MAKETA 6/2 po - Jesseniova lekárska fakulta

ISSN 1335-8421 Acta Med Mart 2006, 6(2)
ACTA MEDICA
MARTINIANA
Journal for Biomedical Sciences,
Clinical Medicine and Nursing
Contents
3
Evaluation of diastolic dysfunction in children
Review
Sylvia Krupičková, Alexander Jurko jr., Alexander Jurko, Vanda Pedanová, Zuzana Lehotská
10
Heart rate variability during hypertensive reaction in spontaneously breathing
and artificially ventilated rabbits
Juraj Mokrý, Tatiana Remeňová, Kamil Javorka
16
Ischemia – reperfusion effect on cochlear function. An animal model
Krzysztof Morawski, Grazyna Lisowska, Kazimierz Niemczyk
21
Experimental meconium aspiration: Effect of dexamethasone treatment
on the lung functions – a pilot study
Daniela Mokra, Andrea Calkovska, Janka Bulikova,
Maria Petraskova, Kamil Javorka
27
Formulation and implementation of the National Immunization Programme
in Slovak Republic
Henrieta Hudečková, Mária Szilágyiová, Vladimír Oleár, Tibor Baška, Štefan Straka
31
Screening of diabetic foot in nursing practice
Jana Nemcová, Tibor Baška, Milan Ochodnický, Dušan Mištuna
Published by the Jessenius Faculty of Medicine in Martin,
Comenius University in Bratislava, Slovakia

A C T A M E D I C A M A R T I N I A N A 2 0 0 6 6/2
E d i t o r - i n - C h i e f :
Javorka, K., Martin, Slovakia
I n t e r n a t i o n a l E d i t o r i a l B o a r d :
Belej, K., Martin, Slovakia
Buchanec, J., Martin, Slovakia
Honzíková, N., Brno, Czech Republic
Kliment, J., Martin, Slovakia
Lehotský, J., Martin, Slovakia
Lichnovský, V., Olomouc, Czech Republic
Mareš, J., Praha, Czech Republic
Plank, L., Martin, Slovakia
Stránsky, A., Martin, Slovakia
Tatár, M., Martin, Slovakia
Żwirska-Korczala, K., Zabrze-Katowice, Poland
E d i t o r i a l O f f i c e :
Acta Medica Martiniana
Jessenius Faculty of Medicine, Comenius University
(Dept. of Physiology)
Malá Hora 4
037 54 Martin
Slovakia
Instructions for authors: http:|www.jfmed.uniba.sk (Acta Medica Martiniana)
T l a č :
P+M Turany
© Jessenius Faculty of Medicine, Comenius University, Martin, Slovakia, 2006

A C T A M E D I C A M A R T I N I A N A 2 0 0 6 6/2 3
EVALUATION OF DIASTOLIC DYSFUNCTION IN CHILDREN
Review
SYLVIA KRUPIČKOVÁ, ALEXANDER JURKO JR., ALEXANDER JURKO, VANDA PEDANOVÁ,
ZUZANA LEHOTSKÁ
Clinic of Children and Adolescents, Jessenius Faculty of Medicine, Comenius University and Martin Faculty Hospital,
Martin, Slovak Republic
A b s t r a c t
It has been determined, that 20 to 40 % of patients with symptoms of heart failure have normal left ventricular ejection
fraction and the reason of heart failure is isolated diastolic dysfunction. Normal diastolic function of the left ventricle
is defined as the capacity to receive filling volume and insure adequate heart output in condition of low ventricular
pressures. Diastolic function is evaluated by transmitral flow and flow in pulmonary veins by ultrasound. Following
parameters are measured: isovolumic relaxation time /IVRT/; deceleration time /DT/; velocity of wave E, A, and their
ratio; velocity-time integral of wave E and A; velocity and duration of wave AR.
Three types of diastolic dysfunction are distinguished. Relaxation disorder is the least severe stage of diastolic dysfunction.
It is characterized by reversed ratio of velocities of wave E and A /less then 1/, prolonged DT over the norm
given for age and lenghtening of IVRT. The restrictive filling pattern is characterized by high velocity of wave E with short
DT and short wave A. Pseudonormal transmitral filling pattern is characterized by wave AR changes in the pulmonary
venous flow. Its amplitude is higher than 25 cm/s and longer than transmitral wave A.
Treatment of diastolic heart failure is difficult because there are only few clinical studies available. The baseline for efective
therapy is identification of the cause of the heart failure and its treatment. There are two main approaches in pharmacological
treatment: repair of abnormal relaxation properties and decrease of filling pressures - elimination of venous stagnation.
K e y w o r d s : diastolic dysfunction, heart diseases, therapy
INTRODUCTION
Pathophysiology of heart failure is different in paediatric and adult population. The most frequent
reason of ventricular dysfunction in children are structural heart diseases, often complicated
by surgical interventions./1,2/
Combined pharmacological therapy /diuretics, digoxin, amrinon, milrinon, ACE inhibitors/
often improves heart failure in adults. However, this is not so successful in children because of
residual structural lesions, immaturity of heart muscle and decreased ability to control of intracellular
calcium homeostasis.
The decrease in incidence of ventricular dysfunction allowed application of one-stage neonatal
surgery and catheter intervention techniques, used e.g. for closure of ductus arteriosus, defect of
interatrial septum and of muscular part of ventricular septum./3/
It has been determined, that 20 to 40 % of patients with symptoms of heart failure have
normal ejection fraction of left ventricule and the reason of heart failure is isolated diastolic dysfunction.
/4, 5/ Systolic dysfunction is determined by disturbance of pumping function of the
ventricle. Diastolic dysfunction means the failure of filling of heart ventricle.
Normal diastolic function of left ventricle is present, when the ventricle can receive adequate
filling volume after early relaxation and with low diastolic pressure in early diastole in condition
of subtle pressure increase. /6/
PATHOPHYSIOLOGY OF HEART DIASTOLIC DYSFUNCTION
Diastole is integral part of heart cycle, essential for accurate function of the heart. It represents
complex process, which needs energy, lasts longer then systole and has its own regulatory
mechanisms. Diastole is the interval between aortic valve closure and mitral valve closure.
Address for correspondence:
MUDr. Sylvia Krupičková, Pod hájom 956/8, 018 41 Dubnica nad Váhom
Phone: +421 905 321 498, e-mail: sylviakrupickova@inmail.sk

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Diastole is divided to 4 phases:
- isovolumic relaxation,
- early diastolic filling,
- diastase,
- atrial contraction. /7/
During early diastole in normal conditions, ventricle receives 55 % of filling volume and during
passive phase 20 % of filling volume. Last phase of diastole is atrial contraction, during which
the remaining 25 % of pulse volume comes into ventricle. /8/
Normal diastolic function of left ventricle is defined by capacity of left ventricle to receive filling
volume of left ventricle and insure adequate heart output at low pressures in left ventricle. /9/
Diastole is divided into early, active phase - relaxation, which is result of changes in myocard
and late, passive phase, which is ifluenced by external forces. So, active relaxation and passive
compliance are distinguished. Both events overlap, because relaxation is not finished until
beginning of the filling.
Diastolic dysfunction of left ventricle is:
1. incompetence to fill left ventricle at rest or at exertion to normal end-diastolic volume without
abnormal increase of end-diastolic pressure in left ventricle or mean pressure in left atrium,
or
2. failure of increase of end-diastolic volume in left ventricle and cardiac output during physical
activity. /7/
Actually, the diastolic dysfunction of left ventricle is incapability of the ventricle to relax and
to fill in.
Systolic function influences relaxation of left ventricle and often also its compliance, so all
patients with decreased ejection fraction of left ventricle have diastolic abnormalities /7/.
The most frequent consequence of diastolic dysfunction is venous congestion of the lungs
/10/. It means, that normal systolic function of left ventricle does not exclude the possibility of
cardiac reason of dyspnoe /5, 11/.
The diastolic dysfunction can cause only little delay of the relaxation of left ventricle without
increase of the pressures in the earliest stages and the patient can be asymptomatic.
Heart failure is clinical syndrome, which is characterised by symptoms and signs of
increased amount of fluids and decreased perfusion of tissues/organs /12/. To evaluate this
clinical syndrome, it is important to measure not only systolic, but also diastolic function. We
speak about diastolic heart failure, if the heart failure is caused predominantly or exclusively by
abnormalities in diastolic dysfunction.
Diagnosis of diastolic heart failure involves fulfilment of three conditions:
a) presence of clinical signs of heart failure, especially left heart failure,
b) normal ejection fraction /over 50%/,
c) increased diastolic filling pressure.
The first 2 criterions can be easily identified. The problem is to find out an indicator of diastolic
pressures.
The invasive method of catheterisation, at which pressure and volume are simultaneously
measured, allows measurement of velocity of diastolic filling and stiffness of myocard. But it is
not possible to use it for routine diagnostic evaluation /13/.
The noninvasive evaluation of diastolic function can be done by 2D and Doppler echocardiography,
TDI, M-mode echocardiography, radionuclid ventriculography and magnetic imaging. It
has been proven, that echocardiography is appropriate for routine measurement of diastolic
function and is often used in clinical studies.

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THE ULTRASOUND EVALUATION OF DIASTOLIC DYSFUNCTION
Ultrasound evaluation of transmitral flow and flow in pulmonary veins /Fig. 1, Fig. 2/ allows
to assess following parameters:
Isovolumic relaxation time /IVRT/ is interval between aortic valve closure and mitral valve
opening. Aortic valve closure can be found out most exactly during simultaneous recording with
phonocardiogram, but more practical way is positioning assay volume of PW Doppler between anterior
cusp of mitral valve and outflow tract of left ventricle. IVRT reflects the velocity at the beginning
of myocardial relaxation. Longer IVRT is a sensitive marker of abnormal relaxation of myocard.
Wave E -is the intensity of pressure gradient between atrium and ventricle at the beginning
of diastole. Its intensity reflects the velocity of ventricle relaxation /in relaxation disorder the
pressure in left ventricle at the beginning of diastole is relatively higher and the velocity of wave
E decreases/, pressure in left atrium /in high filling pressures the velocity of wave E increases/
and compliance of left ventricle.
Deceleration time - DT - reflects the velocity of the pressure increase in left ventricle in early
diastole, which follows after its maximal initial decrease. DT is dependent on duration of relaxation
of left ventricle and its compliance.
Wave A - maximal velocity during atrial contraction. It depends on the compliance of left ventricle,
preload and the contractility of left atrium.
In normal persons the ratio E/A is more than one until the middle age and does not exceed
200 ms. Persons over 50 years have the ratio E/A about 1 and over 60 years bellow 1. So relaxation
disorder appears in increased age.
The main problem of diagnosis of diastolic function disorder with PW Doppler is the fact, that
parameters of transmitral flow are significantly dependent on preload and afterload of atria and
ventricles /14/.
Wave AR – this wave describes retrograde flow in pulmonary veins during atrial contraction.
Its amplitude and duration have relationship to diastolic pressure in left ventricle, compliance of
left atrium and heart rate. In healthy persons the amplitude of AR is less than 30 cm/s and lasts
less then transmitral wave A.
Fig.1. In the left screen,
methodological outline for
the measurement of Doppler
transmitral indexes of diastolic
function. In the right
screen, normal diastolic pattern
(upper part) and pattern
of abnormal relaxation (lower
part). A = atrial velocity
(m/s), DT = deceleration time
of E velocity (ms), E = early
diastolic velocity (cm/s),
IVRT = isovolumic relaxation
time (ms)

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Fig.2. In the left screen,
methodological outline for the
measurement of pulmonary
veins flow. In the right screen,
normal pulmonary veins flow
pattern (upper part) and pattern
of abnormal relaxation
(lower part).
Three types of diastolic dysfunction are distinguished:
Relaxation disorder - is the least severe stage of diastolic dysfunction. The relaxation disorder
leads to deceleration of pressure decrease in left ventricle at the beginning of diastole
between atrium and ventricle. The velocity of wave E decreases. The relaxation
further continues to relatively late diastole, the pressures between atrium and ventricle
equalize slower and this process leads to lenghtening of DT. A big volume of blood remains in left
atrium until late diastole, its preload increases and its contraction intensifies /Frank - Starling
mechanism/. So the velocity of wave A increases. Thus the relaxation disorder is characterized
by reversed ratio of velocities of wave E and A /less then 1/ and prolonged DT over
the norm for given age. Next sign of relaxation disorder is lenghtening of IVRT. The patients
with relaxation disorder are asymptomatic.
Pseudonormal and restrictive pattern. The compliance of left ventricle decreases with
continuing disorder of diastolic function. This leads to increase of end-diastolic pressure in
left ventricle and mean pressure in left atrium. High filling pressures lead to increase of
velocity of wave E with shortening of DT, and the velocity of wave A decreases. The increased
afterload in left atrium causes the larger volume of blood coming during systole of the atrium
into pulmonary veins, where the velocity and duration of wave AR increases. The restrictive
filling pattern is characterized by high velocity of wave E with short DT and short
wave A.
Pseudonormal filling pattern - upon analysis of mitral flow can not be distinguished from
normal filling /E is higher then A/.
The pseudonormal pattern can be distinguished by following:
° left atrium is slightly enlarged - diastolic dysfunction in normal size of left atrium is very unlikely,
° wave AR in the pulmonary venous flow pattern has amplitude more then 25 cm/s and is longer
then transmitral wave A,
° wave Em by examination with TDI is diminished and the E/Em ratio is more then 15 /look below/,
° by examination with color M-mode the velocity of propagation flow is decreased /less then 40 cm/s/
/look below/,

A C T A M E D I C A M A R T I N I A N A 2 0 0 6 6/2 7
Fig.3. In the left screen,
methodological outline for the
measurement of Tissue Doppler
indexes. In the right
screen, normal myocardial
diastolic pattern (upper part)
and pattern of abnormal
myocardial relaxation (lower
part). Am = myocardial atrial
velocity (cm/s), CTm = myocardial
contraction time (ms),
DTm = myocardial deceleration
time of Em(ms), Em = myocardial
early-diastolic velocity
(cm/s), PCTm = myocardial
pre-contraction time (ms),
RTm = myocardial relaxation
time (ms).
° by the change of loading conditions for example with nitroglycerine, nitroprusid or Valsalva maneuver,
relaxation disorder pattern develops,
° patients with pseudonormal pattern have dyspnoe by exertion /15/
TDI /tissue Doppler imaging/ is modification of conventional doppler echocardiography and
is directed for recording of velocities of systolic and diastolic motions of myocard or annulus of
valves. Classic doppler technique uses setting by which higher velocities /10-100 cm/s/ with low
amplitude are recorded, which are typical for motion of flowing blood. On the contrary, TDI analyzes
mainly signals of low velocity and high amplitude, which are typical for motion of myocard
and annulus of valves. /14/.
By pulse TDI, sample volume is positioned to arbitrary site of myocard, which function we
want to evaluate and we receive doppler trace with velocities of motion of myocard in chosen
region.
For evaluation of regional diastolic function are used IVRT /interval between end of wave
S and beginning of wave A/, Em /early diastolic velocity of relaxation - reflects velocity of relaxation
in examinate position, it is independent of preload/ and Am /reflects velocity of motion of
myocard in late diastole//Fig. 3/. In diastolic dysfunction Em decreases, Am increases, Em/Am
ratio decreases under 1. Decrease of Em is a sensitive marker of relaxation disorder of the left
ventricle. We don’t face the problem of pseudonormalisation by increasing of filling pressure of
left ventricle as it is in evaluation of transmitral flow /16/.
It has been found out, that E/Em ratio correlates very well with mean pulmonary capillary
wedge pressure and can be used for examination of wedge pressures /17/.
Color Doppler M-mode mapping /color M-mode/
The velocity of blood flow propagation into left ventricle /Vp/ is one of the newest parameters
used for evaluation of diastolic function of left ventricle and describes mainly the quality of its
relaxation. For its measurement, the largest and longest blood flow from left atrium in the direction
of apex of left ventricle is used.
The velocity of propagation Vp in healthy people is about 80 cm/s, in patients with relaxation
disorder it decreases under 40 cm/s. It is independent on changes of preload and allows to dis-

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A C T A M E D I C A M A R T I N I A N A 2 0 0 6 6/2
tinguish advanced disorders of diastolic dysfunction /pseudonormalisation, restrictive filling
pattern//14, 15/.
TREATMENT OF DIASTOLIC HEART FAILURE
The treatment of diastolic heart failure is difficult and rather empirical, because of few clinical
studies conducted. The baseline for efective treatment is identification of the cause of heart
failure, e.g. ischemia of myocard, arterial hypertension, hypertrophy of myocard, constriction of
myocard and pericard and their treatment. An important role has surgical and interventional
management of congenital heart diseases.
Two main approaches in pharmacological treatment are used:
- repair of abnormal diastolic properties,
- decrease of filling pressures - elimination of venous congestion.
Ca-antagonists improve directly diastolic function, increase homeostasis of Ca and indirectly
decrease blood pressure, decrease myocardial ischemia, support regression of hypertrophy of
left ventricle, reduce frequency of heart rate /verapamil, diltiazem/ and improve filling parameters
of left ventricle.
Sympathetic nervous system affects favourably relaxation of ventricle, it has also positive
chronotropic and inotropic effects.
Despite beta - blockers block this favorable effect of catecholamins, they improve filling of
ventricle by the mechanism of decreasing heart rate and prolongation of time of diastolic filling,
decrease of blood pressure, myocardial ischemia and regression of hypertrophy of left ventricle.
Beta - blockers with smaller beta2-agonistic activity, as celiprolol, are even more effective.
Celiprolol directly improves diastolic relaxation.
ACE - inhibitors directly influence relaxation of myocard and compliance by decreasing of
production of angiotensin II, which is responsible for deposition of interstitial collagen and fibrosis.
The indirect effect of ACE - inhibitors includes decrease of blood pressure, improvement of
filling parameters of left ventricle and regression of hypertrophy of left ventricle.
Positive inotropic and chronotropic medications /digoxin, dobutamin/, arterial vasodilators
/hydralasine/ and blockers of alpha-adrenergic receptors /prazosin/ should be avoided. In
absence of systolic dysfunction, they can worsen diastolic function through increasing of contractility
or heart rate.
Diuretics and nitrates are used in certain situations. In situations when very high pressure
for filling of left ventricle is needed, the decrease of preload can worsen cardiac output.
First of all, we need to maintain sinus rythm, avoid tachycardia /decrease heart rate to
lengthen diastole/ and maintain for patients with diastolic heart failure the contribution of atrial
systole.
CONCLUSION
The Doppler evaluation of diastolic function of heart is a new, nowadyas verified method,
which can be used not only in adults, but also in children. Diastolic function is evaluated in
myocardial ischemia, hypertrophy of left ventricle following arterial hypertension, hypertrophic
cardiomyopathy, restrictive cardiomyopathy, diseases of pericard, hypertrophy of one or both
ventricles following congenital heart diseases, coarctation of aorta, complex diseases of myocard
and in evaluation of function of heart in oncologic patients after treatment.
REFERENCES:
1. Behrman RE, Kliegman RM, Jenson HB. Nelson textbook of pediatrics. Philadelphia: W. B. Saunders Company; 2000.
2. Keck EW, Hausdorf G. Pädiatrische Kardiologie. München: Urban und Fischer; 2002.
3. Hanna BD. Ventricular dysfunction in the pediatric population: evaluation and intervention. J Heart Lung Transplant
1997; 16 (7): 16-18.
4. Jurko A ml. Vybrané echokardiografické parametrov novorodencov a dojčiat. Martin: Flipo; 2000.
5. Grossman W. Defining diastolic dysfunction. Circulation 2000; 101 (4): 2020-2021.

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6. Kohler E, Taturu MCH. Klinische echokardiographie. Stuttgart: Georg Thieme Verlag; 2001.
7. Appleton CHP, Firstenberg MS, Garcia MJ. The echo-doppler evaluation of left ventricular diastolic function. Cardiol
Clin 2000; 18 (3): 513-546.
8.Yoshii K, Iwao H, Fukuda S. Left ventricular diastolic pressure-volume and stress-strain relationship in children. Jap
Circ J 1985; 49 (3): 385-394.
9. Gajderisi M. Diastolic dysfunction and diastolic heart failure: diagnostic, prognostic and therapeutic aspects. Cardiovascular
Ultrasound 2005; 3 (9): 1-20.
10. Chatterjee K, Karliner J, Rapaport E. Cardiology. Philadelphia: J. B. Lippincott company; 1991.
11. Warltier DC. Ventricular function. Baltimore: Williams and Wilkins; 1995.
12. Zile MR, Brutsaert DL. New concepts in diastolic dysfunction and diastolic heart failure: Part I. Circulation 2002;
105 (11): 1387-1402.
13. Rosei EA. Clinical value of diastolic dysfunction in hypertension. J Hypert 2002; 20 (6): 1083-1084.
14. Linhart A, Paleček T, Aschermann M. Echokardiografie pro praxi. Praha: Audioscan; 2002.
15. Roelandt JRTC, Pozzoli M. Non-invasive assessment of left ventricular diastolic (dys)function and filling pressure.
Heart views 2001; 2 (3): 1-14.
16. Niederle P. Echokardiografie. Praha: Triton; 2002.
17. Nagueh SF, Middleton KJ, Kopelen HA. Doppler Tissue Imaging: A noninvasive technique for evaluation of left ventricular
relaxation and estimation of filling pressures. J Am Coll Cardiol 1997; 30 (6): 1527-1533.

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HEART RATE VARIABILITY DURING HYPERTENSIVE REACTION IN SPON-
TANEOUSLY BREATHING AND ARTIFICIALLY VENTILATED RABBITS
JURAJ MOKRÝ 1 , TATIANA REMEŇOVÁ 2 , KAMIL JAVORKA 2
1
Department of Pharmacology, Jessenius Faculty of Medicine, Comenius University, Martin, 2 Department of Physiology,
Jessenius Faculty of Medicine, Comenius University, Martin, Slovak Republic
A b s t r a c t
The purpose of the study was to evaluate the changes of heart rate variability parameters (HRV) during hypertensive
reaction evoked by norepinephrine (NE) infusion in anaesthetized rabbits. Furthermore, these changes were studied
during artificial ventilation to study the mechanisms participating in activity of spectral frequency bands of HRV.
Methods: 8 adult rabbits (Chinchilla) were anesthetized by ketamine and flunitrazepam. The R-R intervals, systemic
blood pressure (BP) and respiratory rate were registered and evaluated. The R-R intervals were derived from the electrocardiogram
signal from subcutaneous needle electrodes. HRV was analyzed by microcomputer system VariaPulse TF3E.
The evaluation of HRV in very low (VLF; 0.01-0.05 Hz), low (LF; 0.05-0.15 Hz) and high frequency bands (HF; 0.15-2.0
Hz) was made and parameters of time and frequency analysis were calculated. The measurements were made before,
during and after 30 minutes lasting NE infusion (10 μg/kg/min) in spontaneously breathing (SB) as well as in artificially
ventilated (AV) anaesthetized rabbits.
Results: The NE infusion in anaesthetized rabbits caused significant increase of systolic and diastolic BP in both SB
and AV animals, which was accompanied by significant prolongation of R-R intervals. The respiratory rate (in SB animals)
was not changed. The HRV parameters, especially total power spectral density (PSD), PSD in VLF and HF bands,
significantly increased during NE infusion. This elevation was not eliminated during artificial ventilation.
Conclusion: Increased spectral activity in the VLF and HF bands during the hypertensive and bradycardiac reactions
evoked by NE infusion reflects both the sympathetic and parasympathetic regulation of the heart rate in Chinchilla
rabbits.
K e y w o r d s : heart rate variability, artificial ventilation, autonomic nervous system, norepinephrine, hypertension, rabbit
INTRODUCTION
The evaluation of heart rate variability (HRV) by spectral analysis is a suitable, sensitive and
non-invasive tool for studying the influence of autonomic nervous system (ANS) and endocrine
system on the heart (1). Short-term fluctuations of the R-R intervals – instantaneous heart rate
– express the beat-to-beat regulation of the heart pacemaker and the fine-tuning of heart rate
around an average value especially via activity of ANS. The interactions of parasympathetic and
sympathetic nervous system together with other intrinsic mechanisms are considered to be
essential for rapid and short-term changes in HRV (2).
In our recent study (3) we showed that the orthostasis in anaesthetized rabbits is accompanied
by decrease of systemic blood pressure, unchanged heart rate and increased characteristics
of heart rate variability, with predominant increase of spectral power in low frequency (LF)
and very low frequency (VLF) bands.
The aim of this study was to evaluate the changes of heart rate variability parameters during
hypertensive reaction evoked by norepinephrine (NE) infusion in anaesthetized rabbits. These
changes were evaluated during spontaneous breathing and artificial ventilation to study the
mechanisms participating in activity of spectral frequency bands of HRV in rabbits.
METHODS
We used 8 adult rabbits (Chinchilla) with mean body weight (b.w.) of 2.6±0.5 kg. The animals
were housed and bred in central menagerie with standard food and water ad libitum.
Address for correspondence:
Juraj Mokrý, MD, PhD.,Department of Pharmacology,
Jessenius Faculty of Medicine, Comenius University, Sklabinská 26, 037 53 Martin, Slovak Republic
Phone: +421 43 4132535, fax: +421 43 4134807, e-mail: mokry@jfmed.uniba.sk

A C T A M E D I C A M A R T I N I A N A 2 0 0 6 6/2 11
During the experiment, the animals were anesthetized by ketamine (Narkamon 5%, Léčiva,
Czech Republic) at the dose of 0.7 ml/kg b.w. and flunitrazepam (Rohypnol 2%, Léčiva, Czech
Republic) at the dose of 0.2 ml/kg b.w. to vena marginalis auriculae. Furthermore, every 30
minutes the combination of ketamine (0.2 ml/kg b.w.) and flunitrazepam (0.07 ml/kg b.w.)
was administered to maintain the sufficient depth of anesthesia. Anesthetics and other drugs
were administered through catheter in the right femoral vein. The systemic BP was monitored
continuously using the electromanometer (LDP 102, Tesla Valašské Meziříčí, Czech Republic)
connected to catheter in arteria femoralis, tidal volume and respiratory rate through the
pneumotachograph (ÚMMT, Bratislava, Slovak Republic) and endotracheal cannula. The registration
was made using 6 NEK 6 recorder (RFT, Dresden, Germany).
HRV was evaluated by microcomputer system VariaPulse TF3E (SIMA MEDIA, Olomouc,
Czech Republic) recording the telemetrically transmitted R-R intervals through a receiver to
computer. The R-R intervals were derived from the electrocardiogram (ECG) signal from subcutaneous
needle electrodes. Special software using spectral analysis (Fast Fourier Transformation)
enables the evaluation of HRV in time and frequency domains in very low (0.01-
0.05 Hz), low (0.05-0.15 Hz) and high frequency bands (HF; 0.15-2.0 Hz) (4,5). The frequency
analysis, besides total spectral power (TP), offers the characteristics of the individual frequency
bands – spectral power VLF, LF and HF, power spectral density (PSD VLF, PSD LF,
PSD HF), and peak of the frequency in the band. Furthermore, the program calculates total
power, relative power VLF, LF and HF) and ratios between activities in each frequency band
(VLF/LF, VLF/HF, LF/HF) useful for evaluation of relative activity of sympathetic or parasympathetic
ANS regulating the heart rate. The range of the HF band in the TF3E system in comparison
to the conventional clinical system (TF3) is wider to map the spectral activities up to
the frequency 2.0 Hz (120/min) respecting higher respiratory rate in rabbits.
The time analysis offers further parameters: R-R intervals (and instantaneous reciprocal
heart rate), and MSSD (mean squared successive differences). These parameters characterize
mean heart rate and the magnitude of HRV, whereas the other parameters from frequency
analysis using fast Fourier analysis of non-harmonic signals informs about the rhythms
(2,6).
The hypertensive reaction was evoked by 30 minutes lasting norepinephrine (NE) infusion
(10 μg/kg/min). After cessation of the infusion and normalization of the blood pressure to the
previous initial values, pipecuronium bromide (ARDUAN, Gedeon Richter, Hungary) at a dose
of 0.3 mg/kg/30 min was administered to animals and the endotracheal canulla was connected
to ventilator (Beat-2, Chirana, Slovakia) to ventilate the rabbit in intermittent positive
pressure ventilation (IPPV) regimen with room air. The respiratory rate was set on average to
36/min with tidal volume from 8 to 10 ml/kg b.w. to keep blood gases (p a
O 2
and p a
CO 2
) in
normal range. The NE infusion was repeated under these conditions.
All the measurements were made before (BEFORE), during NE infusion at 5 th (NE05) and
at 30 th minute (NE30), after connecting to artificial ventilation (AV), during consecutive NE
infusion at 5 th (AVNE05) and 30 th minute (AVNE30) as well as 5 (AV05) and 10 minutes after
stopping the infusion (AV10).
The parameters in Figures (1,2) and in Table 1 are given as means and standard error of
the mean (x±SEM). Non-parametric Wilcoxon test was used for statistical analysis. Statistical
level at p0.05).

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Fig. 1: Changes of systolic and diastolic
blood pressure (for explanations
see the text; significant change of
parameter vs. BEFORE or AV: *
p

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Table 1: Changes of frequency analysis parameters of HRV (for explanations see the text).
Parameter
Spontaneous breathing
Artificial ventilation
BEFORE
NE05
NE30
AV
AVNE05
AVNE30
AV05
AV10
Total
p
*
*
PSD
mean
6.39
31.66
41.90
6.12
18.04
67.22
8.36
8.48
(ms 2 /Hz)
SEM
3.14
9.39
16.64
2.91
6.13
32.27
2.61
3.04
PSD VLF
p
*
(ms 2 /Hz)
mean
5.49
71.76
90.59
4.36
21.37
115.06
7.39
5.17
SEM
0.86
19.13
44.25
2.46
15.80
91.76
2.77
1.63
PSD LF
p
+
+
+
(ms 2 /Hz)
mean
11.44
13.64
28.09
0.85
9.07
62.84
0.86
0.80
SEM
8.96
3.37
10.3
0.48
5.02
54.48
0.39
0.18
PSD HF
p
*
*
+
+
+
+
+
(ms 2 /Hz)
mean
2.13
5.88
7.02
13.17
23.68
23.74
16.83
19.48
SEM
0.94
1.99
1.87
8.05
8.50
7.39
6.22
7.62
Ratio
p
VLF/HF
mean
1.41
1.27
2.78
0.89
1.24
1.79
0.85
0.79
SEM
0.42
0.35
1.12
0.09
0.55
0.82
0.74
0.10
Ratio
p
LF/HF
mean
0.97
0.83
1.25
0.89
0.67
1.34
0.85
0.79
SEM
0.02
0.22
0.28
0.09
0.15
0.46
0.07
0.10
Significant change of parameter vs. BEFORE or AV: * p

14
A C T A M E D I C A M A R T I N I A N A 2 0 0 6 6/2
venous return due to positive pressure), reflex changes (via baroreceptors and pulmonary stretch
receptors), humoral factors and others. Artificial ventilation with almost constant frequency
allows the evaluation of HRV changes, which are independent from changes in respiration.
Also, in AV rabbits with constant frequency of breathing and tidal volume, the NE infusion
caused increase in BP and total PSD based on increase of spectral activities in all frequency
bands, and a decrease in heart rate. Increased spectral activity in HF band without changes of
respiratory characteristics reflects probably enhanced parasympathetic influence on the heart –
bradycardiac reaction, confirming that the activity in HF band is influenced not only by respiratory
sinus arrhythmia, but also via other mechanisms.
Increased PSD HF immediately after initiation as well as during AV compared to SB animals
confirms the decisive role of breathing influences on HRV in determination of the spectral activity
in HF band. Considering the fact the frequency of breathing in SB rabbits was 80-100/min
and in AV animals about 36/min, increased tidal volume to keep blood gases in physiological
range leads to the increased HF band activity. This is in concordance with results of Iwao et al.
(11), who demonstrated the association of HF component of HRV with magnitude of fluctuations
of vagal input associated with respiratory modulation.
We conclude the hypertensive reaction evoked by norepinephrine was accompanied by bradycardia
and increase in heart rate variability in rabbits. The rise of spectral activity in the VLF
and HF bands reflects the sympathetic and parasympathetic regulation of the heart rate in the
conditions. The results confirm that complex influences of both sympathetic and parasympathetic
nervous systems participate in individual frequency bands in Chinchilla rabbits
REFERENCES
1. Kleiger RE, Stein PK, Bosner MS, Rottman JN. The domain measurements of heart rate variability. Cardiol Clin 1992;
10: 487-98.
2. Javorka K. Methods and benefits of examining the heart rate regulation in children (in Slovak). Ces-slov Pediat 1996;
51: 462-8.
3. Mokrý J, Remeňová T, Javorka K. Changes in respiratory rate, blood pressure and heart rate variability in rabbits
during orthostasis. Acta Veterinaria 2006; 75: 3-12
4. Salinger J, Opavský J, Búla J, Vychodil R, Novotný J, Vaverka F. Software equipment of measure instrument TF-2
for spectral analysis of variation of R-R interval in cardiology (in Czech). Lékař a technika 1994; 25: 58-62.
5. Salinger J, Opavský J, Novotný J, Vychodil R, Vaverka F, Hudcová Z. Software equipment of measure instrument
TF-2 for diagnostics of autonomous neuropathy (in Czech). Lékař a technika 1993; 24: 133-8.
6. Tonhajzerová I. Heart rate variability and the benefit of its evaluation in physiological research (in Slovak). PhD thesis.
Comenius University, Bratislava, 2000.
7. Javorka K, Javorková J, Petrášková M, Tonhajzerová I, Buchanec J, Chromá O. Heart rate variability and cardiovascular
tests in young patients with diabetes mellitus type 1. J Pediat Endocrin Metab 1999; 12: 423-31.
8. Tonhajzerová I, Javorka K, Petrášková M. Changes of heart rate variability in mental stress (in Slovak). Ces-slov Pediat
2000; 55: 562-7.
9. Tonhajzerová I. Autonomic nervous system (ANS) and the possibilities of ANS activity assessment in obesity (in Slovak).
Ces-slov Pediat 2005; 60: 228-34.
10. Kawamoto M, Kanek, K, Hardian Yuge O. Heart rate variability during artificial ventilation and apnea in brain-damaged
rabbits. Am J Physiol 1996; 271: H410-6.
11. Iwao T, Yonemochi H, Nakagawa M, Takahashi N, Saikawa T, Ito M. Effect of constant and intermittent vagal stimulation
on the heart rate and heart rate variability in rabbits. Jpn J Physiol 2000; 50: 33-9.
12. Nadareishvili KSh, Meskhishvili II, Kakhiani DD, Ormotsadze GL, Nazarishvili GT, Gvasalia MG, Khvedelidze MT,
Sandodze VY. Heart rate variability in Chinchilla Rabbits. Bull Exp Biol Med 2002; 134: 568-70.
13. Javorka K, Javorková J, Petrášková M, Parížeková I, Buchanec J, Chromá O. Heart rate variability in young patients
with diabetes mellitus type I (in Slovak). Ces-slov Pediat 1997; 52: 17-22.
14. Tonhajzerová I, Javorka K. Evaluation of heart rate variability and its benefit (in Slovak). Ces fysiol 2000; 49: 51-60.
15. Guzzetti S, Dassi S, Pecis M, Casati R, Masu AM, Longoni P, Tinelli M, Cerutti S, Pagani M, Malliani A. Altered pattern
of circadian neural control of heart period in mild hypertension. J Hypertens 1991; 9: 831-8.
16. Novak V, Novak P, de Champlain J, Nadeau R. Altered cardiorespiratory transfer in hypertension. Hypertension
1994; 23: 104-13.
17. Takalo R, Korhonen I, Turjanmaa V, Majahalme S, Tuomisto M, Uusitalo A. Short-term variability of blood pressure
and heart rate in borderline and mildly hypertensive subjects. Hypertension 1994; 23: 18-24.
18. Piccirillo G, Bucca C, Durante M, Santagada E, Munizzi MR, Cacciafesta M, Marigliano V. Heart rate and blood pressure
variabilities in salt-sensitive hypertension. Hypertension 1996; 28: 944-52.

A C T A M E D I C A M A R T I N I A N A 2 0 0 6 6/2 15
19. Olosová A, Javorka K, Zibolen M, Tonhajzerová I, Javorková J, Buchanec J, Petrášková M. Spektrálna analýza variability
frekvencie akcie srdca u juvenilných hypertonikov. Ces-slov Pediat 1999; 54: 340-3.
20. van Ravenswaaij-Arts CM, Hopman JC, Kollee LA, Stoelinga GB, van Geijn HP. The influence of artificial ventilation
on heart rate variability in very preterm infants. Pediat Res 1995; 37: 124-30.
21. Gecelovská V, Javorka K. Cardiovascular and haemodynamic changes during artificial ventilation of the lungs.
Bratisl Lek Listy 1996; 97: 260-6.
22. Javorka K, Drgová A, Petrášková M, Gecelovská V. Plasma catecholamine level during Short-term artificial ventilation
(IPPV/HFJV) in rabbits. Abstract. Eur Respir J 1996; 9: 132.
23. Frazier SK, Moser DK, Stone KS. Heart rate variability and hemodynamic alterations in canines with normal cardiac
function during exposure to pressure support, continuous positive airway pressure, and a combination of pressure
support and continuous positive airway pressure. Biol Res Nurs 2001; 2: 167-74.
24. Shen HN, Lin LY, Chen KY, Kuo PH, Yu CJ, Wu HD, Yang PC. Changes of heart rate variability during ventilator
weaning. Chest 2003; 123: 1222-8.
Acknowledgements: This study was supported by the Grant VEGA No. 1/2305/05.
Authors thank to S. Svorková, D. Kulišková, M. Barčíková, M. Petrášková, and I. Štritz for technical assistance.

16
A C T A M E D I C A M A R T I N I A N A 2 0 0 6 6/2
ISCHEMIA – REPERFUSION EFFECT ON COCHLEAR FUNCTION.
AN ANIMAL MODEL
KRZYSZTOF MORAWSKI 1 , GRAZYNA LISOWSKA 2 , KAZIMIERZ NIEMCZYK 1
1
Department of Otolaryngology, Medical University of Warsaw, Poland
2
Department of Otolaryngology, Medical University of Silesia, Zabrze, Poland
A b s t r a c t
Background and aim: Development of new computer technologies, better and more precise imaging and audiological
diagnostics result in faster diagnosis of patients with cerebellopontine angle tumors (CPAT) in such a stage of this
pathology in which hearing is still relatively well preserved. Therefore, animal experiments enable to develop and check
new conception of intraoperative monitoring of hearing organ and, then, to apply them in clinical practice in patients
with CPAT. The aim of the study was to evaluate and compare the utility of distortion product otoacoustic emissions and
cochlear evoked potentials for monitoring cochlear and eighth nerve functions during reversible cochlear ischemia.
Methods: The authors presented data collected in animal experiments in which the cochlear and the eight nerve
function were monitored during inducing cochlear reversible ischemic episodes. In all cases laser-Doppler cochlear blood
flow techniques (LD-CBF), distortion product otoacoustic emissions (DPOAEs), and evoked auditory potentials (AEP) (i.e.,
cochlear microphonics [CM] and compound action potentials [CAP]) were measured using the otic probe placed into the
round window (RW) niche. Hearing organ activity was assessed by stimulating the basis, middle, and apex of the cochlea.
Results: An animal model of prevention of intraoperative hearing damage was developed and, then, referred to clinical
situations occurring during CPAT surgery. Including and excluding criteria for intraoperative monitoring were presented
with some principles of intraoperative monitoring in patients basing on data collected during animal experiments.
Conclusions: Intraoperative monitoring by AEP was found to be more complex and useful to differ cochlear and
retrocochlear damage occurring intraoperatively. DPOAE is a better method in aspect of monitoring in real time. AEP was
found to be more complex response reflecting changes in cochlear and retrocochlear structures as a result of different
manipulation of surgeon but consuming more time needed for averaging procedure.
K e y w o r d s : cochlear blood flow, otoacoustic emissions, evoked auditory potentials
INTRODUCTION
Surgery of the cerebellopontine angle tumor (CPAT) is associated with a high risk of damaging
such important structures as facial nerve, vestibulocochlear nerve, internal auditory artery, anterior
inferior cerebellar artery, and inner ear function, if they escaped earlier damage by the invading
tumor. Although the attempts to monitor intraoperatively function of the above structures has
been still tested, an efficacious monitoring of the inner ear and the eight nerve function remains
to be established (1-7). Distortion product otoacoustic emissions (DPOAEs) or electrophysiological
recordings using either electrocochleography (EcoG) involving compound action potentials of the
VIII nerve (CAP) and cochlear microphonics (CM), or auditory brainstem responses (ABR), as well
as evoked potentials from the cochlear nucleus provide considerable information about the status
of the peripheral parts of the auditory system (8-11). On the basis of the above tests, any surgically
induced trauma whether directly damaging inner ear structures or indirectly harming
neurepithelial or neural parts of the inner ear through the compromise of the blood vessels supplying
the cochlea, can only be detected after some delay. This delay in recognizing a surgically
induced trauma during the course of an operation can lead to the irreversible damage of cochlear
function and permanent deafness for the ear on the operated side. Audiological tests that permits
recording cochlear activity fast and more directly involves DPOAEs and EcoG.
Evoked otoacoustic emissions (OAEs), are measures of acoustic energy recorded from the ear
canal and generated from the cochlea in response to acoustic stimulation (12, 13). It is thought
that OAEs reflect the function of the cochlea that is associated with electromotility of the outer
Address for correspondence:
Krzysztof Morawski, MD, PhD, Department of Otolaryngology, Medical University of Warsaw,
Banacha 1a Street, 02-097 Warsaw, Poland
E-mail: hno@poczta.onet.pl

A C T A M E D I C A M A R T I N I A N A 2 0 0 6 6/2 17
hair cells (OHCs) that are extremely sensitive to such harmful factors as excessive noise, ototoxic
drugs, and hypoxic or anoxic conditions. Such insults can quickly alter OHC function, which
results in either reduced or absent OAEs, depending on the severity of the damage (13-16). In
particular, the evoked emissions that are used most commonly for clinical applications are the
transiently-evoked (TEOAEs) and DPOAE (13).
The aim of the study was to evaluate and compare the utility of DPOAEs and cochlear evoked
potentials for monitoring cochlear and eighth nerve functions during reversible cochlear
ischemia.
METHODS
Fifteen young (2.5-6-mo old) albino rabbits weighing between 2.5 and 4.0 kg were used for
this study. The animals were anesthetized routinely with an intramuscular injection of ketamine
hydrochloride (50mg/kg) mixed with xylazine hydrochloride (10mg/kg). A head stabilization
device was placed according to a standard procedure previously described by Telischi et al. and
Morawski et al. (11, 17, 18). The first surgical step was a post-auricular approach to expose the
cochlea and round window (RW). Using an operating microscope, the middle ear was entered
through the auditory bulla for placement of the laser-Doppler probe to measure cochlear blood
flow (CBF). The cerebellopontine angle was exposed via a sub-occipital posterior craniotomy.
With the use of the operating microscope, the porus of the internal auditory canal (IAC) was distinguished.
Then, CBF probe tip was positioned at RW niche to measure cochlear blood supply.
DPOAEs response functions were obtained for each ear using special probe at 4, 8 and 12 kHz
GMF by measuring the DPOAEs level as a function of the primary tones at 60 dB SPL. Auditory
responses were obtained using tone bursts at 4, 8 and 12 kHz and 70 dB SPL intensity. Needle
electrodes for EcoG recordings were fixed in the neck muscles (reference), in the back muscles
(ground) and as a measuring electrode the otic probe placed into the RW niche was used (10).
The IAA compression inducing cochlear ischemia was maintained for 3-min. DPOAE-CBF data
obtained in the first subgroup of animals and CM/CAP-CBF obtained in the second subgroup
were recorded from the onset of ischemia through 20 min after reperfusion.
The protocol for the care and use of rabbits was approved by the Institutional Animal Care
and Use Committee.
RESULTS
In all ears following internal auditory artery (IAA) compression CBF was reduced to a background
level. The DPOAEs phase increase for all frequencies occurred within a few seconds while
the DPOAEs amplitudes decreased with slightly longer delay. CM/CAP reduction was analogous
to DPOAEs pattern though in all cases 10-15 sec initial enhancement of CAP was recorded. After
reperfusion, in both animal subgroups, DPOAEs and CM recovered in the same way for both
compressions stabilizing near the baseline. CM measured for 3 min compression for all frequencies
was reduced 1-1.5 dB, while DPOAEs were reduced only at 12 GMF kHz by 0.5-1 dB.
Basically, DPOAEs and CM reduction and recovery patterns are very similar while CAP reduction
and recovery patterns for test frequencies are different. CM and DPOAEs begin dropping in
a couple of seconds, and then, during reperfusion begin recovering with relatively short time of
delay ranging from 35-45 seconds at all test frequencies. CAP patterns occurring just after IAA
compression reveal presence of initial elevation lasting 10-15 sec, and then, during next 20-30
seconds CAP disappears. Following IAA release and subsequent cochlear reperfusion CAP begins
returning though differently at all test frequencies. At 4 kHz CAP reaches 50% of its BL value in
34-38 sec and 100% of its BL value in 42-48 sec after IAA release. At 8 kHz 50% and 100% of
its BL value CAP reaches respectively in 49-54 sec and 91-100 sec, while at 12 kHz respectively
in about 114-125 sec and 215-240 sec. Finally, CAP stabilizes above BL for 4 kHz, while at 8
and 12 kHz around BL values. Figure 1 shows an example of DPOAE, CAP and CM changes following
cochlear ischemia and reperfusion recorded at 8 kHz.

18
A C T A M E D I C A M A R T I N I A N A 2 0 0 6 6/2
Fig. 1. Three minute cochlear
ischemia effect on DPOAEs
(black line), CM (lower gray line),
and CAP (upper gray line) and
their recovery patterns observed
following cochlear reperfusion
recorded at 8 kHz. DPOAEs
–Distortion Product Otoacoustic
Emissions; CM – Cochlear
Microphonics; CAP – Compound
Action Potentials
In the second part of the result section mutual relationships of DPOAEs, CM, CAP and CBF
values were analyzed. As presented in table 1, during the first 60 sec of cochlear ischemia all
parameters correlated each other on statistically significant levels (R ranged from +0.90 to +0.99;
p

A C T A M E D I C A M A R T I N I A N A 2 0 0 6 6/2 19
ing both ischemia onset and reperfusion were non-linear revealing slightly different characteristics
than DPOAEs. (10, 11, 17, 19, 20). Thus, due to CAP nonlinearity and its poorer correlation
with CBF, mostly during reperfusion, its utility in term of intraoperative monitoring of cochlear
ischemic processes in real time domain sees less useful than DPOAEs. Considering intraoperative
monitoring of hearing in people the most complex tool seems to be ABR recording since it
reflects the hearing pathway activity including spiral ganglion neurons and the cochlear nerve,
cochlear nuclei and other structures. Theoretically, this technique could provide information
about hearing pathway dysfunction and the anatomic level at which the hearing pathway was
affected. Practically, in the operating room, electrostatic conditions are may not be optimal,
resulting in a number of artifacts and, at times, only ABR wave V is detectable as an intraoperative
monitoring parameter. Additionally, high level click-stimulation of about 70-100 dB nHL
used and the number of averaged samples ranging between 250-1000 significantly limit both
intraoperative monitoring in real time domain and sensitivity of monitoring (3, 21, 22, 23).
DPOAEs effectively mirrored cochlear ischemia confirming earlier data and revealing stronger
susceptibility of the basal part of the cochlea to damaging effect of reversible local ischemia. Different
susceptibility of the apical and basal hair cells may be due to unequal levels of natural
free-radical scavengers in basal and apical parts of the cochlea. The level of natural glutathione
within the OHCs at the basal cochlea was found to be significantly lower than that at the apical
turn, confirming a key role of the glutathione-dependent antioxidant system in protection
against various factors damaging cochlear function (24). Radical scavengers, iron chelators and
nitric oxide synthase inhibitors attenuated the damaging effects of ROS following
ischemia/reperfusion episodes by enhancing efficacy of the antioxidant system within the
cochlea (18, 25).
Concluding, we showed that DPOAEs and CM showed very similar patterns of reduction and
recovering during ischemia/reperfusion episode confirming its great usefulness to intraoperative
monitoring of the cochlear function. CAP reduction and recovering during ischemia/reperfusion
episode revealed slightly different characteristics than CM or DPOAEs. Neural function changes
observed during both ischemia onset and reperfusion were non-linear. Due to this CAP nonlinearity,
mostly during reperfusion, its utility for monitoring local ischemic processes is poorer
than CM and DPOAEs, though CAP provides better information about the most peripheral neural
auditory function.
REFERENCES
1. Kwartler JA, Luxford WM, Atknins JA, Shelton C. Facial nerve monitoring in acoustic tumor surgery. Otolaryngol Head
Neck Surg 1991; 104: 814-817.
2. Moller AR. Monitoring auditory function during operations to remove acoustic tumors. Am J Otol 1996; 17: 452-460.
3. Colletti V, Fiorino FG. Advances in monitoring of seventh and eighth cranial nerve function during posterior fossa surgery.
Am J Otol 1998; 19: 503-512.
4. Telischi FF, Stagner BB, Widick MP, Balkany TJ, Lonsbury-Martin BL. Distortion-product otoacoustic emission monitoring
of cochlear blood flow. Laryngoscope 1998; 108: 837-842.
5. Battista RA, Wiet RJ, Paauwe L. Evaluation of three intraoperative auditory monitoring techniques in acoustic neuroma
surgery. Am J Otol 2000; 21: 244-248.
6. Kwiek SJ, Bazowski P, Luszawski J, Namyslowski G, Morawski K, Lisowska G, Wolwender A. Monitoring of neurophysiological
modalities during surgery for cerebellopontine angle tumors. Personal experiences. Otolaryngol Pol
2001; 55: 85-90.
7. Morawski K, Telischi FF, Niemczyk K. A Model of Real Time Monitoring of the Cochlear Function During an Induced
Local Ischemia. Hear Res 2006 – in press
8. Morawski K, Namyslowski G, Lisowska G, Bazowski P, Kwiek S, Telischi FF. Intraoperative monitoring of the cochlear
function using distortion product otoacoustic emissions (DPOAEs) in patients with cerebello-pontine angle tumors.
Otol Neurotol 2004; 25: 818-825.
9. Bohórquez J, Ozdamar O, Morawski K, Telischi FF, Delgado R, Yavuz E. Neuromonitoring of Cochlea and Auditory
Nerve with Multiple Extracted Parameters during Induced Hypoxia and Nerve Manipulation. Journal of Neural Engineering
2005; 2(2): 1-10.
10. Yavuz E, Morawski K, Telischi FF, Ozdamar O, Delagado RE, Manns F, Parel JM. Simultaneous measurement of electrocochleography
and cochlear blood flow during cochlear hypoxia in rabbits. Journal of Neuroscience Methods
2005; 147:55-64.

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A C T A M E D I C A M A R T I N I A N A 2 0 0 6 6/2
11. Telischi FF, Mom T, Agrama M, Stagner BB, Ozdamar O, Bustillo A, Martin GK. Comparison of the auditory-evoked
brainstem response wave I to distortion-product otoacoustic emissions resulting from changes to inner ear blood
flow. Laryngoscope 1999; 109: 186-191.
12. Kemp DT. Stimulated acoustic emissions from within the human auditory system. J Acoust Soc Am 1978; 64: 1386-
1391.
13. Probst R, Lonsbury-Martin BL, Martin GK. A review of otoacoustic emissions. J Acoust Soc Am 1991; 89: 2027-2067.
14. Lonsbury-Martin BL, Probst R, Coats AC, Martin GK. Acoustic distortion products in rabbits. I. otoacoustic emissions
by interference tones above f2. I. Basic features and physiological vulnerability. Hear Res 1987; 28: 173-189.
15. Brownell WE. Outer hair cell electromotility and otoacoustic emissions. Ear Hear 1990; 11: 82-92.
16. Whitehead ML, Lonsbury-Martin BL, Martin GK. Evidence for two discrete sources of 2f1-f2 distortion product otoacoustic
emission in rabbits. II. Differential physiological vulnerability. J Acoust Soc Am 1992; 92: 2662-2682.
17. Morawski K, Telischi FF, Merchant F, Namyslowski G, Lisowska G, Lonsbury-Martin BL. Preventing internal auditory
canal vasospasm using topical papaverine: an animal study. Otol Neurotol 2003; 24: 918-926.
18. Morawski K, Telischi FF, Merchant F, Abiy LW, Lisowska G, Namyslowski G. Role of mannitol in reducing postischemic
changes in distortion-product otoacoustic emissions (DPOAEs): a rabbit model. Laryngoscope 2003; 113:
1615-1622.
19. Mom T, Avan P, Romand R, Gilain L. Monitoring of functional changes after transient ischemia in gerbil cochlea.
Brain Res 1997; 751: 20-30.
20. Mom T, Avan P, Bonfils P, Gilain L. A model of cochlear function assessment during reversible ischemia in the Mongolian
gerbil. Brain Res 1999; 4: 249-257.
21. Nadol JB, Chiong CM, Ojemann RG, McKenna MJ, Martuza RL, Montgomery WW, Levine RA, Ronner SF, Glynn RJ.
Preservation of hearing function in resection of acoustic neuroma. Laryngoscope 1992; 102: 1153-1158.
22. Wazen JJ. Intraoperative monitoring of auditory function: experimental observations and new applications. Laryngoscope
1994; 104: 446-455.
23. Witzmann A, Reisecker F. Somatosensory and auditory evoked potentials monitoring in tumor removal and brainstem
surgery. In: Desmedt JE (Ed) Neuromonitoring in Surgery. Elsevier Science Publishers B.V. (Biomedical Division)
1989; pp: 219-241.
24. Sha SH, Taylor R, Forge A, Schacht J. Differential vulnerability of basal and apical hair cells is based on intrinsic
susceptibility to free radicals. Hear Res 2001; 155: 1-8.
25. Tabuchi K, Tsuji S, Asaka Y, Hara A, Kusakari J. Ischemia-reperfusion injury of the cochlea: effects of an iron chelator
and nitric oxide synthase inhibitors. Hear Res 2001; 160: 31-36.

A C T A M E D I C A M A R T I N I A N A 2 0 0 6 6/2 21
EXPERIMENTAL MECONIUM ASPIRATION: EFFECT OF DEXAMETHASONE
TREATMENT ON THE LUNG FUNCTIONS – A PILOT STUDY
DANIELA MOKRA, ANDREA CALKOVSKA, JANKA BULIKOVA,
MARIA PETRASKOVA, KAMIL JAVORKA
Department of Physiology, Jessenius Faculty of Medicine, Comenius University, Martin, Slovak Republic
A b s t r a c t
Since corticosteroids reduce lung edema formation, inflammation, and vasoconstriction, effects of single-dose intravenous
dexamethasone on the lung functions were studied in an animal model of MAS.
Adult rabbits were ventilated with 100% oxygen. Three animals were sacrificed and used as controls. Other animals
were administered 4 ml/kg of saline (n=4) or meconium suspension. When the respiratory failure developed, meconiuminstilled
animals received 0.5 mg/kg of dexamethasone i.v. (n=6) or were left without treatment (n=5), and were ventilated
for additional 5 hours. White blood cell (WBC) count was estimated and lung function parameters were measured.
Then, animals were sacrificed and lungs were excised. Left lungs were lavaged to estimate WBC in the lavage fluid. Right
lungs were dried to determine the wet/dry weight ratio.
Meconium instillation decreased the lung compliance and gas exchange and increased right-to-left shunts, edema
formation and WBC count in the lungs (all p

22
A C T A M E D I C A M A R T I N I A N A 2 0 0 6 6/2
METHODS
Design of experiments was approved by Local Ethics Committee of Jessenius Faculty of Medicine.
Adult rabbits (chinchilla) of the mean body weight (b.w.) of 2.0±0.5 kg were anesthetized with intramuscular
ketamine (20 mg/kg b.w.; Narkamon, Spofa, Czech Republic) and xylazine (5 mg/kg b.w.;
Rometar, Spofa, Czech Republic) followed by continuous infusion of ketamine (20 mg/kg b.w./hour).
Tracheotomy was performed and catheters were inserted into the femoral artery and right atrium for
sampling the blood, and into the femoral vein to administer anesthetics. Animals were then paralyzed
by pipecuronium bromide (0.3 mg/kg b.w./30 min; Arduan, Gedeon Richter, Hungary) and
subjected to the pressure-controlled ventilator Beat-2 (Chirana, Slovakia). All animals were ventilated
with a frequency of 30/min, fraction of inspired oxygen (FiO 2
) of 0.21, peak inspiratory pressure
(PIP) to keep a tidal volume (V T
) between 7-9 ml/kg b.w. and no positive end-expiratory pressure
(PEEP). After the stabilization, ventilatory parameters were recorded and samples of arterial and
mixed venous blood were taken for blood gas analysis and estimation of hemoglobin and white blood
cell (WBC) count. Then, three animals were killed by an overdose of anesthetics and were used as
controls (Contr group, n=3). Other animals were instilled saline (Sal group, n=4) or suspension of
human meconium (25 mg/ml), both at a dose of 4 ml/kg b.w., and from this moment were ventilated
with 100 % oxygen. Then, animals received 5 ml of 4.2 % sodium bicarbonate to keep the blood
pH in the normal range. Within 30 minutes after the meconium instillation respiratory failure developed,
defined as >30% decrease in dynamic lung-thorax compliance (C dyn
) and PaO 2

A C T A M E D I C A M A R T I N I A N A 2 0 0 6 6/2 23
Table. 1. Lung function parameters before and after meconium (M) instillation and 30 minutes, 1, 2, 3, 4, and 5 hours of the treatment in saline-(Sal), meconium-
(Meco) and meconium+dexamethasone-instilled (Meco+Dexa) groups. Data are expressed as means±SEM. Significant between-group differences: a Meco+Dexa vs. Sal
(p

24
A C T A M E D I C A M A R T I N I A N A 2 0 0 6 6/2
Fig. 1. Mean airway pressure (MAP)
before and after meconium (M) instillation
and after the treatment in saline-
(Sal), meconium- (Meco), and meconium+dexamethasone-
(Meco+Dexa)
groups. Significant between-group differences:
Meco vs. Sal since 30 min of
the treatment; Meco+Dexa vs. Sal at 3,
4, and 5 hours of the treatment;
Meco+Dexa vs. Meco at 30 min of the
treatment (all p

A C T A M E D I C A M A R T I N I A N A 2 0 0 6 6/2 25
Lung edema (lung wet/dry weight ratio)
Meconium instillation increased fluid acummulation in the lungs compared to Sal group
(p0.05). Number of blood neutrophils was lower in all Sal, Meco, and Meco+Dexa groups compared
to controls (p

26
A C T A M E D I C A M A R T I N I A N A 2 0 0 6 6/2
ethical problems, neonatal animals are rarely used as models of MAS. Nevertheless, with respect
to the changes observed after meconium aspiration several-week-old rabbits and piglets were
proved to be suitable animal models of MAS.
Finally, we conclude that the single-dose intravenous administration of dexamethasone in
rabbits with meconium aspiration diminished number of neutrophils in the lungs and ventilatory
pressures and slightly reduced lung edema formation and OI. However, further testing of the
corticosteroid use regarding the dosage and possible adverse effects, as well as the testing of
other anti-inflammatory drugs in the management of MAS is warranted.
REFERENCES
1. Cleary GM, Wiswell TE. Meconium-stained amniotic fluid and meconium aspiration syndrome: an update. Pediatr
Clin North Am 1998; 45: 955-81.
2. Fernandes ABS, Zin WA, Rocco PRM. Corticosteroids in acute respiratory distress syndrome. Braz J Med Biol Res
2005; 38 (2): 147-59.
3. Jantz MA, Sahn SA. Corticosteroids in acute respiratory failure. Am J Respir Crit Care Med 1999; 160: 1079-100.
4. Frantz ID, Wang NS, Thach BT. Experimental meconium aspiration: Effects of glucocorticoid treatment. J Pediatr
1975; 86: 438-41.
5. Yeh TF, Srinivasan G, Harris V, Pildes RS. Hydrocortisone therapy in meconium aspiration syndrome: a controlled
study. J Pediatr 1977; 90: 140-3.
6. Soukka H, Halkola L, Aho H, Rautanen M, Kero P, Kääpä P. Methylprednisolone attenuates the pulmonary hypertensive
response in porcine meconium aspiration. Pediatr Res 1997; 42: 145-50.
7. Holopainen R, Laine J, Halkola L, Aho H, Kääpä P. Dexamethasone treatment attenuates pulmonary injury in piglet
meconium aspiration. Pediatr Res 2001; 49:162-8.
8. Khan AM, Shabarek FM, Kutchback JW, Lally KP. Effects of dexamethasone on meconium aspiration syndrome in
newborn piglets. Pediatr Res 1999; 46: 179-83.
9. Wu JM, Yeh TF, Wang JY, Wang JN, Lin YJ, Hsieh WS, Lin CH. The role of inflammation in the development of pulmonary
hypertension in newborn with meconium aspiration syndrome (MAS). Pediatr Pulmonol 1999; S18: 205-8.
10. da Costa DE, Nair AK, Pai MG, Al Khusaiby SM. Steroids in full term infants with respiratory failure and pulmonary
hypertension due to meconium aspiration syndrome. Eur J Pediatr 2001; 160: 150-3.
11. Sevecova-Mokra D, Calkovska A, Drgova A, Javorka M, Javorka K. Treatment of experimental meconium aspiration
syndrome with surfactant lung lavage and conventional vs. asymmetric high-frequency jet ventilation. Pediatr Pulmonol
2004; 38: 285-91.
12. Davey A, Kueser T, Turner H. Randomised controlled trial of early dexamethasone therapy in meconium aspiration
syndrome. Pediatr Res 1995; 37: 329A.
Acknowledgements
The study was supported by Grant VEGA No. 1/2306/05 and Grant of Comenius University No. 43/2004. Authors thank
S. Svorkova, D. Kuliskova, and I. Stritz for technical assistance.

A C T A M E D I C A M A R T I N I A N A 2 0 0 6 6/2 27
FORMULATION AND IMPLEMENTATION OF THE NATIONAL
IMMUNIZATION PROGRAMME IN SLOVAK REPUBLIC
HENRIETA HUDEČKOVÁ 1 , MÁRIA SZILÁGYIOVÁ 2 , VLADIMÍR OLEÁR 3 , TIBOR BAŠKA 1 ,
ŠTEFAN STRAKA 1
1
Department of Hygiene, Institute of Public Health, Jessenius Faculty of Medicine, Comenius University, Martin,
2
Clinic of Infectology, Jessenius Faculty of Medicine, Comenius University, Martin Faculty Hospital, Martin,
3
Aventis Pasteur, Žilina, Slovak Republic
A b s t r a c t
Active immunization of the population against communicable diseases is the most successful and cost-effective preventive
measure of modern medicine. Containment of the last outbreaks of smallpox encircling the detected sources of
infection by immune barriers using centrifugal vaccination was the key to substantial reduce the global incidence of polio
and other infectious diseases and thus to reduce the consequent disability and death. In 2005, the old centralized system
of organization of preventive vaccination has been replaced by a decentralized one which necessitated its thorough
formulation and new strategy of its implementation. The outcome of the work in this field has been the formulation of
the National Immunization Programme of the Slovak Republic (NIP) for the coming years. The current system of preventive
vaccination (NIP) is rational and scientifically based. Its implementation necessitates an active approach of all who
participate in it: comprehensive surveillance, monitoring of epidemiological and economic situation and organization of
vaccination. The indispensable requirement here is maintaining of the highest possible vaccination coverage of the particular
sections of population.
K e y w o r d s : immunization, organization of immunization system, national immunization programme
INTRODUCTION
Active immunization of the population against communicable diseases belongs to the most
effective preventive measures. Its formulation and implementation deserves therefore the utmost
attention and proficiency. Until the time the final document of national immunization could be
issued, it usually would need the work of a well-coordinated team of experts in several scientific
branches: vaccine-producers, paediatricians, infectologists, immunologists, microbiologists,
toxicologists, biochemists, geneticists, economists, public health workers, and primarily epidemiologists.
The team is usually coordinated and led by the Chief Epidemiologist of the respective
country (1).
The main objectives of our contribution are to sum up the links of the final chain of the
National Immunization Programme in Slovakia, to bring up a brief review of the history of its
development, and to define the main issues of the organization of immunization in Slovakia.
HISTORY
Before entering the recent history of immunization let us briefly review its “prehistory”. It
began in ancient China with the first steps of prevention against smallpox which was in that time
the scourge of mankind taking high toll of lives. The method was based on the knowledge of post
infection immunity. The ancient Chinese used several ways how to introduce an artificial infection
with the aim to build up the postinfection immunity: scarification of material taken from
smallpox pustules to the skin, insufflation of the powder made of the smallpox crusts to nostrils,
Address for correspondence:
Henrieta Hudečková, MD, PhD, MPH, Assoc. Prof., Institute of Public Health,
Comenius University in Bratislava,
Jessenius Faculty of Medicine, Martin, Sklabinská 26, 037 53 Martin, Slovak Republic
Phone: ++421 43 4132507, e-mail: hudeckova@jfmed.uniba.sk

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A C T A M E D I C A M A R T I N I A N A 2 0 0 6 6/2
etc. The consequent clinically mitigated disease made the person immune against natural infection,
however it was not without risk. A small proportion of such immunized persons could develop
the clinically severe disease and even die. Another disadvantage of “variolation” was the
spread of infection within the community. Variolation in Slovakia was first used by Jan Adam
Reiman, the Chief Physician of the town of Prešov (1721). Some decades later, Edward Jenner,
an English physician, motivated by the long-years’ experience of milkwomen, scarified material
from vaccinia pustules (a harmless for man zoonosis) of a milkwoman infected from cow to a boy
(1796). After curing from local reaction and general symptoms (fever, malaise), the boy, when
exposed to natural infection with smallpox, proved immune. Thus the era of “vaccination” started
long before man discovered the infectious agents of communicable diseases. Then the way to
scientific immunization had been shown by Pasteur, Koch and others, and in the last century,
vaccination received its steady place as a leading preventive measure in control of communicable
diseases. From that time the scope of preventive vaccines has extended tremendously, tri-,
tetra- and penta-vaccines have been developed, as well as “split” and “subunit” influenza vaccines
that can be used also to pregnant women and people weakened by chronic diseases. All
these achievements can be ascribed to the advances of biotechnology and genetic engineering
(2,3,4).
RECENT ACTIVITIES OF THE GLOBAL MANAGEMENT OF IMMUNIZATION
In 1974, WHO introduced the Expanded Programme on Immunization (EPI) which, along with
the Smallpox Eradication Programme, proved to be the greatest health protecting achievements
of the 20 th century. However, the experiences have shown that the original expectations of EPI
were not met, and, in the early 1990s, the Programme had to be extended by further diseases,
new candidates for elimination and new operational objectives for immunization and surveillance
of communicable diseases and expanded EPI – the EPI Plus. The new immunization visions and
strategies for 2006-2015 have been outlined by WHO/UNICEF with the goals: extended vaccination,
introduction of new vaccines and technologies, integration of immunization and surveillance
of communicable diseases into health care system, and promotion of EPI to the context of
mutual global relations. Highest attention is focused on the support and safety of vaccination,
introduction of new antigens to practical use, elimination of measles and maintaining the poliofree
status in European Region (4,5,6,7,8).
ORGANIZATION OF IMMUNIZATION SYSTEM IN SLOVAKIA
The outcome of the work of our team was the formulation of the National Immunization
Programme of the Slovak Republic (NIP SR), a comprehensive preventive programme focused
on prevention of infectious diseases preventable by vaccination (Fig.1). NIP in Slovakia is legislatively
based on the acts issued in 1994 (NR SR No. 272/1994) and in 1997 (MZ SR No.
79/1997).
The centralized system of distribution of vaccines in Slovakia funded from state budget, has
been changed from January 2005 to a decentralized system. Vaccines in decentralized system
are financed by the health insurance companies and their distribution is maintained by the
Guidelines of the Ministry of Health of the Slovak Republic issued in 2005. Vaccines used in NIP
SR are categorized, and the preventive vaccination of children (category “V”) is completely free of
charge, paid by health insurance. If parents for their children wish to use vaccines beyond the
category “V”, they can be provided by vaccines of the category “S”, and the difference of price
then should be paid from their personal budget.
Regular compulsory vaccination of children should follow the terms and doses determined
by the Vaccination Calendar (Fig. 2). New vaccine and vaccination should be considered to be
integrated into NIP SR, and the Vaccination Calendar should then be adequately supplemented.

A C T A M E D I C A M A R T I N I A N A 2 0 0 6 6/2 29
Fig. 1 National Immunization Programme of Slovak Republic, 2005 (NIP); * Ministry of Health of the Slovak Republic; **
Public Health Authorities of the Slovak Republic; *** Regional Public Health Authorities
Fig. 2 Vaccination Calendar, Slovak Republic, 2005; * The table does not involve categorisation of vaccines

30
A C T A M E D I C A M A R T I N I A N A 2 0 0 6 6/2
DISCUSSION
The current system of preventive vaccination – NIP SR – is rational, scientifically based and
economic, however, its implementation necessitates an active approach of all who participate
in it: comprehensive surveillance, monitoring of epidemiological and economic situation and
organization of vaccination (9,10).
Favourable epidemiological situation in vaccination-preventable infectious diseases that we
currently enjoy in Slovakia, is an important achievement first of all of epidemiologists and paediatricians,
and maximum attention should be paid to maintain the highest vaccination coverage
also in the future. The indispensable requirement here is strict sticking to vaccination programmes
and maintaining the highest possible vaccination coverage of the respective sections of
population.
NIP SR follows adequately the recommendations of WHO, and the application of particular
vaccination doses is in full consonance with the legal regulations (NR SR No. 577/2004).
CONCLUSIONS
In recent time we can witnessed the spread of doubts and misinformation about the efficacy
of vaccination, emphasizing the blown-up reports on its adverse effects and complications. These
confusing pieces of information, lacking scientific arguments, may negatively influence the compliance
of the public with NIP SR. All health workers and a reasonable majority of lay public
should strongly reject such tendencies and support the NIP SR to maintain the favourable epidemiological
situation in Slovakia.
REFERENCES
1. Ajjan N: Vaccination. Pasteur Mérieux Sérums et vaccins, Lyon, 1991, 188 pp. 3
2. Atkinson W, Humiston S, Wolfe CH, Nelson R: Epidemiology and Prevention of Vaccine-Preventable Diseases. 5-th
Edition, Department of Health & Human Services. Public Health Service, CDC, 1999, 289 pp.6
3. Bagar B: 200 years from first vaccination against smallpox. Med. Monit. 2, 1996, s.18-20.
4. Public health surveillance. WHO, www.who.int/immunization_monitoring/burden/routine_surveillance
5. Global Immunization Vision and Strategy 2006 – 2015. WHO/IVB/05.05, October 2005, 80 pp.
6. Immunization against diseases of public health importance. WHO, Fact sheet N.288, Marcch 2005.
7. Salisbury DM, Olivé JM: Immunization in Europe. In:Plotkin SA, Orenstein WA, editors: Vaccines. 4-th ed. Philadelphia:
Saunders, 2004, p.1387-1406.
8. Vaccine-preventable Diseases and Immunization programme. Programme report and future initiatives 2001-2005.
EUR/05/505418, WHO, 2005. 25 pp.
9. Making surveillance work. Modul 1: Rapid assessment of surveillance for vaccine-preventable diseases. WHO,
Department of Vaccines and Biologicals, Geneva, 2001,24 pp.
10. Making surveillance work. Modul 3: Logistic managemnet. WHO, Department of Vaccines and Biologicals, Geneva,
2001,24 pp.
Acknowledgement:
This work is a part of VEGA No.1/2307/05 “Cost - effectiveness, benefit and safety of individual vaccination strategies of
selected vaccination - preventable infectious diseases.”

A C T A M E D I C A M A R T I N I A N A 2 0 0 6 6/2 31
SCREENING OF DIABETIC FOOT IN NURSING PRACTICE
JANA NEMCOVÁ 1 , TIBOR BAŠKA 2 , MILAN OCHODNICKÝ 3 , DUŠAN MIŠTUNA 4
1
Department of Nursing, Jessenius Faculty of Medicine, Comenius University, Martin, 2 Institute of Public Health,
Department of Epidemiology, Jessenius Faculty of Medicine, Comenius University, Martin, 3 Internal Clinic I, Jessenius
Faculty of Medicine, Comenius University, Martin Faculty Hospital 4 Clinic of Surgery I, Jessenius Faculty of Medicine,
Comenius University,Martin Faculty Hospital, Martin, Slovak Republic
A b s t r a c t
Introduction. According to the recommendations of the International Consensus on the Syndrome of Diabetic Foot,
most attention should be paid to its early detection. This can be considerably contributed also by screening assessment
of the feet of diabetics accomplished by the nurse in diabetologic outpatient department. As a tool for this practice we
recommend the nursing standard and the corresponding nursing protocol.
Methods. We carried out screening of 100 diabetic patients with diabetes mellitus of the 2nd type(DM-II) in the Diabetologic
Outpatient Department in Martin Faculty Hospital, Slovak Republic. By means of a screening examination of
neuropathy using the basic equipment – a monofilament 10-g (5.07) and a tuning fork 128Hz, we tried to identify the
risk of diabetic foot. As a reference method served the diagnosed neuropathy established by a neurologist.
Results. We have found 84.8% sensitivity and 79.4% specificity of our screening method. Analysing risk factors by
gender we found statistically significantly higher occurrence in females: halluces, bone prominences, pains of feet. In the
rest of risk factors there were no significant differences between genders.
Discussion. This simple, inexpensive and timesaving method that can be accomplished also by nurses in primary
care could bring, beside its contribution in preventive field, also economic effect. Even if this test cannot detect all patients
in danger of diabetic foot, it could contribute to its earlier diagnosis in wider extent already on the level of outpatient
diabetologic departments.
K e y w o r d s : nursing standards, protocol, screening
INTRODUCTION
To the late complications of diabetes belongs also the syndrome of diabetic foot, affecting 15-
25% of diabetics. The feet of diabetic patient are endangered by the disturbed integrity of the tissues.
The most serious complications here are ulcerations and gangrenes, which can result in
amputation of the affected part of the foot (in 0.5-1.0% of diabetic patients) (4). Considering the
total number of diabetics it is an alarming number. In 2002 in Slovakia 3623 amputations were
performed in diabetics (11).
The current trend in professional training of nurses is that they should take over not only the
responsibility when following the physician’s orders, but also contribute actively to improve the
quality of health care provided to their patients.
One of the possible ways is also using of standards in the field of assessment the risk of diabetic
foot in their patients.
The main objective of our work is to introduce the ways in which nurses can contribute to the
detection of the risk of the development of diabetic foot. Our recommendation here is the screening
evaluation of the feet of diabetics by a nurse.
For the screening evaluation of diabetic feet we recommended a specific nursing standard
and nursing protocol. The screened patients found in higher risk will then be referred to
a neurologist for final diagnosis (reference method). Our objective was also to test the validity
of our screening and nursing protocol worked out for this specific purpose. In prevalence
of risk factors found in our screening we also tried to identify the differences by genders. As
a main marker for a risk we selected positive examination by monofilament and tuning fork
Address for correspondence:
Nemcová Jana, Department of Nursing, Comenius University.
Jessenius Faculty of Medicine, Malá Hora 5, 036 01 Martin, Slovak Republic
Phone: ++421 43 4133 326, e-mail: nemcova@jfmed.uniba.sk

32
A C T A M E D I C A M A R T I N I A N A 2 0 0 6 6/2
according to guidelines of screening examinations of diabetic feet based on the respective
international consensus (1). We also assume that entirely ischaemic form of diabetic foot represents
only 7-13% of all forms.
In our proposed nursing protocol for the diabetic foot screening also other risk factors are
examined such as duration of the diabetic disease, compensation of the diabetes, body mass
index (BMI), dryness of the skin, thylomas, mycoses, excoriations, small injuries, appropriateness
of shoes, previous education of the patient regarding foot care.
METHODS
The main method was screening evaluation of the feet of diabetics carried out according to
the recommendations of International Consensus for the Syndrome of Diabetic Foot (1) in Diabetological
Outpatient Department of the Martin Faculty Hospital. The screening was carried out
with patients with DM-II who came to the department for regular medical check-up from October
2002 to May 2003.
The screening provided information based on subjective data of the patient, from inspection
of the foot and examination of the neuropathy using simple tools – monofilament 10-g (5.07) and
a tuning fork 128Hz (6,8,9).
When the deficiency of the pressure and/or vibration sensitivity were detected, the existing
risk was recorded in the protocol for the risk for diabetic foot.
The screening examination was performed according to the International Consensus for the
Syndrome of Diabetic Foot (1). Table 1 shows the risk of development of diabetic foot found by
the screening examination in our study. Table 2 informs about neurologically based diagnosis of
polyneuropathy among patients of the study.
The protocol recorded also further risk factors: HbA 1C
, body mass index, dryness of skin, thylomas,
infection, inflammation, mycoses, small excoriations, ulcerations, amputations, halluces,
prominences, pain, shoes, instructions to the patient.
In statistical testing of the results the methods of descriptive statistics were used, and data
were analysed by Student’s t-test and Χ 2 -test.
For evaluation of the validity of screening examination we calculated its sensitivity and specificity
(2), where the reference method was the medical diagnosis of polyneuropathy.
Table 1. Patients with DM-2 (n=100) at risk of the development of diabetic foot according to the screening examination
Result of the
females
males
total
screening
positive
negative
total
33
23
56
30
14
44
63
37
100
Table 2. Patients with DM-2 (n=100) with diagnosed polyneuropathy
Polyneuropathy
diagnosed
not diagnosed
total
females
32
24
56
males
34
10
44
total
66
34
100

A C T A M E D I C A M A R T I N I A N A 2 0 0 6 6/2 33
RESULTS
In our series of 100 patients with DM-II were 56 females and 44 males of average age of
66.2±8.9 years, with the average to duration of the disease of DM-II 11.9±7.7 years.
Statistically confirmed was the fact that the patients with the diagnosed polyneuropathy had
in average longer duration of diabetes (p=0.012).
From the comparison of the diagnosed polyneuropathy from the patients’ records and the
examination of tactile and vibration sensitivity we have calculated 84.8% sensitivity and 79.4%
specificity of the used nursing protocol (Table 3.).
In analysis of the occurrence of risk factors between genders we have found statistically significant
difference where females prevailed: halluces (37.5% females and 13.6% males,
p=0.0076), bone prominences (25.0% females and 6.8% males, p=0.0163), pain of feet (10.7%
females and 0.0% males, p=0,0251). In the rest of risk factors there were no significant differences
found between genders.
Table 3. Comparison of the results of screening and diagnosis of polyneuropathy in patients with DM-II (n=100)
risk diagnosed
risk not diagnosed
by the screening
56
by the screening
10
polyneuropathy
diagnosed
polyneuropathy not
diagnosed
sensitivity
84.8%
specificity
79.4%
7
27
DISCUSSION
In practice we often meet the situation when patients have their feet examined for the first time
when already serious problems exist evidencing for the advanced syndrome of diabetic foot. The late
diagnosis of diabetic foot was also proved by the study of 690 patients hospitalised for diabetic foot at
the Surgical Clinic of the Martin Faculty Hospital over the period of 20 years. Important is also time
data evidencing for the fact that the patients experienced their first complains well before admission
to the Surgical Clinic, in average 28.0 months, and they sought for the first medical check-up in average
21 month before. This delay from the first symptoms to consequent surgical treatment resulted
often to the development of extensive inflammatory-necrotic changes of the feet. Gangrenous changes
on foot were present in 50.9% of males and 69.5% of females, while this group had not started specific
treatment of the diabetic neuropathy and in their medical records there was no entry on subjective
and objective changes evidencing for neuropathy despite their obvious presence (7).
The purpose of the screening examination is to detect the symptoms and signs of the risk of
the further development of the diabetic foot in its earliest stage.
The validity of the screening examination recommended by our group and involved in the
nursing protocol has proved to be comparable with the literary data.
In a prospective study of Rith Najarjane the patients were examined for the presence of vibration
sensitivity (biothesiometer, tuning fork) and tactile sensitivity (monofilament 5.07), and the
tests provided sensitivity of 90% and specificity of 86% for the prediction of the development of
the ulcer or amputation. The patients were followed-up for 32 months from the development of
first ulcer or amputation. The patients in whom sensoric sensitivity was disturbed had 5 times
more frequent occurrence of ulcer or amputation than those in which no disturbance of the sensitivity
was found (5).

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A C T A M E D I C A M A R T I N I A N A 2 0 0 6 6/2
The criterion for evaluation of the used tests, which are equal to ours, is in that study the
objective findings of ulcers or amputations. In our study it is the comparison of our testing of
sensitivity with the diagnosed polyneuropathy by a neurologist.
Current studies, e.g. Krahulec (3), recommend to carry out first the screening examination
and not to refer patients straight to neurological examination, which is more expensive. In case
of the suspect neuropathy diagnosed by a diabetologist or in patients screened as positive by
a nurse, the reference neurological examination is indicated.
The recommended nursing protocol could be involved among the documentation of diabetic
patients as a regular component already in diabetological outpatient department.
This simple, cheap and timesaving method (performance of our screening examination lasts
only about 15 minutes), which can be accomplished also by nurses of primary care, could bring
also economic effect.
Though our test is not able to detect all the cases, considering the delayed diagnosis of the
diabetic foot as described in extensive study by Mištuna (7), it could be of assistance in earlier
diagnosis already in patients referred to diabetological outpatient departments.
REFERENCES
1. Apelqvist J., Larson, J. What is the most effective way to reduce incidence of amputation in the diabetic foot? Diabetes
Metab Res Rev. 2000, no 16, (Suppl 1):S75- S83.
2. Fletcher R.H., Fletcher S.W., WAGNER E.H.: Clinical Epidemiology. The Essentials. 3rd Edition, Baltimore, Philadelphia,
London, Williams and Wilkins, 1996, 276 pp.
3. Krahulec B. et al. Diabetic neuropathy. Current diagnostic and therapeutic possibilities. Bratislava: Lufema, 1999.
119 s.
4. Martinka E., Kurča E., Bencúr O. A complex view on the problem of diabetic foot. Lekárske listy, Odborná príloha
Zdravotníckych novín, 2003, č. 14, s. 30-37.
5. Mason J. et al. A systematic review of foot ulcer in patients with Type 2 diabetes mellitus I: prevention. Diabetic Med,
1999, vol 16, pp. 801-812.
6. Meier J.W.G. et al. Clinical diagnosis of diabetic polyneuropathy with the diabetic neuropathy symptom and diabetic
neuropathy examination scores. Diabetes Care, 2003, vol 26, no 3.
7. Mištuna D. Diabetic foot. Martin: Jesseniova lekárska fakulta Univerzity Komenského, 2001. Habilitačná práca. 62
s.
8. Perkins B.A. et al. Simple screening Tests for peripheral neuropathy in the diabetes clinic. Diabetes Care, 2001, 24,
pp 250-256.
9. Vozár J., Kreze A., Klimeš I. Diabetes mellitus. Bratislava: Slovac Academic Press, 1992. 286 s.
10. Zachary S., Feldman E.L. Update on diabetic neuropathy. Cur Opin Neurol, 2002, 15, pp 595-603.
11. http://www.uzis.sk

A C T A M E D I C A M A R T I N I A N A 2 0 0 6 6/2 35
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interest. The structure of the manuscript depends on the authors however, the manuscript must
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One complete original manuscript with one set of high-quality prints of the figures and two
complete copies, each containing tables and copies of the figures, must be submitted to the
address of the Editorial Board Office.
All manuscripts will be peer-reviewed anonymously by external experts pursuant to the standard
evaluation criteria. Based on the review opinions, the Editorial Board will decide, whether
the paper is to be included in the journal.
After a manuscript is accepted for publication, one hardcopy of the final revised, accepted version
of the paper must be submitted along with the same version on a 3.5-in. diskette. Text files
should be saved as word processing document using Microsoft Word. The manuscipt has to
include an attachment as follows: The work is an original, which has not been published in its full
extent yet and will not be submitted elsewhere before a decision has been taken as to its acceptability
by Acta Medica Martiniana. In consideration of the acceptance of the above work for publication,
I do hereby assign and transfer to the publisher the copyright including display of the article
in electronic form on web (open access).
Publication of articles is free of charge excepting the color illustrations.
AMM EDITORIAL BOARD
Dept. of Physiology Jessenius Medical Faculty
Comenius University
Mala Hora Str. N. 4
037 54 MARTIN
SLOVAKIA