szeroke

Fig. 7. Indicator of bars (source: own study) Conclusions of the sign of bars show that examined students are characterized in over the 55% with wide bars, 30% with bars mildwided and in about 14% with narrow bars. Women have narrow bars most oftentimes (50%), wide barges appear at about 30% and at about 20% of the barge mildwided (drawing 7).

120

100

80 □ mężczyźni □ kobiety 60

0 T ramię krępe ramię smukłe

Fig. 8. Indicator of the musculature of the shoulder (source: own study)

All examined men have chunky shoulders, however at women chunky shoulders appears at the 80%, remaining have slender shoulders (drawing 8).

63 Fig. 9. Size the dimorphism of studied trademarks determined by the Mollison indicator

(source: own study) Discussion and conclusions

In the history of the physical anthropology an interest in the human body developed in the diversified way. At first exclusively bone materials were a main domain of the search of anthropologists, at present they stated that getting to know secrets of somatic construction wasn't possible without getting to know of the line-up the body and arrangements of different sizes of components, mutual of their relation and conditioning. In spite of an great interest in these issues she is being in many installments frank, constituting the field of the search [1, 2, 3, 4, 5, 10]. The sexual diversity has its rich references in biological, medical studies, but also in the physical education and sport. Physical exercises, particularly the sports training exert the molding influence on the number of somatic features. Drozdowski [5, p. 134] claims, that (...) in broad outline the build of the woman seems to be less mature, as if kept more infantile character.

With turning over to Skibińska [7] in the morphological typology it is possible to favour two extreme types of figures: type extremely male and extremely female. A strong proliferation of the top half of the body, a strong neck, a big head, a strong shoulder girdle are characteristic of the first type and chest, narrow pelvis, fat are found in the top halves of the body. Type extremely female these are smaller head, more delicate structure, narrower shoulders, with clearly accumulating fatty layers. In the region of thighs and buttocks. The stronger proliferation

64 of muscles at men causes better clenching joints, causing restrictions in the extensiveness of moves.

The skeleton of women is smaller, smaller, lengths of the bone of lower limbs are smaller than at men, the spine has a more strongly developed curve back - round steak. At women also a great width of hips appears towards the width of bars. Dimorphic differences also appear in the musculature. Characteristics of the woman: rather a small head, narrow shoulders, physiological crookedness of upper limbs and bottom, longer towards limbs torso, greater, differently spread adiposis (at women of the 24%, at men of the 15%), more low laid main focus, differences of the under construction skeleton (smaller bones, smaller length of long bones) and smaller musculature (separatness of men of the 42% of the body, separatness of women of the 36%), difference in the range of the system articulated - cord. The pubic hair has a shape of the triangle, at men of the rhombus. The development of boys is slower, lasts longer and leads bodies to the largeness.

Differences also appear sec. for sphere of physiology [8]. Characteristics of the woman: higher frequency of the pulse, smaller thrust and minute's capacity hearts, the lower content of haemoglobin and red blood cells, smaller maximum consuming oxygen, the lower vital capacity. They noticed that the system of the woman better carried the effect of unfavourable environmental stimuli (ecosensitivity), (greater mortality amongst boys and men in all age groups). Women physiologically better carry the phenomenon of the "thermal stress" (what causes smaller loss of bodily fluids - smaller perspiration). The female sex finally population demonstrates the greater life span towards males.

The phenomenon of the sex dimorphism is particularly important in the physical education and sport. For the numerical assessment of the degree of the dimorphism different ways are applied, but the ones which aim at replacing subjective evaluations with arithmetic processes merit attention. An indicator belongs to them A. Skibińska [7], having a form: indicator = (chest measurement + waist size): 2 x hip size. This indicator, according to Skibińska, for men averages 961.7, for women 735.1.

Somatic tests of students studying the physical education at a university of Kazimierz Wielki in Bydgoszcz are led systematically of many years. Comparing results it is possible to state that all examined characteristics of both women and men within the sex keep values moved close in individual years of tests

65 This tests authorise to draw the following conclusions:

1. Dimorphic differences of basic parameters as somatic as the height and the body weight turned out statistically to be substantial (heights of the body on the level of the 5% and mass of the 1%).

2. Mass of fat at examined women was greater than groups of men, (on the level of the 5% of the confidence), and the percentage content of the fat-free body weight was larger at men (statistical difference on the level of the 1%).

3. The most he makes compared groups different (Mollison indicator) width of the hand (1.85) percentage content of the fat-free body weight (1.59).

4. BMI measurements amongst examined men and women show that the majority of persons has a correct build.

5. Amongst examined men and women of persons above the border size of the indicator WHR, but the state of protein feeding up weren't noticed (AMC) is at everyone examined good.

6. Determining the build with Pignet indicator, it is possible to state, around both at men as well as women a very strong structure dominates, about the average torso at men and wide bars and the short torso at women and narrow bars. Most oftentimes at both of sex chunky shoulders appear.

Open Access

References

1. Wolański N., (2006), Rozwój biologiczny człowieka, Wydawnictwo Naukowe PWN, Warszawa. 2. Drozdowski Z., (2002), Antropologia dla nauczycieli wychowania fizycznego, AWF, Poznań. 3. Szymelfejnik J., Jarząbek J., Eksterowicz J., Cichoń R., (2007), Parametry antropometryczne studentów a aktywność fizyczna, [w]: Interdyscyplinarny wymiar nauki o zdrowiu, (red.) Z. Bartuzi Z., Wydawnictwo Collegium Medicum w Bydgoszczy, Bydgoszcz, s. 424-431.

66 4. Eksterowicz J., Napierała M., (2007), Zmiany morfologiczne studentów z kierunku wychowania fizycznego w trakcie letniego obozu sportowego, Medical and Biological Sciences, Tom21/3, Bydgoszcz, s. 49-52. 5. Roy J., Shephard M.D., (1987), Exercise physiology, B.C. Decker INC, Toronto Philadelphia. 6. Drozdowski Z., 1972, Antropologia sportowa, Państwowe Wydawnictwa Naukowe, Warszawa - Poznań, Seria: Podręczniki nr 12. 7. Skibińska A., (1967), Dymorfizm cech somatycznych młodzieży dojrzałej, Materiały i Prace Antropologiczne, nr 65, s. 19-90, Wrocław. 8. Osiński W., (1996), Zarys teorii wychowania fizycznego, Podręczniki nr 47, AWF, Poznań 9. Drozdowski Z., (1998), Antropologia w wychowaniu fizycznym, Podręczniki nr 24, AWF, Poznań. 10. Carlton T., (2007) FCS Teacher Takes on Obesity Epidemic, Journal of Family and Consumer Sciences, v 99 n1 p. 23-24.

Received: 05.10.2012. Revised: 25.12.2012. Accepted: 23.01.2013.

67 Journal of Health Sciences (J o H Ss) 2013; 3(2): 68-91 The journal has had 4 points in Ministry of Science and Higher Education of Poland parametric evaluation. List B item 683.

Toxic and Physiological Aspects of Metabolism of Nitrites and Nitrates

in the Fish Organism

Sergey Dolomatov 1 , Walery Zukow 2 , Magdalena Hagner-Derengowska2 ,

Monika Kozestanska 2 , Iwona Jaworska 2 , Anna Nalazek2

1 Odessa State Environmental University, Odessa, Ukraine

2 Radom University, Radom, Poland

A bstract

Based on the analysis of literature data systematized modern understanding of the phylogenetic and specific features of the role of nitrogen oxide cycle in fish organism, the processes of creation in fish organism and biotransformation in the external aqueous environment nitrites and nitrates. Considered the mechanisms of their toxic impacts on organs and tissues of fish.

Keywords: fishes; nitrites; nitrates; toxicity; nitrogen oxide cycle; physiological role.

68 Introduction

According to the literature1, the main forms of inorganic nitrogen compounds of the aquatic environment are the ammonium cations (NH4+), and nitrite anions (NO2-) and nitrate anions (NO3-).

Ammonium cations, most often, are oxidized to nitrate anions in the natural nitrogen cycle, (natural circulation of inorganic nitrogen compounds in natural habitats. Of course, the sense of poorly chosen symbols of this process is not associated with the cycle of nitric oxide in the body of vertebrates), in consequence, the concentration of nitrate anions in both freshwater and marine ecosystems are generally higher than similar parameters for ammonia and nitrites. In turn, nitrates, ammonium and nitrites intensely absorbed by algae and bacteria. At extremely low levels of oxygen in the water a number of anaerobic bacteria utilize the nitrate anion, restoring it to gaseous nitrogen.

Human activity has a significant impact on the global nitrogen cycle and in addition to natural sources of inorganic nitrogen, significant amounts of nitrogen-containing ions can penetrate into the aquatic ecosystems due to anthropogenic factors. In addition, it is necessary to clarify that nitrites and nitrates are constantly formed in the organism of vertebrates, including fish - NO2- and

NO3- endogenous origin, resulting in oxidation of the molecule nitric oxide, as its transport form.

However, the mechanisms responsible for maintaining the stability of the concentration of nitrites in the internal environment of fish, are not studied well.

Consequently, while reviewing the environmental aspects of the circuit NO2- and NO3-, representative of interest to analyze the kinetics of endogenous NO 2- and NO 3- in organism of fish, as well as the elucidation of the physiological rules of nitrites and nitrates in the organism of various species, depending on the seasons and stages of ontogeny. Since the literature gives much attention to the toxic properties of nitrites in aquatic ecosystems, and the study of manifestations in fish tissue-specific toxic effects nitrites and their derivatives, we cannot exclude that it may be quite promising analysis of the incorporation of exogenous nitrites as a substrate exist in organism of fish the physiological mechanisms re-synthesis of nitric oxide.

69 Thus, the subject of this review is to analyze literature data dedicated to features of

metabolism NO, NO2" and NO 3 ", taking into account the processes of formation of endogenous nitrates and nitrites and routes of administration of exogenous fish NO2- and NO3-. Are considered possible mechanisms of their toxic effects on organs and tissues of fish.

Mechanisms of the toxic effect of nitrites and nitrates (NO 2’ and NO 3") on the organism of vertebrate animals. Features of the toxic impact of nitrites and nitrates in the fish organism

It is well known that NO 2 - and NO 3 - are toxic xenobiotics, whose content in the water and

food products subject to stringent rationing2 . Among the most well-known adverse effects of nitrates include their ability to block the transport processes of oxygen molecule, hemoglobin, thereby inducing hemic hypoxia . Established that the NO 2 - and NO 3 -, entering the body, are involved in the formation of highly toxic low-molecular complexes with strong genotoxic and

carcinogenic effects4 . Several publications reported that the high reactivity of nitrites and nitrates is

the cause of damage to various proteins that make up the body fluids and tissues5 . In the quoted source states that the thiol groups of proteins are most vulnerable to the adverse effects of NO 2 - .

Several studies have shown that inorganic nitrite, forming nitrosothiol complexes of blood plasma

proteins, dramatically increase their cytotoxic properties6 . In addition to direct damage to the protein molecule, nitrites can inhibit the activity of one of the key elements of the antioxidant protection of organism - peroxidase, thereby reducing the rate of neutralization of reactive oxygen species and increasing the degradation of biological macromolecules5. Given that the toxic properties of nitrites significantly higher than that of nitrate, some authors emphasize that the very real threat not only represent the nitrite anions entering the body from the outside - of exogenous origin, but also local intraorganic levels of endogenous nitrite generated by the accelerated oxidation of the molecule nitric oxide7. Fish exposed to 0.6 mmol L-1 nitrites for up to five days could be divided into responding (with elevated metHb) and non-responding individuals. Exposure

70 to 2 mmol L -1 nitrite caused a time-dependent increase in metHb to 59% of total Hb within two

days8 .

Physiological levels of recirculating endogenous nitrites (formed by oxidation of nitric oxide) in the basic biological fluids of humans and animals are fairly constant values. It is reported

that plasma levels of the central flow of human nitrites can vary between 227-428 nmol L -1 9 The

concentration of nitrites in the saliva of healthy people of reproductive age - about 7 mkmol L- 1

10-14

The concentration of nitrite in urine is very low - about 1 pmol L- 1 ., they are excreted by the

kidneys in the form of nitrates. Urinary NO 3 -excretion was 182.0 ± 11.4 pmol mmol- 1 . creatinine

(1861.2 ± 113.1 pmol/24 h) in young healthy volunteers. In elderly control subjects, urinary NO 3-

excretion was 156.0 ± 7.8 pmol mmol-1 creatinine (1717.2 ± 46.0 pmol/24 h; P = NS versus young

healthy subjects11, 15, 1 6 .

Authors 17 of the publication reported that the rate of renal clearance of endogenous nitrates are highly correlated values of their system of production. On the other hand, under the influence of exogenous nitrate content of nitrite and nitrate in serum and saliva of healthy subjects demonstrated a distinct increase after 20 min after intake 18 . These facts suggest that the clearance of physiologically active metabolites of NO - nitrites in the human body is carried by the oxidation of nitrites in physiologically inert form - nitrate (if there are no signs of hypoxia, disorders of the

endocrine status of the body 1 9 , or changes in the kidneys2 0 , followed by excretion of nitrate by the kidneys. In this case, the most accepted criteria for evaluating the metabolism of nitrates and nitrites in humans and animals are the levels of these substances in the blood plasma and the values of their excretion by the kidneys. In this regard, the literature in some detail a systematic guidelines that determine the rate of food proceeds of nitrite and nitrate in the human body, based on their content in drinking water and various food groups 21 .

The effects of nitrite, at varying concentrations (0,25 and 50 mg L - 1 ), on silver sea bream

(Sparus sarba), was assessed after 7 days exposure. Nitrite exposure resulted in an elevated

71 renosomatic index in parallel with increased kidney water content. Nitrite did cause an increase in gill sodium pump (Na+-K+-ATPase) activity, water channel protein, aquaporin 3 (AQP3) was decreased in kidneys of sea bream upon nitrite exposure. Amount of the heat shock protein 70

(HSP70) family were increased in gills, kidney and liver during nitrite exposure whereas amounts of the heat shock protein 90 (HSP90) family increased in kidneys and liver 22 .

A one-month chronic exposure of common carp larvae and embryos to nitrite revealed significant (p < 0.01) differences in total accumulated mortality in fish exposed to 33, 67, and 330 mg L"1 NO2- compared with controls. At the highest concentration, all fish died within 8 d of exposure. On the basis of accumulated mortality in the experimental groups, lethal concentrations of nitrite were estimated at 29 d LC50 = 88 mg L"1 NO2"; lowest-observed-effect concentration

(LOEC) = 28 mg L"1 NO2"; and no-observed-effect concentration (NOEC) = 7 mg L"1 NO2" 23.

Analysis of the specific features of the sensitivity of fish to the toxic effects of nitrite is well founded, since nitrite levels of body burden of fish vary in a much broader range than terrestrial vertebrates, particularly mammals, due to more features of the adaptation mechanisms of fish to environmental factors of the environment. In addition to the fact that attention is paid to the peculiarities of the sensitivity of fish to the toxic effects of nitrite in the early stages of ontogeny in the literature, we find individual information about a possible change in sensitivity of fish to the levels of nitrite stress during maturation of the gonads 24 , as well as during adaptation to changes in temperature25.25 Therefore, in the current literature makes suggestions to carry out the valuation levels of nitrites and nitrates to the fishes to the most sensitive to the toxic effects of nitrites representatives of ichthyofauna habitat26.

Analyzing the general biological principles of the toxic properties of NO2- and NO3-, it should be noted that in higher terrestrial vertebrates intake of these substances in the body due to consumption of food and water contaminated with nitrous and nitrate salts. Therefore, long-term consumption of foods high in nitrite and nitrate anions may contribute to their accumulation in the extracellular fluid of the body6 and in red blood cells7. The results of the study of renal transport of

72 endogenous and exogenous NO2- and NO3- in rats show that high levels of power of the renal clearance can prevent their retention in a single intake of large quantities of nitrite, and if the rate of food proceeds of nitrites and nitrates in the organism are within acceptable standards 20 , 27 - 29 .

In contrast, animals constantly living in water with high content of NO 2- and NO 3-, first, continuously exposed to their toxic effects, and, secondly, high concentrations of NO2- and NO3- in water, in most cases, limit the effectiveness of the physiological mechanisms that liability for their excretion from the organism 30 - 33 . The authors cited publications indicate that the most valuable commercial species of freshwater fish show a high sensitivity to the toxic effects of nitrites.

Freshwater animals appear to be more sensitive to nitrate than marine animals. A nitrates concentration of 10 mg NO3- N L-1 (USA federal maximum level for drinking water) can adversely affect, at least during long-term exposures, freshwater fishes (Oncorhynchus mykiss, Oncorhynchus tshawytscha, Salmo clarki), and amphibians. Safe levels below this nitrate concentration are recommended to protect sensitive freshwater animals from nitrate pollution. Furthermore, a maximum level of 2 mg NO3- N L-1 would be appropriate for protecting the most sensitive freshwater species. In the case of marine animals, a maximum level of 20 mg NO3-N l-1 may in general be acceptable1.

For a long time in the literature was dominated by the view that marine fish species, due to the specific physiological mechanisms of regulation of ion homeostasis and the intensity of the circulation of substances in the oceans, less susceptible to the toxic effects of nitrites34. Currently, accumulating data that the global changes of the hydrological and hydrochemical regimes of the oceans contributes to the accumulation of nitrites, not only in coastal areas of the seas, but also in pelagic waters, increasing the accumulation of nitrites and their complexes with polycyclic hydrocarbons in fish 35 .

In addition, some studies cast doubt on the high tolerance of marine fish species to the toxic action of nitrite. The grounds for such conclusions have served as the experimental confirmation of nephrotoxic effect of exogenous nitrites in some marine fish species 22 . Years of experience proves

73 that in reservoirs used for fish breeding, the levels of nitrites and nitrates in the water are subject to strict regulation, referring to the high toxicity of these compounds. Indeed, the results of modern studies confirm the existence of a direct toxic effect of nitrites on the organism of fish, which is most noticeable in the early stages of ontogeny 23 . The authors of the study showed that nitrites induce a fish fry structural-functional disorders of the gill apparatus and inflammation of muscle tissue. At the same time, most researchers emphasize the hematological effects of exogenous nitrite caused by inhibition of gas-transport function of hemoglobin 31 , 36 , 37 . The emphasis on hematological effects of nitrites is supported by data that toxic properties of nitrites may increase with decreasing concentration of oxygen in water 38 . On the other hand, it is suggested that in fish, in terms of lack of oxygen, nitrites can perform cytoprotective function 39 . Should recognize that the hematological evaluation scale toxic effect of nitrites on fish organism is widely accepted in the scientific community and has many advantages, since it is an objective to judge the intensity of nitrite body burden of fish and executed on the basis of readily available and reliable standardized methods 37 . However, despite the fact that according to some studies, changes in MetHb content in fish do not always reflect the concentration of nitrites in the environment and in the blood40, hematological evaluation criteria nitrite poisoning of fish continue to be relevant when looking markers of toxic effects of nitrites, nitrite correlated with the intensity of pressure on the fish organism41. The value of this group of methods is still in the fact that they can be predictive of tolerance of different fish species to the toxic effects of nitrites38. In some publications present experimental confirmation of the ability of nitrites to inhibit not only hemoglobin but other heme- containing proteins, including cytochrome electron transport chain of mitochondria31, 42 The search for new biological markers of nitrite poisoning of fish are carried out fairly active, as evidenced by reports of hepatotoxic effects of nitrites can also induce hemolytic anemia in fish and breach of physiological constants of acid-base balance of the organism43. Considerable importance is given to studies of tissue-specific toxicity of nitrites, the results of which indicate a high sensitivity to nitrites epithelium of the gill apparatus, as well as tissues of liver, brain and kidney of fish44.

74 Along with this, the literature contains anecdotal reports in the first place, demonstrating the need to further improve the existing regulations governing the threshold values of toxic concentrations of nitrite in water bodies26. Secondly, the authors quoted a source experimentally confirm species specificity sensitivity of fish to the toxic effects of nitrites, suggesting the further development of monitoring systems identified species of fish as bioindicators of nitrite stress in natural waters. Perhaps the sensitivity of different fish species to the toxic effects of nitrites is due to physiological characteristics of the regulatory mechanisms of ion homeostasis, determining levels of income and accumulation of exogenous nitrites in organism of fish8, 33, the species specificity of mechanisms to detoxify the nitrite anions30 and features species sensitivity of the key elements of gluconeogenesis to the damaging effect of nitrites43. Attract attention and anecdotal reports that the cation-transporting system of the gills and kidneys of fish, too, can be considered as relevant targets of the toxic effect of nitrite anions 22 .

According to the results of modern research, this aspect of the problem goes beyond the practical fish farming. Food products made from fish and other aquatic organisms, in most countries are a major source of high-grade dietary protein, and therefore, taking note of the fact that nitrites may accumulate in the body of fish, significantly exceeding the concentrations in the environment 33 ,

45, the system of health standards of fish production requires the improvement of evaluation criteria, taking into account the level of exposure of human genotoxic products formed with the participation of nitrites34, 35, 46. Possessing high reactivity, nitrites in the aquatic environment may be involved in the formation of complex compounds with other xenobiotics, including polycyclic aromatic hydrocarbons, characterized by extremely high cytotoxicity and the presence of small amounts of these complexes in natural waters can cause damage to genetic material of fish, as a possible cause of cancer diseases.

Features of the kinetics of exogenous NO 2’ and NO 3" in the fish organism

75 One of the main channels of exogenous nitrites in the body fish are the gills, regulating the

o intensity of the absorption of nitrites across the anion-transporting system . Therefore, several studies of fish species-specific resistance to exogenous nitrites and nitrates is considered in connection with the peculiarities of transport of mineral substances in the cells of the gill apparatus8,

47 . Another aspect of this research trend is the establishment of normative values of the threshold toxic concentrations of nitrates in fish, depending on the ionic composition of the water environment, since the predominance of cations in water with sodium or potassium to a large extent determines the rate of accumulation of these xenobiotics in fish tissues1. Tight conjugation process of absorption of nitrites from the environment with the mechanisms of chloride reabsorption gill epithelium leads to a massive accumulation of nitrite anions in the body of fish even with a slight increase in their concentration in the external environment8. On the other hand, in the literature, there are experimental confirmation of the view that the low rates of transport of chloride ions in the gill epithelium of freshwater fish species cause the decrease in the accumulation of exogenous nitrite-anions32. In addition, the weakening of the influx of nitrite from the environment, regardless of the expression of chlorine-transporting proteins in the gill epithelium of freshwater teleost fishes, observed with increasing concentration of chloride ions in water, due to the competitive environment of the anions chloride and nitrites, as well as comparative values parameter Km for Cl- and NO2- anions to the transport protein48. It is shown that the transport protein that carries Cl-

/HCO3- antiport in the gill apparatus responsible for the accumulation of nitrites in the body are only bony but phylogenetically more ancient species of fish45.

Thus, the analysis of these data leads to several conclusions. Firstly, a freshwater fish the main channel of entry into the body of exogenous nitrites are gills. Secondly, the process proceeds nitrites and nitrates from outside the body of fish, to a minor extent provided by passive diffusion.

Mass transfer the main part of nitrites is regulated by an indirect means of transport, enabling the movement of nitrites (the rate of absorption of nitrates below), even against a concentration gradient and ability to form higher in comparison with the external environment, the levels of accumulation

76 of these substances in the extracellular fluid of fishes.

However, a number of publications consider the role of ion-transporting systems in the intestine of fish entering the nitrite anions in the internal environment31, 48. It is emphasized that in contrast to freshwater species, which absorb nitrates through the anion-transporting system of the gill apparatus, the marine fish species considerable amounts of nitrites are absorbed in the intestine 48 . The authors quoted a source, using his studies of selective pharmacological inhibitors of transport proteins, offering Cl-/HCO3- antiport and Na+/K+/2Cl- - cotransport, proved that in the intestine of marine teleost fish intake of nitrite-anions is due to Na+/K+/2Cl- - cotransport.

Nitrites that accumulate in the extracellular fluid of fish, may be neutralized by oxidation to less toxic form - nitrates, which, in turn, appear together with other products of catabolism by the kidney or the gills 31 . Along with this, significant amounts of nitrites can enter red blood cells 31 , 47 .

Were previously obtained evidence that human red blood cells can accumulate nitrites in an amount

n substantially higher than their content in the intravascular fluid . Therefore, the study of erythrocyte depot and transport of nitrites in fish, in addition to practical value, promote the formation of a coherent picture of the phylogenetic aspect of this problem by comparing the metabolic pathways of nitrites in a nuclear-free red blood cells and red blood cells that contain the kernel. Same applied to the subject of this manuscript is of interest reported that nitrites are absorbed and reduced to nitric oxide (NO) in the presence of hemoglobin of red blood cells of fish through mediated transport, the intensity of which varies depending on the availability of oxygen and the state of acid-base balance47.

Currently, a lot is known about the role of hemoglobin in the metabolism of nitrates and nitrites, is regarded not only as toxic xenobiotics, but also as a transport form of NO3, 49, 50.

However, the literature gradually accumulate information that is not only hemoglobin but other heme-containing proteins, such as myoglobin and its isoforms may be involved in the metabolism of endogenous and exogenous nitrites 39 . Results of experimental studies obtained by the authors cited publications demonstrate that this family of heme-containing proteins, firstly, is directly

77 involved in the adaptation of fish to the conditions of oxygen deficiency, determinated species- specific resistance to hypoxia. Secondly, myoglobin and its isoforms have nitrite reductase activity.

Significance of this fact for understanding the reactions of fish to exogenous nitrites requires a deeper investigation. However, comparison of data on the levels of expression of myoglobin and its isoforms in different organs and tissues of fish 39 and information about the organ-toxic effects of nitrites44, is consistent with previously expressed in the literature point of view that the toxic effect of nitrites on the organism of higher vertebrates33 and fishes31 31 is largely realized through their involvement in the natural physiological mechanisms of synthesis, resynthesis and transport molecule nitric oxide and its metabolites.

The role of nitrogen oxide cycle in the metabolism of NO 2’ and NO 3" in the fish organism

The term "cycle of nitric oxide" refers to the presence of the organism contained in a single cycle of biochemical reactions of interconversion of the molecule nitric oxide (NO) and its major metabolites, nitrites (Na+/K+/2Cl- ) and nitrates (NO3-) of endogenous origin. Enzymes and proteins

(xanthine oxidase, hemoglobin, and possibly myoglobin) with the nitrite reductase activity, as a substrate molecule did not use L-arginine, and nitrite - in the thermodynamic properties are easily reduced to nitric oxide. However, under hypoxic conditions (systemic or individual organs ischemia) as a substrate are widely used nitrates 3 , 51 . Desirability of the existence of such a cycle due to the need for rational use of biologically valuable substrate - the amino acid L-arginine consumed NO-synthase complexes during the arginine-dependent synthesis of NO. The high reactivity of NO molecules creates favorable conditions for its acceptance of the proteins of blood plasma and red blood cell cytosol52, 53 or rapid oxidation of the molecule to NO2- and NO3- 54

Expressed in earlier publications the view that endogenous nitrites and nitrates (oxidation products of NO) may be regarded as transport forms of the molecule NO3, was confirmed49 the results of further studies of the regulatory physiological role of nitrites and nitrates, are constantly present in

78 the extracellular fluids. The original method of research, based on the inhaled short-lived molecule nitric oxide in the human body to detect possible regulatory effects of NO outside the pulmonary circulation, which confirms the presence of transport forms of NO 53 . However, without denying the involvement of nitrites in the regulation of vascular tone and blood aggregation, the authors believe that still the main transport form of nitric oxide are complexes of NO with hemoglobin and thiol groups of proteins of blood plasma 53 .

The results of most earlier studies of the kinetics of NO and its metabolites in mammals

revealed that the water-soluble products of NO oxidation the kidneys55, 5 6 . The authors also found that the rate of release by the kidneys of the oxidation products of nitric oxide molecules - endogenous NO 2- and NO 3- increase in proportion to the intensity of the system output NO, thereby demonstrating that the parameters of renal clearance of endogenous NO 2 - and NO 3 - can serve as a marker of systemic products nitric oxide. In further studies, it was confirmed that the magnitude of renal excretion of endogenous nitrites and nitrates is positively correlated with the values of system output NO 17 . A more detailed study of the dynamics of concentrations of nitric oxide and nitrates in plasma shows that the nitrate concentration in the extracellular fluid of the body corresponds to the

rate of production of NO in the body5 4 . From these positions are of interest information about the data studying the kinetics of the oxidation of NO in the lumen of blood vessels in human in vivo, according to which the sharp fluctuations in NO production are reflected in the first place, the

content of nitrite in blood plasma9 . On the one hand, the kidneys are the main channel of excretion of mammalian soluble products of exchange reactions, including endogenous nitrites and nitrates, however, the linear dependence between the values of load and tubular excretion of NO metabolites was confirmed only for nitrates - mainly excreted from the body fraction of the oxidation products

of NO 5 7 .

Note that the rate of absorption of exogenous nitrite epithelium of the gill apparatus of fish is also higher than similar values for the transport of nitrate anionsl.

In the fish organism, as well as in higher vertebrates, the endogenous precursor of NO 2 - and

79 NO3- is a molecule of nitric oxide - NO 58 . In fish of NO has important regulatory functions, taking part in the management of the cardiovascular system58, 59, 60, the homeostatic functions of the gill apparatus8,8 39, 39 cytochrome electron transport chain of mitochondria8, 8 the reproductive system of fish 5 , 24 . In turn, the process of NO synthesis is regulated by NO-synthase, using as a substrate amino acid L-arginine. In this case, NO chemically unstable molecule, its life expectancy is measured by several tens of seconds. Directly in tissue NO is rapidly oxidized to NO2- and NO3-, which, in turn, can be used as substrates in the resynthesis NO, thus fulfilling the role of fish in the

o body of the transport form of nitric oxide . Basic physiological mechanisms of interconversion of

NO, nitrites and nitrates in the tissues of fish, in general, coincide with the views on the principles of the functioning cycle of nitric oxide, formulated for higher vertebrates . The results of recent research show that the intensity of fish nitrite (nitrate)-reductase contour cycle of nitric oxide synthesis may sharply increase in oxygen deficiency33,33 59.59 It has been suggested that a lack of oxygen stimulates the organ- and species-specific ways to utilize endogenous nitrites to their intracellular accumulation and a more rational use of nitrite reductase chain reaction58-62. In addition, the found experimental evidence suggested that exogenous nitrites in fish can also be included in the nitrite reductase circuit synthesis NO8, 63, 64 In the quoted source attracts the conclusion that the main channel of entry of exogenous nitrites in freshwater fish are the gills, by regulating the absorption of nitrite anion-transporting system of the gill epithelium. Possibly present in the fish-specific heme-containing proteins that perform the function of maintaining the balance of the activity of arginine-dependent nitrite (nitrate)-reductase contours nitrogen oxide cycle, determine the level of resistance of fish species to oxygen deficiency and the effectiveness of organ protection mechanisms against reperfusion injury39.39 In turn, the species-specific resistance of fish to

8 47 high concentrations of exogenous nitrites , may depend on the intensity of the transport of mineral substances in the cells of the gill apparatus, the rate of accumulation of nitrites in the intracellular sector and the efficiency of hemoglobin-dependent resynthesis NO.

On the other hand, a sudden burst of activity intraorganic arginine-dependent NO synthesis

80 can cause growth intraorganic and systemic concentration of endogenous nitrites in fish. In particular, at certain stages of maturation of oocytes recorded a significant increase in the concentration of nitrite and nitrate anions in the tissues of the gonads and blood plasma of fish 24 .

The authors cited sources that the concentrations of chemically stable metabolites of NO in the ovarian tissue of fish reach a maximum in phase previtellogenesis, however, sharply declining in the phase of vitellogenesis, indicating the important role of NO in the control of reproductive functions of fish, as well as prospective analysis of the dynamics of NO metabolites as an indicator of the state of oogenesis in fish.

Thus, the literature presents data on how the body processes occur fish metabolic clearance of NO, due to the oxidation of molecules in a chemically stable compound - nitrite and nitrate anions. Selected publications disclose specifics intraorgan mechanisms maintaining the balance of the activity of arginine-dependent nitrite (nitrate)-reductase of the contour cycle of nitric oxide.

Expressed changes that in fish metabolism of nitrites exogenous origin may be closely related with the activity cycle of nitric oxide using fish of exogenous nitrites as substrates in reactions resynthesis NO. However, attention is drawn to the following pattern - the authors of most-cited publications recognize that normally the content in the extracellular fluid of fish physiologically active metabolites of NO - endogenous nitrites is constant8, 24, 39, 47, 63, 64. Taking note of the reasoned reviewed publications in the importance of the physiological role of nitrites to fish, the existence of specific mechanisms that determine their kinetics in the body, as well as well-defined ranges of concentration in the extracellular fluid, it can be assumed that normally the level of nitrites is a physiological constant. However, the mechanisms responsible for maintaining the stability of their level, including not only the accumulation in tissues and conversion, but the selection of the body are small and require more in-depth research.

In recent years this area has received increasing attention. On the one hand, the number of publications devoted to this problem is relatively small. However, the fundamental nature of the studies24, 33, 39, 47, 63, 64 goes beyond the interests of ichthyology, ecology of the water biocenosis and

81 fisheries science.

As an illustration of the stated thesis is appropriate to the unique results of analysis of nitrites and nitrates in blood plasma of fish in comparison with the concentrations of nitrites and nitrates in the aquatic habitat of fish, occupying different positions in the taxonomic hierarchy33.33

Moreover, the authors studied the effect of hypoxia on the level of nitrites in the blood plasma of the studied species. The obtained results showed well-defined species boundaries fluctuations concentrations of nitrites and nitrates in blood plasma of fish. Using as objects of study of fish caught in their natural habitat, and fish that were given in the hydrochemical conditions of artificial content, the authors were able to establish that the observed in a number of cases (trout), a significant excess of nitrites and nitrates blood over those in the water, most likely is not related to the accumulation of exogenous nitrite and nitrate anions, due to retentions own products of oxidation of the molecule nitric oxide. It should be noted that the quoted work is interdisciplinary in nature, opening up new areas of research in the field of phylogeny of nitric oxide and its role in the regulation of physiological functions of vertebrates. The authors of this publication and some other studies2424 can be traced fairly obvious interdependence of the intensity of NO synthesis in arginine- dependent circuit loop and the presence of endogenous nitrates and nitrites in the extracellular fluid.

Perhaps, the observed pattern on one side, contains indications that the process of formation of arginine-dependent nitrite (nitrate)-reductase contours cycle proceeded in parallel.

Thus, our analysis of the literature shows that nitrites and nitrates in the water even at concentrations not exceeding the toxic threshold may represent a potential danger to fish, because not yet fully deciphered by physiological mechanisms designed to hold in the extracellular fluid metabolites of endogenous NO contributing to the accumulation of optimal values of the concentration of nitrite and nitrate anions in the fish. Carefully reading the results 33 , we can assume that these mechanisms in fish still incomplete and in some cases accompanied by a surge of endogenous NO production and increase the reaction rate of oxidation observed in conditions of oxygen deficiency33 or at certain stages of the reproductive cycle of fish24, 60, 61, there may be a

82 significant increase in systemic concentration of endogenous quantities of nitrite and nitrate. On the other hand, the effectiveness of their anti-retention and negative effects on various organs and tissues of fish can be mitigated by the presence of these compounds in the environment and insufficient capacity of the physiological mechanisms that determine the tolerance of fish to this

39, 47 group, a nitrogen-containing compounds39, 4 7 .

Conclusions

The analysis published in the literature of studies have shown the relevance of studying the metabolism of nitrates and nitrites in fish. Intake of these substances into the aquatic environment, partly due to the vital functions of aquaculture facilities. In this case, a significant contribution to the accumulation of nitrites and nitrates contribute natural oxidation of ammonium cations bacterial microflora.

However, the most relevant sources of income of nitrites and nitrates in the water environment are now the objects of human activities contributing to the growth levels of nitrites and nitrates not only in inland waters, but also in the oceans. These nitrogen-containing substances are highly toxic. Mechanisms of their toxic effect is not fully understood. Along with this, in literature there are some reports showing that the true threshold of toxicity of nitrites can be characterized by a lower level of their content than it is enshrined in the existing regulatory levels. Also, the question remains open of the combined toxic effect of nitrites (nitrates) and ammonium (ammonia).

Attracts attention and the fact that in the past, literally, a few years appeared in the literature publications containing validating the physiological significance of nitrites and nitrates endogenous origin, formed during the oxidation of the regulatory molecule nitric oxide. Such work, on the one hand, allow us to consider a number of physiological and biochemical problems of an interdisciplinary nature. On the other hand, they provide the methodological basis for further study and scientific substantiation of allowable levels of nitrites and nitrates in the aquatic environment.

83 Taking note of this critical information, we can assume that the threshold values of toxic concentrations of nitrites and nitrates may have species specificity. As is normal in conditions of artificial content in compliance with all environmental requirements for chemical composition of water, most bony fish demonstrate that endogenous levels of nitrites and nitrates in blood plasma significantly exceed the concentration of these substances in the waters of the natural habitat of the species under study.

Open Access

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Received: 05.05.2012. Revised: 25.12.2012. Accepted: 25.01.2013.

91 Journal of Health Sciences (J o H Ss) 2013; 3(2): 92-114 The journal has had 4 points in Ministry of Science and Higher Education of Poland parametric evaluation. List B item 683.

Features of physiological mechanisms control fluid and electrolyte balance in fishes

Sergey Dolomatov 1 , Walery Zukow 2 , Nikolay Novikov 3 , Magdalena Hagner-Derengowska 2, Iwona Jaworska2, Monika Kozestanska , Marek Napierała4, Radosław Muszkieta4, Anna Nalazek2, Ewa Trela5, Jerzy Eksterowicz4

1Odessa State Environmental University, Odessa, Ukraine 2Radom University, Radom, Poland 3Crimea State Medical University, Simferopol, Ukraine 4Kazimierz Wielki University, Bydgoszcz, Poland 5Collegium Medicum UMK, Toruń, Bydgoszcz, Poland

Abstract The review presents data on the characteristics and mechanisms for maintaining the regulation of physiological constants of water and salt balance in fishes. The information about the role of major ion-transporting systems that carry out the absorption of salts from the environment of freshwater fish, or providing inflow and retention of water in marine fish, as well as about their role in adaptation of fish to seawater and to hyper-sodium diet.

Key words: fish; osmotic homeostasis; ion homeostasis; humoral mechanisms; water-salt metabolism.

Introduction

In contemporary literature great attention is paid to maintain the physiological mechanisms of the constants of water-salt balance in fishes, depending on age and conditions of the environment, since the range of problems affecting the most important aspects of fundamental biology and aquaculture science practical issues (Pritchard, 2003; Evans et al., 2005; Evans, 2008;

McCormick et al., 2009; Madsen et al., 2009). It is only natural that the elucidation of the mechanisms of water-salt balance in the body focuses on the functioning of complex systems of transport of ions, their interaction, role in the adaptation of fishes to various hydrochemical parameters of the environment and the principles of the humoral control of the constancy of the ionic composition of extracellular fluid and osmotic homeostasis of the physiological constants fish

(Pritchard, 2003; Evans et al., 2005; Evans, 2008). Numerous studies show that fish one of the main 92 bodies of the efferent regulation of water-salt balance is the gill apparatus in the cells which occur most important transport processes that allow the fish to accumulate the necessary amount of sodium chloride and divalent cations in the habitat of freshwater or provide retention in the body of osmotically free water, and effectively remove excessive amounts of sodium chloride and divalent ions from the body of bony fishes in the sea. The parameters of water-salt balance in vertebrates are strictly regulated intraorganic and neuro-humoral control, providing a constant volume and chemical composition of body fluids, intravascular volume and the volume of cells that make up the body (Strange, 2004; Antunes-Rodrigues et al., 2004 .) Therefore, an important point of analysis of the features of water-salt balance of the fish is to study the basic principles of the efferent organs, which, along with the implementation of the ionosphere, osmotic-and volemic -regulatory functions, direct control processes ensure that the acid-base balance and excretion into the environment of water-soluble metabolic products.

1. Phylogenetic aspects of the physiology of water and salt homeostasis in fish

At the beginning of this manuscript believe it is important to stress that the modern idea of the state transport of ions and water in the fish, depending on their environment, adequately described in a number of review publications (Evans et al., 2005; Evans, 2008). The information cited in the systematic sources is consistent with the notion that maintaining the optimal level of sodium in the body is one of the basic conditions for the observance of which is vital in ensuring the constancy of the ion, the acid-base, osmotic homeostasis and volemic, as well as the physiological flow of metabolic processes in vertebrates (Lang et al., 1998; Reilly, Ellison, 2000; Feraille, Doucet,

2001; Loffing, Kaissling, 2003; Page, Di Cera, 2006). In this case, the fish, because of their phylogenetic and specific features of the environment, compared with mammals, have a number of very significant differences in the homeostatic processes, the main of which - the role of the gill apparatus, as the main body of efferent control of water-salt balance. Reviews of published studies

93 have convincingly demonstrated that a significant amount of work performed by the gill epithelium, which is aimed primarily at maintaining constant water-salt metabolism (Pritchard, 2003; Evans et al., 2005; Grosell, 2006; Nilsson, 2007; Evans, 2008; Wright, Wood, 2009). Reliable quantitative measure of the intensity of transport processes is the amount of energy, covering the needs of the gill apparatus of fish in maintaining the balance of salt and fluid in the body (Nilsson, 2007).

Accents, placed in the cited source, in our opinion, give the sound of two crucial arguments indicated above, the role of sodium balance in the stability of the physiological constants of water- salt metabolism and energy related quantities in fish. Consequently, carrying out a comparative analysis of the mechanisms attempt to maintain homeostasis of water and salt fish and higher vertebrates, while keeping the brackets the conditions and causes the transition from gill to lung breathing type and strengthening the role of the kidneys in the management of water-salt balance of the body, we take as a basis the most energy-consuming mechanisms of balance of sodium, which create the conditions necessary to keep the basic physiological constants of water and salt homeostasis in the range of optimal values.

In connection with the arguments in the future, drawing parallels between the key steps in the implementation and monitoring of water-salt metabolism in fish and mammals, we will be guided by just such assessment scale. On the other hand, features of structural and functional parameters of efferent control of water and salt homeostasis, fish and mammals are also under consideration. As for direct comparisons of the base of the efferent water-salt metabolism in fish and mammals, we can talk, mainly on the kidneys. In the phylogenetic aspect of the development of renal function is closely associated with increased renal blood flow, increased glomerular filtration rate and intensification of the tubular transport of substances in parallel with a significant increase in energy metabolism in kidney tissue (Natochin, 1988). The sharp increase in the intensity of transport processes in the kidney improved the precision and power of regulatory mechanisms and the chemical composition of water basins of the body. The structural and functional unit of the kidney is the nephron. The presence of the regulatory mechanisms of intrarenal autoregulation,

94 along with central neuro-humoral control the activities of the body can maintain the balance of the filtration, reabsorption and secretion at the level of individual nephrons and their populations in accordance with the chemical composition of the extracellular fluids. Thanks to the finely coordinated work of various segments of the nephron, and populations of nephrons realized homeostatic function of the body as a whole. Analysis of the kidneys in an evolutionary perspective suggests that the values of glomerular filtration and tubular transport of substances reach maximum levels in the kidney of mammals (Natochin, 1988). According to the author these features allow the animals with a high level of energy and plastic exchange more efficiently and accurately adjust the parameters of the extracellular fluid of the body (fluid volume, acid-base balance, ionic and osmotic homeostasis).

Like some populations of cells of gill epithelium, characterized by the most intense ion transport (Evans et al., 2005), some populations of tubular epithelium of kidneys of mammals, principally responsible for maintaining the balance of sodium and fluids in the body (Reilly, Ellison,

2000; Feraille, Doucet, 2001), highlighted a high density of mitochondria, which are also, as in the branchial epithelium, located in the basolateral pole of cells in direct contact with the sodium / potassium-transporting ATPase. Such features of the ultrastructure of the gill epithelium of a rich population of mitochondria, like the cortical layer nephrocytes kidneys of mammals, can effectively maintain the desired values of the electrochemical and concentration gradients at the plasma membrane of cells, forming a driving force for intensive transport processes at the apical and basolateral poles of cells (Evans et al., 2005). For these same reasons, the kidneys of mammals

(especially cortical layer body) and the gills of fish that are sufficiently small weights, show maximum values of specific indicators of energy expenditure and is closely related hemodynamic parameters in comparison with other organs and tissues (Evans et al ., 2005; Nilsson, 2007).

It should be emphasized that the state of sodium transport in the gill epithelium of fishes is crucial for the implementation of the excretory and acid secretory body functions, whose implementation in freshwater teleost fish species are directly involved Na +-K +-ATPase, Na + / H

95 +-countertransport and sodium epithelial channels (Evans et al., 2005; Grosell, 2006; Parks et al.,

2009). In mammals, the vast number of protons in the process of regeneration of bicarbonate buffer, is also out of the body in a bound form, mainly due to the ammonium phosphate buffer systems, or tubular (luminal) fluid in the proximal nephron. Excretion of protons into the lumen of the tubule is carried out by nonelectrogennic sodium / proton countertransport at the apical pole of proximal nephrocytes when a concentration gradient for sodium cations, formed by the Na +-K +-ATPase on the basolateral membrane provides a positive input of the unit charge of sodium ion in exchange for a proton. In our view, it is important to note that the gill epithelium of fish, as well as the kidneys of mammals, the major release number of protons in the bound form, attaching them to ammonia to form ammonium (Seshadri et al., 2006). Important contribution to the mammalian kidney acid excretion phosphate buffer system makes the luminal fluid.

Preferably, a freshwater fish teleost species, the process of secretion of protons V-type H +-

ATPase is regarded as one of the central mechanisms and not only acid acid secretory ionoregulation functions branchial apparatus, but also excretory to ensure effective elimination from the body of the final product of nitrogen metabolism - ammonia (Evans et al., 2005; Wright, Wood,

2009; Weihrauch et al., 2009). At the time, as in the kidney of mammals the major number of protons in the lumen of the tubule derived by nonlectrogennic sodium / proton countertransport

(Thekkumkara et al., 1998), although the V-type H +-ATPase is also represented in the kidney of mammals - in collecting duct intercalated cells (Breton, Brown, 2007) and is not directly related to the metabolism of ammonia. In our view, it is important to note that the main differences homeostatic functions of the gill apparatus, and kidneys of mammals, most likely due to the measure of the efficiency of utilization of ion-transporting systems, achieved in mammals by increased accuracy and power of regulatory systems to reduce their energy consumption against the background. In particular, the characteristics of transport of sodium and proton secretion of ammonia in the kidney of mammals suggest that, in comparison with similar transport processes in fish, their level of organization in the mammalian kidney, is higher. Since the mechanism of proton

96 secretion in the proximal nephron segment, carried out by facilitated diffusion, less power consumption. In addition, the activity of the sodium / potassium-ATPase of proximal nephrocytes

(Therien, Blostein, 2000), the rate of absorption of oxygen (Welch et al., 2005), the rate of secretion of ammonia (Nagami, 2002) and the level of expression of the sodium / proton-exchanging protein

(Thekkumkara et al., 1998) are under the direct control of complex multilevel system of intrarenal production of angiotensin-II, which allows to provide the best possible coordinated work of all these transport systems.

Transport of sodium in the gills of fish is also regulated by humoral control systems (Evans et al., 2005; Evans, 2008), modulating their functional activity in response to changes in salt concentration in the external aqueous environment and extracellular fluids of fish. At the same time, the data presented by the authors cited review publications can identify a number of features in the humoral control systems of water-salt metabolism of fish. Firstly, the main regulators of the functional changes in the gill apparatus of fish to adapt to different levels of salinity of the water environment, most likely the prolactin and cortisol. Secondly, the levels of secretion of arginine- vasotocin (similar to arginine vasopressin in higher vertebrates), and angiotensin-II (fish angiotensin-II also has different primary structure compared with the octapeptide mammals) may be changed under the influence of fluctuations in the concentration of sodium. At the same time, although the literature mentions the possible role of angiotensin-II and arginine-vasotocin in the regulation of ion transport, yet the focus is on cardiovascular effects of regulatory peptides (Brown et al., 2000; Imbrogno et al., 2003; Evans et al ., 2005). Then, as in the kidney of mammals vasoactive properties, in particular, arginine-vasopressin is much weaker in comparison with tubular effects. Third, the results of the studies presented in the surveys indicate that the sensitivity of the system osmoreception fish is somewhat lower than in mammals. The basis for this conclusion are the data that the branchial epithelium, which is one of the elements of osmoreception reacts value changes in membrane potential when exposed to the basolateral pole of the cell osmotic stimulus with a force of about 50 mOsm / kg H2O (Evans et al., 2005). That is, to the extent of extracellular

97 fluid osmolality of 50 mOsm / kg H2O. Then, as in mammals, very slight deviations of system variables osmolality are a signal to enhance or suppress the secretion of arginine vasopressin.

Perhaps the need for more accurate control mechanisms of osmotic homeostasis is relevant, for example, euryhaline fishes during adaptation to different levels of water salinity, whereas fish are constantly living in the mid-latitude freshwater or sea do not experience sharp fluctuations in the osmotic stimulus (Evans et al. , 2005; Evans, 2008). Thus the branchial epithelium in direct contact with the external aqueous medium, which is not subject to regulation and a reasonably stable ionic composition. Then, as the quantity of glomerular filtration rate and tubular epithelium of the functional activity of mammals can be changed under the influence of fluctuations in sodium balance in the body through the tubulo-glomerular feedback (Thurau, Schnermann, 1998;

Schnermann, 2003). It should be noted that the evolutionary (Denver et al., 2009; Johnson, Olson,

2009; 2009a; Gwee et al., 2009) and environmental (Tse et al., 2007; Hoshijima, Hirose, 2007) aspects of humoral regulation of water-salt metabolism in fish is one of the most urgent areas of research.

2. Extrabranchial mechanisms of regulation of water and salt homeostasis of fish

In the previous section conducted a brief analysis of the major transport systems responsible for ensuring that the ionic composition of the water sector on fish, as well as humoral mechanisms of their control. It is recognized that a major efferent regulation of body water and salt balance in fish are the gills. Making emphasis on the role of ion-transporting proteins, represented in the gill apparatus of fish and renal parenchyma of mammals in maintaining water and salt homeostasis, we do not in any way trying to minimize the significance of the evolutionary aspects of structural and functional bases of the regulation of homeostasis and organogenesis process in vertebrates certainly worthy of consideration in an independent review. We only note that the mammalian kidney and gill apparatus in fish are the main but not the only bodies involved in regulating the balance of salts and

98 liquids. For example, in mammals an important role in these processes is given organs of digestion.

Indeed, the reabsorption of minerals in the digestive tract is one of the first stages of an adequate control of exposure (Shi et al., 1994). According to figures released in the cited paper, the value of the contents of the small intestine osmolality close to that of extracellular fluid osmolality and is fairly constant. On the other hand, the osmolality of blood is essential in the management of the reabsorption of sodium in the small intestine and the maximum reduction in sodium reabsorption in the small intestine was observed with the introduction of hyperosmotic solution into the portal vein

(Morita et al., 1993). The authors express the opinion of the reflex nature of this mechanism. In addition, shows a close correlation between levels of bioelectrical activity of the nerves of the liver and renal excretion rates of sodium and chloride ions in response to intragastric administration of sodium chloride to dogs (Matsuda et al., 1996). Established that the electrical activity of the liver osmoreceptors has a direct impact on the neuroendocrine control of osmotic homeostasis level

(Morita et al., 1997). Research results suggest that osmoreceptors may be located as well in some parts of the intestine (Osaka et al., 2001). In this case, the gradient between the lumen of the gastrointestinal tract osmolality and extracellular fluid, apparently, is the most important factor.

Perhaps the reaction of the gastro-hepatic vascular circuit in response to intragastric administration of hyperosmotic saline solution may include other mechanisms associated with the release of physiologically active substances by specialized cells in the intestine, such as vasoactive intestinal peptide (VIP) (Hawley et al., 1991) . These findings suggest that metabolic clearance of

VIP significantly reduced under the influence intragastric administration of hyperosmotic sodium chloride solution. Along with the natriuretic effect of its own VIP has a direct impact on the content of angiotensin-II in blood plasma, and intravenous infusion of VIP animals kept on hypersodium diet, accompanied by a pronounced increase in the clearance of angiotensin-II (Davis et al., 1995).

The authors suggest that this mechanism provides a more rapid excretion of excess amounts of sodium by the kidneys, as against the background of hypo-and normosodium significant changes in the diet the rate of secretion and clearance of the hormone have been identified. It is shown that

99 hypersodium diet in rats subjected to denervation of the liver generates a positive sodium balance and blood pressure increase, while, as in intact animals hypersodium group and denervation of the liver in the diet normosodium such changes were observed (Morita et al., 1995) . Most authors agree that the receptor field of the portal vein of the liver belong to one of the key places in the system control osmotic homeostasis (Bourque et al., 1994; Castellano et al., 1994). A comparative study of the sensitivity of osmoreceptors and the jugular vein of the liver showed that an indicator such as the volume of fluid consumed by rats in response to a saline solution into the portal vein of the liver are less likely to change, compared with the introduction of solutions into the jugular vein

(Kobashi, Adachi et al ., 1993). Experimentally proved that the denervation of the liver in rats causes a decrease in diuresis and natriuresis values in response to acute osmotic stress (Ming et al.,

2001). On the one hand, these observations indicate the existence of reflex mechanisms in the interaction inter organs liver and kidney in response to extracellular osmolality changes in the parameters of body fluids. On the other hand, the authors emphasize that a similar effect was observed when administered adenosine into the portal vein of the liver.

Considering the role of the digestive system in the regulation of water-salt metabolism in mammals, in our opinion, it should be recalled that in the human body is normally formed within days to 2 liters of saliva, more precisely, the oral fluid, which should be completely reabsorbed

(Tarasenko et al, 2002). In this case, fairly stable composition of saliva hipoosmotic support mechanisms transepithelial fluid transport and mineral osmolytes parenchyma of salivary glands

(Ma T. al., 1999; Matsuzaki et al., 2004). It is reported that the rate of transport of mineral transepitelial osmolytes and water plays an important role in maintaining the stability of the basic physical - chemical parameters of oral fluid (Evans et al., 2000). It was also established that the discussed mechanisms are closely linked to the system parameters of osmotic homeostasis (Walsh et al., 2004). On the other hand, is an experimental confirmation of the view that there autonomous control systems transport water and salts in the oral cavity, conducive to maintaining a stable transepithelial osmotic gradient (Ma et al., 1999; Nejsum et al., 2002).

100 Briefly mentioning the role of natriuretic peptides in the control of water-salt balance in mammals, it should be noted that Atrial natriuretic peptide (ANP) is a key factor in the regulation of humoral volemicheskogo homeostasis thus reducing the plasma ANP may contribute to retention of fluid, increased blood pressure and disruption of the heart (Wang et al., 2007). However, in addition to this, in the literature is increasingly drawing attention to the involvement of natriuretic peptides in the control of basic metabolic processes (Miyashita et al., 2009), including cell cycle regulation

(Hannken et al., 2001), the regulation of carbohydrate and lipid metabolism and inflammatory responses (Wang et al., 2007).

With regard to the study of water-salt balance of fish, for obvious reasons, studies on mechanisms of formation and reabsorption of saliva are not relevant. On the contrary, fluid metabolism, the main mineral osmolytes extracellular fluid of vertebrates - sodium and chlorine ions, and divalent ions occurring in the intestine, extremely important for the regulation of water- salt metabolism of fish (Evans et al., 2005; Evans, 2008). Most authors emphasize the crucial role of various gastro - intestinal tract in the osmoregulation of marine teleost species of fish and in euryhaline teleosts to adapt to salt water, focusing on the evolutionary aspects of formation of these mechanisms (Evans et al., 2005; Grosell, 2006; Evans, 2008). In modern literature the prevailing view that that in the initial parts of the digestive tract (from esophagus) of marine teleost fish species is an active absorption of salts from the fauces of sea water, excess of which is removed by the secretion of population gill epithelium, rich in mitochondria, and the activity of the complex ion-transporting systems located distal gastrointestinal tract creates conditions for effective absorption of fluids (Evans, 2008). At present, sufficiently studied in detail the unique molecular and cellular mechanisms of these complex processes, allow to maintain a constant flow of water into the body of bony marine fish species, preventing the accumulation in the extracellular fluid of divalent cations and anions (Grosell, 2006). The author cited the review also draws attention to the presence of humoral control of intestinal transport systems in marine species of lower vertebrates.

101 In freshwater teleost species in the extracellular fluid retention of minerals by the gill apparatus a selection from the body of large amounts of osmotically free water is largely determined by water excretory renal function (Evans et al., 2005), at the same time, transport of salts in the digestive tract of freshwater fish also plays an important role in the management of water and salt balance in the body, as the amount of sodium chloride intake in the intestine, can be significantly greater than that of the branchial apparatus, which is indeed very important, when the pH of the water habitat of freshwater fish and reduced homeostatic functions gill epithelium are in a depressed state (Bucking, Wood, 2006). The authors emphasize that the rate of reabsorption in the gastrointestinal tract (GIT) of sodium, potassium and chloride, in food freshwater teleost fish species may depend on the state of water-salt balance in the body of fish and the physicochemical parameters of the environment, with various departments of the digestive tract of freshwater fish demonstrate the ability to a high excretion of fluid.

On the other hand, in fish precise coordination of the movement of fluid through the plasma membrane of cells, depending on the hydrochemical conditions of the environment, possible pore- forming proteins, thanks to the family of aquaporins - AQP. Results of the study of the dynamics of expression of different isoforms of AQP gastro - intestinal tract Atlantic salmon during smoltification and adaptation to life in seawater showed that in the digestive tract of this type revealed the following representatives of AQP: AQP-1a,-1b, -3 (in the esophagus),-8a,-8b, and 10

(small amounts are present in the intestine) (Tipsmark et al., 2010). The authors conclude that, that the increase in the expression in the gastrointestinal tract AQP-8b protein isoforms occurs during smoltification and acclimatize to the conditions of sea water and is a key event in the restructuring of AQP.

Considerable attention is paid to studying the mechanisms of integration of major physiological systems of control of water - salt metabolism in the adaptation of fish to life in sea water and different rates of consumption, salt freshwater fish. The results of studies conducted in this direction for adult specimens of rainbow trout (Oncorhynchus mykiss), the experimental

102 conditions contained in fresh water, adapted to sea water or treated with diet hypersodium content in fresh water, allow the authors to state that in fishes mechanisms volume-, ion- and osmotic- regulation is qualitatively different from those of terrestrial vertebrates (Olson, Hoagland, 2008).

The findings in the cited manuscript indicate that as the fish adapt to sea water and diet hypersodium is a well-defined alteration of transport of water and salts, not only in the gill epithelium, but also in different parts of the intestine, and kidney. The results of previous studies have shown that under similar experimental conditions diet hypersodium causes an increase in fish intravascular volume and glomerular filtration rate against the trend towards the concentration of sodium and chloride ions in the extracellular fluid (Chen et al., 2007). However, it has been suggested that it was studying the principles of forming response of the circulatory system of fish at different rates of intake of salt or osmotically free water will most effectively reveal the problem osmoadaptation fish (Olson, Hoagland, 2008). If you follow the logic of the authors, it becomes clear why so much attention being paid to the effects of major cardiovascular humoral regulation systems of water-salt metabolism in fish (Brown et al., 2000; Evans et al., 2005; Johnson, Olson,

2009). Because the filtering process in the kidneys of fish, unlike terrestrial vertebrates, a phylogenetically ancient mechanism presented, when the rate of renal excretion of substances is largely determined by their rate of tubular load, we can agree with that caused by hypersodium dietary modulation parameters in the system and intraorganic blood flow can be regarded as one of the main reasons for increasing the volume of ultrafiltrate (Chen et al., 2007).

3. The relationship of water-salt balance and nitrogen metabolism in fish

Aquatic ecosystems are considerably richer protein diet, compared with the ground, that allows the fish to less economical use of amino acids from food, actively using them as substrates in the reactions of energy metabolism (Ostroumova, 2001). It is known that in fish breeding of the end product of nitrogen metabolism - ammonia is closely connected with the work of the ion-

103 transporting systems, as well as well as other end products of metabolic rate (Grosell, 2006). In this case, the low pH water habitat of freshwater fish are critical not only for the parameters of ammonia excretion, but also for the processes of reabsorption of salt (Bucking, Wood, 2006).

Along with that, in fish the number of points of interaction of water-salt and nitrogen metabolism are not limited to these examples, their interaction is much more closely. In particular, focusing on a number of important features of the regulation of salt and fluid balance in fish, yet it must be recognized that in mammals, including humans, uses a series of discoveries that have confirmed its effectiveness in the fish and fixed in the further course of evolution. We do not make discoveries, if As an example, the process of ammonia in the proximal nephrocytes mammals, in which actively operates ornithine cycle but they retained the ability to excretion of ammonia, a molecule which is used for renal release of protons in the bound form. In addition, in mammals the ability to maintain high transepithelial osmotic gradients have a population of epithelial cells, lining the ducts of the salivary glands and oral cavity, located in the inner medulla of kidneys, as well as the alveolar epithelium. In this case, activity of the parenchyma of salivary glands on the formation of saliva hipoosmotic largely reproduces the ion-transporting systems have confirmed its reliability in the process of desalination of sea water intake and bony fish (Grosell, 2006).

On the other hand, found that the hyperosmotic environment created sodium chloride solution, affects the metabolic processes in the cell, inducing a complex reaction known as the

"hyperosmotic stress» (Dmitrieva et al., 2000, 2004; Yoshida et al., 2004). Studies show that two fold, with respect to the magnitude of the extracellular osmolality of body fluid osmolality increased to 600 mOsm medium / kg H20 (provided that, main shalt - sodium chloride) triggers the destruction of genetically determined renal tubular epithelium (Dmitrieva et al., 2000). Therefore, preservation and maintenance of high levels of functional activity nefrotsitov located in the deep layers of the renal medulla, is reached including, and due to the accumulation of low molecular weight organic osmolytes (including urea) inner medulla parenchyma (Dmitrieva et al., 2000,

104 2004). Just as is the case with many marine elasmobranch (elasmobranch) fish species, habitat osmolality which is at about 1000 mOsm / kg H2O (Mathai, 2005).

Conclusion

Abstracting from the very obvious structural differences underlying the efferent control of water-salt metabolism in fish and mammals, we can conclude physiological mechanisms that maintain and regulate the ionic, osmotic and volemic homeostasis in fishes have well-defined features, applicable to ensembles of ion-transporting proteins principles of integration between the organ of organs and tissues involved in the exchange of fluids and salts as well as humoral mechanisms controlling water and salt balance.

In addition, published studies show the most progress in the identification and study of various homeostatic functions of the ion-transporting proteins in fishes depending on the species of fish in the taxonomic hierarchy and the physical and chemical conditions of the environment.

Also, a number of publications clearly defined mechanisms osmoreception and outline a range of physiologically active substances that form the control system of water-salt balance.

However, most authors suggest that the cardiovascular system of fish plays an important role in the adaptation of fish to salt stress and acclimation to the conditions of sea water. Accordingly, focusing on the vasotropic effects of humoral regulators volemic and osmotic homeostasis.

Open Access

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Received: 05.05.2012. Revised: 25.12.2012. Accepted: 25.01.2013.

114 Journal of Health Sciences (J o H Ss) 2013; 3(2): 115-129 The journal has had 4 points in Ministry of Science and Higher Education of Poland parametric evaluation. List B item 683.

Ex p e r t s y s t e m s - t h e h e l p f o r v o c a t io n a l g u id a n c e OF MEDICAL PHYSICS GRADUATES

Agnieszka Banaszak-Piechowska, Aleksandra Mrela, Oleksandr Sokolov

Prof. zw. dr hab. inż. Oleksandr Sokolov Nicolaus Copernicus University in Toruń Faculty of Informatics 5, Grudziądzka str. 87-100 Toruń, Poland [email protected] Kujawy and Pomorze University in Bydgoszcz Faculty of Technics 55-57, Toruńska str. 85-023 Bydgoszcz, Poland

Dr Agnieszka Banaszak-Piechowska Kazimierz Wielki University in Bydgoszcz Faculty of Mathematics, Physics and Technology 2 Powstańców Wielkopolskich [email protected]

Dr Aleksandra Mrela Kujawy and Pomorze University in Bydgoszcz Faculty of Technics 55-57, Toruńska str. 85-023 Bydgoszcz, Poland [email protected] © The Author(s) 2013; This article is published with open access at Licensee Open Journal Systems of Radom University in Radom, Poland

Abstract: Higher education institutions apart from teaching student have to measure and validate their competences what is not easy especially according to generic competences. But even more difficult is to assess whether the graduate who has the special set of competences can do a special job effectively or to choose the best graduate from the set of candidates. The paper presents the model of such an expert system which can give advices for graduates, employers and university authorities.

Keywords: expert system, higher education, fuzzy logic.

1. Introduction

Nowadays there is more difficult to find a good job than it used to be, because the required competences which graduates should acquire during their studies are on the one hand more and more specialized but on the other hand more and more general. The subject-specific competences which relate to knowledge and skills needed by the employer are more and more specialized, for example how to use the ultrasound scanner. But the generic competences

115 which relate to the interpersonal skills, for example the ability to work under the pressure of time, should be educated in all students. Because of that, it is difficult for graduates to assess their own competences. The HEIs have created the units which should help students and graduates but it is not easy for them, either. Thus the expert system based on IT technology which can give advices for employers and graduates will be very helpful. If this system is run by the HEIs, the results can be very interesting for the authorities to prepare curricula more suited to the labour market.

2. The medical physics area of study

Professor Cezary Pawłowski1 organized the Division of Applied Physics with the Medical Section of Electrical Engineering on the Faculty of Electricity on Warsaw University of Technology in 1946. This section was the one of the first units in the world which educated specialists in electrical techniques used in medicine.

The first Polish students who wanted to be specialists of medical physics were accepted on University of Warsaw in 1974. In October 2009 the Faculty of Physics of University of Warsaw began the new teaching programme on the medical physics, which is modern, adapted to the requirements of the job market and is a direct continuation of the tradition of a the first curriculum.

The medical physics is a interdisciplinary field of study which apply physics with additional knowledge of biology, chemistry and anatomy, and technical skills, especially practical activities of dosimetry and radiation protection. The graduates should help prevent, diagnose and treat many types of diseases and health problems4. In Poland the three-year undergraduate curriculum meet the requirements of the Council of Ministers of 6 August 2002 on the types of positions important for ensuring safety and radiological protection (...) and detailed conditions and procedures for the authorization of radiological protection inspector, which allow to take the examination for IOR-1. After that graduates can take the two-year

1 Prof. Cezary Pawłowski - the specialist in the fields of general radiology, industrial radiology, radiological surveying, radioactive body surveying and radiological protection, http://apw.ee.pw.edu.pl/tresc/sylw/c- pawlowski.htm, [19.12.2012]. 2 fizykamedyczna.fuw.edu.pl, [19.12.2012].

3 http://brain.fuw.edu.pl/fizyka-medyczna, [15.01.2013]. 4 http://www.prospects.ac.uk/medical_physicist_job_description.htm, [2 0 .1 2 .2 0 1 2 ].

116 master degree program, which matches to the other requirements of specialization in medial physics.5 Moreover, as professor Barbara Gwiazdowska says, nowadays in Poland medical physicists work mainly in hospitals and medical departments using ionizing radiation. In developed countries they work in health units, in university departments, companies of various bio-medical institutes and companies which produce medical devices (in this case they need the experience in the hospital).6

3. The competences of MP graduates

Medical physicists work not only in hospitals but also some of them are employed in companies which manufacture medical equipment, universities, research organizations and companies which use radioactive materials. Thus they are able to, inter alia: - plan and perform treatment of patients using radiotherapy and discuss it with doctors and other medical staff, - process complex image data of patients, - maintain the medical equipment, - study new procedures and new equipment, - develop new techniques which show the changes in the body when different technologies are used, for example: X-ray, ultraviolet, ultrasound and laser, - research new technologies and equipment to improve treatment of patients, - consult protection about radiation, - train and update medical, scientific and technical staff, o - manage laboratories . Because of that the graduates need some key skills to help them work: - a logical mind, - an inquisitive and analytical way of thinking, - IT skills, - ability to work in a team9.

5 http://brain.fuw.edu.pl/fizyka-medyczna/o-programie-nowej-fizyki-medycznej, [2 0 .1 2 .2 0 1 2 ]. 6 http://www.mz.gov.pl/wwwfiles/ma_struktura/docs/80_fizyka_medyczna_13072011.pdf, [18.12.2012]. 7 MP graduates means people who graduated from medical physics area of study. 8 http://www.prospects.ac.uk/medical_physicist_job_description.htm; http://targetjobs.co.uk/careers-advice/job- descriptions/276115 -medical-physicist-j ob-description, [12.01.2013]. 9 http://targetjobs.co.uk/careers-advice/job-descriptions/276115-medical-physicist-job-description, [12.01.2013].

117 4. The foundation of the expert system

People do not use the precise language in daily life because their body is not equipped with suitable measures and moreover it seems that it is not necessary. Nobody can measure with only the eye that the length from their home to the nearest shop is, for example, 1.432 km and of course it seems to be useless to measure it so precisely. The situation is different at work, some jobs require very precise measuring. Moreover some phrases which describe physical concepts change meaning for different people in different situations, for example the word “far” have a lot of variants when there are considered drivers, walkers or plane passengers. When the quality of education is considered, we enter into the field of social sciences. Unlike sciences and technology, physics for instance, the social sciences use very often blurred and unclear language when gathering responses to questions, which are asked to respondents. For example, when people are asked whether they like their job, they can answer: “yes”, “no”, “so-so”, “very much”, “not at all”, and so on. All submitted answers are so called fuzzy. In classical logic there are considered only situations when one can decide whether an examined object belongs to the set or not. For example, a doctor can say whether a patient caught a cold or not. But in fuzzy logic one can considered more complicated situations when somebody is sick with some possibility, for example he has a runny nose but no fever, or another example he had fever yesterday but not today. The similar situation is in education. When one asks graduates whether they were prepared for their job, they can answer “yes” or “no” and the problem can be considered on the basis of classical logic. But more interesting is the situation when there are a variety of different answers: “yes”, “no”, “so-so”, “a little”, “hardly” and so on. Now the problem can be thought of using methods of fuzzy logic. Let us consider the situation when graduates of medical physics are asked how well they can distinguish human bones. They can respond: “very well” (it means they can recognize and describe all the bones of a human body), “well” (it means they can recognize all bones but describe only the main bones), and so on. When researchers want do perform some calculations they asked respondents to put numbers which show their degree of knowledge about human bones, for example the figure 0.8 can mean that they know all the bones, can describe them but are afraid of making some mistakes, whilst the figure 0.2 can mean that the graduates are not prepared well enough and they know that they lack the required knowledge.

118 5. The expert system

The definition of an expert system was given by Ketty Peeva and Yordan Kyosev: “An expert system is a computer-based system with artificial intellect that emulates the reasoning process of a human expert within a specific domain of knowledge10.” The expert system is an example of decision support systems (comp. Fig. 1). They are consisted of Knowledge Base, Data Base, Inference Engine, Decision Support and User Interfaces (UI). To design the expert system the Expert or Experts are required and they give knowledge of the considered field. It is stored in the Knowledge Base by using Fuzzy Relations. To start the system working there must be gathered same data which is stored in the Data Base. The main part of the system is the Interference Engine which has to emulate the way of people thinking and to produce solutions to the problem which was posed by the User. The Interference Engine takes rules from the Knowledge Base and data from the Data Base. The Decision Support explains why the system gives such a response or asks more specific questions or shows the way it produces answers, predictions or advices. The User Interfaces connect people (the Experts and the Users) with the system.

Fu7Tv Riîlatwn» Ç

Kl uv/ et.'qe UI * Base A ' 7 Expert

Data Base -> » Inference Engine » Decision Support

User

Fig. 1 The structure of a Decision Support System for the Identification of Compliance of Graduates with Curriculum and Labour Market Demands

Peeva K., Kyosev Y., Fuzzy relational calculus, Theory, application and software, Advances in Fuzzy Systems - Applications and Theory, World Scientific Publishing, Vol. 22, Singapore, 2004.

119 Source: by Oleksandr Sokołov.

6. The example of the operation of the expert system for making advices

Let us consider two sets X - the set of competences of medical physics graduates, Y - the list of graduates. The Knowledge Base for this expert system can be represented in the form of a matrix of a fuzzy relation (between the sets X and Y), which describes the competences of medial physics graduates. These competences were developed while studying different subjects at university. The assessment was done by the graduates themselves or their employers. The levels of acquirement of these competences are figures which belong to the interval [0,1]. Let X = {x1, ... , x5} and Y ={y1, ... , y6}. The elements of the space X mean that a graduate: - x1 - has knowledge about the bones and skeletal system of human beings, - x2 - has knowledge about basic bodily functions, - x3 - can distinguish human bones, - x4 - can determine the functional features of the body, - x5 - is aware of his own limitations and the ability to continuous learning, - x6 - is able to follow the rules of professional ethics.

The elements of the space Y are surnames of graduates: - y1 - Nowak - y2 - Siwicki, - y3 - Lewandowski, - y4 - Piotrowski, - y5 - Malicki, - y6 - Kowalski.

Assume that the employer needs a MP graduate who acquired competences x1 - x6. On his announcement, six candidates y1 - y6 applied for this job. Let the levels of the acquirement of the competences be put in the tab. 1 in the form of fuzzy relation matrix:

Tab. 1 Values of the fuzzy relation between the acquired competences and MP graduates ^^^^^^Graduates Nowak Siwicki Lewandowski Piotrowski Malicki Kowalski Competences'^ ^ ^ ^ 1 2 3 4 5 6

120 ^^^^^^Graduates Nowak Siwicki Lewandowski Piotrowski Malicki Kowalski Competencès' ^ ^ ^ ^ 1 2 3 4 5 6

0 . 8 1 0.9 0.7 1 1 x i

0.9 0 . 8 0 . 8 0 . 8 0.9 0.9 X 2

0 . 8 0.9 0.9 1 0.7 1 X 3

1 1 0.9 0 . 8 1 1 X 4

0.9 1 0 . 8 0.7 1 0 . 8 X 5

0 . 8 0 . 8 0.7 1 0.9 0 . 8 X 6

Source: by Authors

This employer wants to choose the best one of them but he considers the first competence xi the most important for the job, the second one - a little less important than x1 and so on. Then to find the best person we have to transpose the table 1 and then sort data according to the competence x1, then x2 and so on. The achieved data is put in the tab. 2:

Tab.2 Sorted values of the fuzzy relation between the acquired competences and MP graduates ^^'Competences X1 2 3 4 X5 6 Graduates^^^ X X X X

1 0.9 1 1 0 . 8 0 . 8 Siwicki

1 0.9 0.7 1 1 0.9 Kowalski

1 0 . 8 0.9 1 1 0 . 8 Malicki

0.9 0 . 8 0.9 0.9 0 . 8 0.7 Lewandowski

0 . 8 0.9 0 . 8 1 0.9 0 . 8 Nowak

0.7 0 . 8 1 0 . 8 0.7 1 Piotrowski Source: by Authors.

Considering the data in the tab. 2 there can be easily noticed that the best graduate for this job is Mr. Siwicki, the next one is Mr. Kowalski and so on. Thus, if the levels of acquired competences are given, it is not difficult to find the best graduate. The more demanding problem is to find the graduate who acquired the competences at least on the level required by the employer, so the aim of the considered expert system is to find MP graduates who meet employer’s requirements for the specified level. To do this there must be used the inverse problem what means that there must be found the solution of the equation: (1) A o R = B,

121 where A - the list of graduates with their levels of acquired competences (not given), R - the matrix of the fuzzy relation (data stored in Tab. 1), B - the list of required competences which was made by the employer. To find the solution of this task there can be used the inverse problem solution which was investigated by Sanchez11. Let the employer has been looking for a person who acquired the six considered competences on the levels recorded in the vector B = [0.8 0.8 0.8 0.8 0.8 0.7]. Using the Sanchez’s algorithm we get the solution which the graphic image is Fig. 2.

1 2 3 4 5 6 item No.

Fig. 2 Graphic image of the solution of the problem which the graduate is recommended for the job Source: by Authors.

The degree of possibility the Mr. Lewandowski (the third position - Fig. 3) is equal to 0.8, so he can be recommended for this job. In the case of all other graduates the degree of possibility belongs to the interval [0; 0.7], so at this moment they are worse prepared to do this job than Mr. Lewandowski. Hence, the best person, who should be recommended to the employer, is Mr. Lewandowski.

7. Another example of the operation of the expert system

Let us consider another example. Assume that the employer needs a person who acquires the following competences: - x1 - a graduate has knowledge about the bones and skeletal system of humans,

11 Sanchez E., Resolution of composite fuzzy relation equations, Information and Control 30, 1976, 38 — 48.

122 - x2 - a graduate has knowledge about basic bodily functions, - x3 - the graduate takes responsibility for the work of the team, - x4 - the graduate is able to follow the rules of professional ethics.

Assume now that the entrepreneur has been looking for a MP graduate who acquired all competences xi - x4 and assume that four MP graduates applied for this job with the levels of the acquirement of the competences stored in tab. 3:

Tab. 3 Values of the fuzzy relation between the acquired competences and MP graduates

^^^-Qraduates Siwicki Pawlak Nowak Malicki

Competences^^^ 1 2 3 4

xi 0.7 0 . 8 0.7 1

x2 0 . 6 0 . 6 0 . 6 0.3

x3 0.4 0 . 2 0.4 0.3

x4 0 . 2 0 . 2 0.3 0.3 Source: by Authors.

Let us assume that the employer looks for a person who acquired the competences xi - x4 on the levels recorded in the vector B = [0.7 0.6 0.4 0.2], respectively. Then after using the expert system, the User of the system gets two variants of the solution (comp. Fig. 3) .

1 2 3 4 1 2 3 4 item No. item No.

Fig 3 Graphic images of the solution of the problem which the graduate is recommended for the job Source: by Authors.

123 First variant: (Fig. 4, on the left) The possibility that Mr. Siwicki will work well enough on this position belongs to the interval [0.4; 1], the possibility that Mr. Pawlak will work well is equal to 0.7. In the case of Mr. Nowak and Malicki the possibility belongs to the interval [0;0.2]. Second variant: (Fig. 4, on the right) The possibility that Mr. Siwicki can fulfill the employer’s requirements belongs to the interval [0.7; 1]. But the possibilities that Mr Pawlak, Nowak and Malicki will work well belong to the intervals [0; 0.7], [0; 0,2] and [0; 0.2], respectively. The aim of the expert system is to find the best candidates who meet the employer’s requirements which was put in the vector B. Since the possibility that Mr. Nowak and Malicki will full the requirements are less or equal to 0.2 in both variants and there are better candidates, so they cannot be recommended for this job. In the first variant of the solution, the degree of our confidence (the possibility) that Mr. Siwicki will be a good candidate is greater or equal to 0.4 (so if we consider the lower value, it is too little; but if we consider the upper value, which is equal to 1, it is the greatest possible degree of possibility) and in case of Mr. Pawlak it is equal to 0.7. Thus having only the first variant it would be difficult to choose the best candidate. However, in the second variant the situation is different, because the possibility that Mr. Siwicki will be a good candidate is greater or equal to 0.7 but in case of Mr. Pawlak it is less or equal to 0.7. In summary, taking into account both variants the best candidate, that means with the greater degree of confidence, is Mr. Siwicki and he is recommended for the job.

8. Estimation and control of additional knowledge

During designing the curriculum, for example the MP curriculum, the authorities of HEI have to describe the competences which have to be acquired by students. Very often on one subject there are taught a few competences, so the academic teacher has to decide how much time he should devote for each of these competences. The expert system can also help in this situation because using the optimization methods it can evaluate time which should to devote for teaching each of the competences.

Let us consider the levels of acquirement of competences x 1 - x4 by four MP graduates which are stored in tab. 4:

Tab. 4 Values of the fuzzy relation between the acquired competences and MP graduates

124 ^^^^^Competences Xl X2 X3 X4 Graduates 1 2 3 4 5

Siwicki 0.7 0 . 6 0.4 0 . 2

Pawlak 0.8 0.6 0.2 0.2

Nowak 0.7 0 . 6 0.4 0.3

Malicki 1 0.3 0.3 0.3 Source: by Authors.

On the basis of the data stored in tab. 4 there can be estimated the current quality of education. Namely, it can be estimated which competences are acquired at high or low levels by a few of graduates, and then which subjects or their parts are taught or studied well or which subjects or their parts are educated poorly and try to find a reason for this situation. For instance, the data stored in the column 4 (competence x3) show not high level of acquirement for most students and the figures from the column 5 (the competence x4) show even the worse situation. In such a case the authorities of the faculty of the HEI could adapt the MP curriculum or the syllabuses to the needs of learners in order to help them acquire the competences on the higher level. It means that there could be specified the optimization problem, namely how to distribute the time of a subject to get maximum values in the matrix (tab. 4). To prepare graduates better to the labour market, the following control system can be proposed (comp. Fig. 4). After graduating (the end of Education process), the Testing is organized and The Estimation of quality is carried out, which results are sent to Decision making authorities. They can influence teachers who teach particular subjects using Syllabuses to change course contents, methods of teaching and evaluation to help learners acquire competences on the higher levels.

125 Fig. 4 The control system Source: by O. Sokolov.

For instance, assume that there is a subject on which three competences (x1, x2, x3) are taught. Each competence takes time to be taught, so assume the time distribution of the subject is specified as follows: 0.3 of the time for the competence x1; 0.3 of the time for the competence x2 and finally 0.4 of time for the competence x3. After the first cycle of education (the first loop) the average fuzzy levels of competences were acquired on the levels ( 0.7; 0.3; 0.8). Let us put the data into the table:

Tab. 5 Values of the fuzzy relation between the average fuzzy levels of acquired competences and the time spent by the teacher for their acquirement by learners The percentage of time spent to taught the competence t1 = 0.3 t2 = 0.3 t3 = 0.4 The level of the competence x1 = 0.7 x2 = 0.3 x3 = 0.8 Source: by the Authors.

To optimize the time devoted to teaching these competences there can be used the optimization method. Our goal function is maximize the objective function

f(xi, X2, x3) = xi + x2 + x3 ---- ► max. Considering the achieved data we can assume that there are linear functions between the time spent on teaching and the level of acquirement of competences. Moreover, assume that if there is no time spent on teaching, the level of acquirement of a competence is equal to 0. Thus there can be calculated the conditions: xi = 7/3 ti; x2 = t2; x3 = 2 t3.

126 Besides the levels of acquirement of competences must be high, we assume that in each case the level is bigger or equal to 0.4 and of course not less than before. Hence, there can be described the limits of the optimization problem: 1) xi = 7/3 ti; x2 = t2; x3 = 2 t3; 2) ti + t2 + t3 = 1;

3) x1 0.7;

4) x2 0.4; 5) x3 > 0.8. After solving this problem, we get data stored in the tab. 6: Tab. 6 Optimal values of the relation between the levels of acquired competences and the time spent by the teacher for their acquirement by learners The percentage of time spent to taught the competence t1 = 0.3 t2 = 0.4 t3 = 0.3 The level of the competence x1 = 0.7 x2 = 0.4 x3 = 0.8 Source: by the Authors. As it can be easily noticed that changing a little the distribution of the class time, we can improve the level of acquirement of the competence x2.

9. Conclusions It is very important to help graduates find a good job compatible with their qualifications. HEIs are more and more responsible for helping their graduates. Because there are a lot of information to be considered while designing and improving curricula, for example the levels of acquirement of competences of graduates, the requirements of the job market, the abilities of students, the organizational capacities of institutions and so on, it is very difficult to create the curriculum which fulfills all the needs. Because of that the expert system can be very convenient for all stakeholders. The model of the system, based on fuzzy logic, allows to solve the problem of searching the best graduate for the employer. Moreover, the designed model allows to evaluate the correspondence between curricula of HEIs and demands of the job market and help the stakeholders solve the problem of vocational guidance very successfully. Though it is very useful to monitor and compare the adequacy between HEI curricula with described graduates’ competences and current, or even future, needs of the job market, generalized methods and tools for this aim have not been developed so far. So the perspective direction for the research is to find:

127 1) the most suitable operation o , the importance of which must be examined by research carried out on the area of higher education, 2) the best graduates, who applied for the job and whose competences should meet the requirements of the employer, by solving the inverse problem described for the new operation o.

Open Access

Bibliography Sanchez E., Resolution of composite fuzzy relation equations. Information and Control 30, 1976, 38 — 48,

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Websites http://epp.eurostat.ec.europa.eu. Unemployment rate by age group (less than 25 years), [18.09.2012]. http://www.nauka.gov.pl/szkolnictwo-wyzsze/dane-statystyczne-o-szkolnictwie-wyzszym, [19.09.2012].

Diagnoza stanu szkolnictwa wyższego w Polsce. Raport cząstkowy przygotowany przez Ernst & Young Business Advisory and Instytut Badań nad Gospodarką Rynkową, November 2009, WWW.krasp.org.pl. [19.09.2012].

128 The Key Competences for Lifelong Learning - A European Framework is an annex of a Recommendation of the European Parliament and of the Council of 18 December 2006 on key competences for lifelong learning that was published in the Official Journal o f the European Union on 30 December 2006/L394. http://ec.europa.eu/dgs/education_culture/publ/pdf/ll-learning/keycomp_en.pdf, [19.09.2012]

Received: 05.10.2012. Revised: 25.12.2012. Accepted: 28.01.2013.

129 Journal of Health Sciences (J o H Ss) 2013; 3(2): 130-141 The journal has had 4 points in Ministry of Science and Higher Education of Poland parametric evaluation. Part B item 683.

Prevention of ACL injuries in skiing Prewencja uszkodzeń ACL w narciarstwie

Magdalena Hagner-Derengowska2,3,4, Ewa Trela3,4, Bartosz Kochański1, Krystian Kałużnyi, Kajetan KoneckP, Szymon Gryckiewiczi, Walery Żukow4

iStudent Scientific Circles of the Rehabilitation, Cathedral and Clinic of Rehabilitation CM UMK, Bydgoszcz, Poland 2Bydgoszcz University, Bydgoszcz, Poland 3Cathedral and Clinic of Rehabilitation CM UMK, Bydgoszcz, Poland 4Radom University, Radom, Poland

iStudenckie Koło Naukowe Rehabilitacji, Katedra i Klinika Rehabilitacji CM UMK, Bydgoszcz 2Bydgoska Szkoła Wyższa, Bydgoszcz 3Katedra i Klinika Rehabilitacji CM UMK, Bydgoszcz 4Radomska Szkołą Wyższa, Radom

A bstract Skiing is a great form of recreation. Currently, the society observed a significant increase in interest in this discipline. Beautiful views, great fun and adrenaline makes for many people, "ski" become a life passion. More and more people choose to go skiing, but unfortunately not all of them set off to the slopes properly disposed. Skiing is a sport fast paced, challenging and traumaticgenny. Particularly susceptible to damage is the knee joint and its ligaments. Ligament is the most frequently damaged anterior cruciate ligament (ACL), which is one of the most important elements acting as stabilizers of the knee. What to do to ski trip was a wonderful and unique memories, not dramatic experience in which we experienced trauma? The work is described knee injury prevention and, in particular ACL. Shows the importance of preparing motor prevention body, stretching and a form of kinesiology taping. Drew attention to the pathogenesis of ACL injuries and the role of middle gluteal muscle. Keywords: skiing, prevention, ACL, knee-joint.

Streszczenie Narciarstwo zjazdowe jest niesamowitą formą rekreacji ruchowej. Obecnie w społeczeństwie obserwuje się znaczny wzrost zainteresowania tą dyscypliną. Piękne widoki, świetna zabawa oraz adrenalina sprawiają, że dla wielu osób „narty” stają się życiową pasją. Coraz więcej osób decyduje się na wyjazd na narty, lecz niestety nie wszyscy wyruszają na stoki odpowiednio przygotowani. Narciarstwo jest sportem niezwykle dynamicznym, trudnym i urazogennym. Szczególnie podatny na uszkodzenia jest staw kolanowy i jego więzadła. Więzadłem najczęściej uszkadzanym jest więzadło krzyżowe przednie (ACL), które jest jednym z najważniejszych elementów pełniących funkcję stabilizatorów stawu kolanowego. Co zrobić, żeby wyjazd na narty był wspaniałym i wyjątkowym wspomnieniem, a nie dramatycznym przeżyciem, w którym doznaliśmy urazu? W pracy została opisana prewencja uszkodzeń stawu kolanowego, a zwłaszcza ACL. Przedstawiono profilaktyczne znaczenie przygotowania motorycznego organizmu, stretchingu oraz formy kinesiology tapingu. Zwrócono uwagę na patomechanizm uszkodzeń ACL oraz rolę mięśnia pośladkowego średniego. Słowa kluczowe: narciarstwo, profilaktyka, ACL, staw kolanowy.

130 Causes and risk factors of injuries appearing at skiers Lovers of the skiing constitute the group which most oftentimes receives an injury on the slope. Many persons set off to the slope without no motor preparation. Some treat this motor form as forms of escape from everyday life and of practical problems. The lack of the regular physical activity causes lowering the efficiency and triggers a lot of unfavourable changes in the body. To most important we can rank reducing power, the endurance of both the flexibility of muscles and ligaments, disturbing the motor coordination, the deossification, worse feeding up the joint cartilage, the excess weight and disorders of the cardiovascular system. Very often he achieves injuries during the first downhill race, when it is a skier not being able to not wait until the "skiing" gives up the warm-up, grading the speed of the downhill race and the steepness of the slope. The motor system in combination with the low temperature predisposes Not hot to damage and injury. We can divide risk factors in two groups: subjective and objective (Tbl. 1). First are dependent directly from the knowledge and keeping the skier. The objective factors, independent of the skier form the second group.

Table 1. Risk factors of ACL damage in the skiing. (4, 10, 11, 12, 13, 14). SUBJECTIVEOBJECTIVE

- unpreparedness motor - bad weather, - lack of the warm-up before conventions - poor condition of the snowy bonnet, - of disturbing stabilizing elements, - bad preparing routes, - wrong technology of the ride, - overfilled slopes, - excess weight, - other users of the slope. - psychological conditions, - non-observance of the Ski Code, - dipsomania and of narcotics on the slope - daring ride by the unclassified level of the ability of the skiing - developing market of high rates of speed - the badly selected equipment and ski clothes

Patomechanizm of ACL damage damaging the cruciate ligament of the spiffing knee joint can be caused by the direct injury or the indirect trauma. The direct injury is caused with the contact with

131 base or other element (e.g. other man, tree). The indirect trauma is a result of the riot in the pond of movements being ahead of his physiological scope. (6). We favour a few essential mechanisms of damaging the spiffing cruciate ligament: 1. Mechanism twisting out of shape - reaches him most oftentimes. (20). Outside Rotation of the tibia towards the thigh under the influence of hitting the outside of the limb by the established foot. 2. Mechanism club-footed - internal Rotation of the tibia towards the thigh under the influence of the blow into the internal side of the limb by the established foot. 3. Intense, involuntary growth of tensing the quadriceps - at the risk of falling down on the back. 4. Influence of turning powers on the knee joint - too great rotation of the tibia towards the thigh at the stable foot and changeable bending the knee joint. 5. The influence of forces calling the hyperextension or maximum bending the knee joint - fall by the bent or straightened knee. (1, 5, 9).

It is worthwhile attracting the attention in place of damaging the spiffing cruciate ligament at skiers. It is special and untypical, since considerable their part appears at thigh for trailer. In other sports i.e. the football and the rugby, a centre element of the ligament is damaged. (2). Prevention Prevention of injuries of the knee joint and spiffing cruciate ligament is based above all on proper keep-fit preparing the organism, educating special ski abilities, the improvement in control of a neuromuscular given person, stretching of muscles, form kinesiologytapingu and of education of the skier. Motor preparation In order effectively to prepare for the ski season very much is important in order to take care of the condition. General-developmental exercises should be made a lot of weeks before a skiing trip. A regular physical effort has a positive effect not only to muscles, ponds and ligaments, but also to the psyche causing the growth of the confidence to own abilities. The training should contain elements molding the general function of the organism, improving the inspection nervously - muscle and the exercises characteristic of the skiing. General-developmental classes are aimed at developing power, speed, suppleness, coordination and endurances. An appropriate audit of individual moves and an improvement in the response time of muscles are also an important aspect. Best as exercises they are led in the fresh air, since the skiing is an outdoor sports form. Exercises are recommended to skiers resistance, the bedpan, team games, athletics elements i.e.: jumps, runs, throws. The training must be

132 preceded by the proper warm-up. Apart from exercises being aimed at developing general motor properties exercises specified for the skiing and exercises directed at strengthening the knee joint are very important. (3, 7). Below model exercises directed at knee joints:

Fig. 1, 2. Performing deep knee bends and tilts in being based on one limb (arabesque) 1 - without the bent leg rear one, 2 - with the bent leg rear one. Fig. 3. Wrong way of performing the exercise. It is very important so that in all exercises in the support limb the hip joint, the knee joint and the foot are in one axis.

Fig. 4. Isometric Exercises of muscles of a lower limb and the pelvis in the closed cinematic chain. Performing the deep knee bend, holding position by 10-20 seconds. Fig. 5. Performing deep knee bends and tilts in being based on one limb, the foot second on the thigh of the basal leg.

133 Fig. 6. Low skiping with the jump ahead or put on weight with standing out on the basal limb. Fig. 7. Side jumps one leg with stopping and standing out on the basal limb.

Fig. 8. Example of the exercise proprioception in the closed cinematic chain. I - holding position, II - moving the ball up and the fossa, III - pressing a lower limb into the ball.

Fig. 9. Isometric Exercises of the quadriceps in bending the knee joint. Pressing knees into the roller.

134 Fig. 10. Side Jumps on both feet or one leg above the small bench. Fig. 11. Jumps ahead or to the back on both feet or one leg above the hurdle.

Fig. 12, 13. Standing with one lower limb on the ball - Independent winning the ball with the leg (13) or deflecting with the accompanying person (14).

Stretching

The theory of the stretching is based on static stretching out. He is a form of preparing the motor organ for the physical activity. He plays the greater role in molding the suppleness. Correctly the developed feature causes increasing the effectiveness of given movement and is a form of preventing injuries. The stretching works corrective and stimulatingly on the motor organ. It is aimed: improvement in the flexibility of tissues, reducing the muscle tone, increasing the scope of the movement and reducing the complaint of pains of muscle origin. One should perform exercises 135 slowly, consciously and above all systematically. They recommend executing 2-3 cases during the week both before effort as well as after. (8, 16). Below positions were described for the stretching of particularly important muscles in the skiing.

Fig. 14. Stretching: flat quadriceps thighs, flat iliolumbar. (19). «

BK 9 f 4

Fig. 15. Stretching: flat long and short adductor muscle, flat large adductor muscle, flat slender, flat pectineal. (19).

136 Fig. 16. Stretching: flat dicephalous thighs, flat polsci^gnisty, flat half-membranous. (19).

Fig. 17. Stretching: flat tenser of the fascia lata, flat tailor's, flat pear-shaped, flat twin upper and bottom, flat inside coverer, flat gluteal secondary and small. (19).

Fig. 18. Stretching: flat dicephalous thighs, flat polsci^gnisty, flat half-membranous. (19).

Role of the average gluteus muscle according to the concept kinetic control.

137 Analysing the mechanism of the injury one should pass the exact place of the dysfunction and the direction of movement in the course of which he achieves the injury. By the recalled earlier mechanism twisting out of shape, one should keep an eye on the hip joint. In the course of the movement of twisting the knee in fact he/she reaches the exaggerated internal rotation and driving in the hip joint. It is possible and so to conclude that exactly a hip joint, in which it reaches can be a place of the dysfunction to the lack of the control of the internal rotation. They pass that an average gluteus muscle is a muscle being responsible for an inspection of this move. The failure of this muscle leads to exaggerated twisting out of shape in the knee joint what can result in the ACL injury. to the purpose of the improvement in the control of the internal rotation it is possible to apply stiff taping introduced. (Fig. 14). (18).

Kinesio Taping

Kinesiology Taping is a therapeutic method which is aimed at an improvement in functioning of tissues and of physiological systems by using the special tape. She constitutes the excellent healing form in case of injuries and injuries of the knee joint. It is worthwhile remembering that it is possible also to exploit her as preventive action. The Kinesio Taping application, as the preventive form are aimed: activation of muscles, improvement proprioception, possibility of correcting placing the pond, standardization of the tension, improvement in the microcirculation, improvement in the stabilization of the pond. (15).

Fig. 19A, 19B, 19C - Application to the spiffing cruciate ligament being supposed to assist proprioception of pond. Tape in the shape of the letter I. Beginig of the application atonic below the knee fossa, round the calf. From the protuberance they squeaked up to the condyle of a thighbone. Stretching the tape 75-100 %. Finishing the application atonic. A - front view, B, - rear view, C - side view. (15). 138 Fig. 20. Application preventing the spiffing translation of the tibia with account thigh. Lower limb in the course of sticking bent in the knee to 90°. Base: we stick the centre of the tape ashore closer to the tibia (region of the protuberance) atonic. We stick final- trailers to the side and paracentral surface of the thigh at the course of a thighbone level with the tension of sticking plaster 30-50 %. (15).

Fig. 21. Taping stiff: we stick improvements in the control of the internal rotation to the purpose in the hip joint. We stick 2 sticking plasters in the region of the bigger trochanter, first from them we lead rostrally-dorsally, however second caudally-dorsally, both under the angle 45°. (17).

Conclusions Damage to the spiffing cruciate ligament at skiers is an occurrence more and more frequent. Injuries oftentimes result from factors, to which the skier can have a direct effect. Prevention and abiding by the rules for her are a crucial aspect. She constitutes the excellent form of the fault prevention and for sports injuries. A motor preparation is very important, correctly conducted warm up before downhill races and systematic stretching. A psyche of the skier and keeping it on the slope are also essential. Even one should approach the amateur skiing professionally, to warn principles of the Ski Code and to fit one's abilities to the speed of the ride and the steepness of the slope. One should remember that we aren't alone on the slope and it isn't possible to predict many situations. The daring and unreasonable ride can cause the loss of its health, not to say lives. Although principles 139 mentioned above seem to be straight and obvious, very often are omitted and underestimated. It is necessary appropriately to prepare for the winter season and to remember about the adherence to the principles, in order to during of "skiing" fully and safely to use charms of unusual sport a skiing is which.

References 1. Hagner W., Stec G.: Urazy stawu kolanowego. Cz. I. Więzadło krzyżowe przednie. Podręcznik dla studentów kierunku fizjoterapia. Wydawnictwo „SCRYPT”. Bydgoszcz 2004. 2. Paletta G.A., Warren R. F.: Knee injuries and alpinie skiing. Treatment and rehabilitation. Medicina Sportiva. 1998, 2(4): 313-329. 3. Czopik J., Pasławska M.: Narciarstwo. Wydawnictwo Lekarskie PZWL. Warszawa 2011. 4. Borkowski R.: Czynniki ryzyka w uprawianiu narciarstwa. (Dokument elektroniczny), Tryb dostępu: http://www.skimag.pl/arhiwum.php?nr=6; dostęp 15.01.2006. 5. Widuchowski J., Widuchowski W.: Urazy i obrażenia stawu kolanowego oraz ich następstwa- epidemiologia, patomechanika, klasyfikacje. Fizjoterapia Polska 2004, 4(4): 307-315. 6. Łukasik P., Widuchowski J., Fallus R., Widuchowski W., Kwiatkowski G., Reszka P.: Epidemiologia uszkodzeń więzadła krzyżowego przedniego. Chirurgia Kolana, Artroskopia, Traumatologia Sportowa 2006, 3(3): 27-36. 7. Kolarczyk M.: Przygotowanie fizyczne organizmu, jako czynnik zwiększający poziom bezpieczeństwa w narciarstwie. Ogólnopolska konferencja „Maksymalne bezpieczeństwo w narciarstwie”. Warszawa 2004. 8. Listkowski M.: Stretching, sprawność i zdrowie. Wyd. Listkowski M., Łódź 1994. 9. Widuchowski J.: Kolano urazy i obrażenia sportowe. Wydawnictwo „G-Kwadrat s.c.” Katowice 1997. 10. Witoński D., Kozłowski P.: Więzadło krzyżowe przednie - budowa, czynność, uszkodzenia i naprawa. Przegląd Lekarski 1998, 55(11): 619-621. 11. Chojnacki K.: Ryzyko wypadków narciarskich na terenie TOPR od 2001 do 2005r.. Medycyna Sportowa 2007, Vol. 23, 1(6): 46-49.

140 12. Chojnacki K., Ruchlewicz T.: Przeciążenia stawów kolanowych w narciarstwie zjazdowym i ich profilaktyka. Medicina Sportiva 1998, 2(4), 307-312. 13. Chrzan D.: Obrażenia w sportach zimowych u młodzieży szkolnej - leczenie i rehabilitacja. Medycyna Sportowa 2010, Vol. 26, 2-3(6): 106-114. 14. Chojnacki K., Kusion Ł.: Analiza obrażeń narciarskich u czołowych polskich alpejczyków (1987 2000). Sport Wyczynowy 2001, 9-10: 441-442. 15. Pogorzelec P.: Zastosowanie metody Kinesio Taping w terapii wybranych schorzeń stawu kolanowego. Rehabilitacja w Praktyce, 2012, 4: 41-45. 16. Rosiński M.: Stretching mięśni stawu kolanowego. Rehabilitacja w Praktyce, 2012, 4: 33-40. 17. Góra T, Hadała M.: Funkcjonalna diagnostyka i terapia pacjenta z niestabilnością stawu biodrowego w oparciu o metodę Kinetic Control. Praktyczna fizjoterapia i rehabilitacja, 2012, 27: 4 9. 18. Lubahn A., Kernozek T., et al.: Hip muscle activation and knee frontalplane motion during weightbearing therapeutic exercises. The International Journal of Sports Physical Therapy 2011, 6: 92-103. 19. Solveborn S.: Stretching. Wyd. Sport i Turystyka, Warszawa 1982. 20. Gryckiewicz Sz.: Ekscentryczna niewydolność mięśnia pośladkowego średniego jako częsta przyczyna urazów stawu kolanowego w sporcie na podstawie Kinetic Control., Praktyczna Fizjoterapia i Rehabilitacja, Wydawnictwo FORUM, 2012, 12.

Received: 05.01.2013. Revised: 15.01.2013. Accepted: 01.02.2013.

141 Journal of Health Sciences (J o H Ss) 2013; 3(2): 142-148 The journal has had 4 points in Ministry of Science and Higher Education of Poland parametric evaluation. Part B item 683.

Renal complications in cancer patients in remote period after cisplatin chemotherapy Почечные осложнения у онкобольных в отдалённом периоде после химиотерапии цисплатином

xGozhenko AI, xMoskalenko AM, 2Zukow W. 1 1 2 • Гоженко А.И., Москаленко А.М., Zukow W.

JSE Ukrainian Scientific-Research Institute of Transport Medicine, Odessa, Ukraine 2Radom University, Radom, Poland

1ГП НИИ Медицины транспорта, Одесса 2Radomska Szkoła Wyższa, Radom

Keywords: Cisplatin, nephrotoxicity nephroprotection, urinary syndrome. Ключевые слова: цисплатин, нефротоксичность, нефропротекция, мочевой синдром.

Abstract Confirmed that cancer patients treated with cisplatin holding nephroprotection the traditional method in the long term, especially after several courses of chemotherapy, causes bladder syndrome and increased creatinine.

Резюме Подтверждено, что лечение онкобольных цисплатином с проведением нефропротекции по традиционной методике в отдалённом периоде, особенно после проведения нескольких курсов химиотерапии, вызывает появление мочевого синдрома и повышение уровня креатинина.

Introduction Currently applied in the complex treatment of malignant tumors with chemotherapy often leads to the recovery from the primary cancer. Increasingly important in these patients becomes prevention of side effects of chemotherapy used - in the development of chemotherapy and treatment of it is mandatory. One of the drugs that are widely used today for the treatment of cancer is cisplatin, a side effect of which is marked nephrotoxicity. [1, 2]. In

142 developing the scheme of cisplatin, which is used for more than 30 years, was a prerequisite for prevention of nephrotoxic effects. [3, 4]. Thus, the developed technique does prophylaxis of acute renal failure. Cisplatin feature is the use of several courses of chemotherapy administration, sometimes for 1-2 years. [5, 6]. This raises questions about the effects on the allocation of low-dose platinum on renal function and the possibility of toxic nephropathy and, subsequently, chronic renal disease. [7].

The purpose of the study. To study changes in kidney function in some remote period after chemotherapy with cisplatin.

Material and methods Studied renal function in 22 patients who received chemotherapy with cisplatin in Odessa Ltd. in 2011-2012. The patients were divided into two groups. The first group included 10 patients who underwent a single dose of cisplatin (the first course of chemotherapy with cisplatin). The second selected patients who underwent 2 to 4 cycles of chemotherapy with cisplatin for the year - 12 patients. Of the 12 patients, three were two courses of chemotherapy, 5 - three courses and 4 - four courses of cisplatin. Of the 22 patients with 9 men and 13 women. Males age 50 to 62 years (mean 56 years), women age 51 to 60 years (mean 55.5 years). 10 patients were treated with cisplatin for lung cancer stage III-IV, 2 - for laryngeal cancer stage II-III, 4 - for cancer of the mouth floor stage II-III, 2 patients undergoing treatment for cancer of the uterine body and stage III 4 patients for cervical cancer stage II-III. All patients nephroprotection performed the traditional method - by dehydration in / drip 800 ml. Valium NaCl 0,9%, 400 ml. Valium Ringer then introduced 200 ml. Valium mannitol. Cisplatin 50 mg / m2 of body surface once administered intravenously in 200 ml. Valium NaCl 0,9%. After cisplatin / drip administered pp glucose 5% in the amount of 400 ml. Prior to the first administration of

143 cisplatin and 5 days later studied urinalysis, serum creatinine and blood blood pressure. In patients undergoing 2 to 4 cycles of chemotherapy with cisplatin urinalysis, serum creatinine and blood blood pressure were studied prior to the first administration of cisplatin and 1 year after the start of treatment.

Results and discussion Prior to treatment, patients of the first group of blood creatinine level is 87 ± 3,58, after chemotherapy increased slightly and reached 92 ± 4,61 mmol / l. When assessing the relative importance in the urinalysis of the first group of patients was found to its substantial changes after chemotherapy (1017 ± 0,5 before cisplatin and 1015 ± 0,5 after). Proteinuria at baseline was observed in 1 patient after the introduction - in 2. In 2 patients prior to treatment occurred leukocyturia. After cisplatin number of such patients has increased to 4. Red blood cell before treatment was found in one person, after cisplatin administration - in 3. Before the introduction of chemotherapy glucosuria observed in 1 patient after the introduction - in 2 (see Figure 1).

/ /А / 2 / □ Протеинурия / 4 // A □ Лейкоцитурия 11 / 2 / □ Эритроцитурия / 2 / / До После □ Глюкозурия введения введения цисплатина цисплатина

Fig.1. Manifestations of urinary symptoms after one course of chemotherapy with cisplatin.

144 Thus, the first group of cancer patients after administration of cisplatin was a slight increase in serum creatinine levels. The number of cases of proteinuria, leukocyturia and glycosuria in urinalysis has doubled, and the number of cases of red blood cell - three times, but this was not accompanied by a significant decrease in urine specific gravity. When comparing blood pressure in this group of cancer patients before and after chemotherapy with cisplatin were observed them substantial change - 128,48 ± 0,825 and 126,48 ± 0,602 mm Hg respectively. Patients of the second group before the cisplatin blood creatinine level was 86 ± 4,03 mmol / l. After 1 year, after 2-4 courses of chemotherapy with cisplatin, noted its increase to 97 ± 4,82 mmol / l. The study of urine specific gravity of the second group of patients at 1 year revealed its significant reduction compared with baseline data collected before of cisplatin. Urine specific gravity before treatment is 1016 ± 0,5 after 1 year was 1011 ± 0,4, which may be indicative of the concentration on the development of renal function decline. Proteinuria at baseline observed in 2 patients, after administration of cisplatin was found in 7 patients. In 2 patients prior to treatment in the general analysis of urine was found leukocyturia. After cisplatin number of such patients has increased to 8. Red blood cell before treatment was found in 1 patient after administration of cisplatin - in 5. Before the introduction of chemotherapy glucosuria observed in 1 patient after the introduction - in 4 (see Figure 2).

145 □ npoTeuHypufl

□ Пемкоцмтyрмfl

□ Эрмтроцмтyрмfl

□ r^roK03ypMfl

цмсппатмна цмсппатмна

Fig.2. Manifestations of urinary symptoms after 2-4 courses of chemotherapy with cisplatin.

Thus, in cancer patients of the second group after the treatment with cisplatin incidence of proteinuria increased by 3.5 times, leukocyturia - to 4 fold, red blood cell - 5 times and glycosuria - four times, which indicates the development of their symptoms of urinary symptoms. When comparing blood pressure identified in patients of the second group before the start of chemotherapy with cisplatin and one year after spending 4.2 chemotherapy noted the difference between them - 124,34 ± 0,514 and up 132,54 ± 0,726 mm Hg, respectively, after. Thus, in patients of the second group marks an increase of urinary symptoms to a greater degree than in the patients of the first group, which, in addition, is accompanied by a decrease in urinary concentrating ability and the growth creatininemia, although the level of creatinine is normal. Increase in blood pressure from baseline figures shows a certain involvement of the juxtaglomerular apparatus.

146 Foregoing suggests that ongoing with cancer chemotherapy with cisplatin nephroprotection the traditional method for a year from the start of treatment may cause toxic damage in patients tubular-glomerular apparatus with the subsequent development of chronic kidney disease and the subsequent deterioration of the quality of life.

Conclusions 1. Identified in cancer patients in both groups reject urinalysis due to nephrotoxic effects of platinum - the active ingredient of cisplatin. 2. The patients of the second group after 2-4 courses of chemotherapy with cisplatin increased creatinine blood, increase bladder syndrome, along with a decrease in urine specific gravity are manifestations of chronic kidney disease (CKD), which can then lead to the development of chronic renal failure.

References in transliteration 1. Perazella MA. Drug-induced nephropathy // Expert. Opin Drug Saf., 2005. - Vol. 4. - No. 4. P. 689-706. 2. Naughton C.A. Drug-Induced Nephrotoxicity // Am. Fam. Physician., 2008. - Vol. 78. - No. 6. - P. 743-750. 3. Perevodchikova N.I. Rukovodstvo po himoterapii opuholevyh zabolevanij. - M.: Prakticheskaja medicina, 2005. S 155, 601-603. 4. Gershanovich M.L. Oslozhnenija pri himio i gormonoterapii zlokachestvennyh opuholej. - M.: Medicina, 1982. S 153. 5. Urmancheeva A.F. Sovremennaja himioterapija raka jaichnika. Prakticheskaja onkologija T. 3, # 4 - 2002, s 295-304.

147 6. Jugrinov O.G., Dedkov A.G., Novak E.M., Koval'chuk P.A., Bojchuk S.I., Suprunenko A.A. Neoad"juvantnaja vnutriarterial'naja himioterapija bol'nyh sarkomami kostej konechnostej i taza. Zh. Klinicheskaja onkologija, #5 (1) 2012 , S 138-143. 7. Gozhenko A.I. Patogenez toksicheskih nefropatij // Zh. Aktual'nye problemy transportnoj mediciny, 2006. # 2(4). S 9-13.

References in original 1. Perazella MA. Drug-induced nephropathy // Expert. Opin Drug Saf., 2005. - Vol. 4. - No. 4. P. 689-706. 2. Naughton C.A. Drug-Induced Nephrotoxicity // Am. Fam. Physician., 2008. - Vol. 78. - No. 6. - P. 743-750. 3. Переводчикова Н.И. Руководство по химотерапии опухолевых заболеваний. - М.: Практическая медицина, 2005. С 155, 601-603. 4. Г ершанович М.Л. Осложнения при химио и гормонотерапии злокачественных опухолей. - М.: Медицина, 1982. С 153. 5. Урманчеева А.Ф. Современная химиотерапия рака яичника. Практическая онкология Т. 3, № 4 - 2002, с 295-304. 6. Югринов О.Г., Дедков А.Г., Новак Е.М., Ковальчук П.А., Бойчук С.И., Супруненко А.А. Неоадъювантная внутриартериальная химиотерапия больных саркомами костей конечностей и таза. Ж. Клиническая онкология, №5 (1) 2012 , С 138-143. 7. Гоженко А.И. Патогенез токсических нефропатий // Ж. Актуальные проблемы транспортной медицины, 2006. № 2(4). С 9-13.

Received: 10.01.2013. Revised: 20.01.2013. Accepted: 01.02.2013.

148 Journal of Health Sciences (J o H Ss) 2013; 3(2): 149-173 The journal has had 4 points in Ministry of Science and Higher Education of Poland parametric evaluation. Part B item 683.

Dynamics parameters of the functional state of physical fitness and morbidity in primary school children under the influence of health programs in swimming

Butskaya L.V., MD, PHD, DSc

National Technical University of Ukraine “KPI”, department of the physical rehabilitation

Summary. On the basis of data on the physical state of the examined 205 children of 7 10 years of age have been developed and implemented differentiated programs wellness swimming. After 72 sessions over 6 months was an increase in the level of health and physical fitness of primary school children. Reduced the number of days missed due to illness, the number of cases of acute disease, with 41% to 28% reduction in the number of sickly children. Keywords: differentiated programs recreational swimming, medical control, the level of physical fitness, functionality, fitness, children of primary school age.

Динамика показателей функционального состояния физической подготовленности и заболеваемости детей младшего школьного возраста под влиянием оздоровительных программ по плаванию

Буцкая Л.В.,

к.мед.н., доктор натуральной медицины Национальный Технический Университет Украины «КПИ»

Резюме. На основе полученных данных о физическом состоянии обследованных 205 детей 7-10 летнего возраста были разработаны и реализованы дифференцированные программы оздоровительного плавания. После 72 занятий в течение 6 месяцев отмечено повышение уровня здоровья и физической подготовленности младших школьников. Уменьшилось количество дней, пропущенных по болезни, количество случаев острой заболеваемости, с 41 % до 28 % уменьшилось число часто болеющих детей. Ключевые слова: дифференцированные программы оздоровительного плавания, врачебный контроль, уровень физического здоровья, функциональные возможности, физическая подготовленность, дети младшего школьного возраста,

Under current conditions in a critical situation with the state of health and physical fitness of the child population of Ukraine. According to the Ministry of Health about 90% of children have different variations in health status, and according to

149 Minmolodsporta 59% - an unmet physical fitness. Over the past six years in Ukraine were 15 deaths during the learning process in physical education. As one of the main reasons for this phenomenon is considered the inability of children to adapt to physical activity curriculum for physical education in the low level of health and inadequate adaptation reserves of the body [4]. Studies of many authors proved that training in water improves physical development, extend the functionality of the cardiovascular and respiratory systems, increase the intensity of the metabolic processes in the body, improve the processes of thermoregulation. Quality analysis used programs of teaching and training in swimming, suggests that developed and sold in the current program of swimming lessons for children, as a rule, do not provide the adequate solution of the twin problems of educational and recreational nature. In one embodiment, they are characterized by the pervasive use of rigidly normalized parameters of motor learning tools and can be broadly classified as express - swimming training methods, and in another case, a program of exercise, do not go beyond rehabilitation or recreation and entertainment destinations. Most of the existing techniques for teaching children swimming designed to improve motor skills and technical training. Thus, as a rule, not enough attention is paid to the basic level of health and physical fitness, development of functional abilities of the body and prevent disease. The literature suggests that students do not perceive such tolerant tightly organized forms of employment with their pragmatic orientation and utilitarian goals. At the same time, almost no reasonable system of medical monitoring of children of primary school age, exercise in water [1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 12].

Research problems 1. Development and implementation in practice of physical rehabilitation younger students differentiated programs wellness swimming with the initial level of health and physical fitness and focus on the formation of children motivated interest in activities. 2. Medical control and evaluation of the effectiveness of course the impact of different health programs swimming.

Methods: we used the following methods: a theoretical analysis and compilation of scientific literature; case studies; anthropometry, the state posture, determines the level of physical development (IR) was determined by the level of physical performance (IR), clinical and physiological parameters, express -assessment of the level of physical health by G.L.Apanasenko, score some morbidity, assessment of physical characteristics, methods of mathematical statistics. Statistical analysis of the data was performed using the package "Statistica 6.0" (StatSoft:, USA), and spreadsheet "Excel 2000" (Microsoft).

Study management Sequence of actions in research to improve the health of children is as follows: 1. Checking the health, fitness and swimming training. 2. Picking groups of children of primary school age in levels of physical health.

150 3. Obespechanie medical support process improvement The study involved 205 children in grades 1-4 7-10 years (98 girls and 107 boys), the study examined functional somatometric somatoskopicheskie and characteristics of children. Our studies indicate that the bulk of the junior class - children in low-and lower-middle- physical health, without marked gender differences have poor physical and swimming preparedness. Of the children surveyed were randomly selected younger students in the amount of 78 people of whom were formed control group (KG) (n = 38, 20 boys and 18 girls) and the main group (MG) (n = 40, 21 male and 19 girls) group. KG doing the traditional method of swimming training [13], and the MG according to our program that takes into account the level of physical health and physical fitness of schoolchildren. Control and main groups, participated in all phases of the study, which was carried out on the basis of school - kindergarten - first century. "Prolisok" and secondary schools Darnytsa, Shevchenko and Obolon district of Kyiv. With the organization of classes identified three stages: Stage I (initial training) - used low-intensity exercise and low coordination difficulties. Second round (in-depth study) - used medium intensity exercise, increases coordination, the share of swimming exercises in the lesson. Stage III (improvement) - increasing physical activity by increasing the density of motor coordination of activities and exercises. Increases the time of swimming exercise and swim distance. Assess the level of preparedness of the swimming was held prior to the study, at the intermediate stage and at the end of the study. Each phase of training ends control study, which summarizes the training and educational work. Results and discussion: We performed a study to determine the dynamics of the physical condition of children of primary school age under the influence of recreational diving promotional motor characteristics, levels of physical health and functional abilities of the body (including cardio - vascular and respiratory systems), and aimed at preventing disease. Primary school age is a critical period in a child's development, strengthening its health. Acquisition of skills and abilities in the early school years is the most effective at the level of involuntary memory (in particular in the game) than any [8]. In this connection the development of physical culture and health technologies with motivating students to improve health and physical fitness of the younger generation. According to the results of our study, it was determined that the formation of motivation and efficiency of health and fitness classes in the water with children of primary school age to complement their mobile games and elements of competition. Water games are the most effective means of primary teaching swimming. They form the very first children needed for swimming motion, give rise to the development of physical qualities. With outdoor games and competitions in the water brought will, character, sense of community. The importance of these games is that they both develop

151 motor and mental health problems of the child. To competitively-game method is characterized by: - Emotion and rivalry exhibited in the rules of the game; - Variability application of these skills in connection with the existing rules of the game; - Comprehensive improvement of the physical, moral and volitional qualities: agility, strength, endurance, speed, orientation, as well as resourcefulness, courage and will to win. In the classroom is of great importance to music. Music helps to achieve a given character movements, rhythm, tempo, amplitude, accelerates mastery of the movement. Musical accompaniment can be considered as a factor in a positive impact on the emotional state of children. With the organization of classes to use individual-group method, in which the objectives and content of the program, the amount and timing of its implementation, were common to all students. In the MG adjusted individually for students, united in groups according to the Health Level (HL).

Character of exercises Level of the Health

Table 1 The nature of the coordination of exercises in the classroom with children of the primary with different level of physical health.

152 A verage , Low, below the average medium above the average

For the development of the in the reference position exercises include walking, running, jumping, "float", "jellyfish", "star", the slip, the aquatic environment elements of synchronized swimming, games

- the predominant use of the - The predominant use of exercises in the deep part of The development and exercises in shallow basin; the pool (depth of water on the shoulders and in unsupported improvement of swimming - Supporting the preferential use position); skills of belts, nudlsov, boards, fins - Without using facilitate inventory

Games producing and "Fountain", "mill", "Tumble", "ship", "Boat Race", "motor", "Who has more?", "Fight for the ball" perpetuating swimming skills "Hold the board", "Caterpillar", "Windmill," Hold the board, "" Tumble "

"Seine", "goldfish and carp", "Third-once "Racing in the Water", "The ball Captain "," Fight the riders, "" Games on the development of in the water," "Who will draw", "jumping Drag and drop into your water”, "Swim and run," "Basketball on physical qualities out of the water", "long rod", "Track" water", "pike and carp" - The types of running in slow and - Types of running at a moderate pace in supporting zones in medium tempo, the shallow part of the unsupported position in the deep part of the basin; pool; The use of basic exercises of - The types of jumps (jumps to the transition to a horizontal - Swimming exercises using planks the water-fitness for position, forward, backward, left, right, with forward, noodles, fins, the elements of water polo development of physical backw ard; in the shallow part of the pool; qualities - movement along the - Swimming exercises with and without equipment facilitates - Exercises to develop flexibility: bottom of the pool the elements of water polo in the deepest part of the basin; stretching muscles in the arms, legs, back - Exercises to develop flexibility: stretching arms, legs, back of of the thigh at a side pool - movement the thigh in pairs and at a side pool along the bottom of the pool

Insignificant differences between boys and girls as physiological functions, indicators of physical qualities and level of preparedness swimming allowed to abandon gender approach in solving the problems of content development and program planning. At the same time, there are significant differences in the levels of health and level of physical fitness. On the basis of these differences were completed subgroup of subjects and develop programs separately for children in low-and lower middle HL and children with average or above average HL. Each system was designed for 72 hours. Differences in levels of health and level of physical fitness determine the differences in the features of exercises - the rate, amplitude, exercise, intervals between them, etc. for each group.

The main tools employed in the classroom, is a complex exercise involving elements from the arsenal of swimming (primary education), synchronized swimming, aerobics, water polo, games and fun in the water. Programs for low-and lower-middle, and for the middle and upper middle HL include most of the same sets of exercises, but they differ in volume, intensity and complexity of coordination Exercise was based on the classical technique and divided into three parts: the preparatory, primary and final.

1. Preparatory part (10-15% of the time). The main objectives of the preparatory part were: training the body to perform certain muscle work, the creation of mental attitude for the upcoming activities.

153 2. The main part (up 70-75%). The purpose of the main part of the training was to improve the overall fitness of the body and its functionality, performance, and learning new exercises in the water, strengthening the skills acquired in previous lessons. 3. The final part (up 10.5%). Used to speed up the recovery process and to bring the body in an optimal zone of functioning, removal of high physical and emotional tension fixing swimming skills in the form of games, relay races, fun in the water.

Program for children in low-and lower middle HL wore expressed aerobic consisted of moderate-intensity exercise, which were carried out at the side of the pool and in the reference position. In large classes is often assigned the implementation of strength training with an emphasis on the impact of the major muscle groups, the number of repetitions of one exercise was 8-10. Program for children with average or above average HL also consisted mainly of exercises of aerobic exercises of medium intensity. When using weight training reps is 10-12 times with a shorter duration of rest intervals between series. Exercises were carried out not only in the core, but in the unsupported position (Tabl 2)

Table 2. Distribution of recreational diving different orientation (%%) in classes with children of primary school age with different levels of physical health

The level of development of health medium Character exercises low above the below the average average

Exercises to develop the aquatic environment 8,33 % 4,16 %

Exercises to develop and improve swimming skills 30,55 % 27,77 %

Running in the water 20,83 % 23,61 % Strength training in water 16,66 % 13,88 % dance elements 2,77 % 5,55 % Elements of synchronized swimming 6,94 % 8,33 % The elements of water polo 5,55 % 5,55 % Swimming 8,33 % 11,11 % Higher rates of HL boys MG, compared with KG, were achieved by statistically higher (p <0.05) values of the index Rufe, the power index (p <0.05), Robinson index (p 154 <0.05) . In girls, the MG is statistically significant (p <0.05) higher rates of HL were achieved by increasing the level of physical performance (based on the index Rufe) and Robinson index (p <0.05). Table 3. Indicators of physical health of children and control group before and after ^ swimming wellness Control group (n=38) Main group (n=40)

Figures Xfl

x S x S x S x S

D ata ¡Z3 u X Control group (n=38) Main group (n=40)

Index Rufe, g 13,11 1,62 12,35 1,28 12,55 1,28 10,04** 1,35 conditional units.. b 13,04 1,44 11,84* 1,49 12,91 1,92 9,77** 1,68

Life index, g 50,52 7,66 53,04* 5,86 49,54 8,60 54,45* 6,09 conditional units b 53,39 9,58 56,24* 9,58 51,76 8,71 57,15* 8,11

The power g 21,64 6,76 26,94* 5,44 21,86 5,66 28,88* 6,56 index, conditional b 25,16 5,83 35,15* 9,23 24,41 8,66 43,78** 9,69 units. Index g 90,96 7,50 88,43 8,13 90,97 6,89 80,62** 6,16 Robinson, conditional b 89,89 9,09 85,36* 8,95 88,80 11,21 79,75** 7,46 units. HFA, points g 1,88 1,74 2,83* 2,28 2,15 1,64 5,84** 2,38 b 1,8 2,04 3,5* 2,91 2,33 2,37 6,38** 3,63

Notes: * - statistically significant difference between the rates before and after the experiment (p <0.05); ** - Statistically significant difference between the study and control group (p <0.05)

Table 4. Indicators of physical fitness of children and control group before and after improving navigation

155 before after before after

S S S S X X X X

g 5,86 0,45 5,75 0,45 5,78 0,36 5,53* 0,39

Running 30 m,sek b 5,65 0,47 5,4* 0,38 5,50 0,55 5,20* 0,27

g 12,30 0,54 12,26 0,53 12,27 0,44 11,93** 0,28 "Shuttle" Run 4 x 9 m sek b 12,01 0,76 11,65 0,57 11,78 0,71 11,25** 0,38

g 8,38 3,22 8,88 3,08 9,81 3,65 11,42** 3,96 Flexion and extension of hand- b ups, tim e 15,00 8,48 16,75* 7,09 15,90 8,02 21,04** 5,60

g 137,7 11,73 141,22* 11,54 143,29 13,29 150,10** 11,34 Long jump from their seats, sm b 153,4 16,30 160,35* 11,73 154,36 13,66 168, 42** 9,05

g 32,88 5,76 35,05* 5,82 33,48 5,54 36,84* 6,55 The rise in the saddle body for 1 b m in, tim e 35,3 7,20 37,3 8,19 34,90 8,33 38,85* 5,99

g 9,44 3,41 11,66* 3,54 8,55 6,61 16,68** 3,85 Torso from a seated position, sm b 5,15 3,60 6,95 2,94 3,45 4,19 6,71 3,93

Notes: * - statistically significant difference between the rates before and after the experiment (p <0.05); ** - Statistically significant difference between the study and control group (p <0.05)

Before the course navigation performance of physical fitness of children were not significantly different (p> 0.05). Operational control of the response of the body involved in the training load was performed on heart rate after the exercises. Current control (control of functional changes in the state of the body involved, the reaction of the organism to the standard load of HR performed in 6-12 sessions). Landmark control was performed by comparing the baseline level of functional and physical training dealing with those at 3 and 6 months of training.

After course swimming level of physical fitness as in the CG, and the exhaust gas under the influence of increased employment. But in the MG, these results were more pronounced (Table 4).

156 Significant difference between the KG and the exhaust (p <0.05) was observed in these rates as agility ("shuttle" running 4 x 9 m), strength (flexion and extension arms-ups) and speed-strength performance (jump in length away, cm), and the girls as well - flexibility (trunk bent forward from a sitting position, cm). After the course traced changes in indicators of preparedness swimming towards improvement in the control and in the intervention group (p <0.05). One measure of the effectiveness of the approaches used in the rehabilitation of students is the frequency of acute illnesses and their duration. At baseline incidence rates between treatment groups did not differ among themselves. However, on the second or third week of training run average sick days in all groups increased 2-fold, the number of missed classes in the exhaust was for boys and girls, respectively, 5.90% and 7.56%, in the CG - 5.74% and 10.31%. The highest rates are observed in the incidence of acute CG girls, where the difference in absenteeism compared to the OG of 2.75%. The fourth week of health programs of missed classes in the OG and CG decreased. In the OG it was 2.31% in males and 2.96% in girls. In CG the level was higher. Thus, in the course of the study the children missed school less exhaust to 3.08% than children KG. This confirms the data A. Scalia [13] that in the early days of training in the pool is not going increase the effectiveness of the temperature control and the baby is in a relatively unstable to the low temperature of the water compared to air. According to these data, resistance to water temperature in the pool is for 8-10 sessions. Lower incidence of students exhaust is because the children are doing on differentiated programs with competitively-game character in the water, present a positive effect of emotional recovery, unlike the children of KG, who were engaged in the traditional program of swimming training (hard-normalized swimming of individual segments, that is probably a sense of monotony and certain psychological discomfort). Thus, during the study in the exhaust gas was observed more marked improvement in reducing the incidence of children. During the study period in the exhaust gas, and in the CG showed a decrease in the incidence of acute illness in the school year, and the number of days missed due to illness. In CG reduction was: girls - an average of 4 days, the boys - 3 days, in the OG girls - 5 days, the boys - 7 days (p <0.05). The results showed that children emissions and a decrease in the number of CG missed classes due to illness, from 29% to 18% as well as reducing the number from 41% to 28% of sickly children. In this case, the children exhaust more pronounced decrease in the number of missed classes due to illness and reduced the number of sickly children compared to CG (p <0.05).

ANALYSIS AND SUMMARY OF THE STUDIES

After the implementation of health program level of physical performance, both in the control and in the intervention group improved significantly decreased the number of children in low-and lower-middle level of physical performance compared to the baseline. However, higher rates were observed in the core group of children, boys and

157 girls: 41.5% and achieved an average 7.5% higher than the average level of physical performance, compared to 22.6% and 2.6% of control children the group. Analyzing the dynamics of the functional state of the cardiovascular and respiratory systems involved, it should be noted that all children decreased heart rate at rest (p <0.05), improved performance index Rufe (p <0.05), the power index (p < 0.05), decreased systolic heart function at rest (Robinson index, p <0.05). There was a statistically significant improvement in the results in the exhaust gas compared to the CG performance Genci samples (p <0.05), heart rate parameters at rest (p <0.05). Along with improved functional status younger students, improved performance and physical fitness: speed (18%), endurance (25%), energy (15%), speed and power capacity (23%) and flexibility (28%) . Analysis testing of physical characteristics of children of the experimental group (KG) showed that these children outperform their peers on indicators such as flexibility, agility, strength and endurance. As a result of recreational diving course is marked and positive change in terms of acute illness: Reduce the number of cases of acute disease in the studied schools and the number of days missed due to illness. A decrease in the number of missed classes due to illness, from 29% to 18% as well as reducing the number from 41% to 28% of sickly children. Children MG were significantly (p <0.05) symptoms benefits in some aspects characterizing a decrease in morbidity compared to children KG. These changes are the most conclusive criterion in assessing the effectiveness of training in the pool with the children of primary school age, especially with differentiated programs with elements of recreational swimming competitively-game character in the water, with the level of physical health

CONCLUSIONS:

1. Based on the data on the physical state of surveyed differentiated programs designed with elements of recreational swimming competitively-game character in water, separately for children in low-and lower middle HFA and children with average or above average HFA, justified and implemented, which is available in wide use, the technique medical monitoring of children of primary school age who have recreational swimming, with their level of physical fitness. 2. The 72 hours after the implementation of the 6-month program, engaged in recreational diving a statistically significant increase in the level of health in all sex-age groups surveyed. In this case, all children decreased heart rate at rest (p <0.05), improved performance index Rufe (p <0.05), the power index (p <0.05), decreased systolic heart function at rest (index Robinson p <0.05) and increased the duration of breath as you exhale (Genci test, p <0.05). 3. For the younger students, engaged for 6 months and wellness swimming, made improvements in physical fitness on such indicators as agility p <0.05 ("shuttle" Run 4 x 9 m), the strength of p <0.05 (flexion and extension arms -ups, time) and speed- strength capabilities p <0.05 (long jump away, cm). The girls also noted the positive dynamics in the development of flexibility (trunk bent forward from a sitting position, cm, p <0.05);

158 4. As a result of your exercise program, recreational swimming there was a decrease of cases of acute illness and the number of days missed due to illness from 29% to 18%, and a decrease from 41% to 28% of sickly children. 5. Children OG, who were engaged at tiered health programs with elements of swimming competitively-game character in the water, were significantly (p <0.05) evidence of the benefits of a number of indicators characterizing the increase in health and physical fitness, as well as to reduce the incidence, compared to children KG, who were engaged in the traditional program of swimming training, causing a feeling of monotony and certain psychological discomfort. 6. Results of the study show the effectiveness of recreational diving activities with proper medical supervision, thus improving the performance of the physical state (functional performance, physical health, physical fitness and swimming) children of primary school age.

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Курсовое воздействие различных программ оздоровительного плавания на показатели функционального состояния, физической подготовленности и заболеваемости детей младшего школьного возраста Буцкая Л.В к.мед.н., доктор натуральной медицины Национальный Технический Университет Украины «КПИ», кафедра физической реабилитации Резюме. На основе полученных данных о физическом состоянии обследованных 205 детей 7-10 летнего возраста были разработаны и реализованы дифференцированные программы оздоровительного плавания. После 72 занятий в течение 6 месяцев отмечено повышение уровня здоровья и физической подготовленности младших школьников. Уменьшилось количество дней, пропущенных по болезни, количество случаев острой заболеваемости, с 41 % до 28 % уменьшилось число часто болеющих детей. Ключевые слова: дифференцированные программы оздоровительного плавания, врачебный контроль, уровень физического здоровья, функциональные возможности, физическая подготовленность, дети младшего школьного возраста, Постановка проблемы. В современных условиях сложилась критическая ситуация с состоянием здоровья и физической подготовленности детского населения Украины. По данным Министерства здравоохранения Украины около 90 % детей, имеют различные отклонения в состоянии здоровья, а по данным Минмолодьспорта 59 % - неудовлетворенную физическую подготовленность. За последние шесть лет в Украине произошло 15 случаев со смертельным исходом во время учебного процесса по физическому воспитанию. В качестве одной из основных причин этого явления рассматривается неспособность детей адаптироваться к физическим нагрузкам школьной программы по физическому воспитанию в связи с низким уровнем здоровья и недостаточными адаптационными резервами организма [4]. Исследованиями многих авторов доказано, что занятия в водной среде улучшают физическое развитие детей, расширяют функциональные возможности сердечно-сосудистой и дыхательной систем, увеличивают интенсивность обменных процессов в организме, совершенствуют процессы терморегуляции. Анализ качества используемых программ обучения и тренировки плаванием,

160 свидетельствует о том, что разработанные и реализуемые в настоящее время программы занятий по плаванию для детей, как правило, не создают возможности адекватного решения двуединых задач учебной и оздоровительной направленности. В одном варианте они характеризуются преобладающим использованием, жестко нормированных по двигательным параметрам средств обучения и могут быть в целом классифицированы как экспресс - методы плавательной подготовки, а в другом случае формирующие программу упражнения, не выходят за рамки реабилитационной или рекреационно развлекательной направленности. В большинстве случаев существующие методики по обучению детей плаванию направлены на совершенствование двигательных навыков и техническую подготовку. При этом, как правило, недостаточно внимания уделяется базовому уровню здоровья и физической подготовленности, развитию функциональных возможностей организма и профилактике заболеваний. Данные литературы свидетельствуют о том, что школьники не толерантно воспринимают такие жестко организованные формы занятий с их прагматической направленностью и утилитарными задачами. В то же время практически отсутствует обоснованная система врачебного контроля над детьми младшего школьного возраста, занимающимися физическими упражнениями в воде [1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 12].

Задачи исследований 1. Разработка и внедрение в практику физического оздоровления младших школьников дифференцированных программ оздоровительного плавания, с учётом исходного уровня здоровья и физической подготовленности и акцентом на формирование у детей мотивированного интереса к занятиям. 2. Врачебный контроль и оценка эффективности курсового воздействия различных программ оздоровительного плавания.

Методы исследований: нами были использованы следующие методы исследования: теоретический анализ и обобщение данных научно-методической литературы; социологические исследования; антропометрия; состояние осанки; определялся уровень физического развития (ИК); определялся уровень физической работоспособности (ИР); клинико-физиологические показатели; экспресс-оценка уровня физического здоровья по Г.Л.Апанасенко; оценка некоторых показателей заболеваемости; оценка физических качеств; методы математической статистики. Статистическая обработка полученных данных проводилась с помощью пакета “Statistica 6.0” (StatSoft, США) и электронных таблиц “Excel 2000” (Microsoft).

Организация исследований Алгоритм действий в исследованиях по оздоровлению детей был следующим: 1. Проверка уровня здоровья, физической и плавательной подготовленности.

161 2. Комплектование групп детей младшего школьного возраста по уровням физического здоровья. 3. Обеспечание медицинского сопровождения процесса оздоровления В исследовании приняло участие 205 детей 1-4 классов 7-10 лет (98 девочек и 107 мальчиков), В ходе исследования изучены функциональные, соматометрические и соматоскопические характеристики детей. Проведенные нами исследования, свидетельствуют о том, что основной контингент учащихся младших классов - это дети с низким и ниже среднего уровннями физического здоровья, без выраженных гендерных различий обладающие слабой физической и плавательной подготовленностью. Из числа обследованных детей методом случайной выборки отобраны младшие школьники в количестве 78 человек из числа которых, были сформированы контрольная (КГ) ( п=38; 20 мальчиков и 18 девочек) и основная (ОГ) ( п=40; 21 мальчик и 19 девочек.) группы. КГ занималась по традиционной методике обучения плаванию [13], а ОГ по разработанным нами программам, учитывающим уровень физического здоровья и физическую подготовленность школьников. Основная и контрольная группы, принимали участие на всех этапах исследования, которое проводили на базе школы - детского садика (ШДС) - I ст. «Пролисок» и общеобразовательных средних школ Дарницкого, Шевченковского и Оболонского районов г. Киева. При организации занятий выделяли три этапа: I этап (начальное обучение) - применяются упражнения низкой интенсивности и низкой координационной сложности. II этап (углубленное изучение) - используются упражнения средней интенсивности, повышается координация движений, увеличивается доля плавательных упражнений в занятии. III этап (совершенствование) - увеличение двигательной активности за счет повышения моторной плотности занятия и координационной сложности упражнений. Увеличивается время плавательных упражнений и проплываемая дистанция. Оценка уровня плавательной подготовленности проводилась перед проведением исследования, на промежуточном этапе и в конце исследования. Каждый этап обучения заканчивается контрольным исследованием, на котором подводится итог учебно-образовательной работы.

РЕЗУЛЬТАТЫ И ИХ ОБСУЖДЕНИЕ: Нами были проведены исследования с целью определения динамики физического состояния детей младшего школьного возраста под влиянием оздоровительного плавания способствующего развитию двигательных качеств, повышению уровня физического здоровья и функциональных возможностей организма, (включая сердечно - сосудистую и дыхательную системы), а также направленного на профилактику заболеваний.

162 Младший школьный возраст является важным периодом в развитии ребенка, укрепления его здоровья. Овладение навыками и умениями в младшем школьном возрасте наиболее эффективно проходит на уровне непроизвольного запоминания (в частности в игре), чем произвольного [8,]. В связи с этим необходима разработка физкультурно-оздоровительных технологий с учетом мотивации школьников для улучшения здоровья и физической подготовленности подрастающего поколения. По результатам нашего исследования было определено, что для формирования мотивации и повышения эффективности физкультурно оздоровительных занятий в воде с детьми младшего школьного возраста Характер упражнений Уровень здоровья

необходимо дополнять их подвижными играми и элементами соревнований. Игры в воде являются наиболее эффективным средством начального обучения плаванию. Они формируют у детей самые первые, необходимые для плавания движения, дают начало развитию физических качеств. С помощью подвижных игр и соревнований в воде воспитываются воля, характер, чувство коллективизма. Важнейшее значение этих игр состоит в том, что они одновременно развивают моторную и психическую сферы деятельности ребенка. Для соревновательно-игрового метода характерны: - эмоциональность и соперничество, проявляемые в рамках правил игры; 163 низкий, средний, ниже среднего выше среднего

упражнения в опорном положении: ходьба, бег, прыжки, Для освоения с водной «поплавок», «медуза», «звездочка», скольжение, элементы средой синхронного плавання, игры - преимущественное - преимущественное виспользование использование упражнений на упражнений на мелкой Освоение и глубокой части бассейна (глубина части басейна; совершенствование вода по плечи и в безопорном - преимущественное навыка плавания положении); использование - без использования поддерживающих поясов, облегчающего инвентаря нудлсов, досточек, ласт «Фонтан», «Мельница», «Гонка катеров», «Мотор», «Кто Игры вырабатывающие «Кувырок», «Пароход», дольше?», «Борьба за мяч», и закрепляющие навык «Удержи доску», «Мельница, «Удержи доску», плавания «Г усеница» «Кувырок» «Невод», «Караси и «Гонки в воде», «Мяч капитану», карпы», «Третий-лишний в «Бой всадников», «Перетянуть в Игры на развитие воде», «Кто перетянет», свои воды, «Вплавь и бегом», физических качеств «Выпрыгивание из воды», «Баскетбол на воде», «Щука и «Длинная лоза», караси» «Г усеница» - передвижение по дну - передвижения по бассейна; дну бассейна; - виды бега в среднем темпе, - виды бега в в поддерживающих поясах в медленном и среднем безопорном положении на темпе, на мелкой части глубокой части бассейна; бассейна; - виды прыжков (прыжки с - плавательные переходом в горизонтальное Использование упражнения с положение, вперед, назад, вправо, базовых упражнений использованием досточек, влево, с продвижением вперед, аквафитнесом для нудлсов, ласт, элементы назад; развития физических водного поло на мелкой - плавательные упражнения качеств части бассейна; с использованием облегчающего - упражнения на инвентаря и без, элементы развитие гибкости: водного поло на глубокой части растяжение мышц рук, бассейна; голени, - упражнения на развитие - задней поверхности гибкости: растяжение рук, голени, бедра у бортика бассейна задней поверхности бедра в парах и у бортика бассейна - вариативное применение полученных умений и навыков в связи с имеющимися условиями игры; - комплексное совершенствование физических и морально-волевых качеств: ловкости, силы, выносливости, быстроты ориентировки, а также находчивости, смелости, воли к победе.

164 В занятиях большое значение имеет музыкальное сопровождение. Музыка помогает добиваться заданного характера движений, ритма, темпа, амплитуды, ускоряет овладение техникой движения. Музыкальное сопровождение можно рассматривать как фактор позитивного воздействия на эмоциональную сферу детей. При организации занятий применялся индивидуально-групповой метод, при котором цели и содержание программы, объем и сроки ее выполнения, были общими для всех учащихся. В ОГ нагрузка регулировалась индивидуально для школьников, объединенных в подгруппы в зависимости от УФЗ. Несущественные различия между мальчиками и девочками по состоянию физиологических функций, показателям физических качеств и уровню плавательной подготовленности, позволили отказаться от гендерного подхода в решении поставленных задач разработки содержания и планирования программ. В то же время существуют значительные различия по уровням здоровья и уровню физической подготовленности. На основании этих различий комплектовались подгруппы испытуемых и разрабатывались программы отдельно для детей с низким и ниже среднего УФЗ и детей со средним и выше среднего УФЗ. Каждая программа была рассчитана на 72 часа. Различия по уровням здоровья и уровню физической подготовленности определяют различия в особенностях использования упражнений - темпе, амплитуде выполнения упражнений, паузах между ними и т.п. для каждой группы. Основными средствами, применяемыми на занятиях, являлись комплексы упражнений, включающие элементы из арсенала плавания (начальное обучение), синхронного плавания, аэробики, водного поло, различные игры и развлечения в воде. Программы как для низкого и ниже среднего, так и для среднего и выше среднего УФЗ включают большинство одинаковых комплексов упражнений, однако отличаются объемом, интенсивностью и координационной сложностью (табл1).

Таблица 1 Характер упражнений по координационной сложности в занятиях с детьми младшего школьного возраста с разным УФЗ

Занятие строилось по классической методике и делилось на 3 части: подготовительную, основную и заключительную. 1. Подготовительная часть (10- 15 % общего времени). Основными задачами подготовительной части являлись: подготовка организма к выполнению определенной мышечной работы, создание психического настроя на предстоящую деятельность. 2. Основная часть (продолжительность 70 75 %). Целью основной части занятия являлось повышение общей тренированности организма и его функциональных возможностей, работоспособности, а также изучение новых упражнений в воде, закрепление умений и навыков, приобретенных на предыдущих занятиях. 3.

165 Заключительная часть (продолжительность 5- 10 %). Использовалась для ускорения процессов восстановления и приведения организма в оптимальную зону функционирования, снятия повышенного физического и эмоционального напряжения; закрепления плавательных навыков в виде игр, эстафет, развлечений в воде. Программа для детей с низким и ниже среднего УФЗ носила выраженную аэробную направленность, состояла из упражнений умеренной интенсивности, которые выполнялись у бортика бассейна и в опорном положении. В занятиях значительную часть отводили выполнению силовых упражнений с акцентом воздействия на основные мышечные группы, количество повторений в одном упражнении составляло 8-10 раз. Программа для детей со средним и выше среднего УФЗ также состояла из упражнений преимущественно из упражнений аэробной направленности средней интенсивности. При использовании силовых упражнений количество повторений составляло 10-12 раз с меньшей продолжительностью интервалов отдыха между сериями. Упражнения проводились не только в опорном, но и в безопорном положении (Табл.2). Таблица 2 Распределение средств оздоровительного плавания различной направленности (%%) в занятиях с детьми младшего школьного возраста с разным уровнем физического здоровья Уровень здоровья Характер упражнений низкий, средний, ниже среднего выше среднего

[ражнения для освоения с водной средой 8,33 % 4,16 %

[ражнения для освоения и совершенствования 30,55 % 27,77 % выка плавания

ваджоггинг 20,83 % 23,61 % вабилдинг 16,66 % 13,88 % нцевальные элементы 2,77 % 5,55 % ементы синхронного плавания 6,94 % 8,33 % ементы водного поло 5,55 % 5,55 % станционное плавание 8,33 % 11,11 % Занятия в контрольной группе проходили по традиционной методике обучения плаванию [8,14]. Она включала в себя общеразвивающие и специальные упражнения (выполняемые на суше); упражнения для освоения водной среды; простейшие прыжки в воду; упражнения для изучения техники плавания, что для младших школьников не представляет интереса. После завершения шестимесячного исследования (72 занятия) анализ уровня двигательных качеств и физического здоровья исследуемых свидетельствует о позитивной динамике функций занимающихся (Табл.3).

Таблица 3 166 Показатели состояния физического здоровья детей основной и контрольной групп до и после курса оздоровительного плавания

Контрольная группа (п=38) Основная группа (п=40)

ц о к до Показатели до после после

X Б X Б X Б X Б Индекс д 13,11 1,62 12,35 1,28 12,55 1,28 10,04** 1,35 Руфье, усл.ед. м 13,04 1,44 11,84* 1,49 12,91 1,92 9,77** 1,68

Жизненный д 50,52 7,66 53,04* 5,86 49,54 8,60 54,45* 6,09 индекс, у.е. м 53,39 9,58 56,24* 9,58 51,76 8,71 57,15* 8,11

Силовой д 21,64 6,76 26,94* 5,44 21,86 5,66 28,88* 6,56 индекс, у.е. м 25,16 5,83 35,15* 9,23 24,41 8,66 43,78** 9,69

Индекс д 90,96 7,50 88,43 8,13 90,97 6,89 80,62** 6,16 Робинсона, у е. м 89,89 9,09 85,36* 8,95 88,80 11,21 79,75** 7,46

УФЗ, баллы д 1,88 1,74 2,83* 2,28 2,15 1,64 5,84** 2,38 м 1,8 2,04 3,5* 2,91 2,33 2,37 6,38** 3,63

Примечания: * - статистически достоверная разница между показателями до и после эксперимента (р<0,05); ** - статистически достоверная разница между основной и контрольной группой (р<0,05) Более высокие показатели УФЗ мальчиков ОГ, по сравнению с показателями КГ, были достигнуты за счет статистически более высоких (р<0,05) значений индекса Руфье, силового индекса (р<0,05), индекса Робинсона (р<0,05). У девочек ОГ статистически достоверно (р<0,05) более высокие показатели УФЗ, были достигнуты за счет увеличения уровня физической работоспособности (по результатам индекса Руфье) и индекса Робинсона (р<0,05). До начала курса плавания показатели физической подготовленности детей (Табл.4) достоверных различий не имели (р>0,05). Таблица 4 Показатели физической подготовленности детей основной и контрольной групп до и после курса оздоровительного плавания

167 Контрольная группа(п=38) Основная группа (п=40)

Показатели до после до после Пол

X Б X Б X Б X Б

д 5,86 0,45 5,75 0,45 5,78 0,36 5,53* 0,39 Бег 30 м, с м 5,65 0,47 5,4* 0,38 5,50 0,55 5,20* 0,27

«Челночны д 12,30 0,54 12,26 0,53 12,27 0,44 11,93** 0,28 й» бег 4^9 м, с м 12,01 0,76 11,65 0,57 11,78 0,71 11,25** 0,38

Сгибание и д 8,38 3,22 8,88 3,08 9,81 3,65 11,42** 3,96 разгибание рук в упоре м 15,00 8,48 16,75* 7,09 15,90 8,02 21,04** 5,60 лежа, раз

Прыжок в д 137,7 11,73 141,22* 11,54 143,29 13,29 150,10** 11,34 длину с места, см м 153,4 16,30 160,35* 11,73 154,36 13,66 168, 42** 9,05

Подъем д 32,88 5,76 35,05* 5,82 33,48 5,54 36,84* 6,55 туловища в сед за 1 м 35,3 7,20 37,3 8,19 34,90 8,33 38,85* 5,99 мин., раз Наклон 9,44 3,41 11,66* 3,54 8,55 6,61 16,68** 3,85 туловища д из положения м 5,15 3,60 6,95 2,94 3,45 4,19 6,71 3,93 сидя, см Примечания: * - статистически достоверная разница между показателями до и после эксперимента (р<0,05); ** - статистически достоверная разница между основной и контрольной группой (р<0,05) Оперетивный контроль за реакцией организма занимающихся на тренировочные нагрузки осуществляли по ЧСС после выполняемых упражнений. Текущий контроль (контроль за функциональными изменениями состояния организма занимающихся, за реакцией организма на стандартные нагрузки по ЧСС осуществляли через 6-12 занятий). Этапный контроль проводили путём сопоставления исходных показателей уровня функциональной и физической подготовленности занимающихся с аналогичными показателями через 3 и 6 месяцев занятий. После провденного курса плавания уровень физической подготовленности как в КГ, так и в ОГ под влиянием занятий повысился. Но в ОГ эти результаты более выражены (таблица 4.). Достоверная разница между КГ и ОГ (р<0,05) наблюдается в таких показателях как ловкость («челночный»

168 бег 4^9 м, с), сила (сгибание и разгибание рук в упоре лежа) и скоростно силовые показатели (прыжок в длину с места, см), а у девочек так же - гибкость (наклон туловища вперед из положения сидя, см). После проведенного курса прослеживаются изменения показателей плавательной подготовленности в сторону улучшения как в контрольной, так и в основной группе (р<0,05). Одним из показателей эффективности используемых подходов в оздоровлении учащихся является частота острых заболеваний и их продолжительность. В начале исследования показатели заболеваемости в исследуемых группах между собой не отличались. Однако, на второй-третьей неделе обучения среднее количество пропущенных по болезни дней во всех группах увеличилась в 2 раза, количество пропущенных занятий в ОГ составила у мальчиков и девочек соответственно 5,90 % и 7,56 %, в КГ - 5,74 % и 10,31 %. Наивысшие показатели острой заболеваемости наблюдаются у девочек КГ, где разница в пропусках занятий по сравнению с ОГ составляет 2,75 %. На четвертой неделе реализации оздоровительной программы количество пропущенных занятий в ОГ и КГ уменьшилась. В ОГ он составлял 2,31 % у мальчиков и 2,96 % у девочек. В КГ этот уровень был более высоким. Таким образом, на протяжении исследования дети ОГ пропускали занятия меньше на 3,08 %, чем дети КГ. Это подтверждает данные А. В. Скалий [13] о том, что в первые дни занятий в бассейне ещё не происходит повышение эффективности механизма терморегуляции и организм ребенка находится в состоянии относительно неустойчивом к действию низкой температуры воды по сравнению с воздухом. Согласно этим данным устойчивость к температуре воды в бассейне происходит на протяжении 8-10 занятий. Меньшую заболеваемость у учащихся ОГ объясняется тем, что у детей которые занимались по дифференцированным программам с элементами соревновательно-игрового характера в воде, присутствовал эффект позитивного эмоционального подъёма, в отличие от детей КГ, которые занимались по традиционной программе обучения плаванию (жестко- нормированное проплывание отдельных отрезков, что вызывает, вероятно, ощущение монотонности и определённого психологического дискомфорта). Таким образом, за время исследования в ОГ отмечалась более выраженная положительная динамика в снижении показателей заболеваемости детей. За период исследования как в ОГ, так и в КГ отмечалось снижение количества случаев острых заболеваний в учебном году, а также количества пропущенных дней по болезни. В КГ снижение составило: у девочек - в среднем 4 дня, у мальчиков - 3 дня, в ОГ у девочек - 5 дней, у мальчиков - 7 дней (р <0,05) (рис. 4.1). Результаты исследования показали, что у детей ОГ и КГ наблюдалось снижение количества пропущенных занятий по болезни с 29 % до 18 %, а также уменьшение числа с 41 % до 28 % часто болеющих детей. При этом у детей ОГ более выражено снизилось количество пропущенных занятий по

169 болезни и сократилось число часто болеющих детей по сравнению с КГ (р<0,05).

АНАЛИЗ И ОБОБЩЕНИЕ РЕЗУЛЬТАТОВ

После реализации оздоровительной программы уровень физической работоспособности, как в контрольной, так и в основной группе повысился, значительно снизилось количество детей с низким и ниже среднего уровнем физической работоспособности по сравнению с исходным уровнем. Однако более высокие показатели отмечены у детей основной группы, как у мальчиков, так и у девочек: 41,5 % достигли среднего и 7,5 % выше среднего уровня физической работоспособности, по сравнению с 22,6 % и 2,6 % детей контрольной группы соответственно. Анализируя динамику функционального состояния сердечно - сосудистой и дыхательной систем занимающихся, следует отметить, что у всех детей снизилась частота сердечных сокращений в покое (р<0,05), улучшились показатели индекса Руфье (р<0,05), силового индекса (р<0,05), снизилась систолическая работа сердца в покое (индекс Робинсона; р<0,05). Отмечается статистически достоверное улучшение результатов в ОГ по сравнению с КГ показателей пробы Генчи (р<0,05), показателей ЧСС в состоянии покоя (р<0,05).

170 Наряду с улучшением показателей функционального состояния младших школьников, улучшились и показатели физической подготовленности: быстроты (на 18%), выносливости (25%), силы (на 15%), скоростно-силовых способностей (на 23%) и гибкости (28%). Анализ тестирования физических качеств детей опытной группы (ОГ) показал, что эти дети превосходят своих сверстников по таким показателям, как гибкость, ловкость, сила, выносливость. В результате реализации курса оздоровительного плавания отмечен позитивный сдвиг и по показателям острой заболеваемости: уменьшилось количество случаев острой заболеваемости среди исследуемых школьников и количество дней, пропущенных по болезни. Наблюдалось снижение количества пропущенных занятий по болезни с 29 % до 18 %, а также уменьшение числа с 41 % до 28 % часто болеющих детей. У детей ОГ отмечены статистически достоверные (р<0,05) признаки преимущества по ряду показателей характеризующих снижение заболеваемости, в сравнении с детьми КГ. Эти изменения являются наиболее доказательными критериями в оценке эффективности занятий в бассейне с детьми младшего школьного возраста, особенно при использовании дифференцированных программ оздоровительного плавания с элементами соревновательно-игрового характера в воде, с учётом уровня физического здоровья

Выводы: 1. На основе полученных данных о физическом состоянии обследованных разработаны дифференцированные программы оздоровительного плавания с элементами соревновательно-игрового характера в воде, отдельно для детей с низким и ниже среднего УФЗ и детей со средним и выше среднего УФЗ, обоснована и реализована, доступная в широком использовании, методика врачебного контроля над детьми младшего школьного возраста, занимающихся оздоровительным плаванием, с учётом уровня их физического здоровья. 2. После реализации 72 часовой 6-месячной программы, у занимавшихся оздоровительным плаванием произошло статистически достоверное повышение уровня здоровья во всех полово-возрастных группах обследованных. При этом у всех детей снизилась частота сердечных сокращений в покое (р<0,05), улучшились показатели индекса Руфье (р<0,05), силового индекса (р<0,05), снизилась систолическая работа сердца в покое (индекс Робинсона; р<0,05), а также увеличилась продолжительность задержки дыхания на выдохе (проба Г енчи; р<0,05).

3. У младших школьников, занимавшихся в течение 6 месяцев оздоровительным плаванием, улучшились показатели физической подготовленности по таким показателям как ловкость р<0,05 («челночный» бег 4x9 м, с), сила р<0,05 (сгибание и разгибание рук в упоре лежа, раз) и 171 скоростно-силовые возможности р<0,05 (прыжок в длину с места, см). У девочек также отмечена положительная динамика в развитии гибкости (наклон туловища вперед из положения сидя, см; р<0,05); 4. В результате реализации программы занятий оздоровительным плаванием наблюдалось снижение случаев острой заболеваемости и количества дней пропущенных по болезни с 29 % до 18 %, а также уменьшение с 41 % до 28 % числа часто болеющих детей. 5. У детей ОГ, которые занимались по дифференцированным программам оздоровительного плавания с элементами соревновательно игрового характера в воде, отмечены статистически достоверные (р<0,05) признаки преимущества по ряду показателей характеризующих повышение уровня здоровья и физической подготовленности, а так же снижение показателей заболеваемости, в сравнении с детьми КГ, которые занимались по традиционной программе обучения плаванию, вызывающей ощущение монотонности и определённого психологического дискомфорта.

6. Результаты проведенного исследования свидетельствуют об эффективности занятий оздоровительным плаванием при надлежащем врачебном контроле, что позволило повысить показатели физического состояния (функциональные показатели, уровень физического здоровья, уровень физической и плавательной подготовленности) детей младшего школьного возраста.

Список литературы 1. Аршавский, И.А. Основы негэнтропийной теории биологии индивидуального развития, значение в анализе и решении проблемы здоровья / Валеология: Диагностика, средства и практика обеспечения здоровья. - СПб.: Наука, 1993. - С. 5-24. 2. Ахундов, Р.А. Исследование двигательной активности (основных локомоций) учащихся начальной школы : автореф. дис... канд. наук. / - М., 1970. - 25 с. 3. Апанасенко Г.Л. Попова Л.А. Медицинская валеология.- Киев, Здоровье.- 1998, 247 с. 4. Апанасенко Г. Л. Рiвень здоров’я i фiзiологiчнi резерви оргашзму // Теорiя i методика фiзичного виховання i спорту. - 2007. - № 1. - С. 17-21. 5. Бальсевич В. К. Физическая активность человека - Киев : Здоров’я, 1987. — 226 с. 6. Безматерных, Л.Е. , Куликов В.П. Диагностическая эффективность методов количественной оценки индивидуального здоровья // Физиология человека. - 1998. - Т. 24. -№3.-С. 79-85. 7. Булатова М. М. Здоров’я i фiзична тдготовленють населення Украши // Теорiя i методика фiзичного виховання i спорту. - 2004. - № 1. - С. 3-9. 172 8. Булгакова Н. Ж. Игры у воды, на воде, под водой /- М., 2000.- 77 с. 9. Бундзен П.В., Современные технологии укрепления психофизического состояния и психосоциального здоровья населения (аналитический обзор) // Теория и практика физического воспитания. - 1996. - №2 8. - С. 57-63. 10. Вайнбаум Я. С. Гигиена физического воспитания и спорта : учебное пособие [для студ. высш. пед. учеб. Заведений - М. : Академия, 2003. - 240 с. 11. Вовченко I. I. Програмування занять з оздоровчо! ходьби для дггей молодшого ттткшьного вжу з рiзним рiвнем фiзичного стану : автореф. дис. на здобуття наукового ступеню канд. наук з фiзичного виховання i спорту . - К., 2003. - 17 с. 12. Закон Украши «Про фiзичну культуру i спорт» : за станом на 17 листопада 2009 року / Верховна Рада Украши. - Офщ. вид. - К. : Парлам. вид-во, 2009. - 25 с. - (Серiя «Закони Украши»). 13. Скалш О. В. Комп’ютерш технологи диференщацп процесу фiзичного виховання школярiв (на прикладi навчання плавання) : автореф. дис. на здобуття наукового ступеню канд. наук з фiзичного виховання i спорту.- Львiв, 2002. 20 с. 14. Томенко О. А. Навчання плаванню дггей-швалщв з ушкодженням опорно-рухового апарату з використанням методiв контролю : автореф. дис. на здобуття наукового ступеню канд. наук з фiзичного виховання i спорту. - Луцьк, 2000. - 20 с.

Dynamics parameters of the functional state of physical fitness and morbidity in primary school children under the influence of health programs in swimming Butskaya L.V., MD, PHD, DSc National Technical University of Ukraine “KPI”, department of the physical rehabilitation Summary. On the basis of data on the physical state of the examined 205 children of 7 10 years of age have been developed and implemented differentiated programs wellness swimming. After 72 sessions over 6 months was an increase in the level of health and physical fitness of primary school children. Reduced the number of days missed due to illness, the number of cases of acute disease, with 41% to 28% reduction in the number of sickly children. Keywords: differentiated programs recreational swimming, medical control, the level of physical fitness, functionality, fitness, children of primary school age.

173 Journal of Health Sciences (J o H Ss) 2013; 3(2): 174-197 The journal has had 4 points in Ministry of Science and Higher Education of Poland parametric evaluation. Part B item 683. УДК 615.837.3+615.847+616.74-009.1/.7

ОЦЕНКА БОЛЕВЫХ И СЕНСОРНЫХ ПОРОГОВЫХ ОТВЕТОВ НА ЭЛЕКТРОСТИМУЛЯЦИЮ В ОЦЕНКЕ РЕЗУЛЬТАТИВНОСТИ ЛЕЧЕНИЯ ПАЦИЕНТОВ С ХРОНИЧЕСКОЙ МИОФАСЦИАЛЬНОЙ ЦЕРВИКАЛГИЕЙ

В.В. Ежов, Ф.А. Субботин Крымский государственный медицинский университет имени С.И.Георгиевского (Симферополь, Автономная республика Крым, Украина)

Streszczenie OCENA ODPOWIEDZI CZUCIOWE I BÓLU PROGOWYCH DO ELEKTROSTYMULACJI W OCENIE SKUTECZNOŚCI LECZENIA PACJENTÓW Z PRZEWLEKŁĄ MYOFASCIAL CERVICALGIA VV Jeżow, FA Subbotin Krym State Medical University nazwany S.I.Georgievskogo (Symferopol, Krym, Ukraina) Słowa kluczowe: fizykoterapia, przewlekłe myofascial cervicalgia miogenne punkt wyzwalania, elektrycznie pobudliwy, elektryczne. Łącznie 180 pacjentów (101 kobiet, 79 mężczyzn) z przewlekłą Myofascial cervicalgia. Grading wiek chorych - od 26 do 54 lat. Wiek choroby - 2,0+1,5 roku. Zajmując kompleksowe kliniczne, biomechaniczne kinesteziologicheskie, instrumentalistyka. Oceniano łuski rehabilitacyjne danych. Technika oceny elektroalgometrii nerwowo electroexitability miogenne punkty spustowe u pacjentów z przewlekłą Myofascial cervicalgia. Wykazano, że w punktach mięśniowego wyzwalania stwierdzono podwyższony poziom progu czucia bólu i w porównaniu z innymi symetrycznych części ciała. Technika pozwala wykryć mięśni połączone patologii układu ruchu we wczesnych stadiach choroby. Informacje wysokiej, powtarzalności i całkowitego bezpieczeństwa pacjenta stanowią podstawę kontroli dynamiki w celu procesu rehabilitacji. Złożony system leczenia pacjentów z przewlekłym zespołem bólowym powięziowych w mięśnie szyi i ramion. Leczenie polega na łączne stosowanie leków i różnych terapii fizycznej - śródmiąższowe senność fonoforeza w

174 środowisku alkalicznym i elektrogelya Połtawa bischofite następnie Electromyostimulation dotkniętych mięśni. Narzędzie diagnostyczne opracowane oceny algorytmu nerwowo electroexitability miogenne punkty spustowe polecane w programie obejmują wszechstronną ocenę pacjentów z przewlekłą Myofascial cervicalgia.

Summary ESTIMATION OF PAIN AND SENSORY THRESHOLD RESPONSES TO ELECTRICAL STIMULATION IN THE MEASUREMENT OF THE EFFECTIVENESS OF TREATMENT OF PATIENTS WITH CHRONIC MYOFASCIAL CERVICALGIA VV Yezhov, FA Subbotin Crimea State Medical University named after S.I.Georgievsky (Simferopol, Crimea, Ukraine) Keywords: physical therapy, chronic myofascial cervicalgia, myogenic trigger point, electrically excitable, electrical. A total of 180 patients (101 women, 79 men) with chronic myofascial cervicalgia are observed. Age of patients - from 26 to 54 years. Age of illness - 2.0+1.5 years. Pursuing a comprehensive clinical biomechanical, kinesteziologicheskie, instrumental studies. Data rehabilitation scales are evaluated. A technique for assessing electroalgometria of neuromuscular electroexitability in myogenic trigger points on patients with chronic myofascial cervicalgia. It is shown that in myogenic trigger points found to have elevated levels of sensory and pain threshold compared with other symmetric parts of the body. The technique allows to detect muscle-connected pathology of the musculoskeletal system in the early stages of the disease. High information, repeatability and complete safety for the patient provide a basis for dynamic control of the objective in the process of rehabilitation. A complex system of treating patients with chronic myofascial pain syndrome in the muscles of the neck and shoulder area are given. Treatment involves the combined use of drugs and a variety of physical therapy - interstitial phonophoresis anesthetics in an alkaline medium and elektrogelya Poltava bischofite followed electromyostimulation affected muscles. Diagnostic tool developed evaluation algorithm neuromuscular electroexitability myogenic trigger points recommended in the scheme include a comprehensive assessment of patients with chronic myofascial cervicalgia.

175 Несмотря на обилие работ в литературе, посвященной восстановительному лечению МФБС, многие стороны восстановительного лечения этого заболевания не решены и до настоящего времени подвергаются обсуждению [ 4 ]. К подобным методам относится ЭМС (электромиостимуляция) - локальное воздействие электрическим импульсом на двигательную точку мышцы или нерва с помощью точечного электрода, вызывающее сокращение стимулируемой мышцы [ 18 ]. Электрический ток, изменяя концентрацию тканевых ионов у клеточной оболочки и меняя ее проницаемость, действует по типу естественных биотоков. Физиологическое действие ЭМС проявляется кратковременными, ритмически повторяющимися сверхпороговыми сдвигами концентрации основных ионов (№+, К+, Са+, Mg+) возле полупроницаемых мембран нервных, мышечных и других клеток различных органов и тканей. Это увеличивает количество свободных ионов у клеточных мембран, повышает их проницаемость, активизирует работу №- Са-каналов клетки, способствуют синтезу РНК, ДНК, ферментов, белков, АТФ [ 14, 15 ]. В результате возникает деполяризация тех возбудимых структур, лабильность которых позволяет воспринимать воздействующий импульсный ток, что приводит к сокращению мышечных волокон, восстановлению функции клеток. За счет мышечных сокращений повышается внутрисосудистое давление, улучшаются микроциркуляция, клеточный метаболизм. Лечебное действие ЭМС связывают с усилением притока крови к сокращающимся мышцам и улучшением венозного оттока, что сопровождается местным усилением обменных и пластических процессов, а также с повышением функциональной активности центральной нервной системы. Доказано, что при ЭМС увеличивается капиллярный кровоток, повышается фильтрация жидкости из кровеносных капилляров в тканевые пространства сокращающихся мышц, а это в свою очередь

176 увеличивает лимфообразования и лимфоток [ 13 ]. Лечебный эффект ЭМС, прежде всего, зависит от правильности выбора параметров стимулирующего электрического тока. Выбор параметров воздействия, в свою очередь, определяется степенью нарушения иннервации мышцы и состоянием мышечной ткани. Анализ многочисленных публикаций о применении ЭМС мышц в клинической и спортивной практике показывает, что подавляющее большинство их посвящено обоснованию параметров и режимов стимулирующих сигналов и режимов стимуляции. В то же время весьма важный вопрос об оптимальной длительности сеанса ЭМС, наиболее адекватной для процессов восстановления или улучшения функции нервно мышечных структур, еще требует своего решения. Так, продолжительность сеанса ЭМС определяется умозрительно и, по современным методикам, колеблется от 10 до 30 минут, не отличаясь от длительности большинства физиотерапевтических процедур. Основные фундаментальные положения метода ЭМС разработаны еще не до конца, процедуры у различных субъектов проводятся по общим стандартным рекомендациям. Между тем, у каждого из пациентов имеются существенные различия в функциональном состоянии нервно-мышечных структур. При этом процедура ЭМС, незначительно влияющая на нервный аппарат и мышцы в одних случаях может иметь чрезмерную длительность, тем более у больного человека (приводя к истощению нервных приборов, изменениям биохимизма мышц и нежелательным последствиям) и недостаточную продолжительность в других [ 16 ]. В таких условиях ЭМС даже оптимальными по форме и режиму подачи импульсов не только не способна улучшить состояние пациента, но и может оказать повреждающее, угнетающее воздействие на нервно-мышечные структуры. Отсутствие обоснованных критериев выбора продолжительности сеанса ЭМС на практике

177 приводит к получению отрицательных результатов и дискредитации метода в глазах, как больных, так и специалистов. В то же время недостаточное по продолжительности воздействие на нервно-мышечный аппарат сопровождается малым лечебным или стимулирующим эффектом. В процессе ЭМС воздействия функциональное состояние нервно-мышечного аппарата меняется. Мышца утомляется и ее сократительная способность падает [ 6 ]. Выбор параметров воздействия, в свою очередь, определяется степенью нарушения иннервации мышцы и состоянием мышечной ткани. Поэтому проведению ЭМС мышц всегда должно предшествовать диагностическое исследование. Исходя из вышесказанного, в качестве метода, позволяющего подобрать оптимальные параметры стимулирующего тока, электродиагностика по-прежнему сохраняет свое значение. Кроме того, при отсутствии возможностей осуществления электромиографии, электродиагностика может помочь в установлении степени денервации или реиннервации мышцы. Некоторые современные физиотерапевтические аппараты совмещают возможности проведения, как электродиагностики, так и электростимуляции. Для суждения об изменениях функционального состояния нервов и мышц определяют ответную реакцию, в зависимости от силы тока, необходимой для вызывания пороговой сенсорной или болевой реакции в ответ на раздражение кратковременными, одиночными импульсами. Для суждения об изменениях функционального состояния нервов и мышц определяют его зависимость от силы тока, необходимой для вызывания пороговой сенсорной или болевой реакции на раздражение вызываемые кратковременными, одиночными импульсами. Измерение реакции на электрический стимул, способствует подбору параметров ЭМС, учитывая, что они будут находиться в диапазоне между сенсорным и болевым порогом стимуляции. Клинически прогнозируемая, эффективная ЭМС, возможна только в условиях

178 комплексного электрофизиологического контроля функционального состояния нервной и мышечной систем в зоне воздействия. Важно помнить о том, что стимулировать мышцу надо из расслабленного исходного состояния, чтобы под влиянием тока она имела возможность сокращаться. Недифференцированное сокращение одновременно многих мышц, резкая болезненность свидетельствуют о неправильном проведении процедуры [ 2 ]. Поэтому проведению ЭМС мышц всегда должно предшествовать диагностическое исследование. Исходя из вышесказанного, в качестве метода, позволяющего подобрать оптимальные параметры стимулирующего тока, электродиагностика по-прежнему сохраняет свое значение. Кроме того, при отсутствии возможностей осуществления электромиографии, электродиагностика может помочь в установлении степени денервации или реиннервации мышцы [ 13 ]. Некоторые современные физиотерапевтические аппараты совмещают возможности проведения, как электродиагностики, так и электростимуляции. Для суждения об изменениях функционального состояния нервов и мышц возможно определение его зависимости от силы тока, необходимой для вызывания пороговой сенсорной или болевой реакции на раздражение вызываемые кратковременными, одиночными импульсами. Измерение реакции на стандартный электрический стимул, позволяет подбирать адекватные параметры ЭМС, учитывая, что они будут находиться в диапазоне между сенсорным и болевым порогом стимуляции [ 11 ]. Известна роль оценки электровозбудимости нервно-мышечного аппарата человеческого тела в диагностике миогипертонусов [ 9 ]. Полученные клинико-диагностические данные свидетельствуют о повышенной электровозбудимости болевых миогенных триггерных пунктов (МТП) и важности объективизации сенсорных и болевых ощущений для эффективного лечения хронического миофасциального болевого синдрома (МФБС).

179 Проведенные нами предварительные наблюдения показали, что в области МТП выявляется повышение уровней сенсорных и болевых порогов, а пациент наибольшую болезненность ощущает в точке приоритетного миогипертонуса. Этот феномен послужил отправной точкой данного исследования.

Материалы и методы В соответствии с программой исследования, целью которой являлась комплексная оценка клинико-инструментальных данных при первичном осмотре, проведены наблюдения у 180 (101 женщин, 79 мужчин) больных с результаты миофасциальными цервикалгиями в возрасте от 20 до 60 лет страдающие, в том числе, другими соматическими патологиями. Давность болезни составляла в среднем 2,0 + 1,5 лет. Выраженный болевой синдром при обращении отмечен у 131 (73 %), умеренный - у 36 (20 %), легкой степени выраженности - у 13 (7 %) больных. У 140 (78 %) больных дегенеративно-дистрофические изменения в шейном отделе позвоночника соответствовали начальным или умеренно выраженным проявлениям остеохондроза 1 - 2 стадии. У 40 (22 %) больных выявлялись клинико

рентгенологические признаки спондилоартроза, нестабильности шейного отдела позвоночника. Клинический диагноз МФБС устанавливали в соответствии с критериями Г.А. Иваничева [ 4 ] и Г.Н. Крыжановского [ 7 ]. Оценивались функциональные ортопедические, неврологические клинические показатели, признаки вегетативно-сосудистых расстройств, рисунок боли, реакции на механические, электрические, термические и фармакологические стимулы. Методом кинестетической пальпации по Марсовой-Хорошко [ 8 ] оценивали степень мышечной боли[ 4 ]. По критериям В.А.Карлова [ 5 ] выявлялись группы риска развития МФБС. Выявлялись фазы течения МФБС, факторы

180 усиления боли в МФТТ. Проводилась визуальная оценка статики, постурального мышечного дисбаланса, динамического двигательного стереотипа, атипичного моторного паттерна. Активное выявление МФТТ и их степени выраженности проводилось пальпаторно по методике Корнелиуса в модификации Марсовой-Хорошко [ 8 ] в области основных мышц шейно плечелопаточной группы и верхних конечностей. Клинически, а затем инструментально, исследовались: мышца поднимающая лопатку, дельтовидная мышца, грудино-ключично-сосцевидная мышца, ромбовидная мышца, подостная и надостная мышцы, малая грудная мышца, трапециевидная мышца, малая круглая мышца, двуглавая и трехглавая мышцы плеча. Определение подвижности шейного отдела позвоночника проводилось в положении сидя с помощью гониометра 02.312.01 (DIMEDA Instrumente GmbH, Германия). Кинестезиологическую оценку мышечного синдрома проводили по шкале Салхнова-Хабирова [ 12 ], определялась выраженность спонтанных болей, тонус мышц, болезненность, степень иррадиации, индекс мышечного синдрома. Болевой синдром оценивался с помощью анкеты McGill Pain Questionnaire [ 17 ] и четырехсоставной визуально-аналоговой шкалы боли Qadruple Visual Analogue Scale, Von Koff M., Deyo R.A., et al, (1993). Электродиагностическое исследование проводилось авторским методом электроальгометрии, согласно патенту Украины № 47366 [ 10 ]. При проведении системной альгометрии по основным шкалам McGill Pain Questionnaire регистрировались 20 дескрипторов боли, описывающих сенсорные и эмоциональные ощущения, интенсивность боли, разнообразие болевого синдрома. Ранговая значимость каждого дескриптора болевого синдрома определялась его положением в соответствующем перечне слов, описывающих специфический характер боли. Сумма ранговых показателей определяла ранговый индекс боли. Настоящее болевое ощущение оценивали

181 по шкале от 0 до 5 баллов. Фиксировались дескрипторы, описывающие продолжительность боли. Локализация боли отмечалась на клише, соответствующему контурам тела в передней и задней проекциях. Уровень локального сенсорного и двигательного порога оценивался путем регистрации сенсорных и двигательных реакций на дозированный электрический стимул, генерируемый аппаратом «Радиус-Интер СМ-01» (Беларусь). Параметры электрического стимула в виде синусоидальных модулированных токов (СМТ) - II род работы, несущая частота Fн = 2 кГц, соотношение сигнал/пауза 2:3, глубина модуляции равна 100 %, Fмодуляции = 10 Гц. Для электродиагностики используют электроды с гидрофильными прокладками. Применяются пластинчатые электроды и точечный электрод с кнопочным прерывателем. Точечный электрод диаметром 1 см располагают в проекции предварительно определенной пальпаторно активной ТТ и в стандартных нейромышечных эрбовских точках, соответствующих участкам вхождения нервов шейного сплетения в основные мышцы шейно плечелопаточной группы. Для определения места нахождения двигательных точек используют таблицы Эрба. Второй электрод (пассивный) - большой площади (100 - 150 см2) накладывается в шейно-воротниковой области. При наложении электродов на диагностируемые мышцы необходимо соблюдать следующие условия: электроды должны быть влажными; кожу зоны наложения электродов, необходимо обработать спиртом; электроды должны плотно фиксироваться к телу; межэлектродный участок должен быть сухим; расстояние между электродами должно быть не менее 2 см. Методика проведения электродиагностики мышц надплечья и шеи: положение больного - сидя. Общий комфорт является необходимым условием. Подвергаемая электродиагностике часть тела должна находиться в свободном и расслабленном состоянии, чтобы сокращение мышц проходило

182 беспрепятственно, и было хорошо видно. Перед процедурой пациенту сообщают о характере ощущений возникающих в процессе электродиагностики. При плавном наращивании силы тока достигался сенсорный порог и далее - порог мышечных сокращений в ответ на электрический стимул. Исследовались мышцы верхнего плечевого пояса авторским методом, подтвержденным декларационным патентом Украины [10 ], с помощью аппарата «Радиус-Интер СМ-01» (Беларусь) путем регистрации сенсорных и двигательных реакций на дозированный электрический стимул. Использовались: ток - синусоидальный модулированный, несущая частота — 2 кГц, частота модуляции — 10 Гц, род работы — II , соотношение сигнал/пауза — 2:3 сек, глубина модуляции — 100%. Точечный электрод диаметром 1 см располагали в проекции предварительно определенной пальпаторно активной триггерной точки и в стандартных нейромышечных точках, соответствующих участкам вхождения нервов шейного сплетения в исследуемые мышцы шейно-плечелопаточной группы. Второй электрод площадью 100-150 см2 располагали на шейно-воротниковой области. При плавном наращивании силы тока достигали сенсорного порога (ощущение легкой вибрации под активным электродом) и далее - болевого порога (появление болезненных ощущений). Полученные результаты измерений сравнивали с результатами измерений в контрольных точках, симметричных по отношению к исследуемому МТП. Все 130 больных с МФБС были разделены на 3 группы, однородные по полу, возрасту, характеру и структуре заболевания. В группе контроля К (п = 30) проводились процедуры низкочастотной ультразвуковой терапии (НЧ УЗТ), частотой 44 кГц, с помощью аппарата «МИТ- 11» (Украина) по стабильной методике в области выявляемых МТП, контактная среда - медицинский вазелин; интенсивность (амплитуда)

183 ультразвука — пороговая, до ощущения легкого тепла, в среднем — 2-3 мкм; продолжительность - 2 минуты на точку, общая продолжительность — 8 - 10 минут; на курс - 10 процедур. В группе 1 (п = 50) назначались процедуры НЧ УЗТ, в параметрах, аналогичных группе контроля по методике дерматопарамибного ультрафонофореза, с инъекционным введением в зону приоритетного МТП 0,5 мл 0,5% раствора лидокаина + 0,5 мл 4% раствора бикарбоната натрия. непосредственно перед каждой процедурой УЗ. За один сеанс инактивировали до 3-х МТП, обнаруженных в мышце. По окончании процедуры больной выполнял те активные движения, в которых в максимально полном объеме участвует пролеченная мышца. Курс - 10 процедур. В группе 2 (п=50) применялись процедуры дерматопарамибного ультрафонофореза в области зоны приоритетного МТП, аналогичного группе сравнения 1, отличающейся тем, что добавлялся сертифицированный препарат «Бишофит Полтавский Электро-гель», обладающий специальными электро- и звукопроводящими свойствами. Продолжительность - 8-10 мин, курс - 10 процедур. В группе 3 (п = 50) проводились процедуры лечебно реабилитационного комплекса - 3 (ЛРК-3), включавшие дерматопарамибный ультрафонофорез лидокаина и бикарбоната натрия через контактную среду "Бишофит Полтавский "Электро-Гель", отличающиеся тем, что сразу после озвучивания осуществлялась низкочастотная ЭМС в зоне нервно-мышечного синапса (двигательные точки мышцы по градации Эрба) током синусоидальной формы минимальной пороговой интенсивности, вызывающей изометрическое сокращение мышцы. ЭМС проводили в положении больного сидя, с созданием необходимых условий (подголовник, подлокотники, поролоновые валики) для того, чтобы подвергаемые ЭМС

184 части тела — шея, надплечья, проксимальные участки верхних конечностей находились в свободном и расслабленном состоянии. Для ЭМС использовался аппарат «Радиус» (Беларусь). ЭМС проводили в области m. stemodeidomastoideus, m. trapezius, m. levator scapulae, m. deltoideus, m. supraspinatus, m. Infraspinatus. При определении локализации активного электрода использовали схему двигательных нейромышечных точек Эрба. В связи с вариабельностью расположения двигательных точек при первой процедуре проводили электродиагностику для уточнения соответствующих топических ориентиров и маркировали их спиртовым раствором йода или бриллиантовым зеленым. Для ЭМС использовали 2 электрода с гидрофильными прокладками: активный — круглый точечный электрод с кнопочным прерывателем диаметром 1 см и индифферентный — пластинчатый электрод прямоугольной формы площадью 150 см2. Точечный электрод располагали в области приоритетных МФТТ (определяемых предварительно путем пальпации), индифферентный электрод располагали по средней линии в межлопаточной области. Расстояние между электродами составляло не менее 2 см. Перед процедурой пациенту сообщали о характере ожидаемых ощущений. Кожу в области зоны наложения электродов обрабатывали спиртом, межэлектродный участок оставляли сухим, во избежание формирования поверхностного распространения силовых линий тока, электроды плотно фиксировали к телу. ЭМС проводилась с помощью СМТ в следующих параметрах: II род работы (несущая частота Fн =2 ^ 10 кГц с шагом 1 кГц, Fмодуляции = 1 - 150 Гц); соотношение «сигнал: пауза» (в числителе — фаза «гладкий тетанус», в знаменателе — фаза «покой- расслабление», в сек) — 2,3; 4,6; глубина модуляции — 25 %, 50 %, 75 %, 100 %, 125 %; сила тока — до четко визуализируемого врачом и ощущаемого самим больным изометрического сокращения мышцы; длительность

185 процедуры — 5 - 10 мин; курс - 10 процедур. Указанные параметры устанавливались для каждой процедуры индивидуально. Основой выбора конкретных электрических характеристик ЭМС являлось достижение безболезненного изометрического сокращения при минимальной величине силы тока, согласно показаниям шкалы интенсивности электрического тока.

Результаты исследования Проведенные исследования позволили обосновать возможность повышения эффективности восстановительного лечения больных с МФБС с учетом клинико-патогенетических особенностей заболевания. Выраженная болезненность приоритетных мышечных уплотнений 2 и 3 степени наблюдалась у 159 (88,3 %) пациентов. Интрарегионарный и локальный мышечный дисбаланс выявлялся у 139 (77,3 %). Среди факторов, провоцирующих обострение заболевания отмечались: длительная работа в вынужденной статической позе - у 55 (30,6 %), переохлаждение - у 5 (2,8 %), глубокий ночной сон после переутомления в неудобной позе (подушке), - у 59 (32,8 %), негативные эмоции — у 34 (18,9 %) больных. У всех пациентов в анамнезе выявлялись признаки неоптимального двигательного стереотипа, бытовые или профессиональные статико-динамические перегрузки, наличие соматической патологии. Это позволяет говорить о том, что наличие соматической патологии усугубляет проблемы перегрузки опорно двигательного аппарата связанные с профессиональными биомеханическими нарушениями и потенцировании в формировании МФБС. В то же время, фактором провоцирующим усиление боли являются негативные эмоции, что позволяет говорить о влиянии эмоционального фактора на выраженность течения МФБС. Следует отметить, что влияние других факторов на усиление боли, распределилось примерно одинаково. Это позволяет отметить статистическую однородность причин провоцирующих усиление МФБС.

186 Тем самым, изучение исходного клинико-функционального состояния больных с МФБС по данным клинических, кинестезиологических, инструментальных показателей и комплексных реабилитационных шкал показало, что характерными клинико-биомеханическими особенностями больных в мышцах шеи и плечевого пояса является возникновение множества болезненных триггерных точек, проявляющиеся болями, спазмом и снижением силы мышц, ограничением объема движений. Была проведена регистрация сенсорных и болевых порогов в области максимального приоритетного МТП, определяемого предварительно путем пальпации, (точки наибольшей болезненности). Контрольной точкой измерений служила симметричная точка на здоровой стороне. После проведения электродиагностики в области наиболее болезненного мышечного уплотнения при миофасциальном болевом синдроме, полученные результаты измерений сравнивают с результатами измерений в контрольных точках, симметричных по отношению к исследуемому МТП. Проведенные исследования показали, что в области МТП выявляется повышение уровней сенсорных и болевых порогов, а пациент наибольшую болезненность ощущает в точке приоритетного миогипертонуса. Согласно данных электроальгометрических исследований, представленных в таблице 1, в области МТП выявляется асимметрия в реакции на стандартный электрический стимул. Это свидетельствует об изменении сенсорных и болевых порогов в области приоритетного триггерного пункта. по сравнению с симметричным участком другой половины тела.

Таблица 1

Показатели сенсорных и болевых порогов в области приоритетных миофасциальных триггерных пунктов на стандартный электрический стимул у больных и здоровых ^ А , M±m)

187 Точки измерений Показатели Локальный сенсорный порог: Точка справа (больная сторона) 1,25 ± 0,1 Точка слева (здоровая сторона) 2,55 ± 0,3

1больн - 1здоров -1,3 ± 0,2 Локальный болевый порог: Точка справа (больная сторона) 1.4 ± 0,1 Точка слева (здоровая сторона) 3,45 ± 0,2

1больн - 1здоров -2,05 ± 0,15

Примечание: Iбольн - 1здоров - разница пороговых значений электрического тока между здоровой и больной сторонами.

По результатам динамики показателя электроасимметрии мышечных репрезентативных точек в процессе лечения у наблюдаемых пациентов во всех трех группах отмечалось уменьшение асимметрии (таблица 2).

Таблица 2

Изменения сенсорных и болевых порогов в области приоритетного триггерного пункта на стандартный электрический стимул в процессе лечения ^ А , M±m)

Показатели Контроль К Группа 1 Группа 2 Группа 3 электро- (п = 30) (п = 50) (п=50) (п=50) альгометрии Локальный сенсорный порог:

1больн - 1здоров -1,0±0,2 -1,1±0,2 -0,9±0,1 -0,8±0,1

-0,6±0,2*** -0,4±0,1*** -0,2±0,1*** -0,2±0,1 ** Локальный болевый порог:

1больн - 1здоров -2,1±0,1 -2,0±0,2 2,2±0,2 -1,8±0,1

-1,0±0,2*** -0,4±0,1*** -0,2±0,1*** -0,3±0,1 ** ##

188 Примечания: 1больн - 1здоров - разница пороговых значений электрического тока между здоровой и больной сторонами; после лечения по группам *- р < 0,05,**- р < 0,003; после лечения по отношению к группе К #- р < 0,05,## - р < 0,003.

Установлено, что под влиянием лечебно-реабилитационного комплекса, включающего дерматопарамибный ультрафонофорез лидокаина и натрия бикарбоната и проводится с учетом топографии миофасциальных триггерных точек, типичный уровень боли, по показаниям визуально аналоговой шкалы, снизился до 2,5 баллов (р < 0,003), локальных сенсорных порогов - до 0,4 ± 0,1 тА (р < 0,003), болевых порогов - до 0,9 ± 0,2 тА (р <0,003), а показатель улучшения жизнедеятельности больных - до 7,4 ± 0,2 баллов (р <0,003). Изучена эффективность лечебно-реабилитационного комплекса с включением дерматопарамибного ультрафонофорезу лидокаина и натрия бикарбоната в сочетании с ультрафонофорезом полтавского бишофита «Електрогель», который проводится с учетом особенности топографии миофасциальных триггерных точек и установлено, что типичный уровень боли, по показаниям визуально-аналоговой шкалы, снизился до 1,2 балла (р < 0,003) локальных сенсорных порогов - до 0,3 ± 0,1 тА (р < 0,003), болевых порогов - до 0,5 ± 0,1 т А (р < 0,003), а показатель улучшения жизнедеятельности больных - до 5,1 ± 0,1 баллов (р < 0,003). Установлено, что при применении лечебно-реабилитационного комплекса, включающего дерматопарамибний ультрафонофорез лидокаина и натрия бикарбоната в сочетании с ультрафонофорезом полтавского бишофита «Електрогель» и электромиостимуляция с учетом особенностей топографии миофасциальных триггерных точек типичный уровень боли, по показаниям визуально-аналоговой шкалы, в группе снизился до 1,1 балла (р <

189 0,003), локальных сенсорных порогов - до 0,2 ± 0,1 тА (р < 0,003), болевых порогов - до 0,3 ± 0,1 т А (р < 0,003), а показатель улучшения жизнедеятельности больных - до 3,9 ± 0,1 баллов (р < 0,003). В группе контроля выравнивание асимметрии было менее выражено, тем не менее сохраняется тенденция к прогрессирующему уменьшению асимметрии от группа К > 1 группа > 2 группа. Установлена закономерность проведения электродиагностики сенсорных и болевых порогов в области наиболее болезненного мышечного уплотнения при миофасциальном болевом синдроме. Оценка непосредственных результатов восстановительного лечения после проведенных курсов восстановительного лечения пациентов с МФБС показала, что в группе К - «хорошие результаты» достигались у 53,3 % пациентов; «удовлетворительные результаты» - у 26,7 %, «неудовлетворительные результаты» - у 6 %, в группе 1 - у 72 %, 20 %, 8 %, в группе 2 - у 88 %, 10 %, 2 %, в группе 3 - у 94 %, 6 %, 0 %, соответственно. Полученные результаты, в группе 1, свидетельствуют о большей, в сравнении с традиционным проведением УЗТ, эффективности, саногенетически обоснованных методических подходов к лечению. По нашему мнению, это обусловлено непосредственным воздействием дерматопарамибного ультрафонофореза на болевой синдром, за счет введения в МТП местного анестетика и нейтрализации продуктов ацидоза в области мышечного спазма, путем введения в МТП щелочного раствора, а также на микроциркуляторные и мышечно-тонические компоненты мышечного спазма. При этом, эффект лечения в группе К реализовывался лишь за счет эффектов ультразвука. Несколько лучшие результаты были достигнуты в группе 2. Дополнительное назначение полтавского бишофита способствовало улучшению функционирования магний-кальциевой помпы, благодаря чему снижалась контрактильная активность мышц и улучшался

190 процесс восстановления её функционирования. Лучшие результаты лечения МФБС были достигнуты в группе 3, так как дополнительная ЭМС оказывала положительное влияние на сформированную пространственную деформацию части мышцы в локусе МТП. Для оценки общей эффективности лечения применялась система 5- бальной оценки по пяти параметрам: болевой синдром, чувствительность, мышечный тонус, мышечная сила, объем движений. Средний балл эффективности рассчитывался как среднеарифметический показатель вышеуказанных параметров оценки, «суммарная эффективность» - разность между исходным средним баллом и его уровнем после лечения (таблица 3). Динамика показателей по критериям, составляющим основу проявлений цервикалгий, была наиболее заметна в группах больных, где проводилось восстановительное лечение, включавшее комплексное лечение.

Таблица 3. Клиническая эффективность лечения пациентов с миофасциальной цервикалгией по данным комплексной балльной оценки (в баллах)

ПОКАЗАТЕЛИ Контроль К Группа 1 Группа 2 Группа 3 (в баллах) (п = 30) (п = 50) (п = 50) (п = 50) 3,9 ± 0,2 3,8 ± 0,2 4,0 ± 0,3 4,1 ± 0,2 Болевой синдром 1,7 ± 0,1** 1,3 ± 0,1** # 0,6 ± 0,1** ## 0,5 ± 0,1** ## 2.9 ± 0.2 2,8 ± 0,2 2,9 ± 0,2 2,8 ± 0,2 Чувствительность 1,0 ± 0,1** 0,7 ± 0,2** 0,5 ± 0,1** ## 0,4 ± 0,1** ## 2,1 ± 0,4 2,0 ± 0,3 2,2 ± 0,4 2,3 ± 0,4 Мышечный тонус 1,4 ± 0,2 1,2 ± 0,2* 1,1 ± 0,1* 1,0 ± 0,1* 2,9 ± 0,1 2,8 ± 0,2 2,8 ± 0,2 2,7 ± 0,2 Мышечная сила 3,5 ± 0,1** 3,9 ± 0,1** # 4,0 ± 0,2** # 4,8 ± 0,2** ## 4,2 ± 0,2 4,4 ± 0,2 4,3 ± 0,3 4,3 ± 0,3 Объем движений 4,4 ± 0,3 4,6 ± 0,2 4,7 ± 0,3 4,8 ± 0,3 3,2 ± 0,2 3.2 ± 0,2 3,3 ± 0,2 3,3 ± 0,2 Средний балл 2,4 ± 0,2* 2.3 ± 0,2* 2,2 ± 0,2** 2,3 ± 0,2** Общий итог 0,8± 0,1 0,9 ± 0,1 1,1 ± 0,1 1,0 ± 0,1

191 (Л/ средних баллов) Примечания: 1. после лечения по группам *- р < 0,05, **- р < 0,003, 2. после лечения по отношению к группе К #- р < 0,05, ## - р < 0,003.

Анализируя полученные данные с точки зрения характеристики эффекта в отдельных группах и роли включения отдельных методов в лечебный процесс, мы получили следующие результаты: Болевой синдром - включение отдельных методов привело к положительному результату в улучшении купирования болевого синдрома, что показывают изменения в разнице между исходным средним баллом и его уровнем после лечения в группе К -

1,7±0,01, группе 1 - 1,3±0,02, группе 2- 0,6±0,01, группе 3 - 0,5±0,01. Данные результаты свидетельствуют об эффективности предложенного комплексного метода лечения и значимости отдельных его компонентов, особенно при сочетанном применении методов физиотерапии. Чувствительность - по воздействию на данный показатель, более значимыми оказались введение в МТП раствора лидокаина 0,5 % и бикарбоната натрия в виде 4 % раствора, а также ультрафонофореза бишофита. ЭМС на данный показатель не влияла, что показывают изменения в разнице между исходным средним баллом и его уровнем после лечения в

группе К - 1,0±0,01 балл , группе 1 - 0,7±0,01 балла, группе 2 - 0,5±0,01

балла, группе 3 - 0,4±0,02 балла.

Мышечный тонус - полученные результаты свидетельствуют об эффективности и значимости отдельных компонентов предложенного комплексного метода лечения для данного показателя, особенно выражено влияние ультрафонофореза бишофита и ЭМС. Это подтверждает динамика изменений в разнице между исходным средним баллом и его уровнем после

192 лечения в группе К - 1,4 балла, группе 1 -1,2 балла, группе 2- 1,1 балл, группе 3 - 1,0 балл. Мышечная сила по воздействию на данный показатель, более значимым оказалось введение в МТП раствора лидокаина 0,5 % и бикарбоната натрия в виде 4 % р-ра, и применение ЭМС, что показывают изменения в разнице между исходным средним баллом и его уровнем после лечения в группах

группе К - 3,5±0,1 балла, группе 1 - 3,8±0,1 балла, группе 2 - 4,0±0,1 балла,

группе 3 - 4,8±0,1 балла. Остальные примененные компоненты предложенного метода лечения, оказали менее значимое воздействие на этот показатель. Объем движений - по воздействию на данный показатель, добавление к процессу лечения отдельных компонентов не показало выраженного влияния по отдельности, но применение их в общем комплексе лечения, тем не менее, привело к значительному изменению показателя, что подтверждают изменения в разнице между исходным средним баллом и его уровнем после

лечения в группе. К - 4,4±0,1 балла, группе 1 - 4,0±0,1 6алла, группе 2 -

4,7±0,1 балла, группе 3 - 4,8±0,1 балла. Однако интегративный показатель, по которому рассчитывались общие итоги, дал несколько другой результат. Так рассчитанные по разности средних баллов до и после проведенного лечения, общие итоги были наиболее результативными в группе 2, в которой

данный показатель составил 1,1±0,1 балла и в группе 3 - 1,0±0,1 балла, а в

группе 1 - 0, 9±0, 1 балла, соответственно. В группе К общий итог лечения

составил 0,8±0,1 балла. Полученный результат, ещё раз подчеркивает необходимость анализа полученных данных по отдельно взятым показателям, а не только по интегративным показателям. Исходя из анализа приведенных выше данных, можно отметить нарастание эффекта примененных методов лечения от группы 1 к группе 3. Что свидетельствует о

193 правильном выборе комбинации лечебных факторов примененных в работе. Анализ общей эффективности восстановительного лечения показал, что наличие у пациента с МФБС, соматической патологии, не оказывает влияния на течение процесса лечения основной патологии. В тоже время необходимо учитывать наличие соматической патологии у пациента с целью коррекции лечебной тактики и подбора методов лечения и их комбинации. В целом предложенный подход к лечению показал высокую эффективность метода. Статистические различия по показателю высокой результативности лечения между группами 1, 2, 3 и группой контроля также как и по данным непосредственных наблюдений, были достоверными (р < 0, 0, 5). Статистические различия общей эффективности лечения между сравнительными группами и группой контроля, также как и по данным непосредственных наблюдений, были достоверными (р <0,0,5). Это позволило обосновать дифференцированные подходы к назначению разработанных лечебных комплексов у больных с миофасциальным цервикалгии в амбулаторном восстановительном периоде. Применение метода способствует оптимизации амбулаторно-поликлинического этапа реабилитации и расширяет возможности сано- и патогенетических подходов у указанного контингента больных с целью улучшения качества жизни.

Заключение

Разработан инструментальный диагностический алгоритм оценки нервно-мышечной электровозбудимости, применяемая для оценки локального сенсорного и болевого порога путем регистрации сенсорных и болевых реакций на дозированный электрический стимул Методика позволяет выявлять мышечно-связную патологию опорно двигательного аппарата на ранних стадиях заболевания. Высокая

194 информативность, повторяемость и полная безопасность для больного создают основу для динамического объективного контроля в процессе восстановительного лечения. Предложена комплексная система лечения пациентов с хроническими миофасциальными болевыми синдромами в мышцах шеи и плечевого пояса. Лечение включает сочетанное применение медикаментов и различных средств физиотерапии - внутритканевого ультрафонофореза анестетиков в щелочной среде и электрогеля полтавского бишофита с последующим проведением электромиостимуляции пораженной мышцы. Разработанный инструментальный диагностический алгоритм оценки нервно-мышечной электровозбудимости миогенных триггерных пунктов рекомендовано включать в схему комплексного обследования пациентов с миофасциальными цервикалгиями

Литература

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195 6. Крыжановский Г. Н. Центральные механизмы патологической боли. Журнал неврологии и психиатрии им. С. С. Корсакова, Т. 99, №12, 1999. - С. 4-7. 7. Марсова В. С. Заболевания мышц, имеющие в основе расстройства функции сокращения. Ленинград - Москва, 1935. - С. 5-33. 8. Самосюк И.З. Невропатические, миофасциальные и туннельные болевые синдромы (клиника, диагностика, лекарственные и физические методы терапии). Самосюк И.З., Пашковский И.Б., Самосюк Н.И., Колесник К.Э., Чухраев Н.В. Киев, Ювента, 2004. - 231 с. 9. Суботш Ф.О., Сжов В.В. Патент № 47366 U, UA Споаб диагностики мюфасщального больового синдрому. КДМУ № 200908998; Заявл. 31.08.2009, Опубл. 25.01.2010, Бюл. № 2, 2010 р. - 5 с. 10.Пономаренко Г.Н., Воробьев М.Г. Руководство по физиотерапии.СПб, 2005 - 400 с. 11.Хабиров Ф. А. Клиническая неврология позвоночника, Казань, Медицина, 2001. - 469 с. 12.Ясногородский В.Г. Электротерапия. Москва, Медицина, 1987. -239 с. 13.Gold L. A functional Look at Back Pain and Treatment Methods, USA, Navato Institute, 1998. - 211 p. 14. Graham R. Clinical trials in low back pain. Diseases, Saunders, № 6, 1986. -Р.134-140. 15.Leesa К. H. Myofascial trigger points: the current evidence. Physical Therapy in Sport, Volume 5, Issue 1., Feb., 2004. - P. 2-12 16.Melzack R, Torgerson W.S. On the language of pain. Anesthesiology. № 34, 1971. - P.50-59. 17.Mense S. Biochemical pathogenesis of myofascial pain. J.Musculosceletal Pain, № 4, 1996. - P.145-162.

Резюме ОЦЕНКА БОЛЕВЫХ И СЕНСОРНЫХ ПОРОГОВЫХ ОТВЕТОВ НА ЭЛЕКТРОСТИМУЛЯЦИЮ В ОЦЕНКЕ РЕЗУЛЬТАТИВНОСТИ ЛЕЧЕНИЯ ПАЦИЕНТОВ С ХРОНИЧЕСКОЙ МИОФАСЦИАЛЬНОЙ ЦЕРВИКАЛГИЕЙ В.В. Ежов, Ф.А. Субботин Крымский государственный медицинский университет имени С.И.Георгиевского (Симферополь, Автономная республика Крым, Украина)

Ключевые слова: физиотерапия, хроническая миофасциальная цервикалгия, миогенный триггерный пункт, электровозбудимость, электромиостимуляция.

196 Обследовано 180 больных (101 женщин, 79 мужчин) с хроническими миофасциальными цервикалгиями. Возрастная градация пациентов - от 26 до 54 лет. Давность болезни - 2,0+1,5 лет. Проводились комплексные клинические биомеханические, кинестезиологические, инструментальные исследования. Оценивались данные реабилитационных шкал. Разработана методика электроальгометрии для оценки нервно-мышечной электровозбудимости миогенных триггерных пунктов у больных с хронической миофасциальными цервикалгиями. Показано, что в области миогенного триггерного пункта выявляется повышение уровней сенсорных и болевых порогов по сравнению с симметричным участком другой половины тела. Методика позволяет выявлять мышечно-связную патологию опорно двигательного аппарата на ранних стадиях заболевания. Высокая информативность, повторяемость и полная безопасность для больного создают основу для динамического объективного контроля в процессе восстановительного лечения. Предложена комплексная система лечения пациентов с хроническими миофасциальными болевыми синдромами в мышцах шеи и плечевого пояса. Лечение включает сочетанное применение медикаментов и различных средств физиотерапии - внутритканевого ультрафонофореза анестетиков в щелочной среде и электрогеля полтавского бишофита с последующей электромиостимуляцией пораженной мышцы. Разработанный инструментальный диагностический алгоритм оценки нервно-мышечной электровозбудимости миогенных триггерных пунктов рекомендовано включать в схему комплексного обследования пациентов с хроническими миофасциальными цервикалгиями. Professor Volodymyr Iezhov, D.Sc. M.D [email protected] Crimea State Medical University by S.I. Georgievsky, www.csmu.edu.ua Department of Physical Therapy, Faculty of Postgraduate Education Address: Lenin Avenue, 5/7, 95006. Simferopol, Ukraine Phones +38(067)3177333 +38(0654)230893 +38(0654)327716

Received: 10.01.2013. Revised: 20.01.2013. Accepted: 03.02.2013.

197 Journal of Health Sciences (J o H Ss) 2013; 3(2): 198-207 The journal has had 4 points in Ministry of Science and Higher Education of Poland parametric evaluation. Part B item 683.

UDC: 616.314-007+616.31:616.441-053.2/6 THE STOMATOLOGIC STATUS IN CHILDREN WITH MAXILLODENTAL ANOMALIES AND CONCOMITANT DISEASES OF THE THYROID GLAND

Kolesnik K. A.

SE «Crimean state medical university named after S. I. Georgievsky», department of children's stomatology

Keywords: stomatologic status; children; maxillodental anomalies; concomitant diseases; thyroid gland.

Thyroid gland diseases have the lead positions in structure of children's disease both in Ukraine and all over the world [12]. Thyroid gland hormones play an important role in maxillofacial development. They stimulate growth in sphenooccipital synchondrosis, nose cartilages, growth of the upper jaw in the field of bone seams [13, 14, 15]. Thyroxin, triiodothyronine regulate an expression of genes which control not only bone mass, but also oxidizing properties of muscles of maxillofacial area [18]. Thyroid hormones regulate processes remodel bone and cartilaginous tissues, and endochondral osteogenesis in elements of a temporomandibular joint [18].

198 However frequency and structure of maxillodental anomalies in children with thyroid gland diseases are studied insufficiently. Disturbance of a thyroid gland function is unfavourable reflected in a condition of parodontium tissue, quality of a bone tissue of an alveolar process and jaws [3, 6, 8, 10, 11, 16, 17]. On the other hand maxillodental anomalies are risk factor of development of periodontal diseases [7]. The estimation of the stomatologic status in children with maxillodental anomalies and concomitant diseases of a thyroid gland represents scientifically practical interest. Research objective. Studying of intensity of dental caries and a condition of periodontal tisues in children with the maxillodental anomalies, suffering by diseases of a thyroid gland. Material and methods. Epidemiological examination of 299 children of 6 15 years with thyroid gland diseases (109 children and teenagers with diffuse nontoxic goiter (DNG), 96 - with autoimmune thyroiditis (AIT), 94 - with congenital hypothyrosis) has been carried out for realization of the object. The group of comparison has made 97 children similar on age and sex and the teenagers who have no somatic diseases. Research is spent in the period from 2008 till 2012 on the basis of a department of children's stomatology of SE «CSMU named after S. I. Georgievsky», endocrine department of Republican children's clinical hospital, 3rdrc\ city children's hospital, stomatologic offices of educational institutions of Simferopol. The orthodontic diagnosis put according to classification of Angle, WHO. The diagnosis reflected morphological, functional and aesthetic disturbances [2]. A condition of hard tooth tissues is estimated according to dft, dfs, DMFT, DMFS indexes a condition of parodontium tissues - by means of indexes PMA, odontorrhagia, Schiller-Pisarev's tests, CPITN [5].

The two-selective nonparametric criterion of Mann-Witni for the statistical analysis used [4, 9]. Results of work.

199 Results of research have shown that frequency of maxillodental anomalies was higher than in children of the I-II group of health in all age groups of children with diseases of a thyroid gland (tab. 1, 2, 3). Most often maxillodental anomalies were diagnosed for children with congenital hypothyroidism in all age periods. So, morphological disturbances in maxillodental system at the age of 6-7 years in the given category of children had revealed on 15,6 % more often, than in children with AIT, on 18,4 % more often, than in children with DNG and on 35,8 % surpassed indicators of children who do not have somatic diseases. In the course of formation of a constant bite in children with congenital hypothyroidism the tendency to frequency increase of maxillodental anomalies was observed, which at the age of 12 years made 93,5 %. Further insignificant decrease of anomalies and deformations of the maxillodental system was marked, which frequency is remained at high level - 90,3 %. The increase in percent of revealed maxillodental anomalies with the age was defined in children suffering from AIT. The given tendency also has been expressed in children with DNG. Attracts attention that frequency of maxillodental anomalies increased on 16 % in children with DNG, since the period of an early replaceable bite till the period of a late replaceable bite. In structure of anomalies and deformations of maxillodental system in children with congenital hypothyroidism - a dominating pathology were narrowing of the jaws, the open and deep bite. At the age of 12 years old frequency of distal occlusion to 29,03 % increased. The open bite was registered on the average in 1,9 times more often in children with AIT at the age of 6-7 and 12 years, than at almost healthy children. If the distal bite was diagnosed at the age of 6-7 years with identical frequency both for children with AIT, and for children who have no somatic diseases, further frequency of a distal bite in children with AIT considerably surpassed values of group of comparison. The deep bite was defined more often in all age periods of maxillodental system at the given category of examined children than in almost healthy.

200 The deep bite prevailed in structure of maxillodental-facial anomalies in children with DNG in comparison with almost healthy children. At the age of 12 years high frequency of anomalies of separate teeth (38,2 %), density of teeth (61,7 %), at the age of 15 years - anomalies of teeth position (23,07 %), distal (25,64 %) and an open bite (7,69 %) was marked. During work the cluster analysis for determination of connection between indicators of intensity of dental caries, values of periodontal indexes and presence of maxillodental anomalies in children with diseases of a thyroid gland and in almost healthy has been spent. Clusters were formed of children’s groups with diseases of a thyroid gland and children of the I-II group of health with presence and absence of maxillodental anomalies on analyzed signs: DMFT indexes , PMA, an index of odontorrhagia, Schiller-Pisarev's tests. Table 1 Frequency of maxillodental anomalies in children with diseases of a thyroid gland and in almost healthy at the age of 6-7 years

Children of 6-7 years Indicators healthy children with children children with children DNG with AIT congenital hypothyrosis

Quantity of children 31 36 32 32 Anomalies of teeth 22,6 % 11,1 % 9,3 % 15,62 % Diastema/trema 9,7 % 11,1 % 12,5 % 34,3 % Density of teeth 25,8 % 16,1 % 21,9 % 21,87 % Narrowing of jaws 9,7 % 5,56 % 6,25 % 15,6 % Distocclusion 12,9 % 8,3 % 12,5 % 12,6 % Mesiocclusion 3,2 % 11,1 % 3,12 % - Deep bite 6,4 % 22,2 % 15,6 % 18,8 % Open bite 3,2 % 2,7 % 6,25 % 25,0 % Cross bite 9,7 % 11,1 % 3,12 % 3,12 % Quantity maxillodental anomalies 54,0 % 72,2 % 75,0 % 90,6 %

201 Table 2 Frequency of maxillodental anomalies in children with diseases of a thyroid gland and in almost healthy at the age of 12 years

Children of 12 years Indicators healthy children with children children with children DNG with AIT congenital hypothyrosis

Quantity of children 33 34 31 31 Anomalies of teeth 16,3 % 38,2 % 29,03 % 22,58 % Diastema/trema 12,9 % 8,82 % 6,45 % 12,9 % Density of teeth 19,3 % 61,7 % 22,6 % 32,3 % Narrowing of jaws 9,7 % 14,7 % 9,7 % 29,03 % Distocclusion 12,9 % 17,65 % 19,35 % 22,6 % Mesiocclusion - 5,9 % 3,12 % 3,23 % Deep bite 9,7 % 17,65 % 15,6 % 16,1 % Open bite 3,2 % 2,9 % 6,25 % 16,1 % Cross bite 3,2 % 5,9 % 3,12 % 3,23 % Quantity maxillodental anomalies 74,2 % 88,2 % 80,65 % 93,5 % Tab e 3 Frequency of maxillodental anomalies at children with diseases of a thyroid gland and at almost healthy at the age of 15 years

Children of 15 years Indicators healthy children with children children with children DNG with AIT congenital hypothyrosis

Quantity of children 33 39 33 31 Anomalies of teeth 12,1 % 23,07 % 27,2 % 19,35 % Diastema/trema 6,1 % -- 6,45 % Density of teeth 24,2 % 29,6 % 24,2 % 19,35 % Narrowing of jaws 9,1 % 7,69 % 12,12 % 16,1 % Distocclusion 12,1 % 25,64 % 27,2 % 19,35 % Mesiocclusion 3,03 % 5,13 % 3,03 % - Deep bite 12,1 % 15,4 % 18,2 % 16,1 % Open bite - 7,69 % 9,09 % 12,9 % Cross bite 10,25 % 3,03 % 6,45 % Quantity maxillodental anomalies 72,7 % 87,2 % 81,8 % 90,3 %

202 As the preliminary analysis has shown some samples did not submit to normal distribution, and also had significantly different dispersion. Therefore, there were not preconditions for application of parametrical criteria and the multidimensional dispersive analysis (variant ANOVA). Result meanings of an observable level of significance of Mann-Witni’s nonparametric criterion are presented in the table 4. The table, actually, represents a three-dimensional matrix of decisions, in which for each of considered diseases and for age 6, 12 and 15 years are presented p-value. The data presented in the table testifies that maxillodental anomalies were combined with high intensity of caries of permanent teeth in children with AIT of 12 and 15 years, DNG at the age of 12 years. Thus at the given category of children index of DMFT considerably exceeded a similar indicator of children with AIT and DNG, who had no maxillodental anomalies. The given interrelation was not traced in children almost healthy.

Table 4

Meanings of an observable level of significance hypothesis H0 at comparison of signs in children with presence and absence of maxillodental anomalies

Age Disease Indicator 6 years 12 years 15 years

dft 0,930 0,744 DMFT 0,357 0,007* 0,020* AIT PMA 0,001* 0,023* 0,002* odontorrhagia 0,419 0,148 0,010* test m -n 0,391 0,002* 0,015* DMFT 0,796 0,002* 0,051 PMA 0,001* 0,003* 0,016* DNG odontorrhagia 0,076 0,041* 0,005* test m -n 0,128 0,026* 0,001* DMFT 0,297 N (without MDA <3) 0,650 Congenital PMA 0,015* N (without MDA <3) 0,011* hypothyrosis odontorrhagia 0,126 N (without MDA <3) 0,018* test m -n 0,019* N (without MDA <3) 0,005* DMFT 0,112 0,134 0,198 Practically PMA 0,003* 0,002* 0,242 healthy odontorrhagia 0,001* 0,453 0,871 children test m -n 0,048(0,060) 0,477 0,258

Note: (*) the asterisk marks situations when hypothesis H0 (differences between sign level in considered samples are not statistically significant) should be rejected in favour of alternative H1 (differences between sign level in considered samples are statistically significant).

Maxillodental anomalies at the age of 12 and 15 years with thyropathies were diagnosed on the background of the expressed inflammatory changes in parodontium tissues according to comparisons of indicators of periodontal indexes.

203 Degree and intensity of inflammation in parodontium tissues according to meanings of index РМА, odontorrhagia, Schiller-Pisarev's tests were authentically higher in children with AIT, DNG and congenital hypothyrosis, having maxillodental anomalies in comparison with this category of children, who were without maxillodental anomalies. Such regularity did not reveal in children almost healthy. Indicators of intensity of caries, periodontal indexes in children with the maxillodental anomalies suffering by diseases of a thyroid gland significantly surpassed similar indicators of almost healthy children with maxillodental anomalies. Thus, in children with thyroid gland diseases high frequency of maxillodental anomalies is defined. Most often maxillodental anomalies are diagnosed for children with congenital hypothyrosis. It is characteristic that morphological disturbances in maxillodental system in children with thyropathies are revealed at high intensity of dental caries, inflammatory changes in parodontium tissues. The cluster analysis has shown high probability of a combination of caries and gingivitis in children with thyroid gland diseases at presence of maxillodental anomalies. It dictates necessity of the further researches for the purpose of working out of rational treatment-and-prophylactic measures at complex orthodontic treatment of the given category of children taking into account the dental status and the basic disease.

204 REFERENCES

1. Effect of triiodothyronine on the maxilla and masseter muscles of the rat stomatognathic system / [M. V. Mariuba, F. Goulart-Silva, S. Bordin et al.] // Braz. J. Med. Biol. RES. - 2011. - Vol. 44, № 7. - P. 694-699. 2. Flis P. S. Orthodontia: [textbook for students of high educational establishments] / P. S. Flis. - Vinnytsya: Nova knyga, 2007. - 312 s. 3. Functional activity of neutrophiles int rats with inflammatory process in parodontium on the background of reduced function of thyroid gland / A. V. Vohmintseva, S. S. Rymar, N. N. Mayanskaya [et al.] // Stomatologiya. - 2009. - № 2. - S. 4-7. 4. Gubler E. V. Application of nonparametric criteria of statistics in medical and biologic researches / E. V. Gubler, A. A. Genkin. - Leningrad, 1973. - 73 s. 5. Homenko L. A. Stomatology of children’s age / L. A. Homenko. - Kiyv, 2000. - 320 s. 6. Korenevskaya N. A. Condition of tissues of a marginal periodontitis at chronic stress depends from the thyroid status of the organism / N. A. Korenevskaya, I. V. Gorodetskaya // Vestnik VEMU, 2010. - T. 9, № 1. - S. 1-11. 7. Kosenko D. K. Complex preventive maintenance of the basic dental diseases in children at orthodontic treatment / D. K. Kosenko, O. V. Denga // Visnyk stomatologii. - 2010. - № 4. - S. 78-84. 8. Kozlova M. V. Atrophy of an alveolar part and a shoot of jaws at osteopenic syndrome in patients with pathology of a thyroid gland and hypogonadism: (modern methods of diagnostics and treatment): the author's abstract of dis. ... for a Doctor’s degree in medical sciences by speciality : 14.01.14 - “Stomatology”, 14.00.03 - “Endocrinology” / M. V. Kozlova. - Moskva, 2009. - 32 s.

205 9. Lemeshko B. Yu. About convergence of the statistics distributions and capacities of uniformity criteria of Smirnov and Leman-Rozenblatt / B. Yu. Lemeshko, S. B. Lemeshko // Izmeritelnaya technika. - 2005. - № 3. - S. 12-17. 10.Melnik N. S. Sstruktural-functional state of bone tissue in patients with generalized parodontitis with concomitant disease of thyroid gland / N. S. Melnik, I. P. Masur, V. M. Ryzhyk [et al.] // Arhiv clinichnoy medicini. - 2008. - № 2. - S. 31-34. 11.Oganyan A. V. Clinico-morphological changes of maxillodental system at hypothyrosis: the author's abstract of dis. ... for a Candidate degree in medical sciences by speciality: 14.01.14 - “Stomatology”, 14.03.02 - “Pathological anatomy” / A. V. Oganyan. - Stavropol, 2010. - 22 s. 12.Pankiv V. I. Practical thyroidology / ed. O. Yu. Zaslavsky. - Donetsk, 2011. - 224 s. 13.Persson E. C. The effect of thyroxine on craniofacial morphology in the growing rat. Part I: A longitudinal cephalometric analysis / E. C. Persson, C. Engstrom, B. Thilander // Eur. J. ORTHOD. - 1989. - Vol. 11, № 1. - P. 59-66. 14.Petrovic A. Control of growth of secondary cartilages of the mandible by mechanisms regulating occlusion. Cybernetic model. Trans EOS, 1974. 15.Pirinen S. Endocrine regulation of craniofacial growth / S. Pirinen // Acta Odontol. Scand. - 1995. - Vol. 53, № 3. - P. 179-185. 16.Role of hormones of thyroid and parathyroid glands in pathogenesis of glucocorticoid osteoporosis and parodontium diseases: (experimental research) / S. E Zolotuhin, G. S. Aussi, N. N. Shpachenko [et al.] // Ukraynsky morfologichny almanah. - 2008. - № 2. - S. 10-13. 17.Schneider O. L. The clinical-laboratory substantiation of complex treatment of parodontitis in patients with primary hypothyrosis: the author's abstract of dis. ... for a Candidate degree in medical sciences by speciality : 14.00.21 / O. L. Schneider. - Ekaterinburg, 2008. - 22 s.

206 18.Strnctural and morphometric changes of elements of a temporomandibular joint at experimental hypothyrosis / G. Yu. Shcheglakova, Yu. L. Pisarevsky, V. P. Smekalov [et al.] // Dalnevostochny Meditsinsky Zhurnal. - 2009. - № 2. - S. 105-107.

Summary. Epidemiological study of 299 children with the thyroid gland diseases revealed a high frequency of dentofacial anomalies. Morphological disturbances in maxillodental system in children with thyropathies are revealed at high intensity of dental caries, inflammatory changes in parodontium tissues. The cluster analysis has shown high probability of a combination of caries and gingivitis in children with thyroid gland diseases at presence of maxillodental anomalies.

Резюме. Эпидемиологическое обследование 299 детей с заболеваниями щитовидной железы выявило у них высокую частоту зубочелюстных аномалий. Морфологические нарушения в зубочелюстной системе у детей с тиреопатиями определялись при высокой интенсивности кариеса зубов, воспалительных изменениях в тканях пародонта. Кластерный анализ показал высокую вероятность сочетания кариеса и гингивита у детей с заболеваниями щитовидной железы при наличии зубочелюстных аномалий.

Received: 10.01.2013. Revised: 20.01.2013. Accepted: 04.02.2013.

207 Journal of Health Sciences (J o H Ss) 2013; 3(2): 208-213 The journal has had 4 points in Ministry of Science and Higher Education of Poland parametric evaluation. Part B item 683. © The Author(s) 2013; This article is published with open access at Licensee Open Journal Systems of Radom University in Radom, Poland

Многоуважаемые польские коллеги!

В 2013 году исполняется 150 лет основоположнику украинской научной физиотерапии профессору Александру Ефимовичу Щербаку (1863-1934). Важным этапом научной деятельности проф.А.Е. Щербака является весьма продолжительный период его работы в Варшавском университете (1893-1911 гг). Позднее в 1914 г. проф. А.Е. Щербак организовал в Севастополе Институт физических методов лечения - первый институт подобного профиля в России. Приводим текст энциклопедической статьи посвященной А.Е. Щербаку в Энциклопедии Брокгауза Ф.А. и Ефрона И.А. (1890 - 1916 гг.)

Щербак, Александр Ефимович — невропатолог, род. в 1863 г. Медицинское образование получил в Киевском университете и в СПб. военно-медицинской академии, которую окончил в 1887 г. По окончании академии Щербак оставлен был "врачом для усовершенствования". В 1890 г. защитил диссертацию на степень доктора медицины и командирован за границу. В 1893 г. избран был профессором Варшавского унив. Его труды: "К вопросу о патогенезе склеродермии" ("Сборник работ из клиники проф. А. Г. Полотебнова", СПб., 1886— 87); "К вопросу об изменениях обмена фосфорной кислоты и азота под влиянием умственной работы" ("Вестн. псих. ",ч. VII); "О содержании ф осф орной кислоты в крови у собак во время морфийного сна" (ib.); "Материалы к учению о зависимости фосфорного обмена от усиленной или ослабленной деятельности головного мозга" (СПб., 1890, диссерт.); "Contribution a l' étude de l'influence de l'activité céré brale sur échange

208 d'acide phosphorique et d'azote" ("Arch. de m édé c. experim.", 1893); "К вопросу о локализации вкусовых центров в мозговой коре" ("Вестн. псих.", 1891 и "Centralb. f. Physiol.", 1891); "К дифференциальной диагностике множественного неврита" ("Неврол. вестн.", 1896); "Ueber die Kleinhirnhinterstrangbahn, inre physiol. und pathol. Bedeutung" ("N. C.", 1900); "Клинические лекции по нервным и душевным болезням" (Варшава, 1901); "О способах исследования так наз. костной чувствительности" ("Труды Рус. мед. общ. за 1902 г. " и "Neurol. Centr.", 1903); "Новые данные по физиологии глубоких рефлексов" ("Обозр. псих.", 1902; "Neur. Centr.", 1903 и "R é v. Neurol.", 1903); "Экспериментальные исследования относительно физиологического действия механических вибраций" ("Обозр. псих.", 1903) и др.

Мы будем Вам крайне признательны и благодарны за любую дополнительную информацию, связанную с работой профессора А.Щербака в Варшаве в период 1893 1911. Приглашаем Вас принять участие в качестве дорогих почетных гостей в научно практической конференции с международным участием «Актуальные вопросы физиотерапии и курортологии», посвященной 150-летию со дня рождения профессора А.Е.Щербака. Конференция состоится на базе НИИ имени И.М. Сеченова 10-11 октября 2013 г., г.Ялта АР Крым.

Владимир Ежов Заведующий кафедрой физиотерапии факультета последипломного образования Крымского государственного медицинского университета им. С. И. Георгиевского (Симферополь), д. мед. н, профессор, [email protected]

209 Министерство здравоохранения АР Крым Крымское республиканское учреждение «Научно-исследовательский институт физических методов лечения и медицинской климатологии имени И.М.Сеченова», г.Ялта, АР Крым Государственное учреждение «Крымский государственный медицинский университет имени С.И.Георгиевского», г. Симферополь, АР Крым

ИНФОРМАЦИОННЫЙ ЛИСТ 1

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С большой радостью сообщаем Вам о возможности принять участие в Научно практической конференции с международным участием «Актуальные вопросы физиотерапии и курортологии», посвященной 150-летию со дня рождения профессора А.Е.Щербака. Конференция состоится на базе НИИ имени И.М. Сеченова 10-11 октября 2013 г., г.Ялта АР Крым. Конференция внесена в перечень мероприятий Министерства здравоохранения и Академии медицинских наук Украины (свидетельство №547). Материалы конференции (статьи, тезисы докладов) будут опубликованы в отдельном издании на русском, украинском и английском языках. Конечный срок подачи тезисов в оргкомитет 30 апреля 2013 г.

Основные научно-практические направления конференции 1. Общие вопросы физиотерапии и курортологии, теоретические аспекты физиотерапии и курортологии. 2. Механизмы действия на организм природных и преформированных физических факторов. 3. Роль природных и преформированных физических факторов в востановлении здоровья детей и взрослых. 4. Новейшие физиотерапевтические технологии, особенности их применения в современных условиях.

210 5. Санаторно-курортный этап как важное звено укрепления здоровья, восстановительного лечения и медицинской реабилитации рекреантов и больных: вопросы организации, управления, экономики. 6. Исторические аспекты эволюционного развития отечественной физиотерапии, курортологии и медицинской реабилитации

Об условиях организации конференции, проживания во время проведения конференции, о стоимости всех услуг будет изложено в следующем информационном письме. Приглашаем Вас принять участие в работе конференции.

Адрес оргкомитета конференции: Украина, 98603, АР Крым, г.Ялта, ул. Мухина / пер. Свердлова, 10/3, НИИ имени Сеченова Тел/факс +380654 23-51-91, 23-29-53 Элект.почта: [email protected] Неонила Алексеевна +380673192078; Инна Владимировна +380505621810

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Общие требования 1. Срок подачи материалов - по 30 апреля 2013 г. 2. Статьи проблемного и системно-аналитического характера подаются видными учеными стран СНГ по просьбе оргкомитета конференции. Тезисы подаются другими участниками конференции. 3. В редакционную коллегию сборника статьи/тезисы представляются в электронном виде на русском, украинском и английском языках. 4. Авторы несут полную ответственность за достоверность представленных данных в статьях/тезисах, на что будет указано в титульных условиях публикации сборника. 5. Редакционная коллегия оставляет за собой право отбора присланных статей/тезисов для публикации после научного и предметного анализа их содержания. 6. Электронный адрес редакционной коллегии: [email protected]

211 Требования к оформлению статей/тезисов 1. Объем статьи не более 10 страниц. Объем тезиса не более 1 страниц. В объем статьи/тезиса включаются все их составные части. 2. Поля со всех сторон страницы по 2,0 см. 3. Компьютерный набор текста: MS Word 2003, шрифт - Times New Roman 14 п., 1,0 интервал. 4. Структура статьи, тезиса: УДК БОЛЬШИМИ БУКВАМИ НАЗВАНИЕ инициалы, фамилия автора (-ов) полное название учреждения, город текст статьи, тезиса список литературы для статьи 5. Текст тезисов, содержащих результаты оригинальных исследований, должны иметь следующие разделы (разделы обязательно обозначаются обычным шрифтом): цель исследования материалы и методы исследования (излагаются кратко) результаты исследования заключение (или выводы). 6. В рамках объема статьи/тезиса количество иллюстраций (рисунки, фотографии), таблиц не ограничено. Таблицы выполняются при помощи мастера “Таблица” и помещаются сразу после тех абзацев, где они впервые упоминаются. Иллюстрации выполняются графическими средствами редактора в режиме “Создать рисунок” и помещаются сразу после абзаца с упоминанием о них. 7. В тексте запрещается пользоваться автоматическими нумерованными и маркированными списками, ссылками. Все нумерации и маркеры выставляются вручную.

This is an open access article licensed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which

212 permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the work is properly cited.

Received: 10.01.2013. Revised: 20.01.2013. Accepted: 04.02.2013.

213 Journal of Health Sciences (J Health Sci) 2013; 3(2): 214-233 The journal has had 4 points in Ministry of Science and Higher Education of Poland parametric evaluation. Part B item 683.

COMPARATIVE EVALUATION OF THE EFFECTS OF PHYTO- THERAPEUTIC AND MEDICAL TREATMENT FACTORS ON THE CEREBRAL HEMODYNAMICS IN PATIENTS WITH SYNDROME OF VEGETATIVE DYSTONIA DUE TO RADIATIVE FORCING

Сравнительная оценка влияния фитотерапевтических и медикаментозных лечебных факторов на состояние мозговой гемодинамики у лиц с синдромом вегетативной дистонии вследствие радиационного воздействия

JV.A. Korshnyak, 1E.A. Gozhenko, 1B.A. Nasibullin, JA.V. Zmiyevskiy, 2W. Zukow 1В.А. Коршняк, 1Е.А. Г оженко, 1Б.А. Насибуллин, 1А.В. Змиевский, 2W. Żukow

1SE Ukrainian Scientific Research Institute of Medical Rehabilitation and Balneology Ministry of Health of Ukraine, Odessa, Ukraine 'ГУ «Украинский научно исследовательский институт медицинской реабилитации и курортологии МЗ Украины», г. Одесса

2Radom University, Radom, Poland 2Radomska Szkoła Wyższa, Radom, Polska

Abstract

The authors conducted a survey and treatment of 115 persons with the syndrome vegetative dystonia, advanced as a result of small doses of radiation. Studied the brain activity of peripheral hemodynamics and functional mechanisms of vascular tone. It was revealed that development of the SVD is accompanied by hypertension, decreased cerebral blood flow velocity and increased vasoconstrictor’s activity of peripheral vascular endothelium. Comparison of the results of these patients eliminated physiotherapy factors (EHF- or TCEA-therapy) and standard medical course found that physiotherapeutic successfully adjust dysregulation suprasegmental factors for vascular mechanisms. Farmaco Factors to successfully influence the activity of the peripheral vascular tone regulation mechanisms. The authors believe that enhancing the effectiveness of the treatment of SVD may in the formation of physical and pharmacological complexes.

Keywords: syndrome vegetative dystonia; Doppler; hypertension; EHF therapy; TCEA.

214 Реферат

Авторы проводили обследование и лечение 115 лиц с синдромом вегетативной дистонии, развившейся в результате действия малых доз радиации. Изучалось состояние мозговой гемодинамики и активность периферических функциональных механизмов сосудистого тонуса. Выявлено, что развитие СВД сопровождается гипертензией, снижением скорости мозгового кровообращения и возрастанием вазоконстрикторной активности эндотелия периферических сосудов. Сравнение результатов применения этим больным элиминировано физиотерапевтических факторов (КВЧ- или ТКЕА-терапии) и стандартного медикаментозного курса показало, что физиотерапевтические факторы успешно корригируют дизрегуляцию надсегментарных сосудистых механизмов. Фармакофакторы успешнее влияют на активность периферических механизмов регуляции сосудистого тонуса. Авторы полагают, что повышение эффективности лечения СВД возможно при формировании физико-фармакологических комплексов.

Ключевые слова: синдром вегетативной дистонии; допплерография; гипертензия; КВЧ-терапия; ТКЕА.

Autonomic disorders very common form of neurological diseases [1, 2, 3]. Last years, including an increase in the different incidence of vegetative dystonia syndrome. Autonomic or vasomotor dystonia are assigned to one of the basic conditions conducive to the development of stroke [4, 5]. Among patients with the syndrome of vegetative dystonia, 25% of manifestations of cerebrovascular insufficiency, and another 15% are fixed displays dyscirculatory encephalopathy [6, 7]. Development of the above pathological processes associated most often with dysregulatory pathology suprasegmental structures of the autonomic nervous system, caused by exogenous adverse effects. [8] One of these external troubles is small doses of ionizing radiation [3, 9]. Evidence linking low doses of ionizing radiation and autonomic disorders can serve as observed among

215 Chernobyl liquidators increase in psychosomatic disorders, manifested clinically as vegetative dystonia, which is then transformed into discirculatory encephalopathy [10, 11, 12]. Vegetative dystonia syndrome treatment traditionally involves the use of a set of drugs, including the group adrenolytics central action; ganglioblockators affecting the tone of peripheral blood vessels (a-, p-blockers) are regulated by the activity of the sympathetic and parasympathetic divisions of the SPA. At the same time dysregulatory pathology of functional systems of segmental structures considered most often as second regular task and has received less attention. Besides the impact of non-pharmacological (electromagnetic radiation, electro) in the existing treatment protocols vegetative dystonia syndrome considered as not significant, though by nature they are closest to the functional activity of brain structures. Based on the foregoing, the purpose of this study was to evaluate the hemodynamic changes in the cerebral vascular beds in patients with SVD due to lesions of low doses of ionizing radiation and the possibility of correcting the violations EHF - or TKEA-therapy. Materials and methods Material of the present study is based on results obtained for examination and treatment of 115 patients with the syndrome of vegetative dystonia as a result of the effects of low doses of ionizing radiation (Chernobyl liquidators). Among the patients were 14 women and 101 men. Mean age at the time of the accident was 25-32 years. Of those surveyed, 63 were treated and disabled from the group III disease (14 women, 49 men) and 52 - Group II disability from disease (all men). Blood pressure were monitored during the entire observation period. Hemodynamic status was assessed by Doppler. For this purpose, the device SCIMED PCDOP-842 (firm Medata, Sweden). Ultrasonic transducer (2 216 MHz) was performed location vertebral artery at a depth of 40-60 mm, the main - 60-80 mm. Also carried out a location of the middle cerebral, anterior cerebral and posterior cerebral arteries on the default settings. Evaluated the linear velocity of blood flow. Addition enzyme immunoassay using an appropriate set of firm ACE determined the content of endothelin-1 in serum. Treatment in 50 patients was performed in a course of short-wave therapy using a generator GA-141, the radiation frequency 37,5 - 41,6 GHz, the wavelength of 2 mm, the flow rate of 2 mW / cm2the power monitoring was performed using a power meter SC-22A. At the output of a generator RF unit that allowed an individual to choose a clear therapeutic resonant frequency effects (USSR Patent number 1,807,872 on 10/10/1992, the authors Makolinets VI, Kiselev VK et al.) Irradiation with a flexible waveguide was performed on acupressure points TR5 V B ^ ^ R P ^ VCrM. Session duration of 20 to 35 minutes. The course is 9-12 daily sessions. In 50 patients the treatment was carried out rate TKEA using commercially available device "Etrans-2." The negative electrode was applied to the forehead, double positive electrode is placed on the mastoid process. The first session was conducted in a power saving mode (2nd mode) with a duty cycle component of the stimulating current pulse repetition frequency of 16,5 ± 1 kHz with duty cycle. Subsequent sessions are held in the first mode (no duty cycle component). The electric current was increased from 0.7 to 1.2 mA (before the tingling). Treatment time 20-30 min., the course is 10-15 procedures. 15 patients received a standard course of drug therapy, including: potassium iodide, biochinol, euphylin, triamcur, caviton, trental. Caviton were injected intravenously with 10 mg (2.0 mL, 0.5% solution) in 200 ml of isotonic

solution through a third day, up to 6 infusions. Between drippers caviton 217 appointed on 1 tab. 3 times a day. Trental is used orally for 1 drags 3 times a day. Results and discussion Were held Doppler study, the results of which are shown in Table 1.

Table 1. Speed blood flow in the carotid and vertebral arteries in patients with SVD genesis of radiation at different treatment (cm / s .)

Group Control Before EHF- TCEA Medical (27-45 treatment therapy therapy therapy Indicator years) MCA average speed 59,4±10,6 52,1±12,3 55,6±10,4 56,3±10,9 56,4±8,2 Amplitude Ao 20 28,4 23,6 28,4 22,1 (%) The anterior Average speed 48,8±12,3 43,3±10,4 47,3±2,1 45,5±12,4 47,3±12,3 cerebral of Amplitude Ao 20 27,8 24,4 25,8 23,5 (%) The posterior Average speed 38,6±8,3 32,3±5,1 34,5±6,8 36,0±7,4 36,0±8,2 cerebral of Amplitude Ao 30 46,8 32,9 33,4 36,5 (%) Vertebral artery Average speed 36,3±6,9 20,9±5,2 30,1±5,4 30,4±6,0 32,0±5,8 Amplitude Ao 30 69,7 48,4 44,5 40,1 (%) Summary artery average speed 44,1±10,6 38,6±8,3 38,6±8,3 38,8±8,6 40,0±7,1 Amplitude Ao 30 44,3 37,1 32,1 35,8 (%)

As can be seen from Table 1 in healthy difference in blood flow between the carotid and vertebral arteries masked by the large scatter of individual data. However, it can be argued that the difference in mean blood flow velocity and the posterior cerebral artery is reliable. At the same time it should be noted that the asymmetry of the velocity of blood flow takes place, but it is not rough.

218 According immunoassay research content of endothelin-1 in healthy subjects was 2,38 ± 0,11 pg / ml. Development of vegetative dystonia syndrome as a result of low doses of radiation associated with an increased blood pressure to 160-170/97-110 mm different patients. It should be noted that 17 patients blood pressure in the study remained close to the age norm < 140/90 mm Hg Mentioned change in the velocity of blood flow in vascular beds studied. According to Table 1, the rate of blood flow was reduced in all examined vessels. The greatest decrease occurred in the vertebral arteries, the asymmetry is significantly enhanced blood flow in the vessels studied, especially strongly noted in the same vertebral artery. Should be noted that at the same time dramatically increasing the content of endothelin, which was 25,69 ± 6,52 pg / ml. It can be assumed that the change in endothelial function under the influence of ionizing radiation causes a tendency to vasoconstriction, which is manifested by increased diastolic blood pressure. Combined with reduced blood flow it can become the basis for the development of oxygen-substrate shortage and associated encephalopathy. After a course of EHF-therapy blood flow, according to Doppler (Table 1) increased to near normal in the blood vessels of the carotid artery basin. In the basin of the vertebral arteries blood flow also increased, but to a much lesser extent. There has been a decrease in blood flow asymmetry, but returns to normal, it did not return. It should be noted, a greater than normal monotony indicators. Regarding blood pressure, systolic blood pressure decreased to 140-150 mm Hg, while the diastolic pressure remained high - 90-100 mm Hg Determination endothelin revealed its decline, but it is still many times higher than the norm and was 20,76 ± 5,83 pg / ml.

219 These data suggest that the electromagnetic radiation of short-wave therapy positively influences the activity of suprasegmental structures VNS, so there is a tendency normalization of blood flow, but has very little effect on the functional activity of endothelium damaged by ionizing radiation. After a course of therapy TCEA blood flow in the vessels of the carotid arteries in the vessels almost normalized pool vertebral arteries. In contrast to the short-wave therapy individual response to treatment (range of results) was high, almost like normal. As for the asymmetry of blood flow, it was reduced in the basin of the carotid arteries almost like short-wave therapy, and in the vessels of the vertebral arteries in the pool more. Regard to changes in blood pressure, for patients who received a course TKEA therapy characterized by a large decrease in diastolic pressure. In these patients, systolic blood pressure was 140-150 mm Hg, and diastolic - 90-95 mm Hg At the same time there was a greater reduction in the content of endothelin, compared with the rate of EHF-therapy, it was 10,52 ± 2,53 pg / ml. Perhaps due to this greater reduction in diastolic blood pressure. Overall, we can say more than a short-wave therapy, the effect TCEA therapy on endothelial function and structure, governing vessel basin vertebral arteries. Finally a course of drug therapy has also had a positive impact on the rate of cerebral blood flow. According to Table 1, after the completion of the flow velocity increased in all studied basins to near normal values. Significantly decreased blood flow asymmetry. Select primary pool to which drug therapy is more beneficial effect cannot. Blood pressure is also changed for the better and was 140-150/90 mmHg Since the content of endothelin did not exceed 11,85 ± 1,13 pg / ml, we believed that the best way medicines affect the functional activity of the endothelium. At

220 the suprasegmental structure VNS governing their influence hemodynamics little distinguishable from the effects of physiotherapeutic factors. Thus, our results showed that develops as a result of ionizing radiation vegetative dystonia syndrome associated with a significant decrease in the rate of cerebral blood flow in swimming pools, high blood pressure and multiple content increases endothelin in plasma. The data indicate that there is an impairment of function of suprasegmental structures responsible for the regulation of blood flow; violated peripheral mechanisms of regulation of vascular tone (the tendency to vasoconstriction.) Thus, the conditions for the formation of the substrate-oxygen deficiency of the brain. Application eliminated physiotherapeutic factors or medication has a positive effect on the regulation of hemodynamics, normalizing violations. It should be noted that the enhancement factor is corrected physiotherapy suprasegmental dysregulated vascular regulators but have little effect on the peripheral mechanisms of the regulation of vascular tone. At the same time, medications significantly change the state of the peripheral mechanisms of regulation of vascular tone, and the processes of deregulation of suprasegmental structures have the same effect as physical therapy and medical factors. Obviously, in the future, it is useful to study the possibility of pharmacological physical therapy for the correction of complex structures of the ANS.

221 References in transliteration 1. Bojko T.P. Vpliv transkranial'noi elektroanalgezii na rozvitok metabolichnih zmin u hvorih z nevrologichnimi naslidkami ionizujuchogo oprominennja / T.P. Bojko, V.O. Korshnjak, L.S. Kostbkovs'ka, Ju.G. Holodnij // Eksperimental'na ta klinichna fiziologija ta biohimija. — 2003. — #2 (22). — S. 55— 60. 2. Vashhenko E.A. Mehanizmy realizacii narushenij funkcional'nogo sostojanija nervnoj sistemy ljudej, podvergshihsja oblucheniju vsledstvie Chernobyl'skoj katastrofy / E.A. Vashhenko // Otdalennye medicinskie posledstvija Chernobyl'skoj katastrofy: Materialy 2 mezhdunar. Konf. — Kiev, 1998. — S. 194. 3. Morozov A.M., Kryzhanovskaja A.A. Klinika, diagnostika i lechenie pogranichnyh psihicheskih rasstrojstv u likvidatorov avarii na Chernobyl'skoj AJeS. Kiev. «Chernobyl'interinform». — 1998. — 183 s. 4. Kononenko V.V. Citomegalovirusnij encefalit u doroslih imunokompetentnih hvorih (klinika, diagnostika ta intensivna terapija). / V.V. Kononenko [ta in.]. — Metod. rekomendacii, K. — 2002 — 20 s. 5. Mironenko T.V. Izmenenija soderzhanija nejrospecificheskih belkov u bol'nyh posle legkoj zakrytoj cherepno—mozgovoj travmy // Ukr. visnik psihonevrologii. — 1998. T. 6, vip. 1 (16). — S. 41—44. 6. Vegetativnaja distonija u lic, podvergshihsja radiacionno vozdejstviju pri likvidacii posledstvij avarii na Chernobyl'skoj AJeS. - Metod. rekomendacii. / Pod red. A.I. Njagu. — Kiev, 1991. — 25 s. 7. Vereskun S.B. Sostojanie tonusa arterial'nyh sosudov v polusharijah bol'shogo mozga pri arterial'noj gipertenzii u postradavshih vsledstvie avarii na ChAJeS v zavisimosti ot pola i vozrasta / S.B. Vereskun // Vrachebnoe delo. — 2006. — # 3. — S. 28— 29.

222 8. Vejn A.M. Vegetativnye rasstrojstva. Klinika, diagnostika, lechenie / A.M. Vejn — M.: "MIA". — 2000. — 752 s. 9. Kirpicheva N. B. Sovremennye aspekty patogeneticheskoj terapii sindroma vegetativnoj disfunkcii u detej / N.B. Kirpicheva, N.V. Dombrovskaja, E. A. Kuleshova // Mezhdunarodnyj nevrologicheskij zhurnal. — 2006. — # 4 (8). — S. 32—36. 10. Mjakotnyh V.S., Talankina N.Z., Borovkova T.A. Klinicheskie, patofiziologicheskie i morfologicheskie aspekty otdaljonnogo perioda zakrytoj cherepno-mozgovoj travmy // Zhurnal nevrologii i psihiatrii. — 2002. — # 4. — S. 61— 65. 11. Napreenko A.K. Sistema psihiatricheskoj pomoshhi pri radiojekologicheskih katastrofah i lokal'nyh vojnah / A.K. Napreenko, K.N. Loganovskij // Zhurnal psihiatrii i medicinskoj psihologii. — 2000. — # 1. — S. 14— 18. 12. Netradicionnye metody diagnostiki i terapii. / Pod obshhej red. I.Z. Samosjuk, V.P. Lysenjuk, Ju.P. Limans'kij. i dr. — K.: “Zdorov’ja”, 1994. — 240 s.

Вегетативные нарушения весьма распространенный вид неврологических заболеваний [1, 2, 3]. В последние годы среди них отличается увеличение частоты встречаемости синдрома вегетативной дистонии. Вегетативную или вазомоторную дистонию относят к одному из основных состояний способствующих развитию нарушений мозгового кровообращения [4, 5].

223 Среди больных с синдромом вегетативной дистонии у 25 % отмечаются проявления недостаточности мозгового кровообращения, а ещё у 15 % фиксируются проявления дисциркуляторной энцефалопатии [6, 7]. Развитие вышеуказанных патологических процессов связывают, чаще всего, с дизрегуляторной патологией надсегментарных структур вегетативной нервной системы, обусловленной экзогенными неблагоприятными воздействиями [8]. Одним из таких внешних неблагополучий являются малые дозы ионизирующего облучения [3, 9]. Свидетельством связи малых доз ионизирующего облучения и вегетативных расстройств может служить наблюдаемое среди ликвидаторов ЧАЭС увеличение числа психо-соматических нарушений, проявляющихся клинически как вегетативная дистония, которая затем трансформировалась в дисциркуляторную энцефалопатию [10, 11, 12]. Лечение синдрома вегетативной дистонии, традиционно предусматривает использование набора медикаментозных средств, включающих группу адреналитиков центрального действия; ганглиоблокаторов, влияющих на тонус периферических сосудов (а-, Р- адреноблокаторы); препараты регулирующие активность симпатического и парасимпатического отделов ВНС. В тоже время дизрегуляционная патология функциональных систем над сегментарных структур рассматривается чаще всего как второочередная задача и ей уделяется меньше внимания. Кроме того немедикаментозные воздействия (электромагнитное излучение, электротерапия) в существующих протоколах лечения синдрома вегетативной дистонии рассматриваются как не значимые, хотя по своему характеру они наиболее приближены к функциональной активности структур мозга. Исходя из всего вышесказанного, целью настоящего исследования была оценка изменений гемодинамики в мозговых сосудистых бассейнах у

224 лиц с СВД вследствие поражения малыми дозами ионизирующего излучения и возможность коррекции этих нарушений КВЧ - или ТКЕА-терапией. Материалы и методы исследований. Материалом настоящего исследования послужили результаты, полученные при обследовании и лечении 115 больных с синдромом вегетативной дистонии в результате воздействия малых доз ионизирующей радиации (ликвидаторы ЧАЭС). Среди больных было 14 женщин и 101 мужчина. Средний возраст больных на момент аварии на ЧАЭС составлял 25-32 года. Из числа обследованных и пролеченных 63 были инвалидами III группы по общему заболеванию (14 женщин; 49 мужчин) и 52 - инвалида II группы по общему заболеванию (все мужчины). Проводили мониторинг АД в течении всего периода наблюдений. Состояние гемодинамики оценивали методом допплерографии. Для этого использовали аппарат SCIMED PCDOP-842 (фирма Medata, Швеция). Ультразвуковым датчиком (2 МГц) проводили локацию позвоночных артерий на глубине 40-60 мм; основной - 60-80 мм. Проводили также локацию средней мозговой, передней мозговой и задней мозговой артерий по стандартным параметрам. Оценивали линейную скорость кровотока. Кроме того методом иммуноферментного анализа с помощью соответствующего набора фирмы АСЕ определяли содержание эндотелина-1 в сыворотке крови. Лечение у 50 больных осуществляли в виде курса КВЧ-терапии с использованием генератора ГА-141, частота излучения 37,5-41,6 ГГц, длина волны 2 мм; мощность потока 2 мВт/см2, контроль мощности проводили при помощи измерителя мощности МЗ-22А. на выходе генератора находился СВЧ-блок, позволявший четко подбирать индивидуальную резонансную терапевтическую частоту воздействия (патент СССР № 1807872 от 10.10.1992, авторы Маколинец В.И., Кисилев В.К. и др.). Облучение с 225 помощью гибкого волновода осуществляли на биологически активные точки

ТЯ5; УБ20; Е36; ЯР6; Б3; У С г14. Продолжительность сеанса от 20 до 35 минут. Курс составляли 9-12 ежедневных сеансов. У 50 больных лечение осуществляли курсом ТКЕА с использованием выпускаемого промышленностью аппарата «Этранс-2». Отрицательный электрод накладывали на лоб; сдвоенные положительные электроды располагали на сосцевидных отростках. Первый сеанс проводили в щадящем режиме (2-й режим) с заполнением импульсной составляющей стимулирующего тока импульсами частотою следования 16,5 ± 1 кГц с скважностью. Последующие сеансы проводили в первом режиме (без заполнения импульсной составляющей). Величину электрического тока увеличивали с 0,7 до 1,2 мА (до возникновения чувства покалывания). Продолжительность сеанса 20-30 мин., курс составляли 10-15 процедур. 15 больным проводили стандартный курс медикаментозной терапии, включающий: йодистый калий, биохиноль, эуфилин, триамкур, кавитон, трентал. Кавитон вводили внутривенно капельно по 10 мг (2,0мл, 0,5% р-ра) в 200 мл изотонического раствора через два дня на третий, всего до 6-ти вливаний. Между капельницами кавитон назначали по 1 таб. 3 раза в день. Трентал применяли перорально по 1 дражже 3 раза в день. Результаты исследований и их обсуждение Проведены доплерографические исследования, результаты которых приведены в таблице 1.

226 Таблица 1 Скорость кровотока в сосудах сонной и позвоночной артерии у больных с СВД радиационного генеза при различном лечении (см/с).

Группы Контроль До КВЧ- ТКЕА- Медикаментозная (27-45 лет ) лечения терапия терапия терапия Показатель Средняя 59,4±10,6 52,1±12,3 55,6±10,4 56,3±10,9 56,4±8,2 скорость Амплитуда Средняя мозговая До 20 28,4 23,6 28,4 22,1 (%) Средняя 48,8±12,3 43,3±10,4 47,3±2,1 45,5±12,4 47,3±12,3 скорость Амплитуда

мозговая До 20 27,8 24,4 25,8 23,5 Передняя (%) Средняя 38,6±8,3 32,3±5,1 34,5±6,8 36,0±7,4 36,0±8,2 скорость Амплитуда Задняя

мозговая До 30 46,8 32,9 33,4 36,5 (%) Средняя 36,3±6,9 20,9±5,2 30,1±5,4 30,4±6,0 32,0±5,8 скорость

Амплитуда

артерия До 30 69,7 48,4 44,5 40,1

Позвоночная (%)

Средняя 44,1±10,6 38,6±8,3 38,6±8,3 38,8±8,6 40,0±7,1 скорость Амплитуда

артерия До 30 44,3 37,1 32,1 35,8 Основная (%)

Как следует из данных таблицы 1 у здоровых людей разница в скорости кровотока между бассейнами сонной и позвоночной артерии скрадывается за счет большого индивидуального разброса данных. Однако можно

227 утверждать, что разница в скорости кровотока средней и задней мозговых артерий достоверна. Одновременно можно отметить, что асимметрия скоростей кровотока имеет место, но она не грубая. Согласно результатам иммуноферментных исследований содержание эндотелина-1 у здоровых людей составляло 2,38 ± 0,11пкг/мл. Развитие синдрома вегетативной дистонии в результате действия малых доз радиации сопровождалось повышением артериального давления до 160-170/97-110 мм.рт.ст. у разных больных. Следует отметить, что у 17 больных артериальное давление в ходе исследования оставалось близким к возрастной норме < 140/90 мм.рт.ст. Отмечалось изменение скорости кровотока в изучаемых сосудистых бассейнах. Согласно данным таблицы 1 скорость кровотока снижалась во всех изученных сосудах. Наибольшее снижение имело место в позвоночных артериях, существенно усиливалась асимметрия кровообращения в изученных сосудах, особенно сильно это отмечалось в той же позвоночной артерии. Следует отметить, что одновременно резко повышалось содержание эндотелина, которое составляло 25,69±6,52 пкг/мл. Можно полагать, что изменение функции эндотелия под влиянием ионизирующего излучения обуславливает склонность к вазоконстрикции, что проявляется повышением диастолического давления. В сочетании со снижением скорости кровотока это может стать основой для развития кислород-субстратного дефицита и связанной с ним энцефалопатии. После проведения курса КВЧ-терапии скорость кровотока, по данным допплерографии (табл. 1) возрастала практически до нормы в сосудах бассейна сонных артерий. В бассейне позвоночных артерий скорость кровотока также возрастала, но в существенно меньшей степени. Имело место уменьшение асимметрии кровотока, однако до нормальный значений она не возвращалась. Следует отметить, большее, чем в норме однообразие показателей. 228 Что касается артериального давления, то систолическое давление снижалось до 140-150 мм.рт.ст., в то время как диастолическое оставалось повышенным - 90-100 мм.рт.ст. Определение содержания эндотелина выявило его снижение, но оно всё равно в разы превышало норму и составляло 20,76±5,83 пкг/мл. Полученные данные позволяют полагать, что электромагнитное излучение КВЧ-терапия благоприятно влияет на деятельность надсегментарных структур ВНС, благодаря чему имеет место тенденция к нормализации скорости кровотока, но очень слабо влияет на функциональную активность эндотелия поврежденного ионизирующим излучением. После проведения курса ТКЕА-терапии скорость кровотока в сосудах сонных артерий практически нормализовалась в сосудах бассейна позвоночных артерий. В отличие от КВЧ-терапии индивидуальность реакции на лечение (разброс результатов) был высоким, практически как в норме. Что касается асимметрии кровотока, то она снижалась в бассейне сонных артерий почти как при КВЧ-терапии, а в сосудах бассейна позвоночных артерий в большей степени. Что касается изменений артериального давления, то для больных, получивших курс ТКЕА-терапии характерно большое снижение диастолического давления. У этих больных систолическое давление составляло 140-150 мм.рт.ст., а диастолическое - 90-95 мм.рт.ст. Одновременно имело место большее снижение содержание эндотелина, по сравнению с курсом КВЧ-терапии, оно составляло 10,52±2,53 пкг/мл. Возможно, с этим связано большее снижение диастолического давления. В целом можно констатировать большее, по сравнению с КВЧ- терапией, влияние ТКЕА-терапии на функции эндотелия и структуры, регулирующие деятельность сосудов бассейна позвоночных артерий.

229 Наконец проведение курса медикаментозной терапии оказало также положительное влияние на скорость мозгового кровотока. Согласно данным таблицы 1 после завершения курса скорость кровотока повышалась во всех исследуемых бассейнах практически до значений нормы. Существенно снижалась асимметрия кровотока. Выделить преимущественный бассейн, на который медикаментозная терапия оказывала более благоприятное воздействие нельзя. Артериальное давление также изменялось в лучшую сторону и составляло 140-150/90 мм.рт.ст. Поскольку содержание эндотелина при этом не превышало 11,85±1,13 пкг/мл, мы полагали, что медикаменты наилучшим способом влияют на функциональную активность эндотелия. На надсегментарные структуры ВНС, регулирующие гемодинамику их влияние мало отличимо от влияния физиотерапевтических факторов. Таким образом, результаты наших исследований показали, что развивающийся вследствие ионизирующей радиации синдром вегетативной дистонии сопровождается существенным снижением скорости кровотока в сосудах мозговых бассейнов, повышением артериального давления, многократным увеличением содержания эндотелина в плазме крови. Полученные данные свидетельствуют, что имеет место расстройство функций надсегментарных структур ответственных за регуляцию кровотока; нарушаются периферические механизмы регуляции тонуса сосудов (склонность к вазоконстрикции). Таким образом, создаются условия для формирования субстрат- кислородного дефицита мозга. Применение элиминировано физиотерапевтических факторов или медикаментов оказывает положительное влияние на регуляцию гемодинамики, нормализуя выявленные нарушения. При этом следует отметить, что физиотерапевтические факторы усиленно корректируют дизрегуляцию надсегментарных сосудистых регуляторов, но слабо влияют на 230 периферические механизмы регуляции сосудистого тонуса. В то же время медикаментозные средства существенно меняют состояние периферических механизмов регуляции сосудистого тонуса, а на процессы дизрегуляции надсегментарных структур оказывают такое же влияние, как и физиотерапевтические лечебные факторы. Очевидно, в дальнейшем, целесообразно изучать возможность создания фармако- физиотерапевтических комплексов для коррекции нарушений деятельности структур ВНС.

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232 12. Нетрадиционные методы диагностики и терапии. / Под общей ред. И.З. Самосюк, В.П. Лысенюк, Ю.П. Лиманський. и др. — К.: “Здоров’я”, 1994. — 240 с.

Received: 10.11.2012. Revised: 25.12.2012. Accepted: 07.02.2013.

233 234 235 236 237 238 239 Publishing House: Radomska Szkoła Wyższa w Radomiu, Radom University in Radom Str. Zubrzyckiego 2 26-600 Radom Tel.: +48 48 383 66 05 [email protected] Printing House: Radomska Szkoła Wyższa w Radomiu, Radom University in Radom Str. Zubrzyckiego 2 26-600 Radom Tel.: +48 48 383 66 05 [email protected] ISBN 9781329876309

ISBN 9781329893009

9781329893009

240 ISBN 9781329893009

9781329893009