JHSCI 2011 v1 I2 September

UNIVERSITY OF SARAJEVO FACULTY OF HEALTH STUDIES
UNIVERZITET U SARAJEVU FAKULTET ZDRAVSTVENIH STUDIJA
Journal of Health Sciences

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Editor in chief
Advisory Board
Dijana Avdi (BiH)
Osman Duri
Faris Gavrankapetanovi
Associate editor
Ismet Gavrankapetanovi
Demal Pecar (BiH)
Muhamed Gavranovi
Mirsada Huki
Secretary
Dragan Kosori
Aida Rudi
Lidija Lincender
Slobodan Loga
Members
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Senka Mesihovi-Dinarevi
Amira Duri (BiH)
Muzafer Mujic
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Emela Muji Skiki (UAE)

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Technical editor
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Faruk pilja
Dragi Bankovi (SRB)
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Volume 1, Number 2, September 2011
Table of contents:
Editorial
DIJANA AVDI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
RESEARCH ARTICLES
Microbiological composition of untreated water during different weather conditions
ADNA BEI, ZAREMA OBRADOVI, ARZIJA PAALI, AMAR ILI . . . . . . . . . . . . . . . . . . . . . . . . . . 68 - 74
Is there any relationship between PSA and increased peripheral
CD4+CD25highFOX3+ Treg in prostate cancer patients?
YIGIT AKIN, SADI KOKSOY, SELCUK YUCEL, TIBET ERDOGRU, MEHMET BAYKARA . . . . . . . . . . . . 75 - 82
Helicobacter pylori infection according to ABO blood group among blood donors in Kosovo
BUKURIJE ZHUBI, ZANA BARUTI-GAFURRI, YMER MEKAJ, MIMOZA ZHUBI, IDRIZ MEROVCI,
ILIRIANE BUNJAKU, VALDETE TOPCIU, EMINE DEVOLI-DISHA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 - 89
Acute postoperative pain relief, by intraperitoneal application of local
anesthetics, during laparoscopic cholecystectomy
LJILJANA GVOZDENOVI, VESNA PAJTI, DEJAN IVANOV, RADOVAN CVIJANOVI,
SAVA GAVRILOVI, ZORAN GOJKOVI, SAA MILI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 - 95
Dural tail sign adjacent to different intracranial lesions on contrast-enhanced MR images
SVJETLANA MUJAGI, JASMINA BEIREVI-IBRIEVI, VESNA VRULJEVI-MARTI,
ZLATKO ERCEGOVI, DELIL KORKUT, MIRZA MORANJKI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 - 102
The effect of breakthrough pain on heart and lung function
during the cancer pain treatment in palliative care
SAMIR HUSI, DENITA LJUCA, SENAD IZI, HASAN KARAHASAN . . . . . . . . . . . . . . . . . . . . . . . . . . 103 - 109
CASE REPORTS
Severe anemia: a case report
AMRA MACI-DANKOVI, ANELA UBO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 - 114
INSTRUCTIONS TO AUTHORS
Instructions and guidelines to authors for the preparation and
submission of manuscripts in the Journal of Health Sciences. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 - 118
www.jhsci.ba
Editorial
In the second issue of the Journal of Health Sciences we bring you interesting and current scientific
works in different research fields. Husic et al. and Gvozdenovic et al. addressed pain issues in different settings, i.e. palliative care and laparoscopic surgery, respectively. In a very interesting study
Akin et al. report about the positive correlation of prostate specific antigen (PSA) and peripheral T
regulatory cells of the immune system. The authors suggest that PSA may have a role in maintaining
high number of Treg cells in the peripheral blood. These results will contribute to elucidation of the
effect of PSA on the Tregs or vice versa, as this filed is still controversial and diverse data are reported
from several studies. Next, we bring you the results of the study on the dependence of microbiological composition of untreated water on seasons. Another study on microbes comes from Zhubi et al.
The authors wanted to see whether there is a relation between the ABO blood groups and H. pylori
infection and found that there is no difference in susceptibility in respect to blood group.
The Journal of Health Sciences continues with its policy in publishing high quality papers in the fields
of radiological technologies, laboratory technologies, health care and nursing, physical therapy and
environmental health and human ecology. The editorial board is dedicated to create a strong and
long lasting relationship with authors and researchers for the improvement of scientific environment
and communication, which will bring the science into medical practice, for the good of the patients.
We invite you to visit our web site www.jhsci.ba and find numerous resources for authors, which will
help you in preparation of good quality manuscripts. More efforts are put by the different groups in
the world (statements: CONSORT, STROBE, STARD, PRISMA and other) in the achieving of standards for writing scientific reports. The Journal of Health Sciences supports those efforts and implies
those standards by instructing the authors to use the above mentioned statements when preparing
their manuscripts for submission.
Dijana Avdic, MD, PhD
Editor in chief
JOURNAL OF HEALTH SCIENCES 2011; 1 (2)
67
www.jhsci.ba
Microbiological composition of untreated water

during different weather conditions
Adna Bei1, Zarema Obradovi2,3*, Arzija Paali3, Amar ili2
Institute for Public Health FB&H, M. Tita, 51, 71 000 Sarajevo, Bosnia and Herzegovina. 2 Institute for Public Health of Canton
Sarajevo, M. Pintola, 11/III 71000 Sarajevo, Bosnia and Herzegovina. 3 Faculty for Health Studies, University of Sarajevo,
Bolnika bb, 71 000 Sarajevo, Bosnia and Herzegovina
Abstract
Introduction: Water can support the growth of different microorganisms which may result in contamination.
Therefore, the microbiological examination is required for testing the hygienic probity of water. In the study of
microbial composition of untreated, natural spring and mineral water differences in the presence and number
of bacteria during the two periods, winter and summer, are detectable.
Methods: In our study, we analyzed and compared the following parameters, specified in the Rulebook:
total bacteria and total aerobic bacteria (ml/22 and 37C), total Coliform bacteria and Coliforms of fecal
origin (MPN/100ml), fecal streptococci as Streptococcus faecalis (MPN/100ml), Proteus spp (MPN/100ml),
and Pseudomonas aeruginosa (MPN/100 ml) Sulphoreducing Clostridia (cfu / ml). The paper is a retrospective study in which we processed data related to the period of 2005-2009 year. While working, we used the
descriptive-analytical comparative statistical treatment.
Results: The obtained results show statistically significant differences in the microbial composition of untreated water in the two observed periods,
Conclusions: Findings were consequence of different weather conditions in these periods, which imply a
number of other variable factors.
2011 All rights reserved
Keywords: microbiological composition, untreated water, the time periods.
Introduction
Concerns for securing of sufficient quantities of
hygienically proper drinking water have accompanied the mankind through all the stages of its development. The need for hygienically proper water
is on the rise while existing reserves are reducing
due to a continuous intense pollution. Therefore
the water is becoming a restrictive factor for further
economic development of the country, and a factor
responsible for outbreak of contagious diseases (1).
Bacteriological contamination of water is very
frequent, and therefore the bacteriological examination is very important when determining the
eventual risk of outbreak of contagious diseases.
Bacterial contamination of water by pathogenic
microorganisms is most often a consequence
of inadequate disposition of waste fecal waters
(2). The use of contaminated water may lead to
the outbreak of epidemic spread of various con* Corresponding author: Zarema Obradovi, Institute for Public
Health of Canton Sarajevo and Faculty for Health Studies,
University of Sarajevo, Vrazova 11/IV, 71 000 Sarajevo, Bosnia and
Herzegovina; Tel/fax: 033 667 691; E-mail: zobradovic9@gmail.com
Submitted 4. May 2011 / Accepted 2. August 2011
68
Y-I-2.indb 68
tagious diseases. Bacteria such as Escherichia coli,

Salmonella, Shigella and Vibrio from intestinal
tract of humans and other warm-blooded animals frequently get into water in nature through
feces and urine, leading to contamination (3).
Underground waters are also frequently contaminated, and can hold even up to several million microorganisms in 1 ml of water. Microorganisms get
into such waters from various sources: from the
soil, air, atmosphere and surface waters, from the
rocks themselves, but also as a consequence of the
living organisms activity. The quantity of microorganisms in underground waters depends on the
temperature, presence of organic matter, dissolved
oxygen, certain pH value of environment and so on.
Richer and more versatile population of microorganisms develops in fresh waters than in salty ones.
Besides the global significance for the circulation
of matter, microorganisms in water are important
factors for the process of bio-purification of waters.
By origin, waters may be classified in three
main groups: atmospheric, surface and underground. For human use, i.e. for drinking, all
types of waters are being used, but often prior
10.9.2011 9:20:59
ADNA BEI ET AL.: MICROBIOLOGICAL COMPOSITION OF UNTREATED WATER DURING DIFFERENT WEATHER CONDITIONS
to their use their quality must be improved.

Underground waters from greater depths are
by composition and quality usually pure and
most desirable as drinking water. Shallow underground waters are most frequently not good
quality and are more rarely used for drinking
purposes (4). Underground waters represent
raw material of particular social interest, since
in the majority of countries, and so in ours as
well, due to their advantages, mainly they are the
ones used for water supply for the population
and the part of industry requiring quality water.
The term untreated water denotes the water
which has not been chemically treated, or filtered, or boiled in order to eliminate microorganisms. The underground water reserves are
significantly greater than the needs for water,
but the continuous increase in waste waters that
are, in ours and other underdeveloped countries
and developing countries, without prior purification, dumped into recipient or into the soil, represents a threat in terms of their contamination.
The main sources of natural water contamination
include: waste waters from urban environments,
mineral fertilizers, inorganic matters, acid mine
and drainage waters, waste waters from treatment
and utilization of mineral raw materials, sedimentary and radioactive matters and waste heat.
Composition and quality of water in nature are
very much variable and depend on the series of
factors. Also significant are their origin, history,
chemical composition, but also the presence and
composition of the living forms therein. The quality of water is influenced by: the temperature, the
pH and the oxygen content in water, and other
ecological factors which vary depending on the
time of the day and night, as well as over the year.
Underground water is destitute of organic matters
and their composition depends on the soil they run
through, and if they emerge from shallow depths
their composition is similar to the composition
of surface waters. When surface waters permeate
through the soil to the underground waters they
carry organic matters as well, and a part of these
matters remains in the soil they run through. Underground waters from greater depths are either
thermal or mineral, and frequently healing (5).
The quality of water depends also on the geographical features of the area, particularly important of
Y-I-2.indb 69
which are: the climate, altitude and fouling with

vegetation because they have a direct influence on
the type and quantity of precipitation. In the areas with mountain climate and at greater heights
above sea level in the colder months it snows,
and in the summer months it often rains (6).
The objective of our work was to examine the microbiological characteristics of untreated spring, well
and borehole waters, and to compare the results
in various time periods in order to determine the
eventual impact of external factors on the microbiological contamination of these categories of waters.
Methods
Samples
As a working material, we used the results of untreated water groups analyses by the contractors
and companies from the Department for Microbiology of Food and Water of the Institute for Public Health of the Federation of Bosnia and Herzegovina, from 2005 to 2010. These include the
unprocessed, untreated spring and well waters, as
well as the waters from boreholes, which were analyzed monthly at this Department in accordance
with the Rulebook. Every month, 10 samples were
taken (120 on an annual basis, i.e. 600 in total).
Water samples for bacteriological analysis were
taken in accordance with the Directives of the
Rulebook on the Manner of Taking Samples
and Methods of Bacteriological Analysis of
Drinking Water (Rulebook on the Manner of
Taking Samples and Methods of Laboratory
Analysis of Drinking Water, Official Gazette of Socialist Federal Republic of Yugoslavia, No. 33/87).
Procedures
The bacteriological examination in MPN technique
was conducted by standard laboratory methods
(7). Bacteria were enumerated based on the turbidity in individual specimens by referenced to the
MPN tables (8). Acceptable norms for individual
groups of bacteria were construed upon the Rulebook on Hygienic Properness of Drinking Water.
Statistical analysis
The following methods were used for the analysis of the research results: Descriptive statistics (minimum and maximum value, average
69
10.9.2011 9:21:06
TABLE 1. The results of K-S tests for measurement of the normality

2005 2009
Total
microorg.
2,033
0,001
K-S results z value

K-S results p value
Aerobic
bacteria
1,423
0,035
E. coli S. faecalis Proteus spp.

2,692
0,000
2,670
0,000
P. aeruginosa
/
/
/
/
Sulpho-reducing
Clostridia
3,480
0,000
Sterile
1,235
0,095
TABLE 2. Overview of positive samples by years 2005 2009

Year
Samples with increase

in total of bacteria %
Samples positive on
aerobic bacteria %
2005
2006
2007
2008
2009
Total
9 (7,5)
7 (5,8)
7 (5,8)
7 (5,8)
7 (5,8)
37 (6,2)
10 (8,3)
7 (5,8)
9 (7,5)
9 (7,5)
9 (7,5)
44 (7,3)
Samples positive
on Sulpho-reducing
Clostridia %
2 (1,7)
5 (4,2)
4 (3,3)
0 (0,0)
1 (0,8)
12 (2,0)
Samples posi- Samples positive

tive on E.coli % on S. faecalis %
6 (5,0)
6 (5,0)
4 (3,3)
4 (3,3)
6 (5,0)
26 (4,3)
5 (4,2)
6 (5,0)
3 (2,5)
6 (5,0)
6 (5,0)
26 (4,3)
TOTAL
32 (26,7)
31 (25,8)
27 (22,5)
26 (21,7)
29 (24,1)
145 (24,2)
TABLE 3. Comperative overview of results of untreated water analyzes during the period (October-March and April-September)
from 2005 to 2009.
2005-2009
Period of year
Number
of months
Xmax
Xmin
Avarage value
Weighing error
St.deviation
Coefficient
of variation
z or t
p
Total
microorg.
4/9
10/3
aerobic
bacteria
4/9 10/3
4/9
10/3
4/9
10/3
30
30
30
30
30
30
0
3
1,23
0,17
0,94
0
1
0,13
0,06
0,35
179
7402
2105,8
359,18
1967,31
93,42
30
30
E. coli
0
1
0
0
0
410
6
3
3
1
79,43 3,13 1,20 1,43 0,07
19,57 0,24 0,16 0,17 0,05
107,19 1,33 0,89 0,94 0,25
S.faecalis
Proteus
spp.
4/9 10/3
P. aeruginosa
4/9 10/3
30
30
30
30
0
0
0
0
0
0
0
0
0,00 0,00 0,00 0,00
0,00 0,00 0,00 0,00
0,00 0,00 0,00 0,00
0,00 42,52 73,89 65,25 380,56 75,83 259,31
-6,581
0,000
-5,226
0,000
-5,707
0,000
-4,887
0,000
Sulphoreducing Clostridia
4/9
10/3
Sterile
4/9 10/3
30
30
30
30
0
6
0,63
0,23
1,25
0
2
0,10
0,07
0,40
4
9
6,13
0,21
1,14
7
10
8,57
0,16
0,86
196,61 402,58 18,53 10,02

0,000
1,000
0,000
1,000
-2,554
0,011
-9,35728
0,000
value, standard deviation and variance coeffi- 0, so we do not have the test results, since this is
cient), Kolmongorov-Smirnov test (K-S test) for a series of constants, and not the frequency disthe normality of distribution in the period
tribution. Only for variable sterile, the p value
observed, nonparametric U test and T test. was greater than 0.05 and therefore satisfies the
We started our research with the results of the Kol- assumption of normality. All other variables failed
mongorov-Smirnov test (K-S test) for measure- to satisfy the assumption of normality considment of the normality of distribution of treated
ering that the associated p value of the K-S test
samples in the period of 2005 2009. (Table 1). was less than 0.05. Hence have we used for comFor Proteus spp. and Pseudomonas aeruginosa
parisons of the variable sterile the parametric t
types on all measurements the values were equal - test, and for others the non-parametric U - test.
70
Y-I-2.indb 70
10.9.2011 9:21:06
Results
FIGURE 1. Positive samples by years of observation
FIGURE 2. Presence of some contaminants in water
FIGURE 3. Average value for total bacteria by periods

Y-I-2.indb 71
Our research is based on

the samples which were
taken in the five years
(from 2005. to 2009.), by
individual parameters.
(Table 2, Figure 1). Each
year 120 samples were
taken, out of which various were positive, and
varied from 26 (2008.) to
32 (2005.). The greatest
number of positive samples, 32 was in found in
year 2005, which is 26.7%
of samples taken in that
year. The most frequent
parameter that was not
in accordance with the
Rulebook was the presence of aerobic bacteria
which were found in
44 samples in the fiveyear period observed,
which is 7.3% of total
taken samples (Figure 2).
Our research was directed on presence of
contaminants in water during two periods:
from April until September and from October until March. Overview of results is presented in Table 3. Preciseous
analyzes were conducted by years, for every five
years. Observed parameters were monitored in
the periods from April until September and from
October until March. During this two observed
periods there were large differences in total bacteria (Figure 3). Our results showed that a smaller
total number of microorganisms was identified,
as well as the presence of aerobic bacteria, Escherichia coli, Streptococcus faecalis in the period
from October to March, compared to the period
April-September, when it was sterile and a number
of measurements. We observed a statistically significant difference in the total number of microorganisms, the number of samples with aerobic bacteria, Escherichia coli and the presence of sterile
measurements, because the p values correspond71
10.9.2011 9:21:07
Discussion
Research of the microbiological composition
of the spring untreated
water during different
months of the year was
conducted within our
research. According to
available
information,
so
far
in
our
area, simiFIGURE 4. Number of positive samples per period, according to the contaminants
lar researches were not
done. We analyzed 10
samples each month,
or 120 samples per year,
and this is a total of 600
samples for the 5 years
that we observed. In statistical analyzes, the results are divided into two
periods, winter (October - March) and summer (April - September).
We monitored 7 different
parameters including:
total number of present
microorganisms - quantitatively, and for positive
samples: aerobic bacteria
at 22 and 37 C, Escherichia coli, Streptococcus faecalis, Proteus spp,
FIGURE 5. Average value for different bacteria by periods
Pseudomonas
aeruginosa and Sulphoreducing
Clostridias - qualitatively.
ing U or t - test, were lower than 0.05 (Figure 4). The total number of microorganisms showed sigSulphoreducing Clostridias were significantly nificantly higher values during the summer pehigher in the period April-September for all riod, then winter, and applied statistical tests
observed years except 2009, when they were
showed statistically significant difference. Findings
increased, but not statistically significant. are confirming that different weather conditions,
The most frequently isolated, observed in both especially those who have influence on the melting
periods, were the aerobic bacteria, but with much
snow and runoff water from higher to lower areas
higher frequency in the period April-September. have a significant impact on the contamination
During this period there were followed by the
of underground waters, including waters used in
presence of Escherichia coli, Streptococcus fae- our research. Cabral et al. (4) also did research on
calis and Sulphoreducing Clostridias (Figure 5). effects fecal contaminations on environment. He
In the period April-September, after the aero- points out importance of testing on coliform bactebic bacteria the most frequent were Strepto- ria as important indicator of contaminated waters.
coccus faecalis and Sulphoreducing Clostri- Samples that were analyzed come from traps
dias, while Escherichia coli was rarely isolated. located in mountain area of Bosnia and Her72
Y-I-2.indb 72
10.9.2011 9:21:07
zegovina at the altitude of 820, 1000 and

1200 m. Only one trap was on 450 m above
the sea, though its waters come from nearby
mountain with height of more than 1000 m.
In these areas the mountain climate is predominant. Characteristics of it are increased amount
precipitations during the entire year snow during the winter and rain at springs and summers.
Snowfalls has no important direct impact on
contamination of underground waters, though at
the season of malting snow brings to significant
increase of the mount of the waters on the surface
and its pouring into the ground. That often results
into contamination of underground waters. It
shows indirectly that snowfalls significantly influence on contamination of the underground waters.
During the summer time in this areas are frequent
rainfalls what results into erosion. It makes easier
and increases contamination of untreated wells
and drills. Similar researches are conducted in
Guinea Bissau on 1998. During the rainy season
when epidemics of cholera broke out as well as other diseases related to water. Research was targeting
the termination of microbiological characteristic of drinking water during the rainy season (9).
Microbiological analyzes were including the termination of total number of coliform bacteria,
Escherichia coli and Enterococcus faecalis, what
coincide with microbiological parameters followed in our research. What was obvious was
increase of fecal contamination during the rainy
season showed in our researches as well and significant statistically differences were detected.
Researches and quantitative estimation of
pathogen Pearl River Delta in China, as well as
springs of the drinking water were conducted
on samples of water from six reservoirs in two
seasons during 2006. Results showed that outside environment factors falls, location as well
as certain internal environmental factors, physical and chemical characteristics of water have
direct impact on presence of coliforms (10).
Analyzes done by the seasons showed the level
of coliform bacteria during the fall season as
well as melting the snow showed increase of one
to two lines size compare to a dry season, what
is exactly the same as shown in our researches.
Basic elements of analysis showed the level coliform is tightly connected to physical and
Y-I-2.indb 73
chemical characteristics while fecal coliform

are more connected to the external components brought in by the influence of the seasons.
Contamination of the ground water is connected to human activities and pollution of the waters on the surface (11,12).
Aiming to test environmental effects of bacterial
content of sediment of Dongping lakes in China,
researches were done in six positions for sampling
in two periods July and October to determine
bacterial diversities, what in many aspects is similar to our research. Little differences are founded
amount samples. However, bacterial indexes of
difference where significantly different samples.
Abundance, prevalence and evenness found samples during the dry season (October) where generally higher compare the same found during wet
season (July), while domination of the bacterial
species was higher during the wet season, what
again is similar with findings in our researches.
As a conclusion of this experiment it has been established that environmental factors are affecting
prevalence of bacteria in tested lakes sediment
(13). The other researches showed the level of contamination of the waters directly connected to a
season (14). Some researches were conducted aiming to assess risks of appearance of diseases caused
by drinking water in the US. Contamination of the
drinking water was not spread correctly, though
under the influence of the certain factors: number
of pathogen in the source of the spring, agents of
the water system, quality of it, as well as changes in
climate (15,16). Microbiological contamination of
waters often brings to emergence of different human
diseases, what emphasizes important of the clearness of water as one of the basic preventive measures for combating diseases of that kind (17,18).
This research is preliminary in this area and it presents a screening of possible influence of certain climate and other outside factors on microbiological
content of spring untreated waters, heavily used
in process of further consuming and bottling. Results could signalize coordination of dynamics of
control of this waters and taking of appropriate
measures in controlling of these waters as well as
taking measures in the contamination of springs
in certain period of times during a year, aiming
prevention of emergence or reduction of risks of
spreading infectious diseases spread by the wa73
10.9.2011 9:21:07
ter, what is pointed out by Jha M. and Gu R. (19).

Due to potential increasing problem of supplying
enough quantity of drinking water much more attention has to be dedicated to the laboratory control
of microbiological quality of bottled waters (20).
Conclusions
In this paper we present a research of microbiological contamination of spring water taken from
the trap in mountainous parts of the country. Our
research has shown that the contamination is
much higher during the period April-September
compared to the period October-March, which

can be associated with melting snow and groundwater contamination. It would be useful to continue this research with detailed monitoring of single
climate and other factors of external environment
in order to determine which factor is most related
to water contamination.
Competing interests
Authors declare that they do not have any conflict
of interest.
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10.9.2011 9:21:08
www.jhsci.ba
Is there any relationship between PSA and

increased peripheral CD4+CD25highFOX3+
Treg in prostate cancer patients?
Yigit Akin1*, Sadi Koksoy2, Selcuk Yucel1, Tibet Erdogru1, Mehmet Baykara1
1
2
Department of Urology, School of Medicine, Akdeniz University, Dumlupinar Bul. Kampus Tip fak. 07070, Antalya, Turkey.
Department of Medical Microbiology, Akdeniz University, Dumlupinar Bul. Kampus Tip fak. 07070, Antalya, Turkey
Abstract
Introduction: The aims of this study were first, to determine whether peripheral levels of CD4+CD25highFoxp3+
regulatory T cells (Treg) are elevated in Prostate Cancer (PCa) patients, and second, to determine the direct
correlation between peripheral Treg and total serum Prostate Specific Antigen (PSA) levels in these patients.
Methods: Peripheral Blood Mononuclear Cells from 56 subjects undergoing diagnostic prostate biopsies
(PSA 2.5 ng/ml) were analyzed for Treg numbers. The association between the peripheral Treg and serum
PSA values was first determined in the entire population, including people with no prostate pathology and
PCa and Benign Prostate Hyperplasia (BPH) patients, and second, in nine PCa patients before and after
curative prostatectomy.
Results: This project was performed in Akdeniz University immunology laboratory and urology out patient
clinic from 2008 to 2010. Peripheral Treg frequencies were significantly increased in PCa patients (n = 19,
3.23 1.59) compared with BPH patients (n = 27, 1.66 0.80) and healthy subjects (n = 10, 1.08 0.43)
(p < 0.01). The percentage of Treg in BPH patients was also significantly higher than that of healthy subjects
(p < 0.01). Importantly, the increase in BPH and PCa patients paralleled the elevation in total serum PSA
levels, demonstrating a strong positive correlation (r = 0.75; p < 0.01).
Conclusion: These results demonstrate that peripheral Treg densities are correlated with PSA in BPH and
PCa patients, suggesting that PSA may have a role in Treg induction and/or maintenance in Treg in these
people.
Keywords: CD4+CD25highFoxp3+ Regulatory T cells (Treg), prostate cancer, benign prostate hyperplasia,
PSA, TAA
Introduction
Prostate cancer (PCa) is the most commonly diagnosed cancer among men in the world (1). Approximately two thirds of PCa cases are confined
to the prostate and can be treated by radical
prostate removal or radiotherapy (2). In addition,
approximately 25 to 55% of treated, locally confined tumors reappear within 10 years and may
progress as either a local recurrence or distant
metastases (3). In the quest for effective prevention and treatment modalities for metastatic
* Corresponding author: Yigit Akin, MD. Department of
Urology, Akdeniz University School of Medicine, Dumlupinar
Bul. Kampus Tip fak. 07070, Antalya, Turkey.
Phone: 90-242-2496159, 90-506-5334999; Fax: 90-242-2274488,
e-mail address: yigitakin@yahoo.com
Submitted 27. June 2011 / Accepted 11. August 2011
Y-I-2.indb 75
PCa (4), immunotherapy attempts using several

different methods have shown very limited success (5-9). Various immune evasion mechanisms,
such as defects in antigen presentation, secretion
of immunosuppressive agents by the tumor cells,
and T cell receptor defects, are thought to limit
the success of these trials. Recently, natural regulatory T cells (CD4+CD25high; Treg), one of the
key regulators of self tolerance, have also been
implicated in immune evasion by PCa (10, 11).
CD4+CD25high Treg cells, which are known to control self tolerance in the periphery, derive from
the thymus (12, 13) and constitute 1-2% of peripheral lymphocytes in adult humans (14). The
importance of these cells in tumor immunity was
first demonstrated three decades ago (15). Since
then, especially after the introduction of Foxp3
75
10.9.2011 9:21:08
YIGIT AKIN ET AL.: IS THERE ANY RELATIONSHIP BETWEEN PSA AND INCREASED PERIPHERAL CD4+CD25HIGHFOX3+
TREG IN PROSTATE CANCER PATIENTS?
(16) as a specific marker, stud- TABLE 1. Summary of patient characteristics

ies of numerous mouse tumor
Total
Segment
Healthy
BPH
PCa
models have demonstrated
Subjects
that they can interfere with the
Mean Age*
55 (43-68)
60 (44-70)
62 (41-78)
60 (43-78)
anti-tumor immune response
PSA*
3.3 (2.5-6)
20.4 (2.7-51)
45.4 (4.8-48)
25.3 (2.5-51)
at either the induction or efNumber
10
27
19
56
fector phase. Increased periph*Numbers in parentheses show range
eral and intratumoral Treg
densities have been reported
in lung, ovarian, colorectal, esophageal and gas- Methods
tric, melanoma, head and neck, prostate and Patients and Samples
pancreatic cancers (17-20). Evidence for Treg in This project was performed in Akdeniz UniverPCa patients, however, has been limited to a few sity immunology laboratory and urology out
recent studies with significant controversy (21). patient clinic from 2008 to 2010. A total of 56
Studies from experimental models have demon- patients with total serum PSA values of >2.5 ng/
strated that Tregs may either be induced or ac- ml, who were referred to transrectal ultrasound
tivated within the tumor draining lymph nodes (TRUS)-guided sextant prostate biopsy at Akby tumor-derived factors, including tumor- deniz University Urology Outpatient Clinic, were
associated antigens (TAA). Then, these cells
recruited. The mean age of the patients was 62
prevent tumor-specific immune responses ei- years (range 41 to 78 years). For Treg screenther at the induction phase in the tumor draining, 8 ml peripheral blood samples were drawn
ing lymph nodes or at the effector phase within from patients into heparinized tubes just before
the tumor milieu (22, 23). The first evidence
the biopsy. None of the patients had any known
that TAA-specific Tregs may be involved in sup- current infections, and none were taking any impression of tumor-specific immune responses
munomodulatory medications and none of them
in humans has recently been reported (24). had any cancer before. Blood and biopsy samples
Prostate-Specific Antigen (PSA), a serine pro- were obtained with written consent under an
tease produced by the prostate gland, is the best institutional review board-approved protocol.
known TAA of the prostate. Large amounts of
Of the total number of 56 patients that were anaPSA are produced and released into circulation in
lyzed, 19 were diagnosed with PCa, 27 with BPH and
PCa and BPH patients, as well as in people with 10 with no apparent prostate pathology (Table 1).
prostate inflammation. We demonstrate that the Of Of the 19 PCa patients, 17 had initial stage, loprevalence of Tregs is increased not only in PCa cally confined cancer, while 2 had radiologically
patients, but also in patients with BPH, and that detected bony metastasis. The Gleason score was
this enhancement is strongly correlated with PSA, used to grade prostate cancer; where a high score is
suggesting that PSA may have a role in Treg in- associated with advanced disease and poorer progduction and/or maintenance in these people. nosis. Of the 17 locally confined cancer patients,
The varying results concerning peripheral Treg 1 patient scored 5, 5 patients scored 6, 3 patients
densities in PCa patients and the lack of infor- scored 7 and 10 patients scored 9. Of the 17 with
mation regarding a correlation between PSA lev- locally confined PCa, 9 were treated by laparoscopic radical prostatectomy at our hospital and were
els and Treg cell frequency led us to investigate
the number of peripheral CD4+CD25highFoxp3+ re-analyzed for both total serum PSA and periphTregs and their association with total serum PSA eral Treg levels one month following the surgery.
levels in PCa and BPH patients. Our results sup- 10 who were negative for BPH, PCa and prosport that the frequency of Tregs increase not tatitis through pathological assessment were
only in PCa patients, but also in BPH patients. used as healthy controls. For Treg screenThis enhancement strongly correlates with PSA ing, 8 ml peripheral blood samples were drawn
levels, suggesting a role for PSA in the Treg in- from patients into heparinized tubes just beduction and/or maintenance in these subjects. fore the biopsy. Blood and biopsy samples
76
Y-I-2.indb 76
10.9.2011 9:21:08
were obtained with written consent under an

institutional review board-approved protocol.
counts were determined by using an automated

hematological analyzer (Sysmex XT-2000iV).
Phenotypic and Quantitative Analysis of Lymphocytes:

Peripheral blood mononuclear cells (PBMCs) were
isolated using a Fycoll-Hypaque density gradient.
Surface staining with anti-human CD4-FITC (BD;
555346), CD25-PE (BD; 555432) and intracellular
staining with Foxp3-APC (e-Bioscience; 17-477673) antibodies was performed as previously described (22, 25). Briefly, PBMCs were washed three
times with D-PBS and stained for surface CD4
and CD25 markers for 30 minutes at room temperature. Finally, the cells were washed twice with
saponin buffer and once with washing buffer and
analyzed using a BD FACSCalibur Flow Cytometer.
Flow-Jo software (Tree Star Inc., San Carlos, CA)
was used to analyze the samples and determine
the frequencies of Treg cells. Absolute lymphocyte
Serum PSA Quantification:

Total PSA (free + complexed) from serum samples was measured using an electrochemiluminescence immunoassay (ECLIA) with a Roche
Elecsys Modular Analytics E170 immunoassay
analyzer according to manufacturers instructions.
All of the statistical analyses were performed using
SPSS (version 16; SPSS Inc.). Statistical differences
between groups were evaluated by using Kruskas-Wallis analysis. The differences between two
groups were determined by the Mann-Whitney
test with Benferroni Correction. Correlation was
tested by the non-parametric Spearman method.
The statistical significance (p value) was set at <0.05.
FIGURE 1. (a) The gating strategy used for selecting

CD25high cells was very stringent. (b) The mean frequencies of
CD4+CD25highFoxp3+ Treg cells as percentages of peripheral
lymphocytes were determined for PCa patients, BPH patients
and healthy people, respectively.
Results
In this study, in order to avoid bias, we recruited
patients with serum PSA values of >2.5 ng/ml
(range 2.5-51) at the time of digital rectal examination and biopsy. Of the total number of 56 patients that were analyzed, 19 were diagnosed with
PCa, 27 with BPH and 10 with no apparent prostate pathology. Of the 19 cancer patients, 1 patient
had a total Gleason score of 5.5 had a total Gleason
score of 6.3 had a total Gleason score of 7 and 10
had a total Gleason score of 9. Seventeen of the
cancer patients had initial stage, locally confined
cancer, while two had radiological detected bone
metastasis. Ten people who were negative for BPH,
PCa and prostatitis through pathological assessment were used as healthy controls. Peripheral
Y-I-2.indb 77
77
10.9.2011 9:21:08
Finally,
immunohistochemical staining of
prostate tissue sections
from 19 PCa patients
showed a substantial increase in the number of
Foxp3 expressing Treg in
malignant tissue (Figure
2b) compared with benign tissue (Figure 2a).
There was a strong positive correlation between
the two parameters
with
a correlation coefFIGURE 2. (a) Low expressing Treg in Benign tissue (b) Substantial increase in the number
fi
cient
of 0.75 (p < 0.01).
of Foxp3 expressing Treg in malignant tissue in Pca patients.
Nine
PCa
patients,
who
were
treated
by laparoscopic radical prostatectomy, were
re-analyzed one-month post surgery for peripheral PSA and Treg levels (Figure 3).
The mean level of total serum PSA was 10.00
5.97 and the mean frequency of peripheral Treg
was 3.201.61 before the surgery. After curative
prostatectomy, serum PSA levels of all the patients
were reduced to very low/undetectable levels as
expected [(0.200.49; paired t-test p < 0.01) (Figure 4a, b)]. Strikingly, the mean Treg frequencies
in these patients also decreased significantly [(1.09
0.32; paired t-test p < 0.01) (Figure 4c, d)]. This
result suggests that PSA alone or in combination
with other tumor derived factors may be required
FIGURE 3. Correlation of serum PSA values with peripheral
for the increased presence of Treg in the periphery.
Treg frequencies
In order to rule out a possible post-surgery
stress effect on Treg frequencies, we recruited
blood samples of all the patients at the time of bi- six more patients, in addition to our study group
opsy were analyzed by flow cytometry using CD4, described above, that had previously planned
CD25, Foxp3. The gating strategy used for select- to undergo non-PCa related prostate surgering CD25high cells was very stringent (Figure 1a). ies at our hospital. These people were screened
The mean frequencies of CD4+CD25highFoxp3+ for Treg frequencies before and one month after
Treg cells as percentages of peripheral lympho- the surgery. In these patients, the frequencies of
cytes were determined as 3.23% 1.59% (n = 19), Treg did not change significantly after the surgery
1.66% 0.80% (n = 27) and 1.08% 0.43%, (n = (1.110.20 to 1.130.22; paired t-test p > 0.05),
10) for PCa patients, BPH patients and healthy demonstrating that surgery by itself does not
people, respectively (Figure 1b). Mean frequency cause a decrease in Treg frequency (Figure 4e, f).
of Tregs in PCa patients was significantly higher
than that of the BPH patients (p < 0.01) and healthy Discussion
donors (p < 0.01). In addition, the mean frequen- The purpose of this study was two-fold. First, we
cy of Tregs in BPH patients was also significantly sought to verify whether the peripheral frequenhigher than that of the healthy donors (p < 0.01). cies of CD4+CD25highFoxp3+ Treg cells are elevated
78
Y-I-2.indb 78
10.9.2011 9:21:15
FIGURE 4. (a) Treg frequencies of individual patients before and after the surgery. (b) Mean Treg frequencies (3.20 1.61)
were significantly decreased after the surgery (1.09 0.32). (c) Total serum PSA levels of individual patients before and after
the surgery. (d) Mean serum PSA levels (10.00 5.97) were significantly decreased after the surgery (0.20 0.49). (e) Treg
frequencies of individual patients before and after non-PCa related surgery are shown. (f) Mean Treg frequencies (1.11 0.20)
were not significantly changed after the non- PCa related surgery (1.13 0.27).
in PCa patients; second, we aimed to determine

the direct correlation between the peripheral
Treg and total serum PSA levels in these patients.
We first demonstrated that CD4+CD25highFoxp3+
Treg densities are increased in PCa patients compared with BPH patients and healthy controls. In
addition to this observation, which is consistent
with the findings of Miller et al., (10) we also recorded a significant enhancement in Treg frequenJOURNAL OF HEALTH SCIENCES 2011; 1 (2)
Y-I-2.indb 79
cy in the periphery of BPH patients compared

with healthy controls. Even though Miller et al.,
(10) also clearly showed increased levels of Treg
infiltration in prostate tissue samples of BPH patients, these authors did not analyze those patients
for peripheral Treg densities. Our results and
those of Miller et al., however, contradict findings
of Yokokawa et al.(11), who observed no change in
the frequencies of Treg cells in PCa patients except
79
10.9.2011 9:21:18
in those with metastatic cancers. Seventeen of 19

patients in the current study and all of the patients
by Miller et al.(10) were reported to have locally
confined cancer. Furthermore, despite the fact that
the mean frequency of Tregs in PCa patients were
comparable in all three studies, the mean frequency reported for healthy subjects by Yokokawa et
al.(11) was considerably higher than the recorded
results from our study as well as others, including
Miller et al.(10) This discrepancy might have resulted from the age of healthy controls used, which
was 55 years (range 41-78 years) in our study.
Furthermore, our analysis clearly demonstrates
that Tregs from PCa patients have significant suppressive activity. Secondly and more importantly,
we demonstrate for the first time that a strong association exists between the high density of Tregs
and total serum PSA in both BPH and PCa patients,
suggesting that the increased frequency of Tregs
may not be a result of malignity, but may rather be
caused by the excessive amounts of PSA accumulation in these patients. We obtained the first line of
evidence for this assumption during the diagnostic process, by showing that Treg frequencies were
strongly correlated with serum PSA in patients
with serum PSA levels of 2.5-51 ng/ml, regardless
of the disease status (r = 0.75, p < 0.05). The evidence for the strong association of PSA with Tregs
was obtained from the analysis of nine patients
with locally confined cancers, who were treated by
radical prostatectomy. Treg frequencies of all these
patients subsided remarkably one month following surgery. Interestingly, although three of these
patients had Treg levels near the threshold Treg
frequency of 2.1% (95% CI), these levels further
declined. This suggests that tumor-specific Tregs
might still exist and be depleted upon antigen removal, even in patients whose Treg levels are not
elevated. Our result is in agreement with Kono et
al. (30), who have recently observed a similar reduction of peripheral Treg levels in gastric cancer
patients that underwent curative surgeries. Taken
together, our results strongly suggest that PSA, either alone or with other prostate derived factors,
is involved in either the induction and/or maintenance of peripheral Tregs in BPH and PCa patients.
This study was limited by patients number, because our clinic is not a urologic cancer clinic.
The reason for the enhanced number of Tregs
80
Y-I-2.indb 80
in human cancers is not clear. It is hypothesized

that TAA in the presence of soluble mediators,
such as TGF- and chemokines may be required
for peripheral induction and/or expansion of
Tregs within the tumor-draining lymph nodes.
We also do not know whether other factors, either tumor-derived or tumor-induced, are also
required in these processes. Previous in vitro
studies demonstrated that PSA is able to induce
TGF- production and impair dendritic cell maturation. Both of these pathways are known to induce Tregs, in vivo in experimental models and
in vitro in human PBMC cultures and thus, it is
reasonable to assume that excessive amounts of
PSA in both BPH and PCa patients may invoke
one or both of the above pathways to either induce or expand PSA-specific Tregs. It is also likely
that other mechanisms, such as IDO (Indoleamin
2-3 deoxygenase) or PGE-2 production by the
cells within the tumor milieu might contribute
to the process. Further studies addressing these
questions will be important for our understanding of the biology of the Treg in human cancer.
Restoring peripheral Treg levels upon removal of
cancerous prostates also has important implications
for immunotherapy for PCa. Many prostate-specific vaccine trials using PSA peptides to stimulate tumor-specific immune responses before the surgical
removal of tumors have not yielded desired results.
Conclusions
In this study we present, to our knowledge, the
first evidence in the literature that increased
frequency of circulating CD4+CD25highFoxp3+
Tregs in PCa and BPH patients is correlated
with PSA levels and also the first to demonstrate a strong dynamic association between
a TAA and Tregs in cancer bearing humans.
Our results demonstrate that peripheral Treg densities are correlated with PSA in BPH and PCa
patients, suggesting that PSA may have a role in
Treg induction and/or maintenance in Treg in
these people. In the light of these findings, we
may expect better response of treatment of tumour specific immunotherapy after removal of
prostate gland which includes adenocarcinoma
cells. More comprehensive studies on this issue by
holding the light of findings in immunotherapy
for PCa may provide new forms of treatments.
10.9.2011 9:21:22
Competing interests
The authors declare that we have no financial and per-
sonal relationships with other people or organizations that could inappropriately influence this work.
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www.jhsci.ba
Helicobacter pylori infection according to ABO

blood group among blood donors in Kosovo
Bukurije Zhubi1*, Zana Baruti-Gafurri2, Ymer Mekaj1, Mimoza Zhubi1, Idriz Merovci1,
Iliriane Bunjaku3, Valdete Topciu2, Emine Devoli-Disha2
National Blood Transfusion Centre of Kosovo, Pristine (NBTCK), Mother Theresa st., 10000, Pristine, Republic of Kosovo.
Diagnostic Center, University Clinical Center Kosovo, Mother Theresa st., 10000 Prishtina, Republic of Kosovo. 3 Clinic of Lung
Disease, University Clinical Center Pristine, Kosovo, Mother Theresa st., 10000, Pristine, Republic of Kosovo
Abstract
Introduction: Numerous studies have reported a high prevalence of Helicobacter pylori infection among
healthy and non-healthy persons in different places. The Aim of the study is to investigate the seroprevalence
of H. pylori infection among Kosovos Blood donor associated with ABO/Rhesus blood group.
Methods: 671 blood donors are tested for H. pylori antibodies and results are classified by way of donation,
age, gender, blood groups and education level. Serum antibodies are analyzed by Enzyme Linked Fluorescent Assay test for H. pylori IgG with Biomerieux HPY-VIDAS.
Results: The frequency of IgG antibody for H. pylori among healthy blood donors is 56.9%, there is not found
any difference between voluntary and non-voluntary blood donors (57.4% respectively 56.3%)(OR=1.05;
95% CI 0.76 to 1.43; p=0.8). H pylori IgG antibodies positive are detected in 57.0 % ( 126 of 221) of women,
compared with 56.9 % ( 256 of 450) of men(OR=0.99; 95% CI 0.72 to 1.38; p=0.96). Serpositive donors are
older than seronegative ones (31.9 years, respectively 29.5 years, p=0.02). Mean value of IgG antibody of H.
pylori is 3.61 with no significant difference between males and females (3.72 respectively 3.44; p=0.2). The
seroprevalence of H. pylori infection is similar among blood groups: O (57.4%), A (56.2%), B (59.6%), AB
(51.4%), RhD positive (56.7%) and RhD negative (58.3%).
Conclusions: The seropositivity of H. pylori is moderately higher in the non voluntary and familiar blood
donors among the total Kosovo blood donors. There is not found a significant relationship between infection
with H. pylori and ABO/Rhesus blood group among blood donors.
Keywords: H. pylori infection, blood donors, blood group
Introduction
Numerous studies have reported a high prevalence of H. pylori infection among healthy (1,
2, 3) and non healthy (4, 5, 6) persons in different places (7). H. pylori infection is recognized as the major cause of chronic gastritis
(8), and a factor in the pathogenesis of peptic
ulcer disease (9), gastric adenocarcinoma (10)
and the gastric non-Hodkin lymphoma of mucosa-associated lymphoid tissue (MALT) (11).
H. pylori infect more than half of the population in the world (10), but there are large differences in the prevalence of infection among ethnic
groups (12, 13). Infection occurs early (12) and
* Corresponding author: Bukurije Zhubi, National Blood Transfusion
Centre of Kosovo, Pristine (NBTCK), Mother Theresa st., 10000,
Pristine, Republic of Kosovo; Phone+37744169583
Fax: +38138552720; E-mail: bzhubi@yahoo.com
Submitted 5. July 2011/Accepted 15. August 2011
Y-I-2.indb 83
H. pylori seropositivity increased with age (14,

15). Lower socioeconomic status (crowded living
conditions) is associated with high infection rates
(4, 15). The prevalence of H. pylori in rural communities is higher than in urban population (10).
Transmission is by the oral-oral route, but some
data reports for fecal-oral transmission route
(16). H. pylori infection may, in some instances,
be a zoonosis (6). Once H. pylori infection is acquired, it persists for decades and probably for
life in untreated persons (13).The high prevalence of H. pylori infection 70%-90% is found
among persons in developing countries (9, 13)
but, about 20% of H. pylori infected people develop clinically apparent conditions such as
peptic ulcers or neoplasia. Education level was
associated with negative H. pylori status (17).
Based in above mentioned studies of many authors, H. pylori infection represents a highlighted
83
10.9.2011 9:21:22
BUKURIJE ZHUBI ET AL.: HELICOBACTER PYLORI INFECTION ACCORDING TO ABO BLOOD GROUP AMONG BLOOD DONORS IN KOSOVO
problem in the healthy population of many countries. Because in Kosovo there are no studies in
this area, the aim of this paper is the investigation
of frequency of H. pylori infection in blood donors
according to the type of blood donation (volunteers and familiarly), gender, age, education level
and blood groups. Also it is evaluate mean value of
IgG Antibody to H. pylori according to age group,
gender and blood group among blood donors.
Methods
In this study are evaluated 671 blood donors who
underwent ABO/Rhesus blood typing and measurement of serum anti H. pylori IgG antibodies.
Stored blood donor sera (450 males, mean age
of 32.23 and range 18 to 65 years; 221 females,
mean age of 28.18 and range 18 to 65 years; p is
0.0001) are collected from the March to April
2009 in Kosovos Blood Transfusion Center.
Age, gender, social class, educational level and
ABO/RhD blood groups and IgG values are recorded. All donors are divided in two groups:
voluntary donors and non voluntary or familial
donors who gave blood for their relatives. Blood
donors are categorized into three groups according
to the educational level: group I with primary education level, group II with secondary and group III
with high educational level. Also, they are divided
according to age (group I: 18-19 years, n=164;
group II: 20-29 years, n=216; group III: 30-39
years, n=108, group IV: 40-49 years, n=110; group
V: 50-59 years, n=61, and group VI: 60-65 years,
n=12. Beforehand, blood donors are screened and
anyone taking anti-inflammatory drugs, antibiotics, or corticosteroids or who is found to have any
problem with health is not allowed to donate blood.
Serum antibodies are tested against H. pylori infection by blood groups, age, and gander, which are
later analyzed by ELFA (Enzyme Linked Fluorescent Assay) test for H. pylori IgG with Biomerieux
HPY-VIDAS. The non-invasive serological method
is used for determining presence of H. pylori IgG
antibody in serum. Ten millilitres of blood sample
is taken from each donor and the sera stored at -20
C until required. The assay principle combines a 2
step enzyme immunoassay sandwich method with
a final fluorescent detection (ELFA). The commercial kit for detecting anti-H. pylori antibody is
found to have a sensitivity of 98.10% (Confidence
84
Y-I-2.indb 84
interval 93.12%-99.77%) and a specificity of 90.82

% (Confidence interval 93.12%-99.77%). Interpretation of the test result is done as follows: the result
lower than 0.75 is interpreted as negative, the result between 0.75- <1.00 is interpreted equivocal,
and the values higher than >1.00 is interpreted as
positive. In this study it is found that 48 samples of
blood donors were equivocal to H. pylori antibody,
therefore they are excluded and not evaluated.
Also it is evaluated mean value of Ig G Antibody
to H. pylori according to age group, gender and
Blood group. Blood grouping is performed by
slide agglutination test using monoclonal antiA, anti-B, anti-AB and anti-D (Rho) antibodies.
Statistics. For the parametric variables, values
are expressed as mean DS. Comparison of
means between groups is tested using a Student
t-test. For all statistical tests conducted, the alpha level was set at 0.05. ANOVA-test is used for
the analysis of mean differences of IgG H. pylori
between blood group ABO and age-groups. A
Chi-square test is used for the analysis of distribution of H. pylori infection donors according
to the blood groups. Statistical analysis is performed using INSTAT 2 statistical software system.
Results
From the total number of 671 tested blood donors for H. pylori infection, 382 or 56.9%, required IgG antibody for H. pylori, but there is not
found difference between voluntary (57.4 %), and
non voluntary blood donors (56.3%) (OR=1.05,
95% CI 0.76 to 1.43, and p value 0.8) (Table 1).
Serpositive donors are older 31.9 years, compared
with seronegative ones 29.5 years, p is 0.02 (Table 2).
The rate of H. pylori infection is not significantly
different in male and female with anti H pylori
Ig G antibodies detected in 57.0% (126 of 221) of
women compared with 56.9% (256 of 450) of men
(OR=0.99; 95% CI 0.72 to 1.38; p=0.96) (Table 3).
TABLE 1. Frequency of H. pylori infection among voluntary
and non voluntary (familiar) blood donors
Tested blood donors
Non-voluntary
Voluntary
Total
for anti IgG H. pylori,
Familiar)
(n=408)
(n=671)
no. (%)
(n=263)
H. pylori positive
234 (57.4)
148 (56.3)
382 (56.9)
H. pylori negative
174 (42.7)
115 (43.7)
289 (43.1)
OR=1.05 (95% CI 0.76 to 1.43, p=0.8)
10.9.2011 9:21:22
TABLE 2. Characteristics of blood donors according to age

and infection with H. pylori
Characteristic
Mean ageSD *
Median
Range
H. pylori Positive
donor (n=382)
31.912.9
28.0
18.0-65.0
H. pylori Negative
donor (n=289)
29.512.3
24.0
18.0-65.0
*T-test=2.4, df=669, p=0.02
TABLE 4. Value of IgG Antibody of H. pylori among blood

donors according to gender
Characteristic
Mean value IgG AbSD *
Median
Range
Total
(n=382)
3.62.1
3.1
1.1-11.4
Male
(n=256)
3.72.1
3.4
1.1-11.3
Female
(n=126)
3.42.2
2.6
1.1-11.4
*T-test (M vs. F) = 1.2, df=380, p=0.2
mean value (3.7 respectively 3.4, p is 0.2), (Table 4).

According to age it is found a high frequency of
H. pylori infection among blood donors in all age
Tested blood donors for anti
Males
Females
group: 18-19 years (51.8%), 20-29 years (53.7%),
IgG H pylori, no. (%)
(n=450)
(n=221)
30-39 years (62%), 40-49 years (60.9%), 50-59 years
H. pylori positive
256 (56.9)
126 (57.0)
(65.6%) and age group 60-65 (70%) (Figure 1).
H. pylori negative
194 (43.1)
95 (43.0)
Mean value of Ig G Antibody to H. pylori acOR=0.99 (95% CI 0.72 to 1.38, p=0.96)
cording to age group is higher in age group
50-59 year (3.92, range 1.2-10.2 and median
Mean value of Ig G Ab of H. pylori is 3.6, range 1.13- value 3.57). No significance among mean value
11.4 and median value 3.13. There is not found
of all age groups are found, p is 0.89), (Table 5).
significant difference between male and female Blood donors with secondary level education have
lower levels of infection (56.4%) compared
with subjects with primary and higher education (57.2% respectively
57.8%), but with no
significance between all
groups p=0.95 (Figure 2).
In table 6 it is represented the similar frequency
of H. pylori infection
among blood groups: O
(57.4%), A (56.2%), B
(59.6%) and AB (51.4%)
with p value 0.9. The
similar rate of H. pylori infection is found
among Rh D positive
FIGURE 1. Frequency of IgG antibody to H pylori among blood donors according to age
donors 56.7 %( 333)
group
and Rh D negative donors 58.3% (49 blood
donors) with p value 0.8.
There are not found
variation among seropositive H. pylori mean
value between group O,
A, B or AB (3.67, 3.52,
3.99 respectively 3.53),
FIGURE 2. IgG seroprevalence of H pylori in 671 blood donors according to education level.
TABLE 3. Frequency of H. pylori infection among blood donors according to gender
Y-I-2.indb 85
85
10.9.2011 9:21:22
TABLE 5. Mean values of IgG Ab of H. pylori positive according to age group in Kosovos blood donors
Variables
MeanSD (*)
Median
Range
18-19
(n=85)
3.7 2.4
2.9
1.2-11.7
20-29
(n=116)
3.5 2.0
3.2
1.1-11.4
Age group
30-39
40-49
(n=67)
(n=67)
3.5 2.0
3.7 2.3
3.2
3.4
1.1-9.1
1.2-11.1
50-59
(n=40)
3.9 2.4
3.6
1.2-10.2
60-65
(n=7)
3.2 2.1
2.2
1.2-10.8
(*) ANOVA-Age group: F=0.3, p=0.89
TABLE 6. Frequency of H. pylori infection among blood donors according to ABO blood group and Rh D Antigen
Tested blood donors for anti
IgG H pylori, no. (%)
H. pylori positive
H. pylori negative
O
(n=298)
171 (57.4)
127 (42.6)
A
(n=249)
140 (56.2)
109 (43.8)
Blood Group
B
AB
(n=89)
(n=35)
53 (59.6)
18 (51.4)
36 (40.4)
17 (48.6)
RhD (poz)
(n=587)
333 (56.7)
254 (43.3)
RhD (neg)
(n=84)
49 (58.3)
35 (41.7)
ABO Groups: Chi-test = 0.8, p = 0.9

RhD Groups: Chi-test = 0.08, p = 0.8
TABLE 7. Mean values of IgG Ab of H. pylori positive in relation to ABO blood group and Rh D Antigen in Kosovos blood donors
Variables
Structure (%)
MeanSD (*)
Median
Range
O
(n=171)
44.8
3.7 2.0
3.5
1.1-11.4
A
(n=140)
36.6
3.5 2.3
2.7
1.1-11.3
Blood Group
B
AB
(n=53)
(n=18)
13.9
4.7
4.0 2.2
3.5 2.1
3.8
3.2
1.210.8
1.2-7.8
RhD (poz)
(n=333)
87.2
2.1 3.6
3.2
1.1-11.3
RhD (neg)
(n=49)
12.8
2.7 4.0
3.3
1.1-11.4
(*)ANOVA ABO Group: F = 0.8, p = 0.5

ANOVA RhD Group: F = 1.2, p = 0.3
p is 0.5. Also, it is not found a significant difference between mean value of Ig G Ab of H. pylori
in Rh D Positive donors compare with Rh D negative ones ( 2.05 respectively 2.69) p is 0.3 (Table 7).
Discussion
H. pylori infection has a relevant clinical importance and the testing for H. pylori Antibody helps
in early detection of silent peptic ulcer (18). Previous studies reported a high frequency of H. pylori infection among voluntary blood donation (3).
Akira et al found high seroprevalence of H. pylori
infection in blood donors in four prefectures in Japan (19). Also Bernstein et al found in Canadian
Indian population high prevalence of H. pylori infection (20). The prevalence of H. pylori infection
continues to be higher in developing countries
86
Y-I-2.indb 86
(17, 21). Also there are found the significant associations between H. pylori infection age, ethnicity,
and socio cultural behaviours (13). Results reported by Sitas et al (22), presented that acquisition
of H. pylori infection is related to childhood living conditions (7, 23). The prevalence of infection
was higher in the older age group than in younger
age group, also low education standard was associated with the prevalence of infection (24).
Based in above mentioned data and the unmet
need for such a study in Kosovo we gave the idea
to analyze our blood donors to H. pylori infection
in this healthy group of population. In Kosovo voluntary blood donation is still insufficient to cover
all patients who need transfusion treatment with
blood products, so some donors used to be as familial donors which gave blood for their cousin
10.9.2011 9:21:23
(familial). The topic of this study is to compare

the frequency of H. pylori infection between these
two groups of blood donors according to ABO
group, Rh factor, gender, age and education level.
The overall seroprevalence to H. pylori is 56.9% in
healthy Kosovos blood donors with no difference
between voluntary and familial donors. This is a
moderately high rate of H. pylori infection among
healthy population. The data from previous studies presented large variations of H. pylori infection
among blood donors in different countries, but also
and in different regions in the same place. Previous
studies done in Italy showed a different prevalence
to H. pylori infection among blood donors in different regions: in Bologna it was 42%, in Sardinia
it was 43% and in Torino 47% (18, 6, 25). Some
data showed lower prevalence to H. pylori infection compared with our data which were: In Italy
it was 45% (3), Germany 36.9% (26), Netherlands
35.5% (8), Australia 32% (14), Finland 25% (27),
in Sweden was 18.2% (28), in Malaysia 14.2% (29).
The similar data with ours are presented by other studies, for example: among Spanish blood
donors it was 52.2% (30), blood donors in Guadeloupe 55.2% (2), and in Chinas blood donors
54.9% (31). The higher seroprevalence of H. pylori infection up to 60% is found in Brazil and
Lebanon (68.2%, respectively 68.3%) (9, 32).
Our data showed that the seropositive donors were older than 31.9 years, compared
with seronegative ones 29.5 years. Similar data
are presented and in Iran (33), when seropositive individuals are older than seronegative ones (24.5 years respectively 23.3 years).
Analyzed blood donors by gender showed no difference among men and women (57.89% respectively 57.01%) of H. pylori infection. No sex difference to H. pylori infection is reported either by
other authors (31). Also, no sex difference (17), is
reported by EUROGAST study group which investigates asymptomatic subjects in 17 populations
(24). But, the data offered by Robertson et al (14),
showed a lower frequency for seropositive men
and women blood donors (35%, respectively 28%).
The similar data with a lower frequency (16.8% in
men and 13.6% in female) with no sex difference
are found also, in Malaysian blood donors (male
16.8% and female 13.6%) (29), and in the Swedish blood donors (male 19% and female 16%) (28).
Y-I-2.indb 87
Other data (33) referred the positivity rate of

H. pylori which is similar among men (57.6%)
and women (50%). But data showed by Russo et al (3) presented higher seoprevalence in
men (46.4%) than in women (38.4%). Turkish women are more prone to H. pylori infection than man (60.8% respectively 42.9%) (34).
In this study it is found that about 52% of the
healthy blood donors have acquired H. pylori infection by the age 18-19 years. Further more, 54%
and 62% of the blood donors are seropositive to
H. pylori by the 20-29 and 30-39 age group. Blood
donors at age 40-65 years developed 55.6% Anti
IgG H. pylori antibody. This data showed that
we have increase of H. pylori infection with age,
18 to 59 years and then decrease after 60 years.
The data from previous study have shown a steady
rise of H. pylori carrier rate from under 20 years
to 40 years age (31). Also, the study by Ponzetto
et al (25), in Italian blood donor confirms that
the seroprevalence was higher in older than in
younger blood donors. Another study done in
blood donors in Bologna in Italy by Vaira et al
(18) found increase of H. pylori infection with
age. The study done in the chronic urticaria patients and Finish blood donors presented the
similar data that H. pylori infections rise with
age (27). In Swedish blood donors is showed increase of H. pylori infection till to 39 year, but
also and decrease among age 40 to 65 years (28).
But the data from other authors suggested significant increase of H. pylori infection with age
from 36.1% at 18-19 years to 63.7% at 50-59 years
(2). Our data are similar with data from Russo
et al (3), which found a high frequency to H. pylori (67%) in donors aged greater than 50 years.
But, there are some data from previous study,
which did not match with ours. The prevalence of H. pylori infection among asymptomatic healthy blood donors in Northern Peninsular Malaysia did not increase with age (29).
It is discussed that social class and education level
associated with H. pylori infection (22, 24). In the
contrast to the data of Sitas et al the data of Vaira
D et al (18) suggested no correlation with social
class in blood donors in Bologna. An inverse association with seoprevalence was found for different educational levels in investigated subjects
in Ontario in Canada (15), and in non- complier
87
10.9.2011 9:21:23
subjects in Brazil (12). Our data represented lower

H. pylori infection among Blood donors with secondary level education (56.4%), compared with
previous studies which have shown lower level
(34.1%) of infection in subjects with higher education (24), and the high prevalence of H. pylori infection in donors with a low educational level (3).
H. pylori infection distribution was similar among
ABO blood groups and Rhesus factor in Kosovos healthy blood donors. More studies have revealed no association between the ABO blood
groups and H. pylori serological status either in
healthy (29, 30) or in symptomatic subjects (14,
33, 20, 35). However some data (4, 8) showed a
higher seropositivity to H. pylori in Rh D negative blood donors and in patients with gastrointestinal complaints (76.3%, respectively 84.5%)
compared with our data (56.7%). In contrast to
previous mentioned data and our data, Kanibal
et al in Turkey demonstrated that H. pylori infection can be related to ABO blood group (34). They
found that blood groups O and A are more prone
to H. pylori infection than other blood groups.
No statistically significant differences are observed in mean values of Ig G antibody among

different groups (ABO and Rh D Factor) in blood
donors in Kosovo. The data recorded from Martin et al (30), also have not found differences in
mean value of IgG antibody among blood groups.
Conclusions
The seropositivity of H. pylori is moderately high
in the non voluntary and voluntary blood donors,
unrelated to gender. There is not noted a significant relationship between infection with H. pylori
and ABO/Rhesus blood group among Kosovos
blood donors.
Competing interests
This study is supported by the National Blood
Transfusion Centre of Kosovo in Pristine.
Acknowledgements
We thank Anila Tahiri MD, MSc for her technical
help and finalization of paper.
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89
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www.jhsci.ba
Acute postoperative pain relief, by

intraperitoneal application of local anesthetics,
during laparoscopic cholecystectomy
Ljiljana Gvozdenovi1*, Vesna Pajti2, Dejan Ivanov3, Radovan Cvijanovi3,
Sava Gavrilovi1, Zoran Gojkovi4, Saa Mili5
Clinic of Anaesthesiology and Intensive Care Medicine, Clinical Center of Vojvodina, Hajduk Veljkova 1, 21 000 Novi Sad,
Republic of Serbia. 2 Urgent Center, Clinical Center of Vojvodina, Hajduk Veljkova 1, 21 000 Novi Sad, Republic of Serbia.
3
Clinic of Abdominal and Endocrine surgery, Clinical Center of Vojvodina, Hajduk Veljkova 1, 21 000 Novi Sad, Republic of
Serbia. 4 Clinic of Orthopaedic surgery and Traumatology, Clinical Center of Vojvodina, Hajduk Veljkova 1, 21 000 Novi Sad,
Republic of Serbia. 5 Emergency Medical Service, Health Centre of Inija, J. Duia 8, 22 000 Inija, Republic of Serbia
Abstract
Introduction: Intraperitoneal administration of local anesthetic in combination with an opioid, for the relief
of postoperative pain, has already been reported after laparoscopic cholecystectomy. This study aimed to
assess the analgesic effect of the intraperitoneal administration of bupivacaine and morphine, in patients
undergoing laparoscopic cholecystectomy.
Methods: 90 patients (30 patients in each group) were included in a double blind, randomized manner. At the
end of laparoscopic cholecystectomy, the patients were intraperitoneally treated with 30 ml of: physiological
saline (Group 1) or 0.25% bupivacaine (Group 2) or 0.25% bupivacaine + 2 mg morphine (Group 3). Patients
postoperative pain was evaluated using a visual analogue scale and a verbal rating score. The postoperative
analgesic requirement was assessed by the total dose of Ketorolak, administered by intravenous or intramuscular route. Pain, vital signs, supplemental analgesics consumption and side effects were recorded for
all patients for 12h.
Results: There were no difference between the three groups, regarding pain scores (et rest and coughing)
during the study, except in the first 6 h, when scores were lower for patients receiving intraperitoneal bipuvacaine + morphine (p<0.05).
Conclusions: In the patients undergoing laparoscopic cholecystectomy, the intraperitoneal administration
of bupivacaine + morphine, reduced the analgesic requirements during the first 6 postoperative hours compared with the control groups. The combination of intraperitoneal bupivacaine 0.25% and morphine was more
effective for treatment of pain after laparoscopic cholecystectomy.
Keywords: laparoscopic cholecystectomy, bupivacaine, opioids, morphine, anesthetics, local anesthetics,
pain, surgery.
Introduction
Laparoscopic cholecystectomy (LC) is currently
considered to be a relatively minor operation (1,2).
It has been classified as a basket procedure (analogous to shopping with a supermarket basket) in
the UK governments publications on day-surgery
(3). But, an important factor that limits recovery
* Corresponding author: Prof dr Ljiljana Gvozdenovi,
Clinic of Anesthesiology and Intensive Care Medicine, Clinical Centre
of Vojvodina, Hajduk Veljkova 1, 21000 Novi Sad, Republic of Serbia
Tel: +38163-529-409, Fax: +38121-423-902;
E-mail: profgvozdenovic2010@hotmail.com
Submitted 4. May 2011/ Accepted 28. July 2011
90
Y-I-2.indb 90
is postoperative pain. Intraperitoneal instillation

of local anesthetics is a simple method of analgesia and should be considered in addition to other
morphine sparing analgesics such as NSAIDs, acetaminophen and incisional local anesthetics (4, 5).
Laparoscopic cholecystectomy, in healthy patients is routinely performed at our hospital on a
day case basis. Intraperitoneal instillation of local anesthetic around the operative site has been
used as an analgesic technique on the premise
that conduction from visceral sites is blocked
and may reduce the extent of referred pain to the
shoulder, which results of nerves C3, C4, C5 diaJOURNAL OF HEALTH SCIENCES 2011; 1 (2)
10.9.2011 9:21:23
LJILJANA GVOZDENOVI ET AL.: ACUTE POSTOPERATIVE PAIN RELIEF, BY INTRAPERITONEAL

APPLICATION OF LOCAL ANESTHETICS, DURING LAPAROSCOPIC CHOLECYSTECTOMY
phragm innervation, gas distension and diaphragmatic shifting, in the postoperative period (5,6,7).
However, in previous studies of intraperitoneal
local anesthetics following laparoscopic cholecystectomy it has not been possible consistently
to demonstrate reliable analgesic effects (8,9,10).
This may be related to nociceptive conduction
from incisional sites that are not blocked by local
anesthetics given into the intraperitoneal cavity.
Different regimens have been proposed to relieve pain after laparoscopic surgery, such as
non-steroidal anti-inflammatory drugs, local
wound anesthetics, intraperitoneal anesthetics
and saline, gas drainage, heated gas low-pressure gas and nitrous oxide pneumoperitoneum..
Multimodal analgesia (combined use of two or
more analgesic agents) for pain relief after operation is believed to the more advantageous
than single modality treatment, especially when
different sites of action are involved, or when a
synergistic effect, or both, is achieved (11,12).
The aim of the present study was to determine the
efficacy of the intraperitoneal application of bupivacain-morphine.
Methods
Patients and Procedures
A prospective, randomized, double-blind study was
undertaken with written informed consent which
was obtained from all patients. Each study group
consistent of 30 ASA I-II patients scheduled to undergo elective LC for cholelithiasis under general
anesthesia. The individuals, of both sexes, were
aged 26-63 yr. Criteria for exclusion were: psychiatric disease, allergic reactions to drugs or local anesthetics, morbid obesity and severe chronic disease.
Patients were also excluded, if they underwent surgery for acute cholecystitis or if the operation was
converted to an open procedure. All patients were
given a standard anesthetics comprising propofol
2-4 mg/kg, fentanyl 2 g/kg, ondasetron 4 mg, i.v.,
Rocuronium 0.6 mg/kg was used for muscular relaxation. Patients lungs were ventilated without
nitrous oxide, but with sevoflurane 1-1.5%, with
oxygen. Suppositories of diclofenac 100 mg, were
administered at the induction of anesthesia. Standard patient monitoring was used. Lung ventilation
was adjusted to maintain an end-tidal carbon diJOURNAL OF HEALTH SCIENCES 2011; 1 (2)
Y-I-2.indb 91
oxide partial pressure of 4.7-5.3 kPa. Intra-abdominal pressure during laparoscopy was automatically maintained at 12 mmHg by a CO2 insufflator.
At the end of successful LC, patients were allocated randomly to one of three groups. Group 1
(n=30) received physiological sodium chloride 30
ml, intraperitoneally. Group 2 (n=30) bupivacaine
0.25% 30 ml intraperitoneally. Group 3, (n=30)
bupivacaine 0.25% 30 ml, intraperitoneally plus
morphine 2mg. Each patient received the test
solution in the following way: 15 ml was sprayed
to both sides of the diaphragm, and another 15
ml, was directly applied to the gall bladder bed
and to the right subhepatic space. All patients
received ondasetron i.v., during operation (13).
During closure of the wound, the incisional sites
were infiltrated with bupivacaine 20 ml, 0.25%, 2.5
mg/ml, with epinephrine 5 g/ml, in all patients (14).
Residual neuromuscular blockade was antagonized
with a mixture of neostigmine and atropine (15).
In the postoperative period, patients were assessed
on awakening and then at 1, after 6 and after 12
hours by a trained observer. Intraperitoneal pain
at rest and during deep inspiration and any pain in
the right shoulder were assessed on a visual analogue scale (VAS). The degree of postoperative pain
was assessed with a VAS (0-100 mm) (0 - no pain,
100 - severe pain) at rest and on coughing. Patients
were asked about the location of pain, whether at
the shoulder, incision sites and/or inside the abdomen. Pain relief was rated by the patients on a 4
point verbal rating score (VRS). 0 = no pain relief; 1 = partial pain relief; 2 = good pain relief; 3 =
excellent pain relief, complete analgesia. The VRS
recorded during the study was summed obtaining
the total pain relief score for that period. Total pain
relief scores were used widely in analgesic clinical
trials higher scores signifying better analgesia.
Nausea and sedation were assessed also on a
similar VAS, representing no nausea and fully
awake on the left and worst imaginable nausea and very drowsy on the right, respectively. Pain, sedation and nausea scores for the
first 6 h after operation were summed (11, 24).
Nominal data were analyzed with the 2-test.
Statistical analyses was performed with the software SPSS. p< 0.05 was considered significant.
91
10.9.2011 9:21:24

TABLE 1. Patients characteristics

Gender (m/f)
Age (yr)
Height (cm)
Weight (kg)
Duration of pneumoperitoneum
Group 1
3/27
46 (13)
164 (4)
75 (8)
Group 2
4/26
48 (13)
164 (7)
81 (7)
Group 3
3/27
50 (9)
165 (7)
78 (13)
57 (13)
68 (20)
66 (21)
Results
The groups were similar in regard to gender, age,
height, weight and duration of the pneumoperitoneum (Table 1).
Values are mean (_+SD). There were no significant differences between groups. There were no
significant differences between the three groups
in relation to pain scores (at rest or on coughing)
during the study except in the first 6 h, in regard
to incisional and intra-abdominal pain scores,
respectively, in which pain was significantly
lower (p<0.05) in those patients receiving intraperitoneal bupivacaine plus morphine (Figure 1).
Scores of 2 (good relief) or 3 (complete relief)
on the VRS were reported more often by pa-
tients in Group 3, which resulted in higher total pain relief scores, although the differences
were not significant after six hours (Figure 2).
26 patients of the Group 1, 16 in Group 2 and 2 in
Group 3 needed a rescue dose, of postoperative analgesic drugs, in the first 6 h. No differences in the
incidence of nausea/vomiting were observed between groups (40%, 33%, and 40% in Groups 1, 2
and 3, respectively). None of the other above-mentioned side-effects was reported by any of the groups.
Discussion
The results of this study demonstrated that intraperitoneal administration of bupivacaine 0.25%
30 ml, plus morphine 2mg, significantly reduced
postoperative analgesic requirements during the
first 6 h, after laparoscopic cholecystectomy, compared with the control group. Furthermore, the analgesic requirements were significantly lower during the entire study in patients belong to Group
3, who received intraperitoneal bupivacaine
0.25% 30 ml, plus morphine at the end of surgery.
Accordingly, previously we injected the drugs to
the subdiaphragmatic area. However, we found
a low incidence of shoulder pain in all treatment
groups, because the residual intraperitoneal carbon dioxide was deflated
carefully by the surgeon.
Our study shows that the
intraperitoneal administration of bupivacaine is
effective after LC, as noted
in other reports, although
the amount of pain reduction and duration of effect
FIGURE 1. VAS score at placebo, bupivacain and bupivacain+morphine group.
FIGURE 2. VRS score at placebo, bupivacain and bupivacain+morphine group.

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10.9.2011 9:21:24

were limited (16-19). It has been suggested that

the poor results in pain reduction, when intraperitoneal local anesthesia is used, after LC compared with those in the available gynecological
literature - are due to visceral and parietal pain
being more severe than shoulder pain after LC
(20-24). On the other hand, in a recent study the
intraperitoneal instillation of bupivacaine during
LC resulted in lower pain scores and in reduced
morphine requirements compared with placebo.
We used ketorolak, a non-opioid analgesic
with minor adverse effects and with powerful pain-relieving activity, including surgical
pain, in our study to assess analgesic requirements after operation. Our data also showed
a significant decrease in supplemental ketorolak in patients given morphine intraperitoneal.
We used bupivacaine and low doses of morphine,
intraperitoneally to achieve the additional analgesic benefit from the combined effect of a local anesthetic with an opioid agonist (25-29).
Intraperitoneal local anesthetics would be expected to be useful for treating visceral pain. In
our study it is likely that intraperitoneal bupivacaine in the right hypochondrial area had an
analgesic effect (30). It significantly reduced total abdominal pain during inspiration and there
was a trend towards lower scores for total abdominal pain at rest and total both shoulder pain.
Local anesthetic toxicity is a serious problem, which limits dosage and efficacy. Bupivacaine is used traditionally as it has a long
duration of action. It can cause central and
cardiovascular toxicity and there have been reports of accidental deaths and cardiac arrest (36).
We did not observe any side-effects attributable to
the local anesthetic. We did not measure plasma
concentrations of bupivacaine, but several reports

have shown that the range of mean plasma concentration (0.92 1.14 g/ml) after the intraperitoneal administration of plain bupivacaine (100
150 mg) is well below the toxic concentration of 3
g/ml. The doses of bupivacaine in our study were
lower than those thought to cause systemic toxicity.
Our results are consistent with other studies in
which intraperitoneal administration of local anesthetic has been shown to have a modest analgesic
effect (31, 32). Of 13 clinical trials considered in a
systemic review it was found that the intraperitoneal administration of bupivacaine 50-200 mg, in
volumes of 10-100 ml, produced significant analgesia in seven studies where supplemental analgesic consumption was significantly reduced (33-35).
In summary, we have demonstrated that the intraperitoneal administration of morphine plus
bupivacaine 0.25% in patients undergoing laparoscopic cholecystectomy reduces ketorolak requirements during first 6 h after the operation
compared to a control group. However, the intraperitoneal application of bupivacaine 0.25% combined with morphine, at the end of surgery is effective in achieving reduction in pain (36, 37, 38).
Conclusion
Therefore, we concluded that combination of intraperitoneal bupivacaine and morphine was
better than, bupivacaine without morphine, or
placebo, for pain relief after laparoscopic cholecystectomy. The surgeons involved in the
study continue to use this method of analgesia as part of their routine practice (40, 41).
Competing interests
Authors declare no conflict of interest.
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www.jhsci.ba
Dural tail sign adjacent to different intracranial

lesions on contrast-enhanced MR images
Svjetlana Mujagi1*, Jasmina Beirevi-Ibrievi1, Vesna Vruljevi-Marti1,
Zlatko Ercegovi2, Delil Korkut2, Mirza Moranjki2
Department of Radiology and Nuclear Medicine, University Clinical Center Tuzla, Trnovac bb, Tuzla 75 000, Bosnia and
Herzegovina. 2 Department of Neurosurgery, University Clinical Center Tuzla, Trnovac bb, Tuzla 75 000, Bosnia and Herzegovina
Abstract
Introduction: The aim of this study is to determine the prevalence of dural tail sign (DTS) in meningiomas,
glioblastomas multiforme, metastasis, pituitary macro-adenomas, acoustic neuromas, medulloblastomas,
lymphomas and Wegeners granulomatosis, and to reveal if DTS is specific for meningiomas.
Methods: In this retrospective, cross sectional study 96 patients were included with 95 intracranial and 1
extracranial lesions. The study was conducted in the period from January 2008 to May 2010 and the group
pattern was made consecutively. The patients underwent surgery and all 96 lesions were examined by histopathology analysis. DTS was analysed on contrast T1- weighted spin echo images after injection of 0.1
mmol/kg gadolinium contrast medium. The presence of this sign was defined using Goldsher et als criteria.
Results: Histopathology results of the 96 lesions revealed the presence of: 35 meningiomas, 25 glioblastomas multiforme, 13 metastasis, 10 pituitary adenomas, 5 acoustic neuromas, 4 medulloblastomas, 3 lymphomas and 1 Wegeners granulomatosis. On the contrast-enhanced T1 MR images, DTS was noted in 31
(32.3%) lesions, in the following histological samples: meningioma, GBM, adenoma, schwannoma, medulloblastoma and Wegeners granulomatosis, while in the cases of metastasis and lymphomas DTS was not
noted. We found the dural tail sign to have a sensitivity of 68.6% and specificity of 88.5% in the diagnosis of
meningioma.
Conclusion: The dural tail is a common but not a pathognomic sign of meningioma on contrast-enhanced
T1 MR images. Other intracranial lesions, such as glioblastoma multiforme, pituitary adenoma, schwannoma,
medulloblastoma and Wegeners granulomatosis may also be represented with this sign.
Keywords: dural tail sign, intracranial lesions, magnetic resonance, contrast enhanced study
Introduction
Dural tail sign (DTS), also known as the meningeal sign, dural thickening or flare sign, was
first described by Wilm et al. in 1989. It is a linear thickening of the dura adjacent to an intracranial pathology on contrast-enhanced T1 MR
images (1) (Figures 1, 2, 3). The exact histological nature of DTS is controversial. It was initially
proposed that DTS is a result of direct tumour
extension within or at the surface of the dural
membrane (1, 2), but some other authors have
been able to show little or no direct tumour in* Corresponding author: Svjetlana Mujagi, Department of
Radiology and Nuclear Medicine, University Clinical Center
Tuzla, Trnovac bb, Tuzla 75 000, Bosnia and Herzegovina
Tel: + 387 61 661 080 or + 387 35 394 242; Fax.: + 387 35 251 456
e-mail: svjetlanabh@yahoo.com
Submitted 29. July 2011 / Accepted 25. August 2011
96
Y-I-2.indb 96
volvement. They suggested that DTS might be

attributed to fibrous tissues with loose connective tissue proliferation, hypervascular reaction
and vascular dilatation (2, 3). It is possible that
two mechanisms (tumour invasion and hypervascular reaction) may be responsible for DTS (4).
In 1990, Goldsher et al. (2) devised the following three radiological criteria to reliably establish the presence or absence of DTS: 1) The
tail should be identified on two successive sections through the tumour, 2) the tail should taper smoothly away from the tumour, and 3) the
tail must have an enhancement greater than
that of the tumour itself. If present, as imaging
slices tend to be less than 5 mm, there should
always be at least three sections showing the
dural tail, depending on the slice thickness (5).
DTS was first thought to be pathognomonic of
10.9.2011 9:21:24
SVJETLANA MUJAGI ET AL.: DURAL TAIL SIGN ADJACENT TO DIFFERENT INTRACRANIAL LESIONS ON CONTRAST-ENHANCED MR IMAGES
meningioma, but many later studies demonstrated DTS adjacent to various intra and extra-cranial pathologies as well as in spinal lesions (4, 6).
The aim of this study is to determine the prevalence of DTS in meningiomas and some other intracranial lesions, and to reveal if DTS is specific
for meningiomas.
Methods
Patients
In this cross-sectional study, we retrospectively
examined the magnetic resonance findings of 95
intracranial lesions and 1 extracranial lesion in
96 patients (mean age 51.9 years, ranging from 5
to 76 years) with no history of previous intracranial surgery, trauma or intracranial haemorrhage.
In the study, which was conducted in the period
from January 2008 to May 2010, we included all
patients with discovered intracranial and extracranial lesions which may be associated with DTS.
We studied patients with meningiomas, glioblastomas multiforme, metastasis, pituitary macroadenomas, acoustic neuromas, medulloblastomas,
lymphomas and Wegeners granulomatosis. We
did not have patients with some other lesions
which could be associated with DTS such as chloroma, multiple myeloma, aspergillosis, chordoma,
pituitary apoplexy, hypophysitis, pleomorphic
xanthoastrocytoma, eosinophilic granuloma, Erdheim-Chester disease, sarcoidosis, giant posterior
cerebral artery aneurysm, dural cavernous hemangioma, hemangiopericytoma. We excluded patients with cerebellar stroke. All patients included
in this study underwent surgery and all of 96 lesions were examined by histopathology analysis.
Procedure
MR were performed at the Department of Radiology and Nuclear Medicine, surgical treatment at the Department of Neurosurgery, and
pathohistological analysis at the Department of
Pathology of the Polyclinic for Laboratory Diagnostics of the University Clinical Centre, Tuzla.
MRI was performed on a 1.5 T MR scanner (Avanto, Siemens, Erlangen Germany). DTS was analysed on contrast T1- weighted spin echo images
after 0.1mmol/kg gadolinium contrast medium
injection with the following parameters: TR 500
ms, TE 8.1 ms, 5mm section thickness, 230 mm
Y-I-2.indb 97
field of view, 256x256 matrix. MR images were

obtained on three planes: axial, coronal and sagital plane. The presence of DTS was defined using
Goldsher et als criteria (2): a) the tail was identified on two successive sections through the tumour, b) the tail was taper smoothly away from
the tumour, c) the tail had an enhancement greater than that of the tumour itself. The MR findings were interpreted by one of two radiologists.
The sensitivity and specificity (95% confidence interval-CI) of DTS in diagnosis of meningioma were calculated with diagnostic
test analysis (2 by 2) in Arcus Quickstat Biomedical software (Version 1.0-build 88; 1997).
Results
Histopathology results of the 96 intracranial lesions revealed the presence of: 35 (36.5%) meningiomas, 25 (26%) glioblastomas multiforme (GBM),
13 (13.5%) metastasis, 10 (10.4%) pituitary macroadenomas, 5 (5.2%) acoustic neuromas or schwannomas, 4 (4.2%) medulloblastomas, 3 (3.1%) lymphomas and 1 (1%) Wegeners granulomatosis.
TABLE 1. Presence of the dural tail sign in different intracranial lesions
Intracranial lesions
Meningiomas
Glioblastomas multiforme
Metastasis
Pituitary adenomas
Schwannomas
Medulloblastomas
Lymphomas
Wegeners granulomatosis
Total lesions
Dural tail sign

Present (%)
Absent (%)
24 (68.6)
11 (31.4)
2 (8)
23 (92)
0 (0)
13 (100)
2 (20)
8 (80)
1(20)
4 (80)
1(25)
3 (75)
0
3 (100)
1 (100)
0 (0)
31 (32.3%)
65 (67.7%)
TABLE 2. Presence of the dural tail sign in meningiomas and

other cranial lesions (Data for diagnostic test analysis 2 by 2)
Intracranial lesions
Meningiomas
Other cranial lesions
Total
Dural tail sign

Present
Absent
(test positive) (test negative)
24
7
11
54
35
61
Total
31
65
96
97
10.9.2011 9:21:25
FIGURE 1. The coronal contrast-enhanced T1-weighted image shows a right temporal meningioma with the dural tail
sign below and lateral to the lesion, along the right tentorium.
FIGURE 2. The coronal contrast-enhanced T1-weighted image reveals the left tentorial meningioma with the dural tail
sign along left tentorium
Of these 96 intracranial lesions, 7 tumours were

located in the cerebellopontine angle (CPA) (5
schwannomas and 2 meningiomas), 11 tumours
were located in the sellar and parasellar region
(all 10 pituitary adenomas and 1 meningioma),
4 medulloblastomas and 1 meningioma were located infratentorially, while all of the 25 GBMs, 31
meningimas and 1 Wegeners granulomatosis were
located supratentorially. The linear thickening of
the dura adjacent to an intracranial pathology
(DTS) was noted on the contrast-enhanced T1 MR
images in 31 (32.3%) lesions, while in 65 (67.7%)
DTS was absent. DTS were present in the following
histological samples: meningioma, GBM, adenoma, schwannoma, medulloblastoma and Wegeners granulomatosis, while in the cases of metastasis and lymphomas DTS was not noted (Table 1).
With diagnostic test analysis (Table 2) we found
that DTS had a sensitivity of 68.6% (CI: 50-83%)
and specificity of 88.5% (CI: 77-95) for diagnosis
of meningioma with a positive predictive value of
77.4 (CI: 58-90), negative predictive value of 83.1
(CI: 71-91), positive likelihood ratio of 6, (CI: 2.812.4) and a negative likelihood ratio of 0.4 (CI: 0.20.5). In the CPA, DTS was present in 1 schwanoma
and 1 meningioma, while in the parasellar location,
DTS was present in 2 adenomas and 1 meningioma.
to reveal intracranial pathology but also to give a

diagnosis of the revealed lesion as close as possible
to the histopathology diagnosis. The majority of
meningiomas exhibit highly stereotypic imaging
characteristics, when combined with their select
intracranial dural-adherent localizations, which
often facilitates their diagnosis, especially on MRI
(7). However, it may sometimes be difficult to
differentiate between meninigomas and other tumours in some intracranial locations. For example,
a meningioma in the CPA near to the internal
auditory canal may be mistaken for an acoustic
neurinoma, while a meningioma in the parasellar
region may be mistaken for a pituitary adenoma.
DTS describes a linear enhancement along the dura
mater on contrast T1-weighted resonance images
(Figure 1, 2, 3). This sign is considered as common
and useful for distinguishing meningioma from
other intracranial lesions and was at first thought
to be pathognomonic of meningioma. Many later
studies demonstrated the presence of this sign
adjacent to other intra- and extra-cranial pathologies: lymphoma, chloroma, metastasis, multiple
myeloma, GBM, aspergillosis, chordoma, schwannoma, pituitary adenoma, pituitary apoplexy, hypophysitis, pleomorphic xanthoastrocytoma, eosinophilic granuloma, Wegeners granulomatosis,
Erdheim-Chester disease, sarcoidosis, medulloblastoma, giant posterior cerebral artery aneurysm,
dural cavernous hemangioma, hemangioperi-
Discussion
The aim and task of every radiologist is not only
98
Y-I-2.indb 98
10.9.2011 9:21:25
FIGURE 3 and 4. The axial and coronal contrast-enhanced T1-weighted images show the dural
tail sign adjacent to the heterogeneously enhanced tumour, which corresponds to glioblastoma
multiformetorium.
FIGURE 5 and 6. The coronal and axial contrast-enhanced T1-weighted images show a right
frontal heterogeneously enhanced mass, with linear enhancement of the adjacent dura, which is
better visualised on an axial image.
FIGURE 7. The control MR axial contrastenhanced T1-weighted image shows a

heterogeneously enhanced tumour, with
dural tail sign medial of the tumour. Histopathology exam revealed the glioblastoma
multiforme.
Y-I-2.indb 99
FIGURE 8. The coronal contrast-enhanced T1weighted image shows intense enhancement in

a mass in the left cerebelopontine angle and in
the jugular foramen (circle), which corresponds
to a meningioma. The mass spreads into the internal auditory canal with an evident dural tail
sign (white arrow)
cytoma and in cerebellar stroke (8-30).

In previous studies,
DTS has been reported in 52-72% of meningiomas on MRI
(2, 4, 12, 29, 30, 31).
Goldsher et al. (2)
proposed that DTS
was a highly specific
sign for meningioma.
They found DTS in
18 of 30 meningiomas (60 %), while
Aoki et al. (30) found
DTS in 13 of 18 meningiomas (72 %). In
2006, Rokni-Yazdi
and Sotoudeh (12)
indicated that DTS
has a sensitivity of
58.6 % and a specificity of 94.02% for the
diagnosis of meningioma. In their study,
22 patients with intracranial
masses
exhibited DTS (18
meningiomas, 2 pituitary adenomas, 1
primary
cerebral
lymphoma and 1 fungal brain abscess). In
2009, Rokni-Yazdi et
al. (13) noted DTS in
17 cases of tumours
(12 meningiomas, 3
pituitary adenomas
and 2 schwannomas).
In our study, we
found that DTS has
a sensitivity of 68.6%
for the diagnosis of
meningioma, which
is in accordance with
the published results.
This result is most
similar to the 72%
sensitivity achieved
99
10.9.2011 9:21:25
by Aoki et al. (30). For

diagnosis of meningioma, we found that
DTS has a specificity
of 88.5%. This specificity is 5.52% lower
than the specificity
noted by Rokni-Yazdi and Sotoudeh (12). FIGURE 9 and 10. The axial coronal contrast-enhanced T1-weighted images show an acoustic
DTS has been re- neuroma in the left cerebelopontine angle with the dural tail sign adjacent to the neuroma
ported in only a few
gliomas. In the published literature, we found only dura mater around the lesions (Figure 5, 6). On the
eight cases of GBM associated with DTS (5, 9, 33, second MRI, control scans showed the classic appearance of GBM (Figure 7). The diagnosis of GBM
34). In all eight cases, the dura mater had a normal
appearance on the histological examination, with- was confirmed by the pathologic examinations.
out tumoural invasion (9, 33). Also, because GBM An acoustic neuroma, which arises from the vestibular portion of the 8th cranial nerve, is the
is rarely fed by the vessels of the dura mater, the
enhanced DTS is not likely to develop from vascu- most common of all CPA neoplasms, followed
by meningiomas. Aoki et al. (30) in their study
lar congestion or proliferation (5). In our study we
found DTS in 2 of 25 GBM cases (Figure 3, 4, 5, 6, 7). reported 4 meningiomas in the CPA with linear
In one of the GBM, the first MR exam showed non- enhancement along the internal auditory canal.
specific radiological findings for GBM. The tu- It was suggested that this DTS might be useful in
the differential diagnosis of dural-based and other
mour appeared as a few smaller intra-axial lesions
in the right frontal lobe, slightly hypointense on neoplasms. Some other studies reported DTS adjacent to an acoustic neuroma that can mimic a
the T1-weighted image and slightly hyperintense
on the T2-weighted image, with strongly contrast meningioma, but its hypersignal intensity in the
enhancement and linear enhancement along the T2-weighted image and narrower dural attach-
FIGURE 11. The coronal contrast-enhanced T1-weighted image shows a homogeneously enhancing sellar and left parasellar mass with a dural tail sign. The lesion corresponds to a
pituitary macro-adenoma.
100
Y-I-2.indb 100
FIGURE 12. The coronal contrast-enhanced T1-weighted

image shows intense enhancement in the intra-axial mass in
the left cerebellar hemisphere, with the dural tail sign along
the left tentorium. Histopathology exam revealed the medulloblastoma.
10.9.2011 9:21:25
FIGURE 13. The coronal T1-weighted contrast-enhanced MR

image shows an inflammatory mass in the left frontal lobe in
the patient with Wegener's granulomatosis, focal thickening
and enhancement of the dura overlying the anterior aspect of
the left temporal lobe-dural tail sign.
ment can differentiate this tumour from a meningioma (6, 10, 11, 35). In our study 7 tumours
were located in the CPA (5 acoustic neuromas and
2 meningiomas). We noted DTS in both meningiomas (Figure 8) and 1 neuroma (Figure 9, 10).
Although DTS is a useful sign for differentiating
between pituitary adenomas and meninigomas
in the sellar region, in this case DTS is also not
specific for meningioma. DTS can be seen adjacent to pituitary adenomas in 30% of cases. The
pathophysiology of dural thickening in a pituitary
adenoma is not clear. It is probably the result of
venous congestion and meningeal inflammation
(6, 17, 36). Cases of DTS with pituitary adenomas
have been reported mainly with haemorrhagic
adenomas (18). In study conducted by Catin et
al. (36), DTS was common with both haemorrhagic and non-haemorrhagic adenomas. DTS
mostly extends into the planum sphenoidale and

carotid sulcus. Catin et al. noted slight dural thickening in the presellar region in 50% and marked
thickening in 40% of all cases of pituitary adenomas (36, 17, 36). In our study we noted DTS
in 2 (20%) of 10 pituitary adenomas (Figure 11).
In the published literature we found DTS adjacent to
medulloblastoma in two cases (37, 38). In our study
we noted DTS in 1 of 4 medulloblastomas (Figure 12).
Wegener's granulomatosis of the paranasal sinuses, with cerebral and meningeal involvement, may present with DTS (24, 40). In our
study we also had one patient with Wegener's
granulomatosis with DTS present (Figure 13).
DTS has also been reported in dural-based metastasis and cortical intraparenchymal metastasis, mostly in prostate and neuroblastoma metastasis (9, 39), but in our study in the 13 cases
of metastasis we did not note DTS. Also we did
not find DTS in any of the 3 cases of lymphomas.
Conclusion
Our study suggests that the dural tail is a common
but not a pathognomic sign of meningioma on
contrast-enhanced T1 MR images. Other intracranial lesions, such as glioblastoma multiforme, pituitary adenoma, schwannoma, medullobastoma
and Wegeners granulomatosis, also can present
with this sign. In our study we found the dural tail
sign to have a sensitivity of 68.6% and specificity
of 88.5% in diagnosis of meningioma.
Competing interests
The authors declare that they have no conflict of
interest. This study was not sponsored by any external organization.
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10.9.2011 9:21:26
www.jhsci.ba
The effect of breakthrough pain on heart and

lung function during the cancer pain treatment
in palliative care
Samir Husi1*, Denita Ljuca2, Senad Izi3, Hasan Karahasan4
Centre for Palliative Care, University Clinical Centre Tuzla, Trnovac bb, 75 000 Tuzla, Bosnia and Herzegovina. 2 Gynaecology
and Obstetrics Clinic, University Clinical Centre, Trnovac bb, 75 000 Tuzla, Bosnia and Herzegovina. 3 Anaesthesia and
resuscitation Clinic, University Clinical Centre, Trnovac bb, 75 000 Tuzla, Bosnia and Herzegovina. 4 Department of Gynaecology
and Obstetrics, Cantonal Hospital Zenica, Crkvice 67, 72 000 Zenica. Bosnia and Herzegovina
Abstract
Introduction: The aim of the research was to determine the effect of breakthrough pain (BTP) on heart and
lung function in patients whose cancer pain had been treated with strong opiates.
Methods: A prospective study was conducted on 80 patients who were treated in recumbent patients hospice of Palliative Care Centre (hospice) University Clinical Centre Tuzla. The effect of pain breakthrough on
heart function was monitored by blood pressure and pulse measuring outside. The effect on respiratory function was monitored by measuring the respiration number with SpO2 and pCO2 and pO2 capillary blood values
outside, during and after relieving pain breakthrough.
Results: Mean value for Karnofsky score for patients upon admission was 47.13 11.05 and on discharge
51.25 11.73. The total number of pain breakthroughs for patients within the 10 days of the treatment was
1396. During the pain breakthrough the mean of systolic pressure was 133.1 mmHg and it was statistically
significantly higher than the mean of systolic pressure measured after BTP relief with oral morphine. The
mean of diastolic pressure measured outside of pain breakthrough was 75.9 mmHg and after the BTP relief
it was 72.9 mmHg. The mean pulse outside of pain breakthrough was 92.7 heartbeats per minute and after
the BTP relief 8 9.1 heartbeats per minute.
Conclusion: Pain breakthrough leads to pulse acceleration, increased systolic and diastolic blood pressure
and it also affects respiratory function by accelerating the respiration.
Keywords: breakthrough pain, heart and lung function
Introduction
International Association for the Study of Pain
IASP, defines pain as an unpleasant sensory and
emotional experience associated with actual or
potential tissue damage, or described in terms of
such damage. Pain is the most frequent and the
most severe symptom of in cancer patients and
75-90% of patients in terminal stage endure pain,
the cause of cancer pain can be the cancer itself,
cancer therapy or the accompanying disorders
related to cancer pain. Tumour cells release endothelin, prostaglandins, alpha tumour necrosis
factor (TNF), proteolytic enzymes prostaglandins
* Corresponding author: Samir Husi, Centre for Palliative
Care, University Clinical Centre Tuzla Trnovac bb, 75 000
Tuzla, Bosnia and Herzegovina, Tel: 00387 61 736 211, Fax:
00387 35 303 300, e-mail: drsamirhusic@gmail.com
Submitted 2. July 2011/ Accepted 30. August 2011
Y-I-2.indb 103
(E1 and E2), proinflammatory cytokines (TNF, IL1, IL-6), substance P, tumour growth factor and
they also activate nociceptors that fire spontaneously and create peripheral sensitization and fast
tumour growth of different types of tumours can
lead to compression and nerve damage which
causes ischemia and direct proteolysis (1). Tumour
surgery can lead to nerve damage and neuropathic
pain. Chemotherapy induces the release of algogenic cytokines, radiotherapy leads to tissue fibrosis with nerve compression and painful mucositis
can be caused both by radio and chemotherapy
(2). Breakthrough pain (BTP) is a temporary sudden pain, a subtype of incidental pain that occurs
over the basic pain during the opiate treatment.
It should be differentiated from the weakly controlled basic pain, which is also often a cause of
the occurrence of pain breakthrough, also from
103
10.9.2011 9:21:26
SAMIR HUSI ET AL.: THE EFFECT OF BREAKTHROUGH PAIN ON HEART AND LUNG FUNCTION
DURING THE CANCER PAIN TREATMENT IN PALLIATIVE CARE
TABLE 1. Differentiation of basal cancer and breakthrough pain

Onset
Duration
Characteristics
Treatment
Basal cancer pain

Sudden or occurring gradually
Persistent, lasts for at least 12 hours daily
Dull, painful, sharp
Long-lasting opiates
with regular intake
emergency pain and crescendo pain. When BTP

occurs, basal pain is by definition relatively stable
and under control (3). The governing committee of
European Association for Palliative Care suggested
the use of term episodic pain which they divided into two groups with and without significant
basal pain (4). BTP by its intensity has to be severe
to unbearable on basis of weak or medium severe
pain. Portenoy and Hagen (5) described several
characteristics that are important for understanding the BTP: ratio of BTP with fixed dose of opiates,
temporal characteristics of BTP (duration period,
time of occurrence), the cause of occurrence of
BTP, possible predictability of the occurrence and
pathophysiology and etiology of BTP (Table 1).
BTP occurs in 70-95% of the cases in patients in
advanced stage of cancer disease (6). The intensity
of BTP is often described as very severe and intensive pain (from 7- 10 according to NRS (Numerical Rating Scale) with fast paroxysmal onset (<3
minutes) and the mean of reaching the pain peak
in less than 10 minutes. In 80-90% of the cases the
duration is from 15 to 30 minutes and the mean
frequency in patients in terminal stage of the cancer illness is 4-7 painful episodes a day (7). In 27%
of the cases it occurs spontaneously, while the occurrence of the BTP can be accelerated by activities such as movements, laughter, sneezing, coughing, sitting, touch, distension of hollow organs
(bowels, urethra) or psychosocial stimuli (8). The
cause of the BTP is most often related to bone pain
(27%), local soft tissue tumour invasion (21%) and
brachial plexus syndrome (9%) , and it can be classified as nociceptive, visceral nociceptive or neuropathic (9). Two key components in treating BTP
are: the size of individual salvage dose and tome
interval of administering the drug. Most authors
agree that the average salvage dose should be 10
to 20% of total daily dose of fast-acting strong opiate (10). In 17-30% of the cases, BTP is related to
104
Y-I-2.indb 104
Breakthrough pain
Unexpected, sudden, unpredictable
From few seconds to several hours, usually around 30 minutes
Sharp, shooting, radiant
Urgent therapy, immediately releasing or fast-acting
opiates, intake according to the need
inadequate analgesic treatment, whether it is subdosing analgesics or too long time interval between
the doses, which leads to reduction of concentration in the plasma e.g. opiate in the end of dose
interval which causes the increase of pain intensity
so called end dose insufficiency. At the same time
the patients endure BTP not wanting to take fastacting opiate out of fear of side effects or developing resistance and addiction. The most frequently
used drugs in BTP treatment are fast-acting oral
opiates with the onset of 20 to 30 minutes after the
administration, with maximal effect after 45 to 60
minutes (11). Much better effects in relieving the
BTP, because of its fast acting onset, are achieved
with transmucosal fentanyl citrate, which passes
through the blood brain barrier within 3-5 minutes, with its peak effect within 20-40 minutes
with its overall duration from 2-3 hours after the
administering the drug (12). Intranasally applied
fentanyl citrate spray, relieves the episodic pain significantly faster (within 5-10 minutes) in regard to
oral morphine, with safe way of application, without side-effects and good patient tolerance (13).
The aim of the research was to establish the effect of BTP on heart and lung function in patients
whose cancer pain was treated with strong opiates.
Methods
Patients
A prospective study has been conducted on 80
patients who were treated in recumbent patients
hospice at Palliative Care Centre of Clinical Centre Tuzla in the period of September 2010 to
March 2011. Basal Cancer pain (with 7-10 intensity according to NRS) was treated with strong
opiates (oral morphine and transdermal fentanyl)
whose doses were increased every third day of
the treatment by 50%, unless more than two pain
breakthrough occurred the previous day, in which
case a salvage dose of 8 mg of oral morphine was
10.9.2011 9:21:26
required. General condition of the patients was assessed using Karnofsky score upon admission and
also after 10 days of treatment. The effect of pain
breakthrough on heart function was monitored by
measuring the blood pressure (systolic and diastolic) and pulse outside, during and after relieving the BTP with salvage dose of oral morphine.
The effect on respiratory function was monitored
by measuring the number of respirations, values
of SpO2 measured with pulse oksymeter pCO2
and pO2-from ABS medical report, from capillary
blood, outside, during and after relieving BTP by
salvage dose of oral morphine. The study excluded
the following patients; patients allergic to strong
opiates, patients who have previously used strong
opiates, patients with heavy vomiting that hindered the intake of oral morphine, patients with
increased value of pCO2 due to respiratory insufficiency or as a sign of renal and liver insufficiency.
Statistical analysis was conducted using biomedical application software called MedCalc for Windows version 9.4.2.0. For testing the repeated
measurement of paired samples, depending on
the distribution of variables, paired T-test and
Wilcoxon tests were used. For testing the repeated measurements of samples with more than 2
variables, ANOVA for repeated measurements
was used. For testing the hypothesis of difference in frequency of parameters of dichotomous
scale, the test used was 2 test. Statistical hypothesis were tested based on the level of significance
of = 0.05 meaning that the difference between
samples was considered to be significant if p < 0.05.
Results
Mean value for Karnofsky score for all 80 patients upon admission was 47.13 11.05
and on discharge 51.25 11.73, and after relieving the pain Karnofsky score was statistically significantly better (p = 0.0005).
The total number of pain breakthroughs in all
80 patients within 10 days of treatment was
1396 (1.75 breakthroughs per patient a day). On
the first day of treatment, total number of pain
breakthroughs was 208 (2.6 breakthroughs per
patient a day), on the second day it was 184, and
on the third day 186 BTP (2.3 breakthrough/per
Y-I-2.indb 105
patient/a day). On the fourth day of the treatment the total of 160 BTP were noted (2.0 breakthroughs/per patient/a day) which is statistically
significantly less compared to the first day (p=
0.008). Also, in the following days, the BTP kept
reducing and on the tenth day total of 53 BTP was
registered (0.66 breakthroughs/per patient/a day),
which is statistically significantly less compared to
the day of the admission (p< 0.0001) (Figure 1).
The effect of BTP on cardiovascular system
During the BTP, mean value of systolic pressure
in all 80 examinees (in 1396 measurements) was
133.1 mm Hg (from 115 do 165 mm Hg) and was
statistically significantly greater (p< 0.0001) than
systolic pressure mean measured in a state of
stabile, controlled pain (outside BTP) when the
mean was 120.4 mm Hg (from 100 to 140 mm
Hg). After relieving BTP by salvage dose of oral
morphine the mean of systolic pressure was 114.5
mm Hg (from 80 to 140 mm Hg) and was statistically significantly lower (p<0.0001) compared to
the systolic pressure during the BTP (Figure 2).
The mean of diastolic pressure in all 80 examinees,
monitored outside BTP was 75.9 mm Hg (from 60
to 95 mm Hg). During the BTP the mean of diastolic pressure (in 1396 measurements) was 84.7
mm Hg (from 70 to 130 mm Hg) and was statistically significantly higher (p<0.0001) compared
to measuring outside BTP. The value of diastolic
pressure after relieving the BTP with salvage dose
of oral morphine was 72.3 mm Hg (from 50 to 95
mm Hg) and was statistically significantly lower
(p< 0.0001) compared to diastolic pressure during
the BTP (Figure 2). Measured outside BTP, mean
pulse in for all 80 patients was 92.7 heartbeats per
minute (From 78 to 110 heartbeats per minute).
During the BTP statistically significant pulse acceleration occurs (p< 0.0001) so the mean rises to
102.2 heartbeats per minute (from 83 to 120 heartbeats/min), followed by significant pulse slow
down after relieving the BTP with oral morphine
(p< 0.0001), so the mean shows 89.1 heartbeats per
minute (from 64 to 107 heartbeats/min) (Figure 2).
The effect of breakthrough pain on respiratory system
The mean number of respirations, measured in
a state of stabile, controlled pain was 13.6 per
minute (from 12 to 16), with statistically sig105
10.9.2011 9:21:26
FIGURE 1. Number of BTP through days of treatment in all

examinees
FIGURE 2. The values of blood pressure and pulse depending on BTP
FIGURE 3. The mean of respirations per minute depending

on the number of BTP
FIGURE 4. The mean of pCO2, pO2 and SpO2 depending on

BTP
nificant respiration acceleration (p<0.0001)

during the BTP to the mean of 15.6 per minute
(from 12 to 21 respirations per minute). Relieving BTP with salvage dose of oral morphine
significantly slows down the respiration speed
(p<0.0001) so the mean number of respirations
per minute is 12.8 (from 11 to 16) (Figure 3).
The mean of partial pressure of carbon dioxide
in capillary blood (pCO2) in all 80 patients outside BTP was 40.2 mm Hg (from 29.6 to 51.1
mm Hg) while during the BTP statistically significant (p< 0.0001) increase of pCO2 to the mean
of 44.2 mm Hg occurred (from 30.2 to 57.2 mm
Hg), and relieving BTP with salvage dose of oral
morphine significantly reduces the mean of pCO2
mm Hg (from 28.3 to 51.1 mm Hg) (Figure 4).
Partial pressure of oxygen (pO2) in capillary blood
in all patients outside BTP in mean was 75.9 mm
Hg (from 62.7 to 91.6 mm Hg) and is statistically
significantly higher (p< 0.0001) than pO2 mean
during BTP, which was 71.9 mm Hg (from 55.7 to

88.4 mm Hg) on mean. By relieving the pain by
salvage dose of oral morphine the ventilation improves so the mean of pO2 was 77.7 mm Hg (63.1
to 92.7 mm Hg), which is statistically significantly
higher (p< 0.0001) than during BTP (Figure 4).
The saturation mean (SpO2%) measured with
pulse oximeter in all 80 patients, monitored outside BTP was 92.8 % (from 83 to 96%) only to
be statistically significantly smaller during the
BTP (p<0.0001) when it was 89.1 % (from 79 to
96%) and after relieving BTP with oral morphine,
the mean SpO2 94.5% (from 84 to 98%) and it
was statistically significantly higher (p<0.0001)
compared to the means of SpO2 during BTP
but also before the onset of BTP (Figure 4).
106
Y-I-2.indb 106
Discussion
In the study that monitored the effects of cancer
pain treatment with transdermal fentanyl within
10.9.2011 9:21:26
the period of 3 months, Karnofsky score was

relatively constant during the treatment, with the
mean of 69 2 on the first day, 68 2 at the end
of the second month and 69 2 at the end of the
study (14). In our study, mean value of Karnofsky
score for all 80 patients upon admission was 47
11.05 and upon release 51.25 11.73, so after relieving the pain Karnofsky score was significantly
better (p=0.0005). The study of Marinangeli and
associates on 48 patients in advanced stage of
carcinoma showed, contrary from our study, that
after the opiate treatment with the average duration of 76.66 41.15 and significant reduction of
pain intensity (p = 0.04), statistically significant
reduction of Karnofsky performance status occurs (from 58.92 5.56 upon admission, with the
reduction of 24.04) and the degree of life quality, shows deterioration of general condition (15).
In our study, after relieving the pain with strong
opiates, dyspnea was statistically significantly reduced (p< 0.0001; 4.41 2.13 compared to 1.95
1.43. BTP significantly accelerates respiration,
but no considerable difference was noted compared to the number of respirations before the
BTP (13.6/min) and after relieving the pain with
strong opiates (12. 8/min). A study published for
palliative care units in Japan states that dyspnea
occurs in 29 to 74% of the patients, regardless of
the type of carcinoma in terminal stage of the illness, in which respiratory depression treated by
morphine is defined as deceleration of breathing
by more than 10% and it reduces SpO2 by more
than 5. The mean dose of morphine used was 65
mg/per day/per patient (in our study 52.42 mg
within all ten days of the treatment.) Also, in our
study, there was no significant difference in the
number of respirations (p= 0.117) before and after the application of morphine. In this study the
mean of oxygen saturation (SpO2%) measured by
pulse oximeter was around 88% before, and up to
98% after the morphine treatment (p=0.125), and
as well as in our study there was no statistically
significant difference. This study concurrently
draws a conclusion that if the morphine is applied
in the form of nebulizer (if it is inhaled) it relives
the breakthrough pain or sudden onset of dyspnea significantly faster and it has far less system
side effects (constipation, drowsiness etc.) (16).
In random double-blind controlled study conJOURNAL OF HEALTH SCIENCES 2011; 1 (2)
Y-I-2.indb 107
ducted in Switzerland in older patients in which

dyspnea was treated with 5 mg s.c. of morphine,
measuring taken 45 minutes after the treatment
show, like in our study, a significant (p<0.01 reduction of pain intensity [(according to VAS scale:
57.8 16 before compared to 32.8 15 after the
morphine treatment, while in the placebo group
control measuring shows aggravation of pain from
50.6 18 before, compared to 51.115 after the
application of the placebo)]. The number of respirations after the morphine treatment was smaller
(-2 2.2), while in the placebo group there was no
difference in the number of respirations (p=0.02)
compared to experimental and placebo group. In
this particular study, as well as in our study, there
was no significant difference in blood oxygen saturation before and 45 minutes after the morphine
treatment (0 1.5). The study concludes that the
morphine reduces dyspnea in patients suffering
from cancer without any significant side-effects,
with the use of one quarter of regular 4-hour
dose of morphine used in pain treatment (17).
A study by Estefan and associates follows similar parameters in 30 patients in terminal stage
of cancer disease that is not dependent on oxygen therapy. There was no statistically significant change (p = 0.14) in values of end-tidal CO2
(values before 33.39 5.0 compared to means
after 34.79 5.7 mm Hg) after the morphine
treatment which lead to significant reduction of
pain intensity. In our study as well, there is no
significant change in the mean of partial pressure in the capillary blood (pCO2) before and after
the treatment with oral morphine [39.9 mm Hg
(from 29.6 to 51.1 mm Hg) before compared to
38.2 mm Hg (from 28.3 to 50.8 mm Hg) after the
treatment], although, contrary to the Estefan and
associates study, the means of pCO2 in our study
were somewhat higher after the treatment (18).
A Study conducted at St. Christopher Hospice
monitors the effect of oral morphine on respiratory function in 31 patients. All patients received
over 100 mg morphine sulphate a day in the average doses of 30 mg for every 4 hours (from 20
to 90 mg). The diagnoses of cancer were set approximately 11 moths (from 3 to 174 months)
before the admission to hospice. Following the
value of respiratory parameters blood PH was in
the range from 7.33 to 7.48, pCO2 from 25.8 to
107
10.9.2011 9:21:27
52.1 mm Hg, pO2 from 48.3 to 123.5 mm Hg and

HCO3 from 13.3 to 28.3 mmol/l. The study concludes that the appropriate dose of titration of
oral morphine (regardless of its plasma level) relieves pain well and in addition to that it provides
safety from developing respiratory depression in
cancer pain. In our study, relieving the pain leads
to reduction of pCO2 (from 44.6 mm Hg to 38.2
mm Hg), the increase of mean of pO2 (from 71.4
mm Hg to 78.1 mm Hg), and also the increase of
SpO2 from 89.1% during the breakthrough pain to
94.5% after relieving the breakthrough pain (19).
While the effect of acute pain on heart function
has been studied thoroughly, there are few studies
that talk about the effect of chronic pain on blood
pressure and heart frequency. The research by Radosh et al. (2009) follows the impact of chronic
pain treatment efficiency on heart function. The
research was conducted on 37 patients whose
pain was determined by numerical scale (from 0
to 10), and the treatment, depending on pain intensity was conducted accordingly to the guidelines of tree level scale. The pain intensity during
the first check-up was on average 8 (from 6, 0 to
10, 0), during the first control check-up 5 (from
2.7 to 6.5) and 4 (from 2.5 to 5.3) during the third
examination which is statistically significantly less
(p<0.001). The mean of systolic pressure was, as in
our study as well, significantly reduced (p<0.001)
after relieving the pain, at the control checkup
compared to the first examination [130 (from
120 to 148 mm Hg) compared to 150 (from 130

to 160 mm Hg) ]. The mean of diastolic pressure
was significantly reduced (p<0.007) at the control
check-up [90 (out of 80 to 98 mm Hg) compared
to 80 (from 80 to 88 mm Hg)] which corresponds
with the results of our study, while contrary to
the results of our study, in this research there
was no significant difference in the heart function frequency [p = 0.821; 78 (72 to 83 per minute) compared to 78 (71 to 83 per minute)] (20).
Conclusion
Breakthrough pain, as an acutization of chronic
cancer pain affects the cardiovascular system leading to pulse acceleration, increase of systolic and
diastolic blood pressure. Breakthrough pain affects the respiratory function by leading to respiration acceleration, the increase of pCO2 values,
and the reduction of pO2 and SpO2 values, without statistically significant difference in relation to
mentioned parameters before the onset of breakthrough pain. By using modern fast-acting opiates
such as transmucosal fentanyl citrate or internasal fentanyl citrate spray, the breakthrough pain
is much more easily intercepted (within 5- 10)
minutes and by doing that the effect of BTP on
cardiovascular and respiratory system is reduced.
Competing interests
The authors declare that they have no conflict of
interest.
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E, Tsiatas ML, Vlahos L. Oral transmucosal fentanyl citrate for the treatment of breakthrough pain in cancer
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www.jhsci.ba
Severe anemia: a case report

Amra Maci-Dankovi1*, Anela ubo2
Department of Internal medicine - Cardiology, General hospital Prim. Dr Abdulah Naka, Kranjevieva 12, 71 000 Sarajevo,
Bosnia and Herzegovina. 2 Department of General Practice, Eurofarm Centar Policlinic, Butmirska cesta 14, Ilida, 71 000
Sarajevo, Bosnia and Herzegovina
Abstract
Anemia refers to a hemoglobin or hematocrit level lower than the age-adjusted reference range in healthy
children and adults. Anemia is not a specific disease entity but is a condition caused by various underlying
pathologic processes. The clinical effects of anemia depend on its duration and severity. When a precipitous
drop in the hemoglobin or hematocrit level occurs (eg, due to massive bleeding), the clinical presentation is
typically dramatic and can be fatal if the patient is not immediately treated. Even then, mortality risk is very
high. We report the case of a 76-year-old woman with clinical symptoms and laboratory confirmation of severe anemia with level of hemoglobin 24 g/l, and hematocrit 0.08. Anemia was a sign of malignoma of the
stomach, later patohistologicaly verified gastric adenocarcinoma. Aim of management is to prevent tissue
hypoxia by maintaining an adequate circulating volume and oxiform capacity. However, as shown in this case,
the very rapid correction of anemia and the circulatory volume does not decrease the risk of fatal outcome.
Keywords: anemia, gastric adenocarcinoma, hypovolemic shock, blood transfusion
Introduction
Anemia refers to a hemoglobin or hematocrit level
lower than the age-adjusted reference range in
healthy children and adults (1). The definition of
anemia has attracted considerable interest recently
because of epidemiologic studies that suggest that
anemia may be associated with poorer outcomes in
a variety of disorders (2). Anemia is not a specific
disease entity but is a condition caused by various
underlying pathologic processes. Anemia in cancer patients is multifactorial and may occur as a
either a direct effect of the cancer, as a result of the
cancer treatment itself, or due to chemical factors
produced by the cancer (3). Upper GI endoscopy
can be expected to reveal a cause in between 30
and 50% of patients (4). The clinical effects of anemia depend on its duration and severity (5). When
a precipitous drop in the hemoglobin or hematocrit level occurs (e.g., due to massive bleeding), the
clinical presentation is typically dramatic and can
be fatal if the person is not immediately treated.
* Corresponding author: Amra Maci Dankovic,Department of
of Internal medicine, General Hospital Prim. Dr Abdulah Naka,
Kranjevieva 12, 71 000 Sarajevo, Bosnia and Herzegovina
Tel.: 061/177-743 E-mail: ifsa@bih.net. ba
Submitted 31. March 2011/ Accepted 25. June 2011
110
Y-I-2.indb 110
Even then, mortality risk is very high, as demonstrated in this case report. Fecal occult blood
testing, upper endoscopy and lower endoscopy
should be performed to identify bleeding lesions
(5). A hematocrit of less than 15% can result in
cardiac failure (6). In the largest consecutive series
of patients with anemia, mortality rose as preoperative Hb fell, and postoperative Hb of 5060 g/l
was associated with a strikingly high mortality (6).
Gastric cancer is rare before the age of 40, but its
incidence steadily climbs thereafter and peaks in
the seventh decade of life. Gastric cancer continues to be one of the leading causes of cancer-related death. The diagnosis of gastric cancer requires
histopathologic assessment of tissue or cytologic
assessment of gastric brushing/washes. Consequently, 80% to 90% of patients with gastric cancer present with locally advanced or metastatic
tumors that have poor rates of respectability (7).
Patients may present with anorexia and weight
loss (95%) as well as abdominal pain that is vague
and insidious in nature. Nausea, vomiting, and
early satiety may occur with bulky tumors that
obstruct the gastrointestinal lumen or infiltrative
lesions that impair stomach distension. Ulcerated
tumors may cause bleeding that manifest as heJOURNAL OF HEALTH SCIENCES 2011; 1 (2)
10.9.2011 9:21:27
AMRA MACI-DANKOVI ET AL.: SEVERE ANEMIA: A CASE REPORT
matemesis, melena, or massive upper gastrointestinal hemorrhage (8,9), like in our case. Anemia
is defined as a reduction in red blood cell (RBC)
mass or blood hemoglobin (Hb) concentration resulting in a decrease in the oxygen-carrying capacity of the blood (10). Tissues cannot bank oxygen.
Blood can be thought of as a pipeline that delivers oxygen continuously from pulmonary alveoli
to capillary beds. In healthy subjects, the oxygen
delivery system exceeds resting oxygen needs by
several times. In chronic anemia, the reduced
capacity of the blood to carry oxygen is compensated for by: 1) an increase in cardiac output, 2)
redistribution of blood flow and 3) increase in the
2, 3-DPG content of the red cells, which causes a
shift to the right in the oxygen dissociation curve,
so that at a given degree of oxygen saturation of
Hb, oxygen is more readily given up to the tissues
(11) As the oxygen content is diminished in anemia, the anemic patient can maintain the overall
supply of oxygen to the tissues only by increasing cardiac output and thus reducing the cardiac
reserve. If the coronary blood flow fails to deliver
sufficient oxygen the heart muscle becomes relatively hypoxic, and there will be a fall in cardiac
output and a reduction in systemic blood flow.
Clinical signs of severe anemia are: fatigue, dyspnea, tachycardia, change in mental status, decreased UOP, hypotension, PaO2/FiO2<200. An
extreme reduction in Hb concentration is found
as blood is redistributed from the skin to internal
organs. Pale conjunctivae, tongue, mucous membranes and nail beds evidence the altered perfusion. Pale optic fundi may be accompanied by
retinal haemorrhages. As cardiac output increases,
patients may experience tinnitus and palpitations.
Rapid respiration and shortness of breath at rest
should be considered as disturbing evidence of oxygen deficit and evidence of cardiac decompensation. Dizziness and fainting are common as anemia
progresses, but apprehension, changes in mentation and leg cramps are indications of severe oxygen deprivation and presage coma and death, or
course that may lead to organ failure (1, 11, 12, 13).
When the amount of blood lost rapidly is equivalent to 30% of the blood volume, a subject
may develop oligaemic shock (14). The clinical symptoms of shock are the three windows
to the microcirculation: (a) Mental status/level
Y-I-2.indb 111
of consciousness (cerebral perfusion) agitation, confusion, somnolence or lethargy, (b) Peripheral perfusion cold and clammy skin, delayed capillary re-lling, tachycardia, (c) Renal
perfusion urine output (<0.5 mL/ kg/h) (15).
These clinical ndings help to differentiate whether a patient is haemodynamically normal or
just apparently haemodynamically stable but in
compensated shock. Arterial blood gas can indicate lactate levels, and base decit represents
highly sensitive parameters for recognition of
metabolic acidosis reecting hidden shock (15).
Case study
A 79-year-old female patient presented at
our surgical department with one-month
history of abdominal pain and melena.
The family reported that the patient has had cholecystectomy one year ago. Abdominal pain has
started 5 months after surgery. Upper and lower
GI symptoms in the past 5 months presented
with: a markedly decreased appetite, weight
loss about 12 kg, increased fatigue and reduced
activity, intermittent nausea or vomiting with
black stools. She had the ultrasound (US) exam
done which showed: presence of tumor mass
between stomach and pancreas with retroperitoneal lymphadenopathy, and without metastatic
lesions in the abdomen. Laboratory results before first hospitalization were normal, with Hct
0.36, WBC 8.8x1012/L, PLT 297x109/L. Her family
history revealed no significant medical illnesses.
The physical examination on admission: pronounced pallor of the skin and mucous membranes, mild resting dyspnea, somnolence, malignant cachexia, normal breathing sounds,
arrhythmic heart rate was 90 beats per minute, quiet tones, without murmurs, the arterial
blood pressure was 75/35 mmHg. The abdomen
was soft and non-distended without hepatosplenomegaly, deep palpation revealed palpable
flank mass, 5 cm in diameter, in umbilical area.
There was no evidence of edema in the extremities. Other physical findings were unremarkable.
Additional laboratory studies were obtained, and
a diagnostic procedure was performed. Admission laboratory results: sedimentation 10, RBC
count 1.03x1012/l, Hb 24 g/l, Hct 0.08, MCV 75.7,
MCHC 308 g/l, Platelets 365x109/l, WBC count
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10.9.2011 9:21:27
12.5x1012/l. Electrolyte status revealed mild hypokalemia -3.2 mmol/l, sodium 138 mmol/l,
calcium 1.67 mmol/l, with the proper values of
urea, creatinine, bilirubin, AST, ALT, CPK and
alpha-amylase. Urine findings, alpha-fetoprotein,
CA 125 II, CA 19-9 XR were normal and values
of ferritin 32.38 (4.63 to 204.00), slight iron deficiency 6.5 mol/l. High CEA value of 276.66
g/ml (0.00 to 5.00), together with anamnestic
data, were indications for gastroscopy. ECG demonstrated atrial fibrillation, rarely visible p-wave,
ventricular response was 90/min, low amplitude,
intermediate electrical axis, adequate progression
of R waves in precordial leads, slight horizontal depression of 0.5 mm in D1, aVL and V4-V6.
Based on the history and laboratory evaluation,
a diagnosis of severe hemorrhage anemia was
made, and the patient was started with replacement treatment. The patient received prompt
volume restoration therapy including repeatedly
RBC transfusions and fluid resuscitation. When
Hct value increased to 0.24-0.26, upper GI endoscopy was performed. Endoscopy showed circumferent mucosal defect 2 cm in diameter which
was suspected as a malignant tumor and later
pathohistological examination verified gastric
adenocarcinoma. Patient remained hemodinamically unstable with intermittent hematemesis and
melena. She was admitted to intensive care unit
and continuously monitored. The patient was
transfused with several units of packed red blood
cells. Fluids resuscitation to restore the blood volume and parenteral antiulcer medications were
administered. She regained full conscious and
started enteral nutrition. Fourteenth day after
admission Hct was 0.26, Hb 88 g/l. After an external meal patient condition abruptly worsened.
She became somnolent, dyspneic with chest pain,
her arterial blood pressure and heart rate rapidly declined. She was severely hemodynamically
unstable, and died despite adequate supportive
treatment on the fourteenth day after admission.
Discussion
In this paper, we presented the case of a patient
with gastric adenocarcinoma who developed severe anemia (Hb 24 g/l) due to bleeding from that
lesion. The medical history and physical examination of this patient were important diagnostic clues,
112
Y-I-2.indb 112
followed by essential laboratory tests and endoscopic examination needed to confirm diagnosis.
Hyperanemia is a severe form of anemia, in which
the hematocrit is below 10%. Critical condition of
patient reported in this case, required aggressive
treatment in order to avoid fatal consequences
of anemia and hypovolemia. In this case, patient
had long history of chronic gastric bleeding which
was well compensated until admission in hospital.
Management is aimed at preventing tissue hypoxia by maintaining an adequate circulating
volume of red cells. This requires a multidisciplinary approach including control of the relevant physiological parameters, rapid control of
bleeding, maintenance of tissue perfusion, temperature control and blood component or pharmacological treatment to support coagulation.
The effects of anemia must be separated from
hypovolemia, although both can impede tissue oxygen delivery. Oxygen delivery in healthy
adults is maintained even with hemoglobin
levels as low as 6-7 g/dl. Hb around 10g/L had
previously served as a trigger. Transfusion is
necessary to minimize symptoms and risks associated with symptomatic chronic anemia when
hemoglobin is at 6 g/dl. Trials of acute normovolemic hemodilution in healthy volunteers and
surgical patients found the limit of critical oxygen delivery in humans at about 50 g/l (12, 13).
The goal of early volume replacement is to delay or
prevent the chain of events that leads to irreversible shock (13,15). In hemorrhagic shock, the main
management strategies are the arrest of bleeding
and the replacement of circulating volume. Fluids
used are isotonic and hypertonic crystalloids, colloids (mainly gelatins and starch solutions) and
blood products. Bleeding may be worsened by
injudicious fluid administration as a consequence
of a dilutional coagulopathy and of clot disruption
from increased blood flow, increased perfusion
pressure and decreased blood viscosity. Traditional guidelines generally employ early and aggressive uid administration to restore the blood
volume. Some studies have shown increased mortality rates with rapid infusion of uids compared
with standard infusion, and with immediate compared with delayed resuscitation (13). The concept
of low-volume uid resuscitation or permissive
hypotension avoids the detrimental effects of
10.9.2011 9:21:27
early aggressive resuscitation, while maintaining a

level of tissue perfusion that, although decreased
from normal, is adequate for short periods (16).
This approach is contraindicated in brain and spinal injuries and its effectiveness still needs to be
conrmed in randomized clinical trials (12,15,16).
Patients who have become anemic as a result of
recurrent hemorrhage should be transfused unless it is reasonably certain that risk of further
hemorrhage has abated. Decision about adequate
treatment is always difficult. Whether to employ
early and aggressive fluid administration or standard infusion to restore the blood volume? Bleeding recurs in 3050% of peptic ulcers with nonbleeding visible vessels and adherent clots that
are not treated with endoscopy and in 112% of
patients treated with invasive inpatient therapy.
Overall mortality rate for bleeding peptic ulcers
remains about 67%. Invasive therapies clearly
improve prognosis. Early transfusion in these settings seems prudent lest rebleeding prove fatal before endoscopic or surgical interventions can be
undertaken. As earlier noted, our patient received
prompt volume restoration therapy including
repeatedly RBC transfusions and fluid resuscitation before upper GI endoscopy was performed.
Red blood cells are indicated for patients with a
symptomatic deficiency of oxygen-carrying capacity or tissue hypoxia due to an inadequate circulating red cell mass. They also should not be used as
a source of blood volume, or oncotic pressure or
to improve wound healing, or sense of wellbeing.
The number of RBC units transfused is an independent predictor of worse clinical outcome (17).
Circulatory overload, leading to pulmonary edema, can occur after transfusion of excessive volumes or at excessively rapid rates. This is a particular risk in the elderly and in patients with chronic
severe anemia in whom low red cell mass is asso-
ciated with high plasma volume (6). Overloading

is best prevented by close attention to the state of
the patients circulation (13). High infusion rates
of blood products containing citrate can decrease
calcium concentrations, particularly in patients
with hypothermia or liver failure (who are unable
to metabolize the citrate), so monitoring of serum calcium may be required. Hypothermia carries a risk of cardiac arrhythmia or cardiac arrest.
Conclusion
In conclusion, chronic upper GI tract bleeding
resulting in severe anemia is the most common
sign of upper GI tract neoplasm, in this case
pathohistologically confirmed gastric adenocarcinoma. The clinical symptoms of anemia vary according to the individuals capacity to respond to
blood loss or reduced red cell production. In this
case, patient had history of chronic gastric bleeding which was well compensated, It is clear that
the priority during initial treatment must be the
maintenance of tissue oxygenation with appropriate use of uid and blood components. Volume
overloading is unusual but it does occur. Bleeding may be worsened by injudicious fluid administration. Clinicians should be cautious with the
treatment of such patients because of possible
development of fatal complications. Coagulation
may be supported by controlling temperature
and blood pH and by correcting coagulopathic
deciencies (12). This patient probably died due
to transfusion-mediated coagulopathy which lead
to pulmonary embolism or transfusion-related
acute lung injury. Actual cause of death was never
determined, because autopsy was not preformed.
Competing interests
The authors declare that they have no competing
interests.
References
1. Murphy FM, Pamphilon DH. Practical Transfusion Medicine. 3rd edition.
New York: Blackwell Publishing Ltd;
2009.
2. Bateman ST, Lacroix J, Boven K, et
al. Anemia, blood loss, and blood
transfusions in North American children in the intensive care unit. Am J
Respir Crit Care Med. 2008; 17:26-33.
Y-I-2.indb 113
3. Mercadante S, Gebbia V, Marrazzo

A. and S. Filosto. Anaemia in cancer:
pathophysiology and treatment. Cancer Treatment Reviews. 2000; 26 (4):
303-311.
4. Blood Transfusion and the Anaesthetist: Blood Component Therapy. The
Association of Anaesthetists of Great
Britain and Ireland. London; 2005.
5. Beutler E, Waalen J. The definition

of anemia: what is the lower limit
of normal of the blood hemoglobin
concentration? Beutler E, Waalen J.
The definition of anemia: what is the
lower limit of normal of the blood
hemoglobin concentration? Blood.
2006:107: 1747-1750.
6. Practice guidelines for blood trans-
113
10.9.2011 9:21:27
fusion: A Compilation from Recent

Peer-Reviewed Literature. Second
edition. American National Red
Cross; 2007.
7. Fenogilo-Preiser C, Carneiro F, Correa P, et al. Gastric carcinoma. In:
Hamilton S, Aaltonin L, eds. Pathology and Genetics. Tumors of the Digestive System, vol 1. Lyon, France:
Lyon Press; 2000:3752
8. Dicken B.J, Bigam D.L, Cass C, et al.
Gastric Adenocarcinoma. Ann Surg.
2005; 241(1): 2739.
9. Gore R. Gastrointestinal cancer. Radiol Clin North Am. 1997;35:295
310.
10. Murphy MF, Wallington TB, Kelsey P,
114
Y-I-2.indb 114
et al. Guidelines for the clinical use of

red cell transfusions. Br J Haematol.
2001 Apr;113(1):24-31.
11. Guidelines for the blood transfusion
services in the United Kingdom. 7th
edition. London: Published by TSO;
2005.
12. Hare GM, Tsui AK, McLaren AT, Ragoonanan TE, Yu J, Mazer CD. Anemia and cerebral outcomes: many
questions, fewer answers. Anesth
Analg 2008; 107:1356-70.
13. Stainsby D, Maclennan S, Hamilton
PJ. Management of massive blood
loss: a template guideline. Br J Anaesth 2000; 85: 48791.
14. Blackman CS, Gonzalez del Rey JA.
Hematologic Emergencies: Acute

Anemia. Clin Ped Emerg Med 2005;
6:124-137.
15. Klein GH, Anstee JD. Mollisons
Blood Transfusion in Clinical Medicine. 11th edition. Oxford: Blackwell
Publishing Ltd; 2005.
16. Corwin H.L, Gettinger A, Pearl R.G,
et al. The CRIT Study: Anemia and
blood transfusion in the critically
ill-Current clinical practice in the
United States. Crit Care Med. 2004;
32 (1): 39-52
17. Hoffman R, Benz EJ Jr, Shattil SJ,
Furie B. Hematology: Basic Principles and Practice. New York, NY:
Churchill-Livingstone; 2004.
10.9.2011 9:21:28
www.jhsci.ba
INSTRUCTIONS FOR AUTHORS

Instructions and guidelines to authors for the preparation and submission of manuscripts in the
Objectives and scope of the journal
The Journal of Health Sciences (JHSci) is an international journal
in English language, which publishes original papers in the field
of physical therapy, medical laboratory diagnostics, radiology technology, sanitary engineering, health and ecology, health care and
therapy, and other related fields.
ent manuscripts, letters or parts that cannot be sent electronically,

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Types of papers that can be sent for publication in the JHS
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are responsible for all statements and opinions in their papers.
More information is available at (http://bmj.com/cgi/collection/
authorship).
Submitting a manuscript for publication

The manuscript to be sent to JHSci must be in accordance to the
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in these instructions for authors and the web site of the Journal,
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Manuscripts Submitted to Biomedical Journals" New Engl J Med
1997, 336:309-315 (www.icmje.org), and the recommendations of
the international working group to standardize the appearance and
quality of scientific papers: STROBE (www.strobe-statement. org),
CONSORT (www.consort-statement.org) STARDA (www.stardstatement.org) and others.
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form (ZIP); 2. Manuscript (doc, docx, rtf). IT IS NOT NECESSARY to send the printed version, unless the authors want to pres-
Y-I-2.indb 115
Plagiarism or duplication of a published work

Authors confirm with signature that at the time of submitting the
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Authors must clearly state in the submission form and in the manuscript, in section "Methods", that the study conducted on human
subjects or patients is approved by the national or local Ethics committee. More information can be found in the latest version of the
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authors must confirm that experiments involving animals were
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Authors are required to include all sources of financial assistance
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state it briefly. For more information, see the editorial in the British
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115
10.9.2011 9:21:28
INSTRUCTIONS AND GUIDELINES TO AUTHORS FOR THE PREPARATION AND SUBMISSION OF MANUSCRIPTS IN THE JOURNAL OF HEALTH SCIENCES
righted materials are used, authors must obtain written permission

from the publisher and properly cite the reference in the article.
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116
Y-I-2.indb 116
tions whose financial interests may depend on the material in the

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Article: Meneton P, Jeunemaitre X, de Wardener HE, MacGregor
GA.Links between dietary salt intake, renal salt handling, blood
pressure, and cardiovascular diseases. Rev. Physiol. 2005;85(2):679715
More than 6 authors: Hallal AH, Amortegui JD, Jeroukhimov IM,
Casillas J, Schulman CI, Manning RJ, et al. Magnetic resonance
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200(6):869-75.
Books: Jenkins PF. Making Sense of the chest x-ray: a hands-on
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Book Chapter: Blaxter PS, Farnsworth TP. Social health and class
inequalities. In: Carter C, Peel SA, editors. Equalities and inequalities in health. 2nd ed. London: Academic Press; 1976th p. 165-78.
Internet source: HeartCentreOnline. Boca Raton, FL: HeartCentreOnline, Inc.., C2000-2004 [cited 2004 Oct 15]. Available from:
http://www.heartcenteronline.com/
Personal communications and unpublished works should not appear in the references and should be put in parentheses in the text.
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10.9.2011 9:21:28
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UPUTSTVO AUTORIMA
Upute i smjernice autorima za pripremu i predaju rukopisa u Journal of Health Sciences
Ciljevi i okvir asopisa
The Journal of Health Sciences (JHSci) je internacionalni asopis
na engleskom jeziku, koji objavljuje orginalne radove iz oblasti fizikalne terapije, medicinsko-laboratorijske dijagnostike, radioloke
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Vrste znanstvenih radova koje se mogu poslati za objavljivanje
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Orginalni radovi: orginalne laboratorijske eksperimentalne i klinike studije ne bi trebao prelaziti 4500 ukljuujui tabele i reference.
Prikaz sluajeva: prezentacije klinikih sluajeva koji mogu sugerisati kreiranje nove radne hipoteze, uz prikaz odgovarajue literature. Tekst ne bi trebao prelaziti 2400 rijei.
Pregledni lanci: lanci afirmiranih znanstvenika, pozvanih da ih
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Uvodnici: lanci ili kratki uvodniki komentari koji predstavljaju
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Podnoenje rada za objavljivanje
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for Manuscripts Submitted to Biomedical Journals New Engl J
Med 1997, 336:309315 (www.icmje.org), te preporuka meunarodnih radnih grupa za standardizaciju izgleda i kvaliteta naunih
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Odobrenje Etikog komiteta
Autori moraju u formularu za podnoenje rada i u dijelu rada
Metode jasno navesti da su studije koje su proveli na humanim
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Svi autori rada moraju potpisati formular za podnoenje rada. On
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Izjava o sukobu interesa

Od autora se zahtjeva da navedu sve izvore finansijske pomoi koje
su dobili za istraivanje (grantovi za projekte, ili drugi izvori finansiranja). Ako ste sigurni da nema sukoba interesa, onda to i navedite kratko. Za vie informacija pogledajte uvodnik u British Medical
Journal, 'Beyond conflict of interest' (http://bmj.com/cgi/content/
short/317/7154/291).
Slanje rada
Vri se iskljuivo preko web stranice www.jhsci.ba preko predvienog web formulara. Web formular sadri etiri stranice na kojima
se nalazi: 1. popis stavki koje treba ostvariti prije podnoenja rada;
2. informacije o autoru za korespondenciju; 3. informacije o naunom radu; 4. dio za slanje fajlova. U web formularu autori su duni
ispravno popuniti informacije, unijeti ispravnu e-mail adresu za
korespondenciju, te poslati 2 fajla: 1. Pismo za podnoenje rada;
2. Nauni rad. NIJE POTREBNO slati tampanu verziju, osim ako
Izdavaka prava
U okviru Pisma za podnoenje rada od autora se zahtjeva da prenesu izdavaka prava na Fakultet zdravstvenih studija. Prijenos izdavakih prava postaje punovaan kada i ako rad bude prihvaen
za publiciranje. ira javnost ima prava reproducirati sadraj ili listu
lanaka, ukljuujui abstrakte, za internu upotrebu u svojim institucijama. Saglasnost izdavaa je potrebna za prodaju ili distribuciju
van institucije i za druge aktivnosti koje proizilaze iz distribucije,
ukljuujui kompilacije ili prijevode. Ukoliko se zatieni materijali
Y-I-2.indb 117
117
10.9.2011 9:21:28
UPUTE I SMJERNICE AUTORIMA ZA PRIPREMU I PREDAJU RUKOPISA U JOURNAL OF HEALTH SCIENCES
koriste, autori moraju dobiti pismenu dozvolu izdavaa i navesti

izvor, odnosno referencu u lanku.
Formatiranje (izgled) rada
Predloci (engl. template) za pisanje radova
JHSci je na svojoj web stranici www.jhsci.ba dao predloke (engl.
Template) prema kojima treba formatirati radove. Predloci, takoer, sadre i upute preuzete od strane radnih grupa za standardiziranje formata u pisanju naunih radova i objektivno i potpuno
prikazivanje rezultata studija. Vie informacija o strukturi naunih
radova moe se nai na web stranici www.jhsci.ba i na web stranicama radnih grupa: www.consort-statement.org, www.strobe-statement.org, www.stard-statement.org, i drugih. Predloci se mogu
preuzeti na sljedeem linku: http://jhsci.ba/information-for-authors.html
Skraenice i simboli
Skraenice se moraju definisati prilikom njihovog prvog pojavljivanja u tesktu. One koje nisu internacionalno i generalno prihvaene
trebaju se izbjegavati. Koristiti standardne skraenice. Potrebno je
izbjegavati skraenice u naslovu rada i u saetku.
Kljune rijei
Nakon abstrakta treba staviti 3-10 kljunih rijei ili kratkih fraza
koje e pomoi u indeksiranju rada. Uvijek kada je to mogue, treba koristiti termine iz Medical Subject Headings liste Nacionalne
Medicinske Bibiloteke (MeSH, NLM). Vie informacija na:
(http://www.nlm.nih.gov/mesh/meshhome.html).
Tekst rada
Tekst rada mora biti standardnog naunog formata. Vie informacija dobiete preuzimanjem predloaka sa web stranice urnala:
http://jhsci.ba/information-for-authors.html
Pregledni lanci mogu imati drugaiju strukturu.
Uvod je koncizan dio rada. U njemu se predstavlja problem kojim
se rad bavi i to kreui od ireg konteksta problema i trenutnog
stanja i dosadanjih dostignua u vezi konkrtnog problema, prema
specifinom problemu koji e obraditi ova studija. Na kraju uvoda
je potrebno jasno istaknuti svrhu, ciljeve i/ili hipoteze ove studije.
Metode. Ovaj dio ne treba biti kratak. U predlocima koje je JHSci dao na web stranici nalazi se vie informacija o sadraju ovog
poglavlja.
Rezultati. Dati prednost grafikom prikazu rezultata studije u odnosu na tabelarni, kada je god to primjenjivo. Koristiti podnaslove
radi postizanja vee jasnoe radova. Vie informacija nai u predlocima.
Diskusija. U ovoj sekciji treba dati smisao dobivenim rezultatima,
ukazati na nova otkria do kojih se dolo, ukazati na rezultate drugih studija koje su se bavile slinim problemom. Uporediti svoje
rezultate sa drugim studijama i naglasiti razlike i novine u svojim
rezultatima. U ovom poglavlju treba interpretirati, sveobuhvatno
sagledati dobijene rezultate, te sintetizirati novo znanje iz analize.
Zakljuak. Treba da bude kratak i da sadri najbitnije injenice do
kojih se dolo u radu. Navodi se zakljuak, odnosno zakljuci koji
proizilaze iz rezultata dobivenih tokom istraivanja; treba navesti
eventualnu primjenu navedenih ispitivanja. Treba navesti i afirmativne i negirajue zakljuke.
Zahvala
U ovom dijelu se mogu navesti: (a) doprinosi i autori koji ne zadovoljavaju dovoljno kriterija da budu autori, kao npr. podrka kolega
ili efova institucija; (b) zahvala za tehniku pomo; (c) zahvala za
materijalnu ili finansijsku pomo, obrazlaui karakter te pomoi.
Izjava o sukobu interesa
Autori moraju navesti sve izvore finasiranja svoje studije i bilo koju
finansijsku potporu (ukljuujui dobijanje plae, honorara, i drugo) od strane institucija iji finansijski interesi mogu zavisiti od
118
Y-I-2.indb 118
materijala u radu, ili koji bi mogli uticati na nepristranost studije. Ako ste sigurni da ne postoji sukob interesa, navedite to u radu.
Jo informacija se moe nai ovdje: (http://bmj.com/cgi/content/
short/317/7154/291).
Reference
Reference se trebaju numerisati prema redoslijedu pojavljivanja u
radu. U tekstu, reference je potrebno navesti u zagradama, npr. (12).
Kada rad koji citirate ima do 6 autora, navesti sve autore. Ukoliko
je 7 ili vie autora, navesti samo provih 6 i dodati et al. Reference
moraju ukljuivati puni naziv i izvor informacija (Vancouver style).
Imena urnala trebaju biti skraena kao na PubMedu. http://www.
ncbi.nlm.nih.gov/journals
Primjeri referenci:
Standardni rad: Meneton P, Jeunemaitre X, de Wardener HE,
MacGregor GA. Links between dietary salt intake, renal salt handling, blood pressure, and cardiovascular diseases. Physiol Rev.
2005;85(2):679-715
Vie od 6 autora: Hallal AH, Amortegui JD, Jeroukhimov IM, Casillas J, Schulman CI, Manning RJ, et al. Magnetic resonance cholangiopancreatography accurately detects common bile duct stones in
resolving gallstone pancreatitis. J Am Coll Surg. 2005;200(6):86975.
Knjige: Jenkins PF. Making sense of the chest x-ray: a hands-on
guide. New York: Oxford University Press; 2005. 194 p.
Poglavlje u knjizi: Blaxter PS, Farnsworth TP. Social health and
class inequalities. In: Carter C, Peel JR, editors. Equalities and
inequalities in health. 2nd ed. London: Academic Press; 1976. p.
165-78.
Internet lokacija: HeartCentreOnline. Boca Raton, FL: HeartCentreOnline, Inc.; c2000-2004 [cited 2004 Oct 15]. Available from:
http://www.heartcenteronline.com/
Osobne komunikacije i nepublicirani radovi ne bi se trebali nai u
referencama ve biti navedeni u zagradama u tekstu. Neobjavljeni
radovi, prihvaeni za publiciranje mogu se navesti kao referenca sa
rijeima U tampi (engl. In press), pored imena urnala. Reference moraju biti provjerene od strane autora.
Tabele
Tabele se moraju staviti iza referenci. Svaka tabela mora biti na posebnoj stranici. Tabele NE TREBA grafiki ureivati.
Broj tabele i njen naziv pie se IZNAD tabele. Tabela dobija broj
prema redoslijedu pojavljivanja u tekstu, a naziv treba biti jasan i
dovoljno opisan da je jasno ta tabela prikazuje. npr Table 3. Tekst
naziva tabele..... U radu prilikom pozivanja na tabelu treba napisati
broj tabele u zagradi, npr. (Table 3). Za skraenice u tabeli potrebno
je dati puni naziv ispod tabele. Poeljno je ispod tabele dati objanjenja i komentar, koji su neophodni da se rezultati u tabeli mogu
razumjeti. Prikazati statistike mjere varijacije, kao to je standardna devijacija i standardna greka sredine, gdje je primjenjivo.
Slike
Slike staviti iza referenci i tabela (ako postoje). Svaka slika mora biti
na posebnoj stranici. Slika dobija broj prema redoslijedu pojavljivanja u tekstu. Naziv i broj se piu ISPOD slike, npr. Slika 3. Tekst
naziva slike... U radu, prilikom pozivanja na sliku treba napisati
broj slike u zagradi, npr (Slika 3). Neophodno je da slika ima jasan
i indikativan naziv, a u tekstu ipod slike objasniti sliku i rezultat
koji ona prikazuje, sa dovoljno detalja da ona moe biti jasna bez
pretrage teksta koji je objanjava u radu. Slika mora biti kvaliteta
najmanje 250-300 dpi, formata JPG, TIFF ili BMP.
Jedinice mjere
Mjere duine, teine i volumena trebaju se pisati u metrikim jedinicama (meter, kilogram, liter). Hematoloki i biohemijski parametri se trebaju izraavati u metrikim jedinicama prema International System of Units (SI).
10.9.2011 9:21:28

JHSCI 2011 v1 I2 September

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UNIVERSITY OF SARAJEVO FACULTY OF HEALTH STUDIES

UNIVERZITET U SARAJEVU FAKULTET ZDRAVSTVENIH STUDIJA

Journal of Health Sciences

Dijana Avdi (BiH)

Demal Pecar (BiH)

Jasmina Berbi Fazlagi (BiH)

Amira Duri (BiH)

Fatima Jusupovi (BiH)

Mirsad Mufti (BiH)

Emela Muji Skiki (UAE)

Naris Pojski (BiH)

Borut Poljak (Sl)

Isabelle Rishard (F)

Zerema Obradovi Zubovi (BiH)

Dragi Bankovi (SRB)

Journal of Health Sciences

Volume 1, Number 2, September 2011

Journal of Health Sciences

Volume 1, Number 1, September 2011

JOURNAL OF HEALTH SCIENCES 2011; 1 (2)

Journal of Health Sciences

Volume 1, Number 2, September 2011

Microbiological composition of untreated water

tagious diseases. Bacteria such as Escherichia coli,

to their use their quality must be improved.

which are: the climate, altitude and fouling with

TABLE 1. The results of K-S tests for measurement of the normality

K-S results z value

E. coli S. faecalis Proteus spp.

TABLE 2. Overview of positive samples by years 2005 2009

Samples with increase

Samples posi- Samples positive

0,00 42,52 73,89 65,25 380,56 75,83 259,31

196,61 402,58 18,53 10,02

JOURNAL OF HEALTH SCIENCES 2011; 1 (2)

FIGURE 1. Positive samples by years of observation

FIGURE 2. Presence of some contaminants in water

FIGURE 3. Average value for total bacteria by periods

Our research is based on

JOURNAL OF HEALTH SCIENCES 2011; 1 (2)

zegovina at the altitude of 820, 1000 and

chemical characteristics while fecal coliform

ter, what is pointed out by Jha M. and Gu R. (19).

compared to the period October-March, which

Afr J Med Med Sci 2009;38(2):155161.

Delta, Nigeria Environ Monit Assess.

JOURNAL OF HEALTH SCIENCES 2011; 1 (2)

Journal of Health Sciences

Volume 1, Number 2, September 2011

Is there any relationship between PSA and

PCa (4), immunotherapy attempts using several

(16) as a specific marker, stud- TABLE 1. Summary of patient characteristics

JOURNAL OF HEALTH SCIENCES 2011; 1 (2)

were obtained with written consent under an

counts were determined by using an automated

Phenotypic and Quantitative Analysis of Lymphocytes:

Serum PSA Quantification:

FIGURE 1. (a) The gating strategy used for selecting

JOURNAL OF HEALTH SCIENCES 2011; 1 (2)

JOURNAL OF HEALTH SCIENCES 2011; 1 (2)

in PCa patients; second, we aimed to determine

cy in the periphery of BPH patients compared

in those with metastatic cancers. Seventeen of 19