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Kuna A, Olszański R, Wroczyńska A, Biernat B, Sikorska K. Beach volleyball and Cutaneous Larva Migrans. J Travel Med 2024; 31:taad087. [PMID: 37369007 PMCID: PMC10823481 DOI: 10.1093/jtm/taad087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 06/20/2023] [Accepted: 06/21/2023] [Indexed: 06/29/2023]
Abstract
Cutaneous larva migrans can affect even athletes who travelled to play beach volleyball in Zanzibar. We describe a cluster of CLM infections in travellers who contracted the disease during their trip to Africa, rather than bringing a volleyball trophy. Despite presenting typical changes, all of them were misdiagnosed.
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Affiliation(s)
- Anna Kuna
- Department of Tropical and Parasitic Diseases, Institute of Maritime and Tropical Medicine, Faculty of Health Sciences, Medical University of Gdansk, Poland
| | | | | | - Beata Biernat
- Department of Tropical Parasitology, Institute of Maritime and Tropical Medicine, Faculty of Health Sciences, Medical University of Gdansk
| | - Katarzyna Sikorska
- Division of Tropical Medicine and Epidemiology, Institute of Maritime and Tropical Medicine, Faculty of Health Sciences, Medical University of Gdansk, Poland
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2
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Dinulos JE, Dinulos JG. Present and future: infectious tropical travel rashes and the impact of climate change. Ann Allergy Asthma Immunol 2022; 130:452-462. [PMID: 36574899 PMCID: PMC9789609 DOI: 10.1016/j.anai.2022.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 12/16/2022] [Accepted: 12/19/2022] [Indexed: 12/25/2022]
Abstract
In this article, we discuss pertinent cutaneous findings with which patients may present after travel to tropical destinations. We address arthropod-borne infectious diseases such as cutaneous leishmaniasis, Chagas disease, cutaneous larva migrans, and myiasis. We discuss other relevant diseases with cutaneous signs such as monkey pox and severe acute respiratory syndrome coronavirus 2. We provide clinicians with information regarding the background, diagnosis, treatment, and prevention of these tropical rashes. In addition, we address the impact that climate change will have on the temporal and geographic incidence of these rashes. Viral, fungal, and vector-borne diseases have seen a geographic expansion into more northern latitudes. Among these are tick-borne Lyme disease, aquatic snail-related seabather's eruption, and atopic dermatitis. As these diseases spread, we believe that the updated information within this article is significant to the practicing physician in today's warming world.
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Affiliation(s)
| | - James G Dinulos
- Seacoast Dermatology, PLLC, Portsmouth, New Hampshire; Department of Dermatology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; Department of Dermatology, University of Connecticut School of Medicine, Framingham, Connecticut.
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3
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Strickland J, Larson NR, Feldlaufer M, Zhang A. Characterizing Repellencies of Methyl Benzoate and Its Analogs against the Common Bed Bug, Cimex lectularius. INSECTS 2022; 13:1060. [PMID: 36421963 PMCID: PMC9697005 DOI: 10.3390/insects13111060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 11/10/2022] [Accepted: 11/15/2022] [Indexed: 06/16/2023]
Abstract
Bed bug infestations are on the rise globally, and remediation efforts are becoming more expensive and difficult to achieve due to rising insecticide resistance in the pest populations. This study evaluates Cimex lectularius behavior in the presence of attractive elements-aggregation pheromone or food source (human blood)-and the reported botanical repellent methyl benzoate (MB), several MB analogs, as well as the well-known insect repellent, N,N-diethyl-meta-toluamide (DEET). Utilizing EthoVision, a video tracking system, we now report that MB and several of its analogs exhibit strong spatial repellency against C. lectularius, with methyl 2-methoxybenzoate (M2MOB) and methyl 3-methoxybenzoate (M3MOB) exhibiting the strongest repellent effects. Further, our data showed that MB, M2MOB, M3MOB, and DEET exhibit repellency against a pyrethroid resistant strain of C. lectularius.
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Carter SA, Deol P. Ultrasonographic appearance of soft-tissue infestation with Dermatobia hominis larvae in the returning traveller. BMJ Case Rep 2022; 15:e252717. [PMID: 36261223 PMCID: PMC9582294 DOI: 10.1136/bcr-2022-252717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
| | - Paramjeet Deol
- Chelsea and Westminster Healthcare NHS Trust, London, UK
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5
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The Cutaneous Wound Innate Immunological Microenvironment. Int J Mol Sci 2020; 21:ijms21228748. [PMID: 33228152 PMCID: PMC7699544 DOI: 10.3390/ijms21228748] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 11/17/2020] [Accepted: 11/17/2020] [Indexed: 12/17/2022] Open
Abstract
The skin represents the first line of defense and innate immune protection against pathogens. Skin normally provides a physical barrier to prevent infection by pathogens; however, wounds, microinjuries, and minor barrier impediments can present open avenues for invasion through the skin. Accordingly, wound repair and protection from invading pathogens are essential processes in successful skin barrier regeneration. To repair and protect wounds, skin promotes the development of a specific and complex immunological microenvironment within and surrounding the disrupted tissue. This immune microenvironment includes both innate and adaptive processes, including immune cell recruitment to the wound and secretion of extracellular factors that can act directly to promote wound closure and wound antimicrobial defense. Recent work has shown that this immune microenvironment also varies according to the specific context of the wound: the microbiome, neuroimmune signaling, environmental effects, and age play roles in altering the innate immune response to wounding. This review will focus on the role of these factors in shaping the cutaneous microenvironment and how this ultimately impacts the immune response to wounding.
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Ectoparasites. J Am Acad Dermatol 2020; 82:551-569. [DOI: 10.1016/j.jaad.2019.05.110] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 05/16/2019] [Accepted: 05/31/2019] [Indexed: 12/18/2022]
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7
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Gauthier P, Bellanger AP, Bozon F, Lepiller Q, Chirouze C, Marguet P. A survey investigating the current practice of French health professionals regarding infection risk after monkey bites. Zoonoses Public Health 2019; 67:193-197. [PMID: 31828958 DOI: 10.1111/zph.12665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 10/16/2019] [Accepted: 11/06/2019] [Indexed: 12/01/2022]
Abstract
International tourism is steadily increasing, with 15% of travellers reporting health problems when they come back. Animal bites represent 2% of consulting causes, of which 20% are due to monkey bites. The Monkey B virus (Macacine alphaherpesvirus 1) is an alphaherpesvirus (Herpesviridae, genus Simplexvirus) enzootic in macaques (Genus Macaca). Zoonotic infections with the Monkey B virus following exposure to macaques are exceptionally rare, but can cause fatal encephalomyelitis in humans. An observational survey was undertaken in 2018 to assess the practice of French health professionals regarding infection risk after monkey bites. French health professionals practicing in vaccination and rabies centres were specifically targeted for this study. Standardized questionnaires were sent by email to a sample of French health professionals. They were asked to participate on a voluntary and anonymous basis. The questionnaires requested epidemiological details and included multiple-choice questions about the infection management of monkey bites. The response rate was 33.5%. The frequency of monkey bites in 2017 was variable with a minority of centres managing more than 6 per year (12%), 46% managing 1-5 monkey bites and 42% none. Most of the monkey bites were described as occurring in South Asia at tourist sites, on naked upper limbs, shortly after the travellers arrived at their destination. Tetanus status verification, rabies post-exposure prophylaxis and antibiotic therapy were said to be prescribed in most cases. Knowledge about the Monkey B virus was reported as scarce for 38% of the participants. The number of monkey bites managed per year per centre varied greatly but practices regarding infectious risk after monkey bites were generally homogeneous. The risk of Monkey B virus transmission did not readily come to mind in the differential diagnosis of infection risk for many French health professionals.
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Affiliation(s)
- Pauline Gauthier
- Emergency Department, Regional Hospital of Pontarlier, Pontarlier, France
| | | | - Fabienne Bozon
- Infectious and Tropical Disease Department, University Hospital of Besançon, Besancon, France
| | - Quentin Lepiller
- Virology Department, University Hospital of Besançon, Besancon, France.,EA3181, University Bourgogne Franche-Comté, Besancon, France
| | - Catherine Chirouze
- Infectious and Tropical Disease Department, University Hospital of Besançon, Besancon, France
| | - Philippe Marguet
- Emergency Department, Regional Hospital of Pontarlier, Pontarlier, France
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8
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Ogueta I, Navajas-Galimany L, Concha-Rogazy M, Álvarez-Véliz S, Vera-Kellet C, Gonzalez-Bombardiere S, Wortsman X. Very High- and High-Frequency Ultrasound Features of Cutaneous Larva Migrans. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:3349-3358. [PMID: 31106871 DOI: 10.1002/jum.15023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Accepted: 04/28/2019] [Indexed: 06/09/2023]
Abstract
Cutaneous larva migrans is a common infestation among travelers. Although the diagnosis may be suspected clinically, cases can show atypical presentations. We present the ultrasound features of 4 cases at 18 and 70 MHz. Small linear hyperechoic and hyper-refringent subepidermal and intrafollicular structures suggestive of fragments of larvae, hypoechoic dermal and hypodermal tunnels that match with dilatation of lymphatic ducts, and inflammatory dermal and hypodermal ultrasound signs can support the diagnosis. This work suggests that larvae can penetrate the cutaneous basement membrane through the ostia of the hair follicles and potentially disseminate through the dermal and hypodermal lymphatic network.
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Affiliation(s)
- Isabel Ogueta
- Departments of Dermatology, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Lucas Navajas-Galimany
- Departments of Dermatology, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Marcela Concha-Rogazy
- Departments of Dermatology, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Sergio Álvarez-Véliz
- Departments of Dermatology, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Cristián Vera-Kellet
- Departments of Dermatology, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Ximena Wortsman
- Departments of Dermatology, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- Institute for Diagnostic Imaging and Research of the Skin and Soft Tissues, Santiago, Chile
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9
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Masini P, Zampetti S, Miñón Llera G, Biancolini F, Moretta I, Romani R, Tramontana M, Hansel K, Stingeni L. Infestation by the tropical bedbug Cimex hemipterus (Hemiptera: Cimicidae): first report in Italy. J Eur Acad Dermatol Venereol 2019; 34:e28-e30. [PMID: 31419365 DOI: 10.1111/jdv.15876] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- P Masini
- Cani Anti Cimici©, Perugia, Italy
| | | | | | | | - I Moretta
- Department of Veterinary Medicine, University of Perugia, Perugia, Italy
| | - R Romani
- Department of Agricultural, Food and Environmental Sciences, University of Perugia, Perugia, Italy
| | - M Tramontana
- Dermatology Section, Department of Medicine, University of Perugia, Perugia, Italy
| | - K Hansel
- Dermatology Section, Department of Medicine, University of Perugia, Perugia, Italy
| | - L Stingeni
- Dermatology Section, Department of Medicine, University of Perugia, Perugia, Italy
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Vaughn MG, Holzer KJ, Carbone JT, Salas-Wright CP. Arthropod Bites and Stings Treated in Emergency Departments: Recent Trends and Correlates. Wilderness Environ Med 2019; 30:394-400. [PMID: 31405548 DOI: 10.1016/j.wem.2019.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 05/15/2019] [Accepted: 05/28/2019] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Despite increasing health effects of arthropod bites and associated costs, research on their frequency is limited, especially at the population level. The aim of this study was to estimate the prevalence, correlates, and recent trends in visits to US emergency departments related to arthropod bites and stings. METHODS The prevalence of arthropod bites, including information regarding location of the bite, was calculated for years 2010 through 2014 using data from the Healthcare Cost and Utilization Project Nationwide Emergency Department Sample. Sex- and age-stratified multivariate logistic regression analyses were conducted with "arthropod bite" as the dependent variable and patient and hospital characteristics as independent variables. RESULTS Overall, there were significant increases in bites over the study period with higher rates of bites in the summer months (June-August), especially among children. Individuals who seek treatment for arthropod bites in the emergency department are more likely to reside in zip codes with lower median household income and to be without insurance coverage or with Medicaid rather than private insurance. The cost of care related to arthropod bites increased approximately 40% over the study period. CONCLUSIONS These results provide updated surveillance on the prevalence and correlates of arthropod bites and stings in the US population.
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Affiliation(s)
- Michael G Vaughn
- School of Social Work, College for Public Health and Social Justice, Saint Louis University, Saint Louis, MO; Yonsei University, Seoul, Republic of Korea
| | - Katherine J Holzer
- School of Social Work, College for Public Health and Social Justice, Saint Louis University, Saint Louis, MO.
| | - Jason T Carbone
- School of Social Work, College for Public Health and Social Justice, Saint Louis University, Saint Louis, MO
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11
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Abstract
Chikungunya and Zika virus infections are emerging diseases in the Americas, and dengue continues to be the most prevalent arthropod-borne virus in the world. These arbovirus diseases may spread by endemic transmission or as travel-related infections and have rapidly expanded their geographic distribution secondary to vector spread. All 3 share a similar clinical picture that includes a maculopapular rash. Zika is characterized by pruritic rash, low-grade fever, and arthralgia. Congenital nervous system malformations are a growing public-health concern. Chikungunya distinctive dermatologic manifestations include facial melanosis and bullous eruption. Dengue bleeding complications may be life-threatening and require inpatient management.
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Affiliation(s)
- Jose Dario Martinez
- Department of Internal Medicine, University Hospital "Dr. José E. González", UANL, Mitras Centro, Avenida Gonzalitos y Madero S/N, Monterrey 64460, Mexico.
| | - Jesus Alberto Cardenas-de la Garza
- Department of Dermatology, University Hospital "Dr. José E. González", Universidad Autónoma de Nuevo León, Mitras Centro, Avenida Gonzalitos y Madero S/N, Monterrey 64460, Mexico
| | - Adrian Cuellar-Barboza
- Department of Dermatology, University Hospital "Dr. José E. González", Universidad Autónoma de Nuevo León, Mitras Centro, Avenida Gonzalitos y Madero S/N, Monterrey 64460, Mexico
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12
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Cunha PR, Flora TB, Kroumpouzos G. Travelers' tropical skin diseases: Challenges and interventions. Dermatol Ther 2018; 32:e12665. [PMID: 30216601 DOI: 10.1111/dth.12665] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 06/08/2018] [Accepted: 06/22/2018] [Indexed: 11/29/2022]
Abstract
Tropical regions receive a significant part of the traveling population. It is very important that health professionals are familiar with the main tropical skin diseases and able to advice patients appropriately. This article reviews the main tropical diseases of travelers, with an emphasis on diagnosis, management, and prevention. Among others, cutaneous larva migrans, myiasis, tungiasis, Chagas disease, Dengue fever, African trypanosomiasis, filariasis, and leishmaniasis are discussed. Increasing awareness among travelers and health care professionals can help reduce morbidity and mortality. Continued research on new drugs and vaccines is needed to reduce the risks of tropical diseases.
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Affiliation(s)
- Paulo R Cunha
- Department of Dermatology, Medical School of Jundiaí, São Paulo, Brazil
| | - Thais B Flora
- Department of Dermatology, Medical School of Jundiaí, São Paulo, Brazil
| | - George Kroumpouzos
- Department of Dermatology, Medical School of Jundiaí, São Paulo, Brazil.,Department of Dermatology, Alpert Medical School, Brown University, Providence, Rhode Island.,Dermatoepidemiology Unit, Veterans Affairs Medical Center, Providence, Rhode Island
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13
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A new siloxane embedded benzalkonium chloride-based skin protectant (fiteBac Germicidal Skin Softening Gel) for use against insect bites and related dermal infections. REVISTA MÉDICA DEL HOSPITAL GENERAL DE MÉXICO 2018. [DOI: 10.1016/j.hgmx.2018.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Alter SJ, McDonald MB, Schloemer J, Simon R, Trevino J. Common Child and Adolescent Cutaneous Infestations and Fungal Infections. Curr Probl Pediatr Adolesc Health Care 2018; 48:3-25. [PMID: 29198783 DOI: 10.1016/j.cppeds.2017.11.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Cutaneous infections and infestations are common among children and adolescents. Ectoparasitic infestations affect individuals across the globe. Head lice, body lice, scabies, and infestations with bed bugs are seen in individuals who reside in both resource poor areas and in developed countries. Superficial cutaneous and mucosal candida infections occur throughout the life cycle. Dermatophyte infections of keratin-containing skin and skin structures result in tinea capitis (scalp), tinea corporis (body), tinea pedis (foot), and tinea unguium (nails). Less frequent endemic fungal infections such as blastomycosis, coccidiodomycosis, and histoplasmosis may present with skin findings. This article will describe the epidemiology and transmission of these conditions as well as their clinical manifestations. The approach to diagnosis will be addressed as well as primary prevention and current therapies.
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Affiliation(s)
- Sherman J Alter
- Division of Infectious Diseases, Dayton Children's Hospital, One Children's Plaza, Dayton, OH; Department of Pediatrics, Wright State University, Boonshoft School of Medicine, Dayton, OH
| | - Megan B McDonald
- United States Air Force, OIC Pediatrics Clinic, 28 MDOS/SGOK, Ellsworth Air Force Base, SD
| | - Julie Schloemer
- Department of Dermatology, Wright State University, Boonshoft School of Medicine, Dayton, OH
| | - Ryan Simon
- Division of Infectious Diseases, Dayton Children's Hospital, One Children's Plaza, Dayton, OH; Department of Pediatrics, Wright State University, Boonshoft School of Medicine, Dayton, OH
| | - Julian Trevino
- Department of Dermatology, Wright State University, Boonshoft School of Medicine, Dayton, OH
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Recognize and treat travel-related skin diseases in returning travellers and recommend preventative measures to future travellers. DRUGS & THERAPY PERSPECTIVES 2017. [DOI: 10.1007/s40267-017-0393-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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16
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Olszański R, Siermontowski P, Juszczak D, Dąbrowiecki Z, Pedrycz A. A Case of Cutaneous Leishmaniasis Treated with Hyperbaric Oxygen Therapy. POLISH HYPERBARIC RESEARCH 2017. [DOI: 10.1515/phr-2016-0024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Cutaneous leishmaniasis in Poland is an imported disease mainly occurring in tourists who travelled to tropical countries. Cutaneous symptoms occur as late as between ten and twenty days following the return from the tropics. Lesions connected with cutaneous leishmaniasis were most commonly diagnosed by Polish doctors as furuncle, ecthyma or ulceration and ineffectively treated for several weeks with antibiotics.
The paper presents the case of leishmaniasis in a 30-year-old male with an ulceration of the left shank, ineffectively treated with antibiotics over a period of four months. The ulceration was healed completely only after leishmaniasis was diagnosed and following the application of a treatment based on antimony derivatives, followed by hyperbaric oxygenation performed in a hyperbaric chamber.
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Affiliation(s)
- Romuald Olszański
- Maritime & Hyperbaric Medicine Department, Military Institute of Medicine, Gdynia, Poland
| | - Piotr Siermontowski
- Maritime & Hyperbaric Medicine Department, Military Institute of Medicine, Gdynia, Poland
| | | | - Zbigniew Dąbrowiecki
- Maritime & Hyperbaric Medicine Department, Military Institute of Medicine, Gdynia, Poland
| | - Agnieszka Pedrycz
- Department of Histology and Embryology, Medical University in Lublin, Poland
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Olszański R, Siermontowski P, Dąbrowiecki Z. Cutaneous larva migrans – a threat to divers in the tropics. POLISH HYPERBARIC RESEARCH 2016. [DOI: 10.1515/phr-2016-0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
The article presents a dermatosis that occurs in tropical and subtropical countries. Though the definitive hosts of the cutaneous larva migrans parasite are animals, humans can become accidental hosts and they are infected when their skin comes into contact with damp soil, most frequently sand. The disease is only present in the epidermis where an itch is brought about by the mining activity of the larva. Sunbathers and divers who put on their gear on a beach, on account of the epidermis maceration caused by a prolonged exposure to water, are particularly susceptible to the penetrative activities of the larva. In Poland the cutaneous larva migrans is in most cases mistaken for nettle rash or eczema.
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Affiliation(s)
- Romuald Olszański
- Maritime & Hyperbaric Medicine Department, Military Institute of Medicine, Gdynia
| | - Piotr Siermontowski
- Maritime & Hyperbaric Medicine Department, Military Institute of Medicine, Gdynia
| | - Zbigniew Dąbrowiecki
- Maritime & Hyperbaric Medicine Department, Military Institute of Medicine, Gdynia
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