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HealthMED

Volume 2 / Number 4 / 2008

Journal of Society for development of teaching and business processes in new net environment in B&H

EDITORIAL BOARD Sadržaj / Table of Contents


Editor Mensura Kudumovic
Secretaries Dzenana Jusupovic
Estimation of exhumed male persons’ stature based on
Azra Kudumovic
bayesian analysis
Technical editor Eldin Huremovic
Procjenjivanje visine ekshumiranih osoba muškog spola na
Lectors Mirnes Avdic
Adisa Spahic osnovu bayes-ove analize ................................... 187-191
Members Borut Poljsak Anisa Masovic, Nermin Sarajlic
(Ljubljana) ***
Josip Vincelj Liver function in patients with diabetes mellitus type 2
(Zagreb) and hyperlipidemia
Budimka Novakovic Funkcija jetre u oboljelih od dijabetes melitusa tip 2 i hiper-
(Novi Sad) lipidemijom .......................................................... 192-197
Farid Ljuca, Esad Alibasic, Sabina Nuhbegovic
Dragana Stoisavljevic
***
(Banja Luka)
Dietary factors as protectors or predictors for lung
Bakir Mehic
cancer: survey control study
(Sarajevo)
Faktori ishrane kao zaštitni faktori ili faktori rizika za karci-
Mirsada Hukic
nom pluća: pregledno kontrolno istraživanje ..... 198-205
(Sarajevo) Suvad Dedic, Nurka Pranjic
Slavica Ibrulj ***
(Sarajevo) Socio-Demographic and Health Characteristics of Fre-
Farid Ljuca quent Attender in Family Practice
(Tuzla) Sociodemografske i zdravstvene karakteristike čestih kori-
Emina Nakas-Icindic snika u porodičnoj medicini .............................. 206-213
(Sarajevo) Zaim Jatic, Dzanana Jatic
Fatima Jusupovic ***
(Sarajevo) Basal cell carcinoma of orbital region
Amira Duric Bazocelularni karcinom orbitalne regije .............. 214-218
(Sarajevo) Adi Rifatbegovic, Ermina Iljazovic, Nedret Mujkanovic, Azra
Aida Hasanovic Pasic, Emir Halilbasic, Mufid Burgic
(Sarajevo) ***
Dijana Avdic Effects of Specific Forms of Extramedullary Fixation in
(Sarajevo) Treatment of Diaphyseal Small Bone Fractures
Ago Omerbasic Efekti specifičnih oblika ekstramedularne stabilizacije na
(Sarajevo) sanaciju prijeloma dijafiza malih kostiju ......... 219-224
Zoran Hadziahmetovic, Narcisa Vavra – Hadziahmetovic
Address of the Sarajevo, Bolnicka BB ***
Editorial Board phone/fax 00387 33 640 407 Adipokines and Acute Coronary Syndrome
HealthMed_bih@yahoo.com Adipokini i Akutni Koronarni Sindrom ............. 225-233
Emina Nakas-Icindic, Amina Valjevac, Asija Zaciragic
Published by DRUNPP, Sarajevo
***
Volume 2 Number 4, 2008
Relation of disseased towards feding aditions vitamins
ISSN 1840-2291
and minerals
EBSCO Publishing (EP) USA
Odnos bolesnika prema prehrambenim dodacima vitamina
http://www.epnet.com
i minerala ............................................................ 234-238
Fatima Jusupovic, Arzija Pasalic, Jasmina Mahmutovic, Dijana
Avdic, Azra Kudumovic
HealthMED
Volume 2 / Number 4 / 2008

Journal of Society for development of teaching and business processes in new net environment in B&H

Sadržaj / Table of Contents


Does serum C-reactive protein concentration correlate Application of cognitive behavior therapeutic techniques
with blood pressure values in patients with probable for prevention of psychological disorders in police officers
Alzheimer’s disease? Primjena kognitivno-bihevioralnih psihoterapijskih
Da li koncentracija C-reaktivnog proteina u serumu tehnika u prevenciji psihičkih poremećaja
korelira sa vrijednostima krvnog pritiska kod pacijenata kod policajaca .................................................... 288-292
sa mogućom Alzheimerovom bolesti? ............... 239-245 Sibila Sijaric-Voloder, Dzejna Capin
Asija Zaciragic, Amina Valjevac, Orhan Lepara,
Azra Alajbegovic
*** CASE REPORT
The effects of spirulina platensis on biohumoral markers Trisomy 18 – Edwards’ syndrome
of renal function in gentamicin-induced acute tubular ne- Trisomija 18 – Edwardsov sindrom ..................... 293-297
crosis in rats Izeta Aganovic-Musinovic, Mirela Djurovic, Zimka Seremet
Efekti spiruline platensis na biohumoralne markere bubrežne
funkcije kod gentamicinom-uzrokovane akutne tubularne ne-
kroze kod štakora ....................................................... 246-252 PROFESSIONAL PAPERS
Nesina Avdagic, Esad Cosovic, Emina Nakas-Icindic, Zakira Influence of malignant disease on physical and mental he-
Mornjakovic, Asija Zaciragic, Almira Hadzovic-Dzuvo alth in patients with oncology disease
***
Uticaj malignog oboljenja na tjelesno i duševno zdravlje
Anthropometric values for boys aged 14 – 15 years who onkoloških bolesnika ................................................. 298-304
actively train basketball in comparison to boys of the same Amela Dzubur, Dragana Niksic, Esad Pepic,
age who do not train any sports Amna Pleho Kapic
Antropometrijske vrijednosti kod dječaka uzrasta 14 – 15
godina koji aktivno treniraju košarku u odnosu na dječake
iste dobi koji nemaju sportskih aktivnosti .......... 253-264 PREVIEW PAPERS
Dijana Avdic, Fatima Jusupovic, Mensura Kudumovic Osteophorosis, how prevent and how treat it
***
Osteoporoza, kako spriječiti, kako liječiti ....... 305-306
Methods of removing infectious and laboratory’s waste Dijana Avdic, Edin Buljugic
in clinic centers ***
Metode uklanjanja infektivnog i laboratorijskog otpada u
kliničkim centrima .............................................. 265-272
Instructions for the autors ............................... 307-308
Aida Vilic-Svraka, Zlatko Vucina,
Aida Filipovic-Hadziomeragic, Mirsada Mulaomerovic
***
Repulsing of harmful rodents in specific environmental
conditions of pharmaceutical factory
Suzbijanje štetnih glodavaca u specifičnim uvjetima na po-
dručju farmaceutske tvrtke ................................. 273-282
Suad Habes, Sandra Mramor-Muzevic, Sefkija Muzaferovic
***
The relationship between myocardial viability and col-
lateral circulation
Odnos vijabilnosti miokarda i
kolateralne cirkulacije ........................................ 283-287
Aida Hasanovic
HealthMED - Volume 2 / Number 4 / 2008

Estimation of exhumed male


persons’ stature based on
bayesian analysis
PROCJENJIVANJE VISINE EKSHUMIRANIH
OSOBA MUŠKOG SPOLA NA OSNOVU BAYES-
OVE ANALIZE
Anisa Masovic, Nermin Sarajlic
Institut of Forensic Medicine, Medical School, University of Sarajevo, Bosnia and Herzegovina

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

Journal of Society for development of teaching and business processes in new net environment in B&H 187
HealthMED - Volume 2 / Number 4 / 2008

Introduction In their study, they used samples from 545 whi-


te persons from World War II, using these data as
In the course of the recent war in Bosnia and reference samples, as well as from 177 exhumed
Herzegovina (1992-1995), more than 30,000 per- men killed during war operations in the territory
sons went missing and the search for more than of Bosnia and Herzegovina and Croatia (7). As
10,000 persons is still going on. they did not have data on the stature of the exhu-
In addition to DNA analysis, identification also med persons while still alive, they were using data
implies the designing of a biological profile, which from literature (8).
implies the determining of sex and the estimati- Everything mentioned thus far indicates to the
on of age and stature. Even today identification necessity of developing models for estimating ex-
is greatly hampered by a large number of mixed humed male persons’ stature based on a Bayesian
skeletal remains exhumed from mass graves and analysis and their correlation with the formulae
especially from secondary and tertiary mass gra- obtained by Sarajlić and associates (6) and Ross
ves (1,2). Stature estimation is one of the most im- and Konigsberg (7), which was the main objective
portant procedures in the forensic-anthropologist of this study.
analyses of skeletal remains.
Since 1996, the Trotter and Gleser’s formulae
(3) developed from American Whites have been Materials and methods
used to estimate the stature of the Bosnia and Her-
zegovina population, although the authors them- The research included 105 exhumed and identi-
selves warned about the injudicious use of popu- fied male persons from the territory of the northw-
lation specific formulae on other populations, as est Bosnia at the age ranging from 19 to 65 years.
well as about the obligatory taking into account a Since not all the persons had all the bones, the fol-
secular trend in the development of a population lowing was used for research: 78 left humeri, 105
(4). left femurs, 96 left tibia, 80 left fibulas. Maximum
The development of a sceleton is influenced by lengths of all four bones were measured (9).
many factors which make differences in the pro- Due to an insignificant difference in the length
portion of bones in different geographical areas of the left and right side of the skeleton, the left
and it is these features that provide for a possi- side was arbitrarily taken for the research. The
bility to establish differences among populations, stature of persons while still alive was obtained
groups and individuals (5). based on antemortem data collected from their fa-
Stature estimation formulae developed from milies.
the Bosnia and Herzegovina population were be- Data on the length of bones and the stature of
ing obtained by a regressive analysis method (6), 369 exhumed and identified persons from the Sa-
which is considered to give more distinctive vari- rajlić and associates’ study were taken as a refe-
ations as the distance from the mean value is gre- rence sample (10).
ater, thereby contributing to more imprecise esti- The data were processed by applying descri-
mation of the stature of small and tall persons. In ptive statistics, regressive-correlative analysis and
addition to the aforementioned, the length of long models as per Bayes’ Theorem, based on which
limb bones were being obtained through readings formulae for stature estimation were developed on
of x-ray photographs of cadavers, which also co- the basis of the length of long limb bones.
uld have influence on obtaining of precise results The prediction based on the Bayesian analysis
(6). Therefore, a need arose for the development from this study was compared with the models
of formulae that would give smaller deviations presented by Ross and Konigsberg (7) and Sa-
and more precise data. In 2002, Ross and Konigs- rajlić and associates (10), through calculation of
berg presented new formulae for estimation of the non-explained variability. A lower non-explained
stature of people from the Balkans by applying a variability meant the prediction model was more
Bayesian analysis and using bones of unidentifi- reliable and more accurate.
ed Bosnians and Croats, victims of the recent war.

188 Journal of Society for development of teaching and business processes in new net environment in B&H
HealthMED - Volume 2 / Number 4 / 2008

Results

The formula, which, as per Bayes’ Theorem, is


applied for stature estimation based on the length
of long bones, is as follows (7)

LH: left humerus


where: Graph 1. Comparison of original data with esti-
α and β – are coefficients of a simple linear mation for humerus
regressive model with stature as an
independent variable and the length of
bones as a dependant variable in a reference
sample
- is mean stature in an analysed sample
- is a stature variant in an analysed (target)
sample
- is a stature variant in a reference sample
r - is a coefficient of a simple linear LF: left femur
correlation between the stature and the Graph 2. Comparison of original data with esti-
length of a bone for a reference sample mation for femur
lb - actual value of the length of a bone for an
observed case

Based on the above presented application of


the Bayes’ Theorem, formulae for predicting stat- LT: left tibia
ure were developed based on the length of long Graph 3. Comparison of original data with esti-
bones (in centimetres) for humerus (LH), femur mation for tibia
(LF), tibia (LT) and fibula (Lfib), with the indica-
tion of standard error in estimation (+/-):

ŝ = 55.77 + 3.59 LH +/- 4.52


ŝ = 55.75 + 2.663 LF +/- 3.62
ŝ = 70.66+2.744 LT +/- 3.58
ŝ = 61.58 + 3.018 Lfib +/- 3.94

Deviations of performed estimations from


original measurings from the sample are graphi- Lfib: left fibula
cally presented by dispersion clouds. Graph 4. Comparison of original data with esti-
mation for fibula

Journal of Society for development of teaching and business processes in new net environment in B&H 189
HealthMED - Volume 2 / Number 4 / 2008

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

Journal of Society for development of teaching and business processes in new net environment in B&H 191
HealthMED - Volume 2 / Number 4 / 2008

Liver function in patients with


diabetes mellitus type 2 and
hyperlipidemia
FUNKCIJA JETRE U OBOLJELIH OD DIJABETES
MELITUSA TIP 2 I HIPERLIPIDEMIJOM
Farid Ljuca1, Esad Alibasic2, Sabina Nuhbegovic1
1
Department of physiology, Medical faculty, University of Tuzla, Bosnia and Herzegovina
2
Family medicine department, Dom zdravlja Kalesija, Bosnia and Herzegovina

Summary Conclusion: Poorly regulated glucose homeo-


stasis and hyperlipidemia may contribute to liver
Introduction: Liver plays an important role in injury. It is necessary to make, from time to time,
metabolism of glucose and lipids. There is a mu- screening of liver function and lipid profile in pa-
tual relation between liver disease and diabetes. tients with diabetes mellitus type 2.
Lipid and glucose metabolism abnormalities may Key words: diabetes mellitus type 2, liver
be a consequence of liver disease and reverse. Aim function, hyperlipidemia
of this research was to analyze the liver function
in patients with diabetes mellitus type 2 and hy-
perlipidemia. Sažetak
Patients and methods: This research has been
retrospective-prospective study in which 120 pati- Uvod: Jetra igra važnu ulogu u metabolizmu
ents have been analyzed divided into 2 groups: 1) glukoze i masti. Postoji uzajamni odnos između
patients with diabetes mellitus type 2 and hyper- bolest jetre i dijabetesa. Abnormalnosti metabo-
lipidemia (n=60), 2) patients with diabetes melli- lizma masti, glukoze mogu biti posledica bolesti
tus type 2 and with normal lipid status (n=60). In jetre i obrnuto. Cilj ovog istraživanja je bio anali-
this study only patients who had diabetes mellitus zirati funkciju jetre u oboljelih od dijabetesa tipa
type 2 diagnosed more than two years were inclu- 2 sa hiperlipidemijom.
ded. To analyze liver function we have measured Pacijenti i metode: Ovo istraživanje je retro-
following parameters: bilirubin (total, conjugated spektivno-prospektivna studija u kojoj je analizi-
and unconjugated), aspartate-amino transferase rano 120 pacijenata koji su podijeljeni u 2 grupe:
(AST), alanine-amino transferase (ALT), alkaline 1) oboljeli od dijabetesa tipa 2 sa hiperlipidemijom
phosphatase (ALP), gamma-glutamyl transpepti- (n=60), 2) oboljelih od dijabetesa tipa 2 sa nor-
dase (GGT), albumin, prothrombin time, HbsAg, malnim lipidnim statusom (n=60). U ovu studiju
antiHbsAg, antiHCV. Data have been analyzed by su uključeni samo oni oboljeli od dijabetesa tipa
Student t, Chi square or Fischer’s test 2 koji su na terapiji više od dvije godine. Za pro-
Results: This study has shown that liver functi- cjenu stanja funkcije jetre u svim grupama pacije-
on in patients with diabetes mellitus type 2 and hy- nata urađena je analiza slijedećih funkcionalnih
perlipidemia was more injured than in those with parametara: bilirubini (ukupni, konjugovani i ne-
normal lipid status. konjugovani), aspartat-amino transferaza (AST),

192 Journal of Society for development of teaching and business processes in new net environment in B&H
HealthMED - Volume 2 / Number 4 / 2008

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

Journal of Society for development of teaching and business processes in new net environment in B&H 193
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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

Serum concentration of aspartat aminotransfe-


rase (AST) was higher in patients with DM 2 ha-
ving increased level of lipid status parameters than
in those with normal ones (p<0,001).

Figure 4. Serum ALP level in patients with DM


2 and increased serum lipid parameters

Platelets counts in serum in patients with DM 2


and increased serum lipid parameters and in those
with normal ones have not been statistically dif-
ferent.
Figure 1. Serum AST level in patients with DM 2
and increased serum lipid parameters

Serum level of ALT was statistically higher in


patients with DM 2 and increased serum lipid para-
meters than in those with normal ones (p<0,0001).

Figure 5. Platelet count in patient with DM 2


and increased serum lipid parameters

Prothrombine time was in referent range and


had no difference among values in patients with
Figure 2. Serum level of ALT in patients with DM DM 2 and increased serum lipid parameters and in
2 and increased serum lipid parameters those with normal ones.

194 Journal of Society for development of teaching and business processes in new net environment in B&H
HealthMED - Volume 2 / Number 4 / 2008

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.

Figure 8. Serum unconjugated bilirubin level in


patients with DM 2 Figure 11. Serum albuminlevel in patients with
DM 2
Serum conjugated bilirubin level in patients
with DM 2 and increased serum lipid parameters There was positive correlation among Hb1c,
was statistically higher than in those with normal serum LDL, triglycerides and cholesterol level
serum lipid parameters (p<0,001). and serum AST, ALT and conjugated bilirubin le-

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HealthMED - Volume 2 / Number 4 / 2008

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-

196 Journal of Society for development of teaching and business processes in new net environment in B&H
HealthMED - Volume 2 / Number 4 / 2008

Literature 13. Koshiyama H. Lipid management--treatment goal


and strategy. Nippon Rinsho. 2006; 64(11):2102-
1. Beckman JA (2002) Diabetes and atherosclerosis. 6.
JAMA 287: 2570-2581. 14. Lund SS, Petersen M, Frandsen M, Smidt UM,
2. Kernan WN, Inzucchi SE (2004) Type 2 Diabetes Parving HH, Vaag AA, Jensen T. Sustained post-
Mellitus and Insulin Resistance: Stroke Prevention prandial decrease in plasma levels of LDL cho-
and Management. Curr Treat Options Neurol 6: lesterol in patients with type-2 diabetes mellitus.
443-450. Scand J Clin Lab Invest. 2008; 16:1-14.
3. Ferrannini E, Lanfranchi A, Rohner-Jeanrenaud F, 15. Khan SR, Ayub N, Nawab S, Shamsi TS. Trigly-
Manfredini G, VandeWerve G (1990) Influence of ceride profile in dyslipidaemia of type 2 diabetes
long-term diabetes on liver glycogen metabolism in mellitus. J Coll Physicians Surg Pak. 2008;18(5):
the rat. Metabol 39: 1082-1088. 270-3.
4. Silverman JF, O’Brien KF, Long S, Leggett N, Kha- 16. Chapman MJ. Metabolic syndrome and type 2
zanie PG, Pories WJ, Norris JR, Caro JF (1990) diabetes: lipid and physiological consequences.
Liver pathology in morbidly obese patients with Diab Vasc Dis Res. 2007; 4 Suppl 3:S5-8.
and without diabetes. Am J Gastroenterol 85:1349- 17. Gadi R, Samaha FF. Dyslipidemia in type 2 diabe-
1355. tes mellitus. Curr Diab Rep. 2007;7(3):228-34.
5. O’Connor BJF, Katbamna B, Tavill AS (1997) No-
nalcoholic fatty liver (NASH syndrome). Gastroen-
terol 5: 316-329. Corresponding author:
6. Bacon BR, Farahvash MJ, Janney CG, Neuschw- Farid Ljuca
ander-Tetri BA (1994) Nonalcoholic steatohepati- Zavod za fiziologiju
tis: an expanded clinical entity. Gastroenterol 107: Medicinski fakultet
1103-1109. Bosna i Hercegovina
e-mail: farid.ljuca@untz.ba
7. Zein NN, Abdulkarim AS, Wiesner RH, Egan KS,
Persing DH (2000) Prevalence of diabetes mellitus
in patients with end-stage liver cirrhosis due to he-
patitis C, alcohol, or cholestatic disease. J Hepatol
32(2): 209-17.
8. Lebovitz HE, Kreider M, Freed MI (2002) Evalua-
tion of Liver Function in Type 2 Diabetic Patients
During Clinical Trials. Diebet Care 25: 815-821.
9. Baig NA, Herrine SK, Rubin R (2001) Liver disease
and diabetes mellitus. Clin Lab Med 21(1): 193-
207.
10. Anonymous (2003) The Expert Committee on the
Diagnosis and Classification of Diabetes Mellitus.
Report of the Expert Committee on the Diagnosis
and Classification of Diabetes Mellitus. Diabet
Care 26(suppl 1): S5-S20.
11. Amarapurkar D, Das HS (2002) Chronic liver
disease in diabetes mellitus. Trop Gastroenterol
23(1): 3-5.
12. Afkhami-Ardekani M, Shojaoddiny-Ardekani A.
Effect of vitamin C on blood glucose, serum lipids
& serum insulin in type 2 diabetes patients. Indian
J Med Res. 2007;126(5):471-4.

Journal of Society for development of teaching and business processes in new net environment in B&H 197
HealthMED - Volume 2 / Number 4 / 2008

Dietary factors as protectors


or predictors for lung cancer:
survey control study
FAKTORI ISHRANE KAO ZAŠTITNI FAKTORI
ILI FAKTORI RIZIKA ZA KARCINOM PLUĆA:
PREGLEDNO KONTROLNO ISTRAŽIVANJE
Suvad Dedic¹, Nurka Pranjic²
¹ Clinic of lung disorders and tuberculosis, University Clinic Centre Tuzla, Bosnia and Herzegovina
² Department of Occupational Medicine, Medical school University of Tuzla, Bosnia and Herzegovina

Summary ment of lung carcinoma was deficiency of olives


(OR=1.26), grapefruit (OR=1.47), fish (OR=1.45)
Introduction: It is estimated that one third of and garlic luk (OR=1.38).
the lung cancers is due to the nutritional factors. Conclusion: Lung cancer can be prevented by
The research is conducted with the aim of identi- consumption of adequate alimentation rich with
fying risk, as well as protective factors in alimen- protective factors. Those are especially beans’
tation. Those are related to the occurrence of lung fibers, grapefruit, garlic, olives etc. It seems that
cancer at Tuzla Canton interviewees. the greatest obstacle at choice of nutritive which
Methodology: Interviewees were two hundred would act as protective factors for the develop-
patients of the Tuzla Lung Diseases Clinics. Ex- ment of lung cancer is low social status, as well
perimental group were hundred patients with lung as differences between environments one lives in,
cancer disease. Control group were hundred pa- city vs. village.
tients who did not have lung cancer disease. There Key words: nutritive factors, alimentation,
were no significant differences between experi- lung cancer.
mental and control groups by age and sex. The
data was collected by using anonymous question-
naire. It contains social - demographic, and ques- Sažetak
tions related to the consumption of specific nutri-
tive are alimentation. Time span for the consump- Uvod: Procijenjeno je da su faktori ishrane
tion of nutritive was a day, week, month and year, odgovorni za nastanak jedne trećine karcinoma
and amount of consumption of them. pluća. Istraživanje je provedeno s ciljem da se ot-
Results: Incidence of lung cancer was signifi- kriju faktori rizika, kao i zaštitni faktori u ishrani,
cantly higher among interviewees living in rural a koji su u vezi sa nastankom karcinoma pluća u
areas in comparison to the ones living in urban ar- ispitanika Tuzlanskog kantona.
eas (63% vs.30%, P =0.001). There is a significant Metode: Ispitanike je činilo 200 pacijenata
difference among different social statuses, so that Klinike za plućne bolesti Tuzla. Eksperimentalnu
ones with worse social status were lung cancer skupinu činilo je 100 pacijenata kojima je dijagno-
patients (Z=-4.916, P=0.001). Among nutritional sticiran karcinom pluća, a kontrolnu skupinu 100
factors, the one serving as predictor for develop- pacijenata kojima nije dijagnosticiran karcinom

198 Journal of Society for development of teaching and business processes in new net environment in B&H
HealthMED - Volume 2 / Number 4 / 2008

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

204 Journal of Society for development of teaching and business processes in new net environment in B&H
HealthMED - Volume 2 / Number 4 / 2008

Literature 13. Gao CM, Tajima K, Duroishi T, et al. Protective


effects of raw vegetables and fruit against lung
1. Pranjić N. Bolesti modernog doba i ishrana (Dise- cancer among smokers and ex- smokers: a case-
ases of modern time). U: Pranjić N (ur) Zdravstve- control study in the Tokai area of Japan. J Cancer
na ekologija (Environmental health). Medicinski Res 1993; 84: 594-00.
fakultet Univerziteta u Tuzli 2006; pp 111-120. 14. Fraser GE, Beeson WL, Philips RL. Diet and lung
2. Shibata A, Paganini-Hill A, Ross RK, et al. Intake cancer in California seventh day adventists. Am J
of vegetables, fruits, beta-carotene, vitamin C and Epidemiol 1991; 133: 683-93.
vitamin supplements and cancer incidence among 15. Steinmetz KA, Potter JD, Folsom AR.Vegetables,
the elderly: a prospective study. Br J Cancer 1992; fruit and lung cancer in Iowa women’s health stu-
66:673-79. dy 1993; 53: 536-43.
3. Niki E. Interaction of ascorbate and Alpha tocophe- 16. Feskanich D, Ziegler RG, Michaud DS, et al. Pro-
rol. In: Third Conference on vitamin C. Burns J. J. spective study of fruit and vegetable consumption
Rivers J.M. Machlin JL (eds). The N. York Academy and risk of lung cancer among men and women. J
of sciences. N. York 1997, pp 123-31. Natl Cancer Inst 2000; 92: 1812-23.
4. Margetts BM, Jackson AA. The determinants of pla- 17. Kromhout D. Essential micro-nutritients in rela-
sma beta- carotene: interaction between smoking tion to carcinogenesis. Am J Clin Nutr 1987; 45:
and other lifestyle factors. Eur J Clin Nutr 1996; 1361-67.
50:236-38.
18. Churg A. Lung cancer cell type and occupational
5. Axelsson G, Liljeqvist T, Andersson L, et al. Dietary exposure. In: Samet JM (ed) Epidemiology of lung
factors and lung cancer among men in west Swe- cancer. Marcel Dekker New York, Ny 1994; pp
den. Int J Epidemiol 1996; 25:32-39. 413-36.
6. Bandera EV, Freudenheim JL, Marshall JR, et al. 19. Mayne ST, Janerich DT, Greenwald P. Et al. Di-
Diet and alcohol consumption and lung cancer risk etary beta- carotene and lung cancer risk in US
in the New York State Cohort (United States). Can- non- smokers. J Natl Cancer Inst 1994; 86: 33-
cer Causes Control 1997; 8:828-40. 38.
7. Darby SC, Whitley E, Doll R, et al. Diet, smoking 20. Voorrips LE, Goldbohm RA, Verhoeven DT, et al.
and lung cancer: a case-control study of 1000 ca- Vegetable and fruit consumption and lung cancer
ses and 1500 controls in South-West England. Br J risk in the Netherlands cohort study on diet and
Cancer 2001; 84:728-35. cancer. Cancer Causes Control 2000; 11: 101-
8. Bjelke E. Dietary vitamin A and human lung can- 15.
cer. Int J Cancer 1975; 15: 561-65. 21. Boffetta P, Agudo A, Ahrens W, et al. Multi canter
9. Peto R, Doll R, Buckley JD, et al. Can diatary beta- case- control study of exposure to environmental
carotene materially reduce human cancer rates? tobacco smoke and lung cancer in Europe. J Nat
Nature 1981; 290: 201- 208. Cancer Inst 1998; 90:1440-50.
10. Fontham ET, Pickle LW, Hienszel W, et al. Dietary
vitamins A, and C, and lung cancer among men in
west Sweden. Int J Epidemiol 1996; 25: 32-39. Corresponding author:
Suvad Dedic
11. Ferković V. Registar malignih neoplazmi Tuzlan-
Clinic of lung disorders and tuberculosis,
skog kantona 2001/ 2002 (Register of malign di-
University Clinic Centre Tuzla,
seases in Tuzla Canton 2001/ 2002). Tuzla, Print-
Bosnia and Herzegovina
Com 2004.
email: dedicsuvad@gmail.com
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268- 74.

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HealthMED - Volume 2 / Number 4 / 2008

Socio-Demographic and Health


Characteristics of Frequent
Attender in Family Practice
SOCIODEMOGRAFSKE I ZDRAVSTVENE
KARAKTERISTIKE ČESTIH KORISNIKA U
PORODIČNOJ MEDICINI
Zaim Jatic1,2, Dzanana Jatic1
1
Public Institution Medical Centre of the Sarajevo Canton, Bosnia and Herzegovina
2
Medical Faculty of Sarajevo University, Department for Family Medicine, Bosnia and Herzegovina

Summary Conclusion: FAs are usually characterized as


older people with a bad socio-economic back-
Aim: to estimate the prevalence of frequent at- ground, living in the rural or suburb areas with a
tenders (FA), comparing to their socio-demograph- poor physical and mental health. It is crucial for
ic characteristics, health indicators and health care the family medicine team to develope a strategy
service usage indicators. how to deal with the FA.
Methods: Retrospective and longitudinal Key words: frequent attendees, office visits,
medical charts review of patients registrated in Family medicine, general practice, primary health
four family medicine offices. Medical charts of care, health indicators, socio-demographic charac-
434 randomly chosen patients were screened for teristics,
socio-economic data, health status indicators and
health care system usage indicators.
Results: Prevalence of FA is 23,3%. Significant Sažetak
correlation has been found between frequent visits
and elderly people (t=2,1, df=432, P<0,05), retired Cilj: Procjena prevalencije čestih korisnika
and unemployed people (r=0,104, P<0,05), and (FA) i poređenje njihovih socio-demografskih ka-
people living in rural and suburban areas.(r=0,123, rakteristika, indikatora zdravlja i indikatora upo-
P<0,01) FAs had more chronic diseases. (F=51,6; trebe zdravstvenog sistema.
P<0,01) The most associated diseases found in FA Metod: Retrospektivno, longitudinalno ispiti-
are neoplasms (OR=2,86;95%CI:1,42,5,80), dia- vanje zdravstvenih kartona pacijenata registrira-
betes mellitus (OR= 2,16;95%CI:1,53,3,04) and nih u timovima porodične medicine. Pregledani
mood disorders (OR=2,03; 95%CI:1,13,3,63). FA su socio-ekonomski podaci, indikatori zdravlja i
significantly use more health care services to oth- indikatori upotrebe zdravstvenog sistema u 434
ers (P<0,001). slučajno izabrana kartnona.
Discussion: FAs use significantly more health Rezultati: Prevalencija čestih korisnika je
care system services. Notably, high percentages 23,3%. Nađena je signifikantna povezanost izme-
of the referrals, hospital days, sick leave days and đu čestih korisnika i starije dobi (t=2,1, df=432,
home visits were observed. P<0,05), penzionisanih i nezaposlenih (r=0,104,

206 Journal of Society for development of teaching and business processes in new net environment in B&H
HealthMED - Volume 2 / Number 4 / 2008

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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HealthMED - Volume 2 / Number 4 / 2008

3. Determination of the health features of Results


frequent attenders and comparison to not-
frequent attenders; 434 medical charts out of 10253 registered pa-
4. Comparison of the health care services tients, belonging to above mentioned four FM of-
between FA and NFA. fices have been analyzed. The sample was consist-
ed of 273 female (62.9%) and 161 men (37,1%).
The average age was 59.27 years (SD = 17.46,
Methods min = 7, max = 97). Patients from the sample had
5706 visits in the year of 2006. The Q3 value was
Retrospective, longitudinal study based on data 19 for men and 16 for women regarding the visits.
obtained from 434 randomly selected medical The number of FAs with more visits than Q3 was
charts belonging to patients from four family me- 101 (23.3% of all analyzed medical charts).
dicine offices (1 urban, 2 suburban and 1 rural) in Table 1. Statistics of patients’ visits
Canton of Sarajevo. There are twelve doctors in Results Female Male Total
these family medicine offices and 10253 registe- Number of patients 273 161 434
red patients. Medical charts of patients who had Number of visits 3439 2267 5706
only one visit in 2006 are not included in the sur- Mean 12,6 14,0 13,15
vey. Median 11 13 12
The medical sheet for a period of one year Std. Deviation 7,7 8,9 8,17
(2006) has been analyzed according to three main Minimum 2 2 2
parameters: Maximum 47 64 64
a) Socio-demographic features: age, sex, Percentiles 25 7 8 8
marital status, household members, place 50 10 13 12
of residence; 75 16 19 17
b) Health indicators: smoking status, number
of chronic diagnosis, the leading diseases;
c) Indicators for use of health care resources: Socio-Demographic Characteristics
the number of visits during a year of 2006,
the number of prescribed drugs, the number There were no significant differences between
of referrals to specialists, the number of the numbers of visits of female and male patients.
hospital days, number of days of sick leave, Female sex representatives do not use the frequent
the number of home visits. visits services as much. (r=0,035, P>0,05). How-
Continuous data is presented through out a de- ever, significant differences were found between
scriptive statistics, ie mean and standard deviation age groups.(r=0,105, P<0,05). The number of FA
(SD). Pearson’s correlation coefficient was used grows linearly with increasing of the age. Mean
for measuring correlation between FA and NFA, as age of FAs (M=62,5, SD 14,3) is significantly hig-
well as demographic data and presence of chronic her than mean age of NFA. (M=58, 3, SD 18,2)
diseases. Mann-Whitney Test was used for testing (t=2, 1, df=432, P<0,05) Work status of the pati-
means of health service usage indicators because ents also has a significant impact on the number
data hadn’t been regularly distributed. Odds ratio of frequent visits. (r=0,104, P<0, 05) The largest
and 95% confidence interval were calculated to percent of the FA is in the group of pensioners (M
measure the strength of the association between of age=68,5, SD=10,8), and a group of adults wit-
the presence of disease and the occurrence of fre- hout regular jobs (M of age=44,9, SD=10,2).
quent visits. Small and non-significant differences were
All analyses above were calculated using the found between groups of different marital status.
statistical package SPSS for Windows release (r=0,048, P>0,05). There were not significant dif-
(15.0.). ferences between groups of type of households
(r=0,036, P>0,05)

208 Journal of Society for development of teaching and business processes in new net environment in B&H
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Table 2 Socio-demographic characteristics


FA NFA Total
Female 66 (24,2%) 207 (75,8%) 273 (62,9%)
Male 35 (21,4%) 126 (78,6%) 161 (37,1%)
Age groups
- ≤19 1 (5,6%) 17 (94,4%) 18 (4,1%)
- 20-39 5 (13,9%) 31 (86,1%) 36 (8,3%)
- 40-59 33 (23,7%) 106 (76,3%) 139 (32,0%)
- 60-79 52 (25,2%) 154 (74,8%) 206 (47,5%)
- ≥80 10 (28,6%) 25 (71,4%) 35 (8,1%)
Working status
- Pensioner 73 (26,2%) 206 (73,8%) 279 (64,3%)
- Employed 15 (16,8%) 63 (47,5%) 78 (18,0%)
- Biro 12 (20,3%) 47 (79,7%) 59 (13,6%)
- Student 0 (0%) 3 (100%) 3 0,7%)
- Disciple 1 (6,7%) 14 (93,3%) 15 (3,5%)
Marital status
- Married 65 (24,3%) 202 (75,7%) 267 (61,5%)
- Widow/er 2 (11,8%) 15 (88,2%) 17 (3,9%)
- Divorced 28 (28,9%) 69 (71,1%) 97 (22,4%)
- Never married 6 (11,3%) 47 (88,7%) 53 (12,2%)
Household
- Family (spouse and/or children) 81 (24,5%) 250 (75,5%) 331 (76,3%)
- Single 14 (17,9%) 64 (82,1%) 78 (18,05)
- Other 6 (24,0%) 19 (76,0%) 25 (5,8%)

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

Table 3 Most common diseases of FA


Disease FA NFA Total
1 Essential hypertension (I10)** 75 (74,3%) 178 (53,5%) 253 (58,3%)
2 Diabetes mellitus (E10-E11)** 38 (37,6%) 58 (17,4%) 96 (22,1%)
3 Other forms of heart disease (I30-I52)** 30 (29,7%) 54 (16,2%) 84 (19,4%)
4 Mood disorders (F30-F39)* 16 (15,8%) 26 (7,8%) 42 (9,7%)
5 Neoplasms (C00-D48)** 13 (12,9%) 15 (4,5%) 28 (6,5%)
* P<0,05
** P<0,01

Table 4. Health service usage indicators (data for year 2006)


FA NFA Total
Indicator*
N % M SD N % M SD N M SD
Office Visits 2489,0 43,6 24,6 7,4 3217,0 56,4 9,7 4,3 5706,0 13,1 8,2
Medications 527,0 34,5 5,2 2,8 999,0 65,5 3,0 1,9 1526,0 3,5 2,3
Specialists Referrals/
876,0 45,0 8,7 13,4 1072,0 55,0 3,2 3,1 1948,0 4,5 7,3
consultation
Referrals in the
184,0 33,9 1,8 1,4 358,0 66,1 1,1 1,0 542,0 1,2 1,2
laboratory
Days spent in hospital 627,0 50,5 6,2 13,0 614,0 49,5 1,8 7,6 1241,0 2,9 9,3
Sick leave days** 1193,0 53,4 79,5 106,0 1042,0 46,6 16,5 40,4 2235,0 29,5 28,9
Home visits 40,0 54,1 0,4 1,0 34,0 45,9 0,1 0,4 74,0 0,2 0,6
*P<0,01 for all indicators
** Counted for the group of patients with regular jobs

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
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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
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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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e-mail: jaticzaim@gmail.com
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597-604.

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Basal cell carcinoma of orbital


region
BAZOCELULARNI KARCINOM ORBITALNE REGIJE
Adi Rifatbegovic1*, Ermina Iljazovic2, Nedret Mujkanovic1, Azra Pasic1, Emir Halilbasic1, Mufid Burgic1
1
Department of plastic and reconstructive surgery, Surgery clinic, University clinical center of Tuzla,
Bosnia and Herzegovina
2
Department of pathology, Policlinic for laboratory diagnostics, University clinical center of Tuzla,
Bosnia and Herzegovina

Summary for men and women diagnosed with this tumor,


and in 80% of cases the clinical stage at which ba-
Basal cell carcinoma is slow growing malignant sal cell carcinoma was diagnosed was I.
skin tumor characterized by uncontrolled growth Key words: basal cell carcinoma, orbital re-
of the basal skin layer. It represents very common gion
type of tumor that rarely yields in metastases. It
usually found in craniofacial region, in locations
that make rather simple surgical procedures ap- Sažetak
pear complex, such as orbital and nasal regions.
The most effective treatment of this tumor is radi- Bazocelularni karcinom je maligni tumor kože,
cal surgical excision, sometimes in cases of well sporog rasta koji nastaje nekontroliranim buja-
progressed tumor invasion it also includes and/or njem temeljnog (bazalnog) sloja kože. Predstavlja
radiotherapy, rarely even chemotherapy. The goal vrlo čest, tumor koji rijetko metastazira. Najčešće
of this retrospective study was to determine the se pojavljuje na kraniofacijalnim regijama i to vrlo
prevalence of this tumor in different parts of crani- često na lokalizacijama koje su vrlo kompleksne
ofacial region, its distribution in terms of patient’s za hirurški rad, kao što su orbitalna regija i nos.
gender and age, as well as clinical stage in time Najefikasnija terapija tumora ove regije je radikal-
of the diagnosis. In statistical analysis of acqui- na hirurška ekscizija a kod veoma uznapredova-
red data the methods of descriptive statistics were lih stadija hirurška i/ili radio terapija a nekada i
used, and for the proper level of results significan- hemioterapija. Cilj rada je da se utvrdi učestalost
ce p was made to be <0,001. ovog karcinoma u odnosu na druge dijelove kra-
The basal cell carcinoma represents the most niofacijalne regije. Njegova polana i starosna di-
common epithelial non-melanocytic tumor in this stribucija i klinički stadij u kojem je bolest dija-
region. 127 cases of basal cell carcinoma located gnostikovana. Ovaj rad predstavlja retrospektivnu
in craniofacial region were analyzed through data studiju. U statističkoj obradi dobijenih podataka
obtained during the 5-year period (2004. – 2000.). koristit će se metode deskriptivne statistike sa
Data was obtained from different aspects of me- izračunavanjem srednje vrijednosti i standardne
dical history records, clinical findings, diagnostic devijacije, a za utvrđivanje značajnosti razlika ko-
procedure used, and through surgical treatment of ristit će se χ2 test uz prihvatanje signifikantnosti
choice. 11% of all diagnosed basal cell carcinoma na nivou p<0,001.
found in craniofacial region were those localized Ovaj tumor predstavlja najčešći maligni epi-
in orbital subregion. Gender distribution showed telni nemelanositni tumor u ovoj regiji. U ovom
female dominance in male to female ratio of 1:1,5. radu anlaizirali smo 127 dijagnostikovanih bazo-
There was no significant difference between ages celularnih karcinoma u petogodisšnjem vremen-

214 Journal of Society for development of teaching and business processes in new net environment in B&H
HealthMED - Volume 2 / Number 4 / 2008

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

of “tumor-free” margin varies depending on patho-


histological type of tumor, as well as on size and
tumor localization, but 3-5 mm margin usually suf-
fice. When large defect is present after the removal
of tumor, a reconstructive surgical treatment is nec-
essary. Histomorphologic analysis of excised lesion
and resection margins was done using standard 5µm
thick paraffin cut slices, dyed using standard H&E
Picture 3. Postoperative result method. Imunohistochemical analysis was done for
a certain number of undifferentiated malignant pri-
mary and secondary lesions using three-step imuno-
Aim peroxidase method with streptavidine. In statistical
analysis of acquired data the methods of descriptive
The aim of this study was to determine the prev- statistics were used including χ2 test used in diffe-
alence of basal cell carcinoma (BCC) occurring rence determination, and for the proper level of re-
in orbital region diagnosed in University Clinical sults significance p was made to be <0,001.
Center of Tuzla during 5-year period (01.01.2000.
– 31.12.2004.), its distribution in terms of patient’s
gender and age, as well as its clinical stage in time Results
of the diagnosis. The study included 127 cases of
BCC localized in orbital region during the 5-year During 5-year period (01.01.2000. – 31.12.2004.)
time period. It is a retrospective study during in University clinical center of Tuzla, 881 basal cell
which patient medical history was used for acquir- carcinoma (BCC) occurring in craniofacial region
ing general data, as well as data on clinical find- was diagnosed. 127 of them were localized in or-
ing, diagnostic procedures and surgical treatment. bital region (11%), 51 of which were diagnosed in
Following variables were analyzed: general patient men, and 76 in women. Mean age for both male and
data, age, gender; clinical finding: characteristics of female was about the same (Table 1.).
suspected lesion (anatomical localization and size). This study showed that BCC was usually veri-
Proper diagnosis was based on adequate biopsy and fied in clinical stage I (Graph 1.)
pathohistological verification of tumor. Biopsy of
suspected lesion can be done by curettage, deep
layer aspiration, incision and excision. Excision bi-
opsy stands for complete removal of tumor tissue
together with “clean” (tumor-free) margin, and thus
is of great diagnostic and treatment value. Incision
biopsy stands for surgical removal of only a small
part of tumor tissue, usually when tumor is too large
and has complex location which makes the subse-
quent total removal impossible. Surgical excision
presents very effective way in treatment of all kinds Graph 1. Prevalence of different clinical stages
of skin tumor in many different locations. The size for BCC

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

Discussion der and age distribution analysis it was shown that


diagnosed tumors occur in both male and females
One of the most important characteristics of mostly between third and ninth decade. In men
skin as an organ lays in its sensory function to there is a peak in incidence somewhere between
communicate with surroundings, but it is also the sixth and eighth decade, while in women such
largest organ of the human body that provides peak occurs in seventh and eighth decade. The
protection from all potentially harmful external highest number of diagnosed skin tumors in both
influences. All of the frequently exposed parts of genders was in clinical stage I (80%), and clini-
skin such are those in the regions of face, neck cal stage II (17%), which is in accordance to data
and hands, that are often under constant influence obtained during a study that was done in Izmir,
of multiple external factors such as UV radia- Turky, where 78% of skin tumors was verified in
tion, weather and climate conditions, diet, nico- clinical stage I, with maximal diameter measuring
tine and alcohol with time accumulate effects of 20 mm (Ceylan at all., 2003). Tumors with sizes
such destructive impact. Different world studies 2-5cm in diameter (T2) are large tumors where ex-
conclude increase in skin cancer incidence, espe- cision almost always results in large tissue defects.
cially in past few decades (Corona, 1996; Collins Such defects in this region present exceptional
at all., 2004). In USA alone every year it is ex- problem in terms of its reconstruction. It is often
pected about 1 million newly diagnosed cases of necessary to excise, in variation to its localization,
skin cancer, mostly basal (BCC) and sqamuos cell whole eyelid or at least large part of both upper
carcinoma (SCC), while in Holland, in accordance and lower eyelid including medial or lateral angle
with national cancer registry, predictive calcula- of eye. Reconstruction of such defect in delicate
tions about increase in incidence for these tumors orbital subregion often presents complex surgical
surge up to 80%. 20 654 patients with skin cancer problem. If surgical excision requires resection
were newly diagnosed in the year 2000., and it is all of the eyelid structures, then it is necessary to
expected that the number of those patients for the reconstruct complete eyelid ad integrum. Smaller
year 2015. will be 37 342 (de Vries at all., 2005). defects are usually closed via direct suturing or
Various epidemiological studies showed that pa- using full thickness skin graft from an adequate
tients who are diagnosed with BCC and SCC have donor site, while larger defects are reconstructed
greater risk of developing some other malignant via local skin flaps in combination with conjunc-
disease, although the exact assessment of such risk tiva free flaps from the opposite side or buccal
is not yet known (Karagas at all., 1998). Orbital mucosa and auricular cartilage, or with cartilage
region is very specific and very complex region from nasal septum. Excision radicality should be
for surgical interventions that often necessitates pathohistologically verified during operative pro-
team work form both plastic and ophthalmolog- cedure, which means prior immediate reconstruc-
ic surgeon. That is why the frequency, size and tion. Because of the region’s specificity and its
the type of tumor occurring in this region are of deep structures, it is clear that any mistake made
much interest. During our study, 127 skin tumors during the operative procedure may result in very
were verified in this region, which is completely grave consequence for the patient.
in accordance to data obtained from different rel-
evant literature. It was found that these types of
skin tumors are somewhat more often diagnosed Conclusion
in women (60%), which also coincide to data in
available world literature. It was found that BCC Out of all diagnosed BCC in craniofacial re-
is more often diagnosed (95%) than SCC, mostly gion, 11% was localized in orbital subregion.
in women, while SCC is much more rarely veri- Male to female distribution ratio was 1:1,5. Aver-
fied with equal distribution in both genders. Many age age in both genders was almost identical, and
different studies throughout the world also present BCC was in 80% of the cases diagnosed in clinical
similar results (Szepietowski, 2004; Salomon at stage I. When diagnosed in clinical stage I, BCC
all., 2004; Rubin at all., 2005). During the gen- does not require complicated surgical approach.

Journal of Society for development of teaching and business processes in new net environment in B&H 217
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.
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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(-
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skin cancer: a review. Ann Ist Super Sanita 32(1):
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Changing demographics and pathology of nonme-
lanoma skin cancer in the last 30 years. Seminars
in cutaneous medicine and surgery 23(1):80-83.
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Ernster VL (1998) Occurrence of Other Cancers
among Patients with Prior Basal Cell and Squa-
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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.

218 Journal of Society for development of teaching and business processes in new net environment in B&H
HealthMED - Volume 2 / Number 4 / 2008

Effects of Specific Forms of


Extramedullary Fixation in
Treatment of Diaphyseal Small
Bone Fractures
EFEKTI SPECIFIČNIH OBLIKA
EKSTRAMEDULARNE STABILIZACIJE NA
SANACIJU PRIJELOMA DIJAFIZA MALIH
KOSTIJU
Zoran Hadziahmetovic1, Narcisa Vavra – Hadziahmetovic2
1
Clinic for emergency medicine, Clinical Center of Sarajevo University, Bosnia and Herzegovina
2
Institute for physical medicine and rehabilitation, Clinical Center of Sarajevo University, Bosnia and Herzegovina

Summary were noted in 2 (6.6%) ostheosynthesis; break of


the cerclage wire (1), angulations at the point of
In the article according to the previously set fracture (1). In case of ostheosynthesis with use of
parameters is correlated efficacy of two forms of plate and screws complications were noticed in 3
extramedullary ostheosynthesis in case of diaphy- (10%) ostheosynthesis; slower bone healing (1),
seal small hand and foot bones fractures. loosening of the screws and plate (1), plate bend-
Research goal is to determine definite func- ing (1).
tional and radiography parameters after fractures Conclusion; Extramedullary stabilization of
and bone changes (24 fractures. 6 bone tumors/ fracture and bone changes within the tested sample
cysts) after implementation of the Extramedul- and the two specific group of patients with differ-
lary Fixation with Kirschner wires and Cerclage ent forms of extramedullary ostheosynthesis did
– EFIKS ostheosynthesis and use of technique not show statistically significant differences in the
with plates and screw. final radiology and functioning results according
Material and methodology; Two groups of 15 to the set parameters of research (p>0.05). EFIKS
ostheosynthesis among 26 patients were selected. ostheosynthesis have the possibility for wider ap-
Fist injury was present in 22, and foot in 4 cases. plication in surgery and it is complete acceptable
In case of 2 patients there were open fractures alternative to those who does not have the plates
(Gustilo I/II). and screws. Opposite to this extramedullary fixa-
Results; after the end of the treatment all im- tion of fractures with the use of screws and plates
plants were identified in the primary set posi- is still leading and irreplaceable as the method in
tion. Complete healing of the fractures was in 25 case of joint and metaphyseal fractures.
(83.3%) ostheosynthesis. Reduction of movement Key words; extramedullary ostheosynthesis,
in neighboring joints was in ratio + 50 - 100 . In the bone healing
EFIKS group of ostheosynthesis complications

Journal of Society for development of teaching and business processes in new net environment in B&H 219
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

220 Journal of Society for development of teaching and business processes in new net environment in B&H
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).

Matherial and research methods


Research goal
At the Clinical Center of Sarajevo University
Previous experimental and clinical researches within Clinics for Emergency Medicine as well as
indicated that the radiography and functional trea- Plastic and Reconstructive Surgery in a time pe-
tment results of the small bone diaphyseal fractu- riod from January 1st 2006 until December 31st

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)

1.joint 1.transfersal 1.unstable 1. Multiple MTC fractures 1. multi-fragmented


destructions fractures, stable long and fractures with shortening
2. periaticular and
- arthrodesis fractures skew or and rotation
multiple fractures of the
spiral
joints 2. fractures with segment
diaphyseal
bone loss
fracture 3. multi-fragmented
fractures with shortening 3. open fractures
2. joints
and rotation
fractures 4. Multiple MTC fractures
4. fractures with segment
5. unstable long and
bone loss
skew or spiral diaphyseal
5. open fractures fracture
6. joint destructions - 6. transversal stable
arthrodesis fractures
7. joint destructions -
arthrodesis

Journal of Society for development of teaching and business processes in new net environment in B&H 221
HealthMED - Volume 2 / Number 4 / 2008

2007 we have treated 26 patients (24 fractures and


6 bone tumors/cysts). Selection of ostheosintetic
material or type of the surgical procedure was wit-
hin indication field presented at the Table 1. We
used two forms of extramedullary ostheosynthe-
sis at feet and hands as follows: 14 patients with
15 EFIKS ostheosynthesis (11 diaphyseal, 1 bone
tumor, 3 cysts) and 12 patients which have im-
planted 15 plates 2.7/3.5 mm with screws - AO (13
fractures, 1 bone tumor, 1 cyst) of phalanges and A
metacarpal/metatarsal bones. Fractures and bone
changes on hands were present among 22 patients
and among 4 patients on foot. Ratio between men
and women was 21: 5. Average age of the respon-
dents was 33.4 years (ranging between 12 and
53 years). Under general anesthesia we surgically
treated 22 patients while 4 patients had regional
anesthesia. Average duration of hospitalization
was 8 days. The shortest follow up time (functio-
nal and radiography finding) was after 3, and lon- B
gest after 6 months. 7 patients had open fractures
(Gustilo I/II) within the EFIKS group in 4 cases.

Surgical technique

Surgical treatment approach to all fractures


was in terms of classic surgical procedures which
were conducted immediately after the injury, and
not later than 48 hours, while in case of all bone C
changes (tumors/cysts) previously were condu-
cted adequate diagnostic procedures (CT, MRI, Figure 1 (♂ 1962) Amputation of II and III hand
angiography ..). finger with complete loss of proximal phalanges
In all cases drainage of the wounds was done with of IV and V finger and sub capital fracture of the
one drain. Antibiotics were prescribed as prophy- V metacarpal bone – adaptation fixation intrame-
laxis. Removal of the drainage was done after 48- dullary with Kirschner wires (A). EFIKS osthe-
72 hours. Neither one patient was immobilized. In osynthesis, osteoplastic replacement of proximal
one case there was double fixation with the EFIKS phalanges of IV and V finger with II metacarpal
ostheosynthesis at the same hand, and in case of 1 bone and double arthrodesis PIP and MTCP
patient (serial fractures) we used plates and screws joints on IV and V finger. Fixation of sub capital
on 3 metacarpal bones (Figure 2) and also in one fracture of the V metacarpal bone (B). Healing
patient on metacarpal and proximal phalange. Pati- of the V metacarpal bone with complete fusion at
ents were stimulated to perform movements early. position of arthrodesis after 5 months. Satisfacto-
In case of foot fractures walking and partial load ry functioning effect (C).
was recommended to all patients after 3 months.
Clinical, functioning and radiography testing The followed parameters were: radiography
of ostheosynthesis effectiveness was performed in healing of the fractures, fixation of the implant in
all cases immediately after the surgery, and than relation to the bone and soft tissues, development
after 1, 3, and 6 months. of infection, deformities occurrence, grip in case

222 Journal of Society for development of teaching and business processes in new net environment in B&H
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

What EFIKS ostheosynthesis definitely sho-


B wed, first in experimental research, and than by
comparison of its effects with the intramedullary
Figure 2 (♂ 1950) Spiral fractures of II, III and V forms of adaptation ostheosynthesis, and even
metacarpal bone (A). Repositioning and fixation compared to the rigid ostheosynthesis with plates
with plates 2.7 mm and free screws (B) and screws is without any doubt, one new choice
for all diaphyseal fractures of the fist and foot as
situations of very quality bridging of the bone de-
Results fects with its ostheoplastic replacement (7, 11).
Good functional results is conditioned by the
In all cases early functional mobility is achie- graduate induced movements and dosage of the
ved. All movements in the neighboring joints of load during the post surgery period. It is for sure
the hand and foot were minimally reduced + 50 - that locus minoris resistentiae of EFIKS ostheo-
100. Fist grip was satisfactory, except in two cases synthesis is the possibility that the lever effect can
where is was difficult to achieve for one patient in occur, and which must be prevented that the fra-
EFIKS ostheosynthesis group (amputation injury) cture is the medium locus of the dyaphisis. This
and one with arthrodesis II MTCP joint with plate can lead to loosening of the basic components, pri-
and screws. marily cerclage wire, which happened in one case
By radiography all implants are identified in and it is also confirmed during the experimental
the primary set position. Verification of full bone research (11). By forming the successful bone basis.
healing in case of fractures or fusion in case of Selection of adequate thickness of the Kirschner
arthrodesis is noticed in 25 (83.3%) ostheosynt- wires and number of the cerclage wires at the risk
hesis. In 3 (10%) cases with implanted plate and segments of the bone this complication can be
screws: slower healing of metacarpal fracture is successfully avoided. But within research done by
noticed – 1 which required additional bone stimu- Burge identical secondary movements of the fra-
lation, loosening of the screws and plate without gments were noticed also when using plates and

Journal of Society for development of teaching and business processes in new net environment in B&H 223
HealthMED - Volume 2 / Number 4 / 2008

screws, when bending of the plate and loosening Literature


of the screws occurred (8). Also in our research, ho-
nestly in only 2 cases (at each group one patient) 1. Muller ME, Allgower M, Schneider R, Willenegger
there were these complications. H. Manual of internal fixation. Third edition, Sprin-
Elasticity of the EFIKS ostheosynthesis is addi- ger – Verlag, Berlin, Heidelberg, New York, Lon-
tional factor which leads to avoidance of the large don, Paris, Tokyo, Hong Kong, Barcelona, 2000.
rigid diaphyseal segments which for sure adds ad- 2. Ruedi TP, Murphy WM. AO principles of fracture
ditional stimulating effects to the healing which is management. Thieme, Stuttgart – New York, 2000.
the advantage of the biological fragments fixation. 3. Baumgart F, Wahl D, Owen G. et al. The post–ma-
This have great importance in indicated fusions nufacture manipulation of implants. Dialoge, 2001;
(arthrodesis) where we can expect even resorption 2: 13–4.
of the bone ends and where rigid ostheosynthesis 4. Gooship AE, Kenwright J. The influence of induced
done with plates prevents additional activity of the Micromovement Upon the healing of Experimental.
dynamic-compressive link of muscle-ligament- JBJS, 1985, 76 – B – 650 – 5.
tendons apparatus.
5. Kirchwehm WW, Figura MA, Binning TA. et al.
Although we did not evaluated fractures of the Fractures of internal metatarsals. In; Scurran BL,
joints it is certain that within selection of alenthe- Foot and Ankle Trauma, Churchill Livingstone,
sis is leading decision for plates and screws. 1989: 345–62.
6. Boyes JH. The Hand, 7 ed., Lippincott comp., Phi-
ladelphia – Toronto, 1995.
Conclusion
7. Hadžiahmetović Z. Početna klinička iskustva u lije-
Extramedullary stabilization of the fractures čenju dijafizarnih prijeloma malih kostiju tehnikom
originalne ekstramedularne osteosinteze, Med Arh
and bone changes within the tested sample and two
2006 ; 60 (6, supl. 1) 9 - 12
specific groups of respondents with use of diffe-
rence forms of extramedullary ostheosynthesis did 8. Burge P. Internal fixation of the metacarpals and
not show statistically significant differences in the phalanges,Riv Chir Mano, 2006, :(3), 301 - 543
final radiography and functional results according 9. Foster GT. et al. Hemoptysis due to migration of a
to the set parameters of the research (p>0.05). fractured Kirschner Wire. Chest, 2001; 119: 1285–
Both methods showed sufficient achievement 6.
of stabilization and have full support in treatment 10. Anic D, Brida V, Jelić I, Orlić D. The cardiac mi-
of simple and complex diaphyseal fractures of gration of a Kirschner wire a case report. Tex He-
short and medium bones as well as arthrodesis of art Inst J, 1997 ; 24(4): 359–61.
the IP and MTP/MCP joints. 11. Hadžiahmetović Z, Krasni J. Osteosinteza tehni-
Because of the simple implants (Kirschner wire kom ekstramedularne fiksacije prijeloma Kirsc-
and wire for bone cerclage) as well as necessary hner iglama i serklažom (EFIKS). Tr Glas, 2006;
instruments EFIKS ostheosynthesis have possibi- 4 (3): 27-30.
lity for wider practical application in surgery and it
is cost acceptable for those institutions which lack
plates and screws. Opposite to this extramedulla- Corresponding author:
ry fixation of fractures with the use of screws and Zoran Hadziahmetovic
plates is still leading and irreplaceable as the met- Clinic for emergency medicine,
hod in case of joint and metaphyseal fractures. Clinical Center of Sarajevo University,
Bosnia and Herzegovina
e-mail: HealthMed_bih@yahoo.com

224 Journal of Society for development of teaching and business processes in new net environment in B&H
HealthMED - Volume 2 / Number 4 / 2008

Adipokines and Acute


Coronary Syndrome
ADIPOKINI I AKUTNI KORONARNI SINDROM
Emina Nakas-Icindic1, Amina Valjevac1, Asija Zaciragic1
1
Institute of physiology and biochemistry, Medical Faculty,
University of Sarajevo, Bosnia and Herzegovina

Summary gation, and atherothrombosis in obese human. In


obese subject the production of adiponectin, which
Adipose tissue has traditionally been conside- has protective effects on coronary blood vessels is
red as a tissue devoted mainly to energy storage. suppressed.
Now it is recognized as a multifunctional organ This paper summarizes the role of three adi-
involved in the production of hormones, growth pokines: leptin, resistin and adiponectin in acute
factors and cytokines named adipokines. coronary syndrome and implicates theirs possible
In obese subject the production of adipokines is appliance in clinical practice.
impaired. In obesity high level of leptin, resistin, Key words: Adipokines, leptin, adiponectin,
and low level of adiponectin have been observed resistin, acute coronary syndrome
and implicated in insulin resistance, atherosclero-
sis and metabolic syndrome.
In patients with established coronary atheros- Sažetak
clerosis increased body weight is an independent
predictor of an acute coronary syndrome. The ex- Donedavno se smatralo da je jedna od osno-
act mechanism of obesity induced coronary heart vnih fiziološka uloga masnog tkiva da pohranjuje
disease is not fully elucidated. Current research is energiju. Sada se zna da je masno tkivo multifun-
aimed to determine links between adipokines and kcionalni organ koji proizvodi hormone, faktore
coronary heart disease. rasta i citokine koji se jednim imenom zovu adi-
Leptin, adiponectin and resistin are adipokines pokini. Kod gojaznih osoba produkcija adipoki-
that are implicated in coronary endothelial dysfun- na je poremećena te je uočen visok nivo leptina
ction, trombogenesis and inflammation. These i resistina i nizak nivo adiponektina. Poremećen
processes are known to precipitate atherosclerotic odnos adipokina je povezan sa inzulinskom re-
plaque rupture and acute coronary syndrome. zistencijom, aterosklerozom i metaboličkim sin-
Recent studies demonstrated that high plasma dromom.
leptin and low adiponectin levels as observed in Kod pacijenata sa razvijenom koronarnom
obese subjects impair coronary acetylcholine-me- aterosklerozom, povećana tjelesna masa je ne-
diated vasodilatation in vitro and in vivo. Resistin zavistan prediktor nastanka akutnog koronarnog
also impair coronary vasodilatation but via brady- sindroma. Mehanizmi kojima gojaznost dovodi
kinin pathway. do koronarne bolesti nisu u potpunosti rasvijetlje-
Leptin and resistin show proinflammatory ef- ni. Istraživanja su usmjerena u cilju razjašnjenja
fects upregulating cytokine production in ma- povezanosti adipokina i bolesti koronarnih krvnih
crophages and might lead to destabilization of sudova. Leptin, adiponektin i resistin su adipokini
coronary atherosclerotic plaque. Leptin has been koji dovode do koronarne endotelne disfunkcije,
observed to stimulate angiogenesis, platelet aggre- trombogeneze i inflamacije, procesa za koje se zna

Journal of Society for development of teaching and business processes in new net environment in B&H 225
HealthMED - Volume 2 / Number 4 / 2008

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)

226 Journal of Society for development of teaching and business processes in new net environment in B&H
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

Leptin ferent cells including cardiomyocites and coronary


arteries. Leptin receptors are classified as short
Leptin is a 16 kDa protein predominantly ex- (ObR a,c, d, f), secreted (ObRe) and long (ObRb).
pressed and secreted in adipose tissue, but also ObRb receptor is present in coronary arteries and
produced by other tissues including the heart (6). considered to be involved in full cellular signaling
Plasma leptin concentrations reported in normal, process (8). Its intracellular domain belongs to the
healthy humans are 3–5 ng/mL and in morbidly Janus kinase signal transduction and translation
obese humans leptin concentrations are elevated system (Jak2/STAT3)(7).
and range from 90–95 ng/mL (7). The production of cardiomyocyte derived leptin
Leptin exerts its effect by binding to its recep- is increased by both endothelin-1 and angiotensin
tors which are expressed abundantly in many dif- II suggesting a paracrine or autocrine role of leptin

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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.

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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
HealthMED - Volume 2 / Number 4 / 2008

Conclusion 9. Rajapurohitam V, Javadov S, Purdham DM, Kir-


shenbaum LA, Karmazyn M. An autocrine role for
Adipokines are involved in all stages of acu- leptin in mediating the cardiomyocyte hypertrophic
te coronary syndrome initiation and progression. effects of angiotensin II and endothelin-1. J Mol
With the use of drugs affecting adipokines plasma Cell Cardiol; 41:265–274, 2006.
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nary syndrome. contraction in rat ventricular myocytes. Role of
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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
HealthMED - Volume 2 / Number 4 / 2008

Relation of disseased towards


feding aditions vitamins and
minerals
ODNOS BOLESNIKA PREMA PREHRAMBENIM
DODACIMA VITAMINA I MINERALA
Fatima Jusupovic1, Arzija Pasalic1, Jasmina Mahmutovic1, Dijana Avdic2, Azra Kudumovic2
1
Faculty of Health, University of Sarajevo, Bosnia and Herzegovina
2
Faculty of Medicine, University of Sarajevo, Bosnia and Herzegovina

Summary risni, kao što su dokazi o korisnom učinku voća i


povrća. Cilj je bio analizirati znanje i praksu bole-
The term, feeding additions stands for indivi- snika prema prehrambenim dodacima vitamina i
dual forms or mixtures of feeding materies that minerala, te dati ocjenu korištenja voća i povrća u
serves as feeding additions in order to complete ishrani ispitanika.
it or they are taken directly in concentrated form Ključne riječi: Prehrambeni dodaci, vitamini,
(vitamins, mineral materies, proteins, aminoa- minerali.
cids, lipids). Vitamins and minerals can be taken
into organism in two ways: by taking of food or
by taking of mineral and vitamin additions. The Introduction
products with vitamin additions aren’t that useful
as evidential usage of fruits and vegetables. The The term feeding additions, stands for the single
aim was to analyze the situation and practice of forms or mixtures of feeding materies that serves as
patients and their attitude towards vitamins and additions to food as its’ complement, or these are
minerals and evaluate the taking of fruits and ve- taken directly in concentrated form (vitamins, mi-
getables in everyday feeding. neral matheries, proteins, aminoacids, lipids), (1)
Key words: feeding additions, vitamins, mine- Feeding is basic human need for existence. In
raly process of feeding, the basic nutrition materies
which can be divided in two groups:macronutriti-
Sažetak ens – the primar source of energy (proteins , carbs,
lipids) and mikronutrtients- protective materies
Pod prehrambenim dodacima podrazumijevaju (vitamines and minerals). In process of planing
se pojedinačni oblici ili mješavine hranjivih mate- of feeding it is taken care of that daily meal plan
rija, koje služe kao dodaci prehrani u smislu nje- includes various groceries in order to secure nee-
zinog obogaćivanja ili se uzimaju direktno u kon- ded intake of all anutritive and protecive materies
centriranom obliku (vitamini, mineralne materije, (2). Vitamins and minerals can enter in organism
bjelančevine, aminokiseline, masne kiseline). Vi- in two ways, with food or as additions. Products
tamini i minerali mogu u organizam doći dvojako, with vitamine additions aren’t so usefull as evi-
ili sa hranom ili putem prehrambenih dodataka. denton usefull meaning of fruits and vegetables
Proizvodi sa vitaminskim dodacima nisu tako ko- intake.(3).

234 Journal of Society for development of teaching and business processes in new net environment in B&H
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

Feeding additions of minerals and vitamins are


ussualy bought in pharmacies, 61,61 %,but signif-
ficant percentage belongs to common shops (19,19
Graphic 1. Frequency of using of feeding additi- %). According to research, most of the questioned
ons, minerals and vitamins by the patients treated patients follow the instructions of producer about
in UKC Sarajevo recomended daily doses (68,68 %), and less (49,-
83 %) advisess doctor or pharmacist.

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.

Graphic 6. Attitude on consuming of ruits and ve-


getables apart from using feeding additions.

More than a half of questioned patients consi-


der that it is neccessary to take additions with re-

236 Journal of Society for development of teaching and business processes in new net environment in B&H
HealthMED - Volume 2 / Number 4 / 2008

Discusion optimal feeding after which comes selection of


quality addition to food.
There are totaly 297 patients, out of which 162 Fruits and vegetables are irreplacable part of
males and 135 females in different age group. Ac- quality and balanced feeding, becouse they se-
cording to educationanal level, the most of them cure many of important vitamins and minerals.
are with finished high school (65,55 %), univer- Unfortunately, the large number of them 40,40 %
sity and two-year higher educational level 18,18 consumes fruit and vegetables only several times
% , while others are with finished primary school. a week what excludes important nutrities to orga-
More than a half live in urban area, in suburban nism. In recomendations of SZO about daily in-
area live 26,26 %, and others 22,55 % live in the take of fruits and vegetables , only 5,05 % follow
country. this recomendation.
Speaking in terms of education, the most of them Interesting information would be that very
are employed (44,10 %), retired 22,22 %, students small number13,18 %, eats fruits and vegetables
4,71 %, while others are unemployed. which they have produced themselves, while mot
Vitamine and mineral food addititives use se- of them provides it on the market..
veral times a day, 9,09 % patients. If we exclu- In Slovenia, where similar research was taken,
de those who use them only in exceptional cases the largest number of questioned eats homemade
(30,30 % patients – for ex. In case of illness), and fruits and vegetables ( 6).
those who don’t use them at all (15,48 %), 54% Popularisation of food additions has grown so
of them use vitamin and mineral additions to food much that redesigned oiramid of proper feeding,
what is significantly lower than in other authors’ which includes daily multivitamin and mineral ad-
research. Research conducted in USA 2000 had dition to feeding as usefull prevention of potential
shown that 33,9 % take artificcial additions of vi- feeding gaps.(7).
tamins and minerals, which is 23,2 % higher than There are totaly 297 patients, out of which 162
in 1987. (3). males and 135 females in different age group. Ac-
In question ‘why do they use vitamin and mi- cording to educationanal level, the most of them
neral additions’?, they answered in first place are with finished high school (65,55 %), univer-
(36,48 %), increasing of immunity, than impro- sity and two-year higher educational level 18,18
vement of apetite, overcomming of pyisical wea- % , while others are with finished primary school.
kness, preventing of cardiovascular illnesses. More than a half live in urban area, in suburban
The reasons why some don’t use mineral and area live 26,26 %, and others 22,55 % live in the
vitamin additions in ther food or use them rarely country.
are (22,89 %) are becouse of the attitude that du- Such attitude san be be evaluated as excellent
ring food taking such addittions aren’ t neccessary. becouse nuritients from food are the best selecti-
Many of them are affraid of sideeffects and most on, zhey are ‘wrapped’ in their natural complexes
of them didn’t answered at all. which are best apsorbed and used in the organism.
Patients hospitalised in KC University of Sa- (8).
rajevo, who are in this questionaire processing, As leading risk-factor in creation of illness,
mostly use multivitamin additions (26,26 %), after the questioned persons consider smoking, stress
this, the second place belongs to A + C + E, and exposure at home and at work, increased blood
the least taken are multimineral additions 3,36 %. preasure and than in the same number of opini-
The largest usage of multivitamin additions, ac- ons overweight, disorganised feedeing, the lack of
cording to research is in America (5). body activity and alcohol consuming.
Multivitamin additions in 35,01 % are con- For most of them, the most important meal is
sumed after meal , 27,60 %, during the meal, certainly breakfast (56,90 %). There are those
and the number of those who take before meal who thimk that the main meal is lunch and supper
is even. Todays’ lifestile brings high changes for all in one.
creation of subclinical lack of vitamins and mi-
nerals and expert advise is implementation of

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

238 Journal of Society for development of teaching and business processes in new net environment in B&H
HealthMED - Volume 2 / Number 4 / 2008

Does serum C-reactive protein


concentration correlate
with blood pressure values
in patients with probable
Alzheimer’s disease?
DA LI KONCENTRACIJA C-REAKTIVNOG
PROTEINA U SERUMU KORELIRA SA
VRIJEDNOSTIMA KRVNOG PRITISKA
KOD PACIJENATA SA MOGUĆOM
ALZHEIMEROVOM BOLESTI?
Asija Zaciragic1*, Amina Valjevac1, Orhan Lepara1, Azra Alajbegovic2
1
The Institute of Physiology and Biochemistry, University of Sarajevo, Bosnia and Herzegovina
2
Clinic of Neurology, Clinical Centre University of Sarajevo, Bosnia and Herzegovina

Summary clinically diagnosed probable Alzheimer’s disea-


se by NINCDS-ADRDA criteria. All patients had
Background: Alzheimer’s disease (AD) repre- mini mental state examination (MMSE) score <
sents a progressive dementia. Known risk factors 23 and a Hachinski ischemic score 4 or bellow.
for the development of AD include: age, genetic Fifteen community dwelling, age-matched, appa-
susceptibility, family history of dementia and fe- rently healthy, subjects without dementia served as
male gender. Atherosclerosis, dyslipidemia, hy- the control group. All subjects in this group had a
pertension and inflammation are considered to be MMSE score > 28. Subjects included in the study
possible vascular risk factors for AD. C-reactive underwent history, clinical examination and mini
protein (CRP) is an important marker and media- mental state examination. Serum CRP concentra-
tor of low-grade inflammation. Its possible role in tion was measured by means of particle enhanced
the development and the progression of AD is still immunonephelometry. Systolic and diastolic blo-
not fully understood. Results of numerous studies od pressure was measured with the use of mercury
conducted with the purpose to elucidate the role sphygmomanometer on the right arm after at least
of CRP in AD are conflicting. Association of CRP a 5-min rest.
and systolic and diastolic blood pressure in AD Results: Age, systolic and diastolic blood pres-
patients has not been extensively investigated. sure did not differ significantly between the two
Methodology: AD group consisted of fifteen groups. In AD group we found negative correlati-
institutionalized patients, aged 65 and over, with on between serum CRP concentration and systolic

Journal of Society for development of teaching and business processes in new net environment in B&H 239
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
HealthMED - Volume 2 / Number 4 / 2008

of definite AD requires histopathological confir- sure predisposes the development of Alzheimer’s


mation by postmortem examination (2). disease (8,9). Thus, the influence of dementia pro-
Based on experimental and neuropathologic cess on blood pressure remains inconclusive.
studies, inflammation is postulated to play a cen- The aim of the present study was to examine
tral role in processes leading to neurodegeneration the association between blood pressure values and
as well as vascular injury (3). Neuroinflammation serum C-reactive protein concentration in patients
includes an innate immune system reaction which with probable AD.
results in an attack on host neurons.
C-reactive protein (CRP) is an acute phase pro-
tein and is thought to be a link between innate and Materials and methods
acquired immune system. CRP is not only extre-
mely sensitive marker but as well a mediator of Two groups of subjects were enrolled in the
inflammation and tissue damage. Possible role of present study: Fifteen patients, aged 65 and over,
CRP in the development and the progression of with clinically diagnosed probable Alzheimer`s
AD is still not fully understood. Results of nume- disease by NINCDS-ADRDA criteria. All patients
rous studies conducted with the purpose to eluci- had mini mental state examination (MMSE) score
date the role of CRP in AD are conflicting. < 23 (10). Patients had a Hachinski ischemic score
Study conducted by Yasojima and al. (4) has 4 or bellow (11). We included all patients curren-
demonstrated that CRP is concentrated in pyrami- tly institutionalized at specialized unit for patients
dal neurons and is upregulated in affected areas of with dementia within Health-Care Hospice for
AD brain. According to these findings controlling persons with disabilities and other persons in Sa-
CRP production at tissue level could be significant rajevo, Bosnia and Herzegovina. Fifteen commu-
factor in reducing inflammatory damage in AD. nity dwelling, age-matched, apparently healthy,
On the other hand, Dik et al. (5) have demonstrated asymptomatic subjects without dementia served
that serum concentration of CRP is not associated as the controls. All subjects in this group had a
with cognitive decline in older persons. We have MMSE score > 28. For both groups of subject, the
previously reported that serum CRP concentration exclusion criteria were positive history of cardio-
was significantly higher in patients with probable vascular or thyroid disease, chronic inflammatory
AD compared to age-matched controls (6). disease (asthma and rheumatoid arthritis), hepatic
Evidences suggest that hypertension and hy- or renal insufficiency and cancer. Subjects with
percholesterolaemia may increase the risk of de- self-reported common cold were also not included
mentia by inducing atherosclerosis and impairing in the study. All procedures on human subjects
blood flow, but they can also directly induce neu- were performed in the accord with Helsinki De-
rodegeneration of Alzheimer’s disease. Since the claration of 1975. Informed consent was obtained
neurodegenerative processes in AD may begin in from all subjects and/or their caregivers. Subjects
midlife it is important to identify early risk factors underwent history, clinical examination and mini
for the development of AD. Studies have shown mental state examination.
that mean systolic and diastolic blood pressure Blood pressure was measured manually in a
has a tendency for an increase up to the age of 75 standardized manner using a sphyngomanometer,
but that it decreases afterwards. Important role in with the patient in sitting position after five minu-
blood pressure regulation has the brain but it still tes of rest. Values were based on a single measure-
remains to be elucidated whether neuronal dege- ment. Hypertension was defined as a systolic blo-
neration that occurs with aging contributes to the od pressure of >140 mm Hg or a diastolic blood
decline in blood pressure in elderly (7). pressure of >90 mm Hg or both, with or without
The relationship between blood pressure and the use of blood pressure lowering medications.
dementia is complicated because it has been re- Pulse pressure was calculated as the difference be-
ported that hypertension in midlife is a risk factor tween systolic and diastolic blood pressure. It is
for Alzheimer’s disease but on the other hand the- related to arterial stiffness and as such represents a
re are studies that have shown that low blood pres- measure of atherosclerosis (12)

Journal of Society for development of teaching and business processes in new net environment in B&H 241
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)

WHR 0.90±0.05 0.97±0.03 NS

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

Journal of Society for development of teaching and business processes in new net environment in B&H 243
HealthMED - Volume 2 / Number 4 / 2008

pressure in patients with probable AD compared Conclusions


with controls. According to these authors it still re-
mains unclear whether low systolic blood pressure Our results have shown that negative correlati-
predisposes the development of AD and contribu- on between serum CRP concentration and systolic
tes to its etiology or is the result of neurodegene- and diastolic blood pressure exists in patients with
ration. AD but this correlation is not statistically signifi-
Recent studies suggest that specific inflamma- cant. Obtained results do support the notion that
tory mechanisms contribute to neurodegeneration. low-grade inflammation has no impact on blood
Evidences have shown that there is a local upre- pressure values in patients with AD. Larger pro-
gulation of inflammatory cytokines, acute phase spective studies are required to investigate these
proteins such as CRP, activation of the comple- findings further.
ment cascade and accumulation of microglia in
damaged areas of AD brain (24). Our results have
shown that there is a negative although not signi- Literature
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Journal of Society for development of teaching and business processes in new net environment in B&H 245
HealthMED - Volume 2 / Number 4 / 2008

The effects of spirulina platensis


on biohumoral markers of renal
function in gentamicin-induced
acute tubular necrosis in rats
EFEKTI SPIRULINE PLATENSIS NA
BIOHUMORALNE MARKERE BUBREŽNE
FUNKCIJE KOD GENTAMICINOM-UZROKOVANE
AKUTNE TUBULARNE NEKROZE KOD ŠTAKORA
Nesina Avdagic1*, Esad Cosovic2, Emina Nakas-Icindic1, Zakira Mornjakovic2, Asija Zaciragic1,
Almira Hadzovic-Dzuvo1
1
Institute of Physiology and Biochemistry, Faculty of Medicine, University of Sarajevo,
Bosnia and Herzegovina
2
Institute of Histology and Embryology, Faculty of Medicine, University of Sarajevo,
Bosnia and Herzegovina

Summary necrosis in both experimental groups. The most


significant increase of serum biohumoral markers
The aim of this study was to assess possible of renal function was in gentamicin group (urea;
protective effects of Spirulina platensis on gen- gentamicin group (X=27,47±2,15mmol/L) versus
tamicin-induced renal dysfunction in rats. Adult control group (X=7,08±0,09mmol/L) and creati-
Wistar rats (n=18), both sexes, were divided into nine: gentamicin group (X=192,5±23,68 mmol/L)
three equal groups. First, control group, was trea- versus control group (X=56±1,24 mmol/L) (p=0-
ted with 0,9% sodium chloride, intraperitoneally ,002). Spirulina platensis decreased the serum le-
for 7 consecutive days. Second, gentamicin group vel of biohumoral markers of renal function (urea;
was treated with gentamicin (80 mg/kg per day), gentamicin+spirulina group (X=11,53±1,66mmol/
intraperitoneally also for 7days. Third, gentamici- L) versus gentamicin group (X=27,47±2,15mmol/
n+spirulina group was pretreated for two days with L);(p=0,002) and creatinine; gentamicin+spiruli-
water solution of Spirulina platensis (1000mg/kg na group (X=107,33±20,14mmol/L) versus genta-
in 2 ml of water) per os. Next 7 days was treated micin group (X=192,5±23,68 mmol/L) (p=0,026)
concomitantly with Spirulina platensis per os and and attenuated the gentamicin induced acute tu-
gentamicin intraperitoneally in the same volume bular necrosis. Our results indicate that Spirulina
as animals in previous groups. Renal function was platensis diminished toxic renal effects of genta-
assessed by measuring serum urea and creatinine micin and preserve renal function in gentamicin
concentrations. The light microscopic histological induced acute tubular necrosis in rats.
analysis confirmed the acute tubular necrosis in Key words: spirulina platensis, urea, creatini-
gentamicin and gentamicin+spirilina group. Gen- ne, acute tubular necrosis, gentamicin, nephroto-
tamicin induced renal failure due to acute tubular xicity

246 Journal of Society for development of teaching and business processes in new net environment in B&H
HealthMED - Volume 2 / Number 4 / 2008

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

Journal of Society for development of teaching and business processes in new net environment in B&H 247
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.

Experimental protocol Histology

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.

248 Journal of Society for development of teaching and business processes in new net environment in B&H
HealthMED - Volume 2 / Number 4 / 2008

Results border membranes of almost all cells were disru-


pted. Spirulina platensis partially reduced these
Biohumoral markers changes.
Urea

The significant differences in serum urea con-


centrations were observed between the groups
(p<0,001). The highest value was in gentamicin
group (X=27,47±2,15mmol/L). In gentamicin+-
spirulina group value was higher (X=11,53±1,66
mmol/L, p=0,002) than in control group(X=7,08±
0,09 mmol/L) but significantely lower than in gen-
tamicin group (p=0,002). (Figure 1)

Figure 2. Serum creatinine concentrations


(mmol/L) in control, gentamicin+spirulina and
gentamicin group of rats. Values are expressed
mean ± SEM
*p= 0,002 compared with control;
**p= 0,026 compared with control and gentamicin;
Renal histology

Using Spearman’s rank correlation analysis a


positive, statistically significant, correlation was
Figure 1. Serum urea concentrations (mmol/L) found between histopathological injury score and
in control, gentamicin+spirulina and gentamicin serum urea concentration in total experiment sam-
group of rats. Values are expressed mean ± SEM. ple (r= 0,74; p<0,01) (Figure 3).
*p= 0,002 compared with control;
**p= 0,002 compared with control and gentamicin;

Creatinine

Gentamicin markedly increased the serum cre-


atinine concentrations, and the difference between
groups was statistically significant (p=0,002). The
highest value was in gentamicin group (X=192,-
5±23,68 mmol/L). Spirulina platensis significan-
tly decreased the serum creatinine concentration
(X=107,33 ±20,14 mmol/L) (p=0,002), but it was
still higher than in the control group(X=56±1,24
mmol/L) (p=0,026). (Figure 2).
The standard light microscopy has been used
for histological analysis. In the control group there
were no any changes in structure of renal tissue.
The renal tissue of rats treated with gentamicin Figure 3. Mean serum urea concentration (mmol/
showed necrotic areas in the superficial cortex, L) and kidney histological injury score within
desquamated epithelial cells debris in the lumen control and experimental groups
of proximal tubules and interstitial edema. Brush-

Journal of Society for development of teaching and business processes in new net environment in B&H 249
HealthMED - Volume 2 / Number 4 / 2008

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
HealthMED - Volume 2 / Number 4 / 2008

Conclusion 10. Mao T., Water J.V.D., Gershwin M. Effect of Spi-


rulina on the secretion of cytokines from periphe-
In summary, the results of our study indicate ral blood mononuclear cells. J. Med. Food.2000;
that pretreatment with Spirulina followed by si- 3: 135-140.
multaneous Spirulina and gentamicin treatment 11. Dasguptat T., Baneejee S., Yadav P.K., Rao A.R.
preserve the renal function and ameliorates the Chemomodulation of carcinogen metabolising
severity of renal tubular necrosis in gentamicin in- enzymes, antioxidant profiles and skin and fore-
duced acute tubular necrosis. stomach papillomagenesis by Spirulina platensis.
Mol. Cell. Boichem. 2001; 226: 27-38.
12. Zhang H.Q., Lin A.P., Sun Y., Deng Y.M. Chemo-
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ameliorates gentamicin-induced renal injury in


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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

252 Journal of Society for development of teaching and business processes in new net environment in B&H
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Anthropometric values for boys


aged 14 – 15 years who actively
train basketball in comparing to
boys of same age who do not
train any sports
ANTROPOMETRIJSKE VRIJEDNOSTI KOD
DJEČAKA UZRASTA 14 – 15 GODINA KOJI
AKTIVNO TRENIRAJU KOŠARKU U ODNOSU
NA DJEČAKE ISTE DOBI KOJI NEMAJU
SPORTSKIH AKTIVNOSTI
Dijana Avdic¹, Fatima Jusupovic², Mensura Kudumovic³
¹ KCU Sarajevo, Bosnia and Herzegovina,
² Faculty of Health, Bosnia and Herzegovina,
³ Faculty of Medicine, Bosnia and Herzegovina

Summary weight, height, scope of the body and skin wrin-


kles.
Humane anthropometry (man-measure, Greek) In sport medicine it serves to objectively es-
is a science which deals with the comparative tablish the development of the body, that with the
measurings of the human body, the processing and comparison of consecutive measurements notices
studying of the gained measures. It finds a wide the progress or stagnation in development, and
application in sport, school, military and industrial that on the basis of certain anthropometric dimen-
medicine, and it has touching points with all other sions directs athletes towards sport disciplines in
branches of medicine. Anthropometric investi- which one can expect optimal success.
gations are direct indexes of the morphological The aims of this investigation are to investigate
structure of the body, and indirect indexes of the the anthropometric values of boys on a sample of
exchange of energy and the caloric balance of the 100 tested people, 50 who actively train basketball
organism. The investigations are performed with and 50 who do not train any sports at all, Canton
certain methods and according to the standard Sarajevo, Body Mass Index, the distribution of fat
conditions in the whole world, so the results can tissue and compare the anthropometric measur-
be compared. Anthropometric investigations serve ings.
to follow the growth and development of the hu- The research was performed on a chosen sam-
man organism, they encompass the measuring of ple of 100 boys aged 14 to 15 years, from which

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HealthMED - Volume 2 / Number 4 / 2008

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
HealthMED - Volume 2 / Number 4 / 2008

1. Introduction Anthropometric measurings are performed be-


cause of scientific research or for practical aims.
Anthropometric measurings are reliable and Growth is the increase of certain dimensions
precise, and they are applied as well on an indivi- or the total body mass. The speed of the growth
dual as on certain population groups. In medicine varies during the phases of growth and develop-
the most often used are the anthropologic chara- ment so that it is fast in the pre-natal, during the
cteristics which in a certain period give an idea of first year of life and in adolescence. The length
the health condition. The main rules and principles of a newly-born during birth totals to almost one
during the anthropometric measurings are to alw- third of his or her adult weight, and to the second
ays measure at the same time and if possible to year one half of the height which it will have as
measure with the same equipment and the same an adult.
technique. The control of the measurings should The development is an advancement of skills
be performed by the same person who performed and complex functions. The growth and the de-
the first measuring if possible. velopment are independent, mutually connected
One of the most important morphological cha- processes. The growth usually lasts during the first
racteristics is the body height, which shows the twenty years of life and the development continu-
growth, development, health condition and in- es even after that. The best possible growth and
directly the living conditions of that person. The development require an optimal health.
body height is the vertical distance from the base Factors which have an effect on the growth and
to the highest point on the top of the head. The development:
body height is measured in the morning, conside- Genetic potential A finally reached height and
ring that the height decreases during the day, beca- development of the child depend on the genetic
use of the flattening of the intervertebral discusses. potential of the parents and there is also a good
The measured person stands on an even base ba- corelation between the height of brothers and si-
refoot, straightens up, the hands are spread along sters.
the body, the feet straightened up to the knees, the Sex Male children are longer and heavier at
heels together and the tops of the feet apart. An birth than female children, but the differences fade
anthropometer is the most precise instrument for out with the reaching of the first year of life. Late
the measuring of height. in puberty distinct differences appear in height,
The body mass displays the health condition, weight and the proportions of the body.
physical development and the connection between Seasonal variations The speed of the growth
the morphological and the phisiological characte- in height is the fastest in spring and it can be twice
ristics of the person. The body mass is measured in as fast from the speed of growth in autumn, con-
the morning hours, after the emptying of the blad- trary to that the speed of the increase of body mass
der and the digestive tract, on an empty stomach if is the fastest in autumn.
possible without or with a minimum of underwear. Diet A regular and healthy diet provides a phy-
The body mass is measured with a medicinal deci- sically healthy growth and development, and a
mal scale with an additional weight. highly caloric and unhealthy diet leads children to
The indexes of the muscular and the body mass, physical problems and illnesses. A chronic malnu-
the functional condition and the physical develop- trition disables the child from reaching the height
ment of the organism are the body scopes. The body predicted by the genetic potential. Populations
scopes are measured on clearly defined points, desi- which suffer from chronic malnutrition do not
rably in the morning hours. The scope of the waist only have less body weight but they also have less
is measured in the middle between the rib arc and than average height. If a period od malnutrition did
the crest of the bone, and the scope of the hips on not last long the remnants can be substituted for in
the widest part of the flanks. The scopes of the body height with an accelerated growth. Shorter periods
are measured with a metal or plastic centimetre strip of malnutrition result only in the losing of weight,
and never with a linen one because of the impreci- without an effect on the height of the child.
seness which arises during the stretching.

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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)

• Physical development of the player


• The development of cognitive functions

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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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• 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

Body height (cm) • Anthropometric indexes represent certain


relations of the anthropometric measurings
• The body height was measured with an mutually, that is, the calculating of certain
anthropometer which consists of one vertical proportions.
metal rod with a scale, on which there is a • For the comparison of the somatic growth
mobile horizontal leg. of children many countries have set their
• The tested people were measured by standards, the so-called curves of growth and
standing on an even base barefoot with their development of children. For international
heels together and a little separated toes, comparings and for countries which do
their body and the top of their head resting not have such curves, such as Bosnia and
on the measuring scale. With the mobile leg Herzegovina, curves of growth are applied
of the anthropometer we touch the top of the which have been accepted by the World
head and we note down the height. Health Organisation.

Body weight (kg) 5. The results of research

• 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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HealthMED - Volume 2 / Number 4 / 2008

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%

Table 5. Body weight shown in percentages


Age 14 - 15
Percentages 3 - 25 26 -75 76 - 97 >97 Number
%
Body height (cm) 150-162cm 163-177cm 174-181cm >182cm of boys
Sport inactive boys 6 12% 26 52% 13 26% 5 10% 50 100%
Basketball players
0 0 5 10% 7 14% 38 76% 50 100%
K.K. “Željezničar”
Total 100
% %

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HealthMED - Volume 2 / Number 4 / 2008

Graph 1. Body height

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.

Table 6. Body height shown in percentages


Age 14 - 15
Centimeters 3 - 25 26 - 75 76 - 97 >97 Number
%
Body weight (kg) 39 – 49 kg 50 – 63 kg 64 – 81 kg >82 kg of boys

Sport inactive boys 7 14% 27 54% 13 26% 3 6% 50 100%


Basketball players
0 0 13 26% 35 70% 2 4% 50 100%
K.K. “Željezničar”
Total 100
% 100%

Table 7. The BMI of boys presented in percentages


Age 14 - 15
Percentages 3 - 25 26 - 75 76 - 97 >97 Number
%
BMI 16 - 18 18,1 – 21,5 21,6 - 27 >27 of boys

Sport inactive boys 33 66% 12 24% 5 10% - - 50 100%


Basketball players
15 30% 31 62% 4 8% - - 50 100%
K.K. “Željezničar”
Total 100
% 100%

260 Journal of Society for development of teaching and business processes in new net environment in B&H
HealthMED - Volume 2 / Number 4 / 2008

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

The values of the BMI on the graph show a


meek malnutrition in 66% of sport inactive boys
and 30% of basketball players, the normal nutriti- Graph number 4. DTM

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

Journal of Society for development of teaching and business processes in new net environment in B&H 261
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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-

262 Journal of Society for development of teaching and business processes in new net environment in B&H
HealthMED - Volume 2 / Number 4 / 2008

yed in the percentage curves. The average body Recommendations


height was established for 90% of boys without
sport activities. For basketball players the average To promote natural diet of newly-borns and he-
body height was established for 24%. The avera- althy ways of living in the family. Perform syste-
ge body weight was established for 94% of boys matic and especially periodic check-ups if school
without sport activities. For basketball players the children and youth because of an early detection
average body height was established for 96%. The and prevention in the deviations of growth and
average BMI was established for 100% of basket- development. Perform health enlightenment of
ball players. The average values of the DMT was school children and youth, professors and educa-
established for 56% of boys without sport activi- tors and parents. Children in pre-school age sho-
ties. For basketball players the average DMT was uld be introduced to organized programs of sports
present in 94% of them. The deviations in body (children playhouses), which enables an individu-
height was established for 10% of boys without al development of intelligence and physical abili-
sport activities, and deviations in body height was ties with play and socialising. Recommend speci-
established for 76% of basketball players. The de- al sport activities to children encompassed in the
viations in body weight was established for 6% sport clubs.
of boys without sport activities, and deviations in
body weight were established for 4% of basketball Advantages and use from training sports
players. The deviations in relation to the BMI are for children
neither present in boys without sport activities nor
in basketball players, and deviations in relation to A haromonious growth and development of all
the DMT were established for 44% of boys wit- organic systems and especially the cardiovascular
hout sport activities. The deviations in relation to system, the respiratory system and the muscular
the DMT were established for 6% of basketball – bone system. A positive effect on the psychic
players. Our results have shown an above avera- functions especially on the reduction of stress, the
ge height for even 76% of basketball players, so strengthening of self-confidence, one learns per-
one sets the question whether intensive training of sistence, the acquiring of working habits, moral
basketball has an effect on the body height or do responsibility is developed through a respectful
the boys with an above average height more often and correct relationship towards the teammate and
decide to train basketball. In the group of boys opponent. Children athletes are not: obese, they do
without sport activities we had 10% of an above not consume alcohol, they do not smoke, they do
average height. There is only one more distinct in- not take drugs, they are even less absent from their
dicator in the deviations and that is the DMT for lessons, they have fewer risks of falling ill from
boys without sport activities, 44% of them has an chronic diseases.
increased or risky DMT. For the DMT we are sure
that basketball has a positive effect because the
majority of basketball players had an ideal relation
of waist and hips.

Journal of Society for development of teaching and business processes in new net environment in B&H 263
HealthMED - Volume 2 / Number 4 / 2008

Literature 13. Jusupovic F, Pokorn D, Kudumovi A, Hadzihali-


lovic J, Kudumovic M, Stoisavljevic D. Skin folds
1. Jannssen I, Katzmaryzk PT, Ross R. Body mass in- under the chin for scholage children, HealthMED
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2. International Obesity Task Force. Childhood Obe-
Dijana Avdic
sity. Report 2004;1-5.
KCU Sarajevo,
3. Lobstein T, Frelut ML. Prevalence of overweight Bosnia and Herzegovina,
among children in Europe. Obes Res 2003;4(4):1- e-mail: dijana2007@gmail.com
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4. Willms JD, Tremblay MS, Katzmaryzk PT. Geogra-
phic and demographic variation in the prevalence
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dren living in the province of Belgian Limburg. Eur
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6. Ogden C, Flegal K, Carroll M, Johnson C. Preva-
lence and trends in overweights among US children
and adolescents, 1999-2000. JAMA 2002; 288 (14):
1728-32.
7. Kafatas A, Codrington CA. “Eurodiet”. Nutrition
and diet for healthy lifestyles in Europe.European
Commission, 2001.
8. Kolacek S, Kapetanovic T, Luzar V. Early determi-
nants of cardiovascular risk factors in adults. B:
Blood pressure. Acta Paediatr 1993;82:377-82.
9. Tuvemo T, Cnattingius S, Jonsson B. Prediction of
male adult stature using anthropometric data at
birth: a nationwide population-based study. Ped
Res 1999;46:491-5.
10. Apostolidis N, Nassis GP, Bolatoglou T, Geladas
ND. Physiological and technical characteristics
of elite young basketball players. J Sports Med
Phys Fitness. 2004 Jun;44(2):157-63.
11. Fett C, Fett W Fabbro A, Marchini J. Dietary Re-
education, Exercise Program, Performance and
Body Indexes Associated with Risk Factors in
Overweight/Obese Women. J Int Soc Sports Nutr.
2005 Dec 9;2:45-53.
12. Drinkwater EJ, Hopkins WG, McKenna MJ, Hunt
PH, Pyne DB. Modelling age and secular diffe-
rences in fitness between basketball players: a 10-
year-period investigation. Br J Sports Med. 2008
Jan;42(1):25-30. Epub 2007 May 25.

264 Journal of Society for development of teaching and business processes in new net environment in B&H
HealthMED - Volume 2 / Number 4 / 2008

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

Summary some variations and calculating hi-square of test


for comparable some variations.
Introduction: Health facilities are big produ- Results: Research have shown that in three the
cers of infectious and laboratory’s material waste biggest Clinical centers in area of Federation of
which present the most dangerous sorts of medical Bosnia and Herzegovina, 60% of infectious and
waste because of high degree of infectious, hur- laboratory’s waste is taking away together with
ting and poisoning. Carrying of this material wa- communal waste.
ste becomes big problem for all health facilities Conclusion: Results of research have shown
and it declares in increasing its quantity. That way that methods of taking away infectious and labo-
danger of spreading infectious illness is increa- ratory’s waste from three the biggest Clinical cen-
sing and it is necessary to respect strict criteria of ters in area of Federation Bosnia and Herzegovina
evidence and supervision from place of approving are not safe, in fact, big part of this waste is taking
this material waste to place it is finally carrying. away in deponia with communal waste. That way,
Target: Research had aim to interrogate the this sort of waste presents big epidemiologic risk.
way of storaging, transportation, carrying and For establishing of complete of infectious waste
control of infectious and laboratorys’ material wa- system in Bosnia and Herzegovina, Federation,
ste in three the biggest clinical centers in area of Canton and health facilities, it is necessary, first of
Federation of Bosnia and Herzegovina. all, to create regulative law and regulations which
Methodology: Sample includes Clinical cen- would regulate system of institutions correctly for
ters in Sarajevo, and Tuzla, and Clinical hospi- command of medical waste. It is necessary to crea-
tal in Mostar. In order to get informations about te three or five year plan of carrying infectious and
producer of infectious and laboratorys’ material the other medical waste and also to create detail
waste, its sort, structure, collection, transportation instructions about principles of operate this sort of
and carrying, we used questionnaire as instrument waste in all levels of health protection.
of research. Research questionnaire is sketched on
the base of directives which is recommended by
CDC from Atlanta. For treatment and review of
information’s we used descriptions statistics (per-
centual perception) in analysis of correlations of

Journal of Society for development of teaching and business processes in new net environment in B&H 265
HealthMED - Volume 2 / Number 4 / 2008

Sažetak otpada iz u tri najveća klinička centra na području


Federacije Bosne i Hercegovine nisu sigurne, ta-
Uvod: Zdravstvene ustanove su veliki proizvo- čnije, veliki dio ovog otpada se odlaže na deponije
đači infektivnog i laboratorijskog otpada, koji zbog zajedno sa komunalnim otpadom. Na taj način ova
visokog stepena rizika od infekcija, ranjavanja i vrsta otpada predstavlja veliki epidemiološki rizik.
trovanja predstavljaju najopasnije vrste medicin- Za uspostavljanje cjelovitog sistema upravljanja
skog otpada. Zbrinjavanje ovog otpada postaje ve- medicinskim otpadom na nivou BiH, Federacije,
liki problem svih zdravstvenih ustanova, a očituje Kantona i samih zdravstvenih ustanova, potrebno je
se u povećavanju njegove količine. Na taj način se najprije stvoriti zakonsku regulativu i propise koji
povećava i opasnost od širenja infektivnih bolesti, bi tačno regulisali sistem upravljanja medicinskim
pa je neophodno poštovati stroge kriterije eviden- otpadom. Neophodna je izrada tro- ili petogodi-
cije i nadzora, od mjesta nastanka ovog otpada, do šnjeg plana zbrinjavanja infektivnog i ostalog me-
mjesta njegovog konačnog zbrinjavanja. dicinskog otpada, kao i izrada i primjena detaljnih
Cilj: Istraživanje je imalo za cilj da ispita na- uputa o principima rukovanja ovom vrstom otpada
čin skladištenja, transporta, zbrinjavanja i kontrole na svim nivoima zdravstvene zaštite.
infektivnog i laboratorijskog otpada u tri najveća
klinička centra na području Federacije Bosne i
Hercegovine. 1. Introduction
Metodologija: Uzorak je obuhvatio Kliničke
centre u Sarajevu i Tuzli, te Kliničku bolnicu u During giving health services (diagnosis, treat-
Mostaru. Da bi se dobili podaci o proizvođaču ment of patient) there are huge amount of infec-
infektivnog i laboratorijskog otpada, njegovoj vr- tious and laboratory’s waste left, which can en-
sti, strukturi, sakupljanju, prevozu i zbrinjavanju, danger health of people and environment. In total
služilo se anketnim upitnikom, kao instrumentom pollution this sort of waste has a big part (5-12%),
istraživanja. Istraživački anketni upitnik je konci- but it consists of waste matters which were creat-
piran na osnovu smijernica koje preporučuje CDC ed to protect health of people and animals’ health
iz Atlante. Za obradu i prikaz podataka koristila and/or similar research, it is necessary to care it
se deskriptivna statistika (procentualno učešće) u according to fast requests.
analizi korelacija pojedinih varijabli, kao i izraču- Infectious waste often contains pathogen bio-
navanje hi-kvadrat testa za uporedni prikaz poje- logical agens which make illness in people who
dinih varijabli. are under that influence because of its type, con-
Rezultati: Istraživanje je pokazalo da se u tri naj- centration and number, and means: culture and
veća klinička centra na području Federacije Bosne i tools from microbiology laboratory, parts of equip-
Hercegovine 60% infektivnog i laboratorijskog otpa- ment, material and tools which come in touch with
da odlaže zajedno sa komunalnim. Najveći problemi blood or secrets of illness people or it is used for
su vezani za skladištenje i tretman ove vrste medi- surgical operations (needle, lancets, syringes, scal-
cinskog otpada. Potvrđeno je postojanje statističkih pels) bandage a wounds (bandages, tampons) and
razlika između pojedinih kliničkih centara. Najne- abductions and waste materials from department
povoljnija situacija jeu Kliničkoj bolnici u Mosta- for isolation patients and department for dialysis,
ru, jer se kompletan čvrsti infektivni i laboratorijski systems for infusions and transfusion, gloves and
otpad odlaže zajedno sa komunalnim. Postrojenja other tools for one way use, clothes of staff, and
za obradu infektivnog otpada u Kliničkom centru u material which is in contact with experimental
Sarajevu, prerađuju 1/3 nastalog infektivnog otpa- animals which are injected with of infectious ma-
da, a situacija je najpovoljnija u Kliničkom centru terial. Pathological waste – parts of human body,
u Tuzli, gdje se svega 13,33% neobrađenog infe- amputated parts, tissues, organs which are remo-
ktivnog i laboratorijskog otpada odlaže zajedno sa ved during surgical interventions, tissues taken in
komunalnim. diagnostic purpose, lancets, and fetuses and so on,
Zaključak: Rezultati istraživanja su pokazali are special sort of potential infectious waste. Path-
da metode odlaganja infektivnog i laboratorijskog ological waste has ethic meaning. (1,2,3)

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;

Journal of Society for development of teaching and business processes in new net environment in B&H 267
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.

Journal of Society for development of teaching and business processes in new net environment in B&H 269
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
HealthMED - Volume 2 / Number 4 / 2008

Repulsing of harmful rodents in


specific environmental conditions
of pharmaceutical factory
SUZBIJANJE ŠTETNIH GLODAVACA U
SPECIFIČNIM UVJETIMA NA PODRUČJU
FARMACEUTSKE TVRTKE
Suad Habes1, Sandra Mramor-Muzevic1, Sefkija Muzaferovic2
1
Fakultet zdravstvenih studija Sarajevo
2
Prirodno-matematicki fakultet Sarajevo

Summary med four times during 2006. Before performing


every act of deratization, it would be wise to detect
In practice, the term deratization is used to des- which rodent species live in the area that we want
cribe all types of measures and actions that are un- to get rid of of the rodents. For the hunting of a co-
dertaken to repulse populations of harmful rodent uple of rodents we used so called “sticky decoys“.
species (mice, rats, mouse like rodents- voles, fi- Also, precaution has been taken that a percentage
eld mice and wood mice). The term deratization of abundance of each species should be known be-
comes from word de-rat which means “get rid of forehand. The assessment has shown that rodent
rats”. Repulsing of harmful rodent species was population is rapidly increasing up to 500-1,000
carried out inside pharmaceutical company in city individuals during the spring and autumn months,
of Zagreb in area which size is 80. 000m2. For the but during summer and winter population estimate
implementation of deratization, the rodenticides is about 100-500 individuals.
Brodilion paraffin blocks from 30, 100 and 200g
as well as Brodifakum paraffin blocks from 25 to
210g were used. The rodents are important pests Sažetak
for humans because they carry out a quite number
of contagious diseases. Especially, they represent U praksi deratizacijom se nazivaju sve mjere i
a great danger when their population is increasing postupci koji se provode s ciljem suzbijanja odno-
rapidly in the areas of the factories that produce sno smanjenja populacije štetnih glodavaca (miše-
food and medical supplies for humans. The most vi, štakori, mišoliki glodavci – voluharice, poljski
important pests to humans are Rattus norvegicus- i šumski miševi). Sam naziv deratizacija dolazi
gray rat, Rattus rattus-black rat, and Mus muscu- od riječi de-rat što zapravo znači «osloboditi od
lus-house mouse. These species contaminate gro- štakora». Suzbijanje štetnih glodavaca je vršeno
ceries, water and surfaces with their urine, feces, unutar jedne farmaceutske tvrtke u Zagrebu čija
saliva, bite and with their ectoparasytes. Also, they je povrsina 80. 000m2. Za deratizaciju su korišteni
are the carriers of many harmful diseases like ba- Brodilion parafinski blokovi od 30, 100 i 200g., te
cterial diseases (salmonella, plague, and brucel- Brodifakum parafinski blokovi od 25 i 210g. Glo-
losis) and rickettsial and viral diseases (typhus, davci predstavljaju velike štetočine i prenosioce
encephalitis). The act of deratization was prefor- zaraznih bolesti. Posebnu opasnost predstavljaju

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
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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
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Results and Discussion spectively. Brodilon 100 g blocks were consumed


in the amount of 5,400g, 200 g blocks in the amo-
First step in our approach was to determine the unt of 1,600g, whereas 3,360 g of Brodifakum 210
level of infestation of investigated area by using g blocks were consumed concomitantly. Overall,
the method of Gunderson. By using the method 48,880 g of different blocks was consumed in four
criteria, we have found that the population size sessions during 2006.
was between 500 and 1,000 during spring and au- Table 2. illustrates a summary data for the Bro-
tumn. Conversely, we have found that the level of dilon paraffin 30 g and Brodifakum 25 g blocks re-
infestation was lower during summer and winter spective consumptions during the execution of four
and that population size was between 100 and 500 acts of deratization in 2006 which was performed
rodents. on the outdoor 20. 000 m2 big green surface area
Table 1. presents a summary data for the pa- and streams (canals) at their entire 400 m length. As
raffin blocks consumption during the execution of expected, overall consumption of paraffin blocks
four acts of deratization of the sewerage system was in accordance with the level of infestation; du-
(drain manholes and revision apertures) performed ring spring and autumn periods, when infestation
in 2006. Since the level of infestation was lower was higher, the deratization was done by placing
during summer and winter sessions, one Brodilon alternately two Brodilon and one Brodifakum block
and Brodifakum paraffin block each were used in at 10m distance intervals (2:1 ratio) on designated
that period. The consumption of paraffin blocks areas whereas during the summer and winter peri-
has increased during spring and autumn due to in- ods, when infestation decreased, the baits were put
crease in rodent population. Accordingly, an incre- at 20 m intervals and at 1:1 ratio. Consequently,
ased amount of paraffin blocks of different weight during spring and autumn sessions of deratization
(100 g, 200 g, and 210 g) was applied. It can be total of 8,500 g of paraffin blocks was consumed in
seen from the table that the consumption of a pa- each period and included the consumption of 6,000
raffin blocks stand at 15,760 during spring as well g Brodilon 30 g blocks and 2,500 g Brodifakum 25
as autumn actions and that 10,800 g of Brodilon g blocks, respectively. An overall paraffin blocks
100 g blocks as well as 1,600 g of Brodilon 200 g consumption during summer and winter period
and 3. 360 g Brodifakum 210 g blocks were used. was 1,730 g of blocks in each period and included
On the other hand, 8,680 g of different blocks were consuming 930 g Brodilon and 800 g Brodifakum
consumed during summer and winter actions, re- paraffin blocks, respectively.
Table 1. Consumption of the 100 g and 200 g Brodilon and Brodifakum paraffin 210 g blocks used for
deratization of the sewerage system (drain manholes and revision apertures).
Brodilon Brodilon Brodifakum
Time of deratization Total
paraffin block 100 g paraffin block 200 g paraffin block 210 g
Spring 10. 800 g 1. 600 g 3. 360 g 15. 760 g
Summer 5. 400 g 1. 600 g 1. 680 g 8. 680 g
Autumn 10. 800 g 1. 600 g 3. 360 g 15. 760 g
Winter 5. 400 g 1. 600 g 1. 680 g 8. 680 g
Total 32. 400 g 6. 400 g 10. 080 g 48. 880 g

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

Journal of Society for development of teaching and business processes in new net environment in B&H 279
HealthMED - Volume 2 / Number 4 / 2008

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

Kumatetralil 16. 5 Brodifakum 0. 3

Difacinon 3. 0 Flokumafen 0. 4

Warfarin 58. 0 Bromadiolon 1. 3

Pival 50. 0 Difenakum 1. 6

Klorfacinon 20. 5

280 Journal of Society for development of teaching and business processes in new net environment in B&H
HealthMED - Volume 2 / Number 4 / 2008

Conclusions 8. Based on overall data, it has been concluded


that the measures which have been
1. Efficacious eradication of rodents is based undertaken during 2006 were successful
on the comprehension of their biological, and that the choice of paraffin decoys was
etiological, and ecological distinctiveness. appropriate for the act of deratization in
The act of deratization is a complex and wet conditions in the open green areas and
responsible action requesting methodical sewerage system of the pharmaceutical
preparatory and organizational activities and factory in Zagreb.
requests skilled staff to execute it properly.
2. Deratization in wet conditions is a
unique activity which asks for additional
Literature
organizational efforts, particularly the
determining the most efficacious formulation 1. Capak K. : Javnozdravstvena važnost deratizaci-
and suitable form of decoys which will be je, Zbornik predavanja, Glodavci i ptice, Zagreb,
used. 2002: 1
3. For the purpose of the eradication of 2. Capak K. , Korunić Z. : Javnozdravstvena i gospo-
rodents in wet environments, specifically darska važnost štetnika uskladištenih poljoprivre-
the deratizations of the open green areas dnih proizvoda i hrane, Zbornik predavanja, Štetni-
and sewerage system of the pharmaceutical ci hrane, uskladištenih poljoprivrednih proizvoda i
factory, the manufactured paraffin blocks of predmeta opće uporabe te muzejski štetnici, Zagreb,
different weight and dimensions containing 2005 : 3
anticoagulants of the second generations 3. Krajcar D. : Dezinfekcija, dezinsekcija, deratizacija,
(Brodilon and Brodifakum), were used. Zagreb: Zavod za javno zdravstvo grada Zagreba,
2001, 167-198
4. During four sessions of deratization in 2006
the amount of 55,600 g Brodilon paraffin 4. Bakić J. : Naši sinantropni mišoliki glodavci, Zbor-
blocks as well as 18,480 g Brodifakum was nik predavanja, Glodavci i ptice, Zagreb, 2002: 1
spend. 5. Pravilnik o načinu obavljanja obvezatne dezinfekci-
5. Generally, full amount of spent paraffin je, dezinsekcije i deratizacije (NN 38/98)
blocks which were chosen for deratization 6. Krajcar D. : Praktična provedba deratizacije, Zbor-
in wet conditions in 2006 was 74,080 g. The nik predavanja, Glodavci i ptice, Zagreb, 2002: 43
degree of infestation was assessed by using
7. Zidar R. , Poljak V. : HACCP-teorija i praksa s po-
method of Gunderson.
sebnim osvrtom na kontrolu štetočina, Zbornik pre-
6. The level of infestation and the size of rodent davanja, Dezinfekcija, dezinsekcija i deratizacija u
population in designated area was calculated HACCP sustavu, Zagreb, 2004: 11-23
to be between 500 and 1,000 during spring 8. Molek K. : Analiza rizičnih kontrolnih mjesta za
and autumn whereas population size was sprovođenje djelotvorne deratizacije (HACCP),
estimated to be between 100 and 500 during DDD i ZUPP 2001, Novine u djelatnosti dezinfe-
the summer and winter time. kcije, dezinsekcije, deratizacije i zaštite uskladište-
nih poljoprivrednih proizvoda, Poreč, 2001:226
7. Three weeks after performing of deratization
additional evaluation of the level of 9. Milinković Lj. : Suzbijanje glodavaca, DDD i ZUPP
infestation was done; it has been concluded 2001, Novine u djelatnosti dezinfekcije, dezinsekci-
that population size has been reduced bellow je, deratizacije i zaštite uskladištenih poljoprivre-
dnih proizvoda, Poreč, 2001: 216
100 rodents.

Journal of Society for development of teaching and business processes in new net environment in B&H 281
HealthMED - Volume 2 / Number 4 / 2008

10. Lukić I. , Veledar H. : Preventivna sustavna de-


ratizacija kanalizacijske mreže-nova saznanja , 5.
znanstveno stručni skup iz DDD-a s međunaro-
dnim sudjelovanjem, Pouzdan put do zdravlja ži-
votinja, ljudi i njihova okoliša, Mali Lošinj, 2004:
380
11. Bakić J. : Način provedbe obvezatne dezinsekcije
i deratizacije, Zbornik predavanja, Oživotvorenje
Pravilnika o uvjetima i načinu provođenja obve-
zatnih DDD mjera-provedba u praksi, Zagreb,
2006: 31,32
12. Bakić, J. : Prednosti krutih raticidnih meka s djela-
tnim sastavcima I i II generacije antikoagulanata
u sustavnoj deratizaciji razorenih naselja. Zbor-
nik 2. znanstveno stručnog skupa s međunarodnim
sudjelovanjem DDD u zaštiti zdravlja životnja i
očuvanju okoliša, Umag, 1995: 267-273

Corresponding author:
Suad Habes
Fakultet zdravstvenih studija Sarajevo
Bosna i Hercegovina
e-mail: hsuad@hotmail.com

282 Journal of Society for development of teaching and business processes in new net environment in B&H
HealthMED - Volume 2 / Number 4 / 2008

The relationship between


myocardial viability and
collateral circulation
ODNOS VIJABILNOSTI MIOKARDA I
KOLATERALNE CIRKULACIJE
Aida Hasanovic
Institute of Anatomy, University of Sarajevo, School of Medicine, Bosnia and Herzegovina

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

Journal of Society for development of teaching and business processes in new net environment in B&H 283
HealthMED - Volume 2 / Number 4 / 2008

Introduction culation angiographically documented on myocar-


dial viability in patients with coronary occlusion.
The relationship between the presence of viable
myocardium and the extent of coronary collateral
circulation to the infarct area during occlusion of Patients and methods
coronary arteries was evaluated by authors (1, 2,
3, 4). Eighty patients with angiographically docu-
Although coronary arteriography provides cle- mented coronary artery disease at the Department
ar definition of significant coronary artery disease of Nuclear Medicine were investigated by (201Tl)
it is less satisfactory in the delineation of coronary myocardial scintigraphy, shortly after coronary
collateral vessels for it reveals only epicardial ana- artery disease had been demonstrated by contrast
stomoses of a size no smaller than 100-200 ų and arteriography.
not the deeper connections which exist within the All patients selected for myocardial imaging
myocardium (5,6,7). had severe stenosis or total occlusion of at least
Angiography is used for measuring coronary one major coronary artery. The majority of pati-
artery lumen norrowing; however, it is not the ide- ents had complete occlusion of at least one vessel.
al method for determining its physiologic signifi- A significant coronary stenosis was defined as re-
cance (8). duction of the coronary lumen by more than 50
Myocardial imaging using thallium-201 (201Tl) per cent, and severe stenosis as a reduction in dia-
is a non–invasive technique which is valuable in metar greater than 80 per cent.
the analysis of regional myocardial perfusion. Re- Patients with hypertension, valvular heart dise-
gions of ischemia caused by severe coronary dise- ase, or primary myocardial disease were excluded
ase appear as functional defects of tracer accumu- from this study.
lation in the myocardial scintigram (9,10). The study was approved by the local ethical
The most widely available method for iden- commitee and conducted in accordance with the
tification of viable myocardium is single photon Helsinki declaration.
emission computed tomographic (SPECT) ima-
ging with thallium-201 (Tl-201).
Thallium 201 enters myocytes primarily by Coronary Angiography
active transport, which means that regional my-
ocardial concentration of Tl-201 is dependent on Selective coronary angiography was perfor-
regional blood flow, extraction and clearance. Ne- med in multiple projection using the Judkins tec-
crotic myocardium, without an intact cell mem- hnique. All coronary arteriograms were reviewed
brane, is unable to retain Tl-201. In viable myo- independently by two observes in ignorance of the
cardium, Tl-201 is continuously exchanged betw- scintigraphic analysis, and note was made of the
een the myocardium and the blood stream, with site and number of complete coronary occlusions
the rate of exchange in proportion to the difference and severe coronary stenoses together with any as-
in Tl-201 concentration between the myocardium sociated coronary collateral channels.
and the blood stream. Therefore, after the admini- We determinated a maximal lumen constriction
stration of Tl-201, the myocardium concentration of the coronary artery (right coronary artery-RCA,
is greatest in those areas of myocardium with the left anterior descending artery-LAD, and circum-
highest blood flow. Over time, a tendency toward flex artery –Cx) and the existence, origin and the
equilibrium of Tl-201 concentration in viable my- direction of collateras.
ocardium. This phenomenon is termed „redistri- On the angiograms we analyzed collaterals
bution“. Therefore, a Tl-201 perfusion defect that as “adequate” (average calibar greater than 1,0
is reversible is considered indicative of ischemic mm) and “inadequate” (average calibar -1mm and
but viable myocardium (11). less).
Using 201Tl imaging, we have analysed the in- For all patients we applied left ventriculogra-
fluence of well-developed coronary collateral cir- phy for the evaluation of its function, ejective fra-

284 Journal of Society for development of teaching and business processes in new net environment in B&H
HealthMED - Volume 2 / Number 4 / 2008

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

Studies of regional myocardial perfusion were Results


performed at rest and during pressure (a maximal
exercise test on a bicycle ergometer). All patients The study included 80 patients with chronic
had a complite physical examination, resting 12 total occlusion who underwent rest-stress myo-
lead electrocardiogram, and an electrocardiogram cardial perfusion scintigraphy and coronary angi-
recorded during a maximal exercise test on a Mo- ography.
nark bicycle ergometer with lead V5 monitoring. Patients were divided into two groups accor-
During the exercise test each patients received ding to the presence (group 1, n =45) or absence
1,5 mCi of 201Tl through an indwelling intraveno- (group 2, n =35) of viable myocardium in the per-
us canila at the onset of angina pectoris or limiting fusion territory of the infarct-related artery.
dispnoea. In the first group we established well-develop-
The exercise end-point was maintained for one ment coronary collateral vessels and predominan-
and a half to two minutes so that there was maxi- tly normal or hypokinetic left ventricular function.
mal myocardial uptake of circulating tracer in the In the group with poor collaterals in the vast majo-
presence of symptoms. rity cases demonstrated akinesia or dyskinesia of
After a 10–minute recovery period, myocardial the corresponding myocardial segment.
imagining was performed with subjects in the su- The difference between the two groups was si-
pine positions using a gamma camera and a high- gnificant at the 0.001 level. An ejection fraction in
sensitivity parallel-holed collimator. the group with well-developed coronary collateral
Anterior, left anterior oblique 45º and 70º were vessels and good left ventricular function was >
routinely acquired in every patients (each positi- 50%; in the group with inadequate collateral cir-
on-five minuts) after exercise and redistribution culation was 35%.
after 3 hours. A 20 % symmetric energy window The viability of myocardial tissue was assessed
centered on the 72 keV peak was used. by exercise thallium-201 myocardial scintigraphy.
All projections images were stored on ma- Our patients with chronic total occlusion had
gneto-optic disks in a 64x64 matrix. The digital severe and extensive stress-induced myocardial
images were displayed on a TV monitoring. After perfusion defects regardless of the grade of angi-
computer treatment a digital scintigraphic images ographic coronary collaterals. The perfusion de-
were described by one interpreter. fects in the group with good collateras were pre-
Localisation of perfusion defects in relation dominantly reversible (Figure 1), suggesting that
with corresponding blood vessel determinated well-developed coronary collaterals preserved
visual on each image divided into five segments. myocardial viability in the regions subtended by
Each defect was further classified as moderate or a total coronary occlusion. In the group with poor
severe according to the degree of tracer deficit coronary collateral development the perfusion de-
seen in that region. fects were predominantly ireversible.
The result was considered “positive“ when a re-
versible defect was allocated to the perfusion territo-
ry of the coronary artery of interest. Defects located
in the anterior wall and septal region were allocated
to the left anterior descending artery, defects in the
lateral wall were allocated to the left circumflex co-
ronary artery, and defects in the inferior wall were
allocated to the right coronary artery.

Journal of Society for development of teaching and business processes in new net environment in B&H 285
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dial perfusion defects regardless of the grade of


angiographic coronary collaterals.
Several studies have suggested that coronary
collaterals preserve resting myocardial flow but
are inadequate to protect againist reduced blood
flow during hyperemic stress (6,7). In contrast,
several studies with planar 201 scintigraphy sugge-
sted that coronary collaterals also prevent stress-
induced ischemia (1,2,3, 8,11).
Our study showed that the perfusion defects in
the group with good collateras were predominan-
tly reversible, suggesting that well-developed co-
ronary collaterals preserved myocardial viability
in the regions subtended by a total coronary oc-
Figure 1. Single-photon emission tomography of clusion. In the group with poor coronary collateral
the heart with 201tallium was performed accor- development the perfusion defects were predomi-
ding to standard stress (planar projection -45 º); nantly ireversible. In this group the absence of vi-
Analysis of perfusion scintigrams in patients with able myocardium in the perfusion territory of the
angiographically documented collaterals referen- infarct-related artery was established.
ce to reversible defect of infero-lateral segment, The relation between the degree of coronary
and ischemia of this region collateral development assessed angiographicaly
and the severity of 201 Tl uptake defects seen in the
The relation between the degree of coronary myocardial scintigram in our patients showed a
collateral development assessed angiographicaly association between well-developed coronary col-
and the severity of 201 Tl uptake defects seen in the lateral vessels and accompanying preservation of
myocardial scintigram showed a highly significant myocardial 201 Tl uptake.
association between well-developed coronary col- Using 201Tl myocardial scintigraphy many pa-
lateral vessels and accompanying preservation of tients with total occlusive disease of a dominant
myocardial 201 Tl uptake. Similary, poor or absent right coronary artery are seen to have adequate
coronary collateral development was usually as- collateral vessels providing complete protection
sociated with severe deficit of tracer in correspon- from ischemia in the distribution of this artery du-
ding regions of the scintigram. ring dynamic exercise. Patients with left anterior
Angiographically invisible collaterals were ne- descending disease, however, were not protected
ver associated with complete scintigraphic prote- from the appearance of ischaemic uptake defects
ction and usually conferred no protective benefit. (4,5).
Similary, vessel ghosting was always accompanied Although the mechanism for this protection is
by severe scintigraphic uptake defects. Bridging not clear the normal pressure gradient that exists
collaterals also offered inadequate protection from between left and right ventricles may be increased
myocadial ischemia during exercise. during dynamic exercise, particulary during dia-
stole in an ischaemic left ventricle, so that collate-
ral flow is maintained or increased in the direction
Discussion of the low pressure right ventricular myocardium.
This effect probably accounts for the preservation
In patients with a chronic total occlusion, our of tracer uptake in the inferior wall of the left ven-
study investigated the relationship between the an- tricle as seen in 201Tl scintigrams (9,10).
giographic development of collateral circulation However, one relevant limitation of 201TI ima-
and myocardial viability in patients with coronary ging is that relative regional myocardial ischaemia
occlusion. Patients with chronic total occlusion is reflected in the scintigram rather than in terms
had severe and extensive stress-induced myocar- of absolute perfusion. Thus, it is possible that even

286 Journal of Society for development of teaching and business processes in new net environment in B&H
HealthMED - Volume 2 / Number 4 / 2008

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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HealthMED - Volume 2 / Number 4 / 2008

Application of cognitive behavior


therapeutic techniques for
prevention of psychological
disorders in police officers
PRIMJENA KOGNITIVNO-BIHEVIORALNIH
PSIHOTERAPIJSKIH TEHNIKA U PREVENCIJI
PSIHIČKIH POREMEĆAJA KOD POLICAJACA
Sibila Sijaric-Voloder1, Dzejna Capin1
1
Association for psychological assessment, help and consulting ‘’DOMINO’’

Summary into two groups, each consisting of 20 persons.


One group received structured stress management
Introduction: Police work has been recogni- program and another did not. All members of both
zed as high risk for stress. Police officers are expo- groups completed BAI and ASI tests ahead and
sed on daily basis to stressful and traumatic events, after the treatment, as well as three months after
that is, the events outside usual human experience the treatment.
(e.g. serious threat to one’s life and body integrity, Outcomes: Statistical data analyzes revealed
witnessing violent acts or severe physical harm or that the subjects who had received stress mana-
death of another). gement program displayed a statistically signifi-
Consequences and symptoms of stress include cant anxiety sensitivity reduction, developed more
physical and psychosomatic illnesses, behavior active and planned coping strategies for stressful
changes, emotional and cognitive problems. Once situations, had less somatic reactions to stress and
the reaction to traumatic experience, judged by its have thus also achieved improved performance at
intensity and duration, exceeds one’s “subjective work and in private life. The subjects were also
coping threshold” we talk about pathologic reacti- significantly more likely to request medical advice
on to trauma which can cause various psychologi- after completing psychotherapeutic program.
cal disorders. Conclusions:
Objectives: Objective of our work was to de- - The group of police officers who had received
velop a structured stress management program the structured stress management program regi-
based on cognitive behavior therapy principles stered statistically significant anxiety sensitivity
for persons in high risk professions such as police reduction compared to the test group.
officers. Another objective was to evaluate the ef- - The subjects who had completed the program
fects of structured stress management program on were significantly more likely than the subjects
police officers by measuring their anxiety levels from control group to request medical advice in
before and after the treatment. crisis situations.
Materials and methods: The subjects were Key words: cognitive-behavior psychothera-
police officers, aged from 30 to 45 years, divided py, stress management, anxiety.

288 Journal of Society for development of teaching and business processes in new net environment in B&H
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Sažetak - Spremnost da se obrate za stručnu pomoć u


kriznim situacijama je kod ispitanika značajno po-
Uvod: Posao policajca spada u grupu visokori- rasla dok kod kontrolne grupe nije došlo do pro-
zičnih zanimanja po pitanju stresa. Svakodnevna mjena.
je izloženost policajaca stresnim i traumatskim do- Ključne riječi: kognitivno-bihevioralna psiho-
gađajima, odnosno događajima koji su izvan gra- terapija, stres menađment, anksioznost.
nica uobičajenog ljudskog iskustva (npr. ozbiljna
prijetnja životu ili tjelesnom integritetu, pogled na
drugu osobu koja je ozbiljno povrijeđena ili ubije- Introduction
na u nesreći, odnosno nasilnom činu te prisustvo
takvim događajima). Police work has been recognized as high risk
Posljedice ili simptomi stresa su tjelesni-psi- for stress. Police officers are exposed on daily basis
hosomatske bolesti, promjene u ponašanju, emo- to stressful and traumatic events, that is, the events
cionalne posljedice te kognitivne smetnje. Kada outside usual human experience (e.g. serious threat
reakcije na traumatsko iskustvo pređu određenu to one’s life and body integrity, witnessing violent
mjeru po „subjektivnoj nepodnošljivosti“, po obi- acts or severe physical harm or death of another).
mu i trajanju govorimo o tzv. patološkom obliku Consequences and symptoms of stress include
reakcije na traumu koje može biti uzrok razvoja physical and psychosomatic illnesses (hart and co-
različitih psihijatrijskih poremećaja. ronary artery diseases, digestive problems, asthma,
Cilj rada: Cilj rada je bio strukturirati stres dermatologic diseases, spinal problems etc.), be-
menadžment po principima kognitivno-bihevio- havior changes (abuse of alcohol and some medi-
ralne psihoterapije za lica koja obavljaju visoko cines – anxiolitics or social withdrawal, increased
rizične poslove kao što su policajci. consumption of coffee, alcohol, food, excessive to-
Također, cilj rada je bio evaluirati efekte stru- bacco smoking, sleeping disorders, short temper),
kturiranog stres menađmenta za pripadnike poli- emotional problems (anxiety, rage, restlessness,
cijskih snaga utvrđivanjem stepena anksioznosti irritability, guilt, mood swings, sadness) and co-
prije i nakon tretmana. gnitive problems (memory problems, inability to
Materijal i metode: Ispitanici su policajci, concentrate, trouble thinking clearly, indecisive-
starosne dobi od 30-45 godina života podjeljeni u ness, changing opinions, fearful anticipation…).
dvije grupe od po 20 članova. Jedna grupa je pro- Once the reaction to traumatic experience, judged
šle strukturirani stres menađment dok druga nije. by its intensity and duration, exceeds one’s “subje-
Svi su tri puta popunili BAI i IOA; na početku ctive coping threshold” we talk about pathologic
tretmana, nakon završenog tretmana i tri mjeseca reaction to trauma which can cause various psyc-
nakon toga. hological disorders.
Rezultati rada: Statistička obrada podataka je As a result of his research, Blackmore (1) has
pokazala da je kod grupe koja je prošla strukturira- ranked police work among the top 17 occupations
ni stres menađment došlo do statistički značajnog (out of 130) related to increased risk of health pro-
sniženja anksiozne osjetljivosti, povečanja načina blems. Jacobi (1) studied health-related workers’
za aktivno i plansko suočavanje sa stresnim situ- compensation claims to discover that police offi-
acijama, smanjenja somatizacijskih reakcija a sa- cers were seven times more likely than other pro-
mim tim i do poboljšanja njihovog funkcionisanja fessionals to submit such claims, as well as that
u radnoj i privatnoj sredini. Nakon završenog psi- 30% of police officers’ claims were related to back
hoterapijskog programa njihova spremnost da se pain and another 50% to hypertension.
obrate za stručnu pomoć se izrazito povečala. Richard and Fell (2) conducted a research on
Zaključci: the sample of 23 976 workers from Tennessee in-
- Grupa policajaca koji su bili uključeni u stru- cluding 168 police officers. They discovered that
kturirani stres menađment je imala statistički zna- police officers experienced many more health pro-
čajno smanjenje anksiozne osjetljivosti u odnosu blems than other professionals, particularly dige-
na kontrolnu grupu. stive and blood circulation problems.

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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

groups received educational-therapeutic


program of structured cognitive-behavior
stress management.
- Group treatment was organized once a week
over a period of one month. At the start of
the treatment all members of therapeutic
groups completed objective psychological
measurement tests which were also used at
the end and three months after the treatment
in order to evaluate effects. In the therapeutic
part of the program we used cognitive-
behavior therapeutic techniques, while
educational part of the program focused on
the issues related to stress and trauma.
- The control group completed the same
psychological tests at the same time as the
experimental group but no member of this
group has taken part in the program during
that period.
- Stress management was structured in such Statistical data analyses were conducted using
way to cover the following issues: ANOVA (variance analyses), in that, it was sin-
gle-factor analyses (participation in stress mana-
1. Concept of Stress gement program). The analyses proved that BAI
2. Coping strategies, normal and and ASI scores of the subjects who received stress
pathological reactions to stress management program have fallen and that the dif-
3. Results, consequences of stressful ference between their and the control group’s sco-
events (short-term and long-term) res on the two scales was statistically significant.
4. Trauma; Post-Traumatic Stress disorder Results of this research show that the subjects
5. Relaxation techniques (breathing continued to use newly-acquired techniques after
techniques, progressive muscular receiving structured stress management program
relaxation) based on cognitive-behavior therapy, which has
6. Problem-solving technique resulted in further decline in the above-mentioned
7. Communication skills parameters.

d) Research instruments Discussion


1. Beck Anxiety Inventory (BAI); (Osman,
Kooper, Barrios, Osman & Wade 1997) High risk occupations, such as policing job,
2. Anxiety Sensitivity Index (ASI) place persons at risk of being in situations which
are outside usual human experience. Members of
police experience a different kind of work stress
Results compared to other professions. This kind of stress
is called burst stress. Burst stress means there is
The following diagrams show mean BAI and not always a steady stressor, but at times, there is
ASI scores of the two samples, during specific an immediate “burst” from low stress to a high
measurement periods. stress state. In usual stressful situations, most indi-
viduals develop their own ways to reduce or adapt
to stress and attempt to control their behavior in
various ways. However that is not the case among

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.

Literature Corresponding author:


Sibila Sijarić-Voloder
1. Moro, Lj. (1994). Što su stres i psihotrauma i kako Association for psychological assessment, help
ih prevladati? TIP, A.G. Matoš, Samobor. and consulting ‘’DOMINO’’
e-mail: voloder@mef.unsa.ba

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

Summary dva mjeseca za 50% ove djece, a 95% umre unutar


prve godine.
People with trisomy 18 have additional DNA Ključne riječi: trisomija 18 (tipovi), citogene-
from chromosome 18 in some or all of their cells. tička analiza, kratak životni vijek
The extra material disrupts the normal course of
development, causing the characteristic features of
trisomy 18. It can appear like three forms: comple- Introduction
te trisomy 18, mosaic trisomy 18 and as a translo-
cation type (partial trisomy for chromosome 18). The patient with trisomy 18 was first described
Genetic testing by amniocentesis before birth by Edwards (1960). Physical abnormalities may
or blood test after birth can confirm the diagnosis. point to Edwards’ syndrome, but definitive dia-
Most of the children with trisomy 18 die within gnosis relies on karyotyping – cytogenetic testing.
the first year of life. Middle life span is less than Trisomy 18 affects about 1 : 5000-8000 newborn,
two months in 50% of these children, 95% die wit- or 1:3000, regarding different references. (3, 11).
hin the first year. Girls are affected more often than boys. (1)
Key words: Trisomy 18 (types), cytogenetic Humans normally have 23 pairs of chromo-
findings, short life span somes. Chromosomes are numbers 1-22, and the
23rd pair is composed of the sex chromosomes,
X and Y. A person inherits one set of 23 chromo-
Sažetak somes from each parent. Occasionally, a genetic
error occurs during egg or sperm cell formation.
Osobe sa trisomijom 18 imaju višak DNA koji A child conceived with such an egg or sperm cell
potiče od hromosoma 18 u nekim ili svim njiho- may inherit an incorrect number of chromosomes.
vim stanicama. Ovaj višak materijala dovodi do (1, 4)
ometanja normalnog razvoja, uzrokujući karakte-
ristične simptome za trisomiju 18. Javlja se u tri
oblika: kompletna trisomija 18, mozaični oblik i Clinical report
translokacijski oblik.
Genetičko testiranje koristeći amnocentezu pri- In last ten years, in our Center for human gene-
je rođenja ili citogenetska analiza poslije rođenja tics, there have been registrated three cases of Sy
može potvrditi dijagnozu. Edwards, two boys and a girl. Boys had complete
Većina djece sa trisomijom 18 umre unutar prve trisomy 18, while a girl had mosaic type of triso-
godine života. Prosječan životni vijek je manji od my 18 – all died within first two months of life.

Journal of Society for development of teaching and business processes in new net environment in B&H 293
HealthMED - Volume 2 / Number 4 / 2008

Cytogenetics

Definitive diagnosis relies on karyotyping,


which involves cytogenetic microscopic examina-
tion of the chromosomes, using special stains for
standard G-band examination.

Picture 3. Reviles typical pes equinovarus

Picture 1. Kariotype of child with trisomy 18

Picture 4. Typical position of hand fingers (2.


Picture 2. Normal kariotype overlaps 3. and 5. overlaps 4.)

Basic symptoms of clinical report

Trisomy 18 severely affects all organ systems


of the body. Symptoms may include:
1. Nervous system and brain – mental retarda-
tion and delayed development (100% of
individuals), high muscle tone, seizures, and
physical malformations such as brain defects.
2. Head and face – small head (microcephaly),
small eyes, epicanthal folds, small lower jaw.
3. Heart – congenital heart defects (90% of Picture 5. Low set position and unmodulated ears
individuals) such as ventricular heart defect
and valve defects. In table are shown characteristic symptoms
4. Bones – severe growth retardation, clenched of trisomy 18, whereas can be seen the presence
hands with 2nd and 5th fingers on top of the of symptoms at complete trisomy 18 and mosaic
others, and other defects of the hands and type of trisomy. Based upon shown data, it can be
feet. stated that in both cases are present anomalies in-
5. Malformations of the digestive tract, the compatible with life, but some symptoms more or
urinary tract and genitals. (2) less are not present in mosaic type of trisomy 18.

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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 * * -

Discussion Trisomy 18 results when each cell in the body


has three copies of chromosome 18 instead of the
People with trisomy 18 have additional DNA usual two copies. A small percentage of cases oc-
from chromosome 18 in some or all of their cells. cur when only some of the body’s cells have an
The extra material disrupts the normal course of extra copy of chromosome 18, resulting in a mix-
development, causing the characteristic features ed population of cells with a differing number of
of trisomy 18. (4) chromosomes. Such cases are sometimes called
mosaic trisomy 18.

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Very rarely, a piece of chromosome 18 beco- Conclusion


mes attached to another chromosome (transloca-
ted) before or after conception. Affected people Since trisomy 18 babies frequently have major
have two copies of chromosome 18, plus extra physical abnormalities, doctors and parents face
material from chromosome 18 attached to another difficult choices regarding treatment. Abnormali-
chromosome. With a translocation, the person has ties can be treated to a certain degree with surgery,
a partial trisomy for chromosome 18 and often the but extreme invasive procedures may not be in the
physical signs of the syndrome differ from those best interests of an infant whose lifespan is measu-
typically seen in trisomy 18. (3, 9) red in days or weeks, so is questionable their use.
Most cases of trisomy 18 are not inherited, but (5). Medical therapy is basically supportive care
occur as random events during the formation of re- with the goal of making infant comfortable, rather
productive cells (eggs and sperm). An error in cell than prolonged life.
division called nondisjunction results in reprodu- Most children born with trisomy 18 die within
ctive cells with an abnormal number of chromo- their first year of life. The average lifespan is less
somes. If one of these atypical reproductive cells than two months for 50% of the children, and 90-
contributes to the genetic makeup of the child, the 95% dies before their first birthday. 5% of the chil-
child will have an extra chromosome 18 in each dren who survive their first year are severely men-
cell of the body. (9) tally retarded. (10) They need support to walk, and
Mosaic trisomy 18 is also not inherited. It oc- learning is limited. Verbal communication is also
curs as a random error during cell division early in limited, but they can learn to recognize and inte-
fetal development. As a result, some of the body’s ract with others. (1, 8)
cells have the usual two copies of chromosome Without questioning ethical, population, euge-
18, and other cells have three copies of the chro- nic and disgenetic discussions, we would conclu-
mosome. de that genetic information is equal part of child
Translocation trisomy 18 can be inherited. medical care and protection.
An unaffected person can carry a rearrangement The way of improvement and protection of hu-
of genetic material between chromosome 18 and man health is antenatal reveal of inherited disea-
another chromosome. This rearrangement is cal- ses. Modern medicine is using several methods to
led a balanced translocation because there is no achieve this. These methods are: physical (exami-
extra material from chromosome 18. People who nation of pregnant women, ultrasound, fetoscopy
carry this type of balanced translocation are at an or amniscopy and amniocentesis. Close related to
increased risk of having children with the condi- these are physico-chemical methods. Cytogenetic
tion. (2) methods have special place and significant impor-
Before birth, ultrasound can detect abnormali- tance as a base for genetic consulting and infor-
ties in the fetus. (7) Genetic testing by amniocen- ming in this field.
tesis before birth or blood testing after birth can The main cause for this kind of information
confirm the diagnosis. (10) is not just to prevent having the affected child or
to prevent having the infant with inherited mal-
formations, but to make possible to all parents,
especially those from families with risk, to have
healthy child.

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Literature Corresponding author:


Izeta Aganovic-Musinovic
1. Julia Barrett, Gale Encyclopedia of Medicine, De- Center for human genetics,
cember 2002, (updated 14. 08. 2006.) Medical colleage of University of Sarajevo,
Bosnia and Herzegovina
2. Chen, H, (2004). Trisomy 18. eMedicine, accessed e-mail: semirmusinovic@yahoo.com
at http://www.emedicine.com/ped/topic 652.htm
(updated may 2, 2004.)
3. Cassidy, Suzanne B; Allanson, Judit E; Manage-
ment of genetic syndromes; 2nd ed; Hooboken,
N.J.: John Wiley & Sons, c2005. NLM Catalog.
4. Chen CP, Chern SR, Tsai FJ, Lin CY, Lin YH, Wang
W. A comparation of maternal age, sex ratio and
associated major anomalies among fetal trisomy 18
cases among different cell divison of error. Prenat
Diagn. 2005 Apr; 25 (4):327-30. PubMed citation.
5. Graham EM, Bradley SM, Shirali GS, Hills CB, Atz
AM; Pediatric cardiac Care Consortium. Effecti-
veness of cardiac surgery in trisomies 13 and 18
(from the Pediatric Cardiac Care Consortium). Am
J Cardiol. 2004 Mar 15;93(6):801-3. PubMed cita-
tion.
6. Huether CA, Martin RL, Stoppelman SM, D’Souza
S, Bishop JK, Torfs CP, Lorey F., et al. Sex ratios in
fetuses and liveborn infants with autosomal aneu-
ploidy. Am J Med Genet. 1996 Jun 14;63(3):492-
500. PubMed citation.
7. Moyano D, Huggon IC, Akkab KD. Fetal echocar-
diography in trisomy 18. Arch Dis Child Fetal Neo-
natal Ed. 2005 Nov; 90(6);F520-2. Epub 2005 May
24. PubMed citation.
8. Petek E, Pertl B, Tschernigg M, Bauer M, Mayr J,
Wagner K, Kroisel PM. Characterisation of a 19-
year old «long-term survivor» with Edwards syn-
drome. Genet Couns. 2003,14(2);239-44. PubMed
citation.
9. Ramesh KH, Verma RS. Parental origin of the extra
chromosome 18 in Edwards syndrome. Ann Genet.
1996;39(2):110-2. PubMed citation.
10. Rasmussen SA, Wong LY, Yang Q, May KM, Frie-
dman JM. Population-based analyses of mortali-
ty in trisomy 13 and trisomy 18. Pediatrics. 2003
Apr;111(4 Pt 1):777-84. PubMed citation.

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HealthMED - Volume 2 / Number 4 / 2008

Influence of malignant disease


on physical and mental health in
patients with oncology disease
UTICAJ MALIGNOG OBOLJENJA NA TJELESNO I
DUŠEVNO ZDRAVLJE ONKOLOŠKIH BOLESNIKA
Amela Dzubur1, Dragana Niksic1, Esad Pepic2, Amna Pleho Kapic2
1
Department of social medicine, Medical Faculty, University of Sarajevo, Bosnia and Herzegovina
2
Department of pathophysiology, Medical Faculty, University of Sarajevo, Bosnia and Herzegovina

Summary Sažetak

Increased incidence of chronic mass noninfecti- Na području Kantona Sarajevo se u posljednjih


ous diseases such as hypertensive disease, diabetes pet godina bilježi porast hroničnih masovnih ne-
mellitus and malignant neoplasms has been obser- zaraznih oboljenja kao što su hipertenzivna obo-
ved during the last five years in Canton of Sarajevo. ljenja, dijabetes i maligne neoplazme. Maligne
Malignant diseases in 2004 accounted for 23,7% of neoplazme su u 2004 činile 23,7% svih uzroka
all death causes among Canton of Sarajevo popu- smrti stanovništva u Kantonu Sarajevo. Cilj rada
lation. Aim of the study was to investigate the type je bio ispitati vrstu i dužinu trajanja malignog
and duration of malignant disease and the influence oboljenja, kao i uticaj malignog oboljenja na tje-
of malignant disease on physical and mental health lesno i duševno zdravlje onkoloških bolesnika u
in patients with malignant disease in terminal sta- terminalnom stadiju bolesti Studija je prospekti-
ge of the disease. This prospective, study has been vna, populaciona sa jednom grupom ispitanika. U
conducted in one population group in Canton of Sa- studiju je uključeno 400 ispitanika u dobi od 18
rajevo area during the period from 2005-2006. This do 65 godina koji boluju od maligne neoplazme u
study included 400 subjects, age 18-65, in terminal terminalnom stadiju bolesti Istraživanje je sprove-
stage of a malignant disease. This study showed deno na području kantona Sarajevo u 2005 i 2006
that the most frequent neoplasms are respiratory godini putem anketnog upitnika za ispitivanje pa-
and intrathoracic organs malignant neoplasms and lijativne njege. U ovoj studiji je utvrđeno da su
digestive organs. Least present was malignant neo- najzastupljenije maligne neoplazme respiratornog
plasms of bone and articular cartilage. Patients in trakta i digestivnog trakta. Najmanje oboljelih je
terminal phase of malignant disease are not able to bilo sa malignim neoplazmama kostiju i zglobne
perform regular activities and most of the patients hrskavice.
are not mobile. It can be concluded that patients Onkološki bolesnici u terminalnoj fazi bolesti
with malignant disease are completely dependant nisu u mogućnosti da obavljaju umjerene kućne
on care from other persons and require efficient and aktivnosti i velika većina onkoloških bolesnika
effective palliative care service which can be help- nije pokretna. Možemo zaključiti da su onkološki
ful in relieving psychological disorders in terminal bolesnici u terminalnoj fazi bolesti potpuno ovi-
stage of the disease. sni o njezi drugih lica. Takvi bolesnici zahtijevaju
Key words: oncology patients, physical health, i njegu palijativne službe koja svojom efektivno-
mental health šću i efikasnosću uveliko može da ublaži psiho-

298 Journal of Society for development of teaching and business processes in new net environment in B&H
HealthMED - Volume 2 / Number 4 / 2008

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.

Increased incidence of chronic mass noninfe-


ctious diseases such as hypertensive disease, dia- Results
betes mellitus and malignant neoplasms has been
observed during the last five years in Canton of Sa- This study included 400 patients, 194 females
rajevo. Malignant diseases in 2004 accounted for (48,5%) and 206 males (51,5%). Average age was
23,7% of all death causes among Sarajevo Kan- 65,1 years (SD =11.9566; M=67,000). Most pati-
ton population. Incidence of death caused by ma- ents (54,14%) belonged to age group older than
lignant disease was 2,1‰ , while there were 846 65 years (females 65,16%; males 53,17%), while
deaths caused by malignant disease (1). 24,31% of patients belonged to age group 55-65
Patients with oncology disease, especially in years (female 25,5%, male 23,4%). There was a
the terminal stage of the disease, usually experi- decrease in incidence of malignant disease as the
ence psychological disorders and not just physical age decreased so in the age group 45-54 years be-
disorders related to presence of the tumor. longed 15,7% of patients (females 13%; males
Physical disorders in patients with malignant 17%), in age group 35-44 years 4,7% patients (fe-
disease can be caused by the presence of the tumor, males 4%; males 5%), in age group 25-34 years
related to the treatment and/or invalidity caused there were 0,75% of patients (females 3; male 0),
by the tumor and other disorders, among which and in the age group 18-24 years there were 0,25%
usually are pain, nausea, insomnia, vomiting and patients (female 0; male 1)(Graph 1). There was
others. Many patients together with their family no statistically significant difference in sex betw-
members are faced with problems of psychologi- een the age groups, but significant difference was
cal origin. Most common psychological disorders found in age groups incidence (p<0,05).Average
are worry, sadness, nervousness, sleep disorders, income in a family was 1014,68 KM (SD=704,5;
irritability and lack of concentration (2, 3, 4, 5). M=800,00KM). Patients spent in average 337,7
KM for the treatment (SD=398,6; M=312,5).

Aim of the study

Aim of the study was to investigate the type


and duration of malignant disease and the influ-
ence of malignant disease on physical and mental
health in patients with malignant disease in termi-
nal stage of the disease.

Graph 1. Age structure of oncology patients


Subjects and work method
Investigating the type of malignant disease it
This prospective, population study has been was found that 32% of patients had malignant ne-
conducted in Canton of Sarajevo area during the oplasms of respiratory and intrathoracic organs
period from 2005-2006. This study included 400 and 30% of patients had malignancy of digestive
subjects, age 18-65, in terminal stage of a mali- organs (Table1).
gnant disease. Subjects were selected randomly

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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)

mobility around the house 291 73,7 81 20,2 28 7,0


bathing, dressing 211 52,7 180 45,0 9 2,2
sitting 170 42,5 163 40,7 67 16,7
Self feeding 190 47,5 99 24,7 111 27,7
Bathroom habits 211 52,7 164 41 25 6,2

Table 4. Influence of malignant disease on psychological reaction presence in oncology patients;


(No=number of patients)
very often sometimes seldom never
Psychological reactions
No % No % No % No %
Very moody, sad, blue 215 52,7 65 16,2 53 13,2 71 17,7
Worried, anxious 260 65,0 96 24,0 32 8,0 12 3,0
Fear of pain, death 301 75,3 32 8,0 61 15,2 6 1,5
Guilt 56 14,3 151 37,7 121 30,0 72 18,0
Aggressive, angry 28 7,0 37 9,2 201 50,3 134 33,5

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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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HealthMED - Volume 2 / Number 4 / 2008

Discussion Our study showed that the efficiency of pallia-


tive care was associated with psychological reac-
According to the data from World Health Or- tions such as anger and rage in patients with malig-
ganization, average life duration has increased, in nant disease. It is observed that the anger and rage
Europe and other developed countries in the world, were less frequent if the waiting time for nursing
with more people living longer than 65 years (6). is less, if the patients are more satisfied with pal-
There are constantly more persons who die in old- liative care and if the patient’s general state is im-
er age from chronical diseases such as malignant proved upon the palliative care arrival. Our study
neoplasms, causing large array of physical, psy- did not find any association between symptoms
chological and social problems. Health care sys- relive and physical needs such as pain, breathing
tems need to be able to satisfy the needs of those difficulties, lack of appetite and others for which
patients easing the pain and giving the support to the palliative care was called.
their families (7, 8, 9, 10).
In this study it was found that the great num-
ber of patients (32%) is suffering from malignant Conclusion
neoplasms of respiratory and intrathoracic organs,
and less percentage (30%) of patients are having This study showed that the most frequent are
malignant neoplasms of digestive organs. This respiratory and intrathoracic organs malignant neo-
study found that the most patients with malignant plasms and digestive organs. Least present was ma-
disease in terminal stage of the disease are experi- lignant neoplasms of bone and articular cartilage.
encing great restriction in physical activities caus- Patients in terminal phase of malignant disease
ing psychological disorders. In many patients ma- are not able to perform regular activities and most
lignant disease enabled them to do house chores, of the patients are not mobile. It can be concluded
kneel, independent movement, bathing and dress- that patients with malignant disease are complete-
ing, feeding. Among leading psychological reac- ly dependant on care from other persons and re-
tions are fear of pain and death, worry, anxiety, quire efficient and effective palliative care service
depressive moods and sleep disturbances. which can be helpful in relieving psychological
Similar psychological reactions were found disorders in terminal stage of the disease.
by Wong et al. and other researchers, where most
common psychological disorder were worry in
72% of patients, sadness in 67%, nervousness
in 62%, sleep disturbances in 53%, irritability in
47%, and lack of concentration in 40% of patients
(2, 3, 4, 5). Previous studies of palliative care have
mostly been concentrated on patients with mali-
gnant disease. Most attention was dedicated to the
need for communication inside the family, and the
help which health professionals can offer in order
to overcome pain, anxiety and depression.
Pain is one of the symptoms causing the pa-
tients and their family members to call a palliative
care service. Other common symptoms are breath-
ing difficulties, personal hygiene, depression, apa-
thy, guilt or aggressiveness. Similar results found
researchers in Great Britain, USA and Canada
(11,12). Family members and fosters usually call
for help and support in taking care of the patient
and for overcoming anxiety and depression.

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Literature Corresponding author:


Amela Dzubur
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tegija razvoja zdravstva na Kantonu Sarajevo Medical Faculty,
2006-2015. Sarajevo, Novembar 2005. University of Sarajevo,
Bosnia and Herzegovina
2. Wong RKS, Franssen E, Szumacher E, Connolly R, e-mail: ameladzubr@gmail.com
Evans M, Page B, et al. What do patients living with
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theory: strategies for qualitative research. New
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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

About a book gnosis. They paid a special attention to measures of


prevetion and its treatment. Book has been written
Osteophorosis has been defined as a disease using a very simple and understandable language,
characterized by low bone mass and micro archi- so it is easy to read for everyone. Besides essence
tectural deterioration of bone tissue leading to en- facts, authors are using theirs own experinces in ex-
hanced bone fragility and a consequent increase in plaining things. They believed that the most impor-
fracture risk. Many clinical, social and economic tant part in all way of procedure of a disease lie in
consequence are coming from those facts. Oste- identification of a “risk” group because it helps very
ophorosis’ treatmants takes a lot of money inclu- much in prevention. Text has been illustarted by ta-
ding expences for fractures treatment. Modern and bles and pictures, which are so clear and original
adequate diagnosis helps in discovering disease on made. This book containes precious informations
time, before fracture happens, which means make for the good of the service for doctors from general
as less as possible of its costs. practitioner and family me-
There is a good ways of a pre- dicals and others specialists
vention of Ostephorosis like a to students of medicine, sto-
good diagnosis and succeeds in matology, pharmacology as
treatmant of it. Therefore, it is a much as to a people who are
very important to raise a medical willing to take care of theirs
and public consciences about si- health by preventing a dise-
gnificance of Osteophorosis, so ase also called “a quite thief
we can reduce clinical, social of the bones”.
and economic consequences. The book will take place
A book, has been wrote in a in a medical library of a do-
monography style. With all in- mestic authors, which is in
clusive detials this book very our country kind of an em-
successfuly presenting Osteo- pty place. Readers will find
phorosis as a disease for a con- informations on a questions
temporary human and a society given in an ordinary life and
in general. Authors have been in a medical practice, as
choosen for all relevant facts abo- well.
ut Osteophorosis including a dia-

Journal of Society for development of teaching and business processes in new net environment in B&H 305
HealthMED - Volume 2 / Number 4 / 2008

O knjizi Corresponding author:


Dijana Avdic
Osteoporoza je najčešće metaboličko oboljenje KCU Sarajevo,
koštanog tkiva karakterizirano poremećenom gu- Bosnia and Herzegovina,
stoćom kosti i povećanim rizikom za prelom kosti, e-mail: dijana2007@gmail.com
a iz čega proizilaze kliničke, socijalne i ekonom-
ske posljedice osteoporoze. Troškovi tretmana
osteoporoze i osteoporotskih preloma su znatni.
Savremena dijagnostika omogućava pravovre-
meno otkrivanje bolesti, prije nastanka preloma,
a time i intervenciju koja zahtjeva znatno manje
materijalne troškove. Osteoporoza je bolest koju
je danas moguće prevenirati, dijagnosticirati i
uspješno liječiti. Stoga je važno podići svijest me-
dicinskih profesionalaca i javnosti o značaju ove
bolesti kako bi se umanjile njene kliničke, soci-
jalne i ekonomske posljedice, a time direktni i in-
direktni troškovi nastali tokom zbrinjavanja ovih
bolesnika.
Knjiga, u vidu monografije, je uspjela da sve-
obuhvatno prezentira osteoporozu kao bolest zna-
čajnu za savremenog čovjeka i društvo u cjelini.
Autori su odabrali sve relevantne podatke o oste-
oporozi, dijagnostici oboljenja, a posebno su po-
svetili pažnju mjerama prevencije i liječenja. Sva
poglavlja su obrađena iscrpno i kompetentno, na
vrlo jednostavan i razumljiv način, tako da knjigu
mogu čitati svi. Pri tome se autori služe relevan-
tnim podacima iz literature, ali i vlastitim iskustvi-
ma. Najveću nadu polažu u identifikaciji “rizične”
grupe, jer će se na taj način moći poduzeti mjere
prevencije. Tekst je ilustriran tabelama i slikama
koje su vrlo pregledne i originalne.
Ova knjiga sadrži dragocjene informacije po-
trebne ljekarima, kako opšte i porodične medicine,
tako i onima različitih usmjerenja i specijalnosti,
studentima medicine, stomatologije, farmacije,
osobama koje žele sačuvati svoje zdravlje preve-
nirajući oboljenje, pacijentima koji već imaju ovo
oboljenje i drugim zainteresiranima. Knjiga će po-
puniti literaturu o osteoporozi, koja je kod nas više
nego skromna, a čitaoci će naći u njoj informacije
i odgovore na pitanja koja se postavljaju u svako-
dnevnom životu i medicinskoj praksi.

306 Journal of Society for development of teaching and business processes in new net environment in B&H
HealthMED - Volume 2 / Number 4 / 2008

INSTRUCTIONS FOR THE AUTHORS


All papers need to be sent to e-mail: healthmed_bih@yahoo.com
Every sent magazine gets its number, and author(s)
will be notified if their paper is accepted and what is the REFERENCES
number of paper. Every corresponedence will use that Quoting references must be in a scale in which they
number. The paper has to be typed on a standard size pa- are really used. Quoting most recent literature is recom-
per (format A4), leaving left margins to be at least 3 cm. mended. Only published articels (or articles accepted
Ali materials, including tables and references, have to be for publishing) can be used as references. Not-published
typed double-spaced, so one page has no more than 2000 observations and personal notifications need to be in text
alphanumerical characters (30 lines). Sent paper needs to in brackets. Showing references is as how they appear
be in the form of triplicate, considering that original one in text. References cited in tables or pictures are also
enclosure of the material can be photocopied. Presenting numbered according to quoting order. Citing paper with
paper depends on its content, but usually it consists of a six or less authors must have cited names of all authors;
page title, summary, text references, legends for pictures if seven or more authors’ wrote the paper, the name of
and pictures. Type your paper in MS Word and send if the first three authors are cited with a note “et all”.
on a diskette or a CD-ROM. If the author is unknown, at the beginning of papers
reference, the article is named as “unknown”. Titles of
TITLE PAGE the publications are abbreviated in accordance to Index
Every article has to have a title page with a title of no Medicus, but if not listed in the index, whole title of the
more than 10 words: name (s), last and first of the author journal has to be written.
(s), name of the instituion the authors (s) belongs to, Footnote-comments, explanations, etc., cannot be
abstract with maximum of 45 letters (including space), used in the paper.
footnote with acknowledgments, name of the first aut-
hor or another person with whom correspondence will STATISTICIAL ANALYSIS
be maintained. Tests used for statistical analysis need to be shown in
text and in tables or pictures containing statistical ana-
SUMMARY lysis.
Second page needs to contain paper summary, 200
words at the most. Summary needs to hold all essential TABLES AND PICTURES
facts of the work-purpose of work, used methods (with Tables have to be numbered and shown by their or-
specific data, if possible) and basic facts. Summaries der, so they can be understood without having to read
must have review of underlined data, ideas and con- the paper. Every column needs to have title, every me-
clusions from text. Summary has no quoted references. asuring unit (SI) has to be clearly marked, preferably in
For key words, at the most, need to be placed below the footnotes below the table, in Arabian numbers or sym-
text. bols. Pictures also have to be numbered as they appear
in text. Drawings need to be enclosed on a white paper
CENTRAL PART OF THE ARTICLE or tracing paper, while black and white photo have to be
Authentic papers contain these parts: intro-duction, printed on a radiant paper. Legends next to pictures and
goal, methods, results, discussion and conclusion. Intro- photos have to be written on a separate A4 format paper.
duction is brief and clear review of a problem. Methods All illustrations (pictures, drawings, diagrams) have to
are shown so that interested reader is able to repeat des- be original and on their backs contain illustration num-
cribed research. Known methods don’ t need to be iden- ber, first author last name, abbreviated title of the pa-
tified, it is cited (referenced). Results need to be shown per and picture top. It is appreciated if author marks the
clearly and legically, and their significance proven by place for table or picture. Preferable the pictures format
statistical analysis. In discussion, results are interpreted is TIF, quality 300 DPI.
and compared to existing, previously published findings
in the same field. Conclusions have to give an answer to USE OF ABBREAVIATIONS
author’s goal. Use of abbreviations has to be reduced to minimum.
Conventional units can be used without their defini-
tions.

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

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