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Journal of Society for development of teaching and business processes in new net environment in B&H
Journal of Society for development of teaching and business processes in new net environment in B&H
Summary Sažetak
The basis in the process of identifying ex- U procesu identifikacije ekshumiranih posmr-
humed skeletal remains is the identification of a tnih ostataka osnovu predstavlja određivanje bio-
biological profile and, within it, stature estimation loškog profila, u sklopu kojeg je i procjenjivanje
as one of the most important parameters. Since visine kao jedan od najvažnijih parametara. Od
1996, the estimation of war victims’ stature in 1996 godine na području Bosne i Hercegovine
the territory of Bosnia and Herzegovina has been procjenjivanje visine ekshumiranih žrtava rata, vr-
carried out based on formulae obtained through šeno je na osnovu formula dobijenih ispitivanjem
research on American population. In this study, na američkoj populaciji. U ovoj studiji procjenji-
stature estimation was carried out by applying a vanje visine je izvršeno primjenom Bayes-ove
Bayesian analysis on 105 exhumed and identified analize na 105 ekshumiranih i identificiranih oso-
male persons from the territory of the northwest ba muškog spola sa područja sjevero-zapadne Bo-
Bosnia, namely of 78 left humeri, 105 left femurs, sne, i to 78 lijevih humerusa, 105 lijevih femura,
96 left tibia and 80 left fibulas. 369 persons from 96 lijevih tibija i 80 lijevih fibula. Kao referentni
the Sarajlić’s study were used as a reference sam- uzorak korišteno je 369 osoba iz Sarajlićeve stu-
ple. Stature estimation formulae were developed dije. Primjenom Bayes-ove analize su razvijene
by applying the Bayesian analysis and were com- formule za procjenjivanje visine, koje su kom-
pared with the formulae obtained by Ross and parirane sa formulama dobijenim po Ross-ovoj i
Konigsberg and Sarajlić and associates. Results Konigsberg-u, te Sarajliću i suradnicima. Rezulta-
show that the formulae developed in this study are ti su pokazali da formule razvijene u ovoj studiji
more precise for the estimation of exhumed per- preciznije procjenjuju visinu ekshumiranih osoba
sons’ stature than the models compared, except for u odnosu na komparirane modele, izuzev formu-
the formula for tibia, where the Sarajlić’s formula le za tibiju, gdje se Sarajlićeva formula pokazala
proved to be more accurate. tačnijom.
Key words: Forensic anthropology, stature es- Ključne riječi: forenzička antropologija, pro-
timation, Bosnian population, Bayesian analysis. cjena visine, bosanska populacija, Bayes-ova ana-
liza
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188 Journal of Society for development of teaching and business processes in new net environment in B&H
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Results
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In order to numerically test whether the predicti- ror was obtained when applying the formula using
on based on the Bayesian analysis from this study the tibia length, which means that the use of tibia
gives more reliable (more precise) data compared gives most precise results in stature estimation.
to the models presented by Ross and Konigsbergu The greatest standard error and, consequently, the
(7) and Sarajlić (10), a non-explained variability least precise stature estimation was obtained when
or mean square deviation (MQD) was calculated applying the formula using the humerus length for
as per the following model: stature estimation, which is in compliance with to-
dates researches (3, 7) indicating that stature esti-
non-explained variability = ∑ (soriginal – ŝobtained through estimation)2 mation is more precise when the length of long
number of actual measurings
limb bones is used.
In order to test whether the prediction based on
The obtained expression for the non-explained the Bayesian analysis and resulting from this stu-
variability is in direct relationship with the devia- dy gives more precise data on stature estimation
tion in estimation from the original measuring. A compared to other prediction models, a non-ex-
lower non-explained variability means the predi- plained variability was calculated.
ction model is more reliable and more accurate. When prediction based on humerus was con-
Predictions based on humerus gave the follow- cerned, the comparison of the model from this
ing results in terms of non-explained variability: ac- study with the Ross and Konigsberg’s model sho-
cording to the prediction from this study – 231.621, wed that the non-explained variability is smaller
and according to Ross and Konigsberg 451.569. when stature estimation is carried out based on
Predictions based on femur gave the following the model from this study and it amounts 231,621
results in terms of non-explained variability: ac- compared to the Ross and Konigsberg’s model in
cording to the prediction from this study – 1662.7, which it amounts 451,569. The comparison with
according to Ross and Konigsberg – 2088.19, and the Sarajlić and associates’ model was not possi-
according to Sarajlić – 1885.18. ble, because they did not present formulae for hu-
Predictions by tibia gave the following results merus. Although Ross and Konigsberg used a Ba-
in terms of non-explained variability: according yesian analysis in their study, deviations are evi-
to the prediction from this study – 275.506, ac- dent when compared with this study in which the
cording to Ross and Konigsberg – 563.394, and same model was used. The difference in results is
according to Sarajlić – 196.558. probably the consequence of parameters they used
Predictions based on fibula gave the following in their study. They made a study on the Balkan
results in terms of non-explained variability: ac- population and had at their disposal the length of
cording to the prediction from this study – 114.5- the bones of exhumed persons from Bosnia and
24, and according to Sarajlić 117.302. Herzegovina and Croatia. However, they did not
have data on the actual height of the exhumed per-
sons for whom they had data on the length of the
Discussion bones and used data from literature (8) instead.
They used data on American Whites from World
In this research, estimation of exhumed male War II as a reference sample. Differences among
persons’ stature was carried out based on the length populations, secular trend in the development of
of long bones of both extremities. The male sex a population and, consequently, probable non-re-
was included as the largest number of missing per- levance of data they applied as reference samples
sons in Bosnia and Herzegovina is of male sex. are possible reasons for greater deviations in the
This way, formulae for stature prediction were application of their formulae compared to the re-
obtained based on a Bayesian analysis. When ap- sults in this study.
plying formulae on samples used in this study, Identical results were obtained when predicting
the standard error was: for humerus (4.53), femur stature based on the femur length. The non-explai-
(3.62), tibia (3.58), fibula (3.94). It follows from ned variability as calculated as per the model from
the aforementioned that the smallest standard er- this study was 1662.7, as per the Sarajlić and asso-
190 Journal of Society for development of teaching and business processes in new net environment in B&H
HealthMED - Volume 2 / Number 4 / 2008
ciates’ model - 1885.18, and as per Ross and Ko- compared to the formulae developed by Ross and
nigsberg’s model - 2088.19. Konigsberg on the Balkan population, which indi-
Predictions based on tibia, when comparing cates to the necessity of developing adequate mo-
models from this study with the models developed dels specific for a population.
by Ross and Konigsberg and Sarajlić and associa-
tes, show that the lowest values of non-explained
variability were obtained by using the Sarajlić and Literature
associates’ model, they were followed by those
1. Zečević D. i suradnici. Sudska medicina i deontolo-
based on this study and the greatest were those gija, 4. obnovljeno i dopunjeno izdanje (Zečević D
using the Ross and Konigsberg model. A possible and Associates. Forensic Medicine and Deontolo-
explanation for the obtained results of comparison gy, 4th reprinted and supplemented edition), Zagreb,
for tibia, where the formula developed by Sarajlić 2004; p 189-191.
and associates proved to be the most precise one, 2. Sigel J, Knupfer G, Saukko P. Encyclopedia of Fo-
perhaps lies in the fact that tibia is a bone that is rensic Sciences, Three- Volume Set, 1-3, 1 edition,
most difficult to measure. X-ray measurings of the Hardbound: Academic Press, 2000; p 252-284.
tibia length, which were used by Sarajlić and as- 3. Trotter M, Gleser GC. A reevaluation of stature
sociates, could have been more precise than the based on measurements of stature taken during life
measuring of the tibia length carried out on an and of long bones after death. Am J Phys Anthrop,
1958; 16:79-123.
osteometric table and used in this study.
4. Trotter M, Gleser GC. The effect of ageing on statu-
The comparison of results for fibula was possi- re. Am J Phys Anthrop., 1951; 9: 311-324.
ble only with the formulae developed by Sarajlić 5. William G, Eckert. Introduction to forensic scien-
and associates, as Ross and Konigsberg did not ces, New York, CRC press, 1997.
use this bone. The lowest values of non-explained 6. Sarajlić N, Cihlarž Z, Klonowski EE, Selak I.
variability and, consequently, the most precise re- Stature estimation for Bosnian male population.
sults in stature estimation were obtained when ap- Bosn. J Basic Med Sci, 2006; 6(1): 62-67.
plying the formulae developed in this study. 7. Ross AH, Konigsberg LW. New formulae for esti-
The obtained results confirm that the formulae mating stature in the Balkans. J Forensic Sci, 2002;
obtained by applying a Bayesian analysis on Bo- 47(1): 165–167.
snia and Herzegovina population give statistically 8. Tomazo-Ravnik T. Secular trend in growth of scho-
olchildren in Yugoslavia, Coll Anthropol, 1988; 12:
more precise results in the estimation of the stature
121–33.
of exhumed male persons in Bosnia and Herzego- 9. Moore-Jansen PH, Ousley SD, Janty RL. Data col-
vina than the previously derived Ross and Konigs- lection procedures for forensic skeletal material,
berg’s models on the Balkan population (7) and Report of investigations no. 48, The University of
Sarajlić’s models, with the utilization of regressi- Tennessee, Knoxville, 1994.
on analysis (10). 10. Sarajlić N, Cihlarž Z, Klonowski EE, Selak I.
Stature estimation for Bosnian male population.
Bosn. J. Basic Med Sci, 2006; 6(1): 62-67.
Conclusion 11. Bralić I. Paediatr Croat, Sekularne promjene rasta
i razvoja (Secular Changes in Growth and Develop-
The results of research show that stature esti- ment), 2008; 52 (1): 25-35.
12. Trotter M, Gleser GC. Estimation of stature from
mation based on the length of humerus, femur and
long bones of American Whites and Negroes. Am
fibula by applying Bayes’ Theorem is more preci- J Phys Anthrop, 1952; 10: 463-514.
se compared to the models developed by Sarajlić
and associates, with the utilization of the regressi- Corresponding author:
on analysis. Only stature estimation based on the Anisa Masovic
length of tibia and utilizing regressive analysis gi- Institut of Forensic Medicine, Medical School,
ves more precise results than this research. University of Sarajevo
All formulae developed in this study give more Bosnia and Herzegovina
precise estimation of exhumed persons’ stature e-mail: anisa_mas@hotmail.com
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alanin-amino transferaza (ALT), alkalna fosfataza cular and macrovesicular and it may progress into
(ALP), gama-glutamil transpeptidaza (GGT), al- fibrosis and cirrhosis. Level of glycemia control
bumin, protrombinsko vrijeme, HbsAg, antiHb- correlates with lipid accumulation (4). The most
sAg, antiHCV. Usporedba između ispitivanih gru- frequent clinical symptom is hepatomegalia, and
pa pacijenata je napravljena pomoću Studentovog the most patients have normal or mild abnormal
t testa za kontinuirane varijable i Hi kvadrat ili Fi- transaminase level and normal serum bilirubin le-
sher-ovog testa za kategoričke varijable. vel. Liver biopsy is obviously the best method for
Rezultati: Ovo istraživanje je pokazalo da je detection of lipid accumulation in the liver (5).
funkcija jetre u oboljelih od dijabetesa tipa 2 sa Non-alcoholic steatohepatitis (NASH) is a va-
hiperlipidemijom je više oštećena nego u onih sa riant of liver steatosis in that beside lipid accumu-
normalnim lipidnim statusom lation in hepatocites there is lobular inflammation
Zaključak: Loše regulirana glikemija i hiperli- and steatonecrosis. In diabetic patients having ste-
pidemija mogu dovesti do oštećenja funkcije jetre. atohepatitis, Mallory bodies similar to those seen
Potrebno je napraviti povremeni skrining funkci- in alcoholic liver disease. NASH is most frequent
je jetre i lipidnog statusa u oboljelih od dijabetesa in obese diabetic patients. There is high prevalen-
tipa 2. ce prevalence of NASH in patients with diabetes
Ključne riječi: dijabetes melitus tip 2, funkcija mellitus type 2 treated by insulin (6). Spectra of
jetre, hiperlipidemija clinical symptoms in patients with liver steatosis
and steatohepatitis vary from asymptomatic incre-
ase of liver enzymes to severe liver disease with
Introduction fibrosis and nodular regeneration. Patients with
NASH may develop progressive liver disease and
Liver plays an important role in metabolism complication such severe that liver transplantati-
of glucose and lipids. There is a mutual relation on is needed (7). NASH should be considered as
between liver disease and diabetes. Lipid and glu- a cause of chronic increase of liver enzymes in
cose metabolism abnormalities may be a consequ- asymptomatic diabetic patients especially in those
ence of liver disease and reverse. Diabetic patients who are obese and with hyperlipidemia. In pati-
develop macrovascular complications such as: co- ents with diabetes mellitus type 2 with or without
ronary artery disease, cerebrovascular disease and obese, 30% of them have liver steatosis and in-
peripheral vessels disease (1) and microvascular flammation, 25% fibrosis and 1–8% cirrhosis (8).
complications such as: retinopathy, nephropathy, Incidence of cirrhosis in diabetic patients is in-
neuropathy and foot problems (2). creased, and 80% patients with cirrhosis have glu-
Glycogen accumulation in the liver has been cose intolerance (9). Diabetes mellitus increases
observed in 80% diabetic patients. Glycogen synt- risk for steatohepatitis that can progresses in cirr-
hesis in the liver of diabetic patients at the onset of hosis (10, 11). Aim of this research was to analyze
disease is insufficient due to abnormal activation the liver function in patients with diabetes mellitus
of glycogen sinthase. In patients with chronic di- type 2 and hyperlipidemia.
abetes Glycogen accumulation in the liver is pre-
sent, but mechanism is that long-term of lacking
of insulin facilitates glycogen synthase activity. In Patients and methods
addition to that gluconeogenesis increased lead to Patients
glycogen accumulation (3).
Glycogen accumulation in the liver is well- This research has been retrospective-prospecti-
known complication in diabetes is observed in ve study in which 120 patients have been analyzed
40–70% cases. Lipids are accumulated in trigly- divided into 2 groups: 1) patients with diabetes mel-
ceride form and it might be duo to increased lipid litus type 2 and hyperlipidemia (n=60), 2) patients
intake lipids in the liver, lipid synthesis increased with diabetes mellitus type 2 and with normal lipid
and lower level of oxidation and decreased lipid status (n=60). In this study only patients who had
outtake from the liver. Steatosis can be microvesi- diabetes mellitus type 2 diagnosed more than two
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years were included. To analyze liver function we There was no difference between serum levels
have measured following parameters: bilirubin (to- GGT and ALP in patients with DM 2 and increa-
tal, conjugated and unconjugated), aspartate-ami- sed serum lipid parameters and in those with nor-
no transferase (AST), alanine-amino transferase mal ones.
(ALT), alkaline phosphatase (ALP), gamma-gluta-
myl transpeptidase (GGT), albumin, prothrombin
time, HbsAg, antiHbsAg, antiHCV. Data have been
analyzed by Student t, Chi square or Fischer’s test.
All tests have been measured routine methods
on AR and Dimension RxL devices at UKC Tu-
zla. Ultrasonography has been done to determine
presence of steatohepatitis. It has been done at De-
partment Radiology, UKC Tuzla. To all diabetic
patients blood glucose level (fasting and 2 hours Figure 3. Serum GGT level in patients with DM
postprandial) and HbA1c have been measured. 2 and increased serum lipid parameters
Results
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Figure 6. Prothrombin time in patients with DM Figure 9. Serum conjugated bilirubin level in pa-
2 and increased serum lipid parameters tients with DM 2
Serum bilirubin level in patients with DM 2 and There was no difference among serum protein
increased serum lipid parameters was statistically and albumin levels in patients with DM 2 and in-
higher than in those with normal ones, however in creased serum lipid parameters and in those with
all patients level was in referent range. normal ones.
Figure 7. Serum total bilirubin level in patients Figure 10. Serum protein level in patients with
with DM 2 and increased serum lipid parameters DM 2
There were no statistically significant differen- There was no difference among negative and
ce between serum unconjugated bilirubin levels positive HbsAg, anti HbsAg and anti HCV cases
in patients with DM 2 and increased and normal in patients with DM 2 and increased serum lipid
serum lipid parameters. parameters and in those with normal ones.
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Table 1. Correlation among Hb1c, serum lipid parameters and liver functional parameters in patients
with DM 2
Hb1c
Liver functional parameter
LDL HDL Triglycerides Cholesterol
AST 0,72 -0,60 0,52 0,57
ALT 0,86 -0,69 0,58 0,64
Conjugated bilirubin 0,91 -0,75 0,73 0,71
vels. The strongest level of correlation was among vels. The strongest level of correlation was among
Hb1c, LDL and conjugated bilirubin (table 1). Hb1c, LDL and conjugated bilirubin. Our results
There was negative correlation among Hb1c, have shown negative correlation among Hb1c,
HDL and liver functional parameters (AST, ALT HDL and liver functional parameters (AST, ALT
and conjugated bilirubin). The strongest level of and conjugated bilirubin). The strongest level of
correlation was among Hb1c, HDL and conjuga- correlation was among Hb1c, HDL and conjuga-
ted bilirubin (table 1). ted bilirubin.
Other liver functional parameters did not cor- Several research studies have shown similar re-
relate with Hb1c and serum lipid parameters in sults about additional harmful effect of abnormal
patients with DM 2. lipid metabolism on the function of different or-
gans in patients with DM (14, 15,16, 17).
Discussion
Conclusion
Diabetes mellitus (DM) is one of the most freq-
uent metabolic disease causing micro- and macro- Poorly regulated glucose homeostasis and hy-
vasculcar complications (12). Patients with DM perlipidemia may contribute to liver injury. It is
develop macrovascular complications such as: co- necessary to make, from time to time, screening
ronary artery disease, cerebrovascular disease and of liver function and lipid profile in patients with
peripheral vessels disease (1) and microvascular diabetes mellitus type 2.
complications such as: retinopathy, nephropathy,
neuropathy and foot problems (2). All complica-
tions develop faster and they are more severe if
patients with DM have hyperlipidemia.
Due to additional risk of hyperglycemia and
hyperlipidemia for cardiovascular and other dise-
ases, metabolism abnormalities and their influen-
ce to function of different organs, they should be
tested in DM (13). This study has shown that liver
function in patients with diabetes mellitus type 2
and hyperlipidemia was more injured than in those
with normal lipid status. Serum concentration of
AST, ALT and conjugated bilirubin were higher in
patients with DM 2 having increased level of lipid
status parameters than in those with normal ones
There was positive correlation among Hb1c,
serum LDL, triglycerides and cholesterol level
and serum AST, ALT and conjugated bilirubin le-
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198 Journal of Society for development of teaching and business processes in new net environment in B&H
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pluća. Između kontrolne i eksperimentalne sku- illuminated yet, but it can be rightfully said that
pine nisu postojale signifikantne razlike po dobi nutritional factors can modify its process. The
i spolu. Podaci su prikupljeni upotrebom anonim- plant fibers are shortening the exposition time of
nog upitnika, koji sadrži socio- demografska pi- the potential carcinogens decreasing the time of
tanja, pitanja u vezi sa unosom pojedinačnih nu- the food passing through the intestinal tract (3).
tritijenata u ishrani, a prema dnevnoj, sedmičnoj, Broccoli contains three active protective substan-
mjesečnoj i godišnjoj učestalosti unosa i količini ces that inactivate carcinogen compounds: sulpho-
istih. raph, beta-carotene and indol - carabinol. Spinach
Rezultati: Značajno veća učestalost karcino- contains glutathione, tomato - licopen, citrus fruit
ma pluća bila je zastupljena u ispitanika koji su bioflavonoid and vitamin C, carrot retinol and beta
živjeli na selu u odnosu na one koji su živjeli u carotene, and the onion - alicin. Pickled vegetables,
gradu (63% vs. 30%, P =0.001). Pacijenti koji su alcohol, salty, greasy and fried food represent the
imali lošiji imovinski status imali su signifikantno risk factors for the occurrence of the cancer of the
veću učestalost oboljevanja od karcinoma pluća abdominal organs, but not the lungs (4). Potential
u odnosu na one sa boljim imovinskim statusom protective vitamins characteristics are at the cen-
(Z=-4,916, P=0.001). Prediktori za razvoj karci- tre of the investigation at present, especially the A,
noma pluća među faktorima ishrane su smanjen C, D and E vitamin. Protective characteristics of
unos zaštitnih faktora u ishrani: masline (OR=- the vitamins can be explained by the anti- oxidant
1.26), grejpfrut (OR=1.47), riba (OR=1.45) i bije- effects and by the degradation of the free radicals
li luk (OR=1.38). that contributes to the decreasing of the substan-
Zaključak: Kacinom pluća se može spriječiti ces that are the potential causes of the cancer in
odgovarajućim unosom zaštitnih faktora u ishrani the human body. Selene compounds have anti-
naročito vlakana u grahu, buraniji, grašku zatim oxidant characteristics and the important role in
grejfruta, bijelog luka, maslina i drugih. Čini se da the metabolism of the glutathione-peroxidaze, the
najveći problem u odabiru namirnica koje bi bile enzyme that has the protective characteristic aga-
protektivni faktor za razvoj karcinoma pluća čini inst the oxidative damage of the tissue. (1) Selene
loš imovinski status stanovništva, kao i razlike u present in the food decreases the occurrence of the
odnosu na mjesto življenja selo- grad. chemical induced tumors on few locations. (1-2)
Ključne riječi: faktori ishrane, ishrana, karci- Specific micro nutrition such as retinol, all caro-
nom pluća tenoids and Vitamin C are considered the protecti-
ve factors in the development of the lung cancer
(4-7). Theoretically, they have stronger protective
Introduction role when continuously consumed, and the prote-
ction depends on the doses/ amount of the intake
Epidemiological studies indicate the strong re- of those protectors (4-5). Fruits and vegetables re-
lation between the nutritious factors and the oc- present protective factors in the development of
currence of the particular types of cancer, so it is the lung cancer because of the contents of the use-
estimated that the nutritious factors are responsi- ful ingredients (carotenoids, vitamins A, E, C and
ble for the one third of the cancer occurrence (1- minerals.) Because of the insufficient intake of the
3). Big part of different types of cancers is poten- fruit and vegetable the risk of getting the cancer
tially related to the nutrition habits and factors. It of many organs, as well as the lung is increasing
is assumed that 30 % of cancer mortality could (5). Vitamin A controls the growth and the diffe-
be evaded by the modification of the eating ha- rentiation of the cells (decreases the risk of the de-
bits through one’s life. Considering the different velopment of the gastrointestinal and respiratory
cultural nutrition habits in different countries we cancer). Vitamin C inactivates O2 radicals at the
can talk about the international risks as well as the cell level, increases the produce of the collagen,
protective factors of cancer (2). whereby obstructs the penetration of the mali-
The mechanism of the nutrition effect to the gnant cell in the environment. Vitamin E, calcium,
development of the carcinogenesis has not been selenium block the process of the carcinogenesis,
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HealthMED - Volume 2 / Number 4 / 2008
by the decreasing of the excretion of the tertiary ( how often: never, 2x yearly, 1-3 x yearly, 5-6 x
galls and fatty acids (6-7). Micro- nutritionist such yearly, 1 x monthly, 2 x monthly, daily), intake:
as retinol, total carotenoids, B- carotene and Vi- intake half of plate –fresh, fried or boiled carrot,
tamin C protect the cells from the oxidant DNA half of plate – grapefruit, banana, apple, half of
damages, and in that way protect from the cancer plate- blueberry, blackberry, raspberry, half of pla-
(4, 8-10). Diet enriched by the fibers (bean, peas, te –broccoli, spinach, bulb, egg plant, lettuce, pep-
lentil, fruit and vegetables) help in elimination of per, green salad, ( regular consumption frequency-
the toxins in the body. never, 1-3x monthly, 1x weekly, 2-4 x weekly, 5-
Habits, cultural characteristics and the assets 6x weekly, and daily), intake of one plate of beans,
influence the eating habits and the choice of the lentil, or peas(contain fibers), 1-2 dcl natural fruit
nutrition’s. In Bosnia and Herzegovina, the conti- juice-lemon, orange, tomato or carrot ( regular
nuing increase of the incidence and the death rate consumption frequency - never, 1-3x monthly,
of the lung cancer are noted. (11) The aim is to 1x weekly, 2-4 x weekly, 5-6x weekly, and daily),
identify the nutrition risk factors for the occurren- 2-5 olives (regular consumption frequency - ne-
ce of the lung cancer and to estimate the relation ver, 1-3x monthly, 1x weekly, 2-4 x weekly, 5-6 x
of the protective nutrition factors and the lung can- weekly, and daily).
cer diseased in Tuzla Canton. Therefore, answers about the regular menu of
the 13- types of nutritionist or micro nutritionist
were created in accordance to the questionnaires
Subjects and methods done before for the conducted research (3-10). Re-
liability of the questionnaire is tested by the Cron-
Control study involved 200 patients who are bach alpha coefficient of the consistency and in
cured at the Clinic for the lung diseases and tuber- the total sample is sufficient >70% and the sum is
culosis University - clinical centre of Tuzla since α = 0.76.
the 1st January 2007 to the 31st December 2007.
Experimental group was formed of the incidence
diagnosed with the lung cancer. Control group Statistical analysis
was formed of 100 examinees that are not diagno-
sed with the lung cancer, or any other malignant During the statistical analysis of the results
disease. Research has been done by the method of standards method of descriptive statistics were
the poll, and the instrument of the poll was the qu- used (central tendency and dispersion measures).
estionnaire which has been designed specially for We used Mann- Whitney non parametric test to
this research. The first part of the questions was assess the differences between experimental and
made of the questions containing: demographic control group subjects. Multivariate analysis of
information (gender, age, education, working sta- variance (ANOVA; multivariate regression analy-
tus, location, asset, satisfaction with the financial sis) was performed to test the relationship betw-
situation), family history of the lung cancer. The een predictive variables (13- types of nutritionist
other part of the questions referred to the evalua- or micro nutritionist). The results were presented
tion of the food. Supplements to the diet are every as regression coefficient β (R), adjusted odds ratio
active substance that is taken orally for the sake (OR) with 95% confidence intervals (CI). Stati-
of diet enrichment, and contains one of the next stical hypothesis were tested on the significance
components: vitamins, minerals, herbs, or medical level of Alfa = 0.05.
plants, their concentrates or extracts or their mixtu-
re (with the premises that is not the medicament).
Through the answers to the questions the intake Results
of the fruit and vegetables, meat, milk, has been
estimated, onion, fish, preparations ( intake freq- Lung cancer is the disease which in Tuzla Can-
uency: 1-3 x monthly, 1 x weekly, 2-4 x weekly, ton has 9 fold higher incidences at male when
5- 6 x weekly and daily), vitamins in supplements compared to female population, ages 50-79 (77%).
200 Journal of Society for development of teaching and business processes in new net environment in B&H
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Lung cancer patients in a statistically significant better than majority, 59% estimates to be as wealt-
manner belong to the pensioned group of intervi- hy as others, and 31% practically lives in poverty.
ewees when compared to the group which didn’t There is significant difference in social status at
have lung cancer disease (28% vs. 7%, P=0.001). patients’ group when compared to healthy group.
They also in a statistically significant manner be- Lung cancer patients have worse social status (z=
long less to the group of employed when compared -4.916, P= 0.001). Poverty is important determi-
to the group which didn’t have lung cancer disease nant at becoming sick of lung cancer. In the total
(29% vs.11%, P= 0.001, z= 4.819). sample majority has declared that there is no fa-
The interviewees suffering from the lung can- mily history of lung cancer (82%), 86% at control
cer disease have statistically significant lower group and 78% at patients group. Significant diffe-
educational level when compared to the healthy rence for family predisposition to becoming ill of
(Mann- Whitney test; Z= -6.174, P= 0.001). Signi- lung cancer was not noticed in experimental when
ficantly greater incidence of lung cancer patients compared to control group (z= -1.273, P= 0.203).
lives in villages when compared to the patients There was significantly higher number of smokers
living in the cities (63% vs.43%, P= 0.001) only in experimental when compared to control group.
10 % of lung cancer patients is well off, that is, (P=0.001).
Table 1 Distribution of the interviewees (N=200) according to the demographic characteristics and
the groups
Control group Experiment group
Demographic characteristics of examiners P
N (%) N (%)
Educational level
Uncompleted primary school 11 (11) 29 (29)
Completed primary school 5 ( 5) 18 (18)*
High school 38 (38) 46 (46)*
Completed High school 24 (24)* 2 ( 2)
Academy 7 ( 7)* 2 ( 2)
Faculty 15 (15)* 3 ( 3) 0.001
Location
Town 45 (45) 30 (30)
Country 43 (43) 63 (63)
Near the industrial facilities 12 (12) 7 ( 7) 0.001
Financial situation compared with other
Much better than the others 6 ( 6) 1 ( 1)
Better then the majority 29 (29) 9 ( 9)
Similar to the majority 54 (54) 59 (59)
Somehow less then the majority 8 ( 8) 17 (17)
Much less than the majority 3 ( 3) 10 (10)
Much less than the rest 0 ( 0) 4 ( 4) 0.001
Family predisposition for the lung cancer
No, no one 86 (86) 78 (78)
One of the parents 6 ( 6) 15 (15)*
Brother or sister 1 ( 1) 4 ( 4)
Uncles/aunts 1 ( 1) 1 ( 1)
Grandfather or his brother or sisters 2 ( 2) 0 ( 0)
Other relatives 4 ( 4) 2 ( 2) 0.203
Smoking status
I have never smoked 36 (36) 9 ( 9)
I quit this year 7 ( 7) 1 ( 1)
I quit 2 years ago 2 ( 2) 5 ( 5)
I smoked less than 10 years 17 (17) 4 ( 4)
I smoked more than 20 years 18 (18) 16 (16)
I smoked more than 30 years 13 (13) 29 (29)
I have been smoking more than 40 years 7 ( 7) 36 (36) 0.001
* Mann Whitney non parametric test
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Culture and eating habits of our interviewees of the interviewees there is drinking habit of con-
have the next characteristics: >80 % of all intervi- suming the natural fruit juice in their diet. There is
ewees consume the right amount of fruit and ve- enough consuming of vegetables that have active
getable, but the less of half eat the right amount of substances such as broccoli, bulb, egg plant, let-
carrot weekly. Among the lung cancer patients 87 tuce, spinach, green salad and pepper (75 % the
% are of those who have the habit of consuming right amount). The deficiency of our kitchen is
the fruit and vegetable 2- 4 x weekly to daily. As in the shortage of the intake of: vegetables with
for this habit, there is almost no difference in ta- fibers (beans, peas, and lentil), olive, blueberry,
king the fruit and vegetable among the lung cancer blackberry, raspberry, and fish and increased/often
patients and in the control group. Among the 60 % intake of meat and meat products, milk and dai-
Table 2 Distribution of the nutrition and micro- nutrition input and in the interviewees diet (N=200)
according to the frequency and the group
Nutrition and micro- nutrition in a diet Control group Experimental group
P
according to the frequency N (%) N (%)
Fruit and vegetable*
Rarely 16 (16) 13 ( 13)
Often 84 ( 84) 87 ( 87) 0.070
Half of plate of carrot
Rarely 55 (55) 66 (66)
Often 45 (45) 34 (34) 0.091
1-2 dcL natural juice of citrus fruit
Rarely 31 (31) 40 (40)
Often 69 (69) 60 (60) 0.300
Half of plate of broccoli, spinach, lettuce, egg plant,
green salad, bulbs, pepper
Rarely 21 ( 21) 25 (25)
Often 79 (79) 75 ( 75) 0.508
Plate of beans, green beans, lentil, peas
Rarely 45 (45) 81 (81)
Often 55 (55) 19 (19) 0.001
2-5 olives
Rarely 75 (75) 94 (94)
Often 25( 25) 6 ( 6) 0.001
Half of portion blueberry, blackberry, raspberry
Rarely 75 (75) 90 (90)
Often 25 (25) 10 (10) 0.001
Half of plate of grapefruit, banana, apple
Rarely 48 (48) 29 (29)
Often 52 (52) 71 (71) 0.001
Garlic
Rarely 33 (33) 18 (18)
Often 67 (67) 82 (82) 0.001
Fish
Rarely 98 (98) 80 (80)
Often 2 (02) 20 (20) 0.001
Intake of the vitamins A, C and E in a supplement±
Very rarely 87 (87) 96 (96)
often 13 (13) 4 ( 4) 0.001
Intake of meat and meat products
Rarely 10 ( 10) 5 ( 5)
Often 90 (90) 97 (97) 0.040
Intake of milk and dairy products
Rarely 13 ( 13) 5 ( 5)
Often 87 (87) 95 (95) 0. 002
Mann Whitney non parametric test
* (dichotomized often and rarely): often: 2-4 x weekly, 5-6 x weekly; daily: 1x weekly, 1-3 x monthly and never;
± (dichotomized often and rarely): often: 1x monthly; 2x monthly and daily; very rarely: 5-6 x yearly, 1-3 x yearly and never;
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Table 3 Predictors of the lung cancer due to the decreased intake (rare) or often intake of the significant
nutrition’s and micro nutrition’s in a diet of the interviewees of the experimental and the control group.
Lung Cancer
Intake of the nutrition or micro- nutrition a diet Model 1 Model 1 P
β0* β2±
Often intake of fruit and vegetable 0. 657 0.993 0.884
Decreased intake of the fresh, fried or boiled carrot 0.852 0.926 0.113
Often intake 1-2 dcL natural fruit juices 0.687 0.952 0.303
Often intake of broccoli spinach, egg plant, bulbs... 0.619 0.965 0.407
Decreased intake of green beans, beans peas and lentil 0.817 0.835 0.001
Decreased olive intake 0.986 0.986 0.519
Decreased intake of blueberries, raspberry and blackberry 0.946 0.993 0.811
Often intake of grapefruit, banana, apples 1.190 0.187 0.006
Decreased intake of fish 0.959 0.913 0.033
Decreased consumption of preparations vitamins A, C, E in a
0.624 1.117 0.023
supplement
Often intake of garlic 0.678 0.913 0.033
Often consumption of meat and meat products 0.514 0.986 0.177
Often consumption of milk and dairy products 0.503 1.000 1.000
Logistic regression analysis
*β0- for the diseased group
±β2- for the control group
ry products. There is no regular consumption of products among the lung cancer patients and the
the vitamins A, C and E in the supplement. There control group (P= 0,040), as for the frequent milk
is statistically significant difference of the con- and dairy products consumption (87% vs. 95%;
sumption frequency of the meat, milk and their P=0.002)
Table 4 Estimation of the relative risk for the lung cancer due to the decreased intake of the nutrition
and micro- nutrition in the total sample
Decreased intake of nutrition and micro- nutrition’s OR ( 95% CI) P
Fruit and vegetable 1.044 (0.587- 1.857) 0.060
Fresh, fried or boiled carrot 1.588 (0.897- 2.812) 0.001
Natural fruit juice 1.359 (0.760- 2.430) 0.002
Broccoli, lettuce, egg plant, bulbs... 1.322 (0.685-2.459) 0.001
Beans, green beans, peas, lentil 3.488 (1.846- 6.590) 0.001
Olive 1.532 (0.419- 5.613) 0.001
Blueberry, raspberry, blackberry 1.123 (0.436- 2.895) 0.001
Grapefruit, banana, apple 2.260 (1.261. 4.051) 0.001
Fish 2.006 (1.044- 3.854) 0.001
Vitamins A, C, E in a supplement 0.519 (0.295- 0.915) 0.001
Garlic 2.047 (1.054- 3.973) 0.001
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Predictors for the development of the lung can- fish, once a week when compared to the control
cer among the nutrition factors are the deficiency group (P=0.04).
of the fibers intake in the diet of the beans, peas Many studies about the diet and lung cancer
and lentils (P=0.001), decreased consumption of have been focused to the hypothesis that the diet
the fish (P=0,033) and decreased consumption of rich with antioxidants can protect from the oxida-
the vitamins A, C and E in the supplement (P= 0.0- tive damage of DNA and considering that protect
23). Protective factors for the development of the from the carcinoma (9). At the researches it has
lung cancer in our interviewees’ diet are: increased been noted that diet enriched by fruit had clear
intake of grapefruit, banana and apple (P=0.006), protective role in a development of the lung can-
frequent garlic intake (P=0.033). cer, in 4 studies (5, 10, 13, and 2). In 2 studies it
Lung cancer can be prevented by the adequate has been supposed that fruit has the protective role
intake of the protective factors in diet especially (14-15).
fibers in beans, peas and lentil, enough amount of Traditionally, in Bosnia and Herzegovina diet
the carrot, fish, garlic, blueberry, raspberry, grape- fruit and vegetable intake is represented in the suf-
fruit, banana and apple, olive and others. ficient amount. We have not noted significant dif-
Results of the logistic regression analysis indi- ferences among the lung cancer patients and in the
cate that the significant protective factors among control group for this habit, so we couldn’t note
the smokers for the development of the lung can- their clear significant protective role. Consequen-
cer are only the decreased intake of milk and dairy tly our results are in accordance with the results of
products (β= 1.001; P=0.002) and the consumption the others studies, and it’s not the protective factor
of the sufficient amount of grapefruit, banana and in two studies (16-17). That doesn’t mean that we
apple (β= -0.133; P= 0.025; data was not shown). have to stop this good habit in our diet. Decrea-
sed daily intake of the fresh, fried or boiled carrot
in our research presents significant relative risk
Discussion and conclusion for the lung cancer (OR= 1.588, 95% CI 0.897-
2.812). Evidences related to the diet richen with
Last years in the world many researchers have retinol are combined with the decrease risk of the
been done which involve risky population gro- lung cancer noted in many studies (8, 18-19), and
ups with the main aim to identify the risk factors protective role of the diet rich with beta carotene
that are significant for the development of the in results of the next studies (2, 15, 20). Smoking
lung cancer (6, 12). According to the regression is strongly connected to the bad life style, so it is
analysis statistically significant predictors for the hard to reveal which nutrition factor except the
development of the lung cancer among the nu- smoking represent the cancerous risk (4, 21). We
trition factors are: deficit of the fibers intake in have revealed that the adequate intake of grape-
a diet enriched by them such as beans, peas, len- fruit, banana and apple can decrease the cancerous
til, then grapefruit, fish, vitamin preparations in risk as the decreased intake of milk and dairy pro-
a supplement and garlic. The same groceries are ducts in a smokers’ diet. In our circumstances that
the protective factors from the emergence of the is especially related to the rural population.
lung cancer. Statistically significant risk factor for Lung cancer can be prevented by the intake of
the lung cancer exists in the decreased intake of the right amount of the protective factors in a diet
the protective factors in a diet: olive (OR=1.26), especially fibers in beans, pulse, peas, then grape-
grapefruit (OR=1.47), fish (OR=1.45) and garlic fruit, garlic, olive and others.
(OR=1.38). According to the results non-consum-
ption or decreased consumption of the vitamins in
a supplement represents the protective factor (re-
gression linear analysis of the risk factors). In the
control group the risk factor is increased due to the
continuing intake of the vitamin in the supplement
(OR=1.39). Diseased significantly less consume
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P<0,05) i osoba koje žive na selu i predgrađu.(- has shown that the female sex- that is divorced fe-
r=0,123, P<0,01) Česti korisnici imaju prosječno males, widows and women above 65- is a domi-
više hroničnih bolesti. (F=51,6; P<0,01) Najčešće nant sex when the socio-demographic features of
udružene bolesti kod ovih pacijenata su neopla- these patients are taken into consideration. (2, 3, 4,
zme (OR=2,86;95%CI:1,42,5,80), diabetes mel- 6, 7, 8) FAs are the perfect choice for the ‘’super-
litus (OR= 2,16;95%CI:1,53,3,04) i poremećaji ficial examination’’ and for the referrals to specia-
raspoloženja (OR=2,03; 95%CI:1,13,3,63). Oni i lists. (9) They have lower educational status, more
signifikantno više koriste usluge zdravstvenog si- often choose experienced doctors and doctors who
stema od drugih pacijenata.(P<0,001). does not use the appointment system, and they are
Diskusija: Česti korisnici znatno više koriste more satisfied with health services. (10) FA, also,
zdravstveni sistem. Posebno su visoki procenti often have elements of low quality health care,
upućivanja specijalistima, bolničkih dana, dana they have a notion that the physicians don’t under-
bolovanja i kućnih posjeta. stand complexity of their problems which is a ca-
Zaključak: Česte korisnike karaterizira starija use to a dysfunctional relationship between doctor
dob, loši socio-ekonomski uslovi, stanovanje na and patient. (11, 12, 13)
selu i predgrađu, loše fizičko i mentalno zdravlje. There are various definitions of FAs: those who
Bitno je da timovi porodične medicine razviju visit family doctors more than 5 times (14), more
strategiju rada sa čestim korisnicima than 9 times (2), more than 10 times (3) more than
Key words: česti korisnici, ljekarski pregle- 12 times annually (3, 8, 15, patients who have a
di, porodična medicina, opšta praksa, primarna number of visits above 75th percentile per year (16,
zdravstvena zaštita indikatori zdravlja, socio-de- 17) or above of 90th percentile for age and sex gro-
mografske karakteristike, up. (7, 9, 18) Some FAs are defined as patients who
visit the family medicine offices more than average
people from their age and sex group. (19, 20) So-
Introduction metimes FA is defined as a person who has twice or
more consultation than an average patient from the
Researches dating back from the second half of same age and sex group. (21) Weight of patient’s
the 20th century point out that the small percentage medical record greater than 100 g is a turning po-
of patients were responsible for the majority of the int which separates FAs from other patients.(22) It
visits paid to the family physician (1). Since then, must not be forgotten that the term FA sometimes
a significant number of researches regarding the in the medical jargon has a derogatory meaning for
causes and reasons why people frequently use the people who cause “an unnecessary and unwelcome
services of family medicine have been conducted. workload’’ and “Thick-file case”. (12, 13, 23) There
These patients are called frequent attenders (FA), are other numerous, mostly pejorative names, used
constant attenders, high users or high utilizers. by health professionals for these patients. (25)
Patients that frequently visit family doctors In the survey FAs are defined as persons who
significantly use more resources of health care had more visits than 75th percentile (Q3) for his/
system. Researches conducted in countries with her sex group in the year of 2006.
different health systems show similar results. A A visit is defined as encounter between a pati-
group of 4 to10% of patients called frequent at- ent and a doctor ‘’face to face’’.
tendees make up about 21to 60% of all visits. (2,
3) It has also been proven that FAs have more
mental and physical illnesses, social and econo- Aims
mic problems and that they are under increasing
emotional stress. (4, 5) 1. Estimation of the prevalence of frequent
Frequent visits lead to the consumption of limi- attenders (FA);
ted health resources, cause an overload of medical 2. Estimation and comparison of socio-demo-
professionals and spread frustration among the graphic characteristics of frequent attenders
members of Family Medicine team. This Research and non-frequent attenders (NFA);
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The highest percentage of FAs live in a rural 3. Other forms of heart disease [I30-I52]
parts (29,7%), suburbs (26,0%) and the smallest (19,4%; OR= 1,83; 95%CI: 1,24, 2,70),
percentage (17,3%) in the urban parts of Canton 4. Diseases of oesophagus, stomach and
of Sarajevo. (r=0,123, P<0,01) duodenum [K20-K29] (15,7%; OR= 1,05;
95%CI:0,90, 1,23),
5. Dorsopathies [M40-M54] (13,8%; OR=
Health Indicators 1,1; 95%CI: 0,64, 1,89),
6. Ischemic heart diseases [I20-I25] (12,9%,
Smoking prevalence among FAs is 23,0%. OR= 1,44; 95%CI:0,85, 2,43),
There were not significant differences with 7. Mood disorders [F30-F39] (9,7%, OR=
smoking prevalence of NFAs (23,6%). (r=0,048, 2,03, 95%CI:1,13, 3,63),
P>0,05) All patients had an average of 2,66 (SD 8. COPD [J44] (8,3%; OR= 1,27; 95%CI:
1,5) of chronic diseases. FAs had significantly 0,63, 2,54),
more chronic diseases (M=3,48, SD 1,67) than 9. Neoplasms [C00-D48] (6,5%; OR= 2,86;
NFAs (M=2,34, SD 1,31). (F=51,6; P<0,01) 95%CI: 1,42, 5,80),
These are top ten diseases or disease groups 10. Disorders of lipoprotein metabolism and
followed with ICD-10 cods, total percentage, odds other lipdaemias [E70] (5,1%; OR=0,97;
ratio (OR) and 95% confidence interval (95%CI). 95%CI: 0,37, 2,56),
1. Essential hypertension [I10] (58,3%, OR=
1,39, 95%CI: 1,19, 1,62) , Table 3 shows diseases significantly associated
2. Diabetes mellitus [E10-E11] (22,1%, OR= with frequent visits.
2,16, 95%CI: 1,53, 3,04),
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HealthMED - Volume 2 / Number 4 / 2008
Health service usage indicators alence 22%) (16) and Slovenia (24%) (10). How-
ever, our patients had a much higher mean of visits
FAs (23,3%) used among 33,9% to 54,1% ser- to those in Croatia and Slovenia.
vices out of 7 health service usage indicators. Most results of the research link FAs with old-
Significant differences on the level P< 0,01 were er age and female sex. (7, 15, 21, 22, 26, 27, 28)
found between FAs and NFAs Non-significant differences were fond between sex
groups in this study.
Working status had significant impact on num-
Discussion ber of visits. Pensioners were more in number to
those in other groups. This could be explained by
The Research of the prevalence of FAs can in- the fact that pensioners are elderly people and prob-
clude population of registered patients in the med- ably have less income. Also, unemployed patients
ical clinics (2, 5, 7, 8, 14, 18) or less frequently, the have more visits per year than others. Both these
general population. (9, 25) The first type of stud- results match the researches conducted in different
ies have considerably greater prevalence than the countries. (2, 3, 7, 8, 15, 21, 26, 27, 29)
second type (5-26%vs.3-4,7%). FAs prevalence Many of researches highlighted the importance
in this study is very similar to results of studies of the influence of marital status on the number of
conducted in neighboring Croatia (total FAs prev- visits. (2, 3, 7, 15, 26) In this research marital sta-
210 Journal of Society for development of teaching and business processes in new net environment in B&H
HealthMED - Volume 2 / Number 4 / 2008
tus correlated non-significantly with the number alth care and an improper use of health systems.(-
of visits, although the divorced group had largest 28, 33) It is often an indication of undiagnosed
percentage FA (28,9%). problems, especially hidden depression.(19)
Significantly greater percentage of FAs in the It is very important that family medicine team
rural and suburban group could be explained by members to develop a strategy how to deal with
the influence of low education level, health illit- the FA, especially with those who have a very lar-
eracy, as well as low socio-economic status. ge number of visits.(16, 27)
There is a vast amount of evidence that FAs The first step is the identification of FAs and
have more chronic physical and psychiatric is- their health and other problems. It is possible to
sues. (2, 3, 7, 8, 9, 11, 15, 16, 18, 25, 26, 30) The divide these patients into the following subgroups:
results of this study are similar to others. It has “(1) patients with entirely physical illnesses; (2)
been shown that FAs had more diseases, especial- patients with clear psychiatric illnesses; (3) crisis
ly essential hypertension, diabetes mellitus, other patients; (4) chronically somatizing patients; and
forms of heart disease, mood disorders and neo- (5) patients with multiple problems.’’(31) An ana-
plasms. Smoking is not connected with frequent lysis of families and communities capabilities to
visits as results of other researchs.(17) help patient is needed. Most of them really have a
Smaller group of patients, the FAs used signifi- serious chronic illnesses, which implicate the sec-
cantly more health care system services then more ond step- thoroughly planning and management of
numerous groups of NFAs. Such results match those chronic diseases. The third step is to resolve
with other researches.(9, 26) Especially there were social and other problems, if possible, with the en-
high percentages of the referrals to other special- gagement of all available resources.
ists, hospital days, sick leave days and home vis- Continuous monitoring of those diseases
its. through out a longer period of time is the next step
which needs to be ensured for these patients. There
is a need to assess and heal a so called “iatrogenic
Conclusion factor’’ that is common in FAs. Iatrogenic factor
is characterized with a lack of information for pa-
In all health systems, there is a certain percent- tients, polypharmacy, excessive and unnecessary
age of patients who can be identified as FAs. These tests and treatments. (28, 34, 35, 36)
are the people mostly defined as elderly men and There are other possible causes for such a high
women with a bad socio-economic background, percentage of FAs estimated in this study such as:
coming form the rural and suburban parts of the poor health of our residents in comparison to other
country, and most importantly with a poor physi- countries, the poor work organization FM teams,
cal and mental health. FAs have significantly more a low level of quality of management of chronic
chronic diseases and are frequent consumers of the diseases (especially hypertension, diabetes, heart
services and resources of the health system, espe- diseases, depression and malignant diseases),
cially, patients with specific chronic illnesses such obstacles associated with the regulation of drugs
as hypertension, diabetes mellitus, and other forms prescription, the lack of healthcare information
of heart disease, mood disorders and neoplasms. systems and poor and ineffective cooperation with
Other researches also emphasize the specificity of other health levels.
hypertension and diabetes (31) The fact that they Limitation to this study is a relatively small
feel the need for frequent doctor visits, reflects number of analyzed medical charts, only 4 FM of-
their need and vulnerability (17), which requires fices in Canton of Sarajevo, a limited level of in-
special care for this group of patients. formation about patients in medical charts (a lack
In addition, it is a common thing to have FAs of essential parameters about of income, specific
who have unrecognized and unsolved medical education and detailed information about patients’
problems. (19, 32) jobs, family cycles and family relations, the level
A higher percentage of Fas in family medicine of stress, somatoform disorders) Level of patients
office may be indicator of low quality level of he- satisfaction is not explored.
Journal of Society for development of teaching and business processes in new net environment in B&H 211
HealthMED - Volume 2 / Number 4 / 2008
Future researches in our region should involve 11. Scaife B, Gill P, Heywood P, Neal R. Socio-eco-
a greater number of patients in more FM offices nomic characteristics of adult frequent attenders
and secondary health care. They have to focus on in general practice: secondary analysis of data.
finding ways for easier FAs identification, effec- Fam. Pract. 2000; 17(4): 298 - 304.
tive preservation and continuity of health care and 12. Hodgson P, Smith P, Brown T, Dowrick C. Stories
finding efficient management methods of health from Frequent Attenders: A Qualitative Study in
and other FAs problems. Primary Care. Ann. Fam. Med, 2005; 3(4): 318
- 323.
13. Jackson JL, Kroenke K. Difficult patient encoun-
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5. Vedsted P, Fink P, Olesen F, Munk-Jřrgensen Collins M, Cashman SB.Characteristics of freq-
P.Psychological distress as a predictor of frequent uent attenders at a community health center.J Am
attendance in family practice: a cohort study.Psyc- Board Fam Med. 2006 May-Jun;19(3):265-75.
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6. Carney TA, Guy S, Jeffrey G. Frequent attenders in ty and depression among high utilizers of health
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study. Br J Gen Pract. 2001 Jul;51(468):567-9. 19. Smits FT, Mohrs JJ, Beem EE, Bindels PJ, van
7. Westhead JN.Frequent attenders in general practi- Weert HC.Defining frequent attendance in general
ce: medical, psychological and social characteri- practice.BMC Fam Pract. 2008 Apr 15;9:21.
stics.J R Coll Gen Pract. 1985 Jul;35(276):337- 20. Howe A, Parry G, Pickvance D, Hockley B. De-
40. fining frequent attendance: evidence for routine
8. McArdle C, Alexander WD, Murray Boyle C. Freq- age and sex correction in studies from primary
uent attenders at a health centre. Practitioner 1974; care settings. Br J Gen Pract. 2002;52:561–562.
213:696-702 21. Dowrick CF, Bellon JA, Gomez MJ. GP frequent
9. Svab I, Zaletel-Kragelj L. Frequent attenders in ge- attendance in Liverpool and Granada: the impact
neral practice: a study from Slovenia. Scand J Prim of depressive symptoms. Br J Gen Pract. 2000;50:
Health Care. 1993;11:38-43. 361-365.
10. Kersnik J, Svab I, Vegnuti M. Frequent attenders 22. Goodridge DMG An analysis of fat folders. J R
in general practice: quality of life, patient satisfa- Coll Gen Pract.1982;32: 239-241.
ction, use of medical services and GP characteri- 23. Mathers N, Jones N, Hannay D. Heartsink pati-
stics. Scand J Prim Health Care. 2001 Sep;19(3): ents: a study of their general practitioners. Br J
174-7 Gen Pract. 1995;45:293-296.
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24. Gill D, Dawes M, Sharpe M, Mayou R. GP fre- 35. Kouyanou K, Pither CE, Rabe-Hesketh S,Wessely
quent consulters: their prevalence, natural histo- S. A comparative study of iatrogenesis, medication
ry, and contribution to rising workload. Br JGen abuse, and psychiatric morbidity in chronic pain
Pract. 1998;48:1856-1857 patients with and without medically unexplained
symptoms. Pain. 1998;76:417-26.
25. Jyväsjärvi S. Frequent attenders in primary health
care A cross-sectional study of frequent attenders’ 36. Wilkie A, Wessely S. Patients with medically une-
psychosocial and family factors, chronic disea- xplained symptoms. Br J Hosp Med 1994; 51:4-
ses and reasons for encounter in a Finnish health 21-7.
centre , Doktorska disertacija, University of Oulu,
2001; 24-25
Corresponding author:
26. Heywood PL, Blackie GC, Cameron IH & Dowell Zaim Jatic
AC (1998) An assessment of the attributes of freq- Public Institution Medical Centre
uent attenders to general practice. Fam Pract 15: of the Sarajevo Canton,
198-204. Bosnia and Herzegovina
e-mail: jaticzaim@gmail.com
27. Neal RD, Heywood PL, Morley S, Clayden AD,
Dowell AC. Frequency of patients’ consulting in
general practice and workload generated by fre-
quent attenders: comparisons between practices.
Br J Gen Pract.1998; 48: 895-898.
28. Reid S, Wessely S, Crayford T, Hotopf M. Medical-
ly unexplained symptoms in frequent attenders of
secondary health care: retrospective cohort study.
BMJ 2001; 322; 767-771
29. Báez K, Aiarzaguena JM, Grandes G, Pedrero E,
Aranguren J & Retolaza A. (1998) Understanding
patient-initiated frequent attendance in primary
care: a case-control study. Br J Gen Pract 48:
1824-1827.
30. Leung KWM, Tsui WSW, Chu DWS. Survey on fre-
quent attenders - a study to analyze the associati-
ons between frequency of attendance and chronic
illness and socio-economic factors in an outpati-
ent clinic. HK Pract 2007;29:189-198
31. Foster A, Jordan K, Croft P. Is frequent attendan-
ce in primary care disease-specific? Fam. Pract.
2006;23:444-452,
32. Karlsson H, Joukamaa M, Lahti I, Lehtinen V,
Kokki-Saarinen T: Frequent attender profiles: dif-
ferent clinical subgroups among frequent attender
patients in primary care. J Psychosom Res. 1997,
42:157-166.
33. Stewart P, O’Dowd T: Clinically inexplicable
frequent attenders in general practice. Br J Gen
Pract 2002, 52:1000-1001.
34. Kouyanou K, Pither C, Wessely S. Iatrogenic fa-
ctors and chronic pain. Psychosom Med 1997;59:
597-604.
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214 Journal of Society for development of teaching and business processes in new net environment in B&H
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skom periodu (2000-2004). Rad predstavlja re- 2:3. BCC in head and neck regions can invade
trospektivnu studiju u kojoj smo iz istorija bolesti deeper structures and can have endo- and peri-
sagledali: anamnestičke podatke, klinički nalaz, neural spread which can additionally complicate
dijagnostičke procedure i primjenjenu hirurško-te- the course of the disease and proper treatment.
rapijsku mjeru. U odnosu na sve dijagnostikovane Orbital region presents a bilateral facial subregion
bazocelularne karcinome kraniofacijalne regije na that is further divided into four distinct parts: me-
orbitalnoj regiji dijagnostikovan je u 11% slučaje- dial and lateral angle of eye, and upper and lower
va. Polna distribucija muškarci u odnosu na žene eyelid. This type of subregional distinction is made
nalazi se u omjeru 1:1,5. Prosječna starosna dob because of easer orientation, detailed localization
je skoro identična a u 80% slučajeva karcinom je of pathological process and different surgical ap-
dijagnostikovan u kliničkom stadiju I. proach. Tumors of this region are very common
Ključne riječi: Bazocelularni karcinom, orbi- in clinical practice. The most effective treatment
talna regija of tumors in this region is radical surgical exci-
sion, and for those diagnosed in late stages surgi-
cal and/or radiotherapy, followed by chemothera-
Introduction py when needed. The most common localizations
are as follows: lower eyelid 48,9%, medial angle
Basal cell carcinoma (BCC) is slow growing of eye 27,6%, upper eyelid and lateral angle of
malignant skin tumor characterized by uncon- eye 23,5% (Cook i Bartley, 1999). Postoperative
trolled growth of the basal skin layer. It represents defects are often very complex for proper closure
very common type of tumor that rarely yields in since the radical excision is absolute priority and
metastases. BCC has a tendency to occur in skin since reconstruction must be functionally impec-
regions that are chronically exposed to sun, and in cable as well as aesthetically flawless (Picture 1, 2.
people with pale-looking skin (Hurt i Santa Cruz, and 3.) BCC is most common epithelial non-me-
2003; Rosai, 2004). Radiation with 20-50 year lanocytic tumor of this region. It is often necessary
latency period and long-term contact exposure to to clinically determine if the suspicious lesion is
arsenic, as well as UV radiation are all considered in fact tumor or some local inflammatory reaction
to be important risk factors in development of since in some cases the appearance is very simi-
BCC. It has a very good prognosis, if treatment is lar. Eyelid tumors are relatively frequent finding
adequate, but on the other hand untreated lesions in clinical practice.
locally do invade deeper tissue structures. Dur-
ing a large study which involved 900.000 people
(550.000 men and 350.000 women) it was found
that BCC incidence for men was 475 and 250 for
women which then translated in to 33-39% risk
for Caucasian men, and 23-38% for Caucasian
women (Ramsey, 2004). This skin tumor most
commonly occur in the regions of head and neck
(91,5%) (Tiftikcioglu i sar., 2006) usually local- Picture 1. BCC of lower eyelid
ized in places that are much complex for surgi-
cal treatment such as eyelids and nose, although
they also occur in different bare parts of the body
such as hands, and very rarely on the parts of the
body that are usually cover with clothes. It can be
exulcerated in late stages of the disease. BCC me-
tastases occur in 0,0028 to 0,1% of cases (Patel,
Thigpen, Vance, Elkins i Guo, 1999). Fatal out-
come is very rare in case of basal cell carcinoma. Picture 2. Radically excised BCC with recon-
Frequency of occurrence for men and women is structive procedure planned
Journal of Society for development of teaching and business processes in new net environment in B&H 215
HealthMED - Volume 2 / Number 4 / 2008
Table 1. Mean age of patients diagnosed with BCC in orbital region in respect to gender
Orbital region
Min. i max. age
Mean age
Type of skin tumor M FŽ
M F Min. Max. Min. Max.
Basal cell carcinoma 66 65 39 89 33 86
216 Journal of Society for development of teaching and business processes in new net environment in B&H
HealthMED - Volume 2 / Number 4 / 2008
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HealthMED - Volume 2 / Number 4 / 2008
BCC with large diameters are sometimes associ- 11. Salomon J., Bieniek A., Baran E., Szepietowski JC
ated with excessive surgical procedures, and ra- (2004) Basal cell carcinoma on the Eyelids: Own
diotherapy with or without chemotherapy follows. Experience. Dermatol Surg 30:257-263.
Every BCC classified as T1 have good prognosis 12. Szepietowski JC (2004) Basal cell carcinoma on
following surgical treatment. the eyelids: Own experience. Dermatol. Surg. 30:
257-263.
13. Rubin P, Mykula R, Griffiths R.W. (2005) Ectropi-
Literature on following excision of lower ejelid tumours and
full thickness skin graft repair. Britis Journal of
1. Hurt MA., Santa Cruz DJ (2003) Tumors of the Plastic surgery 58:353-360.
skin. In: Fletcher CDM, Diagnostic histopatholo-
14. Ceylan C., Ozturk G., Alper S (2003) Non-Mela-
gy of tumors, 2nd ed, Vol 2, Churchill Livingstone,
noma skin cancers between the years of 1990 and
Edinburg: 1373-1380.
1999 in Izmir, Turkey: demographic and clinico-
2. Rosai Juan (2004) Tumors and tumorlike conditi- pathological characteristics. J Dermatol. 30(2):1-
ons. In: Rosai and Ackerman’s Surgical pathology, 23-131.
9th ed, ed by Rosai Juan, Vol. 1, Mosby: Edinburgh,
15. Meads SB., Greenway HT (2006) Basal Cell Car-
136.
cinoma Associated with Orbital Invasion: Clinical
3. Ramsey ML (2004) Basal Cell Carcinoma. www. Features and Treatment Options. Dermatol. Surg.
eMedicine.com 32:442-446.
4. Tiftikcioglu YO., Karaaslan O., Aksoy HM., Aksoy
B., Kocer U (2006) Basal cell carcinoma in Turkey.
Corresponding author:
The Journal of dermatology 33(2):91-95.
Adi Rifatbegovic,
5. Patel MS., Thigpen JT., Vance RB., Elkins SL., Guo Department of plastic and reconstructive surgery,
M. (1999) Basal cell carcinoma with lung metasta- Surgery clinic, University clinical center of Tuzla,
sis diagnosed by fine-needle aspiration biopsy. The Bosnia and Herzegovina
Southern Medical Journal 92(3): 321-324. e-mail: adi.rifatbegovic@bih.net.ba
6. Cook BE., Bartley GB (1999) Epidemiologic cha-
racteristics and clinical course of patients with
malignant eyelid tumors in an incidence cohort in
Olmsted County, Minnesota. Ophthalmology 106(-
4):746-750.
7. Corona R (1996) Epidemiology of nonmelanoma
skin cancer: a review. Ann Ist Super Sanita 32(1):
37-42.
8. Collins GL., Nickoonahand N., Morgan MB (2004)
Changing demographics and pathology of nonme-
lanoma skin cancer in the last 30 years. Seminars
in cutaneous medicine and surgery 23(1):80-83.
9. Karagas MR., Greenberg ER., Mott LA., Baron JA.,
Ernster VL (1998) Occurrence of Other Cancers
among Patients with Prior Basal Cell and Squa-
mous Cell Skin Cancer. Cancer Epidemiology, Bio-
markers & Prevention, Vol. 7, 157-161.
10. Meads SB., Greenway HT (2006) Basal Cell Car-
cinoma Associated with Orbital Invasion: Clinical
Features and Treatment Options. Dermatol. Surg.
32:442-446.
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HealthMED - Volume 2 / Number 4 / 2008
Sažetak Introduction
U radu se prema zadanim parametrima kore- When discussing about the ostheosynthesis of
lira efikasnost dva oblika ekstramedularne osteo- the small bones still today there is an always pre-
sinteze kod prijeloma dijafiza malih kostiju šake i sent problem of ostheosintetic material selection
stopala. as well as adequate fixation of the fractures, espe-
Cilj istraživanja je utvrđivanje definitivnih cially when it is a case of unstable fracture of fist
funkcionalnih i radiografskih parametara poslije and foot. Majority of authors as only or alternati-
prijeloma i koštanih promjena (24 prijeloma. 6 ve solution see in preference for Kirschner wires
koštanih tumora/cista) nakon provođenja Ekstra- or screws positioned intramedullary (adaptation
medularne FIksacije Kirschner iglama i Serklažom ostheosynthesis), even in situation when there are
– EFIKS osteosinteze i tehnike korištenjem complex fractures of one or multiple bones (se-
pločica sa vijkom. rial fractures of metacarpal/tarsal bones). What
Materijal i metode; Selektirane su dvije grupe is actually in use in these situations is the use of
od po 15 osteosinteza kod 26 pacijenata. Povreda generally mini plates of 2.7 mm according to AO
šake je bila kod 22, a stopala kod 4 ispitanika. authors(1,2). Regardless of the fixation type used
Kod 2 pacijenta prijelomi su bili otvoreni (Gustilo (tension band, wire loop, plates, screws, external
I/II). fixator) the main goal is to achieve positive fixati-
Rezultati; Po završenom liječenju svi implan- on effect trough dynamic compression where with
tati su bili identificirani u primarno postavljenoj mobility and muscle activity compressive to the
poziciji. Potpuna sanacija prijeloma je bila kod 25 point of fracture will increase. What is also impor-
(83,3%) osteosinteza. Redukcija kretnji na susjed- tant is the limited contact between the implant and
nim zglobovima je bila u omjeru + 50 - 100. U gru- the bone („low contact plate/ no contact plate“)
pi EFIKS osteosinteza komplikacije su zabilježe- with which principles of the „biological fixation”
ne kod 2 (6,6%) osteosinteze; pucanje serklažne of the fracture are achieved. With this preserved
žice (1), angulacija na mjestu prijeloma (1). Kod are elements of moderate elasticity, rigidness,
osteosinteze sa pločicom i vijcima komplikacije better biological tolerance as well as presence of
su evidentirane kod 3 (10%) osteosinteze; uspo- the sufficient compression between fragments (3,4).
reno koštano cijeljenje (1), razlabavljenje vijaka What is the crucial problem in case of isolated
i ploče (1), savijanje ploče (1). intramedullary adaptation ostheosynthesis is the
Zaključak; Ekstramedularna stabilizacija pri- control over the bone axis disorder such as: tor-
jeloma i koštanih promjena u ispitivanom uzorku sion, angulations or contraction of the fragments,
i dvije specifične grupe ispitanika sa različitim ob- and which are caused by bending or fracture of the
licima ekstramedularnih osteosinteza nija pokaza- ostheosintetic material after the fragments are kept
la signifikantne razlike u konačnim radiografskim in bad (“mal”) position. This often escalates to the
i funkcionalnim rezultatima prema zadanim para- lack of healing, poor healing with the consequen-
metrima istraživanja (p>0,05). EFIKS osteosinte- tial deformities and biomechanical disorders (5,6).
za ima mogućnost šire praktične hirurške primje- Today in use is the large number of fixation tec-
ne i potpuno je prihvatljiva alternativa za one koji hniques for the diaphyseal fractures small bones
ne raspolažu pločicama i vijcima. Nasuprot tome fractures. That is usually stabile extramedullary
ekstramedularna fiksacija prijeloma sa vijcima or instable intramedullary fixations which are lin-
i pločicama još uvijek je suverena i nezamjenjiva ked to the especially adapted instruments as well
kao metoda u situacijama zglobnih i metafizarnih as implants of various sizes and shapes (7). When
prijeloma eventually thinking of external fixation in case
Ključne riječi; ekstramedularna osteosinteza, of small diaphyseal fractures of foot and fist that
koštano cijeljenje it is very inappropriate in case of load or muscle
activity, which leads to loosening of the complex
screw - external fixator, as well as movement of
the fracture, so it is reserved exclusively for the
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HealthMED - Volume 2 / Number 4 / 2008
larger defects of the soft tissue and the bone as res with specific, original model of extramedullary
temporary procedure. fixation of the fractures (Extramedullary Fixation
Voluminous implants which are implanted with Kirschner Wires and Cerclage - EFIKS) in
in proclaimed surgical procedures often leads to comparison to intramedullary ostheosynthesis
huge surgical and post-surgical hazard; soft tissue much better with less complications (7,11). This
destruction, increase of periosteal necrosis in large initiated further research in terms of determining
segmented bone fields (endangered local vascula- definite functional results after conducted EFIKS
rization), reduced elasticity of the bone and others. ostheosynthesis and other extramedullary ostheo-
This have as a consequence progression of prima- synthesis under same conditions of traumatic sub-
ry state and occurrence of above mentioned com- strate which will give an answer about:
plications (8). Due to this large number of authors
modified their implantation techniques giving pri- • process of bone healing in case of fractures
ority to the minimally invasive surgical procedu- and bone fusions (arthrodesis) by use of
res, without open presentation of the fracture site elastic and non elastic (rigid) extramedullary
and with fluoroscopic guidance of the fragment ostheosynthesis of the small diaphyseal
until reduction and fixation of the fracture. Among fractures
other complications we should mention migration • surgical applicability of these two forms of
of alanthesis which can have extensive consequ- ostheosynthesis
ences (9,10).
Table 1 Indications for implantation of the ostheosintetic material in certain fractures types
Screw /
Extramedullary fixation
Tension band Kirsch. wire Tension
Plate with screws (8)
with Kirschner wires
(Zuggurtung) intramedullary, screw (8)
and cerclage
cerclage (8)
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Surgical technique
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HealthMED - Volume 2 / Number 4 / 2008
of fist fractures, movements in neighboring joints, migration of the spiral metacarpal fracture to, but
as well as baropodometric evaluation of plantar with healed fracture – 1, bending of the plate with
foot pressure distribution and supportive walk poor position of the fragments in case of metatar-
analysis. sal fracture – 1, without need for additional corre-
ction. In 2 (6,6%) cases with EFIKS ostheosynt-
hesis noticed is the break of one of the cerclage
wires inn case of transversal diaphyseal fracture of
the metacarpal bone – 1, without consequences on
final healing. angulations at the point of fracture
with defect of the primary base on the V metatar-
sal bone – 1, with normal bone healing. Baropo-
dometric evaluation of walk and posture in 4 cases
of patients with ostheosynthesis of the foot was
adequate (analysis 5 months after surgery) without
A need for correction.
Two patients had signs of local inflammation
without involvement of the bone or ostheosynthe-
sis. After 2 and 4 weeks inflammation is coupled
with the targeted antibiotic therapy.
Discussion
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da potiču ruturu aterosklerotskog plaka i nastanak Circulating adipokine levels are elevated in
akutnog koronarnog sindroma. obese and insulin-resistant states in animals and
Nedavno objavljene studije su pokazale da vi- humans. Weight loss is associated with a decrease
sok nivo leptina i nizak nivo adipokina, uočen kod in the serum levels of most of these adipokines,
gojaznih osoba, inhibira vazodilataciju koronarnih with the exception of adiponectin, which is in-
krvnih sudova preko acetilholina in vitro i in vivo. creased (3).
Resistin također inhibira koronarnu vazodilataciju Obesity is an independent risk factor for de-
ali preko bradikinina. velopment of atherosclerosis. In patients with es-
Leptin i resistin djeluju proinflamatorno dovo- tablished coronary atherosclerosis increased body
deći do povećane ekspresije citokina u makrofazi- weight is an independent predictor of an acute cor-
ma, procesa koji može biti okidač destabilizacije onary syndrome (ACS) (4). The exact mechanism
koronarnog aterosklerotskog plaka. Uočeno je da by which increased body weight leads to coronary
leptin stimulira angiogenezu, agregaciju trombo- artery disease is not fully understood.
cita i aterotrombozu kod gojaznih osoba. Istovre- The term acute coronary syndrome refers to a
meno višak masnog tkiva dovodi do smanjenog range of acute myocardial ischemic states. It en-
stvaranja adiponektina, koji djeluje protektivno na compasses unstable angina, non-ST and ST seg-
koronarne krvne sudove. ment elevation myocardial infarction and sudden
Ovaj članak ima za cilj da sumira ulogu nave- ischemic death. Underlying mechanism precipi-
dena tri adipokina: leptina, resistina i adiponektina tating acute coronary syndrome in a majority of
u akutnom koronarnom sindromu kao i da implici- cases, is coronary atherosclerotic plaque rupture
ra njihovu moguću primjenu u kliničkoj praksi. and consequent thrombus formation. The vulner-
Ključne riječi: Adipokini, leptin, adiponektin, ability of a plaque to disruption appears to be de-
resistin, akutni koronarni sindrom termined by the presence of a large lipid-rich core,
a thin fibrous cap, and an inflammatory cellular
infiltrate. Endothelial dysfunction is present in pa-
Introduction tients with atherosclerosis, even in the early stages
of disease. Dysfunctional endothelium encoura-
Adipose tissue has traditionally been conside- ges the recruitment of leukocytes into the arterial
red as a tissue devoted mainly to energy storage. wall and thereby predisposes to inflammation and
Adipose tissue is now recognized as a multifuncti- plaque disruption. In addition to plaque disruption
onal organ producing proteins and peptides named and thrombosis, characteristic feature of coronary
adipokines. Adipokines are hormones, growth fa- artery disease is enhanced coronary vasoconstric-
ctors and cytokines acting via endocrine, paracrine tion (5).
and autocrine modes (1). Adipokines might play an important role in ini-
Leptin was one of the first adipocyte-derived tiation and progression of atherosclerotic plaque
hormon which signals the status of energy stores rupture enhancing endothelial dysfunction, im-
and its secretion can reduce appetite and increase mune response and thrombogenesis but the find-
energy expenditure (2). Since the initial identifi- ings regarding exact mechanism of their action are
cation of leptin, numerous adipocyte-derived pro- contradictory and inconclusive.
teins and peptides have been discovered. Besides Aim of this paper is to summarize current find-
leptin, adiponectin and resistin have been given ings regarding the role of adipokines in acute cor-
much attention in research lately. onary syndrome and possible appliance of adipo-
Adipokines are known to contribute to the kines blocking and boosting agents in clinical
chronic low grade inflammation state observed in setting. Clinical significance of adipokines mea-
obese patients. In the same time they participate surement during acute coronary syndrome is also
in the development of obesity-related comorbiditi- discussed.
es, such as insulin resistance, metabolic syndrome
and atherogenesis (1)
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HealthMED - Volume 2 / Number 4 / 2008
Table 1. Main adipokines outline: most important physiological functions and involvment in diseases.
Adipokines Physiological function Related diseases
Energy and glucose homeostasis ↑2
Trombogenesis ↑ 18 Obesity ↑ 11
Leptin
Immunity ↑ 1 Atherosclerosis ↑ 12
Haematopoesis ↑ 17
Insulin sensitivity ↑ 31
Obesity ↓23
Energy expenditure ↑ 31
Dislipidemia ↓ 23
Fatty acid oxidation ↑ 31
Atherosclerosis ↓ 23
Vasodilatation ↑ 25
Adiponectin Nonalcoholic fatty liver disease ↓40
No production ↑ 25
Nonalcoholic steatohepatitis ↓40
Inflammation ↓ 1
Diabetes mellitus type 2 ↓ 23
Cell proliferation ↓ 22
Cancer ↓1
Tissue remodeling ↓ 22
Obesity ↑ 34
Glucose production ↑ 34
Resistin Insuline resistance ↑ 34
Inflammation ↑ 40
Atherosclerosis ↑ 36
Obesity ↑ 44
Vistatin Insulin sensitvity ↑ 44
Diabetes mellitus type 2 ↑ 44
Adipsin Complement activation ↑ 43 Obesity ↑43
Acute phase protein synthesis ↑ 1
Hypothalamic–pituitary axis ↑1 Obesity ↑ 3
IL-6 activation↑ 1 Acute and chronic inflamatory diseases ↑3
Thermogenesis ↑1 Atherotrombosis ↑6
Coagulation ↑1
Chronic inflammation ↑1
Malignancy ↑1
Inflammation ↑ 1
Obesity ↑ 3
TNF-α Cellular proliferation ↑1
Anorexia ↑3
Cellular differentiation ↑1
Insuline resistance ↑3
Coronary heart disease ↑6
Obesity ↑1
Trombogenesis ↑ 6
Hyperglicemia ↑1
PAI-1
Hyperlipidemia ↑6
Atherotrombosis ↑6
Journal of Society for development of teaching and business processes in new net environment in B&H 227
HealthMED - Volume 2 / Number 4 / 2008
in the regulation of cardiac functions particularly in vivo. In contrast, normal concentrations of leptin
under pathological conditions (9). The primary (4 ng/mL) do not affect vasodilatation to acetyl-
cardiac response to leptin in terms of physiologi- choline. Therefore, concentrations of leptin found
cal function appears to be a negative inotropic re- in obese subject appear to have deleterious effects
sponse which has been shown primarily in cardio- on coronary endothelial function and myocardial
myocytes and which is mediated by endogenously blood flow acutely.
produced nitric oxide (NO) (10). Leptin has been linked to all processes under-
High circulating plasma leptin levels in obesity ling acute coronary syndrome. Leptin leads to T-
are thought to play a role in the hastened develop- cell proliferation, phagocytosis and upregulation
ment of coronary artery disease (11). Again, se- of cytokine production in macrophages. On endo-
veral clinical, epidemiologic studies have shown thelial cells leptin has been shown to upregulate
a strong association between hyperleptinemia and endothelin-1 and NO synthase, and at the same
risk for coronary artery disease (12, 13). There are time it induces oxidative stress (18).
still numerous unresolved issues regarding the ex- In addition, leptin has been observed to stimu-
act nature of leptin’s effects on coronary arteries late angiogenesis, platelet aggregation, and ath-
and during acute coronary syndrome. Plasma le- erothrombosis in human obesity (1).
ptin levels were found to be significantly higher in Dubey et al. (19) analized angiographically
patients presenting with acute coronary syndrome simple and complex lesions on coronary arteries
compared to the patients with stable angina and in patients presenting with unstable angina pecto-
healthy subjects (14). Leptin correlated positively ris and found leptin to be an independent predictor
with interleukin-6 and high-sensitivity C-reactive of complex lesion suggesting its potential role as
protein in patients with acute coronary syndrome useful biomarker for risk stratification in patients
suggesting its possible role in systemic inflamati- with unstable angina.
on and in asssesing the risk for developing acute Damaging effect of leptin on acutely ischemic
coronary syndrome. myocardial tissue might be inhibited with novel
Earlier studies have demonstrated that leptin is pharmacological tools targeting leptin receptors.
vasoactive in noncoronary vascular beds (2,15), Therefore, with the development of specific ObR
but the coronary vascular effects of leptin are antagonists a clear and consistent consensus will
largely uncharacterized. However, few studies to be reached regarding the role of leptin on isch-
date have examined the effects of leptin on the co- emic myocardial tissue. Leptin receptors antago-
ronary circulation. Several studies suggested that nists called muteins could promiuse as a possible
leptin affects coronary vascular resistance but the therapy in patients with coronary atherosclerotic
findings are inconclusive. Matsuda et al. (16) were disease and acute coronary syndrome (20).
first to report that leptin increases coronary blood
flow approximately 40% in patients undergoing
cardiac catheterization and that this vasodilata-
tion is independent of nitric oxide (NO) synthase. Adiponectin
On the contrary, Knudson et al. (17) demonstrated
that high pharmacologic concentrations of leptin Adiponectin is 30 kDa protein mostly secret-
induce nitric oxide–dependent vasodilatation of ed by adipose tissue. Adiponectin concentration
coronary arterioles in animal models. But, leptin- ranges from 1.9–17.0 mg/dL in normal healthy
mediated coronary vasodilatation in the studies subjects (1).
was only observed at extremely high leptin con- Adiponectin expression and release from adi-
centrations (160 ng/mL) which are rarely seen in pocytes are stimulated by activation of peroxi-
obese subjects. Knudson et al. (8) recently dem- some proliferator-activated receptor PPAR-γ, a
onstrated that increasing plasma leptin concentra- key transcriptional factor involved in adipocyte
tions to levels similar to those observed in obese differentiation (21). Adiponectine can function as
subjects (10–90 ng/mL) significantly impaired full length proteine which binds to AdipoR1 (adi-
acetylcholine-mediated vasodilatation in vitro and ponectin receptor 1) or smaller globular fragment
228 Journal of Society for development of teaching and business processes in new net environment in B&H
HealthMED - Volume 2 / Number 4 / 2008
binding to AdipoR2 (adiponectin receptor 2). In would be extremely expensive. An alternative ap-
myocardial tissue, AdipoR1 is expressed in sub- proach is to use pharmacological or dietary inter-
stantially greater abundance compared to AdipoR2 vention to increase the suppressed endogenous adi-
(22). ponectin production in obesity, or to enhance adipo-
Plasma adiponectin levels correlate inversely nectin actions in its target tissues. In this respect, it is
with body fat content and in obese subjects low interesting to note that the PPAR-γ agonists thiazo-
plasma adiponectin level is an independent pre- lidinediones (TZDs), such as rosiglitazone and pio-
dictor of all-cause mortality, cardiac mortality, glitazone, which increase adiponectin production in
and myocardial infarction in patients presenting both humans and rodents, demonstrate many of the
with chest pain (23). Also, decreased circulating therapeutic effects of adiponectin, such as insulin-
adiponectin levels in obesity are associated with sensitizing, vasoprotective, and anti-inflammatory
an increased risk of coronary artery disease and properties (31). Whether the therapeutic effects of
myocardial infarction (24). the PPAR-γ agonists are mediated via induction of
Wolk et al. (25) found that patients with acute adiponectin remains to be investigated. In addition,
coronary syndrome (ACS) had significantly lower metformin, another commonly used antidiabetic
adiponectin levels than those without ACS, inde- drug, as well as beta-blocking drugs which are used
pendent of a variety of cardiovascular risk fac- during myocardial infarction have been shown to
tors. mimic the action of adiponectin (32).
Within the last year a few studies examining the
role of adiponectin in coronary vasomotor func-
tion have been published. Epicardial adipose tis- Resistin
sue produces adiponectin. Furthermore, in humans
with coronary artery disease, there is a reduction Resistin is 12 kDa protein named after the ob-
in local epicardial adiponectin production (26). servation that it leads to insulin resistance. Alt-
A study by Date et al. (27) observed a significant hough it was detected in adipose tissue of obese
correlation between coronary flow reserve and the subjects, resistin levels are substantially higher in
transcardiac adiponectin gradient (i.e., great car- human inflammatory cells (33). Plasma resistin
diac vein concentration minus left coronary artery concentration is in the range of 3–13 ng/ml in he-
concentration) in 22 nondiabetic, healthy subjects althy subjects with levels approaching 40 ng/mL
with angiographically normal coronary arteries. in obese individuals (34). Although resistin cell
Those subjects with higher transcardiac adiponec- receptors are yet to be identified, direct action of
tin gradients exhibited higher coronary flow re- resistin in the heart and specifically on cardiomy-
serves. Another recent study by Takano et al. (28), ocytes has been described. Mouse adult cardio-
found a positive correlation between transcardiac myocytes treated with resistin show a reduction in
adiponectin gradient and acetylcholine-induced insulin-stimulated glucose uptake (35).
increases in coronary artery diameter. The authors Studies by Kougias et al. (36) and Dick et al.
concluded that adiponectin plays a role in coro- (37) demonstrated that resistin alters coronary va-
nary endothelial function (as assessed by acetyl- somotor responses in vivo and in vitro imparing
choline-mediated coronary vasodilation). coronary vasorelaxation to bradykinin in both por-
Adiponectin is associated with induction of cine and canine coronary circulations.
antiinflammatory cytokine production (IL-10 and Studies regarding resistin effect on ischemic
IL-1) (29). It has also been shown that adiponectin myocardium are scarce and conflicting. In one
plays a role in endogenous antithrombosis (30). study resistin depressed functional recovery from
Promising results obtained from numerous ani- ischemia in isolated perfused rat hearts, an effect
mal experiments and human epidemiological stu- which appeared to be dependent on NF-kB activi-
dies support the role of adiponectin as a potential ty (38). In contrast, resistin reduced infarct size in
drug target in treating obesity-related chronic low mice subjected to coronary artery occlusion and
grade inflamatory diseases. Direct supplementati- reperfusion (39). The obvious discrepancy requi-
on of recombinant adiponectin in human subjects res further research.
Journal of Society for development of teaching and business processes in new net environment in B&H 229
HealthMED - Volume 2 / Number 4 / 2008
Qiao at al. (40) reported increased serum re- plasma leptin concentration in patients with myo-
sistin levels in patients with acute coronary syn- cardial infarction is in the lower obese range and
drome and in patients with stable angina pectoris significantly higher compared to the patients with
(SAP) compared with the healthy subjects. The unstable angina. Leptin concentration in obese
highest serum resistin values were found in acu- range (10-90 ng/mL) was found to impair acetylc-
te myocardial infarction (AMI), followed by un- holine mediated coronary relaxation and could be
stable angina pectoris (UAP) and SAP. Serum attributable to prolonged myocardial ischemia (8).
resistin levels positively correlated with CKmax, It remains to be assessed whether the predetermi-
CK-MBmax, cTnImax, WBC and hsCRP. Lubos et al. ned ranges of plasma adipokines concentration co-
(41) reported that resistin levels were elevated in uld be used as a useful biomarker for stratification
patients presenting with unstable angina, non-ST- of patients with coronary heart disease. It has not
elevation myocardial infarction and ST-elevation been assessed whether elevated concentrations of
myocardial infarction. adipokines during myocardial ischemia changes
Resistin might reflect an inflammatory proces- during and after acute coronary syndrome. Du-
ses occurring in mononuclear cells during acute ring myocardial infarction, increased sympathetic
coronary syndrome. Because of diverse myocar- activity causes release of renin and elevation of
dial ischemia and ischemic impairment in AMI\ plasma leptin concentration could be due to incre-
UAP\SAP patients, the inflammatory factors ased plasma angiotensin II levels, which is known
might be released in different degrees. Serum resi- to stimulate leptin release.
stin levels increased with the severity of myocar- There are numerous challenges facing investi-
dial impairment and therefore might play a role as gators in this field. Important among these is the
a diagnostic marker. fundamental question of precisely how leptin,
adiponectin, and other adipokines affect cardiac
pathology. This task will undoubtedly be facilita-
Discussion ted and expedited with the eventual development
of new pharmacological tools targeting specific
Increased adipose tissue in obese subject pro- adipokine systems. A second major challenge is
duces more adipokines such as leptin and resistin to understand how the various adipokines inte-
which have recently been implicated in the pat- ract with each other since numerous adipokines
hogenesis of acute coronary syndrome affecting with diverse biological properties can be released
coronary vasculature, inflammatory processes and simultaneously and, as such, the net effect of in-
thrombogenesis and thus predisposing the ruptu- creased adipokine production may not reflect the
re of coronary atherosclerotic plaque. On the ot- actions of a single individual substance. This re-
her hand, increased adipose tissue suppresses the mains a challenge for future investigations which
production of an adipose tissue hormone, adipo- are important not only to fully understand the role
nectin, which has protective effects on coronary of adipokines in cardiac regulation but in terms of
vasculature. potential for the development of novel cardiac the-
Disruption of physiologic adipokine plasma le- rapeutic targets.
vels and perturbations in adipokine signaling wit-
hin the coronary vascular wall culminates in co-
ronary endothelial dysfunction. Thus, alterations
in adipokine biology may be a major precipitating
factor in the initiation of coronary artery disease in
individuals with metabolic disease.
Plasma concentration of leptin and resistin is
associated with the extent of coronary occlusion
during acute coronary syndrome while plasma
concentration of adiponectin correlates inversely
with the degree of myocardial ischemia. Average
230 Journal of Society for development of teaching and business processes in new net environment in B&H
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Journal of Society for development of teaching and business processes in new net environment in B&H 231
HealthMED - Volume 2 / Number 4 / 2008
19. Dubeya L. Zenga H., Hashimb S., Hongjiea W., 28. Takano H, Kodama Y, Kitta Y, Nakamura T, Obata
Taoa H. Association of plasma leptin levels and JE, Mende A, Kawabata KI, Saito Y, Fujioka D,
complexity of the culprit lesion in patients with Kobayashi T, Hasebe H, Kugiyama K. Transcar-
unstable angina. International Journal of Cardi- diac adiponectin gradient is independently related
ology. Article in press. to endothelial vasomotor function in large and re-
sistance coronary arteries in humans. Am J Physi-
20. Gertler A.Development of leptin antagonists and ol Heart Circ Physiol 291:H2641–H2646, 2006.
their potential use in experimental biology and
medicine. Trends in endocrinology and metabo- 29. Wolf AM, Wolf D, Rumpold H, Enrich B, Tilg H.
lism 17, 372-378, 2006. Adiponectin induces the anti-inflammatory cytoki-
nes IL-10 and IL-1RA in human leukocytes. Bioc-
21. Maeda N, Takahashi M, Funahashi T, Kihara S, hem Biophys Res Commun 323:630–635, 2004.
Nishizawa H, Kishida K et al. PPARg ligands in-
crease expression and plasma concentrations of 30. Kato H, Kashiwagi H, Shiraga M, Tadokoro S,
adiponectin, an adipose-derived protein. Diabete- Kamae T, et al. Adiponectin acts as an endoge-
s;50:2094–2099, 2001. nous antithrombotic factor. Arterioscler Thromb
Vasc Biol 26:224–230, 2006.
22. Yamauchi T, Kamon J, Ito Y, Tsuchida A, Yokomizo
T, Kita S et al. Cloning of adiponectin receptors 31. Chaldakov GN., Stankulov I.S., Hristova M., Ghe-
that mediate antidiabetic metabolic effects. Natu- nev P.I. Adipobiology of disease: Adipokines and
re;423:762–769, 2003. adipokine-targeted pharmacology. Current Phar-
maceutical Design, 9,1023-1031, 2003.
23. Cavusoglu E, Ruwende C, Chopra V, Yanamada-
la S, Eng C, Clark LT, Pinsky DJ, Marmur JD. 32. Delporte ML, Funahashi T, Takahashi M, Matsu-
Adiponectin is an independent predictor of allca- zawa Y, Brichard SM. Pre- and post-translational
use mortality, cardiac mortality, and myocardial negative effect of beta-adrenoceptor agonists on
infarction in patients presenting with chest pain. adiponectin secretion: in vitro and in vivo studies.
Eur Heart J 27:2300–2309, 2006. Biochem J 367:677-685, 2002.
24. Sattar N, Wannamethee G, Sarwar N, Tcherno- 33. Yang RZ, Huang Q, Xu A, McLenithan JC, Eisen
va J, Cherry L, Wallace AM, Danesh J, Whincup JA, Shuldiner AR, Alkan S, Gong DW. Compara-
PH. Adiponectin and coronary heart disease: a tive studies of resistin expression and phylogeno-
prospective study and meta-analysis. Circulation mics in human and mouse. Biochem Biophys Res
114:623–629, 2006. Commun. 2003;310(3):927–935.
25. Wolk R, Berger P, Lennon RJ, Brilakis ES, Davi- 34. Pfutzner A, Langenfeld M, Kunt T, Lobig M, Forst
son DE, Somers VK. Association between plasma T. Evaluation of human resistin assays with serum
adiponectin levels and unstable coronary syndro- from patients with type 2 diabetes and different de-
mes. Eur Heart J 28:292–298, 2007. grees of insulin resistance. Clin Lab 49:571–576,
2003.
26. Iacobellis G, Pistilli D, Gucciardo M, Leonetti F,
Miraldi F, Brancaccio G, Gallo P, di Gioia CR. 35. Graveleau C, Zaha VG, Mohajer A, Banerjee RR,
Adiponectin expression in human epicardial adi- Dudley-Rucker N, Steppan CM et al. Mouse and
pose tissue in vivo is lower in patients with coro- human resistins impair glucose transport in pri-
nary artery disease. Cytokine 29:251–255, 2005. mary mouse cardiomyocytes, and oligomerization
is required for this biological action. J Biol Chem
27. Date H, Imamura T, Ideguchi T, Kawagoe J, Sumi 2005;280:31679–31685.
T, Masuyama H,Onitsuka H, Ishikawa T, Nagoshi
T, Eto T. Adiponectin produced in coronary circu- 36. Kougias P, Chai H, Lin PH, Lumsden AB, Yao Q,
lation regulates coronary flow reserve in nondia- Chen C. Adipocyte derived cytokine resistin cau-
betic patients with angiographically normal coro- ses endothelial dysfunction of porcine coronary
nary arteries. Clin Cardiol 29:211–214, 2006. arteries. J Vasc Surg 41:691–698, 2005.
232 Journal of Society for development of teaching and business processes in new net environment in B&H
HealthMED - Volume 2 / Number 4 / 2008
Corresponding author:
Emina Nakas-Icindic
Institut of physiology and biochemistry,
Medical faculty University of Sarajevo,
Bosnia and Herzegovina
e-mail: nakasicindic@yahoo.com
Journal of Society for development of teaching and business processes in new net environment in B&H 233
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HealthMED - Volume 2 / Number 4 / 2008
The aims of the work Vitamins and mineral additions, only in extreme
situations, use 30,30 % of questioned (ex. In case
Analasys of knowledge and practice of of dissease ), several times a day 9,09 %,and there
patient towards feeding additions vitamins are those who don’t use them at all, 15,48%.
and minerals The reasons why the patients don’t use artifici-
Give evaluation of fruit and vegetables using al preparats of vitamins and minerals or use them
in patients' feeding rarely are in the largest percentage (22,89 %, at-
titude that during intake of various food in orga-
Material and methods nism isn’t necessary to take other supplements. It
is very signifficant to point out that quite number
The used method of work is questionaire consi- of patients are affraid of side effects of these ad-
sting 30 questions. Questioning is divided in four ditions. The most of users didn’t answer at all or
parts: status of qustioned persons, fruit and vege- mentioned any reason.
tablesin feeeding of qustioned ones, artifitial pre-
parats of vitamins and minerals in their feeding,
their attitudes on the way of feding.
There were 297 patients of different age, disseases
and hospitalised in several clinics of Clinical centre
University of Sarajevo, by method of random cause.
the questioning was realised in decembre 2007. Graphic 2. The most often used feeding additions
of minerals and vitamins by the patients treated
in UKC Sarajevo
Results and discussion
Patients hospitalised in KC Univerzity of Sa-
There were totaly 297 patients, out of which rajevo, use multivitamin additions ( 26,26 % ), the
162 males and 135 females in different age gro- second place belongs to A + C + E (23,56%), and
up. According to educationanal level, the most the least used are multimineral additions 3,36 %.
of them are with finished high school (65,55 %), Multivitamin additions, 35,01 % of questioned
university and two-year higher educational level patients use after meal, 27,60 %, during meal and
18,18 % , while others are with finished primary even number consume before meal.
school. More than a half live in urban area, in su-
burban area live 26,26 %, and others 22,55 % live
in the country
As for employment, there was the largest num-
ber of employed (44,10 %), retired 22,22 %, stu-
dents 4,71 %, whilie others were unemployed.
Feeding additions of vitamins and minerals in
feeding of qustioned patients. Graphic 3. The usual place of getting of feeding
additions and minerals by patients treated in
UKC Sarajevo
Journal of Society for development of teaching and business processes in new net environment in B&H 235
HealthMED - Volume 2 / Number 4 / 2008
About medical action of these suplements, the gular intake of fruit and vegetables while 46,12 %
largest number of users recieved the information of them dissagree.
from the media (47,47%), doctora (22,89 %), and Out of total number of questioned patients 85,-
10,77% cases from the pharmacist. 52 %, thinks that taking of additional vitamins and
Fruits and vegetables are irreplaceble part of qu- minerals as supplements, doesn’t have good effect
ality and balanced feeding becouse provide many on organism without intake of fruits and vegeta-
important vitamins and minerals and it important bles.
to overlook the intake of fruit and vegetables what With attitude that bought groceries lose the
can be seen in the following graphic (graphic 5.). necessary vitamins and minerals by modern pro-
cessing, one third of them partialy agrees 8,75 %
disagrees , while others fully agree.
Confirmative answer on claim that inappropri-
ate preparation of grocerries decreases the content
of vitamins has given 92,92 % of questioned pati-
ents, others dissagree with this. Obviously, most of
them think that vitamins are instabile connections
Graphic 4. The source of information about fe- sensitive on heat, light and storage and the way of
eding additions of minerals and vitamins by the food preparation.
patients treated in UKC Sarajevo Evaluation of influence of vitamins and mine-
rals, regardless their origin, on health improvement
of patients evaluation n1-5 has given the following
results: mark 1 gave 3,7 % of questioned patients,
mark 2-18,18 % , mark 3-41,07 %, mark 4-20,53
% and mark 5-16, 49 % of questioned patients.
Various feeding is one of the main marks of
Graphic 5. Fruits and vegetables in feeding helthy feeding and most of our patients, 88,21 %
remarks that their feeding is as such. Others claim
The great number of questioned patients (40,40 that their feeding isn’t as it should be ant they are
%) consumes fruits and vegetables only several consuming 2 and less meals a day. There are those
times a week what leaves the organism without who try to have 4-5 meals but the average is 3 me-
important nutritiens. In recomendations of SZO als per day in 53,53 %. Approximately, the same
in daily intake of fruits and vegetables. 5,05 % of number questioned patients 57, 91 % , thinks that
users take it. they do give enough attention to healthy lifestile.
Interesting information would be that very
small number 13,18 %, eats fruits and vegetables
which they have produced themselves, while most
of them provides it on the market what is shown in
thwe folowing graphic.
236 Journal of Society for development of teaching and business processes in new net environment in B&H
HealthMED - Volume 2 / Number 4 / 2008
Journal of Society for development of teaching and business processes in new net environment in B&H 237
HealthMED - Volume 2 / Number 4 / 2008
Conclusions Literature
Participation of feeding aditions vitamins and 1. Službene Novine Federacije, broj 7/2004.
minerals in feeding of patient is significant 2. Kocijančić R., Pecelj-Gec M.,Higijena, Značaj ish-
(54%). rane, XX; Zavod za udžbenike i nastavna sredstva;
Feeding aditions are taken randomly, without Beograd;2002;334-339
previous evaluation of nutritive status by the 3. Anonimous, najboljša je pestra prehrana. Zdravje
experts in this area of expertise and the most 1999; 228: 31.
used are multivitamin preparts (26,26%).
4. Shaw GM,etal.,Journal of the American Medical
The great role in popularisation of feeding
Assotiation;2000;54-55
additions have the media with constant
advertising 5. Millen A.E., Dodd K.W., Subar A.F. Use of Vitamin,
Vegetables and fruits on the menu, as natural Mineral, Nonvitamin, and Nonmineral Supplements
source of vitamins and minerals in feeding in the United States: The 1987, 1992, and 2000 Na-
tional Health Interview Survey Results: Jurnal of
of questioned patients isn’t sattisfying.
The American Dietetic Association 2004; 104; 943-
Consuming of fruits and vegetables several
944.
times a week (40, 40%) is a habit that needs
to be changed in future 6. Erjavec M , Vitaminski i mineralni pripravki u pre-
Education level of our population about hrani Slovencev, Diplomska naloga, Univerza v
Ljubljani, 2005; 6-28.
healthy and balanced feeding is minimal
becouse there is no quality source of 7. J.M.Kinney,Challenges to rebuilding the US food
information. pyramid.Curr Opin Clin Nutr Metab Care 8; 2005;
The area of nutricionism is still without a 1-7
place that is deserved in a sense of promotion 8. Moore K. L., Saddam A. M. Dietary suplement use
of healthy way of life. among undergraduate college students. Journal of
the American Dietetic Association: 1999
Corresponding author:
Fatima Jusupovic
Faculty of Health,
University of Sarajevo,
Bosnia and Herzegovina
e-mail: fatimajusupovic@yahoo.com
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HealthMED - Volume 2 / Number 4 / 2008
blood pressure (r=-0.43) but this correlation was je laser nefelometrijom. Sistolni i dijastolni krvni
not statistically significant. Likewise, negative alt- pritisak izmjeren je upotrebom živinog sfingoma-
hough not significant correlation was found betw- nometra na desnoj ruci nakon najmanje 5 minuta
een serum CRP concentration and diastolic blood odmora.
pressure (r=-0.35) in AD group. Rezultati: Dob, sistolni i dijastolni krvni pri-
Conclusions: Our results have shown that ne- tisak nisu signifikantno bili različiti između dvije
gative correlation between serum CRP concen- grupe. U AB grupi utvrdili smo negativnu korela-
tration and systolic and diastolic blood pressure ciju između koncentracije CRP u serumu i sistol-
exists in patients with AD but this correlation is nog krvnog pritiska (r=-0.43) ali ova korelacija
not statistically significant. Obtained results do nije bila statistički signifikantna. Također, negati-
support the notion that low-grade inflammation vna mada ne i signifikantna korelacija utvrđena je
has no impact on blood pressure values in patients između koncentracije CRP u serumu i dijastolnog
with AD. Larger prospective studies are required krvnog pritiska (r=-0.35) u AD grupi.
to investigate these findings further. Zaključci: Naši rezultati su pokazali da postoji
Key words: Alzheimer’s disease, C-reactive negativna korelacija između koncentracije CRP
protein, systolic blood pressure, diastolic blood u serumu i sistolnog i dijastolnog krvnog pritiska
pressure kod pacijenata sa AB ali ova korelacija nije stati-
stički signifikantna. Dobijeni rezultati ukazuju da
inflamacija niskog stepena nema uticaja na vrije-
Sažetak dnosti krvnog pritiska kod pacijenta sa AB. Veće
prospektivne studije su potrebne da bi se ovi nala-
Uvod: Alzheimerova bolest (AB) predstavlja zi opsežnije istražili.
progresivnu demenciju. Poznati riziko faktori za Ključne riječi: Alzheimerova bolest, C-reakti-
nastanak AB uključuju: dob, genetsku predodre- vni protein, sistolni krvni pritisak, dijastolni krvni
đenost, porodični istoriju demencije i ženski spol. pritisak
Ateroskleroza, dislipidemija, hipertenzija i infla-
macija se smatraju mogućim vaskularnim riziko
faktorima za AB. C-reaktivni protein (CRP) je va- Introduction
žan marker i medijator inflamacije niskog stepena.
Njegova moguća uloga u nastanku i progresiji AB Alzheimer’s disease (AD) represents a pro-
još uvijek nije u potpunosti rasvjetljena. Rezultati gressive dementia neuropathologically characteri-
brojnih studija sprovedenih sa ciljem pojašnjenja zed by widespread ß amyloid deposits (plaques)
uloge CRP kod AB su oprečna. Povezanost CRP i in cerebral arterial walls, development of neuro-
sistolnog i dijastolnog krvnog pritiska kod pacije- fibrillary tangles in brain tissue and neuronal loss.
nata oboljelih od AB nije opsežno istraživana. Primary symptom of AD is decline in cognition
Metodologija: AB grupa se sastojala od petna- and memory, with changes in personality. These
est institucionaliziranih pacijenata, starijih od 65 changes can be one of the first symptoms of the di-
godina, sa klinički dijagnosticiranom mogućom sease, followed with behavioral impairment inclu-
Alzheimerovom bolesti prema NINCDS-ADRDA ding delusions, hallucinations and agitation. All of
kriterijima. Svi pacijenti su imali mini mental sta- the above symptoms ultimately lead to impaired
te examination (MMSE) skor < 23 i Hachinskijev daily functioning and patients with AD in later and
ishemični skor 4 ili manje. Petnaest, dobno odgo- more sever stages of disease require total care (1).
varajućih, zdravih pacijenata bez demecije služili The etiology and pathophysiology of AD is still
su kao kontrolna grupa. Svi ispitanici u ovoj grupi not fully understood. In diagnostics of AD stan-
imali su MMSE skor > 28. Ispitanici uključeni u dard clinical diagnostic criteria designed by Nati-
istraživanje bili su podvrgnuti uzimanju anamne- onal Institute of Neurological and Communicative
ze, kliničkom pregledu i ispitivanju kognitivne Disorders and Stroke and Alzheimer’s disease are
funkcije primjenom mini mental state examinati- used. Based on these criteria, diagnosis of AD can
on testa. Koncentracija CRP u serumu određena be definite, probable and possible. The diagnosis
240 Journal of Society for development of teaching and business processes in new net environment in B&H
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HealthMED - Volume 2 / Number 4 / 2008
Non-fasting blood samples were drawn from waist/hip ratio between the groups. MMSE score
antecubital vein into siliconized tubes. Samples was significantly lower in subjects with AD com-
were centrifuged at 4000 r.p.m. for 10 minutes to pared to controls (p<0.0001). Subjects with AD
separate serum and were immediately used for the had statistically significantly higher pulse pressure
measurement of serum CRP concentration. values compared to the control group (p<0.05).
Serum CRP concentration was determined by Data are presented as mean ±SEM.
means of particle enhanced immunonephelome- MMSE score: Mini Mental State Examination
try with the use of BN II analyzer at the Institute score; BMI: Body Mass Index; WHR: waist/hip
of Clinical Chemistry and Biochemistry, Clinical ratio; PP: Pulse Pressure; Alzheimer’s disease
Centre of the University of Sarajevo. CardioPha- (AD) group
se high-sensitivity CRP (DADE BEHRING) was As shown in Figure 1, no statistically signifi-
used as a diagnostic reagent. CardioPhase hsCRP cant difference was observed in systolic and dia-
consists of a suspension of polystyrene particles stolic blood pressure between control group and
coated with mouse monoclonal antibodies to CRP. patients with probable Alzheimer’s disease.
Reference interval for CRP with the use of this
method is from 0 to 5 mg/l.
Data are reported as mean ± SEM. Since CRP
is highly skewed and the study sample is small,
data were analysed with Mann-Whitney U Test
which is the nonparametric alternative for the un-
paired t test. Associations between continuous
variables were tested with Spearman`s rank cor-
relation analysis. Two-tailed p values <0.05 were
considered statistically significant. Statistical ana-
lyses were performed using SPSS 12.0 statistical
software system. Figure 1. Mean values of systolic blood pressure
(SBP) and diastolic blood pressure (DBP) in the
control group and Alzheimer’s disease (AD) group.
Results
As presented in Table 2, negative although
The baseline characteristics of the two groups not significant correlation between systolic blood
enrolled in the study are reported in Table 1. No pressure and CRP in patients with AD was obser-
difference emerged in age, body mass index and ved (r =-0.43). Likewise, there was a negative cor-
Table 1. Baseline characteristics of control subjects and patients with probable Alzheimer’s disease.
Control group AD group
Variables p<
(n=15) (n=15)
Age
69.93±2.57 73.46±2.57 NS
(year)
MMSE
28.4±0.34 9.07±1.17 p<0.0001
score
BMI
25.86±0.98 27.62±1.68 NS
(kg/m2)
PP
49.33±2.00 56.67±3.57 p<0.05
(mmHg)
242 Journal of Society for development of teaching and business processes in new net environment in B&H
HealthMED - Volume 2 / Number 4 / 2008
relation between diastolic blood pressure and CRP Among persons with high blood pressure decre-
in patients with AD but it was not statistically si- ased cognitive performance has been reported as
gnificant (r =-0.35). Statistically positive correlati- well as greater cognitive decline with age (16).
on was observed between systolic blood pressure On the contrary, Morris and al. (17) have shown
and MMSE score in AD group (r=0.58, p< 0.05). that high blood pressure was not associated with
Positive correlation between diastolic blood pres- an increased risk of AD in logistic regression mo-
sure and MMSE score was determined but it was dels adjusted for age, sex, and level of education.
not statistically significant (r=0.50). Interestingly, findings of Skoog et al. (8) suggest
Table 2. Spearman correlation analysis (unadju- that before disease onset in subjects with demen-
sted) of systolic and diastolic blood pressure with tia blood pressure begins to decline which might
C-reactive protein and Mini mental state exami- implicate that disease process may decrease blood
nation (MMSE) score in patients with probable pressure values.
Alzheimer disease. In a large epidemiologic study, Wu et al. (18)
SBP DBP have identified high blood pressure as a risk factor
for AD. On the other hand, low diastolic blood
C-reactive protein r =- 0.43 r =- 0.35
pressure (≤65 mm Hg) was also associated with
MMSE score r = 0.58* r = 0.50‡ the increased risk of AD (19). A study by Kivi-
*p< 0.05 pelto et al. (20) found that elevated systolic blood
‡p=0.057 pressure and high cholesterol, and in particular
combination of these risks in midlife, increases
the risk of AD in later life, whereas diastolic blood
Discussion pressure in midlife has no significant effect on the
risk of AD.
Numerous findings from clinical, epidemiolo- According to numerous reports blood pressure
gical and pharmacological studies suggest that va- declines in the years preceding dementia onset and
scular factors play fundamental role in the patho- further declines during the course of AD. Even
genesis of AD (13). Still, the mechanisms linking thought it is believed that the low blood pressure in
vascular risk factors to AD remain unclear. subjects with dementia and neuronal degeneration
It has been shown that disruption of cerebral are secondary to the brain lesions, the possibility
blood vessels and reduced blood flow can have that low blood pressure causes brain damage sho-
severe consequences on neural activity. Hypo- uld not be excluded. A study conducted by Hanon
perfusion is thought to have important role in the et al. (21) found a significant decrease of blood
development of AD by triggering mitochondrial pressure in patients with Alzheimer’s disease after
dysfunction and increased oxidative stress. Cli- one year of follow up which was independent of
nical observations have shown that episodes of age, gender, BMI and antihypertensive therapy.
hypotension may result in cerebral hypoperfusion, Patients with the most severe impairment in de-
which may play a causative role in the develop- mentia at baseline had largest decrease in blood
ment of dementia. Decreased cerebral blood flow pressure. Some authors speculate that blood pres-
is known to occur in AD, and the degree of redu- sure decrease might be an early manifestation of
ction generally correlates with the severity of de- the dementing process. However, it is possible that
mentia. It seems possible that low blood pressure clinically unrecognized vascular lesions in the bra-
may accelerate the process of dementia by low- in or atherosclerosis may be responsible for both
ering cerebral blood flow. Zhu and al. (14) have blood pressure decrease and cognitive decline in
demonstrated that oxidative stress represents one patients with AD (22).
of the earliest changes in AD affected brain and In our study there was no statistically signifi-
plays a vital role in the vascular abnormalities un- cant difference in mean systolic and diastolic blo-
derlying metabolic defects in AD. od pressure between patients with probable AD
It has been proposed that high blood pressu- and apparently healthy controls. Conversely, Ra-
re may increase risk of Alzheimer disease (15). zay et al. (23) found lower mean systolic blood
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HealthMED - Volume 2 / Number 4 / 2008
244 Journal of Society for development of teaching and business processes in new net environment in B&H
HealthMED - Volume 2 / Number 4 / 2008
9. Verghese J, Lipton RB, Hall CB, Kuslansky G, Katz 20. Kivipelto M, Helkala EL, Laakso MP, HanninenT,
M. Low blood pressure and the risk of dementia in Hallikainen M, Alhainen K, Soininen H, Tuomile-
very old individuals. Neurology. 2003;61:1667- hto J, Nissien A. Midlife vascular risk factors and
1672. Alzheimer’s disease in later life: longitudinal, po-
pulation based study. BMJ 2001; 322:1147-1451.
10. McKhann G, Drachman D, Folstein M, Katzman
R, Price D, Stadlan EM. Clinical diagnosis of Alz- 21. Hanon O, Latour F, Seux ML, Lenoir H, Forette F,
heimer`s disease: report of the NINCDS-ADRDA Rigaud AS. Evolution of blood pressure in patients
work-group under the auspices of the Department with Alzheimer’s disease: a one year survey of a
of Health and Human Services Task Force on Alz- French Cohort (REAL.FR). J Nutr Health Aging.
heimer`s disease. Neurology. 1984;34:939-944. 2005; 9(2):106-111.
11. Hachinski VC, Iliff LD, Zilhka E, Du Boulay GH, 22. Moretti R, Torre P, Antonello RM, Manganaro D,
McAllister VL, Marshall J, Russell RW, Symon L. Vilotti C, Pizzolato G. Risk factors for vascular
Cerebral blood flow in dementia. Arch Neurol. 19- dementia: hypotension as a key point. Vasc Health
75;32:632-637. Risk Manag. 2008;4(2):395-402.
12. van Popele NM, Grobbee De, Bots ML, Asmar R, 23. Razay G, Vreugdenhil A, Wilcock G. The metabo-
Toponchian J, Reneman RS, Hoeks AP, van der lic syndrome and Alzheimer disease. Arch Neurol.
Knip DA, Hofman A, Witteman JC. Association 2007;64:93-96.
between arterial stiffness and atherosclerosis: the
24. Czlonkowska A, Kurkowska-Jastrzebska I. The
Rotterdam study. Stroke 2001;32:454-60.
role of inflammatory reaction in Alzheimer’s di-
13. de la Torre JC. Alzheimer disease as a vascular sease and neurodegenerative processes. Neurol
disorder: nosological evidence. Stroke 2002; 33: Neurochir Pol. 2002;36(1):15-23.
1152-1162.
25. Fischer P, Zehetmayer S, Bauer K, Huber K, Jung-
14. Zhu X, Smith MA, Honda K, Aliev G, Moreira PI, wirth S, Tragl KH. Realation between vascular
Nunomura a, Caadesus G, Harris PLR, Siedlak risk factors and cognition at age 75. Acta Neurol
SL, Perry G. Vascular oxidative stress in Alzhe- Scand. 2006;114(2):84-90.
imer disease. J Neurol Sci. 2007; 257(1-2):240-
26. Guo Z, Fratiglioni L, Winblad B, Viitanen M. Blo-
246.
od pressure and performance on the Mini-Mental
15. Skoog I. Vascular aspects in Alzheimer’s disease. State Examination in the very old. Am J Epidemi-
J Neural Transm Suppl. 2000; 49:37-43. ol. 1997;145(12):1106-1113.
16. Launer LJ, Masaki K, Petrovitch H, Foley D, Ha- 27. Scherr PA, Hebert Le, Smith LA. Relation of blood
vlik RJ. The association between midlife blood pressure to cognitive function in the elderly. Am J
pressure levels and late-life cognitive function: the Epidemiol. 1991;134:1303-1315.
Honolulu-Asia Aging Study. JAMA. 1995; 274:1-
846-1851.
17. Morris MC, Scherr PA, Hebert LE, Glynn RJ, Corresponding author:
Bennett DA, Evans DA. Association of incident Asija Zaciragic
Alzheimer disease and blood pressure measured Institute of Physiology and Biochemistry,
from 13 years before to 2 years after diagnosis in University of Sarajevo,
a large community study. Arch Neurol. 2001; 58: Bosnia and Herzegovina
1640-1646. e-mail: zarias@lsinter.net
18. Wu C, Zhou D, Wen C, Zhang L, Como P, Qiao Y.
Relationship between blood pressure and Alzhei-
mer’s disease in Linyian County, China. Life Sci
2003;72(10):1125-1123.
19. Qiu C, von Strauss E, Fastbom J, Winblad B, Fra-
tiglioni L. Low blood pressure and risk of demen-
tia in the Kungsholmen Project. A 6-year follow-
up study. Arch Neurol 2003; 60:223-228.
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246 Journal of Society for development of teaching and business processes in new net environment in B&H
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Sažetak Introduction
Cilj ove studije je bio da procjeni moguće pro- Aminoglycoside antibiotics (gentamicin) are
tektivne efekte Spiruline platensis kod gentamici- widely used in clinical medicine because of their
nom-uzrokovane renalne disfunkcije kod štakora. favorable antimicrobial efficacy against Gram-ne-
Odrasli Wistar štakori (n=18), oba pola, podjeljeni gative infections. Unfortunately, the clinical use of
su u tri jednake grupe. Prva, kontrolna grupa, je aminoglycoside is limited by their potential oto-
primala 0,9% natrium hlorid, intraperitonealno 7 toxicity and nephrotoxicity (1). The pathophysi-
uzastopnih dana. Druga, gentamicin grupa, je pri- ology of aminoglycoside nephrotoxicity has not
mala gentamicin (80 mg/kg dnevno), intraperito- been completely elucidated. Several mechanisms
nealno također 7 dana. Treća, gentamicin+spiru- could be involved in gentamicin induced renal dy-
lina grupa, je dva dana prije tretirana sa vodenim sfunction. These include binding of gentamicin to
rastvorom Spiruline platensis (1000mg/kg u 2 ml phospholipids and inhibiting the activity of phos-
vode) per os. Sljedećih 7 dana je istovremeno tre- pholipase A and C which alters the function and
tirana sa Spirulinom platensis per os i gentami- structure of cellular and intracellular membrane
cinom intraperitonealno u jednakoj količini kao (2,3). Gentamicin may also cause mitochondrial
i životinje iz prethodne grupe. Renalna funkcija damage or direct inhibition of mitochondrial oxi-
je procjenjivana mjerenjem koncentracije uree i dative phosphorylation (4). Reactive oxygen spe-
kreatinina u serumu. Histološkom analizom koja cies (ROS) may participate in the pathogenesis
je rađena svjetlosnim mikroskopom potvrđena je of gentamicin-induced renal dysfunctions (5). In
akutna tubularna nekroza kod gentamicin i gen- previous studies some synthetic and natural anti-
tamicin+spirilina grupe. Gentamicin je uzrokovao oxidants have been used to attenuate gentamicin-
renalno zatajenje zbog akutne tubularne nekroze induced oxidative stress and renal dysfunctions
u obje eksperimentalne grupe. Najsignifikantnije (6,7).
povećanje serumskih biohumoralnih markera bu- Spirulina platensis, blue green algae, has a
brežne funkcije je bilo u gentamicin grupi (urea; long history of use as food supplement. It is rich
gentamicin grupa (X=27,47±2,15mmol/L) versus of proteins, essential amino and fatty acids, vi-
kontrolna grupa (X=7,08±0,09mmol/L) i kreati- tamins, especially vitamin B12 and provitamin A
nin: gentamicin grupa (X=192,5±23,68 mmol/L) (β-carotene), and some vital elements like zinc,
versus kontrolna grupa (X=56±1,24 mmol/L) (p=- magnesium, selenium (8,9). Spirulina platensis
0,002). Spirulina platensis je smanjila serumski has immunomodulatory (10), anticancer (11,12),
nivo biohumoralnih markera bubrežne funkcije antioxidant (13,14), antihyperlipidemic (15), an-
(urea; gentamicin+spirulina grupa (X=11,53±1,- tidiabetic effects (16) and prevents lead toxicity
66mmol/L) versus gentamicin grupa (X=27,47±- (13,17).
2,15mmol/L);(p=0,002) i kreatinin; gentamicin+- The aim of the present study was to assess whet-
spirulina grupa (X=107,33±20,14mmol/L) versus her treatment with Spirulina platensis may prevent
gentamicin grupa (X=192,5±23,68 mmol/L) (p=0- or ameliorate renal dysfunction and injury in gen-
,026 ) i umanjila efekte gentamicinom uzrokovane tamicin-induced acute tubular necrosis in rats.
akutne tubularne nekroze. Naši rezultati ukazuju
da Spirulina platensis umanjuje renalne toksične
efekte gentamicina i štiti renalnu funkciju kod Materials and methods
gentamicinom uzrokovane akutne tubularne ne-
kroze kod štakora. Animals
Ključne riječi: Spirulina platensis, urea, kre-
atinin, akutna tubularna nekroza, gentamicin, ne- The experiment was performed in adult Wistar
frotoksičnost rats (n=18) weighing 200 to 300g in accordance
with the approval of local Ethic Committee. Befo-
re the experiments all animals were housed under
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HealthMED - Volume 2 / Number 4 / 2008
standard laboratory conditions and were allowed Biohumoral markers of renal functions
one week of adaptation period. Standard rat chow
and tap water were given ad libitum. Animals Urea
were divided into three groups, consisting of six
rats each: control, gentamicin and gentamicin+- Serum urea concentration was determined by
spirulina group. enzymatic method. Absorbance was measured at
340 nm. The results were expressed as mmol/L.
Drugs
Creatinin
Gentamicin was purchased, injection solute
(under the trade name Bosnalijek). Spirulina pla- Jaffe’s reaction was used for determination of
tensis was obtained commercially as a dark blue- serum creatinine concentration. Absorbance was
green dry powder (from Nutrex Hawaii M.D. For- measured at 500-520 nm. The results were expres-
mulas™ ). sed as mmol/L.
Control group was treated with 0,9% sodium For microscopic evaluation kidneys were fixed
chloride, intraperitoneally for 7 consecutive days. in 10% formalin and then embedded in paraffin
Gentamicin group was treated with gentamicin wax. Tissue sections of 5μm were stained with
(80 mg/kg per day), intraperitoneally also for 7 hematoxylin-eosin (HE) and Periodic acid-Schiff
days. Gentamicin+spirulina group was pretrea- (PAS). A minimum of 10 fields by light microsco-
ted for two days with water solution of Spirulina py for each kidney sections were examined and
platensis (1000mg/kg in 2 mL of water) per os, assigned for severity of changes according to Ho-
followed by administration of Spirulina (1000mg/ ughton et al. (17).
kg in 2 mL of water) per os, and gentamicin (80
mg/kg per day) intraperitoneally for 7 days. The
injections were given between 9.00 and 9.30 a.m. Statistical analysis
to minimize the circadian variation seen in genta-
micin-induced nephrotoxicity (18). Statistical analyses were performed using SPSS
At the end of the experiment, 24 hours after the software, version 12. Results were expressed as
last gentamicin, gentamicin+spirulina and nor- mean ± SEM. The difference in values of tested
mal saline injection, and rats were sacrificed un- parameters was assessed by Kruskal-Wallis test.
der deep ether anesthesia and the front wall of the Afterwards, Mann-Whitney test was used to test
abdominal cavity was opened. Blood was drawn the significance of mean values differences betw-
from the abdominal aorta for the measurement of een the two groups. Association between serum
serum urea and creatinine concentrations. Kidne- urea concentrations and histological injury score
ys were immediately removed, vertically divided was tested with Spearman’s rank correlation ana-
into two sections and fixed in 10% formalin and lysis. The same test was used to investigate asso-
then embedded in paraffin wax for histological ciation between serum creatinine concentrations
analyisis. and histological injury score in total experimental
sample. The statistical significance was conside-
red at p<0,05.
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Creatinine
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In total experimental sample a positive, statisti- urea and creatinine concentration in ATN caused
cally significant, correlation between histological by gentamicin. These results, as well as the results
injury score and serum creatinine concentration of our study, indicate that Spirulina platensis can
also was found (r= 0,62; p<0,01) (Figure 4). ameliorate gentamicin-induced renal dysfunction
in rats.
Kuhad et al. (24) and Mohan et al. (25) tested
protective effects of Spirulina in ATN caused by
cisplastin, where as Khan M. et al. (26) also te-
sted protective effects of Spirulina in ATN caused
by ciclosporin. Results of these studies confirmed
that Spirulina platensis has renoprotective effect
and decreased the serum urea and creatinine con-
centration and significantly prevents nephrotoxici-
ty due to its antioxidant actions.
The renoprotective effects of Spirulina have
been confirmed in experiments in which ATN was
caused by mercury chloride (HgCl2) (27). Humo-
ral markers of renal function, serum urea and cre-
atinine concentration were significantly lower in
animals that concomitantly with mercury chloride
received Spirulina.
Figure 4. Mean serum creatinine concentration Results of light microscopic analysis in our
(mmol/L) and kidney histological injury score study showed various level of reanl injury (ATN)
within control and experimental groups in animals both treated with gentamicin and genta-
micin+spirulina concomitantly. In the gentamicin
group marked necrosis of cortical tubules, intersti-
Discussion tial edema and tubular brush border loss were ob-
served. Desquamated epithelial cells debris in the
Acute tubular necrosis (ATN) is most frequen- proximal tubular lumen was also observed widely
tly caused by constriction of blood vessels, but it in these necrotic areas. Treatment with Spirulina
can be also caused by cisplatin, heavy metals, radi- platensis reduced these changes.
ological contrasts, as well as other compounds of Morphological changes in kidney specimens in
lesser importance (20, 21). Gentamicin and other our study were similar to those observed by Kuhad
aminoglycoside antibiotics caused acute tubular et al. (9) who also investigate protective effects of
necrosis and renal dysfunction in rats (22, 23). Spirulina in gentamicin-induced acute tubular ne-
The protective effects of Spirulina platensis crosis in rats. In this study use of Spirulina platen-
were investigated in present study in animal mo- sis also decreased level of kidney damage.
del of ATN caused by gentamicin. The renal dy- Results of our study are also in the accordan-
sfunction due to gentamicin induced acute tubular ce with results of Sharma et al. (27) who induced
necrosis (ATN) has been conformed by increased ATN with mercury chloride. The results from their
of biohumoral markers of renal function, serum study suggest that Spirulina can significantly mo-
urea and creatinine concentration especially in dify the renal damage in mercury chloride induced
animals treated only with gentamicin. Spirulina toxicity.
diminished this increase.
These results are in accordance with the results
of Kuhad et al. (9) who used higher dose of gen-
tamicin (100mg/kg) and three different doses of
Spirulina (500, 1000, 1500mg/kg). Their results
have showed that use of Spirulina lowers serum
250 Journal of Society for development of teaching and business processes in new net environment in B&H
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Corresponding author:
Nesina Avdagic
Institute of Physiology and Biochemistry
School of Medicine, University of Sarajevo
Bosnia and Herzegovina
e-mail. avdagicn@yahoo.com
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50 actively train basketball in the basketball club nizma. Ispitivanja se vrše određenim metodama i
“Željezničar”, and 50 boys who do not train any pod standardnim uslovima u cijelom svijetu, te se
sports. rezultati mogu upoređivati. Antropometrijska ispi-
The measurings were performed on boys who tivanjaj služe za praćenje rasta i razvoja čovječijih
attend the following elementary schools: organizama, obuhvataju mjerenje težine, visine,
Elementary school “Isak Samokovlija”, and el- obima tijela i kožnih nabora.
ementary school “Vladislav Skaric” and on boys U sportskoj medicini služi da objektivno usta-
who attend the same school and train basketball in novi razvoj tijela, da poređenjem uzastopnih mje-
the basketball club “Željezničar”, the height cat- renja uoči napredak ili stagnaciju u razvoju, te da
egory of a cadet. na bazi pojedinih antropometrijskih dimenzija
The standards which we used are displayed on usmjerava sportaše prema sportskim disciplinama
the percentage curves. We established an average u kojim se može očekivati optimalan uspjeh.
body height for 90% of boys who do not train any Ciljevi ovog istraživanja su ispitati: antropo-
sports. We established an average body height of metrijske vrijednosti dječaka na uzorku 100 ispita-
24% for basketball players. We established an av- nika, 50 koji se bave aktivno košarkom i 50 koji se
erage body weight for 94% of boys who do not ne bave sportskim aktivnostima, Kanton Sarajevo,
train any sports. We established an average body Body Mass Indeks, distribuciju masnog tkiva i
weight of 96% for basketball players. An average uporediti antropometrijska mjerenja
BMI was established for 100% of boys who do not Istraživanje je rađeno na odabranom uzorku od
train any sports. An average BMI was established 100 dječaka starosti 14 – 15 godina, od kojih 50 ak-
for 100% for basketball players. We established tivno trenira košarku u košarkaškom klubu “Želje-
an average value of DMT for 56% of boys who do zničar”, i 50 dječaka koji se ne bave sportom.
not train any sports. Mjerenja su izvršena kod dječaka koji pohađaju
Our results have shown an above average height osnovne škole: O.Š. “Isak Samokovlija”i O.Š
for even 76% of basketball players, so one sets the “Vladislav Skarić” i kod učenika koji pohađaju
question whether intensive basketball training has istu školu a košarku treniraju u košarkaškom klu-
any effect on the body height or do boys with an bu “Željezničar”, uzrasne kategorije kadeta.
above average height more often decide to train Standardi kojima smo se služili prikazani su u
basketball. percentilnim krivuljama. Prosječnu tjelesnu visinu
Children who train sports are not: obese, they ustanovili smo kod 90% dječaka bez sportskih ak-
do not consume alcohol, they do not smoke, they tivnosti. Kod košarkaša prosječnu tjelesnu visinu
do not take any narcotics, they are less absent from ustanovili smo kod 24%. Prosječnu tjelesnu težinu
their lessons, they have less chances of becoming ustanovili smo kod 94% dječaka bez sportskih ak-
ill from chronic diseases. tivnosti. Kod košarkaša prosječnu tjelesnu težinu
Key words: the sport medicine of anthropo- ustanovili smo kod 96%. Prosječan BMI usta-
metric values, Body Mass Index, novljen je kod 100% dječaka bez sportskih akti-
vnosti. Prosječan BMI ustanovljen je kod 100%
košarkaša. Prosječnu vrijednost DMT ustanovili
Sažetak smo kod 56% dječaka bez sportskih aktivnosti.
Naši rezultati su pokazali nadprosječnu visinu
Humana antropometrija (čovjek–mjera, grč.) kod čak 76% košarkaša, pa se postavlja pitanje da
je nauka koja se bavi komparativnim mjerenjima li intenzivno treniranje košarke ima uticaja na tje-
ljudskog tijela, obradom i proučavanjem dobi- lesnu visinu ili se dječaci sa nadprosječnom visi-
venih mjera. Nalazi široku primjenu u sportskoj, nom češće odlučuju na treniranje košarke.
školskoj, vojnoj i industrijskoj medicini, a ima do- Djeca sportisti nisu: gojazni, ne piju, ne puše, ne
dirne tačke i sa svim drugim granama medicine. drogiraju se, manje čak izostaju sa nastave, imaju
Antropometrijska ispitivanja su direktni pokaza- manje rizika od obolijevanja od hroničnih bolesti.
telji morfološke građe tijela, te indirektni pokaza- Ključne riječi: sportska medicina antropome-
telji izmjene energije i kalorijskog bilansa orga- trijske vrijednosti, Body Mass Indeks,
254 Journal of Society for development of teaching and business processes in new net environment in B&H
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HealthMED - Volume 2 / Number 4 / 2008
Health condition Chronic diseases lead to a • The development of healthy and the adoption
decrease of growth while brief infections do not of new positive habits
have an effect on the speed of growth. • The development of personal and social
Functions of the individual endocrine glands values which are very important in the
The function of individual endocrine glands has upbringing of children
an effect on the increase of cells, as on their gro- • The accepting of obligations towards others
wth and especially on the growth of bones. • Individual and team responsibilities
Socio-economic state of the family Socio- • Self-respect, the respecting of others and the
economic state of the family has an effect on the respecting of rules
speed of the growth and development as on an • A development of persistence, working
utmost reached body height and weight. habits and moral responsibility through a
Physical activity of the child-sports Sport ex- respectful relationship towards the teammate
ercise is a mean of sport education and its effect on and opponent.
children is important. Physical activity is a basic
human need from his or her birth to old age. For The growth of body height, weight and the
the physical activity to have a positive influence on BMI of the centimeter curve In everyday praxis
the development of a young organism it has to be: for the evaluation of physical progress of the infant
programmed, planned, organised, time scheduled first of all serves the body weight, and after the first
(6 to 8 hours weekly), performed by a professi- year of life for the long-term supervision the body
onalist. It is considered that stimuli which cause height. Body height, weight and the BMI of a cer-
systematic physical activity urge the young orga- tain child we compare with the corresponding me-
nism to correct growth and development which is asures of a group of healthy children. The curves
especially tumultuous in adolescence. Program- of the growth of height, weight and the BMI are
med physical activity – training, raises the level made on the basis of statistically processed data of
of some psychomotoric abilities: speed, strength, a big number of healthy children in the coordinate
endurance and skills. Psychomotoric abilities re- system in which the abscissa tells the age of the
present a complex readiness for the carrying out of child and on the ordinate the reached weight, he-
certain movements, and in its development have ight or BMI for that age. The percentages on those
a similar curve like other human characteristics, graphs represent average child height, weight and
the culmination is reached with the reaching of BMI. The centimeter curves are in a span of P = 3
the 25th year of life. Programmed physical activi- – 97. Children with the parameters below 3, that
ty positively stimulates the function of the inner is, above 97 in a considerable measure step away
organs, especially the cardiovascular system, the from the biggest number of children of that same
respiratory system, organs which play a part in the age.
metabolic processes and the autonomic nervous
system. Besides all the positive aspects sport has
on the growth and the development of the orga-
nism there is a significant influence on the normal
mental development. The majority of sports and
especially collective sports have an effect on the
creativity of the child.
Basketball is a sport which is played and tra-
ined in the whole world and also one of the most
trained sports between boys and girls. Active trai-
ning of basketball contributes to: Picture 1. The centimeter curve of height (boys)
256 Journal of Society for development of teaching and business processes in new net environment in B&H
HealthMED - Volume 2 / Number 4 / 2008
Body Mass Index – BMI 50 who do not train any sports, Canton
Sarajevo.
The most frequent method for the establishing 2.2 Examine the Body Mass Index
of nutrition which is used today in epidemiologic 2.3. Examine the distribution of fat tisssue
research but more and more often in daily practi- 2.4. Compare the anthropometric measurings.
ce is the establishing of the index of body mass
(BMI). The BMI is calculated on the basis os the
relationship between the body mass and the body 3. The examiners and the methods of work
height squared, which can be presented as: 3.1 Examiners
• BMI = Body weight/body height (m)²; • The research was performed on a chosen
• The calculation of the relationship of the body model of 100 boys aged 14 – 15 years,
mass and the height show the measure of the from which 50 actively train basketball in
level of nutrition, but not the constitution; the basketball club “Realway”, and 50 boys
• BMI changes for children with age and who do not train any sports.
it is highly dependent on the BMI of the • The measurings were performed on boys
biological parents; who attend the following elementary
• The risk of developing obesity exists for schools:
children if their BMI is above the 85th
percentage, and they are obese if the BMI is Elementary school “Isak Samokovlija” and
bigger than the 95th percentage; elementary school “Vladislav Skaric” and on stu-
• A person who follows the growth and dents who attend the same school but train basket-
development of a certain child is compared ball in the basketball club “Realway”, becoming
to the BMI with the values on the percentage category of cadets.
curve and can early notice the threats to
developing obesity or malnutrition.
3.2 Methods of research
The distribution of fat tissue – DMT Beside
the level of obesity one needs to pay attention to In this research the following anthropometric
the distribution of fat tissue, because the central methods were used which include the measuring of:
distribution with the accumulation of fat on the - body height
trunk and abdomen are united with a big number - body weight
of breakdowns. For children up to puberty there is - scope of the waist
no difference in the distribution of fat tissue accor- - scope of the hips
ding to the sexes. Only in puberty as a consequen-
ce of the producing of sex hormones, they develop • The data was incorporated in the appropriate
differences characteristic for the male or female form (example 1). The anthropometric measu-
sex. Through the relationship of the scope of the rings were carried out according to standard
waist and hips one determines the distribution of methods by which the anthropometric
fat tissue (DMT). Men are under a risk if the relati- protocol was respected with the instructions
onship of the scope of the waist/hips is bigger than on the procedure of measuring.
0,95cm and women if it is bigger than 0,85cm.
Anthropometric measurings
2. The aims of research
• During the measurings the boys had on them
2.1. To examine the anthropometric values for only the underwear and they were measured in
boys on a model of a 100 tested people, the morning hours, before breakfast and after
50 who actively train basketball and the carrying out of the physiological needs.
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HealthMED - Volume 2 / Number 4 / 2008
• Before the measurings the instruments • The waist circumference is measured in the
were checked in order for the measurings level of the umbilicus, between the rib arc and
to be as precise as possible and mutually the crest bone, and the hips circumference
comparable, they were carried out by the on the widest part of the flanks.
same team, with the same apparatus and
method at the same time.
Anthropometric indexes
• The body weight was measured with a Table 1. The display of the tested people accor-
medicinal decimal scale with a supporting ding to age and sport activities
weight. Sport inactive Basketball players
• The tested people were measured by standing Age
boys K.K. “Željezničar”
on the scale, they do not move during the
Number Number
measuring and the noting down of the body % %
14 - 15 of boys of boys
weight.
50 50 % 50 50 %
Total 100
Body circumference (cm)
% 100 %
• Body circumference is measured with a
plastic centimeter strip.
Table 2. Body height, body weight and their middle values of the total sample
Age 14 - 15
Number of Body height Body weight
Body height and weight % X X
boys (cm) (kg)
Sport inactive boys 50 100% 158-187 cm 167,2 cm 45-90kg 59,2 kg
Basketball players
50 100% 165-196cm 184,5 cm 52-86kg. 71 kg
K.K. “Željezničar”
Total 100
% 100%
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Table 3. Body mass index, the distribution of fat tissue and their middle values
Age 14 - 15
BMI and DMT Number of boys % BMI X DMT X
Sport inactive boys 50 100 13,9 – 25,4 17,9 0,79 – 0,94 0.88
Basketball players K.K. “Željezničar” 50 100 15,4 – 21,9 18,8 0,67 – 0,89 0.85
Total 100
% 100%
In the table there is a display of the tested peopl For basketball players the middle value of the
aged 14 – 15 years devided according to the sport BMI is 18,8, and the middle value of the DMT
activities, from which 50 boys do not train sports amounts to 0,85 cm.
and 50 boys who actively train basketball in the ba- The middle values for body height, weight,
sketball club “Željezničar”, and all are students of BMI and DMT for boys who are sport inactive
two elementary schools in the Municipality center. show the standard values. For basketball players
In the totally expressed sample the middle value the middle value of the body height deviates from
of the body height of boys without sport activities the standard one for this age concerning the abo-
amounts to 167,2 cm, the middle value for weight ve average, while the BMI and the DMT are also
is 59,2 kg. For basketball players the middle value standard.
of body height is 184,5 cm, the middle value for In the representative sample the measuring of
weight is 71 kg. body height was performed and the gained results
The middle value of the BMI for boys who do show distinct differences in body height for these
not train sports is 17,9 and the middle value of the two groups of tested people.
DMT is 0,88 cm.
Table 4. Body height, weight, BMI, DMT and their middle values
Age 14 - 15
Anthropometric measurings Body height Body weight BMI DMT
Span Span Span Span
Anthropometric values X X X X
(cm) (kg) (cm) (cm)
Sport inactive boys 158-187 167,2 45 - 90 59,2 13,9-25,4 17,9 0,79-0,94 0,88
Basketball players K.K.
165-196 184,5 52 - 86 71 15,4-21,9 18,7 0,67-0,89 0.85
“Željezničar”
Total 100
% 100%
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Sport inactive boys with the standard body he- Graph 2. Body weight
ight of 150-181cm, that is, between 3-97 P we have
90% and while the above average body height of > In the total sample the standard body weight
97 P or >182 cm is present in 10% of boys. between 39-81 kg, that is, from 3-97 P is present
Basketball players with a standard body height in 94% and an above average weight of >82kg,
of 150 – 181 cm, that is, 3-97 P we have 24% whi- that is, of >97 P is present in 6% of sport inactive
le distinctly high > 97 P, that is, >182 cm there is boys.
present in 76% of basketball players. The standard weight of 39 – 81 kg, that is, from
In the body weight of these two groups there 3-97 P is present in 96% of basketball players,
are distinct differences but not the same ones as while an above average body weight of >82 kg is
for the body height. present in 4% of basketball players.
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Malnutrition and obesity have significant here- on is present in 24% of sport inactive and 62% of
ditary predispositions, it is believed that the genes basketball players, a moderate pre-obesity is pre-
for nutrition operate on the level of the hormonal sent in 10% of sport inactive and 8% of basketball
regulation, so that some people from the same players, while there are no obese people in either
“raw material” produce more fats than others. of the groups.
That leads to an increase of the total mass and to The DMT is a measure for the determining of
a change of body dimensions, proportions and the the type of obesity, and an important indicator of
shape. the risks for health. For boys in adolescence there
is an increase in the number of muscular cells, and
the amount of fats slowly decreases, so that the
weight for boys increases on account of the mu-
scular tissue, and if they are even sport active they
can have the ideal anthropometric measures.
Graph 3. BMI
Table 8. The DMT of boys of the total sample displayed in the following table
Age 14 - 15
DMT (cm) 0,70 – 0,79 0,80 – 0,89 0,90 – 0,94 >0,95 Number of boys %
Sport inactive boys 2 4% 26 52% 18 36% 4 8% 50 100%
Basketball players
5 10% 42 84% 3 6% - - 50 100%
K.K. “Željezničar”
Total 100
% 100%
Table 9. The relations of the tested values: body height, weight, BMI and DMT
Age 14 - 15
Anthropometric
Body height Body weight BMI DMT
measurings
Percentages <3 3-97 >97 <3 3-97 >97 <3 3-97 >97 <3 3-97 >97
Sport inactive boys - 45 5 - 47 3 - 50 - - 46 4
Basketball players
- 12 38 - 48 2 - 50 - - 50 -
K.K. “Željezničar”
Total - 57 43 - 95 5 - 100 - - 96 4
% - 57 43 - 95 5 - 100 - - 96 4
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Compared to the normal values, we have 4% methods and that of height, weight, waist circum-
of boys who are sport inactive, 10% of basketball ference and hips and the recalculating of the BMI
players with a decreased value of the DMT, 52% of and the DMT. After that the analysis was perfor-
sport inactive boys and 84% of basketball players med and the tabeling of the data and after that the
with the ideal values of the DMT, the maximum comparison of the gained results. The results of
values are present in 36% of sport inactive boys the analysis of the fout most important physical
and 6% of basketball players, and 8% of sport ina- indicators (body height and weight, waist circum-
ctive boys have the abdominal type of obesity, and ference and the hips) together with the recalcula-
there are no basketball players in this group. ted BMI and DMT enable the defining of the right
The gained results show that we have distinct growth and development as well as the following
deviations in body height for sport inactive boys of the effect of sports on the same. In our research
and basketball players and the standard values for the boys from the sample belong to a group of tall
body weight, BMI and DMT for both of them. boys because the average body height of sport ina-
The body height of 3 – 97 percentages (150 ctive boys amounts to 167,2 cm and for basketball
– 181 cm) is present in 90% of sport inactive boys players it is 184,5 cm. The average body weight
and 24% of basketball players, while over 97 per- for sport inactive boys amounts to 59,2 kg and for
centages (>182 cm) there is present in 10% of basketball players it is 71 kg. In our research an in-
boys who are sport inactive and 76% of basketball creased BMI was present in 10% of sport inactive
players. boys and 8% of basketball players, the others were
The body weight between 3 – 97 percentages in the framework of the standard. The DMT for
(39 – 81kg) there is present in 94% of boys who 100% of basketball players was in the framework
are sport inactive and 96% of basketball players, of the standard. The maximum DMT was present
over 97 percentages (> 81 kg) there is present in in even 36% of sport inactive boys and 8% of an
6% of boys who are sport inactive and 4% of ba- increased DMT.
sketball players. Sports as movement in general, represents a
The BMI of the total sample is between 3 – 97 stimulans to growth and development of the or-
percentages (16 – 27). ganism. For the sport activity to give its positive
The DMT of 3 – 97 percentages there is pre- stimuli to growth and development, it is not eno-
sent in 100% of basketball players, while for sport ugh for it to be just exhaustive, but also frequent
inactive boys 92% is between the 3 – 97 percenta- enough, systematic and so used that it makes up
ges and 8% have an increased DMT, that is, risky. for the rest and insufficient movement to which
children and youth are forced to during the day.
5. Discussion
6. Conclusion and recommendations
A right growth and development are one of the
fundamental conditions for a later harmonious and This research had the aim of examining the
healthy way of living. The body height and weight anthropometric values for boys who actively train
are factors which tell us about growth and deve- basketball and those who do not train any sports
lopment, considering that in comparison to height on a sample of Canton Sarajevo. Also to examine
the weight is a vague indicator and criterium for the Body Mass Index, the distribution of fat tis-
the evaluation of physical development. The BMI sue, and compare the anthropometric measurings.
is the most precious indicator of the nutritive con- The narrow aim of the research was to examine
dition. The DMT is a useful indicator of the type the average body height and weight of boys in
of the type of obesity. The research was conducted the Sarajevo Canton and the deviations from the
on a sample of 100 tested people of the male sex standard values. To the deviations in growth and
aged 14-15 years in the municipality Center, Can- development which arise during puberty, in a big
ton Sarajevo. The measuring of the anthropome- measure physical activity can have an effect or
tric parameters was performed with the standard inactivity. Standards which we used are displa-
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264 Journal of Society for development of teaching and business processes in new net environment in B&H
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Methods of removing
infectious and laboratorys’
waste in clinic centers
METODE UKLANJANJA INFEKTIVNOG I
LABORATORIJSKOG OTPADA U KLINIČKIM
CENTRIMA
Aida Vilic-Svraka1, Zlatko Vucina1, Aida Filipovic-Hadziomeragic1, Mirsada Mulaomerovic1
1
Institute for public-health of Federation of Bosnia and Herzegovina
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266 Journal of Society for development of teaching and business processes in new net environment in B&H
HealthMED - Volume 2 / Number 4 / 2008
In clinical-chemistry laboratory and X-ray labo- in touch with it, one can be infected easily. Risk
ratories ussualy appears medical chemistry liquid from scalpel, lancet or some other sharp object is
waste. It contains of chemicals which have dan- less than risk from needle bit, probably because
gerous substances (laboratory reagenses liquides there is more blood left in needle. Virus hepatitis
for disinfection based on phenol or perohloretilen, B is really resisted and can live one week or even
waste with great concentration of hard metal, dif- longer out of body. On 30 °C this virus can keep
ferent chemicals and radioactive waste material). infection till 6 months, and on 60 °C – four hours.
Denatured alcohol, calciumcarbid, halogen organ, It is similar with virus hepatitis C. Virus of human
dissolvers, radio-active and other dangerous waste immunodeficiency (HIV), is also transmitting
matters mustn’t be in canalization system. with infected blood, blood products, contaminated
Nonmedical chemical liquid waste consists of needles, sprayers and other instruments. However,
means for cleaning of rooms and sanitary equip- this virus is less resisted (it can live 3-7 days on
ment for example different sorts of detergent and room temperature). (7, 8, 9)
other means for washing, salt acid, hydrogen and Chemicals used in hospitals are potential so-
different disinfects. This sort of chemical liquid urce of pollution, mostly through water, by sew-
waste is mainly removed by releasing it in sewage age system. Small amounts of dangerous chemical
system, but type and quantity of that material must waste can cause poisoning and chemical burns.
be limited. Taking care of infectious and laboratory waste
In clinical laboratory either hard chemistry is becoming great problem of health institutions.
waste appears (which can consist a lot of toxic Proper handling with infectious material waste is
and infectious substances) and radioactive waste. important measure in preventing hospital infec-
Waste which consists of hard metals is presented tions. One of the general measures is environmen-
under category of dangerous waste which is very tal protection and classifying, collecting, storag-
toxic. For example, waste of mercury appears ing and treatment, in fact disinfection of infectious
dropping during break of medical equipment but material waste. Interesting information is that rich
waste of sodium appears of expending battery. countries are not necessarily had to take care of
Special category is radioactive waste which has material waste. It is necessary to set aside 0, 5% of
specific way of elimination and carrying. (4,5) bruto national income per inhabitant. That means
Waste water from hospitals contains many pat- that countries with low bruto national income
hogenic bacteria that cause intestinal diseases. This should set aside between 0,18 and 6 dollars per
water often contains Koch’s bacilli, enteroviruses inhabitant per year.(10,11,12).
(include Coxsackie viruses, rhinoviruses, polioviru-
ses) and Hepatitis A viruses. Pollution by drinking
water with hospital waste may cause epidemics. As 2. Methodology of research
viruses are more resistant to physical and chemical
inactivation than bacteria, proper treatment of wa- Sample encircled tertiary level of health prote-
ste water is necessary. Discharge of liquid medical ction – three the biggest Clinical centers on the area
waste out of sewage system is allowed only if pro- of Federation Bosnia and Herzegovina (hospital de-
per treatment has been applied.(6) partments and laboratories). Research has been done
When we talk about solid infectious waste, the due to protocol of research, by standard phases:
main problem is taking away of sharp objects: 1. Production of situation analyze based on
scalpels, needles, lancets, used in interventions. existing data and research:
On city depo, it is often possible to see needles, 2. Production of suggestions of research;
bandages and other material waste which is poten- 3. Production of action and financially plan;
tial source of infection. Pipettes, lancets and blood 4. Implementation of research (preparement
needles for hematology research, are often trans- of research questionnaire, data collecting,
mitters of virus hepatitis B (VHB) and virus hepa- entering data base, statistic processing of
titis C (VHC). Causes of infection are staying lon- data);
ger in needles, so if someone accidentally comes 5. Evaluation and producing the report;
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HealthMED - Volume 2 / Number 4 / 2008
Research encircled next variable: lyzed units, in 40% is intended plastic wrapping
material, and in 20% carton boxes are being used.
1. Sharp objects (needles with syrers, lancets, For packaging of laboratory’s waste in 46,67% of
scalpels, and tweezers) analyzed units, plastic wrapping material is being
2. Bandage materials (tampons, bandages, used, in 26,67% plastic bags are being used, and
gazes, absorbent cotton) in 20% carton boxes are being used. One third of
3. Systems for infusion and transfusion of analyzed units (33,33%) keep sharp objects in in-
blood tended, solid covered dishes which are safe from
4. Supplies for one way use (gloves …) penetration and opening.
5. Other infectious material waste Wrapping material for infectious and laborato-
6. Cultures and supplies from laboratory ry waste, which is waterproofed and insured from
7. Chemicals containing other dangerous spilling of the content, have 40% of analyzed units,
substances (laboratory reagents, means while 33,33% of analyzed units have wrapping
for disinfection based on phenol or material marked with proper color (red or oran-
perochloretilen, acids, bases, waste with ge for infectious, yellow for chemical waste). In
great concentration of hard metals…) 66,67% of analyzed units wrapping material with
8. Other chemicals infectious and laboratory’s waste can not be open
without authority.
In process of data treatment SZO and CDC, EPI Special storage for infectious and laboratory
info 2000 with SAAS/SUDAN software packet waste, which is covered, marked and intended only
has been used, with aim to calculate the sample, for that purpose have 33,33% of analyzed units.
values of factors in data base, to calculate standard Storaging of untilled infectious laboratory waste
mistakes and coefficient of variation. Statistical lasts till 24 hours, and longer than 24 hours for la-
differences in range from 95% interval of correc- boratory waste which is being collected for taking
tness’s were defined. For showing data, we used away with authorized companies with whom the
descriptive statistics (percent inclusion) in analysis contract has been signed. Treatment of infectious
of correlation of some variables, as well as getting material waste with disinfection and sterilization,
hi-square test for compare view of some variables, in fact, taking it away with authorized companies,
where according to analyze of data some hypothe- is being done in 33,33% of analyzed units. Until-
ses were seen important for statistic differences in led infectious and laboratory waste is being taken
relation on acting of some variables. away together with communal waste in 66,67% of
analyzed units. In all analyzed units, human tissu-
es are being burried on cemetery. Liquid infectious
3. Results and laboratory waste is not processing before re-
leasing it into sewege system in 60% of analyzed
Clinical center in Sarajevo doesn’t have three units. Other liquid infectious and laboratory waste
year or five year plan for taking care of medical is being treated with disinfection, in fact it is being
material waste, while 60% of analyzed units have taken away with authorized companies.
documentation about this sort of waste. Person in In Clinical center in Sarajevo, 46,67% of staff
charge for organization and indoor supervision working on classifying and processing of infecti-
don’t have 40% of analyzed units, and person in ous and laboratory waste material, is educated for
charge for taking care of data base about medical that kind of job, 73,33% of staff have full protective
waste, making and delivering monthly report to clothes. In most of analyzed units, final treatment
person in charge for organization and indoor su- of infectious and laboratory waste is huge problem.
pervision don’t have 86, 67% of analyzed units. Next problem is storaging, classifying and transpor-
Partly selection of infectious and laboratory’s ting infectious and laboratory waste materials.
waste on place where they happened make 80% of Clinical center in Mostar doesn’t have 3 year
analyzed units. For packaging infectious material or 5 year plan for taking care of medical material
waste, plastic bags are being used in 40% of ana- waste, as well as documentation about this sort of
268 Journal of Society for development of teaching and business processes in new net environment in B&H
HealthMED - Volume 2 / Number 4 / 2008
material waste. None of the analyzed units don’t Clinical center in Tuzla has 5 year plan for ke-
have person in charge for organization and indoor eping of medical waste and all analyzed units have
control for medical material waste, as well as per- documentation about this sort of waste, as well as
son in charge for taking care of data about medical person in charge for organization and indoor supervi-
waste who makes monthly report and deliver it to sion who makes and deliver monthly report to person
person in charge for organization and indoor su- in charge for indoor supervision. All analyzed units
pervision. make full selection of infectious and laboratory wa-
All analyzed units are doing partial selection ste on place where they happened. Intended plastic
of infectious and laboratory waste on place whe- bags are being used for packaging infectious and la-
re they happened. Simple plastic bags and carton boratory waste in 40% of analyzed units, and in 60%
boxes are being used for packaging infectious and of them, plastic wrapping material is being used.
laboratory waste. Intended plastic wrapping ma- All analyzed units keep sharp objects in inten-
terial is being used for laboratory waste in 20% ded, solid and covered dishes which are insured
of analyzed units. In 13,33% of analyzed units, from penetration and opening. All analyzed units
sharp objects are being stored in intended, solid, have wrapping material for infectious and labo-
closed dishes which are insured from penetrati- ratory waste which is waterproofed and insured
on and opening. None of the analyzed units don’t from dropping or spilling the content and which is
have wrapping material for waste which is water- marked with proper color (red or orange for infe-
proofed and marked with proper color. Wrapping ctious, yellow for chemical waste). This wrapping
material with infectious and laboratory material material couldn’t be opened without authority.
waste can not be open without authority. There is storehouse for infectious and labora-
There is no specific storehouse for infectious tory waste which is covered marked and predicted
and laboratory waste which is covered, marked only for that purpose. Storaging of untilled infe-
and predicted only for that purpose. In most of ctious waste in most of analyzed units lasts from 1
the analyzed units, storaging of untilled laboratory to 12 hours. Storaging of untilled laboratory waste
waste lasts 3-12 hours. Storaging of untilled labo- lasts up to 12 hours (it is collecting for taking it
ratory waste last 24 hours, and releases into a sew- away by authorized company with whom the con-
erage system without previous processing. tract has been signed, with residence in Tuzla). All
Transportation of infectious and laboratory wa- analyzed units with human tissues as infectious
ste is exclusively done by communal service vehi- waste are using freezers for their storaging. Stora-
cles without any time planning. ging of human tissues lasts from 3 to 12 hours. For
Solid infectious and laboratory waste treatment 86,67% of analyzed unites transportation of infe-
is not part of any analyzed unit; in fact it has been ctious and laboratory waste is done with vehicles
put aside together with communal waste. In all made only for that purpose, and vehicles are easy
analyzed units, only human tissues are being bur- to clean and disinfect, and in those units there is
ried in cemetery. Liquid infectious and laboratory time planed for transportation of this sort of waste
waste is processed before releasing into a sewera- material.
ge system in 6,67% of analyzed units. Other liquid Infectious and laboratory waste treatment with
infectious and laboratory waste releases into a se- disinfection and sterilization, in fact taking labo-
werage system without previous processing. ratory waste away is part of 86,67% of analyzed
In Clinical hospital in Mostar, 26,67% of staff units. Both, communal and untilled infectious and
that works on classifying and processing of infe- laboratory waste are being taken away by 13,33%
ctious and laboratory waste, is educated for that of analyzed units. In all of analyzed units, human
kind of job, and 66,67% of staff have full pro- tissues are being burried in cemetery. In 13,33%
tective clothes. In most of analyzed units, final of analyzed units, liquid infectious and laboratory
treatment of infectious and laboratory waste is a waste are not processed before releasing into a se-
huge problem. Next problem is storaging, classi- werage system. Other liquid infectious and labora-
fying and transportation of infectious and labora- tory waste is processed by disinfection, in fact it is
tory waste. taken away by authorized companies.
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HealthMED - Volume 2 / Number 4 / 2008
In Clinical center in Tuzla 99,33% of staff wor- In order to give appraisal in clinical centers in
king on classifying and processing infectious and Sarajevo, Mostar, and Tuzla, and also to compare
laboratory waste, is educated for that kind of job those appraisals, there is appraisal created for each
and 93,33% of them have full protective clothes unit from the sample according to answers on re-
– those who are working with infectious and labo- levant questions from question mark. The biggest
ratory material waste. In most of analyzed units, possible appraisal is 23, and the lowest is 0. Ac-
final treatment of infectious and laboratory waste cording to statistical processing of those given ap-
is huge problem, since 86,67% of this waste is be- praisals for three clinical centers, the results are:
ing burned in places predicted for that, and it is not
due to hygiene standards (connected to a boiler
room chimney, without filters and without control
of outlet gas emission).
This research has shown that there is statistical
important difference between clinical centers in
Sarajevo, Mostar and Tuzla, in relation with met-
hod insurance. The best evidenced situation is in
Clinical center in Tuzla, and the worst evidenced
situation is in Mostar (high average appraisal of
methods which are being used in Clinical center Graph 1: Average appraisal of insure method of
in Tuzla, exists of epidemiology-hygiene Sector infectious and laboratory waste in clinical cen-
for supervision, where specialists for hygiene and ters (comparison according to clinical centers)
epidemiology are taking seriously this issue.)
Observing full sample with average appraisal In order to check if there is statistical important
of 10,91 (maximum appraisal is 23), conclusion is difference according to average appraisal between
that methods for removing infectious and labora- clinical centers in Sarajevo, Mostar, and Tuzla, va-
tory waste in clinical centers in the area of Fede- riance analyze have been done (ANOVA) and the
ration of Bosnia and Herzegovina are not insured results are in table 1.
because 60% of this sort of waste is taking away Since F empirical > F theoretical, in fact p value is
together with communal. It is a great risk for me- less then 0,05 = that means that difference in ave-
dical staff health, and health of patients and all pe- rage appraisal is very important. According to re-
ople. moving method of infectious and laboratory waste
Table 1
Anova: Single Factor
SUMMARY
Groups Count Sum Average Variance
KC Sarajevo 15 140 9,33 67,45
KC Mostar 15 46,5 3,10 2,26
KC Tuzla 15 318 20,86 2,89
ANOVA
Source of Variation SS df MS Fempirical p-value Theoretical
Between Groups 2536,41 2,00 1268,21 52,41 0,00 3,22
Within Groups 1016,33 42,00 24,20
Total 3552,74 44,00
270 Journal of Society for development of teaching and business processes in new net environment in B&H
HealthMED - Volume 2 / Number 4 / 2008
in Clinical centers in Tuzla, Sarajevo and Mostar, risk for medical staff health as well as for patients
the best evidenced situation is in Clinical center in and all people’s health.
Tuzla, and the worst is in Clinical hospital in Mo- At the same time, Clinical center in Sarajevo,
star. Since average appraisal for complete sample 33,33% of infectious waste refine in special instru-
is 10,91, and the maximum appraisal is 23, it is ments for sterilization through the microwaves. It
relative small share (less than 50%), conclusion is is a method that gives complete sterilized materi-
that removing methods of infectious and laborato- al, and sharp objects are crushing with special cru-
ry waste in clinical centers are not insured, which shers. This is ecological completely safe and good
presents risk for medical staff health, as well as method for destroying infectious waste material,
risk for patients and all people’s health. because what’s given from the method can be taken
away together with communal waste material.
Non existing systems for taking care of infe-
4. Discussion and conclusions ctious and laboratory waste, lack of information
about health risks, lack of material and human re-
Infectious and laboratory waste is the most dan- sources, and bad control for taking care of, are the
gerous and the biggest part of medical waste and most common problems connected with this sort
it should be treated due to management principles of waste materials. The most important is to clear-
which are part of EU and developed countries of the ly define responsibilities for correct handling with
world. In Europe and in the world, there are clearly this waste and it is finally provided:
defined regulations for taking away medical waste - System establishing for handling with
and according to them there are obligations and infectious and other medical waste, it is
responsibilities for law and physical subjects how necessary to make legislative regulative and
to treat material waste. In that way, Institutions for regulations for exact handling with this sort
health commit themselves to take care of their infe- of waste. Based on legislative regulations,
ctious waste on ecological accepted way. (13,14) obligations and responsibilities for law and
Legislative-regulatory frame existing in our re- physic subjects should be defined. So, even
gion is not in conformity with EU countries which a health institutions – producers of this
has influence on quality of medical interventions dangerous waste, should be obligated to take
and appearing epidemiology risks (15). care of waste on ecology accepted way.
Results of this research have shown that three - Development of system for handling and
of the biggest clinical centers in Federation Bosnia final taking care of waste which includes
and Herzegovina, 60% of untilled infectious and defining responsibilities and providing
laboratory waste take it away together with com- means for using it. It is a long-term process.
munal waste. When we talk about taking care of - Rising up level of consciousness in public,
infectious and laboratory waste in clinical centers, education about risks connected with
the best evidenced situation is in Clinical center infectious waste and taking care of it safely.
in Tuzla, and the worst is in Clinical hospital in - Choosing safe environmental solutions, so
Mostar. High average appraisal for Clinical center people could be protected from danger during
in Tuzla can be explained by existing hygiene-epi- collecting, handling, classifying, transporta-
demiology Sector for supervision, where employ- tion, treatment or final taking care of infectious
ed doctors – hygiene and epidemiology specialists and other medical material waste (16,17).
are seriously do their job. However, methods for
taking care of infectious and laboratory waste do Most economic measures for treatment of infe-
not completely satisfy hygiene principles. Incine- ctious/medical waste in transitional period are ste-
rator, where 86, 67% of infectious and laboratory rilization with high temperatures, with chemical
waste is destroying, is old-fashioned method and means, ionization radiation (gamma and UV rays)
partly satisfy hygiene standards. It is connected to and nonionizational radiation (new technology
a chimney of existing boiler room. There is no su- – micro and radio waves) which is most accepta-
pervision of air pollution emission what represents ble method. Open container for keeping infectious
Journal of Society for development of teaching and business processes in new net environment in B&H 271
HealthMED - Volume 2 / Number 4 / 2008
waste materials must be replaced with solid, impe- 5. Đukanović, M.: Životna sredina i o, Elit, Beograd,
netrable covered dishes, and transportation should 1996.
be done with intended vehicles. 6. Presečki V. i sur.: Virologija, Medicinska naklada,
It is necessary to reduce number of disorganized Zagreb, 2002.
depo-places, and to increase number of depos which 7. Rutala, W.A., Sarrubi, F:A:; Management of infe-
ctious waste from hospitals. Infect. Control, 1983,
will satisfy minimum of sanitary conditions, and
4, 198-203.
cleaning city waste water before releasing it into a 8. Chou, S., Division of infectious diseases, Oregon He-
water current (mechanical and chemical treatment). alth and Science University, Portland, OR 97239.
The best solution would be construction of Regio- 9. Zvizdić, Š., Bešlagić, E., Kapić, E., Mikrobiologija
nal factory – modern incinerator for destroying of sa parazitologijom – dijagnostika i terapija, Uni-
this waste which is case in EU. Those incinerators verzitet u Sarajevu, Farmaceutski fakultet, Katedra
are placed in centers of big towns (for example, in za mikrobiologiju, Sarajevo, 2006.
Vienna), because energy produced by combustion 10. WHO Regional guidelines for health care waste
of waste is using for heating the apartments. They management in developing countries (draft), Ku-
have great capacity and medical waste from all regi- ala Lumpur: World Health Organization, Western
ons can be processed in them. They are constructed Pacific Regional Environmental Centre; 1994.
11. Upravljanje i minimizacija zdravstvenog otpada,
due to ecology principles, because whole emission
IWM, UK; 2000, ISBN 0
in the air is water steam and carbon dioxide. Con- 12. Priručnik o “Sigurnom upravljanju otpadom od
struction of factory like this is very expensive, so aktivnosti zdravstvene zaštite”, WHO 1990 ISBN
we can think about it only in future period. 92 4 154525
Incineration large amount of halogen solvents 13. Marković, D., Đarmati, Š., Gržetić, I., Veselinović,
(which contains chloral or flour) shouldn’t been D., Fizičko-hemijski osnovi zaštite životne sredi-
done if machines don’t have proper equipment for ne, II knjiga, 1996, Beograd
cleaning gases. 14. Ilić, M., Miletić, S., Upravljanje zaštitom životne
Any waste material that couldn’t been efficien- sredine prema Evropskom zakonodavstvu, Zbor-
tly burned, should be given to organization or com- nik radova, XX kongres JUDIMK, Beograd, 18-
pany authorized for handling with dangerous waste. 19. novembar, (1999), 245-250.
15. Zakon o upravljanju otpadom, Službene novine
Those organizations can eliminate waste in rotation
Federacije Bosne i Hercegovine, br.01-335/03
furnace, treat it chemically or storage it on places for 16. Ilić, M., Miletić, C, Osnovi upravljanja čvrstim
dangerous chemicals. Other possibility for taking otpadom, Institut za ispitivanje materijala, 1998,
away dangerous chemical waste materials includes Beograd, ISBN 86-82081-11-3
its return to producer. This waste can be exported 17. Ćatović, S., Kendić, S., Ćatović, A., Higijena, Uni-
to countries which have staff and machines for safe verzitet u Bihaću, Bihać, 2004.
treatment of this dangerous waste. Deliveries like 18. Leder, K., Infectious Diseases Epidemiology Unit,
this should satisfy international agreements such as Department of Epidemiology and Preventive Medi-
Basel convention. (18, 19, 20). cine, Monash University, Victoria 3181, Australia
19. R.Jerome, K., Department of Laboratory Medici-
ne, University of Washington Program in Infecti-
Literature ous Diseases, Fred Hutchinson Research Center,
Seattle, WA 98109.
1. Guidance for evaluating Medical Waste treatment 20. World Health Organization (2004): Policy Brief:
Technologies, Final report, EPA, Office for solid Provision of sterile injecting Equipment to reduce
waste, 1993. HIV transmission, WHO/HIV/ 2004.03.
2. Bašić, F., Bešlagić, E., Mikrobiologija – Morfološki
aspekti sa dijagnostikom, Univerzitet u Sarajevu,
Medicinski fakultet, Sarajevo, 1998. Corresponding author:
3. Puvačić Z., Epidemiologija, Sarajevo, 1997. Aida Vilic-Svraka
4. Department of Health and Human Services, Agency Institute for public-health
for Toxic Substances and Medical Waste: A Report Bosnia and Herzegovina
to Congress, Executive Summary. e-mail: aidavilicsvraka@yahoo.com
272 Journal of Society for development of teaching and business processes in new net environment in B&H
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Journal of Society for development of teaching and business processes in new net environment in B&H 273
HealthMED - Volume 2 / Number 4 / 2008
kada se namnože unutar postrojenja koje prave mammal on the planet. There are approx. 5,000
hranu i lijekove za potrebe čovjeka. Najveće šte- species of mammals on Earth, with as many as 2,-
točine predstavljene su sljedećim vrstama; Rattus 000 rodent types (1). For the last 50 million years,
norvegicus-sivi štakor, Rattus rattus-crni štakor te the rodents have evolved and easily adapted to the
vrsta Mus musculus-kućni miš. Ove vrste oneči- climatic changes conditions.
šćuju namirnice, vodu i površine urinom , fece- It is not without reason that rodents are claimed
som, slinom, ugrizom, te preko ektoparazita. Ta- to be the most intelligent and destructive mammals
kođe, prenose brojna bakterijska (kuga, bruceloza, on the planet, having survived to this day primarily
salmoneloza) i virusna oboljenja (tifus, bjesnilo, thanks to their phenomenal ability to adapt and their
šap, slinavka). Deratizacija je vršena u četiri na- fast breeding capabilities. For us, the most impor-
vrata tokom 2006. god. Prije svake deratizacije tant species are commensal rodents, which live in
treba prvo pristupiti identifikaciji vrsta glodavaca the vicinity of the humans and feed on human food,
koji obitavaju na području koje treba biti deratizi- while causing significant damage and causing a se-
rano. Za izlov uzoraka upotrebljavani su tzv. lje- rious health problem since they are a natural carri-
pljivi mamci u koje se uhvatilo nekoliko primje- ers of many infectious and parasite diseases of both
raka od svake vrste. Također proveden je i stupanj humans and livestock. (8) The most important com-
infestacije kojim je konstatovano da je u proljeće mensal rodents in the world, including Croatia, are
i jesen populacija glodavaca procjenjena na 500- the gray rat (Rattus norvegicus), black rat (Rattus
1000 jedinki, dok je tokom zimskih i ljetnih mje- rattus) and the household mouse (Mus musculus).
seci populacija glodavaca procjenjena na 100-500 (7) At the end of the 19th century, when the functi-
jedinki. on of the rats in the spreading of diseases, namely
Deratizacijom su obuhvaćena 54 slivna šahta i the plague, was discovered, the humans have come
16 revizionih otvora. Tokom zime i ljeta na otvo- to realize that rodents are a serious enemy and have
rima šahtova i na revizionim otvorima se stavljao taken more care in their containment (2).
po jedan Brodilion parafinski blok ili Brodifakum In 1397, the Dubrovnik Senate Council has
parafinski blok, dok je tokom proljeća i jeseni na become the first city in the world to introduce
otvorima šahtova stavljana dva Brodilion parafin- mandatory 40-day quarantine for all travelers and
ska bloka ili Brodifakum parafinska bloka, dok je goods in order to prevent the spreading of plague.
na revizionim otvorima stavljan po jedan blok. Svi In 1805, the same Council ruled that all ships ente-
blokovi su fiksirani žicom da ih kojim slučajem ring the Gruz port of Dubrovnik must exterminate
glodavci nebi prenijeli na druga mjesta. rats by burning coal. This is the first written docu-
Oba otrova su probavni otrovi koji se mješa- ment concerning the mandatory destruction of rats
ju sa hranom koju glodari rado konzumiraju. Po- (3). The named procedure mainly indicates the
sebno velika konzumacija hrane zabilježena je u eradication of rats and mice that cause significant
proljeće i jesen kada nastupa i sezona razmnoža- health and economical damage.
vanja. Otrovi su mješani sa sljedečom hranom; Economical damage stems from rodents con-
meso, riba, sir, voće i povrće. Ovi otrovi su bio- suming, damaging or spoiling large quantities of
loški veoma učinkoviti i glodavci ugibaju nakon food, raw goods and other items used by humans.
samo jedne uzete doze (single doze). It is almost impossible to quantify the amount of
20 dana nakon deratizacije napravljena je pro- financial loss caused by rodent infestation. It is
cjena infestacije koja je pokazala da glodavci više estimated that rodents damage 10 times more food
nisu prisutni unutar kompanije. than they need and that they consume up to a third
of their body volume daily.
The World Health Organization (WHO) esti-
Introduction mates that rodents destroy approx. 30 million tons
of food annually and devour or damage approx. 5
Rodents can be found in every corner of the billion dollars worth of goods. It is also estimated
world. They have followed mankind in its histo- that they cause a 5% damage in consumer goods
rical development, becoming the most prevalent production, roughly sufficient for 130 million pe-
274 Journal of Society for development of teaching and business processes in new net environment in B&H
HealthMED - Volume 2 / Number 4 / 2008
ople (1,2) According to estimates by experts in So- Additionally, it is not uncommon to encoun-
uth East Asia, rodents destroy 15% of rice growths ter cases of physical attack against children and
(food for 12 million people) during the vegetative household pets (3). It is for these reasons that the
period. In Congo, rodents destroy up to 40% of ta- number of rodents should be reduced, i. e. kept at
pioca plants. They also attack sugarcane, sesame, the biological minimum, which is at the number
coconut, cacao, and potato plantations. of units that will ensure the survival of the species
In European warehouses, they damage wheat, while being acceptable to the humans (10).
rye, corn, fruit, beans, and root vegetables. Thro- To achieve this, measures of sustained extermi-
ughout a year, a single gray rat can deposit up to 7 nation need to be enforced in all spaces occupied
liters of urine (droplets) and 18 kg of feces (turds), by humans. The above practice includes all met-
causing infected food to be declared unusable for hods that result in the reduction of the population
humans. Much of the damage is also caused by of rodents (mice, rats, mouse like rodents like vo-
‘nibbling for the sake of nibbling’. This way, ho- les, field mice and forest mice) although the root of
use infrastructure, sewer lines, gas lines, heating the word deratization means de-rat, ‘to be free off
lines, and telephone and electric cables are dama- rats”. The successful extermination requires the
ged, resulting in shortcuts and fires (4). use of biological, mechanical, physical, and che-
Rodents also damage art works and documents mical measures followed by the sanitization of the
in libraries, museums and archives. The aesthetic environment. Unfortunately, mostly chemical me-
aspect of the rodent extermination must also be ta- asures are used today, causing the extermination
ken into account, since they cause fear, revulsion to be treated merely as setting up poisoned traps,
and even panic. This is of particular importance for which is incorrect.
tourism sites, like camps, hotels and similar sites, Chemical measures include the use of pestici-
where the very presence of rodents may cause eco- des that will cause poisoning or sterilization of the
nomical damage. It is almost impossible to over- rodents. These pesticides are known by a collecti-
emphasize the importance of rodent suppression. ve name of raticides or rodenticides and can be
Concerning health aspects, rodents are one the used in different combinations.
primary carriers of infectious diseases for both hu- The choice of the combination, the method and
mans and livestock. Since they are always present the application of precautionary measures are de-
in the vicinity of humans, the chance for transmis- pendent on the type of the rodent against which
sion is very high. Rodents usually spread diseases they are used, namely the biological conditions,
in the following manners: the size of the population and location of certain
- Pollution of water sources, goods and construction (11). Humidity plays an important
surfaces by urine, feces, mucus, secretion part when performing deratization since not all ro-
from the smell gland (near tail), and by denticides can be used in humid conditions.
biting (mucus, teeth) The deployment of scattered baits, whether it is
- Via ecto-parasites (lice, fleas, ticks, mosqu- in the form of grains or pellets, is not suitable for
itoes) humid environment due to degradation of said ba-
its. In humid conditions, mold often forms on the
Diseases that rodents can transmit can be divi- baits, making them inadequate for the use. Mo-
ded into several categories: dern methods of extermination in wet conditions,
like cellars, sewers or brooks, is based on solid
Bacterial - Leptospirosis, salmonellosis, tula- paraffin baits, created by mixing 40-45% paraffin
remia, plague, brucellosis; (melting point 80ºC) with rat food. Such baits are
Rickettsial and viral - Foot - and - mouth very attractive to rats, which often carry them to
disease, rabies, hemorrhagic fever, typhus, their dens. Due to their resistance to environment
viral encephalitis; conditions (because of paraffin), they remain acti-
Parasitic - Trichinellosis, leishmaniasis; ve for a longer period.
Protozoal – Toxoplasmosis, amebiasis; In addition to the composition of the bait, the
Fungal – Dermatomycoses. active ingredient is also important, namely the po-
Journal of Society for development of teaching and business processes in new net environment in B&H 275
HealthMED - Volume 2 / Number 4 / 2008
ison that will kill the rodent. It must be mixed well the bait block traps and pellets contain
into the bait, because otherwise, the rodents will bromadiolone. According to the law
not notice it and will not indigest it. regulating the poisonous substances (NN
Today, most used rodenticides are anticoagu- 27/1999) and the register of permissible
lants (1). poisons (NN 7/2001) bromadiolone is listed
the group III poison at concentration of 0.
005%. Brodilon rodenticide paraffin block
Aims of the Study is a very efficacious tool for the eradication
of gray and black rats and household mice
- To describe the suppression of rodents in the communal hygiene and public health
in specific conditions in the area of a setting.
pharmaceutical company in 2006 b) Brodifakum paraffin blocks contain 0.
- To show results of suppression after 005 % brodifacoum as the active compound
deployment of suppression measures which belongs to group II poisons.
- To estimate effectiveness of executed Brodifakum paraffin blocks weighing 25 g
measures are suitable for the use in open areas. When
the rats are targeted for the eradication,
two brodifakum blocks should be applied.
Material and Methods Conversely, one block is applied in the
case of mice eradication. The brodifakum
The eradication of harmful rodents (deratizati- paraffin blocks of 210 g weight connected
on) in wet environment conditions has been done to the wire are also available and they can
within the property area of a pharmaceutical com- be hanged for the use in the drainage system
pany in Zagreb. The size of entire area is 80 000 apertures.
m² whereas the green and traffic areas, on which
an external eradication linked to wet conditions For the purpose of investigation which included
was performed, have about 20 000 m² in size. an estimation of the size of rodents’ population oc-
The horizontal sewerage system which serves for cupying the area of a pharmaceutical company in
the drainage of the part of the industrial water as Zagreb, the method of Gunderson was used and
well as precipitations has its drainpipe connected the following criteria were applied:
to filtering system. The length of the system pipe
network is about 8 000 m in conjunction with the - If the rodents cannot be seen but the damage
network of 16 metallic control channels (revisi- attributed to their presence is observable,
on apertures) and 54 drain manholes which are the size of rodent population is between 1
covered with iron bars for collecting precipitati- and 100,
ons. Also, the channel-like watercourse, 400 m in - If the rodents can occasionally be seen at the
length, passes through the area and both the pede- sunset and during the night, population size
strian and traffic bridge span over it. The emban- is between 100 and 500,
kments on both stream sides are arranged and well - If the rodents are regularly seen during the
maintained. night as well as occasionally on the daytime,
For the deratization of external areas Brodilon population size is between 500 and 1,000,
paraffin blocks (30 g, 100 g, and 200 g) as well as - If the rodents are regularly seen both during
Brodifakum paraffin blocks (25 g and 210 g) were the night and in broad daylight, population
used. Accordingly, the following chemical com- size is estimated to be between 1,000 and
pounds were used during eradication procedure: 5,000.
a) Brodilon paraffin blocks contain hydroxy In addition, the assessment of the level of infe-
coumarin derivative bromadiolone, second station of investigated area is based on informati-
generation anticoagulant rodenticide. Both on obtained by quizzical of the company working
276 Journal of Society for development of teaching and business processes in new net environment in B&H
HealthMED - Volume 2 / Number 4 / 2008
staff and by our direct observations throughout gases such as methane or hydrogen sulfide (H2S)
period of the research conduct in the designated or any other potentially explosive gas by using
area which, amongst other, include finding rodent Dräger’s detector which is equipped with special
feces and other trails, damages done by their pre- tubes for detection of explosive gases. Afterward,
sence and by the discovery of systems of tunnels deratization was done by using Brodilon 200 g pa-
and active holes which the rodents built on the cer- raffin blocks as well as 210 g Brodifacum paraffin
tain locality. blocks equipped with wire noose which impro-
ves the accessibility to certain places. Also, wire
noose increasingly prevents rats of taking away
Eradication procedure and relocating paraffin blocks to more convenient
place for them. Additionally, wire noose has been
The eradication procedure was performed in shown a reliable tool in the fixing paraffin block
the accordance with the Guidelines describing the within a specific control place of the drain system
exact means by which obligatory disinfection, de- which thus prevents paraffin blocks to be carried
sinsection, and deratization are carried out. away by water stream. Accordingly, one paraffin
block equipped with wire noose was placed into
each shaft and was fixed to the metal frame of the
a) Deratization within the area of control channel in a way that the paraffin block
pharmaceutical company was put down to the level of the branching of the
drainage network tubes. When put properly, the
Having in mind specific and sensitive nature of lure is hanging in the air above the embankment
the working activities within the pharmaceutical which serves as a place of rest for the rats and thus
corporation, an enormous emphasize is given to presents an ideal place for luring tired rats to stop
proper sanitation of all the factory buildings and and have a rest and frequently consume the bait.
structures and their environs. Along these lines, it As mentioned before, there are also 54 manho-
is particularly important to perform a proper dera- le shafts 0. 47 x 0. 47 m in the diameter which are
tization within the structures and spaces of sewe- covered with iron bars for collecting precipitati-
rage system due to following reasons: ons. For deratization purpose, in each collecting
shaft at least one light-green 100 g Brodilon wire
- The drainage network is unlimited source of noose-equipped paraffin block (5 x 5 x 4 cm) was
constant food supply to rodents, inserted as described previously.
- The drainage network and its microclimate For deratization of the channel-like watercour-
offer favorable conditions for rodent growth se in its entire length (400 m) and the green areas
and reproduction, (20. 000 m2) Brodilon paraffin blocks of 30 g mass
- The drainage network is simplest but yet the were used, covered by plastics. Additionally, 25 g
best way for rats to communicate. Brodifakum paraffin blocks were put in different
quantities which were depending on the asses-
Given that our investigation was focused on sment of the level of infestation.
performing deratization procedure in wet conditi- Five days after performing external deratizati-
ons, we shall describe those deratization activities on, control checking was done and the damaged
which were done on the external green and traffic and consumed lures were replenished. The dera-
areas of the pharmaceutical company and its dra- tization procedure was done during 2006 and was
inage system. repeated four times within three month time inter-
The network of metallic corrective control vals. The assessment of infestation was done prior
channels of the sewerage system consists of 16 to and after performing deratization procedure and
shafts on designated area. Each shaft has 0. 65 m x the efficacy of eradication procedure in wet condi-
0. 65m dimension. Previous to setting of any bait tions was evaluated accordingly.
within the shafts, it is necessary to carefully check
after opening of shaft for the presence of explosive
Journal of Society for development of teaching and business processes in new net environment in B&H 277
HealthMED - Volume 2 / Number 4 / 2008
Table 2. Consumption of the Brodilion 30 g and Brodifakum 25 g paraffin blocks used for deratization
of outdoor green surface areas and streams (canals).
Brodilon Brodifakum
Time of deratization Total
paraffin block 30 g Paraffin block 25 g
Spring 6. 000 g 2. 500 g 8. 500 g
Summer 930 g 800 g 1. 730 g
Autumn 6. 000 g 2. 500 g 8. 500 g
Winter 930 g 800 g 1. 730 g
Total 13. 860 g 6. 600 g 20. 460 g
278 Journal of Society for development of teaching and business processes in new net environment in B&H
HealthMED - Volume 2 / Number 4 / 2008
Overall, 20,460 g of different paraffin blocks similar and averaged 650 g of consumed blocks in
was consumed in four sessions of deratization each of two periods. It was reasonable to expect
of green area and water stream systems during the difference between data having in mind hig-
2006. her level of infestation during spring and autumn
In addition, we would like to emphasize that periods. Overall, we have verified throughout in-
we have created ‘eradication map’ before perfor- spection and decoy replenishment that 4,740 g of
ming act of deratization. The map was showing all paraffin blocks were consumed during four sessi-
the places at which the baits were to be located. ons of external deratization in 2006.
Additionally, the baits were placed into the rodent Table 4. reviews total consumption of Brodilon
active holes and hidden places and rodent paths, and Brodifakum paraffin blocks that were spent
were afterward carefully masked and covered by on deratization of the sewerage system and outdo-
the layers of earth to prevent any accidental ex- or surface areas of pharmaceutical factory area du-
posure of humans and animals to these poisonous ring four sessions of deratization in 2006. The use
traps. Also, the protective gloves were used during of Brodilon paraffin blocks amounted to 55,600g
the placing of baits which prevented the possibili- whereas Brodifakum paraffin blocks were used at
ty that human sweat could come in contact with 18,480 g quantity. Thus, total yearly consumption
the baits and repulse rats of taking it. of both Brodilon and Brodifakum baits used for
Table 3. summarizes the consumption of Bro- the deratization in wet conditions was 74,080 g.
dilon and Brodifakum paraffin blocks during time Also, we have observed that the rodents did not
of the inspection and the replenishment of deco- discriminate between Brodilon and Brodifakum
ys which was done five days after deratization of blocks and they consumed both types of baits eq-
external areas. The biggest quantity of paraffin ually well. This finding testifies that both types of
blocks was consumed after autumn session (1,950 decoys were equally attractive and well prepared.
g) whereas somewhat lesser amount (1,490 g) of It has previously been stated that rodenticides
paraffin blocks was consumed after spring sessi- are digestive poisons and thus they should be in-
on of deratization. The consumption of the blocks gested to get in touch with rodent organism. Sin-
during summer and winter acts of deratization was ce the poison active compound is not attracting
Table 3. Consumption of the Brodilon 30 g and Brodifakum 25 g paraffin blocks during the inspection
and supplementation of the decoys, carried out five days after deratization of the outdoor surface area.
Brodilon Brodifakum
Time of deratization Total
paraffin block 30 g paraffin block 25 g
Spring 990 g 500 g 1. 490 g
Summer 300 g 250 g 550 g
Autumn 1. 200 g 750 g 1. 950 g
Winter 450 g 300 g 750 g
Total 2. 940 g 1. 800 g 4. 740 g
Table 4. The review of total consumption of Brodiion and Braodifakum paraffin blocks utilized for de-
ratization of sewerage system and outdoor surface in pharmaceutical factory area during 2006.
Brodilon Brodifakum
Location Total
paraffin blocks Paraffin blocks
Sewerage system 38. 800 g 10. 080 g 48. 880 g
Outdoor green areas 13. 860 g 6. 600 g 20. 460 g
Decoy supplement 2. 940 g 1. 800 g 4. 740 g
Total 55. 600 g 18. 480 g 74. 080 g
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rodents, it should be mixed with a kind of food Currently, there are different decoy nouris-
which rodents prefer. Such mixture of the poison hment preparations present on the market called
and attractive food is called ‘mamak’. Mamak, ir- the carriers. They use different types of attractive
respective of its way of manufacturing, should be food stuff such as meat, fish, cheese, fruits and ve-
of highest quality because overdosing it may deter getables, as well as different types of grains. On
rodents of taking it whilst the sub dosing of the the other hand, fresh decoys should be prepared
poison may result in the development of resistance just prior to use to prevent spoil of the ingredients.
to the poison. In addition, mamak’s organoleptic Also, cooking oil is added to ensure better mixing
features should be well manufactured to attract ro- of the poison and food compound. On the other
dents. hand, liquid rodenticides, which dissolve in wa-
Graph 1. illustrates the overall consumption ter, are seldom used. In addition, decoy powdered
of all types of Brodilon and Brodifakum paraffin forms are used to cover active holes and rodent
block rodenticides that were used for deratization communication paths. However, solid paraffin de-
of sewerage system and outdoor surface in phar- coys are only forms of decoys which are stable in
maceutical company area during 2006. wet conditions.
In order to attract rodents the decoys also con-
tain a moderate amount of different smelly and ta-
sty attractants such as anis, smoked meat, cheese,
sugar, salt, etc. Today, it is generally recognized
that rodenticides of choice for the eradication of
rodents in wet conditions are solid forms of the se-
cond generation anticoagulants whose active com-
pound is based on bromadiolon and brodifakum.
The main characteristic of the second generation
of anticoagulants is that they are highly efficacio-
us at single dose. On the other hand, first generati-
on of the anticoagulant rodenticieds is efficacious
only after five to six days of constant consumption
Graph 1. Total consumption of all types of Bro- by rodent.
dilon and Brodifakum paraffin blocks used for In Table 5. presented are the LD50 values for
deratization of the sewerage system and outdoor the first and second generation of anticoagulant
surface area in pharmaceutical company during rodenticides obtained on brown rat.
2006.
Table 5. LD50 values of anticoagulant rodenticides of the first and second generation for the brown
rat.
Antikoagulants - LD50 mg/kg Antikoagulants -
LD50 mg/kg brown rat
first generation brown rat second generation
Difacinon 3. 0 Flokumafen 0. 4
Klorfacinon 20. 5
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Corresponding author:
Suad Habes
Fakultet zdravstvenih studija Sarajevo
Bosna i Hercegovina
e-mail: hsuad@hotmail.com
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Summary Sažetak
The present study evaluated the relationship Studija evaluira odnos postojeće vijabilnosti
between the presence of viable myocardium and miokarda i razvoja kolateralne cirkulacije u infar-
the develompment of collateral circulation to the ciranom području kod pacijenata sa totalnom ko-
infarct area in patients with total coronary occlu- ronarnom okluzijom.
sion. Studija je obuhvatila 80 pacijenata sa okluzi-
The study group consisted of 80 patients with jom najmanje jedne veće koronarne arterije.
occlusion of at least one major coronary artery. Pacijenti su kategorizirani u dvije grupe na
The patients were categorized in two groups osnovu veličine kolateralne cirkulacije: grupu
depending on the extent of their collateral circu- 1 (n=45) su činili pacijenti sa dobro razvijenom
lation: group 1 (n =45) - patients with well-deve- kolateralnom cirkulacijom, dok je druga grupa (n
loped coronary collaterals to the infarct-related =35) obuhvatila pacijente sa neadekvatnom kola-
coronary artery; group 2 (n =35) - patients with teralnom cirkulacijom. U prvoj grupi smo ustano-
poor coronary collateral development or without vili postojanje vijabilnog miokarda u perfuzionom
significant collateral circulation. In the first group području infarktom zahvaćene arterije.
we established the presence of viabile myocardi- Perfuzioni defekti u grupi sa dobrom kolateral-
um in the perfusion territory of the infarct-related nom cirkulacijom su bili pretežno reverzibilni, što
artery. ukazuje da koronarne kolaterale štite mikardnu vi-
The perfusion defects in the group with good jabilnost u području sa totalnom koronarnom oklu-
collateras were predominantly reversible, sugge- zijom. Uočena je signifikantna korelacija između
sting that coronary collaterals preserved myocar- dobrih kolaterala i kompletne zaštite i loših kola-
dial viability in the regions subtended by a total terala bez zaštite miokardne vijabilnosti.
coronary occlusion. A significant correlation be- Ovi rezultati ukazuju da dobro razvijena ko-
tween good collaterals with complete protection lateralna cirkulacija može dovesti do smanjenja
and poor collaterals with no protection was noted. infarciranog područja i da predviđa postojanje vi-
These results suggest that the existance of well- jabilnog miokarda.
developed coronary collaterals may contribute to Ključne riječi: miokardna vijabilnost, kolate-
minimizing the infarct area and to prediction of ralna cirkulacija, koronarna okluzija
the presence of viable myocardium.
Key words: myocardial viability, collateral cir-
culation, coronary occlusion
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ction and kinetics. Left ventriculography was per- Statistical comparison of data was perfomed
formed in the right anterior oblique projectin. using the Chi-square test. Using Chi-square test,
the differences between the groups were signifi-
cant (P<0.001).
Thallium-201 Myocardial Scintigraphy
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the right coronary artery territory is ischemic du- 4. Sand NP, Rehling M, Bagger JP, Thuesen L, Flo C,
ring exercise, though better perfused than the left Nielsen TT. Functional significance of recruitable
coronary artery. collaterals during temporary coronary occlusion
evaluated by 99mTc-sestamibi single-photon emis-
sion computerized tomography. J Am Coll Cardi-
ol.2000;35:624-632.
Conclusions
5. Wainwright RJ, Maisey MN, Edwards AC, Sowton
1. The clear correlation between the angio- E. Functional significance of collateral circulation
graphic grade of collaterals and corresponding during dynamic exercise evaluated by thallium-201
areas of protection seen in the scintigram gives myocardial scintigraphy.Br Heart J 1980:47-55.
the angiographer reasonable reassurance 6. Werner GS, Ferrari M, Betge S, Gastmann O, Ric-
that there is functional relevance in a detail hartz BM, Figulla HR. Collateral function in chro-
description of these important channels. nic total coronary occlusions is related to regional
2. Reversible perfusion defects on stress myocardial function and duration of occlusion. Cir-
thallium imaging in the group with adequate culation.2001;104:2784-90.
collateral circulation suggesting that well-
7. Tajfl D, Kamenica S, Spaić R, Milošević A, Oda-
developed coronary collaterals preserved vić M. Uticaj kolateralnog srčanog krvotoka na
myocardial viability in the regions subtended rezultate scintigrafije srčanog mišića u bolesnika
by a total coronary occlusion. sa ishemijskom bolešću srca. Vojnosanit Pregled.
3. These findings indicate that the presence 1987 44 (2): 128-131.
of ischemic but viable myocardium is
intimately related to the development 8. Hasanović A, Kulenović A, Šišić F. The role of col-
lateral circulation in preserving myocardial functi-
of collateral circulation in patients with
on. Bosn J Basic Med Sci. 2006;6(4):29-31.
myocardial infarction, and the existence of
well-developed collateral channels predicts 9. Hasanović A, Jurić I, Fazlibegović E. Perfuziona
the presence of viable myocardium in the scintigrafija miokarda i ehokardiografija kod pa-
infarct area. cijenata sa koronarnim kolateralama.Medic. Žurn.
2002; 8 (1):12-17.
10. Hasanović A. Angiogenesis of ischemic myocardi-
Literature um. HealthMED. 2007; 3(1): 89-93.
1. Fujita M, Ohno A, Wada O, Miwa K, Nozawa T, 11. E Skoufis, AI McGhie. Radionuclide techniques for
Yamanishi K, Sasayama S. Collateral circulation the assessment of myocardial viability. Tex Heart
as a marker of the presence of viable myocardium Inst J. 1998; 25 (4): 272-279.
in patients with recent myocardial infarction. Am
Heart J. 1991;122(2):409-14.
2. Fukai M, Li M, Nakakoji T, Kawakatsu M, Nariy- Corresponding author:
ama J, Yokota N, Negoro N, Kojima S, Ohkubo T,
Hoshiga M, Nakajima O, Ishihara T. Angiographi- Aida Hasanovic
cally demonstrated coronary collaterals predict re- Institute of Anatomy,
sidual viable myocardium in patients with chronic University of Sarajevo,
myocardial infarction: a regional metabolic study.J School of Medicine,
Cardiol. 2000;35(2):103-11. Bosnia and Herzegovina,
email: ahasanovic69@yahoo.com
3. Aboul-Enein F, Kar S, Hayes SW, Sciammarella M,
Abidov A, Makkar R, Friedman JD et all. Influence
of angiographic collateral circulation on myocardi-
al perfusion in patients with chronic total occlusion
of a single coronary artery and no prior myocardial
infarction. J Nucl Med. 2004;45(6):950-5.
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Unfortunately, most police officers request me- appraisal of the situation, in that, all coping styles
dical assistance at the point when stress at work have their own function.
had already caused long-term consequences on Results of evaluation of cognitive-behavior
their health and professional efficiency. They rare- stress management used on different groups of cli-
ly require psychiatric or psychological assistance ents point to positive outcomes of programs used
out of fear of stigmatization, but also fear that they (3), (4), (5). Several studies show that the use of
will be judged as incapable of police work. They cognitive-behavior stress management leads to
are little or not at all educated about the concept of normalization of some physiological parameters
stress and trauma, normal and pathological reacti- such as blood pressure (6), while studies of blood
on to stress and traumatic experience. In addition parameters are contradictory (7), (8).
to psychological and physical health consequen- Most previous studies (9), (10) conclude that
ces, the above can also jeopardize their professi- stress management programs have positive effects.
onal safety. Despite numerous positive consequences of the
Coping with stress is different to simple and modern lifestyle, it also affects human organism
automatic adaptive reaction to a new situation in the way of producing various psychological and
because it includes cognitive efforts to adjust to somatic changes. Such effects of modern lifestyle
a new situation which exceeds one’s capacities at are further intensified in transitional, post-war co-
the point when possibility of automatic adaptation untries such as Bosnia and Herzegovina.
is excluded.
It cannot be valued as good or bad because it
is defined as investing efforts into overcoming Research objectives
specific obstacles. There are two primary functi-
ons of stress coping: regulating emotions resulting Objective of our work was to develop a structu-
from stressful situations and attempting to solve red stress management program based on cogniti-
the problem. This sets the basis for the basic clas- ve behavior therapy principles for persons in high
sification of stress coping styles as: problem-ori- risk professions such as police officers. Another
ented coping and emotion-oriented coping, also objective of our work was to evaluate the effects
known as active and evasive coping. However, of structured stress management program on poli-
such a broad definition of coping styles was pro- ce officers by measuring their anxiety levels befo-
ven to be imprecise, because they both include re and after the treatment.
different distinct strategies. Problem-oriented sty-
les include planning actions, active confrontation,
suppressing competing activities, direct action, Subjects (material) and research methodology
problem solving, negotiation, information seeking
etc, while emotion-based coping styles include de- a) Subjects
nial, self-blame, suppression, imaginary thinking, Our subjects are police officers. Experimental
wishful thinking, turning to religion, using humor, group consisted of 20 randomly selected police
positive thinking, reappraisal, passivity, holding- officers serving with the Interior Ministry of the
back emotions etc. Sarajevo Canton, aged from 30 to 45 years.
There is also the difference between cognitive
and behavioral coping strategies. Behavioral stra- b) Control group
tegies can include visible action taken to reduce Control group consisted of 20 randomly sele-
the effects of stress, while cognitive coping strate- cted police officers serving with the Interior Mi-
gies include attempts to re-interpret the situation. nistry of the Sarajevo Canton, aged from 30 to 45
However, despite the above distinction, diffe- years.
rent coping strategies do not exclude one another.
It is common for a person to use different coping c) Procedure (organization of research)
strategies in similar situations, depending on per- - In cooperation with the Ministry of Interior,
sonality, as well as characteristics and cognitive two groups of 10 people were formed. The
290 Journal of Society for development of teaching and business processes in new net environment in B&H
HealthMED - Volume 2 / Number 4 / 2008
Journal of Society for development of teaching and business processes in new net environment in B&H 291
HealthMED - Volume 2 / Number 4 / 2008
police officers because their stress does not deve- 2. Milovanović, R (1998). Policijska psihologija. Po-
lop gradually but comes in a burst, like an explosi- licijska akademija, Beograd.
on. Police work is reactive and not proactive. It is 3. Jane Sims (1997). The evaluation of stress mana-
very difficult for police officers to deal with stress. gement strategies in general practice: an evidence-
Due to cumulative effects of exhaustion and stress led approach; British Journal of General Practice,
police officers become prone to making mistakes 47, 577-582.
at work, which is often intolerable and very dan- 4. Frank M. Perna, Michael H. Antoni, Andrew Bra-
gerous. Besides, cumulative effects of exhaustion um, Paul Gordon, Neil Schneiderman (2003). Co-
and stress negatively impact police officers’ fami- gnitive Behavioral Stress Management Effekts on
Injury and Illiness Among Competetive Athletes: A
ly and social life, placing them in an even more
Randomized Clinical Trial; Ann Behav Med, 25(1):
difficult situation.
66-73
This paper studied the effects of structured
5. Kathryn A Mannix, Ivy Marie Blackburn, Anne
stress management on police officers.
Garland, Jannifer Gracie, Stirling Moorey, Barba-
Results have shown that the stress management ra Reid, Sally Standard, Jan Scott (2006). Effekti-
has helped persons in a high risk profession to de- veness of brief training in cognitive behaviour the-
velop new ways for coping with stressful situati- rapy techniques for palliative care practitioners;
ons and to further improve already existing coping Palliaiative Medicine; 20: 579-584.
skills. Also, reduced anxiety sensitivity has lead 6. Silja Vocks, Margit Ockenfels, Ralf Jurgensen, Lutz
to their improved psychosocial functioning which Mussgaz and Heinz Ruddel (2004). Blood Pressure
had a direct impact on their interpersonal commu- Reactivity Can Reduced by a Cognitive Behavioral
nication. Stress Management Program; International Jour-
Increased readiness to seek medical advice nal of Behavioral Medicine; Vol.11.No. 2, 63-70.
when experiencing psychological problems wo- 7. Jens Granath, Sara Ingvarsson, Ulrica von Thiele
uld be of enormous significance, because it would and Ulf Lundberg (2006). Stress Management: A
enable taking appropriate measures early after pat- Randomized Study of Cognitive Behavioural The-
hological reactions occur. rapy and Yoga; Cognitive Behavioural Therapy;
Vol 35, No1, pp. 3-10.
8. M. Claesson, L.S. Birgander, J.H. Jansson, B. Lin-
Conclusions dahl, G.Burell, K. Asplund and C. Mattson (2006).
Cognitive-behavioural stress management does not
improve biological cardiovascular risk indicators
- The scores on BAI scale of the subjects who
in women with ischaemic heart disease: a randomi-
received stress management program have zed-controlled trial; Journal of Internal Medicine;
fallen and the difference between their and 260:320-331.
the control group’s scores was statistically 9. Vicki R. LeBlanc, Cheryl Regehr, R. Blake Jelly and
significant. Irene Barath (2008). The Relationship Between Co-
- The experimental group also registered a ping Styles, Performance, and Responses to Stres-
significant fall in the scores on ASI scale sful Scenarios in Police Recruits. International Jo-
compared to control group. urnal of Stress Management, Vol. 15, No.1, 70-93.
- After stress management program was 10. Sima Zach, Shula Raviv, Reuven Inbar (2007). The
completed, the experimental group continued Benefits of Graduated Training Program for Secu-
to register statistically significant fall in BAI rity Officers on Physical Performance in Stressful
and ASI scores compared to control group. Situations; International Journal of Stress Mana-
gement, Vol. 14, No.4, 350-369.
292 Journal of Society for development of teaching and business processes in new net environment in B&H
HealthMED - Volume 2 / Number 4 / 2008
Trisomy 18 – Edwards’
syndrome
TRISOMIJA 18 – EDWARDSOV SINDROM
Izeta Aganovic-Musinovic, Mirela Djurovic, Zimka Seremet
Center for human genetics, Medical colleage of University of Sarajevo, Bosnia and
Herzegovina
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Cytogenetics
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Table 1.
Patient 1 Patient 2 Patient 3 (mosaic type
Symptoms
(Trisomy 18) (Trisomy 18) 46 XX/47 xx*18)
Head:
* - +
Dolichocephalism
Microcephaly * - -
Hypoplastic orbits - - -
Microphtalmy * + -
Corneal opacities - - -
Insert nose base * + -
Small mouth - - +
Narrow, high palate * - -
Microghnaty * + -
Irregular formed ears * + +
Extremities:
-Typical position of hand (2. over 3., * + +
and 5. over 4. finger)
Hipoplasic nails * - -
Born with * - +
Prominent heels * - -
Foot thumb in dosoflexy position - - -
Syndactily * + -
Other:
* + +
Heart malformations (95%)
Malformations of GIS * + -
Kidney malformations * - -
CNS malformations - + -
Chryptorchysam * + -
Hypoplastic large labia with
- - +
hypertrophy of clitoris
Short sternum * -
Weakness and fragileness * + +
Mental retardation * + +
Partial hemi vertebra * * -
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Summary Sažetak
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loške potrebe onkoloških bolesnika u terminalnoj with insight in evidence of patients with oncology
fazi bolesti. disease receiving palliative care in ambulance for
Ključne riječi: Onkološki bolesnici, fizičko palliative care “Jablanička” in Canton of Sarajevo.
zdravlje, mentalno zdravlje International questionnaire for palliative care, de-
signed in accord with World Health organization
methodology, was used. All patients gave formal
Introduction consent for participating in the study.
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Table 1. Patient with different types of malignant disease grouped by International malignant disease
classification No=number of patients
International 1. Malignant neoplasms of lip, oral cavity and pharynx
disease No % 2. Malignant neoplasms of digestive organs
classification 3. Malignant neoplasms of respiratory and intrathoracic
organs
1 13 3,3
4. Malignant neoplasms of bone and articular cartilage
2 120 30,0 5. Melanomas and other skin neoplsms
3 130 32,0 6. Malignant neoplasms of mesothelial and soft tissue
7. Breast malignant neoplasms
4 8 2,0
8. Malignant neoplasms of female genital organs
5 4 1,0 9. Malignant neoplasms of male genital organs
7 25 6,3 10. Malignant neoplasms of urinary tract
8 28 7,0 11. Malignant neoplasms of eye, brain and other parts of
central nervous system
9 11 2,8
12. Malignant neoplasms of thyroid and other endocrine
10 26 6,5 glands
11 19 4,8 13. Malignant neoplasms of ill-defined, secondary and
unspecified sites
12 7 1,8
14. Malignant neoplasms, stated or presumed to be primary, of
13 8 2,0 lymphoid, haematopoietic and related tissue
14 2 0,5 15. Malignant neoplasms of independent (primary) multiple
Σ 400 100,0 sites
It was found that incidence of malignant disea- group has been observed in case of pharynx, oral
se is greatest after the age of 45 years. Decrease in and lymphoid tissue malignancy. Increased inci-
malignant neoplasm incidence related to older age dence of other malignancy types was associated
Table 2. Malignant disease type in accord with Interantional malignant disease classification (IMCD)
in relationship with the disease duration (No=number of patients)
IMDC Up to 6 months 6-12 months 1-2 years 2-5 years 5 years and more
No % No % No % No % No %
1 0 0 7 5,47 5 4,95 1 1,06 0 0
2 7 21,21 38 29,69 36 35,65 30 31,92 9 20,93
3 17 51,52 37 28,90 29 28,71 31 32,98 14 32,55
4 0 0 5 3,91 3 2,97 0 0 0 0
5 0 0 1 0,78 0 0 2 2,13 1 2,33
7 1 3,03 13 10,16 4 3,96 5 5,32 2 4,65
8 1 3,03 8 6,25 5 4,95 9 9,58 5 11,63
9 2 6,06 7 5,47 1 0,99 1 1,06 0 0
10 2 6,06 6 4,69 9 8,91 5 5,32 4 9,30
11 1 3,03 3 2,34 5 4,95 3 3,19 7 16,28
12 1 3,03 2 1,56 1 0,99 3 3,19 0 0
13 1 3,03 1 0,78 3 2,97 3 3,19 0 0
14 0 0 0 0 0 0 1 1,06 1 2,33
Σ 33 10,7 128 32 101 25,2 94 8,5 43 10,7
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with older age group. Most common malignant reported that malignant disease restricted mobili-
neoplasm in female patients was in digestive or- ty (p<0,01) and 52% of patients reported that the
gans (36,7%), followed by malignant neoplasm disease enabled them to bath and dress alone (p<-
of respiratory and intrathoracic organs (21,7%), 0,05), many (42%) reported on impossibility to
and breast (11,9%). Most common malignant ne- sit alone (p<0,05), and 47% of patients reported
oplasm in male patients was malignant neoplasms that the disease disallowed feeding by the patients
of respiratory and intrathoracic organs (41,7%), alone (p<0,05), and significant number of patients
followed by malignant neoplasm of digestive or- (52,7%) were not able to go to the bathroom alone
gans (24,7%) and malignancies of urinary tract (p<0,05) (Table 3).
(10,2%). Most patients reported that the time span Malignant disease was cause of psychological
from fist symptoms appearance to the examination disorders in many patients It was found that among
day was 6-12 months (32%), and only 8,5% of pa- numerous psychological disorders, most common
tients reported time span of 2-5 years (Table 2). were fear of death and pain found in 75,3% of pa-
Investigating the influence of malignant disease tients, followed by worry and anxiety reported by
on physical health, a statistically significant num- 65% of patients, depressive mood was found in
ber of patients (80%) reported that malignant dise- 52,7% of patients while least reported psychologi-
ase was restricting them in doing everyday activi- cal disorder was aggressive behavior found in just
ties such as home chores, kneeling etc. (p<0,05). 7,0%of patients (Table 4).
Statistically significant number of patients (73%)
Table 3. influence of malignant disease on physical health of oncology patients (No=number of patients)
Yes, very restricting Yes, partly Not restricting
Activity
No % No % No %
Moderate activity
(cleaning, vacuum- 320 80, 0 71 17,7 9 2,2
cleaning)
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Investigating the influence of malignant disease Using the regression coefficient it was found a
on invalidity it was found although not significant significant positive correlation between psycholo-
that 35% of patients reported invalidity. No signi- gical reactions such as anger and rage and the time
ficant difference was found between the sexes. Si- waited for home visit by a nurse or a doctor (r=-
gnificant number of patients 50,7% reported sleep 0,21, p<0,05). A significant negative correlation
disorders (p<0,05). Most common cause of sleep was found between psychological reactions such
disorder was pain (85,7%) and difficulty in breat- as anger and rage and satisfaction with palliative
hing (12,1%). Analyzing psychological reactions, care (r=-0,166, p>0,05), and between psychologi-
64 (16,1%) patients reported experiencing rage or cal reactions such as anger and rage and improve-
anger during the disease, while wish to talk was ment in general state upon palliative care arrival
reported by 177 (44%) patients. All patients who (r=-1,98, p<0,05) (Table 5).
belonged to age groups 18-24 years and 25-34 Analyzing the association between calls to the
years experienced both range and anger and also palliative care for patients physical disorders and
wish to talk. Out of patients who expressed anger symptoms relive no correlation was found using
during the disease, 46% belonged to age group 46- regression analysis between patients physical
54 years. Greatest percentage of patients who ex- needs such as pain, difficulties in breathing, bad
pressed whish to talk belonged to age group older appetite and decrease in symptoms of the disease
than 65 years. upon the palliative care arrival (Table 6).
Table 5. Regression analysis coefficient between observed parameters in palliative care service and
psychological reaction such as anger and rage in patients with malignant disease
Coefficient t P
Waiting for home visit by doctor or nurse 0.210 2.717 0.007
Satisfaction with palliative care service -0.166 -2.112 0.036
Improvement in general state upon palliative care arrival -0.198 -2.666 0.008
Symptoms relieve 0.002 0.034 0.973
Table 6. Regression analysis coefficients between physical needs parameters and symptoms ease in patients
with malignant disease
Coefficient t P
Pain 0.042 0.660 0.510
Breathing difficulties 0.008 0.135 0.893
Bad appetite -0.074 -1.379 0.169
Elimination of feces and urine -0.042 -0.742 0.458
Maintains of hygiene 0.005 0.095 0.924
Sleep difficulties -0.017 -0.263 0.793
vomiting -0.072 -1.014 0.311
bleeding 0.062 0.903 0.367
restlessness 0.034 0.547 0.585
immobility -0.023 -0.405 0.685
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Book preview
Osteophorosis, how prevent
and how treat it
OSTEOPOROZA, KAKO SPRIJEČITI, KAKO
LIJEČITI
Dijana Avdic, Edin Buljugic
KCU Sarajevo, Bosnia and Herzegovina
Journal of Society for development of teaching and business processes in new net environment in B&H 305
HealthMED - Volume 2 / Number 4 / 2008
306 Journal of Society for development of teaching and business processes in new net environment in B&H
HealthMED - Volume 2 / Number 4 / 2008
Journal of Society for development of teaching and business processes in new net environment in B&H 307
HealthMED - Volume 2 / Number 4 / 2008
UPUTSTVO ZA AUTORE
Sve rukopise treba slati na e-mail adresu healthmed_bih@yahoo.com
Svaki upućeni časopis dobija svoj broj i autor(i) se Rezultate treba prikazati jasno i logički, a njihovu značaj-
obavještavaju o prijemu rada i njegovom broju. Taj broj nost dokazati odgovarajućim statističkim metodama. U
koristit će se u svakoj korespondenciji. Rukopis tre- raspravi se tumače dobiveni rezultati i uspoređuju s po-
ba otipkati na standardnoj veličini papira (format A4), stojećim spoznajama na tom području. Zaključci moraju
ostavljajući s lijeve strane marginu od najmanje 3 cm. odgovoriti postavljenom cilju rada.
Sav materijal, uključujući tabele i reference, mora biti
otipkan dvostrukim proredom, tako da na jednoj strani REFERENCE
nema više od 2.000 alfanumeričkih karaktera (30 linija). Reference treba navoditi u onom obimu koliko su
Rad treba slati u triplikatu, s tim da original jedan pri- stvarno korištene. Preporučuje se navođenje novije li-
log materijala može biti i fotokopija. Način prezentacije terature. Samo publicirani radovi (ili radovi koji su pri-
rada ovisi o prirodi materijala, a (uobičajeno) treba da hvaćeni za objavljivanje) mogu se smatrati referencama.
se sastoji od naslovne stranice, sažetka, teksta, referenci, Neobjavljena zapažanja i lična saopćenja treba navoditi
tabela, legendi za slike i slika. Svoj rad otipkajte u MS u tekstu u zagradama. Reference se označavaju onim
Wordu i dostavite na disketi ili kompakt disku Redakcij- redom kako s pojavljuju u tekstu. One koje se citiraju
skom odboru, čime će te olakšati redakciju vašeg rada. u tabelama ili uz slike također se numeriraju u skladu s
redoslijedom citiranja. Ako se navodi rad sa šest ili ma-
NASLOVNA STRANA nje autora, sva imena autora treba citirati; ako je u citi-
Svaki rukopis mora imati naslovnu stranicu s naslo- rani članak uključeno sedam ili više autora, navode se
vom rada ne više od 10 riječi: imena autora; naziv usta- samo prva tri imena autora s dodatkom “et al”. Kada je
nove ili ustanova kojima autori pripadaju; skraćeni na- autor nepoznat, treba na početku citiranog članka ozna-
slov rada s najviše 45 slovnih mjesta i praznina; fusnotu čiti “Anon”. Naslovi časopisa skraćuju se prema Index
u kojoj se izražavaju zahvale i/ili finansijska potpora i Medicusu, a ako se u njemu ne navode, naslov časopisa
pomoć u realizaciji rada, te ime i adresa prvog autora ili treba pisati u cjelini. Fusnote–komentare, objašnjenja,
osobe koja će s Redakcijskim odborom održavati i kore- itd. Ne treba koristiti u radu.
spondenciju. STATISTIČKA ANALIZA
Testove koji se koriste u statističkim anaizama treba
SAŽETAK prikazivati i u tekstu i na tabelama ili slikama koje sadrže
Sažetak treba da sadrži sve bitne činjenice rada-svr- statistička poređenja.
hu rada, korištene metode, bitne rezultate (sa specifičnim
podacima, ako je to moguće) i osnovne zaključke. Sa- TABELE I SLIKE
žeci trebaju da imaju prikaz istaknutih podataka, ideja i Tabele treba numerirati prema redoslijedu i tako ih
zaključaka iz teksta. U sažetku se ne citiraju reference. prikazati da se mogu razumjeti i bez čitanja teksta. Svaki
Ispod teksta treba dodati najviše četiri ključne riječi. stubac mora imati svoje zaglavlje, a mjerne jedinice (SI)
moraju biti jasno označene, najbolje u fusnotama ispod
SAŽETAK NA BOSANSKOM JEZIKU tabela, arapskim brojevima ili simbolima. Slike također,
Prilog radu je i prošireni struktuirani sažetak (cilj), treba numerisati po redoslijedu kojim se javljaju u tekstu.
metode, rezultati, rasprava, zaključak) na bosanskom je- Crteže treba priložiti na bijelom papiru ili paus papiru, a
ziku od 500 do 600 riječi, uz naslov rada, inicijale imena crno-bijele fotografije na sjajnom papiru. Legende uz cr-
i prezimena auora te naziv ustanova na engleskom jezi- teže i slike treba napisati na posebnom papiru formata A4.
ku. Ispod sažetka navode se ključne riječi koje su bitne za Sve ilustracije (slike, crteži, dijagrami) moraju biti origi-
brzu identifikaciju i klasifikaciju sadržaja rada. nalne i na poleđini sadržavati broj ilustracije, prezime pr-
vog autora, skraćeni naslov rada i vrh slike. Poželjno je
CENTRALNI DIO RUKOPISA da u tekstu autor označi mjesto za tabelu ili sliku. Slike je
Izvorni radovi sadrže ove dijelove: uvod, cilj rada, potrebno dostavljati u TIFF formatu rezolucije 300 DPI.
metode rada, rezultati, rasprava i zaključci. Uvod je kra-
tak i jasan prikaz problema, cilj sadrži kratak opis svrhe KORIŠTENJE KRATICA
istraživanja. Metode se prikazuju tako da čitaoci omo- Upotrebu kratica treba svesti na minimum. Konven-
guće ponavljanje opisanog istraživanja. Poznate metode cionalne SI jedinice mogu se koristiti i bez njihovih de-
se ne navode nego se navode izvorni literaturni podaci. finicija.
308 Journal of Society for development of teaching and business processes in new net environment in B&H