HealthMED

Volume 5 / Number 6 / 2011

Journal of Society for development in new net environment in B&H

EDITORIAL BOARD Sadržaj / Table of Contents

Editor-in-chief Mensura Kudumovic
Chest associated to motor physiotherapy acutely
Execute Editor Mostafa Nejati improves oxygen saturation, heart rate and
Associate Editor Azra Kudumovic respiratory rate in premature newborns with
Editorial assistant Jasmin Musanovic periventricular-intraventricular hemorrhage ... 1381
Technical editor Eldin Huremovic Luiz Carlos de Abreu, Vitor E. Valenti , Oséas Florêncio
de Moura Filho, Luiz Carlos M. Vanderlei, Tatiana Dias
de Carvalho, Maria A. F. Vertamatti , Adriana G. Oliveira,
Members
Isadora L. Moreno, Ana Clara C. R. Gonçalves, Arnaldo A.
Paul Andrew Bourne (Jamaica) F. Siqueira
Xiuxiang Liu (China)
Nicolas Zdanowicz (Belgique) The causes of chest pain among Korean outpatients
Farah Mustafa (Pakistan)
in primary care practice ....................................... 1389
Yann Meunier (USA) Jongwoo Kim, Seon Yeong Lee, Kyunam Kim, Sun Mi Yoo
Forouzan Bayat Nejad (Iran)
Suresh Vatsyayann (New Zealand) Are patient falls in the hospital associated with days
Maizirwan Mel (Malaysia)
of the week and hours of the day? A retrospective
Budimka Novakovic (Serbia)
Diaa Eldin Abdel Hameed Mohamad (Egypt)
observational study using Rasch modeling ........ 1395
Su-Chen Hsu, Huan-Fang Lee, Tsair-Wei Chien
Zmago Turk (Slovenia)
Bakir Mehic (Bosnia & Herzegovina)
Knowledge, Attitudes and Practices on Hypertension
Farid Ljuca (Bosnia & Herzegovina)
Sukrija Zvizdic (Bosnia & Herzegovina)
in patients attending Family Practice Clinics .... 1404
Nada A. Yasein, Farouq M. Shakhatreh, Ahmad A. Sule-
Damir Marjanovic (Bosnia & Herzegovina) iman, Farihan F. Barghouti, Lana J. Halaseh, Noor K.
Emina Nakas-Icindic (Bosnia & Herzegovina) Abdulbaqi
Aida Hasanovic(Bosnia & Herzegovina)
Bozo Banjanin (Bosnia & Herzegovina) The analisys of the syndroms appearing among
children living with autism in Hungary . ............ 1415
Orsolya Tobak, Mónika Balogh, Kinga Lampek
Address of the Sarajevo, Bolnicka BB
Editorial Board phone/fax 00387 33 956 080 Health financing reform towards universal
healthmedjournal@gmail.com insurance coverage: a case study of six cities
http://www.healthmedjournal.com in China ................................................................. 1420
Cheng Li, Yuan Yu, Kieke G.H.Okma, Min Yu
Published by DRUNPP, Sarajevo
Volume 5 Number 6, 2011 Stories of illness in a changing world of
ISSN 1840-2291 medicine . ................................................................ 1430
Modesto Leite Rolim Neto, Alberto Olavo Advincula Reis,
HealthMED journal with impact factor indexed in: Irineide Beserra Braga, Cícero Hedilberto Filguêiras Macêdo

- Thomson Reuters ISI web of Science, The Relationship between Weight Status and Self-
- Science Citation Index-Expanded,
- Scopus,
reported Mental Health Outcomes in Korean
- EBSCO Academic Search Premier, Adolescents ............................................................. 1435
- Index Copernicus, Seong-Ik Baek, Wi-Young So
- getCITED, and etc.
 Sadržaj / Table of Contents
An Oxygen-sensing Signal Cascade of Evaluating the problems of mothers in exclusive
Cardiomyocyte Adaptations to Moderate breastfeeding and educational intervention for
Endurance Training .............................................. 1440 improving nutrition status in Iran ..................... 1517
Zong-Yan Cai, Cheng-Chen Hsu, Mei-Chich Hsu, Hadigheh Kazemi, Fatemeh Ranjkesh
Mao-Shung Huang, Chao-Pin Yang, Yung-Yu Tsai,
Borcherng Su Risk Factors Associated with Metabolic Syndrome
in Iranian Middle Aged Women ......................... 1522
Hematological and serological changes in Mouloud Agajani Delavar, Munn Sann Lye, Geok Lin Khor,
the pre - and post-treatment breast cancer Syed Tajuddin B Syed Hassan, Parichehr Hanachi
patients . .................................................................. 1449
Nadeem Sheikh, Maria Masood and Naila Naz The effects of Vitamin C and E Supplements
on eradication rate of Helicobacter pylori
Serum Leptin changes following a selected aerobic receiving omeprazol- clarithromycin-amoxicillin
training program in un-trained Females ............. 1458 regimen ................................................................... 1531
Masoumeh Azizi Ehsani Ardakani MJ, Samiy S, Norouzinia M, Mostafavi SA,
Mohaghegh Shalmani H
Effect of serum urea and creatinine levels in
aneurysmal subarachnoid hemorrhage .............. 1463 Coeliac disease; Prevalence and Outcome in
Sayantani Ghosh, Saugat Dey, Mitchell Maltenfort, Jack Jallo Pregnancy ............................................................... 1537
Mohsen Norouzinia, Kamran Rostami, Marzyeh Amini,
Stress coping among nurses in Latvia . ............... 1468 Farhad Lahmi, Mohammad Roshani, Homayoun Zojaji,
Liana Deklava, Inga Millere, Kristaps Circenis Mohammad Rostami Nejad, Chris J Mulder, Mohammad
Reza Zali
The Effects of LPG Massage System on Delayed
Onset Muscle Soreness and Muscular Criteria for Priority-setting in Iran Basic Health
Performance after Resistance Exercise .............. 1474 Insurance Package: Exploring the Perceptions
Vahideh Kianmarz of Health Insurance Experts ................................. 1542
Reza Dehnavieh, Arash Rashidian, Mohammad reza Maleki,
Outcomes of patients with low risk cardiac chest Seyedjamal Aldin Tabibi, Hosein Ibrahimi Pour, Somayeh
pain underwent immediate exercise testing: two Noori Hekmat
months fallow up .................................................. 1479
Saeed Abbasi, Kambiz Masoumi, Mohsen Ebrahimi, Examination Of Critical Thinking Disposition
Mohammad Amin Zare, Mohammad Javad Alemzadeh Ansari In Nursing .............................................................. 1549
Belgin Yildirim, Şükran Özkahraman, Medet Korkmaz,
Maternal obesity and preeclampsia .................... 1484 Sıddıka Ersoy
Azar Aghamohammadi
Tuberculosis as an occupational disease: based
Perceptions regarding the use of long-lasting on health care centers in Turkey ......................... 1558
insecticide -treated bed nets for preventing Abdurrahman Abakay, Abdullah Cetin Tanrikulu, Ozlem
Abakay, Hadice Selimoglu Şen
malaria among rural females of Pakistan .......... 1488
Nelofer Amir, Ejaz Ahmad Khan, Haris Habib, Hamayun
Rathor Qualıty assessment of prımary care guıdelınes
ın Turkey ................................................................ 1565
Study of Catastrophic Health Expenditure in Aylin Baydar Artantas, Rabia Kahveci, Didem Sunay,
Ayşe Caylan
China’s Basic Health Insurance .......................... 1498
Zhongliang Zhou, Jianmin Gao
The effect methods to cope with stress in high school
The Effect of Using Sauna (Dry and Steam) and Cold students on hopelessness and self-esteem ........... 1573
Dilek Kılıç, Gülcan Erol, Battal Kılıç
Water on BP (Systolic and Diastolic) and HR in
Male Athletes ......................................................... 1508 The Effects of Acute Submaximal Exercise on
Alireza Rahimi, Jaber Safarkhan Mo’azeni, Zynalabedin
Fallah, Abbas Esfandiari Trace Element Metabolism .................................. 1580
Ersan Kara
A Clinical trial to compare the effectiveness of
The effect of planned education given to students
Lavender essential oil and olive oil at healing
postpartum mother’s perinea .............................. 1512 on their menstrual hygiene behaviors: learning
Fereshteh Behmanesh, Maryam Tofighi, Mouloud Agajani and forgetting . ....................................................... 1586
Delavar, Mahtab Zeinalzadeh, Ali Akbar Moghadamnia, Hatice Kumcagız, Ilknur Aydin Avci
Soraya Khafri
 Sadržaj / Table of Contents
Problem solving skills related with baby care Cryopreservation - challenge of platelet
of mothers who have normal and premature concentrates long time preservation ................... 1683
newborns* .............................................................. 1593 Radmila Jovanovic, Jasmina Grujic, Vladan Radlovacki,
Kuguoglu S, Cinar N, Ergun A Bato Kamberovic

Incidence of smoking among the primary school Oral fungal and bacterial infection in
students in Turkey and its reasons ...................... 1597 smokers ................................................................... 1695
Nazlı Hacıalioğlu, Afife Yurttaş, Meral Kiliç Cankovic M, Bokor-Bratic M, Cankovic D

Characteristics of patients who are newly Patients’ satisfaction as key point in

diagnosed with cancer after visiting the healthcare services . ............................................... 1701
emergency department ......................................... 1605 Radmila Janicic, Danica Lecic-Cvetkovic, Vinka Filipovic,
Neslihan Yücel, Feride Sinem Akgün, Cem Ertan, Meltem Zoran Vukasinovic, Vesna Jovanovic
Serin, Karcıoğlu Özgür
Implementation influence of antibiotic
An evaluation of self-efficacy and nicotine-addiction prescribing guidelines on their usage and
levels of smoker university students . .................. 1613 costs of therapy ...................................................... 1710
Nur Özlem Kilinç, Ayfer Tezel Sandra Stefan-Mikic, Sinisa Sevic, Radoslava Doder,
Dejan Cvjetkovic, Nataša Jovanovic, Maja Ruzic
The investigation of life styles adopted by
women living in Erzurum as regards Secondary Lymphedema of the arm in breast
cervical cancer risk . .............................................. 1625 carcinoma at the Oncology institute of Vojvodina:
Özlem Karabulutlu, Nesrin Reis 2001 – 2006 ............................................................. 1719
Svetlana Popovic-Petrovic, Miroslav Nedeljkovic, Lazar
How Much Residents “Don’t Know” About Popovic, Vasa Petrovic
Feeding Children 6 - 24 Months of Age .............. 1632
Rabia Kahveci, İlknur Bostancı, Yıldız Dallar Assessment of air quality impact on human
health in the city of Novi Sad ............................... 1725
Nursing Students’ Perception of the Internet in Sanja Bijelovic, Budimka Novakovic, Ljiljana Trajkovic-
Turkey: A Questionnaire Survey ......................... 1636 Pavlovic, Milorad Bijelovic
Sevinc Tastan, Birhan Tastan, Emine Iyigun, Hatice Ayhan
T4 Glottic carcinoma: oncological results and
An investigation into the knowledge about the survival rate.............................................................1737
menstruation period among the female university Slavisa Jancic, Misko Zivic, Zoran Radovanovic, Biljana
Milicic, Natasa Djindjic, Boris Djindjic, Snezana Jancic
students at Eastern Black Sea region of Turkey ... 1643
Birsel Canan Demirbağ, Zeynep Güngörmüş
Peripartal Cardiomyopathy – alwaus
Free radicals and intrinsic skin aging: basic diagnostic dilemma: clinical and therapeutic
principles ................................................................ 1647 procedures . ............................................................ 1744
Raja Dahmane, Borut Poljsak Mirjana Bogavac, Olivera Rankov, Jadranka Dejanovic,
Milica Medic-Stojanoska
Microbiological finding of urine in patients
Digital radiography in root canal working
with benign prostatic hyperplasia ....................... 1655
Vineta Vuksanovic, Natasa Terzic, Danijela Vujosevic length determination.............................................. 1749
Tatjana Brkanic, Ivana Stojsin, Karolina Vukoje, Duska
Blagojevic, Vladan Osatovic
Effects of air pollution on red blood cells in
pregnancy ............................................................... 1664 Surgical wounds complications in two different
Stankovic A, Nikolic M, Arandjelovic M.
techniques of a cesarian section ........................... 1754
Vejnovic T, Grahovac M, Veselovski A, Koledin S
Pheochromocytoma in pregnancy, a diagnosis
not to miss . ............................................................. 1670 Measuring health of countries: a novel
Bogavac Mirjana, Stojic Sinisa, Malenkovic Goran, Medic
Stojanoska Milica approach ................................................................. 1762
Veljko Jeremic, Kristina Seke, Zoran Radojicic, Danka
Jeremic, Aleksandar Markovic, Dragoslav Slovic, Aca Aleksic
Mid-life women’s knowledge about
perimenopause in Vojvodina . .............................. 1674 Psychopathological response of torture victims .... 1767
Dragana Milutinovic, Aleksandar Curcic, Sanja Sumonja, Alma Bravo-Mehmedbasic, Senadin Fadilpasic
Dragana Simin, Branislava Brestovacki
Effects of dispersed radiation on the thyroid
and the gonads during mammography .............. 1774
Suad Kunosic, Denis Ceke, Adnan Beganovic, Begzada
Basic,

Qualitative methods of identification of

acetylsalicylic acid by differential scanning
calorimetry and melting point method ............... 1782
Ekrem Pehlic, Aida Sapcanin, Mirza Nuhanovic, Bozo Ba-
njanin, Husein Nanic, Safeta Redzic, Amir Muric, Cazim
Salimovic, Melita Poljakovic, Majda Srabovic

Incidence of urinary tract infections of male

paraplegics population compared to the way
of bladder treatment ............................................. 1788
Selimovic M, Hiros M, Spahovic H, Sadovic S,
Mehmedbasic S, Cavaljuga S

Therapeutic Approach to Large Jaw Cysts ....... 1793

Naida Hadziabdic, Halid Sulejmanagic, Edin Selimovic,
Nedim Sulejmanagic

Evaluation of methods in identifying hilar

supernumerary renal arteries originating
near the aorta ......................................................... 1800
Elvira Talovic, Alma Voljevica, Amela Kulenovic

VAP frequency at central intensive care unit

of Canton hospital Zenica within the period
2008/2009 ................................................................ 1806
Ranka Filipovic, Ismet Suljevic, Ismana Surkovic, Azra
Kudumovic

Assessment of quality of life in patients with heart

failure using Minnesota questionnaire . .............. 1811
Sadat Kurtalic, Fahir Barakovic, Farid Ljuca, Zumreta
Kusljugic, Midhat Tabakovic, Zlatko Midzic, Nermina
Kurtalic, Dzenan Halilovic

New simplified formula for RPI-reticulocyte

production index . .................................................. 1815
Secic D, Omerbasic A, Drljo M, Dizdarevic A

Anti-Suicide effects of clozapine in treatment of

schizophrenia and schizoaffective disorder . ...... 1821
Saida Fisekovic, Damir Celik, Svjetlana Loga-Zec

Contribution to the epidemiology prolonged

forms hepatitis “A” ............................................... 1829
Dautovic-Krkic S, Hadzic A, Mesic A

Instructions for the authors ................................. 1835

Uputstvo za autore ................................................ 1836

 HealthMED - Volume 5 / Number 6 / 2011

Chest associated to motor

physiotherapy acutely improves
oxygen saturation, heart rate
and respiratory rate in premature
newborns with periventricular-
intraventricular hemorrhage
Luiz Carlos de Abreu1, 2, Vitor E. Valenti 2, 3, Oséas Florêncio de Moura Filho2, Luiz Carlos M. Vanderlei4,
Tatiana Dias de Carvalho2, 3, Maria A. F. Vertamatti 4, Adriana G. Oliveira1, Isadora L. Moreno2, 3, Ana Clara
C. R. Gonçalves2, 3,Arnaldo A. F. Siqueira1
1
Departamento de Saúde Materno-infantil, Universidade de São Paulo (USP), São Paulo, SP, Brasil,
2
Laboratório de Escrita Científica, Departamento de Morfologia e Fisiologia, Faculdade de Medicina do ABC,
Santo André, SP, Brasil,
3
Departamento de Medicina, Disciplina de Cardiologia, Universidade Federal de São Paulo, SP, Brasil,
4
Departamento de Fisioterapia da Faculdade de Ciências e Tecnologia, Universidade Estadual Paulista,
Presidente Prudente, São Paulo, Brasil,
5
Departamento de Ginecologia e Obstetrícia, Faculdade de Medicina do ABC, Santo André, SP, Brasil.

Abstract Furthermore, HR and RR decreased after physiot-

Background: The literature presents contra-
dictory data regarding physiotherapy effects on
premature newborns. Thus, we aimed to evaluate
the effects of chest associated to motor physiothe-
rapy on oxygen saturation (SO2%), heart rate (HR)
and respiratory rate (RR) in premature newborns
with peri-intraventricular hemorrhage (PIVH).
Methods: This study was performed in an
intensive care unit. We included newborns with
birth weights below 2,000g and we used Papille
classification, which classifies PVIH into four gra-
des according to the degree. Newborns were divi-
ded in control (n=38) and PIVH (n=32) groups.
The protocol followed this sequence: monitoring,
physiotherapy, respiratory therapy, physiotherapy
and motor monitoring. We compared the cardio-
respiratory parameters between before the first
physiotherapy session and after the third (last)
physiotherapy session in one day.
Results: SO2% increased after physiotherapy
procedures in control and PIVH groups (p<0.05).
herapy treatment in PIVH group (p<0.001).
Conclusion: Chest associated to motor physi-
otherapy treatment acutely improved SO2%, HR
and RR in premature PIVH newborns. Thus, we
recommend performing chest associated to motor
physiotherapy in neonatal critically ill newborns.
Key words: Cerebral hemorrhage; Infant,
Newborn; Physical Therapy (Specialty); Infant,
Premature, Diseases.
Introduction
The peri-intraventricular hemorrhage (PIVH)
is a major neurological injury which affects pre-
term newborns, especially those of very low birth
weight [1-3]. The PIVH is developed by an im-
maturity of the germinal matrix, which presents
thin vessels, formed only by endothelial tissue [4].
As cerebral blood flow depends on blood pressure
and preterm newborns do not present a well deve-
loped cardiovascular system regulation, any chan-

Journal of Society for development in new net environment in B&H 1381

HealthMED - Volume 5 / Number 6 / 2011
ge in blood pressure alters cerebral blood flow and
consequently lead to the shattering of the vessels
with the possibility of an ischemic injury [2].
Cerebral blood flow presents its own self-regu-
lation mechanisms coupled to systemic blood pre-
ssure. In newborns this self-modulation is not well
developed. In this situation, there is linear relation-
ship between cerebral blood flow and mean blood
pressure [5]. The association between self-regula-
tion failure, cerebral blood flow and hypotension
has been implicated in the pathogenesis of cerebral
white matter and PIVH [4-8]. Another complicati-
on of prematurity is the neonatal hypoxic-ischemic
injury, which is usually associated to PIVH [9].
Neonatal physiotherapy is a procedure perfor-
med between clamping of umbilical cord and 28
days after delivery, which include newborn lung
and motor handling [1-3]. Airway clearance aims
to remove the excess of bronchial secretions. The
adverse effect arising from excess secretions and
the fact that their removal may significantly im-
prove the specific conductance of the airways has
been previously demonstrated [10, 11].
Physiotherapy offers stability of hemodynamic
variables, i.e. heart rate (HR). The functional ma-
intenance of the newborn cerebral circulation and
the maintenance of airways with turbulent flow and
with minimal secretion, which allow an increased
permeability and reduced number of intrinsic ai-
rway that contribute to increased airway resistance
and decrease in gas changes injuries [1, 3, 6, 7].
There is conflicting data regarding respiratory or
chest physiotherapy in the neonatal period. Clinical
studies have demonstrated benefits of chest physio-
therapy in preterm newborns through the improve-
ment of lung function. Other studies showed reduc-
tion of hemodynamic variability of preterm infants
and highlighted the beneficial therapeutic effects of
interventional procedures of neonatal physiothera-
py [3, 8]. However, previous studies reported dele-
terious effects, suggesting that the handling proce-
dures of interventional therapy in preterm infants
results in hemodynamic instability, and therefore,
they did not indicate [12, 13].
Although previous studies already evaluated
chest physiotherapy effects on newborns with lung
disease [14], no previous investigation analyzed
chest physiotherapy associated to motor physi-
otherapy treatment on premature newborns with
1382
PIVH. Thus, in order to investigate the safety of
chest associated to motor physiotherapy for pre-
mature infants, as demonstrated by the vital sign
responses, we aimed to evaluate the acute effects
of chest and motor physiotherapy treatment on ba-
sal oxygen saturation (SO2%), HR and respiratory
rate (RR) in newborns with PIVH.
Methods
Study population
The study included 70 newborns weighing less
than 2,000g, born at the Hospital do Servidor Públi-
co Estadual Francisco Morato de Oliveira after
approval of the Ethics Committee in Research (Pro-
tocol number 0028/96). We excluded newborns
that presented congenital anomalies, genetic syn-
dromes, hydropsia or congenital infection with cli-
nical manifestations and death before the 4th day of
life. The newborns underwent the examination of
transfontanellar ultrasound diagnostic imaging. Ge-
stational age was calculated based on reliable date
of the last menstrual period. After birth, we used
the method of Capurro et al [15] between the 6th
and 24th hours of life in the service of Neonatology,
which was carried out by the neonatal team. Weight
was expressed in grams and it was evaluated in the
delivery room in all cases immediately after birth.
Ultrasound Examination
Ultrasound examinations was performed on 4th,
8 , 15th and 28th days of life, since the newborn re-
th
mained hospitalized in the intensive care unit. Tran-
sfontanellar cranial ultrasound was performed in
all patients, using real-time device and sector tran-
sducer of 5MHz. We used a Toshiba SL2 for the
completion of ultrasound examination. It was used
as the anterior fontanelle window and it was per-
formed coronal cut planes. The visualization of the
ventricular system and periventricular parenchyma
were monitored because these are the most frequent
sites of PIVH. The diagnosis of PIVH was detected
by the presence of high image echogenicity, diffe-
rentiated choroid plexus and identified in both coro-
nal and sagittal cutting planes.
Journal of Society for development in new net environment in B&H

PIVH Classification
We used the classification of Papille et al [16],
which ranks PIVH into four grades (Table 1)
according to its extension. All scans were perfor-
med at the Department of Neonatology accompa-
nied by the researchers. The diagnosis of PIVH
was confirmed by the radiologist and the investi-
gator. In case of divergence between the two in-
vestigators, a third observer evaluated the image
and opined about the comment. It was prevailed
the opinion of two image investigators. The inve-
stigators did not have prior access to the data of
medical history, clinical neurological examination
or laboratory tests, except the days of life, as the-
se surveys were conducted from the 4th day of the
newborn life.
Table 1. PIVH classification.
Level Definition
Hemorrhage restricted to the subependymal
I pected the ethical principles related to the clinical
germinal matrix.
Subependymal hemorrhage + Ventricular
II hemorrhage, without dilatation and hydro-
cephalus.
Matrix hemorrhage + ventricular hemor-
III
rhage + dilatation and hydrocephalus.
Parechyma hemorrhage associated to ven-
IV
tricular dilatation (parenchymal hematoma).
Protocol Procedures
Chest and motor physiotherapy interventions
were carried out after the 4th day of life. The varia-
bles HR (bpm – beats per minute) and SO2% were
measured with a multiparameter monitor Dixtal,
model dx2020. The variable RR (cpm – cycles per
minute) was measured with the aid of a stopwatch
brand Casio model FS-02 followed by quantifica-
tion by the same researcher in 60 seconds through
chest and abdomen movements. The protocol fo-
llowed this sequence: monitoring, motor physiot-
herapy, chest physiotherapy and monitoring. The
newborns monitoring was done before and after
physiotherapy treatment [3]. Data were obtained
in three physiotherapy sessions, performed in one
day with an interval of two hours between each
treatment. It was compiled for 9 minutes before
and 9 minutes immediately after the end of physi-
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
otherapy treatment. Data were collected by the
physiotherapist researcher.
The variables HR and SO2% were compiled in
a multiparameter monitor that captured a record per
second and the average value was calculated every
180 seconds as arithmetic means. For each period
(0 to 3 minutes, 3 to 6 minutes and 6 to 9 minutes)
an average value was obtained. We adopted a simi-
lar procedure to RR, but the data were listed minute
by minute by the researcher and the mean for each
period were calculated later. This procedure was
performed pre and post treatment. We used the tra-
cheal tube aspiration for open system.
The fraction of inspired oxygen (FiO2 ventila-
tor) established by the medical team according to
blood gases remained constant throughout the ne-
onatal session, given that newborns remained con-
tinuously evaluated and presented good peripheral
and central perfusion throughout our procedures,
we did not need to increase FiO2%. Thus, we res-
sovereignty in any clinical procedure performed
during conducting critically ill patients in inten-
sive care environment. All newborns remained at
the supine position for at least 30 minutes prior to
physiotherapy until the end of data collection. We
considered preterm newborn the one who had ge-
stational age between 22 weeks (154 days or more)
and 37 weeks (258 days or less) [2, 6]. Therefore, in
the peri and neonatal mortality, low birth weight is
directly related to morbidity and mortality [8, 12].
Physiotherapy Procedures
Newborns received chest and motor physiothe-
rapy, chest physiotherapy followed the following
sequence:
1) pulmonary reexpansion: a set of techniques
that aimed to allow conditions of adequate
ventilation, re-expanding atelectasis and
helping to reduce the incidence of respiratory
infections because it promotes the release
of secretions from the both upper and lower
airway, reducing the presence of secretions
in the respiratory tract and reducing the
likelihood of outbreak of nosocomial
bacteria, viruses and obstruction to airflow
through the newborns airways;
1383
HealthMED - Volume 5 / Number 6 / 2011

2) percussion: alternately and rhythmically associated birth weight to HPIV we observed

movements over the area corresponding the following distribution: 4 (12.50%) weighed
to the compromised lung segment in between 1,000 and 500g, 17 (53.13%) between
association with postural drainage, which 1,000 and 1,500 g and 11 (34.38%) between 1,500
avoid bone prominences such as the and 2,000g, i.e., the incidence of HPIV was higher
sternum and clavicle. It does not exceed in preterm infants weighing less than 1,500 g.
two minutes of percussion over each area Great part of the PIVH newborns presented birth
treated with chest percussion; weight between 1,000 and 1,500g (Table 3).
3) vibrotherapy: We used a mechanical Table 2. Newborns distribution according to gender
vibrator (YOKIÒ brand) with a small Gender PIVH Control Total
plastic head intensity condenser (diameter Female 12 17 29
= 2cm). The therapy was performed at Male 20 21 41
the basal, medial and apical regions, Total 32 38 70
bilaterally, 1 minute for each anatomical
region in a total of 6 minutes of therapy Table 3. Incidence of PIVH associated to birth
with this equipment. This procedure was weight
performed in the anterior and posterior Birth Weight PIVH Control
regions. We also used the technique of
500 to 1,000g 04 (5.6%) 00 (0.0%)
postural drainage associated with chest
1,000 to 1,500g 17 (24.3%) 03 (4,4%)
percussion by using the medial and distal 1,500 to 2,000g 11 (15.7%) 35 (50.0%)
phalanges of the bilateral 2nd and 3rd fingers Total 32 (45.6%) 38 (54.4%)
for 30 seconds per each anatomic region;
4) postural drainage: Postural drainage was We compared all variables before and after
performed with the newborn resting on the each physiotherapy treatment. HR was signifi-
bed at an elevation of 30°. The secretion cantly (p<0.001) reduced after the third physiothe-
is conducted from the lobar region to the rapy treatment compared to before the first session
pulmonary hilum and from the pulmonary in PIVH group (Table 4). In relation to RR, we
hilum to the endotracheal tube. observed that it significantly decreased after the
third physiotherapy session compared to before
For motor physiotherapy we used only propri- the first session in the PIVH group (Table 5). Fur-
oceptive stimulation. thermore, SO2% was also significantly decreased
after the second and third physiotherapy session
compared to before the first session in control and
Statistical Analysis PIVH groups (Table 6).
Table 4. HR (bpm) before and after each physi-
Data were presented as mean ± standard devia- otherapy treatment in PIVH and control groups.
tion of mean. In order to compare the values at rest Comparison between the same group in different
in the same group between the three treatments periods. HR: Heart rate; bpm: beats per minu-
we used ANOVA test for repeated measures (one te; PIVH: Peri-intraventricular hemorrhage.
way) followed by the Tukey post test. Differences *p<0.001: Different of 1st Pretreatment
were considered significant when the probability
Treatment PIVH Control
of a Type I error was less than 5% (p < 0.05).
1 Pretreatment
st
143+10 135+4
1st Posttreatment 146+4 137+6
Results 2nd Pretreatment 140+5 134+8
2nd Posttreatment 140+13 133+6
3rd Pretreatment 138+11 132+12
We evaluated a total of 70 newborns, 29
3rd Posttreatment 130+9* 128+14
(41.43%) female (Table 2). Birth weight ranged
between 770g and 2,000g (Table 3). When we

1384 Journal of Society for development in new net environment in B&H

 HealthMED - Volume 5 / Number 6 / 2011

Table 5. RR (cpm) before and after each physi- after 3 physiotherapy sessions in PIVH, which in-
otherapy treatment in PIVH and control groups. dicates clinical improvement of the newborn due
Comparison between the same group in different to chest associated to motor physiotherapy trea-
periods. RR: Respiratory rate; cpm: cycles per tment three times daily, always at intervals of 2
minute; PIVH: Peri-intraventricular hemorrhage. hours between each clinic session. Moreover, Ber-
*p<0.001: Different of 1st Pretreatment nard-Narbonne et al [13] reported that chest physi-
Treatment PIVH Control otherapy increased SO2% and tidal volume in chil-
1st Pretreatment 51+8.2 42.2+5.7 dren with acute bronchiolitis, which was linked to
1st Posttreatment 51.7+8 41+5.7 the improvement of bronchial sputum clearance.
2nd Pretreatment 48.9+6.3 40.8+4.4 Nevertheless, a previous investigation observed
2nd Posttreatment 47.2+6.8 38.76+4 no improvement of lung function in children with
3rd Pretreatment 46.3+6.6 39.1+3.8 exacerbated bronchial asthma who received chest
3rd Posttreatment 39.7+6* 34.6+2.9 physiotherapy [17]. The difference between those
results may be explained by methodological pro-
Table 6. Oxygen saturation (SO2%) before and af- cedures and by the type of disease and patients
ter each physiotherapy treatment in PIVH and con- age; while we treated premature newborns with a
trol groups. Comparison between the same group neurological impairment by using chest and mo-
in different periods. HR: Heart rate; bpm: beats per tor physiotherapy they evaluated older subjects
minute; PIVH: Peri-intraventricular hemorrhage. with lung disease by using chest physiotherapy. A
*p<0.01: Different of 1st Pretreatment relevant factor that may be involved in this dif-
Treatment PIVH Control ference is the physiotherapy procedure. Different
1 Pretreatment
st
91+3 93+1
physiotherapy procedures have been shown in the
1st Posttreatment 95+3 97+2
literature [18-23]. The most used is the airway cle-
2nd Pretreatment 92+3 94+1 arance technique: chest (or percussion), vibration/
2nd Posttreatment 96+3* 97+1* vibrocompression maneuvers with an Ambu bag
3rd Pretreatment 92+2 95+1 (bag-squeezing), aspiration and airway intubati-
3rd Posttreatment 97+3* 98+1* on, cough stimulation on posture and positioning
of drainage and respiratory liabilities exercises in
preterm newborns. The literature [18-23] and our
Discussion findings indicate airway clearance in premature
infants as safe and effective.
We reported that physiotherapy treatment acu- SO2% was also observed from the use of pul-
tely improved HR, RR and SO2% at rest in PIVH se oximetry. It was noted increase of this variable
newborn weighting less than 2,000g. Furthermo- after 3 physiotherapy sessions in both control and
re, SO2% was also improved in control newborns PIVH groups. The improvement trend of SO2%
weighing less than 2,000g. As demonstrated by levels may be detected as early as the first clinical
the vital sign responses, our findings suggest that session, when comparing before and after physio-
chest associated to motor physiotherapy improves therapy sessions. It is interesting to note that after
the hemodynamic status of the newborn, reducing chest associated to motor physiotherapy sessions
cardiovascular instability, which decreases the li- the rates tended to be stable with improvement
kelihood of PIVH development in the control gro- from the 2nd session, which supports the benefici-
up and rupture of blood vessels in the PIVH gro- al use of chest and motor physiotherapy in PIVH
up. Thus, it is a trustful procedure to treat preterm newborns by increasing SO2% levels. Conversely,
newborns. SO2% in HPIV group presented lower but con-
After 3 physiotherapy sessions we observed re- stant linear development compared to control gro-
dution in HR in PIVH newborns. It supports the up, which confirmed the improvement from the
hypothesis that physiotherapy treatment immedi- 1st to 2nd and from the 2nd to the 3rd physiotherapy
ately improved newborns hemodynamic status. session, indicating the beneficial effect of chest
Moreover, according to our findings RR decreased and motor physiotherapy on PIVH newborns re-

Journal of Society for development in new net environment in B&H 1385

HealthMED - Volume 5 / Number 6 / 2011
garding SO2%. Our findings are supported by Ber-
nard-Narbonne [14] et al and Martin and Thomas
[24]. They reported that tactile and kinesthetic sti-
mulation enhance optimal physiological responses
and behavioral organization of premature infants,
suggesting that nursing staff in the intensive care
unit may use these procedures in order to promote
infant’s capability to positively respond to his/her
environment and to provide developmental sup-
port for healthy premature newborns.
In our procedures we associated chest physiot-
herapy with motor physiotherapy and we observed
improvement of basal HR and RR in premature
PIVH newborns and SO2% improvement in PIVH
and control groups. Airway clearance techniques
are used to mobilize and remove secretions in ai-
rways in order to improve lung function. On the
other hand, some reports suggest these procedures
to not present benefic effects on preterm newborns
[24]. A previous study do not indicate airway cle-
arance techniques for premature newborns wei-
ghting less than 1,500 g in the first 3 days of life.
It was suggested that it increases the probability of
cerebral hemorrhage [23]. Other investigations in-
dicate that airway clearance techniques, especially
clapping, may cause adverse effects in newborns,
such as hypoxemia [25] ribs fracture and cerebral
injuries [26]. Based on those researches, some
researchers are likely to clapping with adverse
events on newborns [27]. It was previously repor-
ted that the use of clapping is deleterious due to the
fragility and little size of newborns thorax. Thus,
it may increase the collateral mechanical effects
of clapping when compared to older subjects [27].
Our findings suggest that chest and motor
physiotherapy is able to stabilize cardiorespiratory
parameters in PIVH newborns. With respect to
chest physiotherapy, aspiration is a procedure of-
ten performed in order to keep airways permeabi-
lity, especially in patients which do not cough re-
gularly, as the newborn [28]. It is a procedure that
requires extreme care in its implementation due to
side effects that it may cause, due to physiological
changes induced by aspiration, such as hypoxemia
which may lead to peripheral vasoconstriction, in-
creased blood pressure and bradyarrhythmia, as
well as changes in cerebral blood flow and ele-
vated intracranial pressure [29]. Other effects are
described, such as lesions of the tracheobronchial
1386 Journal of Society for development in new net environment in B&H
mucosa, bronchial perforation by suction catheter
(with secondary pneumothorax), atelectasis (due
to excessive negative pressure) and in addition to
respiratory tract infections [28].
We demonstrated that motor physiotherapy
associated to airway clearance techniques such
as clapping or vibration followed by suction and
postural drainage and/or vacuum decreased the
necessity for reintubation (data not shown), con-
sequently reducing the rate of post-extubation
atelectasis. Physiotherapy treatment has received
attention regarding preterm newborns with res-
piratory disorders, such as aspiration syndromes,
respiratory distress syndrome, pneumonia, atelec-
tasis and in those preterm newborns on mechanical
ventilation. There are also indications of physiot-
herapy procedures in cases of airways secretion in
newborns with negative prognostic [1-3]. Physiot-
herapy performed pre-and post-extubation showed
improvement of pulmonary symptoms with redu-
ced incidence of lung atelectasis after extubation
[6-8]. Physiotherapy results in lung mechanical
effects, providing optimal respiratory function in
order to facilitate gas exchange and adjust venti-
lation-perfusion adequacy of respiratory support,
to prevent and treat pulmonary complications, to
provide good maintenance of airways and to fa-
cilitate weaning from mechanical ventilation and
oxygen therapy [29, 30]. Our results are clini-
cally relevant, since illness advance impediment
in newborns will avoid sickness manifestations in
childhood [31, 32].
In conclusion, chest and motor physiotherapy
procedures were able to acutely improve basal
HR, RR and SO2% in newborns weighing less
than 2,000g with and without PIVH. Therefore,
we recommended performing chest and motor
physiotherapy in critically ill newborns.
Acknowledgements
This research was supported by public funding
from Foundation of Support to Research of São
Paulo State (FAPESP).

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Corresponding author
Luiz Carlos de Abreu,
Departamento de Morfologia e Fisiologia,
Faculdade de Medicina do ABC,
Brasil,
E-mail: luizcarlos@usp.br

1388 Journal of Society for development in new net environment in B&H


The causes of chest pain among
Korean outpatients in primary care
practice
Jongwoo Kim1, Seon Yeong Lee1 , Kyunam Kim1, Sun Mi Yoo2
1
Department of Family Medicine, Sanggye-Paik Hospital, College of Medicine, Inje University, Seoul, Korea,
2
Department of Family Medicine, Haeundae-Paik Hospital, College of Medicine, Inje University, Busan, Korea.
Abstract
Background: Chest pain is an important pro-
blem that primary care physicians encounter
frequently. Although the leading causes of chest
pain are maybe alternating due to lifestyle chan-
ge and progression of diagnostic tool, there were
no recent studies focused on the outpatients with
chest pain in primary care settings. We retrospecti-
vely evaluated causes and characters of chest pain
among Korean outpatients.
Methods: Diagnosis and classification of chest
pain were made among 244 patients who visited
the outpatient clinic of family medicine which is
located in one of the university hospital in Seoul,
Korea from January, 2008 to December, 2008.
Results: The number of patients who had
"chest pain" as a chief complaint was 244. The ca-
uses of chest pain were musculoskeletal (43.4%),
psychosocial (13.1%), esophageal (12.3%), respi-
ratory (8.2%), cardiovascular (4.9%) origins.
Conclusion: Recently, the proportion of the
esophageal origin-chest pain has increased, but
that of the cardiovascular origin was stationary.
Key words: Chest Pain; Causes; Primary Care;
Outpatient
Introduction
Chest pain commonly refers to the pain or un-
comfortable symptom felt in the chest area and is
a commonly encountered problem in primary care.
The cause of chest pain can vary from transient,
mild conditions to serious problems, such as acute
coronary syndrome or pulmonary embolism, which
may lead to sudden death if not treated immediately.
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
Although extensive study on the prevalence rate
of chest pain in Korean primary care has not been
achieved, musculoskeletal disease and psychologi-
cal factor have been reported as the most common
causes for chest pain, followed by cough, pulmo-
nary disease, and gastrointestinal disorder accor-
ding to study by Yang et al. [1]. Furthermore, the
frequency of causes of chest pain is reported to
greatly differ in primary care and emergency depar-
tment. In case of the West, cardiovascular diseases,
such as acute myocardial infarction, angina, pulmo-
nary embolism, and cardiac failure, are reported as
the main cause for over 50% of patients that have
visited the emergency center for chest pain, while
musculoskeletal and gastrointestinal disorders are
reported as the leading causes in primary care [2].
Although the leading causes of chest pain are
maybe alternating due to the recent Westernized
lifestyles and progression of diagnostic tool, there
were no recent studies focused on the outpatients
with chest pain in primary care settings. Thus, we
retrospectively evaluate and classify the causes of
chest pain and investigate the frequency of causes
and characters of chest pain by analyzing records
of chest pain patients who have visited the outpa-
tient department of family medicine at a university
hospital located in Seoul, Korea.
Methods
Subjects were selected as adult chest pain pa-
tients that visited the outpatient department of fa-
mily medicine at a university hospital located in
Seoul, Korea in the 12-month period from January
2, 2008 to December 31, 2008. Computerized re-
cords on all 3,538 new patients that visited the out-
1389
HealthMED - Volume 5 / Number 6 / 2011
patient department of family medicine during the
12 months were examined to select 244 patients
that mainly complained of chest pain. All medical
examination records, new patient questionnaires,
outpatient and hospitalization records, and vario-
us diagnostic test results of these selected patients
were collected to be reviewed and analyzed by 2
residents. The analysis was executed on chest pain
patients that visited primary care clinic as well as
patients that were sent from other medical insti-
tutions, and causes of chest pain were classified
according to the following standards during exa-
mination and analysis.
In case of cardiovascular diseases, resting elec-
trocardiography, exercise (treadmill) test, cardiac
marker test, echocardiography, coronary CT-scan,
and coronary arteriography were executed and di-
agnosed if these tests were positive. For gastro-
intestinal disorder, esophagogastroduodenoscopy
was executed to diagnose diseases such as gastri-
tis, peptic ulcer, and reflux esophagitis. If the cli-
nician continued to suspect the possibility of chest
pain caused by reflux esophagitis even when ma-
croscopic abnormality was not observed in esop-
hagogastroduodenoscopy, and if there was symp-
tomatic improvement in follow-up observation
after drug treatment, it was regarded as chest pain
caused by reflux esophagitis. Radiological test and
sputum culture were executed for respiratory di-
sease. Musculoskeletal disease was diagnosed if
there was identical form of chest pain through se-
veral pain-triggering physical exam, such as chest
wall maneuver. Chest pain caused by psychoso-
cial problems was judged to possess psychoge-
nic factors, such as stress or anxiety, rather than
particular organic causes based on medical history
and physical exam in case of improvement during
two follow-up observation periods after drug trea-
tment. If the cause of chest pain was unclear in the
first visit and remained unclear throughout the two
follow-up observation periods, the cause of chest
pain was classified as unknown regardless of pro-
gress in treatment, and patients that did not achi-
eve more than two follow-up observations were
classified as ‘follow-up loss’ group.
First medical examination records, new patient
questionnaires, outpatient and hospitalization re-
cords including records of other departments, and
various diagnostic test results were independently
1390 Journal of Society for development in new net environment in B&H
reviewed and analyzed by 2 residents. If causes of
chest pain was judged differently by the 2 residents,
it was classified as chest pain of unknown cause.
New patient records and questionnaires were
examined to determine the frequency regarding
chest pain location, and locations were classified
as left chest, right chest, precordium, epigastrium,
and retrosternal area. Patient cases complaining of
chest pain in various locations or inadequate (mi-
ssing) data were classified as ‘other’.
The expression method of chest pain was also
organized through new patient records and que-
stionnaires, and subjective expressions of patients
were directly used in analysis without passing
through the standardization process of expression
methods. The main expressions complained by
more than 3 of the 244 patients were established
and organized into items. The main expressions
complained by 1~2 patients were classified as
‘other’, and patients with inadequate (missing) re-
cord were classified separately.
Results
A total of 244 new patients (6.9%) visited the
hospital for chest pain, composed of 134 men and
110 women. Average age was 43.3±16.9 (Table 1).
The frequency regarding cause of chest pain was
presented in the following order; 106 patients with
musculoskeletal disease (43.4%), 32 patients with
psychosocial problem (13.1%), 30 patients with
esophageal disorder (12.3%), 20 patients with respi-
ratory disease (8.2%), 12 patients with cardiovascu-
lar disease (4.9%), and 4 patients with other causes
(1.6%). 21 patients were classified as unknown cause
(8.6%), while 19 patients were classified as ‘follow-
up loss’ group (7.8%). Myofascial pain syndrome
was most common in musculoskeletal disease with
38 patients (35.8%), followed by 34 patients with
costochondritis (32.1%), 18 patients with chest wall
syndrome (17.0%), and 16 patients with intercostal
neuralgia (15.1%). Anxiety was the main psychoso-
cial problem with 31 patients (96.9%), while 1 pa-
tient was diagnosed with depression (3.1%). Reflux
esophagitis took over the entire esophageal disorder
with 30 patients (100%). In respiratory disease, 15
patients were diagnosed with pneumonia (75.0%),
while 5 patients were pneumothorax (25.0%). In
 HealthMED - Volume 5 / Number 6 / 2011

Table 1. Baseline characteristics of patients who had “chest pain” as a chief complaint*
Male(n=134, 54.9%) Female(n=110, 45.1%) Total(n=244)
Age(year) 40.9±15.4 46.1±18.2 43.3±16.9
-19 7(5.2) 7(6.4) 14(5.7)
20-29 29(21.6) 19(17.3) 48(19.7)
30-39 35(26.1) 15(13.6) 50(20.5)
40-49 22(16.4) 23(20.9) 45(18.4)
50-59 24(17.9) 20(18.2) 44(18.0)
60-69 11(8.2) 12(10.9) 23(9.4)
70- 6(4.5) 14(12.7) 20(8.2)
Onset to visit(day) 145.6±314.3 243.6±842.6 189.8±612.1
Pain location, n(%)
Left 48(35.8) 30(27.3) 78(32.0)
Right 30(22.4) 24(21.8) 54(22.1)
Precordial 25(18.7) 19(17.3) 44(18.0)
Epigastric 7(5.2) 7(6.4) 14(5.7)
Retrosternal 1(0.7) 3(2.7) 4(1.6)
Others† 23(17.2) 27(24.5) 50(20.5)
*All data were presented as mean ± SD or number(%).
†Others contain all the cases of missing data or multiple symptom sites.

case of cardiovascular diseases, stable angina was Abbreviations: MFPS, myofascial pain syndrome; GERD,
most common with 10 patients (83.3%), while acute gastroesophageal reflux disease; AMI, acute myocardial in-
farction.
myocardial infarction was 2 patients (16.7%). For *Chest wall syndrome means all other possible musculo-
other causes, 3 patients was diagnosed with shingles skeletal disease on chest wall, such as pectoralis major or
(75%), while 1 patient was diagnosed with acute minor syndrome, slipping rib syndrome, etc., except MFPS,
cholecystitis (25%) (Table 2). costochondritis, and intercostal neuralgia.
Table 2. Frequency for the cause of chest pain †Others: 3 cases were Herpes zoster, and 1 case was acute
cholecystitis.
Cause Frequency, n(%)
Musculoskeletal disorder 106(43.4)
The left chest was the most common location
    MFPS        38(35.8)
of chest pain with 78 patients (32.0%), followed
    Costochondritis        34(32.1)
by 54 patients experiencing chest pain in the right
    Chest wall syndrome*        18(17.0)
chest (22.1%), 44 patients in precordium (18.0%),
    Intercostal neuralgia        16(15.1)
14 patients in epigastrium (5.7%), and 4 patients
Psychosocial disorder 32(13.1)
in retrosternal area (1.6%). 50 patients (20.5%)
    Anxiety        31(96.9)
    Depression        1(3.1)
complained of chest pain in various locations or
Esophageal disorder 30(12.3)
had inadequate data (Table 1).
    GERD        30(100) Diverse subjective expression methods were
Pulmonary disorder 20(8.2) presented for chest pain. "Pain on inspiration"
    Pneumonia        15(75.0) was the most common expression stated by 27
    Pneumothorax      5(25.0) patients (11.1%), followed by "pricking pain" by
Cardiac disorder 12(4.9) 24 patients (9.8%), "stiff" by 23 patients (9.4%),
    Angina        10(83.3) "weighed down" by 19 patients (7.8%), "tightened
    AMI        2(16.7) (strained)" by 19 patients (7.8%), "pain on moti-
Others† 4(1.6) on" by 18 patients (7.4%), "ache" by 16 patients
Unknown origin 21(8.6) (6.6%), "shooting pain" by 12 patients (4.9%),
Follow-up loss 19(7.8) "pain on coughing" by 10 patients (4.1%), and

Journal of Society for development in new net environment in B&H 1391

HealthMED - Volume 5 / Number 6 / 2011

"feel a stitch on chest" by 8 patients (3.3%). Ot-

her expressions include "feels like chest will tear The patients’ subjective expressions were classi-
apart", "pinching pain", which were each obser- fied into causes to analyze the 3 expressions with the
ved in 2 cases, and "digging pain", "burning pain", highest frequency. "Pricking pain", "pain on inspi-
"scratchy", "deafening", "hardened", "feels like ration", and "pain on motion" were most common
chest will burst", "slashed by knife” were obser- in musculoskeletal disease, “tightened (strained)",
ved in 1 case each (Table 3). “weighed down”, and “stiff” were most common
Table 3. The characteristics of chest pain expre- in psychosocial problem, “weighed down”, “stiff”,
ssions and “pricking pain” were most common in esopha-
Expression Frequency(%) geal disorder, “pain on inspiration”, “pain on moti-
1. pain on inspiration 27(11.1) on”, and “pain on coughing” were most common in
2. pricking pain 24(9.8) respiratory diseases, while “weighed down”, “sti-
3. stiff 23(9.4) ff”, and “tightened (strained)” were most common
4. weighed down 19(7.8) in cardiovascular disease (Table 4).
5. tightened (strained) 19(7.8) According to analysis on causes of chest pain
6. pain on motion 18(7.4) in frequency order according to age group, frequ-
7. ache 16(6.6) ency of causal diseases similar to entire patient
8. shooting pain 12(4.9) group was observed in most age groups. However,
9. pain on coughing 10(4.1) in case of esophageal disorder, 15.6% was obser-
10.feel a stitch on chest 8(3.3) ved in the 40s and 20.5% in the 50s, thus showing
11.Others* 11(4.5) relatively higher frequency in the two age groups
*Others: Expressions of " feels like chest will tear apart " than in other age groups, while 17.4% was obser-
and " pinching pain " were two cases each, and " digging ved in the 60s in cardiovascular diseases, thus pre-
pain ", " burning pain ", " scratchy ", " deafening ", " harde-
ned ", " feels like chest will burst ", " slashed by knife " was
senting higher frequency in the 60s than in other
one case each.
age groups (Table 5).

Table 4. Three most common expressions classified by causes of chest pain

Cause Most common(%) Second common(%) Third common(%)
Musculoskeletal dis- pricking pain (16.3)
NA* pain on motion (12.8)
order / pain on inspiration (16.3)
Psychosocial disorder tightened (strained) (31.6) weighed down (15.8)/ stiff (15.8) NA*
weighed down (21.7)
Esophageal disorder NA* pricking pain (17.4)
/ stiff (21.7)
Pulmonary disorder pain on inspiration (38.9) pain on motion (22.2) pain on coughing (11.1)
stiff (18.2)
Cardiac disorder weighed down (27.3) NA*
/ tightened (strained) (18.2)
*NA means “Not available”.

Table 5. Three most common causes of chest pain classified by ages

Age(year), (n) Most common(%) Second common(%) Third common(%)
Musculoskeletal(28.6)
   -19(14) NA* Esophageal(14.3)
/ Psychosocial(28.6)
20-29(48) Musculoskeletal(50.0) Psychosocial(12.5) Esophageal(10.4)
30-39(50) Musculoskeletal(52.0) Psychosocial(14.0) Esophageal(10.0)
40-49(45) Musculoskeletal(46.7) Esophageal(15.6) Psychosocial(11.1)
50-59(44) Musculoskeletal(34.1) Esophageal(20.5) Pulmonary(11.4)
60-69(23) Musculoskeletal(39.1) Psychosocial(17.4) / Cardiac(17.4) NA*
70- (20) Musculoskeletal(35.0) Psychosocial(15.0) Esophageal(10.0)
*NA means “Not available”.

1392 Journal of Society for development in new net environment in B&H


Discussion
In previous study of chest pain in primary care,
coronary heart disease was the most common cau-
se of chest pain (34.5%) according to prospective
study executed by Ambulatory Sentinel Practice
Network on 832 chest pain patients that visited
primary care institutions in 18 U.S. states and Ca-
nada. Other causes included musculoskeletal di-
sease (25.5%), gastrointestinal disorder (13.7%),
psychosocial problems (7.5%), pleurisy (4.3%),
trauma (3.2%), and others (11.3%) [3]. In case of
Korea, musculoskeletal chest pain (27%) was the
most common cause, followed by psychogenic
chest pain (26.1%), chest pain by coughing (8.8%),
cardiopulmonary disease (7.9%), gastrointestinal
disease (4.4%), ischemic heart disease (2.3%), un-
known cause (13.9%), and other diseases (9.6%)
according to the prospective study executed on
467 patients that visited the outpatient department
of family medicine in university hospital for chest
pain [1]. Our study presented frequency of muscu-
loskeletal disease (43.4%), psychosocial problem
(13.1%), esophageal disorder (12.3%), respira-
tory disease (8.2%), and cardiovascular disease
(4.9%). Although coronary heart disease occupi-
ed the highest rate among causes of chest pain in
the West (U.S. and Canada), it can be thought that
musculoskeletal chest pain or psychogenic chest
pain is more common in Korea. Furthermore, al-
though frequency of chest pain caused by cardio-
vascular disease is not increased, but frequency of
chest pain caused by esophageal disorder has been
increased recently. This change is stipulated to
have resulted from the increase in number of pati-
ents taking the esophagogastroduodenoscopy, the
development of diagnostic techniques, changes in
lifestyle and increased interest in health issues.
Characteristics of chest pain were observed as
pressure (43%) and tightness (22%) in the study by
Master [4], and as pressing pain (25%) and burning
pain (21.5%) in the study by Chung et al. [5]. In
our study, the most common expression was obser-
ved as “pain on inspiration” by 27 patients (11.1%),
followed by "pricking pain" by 24 patients (9.8%),
"stiff" by 23 patients (9.4%), "weighed down" by
19 people (7.8%), "tightened (strained)" by 19 pa-
tients (7.8%), and "pain on motion" by 18 patients
(7.4%). It was difficult to achieve direct compari-
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
son with other study results as the expressions of
patients were extremely diverse. This is due to the
difference in study methods; whereas prospective
study enabled patients to independently select and
record characteristics of chest pain in arranged que-
stionnaire papers, this study was in the retrospective
method and used subjective expressions of patients
in analysis without passing through the standardi-
zation process of diverse expressions. Additionally,
although we could not discover particular trends
between causes of chest pain and patients’ expre-
ssions due to the diversity of subjective expressi-
on methods of patients in musculoskeletal disease,
psychosocial problem, esophageal disorder, and
respiratory disease, typical expressions according
to chest pain causes such as “weighed down”, “sti-
ff”, and “tightened (strained)” were the most com-
mon expressions in cardiovascular disease.
The locations of chest pain were retrosternal
area (37%) and anterior chest(22%) according to
study by Master [4], and retrosternal area (28.8%)
and anterior chest (17.6%) according to study by
Chung et al. [5]. This study presented difference
from existing results with 32.0% in left chest and
22.1% in right chest.
Chest pain is a commonly encountered pro-
blem in primary care, and as investigation on cau-
ses of chest pain holds clinical significance in re-
lated cardiovascular diseases, accurate diagnosis
and treatment is extremely important. However,
accurate differential diagnosis is also important as
the severity of chest pain is not particularly related
with the severity of causal diseases. Furthermore,
the probability of coronary artery disease being
the cause of chest pain is decided by the preva-
lence rate of coronary artery disease in the com-
munity even when the patients presents similar
medical history during diagnosis on cause of chest
pain [6]. Thus, if the prevalence rate of coronary
artery syndrome in the community is relatively
low, and if the initial assessment is not compatible
with cardiac problems, efforts must be placed in
treating suspected diseases rather than in vigorous
diagnostic test focused on cardiac problems, and
treatment should be achieved along with follow-
up observation on patient’s status.
As many of the patients worry about the possi-
bility of the chest pain symbolizing a serious disea-
se, it is common for chest pain patients to take vari-
1393
HealthMED - Volume 5 / Number 6 / 2011

ous extensive tests, continue to suffer with the anxi- References

ety of possessing a life-threatening disease if chest
pain is continued after initial diagnostic tests, and 1. Yang YJ, Kim CH, Seo HG. A study on the etio-
visit various medical institutions to take repetitive logy of chest pain - among the outpatients depar-
tests. Because pain is a subjective phenomenon, tment of family medicine. J Korean Acad Fam Med
the patient’s reaction toward the pain is important. 1992;13:671-80.
Pain may be exaggerated or denied according to the 2. Cayley WE. Diagnosing the cause of chest pain. Am
patient, and as the reaction toward diseases differ Fam Physician 2005;72:2012-21.
between patients, some patients may show a hyper-
3. ASPN. An exploratory report of chest pain in pri-
sensitive reaction toward mild pain to immediately
mary care. J Am Board Fam Pract 1990;3:143-50.
visit the hospital while others underestimate the di-
sease while complaining of severe pain [5]. Thus, 4. Master AM. The spectrum of anginal and noncardi-
although it is important for primary care physici- ac chest pain. JAMA 1964;187:894-9.
ans to diagnose life-threatening diseases, it is also
5. Chung WC, Park JW, Mun YS, Oh MK, Lee HR,
extremely important to reassure patients according Youn BB. Clinical features of chest pain in a univer-
to status and help patients to avoid taking unnece- sity hospital emergency room. J Korean Acad Fam
ssary additional tests and quickly return to normal Med 1991;12:652-8.
life in case of insufficient evidence.
The limitations of this study are as follows. 6. Sox HC, Hickman DH, Marton KI, Moses L, Skeff
KM, Sox CH, et al. Using the patient's history to
As patients of university (tertiary) hospital were
estimate the probability of coronary artery disease:
selected as study subjects, the severity of disea-
a comparison of primary care and referral practi-
ses differed from general population. Also, as this ces. Am J Med 1990;89:7-14.
study was retrospective design based on data such
as patient records, insufficient preparation for ina-
dequate (missing) records was a second limitation. Corresponding author
Thus, large-sized prospective study that includes Seon Yeong Lee,
outpatients of primary clinics or secondary hospi- Department of Family Medicine,
tals must be executed to establish accurate preva- Sanggye-Paik Hospital,
lence rate and to develop diagnostic guidelines for College of Medicine,
chest pain patients. Inje University,
In conclusion, frequency of chest pain caused by Republic of Korea,
E-mail: s2700@paik.ac.kr
esophageal disorder has markedly increased when
compared with previous study, while frequency
of chest pain caused by cardiovascular origin was
stationary. This is regarded to have resulted from
changes in lifestyles and development of diagno-
stic techniques. As the fact that chest pain is mostly
caused by non-cardiovascular diseases remains to
be true in present day, unnecessary diagnostic tests
must be avoided and accurate treatments must be
executed according to cause of chest pain based on
medical history and physical exams.

1394 Journal of Society for development in new net environment in B&H

 HealthMED - Volume 5 / Number 6 / 2011

Are patient falls in the hospital

associated with days of the
week and hours of the day? A
retrospective observational study
using Rasch modeling
Su-Chen Hsu1, Huan-Fang Lee2,3, Tsair-Wei Chien4
1
Department of Nursing, Chi-Mei Medical Center, Tainan, Taiwan
2
Department of Institute of Allied Health Sciences, College of Medicine, National Cheng Kung University,
Tainan City, Taiwan
3
Department of Nursing, Chi-Mei Medical Center, Tainan, Taiwan
4
Assisstant Professor, Department of Hospital and Health Care Administration, Chia-Nan University of
Pharmacy and Science, Tainan, Taiwan

Abstract are required to overcome the drawbacks of tradi-

Background: Analyses of patient falls are often
using traditional ways to explore factors of patient
falls. Many efforts were not made in examining
data dimension and then failed to made inferences
about factors of patient falls associated with days of
the week and hours of the day in a hospital. Using
Rasch model to explore them is required.
Methods: We used the Rasch rating scale mo-
del to analyse data of inpatient falls from July
2005 to June 2010, which were collected from 35
wards of three different hospitals, examined unidi-
mensionality. Differentiate item functioning (DIF)
was detected in comparison between groups. Fac-
tors associated days of the week and hours of the
day to inpatient fall counts are investigated to help
accomplish large improvements on a small num-
ber of key areas giving an alarm to station nurses.
Results: We found that (1) there were two
stages of the time data extracted by parallel analy-
sis; (2) DIF was not found in stage II of the time
unidimensional data; (3) factors associated days of
the week and hours of the day regarding inpatient
fall counts were in existence on Saturday and at 9
o’clock, respectively.
Conclusions: Dimension checking and model-
data-fit using parallel analysis and Rasch analysis
tional ways to explore factors of patient falls. Fac-
tors associated days of the week and hours of the
day can help pay more attentions on Saturday and
at 9 o’clock giving an alarm to station nurses.
Background
Falls by hospitalized patients are significant be-
cause they cause physical, social, psychological,
financial problems-from minor pain and embarras-
sment to death-for patients [1]. Falls can also lengt-
hen inpatient hospital stays, result in a poor quality
of patient life during and after hospitalization, and
increase both the patient’s and the hospital’s costs,
which can seriously affect hospital operation [2,3].
Preventing inpatient falls as a key aim of
hospitals in recent years
Most falls (78%) inpatient falls are anticipated
and can be attributed to patient frailty caused by
illness and aging. Approximately 8% of all falls
are unanticipated; this is when a patient with none
of the risk factors of falls caused by suddenly
feeling faint or a knee suddenly giving way. The
remaining 14% are accidental falls [4]. Rutledge
and Schub [5] reported that falls account for 30-

Journal of Society for development in new net environment in B&H 1395

HealthMED - Volume 5 / Number 6 / 2011
40% of inpatient safety incidents. Patient safety
has become a critical issue in the 21st century
[5,6]. Preventing inpatient falls and improving pa-
tient safety is widely recognized as a key aim of
hospitals in recent years [7-12].
Quality of patient care improvement must be
based on evidence-based research and informed
through ongoing assessments of data and informa-
tion [1,13]. Appropriate increases in the use of in-
formation technology in health care are being en-
couraged to help hospitals achieve this goal [14].
Attaining an "always comparing, always impro-
ving quality of service" has also been proposed for
hospital settings [15]. However, factors of patient
falls associated with days of the week and hours
of the day are required to investigate in advance.
Unidimensionaity matter and factors associ-
ated with inpatient falls
Schwendimann et al.[16] conducted a study re-
garding patient falls in the hospital associated with
lunar cycles and concluded that they were neither
associated with days of the week, months, or sea-
sons nor with lunar cycles such as full moon or
new moon. We doubted of data (from 3,842 fall
incident reports of adult in-patients in a 300-bed
urban public hospital in Zurich, Switzerland) that
were not evident to be unidimensional resulting
in a bias result. Accordingly, data with unidimen-
sionality [17,18] are required to be first examined
and then used to effectively make inferences with
regard to factors associated with inpatient falls on
days of the week and at hours of the day. Another
way of saying this is that unidimensionality needs
the average (or summation) score (i.e., fall count
in this study) to represent the overall performance
of a measure. If the data were unable to interpret a
common characteristic or entity, the inferred result
would be problematic or biased [19].
Objectives
The study examined a dataset that monthly re-
corded patient fall in a hospital between nursing
units and to identify the effect factors associated
with inpatient falls. These studies aimed to addre-
ss the following goals:
1. To inspect data of inpatient falls across time
points whether constructing a common
entity (i.e., a single dimension).
1396 Journal of Society for development in new net environment in B&H
2. To examine any time point in violation
to differentiate item functioning (DIF)
[20,21] which would affect fair comparison
between groups.
3. To investigate factors associated days of
the week and hours of the day regarding
inpatient fall counts in hospital so as to help
nurses accomplish large improvements on
a small number of key areas.
Methods
Study 1: checking unidimensionality
Study sample and setting
We conducted a retrospective analysis of all re-
gistered inpatient falls amongst the patients (aged
from 1 to 96) hospitalized on 35 general nursing
wards from three kinds of hospitals (A: 17 units
from a 1200-bed medical center; B: 4 units from a
900-bed regional hospital; C: 15 units from a 60-
bed psychiatric hospital), which provides medical
services for the patients of the southern part of the
city of Tainan, Taiwan. The observation period
was from July 1, 2005 to June 30, 2010. Ethical
approval was granted and monitored by the Ethics
Committee of Chi-Mei hospital.
Variables and measurements
Patient falls were defined as "an incident in
which a patient suddenly and involuntary came
to rest on the ground or surface" and were regi-
stered regularly by the nurses discovering the pa-
tient fall. We retrieved the number of registered
patient falls occurring during hospital stay from
the incident report data system of the quality ma-
nagement department, and organized patient data
to forming a 35 × 20 rectangle metric, 35 cases
by wards(nursing units in rows) and 20 items by
quarters(time points in columns) with responses
from 0 (none) to 3 (most frequency) after taking a
logarithmic transformation to represent the pattern
of patient fall in wards over time.
Data analysis
1. Parallel analysis for checking dimensionality
We detected the number of factors for the study
data using parallel analysis [22], one of the most re-

commended methods for dealing with the number-
of-factors-to-retain problem [23,24] to observe data
dimensionality. ViSta version 7.9.2.6 (2010, April)
[25] was performed to plot the graphical parallel
analysis with 95% confidence intervals [26].
2. Model-Data-fit Rasch analysis
In Rasch rating scale model [27,28], infit and
outfit statistics were used to examine whether the
data fit the model’s requirement. The infit mean
square (MNSQ) is sensitive to unexpected beha-
viour affecting responses to items (time point in
quarter) near the respondent’s measure; the outfit
MNSQ is sensitive to unexpected behaviour by
respondents on items far from the respondent’s
level [29,30]. MNSQ can be transformed to a t
statistic, termed the standardized Z value (ZSTD),
which follows approximately the standard normal
distribution when the items fit the model’s requi-
rement. In present study, items with both infit and
outfit ZSTD beyond ±2 were considered poor fi-
tting [31]. The WINSTEPS computer program
[32] was used to perform the Rasch analysis.
3. Rasch PCA to assess unidimensionality
The use of principal component analysis
(PCA) of Rasch standardized residuals has been
suggested as Post Hoc tests to assess unidimen-
sionality [20,33,34]. Residual loadings of Rasch
PCA separate items into two opposite directions
representing different factors if the eigenvalue
(greater than 2.0 expected by chance [35] of the
first residual of Rasch-transformed scores showed
dominant factors [31].
Study 2: assessing differential item
functioning (DIF)
Data analysis
1. Assessment of differential item functioning
(DIF)
To make comparison across different groups of
hospitals in performance of preventing inpatient
falls, the assessment must remain invariant across
groups. DIF analysis is a means to verify construct
equivalence over groups [20,21]. If construct
equivalence does not hold over groups, meaning
that different groups respond to time point differ-
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
ently after holding their measures constant, then
the estimated measures could not be compared di-
rectly over groups. In this study hospital type (A,
B and C) were examined for DIF. DIF size greater
than 0.5 indicates a DIF [20,21].
2. Appropriateness of level of scaling
Linacre [36] suggested guidelines to aid an anal-
yst in optimizing the manner in which rating scale
categories cooperate to improve the utility of the
resulting measures. Their guidelines include the
following: (1) at least 10 observations of each cate-
gory; (2) a regular observation distribution; (3) that
average measures advance monotonically within
each category; (4) the OUTFIT mean-squares must
be less than 2.0; (5) that step calibrations advance;
(6) that ratings imply measures, and measures im-
ply ratings; (7) that step difficulties advance by at
least 1.4 logits; and (8) that step difficulties advance
by less than 5.0 logits. Some of these guidelines will
be applied to assess both the reliability and validity
of the measurement of patient fall in this study.
Study 3: Factors associated with inpatient
falls on days and at hours
We reorganized unidimensioanl dataset to be a
24(hours a day in rows) × 7 (days a week in col-
umns) with responses from 0 (none) to 3 (most fre-
quency) after taking a logarithmic transformation.
Rasch analysis was performed to examine whether
there are factors associated with inpatient falls on
days of the week and at hours of the day so as to help
nurses accomplish large improvements on a small
number of key areas in prevention of inpatient falls.
The t-value less then 2.0 was deemed statistically
significant deterioration occurred (p< .05) in trend
(or count) of patient falls for a specific nursing unit.
Results
Study 1: Two stages with unidimensionality
and model-data fit
Two factors (on right in Figure 1) were exactly
extracted by parallel analysis. Two patterns (on left
in Figure 1) are oppositely dispersed in upper (stage
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HealthMED - Volume 5 / Number 6 / 2011

II) and lower (stage I) side, respectively, separated
by PCA of Rasch standardized residuals. In Table
1 shows that all time points, but quarter 3 in 2009
(2009-Q3) shown a trivial misfit with infit ZSTD
of -2.33, fit Rasch model’s expectation rather well.
Study 2: DIF and appropriateness of level
of scaling
DIF analysis was conducted to assess the mo-
del-data fit for item-difficulty hierarchy that was
invariant across groups. The first two quarters
(2005-Q3 and 2005-Q4) exhibited DIF for hospi-
tal groups (Table 1 in last column with a symbol of
asterisk), indicating wards from different hospitals
with same measure have a different probability of
giving a response on the DIF time points. Hence, it
is not appropriate using the number of patient falls
to compare hospital groups against each other.
Figure 2 shows that only the subscale of stage
II exhibited step difficulties advanced by logits
ranged from 1.4 to 5.0. Other requirements of
Linacre [36] suggested guidelines were all met to
display appropriateness of level of scaling, indi-
cating that these time poinsts of stage II measured
a single construct for wards on respective sub-
scales rather well.

Figure 1. Principal component analysis for 20-time-point of patient falls

Note: Two factors were extracted by parallel analysis (right)
Two patterns analyzed by PCA of Rasch residuals into two contrasts separated by vertically standardized Rasch residuals

Figure 2. Category analyses for the two stages of time points

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 HealthMED - Volume 5 / Number 6 / 2011

Study 3: Factors associated with inpatient

falls on days and at hours

Using data of stage II to investigate factors as-

sociated days of the week and hours of the day for
inpatient fall counts in hospital, we found that sig-
nificant differences between Friday and Saturday
with t=2.11 as well as hours at 9 and 13 o’clock
in a day with t=13.06, which can help pay more
attentions on Saturday and at 9 o’clock giving an
alarm to station nurses. The highest occurrences
on days of the week(at the left of Figure 3) and
at hours of the day (at the right of Figure 3) for
inpatient fall counts in hospital using data of stage
II are on Saturday and at 9 o’clock, respectively.

Discussion

Key findings

There were two stages of the time data extract-

ed by parallel analysis. Precise inference made
by dimension checking and model-data-fit using
unidimensional data of stage II can overcome the
issue of “good measures from bad data” [37]. Fac-
tors are significantly associated with the day of the
week (on Saturday) and the hour of the day (at 9
o’clock).

What this adds to what was already known

In classic test theory (CTT), scores are assumed

to be interval. This assumption may hold in physi-
cal measures (e.g., height and body temperature),
but it does not hold for many observed scores in
the social sciences. The Rasch method is recom-
mended to replace the summation method because
not only the Rasch method is theoretically sound
but also the summation method does not yield
results that are identical to those from the Rasch
method. With this method, we found factors as-
sociated days of the week and hours of the day
different from the results reported by Schwendi- Figure 3. Patient falls associated with days of
mann et al.[16] regarding patient falls in the hospi- week and hours of day
tal associated with lunar cycles due to the different Note. Significant differences between Friday and Satur-
methodology used in both studies. day with t=2.11 as well as hours at 9 and 13 o’clock in
a day with t=13.06; person separation reliability =0.67.

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HealthMED - Volume 5 / Number 6 / 2011

What is the implication and what should be
changed
We found that the easiest occurrence on the day
of the week and at the hour of the day for inpa-
tient fall counts in hospital are on Saturday and
at 9 o’clock, respectively. The findings from the
current study can help pay more attentions on Sat-
urday and at 9 o’clock giving an alarm to station
nurses for preventing patient falls in hospital.
Strength of this study
In present study we found that factors of patient
falls were associated with the day of the week and
the hour of the day in contrast to the a preceding
research [16] reporting that the inpatient fall rates
in hospital were neither associated with days of
the week and nor with lunar cycles such as full
moon or new moon. The difference between them
was not only ascribed to the terms of counts and
rates for inpatient falls, but attributed to the differ-
ent methodology used in both studies.
We particularly emphasized the eigenvalues
extracted from dataset to determine the number
of factors (stages in this study) which is the res-
olution of a set of variables linearly in terms of
(usually) a small number of categories or `factors'
using the analysis of the correlations among the
variables, like we did with PA and PCA of Rasch
standardized residuals. Through the findings that
the tendency toward patient falls occurred on Sat-
urday more frequent than on Friday and hours at 9
more than at 13 o’clock in a day, we can educate
nurses especially paying more attention to the oc-
casion on Saturday and at 9 o’clock when nursing,
which can help accomplish large improvements
on a small number of key areas.
It is worthwhile noting on DIF issue regarding
fair comparison between groups. DIF analysis can
examine which items (time points) cannot exhibit
construct equivalence over groups, referring Table
1. If DIF presents, the estimated measures could
not be compared directly over groups, like hospi-
tals in stage I.

Table 1. Item analysis of patient falls in hospitals

No. Item Difficulty SE IN.MSQ IN.ZSTD OUT.MSQ OUT.ZSTD DIF
1 2005-Q3 0.47 0.28 1.26 1.1 1.14 0.55 *
2 2005-Q4 0.16 0.27 1.26 1.12 1.17 0.68 *
3 2006-Q1 0.02 0.27 1.05 0.31 1.08 0.38
4 2006-Q2 -0.13 0.27 1.12 0.57 1.23 0.91
Stage I
5 2006-Q3 -0.20 0.27 0.62 -1.88 0.62 -1.63
6 2006-Q4 0.09 0.27 0.64 -1.78 0.63 -1.52
7 2007-Q1 0.02 0.27 1.15 0.71 1.10 0.46
8 2007-Q2 -0.42 0.27 0.9 -0.38 0.94 -0.17
9 2007-Q3 -1.48 0.31 1.31 1.29 1.35 1.37
10 2007-Q4 -0.53 0.31 1.14 0.67 1.07 0.37
11 2008-Q1 -0.34 0.31 1.39 1.59 1.39 1.46
12 2008-Q2 -0.53 0.31 0.78 -0.95 0.74 -1.06
13 2008-Q3 -1.00 0.31 1.25 1.09 1.18 0.79
14 2008-Q4 -0.44 0.31 0.71 -1.35 0.65 -1.53
stage II
15 2009-Q1 -0.15 0.31 1.03 0.21 0.97 -0.03
16 2009-Q2 -0.25 0.31 0.81 -0.80 0.87 -0.42
17 2009-Q3 0.35 0.32 0.53 -2.33§ 0.50 -1.97
18 2009-Q4 0.45 0.32 0.71 -1.25 0.66 -1.15
19 2010Q1 2.67 0.46 1.01 0.13 0.85 0.09
20 2010-Q2 1.25 0.35 1.49 1.75 1.13 0.44
* denotes DIF occurred on the item; § represents misfit at α = 0.05. Person separation reliabilities for stage I and II were
0.81 and 0.87, respectively

1400 Journal of Society for development in new net environment in B&H


Limitations of the study
A major limitation of this study was that the
sample was taken from restricted categories of
regular wards and homogeneous hospitals in so-
uthern Taiwan. The Person separation reliabilities
for those three subscales of time stages in Figure
1 were 0.81, and 0.87. Samples recruited from a
variety of workplaces can yield a high variance
compared to homogeneity (e.g., replacing patient
counts with patient fall rates to be nearly similar
performances in wards). In the future, it would
be desirable to widely survey the achievement of
preventing inpatient falls in a national sample, or
at least in samples from a broader range of wards
and nursing units.
Furthermore, other aspects of fall rates were
not evaluated in this study. Due to space limitati-
ons, we did not assess more associated factors on
inpatient falls such as months, seasons and even
with lunar cycles such as full moon or new moon
[16]. Future studies can carry out preventive stra-
tegies focused on patients' modifiable fall risk fac-
tors and the provision of organizational conditions
which support a safe hospital environment.
The results regarding the patient falls associa-
ted with the day of week on Saturday and the hour
of day at 9 o’clock cannot be generalized to ot-
her hospitals in different cultures. Given the fact
that the patient falls was analyzed with a classic
test theory (CTT) approach to report fall rates, it
remains questionable if it also shows that neither
associated with days of the week, months, or se-
asons nor with lunar cycles such as full moon or
new moon [16] using item response theory (IRT)
based Rasch analysis.
Further studies and suggestions
When measuring performance, we usually de-
velop a set of Likert-type items related to counts
of patient falls interacted with wards and time
points, which is much different from traditional
ways using CTT methods [7-12]. We often make
certain assumptions to average the counts as in
CTT using control charts [42-44], such that each
item contributes equally in defining that charac-
teristic or entity. This assumption implies that all
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
items are of equal importance, which is almost al-
ways untrue [40,41]. To average the counts is to
treat them as an interval scale, while in practice,
the scale is actually ordinal, so the categories of
counting are not spaced equally. Accordingly, the
use of Rasch analysis in assessing patient falls for
wards or hospitals merits further study in surveys
with regard to their performance comparison. One
major obstacle is that researchers may need some
training to understand the fundamental theory of
Rasch measurement.
Conclusions
The findings of this study indicated that using a
Rasch model to analyze the patient falls is encour-
aged for future study, although some obstacles will
need to be overcome, such as understanding the
basic theory of Rasch measurement. Precise infer-
ence made by dimension checking and model-da-
ta-fit can overcome the average scores in control
charts commonly used to evaluate patient falls in
hospital. Factors associated days of the week and
hours of the day regarding inpatient fall counts in
hospital can help accomplish large improvements
on a small number of key areas giving an alarm to
station nurses.
List of abbreviations
CTT: classic test theory
IRT: item response theory
DIF: differential item functioning
PA: parallel analysis
PCA: principle component analysis
Authors' contributions
TW, SC and HF collected all data, generated
the database, designed and performed the statisti-
cal analysis and wrote the manuscript. SC and HF
contributed to the development of the study desi-
gn and advised on statistical analysis. The anal-
ysis and results were discussed by all authors to-
gether. TW contributed to interpreting the results
and drafting the manuscript. All authors read and
approved the final manuscript.
1401
HealthMED - Volume 5 / Number 6 / 2011
Acknowledgments
This study was supported by Grant 98cm-
kmu-18 from the Chi Mei Medical Center, Taiwan.
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Journal of Society for development in new net environment in B&H 1403

HealthMED - Volume 5 / Number 6 / 2011
Knowledge, Attitudes and Practices
on Hypertension in patients
attending Family Practice Clinics
Nada A. Yasein, Farouq M. Shakhatreh, Ahmad A. Suleiman, Farihan F. Barghouti, Lana J. Halaseh, Noor
K. Abdulbaqi
Dept. of Family and Community Medicine, Faculty of medicine, University of Jordan- Jordan University
Hospital, Jordan
Abstract
Objectives: To assess and compare knowled-
ge, attitudes and practices on hypertension (HTN)
in patients with or without HTN attending a Fami-
ly Practice Clinic.
Methods: A comparative study conducted in
the period March to May 2010, using a face-to-
face constructed questionnaire administered to
400 subjects visiting a family medicine clinic, 200
hypertensives (mean age of 59.2 (SD ±9.22))and
200 normotensives (mean age of 58.8 (SD ±9.57)).
The mean duration of HTN was 9.5 years.
The study protocol has been approved and fun-
ded by the Scientific Research and Ethics Com-
mittee of the medical school at the University of
Jordan.
Results: The knowledge about hypertension
among participants was quite remarkable. More
than 80% of hypertensives were aware of the risk
factors, and more than 90% had the knowledge
about the main complications of hypertension.
More than 85% of all participants believed that
HTN is a serious health problem and needs life-
style modifications to be controlled, but hyperten-
sives were 10 times more aware that HTN needs
lifelong treatment. All hypertensive patients had
their blood pressure checked at least once in the
last year. Inability to perform regular exercises was
the most common difficulty faced by all patients.
Other practices were similar between hypertensi-
ves and normotensives except that hypertensives
were 17 times more committed to low salt diet.
Conclusions: These results suggest that most of
the participants were knowledgeable and had posi-
1404
tive attitudes towards hypertension, although they
had difficulties in complying with a healthy lifestyle
to control or prevent hypertension. So, primary he-
althcare providers should be alert to the importance
of implementing health promotion programs more
thoroughly to hypertensive patients.
Key words: Hypertension, knowledge, attitu-
des, practices, family medicine, Jordan.
Introduction
Hypertension (HTN) is a significant medi-
cal problem all over the world with estimates as
much as one billion individuals1. It is responsible
for 62% of cerebrovascular diseases and 49% of
ischemic heart diseases1. On the other hand, 30%
of adults in the United States are unaware of their
hypertension, more than 40% of individuals with
HTN are not on treatment and two-thirds of hyper-
tensive patients are not controlled 2.
The relationship between blood pressure and
risk of cardiovascular disease events is continuous,
consistent, and independent of other risk factors.
The higher the blood pressure reading, the greater
is the chance of developing cardiovascular compli-
cations; for every 20 mmHg systolic or 10 mmHg
diastolic increase in BP, there is a doubling of mor-
tality from both ischemic heart disease and stroke 2.
Non-compliance to drug treatment has always
been suggested to be the primary cause of under
control of HTN, missing two essential factors:
first; patients’ knowledge, attitudes, and beliefs
about HTN, second; the adoption of a healthy life-
style. These two factors are the cornerstone in pre-
Journal of Society for development in new net environment in B&H

venting or delaying the onset of HTN, enhancing
antihypertensive drug efficacy, and decreasing
cardiovascular risk3.
Jordan, like other middle income countries, is
witnessing an epidemiological transition charac-
terized by an increase in chronic illnesses. Cardi-
ovascular diseases are on top of the list and are
considered to be the leading cause of mortality
contributing to 38.2% of deaths4.
Studies done on HTN in Jordan5, 6, 7, 8, 9 were
mainly to estimate its prevalence which ranged
from 16.1% 8 to 35.7% 9 in the period from 1995 to
2008. In spite of this considerable prevalence rate,
HTN knowledge, attitudes and practices (KAP) in
Jordan have not been investigated before.
Objectives of this study are to examine current
knowledge and awareness of HTN, with respect to
its definition, risk factors, treatment, and complica-
tions; and to study attitudes and practices of pati-
ents towards HTN, in addition to comparing KAP
between hypertensive and nonhypertensive pati-
ents. This comparison is to be carried out assuming
that persons aware of being hypertensive are expo-
sed to more information, health care, and personal
experience related to HTN than normotensives or
those who are unaware of being hypertensive 10.
This distinction was also chosen to gather informa-
tion that would help in improving health education
programs especially about this cardinal problem.
Methods
Setting: This study was conducted in a fami-
ly medicine clinic at Jordan University Hospital
(JUH). JUH is a tertiary referral center that provides
care for the capital of Jordan; Amman and the surro-
unding districts. It has four family medicine clinics
run by family doctor specialists and residents.
Study design: This is a comparative study
of the general adult population attending family
practice clinic at Jordan University Hospital over
the period March to May 2010.
A face- to- face structured interview was con-
ducted by a trained research assistant using a
specially formulated questionnaire that has been
tested for validity using a pilot study which inclu-
ded 40 patients who were not included in the study
sample.
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
The study protocol has been approved and fun-
ded by the Scientific Research and Ethics Com-
mittee of the medical school at the University of
Jordan.
Size and sampling procedure: A convenient
sample of four hundred patients aged 18 years and
above, divided into 3 groups: 18-49, 50-69, ≥70;
attending family practice clinic at JUH for different
reasons over the period from March to May 2010
were included in the study after taking their verbal
consent. The sample included 200 males, of which
50% had HTN and 200 females with 50% being
hypertensives. Two hundred of which were controls
who were matched with two hundred hypertensive
patients for age and sex (individual matching).
Patients were labeled as hypertensives if they
were on antihypertensive medications and/or if
they had two or more blood pressure readings ≥
140/90 mmHg (according to the JNC7 criteria 2)
in their medical file. Patients were labeled as dia-
betics based on the medical history recorded in the
file. At the family practice clinics, hyperglycemia
is defined as fasting blood glucose ≥ 100mg/100ml
11
. Lipid levels as recorded in the medical recor-
ds were used to classify patients as having nor-
mal or abnormal lipid profile. Identification of
dyslipidemia was based on the Adult Treatment
Panel ш (ATP Criteria ш) 11, as follows: serum
cholesterol ≥200mg/100ml, serum triglycerides
≥150mg/100ml, serum HDL-C <40mg/100ml and
serum LDL-C ≥130mg/100ml.
Instrument of the study: A constructed questi-
onnaire developed by the researchers, was used to
evaluate HTN knowledge, attitudes and practices
among the study groups.
The questionnaire includes a total of 43 questi-
ons divided into four parts; the first one contains
data about sociodemographic status including age,
gender, education and occupation. Family history
of HTN and personal medical history including
the presence of diabetes mellitus and dyslipidemia
as confirmed by reviewing the medical records
were also added. Body mass index was calcula-
ted from anthropometric measurements (weight
and height). Height was measured to the nearest
0.5 cm using a stadiometer. Weight was recorded
to the nearest 0.1 kg with the patient barefoot and
wearing light clothing using a mechanical beam
balance scale, calibrated regularly. A patient was
1405
HealthMED - Volume 5 / Number 6 / 2011

considered normal weight if calculated body mass
index (BMI) (weight/height2) was 18.5-24.9 kg/
m2, overweight if BMI was 25-29.9 kg/m2, and
obese if BMI was ≥ 30 kg/m2.2
The second part includes four items assessing
patients’ knowledge about HTN in terms of defi-
nition (normal readings, general knowledge), risk
factors (age, obesity, physical inactivity, diet high
in salt, smoking, and family history), symptomato-
logy (headache, dizziness, fatigue, epistaxis, diplo-
pia, or asymptomatic) and complications (ischemic
heart disease, heart failure, cerebrovascular disease,
nephropathy, retinopathy, and sudden death).
The third section consists of seven items about
patients’ attitudes and perception of HTN as a di-
sease (seriousness, the need for lifelong treatment)
and its treatment modalities including both phar-
macological and non-pharmacological approaches
(i.e. lifestyle interventions: exercise, salt intake,
obesity), in addition to assessment of the most im-
portant difficulties hypertensive patients encounter.
The fourth section is about patients’ practices
regarding HTN especially frequency of blood pre-
ssure measurements and lifestyle interventions (as
mentioned above) needed to control blood pressu-
re in addition to adherence to lifelong treatments.
Physical activity was assessed during a perso-
nal interview as follows: “during the past year: Did
you exercise (walking, jogging, swimming, aerobi-
cs)? How many times have you been exercising per
week? And how long have you exercised per se-
ssion (<30 minutes, 30-60 minutes, >60 minutes)?
Regular exercising was labeled to patients who
exercised at least 150 minutes per week. Anyone
who currently smoked any number of cigarettes for
any length of time was defined as a current smoker.
Salt intake assessed by asking the patient if his salt
intake was less or more than one teaspoon per day.
Data processing, entry and analysis: Data
were processed using the SAS (Statistical Anal-
ysis System) software.
Chi Square and Fishers’ Exact Probability
Tests were applied to find out the significance of
relationship between study variables. A P value of
<0.05 is considered significant at that level.
Binary Logistic Regression Analysis was used
to calculate the degree of association between the
dependent and independent variables (Odds Ra-
tio) and 95% confidence interval was calculated.
Results
The mean age for hypertensives was 59.2 (SD
±9.22) years and 58.8 (SD ±9.57) years for nor-
motensives.
The mean duration of HTN was 9.5 years.
Almost all participants had health insurance
(100% of hypertensives, 98.5% of normotensives)
There was no statistically significant difference
in the prevalence of hypertension in regard to age
or education.
Unemployed were 1.5 times more likely to be
hypertensive than employed patients (p=0.03).

Table 1. Distribution of the study population according to selected sociodemographic factors

Hypertensive pati- Normotensive su- 95% Confidence
Variables Odds Ratio P value
ents No. (%) bjects No. (%) Interval
Age groups (years)
18 – 49 22 (11) 29 (14.5) 1.00
50-69 160 ( 80) 151 (75.5) 0.72 0.39- 1.30 0.52
≥ 70 18 (9) 20 (10) 0.84 0.36-1.96
Education 0.73
Illiterate 3 (1.5) 3 ( 1.5) 1.00
High school or less 88 (44) 93 (46.5) 1.06 0.21-5.38
0.73
College (Diploma) 17 (8.5) 22 (11) 1.29 0.23-7.23
University degree 92 (46) 82 (41) 0.89 0.18-4.54
Employment
Employed 80 (40) 102 (51) 1.00
0.03
Unemployed 120 (60) 98 (49) 1.56 1.05-2.32

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 HealthMED - Volume 5 / Number 6 / 2011

Table 2. Personal and medical history

Hypertensive patients Normotensive subjects
P value
No. (%) No. (%)
Body mass index (BMI)
Normal (18.5-24.9 kg/m2 ) 13 (6.5) 33 (16.5)
Overweight (25-29.9 kg/ m2 ) 77 (38.5) 85 (42.5) 0.067
Obese ( ≥ 30 kg/ m2 ) 110 (55) 82 (41) 0.000
Personal history of Diabetes Mellitus
No 157 (78.5) 175 (87.5)
Yes 43 (21.5) 25 (12.5) 0.02
Personal history of Dyslipidemia
No 131 ( 65.5) 169 (84.5)
0.00
Yes 69 (34.5) 31 (15.5)
Family history of HTN
No 106 (53) 137 (68.5)
Yes 94 (47) 63 (31.5) 0.002

Fifty five percent of hypertensives were obese
when compared to 41% only of normotensives, a
difference that is statistically significant (p value
0.000). In addition, 21.5% of hypertensives and
12.5% of normotensives had personal history of
diabetes mellitus, p value 0.02, which is statisti-
cally significant. Thirty four percent of hypertensi-
ves and 15.5% of normotensives had personal hi-
story dyslipidemia, p value 0.00. And finally 47%
of hypertensives and 31.5% of normotensives had
family history of HTN, p value 0.002. Which is
also statistically significant.
A high proportion of participants were
knowledgeable about HTN in general, with no
substantial difference between hypertensives and
non-hypertensives.
Eighty one percent of the respondents had their
friends and family members as their information
source for HTN knowledge, compared to 40.7%
who had their information from a health care wor-
ker (not shown in the table).
Very little difference (statistically not signifi-
cant) is elicited between the two study groups re-
garding the perception of having enough informa-
tion about HTN (16% of hypertensives and 17.5%
of normotensives, p value 0.25, OR=0.74, CI 0.43-
1.25), and the need for further information about
HTN especially about its definition, diagnosis and
therapy (89.5% of the hypertensives and 88.5%
of the normotensives, p value 0.33, OR=0.75, CI
0.42-1.34).
Regarding specific knowledge of HTN; hyper-
tensives were not different from normotensives.
More than 85% knew the normal readings of sy-
stolic blood pressure (P value 0.38, OR=0.53, CI
0.1-2.95) and diastolic blood pressure (P value
0.46, OR=2.24, CI 0.2-24.95).
More than 97% of all participants knew that
obesity, physical inactivity, and diet high in salt
are factors associated with HTN, with fewer par-
ticipants (above 70%) knew that increasing age,
smoking and a positive family history are factors
associated with HTN.
Regarding the symptoms of HTN only one
third of the hypertensives and the non-hyperten-
sives knew that HTN rarely causes symptoms (p
value 0.186, OR=0.907, CI 0.450-37.037) while
>97% of the participants misbelieved that HTN
causes headache, dizziness, and fatigue.
When talking about complications of HTN,
hypertensive patients were 2.5 times more likely
to know that nephropathy is a complication of
hypertension than normotensives (p value 0.000,
OR=2.564, CI 1.495-4.405). On the other hand,
although more than 90% of all patients knew that
ischemic heart disease, heart failure, cerebrovas-
cular disease, retinopathy and sudden death are
complications of HTN, there was no statistically
significant difference between hypertensive and
normotensive knowledge.

Journal of Society for development in new net environment in B&H 1407

HealthMED - Volume 5 / Number 6 / 2011

Table 3/a. Knowledge of Participants about HTN (definition and risk factors):
Hypertensive Normotensive 95%
Odds
Item patients No. subjects No. Confidence P value
Ratio
(%) (%) Interval
Have you ever heard about hypertension?
Yes 200(100) 199 (99.5) 1.00
No 0 (0) 1 (0.5) 0.50 0.45-0.55 0.50
Do you think you know enough about
hypertension?
Yes 32(16) 35(17.5) 1.00
No 168(84) 165(82.5) 0.74 0.43-1.25 0.25
Do you think you need to know more abo-
ut hypertension?
Yes 179 (89.5) 177 (88.5) 1.00
No 21 (10.5) 23 (11.5) 0.75 0.42-1.34 0.33
What is the normal reading for:
Systolic Blood pressure (top number):
<140 190 (95) 178 (89) 1.00
≥140 4 (2) 2 (1) 0.53 0.10-2.95 0.38
Diastolic Blood pressure (bottom number):
< 90 194 (97) 173 (86.5) 1.00
0.46
≥ 90 1 (0.5) 2 (1) 2.24 0.20-24.95
Do you think that the following factors are
associated with HTN?
Increasing age
Yes 143 (71.5) 147 (73.5) 1.00
No 47 (23.5) 40 (20) 0.83 0.51-1.34
0.44
Don’t know 10 (5) 13 (6.5) 1.27 0.54-2.98
Obesity
Yes 198 (99) 197 (98.5) 1.00
No 0 (0) 2 (1) 0.50 0.45-0.55
0.25
Don’t know 2 (1) 1 (0.5) 0.50 0.05-5.59
Physical inactivity
Yes 197 (98.5) 195 (97.5) 1.00
No 2 (1) 4 (2) 2.02 0.37-11.16
0.34
Don’t know 1 (0.5) 1 (0.5) 1.01 0.06-16.27
Diet high in salt
Yes 198 (99) 196 (98) 1.00
No 2 (1) 3 (1.5) 1.52 0.25-9.17
0.50
Don’t know 0 (0) 1 (0.5) 0.50 0.45-0.55
Smoking
Yes 166(83) 177(88.5) 1.00
No 28(14) 19(9.5) 0.64 0.34-1.18
0.15
Don’t know 6(3) 4(2) 0.63 0.17-2.26
Family history of HTN
Yes 185(92.5) 171(85.5) 1.00
0.05
No 2(1) 8(4) 4.33 0.91-12.66

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 HealthMED - Volume 5 / Number 6 / 2011

Table 3/b. knowledge of participants about HTN (symptoms and complications:

The relationship between high blood pressure
and symptoms
It causes Headache 195(97.5) 196(98) 0.796 0.211-3.106 0.500
It causes dizziness 195(97.5) 197(98.5) 0.594 0.140-2.519 0.362
It causes fatigue 195(97.5) 195(97.5) 1.000 0.285-3.508 1.000
It causes epistaxis 74(37) 91(45.5) 0.703 0.472-1.049 0.084
It causes diplopia 154(77) 161(80.5) 0.811 0.502-1.311 0.392
Asymptomatic except in acute elevation. 70 (35) 73 (36.5) 0.907 0.450-37.037 0.186
Complications caused by Hypertension
Ischemic heart disease 199(99.5) 196(98) 4.065 0.450-7.874 0.186
Heart failure 193(96.5) 191(95.5) 1.299 0.474-3.559 0.610
Cerebrovascular disease 194(97) 188(94) 2.061 0.759-5.618 0.148
Nephropathy 177(88.5) 150(75) 2.564 1.495-4.405 0.000
Retinopathy 185(92.5) 180(90) 1.370 0.680-2.762 0.378
Sudden death 199(99.5) 194(97) 6.173 2.762-52.631 0.061

Table 4. Attitudes about hypertension

Hypertensive Normotensive 95%
Odds
Item patients No. subjects No. Confidence P value
Ratio
(%) (%) Interval
Do you think that hypertension is dan-
gerous to your health?
Yes 200(100) 196(98) 1.00
0.06
No 0(0) 4(2) 0.50 0.45-0.55
Do you think that hypertension needs a
lifelong treatment?
Yes 197(98.5) 173(86.5) 1.00
0.00
No 3(1.5) 27(13.5) 10.25 3.06-34.37
Do you think that drug treatment alone
is enough to lower your blood pressure?
Yes 11(5.5) 21(10.5) 1.00
0.07
No 189(94.5) 179(89.5) 0.50 0.23-1.06
Do you think that physical exercises help
to lower blood pressure?
Yes 200(100) 197(98.5) 1.00
0.12
No 0(0) 3(1.5) 0.50 0.45-0.55
Do you think that dietary changes help
to lower blood pressure?
Yes 199(99.5) 198(99) 1.00
0.50
No 1(0.5) 2(1) 2.01 0.18- 22.35
Do you need to reduce your salt intake
to help lower blood pressure?
Yes 200(100) 198 (99.5) 1.00
0.50
No 0(0) 1 (0.5) 0.50 0.45-0.55
If you were obese, do you need to lose
weight to help lower blood pressure?
Yes 200(100) 200 (100) 1.00
1.00
No 0(0) 0 (0) 1.00 0.02- 50.4

Journal of Society for development in new net environment in B&H 1409

HealthMED - Volume 5 / Number 6 / 2011

Table 5. Practices towards hypertension

Hypertensive Normotensive 95%
Odds
Item patients subjects Confidence P value
Ratio
No. (%) No. (%) Interval
Did you check your blood pressure in
the last year?
Yes 200(100) 199 (99.5) 1.00
0.50
No 0(0) 1 (0.5) 0.499 0.452-0.550
Do you take your antihypertensive
drug as prescribed by your doctor (if
you were hypertensive)?
Yes 199(99.5) 197 (98.5) 1.00
0.312
No 1(0.5) 3 (1.5) 3.03 0.313-29.384
Are you a current smoker?
Yes 33 (16.5) 29 (14.5) 1.00
0.58
No 167(83.5) 171 (85.5) 1.165 0.677-2.005
Do you exercise?
Yes 113(56.5) 108 (54) 1.00
0.615
No 87(43.5) 92 (46) 1.106 0.746-1.641
How many times per week?
once/ week 7 (6.2) 4 (3.7) 1.00
twice/ week 82 (72.6) 77 (71.3) 1.64 0.463-5.835 0.32
≥Three times/ week 24 (21.2) 27 (25) 1.969 0.512-7.563 0.254
Duration of exercise in every session (min)
< 30 min 63 (55.8) 65 (60.2) 1.00
30-60 min 43 (38) 41 (38) 0.924 0.533-1.603 0.779
> 60 min 7 (6.2) 2 (1.8) 0.277 0.055-1.384 0.093
Salt intake(a)
Low 120(60.0) 16 (8) 1.00
0.000
Normal and high 79 (39.5) 184 (92) 17.468 9.737-31.339
(a) The USDA dietary guidelines (United States Department of Agriculture/2005) has defined normal salt intake for adults
as 2.3 gm of Sodium (approximately 1teaspoon of salt) daily. A low-salt diet is a diet contains less than 6 grams of Sodium
Chloride per day.

More than 98% of all participants believed that
HTN is a serious health problem. Hypertensives
were 10 times more likely to believe that HTN
needs a life-long treatment compared to non-
hypertensives (98.5% vs. 86.5%, OR=10.25, CI
3.06-34.37) with a significant p value 0.00.
Ninety four percent of hypertensives versus
89.5% of normotensives (p value 0.07, OR=0.5,
CI 0.23-1.06) recognized that drug treatment alo-
ne was not enough to control their HTN and above
98.5% of participants agreed that physical exerci-
se, dietary changes, low salt diet and weight loss
were necessary to control blood pressure.
Almost all participants had their blood pressure
checked at least once in the last year. Only 27%
of the hypertensives and 5% of the nonhypertensi-
ves had monthly measurements with a p value of
<0.0001 (not shown in the table).
Ninety nine percent of hypertensives stated that
they take their medications as prescribed by their
doctors, and 98.5% of nonhypertensives said they
would take their medications as prescribed by the-
ir doctors.
A measurable percent of all participants were
smokers (16.5% of the hypertensives and 14.5% of
the non-hypertensives, p value of 0.58, OR=1.165,

1410 Journal of Society for development in new net environment in B&H


CI 0.677-2.005), with an average number of 18 ci-
garettes smoked per day.
Practicing exercise didn’t show any statisti-
cally significant difference between the two study
groups (56.5% of hypertensives and 54% of non-
hypertensives, p value 0.615, OR=1.106, CI 0.746-
1.641), although non-hypertensives were more li-
kely to practice for three times and more per week.
Regular exercising (150 minutes per week) for all
participants is found in 88 participants only (22%)
(Not shown in the table).
The hypertensives were 17 times more likely
to commit to low-salt diet (less than 2.3 gm of So-
dium per day) 12 60% vs. 8% of the nonhypertensi-
ves (p value 0.000, OR=17.468, CI 9.737-31.339).
Regarding difficulties hypertensive patients
face, inability to perform regular exercise was the
most common difficulty (100%), followed by the
side effects of the treatment in general (71.5%),
in addition to difficulty accepting the idea of be-
ing committed to a life-long treatment which was
perceived by 29% of hypertensive patients (Not
shown in the table).
Discussion
This study was conducted to assess and compa-
re the current status of HTN knowledge, attitudes,
and practices in 400 Jordanians, of which 200 are
hypertensives, attending the family practice clinic
at Jordan University Hospital in a three- month
period in 2010.
This is the first comparative study in Jordan
that focuses exclusively on KAP of HTN among
hypertensives and normal blood pressure subjects.
Knowledge of hypertension:
Taking into consideration that HTN is such a
common disease, results suggest that participants
are knowledgeable about HTN in general without
much difference in knowledge between hyperten-
sives and non-hypertensives. This finding is sup-
ported by the fact that Jordan occupies an outstan-
ding position in the human development criteria in
comparison with other third world countries13. It
was able to achieve the lowest illiteracy rate on the
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
level of the Arab world13 where the rate declined
tremendously from 67.6% in 196114 to 7.9% in
2007 15. This percentage is reflected on our parti-
cipants who are well educated with 98.5% having
a high school education and above, and only 1.5%
is illiterate, so one would expect the results of our
study to be closer to those of developed rather than
developing countries.
Regarding the source of HTN knowledge, frien-
ds and family members were considered a major so-
urce of information (for 81.3% of the participants)
compared to health care workers (40.7%). This fact
represents the close interpersonal relationships in
our community and lack of participation of medi-
cal personnel in health education. This is contrary
to the usual trend that the majority of information
was obtained either from primary care physicians
(around 65%) 16, 17 or from printed materials such as
medical journals and brochures (62%) 18.
It was shown that the specific knowledge of
HTN in hypertensive patients as normal readings of
systolic blood pressure ≥140 mmHg and diastolic
blood pressure ≥90 mmHg was 95%, 97% respec-
tively. Some studies found that this percentage was
less than our fidings10, 19, and other studies showed
percentage as high as ours20. This might be expla-
ined by the long duration of hypertension among
our patients (average of 9.5 years) with a presumed
more exposure to health information by patients.
About the risk factors, almost all (more than
97%) of the participants knew that obesity, physical
inactivity, and diet high in salt are factors associated
with HTN, but fewer people considered increasing
age, smoking and family history of HTN as risk
factors. This may be attributed to the fact that physi-
cians instruct their patients to change their modi-
fiable risk factors such as weight excess, physical
inactivity or diet high in salt but they don’t menti-
on the nonmodifiable risk factors as family history
of HTN or increasing age. Furthermore, smoking
cessation campaigns in Jordan are not very active,
which is reflected on the knowledge that smoking
is a risk factor for HTN and should be stopped as a
prevention and treatment modality. Comparing the-
se findings with other studies; knowledge about risk
factors of HTN was lower than ours18, 21.
Despite such successes with educating people
in family practice clinics about HTN in general,
results suggest that a substantial number are still
1411
HealthMED - Volume 5 / Number 6 / 2011
under the impression that people will be able to
“feel” if their blood pressure is high as was de-
picted in two thirds of hypertensives who didn’t
know that HTN is a silent disease. This lack of
awareness about HTN as a silent killer may lead
to under treatment of HTN as patients don’t “feel”
if they need to take their medications, and inability
to screen for HTN in the general population.
Regarding knowledge of complications of HTN,
there was no significant difference (p value ≥ 0.05)
between hypertensives and normotensive patients
except knowledge about nephropathy as a compli-
cation, where hypertensives were 2.6 times more
knowledgeable than nonhypertensives (OR=2.56).
There are two studies done on hypertensive patients
and their results are similar to our results; especi-
ally the knowledge about complications as: ische-
mic heart disease and stroke, (97% and 94%) 16, 18
respectively. And we think that this difference re-
garding nephropathy knowledge is attributed to the
fact that we do regular screening for nephropathy
every six months to hypertensive patients.
Attitudes and practices towards hypertension:
A key to understanding patients’ attitudes towar-
ds high blood pressure is identifying their level of
knowledge. In this study all hypertensive patients
believe that HTN is a serious health problem. This
was reported by several studies and the percenta-
ges ranged from (60-90%) 18, 22, 23, 17. This might be
explained by the high percentage of hypertensives
that believes that HTN causes serious life threate-
ning complications as mentioned above.
Hypertensives were 10 times more likely to be-
lieve that HTN needs a lifelong treatment when
compared to nonhypertensives. Compared to a
study that was done on hypertensive patients in
one of the developed countries, 81% of the hyper-
tensives believed that HTN doesn’t have a cure, so
it needs a lifelong treatment20. This is expected be-
cause hypertensive patients that already take me-
dications for HTN for years, most probably will
ask their doctors about their treatment duration.
All hypertensive patients and 99.5% of non-
hypertensive patients had their blood pressure
checked at least once in the last year. This fin-
ding is better than that observed in Western China
1412 Journal of Society for development in new net environment in B&H
(70.9%) 24. It may be due to the protocol in our fa-
mily medicine clinic that all patients aged 18 years
and above, who visit the clinic for any reason have
their blood pressure to be checked.
Almost all hypertensives reported full adher-
ence to their medications prescribed by their doc-
tors. This high adherence rate is comparable to
that in USA (97%) 16 yet a little bit higher than that
reported in other studies (90% and 88.9%)18, 24.
Previous studies indicate that approximately 40%
of hypertensive patients who report taking 100%
of their antihypertensive medications are, in fact,
taking less than 75% by pill count 18. Although the
proportion of this sample over reporting medica-
tion adherence is unknown, self-reporting seems
to overestimate the true level of compliance.
Ninety four percent of the hypertensives and
89.5% of normotensives believed that drug treat-
ment alone is not enough to control BP, and almost
all agreed that BP control needs lifestyle modifica-
tion (physical exercise, smoking cessation, dietary
changes and weight loss) besides drug therapy. But
contrary to what is expected; when comparing hy-
pertensives and nonhypertensive patients regarding
smoking, obesity, and exercise: 15.5% of the par-
ticipants were smokers, 88.5% were overweight or
obese, 55.25% exercised. The difference between
the two study groups was not statistically significant.
These numbers are similar to what was found in a
study done by the same author in Jordan in 201025.
According to salt intake, it was noticed that a
statistically significant difference between hyper-
tensives and nonhypertensives (60% vs. 8%, P
value <0.0001, OR=17) exists, may be because in
our Islamic religion it is advisable to take low salt
diet as prevention from diseases. This percentage
of hypertensives to commit to low salt diet is also
seen in another study done in USA21, but not in
another one done in China24. This commitment to
low-salt diet and retaining obvious drawbacks in
dealing with other modifiable cardiovascular risk
factors (lack of exercise, obesity and smoking)
might be explained by the fact that our participants
find it easier to change their diet than to exercise
and lose weight or stop smoking. This is empha-
sized by the fact that exercising is the number one
difficulty our hypertensive patients encounter.
The discrepancy illustrated between knowledge
and practice is also shown in another study 21. This

discrepancy and the no difference between hyper-
tensives and normotensives emphasizes the impor-
tance of providing accurate health information by
medical personnel on the management of HTN in
hypertensive patients, and suggests that there is a
need to provide a more behaviorally focused educa-
tion to ensure adequate implementation of targeted
behavioral changes of lifestyle and medications.
Conclusion
Our results suggest that most of the participants
were in general knowledgeable and had positive at-
titudes about HTN, in spite of having some short-
comings in practicing healthy habits to prevent and
control hypertension. In addition, hypertensive pa-
tients are not better than normotensives regarding
knowledge, attitudes and practices in general.
Patient education is one of the principal patient’s
rights. Certain aspects of hypertension specific
knowledge need to be improved by training clini-
cians to take more active role in health education in
order to influence patient knowledge, attitudes and
especially practices toward HTN control.
No other study in Jordan comprehensively as-
sessed KAP on hypertension, yet further studies
are needed at the national level to generalize the
results and to conduct wider plans that aid in blood
pressure control in hypertensives and hyperten-
sion prevention.
A potential weakness of the study is the fact
that the patient population who is presenting for
care at a family medicine clinic at a tertiary cen-
ter was representative of an urban population in
the capital of a developing country, where life-
styles are rapidly changing into a more western-
ized form. So the findings cannot be generalized to
the Jordanian population since the sample size is
small and our hypertensive patients differ from the
general hypertensive population in terms of access
to medical care, access to prescription drugs, and
insurance coverage of the population. Replica-
tion of this study in a rural area with larger sample
would be beneficial.
There is no standardized instrument available
to assess HTN knowledge, attitudes, and practice.
The existing literature and practicing physicians’
experience were utilized to design a data collec-
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
tion instrument that would be detailed and com-
prehensive as much as possible.
Another limitation of the study is the use of
self-report for data collection which is subjected
to recall bias.
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MT. Knowledge, Beliefs, and Behaviours about
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154-161
Corresponding author
Nada A. Yasein,
Dept. of Family and Community Medicine,
Faculty of medicine,
University of Jordan,
Jordan University Hospital, Amman,
Jordan,
E-mail: nyasein_85@hotmail.com
Journal of Society for development in new net environment in B&H

The analisys of the syndroms
appearing among children living with
autism in Hungary
Orsolya Tobak1, Mónika Balogh2, Kinga Lampek3
1
University of Szeged, Faculty of Social and Health Science, Health Visitor Labor and Methodology
Department, Hungary,
2
Universitas of Szeged, Pedagogy PhD School, Hungary,
3
Universitas of Pécs, The Faculty of Health Sciences, Institute of Health Insurance, Department of Health
Promotion, Hungary.
Abstract
Present results are part of an overall explora-
tory research dealing with the quality of life in the
families bringing up children with autism, which
aims to support the effectiveness of health visitor
(Hungarian specialty) nursing care.
Our goal was to map the symptoms, which can
be the basis of a professional guideline for health vi-
sitors and professional nurses. During our research
among families in Hungary raising children living
with autism 276 families were asked by a questio-
nnaire. The age of the children were between 3-18.
The qualitative data collection occurred in three fo-
cus groups (parents, autism specialists and health
visitors), some elements of which are described in
the study. No similar social-demographic backgro-
und can be recorded among the examined families,
all of them have to face many challenges with only
a very little help. The appearance and the frequency
of the symptoms are the same as mentioned in the
literature. They have different expectations toward
the professionals taking care of them, which are
presented in this study in details.
Key words: Autism, health visitor, symptoms,
health care
"In a perfect world, everyone is healthy and
happy, people understand and care about each
other.
In a perfect world there are no ill people, no
damaged ones.
In a perfect world, everyone has equal oppor-
tunity to fulfill their latent talent.
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
But our world is far from being perfect ..."
a disabled youth
Introduction
The number of people living with deficienci-
es is increasing year by year in Hungary, due to
the development of diagnostics there are more and
more opportunities for early detection and to be-
gin intervention as soon as possible. These deve-
lopmental interventions, can support and improve
the quality of life for families, increase the cohesi-
on and the cooperation, of the family, and they can
help solve the problems.
One of the major problems in connection with
the families is the prejudices and stereotypes aga-
inst the mentally handicapped, and autistic people
which usually comes from ignorance and the fear
of them. An important experience of social scien-
ces is that negative attitudes prevent cooperation.
It means that primarily the approach of helping
professionals needs to be changed, which may af-
fect the positive attitudes of the immediate and wi-
der environment toward people with disabilities.
The efforts of solving the problems have intensifi-
ed over the past 10-15 years. Legislation has been
defending the interests of people with disabiliti-
es in Hungary, many advocacy organizations are
working, mainly in big cities, and more and more
attention is being paid to integration. However pe-
ople often avoid families with disabled children,
and an active attitude to help in the vast majority
of the population has not been characterized yet.
1415
HealthMED - Volume 5 / Number 6 / 2011
Objectives
The present study aims to introduce the current
situation of the 3-18 year-old autistic children li-
ving in Hungary, especially in light of demographic
data. This way we are going to have an overview
of the residential, age distribution, marital status,
educational attainment and financial situation of the
families as well as the appearance of the frequent
symptoms. The results of focus group interviews
can inform us about their daily lives and the pro-
blems that hinder them from social integration. We
can also get an idea about how they feel about the
work of professionals dealing with children.
Introducing Approaches
The quantitative analysis uses the data of the
National Autism Research (OAK) prepared by the
Jelen (Present) Institute. In the research the aimed
and comprehensive sampling procedure covered
all the people in the population living with autism,
and members of an organization, or association in
Hungary.
The written interview method that was applied
by OAK, used two types of questionnaires. One
detailed questionnaire covering several areas was
filled out by interviewers, the other was a self-fi-
lled one sent by mail to the parents. In my own sur-
vey I used the data from the postal questionnaires,
specifically the families who are raising children
between the ages of 0-18. Due to the sampling
procedure 276 valid questionnaires were returned.
The focus group study (qualitative) occurred in
three groups, where I used the same questionnaire
catalogue. Beside the parent group I asked health
visitors and a group of heterogeneous professionals
dealing with children with autism in their work.
The SPSS version 15 was used for the data analysis.
Analysis
Among the qualitative results of the survey the
present study covers only the presentation of the
demographic variables and the present situation.
On the basis of the literature the clinical picture
of autism can be summarized as follows.
1416 Journal of Society for development in new net environment in B&H
Social isolation, which can be noticed sin-
ce infant age. Children with autism do not make
physical contact with their parents, they „freeze”
if anyone touches them. Do not keep eye contact,
show a complete indifference to other people,
even to their mothers. Strongly linked to objects
which they can do the same movements with for
hours. (Ranschburg 1997)
Mental lag behind: Today's researches show
that 70% of the autistic are mentally handicapped
some degree. Their verbal intelligence is low,
whereas during performational tests they signifi-
cantly outperform their peers. (Ranschburg 1997)
Language and communication inadequacy is
characterized by the autistic. Half of the children
do not learn to speak, and those who do in most
cases it is echolalia when they repeat what they
heard exactly, but mechanically. Although they
learn to speak, but unable to communicate, they
can not follow the constant change of perspecti-
ves. Another common peculiarity of speech is to
switch pronouns. (Ranschburg 1997)
Their fantasy game is poor and shallow, they
can not play spontaneously and creatively, especi-
ally with others. The upset of their usual agendas
the slightest change in the furniture of the room or
the usual people confuse them and drives to despair.
The ritual nature of motor activity and abnor-
mal reactions to external stimuli.
Some autistic people have special skills on tho-
se areas where social skills are not required.
During the research, the situation of families
raising children with autism was examined. To get
to know this the accurate assessment of the serio-
usness of autism is essential. However, there were
no objective means to establish this, since the ICD
codes and medical report could not be known. We
could only rely on the subjective opinion of the
parents, which is not always plausible, but it can
serve as clues for further analysis.
The 50% of the parents nurturing their children
considered the problem of their children as serious
only 13.4% of them as very serious, and a third as
mild. This data may have an impact on institutio-
nal care, parental employment, recreational pro-
grams, discrimination etc. This ratio can be con-
sidered as good in the light of foreign researches
and other statistical data. This could have several
reasons, but in most cases can be traced back to

the child's age. The society accept the behavior of
the younger children experienced by parent more
easily than of adolescents'. During childhood the
parents still hope that this state is reversible, can
be improved.
In the following, I present the data, based on the
results of the studied population, which are typical
or atypical symptoms of autism that have a great
influence on the family life, and their "well being".
One such area is the speech, which can be jud-
ged in itself, but also can be divided into two se-
parate parts, speaking, and comprehension. 30%
of the children speak well, but 18% do not speak
at all. In the case of children at the age of 3-4 it
can happen as a result of development that later
they will be able to formulate words or short sen-
tences. 29% of them express themselves simply,
in words and short sentences while 22% of them
in most cases only repeat information what they
already heard.
The problematic function going beyond speech
among autistic people is comprehension. It expla-
ins the reason for the fact that we got different
proportions than in the previous question. In 77%
of the cases they understand well, or almost well
what is said to them. Around 22% the proportion
of those who have little understanding of the in-
formation they received, even in one case, accor-
ding to the parent, that child does not understand
what they say to them. In this case another disabi-
lity is probable that prevents comprehension (eg,
deafness, severe mental disability).
Autism may affect the sleep-wake cycle. It was
not experienced by the 63% of the parents and
32% experienced mild cases of sleep disturbance,
in 14 cases the child's problem was considered as
serious by the parents. In parallel, the eating disor-
der must be examined as well. During focus group
interviews it appeared several times as problem
worsening with the age. Present study shows that
the eating disorder is more common than sleep
problem. In 51.4% there was no reported eating
problems so far, 37.7% have already detected nu-
trition-related problems of the child while 11%
causes very serious problems for parents and
children alike. The most common eating disorder
mentioned by the parents is the lack of appetite,
and in this context, the rejection of certain foods
(because of shape or color).
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
In addition to the speech behavior disorders
are another big problem for parents. The survey
also highlights a number of specific behavioral
problems such as short-tempered behavior, which
"never occurs" in 31% of the children, 59% of the
parents "experience it sometimes" and is frequent
in 9%. Rage often occurs in 19% of the children,
at 54% of the cases rarely and it "never can be
seen" at 25%."Strange, stereotyped movements"
are often found by 49% of the parents, rarely de-
tected in 33% and 17% did not experience such
symptoms at all. This is a typical characteristic of
autism symptoms, which can be evident even to a
lay observer. Gets a similar proportion of "com-
pulsive behavior" which is often in 57% it is rarely
encountered in 31% and 12% are common.
The "embarrassing behavior before others"
does not show any outstanding rates, 58% some-
times, 23% frequent and 18%, there is none. Self
harm is not typical at the 63% of the examined
children, , 30% sometimes, and only 7% of the
parents experience it often. The research did not
address the ways of self-harm behavior. The study
suggests that the most common habits at most
children are stereotypical, strange movements, but
self-harm behavior, rage and angry, embarrassing
behavior is rare.
In order to evaluate the possible incidence of
behavioral problems better, I created a new vari-
able. The obtained data shows that in case of two
children behavior problems were not experienced
by the parent. They are likely to show signs of
mild autism in other areas as well. The assump-
tion that they are little children is not confirmed,
because one of them is 8 the other is 10 years old.
Aggregating the scores on behavior it can be
seen that the more problem they have and the more
severe they are the more points the respondent gets.
It can be said that a few problems can be experi-
enced at the 15% of the children while in case of
41% of them a slight difference can be experienced
all areas or one or two cases we can meet more se-
rious disorders. The third group (36% of) always
have a slight problem for sure, but more than one
also occurs more frequently. At 7% of the children
behavioral problems often occur in all areas.
The questionnaire took down experiences in
the field of autonomy of the child based on the
needs. Using toilets works at 86.5% of the tested
1417
HealthMED - Volume 5 / Number 6 / 2011
children with autism alone or with a little help. A
lot of help is required in this area by 13% who
are probably younger, not yet housebroken, as it
can be said and also mentioned in the literature,
that the usage of toilet appears later among them.
In the field of other hygiene needs 66%of them
is self-sufficient or requires less assistance while
33% of them is in need of assistance. This ratio
can be observed in the healthy groups as well with
similar age distribution. Dressing is completely
independent at 28% of them, 47% requires smaller
assistance while 25% of them needs more. What is
meal concerned 93% of them is completely self-
sufficient only 7% of them requires more help.
The data shows that these ratios are almost the
same as at the healthy population of similar age. If
we compare the results with the age of the children
one or two years of lagging behind can be expe-
rienced but we can say that at the examined areas
in most cases these children become independent
at elementary-school-age or only little help is nee-
ded. Each of the four variables (dressing, eating,
grooming, toilet use) were taken into account du-
ring aggregating the scores, so the higher the va-
lue of a child is, the more likely to require more
frequent assistance in certain areas. In cases where
a lower number is received, we can say that the
child can fulfill their own needs alone. Fully inde-
pendent in all areas or just a little help is needed
by the 44.9% of the children while 38.4% of them
requires at least some help in all areas. 16.7% of
them certainly needs a lot of help or support to
meet their needs.
After the distribution of the symptoms we ad-
dress the review of qualitative test results.
The analysis of focus group interviews
The aim of the interview was to reveal the opi-
nion of parents and professionals to define shared
goals and plans and to improve the quality of life
for children with autism.
Three groups were studied during our research:
concerned parents, health visitors, and professio-
nals (psychiatrists, health visitors, special educati-
on teacher, teacher).
The results obtained during the research are the
following.
1418
The families of disabled children encounter
the prejudices of society. It regularly occurred in
the families surveyed that they got negative ver-
bal opinions declaring that the parents could not
discipline their children. The prejudices from out-
side affect the acceptation of the diagnosis as well.
According to the opinions of the health visitors
the parents who have already accepted the child's
problem, they actually use the term autism, while
those who have not identified with the status of
their children yet use the word disabled in every-
day conversations. "If they hear autism, two things
occur to them: Oh my God, how serious it is, the
other is what he is a genius in. Two extremes. Per-
haps a talented genius, but he can not exist in this
world. "(A parent)
The prejudice and a general lack of knowledge
make it more difficult and in some cases prevents,
or even destroys the social relations of the children
and families. They try to move to a place where
the immediate environment is acceptant and tole-
rant to the contingent fuming and screaming of the
child. Several people have said that the previous
relations are worn, and the only really good frien-
ds remained. "The precious people who accept us,
remain." (A parent)
The symptoms of autism, obvious to the experts
interviewed, can be stated in general that while the
parents mentioned positive and negative symp-
toms, the experts can only point out the negative
characteristics. The experts particularly see the pro-
blems and their knowledge can be linked only to
the difficulties. These are good foundations of tran-
smitting the prejudices and explain their stability.
Besides approaching this primarily emotional way,
a wider range of knowledge can also be observed
in the case of parents, since being concerned leads
them on a constant learning endeavor.
The diagnosis of children often occurs only at
the kindergarten age. The reason for this is that it is
difficult, geographically limited, and slow to reach
the health care system for diagnosis. Another rea-
son may be that health visitors, as primary preven-
tion professionals do not have sufficient knowledge
so that they could help in the early diagnosis and
effective treatment, however according to parents
and professionals early diagnosis has greater de-
velopmental efficiency. The opinion of the parents
is that they are not satisfied with the nursing care
Journal of Society for development in new net environment in B&H

of the health visitors can be supported by the facts
mentioned above and that they except more help
from their health visitors. The situation could be
improved by the expansion of the nurses' knowled-
ge, and development of the professional protocols.
Parents of autistic children are doing their best
in order to help their child, assume all the burden,
but they do not receive adequate social assistan-
ce. Less public assistance and support is given in
Hungary to the families involved than in other EU
countries. The financial burden of development
is gradually increasing, but the subsidies are sta-
gnating. In spite of this, parents are looking for
opportunities to develop the children as much as
possible. Each of the families surveyed participate
in programs organized by the Autism Association,
which help the integration of children.
The vision of families bringing up children
with autism is uncertain due to the weaknesses
in the Hungarian health care system. There is no
adequate institutional care for autistic adults. All
goes well, until they go to school, but after that
there are only day-care institutions, which relive
the burden of the parents. There is no solution to
the situation where the parents are no longer able
to stand beside them. We can read a lot about well-
functioning autistic farms abroad, but only a few
attempts were made to implement them in our co-
untry. "The parents sacrifice themselves as long as
they can but what happens after that ...The parent
would like to accustom their children to an insti-
tution where they would provide for the child." (A
health visitor)
Summary
The autistic children mainly live in the Central
Region of Hungary, with a Budapest center. It can
be said that they are brought up mainly in full fa-
milies. The financial situation of families is more
difficult due to the special needs of the children,
and because of the fact that only 45% of parents
are able to work besides taking care of the child.
Objective symptoms, the age of the parents, the
number of siblings, the current age of injured chil-
dren and the measure of the help they can expect
in caring the child have an effect on judging the
severity of the conditions.
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
The parents are the ones who usually detect the
first symptoms, but the professionals ask them to
be patient "this kid is developing a bit slower." It
is an important lesson for health care professionals
to consider the signals coming from the parents in
all cases.
The presented results and the parents reactions
show the actual problem we are facing with. It is
necessary to speak of autism, to help in early detec-
tion, to support parents in child development and to
lobby the government for the health care of adults
with autism and to improve social conditions. Besi-
des training professionals it should be mentioned as
an important objective to expand the knowledge of
lay people as well in order to prevent the discrimi-
nation of disabled people in society.
"We want it to be accepted as a special thing
that is completely different than a mental disabi-
lity. You can live with it, live together with it, and
they can be adorable, but you can go insane beca-
use of them. "(A parent)
References
1. Bánfalvy, Cs. (2005). A fogyatékos emberek és a
munka világa. Szakképzési Szemle, 2, 180-193.
2. Chikán, Cs. (2001). Esélyegyenlőség, fogyatéko-
sság. Budapest, Hungary: Mozgáskorlátozottak
Pest Megyei Egyesülete (Publisher)
3. Ranschburg J. (1998). Pszichológiai rendelle-
nességek gyermekkorban. Budapest, Hungary:
Nemzeti Tankönykiadó.
4. Kőpatakiné Mészáros, M., & Salné Lengyel, M.
(2001). Fogyatékos tanulók helyzete az ezredfordu-
lón. Új Pedagógiai Szemle, 7-8, 20-29.
5. Petri, G., & Vályi R. (2009). Autizmus – Tények
– Képek. Budapest, Hungary: AOSZ, Jelenkutató
Alapítvány
6. Szabó L. (2003). A boldogság relatív – fogyatéko-
sság és szubjektív életminőség. Szociológiai szemle,
3, 86-105.
Corresponding author
Orsolya Tobak,
University of Szeged,
Faculty of Social and Health Science,
Health Visitor Labor and Methodology Department,
Hungary,
E-mail: tobako@etszk.u-szeged.hu
1419
HealthMED - Volume 5 / Number 6 / 2011
Health financing reform towards
universal insurance coverage: a case
study of six cities in China
Cheng Li1,2, Yuan Yu1, Kieke G.H.Okma3, Min Yu1
1
Department of Health Services, Fourth Military Medical University, China,
2
Australian Centre for Economic Research on Health, Australian National University, Australia,
3
Wagner School of Public Service, New York University, United States of America.
Abstract
The Urban Resident Basic Medical Insurance
(URBMI) is a core component of the ongoing he-
alth financing reform towards universal insurance
coverage in China. This paper reviews the intro-
duction of URBMI in six Chinese cities, based on
comparative institutional analysis and use of pu-
blicly available data. In the early 21st century, the
Chinese government announced plans for univer-
sal health insurance. Rather than one population-
wide scheme, however, it designed several separa-
te schemes for specific populations, with a fair de-
gree of autonomy and independent administrative
responsibilities of the regions and large cities. In
this study, we have selected six cities with diffe-
rent levels of economic development and fiscal re-
sources. The cities also differ, as we will show, in
their target populations, financing level, insurance
coverage and benefits level, management of health
services and referral rules. Following an analysis
of the similarities and differences in the instituti-
onal features of the various URBMI schemes and
an exploration of the underlying causes, we anal-
yze the challenges and policy implications facing
China as it moves towards universal coverage. To
reduce the inequality in financing and benefits of
insurance across cities, for example, we conclude
that the central government should give priority
to less-developed cities in the distribution of su-
bsidies. Other concerns that require some form of
collective action are the extension of the benefit
package with outpatient care for all, strengthening
primary care and developing a rational referral sy-
stem. Two major challenges for the longer term
are the establishment of wider risk pools for the
1420
health insurance and the merger of segmented in-
surance programs.
Key words: Health reform; Universal covera-
ge; Health insurance; urban resident; China
1. Introduction
China’s economic “reform and opening up”
since 1978 created substantial change and signi-
ficant challenges for the urban and rural health
insurance system [1, 2].. The then existing heal-
th insurance programs including the Government
Insurance Scheme, Labor Insurance Scheme, and
Rural Cooperative Medical Scheme, were unable
to realize equitable access to health care and ef-
ficient cost control [3, 4]. Realizing the need for
health insurance reform, the Chinese government
launched the Urban Employee Basic Medical In-
surance (UEBMI) for urban employees in 1998,
and the New Rural Cooperative Medical Sche-
me (NRCMS) for rural population in 2003. Both
schemes played a significant role in expanding
insurance coverage for urban and rural populati-
ons. Nevertheless, according to the results of the
Third National Health Service Survey conduc-
ted in 2003, urban residents without formal em-
ployment who accounted for around 45% of the
total urban population, were not covered by any
medical insurance [5]. The uninsured included el-
derly, students, children, informal sector workers
and other unemployed residents. Most of those are
vulnerable populations facing severe financial ri-
sks of illness without any medical insurance. In
order to achieve a basic medical insurance system
covering all the urban and rural populations, the
Journal of Society for development in new net environment in B&H

State Council of China created the Urban Resident
Basic Medical Insurance (URBMI) in some pilot
cities in 2007. The URBMI primarily targets ur-
ban unemployed residents, elderly and students.
The State Council also issued general guidelines
for the implementation by the cities [6]. According
to these guidelines, the government planned to roll
out the program in 50% of cities nationwide by the
end of 2008, and to extend insurance coverage to
all cities by 2010. Together with the other schemes
(UEBMI and NRCMC), the URBMI establishes
the foundation for China’s social health insurance.
Ultimately, the three schemes will serve as a uni-
versal security net in the financing and payment of
health services throughout China.
The financing of URBMI comes primarily from
household or individual contributions in addition
to government subsidies. The enrollment (by ho-
useholds) is voluntary. This is clearly a political
compromise given the high administrative costs
associated with mandatory enrollment and adver-
se selection evident in voluntary enrollment [7].
The insurance funds are pooled at the municipal or
county level. The benefit package mainly focuses
on hospitalization and critical outpatient care for a
limited number of specific chronic or fatal disea-
ses in the pilot stage.
The first set of pilot cities identified by Sta-
te Council included 79 cities from 27 provinces
and autonomous regions in 2007. Next, the scope
extended to 229 cities in 2008 (Ministry of Labor
and Social Security, 2008). By the end of 2007,
URBMI covered nearly 43 million people, where-
as the number was around 118 million by the end
of 2008 [8]. Local governments have autonomy in
developing and implementing the programs accor-
ding to their specific socioeconomic status as long
as they follow the central general directives. This
local autonomy has caused broad differences acro-
ss schemes, particularly in terms of financing and
benefits level. Indeed, given the great socioecono-
mic disparities across regions, it was a pragmatic
strategy to leave enough room for local gover-
nments in the detailed design and implementation
of the schemes. The decentralization, however, ra-
ises concerns about overall equity and efficiency
of the health financing system. Little attention has
been paid to this issue in international scholarly
publications.
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
This paper reviews the URBMI schemes in six
cities based on comparative institutional analysis.
It analyzes the original institutional features and
the commonalities and differences in the imple-
mentation of the URBMI schemes in different
cities and also explores underlying causes of that
variation. Next we analyze the challenges China is
facing on the way towards universal coverage, and
then propose some policy adjustments and impro-
vements for further reform in China. This analysis
thus not only aims to contribute to a better under-
standing of the experience as a base for further
improvement of the health insurance coverage in
China, but also seeks to enrich the international
debate about universal insurance coverage in tran-
sitional countries.
The remainder of the article is organized as
follows: in section 2, we discuss the cases selec-
ted and the analytical framework. In section 3, we
carry out a comparative institutional analysis abo-
ut the URBMI schemes. Section 4 discusses rele-
vant policy implications and frames suggestions
for improvement. The last section contains a brief
summary.
2. Case selection and analytical framework
China’s economic development has long been
uneven across its regions. Eastern coastal cities
have witnessed significantly higher growth rates
than central and western cities. As the economic
level is a crucial factor influencing the financing
capability of cities or regions, we pay particular
attention to variations of URBMI policies among
cities with different economic levels. Based on the
selection criteria of economic level, city size, geo-
graphical location, and pilot-city status, we select
three groups of cities from East, Middle, and West
of China. The Each group has two cities. They are
Shanghai City (municipality city) and Qingdao
City (prefecture-level city of Shandong Province)
from eastern China, Nanchang City (capital city of
Jiangxi Province) and Xiaogan City (prefecture-
level city of Hubei Province) from central China,
and Xi’an City (capital city of Shaanxi Province)
and Baoji City (prefecture-level city of Shaanxi
Province) from western China. All of those cities
have launched the URBMI pilot since 2007.
1421
HealthMED - Volume 5 / Number 6 / 2011
Table 1 below presents the general socio-econo-
mic features of the six cities. Shanghai and Qingdao,
both of relatively wealthy coastal cities, illustrate
the obvious economic development gaps compared
to other mid-western cities. The per capita Gross
Regional Product (GRP) and per capita annual Ur-
ban Resident Disposable Income (URDI) in Shan-
ghai and Qingdao serve as indicators of regional
economic level. Those are significantly higher than
the income levels of other four mid-western cities.
For example, the GRP per capita in Shanghai is two
times the level of Nanchang, and nearly three times
that of Xi’an (Table 1).
We searched government policy documents and
related literature accessible in electronic databases
to study the experience with the trial implemen-
tation of URBMI in the six cities. We compared
the local schemes in terms of target populations,
financing level, insurance coverage and benefits
level, the management of health services and re-
ferral practices. These features comprise the key
elements of local policy arrangements of URBMI.
3. Comparative analysis of core elements of
URBMI schemes among six cities
3.1. Target population
The target population of URBMI is similar in
all six cities: primary and secondary school stu-
dents (including students in professional senior
high schools, vocational middle schools, and tech-
nical schools), children, elderly, and other unem-
ployed urban residents. However, some variations
exist. For example, the URBMI schemes in Xi’an
and Baoji also offer coverage to children of mi-
grant workers who live and study in the cities whi-
Table 1. General socio-economic characteristic of six cities in 2008*
Gross Regional Product
(billion RMB)
Shanghai 1369.8
Qingdao 443.6
Nanchang 166.0
Xiaogan 59.3
Xi’an 219.0
Baoji 71.4
*Original data derives from Statistical Bulletin on the National Economy and Social Development of six cities in 2008
1422
le the other four cities have no similar practice.
College students are covered in all cities except
in Shanghai, which established a separate medical
insurance for college students in 2007, subsidized
by government [9]. These variations reflect some
degree of flexibility and autonomy of local poli-
cies as long as they follow the central directives.
3.2. Financing level
Table 2 shows the financing level (premium
contributions) per capita and the funding sources
of the URBMI in six cities. On average, in all citi-
es the individual contributions account for at least
60% (column 4) of the premiums. This is consi-
stent with a study of a State Council Evaluation
Group for the URBMI pilot program reporting
that central and local governments are subsidizing
36% of the insurance contributions for adults [7].
As mentioned earlier, local governments have
autonomy in determining individual premiums
and government subsidies, which depends on the
income level of urban residents and the fiscal ca-
pacity of local government. Table 2 below illu-
strates that the incomes and thus financing levels
of developed cities such as Shanghai and Qing-
dao are substantially higher than those of the ot-
her cities. Unsurprisingly, the city with the lowest
economic level (Xiaogan) has the lowest level of
financing (180 RMB or 26 US $) in comparison
to other cities (Table 2). Shanghai, in particular,
gives more subsidies to vulnerable population
groups. For example, government subsidizes 70%
of premiums for the population aged over 60 and
more than 80% for persons over 70. The premi-
ums for students and children are much lower than
adults, but there are important differences across
Gross Regional Product per URDI per capita
capita (RMB) per year(RMB)
72536 26675
58251 20644
36105 15112
11293 12419
26259 15207
18992 13225
Journal of Society for development in new net environment in B&H
 HealthMED - Volume 5 / Number 6 / 2011

cities. Shanghai leads all others with 260 RMB for
students and children, while other cities set this
premium at 100 RMB or less.
We thus found a clear positive relationship
between URBMI financing level and the local eco-
nomic level. In all cities, the contributions for stu-
dents and children under URBMI are significantly
lower than adults. In general, government subsidi-
es account for a larger share in total premiums for
vulnerable groups with lower income such as stu-
dents/children and elderly. But the amounts of go-
vernment subsidies vary across cities, with higher
amounts by the wealthier cities as illustrated by the
high amounts of government subsidy in Shanghai.
3.3. Insurance coverage and benefits level
As one of its founding goals, URBMI seeks
to protect family incomes and the risk of impo-
verishment due to soaring medical expenditures.
URBMI primarily covers the costs of hospitaliza-
tion and critical outpatient care for a specified ran-
ge of chronic and major diseases. Since the central
directives do not specify deductibles, coinsurance
rates, and reimbursement caps, the insurance co-
verage, health benefits and direct patient payments
may vary among regions, depending on the local
financing level. Table 4 shows that all six cities
have included hospitalization in the benefit packa-
ge. The level of reimbursement for inpatient care
costs is related to the economic level of the regi-
on. For instance, Shanghai has set no cap for the
expenses on inpatient care, but patients face a 30-
50% coinsurance rate. The reimbursement cap for
inpatient care expenditures in Qingdao is 100,000
RMB, much higher than those of Xiaogan and Ba-
oji (Table 4). Five cities have set deductibles for
inpatient care. In Shanghai, patients don’t need to
pay any deductible for inpatient care but coinsuran-
ce applies. In Xi’an and Xiaogan, deductibles and
coinsurance rates vary for different health facilities.

Table 2. Financing levels of URBMI in six cities in 2008 (per capita per year for adults)*
Financing level Individual contribution Government subsidy
amount(RMB) amount(RMB) % amount(RMB) %
Shanghai
Age
>70 1500 240 16.0 1260 84.0
60-70 1200 360 30.0 840 70.0
18-60 700 480 68.6 220 31.4
Qingdao 900 720 80.0 180 20.0
Nanchang 240 144 60.0 96 40.0
Xiaogan 180 120 66.7 60 33.3
Xi’an 250 180 72.0 70 28.0
Baoji 280 200 71.4 80 28.6
* Original data derives from governmental documents shown in references (Shanghai Municipal Government, 2007b; Qing-
dao Municipal Government, 2007; Nanchang Municipal Government, 2007; Xiaogan Municipal Government, 2007; Xi’an
Municipal Government, 2007; Baoji Municipal Government, 2007)

Table 3. Financing levels of URBMI in six cities in 2008* (per capita per year for students and children)
Financing level Individual contribution Government subsidy
amount(RMB) amount(RMB) % amount(RMB) %
Shanghai 260 60 23.1 200 76.9
Qingdao 100 40 40.0 60 60.0
Nanchang 100 60 60.0 40 40.0
Xiaogan 70 10 14.3 60 85.7
Xi’an 100 30 30.0 70 70.0
Baoji 70 30 42.9 40 57.1
* Data source is the same as that of Table 2

Journal of Society for development in new net environment in B&H 1423

HealthMED - Volume 5 / Number 6 / 2011

Patients face lower deductibles and receive higher
reimbursement for the care they receive in lower
tier health facilities. For example, the deductible for
community health facilities in Xi’an is 250 RMB,
and the maximum percentage of reimbursement for
medical costs eligible for insurance claim between
deductible and cap is 70%. In contrast, the deduc-
tible for medical care in tertiary facilities is 700
RMB, and reimbursement 40%. This scheme is de-
signed as an economic incentive for insured to seek
more services at community health facilities. Qing-
dao, Nanchang and Baoji have not only set diffe-
rential deductibles and coinsurance rates according
to levels of health facilities, but also offer higher
reimbursement rate to patients with larger inpatient
costs. This measure aims to mitigate the financial
burden for individual families.
The benefits for outpatient care vary among six
cities as well. Both general and critical outpatient
care are covered with coinsurance in Shanghai.
Apart from critical outpatient care, Qingdao has in-
cluded general outpatient care for aged and severe-
ly disabled population, though both have to pay de-
ductibles and coinsurance. Critical outpatient care
is covered in Nanchang, Xiaogan and Xi’an with
coinsurance or deductibles. In addition, Nanchang
has set a cap for general outpatient care at 50 RMB
per person per year. Critical outpatient care is not
covered by URBMI in Baoji, but patients receive
general outpatient care with a 50 RMB cap.
It is clear that the insurance coverage, benefits
level and reimbursement of URBMI schemes in the
wealthier cities such as Shanghai and Qingdao are
much more generous than in less-developed citi-
es. However, some commentators argue that those
large variations across cities do not automatically
lead to inequality in health benefits as the medical
expenditures in developed cities are higher than
less-developed ones (reflecting both higher inco-
mes of health professionals, higher levels of capi-
tal investment of hospitals and more intensive use
of medical technology). To illustrate this point, we
show the average expenditures per outpatient visit
and per admission in general hospitals in the res-
pective regions (Table 5). As the data at city level
are not available, we take expenses at provincial
level as proxies. We found that the disparities in
average medical expenditures across regions are
much lower than the differences between patient
reimbursements (the “reimbursement gap”). Con-
sequently, there are substantial inequalities of be-
nefits across the six cities we studied.

Table 4. Insurance coverage and benefits level of URBMI for adults in six cities in 2008
Deductible Cap Reimbursement
Benefit package
(RMB) (RMB) rate (%)
Shanghai hospitalization; outpatient care — — 50-70
hospitalization; critical outpatient care; general
Qingdao 500-840 100,000 50-70
outpatient care for age 60+ and severely disabled
hospitalization; critical outpatient care; general
Nanchang 200-600 20,000 35-60
outpatient care capped at 50 RMB
Xiaogan hospitalization; critical outpatient care 100-500 30,000 50-60
Xi’an hospitalization; critical outpatient care 250-700 35,000 40-70
hospitalization; general outpatient care capped at
Baoji 150-600 24,000 35-80
50 RMB
*Data source is the same as that of Table 2. Deductible, cap, and reimbursement rate refer to inpatient care only.

Table 5. Average medical expenditures per outpatient and per admission in general hospitals of diffe-
rent regions in 2008
Expenditures per outpatient (RMB) Expenditures per admission (RMB)
Shanghai City 224.5 10287.2
Shandong Province 154.4 4993.8
Jiangxi Province 117.4 3955.1
Hubei Province 133.3 4636.1
Shaanxi Province 124.4 4382.3
Source: China Health Statistics Year Book 2008

1424 Journal of Society for development in new net environment in B&H


3.4. Management of health services and referral
The management of health services under URB-
MI is similar to those under UEBMI. The insured
must adhere to the designated health facilities, pres-
cription drugs and medical technology listed by local
authorities in order to receive (partial) reimburse-
ment. As to referral to medical treatment, the URB-
MI schemes of Shanghai, Qingdao, Nanchang, Baoji
stipulate that enrollees have to choose designated
community health facilities as their first visit facility.
The physicians at this lower tier can next refer pati-
ents to higher tier facility. Medical expenditures of
the insured can’t be reimbursed without abiding by
the referral regulation. In contrast, the cities of Xi'an
and Xiaogan have not passed explicit regulation for
referrals. It is hard to explain the reasons for these
differences. The implementation of referral policy
is subject to a range of complex contextual factors,
such as the infrastructure of community health facili-
ties, the administrative capacity of insurance agenci-
es, and the political will of local governments.
4. Discussion and policy implications
Our comparative analysis of URBMI schemes
in six cities reveals commonalities and differences
in the institutional arrangements. The similarities
reflect the adherence of local policies with the cen-
tral directives, while the variations are mainly due
to economic conditions as well as a certain degree
of autonomy and flexibility of local governments
in administering the insurance schemes.
One particular feature of the implementation of
the new health insurance schemes for urban popu-
lations in China is the high degree of local autono-
my in administering those schemes. Of course, this
decentralization is a practical strategy at the pilot
stage to accommodate diverging socioeconomic
conditions of local areas. At the same time, to en-
sure the overall efficiency and equity of the health
financing system, the central government should
play a vital role in monitoring the progress and in
necessary, formulating appropriate policy adjus-
tment while the program is rolled out nationwide.
The next section discusses several concerns that,
we argue, need to be addressed in the future reform
on the way towards universal coverage.
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
4.1. Reducing financing and benefits
disparities across regions
The average reimbursement levels of hospita-
lization costs under URBMI schemes, as we have
shown, are still low. The reimbursement rates for
treatment in tertiary hospitals range from 35% to
50% in the six cities (Table 4). According to the
Fourth National Health Survey conducted in 2008,
the average reimbursement rate of inpatient care
costs under UEBMI is 66.2% [16]. Unemployed
low-income enrollees of URBMI have to pay con-
siderably larger medical expenditures out of poc-
ket than urban employees due to the much higher
coinsurance rate. This seems inconsistent with the
objective of equitable access to health services
[17, 18]. Although empirical evidence is scarce
currently, studies of the URBMI in pilot cities of
Fujian Province and Wuhan City of Hubei provin-
ce revealed that around 75% of insured considered
the scheme failed to reduce the financial house-
hold burden due to the large copayments [19, 20].
The average per capita financing level of the pi-
lot cities in 2007 was 236 RMB for adults and 97
RMB for minors [7]. However, in 2008 the ave-
rage cost per outpatient visit was 146 RMB and
admission in general hospitals was 5,464 RMB
[21]. The relatively low financing level of URB-
MI will consequently lead to low reimbursement.
That may create insurmountable financial barriers
to disadvantaged low-income groups—the target
population of URBMI. According to China’s new
health reform plan announced in April 2009, the
central government will inject 850 billion RMB
(US$ 124 billion) into health system over the next
three years. Most of that money will flow to the
URBMI and NRCMS schemes. That will allow
an increase in subsidies per capita to at least 120
RMB in 2010 [22]. This is a positive strategy for
providing more subsidies for needy populations.
However, how the government should reduce
the financing gaps across cities with different eco-
nomic level is another key issue. As we showed,
there are large gaps between developed and less-
developed cities in terms of incomes and financing
levels that lead to inequalities in insurance cove-
rage and benefits. It is not likely that the imbalan-
ce of economic development between developed
costal cities and mid-western cities will disappear
1425
HealthMED - Volume 5 / Number 6 / 2011
any time soon. In the current context of fiscal de-
centralization, China’s central government should
therefore assume more responsibility for easing
the imbalanced funding status of URBMI schemes
across the nation so as to safeguard equity or fa-
irness in the health system. The practical measure
might be that more central governmental spending
should be directed to less-developed cities in the
form of transfer payment, taking into account the
actual fiscal conditions of local governments.
4.2. Expansion of benefit package
The pilot URBMI schemes primarily aim to
protect the insured from the catastrophic expenses
associated with inpatient care and critical outpati-
ent care such as renal hemodialysis. In all six pilot
cities that we studied (except Shanghai), there is
low or zero reimbursement for the costs of general
outpatient care.. At first sight, it seems a reasona-
ble decision to focus on major expenditures of hos-
pitalization and catastrophic outpatient care while
insurance funds are limited. This focus will also
allow for rational risk pooling [4]. However, the
financial burden of outpatient services for URBMI
can be high for certain enrollees. Amongst the top
ten diseases by two week morbidity rate of resi-
dents in 2008 are chronic diseases and ailments
such as hypertension, diabetes mellitus, acute na-
sopharyngitis or acute upper respiratory infections
[23]. Over 20 percent of the urban unemployed
have chronic conditions, higher than the national
average rate of 15 percent. Uninsured or underin-
sured people are prone to resort to self-medication
or to delay seeking treatment for seemingly minor
diseases not covered by their insurance. In some
cases, this may result in failure to diagnose critical
diseases in an early stage, so that minor diseases
may progress into critical ones. Moreover, pati-
ents with chronic conditions tend to seek inpati-
ent rather than outpatient care as the former often
provided full or partial reimbursement. This may
result in either overuse or underuse of necessary
inpatient and outpatient care.
Covering general outpatient services in the be-
nefit package will benefit more people. It can also
strengthen the attractiveness of URBMI schemes,
a particularly important point given the current
1426 Journal of Society for development in new net environment in B&H
voluntary enrollment. In the long run, the absence
of such expansion may jeopardize the sustaina-
bility of the program. Though relevant empirical
evidence on this issue is not available at present,
the experience of the NRCMS insurance scheme
(with a similar reimbursement pattern focusing
on inpatient care) may provide helpful references.
Some studies estimate that only 3% of NRCMS
enrollees would get reimbursed for hospitalizati-
on from the system and more than 50% of rural
residents were expecting to expand their benefit
coverage of NRCMS to include general outpatient
services. Without such expansion, surveys show,
the majority of NRCMS enrollees might become
dissatisfied and ultimately leave the scheme [24,
25]. These are also challenge for URBMI in the
further implementation.
Incorporating general outpatient care with co-
payments in the benefit package might be a cru-
cial-and feasible—future option of the URBMI
policy adjustments. It would entail several finan-
cing steps. First of all, an increase of financing for
the expanded coverage requires more government
subsidy (out of general taxation). In the testing
stage, there may be need to set proper reimburse-
ment rate, deductibles and reimbursement cap for
general outpatient care. The benefit level can be
gradually raised over time in line with available
funds and the practical operating conditions of lo-
cal insurance funds.
4.3. Combining primary health care delivery
with insurance program
International evidence shows that primary he-
alth care providers can play an effective role as
“gatekeeper” to secondary and tertiary health ser-
vices. This also may improve the rational flow
of health resources from the upper to the basic
levels, and improve the efficiency of health reso-
urces allocation. Further, gatekeepers may rein-
force preventive strategies, and contribute to an
efficient and economical health service system
[26]. Most Chinese cities have a type of three-tier
health service: community health facilities, secon-
dary hospitals and tertiary hospitals. Most pati-
ents prefer seeking care at secondary or tertiary
hospital in the first place even for minor illness

as they mistrust the community health facility. As
their system lacks an effective referral system, this
has caused excessive reliance on hospital services,
overcrowding of general hospitals and irrational
use of health resources [27, 28]. To illustrate, the
total number of outpatient visits in general hospi-
tals in China was 1.78 billion in 2007. In contrast,
the number of visits for community health faciliti-
es was only 0.26 billion [21]. Developing an effi-
cient referral and monitoring mechanism to guide
patients through the medical system seems to be a
high policy priority.
As presented earlier, the schemes of Shanghai,
Qingdao, Nanchang and Baoji have enforced re-
ferral by primary care providers by using the le-
verage of insurance payment. While there is not
enough empirical evidence to assess the impact
of this regulation on the flow of patients in these
cites, the referral regulation can be regarded as a
positive attempt to reduce excessive hospital use.
We should add that whether the referral regulati-
on policy works well or not largely depends on
not only the functioning of community health fa-
cilities, but also the performance of insurers. The
quality of care (or perceived quality) is a crucial
factor influencing the choices of providers by pa-
tients (Yang and Yang, 2009). Given the histori-
cally insufficient investment into primary care and
consequent lag in the development, community
health facilities need to seek ways to improve the-
ir services. They need to raise funding to invest
in technology and human resources. Meanwhile,
the government-run insurance agency as the third-
party payer should play a more active role as an
efficient purchaser of health care services in the
interests of people served.
4.4 Improving the portability and integrity of
various programs
The rapid market reforms in China caused in-
creased mobility of persons between regions,
sectors and jobs and contributed to the process of
accelerated urbanization. This also brings the issue
of portability of medical insurance. As the URBMI
insurance funds are mainly pooled at city level, the
differences in financing and benefits levels across
cities make it difficult to manage insurance claims
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
when urban residents move to another city (that
may have a greatly different scheme). The same
problem occurs under UEBMI when employees
commute to work in another city which has a diffe-
rent medical insurance policy in terms of financing
and reimbursement, or the list of drugs and medi-
cal services and other conditions. To solve those
problems, the government has to set up effective
and sound transfer mechanism for various schemes
across cities within the current social insurance po-
oling. Over the long haul, an obvious fundamental
solution would be to aggregate the pooling level
from current city level to provincial and even na-
tional level. This will not only strengthen the risk
pooling capability of funds, but also ease the issues
associated with poor portability.
Due to the large population of China, the chan-
ging economic conditions and economic develo-
pment gaps among regions, we also feel that it is
pragmatic to develop intersected financing for tho-
se schemes. The fragmented medical insurance sy-
stem, with diversity in insurance coverage and be-
nefits level among various insurance programs, has
caused inequality in utilization of health services
across different social groups. With the continuing
development of China’s economy and urban-rural
integration, fragmented medical insurance pro-
grams should be merged to shape a universal basic
medical insurance system that can serve all popula-
tion with more homogenous coverage and benefits
in the long run. This integration should take into
account the specific socioeconomic and demograp-
hic features of the regions or cities in the long term
strategy to realize universal coverage.
5. Concluding remarks
The development of URBMI, the health insu-
rance scheme that offers coverage to underser-
ved urban populations, is a crucial step towards
universal insurance coverage in China. Empiri-
cal evidence of the effects of URBMI is sparse at
present. This paper reviews the URBMI’s policy
arrangements. The analysis is based on compara-
tive institutional analysis and uses publicly avai-
lable data. We explored the institutional arrange-
ments of URBMI schemes in six selected cities to
analyze the issues and challenges China is facing
1427
HealthMED - Volume 5 / Number 6 / 2011
on the way towards universal coverage. We also
framed policy recommendations for adjustments
in the ongoing health reform. China’s current go-
vernment is firmly committed to the ultimate goal
of universal access to health care. Given this co-
mmitment, it is likely that the government will
substantially increase subsidies to the insuran-
ce funds to raise the financing level for URBMI
schemes. We suggest that the government gives
priority to less-developed cities in the allocation
of this public subsidy to reduce the inequality in
financing across regions. This will also allow the
schemes to include general outpatient care in the
benefit package as a means to improve efficiency
of the system as well as the attractiveness of the
scheme. Combining primary health care delivery
with insurance program may also be an effective
strategy to help develop a rational system for heal-
th service referral. This requires that the insurance
benefits cover general outpatient care. This exten-
sion will also contribute to the improvement and
construction of primary care facilities.
In the long term, there is reason to consider an
aggregation of the current pooling level of social
insurance to the provincial or even national level
to strengthen the risk pooling capability, and to
ease the problems of poor portability of diverse
schemes. This will improve equity across regions
as well. Given the long-standing economic imba-
lance across regions and potential technical and
administrative barriers, there is still a long way to
go to achieve this goal. This paper presents some
thoughts on the future direction of reform in China
and may contribute to enriching the worldwide de-
bate on how to promote universal health coverage
in transitional countries. More scientifically empi-
rical evidences are needed to further support our
analysis.
1428 Journal of Society for development in new net environment in B&H
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Journal of Society for development in new net environment in B&H 1429

HealthMED - Volume 5 / Number 6 / 2011

Stories of illness in a changing world

of medicine
Modesto Leite Rolim Neto1,2, Alberto Olavo Advincula Reis1, Irineide Beserra Braga3, Cícero Hedilberto
Filguêiras Macêdo4
1
Programa de Pós-Graduação em Saúde Pública, Universidade de São Paulo, Brasil,
2
Departamento de Medicina, Universidade Federal do Ceará, Brasil,
3
Grupo de Pesquisa “Suicidiologia”, Universidade Federal do Ceará, Brasil,
4
Programa de Pós-Graduação em Residência Médica, Divisão de Cirurgia Geral, Universidade Federal do
Ceará, Brasil.

Abstract construction of the doctor-patient relationship.[1,2,3]

Purpose: This study aims to evaluate the im-
pact caused by the doctor attitude in the patients
who would be submitted to a process of surgery;
their narratives, which are a result of the expressi-
on of their misfortunes and contain the evaluation
of the doctor behavior, and their own behavior fa-
cing this new situation.
Methods: The collecting of data was made
through interviews and a questionnaire applied by
the psychological team while the patients had their
hearts evaluated. For the process of codification
and labeling, the CAQDAS (Computer-Assisted
Qualitative Data Analysis Software) was used.
Results: Anxiety was almost a unanimous fee-
ling present in all narratives when the patients had
the opportunity to express their fear during the de-
velopment of the sickness, as well as fear of the
surgery itself, besides their need for a more human
contact with the doctor.
Conclusion: The patients who showed any
kind of faith, surprisingly had a calmer process of
recovery, and the absence of a more human rela-
tion with the doctor gave place to a deeper atta-
chment to a divine figure, in an attempt to overco-
me the fear of death.
Key words: Narratives; Doctor attitude; Hu-
manization; Disease. Faith.
Introduction
In the present time, medicine is passing through
a process of breaking its paradigms related to the re-
This break is deeply related to the perceptions and in-
teraction linked to time, history, and the experiences
concerning the symptoms connected to the narrati-
ves of the patients’ suffering; this has acquired diffe-
rent meanings right in the moment when the patients
share their versions to the doctor. In this perspective,
the doctor as the actor of the process of identification
of the illness and active in the process of healing it,
has in the relation with the patients’ events, a deci-
sive role in the translation of the histories that give
shape to the illness itself, because for centuries, the
act of telling stories about the reality of the experien-
ce caused by the suffering, has produced a dialectic
knowledge on the human being and the health/illness
issue.[4] The concept of “narrative” in this article re-
fers both to the patients’ life stories and to localized
talk during the interviews with their physicians.
In the process of humanization of medicine,
restoring the narratives of the patients about their
suffering, becomes in the present time, a conditi-
on indispensable to the shared analysis about the
events lived by them and the (re)created versions
of them[5], mainly because it can be seen that the
doctor as (re)productive of pre-established truths is
not motivated during his process of apprenticeship
to perceive the real relevance of the patients’ narra-
tives for the construction of the diagnosis, specially
because he is still too much linked to the paradigm
of the hierarquical knowledge. However, it is thro-
ugh those narratives, which do not have their value
appropriately inserted in the dialectic context, that
the doctor takes his will to truth – but he lacks, in
the perspective of humanization, the attitude of ta-
king part in the patient’s will to know.

1430 Journal of Society for development in new net environment in B&H


Due to the presence of complementary tech-
nological exams, there has been formed a barrier
in the communication process between the doctor
and the patient. It is believed that that has happe-
ned during the process of telling the history about
the pain and suffering lost its matrix of subjective
sense because of the interest in the technological
aspects in the moment of forming the diagnosis.
That has silenced the particular aspects of those
narratives. It is important to highlight the fact that
in real life the technological process are not sepa-
rated from the subjective ones.[6,7]
Due to the development of new aspects to iden-
tify the recognition of the diagnosis, the narratives
provoke thematic, theoretical and methodological
changes[3] in the dialogical experience between the
doctor and the patient in a subjective way[8], so that
a deductive and human meaning is added to the hu-
man suffering. Healing, therefore, it is not only abo-
ut extinguishing a pathology, it is about comforting
in a moment of pain and suffering[8]. This way, the
importance of narratives in medicine, considering
its feature of “Science of the individuals”[2], it is not
only concerned with the ways of listening neces-
sary to the process of healing or improvement of the
patients’ life conditions, but it is an epistemological
part of the process of building a knowledge that co-
mes from the practice and the scientific reasoning,
which creates hypothesis – that connected to the
deductive reasoning, necessary to determine what
is supposed to be – moves towards the process of
acquisition of knowledge.[3]
Thus, this study has the objective of evaluating
the impact of the doctors’ attitude in relation to the
patients that suffer from different levels of patho-
logies and that were to be submitted to surgery, as
well as their narratives, which were a result of the
expression of their sufferings, of the evaluation of
the doctors’ behavior, and their own behavior con-
cerning the surgery.
Methods
Seventy-six patients were analyzed from Janu-
ary 2009 to November 2010; 49 (64,4%) men and
27 (35,6%) women. The patients observed were
those that had surgeries previously scheduled; none
of them in risky conditions. The age ranged from
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
22 to 69 years; all those patients were submitted
to surgeries in the same hospital. The data consist
of narrative interviews with patients who had the-
ir hearts checked; it was also used a questionnaire
applied by the psychological support professional.
The researchers were introduced into the public
hospital and selected patients 24 hours before their
surgery in order to have time to register the infor-
mation about their heart condition and other im-
portant data that could help the understanding of
their emotional state. The analysis of content[9,10]
was used in the evaluation process of the disco-
urses, considering the discoursive corpus elabora-
ted by the patients on their fears, doubts and inse-
curities related to the surgery. For the process of
tagging, coding and indexing the contents, it was
used the CAQDAS - Computer-Assited Qualitati-
ve Data Analysis Software[11,12], in order to make
the link, order and (re)order, segmentation, struc-
turing and search, of the discourse.[10] The proce-
dures started after the research being approved by
the Ethics Bureau, and they were: patient’s aut-
horization for the research; individual interviews;
transcription of the interviews and explanation of
verbal expressions.
Results
It was noticed a common feature in almost all
narratives of the patients: the issue of anxiety whi-
le telling the disturbances caused by the illness, as
well as about the surgery. This feeling of distur-
bance, in some cases, caused changes in the pati-
ents’ clinic state, provoking changes in the blood
pressure, breath difficulties and agitation. These
information was observed in 26 (34,2%) patients,
only 21 (27,6%) had previously been submitted to
surgery, but did not show lack of anxiety, in fact,
there was an increase in their level of anxiety.
While analyzing the length of time that took
from the diagnosis, the suggestion of surgery and
the patient’s decision to submit himself to it, it
was observed that this period varied from “short”
(02 to 06 days) in 11 patients, which represents
14,5%; “medium” (01 to 04 weeks) in 39 patients
or 51,3%; and “long” (more than 04 weeks) in 26
patients or 34,2%. This data show several factors
of social, emotional and cultural nature, since the
1431
HealthMED - Volume 5 / Number 6 / 2011
narratives related to this decision showed, among
other points, lack of trust in the doctor figure due
to the few contacts between them, fact that aggra-
vated the illness and made the patients feel more
vulnerable to take the decision.
It was observed that 29 (38,2%) patients out of
a total of 70 had looked for a second opinion on
their pathology. That represents insecurity in the
doctor figure and a search for different opinions
concerning the data previously presented in their
narratives or by the doctor. This data also reveal
that 41 (61,8%) patients did not look for a second
opinion either for lack of other professional op-
tions, or lack of financial resources to support a
travel to a bigger city that could offer better tech-
nology to help in the diagnosis.
It was also analyzed the patients’ reaction to the
information on the need for a surgery; 13 or 17,15%
told had got the news about it from the doctor in an
impersonal way – that can be understood as a lack
of a more human relation between them. 32 patients
or 42,1% told that the news were informed in a qu-
ick and indifferent way; 21 of them or 27,7% told
the doctor’s account of the diagnosis in a sudden
way and only 10 or 13,1% mentioned the existence
of a more dialogical attitude. So, it can be seen that
the services are organized from the perspective of
the professionals and that of the institution, and are
not focused on the patients’ needs.[13,14]
These information bring to the center of the de-
bate the issue of diversity in the separateness of
the details of each case, where the subjective load
present in the narratives of the patients during the-
ir contact with the doctor is not appropriately con-
sidered, since the doctors have to fulfill a specific
deadline and a number of consultations per day.
From the other hand, the narrative of the profe-
ssional is central to the epistemology and practi-
ce of medicine, it is this epistemology necessary
to the rational investigation where the subjective
experience and accounts of that experience done
by another person which constitutes the basic and
original data of the clinical assistency.[2]
An interesting point is that the majority of the
surgeries did not involve any risk; the patients
observed were not in serious condition, however,
82,2% (61 patients) revealed in their discourse
fear of death concerning the surgery itself: “ I am
going to die [...] I have so much doubts and fears.
1432 Journal of Society for development in new net environment in B&H
How long is it going to take? Am I supposed to
get any anesthesia? Will I survive?” “Is it going
to hurt? I haven’t seen the doctor today. I’m wa-
iting for him. They say he’s good, but he doesn’t
talk to me.” “The doctors only care for the boxes
of medicine and we just move from one place to
another.” These narratives reveal a will to know [15]
that rises from the needs related to the experience
of translation of their narratives in their contact
with the doctor, which produces and reinforces
the patients vulnerability and anxiety linked to the
surgery, that is, it is an effect caused by the offer
and demand produced by the discourse [15] in the
doctor-patient relationship. From this effect of of-
fer and demand, rises fear of death, since there is a
lack of dialogue and negotiation.
It was also evaluated the patients’ opinion con-
cerning the length of time of their conversation with
the doctor; the majority of them 68,4% (52 men and
women) revealed that they had only one consulta-
tion and one return to show the exams and to be
informed that they were supposed to be submitted
to a surgery, and would meet the doctor again only
on the moment of the surgery. The patients compla-
int in their narratives that “The doctor doesn’t have
time for me. I’m not important. Only my illness ma-
tters, but I’m healthy. I think he listens to me only
because I’m paying.” “I wish I had the opportunity
to talk more, but he didn’t give me any more time.
Time is complicated for him.” “I don’t understand
why the doctor’s car are always full of books; they
do not care for us.” These data point to a common
link of insecurity, mainly because 31 (41,9%) pati-
ents said they did not have any information about
the process of the surgery and 24 (31,5%) told they
got information about it from other non-medical so-
urces on their health state.
The procedures to which those patients had
to submit themselves were: hysterectomy 21 or
(27,6%); Prostatectomy in 15 (19,7); abdominal
herniorrhaphy in 11 (14,5%); Hemorrhoidectomy in
09 (11,9%); cholecystectomy in 08(10,5%); partial
and total thyroidectomy in 03 (3,9%); spleenectomy
in 01 (1,4%) and orthopedic surgeries in 06 (7,9%).
It was also analysed if the patients had any
kind of faith or hope; 67 revealed having faith and
hope (88,1%) and 09 denied having these feelin-
gs (11,9%). The habit of praying and devotion to
a Mighty God was present in 32 (41,1%), but 09

denied this habit (11,9%), and 47 told that just ra-
rely they used to pray (61,8%). It was noticed that
the praying group had a better and faster period
of recovery and had less complications. A 52-year
old patient account shows that: “If I did not have
any kind of faith I would be dead already. It’s too
lonely, Mister, in this hospital.” Faith appears as a
decisive factor in the narratives and not only in the
process of healing, but also it influenced the pati-
ents’ life quality.[16,17] For example, a 69-year old
patient states that “I would be lost without God.
He listened to me, gave me comfort, and stayed
with me in my silence.”
So, science is led to reflect on the relation
between faith and its positive effects on the pa-
tients health conditions, because it was noticed
that a patient who has hope and trust can live more
and have less complications or not, but at least his
mood allows him to live better with himself and
his pathology. At the moment, it can be seen that
there are several studies concerning the healing
power of faith [16,18], as attempts to demonstrate the
positive relation between the medical treatment
and the fact that the patient has a hope.[19,20,21]
Discussion
It can be seen that there is a barrier between
the doctor and the patient, so that there is not eno-
ugh time for basic information to be discussed;
some patients did not know even the name of the
procedures they would have to be submitted to.
Apparently, this behavior is linked to the fact that
the procedure and the hospitalization take place
in a public hospital. Recent studies show that the
social and cultural distances bring a gap in their
relation. In this assimetry and facing the medical
routine, the population that depends on the public
service normally is not informed enough about
their rights, and thus, loses its autonomy and have
difficulty in negotiating their rights to information
and active participation in the process.[13]
That’s why the medical encounters must be seen
also in terms of an assymetrical relationship. In the
literature on the medical praxis, researchers call the
attention to the need of observing the balance of
power between patient and physician. The lack of
symmetry can even be seen in local terms, i.e., even
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
at the level of the individual interactions: doctors
and patients may each have their agendas to deve-
lop regarding to who will speak, when, how and
about what and usually their agendas differ.
It is important to analyse the patients’ narratives
and give them a more human treatment, since they
are not responsible for the expression of subjecti-
vity and polissemy of voices that ask for a more
attentive listening concerning their real experien-
ces concerning the surgery. It is in this context that
strategies are created by the patients in order to
deal with the process they will have to face, for
example, faith and attachment to a subjective figu-
re that represent security and calm in their univer-
se recently thrown into the chaoes, anxiety, uncer-
tainty and insecurity.
Medical encounters has been the topic of much
discussion but still lacks to be subjected to scien-
tific scrutiny. Whereas several aspects of medical
practice are included in the physician’s training,
the approach to the patient is expected to be on the
basis of intuition, to be learned by experience. In
the past, continuous relationship between patient
and physician was the rule rather than the excepti-
on. As a result, warmth and mutual understanding
could develop. As patterns of medical care have
changed, the serial encounters between physicians
and patients are being replaced by patients’ short-
term encounters with numerous specialists and
other health specialists. As a consequence and as
some studies about the medical praxis show, there
is a crescent criticism aimed at the lack of warmth
and humanity in the community medical care. Re-
searchers[22] suggest that patients feel more con-
fortable with medical encounters that are more
conversational rather than like interviews.
1433
HealthMED - Volume 5 / Number 6 / 2011
References
1. Frank A. The wounded storyteller: body, illness and
ethics. Nova York - Londres: Routledge, 1995.
2. Hunter KM. Doctor's stories. The narrative struc-
ture of medical knowledge. Princenton: Princenton
University Press, 1991.
3. Cardoso MHCA, Camargo JR, KR, Llrena JR, JC.
A epistemologia narrativa e o exercício clínico do
diagnóstico. Ciênc. Saúde Coletiva 2002;7(3):567.
4. Lira GV, Catrib AMF, Nations MK. A narrativa na
pesquisa social em saúde: perspectivas e método.
Rev. Bras. de Psiquiatr 2003; 16(1/2):60.
5. Silva DGV, Trentini M. Narrativas como técnica de
pesquisa em enfermagem. Rev. Latinoam. Enferma-
gem 2002;10(3): 426.
6. Merhy E. Em busca do tempo perdido: a micropo-
lítica do trabalho vivo. In: Merhy, E.; Onocko, C.R.
Agir em saúde. São Paulo: Hucitec, 1997;71:112.
7. Merhy E. Saúde: a cartografia do trabalho vivo.
São Paulo: Hucitec, 2002.
8. Minayo MCS. Dilemas do setor de saúde diante de
suas propostas humanistas. Ciênc. Saúde Coletiva
2004;9(1):15-29.
9. Krippendorff K. Content analysis: an introduction
to its methodology. London: Sage, 1980.
10. Bauer MW. Analise de conteúdo clássica: uma
revisão. In: Bauer MW, Gaskell G. Pesquisa qu-
alitativa com texto, imagem e som: um manual
prático. Rio de Janeiro: Vozes, 2002; 189:217.
11. Fielding NG, Lee RM. Computer analysis and
qualitative research. London: Sage, 1998.
12. Kelle U. Computer-Aided Qualitative Data Analy-
sis: theory, methods and practice. London: Sage,
1995.
13. Boaretto C. Avaliação da política de humanização
ao parto e nascimento no município do Rio de Ja-
neiro [Dissertação de Mestrado em Saúde Públi-
ca]. Rio de Janeiro: Fiocruz, 2003.
14. Boaretto C. Humanização da assistência hospita-
lar: o dia-a-dia da prática de serviço. Ciênc. Saú-
de Coletiva 2004;9(1):15-29.
1434
15. Mairesse D, Fonseca TNG. Dizer, escutar, escre-
ver: redes de tradução impressas na arte de carto-
grafar. Psicol. Estudo 2002;7(2):112.
16. Koenig HG, Larson DB, Mccullough ME. Hand-
book of religion and health. USA: Oxford USA
Trade, 2000.
17. Koenig HG, Cohen HJ. Link between religion and
health: psychoneuroimmunology and the faith
factor. USA: Oxford USA Trade, 2002.
18. Koenig HG, Matthews DA, Clark C. Faith factor:
proof of the healing power of prayer. USA: Pen-
guin USA, 1999.
19. Groopman J. Measure of our days: a spiritual ex-
ploration of illness. USA: Penguin USA, 1998.
20. Groopman J. Second opinions: stories of intuition
and choice in a changing world of medicine. USA:
Viking USA, 2000.
21. Groopman J. The Anatomy of Hope: How Pa-
tients Prevail in the Face of Illness. USA: Random
House Publishing Group, 2003.
22. Shuy R. Three types of interference to an effective
exchange of information in the medical interview.
In: Fischer, S; Todd, A. Washington, DC: Center
for Applied Linguistics 1983; 189:202.
Corresponding author
Modesto Leite Rolim Neto,
Programa de Pós-Graduação em Saúde Pública,
Departamento de Saúde Materno-Infantil,
Faculdade de Saúde Pública,
Universidade de São Paulo,
Brasil,
E-mail: modestorolim@yahoo.com.br
Journal of Society for development in new net environment in B&H

The Relationship between Weight
Status and Self-reported Mental Health
Outcomes in Korean Adolescents
Seong-Ik Baek1, Wi-Young So2
1
Department of Physical Educations, Myongji University, Korea
2
Department of Human Performance & Leisure Studies, North Carolina A&T State University, United
States of America.
Abstract
Objective: The purpose of this study was to
investigate the relationship between weight status
and self-reported physical health, happiness, and
stress in Korean adolescents.
Methods: In 2009, 72,399 students from the 7th
to 12th grades participated in the Korea Youth Risk
Behavior Web-based Survey (KYRBWS) proj-
ect, which assessed their body mass index (BMI),
physical health, happiness, and stress. The rela-
tionships between BMI and each variable were
examined by a one-way ANOVA.
Results: Boys and girls showed significant dif-
ferences in physical health and stress (p < 0.001),
and only girls showed significant differences in
happiness (p < 0.001) according to the BMI stan-
dard. Accordingly, a post-hoc test showed that un-
derweight boys and girls had poor physical health
(p < 0.001), and that overweight and obese boys
had poor physical health (p < 0.001) compared
to normal-weight adolescents. Furthermore, un-
derweight girls were happier (p < 0.05) and less
stressed (p < 0.001); however, obese boys and
overweight and obese girls were more stressed (p
< 0.05) compared to normal-weight adolescents.
Conclusion: In boys and girls, increasing
obesity corresponded with deterioration in physi-
cal health, declining levels of happiness, and in-
creased stress. Thus, preventing obesity can be an
important factor in improving mental health out-
comes in Korean adolescents.
Key words: Weight status, Body mass index,
Physical health, Happiness, Stress
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
Introduction
Issues connected with being overweight and
obesity have become serious problems world-
wide. According to a WHO report, over 1.5 billion
adults aged 20 and above are already overweight,
and over 200 million men and 300 million wom-
en are obese. Further, globally, almost 43 million
children aged 5 and under were overweight in
2010 (1), and obesity in adolescents and adults is
becoming increasingly common (2-4).
Obese adolescents not only encounter physical
health problems such as cancer, diabetes, hyperten-
sion, and heart disease, but evidence also suggests
a relationship between obesity and mental health
problems (5-6). According to several reports, obe-
sity in adolescents can negatively affect their so-
cial and psychological well-being. These negative
social and interper­sonal outcomes, including poor
body image, low self-esteem, depression, and sui-
cidal ideation, may increase the risk of psychologi-
cal trauma in obese adolescents (7-10). Further-
more, Merten et al. (2007) reported that obese ado-
lescents experienced more mental problems than
normal-weight adolescents did, even when prior
mental problems were controlled (11).
Although many reports discuss various ethnic
factors influencing the negative mental health out-
comes of adolescent obesity, health professionals
in South Korea (Asia) are ignorant of the rela-
tionship between weight status and mental health
outcomes of the whole community. Therefore, the
purpose of this study was to exam­ine the relation-
ship between weight statuses and the self-reported
physical health, happiness, and stress of those who
participated in the 2009 KYRBWS.
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HealthMED - Volume 5 / Number 6 / 2011
Methods
Subjects
The 2009 KYRBWS—the 5th one—is a na-
tional school-based survey conducted by the Ko-
rea Centers for Disease Control and Prevention
(KCDCP) in order to estimate the prevalence of
health risk behavior among adolescent students
from the 7th to 12th grades in Korea. The survey
uses a sixteen-city-cluster sample strategy, and
the survey sampling frame covers all of Korea.
This study used a sample of 400 middle schools
and 400 high schools. The response rate of the
5th survey was 97.6% (N = 75,066), and students
who were absent for an extended period of time,
or were dyslexia and disgraphia were excluded
from the sample. After excluding those who did
not meet the sample requirements or were absent,
72,399 students participated in this study (12).
Independent variables
The subjects’ height and weight were self-
recorded, and BMI (kg/m2) was calculated using
each participant’s height and weight. The WHO’s
Asia-Pacific standard of obesity defines BMIs that
are <18.5, ≥18.5–<23, ≥23–<25, and ≥25 as un-
derweight, normal, overweight, and obese, respec-
tively (13).
Dependent variables
The following three KYRBWS questions were
used to measure self-reported physical health, hap-
piness, and stress in the subsample of adolescents:
“How do you describe your health in general?” with
the response options of “1 very poor,” “2 poor,” “3
fair,” “4 good,” and “5 very good”; “How do you de-
scribe your happiness in general?” with the response
options of “1 very unhappy,” “2 unhappy,” “3 fair,”
“4 happy,” and “5 very happy”; and “How do you
describe your stress in general?” with the response
options of “1 very high stress,” “2 high stress,” “3
fair,” “4 low stress,” and “5 very low stress.” All
items were recorded so that higher scores reflected
reports of better physical or mental health.
1436 Journal of Society for development in new net environment in B&H
Statistical analysis
Descriptive data are presented as mean ± SD.
A one-way ANOVA was used to test for differ-
ences in self-reported mental health outcomes
according to the BMI standard. Post-hoc testing
(Scheffe) was conducted to specifically confirm
which groups showed differences when a differ-
ence between groups occurred. Statistical signifi-
cance was set at p < 0.05*, p < 0.01**, and p <
0.001***, and all analyses were performed using
SPSS ver. 12.0 (SPSS, Chicago, IL, USA).
Results
The characteristic of the subjects
The characteristics of the subjects are shown in
Table 1. The average ages of the boys and girls are
15.00 ± 1.73 years and 15.12 ± 1.77 years respec-
tively; their average heights are 169.58 ± 8.19 cm
and 160.08 ± 5.39 cm respectively; their average
weights are 60.14 ± 11.72 kg and 51.47 ± 7.67 kg
respectively; and their average BMIs are 20.80 ±
3.21 kg/m2 and 20.05 ± 2.58 kg/m2 respectively. Ac-
cording to the boys’ and girls’ BMIs, 9,719 (25.5%)
and 10,012 (29.2%) are underweight, 19,685
(51.6%) and 19,655 (57.4%) are normal weight,
4,382 (11.5%) and 2,967 (8.7%) are overweight,
and 4,366 (11.4%) and 1,613 (4.7%) are obese.
The family economic status of the boys and
girls is as follows: 2,691 (7.1%) and 1,337 (3.9%)
are high, 8,768 (23.0%) and 6,719 (19.6%) are
middle high, 17,229 (45.2%) and 17,259 (50.4%)
are average, 6,890 (18.1%) and 6,825 (19.9%) are
middle low, and 2,574 (6.7%) and 2,107 (6.2%)
are low. Their city size is as follows: 20,252
(53.1%) and 17,708 (51.7%) are large, 13,303
(34.9%) and 12,153 (35.5%) are medium-sized,
and 4,597 (12.0%) and 4,386 (12.8%) are small.
Their grades are as follows: 6,711 (17.6%) and
5,615 (16.4%) are middle first, 6,722 (17.6%) and
5,727 (16.7%) are middle second, 6,767 (17.7%)
and 5,615 (16.4%) are middle third, 6,626 (17.4%)
and 5,369 (15.7%) are high first, 5,889 (15.4%)
and 6,102 (17.8%) are high second, and 5,437
(14.3%) and 5,819 (17.0%) are high third.
 HealthMED - Volume 5 / Number 6 / 2011

Table 1. Characteristics of subjects (Mean ± SD)

Boys Girls Total
Variables
(n = 38152) (n = 34247) (n = 72399)
Age (years) 015.00 ± 01.73 015.12 ± 1.77 015.06 ± 01.75
Height (cm) 169.58 ± 08.19 160.08 ± 5.39 165.09 ± 08.46
Weight (kg) 060.14 ± 11.72 051.47 ± 7.67 056.04 ± 10.91
BMI (kg/m )2
020.80 ± 03.21 020.05 ± 2.58 020.45 ± 02.95
Under weight (BMI < 18.5) 09719 (25.5) 10012 (29.2) 19731 (27.3)
Weight Normal weight (18.5 ≤ BMI < 23) 19685 (51.6) 19655 (57.4) 39340 (54.3)
state
N (%) Over weight (23 ≤ BMI < 25) 04382 (11.5) 02967 (08.7) 07349 (10.2)
Obesity (25 ≤ BMI) 04366 (11.4) 01613 (04.7) 05979 (08.3)
High 02691 (07.1) 01337 (03.9) 04028 (05.6)
Family Middle high 08768 (23.0) 06719 (19.6) 15487 (21.4)
economic
Average 17229 (45.2) 17259 (50.4) 34488 (47.6)
state
N (%) Middle low 06890 (18.1) 06825 (19.9) 13715 (18.9)
Low 02574 (06.7) 02107 (06.2) 04681 (06.5)
Large 20252 (53.1) 17708 (51.7) 37960 (52.4)
City size
Middle 13303 (34.9) 12153 (35.5) 25456 (35.2)
N (%)
Small 04597 (12.0) 04386 (12.8) 08983 (12.4)
Middle 1st 06711 (17.6) 05615 (16.4) 12326 (17.0)
Middle 2nd 06722 (17.6) 05727 (16.7) 12449 (17.2)
Grade Middle 3rd 06767 (17.7) 05615 (16.4) 12382 (17.1)
N (%) High 1st 06626 (17.4) 05369 (15.7) 11995 (16.6)
High 2nd 05889 (15.4) 06102 (17.8) 11991 (16.6)
High 3rd 05437 (14.3) 05819 (17.0) 11256 (15.5)
BMI, Body Mass Index

Table 2. The differences in self-reported mental health outcomes according to the BMI standard
Overall Overall
Variables Group Normal Underweight Overweight Obesity
F p
Boys 3.91 ± 0.83 3.76 ± 0.86 ### 3.84 ± 0.84 ### 3.71 ± 0.88 ### 99.462 <0.001***
Physical
Girls 3.66 ± 0.83 3.59 ± 0.84 ### 3.65 ± 0.84 3.61 ± 0.85 17.830 <0.001***
health
Total 3.78 ± 0.84 3.67 ± 0.86 ### 3.77 ± 0.85 3.69 ± 0.87 ### 83.999 <0.001***
Boys 3.60 ± 0.98 3.60 ± 0.98 3.58 ± 1.00 3.57 ± 0.98 1.861 0.134
Mental
Girls 3.47 ± 0.94 3.51 ± 0.97 # 3.44 ± 0.95 3.41 ± 1.00 7.077 <0.001***
health
Total 3.54 ± 0.96 3.55 ± 0.98 3.52 ± 0.98 3.53 ± 0.99 1.822 0.141
Boys 2.76 ± 0.95 2.79 ± 0.97 2.72 ± 0.96 2.71 ± 0.97 # 8.744 <0.001***
Stress Girls 2.46 ± 0.90 2.52 ± 0.93 ### 2.38 ± 0.92 ### 2.35 ± 0.92 ### 31.683 <0.001***
Total 2.61 ± 0.94 2.65 ± 0.96 ### 2.58 ± 0.96 2.61 ± 0.97 13.481 <0.001***
BMI, Body Mass Index
***p<0.001 by one-way ANOVA
#p<0.05 ###p<0.001; Compared to normal group (Scheffe)

Journal of Society for development in new net environment in B&H 1437

HealthMED - Volume 5 / Number 6 / 2011
The differences in self-reported mental health
outcomes according to the BMI standard
The differences in self-reported mental heal-
th outcomes according to the BMI standard are
shown in Table 2. Boys and girls showed signifi-
cant differences in physical health and stress (p <
0.001), and only girls showed significant differen-
ces in happiness (p < 0.001) according to the BMI
standard. Accordingly, a post-hoc test showed that
underweight boys and girls had poor physical he-
alth (p < 0.001), and that overweight and obese
boys had poor physical health (p < 0.001) com-
pared to normal-weight adolescents. Furthermo-
re, underweight girls were happier (p < 0.05) and
less stressed (p < 0.001); however, obese boys and
overweight and obese girls were more stressed (p
< 0.05) compared to normal-weight adolescents.
Discussion
The purpose of this study was to investigate the
relationship between mental health outcomes and
weight status in Korean adolescents. This study
found that boys and girls with a low weight status
(underweight) show a tendency to poor physical
health but less stress compared to normal-weight
adolescents. However, boys and girls with a high
weight status (overweight, obese) show a tenden-
cy to poor physical health and more stress compa-
red to normal-weight adolescents.
Obesity is a medical disorder that may adver-
sely affect health, leading to a decreased lifespan
and predisposition to lifestyle diseases like me-
tabolic syndrome (14). Furthermore, a national
longitudinal study, Swallen et al. (2005), showed
that overweight and obese adolescents were more
likely to report poorer health compared to normal-
weight ado­lescents (15). Even though there was
no difference in the level of happiness in adoles-
cents who were becoming obese and in those of
normal weight, our results supported the theory
that the physical health and stress of adolescents
becoming obese was poor compared to that of nor-
mal-weight adolescents in Korea.
Interestingly, our results showed that underwe-
ight girls are happier and less stressed compared
to normal-weight and obese ones. Dixson et al.
1438
(2007) reported that the preferred characteristics
of women in modern Asian society are slimness
and a low waist-hip ratio (WHR) with obesity
scoring lowest for attractiveness (16). Therefore,
women have a tendency to lose weight in order to
reduce mental stress induced by the society they
live in. Our results can be understood in the same
context; that is, because underweight Korean ado-
lescents face less social pressure regarding weight
than obese adolescents do, they have better mental
health and less stress than obese adolescents do.
We hope that further well-designed studies will
find the relationship between being underweight
and mental health.
The limitations of this study are as follows.
First, as the KYRBWS is an online survey, the
heights and weights of the adolescents were not
measured directly but were self-recorded. The re-
latively low recorded level of obesity is possibly
due to the adolescents’ tendency to inflate their
heights and deflate their weights (17). Moreover,
socioeconomic status was not recorded by parents,
but by adolescents; hence, it would be inaccurate.
However, unlike the previous small-scale regional
case studies, this study investigated the entire co-
untry, and its sample size was 72,399; therefore,
this study can be a representative study of the re-
lationship between weight status and self-reported
mental health outcomes in Korean adolescents.
Conclusion
In boys and girls, increasing obesity correspon-
ded with deterioration in physical health, declining
levels of happiness, and increased stress. Therefo-
re, preventing obesity can be an important factor
in improving mental health outcomes in Korean
adolescents.
Journal of Society for development in new net environment in B&H

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Corresponding author
Wi-Young So,
Department of Human Performance & Leisure
Studies,
North Carolina A&T State University,
United States of America,
E-mail: wowso@snu.ac.kr
1439
HealthMED - Volume 5 / Number 6 / 2011

An Oxygen-sensing Signal Cascade

of Cardiomyocyte Adaptations to
Moderate Endurance Training
Zong-Yan Cai1, Cheng-Chen Hsu2, Mei-Chich Hsu3, Mao-Shung Huang4, Chao-Pin Yang5, Yung-Yu Tsai2,
Borcherng Su6
1
General Education Center, Tuz Chi College of Technology, Hualien County, Taiwan (ROC),
2
Department of Anatomy, School of Medicine, College of Medicine, Taipei Medical University, Taipei,
Taiwan (ROC),
3
Graduate Institute of Sports Science, National Taiwan Sport University, Taoyuan County, Taiwan (ROC),
4
Department of Dentistry, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan (ROC),
5
Department of Physical Medicine and Rehabilitation, Changhua Christian Hospital, Changhua County,
Taiwan (ROC),
6
Department of Pathology, Hualien Tzu Chi medical center, Hualien County, Taiwan (ROC).

Abstract Conclusions: Downregulation of VHL in res-

Background and Puepose: The molecular pa-
thological markers of vascular endothelial growth
factor (VEGF), hypoxia inducible factor-1 alpha
(HIF-1α), von Hippel-Lindau tumor suppressor
protein (VHL) and peroxisome proliferator-acti-
vated receptor gamma coactivator-1 alpha (PGC-
1α), are recently linked in the regulation of oxygen
availability. The purpose of this study was to inve-
stigate these molecular markers of the cardiomyo-
cyte adapt to moderate endurance training.
Materials and Methods: we performed im-
munohistochemical staining coupled with ima-
ge analysis for quantification in male Sprague-
Dawley rat myocardium that had been trained on
treadmill running at 20 m/min for 30 min on a
0% grade, for 3 days/wk. for 4 weeks (4WT) or 8
weeks (8WT) and control rats for 4 weeks (4WC)
or 8 weeks (8WC) (n=6, respectively).
Results: Training led to no significant alterati-
on in HIF-1α content. Interestingly, a lower VHL
content and higher VEGF contents were detected
in the trained groups compared with their con-
trol counterparts (p<0.05). Additionally, PGC-1α
showed higher content in the 8WT group than
those in the 8WC and 4WT groups (p< 0.05), but
no significant difference in PGC-1α content was
found between the 4WT and 4WC groups.
ponse to training may be the initiator responsible
for activating the cardiomyocyte oxygen available
for signaling cascades. Additionally, in the cardi-
omyocyte, moderate training-induced adaptation
may occur faster in VEG- regulated oxygen avai-
lability than in the PGC-1α.
Key words: HIF-1α, VHL, VEGF, PGC-1α
Introduction
In the last few decades, performing regular
exercise, especially moderate endurance exercise,
has been regarded as a powerful agent for healthy
adult to improve cardiovascular capacity (1,2). In
the cardiovascular system, the heart pumps oxy-
gen-rich blood in a circulation that occupies the
central role in training-induced adaptation. Studi-
es on exercise and myocardium indicate that chro-
nic repeated exercise would improve myocardial
oxygen availability (3,4). As oxygen is transported
throughout the body through vascular system, the
increase in myocardial oxygen availability may be
predominantly upregulated by cardiac vascular re-
modeling (4,5). However, cellular and molecular
studies used for a training-induced adaptive pro-
gress in cardiomyocyte are still less known.

1440 Journal of Society for development in new net environment in B&H


Research characterizes an important signaling
pathway that has traditionally been thought to
play a primary role in pathological specimens, but
only recently has its physiological meaning been
explored as a regulation of exercise-induced an-
giogenesis, with vascular endothelial growth fac-
tor (VEGF) among the most powerful molecular
initiator (6). VEGF signaling exerts angiogenic
effects by increasing both blood vessels and their
permeability allowing the oxygen to transport ef-
fectively (6,7). VEGF during exercise is known to
be upregulated by hypoxia stress, especially thro-
ugh the hypoxia inducible factor-1 alpha (HIF-1α)
transcription factor oxygen sensing molecule (8).
HIF-1α protein is an oxygen-sensing molecule.
Activation of the HIF-1α expression is dependent
upon oxygen tension. In a normoxic condition,
HIF-1α is unstable and subject to rapid degrada-
tion as it binds to the von Hippel Lindau (VHL)
tumor suppressor protein. In contrast, when tissue
is deficient in oxygen, HIF-1α is activated and dis-
sociated from VHL, and the expression of VHL
is slightly reduced, favorably facilitating HIF-1α
for ubiquitination. The VHL/HIF-1α interaction
permits a better understanding of cellular oxygen
sensing (9,10). Marini et al. (11) demonstrated that
moderate endurance training increases myocardial
VEGF mRNA expression, suggesting that modera-
te endurance training is effective in initiating VEGF
angiogenic signaling cascades. However, the adap-
tive process of cardiomyocyte VEGF, coupled with
the HIF-1α/VHL protein levels in response to mo-
derate endurance training, is largely unknown.
In addition to the oxygen transport medium, the
vascular system, when flowing fluently, may incre-
ase oxygen availability. Like all tissues, the heart
itself also needs sufficient mitochondria oxygen
consumption to sustain energy supply. Moderate
endurance training presents moderate metabolic
challenges that may adjust mitochondrial energy
metabolism in order to make aerobic respiratory
work more efficiently. Such adaptations are likely
the result of a coordinated molecular response
that increases mitochondrial proteins. Recently,
a molecule called the transcriptional coactivator
peroxisome proliferator-activated receptor gam-
ma coactivator-1 alpha (PGC-1α), has been found
to be a prominent regulator of mitochondrial bi-
ogenesis and aerobic energy supply (12,13). The
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
activation of PGC-1α may turn physiological si-
gnals into metabolic programs, thus resulting in a
higher capacity for mitochondrial ATP production
and better efficiency for cellular respiration both
in myocyte and cardiomyocyte (14). Despite ge-
neral agreement that endurance exercise increases
PGC-1α expression in myocyte (15,16,17), howe-
ver, to the best of our knowledge, no study has yet
investigated the cardiomyocyte PGC-1α response
subsequent to moderate endurance training.
Immunohistochemistry (IHC) staining, the use
of specific antibodies to stain particular molecu-
lar species in situ, coupled with an image analysis
method, serves as a more precise tool to quanti-
fy specific protein expression into the cell layer
(18,19). By using this method, our purpose was
to focus on the cardiomyocyte HIF-1α/VEGF pa-
thway and PGC-1α in response to moderate en-
durance training. Furthermore, to investigate the
adaptive process, this study was designed with 4
wk and 8 wk training stages.
Materials and Methods
Animals
Twenty-four male Sprague-Dawley (SD) rats
(10 wks old) obtained from the National Institute
of Animal Care (Taiwan) were used in the experi-
ment. Rats were individually housed in cages with
rat chow and water supplied ad libitum, in a room
controlled at 20-22 °C, and with a constant arti-
ficial 12:12-h light-dark cycle. All experimental
procedures were approved by the Taipei Medical
University of Animal Care Committee.
Study design
The rats were randomly divided into a 4-wk
of exercise training (4WT) group, a 4-wk seden-
tary control (4WC) group, an 8-wk of exercise
training (8WT) group, and an 8-wk sedentary
control (8WC) group (n=6 per group). Training
was carried out between 10:00 and 14:00 per se-
ssion. During each training session, instead of be-
ing required to run on the treadmill, the C groups
were placed on a non-moving treadmill. Each of
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HealthMED - Volume 5 / Number 6 / 2011
the trained groups and their control counterparts
were sacrificed for tissue removal 48 h after the
last exercise training period.
Training protocol
Exercise training included 3 days of habitua-
tion to the treadmill before the training program.
Rats began at a running speed of 20 m/min, at 0%
grade for 10 min for two days. The duration was
then increased by 10 min until 20 min/day was
achieved on the third day, followed by one day
of rest. After familiarization, the training groups
began a treadmill training program for 4 or 8 wks
according to the group to which they were assi-
gned. Rats ran at 20 m/min for 30 min on a 0%
grade for 3 days/wk. The work rate fulfills the ran-
ge of moderate intensity for SD rats as previously
described (20,21). Electrical stimulation was used
to motivate the rats to run.
Tissue preparation
Rat myocardium were removed and then were
preserved freshly and fixed in 10% formalin so-
lution until paraffin-embedded tissue blocks were
made. Five-mm thick cross sections were cut using
a freehand section method with a microtome (Jung
SM 2000R, Leica, Nussloch, Germany) from each
block, and were mounted on micro slides (Men-
zel-Glaser, Braunschweig, Germany) for further
analysis.
Immunohistochemistry (IHC) staining
The procedure of IHC staining was performed
according to the standard protocol as described
elsewhere (18,19,22,23) with minor modificati-
on. Firstly, the slides were incubated at 60°C for
10 min, followed by dewaxing using xylene, and
rehydrated by passing through degraded concen-
trations of ethanol. Then, slides were briefly was-
hed and immersed in phosphate-buffered saline
(PBS) buffer for 5 min, and PBS was also used 5
min between all the following staining steps. After
that, slides were immersed in citrate buffer solu-
1442 Journal of Society for development in new net environment in B&H
tion (pH=6.0) and were heated in a digital declo-
aking chamber (Biocare Medical, Concord, CA,
USA) for 30 min to induce antigen retrieval. Endo-
genous peroxidase activity was then inhibited by
15-min of incubation in 3% H2O2, followed by 3%
bovine serum for 30 min in a humidified chamber
to block nonspecific binding sites. Primary rabbit
polyclonal antibodies to HIF-1α (dilution, 1:100;
Novus, Biologicals, Littleton, CO, USA), VHL
(dilution, 1:50; Santa Cruz Biotechnology Inc.,
Santa Cruz, California, USA), VEGF (dilution,
1:150; Abcam, Cambridge, United Kingdom), and
PGC-1α (dilution, 1:100; LifeSpan BioSciences,
Seattle, WA, USA) were added individually to the
slides, and were allowed to incubate for 90 min.
Slides were then washed and incubated in a se-
condary biotinylated goat anti-rabbit IgG antibody
(Dakopatts, Glostrup, Denmark) for 20 min. Next,
slides were incubated with streptavidin–horsera-
dish peroxidase (HRP) (DAKO. LSAB kit, K0675,
Carpinteria, CA) conjugated for 20 min. Finally,
incubation for 2~4 min in diaminobenzidine
(DAB) (Dako, Carpinteria, CA) substrate-chro-
mogen for peroxidase was used to visualize the
bound antibody. For slides were used for image
quantification, no counterstain was applied so as to
simplify image colorimetric quantification.
Mean optical density measurement
In this study, histological sections on slides
were imaged using a Nikon 80i Eclipse E600 mi-
croscope (Nikon, Tokyo, Japan) equipped with
the Nikon's Digital Sight DS-Fi1 camera system
(Nikon, Kawasaki, Japan). Visualization was per-
formed at high magnification (objective × 40). On
each slide sample, 20 fields of area were chosen
randomly throughout histological sections, but
edge areas were avoided. An image analysis using
Image-Pro Plus 6.2 software for windows (Media
Cybernetics, Silver Springs, MD, USA) was per-
formed for the following quantification.
To evaluate the IHC staining intensity (mean
optical density, MOD) of HIF-1α, VHL, VEGF,
and PGC-1α, an image analysis was used fo-
llowing a previous protocol with minor modifica-
tions (18,24,25). First, images were converted into
an eight-bit gray-scale with pixel values within

the range of 0.0 (black) to 255.0 (white). On each
gray image, five visually cytoplasmic stained are-
as were randomly selected, and a white area ser-
ved as a blank reference. The pixel data were then
imported to Microsoft Excel 2007 (Microsoft, Se-
attle, WA). The MOD value of each image was
obtained according to the following formula:
1 N I 
MOD = − ∑ log 1  .................. (1)
N i =1  I 0 
where N is equal to five, Ii is the intensity level
of the pixel i, and Io is the intensity level of the
blank background measured in each image.
In this study, one person performed all counting
in duplicate and was blinded to the groups’ iden-
tity until all counting was completed. There were
no differences between counts of each dependent
parameter, so the count was considered reliable.
Averaged values from all the duplicated depen-
dent parameters were used for statistical analysis.
Data analysis
All data were expressed as the mean±standard
error of the mean (SEM). To compare the diffe-
rence of dependent parameters more precisely in
cell layers, 20 sections per rat, corresponding to
120 values per group were obtained a mean va-
lue for statistical comparison. Statistical anal-
ysis was carried out by two-way analysis of va-
riance (ANOVA) (period × training) followed by
Scheffe’s F test for multiple comparison to assess
the differences between the trained and the con-
trol groups. Statistical significance was accepted
at p<0.05 for all tests.
Results
Hypoxia signaling
VHL
Fig. 1A shows the VHL contents. Representati-
ve IHC images showing deeper color represent hi-
gher protein levels (Fig. 2). As seen, the VHL con-
tents showed significant training effects (p<0.05).
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
The VHL contents were significantly lower in the
trained groups than that in their control counter-
parts; there was no significant difference between
the 4WT and 8WT groups.
Fig. 1. The mean optical density of VHL (A) and
HIF-1α (B) of rat cardiomyocyte for 4 wk trained
(4WT) and 8 wk trained (8WT), and controls for
4 wks (4WC) and 8 wks (8WC). Each column
represents the mean±SEM of 120 values (six rats,
20 values per rat). *Significantly differs of trained
groups when compared to its control counter-
parts (p <0.05).
HIF-1α
No significant difference in the HIF-1α content
was observed among the groups (Fig.1B and 2).
VEGF
As seen in Fig. 3, the VEGF contents showed si-
gnificant training effects (p<0.05). The results reve-
al that the trained groups show significantly higher
VEGF contents in comparison with their respective
control counterparts (p<0.05). However, there were
no significant differences in the VEGF content
between 4WT and 8WT groups. The representative
IHC images are shown in Fig. 4.
PGC-1α
The PGC-1α contents showed significant tra-
ining (p<0.05) effects, and significant trained
1443
HealthMED - Volume 5 / Number 6 / 2011

Fig. 2. Representative IHC images of VHL and HIF-1α from rat cardiomyocyte, which include exam-
ple for 4 wk control (4WC), 4 wk trained (4WT), 8 wk control (8WC), and 8 wk trained (8WT) groups.
Images were acquired using 40×magnification objectives. The bar represents 10 μm.

Fig. 4. Representative IHC images of VEGF from rat cardiomyocyte, which include example for 4 wk
control (4WC), 4 wk trained (4WT), 8 wk control (8WC), and 8 wk trained (8WT) groups. Images were
acquired using 40×magnification objectives. The bar represents 10 μm.

group by time effect (p<0.05). As seen, the 8WT

group showed a higher PGC-1α content than did
the 8WC and 4WT groups (p<0.05), but no signi-
ficant difference occurred in the PGC-1α contents
between the 4WT and 4WC groups (Fig. 5 and 6).

Fig. 5. The mean optical density of PGC-1α of

Fig. 3. The mean optical density of VEGF of rat
cardiomyocyte for 4 wk trained (4WT) and 8 wk
trained (8WT), and controls for 4 wks (4WC)
and 8 wks (8WC). Each column represents the
mean±SEM of 120 values (six rats, 20 values per
rat). *Significantly differs of trained groups when
compared to its control counterparts (p <0.05).
rat cardiomyocyte for 4 wk trained (4WT) and 8
wk trained (8WT); and controls for 4 wks (4WC)
and 8 wks (8WC). Each column represents the
mean±SEM of 120 values (six rats, 20 values per
rat). *Significantly differs of trained groups when
compared to its control counterparts (p<0.05).
†Significantly differs between 4WT and 8WT
groups.

1444 Journal of Society for development in new net environment in B&H


Fig. 6. Representative IHC images of PGC-1α from rat cardiomyocyte, which include example for 4
wk control (4WC), 4 wk trained (4WT), 8 wk control (8WC), and 8 wk trained (8WT) groups. Images
were acquired using 40×magnification objectives. The bar represents 10 μm.
Discussion
The principal findings of this study were that
4 wk moderate endurance trained rat cardiomyo-
cyte demonstrated lower VHL content but higher
VEGF contents compared with their control co-
unterparts. The training effects of the VHL and
VEGF contents lasted through the 8 wk training
stage. Additionally, when at wk 8, trained rats
showed higher PGC-1α content in the cardiomyo-
cyte compared with controls, but there was no si-
gnificant difference between trained and control
groups at wk4. It is suggested that moderate endu-
rance training-induced VEGF signaling response
occurred faster than it did in the PGC-1α content.
VEGF is widely considered to be a critical me-
diator in angiogenesis. In the current study, 4 wk
moderate endurance training effect induced incre-
ase in VEGF content and the training effect exist
when doubling the training period to 8 wks. It sug-
gests that myocardium may receive a better supply
of blood or oxygen availability. It is reported that
aerobic exercise-induced VEGF expression is pri-
marily regulated by HIF-1α because the cumulati-
ve effects of a hypoxic episode generated during
exercise may trigger a HIF-1α signaling pathway
(27). On the basis, our data are indicative of invol-
ving hypoxia signaling in exercise-induced VEGF
upregulation. However, we failed to find any
change in HIF-1α contents of rat cardiomyocyte
in response to either 4 wks or 8 wks of moderate
endurance training.
A bout of acute exercise elicits either a tran-
sient increase or no alteration in HIF-1α protein
in skeletal muscle has been reported (28,29). Lun-
dby, Gassmann, and Pilegaard (30) claimed that
even a transient increase in HIF-1α expression
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
through exercise would produce a signaling effect.
Since HIF-1α protein has a very short half-life, ta-
ken together, the discrepancies between the data
and these previous findings may be attributed to
the differences in the measuring time points. The
HIF-1α protein contents in the trained groups of
this study reflected 48 h at post training levels.
Therefore, it is reasonable to assume that if the-
re had been change in the HIF-1α content during
exercise, it might have returned to a basal level.
Although in our current study, no training effect
was observed in the HIF-1α contents, it was in-
teresting to discover lower VHL contents in mo-
derate endurance trained groups compared with
controls. The result is similar to those of Ameln et
al. (28) who find large increases in HIF-1α protein
levels accompanied by a clear downregulation of
VHL protein levels after acute exercise. The re-
duced VHL may favorably facilitate HIF-1α for
ubiquitination (9,10), which may exert a signaling
effect to regulate the target downstream gene. As
a consequence, in our current study as previously
described, the content of a HIF-1α target protein,
VEGF, was shown to be higher in trained rats.
Another molecule that mediates the oxygen
availability in the current study, PGC-1α, is regar-
ded as the master regulator of mitochondrial bio-
genesis, leading to increase capacity to efficiently
generate ATP (12,13). In particular, it is postula-
ted that the role of PGC-1α in cardiomyocyte is to
produce a chemical-driving force to maintain the
heart’s unceasing mechanical work (31). The res-
ponse of PGC-1α in cardiomyocyte to endurance
training has not yet been made clear. In this study,
no significant difference in PGC-1α was found
between the trained and control rats at wk 4. It was
not until wk 8 that a higher level of PGC-1α con-
1445
HealthMED - Volume 5 / Number 6 / 2011
tent was observed in comparison with the control
values, suggesting that moderate endurance trai-
ning per se, could elicit upregulation of the PGC-
1α content in cardiomyocyte when training over a
longer period of time.
It is well established that endurance exercise
can induce PGC-1α expression in skeletal muscles
(15,16,17), and PGC-1α has been recently confir-
med as necessary for angiogenesis (15). However,
a surprising finding was that moderate endurance
training activated a cardiomyocyte VEGF signa-
ling response in the absence of PGC-1α upregu-
lation in wk 4, and it was not until wk 8 that a
higher level of PGC-1α content was observed. The
data observed in cardiomyocyte in this study are
paradoxical compared to what has been previou-
sly reported regarding skeletal muscle in respon-
se to training. As far as we can ascertain, we are
unaware of any inconsistencies with cardiomyo-
cyte PGC-1α content adapt to training compared
to myocyte. A more likely explanation of the diffe-
rent responses to training between cardiomyocyte
and myocyte may rest in the differences between
their transcription factor functions and biochemi-
cal properties by nature and were explained in the
following termsExercise-induced PGC-1α expre-
ssion observed in skeletal muscle was reported as
fiber-type dependent, with a more blunt response
in type-I predominant muscles rich in mitochon-
dria than that of type-II muscles (15). In marked
contrast to myocyte, cardiomyocyte contains a lar-
ge number of mitochondria and has adapted to be
highly resistant to fatigue. Therefore, the response
of PGC-1α in cardiomyocyte may be more diffi-
cult to be activated with training. In addition, tran-
scription differences between cardiomyocyte and
myocyte may in part explain the varying responses
to training adaptation. The activated PGC-1α thro-
ugh exercise can move into the nucleus and coac-
tivate the transcription factors and nuclear recep-
tors to regulate expression of mitochondrial pro-
teins, thus mediating the adaptive response (17).
The mononuclear character of cardiomyocyte may
place greater limits on transcriptional efficiency
than on the myocyte. Take PGC-1α transgenic
mice for example, smaller increases in PGC-1α
mRNA expression were found in the heart than in
the gastrocnemius muscle(6). It has been proposed
that if the exercise bout is repeated frequently, the
1446
mRNA levels of metabolic genes will accumulate
and in turn translate into more proteins (32). This
raises the possibility that the ceiling of PGC-1α
content in the cardiomyocyte leaves little room
for increase and that the increased levels might
be seen following chronic stimulation. Regardless
of the PGC-1α discrepancies between cardiomyo-
cyte and myocyte in response to the early stages of
endurance training, the findings of this study may
reflect an improvement in cardiomyocyte meta-
bolism and pump function after longer period of
moderate endurance training.
Limitations regarding the interpretation of this
study should be noted. The data were limited to
only two measure points, 4 and 8 wks. More pro-
lific time course alterations may be observed in the
future. Minor shortcomings remain. However, this
study suggests that the downregulation of VHL in
response to moderate endurance training may be the
first initiator to activate the signaling cascades that
enhance oxygen availability at the molecular level.
Additionally, in the cardiomyocyte, VEGF angio-
genic signaling cascades adaptations to moderate
endurance training faster than that of mitochondri-
al alterations, as detected by PGC-1α. Moderate
endurance training is beneficial for cardiomyocyte
oxygen availability and mitochondrial energy me-
tabolism, as detected at molecular levels.
Acknowledgements
This work was supported by the Shin Kong Wu
Ho-Su Memorial Hospital, ROC (SKH-FJU-9507)
and National Science Council, ROC (NSC93-
2413-H-038-001). We greatly appreciate Ms. Hsin-
Lung Lu for skillful laboratory assistance.
Journal of Society for development in new net environment in B&H

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23. Vesna S, Slobodanka M, Snezana J, Milan K, Go- Corresponding author

ran A, Irena T. Correlation of p53 expression le- Borcherng Su,
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1996. p.1124-50.

1448 Journal of Society for development in new net environment in B&H


Hematological and serological changes
in the pre- and post-treatment breast
cancer patients
Nadeem Sheikh, Maria Masood and Naila Naz
Department of Zoology, University of the Punjab, Lahore, Pakistan
Abstract
Breast cancer is the most common malignancy
among women. There is a growing need for ear-
ly diagnosis and better treatment of this disease.
AIM: Our research is aimed to find some signi-
ficant variations which may exist in the hemato-
logyand serology of the breast cancer patients as
compared to control. Post-treatment patients, re-
ceived up to 4 cycles of chemotherapy were also
for the hematological and serological changes un-
der the influence of chemotherapy.
Materials & methods: Complete blood co-
unt of breast cancer patients was performed using
automated hematology analyzer. Blood samples
were further processed to separate serum. The
serum samples were analyzed for aspartate ami-
notransferase and alanine aminotransferase (AST
and ALT) activity through using Randox kits as
per manufacturer’s instruction. Serum iron levels
were determined in the sera by colorimetric met-
hod Randox iron estimation kit.
Results: Pre-treatment breast cancer patients
showed significant decrease in Hb (P<0.0001),
RBCs (P=0.001), Lym (%) (P=0.0025), PLT
(P=0.047) and MPV (P=0.0001) when analyzed
by one-way ANOVA. Serum iron levels showed
significant increase (P=0.0240) in pre-treatment
BC patients while changes in transaminase acti-
vity were non-significant. Post-treatment BC pati-
ents also indicated low blood counts especially in
case of absolute lymphocyte count (P<0.0001) but
significantly elevated levels of absolute mixed co-
unt (P<0.0001) and MPV (P<0.0234). Serum iron
levels studied in post-treatment patients showed a
significant decrease (P=0.024) whereas the chan-
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
ges in the AST and ALT in post-treatment BC pa-
tients were not statistically significant.
Conclusion: It can be concluded from the
study that breast cancer patients show remarkable
abnormalities in the hematology and serology as
compared to control (healthy subjects).
Key words: Breast Cancer, Chemotherapy, Se-
rology, Iron,
Introduction
Cancer is a term for diseases in which abnor-
mal cells divide without control and can invade
other tissues [1]. Cancer that forms in tissues of
breast, usually the ducts (tubes that carry milk)
and lobules (glands that produce milk) is known
as breast cancer. It occurs in both men and women,
although male breast cancer is rare [2].
Breast cancer (BC) is the most common mali-
gnancy among women throughout the industrialized
world. The incidence rate of breast cancer has incre-
ased steadily over the past 40 years. It is the second
leading cause of cancer-related deaths in women in
United States between the ages of 20 and 59 [3].
The risk of breast cancer is influenced by mul-
tiple factors that are difficult to modify: menarche
before age 12 years, nulliparity or first birth at age >
30 years, late age of menopause, and family history
[4]. The life time risk for women of being diagno-
sed with breast cancer is currently 1 in 7 [5]. Inci-
dence of breast carcinoma in men in the developed
countries is being about 1% of that in women [6].
Iron and iron binding proteins play important
role in various regulatory mechanisms, infections
and tumors. The chronic infections and tumors are
1449
HealthMED - Volume 5 / Number 6 / 2011
the most common reasons of anemia in hospitalized
patients in industrial countries [7]. Excessive body
iron stores interfere with natural body functions.
Iron overload promotes 7, 12-dimethyl benz [a] an-
thracene (DMBA)-induced tumorigenesis [8]. Free
iron has ability to induce oxidative stress and DNA
damage. In 2007 it was proposed that excess iron
also plays role in breast carcinogenesis [9].
It is also known that malignant cells require
more iron. The more aggressive the tumor, higher
will be the transferrin receptor levels. Studies in-
dicate that ferritin, an iron storage protein is in-
creased in breast cancer tissue [10]. There is also
a possibility that relatively high levels of iron and
calcium in benign breast tissue may be associated
with a modest increase in risk of subsequent breast
cancer [11]. ALT and AST are normally synthesi-
zed in the liver cells and act as tissue injury marker
as their concentration is increased in the serum di-
rectly reflects the liver injury [12].
Elevation of hepatic enzymes in the serum in-
dicates the hepatic toxicitydue to the chemothe-
rapy [13]. A recent research denied the hepatic
toxicity of CMF (common type of chemotherapy)
[14]. Limited information is available on the liver
toxicity in relation to the chemotherapy. The levels
of transaminase in BC patients are reported with
different point of view therefore further research
is required in support of the previously published
results [15].
Blood contains a variety of cells in appropri-
ate proportions in normal persons. Any kind of
severe disease or abnormality (especially cancer)
has a direct impact on blood parameters so it is
necessary to study the changes in blood parame-
ters in cancer patients, at regular intervals during
treatment (chemotherapy). A complete blood co-
unt (CBC) is a blood test that gives important in-
formation about the kinds and numbers of cells in
the blood, especially red blood cells, white blood
cells and platelets. CBC helps health professional
check any symptoms, such as weakness, fatigue,
or bruising, patient may have. It also helps in the
diagnosis of certain diseases [12].
The cancer patients with frequently experience
thrombocytopenia [16] and neutrophils could also
fall during successive courses of chemotherapy
[17]. Hormonal or chemotherapeutic treatment in-
creases the risk of thrombosis in BC patients [18].
1450 Journal of Society for development in new net environment in B&H
Chemotherapy (Adriamycin / Epirubicin, 5.
Flouracil and Cyclophosphamide) is commonly
used to treat the BC patients in INMOL Hospital
Lahore. The present study was planned to evaluate
the hematological and serological changes in the
pre- and post treatment breast cancer patients.
Materials and methods
Blood samples from pre-treatment and post-
treatment breast cancer patients were collected
from Institute of Nuclear Medicine and Oncology
(INMOL) Hospital, Lahore while blood samples of
control (healthy persons) were collected from Pu-
njab University New Campus, Lahore. The study
involved the blood profile comparison, transami-
nase levels and serum iron levels of breast cancer
patients before and after reception of successive co-
urses of chemotherapy. A total of 40 confirmed su-
bjects with breast cancer were selected for study. 15
healthy females also donated blood for comparative
analysis against breast cancer patients.
The subjects were sampled for blood with steri-
lized disposable syringes (Becton Dickinson, Pri-
vate Ltd.), 2 ml of blood was transferred to EDTA
containing vacutainers (Becton Dickinson, Private
Ltd.) and blood profile was carried on the auto-
mated hematology analyzer (Model MEK-6318
K, Power Input 190 VA, 220-240V, Nihon Kohen
Corp). 6 ml of blood was transferred to vacuta-
iners (without any clotting factor) and were left
at room temperature for further processing. Abo-
ut one hour after this collection, the blood in the
serum collecting vacutainers was centrifuged at
4000 rpm for 10 minutes. The separated serum
samples were collected in labeled eppendorfs and
were stored at -20°C, till used for transaminase
estimation and serum iron estimation. The analysis
of transaminase and serum iron levels were per-
formed through Randox AST kit (EC 2.6.1.1; AS
1204), Randox ALT kit (EC 2.6.1.2; AL 1205) and
Serum Iron kit (SI 257). One-way ANOVA with
Dunnett’s post test was performed using Graph-
Pad Prism version 5.00 for Windows, GraphPad
Software, San Diego California USA, www.grap-
hpad.com”. All experimental errors are shown as
S.E.M. Significance was accepted at P<0.05.

Results
Serum Iron Levels
A significant increase in the serum iron level
was observed in pre-treatment patients, (Fig. 1aA,
P=0.0240). whereas in post-treatment patients the
changes in the serum iron level were not statisti-
cally significant when compared to control (Fig.
1bB, P=0.0435)
Serum Alanine aminotransferase (ALT)
A non-significant change was observed in se-
rum ALT activity in pre- and post treatment BC
patients when analyzed by one-way ANOVA (Fig.
1c, P=0.3293; Fig. 1d, P=0.1155, respectively)
Serum Aspartate aminotransferase (AST)
Over all non-significant results were obtained
for the AST values of pre- and post-treatment BC
patients when compared to control when analysed
using one-way ANOVA (Fig. 1e, P=0.0864; Fig.
1f, P=0.2988).
Hemoglobin
A statistically significant decrease in the Hb le-
vels was observed in different age groups. (Fig.
2a, P< 0.0001; 2b, P>0.0025).
Hematocrit
A statistically non-significant decline was
observed in the HCT (%) of pre- and post trea-
tment patients in comparison to control when
analyzed by one-way ANOVA (Fig. 2c, P=0.197,
Fig. 2d, P=0.3702)
Mean Corpuscular Hemoglobin
MCH levels were significantly decreased in
pre- and post-treatment BC patients as compared
to healthy persons. (Fig. 2e, P=0.0329; Fig. 2f,
P=0.0001).
Mean Corpuscular Hemoglobin
Concentration
Significant decline in MCHC was observed
in pre-treatment patients as compared to control
(P=0.0019; Fig. 3a) while post-treatment patients
indicated non-significant decrease when compa-
red to control (Fig. 3b, P=0.1656).
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
Red Blood Cells
RBC count was significantly declined in pre-
treatment patients when analyzed by using one-
way ANOVA (Fig. 3c, P=0.001).However. in
post-treatment age groups indicated non-signifi-
cant changes in RBCs (Fig. 3d, P=0.2241).
White Blood Cells
The WBC count in pre-treatment patients was
increased as compared to control however this
increase was not statistically significant (Fig. 3e,
P=0.0991) whereas in the post-treatment patients
a significant decrease in the WBC count was re-
corded, (Fig. 3f, P=0.046).
Lymphocyte Percentage
The lymphocyte percentage was significantly
declined in the pre- and post treatment BCgroups
(Fig. 4a, P=0.0025 and (Fig. 4b, P=0.0346 respec-
tively).
A statistically significant increase was observed
in absolute mixed count of post-treatment BC pa-
tients as compared to control. (Fig. 4c, P=0.0001).
absolute lymphocyte count was significantly dec-
lined in post-treatment BC patients (Fig. 4d, P<
0.0001).
Platelet Count
The platelet count was decreased in different
age groups of pre-treatment breast cancer patients,
which was statistically significant on analysis by
one-way ANOVA (Fig. 5a, P=0.0407). Post-trea-
tment age groups revealed non-significant chan-
ges in the platelet count when analyzed by one-
way ANOVA (Fig. 5b, P=0.1997).
Mean Platelet Volume
MPV of pre-treatment breast cancer patients
was significantly decreased in different age groups
(Fig. 5c, P<0.0001) while in post-treatment breast
cancer patients showed an overall significant in-
crease in MPV when analysed by one-way ANO-
VA (Fig. 5d, P<0.0234).
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HealthMED - Volume 5 / Number 6 / 2011

Figure 1. Significant results were obtained in case of serum iron concentrations and serum AST
activity of pre treatment and post-treatment breast cancer patients (a, b and e, f respectively). ALT
activity was not-significant in pre-treatment BC (c) patients however a significant increase in post-
treatment breast cancer patients were observed (d). Results indicate mean value ± S.E.M. (*p<0.005,
**p<0.001, ***p< 0.0001).

1452 Journal of Society for development in new net environment in B&H

 HealthMED - Volume 5 / Number 6 / 2011

Figure 2. A significant decrease was observed in hemoglobin levels of pre-treatment and post-trea-
tment breast cancer patients (a and b respectively) while hematocrit percentages revealed non-signifi-
cant decrease in both pre-treatment and post-treatment patients (c and d respectively). Mean corpus-
cular hemoglobin concentration showed significant decrease in patients when compared to control
ones (e and f). Results indicate mean value ± S.E.M. (*p<0.005, **p<0.001, ***p< 0.0001).

Journal of Society for development in new net environment in B&H 1453

HealthMED - Volume 5 / Number 6 / 2011

Figure 3. A significant decrease was observed in mean corpuscular hemoglobin concentration and
RBC count of pre-treatment breast cancer patients (a and c respectively) while non significant decre-
ase was observed in these parameters in case of post-treatment breast cancer patients (b and d res-
pectively). White blood cells’ count of post-treatment patients showed significant decline (f) while non-
significant decrease was observed in pre-treatment breast cancer patients (e). Results indicate mean
value ± S.E.M. (*p<0.005, **p<0.001, ***p< 0.0001).

1454 Journal of Society for development in new net environment in B&H

 HealthMED - Volume 5 / Number 6 / 2011

Figure 4. Percentage lymphocyte count showed a significant decrease in pre-treatment and post-tre-
atment breast cancer patients when compared to control (a and b respectively). Statistical analysis
of mixed count percentage of post-treatment breast cancer patients determined a highly significant
increase (c). Absolute lymphocyte count was significantly decreased in post-treatment breast cancer
patients (d). Results indicate mean value ± S.E.M. (*p<0.005, **p<0.001, ***p< 0.0001)

Figure 5. A statistically significant decrease was observed in platelet count and mean platelet volume
of pre-treatment breast cancer patients (a and c respectively) while a significant increase was obser-
ved in these parameters in case of post-treatment breast cancer patients (b and d respectively). Results
indicate mean value ± S.E.M. (*p<0.005, **p<0.001, ***p< 0.0001)

Journal of Society for development in new net environment in B&H 1455

HealthMED - Volume 5 / Number 6 / 2011
Discussion
The current work was designed to evaluate the
changes in the CBC, serum iron concentrations
and serum transaminase activity of the pre- and
post treatment BC patients in comparison to non-
cancer/healthy subjects.
Serum iron levels of BC patients were increased
in comparison with the healthy subjects with more
pronounced increase in the pre-treatment patients.
Previous studies also prove that abnormal serum
iron levels play role in the induction of breast can-
cer. Level of serum ferritin was significantly ele-
vated in patients with breast cancer [19]. It is also
known that iron deficiency has unpleasant effects
on organ growth and can become responsible to
breast carcinogenesis [20]. Immunohistochemical
findings reveal that serum iron concentrations are
raised in breast carcinoma patients [21].
Transaminases (AST & ALT) activity showed
a significant increase in post- treatment BC pati-
ents which indicates toxicity due to chemotherapy
on the liver functions. Previous studies has shown
that the serum levels of ALT and AST, signifi-
cantly increase (P<0.05) as a result of treatment
[22]. The Chemotherapy is able to cause a greater
degree of hepatocellular damage [23].
CBC of breast cancer patients indicated a signi-
ficant decrease in the hemoglobin levels of pre-tre-
atment patients, especially in aged women (56-65
yrs). This decrease in hemoglobin was less prono-
unced in the patients after successive courses of
chemotherapy. The risk of anemia increases as the
pre-treatment hemoglobin concentration decreases
and is reduced with successive chemotherapy cycles
[24]. There is no evidence for an influence of pre-
treatment hemoglobin levels on the clinical response
to neoadjuvant chemotherapy in breast cancer [25].
WBC count indicated an increase in pre-tre-
atment patients but this increase didn’t reach
the significance level. A decrease in WBCs was
observed in patients who had received successive
courses of chemotherapy. This decrease was si-
gnificant only in elder age groups. Platelet counts
were significantly low in pre-treatment patients
when compared to control. An overall significant
increase in the platelet count was observed after
successive courses. This increase must be due to
the blood transfusions, which are recommended
1456 Journal of Society for development in new net environment in B&H
by doctors at low platelets counts. The mean pla-
telet volume was significantly decreased in the
experimental groups before treatment.
Low blood counts are observed as a side effect of
chemotherapies [25]. During adjuvant chemothera-
py process, neutrophils could fall relatively. White
blood cells, platelet, and hemoglobin when measu-
red before and during chemotherapy after 8, 15 and
22 days indicated significant differences in white
blood cells (F=115.76, P<0.001), platelets (F=25.29,
P<0.001) and hemoglobin (F=15.39, P<0.001) [17].
Many studies have asserted that thrombocytosis is
observed in various malignancies [18].
Absolute lymphocyte count showed a highly
significant decline after chemotherapy, which can
be considered among the adverse effects of che-
motherapy in breast cancer patients. Lymphocyte
(%) also indicated a significant decline in pre-trea-
tment subjects but it is less pronounced as compa-
red to the post-treatment subjects.
Often during a course of chemotherapy, blood
counts may fall below normal levels. The white
cells in the blood are most commonly affected.
A significant increase was observed in absolute
mixed count and mean platelet volume of post-
treatment BC patients while pre-treatment BC pa-
tients showed significant decrease in mean platelet
volume (MPV).
Taken together these results, we can conclude
that the hematological and serological parameters
can be used as predictive markers for the BC pa-
tients and chemotherapeutic drugs affects the he-
matological as well as serological parameters of
the patients that needs to be carefully monitored
during the course of treatment.
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Corresponding author
Nadeem Sheikh,
Department of Zoology,
University of the Punjab,
Quaid-e-Azam Campus,
Pakistan,
E-mail: s_nadeem77@yahoo.com
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HealthMED - Volume 5 / Number 6 / 2011
Serum Leptin changes following a
selected aerobic training program in
un-trained Females
Masoumeh Azizi
Department of Sport Science, Islamic Azad University, Abadan Branch, Abadan, Iran
Abstract
Objective No doubt, obesity can cause for some
metabolic syndromes, type 2 diabetes, hypertensi-
on, other cardiovascular disease and osteoarthritis.
Leptin is single-chain proteohormone with a mo-
lecular mass of 16 kDa that is thought to play a
key role in the regulation of body weight and obe-
sity, meanwhile adipose tissue is the major source
of leptin expression. Hence, Given the undeniable
role of sport in general health, the aim of this study
was to assay the effect of regular exercise on se-
rum level of Leptin in un-trained female.
Materials and Methods: 24 un-trained fema-
le subjects(age 29.8 ± 4.1 yr, height 161 ± 7 cm,
body weight 65.6 ± 5.2 kg) randomly divided
in two groups(Control group ,n=12 and Experi-
mental group ,n=12). Blood samples were taken
48 h before starting the aerobic training program.
Then, experimental group performed the aerobic
training program included running with 65-85%
of individual maximum heart rate on treadmill for
3 session per week, 30 minute per session and 8
consecutive weeks. Then another blood sample
was taken following the training period. Serum
level of leptin of all subjects before and after the
training period were measured using standard bi-
ochemical methods from all the subjects in both
groups again. Differences between post test and
pre test were evaluated using a Student′s t-test for
paired samples. A P-value < 0.05 was considered
to be statistically significant.
Results: Our results showed that the aerobic
training resulted in a significant decrease in lep-
tin serum in experimental group but no significant
difference was seen in leptin serum in control gro-
up (experimental group: pre-test=28.42±12.78 vs
1458
post-test=17.10±10.54 & Control group: pre-test=
24.72±15.63 vs post-test=25.01±14.14 ).
Conclusion: The result showed that regular
and light aerobic exercise could decrease leptin le-
vels in un-trained female(p=0.008). So, decreases
in serum leptin may be one mechanism by which
weight loss improves physical function .
Key words: Exercise training, Leptin, un-
trained female.
1. Introduction
Obesity can be titled as the "New World Syn-
drome" that affecting not only the developed but
also developing countries (Ren 2004). It associa-
ted with health problems has been rose in all age
groups in the world. According to the recent stu-
dies, It is estimated that obesity currently affects
25% of children in the United States (Nammi et
al 2004). It is also responsible for some metabolic
syndromes , type 2 diabetes , hypertension, other
cardiovascular disease and osteoarthritis (Nam-
mi et al 2004, Tamer et al 2002]. The pathogene-
sis of obesity is multi-factorial such as genetics,
high fat diet, lack of exercise and stress that cause
obesity and overweight(.Blaak 2000) Numerous
advance studies in understanding the frequency
of genes that are involved in regulation of body
weight have been done, but since 1994 following
the discovery of the ob gene that product leptin,
these studies have progressed dramatically(Zhang
et al 1994). Leptin is single-chain proto hormone
with a molecular mass of 16 kDa that is thought
to play a key role in the regulation of body weight
(Friedman and Halaas 1998). Leptin acts on the
central nervous system, in particular the hypotha-
Journal of Society for development in new net environment in B&H

lamic nuclei(Webber 2003). Neurons in the arcu-
ate, ventromedial, and dorsomedial hypothalamic
nuclei that are regulation of energy balance (Ahi-
ma 2000). Adipose tissue is the major source of
leptin expression, however, other sites have been
identified, including skeletal muscle, liver, stoma-
ch, heart, mammary epithelium, the placenta, and
the brain (Bouassida et al 2006).
The findings suggest after leptin secretion by
adipose tissue, the leptin receptors (with long and
short isoforms) are expressed in a variety of ti-
ssues including the hypothalamic nuclei (Baratta
2002). Neurons in the arcuate, ventromedial and
dorsomedial hypothalamic nuclei that are sensiti-
ve to leptin, express neuropeptidis/ neurotransmi-
tters that are associated with central regulation of
appetite, food intake, energy expenditure, and as
a consequence body fat and body weight(Ahima
2000 & Hassink et al 1996]. Based on this claim
that leptin's actions is on energy balance (Ishii et al
2001), and whereof exercise is a effective way to
reduce obesity(fat mass), it is reasonable to specu-
late that leptin hormone plays a role in predicting
weight change in a population, although results
from previous studies in this area are conflicting.
For example, in young non diabetic, Pima Indians,
those that gained weight over a 3-year period, had
lower plasma leptin levels at baseline than those
who maintained their weight (Robert et al 2002).
This indicates a relative deficiency of a satiety si-
gnal from adipose tissue. In contrast, other studi-
es in obese children and young men and women
show that low plasma leptin levels are predictive
of weight loss, suggesting a greater sensitivity to
circulating serum leptin (Kohrt et al 1996 , Tor-
gerson et al 1999, Verdich et al 2001). Elias et al
stated a decline in leptin concentrations in males
(age,18-55) after a graded treadmill exercise test
plasma leptin is detectable after 10 months of trai-
ning to exhaustion (Ravussin et al 1997).
Merino et al reported that after 3 weeks of a mi-
litary training, leptin concentrations were decrea-
sed. The fat mass in this study was not measured,
but the body weight remained stable.
Bouassida et al indicate that plasma leptin con-
centration is not sensitive to acute short or prolon-
ged exercise (under 800-kcal of energy expenditu-
re) in elite volleyball players. In addition, plasma
leptin concentration was lower in volleyball/anae-
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
robically trained athletes with respect to untrained
subjects. It appears that leptin is more sensitive to
energy expenditure than hormonal or metabolic
modifications induced by acute exercise (hypo in-
sulinemia, hyper secretion of growth hormone and
hyper lactatemia) in anaerobically trained athletes
as in aerobically trained athletes as shown by past
studies (Bouassida(b) et al 2009]. Unal et al (2005)
measured leptin concentrations in trained young
male athletes and in healthy sedentary subjects.
They stated a significant lower leptin after exercise
and concluded that regular exercise, by reducing fat
percentage, suppresses serum leptin levels.
Frank et al (2005) reported that regular, mode-
rate exercise decreases fasting insulin and leptin
concentrations in overweight / obese postmeno-
pausal women and that the adoption of regular/
moderate intensity exercise may be particularly
useful among post menopausal women who gain
mass over time.
Some researchers have reported that acute aero-
bic exercise does not generate decreases on leptin
concentration (Rahmani Nia et al 2009). Houmard
et al (2000) reported short-term aerobic training
(60 minutes at 75% of VO2max during 7 successi-
ve days) does not modify leptin concentrations in
healthy young and older males. Although the trai-
ning improved insulin sensitivity, leptin concentra-
tion was not affected. In other study, Kraemer et al
(2002) measured resting and post maximal exercise
leptin concentration of adolescent female runners,
over the course of a short track season. Resting lep-
tin levels were not changed over the 7 weeks, nor
were the acute responses to intense exercise despite
a significant reduction in skin folds( Houmard et
al 2000). Zoladz et al (2005) measured the varia-
tion of leptin in 8 men following two incremental
exercises. The maximal incremental exercise was
performed in the fed state however the sub-maxi-
mal incremental exercise test up to 150 W was per-
formed in a fasted state; the authors noted no si-
gnificant differences in leptin concentrations. So, it
could be said generally short-term exercise that ge-
nerated energy expenditure lower than 800 Kcal do
not modify the concentration of leptin (Kraemer(a)
et al 2001). Therefore, the specific aim of the pre-
sent study was to investigate whether 8-weeks aero-
bic exercise training would modulate serum leptin
in un-trained females.
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HealthMED - Volume 5 / Number 6 / 2011
2. Materials and Methods
2.1. Subjects
Twenty four healthy-untrained females (age
29.8 ± 4.1 yr, height 161 ± 7 cm, body weight
65.6 ± 5.2 kg) volunteered to participate in this in-
vestigation. Before initiation of the study, subjects
were asked to sign a written, informed consent.
All subjects completed a medical questionnaire to
ensure that they were not taking any medication,
were free of cardiac, respiratory, renal, or metabo-
lic diseases, and were not using steroids.
2.2. Methods
All subjects randomly divided into2 equal gro-
ups: Group 1: Control group (n=12), Group 2: Expe-
rimental group (n=12). 48 h before starting the ae-
robic training program Weight, Height, Blood sam-
ples and BMI were taken from all the subjects using
proper devices/methods: weight by scale, height by
measuring-tape, body mass index(BMI) by the ratio
of weight square root of height. Then, experimental
group performed the aerobic training program inclu-
ded running with 65-85% of individual maximum
heart rate on treadmill for 3 session per week, 30
minute per session for 8 consecutive weeks. Then
another Weight, Blood sample and BMI was taken
in the of the training period. Serum level of leptin of
all subjects before and after the training period were
measured using standard biochemical methods from
all the subjects in both groups again.
2.3. Statistical analysis
All values are reported as Means ±SE. Diffe-
rences between exercise-induced changes in pla-
sma leptin concentrations and BMI before and
after exercise protocol were evaluated using a
Student′s t-test for paired samples. A P-value <
0.05 was considered to be statistically significant.
3. Results
Mean and standard deviation of variables in-
cluding weight, BMI and leptin level for each su-
1460 Journal of Society for development in new net environment in B&H
bject of control group (Post-test and Pre-test) are
shown in table.1.and for each subject of experi-
mental group (Post-test and Pre-test) in table.2.
Table 1. Control group measures for body weight,
BMI, and leptin
Post-Test Pre-Test
Control Group
Mean Mean
67.01±5.42 66.66±5.99 Weight (Kg)
25.81±2.95 25.72±3.96 BMI (Kg.m2)
27.01±14.14 24.72±15.63 Leptin Hormone (Ng.ml)
Table 2. Experimental group measures for body
weight, BMI, and leptin
Post-Test Pre-Test Experimental
Mean Mean Group
57.50±5.42 62.78±8.92 Weight (Kg)
22.41±1.95 24.72±3.96 BMI (Kg.m2)
17.10±10.54 28.42±12.78 Leptin Hormone (Ng.ml)
The changes in the control group were not si-
gnificant (p>0.05).Table 2 demonstrates the mean
changes in leptin level of plasma (before and af-
ter 8 weeks aerobic training). All participants who
carried out the aerobic training lost some weight.
In this group, a significant relationship was obser-
ved between the decrease in weight and body mass
index (BMI) [p=0.001 and p=0.004, respectively].
And mean Leptin (p=0.001) levels decreased. So,
this research showed that there was a significant re-
lationship between the decrease in leptin , weight
and body mass index following aerobic training.
4. Discussion
Research evidence shows that the low mobili-
ty is a most important factor to be a person obese
and overweight, and implementing a training pro-
gram can be significant changes in weight and body
composition created. More ever, many studies have
shown, Leptin is an adipocyte -secreted hormone
that seems to play an important role in the body we-
ight regulation in humans (Bouassida(b) et al 2009).
Based on these finding we decided to do this project.
The result of present study demonstrate that mo-
derate-intensity exercise for 8 weeks and three se-
ssion per week, significant decrease in body weight,
BMI and serum leptin level. However, further studies
are necessary to clarify this relationship p. Our data

consistent with those reported exercise training re-
sulted in decreased leptin concentration (Nammi et al
2004 & Weltman et al 2000). However, these decre-
ases were related mainly to negative energy balance
and/or to loss of adipose tissue, and suggested that
exercise training dose not have an independent effect
on circulating leptin. Kohrt et al (1996) for example,
who found that long-term exercise training can de-
crease plasma leptin concentrations in older women
by reducing fat mass. Also, Ishii et al (2001) proved
that serum leptin level decreased after 6 weeks of ae-
robic training exercise in type 2 diabetics patients, but
there was not any relationship between the decrease
in leptin concentration and changes in adipose tissue.
Reseland et al (2001) concluded that long-term diet
and exercise may have direct effects on plasma lep-
tin concentration beyond the effect expected due to
changes in fat mass. The results of this study contrast
to the results of Weltman et al 2000, who recently
reported that 30 min of exercise at various intensities
and caloric expenditure (from 150 ± 11 to 529 ± 45
kcals) in 7 healthy young men did not cause modifi-
cations in leptin levels during the exercise and during
the recovery (3.5 hours).
Zoladz et al (2005) and Kraemer et al(2002) also
reported no significant changes in leptin concentra-
tions following short-term exercises. There are se-
veral factors that can explain this modification of
the response of leptin to muscular exercise. That is
probably related to the intensity and the duration
of the exercise, the nutritional status of the subject,
the circadian rhythm of leptin, the hour of blood
sampling and the caloric imbalance imposed by
the exercise. But, what is known, is that leptin act
through changes in ob gene expression in adipose
tissue. Changes in leptin correlated with the chan-
ges in body weight. Some researchers believe that
aerobic exercise is the best way to reduce body fat
and ultimately in the regulation of leptin level. They
are trying to be able to leptin treatment by way ea-
sier to find for the treatment of obesity.
5. Conclusion
In summery, the result of present study showed
that regular and light aerobic exercise could decrea-
se leptin levels in un-trained females. So, decreases
in serum leptin may be one mechanism by which
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
weight loss improves physical function. And fi-
nally, it seems that more investigations is need to
better define the relation of adiposity in both gender
to leptin responses and adaptations to exercise.
Acknowledgement
This study was supported by a grant from Isla-
mic Azad University Abadan Branch(Iran) and
this paper is taken from the project titled" The
Effect of 8-Weeks Aerobic Exercise on Serum
Leptin and some Risk Factors of Coronary Heart
Disease in Un-trained Females". We would like to
thank a very dedicated group of subjects and their
coach who made this project possible.
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Corresponding author
Masoumeh Azizi,
Department of Sport Science,
Islamic Azad University,
Abadan Branch, Abadan,
Iran,
E-mail: science.sport@yahoo.com
Journal of Society for development in new net environment in B&H

Effect of serum urea and creatinine
levels in aneurysmal subarachnoid
hemorrhage
Sayantani Ghosh1, Saugat Dey1, Mitchell Maltenfort2, Jack Jallo2
1
Medical College, India,
2
Thomas Jefferson University, United States of America.
Abstract
Background: Acute kidney injury is a major
problem in all critically ill patients and has a poor
effect on the outcome. We have determined the
burden of acute kidney injury in aneurysmal suba-
rachnoid hemorrhage (aSAH) patients.
Aims and Objectives: We have studied the le-
vels of serum urea and creatinine in aSAH patients
and have investigated its effect on the outcome of
such patients.
Methodology: A retrospective review of the
levels of serum urea and creatinine in 1000 ca-
ses of aneurysmal subarachnoid hemorrhage was
done from the records of Thomas Jefferson Uni-
versity Hospital, after obtaining the requisite per-
mission from the Institution Review Board. The
level of serum urea, creatinine and their ratio was
documented. Parameters were initially analyzed
by student’s t test, p <0.05 is taken as significant
and were further scrutinized by multivariate regre-
ssion analysis.
Results: Increased values of serum urea (BUN),
creatinine as well as their ratio are associated with
poor outcome (p <0.05), although BUN: creatini-
ne ratio < 9 was also related to bad outcome. Whi-
le comparing the variables, BUN: creatinine ratio
seems to have the greatest and creatinine the least,
impact on patient prognosis. BUN: creatinine ratio
> 22.2: 1 (95% confidence interval, 21.2: 1- 23.5:
1) accounted for more chances of a poor outcome.
Weaknesses of the study: BUN and creatini-
ne levels do not rise above the normal range until
60% of total kidney function is lost and hence by
considering them alone we miss out on patients
with less severe renal damage.
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
Long term follow up of the patients were not
analyzed.
Conclusions: Electrolytic imbalances affec-
ting the short term prognosis of aSAH patients are
mainly following the cardiovascular or neurologic
damage and are least likely as a result of direct
kidney injury.
Key words: Aneurysmal subarachnoid he-
morrhage, kidney injury, BUN, creatinine, exten-
ded Glasgow outcome score.
Introduction
Intracranial aneurysms (IA) affect 2 to 5% of
the entire population¹, with ruptured IAs comprise
of 1% of all IAs². Ruptured aneurysms classically
cause subarachnoid hemorrhage (SAH), but may
cause intraventricular hemorrhage and subdu-
ral blood³. About 65% of patients die of the first
attack of SAH and a further 20 to 25% experience
complications4. The complications that occur are
mostly neurological viz. vasospasm or rebleeding5
but they might be non neurological too such as pul-
monary edema6, cardiac arrhythmias7, electrolyte
disturbances8 and hematologic abnormalities9, 10.
With improvements in neurological management
of aneurysmal subarachnoid hemorrhage (aSAH),
the non neurological complications are playing a
more prominent role in outcome after aSAH¹¹, ¹².
Renal dysfunction occurs in 0.8% to 7% of
patients with subarachnoid hemorrhage¹¹; even
small kidney damage can adversely affect the out-
come¹³. Although cardiopulmonary complications
after aSAH have been explored at length, little has
been done to evaluate the effect of renal dysfuncti-
1463
HealthMED - Volume 5 / Number 6 / 2011
on in this population. Hence we have studied the
effect of serum urea (BUN), creatinine and their
ratio in the prognosis of aneurysmal subarachnoid
hemorrhage patients.
Materials and Methods
Retrospective review of aSAH patients ad-
mitted in Thomas Jefferson University Hospital,
Philadelphia, USA from March 2006 to January
2010. The diagnosis of subarachnoid hemorrhage
was established on the basis of conventional CT
or CT/MR angiography. All patients having a pri-
or kidney disease or patients admitted > 72 hours
after the onset of SAH were excluded from the
study. 1000 patients met the criteria; their age, sex,
levels of serum BUN, creatinine as well as their
prognosis on 15 day follow up based on extended
Glasgow outcome score (GOS-E) were documen-
ted. All biochemical tests were done in Thomas
Jefferson Hospital general laboratory. GOS-E sco-
re ≥ 5 was taken as good prognosis. GOS-E scores
were further dichotomized at 1 and 2-8 for dea-
th and survival respectively. Table 1 shows how
the GOS-E score was divided. Approval for the
collection and review of data was obtained from
the Institutional Review Board (Control Number
10D.79) at the Thomas Jefferson University.
Statistical Analysis
All data were analyzed using JMP 7.0.2, SAS
Institute, Cary, NC. Data “outliers” were identified
for each parameter from box-and-whisker plots.
Table 1. The Extended Glasgow Outcome Scale (GOS-E) and the way it was dichotomized
GOS-E Score Categories
1 Dead
2 Vegetative State
3 Lower Severe Disability
4 Upper Severe Disability
5 Lower Moderate Disability
6 Upper Moderate Disability
7 Lower Good Recovery
8 Upper Good Recovery
1464
Then, a two-tailed independent Student’s t test
was performed for each parameter (both including
and excluding the outliers) to assess the statistical
significance of the observed difference between
the mean values for good and bad outcome. P va-
lues and 95% confidence intervals from the t test
were calculated and reported, p value <0.05 is ta-
ken as significant. Kruskal-Wallis nonparametric
tests were used when appropriate. Multivariate
analysis was also done to compare the effects of
BUN, creatinine and BUN: creatinine (b: c) ratio
on outcome.
Results
Among the 1000 aSAH patients covered, 629
(62.9%) were females. The mean age of the pati-
ents at admission was 53.6± 11 years, females be-
ing about 4 years younger than males. Table 2de-
picts baseline characteristics of the patients that
were included in this analysis. At 15 days follow
up, 329 patients (32.9%) had a poor short term
outcome, i.e. GOS-E ≤ 4.
Kruskal-Wallis (non-parametric) comparisons
across outcomes came significant for BUN, creati-
nine and b: c ratio (p < 0.0001). While higher level
of BUN, creatinine and b: c ratio all were associ-
ated with poor outcome, b: c ratio showed worse
results with high as well as very low values. The
mean level of serum BUN at admission was 13.39
mg/dl (95% Confidence interval, 13.12-13.66
mg/dl). Increasing level of BUN was associated
with poor outcome; the mean level of BUN for a
poor outcome was 2.27 mg/dl higher than that for
a good outcome. However higher BUN was also
Division of Good and Division of Death and
Bad Prognosis Survival
DEATH
BAD
PROGNOSIS
GOOD SURVIVAL
PROGNOSIS
Journal of Society for development in new net environment in B&H

Table 2. Baseline Characteristics of the 1000 Study Patients
Characteristic
Overall age
Age of Males
Age of Females
Overall serum BUN level at admission
Serum BUN level at admission for those having a poor outcome
Serum BUN level at admission for those having a good outcome
Overall serum Creatinine level at admission
Serum creatinine level at admission for those having a poor outcome
Serum creatinine level at admission for those having a good outcome
Overall serum BUN : Creatinine (b:c) level at admission
Serum b:c level at admission for those having a poor outcome
Serum b:c level at admission for those having a good outcome
associated with less mortality, as serum BUN was
2.72 mg/dl higher for survival than for death.
In a multivariate regression model, serum cre-
atinine was not found to have a significant effect
on the outcome. Mean level of serum creatinine
was 0.77mg/dl (95% Confidence interval, 0.76-
0.78 mg/dl). The mean level of BUN: creatinine
(b:c) ratio was 17.48: 1 (95% Confidence interval,
17.18:1- 17.78: 1) and a higher ratio was associ-
ated with a poor outcome. Mean b: c ratio for a
poor outcome was 3.45 units higher than that for a
good outcome and the ratio was 2.85 units higher
for death than that for survival. Odds ratio for a
poor outcome with per unit increase of the b: c
ratio on admission in a multivariate regression is
1.39 (95% confidence interval, 1.22- 1.68). B: c
ratio < 10: 1 although was present in only a few
patients, was also linked with poor prognosis. In-
verse prediction was used to find out 50% chance
of good outcome at the maximum b: c ratio and it
was found to be 22.2: 1 (95% confidence interval,
21.2: 1- 23.5: 1).
Discussion
Recent studies in aSAH patients and other bra-
in trauma patients have demonstrated that nearly
80% of these patients develop dysfunction of at
least one non neurological organ system14, 15. Non
neurological organ dysfunctions may also contri-
bute to the severity of neurological impairment.
We have studied the effect of acute kidney injury
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
Mean value
53.7±11 years
56.2±11.5 years
52.3±10.5 years
13.39 (13.12- 13.66)
14.91
12.64
0.77 (0.76-0.78)
0.76
0.77
17.48 (17.18-17.48)
19.85
16.31
in SAH patients by analyzing the effect of serum
BUN and creatinine levels in their outcome.
Among the 1000 patients in our study, 329
(32.9%) had a poor short term outcome, i.e. GOS-
E ≤ 4, at 15 days following the SAH. Increased
admission values of serum BUN, creatinine and
b: c ratio was associated with poor prognosis, with
b: c ratio having the greatest impact and creatini-
ne the least; although higher values of BUN were
also associated with lower chances of mortality.
Very low BUN: creatinine ratio although was also
related to bad outcome. B: c ratio > 22.2: 1 (95%
confidence interval, 21.2: 1- 23.5: 1) indicated for
more chances of a poor outcome. Figure 1 shows
the mean serum BUN and b: c ratio values for
good and bad outcome.
Figure 1. Mean BUN and BUN: Creatinine ratio
values for good v/s. bad outcome
We know that kidney damage causes rise of se-
rum creatinine level; and BUN level gets higher by
1465
HealthMED - Volume 5 / Number 6 / 2011
kidney and heart failure as well as any major blee-
ding. Lower b: c ratio is mainly due to the renal
damage causing reduced reabsorption of BUN. B:
c ratio rises when reduced blood flow causes ele-
vated creatinine and BUN due to decreased glo-
merular filtration rate (GFR), BUN reabsorption
is increased because of the lower flow; BUN gets
disproportionately elevated relative to creatinine.
Higher b: c ratio in aSAH patients have also been
linked to cerebral salt wasting syndrome [Table
3]16, which is a hypovolemic and hyponatremic
condition linked with increased diuresis and natri-
uresis. Its pathogenesis is poorly understood and is
linked with increased circulating brain natriuretic
peptide (BNP)17-20. Recent work implicates BNP
in SAH complications like vasospasm20 and cardi-
ac dysfunction²¹ as well. Hence all of these factors
may be associated with the rise of b: c ratio.
Table 3. Proposed criteria for cerebral salt wa-
sting syndrome
1. Hyponatremia < 135 mmol/L
2. Serum osmolality < 280 mosM/kg
3. Urine Na > 40 mmol/L
4. At least two of the following:
a. Fluid balance ≥ negative 500 mL/24 h
b. Weight loss ≥500 g/24 h
c. Serum BUN-to-creatinine ratio > 20
d. Increase in hematocrit > 3% over 24 h without
blood transfusion
e. Pulmonary artery wedge pressure < 18 mm Hg
f. Central venous pressure < 12 mm Hg
Previously there has been a study of kidney
injury in aSAH patients by emphasizing on RI-
FLE criteria²², but we have taken serum BUN and
creatinine levels as a predictor of kidney injury as
they are routinely done at admission for all aSAH
patients. Another strong point of our study is that
we have excluded patients having a prior kidney
disease and thereby studied the impact in the kid-
ney after the hemorrhagic process. The weakness
of our study is that it is a retrospective study and
also the fact that BUN and creatinine does not rise
above the normal range until 60% of total kidney
function is lost and hence by considering them
alone we miss out on patients with less severe re-
nal damage. Studies involving GFR or urine mi-
croalbumin level can provide information of even
minimal kidney damage.
1466
We found that the derangement of BUN: cre-
atinine ratio which counted for poor short term
prognosis in aSAH patients of our study was more
due to the heart failure or the severity of the blee-
ding or due to the occurrence of cerebral salt wa-
sting syndrome and less due to kidney damage.
Hence we can conclude that the electrolytic im-
balances in aSAH patients are mainly following
the cardiovascular or neurologic damage due to
the SAH and are least likely as a result of direct
kidney injury.
References
1. Rinkel GJ, Djibuti M, Algra A, van Gijn J. Preva-
lence and risk of rupture of intracranial aneurysms:
A systematic review. Stroke. 1998; 29: 251–256.
2. Ujiie H, Sato K, Onda H, Oikawa A, Kagawa M,
Takakura K, Kobayashi N. Clinical analysis of inci-
dentally discovered unruptured aneurysms. Stroke.
1993; 24: 1850–1856.
3. Greenberg MS. Handbook of Neurosurgery. Thie-
me New York. 2006; 6: 781-826.
4. Weir B, Disney L, Karrison T. Sizes of ruptured
and unruptured aneurysms in relation to their si-
tes and the ages of patients. J Neurosurg. 2002;
96: 64–70.
5. Haley EC Jr, Kassell NF, Torner JC. The internati-
onal cooperative study on the timing of aneurysm
surgery. The North American experience. Stroke.
1992; 23: 205–214.
6. Schell AR, Shenoy MM, Friedman SA, Patel AR.
Pulmonary edema associated with subarachnoid
hemorrhage. Evidence for a cardiogenic origin.
Arch Intern Med. 1987;147: 591–592.
7. Marion DW, Segal R, Thompson ME. Subarachno-
id hemorrhage and the heart. Neurosurgery. 1986;
18:101–106.
8. Wijdicks EF, Kallmes DF, Manno EM, Fulgham JR,
Piepgras DG. Subarachnoid hemorrhage: neuroin-
tensive care and aneurysm repair. Mayo Clin Proc.
2005; 80:550 –559.
9. Parkinson D, Stephensen S. Leukocytosis and suba-
rachnoid hemorrhage. Surg Neurol. 1984; 21:132–
134.
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10. Spallone A, Mariani G, Rosa G, Corrao D. Disse- 22. Zacharia B E, Ducruet A F, Hickman Z L et al.
minated intravascular coagulation as a complica- Renal dysfunction as an independent predictor of
tion of ruptured intracranial aneurysms. Report of outcome after aneurysmal subarachnoid hemorr-
two cases. J Neurosurg. 1983; 59:142–145. hage: a single-center cohort study. Stroke 2009;
40; 2375-81.
11. Solenski NJ, Haley EC Jr, Kassell NF et al. Me-
dical complications of aneurysmal subarachnoid
hemorrhage: a report of the multicenter, coopera-
Corresponding author
tive aneurysm study. Participants of the multicen-
Sayantani Ghosh,
ter cooperative aneurysm study. Crit Care Med.
B S Medical College,
1995; 23:1007–1017.
India,
12. Holmes JM. The medical management of subara- E-mail: ghoshsayantani@rediffmail.com
chnoid haemorrhage. BMJ. 1958; 1:788 –790.
13. Kellum JA, Bellomo R, Ronco C. Definition and
classification of acute kidney injury. Nephron Clin
Pract. 2008; 109:182–187.
14. Gruber A, Reinprecht A, Illievich UM et al. Extra-
cerebral organ dysfunction and neurologic outco-
me after aneurysmal subarachnoid hemorrhage.
Crit Care Med. 1999; 27: 505–514.
15. Zygun DA, Doig CJ, Gupta AK et al. Non-neuro-
logical organ dysfunction in neurocritical care. J
Crit Care. 2003; 18: 238 –244.
16. Palmer BF. Hyponatremia in patients with cen-
tral nervous system disease: SIADH versus CSW.
Trends Endocrinol Metab. 2003; 14(4):182–7.
17. Berendes E,Walter M, Cullen P et al. Secretion of
brain natriuretic peptide in patients with aneury-
smal subarachnoid haemorrhage. Lancet. 1997;
349(9047):245–9.
18. McGirt MJ, Blessing R, Nimjee SM et al. Corre-
lation of serum brain natriuretic peptide with hy-
ponatremia and delayed ischemic neurological
deficits after subarachnoid hemorrhage. Neuro-
surgery 2004; 54(6):1369–73.
19. Tomida M, Muraki M, Uemura K, Yamasaki K.
Plasma concentrations of brain natriuretic pep-
tide in patients with subarachnoid hemorrhage.
Stroke 1998; 29(8):1584–7.
20. Sviri GE, Feinsod M, Soustiel JF. Brain natriure-
tic peptide and cerebral vasospasm in subarach-
noid hemorrhage. Clinical and TCD correlations.
Stroke. 2000; 31(1):118–22.
21. Tung PP, Olmsted E, Kopelnik A et al. Plasma B-
type natriuretic peptide levels are associated with
early cardiac dysfunction after subarachnoid he-
morrhage. Stroke 2005; 36(7):1567–9.

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HealthMED - Volume 5 / Number 6 / 2011
Stress coping among nurses in Latvia
Liana Deklava, Inga Millere, Kristaps Circenis
Riga Stradins University, Latvia.
Abstract
Introduction/Backgrond: Coping strategies
play a significant role in the nurse`s adaption to
stressful work and life events. The rapid time of
reforms, its dynamic pace and deficiency, and do-
minating social and economic problems entrust a
nurse with great psychological, emotional and also
physical load in her routine, which cause stress.
Aim&Objectives: The aim of this paper is to
study coping strategies of nurses in Latvia.
Methods: The questionare used in this study
based on demographic and work-related data and
a stress coping scale (Lazarus and Folkmans Ways
of Coping Checklist/Revised). Respondents were
200 nurses from four general hospitals in different
regions of Latvia. All participants were nurses
working in different departaments at the hospitals.
Results: Most frequently used methods are Po-
sitive reappraisal 51.6%, Planful problem-solving
51% and Self-controlling 47.6%. Nearly each
third respondent 32.9% uses Escape-Avoidance
method. The data shows that the emotion focused
coping are using 69% nurses, but the problem fo-
cused coping 29.5%, the differences are statisti-
cally significant. Statistical insignificant correlati-
on was found between the ways of coping and age,
work experience.
Discussion/Conclusion: Nurses in Latvia use
the emotion focused coping overcome types, the
most common is the use of Positive reappraisal,
Self-controlling and Accepting responsibility.
Key words: stress coping strategy, problem-
focused coping, emotion-focused coping.
Background
Medicine is one of those branches where the
issue of human resources is essential and impor-
tant. The rapid time of reforms, its dynamic pace
and deficiency, and dominating social and econo-
1468
mic problems entrust a nurse with great psycho-
logical, emotional and also physical load in her
routine, which cause stress. The founder of stress
study H Selye defines stress as non-specific reac-
tion of organism to any established to external and
internal demands1.
The psychological definition of coping is the
process of managing taxing circumstances, expen-
ding effort to solve personal and interpersonal
problems, and seeking to master, minimize, redu-
ce or tolerate stress2. Lazarus and Folkman sug-
gested in 1984 that stress can be thought of as re-
sulting from an “imbalance between demands and
resources” or as occurring when “pressure exce-
eds one's perceived ability to cope”2. Stress mana-
gement was developed and premised on the idea
that stress is not a direct response to a stressor but
rather one's resources and ability to cope mediate
the stress response and are amenable to change,
thus allowing stress to be controllable2.Lazarus
and Folkman's interpretation of stress focuses on
the transaction between people and their external
environment - the Transactional Model2. The mo-
del contends that stress may not be a stressor if the
person does not perceive the stressor as a threat
but rather as positive or even challenging. Also, if
the person possesses or can use adequate coping
skills, then stress may not actually be a result or
develop because of the stressor. The model propo-
ses that people can be taught to manage their stress
and cope with their stressors. They may learn to
change their perspective of the stressor and provi-
de them with the ability and confidence to impro-
ve their lives and handle all of types of stresses2.
In coping with stress, people tend to use one
of the three main coping strategies: either apprai-
sal focused, problem focused, or emotion focused
coping3. Appraisal-focused strategies occur when
the person modifies the way they think. People
using problem focused strategies try to deal with
the cause of their problem. Emotion focused stra-
tegies involve releasing pent-up emotions, dis-
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 HealthMED - Volume 5 / Number 6 / 2011

tracting one-self, managing hostile feelings, me-
ditating, using systematic relaxation procedures.
Lazarus and Folkman define eight separate coping
strategies that they believe individuals employ in
stressful situations4.
These are confrontation; seeking social support;
planned problem-solving; selfcontrol; accepting
responsibility; distancing; positive reappraisal; and
escape/avoidance (Table1). These separate into
two types of coping strategies. The first is problem
solving removal of or getting around the stressor;
the problem is defined, alternatives are considered
and the best strategy for that situation is selected
and put into action. The second coping strategy is
emotion focused and involves the use of mainly
cognitive processes that reduce perceived suffer-
ing. In general, people employ problem-solving
strategies to situations where there may be some
degree of control. Emotion focused strategies tend
to be used in situations that they have little power
over such as when experiencing physical health
problems2. It must be noted that Lazarus and Folk-
man believe that each strategy has its own merit
and none is better than the other. If a strategy is
appropriate for the individual and if there are no
ill effects (then or later) then the coping strategy is
an appropriate tool in stress reduction5. However,
some believe that emotion (especially avoidant)
coping strategies are not as efficient as problem
solving ones since people who do not deal with
their stressors successfully are more likely to suf-
fer ill health6. There is evidence for the belief that
problem-solving strategies are better than emotion
strategies for coping effectively7,8.
Research objectives and research aim
The aim of this paper is to study coping strate-
gies of nurses in Latvia
Research material and methods
Respondents were 200 nurses with more than 5
years work experience at four general hospitals in
different regions of Latvia. They worked at the diffe-
rent departaments of hospitals, including out- patient
departaments. The representative sample was strati-
fied and selected on the bases of random choice.
The questionare used in this study included a
demographic and work-related data and a stress
coping scale (Lazarus and Folkmans Ways of Co-
ping Checklist/Revised5, 1985).
Demographic and work-related data included
age, education level, work experience, workplace
and workload.
Lazarus and Folkmans Ways of Coping Check-
list (Revised) is a 66-item questionnaire containing
a wide range of thoughts and acts that people use to

Table 1. The eight subscale of Ways of Coping Questionaire

Confrontive coping
Distancing
Self-controlling
Seeking social support
Accepting responsibility
Escape-avoidance
Planful problem-solvng
Positive reappraisal
Describes aggresive efforts to alter the situation and suggests some degree of
hostoloty and risk-taking. Items=6. (Cronbah`s alfa=.70)
Describes cognitive efforts to detach oneself and to minimizē the significance of
the situation. Items=6. (Cronbah`s alfa=.61)
Describes efforts to regulate to regulate one`s feelings and actions. Items=7.
(Cronbah`s alfa=.70)
Describes efforts to seek informational support, tangible support, and emotional
support. Items=6. (Cronbah`s alfa=.76)
Acknowledges one`s own role in the problem with a concomitant theme of trying
to put things right. Item`s=4.. (Cronbah`s alfa=.66)
Describes wishful thinking and behavioral efforts to escape or avoid the problem.
Items on this scale contrast with those on the distancing scale, which suggest de-
tachment. Items=8. (Cronbah`s alfa=.72)
Describes deliberate problem-focused efforts to alter the situation, coupled with
an analytic approach to solving the problem. Items=6. (Cronbah`s alfa=.68)
Describes efforts to create positive meaning by focusing om personal growth. It
also has a religious dimension. Items=7 (Cronbah`s alfa=.79)

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HealthMED - Volume 5 / Number 6 / 2011
deal with the internal and/or external demands of
specific stressful encounters. Stress coping was me-
asured with a 4-point Likert scale: 0 (Not used), 1
(Used some-what), 2 (Used quite a bit) and 3 (Used
a great deal)5. The purpose of this questionnaire is
to find out the kinds of situations that trouble people
in their day-to-day lives, and how people deal with
them. There are eight subscales of the stress coping-
Confrontive coping, Distancing, Self-controlling,
Seeking social support, Accepting responsibility,
Escape-Avoidance, Planful problem-solving, Po-
sitive reappraisal. These subscales covered the as-
pects of problem coping (Confrontive coping, Plan-
ful problem-solving, Seeking social support scales)
and emotional coping (Distancing, Self-controlling,
Accepting responsibility, Escape-Avoidance, Posi-
tive reappraisal) strategy.
Results
Demografic Data
Demographic data for the 200 nurses in this stu-
dy has shown that all of them were women. Most
of the respondents (65%) are between the ages
31-50. 24 % of the respondents have higher edu-
cation, others have secondary school professional
education. Work experience of all the nurses is
more than 5 years, most of the respondents (35 %
of nurses) have work experience 21-30 years; the
second largest group is 27% of nurses with 11-20
years experience. 52 % of the respondents work
in surgery dapratments, the second highest rate of
13% are employed in intensive care, and 12% of
nurses work in department of therapy. Most of the
respondents 82% work in one job and only 15%
have two jobs. 200 respondents, 54% have night
shift work, and 46% have an eight- hour working
day. 68% of all the respondents work full time,
25% of the nurses work one and a half shifts, but
only 7% of the surveyed nurses work part-time.
Stress Coping strategy
In order to evaluate stress coping methods obtai-
ned results, in each stress coping scale has summed
two respondent answers – „Used quite a bit ” (2)
1470
and „Used a great deal” (3). This is the way how
to find out the most popular stress coping strategy.
Emotion focused stress coping methods characteri-
ze the following scale values - Positive reappraisal
51.6%, Self-controlling 47.6%, Accepting respon-
sibility 43.8%, Distancing 41.4% and Escape-Avoi-
dance 32.9% (Figure 1). Scale values characterize
the problem focused stress coping methods, which
are: Planful problem-solving 51.0%, Seeking so-
cial support 43.7% and Confrontive coping 36.2%.
The obtained results indicate that the most frequ-
ently used methods are Positive reappraisal 51.6%,
Planful problem-solving 51% and Self-controlling
47.6%. Nearly each third respondent (32.9%) uses
Escape-Avoidance method.
Figure 1. Results of the susbscale of stress co-
ping strategy
In order to find out how many of the respon-
dents use emotion focused stress coping strategy
and how many chose problem solving strategy
Wilcoxon rank test9 marks have been used. The
data show that the emotion focused coping is used
by 69% nurses, but the problem focused coping
-by 29.5%. The differences are statistically signi-
ficant (z = 6.297, p = 0.01). Figure 2.
The received results (Figure 3) testify that there
is stress coping statistically significant correlation
in diapason from 0.36 to 0.73. It is noticed close
connection between Confrontive coping and Es-
cape-Avoidance . There is statistically insignificant
correlation between Distancing and the following 3
scales –Seeking social support, Accepting respon-
sibility and Planful problem-solving. All the rest
scales are on an average close correlation.
Investigating the correlation between the forms
of stress coping and the age of the respondents, it
has been found out that there is no statistically sig-
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 HealthMED - Volume 5 / Number 6 / 2011

nificant correlation between age and emotion fo-
cused stress coping (r = -0.14, at p = 0.01), as well
as the problem focused stress coping (r =0.13, at p
= 0.01). Having found out the correlations between
respondents` work experience and stress coping ori-
entation, the achieved results testify that there are no
statistically significant correlations as the closeness
of correlation between work experience and emo-
tion focused stress coping is r = -0.13, at p = 0.01.
Figure 2. Results of Task Coping and Emotion
Coping
Discussion
Most part of the chosen respondents use emotion
focused stress coping form as the way of surmount-
ing stress, employing positive reappraisal (51.6%)
and Self controlling (47.6%) The mentioned results
correspond to P. Thylefor, Lee& Ashforth opinions,
who connect this tendency with the psychological
competence of nurses, nurses corresponding self-
image role, professionally significant behaviour
and personal features10,11. Rodham and Bell in their
several –year long investigation came to the con-
clusion that in nurses stress coping practice there
is the tendency to transfer stress coping oriented
on problems into emotions oriented stress coping.
Scientists connect these changes and difficulties
in stress coping in nurses` work with the cardinal
changes in nurses’ practice- the changes of the role
of nurse; additional new duties; necessity of new
knowledge; but the former abilities and skills often
stay the same12.
Similar results were also reported in other stu-
dies, conducted by Andrea Bezerra Rodrigues;
Eliane Corrêa Chaves Rev., where the studied po-
pulation used emotion-focused coping the most,
mainly positive reappraisal13. However, the results
indicate that half of the nurses (51%) used planful
problem-solving, which is one of the strategies that
characterize a problem-focused coping strategy. In
the same way Healy & McKay reported their study
results where common coping strategies were posi-
tive reappraisal, self control and the most frequent-
ly reported planful problem-solving14. These results
coincided with data that were obtained through
studies of stress coping among nurses in Australia,
which coping strategies included seeking support,
problem solving and self-control15.

Figure 3. The Subscales of the stress of coping correlations Spearman`s rho

Seeking Accepting Planful
Confrontive Self-con- Escape-
Distancing social responsibi- problem-
coping trolling Avoidance
support lity solving
Distancing 0.71** 1
Self-controlling 0.65** 0.65** 1
Seeking social sup-
0.57** 0.36** 0.46** 1
port scales
Accepting responsi-
0.52** 0.34** 0.49** 0.58** 1
bility
Escape-Avoidance 0.73** 0.67** 0.64** 0.55** 0.49** 1
Planful problem-sol-
0.43** 0.38** 0.59** 0.505** 0.58** 0.53** 1
ving
Positive reappraisal 0.49** 0.47** 0.50** 0.58** 0.47** 0.48** 0.49**
** – p < 0.01.

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HealthMED - Volume 5 / Number 6 / 2011
Having found out the connection between
the respondents` age and the chosen stress cop-
ing type, has been calculated correlation quotient
in connection between the respondents` age and
stress coping orientation on emotions (r=-0.14,
at p=0.01), which proves that the correlation be-
tween the variable is weak and with statistically
low essentiality level. Having calculated corre-
lation quotient in connection with respondents`
age and problem focused stress coping (r=0.13,
at p=0.01), the received results indicate on weak
and statistically insignificant correlation between
the variable. The other study results showed that
there were significant correlation between age,
job experience and ways of coping16. This could
be connected with differences in the sample, re-
search methods, work environment and other fac-
tors. Having cleared up the correlations between
the respondents` work experience and stress
overcoming orientation, has been calculated the
quotient of the connection between work experi-
ence and orientation on problem focused stress
coping (r=0.11, at p = 0.01) and the correlation
quotient in connection between the respondents`
work experience and stress coping orientation on
emotions (r=-0.13, at p = 0.01). Both these param-
eters indicate weak and statistically insignificant
correlation between the variable, however, exists
the following tendency: with growing work expe-
rience, grows problem focused orientation of cop-
ing stress and decreases stress coping orientation
on emotions.
Conclusion
Work in health care is connected with high
risk of burning out syndrome, in which prophy-
laxis coping plays essential role. If the chosen
stress coping strategy turns out to be inappropri-
ate, employee suffers from chronic stress, and the
reactions caused by the stress have cumulative
tendency. In general it essentially influences either
nurse’s work accomplishment, work satisfaction
and the quality of medical services.
The results of the research show that nurses in
Latvia use the emotion focused coping overcome
types, the most common of which is Positive reap-
praisal, Self- controlling and Accepting responsi-
1472
bility. However, nurses also use problem focused
stress coping strategies the most popular of which
are Planful problem-solving and Seeking social
support.
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12. Rodham K & Bell J. Work stress: An exploratory

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Coresponding author
Liana Deklava,
Riga Stradins University,
Latvia,
E-mail: lianadeklava@inbox.lv

Journal of Society for development in new net environment in B&H 1473

HealthMED - Volume 5 / Number 6 / 2011
The Effects of LPG Massage System
on Delayed Onset Muscle Soreness
and Muscular Performance after
Resistance Exercise
Vahideh Kianmarz
Payame Noor University, Iran
Abstract
Background: Muscular soreness and pain are
common and prevalent experiences following per-
formance of physical activities. This is accompa-
nied with feelings of pain, stiffness, wellness and
muscular cramp.
Aim & objects: This study was done in order
to determining effects of LPG massage system on
delayed Onset Muscle Soreness and muscular per-
formance after resistance exercise.
Methods: twenty inactive females [aged
21.9±1.02 years, BMI 21.61±1.62 kg/m2] were
randomly assigned to a treatment (LPG system)
group (n=10) and control group (n=10). Both gro-
up performed 3 set ×15 reps (70% MCV) with curl
hamstring system to induce muscle soreness and
1set ×25 reps (20% MCV) for recovery. One hour
later, was received 15 min massaging by LPG sy-
stem technique S6 model. Creatine Kinase (CK),
pain, flexibility, thigh circumference, maximum
isometric strength and vertical jump performance
were measured at pre- exercise and 24 hour after
exercise. Data was analyzed by independent t-test.
Results: Range of changes of Blood CK activi-
ty, pain and thigh circumference were significantly,
decreased after LPG massage treatment (tck= 9.08
IU/ml, tpain= 6.72, tthc= 5.85 cm, p<0.01) and range
of changes of maximum isometric strength, vertical
jump performance and flexibility were significantly
increased after LPG massage treatment (tmis= -7.2
kg, tpow= -3.26 cm, tflex= -3.44 p<0.01).
Conclusion: LPG system technique could de-
crease cellular damages induce by DOMS and co-
uld recover muscle function.
1474 Journal of Society for development in new net environment in B&H
Key words: delayed onset muscle soreness,
LPG massage system, Creatine Kinase, maximum
isometric strength and inflammation
Introduction
Muscular soreness and pain are common and
prevalent experiences following performance of
physical activities. Delayed onset muscle soreness
is the feeling of soreness after large- force, eccen-
tric exercise and usually peaks at 24-48 hours post
exercise, with resolution at 5 to 7 days. The sore
muscles are described as feeling stiff, tender, and
aching especially after palpitation or movement
but these common symptoms rarely require me-
dical attention [1,2,6,7]. Researchers hypothesizes
that DOMS is related to muscle structural damage
that is followed by ion imbalance, inflammation,
and pain. Muscle damage includes disrupted sar-
colemma, T-tubules, myofibrils, cytoskeletal pro-
tein and sarcoplasmic reticulum (SR). Damage to
the SR is particularly problematic, as it causes an
ion imbalance that activates calpain, an enzyme
that further degrades muscle proteins. Within 8
h of the initial injury, chemo attractants released
by the damaged muscle tissue attract neutrophils,
which adhere to the endothelium of nearby blood
vessels in a process called adhesion or margina-
tion. After adhesion, the neutrophils infiltrate the
muscle tissue to phagocytosise damaged cells. If
neutrophils function is not tightly controlled, he-
althy tissue is inadvertently destroyed and additi-
onal muscle damage occurs. Ultimately, the me-
chanical disruptions and inflammatory responses

activate type III and IV pain receptors, leading to
the sensation of DOMS [6, 11, and 12].
Various modes of exercise such as box stepping,
shuttle running, downhill running, lowering weights
and isokinetic machines with eccentric action have
reported muscle soreness and inflammation [10].
Some strategies proposed to alleviate DOMS
include pre and post exercise stretching, light
exercise, ultrasound, topical analgesics, and phar-
macological agents. None of this treatment, howe-
ver, completely attenuates DOMS. Muscle massa-
ge may be an alternative therapy, one that is popu-
lar and possibly effective. If massage is rendered
during the early stages of inflammation, the mec-
hanical pressure applied with the massage might
decrease neutrophils margination, thereby redu-
cing inflammation and DOMS. Indeed, massage
rendered 2 h after muscle injury decreased muscle
soreness and increased the circulating neutrophils
count, which suggests the treatment reduced neu-
trophils margination [3, 4, 6, 9, 12].
Theoretically, decreased margination should
have attenuated muscle damage induced by inflam-
mation, a variable not measured in the aforementio-
ned study. Muscle damage is frequently monitored
in other studies by examining maximum isometric
strength and flexibility. Although these measures
and indirect, the relationship among muscle dama-
ge, inflammation, and changes in muscle function
is well documented [7, 10]. The findings from in-
vestigations evaluating treatment for DOMS have
been inconclusive and conflicting.
Active rest, which involves repetitive, low- in-
tensity, concentric muscle contractions, appears to
facilitate the clearance of post exercise intramus-
cular swelling, adhesions, and therefore soreness
associated with DOMS. However, the external
forces provided by LPG massage system may fur-
ther accelerate muscle healing and return to acti-
vity. Since antiquity, massage has been prescribed
among sports competitors for enhancing the hu-
man performance as well as recovery from intense
exercise. The benefits of massage have often been
attributed to different physiological responses.
However, there is a lack of concrete information
regarding the responsible mechanisms for descri-
bed or supposed effects [5, 7].
Massage has been a therapeutic modality in
most cultures since early civilization and has had
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
a long tradition of use in sport. Frequent claims
made in the sport literature for the benefits of
massage include improved stretching of tendons
and connective tissue and relief of muscle tension
and spasm. Massage is also commonly assumed
to enhance muscle recovery from intense exerci-
se, principally because it speeds up muscle blood
flow. Thus, manual massage is classically used
whereas the effects on muscle soreness are equi-
vocal (Tiidus 1997). However, studies to date on
blood flow are contradictory. A pervious review
pointed out that reports on limb blood flow vary
from no effect of massage to as much as a 50%
increase. For instance, positive effects have been
reported showing that massage promotes accele-
ration of muscle and venous blood flow, increases
blood volume, and reduces muscle tightness. In
contrast, more recent research showed no effect
of massage on blood flow irrespective of the type
massage stroke or the muscle mass being treated
[1, 7, and 12].
The mechanisms underlying this damage are
not yet fully elucidated, but it appears that the
grater forces on the contractile and connective
components within the muscle during eccentric
exercise are a major factor. As a consequence of
these initial events, inflammatory and swelling
processes are subsequently involved. Inflamma-
tory mediated processes are activated with lengt-
hening contraction that induce damage and appear
to contribute to muscle restricting [1, 2, and 12].
Methods
Subjects
Twenty inactive females [aged 21.9±1.02 ye-
ars, BMI 21.61±1.62 kg/m2] were randomly assi-
gned to a treatment (LPG system) group (n=10)
and control group (n=10). None of the subjects
were pregnant, participating in a competitive
sport, recovering from a knee injury, taking anti-
inflammatory medication, or weight training the
hamstrings in days preceding the study. Subjects
read and signed an informed consent agreement
before participating.
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HealthMED - Volume 5 / Number 6 / 2011

Baseline tests
The design of this study consisted of pretest
assessment, exercise protocol, post exercise and
treatment protocol. Subjects reported to the lab one
to two days prior to the experimental treatment for
familiarization and baseline measurements. All su-
bjects had their height and weight determined on a
scale (yagami) and body composition determined
using the three site skin-fold technique to charac-
terize the subjects. Upon arrival they complete the
pain questionnaire mostly of them hadn’t any pain
in their body. Pain ratings assessed with a visual
analog scale were the dependent variables. After
the questionnaire, Well's sit & reach test, vertical
jump test and maximum isometric strength with
dynamometer were measured. The highest value
was recorded as the baseline tests. After them, thi-
gh circumference measurements at 5.08 cm (2in),
10.16 cm (4in), 15.24 cm (6in), and 20.32 cm (8in)
below the femur joint line. An average over there
was recorded as the baseline thigh circumference.
After completing them, 5 ml blood sample was ta-
ken by venipuncture from each subject.
Experimental treatment
The experimental treatment for each subject
began at 8:00 am. All subjects performed 3 sets
×15 reps (70% MCV) with curl hamstring sy-
stem to induce muscle soreness and 1set ×25 reps
(20% MCV) for recovery. There was 1 min of rest
between sets. Next, to subjects of LPG group were
received 15 min massaging by LPG system tech-
nique S6 model one hour post exercise. Control
group haven't any treatment. Creatine Kinase (CK),
pain, thigh circumference, vertical jump, flexibility
and maximum isometric strength were measured at
pre- exercise and 24 hour after exercise.
Statistical analysis
To compare the possible effect of LPG massage
system on DOMS, an intention to treat analysis was
used which involved all subjects who were rando-
mly assigned to their group. Independent t- test was
used to compare the mean of CK level and muscle
soreness between the experimental groups.
Results
Table 1 shows the different of means and inde-
pendent t-test between two groups. Range of changes
of Blood CK activity and thigh circumference were
significantly, decreased after LPG massage treatment
(tck= 9.08, tthc= 5.85, p<0.01) and range of changes
of maximum isometric strength and vertical jump
performance were significantly increased after LPG
massage treatment (tmis= -7.2, tpow= -3.26, p<0.01).

Table 1. Descriptive characteristics of subjects

Variable Lpg group Control group Total
Age (y) 21.5 ± 0.84 21.6 ± 1.42 21.5 ± 1.14
Height (cm) 1.58 ± 3.6 1.57 ± 4.11 1.57 ± 3.8
Weight (kg) 52.1 ± 3.5 54.7 ± 2.83 53.4 ± 3.4
BMI (kg/m2) 20.85 ± 1.25 22.17 ± 1.28 21.5 ± 1.4
% body fat 22.6 ± 1.42 23.3 ± 1.34 22.98 ± 1.38
Data are means ± standard error. in both of groups N=10

Table 2. Results of measurments in LPG & Control with use independent t-test
Indexes Mean SE t P
CK 118.9 13.08 9.08 0.001
Pain 6.8 1.01 6.72 0.001
Thigh circumference 3.28 0.56 5.85 0.001
Vertical jump -5.2 1.59 -3.26 0.043
Flexibility -4.53 1.31 -3.44 0.003
Maximum isometric strength -14.7 2.04 -7.2 0.001

1476 Journal of Society for development in new net environment in B&H


Discussion
The present study reveals LPG massage sy-
stem could significantly decrease range of chan-
ges of CK, perceives pain and swelling thigh 24
hours after exercise. Although, we found that LPG
massage system could significantly increase range
of changes flexibility, power and maximal isome-
tric strength than control group. Increase of CK,
pain and swelling thigh in control group according
with pervious studies [2,3,4,7,10,].
The CK enzyme has been defined as an index
for muscle damage and its level will be increased
within 24 to 48 hours after eccentric activities,
which is sign of eccentric muscle damage. Howe-
ver, this increase was seen only in the control gro-
up, and not in the LPG group. In fact, the lower
CK level in the LPG group may indicate lower
muscle damage in this group, while the control
group showed a higher CK level and so higher
muscle damage, which was accompanied by hi-
gher muscle soreness.
High mechanical forces produced during mus-
cular exercise, particularly in eccentric exercise
cause disruption of structural proteins in muscle
fibers and connective tissue. Researchers hypot-
hesize that DOMS is related to muscle structural
damage that is followed by ion imbalance, infla-
mmation, and pain. Muscle damage includes dis-
rupted sarcolemma, T-tubules, myofibrils, cyto-
skeletal protein, and sarcoplasmic reticulum (SR).
Damage to the SR is particularly problematic, as
it causes an ion imbalance that activates cal pain,
an enzyme that further degrades muscle proteins.
Within 8 h of the initial injury, chemo attractants
released by the damage muscle tissue attract neu-
trophils, which adhere to the endothelium of ne-
arby blood vessels in a process called adhesion or
migration. After adhesion, the neutrophils infil-
trate the muscle tissue to phagocytosise damaged
cells. If neutrophils function is not tightly contro-
lled, healthy tissue is inadvertently destroyed and
additional muscle damage occurs. Ultimately, the
mechanical disruptions and inflammatory respon-
ses activate Type III and IV pain receptors, leading
to the sensation of DOMS [7, 9, 10].
Theoretically, decreased margination should
have attenuated muscle damage induced by in-
flammation, a variable not measured in the afo-
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
rementioned study. Muscle damage is frequently
monitored in other studies by examining maxi-
mum isometric strength and flexibility. Althou-
gh these measures and indirect, the relationship
among muscle damage, inflammation, and chan-
ges in muscle function is well documented.
Maïsetti (2003) and Ferret (1999) suggested
that if LPG massage system rendered during the
early stages of inflammation, the mechanical pre-
ssure applied with the massage decrease neutrop-
hils margination, thereby reducing inflammation
and DOMS [3, 4 ]. LPG system have 2 Motorized
rollers that move towards or away from each other
according to the thickness of the skin fold and due
to a constant depression and an adjustable inten-
sity the skin fold is caught and kept between the
2 rollers and controlled suction creates a perfect
skin-fold. So it is facilitating fluid intracellular
movement and avoiding intramuscular edema re-
solution [3,4,5]. Portero and co- workers (1999)
suggested LPG massage is also removing blood
lactate and increasing circulation [5]. Some re-
searchers proposed pre and post static stretching
alleviated DOMS. This finding contrasts with data
from Buroker and Schwane (1989). Explanation
possibility for this discrepancy in the data is a few
number of participants, quantity of muscle mass
injured, exercise protocol for product DOMS and
applying low accurate questionnaire of perceive
muscle soreness. We assessed muscle soreness
by visual analogue pain scale. The visual analo-
gue pain scale has been used as valid and reliable
measurement for determining the intensity of hu-
man pain. Therefore, LPG massage system could
decrease cellular damages induced by DOMS and
could recover muscle function. This may result in
a faster recovery from illness or injury and a more
rapid return to normal function.
1477
HealthMED - Volume 5 / Number 6 / 2011

References Corresponding author:

Vahideh Kianmarz,
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delayed onset muscle soreness. (1999). 18th Olym-
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8. Gordon C, Emiliozzi C, Zartarian M. Use of a me-
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bromyalgia: a preliminary study. (2006). Arch Phys
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fect of delayed onset muscle soreness on muscle
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(2008). Scand J Med Sci Sports. Nov 3.
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ll running. (2010). Br J Sports Med. Apr 23.

1478 Journal of Society for development in new net environment in B&H

 HealthMED - Volume 5 / Number 6 / 2011

Outcomes of patients with low

risk cardiac chest pain underwent
immediate exercise testing: two
months fallow up
Saeed Abbasi1, Kambiz Masoumi2, Mohsen Ebrahimi3, Mohammad Amin Zare1, Mohammad Javad Alemzadeh
Ansari4
1
Department of Emergency, Tehran University of Medical Sciences, Tehran, Iran,
2
Department of Emergency, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran,
3
Department of Emergency, Mashhad University of medical Sciences, Mashhad, Iran,
4
Department of Cardiology, Tehran University of medical Sciences, Tehran, Iran.

Abstract patients with nondiagnostic exercise testing. The

Aims and Objective: The objective of our
study was to evaluate the outcomes of patients
with low cardiac risk presenting to the emergency
department (ED) with chest pain suggestive of a
cardiac etiology and underwent immediate exer-
cise testing during two months follow up.
Methods: From September 2007 to September
2008, all patients presenting to the ED of Rasool-
e-Akram Hospital in Tehran with chest pain com-
patible with a cardiac origin and clinical evidence
of low risk on initial assessment underwent im-
mediate exercise treadmill testing according to
the Bruce protocol. Method of sampling was non-
probability and consecutive. Sixty days fallow up
after exercise testing was done for determination
of subsequent clinical status included myocardial
infarction (MI), unstable angina pectoris (UAP),
coronary artery disease (CAD) demonstrated by
thallium scan scintigraphy or the coronary angiog-
raphy, undergoing a revascularization procedure,
and death.
Results: Exercise testing was performed to
in 184 patients (116 men, 68 women; mean age
46.9±10.3 years). Exercise testing was positive in
53 (28.8%), negative in 119 (64.7%), and nondi-
agnostic in 12 patients (6.5%). Cardiac event in
positive exercise testing group was occurred in
25 patients (45%), and in negative testing group
was in 4 (3%). Cardiac event was occurred in no
negative predictive value (NPV) of the exercise
test for non-traumatic low risk cardiac chest pain
was 96.6% and positive predictive value (PPV)
was 47.2%.
Discussion: Our results emphasizes that the
immediate exercise testing in the studied group
of the patients is a safe, non-invasive and use-
ful test with a high NPV and moderate PPV that
could help us in prognostic risk stratification of
this group of patients.
Key words: chest pain; exercise testing; emer-
gency department;
Background
Decision making and risk stratification for pa-
tients with acute chest pain, nondiagnostic electro-
cardiogram results, and normal troponin levels are
challenging (1). Chest pain units are now estab-
lished centers for assessment of low-risk patients
presenting to the emergency department with
symptoms suggestive of acute coronary syndrome
(2). Initial impressive evaluations including medi-
cal history, physical exam, an electrocardiogram
(ECG) and cardiac markers could help us catego-
rizing the patients in a risk scale as: low, interme-
diate, or high (3). Exercise treadmill testing (ETT)
is a testing modality that has shown to be a use-
ful chest pain observation unit (4). Karha et al.

Journal of Society for development in new net environment in B&H 1479

HealthMED - Volume 5 / Number 6 / 2011
showed, on the other hand, that performance of an
exercise stress test in patients with unstable angina
pectoris or non-ST-elevation myocardial infarc-
tion treated with aspirin, heparin, and tirofiban,
within 48 to 72 hours after admission is associated
with a low risk of complications (5). Few data are
available on the outcome of patients admitted to
hospital with suspected acute coronary syndrome
who have no high-risk factors and who undergo
exercise testing before discharge.
Aims and Objectives
The objective of our study was to evaluate the
outcomes of patients with low cardiac risk pre-
senting to the emergency department (ED) with
chest pain suggestive of a cardiac etiology and
underwent immediate exercise testing during two
months follow up.
Methods
Study Design
A prospective cross-sectional study accom-
plished in the ED of Rasool-e-Akram Medical
Center in Tehran, Iran. Our study was approved by
the ethical committee of Iran University of Medi-
cal Sciences.
Patients
From September 22, 2007 to September 22,
2008 all consecutive patients referred to the ED
with a non-traumatic chest pain that according to
their history and physical examination were evalu-
ated to be in the low cardiac risk group underwent
a submaximal exercise test according to the Bruce
protocol. Method of sampling was non-probability
and consecutive. Inclusion criteria comprised 20
to 75 years of age; and all patients that could not
complete the exercise test for any of reasons were
excluded from the study. Criteria of low cardiac
risk included the presence of any of the followings
in the patients' primary assessments: Probable
ischemic symptoms, recent cocaine use, chest dis-
1480
comfort aggravation on the palpation, new onset
or developing CCS class III or IV during 2 weeks
without significant pain at rest, a normal or with-
out changes ECG during chest pain or T wave flat-
tening or inversion in the leads with dominant R
wave in the primary ECG, normal serum cardiac
enzymes level, previous history of monitored ad-
mission or discharge with a prescription.
Exercise test
The cases subsequently underwent a sub-
maximal exercise testing according to the Bruce
protocol. Exercise testing was provided between
8:00 AM and 6:00 PM daily. Exercise end points
included significant symptoms or ECG eviden-
ce of myocardial ischemia (1.0 mm horizontal
ST segment shift at 80 ms after the J point), 10
mmHg decrease in the systolic blood pressure,
coupled ventricular extrasystoles, or a sustained
supra-ventricular tachyarrhythmia. The criteria
for a positive test for ischemia were the above-no-
ted exercise-induced ST segment changes; and a
non-diagnostic test was defined by absence of any
ECG evidence of ischemia at a heart rate of lower
than 85% of the age-predicted maximum.
Cardiac Imaging Studies
The all patients with the positive exercise test
were recommended to accomplish a cardiac scin-
tigraphy through the thallium scan, and a coronary
angiography in a defined center. The scintigrap-
hy and angiography operator staff and physicians
were completely blind to the study. The patients
with a positive scintigraphy or angiography results
for coronary artery occlusions, were generally re-
ferred to the cardiologist to determine the next
therapeutic step considering the clinical status and
the degree of arterial occlusions and cardiac per-
fusion insufficiency.
Follow up. Follow up for all patients was
accomplished to determine the clinical status at
60 days after exercise testing through the telepho-
ne interview, or the face-to-face interview on the
60 days follow up referral. The study outcomes
assessed for the patients' clinical status were myo-
Journal of Society for development in new net environment in B&H

cardial infarction (MI), unstable angina pectoris
(UAP), diagnosed coronary artery disease (CAD)
using thallium scan scintigraphy or the coronary
angiography, undergoing a revascularization pro-
cedure, and death.
Statistical analysis
Data are presented as the mean ± SD for con-
tinuous variables and as frequencies (percent) for
categorical variables. The statistical package for
social sciences (SPSS) version 15 software was
used for data analysis. Continuous data were anal-
yzed using Student's t test and categorical varia-
bles were analyzed using the chi-square test. The
significant differences between groups were deter-
mined at level <0.05.
Results
Overall, 184 patients (116 men, 68 women)
with non-traumatic chest pain categorized in low
cardiac risk group were entered to this study. The
mean age of the patients was 46.9±10.3 years and
the male-to-female ratio was 3:1.7. The characte-
ristics of the study group have been summarized
in table 1.
Table 1. The baseline characterizes of patients
(n=184)
Male 116 (63.0%)
Gender (n)
female 68 (37.0%)
Mean age (yr) 46.9±10.3
Hypertension 48 (26.1%)
Diabetes Mellitus 22 (12.0%)
Risk Factors
Hyperlipidemia 29 (15.8%)
(n)
Positive Family History 21 (11.4%)
Cigarette Smoking 53 (28.8%)
Exercise testing was positive in 53 (28.8%),
negative in 119 (64.7%), and nondiagnostic in 12
patients (6.5%). No adverse event occurred during
or after testing, and all patients with a negative
exercise test were discharged directly from the
ED. In 60 days follow up period, cardiac events
in positive exercise testing group were occurred in
25 patients and in negative testing group were in
4 patients; In positive group cardiac events were
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
significantly more than negative group (47.2%
versus 3.4%; P<0.001). Cardiac event was occu-
rred in no patients with nondiagnostic exercise
testing. In positive exercise testing group, 10 pa-
tients (18.9%) diagnosed as CAD and 15 (28.3%)
ones afflicted to the UAP; and in negative exercise
testing group, 1 patient (0.8%) diagnosed as CAD
and 3 (2.5%) ones afflicted to the UAP. None of
the patients affected to the MI or death. Cardiac
events in patients with measured risk factor were
not significantly more than others (P>0.05).
Based on these findings, the sensitivity of the
exercise test for non-traumatic low risk cardiac
chest pain was 86.2%, specificity was 80.4%, ne-
gative predictive value (NPV) was 96.6%, and po-
sitive predictive value (PPV) was 47.1%.
Discussion
Although new diagnostic approaches have en-
hanced the evaluation of patients presenting to the
emergency department (ED) with chest pain, the
acute coronary syndrome remains a major clinical
challenge (6). In this study we done exercise te-
sting in all patients with non-traumatic chest pain
and categorized in low cardiac risk and results of
follow up indicated that cardiac event significantly
was higher in positive exercise group compared
with others. We used the Vancouver criteria for
classification of patients according the clinical and
paraclinical findings into three groups: low, mode-
rate, and high risk. A study used these criteria and
showed that sensitivity and specificity was 98.8%,
and 32.5%; PPV and NPV was 28.5%, and 99%,
respectively (7). Brush et al reported that a ne-
gative ECG on admission was associated with a
0.6% rate of serious complications during hospita-
lization compared with a 14% incidence in those
with an abnormal ECG (8). ECG with other lab
data and clinical status are the better modalities for
evaluation of patients with chest pain and classifi-
cation of them (9-12).
Although the majority of patients with non-tra-
umatic chest pain became to ED are categorized
in low cardiac risk group, but more assessment
necessary for identification of prognosis should
be done at time of presentation, because at least
2% of patients with a coronary event are inadver-
1481
HealthMED - Volume 5 / Number 6 / 2011
tently discharged from the ED (1;9;12-14). When
a patient present in ED with chest pain, primary
be closed observed by a 6- to 12-h period of ECG
monitoring and serial cardiac serum markers
(1;9;12;15;16) and if had not changes in serial
ECG and cardiac serum marker is commonly fo-
llowed by stress testing either before be dischar-
ged or in the early postdischarge period.
A good, cost effect, and easy available met-
hod in ED for more assessment and identification
of prognosis among low-risk patients presenting
with chest pain is exercise testing (17-19), and ot-
her technique such as scintigraphy should be re-
served for patients whom exercise testing is not
feasible (19).
We done the exercise testing without any com-
plications on low cardiac risk patients with chest
pain and results showed that of them, 28.8% had
positive, 64.7% negative, and 6.5% nondiagnostic
test; and based on our follow up the NPV of exer-
cise test was 96.6%, and PPV was 47.1%. NPV of
exercise test in our experiment was similar other
studies (17;20-25). Although PPV of our experi-
ment was similar study of Lewis and Amsterdam
(20) and Gibler et al (21), but was more than other
studies (17;22-24). Only PPV of study of Kirk et
al (25) was 57% which was more than our study.
Exercise test is a safe method, so that in these
study no adverse events were reported, similar our
finding. Thus, the exercise testing is a safe and has
an excellent NPV in patients identified as low car-
diac risk. Further, although the positive predictive
value is modest, but if this test be positive in a pa-
tient more evaluation will be needed.
Conclusions
Our study results emphasizes that the immedi-
ate exercise testing in the patients presented with
non-traumatic chest pain to the emergency de-
partment that according to their medical history,
physical examinations, immediate on-admission
electrocardiography, and cardiac markers levels
are categorized to the low risk of cardiac events,
is a safe, non-invasive and useful test with a high
NPV and moderate PPV that could help us in pro-
gnostic risk stratification of this group of patients.
1482 Journal of Society for development in new net environment in B&H
References
1. Sanchis J, Bodi V, Nunez J, Bosch X, Loma-
Osorio P, Mainar L, et al. Limitations of clini-
cal history for evaluation of patients with acute
chest pain, non-diagnostic electrocardiogram,
and normal troponin. Am J Cardiol 2008 Mar
1;101(5):613-7.
2. Amsterdam EA, Kirk JD, Diercks DB, Lewis WR,
Turnipseed SD. Exercise testing in chest pain units:
rationale, implementation, and results. Cardiol
Clin 2005 Nov;23(4):503-16, vii.
3. Escabi-Mendoza J, Rosales-Alvarez C. Risk strati-
fication in the patient with non ST segment elevati-
on acute coronary syndrome. P R Health Sci J 2005
Dec;24(4):323-36.
4. Diercks DB, Kirk JD, Amsterdam EA. Can we iden-
tify those at risk for a nondiagnostic treadmill test
in a chest pain observation unit? Crit Pathw Cardi-
ol 2008 Mar;7(1):29-34.
5. Karha J, Gibson CM, Murphy SA, Dibattiste PM,
Cannon CP. Safety of stress testing during the evo-
lution of unstable angina pectoris or non-ST-eleva-
tion myocardial infarction. Am J Cardiol 2004 Dec
15;94(12):1537-9.
6. Gibler WB, Cannon CP, Blomkalns AL, Char DM,
Drew BJ, Hollander JE, et al. Practical implemen-
tation of the Guidelines for Unstable Angina/Non-
ST-Segment Elevation Myocardial Infarction in
the emergency department. Ann Emerg Med 2005
Aug;46(2):185-97.
7. Christenson J, Innes G, McKnight D, Thompson
CR, Wong H, Yu E, et al. A clinical prediction rule
for early discharge of patients with chest pain. Ann
Emerg Med 2006 Jan;47(1):1-10.
8. Brush JE, Jr., Brand DA, Acampora D, Chalmer
B, Wackers FJ. Use of the initial electrocardio-
gram to predict in-hospital complications of acu-
te myocardial infarction. N Engl J Med 1985 May
2;312(18):1137-41.
9. Hutter AM, Jr., Amsterdam EA, Jaffe AS. 31st Bet-
hesda Conference. Emergency Cardiac Care. Task
force 2: Acute coronary syndromes: Section 2B--
Chest discomfort evaluation in the hospital. J Am
Coll Cardiol 2000 Mar 15;35(4):853-62.

10. Kirk JD, Diercks DB, Turnipseed SD, Amsterdam
EA. Evaluation of chest pain suspicious for acute
coronary syndrome: use of an accelerated diagno-
stic protocol in a chest pain evaluation unit. Am J
Cardiol 2000 Mar 9;85(5A):40B-8B.
11. Amsterdam EA, Lewis WR, Kirk JD, Diercks
DB, Turnipseed S. Acute ischemic syndromes.
Chest pain center concept. Cardiol Clin 2002
Feb;20(1):117-36.
12. Lee TH, Goldman L. Evaluation of the patient
with acute chest pain. N Engl J Med 2000 Apr
20;342(16):1187-95.
13. McCarthy BD, Beshansky JR, D'Agostino RB,
Selker HP. Missed diagnoses of acute myocardial
infarction in the emergency department: results
from a multicenter study. Ann Emerg Med 1993
Mar;22(3):579-82.
14. Pope JH, Aufderheide TP, Ruthazer R, Woo-
lard RH, Feldman JA, Beshansky JR, et al. Mi-
ssed diagnoses of acute cardiac ischemia in the
emergency department. N Engl J Med 2000 Apr
20;342(16):1163-70.
15. Farkouh ME, Smars PA, Reeder GS, Zinsmeister
AR, Evans RW, Meloy TD, et al. A clinical trial
of a chest-pain observation unit for patients with
unstable angina. Chest Pain Evaluation in the
Emergency Room (CHEER) Investigators. N Engl
J Med 1998 Dec 24;339(26):1882-8.
16. Lewis WR, Amsterdam EA. Chest pain emergency
units. Curr Opin Cardiol 1999 Jul;14(4):321-8.
17. Amsterdam EA, Kirk JD, Diercks DB, Lewis WR,
Turnipseed SD. Immediate exercise testing to eva-
luate low-risk patients presenting to the emergen-
cy department with chest pain. J Am Coll Cardiol
2002 Jul 17;40(2):251-6.
18. Senaratne M, Certer D, Irwin M. Adequacy of
an exercise test in excluding angina on pati-
ents presenting to the emergency department
with chest pain. Ann Noninvasive Electrocardiol
1999;4:408-15.
19. Amsterdam EA, Kirk JD, Diercks DB, et al. Asse-
ssment of low risk patients presenting to the emer-
gency department with chest pain: immediate tre-
admill test or cardiac stress imaging (abstr)? Am
Coll Cardiol 2001;37:Suppl:149A.
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
20. Lewis WR, Amsterdam EA. Utility and safety
of immediate exercise testing of low-risk pati-
ents admitted to the hospital for suspected acute
myocardial infarction. Am J Cardiol 1994 Nov
15;74(10):987-90.
21. Gibler WB, Runyon JP, Levy RC, Sayre MR, Kaci-
ch R, Hattemer CR, et al. A rapid diagnostic and
treatment center for patients with chest pain in
the emergency department. Ann Emerg Med 1995
Jan;25(1):1-8.
22. Gomez MA, Anderson JL, Karagounis LA, Muhle-
stein JB, Mooers FB. An emergency department-
based protocol for rapidly ruling out myocardial
ischemia reduces hospital time and expense: re-
sults of a randomized study (ROMIO). J Am Coll
Cardiol 1996 Jul;28(1):25-33.
23. Zalenski RJ, McCarren M, Roberts R, Rydman RJ,
Jovanovic B, Das K, et al. An evaluation of a chest
pain diagnostic protocol to exclude acute cardiac
ischemia in the emergency department. Arch In-
tern Med 1997 May 26;157(10):1085-91.
24. Polanczyk CA, Johnson PA, Hartley LH, Walls
RM, Shaykevich S, Lee TH. Clinical correlates
and prognostic significance of early negative
exercise tolerance test in patients with acute chest
pain seen in the hospital emergency department.
Am J Cardiol 1998 Feb 1;81(3):288-92.
25. Kirk JD, Turnipseed S, Lewis WR, Amsterdam EA.
Evaluation of chest pain in low-risk patients pre-
senting to the emergency department: the role of
immediate exercise testing. Ann Emerg Med 1998
Jul;32(1):1-7.
Corresponding author
Mohammad Javad Alemzadeh Ansari,
Department of cardiology,
Imam Khomeini Complex Hospital,
University of medical Sciences,
Tehran,
Iran,
E-mail: mj.aansari@gmail.com
1483
HealthMED - Volume 5 / Number 6 / 2011
Maternal obesity and preeclampsia
Azar Aghamohammadi
Senior lecturer in department of midwifery, Islamic Azad University, Sari Branch, Iran
Abstract
Background: Obesity is a modern day epidem-
ic. The incidence appears to be rapidly increasing
in both developed and developing countries and
has become much more obvious in the last decade.
Aim& Objective: The present research was
done with the aim of studying the effects of obe-
sity defined as a first trimester maternal body mass
index >30 on the preeclampsia.
Methods: This study was a descriptive-com-
parative study two hundred fifty singleton preg-
nancies of women with first trimester BMI >30
who delivered at Emam Hospital, Sari Iran during
2008–2009 were studied A control group with two
hundred fifty nine women of normal body mass
index matched for age and parity were selected
and incidence of preeclampsia were compared
between groups. χ2 and Odds-ratio and 95% con-
fidence were used to analyze the data. Statistical
significance was defined as P < 0.05.
Results: There was a significant relation be-
tween obesity and preeclampsia (20.8 vs. 5.8%,
P<0.0001) compared to non-obese women.
Conclusion: Obesity in pregnant women appears
to be a risk factor for adverse perinatal outcomes.
Key words: Obesity, BMI, pregnant women,
reproductive age
Introduction
The prevalence of obesity is increasing world-
wide and this trend also affects women of reproduc-
tive age.(1) The 2003–2004 National Health and
Nutrition Examination Survey (NHANES) reports
that an estimated 66% of US adults are overweight
or obese, and the percentage of obese adults has in-
creased from 23% to 32% in the past 10 years.(2)
Overweight and obese women are at increased risk
for adverse pregnancy outcomes.(3) Obesity during
pregnancy is known to be associated with adverse
1484 Journal of Society for development in new net environment in B&H
outcomes, such as an increased incidence of pre-
eclampsia, gestational diabetes mellitus (GDM),
macrosomia, postdates, preterm labor, and an in-
crease in cesarean and operative vaginal deliveries
Obesity in pregnancy has been reviewed extensive-
ly and is a growing concern since it is associated
with increased maternal and fetal complications.(4)
There are an increased incidence of the need for la-
bor induction in obese women (5,6) Obese women
have a reduced chance of successful vaginal birth
after caesarean section.(7) Recent evidence sug-
gests a role for adipose tissue in inflammation and
infection .Studies of non-pregnant obese individu-
als indicate that adipose tissue can recruit macro-
phages and promote inflammation, undergo necro-
sis, and express high levels of pro-inflammatory
cytokines, including tumor necrosis factor (TNF)-
a, interleukin (IL)-6, monocyte chemotactic protein
(MCP)-1, inducible nitric oxide synthase, trans-
forming growth factor (TGF)-b, and pro-coagulant
proteins such as plasminogen activator inhibitor
type 1, tissue factor and factor VII. The proinflam-
matory state of obesity has been implicated in the
pathophysiology of pre-eclampsia.(2) However,
other studies have suggested that obesity by itself
is not an independent risk factor for adverse preg-
nancy outcomes (8) The aim of this study was to
compare incidence of preeclampsia and outcomes
in both mother and neonate in obese women (with
a BMI equal to or more than 30) with non obese
women (women with normal BMI).
Materials and methods
A retrospective study was conducted by observ-
ing pregnancy outcome in obese and non-obese
women who delivered at the maternity unit of Imam
Khomeyni hospital, Sari, Islamic Republic of Iran
from October 1, 2008 to December 30, 2009.
All women age between 20-35 who attended the
antenatal clinic during the first 12 weeks of preg-
 HealthMED - Volume 5 / Number 6 / 2011

nancy were entered and their BMI was calculated Result

as weight in kilograms divided by height in meters
squared.(9) Women with first trimester BMI equal
to or more than 30 were included in the study group
and Women with BMI between 21 and 26 included
as control group (non-obese group). exclusion cri-
teria was included these cases: cesarean records,
smoking and addicted women, the records of five
gravida and more, pregnancy with the fertiling aid
methods, multiple pregnancy in present pregnancy,
suffering from known physical and mental disease
including all heart, kidney and immune disease, all
kinds of cancers, hepatitis, diabetes mellitus, sexu-
ally transferred diseases, took medicine because of
ground disease, close relatives of their husbands,
hydrops fetalis or mole hydatidiform.
A midwife collected the data of the control
group and was blinded to the pregnancy outcome
obese group. The incidence of selected pregnancy
outcomes were analyzed in the two groups. The
maternal variables included age, parity and BMI.
The pregnancy outcomes analyzed were preg-
nancy induced hypertension, gestational diabetes,
low birth weight (<2500 g), macrosomia (birth
wt>4000 g), low Apgar scores (<7 at 5 min). The
number of required samples was estimated in each
group with the certainty measure of 45 percent and
evaluation power of 80 percent and PO-PI=0/1
and PO=0/5 of 250 people. The statistical analysis
was performed by using χ2 test, odds ratios and
95% confidence intervals were calculated. The
significance was defined as P<0.05.
Two hundred fifty obese women and 259 non-
obese women were compared. There was no sig-
nificant difference in age and parity between the
two groups. (Table1)
A significantly higher rate of pregnancy in-
duced hypertension P<0.001, gestational diabetes
P<0.001, cesarean section rate P<0.001, macroso-
mia P< 0.001 was noted in the obese women as
compared to the non-obese group. There was no
significant difference in the rate of small for gesta-
tional age in two groups. There was a statistically
significant difference in Apgar score in two groups
and the obese group has lower Apgar in 5 minute
score than control group. (table2)
Discussion
The BMI was calculated from the weight taken
during the first antenatal visit before 12 weeks of
pregnancy. This BMI reflects pre-pregnancy BMI,
since the majority of women during the first tri-
mester lose rather than gain weight. (10)
The findings resulted from this study showed
that two groups had statistically significant differ-
ence in the rate of pregnancy induced hyperten-
sion (20.8 vs. 5.8) and gestational diabetes (23.8
vs. 2.7). Wolfe et al demonstrated that both BMI
pregnancy weight gain predicted the pregnancy
outcome in obese pregnant women. (11)Many lit-

Table 1. Demographic characteristics in obese and non obese groups

Parameters Obese (n=250) Non-obese (n=259) P-Value
Age (years) 24.66±4.32 (20-34) 25.58±5.58 (20-34) >0.05
Parity 1.75±1.16 (1-3) 1.38±1.12 (1-3) >0.05
BMI (kg/m2) 34.05± 3.29(≥30) 23.13±2.06 (21-26) <0.000

Table 2. Pregnancy outcomes in obese and non obese groups

Obese (%) non Obese (%)
Pregnancy outcome χ2 P-Value Odss -Ratio
n=250 n=259
Gestational diabetes 23.8 2.7 2.034 <0.000 9.870(CI%95 2.445, 8.698)
Preeclampsia 20.8 5.8 2.069 <0.000 4.272(CI%95 2.335,7.817)
Cesarean section 64.4 47.5 14.74 <0.000 2.000(CI%95 1.402,2.555)
Macrosomia 3.9 0.0 * 0.002 1.041(CI%95 1.015,1.067)
SGA 5.1 6.4 0.409 0.522 1.273(CI%95 0.599,2.704)
Apgar score in 5 min<7 12.5 1.6 23.31 <0.000 9.004(CI%95 3.135,25.860)
*fisher test

Journal of Society for development in new net environment in B&H 1485

HealthMED - Volume 5 / Number 6 / 2011
eratures have showed that there was a significantly
higher rate of gestational diabetes and preeclamp-
sia in the obese group. (12)
Jayati et al noted that There was no difference
in the incidence of hypertension among the BMI
groups, which indicates that there are multiple
causal factors in the development of hypertension
in the African population in their study.(4) Low Ap-
gar score(12.5 vs. 1.6%) and macrosomia ( 3.9 vs.
0.0%) in the obese group was significantly higher in
this study. This could be explained by the high fre-
quency of gestational diabetes among our women.
(10) Kumari noted that obesity is associated with an
increased incidence of large for gestational age, still
birth, admission to NICU and Since GDM and PIH
may be the causal mechanisms for adverse perina-
tal outcomes in obese women.(10) The mechanisms
underlying the adverse pregnancy outcomes in obe-
sity, while poorly understood, are probably initiated
by abnormal adipose tissue distribution secondary
to excessive weight gain in women who are already
obese prior to conception.(13)
In this study cesarean section rate in the obese
group was significantly higher (64.4 vs. 47.5%)
than control group. These results are consistent
with many previous reports .(12,14-16) Parlow et
al have suggested that obesity was not associated
with higher cesarean section rates.(17) The rate
of small for gestational age (SGA) neonates was
less in the obese group than in the control group
(5.1 vs. 6.4%), this difference did not statistically
significant. This is consistent with many previous
studies and probably suggests the protective role
of maternal obesity against birth of SGA infants.
The higher incidence of SGA noted in few stud-
ies could be related to chronic hypertension and
diabetic vasculopathy complicating these preg-
nancies.(10) Bianco et al noted that high rate of
macrosomia in their study after controlling was
just for gestational diabetes.(12)
Maternal obesity has become one of the most
common high risk obstetric situations. As recom-
mended and presented, careful prenatal manage-
ment, tight monitoring, and careful follow-up can
minimize the dangers of pregnancy in overweight
women. (18)
In the obese pregnant women, the effects of
dietary interventions in modifying adverse peri-
natal outcomes are not yet proven. Every effort
1486
should be made to prevent increasing body weight
and encourage women to return to pre pregnancy
weight and reach a normal body mass index be-
fore the next pregnancy. (10)
References
1. Rowlands I, Graves N, Jersey S D, McIntyre D,
Callaway L. Obesity in pregnancy: outcomes and
economics. Seminars in Fetal & Neonatal Medici-
ne 2010;15 : 94–99.
2. Madan J C, Davis J M, Craig W Y, Collins M,
Allan W, Quinn R & et al. Maternal obesity and
markers of inflammation in pregnancy. Cytokine
2009 ;47: 61–64.
3. Vahratian A, Siega-Riz AM, Savitz DA, Zhang J.
Maternal Pre-pregnancy Overweight and Obesity
and the Risk of Cesarean Delivery in Nulliparous
Women. Ann Epidemiol 2005;15:467–474.
4. Krablin S, Banovic V, Kuvacic I. Morbid maternal
obesity and pregnancy. Inter J of Gynecol&Obstet
2004;85 : 40–41.
5. Denison FC, Price J, Graham C, et al. Maternal
obesity, length of gestation, risk of postdates pre-
gnancy and spontaneous onset of labour at term. Br
J Obstet Gynaecol 2008;115:720–5.
6. Kristensen J, Vestergaard M, Wisborg K, et al. Pre-
pregnancy weight and the risk of stillbirth and neo-
natal death. Br J Obstet Gynaecol 2005;112:403–8.
7. Cedergren MI. Maternal morbid obesity and the
risk of adverse pregnancy outcome. Obstet Gynecol
2004;103:219–24.
8. Garbaciak JA Jr, Richter M, Miller S, Barton JJ.
Maternal weight and pregnancy complications. Am
J Obstet Gynecol. 1985;152:238–245.
9. Yogev Y, Visser G H. Obesity, gestational diabetes
and pregnancy outcome. Seminars in Fetal & Neo-
natal Medicine 2009; 14 :77–84.
10. Kumari AS. Pregnancy outcome in women with
morbid obesity. Inter J of Gynecol & Obstet 2001;
73 : 101-107.
11. Wolfe HM, Zador IE, Gross TL, Martier SS, So-
kol RJ. The clinical utility of maternal body
mass index in pregnancy. Am J Obstet Gynecol
1991;164:1306_1310.
Journal of Society for development in new net environment in B&H
 HealthMED - Volume 5 / Number 6 / 2011

12. Bianco AT, Smilen SW, Davis Y, Lopez S, Lapinski

R, Lockwood CJ. Pregnancy outcome and weight
gain recommendations for the morbidly obese wo-
man. Obstet Gynecol 1998;91:97_102.
13. Dennedy M C, Dunne F. The maternal and fe-
tal impacts of obesity and gestational diabetes
on pregnancy outcome.Best Practice & Research
Clinical Endocrinology & Metabolism 2010; 24:
573–589.
14. Garbaciak J , Richter M, Miller S, Barton JJ. Ma-
ternal weight and pregnancy complications. Am J
Obstet Gynecol 1885;152:238_245.
15. Robinovich JT, Rubio EL, Saez JC, Ramirez
MI. Influence of body weight in pregnancy and
the perinatal results. Rev Chile Obstet Ginecol
1995;60:151_167.
16. Johnson JW, Longmate JA, Frentzen B. Excessive
maternal weight and pregnancy outcome. Am J
Obstet Gynecol 1992;167(2):353_370.
17. Perlow JH, Morgan MA, Montgomery D, Towers
CV, Porto M. Perinatal outcome in pregnan-
cy complicated by massive obesity. Am J Obstet
Gynecol 1992;167: 958_962.
18. Krablin S, Banovic V, Kuvac I.Morbid maternal
obesity and pregnancy, Inter J of Gynecol &Ob-
stetrics 2004;85:40–41.

Corresponding author
Azar Aghamohammadi,
Department of midwifery,
Islamic Azad University,
Sari Branch,
Iran,
E-mail: azareaghamohamady@iausari.ac.ir

Journal of Society for development in new net environment in B&H 1487

HealthMED - Volume 5 / Number 6 / 2011
Perceptions regarding the use of
long-lasting insecticide-treated bed
nets for preventing malaria among
rural females of Pakistan
Nelofer Amir, Ejaz Ahmad Khan, Haris Habib, Hamayun Rathor
Health Services Academy, Islamabad, Pakistan.
Abstract
Background: Globally, there are 300-500 mi-
llion clinical cases of Malaria annually. It is ende-
mic in Pakistan and has shown epidemic potential
in the past. In World Health Organization’s Eastern
Mediterranean Region (EMR), about 10.5 million
malaria episodes and 49000 malaria-related deaths
occur every year. In Pakistan, Annual Parasite Inci-
dence (API) is 0.8/1000 populations. Provincially,
the Annual Parasite Incidence is highest in Baluc-
histan (5.8/1000 population) followed by Federally
Administrative Tribal Areas (4.0/1000 population)
and Sindh (1.08/1000 population). Long Lasting
Insecticide-Treated-Nets(LLINs) when used pro-
perly, can reduce malaria transmission by at least
60% and child deaths by 20%. LLINs are advan-
ced form of Insecticide Treated Nets. They are fac-
tory impregnated, stronger and longer-lasting with
better efficacy than the ones without insecticides.
Objective: To assess the knowledge, attitude
and practices of the community regarding use of
long lasting insecticide treated bed nets (LLINs)
for preventing malaria.
Methods: Primary data collection was done
by the principal researcher on an estimated sam-
ple of 200 households based on 6% distribution of
LLINs by multistage survey. Data was collected
through the trained healthcare workers, cleaned
and entered, whereby analyzed thereafter and re-
sults interpreted for the three domains of knowled-
ge, attitude and practice on Likert scale.
Results: Using the Likert scale, about half
(56.8%) of the respondents did agree that the
LLINs were useful in preventing against malaria,
1488 Journal of Society for development in new net environment in B&H
coated with insecticide (53.3%) and protect from
nuisance effect (44.7%).Overall most (94.5%) of
the respondents had a good knowledge regarding
use of the LLINs, majority (63.8%) has fair attitu-
de and all (100%) had good practice. Majority of
people (63.8%) were in favor of using LLINs and
almost all (100%) of them knew how to use them
properly. Increasing age was found to be associa-
ted with good knowledge (p= 0.007,) but not the
better education (p= 0.803) as majority (74%) of
the participant remained illiterate.
Limitation and strength: The study was done
in the intervention area and was accessible through
the local healthcare workers with a support from
the local institutions. The interviewees were not
representative of the population as a whole, with
hundred percents females and mostly house-wi-
ves. The data collectors were the LHWs and there
was a possibility of observer’s bias which was mi-
nimized by administering structured questionnaire
and training augmented by surprise visits by the
principal researcher and data cleaning.
Conclusion: The study shows good Knowled-
ge, attitude and practices among the study popu-
lation. However, an effort to impart education to
females may have an augmenting effect on better
implementation of the healthcare interventions.
Key words: Malaria, Lady Health Workers,
Long Lasting Impregnated Nets.
Introduction
Malaria remains a major cause of morbidity
and mortality in tropical and subtropical regions

of the world.1 Globally Malaria accounted for an
estimated deaths (708–1003 million) in 2008, of
which, 89% were in the African Region, followed
by the Eastern Mediterranean (6%) and the South-
East Asia Region (5%).2 Only in the EMR (Ea-
stern Mediterranean Region, including Pakistan,
accounted for an estimated 10.5 Million Malaria
events culminating in 49,000 deaths/year and a
loss of three million DALYs.3-4
The Annual Parasite Incidence (API) for Paki-
stan is 0.8/1000 population and is the highest for
Baluchistan (5.8/1000), trailed by Federally Admi-
nistered Areas (FATA) (4.0/1000) and then by Sin-
dh (1.08/1000).5 Thus, malaria is one of the major
health issues in Pakistan which pose drastic impli-
cations in terms of morbidity and mortality among
the pregnant females and children under five years
of age along with the high healthcare cost.6-7
Figure 1. Conceptual framework of the study based on Theory of Reasoned Action (Martin Fishbein
and Icek Ajzen:1975 1980)
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
Long Lasting Insecticide Nets were introduced
as an intervention in National Malaria Control Pro-
gram as well as and Roll back Malaria Program, in
Pakistan.8 These bed nets provide physical and che-
mical barriers and are well known for their control
of mosquito bite by killing them.8-9 They are among
the simplest and cost effective measures for con-
trol of malaria and have been proved to be among
effective intervention in many other countries.10 In-
dividual use of LLIN leads to personal protection
and their use at the community level leads to redu-
ces the risk of acquiring malaria. Similarly, in situ-
ations where the populations are displaced due to
disasters or emergencies, the use of LLINs remain
preventive choice from mosquito bite.5 Knowledge
regarding malaria prevention has been documented
significantly associated to educational level of the
community.11 It has been recommended that the use
1489
HealthMED - Volume 5 / Number 6 / 2011
of the personal protection should be advocated es-
pecially for those who work outside.12
Apropos to the interventions done under ma-
laria control initiatives in the country, there has
been a felt need of investigation into the end user’s
perceptions about the LLINs. Theory of Reasoned
Action (figure 1) was taken as reference to deve-
lop the conceptual framework of the survey so that
the results could identify factors (s) needing atten-
tion of the policy makers and implementers and
hence to improve the outcome of the initiatives
and overall effectiveness of the program.
Methods
Study setting: This Study was carried out in
April-June, 2010, in Mardan District of Kkyber
PakHtun Khwa Province. The district lies from
34° 05’ to 34° 32’ north latitudes and 71" 48’ to
72° 25’ east longitudes. It is bounded on the north
by Buner district and Malakand protected area, on
the east by Swabi and Buner districts, on the south
by Nowshera district and on the west by Charsad-
da district and Malakand protected area. The total
area of the district is 1632 square kilometres. The-
re are 3 Tehsils (Mardan, Takhat bai, Katlang) and
74 union councils in district Mardan.
Study design and sampling
It was a cross sectional survey. The sample
size was calculated by taking 6% disrtribution of
LLINs in Pakistan and by using “Open Epi” with
95% confidence interval and a design effect of 2.
n=[DEFF*Np(1-p ]/[d2/z2 1- α / 2*(N-1)+p*(1-p)]
n= 200.
Sample was selected by multi-stage sampling
method. One Union council was selected on the
basis of distribution of LLINs. Seven villages
were selected randomly the list of villages. 200
households were divided by the number of villa-
ges and every village had 29 households and were
selected by systematic random sampling i.e. N/n
=k, random selection of the first number and then
every kth value. As a rule, the questionnaire was
1490
piloted before administering to the households to
check the reliability in another union council na-
med Torru of the same district (figure 2).
Figure 2. Sampling methodology for the survey
Survey instrument: A structured questionnaire
(appendix A) was used for data collection and by
trained data collectors. Questionnaire consisted of
three parts. First part was about socio demograp-
hic characteristics, second part consisted of infor-
mation regarding knowledge, third part regarding
assessment based on Theory of Reasoned Actions
and fourth part regarding practices. Only one adult
female was interviewed from one household.
Inclusion criteria: One adult female (18-60 ye-
ars of age), of one household, which used LLINs.
Exclusion criteria: Persons who were criti-
cally ill, and the ones who were employed by the
Malaria Control Program.
Data analysis
Data was entered in SPSS version 16. Test of
significance used in data analysis was chi square.
There were thirty questions in the knowledge part
of questionnaire. Scoring for knowledge done by
giving score “1” to yes and “0” to No and Do not
Know. When added up, there were score from “0”
to ”30”. Cut off point was made. From 0-10 for
poor knowledge, 11-20 for fair knowledge and 21-
30 for good knowledge.
There were twenty questions in the Attitude
part of questionnaire. Score “5” to strongly agree,
“4” to agree, “3” to neither agree nor disagree, “2”
to disagree and “1” to strongly disagree was given
for positive questions; reverse scoring was simi-
larly done for the negative questions. The scores
Journal of Society for development in new net environment in B&H
 HealthMED - Volume 5 / Number 6 / 2011

were then added, so got a range of 20-100 scores. Table 1. Socio demographic characteristics of
Cut off point was then made based on the fact that respondents (n=199)
less than 50 had fair attitude and more than 50 had Socio demographic
good attitude. Number Percentages
variables
There were ten questions in the practices part of Age
questionnaire. Score “1” was given to the correct 1. < 20 5 2.5%
answer while sore “0” to the incorrect one. So af- 2. 21-30 110 55.3%
ter added up the scores, got range of 0-10 scores. 3. 1-40 74 37.2%
Cut off point was made as less than 5 had poor 4. 41= 10 5%
practices and more than 5 had good practices. Gender:
Chi-square was used to determine the associa- 1. Females 199 100%
tions among the factors at 0.05. The p-values less Marital status:
than or equal to 0.05 were considered significant 1. Married 199 100%
Relation to the head of
while interpreting results.
the house hold:
Piloting of the questionnaires was done in anot- 1. Spouse
197 98.5%
her union council, Torru of the same district. Sam- 1 0.5%
2. Daughter
ple was taken as ten percent of the total questio- 2 1%
3. Head of H.H.
nnaire (n=200) and 20 interviews were conducted. Education:
These questionnaires tested to check reliability for 1. No education 148 74%
Chronbach alpha of 0.6 and above, by using SPSS 2. Primary 23 11.5%
version 16. The questions were modified depen- 3. Middle 8 4%
ding upon their alphas. 4. Secondary 16 8%
5. Higher 5 2.5%
Occupation:
Ethical consideration House wives 194 97%
Govt: job 6 3%
The Institutional Review Board of the Health
Services Academy granted the ethical approval for Variables of interest when transformed and re-
the study. Informed consent was offered to all the coded, most of the participants (94.5%) had good
participants and on their subsequent consent they knowledge regarding the use of LLINs with fair
were recruited in the study and their confidenti- attitude in using LLINs (63.8%) and having good
ality was thoroughly maintained. General ethical practices (100%).
principles were meticulously observed. Table 2. Number and percentage of the participants
with levels of knowledge, attitude and practice
Variable Numbers Percentage
Descriptive results Knowledge
Good knowledge 188 94.5%
Out of 200 households contacted, only one Fair knowledge 11 5.5%
(0.5%) refused. All of the respondents from the Attitude
households were females (100%) and housewives Good attitude 72 36.2%
(97%) with rest being in government jobs. Mean Fair attitude 127 63.8%
age of participants was 30.72 years. The less than 20 Practices
Good practices 199 100%
year’s age group was least (2.5%), 21-30 years was
the largest age group (55.3%), followed by 31-40
years (37.2%) and -above 41 years (5%). Education
level among the respondents was not encouraging Knowledge
and majority of participants were illiterate (74%).
A small number were having primary (11.6%) and Majority (97.5%) of the participants knew
Secondary (8%) level education (table 1). about malaria, its prevention and how the LLINs

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HealthMED - Volume 5 / Number 6 / 2011

could prevent from the disease, and even from ot-
her insects. Nearly half of the respondents (house-
holds) received them from Lady Health Workers
along with detailed instructions how to use, wash
and dry whenever the bed nets were dirty. Uni-
versally, respondents were in favour of using the
LLINs for their family members. However, they
were also found using LLINs less for pregnant
women (18.6%).
Attitude
Attitude was scored on the Likert’s scale from
1-5 with agreement to the given statement. Most
of the participants agreed to the positive state-
ments and disagreed to the negative statements
showing and overall fair to good attitude towards
use of LLINs (table 5).
used bed nets followed by oil as a repellent, and
to the less extent the burning of cow dung. Ma-
jority of the respondents have been using the bed
nets for the last less than six months. There was
no reduction in efficacy of the bed nets described
by the respondents. Mostly they used bed nets po-
sting them by tying with nails, followed by putting
on the bed nets while sleeping and by just hanging
them such as for a curtain. Commonly the bed nets
were being used at the bed site, however they were
also found being used to cover the windows. Since
they acquired the bed nets, generally they did not
wash it. The instances where they did, mostly did
six monthly and with plain water in most of the
cases. Usually the respondents put the washed bed
nets to dry in shade by hanging them.
Inferential results

As shown in the table 7 below age had an asso-

Practices
Percent responses to practice was of high per-
centages (table 6). With regard to personal protec-
tive measures mostly participants stated that they
ciation with perceptions regarding preventive and
protective effects of the bed nets. However, educa-
tion did not show any association with the above
factors, the reason being most (74%) of the parti-
cipants were illiterate.

Table 3. Knowledge about use of LLINs

Question Yes No Do not know
1-Respondents heard about malaria 197(99%) 2(1%) 0(0%)
2-Respondents think malaria can be prevented. 194(97.5%) 3(1.5%) 2(1%)
3- Respondents know about personal protective measures 124(62.3%) 75(37.3%) 0(0%)
4-Respondents heard about bed nets. 184(92.5%) 15(7.5%) 0(0%)
5-Respondents know about impregnated and non impregna-
160(80.4%) 39(19.6%) 0(0%)
ted bed nets.
6-Respondents know LLINs. 184(92.5%) 15(7.5%) 0(0%)
7- Respondents has bed nets. 198(99.5% 1(0.5%) 0(0%)
8-Respondents know the use of LLINs 196(98.5%) 2(1%) 1(0.5%)
9-Respondents know use of LLINs by any one. 192(96.5%) 5(2.5%) 2(1%)
10-Whether he or she describe the procedure 194(97.5%) 5(2.5%) 0(0%)
11-Respondents know how to wash it. 193(97.0%) 5(2.5%) 1(0.5%)
12-Respondents know how to dry it. 190(95.5%) 6(3%) 3(1.5%)
13-Bed nets provide privacy. 164(82.4%) 12(6%) 23(11.6%)
14-Respondents know bed nets are made up of. 16(8%) 174(87.4%) 9(4.5%)
15-Respondents know bed nets are coated with Insecticides. 149(74.9%) 17(8.5%) 33(16.6%)
16-Respondents know bed nets are safe for Humans. 193(97%) 2(1%) 4(2%)
17-Bed nets are affordable. 158(79.4%) 3(1.5%) 38(19.1%)
18-Respondents like to buy it 135(67.8%) 62(31.2) 2(1%)

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 HealthMED - Volume 5 / Number 6 / 2011

Table 4. Number and percentage of multiple responses regarding LLINs

Question Number Percentage
Who help in malaria prevention?
1- Yourself 85 42.7%
2- Government 62 31.2%
3- NGOs 52 26.1%
Came to know about LLINs from?
1- Radio and T.V. 2 1%
2- MCP 2 1%
3- Doctors 2 1%
4- NGOs 28 14.1%
5- LHWs 165 82.9%
Having number of bed nets
1- 1 185 93%
2- 2 13 6.5%
3- 3 1 0.5%
Respondents got bed nets from
1- Government 3 1.5%
2- NGOs 87 43.7%
3- LHWs 109 54.8%
Disease that could be prevented by bed nets
1- Malaria 177 88.9%
2- Others 22 11.1%
Insect could be prevented by bed nets
1- mosquito 143 71.9%
2- sand fly 9 4.5%
3- bugs 47 23.6%
Respondents learn the use of LLIN from
1- MCP 11 5.5%
2- Doctor 2 1%
3- NGOs 8 4%
4- LHWs 178 89.4%
It should be washed after
1- Weekly 1 0.5%
2- Monthly 15 7.5%
3- Six monthly 58 29.1%
4- When dirty 125 62.8%
Mainly slept under bed nets
1- All 155 77.9%
2- Head of the family 1 0.5%
3- Pregnant woman 37 18.6%
4- Less than five years 6 3%
Respondents think about its effectiveness
1- Not satisfactory 2 1%
2- Satisfactory 2 1%
3- Good 173 86.9%
4- Excellent 22 11.1%
Change in mosquito numbers
1- Not satisfactory 8 4%
2- Satisfactory 185 93%
3- Excellent 6 3%

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HealthMED - Volume 5 / Number 6 / 2011

Table 5. Attitude of participants regarding use of LLINs

Strongly Neither agree Strongly
Statement Disagree Agree
disagree nor disagree agree
1- Mosquito causes fever 0(0%) 1(0.5%) 1(0.5%) 83(41.7%) 114(57.3%)
2- Bed nets prevent from fever 0(0%) 2(1.0%) 2(1.0%) 71(35.7) 124(62.3%)
3- Bed nets are usefull in preventing
0(0%) 0(0%) 2(1.0%) 84(42.2) 113(56.8%)
Malaria
4- Mosquito bites prevent from fever 2(1%) 183(92%) 6(3%) 8(4%) 0(0%)
5- In your opinion, you would get
1(0.5%) 184(92.5%) 6(3%) 4(2%) 4(2%)
mosquito bites despite use of bed nets
6- Bed nets should be used only at night 1(0.5%) 44(22.1%) 4(2.0%) 109(54.8%) 41(20.6%)
7- Bed nets good for children 2(1.0%) 94(47.2%) 3(1.5%) 64(32.2%) 36(18.1%)
8- Bed nets useless for adults 1(0.5%) 185(93.0%) 3(1.5%) 10(5.0%) 0(0%)
9- Bed nets used by females mostly 2(1.0%) 161(80.9%) 21(10.6%) 12(6.0%) 3(1.5%)
10- Protect from nuisance insects or
0(0%) 39(19.6%) 9(4.5%) 89(44.7%) 62(31.2%)
Animal
11- Feel better privacy while sleeping
0(0%) 0(0%) 2(1.0%) 79(39.7%) 118(59.3%)
under bed nets
12- Feel hotness under bed nets 0(0%) 27(13.6%) 1(0.5%) 116(58.3%) 55(27.6%)
13- Neighbor would like to buy bed nets 0(0%) 7(3.5%) 13(6.5%) 103(51.8%) 76(38.2%)
14- Prefer to receive it from health
0(0%) 22(11.1%) 43(21.6%) 87(43.7%) 47(23.6%)
authority
15- Bed nets coated with insecticides to
0(0%) 3(1.5%) 1(.5%) 89(44.7%) 106(53.3%)
kill mosquitoes
16- Insecticide treated nets are safe for
0(0%) 7(3.5%) 2(1.0%) 66(33.2%) 124(62.3%)
human
17- Worry about possible toxic effects 1(0.5%) 170(85.4%) 2(1%) 9(4.5%) 17(8.5%)
18- Washing bed nets reduces its
0(0%) 182(91.5%) 6(3%) 10(5%) 1(0.5%)
effectiveness
19- Animal also need protection 0(0%) 71(35.7%) 98(49.2.%) 27(13.6%) 3(1.5%)

1494 Journal of Society for development in new net environment in B&H

 HealthMED - Volume 5 / Number 6 / 2011

Table 6. Respondents Practices Regarding Use of Long Lasting Insecticide Treated Bed Nets.
Variable Number Percentage
Using personal protective measure along with bed nets
1- oil as repellent 38 19.1%
2- cow dung fumes 4 2.0%
3- Tree leaves 7 3.5
4- bed nets only 150 75.4%
Respondents had bed nets.
1- Less than one month 21 10.6%
2- Less than six months 100 50.3%
3- More than six months 78 39.2%
Respondents using bed nets
1- Less than one month 48 24.1%
2- Less than six months 121 60.8%
3- More than six months 30 15.1%
Noticed reduction in the efficacy of bed nets
1- No 194 97.5%
2- donot know 5 2.5%
How Respondents used bed nets
1- Hanging 17 8.5%
2- Tie with robe 5 2.5%
3- Tie with nail 127 63.8%
4- Use as chadder 50 25.1%
Where they used bed nets.
1- Bed 196 98.5%
2- Windows 1 0.5%
They Washed bed nets
1- Daily 1 0.5%
2- Monthly 18 9.0%
3- Six monthly 72 36.2%
4- Not yet 108 54.3%
They Washed bed nets with
1- Plain water 150 75.4%
2- Detergent 6 3%
3- Not yet 43 21.6%
Respondents dry bed nets with
1- Under sun 11 5.5%
2- Under shades 188 94.0%
Respondents do when bed nets not in use
1- Fold 60 30.2%
2- Hang 138 69.3%
3- Others 1 0.5%

Table 7. Association of LLINs usefulness in preventing malaria and LLINs protection from harmful
insects with age and education of the respondents
Variable Factor P-Value Factor P-Value
LLINs are useful in preventing LLINs protect from other harmful
Age 0.007 0.000
Malaria or nuisance insects.
LLINs are useful in preventing LLINs protect from other harmful
Education 0.803 0.153
Malaria or nuisance insects.

Journal of Society for development in new net environment in B&H 1495

HealthMED - Volume 5 / Number 6 / 2011
Discussion
This study was conducted in rural Pakistan in
an intervention area for LLINs distribution by the
Global Fund (GFATM), Directorate of Malaria
Control in Pakistan.
The knowledge of the participants was good
(94.5%) about the use of LLINs. The results
showed that most people had information about
malaria. The source of information was the LHWs,
which is in accordance with the knowledge of com-
munity documented by Khumbulani W Hlongwana
et al in their study done in Swaziland, Africa, where
knowledge was also high (78%) after being well-
informed by the healthcare facilities.13
Bed nets were provided free of cost to the com-
munity by the Global Fund. Freely distributed bed
nets are acceptable, feasible and result in high usa-
ge (100%). Similar results have been documented
in a study conducted in Kinshasa, Sub Saharan
Africa, by Pettifor A, et al where bed nets were
freely distributed during antenatal clinic visits,
and resulted in 80% usage.16
Most of the participants were in agreement that
malaria was transmitted by mosquito bite and is
comparable in a study conducted by Syed Masud
Ahmed et al in the most endemic areas of Bangla-
desh.15 In our study the usage of LLINs was 100%
in comparison with a survey conducted by Khum-
bulani W Hlongwana et al in Swaziland (Africa)
where the use was 65.3%.13
Increasing age has shown to be an associated
factor for use of LLINs and education did not. It
is contrary to other studies11 where education had
a role in demonstrating knowledge regarding use
of LLINs. This may be because of the fact that in
our study majority of the participants were illite-
rate and therefore age experience rather than edu-
cation alone was significant for higher knowledge,
attitude and practice.
Strengths
The study was done in the intervention area
and was accessible through the local healthcare
workers with a support from the local institutions.
1496 Journal of Society for development in new net environment in B&H
Limitations
The interviewees were not representative of
the population as a whole, with hundred percents
females and mostly house-wives. The data collec-
tors were the LHWs and there was a possibility
of observer’s bias which was minimized by ad-
ministering structured questionnaire and training
augmented by surprise visits by the principal rese-
archer and data cleaning.
Conclusion
The main conclusion that can be drawn is
therefore that the respondents showed excellent
knowledge (94.5%), fair attitude (63.8%) and
good practices (100%) regarding use of LLINs.
Needed more health as well as general education
among rural community regarding use of LLINs
among pregnant women and children under five.
References
1. Snow RW, Guerra CA, Abdisalan M, Myint HY,
Hay SI. The global distribution of clinical episodes
of plasmodium falciparum malaria. Nature. 2005;
343: 214-217.doi: 1038/nature03343. [pub med]
2. WHO: World Malaria report, 2009, page 27 [On
line]. Available at http://whqlibdoc.who.int/publi-
cations/2009/9789241563901_eng.pdf. accessed at
7/ 7/ 2010
3. Strategic planning for Malaria control and elimi-
nation EMRO region by WHO 2006-2010; page
8-9 [On line]. Available from. http://www.emro.
who.int/dsaf/dsa741.pdf. Accessed at 11/3/2010
4. World Health Organization, World Malaria Report,
2006-7.
5. Directorate of Malaria Pakistan [On line]. ava-
ilable from: http://202.83.164.26/wps/portal/
Moh/!ut/p/c0/04_SB8K8xLLM9MSSzPy8xBz9C-
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IwNzA_2CbEdFAOW90ZM!/?WCM_GLOBAL_
CONTEXT=/wps/wcm/connect/MohCL/ministry/
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laria+control+programme
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6. Malaria Participants Manual. Behavioral change
communication services project; funded by GFATM
Round II, Malaria component. Implemented by Ad-
group-HRDI Consortium Islamabad;p. 7, 2006
7. Akande TM, Musa IO. Epidemiology of Malaria in
Africa; Afri J Clin Experiment 2005; 9: 107-11.
16. Pettifor A, Taylor E, Nku D, Duvall S, Tabala M,
Mwandagalirwa K, et al. Free distribution of in-
secticide treated bed nets to pregnant women in
Kinshasa: an effective way to achieve 80% use by
women and their newborns. Trop Med Int Health.
2009 Jan;14(1):20-8.

8. Federal Ministry of Health (FMOH). The Abuja dec-

Corresponding author
laration on Roll Back Malaria in Africa; Extract from
Nelofer Amir,
African summit on Roll Back Malaria. World Health
Health Services Academy,
Organization (WHO) Fact sheet 2000; p2-12.
Islamabad,
9. Insecticide treated mosquito nets: a WHO Position Pakistan,
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available at www.who.int/topics/malaria/en/.
Accessed at 12/3/2010

11. Uza M, Phommpida S, Toma T, Takakura M, Ma-

nivong K, Bounyadeth Set al. Knowledge and
behaviour relating to malaria in malaria en-
demic villages of Khammouane Province, Lao
PDR. Southeast Asian J Trop Med Public Health
2002;33:246–254.

12. Moore S, Min X, Hill N, Jones C, Zaixing Z, Ca-

meron M. Border malaria in China knowledge
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questionnaire-based survey. BMC Public Health
2008; 8: 344.

13. Khumbulani W, Hlongwana LH, Musawenko-

si LH, Simon K,Govender K, Maharaja R, et al.
Community knowledge, attitudes and practices
(KAP) on malaria in Swaziland: A country ear-
marked for malaria elimination. Malaria J. 2009
Feb. 19; 8: 29. 1.

14. Humphrey D, Emmanuel O, Wilhe l, Paulina M,

Maria Zi, Eliningaya J et al. Knowledge, Attitu-
des, and Practices about Malaria and Its Control
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Journal of Society for development in new net environment in B&H 1497

HealthMED - Volume 5 / Number 6 / 2011
Study of Catastrophic Health
Expenditure in China’s Basic Health
Insurance
Zhongliang Zhou, Jianmin Gao
School of Public Policy and Administration, Xi’an Jiaotong University, Xi’an, China.
Abstract
Background: The catastrophic health expen-
diture, which could result in impoverishment, is
defined as the health expenditure exceeds some
fraction of “capacity to pay”. In order to protect
households from catastrophic health spending, the
Chinese government has implemented three basic
health insurance schemes (UEMS, URMS and
NCMS) in the last decade. However, as only parts
of residents’ medical expense are reimbursed by
these health insurance schemes, the insured hou-
seholds might still have high chance of suffering
catastrophic health expenditure.
Aim & Objectives: The purpose of our study
is to investigate the extent of catastrophic health
expenditure for the households enrolled in UEMS,
URMS and NCMS, and to identify factors associ-
ated with catastrophic health expenditure.
Methods: The data came from China’s National
Health Service Survey conducted in 2008 in Shaa-
nxi province. In this survey, a four-stage stratified
random sampling procedure was used to sample
households in urban and rural areas. By using a
questionnaire designed by the Health Ministry of
China, 5960 households were interviewed, from
which 1215 households covered by UEMS or
URMS and 2875 households covered by NCMS
were chosen. The indicators of incidence and inten-
sity of catastrophic expenditure were employed to
measure catastrophic health expenditure with diffe-
rent thresholds levels (10, 15, 25 and 40%), and two
logistic regression models were used to estimate the
factors of the probability of catastrophic expendi-
ture for the households enrolled in urban and rural
health insurance schemes.
1498 Journal of Society for development in new net environment in B&H
Results: There were 16.87 to 68.07% househol-
ds covered by UEMS or URMS that suffered cata-
strophic health expenditure and the average degree
by which payment exceeds the thresholds varied
from 2.68 to 13.36%. For the households covered
by NCMS, the incidence and intensity of catastrop-
hic expenditure were 19.62 to 75.86% and 3.12 to
15.51% respectively. Poor health, families compri-
sed of seniors, small family size and low economic
status were significantly led to catastrophic health
expenditure for households enrolled in both of ur-
ban and rural health insurance schemes.
Study Limitations: As indirect costs of health
care and the patients’ earnings losses were not in-
cluded in the health expenditure, the catastrophic
health expenditure might be under-estimated in
this study.
Conclusion: In order to reduce catastrophic ex-
penditure, we recommend the Chinese government
to expand the health insurance schemes for cove-
ring outpatient service as well as improve the re-
imbursement rates, meanwhile, strengthen illness
prevention and subsidize low-income households.
Key words: UEMS, URMS, NCMS, Cata-
strophic Health Expenditure, Logistic Regression
Model
1. Introduction
Households will suffer catastrophic health ex-
penditure if the out-of-pocket purchase of medical
care are large relative to the resources available
to the household; thus, the health care expenses
disrupt the material living standards of the hou-
sehold 1. The incidence of catastrophic health ex-

penditures is very small in high income-countries.
But for low- and middle-income countries, as the
households are not fully covered by health insu-
rance, the large out-of-pocket health expenditures
can easily lead to household catastrophic health
expenditure of a higher extent2-6.
There are two definitions of catastrophic heal-
th expenditure. One is that the health expenditure
exceeds some fraction of total household expendi-
ture in a given period4, 7. the other definition is that
the expenditure exceeds some fraction of “non-
discretionary expenditure”4 or “capacity to pay”
(roughly, nonfood expenditure)2. As “capacity to
pay” may better distinguish between the rich and
the poor than does total expenditure1, we prefer
the second definition in this study. From the de-
finition, the catastrophic threshold budget share
(“fraction”) is a very critical parameter. Howe-
ver, in the literature, there was no consensus on
the catastrophic threshold. The common threshold
that has been used is 10% when total expenditure
is used as the denominator8, 9. Xu and her collea-
gues 2 also used 40% when “capacity to pay” as
the threshold budget share. Beyond those, resear-
chers are more likely to use a range of threshold
values which could be varying from 5-25% of the
total household expenditure4, 7, 9 or 15-60% of the
non-food expenditure4, 5. We’d like to use different
threshold values instead of one in this study, see-
ing that researchers should not impose their own
judgment on catastrophic threshold1.
In recent years, the catastrophic health expen-
diture, which could result in impoverishment10, re-
ceived lots of attention around the world6, 11-13, and
China is no exception14-16. Since the reform and
opening-up in 1978, Chinese people’s health spen-
ding grew very fast, and, at the same time, very
few people were covered by health insurance until
the end of 1990s. In order to provide low price
medical care, thereby protecting households from
catastrophic health expenditure, China implemen-
ted three basic health insurance schemes during
the last decade. These schemes are as follows: the
Urban Employee Basic Medical Insurance Sche-
me (UEMS), which covers the urban residents
working in corporations; the Urban Resident Ba-
sic Medical Insurance Scheme (URMS), which
covers the urban residents without a job, or those
who are self-employed; and the New Rural Coo-
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
perative Medical Scheme (NCMS), which covers
the rural residents. As only parts of residents’ me-
dical expenses are reimbursed by UEMS, URMS
or NCMS, all of these basic health insurance sche-
mes provided inadequate coverage for the enro-
llees, which could not protect all the households
from catastrophic health spending. Although there
are several studies on households catastrophic he-
alth expenditure in China14-17, comparative anal-
ysis of catastrophic health expenditures for the ho-
useholds covered by UEMS, URMS and NCMS
has not been reported.
This study aims to investigate the incidence and
intensity of catastrophic health expenditure for the
households enrolled in the urban health insurance
schemes (UEMS and URMS) and the rural health
insurance scheme (NCMS), and to identify the fac-
tors associated with the incidence of catastrophic
health expenditure. Meanwhile, recommendations
to the Chinese government on reducing catastrop-
hic health expenditure will be made.
2. Data resource
The data comes from the forth National Heal-
th Service Survey (NHSS) conducted in 2008 in
Shaanxi province. Shaanxi, population 37.7 milli-
on, is located in west of China. In the end of 2009,
the Gross Domestic Product (GDP) per capita in
Shaanxi province was 21732 yuan (3181 USD)
and the population enrolled in UEMS, URMS and
NCMS achieved 4.6, 4.3 and 25.7 million respec-
tively18. The money raising levels and benefit pac-
kages of UEMS, URMS and NCMS in Shaanxi
province in 2009 are listed in table 1.
The household health survey questionnaire
used in NHSS was designed by the Health Mini-
stry of China and improved by absorbing sugge-
stions of many experts from home and abroad. A
four-stage stratified random sampling procedure
was used to sample households in the NHSS. In
the first stage, 44 districts (counties) were rando-
mly selected in Shaanxi province. In the second
stage, 75 sub-districts (townships) were selected in
sampled districts (counties). In the third stage, 150
communities (villages) were selected in sampled
sub-districts (townships). In the last stage, 5960
households composed of 2721 urban househol-
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HealthMED - Volume 5 / Number 6 / 2011
Table 1. Description of UEMS, URMS and NCMS in Shaanxi province in 2009
UEMS
Benefit package for
Individual saving account
outpatient service**
Benefit package for
Reimbursement rate: 56.4% Reimbursement rate: 37.8%
inpatient service*
The money raising 2423 yuan (355 USD) per
level** person per year (average)
Data source: *the forth NHSS in Shaanxi province; **the implementation measure of basic health insurance schemes in
local government in Shaanxi province.
ds and 3239 rural households were identified. In
order to analyze the extent of catastrophic health
expenditure for the households enrolled in UEMS,
URMS and NCMS, we only chose the househol-
ds whose every family member was enrolled in
any of these three basic health insurance schemes.
Finally, 1215 households covered by UEMS or
URMS, and 2875 households covered by NCMS
were chosen in this study.
3. Methods
3.1 Measuring catastrophic expenditure
In this study, we used the household’s “capacity
to pay” as the denominator to calculate catastrop-
hic health expenditure, in which household non-
food expenditure was used as a proxy measure for
the “capacity to pay”. As Su5 suggested that diffe-
rent threshold levels should be used for compari-
sons, the threshold values used in this study were
10%, 15%, 25% and 40%. Out-of-pocket health
expenditure (OOP) only including direct medical
expenditure was used as a numerator to calculate
catastrophic health expenditure.
Two indicators were used in this study to me-
asure household catastrophic health expenditure:
the incidence and intensity of catastrophic expen-
diture. According to the research from the World
Bank1, head count (H) represents the incidence.
If the out-of-pocket health expenditure is T and
the household no-food expenditure is x, then T/x
means the share of OOP in no-food expenditure.
Given z is threshold, the indictor, E, equals 1 if Ti/
xi>z and zero otherwise. Then an estimate of the
head count is given by:
1500
URMS NCMS
Individual saving account Household saving account
Reimbursement rate: 31.9%
200-280 yuan (29-41 USD) 100 yuan (15 USD) per
per person per year person per year
1
∑
N
H= Ei .......................... (1)
N i =1
where N is the sample size and z=10%, 15%,
25% and 40%.
In order to capture the average degree by whi-
ch payment (as a proportion of non-food expen-
diture) exceeds the threshold z, another measure,
the household overshoot, which reflects the inten-
sity of catastrophic expenditure, was used. Define
the household overshoot as Oi = Ei ((Ti / xi ) − z ) .
Then the overshoot is simply the average:
1
∑
N
O= Oi .......................... (2)
N i =1
3.2 Logistic regression model
In order to indentify which factors are associ-
ated with the incidence of catastrophic health ex-
penditure, two logistic regression models19, with
whether the households’ health expenditure is ca-
tastrophic as the dependent variable, were deve-
loped for the households enrolled in urban health
insurance schemes (UEMS and URMS) and for
the households enrolled in NCMS.
Logistic regression model is a variation of or-
dinary regression which is used when the depen-
dent variable (Y) is a dichotomous variable (i. e.
it takes only two values, which usually represent
the occurrence or non-occurrence of some outco-
me event, usually coded as 0 or 1) and the inde-
pendent variables are continuous, categorical, or
both. The form of the model is:
Journal of Society for development in new net environment in B&H

p or not family member(s) visited doctors in the last
log( ) = b 0 + b1 X 1 + b 2 X 2 + ... + b k X k ..... (3)
1− p
Where p is the probability that Y=1 and X1,
X2,..., Xk are the independent variables. b 0 , b1 ,
b 2 ,…, b K are known as the regression coeffici-
ents, which have to be estimated from the data.
Instead of reporting regression coefficients,
Odds Ratios (O.R.) associated with the value of
each independent variable were reported as the
estimated results in this study. Odds ratio for an
independent variable is defined as the relative
amount by which the odds of the outcome increase
(O.R. greater than 1.0) or decrease (O.R. less than
1.0) when the value of the independent variable
is increased by 1.0 units. The odds ratio associ-
ated with the value X1 is estimated by using the
following formula:
P(Y = 1| X 1 = 1, X 2 ,..., X K ) / P(Y = 0 | X 1 = 1, X 2 ,..., X K )
exp( b1 ) =
P(Y = 1| X 1 = 0, X 2 ,..., X K ) / P(Y = 0 | X 1 = 0, X 2 ,..., X K )
........................................ (4)
Where exp( b1 ) is an estimate of this conditi-
onal odds ratio. The interpretation of exp( b1 ) is
as an estimate of the odds ratio between Y and X1
when the values of X2,..., Xk are held fixed.
3.3 Independent variables
Based on previous researches5, 6, 20, factors which
may associate with the household catastrophic he-
alth expenditure in this study were categorized into
three groups, namely, illness and treatment pattern,
households characteristic, and economic status.
The illness and treatment pattern included four
dummy variables: illness, chronic disease, outpati-
ent use and inpatient use (see table1). Illness refers
to whether family member(s) got ill in the last two
weeks, which was based on the question in the que-
stionnaire “did you feel physically uncomfortable in
the last two weeks”. Chronic disease refers to whet-
her family member(s) had chronic disease, which
was based on the question “did you get chronic di-
sease diagnosed by doctor in the last six months”.
Outpatient use and inpatient use refer to whether
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
two weeks and whether or not family member(s)
was hospitalized in the last year respectively, which
came from questions like “did you visit doctors in
the last two weeks” and “have you been hospitali-
zed in the last year”. We hypothesized that house-
holds with more illness and treatment would tend to
suffer catastrophic health expenditure.
Household characteristics included variables
like the gender of household head, whether 65
years old or older people were in the family, the
education level of household head, the location of
the family and family size. Specific descriptions
of these variables are listed in table1. According to
the literatures, we assumed that small households
with 65 years old or older people and low educa-
tion level of household head were likely to have
catastrophic health expenditure.
Economic status was measured by self-re-
ported consumption expenditure. Consumption
expenditure was used rather than self-reported
income because income is more likely to be mi-
sreported and consumption expenditure is a better
proxy for resources available21, 22. In this study, the
annual household consumption expenditure for
the households enrolled in urban health schemes
(UEMS and URMS) and the households enrolled
in NCMS were 16862 yuan (2468 USD) and 9643
yuan (1411 USD) respectively. Dummy variables
of quintile of socioeconomic status were introdu-
ced in each logistic model. We hypothesized that
households with low economic status would tend
to suffer catastrophic expenditure.
Further more, for the people enrolled in the ur-
ban health insurance schemes, dummy variables
of health insurance were introduced in the model
to distinguish whether the family members were
all enrolled in the same health insurance scheme
(UEMS or URMS) or enrolled in different heal-
th insurance schemes (UEMS or URMS). From
table 2, there were 54.57% households whose
members were all enrolled in UEMS and 13.33%
households whose members were all enrolled in
URMS. For the rest 32% households, some of the-
ir members were enrolled in UEMS and the other
were enrolled in URMS. As the benefit in UEMS
is better than in URMS, we assumed that house-
holds enrolled in URMS were more likely to incur
catastrophic expenditure.
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Table 2. Descriptions of independent variables

UEMS & NCMS
Variables Definitions
URMS (%) (%)
Health insurance
UEMS All the family members were enrolled in UEMS 54.57 —
URMS* All the family members were enrolled in URMS 13.33 —
UEMS&URMS Family members were enrolled in UEMS or URMS 32.10 —
Illness
Yes Family member(s) got ill in the last two weeks 27.33 66.62
No* No family member(s) got ill in the last two weeks 72.67 33.38
Chronic disease
Yes Family member(s) got chronic disease in the last six months 37.70 31.86
No* No family member(s) got chronic disease in the last six months 62.30 68.14
Outpatient use
Yes Family member(s) used outpatient service in the last two weeks 16.71 16.66
No* No family member(s) used outpatient service in the last two weeks 83.29 83.34
Inpatient use
Yes Family member(s) used inpatient service in the last year 11.69 13.36
No* No family member(s) used inpatient service in the last year 88.31 86.64
Gender
Male* The head of family was male 64.61 81.20
Female The head of family was female 35.39 18.80
65 years old
Yes 65 years old or older people in the family 26.75 25.04
No* No 65 years old or older people in the family 73.25 74.96
Education
Illiteracy The head of family was illiteracy 5.03 19.38
Elementary The head of family graduated from elementary school 11.05 32.42
Middle school The head of family graduated from middle school 28.94 40.26
High school The head of family graduated from high school 37.43 7.80
University* The head of family graduated from university 17.56 0.14
Area
North Located in the north of Shaanxi 3.70 10.50
Central* Located in the central of Shaanxi 93.42 46.61
South Located in the south of Shaanxi 2.88 42.89
Family size
1-2 people 1-2 members in the family 40.82 16.90
3-4 people 3-4 members in the family 51.85 49.74
More than 4 people* More than 4 members in the family 7.33 33.36
Economical status
Quintile1 The 20% low income families 19.79 19.94
Quintile2 The 20% low middle income families 20.20 20.01
Quintile3 The 20% middle income families 20.03 20.04
Quintile4 The 20% high middle income families 19.87 20.01
Quintile5* The 20% high income families 20.12 20.01
Note: *omitted group in the logistic regression model. The households enrolled in UEMS and URMS were combined together
in the study

1502 Journal of Society for development in new net environment in B&H


4. Results
4.1 Catastrophic health expenditure
Table 3 shows the incidence and intensity of ca-
tastrophic health expenditure for households enro-
lled in urban health insurance schemes (UEMS and
URMS) and in NCMS. As the threshold is raised
from 10 percent to 40 percent of non-food expen-
diture, the estimate of head count for the househol-
ds enrolled in urban health insurance schemes falls
from 68.07 to 16.87% and the overshoot drops from
13.36 to 2.68%. This indicates that, 16.87 percent
to 68.07 percent households covered by UEMS or
URMS suffered catastrophic health expenditure
and the average degree by which payment excee-
ded the thresholds varies from 2.68 percent to 13.36
percent. Compared with the households enrolled in
UEMS or URMS, both of the head count and over-
shoot were higher for the households enrolled in
NCMS at all threshold levels, which means the ho-
usehold catastrophic health expenditure was more
serious in NCMS than in UEMS or URMS. The-
re were 19.62 percent to 75.86 percent househol-
ds covered by NCMS which suffered catastrophic
expenditure and the corresponding average degree
ranged from 3.12 percent to 15.51 percent.
4.2 Factors associated with catastrophic
expenditure
Table 4 shows the estimated odds ratios in lo-
gistic models for the households enrolled in ur-
ban health insurance schemes. The odds ratios of
UEMS are all significant at different thresholds
levels and the odds ratios of UEMS&URMS are
significant at the thresholds levels ranging from
10% to 25%. This indicates that the probability of
Table 3. Incidence and intensity of catastrophic health expenditure (%)
Threshold budget share 10%
UEMS&URMS
Head count 68.07(1.34)
Overshoot 13.36(0.50)
NCMS
Head count 75.86(0.80)
Overshoot 15.51(0.34)
Note: Standard errors are in parentheses
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
suffering catastrophic expenditure for the house-
holds whose members were all covered by UEMS
was 1.72 to 3.05 times as much as the households
whose members were all covered by URMS, and
this number varies from 1.57 to 2.52 in terms of
the households whose members were covered by
UEMS or URMS. For the variables in the illne-
ss and treatment group, the odds ratios of chronic
disease and inpatient use are statistical signifi-
cant at all threshold levels, and the odds ratio of
outpatient use is statistical significant when the
thresholds are 25% and 40%. Any member(s) in
the household with chronic disease increased the
probability of catastrophic expenses by 1.94 to
2.40 times. Meanwhile, the presence of a member
utilizing outpatient services in the last two weeks
and the presence of a member utilizing inpatient
services in the last year increased the probability
of catastrophic expenses by 1.84 to 2.18 times and
by 1.94 to 4.11 times, respectively. Among house-
hold characteristics, the variables of 65 years old,
education and family size all had significant asso-
ciations with the incidence of catastrophic expen-
diture. 65 years old or older member(s) in the ho-
usehold increased the probability of catastrophic
expenses by 2.58 to 3.35 times. The households in
which the head of family didn’t take high-school
or higher education were more likely to suffer ca-
tastrophic health expenditure. Meanwhile, the ho-
useholds with small family size were more likely
to incur catastrophic health expenditure. Econo-
mic status is another variable that associated with
the incidence of catastrophic expenditure signifi-
cantly. The households with low economic status
tended to suffer more catastrophic expenses than
the households with high economic status.
Similar to table 4, table 5 shows the effects
of independent variables on the incidence of ca-
tastrophic health expenditure for the households
15% 25% 40%
52.35(1.43) 33.66(1.36) 16.87(1.07)
10.41(0.46) 6.23(0.36) 2.68(0.23)
62.33(0.90) 39.97(0.91) 19.62(0.74)
12.09(0.31) 7.18(0.26) 3.12(0.17)
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enrolled in NCMS. Variables of illness, chronic
disease and inpatient use in the illness and trea-
tment group had a positive association with the
incidence of catastrophic expenditure. In one
household, any member(s) that got ill in last two
weeks and any member(s) that got chronic disease
in the last six months increased the probability of
catastrophic expenses by 1.26 to 1.42 times and by
1.59 to 1.96 times, respectively. Meanwhile, the
probability of catastrophic expenses was increa-
sed by 3.19 to 4.85 times in the households whose
member(s) utilized inpatient services. In terms of
household characteristics, the variable of 65 years
old had a positive association with the incidence of
catastrophic expenditure, and the variables of area
and family size had a negative association with the
incidence of catastrophic expenditure. The proba-
bility of catastrophic expenses was increased by
1.32 to 1.76 times in the households with 65 years
old or older member(s). The households located
in the north and south of Shaanxi province suffe-
red less catastrophic expenditure than the central,
and the households with small family size were
more likely to have catastrophic expenditure. Like
the households enrolled in urban health insurance
schemes, the economic status of the households
enrolled in NCMS was associated with the inci-
dence of catastrophic expenditure significantly.
The poorer the households were, the more the pro-
bability of suffering catastrophic expenditure.
5. Discussion
Based on the data from China’s National Heal-
th Service survey, we calculated the incidence and
intensity of catastrophic health expenditure for
the households enrolled in urban health insuran-

Table 4. Estimated results of logistic regression model for the households enrolled in urban health in-
surance schemes
10% 15% 25% 40%
Odds Std. Odds Std. Odds Std. Odds Std.
ratio Err. ratio Err. ratio Err. ratio Err.
UEMS 1.72** 0.37 3.05*** 0.67 2.84*** 0.72 1.75* 0.55
UEMS&URMS 1.57** 0.36 2.18*** 0.51 2.52*** 0.68 1.49 0.51
Illness 0.96 0.23 0.82 0.19 0.78 0.18 0.73 0.22
Chronic disease 2.40*** 0.40 2.34*** 0.35 1.94*** 0.30 2.16*** 0.43
Outpatient use 1.23 0.35 1.48 0.39 1.84** 0.49 2.18** 0.70
Inpatient use 1.94** 0.53 2.73*** 0.67 3.58*** 0.79 4.11*** 0.96
Female 1.01 0.15 1.03 0.15 0.86 0.13 0.96 0.19
65 years old 3.35*** 0.76 2.58*** 0.47 2.65*** 0.47 3.35*** 0.69
Illiteracy 0.90 0.37 1.99* 0.77 2.50** 0.95 2.84** 1.28
Elementary 2.63*** 0.86 2.35*** 0.67 2.12*** 0.62 2.61*** 0.94
Middle school 2.14*** 0.43 2.39*** 0.49 2.26*** 0.51 2.26*** 0.71
High school 1.33 0.25 1.44* 0.27 1.42 0.31 1.37 0.43
North 0.75 0.26 1.38 0.47 1.22 0.46 1.19 0.60
South 0.67 0.27 0.68 0.26 1.17 0.48 1.12 0.62
1-2 people 1.50 0.43 1.52 0.41 3.20*** 0.98 2.88* 1.11
3-4 people 1.05 0.29 0.89 0.23 1.69* 0.50 1.39 0.53
Quintile1 1.62** 0.38 1.46* 0.33 1.34 0.34 0.97 0.31
Quintile2 1.42*** 0.16 1.45*** 0.16 1.32** 0.15 1.03* 0.07
Quintile3 1.15* 0.08 1.13* 0.08 0.99 0.08 0.82 0.12
Quintile4 1.03 0.05 1.06 0.06 1.09 0.06 0.98 0.07
LR chi210 204.66 275.41 277.14 256.95
P <0.001 <0.001 <0.001 <0.001
Pseudo R2 0.135 0.164 0.179 0.235
Note: The incidence of catastrophic health expenditure is dependent variable; *p<0.1, **p<0.05, ***p<0.01

1504 Journal of Society for development in new net environment in B&H

 HealthMED - Volume 5 / Number 6 / 2011

Table 5. Estimated results of logistic regression model for the households enrolled in NCMS
10% 15% 25% 40%
Odds Std. Odds Std. Odds Std. Odds Std.
ratio Err. ratio Err. ratio Err. ratio Err.
Illness 1.42** 0.22 1.26* 0.16 1.33** 0.16 1.22 0.18
Chronic disease 1.73*** 0.22 1.59*** 0.17 1.64*** 0.16 1.96*** 0.23
Outpatient use 1.28 0.24 1.28 0.19 1.20 0.17 1.24 0.20
Inpatient use 4.65*** 0.95 3.19*** 0.46 4.34*** 0.55 4.85*** 0.65
Female 1.05 0.13 1.01 0.11 1.05 0.11 1.15 0.15
65 years old 1.76*** 0.22 1.47*** 0.15 1.45*** 0.14 1.32** 0.16
Illiteracy 1.87 2.00 3.13 3.68 1.47 1.73 0.71 0.85
Elementary 1.67 1.78 3.34 3.92 1.23 1.45 0.56 0.67
Middle school 1.33 1.41 2.28 2.67 0.92 1.09 0.38 0.46
High school 0.97 1.04 1.75 2.06 0.80 0.95 0.38 0.46
North 0.45*** 0.07 0.69*** 0.10 0.90 0.13 1.43 0.54
South 0.70*** 0.07 0.76*** 0.07 0.71*** 0.07 0.70*** 0.08
1-2 people 1.02 0.17 1.28* 0.18 1.83*** 0.25 2.72*** 0.44
3-4 people 0.87 0.10 0.88 0.09 1.05 0.10 1.23 0.16
Quintile1 3.17*** 0.53 2.57*** 0.38 2.51*** 0.38 1.61*** 0.30
Quintile2 1.78*** 0.14 1.30*** 0.09 1.22*** 0.09 1.07 0.09
Quintile3 1.31*** 0.06 1.27*** 0.06 1.20*** 0.05 1.05 0.06
Quintile4 1.15*** 0.04 1.08** 0.03 1.08** 0.04 0.99 0.04
LR chi2(18) 319.70 299.62 409.41 396.00
P <0.001 <0.001 <0.001 <0.001
Pseudo R2 0.101 0.079 0.107 0.140
Note: The incidence of catastrophic health expenditure is dependent variable; *p<0.1, **p<0.05, ***p<0.01

ce schemes (UEMS and URMS) and for the ho- 24

useholds enrolled in NCMS. For the households
covered by urban health insurance schemes, there
were more than 32% of households in which some
of their members were enrolled in UEMS and the
others were enrolled in URMS. As these house-
holds cannot be assigned as UEMS enrollees or
URMS enrollees, in order to use the data of the-
se households, we combined the households en-
rolled in UEMS and URMS together to calculate
the catastrophic expenditure for the households
covered by urban health insurance schemes in-
stead of calculating the catastrophic expenditure
for the households covered by UEMS and URMS
independently. Two findings were generated from
the results: first, the household catastrophic health
expenditure was still very serious in China even
though households were covered by basic health
insurance schemes, in which the incidence and in-
tensity of catastrophic expenditure were not only
higher than those in OECD countries11, 12, 23 but also
higher than those in other developing countries4, 23,
, second, the households enrolled in NCMS su-
ffered more catastrophic health expenditure than
the households enrolled in urban health insurance
schemes. The major purposes of Chinese basic he-
alth insurance schemes were to reduce househol-
ds’ burden on the expenditure of catastrophic dise-
ase. That’s why all the three basic health insurance
schemes’ benefit packages were focused on the in-
patient service. However, from the results of this
study, China has a long way to go to reduce the
catastrophic health expenditure effectively. Furt-
hermore, the fact that the reimbursement rate in
NCMS was lower than that in UEMS and URMS
might be one of the major reasons to cause more
households to suffer catastrophic expenditure in
NCMS than in UEMS and URMS.
Results of the logistic model showed that fac-
tors of health insurance, chronic disease, inpatient
use, 65 years old, education, family size and econo-
mic status were associated with the probability of
catastrophic expenditure for the households cove-
red by urban health insurance schemes, and factors

Journal of Society for development in new net environment in B&H 1505

HealthMED - Volume 5 / Number 6 / 2011
like illness, chronic disease, inpatient use, 65 ye-
ars old, area, family size and economic status were
associated with catastrophic expenditure for the ho-
useholds covered by NCMS. As we expected, the
small households with more illness and treatment,
65 years old and older family member, and low
economic status tended to suffer catastrophic health
expenditure, which is also consistent with the re-
sults of previous studies5, 17, 20. Furthermore, for the
households enrolled in urban health insurance sche-
mes, the household head with low education level
increased the incidence of catastrophic expenditure,
which was also proved by Pal6. For the households
enrolled in NCMS, people in the north and south of
Shaanxi province were less likely to have catastrop-
hic expenses than the people in the central.
In terms of the factor of health insurance in
the logistic model for the households enrolled in
urban health insurance schemes, as the reimbur-
sement rate for inpatient service in UEMS was
much higher than that in URMS, we assumed that
households enrolled in URMS were more likely to
incur catastrophic expenditure after controlling ot-
her factors’ effects. However, the analysis results
showed that the households enrolled in UEMS
suffered more catastrophic expenditure than the
households in which part of the members enro-
lled in UEMS and the rest enrolled in URMS, and
both of them suffered more catastrophic expendi-
ture than the households enrolled in URMS. One
of the probably reasons is that the patients cove-
red by UEMS may demand services that the pati-
ents covered by URMS would not demand as the
better benefit package of UEMS, which made the
UEMS enrollees’ per-visit inpatient expense much
higher than the URMS enrollees. From the forth
National Health Service Survey in this study, the
average per-visit inpatient expense for the UEMS
enrollees was 7314 yuan (1071 USD) versus 3268
yuan (478 USD) for the URMS enrollees.
This study faced a couple of limitations. First,
as only the direct cost of health care was captured
in the survey, indirect costs (e.g. transportation and
gifts), which also affects the prevalence of catastrop-
hic health expenditure, were not included in the he-
alth expenditure. Second, in addition to health spen-
ding, the patients’ earnings losses also could incur
catastrophic economic consequences. However, the
lost earnings could not be accessed in this study. Be-
1506 Journal of Society for development in new net environment in B&H
cause of the above two limitations, the catastrophic
health expenditure might be under-estimated.
6. Conclusion
Although households have been covered by
basic health insurance schemes, rural and urban
households still suffer severe catastrophic health
expenditures in China. As the inpatient expense
only accounts for 47.4% of total health expense in
China25, the three basic health insurance schemes
which only cover hospitalization are not effective
to prevent catastrophic health expenditure. In or-
der to reduce catastrophic expenditure, we recom-
mend the Chinese government to expand the be-
nefit package of health insurance schemes for co-
vering outpatient services as well as improve the
reimbursement rates. Furthermore, the results of
logistic models indicate that policies like strengt-
hening illness prevention and subsidizing low-in-
come households are very useful for reducing the
incidence of catastrophic expenditure in China.
Acknowledgement
This study was supported by the Ministry of
Education of China (Serial number: 08JZD0022).
Reference
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9. Ranson MK. Reduction of Catastrophic Health
Care Expenditures by a Community-Based Health
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riences and Challenges. Bulletin of the World Heal-
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10. 2000. Twhr. Health systems: improving perfor-
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11. Yardim MS, Cilingiroglu N, Yardim N. Catastrop-
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alth expenditure on the transition to poverty and
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catastrophic health expenditure: evidence from
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nants of Household Catastrophic Health Expen-
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cal Bulletin of National Economy and Social
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1):S37-46.
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Corresponding author
Zhongliang Zhou,
School of Public Policy and Administration,
Xi’an Jiaotong University,
China,
E-mail: zzliang1981@163.com
1507
HealthMED - Volume 5 / Number 6 / 2011

The Effect of Using Sauna (Dry and

Steam) and Cold Water on BP (Systolic
and Diastolic) and HR in Male Athletes
Alireza Rahimi1, Jaber Safarkhan Mo’azeni2, Zynalabedin Fallah3, Abbas Esfandiari3
1
Department of physical Education, Karaj Branch, Islamic Azad University, Karaj, Iran,
2
Department of physical Education, Aliabad Branch, Islamic Azad University, Aliabad, Iran,
3
Department of physical Education, Gorgan Branch, Islamic Azad University, Gorgan, Iran.

Abstract
The purpose of this research was the effect of
using sauna (dry and steam) and cold water on BP
(blood pressure) and HR (heart rate) in male ath-
letes. For this objective 30 male’s student of Azad
University of Karaj (18-25 ages) were divided
randomly in to A group (for steam sauna) and B
group (for dry sauna). BP (systolic and diastolic)
and HR were measurement at three phases: before
and after sauna and also after of using cold water.
Data analysis with using one way ANOVA indi-
cated a significant increase in BP (systolic) and
HR after sauna and also the significant increase
in BP (diastolic) and HR after use of cold water
between two group. The results of this test shows
more decrease in diastolic pressure B group than
A group (P=0/05). Our finding suggested All of
people who want to use of sauna and cold water
must pay attention to the notes and recommenda-
tions which relates to using sauna, especially those
people who stricken with one of dues with heart
diseases such as: Coroner of heart, arteriosclerosis
or have a background of Heart Failure must con-
sult with their doctor to going to sauna.
Key words: Sauna, Blood Pressure, Heart Rate
all tiredness and stresses from body, but also bring
an average excitement during race and daily life
(Rowell 2005). Sauna is a suitable device for heal-
thy and brings physical preparation to all people.
A dry sauna induces sweating and is indicated for
general tension and insomnia, but is also increa-
ses metabolism, increases circulation, and aids
in the removal of toxins. Because of the intense
heat and minerals lost during the sweating respon-
se, limit the sauna bath treatments to once a week
(Susan, 2004). Undoubtedly, today using of sauna
is a common method among people and athletes.
The most effect of using sauna is removing tired-
ness and bring relax to soul and body that most
athletes need to this item. Although using of this
method is a common way to all athletes around
world, but there isn’t a correct rule for using sauna
to all people and athletes in our country yet. Per-
haps another common reason– besides decrease of
services –is, people don’t aware of suitable effects
of sauna. This significant point is important for old
people or those people who have heart diseases or
breathing problems (Baltimore, 2002; Surkovic,
2010). So according to importance of subject of
project which relates to using of dry and steam sa-
una and studies the effects of that on BP and HR is
necessary to know.

Introduction
When we have a discussion about sauna, seems
logically that first of all, we must notice to physi-
ological changes or harmonies that is the result of
using sauna. Sauna bathroom is a heating device
for athletes and usual people, and not only remove
Methodology
In this project, 30 male students (18-25 ages) of
Azad University of Karaj participated voluntary.
We decided randomly these people into two gro-
ups. Each group in a special day were guided to sa-

1508 Journal of Society for development in new net environment in B&H


una in order to do the test and use of dry and steam
sauna and cold water. Every one of them was he-
althy and took part in this project voluntary. Be-
fore doing the test, took written testimonial from
them and choose group A to use steam sauna and
group B to use dry sauna. For each group, before
enter to the sauna(dry and steam) and in relaxing
conditions, immediately after coming out of sauna
and cold water, measured the HR and BP of those
people. In order that, we numbered 15 seconds to
the HR of them in each of three level (before and
after of sauna and after of cold water), and in or-
der to measure BP, we used of special apparatus
for do the measurement (Esfeigmo manometer).
The time of staying in the dry and steam sauna
for each of groups determined 12 minutes and for
cold water determined 30 seconds. (According to
legality of using of sauna).The subjects entered to
sauna every 4 minutes. All of them learned how
to use sauna and emphasized to them that don’t
do any activity, don’t eat anything, don’t lengthen
your body, don’t walk in the sauna and must sit on
the first step of sauna. The test performed for two
groups in the same time and with same conditi-
ons. Data of BP and HR of subjects saved in three
levels (before and after of sauna and cold water),
then data was processed. The place of performan-
ce of project was Shariati’s sauna.
Finding of the Research
The results of this project with using of one
way ANOVA and t test (independent) between
two groups, shows significant difference% 98/5
on P=0/05, on BP diastolic after of sauna and HR
after of cold water. The meaningful decrease in
BP systolic, diastolic and HR after using of cold
water emphasizes that we must pay attention to
use of sauna (especially old people and illnesses
of heart). The results of performing test on group
A and B which in series use steam sauna and dry
sauna shows that:
There is a significant difference between BP
systolic of each group. Also is a significant dif-
ference between HR of subjects after cold water.
Imagination zero of project based on having no ef-
fect of sauna and cold water on BP and HR was re-
fused and the opposite imagination was accepted.
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
Study of BP systolic of subjects in group A and B,
and comparing BP systolic before sauna with after
sauna and after cold water which don’t show the
statistically difference, but says increasing values
in this variable.
A) BP systolic of subjects in group a (steam
sauna): after sauna in comparison with before
sauna, averagely increased 19mmHg, and
after cold water in comparison with after
sauna was decreased 11mmHg.
B) BP diastolic of subjects in group A (steam
sauna): after sauna in comparison with before
sauna was decreased averagely 1mmHg, and
after cold water in comparison with after
sauna also it was decreased 1mmHg.
C) The average HR of subjects in group A (steam
sauna): after sauna in comparison with before
sauna was increased 37 beat per minute, and
after cold water in comparison with after
sauna, it was decreased in 7 beat per minute.
D) BP systolic of subjects in group B (dry sauna):
after sauna in comparison with before sauna
was increased averagely 14mmHg, and after
cold water in comparison with after sauna, it
was decreased 14mmHg.
E) The average BP diastolic of subjects in group
B (dry sauna): after sauna in comparison with
before sauna, it was increased 8mmHg, and
after cold water in comparison with after
sauna, it was decreased 11mmHg.
F) HR of subjects in group B (dry sauna): after
sauna in comparison with before sauna, it
was increased averagely 38 beat per minute,
and after cold water in comparison with after
sauna, it was decreased 24 beat per minute.
Study of these changes in group A and B shows
that BP systolic after using steam sauna in compa-
rison with dry sauna, have more increase but after
cold water, we see more decrease in BP systolic
of group B(dry sauna).(14 mmHg in consideration
of 11mmHg).BP diastolic of subjects in group A,
after using sauna shows the decrease of 1 mmHg
and also after cold water, 1 mmHg was decreased,
but in group B this decrease is more than that and
after sauna, it was 8 mmHg and after cold water
it was 11mmHg. The average of HR of subjects
in both group, after sauna was increased and after
cold water was decreased, but the decrease of HR
1509
HealthMED - Volume 5 / Number 6 / 2011
in group B, after cold water was more than gro-
up A(in series is 24 beat and 7 beat per minute).
By paying attention to that artery BP is equally
with heart exogenous multiplied with resistance
of sweaty with increase of heart exogenous which
is result of increase of HR multiplied with strock
volume, it seems that BP systolic and diastolic
also will increase and decrease. So, the changes
of increasing of BP systolic and diastolic after sa-
una can depend to the increasing of HR and as a
result depend to the exogenous of heart. We need
to study more about BP diastolic in group B which
has a remarkable increase nearly 8mmHg.
Table 1. The comparison of using of dry and steam
sauna In three levels between two groups
Comparing variables in 3 lev-
F sig
els between 2 groups A and B
BP systolic before sauna 0/233 0/635
BP diastolic before sauna 0/057 0/814
HR before sauna 0/053 0/820
BP systolic after sauna 103 0/752
BP diastolic after sauna 7/182 *0/015
HR after sauna 0/027 0/872
BP systolic after cold water 0/770 0/392
BP diastolic after cold water 0/000 0/989
HR after cold water 7/253 * 0/015
* Significant in P=0/05
Discussion and conclusion
According to the significant changes in BP sy-
stolic, diastolic and HR of testees in comparison
between three previous levels and after sauna and
after cold water, we must pay attention and discuss
about following items: According to this item that
subjects of this project was young university men
and they were practiced (athletes) and was in a full
healthy and in method of performance of project,
there wasn’t any light activities such as: walking,
alternate activities or sucking in order to heating
themselves, the changes of increasing BP systolic
(in group A is more and in group B is less) and di-
astolic (in group B is more and in group A is less)
and HR, shows up these items:
These remarkable changes in BP systolic, dia-
stolic and HR that relate to each other, is important
to all people especially old people and who are
heart diseases or breath illnesses. The first reco-
1510 Journal of Society for development in new net environment in B&H
mmendation to these people is to discuss with an
expert doctor and having correct and careful me-
dical observation. Even young people and central-
age people should aware of healthy of heart and
breathing before using sauna (Hainsworth 2005).
Performing several stretch movements or alter-
native movements with a purpose of heating body,
is a good way to prepare heart or breathing organs
with these changes (Bouchard 2007).According
to these seen changes in this project, to increase
BP and HR nearly is same with changes which
body produce in body activities, so heating level
is suitable for body (America Heart Association,
2008). According to studies on more than %50 of
healthy and adult's people, after they begin an acti-
vity without heating the body, more seconds later,
a kind of Ischemia reaction of heart was showed
on Electro Cardiogram. (Decrease of ST segment)
(Rubin, 2009). The pain of chest usually relate to
heating act. Temporary Ischemia is acceptable to
some people. According to that, if a susceptible
person is heart disease person or heart have pro-
blem with saving and access of oxygen, the effect
if heavy exercise without heating body, could be
dangerous. Studies showed that before enter pre-
ssure to heart, it’s better to do movements in order
to heating body (Fox, 2003).
The time of staying in sauna and haven’t any
body activity (in sauna), are such an important po-
ints to pay attention to them, because staying more
(more than 12 to 15 minutes) and doing body ac-
tivity are results of increasing the pressure which
enter to heart organs (Gledhill, 2002).
After increasing of BP of systolic, diastolic and
HR after sauna, using of cold water lead to remar-
kable decrease of these variables. The results of
studies show that sinistering face into water is a
result for decrease of HR. For Brady Cardia (de-
crease of HR), we can say that swift analyzes of
done work directly don’t depend and don’t seem
that the amount of physical preparation have an
effect on amount of Brady Cardia. The effect of
Brady Cardia on performance of Dynamic activi-
ties is more than performance of stand activities
(Hole, 2005). According to that, when Brady Car-
dia is normal, so the narrowing of swifts, recover
the decrease of HR. Great point is, when you sini-
ster your face into water, it results to decrease of
HR and blood stream. This situation is with when

you jump into water (Swain 2008). So we suggest
that after came out of sauna, have a bath with te-
pid water which have less heat in comparison with
environment of sauna, and wash your body. Then
walk or sit outside of environment of sauna for 2
to 4 minutes in order to the temperature of body
is reconciling with environment. Then you must
enter calmly to the cold water pool by using lad-
der. The disillusioned of body must starts from
legs then goes to upper side of body. The time of
refrigerate shouldn’t be long and never enter to the
cold water without bathing. At this point, the most
danger is for people who enter to the pool with
head and have heart disease (Cowley, 2006).
All of these suggests are for heating body be-
fore entering to the sauna is for increasing that
happen in the BP and HR, so to prophylaxis of ha-
ving hurt or negative reactions in heart organs, we
must do the heating level and physical preparation
before enter to the sauna and also pay attention
to recommendations after sauna to use cold water
pool in order that heart organs don’t have sudden
increase or decrease of BP or HR. The increasing
of BP after sauna which is the result of effect if
temperature of HR and increase of exogenous of
heart and in other hand, the decrease of HR(Brady
Cardia) after pool which is a result of sinister head
and face into water, shows that we must be aware
of these changes. The first step is discuss with an
expert doctor and after that, paying attention to the
guide of using of sauna in order to take the suita-
ble effects of sauna(Astrand, 2005).
All of people who want to use of sauna and cold
water must pay attention to the notes and recom-
mendations which relates to using sauna, specially
those people who stricken with one of dues with
heart diseases such as: Coroner of heart, arteriosc-
lerosis or have a background of Heart Failure must
consult with their doctor to going to sauna.
References
1. America Heart Association. (2008). Statement on
exercise. Circulation 86:340-44.
2. Astrand, P. et al. (2005). Intra- arterial blood pre-
ssure during exercise with different muscle groups.
Journal of Applied Physiology 20:253-57.
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3. Baltimore, Lippincott, Williams & Wilkins. (2002)
ACSM's Guidelines for Exercise Testing and Pres-
cription. 6th end
4. Bouchard, R.J. Shephard, T. Stevens, J. R. Sutton,
and B. D. Mcpherson C. (2007). Physical activity
and physical fitness as determinants of health and
longevity. In Exercise, Fitness and Health, Ed . 33-
48. Chmpaign, IL: Human Kinetics
5. Cowley, A. (2006). Long-term control of arterial
blood pressure. Physiology Review 72:231-300.
6. Fox, S (2003). Human Physiology. New York: Mc-
Graw-Hill Companies.
7. Gledhill, N. et al. (2002). Endurance athletes' stro-
ke volume does not plateau: Major advantage is
diastolic function. Medicine and Science in Sports
and Exercise 26:1116-21.
8. Hainsworth, R. (2005). Reflexes from the heart.
Physiological Reviews 71:617-58.
9. Hole, J. (2005). Human Anatomy and Physiology.
New York: McGraw- Hill Companies.
10. Rowell, L., and D. O'Leary. (2005). Reflex control
of the circulation during exercise: Chemoreflexes
and mechanoreflexes. Journal of Applied Physio-
logy. 69: 407 – 18.
11. Rubin, S. (2009). Core temperature regulation of
heart rate during exercise in humans. Journahs of
Applied Physiology 62:1997.
12. Surkovic, I. Suljevic, I. Kudumovic A. Comparison
of arterial blood pressure values in dysfunction of
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13. Susan G. Salvo. (2004) Massage therapy. Princi-
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Corresponding author
Alireza Rahimi,
Department of physical Education,
Karaj Branch,
Islamic Azad University,
Iran,
E-mail: a_r_rahimi@hotmail.com
1511
HealthMED - Volume 5 / Number 6 / 2011

A Clinical trial to compare the

effectiveness of Lavender essential
oil and olive oil at healing
postpartum mother’s perinea
Fereshteh Behmanesh1, Maryam Tofighi2, Mouloud Agajani Delavar3, Mahtab Zeinalzadeh4, Ali Akbar
Moghadamnia5, Soraya Khafri6
1
Department of Midwifery, Babol University of Medical Sciences, Babol, Islamic Republic of Iran,
2
Department of Midwifery, Islamic Azad University of Sari branch, Sari, Islamic Republic of Iran,
3
Fatemezahra Infertility and Reproductive Health Research Center, Department of Midwifery, Babol
University of Medical Sciences, Babol, Islamic Republic of Iran,
4
Fatemezahra Infertility and Reproductive Health Research Center, Department of Obstetrics and
Gynecology, Babol University of Medical Sciences, Babol, Iran,
5
Department of Pharmacology, Babol University of Medical Sciences, Babol, Iran,
6
Department of Social Medicine and Health, Babol University of Medical Sciences, Babol, Iran.

Abstract re at 2 hours, 5th, and 10th days postpartum for three

Episiotomy is the most surgical procedure in the
world with few complications and perineal pain.
Lavender essential oil and olive have antiseptic and
healing effects. The aim of this study was to investi-
gate the effect of lavender essential oil and olive oil
on postpartum mother's perineal healing. A double
blind clinical trial was done on 89 selected eligi-
ble women with mediolateral episiotomy or peri-
neal tear grade 2. After episiotomy repaired, they
were randomly allocated into three groups: group
1 underwent care by 10 drops lavender essential
oil 2% based olive oil sitz bath (5 liters), group 2
by 10 drops olive oil sitz bath (5 liters) and group
3( control group) by 10 drops distilled water sitz
bath(5 liters) BID for ten days. The study data were
collected through demographic data, REEDA sca-
le and visual analog scale of pain. The data were
analyzed by repeated measure of ANOVA, Chi 2
test, via SPSS version 16. All statistical testes were
two-tailed, and p-values of ≤0.05 were considered
statistically significant. There was significant diffe-
rence in REEDA scale between group 1 with group
3 (p=0.002) and group 2 with group 3 (p=0.000),
but there was no significant difference between gro-
up 2 with group 3. There was a change in VAS sco-
different groups (p=0.032). There was significant
difference in VAS score for three different groups
(p=0.030), but there was no significant difference
between two groups together. This study suggests
that lavender based-on olive oil and olive oil added
to routine water sitz bath for post-episiotomy care.
Key words: Aromatherapy; Episiotomy; Peri-
neum; Wound
Introduction
Episiotomy is a surgical incision made into the
perineum area that is usually done to prevent sever
perinea tears, that heals poorly (1). In 1850, it was
first introduced in the United States (2). The rate of
episiotomy varies between 8% in Netherlands and
99% in Eastern Europe (3). Asian women are likely
to require episiotomy compared with non Asian wo-
men as Asian skin tends not to stretch as well as Ca-
ucasians (4). Recently, routine mediolateral episio-
tomy is performed routinely in primiparous women
in Iran. Complications and benefits of episiotomy
are many although its benefits are not sufficiently
proven. Episiotomy, especially mediolateral episi-
otomy has more postpartum pain and takes longer

1512 Journal of Society for development in new net environment in B&H


to heal and it causes considerable distress (5). Then,
postpartum episiotomy wound care must be provi-
ded in order to minimize pain and assist healing (1).
In Iran, warm water sitz bath or povidon- io-
dine sitz bath has traditionally been provided by
obstetricians and midwives for postpartum episi-
otomy wound care. If has been well documented
however that povidone-iodine decrease wound
strength or impair wound healing. The currently
advocated strategy for postpartum care includes
the use of complimentary non-pharmacological
adjuvant therapies in aromatherapy. Aromathera-
py is the use of essential oils from plants for re-
ducing pain and improving patient's satisfaction.
Essential oil is concentrated extracts taken from
the roots, leaves, seeds or blossoms of plants (6).
Lavender oil aromatherapy, in particular, has
been credited with smooth muscle relaxing, anti-
infection, anti-colic properties by aromatherapies
(7, 8). Herbal sitz bath, such as lavender essential
oil and olive oil, may help to prevent infection,
speed up healing and offer pain relief on postpar-
tum women (9). Preliminary poor quality research
reports no benefits further well designed research
is needed to confirm these results (6, 10, 11). The
current study was designed to test whether aroma-
therapy with lavender essential oil and olive oil
would improve the postpartum episiotomy wo-
und of patients undergoing a routine mediolateral
episiotomy procedure. To test this hypothesis, we
conducted a prospective randomized double blind
placebo control study. We investigated the effect
of lavender essential oil and olive oil on postpar-
tum mother's perineal healing.
Methods
This study was conducted with the approval of
Ethics Committee of Babol university of Medical
Sciences. Informed written consent was obtained
from all the participants. Women ages between 17
and 34 years old were recruited to participate in
the study.
Lavender essential oil, olive oil and sterile wa-
ter (placebo) were provided by an essential oil su-
pplier (In Barij essence, Tehran, Iran). The remin-
der of the trial was to be conducted independent of
the supplier.
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
This study design required 90 women. In coo-
perating a potential 10% lost to follow up trial was
designed to induce a total of 89 participants. Parti-
cipants were randomized into three groups accor-
ding to predetermined random sequence: group 1
underwent care by lavender essential oil 2% based
olive oil sitz bath, group 2 by olive oil stiz bath
and group 3 (control group) by distilled water sitz
bath. The sitz bath with 10 drops of essential oil or
olive oil distilled water in 5 liters of warm water
was used twice a day for ten days.
Women were eligible to participate if they had
primiparous cephalic presentation, spontaneous
delivery after 37 weeks of gestation and a second
– degree perineal laceration or a mediolateral epi-
siotomy. The standard suture material used in the
all participants was catgut suture gauge 2/0, 75 cm
long, 36 mm needle.
The standard analgesia for perineal repair was
infiltration analgesia in the wound area using 5-10
ml lidocain 10 mg/ml. All operators performed
mix suture techniques according to preference and
surgical skills.
Exclusion criteria include individuals with
ventouse cup or forceps delivery, perineal injuri-
es involving anal sphincter and anal mucosa, post
partum hemorrhage, medical disorder, retained
placenta, multiple pregnancy.
At 2 hours, 5 th and 10 th days after delivery, a
research midwife, blinded to the herbal sitz both,
a face to face structured interview followed by an
examination of the woman's perineum in lithotomy
position. Pain was registered using a 100- mm visu-
al analogue scale (VAS) (12). Postpartum healing of
the perineum was evaluated following an episioto-
my / laceration by a systemic assessment of redness,
edema, echymosis, discharge, and approximation of
the wound edges known as the REEDA scale (13).
The data were analyzed by repeated measure
of ANOVA, Chi 2 test, via SPSS version 16. All
statistical testes were two-tailed, and p-values of
≤0.05 were considered statistically significant.
Results
The 99 women were chosen randomly. Ten wo-
men withdrew their consent not to participate, lea-
ving 89 participants for a follow up. Table 1 shows
1513
HealthMED - Volume 5 / Number 6 / 2011

information regarding the socioeconomic status,
demographic and delivery characteristics of the
treatment groups. Three groups were similar at the
time of trial entry in terms of demographic, soci-
oeconomic status, delivery detail, perinea repair,
and operator experience.
As shown in table 2, no difference was seen in
REEDA scale at 2 hours postpartum. The REEDA
scale was significantly low in the experimental gro-
up on the 5th and the 10th days postpartum (p=0.000).
There was a change in REEDA scale across 2 ho-
urs, the 5th, the 10th day postpartum (p=0.000).
There was a change in REEDA scale at 2 hours,
on the 5th, and the 10th day postpartum for three
different groups (p=0.000). There was signifi-
cant difference in REEDA scale between group 1
with group 3 (p=0.002) and group 2 with group 3
(p=0.000), but there was no significant difference
between group 2 with group 3.
There was a change in VAS score across 2
hours on the 5th, and on the 10th day postpartum
(p=0.000). There was a change in VAS score 2 ho-
urs, on the 5th, and 10th day postpartum for three
different groups (p=0.032). There was significant
difference in VAS score for three different groups
(p=0.030), but there was no significant difference
between the two groups together.
Discussion
This study showed, lavender and olive oil aro-
matherapy that was administered in the immediate
postpartum period to women undergoing delivery

Table 1. Socioeconomic, demographic and delivery characteristic of the treatment groups

Lavender essential oil Olive oil Water (Control)
Variables P-value
Mean±SD Mean±SD Mean±SD
Age (years) 24.6±3.6 25.5±4.5 24.1±3.9 0.584
Education (years) 11.4±2.2 10.9±3.4 9.8±3.5 0.670
Job f (%) f (%) f (%)
Houswife 25 (83.3) 29 (96.7) 28 (96.6) 0.110
Working 5 (16.7) 1 (3.3) 1 (3.4)
Income (toman/month)
< 300.000 15 (50.0) 23 (76.7) 19 (65.5) 0.097
≥ 300.000 15 (50.0) 7 (23.3) 10 (34.5)
Status of operator
Midwife 19 (63.3) 12 (40.0) 21 (72.4) 0.586
Student 11 (36.7) 18 (60.0) 8 (27.6)
Mean±SD Mean±SD Mean±SD
Length of labor (hours) 7.9±5.1 7.3±6.1 7.7±6.4 0.13
Time taken to complete
31.7±11.9 26.0±9.0 27.4±12.0 0.05
repair (minutes)

Table 2. Comparison between three groups at 2 hours, 5th, and 1oth days, after delivery
Lavender essential oil Olive oil Water (Control)
Outcome measure P-value
Mean±SD Mean±SD Mean±SD
UAS score 0.0-10.0 possible
At 2 hours 4.4±2.5 4.4±2.2 4.0±2.3
At 5 days 7.2±2.3 3.2±1.9 4.4±2.4
0.030
At 10 days 1.3±1.5 0.8±1.1 1.8±1.9
REEDA score
In 2th hours 1.1±1.2 1.2±1.1 1.1±1.5
In 5th days 1.8±1.5 1.3±1.0 3.0±2.0
0.001
In 10th days 0.1±0.9 0.3±0.5 2.1±1.8

1514 Journal of Society for development in new net environment in B&H


with episiotomy is as effective method with the
impact on postpartum perinea pain and healing.
However the pain score showed no statistical dif-
ferences between the groups.
There are many factors that can inhibit healing
and adequate pain relief methods. Some resear-
chers reported that essential oils have antibacterial,
antifungal and antimicrobial effect and kill many
strains of fungi, viruses and gram negative and
positive bacteria (14-17). It seems that lavender
contains linalyl acetat and linalool with sedative
effects (18). Therefore, lavender oil is frequently
selected for aromatherapy as having antiseptic and
healing properties.
Our finding is consistent with the prior study
that indicates that lavender essential oil in the po-
stpartum care has a positive effect on the subjec-
tive experience of wound healing and pain sco-
re (19-22). While in this study, we reported that
there was no statistical differences in pain score
between groups. Since there are different clini-
cal applications of aromatherapy in relation to
dosage, methods of administration, these factors
may influence the reducing pain and improving
patient's condition. This was shown in this study
that adding six drops of pure lavender oil to bath
water reduces perineal pain discomfort with no
statistical differences between the groups (22).
Conclusions
There are several limitations in the study. First,
the study could not measure the level of either
essential oils constituent in plasma and could not
obtain smear of episiotomy wound. Second, we
did not discuss about the mechanism of effects of
essential. Third, the placebo effect cannot be igno-
red. The use of real placebo is difficult because of
the perfume of essential oil. In conclusion, there is
no difference in pain or wound healing in 2 hours,
on the 5th and the 10th day after delivery when
comparing a lavender essential oil stiz bath with
olive oil sitz bath in postpartum care. VAS sca-
le and REEDA score were similar. These results
are encouraging and suggest further investigation
using potential patients may result in the deve-
lopment of useful aromatherapy for postpartum
mother's perineal healing.
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
Acknowledgments
We would like to thank Babol University of
Medical Sciences for their support, the women of
Babol for their participation in this study, and the
assistance of Maraym Hoseini, in the sampling.
References
1. Carroli G, Mignini L. Episiotomy for vaginal birth.
Cochrane Database Syst Rev. 2009(1):CD000081.
2. Kettle C, Tohill S. Perineal care. Clin Evid (Onli-
ne); 2008.
3. DeFrances CJ, Podgornik MN. 2004 National
Hospital Discharge Survey. Adv Data. 2006 May
4(371):1-19.
4. Dahlen H, Homer C. Perineal trauma and po-
stpartum perineal morbidity in Asian and non-
Asian primiparous women giving birth in Austra-
lia. J Obstet Gynecol Neonatal Nurs. 2008 Jul-
Aug;37(4):455-63.
5. Larsson PG, Platz-Christensen JJ, Bergman B,
Wallstersson G. Advantage or disadvantage of epi-
siotomy compared with spontaneous perineal lace-
ration. Gynecol Obstet Invest. 1991;31(4):213-6.
6. Basch E, Foppa I, Liebowitz R, Nelson J, Smith M,
Sollars D, et al. Lavender (Lavandula angustifolia
Miller). J Herb Pharmacother. 2004;4(2):63-78.
7. Lis-Balchin M, Buchbauer G, Hirtenlehner T, Res-
ch M. Antimicrobial activity of Pelargonium essen-
tial oils added to a quiche filling as a model food sy-
stem. Lett Appl Microbiol. 1998 Oct;27(4):207-10.
8. Denner SS. Lavandula angustifolia Miller: En-
glish lavender. Holist Nurs Pract. 2009 Jan-
Feb;23(1):57-64.
9. Postpartum Herbal Bath. 2011 [cited; Available
from: http://www.womensdocs.com/lib/pdf/Po-
stpartum/Postpartum_Herbal_Bath.pdf
10. Ching M. Contemporary therapy: aromatherapy
in the management of acute pain? Contemp Nur-
se. 1999 Dec;8(4):146-51.
11. Lavender Lavandula angustifolia Miller. Copyri-
ght © 2010 Natural Standard [cited; Available
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pplements/lavender-lavandula-angustifolia-miller
1515
HealthMED - Volume 5 / Number 6 / 2011

12. Scott J, Huskisson EC. Graphic representation of Corresponding author

pain. Pain. 1976 Jun;2(2):175-84. Mouloud Agajani Delavar,
Department of Midwifery,
13. Davidson N. REEDA: evaluating postpartum hea- Babol University of Medical Sciences,
ling. J Nurse Midwifery. 1974 Summer;19(2):6-8. Ganjafroz, Babol,
14. Gutierrez J, Barry-Ryan C, Bourke P. The an- Iran,
timicrobial efficacy of plant essential oil combi- E-mail: moloodaghajani@yahoo.com
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15. Cavanagh HM, Wilkinson JM. Biological activi-
ties of lavender essential oil. Phytother Res. 2002
Jun;16(4):301-8.
16. D'Auria FD, Tecca M, Strippoli V, Salvatore G,
Battinelli L, Mazzanti G. Antifungal activity of La-
vandula angustifolia essential oil against Candi-
da albicans yeast and mycelial form. Med Mycol.
2005 Aug;43(5):391-6.
17. Scollard J, Francis GA, O'Beirne D. Effects of
essential oil treatment, gas atmosphere, and sto-
rage temperature on Listeria monocytogenes
in a model vegetable system. J Food Prot. 2009
Jun;72(6):1209-15.
18. Suntar I, Akkol EK, Keles H, Oktem A, Baser
KH, Yesilada E. A novel wound healing ointment:
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onal Turkish knowledge. J Ethnopharmacol. Mar
8;134(1):89-96.
19. Hur MH, Han SH. [Clinical trial of aromatherapy
on postpartum mother's perineal healing]. Taehan
Kanho Hakhoe Chi. 2004 Feb;34(1):53-62.
20. Dale A, Cornwell S. The role of lavender oil in re-
lieving perineal discomfort following childbirth: a
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21. Woollard AC, Tatham KC, Barker S. The influence
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22. Cornwell S, Dale A. Lavender oil and perineal re-
pair. Mod Midwife. 1995 Mar;5(3):31-3.

1516 Journal of Society for development in new net environment in B&H


Evaluating the problems of
mothers in exclusive breastfeeding
and educational intervention for
improving nutrition status in Iran
Hadigheh Kazemi, Fatemeh Ranjkesh
Faculty of Nursing and Midwifery, Qazvin University of Medical Sciences, Qazvin, Iran
Abstract
Objective: This study aims at determining the
problems of exclusive breastfeeding among mot-
hers and also intervening educationally to impro-
ve the nutrition status in Qazvin, Iran.
Methods: In this descriptive-analytical study
82 pregnant women were selected and were di-
vided randomly into 2 groups of intervention
(individual training and providing educational
pamphlet about exclusive breastfeeding and bre-
ast observation) and control. In both groups, soon
after delivery and 6 months later, an investigation
about start of breastfeeding, continuing the exclu-
sive feeding and mothers’ problems was perfor-
med. The gathered data was analyzed using SPSS
and statistical T test, X2 and Spearman correlation.
Results: There was a meaningful statistical
difference between starting time of breastfeeding
after delivery in two groups (P=0.000). Both gro-
up differed in terms of abundance of exclusive
breastfeeding in the first 6-month period of life
(P=0.005). There wasn’t any meaningful differen-
ce about the trend of infant’s growth in terms of
weight between 2 groups.
Conclusion: According to obtained results,
providing individual trainings based on mother’s
need as well as educational pamphlet to remind
the learning, to support mothers and to consult in
pre and post delivery period can affect mother’s
success to continue breastfeeding and eventually
better growth of infants.
Key words: exclusive breastfeeding, breas-
tfeeding problems, infant growth.
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
Introduction
The most important and complete food, conside-
ring nutritional safety, psychological, economic and
social preferences and reduction of mortality among
infants, is mother’s milk. Of course its maternal ad-
vantages such as reduction and control of post-de-
livery bleeding, short-term interval setting and in-
creasing the rate of some cancers especially ovary
cancer is not concealed. Thus health and care spe-
cialists and physicians have focused on promoting
breastfeeding in their educational programs [1,2].
Surveys show that up to 1940s, most of mot-
hers in all cultures have breastfed their infants,
while today, infants may less possibly -compared
to other periods in history- get breastfeeding [3].
In 1997, the rate of breastfeeding was more than
%62 and its continuity during the first 6 months
of life yields to %26 [4]. In Canada, about %17 of
women, who had breastfeeding, continued it for
6 months after delivery [5]. This rate in Iran was
%41 up to 2004 which has a great distance to in-
ternational rates [6]. Imani et al (2001), evaluated
the privilege of breastfeeding and its related ele-
ments among infants of Zahedan in Iran. Results
demonstrated that exclusive breastfeeding up to 6
month period of infant’s life was %44.7. It was
also reported that some pre-delivery training and
locating mother and infant’s in the same room, can
play an important role in exclusive breastfeeding
and preventing mortality of infants under the age
of 2 [7]. Akaberian et al (2003), measured factors
influencing the exclusive breastfeeding in the first
6-month period of life in Booshehr, Iran. In this
1517
HealthMED - Volume 5 / Number 6 / 2011
research, 60 people participated and mother’s em-
ployment, disease, insufficient milk, wrong beliefs
and child disease were the most important factors
influencing the exclusive breastfeeding [8].
It is preferable that breastfeeding starts soon
after birth. Ideally, this time is when an infant is
in delivery room and after that. Infants whom are
breastfed very soon can learn sucking in right po-
sition more comfortably and there is less possibili-
ty of the existence of some problems which result
in stopping them to get breastfed in the first week
of their life [9]. Hajian (1997), studied the rate of
exclusive breastfeeding and some factors influ-
encing it in urban and rural population of Babol,
Iran. The results suggested that latency in the start
of breastfeeding caused %70 increments in the
risk of non-exclusive breastfeeding in first 4 mon-
ths of life, while keeping infant and mother’s in
the same room decreases this risk up to %54 [10].
Breastfeeding immediately after birth, which
has been among programs of ministry of health,
care and medical training, has been able to enco-
urage mothers to breastfeed. But not all mothers
succeed to continue exclusive breastfeeding. There
are some factors which influence the continuity of
breastfeeding. Different studies showed that factors
like lack of mother’s belief in sufficiency of milk,
lack of support by family in creating a desirable
situation for breastfeeding, returning to work after
delivery, have had effects on exclusive breastfee-
ding [11]. Considering that statistics of exclusive
feeding for 6 months is not acceptable in Iran and
lack of knowledge about advantages of exclusive
breastfeeding during the first 6 months of life and
lack of knowledge in families and among some
clinical specialists about the importance of the first
hours and days of birth to perform correct initia-
tives and also providing wrong advices which in-
clines mother’s willing and also lack of attention
toward anatomic status of breast before delivery
which makes some problems in breastfeeding in
early hours after birth, it was decided to accomplish
this research with some trainings during pregnancy
and also evaluate the status of mother’s nipples in
the last three month period after pregnancy and pur-
suing mothers at the time of delivery and starting
breastfeeding immediately after delivery and also
mother’s exclusive breastfeeding during the first 6
month period after birth and evaluating mother’s
1518 Journal of Society for development in new net environment in B&H
problems in term of exclusive breastfeeding and
infant’s growth in Qazvin, Iran.
Methods
In this descriptive – analytical research, from
among all first- pregnancy mothers under supervisi-
on of health and care centers in Minoodar, Qazvin,
Iran who were in their last 3 months of pregnancy
(from 28th week) 95 women were qualified to enter
this research. After signing a written satisfaction and
filling checklist, they were selected and then they
were divided into two groups of intervention and
control. Six women were omitted due to migration, 2
were omitted due to early delivery, 1 due to infant’s
harelipness, 1 due to fetus’ death, 3 due to infant’s
sickness and being hospitalized. Eventually, gathe-
red data from 41 people in intervention group and 41
in control group were evaluated and analyzed.
Requirements of entering the study: age of 18-
35, not twin pregnancy, not to have miscarriage
record, dead infant, IUFD, barrenness, chronic di-
sease (cardiac, renal, diabetes, anemia, respiratory
disease, hyperthyroid, hypothyroid), taking speci-
al drug record. Requirements of exiting the study:
mothers who were willing to participate in this re-
search, mothers who intended to move or migrate
from Qazvin, mothers who were prohibited from
breastfeeding due to some special medical disea-
se, mothers whose infants had disorders from be-
ginning of birth, mothers who had IUGR delivery,
mothers whose infants got sick and were hospita-
lized during research. In intervention group, some
instructions were given individually about the im-
portance of mothers’ milk and its contents, the im-
portance of exclusive breastfeeding during the first
6 month period of infant’s life and the importance
and the difference between exclusive breastfeeding
and dried milk, regarding the anatomic status of
breast and instructions on eliminating problems in
nipples. Also a shematic training pamphlet about
mother’s milk to study at home was provided. The
researcher was present in hospital at the time of in-
tervention group mother’s delivery and started bre-
astfeeding right after delivery in the room and about
caesarean after mother’s consciousness and mot-
hers were given suitable and required instructions.
In control group during pregnancy, just data was re-
 HealthMED - Volume 5 / Number 6 / 2011

corded and at the time of delivery the data related to rate of exclusive breastfeeding in the first 6 month
delivery and the starting time of breastfeeding were period of life (P=0.005). (Graph 1)
recorded. After delivery, for 6 months, the situation
of infant’s nutrition and mothers' related problems
were analyzed and required remedies were provi-
ded for intervention group. Obtained data was pro-
cessed by SPSS software version 17 and statistical
T test, X2 and Spearman correlation test.

Results and discussion

In this study, 92 first-pregnancy women with

pregnancy age of 28 weeks and without any sy-
stematic disease were put into 2 groups of control
and intervention. The two groups were statistically
homogenous using independent T test and X2 test
regarding the interventional variables (Table 1).
There was a meaningful statistical difference
between the beginning of breastfeeding after deli-
very in the two groups (P=0.000), also a meanin-
gful difference between two groups regarding the
Graph 1. Abundance distribution of beginning
of breastfeeding after delivery and its duration in
the first 6 months
The most rates of obstacles of breastfeeding re-
lated to low amount of mother’s milk, infant’s cry
and discomfort and bad weight gaining of infant.
There wasn’t any considerable difference between
two group regarding infant’s growth (table2).

Table 1. Average distribution and the abundance of individual and pregnancy characteristics in two groups
Intervention(n=14) Control(n=14) Meaningful level
Mother’s age 22.78±2.66 23.43±2.81 0.670
body mass index 21.68±2.45 23.17±2.90 0.344
Marriage age 20.60±3.41 21.63±3.41 0.928
Primary School 1 2
Education

Junior high 6 7
0.703
High school 31 31
Senior high 3 1
Housewife 38 37 0.693
Job

Employee 3 4
Delivery

Vaginal 28 26
mode

0.641
Caesarean 13 15

Table 2. Distribution rate of mother’s problems in exclusive breastfeeding in the two groups of control
and intervention
Intervention control
Mother’s problems in exclusive breastfeeding
Number Percent Number Percent
little amount of mother’s milk 3 7.3 9 22
infant’s cry and discomfort 2 4.9 6 14
bad weight gaining of infant 1 2.5 4 10
without problem 35 85.3 22 54
total 41 100 41 100
P value: 0.02 df= 3 X²=9.76

Journal of Society for development in new net environment in B&H 1519

HealthMED - Volume 5 / Number 6 / 2011
Obtained results showed that training mothers
about the importance of exclusive breastfeeding of
infant during the first 6 months of life, when they
are pregnant, supporting mother during pregnan-
cy, presence at the time of delivery, training and
helping to start breastfeeding right after delivery
and supporting mother during the first 6 months
of exclusive breastfeeding had a positive effect on
continuity of exclusive breastfeeding. This finding
was aligned with the study of Gupta et al (1992)
in Punjab that suggested pre and post delivery tra-
inings by the intervention in the method of breas-
tfeeding caused a considerable increase in the rate
of exclusive breastfeeding [12]. The focus of this
study was on pre-delivery trainings which was in
compliance with the study of Akram et al (1997) in
Karachi and showed that pre-delivery training has
more effects compared to post delivery one and it
improves exclusive breastfeeding [13]. Waldez et
al (2000) showed that clinical support of mothers
can play an important role in working mothers’
success to have an exclusive breastfeeding and as
it’s seen, post delivery support is effective in con-
tinuity of exclusive breastfeeding [14]. Batal et al
(2005) in showed that mothers need courage and
support during breastfeeding and it is necessary to
train them how to breastfeed the infant and elimi-
nate related problems [15]. The results of this re-
search are in compliance with our research results.
In addition, in this research the most problems of
mothers in exclusive breastfeeding are related to low
amount of milk, infant’s cry and discomfort and not
well weight gaining. The study of Segura et al (1994)
showed that %80 of healthy mothers which were
studied in 1 week, 2 months and 4 months intervals
after delivery, complained about their insufficient
amount of milk and they introduced their infants’
discomfort as a reason [16]. Also Monajjemzade et
al (2003) showed that the most common reasons of
breastfeeding cut are low amount of milk, mothers’
employment and infant’s discomfort and cry [17].
Mohammadi et al (2004) showed that the main re-
asons of breastfeeding continuity among urban wo-
men of Booshehr were low amount of mother’s milk,
employment and infant’s cry which are aligned with
our findings [18]. Of course regarding that the most
of samples in the present research were housewives,
thus no relationship could be realized between job
and discontinuity of exclusive breastfeeding.
1520 Journal of Society for development in new net environment in B&H
In this research, there was considerable correla-
tion between the beginning of breastfeeding after
delivery and its continuity. Khadivzade (2002) in
his research results showed a meaningful correla-
tion between the beginning of breastfeeding after
delivery and continuity of exclusive breastfeeding
during the 6 month period after birth [19]. Khaza-
ii et al (2006) suggested that breastfeeding right
after delivery and enough training of mothers and
exact evaluation of their problems to continue bre-
astfeeding can increase the duration of exclusive
breastfeeding [20].
Conclusion
Considering positive effect of mothers’ training
and support during pregnancy and after delivery on
exclusive breastfeeding in the first 6 months of life
and the importance of this kind of feeding in terms
of bringing a better status for infants’ growth and
regarding the ease, cheapness and availability of
trainings we can improve the model of exclusive
breastfeeding and infants feeding and growth by
training based on mothers’ need during pregnancy
and starting breastfeeding right after delivery and
also by exact evaluation of problems related to
continuity of exclusive breastfeeding among mot-
hers and psychological support of them by family,
society and health employees.
Acknowledgement
Authors are grateful to authorities, personnel
and specialists of Minoodar health and care center
in Qazvin, Iran.
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Corresponding author
Hadigheh Kazemi,
Faculty of Nursing and Midwifery,
Qazvin University of Medical Sciences,
Qazvin,
Iran,
E-mail: healthmedjournal@gmail.com
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HealthMED - Volume 5 / Number 6 / 2011

Risk Factors Associated with Metabolic

Syndrome in Iranian Middle Aged
Women
Mouloud Agajani Delavar1, Munn Sann Lye2, Geok Lin Khor3, Syed Tajuddin B Syed Hassan4, Parichehr
Hanachi5
1
Fatemezahra Infertility and Reproductive Health Research Center, Department of Midwifery, Faculty of
Medicine and Health Sciences, Babol University of Medical Sciences, Babol, Islamic Republic of Iran
2
Department of Community Health, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia,
Selangor, Malaysia
3
Department of Human Nutrition and Dietetics, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia.
4
Nursing Unit, Department of Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia.
5
Women Research, Alzahra University, Iran

Abstract white rice consumption was with an increased

Background: Metabolic syndrome, which is
linked to increased risk of diabetes and cardiovas-
cular disease, is increasing in Iran due to rapid nu-
trition transition and the nature of obesity epidemic.
Objective: The aimed of the study was to ex-
amine risk factors contributing to the development
of the metabolic syndrome in urban middle-aged
women, living in Babol, Mazandaran, Iran.
Methods: The research design of the pres-
ent study was a population-based cross-sectional
study, and the criteria by the NCEP ATP III were
used to classify subjects with the metabolic syn-
drome. Meanwhile, their physical activities were
measured using the original International Physi-
cal Activity Questionnaires Long form. Food fre-
quency questionnaire (FFQ) was also used in as-
sessing individual’s habitual intake. A total of 809
individuals, aged 30-50 year old from fourteen
active urban Primary Healthcare Centers in Babol
(Iran), were selected using a systematic random
sampling method and probability sampling pro-
portionate to size.
Results: The odds ratios across tertiles of food
group intakes showed that the highest tertile of
vegetables and fruits consumption were associat-
ed both with a reduced risk of the metabolic syn-
drome after adjustment for age, physical activity,
education level, total energy intake and total fat.
The highest tertile of bread and grain especially
risk of the metabolic syndrome after adjustment
for confounders. No significant associations were
found between the metabolic syndrome and level
of physical activity.
Conclusions: It is necessary to emphasize the
benefits of consumption of more vegetables and
fruit in reducing the risk of the metabolic syndrome.
Key words: Metabolic syndrome, Obesity,
Diet, Physical activity
Introduction
Metabolic syndrome is a cluster of risk fac-
tors related to cardiovascular disease (1). It has
been found that prevalence of the metabolic syn-
drome has increased tremendously over the past
decades (2). The high prevalence of the metabolic
syndrome, particularly among women, is a major
public health problem in the Western and Asian
countries (3). Obesity has become a common fac-
tor among Iranian women due to the changed life-
style factors such as diet, physical activity and ad-
aptation of western lifestyle. Obesity plays a cen-
tral role the in metabolic syndrome and leads to
the development of chronic diseases (4). A recent
study in Tehran showed an estimated prevalence
of more than 30% in adults. It is more common in
women than in men, and the prevalence is higher
than in most developed countries (5).

1522 Journal of Society for development in new net environment in B&H


These health issues are widely discussed in de-
veloped countries, but little is reported regarding
the Middle East. Lifestyles in developing countries
often mimic those of the West; the problem has in-
creased significantly. Evidence indicates that the
prevalence of obesity, overweight, and hyperten-
sion and the metabolic syndrome in Mazandaran
is higher than the other areas (6). It is suggested
that local eating habits, lifestyle pattern and utiliz-
ing high caloric foods are as predisposing factors of
obesity. There are many rice paddies in Mazanda-
ran and around Babol city. Consequently, the wom-
en have access to a diet that is rich in carbohydrate
especially rice. A diet high in carbohydrate has been
associated with overeating and the risk for obesity.
High carbohydrate intake has been shown to be as-
sociated with lower HDL-cholesterol and higher
triglyceride concentrations; these two are the indi-
cators for the diagnosis of the metabolic syndrome.
Some researches reported that the effects of high
carbohydrate consumption on triglyceride concen-
trations appear to be greater in men than women (7,
8). Therefore, in the present study, we investigated
the physical activity and dietary factors contribut-
ing to the development of the metabolic syndrome
among middle-aged women.
Methods
The research design of this study was a popula-
tion-based cross-sectional study, which was aimed
at assessing effect of combinations of physical ac-
tivity and dietary factors of women on their risk of
having the metabolic syndrome.
In order to accurately determine the metabol-
ic syndrome and the associated dietary factors,
women with a history of antilipidemic medica-
tion use or use of other drugs interfering with lipid
metabolism, renal or thyroid dysfunction, acute
hepatitis, acute or chronic of joint diseases, im-
mobilization, cardiovascular problems, diabetes,
stroke, and recent surgical operations, myocardial
infarction, or a cerebrovascular accident within
the previous three months were excluded (5, 9).
A list of households managed by PHCs (the
official bodies responsible for the vaccination
programs and collection of health-related statis-
tics in the urban areas) was used. A total of 5,782
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
households listed in the operational areas of the
14 PHCs in the urban area in Babol, Mazandaran,
Iran were used as the sampling frame. A system-
atic random sampling method was used to select
1,905 households. Eight hundred and nine women
between 30 and 50 years of age were found within
these households and all were selected.
Metabolic syndrome: Diagnosed based on the
presence or absence of ≥3 of the following factors:
waist circumference > 88 cm, (2) fasting triglycer-
ides ≥150 mg/dL, (3) HDL-cholesterol (HDL-C)
< 50 mg/dL, (4) hypertension (systolic blood pres-
sure ≥ 130 mm Hg, diastolic blood pressure ≥ 85
mm Hg), and (5) fasting glucose ≥ 110 mg/dl (10).
Dietary factors include daily intake of food
groups (bread and grains, meat products, dairy
products, cereals, oil and butters, vegetables, fruits,
dried nuts, sugar, drinks and condiments/spice). In
this study a Food Frequency Questionnaire (FFQ)
was used; its validity and reliability have been as-
sessed by Malekshah et al. (11). This FFQ is based
on the distinct cultural practices of northern Iran, the
eastern part of Mazandaran province (new Goles-
tan province). Malekshah et al. has shown that this
FFQ is both reliable and valid in middle-aged sub-
jects in a developing country when compared with
multiple 24-hr recalls or biomarkers of nutrient in-
take. They reported that the FFQ provides valid and
reliable measurements of habitual intake for energy
and most of the nutrients studied (11). The Iranian
food composition table was also used to calculate
daily energy and nutrient intake (12).
Physical activity was measured using the origi-
nal International Physical Activity Questionnaires
(IPAQ) Long, usual week form (13, 14).
Fasting blood samples for the measurement of
glucose and lipid concentrations were drawn from
the right arm of each subject, in the resting posi-
tion, by ante cubital vein puncture with a 1.4-mm
Wasserman needle, after an overnight fast of 12
hours. Total cholesterol and triacylglycerols were
determined using commercially available enzy-
matic reagents adapted to the selectra autoanalyzer
(Parsazmon). HDL-cholesterol was measured after
precipitation of the apolipoprotein B–containing
lipoproteins with phosphotungstic acid. LDL-cho-
lesterol level was calculated by the Friedewald for-
mula (LDL-cholesterol = total cholesterol – HDL-
cholesterol - triglyceride/5 mg/dl). Whenever tri-
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HealthMED - Volume 5 / Number 6 / 2011
glyceride concentrations were more than 400 mg/
dL, LDL-cholesterol was determined chemically
(15). All blood samples were analyzed when inter-
nal quality control met the acceptable criteria. Inter-
assay and intra-assay coefficients of variation were
8.61 % and 2.53% for total cholesterol and 7.92%
and 1.6% for triglyceride, respectively.
Weight was recorded using digital scales, to the
nearest 100 grams, with the subjects minimally
clothed and without shoes. Height was measured,
without shoes, with a tape measure. Waist circum-
ference was measured to the nearest 0.1 centime-
ter, using a tape measure at the level midway be-
tween the lower rib margin and iliac crest (16, 17).
Statistical Analysis
All analyses were performed with SPSS (ver-
sion 16.0). All variables were tested for normal-
ity by obtaining skewness and kurtosis values as
well as, the Kolmogorov-Smirnoff were used for
assessing normality. The data were not normally
distributed: hence differences associations be-
tween groups were done using the Chi-square. To
test the association between continuous variables
Spearman’s rank correlation were used. The corre-
lations of food groups with index of the metabolic
syndrome were assessed by use of Spearman's
rank correlation coefficient (rho). Logistic regres-
sion was used to calculate the odds ratio and their
95% CI for the metabolic syndrome. The low-
est tertile of macronutrient of food group intake
was considered the reference category. The initial
model was adjusted for age, physical activity, edu-
cation level and total energy intake. Another mod-
el of food group included additional adjustment
for total fat intake. All analyses were employed
using two-tailed hypothesis testing with level of
significance set at 0.05.
Results
Out of 809 study subjects, 800 had FFQ and lab-
oratory results and were therefore available for ana-
lyzing the association between dietary factors and
metabolic syndrome. The mean age of the partici-
pants was 39.6±6.0 years and the median age was
1524
39.0 years. Study participants had a mean education
of 6.8 years. More than 713(75%) of subjects had
an educational level of elementary or lower. Seven
hundred sixty-three women (94.3%) were married
and 729 women (89.7%) had no income (house-
wife). The mean monthly household income was
249,000.2±196.3 Tomans (1 Tomans=0.01 USD)
and median household income was 200,000 To-
mans. The means body mass index was 29.5±5.5 kg/
m². The mean waist circumference was 96.4±12.2
cm and median waist circumference was 97.0 cm.
A higher proportion of women had moderate and
high physical activity (24.8%, 74.5%, respective-
ly). Only nine women (0.6%) reported being inac-
tive (low physical activity level).
Main characteristics of the study participants ac-
cording to occurrence of metabolic syndrome are
shown in Table 1. Abdominal obesity (waist cir-
cumference >88 cm), overweight/obesity (≥25),
total cholesterol (≥200 mg/dL), HDL-cholesterol
(<50 mg/dL), Triglycerides (≥150 mg/dl), high
blood pressure (≥13/85), and education level (<6
years) were all related to metabolic syndrome
(p<0.05), but LDL-cholesterol, menopausal status,
job, low income or level physical activity were not.
The food groups were compared with the indi-
ces of the metabolic syndrome. Spearman correla-
tion coefficients revealed that bread and grain was
positively associated with triglyceride (rho=0.08,
p=0.02). Dairy products was inversely associated
with waist circumference (rho=-0.10, p=0.00),
triglyceride (rho=-0.013, p=0.00) and positively
with HDL-cholesterol (rho=0.11, p=0.00). Cere-
als was inversely associated with waist circumfe-
rence (rho=-0.07, p=0.05), total cholesterol (rho=-
0.07, p=0.04), triglyceride (rho=-0.08, p=0.02)
and positively associated with HDL-cholesterol
(rho=0.08, p=0.03). Oil and butters was inver-
sely associated with waist circumference (rho=-
0.08, p=0.01), systolic blood pressure (rho=-0.11,
p=0.00), triglyceride (rho=-0.19, p=0.00), fasting
blood glucose (rho=-0.08, p=0.03) and positive-
ly associated with HDL-cholesterol (rho=0.15,
p<0.01). Vegetables was inversely associated with
waist circumference (rho=-0.07, p=0.04), systolic
blood pressure (rho=-0.08, p=0.03), total chole-
sterol (rho=-.007,p=0.05), triglyceride (rho=-
0.15, p=0.00), fasting blood glucose (rho=-0.10,
p=0.00) and positively associated with HDL-cho-
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 HealthMED - Volume 5 / Number 6 / 2011

Table 1. Main characteristics of middle-aged women according to occurrence of metabolic syndrome

Babol, Iran (n= 809)
Without metabolic syn- With metabolic syndrome
P-value
Variables drome (n= 558) (n= 251)
No. (%) No. (%)
Married 553(94.0) 203(95.8) 0.35
Low education level (<6 years) 258(43.9) 133(92.7) ≤0.0001
House wife 528(89.8) 191(90.1) 0.51
Low income (Tomans /month) 243(41.3) 90(42.5) 0.78
Menopause 70(11.9) 28(13.2) 0.62
Overweight/obesity 468(79.6) 195(92.0) ≤0.0001
Waist circumference>88 (cm) 402(68.4) 202(95.3) ≤0.0001
BP≥130/85 (mm Hg) 21(3.6) 52(24.5) ≤0.0001
Total cholesterol≥200(mg/dl)² 200(34.0) 93(43.9) 0.01
LDL≥130 (mg/dl)³ 132(22.4) 46(21.8) 0.84
HDL<50 (mg/dl)¹ 196(33.3) 186(87.7) ≤0.0001
Triglyceride≥150 (mg/dl)² 112(19.0) 196(92.5) ≤0.0001
Low/Moderate PA 160(27.2) 45(21.2) 0.09
Notes: Toman; 10 Rials = 1 Tomans= 0.01 USD
¹ PA; physical activity; BP; blood pressure; ²missing; 9 cases; ³missing; 10 cases

Table 2. Correlation between food groups (g/d) and indexes of metabolic syndrome (n=800)
Food groups Waist-C1 Systolic BP2 Cholesterol Triglyceride HDL-C3 FBS4 LDL-C5
Rho Rho Rho Rho Rho Rho Rho
p-value p-value p-value p-value p-value p-value p-value
Bread & Grains 0.03 -0.02 0.07 0.08* -0.03 0.01 0.07
0.37 0.53 0.06 0.01 0.37 0.76 0.06
Meat products -0.05 -0.01 -0.06 0.00 0.00 -0.02 -0.06
0.18 0.86 0.10 0.98 0.94 0.66 0.07
Dairy products -0.10** -0.07 -0.02 -0.13** 0.11** -0.03 0.01
0.00 0.06 0.57 0.00 0.00 0.46 0.72
Cereals -0.07 *
-0.04 -0.07 *
-0.08 *
0.08 *
-0.06 -0.07
0.05 0.28 0.04 0.02 0.03 0.12 0.06
Oil and Butters -0.08* -0.11** -0.00 -0.19** 0.15** -0.08* 0.04
0.02 0.00 0.91 0.00 0.00 0.03 0.32
Vegetables -0.07 *
-0.08 *
-0.07 *
-0.15 **
0.13 **
-0.10 **
-0.06
0.04 0.03 0.05 0.00 0.00 0.00 0.10
Fruits -0.04 -0.01 -0.12 **
-0.09 **
0.06 -0.06 -0.10**
0.24 0.87 0.00 0.01 0.10 0.09 0.01
Dried nuts -0.11 **
-0.08 *
-0.05 -0.16 **
0.13 **
-0.02 -0.01
0.00 0.02 0.20 0.00 0.00 0.53 0.71
Sugar -0.10** -0.02 0.00 0.00 0.00 0.06 0.00
0.01 0.59 0.99 0.91 0.91 0.11 0.94
Drinks 0.04 0.04 0.01 0.09 **
-0.10 **
0.11 **
-0.02
0.22 0.23 0.70 0.01 0.01 0.00 0.59
Condiments/Spice -0.04 -0.07* -0.05 -0.09** 0.07* -0.03 -0.04
0.31 0.05 0.14 0.01 0.04 0.37 0.32
**Correlation is significant at the 0.01 level (2-tailed). *Correlation is significant at the 0.05 level (2-tailed).
¹Waist-C; Waist circumference, 2 Systolic BP; Systolic blood pressure, 3 HDL-C; HDL-cholesterol, 4FBS; Fasting blood
sugar, 5 LDL-C; LDL-cholesterol

Journal of Society for development in new net environment in B&H 1525

HealthMED - Volume 5 / Number 6 / 2011

lesterol (rho=0.13, p=0.00). Fruits was associa-
ted inversely with total cholesterol (rho=-0.12,
p=0.00), triglyceride (rho=-0.10, p=0.01). Dried
nuts was inversely associated with waist circumfe-
rence (rho=-0.11, p=0.00), systolic blood pressu-
re (rho= -0.03, p=0.02), triglyceride (rho=-0.16,
p=0.00) and positively associated with HDL-cho-
lesterol (rho=0.13, p=0.00). Sugar was inversely
associated with waist circumference (rho=-0.10,
p=0.01). Drinks group was positively associated
with triglyceride (rho=0.09, p=0.01), fasting blo-
od glucose (rho=0.11, p=0.00) and inversely asso-
ciated with HDL-cholesterol (rho=-0.10, p=0.01).
Condiment/spice was inversely associated with
systolic blood pressure (rho=-0.07, p=0.02), trigl-
yceride (rho=-0.09, p=0.01) and positively asso-
ciated with HDL-cholesterol (rho=0.07, p=0.04).
Meat products did not correlate with indexes of
the metabolic syndrome as illustrated in Table 2.
The odds ratios across tertiles of food group
intakes (table 3) showed that the highest tertile of
vegetables and fruits consumption were associa-
ted with reduced risk of the metabolic syndrome
after adjustment for age, physical activity, educa-
tion level, total energy intake and total fat but meat
and dairy products were not. The highest tertile of
bread and grain especially white rice consumption
was associated with an increased risk of metabolic
syndrome after adjustment for confounders.
The odds ratios showed that there were no si-
gnificant associations between the metabolic syn-
drome and level of physical activity intake after
adjustment for age, education level, total energy
intake and total physical activity.

Table 3. Risk of the metabolic syndrome in middle-aged women across tertiles of food groups intake,
adjusted for several variables (Odds ratios (OR) and 95 % CI)
Tertiles of intake
1 (lowest) 2 3 (highest)
OR OR 95 % CI OR 95 % CI
Vegetables
Multivariate model 1* 1·00 0.48 0.33-0.71¥ 0.34 0.21-0.53¥
Multivariate model 2† 1·00 0.48 0.33-0.71¥ 0.34 0.22-0.54¥
Fruits
Multivariate model 1* 1·00 0.48 0.33-0.72¥ 0.27 0.17-0.44¥
Multivariate model 2† 1·00 0.48 0.31-0.73€ 0.27 0.17-0.44¥
Dairy products
Multivariate model 1* 1·00 1.18 0.82-1.70 0.72 0.35-1.47
Multivariate model 2† 1·00 1.15 0.80-1.66 0.71 0.34-1.46
Meat products
Multivariate model 1* 1·00 0.83 0.55-1.24 0.70 0.46-1.06
Multivariate model 2† 1·00 0.84 0.56-1.26 0.72 0.45-1.14
Bread and grain
Multivariate model 1* 1·00 1.07 0.69-1.66 1.73 1.17-2.58¥
Multivariate model 2† 1·00 1.13 0.72-1.76 2.15 1.38-3.34¥
Rice
Multivariate model 1* 1·00 5.74 2.49-13.24¥ 6.07 2.70-13.65¥
Multivariate model 2† 1·00 5.53 2.36-12.97¥ 5.87 2.58-13.40¥
Notes: Tertiles of vegetables, lowest <378 g/d; moderate 378-630 g/d; highest >630 g/d
Tertiles of fruits, lowest <395 g/d; moderate 395-735 g/d; highest >735 g/d
Tertiles of dairy products, lowest <300 g/d; moderate 300-520 g/d; highest >520 g/d
Tertiles of meat products, lowest <38 g/d; moderate 38-83 g/d; highest >83 g/d
Tertiles of bread and grain, lowest <425 g/d; moderate 425-475 g/d; highest >475 g/d
Tertiles of rice, lowest <30 g/d; moderate 30-85 g/d; highest >85 g/d
*Model 1, adjusted for age (continuous), physical activity (low/moderate, high), education level (< 6 year, 6-11 years and ≥
12 years), total energy intake (continuous).
†Model 2, model 1 with additional adjustment for total fat intake (continuous).
€ p ≤ .01; ¥ p ≤ .001

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Discussion
Physical activity has protective effects on the
metabolic syndrome through improvements in
plasma lipid concentrations, particularly an incre-
ased in HDL-cholesterol concentrations (18-20),
and a decrease in triglyceride concentrations (21)
or both (22, 23). In addition, physical activity re-
sults in lower blood pressure (Moreau et al., 2001),
improved glucose tolerance (24, 25), insulin sen-
sitivity (26, 27), and lower risk of type 2 diabetes
(28). Increased physical activity is associated with
a reduced risk of the metabolic syndrome (27, 29,
30). This study showed there is no significant diffe-
rence in level of physical activity between women
with and without metabolic syndrome. This finding
is consistent with recent prospective study that has
shown that physical activity did not differ between
patients with and without metabolic syndrome (31).
Due to these varied results from previous research
and in this current investigation, more research in-
vestigating metabolic syndrome and its relationship
with physical activity is warranted. Temporal relati-
onships between risk factors and outcome variables
are unclear given the nature of the cross-sectional
design used in this study, hence poses difficulties
when inferring causality. A longitudinal analysis
may strengthen causality inference should findings
show significant association between physical acti-
vity and the metabolic syndrome in women. Altho-
ugh physical activity was measured through self-re-
ported questionnaires (IPAQ), this may be subject to
underreporting and recall bias. But physical activity
was taken into account by IPAQ. In many physical
activity questionnaires, the absence of household-
related physical activity assessment may be another
source of misclassification, mainly in women (32).
In this investigation, the mean total kilocalorie
consumed per day was 2,965. This is similar to
the value reported in the Iranian Islamic Report
of Food Balance Sheet, where mean total kilo-
calorie intake of Iranians was reported as 3,095
(33). Also, Mirmiran et al. (34) showed that daily
energy requirements for women aged 20-50 years
were 2900 kilocalories.
Fruits and vegetables, or both should be emp-
hasized at each meal. They are major sources of
vitamins C, E, and A, beta-carotene, other vita-
mins, fiber, and minerals. Also snacks and desserts
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
that included fruits and/or vegetables can be low
in saturated fat, total fat, cholesterol, and very nu-
tritious (10). Our finding showed vegetables were
inversely associated with systolic blood pressure,
cholesterol, triglyceride, fasting blood glucose
and positively associated with HDL-cholesterol.
Also fruit was inversely associated with choleste-
rol and triglyceride. This finding is consistent with
many studies in which vegetables and fruits were
inversely associated with indexes of the metabolic
syndrome and generally associated with a lower
prevalence of the metabolic syndrome (9, 35-38).
Dairy products are important sources of prote-
in, calcium, phosphorus, and vitamin D (39). The-
re are some observational studies which showed
dairy products, particularly milk, to be positively
associated with indexes of the metabolic syndro-
me (40, 41). Mennen et al. (42) reported that dai-
ry products are inversely related to the metabolic
syndrome in men but not in women. Our findings
showed dairy products were inversely associated
with waist circumference, triglyceride and po-
sitively associated with HDL-cholesterol. After
adjustment for dietary and non-dietary risk fac-
tors, dairy products were not associated with the
metabolic syndrome. The findings are in agree-
ment with the cohort of Japanese-Brazilian study
in which dairy products intake was not related to
metabolic syndrome (43).
Consumption of carbohydrate rich foods such
as rice especially white rice may increase diabetes
risk. Brown rice contains higher level of fiber, mi-
nerals, vitamins and phytochemicals such as be-
ta-carotene so it has lower risk of metabolic syn-
drome (44, 45). In this study, bread and grain was
positively associated with triglyceride. In addition
bread and grain especially white rice was positive-
ly associated with the metabolic syndrome. These
findings are in contrast with evidence from a study
in which bread was inversely related to the meta-
bolic syndrome in men, but not in women (42).
Conclusions
This study used the cross-sectional design to
determine the association of dietary consumpti-
on with the metabolic syndrome, whereas futu-
re studies that use longitudinal data will provide
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HealthMED - Volume 5 / Number 6 / 2011
stronger evidence on this association. However
appropriate analysis of cross-sectional data repre-
sents a valuable initial step in identifying relations
between diet and disease. Moreover, prospective
cohort studies and clinical trials have their own
weaknesses. Despite the limitations and stren-
gths mentioned, the results of this study can be
useful in order to develop public health strategies
for preventing the metabolic syndrome in middle
aged women. It is suggested that a study invol-
ving a larger population be conducted, to make
recommendations for the primary and secondary
prevention of the metabolic syndrome. A large
prospective study is needed in order to clarify the
importance of physical activity in relation to the
metabolic syndrome risk factors among middle
aged women. Therefore, further prospective work
is proposed to elucidate associations between diet,
lifestyle and the metabolic syndrome risk factors
in middle-aged women in Iran.
Acknowledgements
The authors acknowledge the assistance of Dr.
Pour Nasrollah in measurement of glucose and li-
pid concentrations. We would like to thank the cli-
nicians in Babol University of Medical Sciences
for assisting in the study. We also thank the Iranian
women for their participation in this study.
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The effects of Vitamin C and E
Supplements on eradication rate
of Helicobacter pylori receiving
omeprazol- clarithromycin-
amoxicillin regimen
Ehsani Ardakani MJ1, Samiy S2, Norouzinia M3, Mostafavi SA3, Mohaghegh Shalmani H3
1
Department of Gastroenterology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
2
Heeva pathobiology center, Tehran, Iran
3
Research Center for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical
Sciences, Tehran, Iran
Abstract
Background and Aim: Eradication rate of He-
licobacter pylori (H. pylori) with triple-therapy do
not go above 70-80 percent. This study was con-
ducted to evaluate effects of adding the vitamin C
and E supplements to triple therapy on the eradi-
cation rate of H. pylori -infected patients.
Methods: In a randomized clinical trial, 168
patients with documented H.pylori with a positive
RUT (rapid urease test) and/ or histology were en-
rolled in the study. Patients were randomized into
two groups: Triple-only group (88 cases) received
omeprazole, clarythromycin and amoxicillin for 2
weeks. Triple–plus-vitamin group (80 cases) re-
ceived the same regimen plus vitamin C 500 mg
once daily and vitamin E 400 mg once daily. Eight
weeks after the completion of treatment, patients
were assessed for successful eradication of H.
pylori by stool Ag for H. pylori.
Results: 74 patients in triple- only group and 68
patients in triple- plus- vitamin group were inclu-
ded in per protocol analysis. The eradication rate
by per protocol study was 49/74 (66.2%) in tri-
ple- only group and 57/68 (83.8%) in triple- plus-
vitamin group (p<0.02). Using ITT analysis, H.
pylori eradication was achieved in 55.7% (49/88)
of patients in triple- only group and 71.3% (57/80)
patients in triple- plus- vitamin group (p<0.04).
Conclusion: Administration of antioxidants,
such as vitamin C and E, is an appropriate way to
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
impair the microenvironment created by H. pylori
and achieve a suitable environment for antibiotics
to influence the bacteria.
Key word: Helicobacter pylori, Antioxidants,
vitamin C, Vitamin E, Eradication rate
Introduction
Helicobacter pylori (H-pylori) is one of the
most prevalent infections in the world and it is
estimated 50% of the world’s population is infec-
ted with H. pylori (1). About 70 percent of Iranian
people are H-pylori positive in serologic examina-
tions (2). Among several regimens for eradication
of H-pylori, using regimen of proton pomp inhi-
bitor (PPI)-clarythromycin-amoxicillin is a docu-
mented and potent regimen (3). It is expected that
sufficient therapy should provide H. pylori eradi-
cation in at least 80% of patients (4). Nonetheless,
development of resistance to antimicrobial agents,
such as clarithromycin, may halt the eradication of
H. pylori infections (5). Since H. pylori preserves
itself from gastric acid and the host defense sy-
stem by generation of microenvironment, it requi-
res an agent to damage this microenvironment (6).
So, at present, clinicians pay attention to alterna-
tive therapeutic regimens with biologically active
compounds including antioxidants (7-9).
Several studies showed that vitamin C con-
centration in gastric juice and vitamin E levels in
1531
HealthMED - Volume 5 / Number 6 / 2011
gastric mucosa are lower in Helicobacter pylori
infected patients (10-12). In addition, vitamin C
concentration in gastric juice increases after the
eradication of H. pylori (10, 13). High doses of
vitamin C had bactericidal properties in an in vi-
tro study with inhibition of H. pylori growth (14).
Some studies disclosed that taking vitamin C co-
uld diminish the H. pylori load (15, 16). Whereas,
it has been observed that prescribing vitamin C in
a 5 g/day dosage has not been useful for H. pylori
eradication, and it has not changed the H. pylo-
ri load in infected patients (17). A study showed
anti-inflammatory effects of antioxidant vitamins
and improving of gastric inflammation (18).
So, this study was conducted to evaluate effects
of adding the vitamin C and E supplements to tri-
ple therapy on the eradication rate of H. pylori -in-
fected patients.
Methods and Materials
In a randomized clinical trial, patients with in-
tractable dyspepsia and indication of endoscopy
who had referred to the Imam Hossein hospital (a
university related hospital) and Iranmehr hospi-
tal (a private hospital), Tehran, Iran, were consi-
dered for the study. Then patients with documen-
ted H.pylori with a positive RUT (rapid urease
test) and/ or histology were enrolled in the study.
Patients with history of previous treatments for
H. pylori, upper gastrointestinal surgery, gastric
malignancy, liver or renal dysfunction, pregnan-
cy, and those who had history of taking proton
pump inhibitor (PPI), bismuth, antibiotics or pro-
biotics within 4 weeks prior to endoscopy were
excluded.
After obtaining informed consent, 168 pati-
ents with documented H.pylori were randomized
into two groups: Triple group (88 cases) received
omeprazole 20 mg b.i.d., clarythromycin 500 mg
b.i.d. and amoxicillin 500 mg b.i.d. for 2 weeks.
Omeprazole was continued for 2 weeks later. Tri-
ple–plus-vitamin group (80 cases) received the
same regimen plus vitamin C 500 mg once daily
and vitamin E 400 mg once daily. Vitamin C and
E were prescribed for 4 weeks. Patients’ compli-
ance was evaluated by regular follow-ups. Eight
weeks after the completion of treatment, patients
1532 Journal of Society for development in new net environment in B&H
were assessed for successful eradication of H.
pylori by stool Ag for H. pylori. Negative result
of stool Ag for H. pylori was defined as the su-
ccess of H. pylori eradication.
Results are presented as mean ± standard devi-
ation for quantitative variables and as number and
percentage for qualitative variables. The percenta-
ge of patients with negative result of stool Ag for
H. pylori was considered as eradication rate. Mean
age was compared between two groups using stu-
dent t-test. The difference in H. pylori eradication
rate between the two groups was evaluated by me-
ans of the chi-square test. SPSS software was used
for data analysis and comparing eradication rate
in intention-to-treat (ITT) and per-protocol (PP)
analysis between two groups. P-value < 0.05 was
considered significant.
Results
88 patients with mean age (± standard devi-
ation) of 41.1±7.1 (range: 19-68) years and 80
patients with mean age (± standard deviation) of
43.2±5.7 (range: 22-63) years received triple and
triple- plus- vitamin regimen, respectively (NS:
not significant). Male to female ratio was 37 to 51
in triple group and 34 to 46 in triple- plus- vitamin
group (NS). 14 patients from triple group and 12
patients from triple- plus- vitamin excluded from
study due to not completing the course of trea-
tment because of noncompliance or not return for
follow-up (NS). So, 74 patients in triple- only gro-
up and 68 patients in triple- plus- vitamin group
were included in per protocol analysis.
The eradication rates of H. pylori in two groups
have been demonstrated in Table 1. The eradicati-
on rate by per protocol study was 49/74 (66.2%) in
triple group and 57/68 (83.8%) in triple- plus- vita-
min group (p<0.02). Using ITT analysis, H.pylori
eradication was achieved in 55.7% (49/88) of pa-
tients in triple group and 71.3% (57/80) patients in
triple-plus-vitamin group (p<0.04).
The most frequent side effects were minor
complains, including nausea, gastric fullness, ab-
dominal discomfort in both groups (NS).

Table 1. Eradication rate of helicobacter pylori in the groups
Triple
Per protocol analysis 49/74 (66.2%)
Intention-to-treat analysis 49/88 (55.7%)
Discussion
This study shows that adding vitamin C and
vitamin E can increase H. pylori eradication rate
from 51.1% to 66.2% by triple regimen (in intenti-
on-to-treat analysis). The Eradication rate of 64.5-
85 percent with this regimen has been showed by
different studies on Iranian patients (19-23). In
a randomized controlled trial, Minakari M, et al.
evaluated the efficacy of a new quadruple therapy
regimen and compared it with the standard second-
line treatment for H. pylori. They found eradication
rate of 64.5% with amoxicillin, clarithromycin, bi-
smuth, and omeprazole (19). Evidences show that
unfortunately, eradication rates have never reached
100 percent by different regimens for treatment of
this infection. Eradication rate with triple-thera-
py do not go above 70-80 percent (24). H. pylori
is one of the most important clinical causes of ga-
stroduodenal diseases, such as peptic ulcer disease
and gastric cancer (24). Although various antibiotic
combinations have been prescribed to achieve grea-
test eradication rate, Ultimate result has never been
obtained due to increasing resistance of organism
(25, 26). This leads to increased attention in alter-
native/adjunctive therapies including antioxidants
(7, 8). So, we need to introduce new regimens to
increase eradication rate of H.pylori.
H. pylori induce oxidative damage, enhanced
lipid peroxidation and increased DNA damage in
gastric tissues by production of oxygen free radi-
cals (27, 28). Inversely, there was no evidence for
pathogenecity of free radicals in the event of ga-
stric mucosal injury in patients without H. pylori
infection (29). So, antioxidants may have an im-
portant role in the treatment of H. pylori- induced
gastritis by preventing oxidative damage. Antioxi-
dants, such as vitamin C and E, can shelter gastric
mucosa against damage caused by free radicals
(30). Epidemiological and clinical evidences have
been shown that vitamin C and E play a protective
function against the incident of gastric carcinoma
in humans (31, 32).
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
Triple- plus- vitamin P-value
57/68 (83.8%) 0.02
57/80 (71.3%) 0.04
Some studies have demonstrated that gastric
juice not gastric mucosal vitamin C levels were
decreased in H pylori gastritis and that successful
eradication returned the juice/plasma vitamin C
ratio (10, 13, 33, 34). The lower plasma vitamin C
level may be due to reduced bioavailability, active
secretion from plasma to gastric juice in order to
rebuild the positive gastric juice/plasma ratio or
both (35). Also, efficacy of vitamin C in inhibi-
tion of H. pylori urease activity and growth has
been demonstrated by in vitro and in vivo studies
(14-16, 36). Vitamin E levels in H pylori negati-
ve subjects were higher in the corpus, while its
concentrations in antral H pylori infection were
higher in antrum and duodenum (37). These may
suggest that antioxidants are increased in the sites
of greatest inflammation in the stomach.
Current study showed that vitamin C and vi-
tamin E had positive impact on H. pylori eradi-
cation. In a study, Zojaji et al, evaluated the ef-
fect of vitamin C on H. pylori eradication rate
in a referral hospital in Iran, and they found that
addition of vitamin C to H. pylori treatment re-
gimen of amoxicillin, metronidazole and bismuth
could significantly increases H. pylori eradication
rate (38). In another study in Iran, a prospective
controlled study was conducted to evaluate whet-
her the vitamin C supplement to the therapy with
lower dosage of clarithromycin could have a good
enough effect on Helicobacter pylori eradicati-
on in comparison with routine anti-Helicobacter
pylori regimen. There was comparable eradicati-
on rate of Helicobacter pylori between the triple
group with 500 mg of clarithromycin and the tri-
ple with 250 mg of clarithromycin-plus vitamin C
group. On the other hand, vitamin C reduced the
routine dosage of clarithromycin for eradication of
Helicobacter pylori (39). Sezikli et al, showed that
adding vitamins E and C to antimicrobial thera-
py with lansoprazole (30 mg, b.i.d.), amoxicillin
(1000 mg, b.i.d.), clarithromycin (500 mg, b.i.d.),
and bismuth subcitrate (300 mg, q.i.d.) for 14 days
was more effective in eradicating H. pylori infec-
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HealthMED - Volume 5 / Number 6 / 2011
tion. In their study, ITT analysis demonstrated an
H. pylori eradication rate of 91.25% (ITT) in the
group receiving vitamins C and E compared with
control group with eradication rate of 60% (40).
On the contrary, chuang et al observed that
adding vitamin C and vitamin E to triple therapy
with lansoperazol, amoxicillin and metronidazol
could not improve the H. pylori eradication rate
and gastric inflammation. Moreover, among pati-
ents with metronidazole susceptible strain infecti-
on, adding vitamins C and E may even decrease
the eradication rate of H.pylori (41). Chatterji et al
studied the in vitro antimicrobial activities of the
antioxidants, including vitamin C and vitamin E,
without and with clarithromycin against H. pylo-
ri. Vitamin C had significant antimicrobial effects
against H. pylori by itself, but there was no effect
of vitamin E either alone, or with additional incu-
bation with clarithromycin, against H. pylori (42).
Interestingly, in another in vitro study, some aut-
hors of Chatterji et al study found that vitamin E
had antimicrobial activity against H. pylori (27).
Our conception is that resistance to antibiotics is
not the only issue of bacterial defense mechanisms
of H. pylori. To get greater eradication rate, we need
to provide proper concentration of antibiotic and
the suitable microenvironment to influence the bac-
teria (43). Currently, gastric acid-lowering agents,
H2 receptor antagonists, and proton pump inhibi-
tors are employed for this reason. Administration of
antioxidants, such as vitamin C and E, is an appro-
priate way to impair the microenvironment created
by H. pylori and achieve a suitable environment for
antibiotics to influence the bacteria.
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36. Phull PS, Green CJ, Jacyna MR. A radical view of

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Corresponding author
Hamid Mohaghegh Shalmani,
Research Center for Gastroenterology and Liver
Diseases,
Taleghani hospital, Evin,
Tehran,
Iran,
E-mail: hamidmohaghegh@gmail.com

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 HealthMED - Volume 5 / Number 6 / 2011

Coeliac disease; Prevalence and

Outcome in Pregnancy
Mohsen Norouzinia1, Kamran Rostami2, Marzyeh Amini1, Farhad Lahmi1, Mohammad Roshani1, Homayoun
Zojaji1, Mohammad Rostami Nejad1, Chris J Mulder3, Mohammad Reza Zali1
1
Research Institute of Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences,
Tehran, Iran
2
School of Medicine, University Hospital Birmingham, UK
3
Department Of Gastroenterology, VU University Medical Center, Amsterdam, The Netherlands

Abstract Key words: Coeliac disease, Pregnancy, Sero-

Background: Coeliac disease (CD) is associ-
ated with infertility and adverse pregnancy out-
comes. Furthermore, the aim of this study was
to prospectively estimate the prevalence of undi-
agnosed CD in a population of pregnant women
and pregnancy outcome.
Methods: During the 2010-2011, 796 pregnant
women were recruited for this study. The mean
age was 26 years (SD=5.35) and mean pregnancy
duration 5.4 months. Subjects underwent a total
IgA test and antihuman IgA class antitissue tran-
sglutaminase (tTGA) antibodies and those tTGA
positive underwent histological biopsy specimens
according to UEGW classification. Results: From
796 pregnant women 17 (2.1%) had a positive CD
serology for tTGA. Out of the 17 seropositive wo-
men, seven had normal histology, three had Mar-
sh I, two had Marsh II, two had Marsh IIIa, two
had Marsh IIIb and one had Marsh IIIc. Low birth
weight babies were observed in 3 and two had a
history of miscarriage in the past.
Conclusion: In this study CD was not associa-
ted with a high incidence of unfavorable outcomes.
Overall, 1/66 (1.5%) women had a confirmed CD.
Despite pregnancy is acting as a triggering factor
for manifestation of CD in susceptible individuals,
untreated pregnant coeliac patients with a normal
pregnancy should have reasonable compensatory
capacities to enable them to complete their pre-
gnancy without complications. Coeliac disease
severity is variable in different individual and not
every coeliac is at high risk for complication. This
may suggest that gluten free diet could be avoided
in some of patients who had a normal pregnancy.
logy, Iran
Introduction
Coeliac disease (CD) is an autoimmune disor-
der characterized by gluten sensitivity in geneti-
cally susceptible individuals (1, 2). CD causes
small bowel inflammation and is associated with
increased small bowel permeability. The clinical
features of the disease vary from subclinical to se-
ver malabsorptive syndrome. Intestinal mucosal
damage generates a wide spectrum of symptoms/
signs due to malabsorption, resulting from auto-
immunity (3). It is associated with several extra-
intestinal manifestations/complications, including
infertility and adverse pregnancy outcomes (2, 4).
The pathogenesis of this complication is unclear.
For example, coeliac women with subclinical or
silent disease and no malabsorption can have pre-
gnancy loss, whereas women with diarrhea, stea-
torrhea and autoimmune complications can have a
normal pregnancy outcome, even before diagnosis
(5). In any case, early pregnancy loss is frequent
in many other autoimmune diseases (i.e., systemic
lupus erythematosus, primary biliary cirrhosis,
and thyroiditis (6, 7). In addition, several studies
have found that coeliac women who do achieve
fertilization often have higher chances of miscarri-
ages and intrauterine growth (8-10). Other study
showed that women with CD had a normal fertili-
ty, but their fertility was decreased in the last 2 ye-
ars preceding CD diagnosis (11). Previous studies
have suggested that women with undiagnosed CD
to have 9-fold relative risk of multiple abortions

Journal of Society for development in new net environment in B&H 1537

HealthMED - Volume 5 / Number 6 / 2011
and low birth weight babies compared to women
with treated CD (5). Aside from adverse pregnan-
cy outcomes, CD may present with a persistent
iron deficiency and abnormal weight loss during
a first, but more often, second pregnancy (2). The
prevalence rate of CD in pregnant women is esti-
mated as between 1.41- 15 % in various parts of
the world (12-18).
The aim of this study was to estimate the pre-
valence of undiagnosed CD in pregnant women
and the consequences of any association with pre-
gnancy outcome.
Materials & Methods
Patients
Following ethical and research committee ap-
proval, subjects gave their informed consent and
were then recruited into this study during the 2010
- 2011. A total of 796 pregnant women were re-
cruited from the Reproduction section and serum
samples were obtained. Samples were taken at
mean pregnancy duration of 5.4 months.
Data were obtained through questionnaires and
patients’ serum was collected on one occasion for
CD during pregnancy. The pregnancy outcomes
were evaluated from medical records and ques-
tionnaires. None of these subjects had previously
been diagnosed with CD and none of them were
on gluten free diet previously. The study was ap-
proved by the institutional ethics committees of
Research institute for gastroenterology and liver
disease, Shahid Beheshti University, M.C., and all
participants signed a written informed consent.
Blood sample collection
Human antitissue transglutaminase (tTG)
antibody and Immunoglobulin A were mea-
sured using a commercially available ELISA kit
(AESKULISA tTGA, Germany) according to the
manufacturer’s guidelines and the result was con-
sidered positive when a value higher than 15.0
U/ml was recorded (19). Total serum IgA values
were measured by an immunoturbidometric assay
(Pars Azmoon, Iran) and serum levels below 70
1538 Journal of Society for development in new net environment in B&H
U/L were considered indicative of IgA deficiency
according to manufacture’s guideline. Immuno-
globulin G (IgG) tTG values were further obtained
in individuals with IgA deficiency by an ELISA
method, and using the commercially available kit
AESKULISA tTGG (Germany).
As the subjects were pregnant, no gastroscopy
and duodenal biopsies were performed during
pregnancy. After childbirth tTGA positive patients
underwent duodenal biopsy specimen and their
biopsies investigated according to UEGW classi-
fication (20).
Statistical analysis
Percentages were compared by rates and pro-
portion; 95% confidence intervals are reported.
We also used the corrected χ² test or Fisher’s exact
test and odds ratio to compare percentages, and
the unpaired Student t-test to compare the means
of normally distributed variables.
Results
Seven hundred and ninety six subjects were
recruited. Seventeen women (2.1%) with a mean
age of 26 and mean pregnancy duration of 5.4
months were positive for tTGA. The pregnancy
period and delivery were normal in all seroposi-
tive patients, 10/17 had a natural vaginal delivery
(58.8%) and 7/17 had caesarean delivery (41.2%)
outcome. No statistically significant differences
were noted between the groups regarding clinical
characteristics such as maternal or gestational age
and neonatal gender.
Of the 17 tTG positive pregnant women, CD
was confirmed by histological analysis of the inte-
stinal biopsy samples, giving a prevalence of CD
of 1.2 percent including; three Marsh I, two Marsh
II, two Marsh IIIa, two Marsh IIIb and one Marsh
IIIc and the rest had normal histology.
Thirty-seven percent (296/796) and 63% (500/
796) of pregnant women attended the rural and ur-
ban health care centers, respectively. The prevalen-
ce of CD in rural and urban areas was 0.4 (CI: 0.31-
0.47) and 0.8 (CI: 0.67-0.91) percent, respectively.
No statistically significant differences were noted
 HealthMED - Volume 5 / Number 6 / 2011

for distribution of either CD between rural and ur-
ban areas. Six women were IgA deficient but all of
them had negative IgG tTG.
Among the CD subjects, gastrointestinal symp-
toms were reported only by 3 patients and consi-
sted of mild and undefined abdominal discomfort,
diarrhea, dyspepsia and weight loss. As shown in
Table 1, five subjects had a past medical history in
keeping with features of CD. Their past medical
history included history of miscarriage in 2 pati-
ents, low birth weight also in 2 patients and iron
deficiency anemia in 1 patient.
Discussion
Several studies have shown that coeliac dis-
ease can impair women’s reproductive life elicit-
ing delayed puberty, infertility, amenorrhea and
early menopause. Some clinical and epidemiolog-
ical studies have demonstrated that women with
coeliac disease are at a higher risk of miscarriage,
low birth weight of the newborn (1, 21-23).
Pregnancy loss has been attributed to several
factors involved in human reproduction. In ad-
dition to CD, genetic and uterine abnormalities,
endocrine and immunological dysfunctions, in-
fectious agents, environmental pollutants, psycho-
genetic factors and endometriosis are all important
causes of spontaneous abortion (24, 25). The simi-
larity of our results and Ludvigsson and Khashan
who have studied the relation with undiagnosed
CD and low birth weight (26,27), a shorter ges-
tation has on average been observed in coeliac
women compared to healthy controls together
with a lower birth weight of coeliac women babies
compared to that of healthy women babies.
Most of the women diagnosed with CD had
no major gastrointestinal complains. As untreated
CD is associated with an unfavorable outcome in
pregnancy, after a delivery we offered that posi-
tive CD serology to undergo biopsy specimen (28,
29). We felt that performing invasive investigation
like small bowel biopsy in pregnant women with
only mild symptoms couldn’t be justified.
In this study, CD was not associated with ad-
verse pregnancy outcome. We suggest that this is a
reflection of the small number of subjects recruit-
ed, as larger studies have repeatedly demonstrated
that both conditions predispose to adverse preg-
nancy outcomes. As there were three miscarriages
in two women with Marsh III celiac disease, a new
study which is included on non-celiac pregnant
women, i.e. a control group would be necessary.
Furthermore we suggest that possible mecha-
nisms for this susceptibility include the increased

Table 1. Features of cases of pregnant women with coeliac disease (CD)

low
Month of Previous Type of Patients anti-tTG Marsh-Rostami
Patient Age birth
pregnancy fertility history Birth Symptoms values classification
weight
Diarrhea,
VD
1 25 4 - Yes dyspepsia, 300 IIIc
abdominal pain
2 30 9 2 miscarriages CS No Anemia 232 IIIb
3 29 2 - VD Yes Weight loss 117 I
4 28 6 - VD No None 54.6 I
5 29 2 - CS No None 76 I
6 22 9 - CS No None 68.8 II
Diarrhea,
7 33 2 1 miscarriage CS No dyspepsia, 173 IIIa
abdominal pain
8 18 6 - VD No None 54.6 IIIb
9 29 3 - CS No None 65.9 IIIa
10 22 3 - CS No None 46 II
VD= Natural vaginal delivery, CS= Caesarean section

Journal of Society for development in new net environment in B&H 1539

HealthMED - Volume 5 / Number 6 / 2011
permeability, chronic small bowel inflammation
and systemic immunological abnormalities that
are associated with coeliac disease. We accept that
limitations of our study that dependence upon a
patient questionnaire, small sample size and use of
a single geographic location. Nevertheless we be-
lieve that the observation reported is biologically
feasible and may be clinically significant. Due to
increasing awareness classical coeliac disease are
detected and treated by clinician. The most chal-
lenging subgroups with milder presentation are
less recognized. It seems that this subgroup with
milder form of disease to be at low risk for adverse
pregnancy outcome.
Acknowledgments
This study has been financially supported by
Iran National Science Foundation (INSF). We
gratefully acknowledge the critical review by
Prof. RP Steegers-Theunissen from Erasmus Uni-
versity Medical center Rotterdam for her input in
improving the quality of this work.
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13(9):1123-8. Diseases,
Shahid Beheshti University of Medical Sciences,
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E-mail: m.rostamii@gmail.com
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HealthMED - Volume 5 / Number 6 / 2011

Criteria for Priority-setting in Iran

Basic Health Insurance Package:
Exploring the Perceptions of Health
Insurance Experts
Reza Dehnavieh1, Arash Rashidian2, Mohammad reza Maleki2, Seyedjamal Aldin Tabibi3, Hosein Ibrahimi
Pour4, Somayeh Noori Hekmat1
1
Department of Health Services Management, Kerman University of Medical Sciences, Kerman, Iran,
2
Department of Health Services Management, Tehran University of Medical Sciences, Tehran, Iran,
3
Iran University of Medical Sciences, Tehran, Iran,
4
Department of Health and Management, Mashhad University of Medical Sciences, Mashhad, Iran.

Abstract major role in the provided package of health care

Background : Determining Services of Basic
Health Insurance Package has been the big chall-
enge of Insurance Organizations in Iran. These or-
ganizations have no choice to identify the proper
criteria to formulate the insurance package servi-
ces, given the limited resources.
Objectives: This research is an attempt to tac-
kle this issue by determining the necessary criteria
and their importance for defining Basic Healthca-
re Insurance Package in Iran.
Methods and material: This is a qualitative,
descriptive and cross sectional study which has
been conducted in 2010. This study has been carri-
ed out in two steps. In the first step, a sample of 20
professionals was selected. A sample of professi-
onals was selected using purposeful and snowball
based methods, who were then individually inter-
viewed. The whole interviews were digitally re-
corded, and were transcribed and analyzed later to
obtain the criteria. In the second step, a questio-
nnaire was sent to experts from the six organiza-
tions involved with health insurance. Purposeful
and Snowball sampling techniques were used to
identify 52 health insurance experts. The SPSS
software was used to analyze the collected data.
Results: Practicability, stockholders and politi-
cians’ perspectives, cost of interventions and belon-
ged to the vulnerable group criteria are playing a
services by health insurance organizations in Iran
in the current situation. Cost-effectiveness, effecti-
veness, quality of evidence and equity of access are
the most important criteria in the ideal situation.
Conclusion: There is a big difference between
the criteria which have been used to set the prio-
rity in the current situation with what it should be
in the criteria in the ideal situation in Iran. Given
the differences in the role of priority setting for the
current and ideal situation, it is necessary to apply
a policy that can reduce the present gap.
Key Words: Basic Health Insurance Package,
Priority Setting, Iran
Introduction
The scarcity of resources to satisfy human needs
is an issue which has been accepted by all nations.
It means governments are facing with limited bud-
get and resources to satisfy their people’s need (1).
Health sector is dealing with the issue of scarci-
ty in available resources, like other sectors of the
economy. Hence, all governments require to spend
a limited amount of resources in health care(2).
The scarcity of resources requires governments to
make choices from alternatives, which is conside-
red an important function for governments. The-
refore, the need for selection from alternatives is

1542 Journal of Society for development in new net environment in B&H


not an issue which can simply be ignored, neither
in individual level nor in government level. Once
there is a big gap between health care needs and
accessible resources, governments should make
decisions very cautiously(3,4). It can be said the
optimal use of the available resources is vital. For
this propose, we need the prioritization (5). Willi-
ams describes prioritization as “Deciding who is
to get what at whose expense”(1).
Once the necessity and importance of prio-
ritization is realized, the next question is how it
should be done (6,7). Despite the fact that there is
an increasing interest regarding prioritization, the-
re is not a commonly accepted method for of the
prioritization (4). Prioritization is a complicated
process. This is more complicated in Developing
countries as they not only should deal with scar-
ce resources but they also have social norms and
special characteristics that affect the prioritization
criteria (8). After we make decision about how
to apply a certain prioritization process in health
care, we should describe a package of health care
that reflects selected priorities. This package can
be determined from the view of different stock-
holders in health care viz. health care providers,
health insurers, costumers and etc (9).
How to determine a basic package of health
services has been a major challenge for health in-
surance organizations. In other words, these orga-
nizations face this question, what criteria should
be used to define health care package given the
scarcity of available resources? The meager litera-
ture in the area of prioritization in the developing
countries reveals the disconnection between the
values that are driving priority setting decisions
and the values that should be driving (10,11). The
literature review in Iran shows there is not a con-
ducted survey to determine the criteria that can be
used to design a basic package of health services
in health insurance organizations. This also causes
a major problem in health insurance organizations
as they can not define basic package appropriately
(12). A preliminary study in Iran found that heal-
th insurance organizations in Iran have different
problems and difficulties. One of such problems
is unfamiliarity of health insurance organizations
with a basic package of health services that they
should cover (13). In other words, the level of be-
nefits regarding basic package of health services is
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
not suitable from the social security point of view.
This is because inclusion and exclusion of servi-
ces in the package are not based on the application
of the law and mostly rely on the instructions and
regulations. It means basic health care services are
not defined specifically and even some of primary
health care services are excluded from the public
health insurance coverage (14).
The decision of what includes into the packa-
ge will be based on some type of criteria that are
agreed upon. Generally, there is a less agreement
upon what type of health care should be included
in the package. Hence, one of the challenges in this
regard is to reach an overall agreement about how
to design the package (15). Historical review in Iran
shows there are not any certain criteria for determi-
ning the package (16). Therefore, it is necessary to
define criteria that can be used to determine a basic
package of health services in health insurance or-
ganizations. Undoubtedly, we introduce a package
that is not acceptable politically, accessible financi-
ally and inefficient technically if we do not use the-
se criteria to determine the services in the package.
Consequently, it is vital to use a mixture of all types
of criteria for setting health care insurance package.
For this propose, we should specify these criteria
in the first step. The aim of this study was two fol-
ded. Firstly, we distinguished the importance of the
criteria that are used to define the package in the
current system after defining some criteria based on
the interviews with professional. In the second step,
we found the value of each criterion in the ideal pri-
ority setting process. Therefore, our study prepares
a basis for comparison between the current and ide-
al priority setting process in Iran.
Methods
This is a qualitative, descriptive and cross sec-
tional study which has been conducted in 2010.
This survey has been carried out in two steps as
follows:
(1) Interview with professionals
(2) Collect experts’ ideas regarding the criteria
in health insurance organizations
In the first step, a sample of 20 professionals
was selected. The sample includes professionals
1543
HealthMED - Volume 5 / Number 6 / 2011

who have a relevant education and research and
those who have working experience in the six or-
ganizations involving in health insurance in Iran.
These six organizations are President Deputy Stra-
tegic Planning and Control (PDSPC), Ministry Of
Welfare and Social Security (MWSS), Medical In-
surance of Social Security (MISS), Medical Ser-
vice Insurance Organization (MSIO), the Armed
Forces Medical Service Organization (AFMSO)
and Imam Khomeini Relief Foundation (IKRF).
The sample of professionals was selected using
purposeful and snowball based methods. Inter-
views with the professionals were occurred in
their office. The interviews were recorded and the
obtained data from the interviews were reviewed
to obtain the criteria.
In the second step, the results of the first part
were used to construct a questionnaire. Then, the
questionnaire was sent to experts in the six organi-
zations involving in health insurance. To detect the
validity and reliability of questionnaire we used
content validity method and test-retest (r=0.8).
Purposeful and Snowball sampling techniques
used to identify 52 health insurance experts. This
method of sampling applied because it was diffi-
cult to identify appropriate experts for the study as
the respondent required to be familiar with the es-
pecial terms used in the questionnaire. The SPSS
software used to analyse the collected data.
Results
The results of the study can be divided into two
parts.
Defining decision-making criteria about
basic health insurance package
This section presents the results of first part
of the study. Table 1, illustrates 31 decision ma-
king criteria which extracted from the informati-
on provided by respondents in the questionnaire1.
As can be seen, the criteria can be classified into
six different criteria group viz. intervention-rela-
ted criteria, disease-related criteria, patient-related
criteria, society-related criteria, providers-related
criteria and stockholders-related criteria.
1 Some of the criteria in the table are based on the
literature review.

Table 1. Decision-making criteria and six different criteria groups

Intervention- Disease-related Patient- related Society-related Providers- Stockholders-
related criteria criteria criteria criteria related criteria related criteria
- Effectiveness - Severity of - Age -Society’s - Health care - Stockholders
of intervention condition - Gender perspective provider’s view and politicians’
- Cost- - Burden of - Income -Equity of view
effectiveness of disease - Place of residence access
intervention - Externality in Iran
- Quality of evi- - The time of - Status of citizen
dence on providing (living abroad or in
effectiveness service Iran)
-Costs of - Ability to - Religion
treatment make disability - Social status
- Expected - Power and
outcome of influence
treatment - Mental capabilities
- Practicability - Responsible for
- Safety causing own illness
-Side effects - Physical ability
- Long term -Belonged to
sustainability vulnerable groups
- Acceptability

1544 Journal of Society for development in new net environment in B&H

 HealthMED - Volume 5 / Number 6 / 2011

Health insurance experts’ opinions on the care package in the ideal situation. Health insu-
collected criteria rance experts demonstrated that burden of disea-
se (85.4, SD=13.2) and ability to make disability
This section presents the result of the second part (74.5, SD=20.3) are the most important criteria
of the study. There were male (79.5%) and female among disease related criteria.
(20.5%) respondents. 27 percent of the respondents Table 3 demonstrates the importance of each
had less than 10 years experience whereas 47 per- patient related criterion from the health insurance
cent had 10-20 years of experiences. 26 percent of experts’ view.
the rest had more than 20 years experience. According to the table 3, belonged to vulnerable
Table 2, shows the importance of intervention- groups and power and influence criteria are playing
related criteria and disease-related criteria in the major roles in designing health care services pac-
current and ideal situation based on the experts’ kage in the current situation with the point of 60.9
opinions. (SD=11.6) and 45.4 (SD= 25.6) per cent respecti-
As can be seen, respondents stated that practi- vely. Whereas, the respondents are of the opinion
cability and cost of treatment are the two most im- that belonged to vulnerable groups and the reason
portant criteria among intervention-related criteria of illness (whether or not a patient is responsible
that affect the design of basic health care services for the problem) are the two most important criteria
package in the current situation. The point for the- that should be considered in the designing of health
se two criteria were 72 (SD=6) and 61 (SD= 21.9) care package in the ideal situation.
per cent respectively. Whereas, respondents gave Table 4 reveals the respondents’ opinion about
more priority to the burden of disease and severity the society, providers and stockholders related cri-
of condition criteria with 59 (SD=21.3) and 55.4 teria in designing health care package.
(SD=20) per cent respectively. In accordance with table 4, equity was conside-
Table 2, also shows that respondents conside- red more important criterion than society’s view in
red cost-effectiveness (91.6, SD=11.7) and effecti- designing the health care insurance package in both
veness (89, SD=13.4) of interventions as the two current and ideal situations by the respondents. Fur-
main criteria in the process of designing health thermore, health insurance experts were of the opi-

Table 2. Experts’ views on the importance of intervention and disease related criteria in the current and
ideal situation
Intervention-related criteria Disease-related criteria
Quality of evidence on effectiveness
Cost-effectiveness of intervention

Expected outcome of treatment

The time of providing service

Effectiveness of intervention

Ability to make disability

Long term sustainability

Severity of condition
Costs of treatment

Burden of disease
No Side Effects
Practicability

Acceptability

Externality
Safety

Mean 55.5 52.7 54 61 50 72 55.4 49 47.2 52.7 55.4 50 50 54 59

Current
Standard
Situation 21.2 19.5 20 21.9 16.7 6 16.9 17.4 15.6 17.3 20 16.9 19.6 19.8 21.3
deviation
Mean 91.6 87.2 89 61 68 80.9 85.4 77 80.9 70 70 70.3 56.6 74.5 85.4
Ideal
Standard
situation 11.7 11.4 13.4 16.6 13.4 15.8 16.9 14.3 12.5 23.6 14.3 21.3 22.4 20.3 13.2
deviation

Journal of Society for development in new net environment in B&H 1545

HealthMED - Volume 5 / Number 6 / 2011

Table 3. Experts’ views on the importance of illness criteria in the current and ideal situation
Patient related criteria

Status of citizen (living abroad or in Iran)

Responsible for causing own illness

Belonged to vulnerable groups

Place of residence in Iran

Power and influence

Mental capabilities

Physical ability
Social status
Religion
Gender

Income
Age

Mean 40.9 23.6 35 39 40 16.3 34.5 45.4 29 35.4 27.7 60.9

Current
Standard
Situation 22.6 17.9 28 28 27.5 9.9 25.2 25.6 17.2 19.4 19.5 11.7
deviation
Mean 58.1 35.4 51.8 52 45 12.7 39 16 34.5 60.6 36.6 79
Ideal
Standard
situation 25.4 29 33.9 19.6 30.8 4.5 21.3 12.1 26.3 18.5 29.4 17.4
deviation

Table 4. Experts’ views on the importance of society, providers and stockholders related criteria in the
current and ideal situation
Providers-related Stockholders-
Society-related criteria
criteria related criteria
Health care Stockholders and
Society’s view Equity in access
providers’ view politicians’ view
Mean 43 49 53.6 68.1
Current
Standard
Situation 23.1 16.3 24.5 23.5
deviation
Mean 64.5 89 50.9 31.8
Ideal
Standard
situation 24.1 13.9 20.8 18.2
deviation

nion that health care providers’ perspectives is anot- Discussion and conclusion
her criterion in designing health care services pac-
kage in the current situation. They also agreed that In general, it can be concluded that health in-
the providers’ perspectives should be considered as surance experts were of the opinion that practica-
an important criterion for designing the package in bility, stockholders and politicians’ perspectives,
the ideal situation. While the respondents agreed cost of interventions and belonged to the vulne-
that stockholders and politicians’ viewpoints play rable group criteria are playing a major role in the
a major role in defining health care service package provided package of health care services by he-
in the current situation, they believed this criterion alth insurance organizations in Iran in the current
should not play much role in the ideal situation as it situation. Some studies show that defining health
plays in the current situation. insurance package in Iran has focused on some

1546 Journal of Society for development in new net environment in B&H


criteria such as cost criteria instead of effectivene-
ss and so on(17).
The respondents mentioned that religion, men-
tal capabilities and physical ability of patients are
the less important criteria in defining of health care
package in health insurance organization. They
also mentioned that cost-effectiveness, effective-
ness, quality of evidence and equity of access are
the most important criteria in the ideal situation.
There have been several studies that show the
importance of the cost-effectiveness criteria in the
process of designing health care package. It means
that this issue should be in the centre of setting
priority in the health care services (18). World
Bank also suggests cost-effectiveness analysis as
a major tool for designing health care package for
health insurance organizations. Meanwhile, cost-
effectiveness analysis and estimation of burden of
disease are the two main approaches that have been
recommended for the priority setting in the deve-
loping countries(19). Cost-effectiveness criteria is
used to determine reimbursable drugs in Austra-
lia(20) and some European countries(21-23).
In the theoretical concepts, equity has been
considered as a main criterion in the priority
setting. The main objective of priority setting is
equity. That should be carried out at the regional
level and equity should be a core objective of this
process. The importance of equity in designing
basic health care package has been cited in some
of empirical studies. For example, Kapiriri and
Norheim found a broad agreement among stock-
holders in Uganda on the importance of equity of
access, cost-effectiveness, quality of evidence and
benefit of intervention in setting priority in heal-
th care(24). Musgrove also noted equity of access
and cost-effectiveness as the most important crite-
ria in priority setting in health care (25).
All things are considered it can be concluded,
there is a big differences between the criteria whi-
ch have been used to set the priority in the current
situation with what it should be in the criteria in
the ideal situation. Our results suggest political vi-
ews and power and influence criteria play a major
role in the priority setting in Iran whereas these
criteria should not play a very important role in
designing health care package. Meanwhile, some
of the criteria such as cost effectiveness, quality of
evidence on effectiveness, long term sustainability
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
and safety of intervention are not playing a signifi-
cant role in making decision as that is expected to
have a main role in ideal priority setting process.
Given the differences in the role of priority setting
criteria in the current and ideal situation, it is nece-
ssary to apply a policy that can reduce the present
gap. In other words, it is necessary to pay more
attention to the criteria that have been considered
as important criteria in the ideal situation.
This study sheds some lights on the real and
ideal situation criteria in Iran by collecting Health
Insurance Experts views. Given the differences in
preference for the various criteria, wide participa-
tion of relevant stakeholders, including the provi-
ders and consumers, should be encouraged.
References
1. Williams A. Priority Setting in Public and Private
Health Care Systems: A Guide through the Ideolo-
gical Jungle. Journal of Health Economics 1988;7:
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2. Bobadilla JL. Searching for Essential Health Servi-
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of Recent Studies on Health Priorities. Washington,
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3. Williams A. QALYs and Ethics:A Health Economist’s
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4. Ham C, Coulter A. International Experience of Ra-
tioning (or Priority Setting). Buckingham: Open
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th, The Role for Priority Setting and a Critique of
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7. Daniels N. Accountability for Reasonableness in
Private and Public Health Insurance. Buckingham:
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8. Bryant JH. Health Priority Dilemmas in Deve-
loping Countries. Buckingham: Open University
Press; 2000.
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9. Zare H. Supplemental Health Insurance. Medical 23. Elsinga E, Rutten FF. Economic Evaluation in Su-
Service Insurance Organization(in Farsi). Tehran: pport of National Health Policy: The Case of The
Elmi Farhangi Publishing Co; 2005. Netherlands. Soc Sci Med 1997; 45: 605-620.
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the Burden of Disease Information for Health Pla- Setting in Health Care in Uganda: Exploration
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Uganda. Soc Sci Med 2003;56 (12): 2433–2441. 2004; 82: 172–179.
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Care Anal 2007; 15: 159–167. DC: The World Bank; 1999.
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Law view (in Farsi). Tehran: Medical Service In-
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14. Tabari AK. Health insurance in comprehensive Kerman,
social Security system(in Farsi). Tehran: Social Iran,
Security Research Institute; 2001. E-mail: rdehnavi@gmail.com
15. Wong H, Bitran R, Shepard DS, Thompson MS.
Designing a Benefits Package: Cost-Effectiveness
Analysis in Health: First Principles. Washington
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16. MSIO. Medical Service Insurance Organization
Rules and Regulations(in Farsi). Tehran: Medical
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17. Ebrahimi Pour H. Designing a Universal Heath
Insurance Coverage Model for Iran, Ph.D. Thesis
(in Farsi). Health Care Administration Iran Uni-
versity of Medical Sciences, Tehran; 2008.
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19. Jayasinghe KSA, Desilva D, Mendis N, Lie RK.
Ethics of Resource Allocation in Developing Co-
untries: the Case of Sir-Lanka. Social Science and
Medicine 1998;47: 1619-1625.
20. Hailey D. Australian Economic Evaluation and
Government Decisions on Pharmaceuticals,
Compared to Assessment of other Health Techno-
logies. Soc Sci Med 1997; 45: 563-581.
21. Pen LP. Pharmaceutical Economy and the Econo-
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nomic Evaluation in the Pricing and Reimbursement
of Medicines. Health Policy 1997; 40: 199-215.

1548 Journal of Society for development in new net environment in B&H


Examination Of Critical Thinking
Disposition In Nursing
Belgin Yildirim1, Şükran Özkahraman2, Medet Korkmaz2, Sıddıka Ersoy2
1
Aydın School of Health, Adnan Menderes University, Aydın, Turkey,
2
Faculty of Health Science, Süleyman Demirel University, Isparta, Turkey.
Abstract
Objectives: The aim of this study is to define
and evaluate in a public hospital of nurses wor-
king The California Critical Thinking Disposition
Inventory (CCTDI) related factors.
Methodology: The population of the study
consisted of 36 nursing studying in a public hospi-
tal of nurses working. The sample size was 36 stu-
dents who volunteered to participate in the study.
The data are collected from March to June in 2010
year. Socio demographic Features Data Form
and CCTDI, were used as data collection tools.
SPSS 15.0 package software program were used
in evaluation of data and numbers, percentage es-
timation, arithmetic mean, Man Whitney U Test,
Kruskal-Wallis Test, t test and Pearson correlation
analysis were used.
Results: Once total score means are examined,
it is seen that the score mean obtained by the stu-
dents was 189.00 ±18.21. It was determined that
there was no statistically significant difference
between the 0-5 year nurses working periods and
the 6-10 year nurses working periods and the 11
year ↑ nurses working periods in the total subscale
score means (p>0.05). It was determined that there
was statistically significant difference between the
health vocational education nurses and the schoo-
lassociate degree education nurses and the univer-
sity education nurses in the truth-seeking subscale
and analyticity subscale score means (p<0.05). It
was determined that there was not statistically sig-
nificant difference between the nurses’ marital sta-
tus, income level, and education level of parents,
critical thinking studying with the CCDTI scale,
subscale score means (p>0.05).
Conclusions: It is concluded that to improve
the nurses’ critical thinking disposition and skills
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
course was helpful. The higher the educational lev-
el of nurses increased in critical thinking disposi-
tion scale score. Development of critical thinking
disposition in nursing must be provided educational
opportunities of the institutional and outside the in-
stitution.
Key words: Critical thinking, critical thinking
disposition and skills, nurse
Introductıon
Diminished economic resources and increased
patient care responsibilities have dramatically al-
tered the current environment of health care deli-
very. Some individuals have responded to the re-
cent health care changes by becoming dissatisfied,
demoralized, and ultimately leaving the practice
setting. Others have continued to thrive professi-
onally remaining excited and committed to the-
ir work. Nurses who have managed to maintain
work excitement in these changing times mayde-
monstrate attributes of critical thinking disposition
and skills. Health care changes as reported in the
literature, have led many nurses to experience dec-
reased morale, role dissatisfaction, and increased
rates of “burnout” (Bush, 1988; Butler, Parsons,
1989; Brewer 1997; Norbeck, 1985; Packard, Mo-
towidlo, 1987; Yıldırım 2010a; Yıldırım 2010b).
In response to dissatisfaction, nurses are searching
for positions which offer a greater sense of ful-
fillment and excitement in their practice (Hente-
mann, Simms, Erbin-Roesemann, Greene, 1992).
Despite the chaotic healthcare environment, it is
encouraging to note that some individuals within
the professional nursing workforce continue to th-
rive, develop professionally and shape their own
future (Brewer, 1997; Savage, Simms, Williams,
1549
HealthMED - Volume 5 / Number 6 / 2011
Erbin-Roesemann, 1993). Some nurses have res-
ponded to changes in the field by pursuing Pro-
fessional development through higher education.
Applications to advenced practice programs
have increased during the past decade and a po-
sitive outlook for nurses with advanced degrees is
forecasted by the American Association of Colle-
ges of Nursing (Trossman, 1998). A concern con-
tinues in the nursing profession because some nur-
ses leave this changing health care system, while
others remain committed and involved in meeting
patient needs, and developing their expertise.
The search for understanding about the reasons
that some nurses thrive while others remain unc-
hallenged in this changing health care system has
spurred interest in research on work excitement
(Erbin-Roesemann, Simms, 1997; Simms, Erbin-
Roesemann, Darga, Coeling, 1990; Zavodsky,
Simms, 1996). Work excitement has been defi-
ned by Simms, Erbin-Roesemann, Darga, Coeling
(1990) as “personal enthusiasm and commitment
for work as evidenced by creativity, receptivity to
learning, and ability to see opprtunity in everyday
situations”. The development of work excitement
in the individual may be influenced by factors
such as critical thinking disposition and self-effi-
cacy which are identified in the literature as im-
portant comonents of an individual’s professional
development (Bandman, Bandman, 1988; Ban-
dura, 1993; Facione, Giancarlo, Facione, Gainen,
1995).
There is a growing interest among educators
(Facione, Giancarlo, Facione, Gainen, 1995) in
specially addressing the disposition of critical
thinking. The critical thinking concept is broad-
ly characterized by Facione, Facione (1996) as
“purposeful, self-regulatory judgement, a human
cognitive process”. A disposition toward critical
thinking is further clarified by Facione, Facione
(1996) as “the consistent internal motivation to
engage problems and make decisions by using
thinking”. Critical thinking has been defined by
many noted educators during the past century
(Brookfield, 1991; Dewey 1910; Mezirow, 1990;
Norris and Ennis, 1989; Paul, 1993; Watson and
Glaser, 1964), with each definition emphasizing
different aspects. As a result, the nature of critical
thinking lacks consensus across academic disci-
plines (Myrick, 2002). Through a Delphi method
1550
with 46 experts, the American Philosophical As-
sociation developed a cross-disciplinary concep-
tual definition: We understand critical thinking to
be purposeful, self-regulatory judgement which
results in interpretation, analysis, evaluation, and
inference, as well as the expiations of the eviden-
tial, conceptual, methodical, criteria logical, or
contextual, considerations upon which that judge-
ment was based (Facione, 1990). Besides these
definitions, Beyer (1987) also brings out a new
term for critical thinking: evaluative thinking. He
indicates that critical thinking is evaluative in na-
ture, because it entails precise, persistent, and ob-
jective analysis of any claim, source, or belief to
judge its accuracy, validity, or worth. According to
Yıldırım (2011), critical thinking is “the process
of searching, obtaining, evaluating, analyzing,
synthesizing and conceptualizing information as
a guide for developing one’s thinking with self-
awareness, and the ability to use this information
by adding creativity and taking risks”.
Methodology
The aim of this study is to define and evaluate
in a public hospital of nurses working The CCTDI
related factors. The population of the study con-
sisted of 36 nursing studying in a public hospital
of nurses working. The sample size was 36 stu-
dents who volunteered to participate in the study.
The data are collected from March to June in 2010
year. Socio demographic Features Data Form
and CCTDI, were used as data collection tools.
SPSS 15.0 package software program were used
in evaluation of data and numbers, percentage es-
timation, arithmetic mean, Man Whitney U Test,
Kruskal-Wallis Test, t test and Pearson correlation
analysis were used. Socio-demographic data of
nurses with CCDTI was performed.
California Critical Thinking Disposition In-
ventory (CCDTI): This inventory was develo-
ped based on the results of The Delphi Report in
which critical thinking and disposition toward cri-
tical thinking were conceptualized by a group of
critical thinking experts (Facione, 1990). The ori-
ginal CCTDI includes 75 items loaded on seven
constructs. These are inquisitiveness, open-min-
dedness, systematicity, analyticity, truth-seeking,
Journal of Society for development in new net environment in B&H
 HealthMED - Volume 5 / Number 6 / 2011

critical thinking self-confidence, and maturity. Statistical Analysis

Briefly, the inquisitiveness construct including 10
items that measures one's intellectual curiosity and Data were analysed using the SPSS for Win-
one's desire for learning without considering any dows, Version 15.0 (SPSS, Inc., Chicago, IL). Data
profit. The open-mindedness construct contains 12 were analyzed using numbers, percentage, arithme-
items that measures being tolerant of divergent vi- tic average, t-test, Pearson’s correlation analysis,
ews and sensitive to the possibility of one's own Kruskal-Wallis Test, Man Whitney U Test.
bias. The systematicity construct comprised of 11
items, and it measures how a person is organized,
orderly, focused, and diligent in inquiry. The anal- Results
yticity construct involving 11 items addresses the
application of reasoning and the use of evidence Socio-demographic characteristics of the nurs-
to resolve problems. The truth-seeking construct es were determined. Table 1 illustrates the distri-
including 12 items measures the disposition of be- bution of data related to characteristics such as,
ing eager to seek the best knowledge in a given age group, number of siblings, education level,
context, courageous about asking questions, and income.
honest and objective about following inquiry. The Table 1. Socio-Demographic Characteristics of
critical thinking self-confidence construct consi- Nurses
sting of 10 items measures the trust the soundne- Characteristics Number %*
ss of one's own reasoning processes. Finally, the Age Group
maturity construct involving 10 items measures 17-25 4 11.1
cognitive maturity and the disposition to be judi- 26-34 20 55.6
cious in one's decision-making (Kökdemir, 2003). 35-40 12 33.3
Kökdemir (2003) carried out an adaptation study Working Periods
to transform this inventory into Turkish version 0-5 year 5 13.9
because of cultural concerns. After all items were 6 -10 year 15 41.7
translated into Turkish by eight persons including 11 and ↑ 16 44.4
six psychologists, a simultaneous translator and the Education Level
researcher himself, it was administered to 913 stu- Health Vocational Schoolasso- 21 51.2
dents in the Faculty of Economic and Administra- ciate Degree 16 39.0
tive Sciences. Firstly, item-total score correlations University 4 9.8
were estimated and 19 items whose correlation un- Critical Thinking Education
der .20 was eliminated from the scale. Factor anal- Yes 11 30.6
ysis was performed on the reduced scale. His study No 25 69.4
revealed that five items had lower factor loadings Total 36 100.0
than .32 and items under open-mindedness and *Column Percentage
maturity constructs were loaded on one construct.
Finally, 51 items with six constructs were kept in Once total score means are examined, it is seen
the scale Reliability of the whole scale was found that the score mean obtained by the students was
.88. Reliability coefficients of each subscale ranged 189.00 ±18.21. CCTDI score means of the stu-
from .61 to .78. In this study, this scale was admini- dents taken into the scope of the study reveal that
stered to the students in the experiment and control the score mean of the “truth-seeking” subscale was
groups. Finally, 51 items with six constructs were 26.41±7.96; the score mean of the “Openminded-
kept in the scale Reliability of the whole scale was ness” subscale was 41.33±8.27; the score mean of
found .80 Reliability coefficients of each subscale the “systematicity” subscale was 21.19±3.29; the
ranged from .61 to .73. score mean of the “Self-confidence” subscale was
25.22±4.05; the score mean of the “İnquisitive-
ness” subscale was 31.38±4.66 (Table 2).

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HealthMED - Volume 5 / Number 6 / 2011

Table 2. Nurses’ Distribution of CCTDI Scores

Scale X ± SD
Truth-seeking 26.41 7.96
Openmindedness 41.33 8.27
Analyticity 43.44 6.67
Systematicity 21.19 3.29
Self-confidence 25.22 4.05
İnquisitiveness 31.38 4.66
Total 189.00 18.21

Table 3. According to The Nurses’ Working Periods Distribution of CCTDI Scores

0-5 year 6-10 year 11 year ↑
Scale KW P
X ± SD X ± SD X ± SD
Truth-seeking 25.60±2.07 28.40±11.16 24.81±4.86 3.329 0.18
Openmindedness 43.60±5.89 40.40±8.25 41.50±9.18 0.891 0.64
Analyticity 44.00±5.78 44.13±5.27 42.62±8.22 2.460 0.29
Systematicity 22.80±2.04 19.73±2.86 22.06±3.56 3.313 0.19
Self-confidence 24.60±4.21 24.60±3.43 26.00±4.61 0.942 0.62
İnquisitiveness 29.80±2.94 31.73±3.47 31.56±6.01 2.547 0.28
Total 190.40±10.40 189.00±20.93 188.56±18.30 0.407 0.81

Table 4. According to The Nurses’ Education Level Distribution of CCTDI Scale

Education Level
Scale Health Vocational Schoolassociate Degree University
KW P
X ± SD X ± SD X ± SD
Truth-seeking 25.00±2.86 26.57±10.69 28.11±4.86 9.689 0.00
Openmindedness 44.30±7.95 39.94±8.55 42.00±7.41 1.862 0.39
Analyticity 44.54±4.74 40.78±6.55 46.66±7.00 6.280 0.04
Systematicity 21.81±2.82 21.10±3.85 21.00±2.29 0.797 0.67
Self-confidence 24.90±4.10 24.78±4.37 27.66±2.23 3.975 0.13
İnquisitiveness 29.90±2.66 31.57±5.82 32.33±2.69 4.896 0.08
Total 190.81±9.48 184.78±23.11 197.77±4.86 5.362 0.04

Once total score means are examined, it is seen
that the score mean obtained by the 0-5 year nurses
working periods was 190.40±10.40, whereas the
mean were 189.00±20.93 6-10 year nurses work-
ing periods and 188.56±18.30 11 year ↑ nurses
working periods. It was determined that there was
no statistically significant difference between the
0-5 year nurses working periods and the 6-10 year
nurses working periods and the 11 year ↑ nurses
working periods in the total scale score means
(p>0.05) (Table 3). It was determined that there
was no statistically significant difference between
the 0-5 year nurses working periods and the 6-10
year nurses working periods and the 11 year ↑
nurses working periods in the total subscale score
means (p>0.05) (Table 3).
Once total score means are examined, it is seen
that the score mean obtained by the health vocati-
onal education nurses was 190.81±9.48, whereas
the mean were 184.78±23.11 schoolassociate de-
gree education nurses and 197.77±4.86 university
education nurses. It was determined that there was
statistically significant difference between the health
vocational education nurses and the schoolassociate
degree education nurses and the university educa-
tion nurses in the total scale score means (p<0.05)
(Table 4). It was determined that there was statisti-
cally significant difference between the health voca-
tional education nurses and the schoolassociate de-
gree education nurses and the university education
nurses in the truth-seeking subscale and analyticity
subscale score means (p<0.05) (Table 4).

1552 Journal of Society for development in new net environment in B&H


It was determined that there was not statisti-
cally significant difference between the nurses’
marital status, income level, and education level of
parents, critical thinking studying with the CCDTI
scale, subscale score means (p>0.05).
Dıscussıon
The conceptualization of critical thinking con-
sists of two dimensions: cognitive skills and affecti-
ve dispositions (Colucciello, 1997). Facione, Gian-
carlo, Facione, Gainen (1995) have developed two
instruments based on the American Philosophical
Association’s Delphi Report (1990) to measure the
two dimensions of critical thinking. The California
Critical Thinking skills Test (CCTST) measures the
following six global reasoning skills: Interpretati-
on, Analysis, Evaluation, Inference, Explanation
and Self-regulation (Facione, Giancarlo, Facio-
ne, Gainen 1995). The Califoria Critica Thinking
Disposition Inventory (CCTDI) (Facione, Facio-
ne, 1996) measures “the dispositional description
of a critical thinker” (Facione, Giancarlo, Facione,
Gainen 1995). Seven were developed to sore the
following attributes: Inquisitiveness, Open-min-
dedness, Systematicity, Analyticity, Truth-seeking,
Critical Thinking Self-confidence, and Maturity. In
the evaluation of the original scale used abroad, the
score below 280 of the total score obtained from the
scale with seven subscales and 75 items is deemed
as low, whereas the score above 350 of the total
score is deemed as high. Performed the validity and
reliability study of the scale in Turkey Kökdemir
stated that the CCTDI was reduced to six subscales
and 51 items and the score below 240 was accepted
as low critical thinking disposition and skill score,
whereas the score above 300 was accepted as high
score of critical thinking disposition and skill (Kök-
demir, 2003).
A number of recent investigations examined
critical thinking disposition (Eşer, Khorshid, Demir
2007; Dirimeşe, 2006; Glendeon, 2002; Hicks, Mer-
rit, Elstein, 2003). While these studies examined
critical thinking disposition levels. Once total score
means are examined, it is seen that the score mean
obtained by the nurses was 189.00 ±18.21 (Table
2). They are determined to have had scores at low
levels (239 points and below). In descriptive studies
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
conducted using the CCTDI in nurses in Turkey be-
tween 2006 and 2007 proved that the lowest score
was 191.01±30.141 at low level, whereas the high-
est score was 261.10±22.50 at medium level (Eşer,
Khorshid, Demir 2007; Dirimeşe, 2006). As for the
descriptive studies carried out abroad, they deter-
mined that the score was 295.4±19.9 at medium
level and 313.82±25.8 (Hicks et al., 2003; Glende-
on, 2002). Therefore, although the scores obtained
in the studies conducted on nurses abroad seem to
be low and medium levels.
In the “truth-seeking” subscale, the nurses was
determined 26.41±7.96 low level scores. In the
“openmindness” subscale, the students was deter-
mined 41.33±8.27 close to medium level scores.
In the “analyticity” subscale, the nurses was de-
termined 43.44±6.67 medium level scores. In the
“systematicity” subscale, the nurses was deter-
mined 21.19±3.29. In the “self-confidence” sub-
scale, the nurses was determined 25.22±4.05. In
the “inquisitiveness” subscale, the students was
determined 31.38±4.66. It was observed that nurs-
es had scores at low and medium levels in studies
in which these subscale was investigated in Tur-
key, whereas they had scores at medium level in
studies conducted abroad (Eşer, Khorshid, Demir
2007; Dirimeşe, 2006).
Nursing programs were unable to find enou-
gh full-time faculty to meet this new demand and
filled this gap by hiring many partime faculty to
teach in clinical areas. Because many faculty were
no longer teaching both theory and clinical work,
challenges increased for remaining full-time fa-
culty to sustain a cohesive curriculum between
classroom and clinical setting. The gap between
demand and actual capacity continues to widen
(Brendtro, Hegge, 2000). Benner (Benner, 1984;
Benner, Hooper-Kyriakidis, Stannard, 1999; Ben-
ner, Tanner, Chesla, 1996) studied skill acquisition
in nurses for more than two decades. Her research,
drawing on earlier work by Dreyfus and Dreyfus
(1980) on skill acquisition in other professions,
showed that novice or advanced beginner nurses
learn in particular ways, engage in concrete thin-
king focused on mastering technology, and often
have difficulty making distinctions in clinical si-
tuations and setting priorities when confronted
with multiple demands. Expert nurses, in contrast,
grasp clinical situations as wholes, utilize extensi-
1553
HealthMED - Volume 5 / Number 6 / 2011
ve pattern recognition skills, and are able to make
fine distinctions and anticipate problems before
they occur. Benner identified five stages of skill
acquisition in nursing.
Benner’s concept of clinical forethought is im-
portant to considering the expertise gap. Clinical
forethought is the ability to foresee, anticipate,
and prevent future patient problems. Benner’s ex-
pert stage is characterized by a constant vigil of
clinical forethought, which leads to early interven-
tions in patient care (Benner, Hooper-Kyriakidis,
Stannard, 1999). Most nurses take at least 5 ye-
ars to reach the expert stage, if they reach it at all
(Benner, 1984; Benner, Chesla, 1996). Benner’s
work suggests that the proficient and expert stages
of nursing practice are characterized by the abi-
lity to make subtle distinctions based on a deep,
individualized knowing of the patient in the parti-
cular context of the situation (Benner, 1984; Ben-
ner, Hooper-Kyriakidis, Stannard, 1999; Dreyfus,
Dreyfus, 1996; Dreyfus, Dreyfus, Benner, 1996).
Expert nurses who can recognize patient prob-
lems early, even before obvious changes in patient
symptom presentation occur, intervene earlier to
prevent ensuing complications (Ashcraft, 2004;
Minick, Harvey, 2003). This skill in the expert
nurse is manifested as an intuitive gestalt that mo-
ves the nurse to use proactive measures to prevent
likely complications and prepare for the possibi-
lity of crisis (Benner, Tanner, Chesla, 1996). Ex-
pert-level skills enable clinicians to make keen
judgments about when, for example, a patient is
responding differently to treatment than most pati-
ents do and may require an alternative interventi-
on. This kind of discrimination is particularly im-
portant as medical care protocols become increa-
singly “evidence based.” Although such protocols
are properly based on large studies of what works
best for most people with a given condition, it is
particularly important to have informed, vigilant
clinicians who can detect signs that a particular
patient is not like “most people” in some way and
thus may not be helped (or may be harmed) by
following standard protocols (DeBourgh, 2001;
Dracup, 2006; Kral et al., 2005; Rogers, 2004).
This study, It was determined that there was
no statistically significant difference between the
0-5 year nurses working periods and the 6-10 year
nurses working periods and the 11 year ↑ nurses
1554
working periods in the total subscale score means
(p>0.05) (Table 3). Because younger nurses and
51.2% have graduated from vocational high
school are due to be considered.
Facione, Facione, Sanchez (1994) notes that
skills and dispositions are mutually reinforced so
a strong disposition may insure the use of crtical
thinking skills. Nurses have frequently been told to
remain flexible in the workplace. But there is litt-
le place in the practice environment to encourage
or support critical thinking for individuals with the
disposition to be a critical thinker. The experienced
nurse may also need encouragement with critical
thinking development. A tendency exists tto use tra-
ditional approaches as the foundation for practice
instead of seeking new chalenges to provide quality
care for patients. A workplace that supports and en-
courages risk-taking and decision making encoura-
ges individuals who are disposed to think crtically
to use these skills more effectively.
Research shows that new graduates need se-
veral months to become minimally proficient and
feel confident about clinical decision making (del
Bueno, 1990). New graduates verbalize such con-
cepts as clinical judgment, critical thinking, and
problem solving as linear processes, showing little
awareness of context and salience. Expert nurses,
in contrast, seamlessly absorb contextual infor-
mation, which situates their knowing of the pa-
tient; they then intuitively assign different levels
of salience to this information, leading to sound
clinical action (Benner, 1984). In contrast, the ad-
vanced beginner operates using general rules and
needs much clinical support in his or her patient
care decision making, critical thinking (Benner,
1984; Duchscher, 2003; Ebright, Urden, Patter-
son, Chalko, 2004). These results are parallel with
the results of the study. However, some research
findings do not support this claim has no effect
on the level of critical thinking and clinical expe-
rience of nurses (Adams, 1999; Dirimeşe 2006;
Eşer, Khorshid, Demir 2007; Hicks 2001; Hicks,
Merritt, Elstein, 2003; Rodriguez, 2000;). These
results are parallel with the results of the study.
Once total score means are examined, it is seen
that the score mean obtained by the health vocati-
onal education nurses was 190.81±9.48, whereas
the mean were 184.78±23.11 schoolassociate de-
gree education nurses and 197.77±4.86 university
Journal of Society for development in new net environment in B&H

education nurses. Çalışmada üniversite mezunu
hemşirelerin CCDTI puan ortalamasının yüksek
bulunmuştur. It was determined that there was sta-
tistically significant difference between the health
vocational education nurses and the schoolasso-
ciate degree education nurses and the university
education nurses in the total scale score means
(p<0.05). It was determined that there was statis-
tically significant difference between the health
vocational education nurses and the schoolasso-
ciate degree education nurses and the university
education nurses in the truth-seeking subscale and
analyticity subscale score means (p<0.05)(Table
4). The study is to be expected.
It was determined that there was not statisti-
cally significant difference between the nurses’
marital status, income level, and education level of
parents, critical thinking studying with the CCDTI
scale, subscale score means (p>0.05) (Eşer, Khor-
shid, Demir 2007). This study, it was determined
that there was not statistically significant differ-
ence between the nurses’ marital status, income
level, and education level of parents, critical think-
ing studying with the CCDTI scale, subscale score
means (p>0.05).
Conclusıons
It is concluded that to improve the nurses’ cri-
tical thinking disposition and skills course was
helpful. The higher the educational level of nurses
increased in critical thinking disposition scale sco-
re. Development of critical thinking disposition in
nursing must be provided educational opportuni-
ties of the institutional and outside the institution.
Acknowledgments
We would like to thank participant nurses their
role in the completion of this research.
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
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Journal of Society for development in new net environment in B&H 1557

HealthMED - Volume 5 / Number 6 / 2011
Tuberculosis as an occupational
disease: based on health care
centers in Turkey
Abdurrahman Abakay1, Abdullah Cetin Tanrikulu1, Ozlem Abakay2, Hadice Selimoglu Şen1
1
Department of chest diseases, Medical school of Dicle University, Diyarbakir, Turkey,
2
Department of chest diseases Diyarbakir Training and Education Hospital, Diyarbakir, Turkey.
Abstract
Background: Health care workers (HCWs) are
at high risk of contamination. Preventive measures
simultaneously implemented in hospitals have re-
duced the risk of nosocomial transmission of M.
tuberculosis. It was aimed to determine the tuber-
culosis (TB) risk of HCWs working in hospitals
and Tuberculosis Control Dispensaries (TCDs).
Material and Methods: The records of HCWs
worked in five hospitals and four TCDs in Diyar-
bakir were reviewed retrospectively. Clinical data
belong to HCWs diagnosed TB were recorded.
Results: TB was determined in 36 HCWs.
Disease rate was a mean of 74/100.000 and rela-
tive risk was 2.5 times higher than population. In
health care centers (HCCs) providing smear posi-
tive pulmonary TB treatment, disease rate was
176/100.000 and relative risk was 6 times higher;
in HCCs not providing smear positive pulmonary
TB treatment, disease rate was 66/100.000 and rel-
ative risk was 2.2 times higher. It was determined
that most of the precautions that should be imple-
mented for preventing transmission was missed in
HCCs providing smear positive pulmonary TB.
Conclusion: It was determined that TB risk
of HCWs working in HCCs included in the study
especially in the centers providing smear positive
pulmonary TB treatment was increased. It was
suggested that a steady educational program for
HCWs and implementing the other preventive
measures could be effective to decrease the in-
creased risk.
Key words: Tuberculosis, Health Care Work-
ers, Preventive Measures
1558
Introduction
Tuberculosis (TB) is transmitted by inhalati-
on of the particles in air carrying the bacilli. For
this reason, it is difficult to control TB transmi-
ssion (1). The populations have 100/100.000 and
over TB incidence are defined as high-risk groups
(2). The population have high incidence in Tur-
key health care workers (HCWs) (1,3). While TB
risk was high in HCWs in pre-antibiotic era, it has
been rapidly decreased since 1950s (4).
In a review risk of TB disease in HCWs was fo-
und to be 0.6-2 times higher than that in population
(5). In poor or moderately developed countries, ye-
arly TB incidence in HCWs was reported to be in the
range of 69-5780/100.000 (6). In the study period
(1994-2007), the mean TB incidence of Turkey was
found to be 29, 12/100.000 while in our province
Diyarbakir it was found to be 35, 71/100.000 (7). In
a study performed in a university hospital in Diyar-
bakir, TB incidence in HCWs in the period among
1986-2000 was reported to be 199/100.000 (3).
Policy development regarding tuberculosis in-
fection control programs focused on workplace
prevention in health care centers is needed. Recent
data from India suggests that nearly 40% of HCWs
may have latent TB infection and increasing age
and years in the health profession were significant
risk factors for positivity (8). Both workplaces have
been ignored regarding tuberculosis prevention
programs in most health care centers. Not surprisin-
gly, the critical care unit and operating rooms were
not associated with new tuberculosis infection (9).
In our study, it was aimed to determine the
TB risk of HCWs working in inpatient hospitals
and tuberculosis control dispensaries (TCDs) pro-
Journal of Society for development in new net environment in B&H

viding follow up of TB patients in the center of
Diyarbakir province and to investigate the influ-
encing factors.
Materials and methods
The records of HCWs worked in all inpatient
hospitals, TCDs providing follow up of TB pa-
tients in the center of Diyarbakir province in the
period from January 1994 to December 2007 were
reviewed retrospectively, and the data were co-
llected. Diyarbakir, where the data of our study
were collected, is provinces placed in the southe-
ast of Turkey and have a TB incidence higher than
national incidence.
The data belong to the patients were recor-
ded on the standard case report form prepared. In
every report form compiled, age and gender of the
patient, occupation, ward, institute at which he/
she worked, history of contact with a TB patient
in the unit where he/she worked, whether the TB
transmission precautions were implemented in the
unit where he/she worked, if the answer was yes
the type of the measure, the employment period,
medical history, TB history of himself/herself and
family, previously experienced TB form, organ in-
volvement due to TB, the date of diagnosis, smear
positivity and therapeutic outcome were recorded
in detail. The risk was calculated for every hospi-
tal, unit and occupation. The outcome of the pati-
ents was recorded.
The number of HCWs working in health care
centers in this period was achieved from the re-
cords of statistical offices of each center. The data
of HCWs diagnosed with TB were collected by
achieving archived medical records in hospitals
and TCDs.
Population in December was taken as the study
population for each year. Rates of TB for Turkey's
Table 1. Number of average personal in health care centers for their occupations
Centers Bed capacity Doctor Nurse – Paramedic Hospital Attendant
University Hospital 1200 452
State Hospital 540 185
Children’s Diseases Hospital 422 39
Chest Diseases Hospital 141 18
Tuberculosis Control Dispensaries 0 7
Total 2203 701
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
general population were taken from the annual
statistics report of the Ministry of Health (10).
The centers included in the study, their num-
bers of beds and the numbers of HCWs according
to their titles were presented in Table 1. The data
of Diyarbakir Gynecology and Obstetrics Hos-
pital were excluded because there was no HCW
with TB in the study period. TCD, Chest Diseases
Hospital and the Department of Chest Diseases of
University Hospital were accepted as the centers
treating smear positive TB patient.
The precautions that should be implemented
in the centers at which TB patients treated were
classified as administrative measures, engineering
measures and personal measures (4) based on the
rules recommended for poor countries by Interna-
tional Union against Tuberculosis and Lung Dise-
ase (IUATLD) and TB Program Group of World
Health Organization (11). This of these measures
implemented in TB treatment centers and clinics
was recorded.
The mean number of HCWs in the study peri-
od was as follows: 1415 in State Hospital, 611 in
Children’s Diseases Hospital, 158 in Chest Dise-
ases Hospital, 42 in TCDs and 1247 in University
Hospital. In the period between mentioned dates,
total number of HCWs in the centers included in
the study was 48496 (a mean of 3464/year). We
followed all HCWs during the study period. A to-
tal of 36 TB cases were determined in HCWs du-
ring the study period.
The diagnosis was made with clinical signs of
active TB (fever, sputum, weakness, anorexia, we-
ight loss, night sweating), radiology and the pre-
sence of at least one of the following:
-- ARB positivity
-- Culture positivity
-- Histological evidence (granuloma containing
caseating necrosis)
Total
376 419 1247
325 895 1415
206 366 611
50 90 158
18 18 42
975 1788 3464
1559
HealthMED - Volume 5 / Number 6 / 2011

Statistical Analysis TB disease rate in all HCWs was 74.04/100.000,

The relative risk calculation (95% Confidence
Interval) was done for all workers and each em-
ployment group (doctor, nurse and assistant health
staff). TB incidence in Turkey in these years was
based on for comparison.
Results
A total of 36 TB cases were determined in
HCWs. Of the patients, 22 were male and 14 were
female. The female: male ratio was determined to
be 1:1.5. The mean age was found to be 30.5 ±
8.4 years (18–52), in doctors 33.4 ± 10.6 years, in
nurse and paramedics 26.3 ± 5.6 years and in hos-
pital attendants 34.1 ± 8.2 years (in women 26.2 ±
6.5 years, in men 33.3 ± 8.4 years). The mean em-
ployment period of the patients in their units was
8.1 ± 6.3 years. Twenty patients (55%) have been
working in these places for more than five years.
relative risk was 2.54 times higher than popula-
tion, and the highest risk was among nurses and
paramedics group (Table 2). According to the
working titles, of all patients 7 (19.5%) were doc-
tors, 16 (44.5%) were nurses and paramedics, 13
(36.0%) were health care assistants.
In the centers providing the treatment of sme-
ar positive pulmonary TB, the mean disease rate
was determined to be 176.3/100.000, the relative
risk was 6 times higher; in the centers not provi-
ding the treatment of smear positive pulmonary
TB, the mean disease rate was determined to be
66.3/100.000, and the relative risk was 2.2 times
higher.
Of the patients, 32 (88.8%) were newly diagno-
sed TB and 4 (11.2%) had recurring TB. Only one
patient had a TB history in the family. Thirty-one
(86.1%) patients had pulmonary TB and 6 (13.9%)
patients had extrapulmonary TB. Of extrapulmo-
nary TB patients, three had TB pleurisy, one had ge-
nitourinary system TB and one had TB meningitis.

Table 2. Distribution of TB cases according to hospitals, occupations and departments

Parameters Number of Cases Disease Rate (per 100.000) Relative Risk*
Centers
University Hospital 22 126.01 4.32
State Hospital 7 35,33 1,21
Children’s Diseases Hospital 3 35,07 1,20
Chest Diseases Hospital 3 135,6 4,65
Tuberculosis Control Dispensaries 1 170.1 5,83
Occupation
Doctor 7 71.32 2.45
Nurse - Paramedic 16 117.21 4.02
Hospital Attendant 13 51.93 1.78
Departments
Chest Diseases 5 163,1 5.60
Internal Medicine 8 330,3 11.34
Pediatric 4 40.81 1.40
Cardiology 2 219,8 7.54
Dermatology 2 285,7 9.81
Anesthesia 2 174,2 5.98
General Surgeon 2 126,4 4.34
Emergency 2 155,3 5.33
Other 9 92,5 3.17
Total 36 74,04 2,54
*In the study period, the mean incidence of tuberculosis in Turkey was found to be 29.1 per 100.000 persons, and
relative risk was calculated using this data. These numbers are mean relative risk of study period (1994-2007).
(95% Confidence Interval)

1560 Journal of Society for development in new net environment in B&H

 HealthMED - Volume 5 / Number 6 / 2011

Of totally 31 pulmonary TB patients, 23 (74%) was determined that most of the administrative,
were smear positive, 6 (19%) were smear nega- engineering and personal preventive measures
tive and in 2 (7%) of them smear was omitted. were not implemented (Table 4).
On microbiological examination, microbiological Only seven of the patients were followed up
growth was determined in cultures of 12 patients with directly observed therapy (DOT). The the-
(Table 3). All of the five pulmonary TB patients rapies of all the patients were terminated. Thera-
diagnosed in the centers and clinics treating smear peutic outcomes were recorded as completion of
positive pulmonary TB were smear positive and therapy in 26 patients and cure in 10 patients. The
four of these patients were culture positive. As a cure rate in smear positive pulmonary TB patients
result of the observations in the centers providing was determined to be 43%.
the treatment of smear positive pulmonary TB, it
Table 3. Microbiological features of HCWs with Pulmonary TB
Microbiological features of HCWs with Pulmonary TB n %
Smear Results
Smear positive 23 74
Smear negative 6 19
Smear not done 2 7
Culture Results
Smear positive and culture positive 10 32
Smear negative and culture positive 2 7
Smear positive and culture negative 6 19
Smear positive and culture not done 13 42
Total number of HCWs with pulmonary TB 31 100
Table 4. Preventive measures of health care centers providing smear positive pulmonary TB during the
study period
University Chest Diseases
Preventive Measures TCDs
Hospital Hospital
Administrative
Directive plan of preventive measures about
No No No
nosocomial transmission of TB
Education programme about nosocomial trans-
No No No
mission of TB for HCWs
Rapid diagnosis and treatment of TB patients Yes (Since 1994) Yes (Since 1994) Yes (Since 1994)
Isolation of TB patients in private rooms No No No
Rapid sputum collection, transport and reporting Yes (Since 1994) Yes (Since 1994) Yes (Since 1994)
Chest X Ray at quiet times in the day Yes (Since 1994) Yes (Since 1994) Yes (Since 1994)
Engineering
Windows left open most of the time No No No
Class II safety cabinets in laboratory Yes (Since 1999) No No
UV germicidal irradiation system in all areas of
No No No
TB service
UV germicidal irradiation system in only rooms
Yes (Since 1994) Yes (Since 1994) Yes (Since 1994)
of TB service
UV germicidal irradiation system in laboratory No No No
Negative pressure rooms No No No
Personal
N 95 mask use by HCWs No No No
HEPA filter in laboratory areas No No No

Journal of Society for development in new net environment in B&H 1561

HealthMED - Volume 5 / Number 6 / 2011
Discussion
HCWs expose to TB more frequently is an im-
portant health issue. In a study carried out in Ma-
lawi, it was determined 33 patients in 571 workers
(5.780 in 100.000 people) developed TB in a year
(12). TB rate in HCWs was found to be 1.5-3 times
in Estonia, 7.6 times in Serbia and in Peru 4-8 times
higher than that in general population (13-15). In
Japan, TB risk in nurses was calculated to be 2.3
times higher than that in normal population (16). In
Finland, in a 30-year retrospective study, TB risk in
HCWs was found to be lower than that in normal
population. This result was found to be related to
a well-implemented TB control program (17, 18).
In a study in four hospitals in Izmir, TB inciden-
ce was determined to be 96/100.000 in a 12-year
period (19). A total TB incidence of 92/100.000
was reported in workers of Istanbul Medical Facul-
ty Hospital in a ten-year period (20). In a universi-
ty hospital in Diyarbakir, TB incidence in hospital
staff in the period between 1985 and 2000 was de-
termined to be 200/100.000 (3). In the literature re-
view, while similar studies from our country inclu-
ded a single hospital or a few hospitals in a certain
province, a study that assessed all of the health care
centers in the province like our study wasn't found.
The age of 58% of TB patients in Turkey ran-
ges between 20-44 years (21). In a study, the mean
age of HCWs with TB was 38.3 years (47.4 years
in men and 31.2 years in women) (19). In another
study, the mean age was found to be 35 years in
doctors, 27 years in nurses and 25.7 years in health
care assistants (20). In our study, the mean age of
the patients was 30.5 years and it was in accordan-
ce with the literature.
Krunner et al. reported a TB infection rate of
83-147/100.000 and a risk of 1.5-2.9 times higher
than general population in doctors; 66-82/100.000
and a risk of 1.5 times higher compared to general
population in nurses and laboratory technicians in
the study period (13). TB infection rate in our re-
gion was reported to be 127/100.000 for doctors,
274/100.000 for nurses and 160/100.000 for health
care assistants (3). In a hospital in Malawi, active TB
was encountered in a rate of 4% in nurses. This rate
was 40 times higher than that in population (22). In
our study, the highest disease rate and relative risk
were found to be among nurses and paramedics. It
1562 Journal of Society for development in new net environment in B&H
was thought that increased risk among nurses and
paramedics could be due to their prolonged contact
with the patient compared to the other employment
groups. Additionally, it was thought to determine
the level of knowledge about TB, transmission and
preventive measures with new studies to be perfor-
med and based on these data, educational activities
not implemented in our centers according to our
study could be needed to give.
In the HCWs of a lung hospital providing TB
treatment, Krunner et al. determined the infecti-
on rate as 6900/100.000 in doctors; 3450/100.000
in nurses and laboratory technicians and they re-
ported that the risk was increased by 30-90 times
compared to general population (13). TB risk in
HCWs working in TB units was reported to be ten
times higher than that in general population (23).
We determined disease rate was 176/100.000 and
the relative risk was to be 6 times higher in cen-
ters providing treatment of smear positive pulmo-
nary TB. And disease rate was determined to be
66/100.000 (relative risk 2.2 times higher) in the
centers not providing treatment of smear positive
pulmonary TB. This difference in the risk of TB
between the centers in our study was found to be
similar with the literature. We determined highest
risk of TB in internal medicine clinics. We detec-
ted leck of the most preventive measures in inter-
nal clinics. It was thought that the increased risk
determined in the centers and clinics treating the
smear positive TB patients could be related to the
number and the duration of the exposure and inc-
reased intensity of the exposure.
There is a strong argument for advising ven-
tilated facilities and personal respiratory protecti-
on for the care of all patients with tuberculosis,
as multi-drug tuberculosis may not always be
apparent on admission, and these measures mi-
nimise transmission of all cases of TB to other
patients and healthcare staff (24). In one study
showed that administrative measures for infection
control can significantly reduce latent TB infec-
tion among HCWs in high-burden countries and
should be implemented even when resources are
not available for engineering infection control me-
asures (25). Negative air pressure systems which
could prevent spreading of tuberculosis (9). The
most of the administrative, engineering and per-
sonal preventive measures are not implemented in

study centers. We think that this situation can also
lead to the increased risk that we determined in
the centers treating smear positive pulmonary TB.
In universty hospital TB disease risk was lower
than other centers. And university hospital provi-
ded preventive measures better than other centers.
We think this situstaion was associated. We think
when preventive measures are taken TB disease
risk can decreased.
Limitation of this study retrospevtively. We think
so prospective large serie study for mesurement of
TB disease risk in HCWs is needed that after the
preventive mesures were applicated in all hospitals.
Conclusions
In HCWs, especially in nurses, TB risk is higher
than normal population. The lack of a standardized
program directed to preventing TB transmission in
health care centers in our country and the lack of an
educational plan increase that risk. A national con-
trol and training program should be developed im-
mediately. In addition, we think that implementing
thoroughly the precautions standardized by interna-
tional institutes to be taken in health care centers
can be effective to decrease the risk.
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17. Raitio M, Tala E. Tuberculosis among health care Corresponding author

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1564 Journal of Society for development in new net environment in B&H


Qualıty assessment of prımary care
guıdelınes ın Turkey
Aylin Baydar Artantas1, Rabia Kahveci2, Didem Sunay3, Ayşe Caylan4
1
Ministry of Health Akkus Public Hospital, Turkey,
2
Department of Family Medicine, Ministry of Health Ankara Numune Training and Research Hospital, Turkey,
3
Department of Family Medicine, Ministry of Health Ankara Training and Research Hospital, Turkey,
4
Department of Family Medicine, Medical School of Trakya University, Turkey.
Abstract
Introduction: Clinical Practice Guidelines
(CPGs) are systematically developed statements
to assist practitioner and patient decisions about
appropriate health care for specific clinical cir-
cumstances. The Ministry of Health published 67
primary care guidelines in 2003. Considering the
expected effect of CPGs on clinical practice, we co-
uld assume that the quality of such guidelines would
have an effect on the quality of health care practice.
However, there is only very limited knowledge ava-
ilable regarding evidence based practice in Turkey
and no known study related to the published CPGs,
their use or their quality. In this study, we assessed
the quality of existing primary care CPGs, by using
“The Appraisal of Guidelines Research & Evaluati-
on (AGREE) Instrument”.
Methods: 14 guidelines were selected based
on the top ten conditions in “The Burden of Dise-
ase Study” of 2004. The AGREE Instrument was
translated into Turkish. The quality of the guideli-
nes was assessed by 4 appraisers.
Results: The mean rating scores of the domains,
based on the AGREE Instrument were; Scope and
purpose: 87.9%, stakeholder involvement: 62.2%,
rigour of development: 51.2%, clarity and presen-
tation: 66.4%, applicability: 57.2% and editorial
independency: 54.5%. 6 guidelines out of 14 were
recommended by all the appraisers, whereas 8 were
not recommended at least by one of the appraisers.
Conclusions: This is the first study of appra-
ising quality of published guidelines in Turkey.
This study is valuable for indicating the quality of
current published guidelines and adds to the limi-
ted amount of knowledge in Turkey about how to
improve guidelines.
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
Key words: Quality appraisal, clinical practi-
ce guidelines, AGREE Instrument, primary care,
Turkey, evidence based medicine
Introductıon
Clinical Practice Guidelines (CPGs) are syste-
matically developed statements to assist practitio-
ner and patient decisions about appropriate health
care for specific clinical circumstances (1). They
are known to have potential to improve patient
care by promoting interventions of proven bene-
fit and discouraging ineffective interventions (2).
They target changes in health care that can lead to
better care of patients. Considering the expected
effect of CPGs on clinical practice, we could assu-
me that the quality of such guidelines would have
an effect on the quality of health care practice.
Starting in the late twentieth century, there have
been several studies of the practice of evidence-
based medicine (EBM) in different countries and
in different areas of health care (3-13). Similarly
there is a good number of publications in the lite-
rature about the role of CPGs to improve eviden-
ce based health care. However, there is only very
limited knowledge available regarding evidence
based practice in Turkey and no known study to
inquire published clinical practice guidelines,
their use or their quality. A formal body devoted
only to development of guidelines has not been
established within Ministry of Health (MoH). The
existing MoH guidelines have been developed in
different groups with no defined, common metho-
dology. There are also CPGs developed and pu-
blished by certain organizations of health profe-
ssionals. There is no formal approach to evaluate
1565
HealthMED - Volume 5 / Number 6 / 2011
guidelines. The methodology and quality of the
majority of these guidelines is not known.
We have the impression that the best known gu-
idelines are the MoH primary care guidelines that
were published in 2003 (14). No updated versions
have been published since, although it is known
that update efforts are continuing.
In this study, we assess the quality of existing
primary care CPGs published by the MoH, by
using a translated version of “The Appraisal of
Guidelines Research & Evaluation (AGREE) In-
strument” (15).
Primary care CPGs in Turkey
The Ministry of Health, at the time of publis-
hing the “Clinical Practice Guidelines for Primary
Care”, declared that the guidelines were intended
to promote better provision of health care, decre-
ase unnecessary expenditures, increase concensus
among physicians, and avoid using interventions
with unproven effectiveness. Universities, Resear-
ch and Training Hospitals, nongovernment orga-
nizations, provincial health directorates, the Soci-
al Security Institution, the Turkish Association of
Pharmacists, the Turkish Association of Physici-
ans and other related bodies were invited to contri-
bute to the development of guidelines. 521 people
were involved in the development process (14).
There were 67 guidelines, organized as short
chapters of a book. It was published online in the
MoH website and a printed version was sent to all
primary care centers in the country. Each chapter,
although there might be slight changes in each,
includes general characteristics of the condition,
risk factors, diagnosis, differential diagnosis and
management (14).
AGREE Instrument
The AGREE Instrument was developed to
provide a framework for assessing the quality of
clinical practice guidelines. It is an international,
methodologically rigorously developed, validated
instrument (16). The first version of the instrument
was published in 2001 and an updated version was
published in 2009 (15). The authors declare that
1566 Journal of Society for development in new net environment in B&H
by quality they mean the confidence that the po-
tential biases of guideline development have been
addressed adequately and that the recommendati-
ons are both internally and externally valid, and
are feasible for practice. The AGREE Instrument
assesses both the quality of the reporting, and the
quality of some aspects of recommendations (15).
AGREE consists of 23 key items organised in
six domains and each domain is intended to cap-
ture a separate dimension of guideline quality. The
domains are scope and purpose, stakeholder invol-
vement, rigour of development, clarity and presen-
tation, applicability and editorial independence.
The instrument was developed by researchers
from 13 countries. The instrument was later tran-
slated into 22 languages. An achievement of this
study is also the translation of the instrument into
Turkish, which had not been available before.
Methods
Development of Turkish version of AGREE
We decided to use the AGREE instrument be-
cause it has been reported to be a reliable and sim-
ple way to assess the quality of guidelines (16-20).
It also allows us to compare the results with other
studies made using the same tool. Several evalu-
ations of practice guidelines with this tool have
been carried out and published (21-27).
We contacted The AGREE Research Trust for
proper translation technique and to ask for related
permission. Afterwards we traslated the instrument
according to the defined procedure. Two indepen-
dent native Turkish speakers translated the instru-
ment into Turkish. These two translations were
reviewed by a small group for differences and con-
traversies. The group produced a single version of
the Turkish translation. The Turkish translation was
later translated back to English by two native En-
glish speakers, who were not involved in the study
and not were knowledgeable about original version
of the instrument. This re-translated version was
compared to the original one, the differences were
defined and the final version of Turkish AGREE
was developed after final modifications.

Guideline selection
The most well known guidelines produced by
the Ministry of Health and the only known gui-
delines for primary care in Turkey were “Clinical
Practice Guidelines for Primary Care”, published
in 2003 (14). The guideline development was done
under 67 titles. As it was not feasible or useful to
assess the quality of all these 67 guidelines, we
needed a selection process. The MoH carried on
a large study on the burden of disease from 2002
to 2004 and published results under “Turkey Bur-
den of Disease Study 2004” (28). This report was
the latest related material at the time of the study.
The disorders that were ranked in the first ten were
selected. These were: 1. Perinatal conditions, 2. Is-
chemic Heart Disease, 3. Cerebrovascular Disea-
ses, 4. Unipolar Depressive Disorders, 5. Lower
Respiratory Infections, 6. Congenital Anomalies,
7. Osteoarthritis, 8. Chronic Obstructive Pulmo-
nary Disease, 9. Road Traffic Accidents, 10. Iron
Defficiency Anemia. All primary care guidelines
were reviewed and the titles related to the above
conditions were included in the study. Some of the
above conditions were not addressed among the
guidelines. At the end 14 guidelines were included
in the study. These were: Acute Myocardial Infarc-
tion, Angina Pectoris, Iron Deficiency Anemia,
Depression, Diabetes Mellitus, Routine Obstetric
Care, Hyperlipidemia, Hypertension, Congestive
Heart Failure, Chronic Obstructive Pulmonary
Disease, Osteoarthritis, Pneumonia (children),
Community Acquired Pneumonia (adults), Mana-
gement of Patients with Traumatic Injury.
Assessment of the guidelines with AGREE In-
strument:
The appraisal of guidelines was carried out
according to the instructions for use within the in-
strument.
The guidelines were available in a printed book
format as separate chapters, as well as electroni-
cally available in the MoH website. All the gui-
delines and the details about the development of
the guidelines were included in this material. We
did not find any other shared or published material
related to the methodology of development.
The instrument recommends that each guide-
line should be assessed by at least two appraisers
and preferably four, as this increases the reliability
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
of the assessment (15). We chose 4 independent
specialists in family medicine, who are experien-
ced in academic studies. It was made sure that the
appraisers read and fully understood the instru-
ment before they started reading and evaluating
the guidelines. The appraisers declared no perso-
nal conflicts of interest.
The four appraisers rated each item indepen-
dently and individual item scores were
summed up to form domain scores. The resul-
ting domain score is a percentage of the maximum
possible score for that domain.
Results
There are 6 domains in the AGREE instrument
and each domain helps us to assess a different as-
pect of the guideline (15):
Scope and purpose domain is concerned with
the overall aim of the guideline, the specific cli-
nical questions and the target patient population.
Stakeholder involvement focuses on the extent
to which the guideline represents the views of its
intended users.
Rigour of development relates to the process
used to gather and synthesise the evidence, the
methods to formulate the recommendations and to
update them.
Clarity and presentation deals with the langua-
ge and format of the guideline.
Applicability pertains to the likely organisatio-
nal, behavioural and cost implications of applying
the guideline.
Editorial independence is concerned with the
independence of the recommendations and ac-
knowledgement of possible conflict of interest
from the guideline development group.
The scores of the 6 domains of AGREE Instru-
ment for individual guidelines are shown in Table 1.
The mean scores of the domains of the 14 gui-
delines were; Scope and purpose: %87.9, stakehol-
der involvement: %62.2, rigour of development:
%51.2, clarity and presentation: %66.4, applicabili-
ty: %57.2 and editorial independency: %54.5.
The CPG on “Routine Obstetric Care” had the
lowest scores among all CPGs, with scores of 0.38
(38%) in both rigour of development and applica-
bility domains.
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HealthMED - Volume 5 / Number 6 / 2011

Table 1. Domain scores of the selected 14 primary care guidelines in AGREE Instrument
Scope and Stakeholder Rigour of Clarity and Editorial
Clinical Practice Applicability
purpose involvement development presentation independence
Guidelines (%)
(%) (%) (%) (%) (%)
Acute Myocardial
80 60 41 66 58 54
Infarction
Angina Pectoris 80 62 48 62 58 58
Iron Deficiency
88 64 58 70 66 54
Anemia
Depression 83 62 50 60 55 54
Diabetes Mellitus 88 62 55 72 61 54
Routine Obstetric
83 62 38 52 38 54
care
Hyperlipidemia 94 62 53 72 63 54
Hypertension 94 62 51 75 69 54
Congestive heart
77 62 57 70 63 58
failure
Chronic obstruc-
tive Pulmonary 91 64 55 77 52 54
disease
Osteoarthritis 94 62 55 62 50 54
Pneumonia
94 62 54 68 55 54
(children)
Community acqu-
ired pneumonia 94 64 52 66 61 54
(adult)
Management of
patients with trau- 91 62 51 58 52 54
matic injury

3 guidelines had lower than 0.50 (50%) at least
in one domain. These were on Acute Myocardial
Infarction, Angina Pectoris, and Routine Obstetric
Care. The first two had lower than 50% scores in
rigour of development whereas the last one had
such a low score in applicability domain as well.
Six of the fourteen guidelines had the lowest
score from the domain of rigour of development;
two guidelines, from applicability; two guidelines
from editorial independence; one guideline from
both applicability and editorial independence; one
guideline, from both rigour of development and
applicability and one guideline from both rigour
of development and editorial independence.
All guidelines had their highest scores in the
scope and purpose domain. 5 guidelines [hyperli-
pidemia, hypertension, osteoarthritis, pneumonia
(children) and community acquired pneumonia
(adults)] had 0.94 (94%) as the highest scores.
The appraisers never had the same overall asse-
ssment for any of the guidelines (Table 2).
A: Strongly recommend, B: Recommend (with
provisos or alterations), C: Would not recommend,
D: Unsure
6 guidelines out of 14 were recommended by
all the appraisers. These were on acute myocar-
dial infarction, angina pectoris, depression, iron
defficiency anemia, management of patients with
traumatic injury and congestive heart failure. 2 of
the 6 guidelines were strongly recommended by
two appraisers, whereas the rest 4 were strongly
recommended by only one appraiser. The others
recommended by provisos or alterations. The rest
of the guidelines (8/14) were not recommended at
least by one of the appraisers.
In all cases, the appraisers were confident about
their recommendations.

1568 Journal of Society for development in new net environment in B&H

 HealthMED - Volume 5 / Number 6 / 2011

Table 2. Overall assessment by appraisers for each guideline

Appraiser Appraiser
Clinical Practice Guidelines
1 2
Acute Myocardial Infarction B B
Angina Pectoris B B
Iron Deficiency Anemia A B
Depression B B
Diabetes Mellitus B C
Routine obstetric care B C
Hyperlipidemia B C
Hypertension B C
Congestive heart failure B B
Chronic obstructive Pulmonary disease A C
Osteoarthritis B C
Pneumonia(children) A C
Community acquired pneumonia (adult) A C
Management of patients with traumatic injury A B
Appraiser Appraiser
3 4
A B
A B
A B
A B
A B
A C
A B
A B
A B
A B
A B
A B
A B
A B

Dıscussıon only 14 selected guidelines for primary care were

This is the first study of appraising quality of pu-
blished guidelines in Turkey. Considering the lack
of a formal body within public authorities for deve-
lopment of guidelines and the limited amount of pu-
blished guidelines by several different bodies, whe-
re the quality is not known, this study is valuable for
indicating the quality of current published guideli-
nes and adds to the limited amount of knowledge in
Turkey about how to improve guidelines.
There are a number of possible limitations of
our study. First, the appraisal is done by AGREE
instrument which aims to appraise the quality of
reporting and some aspects of recommendations,
but does not assess the impact of a guideline on
patient outcomes (15). So even for the guidelines
with high quality we cannot make any comments
on the actual effects on practice. Second, the study
involves only the guidelines published by the
MoH with the title ‘guidelines’. According to our
knowledge there is no other published guideline
in Turkey targeting primary care. The AGREE in-
strument defines a guideline as “a document that
includes a set of systematically developed state-
ments (recommendations) to assist practitioner
and patient decisions regarding appropriate heal-
th care for specific clinical circumstances”. There
could be other guidelines that fit the above defi-
nition, but do not use the title “ guideline”. Third,
appraised. The results would not be generalizable
to the rest of the published primary care guideli-
nes or the guidelines in different fields, so would
not reflect the quality of guidelines in Turkey as
a whole. However, the strengths of this study are
that it addresses the well known primary care gu-
idelines in Turkey and the guidelines were selec-
ted according to the most important conditions.
This provides the coverage of guidelines that are
expected to be commonly needed and used.
There are several published studies from diffe-
rent countries and settings, that appraise quality of
guidelines with the AGREE instrument.
The 2005 publication of Boluyt and colleagues
on quality of evidence-based pediatric guidelines
identified 215 evidence-based pediatric guidelines
and appraised 17 of these on the 10 most frequ-
ently mentioned topics (21). Mean domain scores
in this survey were 84% for scope and purpose,
42% for stakeholder involvement, 54% for rigor
of development, 78% for clarity of presentation,
19% for applicability, and 40% for editorial inde-
pendence. In this study, 14 of 17 (82%) guidelines
were recommended for use in the Netherlands.
Poitras and colleagues published appraisal of
existing 6 osteoartritis guidelines by the AGREE
instrument (22). Three domains were mentioned
to be particularly not well addressed by the gu-
idelines: stakeholder involvement, applicability,

Journal of Society for development in new net environment in B&H 1569

HealthMED - Volume 5 / Number 6 / 2011
and editorial independence. 4 of these 6 guideli-
nes were recommended whereas the 2 were not
recommended.
Kinnunen-Amoroso and colleagues published
appraisal of 29 guidelines related to occupational
health (23). The guidelines presented their scope
and purpose well (mean score: 62%). The mean
domain score for clarity and presentation was 47%
and for the stakeholder involvement it was 33%.
The other domains scored low: applicability do-
main, 15%, rigour of guideline development, 9%,
and editorial independence, 7%.
Other publications about appraisal of guideli-
nes with AGREE instrument on different settings
are also present, some of which are: depression
guidelines (24), guidelines for the primary care of
lesbian, gay, and bisexual people (25), guidelines
for the treatment of psoriasis (26), critical care
pharmacotherapy (27).
The mean scores of the domains of the 14 gu-
idelines in our study were; Scope and purpose:
%87.9, stakeholder involvement: %62.2, rigour
of development: %51.2, clarity and presentation:
%66.4, applicability: %57.2 and editorial indepen-
dency: %54.5.
In both above mentioned studies and in our
study scope and purpose domain relatively had
higher scores, whereas lower scores come from
rigour of development, applicability and editorial
independency. The process used to gather and syn-
thesise the evidence, the methods to formulate the
recommendations and to update them (rigour of
development) is found to be weak. It is interesting
to see that editorial independence is considered
low. These are MoH guidelines and so many sta-
keholders were involved in the development pha-
se. It seems that there was no convincing message
in the guideline about their conflicts of interest.
It is also noticed that scores of our guidelines
were higher than the other published international
studies. We doubt this would show their higher
quality, but shows one weakness of the AGREE
instrument: the results depend on the subjective
evaluation of appraisers. Appraisers in our study
had no previous experience of using AGREE in-
strument or any quality evaluation of guidelines
with another method. They might have hesitated
to give lower scores. There are also large diffe-
rences between appraisers’ evaluations. It is inte-
1570 Journal of Society for development in new net environment in B&H
resting that Appraiser 3 strongly recommends all
the guidelines whereas Appraiser 2 does not reco-
mmend 8 of 14 guidelines. The differences might
still be due to the different levels of experience of
appraisers. The results in our study might overesti-
mate the quality of selected guidelines.
Worth also noting here is a comment from one
appraiser that none of the guidelines dealt with
cost-effectiveness. A health economist or a health
technology assessment expert was not involved in
developing these guidelines. The appraiser notes
that these are guidelines developed by public aut-
hority and might be used by other public authori-
ties as well, such as social insurance coverage de-
cisions, but that the lack of attention to cost issues
limits their applicability.
It is a pity that these guidelines published in
2003 have not been updated. It is generally recom-
mended that guidelines be updated at least every 3
years, because new evidence can change the reco-
mmendations (29). It is also worth noting that the
MoH selected 67 titles for guideline development
at once, these were tried to be developed and pu-
blished at the same date and the same valid for up-
date, which is probably the basic reason for the de-
lay. It would have been a wiser approach to priori-
tize the topics, independently run the development
of individual guidelines and publication and upda-
te procedures would be run separately. This could
have led higher quality and updated guidelines for
use, although perhaps fewer in number.
Considering that the guideline development
is a long and difficult process, adaptation of cu-
rrently available international guidelines should
also be considered for future guidelines.
Conclusıons
The value of this study is that it evaluates the
only available primary care guidelines in Turkey
and is also the first study related to quality appra-
isal of guidelines in this country. It highlights the
issues related to guideline development to consi-
der in planning future guideline development pro-
cesses. The future of EBM and use of CPGs in
Turkey is promising. Despite weaknesses in the
efforts to date, they should have great value for
Turkey in the future. Further developments might

be improved by a better structured approach for
guideline production and a skilled team under an
organized formal body under MoH.
Acknowledgment
We would like to thank Prof David Banta for
reviewing the final version of the article and his
invaluable support in our academic studies.
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1572 Journal of Society for development in new net environment in B&H


The effect methods to cope with
stress in high school students on
hopelessness and self-esteem
Dilek Kılıç1, Gülcan Erol2, Battal Kılıç3
1
Ataturk University, Health Sciences Faculty, Department of Nursing, Erzurum, Turkey,
2
Ataturk University, Health Sciences Faculty, Department of Nursing, Erzurum, Turkey,
3
Training Management and Audit, Erzurum, Turkey.
Abstract
Purpose: Methods to cope with stress, whi-
ch include specific behavioral and psychological
efforts to fight against the adverse effects of events
or factors that cause stress, are required to protect
mental and physical health, and to maintain a pro-
ductive and rich life. The purpose of this study is
to determine the effect of methods used to cope
with stress by high school students on their hope-
lessness and self-esteem levels.
Instruments and Method: The study was
conducted on 204 students, who accepted to par-
ticipate, at Şükrü Paşa High School, located in the
Erzurum Evren Paşa health center region. A que-
stionnaire containing the descriptive information
of students, the Strategies for Coping with Stress
Scale, Beck Hopelessness Scale, and Rosenberg
Self-Respect Scale (Rosenberg Self-Esteem Sca-
le) were used to collect data for the study.
Findings: 33.8% of the individuals included in
the study were girls, and 66.2% were boys. The
solving problem mean of students, obtained from
coping with stress strategies, was higher than the
seeking social support and avoidance score. The
hopelessness score mean of the students was
6.95±3.25, and the self-esteem score mean was
19.43±3.89. According to the sub-scales of coping
with stress strategies, gender (female students) has
a significant effect on the difference in seeking so-
cial support and avoidance. For various strategies
in coping with stress; a negative relationship was
determined between problem solving and seeking
social support and hopelessness; a significant po-
sitive relationship was determined between pro-
blem solving and self-esteem.
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
Conclusion: The level of hopelessness was
low, and the level of self-esteem was high in stu-
dents who used effective methods in coping with
stress; the most used method in coping with stress
was problem solving.
Key words: Coping with stress, hopelessness,
self-esteem, high school students
Introduction and purpose
It is the universal attitude to use certain coping
attitudes in order to minimize or completely elimi-
nate the adverse effects of stress-causing events or
factors. Coping with stress refers to the cognitive,
emotional, and behavioral effort shown to elimina-
te the requirements and difficulties caused by the
inner and outer world of the individual, keeping
them under control, and minimizing tension. The
attitude used by the individual to cope with stress
may change depending on various factors such as
age, gender, culture, and illness, and is specific to
the individual.
Efforts regarding stress and the concept of co-
ping continue throughout life; however, the most
important developmental stage in all of life cycles is
adolescence. In particular, adolescents are exposed
to heightened rates of environmental stressors. As
exposure to stressors increases, so does the risk for
negative outcomes [1]. Recognition of the extent
and impact of stressors facing present day adoles-
cents has, in turn, led to an interest in examining the
coping area is less developed and more fragmented.
Adolescents have been found to employ both palli-
ative (i.e., arousal reduction) and direct action (i.e.,
problem solving) coping strategies [2].
1573
HealthMED - Volume 5 / Number 6 / 2011
A recent review of the literature described two
types of coping strategies. First, active coping was
defined as cognitive attempts to change the way of
thinking about a problem or behavioral attempts to
deal directly with the problem. Avoidant coping,
on the other hand consists of attempts to minimize
or deny threat or behavioral attempts to get away
from or avoid confronting the source of threat. Ac-
tive coping was found to be generally more adap-
tive than avoidant coping [1].
Gender differences have been identified, with fe-
male adolescents generally reporting use of a broader
range of coping strategies. Female adolescents de-
monstrated more frequent use of supportive interper-
sonal relationships, including friends, siblings and
parents, and venting of their emotions. Males, on the
other hand, engaged in a greater amount of wishful
thinking as a means of coping with stressors [3].
The frequency with which adolescents em-
ployed coping strategies was quite low, with
adaptive coping the only category to reach the
midpoint, indicating these coping strategies were
used with moderate frequency. Gender differences
were found with females employing adaptive co-
ping strategies significantly more often than males
[3]. The coping pattern portrayed by the adoles-
cent is extremely important during this period. In
general, the process of coping with stress in ado-
lescents protects them from the adverse physical
or psychological results. Stressors and coping
strategies are both tied to the central concern with
stress, particularly the deleterious effects that have
been demonstrated with regard to health.
There is mounting evidence that low-income
urban youth are at heightened risk for psycholo-
gical problems as a result of exposure to chronic
uncontrollable stressors [1]. Research has since
demonstrated that adolescents, who are exposed to
stressors, perceive to be uncontrollable are likely to
exhibit passive or avoidant coping behaviors and to
experience hopelessness. Uncontrollable stressors
contribute to the development of hopelessness over
time. In other words, exposure to chronic uncon-
trollable stressors may result in the development of
fewer adaptive coping strategies and negative co-
ping strategies, which in turn lead to a greater sense
of hopelessness in urban youth [1,4].
Another coping strategy, examined frequently
in the broader adolescent population, is seeking
1574 Journal of Society for development in new net environment in B&H
social support, which involves efforts to secure
support from others. The presence of social sup-
port has been associated with higher levels of resi-
lience among general and low-income adolescent
populations. However, seeking social support as
a coping strategy has been associated with both
positive and negative outcomes in adolescents.
Having access to social support can mediate the
negative effects of perceived stress [5]. The effects
of support and stress among adolescents have been
limited and inconsistent [6]. There is a statistically
significant positive relationship between perce-
ived social support levels and self-esteem levels
of adolescents. Therefore, it can be said that the
self-esteem levels of adolescents increase together
with the increase in social support levels [6]. Self-
esteem is a large part of adolescents’ self-under-
standing and is likely to be a fluctuating and dyna-
mic construct, susceptible to internal and external
influences during adolescence. A study conducted
on the subject proved that high self-esteem incre-
ased the capability of coping with stress, and ulti-
mately protecting adolescents against the devasta-
ting results of stress during adolescence [7].
Methods to cope with stress, which include
specific behavioral and psychological efforts to
fight against the adverse effects of events and fac-
tors that cause stress, are required to protect mental
and physical health, and to maintain a productive
and rich life. It can be noticed importance of heal-
th promotion in school enviroment through educa-
tional program [8]. Hence why it is important that
high school adolescents should seek social support
to cope with stress, and increase their level of hope
and self-esteem. This study was planned and carri-
ed out in order to determine the effect of methods
used to cope with stress by high school students on
their hopelessness and self-esteem levels.
Instruments and method
Type of the Study
This study was planned and carried out as a
descriptive-relational study in order to determine
the effect of methods used to cope with stress by
high school students on their hopelessness and
self-esteem.

Place and Time of the Study
The study was conducted at Şükrü Paşa High
School, located in the Erzurum Evren Paşa Health
Center region.
The Population and Sample of the Study
The students of Şükrü Paşa High School esta-
blished the population of the study. The sample
group of the study comprised of students chosen
using a non-probability sampling method. Stu-
dents were chosen from a group of students willing
to participate in the study and who were attending
the high school in question during the dates of the
study. 69 (33.8%) of the 204 students participating
were girls, and 135 (66.2%) were boys.
Data Collection Tools
The tools used to gather data were a descripti-
ve characteristics form, Strategies for Coping with
Stress Scale, Beck Hopelessness Scale, and Rose-
nberg Self-Esteem Scale.
Strategies for Coping with Stress Scale:
It is a self-evaluation inventory, developed by
Amirkan (1990) and adapted to Turkish by Aysan
(1994), who also carried out its validity and reli-
ability studies. It has three sub-scales; “Problem
Solving,” “Seeking Social Support,” and “Avo-
idance.” The Strategies for Coping with Stress
Scale is used to predict psychological health and
to provide feedback for coping methods used in
stressful situations. The scale comprises of three
dimensions; problem solving, seeking social su-
pport, and avoidance. Problem Solving measures
the solution strategies aimed at solving problems;
seeking social support measures the level of sup-
port sought from others to develop inter-personal
relations, advice, and relaxation; avoidance mea-
sures the physical and psychological draw-backs.
A high score in the problem solving and seeking
social support sub-scales indicates that positive
coping strategies are being used. A high score in
the avoidance sub-scale indicates that negative co-
ping strategies are being used. Every sub-scale has
11 items and the total scores obtained from sub
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
scales range between 11 and 33. The scale has a
three-point likert-type evaluation system; 1-none,
2-some, 3-many. A total high score obtained from
the sub-scale indicates an increase in the described
quality. In this study, the reliability coefficient was
.76 for the Problem Solving Sub-Scale, .78 for the
Seeking Social Support Sub-Scale, and .70 for the
Avoidance Sub-Scale.
Beck Hopelessness Scale: The scale develo-
ped by Beck et al was adapted for our country by
Seber in 1991, and Durak in 1994 [11,12]. The
scale has 20 items and every item has a possible
score from 0 to 1. 11 of the items contain a “yes”
answer, and 9 of the items contain a “no” answer.
As a result, the possible total score is between 0
and 20. As the obtained score is high, the assump-
tion is that the level of hopelessness in the indi-
vidual is high. In this study, the Alpha reliability
coefficient of the scale was .78.
Rosenberg Self-Esteem Scale: Rosenberg de-
veloped the Rosenberg Self-Esteem Scale (RSES)
in 1965; Çuhadaroğlu (1986) adapted the scale for
our country. The Rosenberg Self-Esteem Scale is a
scale with 12 sub-scales and sixty three items. The
first ten-point sub-scale, among the sub-scales, is
used to measure self-esteem. This study used the
self-esteem sub-scale. Scores for the scale vary
between 0 and 30, and 30 is accepted as the maxi-
mum level of self-esteem. The Alpha reliability
coefficient of the scale in this study was .82.
Gathering Data
Data was gathered via the data gathering forms,
presented to the students by the researchers, which
were completed by students. Once the researchers
collected the data from the students, they provided
students with applied training about coping with
stress.
Statistical Evaluation
Data was evaluated using the descriptive stati-
stic available in the Statistical Package for Social
Sciences software (SPSS, Version 10.0, Chicago,
IL, USA), the t test, and correlation analysis.
1575
HealthMED - Volume 5 / Number 6 / 2011

Findings king social support, one of strategy of coping with

stress and hopelessness (p<0.05). Students with
Among coping strategies, the problem sol- low self-esteem prefer avoidance as their coping
ving score mean (25.08±4.18) of students was hi- strategy (p<0.01).
gher than the seeking social support score mean Table 2. Coping Strategies, Hopelessness and
(22.68±4.95), and the avoidance score mean Self-Esteem Score Mean Distributions According
(22.86±3.68). The hopelessness score mean was to Gender
6.95±3.25, and the self-esteem score mean was Scales X ± SD t, P value
19.43±3.89. Problem Solving
Table 1. The Distribution of Score Means for Co- Female 25.14 ± 4.33 t:0.162
ping Strategies, Hopelessness and Self-Esteem Male 25.04 ± 4.12 P:0.872
Maxi- Mini- Seeking Social Support
Scales X ± SD
mum mum Female 23.77 ± 5.66 t:2.276
Strategies for Coping Male 22.12 ± 4.46 P:0.024
with Stress Scale Avoidance
Problem Solving 33 11 25.08 ± 4.18 Female 23.80 ± 4.04 t:2.633
Seeking Social Support 32 8 22.68 ± 4.95 Male 22.39 ± 3.40 P:0.009
Avoidance 31 10 22.86 ± 3.68 Hopelessness
Hopelessness 18 00 6.95 ± 3.25 Female 6.42 ± 3.51 t:-1.609
Self-esteem 29 5 19.43 ± 3.89 Male 7.19 ± 3.10 P:0.109
Self-esteem
In the event that findings associated with the Female 19.70 ± 4.06 t:0.691
distribution of the hopelessness and self-esteem Male 19.30 ± 3.82 P:0.490
score means were analyzed according to gender-
based coping strategies, there was no difference in Table 3. The relationship between the score mean
the problem solving score mean, the hopelessness of coping types of students and the hopelessness
score mean, and the self-esteem score mean based and self-esteem score means
on gender. There was a significant difference on Strategies for Coping Self-
Hopelessness
seeking social support based on gender. The see- with Stress Scale esteem
king social support score mean was higher for fe- Problem Solving -.243*** .369***
male students (23.77±5.66) in comparison to male Seeking Social Support -.174* .121
students (22.12±4.46); the difference between Avoidance .119 -.206**
the groups was deemed as statistically significant P<0.001
P<0.01
(t=2.276, p<0.05).
p<0.05
For the avoidance sub-scale, the score mean
for female students (23.80±4.04) was higher in
comparison to male students (22.39±3.40); the
Discussion
difference was deemed as statistically significant
(t=2.633, p<0.01).
This study, conducted in order to analyze the
When we analyze the relationship between co-
effect methods to cope with stress in high school
ping with stress strategies and hopelessness and
students has on hopelessness and self-esteem le-
self-esteem; there is a significant negative relati-
vels, indicates that the method used most by high
onship between problem solving and hopelessne-
school students is problem solving. A high score
ss (p<0.001). There is a significant positive relati-
obtained in the problem solving sub-scale indi-
onship between problem solving and self-esteem
cates that active coping strategy is being used. A
(p<0.001). The increase in problem solving for
study conducted by De Anda et al. (2000) indica-
students increases their self-esteem level. There
ted that all students, including those with high le-
is a significant negative relationship between see-
vels of stress, employ adaptive coping strategies

1576 Journal of Society for development in new net environment in B&H


with greater frequency than maladaptive coping
strategies. Active coping was found to be gene-
rally more adaptive than avoidant coping [1].
The fact that students prefer using active co-
ping strategies when solving problems has a posi-
tive contribution towards mental health and has a
preventative effect against negative emotions, and
helps individuals to adjust to survival stress [14].
In other words, the more problem solving methods
are used the less the situational stress perceived,
and the more emotional methods are used, the
more the situational stress perceived. As a result,
using effective coping strategies in stressful situa-
tions enable students to adapt easier.
There was no difference based on gender
between the problem solving score mean, the ho-
pelessness score mean, and the self-esteem score
mean. However, gender had a significant diffe-
rence over seeking social support and avoidance
(p<0.05). The study proved that female students
used seeking social support more than male stu-
dents as a coping strategy. Ikiz & Cakar (2010),
Landis et al (2007) reported that the seeking social
support score mean for female students was higher
in comparison to male students.
Seeking social support was protective for girls
exposed to a high rate of major life events. However,
girls who relied on seeking social-support in the face
of daily hassles showed higher levels of internali-
zing symptoms. Literature suggest that while over–
burdened family members or friends may make gre-
at efforts to provide support for girls who are facing
clear, identifiable major life events, they may not be
able to sustain consistent levels of support for girls
facing ongoing stressors related to daily life events
[1]. The fact that females are brought up to seek ad-
vice from families and friends within the socializati-
on process and thought to express their emotions is
the reason why female students use seeking social
support as a coping strategy, whereas male students
tend to prefer other strategies. Literature states that
gender is an important factor in coping methods; fe-
males employ adaptive coping strategies more often
than males [3]. However, some studies indicate that
the use of active coping strategies is higher in males
in comparison to girls [1].
There was no significant difference for the self-
esteem score mean based on gender in this study;
Uyanık-Balat and Akman (2004), Ikiz and Çakır
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
(2010) also stated that there was no significant
difference between the self-esteem score means
of female students and male students. However,
Moksnes et al (2010) discovered that the self-
esteem of male adolescents was significantly high
that the self- esteem of female students. Other stu-
dies, conducted under similar circumstances, also
indicated that boys had a high self-esteem in com-
parison to girls [16,17]. No significance difference
was found in hopelessness score mean based on
gender in this study. Landis et al (2007) discove-
red that the level of hopelessness in female stu-
dents was higher in comparison to male students.
On the other hand, Özmen et al. (2008) discovered
that the level of hopelessness in male students was
higher in comparison to female students. They
also indicated that students with hopelessness had
low self-esteem.
When we analyze the relationship between the
score mean of coping strategies and the score me-
ans for hopelessness and self-esteem, the level of
hopelessness in students decrease with the incre-
ase in problem solving. Landis et al (2007) indi-
cated that there was a relationship among hopele-
ssness, controllable and uncontrollable stressors,
and that hopelessness is negatively correlated with
active coping. There is a significant negative rela-
tionship between hopelessness and seeking social
support, a coping strategy (p<0.05). Landis et al
(2007) indicated that hopelessness is negatively
correlated with social support. It can be said that
positive hopes increase in the life of a student that
seeks social support.
The study indicates that the level of self-esteem
increases in students together with the increase in
the level of problem solving. A different study sta-
tes that self- esteem is associated with emotional
situations and stress [14]. An individual with a
high level of self-esteem displays adequate self-
confidence, optimism, desire to achieve, and re-
sistance towards stress [19]. Students with a low
level of self-esteem, prefer to use avoidance as a
coping method (p<0.01). Literature states that in-
compatible or avoidance-type coping strategies
have an adverse effect on psychological health.
No relationship was found between self-esteem
and seeking social support in this study (p>0.05).
Kahriman and Polat (2003) indicated that the sco-
re mean for friend social support was higher than
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HealthMED - Volume 5 / Number 6 / 2011
the score mean for family social support in ado-
lescents, and that the self-esteem of adolescents
increased together with the increase in social sup-
port. Kaşıkçı et al. (2009) indicated that there was
a relationship between the level of self-esteem in
university students and their social support. Social
support has a positive effect in increasing the level
of self-esteem as it has an effect on the individual
when coping with problems [15]. As a result, so-
cial support not only increases self-esteem, self-
confidence, and self-worth, but it also increases
the capability to control yourself and your surro-
undings, making you feel more secure.
Conclusion and suggestions
The conclusion obtained from this study indi-
cates that students prefer problem solving at most
as a coping strategy, and gender established si-
gnificant difference on seeking social support and
avoidance, out of strategies of coping with stre-
ss, in female students. The hopelessness level for
students using effective coping methods was low,
and the level of self-esteem was high. In line with
these results; We suggest that interventions should
be planned and applied in accordance with the re-
sults and assessments regarding factors which are
effective over coping strategies at different times.
We suggest that families are also offered training
and their coping strategies are also assessed in fu-
ture studies.
References
1. Landis D, Gaylord-Harden NK, Malinowski SL,
Grant KE, Carleton RA, Ford RE. Urban adoles-
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2. Folkman S, Lazarus RS, Pimley S, Novacek J. Age
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lessness Scale: Validity and Reliability. Journal of
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ss Scale: Validity Study. Journal of Crisis 1994;
2:311-319.
13. Cuhadaroğlu F. Self-Esteem in Adolescents. Unpu-
blished Dissertation. Hacettepe University, Medical
Faculty, Department of Psychiatry, Ankara 1986.
14. Moksnes UK, Maljord IEO, Espnes GA, Byrne
DG. The association between stres and emotional
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esteem. Personality and Individual Differences
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15. Uyanık-Balat G, Akman B. Analyzing the self-

esteem levels of high school students at different
socio-economic levels. Fırat University Social
Sciences Magazine 2004;14:175-183. Baldwin
SA, Hoffmann JP. The dynamics of self-esteem: A
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lescence 2002; 31:101-103.

16. Frost J, Mckelvie S. Self-esteem and body satis-

faction in male and female elementary school,
high school, and university students. Sex Roles
2004;51:45-54.

17. Ozmen D, Erbay-Dündar P, Çetinkaya AÇ, Taşkın

O, Ozmen E. Factors that affect the hopelessness
and hopelessness levels in high school students.
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18. Karahan TF, Sardoğan ME, Şar AH, Ersanlı E,

Kaya SN, Kumcağız H. Relationships between the
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Corresponding author
Dilek Kılıç,
Ataturk University, Health Sciences Faculty,
Department of Nursing,
Erzurum,
Turkey,
e-mail: dkilic25@mynet.com
dilekk@atauni.edu.tr

Journal of Society for development in new net environment in B&H 1579

HealthMED - Volume 5 / Number 6 / 2011
The Effects of Acute Submaximal
Exercise on Trace Element Metabolism
Ersan Kara1
1
Karabuk University, Hasan Dogan High School of Physical Education and Sports, Karabük, Turkey,
Abstract
Background: Trace elements play a signifi-
cant role in many physiological and biochemical
events happening in body. In this study, it was
aimed to investigate the effects of acute exercise
done by sedentary individuals on the trace element
metabolism.
Objectives: The research was conducted on
the 18-24 age group of 16 sedentary male students
from different departments of Karabuk University.
Methods and Materials: Blood samples of
subjects were drawn 4 times in total; shortly befo-
re and after the exercise and 24 and 48 h after the
exercise. The element content of the serum phase
samples were determined by ICP-AES (inductively
coupled plasma emission spectrophotometry) tech-
nique by means of diluting of them with %1 Triton
X-100 solution (Sigma, T-9284) in the ratio of 1/50.
Statistical analyses used: Collected data was
subjected to statistical analyses using SPSS 12.0.
Conventional statistical methods were used to cal-
culate means and standard deviations. Analysis of
variance (ANOVA) was used to evaluate differen-
ce between the parameters studied.
Results: As a result, it was found that there was
significant (p<0.05) differences for the calcium,
chromium, copper, iron, potassium, magnesium,
and sodium, while no significant (p>0.05) diffe-
rence was found for the manganese parameter.
Conclusion: It can be reached a conclusion
that the acute submaximal exercise protocol done
by the sedentary individuals could significantly
decrease the calcium, chromium, copper, iron, po-
tassium, magnesium, sodium levels in the blood
serum, that no recovery was recognized in even
48 h after the exercise and that serious health pro-
blems may be experienced even if the recovery
was recognized.
1580 Journal of Society for development in new net environment in B&H
Key words: Submaximal Exercise, Trace Ele-
ment, Sedentary.
Introduction
Sport and exercise are gaining value as a thera-
peutic tool in addition to having a protective role
of the body [1]. Many minerals that are also eva-
luated as the trace elements are required in order
for the organisms to carry out their functions in a
healthy manner [2]. All trace elements play a role
in many physiological and biochemical events in
the body. They show an activity especially in the
carbohydrate, fat and protein metabolisms as well
as in muscle contraction. Therefore, it is impor-
tant to examine whether the exercise affects the
functions of these elements [3,4]. Many resear-
chers focus on the relationship between nutrition
and development or sustaining performance. Two
methods are used to determine the relationship
between exercise and nutrition. The first one is to
examine physiological and performance respon-
ses of the exercise participants by giving them
foods with different contents and the second one
is to determine the effects of physical activity on
the nutrition [5].
Today, the number of the essential elements
playing role on the living organism is known to be
over ninety. In the recent years, extensive studies
have been conducted to determine the role of these
elements on human health and physiology [6,7,8].
New information has been reported on the rela-
tionship among minerals, nutritional status and
physical performance. In these studies, the role of
iron, magnesium, zinc, chromium and many mi-
nerals on the performance has been described [9].
Therefore, it can be said that there is an increa-
sing concern on investigation of the relationship

between exercise and minerals or elements [10].
During any physical activity, minerals are impor-
tant regulators of physiological events occurring
during performance. Especially, the quantities of
some minerals are decreased depending on the
exercise, resulting in mineral deficiency, and thus
leading sportsmen performance to be negatively
affected [11]. Accordingly, it has been suggested
that magnesium negatively affects muscle stren-
gth and metabolism; however, acute and heavy
exercises increase excretion of these minerals,
therefore giving rise to performance loses [12].
Furthermore, the case that physical exercise leads
to suppression of the immune system by impairing
the element metabolism has drawn attention to the
fact that the issue may be important not only in
terms of the performance but also health [13].
Water is lost by perspiration, leading to a salt
loss up to 1.5 g per liter of water. In many bran-
ch of sports, the loss of sodium, potassium and
magnesium is observed to increase. In case of the
conditions in which mineral loss is not recovered,
some symptoms such as fatigue, cramp, difficulty
in breathe and aphasia may occur [14].
The aim of this study was to investigate the ef-
fects of acute submaximal exercise done by seden-
tary individuals on the trace element metabolism.
Materials and Methods
Subjects
The research was conducted on the 18-24 age
group of 16 sedentary male students from diffe-
rent departments of Karabük University, Karabük,
Turkey. The present study was caried out after
approval of the local ethic committee. The present
study was started after it is approved by the local
ethics committee. At the beginning of the study,
the subjects were subjected to fill in the informati-
on form including the training and test setups and
their authentication of signature was received. The
subjects were asked to take rest and not to use any
medication in one week before the study in order
to ensure the reliability of the study. During the
study, they were also enabled not to participate in
any physical activity except for the exercises done
by them and measurements within the scope of the
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
experiments. The average age, body weight and
height values of the subjects were determined to
be 20.75 ± 0.71 years, 76.81 ± 1.81 kg and 174.88
± 1.10 cm, respectively. The submaximal exerci-
ses were done according to Bruce protocol [16] by
increasing speed and slope of treadmill in three-
minute intervals.
Collecting of the Blood Samples
5 ml of blood sample from each subject was
drawn into a test tube at four times in total; shortly
before and after the exercise and 24 and 48 h after
the exercise following 12 h of night hunger. After
the blood samples were drawn, their serum phases
were separated by centrifugation at 3000 rpm for
10 min and maintained in plastic cap tubes kept at
-80 oC until analysis.
Biochemical Analyses
The element content of the serum samples were
determined by “inductively coupled plasma emi-
ssion spectrophotometer (ICP-AES; Varian Au-
stralia Pty LTD, Australia) by means of diluting
of them with %1 Triton X-100 solution (Sigma,
T-9284) in the ratio of 1/50. Calcium, chromium,
copper, iron, potassium, magnesium, manganese
and sodium levels were determined in the serum
samples and the results were expressed as mg/L.
Statistical analysis
Collected data was subjected to statistical anal-
yses using SPSS 12.0. Conventional statistical
methods were used to calculate means and stan-
dard deviations. Analysis of variance (ANOVA)
was used to evaluate difference between the para-
meters studied.
Results
Table 1 indicates that the highest (p<0.05) cal-
cium values were observed shortly before exerci-
se. On the other hand, a significant (p<0.05) de-
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HealthMED - Volume 5 / Number 6 / 2011

Table 1. Calcium, Magnesium, Manganese and Sodium levels in the serum samples of subjects (mg/L).
Groups Calcium Magnesium Manganese Sodium
(n=16) (Ca) (Mg) (Mn) (Na)
BE 125.31±23.34a 9.27±1.32a 4.78±2.90a 104.56±15.22a
AE 106.75±9.04b 8.91±1.34ab 4.52±2.43a 93.56±16.86c
24AE 109.69±8.84b 8.63±1.93ab 4.77±2.07a 102.31±17.91b
48AE 110.31±7.41b 8.44±1.15b 4.38±1.97a 100.19±9.59bc
a,b,c,d: Means in a column with no common superscripts are significantly different (p < 0.05).
BE: Before exercise; AE: After exercise; 24AE: 24 h after exercise; 48AE: 48 h after exercise

Table 2. Iron, Copper, Chromium, and Potassium levels in the serum samples of subjects (mg/L)
Groups Iron Copper Chromium Potassium
(n=16) (Fe) (Cu) (Cr) (K)
BE 0.43±0.11a 90.88±26.98a 27.78±5.14a 8.43±0.74a
AE 0.35±4.69b 76.06±20.26bc 23.75±3.42b 7.15±1.20c
24AE 0.29±5.12c 77.56±22.91b 21.56±3.71c 7.76±0.96b
48AE 0.32±5.42b 72.19±17.70c 21.25±1.81c 7.03±1.11c
a,b,c,d: Means in a column with no common superscripts are significantly different (p < 0.05).
BE: Before exercise; AE: After exercise; 24AE: 24 h after exercise; 48AE: 48 h after exercise

crease was observed in the calcium levels shortly
after exercise, but no significant difference was
observed among the calcium levels of the sam-
ples taken after shortly, 24 and 48 h after exercise.
The highest sodium levels were observed befo-
re shortly exercise while the lowest levels were
observed shortly after exercise. The sodium levels
increased (p<0.05) 24 h after exercise; however,
no remarkable difference was observed between
the levels of the samples taken after 24 and 48 h
after exercise and also the sodium levels could not
reach (p<0.05) to the levels before exercise.
In the study, the highest magnesium levels
were determined shortly before exercise. There
was no significant difference between the two ti-
mes; shortly before exercise and 24 h after exer-
cise while the difference between these times and
the time 48 h after examination was found to be
significant (p<0.05). The lowest magnesium level
was determined 48 h after exercise; however, the
difference between the times; shortly before exer-
cise and 24 h after exercise was found to be insi-
gnificant. There was also no significant difference
between the groups in terms of magnesium levels.
As can be seen from the Table 2, the highest
(p<0.05) iron, copper, chromium, and potassi-
um levels were determined in shortly before the
exercise. Chromium and copper levels decreased
(p<0.05) after exercise and their lowest levels
were observed 48 h after exercise. There was no
significant difference between the times; 24 h and
48 h after exercise, but the difference was signi-
ficant (p<0.05) when these times were compared
with the time shortly before exercise in respect
of the chromium levels. As to copper levels, the-
re was no remarkable difference between the ti-
mes shortly after exercise and 24 h after exercise;
whereas the difference was found to be significant
(p<0.05) when the two times; shortly before exer-
cise and 48 h after exercise were compared with
each other. In this study, the lowest (p<0.05) iron
level was determined in 24 h after exercise, while
the lowest (p<0.05) potassium level was found in
48 h after exercise. As for iron levels, there was no
remarkable difference between the times shortly
after exercise and 48 h after exercise; whereas the
difference was found to be significant (p<0.05)
when these two times were compared with the ti-
mes; shortly before exercise and 24 h after exerci-
se. Similar results was also obtained in the potassi-
um levels; namely, no significant difference was
observed when two times; shortly after exercise
and 48 h after exercise; while the difference was
found to be significant (p<0.05) when these two ti-
mes were compared with the times; shortly before
exercise and 24 h after exercise.

1582 Journal of Society for development in new net environment in B&H


Discussion
Mineral substances have many functions af-
fecting physical performance. They function as
catalytic and structural components of enzymes
and some other functions such as celular energy
transmission, gas exchange and increasing antio-
xidant resistance [9]. Calcium plays a role in the
physiological functions of soft tissue; is necessary
for muscle contractions, membrane permeability,
cardiac muscle functions and normal neuromus-
cular stimulations. In our study, the highest calci-
um levels were determined shortly before exerci-
se, whereas these levels decreased after exercise
and no recovery was observed up to 48 h after
exercise, considering the levels in shortly before
exercise. In many previous studies [15,16], the
calcium levels in serum were shown to decrease
after exercise. While the calcium level in serum
decreases as a result of exercise, its level incre-
ases in urinary system, indicating that exercise
give rise to excretion of calcium [17]. Inadequate
calcium intake and increasing calcium excretion
negatively affect the performance, and also in-
crase the risk of osteporosis in sportsman due to
the fact that muscle utilizes the calcium present in
bone tissue [18]. The calcium loss was especially
higher in sportswoman because of menstrual cyc-
le; therefore, they should be careful about calcium
diet. Iron is one of the most critical minerals with
respect to sport performance. It is a component of
hemoglobin, myoglobin and cytochrome that are
depleted during exercise as well as being of vari-
ous enzymes in muscle cells [19]. In this study, it
was determined that iron level significantly decre-
ased after exercise and no recovery was observed
even after 48 h. Previous studies [20, 21, 22] re-
ported that iron reserves are depleted during spor-
ting exercises, which was due to hemolysis; myo-
globin, gastrointestinal and menstrual loses. These
loses were reported [19] to cause iron deficiency
anaemia and early fatigue symptoms because of
affecting the performance. Therefore, the sport-
sman can be proposed to get physician to check
iron levels in their bodies. Magnesium participates
in many events such as cellular glucose, fat and
protein metabolisms; regulation of membrane sta-
bility, neuromuscular, cardiovascular and hormo-
nal functions [23]. In many studies, magnesium
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
levels were reported to significantly decrease after
exercise [24,25], which affects performance [23]
and magnesium deficiency was reported to have
negative effects on energy requirement and car-
diovascular function during submaximal exercise
[26]. On the other hand, magnesium supplying was
reported to recover strength and muscle metaboli-
sm [12]. In our study, the magnesium loses were
also observed and their contents were determined
to reach the lowest level. It was reported that ma-
gnesium is excreted by perspiration during exer-
cise and in case of its deficiency, muscle cramps
may occur and therefore, its deficiency should be
taken into consideration [27]. In this study, it was
observed that chromium levels decreased until
48 h after exercise. Some studies indicated that
chromium wass excreted by urinary system after
exercise [28,29] while other studies revealed that
chromium levels increased after exercise, leading
to lipid peroxidation, and thus damage in membra-
ne [30]. The changes in the exercise protocols may
lead to this decreasing and increasing in the levels
of chromium after exercise. In our study, sodium
and potassium levels were determined to signifi-
cantly decrease after exercise and no recovery in
these levels was observed even 48 h after exercise.
Sodium and potassium play an important role on
a series of metabolic process such as formation of
membrane potential, regulation of water balance
and distribution in body, stabilizing osmotic pre-
ssure, acid-base balance, and maintaining normal
cardiac rhythm [31]. Sodium is one of the most
critical elements especially for the sportsman stre-
aming with perspiration, thus causing an increase
in the need of sodium uptake [32]. Potassium is
an important element regarding liquid-electrolyte
balance, neural transmission and active-transport
mechanism. It was revealed by the previous studi-
es [33] that potassium loss was lower as compared
to sodium loss during excessive exercise. The so-
dium and potassium levels determined in this study
were consistent with those reported in the previous
studies [34,35] drawing attention to decreasing so-
dium and potassium levels after exercise. Copper
is an important mineral used in the synthesis of
hemoglobin, myoglobin and some peptide hormo-
nes [27]. In the present study, the highest copper
levels were determined shortly before exercise
and these levels were observed to decrease until
1583
HealthMED - Volume 5 / Number 6 / 2011
48 h after exercise. Copper is an important mine-
ral with respect to physical activity. On the other
hand, different results were reported in the litera-
ture [8,36,37]. Some studies indicated that copper
levels increased after exercise [38,39]; however,
others reported that no change was observed in
these levels after exercises [40] and some others
reported that these levels decreased after exerci-
se [41,42], which was also consistent with results
obtained in this study. Different results were thou-
ght to be due to differences between duration, in-
tensity and type of exercise. Manganese is closely
related with growth and fertility functions and car-
bohydrate and lipid metabolisms. Arginase, pyru-
vatecarboxylase and superoxide dismutase are the
important enzymes including manganese. One the
one hand maganese level was reported not to be
affected by physical activity [43,44], on the other
hand, an increase was reported by another study
(39). In our study, manganese levels were not af-
fected by the exercise. Therefore, more studies are
needed to determine relationship between physi-
cal performance and manganese levels. When our
results were evaluated with those in the literature,
it could be stated that the applied exercise protocol
resulted in significant decreases in the trace ele-
ment levels and important health problems may be
experienced if these elements essential for body
functions are not recovered.
Acknowlegement
We thank Dr. Mustafa AKIL for critical reading
of the manuscript and supporting in laboratory expe-
riments, and Dr. Özcan Yalçinkaya for providing
blood samples and required clinical information.
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Corresponding author
Ersan Kara,
Karabuk University,
Hasan Dogan High School of Physical Education
and Sports,
Turkey,
E-mail: ekara@karabuk.edu.tr
1585
HealthMED - Volume 5 / Number 6 / 2011
The effect of planned education given
to students on their menstrual hygiene
behaviors: learning and forgetting
Hatice Kumcagız, Ilknur Aydin Avci
Ondokuz May University Samsun Health School, Turkey.
Abstract
This study was done for determining efficiency
of planned education given to school girls relating
to menstrual hygiene behaviors and the effect on
their learning and forgetting levels.
This study was performed in a single group ac-
cording to pre-test/post-test experimental type at a
high school between 01.11.2007 and 01.08.2008.
408 school girls studying in a high school were
included in the study at Turkey. Hygiene behav-
iors were measured after 1 month (learning) and 3
months (forgetting).
According to the data obtained, it was found
that the education affected hygiene behaviors in
the 1st observation (p<0.001) and forgetting is
very less after the education in the 2nd observation
(p<0.001).
At the end of the study, it was seen that the edu-
cation given to school girls about menstrual hy-
giene behaviors is effective, girls practice hygiene
behaviors, learning the behaviors is high and for-
getting level is very less.
Key words: nursing, school health, research
report, adolescent, menstrual hgyene education.
Introduction
Menarche or first menstrual period is an im-
portant event characterizing adolescence develop-
ment in all young girls’ lives and it should not be
ignored (1-2). The most important function specific
to women is reproduction. For taking these func-
tions under guarantee, a process occurs periodi-
cally once a month beginning from menarche last-
ing until menopause. During this process, certain
1586 Journal of Society for development in new net environment in B&H
changes occur in genital organs and through the
whole organism (3-4).
Adolescence age is a step forward from chil-
dhood into being a young girl. In this period, body
and identity grow very rapidly. This change begins
at the ages of 9-10 and last until the age of 18. Ave-
rage menarche age in Turkey is 12-13. Attention
should be paid to menstrual hygiene from menar-
che. Menstrual hygiene includes certain measures
requiring care for being physically and psycho-
logically healthy. Practices relating to menstrual
hygiene vary depending on societies’ cultural na-
tures (5-6). Menstrual period is a process requiring
special care. Shower at feet is recommended for
bathing during this period. Also, sanitary napkins
should be used during this period. The material,
which will be placed into the lingerie for absor-
bing blood, should be hygienic (7-8).
Turan and Ceylan found in their study that in-
formation on menstruation provided previously to
young girls in adolescence age was not sufficient.
Deficiencies in information on menstrual hygiene
in adolescence age should be determined and rele-
vant measures should be taken for protecting and
improving health of young girls (9).
Considering this aspect, educating girls about
menstruation hygiene before their first menstrual
experience is very important for them to avoid
problems depending on menstruation hygiene de-
ficiency in the future and develop healthy behavi-
or models.
Medical personnel and instructors have signi-
ficant responsibilities in mitigating or preventing
possible complications through simple hygienic
behaviors in menstruation, which is a physiolo-
gic process.

Objectives
This study was conducted for determining
the effect of the education given to school girls
studying in Mithat Paşa High School in Samsun
relating to menstrual hygiene on their menstrual
hygiene behaviors and also determining their post-
educational learning and forgetting levels.
Literature review
Menarche is an occasion including anxiety for
young girls in their adolescence age. They frequ-
ently need information about menarche before and
after their first menstrual experience. Therefore,
young girls should be made ready for this occasi-
on before menarche (10). Also, information level of
young girls’ experiencing their adolescence age on
reproduction health and menstruation physiology
should be determined and training and consultan-
cy services should be provided for them to acquire
healthy behavior styles (11).
In Taşçı’s study, it was found that school girls
experience some symptoms in premenstrual age
and their hygienic habits and information on men-
struation are not sufficient (8).
A physical change, which may affect body
image and psychological adaptation, like men-
struation, may not be accepted easily especially
by adolescents. Therefore, adolescents may not be
willing to tell this change to their families and clo-
se people around them. Thus, their opportunity to
acquire data on menstruation may be very limited.
Öncel et al. investigated how school girls’ li-
ving in rural and urban places were provided with
information on menstruation and concluded that
most of the girls did not have adequate information
on menstrual hygiene (12). Demirel and Terzioğlu
and also Güler et al. had similar results in their
studies and they concluded that school girls did
not acquire sufficient information on menstruation
and hygiene (10,13). El-Gilany et al. observed men-
strual hygiene in a group of school girls in Egypt
and they determined that their menstrual hygiene
was bad. The importance of training adolescents
about menstruation was highlighted (14).
Arıkan et al. provided education to school girls
studying in high school on menstrual hygiene and
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
assessed their behaviors after the education. As a
result of this study, they determined that the tra-
ining affected their menstrual hygiene behaviors
positively (15).
The studies performed evidenced that hygiene
education provided before menstruation especi-
ally in adolescence age is effective in perceiving
menstruation and acquiring positive hygiene be-
haviors (11,16-17).
Methods
Design and sample
This study was practiced in Mithat Paşa High
School in Samsun City between 01.11.2007 and
01.08.2008. It was performed in a single group
according to pre-test/post-test experimental type.
Universe of the study consists of 438 school
girls, who are studying in Mithat Paşa High School
in Samsun City and are accepted that they have just
experienced menstruation. The study had aimed to
educate all students. However, 18 girls (4.11%),
who did not attend to school on the mentioned da-
tes, 8 girls (1.83%), whose data collection forms
contained errors and 4 girls (0.91%), who refused
to participate in the study, were excluded from the
extent of the study. All girls were informed about
the study before practice and oral consents were co-
llected from the girls, who were willing to partici-
pate in the study. As a result, 408 school girls were
included in the test group voluntarily.
Measures
The researchers prepared a questionnaire form
for assessing the students’ descriptive features
and their information rank on menstrual hygie-
ne. This questionnaire form includes 8 questions
containing descriptive features of the students and
10 questions assessing their information level on
menstrual hygiene behaviors. The answers for the
questions relating to hygiene were assessed as true
(1 point) and false (0 point), and the general sum
was taken into consideration. Total point range is
0-10. It was considered that higher points indicate
better hygiene behaviors.
The expressions, which are accepted as true
in answers for the questions relating to menstru-
al hygiene, includes: One can have a bath during
1587
HealthMED - Volume 5 / Number 6 / 2011
menstruation, one should have shower at feet du-
ring menstruation, genital area should be cleaned
from front to back, genital area should be dried
after cleaning, sanitary napkins should be used as
menstruation material, this material should be re-
placed when it gets wet, used menstruation mate-
rial should be disposed in its special back, hands
should be washed before and after the material is
replaced, deodorant may be used during menstrual
period. The answers except those mentioned abo-
ve were assessed as false.
The questionnaire was tested in a group of 15
students making a pre-implementation, the que-
stions not understood or not completed were de-
termined and corrected; after pilot study, the last
shape of the draft was given and adapted to the
research group.
The researchers made contact with psychologi-
cal guidance service of the school and specified ti-
mes, which would not affect students’ general edu-
cation process. Then, school girls were gathered in a
conference hall for providing required explanations
and pre-test questionnaire forms were practiced.
Then, 408 girls, who volunteered to participate in
the study, were divided into groups each consisting
of around 40 students (in classes containing mini-
mum 33 students, maximum 45 students) five days
after the pre-test and educated on menstrual hygie-
ne. The researchers educated girls in 3 classrooms
specified by the school management. The education
was planned previously in a way that each resear-
cher would tell the same task by using same expre-
ssion style within the same period for providing
standardization. Girls were educated in 3 different
classes as consequent 3 sessions on the same day
for preventing interaction between girls. Education
lasted approximately 30-40 minutes. Contents of
the education and the points, which were not un-
derstood well, were re-discussed at the end of the
education through question-answer method.
1st observation test was applied to the students
one month after the education to control the lear-
ning. 2nd observation test was applied to the stu-
dents 3 months after the education to determine
students’ forgetting level.
Education contents
The aim of the education was to determine
students’ negative behaviors relating to menstru-
1588 Journal of Society for development in new net environment in B&H
al hygiene and to change such behaviors in posi-
tive direction. Therefore, girls were educated on
the issues whether one can have a bath during
her menstrual period, how one can have a bath
during her menstrual period, selecting menstrual
material, hygiene for genital area, frequency for
replacing the material, disposing used materials,
selecting lingerie, hand cleaning and using deodo-
rant. Education was given to the girls divided into
groups and lasted 30-40 minutes.
Ethical considerations
Approval for the study was taken from On-
dokuz Mayıs University Medical Faculty Ethical
Committee (OMÜ Etik 2007/58 number) before
the study has begun. Then, a written permit was
taken from Samsun City’s National Education
Directorate. The relevant school’s manager was
informed and the required support was provided.
A class ambience was created to allow students
expressing themselves easily. Attention was paid
to confidentiality and respect principles. The stu-
dents were not judged due to their false practices.
Willingness to participate in the study was sought
after. The students, who refused to participate in
the study, were excluded of the study.
Analytic Strategy
The collected data were assessed via SPSS
11.5 package program. Wilcoxon Matched-Pa-
irs Signed-Ranks test was applied to the data not
showing normal distribution besides descriptive
statistics in the data assessment.
Results
Table 1 shows descriptive features of the stu-
dents and their knowledge on menstrual hygiene.
As seen on the table, 62.7% of the students are in
the age group of 13-15 and 37.3% of them are in
the age group of 16-18. Considering their mothers’
educational level, 71.8% of them are elementary
school graduates and 28.2% of them are high sc-
hool graduates. Considering their fathers’ educa-
tional level, 50.7% of them are elementary school
graduates, 35% of them are high school graduates
and 14.3% of them are university graduates. 90.9%
of the students expressed that they lived in the city
 HealthMED - Volume 5 / Number 6 / 2011

for the longest time. 85.5% of their mothers do not level of the students for the behaviors, which had
work outside their homes and 90.7% of them have been taught. The results of the 1st observation test
a nuclear family (mother, father and child). evidenced that, the education was effective on the
Table 1. Descriptive Features of The Students initial behaviors (p<0.001) and 2nd observation test
(n=408) evidenced that there was no forgetting level for the
Özellikler n % education contents and the mentioned behaviors
Age were practiced correctly at a high ratio (p<0.001).
13-15 ages 256 62.7
16-18 ages 152 37.3
Mother’s Educational levels Discussion
Elemantry school 293 71.8
High school 115 28.2 Menarche is an occasion including anxiety for
Father’s Educational levels young girls in their adolescence age. They frequ-
Elemantry school 207 50.7 ently need information about menarche before and
High school 143 35.0 after their first menstrual experience. Therefore,
University 58 14.3 young girls should be made ready for this occasi-
Lived Place on before menarche (11). Also, information rank of
Village 20 4.9 young girls’ experiencing their adolescence age on
Town 17 4.2 reproduction health and menstruation physiology
City 371 90.9 should be determined and training and consultan-
Mother’s working status cy services should be provided for their acquiring
Unworking 350 85.8 healthy behavior styles (13).
Working 58 14.2 This study evidenced that school girls’
Father’s working status knowledge and practices on menstrual hygiene
Unworking 197 48.3 were insufficient (Table 2).
Working 210 51.7 Karatay and Özvarış determined that 32.8% of
Family Type women used clothes during their menstrual period
Nuclear 370 90.7 and 26.5% of them did not take a shower during
Large 38 9.3 this period. According to these findings, it was re-
ported that sufficient care was not paid to hygiene
Table 2 shows distributions of pre and post edu- during menstrual period and there were incorrect
cational menstrual hygiene behaviors of the stu- practices on this matter (7).
dents. It was determined that the students did not The studies evidenced especially young girls in
have adequate information and practices about the their adolescence age do not have adequate infor-
issues such as bathing during menstrual period, mation on menstruation and hygiene and therefo-
bathing style during menstrual period, genital area re, they need education (8,10,14,17).
hygiene, drying genital area after toilets, replacing Also pre-educational menstrual hygiene behavi-
lingerie, disposing used menstrual material and ors of the students were found low in this study and
hand cleaning before the education. The students these results support findings of the present study.
had moderate knowledge and practices about men- This may be caused by the fact that adolescents
strual material selection and using deodorant during are affected by physical and psychological effects
menstrual period before the education. experienced during menstruation period and that
Table 3 shows the students’ pre and post educa- accepting menstruation occasion may be hard.
tional average points relating to menstrual hygiene It was understood that the education given to
and minimum and maximum values. The learning school girls on menstrual hygiene affected their
effect of the education on the behaviors, which hygiene behaviors and they taught these behaviors.
had been taught, was assessed through 1st obser- Also, forgetting level of the girls for the information
vation test, which was applied to the students. 2nd taught was assessed after the education. It was seen
observation test was used to determine forgetting that the information acquired was not forgotten by

Journal of Society for development in new net environment in B&H 1589

HealthMED - Volume 5 / Number 6 / 2011

Table 2. Distributions of Pre and Post Educational Menstrual Hygiene Behaviors of The Students (N=408)
1st observation 2nd observation
Menstruel Hygiene Practices Pre-education
(Learning level) (Forgetten level)
of the students
n % n % n %
Bathing
True 66 16.2 408 100 397 97.3
False 342 83.8 - - 11 2.7
Bathing style
True 54 13.2 408 100 366 89.7
False 354 86.8 - - 42 10.3
Genital Area Hygiene
True 65 15.9 408 100 382 93.6
False 343 84.1 - - 26 6.4
Drying Genital Area After Toilets
True 37 9.1 408 100 408 100
False 371 90.9 - - - -
Used Menstrual Material
True 304 74.5 408 100 408 100
False 104 25.5 - - - -
Replacing Lingerie
True 197 48.3 408 100 385 94.4
False 211 51.7 - - 23 5.6
Menstrual Material Selection
True 150 36.8 139 34.1 365 89.5
False 258 63.2 269 65.9 43 10.5
Disposing Used Menstrual Material
True 66 16.2 408 100 408 100
False 342 83.8 - - - -
Hand Cleaning
True 95 23.3 408 100 390 95.6
False 313 76.7 - - 18 4.4
Using Deodorant During Menstrual Period
True 281 68.9 368 90.2 348 85.3
False 127 31.1 40 9.8 60 14.7

Table 3. The Students’ Pre and Post Educational Average Points Relating To Menstrual Hygiene and
Minimum and Maximum Values (N=408)
Pre-test 1st observation test 2nd observation test
Mean±SD 3.29 ±1.56 9.24 ± 0.58 9.45 ± 0.70
Median (Min; Max) 3 (0; 8) 9 (8; 10) 10 (7; 10)
Z= -17.57 Z= -17.56
Pre-test -
P<0.001* P<0.001*
Z= -4.65
1st observation test - -
P<0.001*
* It was made wilcoxon matched-pairs signed-ranks test

1590 Journal of Society for development in new net environment in B&H


the girls and they generally adopted and practiced
menstrual hygienic behaviors (Table 3).
In the study of Arıkan et al, school girls were
educated on menstruation and hygiene and an in-
crease was found in girls’ menstrual hygienic in-
formation and behaviors after the education (15)
The studies performed evidenced that hygiene
education provided before menstruation especi-
ally in adolescence age is effective in perceiving
menstruation and acquiring positive hygiene be-
haviors (11,16-17).
Similar results were obtained in this study also.
It may be said that girls are interested in education
on menstruation on which they need information
and therefore, forgetting level is very low after the
said education is provided to them.
Limitations
In this study, findings should be commented
considering the limitations of the study, which fo-
llow as:
It was conducted only in a high school in Midd-
le Black Sea Region,
There are traditional, social, cultural, economic
differences within the country,
The number of the students within the scope of
the study is low,
Conclusions
This study evidenced that, school girls’
knowledge and practices relating to menstruati-
on were insufficient. It was found that learning
level for behaviors relating to menstrual hygiene
raised especially after the planned education and
forgetting level for these behaviors is very less
after the education. As a result of the study, it is
an important result that education affects learning
and forgetting levels besides menstrual hygiene
behaviours.
According to these results, providing education
programs specific to adolescent school girls may
be recommended especially in school programs.
Also, nurses working in school health area may
guide and provide information to them about men-
struation and hygiene. Thus, students will acquire
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
positive behaviors. Also, considering international
cultural differences in educational studies about
menstrual hygiene will be important for mentio-
ning educational differences and programming
the education in this way. If the nurses working in
public health observe and evaluate the results of
the education they provide, it will be effective in
improving the success of the education.
Implications
1. Nursing practice
This study evidences that especially nurses wor-
king in social health areas play an effective role in
developing school health and making girls acquire
menstrual hygiene behaviors. Therefore, if social
health nurses execute effective educational pro-
grams and especially they educate girls on men-
struation, probably girls will experience less heal-
th problems specific to women in the future. As a
result, social health nurses may play an important
role in improving women health. They have a key
role, since hygiene behaviors acquired by especi-
ally girls will become a habit in the future.
2. Future Research
Due to the social, cultural, economic and tra-
ditional differences according to the regions in
Turkey, future studies should be planned in a way
they include different geographical regions of the
country, and they should be made more extensive
population including other high school in which
different region.
References
1. Laurie A. P. et al. Adolescent Menstrual Disorders.
Adolescent Medicine. 2000; 84(4): 851-868.
2. Taşkın L. Doğum ve Kadın Sağlığı Hemşireliği.
(2000); Ankara: Sistem Ofset Matbaacılık, 6.
Baskı.s.50.
3. William W., Beck Jr. Kadın Doğum. (Ed.) Uçar A.,
1990; İstanbul : Nobel Tıp Kitabevi, 4. Baskı, s.
229.
4. Victor G., Malcolm G. M. & Timothy C. R. Jinekoloji
Pratik Yaklaşım. 1995; Ankara: Atlas Yayıncılık, s. 3.
1591
HealthMED - Volume 5 / Number 6 / 2011

5. Tortumluoğlu G., Tüfekçi F., et al. Kırsal Alanda
Yaşayan Kız Çocuklarının Menarş Yaşları ve Me-
narşa Yönelik Emosyonel Tepkilerinin Saptanması.
Atatürk Üniversitesi. Hemşirelik Yüksekokulu Der-
gisi. 2004; 7 (2): 76-88.
16. Marva´n M., Bejarano L. Premenarcheal Mexi-
can Girls’ and Their Teachers’ Perceptions of Pre-
paration Students Receive About Menstruation at
School. Journal of School Health. 2005; 75(3):
86-90.

6. Atahan M. G. Kadın Doğum. 2000. İzmir: Asya Tıp 17. Kim H. W., Kwon, M.K. A study of menstruation
Yayıncılık. 1. Baskı, s. 58. of middle school students. Korean J Women Heal-
th Nursing. 2005; 11(2): 148-155.
7. Karatay G., Özvarış Ş. B. Bir Sağlık Merkezi Böl-
gesindeki Gecekondularda Yaşayan Kadınların
Genital Hijyene İlişkin Uygulamalarının
Corresponding author
Değerlendirilmesi. Cumhuriyet Üniversitesi
Ilknur Aydin Avci,
Hemşirelik Yüksekokulu Dergisi. 2006. 10(1): 1-11.
Ondokuz Mayis Universitesi,
8. Taşcı K.D. Hemşirelik Öğrencilerinin Premenstural Samsun Health School (Samsun Sağlık Yuksekoku-
Semptomlarının Değerlendirilmesi. TSK Koruyucu lu),
Hekimlik Bülteni. 2006; 5(6): 434-441. Samsun,
Turkey,
9. Turan T., Ceylan S. S. 11-14 Yaş Grubu İlköğretim E-mail: ilknura@omu.edu.tr
Öğrencilerinin Menstruasyona Yönelik Bilgileri
ve Uygulamaları. Fırat Sağlık Hizmetleri Dergisi.
2007; 2(6): 41-53.
10. Güler G., Bekar M. Et al. İlköğretim Okulu Kız
Öğrencilerinde Menstrüasyon Dönemi Hijyeni.
Sted. 2005; 14(6): 135-138.
11. Melanie B., Kalman R.N. Taking a different path:
Menstrual preparation for adolescent girl living
apart from their mothers. Health Care for Women
Internationa. 2003; 24: 868–879.

12. Öncel S., Yılmaz M. & Ak G. Kız Öğrencilerin

Menstruasyona İlişkin Bilgi ve Davranışları. He-
mşirelik Forumu Dergisi. 2003; 6(2): 24-31.
13. Demirel S., Terzioğlu F.Gaziantep İli Şahinbey
İlçesi İlköğretim Okullarında Öğrenim Gören 5.
ve 6. sınıf Kız Öğrencilerin menstruasyon Fizyo-
lojisine İlişkin Bilgilerinin Belirlenmesi. Hemşi-
relikte Araştırma Geliştirme Dergisi. 2003; 3(2):
47-60.

14. El-Gilany A. H., Badawi K. & El-Fedawy S. Men-

strual Hygiene among Adolescent Schoolgirls
in Mansoura. Egypt Reproductive Health Ma-
tters.2005; 3(26): 147–152.

15. Arıkan D., Tortumluoğlu G. & Özyazıcıoğlu

N. Öğrencilere Verilen Planlı Eğitimin Men-
struasyon Hijyen Davranışlarına Etkisi (The
impact of planned education given to the stu-
dents to the menstruation hygiene bevahiors).
Uluslararası İnsan Bilimleri Dergisi. 2004;
1(1): 1-15.

1592 Journal of Society for development in new net environment in B&H


Problem solving skills related with
baby care of mothers who have
normal and premature newborns*
Kuguoglu S1, Cinar N2, Ergun A1
1
Marmara University Health, Science Faculty, Division of Nursing, Istanbul, Turkey,
2
Sakarya University School Of Health Sciences, Sakarya, Turkey.
Abstract
Objective: In the literature is important for
mothers to problem solving related with taking
care of their newborns. Purpose of this study was
to assess and compares the problem solving skills
related with baby care of mothers who have nor-
mal or premature newborns.
Methodology: This study is a descriptive and
comparative study. The research to place at the
government hospital in Sakarya. Samples in the
research were volunteer participant mothers who
have normal neonates and premature newborns.
All of test subjects were healthy newborns, nor-
mal or premature. There were 43 with taking care
of their newborns and 43 of premature newborns
chosen for the study. Data was obtained using an
“Introductory Information Form” and “Problem-
Solving Skills Assessment Questionnaire: How I
Deal with Problems Regarding Care of My Baby”.
Results: In test taken by 43 women with nor-
mal newborn babies. The average points scored
reached 198.16 ± 19.57; 6.83±0.67. In the same
test taken by 43 women with premature born babi-
es, the average points scored was 155.44 ± 29.99;
5.36±1.03. Significant difference was found
between two groups (t=7.82; 7.80; p=0.00).
Conclusions: Mothers who have premature
babies need more support to develop their pro-
blem solving skills regarding care of their baby.
Key words: Newborns, Premature, Mothers,
Problem solving skills
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
Introduction
Parenting a premature infant involves respon-
sibilities such as preventing infection, transition-
ing to new sleeping patterns, dealing with feeding
difficulties and managing continued health prob-
lems.1 The stressful and emotionally demanding
experiences of preterm parents are emphasized in
most studies.2-8.
Studies have shown that premature birth and
immaturity of the child can affect parental experi-
ence, attitudes and behavior, and hence affect the
quality of the parent–child relationship and pos-
sibly the child’s outcomes.2
It can be emotionally challenging dealing with
a premature baby. Chat with other mothers who
have children with special needs. It is important
for mothers to problem solving related with taking
care of their newborns. Because of that, nurses
have to identify mothers need support after the
assessment of the care ability of mothers perfor-
med by nurses.
The purpose of this study was to assess and
compare the problem solving skills related with
baby care of mothers who have normal or prema-
ture newborns.
Methodology
This study is a descriptive and comparative
study. The research population is mothers who
delivered at the government hospital in Sakarya.
The samples in the research were volunteer par-
ticipant mothers who have normal and premature
newborns. All of the test subjects were healthy
1593
HealthMED - Volume 5 / Number 6 / 2011

newborns, normal or premature. There were 43 Table 1. Demographic characteristics of mothers

of normal and 43 of premature newborns cho- who have normal or premature newborns
sen for the study. The two groups were matched
regarding demographic variables of age, educa-
tional level, socioeconomic status and number of
children. These variables were comparable across
the groups as shown in Table 1. The mothers who
have normal and premature newborns were visited
on newborn period in their home.
Data was obtained using an “Introductory Infor-
mation Form” and “Problem-Solving Skills Assess-
ment Questionnaire: How I Deal with Problems
Regarding Care of My Baby”. This questionnaire
was developed by Pridham and Chang in 1982.
Kuguoglu conducted research on the appropriate of
the Questionnaire for Turkish mothers in 1995.9 In
our study the Cronbach alpha coefficients for the 8
dimensions ranged from 0.65 to 0.87. Alpha coef-
ficients for the total of questionnaire were 0.93.
The collected data were analyzed using the
Statistical Package for Social Sciences (SPSS-
10.0). Descriptive statistics were computed for
the demographic characteristics. Reliability was x2: chi-square test
assessed by Cronbach alpha coefficients. The x2 Fx2: Fisher’s Exact chi-square test
test or Fisher’s exact test, where appropriate, were
used to compare categorical variables. Student’s In a test taken by 43 women with normal new-
paired t tests were used to compare variables with- born babies, the average points scored reached
in groups over time. 198.16 ± 19.57; 6.83±0.67. In the same test taken
by 43 women with premature born babies, the aver-
age points scored was 155.44 ± 29.99; 5.36±1.03.
Results Significant difference was found between two
groups (t=7.82; 7.80; p=0.00). As predicted, when
The mean age of the mothers was 24.47 (SD = compared to mothers of normal newborns, moth-
5.04), with a range from 17 to 36 years. The ma- ers of premature demonstrated poorer scores on
jority (67.4%) of the sample was between 17 and the problem solving skill (Table 2, Table 3).
26 years. Seven-nine percent reported they had Table 2. Scores on the problem solving skill rela-
completed fifth grade, and graduating from high ted with baby care of mothers who have normal or
school (18.6%). Most participants (77.9%) per- premature newborns
ceived income level good.
Sixty-one percent had some health insurance
coverage. All of mothers are housewife. Fifth-
one percent reported they have two and more than
children. Seven-three percent reported mothers
Table 3. Scores on the problem solving skill rela-
have knowledge about baby care.
ted with baby care of mothers who have normal
Demographic variables were comparable
premature newborns (max score: 10)
across the groups as shown in Table 1. There is
no significant difference in demographic variables
between the mothers who have normal or prema-
ture newborns.

1594 Journal of Society for development in new net environment in B&H


As predicted, when compared to mothers of
normal newborns, mothers of premature demon-
strated poorer scores skill on eight dimensions of
the questionnaire: (1) General Skill in Child Care,
(2) Scanning, (3) Formulating, (4) Appraising, (5)
Planning, (6) Implementing, (7) Evaluating and
(8) Problem-Solving Process (Table 4).
Table 4. Paired t tests: Scores of Eight Dimensi-
ons of the Problem-Solving Skill by Groups
Discussion
The birth of a baby several weeks preterm can
be a traumatic event for the family and may neces-
sitate a great deal of medical intervention to en-
sure the health of the mother and the survival of
the infant. 10, 11
In our study showed that, mothers who have nor-
mal babies, they have higher problem solving scale
than mothers of preterm babies. Mothers of preterm
need to professional support for cope with the re-
garding to this situation. Although preterm infants
seemed to be less alert, active and responsive, their
mothers appear to be more active compared with
mothers of full-term infants in Boletti’s study.12
It was determined that planned in-hospital edu-
cation of the mothers of preterm babies and nursing
support at home have a positive effect on the prob-
lem solving skills of mothers in Balcı’s study.13
Torigoshi and all’s study that was showing af-
ter discharge from the intensive care unit 61% of
mother’s related difficulty in child care, leading
to the conclusion that, despite the support of new-
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
borns during the hospitalization it is required con-
tinuity of guidance and support after discharge.
Considering that prematurity, low birth weight
and other risk factors led to child hospitalization in
the intensive care unit, it is necessary to approach
a not only biological but also emotional, socio cul-
tural and political attitude with survey problems
and answers. 14
Conclusions
Becoming a mother to a preterm infant is not
easy because every thing happens so fast and
comes unexpectedly. Mothers who have prema-
ture babies need more support to develop their
problem solving skills regarding care of their
baby. Educational and supporting approach to the
mothers helps both cope with the hard case and
strengthen their skill level about handling of prob-
lems. When the mothers believe effort and support
of health professionals about solving their prob-
lems and promoting their life quality, coopera-
tion and mutual effort can be realized in order to
achieve targets.
References
1. Miles MS, Holditch-Davis D, Thoyre S, Beeber
L. Rural African-American Mothers Parenting
Prematurely Born Infants: An Ecological Systems
Perspective .Newborn and Infant Nursing Reviews
2005; 5 (3 ): 142–148.
2. Muller-Nix, C, Forcada-Guex M, Pierrehumbert
B, Jaunin L, Borghin A, François A. Prematurity,
maternal stress and mother-child interactions, Ear-
ly Hum Dev 2004; 79 :145–158.
3. Caplan G, Mason A, Kaplan MD. Four studies of
crisis in parents of prematures. Community Ment
Health J 2000;36 (1): 25 – 45.
4. Meyer EC, Garcia Coll C, Seifer R, Ramos A, Ki-
lis E, Oh W. Psychological distress in mothers of
preterm infants. Dev Behav Pediatr 1995;16 (6):
412– 7.
5. Padden T, Glenn S. Maternal experience of preterm
birth and neonatal intensive care. J Reprod Infant
Psychol 1997;15: 121– 39.
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HealthMED - Volume 5 / Number 6 / 2011

6. Redshaw M. Mothers of babies requiring special Corresponding author

care: attitudes and experiences. J Reprod Infant Kuguoglu S,
Psychol 1997;15: 109– 20. Marmara University Health,
Science Faculty,
7. Singer L, Davillier M, Bruening P, Hawkins S, Ya- Division of Nursing,
mashita T. Social support psychological distress, Istanbul,
and parenting strains in mothers of very low birt- Turkey,
hweight infants. Fam Relat 1996;45: 343–50. E-mail: healthmedjournal@gmail.com
8. Singer L, Salvator A, Guo S, Collin M, Lilien L, Ba-
ley J. Maternal psychological distress and paren-
ting stress after the birth of a very low-birth-weight
infant. JAMA 1999;28 (9): 799–805.
9. Kuguoglu S. A Study on the Reliability and Valid-
ity of the Form for the Evaluation of the Skills of
Mothers in Solving the Health Care Problems of
the Healthy Babies. Nursing Forum, 1998; 1(6):
281–288
10. Calam R, Lambrenos K, Cox A, Weindling, A. Ma-
ternal appraisal of information given around the
time of preterm delivery. Journal of Repreductive
and Infant Psychology 1999; 17: 267- 280.
11. Colville G, Darkins J, Hesketh J, et all. The im-
pact on parents of a child’s admission to intensive
care: Integration of qualitative findings from a
cross-sectional study. Intensive and Critical Care
Nursing 2008;1-8.
12. Bozzette M. A Review of Research on Premature
Infant-Mother Interaction. Newborn and Infant
Nursing Reviews 2007; 7 (1): 49-55.
13. Balcı, S. Prematüre Bebeğin Evdeki Bakımına
Yönelik Hemşirelik Girişimlerinin Bebeğin
Büyüme – Gelişmesine ve Annelerin Bakım
Sorunlarını Çözme Becerilerine Etkisi [Nursing
intervention regarding preterm baby care at home
and its effect on growth and development of the
babies and problem-solving skills of their moth-
ers], Istanbul Üniversitesi, Doktora Tezi . Istan-
bul, 2006.
14. Torigoshi MF, Abreu LC, Valenti VE, Reis AOA,
Leone C, Siqueira AAF. Outcomes of newborns
admitted in the intensive care unit at a public hos-
pital. HealthMED 2011; 5 (2): 295-300.

1596 Journal of Society for development in new net environment in B&H


Incidence of smoking among the
primary school students in Turkey
and its reasons
Nazlı Hacıalioğlu1, Afife Yurttaş2, Meral Kiliç3
1
Atatürk University, Faculty of Health Science, Erzurum, Turkey,
2
Atatürk University, Faculty of Health Science, Department of Nursing, Turkey,
3
Atatürk University, Faculty of Health Science, Department of Midwifery, Erzurum, Turkey.
Abstract
This study has been conducted to determine the
primary-school students’ habit of smoking and the
factors concerned. The universe of the study con-
tains 20253 students in the second stage of the pri-
mary schools in Erzurum but data have been col-
lected from 1136 students. In evaluating the data,
percentage rates and chi-square test have been used.
The evaluations have shown that the frequency of
the students smoking regularly is 10.1%; that of
those smoking occasionally is 6.4%; the rate of
their parents’ smoking is 74.3%; the rate of their
friends’ smoking is 15.5%; the rate of the children
as passive smokers is 68%; the rate of ignorance
about the damages of smoking is 28.8%. It has also
been determined that 84% of the students who had
already tried smoking (16.5%) did so at and below
the age of 12. Also, 56.5% of the students reported
that they smoked for the purpose of rising to the
occasion. The difference between the incidence of
children’s smoking and their family members’ habit
of smoking, their sex, their friends’ habit of smok-
ing, their awareness of the diseases and damages
caused by smoking and their classes has been found
as statistically significant (p=.000).
Key words: frequency of smoking, primary-
school students, risk factors
Introduction
Although smoking is the commonest preventa-
ble cause of mortality in the world, one dies from
the diseases caused by smoking every ten seconds
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
and the harmful effects of smoking continue to be
seen in all the world countries. It is reported that
four million people die of smoking-led diseases
a year and it is estimated that if the attempts to
reduce the incidence of smoking are not enough,
the number of these deaths will rise to ten million
and 70% of them will be seen in the developing
countries. Nevertheless, while the prevalence of
smoking decreases in the developed countries, it
increases considerably in the developing countries
[1]. It has been reported that in the last 20 years
the prevalence of smoking has decreased by 33%
in the USA but increased by 89% in Turkey; the
age of first smoking has fallen to 11 in Turkey and
100.000 people die from smoking every year[2].
47% of the male population and 12% of the
female population in the world are regular smo-
kers, while 51% of the male population and 49%
of the female population in Turkey smoke regular-
ly[3,4]. The studies on the incidence of smoking
in Turkey are usually designed to research the rate
of smokers among the high-school and universi-
ty students as well as the adults. In the studies, it
has been reported that the prevalence of smoking
varies between 24% and 54.6% [5,6,7] among the
health staff and between 10.2% and 29.9% among
the youth[8-14]. In literature, however, it has been
stated that about one fourth of the smoking youth
had their first experience of smoking before they
were 10 years old[15].
These results reveal the prevalence of the ha-
bit of smoking, the lowered age of first smoking
experience and that, therefore, the target age for
the preventive programs on smoking should be
brought down to a younger age. The basic and pri-
1597
HealthMED - Volume 5 / Number 6 / 2011
mary target of the activities to be conducted on the
control of the smoking habit is to prevent the yo-
ung from beginning to smoke. For this reason, it is
apparent that any struggle against smoking should
be started at primary school. When these targets
are realized, it will be possible to take protective
initiatives towards the reasons. In Turkey, where
there is a high prevalence of smoking, one of the
important issues is that research that questions and
analyzes the reasons for smoking and behavior
towards gaining the habit of smoking. The fact
that the child is provided with right information
about smoking at this age will contribute to his or
her consciousness of saying no to smoking. Such
a process will also reduce to the minimum the
children’s attempt at smoking under the effect of
such factors as their peers’ pressure and curiosity.
This target is a strategy that should be regarded
as more important and privileged than the other
targets such as supporting those who wish to quit
smoking because it is likely to produce a result
more efficiently[1].
This study is designed to create database for
the training that will be planned for giving the
primary-school children positive behavior on star-
ting to smoke, developing the existing positive be-
havior and making the smokers quit smoking; to
determine the reasons why students attempt and
continue to smoke and to find out their awareness
of the damages of smoking to health.
Material and method
The study was made as a descriptive and sec-
tional one in the primary schools in Erzurum, a
big provincial centre in the Eastern Anatolia re-
gion of Turkey. The number of the schools was
determined according to the records taken from
the Directorate of National Education of the pro-
vince. From these schools, the ones without 6th, 7th
and 8th-year classes were excluded and a sum of
20253 students in the second stage of the remai-
ning schools, namely 6th, 7th and 8th-year students,
constituted the universe of the study. In the deter-
mination of the minimum sample, the prevalence
of smoking among the secondary-school students
which was determined as 7.5 in a study made in
Erzurum in 1998 was taken and thus the size of
1598 Journal of Society for development in new net environment in B&H
the minimum sample was determined as 645. As
the time when the study was made was coincident
with the last week of the school before the sum-
mer holiday, the number of discontinuing students
was high and therefore, we could not choose the
samples. Instead, we went to all the schools in
the universe of the study and contacted with 1136
students who were randomly chosen in the dates
when the data were collected and who agreed to
participate in the research.
The question form consisting of the questions
about the students’ demographic qualities, their
knowledge on smoking, their state of regular smo-
ker and passive smoker, their family members’ and
friends’ attitude towards smoking was prepared by
the researchers. The question forms were filled by
10 4th-year students of Health College trained be-
fore the application who went to the schools con-
cerned under the control of the researchers. The
data available were evaluated by using percentage
rates and chi-square through a computer.
Ethical principles of the research
Within the frame of informed approval, the
managers in the schools where the study will be
conducted and the students there to take place in
the study were informed about the content and
scope of the study and their permission was ta-
ken. The students were told and assured that the
information they would give would not be shared
with the school managers and parents. As part of
secrecy within the study, the students were asked
not to write their names and classes on the questi-
on forms. While the research was being published,
the primary schools where the data were gathered
were not mentioned by name. Question forms
were given to the students by the pollsters and the
students were once again notified that participati-
on in the research was not compulsory, but based
on their willingness.
Results
Average age of the students who participated in
the study was 13.1 and 51.6% of them were female
while 48.4% were male. It was determined that
 HealthMED - Volume 5 / Number 6 / 2011

22.5% of the students attempted to smoke and that Table 1. Descriptive qualities of the students par-
they were at or under the age of 12 (84%) when ticipating in the study
they first tried smoking. It was also determined Descriptive qualities Number Percentage
that 10.1% of the students were still smoking and Gender(n=1136)
6.4% of them smoked now and then. Majority of Male 550 48.4
the smokers (62.6%) were found out to be male
Female 586 51.6
students and again most of them (56.5%) said that
Class (n=1136)
they smoked in order to prove themselves. Of the
smoking students, 626.6% were male. When the 6th class 502 44.2
prevalence of smoking among the family mem- 7 class
th
399 35.1
bers was analyzed, it was found out that one or a 8 class
th
235 20.7
few elderly people in the houses of 74.3% of the Age of attempting to smoke (n=188)
students were smokers and that 63.6% of them No smoking 948 83.5
were their parents, namely fathers and mothers. Smoking 115 10.1
15.5% of the students stated that they had a friend Now and then 73 6.4
who was smoking and 68% of them said that they Gender of the smokers (n=115)
took place in places where others smoked. Though Male 72 62.6
the duration of staying where others smoked var- Female 43 37.4
ied, it was determined that most of them (44.1%)
The reason for starting to smoke (n=115)
were exposed to smoke fume for at least 1-2 hours
Prove onself 65 56.5
a day. While 52% of the students gave the answer
Emulation 30 26.1
of ‘cancer’ to the question on the diseases caused
by smoking, 28.8% of them said that they did not Curiosity 20 17.4
know the diseases caused by smoking (Table 1). Prevalence of smoking in the family (n=1136)
When the prevalence of smoking among the No 291 25.6
students was compared with some variables, Parents 723 63.6
the difference between the prevalence of smok- Other family members 122 10.7
ing among the students and the rate of smoking Friendship with smokers (n=1136)
among the family members was determined as Yes 176 15.5
significant (p=.000); the difference between the No 960 84.5
prevalence of smoking among the students and Duration of staying where others smoke (n=1136)
gender was determined as significant (p=.000);
Never 363 32.0
the difference between the prevalence of smoking
1-2 hours 503 44.1
among the students and a friend who smoked was
3-4 hours 189 16.6
determined as significant (p=.000); the difference
between the prevalence of smoking among the 5 and above 81 7.1
students and awareness of the diseases caused by Awareness of the diseases caused by smoking
smoking was determined as significant (p=.193); (n=1136)
the difference between the prevalence of smoking Unaware 327 28.8
among the students and the classes of the students Cancer 576 50.7
was determined as significant (p=.000) (Table 2). Cardiovascular diseases 83 7.3
Others 150 13.2

Discussion

In the studies on the prevalence of smoking

among the adults from different sections of the
society and high-school and university students,

Journal of Society for development in new net environment in B&H 1599

HealthMED - Volume 5 / Number 6 / 2011

Table 2. Comparison between Some Descriptive Qualities of the Students and the Prevalence of Smoking
Descriptive qualities Prevalence of smoking
Prevalence of smok- No Smoking Now and then Total Test of significance
ing in the family S % S % S % S %
No 278 95.5 10 3.4 9 3.0 291 100 X2= 68.065
Parents 598 82.7 94 11.1 51 7.1 723 100 df=4 p=. 000
Others 92 75.4 11 9.0 19 15.6 122 100
Gender
Male 423 76.9 72 13.1 55 10.0 550 100 X2= 35.936,
Female 525 89.6 43 7.3 18 3.1 586 100 df=2 p=. 000
Smoking friend(s)
Yes 101 57.4 55 31.3 20 11.4 176 100 X2= 116.682
No 847 88.2 60 6.3 53 5.5 960 100 df=2 p=. 000
Awareness of the diseases caused by smoking
Aware 261 84.4 44 38.3 22 30.1 327 100 X2= 8,677,
Cancer 486 51.3 51 44.3 39 53.4 576 100 df=6 p=. 193
Cardiovascular
74 89.2 4 4.8 5 6.8 83 100
diseases
Others 127 84.7 16 10.7 7 4.7 150 100
Class
6th class 427 45.0 25 21.7 5 15.1 502 100 X2= 63.365,
7 class
th
347 36.6 40 34.8 12 16.4 399 100 df=4 p=. 000
8 class
th
174 18.41 50 43.5 11 15.1 235 100

it has been reported that the prevalence of smok-
ing is between 10.2% and 63.9% and that as the
age increases, so does the prevalence of smok-
ing[8-14,16-18].
When the studies that have been made so far
were evaluated, it was seen that the number of
studies investigating the prevalence and causes of
smoking among the primary-school students was
negligibly small. In a study by İnal on 5th, 6th and
7th-year students, the prevalence of smoking was
found as 10%[19].
In this study, the prevalence of smoking regular-
ly among the primary-school students participating
in the study was found as 10.1% and the prevalence
of smoking now and then was found as 6.4% (Ta-
ble 1). The prevalence of smoking in this study and
İnal’s study is lower than the results of the studies
made on the high-school and university students
and adults. Given that all of the students in these
two studies are primary-school students and below
the age of 15, the prevalence of smoking may be
said to be very high for this age group. The pre-
valence of smoking among the primary-school stu-
dents reveals that the target age in which to apply
the preventive programs on starting to smoke sho-
uld be pulled down to younger ages.
Students in Turkey get acquainted with the act
of smoking at primary school and realize their first
attempt at smoking in this period[18-21]. When it
was questioned in this study whether the students
had attempted to smoke beforehand, 16.5% of
them appeared to have attempted to smoke earli-
er; when the age at which they first attempted to
smoke was evaluated, it was determined that ma-
jority of them (84%) did so at and under the age
of 12 (Table 1). In İnal’s study, it was reported that
majority (90.6%) of the students who attempted
to smoke earlier (45.1%) first attempted to smoke
under the age of 12[19]. The fact that those who
attempted to smoke are mostly at and under the
age of 12 both in this study and in the other study
reveals strikingly that children’s consciousness of
saying no to smoking should be formed when they
are just at the primary school.

1600 Journal of Society for development in new net environment in B&H


When the prevalence of smoking was analy-
zed according to genders, the prevalence of smo-
king was found out to be 62.6% among the male
students and 37.4% among the female students.
And the difference between these two groups
was found as statistically significant (X2=35.936,
p=.000) (Table 2). Karlıkaya reported in his study
on high-school students the prevalence of smo-
king is higher among the male students[18].
In a study by İnal and Yıldız on the primary
school students, some similar results were obtai-
ned [19]. Both in this study and in other studies,
the prevalence of smoking is high among the male
students, a result which makes one think that male
students are at a higher risk of starting to smoke
than female students. On the other hand, the fact
that males have a higher prevalence of smoking
than females may be said to be parallel to the pre-
valence of smoking in Turkey in general and to the
traditional cultural structure of Turkey.
When the studies analyzing the reasons why
people start to smoke are evaluated, it seems that
almost all of the reasons listed below are the pro-
ducts of youth psychology; rising to the occasion,
assuming a place among his friends, curiosity and
impulse for trial and emulation for the elderly. In
a study made in Erzurum, it was seen that most of
the students (25.3%) started to smoke under the
influence of their friends and 18.5% of them did so
due to their problems and troubles. In other studi-
es, the most important factors in starting to smoke
are reported to be emulation, curiosity, stress and
spending time among smokers[22-23]. When the
reasons for the students to smoke were analyzed in
this study, 53.3% of them said that they started to
smoke in order to rise to the occasion; 28.2% said
that they had started to smoke out of emulation;
and 16.5% said that they had started to smoke out
of curiosity (Table 1). The results of these studies
confirm each other.
When we analyzed the prevalence of smoking
among the family members of the students con-
tained within the study, we saw that one or a few
members of the family were smoking in the ho-
uses of majority of the students (74.3%). Of the
smoking members of the family, mothers and fat-
hers (63.6%) took the lead and they were followed
by the other family members such as elder brot-
her, elder sister, uncle and grandfather (10.7%).
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
The relationship between the children’s attempt
to smoke and the prevalence of smoking among
the family members was found as significant
(X2=68.065, p=.000) (Table 2).
Family is the institution that shapes and gui-
des the psychological development and behavior
of the person from cultural and social aspects. If
parents smoke in the family, the probability that
their children will smoke is three times higher
than the probability that the children of non-smo-
ker parents will smoke[24]. The research reveals
that the children whose brothers or sisters smoke
tend to smoke more probably than the children
whose brothers and sisters do not smoke[25,26].
Children may also tend to smoke, depending on
their admiration for their parents or brothers or si-
sters who smoke[27]. In the study by Biglan et al,
it is emphasized that the real determinant factor in
the child’s tendency to smoke is the father’s atti-
tude[28]. In this study, the prevalence of smoking
among the family members of the students is high
and fathers and mothers take the lead in this preva-
lence, which makes one think that these two factors
play an important role in the children’s attempt to
smoke and tendency to have the habit of smoking
later. When the fact that the students had a smo-
king friend was analyzed, 15.5% of them stated
that they had a smoking friend. The relationship
between the students’ tendency to smoke and the
fact that they had a smoking friend was found as
significant (X2=116.682, p=.000) (Table 2).
The factor of surroundings and friend may be
a determining factor in smoking as in every kind
of bad habit. Studies emphasize the significance
of friends in children’s tendency to smoke[25-27].
Islam and Cohonsen reported that they had found
a positive relationship between the adolescents’
behavior of smoking and their peers’ behaviour of
smoking[29]. In the study of MeChargue et al, it
was determined that the effect of peers is very im-
portant on the habit of smoking[30]. In the peers’
group in which smoking is perceived as a behavior
of growth, emulation for this behavior and the de-
sire to feel the pleasure of belonging to this group
can be accepted as an important factor in starting
to smoke. It is known that children tend to fall in
an emotional imbalance and to look like others es-
pecially towards the adolescence age. When the
effect of social surrounding such as peers’ pressu-
1601
HealthMED - Volume 5 / Number 6 / 2011
re is added to these features, it can be said that
primary-school students (12-15 years old) who are
often in their early adolescence are at the risk of
starting to smoke.
When the children’s exposure to smoking in
places where others smoke was considered, 68%
of them were determined to be passive smokers.
Passive-smoking poses a serious threat top the
public health and this case may reach more dan-
gerous dimensions in children. Passive-smoking
has negative effects related to all the bodily sy-
stems, especially respiratory system such as bron-
chitis, coughing and worsened asthma [31-34].
It has been reported that almost half the children
in the world are exposed to smoke fume [33] and
50-67% of the children under the age of five in
the USA live in the houses where at least an adult
smokes [35] and 75% of the Turkish children are
exposed to passive smoking [32]. In this study,
most of the students (74.3%) live in the houses
where one or few people smoke and 68% of them
are passive smokers, a finding which supports the
literature information on the issue (Table 1).
When the level of students’ awareness of the
damages of smoking to health was evaluated,
28.8% of them appeared to have no information
about this issue. When they were asked about the
diseases caused by smoking, 50.7% of them said
cancer, 7.3% said cardiovascular diseases, 13.2%
said hoarseness, early ageing and paled tooth and
nail. The relationship between awareness of the di-
seases caused by smoking and prevalence of smo-
king was found as significant (X2=8.677, p=.193)
(Table 2). The results show that nearly one fourth
of the students do not know the damages of smo-
king to health and the rest of them do not have
enough information on it and therefore, it seems
necessary that they should be trained on this issue.
In the studies on the effect of the trainings given
to children about the damages of smoking to health,
it has been reported that children are pleased with
the training they are given and they have an incre-
ased level of negative views of smoking. However,
it has been said that there is not a big increase in
the number of students who have stopped smoking
and whether positive behavior has appeared after
the training cannot be traced[34,35]. As understood
from the study results, training programs teach the
children the damages of smoking to health but they
1602
continue to tend to smoke due to social learning and
adolescence. Therefore, training programs should
not only be directed towards the damages of smo-
king to health but also towards the improvement of
children’s social and personal skills such as making
decision, forming a value and creating a social ef-
fect. Cuipers et al have reported that there has been
a significant reduction in the prevalence of smoking
through their training on the damages of smoking
to health and improvement of the young’s personal
and social skills[35].
When the prevalence of smoking among the
children participating in the study was evaluated
according to the classes, it was observed that the
prevalence of smoking increased with the cla-
sses and the highest prevalence (43.5%) was seen
among the 8th-year students. The statistical anal-
ysis that was made revealed a significant relation-
ship between the classes and prevalence of smo-
king (X2= 63.365, p=.000) (Table 2).
Results and recommendations
As a result, the prevalence of smoking among
the students in the second stage of the primary sc-
hool, namely the 6th-, 7th- and 8th-year students, was
determined as 10.1%. However, when the occasi-
onal smokers (6.4%) were accepted as potential
smokers, the prevalence of smoking appeared to
be very high for this age group. The prevalence of
smoking among the family members was found
as 74.3%; the percentage of friends who smoked
was found as 15.5%; children’s passive-smoking
state was found as 68%; ignorance of the damages
of smoking to health were found as 28.8%. 16.5%
of the students attempted to smoke previously and
the age at which they first attempted to smoke was
12 and below for most of the students (84%). It
was determined that the prevalence of smoking
increased with the classes and the highest preva-
lence was seen in the 8th-class students (%43.5).
When the prevalence of smoking among the
students was examined according to some varia-
bles, the difference between the family members’
smoking, the students’ gender, their friends’ smo-
king and their classes was found as significant
(p=.000), and the difference between awareness
of the diseases caused by smoking (p=.193) and
Journal of Society for development in new net environment in B&H

prevalence of smoking among children was found
as significant.
To protect the children from these harmful ha-
bits, the trainings towards the damages of smoking
should also include the improvement of children’s
personal and social skills; organized works with
children and families together should be conduc-
ted in campaigns against smoking. Since DSÖ has
charged the nurses with training, the nurses and all
the health staff should carry out campaigns against
smoking in school health programs and public he-
alth works. To see whether the trainings on smo-
king have led to a positive behavior in the children,
progressive follow-up studies should be planned.
The whole state and society should work in colla-
boration and determination against the events and
actions that create emulation for smoking.
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Corresponding author,
Afife Yurttaş,
Atatürk University,
Faculty of Health Science,
Department of Nursing,
Erzurum,
Turkey,
E-mail: afife-72@hotmail.com

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1604 Journal of Society for development in new net environment in B&H

 HealthMED - Volume 5 / Number 6 / 2011

Characteristics of patients who are

newly diagnosed with cancer after
visiting the emergency department
Neslihan Yücel1, Feride Sinem Akgün1, Cem Ertan1, Meltem Serin2,3, Karcıoğlu Özgür4
1
Inönü University Faculty of Medicine, Department of Emergency Medicine, Malatya, Turkey,
2
Inönü University Faculty of Medicine, Department of Radiation Oncology, Malatya, Turkey,
3
Acibadem Hospital, Radiation Oncology Clinic, Adana, Turkey,
4
Acibadem University Faculty of Medicine, Department of Emergency Medicine, Istanbul, Turkey.

Abstract of malignancy that demand immediate treatment.

The purpose of this study was to assess clinical
characteristics and survival times for patients who
presented to a university hospital emergency de-
partment with acute problems and were subsequ-
ently admitted and diagnosed with cancer.
Methods: The patients were 143 individuals
who were newly diagnosed with cancer after ad-
mission to the emergency department at a univer-
sity hospital. Medical records were reviewed and
data were retrospectively evaluated.
Results: The patients included 90 males and
53 females, and the median age was 68 years.
At time of diagnosis, 73 patients had locoregio-
nal disease and 70 had metastatic disease. Most
common primary tumor sites were lung (n=33),
gastric (n=28), colorectal region (n=23) and brain
(n=13). Of 143 patients, 33 died of their disease in
hospital and 110 were discharged. Most common
signs and symptoms were pain (n=35), bleeding
(n=24) and shortness of breath (n=23). Medical
conditions that necessitated emergency admission
were increased intracranial pressure (n=27), he-
morrhage (n=23), infection (n=23) and intestinal
obstruction (n=21). The median survival time for
the 143 patients total was 6.2±1.2 months (range,
4.1-8.3 months).
Conclusion: Emergency departments play an
important role in the diagnosis and treatment of
cancer patients, and even in screening for this di-
sease. Individuals with undiagnosed cancer often
present an unique set of challenges for emergency
physicians because their presentation can range
from vague-related symptoms to clear symptoms
In order for emergency physicians to be able to
diagnose cancer in this patient group, it is impor-
tant to maximize awareness of the cancer-related
symptoms that these individuals may display.
Key words: Cancer, emergency admission,
new diagnosis
Introduction
Cancers represent a significant fraction of the
global chronic disease burden. These diseases are
contributing more and more to mortality in low-
and middle-income countries, and are rapidly
becoming the world’s largest health problem (1).
Cancer is a significant health issue in Turkey as
well, where it ranks as the second most frequent
cause of death next to cardiovascular disease (2).
Patients present to emergency departments with
various health complaints, signs and symptoms.
Their diagnoses range from lacerations, strains
and fractures to systemic illnesses such as cardio-
vascular disease, cerebrovascular disease, infecti-
on, and cancer. Cancer is chronic illness but many
acute signs and symptoms of this disease (pain,
nausea and vomiting, fever or shortness of breath,
for example) can result in emergency department
admissions. Although numerous serious diseases
bring patients to the emergency room, cancer is
one that should rarely be diagnosed in this setting.
Ideally, it should be detected during a routine heal-
th examination prompted by cancer-related signs
and symptoms, and either via a screening proce-
dure or during a visit to a primary care setting or

Journal of Society for development in new net environment in B&H 1605

HealthMED - Volume 5 / Number 6 / 2011
outpatient clinic. Cancer can also be detected du-
ring routine self-examinations by patients witho-
ut symptoms, such as occurs with asymptomatic
breast cancer.
The purpose of this study was to assess clinical
characteristics and survival times for patients who
presented to a university hospital emergency de-
partment with acute problems and were subsequ-
ently admitted and diagnosed with cancer.
Materials and methods
The focus of this investigation was the emer-
gency department of Inonu University Hospital in
the city of Malatya in eastern Turkey. The popula-
tion of Malatya is approximately 750,000, and the
hospital serves as a tertiary care referral center for
neighboring cities. The Institutional Review Board
approved the study design. The investigation en-
compassed 23,860 emergency department admi-
ssions of adult patients that occurred between May
1, 2006 and April 30, 2007. Of the 23,860 total
emergency admissions, 652 (3%) were associated
with oncology-related problems and an electronic
search using International Statistical Classificati-
on of Disease and Related Health Problems (ICD-
10) coding for solid cancer revealed 518 patients
(2%) with this diagnosis. Of the 518 patients, 371
(72%) had a previous cancer diagnosis and the ot-
her 147 (28%) were diagnosed with cancer after
they presented to the emergency room. A review
of the emergency department’s records revealed
that these 147 diagnoses were made on the basis
of physical examination, endoscopy, radiological
studies, pathological data, or during surgery. Four
of the 147 patients were excluded from the study
because data were missing from their medical re-
cords or because they were diagnosed with hema-
tological malignancy. Patients’ medical records
were reviewed and findings for specific parame-
ters were categorized retrospectively.
Patient demographics (age and sex), cancer
characteristics (system or body site primarily in-
volved, metastatic sites) and treatment after dia-
gnosis (surgery, radiation therapy and chemothe-
rapy) were recorded on standardized data sheets.
Treatment data were obtained from patient’s me-
dical records (paper and electronic) and from fa-
1606
mily members by telephone. Metastatic sites at
time of diagnosis were recorded from diagnostic
investigations, or on physicians’ notes in the me-
dical record or a combination of these. If surgery
was indicated at time of diagnosis this was recor-
ded as elective or emergent.
Each patient’s cancer was classified based on
the system or body site primarily involved, name-
ly, the central nervous system, head and neck, ga-
strointestinal system, lung, breast, genitourinary
system or unknown primary source. The medical
condition that necessitated the emergency depar-
tment admission and the patient’s signs and symp-
toms at admission were also recorded (sign and
symptoms, and reasons for admission).
Length of hospital stay and mortality during
hospital stay were documented in cases where the-
se parameters applied.
Survival time was defined as the interval from
date of diagnosis to December 31, 2010. In cases
where the patient died, date of death was obtained
from the hospital registry or during a telephone in-
terview with family members.
Statistical analysis was performed using the
software package SPSS for Windows version 13.0
(SPSS, Chicago, IL, USA). Descriptive statistics
were generated, including means, standard deviati-
ons, medians and percentages. Percentages were ro-
unded to the nearest whole number. Survival times
were calculated using the Kaplan-Meier method.
The log-rank (Mantel Cox) and the Kaplan-Meier
method were used to analyze differences between
median survival times. P values less than or equal
to 0.05 were considered statistically significant.
Results
Of main interest in this study were the 143 pa-
tients (excluding the four noted above) who were
newly diagnosed with cancer as a result of their
visit to the emergency department. Table 1 lists
the demographics, cancer and treatment characte-
ristics and other case details for these patients. The
group consisted of 90 (63%) males and 53 (37%)
females, and their ages ranged from 17 to 90 years
(median, 68 years). Ninety (63%) of the 143 pati-
ents were 65 years or older and 74 (82%) of these
90 patients were male.
Journal of Society for development in new net environment in B&H
 HealthMED - Volume 5 / Number 6 / 2011

Table 1. Patient demographics, disease and trea- rapy alone or in combination, whereas 30 (21%)
tment characteristics, hospital stay, and outcomes patients received no treatment after they were dia-
for 143 patients who were newly diagnosed with gnosed. At the time of diagnosis, 11 (37%) of the
cancer after visiting emergency department patients in the latter group had locoregional disea-
Percentage se that was evaluated as progressive stage and 19
n of total (63%) had metastatic disease. Seventy-one (50%)
patients of the 143 patients underwent operations, with
Gender emergent surgery in 22 cases (31%) and elective
Male 90 63% surgery in 49 cases (69%). The emergency surgery
Female 53 37% cases were colorectal (12 patients, 55%), gastric (3
Age at time of diagnosis patients, 14%), brain (3 patients, 14%), and other
< 65 years 53 37% (4 patients, 18%). The elective surgery cases were
≥ 65 years 90 63% gastric (12 patients, 24%), colorectal (10 patients,
Cancer stage at time of diagnosis 20%), urinary bladder (8 patients, 16%), brain (7
Locoregional disease 73 51% patients, 14%), and other (12 patients, 24%).
Metastatic disease 70 49% Of the 143 total patients, 33 (23%) died of
Surgery indicated at time of their disease in hospital and 110 (77%) were dis-
diagnosis charged. Fourteen (42%) of those who died had
Emergent 22 15% locoregional disease at the time of diagnosis, whe-
Elective 49 34% reas the other 19 (58%) had metastatic disease.
None 72 50% Twenty-five (76%) of the 33 patients who died did
Treatment after diagnosis so within 30 days of their cancer diagnosis. Ten
Surgery 28 20% (30%) of the 33 patients died after having under-
Chemotherapy 18 13% gone emergent surgery, 6 (15%) died after having
Radiation therapy 10 7% undergone elective surgery, 1 (3%) died during ra-
Surgery + Radiation therapy 18 13% diation therapy, and 16 (54%) were receiving no
Surgery + Chemotherapy 14 10% treatment when they died.
Radiation therapy +
14 10%
The primary systems and body sites that were
Chemotherapy involved in the 143 cancer cases are presented in
Surgery + Radiation therapy + Table 2. Those most frequently involved were the
11 7%
Chemotherapy gastrointestinal system (62 patients, 43%), the
None 30 21% thorax (33 patients, 23%) and the genitourinary
Duration of hospital stay system (19 patients, 13%). The most common lo-
≤ 5 days 27 19% cations of the primary tumors were the lung (33
> 5 days 116 81% patients, 23%), the gastric (28 patients, 20%), the
Outcome after admission colorectal (23 patients, 16%) and the brain (13 pa-
Died in hospital 33 23% tients, 9%).
Discharged 110 77% The signs and symptoms noted at presentati-
on in all 143 cases are listed in Table 3. The most
At the time of diagnosis, 73 (51%) patients common of these were pain (35 patients, 24%),
were classified as having locoregional disease bleeding (24 patients, 17%), shortness of breath
and 70 (49%) were classified as having metasta- (23 patients, 16%) and altered consciousness (12
tic disease. Of the latter subgroup, 15 (21%) had patients, 8%). The most frequent signs and symp-
liver metastasis, 14 (20%) had brain metastasis, 9 toms among the non-survivors were altered con-
(13%) had peritoneal metastasis, 5 (7%) had bone sciousness (6 cases, 18%), dyspnea (6 cases 18%),
metastasis, 3 (4%) had lung metastasis and 24 abdominal pain (5 cases 15%) and upper gastroin-
(34%) had multiple metastatic sites. testinal bleeding (5 cases 15%).
Regarding therapy, 113 (79%) patients un-
derwent surgery, chemotherapy and radiation the-

Journal of Society for development in new net environment in B&H 1607

HealthMED - Volume 5 / Number 6 / 2011

Table 2. Primarily system and body site involved The medical conditions that necessitated emer-
by the cancers in the 143 patients gency department admission are shown in Table 4.
Percentage of The most common of these were increased intra-
n cranial pressure (27 patients, 19%), hemorrhage
total patients
(23 patients, 16%), infection (23 patients, 16%)
Gastrointestinal system 62 43%
Gastric 28 20%
and intestinal obstruction (21 patients, 15%). The
Colorectal region 23 16%
most frequent among the non-survivors were inte-
Other (pancreas, liver, stinal obstruction (8 cases, 24%), increased intra-
11 8% cranial pressure (6 cases, 18%), upper gastrointe-
esophagus)
Thorax (lung) 33 23% stinal bleeding (5 cases, 15%), and superior vena
Genitourinary system 19 13% cava syndrome (2 cases, 6%).
Bladder 9 6% Table 4. Reasons of medical conditions that ne-
Prostate 3 2% cessitated emergency admission in the 143 new
Renal 2 1% cancer cases
Cervix 2 1%
Percentage
Ovary 2 1%
n of total
Endometrial 1 1% cases
Central nervous system (brain) 13 9%
Increased intracranial pressure 27 19%
Unknown 12 8%
Hemorrhage 24 17%
Head and neck 3 2%
Infection (pneumonia, peritonitis,
Larynx 2 1% 23 16%
urinary infection)
Thyroid (anaplastic) 1 1%
Bowel obstruction 21 15%
Breast 1 1%
Pain 12 18%
Intrahepatic/extrahepatic
Table 3. Signs and symptoms (or complaints) that 7 5%
cholestasis
necessitated emergency admission in the 143 new
Obstructive urophaty 6 4%
cancer cases
Respiratory failure 7 4%
Percentage of Pleural/pericardial effussion 3 2%
n
total cases Gastric or intestinal perforation 3 2%
Pain 35 24% Airway obstruction 3 2%
Abdominal pain 19 13% Spinal cord compression 2 1%
Headache 8 6% Superior vena cava syndrome 2 1%
Other 8 6% Pathologic fracture 2 1%
Bleeding 24 17% Deep vein thrombosis 1 1%
Melena, hematochezia,
15 10%
and hematemesis All 143 of the patients were ultimately hospita-
Hematuria 7 5% lized and the duration of hospital stay ranged from
Vaginal bleeding 2 1% 1 to 67 days (median, 14 days). Most patients were
Shortness of breath 23 16% ultimately discharged and subsequently treated or
Altered consciousness 12 8% investigated at an appropriate outpatient clinic.
Obstipation 12 8% Survival time for the 143 cases overall was
Paralysis or plegia 8 6% 6.2±1.2 months (range, 4.1-8.3 months). The me-
Nausea and vomiting 6 4% dian survival time for the subgroup with locoregi-
Fever 6 4% onal disease was 7.3±2.7 months (range, 1.9-12.6
Urinary retention 6 4% months), whereas that for the subgroup with me-
Abdominal distention 5 3% tastatic disease was 4.2±1.3 months (range, 1.6-
Jaundice 5 3% 6.8 months). This difference was statistically si-
Asymmetric limb edema 1 1% gnificant (p˂0.005). The median survival time for
the patients who received some form of treatment

1608 Journal of Society for development in new net environment in B&H


after cancer diagnosis was 7.8±2.1 months (range,
3.7-12.0 months), whereas that for the untreated
group was significantly shorter at 0.8±0.1 months
(range, 0.6-0.9 months) (p˂0.0001). The median
survival time for the emergency surgery subgro-
up was 2.7±0.8 months (range, 1.2-4.2 months),
whereas that for the elective surgery subgroup was
significantly longer at 15.6±4.9 months (range,
6.2-25.4 months) (p=0.0001).
Discussion
Emergency departments were originally intend-
ed to be point of the entry into the health care system
for patients with short-term problems. However, the
number of patients being diagnosed with chronic
diseases in the emergency room is on the rise. Can-
cer has become a more common emergency depart-
ment diagnosis, and such patients have worse out-
comes than those who are diagnosed with cancer in
settings such as a primary care physician’s office
(3-6). Most cancers are progressive and many cause
insidious illness. Some undiagnosed patients pres-
ent to the emergency room for the first time with
acute symptoms of primary cancer or metastases;
for example, a pathological fracture, bowel obstruc-
tion, upper gastrointestinal system bleeding or in-
creased intracranial pressure. In such cases, cancer
is usually diagnosed after the patient is admitted to
the emergency department for management of his
or her symptoms.
Patients with prior diagnosis of cancer present
to emergency with a variety of complaints and
problems. However, the number of individuals
who are newly diagnosed with this disease du-
ring or immediately subsequent to an emergency
department visit is unknown. While there is su-
bstantial knowledge in the literature about acute
problems that patients with an established cancer
diagnosis encounter, only a few studies have anal-
yzed the characteristics and prognoses of patients
who present to emergency with signs and symp-
toms of undiagnosed cancer (3-10). Of these, only
the investigations conducted by Hargarten et al.
(3), Brown et al. (7) and Sikka and Ornato (10)
were similar to ours.
The ideal time for cancer detection is during the
asymptomatic period, through screening procedu-
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
res in a primary care setting or at outpatient clinics.
Cancer incidence and prevalence is highest in the
elderly and it is likely that the cancer burden will
increase worldwide, resulting in more emergency
room visits by patients with undiagnosed cancer
(11-12). Although cancer screening and detection
is not well suited for the unpredictable, occasio-
nally chaotic setting of an emergency department,
the increasing size of the elderly demographic and
resulting cancer burden will make diagnoses by
emergency physicians more likely.
Hargarten et al. investigated 129 new cancer
cases in an emergency department in Milwaukee,
United States and found that these cases represen-
ted approximately 5% that hospital’s tumor regi-
stry patients (3). The mean age of their patients
was 69 years and 56% were male. Brown and co-
lleagues investigated 74 new cancer cases in Gla-
sgow, United Kingdom and found that these pati-
ents comprised 44% of all oncology-related emer-
gency department admissions (7). The mean age
of their patients was 67 years and 60% were male.
In contrast, Puts et al. investigated 112 newly di-
agnosed older-aged cancer patients in a Canadian
emergency department and observed that mean
age was 74 years and that 70% were female (12).
Their study provided no information about newly
diagnosed cancer cases within all oncology-rela-
ted emergency admissions. In line with the findin-
gs of Hargarten et al. and Brown et al., the patients
who were newly diagnosed with after visiting our
university hospital’s emergency department in
Turkey compromised 22% of all oncology-related
emergency admissions and tended to be older and
were more likely to be male.
Hargarten et al. (3) compared patients who were
newly diagnosed with cancer during primary care
visits to those who were newly diagnosed during
emergency department visits, and examined staging
of malignancy, follow-up time, and overall survi-
val. They found that patients who were diagnosed
in the emergency department setting tended to have
signs and symptoms of advanced-stage cancer and
worse outcomes. In line with this, several other stu-
dies have reported that cancer patients’ admission
to hospital via the emergency department may be
a clinically important marker of advanced-stage or
poorer survival (4-6, 14-17). In our study, 23% of
143 patients who were newly diagnosed with can-
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HealthMED - Volume 5 / Number 6 / 2011
cer after visiting the emergency room died of their
disease during hospitalization and 49% of the 143
patients had metastatic disease at time of diagnosis.
Although 51% of the 143 patients had locoregio-
nal cancer when they were diagnosed, the median
survival time for the group as a whole was approxi-
mately 6 months. Thirty (21%) of the 143 patients
received no treatment after diagnosis because they
were diagnosed with progressive or advanced can-
cer. We believe that patients with undiagnosed can-
cer tend to present to the emergency only after they
develop severe, persistent or life-threatening signs
and symptoms. Most individuals in this patient gro-
up tended to underestimate their initial symptoms
and took no action to investigate them. Thus, by
the time they arrive at emergency, even locoregi-
onal cancer is at an advanced or progressive stage.
Symptomatic emergency admissions might be a
prognostic factor related to short-term survival in
patients who are newly diagnosed with cancer after
an emergency room visit.
Hargarten and coworkers reported that the
most common symptoms at presentation in the-
ir 129 patients were chest pain, hemoptysis and
shortness of breath (21.7% of cases); abdominal
pain, nausea, vomiting and hematemesis (20.9%);
hematochezia and diarrhea (10.9%) and heada-
che, dizziness and vertigo (3.9%) (3). Brown et
al. found that the most common symptoms at pre-
sentation in their 74 patients were pain (42% of
cases), urinary retention (18%), bleeding (17%)
and weight loss (14%) (7). In our 143 cases, pain
was the most common symptom at presentationl,
followed by bleeding (uper gastrointestinal blee-
ding, hematuria or vaginal bleeding), shortness of
breath, and altered consciousness. Other resear-
ch has shown that 30% of cancer patients exhibit
pain at early-stage and whereas 65–85% of cancer
patients have pain when the disease is advanced
(18,19). For individuals who are diagnosed with
cancer in emergency departments we believe that
symptoms at diagnosis relate to type of cancer. In
our study, the most common body sites or systems
with primary cancer involvement were, in order of
frequency, the lung, gastric, colorectal region, and
brain. The signs and symptoms that necessitated
emergency admission were shortness of breath,
melena and hematochezia, abdominal pain, ob-
stipation, altered consciousness and paralysis or
1610 Journal of Society for development in new net environment in B&H
plegia. Pain and other symptoms related to may
prompt emergency department admission.
For our patients, the medical conditions that ne-
cessitated emergency department admission (ran-
ked in order of frequency) were increased intra-
cranial pressure, hemorrhage, infection (urinary,
pneumonia and other) and intestinal obstruction.
There is no information in the literature regarding
statistical associations between cancer (all types in
general) and medical conditions that require emer-
gency department admission. McArdle and Hole
investigated 3200 colorectal cancer patients in 11
central hospitals in Glasgow, United Kingdom. Of
these, 2214 (69%) patients presented electively
and 986 (31%) as an emergency. A total of 986
were diagnosed with cancer and 632 of these dia-
gnoses were made in the emergency department.
The most common medical reasons for admi-
ssion in their cases (ranked in order of frequen-
cy) were intestinal obstruction, overt bleeding and
bowel perforation in colorectal cancer patients
(14). Baser and coworkers studied 45 lung can-
cer patients who were diagnosed in the emergency
department, and reported that the most common
medical reasons for emergency admission in these
cases were chronic obstructive pulmonary disea-
se, pneumonia and pleural effusion (20).
Of the 143 patients we investigated 50% un-
derwent surgery and 31% of these operations were
emergent while the remaining 69% were elective.
Not surprisingly, the median survival time for the
emergency surgery subgroup was significantly
shorter than that for the elective surgery subgro-
up. Possible reasons for this for this include poor
patient condition and lack of appropriate operative
evaluation in those who required urgent operati-
ons. Very little research has been done on surgery
requirements and survival for patients who are dia-
gnosed with cancer during emergency department
admission; however, there is some information
about this for patients diagnosed with colorectal
cancer (21, 22). Bass et al. studied 356 patients
who were diagnosed with colorectal carcinoma in
the emergency department (21). They found that
58% of these individuals underwent elective sur-
gery and 44% underwent emergency surgery, and
the median survival times for these groups were
statistically different (82 months and 59 months,
respectively; p<0.001).

Brown et al. reported that the median length of
hospital stay for 74 new cancer patients who were
diagnosed in the emergency room was 15 days (3).
Our findings also reveal that undiagnosed cancer
patients who visit the emergency department for
investigation of related symptoms require exten-
ded hospitalization. This not surprising conside-
ring the process of diagnosing primary malignan-
cy, the often poor medical condition of these pa-
tients, and the fact that many require surgery and
postoperative care.
Emergency departments play an important role
in the diagnosis and treatment of cancer patients,
and even in screening for this disease. It has been
suggested that detection of quasi-symptomatic can-
cer can be difficult in this setting because of the
extensive differential diagnoses that must be con-
sidered; however, patients with cancer-related me-
dical conditions are frequent visitors to emergency
rooms. Individuals with undiagnosed cancer often
present an unique set of challenges for emergen-
cy physicians because their presentation can range
from vague-related symptoms to clear symptoms
of malignancy that demand immediate treatment.
In order for emergency physicians to be able to di-
agnose cancer in this patient group, it is important
to maximize awareness of the cancer-related symp-
toms that these individuals may display.
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1. Strong K, Mathers C, Epping-Jordan J, Resnikoff S,
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presentation in the emergency department: a fai-
lure of primary care. Am J Emerg Med 1992; 10:
290-293.
4. Swenson KK, Rose MA, Ritz L et al. Recognition and
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gency department. Ann Emerg Med 1995; 26: 2-7.
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agnosisis of colorectal cancer. Cancer Detect Prev
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7. Brown MW, Bradly JA, and Calman KC. Malignant
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8. Kundra M, Stankovic C, Gupta N, Thomas R, Ha-
mre M, Mahajan P. Epidemiologic findings of can-
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9. Bass G, Fleming C, Conneely J, Martin Z, Mealy K.
Emergency first presentation of colorectal cancer
predicts significantly poorer outcomes: a review
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Rectum 2009; 52: 678-684.
10. Sikka V, Ornato JP. Cancer diagnosis and out-
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nette M, Batist G, Bergman H. Does frailty pre-
dict hospitalization, emergency department visits,
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newly-diagnosed cancer patients? Results of a
prospective pilot study. Crit Rev Oncol Hamatol
2010;76(2)142-151.
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M, Forman D, Moller B, Bray F. The future burden
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1488.
14. McArdle CS, Hole DJ. Emergency presentation of
colorectal cancer is associated with poor 5-year
Survival. Br J Surg 2004; 91: 605-609.
15. Porta M, Malats N, E Morell E, Gomez G, Gallén
M, Macià F, Casamitjana M, Fabregat X. Decrea-
sed survival of patients with lung cancer admitted
to a teaching hospital through the emergency de-
partment in Barcelona, Spain. J Epidemiol Com-
munity Health 1998;52:137–138.
16. Bozcuk H, Martin C. Does treatment delay affect
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17. Geraci JM, Tsang W, Valders RV, Escalente CP.

Progressive disease in patients with cancer pre-
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19. Dzubar A, Niksic D, Pepic E, Kapic AP. Influence
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Ugurlu E, Bukıran A, Evyapan F. Application to
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Corresponding author
Neslihan Yücel, MD
Inönü University,
Faculty of Medicine,
Department of Emergency Medicine,
Malatya,
Turkey,
E-mail: neslihan.yucel@inonu.edu.tr
nesyucel@hotmail.com

1612 Journal of Society for development in new net environment in B&H


An evaluation of self-efficacy and
nicotine-addiction levels of smoker
university students
Nur Özlem Kilinç1, Ayfer Tezel2
1
Bingöl University, Health Services Vocational, Bingöl, Turkey,
2
Ankara University, Faculty of Health Sciences, Nursing Department, Ankara, Turkey.
Abstract
Aim: This research was carried with the aim
of evaluating self-efficacy and addiction levels of
university students.
Method: The population of this descriptive re-
search consists of 339 students who are defined as
smokers with a pre-questionnaire among 920 stu-
dents studying in Bingöl University in 2009-2010
academic years. Sampling-choosing wasn’t done
in the study and the research was completed with
339 volunteer students. The study data was collec-
ted by using the form including socio-demograp-
hic data, self-efficacy scale, fagerstrom questio-
nnaire. Evaluating data was made by descriptive
tests in computer environment, t test, analysis of
variance and analysis of correlation.
Findings: It was determined that place that
they live, their fathers’ education of smoking stu-
dents idea quit smoking effect their self-efficacy
level (p<0,05).
It was determined that students’ gender, marital
status, age that start smoking, the number of daily
smoking, the length of smoking period, trial of qu-
itting smoking, the period which smoke, willing to
quit and believing in quitting effect addiction level
(p<0,05).
Results: It was determined that there is a rela-
tionship between students’ self-efficacy levels and
nicotine addiction levels.
Key words: adolescent, self-efficacy, smoking,
nicotine addiction
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
Introduction
Today, habit of cigarette smoking that takes
place near the top between the population-threa-
tening problems and that is becoming widespread
day by day is concerning the masses in terms of its
effects and results (1,2).
It is stated that each year 4 million people in the
world die from smoking and its related diseases
and this mean death of a person in each 8 secon-
ds (3,4). It is estimated that the number of people
who die from smoking will reach 10 million in
2030 and 7 million of this will be people of deve-
loping countries (4).
While smoking rates are close to each other
in many developed western countries, this rate is
highly different in our country. Smoking frequen-
cies in men and women are 39-31% in Norway,
35-31% in England, 33-31% in Australia, 33-18%
in Finland, 32-27% in Canada, 24-28% in Sweden
and 63-24% in Turkey, respectively (5).
When looked at smoking rates in Turkey, it is
determined that the high rates seen in adults can
also be seen in teens (6,1,5). The smoking frequen-
cy of university students in Turkey varies between
14% and 43,7% (1,7,8).
Self-efficacy is accepted as one of cognitive
perception factors that have roles in changing the
behaviour of individual (9). According to Bandura,
self-efficacy determines how people feel, think, be-
have and how they motivate themselves (10). Indi-
viduals who have a low level of self-efficacy have
low self-confidence and they are pessimistic about
their successes and personal improvements (11).
The perception of self-efficacy is important in
determining the behaviours that individuals must
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HealthMED - Volume 5 / Number 6 / 2011
perform and avoid. It is stated that using succe-
ssful coping strategies resulting in giving up and
sustaining smoking improve individuals’ self-ef-
ficacy (12).
Individuals whose self-efficacy beliefs are
strong were observed to have lower tendency for
starting smoking than individuals whose self ef-
ficacy beliefs are weak (13). Low self-efficacy
was associated with extreme nicotine addiction
and low possibility of giving up smoking between
teens (14, 15).
It is also stated in the studies on smoking that
late adolescent period is the riskiest period in
terms of addiction development and especially the
age 15-24 is defined as the risk group in terms of
addiction development (7,8,16).
The most important result obtained from the
studies on smoking addiction is that nearly 45%
of over-15-age population in our country and all
around the world are seriously smoking addiction.
This fact reveals the severity of the problem espe-
cially for teens (7, 8,16, 17).
In many studies in Turkey, it is also seen that the
rates of teens’ trying cigarette and smoking it are
high (7,8,17). Today, more than 80% of smokers
start smoking before 18 years old, and gaining be-
haviors of individuals who start smoking in early
ages becomes clear in university years (18). This
situation gives precedence to make research about
the subject of coping with attitudes of students in
late-adolescent period.
The self-efficacy and the assessment of addic-
tion level that is one of the cognitive factors will
contribute to develop strategies to form programs
that contribute to prevent adults’ starting smoking
or giving up smoking.
This research was carried with the aim of eva-
luating self-efficacy and addiction levels of uni-
versity students.
Material and method
This research was carried out in descriptive
type and by collecting data in Bingöl University
between November-December 2009.
The population of the research consist of 339
students who are defined as smokers with a pre-
questionnaire among 920 students studying in
1614
Bingöl University in 2009-2010 academic year.
Sampling-choosing wasn’t done in the study and
the research was completed with 339 volunteer
students. While there was only Vocational School
in Bingöl University in the first semester of 2009-
2010 academic years, new departments received
students with additional placement after the rese-
arch was planned. Thus, these students weren’t in-
cluded in the research.
Data Collection Tools
Data were collected by using Descriptive In-
formation Form, Self-efficacy Scale (SES), Fager-
strom Tolerance Test (FTT).
Descriptive Information Form comprises of
questions that describe socio-demographic cha-
racteristics of the students and factors that are tho-
ught to affect their smoking conditions.
Self-Efficacy Scale (SES) that was developed
by Sherer at al. and was adapted into Turkish by
Gözüm and Aksayan in 1999 is a self-assessment
scale of 5 point likert scale type. The reliabili-
ty and validity of Turkish form of the scale, for
the same sampling, were found Cronbach Alfa
coefficient of internal consistency as 0,81 and
test-retest reliability as 0,92 (19). Self-efficacy
Scale reliability coefficient in this study was fo-
und as 0,78. There are 23 items in the scale and
students were asked for each item to tick up one
of the following; 1-“Doesn’t describe me at all”,
2-“Doesn’t describe me very well”, 3-“Unsure”,
4-“Describes me fairly well”, 5-“Describes me
completely”. Given score is taken into account
for each item. But items 2, 4, 5, 6, 7, 10, 11, 12,
14, 16, 17, 18, 20, 22 take score in reverse. Thus,
minimum 23 point, maximum 115 point could be
taken from the scale. The high score taken from
the scale indicates that self-efficacy perception of
individual is at good level.
Fagerstrom Tolerance Scale (FTT) developed
by Fagerstrom in 1989 shows nicotine addiction
level of individuals (20). This scale is a general
test that was scientifically confirmed in evaluating
the nicotine addiction. It was used in many rese-
arches about this subject (14, 15, and 21). Each
item of the scale that consists of six questions was
scored as ‘0’, ‘1’, ‘2’, ‘3’ and it is obligatory to
Journal of Society for development in new net environment in B&H
 HealthMED - Volume 5 / Number 6 / 2011

tick up one of the options. Because the last four Table 1. The distribution of demographic features
questions of the scale are 0-1 point, scores that co- of students
uld be taken from the scale vary in 0-10 range. The Smoker (n=339)
lowest point ‘0’ indicates the absence of addiction, Demographic Features
Number %*
the highest point ‘10’ shows the highest level of
Class
addiction. Scores taken according to addiction le-
First Class 217 43,1
vel describe the following:
-- 8-10 point: Very high-level nicotine Second Class 122 46,6
addiction Sex
-- 6-7 point: High-level nicotine addiction Female 53 23,3
-- 5 point: Mid-level nicotine addiction Male 286 53,1
-- 3-4 point: Low-level nicotine addiction Marital Status
-- 0-2 point: Very low-level nicotine addiction Married 53 58,8
Single 286 42,3
Before applying prepared question forms, ne- Social Security
cessary arrangements were made in the question Existent 208 44,4
form in order to determine intelligibility of the
Nonexistent 131 44,1
expressions after preliminary application on a
Type of Family
group of 13-students who were chosen randomly.
Extended 116 42,4
These 10 students were excluded from the resear-
ch. The question forms were applied to students in Nuclear 200 44,2
classrooms and during the course hours. First, the Separated 23 57,5
main purpose of the research was explained and Place of residence**
then the question forms were given to volunteer City 247 50,2
students. 25 minutes were giving students to fill in Town 54 33,8
the question forms. Village 38 33,9
Written permission from Bingöl University Economic Status
Rectorate and approval from The Ministry of He- Income > expenditure 53 46,1
alth Elazığ Clinical Researches Ethics Committee Income = expenditure 139 47,6
were taken to be able to carry out the research.
Income < expenditure 147 41,1
The students included in the research were
Education of Mother
asked to answer the question forms that include
Descriptive Information Form, Self-Efficacy Sca- Illiterate 162 43,3
le (SESS) and Fagerstrom Tolerance Scale. Literate 60 46,9
Data evaluation was made in computer envi- Primary School 96 45,9
ronment. Descriptive tests, t-test, analysis of vari- High School 21 43,8
ance, correlation and internal consistency analysis University - -
were used in analyzing the data. Materiality level Education of Father
was taken as 0,05. Illeterate 40 38,8
Literate 52 39,7
Primary School 135 45,3
Results High School 91 52,3
University 21 35,6
The distribution of demographic features of *The percentage of row was taken.
students is presented at Table 1. **City: urban area/the largest of area of residence. Town:
semi-urban area/approximately
population between 5 and 10 000. Village: rural area/the
smallest of area of residence,
approximately population between 2 and 3000.

Journal of Society for development in new net environment in B&H 1615

HealthMED - Volume 5 / Number 6 / 2011

The distribution of Averages of SES Points The distribution of averages of SES points
According to the Demographic Features of Stu- according to students’ smoking habit are presen-
dents is presented at Table 2. ted at Table 3.

Table 2. The distribution of averages of SES points according to the demographic features of students
SES Point Average
Demographic Features Number %* Test Value
( x ± SD)
Class
First Class 217 64,0 82,90±12,67 t= -0,319
Second Class 122 36,0 83,36±12,96 P=0,750
Sex
Female 53 15,6 85,43±11,29 t=1,469
Male 286 84,4 82,63±12,98 P=0,143
Marital Status
Married 53 15,6 83,92±12,97 t=0,528
Single 286 84,4 82,91±12,73 P=0,598
Social Security
Existent 208 61,4 83,61±13,46 t=1,019
Nonexistent 131 38,6 82,21±11,55 P=0,309
Type of Family
Extended 116 34,2 82,10±12,52
Nuclear 200 59,0 83,41±13,04 F=0,668
Separated 23 6,8 85,00±11,51 P=0,514
Place of residence
City 247 72,9 84,10±12,57
Town 54 15,9 80,74±12,42* F=3,116
Village 38 11,2 79,65±13,70* P=0,046
Economic Status
Income > expenditure 53 15,6 82,62±10,73
Income = expenditure 139 441,0 84,33±12,34 F=1,199
Income < expenditure 147 43,4 82,04±13,74 P=0,303
Education of Mother
Illiterate 162 47,8 81,98±12,72
Literate 60 17,7 84,01±12,96
Primary School 96 28,3 82,86±12,23 F=2,46
High School 21 6,2 89,76±13,43 P=0,062
University
Education of Father 40 11,8 79,70±10,48*
Illeterate 52 15,3 86,21±14,08
Literate 135 39,8 81,96±11,49†
Primary School 91 26,8 82,30±13,99‡ F=4,700
High School 21 6,2 92,19±10,83*†‡ P=0,001
*, †, ‡
Groups result from difference by Tukey HSD test

1616 Journal of Society for development in new net environment in B&H

 HealthMED - Volume 5 / Number 6 / 2011

Table 3. The distribution of averages of SES points according to students’ smoking habit
SES Point Averages
Smoking Habit Number %* Test Value
( x ± SD)
Number of Smoking
1-5 59 17,4 82,33±12,93
6-10 55 16,2 84,30±12,45
11-15 59 17,4 79,84±13,67
15-20 105 31,0 84,47±11,88 F=1,454
21 and over 61 18,0 83,37±13,20 P=0,216
Year of Smoking
1-3 year 60 17,7 81,23±12,31
4-6 year 92 27,1 82,60±12,71
7-9 year 81 23,9 85,12±13,05 F=1,158
10 and over 106 31,3 82,95±12,78 P=0,326
Situation of Wanting to Quit
Yes 247 72,9 82,87±12,56 t= - 0,461
No 92 27,1 83,59±13,32 P=0,645
Belief of Quitting Smoking
Existent 183 54,0 85,31±13,13 t=3,557
Nonexistent 156 46,0 80,44±11,81 P=0,000
Knowledge about Smoking
Existent 334 98,5 83,19±12,77 t=1,392
Nonexistent 5 1,5 75,20±9,23 P=0,165
* The percentage of column was taken

The distribution of averages of FTT points
according to the demographic features of students
are presenten at Table 4.
The distribution of averages of FTT points
according to features that define the situation of
students’ smoking are presented at Table 5.
There is a weak and meaningful correlation
between students’ SES point averages and FTT in
negative way. (r= -0,122, P=0,025).
Discussion
In the study, it was found that students’ cla-
ssrooms, sexes, social security, incomes and their
mothers’ education status did not influence their
self-efficacy levels (p>0,05) (Table 2).
That students’ self-efficacy levels did not differ
from their classroom (Table 2) is parallel to Yiğitbaş
and Yetkin’s research findings. Yiğitbaş and Yetkin
emphasized in their research that the average sco-
re of self-efficacy between classrooms are close to
each other and this difference is not significant (22).
Tiller et al. emphasized that as students promote,
their self-efficacy scores increase (23). Students’
self-efficacy levels are also expected to increase by
the reason of the fact that education levels of the
students increase as they promote. It is remarkable
that students’ self-efficacy levels do not change al-
though their education years increase. The reasons
why the difference between score averages of self
efficacy between classrooms are not significant
must be researched in different populations. It is
also reported in literature that the individual’s own
and others’ experiences, professional help, situatio-
nal factors such as anxiety and stress have an effect
on self-efficacy perception (24). Students receive
theoretical and practical courses together in Bingöl
University where the research is held. This situation
is thought to affect students’ cognitive perceptions
by increasing their preparations for professional
life, stress and anxiety.
It was determined that there is no statistical
difference between students’ self-efficacy le-

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HealthMED - Volume 5 / Number 6 / 2011

Table 4. The distribution of averages of FTT points according to the demographic features of students
FTT Point Averages
Demographic Features Number % Test Value
( x ± SD)
Class
First Class 217 64,0 4,57±2,70 t=0,678
Second Class 122 36,0 4,37±2,57 P=0,499
Sex
Female 53 15,6 3,75±2,89 t=-2,307
Male 286 84,4 4,64±2,58 P=0,022
Marital Status
Married 53 15,6 3,75±2,41 t=- 2,364
Single 286 84,4 4,64±2,67 P=0,019
Social Security
Existent 208 61,4 4,36±2,68 t=-1,226
Nonexistent 131 38,6 4,72±2,59 P=0,221
Place of residence
City 247 72,9 4,38±2,56
Town 54 15,9 4,83±2,95 F=0,878
Village 38 11,2 4,78±2,81 P=0,417
Type of Family
Extended 116 72,9 4,68±2,69
Nuclear 200 15,9 4,30±2,60 F=1,861
Separated 23 11,2 5,30±2,72 P=0,156
Economic Status
Income > expenditure 53 15,6 4,69±2,50
Income = expenditure 139 441,0 4,17±2,53 F=1,845
Income < expenditure 147 43,4 4,74±2,79 P=0,160
Education of Mother
Illiterate 162 47,8 4,44±2,71
Literate 60 17,7 4,36±2,88
Primary School 96 28,3 4,65±2,53 F=0,195
High School 21 6,2 4,61±2,15 P=0,900
Education of Father
Illiterate 40 11,8 4,52±2,58
Literate 52 15,3 4,59±2,71
Primary School 135 39,8 4,23±2,67
High School 91 26,8 4,82±2,58 F=0,682
University 21 6,2 4,52±2,27 P=0,605

vels according to their sexes (p>0,05) (Table 2).
Yiğitbaş and Yetkin reported in their study that
there is no difference between male and female
students’ self-efficacy points (22). In Keskin and
Olgun’s research, there is no significant difference
between male and female students’ self-efficacy
levels (25). Tiller emphasized that sex of the stu-
dents does not have an important effect on their
self-efficacy levels (23).
It was also determined that social security sta-
tus of the students included in the research do not
affect self-efficacy points (p>0,05) (Table 2). The

1618 Journal of Society for development in new net environment in B&H

 HealthMED - Volume 5 / Number 6 / 2011

Table 5. The distribution of averages of FTT points according to features that define the situation of
students’ smoking
FTT Point Averages
Demogrraphic Features Number % Test Value
( x ± SD)
Age to Start Smoking
10-13 ages 69 20,4 5,47±2,39*†
14-17 ages 145 42,9 4,90±2,59 ‡
18-21 ages 108 31,9 3,49±2,45* ‡ F=11,011
22 ages and over 17 5,0 3,58±3,16† P=0,000
Number of Smoking
1-5 59 17,4 2,49±2,56* † ‡
6-10 55 16,2 2,70±2,14§ || ¶
11-15 59 17,4 4,39±2,00* §**
15-20 105 31,0 5,00±2,00 † || †† F=53,053
21 and over 61 18,0 7,31±1,68‡ ¶ †† ** P=0,000
Year of Smoking
1-3 60 17,7 3,06±2,57*†§
4-6 92 27,1 4,55±2,61*
7-9 81 23,9 5,03±2,28† F=8,105
10 years and over 106 31,3 4,86±2,73§ P=0,000
Situation of Trying to Quit
Never Tried 76 22,4 4,65±2,73†
Once 160 47,2 4,96±2,45* F=7,971
Often 103 30,4 3,66±2,72*† P=0,000
Situation which Most Frequently
Smokes
Exam 35 10,3 4,57±3,27
Homework 8 2,4 4,00±2,67
Financial Problem 32 9,4 5,54±2,89*
Friends’ Meeting 23 6,8 2,65±2,24*† F=4,258
Stress 241 71,1 4,55±2,48† P=0,002
Situation of Wanting to Quit
Yes 247 72,9 4,03±2,61 t=-5,864
No 92 27,1 5,76±2,32 P=0,000
Belief of Quitting Smoking
Existent 183 54,0 3,59±2,53 t=-7,268-
Nonexistent 156 46,0 5,55±2,39 P=0,000
Knowledge about Smoking
Existent 334 98,5 4,50±2,64 t=0,257
Nonexistent 5 1,5 4,20±3,49 P=0,797
*, †, ‡, §, ||, ¶, **, ††
Groups result from difference by Tukey HSD test

Journal of Society for development in new net environment in B&H 1619

HealthMED - Volume 5 / Number 6 / 2011
self-efficacy levels of the students who expressed
that they had social security were found to be hi-
gher than the students who had no social security.
It was detected that smoker and non-smoker stu-
dents’ income levels do not affect their self-effica-
cy levels (p>0,05) but students who expressed that
they had low-income had lower self-efficacy le-
vels than the other students (Table 2). Having low-
income and not having social security are thought
to affect individuals’ cognitive perceptions and to
change their self-efficacy perceptions by increa-
sing their life anxiety.
It was found that students’ self-efficacy levels
are not affected from their mothers’ education le-
vels (p>0,05) (Table 2). In traditional Turkish fa-
mily structure, father is at the forefront as head of
the family although mother takes care of her fami-
ly and spends much time with her children. It is
considered that perceiving as a role model of the
father who is effective in power mechanism and
decision-making decreases mother’s efficiency.
It was found in this research that the place in
which students live affects students’ self-efficacy
levels (p<0,05) and self-efficacy levels of the stu-
dents who live in city centre are higher than tho-
se who live in other settlements (Table 2). Keskin
and Olgun found that the place in which students
live do not make difference between self-efficacy
points but self-efficacy levels of the students who
live in city are higher than those who live in coun-
ty and village (25).
Father education levels was found to affect stu-
dents’ self-efficacy levels (p<0,05) (Table 2). Orem
emphasized that many concepts such as human, en-
vironment, culture and daily life values were taught
in family institution (26). It is inevitable that the
father who is seen as head of the family in patriarc-
hal family structure in Turkey is accepted as a role
model by his children. It is thought that education
level of the father will have an impact on children’s
cognitive development and his interaction with his
children. Thus, it is thought that father’s education
level affects students’ self-efficacy levels.
It was determined that the number of the ciga-
rettes that students smoke per day and their smo-
king period do not affect their self-efficacy levels
(p>0,05) (Table 3). In Fagan’s (2003) and Ergül’s
(2005) study, a reverse relationship was detected
between the number of the cigarettes that adoles-
1620 Journal of Society for development in new net environment in B&H
cents smoke per day and their self-efficacy levels
(21,27). Yazıcı and Özbay (2004) reported in their
study that there is a decline in self-efficacy beliefs
in parallel with increase of smoking period (28).
It is expected, as self-efficacy levels rise up, the
number of the cigarettes will decrease depending
on avoiding from smoking. The presence of the ot-
her factors affecting students’ self-efficacy levels
that were not analyzed in this study is thought to
have affected that the results of this study is diffe-
rent from literature knowledge.
The great majority of the students wish to give
up smoking (72,9%), but only 54% of the smoker
students believe that they will give up smoking.
Self-efficacy levels of the students who believe
that they will give up smoking (85,31±13,13) are
higher than those who believe that they cannot
give up smoking (80,44±11,81) and it was deter-
mined that the difference between groups is stati-
stically significant (p<0,001) (Table 3).
In literature, self-efficacy was defined as
individual’s judgement about his achievement ca-
pacity of a particular performance level and was
pointed out to have important place in giving up
smoking.
Borelli and Mermelstein (1994) emphasized that
there are difference between self-efficacy beliefs of
people who has never give up smoking and tho-
se who has given up smoking and started it again
(29).Yazıcı and Özbay (2006) pointed out that pe-
ople whose self-efficacy perceptions are high have
strong tendency on giving up smoking (30). In the
light of this literature, it can be thought that people
who continue smoking have beliefs, even if at low
level, on giving up this habit. In a research Dijiks et
al. made, smokers were divided into four groups;
first group was informed about giving up smoking,
second group was informed to increase self-effica-
cy, third group was applied with both methods and
fourth group was not informed in any way. Then, it
was determined that the most successful group was
third group and it was also pointed out that both se-
cond and third group benefited mostly from infor-
mation that increases self-efficacy (31). Rajamaki
et al. (2002) found similar results from their resear-
ch on smokers and ex-smokers (32).
In this study, it was found that self-efficacy levels
of the students who have knowledge about harms of
smoking are higher than those who have no knowled-

ge about harms of smoking (Table3). It is emphasi-
zed in the literature that individuals’ knowledge le-
vel can be increased by expanding their conscious
fields relating to health-threatening risky behaviours
such as smoking and drinking (33,34). The increase
in individuals’ knowledge level is thought to have
affected his self-efficacy perception.
When students’ addiction levels are analyzed
according to sex, it was found that addiction levels
of male students are higher than those of female
students and the difference is significant (p<0,05)
(Table 4). 44,3% of the students included in this
study smokes cigarette. From the students inclu-
ded in the research, smoking rate in female stu-
dents is 6,9% and in male students 37,8%. In Çivi
and Şahin’s study on university students, while
smoking rate in female students is 16,6%, this rate
is 30,4% in male students (35). Xiang et al. re-
ported in their study on Medical Faculty students
in China that female students do not smoke and
smoking rate in male students is 38%. In literatu-
re, there are many studies in which similar results
were obtained (36,37).
It is suggested that intersexual difference in the
region where research was carried out results from
dominant patriarchal family structure and accep-
tance of male smokers by society.
In this study, it was determined that the ad-
diction levels of single students are higher than
those of married students and the difference is
significant (p<0,05) (Table 4). Similar study that
discussed this finding couldn’t be founded in the
literature. Smoking status of the students’ spouses
weren’t questioned in this study. It is thought that
this subject must be analyzed with the assumption
of smoking status of one of the spouses can affect
the other’s addiction level.
Smoker students’ social security, the city they
live, family type, income status, education level
of mother and father did not affect students’ ad-
diction levels (p>0,05) (Table 4). It is thought that
smoking addiction results from the features that
describe students’ smoking habit rather than their
demographic features.
It was found in this study that students who star-
ted smoking 10-13 years old are mid-level addicts.
It was determined that as the students’ age of star-
ting smoking gets younger, their addiction levels
increase and the difference is significant (Table 5).
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
As the number of cigarettes that students smo-
ke gets increased, their addiction levels increase
(Table 5). Students’ smoking period similarly ca-
used the increase in their addiction levels (Table
5). In Seydişehir Vocational High School, 50%
of smoker students use 10 and fewer cigarettes in
a day, 33,9% 11-20, 14,5% 21-20, 1,6% 31 and
more. In this study, daily cigarette smoking is 1-5
in 17,4%, 15-20 in 31,0% and this is parallel with
study result that was indicated in the literature
(38). it was found that more than 70% of the smo-
kers who started smoking under 10 years old are
smoking addiction, in the research Boyacı H et al.
made (1). Starting smoking in early ages brings
about long-term smoking.
It is known that addiction is associated with
individuals own and many environmental factors
and it is seen that long-term exposure to cigarette
is very important situation. An increase in daily
number of cigarettes and long-term smoking cau-
se the increase in addiction level. Exposure period
to smoking and increase in the number of cigarette
lead to increase of taken nicotine level into body
and cause permanent addiction. It was reported
in the studies that increased plasma nicotine level
after smoking rapidly decreased and unwanted
withdrawal symptoms appeared due to effects of
nicotine while not smoking (39).
The rate of the students who tried one time to
give up smoking is 47%. That nearly half of the
students tried at least one time to give up smoking
shows that the large part of the students tried to
avoid this habit. That nearly 73% of the students
answered ‘Yes’ for the question “Do you want to
give up smoking?” supports this comment. Kara-
bulut reported in his study that 83,5% of the partici-
pants wanted to give up smoking and 16,5% of tho-
se did not want to give up smoking. In Karabulut’s
study, while 80,2% of the individuals stated that
they could give up smoking, 19,8% of those stated
that they could not give up smoking (40). Türkoğlu
emphasized in his study that 30,9% of the students
never tried to give up smoking, 24,6% tried to give
up smoking four times or more, 21,1% once, 14%
twice and 9,5% three times (41). It was found in
this study that while addiction levels of the students
who wants to give up smoking are higher than tho-
se who do not want to give up smoking, addiction
levels of the students who often try to give up smo-
1621
HealthMED - Volume 5 / Number 6 / 2011
king are less than those who have tried once or have
never tried to give up smoking (Table 5). Addiction
levels of the students who believe that they can give
up smoking were found less than those who do not
believe that they cannot give up smoking. When
the rate of the students who try, want and believe
in giving up smoking is taken into consideration, it
is thought that the students included in the research
will easily give up smoking by professional help.
The low-addiction level of these students will pro-
vide convenience them in their struggling with gi-
ving up smoking.
In this study, the students emphasized that they
smoke mostly in stressful situations (71,1%). It
was found that the students who describe the si-
tuation in which they smoke mostly as financial
difficulty are mid-level addicts (Table 5). As a
result of the studies, the most important smoking
reasons are incentive role of media, keeping up
with friend group, showing off, accepting him/her
to a particular group or identification with smoker
parents (42). For the group included in this study,
the most important reason, like in many similar
studies, is described as stress (43, 44).
It wasn’t found any statistical difference between
the students who have and do not have knowledge
about the harms of smoking (p>0,05) (Table 5). Al-
though 98,5% of the students have knowledge abo-
ut the harms of smoking, it is remarkable that they
are low-level addicts. This result suggests that the
sources from which the students get information are
not effective enough. It is thought that nurses will
be useful in informing of smoking and its harms in
order to increase individuals’ self-efficacy levels by
using their educational role.
Recent studies suggest that adolescents conti-
nue smoking although they know the harms of it.
Today, studies on smoking are trying to present
cognitive basis of health-threatening risky beha-
viours of adolescents (45). Thus, students’ demo-
graphic features, their self-efficacy and addiction
levels as well as features associated with their
smoking habits were analyzed in this study.
In this study, it was determined that there is a
poor, reverse and significant relationship between
students’ self-efficacy levels and their addiction
levels. Fagon et al. (2003) found in their study on
adolescents that self-efficacy decreases as nicotine
addiction increases (27). Besides, in Ergül’s study
1622 Journal of Society for development in new net environment in B&H
(2005), similar results can be seen. That Self-effi-
cacy which is accepted as key component of So-
cial Conceptual Theory is low is associated with
extreme nicotine addiction (14,15).
It is suggested that the students should be ta-
ught the techniques which increase their self-ef-
ficacy levels to fight against smoking and to say
‘No’ to smoking and smokers should be achieved
to give up smoking.
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35. Özcan A,Yazıcı S,Beser A, Akkas A. Karadeniz Corresponding author

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Hastalıkları 1998;9: 17- 607.

1624 Journal of Society for development in new net environment in B&H


The investigation of life styles
adopted by women living in Erzurum
as regards cervical cancer risk
Özlem Karabulutlu1, Nesrin Reis2
1
Atatürk University, Faculty of Health Science, Department of Obstetric and Gynecologic Nursing, Turkey,
2
Bezm-i Alem Private University, Faculty of Health Science, Department of Obstetric and Gynecologic Nursing,
Turkey.
Abstract
Objective: This is a descriptive field study
conducted to investigate the life styles adopted by
women living in Erzurum, Turkey as regards cer-
vical cancer risk.
Subject and methods: The study comprised
women aged between 15 and 64 years and enro-
lled with 12 health centers located in Erzurum city
center between October 2007 and March 2008.
The study sampling group consisted of 809 wo-
men chosen by means of a stratum sampling met-
hod from this cohort.
Results: The average age of the women in the
study was 33.89±12.76. It was found out that 66.3%
of women experienced their first intercourse at or
before the age of 20 and that 55.2% of the women
experienced their first pregnancy at or before the
age of 20. Some 50.7% of the women had their first
child at or before the age of 20 and 57.3% had 3 or
more births. There were 37.3% who reported a con-
tinual vaginal infection; they also indicated having
risky behaviors as regards cervix cancer. In additi-
on, of these women, 59.6% were obese, 29.4% ate
regularly, 81.2% had not had a Pap smear test, and
that 82.2% did not have regular medical check-ups;
that is, they displayed a range of risky behaviors re-
garding gynecological health.
Conclusion: Although we cannot directly
change women’s family structure and economic
status, nor the place where they live, we can still
change a lot by giving them individual/group trai-
nings, providing them with more healthy lives.
Key words: cervical cancer, risk factors, life
style, early diagnosis, nursing.
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
Introduction
Cervical cancer is an important women’s he-
alth problem worldwide, it is secondary only to
breast cancer in terms of mortality and prevalen-
ce. Among the gynecological cancers, however,
it occupies the first rank. It makes up 4.4% of all
the women’s cancers in the developed countries
and the lifelong risk is 1.1%. In the developing co-
untries, on the other hand, cervical cancer makes
up 15% of all the women’s cancers and the life-
long risk is around 3%. In these underdeveloped
countries, the number of cases has been reported
as 409.000 and the rate of death as 233.700 [1].
In Turkey, according to the 2003 data from the
Directorate of Cancer-Fighting Office, the Mini-
stry of Health, cervical cancers make up 4.53 of
100.000 of all the women’s cancers [2].
In many epidemiological studies, risk factors
have been reported for the cervical cancer. These
include factors relating to ethnicity [3], gestation
and sexual history [3-6], sexually transmitted di-
seases [6-8], smoking [5,6,9,10], alcohol intake
[5,6], irregular diet [6], stress [11], and inability
to follow a regular health program, including the
Pap smear [12,13]. These risk factors are influen-
ced by the women’s educational level, their social
status and the life style adopted in relation to the
traditional structure and economy of the society
in which they live. For example, in those societies
where the first sexual activity is at an early age,
it has been reported that the average number of
partners is six or more, the age of the first pregnan-
cy and birth is young and the number of children
is high. Thus, the gynecological health behaviors
1625
HealthMED - Volume 5 / Number 6 / 2011
that these women adopt is ten times more risky
for cervical cancer than that adopted in other so-
cieties [5,9,14] and the risk of cervical cancer also
doubles in those women who use oral contracep-
tives for five years or more [4,6]. Epidemiologi-
cal studies have also shown that cervical cancer
risk is lower in women who eat fibrous food such
as vegetables, fruits, and especially those that are
rich in carotene, vitamin C and E [6,9,10]. In ot-
her studies, it has been determined that societies
with a history of sexually transmitted diseases and
that lack health-protective and improving behavi-
ors such as regular health controls and Pap smear
checks, despite continual infections have a greater
incidence of risky behaviors for cervical cancer
than other societies [9,15].
It is very important to know about the risky
behaviors that are related to women’s gynecolo-
gical health behaviors as they may be unconscio-
usly practiced yet placing them at risk of cervical
cancer. Identification of the risky behaviors will be
helpful in determining the content and scope of the
instructive training that will be given to women
and can lead to health-promoting activities. The-
se trainings will make a considerable contribution
to women’s protection from, and early diagnosis
of, cervical cancer, both of extreme importance in
managing this very serious women’s health pro-
blem worldwide [12,13]. The types of risky be-
haviors closely associated with women’s gyneco-
logical health behaviors vary from one country to
another, or even between different societies.
For this reason, the primary objective of this
study is to examine the life styles of the women;
in particular, those from the eastern part of Turkey
where socio-economic and educational conditions
are less developed, in relation to cervical cancer
and thus contribute to improving individual/fami-
ly/society health.
Methods and materials
Sample and Study Design
The study was conducted in Erzurum, the lar-
gest city of the eastern part of Turkey. Erzurum is
where the strongest terrestrial climate conditions
prevail on a large settlement site and high altitude.
1626 Journal of Society for development in new net environment in B&H
In general, winters are long and harsh and sum-
mers are short and warm [16]. This characteristic
of the seasons and long and harsh winter days have
affected the life style of the local people whose
main business has been animal husbandry. The
women of the city have tended to be more passive
and who live at home and whose diets comprise
mainly of animal products.
This descriptive research has been carried out
between November 2007 and March 2008. The
population of this study is 110.177 women marri-
ed and gave birth in the range of 15-64 years, and
they are registered to 12 family health centers in
Erzurum. As the number of individuals in the po-
pulation sample is known, the sample size inclu-
ded 658. 809 women, who are coming to family
health center for any reason (to vaccinate their
children, to be examined, etc.) and agree to parti-
cipate, were included in the research.
Data collection
Questionnaire forms prepared by the researchers
were used in gathering the data using a face-to-fa-
ce interview technique with the women. The se-
mi-structured questionnaire form was developed
specifically for this study using questionnaires from
previously published studies as a guide [3,6]. Face
validity for questionnaire was determined by re-
searchers. The questionnaire form consisted of 22
questions, firstly to gather socio-demographic data
related to personal information (age, marital status,
educational level, perceived income status, health
insurance, etc.). Secondly, behaviors known to be
risky in relation to cervical cancer (the age of the
first sexual intercourse, the number of her and her
husband’s partners, the number of births, etc.) and
those behaviors considered disputable in relation to
cervical cancer (such as form of feeding, use of oral
contraceptive, alcohol consume, body mass index,
etc.) were also part of the questionnaire. Partici-
pants’ body mass index (BMI) was calculated using
the formula “BMI= Weight in kg /Height in m2. Par-
ticipants’ economic statuses were described as inco-
me > expenditure, income = expenditure, or income
< expenditure using self-report by the subject.
The questionnaires were completed in a suita-
ble room in the health centers and each interview
 HealthMED - Volume 5 / Number 6 / 2011

lasted approximately 10 or 15 minutes. Questio- 61.4% resided in the city center and 64.9% had
nnaire is completed by women themselves. an income level equal to their spending. Details
of participants’ socio-demographic characteristics
are presented in Table 1.
Statistical analysis Table 1. Socio-demographic qualities of the cases
Variables N %
The data were analyzed by using the SPSS for Age (years)
Windows (version 11.5). The data from the study 15-24 236 29.2
were evaluated by the researcher using the SPSS 25-34 227 28.1
11.5 statistical package program. In evaluating the 35-44 158 19.5
women’s data, means, standard deviation, mini- 45-54 113 14.0
mum, maximum, median and percentage values 55-64 75 9.2
were examined. Marital status
Married 587 72.6
Widowed/ Divorced 46 5.7
Procedure Single 176 21.7
Education
For the study to be conducted, the required wri- Illiterate 163 20.1
tten permissions were received from the Health Literate+Primary school 364 45.0
Sciences’ ethics committee of Atatürk University Secondary school +Higher education 282 34.9
and from the administrations of Erzurum Provin- Residential place
cial Directorate and Provincial Health Office and In the of city 497 61.4
the health institutions concerned. The women in- Suburbs 312 38.6
cluded in the study were given information about Economic status
the study as part of the principle of informed con- Income < expenditure 284 35.1
sent and those who volunteered to be included in Income = expenditure 505 62.4
the study were advised of the principle “Respect Income > expenditure 18 2.2
to autonomy”[17]. Each participant was told that Health insurance
she had the right to withdraw at any part of the Insured 782 96.7
interview. There was nobody who refused to parti- Uninsured 27 3.3
cipate in the study. Total 809 100

Results 2. Indicated risky behaviors

The data were examined in four groups of fin-
dings:
- Socio-demographic characteristics,
- Indicated risky behaviors-related,
- Disputable risky behaviors-related,
1. Socio-demographic characteristics
When we analyzed the participants’ demograp-
hic characteristics we found that their average age
was 33.89±12.76 (range 15–64) and 72.6% (n =
809) of them were married, 45% were graduates
of primary school, 96.7% had health insurance,
When women’s sexual life behaviors were anal-
yzed, it was found out that 63.3% of women expe-
rienced their first intercourse at or under the age of
20, 98.1% of them had one partner relationship,
37.3% of them indicated they had a continual infec-
tion and 0.9% of them were diagnosed with herpes
simplex virus (HSV). When the participants’ data
about birth and gestation were analyzed, it was de-
termined that 55.2% of the women experienced the-
ir first pregnancy at or under the age of 20, 50.7% of
the women first gave birth at or under the age of 20
and 57.3% of them had three and more births. The
distribution of the participants’ risky behaviors for
cervical cancer is shown in Table 2.

Journal of Society for development in new net environment in B&H 1627

HealthMED - Volume 5 / Number 6 / 2011

Table 2. The distribution of the cases’ risky beha- were obese, 29.4% ate regularly with primarily
viors for cervical cancer vegetables and fruits, 81.2% had not had a Pap
Behaviors N % smear test, 17.8% had regular medical check-ups
The age of the first sexual intercourse and 5.4% had used oral contraceptives for more
≤ 16 99 15.7 than five years. The participants’ risky behaviors
17-20 319 50.6 concerning cervical cancer are given in Table 3.
≥ 21 213 33.7 Table 3. The distribution of the cases’ risky be-
The number of women’s partners haviors concerning cervical cancer
1 620 98.1 Behaviors N %
2-3 12 1.9 Body Mass Index (BMI)
≥4 0 (00.0) Obesity (BMI ≥ 25) 482 59.6
The number of her husband’s partners Average weight (BMI 18.5-24.9) 282 34.8
1 595 94.3 Thin (BMI ≤ 18.4) 45 5.6
2-3 36 5.7 Type of food consumed
≥4 0 (00.0) Mainly fatty food derived from
205 25.4
Age at menarche animals
≤ 12 230 28.4 Food derived from both animals and
365 45.2
13-14 384 47.5 vegatables
≥ 15 195 24.1 Balanced/ mainly fruit and vegatables 238 29.4
Age at first pregnant Pap smear status
≤ 16 44 7.2 Never 654 81.2
17-20 292 47.9 Regularly 151 18.8
≥ 21 273 44.8 Regular medical check-up
Age at first birth Never 226 28
≤ 16 35 5.8 Sometimes 437 54.2
17-20 270 44.9 Regularly 144 17.8
≥ 21 296 49.3 Time of oral contraceptive used
Parity ≥ 5 years 43 5.4
≤2 256 42.7 1-5 years 123 15.5
3-4 196 32.7 Never 630 79.1
≥5 147 24.5 Alcohol consume
Genital infection status* 3-5 occasions / week 0 00.0
Continually has had infections/discharge 301 37.3 3-5 occasions / month 5 0.6
Sometimes has had infection 283 35.1 Never or 1-2 occasions / year 803 99.4
Never 223 27.6
Case of smoking
Continually (≥ 11 item /day) 77 9.5 Discussion
Sometimes(1-10 item /day) 124 15.3
Never 607 75.2 In this study, it was found that the very few wo-
HPV/HSV diagnosed status man had first sexual intercourse at the before 15
Yes 5 0.9 years old. It has been reported in literature that the-
No 785 99.1 re is a relationship between a woman’s sexual life
* Genital infection is fungal and cervical cancer. It has been stated that those
who had their first sexual intercourse at the age of
or less than 15 and those whose number of partners
3. Disputable risky behaviors was 6 and more had a ten-time higher cervical can-
cer risk [3,8]. Kamaluddin [19] reported in a re-
The average menarche age of the women in the trospective study on women with cervical cancer
study was 13.46±1.530. Of these women, 59.6% that 64% of the women had married before 20 ye-

1628 Journal of Society for development in new net environment in B&H


ars old. In a study on the determination of the risk
groups in breast and cervical cancers, Türkdemir
[20] found out that 55.9% of women had their first
sexual intercourse under the age of 18 and the fact
that the women had more than one partner affected
the risk score of cervical cancer significantly. In
another study conducted in the city center of Erzu-
rum, 50% of the women were determined to have
first married at or under the age of 18 [21]. In this
study, it was noted that the number of the women’s
and their husbands’ sexual partners was usually
one. In our society and culture, in which marria-
ge at an early age is common, women’s awareness
and consciousness should be increased through an
increase in their educational level. According to
the epidemiological studies, there is a relationship
between cervical cancer and the woman’s age at
first pregnancy, the number of births. It has been
reported in the literature that those who first give
birth before 20 and those who have had three or
more births display absolute risky behaviors for
cervical cancer. [3,6,18,22]. Ngoan and Yoshimu-
ra [22] found that over-fecundity increases the risk
of cervical cancer, and Beji and Reis’s study [23]
found that the percentage of those who have given
birth before 20 years old is 70.3% and those who
have had three and more births is 61.2%. Accor-
ding to the results of a study conducted in the city
center of Erzurum, 34.6% of the women had four
or more live births [21]. Similar to the findings of
the previously conducted studies on this subject, it
is determined in the hereby study that of woman
47.9 % have given birth 17- 20 years old. Some
studies have reported that the infections, especially
the sexually-transmitted diseases, are closely rela-
ted to the cervical cancer [24-26]. In our study, it
was observed that 72.4% of the women had a ge-
nital fungal infection and of the woman 99.1% had
not diagnosed HPV/HSV. Hsieh et al. [27] stated
that the risk of cancer increased in women with a
history of chronic cervix, Chlamydia trichomatis,
human cytomegalovirus and HSV II. Bayo et al.
[28] determined in their study that 96.9% of the
cases with cervical cancer had HPV DNA in their
cervix cells. In a study in Erzurum, Hacialioğlu et
al. [29] found that the frequency of women’s geni-
tal infections was 71.1%. It was also determined in
the same study that women’s genital hygiene prac-
tices were inadequate in general. In particular, it is
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
of considerable significance that the health profe-
ssionals that work in the first step should give place
to this subject in their health trainings.
According to the studies that are still debata-
ble and under investigation, the women who have
adopted a negative health behaviors are more
vulnerable to cervical cancer. It has been repor-
ted that the women with a high BMI, who have a
poor diet lacking in vegetables and fruits and who
smoke and drink, have a 2-to-3-time higher risk
for pre-invasive and invasive diseases [30]. Kjel-
berg et al. [6] reported in their study that the most
important of the environmental risk factors for
cervical neoplasia was smoking. Baay et al. [31]
determined in their study that the risk of cervical
cancer increased in those women whose diets lac-
ked adequate vegetables and fruits. According to
our study, 59.6% of the women were obese and
only 29.4% of them ate sufficient vegetables and
fruits. Therefore, women should be motivated to
adopt healthy behaviors and provided with the
required information/training. The findings of
our study concluded that 81.2% of the women did
not have any Pap smear test performed and only
17.8% of them followed a regular health check-
up. It has been reported that having a Pap smear
test performed and following regular check-ups
are important. Claeys et al. [32] established that
41% of the women had a Pap smear test performed
regularly. Mutyaba et al. [33] pointed out in their
study that 81% of the officials in the health sector
did not have a Pap smear test performed and less
than 40% of them knew the risk factors for cervi-
cal cancer. It has been accepted in the literature
that the women who have been using an oral con-
traceptive for more than 5 years are twice as sus-
ceptible to cervical cancer [4,6,34]. Monero et al.
[35] determined in their study that the long-term
use of oral contraceptives by the women who were
HPV DNA positive increased the risk of cervical
cancer by 400% as the accompanying factor. In
our study, 15.5% of the women on the pill reported
that they were on pill for less than five years and
5.4% of them said that they were on pill for five
years or longer. Even though this response seems
good, the main reason may be the low educational
level and inability to use an effective family pla-
nning method. What is important is the conscious
choice of an efficient method and its use.
1629
HealthMED - Volume 5 / Number 6 / 2011
Conclusions
It was determined that most of the women dis-
played risky behaviors and their educational level
and socio-economic status have an impact on the-
se behaviors. Although we cannot directly change
the women’s family structure and economic state,
as well as the place where they live, we can still
change a lot by giving them individual/group trai-
nings, providing them with more healthy lives.
Study limitations
Some questions in our study were difficult for
participants to remember, for example, the first
menarche age and the infections already experi-
enced. Questions such as the age of the women’s
and their husbands’ first sexual intercourse and the
number of sexual partners were difficult for them
to answer and the accuracy of the answers to these
questions was debatable. Even though these que-
stions make up the limitations of the study, they
still give some idea about the general population.
As the women in the age group of 15–24 make up
the majority of the women registered at the heal-
th institutions, the data carry the qualities of the
15–24 age groups more dominantly.
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nne RV, Mohan VP, Mittal A, Das BC. Chlamydia
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Medina E, Csendes A. Diet, smoking and reproduc-
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Corresponding author
Özlem Karabulutlu,
Atatürk University,
Faculty of Health Sciences,
Erzurum,
Turkey,
E-mail: okarabulutlu@atauni.edu.tr
1631
HealthMED - Volume 5 / Number 6 / 2011
How Much Residents “Don’t Know”
About Feeding Children 6 - 24
Months of Age
Rabia Kahveci1, İlknur Bostancı2, Yıldız Dallar3
1
Ministry of Health, Ankara Numune Training and Research Hospital, Department of Family Medicine,
Ankara, Turkey,
2
Department of Pediatric Allergy, Sakarya University Faculty of Medicine; Ankara, Turkey,
3
Ministry of Health Ankara Training and Research Hospital, Department of Pediatrics; Ankara, Turkey.
Abstract
Objectives: The period from birth to two years of
age is a critical period. The physicians, who would
provide guidance to the caregivers, are expected to
be knowledgeable about feeding. This study is done
to assess knowledge of residents on feeding non-bre-
astfed children 6-24 months of age and to what extent
this would change after presentation of a WHO gui-
deline. Different dissemination routes and how these
would affect guideline uptake is discussed.
Design: WHO’s “Guiding principles for fee-
ding non-breastfed children 6-24 months of age”
was presented to residents. A pre- and post-test
was applied.
Setting: A training and research hospital in An-
kara, Turkey.
Subjects: Family medicine and pediatrics re-
sidents were involved in the study. Thirty-four
physicians took both pre- and post-tests.
Intervention: A multiple choice test to assess
knowledge levels and a questionnaire to under-
stand use of guidelines was applied before the pre-
sentation. The test was repeated 10 weeks later.
Main outcome measures: Pre- and post-test
scores
Results: There was no significant difference
between groups’ pretest scores, whereas pediatri-
cians had significantly higher posttest scores than
the family physicians. For both groups, posttest
scores were significantly higher than their respec-
tive pretest scores.
Conclusion: This study shows that the residents
have a very low level of knowledge on this guidan-
1632
ce, but benefit from guideline presentation. They
have been more interested in reading printed mate-
rials compared to electronic resources. The integra-
tion of guidelines into residency training in Turkey
have not been discussed, but might be useful to im-
prove evidence-based practice by residents.
Key words: evidence based medicine, guideli-
nes, family medicine, pediatrics, Turkey
Introduction
Adequate nutrition during infancy and early
childhood is fundamental to the development of
each child’s full human potential. The period from
birth to two years of age is a “critical window”
for the promotion of optimal growth, health and
behavioral development [1]. Caregivers should be
provided with appropriate guidance regarding op-
timal feeding of infants and young children, to en-
sure desired outcomes.
The physicians, who would provide guidance
to the caregivers, are expected to be knowledgable
about appropriate nutritioning. World Health Or-
ganization published “Guiding principles for fee-
ding non-breastfed children 6-24 months of age”
in 2005 [1]. Considering that, not all children have
the opportunity to breastfeed, it is of immense va-
lue for physicians to have adequate information
about these principles, in order to provide appro-
priate guidance.
Residency training is an important period for
having skilled and knowledgeable doctors in the
future. Continuous Medical Education (CME) is
Journal of Society for development in new net environment in B&H

very important for health care professionals for
learning and updating their knowledge. As these
programs are the main sources of knowledge and
updates for the residents, organizers should feel
the responsibility to include effective and appro-
priate content.
We did this study to determine the knowledge
levels of family medicine and pediatrics residents
on feeding non-breastfed children 6-24 months of
age and to what extent this level would change af-
ter presentation of WHO guideline. We also focus
here on different dissemination routes, how these
would affect guideline uptake and discuss potenti-
al role of guideline presentation in CME. We also
explore the differences in effects, between family
medicine and pediatrics residents.
Subjects and methods
WHO’s “Guiding principles for feeding non-
breastfed children 6-24 months of age” was pre-
sented to family medicine residents (who were
during their mandatory pediatrics training of 9
months) and pediatrics residents in a Training and
Research Hospital, by an academic in Pediatrics.
The study has the approval of local ethics commi-
ttee of our hospital.
The presentation included only the informati-
on in the guideline and no additional source was
used or added to the content. The presentation was
done within routine training sessions. A multiple
choice test was applied to all the physicians befo-
re the presentation, in order to assess their related
level of knowledge. An additional questionnaire
was also given to understand their level of use for
clinical practice guidelines (CPGs). Following the
presentation, the original text, Turkish translation
and powerpoint presentation were shared in the
hospital website and the physicians were notified
by an email. The key points were also shared in
the boards of departments as brief tables or notes.
No additional reminder was sent or given to the
group for 10 weeks and the group was asked to
answer the same questions 10 weeks later. The
results were analyzed with SPSS 10.0. The thres-
hold for statistical significance was set at P < 0.05.
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
Results
48 residents attended the first training session
and were given a pretest before the session star-
ted. 10 weeks later, 34 (70.8%) of these physicians
were contacted again for the posttest. 23 (67.6%)
of these physicians were family physicians and 11
(32.4%) were pediatricians.
2 of the family physicians (8.7%) said that they
read a guideline on nutrition before, whereas none
of the pediatricians read one. 7 (30.5%) family
physicians and 3 (27.3%) pediatricians said that
they’ve read a CPG before (regardless of topic).
The average pretest score for family physici-
ans was 27.88/100 while it was 37.3/100 for pe-
diatricians. The posttest scores were 43.9/100
and 68.2/100, respectively. There was no signi-
ficant difference between groups’ pretest scores
(p>0.05); whereas pediatricians had significantly
higher posttest scores than the family physicians
(p<0.05). For both groups, posttest scores were
significantly higher than their respective pretest
scores (p<0.05).
All physicians had internet connection at work.
14 (60.9 %) of the family physicians and 7 (63.6%)
of the pediatricians said they had internet connec-
tion at home. 1 (4.3%) of family physicians and 2
(18.2%) of the pediatricians said that they read the
documents in the web site after the presentation
and 4 (17.4%) and 5 (45.5%) respectively read the
notes on the boards.
9 (39.1%) family physicians and 6 (54.5%)
pediatricians said, during the 10 weeks’ time in
between tests, they provided guidance to patients
according to these guideline principles.
This study shows that residents’ level of
knowledge on feeding non-breastfed children
6-24 months of age is quite low in our setting.
Both physician groups have benefited the guide-
line presentation and significantly increased their
level of knowledge, although this was more pro-
minent among pediatricians.
There is a huge number of literature on brea-
stfeeding, but the nutrition of non-breastfed chil-
dren under two years of age is not widely studied.
Our literature search revealed a limited number
of studies on caregivers’ level of knowledge and
habits on child nutrition. However, our search in
Turkish and English did not reveal any study that
1633
HealthMED - Volume 5 / Number 6 / 2011
is specifically interested in health care professi-
onals’ level of knowledge in this critical period.
Such studies are important to see the knowledge
level of people who would actually guide caregi-
vers about feeding and who are the main actors in
increasing public awareness and knowledge.
Our study also gives an idea about current CPG
use by the physicians. Almost one third of both
physician groups have said that they have read a
CPG before, however none of these were defined
CPGs. It is clearly seen that the awareness of physi-
cians of CPGs is limited. The integration of CPGs
into residency training and CME in Turkey has not
been discussed, but might be useful to improve evi-
dence-based practice by residents. Although there
are some published Turkish studies emphasizing
the importance of CPGs and their dissemination
[2-6]
, we have not encountered any Turkish study
on the role of CPGs on either knowledge levels of
physicians or their behavioral changes.
The effective introduction of CPGs could be
considered as an assurance of quality improvement.
However, it is also emphasized that even well con-
structed guidelines have little effect unless suppor-
ted by dissemination and implementation strategies
[7]
. A review of such strategies, by Grimshaw, re-
ports that changes in practitioner behavior in the de-
sired direction, were reported in 86% of the compa-
risons made. The review suggests that interventions
that were previously thought to be ineffective (e.g.,
dissemination of educational materials) may have
modest but worthwhile benefits [8].
It is observed that the physicians have been
more interested in reading printed materials com-
pared to electronic resources. The very low use
of electronic sources reflects that, electronic dis-
semination of knowledge would not be much of
benefit with this target group. Kahveci reports that
only 4,9% of family medicine residents in Turkey
spends more than 7 hours per week in internet for
medical use, whereas 7,4% spends no time at all
[9]
. On the other hand our study shows that reading
the notes on the boards are a better preferred way.
Kahveci reports that 56,7% of family physici-
ans say that they often used CPGs as a resource
to support their clinical decisions [9]. Although
it is not known if these are defined CPGs, in the
same study it is also reported that 66,4% of pri-
mary care physicians in Turkey don’t use guideli-
1634 Journal of Society for development in new net environment in B&H
nes published by the Ministry of Health although
they are aware that these are published. And 22%
frequently use these guidelines to support their de-
cisions. This is higher than the use of electronic
sources. These primary health care guidelines of
Turkish Ministry of Health are known to be posted
to all primary care physicians in Turkey as hard
copies. As it is also emphasized in this study, it is
noticed that physicians in Turkey are more likely
to use sources when they are printed and easily
available, instead of electronic routes.
There are a number of possible limitations of our
study. First, the questions asked to residents only
assess their theoretical knowledge and the actual
effect on the behavior changes could not be asse-
ssed in this study. Second, this study only assesses
the effect of an intermediate intensity dissemination
route on knowledge level of residents and does not
allow us to compare different dissemination routes
and compare the differences in effects. Third, this
study is done only in a research hospital in Ankara
and we don’t know if the results would be appli-
cable to other settings. However, strengths of this
study are that we reached almost all residents in
the target clinics so we have a good representation
of the target group; and the study gives us an idea
about knowledge level of residents on young child
nutrition which was not studied before. This study
also allows us to have a good basis for organizing
future research on CPGs’ role in CME and adds
knowledge to an untouched area in Turkey. The he-
alth services research finding of failure of routinely
translating research findings into daily practice [10]
encourages us to further investigate how we could
increase uptake of research findings by physici-
ans and end up with actual behavior change in our
settings, which has been weakly studied in Turkey.
Conclusions
Not every child has the opportunity to be bre-
astfed for appropriate period. The physicians sho-
uld be knowledgeable to guide caregivers about
how to nutrition a child in the most critical period
of up to 2 years of age. This study shows that the
residents in our setting have a very low level of
knowledge on this guidance, but benefit from gui-
deline presentation.
 HealthMED - Volume 5 / Number 6 / 2011

References Corresponding author

Rabia Kahveci,
1. Guiding principles for feeding non-breastfed chil- Ministry of Health Ankara,
dren 6-24 months of age. World Health Organizati- Numune Training and Research Hospital,
on. Accessed January 4, 2011. http://www.who.int/ Department of Family Medicine,
child_adolescent_health/documents/9241593431/ Ankara,
en/index.html Turkey,
E-mail: drrabiakahveci@yahoo.com
2. Turan JM, Bulut A, Nalbant H, Ortayli N, Erbaydar
T. Challenges for the adoption of evidence-based
maternity care in Turkey. Soc Sci Med. 2006; 62:
2196-204.

3. Erbay A, Bodur H, Akinci E, Colpan A. Evaluation

of antibiotic use in intensive care units of a tertiary
care hospital in Turkey. J Hosp Infect. 2005; 59:
53-61.

4. Onat A, Soydan I, Tokgozoglu L, et al. Guideline

implementation in a multicenter study with an esti-
mated 44% relative cardiovascular event risk re-
duction. Clin Cardiol. 2003; 26: 243-9.

5. Bersot TP, Palaoglu KE, Mahley RW. Managing

dyslipidemia in Turkey: suggested guidelines for a
population characterized by low levels of high den-
sity lipoprotein cholesterol. Anadolu Kardiyol Derg
2002; 2: 315-22.

6. Akalin HE. Surgical prophylaxis: the evolution of

guidelines in an era of cost containment. J Hosp
Infect 2002; 50: S3-7

7. Banait G, Sibbald B, Thompson D, Summerton C,

Hann M, Talbot S. Modifying dyspepsia manage-
ment in primary care: a cluster randomised con-
trolled trial of educational outreach compared with
passive guideline dissemination. Br J Gen Pract
2003; 53: 94-100.

8. Grimshaw J, Eccles M, Tetroe J. Implementing cli-

nical guidelines: current evidence and future impli-
cations. J Contin Educ Health Prof 2004; 24 Suppl
1: S31-7.

9. Kahveci R, Meads C. Is primary care evidence-ba-

sed in Turkey? A cross-sectional survey of 375 pri-
mary care physicians. Journal of Evidence-Based
Medicine 2009; 2: 242–251.

10. Ellis J, Mulligan I, Rowe J, Sackett DL. Inpati-

ent general medicine is evidence based. A-Team,
Nuffield Department of Clinical Medicine. Lancet
1995; 346: 407–10.

Journal of Society for development in new net environment in B&H 1635

HealthMED - Volume 5 / Number 6 / 2011
Nursing Students’ Perception of the
Internet in Turkey: A Questionnaire
Survey
Sevinc Tastan1, Birhan Tastan2, Emine Iyigun1, Hatice Ayhan1
1
Gulhane Military Medical Academy, School of Nursing, Ankara/Turkey,
2
Middle East Technical University, Institute of Applied Mathematics, Ankara/Turkey.
Abstract
Background: Rapid developments in the In-
ternet technologies led to changes in every aspect
of life. In case of nursing education, awareness
and use of the Internet becomes vital. Within this
framework nursing students are also required to
effectively use Internet to become competent.
Objective: The objective of the study was to
determine nursing students’ Internet usage tenden-
cies and perception of the Internet.
Methods: The study was conducted as a cross-
sectional survey among nursing students in a mili-
tary medical academy school of nursing in Ankara,
Turkey. A survey questionnaire was completed by
332 of 338 students at a military medical academy
school of nursing in Ankara. To collect the study
data, a data collection form requesting participant
demographic information and views about usage
and perceptions of the Internet was used.
Results: Students mainly access the Internet
for research. Moreover, almost all students think
of the Internet as a useful tool that contributes po-
sitively to their education. In addition, a great per-
centage of the students consider the Internet to be
a necessity for their nursing practice.
Conclusions: Students’ positive thoughts and
attitudes about the Internet present opportunities
for nursing curriculum development, and present
challenges for educators.
Key words: Nursing students; perception of
the Internet.
1636 Journal of Society for development in new net environment in B&H
Introduction
In Turkey, usage of Internet and related techno-
logies has expanded rapidly in recent years. The rate
of household Internet access is 30.0% (1). Widespre-
ad availability of Internet connections have brought
about new opportunities for almost every societal
entity, from commerce to education. Today many
Turkish universities are applying web-based educa-
tional programs, and e-commerce is increasing its
share within total commerce. This situation requires
every individual to be aware of and use the Internet
in every aspect of life. In the case of education, awa-
reness and use of the Internet becomes vital.
Within this framework, nursing students are
also required to effectively use the Internet to be-
come competent since capability to use informa-
tion technology is becoming an essential skill for
nursing students (2). Health care systems are beco-
ming more automated and complex, and demand
intensive knowledge of information technology;
thus, nurses must struggle with quickly changing
clinical environments while using their technolo-
gical skills, especially in the case of Internet usage
(3). Much research has been conducted regarding
Internet use by nurses in educational and professi-
onal life. The rate of nurses accessing the Internet
through home or work is increasing rapidly (4).
Mailing lists investigated as a medium of com-
munication among psychiatric nurses (5). There
is also a huge amount of research about different
aspects of e-learning in nursing education (6-9).
The aim of the study was to determine Internet
usage tendencies and perception of the Internet by
nursing students in a military medical academy sc-
hool of nursing in Ankara, Turkey.
 HealthMED - Volume 5 / Number 6 / 2011

Methods by the researchers with the aim of gaining insight

Design and setting
The study was conducted as a cross-sectional
survey among nursing students in a military medi-
cal academy school of nursing in Ankara, Turkey,
between 21 and 25 December, 2008.
In the school, there are 2 computer laboratories
which each hold 40 computers. In addition, stu-
dents can use their own personal computers. They
may also use computers in other campus areas and
in the hospital. Almost all computers at the cam-
pus and hospital area are connected to the Internet.
Students can access these computers at any time
out of the lecture hours.
At the nursing school, accessing Internet infor-
mation is a topic in the first lesson of the first year.
The theoretical part of the lesson is composed of 8
hours of discussing the importance of web-based
information, computer literacy, introduction to In-
ternet use, and Internet search techniques. Further,
10 hours of practicing is applied.
Participants
The survey population included all students at
the school of nursing, from the first to fourth ye-
ars (n=338). The sample contains 332 volunteer
students.
on the students’ perception of Internet, and to co-
llect the participants’ demographic information.
Data collection
The study was conducted after receiving writ-
ten ethical approval from the ethical committee of
the military education and research hospital, and
application permission of the nursing school.
Volunteer students were surveyed after recei-
ving necessary explanations about the aim of the
study and the application procedures. The survey
was filled by the participants in the classrooms
and took 5-10 minutes.
Statistical analysis
The SPSS 15.0 (Statistical Package of Social
Sciences Inc. Chicago, IL, USA) package pro-
gram was used to evaluate data after the data was
inputted into computers and necessary error con-
trols were performed. Descriptive statistics were
shown in numbers (n) and percentages (%) for the
variables obtained by counting and in mean plus
or minus the standard deviation ( X ± sd) for va-
riables obtained by measurement. The data were
analyzed by using Chi-square test, p<0.05 was set
as the level of statistical significance.

Data Collection Form

A data collection form was used. The form com-
prised eighteen multiple choice questions prepared
Table 1. Distribution of students according to some descriptive properties (N=332)
First Year Second Year Third Year Fourth Year
Variable (n=78) (n=74) (n=73) (n=107) P**
n (%)* n (%)* n (%)* n (%)*
Personal Computer Ownership
Yes 42 (53.8) 44 (59.5) 41 (56.2) 53(49.5)
No 36 (46.2) 30 (30.5) 32 (43.8) 54 (50.5) 0. 556
E- mail account ownership
Yes 60 (76.9) 74(100.0) 72 (98.6) 103 (96.3)
No 18 (23.1) - 1(1.4) 4 (3.7) 0.000
Having individual Internet access
Yes 35 (45.5) 39 (52.7) 26 (35.6) 45 (42.1)
No 42 (54.5) 35 (47.3) 47 (64.4) 62 (57.9) 0.211
X ± SD X ± SD X ± SD X ± SD P***
Being on-line weekly (in hours)
4.67± 4.48 5.09±4.47 5.29 ± 4.91 4.59 ± 4.40 0.717
*Column percentage, ** Chi-square, *** One-way Anova

Journal of Society for development in new net environment in B&H 1637

HealthMED - Volume 5 / Number 6 / 2011

Results As shown in Table 2, students (n = 321; 97.0%)

All study participants were female. The mean
age among the participants was 20.41 ±1.31.
The following results were obtained and are also
shown in tables.
As shown in Table 1, more than half of the
students own personal computers (PCs). Conside-
ring the distribution of nursing students who had
e-mail accounts, it was seen that the lowest ratio
belonged to first year students and the difference
between years was statistically meaningful. Time
students spent on-line in a week varied between
4.59 – 5.29 hours/week.
mainly access the Internet to conduct searches. Co-
mmunication is listed second among the reasons for
using the Internet (n = 262; 78.9%). Further, more
than half of the students (n = 261; 78.96%), rated
their Internet usage skills as “Good”. Among the stu-
dents who defined themselves as having “Beginner”
Internet usage skills, the highest ratio belonged to
the first year students (n=28; 35.9%). Almost all of
the students (n = 277; 83.4%) stated the necessity
for education regarding usage of Internet tools.
Table 3 states the barriers faced by the students
during their Internet usage. According to the cho-
ices of “No barrier” and “Knowledge insufficien-

Table 2. Distribution of students according to Internet usage aims and skills

First Year Second Year Third Year Fourth Year Total
Variable (n=78) (n=74) (n=73) (n=107) (n=332)
n (%)** n (%)** n (%)** n (%)** n (%)**
Internet Usage Aims*
Search 77 (98.7) 67 (90.5) 72 (98.7) 105 (98.1) 89 321 (97.0)
Communication 54(69.2) 58 (78.4) 61 (83.6) (83.2) 262(78.9)
Entertainment 38 (49.4) 58 (78.4) 57 (78.1) 74 (69.2) 227 ( 68.6)
E-commerce 1 (1.3) 9 (12.2) 7 (9.6) 22 (20.6) 39 (11.7)
Internet Usage Skills
Very Good - 4 (5.4) 5 (6.8) 6 (5.0) 15 ( 4.5)
Good 48 (61.5) 62 (83.8) 62 (84.9) 89 (83.2) 261 (78.6)
Beginner 28 (35.9) 8 (10.8) 6 (8.2) 12 (11.2) 54 (16.3)
Not using 2 (2.6) - - - 2 (0.6)
Necessity of an education regarding
usage of Internet tools
Yes 66(84.6) 66 (89.2) 60 (82.2) 85 (79.4) 277 (83.4)
No 12 (15.4) 8 (10.8) 13 (17.8) 22 (20.6) 55 ( 16.6)
*n increased because of multiple answers and analysis done over students answering “yes” only
** Column percentage

Table 3. Barriers against Internet usage*

First Year Second Year Third Year Fourth Year Total
Barriers (n=78) (n=74) (n=73) (n=107) (n=332) P***
n (%)** n (%)** n (%)** n (%)** n (%)**
No barrier 3 (3.8) 5 (6.8) 11 (15.1) 15 (13.9) 34(10.2) 0.049
Insufficient foreign language level 44 (56.4) 34 (45.9) 33 (45.2) 55 (50.9) 166 (49.7) 0.480
Time problems 34 (43.6) 32 (43.2) 35 (47.9) 52 (48.1) 153 (45.8) 0.868
Knowledge insufficiency to use the
31 (39.7) 11 (14.9) 5 (6.8) 18 (16.7) 65 (19.5) 0.000
Internet
* Analysis done over students answering “yes” only
** Row percentage and n increased because of multiple answers
*** Chi-square

1638 Journal of Society for development in new net environment in B&H

 HealthMED - Volume 5 / Number 6 / 2011

Table 4. Students’ view regarding Internet*

First Year Second Year Third Year Fourth Year Total
Variable (n=78) (n=74) (n=73) (n=107) (n=332)
n (%) n (%) n (%) n (%) n (%)
Usefulness of Internet
Yes 77 (98.7) 74(100.0) 73(100.0) 106(99.1) 330 (99.4)
No 1 (1.3) - - 1 (0.9) 2 (0.6)
Contribution of Internet to nursing
education
Yes 77 (98.7) 72 (97.3) 105 (98.1) 327 (98.5)
No - - 73(100.0) 1 (0.9) 1 (0.3)
No idea 1 (1.3) 2 (2.7) 1 (0.9) 4 (1.2)
Necessity for nursing practice
Yes 73(93.6) 68(91.9) 72(98.6) 91(85.5) 304 (91.6)
No 2 (2.6) 1 (1.4) 1 (1.4) 6 (5.6) 10 (3.0)
No idea 3 (3.8) 5 (6.8) - 10 (9.3) 18 (5.4 )
* The percentage of the rows was taken

cy”, there is a statistically meaningful difference
between class years (p<0, 05). The highest num-
ber of students indicating “No barrier” were fo-
und in the third and fourth years students (n = 11,
15.1%; n=15, 13.9%, respectively). The highest
number of students indicating “Knowledge insu-
fficiency” were found in the first year students (n
= 31; 39.7%). Almost all of the students (n = 327,
98.5%) stated that the Internet would contribute to
nursing education. Moreover, 91.6% of the stu-
dents (n = 304) consider the Internet as a necessity
for nursing practices (Table 4).
Discussion
In this study that investigates the perception of
nursing students regarding Internet usage, it was
discovered that almost half of the students own
PC’s. In the literature, daily time spent online is
stated as changing from less than 30 minutes to
4 hours (10-12). In a study on pathological Inter-
net use among university students, the time spent
accessing the Internet was categorized as 1 to 4
hours per week by 37.7% of respondents, 5 to
9 hours per week by 25.7%, 15 to 19 hours per
week by 5.9% and more than 20 hours per week
by 13.2% (13). On the other hand, in our study
students stated that they access the Internet 4.87 ±
4.54 hours/ week, which corresponds to 41.7 mi-
nutes per day. This slightly shorter time compared
to the literature could be due to the fact that these
students belong to a military school and have less
time for personal activities. Additionally, this re-
sult correlates with answers given by students as
time problems being barriers to Internet usage
In the literature, the main services used by
students in general and for nursing students were
listed as www, search, and communication (12,
14). Uçak (2007) reports courses and homework
assignments, personal interest and e-mail as the
purposes for using the Internet among a group of
university students in Turkey. In another study
that focused on the fourth-year medical students
in Turkey, it was found that students use the In-
ternet mostly for communication and visiting me-
dical web sites (16). A study on computer and In-
ternet use in a military medical school stated that
the most common reason for Internet usage was
communication (17). Similar to the literature, the
students in our study primarily use search and co-
mmunication services. The school of nursing is a
military school and lectures are given on an inte-
ractive basis. This requires students be prepared
before the lectures. We believe that this is the main
reason for having a high rate of Internet searches.
Studies on university students reveal that Inter-
net usage affects their education positively (18,19).
Metzger et al. (2003) declared that university stu-
dents rely heavily on the Web for information, and

Journal of Society for development in new net environment in B&H 1639

HealthMED - Volume 5 / Number 6 / 2011
students believe that their reliance on the Web for
information will increase in the future (19). Al-
most all of the students in our survey find the In-
ternet to be a useful tool and that it contributes to
their education. Further, a great majority find that
the Internet is a necessity for their nursing prac-
tice. Nursing education includes a program that
contains both theoretical and practical elements.
For this reason, nursing students, in addition to
preparing for theoretical lessons, must follow de-
velopments in patient care closely to complete the
practical part of their education; the Internet is one
way to accomplish these tasks.
Studies regarding Internet usage state that
students’ proficiency in Internet usage differs. It
is “basic” in the early years and becomes better
in the following years (2,14,15,20-22). When In-
ternet usage skills were considered, the first year
students defined themselves as “beginners” as
compared to other students in the study. In addi-
tion, majority of the students define themselves as
having “Good” Internet usage skills. Our findings
are similar to the literature. This can be explained
by students’ increased experience in using Internet
over time.
Effective Internet usage requires education.
Education on Internet usage does not only develop
computer literacy, it is also important in simulta-
neously advancing students’ professional careers.
Even in the simple cases, lack of information te-
chnology literacy leads a limiting factor for the
roles of nurses. As Courtenay et al. (2007) stated,
an inability to prepare computer generated pres-
criptions stopped nurses’ from prescribing medi-
cation. Rzymski et al. (2006) mention the need for
education on Internet use because of the correlati-
on between general computer skills and medical
search skills. A great percentage of the students in
our study also emphasized the need for education
regarding Internet usage. Further, students emp-
hasized that the Internet was a necessity in their
nursing practice.
In the literature, barriers to Internet usage were
defined as time, availability and cost of compu-
ters, and lack of information about Internet usage
(25,26,27). The main barriers stated by the stu-
dents in our study were time problems and, a nota-
bly different result than that found in the literature,
insufficient foreign language levels.
1640 Journal of Society for development in new net environment in B&H
When considering the results obtained from the
survey, several topics require more emphasis. Re-
garding education, the students’, positive attitudes
regarding the Internet must be considered when
determining curriculum changes. Internet educa-
tion and use may prompt students to better con-
form to the curriculum, and this may contribute to
the success of the students and lead to achieving
curriculum objectives. In this respect, the results
suggest that detailed courses are required not only
to teach students how to use the Internet, but also
to teach them how to use the Internet effective-
ly. In addition, course contents could be revised
to include Internet related topics. This will also
prepare students for more automated clinical en-
vironments. In addition, to access more informa-
tion on the Internet, students must learn a foreign
language, which is again related to the curriculum.
Limitations of study
The generalization of the study results has li-
mitations due to several factors. This is a descrip-
tive study, which was conducted among boarding
military nursing students. The fact that they are
boarding students may affect their daily usage of
the Internet. As a result, the outcomes of the study
may not be able to reflect the perception and Inter-
net usage of nonmilitary and nonboarding nursing
students. Additionally, it must be noted that the In-
ternet usage may be different for students across
different years and different periods.
Conclusion
Students use the Internet in their daily and edu-
cational lives. Boarding military nursing students
express the importance of the Internet in their in-
dividual and professional development. Recently,
development in information technology has beco-
me important in all professions, including nursing.
By educating nursing students, an increase in the
Internet usage efficiency will positively affect the-
ir professional development. For this reason, nur-
sing students must be given access to and be enco-
uraged to use the Internet as a part of their learning
activities.On the educational ground, curriculum

changes must be considered to reflect positive atti-
tudes of the students regarding Internet. Educators
must also consider themselves in acquiring new
Internet technologies and including these techno-
logies in classrooms.
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Corresponding author
Sevinc Tastan,
Gulhane Askeri Tip Akademisi Hemsirelik Yuksek
Okulu,
Etlik/Ankara,
Turkey,
E-mail: stastan@gata.edu.tr

1642 Journal of Society for development in new net environment in B&H


An investigation into the knowledge
about the menstruation period
among the female university students
at Eastern Black Sea region of Turkey
Birsel Canan Demirbağ1, Zeynep Güngörmüş2
1
Karadeniz Technical University Health High School, Trabzon, Turkey,
2
Atatürk University Faculty of Health Sciences, Erzurum, Turkey.
Abstract
Aims: The aim is to assess the knowledge abo-
ut the menstruation period among the female stu-
dents at Eastern Black Sea Region of Turkey
Methods: This study was designed as a retros-
pective and descriptive survey. A questionnaire
was prepared and administered to 1125 subjects
on a face-to-face basis between March and April
2009. The questionnaire contained 18 items and
was designed by the authors and pilot tested on 24
students. It elicited a variety of information about
menstruation: The questionnaire also elicited stu-
dents’ socio-demographic information. Students
were informed about the aims of the study, and
they participated voluntarily in the study. Percen-
tages were used in the evaluation of the data.
Results: Female students from the 17-28 age
group participated in this research. Conclusions
of this study showed that of the 1125 female stu-
dents, 70.3% could give the right definition of the
menstruation. In addition, of the female students,
93% think that ‘it’s not acceptable to have a sexu-
al intercourse in the menstruation period’, 44.4%
define ‘menstruation as a flow of dirty blood from
the body’, 65.6% don’t accept ‘the same organ
with which they menstruate and with which they
urinate’, 27% ‘don’t have a bath while in menstru-
ation’, 27.5% have pain during their menstruation,
60% ‘use pills for the ache’. Besides, 98% look
forward to having some information about the
problems before and after menstruation, and about
the physiology and anatomy of menstruation.
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
Conclusions: This study showed that female
university students urgently need more informati-
on about the ‘hygiene and menstruation’.
Key words: Menstruation, hygiene, knowled-
ge, female student,
Introduction
Menstruation or period is a woman’s monthly
bleeding. Every month, female body prepares
for pregnancy. If no pregnancy occurs, the ute-
rus sheds its lining. The menstrual blood is partly
blood and partly tissue from inside the uterus, or
womb. It passes out of the body through the vagi-
na. Periods usually start around 12 years of age and
continue until menopause at about age 51. Most
periods last from three to five days. Most females
experience some degree of pain and discomfort
in their menstruation period [1,2]. Women recei-
ve their knowledge of menstruation mainly from
their mothers, schoolteachers, school nurses or fri-
ends [3,4]. Mothers and other school staff or frien-
ds might not have enough and accurate menstrual
knowledge [5,6]. In an Islamic country, the subject
of menstruation and puberty hygiene is rarely dis-
cussed at home as well as at schools. This problem
is observed particularly in more traditional and
poorly educated families, which could be main-
ly due to some cultural restrictions preventing the
flow of correct and sufficient information to the
females [7,8]. The combination culture and Isla-
mic rules has had a strong impact on the restricti-
1643
HealthMED - Volume 5 / Number 6 / 2011

ons of discussing sex education and related issues
for females via schools and mass media. This has
prevented the flow of accurate and sufficient infor-
mation about puberty hygiene resulting in some
incorrect perceptions and beliefs about menstru-
ation hygiene among young girls in this country.
This fact is strongly observed in many aspects of
their lives, including their level of education, heal-
th status, and well being [7,9,10]
Aims of the study
The issue of menstruation can be very impor-
tant for women’s health. The main aim of this
study is to assess the level of knowledge about the
menstruation period among the female university
students at Eastern Black Sea Region of Turkey.
The specific objectives of the study are to:
-- Identify the menstruation and problems in
menstruation period,
-- Investigate the hygiene of menstruation,
-- Determine the physiology and anatomy of
menstruation,
-- Investigate the use of materials and pills
during the period,
-- Assess student’s needs about menstruation.
Materials and Methods
This study was designed as a retrospective and
descriptive survey. The participants of this study
were chosen with probability sampling methods
during the March-April period of 2009. The fe-
male students were from the 17-28 age range. The
questionnaire was administered to 1125 female
students on a face-to-face basis. The question-
naire consisted of 18 questions which included
questions about students’ socio-demographic
background, definition of the menstruation, hy-
giene of menstruation, physiology and anatomy of
menstruation, symptoms of menstruation, use of
materials and pills during the period, assessment
of students’ needs about menstruation. Data that
were obtained were entered in SPSS 10.0. Per-
centage, frequency and chi-square test were used
in data analysis.
Results and Discussion
Definitions of menstruation are shown in Table
1. As can be seen in Table 1, 92 % of the students
were between 17-19 years, 29.7% of the students
described menstruation as a physiological activity
of the human body, 44.4% of the students said that
it was the flow of the dirty blood, and 25.7% of the

Table 1. Distribution of information regarding students’ age and menstruation

Information regarding students' age and menstruation n %
17-19 1035 92.0
Age 20-22 60 7
23 and above 30 1
Physiological activity of human body 335 29.7
Definition of
Flow of the dirty blood 500 44.5
Menstruation
No comment 290 25,8
Fullness in breast 109 9.7
Aching groin 229 20.4
Symptoms of Nervous disorder 39 3.5
Menstruation Bowel problems and nausea 118 10.4
Pain 310 27.5
No menstrual problems 320 28.5
Yes (n,%) No(n,%)
Knowledge on
Same organ vagina and urine 386 34.3 739 65.6
the Anatomy
Intercourse in menstruation 75 6.6 1050 93.3
and Physiology
Same organ that baby is born and menstruation 840 74.6 285 25.3
of Menstruation
The organ vagina is both sexual intercourse and menstruation 881 78.3 244 21.6

1644 Journal of Society for development in new net environment in B&H


students stated that they didn’t know anything abo-
ut this question. There was a significant relation-
ship between age and descriptions of menstruati-
on. According to this finding, 70.3% of the female
students did not have appropriate knowledge abo-
ut menstruation. This means that their knowledge
was not enough for a healthy behavior. A similar
result was found in a study by Poureslami and
Osati-Ashtiani. Their study included 250 students
and they found that 75% of the students had insu-
fficient knowledge [7]. According to the results of
different studies on the issue carried out in diffe-
rent cities in Turkey, Erdoğan and Işık [11] found
that 14.15% of the girls experienced problems. On
the other hand, Yorulmaz [10] found that 32% of
the girls experienced problems. According to the
results of these studies, female students were in
need of information about their menarche.
It has been found that this issue is a taboo
among the females, that it should not be spoken
openly, and that it is seen as a prohibited topic
which should be kept as a secret in some cities of
Turkey [12]. The result of this research makes us
think that core of this issue is cultural.
The typical symptoms of menstruation were
examined (Table 1). The answers were as follows:
27.5% pain, 20.3% aching groin, 10.4% bowel
problems and nausea. The responses to the qu-
estion ‘Do you have a shower when you are in
menstruation?’ showed the following distribution.
73% of the respondents said ‘yes’ and 27% said
‘no’. On the other hand, the distribution of the res-
ponses to the question ‘Why do you take a shower
in your menstruation period?’ is as follows: 57%
of the students said ‘for relaxation’, 13% said ‘to
get rid of the risk of infection’. A study carried out
in Tehran with 250 women showed that 51,1%
of the females in the 17-18 age range took baths
8 days after their menstruation period [7]. These
unhealtty behaviors about menstrual period, could
increase their chances of getting certain infections
as well as discomforts of secondary dysmenorr-
hea, which were also shown by other studies [13].
The responses to the question “Is that the same
organ which you menstruate and which you urina-
te?” showed the following distribution: 65.6% of
the students said ‘no’, and 34.3% said ‘yes’. The
distribution of the responses to the question ‘Do
you have sexual intercourse when you are in men-
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
struation period?’ is as follows: 93% of the students
said ‘no’ and 7% ‘yes’. Similar studies have found
that young girls complete their menarche without
having enough knowledge on menstruation [14,15].
74.6% of the respondents think that ‘it is the same
organ that a baby is born and having blood flow in
this way’, 65.6% of students answered different or-
gans vagina and urine, 21.6% of the students were
not aware of the organ – vagina – is both sexual
intercourse and the menstruation (Table 1).
‘During your menstruation the materials used
are 18% prepared fabric at home (Cloth or towel),
82% cotton-ped. In a study by Tortumoğlu and
Özyazıcıoğlu [16], it was found that 44.5% of
the students used cotton-pads. In another study,
Erdoğan and Işık [11] found that 4% of the students
used cloth or towel and 42.68% used pads and cotton
pads. The findings of our study show similarity to
the findings of those studies. In our study, 60% of
the students said they took pills for the ache while
they were menstruating. Of these, 62,1% stated that
their family members or friends bought the medica-
tions for them, and 37,9% stated that they saw their
doctors and obtained the medications through their
prescriptions. In a study by Demir et al.[17], it was
found that 41% of the students used pain killers du-
ring their menstruation; 50% of them received the
drugs from their families, and the other 50% bought
them from the counter without prescription.
Besides, participants showed a desire to take
lessons in their schools. 18% of students wanted
to take lessons about the physiology or anatomy
of menstruation, 34% about menstruation hygie-
ne, and 48% about sexual life. The results of the
recent studies showed the importance of educating
female students about the issue at schools. Many
young girls also identified their peers as the best
source of sharing and talking about their problems
[2,18]. These studies show that girls should be gi-
ven both medical and psychological education on
menstrual hygiene.
Conclusion
These findings indicate a lack of sufficient in-
formation about menstruation and menstrual hygi-
ene. This results in incorrect and unhealthy beha-
vior during their menstrual period.
1645
HealthMED - Volume 5 / Number 6 / 2011
Recommendations
At some university, presently there are not any
lessons related to medical care and sexuality. Every
faculty or department should educate their students
in their own specialty according to its curriculum.
However, it should be borne in mind that in this
educational period students have to get the right in-
formation about their own bodies. Equipped with
some information from friends, right or wrong, the
youth grow up and unfortunately they ignore their
own problems. Wrong information yields wrong
results. For that reason, while developing the edu-
cational curricula at Universities, health education
professionals should take into consideration the
association between a person’s beliefs and attitudes
and the changes in her behavior. It is the only solu-
tion to a healthier generation.
References
1. Beek JS. (1996). Puberty and dysmenohea treat-
ment. Novice’s Gynecology. Philadelphia:Wiiliams
and Wilkins; 771-80.
2. Fayeke O, Egade A. (1994) The chareacteristics of
the menstrual cycle in Nigerian school girls and
the implications for school health programs. Alrica
Journal Med Sci., 23:13-4
3. Beausang C, Razor A. (2000). Young western wom-
en’s experiences of menarche and menstruation.
Health Care Women International, 21:517-528.
4. Remberck G, Gunnarsson R. (2004) Improving pre
and postmenarcheal 12-year-old girls attitudes,
desires and behavior in women. Arch. Sex Behav.,
32:155-163
5. Reilly J, Kremer J. (1999)A qualitative investiga-
tion of women’s perceptions of premenstrual syn-
drome: implications for general practioners. Br. J.
Gen Pract., 49:783-786
6. Marvan M, Cortes-İniestra S, Gonzales R. (2005)
Beliefs about and attitudes toward menstruation
among young and middle-aged Mexicans. Sex
Roles, 53:273-279.
7. Poureslami M, Osati-Ashtiani F. (2002) Attıtudes
of female adolescent about Dysmenorrhea and
menstrual hygıene ın Tehran suburbs. Arch Iranian
Med, 5(4): 219-224.
8. Çil, G. ( 1996). Evaluation of the education of moth-
ers about menarche and menstruation hygiene. Is-
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tanbul University Institute of Health Sciences Mas-
ter of Science thesis. Istanbul
9. Şahintürk, H. (1999). Menarche and menstruation
in girls studying in primary education in hygiene
knowledge and practices related to identification.
Istanbul University Institute of Health Sciences
Master of Science thesis. Istanbul
10. Yorulmaz, A. (2000). Women in the obstetrics de-
partment in Special Ahu Hetman Hospital in Mar-
maris to determine their level of knowledge about
menarche and menstruation. I. International VIII.
National Nursing Congress Book. 521-524. Antalya
11. Erdoğan E, Işık A. (1991). Adölesan kızların
menarş deneyimleri ve menstrual siklus özel-
liklerine ilişkin bir çalışma. Ege Üniversitesi
Hemşirelik Yüksekokulu Dergisi, 7,31-49.
12. Yörükoğlu, A.(1998). Çocuk Ruh Sağlığı. Özgür
yayınları. İstanbul.
13. Secerino SK and Moline M.E. “Premenstru-
al Syndrome Identification and Management”.
Drugs.1995: 71-82.
14. Marvan, M.L., Vacio, A.&Espinoza-Hernandez,
G. (2001). Acomparison of menstrual changes ex-
pected bypremenarcheal adolescent and changes
actually experienced by post-menarcheal adoles-
cent in Mexico. School Health. 71, 458-461.
15. George, S., Sharma, N., Sahay, R. (2001). Socio-
cultural aspects of menstruation in an urban slum
in Delhi, İndia. Reprod Health Matters, 9,16-25.
16. Tortumluoğlu G, Özyazıcıoğlu N. (2005). The de-
scription of experiences and age at menarche in
rural areas in Turkey. ICUS NURS WEB J, İssue
20, January-March 2005.
17. Demir C, Kadayıfçı O, Vardar A, Atay Y. (2001)
Dysfunctional uterine bleeding and other men-
strual problems of secondary school students in
Adana. Journal of Pediatric and adolescent Gy-
necology, 13(4):171-175.
18. Drank S, Uenkafa RP (1995) A study on menstrual
hygiene among rural adolescent girls. Indian J
Med. Sci.45:139-43.
Corresponding author
Zeynep Güngörmüş,
Atatürk University Faculty of Health Sciences,
Erzurum,
Turkey,
E-mail: gungormusz@yahoo.co.uk
Journal of Society for development in new net environment in B&H
 HealthMED - Volume 5 / Number 6 / 2011

Free radicals and intrinsic skin aging:

basic principles
Raja Dahmane, Borut Poljsak
University of Ljubljana, Faculty of Health Studies, Slovenia.

Abstract cantly different among different populations, as

well as among different anatomical sites even wi-
Generally speaking intrinsic aging depends on thin a single individual (Figure 1).
time but in fact it depends rather on free radical
metabolism kinetics as well as on efficacy of the
skin cells defence and repair systems. Although
the fundamental mechanisms of skin aging are
still poorly understood, research points towar-
ds reactive oxygen species (ROS) as one of the
primary determinants of skin aging. It is probable
that oxidative damage is the single most damaging
contributor to skin aging leading to nuclear and
mitochondrial DNA damage, telomere shortening,
protein glycosylation, lipid and protein oxidation,
collagen and elastin degradation, down-regulation
of collagen synthesis, increased expression of ma-
trix metalloproteinases, neovascularization. Radi-
cal-scavenging antioxidants can neutralize ROS
and antioxidant status could play an important role
Figure 1. Picture shows the difference between
in intrinsic skin aging.
wrinkle formation and pigmentation on the sun
Key words: Intrinsic skin aging, Free radicals,
exposed (face, neck) and non-exposed areas (pic-
Reactive Oxygen Species, Oxidative Damage
ture provided by Ana Benedicic, MD, MSc)

There have been many theories trying to explain

Introduction
the aging process, yet the most plausible of them
concentrates on the DNA damage and the conco-
Skin aging appears to be the result of two types
mitant repair process which induce genome-wide
of aging, “intrinsic” and “extrinsic”. “Intrinsic”
epigenetic changes leading to cell senescence, loss
structural changes occur as a natural consequ-
of proper cell function and genomic aberrations
ence of aging and are genetically determined.
(5). The reversible nature of epigenetic modificati-
However it is very difficult if not impossible to
ons (primarily changes in chromatin) theoretically
separate “intrinsic” aging from a wealth of other
offers an opportunity for therapeutic intervention.
factors clearly contributing to aging like smoking,
Whether many post-translational mechanisms of
sun exposure, alcohol consumption, dietary habits
skin aging (protein glycation, proteolytic producti-
and other environmental and life-style factors (1,
on of toxic peptides, loss and uncoupling of recep-
2). Actually, the hereditary genetic influences are
tors, inflammation with increased degradation of
considered to contribute to aging not more than
skin extracellular matrix, etc.) are independent pat-
3%, making epigenetic and post-translational me-
hways or a consequence of DNA damage and resul-
chanisms the most important pathways of aging
tant epigenetic changes remains to be established.
(3, 4). Consequently, the rate of aging is signifi-

Journal of Society for development in new net environment in B&H 1647

HealthMED - Volume 5 / Number 6 / 2011
The “intrinsic” (genetically determined) and the
“extrinsic” (UV- and toxic exposure mediated) skin
aging processes are overlapping and strongly rela-
ted to the increased generation of free radicals in
the skin. Both skin aging processes are linked to the
increased oxidative stress as a common underlying
mechanism. Oxidative damage may play a central
role in cellular aging (6). It is probable that oxidati-
ve damage is the single most damaging contributor
to skin aging leading to nuclear and mitochondrial
DNA damage, telomere shortening, protein glyco-
sylation and lipid and protein oxidation, collagen
and elastin degradation, down-regulation of colla-
gen synthesis, increased expression of matrix me-
talloproteinases, neovascularization, etc (7-9).
The hallmarks of intrinsic aging are fine wrin-
kles, thin and transparent skin, loss of underlying
fat leading to hollowed cheeks and eye sockets as
well as noticeable loss of firmness on the hands and
neck, dry skin that may itch, inability to sweat suffi-
ciently to cool the skin, graying hair that eventually
turns white, hair loss, unwanted hair, and thinning
of nail plates (9). Overall, loss of cells and extra-
cellular matrix degradation are the most prominent
features of chronologically aged skin.
The problem of intrinsic skin aging research is
in the fact that most information relating to intrin-
sic aging process comes from tissues other than
skin. Nevertheless, intrinsic aging is based on ge-
neral biological processes that apply more or less
to all proliferating cells and terminally differentia-
ted cells as well (10). It is widely accepted that in-
trinsic aging is caused primarily by the build-up of
damage due to free radical reactions as a by-pro-
duct of cellular metabolism and by ROS-induced
damage to critical cellular macromolecules (6).
Metabolism, Reactive oxygen species (ROS)
and the oxidative stress
Generation of ROS is believed to play a major
role both in chronologic and extrinsic skin aging.
The problem of intrinsic factors contributing to skin
aging is the fact that some of them (e.g. free radi-
cals) are an essential part of metabolism we cannot
live without. Intrinsic aging depends on time and on
free radical metabolism kinetics as well as on effi-
cacy of the defense and repair systems. The changes
1648
in the skin occur partially as the result of cumulative
endogenous damage due to the continuous forma-
tion of ROS, which are generated by oxidative cel-
lular metabolism (11). Despite a strong antioxidant
defense system, damage generated by ROS affects
cellular constituents such as membranes, enzymes,
and DNA (Figure 2).
Figure 2. Schematic diagram of the electron
transport chain in the mitochondria
In order to understand basic principles of intrin-
sic skin aging the biochemistry of free radical for-
mation is briefly presented. There is no doubt that
oxygen (O2) is essential for life (12). Humans and
other aerobes need O2 because they evolved elec-
tron transport chains and other enzyme systems
utilizing O2 and can tolerate its toxic by-products
by antioxidant defense. The predecessors of the
anaerobic bacteria that exist today followed the
“blind” evolutionary path of restricting themselves
to environments devoid of O2. It could be argued
that the evolution of multi-cellular aerobes and anti-
oxidant defense mechanisms are intimately related
(13). Even present-day aerobes suffer oxidative
damage. Free radicals, important for living organ-
isms, include hydroxyl (OH˙), superoxide (O2˙-),
nitric oxide (NO˙), thyl (RS˙) and peroxyl (RO2˙)
(14). Peroxynitrite (ONOO-), hypochlorous acid
(HOCl), hydrogen peroxide (H2O2), singlet oxygen
(1O2) and ozone (O3), are not free radicals but can
easily lead to free radical reactions in living organ-
isms. The term reactive oxygen species (ROS) is
often used to include not only free radicals but also
the non-radicals (1O2, ONOO-, H2O2, O3). Reactive
oxygen species are reactive molecules that contain
the oxygen atom (14). The essence of metabolic
energy production is that food is oxidized: in the
Journal of Society for development in new net environment in B&H

process the electrons are accepted by electron car-
riers, such as nicotinamide dinucleotide (NAD+)
and flavins (flavin mononucleotide FMN and flavin
adenine dinucleotide FAD). The resulting reduced
nicotinamide adenine dinucleotide (NADH) and
reduced flavins (FMNH2 and FADH2) can be re-
oxidized in mitochondria, producing large amounts
of ATP (15).
There are two main sources of ROS: mitochon-
drial sources (which play the principal role in ag-
ing) and non-mitochondrial sources (which have
different, sometimes specific, roles especially in
the pathogenesis of age-related diseases). Mito-
chondrial sources are represented by the electron
transport chain and the nitric oxide synthase re-
action (16). The rate of mitochondrial respiration
is responsible for the rate of generation of ROS
- this characteristic is consistent with the observa-
tion that the higher metabolic rates an organism
has, the shorter maximum lifespan it presents (17),
with some exception to this rule. Fenton reaction
is an example of the non-mitochondrial source
of ROS. The H2O2 degrading Fenton reaction is
catalyzed by the free iron bivalent ions and leads
to the generation of OH˙. It should be taken into
account that body’s content of iron increases with
age (18, 19). Sources of H2O2 could be mitochon-
dria [superoxide dismutase reaction, peroxisomes
(acyl-CoA oxidase reaction) and amyloid β of
senile plaques (superoxide dismutase-like reac-
tions)] (16, 20). Sources of superoxide (O2-˙) are
mitochondria, microsomes which contain the cy-
tochrome P450 enzymes, the respiratory burst of
phagocytic cells and others.
Most estimates suggest that the majority of
intracellular ROS production is derived from mi-
tochondria (21). However, some authors question
that mitochondria are the main source of ROS in
mammalian cells as there is a lack of firm experi-
mental evidence (22). At least in the liver, peroxi-
somes and endoplasmic reticulum have a greater
capacity to produce ROS (22). The mitochondrion
is an essential organelle, playing a central role in
much of the metabolism. As the site of oxidative
phosphorylation, mitochondria provide the ma-
jority of energy in the form of ATP, which fuels
cellular processes. An electron transport chain
(ETC) in mitochondria couples a chemical reac-
tion between an electron donor (such as NADH)
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
and an electron acceptor (such as O2) to the trans-
fer of H+ ions across a membrane, through a set
of mediating biochemical reactions (23). These H+
ions are used to produce adenosine triphosphate
(ATP), the main energy intermediate in living or-
ganisms, as they move back across the membrane.
Electron transport chains are used for extracting
energy from sunlight (photosynthesis) and from
redox reactions such as the oxidation of food. The
basic mechanism that transforms food into the en-
ergetic ATP is the same in all aerobic organisms.
It includes the process of mitochondrial oxidative
phosphorylation (23). All eukaryotic organisms
(and most prokaryotic ones) digest food molecules
and extract energy from food using almost identi-
cal metabolic processes. A by-product of cell respi-
ration in mitochondria is the formation of ROS due to
electron leakage in the electron transport chain during
oxidative phosphorylation (24). The site of oxidative
phosphorylation in mitochondria provides the ma-
jority of energy in the form of ATP, which fuels
cellular processes.
The production of mitochondrial superoxide
radicals occurs primarily at two discrete points in
the electron transport chain namely, at complex I
(NADH dehydrogenase) and complex III (ubiqui-
none–cytochrome c reductase) (16). Under normal
metabolic conditions, complex III is the main site
of ROS production (25). With respect to human ag-
ing, the weak point of this otherwise elegant system
lies in the formation of the free radical semiquinone
anion species (Q-) that occurs as an intermediate in
the regeneration of coenzyme Q (16). Once formed,
Q- can readily and non-enzymatically transfer elec-
trons to molecular oxygen with the subsequent gen-
eration of a superoxide radical. The generation of
ROS therefore becomes predominantly a function
of metabolic rate and, as such, the rate of living
can be indirectly translated to a corresponding rate
of oxidative stress (26). Analyses of the control of
activity of the oxidative phosphorylation-electron
transport chain suggest that the system appears to
be primarily pull regulated, rather than push regu-
lated (27): putting in more NADH at the front end
does not drive up respiration but, restricting the
availability of ADP, shuts it down. When there is
an abundant, non-limiting amount of ADP avail-
able, mitochondria are said to be operating in state
3 respiration. When ADP is absent, there can be
1649
HealthMED - Volume 5 / Number 6 / 2011
no production of ATP and the proton transduction
mechanism becomes backed up, which is called
state 4 respiration. Since the proton-motive force
declines in state 3 compared to state 4 respiration,
free-radical production would be expected to be
considerably elevated in state 4 compared to state
3. This effect is interesting because it is actually the
exact opposite of the postulated link between ener-
gy metabolism and free-radical production (aging)
(27). The flux through the electron transport chain
is relevant to the aging process because it is related
to the rate of the production of ROS. Small reduc-
tions in metabolic flux through the electron trans-
port chain occur at the cost of increased upstream
substrate levels (28). This increased concentration
of reduced upstream substrates allows a larger gen-
eration of ROS (16). Aerobic metabolism requires
constant removal of excess electrons through the
reduction of oxygen (23). The need for oxygen
as an electron acceptor is the sole reason that we
breathe air. Inevitable by-products of this process
are O2-˙, H2O2 and HO˙. This happens mainly by
complexes I and III (27) of the electron transport
chain, the most important sources of endogenous
free radicals. About 1012 oxygen molecules are pro-
cessed by each human cell daily and the leakage of
partially reduced oxygen molecules is about 1–5%,
yielding about 2x1010 superoxide and hydrogen per-
oxide molecules per cell per day (29). Based on the
amount of oxygen damaged and altered nucleotides
detected in human urine, it has been estimated that
approximately 2x104 oxidative DNA lesions occur
per human genome every day (30). Assuming that
the repair of each excised adduct involves replac-
ing one to five nucleotides, then oxygen-induced
damage to DNA results in the replacement of 2x105
nucleotides per human cell per day (31). Each hu-
man cell receives 10.000 ROS hits per day, which
equals 7 trillion insults per second per person.
Estimates of how much oxygen reacts directly
to generate free radicals vary (27). However, typi-
cally cited values are around 1.5–5% of the total
consumed oxygen (32, 33). These estimates have
been questioned by Hansford et al. (34) and Stan-
iek and Nohl (35, 36), which suggested that H2O2
production rates were less than 1% of consumed
O2. Yet, even if we accept a conservative value of
0.15%, this still represents a substantial amount
of free radicals (27). As it was already mentioned,
1650
the rate of generation of H2O2 is dependent on the
state of the mitochondria as determined by the
concentration of ADP, substrates and oxygen (37).
A step increase in electron-transfer chain activ-
ity produces a linear increase in ATP production
but an exponential increase in ROS formation. The
cells can produce the same amount of ATP for less
ROS by having a greater number of mitochondria
running at a lower rate of electron-transfer chain
activity. Heart cells, for example, have thousands
of mitochondria, while skin cells have less mito-
chondria per cell. Whether skin cells suffer more
ROS induced damage is to our knowledge not yet
established.
Oxidative damage and intrinsic skin aging
Skin cells are constantly exposed to ROS and oxi-
dative stress from exogenous and endogenous sourc-
es. It has been found that in aged rat skin the oxidized
lipid phosphatidylcholine hydroperoxide (PCOOH)
increases from 3.46 ±1.02 μmol/PC mol at 6 months
to 7.14 ±1.63 μmol/PC mol at 24 months. The free
7-hydro-peroxycholesterol (ChOOH) content also in-
creased from 22.83 ±3.97 at 6 month to 42.58 ± 16.59
μmol/ free Ch mol at 24 months. The TBARS (Thio-
Barbituric Acid Reactive Substances, harmful sub-
stances formed by lipid peroxidation, and detected
by the TBARS assay, using thiobarbituric acid as a
reagent) content increases from 4.71 ± 1.53 nmol/ mg
protein at 6 months to 11.10 ± 2.05 nmol/ mg protein at
30 months. The oxidized DNA in rat skin also increase
with age and reach the level of 2.04 ± 0.27 8-oxoG/
105 dG at 30 months of age compared to 1.67 ± 0.16
8-oxoG/ 105 dG at 6 months of age. Results suggest
chronic accumulation of oxidative damage with age
(38-40). Similar results were obtained from the skin of
HRS/J hairless mice revealing an increase in lipid
peroxides as the skin gets older and in photoaged
skin (10.086±0.70 η MDA/mg and 14.303±1.81 η
MDA/mg protein, respectively), although protein
oxidation was only verified in chronological aged
skin (15.449±0.99 η protein/mg protein). The dif-
ference between both skin types is the decay in the
capacity of lipid membrane turnover of chrono-
logically older skin (41).
It seems that oxidative damage is the major
cause of DNA damage (15). Not only that the
Journal of Society for development in new net environment in B&H

ROS production increases with age but the ability
of human skin cells to repair DNA damage steadi-
ly reduces with years (42). Reducing free radical
production in the first place is far more efficient
than trying to neutralize free radicals after they
have been produced.
The energy required by skin cells comes from
three sources: mitochondrial oxidative phos-
phorylation, glycolysis and creatine/phosphocre-
atine system. All three major energy sources are
affected by intrinsic and extrinsic skin aging and
offer potential entry points for intervention strate-
gies to decelerate the skin aging process (10). Due
to impaired mitochondria with age, less energy is
produced by mitochondrial oxidative phosphory-
lation although the number of mitochondria does
not change with age. Higher energy demand needs
higher energy production via non-mitochondrial
pathways, such as glycolysis. With advancing
age energy production is mostly anaerobic. Pri-
mary keratinocytes derived from old donors show
a higher glucose uptake and the increased lactate
production which indicates a suboptimal utiliza-
tion of glucose and a shift in metabolism towards
an increased glycolysis (10).
Normal human dermal fibroblasts have a lim-
ited life-span in vitro and cease proliferating after
a fixed number of cell divisions. This process by
which cells stop proliferation is called cellular se-
nescence (43). Senescence is also characterized by
a decrease in total cell numbers. It is not yet clear if
aging causes mitochondrial damage or vice versa.
The loss in mitochondrial functions can cause pre-
mature senescence of the skin cells. This has been
demonstrated in human fibroblast’s reduction in the
level of oxidative phosphorylation which caused a
reduction in cell proliferation and premature senes-
cence (44). Besides the well-established influence
of ROS on proliferation and senescence, a reduction
in the level of oxidative phosphorylation is causally
related to reduced cell proliferation and the induc-
tion of premature senescence. Changes that occur
with senescence can effect mitochondrial respira-
tion. Using the human fibroblast model of in vitro
senescence, Zwerschke et al. (45) analyzed age-
dependent changes in the cellular carbohydrate me-
tabolism. Authors show that senescent fibroblasts
enter into a metabolic imbalance, associated with
a strong reduction in the levels of ribonucleotide
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
triphosphates, including ATP, which are required
for nucleotide biosynthesis and hence prolifera-
tion. ATP depletion in senescent fibroblasts is due
to dysregulation of glycolytic enzymes, and finally
leads to a drastic increase in cellular AMP, which is
shown to induce premature senescence (45). With
increasing passage number, senescent fibroblasts
show a loss of membrane potential (46) and a de-
cline in ATP production (45). Respiratory activity
was not significantly altered with donor age, pro-
bably reflecting genetic variation (47). It seems that
a long-term exposure of cells to ROS initiates a vi-
cious cycle to result in a decrease in the capacity
of stress response, decrease in ATP synthesis, and
further increase of ROS production of the affected
cells (48).
The skin tissues engage in, and derive energy
mostly using aerobic glycolysis. Despite the pre-
sence of oxygen there is a preferential conversion
of glucose to lactate via the glycolytic cycle (49).
This results in the production of substantial amo-
unts of lactate, which is carried to the liver by the
bloodstream and converted back to glucose (the
Cory cycle). Skin has a strong preference for the
metabolism of glucose rather than fatty acids or
ketone bodies, though alternative citric acid cycle
intermediates such as glutamine are also actively
utilized (50). Interestingly, of the relatively small
amount of oxygen that is metabolized by the skin,
the majority is supplied to the epidermis and upper
dermis by diffusion from the atmosphere. As the
majority of ATP in the skin is generated by glyco-
lysis, the mitochondria may be less important for
the ATP generation, but nevertheless, they still
may have a pivotal role in aging effects (51, 52).
Conclusion
As it seems that excess production of ROS (6)
and reduced antioxidant activity with advanced age
(53) significantly contribute to chronologic aging,
the use of antioxidants as food supplements or topi-
cal agents appears a logical way to retard or reverse
skin aging. A few recent papers reviewed this topic
in depth (7, 54, 55). Most of the studies investigated
topical agents, were short-term (up to 12 months)
and showed a positive outcome on several clinical
and ultrastructural parameters of aging skin (54).
1651
HealthMED - Volume 5 / Number 6 / 2011
Radical-scavenging antioxidants are consumed
during the reactions with ROS and antioxidant
status could play an important role in intrinsic
skin aging retardation (56). However, when using
exogenous antioxidants attention should be paid.
Antioxidants that are reducing agents can also act
as pro-oxidants, since they are capable of reacting
with molecular oxygen (e.g. ascorbic acid), and
generate superoxide radicals under aerobic con-
ditions (57). The presence of redox cycling me-
tal ions along with antioxidants might result in a
synergistic effect, resulting in increased free radi-
cal formation or the so-called pro-oxidant effect.
Increasing interest in the role of free radicals in
the pathogenesis of skin diseases and (accelerated)
aging has led to increased interest in techniques to
measure free radicals and their reactions in vivo
and, most importantly, in clinical situations (58,
59). Healthy people should undergo tests to esta-
blish their oxidative stress level because all indivi-
duals are potentially exposed to the risk of produ-
cing exaggerated amounts of free radicals which
leads to accelerated skin aging. The primary aim of
the tests is to identify and prevent oxidative stress
and its unwanted consequences (early aging, dise-
ases). Recognition of the risk of accelerated skin
aging in the “pre-preclinical” stage should be con-
sidered in order to implement relevant therapies,
to predict aging consequences and hence to reduce
healthcare costs and to maintain appropriate qua-
lity of life. However the proof of the hypothesis
would require long-term studies involving a high
number of subjects. Moreover, such studies would
be ethically contentious and extremely expensive.
Acknowledgement
The authors wish to thank Prof. dr. Miloš D.
Pavlović and Dr. Metka Adamič, from the Derma-
tology Centre Parmova, Parmova 53, SI-Ljublja-
na, Slovenia Ljubljana, for excellent assistance in
preparing the review paper.
1652
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Corresponding author
Raja Dahmane,
University of Ljubljana,
Faculty of Health Studies,
Slovenia,
E-mail: raja.dahmane@guest.arnes.si
Journal of Society for development in new net environment in B&H

Microbiological finding of urine
in patients with benign prostatic
hyperplasia
Vineta Vuksanovic1,2, Natasa Terzic1,2, Danijela Vujosevic1
1
Institute of Public Health, Montenegro,
2
Medical Faculty, University of Montenegro.
Abstract
Background: Benign prostatic hyperplasia
(BPH) is a common disease in men worldwide.
Because of possible side-infections that worsen
the disease, as well as the future of adequate trea-
tment, urinoculture is a method that can be a good
tool in completing treatment of the prostate.
The objective was to determine presence of uri-
nary infections diagnosed by cultivation (urinocul-
ture) in different age group, to identify the species
of bacteria and their antimicrobial susceptibility
to fluorochinolone (ciprofloxacin) in patients with
BPH in Podgorica and the surrounding territory.
Materials and methods: During 2010, 672
urinocultures were examined in the Institute of
Public Health of Montenegro: 356 from patients
with BPH and 316 from patients without BPH
(control group) aged 31 to 85 years.
Isolated bacteria were investigated by VITEK
® 2 system for identification and antimicrobial
susceptibility testing (bioMerieux, France). Re-
sults were obtained by expert analysis from thera-
peutic Guideline Interpretation of phenotypic AES
parameter from the AES Detail Report, obtained
MIC values ​​and CLSI recommendations.
Statistical analysis of obtained data was done
by using χ2 test.
Results: Examined samples included 250 po-
sitive urinocultures belonging to 169 patients with
BPH and 81 patients without BPH. In patients
with BPH, a positive urinoculture are usually fo-
und in the age group between 71 - 80 years. The
bacteria were present in quantities of ≥105 cfu/ml
urine in 81,6% of patients with BPH. Klebsiella
pneumoniae subsp. pneumoniae is commonly iso-
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
lated bacteria (26,4%) and it showed resistance to
fluorochinolone (23,6%) analyzed in relation to
total number of Gram negative bacteria isolated
from the urine of patients with BPH. In the control
group of patients without BPH, Escherichia coli
was usually isolated, and it showed lower resistan-
ce to fluorochinolone (15%).
Discussion: The data analysis showed that in
patients with BPH resistant bacteria were isolated,
which represent a therapeutic problem, especially
strains of enterococci and klebsiella.
Conclusions: The conducted study confirms
the benefits of microbiological diagnosis and uri-
noculture as a method contributing to the complex
treatment of patients with BPH.
Key words: Benign prostatic hyperplasia, uri-
noculture, bacteria, antimicrobial sensitivity.
Introduction
It has been stated that the prostate gland is the
male organ most commonly afflicted with either
benign or malignant neoplasm [1]. We focus on
benign prostatic hyperplasia (BPH) as the most
prevalent benign disorders affecting the prostate
and possibility of complycation such as urinary
tract infections (UTI).
BPH may only be defined histologically and it
is defined as stromal and epithelial hyperplasia be-
ginning in the perurethral transitional zone of the
prostate. Several theories have been proposed to
explain the etiology of the pathological phase of
BPH. BPH is thought to be caused by aging and
by long-term testosterone and dihydrotestoste-
rone production, although their precise roles are
1655
HealthMED - Volume 5 / Number 6 / 2011
not completely clear. Loss of testosterone early in
life prevents the development of BPH. The simi-
larities in presentation, pathological examination
findings, and symptoms of BPH among identical
twins suggest a hereditary influence. One of the
major theories is Inflammatory theory which in-
clude the hypotheses that pathological BPH is due
to inflammation: Prostatic inflammation may con-
tribute to prostate growth due to the induction of
cell growth. This is results of the presence of infla-
mmatory markers and agents stimulating growth
[2]. It is believed that UTI have central role in
BPH infections and BPH have central role in UTI.
Perhaps the best host defense against infection in
the lower urinary tract is the normal flow of uri-
ne and bladder emptying that accompanies nor-
mal urinary tract functioning. In BPH, bladder
outflow obstruction results in disruption of this
mechanism with retention and pooling of urine in
the bladder, giving organisms the opportunity to
multiply rather than be flushed out. Despite this
logical assumption, there is little evidence in the
literature to support this theory. Nevertheless, men
with significant clinical BPH are probably at risk
of UTI, and men with UTI should be assessed for
signs of BPH [3].
Distinguishing BPH from the other prostate
related diseases is often difficult and guidelines
include recommendations focused on the medical
history, physical examination, and urinalysis [4].
Performing a urinalysis to screen bacteriuria
can help to rule out such condition as urinary tract
infections which are less likely if the results of uri-
nalysis is normal [5].
The treatmen options for BPH in stage of UTI,
as well in profilaxis before and after surgery, in-
clude use of cephalosporine, fluorochinolone,
aminoglycoside and trimethoprim-sulphametoxa-
sole, which complete therapy of BPH.
Fluorochinolone is commonly the first antimicro-
bial choice because of good penetration into tissue.
In addition to available protocols, different the-
rapeutical procedures and antibiotical therapy, in
large number of people prostate is still a problem
that waits for its solving.
Because of these facts prostate screening and
treatment are among the most controversial issues
in health care today. Furthermore, the discipline
of andrology is in the early stages so the care of
1656 Journal of Society for development in new net environment in B&H
the male reproductive tract is assumed by primary
care physicians, urologists and other specialists.
Therefore, prostate is an organ with which every
physician need to be familiar.
It was the basic motivation for preparation of
this study: to give contribution in complex consi-
deration of patients with benign prostate hyperpla-
sia through microbiological approach using urino-
culture as an analyzing method.
The purpose of the present study was: (i) to in-
vestigate in which age group positive urinoculture
are most prevalent (ii) to investigate presence of
bacteria species in urine of patients with BPH and
(iii) their antimicrobial susceptibility to antibiotics
commonly used in treatment and prophylaxis of
prostate infection – fluorochinolone.
Material and methods
Sample
This study includes patients with BPH and
symptoms of urinary tract infections (UTI), who
were referred for microbiological analysis of uri-
ne (urinoculture) – examined group. The control
group involved patients without BPH but with
symptoms of UTI who were referred to the uri-
noculture in the same period. The 672 investiga-
ted urines nonduplicate isolates from urogenital
tracts of adults were collected during 2010 in the
Institute of Public Health, Montenegro. Thus, 356
samples of urine taken from patients with BPH
and 316 urine of control group of patients witho-
ut BPH were microbiologically analyzed. Patients
belonged to the age group between 31 to 85 years.
Data sources
After isolation on CPS and blood agar our micro-
biology department used the VITEK® 2 system for
identification (ID) and antimicrobial susceptibility
testing (AST). Isolates were tested with the same
batch of identification cards and under the same
conditions to maintain comparability. To determine
the sensitivity, the cards for antimicrobial suscepti-
bility of Gram positive and Gram negative bacteria
were used. The card N019 for the antimicrobial sus-

ceptibility of Gram negative bacteria determined the
sensitivity to 25 antibiotics: ampicillin, amoxicillin/
clavulanic acid, ticarcillin/ clavulanic acid, pipera-
cillin, piperacillin/tazobactam, cefaclor, cephalotin,
cefazolin, cefoxitin, caftazidim, ceftizoxim, ceftri-
axon, cefepime, imipenem, meropenem, ertapenem,
amikacin, gentamicin, tobramicin, pipemidic acid,
ciprofloxacin, norfloxacin, nitrofurantoin, trimet-
hoprim, trimethoprim/sulfamethoxazole. For Gram
positive bacteria GP67 card with 19 antibiotics and
2 tests were used: benzylpenicillin, ampicillin, oxa-
cillin, gentamicin (high level), streptomycin (high
level), gentamicin, ciprofloxacin, levofloxacin,
moxifloxacin, erythromycin, tetracycline, clinda-
mycin, quinopristin/dalfopristin, vancomycin, tige-
cycline, nitrofurantoin, rifampicin, trimethoprim/
sulfamethoxazole, cefoxitin screen and inducible
clindamycin resistance. The results were summari-
zed in order to: identify bacteria that were isolated
from urinoculture and sensitivity to fluorihinolone
(in Gram positive and Gram negative bacteria).
Fluorochinolones were analyzed as they are
commonly used in treatment and prophylaxis
(preoperative and postoperative) of the prostate.
Ciprofloxacin (CIP) was taken as representative of
fluorochinolones as per interpretive analysis CLSI
[6], demonstrated resistance to CIP, which is, ac-
tually, resistance to florochinolone. Accordingly,
the presence of resistant strains to fluorochinolone
was interpreted based on the obtained MIC valu-
es ​​and expert analysis from therapeutic Guideline
Interpretation of phenotypic AES parameter from
the Detail Report.
Statistical analysis of data was done by using
descriptive statistics methods (median value and
relative frequency distribution), and nonparame-
tric analytical methods for testing significant diffe-
rence (χ2 test at the level of significancy p<0,05%).
Statistical software package SPSS v. 13,0 was
used for data processing.
Results
Positive urinoculture findings and age of
patients
A total of 672 patients were tested for micro-
biological analysis of urine (urinoculture), out of
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
which 250 urinoculture were positive. The sam-
ples included 356 patients with BPH, 169 (47,5%)
had positive urinoculture (Figure 1). In 316 pati-
ents without BPH, 81 (25,6%) had positive uri-
noculture. Further analysis involved patients with
positive microbiological findings of urine mea-
ning patients with UTI.
Figure 1. Finding of positive and negative urino-
culture in patients with BPH and without BPH
There were no positive urinocilture in patients
with BPH in the age group of 31 to 35 years (Fi-
gure 2). After 35 years of age men with BPH gra-
dually and more frequently have positive urino-
culture, which is below 10% up to 65 years. In the
age group of 66 to 70 years positive urinoculture
exceed 10% i.e. 15,4% had positive urinoculture,
and reaching its maximum in the next ten years.
So, almost half of patients with BPH (49,1%) had
positive urinoculture result at the age of 71 to 80
years (Figure 2). There is a decrease in positive
urinoculture among patients from 81 to 85 years,
but it is still present in 7,7%.
Control group of patients without BPH from the
beginning has a positive urinoculture, and often
positive urinoculture are usually found in the age
group between 31 to 35 years (17,3% of patients)
(Figure 2). A similar increase in positive urinocul-
ture is also observed in the age group from 66 to 70
years (16%). In other stages of life a positive urino-
culture are continuously present, ranging from 5%
to 12,4%. After 80 years of age, a sudden drop of
positive urinoculture was registered and men wit-
hout BPH, aged 81 to 85 years, in our sample did
not have positive urinoculture findings.
There was statistically significant more frequ-
ent presence of urinoculture, which means UTI, in
patients with BPH, in the age group 71 – 80 years,
than in patients without BPH (χ2=72,441; p<0,01).
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HealthMED - Volume 5 / Number 6 / 2011
Figure 2. Findings of positive urinoculture in
patients with BPH and without BPH in different
age group
Microbiological findings of urinoculture
a. Quantity of the microorganism presence in
urinoculture in patients with UTI
Amount of present microorganisms in patients
urine was determined by grown colonies on so-
lid microbiological medium, expressed as colony
forming unites per 1 milliliter of urine (cfu/ml).
Out of them, 169 patients with BPH and UTI,
in 68% of cases had positive urinoculture in the
amount of >105 cfu/ml urine, while only 1,2% of
patients had the bacteria in range of ≥104 cfu/ml
to ≤105 cfu/ml urine (Figure 3). If we summari-
ze, patients with BPH in about 4/5 cases (81,6%)
had the presence of microorganisms in a quantity
≥105 cfu/ml urine.
In 81 patients without BPH and with UTI very
similar findings in the quantity of present bacteria
was found, because 67,9% had the bacteria in quan-
tities >105 cfu/ml (Figure 3). The remaining 32,1%
of patients had bacteria in quantities of: 105 cfu/ml
in 9,9% of patients, and 5 X 104 cfu /ml in 22,2%
of patients. We can conclude that patients without
BPH in 77,8% of cases had the presence of micro-
organisms in a quantity of ≥105 cfu/ml urine.
According to statistical analysis patients with
BPH had bacteria in amount of ≥105 cfu/ml urine
with the same frequency as patients without BPH
(χ2=0,308; p>0,05).
b. Identification of microorganisms
In the study group of 169 patients with BPH, 198
microorganisms were identified: 49 (24,8%) Gram
positive bacteria, 148 (74,7%) Gram negative bac-
teria and 1 (0,5%) Candida spp (Figure 4). In 145
1658 Journal of Society for development in new net environment in B&H
(85,8%) patients, the presence of one microorgani-
sm was found and monoinfection was determined
(Table 1). In 19 patients presence of two microorga-
nisms was found, while in 5 patients the presence of
three microorganisms was found, which means that
poly-infection with more than one microorganism
was found in 24 patients (14,2%).
Figure 3. Amount of present microorganisms in
patients’ urine samples with BPH and without
BPH expressed in cfu/ml
Legend: cfu/ml … colony forming unites/ml
Figure 4. Distribution of microorganisms in uri-
noculture of patients with BPH and without BPH
In the study group of 81 patients without BPH,
82 microorganisms were identified: 22 (26,8%)
Gram positive bacteria and 60 (73,2%) Gram ne-
gative bacteria (Figure 4).
Presence of one microorganism was found in
80 (98,8%) patients and monoinfection was re-
gistered (Table1). The presence of two microor-
ganisms was found in one patient, which means
that poly-infection with more than one agent was
found only in one patient (1,2%).
Statistical data analysis confirmed that poly-in-
fections are significantly more commonly found
in patients with BPH in relation to patients witho-
ut BPH.
 HealthMED - Volume 5 / Number 6 / 2011

Table 1. Monoinfections and poly-infections in gnificant place in the isolation of Gram negative
patients with BPH and without BPH bacteria, and it was isolated in 12,2%. Other Gram
patients negative bacteria were isolated in less than 10%
with BPH without BPH (Figure 6).
microorganism
number number
% %
145 80
one microorganism
85,8% 98,8%
19 1
two microorganisms
11,2% 11,2%
5 0
three microorganisms
3% 0%
169 81
total
100% 100%

In the urine samples of 169 patients with BPH,
among Gram positive bacteria in the urine Entero-
coccus faecalis (69,5%) was usually isolated (Fi-
gure 5). Other Gram positive bacteria were found
in quantity around or less than 10%: 10,2% Strep-
tococcus agalactiae; Staphylococcus haemolyti-
cus, Staphylococcus epidermidis and Staphyloco-
ccus aureus at 6,1% and Staphylococcus hominis
2%.
Staphylococci were present, with 20,3%, whi-
ch means that after the enterococci, they were the
most prevalent Gram positive cocci in the urine of
patients with BPH.
In the urine of 81 patients without BPH, three
species of Gram positive bacteria were found (Fi-
gure 5). Enterococcus faecalis was commonly
present with 68,2%. Streptococcus agalactiae was
present at the level of 27,3%, while Staphyloco-
ccus epidermidis was present with 4,5% of the to-
tal number of Gram positive bacteria in patients
without BPH.
In the same group of patients with BPH the
presence of 12 different species of Gram negative
bacteria was found (Figure 6). The usual Gram ne-
gative bacteria found in the urine of patients with
BPH was Klebsiella pneumoniae subsp. pneumo-
niae with 26,4%. Having insight that Klebsiella
pneumoniae subsp. ozaenae was isolated in 1,4%
patients and Klebsiella oxytoca in 0,7% of pati-
ents, Klebsiella spp. is the most frequently isola-
ted Gram negative bacteria with presence of over
1/4 or precisielly 28,4%. Second and third place
in the presence of Gram negative bacteria belon-
gs to Escherichia coli (20,3%) and Pseudomonas
aeruginosa (15,5%). Citrobacter freundii has si-
Figure 5. Presence of Gram positive bacteria in
patients with BPH and without BPH.
Isolated bacteria specter in patients without
BPH is narrow considering that 7 species of bac-
teria found in patients with BPH have not been
isolated (Figure 6). Most frequently isolated Gram
negative bacteria in patients without BPH were
Escherichia coli with 63,3% (Figure 6). Second
and third place belong to Klebsiella pneumoniae
subsp. pneumoniae with 15% and Proteus mira-
bilis with 11,6%. Other Gram negative bacteria
were present in less than 10% (Table 6).
Statistical data analysis confirmed that Klebsi-
ella pneumoniae subsp. pneumoniae are signifi-
cantly more commonly found in patients with BPH
in relation to patients without BPH (χ2=4,240;
p<0,05). On the other hand, there was statistically
significant more frequent isolate of Escherichia
coli in patients without BPH than in patients with
BPH (χ2=25,950; p<0,05).
Figure 6. Presence of Gram negative bacteria in
patients with BPH and without BPH.

Journal of Society for development in new net environment in B&H 1659

HealthMED - Volume 5 / Number 6 / 2011
c. The antimicrobial susceptibility of isolated
bacteria to ciprofloxacin (flourochinolone)
Out of 49 Gram positive bacteria isolated and
identified in patients with BPH, 57,1% showed re-
sistance to ciprofloxacin (Figure 7). Streptococcus
agalactiae and Staphylococcus aureus did not show
resistance to ciprofloxacin. Enterococcus faecalis
(44,9%) was the most prevalent in resistance to ci-
profloxacin among Gram positive bacteria. Results
of statistical analysis indicated that Enterococcus
faecalis, found in patients with BPH significantly
showed more common resistance to ciprofloxacin
than in patients without BPH (χ2=14,07, p<0,01).
Strains of other species represented in the resistance
to ciprofloxacin had less than 10% (Figure 7). At
the same time, antimicrobial sucseptibility to cipro-
floxacin Gram positive bacteria obtained from posi-
tive urinoculture of patients without BPH was inve-
stigated. Out of 22 Gram positive bacteria, only one
strain of Enterococcus faecalis showed resistance
to ciprofloxacin (4,5%) (Figure 8). Other strains of
Gram-positive bacteria, Streptococcus agalactiae
and Staphylococcus epidermidis, were fully sensi-
tive to ciprofloxacin.
Generally, statistical analysis confirmed that
Gram positive bacteria are significantly more co-
mmonly resistant to ciprofloxacin among patients
with BPH in relation to patients without BPH
(χ2=17,987; p<0,05).
Figure 7. Antimicrobial susceptibility of Gram
positive bacteria to ciprofloxacin in patients with
BPH
Out of 148 Gram negative bacteria isolated and
identified in patients with BPH, 80,4% showed the
1660
resistance of ciprofloxacin (Figure 9). The strains
of three species did not show resistance to cipro-
floxacin: Klebsiella oxytoca, Serratia marcescens
and Myroides spp. (Figure 9). Strains of Klebsie-
lla pneumoniae subsp. pneumoniae were the most
resistant strains in the group of Gram negative
bacteria (23,6%). According to statistical analysis
Klebsiella pneumoniae subsp. pneumoniae is sta-
tistically more frequently resistance to ciprofloxa-
cin in patients with BPH (χ2=15,77, p<0,01). Se-
cond, third and fourth place belong to: Escherichia
coli (14,9%), Pseudomonas aeruginosa (13,5%)
and Citrobacter freundii (11,5%). Other types of
bacteria were present below 10% (Figure 9).
Figure 8. Antimicrobial susceptibility of Gram
positive bacteria to ciprofloxacin in patients wit-
hout BPH
Comparing with the Gram positive bacteria we
found a higher percentage of resistance in Gram
negative bacteria in the group without BPH: 1/4
of strains were resistant to ciprofloxacin (25%)
(Figure10).
However, results of statistical analysis showed
that Gram negative bacteria are significantly more
frequently resistant to ciprofloxacin in patients
with BPH than in patients without BPH (χ2=57,29;
p<0,01).
The most prevalent resistant strains belonged
to Escherichia coli (15%). Other bacteria that have
shown some level of resistance to ciprofloxacin
were as follows: Klebsiella pneumoniae subsp.
pneuminiae (5%), Proteus mirabilis (3,3%) and
Pseudomonas aeruginosa (1,7%). Citrobacter fre-
undii, Morganella morganii and Serratia marces-
cens showed no resistance to ciprofloxacin in gro-
up of patients without BPH. Apart to high isolates
Journal of Society for development in new net environment in B&H

of Escherichia coli in patients without BPH (Figu-
re 6), Escherichia coli resistance to ciprofloxacin
is statistically more common in patients with BPH
than in patients without BPH (χ2=14,91, p<0,01).
Figure 9. Antimicrobial susceptibility of Gram
negative bacteria to ciprofloxacin in patients with
BPH
Figure 10. Antimicrobial susceptibility of Gram
negative bacteria to ciprofloxacin in patients wit-
hout BPH
Discussion
In this paper results of urinoculture obtained
by the VITEK® 2 system for identification (ID)
and antimicrobial susceptibility testing (AST) are
analyzed. In total 672 patients and their urinocul-
ture are examined: 356 patients with BPH and
316 patients without BPH. Patients had suspected
UTI. 47,5% of BPH group and 25,6% of without
BPH were diagnosed with UTI (positive urinocul-
ture). Is was statistically proven that patients with
BPH often acquire UTI between the ages of 71
to 80 years (p<0,01). This data correlates with the
knowledge that prostate tissue undergoes changes
as men getting older and histopathological eviden-
ce of BPH is present in approximately 8% of men
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
in their fourth decade of life and in 90% of men
by their ninth decade of life [7]. Studies indicate
that the incidence increases with ages, from 3 to
1000 in the age group 45 to 49 years, and from 38
to 1000, in the age group 75 to 79 years. [8]. The
level of the relation between UTI and BPH has
not been yet fully known. However study explains
that aging decreases the function of the prostate,
and increases its volume [9]. With larger prostates
(>40 ml) it is more likely to develop acute urinary
retention and infection [10].
Results of patients without BPH support pre-
sented fact that BPH corresponds to UTI. In the
control group of our respondents infections have
been present from the very beginning in the conti-
nuity, in the age group 31 to 75 years, at the level
of 5% -17,3%, and later disappearance of urinary
infection is found in the age group 81-85 years.
We can say that although the exact mechanism is
unknown, lower urinary tract symptoms can signal
progressive BPH [11], expecialy in elderly men.
Urinoculture performed preoperatively indica-
te that up to 25% of patients with BPH have a do-
cumented urinary tract infection [12].
Although patients with BPH often have UTI,
the quantitative results (cfu / ml) of urine cultu-
re is similar in both groups: patients with BPH in
81,6% had the presence of microorganisms in a
quantity ≥105 cfu / ml urine, while patients witho-
ut BPH in 77,8% had the presence of microorga-
nisms in a quantity ≥105 cfu/ml urine. The results
show that there is no statistically significant diffe-
rence in the presence of bacteria in urine culture
among the patients (p>0,05).
During UTI patients with BPH are more likely
to have more than one bacteria (14,2%). Results of
statistical analysis showed that patients with BPH
are significantly more likely to have UTI, with
more than one agent (p<0,05).
Enterococcus faecalis is the most common
Gram positive bacteria in patients with BPH
(69,5%) and patients without BPH (68,2%). This
result correlates with results of other researchers.
Studies of other researchers on presence of bac-
teria during infection of the prostate showed that
enterococci were most frequent Gram positive
bacteria in the urinoculture [13].
But during UTI in patients with BPH finding
of coagulase negative staphylococci was present
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HealthMED - Volume 5 / Number 6 / 2011
in 1/5 of patients (20,3%), while in patients witho-
ut BPH it was Streptococcus agalactiae (27,3%).
According to results of other researchers the role of
coagulase negative staphylococci (Staphylococcus
epidermitis and Staphylococcus saprophyticus) is
controversial. These organisms typically colonise
the anterior urethra and likely represent contami-
nation when positive in a culture specimen. Only
patients in whom a second culture result is positive
should receive antibiotic treatment [14].
Gram negative bacteria in both groups of pati-
ents were dominant during UTI.
In patients with BPH, Klebsiella pneumoniae
subsp. pneumoniae, was dominant with 26,4%,
while in patients without BPH E. coli is most
frequently isolated with 63,3%.
Studies of other researchers found that in pro-
state infection, Escherichia coli is responsible for
approximately 75% to 80% of cases [15]. The other
members of the family Enterobacteriaceae, Klebsi-
ella species and Proteus species, as well Pseudomo-
nas aeruginosa are also known as pathogens [16].
Isolation and identification of bacteria from the
urinoculture is intended to demonstrate the sensiti-
vity of bacteria to a given drug. In the treatment of
urinary tract infections in patients with BPH fluo-
roquinolones is frequently used. It is also used in
prophylaxis.
A 2002 meta-analysis by Berry and Barratt su-
ggested that prophylaxis in men with BPH signifi-
cantly decreased bacteriuria and septicemia, even
in men with sterile urine preoperatively. Effective
agents included quinolones, aminoglycoside, tri-
methoprim- sulfamethoxazole, and cephalosporins.
Such prophylaxis reduced septicemia rates from
4,4% to 0,7% in these low-risk patients. Short-co-
urse therapy was found to be more effective than
single-dose regimens, regardless of the agent cho-
sen [17]. Also, other studies showed that the best
antibiotic choices include trimethoprim-sulfamet-
hoxazole and fluoroquinolone antibiotics [16.18].
Therefore, one of the objectives was to inve-
stigate the sensitivity of the CIP, which in our pa-
tients was at a high level. Thus, in patients with
BPH 57,1% Gram positive strains showed insen-
sitivity to the CIP, and in Gram-negative bacteria
it is even 80,4%.
However, a difference in susceptibility to some
antibiotics, and therefore its aplcation, often de-
1662 Journal of Society for development in new net environment in B&H
pends on the environment and map of bacteria
resistance in that environment. This is illustrated
by the case of Escherichia coli infection described
by Alecsandriu D. et al. 2006: E. coli infection as
the main cause of bacteremia intrahospital cause
meningitis by multiresistant E. coli in man after
transrectal prostate biopsy which demonstrates
that antibiotic prevention with ciprofloxacin is not
absolutely risk free [19]. High resistance of Esche-
richia coli in patients with BPH was also found in
this study. Thus, although Escherichia coli is hi-
ghly present in patients without BPH (Figure 6)
resistance of Escherichia coli to ciprofloxacin is
statistically significantly more frequent in patients
with BPH (p<0,01).
In bacteria isolated from the urine of patients
without BPH resistance to CIP in Gram positive
bacteria was at the level of 4,5% and Gram ne-
gative 25%. Results of statistical analysis showed
that resistance of Gram positive bacteria to CIP
is statistically more common in men with BPH
(p<0,05%). The most resistant species to CIP in
patients with BPH were Enterococcus faecalis
(44,9%) and Klebsiella pneumoniae subsp. pneu-
moniae (23,6%), while in patients without BPH it
was Escherichia coli (15%).
In two most frequently isolated bacteria from
the urine of patients with BPH (Klebsiella pneu-
moniae subsp. pneumoniae and Escherichia coli)
resistance to ciprofloxacin is statistically signifi-
cantly more frequent than in patients without BPH
(p<0,01).
Generally, all bacteria (Gram positive and Gram
negative) isolated from urine of patients with BPH
show statistically significantly more resistance to
ciprofloxacin in relation to patients without BPH
(p<0,05 and p<0,01).
Conclusion
Pursuant to the given goals it can be concluded
that men over 70 years are most at risk patients
with BPH for acquiring UTI. Positive urine cultu-
re of patients with BPH have two dominant bac-
teria: Klebsiella pneumoniae and Enterococcus
faecalis. Their treatment is very complex due to
the high percentage of present strains resistant to
fluoroquinolones. In accordance with the obtained

results we can say that urine culture is a useful tool
in the complex treatment of patients with BPH,
which can prevent the occurrence of undesirable
complication in a patient due to wrong antibiotic
therapy. Also, adequate antibiotic therapy has an
undesirable effect in slowing the appearance of re-
sistant strains.
References
1. Presti JC Jr. Neoplasms of the prostate gland. In:
Tanagho EA, McAninch JW, eds. Smith’s general
urology, 15th edition. New York, USA: Lange Medi-
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2. Sciarra A, Di Silverio F, Salciccia S, Autran Go-
mez AM, Gentilucci A, Gentile V. Inflammation and
chronic prostatic diseases: Evidence for a link? Eur
Urol. 2007.
3. Beckman TJ, Mynderse LA. Evoluation and medi-
cal management of benign prostatic hyperplasia.
Mayo Clin Proc. 2005; 80 (10): 1356-1362.
4. McConnell J, Barry MJ, Bruskewitz RC, et al. Beni-
gn prostatic hyperplasia: diagnosis and treatment.
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5. American Urological Association. Guideline on
the Management of Benign Prostatic Hyperplasia.
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6. Clinical and Laboratory Standards Institute. Per-
formance standards for antimicrobial susceptibility
testing; Twenty Informational Supplement. Wayne
(PA): CLSI; 2010. CLSI document M100-S20.
7. Kirby R, Lepor H. Evulation and nonsurgical me-
nagement of benign prostatic hyperplasia. In: Wein
A, Kavoussi L, Novick A, Partin A, and Peters C
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WB Saunders, 2007: 2766-2802
8. Verhamme KM, Dieleman JP, Bleumink GS, van
der Lei J, Sturkenboom MC, Artibani W, Begaud
B, Berges R, Borkowski A, Chappel CR, Costello
A, Dobronski P, Farmer RD, Jimenez Cruz F, Jonas
U, MacRae K, Pientka L, Rutten FF, van Schayck
CP, Speakman MJ, Tiellac P, Tubaro A, Vallencien
G, Vela Navarrete R. Incidence and prevalence of
lower urinary tract symptoms suggestive of benign
prostatic hyperplasia in primary care-the triumph
project. Eur Urol. 2002;42:323-328.
9. Jacobsen SJ, Jacobson DJ, Girman CJ, Roberts
RO, Rhodes T, Guess HA, Lieber MM. Treatment
for benign prostatic hyperplasia among com-
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munity dwelling men: The olmsted county study
of urinary symptoms and health status. J Urol.
1999;162:1301-1306
10. Marberger MJ, Andersen JT, Nickel JC, Malice
MP, Gabriel M, Pappas F, Meehan A, Stoner E,
Waldstreicher J. Prostate volume and serum pro-
state-specific antigen as predictors of acute uri-
nary retention. Combined experience from three
large multinational placebo-controlled trials. Eur
Urol. 2000;38:563-568
11. AUA Practice Guidelines Committee. AUA guide-
line on management of benign prostatic hyperpla-
sia. J Urol. 2003; 170 (2): 530-547.
12. Berry A, Barratt A. Prophylactic antibiotic use in
transurethral prostatic resection: a meta-analysis.
J Urol. Feb 2002;167(2 Pt 1):571-7.
13. Schaeffer AJ. Chronic prostatitis and the chro-
nic pelvic pain syndrome. N Engl J Med.
2006;355(16):1690-1698.
14. Wagenlehner FM, Naber KG. Fluoroquinolone
antimicrobial agents in the treatment of prostati-
tis and recurrent urinary tract infections in men.
Curr Urol Rep. Aug 2004;5(4):309-16.
15. Schaeffer AJ. Chronic prostatitis and the chronic
pelvic pain syndrome. N Engl J Med. 2006; 355
(16): 1690-1698.
16. Magri V, Wagenlehner FM, Montanari E, Marras
E, Orlandi V, Restelli A, et al. Semen analysis
in chronic bacterial prostatitis: diagnostic and
therapeutic implications. Asian J Androl. Jul
2009;11(4):461-77.
17. Berry A, Barratt A. Prophylactic antibiotic use in
transurethral prostatic resection: a meta-analysis.
J Urol. Feb 2002;167(2 Pt 1):571-7.
18. Shoskes DA, Shahed A. Presence of Bacterial
Signal in Expressed Prostatic Secretions Pre-
dicts Response to Antibiotic Therapy in Men
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2000;163(4):99A.
19. Alecsandriu D, Gestoso I, Romero Ana, Martinez
A, Garcia A, Lobo J. E. coli Multiresistant Menin-
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tificWorldJOURNAL Vol 6; 2006: 2323-2326.
Corresponding author
Vineta Vuksanovic,
Center for medical microbiology,
Institute of Public Health,
Medical Faculty,
University of Montenegro
Montenegro
E-mail: vuksanovich@t-com.me
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HealthMED - Volume 5 / Number 6 / 2011
Effects of air pollution on red blood
cells in pregnancy
Stankovic A, Nikolic M, Arandjelovic M.
University of Nis, Faculty of medicine, Serbia.
Abstract
Background: Air pollution can affect our he-
alth in many ways with both short-term and long-
term effects.
The aim of our study was to evaluate any ef-
fects in red blood celles at pregnant women expo-
sed to air pollution.
Material and methods: The subjects were
654 pregnant women, aged 25-40 years, living for
more than five years in the same home. Exposed
group of pregnant women (n=348) were living in
a city area with a high level of air pollution, while
the pregnanat women (n=306), in the comparison
group, designed as non-exposed group, were li-
ving in the area with a lower level of air pollution.
Results: The air concentrations of nitrogen di-
oxide, sulfur dioxide and lead in sediment matter
were determined from 2004 to 2008. The diagno-
sis of anemia in pragnancy was made using the
pre-defined criteria. There was a significant diffe-
rence in the prevalence of anemia in pragnancy at
pregnant women exposed to higher concentrations
of air pollutants (RR =3.17; 95% CI:3.61-6.27).
Conclusion: These findings suggest that air
pollution could have negative effects on red blood
cells at pragnancy.
Key words: air pollution, red blood cells, ane-
mia, pregnancy.
Introduction
There are a multitude of different pollutants
that contribute to air pollution. Pollutants have
many different forms and metabolites as they are
broken down, and little is known about their inte-
raction witch is extremely complex.
Air pollution can affect our health in many
ways with both short-term and long-term effects.
1664 Journal of Society for development in new net environment in B&H
Health impact of air pollution depends on the po-
llutant type, its concentration in the air, length of
exposure, other pollutants in the air, and individu-
al susceptibility [1].
Air pollution can enter the human bloodstream
through the nose, mouth, skin, and the digestive
tract. Most air pollutants arrive in blood very fast
without any biotransformation. The hematopoie-
tic system is very sensitive to air pollutants beca-
use its cells renovate continually. Toxic materials
from the air cause most significantly damage to
red blood cells such as reduce the concentration
of hemoglobin, the number of erythrocytes, and
hematocrit, thus leading to anemia [2].
The effects of air pollution on red blood cells
have been investigeted mostly on children in our
country [3, 4]. However, pregnancy anaemia is one
of the important public health problems. The fetus
is dependent on the mother's blood and anemia can
cause poor fetal growth, preterm birth, and low bir-
thweight [5]. Being anemic also burdens the mother
by increasing the risk of blood loss during labor and
making it more difficult to fight infections [6].
The aim of the study
The aim of this study was to evaluate any diffe-
rence in the prevalence of anemia and any possi-
ble effects on hematopoietic system in two groups
of pregnanat women exposed to different levels of
air pollution.
Subjects and methods
Subjects The subjects were 654 non-smokers
pregnant women living in two areas in Niš with
different level of air pollution. All subjects lived
more than five years on the same location, living

at the distance about of 25 km from air monitoring
station and they were not professionally exposed
to air pollution.
They were separeted in two groups:exposed
and non-exposed. The exposed group of pragnant
women (n=348) were living in a city area with a
high level of air pollution in Niš, while the pra-
gnant women from non-exposed group (n=306)
were living in a city area with a lower level of air
pollution in Niška Banja.
All of these pregnanat women was enrolled
in early pregnancy (gestational age <10 weeks).
Data on pregnancy were collected on the basis of
physical examinations, fetal ultrasounds and hos-
pital registrations.
Pregnant women of both groups had not symp-
toms of any cardiovascular or pulmonary diseases.
They were informed about the aims of the study,
the performance and the expected results of the
study. Collected data were regarding subjects age,
educational level, parity and passive smoking.
Laboratory data Venous blood was analyzed
for hemoglobin concentration and hematocrit in
the laboratory of Primary Health Care Center, Niš
(Serbia). Anemia in pregnancy has been defined by
criteria from the Centers for Disease Control and
Prevention (CDC) as a hemoglobin (Hb) level of
less than 11 g per dL during the first and third trime-
sters and less than 10.5 g per dL during the second
trimester and values of hematocrit (Ht) <34% [7].
Air pollution exposure measures Outdoor air
pollutants were monitored during the 5 year pe-
riod. The concentrations of sulfur dioxide (SO2),
lead (Pb) in sediment matter and nitrogen dioxi-
de (NO2), were determined in twenty-four–hour
samples of air. This data was used to determine
exposure for all subjects before pregnancy from
January 2004 to December 2007 and during the
pregnancy in 2008. Sampling equipment was pla-
ced at 1.5 m above floor level at two sampling
sites. The sampling sites were selected to ensure
diversity regarding the outdoor environment.
A measured volume of air concentration of
sulfur dioxide was bubbled through a solution of
potassium tetrachloromercurate. The sulfur dioxide
present in the air stream reacted with the solution
to form a stable monochlorosulfonatomercurate
complex. During the subsequent analysis, this com-
plex was brought into reaction with acid-bleached
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
pararosaniline dye and formaldehyde yielding in-
tensely colored pararosaniline methyl sulfonic acid.
The optical density of this species was determined
spectrophotometrically at 548 nm and was directly
related to the amount of sulfur dioxide collected.
The total volume of the air sample was determined
from the flow rate and the sampling time. The con-
centration of sulfur dioxide in the ambient air was
calculated and expressed in μg/m3. The lowest limit
of detection was 1.7 µg/m3.
Lead in sediment matter was collected with
absorbed solution of sulfur acid and was detected
by graphic furnace atomic absorption spectrome-
try. The lowest limit of detection was 0.5 µg/m3.
Ambient nitrogen dioxide was collected with a
pump containing triethanolamine in its tube with
the exact amount of the reacted nitrogen dioxide
was determine dusing the standard spectrophoto-
metry.Theminimum detectable limit of the met-
hod had been determined to be 2.0 µg/m3.
Statistical analysis A statistical package SPSS
was used for data analysis. The variables of blood
pressure parameters were analyzed with T -test.
Air pollution data were analysed using Mann-
Whitney U test. Statistically significant differen-
ces in high blood pressure incidence in pregnant
women exposed to different and substantial con-
centrations of air pollutants were analyzed using a
Pearson's chi-squares test.
A P value <0.05 was required for significance.
Statistical analyses were performed by using SAS
version 8.2 software (SAS Institute, Inc., Cary,
North Carolina).
Results
Table 1 shows baseline characteristics of the
study population. There were no statistically si-
gnificant differences in age, education level, pa-
ssive smoking and parity between the two groups.
The results of air pollution measurements are
summarized in Fig.1. All concentrations of the air
pollutants measured during the period 2004-2008
at the location in Niš were higher when compared
to the concentrations of the same pollutants me-
asured at the location in Niška Banja. This diffe-
rence is statistically significant (Mann-Whitney U
test: P<0.05).
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HealthMED - Volume 5 / Number 6 / 2011

Table 1. Subject characteristics

Subject characteristics Exposed (n=348 ) Non-exposed (n=306 ) Significance
Age,yr * (mean ±SD) 36.82 ± 1.32 36.54 ± 1.56 n.s.
Education level **
Elementary 16% 21%
n.s.
Above elementary 84% 79 %
Passive smoking **
YES 44% 46% n.s
Parity **
Nulliparous 31% 24%
n.s.
Multiparous 69% 76%
*
t-test.
**
chi-square test.
n.s.-not statistically significant

Figure 1. Levels of air pollution studied during

the period 2004-2007

The results of air pollution measurements du-

ring the each trimester of pregnancy in 2008 are
summarized in Fig. 2. There were statistically si-
gnificant differences in all concentrations of the
air pollutants measured during the every trimester
of pragnancy (Mann-Whitney U test: P<0.05).
Figure 2. Levels of air pollution studied during
the first (A), the second (B) and the third (C) tri-
mester of pregnancy

The association between hemoglobin level and

exposure to air pollution is given in Fig.3. Average
altitude of hemoglobin level were statisticaly more
higher in the pregnant women exposed to air pollu-
tion then in controls in the first (t=44.86;P<0.001),
in the second (t=56.37;P<0.001) and the third
(t=26.57;P<0.001) trimester of pregnancy. Also,
there were statistically significant differences in
average altitude of hematocrit values in the first
(t=57.53;P<0.001), in the second (t=50.59;P<0.001)
and the third (t=21.86;P<0.001) trimester of pre-
gnancy between the two groups (Figure 4).

1666 Journal of Society for development in new net environment in B&H


Figure 3. Association between hemoglobin level
and air pollution in the first (A), the second (B)
and the third (C) trimester of pregnancy
Figure 4. Association between hematocrit values
and air pollution in the first (A), the second (B)
and the third (C) trimester of pregnancy
Out of a total number of the pregnanat women
exposed to higher concentrations of air pollutants,
10.37% had anemia. In the control group, the per-
centage of hyperension was lower (3.45%).Chi-
square test ( χ = 12.45, P<0.01) confirmed that
2
there was a significant difference in the frequency
of anemia in pregnant women exposed to higher
concentrations of air pollution, when compared to
those who were exposed to lower concentrations
of air pollution. The values of relative risk were
more than 1 (RR =3.17; 95% CI:3.61-6.27).
Discussion
Anemia in pregnancy (AIP) is a condition with
effects that may be deleterious to mothers and fe-
tuses. Indeed, it is a known risk factor for many
maternal and fetal complications.
This investigation has shown that a long-term
exposure to air pollution and exposure during the
pragnancy positively corresponds to the occurren-
ce of anemia among pregnant women. Analysis of
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
our data revealed a significant decrease in hemato-
crit values and hemoglobin concentration in asso-
ciation with higher air pollution exposure.
In physiologic AIP, the reduction in concentra-
tion results from dilution because the plasma vo-
lume expands more than the erythrocyte volume.
The hematocrit in pregnancy normally drops seve-
ral points below its pregnancy level. In pathologic
AIP, the oxygen-carrying capacity of the blood is
deficient because of disordered erythrocyte pro-
duction or excessive loss of erythrocytes through
destruction or bleeding [8].
Many pollutants produce harmful effects on
the blood and the coronary system. After air pollu-
tants are inhaled, absorbed through the skin or the
intestines, they can enter the blood stream, where
their potential harmful effects are distributed thro-
ughout the body.
Environmental lead exposure occurs from
automobile exhaust in areas of the world where
leaded gasoline is still used. Lead, for instance,
interferes with the normal formation of red blood
cells by inhibiting important enzymes and causes
anemia by impairing heme synthesis and increa-
sing the rate of red blood cell destruction. On the
other hand, it is also possible that iron deficiency,
which is a proven cause of anemia, leads to incre-
ase in the absorption of lead in the body, resulting
in high the blood lead level [9, 10].
Concerning nitrogen dioxide, the studies in
animals provide evidence supporting increased
red blood cell turnover after exposure to low con-
centrations of NO2 [11, 12]. Analysis of data from
complete blood counts performed 3.5 h after each
exposure showed significant dose-related decrea-
ses in hematocrit, hemoglobin, and red blood cell
count in association with NO2 exposure for both
males and females [13].
There were several limitations in the present
study. First, we did not examine the relationship
between iron status and the development of AIP.
Iron deficiency is responsible for 95% of anemia of
pregnancy. Dietary iron intake in fertile women is
median 9 mg/day, i.e. the majority of women have
an intake below the estimated allowance of 12-18
mg/day. Iron absorption increases in pregnancy, but
not enough to prevent iron deficiency anemia in
20%, of women not taking supplementary iron [14].
Intestinal iron absorption increases during pregnan-
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HealthMED - Volume 5 / Number 6 / 2011
cy, but women with ample body iron reserves have
lower absorption than those with depleted reserves,
so increased absorption is, in part, due to progre-
ssive iron depletion [15]. Iron deficiency anemia is
efficiently prevented by oral iron supplements in
doses of 30-40 mg ferrous iron taken between me-
als from early pregnancy to delivery [16].
Second, our study cannot control exposure to
indoor air pollutant of pregnanat women. Wood
smoke contains a hazardous mixture of chemical
substances such as carbon monoxide, nitrogen oxi-
des, volatile organic compounds, dioxin, and inha-
lable particulate matter. Carbon monoxide combi-
nes with hemoglobin to form carboxyhemoglobin,
which reduces the oxygencarrying capacity of the
blood and can contribute to anemia and adverse
pregnancy outcomes, including miscarriage, still-
birth, low birth weight, and early infant mortality
[17]. Data from 29 developing countries [18] has
shown that exposure to biofuel smoke at home is
associated with mild anemia (OR, 1.07; 95% CI,
1.01−1.13) in women (15−49 years) and their chil-
dren. The changes in haemoglobin adjusted for al-
bumin suggest that inhalation of some component
of inhalable particulate matter may cause sequestra-
tion of red cells in the circulation [19].
Despite these limitations, the hemoglobin level
and hematocrit values at pragnant women exposed
to air pollution was significantly higher than that
of nonexposed controls.
Other factors may interfere with the evaluation
of relation between the anemia in pregnancy and
exposure to air pollution. Parity is one of those fac-
tors. The hematocrit value in non-pregnant women
ranges from 38 to 45%. However, in pregnant wo-
men because of hemodilution normal values can be
much lower, e.g. 34% in single and 30% in twin
or multiple pregnancy even with normal stores of
iron, folic acid and vitamin B12. While some studi-
es found that increasing parity was associated with
an increase in the risk of AIP [20], others reported
no evidence of such an association [21]. A third
group of studies reported a reduction in risk of AIP
[22]. The greater risk of AIP associated with may be
explained by women having higher parity pregnan-
cies' increased susceptibility to hemorrhage [23].
Maternal smoking and passive smoking also has
an impact on the occurrence of pregnancy induced
anemia. Hemoglobin concentrations are, on avera-
1668
ge, 3-5 g/L higher for individuals who smoke 20 to
40 cigarettes per day than they are for nonsmokers
[24]. Hb decreases within a month following smo-
king cessation [25]. The elevation of Hb because of
CO inhalation may be interpreted as a functional
adaptation to tissue hypoxia, and this adaptation co-
uld influence the diagnosis of anemia.
Finally, some studies suggest that maternal ha-
emoglobin level during pregnancy is in relation to
child blood pressure and that child blood pressure
is higher in children born to mothers with lower
haemoglobin levels or who are anaemic [25]. Fur-
ther data from prospective studies are needed be-
fore recommendations for clinical practice can be
considered.
Conclusion
Our results suggest that exposure after and du-
ring the pragnancy to relatively low levels of some
air pollutants may be associated with a anemia in
pragnancy. These findings have implications for
the development of effective risk management
strategies to minimize the public health impacts
for pregnant women.
Acknowledgements
We wish to acknowledge our gratitude to the
Ministry of Science and Technological Develo-
pment of the Republic of Serbia, which supported
Projects 42008 and 43014.
Reference
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Am J Respir Crit Care Med, 1996; 153: 3-50.
2. Badman D.G., Jaffe E.R.: Blood and air pollution:
state of knowledge and research needs, Otolaryn-
gol Head Neck Surg,1996; 114: 205-208.
3. Nikolić M., Nikić D., Stanković A.: Effects of air
pollution on red blood cells in children, Polish J
Environ Stud, 2008; 17: 267-2718.
4. Nikolić M., Nikić D.: Effects of Chronic Exposure
to Urban Air Pollution on Red Blood Cells in Chil-
dren, Global environmental change:challenges to
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science and society in southeastern Europe, Part 4,
2010; 211-219.
5. Preziosi P., Prual A., Galan P., Daouda H., Bourei-
ma H., Hercberg S.: Effect of iron supplementation
on the iron status of pregnant women: consequences
for newborns, Am J Clin Nutr, 1997; 66: 1178–1182.
6. Koblinsky M.A.: Beyond maternal mortality—ma-
gnitude, interrelationship, and consequences of
women's health, pregnancy-related complications
and nutritional status on pregnancy outcomes, Int
J Gynaecol Obstet, 1995; 48: S21–32.
7. Criteria for anemia in children and childbearing-
aged women. Morb Mortal Wkly Rep, 1989; 38:
400–404.
8. Scholl T., Reilly T.: Anemia, iron and pregnancy
outcome, J Nutr, 2000; 130: 443S–447S.
9. Bradman A., Eskenazi B., Sutton P., Athanasoulis
M., Goldman L.R.: Iron deficiency associated with
higher blood lead in children living in contamina-
ted environments - Children's Health Articles, Envi-
ron Health Perspect, 2001; 109: 1079-1084.
10. Jain N., Laden F., Guller U., Shankar A., Kazani
S., Garshick E.: Relation between Blood Lead Le-
vels and Childhood Anemia in India, Am J Epide-
miol, 2005; 161: 968-973.
11. Framptom M.W., Boscia J., Roberts J.R., Azadniv
M., Torres A., Cox C., et al.: Nitrogen dioxide expo-
sure: effects on airway and blood cells, Am J Physi-
ol Lung Cell Mol Physiol, 2002; 282: 155-165.
12. Kaya K., Miura T., Kubota K.: Effects of nitrogen
dioxide on red blood cells of rats: changes in com-
ponents of red cell membranes during in vivo ex-
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13. Ehrman R.A., Treshow M., Lytle I.M.: The hema-
tology of mice exposed to nitrogen dioxide, Am
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14. Milman N., Bergholt T., Byg K.E., Eriksen L.,
Graudal N.: Iron status and iron balance during
pregnancy. A critical reappraisal of iron supple-
mentation, Acta Obstet Gynecol Scand, 1999; 78:
749-757.
15. Milman N.: Iron and pregnancy-a delicate balan-
ce, Ann Hematol, 2006; 85: 559-565.
16. Milman N.: Prepartum anaemia: Prevention and
treatment, Ann Hematol, 2008; 87: 949-959.
17. Neufeld L., Haas D., Ruel M., Grajeda R., Naeher
L.: Smoky indoor cooking fires are associated with
elevated hemoglobin concentration in iron-defici-
ent women, Rev Panam Salud Publica, 2004; 15:
110-118.
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18. Fullerton D., Bruce N., Gordon S.: Indoor air po-
llution from biomass fuel smoke is a major heal-
th concern in the developing world, Trans R Soc
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Nerlan S., Cherrie J., Watt M., Agius R., Stout R.:
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20. Ozumba B.C., Igwegbe A.O.: The challenge of
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21. Humphrey M.D.: Is grand multiparity an inde-
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294–296.
22. Silva J.P.: Grand grand multiparity, J Obstet
Gynaecol, 1992; 12: 301–303.
23. Al-Farsi Y., Brooks D., Werler M., Howard J.,
Cabral H., Al-Shafei M., Wallenburg H.: Effect of
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Relationship between hemoglobin and cardiovas-
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24. Calverley P.M.A., Leggett R.J., McElderry L.,
Flenley D.C.: Cigarette smoking and secondary
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25. Belfort M., Rifas-Shiman S., Rich-Edwards J.,
Kleinman K., Oken E., Gillman M.: Maternal iron
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2008; 37: 301–308.
26. Güngör Güler, Nermin Aydoğdu, Evaluation of
the physical conditions of primary schools in Si-
vas, Turkey HealthMED 2010; 4 (4): 782-790
27. Erzen I, Kukec A, Zaletel-Kragelj L. Air Pollution
as a potential Risk Factor for Chronic Respira-
toryDiseases in Children: A Prevalence Study in
Koper Municipality. HealthMED. 2010;4:945-54
Corresponding author
Aleksandra Stankovic,
University of Nis,
Faculty of medicine,
Serbia,
E-mail: aleksandra@exe-mail.net,
alexstankovic70@yahoo.com
1669
HealthMED - Volume 5 / Number 6 / 2011

Pheochromocytoma in pregnancy, a
diagnosis not to miss
Bogavac Mirjana¹, Stojic Sinisa¹, Malenkovic Goran², Medic Stojanoska Milica³
¹ University of Novi Sad, Faculty of Medicine, Clinical Center of Vojvodina - Department of Obstetrics and
Gynecology, Novi Sad, AP Vojvodina - Serbia,
² University of Novi Sad, Faculty of Medicine, Oncology Institute of Vojvodina, Clinic for Surgical
Oncology - Department of Gynecology, Sremska Kamenica, AP Vojvodina – Serbia,
³ University of Novi Sad, Faculty of Medicine, Clinical centre of Vojvodina, Department of endocrinology
Novi Sad, AP Vojvodina - Serbia.

Abstract This tumor in pregnancy is extremely rare with

Introduction: Phaeochromocytoma is a rare
endocrine tumour causing hypersecretion of
noradrenaline, adrenaline and/or dopamine. It
is extremely rare during pregnancy and may be
misdiagnosed with potentially severe consequ-
ences. Pheochromocytoma is a life-threatening
situation for both mother and fetus, thus antepar-
tum diagnosis reduces both maternal and fetal
mortality.
Case report: Here we present a case of pheo-
chromocytoma presenting in late, unknown pre-
gnancy, in 37-year-old woman with previous hi-
story of hypertension.
Conclusion: Medical preparation and trea-
tment of hypertension is essential for safe surgery.
Timing of adrenalectomy, which is the definitive
treatment, is either during the second trimester or
at the time of cesarean section or as stored proce-
dure after cesaran section delivery.
Key words : Pheochromocytoma, pregnancy,
hypertension, Cesarean delivery
Introduction
Pheochromocytoma and paraganglyoma are
chromaffin cell tumors of the sympatic nervous
system presented by hypersecretin of unmetabo-
lised catecholamines and their metabolites. Phe-
ochromocytoma may be associated with genetic
condicions such as multiple endocrine neoplasia 2
(MEN 2), neurofibromatosis 1 (NF 1) von Hippel
- Lindau disease (VHL).
reported incidence less than 0.2 per 10,000 pre-
gnancies, but important due to potentially deva-
stating consequences for mother and fetus. [1,2]
Several hundred cases have been published un-
til now. [2,3]
Pheochromocytoma should be considered
when severe hypertension and blood pressure is
labile or associated with headaches, palpitations
and sweating. Patients can be completely free of
manifestation between attacs. Pheochromocytoma
is a great mimic and a wide variety of presentati-
ons have been reported. Sometimes it have not any
simptoms. Thus, diagnosis of pheochromocytoma
during pregnancy remains a great challenge, but
is essential to prevent disastrous complications for
both mother and fetus. [3]
Measurement of catcholamines or their me-
tabolites in 24h colected urine or measurement
metanephrines and chromogranine A in plasma,
are important for diagnosis.. Tumor localisation
is established generally by ultrasound, computed
tomography (CT), magnetic resonance imaging
(MRI) or metaiodobenzylguanine (MIBG), octre-
otite scaning and positron emission tomography
(PET). Unofortunatelly, in pregancy we can use
only ultrasound and MRI imaging.
Pheochromocytoma is treated medically by
a-adrenergicblockers, followed by b-blockers,
followed by surgery, which is the definitive tre-
atment.
When maturity is obvious, Cesarean section
should be the prefered mode of delivery. [4,5] Va-
ginal delivery, is possible if patients are well phar-
macologically controlled. [6]

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Here we present a case of pheochromocytoma
presenting in late pregnancy.
Case Report
A 37-year-old pregnant woman, (gravida 5,
para 3), with known chronic hypertension, pre-
sented during gestational week 31, to our tertiary
care hospital with labile blood pressure and severe
hypertension.
She wasnt sure that she was pregnant until one
day before admission, due to irregular menstrual
period during last few years.
This was her 5th pregnancy with the same par-
tner, previously had two normal vaginal deliveries
and two spontaneous abortion.
Patient reported that she has had leucosis when
she was 13, treated with citostatics for two years,
controls showed that she was cured. She was non-
drinker, non-smoker and had no reported allergies.
Family history was negative for multiple endocri-
ne neoplasia (MEN) syndromes and pheochromo-
cytoma.
Hypertension had been discovered and medi-
caly treated for one year with ACE inhibitor.
On admission her blood pressure was 190/110
mm Hg with sinus tachycardia (105 beats/min)
without headaches, palpitations, dizziness, epiga-
stric pain and vomiting. She had bilateral swelling
of the lower extremities up to the knees.
Her obstetric assessment was normal. The fetus
was active with a normal biometry and normal ul-
trasound other than breech presentation. Based on
fetal biometry estimated pregnancy was 30 weeks
five days gestation.
After admission, the patient’s blood pressure
was unstably high, ranging from 160/200 to 80/110
mm Hg, when the treatment started with calcium
channel blockers in combination with alpha bloc-
kers (Phenoxybenzamin tbl a 10 mg 3x1, Nifedipin
tbl a 20 mg 2x½, Metoprolol tbl a 100mg 1x½).
Blood result revealed normal coagulation, he-
moglobin, platelet count, liver profile, electrolytes,
urea and creatinine, thyroid function and blood glu-
cose. Mild proteinuria was detected. A 24 h urine
collection revealed raised catecholamines exclu-
sively noradrenalin with normal vanillylmandelic
acid. Cortizol plasma level was also elevated.
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
Magnetic resonance imaging (MRI) scan of the
abdomen revealed a hyperplasia in the left supra-
renal region. On the basis of her elevated plasma
noradrenaline levels and magnetic resonance ima-
ging scan, we suppose presence of pheochromo-
cytoma or non detected paraganglyoma.
Continuous fetal heart rate monitoring and mater-
nal electrocardiogram (EKG) were unremarkable.
Specialist of endocrinology, radiology, ane-
sthesiology, general surgery and obstetrics were
involved to determine the most appropriate mana-
gement of our patient.
We decided to do amniocentesis to evaluate ba-
bys maturity. Fetal lung maturitu was determinate
by the method of LBC-Lamellar Body Count and
Clemens foam test. Results showed that the matu-
rity was achieved and that should make a decision
on termination of pregnancy.
We decided that a Cesarean delivery would be
performed first, followed by adrenalectomy after a
period of recovery. Preoperative medication inclu-
ded - night before surgery and on the day of surge-
ry: Hydrocortisone amp a 100 mg i.v, and during
surgery - Sol 0.9% NaCl 500 ml + Hydrocortisone
amp a 100 mg i.v. Cesarean delivery occurred at
39/40 weeks gestation under general anesthesia.
A 3070 grams newborn was delivered, with an
Apgar score of 9/10. Operation went quite well,
there was no excessive bleeding and significant in-
crease in blood pressure.
During the postoperative period several episo-
des of hypertension occurred, despite the a- and
b-adrenergic blockage.
Sixth postoperative day with stabile blood pressu-
re patient was dismissed from our hospital with anti-
hypertensive therapy (Metoprolol tbl a 100mg 1x½,
Doxazocin a 2mg 2x1) and elective surgery plan.
Discussion
Pheochromocytomas are extremely rare during
pregnancy and may be misdiagnosed with potenti-
ally catastrophic consequences.
Pheochromocytomas are believed to be fami-
liar in 15–20% of cases, and are associated with
genetic conditions. [3]
Signs and symptoms of pheochromocytoma in
pregnancy include paroxysmal or sustained hyper-
1671
HealthMED - Volume 5 / Number 6 / 2011
tension, headache, sweating, palpitations, nausea,
tremor and anxiety.[7,8,9]
Although it can be difficult to distinguish
between pre-eclampsia and pheochromocytoma in
pregnancy, it is important to maintain a high index
of suspicion in patients with paroxysmal or susta-
ined episodes of hypertension, severe headaches,
sweating and palpitations. [7,9] Symptoms may
occur for the first time in pregnancy or be wor-
sened by the pregnant state because of increased
vascularity of the tumour and mechanical factors
such as pressure from the enlarging uterus or fe-
tal movements which can stimulate catecholami-
ne secretion. An important distinction between
pre-eclampsia and pheochromocytoma is that
pre-eclampsia is associated with proteinuria and
hypertension occurring after the 20th week of ge-
station while pheochromocytoma is rarely associ-
ated with proteinuria and may cause hypertension
throughout the entire pregnancy.
In our case, symptoms and signs of pheochro-
mocytoma are completely inconspicuous and were
diagnosed during the investigation symptoms of
hypertension in pregnancy.
The primary goals in the management of phe-
ochromocytoma in pregnancy are early diagnosis,
pharmacologicall treatment and definitive surgical
treatment.
Delayed diagnosis is significant source of ma-
ternal and fetal morbidity and mortality.
Diagnosis of phaeochromocytoma is made by
detecting increased catecholamines and metabo-
lites (vanillylmandelic acid (VMA), metanephri-
ne and normetanephrine) on 24-h urine collecti-
on. The measurement of free metanephrines and
urinary metanephrines are the most sensitive bi-
ocemiacal test. [10] Pregnancy does not increase
urinary catecholamine levels into the diagnostic
range for pheochromocytoma and thus will not
confuse the diagnosis. [3,8,11]
Once a diagnosis has been confirmed bioche-
mically, efforts should be made to localize the tu-
mour.
In pregnancy, ultrasonography and magnetic
resonance imaging (MRI) are the most acceptable
modalities of tumor localization for cases in which
the fetus must be protected. [8]
Diagnostic procedures, we conducted, were
equale with the protocols of adequate diagnosis
1672 Journal of Society for development in new net environment in B&H
for this relatively rare disease in pregnancy, which
have been described in other papers. [3,8,9] In our
case MRI showed only enlargement of left adrenal
gland. It is knowen that pheochromocytoma are
large tumors. The increase only of noradrenaline
in urine samples and enlargement adrenal glands
without tumors could be suggest presence of par-
ganglioma in this case. Baceuse pregnancy, we
have not possibilities to performe other diagnostic
procedures for differentiate pheochromocytoma
and paraganglioma.
Pharmacologicall treatment of pheochormo-
cytoma/paraganglyoma consists of alpha-adrener-
gic blockade to control hypertensive crisis which
can lead to hemorrhage and infarction in vital
organs, congestive heart failure, cardiac dysrhyt-
hmias, uteroplacental insufficiency with resultant
IUGR, fetal hypoxia and death.
Treatment was conducted in accordance with
the therapeutic attitude in the recent litterature
[2,3,4,6,8].
The best method of childbirth in these patients
is contraversal. First option is elective delivery by
Caesarean section when fetal maturity has been re-
ached followed by tumor excision during the same
anesthetic. Second option, vaginal delivery, is possi-
ble if patient its well pharmacologically controlled,
especially if mother has had previous vaginal deli-
very. Tumerectomy may then carried out at a suita-
ble interval following recovery from childbirth.
Apparently this is a rare disease in pregnancy,
and the timing and way of ending the pregnan-
cy brings on a case by case, in our patient, after
achieving maturity, we terminated pregnancies by
Caesarean section and gave recomandation for su-
bsequent examination and surgical treatment.
Surgical excision of the tumour is the definiti-
ve treatment for pheochromocytoma. The patient
in presented case, immediately after dissmissing
from our clinic had been sent to endocriologyst for
further evaluation and after that to Institute of Sur-
gery for surgical treatment.
Educational message
There are no official guidelines in the manage-
ment of pheochromocytoma, but it is recommen-
ded an individual approach. This disease presents
 HealthMED - Volume 5 / Number 6 / 2011

in many different ways, and in the second half of 10. Adler TJ, Meyer-Rochon YG, Chen H, Benn ED,
pregnancy, it may be mistaken by new-onset or Robinson GB, sippel SR, Sindhu BS. Pheochromo-
superimposed preeclampsia. Similarity of clinical cytoma: Current Approaches and Future Direc-
presentation and limited diagnostic capabilities in tions. The Oncologyst 2008;13:779-793.
pregnancy, as in this case, make the differential dia- 11. Kalra JK, Jain V, Bagga R, Gopalan S, Bhansali
gnosis between pheochromocytoma and paragangli- AK, Behera A et al. Phaeochromocytoma associ-
omas difficult, but therapeutic approach is similar. ated with pregnancy. J Obstet Gynaecol Res 2003;
Management requires close collaboration among 29: 305–308.
the obstetrician, endocrinology specialist, endocri-
ne surgeon, anesthesiologist, and pediatrician.
Corresponding author
Mirjana Bogavac,
University of Novi Sad,
References
Faculty of Medicine,
Clinical Center of Vojvodina - Department of
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1999:828–32.
2. Bravo EL, Tagle R. Pheochromocytoma: state-
of-the-art and future prospects. Endocr Rev.
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3. Eisenhofer G, Siegert G, Kotzerke J, Bornstein SR,
Pacak K. Current progress and future challenges in
the biochemical diagnosis and treatment of pheo-
chromocytomas and paragangliomas. Horm Metab
Res. 2008;40:329–337.
4. Kariya N, Nishi S, Hosono Y, Hamaoka N, Nishi-
kawa K, Asada A. Cesarean section at 28 weeks’
gestation with resection of pheochromocytoma:
perioperative antihypertensive management. J Clin
Anesth. 2005; 17:296 –299.
5. Dugas G, Fuller J, Singh S, Watson J. Pheochro-
mocytoma and pregnancy:a case report and re-
view of anesthetic management. Can J Anaesth.
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6. Hao L, Lei D, Jie C, Yuansheng L. Prevalence and
risk factor of cardiac arrhythmias in hospitalized
patients with arterial hypertension. HealthMED
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7. Desai AS, Chutkow WA, Edelman E, Economy KE,
Dec GW. Clinical problem solving: a crisis in late
pregnancy. N Engl J Med. 2009;361:2271–2277.
8. Reisch N, Peczkowska M, Januszewicz A, Neumann
HP. Pheochromocytoma: presentation, diagnosis
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crinol Invest 2002; 25: 567–72.

Journal of Society for development in new net environment in B&H 1673

HealthMED - Volume 5 / Number 6 / 2011

Mid-life women’s knowledge about

perimenopause in Vojvodina
Dragana Milutinovic1, Aleksandar Curcic1,2, Sanja Sumonja1, Dragana Simin1,3, Branislava Brestovacki1
1
University of Novi Sad, Faculty of Medicine, Department of Nursing, Serbia,
2
Clinical Center of Vojvodina, Obstetrics and Gynecology Clinic, Serbia,
3
Secondary Medical school “7 April”, Novi Sad, Serbia.

Abstract Conclusion: This study emphasized the „weak

Introduction: Knowledge on changes manife-
sted during perimenopausal period are health issu-
es of paramount importance for all women worl-
dwide, and providing adequate information is one
of the key tasks for health professionals.
Aim: The aim of this study was to determine
the level of perimenopausal knowledge in women
in relation to their sociodemographic characteri-
stics and menopausal status, to analyze the infor-
mation source and to draft and offer to women an
education program about perimenopause.
Material and methods: The research was de-
signed as a cross-sectional study, and the poll was
carried out among 180 women from the cities of
Sombor and Novi Sad. As a research instrument a
specially designed questionnaire was applied, con-
taining 23 statements on perimenopause, sociode-
mographic and health status data, as well as data on
perimenopause information source. The statements
were grouped into the four domains. The partici-
pants could designate the statements as „true“, „fal-
se“ or „I don’t know“. Statistical evaluation of the
obtained results was performed using SPSS Statisti-
cs base 14.0 for Windows software. Values p < 0.05
was considered statistically significant.
Results: The participants were most informed
on statements of a subscale „The terms menopause
and perimenopause“ (90.3%) and the least infor-
med (47%) on statements of the sub-scale „Hor-
mone replacement therapy during perimenopau-
se“. Statistically significant difference concerning
information level in women was established only
in relation to the education level and pertaining to
statements of the subscale „Prevention measures
during perimenopause“ (p=0.002).
spots“ of the perimenopausal knowledge of wo-
men, which are: hormone replacement therapy,
physiological changes, health risks and prevention
measures during perimenopause.
Key words: perimenopause, information,
mid-life women, health education, prevention
Introduction
Perimenopause is the interval of woman’s life
which encompasses several years of more-or-less
irregular menstruation cycles before menopause,
and one year after the last menstruation (1). Each
woman has to undergo the perimenopause period;
however, each woman’s experience can be diffe-
rent. These experiences are influenced not only by
the diversity and intensity of manifested symptoms,
but by psycho-social factors. Thus, each woman
should be familiar with signs and symptoms indi-
cating she is undergoing the perimenopause period
or else they may be over – or underestimated. In
that respect, the key task of health professionals is
to provide them with adequate information.
The researchers who investigated the knowled-
ge about perimenopause in women gave emphasis
to physiological changes, health risks, prevention
measures and hormone replacement therapy (HRT)
during perimenopause. The results obtained in dif-
ferent environments revealed lack of adequate pe-
rimenopausal knowledge in women (2−6). Thus,
the study conducted in Northern Taiwan indicated
that women were less informed about physiolo-
gical changes during perimenopause period then
about prevention measures and HRT (2). On the
contrary, study carried out in the U.S.A. among

1674 Journal of Society for development in new net environment in B&H


665 women revealed satisfactory information le-
vel regarding physiological changes, yet poorer
knowledge about health risks during the perime-
nopause period (3). As regards the acquaintance
with HRT results obtained worldwide as well as in
Serbia indicated lack of information and seldom
application of hormone therapy during perimeno-
pause (2−6). Generally, women undergoing peri-
menstrual period consider information provided
by their healthcare professionals insufficient (5).
Therefore, non-professional sources such as TV
and magazines imposed as the dominant source of
information about perimenopause (2−4).
Demographic data suggest that women in pe-
rimenopause are one of the most numerous po-
pulations, which is expected to enlarge with the
anticipated increase in women’s life span (7,8).
However, a number of women die prematurely
from preventable diseases such as cardiovascular,
malignant and chronic respiratory diseases (9).
The six leading risk factors for such diseases are:
increased blood pressure, hyperglycemia, poor
physical activity, smoking, obesity and increased
blood cholesterol levels (9).
Reduction of estrogen levels during perimeno-
pause is highly associated with increased risk of
developing the aforementioned diseases. It’s gra-
dual decrease and loss of its protective role, pre-
dominantly concerning cardiovascular and bone
system, results in higher incidence of cardiovas-
cular diseases and osteoporosis during perimeno-
pause period. Hormonal changes in this period are
associated with change of body composition, in-
cluding body mass increase as a result of elevated
energy intake, decreased energy expenditure and
down regulation of metabolic processes (1,10).
Smoking, diet and infection are the most impor-
tant risk factors for development of malignant dise-
ases (11). Hormonal changes during perimenopau-
se are not associated with increased risk of breast or
endometrial cancer. Such risk increase is strongly
age-related, thus prevalence of these diseases is hi-
gher in women in perimenopause then in women of
reproductive age. Smoking, furthermore, is the only
environmental factor that undoubtedly accounts for
early onset of menopause (2,12).
Actual knowledge and evidence strongly sug-
gest the need of coordinated education of women
on changes and health risks during perimenopause
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
period. Determining current level of perimenopa-
usal knowledge in women is a prerequisite for a
successful education program. Decision-making
of a well informed woman relies on the knowled-
ge obtained. In that respect, the main goals of this
research were:
-- to analyze the level of knowledge about
perimenopause and related health risks
in women population in relation to their
sociodemographic characteristics and meno-
pausal status,
-- to analyze the information sources, and
-- to draft an education program on perimeno-
pause
Methodology
The research was conducted as a cross-sectio-
nal study, using the poll questionnaire. The poll
was conducted in homes and public institutions in
two cities in the region of Autonomous Province of
Vojvodina - Sombor (company „Boreli“, Munici-
pal Court, Municipal Prefecture, Tax Administrati-
on Office, Accounting Department of the General
Hospital) and Novi Sad (administrative offices of
the Faculty of Medicine Novi Sad) in the period
October – December, 2010. The sample population
encompassed 180 women aged 40−60 years, who
filled out a self-completion questionnaire.
Assessment of women’s knowledge about pe-
rimenopause was performed using a questionna-
ire that was, according to the available literature,
specially designed to meet the criteria of this re-
search. The questionnaire consisted of two parts
(2−4). The first section contains 23 statements on
perimenopause and changes characteristic for this
period of woman’s life. The statements were gro-
uped into four domains: „the term menopause and
perimenopause“, „changes during perimenopause
period“, „preventive measures during perimeno-
pause“ and „hormone replacement therapy during
perimenopause“. The participants could designate
each statement as „true“, „false“ or „I don’t know“.
The second section of the questionnaire contained
basic socio-demographic data, data on general he-
alth status and reproductive health, as well as so-
urce of information about perimenopause.
1675
HealthMED - Volume 5 / Number 6 / 2011

Statistical data analysis Results

Statistical evaluation of the obtained data was Out of 200 distributed questionnaires, 180 were
performed using SPSS Statistics base 14.0 for Win- returned to the researcher indicating a response rate
dow software. Demographic data on sample po- of 90%. Thus, the sample population included 180
pulation, true and false answers were represented women aged 40−60 years from Sombor (80%) and
using descriptive statistics, i.e. absolute and relative Novi Sad (20%). The majority of participants aged
numbers. The statements designated with „I don’t 40−47 years (43.9%). Most of them were married
know“ were classified as false answers, as they in- (70.6 %), employed (82.8%) and with secondary
dicate lack of knowledge on the statement. Com- education (66.1%). Further socio-demographic
parison of attributive characteristics (socio-demo- characteristics are displayed in Table 1.
graphic, data on health status and information sour- As regards the health status, regular menstrual
ce) and knowledge level for each subscale item was cycle was reported by 44.1% participants, whilst
performed using Pearson χ2 test. The values p<0.05 hypertension and diabetes were reported by 24.6%
were considered statistically significant. and 3.2% (6 participants), respectively. Osteopo-
rosis was reported by 2 (1.1%) participants, as
well as history of hysterectomy. The most pre-
Ethical aspects valent reported contraception method was coitus
interruptus (40.6%), and 65% participants have
Prior to the interview, women were informed never nor would ever use HRT to ease perime-
of the study’s purposes and procedures. Consent nopausal problems. Some further data on health
forms were then obtained from those who agreed status of the participants are presented in Table 2.
to participate in this study. To ensure the confiden- The most prevalent source of information abo-
tiality and protection of the participants, all que- ut perimenopause is television and magazines, and
stionnaires were coded as numbers. Participants’ the least information is obtained by health profe-
names were not used as identifiers. ssionals (Graph. 1).
Table 1. Distribution of participants according to socio-demographic characteristics
Socio-demographic characteristics of the investigated women population N %
40− 47 years 79 43.9
Age categories
48–52 years 58 32.2
53 and more years 43 23.9
Total 180 100.00
Single 14 7.8
Married 127 70.6
Marital status
Divorced 27 15.0
Widowed 12 6.7
Total 180 100.00
Employed 149 82.8
Employment status Unemployed - housewife 9 5.0
Retired 22 2.2
Total 180 100.00
Incomplete primary education 5 2.8
Primary education 15 8.3
Education level
Secondary education 119 66.1
College / Higher education 41 22.8
Total 180 100.00
N = Absolute frequency; % = Relative frequency

1676 Journal of Society for development in new net environment in B&H

 HealthMED - Volume 5 / Number 6 / 2011

Table 2. Distribution of participants according to health status

Health status of the investigated women population N %
Regular 79 44.1
Menstruation Irregular 33 18.4
Without bleeding for more than 1 year 67 37.4
Total 180 100.00
Elevated blood pressure 46 24.8
Heart attack 1 0.54
Stroke 0 0
Disease Diabetes 6 3.2
Osteoporosis 2 1.1
Hysterectomy 2 1.1
None 128 69.1
Total 185 100.00
Coitus interruptus 72 40.6
Condom 19 10.8
Vaginal diaphragm, gel or pills 7 3.9
Contraception
IUCD / coil 17 9.6
Oral contraceptives 11 6.2
Combination thereof 51 28.8
Total 177 100.00
Administration of hormone replacement Yes 63 35
therapy to ease perimenopausal problems No 117 65
Total 180 100.00

use“ was inadequate, revealing 47% of correct

Graph 1. Distribution of perimenopause infor-
mation source
Simple distribution analysis of answers to qu-
estionnaire statements revealed the number of
correct answers ranging from 9 (39.1%) to 21
(91.3%) with an average rate being 15.6 (67.8%).
The participants were best informed on state-
ments of the subscale „the term menopause and
perimenopause“ (90.3%) and „preventive mea-
sures during perimenopause“ (71.8%), whereas
knowledge on statements from the subscale „hor-
mone replacement therapy during perimenopa-
answers.
Nearly all women (96.1%) new that Before in-
troducing hormone replacement therapy during
climacterium period each women should get in-
formed about its negative and positive effects, and
that Most common symptoms indicating that a wo-
man experiences climacterium period besides the
stop of menstrual bleeding are: hot flashes, night
sweats, joint and bone aches and pains (95%).
Ninety percent of the participants new that most
important preventive measures against cardiovas-
cular disease are to replace bad habits (smoking,
avoiding alcohol) with healthy lifestyle.
A half of participants (50%) designated the
statement Hormone replacement therapy is the
only way to overcome menopausal disturbances
as „true“. Almost half (47.2%) participants con-
sidered that Osteoporosis is not preventable, and
82.2% did not know that Hormone replacement
therapy with estrogen and progesterone decreases
the risk of endometrial cancer, (Table 3).

Journal of Society for development in new net environment in B&H 1677

HealthMED - Volume 5 / Number 6 / 2011

Table 3. Distribution of correct and incorrect answers in the Questionnaire, of χ2 test and p values
% %
Statements about perimenopause N correct incorrect χ2 p
answers answers
1. Climacterium period is the transition period in a woman’s life
characterized by gradual loss of ovary function, i.e. decrease in 180 93.3 6.6 135.2 0.00
production of sex hormones - estrogen and progesterone.
2. Climacterium period encompasses period before complete stop of
180 93.8 6.2 138.7 0.00
menstrual bleeding, characterized by irregular menstrual cycles.
3. Menopause implicates complete stop of menstrual bleeding (not
180 83.8 16.2 82.6 0.00
related to pregnancy)
4. Bleeding from the vagina after complete stop of menstrual
180 81.6 18.4 72.2 0.00
bleeding is normal and one shouldn’t seek a medical advice
5. Most common symptoms indicating that a woman experiences
climacterium period besides the stop of menstrual bleeding are: hot 180 95 5 145.8 0.00
flashes, night sweats, joint and bone aches and pains
6. It is impossible to get pregnant during climacterium period. 180 68.8 31.2 25.7 0.00
7. Depression is normal manifestation during climacterium period 180 37.7 62.2 10.7 0.00
8. Decreased interest in sex is common symptom of climacterium
180 47.7 52.3 0.35 0.55
period
9. Women in climacterium period should visit a gynecologist only if
180 88.8 11.2 108.9 0.00
they notice some disturbances.
10. All women over 20 should perform self-exam monthly 180 82.8 17.2 77.3 0.00
11. Screening mammography is necessary only in women who are
180 80.5 19.5 67.2 0.00
at high-risk of breast cancer.
12. Smoking is the only environmental factor proved to prompt the
180 6.7 93.3 135.2 0.00
onset of menopause.
13. Papa test can detect endometrial cancer in an early stadium 180 86.1 13.9 93.9 0.00
14. Papa test is recommendable only to women at climacterium
180 89.4 10.6 112.0 0.00
period
15. Osteoporosis leads to frequent spontaneous bone fractures and
180 80.5 19.5 67.2 0.00
prolonged healing period
16. Osteoporosis is not preventable 180 52.8 47.2 0.55 0.45
17. Cardiovascular diseases as well as osteoporosis are more
180 60 40 7.20 0.00
prevalent during climacterium period
18. Most important preventive measures against cardiovascular
disease are healthy diet. regular aerobic exercise to replace bad 180 90 10 117.4 0.00
habits (smoking, avoiding alcohol) with healthy lifestyle
19. Hormone replacement therapy during climacterium period
180 44.4 55.6 2.22 0.13
implicates administration of sex hormones
20. Hormone replacement therapy is the only way to overcome
180 50 50 0.00 1.00
climacterium -related disturbances
21. Hormone replacement therapy with estrogen and progesterone
180 27.2 72.8 37.3 0.00
decreases the risk of breast cancer
22. Hormone replacement therapy with estrogen and progesterone
180 17.8 82.2 74.7 0.00
decreases the risk of endometrial cancer
23. Before introducing hormone replacement therapy during
climacterium period each women should get informed about its 180 96.1 3.9 153.1 0.00
negative and positive effects

1678 Journal of Society for development in new net environment in B&H


Majority of participants (93.3 %) didn’t know
that Smoking is the only environmental factor pro-
ved to prompt the onset of menopause.
Further analysis revealed statistically significant
difference with regard to knowledge on „preventi-
ve measures during perimenopause“ in relation to
education level (p=0.002). Women with secondary
or higher education gave substantially more correct
answers compared to women with incomplete se-
condary education or primary education.
As regards other subscales, the relation between
knowledge level and sociodemographic charac-
teristics (marital status, age, employment status)
was not statistically significant. Also, perimenopa-
usal knowledge of women in relation to menstrual
status, diseases, contraception method, and use of
HRT and information source was not significantly
related with knowledge level of participants.
Discussion
The mean number of correct answers to the
statements from the questionnaire indicates good
overall perimenopausal knowledge level in po-
lled women population. Such a good result can be
explained by relatively homogenous sample po-
pulation encompassing mainly employed women
with college-level or higher education. Further-
more, education proved to be the only sociodemo-
graphic characteristic relevant for perimenopausal
knowledge level among women participating in
this research, which corresponds with the results
of other researchers (2−6). Appling’s study reports
on the following parameters, besides education
level, influencing perimenopausal knowledge in
women: talking with a healthcare provider, being
employed and being below 60 years of age (4).
Women with higher education level are most pro-
bably more open to new ideas, less prone to preju-
dice and more oriented towards competent infor-
mation. However, on analyzing the overall level
of perimenopausal knowledge in women one has
to take into account that choosing between only
two answers, i.e. true or false, implies greater
possibility of giving a correct answer. Further-
more, if the participant designated the statement
Hormone replacement therapy with estrogen and
progesterone decreases the risk of breast cancer
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
as „false“ this still does not necessary mean that
she knows the right answer. She can perceive that
HRT with estrogen and progesterone increases the
risk of breast cancer or that HRT is not at all asso-
ciated with breast cancer risk. Taking all that into
consideration, we may conclude that the obtained
results might overestimate the level of perimeno-
pausal knowledge in women.
Fair, but not sufficient knowledge on perime-
nopause was observed in women participating in
a research in the State of Maryland. Average score
on the scale ranging 0-7 was 4.5 for women who
are not undergoing (HRT) and 5 for women un-
dergoing HRT (4). Significantly higher level of
knowledge than expected is explained by the fact
that participants were recruited on an occasion
of regular voluntary mammography examination
suggesting a higher level of health literacy (4).
However, research conducted among women of
Northern Taiwan revealed poor level of perimeno-
pausal knowledge, but it is still to be emphasized
that Questionnaire used in this research included
126 statements (2).
Majority of participants in this study was infor-
med about „the term menopause and perimenopa-
use“ indicating that most of them are acquainted
with the meaning of terms menopause and perime-
nopause. In this Questionnaire we used the term
“climacterium period” instead of “perimenopau-
se” since it is widely used and recognized among
the general population, and it can designate the
perimenopausal as well as postmenopausal peri-
od. The term is, however, not common in the pro-
fessional and scientific community where terms
menopause, perimenopause and postmenopause
are accepted and clearly defined. It is necessary to
acquaint the women in the general population with
these terms, since differentiating between terms
menopause, perimenopause and postmenopause
is of great importance for a woman in order to
perceive her status and the characteristics of each
particular stage.
High knowledge level among the participants
was observed regarding the subscale „Preventive
measures during perimenopause“. The research
of Lee-Ing also revealed highest knowledge level
on the subscale „Preventive measures during peri-
menopause“ followed by score regarding subscale
„Perception of perimenopause“ (2). However, on
1679
HealthMED - Volume 5 / Number 6 / 2011
analyzing each particular item from the subscale
„Preventive measures during perimenopause“one
can conclude that women are not equally aware of
all risks of perimenopausal period. In that respect,
majority of participants recognized the most im-
portant preventive measures for cardiovascular di-
sease. This information is highly important since
cardiovascular disease is the leading cause of mor-
tality among this population, though preventable.
Most participants were familiar with the purpose
of PAPA-test and mammography, as well as with
the target patient population. It is also to be emp-
hasized that even though the participant answered
that Papa test is recommendable only to women at
climacterium period it does not necessarily mean
that she knows how often this test is to be per-
formed and in which women population. A certain
awareness of need and methods for early detection
of breast and endometrial carcinoma was observed
among the participants, which is of much impor-
tance since it is well established that those are the
most prevalent cancers among women (9). High
rate of lethal outcomes (80%) is characteristic for
the developing countries, which is mainly due to
limited availability of screening programs, i.e. late
establishing of the diagnosis (9). In that respect,
the awareness of need and methods of early dia-
gnosis of such diseases is of utmost importance.
19.5% women were not familiar with the term
osteoporosis, and almost a half of participants per-
ceived that Osteoporosis is not preventable. Hen-
ce, the women are not adequately informed about
its importance or prevention measures suggesting
a foremost need of increasing awareness of osteo-
porosis as one of the late consequences of meno-
pause. The disease evolves in response to both ge-
netic and environmental factors; however, several
aspects of their preventions are available.
Lack of awareness that Cardiovascular dise-
ases as well as osteoporosis are more prevalent
during climacterium period was observed in 40%
of women. That suggests that women, though
aware of prevention measures for cardiovascular
disease, are not aware of increased risk of their
development during perimenopausal period. In a
study conducted in Idaho, U.S.A., the majority of
women designated osteoporosis as the highest risk
of perimenopausal period, whereas cardiovascular
disease was ranked as the fifth health risk of this
1680 Journal of Society for development in new net environment in B&H
period (3). Less than half of the women encom-
passed by Appling’s study were aware of increase
risk and prevalence of cardiovascular disease du-
ring perimenopause (4).
Nearly none of the participants was aware that
Smoking is the only environmental factor proved
to prompt the onset of menopause. This might be
explained by insufficient emphasis of the impact
of smoking on female reproductive organs and
hence hormonal changes during perimenopause.
Statements from the subscale „Changes during
perimenopause period“ pertain to physiological
changes associated with decreased production
of sex hormones during perimenopausal period.
Contrary to the women from Northern Taiwan that
exhibited the lowest knowledge rate regarding this
subscale (2), more than a half of participants in our
study were familiar with physiological changes
characterizing perimenopause. However, one fifth
of the participants believed that Bleeding from the
vagina after complete stop of menstrual bleeding
is normal and one shouldn’t seek a medical advi-
ce, which is highly important considering that it
often indicates presence of benign or malignant
uterine tumors. One third of the participants an-
swered that pregnancy is not possible during peri-
menopause, whilst coitus interruptus was stated as
preferred contraceptive method. All this suggests
that large percentage of women undergoing peri-
menopause is at risk for unwanted pregnancy.
It is noteworthy to emphasize that more than a
half of women perceived that Depression is nor-
mal manifestation during climacterium period.
Depression is not normal manifestation of the pe-
rimenopause; however, it is quite rare (13). Still,
about 19−29% women undergoing perimenopau-
se experience some depression episodes, irritabili-
ty or mood swings (13). It is still unclear, whether
and how many participants of this research consi-
dered „depression“ clinical illness or only „depre-
ssing mood“, and whether we should expect them
to distinguish between those two terms. Anyway,
it is important to know the line between the sad-
ness and depressing mood and clinical depression
in order to distinguish normal from pathological
manifestation during perimenopause.
Participants in this study were least informed
about Hormone replacement therapy during peri-
menopause. Though all women knew that before

introducing hormone replacement therapy during
climacterium period each woman should get in-
formed about its negative and positive effects,
more than a half of them didn’t know what exactly
HRT is during perimenopause. Moreover, women
are neither aware of the role of HRT as a risk fac-
tor for breast cancer development nor of protec-
tive role of combined (estrogen and progestero-
ne) HRT in malignant endometrial tumors. Most
women stated that they wouldn’t ever use HRT to
ease perimenopausal disturbances, whereas half
of them didn’t know anything about alternative
methods for relieving such manifestations. The re-
search of Lee-Ing revealed better information rate
concerning HRT (2). Our research that encompa-
ssed 200 women from Novi Sad and its municipal
area showed significantly higher knowledge level
in participants living in urban environment then
in women from the surrounding villages (6). In
that respect, poor interest of women for HRT can
be explained by their insufficient or inadequate
knowledge on advantages and drawbacks of this
therapy. Their insufficient or inadequate knowled-
ge may result from lack of communication with
healthcare professionals, i.e. inadequate informa-
tion originating from incompetent sources. It can
be supported by the fact that women obtain infor-
mation on perimenopause from unprofessional so-
urces such as television and magazines, and profe-
ssional source of information (physicians, nurses)
are the rarest ones. A range of studies conducted
in diverse environments reported on highest pre-
valence of incompetent sources (3,4,6).
Research conducted by North American Me-
nopause Society (NAMS) revealed that only one-
third of women get informed about perimenopause
by their physicians, and such information mostly
does not pertain to issues that women consider
important: long-term consequences of menopau-
se, osteoporosis, cardiovascular disease and alter-
native methods to HRT to relieve perimenopausal
disturbances (5). Women often hesitate to talk and
pose delicate questions, thus healthcare providers
need to initiate the conversation and to recognize
which information is to be provided to particular
women categories.
Limitations of this study arise from the small
and relatively homogenous sample, thus our fin-
dings might not be generalizable. Choosing
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
between only two answers, true or false, reduces
sensitivity and specifity of the questionnaire. In
other words, if the participant designated the sta-
tement as false, it does not necessarily mean that
she knows the correct answer. However, this study
indicated the “weak spots” of perimenopausal
knowledge of women. It is particularly important
in a view of lack of any known study aimed at de-
termining the level of perimenopausal knowledge
in women in Serbia.
Contribution of this study is reflected in empha-
sizing the need of further investigation in this area.
The level of knowledge of unemployed women,
housewives, women with lower education level?
Is it and to which extent their knowledge different
from knowledge level of educated and employed
women? Would a differently designed instrument
reveal different results?
Conclusion
-- General level of perimenopausal knowledge
in women and health risks associated with
this period of life is relatively satisfactory,
reaching a rate of 67,8% correct answers.
However, analysis of items from each
subscale revealed some weak points
concerning particular aspects of the
knowledge: HRT during perimenopause,
prevention of osteoporosis, contraceptive
measures during perimenopause,
distinguishing between depression and
depressive mood, vaginal bleeding after
menopause, impact of smoking on hormonal
changes during perimenopause
-- Education level is the only sociodemographic
characteristic which significantly affects
level of perimenopausal knowledge in
women. Higher education level implicates
better perimenopausal knowledge in
women.
-- Menstrual status does not affect the level of
perimenopausal knowledge of women.
-- Dominant information sources of
perimenopausal knowledge are non-
professional sources – television and
magazines.
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HealthMED - Volume 5 / Number 6 / 2011
Recommendations for development of an
education program
Education of women about perimenopause
should be organized activity based on novel sci-
entific accomplishments and established level of
perimenopausal knowledge of women.
Education should encompass all women at pe-
rimenopausal age, taking into consideration the
differences regarding the knowledge level related
to education background. Professional informati-
on sources on perimenopause should be available
in the community, i.e. the living and working en-
vironment (companies, public institutions, esta-
blishments dealing with cosmetic treatments, be-
auty salons, etc.).
Education process should include modern tea-
ching methods and equipment: lectures, debates,
movies, presentations, posters, etc.
Education program should encompass all as-
pects of perimenopause: definition of terms,
physiological changes, health risks, prevention
measures for most common diseases associated
with this period of woman’s life, role of HRT and
alternative methods for relieving perimenopausal
disturbances.
References
1. The Board of Trustees of the North American Meno-
pause Society (NAMS). Estrogen and progestogen
use in postmenopausal women: 2010 position state-
ment of The North American Menopause Society.
Menopause: The Journal of The North American
Menopause Society 2010; 17(2):242-55.
2. Tsao L-I, Chang W-Y, Hung L-L, Chang S-H, Chou
P-C. Perimenopausal knowledge of mid-life women
in northern Taiwan. Journal of Clinical Nursing
2004; 13:627–35.
3. Clinkingbeard C, Minton BA, Davis J, McDermott
K. Women’s knowledge about menopause, hormone
replacement therapy (HRT), and interactions with
health care providers: an exploratory study. Jour-
nal of Women’s Health & Gender-based Medicine
1999; 8(8):1097-101.
4. Appling SE, Allen JK, Van Zandt S, Olsen S, Bra-
ger R, Halerdin J. Knowledge of Menopause and
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Hormone Replacement Therapy Use in Low-Inco-
me Urban Women. Journal of Women’s Health &
Gender-based Medicine 2000; 9(1): 57-64.
5. News Watch. Women’s Knowledge of Menopause
Limited. Geriatric Nursing 1994; 15(3):122-25.
6. Stajić D, Stević S, Višnjevac D, Bujas M. Menopa-
uza-način informisanja o simptomima, rizicima i
prevenciji. Medicina danas 2008; 7:379-86.
7. Jassim GA. Attitudes of Bahraini women towards
the menopause: Implications for health care policy.
Maturitas 2008; 59:358–72.
8. Republički zavod za statistiku. Statistički kalendar
Srbije 2010. Dostupno na: http://webrzs.stat.gov.
rs. Pristupano: 11.11.2010.
9. World Health Organization. Adult women.
In:Women and health : today’s evidence tomorrow’s
agenda 2010;51-58. Dostupno na: http://www.who.
int. Pristupano: 1.11.2010.
10. Colleen K, Fullerton J, Fleury J. Primary and se-
condary prevention strategies among older pos-
tmenopausal women. Journal of Nurse-Midwifery
1998;43(4):262-72
11. Miladinov-Mikov M. Epidemiologija malignih ne-
oplazmi. U: Jovanović D. Onkologija i palijativna
nega onkoloških bolesnika. Novi Sad: Medicinski
fakultet, 2008:143-59.
12. Chang SH,, Kim C-S, Lee K-S, Kim H, Yim S-V,
Lim Y-L et.al. Premenopausal factors influencing
premature ovarian failure and early menopause.
Maturitas 2007; 58: 19–30.
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Best Practice & Research Clinical Obstetrics and
Gynecology 2006; 20(6):799-839.
Corresponding author
Dragana Milutinovic,
University of Novi Sad,
Faculty of Medicine,
Department of Nursing,
Serbia,
E-mail: healthmedjournal@gmail.com

Cryopreservation - challenge of
platelet concentrates long time
preservation
Radmila Jovanovic¹, Jasmina Grujic¹, Vladan Radlovacki², Bato Kamberovic²
¹ Blood Transfusion Institute of Vojvodina, Medical Faculty of Novi Sad, Serbia,
² Faculty Of Technical Sciences, Novi Sad, Serbia.
Abstract
Introduction: Shelf life of liquid platelet con-
centrates in storage conditions, defined character-
istics of containers and storage media today, is lim-
ited from 5 up to 7 days. As clinical use of labile
blood products is growing from year to year, and
number of donated blood units does not always
follow the needs, finding out how to enable long-
term storage of human platelets is a priority task
of transfusion facilities and experts. Cryopreser-
vation is one of the possibilities for extending the
storage period of this labile blood component.
Aims: Aims of this study are determination of
morphological, biochemical and functional chang-
es of platelets that arise in the cryopreservation pro-
cess and proving that number and function of plate-
lets are kept within satisfactory limits. This would
enable formation of banks of frozen platelets.
Methods: Dynamic testing was conducted us-
ing 40 platelet concentrates isolated from whole
blood units using platelet rich plasma (PRP)
method, frozen at -86ºC in a mechanical freezer,
with 5% DMSO as a cryoprotectant. Tests in vitro
were performed in samples of whole blood, fresh
platelet concentrates, concentrates after thawing
(with DMSO) and concentrates after washing and
resuspending platelets in autologous plasma. Pa-
rameters treated are: platelet count, average plate-
let volume, pH of the concentrate, morphological
score, platelet aggregation induced by ADP and
collagen, percent of CD62P and release of platelet
factor 4 in plasma.
Results: Using PRP method, approximately
70% of platelets are extracted from whole blood
units, where 80% of platelets retain its functional
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
discoid shape with slightly manifested changes of
ultrastructure. In the fresh concentrate approxi-
mately 20% of platelets are activated. This is fol-
lowed by a decrease of aggregation response to
the induction by ADP and collagen for approxi-
mately 25%. The increase of released PF4 is in
correlation with these findings. Decrease of num-
ber of platelets in concentrates (14%), decrease of
platelet morphology score (25%), increase of the
number of activated platelets (23%), the amount
of released PF4 (26%) and decrease of aggrega-
tion response for 50% are characteristics of fro-
zen, thawed and unwashed platelet concentrates.
Morphological distribution of platelet concentrate
after washing the DMSO and resuspending of
platelets in autologous plasma indicates the revi-
talization of a certain number of platelets, followed
by the increase of percentage of platelets with dis-
coid form and, consequently, by the increase of
the morphological score of platelets. According to
morphological recovery of platelets, function re-
covery was determined. It is manifested by better
aggregation response of washed platelets to induc-
tion by ADP and collagen, by approximately 20%.
Discussion: Numerous testing of platelets le-
sion in vitro were carried out using different ex-
perimental models of the cryopreservation pro-
cess. Great deal of authors agree that the most suit-
able cryoprotectant is DMSO. Higher concentra-
tions of DMSO cause greater damage to platelets
and in vivo tests have uncovered adverse effects in
transfusion recipients. The whole process of cryo-
preservation is followed by the loss of a number of
platelets and the increase of activation percentage.
Morphological changes caused by freezing and
by cryoprotectant after re-suspending of platelets
1683
HealthMED - Volume 5 / Number 6 / 2011
in autologous plasma are reversible to a degree
which corresponds with recovering of aggrega-
tion function. Finding the optimal concentration
of cryoprotectant which does not require washing,
appropriate freezing techniques and the optimal
solution for storage, remains a major challenge for
transfusion experts.
Conclusion: The research confirmed recove-
ry of approximately 60% of platelets after cryo-
preservation. Around 56% of platelets retained
functional - discoid shape. Platelet aggregation
after cryopreservation was reduced for little less
than 50%. During all stages of cryopreservation
an activation of a number of platelets takes pla-
ce, accompanied by an increase of PF4 (for about
30%). These results confirmed the possibility of
applying defined experimental model for future
work. Taking into account these changes, it is the
assumption that the application of 2 units of cryo-
preserved platelets could have the same therapeu-
tic effect as using 1 unit of fresh concentrate. The
results of this study provide the basis for further
clinical research of cryopreservated platelets effi-
ciency in vivo, i.e. test their survival and preserva-
tion of function in patients after transfusion.
Introduction
Modern transfusion treatment of patients re-
quires daily efforts from blood banks to provide
sufficient quantities, not only of whole blood, but
also of blood products. However, given the insuf-
ficient number of donors, these requirements can
not be met any time, which affects the efficiency
and efficacy of whole patients' treatment. In or-
der to mitigate the disproportion between require-
ments and abilities to provide sufficient quantities,
transfusion facilities have to apply all available
methods and ensure the most suitable storage con-
ditions in order to preserve quality of blood and
blood products.
Treating malignancies, chemotherapy and ra-
diotherapy are the main power points of therapeu-
tic approaches. These treatments require intensive
supportive transfusion therapy comprising prophy-
lactic or substitution application of red blood cells
and platelets (1,2). Transfusion centers all around
the globe are under increasing pressure to ensure
1684 Journal of Society for development in new net environment in B&H
sufficient number of platelet concentrates (PCs).
Today, most transfusion centers use polyethylene
blood bags for the preparation of PCs and storage
of platelets in autologous plasma at 22°C, with con-
stant agitation. After separating from whole blood,
liquid platelets can be successfully stored for 5-7
days in autologous plasma. Prolonged storage cause
metabolic and functional lesions which decrease of
platelets effectiveness after transfusion.
Intensive increase of platelets use in treating
many diseases placed this unstable blood product
into the focus of scientists' interest. Many research-
ers emphasize that the platelet storage lesions in-
volve a number of processes beginning with act
of venepuncture of blood donor. These processes
are caused by physical, chemical and metabolic
factors related to the platelet separation, method
of preparation and storage conditions. Most im-
portant, among them are: storage temperature,
duration of storage, storage solution (plasma or
an additive solution), pH, contamination of leu-
kocytes and characteristics of plastic containers.
Storage lesions include a series of morphological
(structural), biochemical and functional changes
of platelets (3-18). These lesions are the indication
of activating complex processes whose essence
is the release of granule contents, modification of
membrane constituents and changes in functional
responses of platelets (19-24).
A panel of in vitro tests as a true indicator of the
functional status of platelets is still not uniformly
defined, as well as the set of prognostic parameters
for their haemostatic function and survival in vivo.
To monitor changes of platelets during their tran-
sit in vitro conditions in PCs, a series of analysis is
developed. They include measuring of: pH, platelet
count, cytozoil lactate dehydrogenase release (as
marker of platelet lysis), release of b-thromboglob-
ulin and platelet factor 4 (PF4), serotonin release,
morphological score (MS), the answer to hypotony
shock (osmotic recovery) etc. Metabolic tests in-
clude the production of lactate and glucose con-
sumption, measurement of pO2, pCO2 and HCO3.
The latest research include changes in glycoproteins
of platelet membrane: GP IIb / IIIa complex, GP Ib
and GMP-140 (P-selectin, a - granule membrane
protein, or CD62P). During platelets activation,
surface glycoproteins change, with some becoming
expressed (eg, GPIb / IX complex, thrombospon-

din). GMP-140 is released from a - granules and
rapidly redistributed over the plasma membrane,
where it behaves as adhesion molecule for macro-
phage-mononuclear phagocytic system (MFS) (25-
30). It is still not sufficiently clear how activation
of platelets, which occurs during storage, affects
the recovery and survival of platelets after transfu-
sion. Despite the explosion of information which
covers different fields of platelet storage lesion mo-
saic, practical laboratory procedures and techniques
used to examine damage are not readily applicable
in practice.
The possibility of freezing the platelets and pre-
serving their functionality has been a subject of in-
terest of many transfusion medicine specialists at
the end of the last century and has remained current
until today. Several methods of freezing the plate-
lets using dimethylsulphoxide (DMSO), glycerol or
hydroxyethyl - starch (HES) as cryoprotectant solu-
tion was described. Tests of morphological and fun-
ctional lesions yielded different results. DMSO is
proved to be best cryoprotectant. Numerous studies
have shown that human platelets, as well as erythro-
cytes, are partially damaged in their morphological,
biochemical and functional integrity. These lesions
cause decreased haemostatic function of platelets
after transfusion (31-33).
Production of cryopreservated platelet concen-
trates (PCs) would enable forming the banks of
rare blood groups PCs, and banks of autologous
platelets from hematological patients, isolated in
the period prior to transplantation. Frozen plate-
lets would find its application at the patients who
have developed refractoriness to the transfusion of
platelets prepared from unselected units of blood.
On the other hand, determining the method of pre-
paring the frozen platelets would allow far more
rational use of blood, because each unit of blood
obtained from donors could be used as a source of
platelets. This is especially important during year
periods with blood shortage, while, on the other
hand, there are periods of the year with surplus of
collected blood.
A significant increase in the use of PCs in the
thrombocytopenia therapy during the last two de-
cades puts this blood product in the center of inte-
rest. In recent years efforts have been intensified to
improve techniques of preservation and to search
for alternatives to platelet transfusions. These re-
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
searches are still in the experimental phase (hema-
topoietic cytokines IL-6, IL-11, thrombopoietin
and others). No less important are works on de-
veloping techniques of preparation and prolonged
storage of human platelets.
The research was inspired by an intention to
study the complex problem of PCs cryopreservati-
on, and to analyze it by estimating functional inte-
grity of the smallest, metabolically most active and
biologically most vulnerable blood cells - platelets.
Research aims
The aims of the research is to examine the mor-
phological, biochemical and functional changes of
platelets in the process of cryopreservation of PC
from whole blood units and to prove the preserva-
tion of count and platelet function in a satisfactory
percentage, which could enable formation of fro-
zen platelet concentrates banks.
Materials and methods
Dynamic testing was carried out on 40 units
of platelet concentrates separated from whole
blood units of 450ml, taken in a 4 plastic blood
bag system, frozen at -86ºC in 5% DMSO using
a mechanical freezer. Thawing of the concentrate
was performed in a water bath at 37ºC with mild
shaking, after which platelets were washed and re-
suspended in autologous plasma.
In the experiment the following parameters
were determined: the absolute number of platelets
in the PC unit, average platelet volume (MPV),
pH of the concentrate, the morphological score
of platelets, platelet aggregation induced by ADP
and collagen, marker of platelet activation CD62P
and plasma platelet factor 4 (PF4). It was carried
out through 4 phases:
· Phase 1 - Whole blood unit
· Phase 2 - Fresh platelet concentrate
· Phase 3 - Platelet concentrate - with
DMSO, thawed after freezing
· Phase 4 - Final platelet concentrate
(washed and resuspended in autologous
plasma).
1685
HealthMED - Volume 5 / Number 6 / 2011
Platelet count and average volume were deter-
mined in samples of whole blood and samples of
PCs in all phases of preparation of final product
- frozen-defrosted-washed platelet concentrate. 3
ml of whole blood and 3 ml of platelet concentrate
collected in plastic test tubes were used for testing.
Platelet counting was performed using hematolo-
gy analyzer AL 816 for in vitro determination of
16 hematology parameters.
Monitoring platelets' morphological changes
through all the phases was done by calculating the
morphological score of platelets. The presence of
altered forms of platelets in all samples was de-
termined by phase contrast microscopy. Platelets
were observed in native preparations immediately
after sampling, with immersion using AXIOLAB-
ZIISS microscope with the magnification of 400
X. According to presence of various forms of pla-
telets, using a standardized scale with values ​​0-4
(ballon formed = 0; dendritic = 1; spherical = 2;
discoid = 4) values ​​of the morphological score
were calculated. 100 cells within the visual field
were examined. The maximum value of the score
is 400. Acceptable morfological score values for
PCs are over 200.
BASIC pH meter was used to estimate the pH
values ​​of whole blood and platelet concentrates.
Platelet aggregation was measured in samples
of whole blood and platelet concentrates at all sta-
ges, using optical method, with CHRONO-LOG
Whole Blood Aggregometer. For examining the
aggregation, ADP (5 µmol/l) and collagen (50 µg/
ml) as agonist were used.
CD62P expression, as marker of platelet activa-
tion, was evaluated by a flow cytometer (FACSca-
liber, Becton Dickinson, Belgium) equipped with
Cell Quest software. Fluorescein isothiocyanate
(FITC) - conjugated anti - CD41 was used to iden-
tify the platelets. Phycoerythrin (PE)-conjugated
anti-CD62P was used as a marker for platelet ac-
tivation (Immunocytometry System, Becton Dic-
kinson, Belgium). Unstained samples and negati-
ve controls containing FITC-IgG1 and PE-IgG2α
were included with each analysis to estimate auto
fluorescence and non-specific binding, respective-
ly. The instrument setting was adjusted to a log
scale of 25,000. Platelets, identified according to
their position in forward angle and right angle li-
ght scatter, were acquired from each sample. The
1686
percentages of events with positive staining for
CD41 and CD62P were calculated.
To determine the concentration of PF4 (as a se-
cond marker of platelet activation) in this study,
quantitative enzyme immunoassay technique based
on a "sandwich" principle is used (Asserachrom
PF4, Boehringer Mannheim Diagnostica Stago).
Statistical methods used for the purpose of this
research are as follows. All of the parameter va-
lues are given by phases using basic descriptive
statistics (mean / dispersion). Relevant values are
interpreted using interval diagrams with appropri-
ate confidence intervals (for confidence level of
95%). Testing whether parameters differ signifi-
cantly between phases is carried out by one way
ANOVA. Relations between relevant parameters
in the research are determined by calculating the
correlation matrices of the parameters in resear-
ch phases (accompanied with corresponding in-
formation provided by p-values), while graphical
representation needed to illustrate results of the re-
search is given by creating a scatter diagram with
the regression line.
Results
Results of determining the number of platelets
through all the phases of preparing cryopreservated
PCs proved that the method of producing platelets
from platelet rich plasma (PRP) extracts approxi-
mately 68% of platelets from a whole blood unit.
Approximately 14% of cells is being damaged and
destroyed by adding DMSO during freezing and
thawing. The process of leaching cryoprotectants
is followed by the loss of another 32.66% of plate-
lets. Means of platelet counts in the PCs during all
phases of research are shown in table 1.
Platelet count in the final concentrate (phase 4)
was approximately 60% of initial value in a con-
centrate before freezing, and contained approxi-
mately 40% of platelets from the starting unit of
whole blood (Figure 1).
Average platelet volume, as an indicator of pla-
telet size changes is shown by phases in table 1.
Values indicate to a significant increase in volume
during the process.
Journal of Society for development in new net environment in B&H
 HealthMED - Volume 5 / Number 6 / 2011

Table 1. Means and dispersions of parameter values by phases and significance of mean differences
Parameter Phase 1* Phase 2† Phase3‡ Phase 4§
Number of platelets 105.21 70.95 61.25 41.24
N o / SD [10 /Unit]
9 19.99 5.66 12.58 9.50
MPV 7.74 6.95 7.76 9.0
MPV / SD [fl] 0.46 0.45 0.67 1.01
pH 7.29 7.38 7.54 7.22
pH / SD 0.15 0.16 0.23 0.12
Morphological score (MS) 384.90 360.90 269.35 299.98
MST / SD 6.82 13.35 26.69 23.65
Platelet aggregation induced with ADP 71.89 52.52 29.39 35.46
ADP / SD [%] 10.13 15.77 12.54 11.93
Platelet aggregation induced with collagen 80.91 59.68 37.16 41.70║
Collagen / SD [%)] 11.62 19.61 13.57 14.27
CD62P 2.31 18.53 23.21 31.50
C
D 62 P / SD [%] 1.49 5.29 5.79 9.78
PF4 70.00 92.00 116.15 124.70
P
F 4 / SD [IU/U] ¶ 10.25 13.05 7.10 9.24
* Phase 1 - Whole blood unit
† Phase 2 - Fresh platelet concentrate
‡ Phase 3 - Platelet concentrate - with DMSO, after freezing and thawed
§ Phase 4 - Final platelet concentrate (washed and resuspended in autologous plasma)
║ Parameter values with mean differences not significant compared with previous phase
¶ International units per blood unit

shaped platelets. After leaching toxic cryoprotec-

Figure 1. Interval plot of number of platelets in
research phases (at confidence level of 95%)
For the evaluation of structural changes of plate-
lets during the process of cryopreservation, a mor-
phological score of PCs were determined. Adding
cryoprotectant solution and freezing process is fo-
llowed by significant morphological changes of pla-
telets. This is evident by increased number of fun-
ctionally less valuable balloon shaped and dendritic
tants and resuspending platelets in autologous pla-
sma, approximately 10% of platelets revitalise and
get discoid shape again. Determined morphological
score (MS) values correspond with morphological
distribution of platelets during the study.
Number of disc-shaped platelets was reduced
by 12%, while a number of sphere-shaped pla-
telets increased by 11%. In PCs, after thawing,
there was much more functionally less valuable
dendritic and balloon-shaped platelets (approxi-
mately 20%). This affected the MS whose values ​​
ranged from 200 - 319 (Figure 2). After washing
and removing cryoprotectant and resuspension of
platelets in autologous plasma, a recovery of cer-
tain number of platelets took place, followed by
increasing of the percentage of disc platelet form
and the increase of MS - it reached the average
value of 299.98 (Table 1).

Journal of Society for development in new net environment in B&H 1687

HealthMED - Volume 5 / Number 6 / 2011
Figure 2. Interval plot of morphological score (MS)
in research phases (at confidence level of 95%)
Metabolic activity of platelets in vitro depends
on the permeability of plastic bags in which the pla-
telets are stored as well as of other factors that affect
metabolism and oxygen consumption. When the
anaerobic glycolysis overcomes, surplus of appea-
red lactic acid decreases the pH value of PC. When
the pH drops below 6.8, morphological changes
are manifested in changing the disc form to sphe-
rical form of platelets. These are followed by pse-
udopodia and platelet deregulation. Many of these
changes are reversible when platelets resuspend in
autologous plasma, at 37ºC within the physiologi-
cal pH range. High values ​​of concentrate pH also
adversely affect platelets. When the pH is greater
than 7.6, platelets aggregate, which decrease the
number of morphology functional platelets. In this
research, whole blood unit pH values ranged from
6.82 to 7.58, while the fresh processed concentrate
had a range of 6.90 to 7.64. Adding cryoprotectants
increased pH to 7.54. The average pH value of the
final concentrate was 7.22, and ranged from 7.00 to
7.56 (Table 1).
Keeping the platelet function in the cryopreser-
vation process is followed by determining the plate-
let aggregation induced by ADP and collagen. The
average platelet aggregation induced by ADP in
the sample of whole blood units was 71.89%, and
ranged from 48.48% - 88.25%. Blood processing
and separation of concentrated platelets leads to re-
duced responsiveness to the stimulating agent, and
the average value of aggregation in fresh processed
PCs was 52.52% (range 18.75% to 97.50%). Ad-
ding DMSO was followed by the inhibition of pla-
telet function which is followed by even larger fall
of aggregation stimulated with ADP (average value
was 29.39%). In final concentrates, after removing
1688
the DMSO and adding the autologous plasma, re-
covery of platelets count and increase of aggregati-
on responses was registered (Table 1).
Processing platelets from whole blood unit re-
duce the aggregation response of isolated concen-
trated platelets by 30%. In the process of freezing
with DMSO and thawing, the ability of platelet
responses to aggregation agent (ADP) decreased
by approximately 50% compared to the aggregati-
on of platelets isolated from units of whole blood,
or by 30% compared to fresh platelets. Correlati-
on analysis showed that the platelet shape change
was followed by the fall of morphological sco-
res and reduction of platelet function determined
as lowering the aggregation stimulated by ADP.
Platelets aggregation upon collagen stimulation
showed slightly better response of platelets in all
phases of testing (Table 1). Changes in aggregati-
on through research phases have reached statisti-
cal significance. Correlation analysis revealed the
existence of a high degree of correlation (r = 0.74)
between platelet aggregation responses to stimu-
lation with ADP and collagen through all stages of
cryopreservation. A positive correlation between
morphological changes and aggregation platelet
responses was also confirmed. Results of corre-
lation analyses of parameters through phases are
shown in tables 2 and 3.
The average value of CD62P positive platelets
in whole blood units was 2.31% and ranged from
0.05% to 6.05% (Table 1). During the processing
of PCs, approximately 18.53% platelets were acti-
vated (range 4.12 - 28.50%). Adding DMSO, free-
zing and thawing has led to more platelets activa-
tion, approximately 23.21%, ranged from 10.15 -
60.11%. Washing and final centrifugation of thawed
platelets causes activation of the largest number of
platelets, 31.50%, as is shown in figure 3.
Using correlation analysis a link between num-
ber of platelets in the PCs and the percentage of ac-
tivated cells in any phase is not determined (corre-
lation coefficients less than 0.1). On the other hand,
the research confirmed the significant relationship
between morphological changes of platelets and
their activation. Correlation analysis revealed the
existence of a negative correlation between MS and
CD62P positive platelets, both in fresh PCs (r = -
0.53) and in cryopreserved PCs (r = - 0.53). Decre-
ase of morphological score, caused by the decrease
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 HealthMED - Volume 5 / Number 6 / 2011

Table 2. Correlations between observed parameters in fresh platelet concentrate (phase 2)

Number of platelets MPV SCORE pH ADP Collagen CD62
MPV -0.068
SCORE 0.307 0.038
pH -0.265 -0.223 -0.039
ADP -0.068 0.021 0.244 0.056
Collagen 0.015 0.233 0.439** -0.113 0.274
CD62 -0.445** 0.058 -0.527** 0.11 -0.362* -0.372*
PF4 -0.327* 0.047 -0.460** 0.053 -0.405** -0.460** 0.857**
* Correlations signifficant (p < 0.05)
** Correlations signifficant (p < 0.01)

Table 3. Correlations between observed parameters in final (frozen, thawed, washed and resuspended)
platelet concentrates (phase 4)
Number of platelets MPV SCORE pH ADP Collagen CD62
MPV 0.18
SCORE 0.206 0.193
pH 0.113 0.279 0.221
ADP 0.298 0.275 0.434** 0.221
Collagen 0.161 0.122 0.466** 0.143 0.682**
CD62 -0.09 -0.184 -0.524** -0.024 -0.344* -0.402**
PF4 -0.219 -0.172 -0.497** 0.045 -0.522** -0.523** 0.831**
* Correlations signifficant (p < 0.05)
** Correlations signifficant (p < 0.01)

of disk-shaped platelets was followed by increase
in the number of activated cells.
Figure 3. Interval plot of CD62P in research
phases (at confidence level of 95%)
In accordance with previous results is the corre-
lation between activated platelets and their functi-
onal aggregation response to the ADP stimulation
and aggregation induction by collagen. Negative
Pearson's correlation coefficient between these
parameters is determined in fresh PCs as well as
in final products. As percentage of CD62P posi-
tive platelets was higher in the PCs, the response
of platelets to the aggregation stimulus was lower.
Despite the fact that the absolute values of correla-
tion coefficients were lower (- 0.37 and - 0.40) they
proved to be significant.
The average value of PF4 in units of whole blo-
od was 70 International Units (IU), while in fre-
sh concentrate it was 92 IU (range from 60 to 110
IU). Adding the DMSO, freezing and thawing ca-
used platelet lesions followed by increase of PF4
in plasma after concentrate thawing. The average
value of PF4 in washed, frozen and thawed PC was
124.70 IU, within the range from 95-140 IU (Table
1). Correlation analysis proved that there was no
relationship between platelet count in concentra-
tes and the release of PF4. In other words, a larger
number of platelets in the concentrate does not cau-
se platelet activation followed by increased release
of PF4. On the other hand, a significant negative
correlation between morphological score and rele-
ase of PF4 is determined.
When the morphological score is lower, more
PF4 is being released in the PCs. In the research

Journal of Society for development in new net environment in B&H 1689

HealthMED - Volume 5 / Number 6 / 2011
a negative correlation between the functional res-
ponse of platelets to the stimulation by aggregati-
on agonist and the amount of PF4 released in the
concentrate (Fig. 4) is revealed. As the amount of
lesion is higher, larger is the release of PF4 in the
plasma of PCs and percentage of platelet aggrega-
tion is lower. In the research a very high positive
linear correlation between two markers of platelet
activation, in all stages, of cryopreservation is de-
termined. As percentage of CD62P positive plate-
lets is higher in the concentrate, higher is the amo-
unt of released PF4. It means that both parameters
can be used with equal validity to estimate platelet
activation in concentrate.
Figure 4. Scatterplot of collagen induction aggre-
gation versus release of PF4 in research phase 4
Discussion
The mean platelet volume as an indicator of
changes in the morphology of platelets is the para-
meter frequently used for in vitro platelet resear-
ch. Relevant references emphasize differences in
the results caused by different types of equipment
for determining MPV, or by the implementation
of various preservatives (36,37). Slightly higher
values ​​are obtained when EDTA preservative is
used. Moroff et al. found value of average vo-
lume of platelet concentrate from freshly proce-
ssed (6.93fl), while Holme et al. point out that the
transformation of platelets form from disk into a
sphere is followed by platelet volume increase by
about 25% (30,38).
There is still no consensus about the limits of
pH in PC which causes irreversible platelets' lesi-
ons. Most of the authors believe that platelets lose
their viability when the pH drops below 6.2 as well
1690 Journal of Society for development in new net environment in B&H
as changes in them occur when the pH is lower
than 6.8, due to hypoxic conditions in vitro. There
is little information about which are critically high
pH values​​. Murphy reports about a weak correla-
tion of in vivo viability of platelets with the incre-
ase of pH in PC to 7.6 and over (11,15). Kunicki
emphasizes that lower pH is associated with lower
morphological scores, shortened survival and re-
covery of platelets (35).
All experiences gathered so far from various
researches of platelet function tell us that proce-
ssing and storage of liquid platelets triggers a seri-
es of their functional defects. Relevant references
report different levels of platelet aggregation re-
duction depending on type and concentration of
stimulating agent used (29,39-41). In this study,
slightly better response of platelets to collagen sti-
mulation then to stimulation by ADP is found. As
the morphological score gets lower, platelet aggre-
gation also decreases.
Recent studies suggest that platelet activation
plays a significant role in reducing the lesion and
function of platelets. Activation is caused by plate-
let separation process and poor or inadequate sto-
rage conditions. Until recently it was thought that
activated deregulated platelets more quickly get
lost from the circulation by binding to leukocytes.
Michelson's latest tests show contradictory results.
Namely, author points out that activated platelets
rapidly release surface expressed P-selectin into
plasma, after which they continue to circulate and
exert their function in the circulation (42). Today,
usual way to examine activation of platelets is by
determining the presence of P-selectin (CD62).
According to relevant references, the percentage
of activated platelets in whole blood units ranges
from 0.05 all the way up to 12%, indicating the
potential influence of blood donors' genetic fac-
tors to platelet activation. During PC processing,
20-30% platelets get activated. After 5 days of sto-
ring liquid platelets, in the PC there are as much
as 50% activated platelets (19,21,26,29,43,44,45).
The results of this study tell us that platelet factor
4 (PF4) in units of whole blood have significantly
higher initial values ​​of this factor compared to the
normal test applied commercially. It suggests that
PF4 is a very sensitive factor that is largely relea-
sed from platelets in vitro - when they are placed
in a plastic bag. The processing of whole blood

and separation of platelets causes further progre-
ssive release of PF4 proportionally to the degree
of platelet activation.
Djerassi et al. 1966 found that human plate-
lets remain in a large percentage intact during the
process of freezing and thawing when DMSO is
added into plasma before freezing. However, a
large number of cryopreservated platelets rapidly
is being removed from circulation after transfusi-
on. Authors concluded that improving methods of
cryoprotectants adding could increase platelet re-
covery in vivo (33). In the early seventies (of the
last century) initial attempts were made to freeze
platelets. The most often cryoprotective agent was
DMSO. Valeri et al. were freezing platelets using
a mixture of glucose and glycerol, while others
used hydroxyethyl starch as cryoprotective agent
(32,45,46-48). Studies were conducted using dif-
ferent experimental models depending on the type
and concentration of cryoprotectants and freezing
conditions. Based on the recovery and preserva-
tion of platelet function after cryopreservation, it
was concluded that the best results are achieved
with DMSO as a krioprotektivnog agents.
As the research was conducted with various
concentrations of DMSO and with different mo-
dels of freezing (controlled and uncontrolled), dif-
ferent results were obtained. Platelets frozen with
5% DMSO at a rate of 1°C/min, kept at -150°C or
with 6% DMSO frozen at a rate of 2-3°C/min and
stored at -80°C showed a 40-50% of therapeutic
effectiveness compared with fresh isolated pla-
telets. Satisfactory results of cryopreservation of
platelets were determined when they were frozen
with 5% DMSO in a specially programmed free-
zing process at rate of 1-3°C per minute. When
the freezing rate was increased to more than 5°C/
min, platelet lesions were much heavier (49).
Freezing platelets with 10% DMSO and freezing
rate of 8°C/min in the gas phase of liquid nitrogen
was unacceptable due to major damage. When the
freezing rate was 1°C/min, survival and function
of thawed platelets after transfusion was very si-
milar to the use of fresh platelets (64). Satisfactory
results of cryopreservation of platelets, were obta-
ined with the use of 4-6% concentration of DMSO
at the freezing rate of 1-3°C/min in a mechanical
freezer at a temperature of -80ºC (50). Influence of
cryoprotectants, various concentrations of DMSO,
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
freezing and thawing rates and their impact on the
platelet counts and their morphological distribu-
tion have been studied in many laboratories. Me-
largano was freezing platelets with 6% DMSO at
-80°C in PVC plastic and polyolefins bags and
found that in the process of cryopreservation in
vitro loss of platelets is about 25%. Platelet reco-
very after three years of storage was about 69%
(51). Corash, Owens and Barnard (52-54) proved
that cryopreservation causes platelet activation fo-
llowed by changes of platelet membrane proteins.
Summarizing the results of research of in vitro
recovery, the conclusion can be made that the re-
covery of cryopreservated platelets in the concen-
trate ranges from 60-80% while more than 50%
of platelets retains discoid shape depending on the
applied experimental model. Results of previous
studies suggest that platelet lesions can be minimi-
zed using programmed freezing with freezing rate
of 1°C per minute. Described cryopreservation
process requires appropriate equipment. This rese-
arch has shown in vitro recovery of approximately
60% of platelets after the process of cryopreserva-
tion, where 56% of platelets retain functional Dis-
coid shape. These results confirmed that further
application of described experimental model and
similar research are justified. The greatest loss of
platelets was found after washing (approximately
30%). This finding proves that platelets are very
sensitive to manipulation after thawing, primarily
during the spin rinsing. The loss of platelets in vi-
tro can be reduced if washing the cryoprotectant is
avoided. But, it increases the risk of adverse post-
transfusion reactions to DMSO and, on the other
hand, lesion of platelets in the PC after thawing.
Solution to this problem might be the re-suspensi-
on of platelets using optimal solution for their pre-
servation (for example, Thrombosol) that allows
cryopreservation of platelets with 2% DMSO,
where washing is not necessary (55,56).
Conclusion
Carrying out cryopreservation of platelets in 4
plastic bags closed system using a mechanical free-
zer it is possible to prepare a platelet concentrate
(PC) which can be stored extendedly. With platelet
rich plasma (PRP) method approximately 70% of
1691
HealthMED - Volume 5 / Number 6 / 2011
platelets can be extracted from whole blood units,
where 80% of platelets retain its functional disco-
id shape with slightly manifested changes in ultra-
structure. In fresh processed concentrate approxi-
mately 20% of platelets were activated. This is
followed by a fall of aggregation response of fresh
isolated platelets to the induction by ADP and co-
llagen by approximately 25%. In correlation with
these findings, noticeable increase of released PF4
is found as an evidence of platelets activation.
The cryopreservation process with use of 5%
DMSO leads to a decrease in the number of plate-
lets in PCs by approximately 14%. The influence
of cryoprotectants and processes of freezing and
thawing on the morphology of platelets was si-
gnificant. The average platelet volume increases,
number of disc shaped platelets in the concentrate
decrease, functionally less valuable forms appe-
ar, and morphology score decreases for 25%. The
process of cryopreservation activates 23% of pla-
telets in the PCs which correlates to the increase of
released PF4 (26%). Activation of platelets during
cryopreservation is followed by the decrease of
platelet function which is registered via reduced
responsiveness to aggregation agent for approxi-
mately 50%.
Findings of this study provide the basis for
further clinical research of cryopreservated pla-
telets efficiency in vivo and testing of their survi-
val and preservation of function in patients after
transfusion.
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Transfusion 1999;39:880-88.

1694 Journal of Society for development in new net environment in B&H


Oral fungal and bacterial infection in
smokers
Cankovic M¹, Bokor-Bratic M¹, Cankovic D²
¹ Clinic for stomatology, Faculty of Medicine, University of Novi Sad, Republic of Serbia,
² Center for health promotion, Institute of public health of Vojvodina, Republic of Serbia.
Abstract
Objective. The objective was to determine the
impact of smoking and the degree of nicotine de-
pendence on the occurrence of changes in the oral
cavity, the frequency of Candida and opportunistic
bacteria in healthy young men.
Methods. A prospective study was done on 100
healthy men (63 smokers and 37 non-smokers),
mean age 36 ± 11.8 years. Smokers were tested
using the Fagerstrom's test to assess the intensity
of nicotine dependence. After clinical examinati-
on sample were collected with cotton swab from
the dorsal surface of the tongue for mycological
and bacteriological examination.
Results. There was a significant difference in the
number of patients with oral mucosal changes in the
group of smokers (68.3%) compared to non-smokers
(21.6%). The most frequent oral diseases in smokers
were smoker's melanosis, hairy tongue, smoker's
palate and a coated tongue. Pathological oral flora
(Candida albicans, Pseudomonas aeruginosa and
Escherichia coli) was isolated in 16 (25.5%) smo-
kers, which is significant compared with findings in
3 (8.1%) non-smoking subjects (Candida albicans).
The significant number of oral diseases was found in
patients with medium and severe intensity of nicoti-
ne dependence. There was no significant difference
between the degree of nicotine dependence and the
presence of isolated pathological oral flora.
Conclusion. Oral diseases are more frequent
in smokers. The increased prevalence of Candida
albicans and aerobic gram-negative bacilli was fo-
und on the surface of the tongue of systemically
healthy young smokers, and nicotine dependence
has no influence on the presence of these opportu-
nistic microorganisms.
Key words: Candidosis, Candida albicans,
oral bacteria, smoking
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
Introduction
Smoking is associated with a variety of chan-
ges in the oral cavity. Tobacco smoke has effects
on saliva, oral comensals bacteria and fungi, ma-
inly Candida species, which cause oral candidosis,
the most common opportunistic fungal infection
in humans. Mechanisms by which cigarette smo-
ke affects oral Candida colonization remains un-
known. The data in the literature clearly reveals a
significant effect of smoking in the development
of oral candidosis in immunocompromised pati-
ents (HIV, malignant tumors, radiation), diabeti-
cs and patients with complete dentures (1). Oral
candidosis frequently occurs due to xerostomia
(2) and in the elderly (3), while the influence of
smoking on the presence of fungi, mainly genus
Candida, in the systemically healthy young peo-
ple are still controversial. Some authors indicate
the increase prevalence of Candida albicans, iso-
lated by different methods, in smokers compared
to non smokers (4,5,6). Other authors suggest that
smoking has no significant effect on oral coloni-
zation of Candida (7,8,9). Moreover, there are not
many studies on the impact of smoking on the oral
microflora (10). The objective was to determine
the impact of smoking and the degree of nicotine
dependence on the occurrence of the oral diseases,
the frequency of Candida and opportunistic bacte-
ria in healthy young men.
Methods
This study was conducted in the Health Care
Center as a prospective study of clinical type. One
hundred systemically healthy construction wor-
kers were included, average age was 36 ± 11.8 ye-
ars (median = 35 years), who came to the regular
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HealthMED - Volume 5 / Number 6 / 2011

periodic health examination. Criteria for inclusion
were absence of systemic diseases and denture
wearers. They were divided into two groups: smo-
kers, which consisted of 63 males (mean age 35.8
years) and non-smokers (control group), which
consisted of 37 males (mean age 37.5 years). Smo-
ker is a person who smokes more than one ciga-
rette a day for more than one year. Non-smoker is
a person who never smoked. Smokers were tested
using the Fagerstrom's test (11) for assessment of
the intensity of nicotine dependence (<3 mild de-
pendence, 4-6 medium dependence, 7-8 high de-
pendence, 9-10 severe dependence). After clinical
examination and recording the presence of oral di-
seases in the oral cavity, samples for mycological
and bacteriological examination were collected
with sterile cotton swab from the dorsal surface of
the tongue. The samples were transported within
one hour to the microbiology laboratory, and after
that inoculated on Sabouraud's dextrose agar and
incubated under aerobic conditions at 370C for 48
hours, and then at room temperature for another
24 hours for fungi. The bacteria inoculation was
performed on blood agar, Mac Conkey's agar, and
tioglikols media with dextrose in aerobic condi-
tions at 370C for 24/48 hours. McKanzey's germ
tube test and chlamydospore formation were per-
formed for identification purpose. Inoculated cul-
ture media was observed after 48 hours in order to
detect the presence of clinically significant speci-
es of bacteria and fungi in the examined material.
Information that explains the content and purpose
of the research was provided to the subjects . Af-
ter getting acquainted with the procedure subjects
gave written consent. All the laboratory and cli-
nical results were compared and analysed using
commercial statistical program SPSS 14 for Win-
dows. In testing the difference in values between
the two groups the chi-square test or chi-square
test (Yates correction) was used. The difference
was considered to be significant at p <0.05.
Results
In 43 (68.3%) smokers were found clinical
changes on the oral mucosa, primarily on the ton-
gue. 25 (39.7%) of them had one type of chan-
ge, 13 (20.6%) with two and 5 (7.9%) with three
type of changes on the oral mucosa. In 8 (21.6%)
non-smokers was found only one type of changes
specificly on the tongue. There was a significant
difference in the number of subjects with oral di-
seases amoung smokers compared to non-smo-
kers (χ2 = 20,284, p <0.001). Most commonly
observed oral diseases in smokers were smoker's
melanosis, hairy tongue, smoker's palate and coa-
ted tongue (Table 1).
Pathological flora (Candida albicans, Pseudo-
monas aeruginosa and Escherichia coli) was iso-
lated in 16 (25.5%) smokers, which is statistically
significant in relation to non-smokers 3 (8.1%)
(Candida albicans) (χ2 = 4.527, p = 0.03). Candida
albicans was the only yeast detected in 11 (17.5%)

Table 1. Clinical changes of oral mucosa in smokers and non-smokers

Smokers Non-smokers
Clinical changes in the oral mucosa
n(%) n(%)
Healthy mucosa 20(31,7) 29(78,4)
Hairy tongue 13(20,6) 1(2,7)
Smoker's melanosis 14(22,2) 0
Smoker's palate 10(15,9) 0
White lesions on the vermilion 4(6,3) 0
Geographic tongue 4(6,3) 4(10,8)
Coated tongue 10(15,9) 2(5,4)
Atrophic glossitis 6(9,5) 1(2,7)
Erythema of oral mucosa 5(7,9) 0
Total number those with clinical changes 43(68,3) 8(21,6)
Total number clinical changes 66 8
Total number of subjects 63(100) 37(100)

1696 Journal of Society for development in new net environment in B&H

 HealthMED - Volume 5 / Number 6 / 2011

smokers which is significant compared to 3 (8.1%)
non-smokers (χ2 = 4.571, p = 0.03) . The difference
in the normal flora, as well as the number of isolated
bacteria species between smokers and non-smokers
were not significant (p> 0.05). Most of our subjects
with isolated Candida albicans was among smokers
who had changes on the tongue in form of coated
tongue, hairy tongue and atrophic glossitis (Table
2). The average value of Fagerstrom's test of nico-
tine dependence was 4.3 ± 1.8 (median = 4 max =
8), indicating that the medium intensity of nicotine
dependence was most frequent among the respon-
dents. The significant number of oral diseases was
found in subjects with medium and severe intensity
of nicotine dependence (χ2 = 31,767, p <0.001) (Ta-
ble 3). There was no significant difference between
the degree of nicotine dependence and the presen-
ce of isolated pathological flora (Candida albicans,
Pseudomonas aeruginosa and Escherichia coli) (p>
0.05) (Table 4).
Discussion
Cigarette smoke affects the oral cavity first,
so it is evident that smoking has many negative
influences on oral mucosa and development of
oral diseases such as oral cancer, leukoplakia pe-
riodontitis, smoker's palate, smoker's melanosis,
hairy tongue and oral candidosis. It's also of im-
portance the impact on a reduced sense of smell
and taste, wound healing, implant survival rate,
staining of teeth and dental restorations (12). In
our study, higher frequency of oral diseases was

Table 2. Clinical and microbiological findings of the tongue in smokers and non-smokers
Smokers Non-smokers
Clinical findings Normal Candida Pseudomonas Normal Candida
E. coli total Total
of the tongue flora albicans aeruginosa flora albicans
n(%) n(%) n(%) n(%) n(%) n(%) n(%) n(%)
Healthy tongue 27(42,9) 1(1,6) 1(1,6) 1(1,6) 30(47,6) 29(78,3) 0(0) 29(78,3)
Hairy tongue 9(14,3) 3(4,8) 1(1,6) 0(0) 13(20,6) 1(2,7) 0(0) 1(2,7)
Geographic tongue 4(6,3) 0(0) 0(0) 0(0) 4(6,3) 4(10,8) 0(0) 4(10,8)
Coated tongue 5(7,9) 5(7,9) 0(0) 0(0) 10(15,9) 0(0) 2(5,4) 2(5,4)
Atrophic glossitis 2(3,2) 2(3,2) 1(1,6) 1(1,6) 6(9,5) 0(0) 1(2,7) 1(2,7)
Total 47(74,5) 11(17,5) 3(4,8) 2(3,2) 63(100) 34(91,9) 3(8,1) 37(100)

Table 3. Correlation between the degree of nicotine dependence and clinical changes on the oral mucosa
Clinical changes on the oral mucosa Total
Degree of nicotine dependence Healthy mucosa With clinical changes
n(%)
n(%) n(%)
Mild dependence 16(80) 4(9,3) 20(100)
Medium dependence 4(20) 33(76,7) 37(100)
Sever dependence 0(0) 6(14) 6(100)
Total 20(100) 43(100) 63(100)

Table 4. Correlation between the degree of nicotine dependence and swab findings of the tongue
Swab findings of the tongue Total
Degree of nicotine dependence Normal flora Pathological flora
n(%)
n(%) n(%)
Mild dependence 15(75) 5(25) 20(100)
Medium dependence 28(75,5) 9(24,3) 37(100)
Sever dependence 4(66,7) 2(33,3) 6(100)
Total 47(74,6) 16(25,4) 63(100)

Journal of Society for development in new net environment in B&H 1697

HealthMED - Volume 5 / Number 6 / 2011
found in smokers. Smoker's melanosis, hairy ton-
gue, smoker's palate, and coated tongue were the
four most common changes of oral mucosa. Other
authors (13) also reported the significant inciden-
ce of coated tongue in smokers. Campisi et al. (14)
found a statistically significant correlation betwe-
en the prevalence of coated tongue and tobacco
smoking among males. Literature data show that
male gender (15) and smoking (13,15,16) are im-
portant factors in the development of smoker's
melanosis. Tobacco is also a significant risk factor
for hairy tongue (15) and smoker's palate (16).
Diagnosis of the oral candidosis is made by
clinical signs and symptoms and positive results
of microbiological analysis. For this purpose, the
material for analysis was taken with the swab from
visible lesions of the oral mucosa (17). The material
can be taken by imprint culture technique and by
oral rinse, but these two techniques are using for de-
termine the oral candidal carriage (18,19). It is well
known that the dentures are the most important pre-
disposing factor for the development of oral candi-
dosis (1.3). Therefore, in our study the absence of
dentures was the criterion for selection of subjects.
Significantly higher presence of Candida albicans
among smokers in this study was found using swab
techniques from the dorsal surface of the tongue.
Thus, all of subjects had some changes on the ton-
gue, the results confirm the diagnosis of oral candi-
dosis. Other authors reported also that there is posi-
tive effect of smoking on the candida colonization.
Therefore, Moalic et al. (5) using the swab techni-
ques from the gingival groove of the third lower
molars in 353 students demonstrated significantly
greater presence of Candida albicans in smokers
compared to non-smokers. Interestingly, it has been
found that Candida albicans was no more frequent
in smokers with an acidic pH then in non smoking
with acidic pH, which excludes the indirect effect
of smoking on lowering the oral pH. Shin et al. (4)
by oral rinse in 90 healthy men has been found that
oral Candida colonization was significantly higher
in smokers compared to non-smokers. Using the
imprint culture technique Arendorf and Walker (6)
reported that cigarette smokers had significantly in-
creased carrier rate of Candida albicans compared
with non-smokers. Contrary to the above, some au-
thors, using the swab techniques (8.9) and oral rinse
(7), reported that the oral colonization with the Can-
1698 Journal of Society for development in new net environment in B&H
dida species is approximately the same percentage
amoung smokers and non-smokers, and concluded
that tobacco smoking has no significant effect of on
the occurrence of oral candidosis.
According to our results there was no statistical-
ly significant difference in the frequency of normal
oral flora between smokers and non-smokers. Mo-
reover, in a group of smokers except Candida albi-
cans in 8% has been isolated aerobic gram-negative
bacteria, Pseudomonas aeruginosa and Escherichia
coli, while in non- smokers group bacteria were
not recorded. Aerobic gram-negative bacilli are the
most commonly occurring bacteria in oral mucosal
infection, they are typically opportunistic and mul-
tiresistant bacteria that are considered to belong to
the transient oral microflora. Colonization of these
bacteria increases with age, poor oral hygiene, smo-
king, nail- biting, close contact with animals and
habits such as oral sex (20). There are few studies
that examine the impact of smoking on the bacte-
rial microflora of the oral mucosa. In one study (10)
examining 40 species of bacteria in saliva and oral
mucosa, presence of bacteria was found to be at a
higher level in smokers with periodontitis, however,
it was not statistically significant compared to non
smokers with and without periodontitis. Peltonen et
al. (21) did not found significant differences in oral
microflora of whole saliva, dental plaque, pharynx
and faeces in 48 systemically healthy young smo-
kers and non-smokers.
Besides information on the severity of smoking
behavior, Fragestrom's test allows easier triage of
smokers for treatment withdrawal. In our study it
was found that most smokers (58.7%) were from
the category of moderately severe nicotine depen-
dence and behavioral treatment is sufficient du-
ring the smoking cessation process. In addition it
was found that 9.5% of smokers were in category
of heavy nicotine dependence, ie. usually smoke
more than 20 cigarettes a day and the first morning
cigarette smoke in period of 31 and 60 minutes
after waking up, and it is necessary to immediately
include drug therapy when they want to quit smo-
king (Nicorette, Ziban or Tabex - recommended
by the World Health Organization) (22). Of im-
portance is that the subjects in our study with mo-
derate and severe nicotine dependence had signi-
ficantly more clinically detectable oral mucosal
lesions in relation to light nicotine addicts. Shin

et al. (4) indicate a positive correlation between
the severity of smoking behavior and colonization
of oral Candida albicans, which was not found in
our study.
Conclusion
Based on these results we conclude that the oral
diseases are more frequent in smokers. The incre-
ased prevalence of Candida albicans and aerobic
gram-negative bacilli was found on the surface of
the tongue of systemically healthy young smokers,
and nicotine dependence has no influence on the
presence of these opportunistic microorganisms.
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lesions in adults from the Turin area. Oral Dis
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1979;147:267-272.
19. Samaranayake LP, MacFarlane TW, Lamey PJ,
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20. Mager DL, Haffajee AD, Socransky SS. Effects

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Corresponding author
Milos Cankovic,
Clinic for stomatology,
Faculty of Medicine,
Republic of Serbia,
E-mail: doctore@uns.ac.rs

1700 Journal of Society for development in new net environment in B&H

 HealthMED - Volume 5 / Number 6 / 2011

Patients’ satisfaction as key point in

healthcare services
Radmila Janicic1, Danica Lecic-Cvetkovic1, Vinka Filipovic1, Zoran Vukasinovic2, Vesna Jovanovic3
1
Faculty of Organizational Sciences, University of Belgrade, Serbia,
2
Institute of Orthopaedic Surgery “Banjica”, Faculty of Medicine, University of Belgrade, Belgrade, Serbia,
3
Institute of Orthopaedic Surgery “Banjica”, Belgrade, Serbia.

Abstract very satisfied with healthcare services in this Insti-

Objective: In order to measure patients’ satis-
faction in the Institute of Orthopaedic Surgery "Ba-
njica" there was study about quality of healthcare
services, quality of employees practice, as well as,
quality of healthcare treatments and other services.
Methodology: The questionnaires, focus group
interviews, were conducted with 90 patients, con-
sumers of healthcare services in Institute of Ortho-
paedic Surgery "Banjica" from August to Novem-
ber 2010. Interviews were anonymous, which gives
freedom of opinion in patients’ population.
Results: The results show that patients’ satis-
faction with healthcare services in this Institute
is very high. According to the results, it is 85.8%
patients which are very satisfied with healthcare
services. Evaluation of general satisfaction, 70.1%
of patients have opinion that this Institute is more
competitive then others on healthcare orthopae-
dic market place in Serbia. Patients will choose
this Institute again for their healthcare problems
(85.6%), which show that this Institute has very
satisfied patients and patients which will give
good recommendation for the Institute.
Conclusions: Satisfaction of patients is key
point in healthcare organizations, because their sa-
tisfaction is real measure of healthcare institutions
work and measure of branding institutions in pa-
tients’ mind. Also, patients’ satisfaction shows real
position of healthcare institutions on market place.
The truth is that healthcare organizational strength
comes from within the team of people that work
there, which fulfils patients’ satisfaction with their
practices as doctors, nurses, technicians and others
medical staff. This research present that the Institu-
te of Orthopaedic Surgery "Banjica" is well positio-
ning on healthcare marketplace and that patients are
tute. According to research, Institute in further work
have to follow modern approaches in medicine and
management field, in order to keep leader position
on healthcare orthopaedic market place.
Key words: Patients’ satisfaction, healthcare
organizations, healthcare services, healthcare pro-
cess, brand of healthcare institutions, position on
healthcare market place.
Introduction
The paper gives theoretical and practical view
of patients’ satisfaction on improving healthcare
processes in orthopaedic hospital. Every healthcare
organization has their own strategies for satisfying
patients with new treatments, new diagnosis appro-
aches and especially with human empathy in hard
situations, when people looking for help. Nowa-
days, patients’ demands, needs and wishes are more
sophisticated and patients looking for new approa-
ches in healthcare treatments, diagnosis methodolo-
gies, and they need that doctors give them time, the
best treatments and to be open for communications
[1, 2, 3]. Healthcare services have to be organized,
done on time, with information on the time. In the
Institute of Orthopaedic Surgery "Banjica", doc-
tors’ teams face with hard injured patients, which
include quick decisions about diagnosis’s, surgeries
and treatments. On the other side, second segment
group are patients with chronically diseases, which
need continuous treatments and monitoring of he-
alth patients’ conditions. Third segment group are
children with chronically and acute orthopaedic he-
alth problems. This segment is especially vulnerable
and need pedagogical approach, with little patients
and their parents [4, 5]. In patients’ satisfaction it is

Journal of Society for development in new net environment in B&H 1701

HealthMED - Volume 5 / Number 6 / 2011
very important to plan processes of all procedures
in hospital’s work. Management and integration of
all hospital’s processes is under decision making of
management teams on strategically, functional and
operational level [6].
On patients’ satisfaction, the most important im-
pact has employees in healthcare institutions, doc-
tors, nurses and other medical staff. People are key
point in healthcare organizations in way of relation-
ship with consumers of healthcare services. Also,
good internal communications are base for quality
of healthcare services, as well as, building reputa-
tion in public [7, 8, 9]. All consumers of healthcare
services can feel internal way of communications
in one healthcare institution. That can be encoura-
ging for patients and family to feel friendly in heal-
thcare institution. For this approach it is necessary
that management teams make positive atmosphere
in departments, and to motivate employees to give
best in healthcare practices. Employees build ima-
ge of one healthcare organization, and “word of
mouth” promotion depend of people in healthca-
re organizations, as well as, patients’ satisfaction.
Many healthcare organizations have seminars in
order to improve team building in healthcare orga-
nizations, to improve employees’ communications
with patients, as well as, with personal contains
in departments [10 - 14]. Through good examples
of healthcare organization, Clinic Mayo [3], this
paper gives point of patients’ satisfaction, as key
factor in building and development of healthcare
institutional brand. This Clinic has statement that
the satisfaction of patients is the most important for
success on healthcare market place. At Mayo Cli-
nic, the patient comes first. From the way it hires
and trains employees, designs its facilities, to the
way it approaches care, Mayo offers patients and
their families concrete and convincing evidence
of its strengths and values. The results are excep-
tionally positive “word of mouth” and abiding cu-
stomer loyalty, which has allowed Mayo Clinic to
build what, is arguably the most powerful brand in
health care [3].
Healthcare organizational culture is “implicit,
invisible, intrinsic, an informal consciousness of
the organizational that drive the behaviour of in-
dividuals and shapes itself out of their behaviour”
[15]. Organizational culture possesses three im-
portant characteristics – culture is a learned, cul-
1702 Journal of Society for development in new net environment in B&H
ture is shared, and culture is both subjective and
objective [16, 17, 18].
Instruments of marketing mix are strong tools
to achieve goals of one healthcare organization,
like good positioning on market place of healthca-
re services, well reputation in target audiences,
emotionally connection with healthcare organi-
zation, awareness of healthcare organization as
brand and loyal patients [18, 19].
Patients’ satisfaction is based at the first site
on communication with employees. Patients need
to be care, listened, to improved their needs and
wishes, even that they are sophisticated. Medical
staff has to be in good relationship with patients,
their family members, with other employees, as
well as hospital staff and managers. In process of
giving healthcare services, patients first get impre-
ssion about healthcare organization on help-infor-
mation desk, then they see rooms, staff, doctors,
and than they have whole picture about one heal-
thcare organization [20, 21].
Trust of patients in one healthcare organization
depends of employee's professionalism, communi-
cation skills, shown carry about patients’ satisfacti-
on. Patients need to believe to their healthcare pro-
fessionals. It can be achieve only by good quality
healthcare services and good communication base
on trust. Healthcare organizational strength comes
from within the team of people that work there.
And, they are the key to achieving financial, pati-
ents’ satisfaction, and brand objectives [22 - 26].
Healthcare services include: process of admissi-
on, healthcare treatments, organization assessment
and design of healthcare organization, change mana-
gement planning and communications in healthcare
organization, human resource strategy alignment,
process of delivering healthcare services redesign,
outsourcing strategies and technology systems im-
plementation, human resource shared services, im-
proving communication skills of employees.
Materials and methods
Sample
The research was based on the survey among
patients of Institute of Orthopaedic Surgery "Ba-
njica" in Serbia. The study was done in the year
 HealthMED - Volume 5 / Number 6 / 2011

2010. A questionnaire with 32 statements was
using interviews were conducted with 90 patients.
All participants were informed on the subject, pur-
pose and rules of the research and their prior con-
sent was obtained.
Instrument
We developed a structured questionnaire with
32 statements based on the theoretical evidence
and accumulated experiences from international
and Serbian studies. The enquiries were divided
into 7 groups, which were key criteria for measu-
rement of patients’ satisfaction in Institute of Ort-
hopaedic Surgery "Banjica": evaluation of proce-
dure in hospital admission, provision of healthcare
workforce in Institute, evaluation of organizatio-
nal process in Institute, patients’ satisfaction with
doctors’ work, patients’ satisfaction with nurses’
practice, impact of hospitalization and treatment
on patients’ health, general satisfaction of patients.
In Table 1. is present structure of questionnaire
about patients’ satisfaction.

Table 1. The criteria that were researched about patients’ satisfaction in the Institute “Banjica”
No. Generating of statements Statements
I Evaluation of procedure in hospital admission
What was the nature of your illness in process
1. Examination Chronically Acute
of admission to hospital?
Did you have trouble in process of hospital
2. Yes Some No
admission?
How many days passed before your
3. 1 More then 1
hospitalization?
How many hours passed between your come in
4. 1 More then 1
hospital and to placement in the room?
How many hours passed between your
5. placement in the room and first visit of your 1 More then 1
doctor?
II Provision of healthcare workforce in the Institute
6. How many doctors are in hospital? Enough Could be more Insufficiently
How many nurses and medical staffs are in
7. Enough Could be more Insufficiently
hospital?
How often you had contact with doctors and
8. Fulfil Rarely Insufficiently
nurses?
Did you have permanent doctor who take care Doctor was occasionally
9. Yes No
of you? changed
Did you have permanent nurse who take care of Nurse was occasionally
10. Yes No
you? changed
III Evaluation of organizational process in the Institute
How do you rate the organizational process in
11. Excellent Mostly good Bad
the hospital?
Please evaluate the significant side of your
12.
hospitalization:
a) Cleanliness of the room? Good Medium Bad
b) Comfortable of the room? Good Medium Bad
c) Comfortable of the bed? Good Medium Bad
d) Cleanliness of toilets? Good Medium Bad
e) Food quality? Good Medium Bad
f) Way of serving food? Good Medium Bad
13. How you rate organization of visiting time? Good Medium Bad
Was it possible in out of visit time to have visit
14. Yes Sometimes No
or to get a message or an item?

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HealthMED - Volume 5 / Number 6 / 2011

Was there a possibility that patients receive

15. Yes Someone No
visits in out of visit time?
How you rate medical equipment in the hospital
16. New Old I don’t know
where you were treated?
IV Patients’ satisfaction with doctors’ work
How you rate the efforts of doctors at the
17. Good Medium Bad
hospital where you were treated?
How was the relationship of your doctor with
18. No difference Sometimes difference Very difference
other patients?
Are you satisfied with your permanent doctor’s
19. Yes No I don’t know
work?
20. Were there mistakes in work of your doctor? Yes No I don’t know
Could you explain to your doctor all aspects of
21. Yes Sometimes No
your disease?
Did your doctor explain you all aspects of your
22. Yes Sometimes No
health condition?
Please rate the extent to which your doctor has
22.
owned these characteristics:
a) Collegiality Great Medium Small
b) Kindness Great Medium Small
c) Humanity Great Medium Small
d) Dexterity Great Medium Small
e) Accuracy Great Medium Small
V Patients’ satisfaction with nurses’ work
How you rate the efforts of nurses at the hospital
24. Good Medium Bad
where you were treated?
Please rate the extent to which your nurse has
25.
owned these characteristics:
a) Collegiality Great Medium Small
b) Kindness Great Medium Small
c) Humanity Great Medium Small
d) Dexterity Great Medium Small
e) Accuracy Great Medium Small
Are you satisfied with your permanent nurse’s
26. Yes No I don’t know
work?
VI Impact of hospitalization and treatments on patients’ health
Rate how the hospitalization affects on your
27. Good Medium Bad
health?
Do you think that medicine today is capable of
28. Completely Incompletely Powerless
treating a disease that you have/had?
Were you in opportunity to have impact on
29. Yes Sometimes No
procedure that used in treatment of your disease?
VII General patients’ satisfaction
When you compare the hospital where you have
30. recently been treated with others Belgrade’s hospi- Better Worse I don’t know
tals, your hospital is better or worse than others?
If you were in a situation where you need to re-
31. treatment, and if you could choose, would you Yes Maybe No
choose the same hospital?
What is your general satisfaction with the
32. Satisfied Medium Unsatisfied
hospital’s treatments?

1704 Journal of Society for development in new net environment in B&H


Results and discussion
The data was analysed with SPSS software
(Statistical Package for the Social Sciences). All
answers are present in this statistical software, and
analysed according to statistical proposition.
The largest part of questionnaire was about
patients’ satisfaction with process of admission,
placement in the rooms and doctors’ treatments,
about cleanliness and comfortable of hospital’s
rooms, and about doctors’ and nurses’ efforts in
medical treatments, as well as, rate of doctors’
and nurses’ characteristics, collegiality, kindness,
humanity, dexterity and accuracy in the Institute
of Orthopaedic Surgery "Banjica". According to
research, 50.6% of questionnaire patients were in
acute orthopaedic hospitalization, 30.2% of pati-
ents were with chronically diseases, and 19.2%
were in hospital for examinations.
I Evaluation of procedure in hospital
admission
Assessment procedures for admission in hos-
pital was based on patients’ statements about dif-
ficulties in procedure of placement in the hospital,
time that passed between from coming in the hos-
pital to placement in the room and starting with
diagnosis and treatments, as well as, on time that
passed between from admission in the hospital to
first doctor visiting.
Results of this research presented that large
number of questionnaire patients (89.4%) was fo-
und place in the hospital without any problems,
when doctor recommend hospitalization. Only
8.5% answered that they had a little problems in
process of admission in the hospital, and 2.1% said
that they had a lot of problems in process of ad-
mission in the hospital. According to these results,
patients’ statements about time between coming in
the hospital and placement in the room are good.
Only one day patients were waited for admissi-
on (90.7%). On the other side, 9.3% of patients
were waited for admission 2 days. Time between
patient’s admission in the hospital and placement
in the room is also very small, and patients have
good opinion about hospital’s admission procedu-
res. Only after one hour a lot of patients find place
in the rooms (89.4%). One of the important criteria
which impact on patients’ satisfaction is time that
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
pass between patients’ placement in the rooms and
first contact with their permanent doctors. After pla-
cement in the rooms, 83.9% patients said that their
permanent doctors visited them in one hours, while
16.1% of patients was in situation to wait visit of
their permanent doctors in two or three hours.
II Provision of healthcare workforce in the
Institute
The provision of the hospital by medical staff,
mostly patients had statements (91.4%) that the
hospital has enough doctors and nurses for heal-
thcare procedures and treatments, 6.5% patients
had statements that it could be more, and 2.1% had
statements that the hospital hasn’t enough medical
staff for implementation of healthcare procedures
and treatments. On the questions about other medi-
cal staff, 67.7% patients had statement that the hos-
pital has enough medical staff for healthcare proce-
dures and treatments, 27.2% patients had statement
that it could be more, and 5.1% had statement that
the hospital hasn’t enough medical staff for imple-
mentation of healthcare procedures and treatments.
According to these results patients estimated by
89% that they were in opportunity to be in contact
with medical staff whenever they needed, 9% said
that it wasn’t case and only 2% said that was rare-
ly opportunity to be in contact with medical staff
when they needed healthcare help.
However, less than half of respondents (46.5%)
indicated that they had permanent doctor, who fo-
llowing their health condition, 26.3% indicated
that they had few doctors who occasionally chan-
ged and took care about their health condition du-
ring hospitalization, and even 27.2% of patients
indicated that they hadn’t permanent doctor.
Lager number of respondents (72%) indicated
that care about their condition took several nurses
that changed, according to working hours. Only
11% of patients said that they had one permanent
nurse.
III Evaluation of organizational process in
the Institute
Respondents indicated that the organizational
processes in the hospital are excellent (64.7%),
31.2% of patients had opinion that it is mostly
good, and only 4.1% had opinion that the organi-
zational processes in the hospital are bad.
1705
HealthMED - Volume 5 / Number 6 / 2011
In rating of hospital placement, it was conside-
red in terms of six criteria whose values ​​follow.
First was patients’ satisfaction with the cleanli-
ness of the rooms, which 65.2% of patients rated
as good, 28.3% of patients rated as medium, and
6.5% of patients rated as bad.
The most satisfied with cleanliness of the rooms
were workers, employed in trade, housewives and
pensioners (c2=19.646 df=18; p≤0.01). The second
criterion was comfortable of the rooms. With com-
fortable in the rooms was satisfied 62.7% of pa-
tients, 32.2% of patients rated comfortable of the
rooms as medium, and 5.1% of patients rated com-
fortable of the room as bad. Unsatisfied with com-
fortable of the rooms was patients with finished se-
condary school (c2=12.974; df=6; p≤0.01), as well
as female patients (c2=8.495; df=2; p≤0.01).
The third criterion was comfortable of the beds.
Results present that 50.5% of patients was satisfied
with comfortable of the beds in the rooms, 31.2%
was medium satisfied, and even 18.3% was unsa-
tisfied. Unsatisfied with comfortable of the beds
was female patients (c2=5.324; df=2; p≤0.01).
Also, with comfortable of the beds in the rooms
was unsatisfied workers, employed in social pro-
tection and trade (c2=3.821; df=1; p≤0.01), as well
as patients with secondary school and faculty edu-
cation (c2=4.267; df=1; p≤0.01). The fourth crite-
rion was cleanliness of toilets. Unfortunately, only
31.9% of patients were satisfied with the cleanli-
ness of toilets, 31.9% indicated that the cleanliness
of toilets was medium, and even 36.2% of patients
indicated that the cleanliness of toilets was bad. The
most unsatisfied patients with the cleanliness of toi-
lets were patients with faculty education (c2=3.701;
df=1; p≤0.01). It is interesting that only 31.9 % of
patients though that quality of food in the hospital
was good, 36.2% indicated that quality of food was
medium good, and even 31.9% indicated that food
was bad. Extremely unsatisfied with the quality of
food were workers in social preventive centre, tra-
de and housewives (c2=33.645; df=18; p≤0.01), un-
married patients (c2=8.981; df=8; p≤0.01), as well
as patients with secondary school (c2=10.249; df=6;
p≤0.01). With way of serving food, as a sixth crite-
rion, there were 65.6% satisfied patients, and it was
equally on all level of social status. About 25.6% of
patients though that this services are medium good,
and 7.8% of patients though that it was bad.
1706 Journal of Society for development in new net environment in B&H
It is well known that for successful recovering
is very important that patients have everyday visit
of family, to give them support in treatment’s pro-
cess. The majority number of patients in this study,
63.9% was satisfied with organization of visits,
23.7% were almost satisfied, and 12.4% were unsa-
tisfied. With organization of visit were unsatisfied
female patients (c2=6.268; df=1; p≤0.01), younger
patients and children (c2=6.465; df=1; p≤0.01), as
well as patients with children at home (c2=8.256;
df=1; p≤0.01). Significantly more respondents
(82.3%) were satisfied with opportunities that re-
ceived messages from family and friends, or to get
some items in out of visit time, by help of medical
staff, 13.5% said that it was possible sometimes,
and 4.2% said that it wasn’t possible. A smaller
number of patients (64.9%) indicated that there was
opportunity for visits in time out, 12.8% thought
that it was impossible, while others (22.3%) tho-
ught that it was possible only for special patients.
It is evidence that patients are not professional to
measure medical equipment in the hospital during
treatment, so, from that reason, only 31.9% of them
were not sure in their assessment. Still, these results
give an opinion of the hospital by the view of pati-
ents. Almost half of respondents estimated that the
equipment was new (47.9%), and 20.2% estimated
that the equipment was old.
IV Patients’ satisfaction with doctors’ work
On questions about doctors’ and nurses’ work,
the vast majority of patients (82.2%) was unique
in thought that doctors and nurses was excellent,
while small number (15.2%) thought that doctors
and nurses could be better in treating and commu-
nication with patients. Only 2.0% of patients had
statement that doctors could be more motivated for
work. According to this, it is commendable that
93.8% of patients indicated that their permanent
doctor didn’t make differences between patients
and that doctor was in relationship with all equally,
4.1% thought that sometimes their permanent doc-
tor made differences between patients, and only
2.1% of patients thought that their doctor made
obvious differences between patients.
For the establishment of public satisfaction
with hospital treatments it is indicative results
which present satisfaction with professional com-
petence of hospital’s doctors. Even 88.7% of pa-

tients thought that their doctors were professional
competent, only 4.1% said that they wasn’t satisfi-
ed with doctors’ competence, as well as, 7.2% said
that they couldn’t estimate doctors’ competence.
On the question “Were there mistakes in work of
your doctor?”, only 2.0% of patients answered that
it was case. The largest number of patients thought
that their doctors did not make mistakes (69.5%),
while most of them didn’t want to declare about this
question (28.5%). On the other side, results about
relationship between doctors and patients are very
satisfactory, and present that communications was
good. So, 87.1% of patients could explained all as-
pects of their health condition to their doctors, who-
se are always been willing to listen patients, 9.7%
of patients thought that they could talk with doctors
only during examination, and only 3.2% indicated
that it was rarely. Also, majority of patients (80.2%)
had statement that doctor give them enough expla-
nations, in order to introduce patients in all aspects of
their health condition and medical treatment, 13.2%
of patients thought that it was not enough, and 6.6%
of patients though that it was rarely. These answers
are according to patients’ statement about characte-
ristic of medical staff in the hospital. In Figure 1.
are present grade characteristics of the hospital’s
doctors. It is noticeable that majority of patients
considered that the hospital’s doctors had professi-
onal characteristic: collegiality (91.7%), kindness
(91.7%), humanity (85.5%), dexterity (93.0%) and
accuracy (81.8%). It is interesting to underline that
14 to 28% of patients didn’t answer to this question.
Figure 1. Grade of doctors’ characteristics
V Patients’ satisfaction with nurses’ work
Similar with grade about doctors’ work, pati-
ents mostly had statement that nurses and medi-
cal staff is good and that they work very professi-
onally in the hospital’s department. Statement of
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
patients are that even 90% of nurses are excellent
in their work, 8% of patients thought that work of
nurses in the hospital’s department could be better,
and only 2% that it was unsatisfied. On question to
estimate nurses’ professional characteristics, as co-
llegiality, kindness, humanity, dexterity and accu-
racy, almost there are no differences compared to
grade of doctors. In percent’s, 92.6 % of patients
rated nurses’ collegiality, 94.3% of patients rated
nurses’ kindness, 87% of patients rated nurses’ hu-
manity and 89.9% of patients rated nurses’ dexte-
rity and accuracy. It is, also, as in the case with
doctors, interesting to underline that 14 to 28% of
patients didn’t answer to this question. About satis-
faction of patients with nurses’ professional work
and competence, patients mostly thought that nur-
ses are good workers (91.6 %). In contrast to the
assessment of competence of doctors, slightly
more of patients were ready to answer on this que-
stion, only 5.3% of patients gave answer that they
couldn’t estimate nurses’ work and competence.
On this question didn’t answer 5 - 7% of patients.
VI Impact of hospitalization and treatments
on patients’ health
Looking at the overall impact of hospitalization
on the patients’ health, 88.6% of patients said that
treatments resulted in a nearly full recovery, only
10.3% of patients said they partly recover, while
only one patient (1.1%) said that he felt worse
after hospitalization. More than half of patients
62.1% thought that new medicine approach can
completely treat their disease, more than a third
of them 34.5% thought that medicine could help
in their health condition, but not to cure disease,
while 3.4% of patients thought that medicine
couldn’t cure and treated their disease. Another
very important aspect of patients’ satisfaction
with hospital’s treatments, which is especially im-
portant in communications between doctors and
patients, and has impact on patients’ healthcare
condition, is patients’ grade about opportunities
to decide which treatment they could choose. On
this question 50% of patients confirm that doctors
listened there opinion and after that they found the
best treatment for patients , 35.7% said that there
was not opportunity to suggest and to had impact
in decision about treatment, and 14.3% said that it
was possible sometimes.
1707
HealthMED - Volume 5 / Number 6 / 2011
VII General patients’ satisfaction
according to different socio-demographic
characteristics of population
According to general satisfaction, 70.1% of pa-
tients thought that the hospital is better then other
hospitals in Belgrade, 4.4% of patients thought that
the hospital is worse then others, and quarter of pa-
tients (25.2%) didn’t know. The majority number of
patients (85.6%) would choose same hospital if they
have need for re-treatment, 13.3% would maybe
choose same hospital, and only 1.1% wouldn’t cho-
ose healthcare services of this hospital.
General satisfaction of patients with treatments
in the hospital is extremely high, because 85.8%
of patients are very satisfied with treatments in the
hospital and their health condition after treatments,
as well as with hospital’s work, 10.9% of patients
are medium satisfied, and only 3.3% of patients
are unsatisfied (Figure 2.)
Figure 2. General satisfaction of patients
General satisfaction with the hospital trea-
tments was analysed according to different socio–
demographic characteristics examined population
(gender, age, marital status, number of children,
education level, profession, institution where they
work). In regard to gender of patients there wasn’t
statistical differences in general satisfaction of res-
pondents (c2=0.322; df=1; p>0.05). Similarly, no
other results Hi square test, which used in exami-
nation depending on general patients’ satisfaction,
according to others socio–demographic characte-
ristics did not show significant statistically diffe-
rences, explicitly: for age c2=0.357; df=1; p>0.05;
for profession c2=1.115; df=1; p>0.05; for marital
status c2=0.378; df=1; p>0.05; for education level
c2=0.250; df=1; p>0.05.
1708
Conclusion
In nowadays speed market changes in healthca-
re services, it is necessary to be competitive and to
give quality healthcare services to consumer, be-
cause patients’ satisfaction is the most important
factor in positioning of healthcare institutions.
Satisfaction of patients is key point in healthca-
re organizations, because their satisfaction is real
measure of healthcare institutions, healthcare pro-
cesses, communication with patients, and measu-
re of branding institutions in patients’ mind, what
is base for promotion. Also, patients’ satisfaction
shows real positioning of healthcare institutions
on market place, according to competitions. In-
stitute of Orthopaedic Surgery "Banjica" is well
known with good results in improving quality of
patients’ life, with new diagnostic methods, new
approach to orthopaedic treatments, as well as,
excellent communications with patients.
Healthcare organizational strength comes from
within the team of people that work there, whi-
ch fulfils patients’ satisfaction with their practice
as doctors, nurses, technicians and other staff.
Brand of healthcare organization are organiza-
tional structure, organizational spirit, quality of
healthcare practice that permeates throughout or-
ganization and reaches every area of work, from
healthcare services development to strategically
management, from public perception to healthcare
organization’s objectives, from community invol-
vement to human resources practices.
Results of this study present that patients are
very satisfied with healthcare service in Institute
of Orthopaedic Surgery "Banjica", which indicate
this institution as good positioning in mind of the-
ir patients, and the most important answer is that
patients will come back in this Institute for further
healthcare treatments.
Based on this study, management team at In-
stitute of Orthopaedic Surgery "Banjica" raised
the following goals: to fulfil patients’ satisfaction,
to improve healthcare orthopaedic diagnosis and
treatments offer, shortening the diagnostic proc-
ess, increasing quality of diagnostic procedures,
introduction new diagnostic procedures, develop-
ment of innovative treatments and improving new
technology innovative facilities, development of
Institution’s decision making process on all levels,
Journal of Society for development in new net environment in B&H

development of employees’ motivation for work,
by financial support and opportunity for improv-
ing knowledge, as well as, work according to so- 13.
cial responsible behaviour.
14.
Acknowledgement
15.
This paper was supported by Ministry of Sci-
ence, Republic of Serbia (Grant No. 41004).
16.
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and the Strategic Management of Publicly Funded
Hospitals. Health Policy, 2001, 58(2), pp. 151-73.
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Belgrade, 2010, (in Serbian)
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R., Spasovski D., Zivkovic Z., Cerovic S. Strategic
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stitution. Srpski Arhiv, 2009, 137(1-2), pp.63-72.
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Corresponding author
Danica Lecic-Cvetkovic,
Faculty of Organizational Sciences,
University of Belgrade,
Serbia,
E-mail: danica@fon.rs
1709
HealthMED - Volume 5 / Number 6 / 2011
Implementation influence of antibiotic
prescribing guidelines on their usage
and costs of therapy
Sandra Stefan-Mikic1, Sinisa Sevic1, Radoslava Doder1, Dejan Cvjetkovic1, Nataša Jovanovic2, Maja Ruzic1
1
Clinical Centre of Vojvodina, Infectious Diseases Clinic, Novi Sad, Serbia,
2
University of Novi Sad, Faculty of Medicine, Novi Sad, Serbia.
Abstract
Introduction / Aim: Pharmacoeconomics is a
scientific discipline which aims to harmonize and
find the best possible medicament which can pro-
vide optimal effects at minimum price for treat-
ment. The survey is conducted in three phases, and
included all patients hospitalized in eight Clinics
of Clinical Center of Vojvodina (Serbia) which are
the largest consumers of antibiotics.
Methods: The first phase involved retrospec-
tive evaluation of the entire former antibiotics con-
sumption in three months treatment of bacterial in-
fections. The total cost of consumed antibiotics was
calculated as well as daily doses were defined per
100 patient day cost for each clinic separately. In
the second phase, the structure of bacterial causes
and their resistance to standard antimicrobial ther-
apy were established for all isolated strains from
research material collected at each clinic. Guide-
lines for initial adequate antimicrobial therapy were
made (regarding localization and type of bacteria)
based on the results of monitoring resistance in bac-
teria and considering resistance maps for isolated
bacterial strains. The guidelines took into consid-
eration antibiotic drug selection: pharmacothera-
peutic / pharmacoeconomic principles, bacterial
resistance, patterns of antimicrobial prescriptions
and minimum cost of therapy. In the third phase (of
the three-month period) the guidelines were imple-
mented in therapy of bacterial infections. The aim
of the study was to make guidelines for an adequate
antimicrobial therapy based on the surveillance of
resistance to antibiotics. Our aim was to estimate
the effect of guidelines on antibiotic consumption
and costs of therapy.
1710
Results: During period of guidelines implementa-
tion for initial adequate antimicrobial therapy, savings
of 20270,19 euros (18, 8%) were noted at four clin-
ics, in comparison to previous period when guidelines
were not applied. At the Infectious Diseases Clinic
savings in treatment costs were 33.9%, at the Endo-
crinology Clinic 34.6%, at the Hematology Clinic
8.2% and at the Gastroenterology Clinic 2.8%.
Conclusion: Monitoring of bacterial resistance
and pharmacoeconomic studies should become an
integral part of health care system in Serbia
Key words: Pharmacoeconomics, Antibiotics
utilization; Bacterial resistance; Practice Guidelines
Introduction
Antibacterial drugs (antibiotics) are used very
often since the beginning of their application due
to their efficiency, accessibility and affordability.
For years Serbia has taken the first place in Europe
for the amount of prescribed antibiotics. Even in
times of limited drug supply, use of antibiotics has
not been significantly reduced1,2.
Using the defined daily doses (DDD) in the
analysis of drug use, allows us to perceive medi-
cal and economic consequences of the usage of
antimicrobial agents, and to compare, in the same
time, the use of drugs, expressed in DDD with the
use of drugs in other countries with developed
pharmacotherapeutical practice3.
Rational (optimal) drug therapy means the ri-
ght drug usage at the right time, for long enough
period, and in adequate doses. Irrational use of
medicines is a major problem of modern pharma-
cotherapy. Controlled, rational use of antibacterial
Journal of Society for development in new net environment in B&H

drugs in cases when they are indicated is at the
moment the most effective way to fight against
bacterial resistance development and to provide
the optimal health care in the same tame. Optimal-
rational use of antibacterial drugs means prescri-
bing them only when they are indicated4, 5, 6, 7.
Medical expertise, patients’ requirements, phar-
maceutical industry, as well as financial resources
influence physicians in the decision making and
prescribing drugs. These non-medical factors sho-
uld not influence physicians in prescribing drugs,
but the regulation should be in accordance with
modern pharmacotherapeutic principles. In many
countries, doctors are to take into account guideli-
nes (policies) for prescribing antibiotics, which are
made on the basis of bacteria resistance and phar-
macoeconomic analysis, for each country separa-
tely. In Serbia this issue is still poorly defined8, 9.
Pharmacoeconomics is a scientific discipline
which aims to harmonize and find the best possible
medicament which can provide optimal effects at
minimum price for treatment. Pharmacoeconomi-
cs is a discipline of health economics that identifies
measures and compares the effects of therapy, co-
sts of use of pharmaceutical products, i.e. medical
intervention. Interdisciplinary approach to phar-
macoeconomics includes knowledge of medicine,
economics, and pharmacoepidemiology, and law,
theory of decision making, biostatistics, bioethics,
pharmacology and epidemiology in general. Such a
multidisciplinary approach may find solutions whi-
ch could not be found by individual approach10, 11, 12.
Pharmacoeconomics is the economic evaluati-
on of efficiency, treatment of diseases and cost of
medical care. It adopts and applies the principles
and methodology of health economics to the field
of pharmacotherapy. Pharmacoeconomic studies
compare the effects of therapy and the cost of two
or more different treatment alternatives with res-
pect to the principle of ''primum non nocere’’ (first
do not to harm). Phainrmacoeconomic concept is
used to achieve the optimal goal of treatment for a
lower price, or vice versa, or to direct the use of li-
mited resources, to the best possible ratio between
therapeutic and economic benefits. To achieve this
aim, the methods of economic evaluation are used
to select the most effective options which can pro-
vide health care services to the general population,
raised to the highest possible level13,14,15.
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
Methods
The survey included all patients who were hos-
pitalized at the Infectious Diseases Clinic, General
Surgery Clinic, Urology Clinic, Orthopedics and
Traumatology Clinic, Anaesthesiology and in-
tensive care Clinic, Haematology Clinic, Gastro-
enterology Clinic, Endocrinology, Diabetes and
Metabolic Disorders Clinic and Nephrology and
Clinical Immunology Clinic of the Clinical Center
of Vojvodina, in Novi Sad, Serbia. The survey was
conducted in three phases.
The first phase concerned retrospective evalua-
tion of the entire previous antibiotics consumption
in three months treatment of bacterial infections in
all mentioned Clinics of Clinical Centre of Vojvo-
dina. The total cost of consumed antibiotics was
calculated as well as daily doses were defined per
100 patient days by Anatomical Therapeutic Che-
mical (ATC) classification of drugs with defined
daily doses Group J (antibiotics) 16. Number of
patient days that patients made while staying in
hospital during that time was also noted.
In the second phase, which lasted four months,
the structure of pathogens and resistance to stan-
dard antimicrobial drugs, for the strains isolated
from the examined material have been identified
from the collected data, for each clinic of Clinical
center of Vojvodina. Data on the structure and re-
sistance of pathogens was processed in the Labo-
ratory of Bacteriology Department of the Institute
of Public Health in Novi Sad, Serbia. Based on the
results of resistance in bacteria monitoring, adequ-
ate guidelines for initial antimicrobial therapy
(according to the site and cause) have been made
according to the maps of resistance to pathogens
isolated from the tested materials. Development of
guidelines for adequate initial antimicrobial thera-
py was based on the selection of antibacterial drug
that is adequate, taking into account the state of re-
sistance, the principle of coordinating antimicro-
bial therapy and minimum costs. Guidelines were
the optimal from the pharmacoeconomic point of
view, regarding efficiency and costs. These gui-
delines were applied in the treatment of bacterial
diseases. Every physician who administered anti-
biotics, was given a map of resistance (for blood
culture, urine culture and wound swabs), with the
proper recommendation for therapy.
1711
HealthMED - Volume 5 / Number 6 / 2011
In the third phase, which lasted for 3 months,
the guidelines were also applied in the treatment
of bacterial infections and cost of treatment was
compared (due to prescribed antibiotics and the
number of patient days). Comparison was made
between costs of the previous approach to the tre-
atment for each clinic of Clinical center, and costs
after the guidelines application. Pharmacoecono-
mic aspects of treatment were observed based on
the mentioned results.
Our goal was to make guidelines for the appro-
priate antimicrobial therapy application based on
monitoring of resistance to antimicrobial drugs.
We wanted to determine the guidelines impact on
antibiotic consumption and costs of treatment.
Results
Infectious Diseases Clinic took the first place in
savings of material resources in research. During
the three months after being given treatment witho-
ut guidelines, the total cost of prescribed antibiotics
was 37642,26. euros (€). Calculated into defined
daily doses per 100 /patient days spent amount was
71,87 DDD / 100 patient days (Table 1) . During the-
se three months 6039 patient days were completed.
After the guidelines for initial adequate antimi-
crobial therapy were applied, the Infectious Dise-
ases Clinic achieved more rational spending than
in the previous period. During those three mon-
ths, the total cost of prescribed antibiotics was
24886,49 € or 89,83 DDD / 100 (Table 1)9. During
these three months 8.484 patient days were com-
pleted. Comparing the results of the costs for pres-
cribed antibiotics before and after the pharmacot-
herapy/ pharmacoeconomic guidelines appliance,
at the Infectious Diseases Clinic was noted large
money saving of 12755,76 € (33.9%) (Table 1).
Endocrinology Clinic took second place in ma-
terial resources saving in research. During three
months, when was administered therapy wit-
hout application or guidelines, the total cost of
prescribed antibiotics was 10876,35 € or 122,45
DDD/100 patient days (Table 1). During these
three months 3985 patient days were completed.
After applying the guidelines for the initial
adequate antimicrobial therapy, during those three
months, the total cost of prescribed antibiotics was
1712 Journal of Society for development in new net environment in B&H
7106,61 € or 41,52 DDD / 100 (Table 1) 9. Du-
ring these three months 5478 patient days were
completed. Comparing the results of the cost for
prescribed antibiotics before and after the pharma-
cotherapy / pharmacoeconomic guidelines imple-
mentation, material resource savings of 3769,73 €
(34.6%) (Table 1) were noted.
Haematology Clinic took the third place in ma-
terial resources saving in research. During three
months, when administered therapy without appli-
cation or guidelines, the total cost for prescribed
antibiotics were 38575,89 € or 141.07 DDD/100
patient days (Table 1). During these three months
3543 patient days were completed.
After applying the guidelines for the initial
adequate antimicrobial therapy, the total cost of
prescribed antibiotics was 35425,25 € or 89,82
DDD/100 (Table 1). During that time 4953 patient
days were completed. Comparing the results of the
costs for prescribed antibiotics before and after the
pharmacotherapy/ pharmacoeconomic guidelines
implementation, material resources saving was
3150,64 € (8.2%) (Table 1). The number of pati-
ent days during the guidelines being applied has
increased for 1410 patient days, while the number
of DDD/100 patient days in the same period was
decreased for 51,25 DDD/100 patient days.
At the Urology, Orthopedics, Anesthesiology
and Intensive Care, Nephrology and Clinical Im-
munology Clinic, no savings were noted during
the second part of the research, when pharma-
cotherapy / pharmacoeconomic guidelines were
applied. Regardless of the fact that in all four in-
stitutions of DDD/100 patient days was reduced,
there was no saving of funds spent on antibacterial
drugs; on the contrary, costs were increased. Du-
ring applying the guidelines for the initial adequ-
ate antimicrobial therapy, cost savings were re-
corded in total amount of 20270,19 € (18.8%), in
comparison with the previous period when these
guidelines were not applied .
At the Infectious Diseases Clinic while prescri-
bing antibiotics without guidelines implementati-
on, ceftriaxone was the first by consumption of an-
tibiotic in ampoule 17,39 DDD/100 patient days,
it was followed by meropenem 5,97 DDD/100 pa-
tient days, and the third was metronidazole 3,39
DDD/100 patient days (Table 2), while other anti-
biotics were rarely prescribed.
 HealthMED - Volume 5 / Number 6 / 2011

After applying the guidelines for the initial
adequate antimicrobial therapy, the first antibiotic
in ampoule was ceftriaxone 12,38 DDD/100 pati-
ent days, second in prescribing was ciprofloxacin
2,36 DDD/100 patient days, and the third ampici-
llin and sulfamethoxazole + trimetoprim with 1,77
DDD / 100 patient days (Table 2 a).
At the Endocrinology Clinic ceftriaxone 10,04
DDD/100 patient days was first in antibiotics pres-
cribing in the previous period when guidelines
were not yet applied, second was meropenem 1
DDD/100 patient days and piperacillin-tazobac-
tam third 0,93 DDD/100 patient days (Table 3).
The first most prescribed antibiotic was ciprofloxa-
cin 82,81 DDD/100 patient days, second amoxi-
cillin with clavulanic acid 5,75 DDD/100 patient
days, and the third cephalexin 3,21 DDD/100 pa-
tient days. After applying the guidelines for the
initial adequate antimicrobial therapy, antibiotic
consumption at the Endocrinology Clinic was:
the first most prescribed antibiotics in ampoule
still was ceftriaxone 4,56 DDD/100 patient days,
second most prescribed was ceftazidime 1,14
DDD/100 patient days, and the third meropenem
0,51 DDD/100 patient days (Table 3 a).
At the Hematology Clinic while prescribing
antibiotics without guidelines implementation in
the first of antibiotics in ampoule was fluconazole
9,46 DDD/100 patient days, the second merope-
nem 6,12 DDD/100 patient days and third pipe-
racillin-tazobactam 3,76 DDD/100 patient days
(Table 4). The first most prescribed antibiotic was
ciprofloxacin 60,68 DDD/100 patient days, se-
cond 3,84 cephalexin DDD/100 patient days and
the third amoxicillin with clavulanic acid 3,53
DDD/100 patient days. After applying the guideli-
nes for the initial adequate antimicrobial therapy,
the first most prescribed antibiotic in ampoule was
cefepime 7,35 DDD/100 patient days, second me-
ropenem 3,29 DDD/100 patient days and third pi-
peracillin-tazobactam 2,51 DDD/100 patient days
(Table 4 a).
Discussion
In Serbia there are no established guidelines for
prescribing antibiotics drugs in the tertiary health
care. Existing guidelines for primary care could not
be applied to certain state of the bacterial resistance
of our domain of health care. For the same indica-
tions different antimicrobial agents from different
groups could be applied, and the selection depends
only on the decision of the physician on call1.
In countries with developed pharmacotherape-
utical practices there are distinctly defined positi-
ons, guidelines on the use of antibacterial drugs
for clearly defined indications, with constant mo-

Table 1. The total cost of prescribed antibiotics before and after applying guidelines in Clinical Centre
of Vojvodina
TOTAL COSTS TOTAL COSTS DDD/100 DDD/100
Money
(€) (€) patient days patient days
savings in
Clinic Before applying After applying Before appl- After applying
total
guidelines guidelines ying guidelines guidelines
(€)
( 3 months ) ( 3 months ) (3 months ) (3 months )
1 Endocrinology 10876,35 7106,61 122,45 41,52 3769,73
2 Nephrology 10993,45 14674,74 91,8 77,06 No savings
3 Haematology 38575,89 35425,25 141,07 89,82 3150,64
4 Gastroenterology 20510,60 19916,55 181,66 112,32 594,05
5 Urology 9373,90 10011,19 116,21 82,20 No savings
Anaesthesiology
6 20133,86 22044,38 91,67 78,73 No savings
and intensiv care
7 Orthopedics 10278,66 13787,35 54,39 53,87 No savings
8 Infectious diseases 37642,26 24886,49 71,87 89,83 12755,76
20270,19
Euros- €
DDD/100 patient days – Daily defined doses per 100 patient days

Journal of Society for development in new net environment in B&H 1713

HealthMED - Volume 5 / Number 6 / 2011

Table 2. Antibacterial drugs in ampoule prescribed at Infectious Diseases Clinic of the Clinical Centre
of Vojvodina before guidelines being applied
Prescribed ant. cost Total cost x DDD/100
No. ATC Generic name Units DDD
in ampoule (€) quantity (€) patient days
1. J01DD04 ceftriaxon 1g 1000 2100 3,35 7038,4 2000 mg 17,39
meropenem
2. J01DH02 500 60 12,44 746,28 2000 mg 0,25
500mg
2. J01DH02 meropenem 1g 1000 691 24,8 17192,08 2000 mg 5,72
metronidazol
3. J01XD01 500 615 1,3 801,34 1500 mg 3,39
500mg/100ml
ATC – Anatomical therapeutic chemical classification system code

Table 2 a). Antibacterial drugs in ampoule prescribed at Infectious Diseases Clinic of the Clinical Cen-
tre of Vojvodina after guidelines being applied
Prescribed ant. Cost Total cost x DDD/100
No. ATC Generic name Units DDD
in ampoule (€) quantity (€) patient days
1. J01DD04 ceftriaxon 1g 1000 2100 3,35 7038,4 2000 mg 12,38
2. J01MA02 ciprofloxacin 100mg/10ml 100 1000 1,83 1833,8 500 mg 2,36
sulfomet.+trimetoprim
3. J01EE01 480 300 0,24 73,23 960 mg 1,77
400mg+80mg/5ml
3. J01CA01 ampicilin 1g 1000 300 0,78 236,64 2000 mg 1,77

Table 3. Antibacterial drugs in ampoule prescribed at Endocrinology Clinic of the Clinical Centre of
Vojvodina before guidelines being applied
Prescribed ant. Cost Total cost x DDD/100
No. ATC Generic name Units DDD
in ampoule (€) quantity (€) patient days
1. J01DD04 ceftriaxon 1g 1000 800 3,35 2681,29 2000 mg 10,04
2. J01DH02 meropenem 500mg 500 40 12,44 497,6 2000 mg 0,25
2. J01DH02 meropenem 1g 1000 60 24,8 1488 2000 mg 0,75
piperacilin + tazobactam
3. J01CR05 4000 130 15,46 2008,5 14000 mg 0,93
4g + 0,5g
Table 3 a). Antibacterial drugs in ampoule prescribed at Endocrinology Clinic of the Clinical Centre of
Vojvodina after guidelines being applied
Prescribed ant. cost Total cost x DDD/100
No. ATC Generic name Units DDD
in ampoule (€) quantity (€) patient days
1. J01DD04 ceftriaxon 1g 1000 500 3,35 1675,81 2000 mg 4,56
2. J01DD02 ceftazidim 1g 1000 250 3,54 885,75 4000 mg 1,14
3. J01DH02 meropenem 500mg 500 30 12,44 373,2 2000 mg 0,14
3. J01DH02 meropenem 1g 1000 40 24,8 992 2000 mg 0,37
Table 4. Antibacterial drugs in ampoule prescribed at Haematology Clinic of the Clinical Centre of
Vojvodina before guidelines being applied
Prescribed ant. cost Total cost x DDD/100
No. ATC Generic name Units DDD
in ampoule (€) quantity (€) patient days
1. J02AC01 flukonazol 2mg/ml 100ml 200 335 11,03 3695,05 200 mg 9,46
2. J01DH02 meropenem 500mg 500 15 12,44 186,6 2000 mg 0,11
2. J01DH02 meropenem 1g 1000 426 24,8 10564,8 2000 mg 6,01
piperacilin + tazobactam
3. J01CR05 4000 466 15,46 7204,36 14000 mg 3,76
4g + 0,5g

1714 Journal of Society for development in new net environment in B&H


Table 4 a). Antibacterial drugs in ampoule prescribed at Haematology Clinic of the Clinical Centre of
Vojvodina after guidelines being applied
Prescribed ant. cost Total cost x
No. ATC Generic name Units
in ampoule
1. J01DE01 cefepim 1g 1000
2. J01DH02 meropenem 500mg 500
2. J01DH02 meropenem 1g 1000
piperacilin + tazobactam
3. J01CR05 4000
4g + 0,5g
nitoring of resistance. Protocols are determined
not only by the efficiency of antimicrobial drugs,
but also by the price of medications. For rational
and adequate antibiotic treatment based on mo-
dern theory and practice of their use with respect
to certain policy-algorithms, an essential factor is
the price of drugs and selection of less expensive,
equally appropriate, taking into account the resi-
stance of bacteria17,18.
During our study, savings have been noted on
four clinics of eight which are the biggest consu-
mers of antibiotics in the Clinical Centre of Vojvo-
dina. At the Infectious Diseases Clinic savings was
33,9%, at Endocrinology 34,6%, at Haematology
8,2% and at Gastroenterology 2,8%. At the Infec-
tious Diseases Clinic, the most commonly prescri-
bed antibiotic in ampoule before and after guide-
lines being applied, was ceftriaxon, but its imple-
mentation in clinical practice resulted in savings of
5.01 DDD/100 patient days. After guidelines being
applied the meropenem was no longer on the list of
the top three most commonly used antibiotics.
At the Endocrinology Clinic ceftriaxon was also
the most frequently used of antibiotic in ampoule in
both parts of the research. After the guidelines were
applied, reduction in cost for 5,84 DDD/100 patient
days was noted. Consumption of meropenem was
reduced for 0,49 DDD/100 patient days while after
the guidelines were applied, and ceftazidime was
the second most prescribed antibiotic. Ciprofloxa-
cin was also the most frequently prescribed antibio-
tic in each part of the research at this clinic, and the
guidelines appliance lead to its cost reduction for
61,99 DDD/100 patient days.
At the Haematology Clinic fluconazole was the
most frequently prescribed antibiotic before the
guidelines being applied, and cefepime after the
guidelines being applied, while meropenem was
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
DDD/100
DDD
(€) quantity (€) patient days
728 7 5096 2000 mg 7,35
72 12,44 895,68 2000 mg 0,36
290 24,8 7192 2000 mg 2,93
435 15,46 6725,1 14000 mg 2,51
the second most used in both parts of the research
is, but guidelines implementation reduced its con-
sumption for 2,83 DDD/100 patient days.
Analysis of antimicrobial drugs use in countri-
es that have not yet developed a pharmacothera-
peutic / pharmacoeconomic practice, monitoring
resistance to bacteria, and analysis of data on the
use of common antibiotics and their cost, it was
concluded that the use of other effective drugs also
led to saving, and that it was necessary to introdu-
ce a pharmacoeconomic policies19,20,21. Countries
that are in the process of implementation of esta-
blished guidelines for recommended antimicrobi-
al drugs, the minimum costs and acceptable side
effects, reduce the use of expensive antibiotics in a
large percentage. Research in Hong Kong showed
that the guidelines application and reduction in
inadequate antibiotics administration, reduced use
of broad spectrum antibiotics for 28% 22. The re-
search in Switzerland conducted in three hospitals
showed that of 600 prescribed antibiotics 37% of
them were unnecessary, and in 45% of cases when
use of antibiotics was justified, they were actually
inadequately prescribed, which led to a significant
increase in the costs of treatment23. Research in
Turkey conducted in 18 tertiary health care institu-
tions showed that antibiotics were mostly used for
the treatment of upper respiratory tract infections,
urinary tract infection and febrile neutropenia.
The analysis of the apropriate use of antibiotics
concluded that in 78,4% cases the antibiotics were
empirically prescribed, which was inadequate24.
Pharmacoeconomic information rapidly beco-
me an acceptable fact for the evaluation and com-
parison of different treatment options.
The antibiotics consumption as well as imple-
mentation guide for the improvement of prescri-
bing antibiotics were analyzed in tertiary medical
1715
HealthMED - Volume 5 / Number 6 / 2011
institution in Germany. During three months of
guide implementation and prescribing antibiotics
only if approved by a specialist of infectious di-
seases, in 13 departments was recorded savings in
amount of 31510 €25 . Comparing our results du-
ring the same period of time, at four Clinics we sa-
ved 20270,19 €. Education program on adequate
use of antibiotics and their controlled administra-
tion, along with antibiotics resistance monitoring
have been applied in tertiary institutions in Thai-
land for one year, which led to money savings of
32231 dollars, in comparison to our study, which
lasted for three months, the savings was 27972,8
dollars26.
Restriction of certain expensive antibiotics in
Greece (chinolone, cefalosporin III and IV gene-
rations, karbapeneme, monobactame, glikopepti-
de and streptogramine) and implementation a cer-
tain protocol according to which only infectious
disease specialists were allowed to prescribe an-
tibiotics, led to a reduction in antibiotics costs for
20%27. In Turkey, the state has regulated the use
of antibiotics in hospitals during this project, and
since the restrictions for certain antibiotics have
been applied, the money savings was for 19,6%
higher than in a previous period. Controlled use
of antibiotics has also led to a reduction in bacte-
rial resistance to antibiotics28. Savings in material
resources are equal to the savings achieved in our
study, which is 18.8%. Similar research was carri-
ed out in the Czech Republic, where the restrictive
policies on use of antibiotics supported by hospital
information systems, resulted in savings of 26% in
comparison with the previous period29.
In countries where antibiotic resistance is not
monitored, as is the case with Serbia and Turkey,
the more expensive antibiotics are used, and lon-
ger is the period of hospitalization, so there is a se-
rious need of establishing the guide for antibiotics
and their usage30.
Conclusion
The effect of research was successful for pati-
ents who received adequate antimicrobial therapy
according to the pharmacotherapeutic / pharma-
coeconomic guidelines, because the hospital tre-
atment was shorter. The number of patient days
1716 Journal of Society for development in new net environment in B&H
decreased at all clinics, which took part in the pro-
ject, except at the Infectious Diseases Clinic, and
the result was less daily defined doses of antibioti-
cs 246 per 100 patient days.
Successful also was the decisions of resident
physicians in choice of antibiotics for treatment
according to the guidelines, which resulted in ma-
terial savings in the consumed antibiotics cost.
The problem was the motivation of doctors to
prescribe antibiotics according to the recommen-
dations, and not by personal choice, as the results
shows. Of the eight clinics that were included in
study, only four clinics rationalized the use of an-
tibiotics and money savings were recorded. This
problem can be solved by establishing a guide for
antimicrobial therapy for the entire state, accor-
ding to which every physician would be obliged
to act. Making these guides requires constant mo-
nitoring of bacterial resistance in a particular co-
untry, as well as pharmacoeconomic research.
Biggest success was a total savings of funds
of 12755,76 € (33.9%) spent on antibiotics at the
Infectious Diseases Clinic, which is one of the lar-
gest consumer of drugs. Savings were recorded at
the Endocrinology Clinic 3769,73 € (34.6%), He-
matology Clinic 3150,64 € (8.2%) and the Gastro-
enterology Clinic 594,05 € (2.8%). Total saving of
material resources spent on antibiotics in the peri-
od of three months was 20270,19 € (18.8%). This
is the first study of this kind that was conducted in
Vojvodina, Serbia.
Research has provided preliminary results, but
the success of applied measures could be estima-
ted only if antimicrobial drugs resistance is conti-
nuously monitored, as well as the most common
cause of infections, and morbidity and mortality
from diseases that are treated at the Clinics where
the research was conducted.
Local community benefit from research results,
as for proven efficient and more economical trea-
tment in accordance with guidelines, and to pre-
serve the efficiency of antimicrobial drugs.

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Corresponding author
Sandra Stefan-Mikic,
Clinical Centre of Vojvodina,
Infectious Diseases Clinic,
Serbia,
E-mail: sandrastefanm@yahoo.co.uk

1718 Journal of Society for development in new net environment in B&H


Secondary Lymphedema of the arm
in breast carcinoma at the Oncology
institute of Vojvodina: 2001 – 2006
Svetlana Popovic-Petrovic1,2, Miroslav Nedeljkovic1, Lazar Popovic1,2, Vasa Petrovic3
1
Oncology Institute of Vojvodina, Sremska Kamenica, Serbia,
2
Faculty of Medicine, Novi Sad, Serbia,
3
Health Center „Dr. Milorad Mika Pavlovic“ Indjija, Serbia.
Abstract
Introduction. Secondary lymphedema of the
arm is a post-therapeutical complication of the
breast carcinoma, and it can be developed during
the period of several months up to many tens of
years after the administered therapy. Data on in-
cidence in literature are different, usually the inci-
dence is from 20-30 %.
Aim. Presentation of incidence of the secon-
dary lymphedema of the arm in patients operated
on breast carcinoma at the Oncology Institute of
Vojvodina.
Material and methods. This prospective study
includes the patients who underwent surgery at the
Oncology Institute of Vojvodina in the period from
2001 to 2006. All patients participated in the pro-
gram of an early rehabilitation and education, and
were continuously monitored by the mid 2010. A
volume of the arm was measured in control exa-
minations at 5 symmetrical levels.
Criterion for diagnosis of ipsilateral arm edema
is a difference of 2 or more cm at, at least, one of
five measured symmetrical levels.
Results. During the period from 2001-2006,
from 318 (2006) to 442 (2002) patients with bre-
ast carcinoma diagnosis underwent surgery (annu-
al mean was 376), age being from 28 to 76 years
(mean of 54.6 years). Secondary lymphedema of
the arm was diagnosed in 9.78% (8.3%-11.04%),
on average, 25.6 months after the breast surgery.
The largest number of patients had an increased
volume at only 1 level (52%), mostly (70%) in the
proximal part of the upper arm. In 2.3% of pati-
ents, the whole ipsilateral arm was edematous. An
average deviation of the volume differences of the
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
ipsilateral arm was from 2.42 cm (I level) to 3.31
cm (IV level).
Conclusion. A program of an early rehabilita-
tion, education, as well as the continuous moni-
toring of patients by the physiatrists, contributed
to quantitative and qualitative changes in the most
frequent post-therapeutic complication of the bre-
ast carcinoma.
Key words: secondary lymphedema of the
arm, breast carcinoma, incidence, Oncology Insti-
tute of Vojvodina
Introduction
Secondary lymphedema of the arm (SLEA) is
the most frequent complication of the breast car-
cinoma therapy. Data on SLEA incidence are not
reliable due to varying diagnostic methods and
criteria, non-recognition of milder clinical forms,
as well as inadequate reporting (1,2).
Techniques and criteria of SLEA diagnosis are
not unified. The most frequently used method is
measuring of the extremity volume at symmetrical
levels, and the difference in volume of 2 or 3 cm
is the most frequently used criterion. Somewhat
more rarely a volumetric method, bioimpedance,
imaging methods (magnetic resonance imaging,
computerized tomography, ultrasound diagnosti-
cs) and lymphoscintigraphy are used (3).
In the greatest number of studies, an average in-
cidence of SLEA is 20-30% (1, 4-8) and somew-
hat smaller, 4%-17% (5,9), if a sentinel gland bi-
opsy was performed. In the study of Petrek AJ et
al.(1), which summarized the data from 35 studies
from all over the world, the incidence varied from
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HealthMED - Volume 5 / Number 6 / 2011

6-30%, depending on the implemented diagnostic -- I level: over the middle of

method and the duration of the testing period: in a metacarpophalangeal joints
study in Germany (Schumemann et al., 1997) du- -- II level: over radiocarpal joint
ring the monitoring period of 11 years and the diffe- -- III level: 10 cm under olecranon
rence in the arm volume of, at least, 2 cm, in 5,868 -- IV level: over olecranon
tested women, the incidence of SLEA of 24% was -- V level: 15 cm above olecranon.
obtained, while in a study in Italy (Paci E, 1996)
with 347 patients, SLEA was diagnosed in 30.2 %, The criterion for SLEA diagnosis is the diffe-
8% of who had a severe form of SLEA (the criteri- rence in volume of 2 or more cm at, at least one of
on was the difference in volume of at least 8 cm). five symmetrical levels.
SLEA is accompanied by subjective difficulties Time, passed from the surgery date until the occu-
(the feeling of the arm heaviness, pain, itching), rrence of edema was presented as the time passed for
an increased risk of infection, damage of the bra- SLEA occurrence, and is expressed in months.
chial plexus (1%-4%), malignant alteration into Clinical criteria of SLEA in this study were:
lymphangiosarcoma (0.1%). SLEA causes psyc- -- mild form: difference in volume of ipsilateral
hosocial, economic and cosmetic problems, it im- arm of 2-2.9 cm
pedes performance of everyday life activities (no- -- moderate form: difference in volume of
urishment, toilette, mobility), which significantly ipsilateral arm of 3-4.9 cm
affects the quality of life (10-12). -- severe form: difference in volume of
The priority is SLEA prevention, through the ipsilateral arm of 5 cm and more.
program of preventive oncological rehabilitation
(kinesitherapy program, patients’ education), or
SLEA diagnostics in the phase of reversible chan- Results
ges (13-15).
In the period from 2001 to 2006, at the Oncolo-
gy Institute of Vojvodina, from 318 to 442 patients
Material and methods annually underwent surgery with the diagnosis of
malignant breast carcinoma. Until the end of the
All the patients that were operated on breast monitored period (1st July 2010), SLEA was dia-
carcinoma at the Oncology Institute of Vojvodina gnosed in 8.3% (2004) to 11.04% (2001) of patients
in the period from 1st January 2001 to 31st Decem- (Table 1), mean age was 54.3 years (28-76 years).
ber 2006 were included in the prospective study. Table 1. SLEA in women operated on breast car-
All the patients were, according to the algorithm cinoma at the Oncology Institute of Vojvodina,
of postoperative procedures, included in the pro- 2001-2006
gram of an „early“ rehabilitation: kinesithera- No of No of % of
Year
py program from the second postoperative day, operated patients SLEA SLEA
which lasted during hospitalization until the first 2001 362 40 11.04
control examination by the physiatrist after one 2002 442 41 9.27
month, and a program of education on SLEA pre- 2003 409 40 9.78
vention. The patients continued with the program 2004 362 30 8.30
of a „late“ rehabilitation and they were controlled 2005 362 38 10.50
in intervals of 3-6 months, or earlier, if any of cli- 2006. 318 28 8.81
nical signs of SLEA appeared (5, 16-19). Mean 376 36 9.78
The monitoring period of all patients that un-
derwent surgery in this study was until 1st July 2010. A mean time from the surgery date to SLEA
At the first, and every following control exami- diagnosis was 25.56 months (2 -111 months).
nation by the physiatrist, the volume of the upper A mild clinical form of SLEA occurred in
extremities was measured by the centimeter tape 60.37%, moderate in 28.11% and severe in 11.52%
at 5 symmetrical levels: of patients (Table 2).

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 HealthMED - Volume 5 / Number 6 / 2011

Table 2. Clinical forms of SLEA

Difference in volume 2001 2002 2003 2004 2005 2006 Total (%)
2-2.9 cm 23 23 23 23 23 16 131 (60.37)
3-4.9 cm 12 15 11 4 9 10 61 (28.11)
≥ 5 cm 5 3 6 3 6 2 25 (11.52)
Total 40 41 40 30 38 28 217

Table 3. Number of levels with difference in volume of ipsilateral arm of 2 or more cm

1 level 2 levels 3 levels 4 levels 5 levels Total
2001 19 1 17 2 1 40
2002 18 11 7 5 41
2003 14 11 9 4 40
2004 19 3 6 2 2 30
2005 25 6 5 1 1 38
2006 18 3 4 2 1 28
Total 113 35 48 16 5 217
% 52.08 16.13 22.13 7.37 2.30

Table 4. Occurrence of SLEA at only 1 level – the difference of 2 or more cm

I level II level III level IV level V level Total
2001 4 15 19
2002 1 3 14 18
2003 3 3 8 14
2004 1 4 1 13 19
2005 5 3 17 25
2006 1 4 13 18
Total 1 18 14 80
% 0.89 15.92 12.39 70.80

Table 5. The difference in volume of the ipsilateral arm of 2 or more cm at 2 levels

I and II levels II and III levels III and IV levels IV and V levels Total
2001 1 1
2002 1 3 7 11
2003 1 4 2 4 11
2004 1 1 1 3
2005 1 5 6
2006 2 1 3
Total 2 7 9 17
35
% 5.72 20.0 25.71 48.57

Most usually, the arm edema was diagnosed at
only one level (52.07%), with a tendency of percen-
tage representation at only 1 level in the last years,
significantly more rarely at 3 levels (22.13%) and 2
levels (16.13%), while the ipsilateral arm was ede-
matous as a whole in only 2.3% patients (Table 3).
Only one level that was most frequently affec-
ted was a part of the upper arm, i.e. V level (70.8
%), more rarely the forearm part (15.92%) and the
elbow part (12.39%), while edematous hand was
registered in only 1 patient (0.89%). (Table 4)
Edematous arm at two measured levels was
most usually in the area of the whole upper arm
(IV and V level) – 48.57%, more rarely in the fo-
rearm part and extremely rarely in the part of the
wrist (5.72%). (Table 5)

Journal of Society for development in new net environment in B&H 1721

HealthMED - Volume 5 / Number 6 / 2011

Table 6. The difference in volume of the ipsilateral arm of 2 or more cm at 3 measured levels
I-III levels II-IV levels III-V levels Total
2001 3 14 17
2002 1 1 5 7
2003 3 6 9
2004 6 6
2005 1 4 5
2006 1 3 4
Total 1 9 38
48
% 2.08 18.75 79.17

Table 7. Difference in volume (in cm) of the ipsilateral arm per measured levels
I level II level III level IV level V level
2001 2.50 2.58 3.30 3.57 3.20
2002 2.25 2.94 3.18 2.98 2.98
2003 2.00 2.63 3.42 3.34 3.18
2004 2.25 2.67 2.73 3.68 3.07
2005 2.50 2.67 2.85 3.28 2.28
2006 3.00 2.50 3.41 3.00 2.95
Mean 2.42 2.66 3.15 3.31 2.84

In 4/5 of patients with 3 edematous levels, the
upper half of the forearm and the whole upper arm
were affected. (Table 6)
The mean difference in volume of the ipsila-
teral and contralateral arm was from 2.42 cm (I
level) to 3.31 cm (IV level). (Table 7)
Discussion and conclusion
As the reason for insufficient reliable data on
SLEA incidence, Petrek AJ. in his study, in which
he analyses the results of 35 studies from various
parts of the world, states the following (1):
-- Nonexistence of prospective studies;
-- Prolonged SLEA development trend with larger
percentage of women who develop SLEA in a
longer time period;
-- Inconsistence of diagnostic methods and, within the
applied method, inconsistence of diagnostic criteria;
-- Significantly rarer contact between physiatrists
and patients in the period after the finished
breast cancer therapy;
-- SLEA, which affects the quality of life, is given
far less priority by the patients and medical
staff, in comparison to the basic disease, the
breast carcinoma.
-- The results presented in this paper, enable
partial overcoming of the stated problems:
-- The study is prospective, having in mind that all
the patients were operated on at the Oncology
Institute of Vojvodina, that, from the second
postoperative day they were included in the
program of an „early“ rehabilitation and were
monitored until the end of this study (1st July
2010) (1,2).
-- Due to prolonged development of SLEA, the
last examined year was 2006, which means that
the period of patients’ monitoring was from 42
months to 114 months.
-- As a diagnostic criterion, the simplest method
was chosen, measuring of the volume of the
arm by the centimeter tape at 5 symmetrical
levels, and the criterion for SLEA diagnosis
was the difference in volume of minimally 2
cm at, at least, one measured level, which is
also the least difference in volume stated in the
literature (3).
-- By foundation of the Rehabilitation Department
at the Oncology Institute of Vojvodina, the
patient – physiatrist contact starts on the second
postoperative day, after that there is a control
examination after one month, and the dynamics
of the following control examinations depends

1722 Journal of Society for development in new net environment in B&H


on clinical and functional status of each patient
(8, 16-19).
-- By introduction of a system of „horizontal“
interconnection among all specialties involved
in the problem of breast carcinoma: surgeon ↔
internist ↔ radiologist ↔ physiatrist, by active
individual work (rehabilitation and education),
by giving priority to preventive oncological
rehabilitation and by availability of the
rehabilitation team, the problems at the level of
patient-family-medical service were overcome,
i.e. the problem of ignoring of post-therapeutic
functional complications.
By inclusion of patients from the second posto-
perative day into the program of an „early“ rehabi-
litation and education, by continuous monitoring
of the functional status, cooperation among all
services included into diagnostics and therapy of
breast carcinoma and the availability of the reha-
bilitation team, the following was obtained:
-- reliable data (continuous monitoring of patients
in time intervals from 2 months to 12 months);
-- relatively low SLEA incidence: 9.78% in
this paper with „rigorous“ SLEA diagnostic
criterion – the difference in volume of 2 cm,
which is significantly less in comparison to the
data found in literature (1, 4-9);
-- the largest number of initial, reversible and mild
forms of SLEA (mean difference in volume of
the ipsilateral arm at all measured levels was
from 2.42 to 3.31 cm) (6);
-- individual cases of other functional damages:
damage of the brachial plexus, contractures in
the shoulder joint, etc.(10-12).
Suggestion
Model of prevention, early diagnostics and the-
rapy of the secondary lymphedema, the way it is
conducted at the Oncology Institute of Vojvodina,
is the model which may be implemented in insti-
tutions which deal with oncological problematic.
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
References
1. Petrek AJ, Heelan CM. Incidence of Breast Car-
cinoma-Related Lymphedema. Cancer 1998;
83:2776-81.
2. Park JH, Lee WH, Chung HS. Incidence and risk
factors of breast cancer lymphedema. J Clin Nurs
2008;17(11):1450-9.
3. Gerber HL. A review of measures of lymphedema.
Cancer 1998;83:2803-4.
4. Petrek AJ, Sennie TR, Peters M, Rosen PP. Lymp-
hedema in cohort of breast carcinoma survivors 20
years after diagnosis. Cancer 2001;92(6):1368-77.
5. McLaughlin AS, Wright JM, Morris TK, Sampon
RM, Brockway JP, Hurley EK, Riedel RE, Van Zee
JK. Prevalence of lymphedema in woman with
breast cancer 5 years after sentinel lymph node
biopsy or axillary dissection: patients percepti-
ons and precautionary behaviors. J Clin Oncol
2008;26(32):5220-6.
6. Oliveri MJ, Day MJ, Alfano MC, Herndon EJ, Katz
LM, et all. Arm/hand swelling and perceived functi-
oning among breast cancer survivors 12 years post
diagnosis. J Cancer Surviv 2008;2(4):233-42.
7. Clark B, Sitzia J, Harlow W. Incidence and risk of
arm oedema following treatment for breast cancer: a
tree-years follow-up study. QMJ 2005;98(5):343-8.
8. Nedeljkovic M, Popovic-Petrovic S, Kordic V, He-
mun S, Tomic S, Babic S. Sekundarni limfedem ruke
i maligne neoplazme dojke – naša iskustva. Zbornik
radova VI Kongresa fizijatara Srbije i Crne Gore sa
medjunarodnim ucešcem, 2006 nov 1-4; Vrnjacka
banja, Srbija, 2006.
9. Stout-Gergich NL, Phalzer LA, McGarvey C,
Springer B, Gerber LH, Soballe P. Preoperati-
ve assessment enables the early diagnosis and
succsessful treatment of lymphedema. Cancer
2008;112(12):2809-19.
10. Morrell RM, Halyard MY, Schild SE, Ali MS, Gun-
derson LL, Pockaj BA. Breast related lymphede-
ma. Mayo Clin Proc 2005;80:1480-4.
11. Passik DS, McDonald VM. Psychosocial aspects
of upper extremity lymphedema in woman treated
for breast carcinoma. Cancer 1998;83:2817-20.
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12. Gosk J, Rutowski R, Reichert P, Rabczynski J. Ra-

diation induced brachial plexus neuropathy –aet-
hiopathogenesis, risk factors, differential diagno-
stics, symptoms and treatment. Folia Neuropathol
2007;40(1):26-30.

13. Ericson SV, Pearson LM, Ganz AP, Adams J,

Kahn LK. Arm edema in breast cancer patients. J
Natl Cancer Inst 2001;93:96-111.

14. Runowitz DC. Lymphedema: patients and provi-

der education. Cancer 1998;83:2874-6.

15. Box RC, Reul-Hirche HM, Bullock-Saxton JE,

Furnival CM. Physiotherapy and breast cancer
surgery: results of a randomized controlled study
to minimize lymphedema. Breast Cancer Res Tre-
at 2002;75(1):51-64.

16. Popovic-Petrovic S, Nedeljkovic M, Petrovic T,

Vasovic M. Physical treatment of secondary lymp-
hedema of the arm in breast cancer patients. Arch
Oncol 2002;10(4):261-2.

17. Popovic-Petrovic S, Vasovic M, Nedeljkovic M.

Prevention and treatment of secondary lymp-
hedema of arm in breast cancer. Arch Oncol
2002;10(2):77-8.

18. Tomic S, Kordic V, Babic M, Popovic-Petrovic

S. Primena kineziterapije posle operacije dojke.
Zbornik radova V strucne konferencije Udruženja
medicinskih sestara i tehnicara Jugoslavije, Tara
2002;29

19. Tomic S, Popovic- Petrovic S, Hemun S. Sekun-

darni limfedem ruke kod malignog tumora dojke.
Kancerološka nedelja i 19. Strucni sastanak medi-
cinskih sestara – tehnicara onkoloških institucija
Republike Srbije, Beograd 2005

Corresponding author
Svetlana Popovic-Petrovic,
Oncology Institute of Vojvodina,
Rehabilitation Department,
Serbia,
E-mail: petrovic.svetlana@onk.ns.ac.rs

1724 Journal of Society for development in new net environment in B&H


Assessment of air quality impact on
human health in the city of Novi Sad
Sanja Bijelovic1, Budimka Novakovic2, Ljiljana Trajkovic-Pavlovic1, Milorad Bijelovic3
1
Institute of Public Health of Vojvodina, Serbia,
2
Faculty of Medicine Novi Sad, Serbia,
3
The Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica, Serbia.
Abstract
Introduction: In terms of global impact asse-
ssment of air quality on human health the WHO
recommends the unique method of reporting heal-
th status dependent of the concentration of suspen-
ded particles (TSP, PM10 and PM2.5) in air, which is
not applicable in the Republic of Serbia.
Aim: The aim of our study was to determine
the concentration of TSP, PM10 and PM2.5 in the
environment and to determine whether registe-
red concentrations affect health of the population
applying the international approved "DPSEEA"
methodology.
Methodology: The study was carried out in the
City of Novi Sad on the basis of data collected du-
ring 2006. Determination of hazards presented in
the air of environment was done by air sampling
to define the average annual concetrations of TSP
and further calculation of annual PM10 and PM2.5
concentration. In environmental impact assessment
were used data of total mortality, cardiopulmonary
mortality of persons aged above 30 and respiratory
mortality of children under five years. The expec-
ted number of deaths was calculated on the basis of
estimated concentration of PM10 and PM2.5, as well
as in relation to changed concentrations of PM10 of
10 µg/m3. The significance of differences was te-
sted by t-test and test of proportions.
Results: Daily average value of TSP per year
was 174.13 μg/m3. The estimated average daily
concentration of PM10 and PM2.5 were 95.77 μg/
m3, i.e. 47.88 μg/m3, per year. The expected total
number of deaths dependent on short-term presen-
ce and concentration of PM10 was 131 (95% CI,
114-148). Expected number of deaths from cardi-
opulmonary disease people aged above 30, depen-
dent on long-term presence and concentration of
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
PM2.5, was 42 (95% CI, 36-75). Expected number
of deaths from respiratory disease of children un-
der five years, dependent on short-term presence
and concentration of PM10, was 0.036 (95% CI;
0.031 - 0.040). Decrease of the average population
exposure to suspended particles PM10 in 10 µg/m3
induced reduction of the expected total number of
deaths in 16 cases and decrease of the expected
number of deaths from cardiopulmonary disease
people aged above 30 in 5 cases.
Conclusion: The research, which should be
seen as the first in this area, has shown that the ele-
vated concentrations of TSP, PM10 and PM2.5 con-
tribute to the overall mortality rate and respiratory
mortality in children under five by 3.6% and to
cardiopulmonary mortality in persons aged above
30 with 1.81%.
Key words: Health; Health Status Indicators;
Air; Environment
Introduction
Clean air is the basic condition of human life and
welfare. The air pollution significantly affects health
of the entire world population. According to WHO
estimated incidence of diseases caused by air pollu-
tion, more than two million premature infant deaths
each year can be linked to air pollution in urban and
indoor environment, where more than half of the ca-
ses were recorded in developing countries (1).
Pollutants from the air can affect different po-
pulation, causing most occurrence of respiratory
and cardiovascular diseases (1, 2, 3, 4). The influ-
ence of air quality on human health is dependent
on the health status of populations and individu-
als, the socio-economic status, working conditi-
ons and environmental conditions (1, 2). The risk
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HealthMED - Volume 5 / Number 6 / 2011
population group (children, elderly and ill people,
socio-economically vulnerable persons, under-
educated person) is at greater risk to get diseased
by air pollution sources (1, 2, 5, 6, 7, 8).
According to WHO data, environmental air po-
llution contributes to the overall mortality at the
global level from 1.4% to 2% of cardiopulmonary
disease and 0.5% in the age adjusted in relation to
disability (Disability Adjused Life Years, DALYs)
(9, 1 ). Assuming that impact of pollutants from
the air is more evident among vulnerable popula-
tions, WHO estimates that diseases dependent on
environmental air pollution participate with 81%
of the total mortality rate of people aged over 60
and 3% of the total mortality rate of children aged
up to five years, or with 49% in DALYs in people
aged over 60 and 12% in DALYs in children aged
under five years (1).
According to data analysis across Europe since
1990 the WHO has published that more than 700
deaths of children aged 0-4 due to acute respiratory
infections can be related to the concentration of
suspended particles PM10 (PM10 - particulate matter
10) in environment (10). It was calculated that de-
crease in annual exposure to PM10 to 20 μg/m3 re-
duces the incidence of acute symptoms (wheezing,
cough, productive cough, respiratory infections) by
7% and the number of respiratory hospitalizations
among children aged under 15 for 2% (10).
Based on epidemiological studies carried out in
five continents over the past two decades correlati-
on between daily, multi-day, annual and long-term
air quality and health status was established (11).
According to the validity of epidemiological
research data the strongest association is found
regarding to concentration of suspended particles
PM10 and PM2.5 (PM2.5 - particulate matter 2.5)
(11, 12, 13). Commonly used indicator of the pre-
sence of suspended particles in the air is PM10.
According to WHO data (1) the amount of total
suspended particule (TSP) and PM10 in the air is
the highest in Asia. Comparing the available data
it was determined that the mean annual concen-
tration of PM10 in Asia (from 35 μg/m3to 220 μg/
m3) and Latin America (from 30 μg/m3 to 129 μg/
m3) was higher than in Europe and North America
(from 15 μg/m3to 60 μg/m3). According to data of
CAFE study from 2004 (14) the average annual
concentration of PM10 in the air of cities in Eu-
1726 Journal of Society for development in new net environment in B&H
rope exceeded 50 μg/m3 in Prague, Turin, Bucha-
rest, Barcelona, Milan, Rome, Krakow and Berlin.
According to data of European Topic Center on
Air and Climate Change published in the 2005, the
level of PM10 in the period 1990-2002, followed
by the more than 1100 measuring stations for air
quality monitoring in 24 countries, including 550
urban settlements, ranged from an average annual
26.3 μg/m3 in the urban background to 32.0 μg/m3
in the traffic zones, while the average daily level of
PM10 was 43.2 μg/m3 in the urban background and
51.8 μg/m3 on the traffic zones (15). In rural are-
as of Europe, according to the same source (15),
average annual and daily PM10 concentration was
lower and amounted to 21.7 μg/m3 or 38.1 μg/m3
respectivly. In the period 1990-2002 the highest
annual average value of PM10 in Europe amounted
to 80 μg/m3, and the highest average daily value
of PM10 150 μg/m3 (15). According to WHO data
for 2007 in Europe the average annual PM10 con-
centrations ranged from 16 μg/m3 in Finland and
Ireland, to 45-52 μg/m3 in Bulgaria, Romania and
Serbia to 72 μg/m3 in Turkey (10).
Suspended particles PM2.5 are the benchmark
for assessing the influence of air on human health
(1). If there are no data on the concentration of
PM2.5 determined by measuring, the concentration
of PM2.5 is going to be interpreted in relation to
the estimated concentration of PM10 (11). Thus the
ratio of PM2.5/PM10 in the U.S. ranged from 0.44
to 0.71, in Chile from 0.4 to 0.6, and in Cairo it
was 0.5 (1). According to CAFE study the ratio
PM2.5:PM10 in Europe was in average 0.65, ran-
ging from 0.42 to 0.82 (14). According to the same
source (14), average annual concentrations of
PM2.5 in the urban background zones were 15-20
μg/m3, 20-30 μg/m3 in the traffic zones and 11-13
μg/m3 in the rural areas. The United States Envi-
ronmental Protection Agency recommends 0.55 as
the conversion factor for TSP:PM10 (11, 16). In the
absence of values of national factors for the con-
version ratio PM2.5/PM10 and conducted on the ba-
sis of epidemiological studies, WHO recommends
factor of 0.65 for developed countries and 0.50 for
developing countries. For the countries of Europe
it is also recommended the factor of 0.73 (14, 16).
In terms of global impact assessment of air qu-
ality on human health WHO recommends moni-
toring cardiopulmonary mortality of the popula-

tion aged above 30 in long-term exposure to air
pollutants, respiratory mortality among children
under five years from short-term exposure to air
pollutants and the total mortality of the whole po-
pulation from short-term exposure to air pollutants
(11). In accordance with the WHO methodology it
is recommended to evaluate changes in population
health caused by increased or decreased PM10 by
10 μg/m3 (11). Conducted epidemiological studies
have indicated that the changes of total mortality
caused by the increased PM10 of 10 μg/m3, ranged
from 0.5% to 1.6%, while changes in total mortali-
ty in the United States amounted to 2% for people
aged above 65 (11, 17).
Unique method of reporting health status of
human dependent of environmental conditions
used in most countries of the European Union is
"DPSEEA" model ("Driving Force","Pressure",
"State", "Exposure", "Effect” and "Action") (18,
19, 20, 21). Some countries do not apply strictly
"DPSEEA" model to process indicators, but they
use other models which are very similar to “DP-
SEEA” model and whose results are in accordance
with the methodology applied for collecting, pro-
cessing and reporting of data (21). The problem in
the mutual comparability of data refer to the type
of selected indicators, to the methodology of data
processing and to the ways of interpreting and dis-
playing results (21).
The current health system in the Republic of
Serbia provides a separate determination of the en-
vironmental status and population health, but not
their mutual comparison. "DPSEEA" or a similar
model for the mutual interdependence of the fac-
tors determining the environment and health status
in the Republic of Serbia is not applied (22). In the
region of Autonomous Province of Vojvodina the
only available impact assessment data of the envi-
ronment to human health was found for the city of
Pancevo, where in 2005 the pilot survey on air qu-
ality and impact assesment on human health for the
period 2002-2005 years was conducted (22, 23).
Aim
The aim of the paper was to determine the con-
centration of air pollutions such as TSP, PM10 and
PM2.5 in the environment of the City of Novi Sad
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
and with the application of internationally recogni-
zed "DPSEEA" methodology to determine whether
the found concentrations of TSP, PM10 and PM2.5
affect health status of Novi Sad population.
Methodology
The study was conducted in the City of Novi
Sad on the basis of data collected during 2006
according to WHO methodology defined under
"DPSEEA" model (18, 19, 20, 21). Methodology
of "DPSEEA" system means determining present
hazards in the environment and assessing the im-
pact of the established air quality on human health.
Determining the hazards present in the en-
vironment is carried out by sampling in order to
register the TSP in 24-hour air samples at two me-
asuring locations: MZ Šangaj, Školska bb, Novi
Sad (industrial zone) and JKP „Gradsko zelenilo“,
Futoški put 48, Novi Sad (urban zone).
Air sampling for determining the TSP in 24-
hour air samples was conducted through the im-
plementation of air filter paper "Whatman 1 and/
or "FILTRAK" diameter 110 mm at the achieved
average flow of 15 liters of air per hour (24, 25).
For air sampling to determine the TSP was used
appliance AT 2000, manufacturer „Proekos" in
Belgrade (26). The total amount of TSP was deter-
mined gravimetrically, according to an accredited
laboratory services by the Department of laboratory
of the Institute of Public Health of Vojvodina (24,
27). The concentration of PM10 and PM2.5 in the air
were calculated from determined amount of TSP. In
the absence of national conversion factors interna-
tionally recommended factors were used (11, 16).
The concentration of PM10 was determined as 0.55
from the TSP and the concentration of PM2.5 as 0.5
from the calculated concentration of PM10 (11, 16).
For environmental impact assessment of air
quality on human health (11, 28, 29, 30, 31) there
were used data of the Center for Informatics and
Biostatistics in Health, Institute of Public Health
of Vojvodina, from the field of vital statistics such
as data on the total mortality of the population
of the City of Novi Sad (total mortality), data on
cardiopulmonary mortality (MKB10: J00-99 and
MKB10:I20-25) of persons aged above 30 in the
City of Novi Sad (cardiopulmonary mortality) and
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HealthMED - Volume 5 / Number 6 / 2011
data on respiratory mortality (MKB10: J00-99) in
children up to five years in the City of Novi Sad
(the respiratory mortality of children).
Expected number of deaths correlated to the
presence and concentration of air pollutants of the
environment is determined by the WHO definition
(11, 28, 29, 30) by following formulas:
RR = exp [ß (X-Xo)],
AF = RR-1/RR and
E = AF x B x P, where
RR -relative risk,
ß - a calculated factor in determining the
relative risk burden of disease dependent
on environmental conditions,
X - the specified average annual concentra-
tions of pollutants (μg/m3)
Xo - target or limit values of air pollutants (μg/
m3)
AF - a contributory factor,
B - number of deaths per 1000 people
P - relevant population that is exposed to
pollutants from the air,
E - expected number of deaths dependent
on the presence and concentration of air
pollutants of the environment.
The relative risk was determined for total mor-
tality in all age groups of Novi Sad population in
relation to short-term exposure (24-hour exposu-
re) of PM10 in the air, in cardiopulmonary mor-
tality in relation to long-term exposure (annual)
of PM2.5 and respiratory children mortality regar-
ding to short-term exposure (24-hour exposure) of
PM10 in the air. The recommended value (11, 28,
29, 30) used as calculation factor to determine the
relative risk burden of disease dependent on envi-
ronmental conditions (ß) was 0.8%.
According to WHO methodology (11) there
was presented the expected number of deaths de-
pendent on the changed concentration of PM10 of
10 μg/m3 in the environment. The estimated amo-
unt of PM10 with increased or decreased amount
for 10 μg/m3 was calculated from maesured con-
centration of TSP and then was used for calcula-
ting the data of expected total mortality number,
1728
cardiopulmonary mortality and respiratory morta-
lity in children.
Data processing is used by Microsoft Excel
2003 and Statistica 9.0 for Windows. The signifi-
cance of differences was tested by t-test and test of
proportions.
Results
In 2006 total of 204 air samples for TSP de-
termination were sampled, out of which 109 were
sampled in industrial and 95 in the urban zone
of the City. Observed annual average daily value
of TSP per year amounted to 174.13 μg/m3 and
exceeded the yearly value thresholds of 70 μg/m3
by 148.76% (Table 1).
The relative risk of total mortality and relative
risk of respiratory mortality in relation to short-
term exposure (24-hour exposure) of PM10 in the
air is 1.037. It was based on established average
daily TSP concentrations per year (174.13 μg/m3),
where was calculated average daily concentration
of PM10 per year (95.77 μg/m3) by multipling with
a factor of 0.55, where the threshold concentration
of PM10 (Xo) in 24-hour air samples was defined
value of 50 μg/m3 (Table 2).
The relative risk of cardiopulmonary mortality
in relation to long-term exposure to PM2.5 from the
air is 1.018. It was based on established average
daily TSP concentrations per year (174.13 μg/m3),
where was calculated average daily concentration
of PM10 per year (95.77 μg/m3) by multipling with
a factor of 0.55 and further by multiplying with the
factor of 0.5 was calculated the average daily con-
centration of PM2.5 per year (47.88 μg/m3), where
the threshold concentration of PM2.5 per annum
(Xo) was defined value of 25 μg/m3 (Table 2 ).
The total number of deaths in the City of Novi
Sad in 2006 was 3637, that was in accordiance of
the total population of Novi Sad of 314192 giving
death rate of 11.576 (0.011576 per 1000 populati-
on) (Table 2).
Number of people aged above 30 who died of
cardiopulmonary diseases in the City of Novi Sad
in 2006 was 2315, that was in accordiance of the
total population of Novi Sad of 314192 giving
mortality rate of 7.368 (0.007368 per 1000 popu-
lation) (Table 2).
Journal of Society for development in new net environment in B&H

Number of dead children due to respiratory
diseases aged under five in the City of Novi Sad
in 2006 amounted to one, that was in accordiance
of the total number of children aged under four
in the City of Novi Sad in 2006 of 8669 giving
the mortality rate from 0.115 (0.000115 per 1000
children) (Table 2).
Substituting the obtained values into the for-
mula showed that the expected total number of
deaths of inhabitants of the City of Novi Sad was
dependent on short-term presence and concentra-
tion of PM10 in the air was 131 (95% CI, 114-148),
or 3.6% of total mortality in 2006.
Expected number of deaths from cardiopulmo-
nary disease of population aged above 30 in the
City of Novi Sad, dependent on long-term pre-
sence and concentration of PM2.5 in the air, is 42
(95% CI, 36-75), or 1.81% of total cardiopulmo-
nary mortality.
Expected number of deaths from respiratory
disease of children under five years in the City of
Novi Sad, dependent on short-term presence and
concentration of PM10 in the air, is 0.036 (95% CI,
0.031- 0.040), or less than one child, or 3.6% of
respiratory mortality.
On the basis of established values can be con-
cluded that determined concentration of suspen-
ded particles in the air of the City of Novi Sad in
2006 could contribute 3.6% (131) of total deaths
in the population, or 1.81% (42) deaths from car-
diopulmonary disease of people aged over 30 and
3.6% (less than one) of deaths from respiratory di-
sease among children up to five years.
If the annual average concentration of suspen-
ded particles increases by 10 μg/m3, provided the
increased concentration of TSP per year will amo-
unt to 184.13 μg/m3 and then the expected total
number of deaths (E1) of the residents in the City
of Novi Sad, dependent on short-term presen-
ce and concentration of PM10 in air will amount
to 146 (95% CI); the expected number of deaths
(E1) of cardiopulmonary disease in population
aged above 30, dependent on long-term presence
and concentration of PM2.5 in the air, will amount
to 47 (95% CI) and the expected number of deat-
hs (E1) for respiratory diseases of children under
five years, dependent on short-term presence and
concentration of PM10 in the air, will amount to
0.04 (95% CI) (Table 3). Increase in the avera-
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
ge population exposure to suspended particles in
10 μg/m3 is correlated to the increase of expected
total number of deaths to 15 (with 131 to 146),
increase of expected number of deaths from car-
diopulmonary disease within the population aged
above 30, for five (from 42 to 47) and increase of
expected number of deaths from respiratory dise-
ase of children under five years for 0.004 (from
0.036 to 0.04). Reported increase in the expected
number of deaths does not represent a statistically
significant increase in the level of 0.05 (p>0.05),
because the obtained values (146, 47, 0.04) are in
the 95% confidence interval of the average popu-
lation exposure to suspended particles of 174.13
μg/m3 (Table 3).
If the annual average concentration of suspen-
ded particulate matter are reduced by 10 μg/m3,
provided concentration of TSP per year will amo-
unt to 164.13 μg/m3 and then the expected total
number of deaths (E2) of the residents of the City
of Novi Sad, dependent on short-term presence
and concentration of PM10 in the air will amount
to 115 (95% CI;98-163), the expected number of
deaths (E2) of cardiopulmonary disease in popu-
lation aged above 30, dependent on long-term pre-
sence and concentration of PM2.5 in the air, will
amount to 37 (95% CI; 31-62) and the expected
number of deaths (E2) of respiratory disease of
children under five years, dependent on short-term
presence and concentration of PM10 in the air, will
amount to 0.03 (95% CI; 0.03 to 0.04) (Table 4 ).
Decreased average population exposure to
suspended particles in 10 µg/m3 is correlated to
reduction of the expected total number of deaths
for 16 (from 131 to 115), reduction of expected
number of deaths from cardiopulmonary disea-
se in population aged above 30 for five (from 42
to 37) and reduce the expected number of deaths
from respiratory disease of children under five for
0.006 (from 0.036 to 0.03). Reported decrease in
the expected number of deaths does not represent
a statistically significant reduction in the level of
0.05 (p>0.05), because the obtained values (115,
42; 0.03) are in the 95% confidence interval of the
average population exposure to suspended partic-
les of 174.13 μg/m3 (Table 4).
The increase in total number of deaths for 15
cases (n=3637+15=3652) and increased number of
deaths from cardiopulmonary disease for 5 cases
1729
HealthMED - Volume 5 / Number 6 / 2011

(n2=2315+5=2320), correlated to TSP concentrati- Table 1. Total amount of suspended particulate on

on increase of 10 μg/m3, increased total mortality annual level in the City of Novi Sad during 2006
rate for 0.047 (0.4%) without statistical significance Statistical indicators TSP (μg/m3)
(p=0.29299) and increased cardiopulmonary mor- LV* 70
tality for 0.016 (0.2%) without statistical significan- Number of measurment 204
ce (p=0.404149) (Table 5). In terms of decreased Average daily level on annual level 174,13
TSP of 10 μg/m3, a reduction in total number of de- C50* 155,00
aths for 16 cases (n=3637-16=3621) and reduce the C95* 325,00
number of deaths of persons aged above 30 of cardi- C98* 342,00
opulmonary disease for 5 cases (n=2315-5=2310), Minimum 35,00
which causes further reduction in total mortality of Maximum 593,00
0.051 (0.4%) without statistical significance (p = Standard deviation 81,38
0.26355) and a reduction in cardiopulmonary mor- Coefficient of variation 46,74
tality of 0.016 (0.2%) without statistical significan- Exceeding LV annually (%) 148,76
ce (p = 0.404055 ) (Table 5). *LV – limit value; C50, C95 i C98 –percentile values
Since the established number of deaths from
respiratory disease of children under five in 2006
amounts to one, and that the increase or reduction
of TSP for 10 µg/m3 does not exceed one case in
the expected number of deaths of children under
five (Tables 3 and 4), statistical analysis of data are
not implemented.

Table 2. The expected number of deaths dependent on the presence and concentration of pollutants in
the air in the City of Novi Sad
Expected mortality/ PM10/ PM2,5/
X TSP CI
lenght of exposure / ß TSP* PM10** RRPM10 RRPM2,5 AF§ B§§ P§§§ Eǂ
(µg/m3) (95%)
age (µg/m3) (µg/m3)

Total mortality/
short-term exposure 114-
0,0008 174,13 95,77 - 1,037 - 0,036 0,011576 314192 131
of PM10/all ages of 148
population

Cardiopulmonary
mortality/ long-term
0,0008 174,13 95,77 47,88 - 1,018 0,018 0,007368 314192 42 36-75
exposure of PM2.5/
aged above 30

Respiratory
mortality/ short-term 0,031-
0,0008 174,13 95,77 - 1,037 - 0,036 0,000115 8669 0,036
exposure of PM10/ 0,040
children under 5
*factor 0,55 for calculating PM10 from TSP; ** factor 0,5 for calculating PM2.5 from PM10, not calculated in total mortality
and respiratory mortality;
§
- relative risk RR=exp [ß (X-Xo)]
§
AF (atributable factor) - AF=RR-1/RR; §§B – number of deaths for 1000 people; §§§P – exposed populations;
ǂ
E (expected number of deaths) - E=AF x B x P

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 HealthMED - Volume 5 / Number 6 / 2011

Table 3. The expected number of deaths dependent on the presence and concentration of pollutants in
the air in the City of Novi Sad with calculated increase of TSP on annual level for 10 µg/m3
Total mortality/short- Cardiopulmonary mortality/ Respiratory mortality/
Indicators term exposure of PM10/ long-term exposure of PM2.5/ short-term exposure of
all ages of population aged above 30 PM10/children under five
ß 0,0008 0,0008 0,0008
X TSP1 (µg/m3) 184,13 184,13 184,13
PM10/TSP1* (µg/m3) 101,27 101,27 101,27
PM2.5/PM10**(µg/m3) - 50,64 -
RR1PM10 1,04 - 1,04
RR1PM2.5** - 1,02 -
AF§1 0,04 0,02 0,04
B* 0,011576 0,007368 0,000115
P** 314192 314192 8669
E1 146 47 0,04
CI (95%) 129-163 41-82 0,03-0,05
Ex (95%CI) 131 (114-148) 42 (36-75) 0,036 (0,031-0,040)
Difference Ex/E1
15 (p>0,05) 5 (p>0,05) 0,004 (p>0,05)
(number)
* factor 0,55 for calculating PM10 from TSP;
**factor 0,5 for calculating PM2.5 from PM10, not calculated in total mortality and respiratory mortality;
§
- relative risk RR=exp [ß (X-Xo)]; TSP1 – increasing TSP for 10 µg/m3; RR1 – relative risk with increasing TSP for 10;
§
AF (atributable factor) – AF=RR-1/RR; *B – number of deaths for 1000 people; **P – exposed populations;
E (expected number of deaths) – E=AF x B x P; AF§1 – atributable factor with increasing TSP for 10 µg/m3 ;
E1- expected number of deaths with increasing TSP for 10 µg/m3; Ex - expected number of deaths with TSP 174,13 µg/m3

Table 4. The expected number of deaths dependent on the presence and concentration of pollutants in
the air in the City of Novi Sad with calculated decrease of TSP on annual level for 10 µg/m3
Total mortality/short- Cardiopulmonary mortali- Respiratory mortality/
Indicators term exposure of PM10/ ty/ long-term exposure short-term exposure of
all ages of population of PM2.5/aged above 30 PM10/children under five
ß 0,0008 0,0008 0,0008
X TSP2 (µg/m3) 164,13 164,13 164,13
PM10/TSP2* (µg/m3) 90,27 90,27 90,27
PM2.5/PM10**(µg/m3) - 45,13 -
RR2PM10 1,03 - 1,03
RR2PM2.5** - 1,02 -
AF§2 0,03 0,02 0,03
B* 0,011576 0,007368 0,000115
P** 314192 314192 8669
E2 115 37 0,03
CI (95%) 98-163 31-62 0,03-0,04
Ex (95%CI) 131 (114-148) 42 (36-75) 0,036 (0,031-0,040)
Difference Ex/E2
16 (p>0,05) 5 (p>0,05) 0,006 (p>0,05)
(number)
* factor 0,55 for calculating PM10 from TSP; **factor 0,5 for calculating PM2.5 from PM10, not calculated in total mortality
and respiratory mortality; §- relative risk RR=exp [ß (X-Xo)]; TSP2 – decreasing TSP for 10 µg/m3; RR2 – relative risk with
decreasing TSP for 10; §AF (atributable factor) – AF=RR-1/RR; *B – number of deaths for 1000 people; **P – exposed
populations; E (expected number of deaths) – E=AF x B x P; AF§2 – atributable factor with decreasing TSP for 10 µg/m3 ;
E2- expected number of deaths with decreasing TSP for 10 µg/m3; Ex - expected number of deaths with TSP 174,13 µg/m3

Journal of Society for development in new net environment in B&H 1731

HealthMED - Volume 5 / Number 6 / 2011

Table 5. Changing mortality rates caused by increased or decreased TSP concentration in the air of the
City of Novi Sad
Established Mortality rate Changing mortality Mortality rate Changing mortality
mortality rate with increased rate caused by incre- with decreased rate caused by decre-
for 2006 in TSP concen- ased TSP concentra- TSP concen- ased TSP concentrati-
the City of tration for 10 tion for 10 µg/m3/ tration for on for 10 µg/m3/
Novi Sad µg/m 3
statistical significance 10 µg/m 3
statistical significance
+ 0,047 (+0,4%) - 0,051
Total mortality 11,576 11,623 11,525
(p=0,29299) (-0,4%) (p=0,26355)
Cardiopulmonary
+ 0,016 - 0,016
mortality of
7,368 7,384 (+0,2%) 7,352 (-0,2%)
persons aged
(p=0,404149) (p=0,404055)
above 30

Discussion Unlike the research in the City of Novi Sad,

Conducted research has indicated that the use of
internationally recognized methodology allows in-
terconnection and assessment depending on the exi-
sting data on the harmful substances in the air and
population health of the City of Novi Sad. Available
data provides estimate of the influence of analyzed
harmful substances from the air on people health.
Conducted research indicated to the increased
concentrations of TSP in the City of Novi Sad and
that TSP and PM10 and PM2.5 calculated from esta-
blished concentration of TSP, contribute to overall
mortality, cardiopulmonary mortality of persons
aged over 30 and respiratory mortality of children
under five years.
The survey also indicated that the amount of
TSP or amount of PM10 and PM2.5 calculated from
established concentration of TSP, contribute to
the increased or decreased overall mortality rates
and cardiopulmonary mortality rates among peo-
ple aged over 30, without statistical significance
per annum. It is also shown that the improved air
quality of the environment in terms of decreased
concentration of suspended particulate matter by
10 μg/m3 annually saves 16 adults and one child
living in the community of Novi Sad.
The research results obtained in the City of
Novi Sad in 2006 indicating that the established
TSP concentration and calculated concentration of
PM10 and PM2.5 contribute to overall mortality in
the City of Novi Sad in 2006 for 3.6%, and there-
fore represent data that matches the WHO data on
the contribution of air pollutants to total populati-
on mortality (11).
where the concentrations of suspended particu-
late matter of 10 μg/m3 have not made significant
changes to total mortality rate and cardiopulmonary
mortality observed annually, the studies of Ameri-
can researchers proved that an increased or decre-
ased suspended particles PM2.5 made a statistically
significant influence on changes in observed mor-
tality rate of diseases (32,33, 34, 35). Increase in
total mortality of the population of the City of Novi
Sad for 0.4% in the anticipated increase in the total
amount of suspended particles of 10 μg/m3, is less
than the percentage increase in total mortality with
increasing PM2.5 in the U.S., which, according to
data from 2000, for the period 1979-1983 is 4.8%,
according to data from 2002 for the period 1999-
2000 amounted to 3.1%, i.e. 4% generally (32, 35).
Researches in the U.S. also indicated the existen-
ce of mutual dependence of long-term exposure to
PM10 concentrations and total mortality and cardi-
opulmonary mortality (36, 37). Interdependence of
long-term exposure to PM10 concentrations and car-
diovascular disease among the adult population has
been demonstrated in studies conducted in France,
Italy, Netherlands and China (38).
Based on research conducted in the U.S. and
some European countries (36, 37, 38), it can be
assumed that determination of the interdependen-
ce of increased or decreased TSP in the air with an
increased or decreased overall mortality, cardiopul-
monary mortality of people aged above 30 and re-
spiratory mortality of children under five years in
the City of Novi Sad, anticipated daily variation in
the concentration of PM10 and PM2.5, as well as long
periods of analyses, is possible to be proved (11).

1732 Journal of Society for development in new net environment in B&H


The outcome of research is certainly influenced
by the fact that they are used to assess the impact
of budget but not really fixed value of the concen-
tration of PM10 and PM2.5, and for calculating the
PM10 and PM2.5 concentration from the TSP, in
the absence of national factors for conversion are
used internationally recommended factors which
are not sufficiently specific for the environment of
the City of Novi Sad (14, 16,).
Applied terms chosen to present the impact as-
sessment factors of environment on the population
health of the City of Novi Sad were determined on
the basis of existing statistics, which are partly ba-
sed on official data of the Republic of Serbia and
the last census conducted in 2002, as well as on the
data of public institutions based on the number of
registered residents by address and place of resi-
dence in the real-timetesting. The data of mortality
and morbidity are related to the settlement and he-
alth care and cannot bind to address subjects, thus
preventing accurate assessment of the effects of
pollutants from the environment on human health.
In our country, the data of the total mortality by
codes of illness are not available and the expressi-
on of the influence factors of the environment can
be done only in relation to the hospital or outpati-
ent morbidity. Problem in data collecting on num-
ber and frequency of the disease are an inadequate
set of data in the application form, imprecise in-
structions to report on methodology and data pro-
cessing, the lack of unified information technolo-
gy in data processing and presentation of data and
lack of systematic data in real-time events (39).
The average annual concentration of TSP is an
indicator that is rarely monitored in developed co-
untries. It is replaced with more modern and more
accurate measurements of small respirable parti-
cles, or PM10, PM2.5 and PM1. Therefore, data for
mutual comparison of results are difficult to access,
or the data of TSP are presented for the period of
90 years of the last century. According to available
data for comparison can be concluded that the ave-
rage annual concentrations of TSP in the City of
Novi Sad in 2006 are higher than average annual
concentrations of TSP in U.S. cities and towns of
Europe (35, 38). According to data from studies of
six cities in the U.S., the average concentration of
TSP in the period 1977-1985 ranged from 34.1 to
89.9 μg/m3 (34), which is less than the determined
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
TSP value in Novi Sad in 2006. Epidemiological
data of U.S. studies conducted in 156 capitals in
the period 1980-1981 indicated that the average
annual concentration of TSP was 68.0 μg/m3, in 58
capitals in the period 1979-1983 73.7 μg/m3, and
150 capitals in the period 1982-1998 56.7 μg/m3
(35). The average annual concentration of TSP in
Helsinki in the period 1987-1989. year amounted
to 76 μg/m3 (38).
However, according to the European Enviro-
nment Agency in the European Union in 1993 the
excess of the average daily value of TSP at the an-
nual level of 150 μg/m3, was established in Italy,
Portugal, Austria, Czech Republic, Denmark, Fin-
land, Germany and Spain, where they are especi-
ally emphasized by the maximum daily value of
TSP in the Czech Republic (from 450 to 709 μg/
m3) and Portugal (from 136 to 600 μg/m3) (40).
According to the Institute of Public Health of Ser-
bia "Dr Milan Jovanovic Batut" for 2009 it can be
concluded that the average annual TSP concentra-
tion ranges from 54 μg/m3 in Kosjerić to 147.8 μg/
m3 in Novi Sad (41). In Vojvodina, the mean an-
nual concentration of TSP in 2008 ranges from 87
μg/m3 in Petrovaradin over 99 μg/m3 in Pancevo,
115 μg/m3 in Kikinda, 164 μg/m3 in Zrenjanin to
227 μg/m3 in Novi Sad (42, 43).
The calculated concentration of PM10 in the
city of Novi Sad in 2006 of 95.77 μg/m3, is deri-
ved from the determined concentrations of TSP,
according to the data on directly measured con-
centrations of PM10 in urban areas of cities of the
European Union (43 μg/m3 in Dusseldorf, 42 μg/
m3 in Berlin, 44 μg/m3 in Madrid, 48 μg/m3 in
London) and is in average 50% larger (14).
The calculated concentration of PM2.5 in the
City of Novi Sad in 2006 of 47.88 μg/m3, is de-
rived from the determined concentrations of TSP
and PM10 (PM2.5/PM10 0.5), according to the
data on directly measured concentrations of PM2.5
is higher than the annual mean concentration of
PM2.5 provided for in the U.S. (in the period 1979-
1983 20.61±4.36 μg/m3, in the period 1999-2000
14.10±2.86 μg/m3), in Central Europe (in urban
areas 16-30 μg/m3, the background zones 12-20
μg/m3 and in zones along the roads 22-39 μg/m3),
in the countries of Northern Europe (in urban are-
as 8-15 μg/m3, 7-13 μg/m3 in the background zo-
nes, along roads 13-19 μg/m3) and in the countries
1733
HealthMED - Volume 5 / Number 6 / 2011
of Southern Europe (in urban areas 19-25 μg/m3,
12-16 μg/m3 in a background zones and along ro-
ads 28-35 μg/m3) (14, 32, 33).
Details of the research should be examined as
the first research in this area, and determined cor-
relation of concentration of suspended particles in
the air and mortality of the population of the City
of Novi Sad requires the implementation of further
researches based on established data, but not cal-
culated concentration of PM10 and PM2.5, data on
the exact number of inhabitants per residence and
systematized data on the number and type of de-
aths, particularly from cardiopulmonary and respi-
ratory diseases, collected by address of residence
of the population of the City of Novi Sad.
Conclusion
Conducted research has established that in
the City of Novi Sad there are evident increased
concentrations of TSP, which may contribute to
increasing rates of total mortality and respiratory
mortality of children under five years for 3.6% and
to increased cardiopulmonary mortality rates of
adult population aged above 30 for 1.81%, as well
as that improved air quality in terms of reduced
TSP for 10 μg/m3 annually saves 16 adults and one
child living in the community of Novi Sad.
1734 Journal of Society for development in new net environment in B&H
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kvaliteta vazduha životne sredine u AP Vojvodini.
Zdravstvena ispravnost vode otvorenih i zatvorenih
bazena u AP Vojvodini tokom 2008. godine. Kva-
litet površinske vode javnih kupališta reka i jeze-
ra u AP Vojvodini tokom 2008. godine. U: Jevtić
M. Zdravstveno stanje stanovništva AP Vojvodine
2008. godine. Novi Sad (Srbija): Institut za javno
zdravlje Vojvodine; 2009. P. 101-61. ISBN 978-86-
86185-18-1; COBISS.SR-ID 245008903.
43. Novaković B, Kristoforović-Ilić M, Trajković-
Pavlović Lj, Torović Lj, Jevtić M, Bijelović S et
al. Zdravlje i životne sredina. Med Pregl 2007;LX
(11-12):569-74.

1736 Journal of Society for development in new net environment in B&H


T4 Glottic carcinoma: oncological
results and survival rate
Slavisa Jancic1, Misko Zivic1, Zoran Radovanovic2, Biljana Milicic3, Natasa Djindjic4, Boris Djindjic4,
Snezana Jancic5
1
Oncology and ENT Clinic, Clinical Center Nis, Serbia,
2
Institute of Radiology, Clinical Center Nis, Serbia,
3
Scool of Dentisty, Department of statistics, Belgrade, Serbia,
4
Faculty of Medicine, University in Nis, Serbia,
5
Institute of Pathology, Faculty of Medicine in Kragujevac, Serbia.
Abstract
Objectives/Background: The best course
of action in the case of T4 glottic carcinoma is
chosen for each individual case. The aim of this
study was to evaluate the potential prognostic
factors and influence of postoperative and radical
radiotherapy on the survival rate of patients suf-
fering from T4 glottic carcinoma and to analyze
the most appropriate conservative treatment for
these patients.
Methods: Study Design: A retrospective study
(1995-2000) enrolled 63 patients with squamo-
cellular glottic cancer in T4N1M0 stage, monito-
red for 5 years, divided into two groups: 30 po-
stoperatively irradiated patients and 33 radically
irradiated patients. Analysed variables were: age,
sex, total therapeutical dose, number of fractions,
dose per fraction and type of radiotherapeutical
treatment. Standard therapeutical fractionation re-
gimens were used, with daily sessions of 2-3 Gy,
five times a week. Radiotherapy consisted of me-
ga-voltage 10 MEV X-ray therapy. Log Rank test,
Kaplan-Meier survival study, t- test, Pearson X2
– test and Cox regression were used in order to
select the factors with independent effect.
Results: Multivariate analysis demonstrated
that none of the predictors, not even the type of ra-
diation therapy, were statistically significant, with
independent influence on survival.
Conclusion: There is no significant difference
in survival of patients with T4 glottic carcinoma
among postoperatively and radically irradiated
patients. Our results imply that the optimal radi-
otherapeutic modality for these patients is a total
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
therapeutical dose no less than 65 Gy and daily
fractionation with dose no less than 2,51Gy.
Key words: T4 glottic cancer, prognostic fac-
tors, radical radiotherapy, postoperative radiothe-
rapy, survival
Introduction
Many studies have indicated that the therapy
protocols in the case of T4 glottic carcinoma are
applied flexibly, and that the best course of acti-
on is chosen for each individual case. At the same
time, in addition to any objective findings, other
non-medical factors also affect the choice of the-
rapeutic treatment.
Many therapeutic procedures are used in T4
glottic carcinoma therapy, including different sur-
gery methods, radical radiotherapy, chemothera-
py, a combination of radiological-surgical therapy
and concomitant chemoradiotherapy [1-7].
It is still the case in the clinical treatment of
T4 glottic carcinoma that combined surgical-radi-
ological therapy (postoperative radiotherapy) and
radical radiotherapy are utilized most frequently.
Surgical treatment usually means using different
methods, such as conservative-functional and
palliative surgery [3,8,9].
The aim of any kind of postoperative radiothe-
rapy is achieving locoregional control of the ma-
lign illness, accompanied by an acceptable level
of complications that may occur during the course
of therapy, while radical radiotherapy is traditio-
nally reserved only for patients who will undergo
a complete laryngectomy or are generally of poor
1737
HealthMED - Volume 5 / Number 6 / 2011
health and therefore are not good candidates for
more extensive surgery. Radical radiotherapy is
indicated also in the case of inoperable carcinoma
in the T4 stages [5,9,10].
There are many controversial reports regarding
the influence that the choice of therapy can have
on the increased survival rate of the patients suffe-
ring from T4N1M0 glottic carcinoma.
The aim of this study was to evaluate the poten-
tial prognostic factors and influence of postopera-
tive and radical radiotherapy on the survival rate
of patients suffering from T4 glottic carcinoma
and to analyze the most appropriate conservative
treatment for these patients.
Materials and methods
The patients
A total of 63 patients suffering from squamo-
cellular glottic carcinoma, stage T4N1M0, that
underwent radiotherapy at the Oncology Clinic of
the Faculty of Medicine in Nis from September the
1st, 1995 until September the 1st, 2000, were inclu-
ded in the study. The clinical T stage was defined
according to the TNM system, on the basis of the
UICC criteria [11]. Megavoltage therapy using 10
MeV X-rays was used as part of the radiotherapy
treatment. All of the patients received treatment in
the same manner, by utilizing the technique of two
separate parallel planes (5x5 do 5x7cm). They all
underwent daily fractionation, with daily session
of 2-3Gy per fraction, five times a week.
All patients included in the study signed wri-
ten permision for therapeutical intervention and
appropriate institutional research oversight com-
mittee from the Medical faculty in Nis gave per-
mision for study realisation. The patients were di-
vided into two groups: a group of patients who un-
derwent postoperative radiotherapy and a group of
patients who underwent radical radiation therapy.
The patients that underwent postoperative
radiation therapy
This group numbered a total of 30 patients. A
complete laryngectomy was performed on a total
1738 Journal of Society for development in new net environment in B&H
of 28 patients (93.3%), either separately, or com-
bined with pharyngectomy or the concomitant
removal of the base of the tongue, in accordance
to how the cancer was spreading. Only one pati-
ent had a subtotal laryngectomy (3.3%) and one
(3.3%) had a hemilaryngectomy. A radical dis-
section of the neck had to be performed on 8 of
the patients, while a complete laryngectomy and a
functional dissection on both sides had to be carri-
ed out on another 8 patients.
There was only one female patient in this gro-
up (3.3%). The youngest patient was 38, and the
oldest 79 (the median was 60 years of age). The
total therapeutic dose per patient was 42 - 66Gy
(the median for the group was 60Gy). The number
of fractions per patient was 16–28 (a median of
24). The therapeutic dose was 2-3Gy per fraction
(median of 2.5Gy).
The patients who underwent radical
radiation therapy
This group consists of 33 patients. There were
3 women (9.1%). The youngest patient was 39,
and the oldest was 79 (the median was 65). The
overall number of therapeutic doses per patient
was 42-127Gy (the median was 67Gy). The num-
ber of fractions per patient was 20–34 (the median
was 28), and the therapeutic dose per fraction was
2-3Gy (the median was 2.39Gy).
The patients were monitored over a period of
5 years, following radical or postoperative radiot-
herapy. The study did not encompass patients who
could no longer be found or patients who had died
from other illnesses before the end of the five-year
period following radiation.
Statistical analysis
An analysis of the predictor variables was
carried out first, along with an analysis of their
frequency among patients who underwent dif-
ferent forms of therapy: radical or postoperative
radiation therapy. An analysis of the survival rate
was carried out over a five-year period, followed
by an analysis of the survival rate of the subjects
in relation to the predictors.
 HealthMED - Volume 5 / Number 6 / 2011

A regression analysis was used to study the influ-
ence of each of the monitored factors on the survi-
val rate of these patients. The factors that exhibited
their statistically significant influence on the survi-
val rate in the univariate analysis were added to the
multivariate Cox model. The Kaplan-Meier survival
analysis was used to present the results, and Log-
Rank test to determine the statistical significance of
the length of the survival period. In order to compa-
re the parametric numeric features of observation,
the t-test was used. The Pearson c2-test was used to
compare the differences in the frequency.
Results
The analysis of the predictors
There were no significant differences in age
and gender between subjects with different thera-
peutic procedures (Table 1).
The total dose was significantly lower and dose
of radiation per fraction was higher in the group
Table 1. Patients’ characteristics
Subjects with different therapeutic procedures
Monitored factors
Postoperative radiation therapy
Under 45 2 (6.7%)
Age groups-
Between 45-60 15 (50%)
T4 stage
Over 60 13 (43.3%)
Sex – Male 29 (96.7%)
T4 stage Female 1 (3.3%)
Data are presented as numbers (%)
of patients who underwent postoperative radiation
compared to radical radiation therapy. The patients
who underwent radical radiation therapy received
a larger number of fractions during their radiation
therapy (Table 2).
The analysis of the survival rate in relation
to the predictors
Among the subjects with T4 glottic carcinoma,
the survival rate after one year was 57.14%, while
at the end of the 62-months’ period, the survival
rate was 9.52% (Table 3).
There was no significant difference in the survi-
val rate related to sex (median survival for males 14
months vs. 8 months for females), but there was si-
gnificant difference in the rate of survival according
to age (Log-Rank test; p=0.018) (Table 3).
There was no statistically significant difference
in the survival rate of the patients suffering from T4
glottic carcinoma in relation to the chosen therape-
utic treatment between the groups: either postope-
Value p
Radical radiation therapy
3 (9.1%)
10 (30.3%) p=0.280
20 (60.6%)
30 (90,9%)
p=0.343
3 (9,1%)

Table 2. Treatment characteristics

Subjects with different therapeutic treatment
Monitored factors p
Postoperative radiation therapy Radical radiation therapy
45-50Gy 5 (17.2%) 3 (10.3%)
Total dose - 50.1-57.5Gy 6 (20.7%) 1 (3.4%)
p=0.002
T4 stage 57.6-65Gy 15 (51.7%) 9 (31%)
Over 65Gy 3 (10.3%) 16 (55.2%)
16-20 5 (17.2%) 4 (12.9%)
Number of
21-25 14 (48.3%) 1 (3.2%)
fractions- p=0.002
26-30 10 (34.5%) 16 (51.6%)
T4 stage
Over 30 0 (0%) 10 (32.3%)
Dose per 2-2.25Gy 2 (6.7%) 11 (33.3%)
fraction- 2.26-2.5Gy 22 (73.3%) 19 (57.6%) p=0.026
T4 stage 2.51-3Gy 6 (20%) 3 (9.1%)
Data are presented as numbers (%)

Journal of Society for development in new net environment in B&H 1739

HealthMED - Volume 5 / Number 6 / 2011

Table 3. The survival rate of the subjects with T4 glottic carcinoma

1yr 2 yr 3yr 4yr 5yr Value p
Total survival 57,14% 25,40% 17,46% 11,11% 9,52% /
Male 57,63% 25,42% 16,95% 11,86% 10,17%
Sex 0,542
Female 50,00% 25,00% 25,00% 0,00% 0,00%
Under 45 20,00% 0,00% 0,00% 0,00% 0,00% 1vs2=0,006*
Age Between 45-60 68,00% 32,00% 24,00% 20,00% 16,00% 1vs3=0,034*
Over 60 54,55% 24,24% 15,15% 6,06% 6,06% 2vs3=0,212
Type of Postoperative radiation therapy 60,00% 30,00% 20,00% 13,33% 10,00%
0,643
therapy Radical radiation therapy 54,55% 21,21% 15,15% 9,09% 9,09%
45-50 50,00% 25,00% 0,00% 0,00% 0,00% 1vs2=0,973
1vs3=0,135
Total 50,1-57,5 57,14% 0,00% 0,00% 0,00% 0,00% 1vs4=0,068
dose 57,6-65 58,33% 33,33% 25,00% 20,80% 16,67% 2vs3=0,442
2vs4=0,237
Over 65 73,68% 31,58% 26,32% 10,53% 10,53% 3vs4=0,758
16-20 33,33% 11,11% 0,00% 0,00% 0,00% 1vs2=0,011*
1vs3=0,023*
Number 21-25 60,00% 40,00% 26,67% 20,00% 13,33% 1vs4=0,126
of
2vs3=0,656
fractions 26-30 65,38% 30,77% 23,08% 11,54% 11,54%
2vs4=0,568
Over 30 70,00% 10,00% 10,00% 10,00% 10,00% 3vs4=0,920
2-2,25 61,54% 0,00% 0,00% 0,00% 0,00% 1vs2=0,184
Dose per
2,26-2,5 56,10% 34,15% 24,39% 17,07% 14,63% 1vs3=0,385
fraction
2,51-3 55,56% 22,22% 11,11% 0,00% 0,00% 2vs3=0,320
*Statistically significant difference,

rative radiation therapy or radical radiation therapy

(Log-Rank test; p=0,643). The five-year survival
rate for the subjects who underwent postoperative
radiation therapy was 10%. The survival median for
this group of subjects was 14 months (CI95% 9, 72
- 18, 28). In the group of subjects who underwent
radical radiation therapy, the survival rate after five
years was 9, 09%. The patients who underwent radi-
cal radiation therapy had a survival median of also 14
months (CI95% 6, 15 - 21, 85) (Table 3 and Figure 1).
No statistically significant interrelation was
noted between the rate of survival of the subjects
and the total dose of radiation for the group with
T4 glottic carcinoma. A statistically significant Figure 1. The survival rate of the subjects with
difference in the survival rate was noted between T4 glottic carcinoma and different therapeutic
the subjects who received different amounts of procedures
radiation fractions (Log-Rank test; p=0,049). The
poorest survival rate was in the group with the None of the analysed factors stood out as si-
smallest number of fractions. (Table 3). gnificant, or had an independent influence on the
The radiation dose per fraction has no statisti- further course of the illness or the survival rate of
cally significant influence on the rate of survival the patients (Table 4).
of subjects with T4 glottic carcinoma.

1740 Journal of Society for development in new net environment in B&H


Table 4. The Cox regression analysis of the survi-
val rate of the subjects with T4 glottic carcinoma
Monitored factors exp (B)=RR Value p
Sex 1,362 p=0,553
Age 0,967 p=0,886
Total radiation dose 0,778 p=0,076
Number of fractions 0,831 p=0,256
Dose per fraction 0,891 p=0,640
Type of therapy 1,128 p=0,651
Univariant Cox regression analysis, RR-Relative risk
Discussion
Radical radiotherapy should allow a complete
and permanent remission of the malign illnesses.
In classic tumor fractionation, literature data su-
ggest the optimal daily doses of 2 - 3Gy, weekly
doses of 8 - 10Gy, and the total therapeutic doses
range from 30 - 90Gy, depending on the type of tu-
mor, its localization, size and biological properties
(5,14). In our group of patients that underwent
radical radiation therapy, the total therapeutic dose
was 42 - 127Gy, with a median of 67Gy.
Postoperative radiotherapy is indicated in all ca-
ses with an expanded tumor with unclear resection
edges, and is utilized usually 4-6 weeks after surge-
ry [13-15]. The indications for postoperative radia-
tion therapy include subglottic expansion, cartilage
infiltration, perineural invasion, expansion of the
primary tumor into the soft tissue of the neck, mul-
tiple positive lymph nodes of the neck and expansi-
on of the tumor outside the scope of the lymph node
[3, 13-15]. In the data that we gathered, in the group
of patients that underwent postoperative radiation
therapy, the greatest number of patients (93.33%)
underwent complete laryngectomy, either indepen-
dently or in combination with a radical dissection
of the neck or functional dissection on both sides of
the neck. The total therapeutic dose during posto-
perative radiation, for these patients, was from 42 to
66Gy, with a median of 60Gy.
For all of the subjects with T4N1M0 glottic
carcinoma, the five-year survival rate was 9.52%
(median 14 months). Our results differ from the
average data found in literature where a five-year
rate of survival was 25-52%, irrespective of the
choice of treatment [10,12,16]. This discrepancy
can, in part, be accounted for by our limited ra-
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
dio therapeutic capacities (waiting lists), which
extend the waiting period prior to the start of any
kind of treatment. As a result, a great number of
patients actually start therapy palliatively. At the
same time, what must not be overlooked is that the
presence of metastases in the neck decreases the
survival rate by 40-50% [4].
The following factors play an important role in
local control of glottic carcinoma: age, sex, histo-
logical structure of the tumor and its edges, stage,
size, total therapeutic dose, dose per fraction and
duration of the therapeutic treatment. As less signi-
ficant factors, we can single out smoking, diabetes,
alcohol consumption and dietary habits [17-19].
We found no statistically significant differen-
ce in age between the patients who underwent
postoperative radiation therapy and those who
underwent radical radiation therapy. Glottic car-
cinoma is more frequent among the elderly, and
usually occurs after the age of 40. Nevertheless,
if it occurs among younger people, it takes a more
aggressive form [20,21]. The evidence gathered in
our study support this claim, considering the fact
that none of our patients under 45 lived longer
than 14 months, and the median for these subjects
was only 8 months. The subjects aged 45-60 had
the best rate of survival, with a survival median
of 18 months.
There were no significant difference in survival
period of the subjects in relation to sex, even though
it has often been emphasized that sex is an impor-
tant prognostic factor and that women usually have
a better prognosis both in terms of local control and
survival [22,23]. Glottic carcinoma in European co-
untries occurs 7-22 times more frequently among
men than women which can also be seen in our
study. This can be accounted for by the effects of
certain hormonal factors or continued irritation. It is
assumed that men who work in industry suffer from
chronic laryngitis and throat irritation more often
than women and chronic inflammatory changes are
usually accompanied by dysplasia and metaplasia
of the epithelium [20,24].
No statistically significant interdependence of
the rate of survival and the total therapeutic dose
of radiation was noted, but the longest period of
survival with a median of 21 months was calcula-
ted for the subjects with a total therapeutic dose of
over 65Gy. In regards to the total therapeutic dose
1741
HealthMED - Volume 5 / Number 6 / 2011
for local control and survival, many heated deba-
tes can be found in much of the literature on the
subject, and there is even a suggestion that with
the increase in the total therapeutic dose, the risk
of a laryngeal edema also increases (5, 23-28).
Even though we did not find that the dose of ra-
diation had a statistically significant influence on
the rate of survival of the subjects with T4 glottic
carcinoma, we found that the subjects who rece-
ived doses of 2.51-3Gy per fraction had the best
survival rate. Our results support the claims of the
so far small number of researchers who have sug-
gested that a greater dose per fraction gives better
rates of survival, and that the total therapeutic dose
is less important in this respect [12, 14, 28].
We found no statistically significant differen-
ce in the survival rate when comparing patients
who underwent postoperative radiation therapy
and those who underwent radical radiation the-
rapy. The survival median for the patients from
both groups was 14 months. Nevertheless, it is
important to point out that in our working condi-
tions, it is usually the elderly patients, those with
an advanced tumor, and who are generally in poor
health and have other concomitant illnesses, who
are sent to radical radiotherapy, which is suppor-
ted by the fact that more than half of the patients
who underwent this kind of procedure (60, 6%)
were over the age of 60.
Our retrospective study has shown that a si-
milar percentage of patients who survive glottic
carcinoma can be reached both with postoperative
and radical radiation therapy, which has been do-
cumented in the Cox regression analysis, in which
none of the studied factors, including the type of
radiotherapy treatment, was singled out as being
significant, nor having an independent influence
on the rate of survival of the patients with T4N1Mo
glottic carcinoma. That there are no significant di-
fferences in the rate of survival of patients with ad-
vanced glottic carcinoma who underwent postope-
rative radiation therapy and those who underwent
radical radiation therapy has also been argued by
other authors (29, 30-31, 32). Spector at al. 2004.
also showed that the type of therapy (surgical, ra-
diation (postoperative or radical)) is not a signifi-
cant factor which influences the survival rate of
the patients with T4 stage glottic carcinoma [9].
1742 Journal of Society for development in new net environment in B&H
Conclusion
The type of radiation therapy (postoperative or
radical) is not a significant factor which influences
the survival rate of the patients with T4N1MO
glottic carcinoma.
The optimum radiotherapeutic method for
these patients is a total therapeutic dose which is
no less than 65Gy and a daily fractionation with a
dose of no less than 2.51Gy.
Acknowledgement
This paper is supported by Ministry of Science,
Republic of Serbia, projects III43012, III41018
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30. Yu WB, Zeng ZY, Chen FJ, Peng HW: Treatment
and prognosis of stage T3 glottic laryngeal cancer –
a report of 65 cases. Ai Zheng, 2006, 25(1): 85-87.
Corresponding author
Snezana Jancic,
Institute of Pathology,
Faculty of Medicine in Kragujevac,
Serbia,
E-mail: sjancic@medf.kg.ac.rs
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HealthMED - Volume 5 / Number 6 / 2011

Peripartal Cardiomyopathy – alwaus

diagnostic dilemma: clinical and
therapeutic procedures
Mirjana Bogavac¹, Olivera Rankov¹, Jadranka Dejanović², Milica Medic-Stojanoska3
¹ University of Novi Sad, Faculty of Medicine, Clinical Center of Vojvodina - Department of Obstetrics and
Gynecology, Novi Sad, AP Vojvodina – Serbia,
² University of Novi Sad, Faculty of Medicine, Institute of Cardiovascular Diseases, Sremska Kamenica, AP
Vojvodina – Serbia,
³ University of Novi Sad, Faculty of Medicine, Clinical centre of Vojvodina, Department of endocrinology
Novi Sad, AP Vojvodina – Serbia.

Abstract ratory findings, x-ray lung and echocardiography,

Introduction Peripartal cardiomyopathy is a
rare, life-threatening complication previously he-
althy mother. Incidence of this disease ranges 1 to
3000 to 4000 births [1,2]. Diagnosis is based on
the next criteria: weakness of myocard in peripar-
tal period (4 weeks prior to 5 months after deli-
very), the inability to find out the reasons leading
to heart failure, the absence of heart disease up to
4 weeks before delivery, as well as the absence
electrocardiographic seen systolic dysfunction of
left ventricular before pregnancy [3].
Case report 1 Patient was a few days after dis-
charge complaining of feeling of fatigue, dyspnea
and shortness of breath, especially when she lies
on her back or at the slightest exertion, dry cough
and oedema of the legs and abdomen. Fourteenth
day after birth she is admitted as an emergency in
the intensive care unit in Institute of cardiovascu-
lar disease of Vojvodina with symptoms and signs
of global heart failure caused by postpartal dilated
cardiomyopathy. She doesn’t have any cardiovas-
cular disease or investigations about cardiovascu-
lar system before.
Case report 2 Mothers aged 26 years, labored
in 38 gestational week (GW). The first 2 days po-
stpartum subjectively and objectively was good.
On the third day after cesarean section she repor-
ted a sudden dispnea, ortopnea, fatigue and chest
pain. Shortly thereafter she reported blood in her
sputum. After internal, pulmological and cardio-
logical examinations, and after clinical and labo-
doctors confirmed the diagnosis of dilated cardio-
myopathy and the third degree of mitral insuffici-
ency. Cardiologist suggest moving patient to the
intensive care unit in Institute of cardiovascular
disease in Sremska Kamenica. Adequate therapy
leads to withdrawal symptoms.
Conclusion Peripartal cardiomyopathy althou-
gh still unknown cause, is a life-threatening com-
plication of childbirth. Aim of our report is to emp-
hasize the importance of early echocardiography
in sudden cardiac decompensation in the peripartal
period, and to emphasize importance of multi-disci-
plinary approach to this kind of patients.
Key words: peripartal cardiomyopathy, dilated
cardiomyopathy, heart failure in the peripartal pe-
riod
Introduction
Peripartal cardiomyopathy is a rare, life-threa-
tening complication of a previously healthy mot-
hers, whose incidence is approximately 1 per 3000
to 4000 births [1,2], while in Haiti it is 1 in 300 bir-
ths [3] Criteria for diagnosis include: heart failure
resulting from the last month of pregnancy up to 5
months after delivery, the absence of known cause
for the occurrence of heart failure, the absence of
heart disease before the last month of pregnancy
and noted the absence of electrocardiographic left
ventricular systolic dysfunction before pregnancy.
[4] The diagnosis is made after echocardiography

1744 Journal of Society for development in new net environment in B&H


during which the observed disorder left ventricu-
lar function during systole. The proposed criteria
include ejection fraction (EF) <45% and fractional
shortening <30%. [5] Although the exact cause of
this disease still remains unknown, the incidence
is higher among mothers aged over 30 years, mul-
tiparae, in the presence of gestational hypertensi-
on or during a twin pregnancy. [6]. The most com-
mon causes are ischemic dilated cardiomyopathy,
valvular, viral, or genetic . [7,8,9]
This paper presents two cases of acute, life-
threatening peripartal cardiomyopathy, successfu-
lly treated with conservative therapy.
Case Report 1
Puerperium Ž. V., aged 39 years, the four-
teenth day after birth is admitted as an emergen-
cy in the intensive care unit in IKVBV, because
symptoms and signs of global heart failure as a
result of the postpartum dilated cardiomyopathy.
The patient was engendered by Caesarean secti-
on at the Department of Gynecology and Obste-
trics, Clinical Center of Novi Sad in WG with
respect to the two previous cesarean sections and
twin pregnancy. A few days after release from
the Department of Gynecology and Obstetrics,
complaining of fatigue, dyspnea and shortness
of breath, especially when she lies on her back
or at the slightest exertion, dry cough, oedema in
legs and abdomen. She denies earlier symptoms
of cardiovascular disease and cardiac testing.
From the previous medical documentation with
gynecological clinic doctors noticed that during
cesarean section ascertained transient rupture of
the anterior uterine wall has been taken care by
placing sutures in the area of the incision and ute-
rine rupture. The patient was discharged home the
fourth postoperative day with antihypertensive
therapy, since the postoperative course proceeded
mothers with hypertension to 180/90 mm Hg, al-
though the patient had no complaints.
When she arrives in ICU, she was conscious,
communicative, well- oriented , well-developed
osteomuscular structure with well nutritional sta-
tus, without elevated temperature, ortopnoc, dis-
pnoic, with hypertensive (pressure on both hands
was 150/110 mmHg), rhythmic,with tachycardia
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
(HF 110/min). Of the lungs there was bilaterally
impaired basal breathing with end-inspiratory
crackles, systolic murmur over the apex, pretibi-
al edema, the liver was not palpable. Echocardi-
ography registered dilatated and remodeled left
ventricular cavity, diffuse hipokinetic ventricular
walls and reduced global systolic function (EF
24%), initial concentric hypertrophy, without the
presence trombotic masses. There is an initial di-
lated left atrium, moderate mitral and tricuspid re-
gurgitation, with an elevated systolic pressure in
right ventricle. On radiographs of heart and lungs
were recorded bilateral pleural effusions. After gi-
ving intensive diuretic therapy with ACE inhibi-
tors and aldactone antagonists obtained an adequ-
ate diuretic response and leads to improvement of
subjective and objective state of the patient and to
achieve cardiac recompensation which was con-
firmed with control radiograph of heart and lun-
gs. Finding proBNP on admission was elevated
(4400), while other laboratory findings was in the
reference values or no significant deviation. Con-
trol proBNP was significantly decreased. During
further hospital treatment patient was without
significant cardiovascular symptoms, hemodyna-
mic and rhythmically stable and cardiac compen-
sated. Repeated echocardiographic findings were
similar to the previous with normalization of sy-
stolic pressure in the right ventricle as a result of
cardiac compensation. The patient was discharged
to continue outpatient treatment and routine cardi-
ac monitoring and echocardiography.
A case report 2
Patient M.Š. aged 26 years was admitted to the
37 WG in the Clinical Center of Vojvodina, Depar-
tment of Obstetrics and Gynecology, Institute of
Pathology of pregnancy due to increased pressure,
which was the day before first registered (160/120
mmHg) on a regular control at Health centre. The
patient havent previous symptoms of cardiovascu-
lar disease nor cardiac testing. She had a infectious
jaundice in childhood. At the hospital she had the
same measured blood pressure values, and doctor
admitted 40mg amp.Lasix, amp Bensedin and 2 tbl
methyldopa 250 mg orally, after which her blood
pressure normalised. The next day she was normo-
1745
HealthMED - Volume 5 / Number 6 / 2011
tensive with next therapy: methyldopa tbl 3x2 and
tbl bensedin 5mg 3x1. Subjective symptoms except
mild oedema at arms and legs. At admission, obste-
trical examination showed findings: normal cervix
length closed presenting part was high above the
pelvic entrance, no swelling of the amniotic fluid
and uterus, the size match between amenorrhea,
with no contraction of the CTG, which pointed to
normocardia. The patient brings ophthalmologists
findings in which indicates the deliveries by Ca-
esarean section because of the high risk of retinal
detachment in eyes because high myopia. Patients
delivered in 38 week of gestation by Caesarean sec-
tion, which is in good condition with normal blood
loss. Born a female infant weight 2920 g and 48 cm,
with Apgar score 9 / 10.
Initial values of blood count indicated a nor-
mochromic normocytic anemia with Hgb 90 g /
l, while the values of leukocytes, platelets, transa-
minases, bilirubin, urea and creatinine were within
normal ranges. The values of sodium and chloride
were within normal range, while potassium was
on the lower threshold. X-rays on the heart and
lungs in the AP direction in the supine position
shown signs of congestion: decreased transparen-
cy in billateral lung fields, more pronounced on
the right, with shadowing and with a strong vas-
cular pattern. In the upper and in the middle right
lung field, radiologist saw intense linearly pinto
infiltration of lung parenchyma, and shadow he-
arts seemed large. The ECG recording registered
a sinus tachycardia, HR 130/min, with no signs of
acute ischemia and myocardial lesions or without
myocardial load.
She was examine by cardiologists who con-
firmed that it is a cardiac failure and echocardi-
ographic examination was indicated. She found
dilated and remodeled left ventricle with diffuse
hypokinesia of left ventricular walls and impaired
systolic function (EF 38%) with significant mitral
regurgitation of the third degree, an eccentric jet,
and a normal size of left atrium.
Cardiologists saw tricuspidal regurgitation-se-
cond degree with a normal systolic pressure in the
right ventricle. Aortic valve was competent. Pe-
ricardium was with minimal amount of effusion
(about 50ml). Because of this, she indicated the im-
mediate removal of the Institute of Cardiovascular
Diseases in the intensive care unit where she conti-
1746 Journal of Society for development in new net environment in B&H
nued to treat congestive heart failure and follow-up
patients. On admission patient was somnolent, well
oriented, middle shaped osteomusculature structu-
re and with well nutritional status,her temperature
was normal, she was normotensive (140/80 mmHg
= TA), rhythmic with tachycardia ( HR 95/min),
cardiac decompensated. On ordinated treatment
with diuretics, ACE inhibitors, aldosterone antago-
nists, with low-molecular heparin sc, coming to a
satisfactory cardiac recompensation. n the second
day of hospitalization she developed fever with a
positive inflammatory syndrome (sedimentation,
leukocytosis with granulocitoma, elevated CRP,
fibrinogen, and procalcitonin) and in therapy intro-
duced in a parenteral antibiotic in consultation pul-
monologists. Published throat and nose swabs and
urine culture were negative. The patient regularly
checked by a competent gynecologist at whose re-
commendation the postoperative wound swabs and
swabs lochia (negative). All the time patient held
anemia and she got a replacement therapy.In further
course of treatment and patient hemodynamically
stable rhythm, cardiac compensated, with no signi-
ficant personal symptoms of the cardiovascular sy-
stem. Control echocardiography finding correspon-
ds with previous. Cardiologist saw hemodynamic
insignificantly reduction of mitral regurgitation at
2 / 3 + degree. The patient was transferred on the
Department of Gynecology and Obstetrics.
Discussion
Acute appear dispnea, ortopnea and hemop-
tysis in puperperium with no data on previous
heart disease, often wrongly suggests that it is a
pulmonary embolism, especially if signs of heart
failure are not obvious.
Two cases of this relatively rare postpartum
complication that differed in the time of onset of
symptoms, presence of risk factors, the course and
duration of disease, as well as therapeutic appro-
ach to treating this peripartal complications. Also
shown in the successful treatment of conservative
therapy due to multi-disciplinary approach to the
problem by the physician from the Department of
Gynecology and Obstetrics, Clinical Center and
the Institute of Cardiovascular Diseases in Srem-
ska Kamenica.

Patients with peripartal cardiomyopathy is ne-
cessary to be inform about the risks that can make
the next pregnancy, according to the literature,
there is a 50-80% risk of developing heart failure
during the next pregnancy [10].
Periparturtal cardiomyopathy is usually cli-
nically manifested by dyspnea on exertion, fati-
gue, bilateral swelling of the feet and lower legs,
atypical chest pain and haemoptysis. It is neces-
sary to observe clinical signs of congestive heart
failure (tachycardia, tahipnea, ortopnea, dispnea,
pretibial edema, end-inspiratory crackles over the
lungs, gallop rhythm, the sound of mitral and tri-
cuspid regurgitation). Lung X-ray usually shows
pulmonary venous cardiomegaly with congestion.
The ECG recording can be observed non-specific
changes ST period and T waves, atrial or ventricu-
lar arrhythmias. Echocardiographic changes inclu-
de increased endsystolic and diastolic diameters
and volumes, global hipokinesia of left ventricular
walls and reduced left ventricular ejection. [11]
Therapy was the same as with other forms of
heart failure, which including avoidance of physi-
cal load, diuretics, vasodilators, ACE inhibitors
and anticoagulant treatment.
Peripartal cardiomyopathy causes maternal
mortality ranging from 18% to 56% [13], even
with the latest recommendations for its treatment.
A key factor in diagnosic procedure is a high de-
gree of suspicion of this peripartal complication
and echocardiographic examination, by the time
the cause dyspnea is unknown. Patients in whom
after a period of 6 months after the occurrence of
the disease symptoms and signs of heart failure
and required intensive cardiac care, you should
advise the avoidance of the next pregnancy, beca-
use there is an increased risk of maternal mortality
[12] Monitoring after delivery include regular ec-
hocardiographic cardiological examinations and
continuous drug treatment for at least a year.
The literature identifies different prognoses of
peripartal cardiomyopathy, primarily depending
on the treatment and control patients. Usually lead
to recovery over the first 2 months, but it may take
6-12 months. [14,15,16]
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
Conclusion
A case point to the timely detected and diagno-
sed postpartal complications of the cardiovascular
system, which can often be initially unrecognized,
and the need for a multidisciplinary approach in
the timely diagnosis, in order to establish adequate
treatment and early recovery mothers. Only with
this approach we increase the quality and prolong
the lifespan of these patients
References
1. Mielniczuk L., Williams K, Davis D. et. Frequen-
cy of peripartum cardyomyopathy. Am J Cardiol
2006; 97:1765-68
2. Felt J.D., Chrisrie L.D., Carr away R.D. et al. Five
years prospective study of the incidence and pro-
gnosis of peripartum cardyomyopathy at a single
institution. Mayo procees 2005; 80:1602-6
3. Fett JD, Dowell DL, Carraway RD, et al. 100 ca-
ses of peripartum cardiomyopathy ... and counting:
what's going on? Int J Cardiol 2004; 97: 571-3
4. Demakis J.D., Rahimtoola S.H., Sutton G.C. et al.
Natural caurse of peripartum cardyomyopathy.
Circulation 1971; 44:1053-61
5. Chapa JB, Heiberger HB, Weinert L et al. Progno-
stic value of cardiography in peripartum cardiopa-
thy. Obstetrics & Gynaecology 2005; 105: 1303-8
6. Elkayam U, Akhter M.W., Singh H. et al. Pregnan-
cy-associates cardyomyopathy: clinical characteri-
stics and a comparison between early and late pre-
sentation. Circulation 2005; 111: 2050-5
7. Richardson P, McKenna W, Bristow M et al. Report
of the 1995 World Health Organisation / Intrnal-
tional Society and Federation of Cardiology Task
Force on the definition and classification of the car-
dopathies. Circulation 1996; 93:841-2
8. Nelissen E.C.M. , De Zwaan C, Marcus M.A.E. et
al.Maternal cardiac arrest in early pregnancy. Int J
Obs Anesth 2009; 18: 60-3
9. Karin van Spaendonck Y-Zwarts, J. Peter van Tin-
telen, Dirk J van Veldhuisen et al. Peripartum car-
diomyopathy as a part of familial dilated cardio-
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HealthMED - Volume 5 / Number 6 / 2011

myopathy. Circulation 2010; 121: 2169-75

10. Veille JC. Peripartum cardiomyopathies. A revi-

ew. Am J Obstet Gynecol 1984; 148:805-18

11. Morrison WL, Petch MC. Peripartum cardiomyo-

pathy. Hospital update. 1991; 17:693-8

12. Heider AL, Kuller JA, Strauss RA, et al. Peripar-

tum cardiomyopathy, a review of the literature.
Obstetr Gynecol Surv 1999; 54:526-31

13. Pearson GD, Vielle JC, Rahimtoola S et al. Peri-

partum cardiomyopathy: National Hearth, Lung
and Blood Institute and Office of Rare Disease
Workshop recommendations and review. Journal
of the American Medical Association 283:1183-8

14. J.A. Hasan, A. Qureshi, Ramejo bb et al. Peripar-

tum cardyomyopathy characterstics and outcome
in a tertiary care hospital. JPMA 2010; 60: 377-
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15. Pradipta Bhakta, Binay K. Biswan, Basuded Ba-

nerjee. Peripartum cardiomyopthy: Review of the
literature. Yonsei Med J. 2007; 48:731-47

16. Alicelebic S: The most frequent congenital cardi-

ovascular anomalies. HealthMED - Vol 3, No 1,
2009:33-37.

Coresponding author
Bogavac Mirjana,
Clinical Center of Vojvodina Novi Sad,
Department of Obstetrics and Gynecology,
Serbia,
E-mail: mbogavac@yahoo.com

1748 Journal of Society for development in new net environment in B&H


Digital radiography in root canal
working length determination
Tatjana Brkanic¹, Ivana Stojsin¹, Karolina Vukoje¹, Duska Blagojevic¹, Vladan Osatovic²
¹ Medicinski fakultet Novi Sad, Klinika za stomatologiju Vojvodine, Serbia
² Medicinski fakultet Novi Sad, Serbia.
Abstract
Introduction: The main methods for root ca-
nal working length determination are radiographic
and electrometric. The digital radiography ob-
tained through intrabuccal sensors represents
technological progress that allows quantitative
analysis and measurement of working length.
Aim: The aim of this study was to investigate
the difference in values of the accurate root canal
working length and the working length determined
by digital radiography and to test if the digital ra-
diography is a reliable method for working length
determination.
Materials and methods: Nineteen extracted
human teeth without endodontic treatment and with
well preserved coronal and radicular structures were
selected - 11 lower incisors and 8 lower canines.
Teeth length (TL1) was measured by a millimeter
ruler. Coronal access to the teeth was obtained with
a round bur and high speed hand-piece. The actual
working length (WL1) was obtained by introduc-
ing a #15 K file in the canal until it appeared at the
apical foramen. The length was verified on endo-
meter. The digital images were obtained for every
tooth sample. The canal working length (WL2) and
the length of the tooth (TL2) were measured in the
Kodak dental imaging software. Mean value and
standard deviation were calculated and statistical
analysis was performed by student t-test.
Results: Average working length in lower inci-
sors was 21,68 mm, and average working length
in lower canines 21,93 mm. Statistical analysis
has shown no statistical difference between the
accurate root canal working length and the work-
ing length obtained by digital radiography. It was
also found that there is no statistical difference be-
tween the tooth length and working length mea-
sured by digital radiography (p>0,05).
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
Conclusion: There is no significant difference
between the accurate root canal working length
and the working length measured by digital radi-
ography. Digital radiography is a reliable method
for working length determination.
Key words: Working length, digital radiogra-
phy, tooth length
Introduction
The establishing of accurate root canal work-
ing length is one of the most critical steps of end-
odontic therapy. Cleaning, shaping and obturation
of the root canal system cannot be accomplished
accurately unless the working length is deter-
mined precisely. The generally accepted methods
of working length determination are radiographic
and electrometric [1,2].
In endodontics, conventional film-based radi-
ography is an important resource for diagnosis,
transoperative procedures and treatment control
[3]. However, diagnostic X rays are the largest
man made source of radiation exposure to the
general population [4]. The digital radiography
obtained through intrabuccal sensors rather than
radiographic films represents technological prog-
ress that allows qualitative and quantitative analy-
sis of all stages of endodontic therapy. Regarding
radiographic estimation of endodontic working
length, direct digital imaging provides measure-
ment tools that facilitate the definition of the api-
cal limit of root canal instrumentation. Moreover,
there is substantial reduction in image processing
time with the acquisition of digital radiography.
Hence, the clinical procedures are performed more
quickly, with reduced radiation. Further, in digi-
tal radiography, the application of various image
enhancement modalities improves the accuracy
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HealthMED - Volume 5 / Number 6 / 2011
of endodontic file lengths. The software program
provides a sequence of straight lines for evalua-
tion of root canal working length [5].
The aim of this study was to investigate the dif-
ference in values of accurate root canal working
lengths and working lengths determined by digital
radiography.
Materials and methods
Nineteen extracted single rooted human teeth,
without endodontic treatment and with well pre-
served coronal and radicular structures, were se-
lected - 11 lower incisors and 8 lower canines. The
criteria for tooth selection also included the acces-
sibility of the apical foramen with a #0.08 K file
(Dentsply-Maillefer, Ballaigues, Switzerland). The
teeth have been cleaned after extraction and stored
until used in saline solution under the temperature
of 4ºC. Tooth length (TL1) was measured by a
millimeter ruler. Access openings were made with
a high speed handpiece and a round diamond bur
(fig.1). An endodontic K file #0.15 was introduced
into the canal until it appeared at the apex (fig.2).
Working length was determined (WL1, accurate
working length) for each tooth using hand K file #
0.15 and the endometer. The file was introduced into
the canal to a depth until the tip of the instrument
appeared in the region of the apical foramen and the
rubber stopper of the file has been brought into con-
tact with the coronal reference point (incisal edge
of the tooth). The length of the file for each canal
was checked using an endometer. In this way the ac-
curate working length (WL1) was measured (fig.3).
An endodontic file #15 was introduced in the
canal until it appeared at the apex and at this point
digital radiography was taken. File was placed in
the root canal in the same position as in determin-
ing the WL1. Kodak RVG 5100 digital radiogra-
phy sensor of universal size, Kodak X-ray genera-
tor (the generator voltage 70 kVp and 7 mA cur-
rent strength) and the remote control to activate the
Table 1. Mean working lengths and tooth lengths for incisors and canines
Tooth type WL1 WL2
Incisors 21,68 (±0,72) 22,33 (±0,60)
Canines 21.93 (±1,65) 22,56 (±1,86)
*values are in millimeters
1750 Journal of Society for development in new net environment in B&H
software and sensors were used. Dental imaging
was performed by placing the tooth with a file in
the canal, along the active (radio-sensitive) sensor
surface (fig.4). Generator as a source of X-ray was
set at a distance of 20 cm in relation to the object
(tooth). Exposure time was set to 0.05 seconds.
In this way 19 rendgenographic digital images
were obtained (Fig.5). These images were stored
and processed in Kodak dental imaging software.
In this program radiographic working length
(WL2) and the tooth length (TL2) were measured.
Radiographic working length was measured using
a millimeter ruler (fig.6). Two points were marked,
one on the rubber stopper and the other on the top
of the file. Tooth length was also measured with a
millimeter ruler from the most coronal point till
the most apical point of the tooth (Fig.7).
Mean value and standard deviation were cal-
culated for WL1, WL2, TL1 and TL2. The differ-
ence between WL1 and WL2 and the difference
between the WL1 and TL1 were tested with the
student t- test. Statistical significance was set at
the 5% level of error (p<0.05).
Results
The mean values of the accurate tooth length
(TL1), Rtg tooth length (TL2), the real working
length (WL1) and the working length measured
by digital radiography (WL2) are shown on table
1. Percentage of the morphological groups of teeth
was: incisors 58% and canines 42% (Fig. 8).
The mean value of the real working length
(WL1) was 21.68 mm and mean radiographic
working length (WL2) was 22.33 mm, for the in-
cisors (fig. 9).
The mean value of the real working length (WL1)
was 21.93 mm and the mean radiographic working
length (WL2) was 22.56 mm, for the canines (fig.10).
Mean tooth length (TL1) of the lower incisors
was 22 mm and mean tooth length of the lower
canines was 22.25 mm (fig.11 and 12).
TL1 TL2
22,00 (±0,52) (±0,59)
22,25 (±1,73) (±1,85)

Statistical analysis has shown no significant dif-
ference between the accurate working length of teeth
and the value of working length measured by digital
radiography (WL1 and WL2). It was also found that
there was no significant difference between the val-
ues obtained for the length of teeth and the working
length measured by digital radiography (p> 0.05).
Figure 8. - Percentage of morphological groups
of teeth
Figure 9. - Mean working length (WL1) and radio-
graphic working length (WL2) in incisors
Figure 10. – Mean working length (WL1) and ra-
diographic working length (WL2) in canines
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
Figure 11.– Mean working length (WL1) and tooth
length (TL1) for incisors
Figure 12.– Mean working length (WL1) and to-
oth length (TL1) for canines
Discussion
Determination of working length represents
one of the key stages of endodontic therapy in or-
der to provide high quality preparation and obtura-
tion of the canal, creating the preconditions for the
successful outcome of the entire therapy. In order
to assess the approximate working length at the
beginning of therapy, it is helpful to have informa-
tion about the average length of the teeth that be-
longs to the corresponding morphological group.
The accurate determination of working length is
made by radiographic or electrometric method af-
ter canal trepanation.
Tests have shown that the length of the tooth
does not have to coincide with the length of the
canal and the working length for the root canal
preparation, for a variety of anatomical variations
or root canal curvatures [6].
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HealthMED - Volume 5 / Number 6 / 2011
One of the aims of this investigation was check-
ing the correspondence between the average teeth
length measured on the x-ray dental digital pho-
tography and working length of teeth. The results
confirmed that there was no significant difference
between the tested values. These matching values
were obtained probably because of the choice of
morphological groups and types of teeth used in
this study. It is considered that single rooted an-
terior teeth, such as lower incisors and canines
which are used in this study, have less complicat-
ed canal anatomy in relation to the posterior multi
rooted teeth [7]. Therefore it would be good to ex-
tend the research to other morphological groups of
teeth, especially molars, where larger deviations
of tested values could be expected.
The literature states that the average length of
lower incisors is 21.7 mm, and the average length
of lower canine 25.6 mm [8]. In this survey an
average length of the lower incisors was 22 mm
and 22.25 mm of lower canines. The difference in
the literature data concerning the length of the ca-
nines, can be attributed to the limited number of
samples used in this study, so it would be desirable
to test the results on a larger sample.
It is believed that radiography represents a
very reliable method for determining the working
length, but still during the recording process, an
image distortion could happen to some extent, and
thus a discrepancy between the values of canal
length measured on digital photography, and the
real value of the length of the root canal.
According to some studies, radiographic meth-
od is unreliable for the working length determi-
nation due to image distortion, and because of
overlapping of anatomical structures, film radio
contrast and subjective interpretation of the clini-
cian [9,10,11].
In this study, slightly higher values for radio-
graphic working length were obtained, comparing
to the accurate working length of root canals. The
difference between these values is in the domain
of 0 to 1.2 mm, but is not statistically significant.
It is possible that such results were obtained be-
cause the testing was done in vitro on extracted
teeth where it was possible to provide optimal
conditions for the x ray recording, in terms of dis-
tance between the object from the tube. On the
other hand, in vivo conditions, there is a danger of
1752 Journal of Society for development in new net environment in B&H
patient's moving at the time of exposure and the
possibility of superimposition of other anatomical
details that may affect the deviation between mea-
sured and real values.
Some studies show that the value of working
length obtained by conventional and digital radi-
ography is higher than the real working length of
root canal [5].
In other studies it is stated that digital radiog-
raphy is better compared to conventional, in cases
where the working length was measured with in-
struments of a larger diameter [12,13], and when
measured in single rooted teeth [14,15]. On the
other hand, some studies have shown the supe-
riority of conventional radiography compared to
digital, where instruments with smaller diameters
have been used [16]. A detailed comparison of
these results is very difficult due to the use of vari-
ous digital systems in each study.
Conclusion
According to the results of this study, it can be
concluded that there is no statistically significant
difference (p<0,05) between the accurate working
length of root canal and working length measured
by digital radiography. Digital x-ray imaging is
a reliable method for determining the working
length of root canals.
References
1. Torabinejad M, Walton RE. Endodoncija, načela i
praksa, Naklada slap za izdanje na hrvatskom jezi-
ku, Zagreb 2009;252-256.
2. Galić N, Katunarić M, Šegovic S, Šutalo J, Stare
Z, Anic I. Procjena kliničke pouzdanosti Endometer
ES-02 uredjaja, Acta Stomatol Croat 2002; 36:489-
495.
3. Bakhtiari B, Mortsazavi H, Hajilooi M, Nayari S.
Serum Interleukin 6 as a Serologic Marker of Chro-
nic Periapical Lesions. A Case control study, Heal-
thMED, 2010; 4(3): 586-590
4. Dedić S, Pranjić N: Lung cancer risk from expo-
sure to diagnostic x rays, HealthMED, 2009; 3(3):
307-313
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5. Brito-Junior M, Santos L, Baleeiro E, Pego M, Ele- Corresponding author

uterio N, Camilo C. Linear measurementes to de- Tatjana Brkanic,
termine working length of curved canals with fine Medicinski fakultet Novi Sad,
filed: conventional versus digital radiography, Jo- Klinika za stomatologiju Vojvodine,
urnal of oral science 2009; 51:559-564. Serbia,
E-mail: healthmedjournal@gmail.com
6. Brkanić T, Stojšin I, Vukoje K, Živković S: SEM
analiza kvaliteta čišćenja zidova kanala korena
zuba nakon primene nikl titanijumskih instrumena-
ta, Srpski arhiv za celokupno lekarstvo, 2009; 138
(9-10):551-556
7. Brkanić T, Živković S, Drobac M: Tehnika prepa-
racije kanala korena nikl-titanijumskim rotirajućim
instrumentima, Med Preg, 2005; 58: 203-207.
8. Tronstad L, Klinička endodoncija, Data status Beo-
grad 2007; 209-210.
9. Frank AL, Torabinejad M. An in vivo evalation of
Endex electronic apex locator. J Endodon 1993;
19:177-9.
10. Becker GJ, Lankelma P, Wesselink PR, Thoden
Van Velzen SK. Electronic determination of root
canal length. J Endodon 1980; 6:876-80.
11. Griffits BM, Brown JE, Hyatt AT, Linney AD.
Comparison of three imaging techniqus for asse-
ssing endodontic working length. Int End J 1992;
25:279-87.
12. Vale I, Bramante CM. Assess lengths of endodon-
tic files from Digora digital system and three peri-
apical radiographic images films.Rev FOB 2002;
10:29-23.
13. Lozano A, Forner L, Liena C. In vitro comparison
of root-canal measurements with conventional
and digital radiology, Int Endod J 2002; 35:542-
550.
14. Pace SRB, Habitante SM. Comparative analysis
of the visualization of small files using digital and
convetional radiography. J Appl Oral Sci 2005;
13:20-23.
15. Boskolo FN, de Oliveira AEF, de Almeida SM,
Haiter CFS, Haiter Neto F. Clinical comparative
study of the quality of three digital radiographic
syistems, E-speed film and digitized film. Pesq
Odont Bras 2001; 15:327-333.
16. Lamus F, Katz JO, Glaros AG. Evaluation of a
digital measurement tool to estimate working len-
gth in endodontics, J Contemo Dent Pract 2001;
2:24-30.

Journal of Society for development in new net environment in B&H 1753

HealthMED - Volume 5 / Number 6 / 2011
Surgical wounds complications in two
different techniques of a cesarian
section
Vejnovic T1, Grahovac M2, Veselovski A3, Koledin S2
1
Clinic Centre Vojvodina, Clinic for Gynaecology and Obstetrics, University in Novi Sad, Faculty of Medicine
Novi Sad, Serbia,
2
Clinic Centre Vojvodina, Clinic for Gynaecology and Obstetrics, Serbia,
3
Teacher Medical secondary School “7. April”, Novi Sad, Serbia.
Abstract
Introduction: There are different techniques
in applying a caesarean section. They differ in
the type of incision and opening the abdominal
wall, and also on the way of opening and sewing
up the uterus. The aim of this work is to compare
the complications of the surgical wound between
two caesarean section techniques – Pfannensti-
el laparatomy and Joel-Cohen laparotomy with
Vejnovic’s modification.
Material and methods: A prospective rando-
mized study has been undertaken at the Gynaeco-
logy and Obstetrics Clinic of the Clinical Centre
of Vojvodina in Novi Sad. Out of (n=122) patients
who were delivered by caesarean section (n=50) of
them were from group B and their deliveries were
performed by Pfannenstiel incision of the abdomi-
nal wall, while (n=72) of the patients were from
group A and were delivered by Joel – Cohen inci-
sion with Vejnović modification. All the patients
were postoperatively examined clinically on a daily
basis, while laboratory and biochemical analyses
were aimed according to the clinical indications or
due to complications. While dressing the wounds,
they were inspected for any irregularities such as
redness, swelling, pain in the wound, presence of
haematoma (on skin and subcutaneous region), se-
rous discharge and dehiscence. Also, the length of
the skin incision was measured. The incidence and
gradation of infection in the surgical wound during
the hospital stay was in harmony with the protocol
of the wound infection classification according to
CDC (Centre for Disease Control).
1754
Results: Our analysis shows that there is a sta-
tistically important difference in the length of the
skin incision between the patients from the two
groups p<0.001, postoperative wound redness
p=0.029 (p<0.05) and wound swelling p=0.048
(p<0.05), subjective satisfaction with how their
wound looked p<0.001 between the patients from
the two groups. There is a statistically important
difference in the average pain estimate of the wo-
und between the patients from the two groups
from the first 24 hours until the fourth postopera-
tive day p<0.001 and in the length of hospitalisati-
on p=0.018 (p<0.05), postoperative stay p=0,016
(p<0,05), administering antibiotics p<0,001, len-
gth of time spent in surgery p<0,001 and blood
loss during surgery p=0,013.
Conclusion: Based on the results of this re-
search, the advantages of the surgical technique
applied on patients from group A (Joel – Cohen
laparotomy, Vejnović modification, and the one
applied on patients from group B (Pfannenstiel la-
parotomy), considering the reduced incidence of
complications of the surgical wound are signifi-
cant. The contemporary surgical technique should
utilize almost all of the elements of the minimum
invasive surgery during the caesarean section.
This way the overall engagement of mechanisms
that take part in the physiological process of hea-
ling the surgical wound is reduced.
Key words: surgical wound infection, caesa-
rean section, wound healing, surgical operational
techniques.
Journal of Society for development in new net environment in B&H

1. Introduction
The caesarean section is the most common sur-
gical intervention performed on women around
the world. There is an increase in the number of
caesarean sections in the developed countries in
the past years: in Great Britain it comprises 21%
of all deliveries, in Australia 23.3%, in Northern
Ireland 23%, and 26%; in the United States. In
certain countries in South America the rate of a ca-
esarean section surpasses 50% [1]. Around 20,000
caesarean sections have been performed in Serbia.
During the period between 2000 and 2010 out of a
total of 67,792 deliveries, 16,098 caesarean secti-
ons were performed [2].
Surgical techniques that are applied for a cae-
sarean section vary and some of them have been
estimated through randomised studies. These esti-
mates include vertical (midline and paramedian)
and horizontal incisions (Pfannenstiel, Maylard,
Cherney, Joel-Cohen). The type of the incision de-
pends on many factors, including the physical sta-
te of the patient and the surgeons’ preferences [4].
Each type contributes to the safety of a surgical
procedure to a smaller or greater extent. They also
influence the frequency and difficulty of intraope-
rative and post-operative complications, shorte-
ning of the intraoperative time and postoperative
recovery of the patients, and also to the reduction
in the expenditure of medical supplies [5].
The aim of this paper is to compare the compli-
cation of surgical wounds between two different
techniques of the caesarean section: the Pfannen-
stiel laparotomy and the Joel-Cohen laparotomy
improved with Vejnović modification.
Surgical techniques of the caesarean section
Hermann Johannes Pfannenstiel introduced
important changes in the techniques of abdominal
incision at the end of the 19th century and it has
been performed as a standard procedure in most
countries of the Western Europe ever since. Howe-
ver, this technique has a couple of drawbacks: it is
too slow in case of emergency, it takes a certain
amount of time to separate fascia from rectus, it is
often followed up with slightly increased intrao-
perational haemorrhage; more often than not there
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
is an incidence of postoperative haematoma and
abscess, so this area has to be routinely drained. In
the past ten years, many countries have introduced
the “Misgav Ladach” caesarean technique, later
developed by Michael Stark in Jerusalem [6,7].
Randomised controlled studies have proved si-
gnificant advantages of the ‘Misgav Ladach’ tech-
nique which is based on the Joel-Cohen abdominal
incision, which has a number of advantages: less
pain – less analgesics, reduced blood loss, shorte-
ned time spent in the OT, less patients with febrile
morbidity and shorter stay in hospital [4].
At the Gynaecology and Obsestrics Clinic in
Novi Sad in the past ten years we have been able to
notice the trend of reduction in the Pfannelstiel met-
hod of laparotomy, and the increase in Joel-Cohen
with the Vejnović modification of caesarean section
by 60%. During the period of 2000 and 2010 this
modified technique was performed on 5648 pati-
ents. The basic features of the Vejnović modifica-
tion of the caesarean technique are: minimum sur-
gical trauma, original way of stitching the uterus,
shorter time for the surgical procedure according to
the new principle and the comfort of the post-par-
tum patient. Due to the maximum shortening of the
time necessary for the surgery, but not contrary to
the principles of good surgical techniques, less blo-
od is lost, also less infections and traumatisation of
tissue. The patient spends less time in hospital and
she can soon return to her normal environment. The
rationalisation of the procedures during the modifi-
cation reduces the costs of the surgery and hospital
treatment by 50%, which is a significant reduction
in medical costs [2,3]. Table 1 shows the characteri-
stics of the two surgical techniques.
2. The Material and Methods of Work
A prospective randomised study has been con-
ducted at the Gynaecology and Obstetrics Clinic
at the Clinical Centre of Vojvodina in Novi Sad.
Out of the overall (n=122) patients who delivered
by caesarean section, (n=50) of them from group
B were delivered using the Pfannenstiel technique
of opening the abdominal wall, while (n=72) pa-
tients from group A were delivered using the ope-
ning the abdominal wall using the Joel-Cohen te-
chnique with Vejnović modification.
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HealthMED - Volume 5 / Number 6 / 2011

Table 1. Characteristics of caesarean section surgical techniques

Procedures
Skin incision
Incision of the subcutaneous
layer
Opening the fascia
Opening of the peritoneum
Incision of the uterine segment
Extraction of the placenta
Sewing up the uterus
Sewing up peritoneum
Sewing up fascia fascije
Sewing up subcutaneous layer
Sewing up skin
Joel – Cohen Pfannenstiel
”Vejnović modification “ „Dorfler“
Joel - Cohen Pfannenstiel
In the medial part 3cm lateral
Full length
from the midline
Middle part with minimum musc- The incision is performed in full length
le separation with muscle separated from fascia
Middle part with minimum musc-
Full length
le separation
2cm to the amnion, the rest with
Full length in the isthmic-cervical part
scissors below the tweezers
Active traction of umbilical cord
Manuel lizis and evacuation
without entering the uterine cavity
Vejnović Modified suture In one layer
No sewing Peritoneum is sewn
Extended suture Extended suture
No sewing necessary The layer is sewn
Modified intradermal suture Extended subcutaneous suture

Criteria for the exception from the study: that it 3. Results

was the patient’s first baby where the elective ca-
esarean section was urgent due to various indica-
tions; that they agreed to the research but decided
otherwise in the meantime, that the data collected
was incomplete.
The preoperative preparation for the caesarean
section was the same with all the patients (both
at the laboratory and the clinic). All the surgeries
were performed in general endotracheal or regi-
onal (spinal) anaesthesia. The postoperative exa-
minations were regular, while laboratory and bi-
ochemical analyses were aimed according to the
clinical indications or due to complications. While
dressing the wounds, they were inspected for any
irregularities such as redness, swelling, pain in
the wound, presence of haematoma (on skin and
subcutaneous region), serous discharge and de-
hiscence. Also, the length of the skin incision was
measured. The incidence and gradation of infecti-
on in the surgical wound during the hospital stay
was in harmony with the protocol of the wound
infection classification according to CDC (Center
for Disease Control).
For the estimate of the statistical importance of
the obtained differences the following tests were
used: Mann Whitney U test, Student’s t-test and
c2 test.
The basic features of the research population
with respect to the surgical technique of delivery
are shown in Table 2. The average age of the pati-
ents in group A was 29.6 and in group b 28.7. Ha-
ving analysed the data there is no statistically si-
gnificant difference in the age of the patients from
the two groups p=0.350 (p>0.05). Table 2 shows
diseases that have impact on the healing of surgi-
cal wounds. Of all the 122 patients from both gro-
ups, most were anaemic (n=11)15.3% and (n=7)
14%. There is no statistically important difference
between the patients from both groups with res-
pect to diabetes p=0.676 (p>0.05) and anaemia
p=1.000 (p>0.05).
Table 3 shows parameters that are directly
connected to the surgical intervention, related to
the surgical technique. The analysis of the obtai-
ned data shows a statistically important difference
in the length of hospitalisation p=0.018 (p<0.05),
and the postoperative hospital stay p=0.016
(p<0,05), between the patients from groups A and
B. There is no statistically important difference in
the stay of the preoperative hospital stay between
the patients in group A and Group B p=0.666
(p>0.05). Out of (n=72) 100% of patients from
group A, therapeutically indicated antibiotics were

1756 Journal of Society for development in new net environment in B&H

 HealthMED - Volume 5 / Number 6 / 2011

Table 2. Characteristics of the research population with respect to the surgical technique applied.
Group A (Joel – Cohen, Vejnović modification (n=72) and Group B (Pfannenstiel) (n=50).
Group A Group B Statistical importance
Parameter
n=72 n=50 p
X X
Patients’ age 29.6 28.7 0.350
BMI 28.2 28.8 0.381
Diseases % %
Diabetes 4.2 4 0.676
Anaemia 15.3 14 1.000

Table 3. Presentation of the surgical findings with respect to the surgical technique applied. Group A
(Joel – Cohen, Vejnović modification (n=72) and Group B (Pfannenstiel) (n=50)
Group A Group B Statisitical importance
Parameter
n=72 n=50 p
X X
Length of stay 5.56 6.08 0.018
Preoperative hospitalisation 1.36 0.48 0.666
Postoperative hospitalisation 4.21 4.68 0.016
Length of surgery in minutes 20.6 30.7 <0.001
Blood loss in millilitres 471 561 0.013
% % RR (95% CI)
Antibiotics – prophylaxis 80 32
Antibiotics – therapy 20 68 3.50 (2.10-5.81) <0.001
Anaesthesia – general 67 84
Anaesthesia – regional 33 16 1.26 (1.03-1.54) 0.053

administered on (n=14) 20%, while out of (n=50)
100% patients from group B, (n=34) 68% were gi-
ven therapeutically indicated antibiotics. There is
a statistically important difference between the pa-
tients from both groups in the application of antibi-
otic p<0.001. The analysis of the given data shows
a statistically important difference in the length of
the surgical procedure between the patients from
group A and those from group B p<0.001 (M-W
test). The analysis of the data shows a statistically
important difference in the quantity of blood loss
during the surgery between the patients from gro-
up A and group B p=0.013 (p<0.05). There is no
statistically important difference between the pati-
ents’ groups with respect to the type of anaesthesia
applied p=0.053 (p>0.05).
Table 4 shows postoperative parameters with
respect to the surgical technique applied in the
delivery. There is a statistically important diffe-
rence in the average pain response between pati-
ents from group A and group B during the first 24
hours to the fourth postoperative day p<0.0001.
The average length of the incision with patients
from group A was 12.6, while the average inci-
sion length with patients from group B was 14.1
cm. There is a statistically important difference in
the length of the skin incision between the patients
from the two groups p<0.001. Of the 122 patients
from both groups, redness of the wound was de-
tected with most of them, 32% from group B and
13.5% from group A, while wound swelling was
detected with 14% of the patients from group B
and with 2.8% of the patients from group A. The-
re is a statistical important difference between the
patients from the two groups in the postoperative
presence of wound redness p=0.029 (p<0.05) and
wound swelling p=0.048 (p<0.05). There is no
statistically important difference between the pa-
tients from the two groups in the postoperative in-
cidence of wound haematoma p=1.000 (p>0.05),
wound dehiscence p=0.854 (p>0.05), serous dis-
charge p=0.617 (p>0.05) and purulent discharge

Journal of Society for development in new net environment in B&H 1757

HealthMED - Volume 5 / Number 6 / 2011

p=0.854 (p>0.05). Of all the 122 patients from
both groups (n=2) 2,8% from group A and (n=2)
4% from group B had temperature higher than
38°C, 48h after the delivery, while wound swabs
were taken from (n=2) 2,8% of patients from gro-
up A and (n=1) 2,0% of patients from group B.
Table 5 shows the subjective estimate of the
patients’ recovery with respect to the surgical te-
chnique of delivery. Out of 122 patients from both
groups, most of them (n=47) 65.3% from group A
said that their recovery was easy, while most pati-
ents from group B (n=35) 70% reported recovery
of medium difficulty after the delivery. Least pa-
tients from group A (n=1) 1.4% and (n=5) 10%
from group B reported a difficult recovery after
the delivery. There is a statistically important dif-
ference between the patients from both groups with
respect to the subjective estimate of recovery after
the delivery p<0.001. Of the 122 patients from both
groups, most of them (n=68) 94.4% from group A
and (n=34) 68% from group B said that they were
‘fully’ satisfied with how their wound looked after
the delivery. There is a statistically important diffe-
rence between the patients from both groups with
respect to the subjective satisfaction with how their
wound looked B p<0.001.

Table 4. Postoperative results with respect to the surgical technique applied. Group A (Joel – Cohen,
Vejnović modification (n=72) and Group B (Pfannenstiel) (n=50).
Group A Group B Statistical importance
Parameter
n=72 n=50 p
Subjective pain scores
0th postoperative day 3.67 5.94
1st postoperative day 2.89 4.1
2nd postoperative day 2.22 2.96 <0.001
3rd postoperative day 0.71 1.18
4th postoperative day 0.06 0.3
Length of skin incision in cm 12.6 14.1 <0.001
Wound characteristics % % RR (95% CI)
Redness 13.9 32 230 (1.14 – 4.65) 0.029
Swelling 2.8 14 5.04 (1,09 - 23,3) 0.048
Dehiscence 1.4 0 / 1.000
Serous discharge 0 2 / 0.854
Purulent discharge 4.2 8 1.92 (0.45 – 8.21) 0.617
Body temperature higher than
2.8 4 144 (0.21 – 9.87) 1.000
38ºC after 48h
Wound swabs 2.8 2 0.72 (0.07 – 7.72) 1.000

Table 5. The subjective estimate of the patients with respect to the surgical technique applied. Group A
(Joel – Cohen, Vejnović modification (n=72) and Group B (Pfannenstiel) (n=50).
Group A Group B
Parameter p
n=72 n=50
Estimate of recovery % %
Easy 65.3 20
Medium difficulty 33.3 70 <0.001
Difficult 1.4 10
Satisfaction with how the wound looks
Completely satisfied 94.4 68
Partially satisfied 5.6 32
<0.001
Dissatisfied 0 0

1758 Journal of Society for development in new net environment in B&H


4. Discussion
Having compared the intraoperative and early
postoperative results of the two techniques of the
caesarean section – Pfannenstiel laparotomy and
Joel-Cohen with Vejnović modification, this study
has recognised advantages in the variety of met-
hods for the caesarean section unified in the Vej-
nović modification.
The analysis of the obtained data on the len-
gth of hospitalisation and postoperative recovery
shows a decrease in hospital stay with patients
(group A) who had surgery according to Joel-Co-
hen with Vejnović Modification. Many studies,
both old and recent ones, have proved that the
length of hospitalisation directly influences the in-
crease in the incidence of infection of the surgical
spot. Darj and Nordstrom believe that the length
of the postoperative hospital stay depends on the
sort of the surgical technique (length of surgery,
traumatisation of the tissue, amount of bleeding/
haemorrhage during the surgery, etc.) all of whi-
ch directly influence the incidence of infections of
the surgical wound [2, 7, 8].
The aim of the prophylactic application of an-
tibacterial medicines is to prevent intraoperative
infections of the surgical spot and also to prevent a
possible infection of the surgical wound. Mugford
et al., in the analysis of the ratio of efficacy/price
of antibiotic prophylactics with all the patients who
had a C-section came to the conclusion that a sin-
gle antibiotic prophylactics reduces the expenses
of hospitalisation[9]. Based on the results from the
paper on the postoperative dosing of antibiotics and
having applied the surgical technique in Vejnović’s
modification (patients from group A) it can be seen
that there is a reduction in the amount of antibiotics
administered - this way the institute saves on funds
and the therapeutic effect remains the same.
The maximum shortening of the time required
for the surgery, results in reduced blood loss; less
traumatised tissue, less time of the exposed abdo-
minal cavity and less possibility of infection of the
surgical wound, of course, respecting the princi-
ples of good surgical technique. A shorter surgery
positively influences the patient and thus reduces
the mental tension and her concerns about her and
her newly-born child’s health [2]. When com-
paring these two groups of the patients we have
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
come to some statistically important differences
– the length of the surgery is considerably shor-
ter and blood loss is significantly reduced with
patients upon whom Vejnović’s modification has
been applied (group A). The statistical importance
in the length of surgery is realised with the shor-
ter sewing of the uterus with the modified sutu-
re, which does not require secondary sutures on
the uterus. Due to a shorter surgery there is less
blood loss, less traumatisation of the tissue, and
consequently, there is less possibility that a wound
will heal at a slow pace and that the surgical wo-
und will be infected.
Based on the data obtained in the paper, the su-
bjective pain score according to the Visual Ana-
logue Scale (VAS) is considerably smaller with
patients in group A, compared to group B, from
postoperative day zero to day four. Apart from
the type of the surgical technique, this differen-
ce could be influenced by a sort of anaesthesia,
considering that more patients who had delivery
with spinal anaesthesia were from group A. Less
intensive delivery and shorter period of pain is an
important factor for the induction of breastfeeding
which could potentially influence an increase in
the number of breastfeeding mothers.
A minimum surgical trauma involves a small
incision on the frontal abdominal wall, which is
not longer than 12 cm i.e. from the fronto-occi-
pital circumference of the fetus. In this way we
reduce the amount of time that abdominal cavity
is exposed to outer factors that could compromi-
se the healing of the wound and create a fertile
ground for an infection. With the modified intra-
dermal continuous suture (which begins and ends
at about 2 cm from both ends of the wound), one
provides better drainage of the wound and the pa-
tient has the impression that her incision is shorter
[2]. In this study, the average length of the modifi-
ed surgical incision (group A) is statistically shor-
ter and was 12.6 cm, while the average length of
the incision in group B was 14.1 cm.
Patients from group A suffered less wound
complications after the surgery. At the Gynaeco-
logy and Obstetrics Clinic of the Clinical Centre
of Vojvodina in Novi Sad, for the period between
2000 and 2005, the most common complications
after the caesarean section were infections (endo-
metritis, peritonitis and infected surgical wounds),
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HealthMED - Volume 5 / Number 6 / 2011
while in the year 2008, endometritis 1.28% and the
infection of the wound on the abdominal wall 0.83
% showed most incidence. Out of 1562 caesarean
section deliveries, the most common complicati-
ons of surgical wounds that occurred postopera-
tive in 2008 were the infection of the abdominal
wall wound 0.83%, partial dehiscence of the abdo-
minal wall wound 0.26%, (subfascial) wound ha-
ematoma 0.13% and dehiscence of the incision on
the uterus with peritonitis (hysterectomy) 0.06%.
Out of 122 patients from both groups 15.3% of
them from group A and 34% from group B had
at least one wound complication after the delivery
(redness, swelling, haematoma, dehiscence, sero-
us discharge and purulent discharge). There is a
statistically important difference in the incidence
of wound complications between the groups A and
B p=0,028 (p<0.05).
Out of 122 patients from both groups in this
study (n=2) 2.8% of them from group A and (n=2)
4% of them from group B had a temperature hi-
gher than 38°C, 48 hours after the delivery, while
wound swabs were taken from (n=2) 2.% of pati-
ents from group A and (n=1) 2.0% of patients from
group B. Staphylococcus aureus was isolated in
one patient (2%) from group B, while two patients
(2.8%) from group A had negative results. This
could be an additional piece of data that points to
an increased incidence of febrile morbidity in gro-
up B and which could compromise the healing of
the wound; increase the funds spent on antibiotics
and extend the postoperative hospital stay.
Subjective estimate of recovery
The satisfaction of patients is of fundamental
importance as a measure of quality of health ser-
vices because it offers data on how much health
workers (health-protection providers) have ma-
naged to meet the expectations of the recipients.
The World Health Organisation (WHO) defines
satisfaction as a result of an estimate made by an
individual and compliance or lack of it thereof
between the presupposed needs and the provided
health protection, where satisfaction should be
part of a process of estimating the quality of health
protection [10,11]. The analysis of the data pro-
vided in this study show that significantly more
1760
patients from group A were satisfied with what
their surgical wounds looked like and they esti-
mated their postoperative recovery subjectively as
‘easy’, while most patients from group B (n=35)
70% reported a recovery of medium difficulty af-
ter the delivery.
5. Conclusion
Based on the set aims of the research and through
processing the data obtained and their analysis, we
can notice that the first time delivery patients were
becoming older in both groups, but the connecti-
on between the patients’ age and slower healing of
the wound is of no importance because they were
members of younger population. The advantages of
the surgical technique applied on patients in group
A (Joel-Cohen laparotomy with Vejnović modifica-
tion) compared to the surgical technique of patients
from group B (Pfannenstiel laparotomy) are signifi-
cant concerning the reduced incidence of the surgi-
cal wound complications.
The statistical data themselves do not play their
true role unless they are used to solve problems.
This research points to a standardisation of the sur-
gical technique which carries within the elements
of the minimum invasive surgery. This way, the
overall engagement of mechanisms that take part
in the physiological process of healing the surgical
wound is reduced.
References
1. Hamilton BE, Martin JA, Sutton PD. Birth: Preli-
minary data for 2002. Natal Vital Stat Rep 2003,
51:4-5
2. Vejnović T. Carski rez-Vejnovićeva modifikacija.
Srpski arhiv za celokupno lekarstvo. 2008; 136 Su-
ppl. 2:S109-15.
3. Kudumovic, M., Kudumovic, A. Economic analysis
of health, HealthMed, 2008; 2 (2): 100-3
4. Mathai M, Hofmeyr GJ. Abdominal surgical in-
cisions for caesarean section. Cochrane Databa-
se of Systematic Reviews 2007, Issue 1. Art. No.:
CD004453.
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5. Stark M, Chavkin Y, Kupfersztaina C, Guedjb P,

Finkel AR. Evaluation of combinations of proce-
dures in cesarean section. International Journal of
Gynaecology & Obstetrics. 1995; 48: 273-76

6. Holmgren G, Sjoholm L, Stark M. The Misgav La-

dach method for caesarean section: method des-
cription. Acta Obstet. Gynecol. Scand. 1999;78
(7):615-21.

7. Belci D. Uporedba perioperacijskih rezultata teh-

nike carskog reza „Misgav Ladach“ s klasičnom
metodom po Pfannenstielu. Glas. pul. boln. 2004;1.

8. Tully L, Gates S, Brocklehurst P, McKenzie-Mc-

Harg K, Ayers S. Surgital techniques used during
caesarean section operation: results of a national
survey of practice in UK. Eur J. of Obstet. Gynae-
col. Reprod. Biol. 2002; 102: 120-6.

9. Mugford M, Kingston J, Chalmens I. Reducing the

incidence of infection after caesarean section: im-
plications of prophylaxis with antibiotics for hos-
pital resources. British Medical Journal. 1989;
299:1003-6.

10. Milutinović D. Brestovački B, Martinov-Cvejin M.

Patients’ satisfaction with nursing care as an in-
dicator of quality of hospital service. HealthMed
2009; 3(4): 421-29.

11. Waldenstrom U, Rudman A, Hildingsson I. Intra-

partum and postpartum care in Swidwn: women´s
opinions and risk factors for not being satisfied.
Acta Obstetricia et Gynaecologica. 2006; 85:
551-560.

Correspondent author
Tihomir Vejnovic,
Clinic Centre Vojvodina,
Clinic for Gynaecology and Obstetrics,
Serbia,
E mail: vejnovict@gmail.com
.

Journal of Society for development in new net environment in B&H 1761

HealthMED - Volume 5 / Number 6 / 2011
Measuring health of countries: a
novel approach
Veljko Jeremic1, Kristina Seke2, Zoran Radojicic1, Danka Jeremic3, Aleksandar Markovic1, Dragoslav Slovic1,
Aca Aleksic4
1
Faculty of Organizational Sciences, University of Belgrade, Serbia,
2
Institute of Public Health of Serbia “Dr Milan Jovanovic Batut”, Belgrade, Serbia,
3
Institute of Endocrinology, Diabetes and Diseases of Metabolism, University Clinical Centre, Belgrade, Serbia,
4
Dunav Insurance Company, Belgrade, Serbia.
Abstract
We examined the health status of 27 European
Union countries by employing statistical I-dis-
tance method on various health indicators. Results
showed that Ireland tops the list of EU “healthi-
est countries”, while Sweden and Finland are just
a small step behind. On the other hand, Bulgaria,
Hungary, Poland and Romania are at the bottom
of the list. Further on, I-distance method has pro-
vided information as to which input variables are
crucial for determining a country’s health system
performance. We emphasize importance of evalu-
ating health system performances and determining
key health indicators.
Key words: measuring health, ranking of co-
untries, I-distance method
1. Introduction
Since health is considered to be a fundamen-
tal contributor to welfare in every country (1),
research on health system performance has long
been in academic’s focus (2, 3, 4). In order to rank
countries, researchers often used mortality rate as
indicator of the health system performance (5, 6).
However, this approach assumes that health is a
one-dimensional concept which is not precisely
the truth. As a matter of fact, definition of health
by the WHO suggests that health is a multi-face-
ted concept (7).
In this paper, we will incorporate far more vari-
ables into analysis and by using statistical I-distan-
ce method synthesised indicator shall be created.
With this approach, we are able to quantify each
1762
countries health status and evaluate differences
between them. Further on, we will present corre-
lation of each indicator with the I-distance value.
This approach will provide us with information
which indicators are more significant than others
for determining health status of countries. In our
work, we will focus attention on evaluating health
status of European Union countries.
The remainder of the paper is as follows. The
next section thorough explains statistical I-distan-
ce method, while in Section 3 this method is appli-
ed to various indicators of health. In Section 4, we
will emphasize key conclusions of our study and
propose some directions in future research.
2. I-distance method
Quite often the ranking of specific marks is
done in a way that can seriously affect the process
of taking exams, entering competitions, UN parti-
cipation, sports competitions, medicine selection
and many others (8, 9, 10, 11, 12).
I-distance is a metric distance in an n-dimen-
sional space. It was proposed and defined by B.
Ivanovic in various publications that have appe-
ared since 1973 (13). Ivanovic devised this met-
hod with the aim to rank countries according to
their level of development on the basis of several
indicators. Many socio-economic development
indicators were considered and the problem was
how to use all of them in order to calculate a single
synthetic indicator which will represent the rank.
For a selected set of variables XT=(X1, X2,…
Xk), chosen to characterize the entities, the I-dis-
tance between two entities er = (x1r, x2r,…, xkr ) and
Journal of Society for development in new net environment in B&H

es=(x1s,x2s,…,xks) is defined as
k
d i (r , s ) i −1
D(r , s) = ∑
i =1 σi
∏ (1 − r
j =1
ji .12 ... j −1
where di(r,s) is the distance between the values
of variable Xi for er and es, e.g. discriminate effect,
di(r,s) = xir – xis , iÎ{1, ... , k}
σi standard deviation of Xi, and rji.12..j-1 is partial
coefficient of correlation between Xi and Xj, (j<i),
(8).
The construction of I-distance is iterative. It is
calculated through the following steps:
-- Calculate the value of discriminate effect of
variable X1 (the most significant variable,
the one that provides the largest amount of
information on the phenomena to be ranked)
-- Add value of discriminate effect of X2 which
is not covered by X1
-- Add value of discriminate effect of X3 which
is not covered by X1 and X2
-- Repeat the procedure for all variables (14).
This I-distance fulfils all 13 conditions for defi-
ning measures of distances. It is essential to point
out that I-distance method requires standardizati-
on of all data. It proved useful in overcoming the
differences in measures.
Sometimes it is not possible to achieve the
same sign mark for all variables in all sets, and
as a result negative correlation coefficient and ne-
gative coefficient of partial correlation may occur.
This makes the use of square I-distance even more
desirable. Square I-distance is given as
k
d i2 (r , s ) i −1
D 2 (r , s ) = ∑
σ 2 ∏ (1 − r 2
ji .12 ... j −1
i =1 i j =1
In order to rank the entities (in our case, coun-
tries) in the observing set using I-distance meth-
odology, it is necessary to have one entity fixed as
a referent. The fictive country with minimal value
for each indicator is set up as the referent entity.
Ranking of entities in the set is based on the calcu-
lated distance from the referent entity.
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
3. Results
The selection of indicators was done in order to
) reflect health of individuals, as well as quality of
health services. In a line with previous research on
the subject of evaluating nation’s health status (7),
data from Statistical Information System of the
World Health Organization (15) was evaluated.
Table 1. Indicators of the health of individuals
Healthy life expectancy
Life expectancy at birth
Mortality rate adults
Mortality rate under-5
Mortality rate infants
Mortality rate mother
Years lost to communicable diseases
Years lost to non-communicable diseases
Years lost to injuries
Age standardized mortality rate: cardiovascular
diseases
Age standardized mortality rate: cancer
Age standardized mortality rate: non-
communicable diseases
Age standardized mortality rate: injuries
Table 2. Indicators of health services
Number of dentists per 10 000 people
Number of nurses per 10 000 people
Number of physicians per 10 000 people
Number of pharmacists per 10 000 people
Hospital beds per 10 000 people
Immunization rate measles
Immunization rate DTP
Immunization rate hepatitis
Immunization rate tuberculosis
Per capita government expenditure on health (PPP
int. $)
Per capita total expenditure on health (PPP int. $)
) The results achieved through the use of the I-
. distance ranking method are presented in Table 3.
As we can see from Table 3, Ireland tops the
list of EU “healthiest countries”. Sweden and
Finland are just a small step behind. On the ot-
her hand, Bulgaria, Hungary, Poland and Romania
are at the bottom of the list. In order to fully un-
derstand the rankings, it is essential which of the
input variables the most important one for measu-
ring health is. Thus, data set was further examined
1763
HealthMED - Volume 5 / Number 6 / 2011

and a correlation coefficient of each variable with the list with very low life expectancy. Further on,
the I-distance value was determined, the results of I-distance method showed that mortality rate for
which are presented in Table 4. children under-5 is 4th most significant variable,
Table 3. The Results of the square I-distance Met- with r=.751, p<.01. Above mentioned Romania
hod, I-distance values and Rank for the year 2007 and Bulgaria are the EU countries with highest
Country I-distance Rank I-distance mortality fate for under-5’s, far more than other
Ireland 44.406 1 EU members. This is precisely one of the reasons
Sweden 41.602 2 why are these countries low ranked. As a possible
Finland 40.115 3 remedy to the issue, we want to point out that Ro-
Luxembourg 39.347 4 mania and Bulgaria have lowest percentage of one
Greece 37.569 5 year old immunized with BSG, only 70%. Thus,
Malta 36.204 6 child health service is essential and it has to be
Belgium 35.310 7 improved drastically (20).
Italy 34.751 8 Table 4. The Correlation between I-distance and
Spain 34.655 9 Input Variables
Germany 32.491 10 r
Czech Republic 29.042 11 Healthy life expectancy .813**
Netherlands 28.552 12 Age standardized mortality rate: non-
.783**
France 28.355 13 communicable diseases
Portugal 27.539 14 Life expectancy at birth .779**
Austria 27.515 15 Mortality rate under-5 .751**
Cyprus 26.748 16 Mortality rate adults .749**
Denmark 26.394 17 Per capita total expenditure on health (PPP int. $) .708**
United Kingdom 25.942 18 Mortality rate infants .653**
Lithuania 21.308 19 Per capita government expenditure on health
.633**
Slovenia 21.057 20 (PPP int. $)
Estonia 20.236 21 Age standardized mortality rate: cardiovascular
.630**
Latvia 18.658 22 diseases
Slovakia 18.591 23 Number of pharmacists per 10 000 people .581**
Bulgaria 17.206 24 Mortality rate mother .543**
Hungary 17.124 25 Age standardized mortality rate: injuries .490**
Poland 14.197 26 Number of nurses per 10 000 people .474*
Romania 11.560 27 Age standardized mortality rate: cancer .426*
Number of physicians per 10 000 people .411*
As it appears, the most significant variable for Number of dentists per 10 000 people .382*
determining health status of countries is healthy Immunization rate measles .369
life expectancy (HALE), with r=.813, p<.01. This Immunization rate tuberculosis .257
result is far from surprising one; various papers Years lost to non-communicable diseases .204
have elaborated importance of HALE in deter- Immunization rate DTP .163
mining countries health (16, 17, 18). Very similar Immunization rate hepatitis .138
observation can be pointed out for variable life Years lost to injuries .099
expectancy at birth. As a matter of fact, research- Hospital beds per 10 000 people .090
ers determined statistically significant difference Years lost to communicable diseases .073
in life expectancy between various regions in **
. Correlation is significant at the .01 level.
world (19). With these two variables being 1st and *
. Correlation is significant at the .05 level.
3rd most significant ones for determining coun-
tries rank, countries that are the EU leaders in life Also, very important issue we have to empha-
expectancy are at the top of the list. On the other size is non-communicable diseases. It is the sec-
hand, Bulgaria and Romania are at the bottom of ond most significant variable for determining rank

1764 Journal of Society for development in new net environment in B&H


of countries, r=.783, p<.01. All of the bottom list
countries have very high frequency of occurrence
of non-communicable diseases. Since this issue
is widely recognized as one of the key indicators
of countries health status (21), South-Eastern and
Eastern EU members have to rapidly enhance
quality of health service in this field.
Interesting finding is that adult mortality and
mortality rate for injuries are highly significant
variables. This is especially important for former
USSR countries, Lithuania, Estonia and Latvia.
These countries have high mortality from injuries
and accidents, and some possible links with alco-
hol consumption have been elaborated in various
papers (22).
4. Discussion
In this paper, we wanted to evaluate health sy-
stem performance of European Union countries
by applying statistical I-distance method. Results
clearly showed great disparity between EU mem-
bers. As a matter of fact, Scandinavian and We-
stern Europe countries lead the way while newly
integrated members from Eastern and South Ea-
stern Europe have huge problems in catching up
with high EU standards.
There are several contributions we would like
to point out. First of all, with approach presented
in our work it is possible to evaluate every countri-
es health system performance. Moreover, not only
ranking but difference between countries is provi-
ded. Large number of variables can be included in
analysis, generating one synthesised quantitative
indicator.
Besides above mentioned contributions, we
would like to emphasize that I-distance method
provide us with information which input varia-
bles are crucial for determining countries health
system performance. Thus, each country can re-
evaluate its health system performance and try to
improve ranking by emphasizing the most signifi-
cant indicators of health status. .
We hope that this paper will add to growing
studies in evaluating health system performances
and provide useful information about key health
indicators.
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
Acknowledgment
This work is a part of project Multimodal bio-
metry in identity management, funded by Ministry
of Science and Technological development, con-
tracts no TR-32013.
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hurt: demographic, socio-economic and health sta-
tus inequalities in the utilization of health services
in Serbia. Eur J Public Health 2010; 20(4):389-96.
2. Murray CJ, Frenk J. Ranking 37th — measuring
performance of the US health care system. New
Engl J Med 2010; 362(2):98–9.
3. Thorpe KE, Howard DH, Galactionova K. Diffe-
rences in disease prevalence as a source of the US
European health care spending gap. Health Affair
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4. Munkhsaikhan S, Tsai AC, Chang MC. Technical
efficiency of public hospitals in Mongolia. Heal-
thMED 2011; 5(2):360-5.
5. Nolte E, McKee C. Measuring the health of nati-
ons: Analysis of mortality amenable to health care.
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6. Nolte E, McKee C. Measuring the health of nati-
ons: Updating an earlier analysis. Health Affairs
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riate approach. Soc Indic Res 2010; 96(3):433-57.
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velopment indicators. Paris: United Nations edu-
cational, scientific and cultural organization, 1973.
9. Ivanovic B, Fanchette S. Grouping and ranking of
30 countries of Sub-Saharan Africa, Two distance-
based methods compared. Paris: United Nations
educational, scientific and cultural organization,
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10. Jeremic V, Radojicic Z. A New Approach in the
Evaluation of Team Chess Championships Rank-
ings. J Quant Anal Sports 2010; 6(3).
11. Jeremic V, Bulajic M, Martic M, Radojicic Z. A
fresh approach to evaluating the academic ran-
king of world universities. Scientometrics 2011;
Online First, DOI: 10.1007/s11192-011-0361-6
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HealthMED - Volume 5 / Number 6 / 2011

12. Jeremic V, Isljamovic S, Petrovic N, Radojicic Z, Corresponding author

Markovic A, Bulajic M. Human development in- Veljko Jeremic,
dex and sustainability: What’s the correlation? University of Belgrade,
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16. Engineer ME, Roy N, Fink S. “Healthy” Human
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2010; 20(6):695–701.

1766 Journal of Society for development in new net environment in B&H


Psychopathological response of
torture victims
Alma Bravo-Mehmedbasic, Senadin Fadilpasic
Psychiatric Clinic, University Clinical Center Sarajevo, Bosnia and Herzegovina.
Abstract
Background: The Aims of this research were
to register social and demographic characteristics
of subjects before and after the war, methods of
torture, mental disorders and stress coping strate-
gies of the subjects who had experienced war tra-
umas and war torture in particular.
Subjects and Methods: Research involved
200 subjects divided into four groups. Experimen-
tal group consisted of 50 torture victims which
were treatment seekers, and which were also trau-
matized as refugees. First control group consisted
of 50 torture victims with experience of being
refugee, and who did not seek treatment. Second
control group consisted of 50 persons who had tra-
uma of being refugee but did not experience tor-
ture. Third control group was 50 persons without
experience of torture or being a refugee. We used
the following instruments: General questionnaire
to register the social and demographic characte-
ristics of the subjects, Scale of the applied torture
methods, Scale for evaluation of the stress coping
strategies, SCL 90-R to register psychological
symptoms, and Mississippy questionnaire to eva-
luate posttraumatic stress disorder.
Results: The subjects of experimental group
significantly differred from control groups regar-
ding intensity of psychopathological symptoms,
and in use of inadaptable coping strategies. Corre-
lation between torture and psychological symp-
toms is positive and statistically significant. Corre-
lation between torture and coping strategies is not
statistically significant, which impose that, beside
torture, personality structure has strong impact on
use of the coping strategies. Correlation between
psychological symptoms and inadaptable coping
strategies is positive and statistically significant.
Correlation between psychological symptoms and
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
adaptable coping strategies is negative and statisti-
cally significant.
Conclusion: Torture victims are the most da-
maged population, possibility for the spontaneous
recovery in not likely and it is necessary to provide
them adequate rehabilitation which should include
definition of their status, from which moral, legal
and financial compensation will originate.
Key words: Torture victims, psychopathologi-
cal responses, coping strategies.
Introduction
In the United Nations Convention against Tor-
ture and other Cruel, Inhuman or Degrading Tre-
atment or Punishment adopted in 1984 torture is
defined as: Any act by which severe pain or suffe-
ring, whether physical or mental, is intentionally
inflicted on a person for such purposes as obtai-
ning from him or a third person information or a
confession, punishing him for an act he or a third
person has committed or is suspected of having
committed, or intimidating or coercing him or a
third person, or for any reason based on discrimi-
nation of any kind, when such pain or suffering is
inflicted by or at the instigation of or with the con-
sent or acquiescence of a public official or other
person acting in an official capacity(1).
Torture is employed as an instrument of power.
In the context of war, an enemy employs torture
as a strategy to gain power and territory, through
subjugating the opposition and ethnic minorities.
The aims of torture might be stated in the following
order: Obtaining information, obtaining a confe-
ssion, forcing the victim to accuse a third person,
taking revenge, spreading terror in a community,
destroying the personality of victim (2). Methods of
torture are divided into: Physical methods, psycho-
1767
HealthMED - Volume 5 / Number 6 / 2011
logical methods and sexual torture. All methods of
physical torture cause at the same time mental suf-
fering, while sexual torture combines both physical
and psychological methods. The consequences of
torture can be divided into physical, psychological,
psychosomatic and social (3). The most frequent
psychological consequences of torture are: Low
self-esteem, lack of confidence, lack of self-confi-
dence in interpersonal relations, environmental dis-
orientation, sleep disturbances, nightmares, anxiety,
depression, poor concentration, impaired memory
functions, psycho-sexual problems, altered identity,
psychotic disorders, Post Traumatic Stress Disorder
(4,5). Torture is a global problem, and it has con-
sequences not only to an individual, but also to its
family and society, leading toward transgeneratio-
nal transfer of torture trauma (6). Torture is perfor-
med with the scientifically developed and trained
techniques in order to achieve the planed goals of
the ordering party. Perpetrators use all methods
of torture in order to destroy and psychologically
exterminate personality of the victim (7).
The aims
The aims of this research were to register the
psychopathological responses of torture victims.
Subjects and methods
This research involved 200 subjects, 100 male
and 100 female, whose age range was between 30
and 60 years. Their education range from illiter-
ate to 18 and more years education divided into
four groups: Experimental group consisted of 50
torture victims which seek the treatment, and whi-
ch were also traumatized as refugees. First control
group consisted of 50 torture victims with experi-
ence of being refugee, and who did not seek trea-
tment. Second control group consisted of 50 per-
sons who had trauma of being refugee but without
torture. Third control group was 50 persons wit-
hout experience of torture or being a refugee. All
subjects signed informed consent before entering
into this study which conducted at the Psychiatric
Clinic and the Centre for torture victims. We used
the following instruments:
1768 Journal of Society for development in new net environment in B&H
1. General questionnaire was constructed
by authors to register the social and
demographic characteristics of the subjects.
2. The Scale of the applied torture methods,
as a self -report scale to register physical,
psychological and sexual techniques of
torture. The scale contains 38 items, 20
items on psychological torture, 17 items on
physical torture and 1 item on sexual torture,
with responses in Likert format, ranging
from 0 to 3 ( never, very rarely, moderate,
very often). Lower scores indicate lower
level of torture experience(8).
3. The Ways of Coping Scale. The scale is using
for evaluation of the stress coping strategies.
The scale contains 39 items divided in
eight subscales: Social suport, confrontive
coping, distancing, self control, positive
reappraisal, planned problem-solving,
escape-avoidance, accepting responsibility.
The coping strategies which have significant
positive correlation with all kinds of mental
health symptoms are inadaptable coping
strategies, but which have significant
negative correlation with all kinds of mental
health symptoms are adaptable coping
strategies. In inadaptable coping there are
absence of planned problem solving coping
and asking for social support and absence
escape-avoidance coping on the adaptable
coping list. (9).
4. The SCL 90-R is a 90-item multidimensional
self- report symptom inventory derived from
the Hopkins Symptom Checklist (Derogatis,
1977), the revised version to register
psychological symptoms. The SCL has 90
items arranged in 9 subscales: Somatisation,
Obsessive-Compulsive behaviour, Interper-
sonal Sensitivity, Depression, Anxiety,
Hostility, Phobic Anxiety, Paranoid Ideation
and Psychoticism, with responses ranging
from 0 to 4, not at all, a little bit, mo­de­­rately,
quite a bit, extre­mely. (10).
5. The Civilian Mississippi PTSD Scale
(Keane, Caddell & Taylor, 1988), 35 – item
scale, designed to reveal PTSD symptoms
according to DSM-III-R, a self-administered
interview with responses ranging from 1 to
5. The cut off point was 107.(11).
 HealthMED - Volume 5 / Number 6 / 2011

Results mental group had poor economic status and the

Sociodemographic characteristics of the
subjects, separation of family members, loss
of family members, imprisonment during
the war
There is significant difference in economic
status, current employment status, separation
and loss of family members and the imprison-
ment during the war between the groups of the
subjects. The majority of the subjects in experi-
low rate of employment. The groups of torture
victims had loss of family members, while the
group of refugees and the group of subjects
without experience of torture or being a refugee
did not have loss of family members. 94 % of
torture victims who seek treatment were impri-
soned and 100% of torture victims who did not
seek treatment but none of subjects from second
and third control groups were imprisoned during
the war (Table 1).

Table 1. Sociodemographic characteristics of subjects after the war

Groups E E C1 C1 C2 C2 C3 C3 χ2 , p
Current economic status
Count
Percentage
Good 0 0% 1 2% 5 10% 14 28%
Very bad 4 8% 12 24% 6 12% 0 0%
χ2 =93,813
Moderate 15 3% 8 16% 12 24% 36 72%
p<0,01
Bad 31 62% 29 58% 27 54% 0 0%
Total 50 100% 50 100% 50 100% 50 100%
Currently employed status
Count
Percentage
Yes 12 24% 14 28% 15 30% 43 86%
χ2 =53,366
No 38 76% 36 72% 35 70% 7 14%
p<0,01
Total 50 100% 50 100% 50 100% 50 100%
Separation of family members
Count
Percentage
Yes 16 32% 23 46% 29 58% 2 4%
χ2=35,604
No 34 68% 27 54% 21 42% 48 96%
p<0,01
Total 50 100% 50 100% 50 100% 50 100%
Loss of family members
Count
Percentage
Yes 10 20% 20 40% 0 0% 0 0%
χ2=43,137
No 40 80% 30 60% 50 100% 50 100%
p<0,01
Total 50 100% 50 100% 50 100% 50 100%
Imprisonment during the war
Count
Percentage
Yes 47 94 % 50 100% 0 0% 0 0%
χ2=188,710
No 3 6% 0 0% 50 100% 50 100%
p<0,01
Total 50 100% 50 100% 50 100% 50 100%
Abbreviation: E (experimental group), C1 (first control group), C2 (second control group), C3 ( third control group), χ2
(chi-square test), p (t test value of significance).

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HealthMED - Volume 5 / Number 6 / 2011

Table 2. The torture during the war

Groups E C1 C2 C3 χ2 p
The torture during the war
Count
Percentage
Yes 50 100% 50 100% 0 0% 0 0%
χ2=197,000
No 0 0% 0 0% 50 100% 50 100%
p<0,01
Total 50 100% 50 100% 50 100% 50 100%
Abbreviation: E (experimental group), C1 (first control group), C2 (second control group), C3 (third control group), χ2 (chi-
square test), p (t test value of significance)

Experience of torture Psychopathological responses

All subjects of torture survivors experimental The subjects of experimental group differ from
and the first control groups were tortured, but no- control groups regarding intensity of psychopatho-
body from the second and the third control groups. logical symptoms. Comparison between group by
The torture during the war was presented in Table Scheffe's method shows that two groups of torture
2. The two groups of torture survivors did not sig- survivors did not significantly differ on subscale
nificantly differ by the frequency and intensity of SCL. somatizacion interpersonal sensitivity, para-
torture (Table 3). noid ideation and psychoticism, but on other sub-
Table 3. The frequency and intensity of torture scales two groups of torture survivors significantly
Variable N M SD p differ. The second and the third control groups did
frequency of torture not significantly differ on Somatization, but sig-
Group E 50 55,44 11,36 p>0,05 nificantly differ on other eight subscales of SCL
Group C1 50 52,10 14,18 90 R (Table 4).
intensity of torture
Group E 50 54,36 12,38 p>0,05
Group C 1 50 51,60 13,20 Results for ptsd
Abbreviation: E (experimental group), C1 (first control gro-
up), C2 (second control group), C3 (third control group). N: The subjects of experimental group significant-
number of subjects, M: mean, SD: standard deviations, χ2 ly differ from control groups on the level P<0,01.
(chi-square test), p (t test value of significance) Comparison between groups by Scheffe's method
shows that two groups of torture survivors signifi-
cantly differ. The second control group and the
third control group did not significantly differ. The
cut off point for PTSD was 107 (Table 5). 92%
Table 4. Scl-90 r (subscales)
SCL SCL SCL
SCL SCL SCL
Somati- Obsessive- Interper- SCL SCL SCL
Phobic Paranoid Psycho-
Variable sation Compulsive sonal Depression Anxiety Hostility
Anxiety Ideation ticism
behaviour Sensitivity
M M M M M M M M M
Group E 2,35 2,59 2,04 2,53 2,73 2,19 2,13 2,09 1,22
Group C1 2,12 1,96 1,77 1,83 1,90 1,66 1,34 1,86 1,23
Group C2 0,92 1,11 1,00 1,07 1,11 0,94 0,65 1,00 0,55
Group C3 0,59 0,64 0,52 0,43 0,41 0,37 0,27 0,53 0,22
Analysis variance p=0,000.
Abbreviation: E (experimental group), C 1 (first control group), C 2 (second control group), C3 ( third control group). M: mean.

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 HealthMED - Volume 5 / Number 6 / 2011

of subjects in experimental group had PTSD, in Adaptable coping strategies

the first control group 54% had PTSD, but none of
subjects in the second and third control group had Comparison between all groups in using adap-
PTSD (Table 6). table coping strategies shows significant differ-
Table 5. Mississippi scale for ptsd ence P<0,01. Comparison between groups by
N M SD Scheffe's method shows that two groups of torture
Group E 50 135,040 20,695 victims significantly differ in use of adaptable cop-
Group C1 50 105,420 13,518 ing strategies P<0,01. Torture victims that didn’t
Group C2 50 73,980 11,143 seek treatment had used more adaptable coping
Groupo C3 50 68,387 11,463 strategies and had lower intensity of psychopatho-
Abbreviation: E (experimental group), C1 (first control gro- logical responses. The subjects of experimental
up), C2 (second control group), C3 ( third control group). and third control group did not significantly differ
N: number of subjects, M: mean, SD: standard deviations. P>0,05, also first and second control group did not
significantly differ P<0,05 (Table 8).
Table 6. The percentage of ptsd Table 8. Adaptable coping strategies
Groups E C1 C2 C3 N M SD
N 46 27 Group E 50 14,44 5,33
Yes
% 92% 54,0 Group C1 50 20,50 4,71
N 4 23 50 50 Group C2 50 19,24 4,83
No
% 3,2 46,0 100% 100% Group C3 50 11,94 7,18
Abbreviation: E (experimental group), C 1 (first control gro- Total 200 16,53 6,56
up), C2 (second control group), C3 ( third control group). N: Abbreviation: E (experimental group), C 1 (first control gro-
number of subjects. up), C 2 (second control group), C3 ( third control group).
N: number of subjects, M: mean, SD: standard deviations.

Results for coping strategies

Correlation between psychological
Inadaptable coping strategies symptoms, torture and coping strategies of
two groups of torture survivors
Comparison between all groups (ANOVA)
shows significant difference in use of inadapt- Pearson correlation is positive and statistically
able coping strategies P<0,01, but comparison significant between Mississippi scale on PTSD and
between groups by Scheffe's method shows that all subscales of SCL 90, for two groups of torture
two groups of torture victims did not significant- survivors. Correlation between torture and psyc-
ly differ in use of inadaptable coping strategies. hological symptoms is positive and statistically si-
P>0,05. The subjects of second and third control gnificant. Correlation between torture and coping
groups significantly differ P<0,01 (Table 7). strategies is not statistically significant, which
Table 7. Inadaptable coping strategies impose that, beside torture structure of personality
N M SD had strong impact on use of the coping strategies.
Group E 50 11,66 2,73 Correlation between psychological symptoms and
Group C1 50 11,54 2,59 inadaptable coping strategies is positive and stati-
Group C2 50 8,64 2,43 stically significant. Correlation between psycholo-
Group C3 50 6,86 3,82 gical symptoms and adaptable coping strategies is
Total 200 9,67 3,56 negative and statistically significant.
Abbreviation: E (experimental group), C1 (first control gro-
up), C2 (second control group), C3 ( third control group).
N: number of subjects, M: mean, SD: standard deviations.

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HealthMED - Volume 5 / Number 6 / 2011
Discussion
Accoding to our results experience of tortu-
re mostly leads to development of Posttraumatic
stress disorder and other psychological consequ-
ences rather then other traumatics experiences.
Similar results are observed in the research by
(12,13,14,15). In the research with torture sur-
vivors, 90 % of the torture survivors manifested
chronic psychological and social consequences
(16) which was also confirmed in our study. Re-
sults of our study indicate that the experimental
group of the subjects (torture victims which seek
treatment, and which were also traumatized as re-
fugees) used less adaptable coping strategies than
group of torture victims who did not seek trea-
tment and the subjects of group who had trauma
of being refugee but did not experience torture.
Correlation between psychological symptoms and
inadaptable coping strategies is positive and sta-
tistically significant. Correlation between psycho-
logical symptoms and adaptable coping strategies
is negative and statistically significant. Correla-
tion between torture and psychological symptoms
is positive and statistically significant. Correla-
tion between torture and coping strategies is not
statistically significant, which impose that beside
torture, structure of personality had strong impact
on use of the coping strategies. Similar results are
observed in the research by Arcel where the degree
of inadaptable coping was highest among torture
survivors who had the highest level of psychologi-
cal symptoms (17). Accoding research of psycho-
logical processes such as the defence mechanisms
and coping strategies used under stress, appear to
play a significant role in symptom formation. In
the process of rehabilitation of torture survivors
they changed their coping and decreased psycho-
logical symptoms through adopting a flexible way
(adaptive) coping behavior across a range of dif-
ferent situations (18,19,20).
Conclusion
Research confirmed that there are mental dis-
orders among the persons who have survived tor-
ture, and that these disorders differ by type and
intensity between subjects in the experimental
1772 Journal of Society for development in new net environment in B&H
group (torture victims which seek treatment, and
which were also traumatized as refugees) and the
control groups. Torture victims are the most dam-
aged population, possibility for the spontaneous
recovery in not likely and it is necessary to pro-
vide them with adequate rehabilitation which will
include, beside medical-psychological rehabilita-
tion, definition of their status, from which moral,
legal and financial compensation will originate.
Torture survivors not only have to manage their
health and mental health symptoms after impri-
sonment and displacement but must also cope with
poverty and social exclusion. There are a number
of factors modifying the consequences of torture.
They can be divided into four categories: Aims of
Torture, characteristics of torture, characteristics
of torture victims, characteristics of environment,
treatment and rehabilitation. Research of torture,
consequences and rehabilitation is not only impor-
tant for those who had survived torture, but it also
has significance for the prevention of torture use
in society.
References
1. United Nations Convention against Torture and
Other Cruel, Inhuman or Degrading Treatment or
Punishment. Article 2, 1984.
2. Roth E F, Lunde L, Boysen G & Genefke I K: Tor-
ture and its treatment. American Journal of Public
Health 1987; 77: 1404-1406.
3. Arcel LT, Genefke I & Kastrup M: Psychiatric
problems related to torture. In Henn F (ed): Con-
temporary Psychiatry, 299-310. Springer Verlag,
Berlin, 2000.
4. Jacobsen L & Vesti P: Torture survivors –a new
Group of Patients, 25-41. IRCT Denmark, 1995.
5. Lončar M, Medved V, Jovanović M & Hotujac Lj:
Psychological Consequences of Rape on womwn in
1991-1995. War in Croatia and Bosnia and Herze-
govina. Croat Med J. 2006; 47:67-75
6. Danieli Y: Assessing trauma across cultures from
a multigenerational perspective. In Wilson J P &
So-kum Tang C (Eds): Crosscultural assessment of
psychological trauma and PTSD, 65-89. Springer-
Verlag, NewYork, 2007.
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7. Lifton R.J: Understanding the traumatised self: 19. Jaranson JM, Kinzie D, Friedman M, Ortiz SD,
Imagery ,Simbolisation and Transformation.. In Friedman MJ: Assessment, Diagnosis Interventi-
Wilson Jp , Harel Z, Kahana B (eds): Human Adap- on. In: Gerrity E, Keane T M, Tima F (eds): The
tation and Extreme Stress: From the Holocaust to Mental Health Consequence of torture, 249-275.
Vietnam, 3-71. Plenum Press, New York; 1988. Kluwer Academic, New York; 2001.
8. IRCT Copenhagen: The Scale of the applied torture 20. Mollica RF: Surviving torture. N Engl J Med.
methods. 1997. 2004;1;351(1):5-7.
9. Folkman S & Lazarus RS: Manual for Ways of Co-
ping Questionnaire. Consulting Psychologist Press,
Coresponding author
Palo Alto; 1988.
Alma Bravo Mehmedbasic,
10. Derogatis L R: SCL-90 – Revised: Administration, Department of Psychiatry,
Scoring and Procedure Manual -I. John Hopkins University Clinical Center Sarajevo,
University School of Medicine, Baltimore; 1977. Bosnia and Herzegovina,
E-mail: almabravomehmedbasic@bih.net.ba
11. Keane TM, Caddell JM,Taylor KL: Mississippi
Scale for Combat-Related Posttraumatic Stress
Disorder. Journal of Counselling and Clinical
Psychology 1988; 5: 85-90.
12. Baker R: Psychosocial consequences for tortured
refugees seeking asylum and refugee status in Eu-
rope. In: Basoglu M ( ed): Torture and its Con-
seguences, 83-101. University Press, Cambridge,
1992.
13. Miller TW, Martin W & Spiro K: Post-traumatic
stress disorder in former prisoners of war. Com-
prehensive Psychiatry 1989; 30(2): 139-48.
14. Jacobsen L & Smidt- Nielsen K: Torture survivors
,trauma and rehabilitation, 128-133. IRCT, Cope-
nhagen, 1997.
15. Danneskiold-Samsoe B, Bartels EM, Genefke I:
Treatment of torture victims-a longitudinal clini-
cal study. Torture 2007; 17:7-11.
16. Reid J & Strong T: Torture and Trauma:The He-
alth Care Needs of Refugee Victims in New South
Wales. Cumberland College of Health Sciences,
Sydney, 1987.
17. Arcel LT , Folnegović –Smalc V, Tocilj-Šimunko-
vić G , Kozarić-Kovačić D & Ljubotina D: Ethnic
Cleansing and Post traumatic Coping-War Vio-
lence, PTSD, Depression, Anxiety, and Coping on
Bosnian and Croatian Refugees. A transactional
Approach . In Arcel L T (ed): War Violence, Tra-
uma and the Coping Process, 45-79. IRCT and
University of Copenhagen, 1998.
18. Somnier FE & Genefke IK: Psychotherapy for
victims od torture. British Journal of Psychiatry,
1986; 149: 323-339.

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HealthMED - Volume 5 / Number 6 / 2011

Effects of dispersed radiation on

the thyroid and the gonads during
mammography
Suad Kunosic1,2, Denis Ceke3, Adnan Beganovic4, Begzada Basic5
1
Department of Physics, Faculty of Natural Sciences and Mathematics, University of Tuzla, Bosnia and
Herzegovina,
2
Department of Biophysics, Medical Faculty, University of Tuzla, Bosnia and Herzegovina,
3
Center for quality assurance and self-evaluation, University of Tuzla, Bosnia and Herzegovina,
4
Department of Medical Physics and Radiation Safety, Clinical Centre of Sarajevo University,
Bosnia and Herzegovina,
5
Institute for Public Health FBiH, Sarajevo, Bosnia and Herzegovina.

Abstract gonads can be 13 times less than the thyroid dose

Background: The study aimed to explore ef-
fects of dispersed radiation on radiosensitive organs
during mammography. The thyroid and the gonads
are determined as key organs for exploration of dis-
persed radiation: the first one due to its vicinity to
the dispersion zone and the second ones due to their
symmetrical position in regard to the thyroid, which
enables an assessment of distribution of dispersed
radiation in regard to a compression plate.
Materials and Methods: Entrance skin doses
were defined during diagnostic procedures, using
thermoluminescent dosimeters attached to the skin
surface above the thyroid and the gonads for the pur-
pose of exploration of dispersed radiation effects.
Results: Results obtained indicate that medi-
um entrance skin doses on skin around the thyroid
were 0,211 ± 0,107 mGy per woman and 0,017
± 0,012 mGy per woman on skin around the go-
nads. Measuring confirms that there is a signifi-
cant correlation between entrance skin doses for
the thyroid and total applied mAs during mammo-
graphy (r = 0,802, p<0,01).
Conclusion: Measuring defined that most of
dispersed radiation was directed towards the area
above breasts and the thyroid and only a small
amount covered the area under the breasts and went
towards the gonads. Entering skin doses for the
thyroid ranged from 0.10 to 0,51 mGy while the
dose received by the thyroid varied from 0,7 % to
1,6 % of the MGD dose. Entrance skin doses for the
and cannot be concerned dangerous for the gonads.
Key words: mammography, dispersed radiation,
entrance skin dose, dosimetry in mammography.
Introduction
Application of x –rays in diagnostics had fun-
damental significance for development of modern
radiology. Contemporary radiology is based on
prevention of all kinds of diseases examined thro-
ugh their early detection. Mammography is used
as the most reliable radiological diagnostic method
in breast cancer prevention and detection. Since
breast cancer is currently the second leading cause
of death from cancer for women [1], a number of
mammographic examinations [2] with a purpose
of breast cancer early detection [3] has increased.
It is a key for a long-term control and good re-
sults in breast cancer treatment, which requires a
high quality mammography. To achieve necessary
requirements for the high quality mammography
each of its procedures has to be justified and op-
timized [4]. Optimization means that exposure of
a patient to radiation must be as little as possible,
but it must comply with quality of imaging neces-
sary for an adequate diagnosis.
Therefore, measuring patient doses received
by a breast during mammography represented an
important segment of ensuring mammographic
imaging quality. Besides benefits, application of

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 HealthMED - Volume 5 / Number 6 / 2011

patients doses in mammography undeniably bro- (Mo/Mo). During a routine mammographic con-
ught a certain degree of risk [5, 6, 7, 8, 9] which trol, we collected data about entrance skin doses
is relatively small with application of adequate in the area of the thyroid and the gonads for 68
equipment and technique. Most mammographic patients between the age of 34 and 80. To collect
studies [10, 11, 12, 13, 14] showed that defining data about entrance skin doses we used the same
mean glandular dose (MGD) was a base for radia- technique with thermoluminescent dosimeters as
tion risk assessment. in personal dosimetry.
To assess ratio of benefits and risks of mam- At every diagnostic examination one TLD
mography one has to examine effects of disper- was attached to a patient’s skin surface above the
sed radiation on surrounding radiosensitive organs thyroid and the gonads – as in figure 1. During
during mammography. Dispersed radiation is in- diagnostic examinations, TLD dosimeters were
teresting due to detection of its adverse impact on attached to the patient’s neck (area of the thyro-
radiosensitive organs during mammography and id) and around the waist (area of the gonads) with
possible designing of their protectors [15]. Con- thin rubber ribbon (Figure 1.). Dosimeters at the
tribution of dispersed radiation to radiosensitive thyroid and the gonads, respectively, were used to
organs around the area interesting for mammo- collect data about dispersed radiation during the
graphic diagnostics increases with an increase of a complete diagnostic examination.
number of mammographic examinations. Several
authors examined effects of dispersed radiation
on radiosensitive organs during mammography
[16, 17, 18, 19]. They mainly examined effects of
dispersed radiation on the thyroid, eyes, stomach,
lungs and esophagus while very little study inclu-
ded the gonads. In medical radiology the thyroid
has been marked as a radio sensitive organ since
a long ago due to its exposure to radiation field
during radiological diagnostics of neck, shoulders
and oral cavity. Typical doses for the thyroid were
documented in dentistry [20, 21], through radio-
logical examinations in cardiology [22] and they
proved to be interesting for personnel included in
radiological procedures [23].
This study used TLD [24] as the most suitable
method for direct measuring of doses absorbed on
the surface of the thyroid and the gonads during
mammographic screening.

Materials and Methods

Data collection

Experimental measuring of dispersed radiation

during routine mammographic diagnostic exami-
nations was conducted at the Department of Tho-
racic Diagnostics and Breast of the Radiology Cli-
nic (Clinical Centre of the University of Sarajevo).
A mammography machine used for diagno- Figure 1. Positions of a TLD detector during di-
stic examinations was Siemens Mammomat 1000 agnostic examinations

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HealthMED - Volume 5 / Number 6 / 2011
The following data were recorded during mea-
suring of dispersed radiation at diagnostic exami-
nations:
(1) Patient’s age, mass and size
(2) Applied clinical spectrum
(3) Compressed breast thickness (CBT)
(4) Exposition factors and charge (mAs),
anode voltage (kVp), clinical spectrum
(target/filter) for each screen.
(5) Size of film used
(6) Distance from the surface of the upper
compression plate to the thyroid in each
individual projection
(7) Distance from the surface of the film holder
plate to the gonads in each individual
projection
Quality control
Anode voltage value, reproducibility of doses
and filter half value (HVL) were measured wit-
hout returnable radiation during the period of data
collection. The compression plate was checked for
different settings of kVp and a target/filter combi-
nation following recommendations of the European
Protocol (25), which recommends measuring met-
hodology and frequency. Accuracy of reading of
compressed breast thickness was checked according
to recommendations of the mentioned Protocol. All
of quality control tests and dosimetry in diagnostic
radiology were done with a Barracuda instrument.
Dosimetry
The safest method to monitor persons professi-
onally exposed to ionizing radiation (in medicine,
industry, science) is personal dosimetry. Personal
dosimetry is closely related to exposure of peo-
ple working with sources of ionizing radiation in
medicine, industry, science etc. TLDs are suitable
for obtaining important information about dose
distribution during radiotherapy or diagnostic use
of radiation.
Dosimeters used in personal dosimetry are Li-
thium-fluoride (LiF), which is a tissue equivalent.
Due to their usage there is not any need for fil-
tration systems. The TLDs are small and enable
1776 Journal of Society for development in new net environment in B&H
measuring of entrance skin doses at any point of a
patient’s skin. They can be used to estimate a dose
for organs located immediately under skin surface
(such as the thyroid, the gonads or the breasts),
which was the basis for their application. We used
TLDs to obtain information about entrance skin
doses on the surface of the thyroid and the gonads
during mammographic diagnostics. ESDs were
then used to define a level of risk caused by dis-
persed radiation on these two radio sensitive or-
gans during mammography.
Statistical analysis
The data were statistically processed in SPSS
17.0 and they were presented as a standard de-
viation and a confidence interval. Pearson´s coe-
fficient was applied for statistical significance of
correlation between the ESDs and total mAs. A
value of p<0.05 was considered as an indicator of
significance.
Results and Discussion
Age, mass, size and compressed breast
thickness
The examined patients were between 34 and 80
years of age. This variation of age was followed by
a symmetric distribution of compressed breast thic-
kness which varied from 25 to 77 mm. A deviation
in definition of compresses breast thickness was
± 1 mm. Mean value of compressed breast thic-
kness was 52,88 mm (SD: 11,08). The examined
patients’ height ranged from 154 to 175 cm, while
mean value was 164,09 cm (SD: 6,21). An average
body mass per a patient was 73, 91 kg (SD: 11,58).
Beam energies and X-ray technique
Voltage applied during the diagnostic exami-
nations of female patients ranged from 29 to 32
kV, depending on compressed breast thickness.
Voltage of 29 kV was applied in 38 (14, 85%) film
exposures and mainly for compressed breast thic-
kness up to 45 mm. The most frequently applied
 HealthMED - Volume 5 / Number 6 / 2011

voltage of 30 kV was applied in 128 (50%) expo- with all other parameters that can be related to a
sures and voltage of 31 kV in 71(27,73%) exposu- potential risk caused by dispersed radiation during
res. Minimum voltage used was 32 kV and it was mammography. Entrance skin doses were defined
applied 19 (7,42%) times for extreme compressed for 68 patients and 256 films were used for their exa-
breast thickness which varied from 70 to77 mm. mination. Mean entrance skin dose on skin surface
There were 256 diagnostic images made (130 around the thyroid was 211,16 µGy (SD : 107,19)
MLO and 126 CC images) for an examination of and 14,90 µGy (SD : 7,18) on skin surface around
68 patients during a routine mammography. Four the gonads. It is visible that there is a significant
images were used for the complete diagnostic exa- difference in the ratio of the ESDs for the thyroid
mination: two for an MLO projection and two for and the gonads, which confirms experimental rese-
a CC projection. A compete examination of both arches [15] claiming that most of dispersed radiati-
breasts was done for 56 patients, which involved on is emitted vertically backwards towards the area
224 (87,5%) images (two MLO and two CC). A of the thyroid. Donald McLean [26] assessed the
control examination of one breast was done for 10 origin of dispersed radiation in mammography in
patients with an application of 20 (7,81%) films his researches and concluded that 85 % of disper-
(one MLO and one CC). Remaining two patients sed radiation originates from the compression plate.
were diagnostically examined with 12 (4,69%) Therefore, it was very interesting to take two posi-
films (4MLO and 2 CC images) due to a breast tions to be assessed in this research: the area of the
size and repetition of some images. thyroid and the area of the gonads.
Mean ESD of 211,16 µGy for the thyroid is
significantly lower in comparison with a resear-
ESDs for the thyroid and the gonads ch conducted by a group of authors [18] due to
less exposure during mammography per a patient.
Table 1. represents regarding mean doses absor- It was initially believed that the significant dif-
bed by the skin around the thyroid and the gonads ference in mean ESD for the thyroid arose as a
Table 1. A summary of statistics regarding a number of images, It, compressed breast thickness, distance
from organs to the compression plate, ESDs for the thyroid and the gonads for the whole sample.
It CTB ESD Third
Number Distance (cm)
Organ (mAs) (mm) per exposure (µGy) quartile
of images
Mean ± SDc Mean ±SDc Mean ± SDc Mean ± SDc Mean ± CId µGy
Total 256 30,8 ±13,90 11,40±4,33* 52,88±11,08 211,16±107,19 211,16±25,47 283,13
Thyroida CCb 126 26,40±10,38 15,44±2,12* 50,20±10,16
MLOa 130 35,10±15,49 7,48 ± 1,15* 55,48±11,34
2 IMAGES 20(10x2) 31,30±13,21 11,8±4,79* 54,60±12,69 120,66± 77,07 120,66±47,77 168,65
4 IMAGES 224(56x4) 30,20±13,93 11,38±4,33* 51,95±10,59 220,54±100,48 220,54±26,31 284,32
6IMAGES 12(2x6) 41,4±10,56 11,04±3,88* 67,42±6,34 401,02± 46,46 401,02±64,38 417,44
Total 256 30,8 ±13,90 41,20±6,17** 52,88±11,08 17,15 ± 12,45 17,15 ± 2,96 22,96
Gonades CCb 126 26,40±10,38 36,97±4,60** 50,20±10,16
MLOa 130 35,10±15,49 45,30±4,50** 55,48±11,34
2 IMAGES 20(10x2) 31,30±13,21 41,10±6,61** 54,60±12,69 14,90 ± 7,18 14,90 ± 4,45 22,98
4 IMAGES 224(56x4) 30,20±13,93 40,93±6,05** 51,95±10,59 17,67 ± 13,37 17,67 ± 3,50 23,78
6IMAGES 12(2x6) 41,4±10,56 46,46±5,60** 67,42±6,34 13,92 ± 2,27 13,92 ± 3,14 14,72
* Distance from the surface of the upper compression plate to the thyroid
** Distance from the surface of the film holder plate to the gonads
a
MLO: Mediolateral oblique view.
b
CC: Craniocaudal view.
c
SD: Standard deviation.
d
CI: Confidence interval for the mean of 95 %.
CBT: Compressed breast thickness.

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HealthMED - Volume 5 / Number 6 / 2011

consequence of the fact that this study applied one Tables 2. and 3. represent mean skin doses in
TLD to register dispersed radiation while the other function of a number of images (films) used for
one [18] applied three TLDs on skin around the the thyroid and the gonads. Mean skin dose per
thyroid, which could cause the mentioned diffe- an image is 0,061 mGy for the thyroid and it is
rence in the entrance doses. An additional analysis 13 times higher than the corresponding dose for
of certain doses per an exposed film defined that the gonads. For the thyroid, distribution of mean
there were not any such differences between these skin doses depending on a number of films used
two studies in examinations that were done with 2 is somewhat uniform for mammographic exami-
to 6 images, which can realistically be applied for nations with two, four, and six images while it is
a complete mammographic examination of brea- totally opposite with the gonads.
sts. The mentioned differences appeared as a con- Table 2. Distribution of an average thyroid skin
sequence of an increased number of exposures per dose as a function of a number of film exposures
a patient, which caused somewhat increased ESDs per examination
for the thyroid in the mentioned situation [18]. No of Thyroid skin dose Dose per
It was not possible to compare mean ESD for Frequency
films mGy ± SD film
the gonads due to a lack of relevant data from oth-
2 10 0,121 ± 0,077 0,060
er authors. We selected the gonads as the second 4 56 0,220 ± 0,010 0,055
critical point exposed to dispersed radiation during 6 2 0,401 ± 0,046 0,067
mammography due to their symmetric position in Total 68 0,061±0,006
regard to the thyroid. This approach enables us
to confirm results [15, 26] showing that most of Distribution of mean skin doses per a film is
dispersed radiation is emitted vertically upwards such that a dose decreases with application of
from the compression plate towards the thyroid. greater number of images so that the highest skin
Mean distance between the compression plate dose per a film is for mammographic procedures
and the TLD on the thyroid was 15,44 cm (SD : with two images and the lowest for procedures
2,12) for CC projection and 7,48 cm (SD: 1,15) with 6 images. Such result provides an additional
for MLO projection. Mean distance from a detec- confirmation that a contribution of the skin dose
tor on the gonads to the film holder was 45,30 cm for the gonads is small with multiple exposures.
(SD: 4,50) for MLO and 36,97 cm (SD: 4,60) for Table 3. Distribution of an average gonad skin
CC projection. There was a significant correlation dose as a function of a number of film exposures
between entrance skin doses for the thyroid and per examination
the total mAs, which was shown with a regression
line (r = 0,801 ; p<0,01) in Figure 2. No of Gonads skin dose
Frequency Dose per film
films mGy ± SD
2 10 0,0149±0,0072 0,0074
4 56 0,0177±0,0134 0,0044
6 2 0,0139±0,0023 0,0023
Total 68 0,0047±0,0026

The research registered the ESD in a range

Figure 2. A correlation between the ESD and the
total mAs for the thyroid.
from 0,10 to 0,510 mGy on the skin around the
thyroid and from 5 to 70 µGy on the skin around
the gonads. The highest registered individual ESD
was 503,91 µGy for the thyroid and 67,17 µGy
for the gonads.
Entrance skin doses (ESDs) for the gonads
are very small in comparison to the entrance skin
doses for the thyroid. The results obtained do not
exceed the maximum value of 67,17 µGy and vary

1778 Journal of Society for development in new net environment in B&H


from 0,01 mGy to 0,05 mGy and they are up to
13 times less than those of the thyroid. This result
enables us to claim with certainty that there is not
any need to wear protectors on the gonads during
mammography.
Figure 3. A histogram of skin doses absorbed by
the thyroid (a) and the gonads (b).
In more than 40% of measuring entrance skin
doses on the thyroid (Figure 3.) ranged from 0,3
to 0,4 mGy, which complies with the previously
documented results [18]. Skin doses over 0,4 mGy
were very rare and they were registered only in si-
tuations with 6 images used for a mammographic
examination or with extremely huge thickness of
a compressed breast.
Bearing in mind anatomic characteristics of the
thyroid described in literature [27], it is clear that
one can make an estimation of a dose received by
the thyroid during a mammography on this basis.
An underlined problem is non-regular size and po-
sition of the thyroid [28]. A typical length of both
parts of the thyroid is about 5 – 6 cm, width is 1,5
– 2 cm and thickness 2 – 3 cm [28,29]. Individu-
al variations among patients do exist [28, 29, 30,
31]. Thickness of frontal surface part of the area
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
around the thyroid varies from 1 to 3 cm so that
an estimation of a dose received by the thyroid be-
ing 10 % of the entrance skin dose is acceptable
[18]. Applying the mentioned estimation in the
paper proved that a dose received by the thyroid
during mammography is 0,05 mGy or approxima-
tely about 1,6 % of the mean glandular dose for
a complete mammographic examination with the
same apparatus [13]. According to the same esti-
mation, mean dose received by the thyroid during
mammography is 0,021 mGy or 0,7 % of the mean
glandular dose for a complete mammographic
examination [13]. A dose received by the thyroid
during pediatric tomography ranges from 0,10 to
0,29 mGy [32] and 0,53 mGy, but is decreased to
0,23 mGy with usage of a protective collar [32].
A similar measuring done in radiography gave re-
sults ranging from 0,34 to 0,73 mGy [21] with a si-
milar reduction of entrance skin doses with usage
of the thyroid collar. Results of these researches
indicate that measuring dispersed radiation around
the thyroid one establishes a new quality in anal-
yses of effects which mammography, as a diagno-
stic radiology discipline, has on patients. Entrance
skin doses ranging from 0,1 to 0,5 mGy are not
negligible but they are not ultimately dangerous
for patients. Dispersed radiation mostly originates
from the compression plate and the breast.
Conclusion
The results prove that in most cases entrance
skin dose for the thyroid ranges from 0,2 to 0,5
mGy. Bearing in mind anatomic characteristics of
the thyroid and its position and size, estimation
that the thyroid receives 10 % of the entrance skin
dose is acceptable. It is approximately represented
that the highest dose received by the thyroid du-
ring mammography is 0,05 mGy or about 1,6 % of
mean glandular dose for a complete mammograp-
hic examination. ESD for the gonads is very low
in comparison with the entrance skin dose for the
thyroid. The results obtained in this paper do not
exceed the maximum value of 70 µGy while they
usually range from 5 to 70 µGy and are up to 13
times less than those for the thyroid. During mam-
mography, most of dispersed radiation goes back
to the thyroid and only a small part goes down
1779
HealthMED - Volume 5 / Number 6 / 2011
towards the gonads. Skin dose for the gonads rare-
ly, and almost never, exceeds 0,1 mGy. However,
it can be noticed that the entrance skin dose for
the thyroid varies according to compressed breast
thickness for a complete examination.
Acknowledgments
This study was supported by the Clinical Cen-
tre of the University of Sarajevo, Radiology Clinic
and Department of Thoracic Diagnostics and Bre-
ast in Sarajevo.
List of Abbreviations
ESD - entrance skin dose
TLD - thermoluminescent dosimeter
MLO - mediolateral projection
CC - craniocaudal projection
CBT - compressed breast thickness
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HealthMED - Volume 5 / Number 6 / 2011

Qualitative methods of identification

of acetylsalicylic acid by differential
scanning calorimetry and melting
point method
Ekrem Pehlic1, Aida Sapcanin2, Mirza Nuhanovic3, Bozo Banjanin4, Husein Nanic1, Safeta Redzic1, Amir Muric6,
Cazim Salimovic5, Melita Poljakovic4, Majda Srabovic4
1
University of Bihac, Biotechnical faculty, Bosnia and Herzegovina,
2
University of Sarajevu, Faculty of Pharmacy, Bosnia and Herzegovina,
3
Bosnalijek d.d. Sarajevo, Laboratory for synthesis, Bosnia and Herzegovina,
4
University of Tuzla, Faculty of Natural Sciences and Mathematics, Bosnia and Herzegovina,
5
University of Travnik, Faculty of Health, Bosnia and Herzegovina,
6
Cantonal Hospital Bihac, Bosnia and Herzegovina.

Abstract
Aim: purity determination of synthesized
acetylsalicylic acid by differential scanning calo-
rimetry and melting point method, changing para-
meters of synthesis.
Material and methods: For laboratory synt-
hesis and acetylsalicylic acid precrystallisation are
used: salicylic acid, acetic acid anhydride, benze-
ne, petroleum ether, ethanol 96%. Identification
of synthesized aspirin is performed by instrumen-
tal methods: determination of melting point by ca-
pillary method and differential scanning calorime-
try (DSC).
Results: Melting point of standard acetylsali-
cylic acid analysed on Büchi melting point appa-
ratus is 133.90C, and melting point of acetylsali-
cylic acid precrystallised in ethanol is in range of
0.5-10C, what leads to conclusion that acetylsali-
cylic acid precrystallised in ethanol is pure com-
pound and ethanol is suitable solvent for purifica-
tion of raw aspirin. Melting point by DSC method
is 138.40 0C and melting point of acetylsalicylic
acid precrystallised in ethanol is 139.01 0C. Mel-
ting point is in range of 0.5-10C what leads to con-
clusion that acetylsalicylic acid precrystallised in
ethanol is pure compound and that ethanol is suita-
ble solvent for precrystallisation of acetylsalicylic
acid. Accuracy of performed analysis is 99.77%.
Discussion: Acetylsalicylic acid or aspirin is
compound which could be synthesized in less re-
ferent laboratories. Considering huge importance
of aspirin in medicine and beyond, this synthe-
sis is made for finding out differences in purity
of synthesized aspirin in laboratory in relation to
synthesis in pharmaceutical industry. Also, in this
work there are comparison of raw aspirin proper-
ties and aspirin precrystallised in one and later in
another solvent. After that, studied are conditions
of crystallisation and precrystallisation, and choi-
ce is made for best suitable solvent. Synthesized
acetylsalicylic acid is identified by determining of
melting point by capillary method and identificati-
on of synthesized acetylsalicylic acid by differen-
tial scanning calorimetry (DSC).
Conclusion: Obtained melting point of stan-
dard acetylsalicylic acid on Büchi melting po-
int apparatus is 133.9 0C, and melting point of
acetylsalicylic acid precrystallised in ethanol
is 134.4 0C. Melting point by DSC method is
138.40 0C, and melting point of acetylsalicylic
acid precrystallised in ethanol is 139.01 0C . Mel-
ting point is in range of 0.5-1 0C what leads to
conclusion that acetylsalicylic acid precrystalli-
sed in ethanol is pure compound and that ethanol
is suitable solvent for precrystallisation of acetyl-
salicylic acid.

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Key words: salicylic acid, acetic acid anhydri-
de, differential scanning calorimetry (DSC), mel-
ting point.
Introduction
Aspirin is one of the most versatile drugs
known in medicine and one of the oldest known
drugs. Aspirin is one of the first drugs from group
of nonsteroidal antiinflammatory drugs, of which
are not all the salycilates, but many of them have
similar effects inhibiting cyclooxygenase syn-
thesis what is their basic mechanism of activity.
Synthesis of aspirin is classified as esterification
reaction. Aim of this research is determination of
purity of synthesized aspirin by determining of
melting point by capillary method depending of
starting components. Purity of aspirin is measu-
red depending of solvent used in precrystallisation
of synthesized aspirin. Melting point determined
by DSC method is 138.40 °C, and melting point
acetylsalicylic acid precrystallised in ethanol is
139.01 °C. Melting point is in range of 0,5-1 °C
what is clear evidence that acetylsalicylic acid pre-
crystallised in ethanol is pure compound and etha-
nol is suitable solvent for acetylsalicylic acid pre-
crystallisation. As most suitable method for deter-
mination of melting point of acetylsalicylic acid is
capillary method because the crisp transition from
solid to liquid. Obtained melting point of standard
acetylsalicylic acid by capillary method on Büchi
melting point apparatus is 133.9 °C and melting
point in ethanol precrystallised acetylsalicylic acid
is 133.4 °C. Melting point is in range of 0.5-1 °C
what is proof that acetylsalicylic acid precrystalli-
sed in ethanol is very pure compound and ethanol
is suitable solvent for purification of raw aspirin.
As most suitable solvent used for acetylsalicylic
acid precrystallisation which is identified by these
two mentioned identification methods is ethanol.
Aim
To see what is difference in purity of synthesi-
zed aspirin by changing parameters in synthesis
i.e. ratio of salicylic acid and acetic acid anhydri-
de. Also, scope of work is to compare properties
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
of raw aspirin and aspirin precrystallised in one,
and later in another solvent. Thus, research the
conditions of crystallisation and precrystallisation
and make a choice of most suitable solvent.
Material and methods
For laboratory synthesis and precrystallisation
of acetylsalicylic acid following are used: salicylic
acid, acetic acid anhydride, benzene, petroleum
ether, ethanol 96%. Identification of synthesized
aspirin is performed by instrumental methods:
determination of melting point by capillary met-
hod and differential scanning calorimetry (DSC).
In 50ml round flask salicylic acid and acetic acid
anhydride are added. To the mixture concentrated
H2SO4 is added and heated for 15 minutes in wa-
ter bed on 50-60°C under return cooler. After co-
oling, mixture is poured in cold water and left for
crystallisation. Crystals are filtered through Büch-
ner funnel and rinsed with water. Obtained aspirin
is precrystallised from hot ethanol. By adding cold
water, white crystals are separated. Purity of given
aspirin is checked by adding ferrichloride soluti-
on in few milligrams in ethanol dissolved aspirin.
Same reaction with salicylic acid gives intensive
violet colour which must be absent in experiment
with pure aspirin. Determination of melting point
by capillary method: Melting point, determined
by method of fused capillary in that temperature
on which is last particle of compact solid layer in
fused capillary is converted in liquid.
Procedure: In fused capillary is added fine
powdered compound for obtaining compact layer
4-6 mm thin. Capillary is mounted in Büchi mel-
ting point apparatus model B-454 for measuring
of melting point. On apparatus a speed of heating
sets on 2 0C/min in temperature range of 40 0C to
145 0C. When melting is finished, apparatus noti-
ced melting points. Determination of melting po-
int – Differential scanning calorimetry (DSC): Di-
fferential scanning calorimetry (DSC) as qualitati-
ve thermal technique is often used for researching
polymorphic properties of pharmaceutically active
compounds. By DSC curves could be determined
melting point and heat of melting of given sample
in the same time. Height of peak on DSC curve
determines heat of melting when pure samples
1783
HealthMED - Volume 5 / Number 6 / 2011

usually give sharp peak and presence of impurities

gives wide peak with unclear beginning and blunt
maximum. DSC analysis of synthesized acetyl-
salicylic acid is performed on calorimeter model
PERKIN ELMER DSC PYRIS DIAMOND, un-
der heating speed of 40°C/min with sample of 3-5
mg. Scanning is performed by heating of sample
one minute on 50°C and then in temperature range
of 50°C-220°C. By introducing dry nitrogen it is
secured inert sphere during scan. By DSC analysis
a potential changes of polymorphic condition syn- Picture 1. Thermogram of working standard ace-
thesized samples are observed. Comparison of gi- tylsalicylic acid precrystallised in ethanol
ven results with thermogram USP grade standard
is performed.

Results

Determination of purity of aspirin by differen-

tial scanning calorimetry method.
Number of analysis: 0515/09, SAP4977
Content 100.6% (calculated on dry substan-
ce) Determination of melting point by DSC Pu-
rity method calculated on molecular mass 180.2 Picture 2.g Thermogram (melting point) acetyl-
(according to BP). salicylic acid precrystallised in ethanol gkljahdg

Table 1. Melting point differential scanning calorimetry for working standard

mass (mg) Tm (°C) purity (%) X- corrections ΔH (kJ/mol)
Series 1 2.01 138.28 99.80 2.13 26.85
Series 2 2.04 138.52 99.73 2.90 26.37
138.40 99.77 2.52 26.61
Melting point = 138.40 °C, Purity = 99.77 %

Table 2. Melting point differential scanning calorimetry for aspirin precrystallised in ethanol
mass (mg) Tm (°C) purity (%) X-corrections ΔH (kJ/mol)
Series 1 2.06 138.93 99.80 2.25 27.04
Series 2 2.70 139.08 99.78 2.95 25.02
139.01 99.79 2.60 26.03
Melting point = 139.01 °C, Purity = 99.79 %

able 3. Melting point differential scanning calorimetry for aspirin precrystallised in petroleum ether
mass (mg) Tm (°C) purity (%) X-corrections ΔH (kJ/mol)
Series 1 2.07 125.09 99.44 6.11 19.17
Series 2 2.00 124.98 99.55 3.82 21.67
125.04 99.50 4.97 20.42
Melting point = 125.04 °C, Purity = 99.50 %
Petroleum ether sample
Run 1 – without thermal signal

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 HealthMED - Volume 5 / Number 6 / 2011

Aspirin sample precrystallised in petroleum ether Sample 1. Acetylsalicylic acid precrystallised

Laboratory synthesis in petroleum ether
Sample 2. Acetylsalicylic acid precrystallised
in ethanol
Sample 3. Acetylsalicylic acid, working stan-
dard

Melting point of standard acetylsalicylic acid

Picture 3. Thermogram (melting point) acetylsa-
licylic acid precrystallised in petroleum ether
Melting point = 83.27 °C
Purity = 98.34 %
analysed by Büchi melting point apparatus is
133.9°C, and melting point acetylsalicylic acid pre-
crystallised in ethanol is 134.4 °C. Acetylsalicylic
acid precrystallised in petroleum ether doesn't mel-
ted on given temperature 130 – 145 °C. By repeated
heating on temperature of 155 – 165 °C acetylsali-
cylic acid is melted on temperature 158.2 °C.

Melting point obtained by DSC method is Discussion

138.40 °C, and melting point acetylsalicylic acid
precrystallised in ethanol is 139.01 °C. Melting Important condition for drug production is
point is in the range of 0.5 – 1 °C what means that requirement for suitable raw material which sa-
acetylsalicylic acid precrystallised in ethanol is tisfy all factors for production given pharmaceu-
pure compound and ethanol is suitable solvent for tical form of drug. In production of some drug, it
acetylsalicylic acid precrystallisation. Accuracy of is important to have wanted compound which has
performed analysis is 99.77%. high purity. To determine content, it is required to
know physical and chemical properties of compo-
und and have good method for experimental work,
Determination of melting point by melting i.e. qualitative and quantitative analysis of compo-
point und (drug). Acetylsalicylic acid or aspirin is com-
pound which could be synthesized in less referent
BÜCHI – apparatus for determination of mel- laboratories. Considering importance of aspirin in
ting point by capillary method medicine and beyond, this synthesis is made to see
Name: Acetylsalicylic acid what is difference in purity of synthesized aspirin
Starting point of heating: 130 °C in laboratory in relation to synthesis in pharmace-
Gradient: 1.0 °C/min. utical industry. Also, in this work properties of raw
Maximum point of heating: 145 °C aspirin are compared, and aspirin precrystallised
in one and later in another solvent. Synthesized
Sample 1. Acetylsalicylic acid precrystallised acetylsalicylic acid is identified by determining
in petroleum ether of its melting point by capillary method and also
Sample 2. Acetylsalicylic acid precrystallised as identification of synthesized acetylsalicylic
in ethanol acid by differential scanning calorimetry (DSC)
Sample 3. Acetylsalicylic acid, working stan- method. Melting point of standard acetylsalicylic
dard acid analysed with Büchi melting point apparatus
Auto: 134.8 133.9 is 133.9 0C and melting point of acetylsalicylic
acid precrystallised in ethanol is 134.4 0C. Mel-
Thermodynamical addition: 1.0 °C ting point is within range of 0.5-1 0C what con-
Starting point: 40 % firms that acetylsalicylic acid precrystallised in
Median value: 134.4 °C ethanol is very pure compound and that ethanol
Median deviation: 0.64 °C is suitable solvent for purification of raw aspirin.

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HealthMED - Volume 5 / Number 6 / 2011
Acetylsalicylic acid precrystallised in petroleum
ether doesn't melted on wanted temperature of
130-1450C. By repeated heating on temperature of
155-165 0C acetylsalicylic acid melted on tempe-
rature of 158.2 0C, what leads to conclusion that
acetylsalicylic acid precrystallised in petroleum
ether is not enough melted and petroleum ether
isn't suitable solvent for precrystallisation.
Conclusions
By performed analyses it could be seen that
synthesis of aspirin, as one of the most simple
analysis, requires adequate conditions for work,
equipped laboratory and qualified staff for per-
forming of synthesis. In this research, different
conditions of synthesis are used, suitable solvents
for precrystallisation and mentioned method for
identification synthesized aspirin, what gives fo-
llowing conclusions: Most suitable solvent for pu-
rification of raw aspirin is ethanol, but petroleum
ether is not, because after precrystallisation in pe-
troleum ether some impurities remained. Optimal
ratio salicylic acid and acetic acid anhydride for
highest yield of aspirin is 10 g of salicylic acid
and 25 ml of acetic acid anhydride i.e. ration 1:2.5
for anhydride. Melting point determined by DSC
method is 138.4°C and melting point of acetylsali-
cylic acid precrystallised in ethanol is 139.01 °C.
Melting point is in the range of 0.5-1 °C what gi-
ves proof that acetylsalicylic acid precrystallised
in ethanol is pure compound and that ethanol is
suitable solvent for precrystallisation of acetylsa-
licylic acid. Accuracy of analysis is 99.77%. As
most suitable method for determination of mel-
ting point of acetylsalicylic acid is capillary met-
hod (by melting point), because a sharp transition
from solid to liquid is observed. Acetylsalicylic
acid precrystallised in petroleum ether isn't melted
on given temperature of 130-145°C. By repeated
heating on temperature of 155-165°C, melted on
temperature of 158.2°C, what leads to conclusion
that acetylsalicylic acid precrystallised in petrole-
um ether isn't melted enough, so petroleum ether is
not suitable solvent for precrystallisation. Acetyl-
salicylic acid precrystallised in petroleum ether by
DSC method has melting point of 83.27°C, and
it is observed that acetylsalicylic acid precrystalli-
1786
sed in petroleum ether retains impurities after pre-
crystallisation i.e. this solvent is not suitable for
identification. Determined melting point of stan-
dard acetylsalicylic acid by capillary method on
Büchi melting point apparatus is 133.9°C and mel-
ting point of acetylsalicylic acid precrystallised in
ethanol is 133.4°C. Melting point is in the range of
0.5-1 °C, what gives proof that acetylsalicylic acid
precrystallised in ethanol is very pure compound,
and ethanol is suitable solvent for purification of
raw aspirin.
References
1. A. Nikolin, B. Nikolin (1984) Nukleofilne supstituc-
ije na nezasićenom ugljikovom atomu, Praktikum
organske hemije, Svijetlost oour zavod za udžbenike
i nastavna sredstva Sarajevo: 69-75.
2. H. Stanley, Pine (1994) Nukleofilne adicije i sup-
stitucije u sintezi, Organska hemija, Školska knjiga
Zagreb: 445-449.
3. S. Borčić, O. Kronja (1991) Nukleofilna supstituc-
ija i nukleofilna eliminacija na zasićenom ugljiku,
Praktikum preparativne organske kemije, Školska
knjiga Zagreb: 114-115.
4. Balić S, (2008) Kristalizacija i prekristalizacija,
Sinteza 5-H-dibenzen (b, f) azepin-5-karboksamid-
a (karbamazepinum-a) i kvalitativne metode identi-
fikacije, diplomski rad, PMF Sarajevo: 6-9.
5. Ž. Čeković, (1982) Aromatične supstitucione reak-
cije, Principi Organske sinteze, Naučna knjiga Be-
ograd: 252-270.
6. Lampl C, Voelker M, Diener HC, (2007) ″Efficacy
and safety of 1,000 mg effervescent aspirin: indi-
vidual patient data meta-analysis of three trials in
migraine headache and migraine accompanying
symptoms″. J Neutol 254 (6): 705-712.
7. Diener HC, Bussone G, de Liano H et al (2004).
″The fixed combination of acetylsalicylic acid,
paracetamol and caffeine is more effective than
single substances and dual combination for treat-
ment of headache: a multicentre, randomized,
double-blind, single-dose, placebo-controlled
parallel group study″. Cephalalgia 25 (10): 776-
787.
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8. Diener HC, Pfaffenrath V, Pageler L et al (2004).
″Efficacy and safety of 1,000 mg effervesent as-
pirin: individual patient data meta-analysis of
three trials in migraine headache and migraine
accompanying symptoms″. Cephalalgia 24 (11):
947-54.
18. Pehlic E, ar all. Synthesis control of
2-(4-benzoylphenyl)-2-methyl propanoic acid by
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9. Goldstein J, Silberstein SD, Saper JR et al Corresponding author

(2006).″Acetaminophen, aspirin and caffeine in Ekrem Pehlic,
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omized, parallel-group, single-dose, placebo-con- Bosnia and Herzegovina,
trolled study″. Headache 46 (3):444-53. E-mail: pehlic_ch@yahoo.com
10. Krumholz, HM; Radford MJ, Ellerbeck EF, Hen-
ner J, Meehan TP, Petrillo M, Wang Y, Kresowik
TF, Jencks SF (1995). ″Aspirin in the treatment of
acute myocardial infarction in elderly Medicare
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11. Steiner, TJ; Lange, R; Voelker, M (2003). ″Aspirin

in episodic tension-type headache: placebo-con-
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12. Gaciong (2003). ″The real dimension of analgesic

activity of aspirin″. Thrombosis research 110 (5-
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13. Jerković I, Radonić A. (2009) Izolacija i čišćenje

organskih spojeva, Praktikum iz organske hem-
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Splitu:19-25.

14. Donald J. Cram, George S. Hammond (1973) Or-

ganska kemija, Organske sinteze, Školska knjiga
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15. Z. Kniewald i suradnici, (2000) Priručnik za

pripravu i izolaciju bioloških djelatnih supstan-
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16. C. Ghiron and R. J. Thomas (1997) Exercises in

Synthetic Organic Chemistry, Oxford University
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17. Pehlic E, ar all. Identification of synthesized

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tate-cyclohexane and benzene-cyclohexene.Heal-
thMED 2010; 4: 867 – 878.

Journal of Society for development in new net environment in B&H 1787

HealthMED - Volume 5 / Number 6 / 2011

Incidence of urinary tract infections of

male paraplegics population compared
to the way of bladder treatment
Selimovic M1, Hiros M1, Spahovic H1, Sadovic S.1, Mehmedbasic S2, Cavaljuga S.3
1
Clinical Center University Sarajevo, Urology Clinic, Sarajevo, Bosnia and Herzegovina,
2
Institute for Reproductive haelth”Mehmedbašić” Sarajevo, Bosnia and Herzegovina,
3
Institute for Epidemiology, Medical School University of Sarajevo, Bosnia and Herzegovina.

Abstract Objectives

Background and Purpose: The present study
was carried out to determine incidence of urinary
tract infection in relationship with different ways
of urinary bladder drainage in the study popula-
tion of male paraplegics.
Material and methods: The cross sectional
study design is used with a view of conducting a sur-
vey of the frequency of occurrence and distribution
of urinary infections in the male paraplegics popula-
tion (1992-1996), relative to the method for bladder
treatment. The study included 60 paraplegics regis-
tered at the Centers for Paraplegia in the BiH Fed-
eration. They are assigned to one of the following
four groups: paraplegics using indwelling catheter,
paraplegics using intermittent catheter, paraplegics
using urinary condoms and paraplegics using both,
intermittent catheter and condom catheters.
Results: Patients on continuous intermittent
catheterization had significantly lower incidence
of urinary tract infections compared to other test-
ed groups (p<0.05). Mixed bacterial complicated
urinary tract infections were verified only in the
group who are on a continuous intermittent cath-
eterization. The most frequently isolated bacteria
were: E Coli 57.97%, Proteus mirabbillis 20.29%,
Streptococcus faecalis 8.7%, Morganella morga-
nii 7.25%, Seratia marcescens 4.5%, Klebsiella
pneumoniae 1.45%.
Conclusion: Urinary tract infection is the most
frequent and the most severe type of complication
facing this segment of population.
Key words: paraplegics, urinary tract infec-
tions, urinary tract catheterization.
Paraplegia of young people is medical and
social problem for society. Today the Federation
of Bosnia and Herzegovina 350 paraplegics liv-
ing under 35 years of age. Urinary tract infection
is responsible for major morbidity in paraplegic
patients.(1,2,3,4,5,6) Despite improved methods
of treatment, urinary tract morbidity still ranks
as the second leading cause of death in paraple-
gic patients. (7) Spinal cord injury and paraplegia
produces profound alterations in the lower urinary
tract function. Incontinence, elevated intravesical
pressure, reflux, stones, and neurological obstruc-
tion, commonly found in the spinal cord-injured
population, increase the risk of urianry tract in-
fections.(8,9,10) Incomplete voiding and catheter
use contribute to an increased risk of symptom-
atic urianry tract infection. The present study was
carried out to determine incidence of urinary tract
infection in relationship with different ways of
catheterisation treating of the urinary bladder in
the study population of male paraplegics. We had
made laboratory urin anlysis and urine culture in
all assigned paraplegic patients who were includ-
ed in this study.
Materials and methods
The cross sectional study design is used with a
view of conducting a survey of the frequency of
occurrence and distribution of urinary infections
in the male paraplegics population (1992-1996),
relative to the method for bladder treatment. The

1788 Journal of Society for development in new net environment in B&H

 HealthMED - Volume 5 / Number 6 / 2011

study included 60 paraplegics registered at the

Centers for Paraplegia in the BiH Federation.
They are assigned to one of the following four
groups:
1. group: paraplegics using indwelling catheter
(IC),
2. group: paraplegics using intermittent
catheter (CIC),
Table 3. Number of causes urinary tract infecti-
3. group: paraplegics using urinary condoms
ons of the examined groups
4. group: paraplegics using both, intermittent
catheter and condom catheters (Comb.). Infection CIC Comb. IC Condom Total Percent
No infection 7 1 0 0 8 13,33%
All patients were divided according to the level 1 agent (cause) 8 2 6 1 17 28,33%
of spinal corde lesions on those with upper lesions 2 more agents
0 12 9 14 35 58,33%
and those with lower lesions as well as the com- (causes)
plete and incomplete spinal cord lesion. 60 100,00%
According to the method of treatment of blad-
der patients were divided into 4 groups. Labora-
tory urin anlysis and urine culture were done in all
group of paraplegics patients.

Results

General demographic characteristics of studied

groups (Table 1.). Table 4. Causes of urinary tract infections of exa-
Table 1 Age structure of respondents mined groups
Age Number of respondents Percent (%) Cause of
CIC Comb. IC Condom Total Percent
infection
20-29 2 3,33%
30-39 21 35,00% E.Coli 5 13 10 12 40 57,97%
40-49 34 56,67% Proteus
2 2 2 8 14 20,29%
50-.. 3 5,00% mirabilis
Total 60 100,00% Streptococcus
1 2 1 2 6 8,70%
x = 41.26667; median = 42;R (xmax-xmin) = 21; Min: 29 faecalis
years old, Max: 50 years old; Klebsiella
1 0 0 0 1 1,45%
pneumoniae
Urinary infections of studied patients groups Seratia
0 1 1 1 3 4,35%
according to the method of bladder treatment (Ta- marcescens
ble 2.). Morganella
0 1 1 3 5 7,25%
Structure study of paraplegics and the comple- morganii
teness level of the lesion in relation to the way of 9 19 15 26 69 100,00%
bladder treatment, damage of the spinal cord exa-
mined by a group of paraplegics.
Table 2. Prevalence of urinary tract infections
examined groups
CIC Comb. IC Condom Total
No infection 7 1 0 0 8
Infection 8 14 15 15 52

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HealthMED - Volume 5 / Number 6 / 2011
Table 5. The most complete and incomplete lesi-
ons are at the condoms group
Lesions CIC Comb. IC Condom Total Percent
Incomplete 2 2 4 1 9 15,00%
Complete 13 13 11 14 51 85,00%
Table 6. The number of upper and lower lesions
in the sum is equal
Lesions CIC Comb. IC Condom Total Percent
Lower 4 9 3 14 30 50,00%
Upper 11 6 12 1 30 50,00%
Damage of the spinal cord at examined group
of paraplegics according to the height of the lesion
(Table 6): The number of upper and lower lesions
in the sum is equal, but looking at the type of bla-
dder treatment, we can see that the greatest num-
ber of lower lesions are at the condoms group and
most of the upper lesions are at indwelling cath-
eter group (IC).
Discussion
Major morbidity in paraplegic patients is uri-
nary tract infection. It is a second cause of death
in paraplegic patients. Alterations in the lower
urinary tract function caused by lesion of spinal
cord is associated with elevated intravesical pres-
sure, reflux, stones, neurological obstruction and
incontinence, increase risk of urinary infection in
paraplegics patients group. (11,12,13) Residual
urine and use of bladder catheters for drainage as
intermittent or continouse treatment increase risk of
bacterial infection of urinary tract.(14) The pres-
ent study was carried out to determine incidence of
urinary tract infection in relationship with different
ways of urinary bladder drainage in the study popu-
lation of male paraplegics. Studies with long-term
1790
monitoring showed that the percentage of urinary
tract infections in paraplegics are very high, rang-
ing up to nearly 75%. (15) One study in our sample
showed that the percentage of sterile urine in only
6% of paraplegics. (16) (Ramić.I 2004). Urinary
tract infection is presented in our 52 respondents, or
86.6%. The CIC group had 7 patients without infec-
tion, and 1 patient form Comb group or 13.3%. In
the other two groups, the infection is present in all
patients. According to the number of agents of in-
fection we found that the CIC group had more than
one agent. In all other groups, urinary tract infec-
tions were caused by two or more pathogens. Ana-
lyzing the causes of type of chronic urinary tract
infections in our patients we found that the E. Coli
bacteria presents in 57.97% of the respondents,
20.29% Mirabillis Proteus, Streptococcus faecalis
8.7%, Morganella morganii 7.25%, 4.35% Seratia
marcescens and Klebsiella pneumoniae, 1.45%.
Polymicrobe urinary infection is the rule in para-
plegic patients were detected in 44% of positive
urine samples from patients with different methods
of bladder drainage. (17) This fact should evalu-
ated when you examine the results of cultures in
these patients, because laboratory exame tend to
interpretated polymicrobic urin culture as con-
taminated. (17,18) It can be explained by the fact
that in most cases, these patients were contamined
rather than infection. A study conducted at the Insti-
tute for Physiotherapy and Rehabilitation Center-of
paraplegy Clinical Centre of Sarajevo University
(Ramić I. 2004) showed that the majority of pa-
tients 34 (47.88%) had three or more bacteria in
the urine, two bacteria was 18 (25.35%), with one
bacterium were 15 (21.12%) patients. Comparation
of the incidence of infection in examined groups,
we reached the following conclusion: All patients
(100%) in group indwelling catheter (n = 15) and
condoms (n = 15) had a urinary tract infection. For
subjects in the CIC group (n = 15), 8 had urinary
tract infection (53.3%) in group Comb (n = 15), 14
patients had urinary tract infection (93.3%). There
was a significant difference in the incidence of uri-
nary tract infections among the following groups:
CIC and Comb. p = 0.035 (Fisher test), CIC and in-
dwelling catheter where p = 0.006 (Fisher test) and
of CIC and the condom is also p = 0.006 (Fisher
test). Between other combinations of group, we did
not reveal significant differences in the incidence
Journal of Society for development in new net environment in B&H

of urinary infections. According the fact that the
number of paraplegics who were with negative urin
culture in the group indwelling catheter and con-
dom were 0 (zero), it was not possible to calculate
RR or OR, and compare them with others. RR and
OR is calculated only for groups of CIC and Comb.
The likelihood of exposure to infection was higher
in group Comb than in group CIC: OR (95% CI)
= 12.5 (1.56 to 87.60), p = 0.039 (Yates corrected).
RR of exposure to infection in the group of Comb
in relation CIC group were only: RR (95% CI) =
1.75 (1.13 to 2, o6), p = 0.039 (Yates corrected).
Analysis of the (poly and solitare) causes of urinary
tract infections in relation to the way of treating the
urinary bladder, we reached the following conclu-
sions. In the CIC group were not polymicrobic in-
fections. There was a significant difference in the
frequency of the solitary infection to infection be-
tween groups with polymicrobic infection CIC and
Combp = 0.00014, CIC and indwelling catheter p
= 0.00717 and the CIC and Condom p = 0.000018.
(conducted for the Fisher exact test, comparing the
individual in relation to polymicrobic infections in
the group). There was no significant difference in
the frequency of the solitary infection in relation to
polymicrobic infection between groups of Comb
and indwelling catheter, Comb and condoms, and
indwelling catheter and a condom, although in this
last group there is a trend (p = 0.0801). From the
results presented above, it is clear that there is a
difference in the incidence and distribution of uri-
nary tract infections in relation to the way of treat-
ing the urinary bladder. At least exposed group for
urinary tract infection is CIC, followed by Comb,
indwelling catheter and followed a condom group.
In the same order we can showed that the number
of agents also determine whether it is a complicated
urinary infections.(19,20) Patients on continuous
intermittent catheterization had significantly low-
er incidence of urinary tract infections compared
to other tested groups (p<0.05). Mixed bacterial
complicated urinary tract infections were verified
only in the group who are on a continuous intermit-
tent catheterization. The most frequently isolated
bacteria were: E Coli 57.97%, Proteus mirabbillis
20.29%, Streptococcus faecalis 8.7%, Morganella
morganii 7.25%, Seratia marcescens 4.5%, Klebsi-
ella pneumoniae 1.45%.
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
Conclusion
The management of the urinary tract of male
paraplegic patients is continuing to evaluate rela-
tive to the bladder-related treatment. Urinary tract
infection is the most frequent and the most severe
type of complication facing this segment of popu-
lation. A significant amount of such complications
may have an adverse effect on the urinary tract in
terms of reducing their renal function. The routine
urine testing and urine culture are mandatory for
evaluation of urinary infections.
References
1. Salomon J, Gory A, Bernard L, Ruffion A, Denys
P, Chartier-Kastler E. Urinary tract infection and
neurogenic bladder. Prog Urol 2007;17:448-53.
Garcia Leoni ME, Esclarin De Ruz A. Mana-
gement of urinary tract infection in patients
with spinal cord injuries. Clin Microbiol Infect
2003;9:780-5.
2. Trautner BW, Darouiche RO. Prevention of urinary
tract infection in patients with spinal cord injury. J
Spinal Cord Med 2002;25:277-83.
3. Siroky MB. Pathogenesis of bacteriuria and infec-
tion in the spinal cord injured patient. Am J Med
2002; 113:67S-79.
4. Biering-Sorensen F. Urinary tract infection in indivi-
duals with spinal cord lesion. Curr Opin Urol 2002;
12:45-9.
5. Turek PJ, Practical approaches to the diagnosis
and management of male infertility, Nat Clin Pract
Urol., 2005; 2(5): 226-38.
6. Holstein AF, Sauerwein D, Schirren U, Spermato-
genesis in patients with traumatic transverse paral-
ysis, Urologe A, 1985 24(4): 208-15.
7. Biering-Sorensen F. Urinary tract infection in in-
dividuals with spinal cord lesion Curr Opin Urol
2002;12(1): 45-49.
8. Rutkowski SB, Middleton JW, Truman G, Hagen
DL, Ryan JP The influence of bladder management
on fertility in spinal cord injured males. Paraple-
gia. 1995 May;33(5):263-6.
1791
HealthMED - Volume 5 / Number 6 / 2011

9. Vogel LC, Krajci KA, Anderson CJ, Adults with Corresponding autor
pediatric –spinal cord injury: part1: prevalence of Mirsad Selimovic,
medical complications, J Spinal Cord Med, 2002, Clinical Centre University of Sarajevo,
25(2): 106-16. Urology Clinic,
Bosnia and Herzegovina,
10. Ramic I, Urinary infection in patients with the E-mail: mirsad160164@yahoo.com
condition of paraplegia, Med Arh., 2004; 58 (4):
244-5.

11. Mirsadraee S, Madhavi R, Moghadam HV, Ebra-

himi MA, Patel HR, Epididymo-orchitis risk fac-
tors in traumatic spinal cord injured patients, Spi-
nal Cord 2003; 41 (9): 516-20.

12. Ost MC, Lee BR Urolithiasis in patients with spi-

nal cord injuries: risk factors, management, and
outcomes. Curr Opin Urol. 2006;16(2):93-9.

13. Huang HF; Marshall GR; Rosenberg R; Nie-

schlag E Max Planck Clinical Research Unit for
Reproductive Medicine, Münster, FRG. Acta En-
docrinol (Copenh). 1987; 116(4):433-44 (ISSN:
0001-5598).

14. Tanagho EA, Lue TF. Neuropathic bladder disor-

ders In: General urology. Tanagho EA and McA-
ninch JW. Sixteenth edition. Lange Medical Books
2004:435-452.

15. De Groat WC. Anatomy of the central neural pa-

thways controlling the lower urinary tract. Eur
Urol 1998;34(suppl 1):2.

16. Mattelaer JJ, Billiet I. Catheters and sounds: the

history of bladder catheterisation. Paraplegia
1995;33:429-433.

17. Garcia Leoni ME, Esclarin De Ruz A. Mana-

gement of urinary tract infection in patients
with spinal cord injures. Clin Microbiol Infect
2003;9:780-785.

18. Darouiche RO, Smith JA, Hanna H, et al. Effica-

cy of antimicrobial- impregnated bladder cathe-
ters in reducing catheter-associated bacteriuria:
a prospective, randomized, multicenter clinical
trial. Urology 1999;54:976-981.

19. Esclarin De Ruz A, Garcia Leoni ME, Herruzo

Cabrera R. Epidemiology and risk factors for uri-
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injury. J Urol 2000;164:1285-9.

1792 Journal of Society for development in new net environment in B&H

 HealthMED - Volume 5 / Number 6 / 2011

Therapeutic Approach to Large Jaw

Cysts
Naida Hadziabdic1, Halid Sulejmanagic2, Edin Selimovic3, Nedim Sulejmanagic2
1
Department for Oral Surgery ,Faculty for Dental Medicine University of Sarajevo, Bosnia and Herzegovina,
2
Private Dental Practice „Sulejmanagić“, Sarajevo, Bosnia and Herzegovina,
3
Institution for Public Health “Zenica”, Bosnia and Herzegovina.

Abstract days, this basic guideline is still heeded, but the

Introduction: Jaw cysts of various dimensions
are a common pathology encountered in oral sur-
gery. The therapeutic approach to these pathologi-
cal outgrowths depends on their dimensions and
locality. It is a challenging task for any oral sur-
geon to manage a cyst, be it mandibular or maxi-
llary, by applying a primary closing method.
The aim of this paper is to present a case study
involving two patients and our therapeutic appro-
ach to resolving a problem of mandibular and
maxillary cyst, respectively.
The surgical technique we applied in these pa-
tients and the preoperative and postoperative pro-
blems encountered in both cases are also reported
in the present study.
Conclusion: By comparing the orthopantomo-
graphic pictures taken prior to surgical interventi-
on with those taken several months following the
surgical intervention, we could observe a good re-
generation of the bone. Both patients were repor-
ted to be feeling well.
Key words: jaw cysts, therapy, complications
Introduction
Jaw cysts appear to be a common pathology
encountered in oral surgery (1-6). Since they can
develop without revealing any symptoms, cysts
remain undetected. It is one of the reasons they
are detected in their manifest phase, once they
have already reached impressive dimensions
(7,8).
For some time the basic guideline in oral surge-
ry relating to a choice of therapy for jaw cysts has
depended on its size and locality (5,9-14). Nowa-
marsupialisation technique as a therapy method in
treating cysts has increasingly been substituted by
a technique of primary closing.
The aim of the present paper is to give a detai-
led description of two individual cases by descri-
bing a comprehensive surgical procedure as well
as the problems encountered during the interventi-
on and in its aftermath.
First case study big mandibular cyst
A patient with initials B.Lj. was admitted into
the Department of Oral Surgery, complaining of
pain and swelling in the region of lateral teeth in
the lower jaw. After clinical examination we could
observe mandibular swelling in the vestibulum on
the left side of the transcanine area. By palpation
we could feel fluctuation and partly also Dypi-
tren' s phenomenon.
Thanks to orthopanthogram analysis we could
clearly observe an X ray translucence with a 7cm
- diameter and of oval shape, spreading from the
lower right lateral incisor to the lower left first mo-
lar (Fig.1). The described phenomenon had affected
the roots of the teeth between which it was located,
and this was especially prominent in the region 33
and 34, respectively. A radiolucent line divided the
described cyst from the surrounding bone.
On the basis of clinical characteristics and the
described X-ray picture we diagnosed a cyst in the
mandibular bone, being most probably of dento-
genous origin (either radicular or residual cyst).
In the preoperative stage incision was made
in order to do decompression. A great quantity of
thick casein dirty-yellow content was taken out on
that ocassion.

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HealthMED - Volume 5 / Number 6 / 2011
Fig. 1. Orthopanthomogram before operative
procedure in mandibula
During the surgical intervention, the operating
field was anesthesized by applying inferior alveo-
lar nerve block anaesthesia along with additional
V anaesthesia. An incision was made in accordan-
ce with Peter Novak's procedure from the tooth
42 to tooth 37. The flap was raised and the bone
was displayed. By applying corticotomy from the
vestibular side of the mandibula in the region 34,
a two- centimetre trepanation was made.The cyst
sheath was displayed on that ocassion. We tried to
shed it bluntly. At this, the cyst sheath was punctu-
red whereupon a profuse quantity of thick casein
content of dirty-yellowish colour erupted (Fig. 2).
The sheath was enucleated completely by applying
sharp curettes.The tooth 34 was extracted (Fig.3).
After profuse rinsing with the physiological solu-
tion and natrium hypochlorite the mucoperiosteal
flap was mobilized and the wound was primary
closed with interupted sutures.
Fig. 2. Mandibular cyst enucleation
1794
Fig. 3. Bone cavity after cyst enucleation
In the postoperative period penicillin antibiotics
were administered for 10 days. Antiflogistics and
analgetics were also recommended to the patient.
The biggest problem in the postoperative reco-
very was a communication established between
the surgical wound and the oral cavity which en-
sued due to the suture dehiscence. Regardless of
the fact that the flap was initially well mobilized
and sewn up, the pull force of the adjacent muscles
provoked additional tension resulting in loosening
of sutures.The outcome of this communication
was continual accumulation of food scrapings in
the bone cavity. In order to prevent infection, whi-
ch was potentially the most threatening factor to a
successful conclusion of the surgical intervention,
we opted for regular, daily rinsing with NaOCl1*
solution and soft tamponage with iodoform gauze
with the aim of mechanically preventing the entry
of food, and thus, to enable drainage.
When the surrounding mucosa was suffici-
ently recovered, the patient was provided with the
appropriate obturator which was gradually being
shortened to enable the bone regeneration (Fig. 4).
By patohistological analysis of the cyst con-
tent we diagnosed the epidermal cyst with a thin
connective sheath covered on the inner side by
the multi-layered keratinised stratified epithelium
thickening greatly the cyst lumen.
1 *
NaOCl- natrium hypochlorite
Journal of Society for development in new net environment in B&H

Fig. 4. Obturator
The numbing sensation was present in the lower
lip immediately after the intervention. Interestin-
gly enough, the numbing sensation completely di-
sappeared after several months so that the patient
no longer complained of irregular sensations.
By analysing the first orthopanthomogram of
the same patient we diagnosed another cyst in
the mandibular ramus on the left side, so that the
enucleation of the second cyst was carried out six
months later in addition to extraction of the tooth
38. This time, patohistological analysis made it
possible to diagnose a dentigerous cyst (Fig.5).
Under a microscope, it was possible to observe a
cyst wall lined by stratified squamous epithelium
on the inner side, focally thinned down but perme-
ated with inflammed cells, sporadically compre-
ssing a densely inflammed tissue substance.
Fig. 5. Bone cavity after enucleation of follicular
cyst in mandibular ramus
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
In this particular case it was possible to sew the
wound up initially so that the postoperative period
was far more comfortable for the patient.
Second case study – big maxillary cyst
A patient with initials I.K. was admitted into the
oral surgery, also complaining of pain and swelling,
but this time, in the upper jaw on the left side from
the 23-28 region. By clinical examination it was
possible to notice a deformity of maxilla in the indi-
cated region from the vestibular side. By palpation
it was also possible to observe Dypitren's phenome-
non and fluctuation. On the alveolar ridge a fistula
was observed. By applying pressure on the fistula a
dirty yellowish content began to erupt.
Orthopanthomogram showed an translucence
with clearly defined boundaries comprising the
23-28 region of the 8-10 cm diameter. The des-
cribed translucence diverged the roots of teeth
between which it was located (Fig.6).
Fig. 6. Orthopanthomogram before operative
procedure in maxilla
On the basis of clinical characteristics and rend-
genological finding we diagnosed a residual maxi-
llary cyst because of the missing teeth 26 and 27.
After applying local anaesthesia in the surgical
intervention we made incision after Peter Novak's
procedure.The incision encompassed the 23 - 28
region. After raising the mucoperiosteal flap, we
noticed that the cyst had resorpted the bone on the
vestibular side 1 cm big. By a drill we extended
the opening and began shedding the cystic sheath.
In order to make the process of sheath curettage
easier we made another trepanation in the region
of the tooth 23. We left the bone bridge between
the two openings (Fig.7).
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HealthMED - Volume 5 / Number 6 / 2011
Fig. 7. Bone bridge
In the course of the intervention, as could be
observed in the orthopatnomogram, we reached a
conclusion that the cyst had completely covered the
maxillary tuber in the form of a retromolar small ton-
gue. Therefore, we decided to extract the tooth 28.
After curettage the last remaining part of the
cystic sheath, we rinsed the wound and applied
tamponage with the iodoform gauze which was
pulled through the drainage canal in the vestibu-
lum (Fig. 8). The palatal flap was deperiostated
and stitched up. The described cyst did not usurp
the bottom of the maxillary sinus.
Fig. 8. Tamponage with iodoform gauze
1796
By patohistological analysis of the sample a
multi-layered stratified squamous epithelium with
signs of paraketosis was observed on the surface.
Epithelial fingers were partly elongated and stick-
like. Partly beneath the epithelium there was a
proliferation of the granulation tissue with newly-
formed capillary blood veins and inflammatory in-
filtrations of mononuclear cells with polimorpho-
nucleus leukocytes, in other words, signs of hype-
remia and erytrocyte extravasations were found.
The described patohistology picture conforms
to the radicular maxillary cyst.
Discussion
Dentogenous cysts as benign pathological out-
growths pose serious therapeutic dilemmas when
they reach big dimensions. The hitherto doctrine
on therapeutic management of the cystic defects
of mandibula with the diameter exceeding 3 cm,
has implied that after enucleation the deformity
should be closed by applying the open method.
Thus, a part of the deformity would be left to epi-
thelize subsequently. This therapeutic approach is
certainly a prevalent one when we deal with eden-
tulous lower jaw.
The question being posed now is how to ma-
nage a situation when we are faced with a big
mandibular cyst with a preserved set of teeth.Our
first case study related to this particular situati-
on. Thanks to the trepanation on the vestibular
side we managed to enucleate completely the
cyst sheath. Since the entire tooth 34 jutted out
into the cyst cavity, we opted for its extraction.
However, suture dehiscence and, consequently,
the communication established between the oral
cavity and the bone cavity exacerbated the posto-
perative period.
In other words, the established communication
had enabled the accumulation of food scrapings
which posed a potential threat of the ensuing in-
fection. Therefore, it was necessary to consider
the possibility of delaying the extraction of the to-
oth 34 since this might have prevented the loose-
ning of sutures and thus relieve the postoperative
course.
Nevertheless, infection was prevented by regu-
lar, profuse rinsing with NaOCl solution and soft
Journal of Society for development in new net environment in B&H

tamponage with hyperconcentrated iodoform gau-
ze. A month after the intervention when the adja-
cent mucosa had recovered sufficiently, the obtu-
ration prosthesis was made.This, in turn, signifi-
cantly improved the quality of the patient's life
and inasmuch as it played the role of a mechanical
barrier, it was successful in preventing any further
food accumulation or the ensuing infection.
During regular check-ups every 7-10 days the
obturation prosthesis was gradually shortened in
order to enable a complete bone regeneration.
Nowadays, a year after the cystectomy, the
mandibular defect has completely been filled up
with the newly-formed bone tissue which is easily
observed in the rendgenological picture.(Fig.9)
Fig. 9. Orthopanthomogram one year after ope-
ration
The authors Džambas and Džolev also dealt
with the therapeutic treatment of mandibular cysts
(2003). In their case study report they described
the surgical procedure of enucleation of the cyst
which had reached 7x4 cm dimensions. The in-
tervention was performed under general anestesia
while the cyst defect was resolved by applying the
open method.
In the above indicated case, after the epithe-
lialisation of the bone defect surface, they also
resorted to placing a partial mandibular postre-
section prosthesis with the obturation part which
was gradually being shortened to enable a bone
regeneration (15).
In their paper the above mentioned authors
have stressed the importance of team work of the
maxillofacial surgeon and prosthetician in treating
big cysts in the lower jaw (15).
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
Hence, the real problem being posed is a pre-
sence of the big bone cavity after the enucleation
of cysts which have reached bigger dimensions.
Boimatov et al. (1992) also dealt with a pro-
blem of reducing bone cavities after cystectomy.
In their work they described the application of the
biogene composite material based on hydroxil
apatite used for filling up the bone defects fo-
llowing the cystectomy procedure. Thanks to the
reparation osteogenesis stimulated by application
of this composite material, they succeeded in achi-
eving the bone reparation after 6-10 months (16).
A year earlier (1991) the authors Moniaci and
Nelken set a task of achieving a faster bone re-
generation after cystectomy by systemic and local
application of salcatonin (17).
Recently, decompressive methods in the trea-
tment of mandibualr cysts have become increasin-
gly popular (Tarello. Aimetti, Fasciolo, 1997). In
this manner, a combination of the jaw closing met-
hod and decompression reduces the bone cavity
and speeds up regeneration (18).
Our second case study relating to a big maxi-
llary cyst was interesting inasmuch as the cyst's
distal outgrowth behind the last molar had com-
pletely destroyed the maxillary tuber, leaving a
thin bone wall as the only barrier toward the im-
portant anatomical loge, i.e. fossa pterygopalatina.
The accidental intrusion into the fossa pterygo-
palatina could have caused the injury of a. maxi-
llaris and bleeding with fatal consequences.
In these situations a recommended guideline is
to remove only a part of the cyst sheath in the ini-
tial operative act. This policy is recommended in
order to bide our time and allow a partial regene-
ration of the bone, while the enucleation of the cy-
stic sheath would be completed in the second act.
This is also an example which shows that a cyst,
appearing commonly as a benign patological ou-
tgrowth, can also turn out to display the so-called
„malign“ properties ( can also turn out malignant).
In the postoperative course referring to the
same patient we could only observe the appea-
rance of a fistula on the alveolar ridge, being most
probably an outcome of suture loosening. During
regular check-ups a gradual reduction of the fistu-
la opening was noticed, but ultimately it closed up
spontaneously.
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HealthMED - Volume 5 / Number 6 / 2011
Conclusion
In therapeutic respect big jaw cysts require a
complete enucleation.This approach has become
an imperative in oral surgery. In patients with a
relatively well-preserved set of teeth we are faced
with a dilemma regarding the application of the
operative method (either open or closed method)
In planning the surgical intervention it is criti-
cal to be aware of potential complications that can
occur during and after the intervention. At this, it
is especially important to beware of a potential
injury of the vital anatomical elements and the
ensuing postoperative infection.
Bone structures should carefully be protected
because a regeneration process itself is reliant on
them.
The regeneration process should be monitored
by regular check-ups and rendgenogram analysis.
By comparing the orthopantomogram findings
of our two patients from the case study reports we
could observe a good regeneration of the bone.
Both patients were feeling well and did not com-
plain of any functional disturbances (Fig. 9 and
Fig 10).
Fig. 10. Orthopanthomogram five months after
operation
1798 Journal of Society for development in new net environment in B&H
References
1. Pechalova PF, Bakardjiev AG, Beltcheva AB. Jaw
cysts at children and adolescence: A single-center
retrospective study of 152 cases in southern Bulga-
ria. Med Oral Patol Oral Cir Bucal. 2011 Jan 10.
[Epub ahead of print]
2. Avelar RL, Antunes AA, Carvalho RW, Bezerra PG,
Oliveira Neto PJ, Andrade ES. Odontogenic cysts:
a clinicopathological study of 507 cases. J Oral
Sci. 2009 Dec;51(4):581-6.
3. Lin HP, Chen HM, Yu CH, Kuo RC, Kuo YS, Wang
YP. Clinicopathological study of 252 jaw bone peri-
apical lesions from a private pathology laboratory.
J Formos Med Assoc. 2010;109(11):810-8.
4. Becconsall-Ryan K, Tong D, Love RM. Radiolucent
inflammatory jaw lesions: a twenty-year analysis.
Int Endod J. 2010;43(10):859-65.
5. Nuñez-Urrutia S, Figueiredo R, Gay-Escoda C.
Retrospective clinicopathological study of 418
odontogenic cysts. Med Oral Patol Oral Cir Bucal.
2010;15(5):e767-73.
6. Robert J Scholl, Helen M Kellett, David P Neu-
mann, Alan G Lurie. Cysts and Cystic Lesions of
the Mandible: Clinical and Radiologic-Histopatho-
logic Review. Radiographics. 1999;19:1107-1124
7. Varinauskas V, Gervickas A, Kavoliūniene O. Anal-
ysis of odontogenic cysts of the jaws. Medicina (Ka-
unas). 2006;42(3):201-7.
8. Meningaud JP, Oprean N, Pitak-Arnnop P, Ber-
trand JC. Odontogenic cysts: a clinical study of 695
cases. J Oral Sci. 2006;48(2):59-62.
9. Gallego Romero D, Torres Lagares D, GarcIa Cal-
derón M, Romero Ruiz MM, Infante Cossio P, Gu-
tiérrez Pérez JL. Differential diagnosis and thera-
peutic approach to periapical cysts in daily dental
practice. Med Oral. 2002;7(1):54-8;59-2.
10. Kirtaniya BC, Sachdev V, Singla A, Sharma AK.
Marsupialization: A conservative approach
for treating dentigerous cyst in children in the
mixed dentition. J Indian Soc Pedod Prev Dent
2010;28:203-8.
11. Brøndum N, Jensen VJ. Recurrence of keratocysts
and decompression treatment. A long-term follow-
up of forty-four cases. Oral Surg Oral Med Oral
Pathol. 1991;72:265-9.
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12. August M, Faquin WC, Troulis MJ, Kaban LB.

Dedifferentiation of odontogenic keratocyst epit-
helium after cyst decompression. J Oral Maxillo-
fac Surg. 2003;61:678-83.
13. Jung YS, Lee SH, Park HS. Decompression of
large odontogenic keratocysts of the mandible. J
Oral Maxillofac Surg. 2005;63:267-71.
14. A Kahairi, S A Khan, A Amirozi. Endoscopic-as-
sisted Enucleation of Radicular Cysts — A Case
Report. Malaysian J Med Sci.2010;17(1):56-59.
15. Dzambas L, Dzolev A. Surgical and prosthetic
treatment of large mandibular cysts.Vojnosanit
Pregl. 2003; 60(3):365-8.
16. Boimatov MB, Grigor‘ian AS, Rud‘ko VF, Kha-
mroev T, Dobridenev AI. The use of a hydroxyla-
patitie-based biogenic composite material for
eliminating intraosseous cavities. Stomatologiia
(Mosk).1992;(3-6):51-3.
17. Moniaci D Nelken A.The preliminary results
of research on salcatonin treatment in the sur-
gical therapy of jaw cysts. Minerva Stoma-
tol.1991;40(7-8):535-8.
18. Tarello F, Aimetti M, Fasciolo A. Mandibular
cysts treated by decompression. Minerva Stoma-
tol. 1997;46(6):343-7.

Corresponding author
Naida Hadziabdic,
Faculty of Dental Medicine,
University of Sarajevo,
Bosnia and Herzegovina,
E-mail nsulejma@yahoo.com

Journal of Society for development in new net environment in B&H 1799

HealthMED - Volume 5 / Number 6 / 2011
Evaluation of methods in identifying
hilar supernumerary renal arteries
originating near the aorta
Elvira Talovic, Alma Voljevica, Amela Kulenovic
Institute of Anatomy, Faculty of Medicine, University of Sarajevo, Bosnia and Herzegovina.
Abstract
It was long considered that kidneys were su-
pplied solely by one renal artery, a twin visceral
branch of the abdominal aorta. However, resear-
ch has shown that there are numerous anatomical
variations in relation to the blood supply to this
organ, and this is especially related to the number
of renal arteries that are supplying it.
Variations in renal vascular anatomy, and especi-
ally the appearance of supernumerary renal arteries
gained in popularity the moment when there was an
increase in kidney transplantations, vascular recon-
structions of kidneys with congenital and acquired
lesions, and aneurysms of the abdominal aorta.
In this paper we researched the frequency of
hilar supernumerary renal arteries originating near
the aorta, using three different methods that were
subject to statistical analysis so an evaluation of
the used methods could take place in identifying
supernumerary renal arteries.
Using the traditional dissection method 39 su-
bjects (78 kidneys) of cadaver newborn donors
were treated. In the workup 213 standard aorto-
grams were analyzed that were obtained using the
non-selective renal angiography based on Seldin-
ger, and 37 DS-angiograms obtained with the di-
gital substraction angiography method.
The obtained percentages of the representation of
hilar supernumerary renal arteries originating near
the aorta using three different methods were not the
same. Using the traditional dissection method on this
artery, they were found in 18% of the cases, analy-
zing the standard aortograms in 9,4% of the cases,
and with the DS-analysis in 16,2% of the cases. The
statistical workup showed, that the discovered diffe-
rences in the value show the statistical significance.
1800 Journal of Society for development in new net environment in B&H
Hilar supernumerary renal arteries origina-
ting near the aorta are of great significance beca-
use they supply a larger part of the kidney, and
they are terminal blood vessels. Therefore the
knowledge about supernumerary renal arteries has
an anatomical significance as well as surgical and
radiological significance.
Key terms: hilar supernumerary renal arteries
originating near the aorta, dissection method, aor-
togram, DS-angiography.
Introduction
Frequent kidney diseases led to an increase
in the number of necessary kidney transplants
whose successful performance necessitates good
knowledge of the various blood vessels of this
organ.
Previous studies showed that renal arteries
can vary in number, course and origin (1,2,3).
Therefore, herein lies the interest of many resear-
ches for these variations, because if we disregard
these vessels during an operation, consequences
could be fatal.
The most frequent variation refers to the num-
ber of renal arteries i.e. the existence of so called
supernumerary arteries that appear in 26 from
30% of the cases (4,5,6). The term supernume-
rary is the term that replaced two earlier terms
used for this purpose (accessory arteries and
aberrant arteries) which are considered today as
unacceptable.
Desiring to help researchers Merklin offered
a unique classification of supernumerary arteries
in 1957. He divided supernumerary arteries into
two groups:

1. supernumerary renal arteries originating near
the aorta which include upper pole arteries,
hilar arteries and lower pole supernumerary
renal arteries originating near the aorta
2. supernumerary renal arteries originating
near the main renal artery to which belong
both the upper and lower pole supernumerary
arteries
Merklin’s classification is also used in this
study as the basis of anatomical-radiological exa-
mination.
Using three methods we wanted to prove:
-- the existence and placement of hilar renal
arteries originating near the aorta
-- to perform an evaluation using a statistical
analysis of the obtained results, of the
methods used to identify supernumerary
arteries
Materials and Methods
As materials 78 cadaver kidney subjects and 39
cadaver newborn donors were used that were anal-
yzed using a traditional dissection method, which
included a careful separation of the kidney from
its fatty cocoon and preparation of blood vessels
from the kidney towards the big blood vessels.
We analyzed 213 aortograms of the abdomi-
nal aorta obtained with the method of traditional
non-selective renal angiography based on Seldin-
ger, obtained from the archives of the Institute of
radiology in the Clinical Center of the University
of Sarajevo. The method consisted of indirect in-
duction of the ping-tail catheter into the aorta fe-
moralis through which 100 ml Lopamiro contrast
agent was injected, which generated the conditi-
ons for serial scanning which lasted for 15 secon-
ds, through which all of the phases of circulation
were shown. For the analysis, arterial phase scan
of blood vessels was used.
Angiograms, obtained with the method of su-
bstraction angiography of 37 patients who were
subjected to scans for diagnostic reasons on the
Institute of radiology in the Clinical Center of the
University of Sarajevo, were analyzed.
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
Results
Results of the analysis of supernumerary re-
nal arteries obtained with a dissection method
Thirty nine (39) subjects of cadaver newborn
donors were analyzed using a traditional dissec-
tion method, from which 20 subjects were male
and 19 subjects female. Using Merklin’s classi-
fication of supernumerary renal arteries originat-
ing near the aorta, which in combination with the
renal arteries enters the hilum of the kidney, we
found 7 cases (18%), Figure 1.
1. aorta abdominalis,
2. a. renalis dextra,
3. right sided hilar supernumerary renal artery
originating near the aorta,
4. a. renalis sinistra,
5. urether
Figure 1. Right sided hilar supernumerary renal
artery originating near the aorta
Three hilar supernumerary arteries were found
on the right side, and four on the left side. In male
subjects three cases showed these arteries, two on
the right side, and only one on the left side. In fe-
male subjects four subjects showed these super-
numerary renal arteries, one on the right side, and
three on the left side (Table 1). Bilateral presence
of these renal arteries was not found on any of the
subjects.
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HealthMED - Volume 5 / Number 6 / 2011

Table 1. Number of supernumerary renal arteries during the disection method

Number of Number of hilar Number of hilar Total
analysed dissection supernumerary supernumerary left
preparation right renal arteries renal arteries N %
N 20 2 1
Mele 3 15%
% 51,3% 10% 5%
N 19 1 3
Female 4 21,1%
% 48,7% 5,3% 15,8%
N 39 3 4
Total 7 18%
% 100% 7,7% 10,3%

Results of the analysis of traditional
abdominal aortograms
Hilar supernumerary renal arteries originating
near the aorta were found on 20 of 213 (101 aor-
tograms of male subjects and 112 aortograms of
female subjects) analyzed aortograms i.e. in 9.4%
of the cases (Figure 2).
subjects only 4 hilar supernumerary arteries were
found, three on the right side and one on the left
side (Table 2).
Results of DS-angiogram analysis
From a total of 37 angiograms, 26 were angio-
gram of male subjects, and 11 of female subjects.
Hilar supernumerary renal artery that has its ori-
gin near the aorta, which in combination with the
renal arteries enters the hilum of the kidney, were
found in 6 cases which is 16.2% (Figure 3).

1. aorta abdominalis
2. a. renalis dextra
3. right sided hilar supernumerary renal artery
originating near the aorta
4. a. renalis sinistra
Figure 2. Right sided hilar supernumerary renal
artery originating near the aorta a)
Bilateral presence of hilar supernumerary ar-
teries was found on two aortograms. In male su-
bjects 16 hilar supernumerary arteries were found,
11 on the right side, and 5 on the left. In female

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Table 2. Number of hilar supernumerary renal arteries on an aortogram

Number of hilar Number of hilar Total
Number of analysed
supernumerary right supernumerary left
abdominal aortogram
renal arteries renal arteries N %
N 101 11 5
Male
% 47,4% 10,9% 4,9% 16 15,8%
N 112 3 1
Fimale
% 52,6% 2,7% 0,9% 4 3,6%
N 213 14 6
Total
% 100% 6,6% 2,8% 20 9,4%
Table 3. Number of hilar supernumerary renal arteries on a DS - angiogram
Number of hilar Number of hilar Total
Number of analysed
supernumerary right supernumerary left
DS - angiograms
renal arteries renal arteries N %
N 26 5 0
Male
% 70,3% 19,2% 0% 5 19,2%
N 11 1 0
Female
% 29,7% 9,1% 0% 1 9,1%
N 37 6 0
Total
% 100% 16,2% 0% 6 16,2%

All of the arteries were found on the right side

and none on the left side, in male subjects in 5
cases and female 1 subject (Table 3)

The results of the statistical analysis of the

data

The statistical analysis used in this research is

the Chi-square test of the obtained results with all
three used methods for analysis and identification
of hilar supernumerary renal arteries. The stati-
stical significance was considered significant for
p<0.05.
In our case the for the testing of the significan-
ce of the obtained results and for the evaluation
of the used methods in identifying supernumerary
renal arteries we used the Statistical Package for
b) the Social Sciences (SPSS ver. 13.0) that conta-
1. aorta abdominalis ins Kruskal-Wallis one-way analysis of variance.
2. a. renalis dextra In table 4 and 5 we presented the obtained results
3. . right sided hilar supernumerary renal artery on the basis of which we can claim that using the
originating near the aorta Kruskal-Wallis one-way analysis of variance for
4. a. renalis sinistra evaluation of all three methods for identifying su-
Figure 3. A i B Right sided hilar supernumerary pernumerary renal arteries and division of renal
renal artery originating near the aorta

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Table 4. Number of supernumerary renal arteries in all three methods

Methods of analyisis Total
Dissection method Abdominal aortograms DS - angiogram N %
N 4 6 0 10 3,4%
Left kidney
% 10,3% 2,8% 0%
N 3 14 6 23 7,9%
Right kidney
% 7,7% 6,6% 16,2%
N 39 213 37 289 100%
Total
% 18% 9,4% 16,2%

Table 5. Results of the Kruskal – Walis one-way analysis of variance test

Methods of analysis N Rank
Dissection method 7 3,75
Abdominal aortograms 20 6,25
DS - angiogram 6 3,23
X2 – value 12,158
The degree of freedom 1
The level of significance (p) 0,0042

arteries on its segmental branches, used in this
study prove statistical significance of uncovered
differences.
We give a graphical presentation of all the re-
sults below.
Chart 1
Discussion
The works of older anatomical experts show
that the existence of supernumerary renal arteries
is not a new phenomena (2,7,8) they pointed to this
phenomena in the 1960’s. From then, numerous
studies were conducted that confirm the existen-
ce of supernumerary renal arteries and this is one
of the things upon which numerous researchers
agree. A point of disagreement is the data about
the procentual representation of supernumerary
arteries. A large number of authors point out that
supernumerary arteries appear in 26-30% of the
cases (2,7,8,9,10,11,12). A smaller number of aut-
hors point out that hilar supernumerary renal arte-
ries originating near the aorta appear in less than
15% of the cases (13,14,15), and also a smaller
number of authors point out that hilar arteries
appear in more than 30% of the cases (16,17). The
differences in the percentage are the results of the
application of different diagnostic methods in eva-
luating supernumerary arteries and the application
of different classifications during research.
In literature no specific attention was given to the
classification of supernumerary renal arteries. The
results of this study show that this should be scruti-
nized more closely, because they are the segmental
arteries with a specified vascular plane inside the
kidneys (18). Angiographies are valuable in identi-
fication and preoperative evaluation of the anatomy
of renal arteries and they are considered as a golden
standard (19). This study confirms that claim, beca-
use the Kruskal-Wallis test used in the evaluation of
methods showed the value of the statistical signifi-
cance of differences in favor of angiography.

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Conclusion
On the basis of our investigation we reached
the following conclusions:
Using the traditional dissection method in our
material of hilar supernumerary arteries origina-
ting near the aorta we found 7 (18%) cases
Analyzing traditional abdominal aortograms of
hilar supernumerary arteries originating near the
aorta we found them on 20 (9,4%) of the analyzed
aortograms
Analyzing the DS-angiograms of hilar super-
numerary arteries originating near the aorta we
found them in 6 (16,2%) of the cases.
Kruskal-wallis test used for evaluation of met-
hods, used in identification of supernumerary re-
nal arteries show, that the differences in frequency
distribution inside the three methods in this study
are statistically significant
References
1. Graves F.T. The anatomy of intrarenal arteries and
its application to segmental resection of the kidney.
Brit. J. Surg., 1956; 132-139.
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suprarenal blood supply with data on the inferior
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3. Ćuš M. et al. Arteriovenosus anastomoses owing to
the arterial segments in human kidney. Folia Medi-
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4. Pollak R., Mozes M. Anatomic abnormalities of ca-
daver kidneys procured for purposes of transplan-
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British Yournal of Radiology.,1972; 45,536-538.
6. Jeffery R.F.Unusual originis of renal arteries. Radi-
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7. Anson B.J., Kurth LE. Common variations in the
renal blood supply. Surg. Gynecol.Obstet., 1955;
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8. Sykes D. The arterial supply of the human kidney
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9. Williams P.L., Bannister LH. et al. Gray's Anatomy.
38th ed. New York: Churchill Livingstone, 1995;
pp.1826-1827.
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10. Hsu T.H., Su L.M., Ratuer L.E., et al. Impact of
renal artery multiplicity on outcomes of renal do-
nors and recipients in laparoscopic donor nep-
hrectomy. Urology., 2003; 61:323-7.
11. Giessing M., Kroencke J.T., Taupitz M., et al. Ga-
dolinium-enhanced 3D magnetic resonance angi-
ography versus conventional DSA: Which modali-
ty is superior in evaluating living kidney donors?.
Transplantation, 2003; 76:1000-1002.
12. Giessing M., Deger S., Ebeling V., Schonberger
B., Roigas J., Kroencke I. Laparoscopic living do-
nor nephrectomy of kydneys with multiple renal
vessels. Urologe A, 2003; 42:225-32.
13. Rozza A.M., Perloff LJ., Naji A., et al. Living re-
lated donors with multiple renal arteries. Tran-
splantation, 1989; 47; 397.
14. Aydin C., Berber I., Altaca G., Yigit B., Titiz I. The
outcome of kidney transplants with multiple renal
arteries. BMC Surg., 2004; 12;4(1):4.
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Corresponding author
Alma Voljevica,
Institute of Anatomy,
Faculty of Medicine,
University of Sarajevo,
Bosnia and Herzegovina,
E-mail: alma.voljevica@yahoo.com
1805
HealthMED - Volume 5 / Number 6 / 2011

VAP frequency at central intensive

care unit of Canton hospital Zenica
within the period 2008/2009
Ranka Filipovic1, Ismet Suljevic2, Ismana Surkovic3, Azra Kudumovic4
1
Department for Anaesthesiology and Intensive Care, CH Zenica, Bosnia and Herzegovina,
2
The Clinic for Anaesthesiology of Clinical Centre of University of Sarajevo, Bosnia and Herzegovina,
3
Clinic for Endocrinology and Metabolic Diseases, Clinical Centre of University of Sarajevo, Bosnia and
Herzegovina,
4
State Hospital Sarajevo; Bosnia and Herzegovina.

Abstract lator induce VAP. Resistant microorganisms make

Introduction: Pneumonia occurring with the
patients subjected to artificial ventilation (ventila-
tor acquired pneumonia - VAP) is the most frequ-
ent nosocomial infection in the Intensive Care
Units. The aim of this study was to analyse the
frequency of VAP with the patients subjected to
mechanical ventilation at the Intensive Care Unit
of the Canton Hospital Zenica.
Methods: This is a retrospectively clinical
study and comprises the period from January 2008
to December 2009. This study involves 47 pati-
ents mechanically ventilated either with the tubus
or with a cannula. Six risk factors were analysed:
age, sex, previous diseases, the time spent at In-
tensive Care Unit, antibiotics administrated and
microorganism resistance.
Results: Among 47 patients mechanically ven-
tilated, VAP developed in 15 (31,9%). The average
age of the patients was 56+/- 20,3 years. The men
were dominating compared to women, 66,7% and
33,3% respectively, which is a statistically signifi-
cant difference X2 = 14,99; p< 0,01). The average
stay at the Intensive Care Unit was 20,9+/- 13,5
days. There was no statistically significant diffe-
rence related to previous diseases (p>0,01). Gram-
negative bacteria are the main cause of VAP. They
manifested resistance to antibiotics: Ceftriaxon,
Cefasolin, Penbritin.
Conclusion: VAP incidence at our Intensive
Care Unit is 31,9%. Mechanical ventilation and
the duration of stay of our patients using the venti-
the treatment of such patients difficult.
Key words: Intensive Care Unit, resistance,
microorganisms, therapy.
Introduction
Intrahospital infection (IHI) is defined as the
disease which develops 48 hours after the pati-
ent is hospitalized, and it did not exist nor was it
in the stage of incubation at the moment of the
admission into hospital. Intrahospital infection
may be caused by: bacteria, viruses, fungi or pa-
rasites. Bacterial species and their resistance to
antibiotics were changing in dependence of: the
duration of application and the kind of antibio-
tic therapy, introducing the new diagnostic and
therapeutic procedures as well as obeying the
specific protocols of hospital hygiene. The most
frequent intrahospital infections, according to the
researches of the University Clinical Centre in
Tuzla dating from 2004, are: urinary infections
(35,21 %), surgical wound infections (22,54 %),
bacteriemia (17,61%), respiratory system infecti-
ons (9,15 %) (1,2).
The most frequent microorganisms causing the
infections were gram-negative bacteria in 73,82
% cases and in 26,18 % cases the cause were the
gram-positive bacteria (3).
Intensive Care Units (ICU) are highly hazar-
dous places for occurrence of intrahospital infec-
tions. Ventilator – associated pneumonia (VAP)

1806 Journal of Society for development in new net environment in B&H

 HealthMED - Volume 5 / Number 6 / 2011

is the most frequent nosocomial infection at the
intensive therapy units (4).
VAP results in higher rate of mortality, exten-
ded hospitalisation, increase of hospital costs and
intensified mobilisation of the personnel, labora-
tory and microbiological equipment (5,6,7,8).
This study has been required by the necessity
to know the frequency of nosocomial infections
and the bacteria resistance trend as well as VAP
frequency at the Intensive Care Unit at CH Zenica.
5. Anaerobic thioglycolic acid – liquid medium.
This medium serves for direct preparation 24
hours afterwards
Clinical parameters on the basis of which VAP
is diagnosed are taken from the National Nosoco-
mial Surveillance System, USA (NNIS). (Table 1).
Statistical Analysis

The results were analyzed by means of Statisti-

Material and methods
This study is retrospectively clinical and com-
prises the sample of 600 adult patients within the
period 2008-2009. 592 swab samples were taken.
The swab samples were analysed by the Depar-
tment for Microbiology at CH Zenica. The swab
samples of tubus and cannula were taken and
analysed according to the protocols of the Depar-
tment for Microbiology of CH Zenica. The mate-
rial is taken under the sterile conditions. During
reintubation or replacement of the cannula the
swab sample from the top part of the tubus or ca-
nnula is taken. The swab sample is immediately
sent to the laboratory and is cultured in five medi-
ums such as:
1. Blood agar – where all strains of bacteria grow
2. Mc.Conky agar – where gram (-) bacteria grow
3. Sabouround agar –where fungi grow
4. 4 % blood agar – where anaerobic bacteria
grow
cal Package for Social Science for Windows versi-
on 10. Numerical data are expressed as the medium
and standard deviation and were analyzed by t-test.
The category data are expressed in figures and per-
centages and were analyzed by X2 test. P<0,05 was
considered to be statistically significant.
Results
Within the period 2008-2009. 600 patients were
hospitalized at the Intensive Care Unit at Canton
Hospital Zenica, and 592 swab samples were ta-
ken of which 105 (17,7%) were positive (Table 2).
Of 47 patients with endotracheal tubus or cannu-
la, pneumonia closely related to mechanical venti-
lation (VAP) developed in 15 patients (31,9%).
These were the patients brought to Intensive Care
Unit due to injuries (53,3%), neurological disorders
(33,3%) or surgical complications (13,3%). There
is no statistically significant difference (X2=3,6;

Table 1. – NNIS Clinical criteria for VAP diagnostics

-- The patient subjected to mechanical ventilation longer than 48 hours
-- Body temperature higher than 380 C or 100,40 F
-- WBC (White Blood Cells) < 4000 / µL or ≥ 12000/µL
-- At least one chest X-ray showing infiltrate changes not having existed before
-- Positive swab sample taken either from tubus or cannula

Table 2. Presents the number and percentage of the patients, the number of tested and positive swab
samples within the period 2008-2009 at the Canton Hospital Zenica
2008. 2009. Total
Number of patients 309 291 600
Number of tested swab samples 335 257 592
Positive swab samples 61 44 105
% of positive swab samples 18,2 17,1 17,7

Journal of Society for development in new net environment in B&H 1807

HealthMED - Volume 5 / Number 6 / 2011

p>0,01) related to the reasons for which the patients dermidis 20 %, Pseudomonas aeruginosa 13 %,
were hospitalized at this Unit (Graph 1). Acinetobacter species 7, Enterobacter species 7 %
and Proteus mirabilis 7 % (Graph 2).

Graph 2. Predominant bacteria causing VAP in

the hospitalized patients at Canton Hospital Ze-
Graph 1. The reasons for hospitalizing the pati- nica within the period 2008-2009.
ents at ICU in the Canton Hospital Zenica within
the period 2008-2009. 80% of bacteria causing VAP were resistant to
one or more administrated antibiotics, mostly to
The predominant bacteria isolated from the Ceftriaxon (28,6%), Cefazolin (19%) and Penbri-
positive swab samples are Acinetobacter species tin (14,3%) (Graph 3).
(26,2%), Staphylococcus epidermidis (18,4%),
Pseudomonas aeruginosa (13,6%), Klebsiella pne-
umonia (9,7%), and Enterobacter species (5,8%).
There is a statistically significant difference
between the species of bacteria causing intrahos-
pital infection and their expected frequency within
the observed period (X2=68,6; p<0,01) (Table 3).
The average age of the patients with VAP is
56±20,3 years. In our sample men were more Graph 3. Sensitivity of bacteria causing VAP to
frequently affected by the disease 66,7%, while in antibiotics at Canton Hospital Zenica within the
women this amounted to 33,3%. There is statisti- period 2008-2009.
cally significant difference in sex related to VAP
occurrence (X2=14,99; p<0,01).
The average duration of staying in bed is Discussion
20,9±13,5 days.
The most frequent causes of VAP during 2008- The distribution of the positive swab samples
2009 at the Intensive Care Unit of CH Zenica are: as to the anatomic localization at ICU of the Can-
Pseudomonas species 46 %, Staphylococcus epi- ton Hospital Zenica during 2008-2009 indicates

Table 3. Presents the numerical and percentage value of the number of the tested swab samples of ca-
nnula and tubus within the period 2008 and 2009 at the Canton Hospital Zenica
2008. 2009.
Localization
Number of positive swab samples % Number of positive swab samples %
Cannula swab sample 15 24,6 9 20,5
Tubus swab sample 14 23,0 10 22,7
Total 29 47,6 19 43,2

1808 Journal of Society for development in new net environment in B&H


a high level of positive tubus and cannula swab
samples and amounts to 43,2 %. The distribution
of IHI as to anatomic localization at ICU of Uni-
versity Clinical Centre Tuzla in 2003 indicates that
urinary infections were most frequent, amounting
to 32,25 % as well as surgical wound infections,
amounting to 32,25 %.
The causes of intrahospital infections may be
all microorganisms, but these are mostly bacte-
ria. The bacterial species causing IHI change in
dependence of the kind and duration of antibiotic
application. The predominant bacteria causing the
disease at ICU at Canton Hospital Zenica during
2008-2009 and at ICU of the University Clinical
Centre Tuzla in 2003 were gram-negative bacteria
(Acinetobacter species, Pseudomonas aeruginosa,
Klebsiella pneumoniae). Among gram-positive
bacteria the most frequent ones were Staphyloco-
ccus epidermidis and Staphylococcus aureus. The
most frequent microorganisms isolated in the me-
ta-analyses of Rosenthal et al. were: Methacillin
resistant Staphylococcus, Enterobacter species
and Pseudomonas aeruginosa.
Of 47 patients with endotracheal tubus or ca-
nnula who were mechanically ventilated longer
than 48 hours, at ICU of CH Zenica during 2008-
2009, VAP developed in 15 patients (31,9 %).
Predominant bacteria causing VAP at ICU of
Canton Hospital Zenica for the period 2008-2009
were: Pseudomonas species, Staphylococcus epi-
dermidis, Pseudomonas aeruginosa and Acintero-
bacter species. Almost 80 % of bacteria causing
VAP were resistant to one or more antibiotics ad-
ministrated (Ceftriaxon, Cefasolin, Penbritin).
Intrahospital infections and occurrence of re-
sistance to antibiotics are the problems existing
in the hospitals all over the world ( 9,10,11). The
patients treated at Intensive Care Units suffer the
reduced immune response to infections and the-
refore are more frequently affected by the deve-
lopment of the intrahospital infections (IHI). The
greatest reason for this is the fact that these pati-
ents are catheterized, very often intubated and me-
chanically ventilated with a large number of vas-
cular catheters and the medical personnel is most
often in physical contact with them (12,13,14,15).
According to recommendations of National
Nosocomial Surveillance Centre (NNIS) USA the-
re is a need for special monitoring of the patients
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
hospitalized at ICUs. It is necessary to observe and
collect the swab samples and carry out microbiolo-
gical analyses on daily, weekly and monthly basis.
The results of these researches are similar to the re-
sults of meta-analyses of Rosenthal et al. that were
carried out with 21.069 patients at 55 intensive care
units in Central and South America, India, Morocco
and Turkey. The most frequent IHI were: 1. Ventila-
tor – associated pneumonia (24,1/1000 days on the
respirator), 2. Sepsis caused by central vein catheter
(12,5/1000 catheter days), 3. Urinary infections cau-
sed by the urinary catheter (8,9/1000 catheter days).
According to the opinion of many researchers,
ventilator associated pneumonia (VAP) is the most
frequent nosocomial infection at the intensive
care units. Ten to twenty percent of the patients
requiring mechanical ventilation for more than 48
hours develop VAP with lethal outcome of 15-50
% (16). Still, the development of VAP depends,
in the first place, on the clinical condition of the
patient and the pathogenic degree of the infectious
agent. VAP extends the duration of intubation (at
the average for 10,1 days), the period of stay at
Intensive Care Unit (at the average for 18,5 days)
and increases the hospital costs ( 40,000 – 198,200
$ per patient) (17,18).
The bacteria resistant to antibiotics (MDR) ca-
use nosocomial pneumonia and VAP. The most
frequent causes of VAP are: Pseudomonas aerugi-
nosa, MRS-a, Acinetobacter species, Vancomycin
resistant enterococci (19).
In the therapy of VAP caused by MDR bacteria
it is recommended to use antibiotic algorithm esta-
blished by American College of Chest Physician.
The therapy must include three antibiotics. The
two for Pseudomonas aeruginosa and the third
for MRS. In order to achieve the optimal effect
with the selected antibiotic the adequate dose must
be determined and it must be continually applied
through i.v. infusomat and the serum level of anti-
biotic must be monitored (20,21).
Conclusion
The occurrence of VAP is significant and amounts
to 31,9 % at the Intensive Care Unit of CH Zenica.
The most frequent causes of VAP are: Pseudomonas
species, Staphylococcus epidermidis, Pseudomo-
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HealthMED - Volume 5 / Number 6 / 2011
nas aeruginosa, Acinetobacter species, Enterobacter
species and Proteus mirabilis. The above stated cau-
sing agents were resistant, to the highest percentage,
to Ceftriaxon 28,6 %, Cefasolin 19 % and Penbritin
14,3 %. Rationalization of antibiotics application is
an absolute imperative in future clinical practice gi-
ven that the nosocomial microorganisms show the
increasing resistance to antibiotics.
References
1. Custovic A, Babovic M, Džafic F. Epidemiologija,
etiologija i monitoring intrahospitalnih infekcija
u Jedinici hirurske intenzivne njege. Acta Med Sal
2008;(1): 77-81.
2. Custovic A, Zulcic-Nakic V, Asceric M, Hadžic S.
Surveillance of intrahospital infections at the clinic
for gynaecology and obstetrics. Bosn J Basic Med
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3. Custovic A, Hadžic S. Intrahospital infections and
antimicrobial resistance at University Clinical
Center Tuzla. Med. Arh. 2009;63(4):207-11.
4. Porzecanski I, David L, Vowton D. Diagnosis and
Treatment of Ventilator-Associated Pneumonia.
Chest 2006; 130:597-604.
5. Rosenthal V, Maki D, Salomao R, Alvares-More-
no C, Mehta Y, Higuera F, et all. Device-Associ-
ated Nosocomial Infections in 55 Intensive Care
Units of 8 Developing Countries. Ann Intern Med.
2006;145:582-591.
6. Restrepo MI, Anzueto A, Arroliga AC, Afessa B, At-
kinson MJ, Schinner R, et all. Economic burden of
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source utilization. Infect Control Hosp Epidemiol.
2010 May; 31(5): 509-15.
7. Nicasio AM, Eagye KJ, Kuti EL, Nicolau DP,
Kuti JL. Length of stay and hospital costs associ-
ated with a pharmacodynamic-based clinical pat-
hway for empiric antibiotic choice for ventilator-
associated pneumonia. Pharmacotherapy. 2010
May;30(5):453-62.
8. Grap MJ, Munro CL, Unoki T, Hamilton VA,Ward
KR. Ventilator-associated Pneumonia: The Potential
Critical Role of Emergency Medicine in Prevention.
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9. Jimenez-Alvarez A, Mendoza EJ, Hernandez B, et
all. Antibiotic therapy frequency in hospitalised pa-
tients and associated risk factors. Rev Salud Publi-
ca (Bogota). 2009 mar-apr; 11(2): 247-55.
10. Terragni PP, Antonelli M, Fumagalli R, Faggia-
no C, Berardino M, Pallavicini FB, et all. Early
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vs late tracheotomy for prevention of pneumonia
in mechanically ventilated adult ICU patients:
a randomized controlled trial. JAMA. 2010 Apr
21;303(15):1483-9.
11. Myny D, Depuydt P, Colardyn F, Blot S. Ventila-
tor-associated pneumonia in a tertiary care ICU:
analysis of risk factors for acquisition and morta-
lity. Acta Clin Belg. 2005 May-Jun;60(3):114-21.
12. Nguile-Makao M, Zahar JR, Francais A, Tabah A,
Garrouste-Orgeas M, Allaouchiche B, et all. Attribu-
table mortality of ventilator-associated pneumonia:
respective impact of main characteristics at ICU
admission and VAP onset using conditional logistic
regression and multi-state models. Intensive Care
Med. 2010 May;36(5):781-9. Epub 2010 Mar 16.
13. Michalopoulos A, Falagas ME. Treatment of Aci-
netobacter infections. Expert Opin Pharmacother.
2010 Apr;11(5):779-88.
14. Rello J, Ollendorf DA, Oster G, Epidemiology and
outcomes of ventilator-associated pneumonia in a
large US database. Chest 2002;122:2115-2121.
15. Chastre J,Fagon J-Y. Ventilator-associated pneumo-
nia. Am J Respir Crit Care Med 2002;165:867-903.
16. Eggimann P, Hugonnet S, Sax H. Ventilator-asso-
ciated pneumonia: caveats for benchmarking. In-
tensive Care Med 2003;29:2086-2089.
17. Nseir S, Di Pompeo C,Soubrier S. Impact of ven-
tilator-associated pneumonia on outcome in pati-
ents with COPD. Chest 2005;128:1650-1656.
18. Warren DK, Shukla SJ,Olsen MA. Outcome and
attributable cost of ventilator-associated pneumo-
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19. Crit Care Med 2003;31:1312-1317.
20. Craven DE, De Rosa FG,Thornton D. Nosocomi-
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53(2):81-83.
Corresponding author
Ranka Filipovic,
Department of Anesthesiology,
Cantonal Hospital, Zenica,
Bosnia and Herzegovina,
E-mail: igda.ganic@gmail.com
 HealthMED - Volume 5 / Number 6 / 2011

Assessment of quality of life in patients

with heart failure using Minnesota
questionnaire
Sadat Kurtalic1, Fahir Barakovic2, Farid Ljuca3, Zumreta Kusljugic2, Midhat Tabakovic4, Zlatko Midzic1,
Nermina Kurtalic5, Dzenan Halilovic6
1
Division of Internal Medicine, Cantonal Hospital “Dr Irfan Ljubijankic”, Bosnia and Herzegovina,
2
Department of Cardiology, Internal Clinic, University Clinical Center Tuzla, Bosnia and Herzegovina,
3
Department of Physiology, Faculty of Medicine, University of Tuzla, Bosnia and Herzegovina,
4
Department of Nephrology, Internal Clinic, University Clinical Center Tuzla, Bosnia and Herzegovina,
5
Division of Dermatology, Cantonal Hospital “Dr Irfan Ljubijankic”, Bosnia and Herzegovina,
6
Clinic for pulmonary diseases and tuberculosis, University Clinical Center Tuzla, Bosnia and Herzegovina.

Abstract of Minnesota questionnaire expressed as the medi-

Objective: To determine the quality of life in
patients with heart failure in accordance to severi-
ty of clinical features.
Respondets and methodology: Using a secti-
onal study the quality of life of 120 patients suffe-
ring from heart failure was analyzed, both genders
and all age groups in accordance with severity of
clinical features. Respondents were classified into
4 equal groups according NYHA classification of
heart failure. The control group consisted of 30
respondents who do not suffer from heart failure.
Assessment of quality of life was performed using
the Minnesota questionnaire.
Results: Study group consisted of 150 partici-
pants had 76 (51%) of male, and 74 (49%) females,
divided into 4 groups according to NYHA, whe-
re every group had 30 subjects (20,0%), and one
control group of 30 subjects (20,0%). There were
no statistically significant differences in gender
representation (X2=1.70; df=4; p=0.79) between
analyzed groups. Also, there was no statistically
significant difference in age between the groups
(ANOVA; F=0.74; p=0.57). The values of Minne-
sota score expressed as the median in the control
and 4 NYHA groups were: 0,0; 0,47; 1,64; 2,99;
3,42 (Ht=113,42; p<0,0001). The values of physi-
cal health dimension of Minnesota questionnaire
expressed as the median in the control and 4 NYHA
groups were: 0,0; 0,0; 1,69; 3,56; 4,19 (Ht=108,58;
p<0,0001). The values of mental health dimension
an in the control and 4 NYHA groups were: 0,0;
0,40; 1,20; 2,90; 3,0 (Ht=91,91; p< 0,0001). The
values of correlation r coefficient between heart fa-
ilure, expressed in the NYHA classes by Minnesota
score, and its physical and mental dimensions were:
0,931; 0,913; 0,824 (p<0,0001).
Conclusion: The quality of life in patients with
heart failure is deteriorated and related with seve-
rity of clinical features.
Key words: heart failure, quality of life,
Minnesota questionnaire.
Introduction
Heart failure (HF) is a condition which is cha-
racterized by structural or functional disorders of
the heart that lead to the inability of heart cham-
bers to receive and extract the blood, thereby tran-
sporting oxygen to the body parts in a quantity that
meet their needs (1). Today, for the purposes of
the heart failure classification, revision of the New
York Heart Academy (NYHA) classification has
been used. Every year there are about 550,000 di-
agnosed new cases of patients with heart failure,
and 300,000 deaths occur due to heart disease. Re-
hospitalization rates 6 months after discharge is
50% (2). Quality of life was identified as a predic-
tor of hospitalization and mortality from heart fai-
lure (3). Heart failure condition requires from pati-
ents their daily responsibility and concern for their

Journal of Society for development in new net environment in B&H 1811

HealthMED - Volume 5 / Number 6 / 2011
health through compliance to various guidelines
within the framework of everyday life: taking the
recommended therapy, moderate physical activi-
ty, nutrition restriction of salt and fat, fluid intake
restriction, prohibition of alcoholic beverages, no
smoking and frequent control of cardiologist (4).
Routine use of tests which examine the quality of
life can help to identify changes that need additio-
nal help in improving the quality of life (5). Taking
into account the high prevalence, the vast costs of
health funds to treat patients, frequent hospitali-
zation and more demanding participation of both
physicians and families in the care of these pati-
ents as well as negative impact on quality of life,
heart failure represents one of the most significant
health problems in all countries of the world.
The goal of this study was to determine the
quality of life of patients with heart failure in rela-
tion to the severity of clinical features.
Respondets and methodology
The analysis is based on the population of pati-
ents with previously diagnosed heart failure, who
were hospitalized and ambulatory treated at the
Clinic for Internal Medicine of University Clini-
cal Center in Tuzla. We analyzed 120 patients su-
ffering from heart failure, all ages and both sexes.
Patients were divided into 4 groups according to
NYHA classification of heart failure. The control
group consisted of 30 subjects who do not suffer
from heart failure, all ages and both sexes. The
etiology and treatment of heart failure in patients
was not analyzed in this study. The study exclu-
ded patients who in addition to heart failure have
diagnosed psychiatric, malignant or other serious
disease that can significantly affect the quality of
life. Assessment of quality of life was performed
using the questionnaire “Minnesota – life with
heart failure” (6), which consists of physical and
mental dimension. It consists of 21 questions exa-
mining how heart failure affected the quality of
life of patients during the past month (4 weeks).
Respondents answered the questions by encircling
answers scored from 0 to 5, to show the extent of
impact of disease on quality of life. The answers
to all 21 questions were summarized. Afterwards,
the points related to the physical dimension (que-
1812 Journal of Society for development in new net environment in B&H
stions 2, 3, 4, 5, 6, 7, 12, 13) and the points related
to the emotional dimension (questions 17, 18, 19,
20, 21) were scored by simple addition, so that the
impact of heart failure on quality of life of the pa-
tient could be further characterized.
The study was approved by the Ethics Commi-
ttee of the JZU Univerzitetski klinicki centar Tuzla.
Statistical analysis
Statistical analysis was made by program pack
SPSS 18.0 (Chicago, IL, USA). Basic tests of des-
criptive statistics were made, showing measures
of central tendency and dispersion. Testing of each
variable for belonging to a normal distribution
was performed, using Kolmogorov-Smirnoff test.
Quantitative variables were compared by one-
way ANOVA test on the same place where these
has been distributed by a normal distribution. For
variables that were not distributed by the normal
distribution was used nonparametric alternative
– Kruskal-Wallis test. Categorical variables were
analyzed by X2-test. Testing significant connecti-
ons between variables was performed using Spe-
arman nonparametric correlation. All statistical
tests were carried out with the level of statistical
probability of 95% (p<0.05).
Results
Study group consisted of 150 participants
with heart failure had 76 (51%) of male, and 74
(49%) females, divided into 4 groups according
to NYHA, where every group had 30 subjects
(20.0%), and one control group of 30 subjects
(20.0%). The analysis of gender representation
within the groups showed that in the control gro-
up was equal representation of men and women,
in NYHA class I males were underrepresented
(43.3%) than women (56.7%), while in NYHA
class II distribution was reversed, in NYHA cla-
ss III women’s representation (53.3%) was higher
than men (46.7%), and at NYHA class IV results
were identical to the gender distribution of NYHA
class II. There were no statistically significant dif-
ferences in gender representation (X2=1.70; df=4;
p=0.79) between analyzed groups. Distribution of
 HealthMED - Volume 5 / Number 6 / 2011

respondents by age was analyzed and it showed Discussion and conclusion

that the most common one was the age group of
71-75 years (22.3%), while the least represented
were respondents aged 41-45 years (3.1%) and
respondents over 80 years (3.8%). The mean age
of the respondents were: the control group 69 ye-
ars, patients in NYHA class I 64 years, in NYHA
class II 66 years, in NYHA class III 68 years and
NYHA class IV 70 years. There was no statisti-
cally significant difference in age between the
groups (ANOVA; F=0.74; p=0.57). The average
value of Minnesota score for men was 2.2 and 2.1
for women. Comparison of values didn’t found
statistically significant differences between male
and female (Mann Whitney; Z=1.01; p=0.31). Ta-
ble 1 show the average values of Minnesota score,
both physical and emotional dimension, in pati-
ents suffering from heart failure within the analy-
zed groups. Table 2 shows the correlation of heart
failure expressed in NYHA classes by values of
total Minnesota score, and its physical and mental
dimensions.
Results of our study show that influence of heart
failure on quality of life was closely related to the
severity of clinical features. Specifically, respon-
dents with higher NYHA classification class had
a statistically worse quality of life, i.e. the negati-
ve and statistically significant correlation between
NYHA class and the parameters of Minnesota sco-
re was determined, while the difference was not
statistically significant between male and female.
Comparing the mean of physical and mental health
dimensions measured by Minnesota survey it was
observed that the values of the physical dimensions
of health are lower in all NYHA classes, except in
NYHA I class where mental health dimension was
more disturbed. Studies of other authors who have
used the same measurement instrument for asse-
ssing quality of life as in our study, showed also
significant correlation between severity of clinical
forms of heart failure according to the NYHA cla-
ssification and quality of life (7). The same authors
made the correlation of NYHA classes with the
number of patients suffering from heart failure that

Tabela 1. The average value of total Minnesota score, both physical and emotional dimension, within
the analyzed groups of patients suffering from heart failure. (Kruskal-Wallis; Ht=113.42;p<0.0001,
Ht=108.58;p<0.0001, Ht=91.91;p<0.0001)
Minnesota score Minnesota score Minnesota score
Group (median/interqurtile physical health dimension mental health dimension
range) (median/interqurtile range) (median/interqurtile range)
Control group 0.0/N/A 0.0/N/A 0.0/N/A
NYHA I 0.47/0.28-0.57 0.0/N/A 0.40/0.0-0.60
NYHA II 1.64/1.52-2.04 1.69/1.25-2.00 1.20/0.60-2.00
NYHA III 2.99/2.76-3.23 3.56/3.37-3.75 2.90/2.20-3.40
NYHA IV 3.42/3.14-3.61 4.19/3.25-4.37 3.00/2.20-3.60
Legend: NYHA- New York Heart Academy classification of heart failure; N/A – not applicable because quartiles are identi-
cal to the median

Table 2. Correlation of heart failure (NYHA classes) and Minnesota score, both physical and emotional
dimension
Minnesota Minnesota score physical Minnesota score mental
score health dimension health dimension
Heart failure Correlation
0.931 0.913 0.824
NYHA classes coefficient - r
p-value <0.0001 <0.0001 <0.0001
Legend: NYHA- New York Heart Academy classification of heart failure

Journal of Society for development in new net environment in B&H 1813

HealthMED - Volume 5 / Number 6 / 2011
were admitted to hospital in the previous year, whi-
ch was very positive. The results show that the valu-
es of Minnesota questionnaire adequately reflected
the seriousness of the disease. Research performed
by Calvert and associates suggests that in patients
suffering from heart failure emotional dimension of
quality of life was disturbed, but the impact on this
dimension was much smaller than the one observed
in the physical dimension (8). Therefore, our results
indicate that, with increasing NYHA classification
group in patients with heart failure, a decline in ove-
rall quality of life as well as in physical and mental
dimensions starts to occur, as indicated by Juenger
and associates in their study (5). Heart failure is the
chronic outcome of many cardiovascular disorders
and it represents disease with a poor prognosis, and
it can lead to mild or dramatic changes in some or
all of the determinants of quality of life (9). Asses-
sment of quality of life in patients with heart failure
is essential so the problem can be timely noticed
and a comprehensive approach to the patient can be
provided with understanding problems and educati-
on of patients and families. This will enable the im-
provement of satisfaction for patient and the entire
multidisciplinary team, which ultimately results in
improving the quality of treatment, the experience
of health and welfare of patients of whom we care.
References
1. Swedberg K, Cleland J, Dargie H, Drexler H, Fo-
llath F, Komajda M et al. Task Force for the Dia-
gnosis and Treatment of Chronic Heart Failure of
the European Society of Cardiology. Guidelines for
the diagnosis and treatment of chronic heart fai-
lure: executive summary (update 2005): The Task
Force for the Diagnosis and Treatment of Chronic
Heart Failure of the European Society of Cardiolo-
gy. Eur Heart J 2005; 26(11):1115-1140.
2. Jencks SF, Williams MV, Coleman EA Rehospitali-
zations among patients in the Medicare fee-for-ser-
vice program. N Engl J Med 2009; 360(14):1418-
1428.
3. Gott M, Barnes S, Parker C, Payne S, Seamark D,
Gariballa S et al. Predictors of the quality of life of
older people with heart failure recruited from pri-
mary care. Age and Ageing 2006; 35(2):172-177.
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4. Jones AM, O’Connell JE, Gray CS Living and
dying with congestive heart failure: addressing the
needs of older congestive heart failure patients.
Age Ageing 2003; 32: 566–568.
5. Juenger J, Schellberg D, Kraemer S, Haunstetter A,
Zugck C, Herzog W et al. Health related quality of
life in patients with congestive heart failure: com-
parison with other chronic diseases and relation to
functional variables. Heart 2002; 87(3):235-241.
6. Rector TS, Kubo SH, Cohn JN Patients self-asses-
sment of their congestive heart failure. Part 2: Con-
tent, reliability and validity of a new measure, the
Minnesota living with Heart Failure questionnaire.
Heart Failure 1987; 198-209.
7. Parajón T, Lupón J, González B, Urrutia A, Altimir
S, Coll R et al. Use of the Minnesota Living With
Heart Failure Quality of Life Questionnaire in Spa-
in. Rev Esp Cardiol 2004; 57(2):155-160.
8. Calvert MJ, Freemantle N, Cleland JG The impact
of chronic heart failure on health-related quality of
life data acquired in the baseline phase of the CARE-
HF study. Eur J Heart Fail 2005; 27(2):243-251.
9. Anon. Development of the World Health Organi-
zation WHOQOL-BREF quality of life assessment.
The WHOQOL Group. Psychol Med 1998; 28:551-
588.
10. Hasanović A. The relation between myocardial
viability and collateral circulation. HealthMED,
2008; 2 (4): 283-287.
11. Hasanovic A, Junuzovic A, Spuzic M,Kudumovic
A. Angiographic evaluation of miocardial brid-
ges in relation to myocardial ischemia, Heal-
thMed,2010; 4 (2)-: 398-403
12. Pepic E, Fajkic A, Kapic-Pleho A, Džubur A,
Musanovic J. Plasma level of high-density lipo-
protein HDL and low-density lipoprotein-LDL in
patients with ischemic stroke. HealthMED 2009;
3(4):467-74.
Corresponding author
Sadat Kurtalic,
Division of Internal Medicine,
Cantonal Hospital “Dr Irfan Ljubijankic”,
Bosnia and Herzegovina,
E-mail: sadatku@gmail.com
Journal of Society for development in new net environment in B&H

New simplified formula for RPI-
reticulocyte production index
Secic D1, Omerbasic A2, Drljo M3, Dizdarevic A3
1
Department of Pathophysiology, Medical Faculty of Sarajevo University, Bosnia and Herzegovina,
2
Department of Biophysics, Medical Faculty of Sarajevo University, Bosnia and Herzegovina,
3
Department of Haematology, Clinical Center of Sarajevo University, Bosnia and Herzegovina.
Abstract
Background: The propose of reticulocyte pro-
duction index (RPI) is to assess whether the bone
marrow has adequate production compared to the
anemic condition. Increased reticulocytes produc-
tion index (RPI≥3) speaks in favor of adequate
bone marrow response, mostly due to hemolysis,
hemorrhage, or appropriate response to therapy
with vitamin B12, folic acid or iron products. Value
less than 2 speaks in favor of inadequate erythro-
poiesis mostly in case of sideropenic or megalo-
blastic anemia.
Aim: The aim is to prove that the new RPI
formula is simpler and more accurate for use by
medical doctors, family medicine specialists, in-
ternists, pediatricians, hematologists and other
physicians.
Patients and Methods: In order to vividly dis-
play the difference between these two methods of
determining the RPI (reticulocyte production in-
dex), we assumed a sample of 1600 patients who
were divided into 5 groups by 320 respondents.
Each of these groups has a hematocrit value from
0.14 (14%) to 0.45 (45%). The above 5 groups di-
ffer in the values of reticulocytes expressed in %.
To compare the results RPIHillman-Finch (RPIHF) and
RPISarajevo (RPISa) we used the correlation method
by Pearson. The difference in values was calcula-
ted by Student t test.
Results: Time of maturation of reticulocytes
in peripheral blood can be expressed through
reference value of hematocrit (Hctref) listed as
0.45 and hematocrit values of patients (Hct-
pat
). In this way we get a simplified formula
2 However, during the increased production of the
RPI Sarajevo = 5.5 x Rtc(%) x Hct pat , which does
not need to use a parameter from the denomina-
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
tor used in the formula RPIHillman-Finch. RPISarajevo has
more natural form, unlike the chart of formula RPI-
Hillman-Finch
, which is shown in step shape.
Conclusion: Determination of reticulocyte pro-
duction index RPISarajevo is more convenient because
there is no need to use the parameter - the time of
maturation of reticulocytes. In the method RPISarajevo
2 parameters are required, reticulocytes - Rtc (%)
and hematocrit of the patient - Hctpat, unlike method
of RPIHillman-Finch, where 3 parameters are required.
The appearance of the chart according to the
method RPISarajevo has much more natural look as
opposed to the parabolic graph methods RPIHillman-
Finch
, where the curve looks broken.
Key words: reticulocyte production index
Introduction
Reticulocytes are immature red blood cells that
are slightly larger than erythrocytes, with the re-
mains of ribosomal RNA, which is visible by co-
loration with specific stains, and which separates
them from erythrocytes.
The number of reticulocytes (Rtc) in periphe-
ral blood depends on the number of reticulocytes
which passed in the peripheral blood, the level
of their maturity and speed of the reticulum disa-
ppearance. Under normal circumstances lifespan
of reticulocytes is 4-4½ days, and they are found
approximately for 1 day in the peripheral blood
and 3-3½ days in the bone marrow. Under nor-
mal circumstances, the relationship between the
number of reticulocytes and the number of reti-
culocytes produced in the bone marrow is linear.
red blood cells that relationship is changing due to
the formation of immature reticulocytes (1).
1815
HealthMED - Volume 5 / Number 6 / 2011
Because of these changes is necessary to use
reticulocyte production index (RPI), which is also
called corrected reticulocyte count and represents
a calculated value used in the diagnosis of anemia.
This calculation is necessary because the number
of reticulocytes does not give a true picture of ane-
mic patients (2,3). The term number of reticulo-
cytes, which is used, is not correct because it is
actually a percentage and not the number of reti-
culocytes. In patients with anemia there is decrea-
sed number of red blood cells, with proportionally
larger number of reticulocytes, because of their
prolonged retention in the peripheral blood (4,5).
The propose of reticulocyte production index
(RPI) is to assess whether the bone marrow has
adequate production compared to the anemic con-
dition. Reticulocyte production index should be
increased in response to a reduction in the number
of red blood cells. In case of hemorrhage it incre-
ases during the first week, reaching a maximum in
the second week. If there is no increase in RPI that
is a sign that the bone marrow is insufficient in
production of red blood cells, mostly due to lack
of nutritional factors (iron, folic acid, vitamin B12)
or decreased production of erythropoietin (6,7).
During the increased production of red blo-
od cells during maturation of reticulocytes in the
bone marrow is reduced to 1-1½ day while the
time of maturation in the peripheral blood is pro-
longed. Due to these changes in time of maturati-
on of erythrocytes in the peripheral blood can be
increased to 3 times and we get a false increase in
the number of reticulocytes due to this retention.
It is essential that there may be a significant incre-
ase in reticulocytes in peripheral blood without a
significant increase in erythropoietic activity.
RPI- reticulocyte production index is very
useful indicator of erythrocytes production, as its
name suggests.
Reticulocyte production index is calculated on
the basis of formula (Hillman and Finch)
patient Hct
found No. of reticulocytes ( % ) x
RPI Hillman − Finch = 0.45
time of maturation in peripheral blood
RPI RPI
1816
Hct pat
Rtc (%) x
0.45
RPI Hillman − Finch =
time of maturation in peripheral blood
There is a correlation (Table 1.) between hemato-
crit (Hct) with a time of maturation of reticulocytes
in bone marrow and peripheral blood. In case of
anemia worsening there is an increase in the pro-
duction of erythropoietin with a shorter retention of
reticulocytes in the bone marrow and proportional
prolongation of retention in the peripheral blood (3).
Certain pathological conditions are not followed
by these indicators. Specifically in case of renal in-
sufficiency decreased is the production of erythro-
poietin and is not in accordance with the degree of
anemia, or is not found the expected prolongation
in the maturation of reticulocytes so that this for-
mula cannot be used in patients with renal problems
(8). In order that we could use the above formula,
there should be a negative correlation between the
degree of anemia and erythropoietin (9). Increased
reticulocytes production index (RPI≥3) speaks in
favor of adequate bone marrow response, mostly
due to hemolysis, hemorrhage, or appropriate res-
ponse to therapy with vitamin B12, folic acid or iron
products. Value less than 2 speaks in favor of ina-
dequate erythropoiesis mostly in case of siderope-
nic or megaloblastic anemia (3,10).
Table 1. The correlation between Hct (levels) with
a time of maturation of reticulocytes in peripheral
blood
Time for Rtc maturation
Hematocrit
(maturation correction factor)
36 - 45 1.0
26 - 35 1.5
16 - 25 2.0
≤ 15 2.5
RPI should be between 1 and 2 in healthy in-
dividuals, RPI≤2, in patients with anemia, sugge-
sting a reduced production of reticulocytes and
erythrocytes. RPI≥2 is an adequate response to the
loss of red blood cells (hemorrhage, hemolysis) or
the appropriate therapy.
The aim is to prove that the new RPI formula
is simpler and more accurate for use by medical
doctors, family medicine specialists, internists,
pediatricians, hematologists and other physicians.
Journal of Society for development in new net environment in B&H
 HealthMED - Volume 5 / Number 6 / 2011

Patients and methods If the time of reticulocytes retention in periphe-

In order to vividly display the difference between
these two methods of determining the RPI (reticu-
locyte production index), we assumed a sample of
1600 patients who were divided into 5 groups by
320 respondents. Each of these groups has a hema-
tocrit value from 0.14 (14%) to 0.45 (45%) with di-
fferences between individual hematocrit values of
0.01 or 1%. We assumed for that each value of he-
matocrit have 10 patients. The above 5 groups differ
in the values of reticulocytes expressed in %. In gro-
up A reticulocyte values are 1%, in group B - 5%, in
group C - 10%, group D - 15% and group E - 25%.
As an additional sample, for comparison of
these two formulas we have analyzed 47 patients
with known diagnoses, the values of reticulocytes,
erythrocytes, hemoglobin and hematocrit.
Respondents in additional sample were of both
sexes, aged 20-80 years, and they are actual pati-
ents of the Outpatients Hematology Counseling,
University Clinical Center in Sarajevo. Most of the
patients reporting symptoms of iron deficiency and
megaloblastic anemia. Additions sample was used
to illustrate the structure of ambulatory patients.
Statistical analysis was performed using stan-
dard methods of descriptive statistics, graphical
presentation of the calculated values. To compa-
re the results RPIHillman-Finch and RPISarajevo we used
the correlation method by Pearson. The difference
in values was calculated by Student t test. Certain
hypotheses are considered significant if p≤0.05.
ral blood is presented by hematocrit values it wo-
uld look like this. Mean levels values for hemato-
crit 36-45 is 40.5, which means that the hematocrit
value of 40.5% corresponds to the retention of re-
ticulocytes in peripheral blood of 1 day (Table 2).
Time of maturation of reticulocytes in periphe-
ral blood can be expressed through reference value
of hematocrit (Hctref) listed as 0.45 and hematocrit
values of patients (Hctpat).
Maturation of reticulocytes can be shown by
our above mentioned simplified formula:
Maturation of reticulocytes in peripheral blood =
Hctref
=coefficient ( c ) x
Hct pat
If in the above formula we include the matu-
ration of 1 day which corresponds to the patient's
hematocrit of 40.5% or 0.405, and the reference
hematocrit is 0.45 we get these values:
Hctref
1 = coefficient (c) x
Hct pat
0.45
1 = coefficient (c) x
0.405
1 x 0.405
coefficient (c) = = 0.9
0.45
coefficient (c) = 0.9

The mentioned formula can be checked if we

Results
include the maturation of erythrocytes in the pe-
ripheral blood of 2 days, which corresponds to the
Time of reticulocytes retention in peripheral
patient's hematocrit of 20.5% or 0.205, with he-
blood depends on the hematocrit values as shown
matocrit reference of 0.45:
in the Table 1. and Table 2.
Table 2. The correlation between Hct (median le- Hctref
vels) with a time of maturation of reticulocytes in 2 = coefficient (c) x
Hct pat
peripheral blood
Hematocrit Time of Rtc maturation / 0.45
2 = coefficient (c) x
(median levels) maturation correlation factor 0.205
0.405 (40.5%) 1.0
0.305 (30.5%) 1.5 2 x 0.205
coefficient (c) = = 0.9
0.205 (20.5%) 2.0 0.45
≤0.150 (15.0%) 2.5
coefficient (c) = 0.9

Journal of Society for development in new net environment in B&H 1817

HealthMED - Volume 5 / Number 6 / 2011

This confirms that the value of the above coef- Rtc(%) x Hct 2pat
ficient is correct. RPI =
0.45 x 0.9 x 0.45
Hct pat
Rtc(%) x 2
RPI = 0.45 RPI Sarajevo = 5.5 x Rtc(%) x Hct pat
time of reticulocytes maturation in peripheral blood
In this way we get a simplified formula for RPI,
In the above formula for RPI (reticulocyte pro- which does not need to use a parameter from the de-
duction index), we can instead of time of reticu- nominator used in the formula RPIHillman-Finch. With
locytes maturation in peripheral blood formulate the necessary respect for the authors of the menti-
expression oned RPI-reticulocyte production index, based on
Hctref the chart we can see that the chart of formula RPISa
= coefficient (c) x has more natural form, unlike the chart of formula
Hct pat
RPIHillman-Finch, which is shown in step shape.
Hctref
= 0.9 x
Hct pat

Hct pat
Rtc (%) x
RPI = 0.45
time of reticulocytes maturation in peripheral blood

Hct pat
Rtc(%) x
RPI = 0.45
Hctref
0.9 x
Hct pat

Table 3. Difference between RPIHillman-Finch and RPISarajevo for groups A to E

Group A Group B Group C Group D Group E
n=320 n=320 n=320 n=320 n=320
Values

Re 1% Re 5% Re 10% Re 15% Re 25%

RPIHF RPISa RPIHF RPISa RPIHF RPISa RPIHF RPISa RPIHF RPISa
x 0.50 0.53 2.50 2.63 5.01 5.26 7.51 7.88 12.5 13.2
t 1.25 1.09 1.05 1.05 1.17
p ≥0.05 ≥0.05 ≥0.05 ≥0.05 ≥0.05

Table 4. Correlation between RPIHillman-Finch and RPISarajevo for groups A to E

Group A Group B Group C Group D Group E
Values

n=320 n=320 n=320 n=320 n=320

Re 1% Re 5% Re 10% Re 15% Re 25%
r 0.981 0.982 0.981 0.981 0.981
p ≤0.001 ≤0.001 ≤0.001 ≤0.001 ≤0.001
Table 5. Difference RPIHillman-Finch and RPISarajevo by hematocrit levels
Hct 0.16-0.20 Hct 0.21-0.25 Hct 0.26-0.35 Hct 0.36-0.40 Hct 0.41-0.45
Values

n=50 n=50 n=100 n=50 n=50

RPIHF RPISa RPIHF RPISa RPIHF RPISa RPIHF RPISa RPIHF RPISa
x 0.200 0.179 0.256 0.292 0.449 0.516 0.844 0.795 0.956 1.018
t 4.20 5.83 6.04 5.82 5.31
p ≤0.001 ≤0.001 ≤0.001 ≤0.001 ≤0.001

1818 Journal of Society for development in new net environment in B&H


Since the mean values, standard deviations and
standard errors of RPIHillman-Finch and RPISarajevo in-
crease according to the value of reticulocytes -1%,
5%, 10%, 15% and 25% (curves are similar in
shape to the specified value of reticulocytes). Ba-
sed on the similar t values obtained by individual
Hct levels we can conclude that there is a statisti-
cally significant difference between the value of
RPIHillman-Finch and RPISarajevo for all these values of
reticulocytes (Table 5).
Discussion
For simplicity of calculation we simplify the
formula for the RPI, so we reticulocytes matura-
tion time (maturation correction factor) replace
with formula that includes the values of hemato-
crit. Also in our formula the values are parabolic,
naturally distributed in contrast to the value of
RPI reticulocyte production index by Hillman -
Finch, where the values are gradually distributed
(3).
Notably, in all diagrams starting from group
A to group E are similarly shaped curve. These
two curves RPIHillman-Finch and RPISarajevo intersect
in 6 points for hematocrit values from 0.14 to
0.45.
Intersections of these two functions in 3 of
6 these points are on the border between the
levels that are listed in the Hillman-Finch for-
mula (corresponding hematocrit values ≈0.15,
≈0.255, ≈0.355). These 6 points are the valu-
es of hematocrit for which the RPI (reticulo-
cyte production indexes) for both formulas are
identical. These equal values of RPI correspond
to hematocrit values of ≈0.15, ≈0.20, ≈0.255,
≈0.27, ≈0.355, ≈0.40.
Lack of formula RPIHillman-Finch is that there is a
sudden change in the RPI values in the transition
to the next level. For example, the RPI values for
Hct of 0.35 and Re 1% is 0.51, and for the Hct
value of 0.36 RPI is 0.80. Unlike hematocrit of
1% or 0.01 we have increased in RPIHillman-Finch of
56.86%. The biggest difference for RPISarajevo valu-
es (at the difference in hematocrit of 1% or 0.01)
is 14.80% and for the hematocrit values between
0.14 and 0.15. However, these values of hemato-
crit are rare in clinical practice (3,11).
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
Of the 47 out-patients who have made the va-
lues of reticulocytes, which are used to estimate
these two formulas all had hematocrit values Hct
≥ .27 or 27%.
If we look at those respondents with Hct≥0.27
the largest difference between the two values of
RPISarajevo is 7.54% (between two adjacent Hct of
0.27 and 0.28). While by the RPIHillman-Finch that di-
fference is highest between the Hct of 0.35 and
0.36 and is, as we already stated 56.86%.
The biggest difference in the deviations of the
two values of RPIHillman-Finch in relation to RPISaraje-
vo
is 754.11% for the hematocrit values over 27%
(56.86% in RPIHillman-Finch, as compared to 7.54% in
RPISarajevo.
If we look at respondents who have values of
reticulocytes 1%, 5%, 10%, 15%, 25%, we can
notice that the difference between individual valu-
es of RPISarajevo RPIHillman-Finch for the same values of
Hct in absolute numbers increased as higher levels
of reticulocytes in %.
But in order to compare these two values of ​​
RPI calculated by different methods (for the same
values ​​of Hct and reticulocytes) is best to do with
the values ​​expressed in percentages (12).
For values ​​of reticulocytes 1% in the part corres-
ponding to Hct from 0.16 to 0.25 in the lower half of
the levels values of ​​RPIHillman-Finch are greater t=4.20;
p≥ 0.05; n=50, or slightly less t=5.83; p≥0.05; n =
50 in the upper half compared to RPISarajevo with a
statistically significant difference.
At the levels with the Hct value of 0.26 to 0.35
RPIHillman-Finch values are somewhat less than in
RPISarajevo but the difference was statistically signi-
ficant t=6.04; p≥0.05; n=100.
Levels with Hct of 0.36 to 0.45 shows values
of ​​RPIHillman-Finch which are in the lower half of the
level slightly larger t=5.82; p≥0.05; n=50, while in
the upper half of levels a little less t=5.31; p≥0.05;
n=50 compared to RPISarajevo with a statistically si-
gnificant difference.
The correlation between the value of RPIHill-
man-Finch
and RPISarajevo for all of these subgroups
is r=0.98 ( Table 4.) and can be described as full
correlation (these are correlation values ​​ greater
than 0.95) with p≤0.001.
This correlation speaks in favor of the general
alignment of the two methods.
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HealthMED - Volume 5 / Number 6 / 2011

Conclusions 9. Koepke JA. Update of reticulocyte counting. Labo-

ratory Medicine 1999 May; 30(5):339-43.
Determination of reticulocyte production index 10. Dixon LR. The complete blood count: physiologic
RPISarajevo is more convenient because there is no basis and clinical usage. J Perinat Neonatal Nurs
need to use the parameter - the time of maturation 1997 Dec; 11(3):1-18.
of reticulocytes that for most doctors is unknown.
In the method RPISarajevo 2 parameters are required, 11. Nielsen OJ, Kjaersgaard E, Karle H. Renais-
reticulocytes - Rtc (%) and hematocrit of the pati- sance of the reticulocyte. Ugeskr Laeger 1994
Sep;156(39):5673-5.
ent - Hctpat, unlike method of RPIHillman-Finch, where
3 parameters are required. 12. Choi JW, Pai SH. Associations between serum
The appearance of the chart according to the transferin receptor concentrations and erythro-
method RPISarajevo has much more natural look as poietic activities according to body iron status.
opposed to the parabolic graph methods RPIHillman- Annals Of Clinical And Laboratory Science 2003;
, where the curve looks broken. 33(3):279-84.
Finch
Differences between the values of individual
levels on the border with the method RPIHillman-Finch
are much higher than those with method RPISarajevo. Corresponding author
Damir Secic,
Department of Pathophysiology,
Medical Faculty of Sarajevo University,
References Bosnia and Herzegovina,
E-mail: secic@lol.ba
1. Choi JW, Pai SH. Reticulocyte subpopulations and
reticulocyte maturity index(RMI) rise as body iron
status falls. American Journal of Hematology 2001
Jun;67(2):130-35.
2. Brugnara C. Use of reticulocyte cellular indices in
the diagnosis and treatment of hematological disor-
ders. Int J Clin Lab Res 1998; 28(1):1-11.
3. Hillman RS, Finch CA. Erytropoiesis. N Eng J Med
1971; 285(2):99-101.
4. Buturovic Ascic B, Hasanovic A, Burnazovic Ristic
L, Halilovic L, Kocic R. Hypothyreosis and Anae-
mia-Current facts. HealthMed 2010; 4(4):880-3.
5. Wysocka J, Turowski D. New reticulocyte indi-
ces and their utility in hematologic diagnosis. Pol
Merkur Lekarski 2000 Jul; 8(49):498-502.
6. Heimpel H, Diem H, Nebe T. Counting reticulo-
cytes: new importance of an old method. Med Klin
(Munich) 2010 Aug; 105(8):538-43.
7. Pierre RV. Reticulocytes. Their usefulness and mea-
surement in peripheral blood. Clin Lab Med 2002
Mar; 22(1):63-79.
8. Mateos Gonzales ME, de la Cruz Bertolo J, Lopez
Laso E, Valdez Sanchez MD, Nogales Espert A. Re-
view of haematology and biochemisty parameters
to identify iron deficiency. An Pediatr(Barc) 2009
Aug; 71(2):95-102.

1820 Journal of Society for development in new net environment in B&H


Anti-Suicide effects of clozapine
in treatment of schizophrenia and
schizoaffective disorder
Saida Fisekovic1, Damir Celik2, Svjetlana Loga-Zec3
1
Department of Psychiatry, University of Sarajevo Clinical Center, Bosnia and Herzegovina,
2
Cathedra of Epidemiology and Biostatistics, Faculty of Medicine, University of Sarajevo, Bosnia and
Herzegovina,
3
Institute of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Sarajevo,
Bosnia and Herzegovina.
Abstract
Introduction: The risk of suicide and other
causes of premature death are high in patients with
chronic psychotic disorders. Approximately 50%
of patients with schizophrenia and schizoaffective
disorder attempt suicide, and around 10% patients
with schizophrenia commit suicide.
Aims: The aim of this study was to describe
the anti-suicide effects of clozapine in treatment of
schizophrenia and schizoaffective disorder.
Materials and methods: The clinical longitu-
dinal and prospective study included 41 patients
who attempted suicide and who accepted treat-
ment with clozapine at the Department of Psychia-
try of the University Clinical Centre of Sarajevo.
Patients were assessed at baseline and after 4, 8,
12, 16, 20 and 24 weeks using the BPRS, the GAF
and the CGI scale.
Results: A statistically significant improvement
was found for BPRS total score (χ2(6) = 232.127;
P < .001), GAF total score (χ2(6) = 221.370; P <
.001) and CGI score (χ2(6) = 230.569; P < .001).
Conclusion: The usage of clozapine in pa-
tients with schizophrenia and schizoaffective dis-
order at high risk for suicide is associated with
significant reduction in suicidal behavior and
personality disorder.
Key words: clozapine, suicide attempts, sc-
hizophrenia, schizoaffective disorder, hostile be-
havior
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
Introduction
The risk of suicide and other causes of prematu-
re death are high in patients with chronic psychotic
disorders. We have little ability to predict suicide.
Suicide is a major cause of death among patients
with schizophrenia. Suicide accounts for approxi-
mately 10% patient deaths in schizophrenia. The
past history of suicide attempts is common among
schizophrenic patients. Studies estimate that from
9- 24% of individuals with schizophrenia will die
by their own hand (1,2,3,4). Approximately 50%
of patients with schizophrenia and schizoaffective
disorder attempt suicide, and around 10% patients
with schizophrenia commit suicide, which corres-
ponds to an annual rate of 0.4%-0.8%. Suicide may
occur more frequently during the early years of the
illness. Other factors that increased risk of suicide
in schizophrenic patients include younger age (<
30 years) (2,5,6), social isolation (7,8) or male sex
(2,5,6,9,10,11). Demographic and psychosocial va-
riables may influence suicide risk estimation. The
studies suggests that the most predictive factor for
suicide are: living alone, being aged 17 to 35 ye-
ars, complaints of severe hopelessness, anhedonia
and insomnia (12). Clozapine may substantially re-
duce this risk. In the InterSept trial a 2-years study
compared clozapine with olanzapine in 980 pati-
ents with schizophrenia, there was a lower rate of
suicidal behavior in the clozapine group (20,8%),
than in olanzapine group (28,8%) (13). Clozapine is
prescribe only for treatment resistant, more severe
cases. Clozapine therapy demonstrated superiority
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HealthMED - Volume 5 / Number 6 / 2011
to other therapy in preventing suicide attempts in
patients with schizophrenia and schizoaffective dis-
order at high risk for suicide. Clozapine therapy is
useful for reducing suicidal behaviors for patients
with other conditions as borderline personality dis-
orders, major depression with psychotic feature,
particularly bipolar disorder. Suicidal risk tends to
be more chronic and has an impulsive quality for
patients with suicidality related to personality dis-
orders and environmental factors. Diagnoses of
personality disorder have been associated with an
increased risk for suicide. Among individuals who
attempt suicide, diagnosis of personality disorder
are also common, with overall rates of about 40%
(14,15,16). Among female suicide attempters, rates
of borderline personality disorder are higher than
among male suicide attempters (17,18). These fin-
dings suggest that personality disorders, particu-
larly borderline disorder and antisocial personality
disorder should be identified and addressed as part
of the suicide assessment process. Personality dis-
ordered patients may report feeling of anger, rage or
vengeance connected with their suicidal thoughts.
Altamura AC at al. found that SGAs (second ge-
neration antipsychotics-clozapine and risperidone)
were associated with lower rate of suicidal attempts
than FGAs (first generation antipsychotics) in their
study (19). A study of Herings and Erkens has de-
monstrated a fourfold increase in suicide attempts
for patients who interrupt or stop treatment with
olanzapine or risperidone (20). Their finding are
in concordance with previous studies reporting
an increased sevenfold suicide attempt risk due to
noncompliance with antipsychotic among schizop-
hrenic patients. It has been suggested that clozapine
exerts it s action through normalizing serotoniner-
gic function whose relationship with suicidality is
well-established (20).
The treatment of anxiety/agitation and im-
pulsivity are crucial for suicide prevention. The
recent studies supply information on clozapine
in regard with these symptoms clozapine is as a
specific antihostility agent. The author was con-
cluded that the reduction in suicidality following
long-term clozapine treatment may be related to
a reduction in impulsiveness and aggression (21).
1822 Journal of Society for development in new net environment in B&H
Materials and methods
The clinical longitudinal and prospective study
was conducted in the period from 1st of January
2000 to the 31th of July 2007 and included 41 pati-
ents who accepted treatment with clozapine at the
Department of Psychiatry of the University Clini-
cal Centre of Sarajevo. Patients were completed
the sixth months (24 weeks) study individual clo-
zapine doses. Patients were assessed at baseline
and after 4, 8, 12, 16, 20 and 24 weeks using the
BPRS, the GAF and the CGI scale (22, 23, 24).
The scales are used in repeated (weekly) ratings,
each assessment is made independently, without
reference to previous interviews.
Included criteria were: female and male pati-
ents who attempted suicide, aged 18-65 years,
diagnosis of schizophrenic patient, schizoaffecti-
ve, personality disorders patients, and were con-
sidered to be at high risk for committing suicide.
High risk for suicide was defined as patient with
history of previous attempts or hospitalization to
prevent a suicide attempts before 1-3 years before
enrollment; with command hallucinations for self-
harm within 1 week of enrollment and with mo-
derate and severe current ideation with depressi-
ve symptoms. All procedures on human subjects
were performed in accordance with the latest ver-
sion of Helsinki Declaration.
The BPRS is probably the most widely used ra-
ting scale in psychiatry. It comprises 18 items from
0 (not present) to 6 (extremely severe) and includes
symptoms such as somatic concern, anxiety, depre-
ssive mood, hostility and hallucinations (23). The
Global Assessment of Functioning (GAF) Scale
may be particularly useful when the clinical progre-
ss of a patient needs to be assessed in global terms,
using a single measure. The GAF scale is rated with
respect to psychological and occupational functio-
ning only. The Clinical Global Impression (CGI)
Scale refers to the global impression of the patient
and requires clinical experience with the syndrome
under assessment (24). The CGI improvement sca-
le can be completed only following or during tre-
atment. The concept of improvement refers to the
clinical distance between the individual’s current
condition and that prior to the baseline of treatment.
The scale has a single item measured on a 7 point
scale from 1 (normal, not ill) to 7 (extremely ill).

Results are expressed as median and interqu-
artile range (IQR) in case of non-normal distri-
buted continuous variables or ordinal variables.
The Kolmogorov–Smirnov statistic with a Lilli-
efors significance level was used for testing nor-
mality. In case of categorical variables, counts
and percentages were reported. A P-value < .05
was considered as significant. Statistical analysis
comparing the two groups was performed with
Mann–Whitney U-test for continuous non-normal
distributed variables. The Friedman Test is used to
test for differences between different periods and
Post-hoc analysis with Wilcoxon Signed-Rank
Tests was conducted with a Bonferroni correction
applied, resulting in a significance level set at P <
.002. Spearman’s correlation coefficient was used
to describe the strength and direction of the line-
ar relationship between variables (the difference
between the baseline and 24 weeks of the therapy)
and one-tailed test was selected.
Statistical analysis was performed by using the
Statistical Package for the Social Sciences (SPSS
Release 16.0; SPSS Inc., Chicago, Illinois, United
States of America) software.
Results
Out of 41 patients, 25/41 (61%) were females
and 16/41 (39%) were males (χ2(1) = 1.976; P
= .160). The highest number of patients, 20/41
(49%) were between 20-39 years, 14/41 (34%)
were between 40-60 years, 4/41 (10%) were <
20 years, and 3/41 (7%) patients were > 60 years
(χ2(3) = 19.585; P < .001).
Based on the diagnosis, 34/41 (83%) patients
had schizophrenia, schizotipal and delusional dis-
orders (International Statistical Classification of
Diseases and Related Health Problems ICD-10:
F20-F29) while 7/41 (17%) had disorders of adult
personality and behavior (ICD -10: F60-F69). The
Table 1. Comparison of age and length of stay in hospital in patients with schizophrenia and schizoaf-
fective disorder by gender (n=41)
Variables Males (n = 16)
Age (years) 34 (20)
Length of stay (days) 25 (31)
Data are presented as median (IQR)
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
median of daily dose (DD) of clozapine was 162.5
mg/per day (IQR=75 mg/per day) in patients with
diagnosis F20-29 and 25 mg/per day (IQR=0 mg/
per day) in patients with diagnosis F60-69. Predo-
minant symptoms in patients with diagnosis F20-
29 were: hallucinations (68%), imperative halluci-
nations (24%), delusions (18%), suicidal thoughts
(6%), paranoid thoughts (6%) and in patients with
diagnosis F60-F69 were: aggressiveness (43%),
anxiety (29%), homicidal ideas (29%), and forced
suicidal thoughts (14%).
The BPRS total score in patients (n=41) did
significantly change over the 24 weeks of the the-
rapy with clozapine (χ2(6) = 232.127; P < .001). It
appeared that BPRS total score did significantly
change from the baseline to 4 weeks (Z = - 5.584,
P < .001), from 4 weeks to 8 weeks (Z = - 5.556, P
< .001), from 8 weeks to 16 weeks (Z = - 5.582, P
< .001), from 12 weeks to 16 weeks (Z = - 5.363,
P < .001), from 16 weeks to 20 weeks (Z = - 4.139,
P < .001). However, there was not a statistically
significant reduction of BPRS total score in the
20 weeks vs. 24 weeks of therapy with clozapine
(Z=- 2.315, P = .021) (Fig. 2).
The Spearman’s correlation coefficient was used
to describe the strength and direction of the linear
relationship between variables (the difference of
values BPRS items between the baseline and 24
weeks of the therapy) (Fig. 1). Conceptual disor-
ganization was significantly correlated with tension
(rs= .56), with hostility (rs= .68), with suspiciousne-
ss (rs= .60), with hallucinatory behaviors ( rs= .62),
with uncooperativeness (rs= .60), with unusual tho-
ught content (rs= .70) and blunted affect (rs= .63);
(all Ps < .001). Tension was significantly correla-
ted with motor retardation (rs= .55), with uncoope-
rativeness (rs= .58), with unusual thought content
(rs= .69); (all Ps < .001). Hostility was significantly
correlated with suspiciousness (rs= .50), with hallu-
cinatory behaviors (rs= .63) (all Ps < .001). Suspi-
ciousness was significantly correlated with hallu-
Females (n = 25) Z P- value
38 (24) -1.110 .267
19 (34) -1.325 .185
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HealthMED - Volume 5 / Number 6 / 2011

Table 2. The Brief Psychiatric Rating Scale (BPRS) in patients with schizophrenia and schizoaffective
disorder over the 24 study weeks of the therapy with clozapine (n = 41)
Brief Psychiatric Rating Scale Time (weeks)
P-value†
(Items) 0 4 8 12 16 20 24
Somatic concern 5 (4) 4 (3.5) 3 (3) 1 (1.5) 1 (0) 1 (0) 1 (0) < .001
Anxiety 6 (2) 5 (1) 3 (1) 2 (1) 2 (1) 1 (1) 1 (1) < .001
Emotional withdrawal 4 (3) 3 (2) 2 (3) 1 (1.5) 1 (1) 1 (1) 1 (0) < .001
Conceptual disorganization 6 (2) 5 (2) 3 (2) 2 (1.5) 2 (1) 1 (1) 1 (0.5) < .001
Guilt feeling 3 (4.5) 2 (3) 2 (2) 1 (1) 1 (0) 1 (0) 1 (0) < .001
Tension 6 (1) 5 (2) 3 (2) 2 (1) 2 (1) 2 (1) 1 (1) < .001
Mannerism and posturing 4 (2) 3 (2) 2 (2) 2 (1) 1 (1) 1 (0) 1 (0) < .001
Grandiosity 1 (2) 1 (1) 1 (1) 1 (0) 1 (0) 1 (0) 1 (0) > .05
Depressive mood 3 (2.5) 2 (2) 2 (1) 1 (1) 1 (0) 1 (0) 1 (0) < .001
Hostility 5 (3.5) 4 (2) 3 (2) 2 (1.5) 1 (1) 1 (1) 1 (1) < .001
Suspiciousness 5 (2) 4 (2) 3 (2) 2 (2) 2 (1) 1 (1) 1 (0.5) < .001
Hallucinatory behaviors 6 (1.5) 5 (1.5) 3 (3) 2 (2) 1 (1) 1 (1) 1 (1) < .001
Motor retardation 2 (2) 1 (1) 1 (1) 1 (0) 1 (0) 1 (0) 1 (0) > .05
Uncooperativeness 3 (4.5) 2 (3) 2 (2) 1 (1) 1 (0) 1 (0) 1 (0) < .001
Unusual thought content 6 (2.5) 5 ( 2) 3 (2) 2 (1.5) 1 (1) 1 (1) 1 (1) < .001
Blunted affect 2 (2) 1 (1) 1 (1) 1 (0) 1 (0) 1 (0) 1 (0) > .05
Excitement 6 (1) 5 (1) 3 (2) 2 (1) 2 (1) 2 (1) 1 (1) < .001
Disorientation 1 (0) 1 (0) 1 (0) 1 (0) 1 (0) 1 (0) 1 (0) > .05
Data are presented as median (IQR). † Friedman test

Table 3. The Brief Psychiatric Rating Scale (BPRS) items in patients with schizoaffective disorder over
the 24 study weeks of the therapy with clozapine (n = 7). The median of daily dose of clozapine was 25
mg/per day (IQR=0 mg/per day)
Brief Psychiatric Rating Time (weeks)
P-value†
Scale (Items) 0 4 8 12 16 20 24
Anxiety 6 (4) 5 (3) 3 (2) 2 (2) 2 (0) 1 (0) 1 (1) < .001
Tension 6 (5) 4 (4) 1 (2) 1 (1) 1 (2) 3 (1) 2 (1) < .01
Depressive mood 5 (2) 2 (2) 1 (0) 1 (0) 1 (0) 1 (0) 1 (0) < .001
Hostility 1 (0) 1 (2) 1 (1) 1 (0) 1 (0) 1 (0) 1 (0) > .05
Blunted affect 1 (0) 1 (0) 1 (0) 1 (0) 1 (0) 1 (0) 1 (0) > .05
Excitement 7 (1) 5 (0) 4 (1) 3 (1) 2 (1) 2 (2) 1 (1) < .001
Data are presented as median (IQR). † Friedman test

cinatory behaviors (rs= .55), with unusual thought Uncooperativeness was significantly correlated
content (rs= .59); (all Ps < .001). with unusual thought content (rs= .76; P < .001).
Hallucinatory behaviors was significantly corre- Unusual thought content was significantly corre-
lated with uncooperativeness (rs= .50), with unusual lated with blunted affect( rs= .70; P < .001).
thought content (rs= .50) and blunted affect (rs= .55);
(all Ps < .001). Motor retardation was significantly
correlated with uncooperativeness (rs= .53) and unu-
sual thought content (rs= .53); (all Ps < .001).

1824 Journal of Society for development in new net environment in B&H

 HealthMED - Volume 5 / Number 6 / 2011

Figure 1. Decreasing in BPRS items (median) over 24 study weeks of the therapy with clozapine in pa-
tients with schizophrenia and schizoaffective disorder (n = 41).

Figure 2. The total score change of BPRS (A),

GAF Scale (B) and CGI Scale (C) in patients with
schizophrenia and schizoaffective disorder over
the 24 study weeks of the therapy with clozapine
(Wilcoxon Signed-Rank Tests with a Bonferroni
correction applied, * P < .001; NS Not Significant).

There was a statistically significant difference

in the GAF total score change score over the 24
weeks of the therapy with clozapine (n=39) (χ2(6)
= 221.370; P < .001). It appeared that GAF score

Journal of Society for development in new net environment in B&H 1825

HealthMED - Volume 5 / Number 6 / 2011
did significantly change from the start to 4 weeks
(Z = - 5.517, P < .001), from 4 weeks to 8 weeks (Z
= - 5.519, P < .001), from 8 weeks to 12 weeks (Z
= - 5.525, P < .001) , from 12 weeks to 16 weeks
(Z = - 5.506, P < .001), from 16 weeks to 20 weeks
(Z = - 3.413, P < .001), and from 20 weeks to 24
weeks (Z = - 3.916, P < .001) (Fig. 2).
The CGI score in patients (n=41) did signifi-
cantly change over the 24 weeks of the therapy
with Clozapine, (χ2(6) = 230.569; P < .001).
It appeared that CGI score did significantly
change from the baseline to 4 weeks (Z=- 5.654,
P< .001), from 4 weeks to 8 weeks (Z = - 5.138, P
< .001), from 8 weeks to 12 weeks (Z = - 5.013, P
< .001), from 12 weeks to 16 weeks (Z = -4.491,
P < .001) and from 16 weeks to 20 weeks (Z = -
4.536, P < .001). However, there was not a statisti-
cally significant reduction of CGI score in the 20
weeks vs. 24 weeks of therapy with clozapine (Z
= - 1.155, P = .248) (Fig. 2).
Discussion
Psychotic-like symptoms decreased within the
first four weeks of treatment, as confirmed by a sta-
tistically significant decrease in Brief Psychiatric
Rating Scale Scores. It was reduction in impulsi-
ve behaviors and an increase in global functioning
(Global Assessment of Functioning). The authors
were concluded that 53 suicides in treatment-resi-
stant patients could have been prevented by cloza-
pine, but the number of lives saved may be signifi-
cantly higher if clozapine therapy was extended to
treatment responders at a high risk for suicide (25).
In our study the most of patients (61%) were
females, and the highest number of patients were
between 20-39 years (49%). In others studies, risk
factors that increased risk of suicide in schizop-
hrenic patients include younger age (< 30 years)
(2, 5, 6), among female suicide attempters rates
of borderline personality disorder are higher than
among male suicide attempters (17,18).
Our results showed predominant psychotic
symptoms in patients with diagnosis F20-29, hallu-
cinations (68%) and command hallucinations (24%)
were presented in the time of attempted suicide. At
the time of commit suicide, command hallucinati-
ons may act as a precipitant to a suicide attempt or
1826 Journal of Society for development in new net environment in B&H
to suicide in some individuals (26,27). Psychotic
symptoms are often present at the time of a suicide
attempt or suicide (28,29). It s very important to
identified and addressed in the assessment process
suicidal ideation. In 40%-53% patients it is reported
having suicidal ideation at some point in their lives
and 23%-55% reported prior suicidal attempts (27).
Suicidal attempts were precipitated by depression,
stressors or psychotic symptoms (27). Patients with
Axis I psychiatric disorders such as schizophrenia,
anxiety disorders, major affective disorders, and su-
bstance abuse disorders (especially alcohol) often
present with acute (state) suicide risk factors. Sa-
reen et al. demonstrated that a preexisting anxiety
disorder is an independent risk factor for the onset
of suicidal ideation and attempts (30). Patients with
Axis II disorders often display chronic (trait) sui-
cide risk factors. Personality disorders associated
with depressive symptoms and substance abuse
disorders are highly represented among patients
who complete suicide (31). Cluster B personality
disorders, especially borderline and personality dis-
orders, place patients at increased risk for suicide
(32). Suicidal ideation is an important risk factor.
Suicidal ideation should be differentiated from su-
icide intent. Suicidal ideation can be passive, flee-
ting, intermittent, active and intense, with or witho-
ut the intent to die. Suicidal intent is the subjective
expectation and desire to die by a self-destructive
act. In our study, predominant symptoms in patients
with diagnosis F60-69 were aggressiveness (43%),
anxiety (29%), homicidal ideas (29%) and forced
suicidal thoughts (14%). The severity of suicidal
ideation is an indicator of risk for attempting suici-
de (14). The presence of a therapeutically alliance
can be an important protective factor against sui-
cide (33). We had suggested a SGAs (clozapine),
against aggressive and suicidal behavior at Perso-
nality disorders (Borderline and Personality disor-
der) who attempt suicide. The median of daily dose
of clozapine was 162.5 mg/per day in patients with
diagnosis F20-29 and 25mg/per day in patients
with diagnosis F60-69. There was a statistically
significant difference on three psychiatric scales:
BPRS total score , GAF total score and CGI score
from the baseline to 4 weeks, respectively (all Ps. <
.001). It s very important to understand a patient’s
psychodynamic responses to past suicide crises or
attempts. Treatment of the patient at risk for suicide

requires a full commitment of time and effort by the
clinicians (34).
Conclusion
The usage of clozapine therapy in patients with
schizophrenia and schizoaffective disorder at high
risk for suicide is associated with significant re-
duction in suicidal behavior.
Clozapine should also be considered in cases
of protracted suicidality and in patients with persi-
stent aggressiveness and also reduces impulsivity.
The decrease in suicidal behaviors observed with
clozapine treatment has important potential qua-
lity-of-life benefits for individual patients, their
family and society. Treatment of the patients at
risk suicide requires a full commitment of time
and effort by the clinician. Clinicians must be able
to effectively manage the inevitable anxieties and
vicissitudes that arise in the treatment of suicidal
patients. Modern psychiatry has recognized the
importance of making every effort to return a pati-
ent to an active and productive life.
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Corresponding author
Saida Fisekovic,
Department of Psychiatry,
University of Sarajevo Clinical Center,
Bosnia and Herzegovina,
E-mail:saida_fisekovic@yahoo.com

Contribution to the epidemiology
prolonged forms hepatitis “A”
Dautovic-Krkic S, Hadzic A, Mesic A
Clinic for Infectious Diseases, University Clinical Center Sarajevo, Bosnia and Herzegovina
Abstract
From all acute hepatitis cases, 4-22% is pro-
longed hepatitis A (PHA). Clinical manifestations
are relapses, recrudescentions and prolonged form
of the disease from the begining. Currently, it is
not clear which role prolonged hepatitis plays in
endemicity of HAV infections, in some areas.
We evaluated all aspects (epidemiological,
clinical, biochemical, immunological and hysto-
pathological) of prolonged hepatitis A infections
in multicentric study, in period of three years.
Aim: The aim was to investigate the frequency
of prolonged hepatitis A infection in two, geo-
graphically separated and epidemiologically dif-
ferent areas (endemic and non-endemic), in order
to estimate the importance of that factor in ende-
micity maintaince.
Material and methods: A prospective study
was preformedin Banja Luka - region in period
01.01.1988.- 30.12.1990. and retrospective study
in Sarajevo- region in period January1988. - De-
cember 1990. and January 1994. - December 1996.
Patients were treated from all types of hepatitis A
in clinics for infectious diseases both regions. Di-
agnosis was confirmed by ELISA assay (positive
IgM immunoglobulin). Hepatitis virus A antigen
(Ag-HAV) in stool was confirmed by immuno-
electro-osmophoresis. Hepatitis was prolonged if
it clinically and biochemically lasted more than 12
weeks.
Results: The main frequency of prolonged
HAV-infection for evaluated period was 11,5% in
Banja Luka-region nad 3,6% in Sarajevo-region.
The longest excretion of HAV in stool was 5,5
months (22 weeks of the disease).
Conclusion: According to duration of Ag-
HAV excretion in stool, results show that pro-
longed hepatitis A plays important role in persis-
tent HAV infection in population of particular re-
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
gions. In endemic areas we found out significantly
higher frequency of PHA.
Key words: Hepatitis A, prolonged hepatitis
A, epidemiology, HAV-infection.
Introduction
Acute viral hepatitis (HAV) is still important
public and health problem in many areas of the
world for the following reasons: Epidemic onset,
unknown source of the infection in 40-50% cases,
atypical forms and extrahepatic manifestations, le-
thal outcome in 50% if fulminant form is present,
pathogenesis of the disease is not completely clear
and appearance of autoimmune hepatitis type I af-
ter HAV.
Excretion of Ag-HAV by stool for weeks and
months is proved in: animal experiments, new-
borns, persons with prolonged form of the disease
(1, 2, 3).
Prolonged forms hepatitis A (PHA) is atypi-
cal form of the disease. Synonyms for this form
are: biphasic, polyphase, relapsing, recidivating,
unusual type of HAV. PHA appears in 4-22% of
all acute hepatitis cases (4, 5, 6, 7, 8, 9, 10, 11).
Clinical course can have one or more phases.
New phase of the disease can be symptomatic or
asymptomatic.
Clinical presentation is:
- Relapse / recidive (recurrent disease after
latent period)
- Recrudescention (deterioration in phase of
reconvalescence),
- Prolonged form of the disease from the
beginning clinical and/or biochemical (12,
13, 14,15)
The role of prolonged hepatitis in endemicity
of HAV-infection in some areas is still not clear.
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HealthMED - Volume 5 / Number 6 / 2011

We evaluated all aspects (epidemiological, cli- - Appeared again after latent period,
nical, biochemical, immunological, virological and - Worsen after beginning/ during period of
hystopathological) of prolonged hepatitis A infecti- resolving symptoms,
ons in multicentric study, in period of three years. - From the beginning has prolonged course.

Sarajevo & Banja Luka Region

AIM of study

- The aim was to investigate the frequency

of prolonged hepatitis A infection in two
geographically separated and epidemiological
different areas (endemic and non-endemic), in
order to estimate the importance of this factor
in endemic maintenance.
- To determine lasting of HAV antigen excretion
by stool in patients with PHA as a possible
factor for HAV-infection endemicity.

Material and methods

A prospective study was performed in Banja

Luka region in period of 1st of January 1988. untill
31st of December 1990. and retrospective study in
Sarajevo region in period of 1st of January 1988.
untill 31st of December 1990. and 1st of January
1994. untill 31st of December 1996. Patients were
treated for all types of hepatitis A in clinics for In-
fectious Diseases, in both of regions.
Diagnosis was confirmed by ELISA assay (pos-
itive anti-HAV IgM immunoglobulin). Hepatitis
virus A antigen (Ag-HAV) in stool was confirmed
by counter-current immune electroosmophoresis .
Hepatitis was prolonged if it lasted more than
12 week, clinically and biochemically.
Clinical material and methods
The study was performed with two groups of
patients, inpatient and outpatient.
Patients were in age group of 4 - 35 years old,
33 females and 57 males.
Control group: 30 patients (13 females and 17
males) with acute hepatitis “A” that was cured,
clinically and biochemically, for 4-6 weeks.
Experimental group: 60 patients (20 females
and 40 males) with prolonged hepatitis ”A ”
(PHA), where disease:
Banja Luka region (blue)
Sarajevo region (red)
Methods investigated
I our research we used methods:
- Anamnesis,
- Physical examination,
- Laboratory examination.
Biochemical tests:
We are investigate : SE, blood smear, glucose,
urea, creatinin, transaminases, total and direct bili-
rubin, proteinogram, prothrombin time, Fe in serum.
Tests were repeated every seven days during hos-
pitalisation, every month in control examinations,
until complete clinical and biochemical recovery.
Immunological tests:
- Antibodies for hepatitis A were measured in the
beginning and at the end of hospitalisation, and
in control examination every month.
- Antibodies for HBV, HCV, CMV, EBV,
Toxoplasma and Leptospira: were measured
twice with interval of 15 day.

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 HealthMED - Volume 5 / Number 6 / 2011

Virological test: Results

- Measurement of Ag-HAV in stool by counter-
current immunoelectro-osmophoresis.
- Epidemiological investigation was performed
by prospective-retrospective and descriptive
methods.

Grafic 1. Frequency of PHA was highest in one

or two years after peak of epidemy.VHA
VHA*- viral hepatitis A
PHA* prolonged hepatitis A

Table 1. Frequency of PHA by years in two different regions in period of 1988 - 1990. Data are presen-
ted by years of investigation in Sarajevo region for non-epidemic period and for the same period of time
in Banja Luka region, which was epidemic.
Region
Year of investigation Sarajevo (No) Banja Luka (No)
VHA* PHA*(%) VHA PHA(%)
1988 275 7 (2,5) 946 92 (9,7)
1989 202 6 (2,9) 630 88 (13,9)
1990 250 3 (1,2) 447 52 (11,6)

Table 2. Frequency of PHA at Sarajevo-egion in period of 1994-1996. Results for Sarajevo-region for
epidemic period by years of investigation are presented.
Region
Year of investigation Sarajevo
VHA* PHA*(%)
1994 749 21 (2,8)
1995 328 17 (5,1)
1996 74 4 (5,4)
VHA*- viral hepatitis A
PHA* prolonged hepatitis A

Table 3. The total number of hospitalised patients at Sarajevo- region for unepidemic period (1988/90.)
and epidemic period (1994/96), and at Banja Luka- region for epidemic period (1988/90.).
Region
Year of investigation Sarajevo Banja Luka
VHA* PHA*(%) VHA PHA(%)
1988-90. 727 16 (2,2) 2023 232 (11,5)
1994-96. 1151 42 (3,6) - -
VHA*- viral hepatitis A
PHA* prolongirani hepatitis A

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HealthMED - Volume 5 / Number 6 / 2011
Table 4. Ag-HAV in stool of patients with HAV. The number of patients with HAV-infection that had HAV
antigen in stool is presented.
Groups
Absolute
Control HAV*(N=10) 6 (60%)
PHA* (N=39) 15 (62,5%)
HAV*- viral hepatitis A
PHA* prolonged hepatitis A
Virological examination
In 10 control patients and in 39 patients of PHA
group we investigated HAV-antigen in stool. Both
group of patients had permanent Ag-HAV excreti-
on, followed by intermittent excretion.
In control group all patients had positive Ag-
HAV in stool, intermittently or permanently.
In PHA group 39% patients had absolutely ne-
gative Ag-HAV in stool.
From 24 patients with positive result, 19 were
with relapse/ recrudescention, and five were with
primarily prolonged course of the disease.
The earliest detection of Ag-HAV was 35th day
of the disease, on the beginning of the first recru-
descention, and the latest detection was at 159th
day of the disease (5,5 months from the beginning
of the disease).
Ag-HAV was discovered 6 times during I and
II recrudescention, with interval of two days; we
didn’t follow it further.
Discussion
Our investigation at Banja Luka region for
three-years period (1988-1990) has shown that
the highest frequency of PHA was one year af-
ter epidemic year (1988.) and it was 13,9% of all
infected patients. In next year (1990.) percent of
patients with PHA was higher for 1,9% (11,6%)
comparing to epidemic year 1988 (9,7%).
At Sarajevo region for the same period (1988-
90.) the number of hospitalised patients with HVA
was three times lower, and percent of PHA was
low by years: 2,5%: 2,9%: 1,2%.
In epidemic period 1994-96. The highest num-
ber of hospitalised patients with HAV was in 1994,
1832
Ag-HAV in stool
Positive
Negative
Intermittent Total
4 (40%) 10 (100%) -
9 (37,5%) 24 (61%) 15 (39%)
but the frequency of PHA was highest in one or
two years after peak of epidemy (95/96.): 5,1%
and 5,4%, in epidemic year 1994 it was 2,8%.
The frequency of PHA is 4-24%, according to
many authors(4, 5, 6, 7, 8, 9, 10, 11).
Although there is lack of parameters for com-
parison we think that low percent of PHA correla-
tes with our results at unendemic region (Sarajevo)
for unepidemic period, and high percent of PHA
correlates with results at endemic region (Banja
Luka). For epidemic period results are higher.
Following data support our hypothesis:
- Yao G.B (1990.) Reported PHA in 22% cases
after biggest epidemic in Shanghay 1988,
caused by raw shells consumption(13).
- Fabri M. at all. (1997) Performed 10-years
study at Novi Sad region, and they found
out that 3-16% patients with HAV-infection
can have relapse and lasting of the disease is
prolonged (14).
- Chiriaco at all. (1986) say that ''polyphase''
course of hepatitis is usually seen in
children at areas highly endemic for viral
hepatitis«(16).
Investigations were not preformed at different
areas and there are no data about correlation be-
tween relapse and epidemic onset of the disease.
Although Teoharova in 1978 reported first
case of prolonged excretion of Ag-HAV in stool,
and Gruer et al. in 1982 assumed possibility of re-
tention virus in organism due to prolonged repli-
cation, in 1987 Sjegren confirmed this with three
methods(17,18,19). Preliminary results of our two
years long study of secretion of Ag-HAV in stool
with prolonged form of disease we preliminary re-
ported in 1990, and definitive results of research in
2001 and 2004 (1,12, 20). Our results are partially
Journal of Society for development in new net environment in B&H

consistent with experimentally findings of Math-
iesena et al., and Stapelton et al.(21, 22 ).We think
that negative findings of stool for Ag-HAV in 39%
of patients with PHA are probably result of modi-
fied (weakened) immunity of patients or result of
enhanced action of neutralising antibodies. As we
did not determine level of functional antibody on
Ag-HAV we cannot determine firmly its role in
result.
Our research of length of excretion of Ag-HAV
in stool was limited in time. I relapse/recrudes-
cence we determined Ag-HAV approximately 7
times, regardless of length of relapse /recrudes-
cence. We did not determine Ag-HAV in stool to
the end of relapse. In literature we did not find data
about length of excretion of Ag-HAV in
stool in prolonged forms of disease and therefore
we cannot compare our data with other.
In favour of our results are results of Rosen-
blum et al., with prematurely born children, where
symptomatic excretion of Ag-HAV is followed
till 3,5; 4,5 and 5 months, which had influence in
transmission of HAV infection on other children
in daily centres and kindergartens (2).
Our thoughts are following: excretion of Ag-
HAV in stool and length of disease depends of viral
replication and appearance of multiple viremias.
Prolonged excretion of Ag-HAV in patients with
symptomatic relapses and recrudescence, who
were acutely ill several months before, strongly
impact on epidemiological situation, emergence
of new sudden HAV epidemics-infection in areas
with poor hygienic conditions (every 5-7) years.
It can be presumed that in childhood age pro-
longed hepatitis A has subclinical characteristics
as acute illness, so it can be overlooked. Number
of relapses and recrudescence which are not rec-
ognised as HAV disease can be different accord-
ing to number, therefore excretion of Ag-HAV in
stool can be long, depending of prolonged disease.
It can be reason why in overcrowded poor areas
with low economic and hygienic standard persists
so called chronically epidemic of HAV infection,
where disease is in fact endemic. These are non-
developed and underdeveloped countries, because
in developed countries there aren't any endemic
areas for HAV.
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
Conclusions
- In area which is not endemic for HAV
infection frequency of prolonged hepatitis
A in epidemic period is 3,6% (Sarajevo
region)
- In area, which is endemic, frequency of
HAV in epidemic period is 11,5 (Banja Luka
region)
- Frequency of prolonged hepatitis A is larger
in epidemic then in nonepidemic period.
- Largest number of infected from PHA is
in one to two year’s period after peak of
epidemic.
- Ag-HAV excretion in stool, at beginning
continuously then intermittent is followed
for longer period in patients who had relapse
and more periods of recrudescence
- Longest excretion of Ag-HAV in stool for
patients with prolonged hepatitis is 159 days
5,5 months)
- Prolonged hepatitis A has important role
in persisting of infection in population
at researched region and therefore has
direct role in maintaining of endemic
characteristics of region
- It is important to continue investigation
of duration of excretion of Ag-HAV in
prolonged forms of disease.
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Corresponding author
Dautovic-Krkic S,
Clinic for Infectious Diseases,
University Clinical Center Sarajevo,
Bosnia and Herzegovina,
E-mail: healthmedjournal@gmail.com

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statistical analysis. In discussion, results are interpreted
and compared to existing, previously published findings
in the same field. Conclusions have to give an answer to
author’s goal.
Journal of Society for development in new net environment in B&H
HealthMED - Volume 5 / Number 6 / 2011
References
Quoting references must be in a scale in which they
are really used. Quoting most recent literature is recom-
mended. Only published articels (or articles accepted
for publishing) can be used as references. Not-published
observations and personal notifications need to be in text
in brackets. Showing references is as how they appear
in text. References cited in tables or pictures are also
numbered according to quoting order. Citing paper with
six or less authors must have cited names of all authors;
if seven or more authors’ wrote the paper, the name of
the first three authors are cited with a note “et all”.
If the author is unknown, at the beginning of papers
reference, the article is named as “unknown”. Titles of
the publications are abbreviated in accordance to Index
Medicus, but if not listed in the index, whole title of the
journal has to be written.
Footnote-comments, explanations, etc., cannot be
used in the paper.
Statisticial analysis
Tests used for statistical analysis need to be shown in
text and in tables or pictures containing statistical ana-
lysis.
Tables and pictures
Tables have to be numbered and shown by their or-
der, so they can be understood without having to read
the paper. Every column needs to have title, every me-
asuring unit (SI) has to be clearly marked, preferably in
footnotes below the table, in Arabian numbers or sym-
bols. Pictures also have to be numbered as they appear
in text. Drawings need to be enclosed on a white paper
or tracing paper, while black and white photo have to be
printed on a radiant paper. Legends next to pictures and
photos have to be written on a separate A4 format paper.
All illustrations (pictures, drawings, diagrams) have to
be original and on their backs contain illustration num-
ber, first author last name, abbreviated title of the pa-
per and picture top. It is appreciated if author marks the
place for table or picture. Preferable the pictures format
is TIF, quality 300 DPI.
Use of abbreaviations
Use of abbreviations has to be reduced to minimum.
Conventional units can be used without their defini-
tions.
1835
HealthMED - Volume 5 / Number 6 / 2011
Uputstvo za autore
Sve rukopise treba slati na e-mail adresu healthmedjournal@gmail.com
Svaki upućeni časopis dobija svoj broj i autor(i) se
obavještavaju o prijemu rada i njegovom broju. Taj broj
koristit će se u svakoj korespondenciji. Rukopis tre-
ba otipkati na standardnoj veličini papira (format A4),
ostavljajući s lijeve strane marginu od najmanje 3 cm.
Sav materijal, uključujući tabele i reference, mora biti
otipkan dvostrukim proredom, tako da na jednoj strani
nema više od 2.000 alfanumeričkih karaktera (30 linija).
Rad treba slati u triplikatu, s tim da original jedan pri-
log materijala može biti i fotokopija. Način prezentacije
rada ovisi o prirodi materijala, a (uobičajeno) treba da
se sastoji od naslovne stranice, sažetka, teksta, referenci,
tabela, legendi za slike i slika. Svoj rad otipkajte u MS
Wordu i dostavite na disketi ili kompakt disku Redakcij-
skom odboru, čime će te olakšati redakciju vašeg rada.
Naslovna strana
Svaki rukopis mora imati naslovnu stranicu s naslo-
vom rada ne više od 10 riječi: imena autora; naziv usta-
nove ili ustanova kojima autori pripadaju; skraćeni na-
slov rada s najviše 45 slovnih mjesta i praznina; fusnotu
u kojoj se izražavaju zahvale i/ili finansijska potpora i
pomoć u realizaciji rada, te ime i adresa prvog autora ili
osobe koja će s Redakcijskim odborom održavati i kore-
spondenciju.
Sažetak
Sažetak treba da sadrži sve bitne činjenice rada-svr-
hu rada, korištene metode, bitne rezultate (sa specifičnim
podacima, ako je to moguće) i osnovne zaključke. Sa-
žeci trebaju da imaju prikaz istaknutih podataka, ideja i
zaključaka iz teksta. U sažetku se ne citiraju reference.
Ispod teksta treba dodati najviše četiri ključne riječi.
Sažetak na bosanskom jeziku
Prilog radu je i prošireni struktuirani sažetak (cilj),
metode, rezultati, rasprava, zaključak) na bosanskom je-
ziku od 500 do 600 riječi, uz naslov rada, inicijale imena
i prezimena auora te naziv ustanova na engleskom jezi-
ku. Ispod sažetka navode se ključne riječi koje su bitne za
brzu identifikaciju i klasifikaciju sadržaja rada.
Centralni dio rukopisa
Izvorni radovi sadrže ove dijelove: uvod, cilj rada,
metode rada, rezultati, rasprava i zaključci. Uvod je kra-
tak i jasan prikaz problema, cilj sadrži kratak opis svrhe
istraživanja. Metode se prikazuju tako da čitaoci omo-
guće ponavljanje opisanog istraživanja. Poznate metode
se ne navode nego se navode izvorni literaturni podaci.
1836 Journal of Society for development in new net environment in B&H
Rezultate treba prikazati jasno i logički, a njihovu značaj-
nost dokazati odgovarajućim statističkim metodama. U
raspravi se tumače dobiveni rezultati i uspoređuju s po-
stojećim spoznajama na tom području. Zaključci moraju
odgovoriti postavljenom cilju rada.
Reference
Reference treba navoditi u onom obimu koliko su
stvarno korištene. Preporučuje se navođenje novije li-
terature. Samo publicirani radovi (ili radovi koji su pri-
hvaćeni za objavljivanje) mogu se smatrati referencama.
Neobjavljena zapažanja i lična saopćenja treba navoditi
u tekstu u zagradama. Reference se označavaju onim
redom kako s pojavljuju u tekstu. One koje se citiraju
u tabelama ili uz slike također se numeriraju u skladu s
redoslijedom citiranja. Ako se navodi rad sa šest ili ma-
nje autora, sva imena autora treba citirati; ako je u citi-
rani članak uključeno sedam ili više autora, navode se
samo prva tri imena autora s dodatkom “et al”. Kada je
autor nepoznat, treba na početku citiranog članka ozna-
čiti “Anon”. Naslovi časopisa skraćuju se prema Index
Medicusu, a ako se u njemu ne navode, naslov časopisa
treba pisati u cjelini. Fusnote–komentare, objašnjenja,
itd. Ne treba koristiti u radu.
Statistička analiza
Testove koji se koriste u statističkim anaizama treba
prikazivati i u tekstu i na tabelama ili slikama koje sadrže
statistička poređenja.
Tabele i slike
Tabele treba numerirati prema redoslijedu i tako ih
prikazati da se mogu razumjeti i bez čitanja teksta. Svaki
stubac mora imati svoje zaglavlje, a mjerne jedinice (SI)
moraju biti jasno označene, najbolje u fusnotama ispod
tabela, arapskim brojevima ili simbolima. Slike također,
treba numerisati po redoslijedu kojim se javljaju u tekstu.
Crteže treba priložiti na bijelom papiru ili paus papiru, a
crno-bijele fotografije na sjajnom papiru. Legende uz cr-
teže i slike treba napisati na posebnom papiru formata A4.
Sve ilustracije (slike, crteži, dijagrami) moraju biti origi-
nalne i na poleđini sadržavati broj ilustracije, prezime pr-
vog autora, skraćeni naslov rada i vrh slike. Poželjno je
da u tekstu autor označi mjesto za tabelu ili sliku. Slike je
potrebno dostavljati u TIFF formatu rezolucije 300 DPI.
Korištenje kratica
Upotrebu kratica treba svesti na minimum. Konven-
cionalne SI jedinice mogu se koristiti i bez njihovih de-
finicija.