JHSCI 2011 v1 I3 December

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

Editorial Board
Editor in chief
Advisory Board
Dijana Avdi (BiH)
Osman Duri
Faris Gavrankapetanovi
Associate editor
Ismet Gavrankapetanovi
Demal Pecar (BiH)
Muhamed Gavranovi
Mirsada Huki
Secretary
Dragan Kosori
Aida Rudi
Lidija Lincender
Slobodan Loga
Members
Farid Ljuca
Jasmina Berbi - Fazlagi (BiH)
Senka Mesihovi - Dinarevi
Amira Duri (BiH)
Muzafer Mujic
Fatima Jusupovi (BiH)
Mirza Muanovi
Mirsad Mufti (BiH)
Arif Smajki
Emela Muji - Skiki (UAE)

Budimka Novakovi (SRB)
Electronic Publishing
Naris Pojski (BiH)
Refet Gojak
Borut Poljak (Sl)
Muris Pecar
Isabelle Rishard (F)

Sandra Vegar - Zubovi (BiH)
Technical editor
Zerema Obradovi (BiH)
Faruk pilja
Dragi Bankovi (SRB)
Editorial office
Address: Bolnika 25, 71000 Sarajevo, Bosnia Herzegovina
Tel. ++387 33 444 901; 264-820; 264 890;
Fax. 264 821
E-mail: office@jhsci.ba
Journal web site: www.jhsci.ba
www.jhsci.ba
Volume 1, Number 3, December 2011
Table of contents:
Towards the better science (Editorial)
Dijana Avdi . . . . . . . . . . . . . . . . . . . . . . . 121
Research articles
The value of Pap test in women with endometrial
cancer
Aleksandra Petri, Vekoslav Lili,
Radomir ivadinovi, Predrag
Vukomanovi, Olivera Dunji,
Radmila Ignjatovi, Goran Lili. . . . 122 - 125
Gender related differences in demographic and clinical
manifestations in patients suffering from various
subtypes of schizophrenia
Gorana SulejmanpaiArslanagi. . . . . . . . . . . . . . . . . . . . . . . . 126 - 129
Conventional radiotherapy of localized right side breast
cancer after radical mastectomy: development of
innovative field in field technique
Goran Maroevi, Denita Ljuca,
Semir Fazli, Anela Rami,
Hidajet Rahimi. . . . . . . . . . . . . . . . . . . . 130 - 133
Spina bifida in surgically treated infants in Sarajevo
region of Bosnia and Herzegovina
Selma Alielebi, Ermin Agovi. . . . . 134 - 137
Evaluation of the conservative treatment of Trigger
finger by local instillation of corticosteroids
Muris Pecar, Dijana Avdi,
Demal Pecar. . . . . . . . . . . . . . . . . . . . . . 138 - 144
Antibiotic prophylaxis and inflammatory complications
after Cesarean section
Hasan Karahasan, Denita Ljuca,
Nermin Karahasan, Alija uko,
Adnan Babovi, Hidajet Rahimi. . . . 145 - 148
Knowledge and practice of health managers in using
information technology in health system
Suvada vraki, Amer Ovina. . . . . . . 149 - 153
Comparison of ARCHITECT chemiluminiscent

microparticle immunoassay for determination of
Troponin I in serum with AXYM MEIA technology
Nafija Serdarevic . . . . . . . . . . . . . . . . . 154 - 158
Doppler measurements of feto-placental blood stream
in pregnant smokers
Gordana Bogdanovi, Denita Ljuca,
Edin Ostrvica, Adnan Babovi, Enida
Nevainovi, Hidajet Rahimi. . . . . . . 159 - 165
Analysis of disease spectrum of corporate executives
after physical examination
Li Qing, Guo Huailan, Chen Jin,
Chen Jianhua, Yanjun Zeng. . . . . . . . . 166 - 170
Implementation of the hemoprophylactic protocol in
orthopedic surgery
Elvedin Osmanovic, Mensura Asceric,
Esed Omerkic. . . . . . . . . . . . . . . . . . . . . . 171 - 174
Health claims made on multivitamin and mineral
supplements
Jelena Jovii, Budimka Novakovi,
Maja Grujii, Fatima Jusupovi,
Slobodan Mitrovi . . . . . . . . . . . . . . . . 175 - 179
Evaluation of breast symptoms with mammography
and ultrasonography
Emine Devolli Disha, Suzana Manxhuka
Kerliu, Zana Baruti Gafurri,
Valdete Topciu, Bukurije Zhubi,
Hidajet Paqarizi . . . . . . . . . . . . . . . . . . . 180 - 186
INSTRUCTIONS TO AUTHORS
Instructions and guidelines to authors for the
preparation and submission of manuscripts
in the Journal of Health Sciences . . . . . . . . . 187 - 190
www.jhsci.ba
Towards the better science

Editorial
he Journal of Health Sciences successfully closes its first volume with this issue. As the year
approaches its end, we feel it is time to summarize what has been done in the previous period,
and announce what awaits us in the future.
The idea of founding a new scientific Journal, which would specialize in fields closely related to the
University of Sarajevo Faculty of Health Studies, arose from the necessity of covering those fields
in more details. That would eventually result in increase in quality of scientific communication,
knowledge transfer, professional advancement and better education for undergraduate and graduate students. This idea came into real with first issue printed in April 2011. Since that time, including
current issue, Journal has published 32 quality publications coming from authors around world, as
well as from authors from Bosnia and Herzegovina. The Journal has been indexed in IndexCopernicus Journal Master List, which will provide the authors and Journal better visibility, allowing more
citations. Journals web site plays important role as a medium of communication with international
academic community. It also serves as an educational resource, because of the variety of scientific
publishing materials and links to other scientific publishing web sites. In the near future, following
the Journals quality policy, we plan to implement Digital Object Identifier (DOI) system for referencing, and enter the Crossref and Crosscheck services, to achieve high quality standards of scientific
publishing.
The Editorial board of Journal of Health Sciences is determined to stay on current course and even
improve its efforts to raise its standards. We are aware of fact that a new journal may be less attractive for experienced researchers, but our mission and vision is to become a regional leader in scientific
publication in the fields of physical therapy, medical laboratory diagnostics, radiologic technology,
sanitary engineering, health and ecology, health care and nursing, and related fields.
We thank all authors, reviewers and colleagues who have collaborated with us in the past and hope
to continue successful cooperation in the future. We also call and encourage forthcoming authors
to submit their manuscripts to Journal of Health Sciences and present their scientific achievements
to the World.
Dijana Avdic, MD, PhD

Journal of Health Sciences 2011; 1 (3)
Editor-in-chief
121
www.jhsci.ba
The value of Pap test in women with

endometrial cancer
Aleksandra Petri1*, Vekoslav Lili1, Radomir ivadinovi1, Predrag Vukomanovi1,
Olivera Dunji2, Radmila Ignjatovi1, Goran Lili1
1
Clinic of Obstetrics and Gynecology, University of Nis, 48 Dr Zoran Djindjic Blvd, 18 000 Nis, Serbia. 2 Institute of Pathophysiology,
Medical Faculty of Nis, 81 Dr Zoran Djindjic Blvd, 18 000 Nis, Serbia.
Abstract
Introduction: Endometrial cancer is the second most common gynecological tumor. There is still no recommended screening method for endometrial cancer. The application of transvaginal sonography, hysteroscopy
and Pap test may prove useful in screening for this disease. Atypical glandular cells represent an important
finding in Pap tests and they are related to histopathological verification of the endometrium. The aim of the
study was to determine the usefulness of the Pap test in assessing the cervical infiltration, as well as to determine the significance of hormonal status and histopathological type of tumor in a pathological Pap test in
patients with endometrial cancer.
Methods: The study was retrospective. The analysis included the data obtained from 62 operated patients
diagnosed with enometrial cancer, medical history (menopausal status), histopathological findings after surgery (type and stage of the disease) and a preoperative Pap smear. The chi squared and Fishers test were
used.
Results: The difference in the prevalence of pathological Pap test in premenopausal and postmenopausal
group of patients was not statistically significant. The difference in the prevalence of pathological Pap test in
the group of endometrioid and non-endometrioid tumours of the uterine corpus had statistical significance.
The difference in the prevalence of pathological Pap test compared to the present stage (I and II) was not
statistically significant.
Conclusion: Pap smear does not correlate with menopausal status in women with endometrial carcinoma.
Abnormal Pap test is more commonly found in cases of non-endometroid tumours. Pap smears cannot be
used to assess cervical involvement.
2011 All rights reserved
Keywords: Pap smear, endometrial cancer.
Introduction
Endometrial carcinoma makes up 3.9% of all malignant tumors among women (200.000 patients)
and 1.7% of all deaths (50.000) caused by malignant diseases. The rate of incidence increases with
age. The incidence increases begins 5-10 years before menopause and the peak is reached at about
65-70 years of age (2). There is still no recommended screening test for endometrial cancer. The Pap
test is not a routine in the diagnosis of endometrial abnormalities. Most authors believe that the
* Corresponding author: Ass Dr Aleksandra Petri,
Clinic of Obstetrics and Gynecology, University of Nis,
48 Dr Zoran Djindjic Blvd, 18 000 Nis, Serbia
Tel: +381 18 527799; Fax +381 18 4224063
E-mail: sanja.petric@hotmail.com
Submitted 25. August 2011 / Accepted 30. September 2011
122
cytological diagnosis is not sufficiently sensitive in

the detection of endometrial cancer (3). Cytology
has low sensitivity due to anatomical reasons cell
desquamation must pass through the cervical canal and is thereby subject to degenerative changes.
Cervical canal stenosis and reduced number of
cells in the smear are common after menopause (3).
The cytological sampling of the endometrium can
be direct: from the uterus (including aspiration,
brushing, rinsing), and indirect: the sampled cells
are obtained from spontaneous desquamation
through the cervical canal (4). Indirect tests are unreliable and cytologists encounter diagnostic difficulties in differentiating normal from abnormal endometrial cells, whereas direct tests are expensive
and invasive and are only recommended for women at high risk of developing endometrial cancer (5).
Aleksandra Petri et al.: The value of Pap test in women with endometrial cancer
Atypical glandular cells are unusual but they represent an important finding in a Pap smear (6).
The Bethesda system classifies atypical glandular
cells (AGUS) as glandular cells with some degree
of nuclear atypia, but which do not have the features of malignant carcinoma cells. The AGUS
are present in 0.18 to 0.74% of all Pap smears.
An important percentage of these patients has
severe endometrial pathology, and these findings require a serious evaluation (6,7,8,9). The
presence of an atrophic smear, greater than
twice the size of an intermediate cell nucleus and
the absence of clusters with irregular borders
help in identifying endometrial carcinoma (7).
Liquid-based Pap test can be useful in the diagnosis of endometrial carcinoma. The application of this test helps detect endometrial carcinoma with high sensitivity (10).
The combination of cytological diagnosis, transvaginal ultrasound and hysteroscopy may be useful
in selecting the patients who need to undergo histopathological sampling of endometrial tissue (11).
The aim of the study was to determine the usefulness of the Pap test in assessing the cervical infiltration, as well as to determine the
significance of hormonal status and histopathological type of tumor in a pathological
Pap test in patients with endometrial cancer.
Methods
Samples
The study was retrospective and it included patients who had received surgical treatment for
histopathologically verified endometrial cancer.
There were 62 patients diagnosed with endometrial cancer. The analysis included the Pap test, medical history (menopausal status), histopathological
reports after surgery and post-operative stage. The
Pap test results were observed in relation to menopausal status, histological type and stage of tumor.
Table 1. Menopause and Pap tests ratio
Characteristics
Menopause
No (n=5)
Yes (n=57)
Total
Comparison
(n=62)
Pap smear
p=0.257
Normal
5 (100.0%) 45 (78.9%) 50 (80.6%)
Pathological
12 (21.2%) 12 (19.4%)
Statistical analysis
Comparison of the frequency of attribute characteristics between groups was performed with
the chi square test or Fishers exact probability test of the null hypothesis when expected frequency of some features was less than five. The
statistical analysis was performed using SPSS
software and p<0.05 was considered significant.
Results
The research included 62 patients diagnosed with
endometrial cancer. Pap test made during diagnostic procedures or preparation for surgical treatment was analyzed. There were 5 (8%) premenopausal patients and 57 (92%) postmenopausal
patients. All premenopausal patients had normal
Pap smears. Among the postmenopausal patients
there were 12 cases (19.4%) of abnormal Pap
smears. There was no difference in the presence of
pathological Pap smear in premenopausal or postmenopausal groups of women (P = 0.257) (Table 1).
In the study group (62 patients) there were 54 registered endometrioid types of tumor and 8 nonendometrioid types of tumor. The comparison of
the patients with endometrioid and non-endometrioid types of tumors revealed that abnormal
Pap test results were present in 10 (18.5%) patients with endometrioid type of tumor, whereas
in non-endometrioid tumor type there were 2
patients (24%) with abnormal Pap test results
( 2 = 6.92, p = 0.031). (The difference in findings between the groups was statistically significant). Abnormal Pap test was significantly more
common in non-edometrioid tumors. (Table 2).
Pap test was compared with the determined histopathological stage of the disease where the material was removed surgically. In patients with an early
stage of the disease, a normal Pap test was present
in 89.7% and 10.3% in pathological cases, while in
patients with other disease stages, a normal Pap
Table 2. Relationship between Pap smear testing and hptype endometrial cancer
Characteristics
Pap smear
Normal
Pathologic
Non-endometri- Endometrioid
Comparison
oid type (n=8)
type (n=54)
6 (75.0%)
2 (25%)
44 (81.5%)
10 (18.5%)
2=6.92;
p=0.031
123
Table 3. Relationship between the stage and the Pap test.

Disease stage
Pap smear findings
Comparison
I
II
Normal
35 (89.7%) 13 (72.2%)
p=0.123
Abnormal
4 (10.3%)
5 (27.8%)
Total
39 (100.0%) 18 (100.0%)
test was found in 72.2% and abnormal in 27.8%

of cases. Fisher's test did not confirm significant
differences in the prevalence of individual findings
of the Pap test for women with first and second
stage of the disease (p> 0.005). Involvement of the
cervix cannot be detected by Pap smears (Table 3).
Discussion
In our study pathological Pap smear was registered
only in postmenopausal patients but this difference was not statistically significant. According to
data (Bethesda 2001), the occurrence of endometrial cells in cervical cytology in women over 45 is
often associated with endometrial cancer and endometrial hyperplasia (12), but other authors suggest that hormonal status is not relevant in terms
of abnormal glandular cells in Pap smear (13). A
comparison of the results of the Pap test revealed
that abnormal Pap smears were significantly more
frequent in a group of women with tumors with
non-endometrioid histology. These tumors show
more rapid progression, deeper myometrial involvement, more frequent lymphovascular invasion and cervical involvement (14). Cytology
cannot be used as an independent method, but in
combination with transvaginal ultrasound (TVS)
it can be performed for patients with unfavorable
hp types and cervical involvement. (3, 4, 5). Skaznik et al. (15) state that the unfavorable endometrial types of cancers had frequent abnormal Pap
smears. The stages of endometrial cancer are based
on examination of tissue removed during an operation. Compared to earlier clinical staging, this
method has an advantage. Most authors believe
that surgical staging is reliable, particularly in the
case of adverse findings of hp, in the case of cervical involvement and deep myometrial infiltration
(15, 16, 17). Cervical infiltration has a worse prognosis, increases the incidence of metastases and
local recurrence (18). In our research, Pap test results for patients with the disease in an early stage
were normal in 89.7% of cases and abnormal in
10.3% of cases. On the other hand, Pap test results
for patients with the disease in other stages were
normal in 72.2%, and abnormal in 27.8% of cases.
Fishers test did not confirm significant differences
in the prevalence of individual findings of the Pap
test for women with first and second stage of the
disease (p> 0.005). Involvement of the cervix cannot be detected by Pap test. Imaging methods may
be applied in the evaluation of cervical involvement (19, 20). Other authors suggest that Pap
smear is not suitable for the assessment of cervical infiltration in patients with endometrial carcinoma. The exceptions are patients with tumors of
low grade endometrioid type, where a normal Pap
smear indicates a very low risk of cervical involvement and low risk of lymph node metastasis (21).
Conclusion
Patients with endometrial cancer may have abnormal Pap smears regardless of hormonal status. If non-endometrioid type of tumor is present, abnormal Pap test is more common. Cervical
involvement cannot be estimated by Pap tests.
Competing interests
The authors declare that they have no financial or
personal relationship with people or organizations
that could influence this work inappropriately.
References
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JE, Lipscomb JT, Ruiz B. Clinical significance of a cytologic diagnosis of
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9. Obenson J, Abreo F, Grafton WD.
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10. Zhou J, Tomashefski JJ, Khivami A.
Diagnostic value of the thin layer,
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cancer: a retrospective study with
emphasisi on cxtomorphologic features. Acta Cytol 2007; 51(5):735-741.
11. Minagawa Y, Sato S, Ito M, Onohara
Y, Nakaoto S, Kigawa J. Transvaginal
ultrasonography and endometrial
cytology as a diagnostis schema for
endometrial cancer. Gynecol Obstet
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12. Ashfag R, Sharma S, Dulley T, Saboorian MH, Siddiqui MT, Warner C.

Clinical relevance of benign endometrial cells in postmenopausal women.
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13. Karim BO, Burroughs FH, Rosethal
DL, Alli SZ. Endometrial type cells
in cervicovaginal smears: clinicalsignificance and cythopathologic
correlates. Diagn Cytopathol 2002;
26:123-127.
14. Rose P. Endometrial carcinoma. N
Engl J Med 1996; 9(335):640-649.
15. Skaznik-Wikiel ME, Ueda SM, Frasure HE, Rose PG, Fleury A, Grumbine FC et al. Abnormal cervical
cytology in the diagnosis of uterine
papillary serous carcinoma: earlier
detection of a poor prognosticcancer subtype? Acta Cytol. 2011; 55(3):
255-260.
16. Odicino F, Pecorelli S, Zigliani L,
Creasman WT. Hystory of the FIGO
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17. Creasmann W M.D. Controversis in
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18. Orr JW, Holimon JL, Orr PF. Stage
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BN, Homesly HD, Graham JE, Heller
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20. Savelli L, Ceccarini M, Ludovisi M,
Fruscella E, Iaco PA, Salizzoni E et
al. Preoperative local staging of endometrial cancer: transvaginal sonography vs. magnetic resonance imaging.
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C, Angel C, Guzick D. Endometrial
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125
www.jhsci.ba
Gender related differences in demographic

and clinical manifestations in patients suffering
from various subtypes of schizophrenia
Gorana Sulejmanpai-Arslanagi
Department of Psychiatry, University of Sarajevo Clinics Centre, Bolnika 25, 71 000 Sarajevo, Bosnia and Herzegovina
Abstract
Introduction: Schizophrenia is devastating neuropsychiatric disorder that has no clearly identified etiology.
The subtypes of schizophrenia are distinguished by the prevalent symptomatology. The aim of this study was
to determine gender related differences in demographic and clinical manifestations in patients suffering from
various subtypes of schizophrenia.
Methods: A longitudinal, prospective,original,clinical investigation first in our local area, with application of
Structured Clinical Interview for DSM IV Axis I Disorders (SCID I) was used in this work. The study included
121 patients during five years period. Patients were recruited as consecutive admissions to the Psychiatric
clinic, from all parts of Bosnia and Herzegovina, mostly Sarajevo region.
Results: The study was conducted on a group of schizophrenic patients which consisted of 52.1% male and
47.9% female patients. Average duration of the episode was about a month. Majority of patients (male) were
in the group of disorganized (hebephrenic) schizophrenia. The duration of current psychotic episode was
similar in all three groups regarding subtypes of schizophrenia. Psychotic episodes appear equally in both
gender (higher in disorganized group) with a statistically significant difference between all groups (p<0.001).
Conclusions: Male group patients showed tendency to be younger than women. Most of the schizophrenic
individuals start to suffer from this disease between age of 20 and 39 years. Male group patients suffered
mostly of disorganized (hebephrenic) type of schizophrenia. Duration of psychotic episode was proportionally
the same in both groups while in male group the highest number of episodes was found in group of disorganized schizophrenia.
Keywords: schizophrenia, gender differentiality, SCID I, DSM IV
Introduction
Schizophrenia is a disorder with a significant heterogeneous presentation of a variety of symptoms
that can affect virtually all areas of psychological
functioning and which are best understood to
represent separate psychopathological syndromal domains (occurring in about 0.5%-1% of
the population). This major symptom doimains
include positive, negative, cognitive, excitement
and depression/anxiety symptoms and are found
in each patient with schizophrenia to a variable
extent (1). The subtypes of schizophrenia are
distinguished by the prevalent symptomatology. There are various subtypes of schizophrenia as specified by the particular diagnostic system. The most dominant subtypes occurring in
schizophrenia patients, which include paranoid,
disorganized (hebephrenic), catatonic, undifferentiated, and residual schizophrenia (2). The aim
of this study was to determine gender related differences in demographic and clinical manifestations in patients suffering from various subtypes
of schizophrenia using a Structured Clinical Interview for DSM IV Axis I Disorders (SCID I).
* Corresponding author: Gorana Sulejmanpai-Arslanagi,

Department of Psychiatry, University of Sarajevo
Clinics Centre, Bolnika 25, 71 000 Sarajevo, Bosnia
and Herzegovina Phone: 061 262-353, 033 297-538
e-mail: sretnidjecak@gmail.com, Fax:033 265 710
Methods
Patients
A longitudinal,prospective,original,clinical investigation, first in our local area, with application of
Structured Clinical Interview for DSM IV Axis I
Submitted 2. September 2011 / Accepted 15. November 2011
126
Gorana Sulejmanpai-Arslanagi: Gender related differences in demographic and clinical

manifestations in patients suffering from various subtypes of schizophrenia
Table 1. Demographic data of subjects divided according

to gender
Number of
subjects
Age (years)
Range
Age of the onset
(years) Range
Duration of
current psychotic
episode (months)
Number of psychotic episodes
Male
Female
63
58
Students t test
t
p
df=119
32.4 6.4
(22-45)
20.6 2.9
(18-33)
39.0 5.8
5.928
(23- 54)
28.8 4.7
11.624
(18-39)
1.3 0.5
1.5 0.6
1.921
0.057
4.0 1.3
3.4 1.2
2.225
0.028
0.001
0.001
df, degrees of freedom
Disorders (SCID I) was used in this work. SCID

represents diagnostic instrument which covers
up all diagnostic criteria necessary for establishing diagnosis of mental conditions according to
the DSM IV (DSM IV; APA 2000). The study included 121 patients during five years period, out
of this number 63 male and 58 female patients
with schizophrenia older than 18 years. Patients
were recruited as consecutive admissions to the
Psychiatric clinic, from all parts of Bosnia and
Herzegovina,mostly Sarajevo`s region.All patients have signed an informant consent before
they were included in study. Average age of patient

in the time of study was 356.1 years (standard
deviationSD), range 32 to 39 years. A gender related difference was observed in the current age
compared to various subtypes of schizophrenia as
well as: a) in a age of disease onset; b) duration of
psychotic episode; c) number of psychotic episodes.
Results are presented as mean value standard
deviation (SD).The statistical analysis of results
were used Students t test,One Way Analysis of
Variance (ANOVA) and All Pairwise Multiple
Comparison Procedures (Tukey Test). Statistically significant differences were considered those
in which the p value was less than 0.05 (p <0.05).
Results
The study was conducted on a group of schizophrenic patients which consisted of 52.1% male and
47.9% female patients. Statistical analysis of demographic data (Table 1) showed that female patients
with schizophrenia were older than male patients.
In men schizophrenia stared at earlier age with
worse prognosis and pre-morbid history of the
disease than in women. Comparative analysis
of average number of episodes during life to the
moment of investigation regarding gender, demonstrates that there is a statistically significant difference in the
Table 2. Age of disease onset/duration of psychotic episode/number of psyinvestigated sample where more
chotic episodes compared to diagnostic categories-female patients (ANOVA
episodes are found in male paand Tukey test)
tients. In the investigated sample,
comparative
analysis of duration
Disorganized UndifferentiANOVA
Schizophrenia
Paranoid
(month)
of
psychotic
episode does
(hebephrenic) ated schizoF
P
subtypes
schizophrenia
schizophrenia
phrenia
df=2.55
not demonstrate statistically sigNumber of
nificant differences. Average du16
29
13
female subjects
ration of the episode was about a
Age (years)
40.35.9
37.35.8
40.54.3
month. Statistical analysis (Table
2.052 0.138
Range
(26-54)
(23-46)
(36-48)
2, Table 3) comparing the numAge of the
ber of patients regarding subtypes
28.84.5
28.34.7
29.04.5
onset (years)
0.117 0.889
(20-34)
(18-34)
(23-39)
of
schizophrenia indicates that
Range
the
majority of patients (male)
Duration of
were
in the group of disorganized
current psy1.40.71
1.50.59
1.60.73 0.250 0.780
(hebephrenic)
schizophrenia.
chotic episode
(months)
Different subtypes of schizophreNumber of psynia were observed in the cur2.60.8
4.01.03
2.91.08
13.830 <0.001
chotic episodes
rent age as well as in the age of
the onset of disease. Female padf, degrees of freedom
127

Table 3. Age of disease onset/duration of psychotic episode/number of psychotic episodes compared to diagnostic categories-female patients (ANOVA
and Tukey test)
order that has no clearly identified

etiology. The disorder has a similar
incidence (0.6%-1.1%) around the
Disorganized UndifferentiANOVA
world, but it progresses at varying
Schizophrenia
Paranoid
(hebephrenic) ated schizoF
P
subtypes
schizophrenia
degrees of severity. By comparischizophrenia
phrenia
df=2.60
son of number of patients at the
Number of male
14
39
10
onset
of disease, and total number
subjects
of
episodes
with regard to the diAge (years)
32.16.9
32.36.1
33.27.2
0.0910 0.913
agnostic
categories
we observed
Range
(22-40)
(23-44)
(24-45)
in
our
study
that
male group
Age of the
19.82.2
21.03.3
20.31.9
onset (years)
1.040 0.360
of
patients
mostly
was
of disor(18-26)
(18-33)
(18-24)
Range
ganized (hebephrenic) type of
Duration of
schizophrenia what presents stacurrent psytistically
significant difference (7).
1.40.60
1.30.47
1.20.35 0.305 0.738
chotic episode
When
we
consider paranoid and
(months)
undifferentiated
form of the disNumber of
ease
in
a
group
of
female patients
psychotic
2.80.8
4.61.1
3.11.1
17.082 <0.001
episodes
is recorded equally higher number but statistically significant
df, degrees of freedom
difference was not observed (8).
Duration of psychotic episode is
proportionally same in both groups of patients
tients with schizophrenia were older than male
patients in all diagnostic groups. The duration while in men the highest number of episodes was
found in group of disorganized schizophrenia
of current psychotic episode was similar in all
three groups regarding subtypes of schizophre- which was also the most disabling form of the
nia. Analyzing frequency of patients regarding disease (9). Sample of conducted longitudinal,
prospective, original, clinical investigation, first in
the number of psychotic episodes demostrated
that it appears equally in both gender (higher our local area, with application of semi-structured
in disorganized group) with a statistically sig- diagnostic interview, respected common epidenificant difference between all groups (p<0.001). miological criteria regarding frequency of schizophrenic psychosis. Our results, which analyzed age
for disease onset regarding gender distribution,
Discussion
In recent studies higher incidence of schizophre- demonstrate that in male group patients showed
nia is observed in male gender, but it is also be- tendency to be younger that women. Most of the
lieved that majority of these studies are not strictly schizophrenic individuals start to suffer from this
directed to studying gender distribution as a part disease between age of 20 and 39 years. In total
of this disease (3,4). Even though life long risk of number of episodes with regard to the diagnostic
onset of schizophrenia is basically equal in men categories,we concluded that male group of patients mostly was of disorganized (hebephrenic)
and women, age of the disease onset is earlier in
men with worse prognosis, what significantly type of schizophrenia what presents statistically
limits professional training and it confirms that significant difference.When we considered parawomen with schizophrenia function better what noid and undifferentiated form of the disease in
results in more favorable course and outcome of a group of female patients, it was recorded equally
higher number, but with no statistically significant
the disease (5,6). Our results completely match
those of studies which analyzed age for dis- difference.Duration of psychotic episode was proease onset regarding gender distribution. Most portionally the same in both groups while in male
of the schizophrenic individuals start to suffer group the highest number of episodes was found
from this disease between age of 20 and 39 years. in group of disorganized schizophrenia which
Schizophrenia is devastating neuropsychiatric dis- was also the most disabling form of the disease.
128

Conclusion
In schizophrenia, gender diversity could be also
a demonstrator of the disease course and outcome. This process will in turn lead to a better
understanding of underlying illness mechanisms
and in the development of better approaches in the treatment of this complex disorder.
Competing interests
The author declare that there is no financial and
personal relationship with other people or organizations that could inappropriately influence this
work.
References
1. Freedman R. Schizophrenia.New
Engl J Med 2003;349:1738-1749.
2. Walker E, Kestler L, Bollini A, Hockman
KM.Schizophrenia:etiology
and course.Annu Rev Psychol
2004;55:401-430.
3. Abel KM, Drake R, Goldstein JM. Sex
differences in schizophrenia.Int Rev
Psychiatry 2010;22(5):417-428.
4. Riecher-Rssler A, Hfner H. Gender
aspects in schizophrenia: bridging
the border between social and biological psychiatry 2000. Acta Psychi-
atr Scan Suppl.2000;(407):58-62.

5. Aleman A, Kahn RS, Selten J-P.
Sex differences in the risk of
schizophrenia:evidence from a metaanalysis. Arch Gen Psychiatry 2003;
60:565-571.
6. Goldstein JM, Faraone SV, Chen NJ,
Tolomiczencko G, Tsuang MT. Sex
differences in the familial transmission of schizophrenia. Br J Psychiatry
1990; 156: 819-826.
7. Leung A, Chue P.Sex differences in
schizophrenia, a review of the lit-
erature.Acta Psychiatr Scand Suppl.

2000;401:33-38.
8. Aleman A, Kahn RS, Selten J-P. Sex
differences in the risk of schizophrenia. Arch Gen Psychiatry 2003; 60:
565-571.
9. Grossman LS, Harrow M, Rosen C,
Faull R. Sex differences in outcome
and recovery for schizophrenia and
other psychotic and nonpsychotic
disorders. Psychiatr Serv 2006; 57:
844-850.
129
www.jhsci.ba
Conventional radiotherapy of localized right

side breast cancer after radical mastectomy:
development of innovative field in field
technique
Goran Maroevi1*, Denita Ljuca2, Semir Fazli1, Anela Rami1, Hidajet Rahimi3
Department of Radiotherapy, University Clinical Centre Tuzla, Trnovac bb, 75000 Tuzla, Bosnia and Herzegovina. 2 Department
of Gyneacology and obstetrics, University Clinical Centre Tuzla, Trnovac bb, 75000 Tuzla, Bosnia and Herzegovina. 3 Medical
Centre, ivinice, Alije Izetbegovia 17, 75270 ivinice, Bosnia and Herzegovina
Abstract
Introduction: The aim of this paper is to study the distribution of the therapy dosage applied by a modified
conventional field in field technique and compare it to the distribution of the dosage applied by the standard
conventional technique.
Methods: The study included ten patients with right side breast cancer, after they were exposed to radical
mastectomy and chemotherapy. Radiotherapy dosage of TD 50 Gy in 25 fractions was applied to the anterolateral side of the right thoracic wall, with two opposite conventional tangential fields by the linear accelerator
Elekta Synergy and the energy of 6 megavolts (MV). A delineation of the target volume (CTV Clinical Target
Volume) was done within conventional fields. At the XiO system for planning we included additional fields
within the existing conventional fields, which was the so called field in field technique. On the basis of CTV
the Dose Volume Histogram (DVH) was calculated for conventional and field in field plans. VD90%, VD95%,
VD107%, VD115%, CI and HI were calculated for both techniques. Means were pared with the paired Student's t-test. The results were considered significantly different if p<0.05.
Results: VD90% and VD 95% were significantly higher for the field in field technique. Therefore, CI also
favored the field in field technique (p=0.02). There was no difference in VD107% and VD115% between
the compared groups. Consequently, there was no statistically significant difference in HI (1.130.03 vs.
1.130.03, p=0.06).
Conclusion: Conventional postoperative radiotherapy of localized right side breast cancer by field in field
technique provides excellent coverage of the target volume by radiotherapy isodose.

Keywords: conventional radiotherapy, field in field technique, breast cancer
Introduction
Postoperative radiotherapy is a standard approach
in combined treatment of breast cancer. Conventional radiotherapy is based on tangential photon
fields. Most frequently prescribed dose is 50 Gy
in 25 fractions within 5 weeks (1). Conventional
planning of dose distribution on the basis of two
tangential wedged fields, often results is subdosing the target volume; certain part of the target
* Corresponding author: Goran Maroevi,
Department of Radiotherapy, University Clinical Centre Tuzla,
Trnovac bb, 75000 Tuzla, Bosnia and Herzegovina
Phone: +387 35 303 500; Fax: +387 35 250 474
E-mail: mar.goran@hotmail.com
Submitted 1. August 2011 / Accepted 3. October 2011
130
volume receives less than 95% of the dose, while

another part receives more than 107% of the dose.
Such distribution is the factor the negatively affects the treatment outcome as well as the cosmetic effect (2-4). Conventional postoperative
radiotherapy by tangential fields has been used in
breast cancer treatment for decades. Nowadays,
on the basis of computer tomography postoperative conformal and intensity modulated radiotherapy of breast cancer is used. On the basis of
precise delineation of the target volume and the
organs at risk, by using conformal radiotherapy
the homogenous distribution of the therapy dose
is achieved, with maximum saving of healthy organs (lungs, heart) (5-8). After radical mastectomy
Goran Maroevi et al.: Conventional radiotherapy of localized right side breast cancer
after radical mastectomy: development of innovative field in field technique
of right side breast, conventional radiotherapy can

be planned on the basis of computer tomography. Bearing in mind that there is no irradiation
of the region of the pertaining lymph drainage
and that the target is right side breast, the effect
of the dose on the heart and the right lung shall
not be analyzed. Namely, by using the principals
of conformal radiotherapy, it is possible to modify
the conventional technique of tangential fields in
order to achieve optimum isodose distribution.
The aim of this paper is to study the distribution of the therapy dose applied by the modified
conventional (field in field) technique, and
compare it to the distribution of the dose applied by the standard conventional technique.
Methods
Patients
This study included ten patients with right side
breast cancer, who were previously mastectomized
and who received chemotherapy. They were treated at the Department for radiotherapy, University Clinical Center in Tuzla during the year 2010.
The data on patients and radiotherapy plans were
taken from their case histories and Impac Mosaiq
software system for storing data for radiotherapy
at the Department for radiotherapy at the Clinical
hospital for oncology, hematology and radiotherapy of the University Clinical Center Tuzla. Including factors were: patients with localized right side
breast cancer, radical mastectomy made, patients
irradiated by conventional technique with two tangential fields. Excluding factors were: patients with
locally advanced right side breast cancer, radical
mastectomy not made, patients not irradiated by
conventional techniques with two tangential fields.
Procedures
Patients were positioned in the standard supination position and immobilized on the Wing step
immobilization system. CT stimulation was made
for all patients. CT topogram was made from
the mandible angle to the level of 5 cm below
the healthy breast, and 5 mm thick section. The
planning of the isodose distribution was done on
the XiO system for planning transcutaneous radiotherapy. Bolus was put on the right side of the
thoracic wall. Bolus is a tissue-equivalent material
placed directly on the skin surface which is thick

enough to provide adequate dose buildup over the
skin surface (9). By using variable wedges (Elekta
Synergy P) and moving the normalization point,
an optimal plan is made with the existing tangential fields. Radiotherapy dose of TD 50 Gy in 25
fractions was applied to the antero-lateral side
of the right thoracic wall with two opposite conventional tangential fields by the linear accelerator Elekta Synergy and the energy of 6 megavolts
(MV). For planning and executing radiotherapy
treatment Multi Leaf Collimator (MLC) was used
with leaves 1 cm wide at the isocenter. Conventional plans were the control group. The next step
was the delineation of the target volume (CTVClinical Target Volume) within conventional fields.
The delineation of CTV was made on each CT section in such a way that the target volume included
right side front lateral thoracic wall from the skin
to the ribs, medially to the sternum, laterally to the
skin, up to the sternoclavicular joint or the visible
tissue of the healthy left side breast, down up to 1
cm below the visible healthy tissue of the left side
breast. Then, on the XiO system for planning, we
included additional fields within the existing conventional fields, which represented the so called
field in field technique (Figure 1). These plans
were the experimental group. On the basis of CTV
the Dose Volume Histogram (DVH) was calculated for the field in field technique. For both
techniques the volume of CTV was calculated
and determined, expressed in percentages, which
receives the doses of 90% and 95% (VD90% and
VD95%), in order to rate the coverage of CTV by
the therapy dose. In order to rate the homogeneity of the therapy dose within CTV the volume of
CTV was determined which receives the doses of
107% and 115% (VD107% and VD115%). Heterogeneity index (HI) and Coverage index (CI) were
calculated for every plan by the following formula:
HI=maximum dose/therapy dose
CI=minimum dose/therapy dose
For each metric, the mean value and standard deviation (SD) were calculated for each technique.
Means were pared with the paired Student's t-test.
The results were considered significantly different
if p<0.05 (10).
131
Results
The results of radiotherapy planning are shown in
Table 1, while a typical distribution of dose for both
techniques given in Figures 2 and 3. There was no
difference in VD107% and VD115% between the
compared groups. Consequently, there was no
statistically significant difference in HI (1.130.03
vs. 1.130.03, p=0.06). However, VD 90% and VD
95% were statistically significantly higher for the
field in field technique. This is the reason why CI
also favored the field in field technique (p=0.02).
Table 1. Distribution of dose for Conventional and Field in

Field techniques
Parameters
VD 90%
VD 95%
VD 107%
VD 115%
HI
CI
Conventional
(10 plans)
(mean SD)
88.8 % 7.3%
76.2% 12.8%
9.9% 10.2%
0.09% 0.3%
1.13% 0.03%
0.28% 0.23%
Field in Field
(10 plans)
(mean SD)
94.0% 3.9%
89.2% 5.8%
13.2% 3.0 %
0,18% 0.5 %
1.13% 0.03%
0.29% 0.25%
p - value
0.02
0.004
0.07
0.16
0.06
0.02
A B
FIGURE 1. Conventional technique (A) and Field in Field technique additional small fields put within conventional tangential
fields in the position of sub-dosed target volume (B)
FIGURE 2. A typical isodose distribution for conventional plan (on the right) and the field in field technique (on the left). Both
scans belong to the same patient at the level of the same CT section. Field in field plan gives a better coverage of the target
volume by 95% isodose, i.e. the percentage of VD95% is higher. Color scale matches the percentage scale.
Discussion
In this study we found a significant difference between the techniques examined in the coverage of
132
CTV by therapy isodose, expressed as VD90% and

VD95% (Figure 3). Also, CI is significantly better
in the field in field technique and correlates with
FIGURE 3. Comparative dose-volume histogram (DVH). It is seen

that 90% and 95% dose cover the target volume better in the field in
field technique (dotted line) than in the conventional technique (dashed
line)
a small percentage of subirradiated target volume.

This is especially evident in proximal parts of the
thorax, where its thickness and contour are different when compared to the distal part. There was
no difference between the examined techniques in
the volume of CTV covered by the dose of 107%
and 115%, expressed as VD107% and VD115%.
Also, HI did not show a significant difference between the techniques examined, which correlates
with the same level of overdosing the target volume in both techniques. Similar heterogeneity of
dose is evident, regarding the fact that fields in
fields put into the existing conventional

fields under the same angle of gentry
and collimator. Field in field technique
gives a better coverage of the target volume by therapy dose, but at the entrance
of the field it increases the build up of the
dose. Better homogeneity and conformity can be achieved by more advanced,
expensive techniques such as conformal
radiotherapy, intensity-modulated radiotherapy and helical tomotherapy (11).
Conclusion
In postoperative (radical mastectomy)
radiotherapy of localized right side
breast cancer, the field in field technique provides excellent coverage of the target
volume by the radiotherapy isodose. Concerning the fact that better conformity and homogeneity are not achieved, these results pave the
way for the development of a new conventional
technique that would be suitable for radiotherapy of left side breast with careful evaluation of
the effect of the dose on the heart and the lungs.
Competing interests
Authors declare that there is no conflict of interest
related to this study.
References
1. Morganti AG, Cilla S, Valentini V,
Digesu C, Macchia G, Deodato F, et
al. Phase I-II studies on accelerated
IMRT in breast carcinoma: technical comparison and acute toxicity in 332 patients. Radiother Oncol.
2009;90(1):86-92.
2. Gray JR, McCormick B, Cox L, Yahalom J. Primary breast irradiation in
large-breasted or heavy women: analysis of cosmetic outcome. Int J Radiat
Oncol Biol Phys. 1991;21(2):347-54.
3. Neal AJ, Mayles WP, Yarnold JR.
Invited review: tangential breast
irradiation--rationale and methods
for improving dosimetry. Br J Radiol.
1994;67(804):1149-54.
4. Neal AJ, Torr M, Helyer S, Yarnold
JR. Correlation of breast dose heterogeneity with breast size using
3D CT planning and dose-volume
histograms.
Radiother
Oncol.
1995;34(3):210-8.
5. Pierce LJ, Strawderman MH, Douglas KR, Lichter AS. Conservative surgery and radiotherapy for early-stage
breast cancer using a lung density
correction: the University of Michigan experience. Int J Radiat Oncol
Biol Phys. 1997;39(4):921-8.
6. Zackrisson B, Arevarn M, Karlsson
M. Optimized MLC-beam arrangements for tangential breast irradiation. Radiother Oncol. 2000;54: 209
212.
7. Vicini FA, Sharpe M, Kestin L, Martinez A, Mitchell CK, Wallace MF, et al.
Optimizing breast cancer treatment
efficacy with intensity-modulated
radiotherapy. Int J Radiat Oncol Biol
Phys. 2002;54(5):1336-44.
8. Hurkmans CW, Borger JH, Pieters
BR, Russell NS, Jansen EP, Mijnheer
BJ. Variability in target volume de-
lineation on CT scans of the breast.

Int J Radiat Oncol Biol Phys. 2001;
50:13661372.
9. Khan FM. Treatment Planning II: Patient Data, Corrections, and Set-Up.
In: Khan FM (Ed) Physics of Radiation Therapy. Lippincott Williams &
Wilkins, Phyladelphia 2003, pp. 226256.
10. Glantz SA. Primer of biostatistics. 6th
ed. Mc Graw-Hill Medical Publishing: 2005.
11. Caudrelier JM, Morgan SC, Montgomery L, Lacelle M, Nyiri B,
MacPherson M. Helical tomotherapy
for locoregional irradiation including
the internal mammary chain in leftsided breast cancer: Dosimetric evaluation. Radiother Oncol 2009;90:99105.
133
www.jhsci.ba
Spina bifida in surgically treated infants in

Sarajevo region of Bosnia and Herzegovina
Selma Alielebi*, Ermin Agovi
Institute of Histology and Embryology, Faculty of Medicine, University of Sarajevo, ekalua 90, 71000 Sarajevo, Bosnia and
Herzegovina
Abstract
Introduction: Spina bifida is a congenital anomaly characterized by incomplitnes of vertebral arches in the
medial line which occurs in 3rd and 4th month of intrauterine life. It is often associated with other congenital
malformations, but hydrocephalus and Chiary II malformation are the most frequent. Aim: The aim of this
work was to obtain the frequency of surgical cases of spina bifida treated at the Clinic for Neurosurgery, Clinical Center University of Sarajevo, Bosnia and Herzegovina.
Methods: Retrospective study was carried out on the basis of the clinical records during the period January
2005. to December 2008. Standard methods of descriptive statistics were performed for the data analysis.
Results: A total of 31spina bifida cases were surgically treated in the period from 2005. through 2008. Out
of that number 14 (48.2%) were female patients, while 17 (54.8%) were male patients; sex ratio 1.21:1.
The most common type of spina bifida was myelomeningocele, treated in 24 surgical patients (77.45%), and
the most common location was thoracolumbal part of the vertebral column, treated in 13 patients (41.91%).
Conclusion: Anomalies associated with spina bifida were present in 19 patients (61.3%). Hydrocephalus,
in 18 patients (58.05%) and Chiary II malformation, in 5 cases (16.13%) were the most frequent anomalies
associated with spina bifida.
Keywords: spina bifida, frequency
Introduction
Due to the complexity of its embryological development, congenital anomalies of the central nervous system are one of the most common birth
defects. Neural tube defects are a group of severe
birth defects in which the brain and spinal cord
are malformed and lack the protective encasement
of soft tissue and bone and account for the most of
the central nervous system congenital anomalies.
They are called neural tube defects because they
develop out of a tube formed in the early embryo
by the closure of the outer germ layer of tissue.
This tube later develops into the brain and spinal
cord. Normally, the neural tube closure occurs between the 3rd and 4th week of human embryonic
development. When the neural tube fails to close
* Corresponding author: Selma Alielebi, Institute of Histology
and Embryology, Faculty of Medicine, University of Sarajevo,
ekalua 90, 71000 Sarajevo, Bosnia and Herzegovina
Tel: +387 61 505 298; Fax:+387 33 203 669
E-mail: alicelebicselma@gmail.com
Submitted 23. September 2011 / Accepted 3. December 2011
134
properly, a neural tube defect will occur. It is interesting that the prevalence of these anomalies
shows considerable geographical variation (1) and
female predominance (2, 3, 4). Among the most
common tube defects are anencephaly, encephalocele, and spina bifida. Spina bifida is a congenital defect that accounts for about two-thirds of
all neural tube defects. Spina bifida (Latin: "split
spine") is a developmental birth defect involving
the neural tube: incomplete closure of the embryonic neural tube results in malformed vertebrae
that do not fully enclose the spinal cord. Spina bifida is one of the most common birth defects, with
an average worldwide incidence of 1-2 cases per
1000 births, but certain populations have a significantly greater risk (4). Spina bifida ranges from
clinically significant types to minor anomalies
that are clinically unimportant. Spina bifida malformations fall into three categories: spina bifida
occulta, spina bifida cystica (myelomeningocele),
and meningocele. The most common location of
the malformations is the lumbar and sacral areas
Selma Alielebi, Ermin Agovi: Spina bifida in surgically treated infants in Sarajevo region of Bosnia and Herzegovina
of the spinal cord. Spina bifida occulta (occulta is

Latin for "hidden") occurs in L5 or S1 vertebrae
in about ten per cent of otherwise normal people
(5). In spina bifida occulta there is no opening of
the back, but the outer part of some of the vertebrae are not completely closed. The split in the
vertebrae is so small that the spinal cord does not
protrude. The skin at the site of the lesion may be
normal, or it may have some hair growing from it;
there may be a dimple in the skin, or a birthmark
(6). Severe types of spina bifida, involving protrusion of the meninges and/or spinal cord through
the defect in the vertebral arch, are often referred
to collectively as spina bifida cystica because of the
cystlike sac that is associated with these anomalies. Spina bifida cystica occurs about once in every 1000 births. When the sac contains meninges
and cerebrospinal fluid, the condition is called
spina bifida with meningocele. In the most serious form, the sac or cyst not only contains meningeal membranes tissue and cerebrospinal fluid but
also nerves and part of the spinal cord. The spinal
cord is damaged or not properly developed. The
malformation is called spina bifida with meningomyelocele. Meningoceles and meningomyeloceles
may occur anywhere along the vertebral column,
but they are most common in the lumbar region
(7). About 80-90 % of fetuses or newborn infants
with spina bifida - often associated with meningocele or myelomeningocele - develop hydrocephalus. Arnold-Chiari malformation occurs about
once in every 1000 births and is frequently associated with both spina bifida and hydrocephalus
(1, 5). In our previous study we found that spina
bifida is the most common of the CNS congenital
anomalies among cases hospitalized in a Department of Neurosurgery, Clinical Center University
of Sarajevo, Bosnia and Herzegovina (8). The aim
of this work was to obtain the frequency of spina
bifida types among cases hospitalized in a Department of Neurosurgery, Clinical Center University of Sarajevo, Bosnia and Herzegovina, during the period January 2005. to December 2008.
Methods
Patients
Retrospective study was carried out on the basis of
the clinical records in a Department of NeurosurJournal of Health Sciences 2011; 1 (3)
gery of Clinical Center University of Sarajevo, Bosnia and Herzegovina. From 1st January 2005 to 31st
December 2008, a total of 2848 patients were hospitalized and out of that number 31 cases (1.12%)
were diagnosed as having some type of spina bifida.
Standard methods of descriptive statistics were
performed for the data analysis.
Results
A total of 31cases were treated in the Department of Neurosurgery of Clinical Center of Sarajevo during the period from January 2005 to
December 2008. Table 1. shows the number of
treated spina bifida cases in the observed period.
Surgically treated cases of spina bifida were from the
whole Federation of Bosnia and Herzegovina and
their geographical distribution is shown in Table 2.
The structure of patients with spina bifida treated
according to the gender is shown in Table 3. Out
Table 1. Frequency of treated spina bifida cases from January 2005 to December 2008
Year
2005
2006
2007
2008
No
14
5
6
6
= 31
Table 2. Frequency of spina bifida in the observed geographical region

Canton
Una-Sana
Sarajevo
Central Bosnia
Zenica-Doboj
Herzegovina-Neretva
No
13
7
7
2
2
= 31
Table 3. Total number and gender of treated spina bifida

cases
GENDER
MALE
FEMALE
TOTAL
No
17
14
31
%
54.8
45.2
100
135
of that number 17 (54.8%) were male, while 14

(45.2%) were female patients; sex ratio 1.21:1.
Different types of surgically treated spina bifida
cases were myelomeningocele (78%), meningocele (19%) and spina bifida occulta (3%) (Figure 1).
FIGURE 1. Frequency of particular types of spina bifida
FIGURE 2. Frequency of particular localizations of spina bifida
FIGURE 3. Frequency of spina bifida with associated anomalies

136
The most frequent localizations of spina bifida

were spina bifida thoracolumbalis (42%) and
spina bifida lumbosacralis (36%) (Figure 2).
Isolated spina bifida occurs in twelve cases,
multiple malformations were found in nineteen cases (61.3 %), fourteen with one and five
with two associated malformations (Figure 3).
Hydrocephalus, in 18 patients (58.05 %) and Chiary
II malformation, in 5 cases (16.13 %) were the most
frequent anomalies associated with spina bifida
Discussion
In the period from 1 January 2005 to 31 December 2008 a total of 31 cases of spina bifida were
registered and that 17 (54.8%) were male, while
14 (45.2%) were female patients; sex ratio 1.21:1.
The most frequent type of surgically treated spina
bifida was myelomeningocele (77.45 %) and the
most frequent localizations of spina bifida were
spina bifida thoracolumbalis (41.91 %) and spina
bifida lumbosacralis (35.49%). These findings correspond with literature ones (8, 9). Anomalies
associated with spina bifida were present in 19
patients (61.3 %). Hydrocephalus, in 18 patients
(58.05%) and Chiary II malformation, in 5 cases
(16.13 %) were the most frequent anomalies associated with spina bifida. These findings correspond with literature ones (9, 10). It was found
that the most of the patients (13, 41.94%) were
from the Una-Sana Canton, which is probably
associated with a deficiency of folic acid. Prevention of birth defects is one of the greatest national
interests and prevention of spina bifida through
dietary folate supplements and prenatal counseling is now widespread. In our country must be
given more attention to the prevention programs
and activities. There is a need to consider an intensive approach to periconceptional folic acid
supplementation, genetic counseling and to the
establishment of country congenital anomaly registries. The establishment of congenital anomaly
registries has taken place for the purpose of the
surveillance of the birth defects in a view of their
growing contribution in infant morbidity and
mortality structure. However, despite several attempts (8, 9, 11), up to now, in our country, no
State Register for Congenital Malformations or the
Referral Centre of the Ministry of Health for Surveillance of Birth Defects have been established.
Conclusion
According to this investigation, the number of
surgically treated spina bifida decreased for about
55% from from 1 January 2005 to 31 December
2008 and it was slightly higher in males (54.8 %).
The most frequent type of surgically treated spina
bifida was myelomeningocele (77.45 %) and the
most frequent localizations of spina bifida were
spina bifida thoracolumbalis (41.91 %) and spina
bifida lumbosacralis (35.49 %). The most of the
patients (13, 41.94 %) were from the Una-Sana
Canton. The most frequent anomalies associated
with spina bifida were hydrocephalus, in 18 patients (58.05 %) and Chiary II malformation, in 5
cases (16.13 %). Prevention of birth defects is one
of the greatest national interests and it is necessary
to establish Bosnia and Herzegovina Register for
Congenital Malformations.
Competing interests
The authors declare that we have no financial and personal relationships with other people or organizations that could inappropriately influence this work.
References
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137
www.jhsci.ba
Evaluation of the conservative treatment

of Trigger finger by local instillation of
corticosteroids
Muris Pecar*, Dijana Avdi, Demal Pecar
Faculty of Health Studies, University of Sarajevo, Bolnika 25, 71 000 Sarajevo, Bosnia and Herzegovina
Abstract
Introduction: Trigger Finger (tenosynovitis stenosans) is a specific, named disease from a group of repetitive strain injury (RSI) diseases, caused by inflammation which results in difficulties during muscle contraction and weakened and painful tendon movement. It is common in the outpatient physical medicine and
rehabilitation practice. The aim of our study was to evaluate the success of conservative treatment of Trigger
Finger by local instillation of corticosteroids.
Methods: The study was designed as an observational and open analysis of the results of conservative treatment of 45 patients. We used precise instillation of steroid anti-inflammatory antirheumatic drugs in the area
of patho-anatomic, microtraumatic injuries of tendon and its sheath. Patients were evaluated before and after
the treatment with 0 to 5 evaluation score scale. The data were analyzed using X2 test.
Results: Most of the patients had evaluation score of 2, 3 and 4, before the treatment. After the treatment
10 (29%) patients had achieved score 4 and 35 (71%) patients had achieved score 5. All of the patients with
score 5 had excellent working ability with full working capacity. Other patients had well-preserved working
ability, which improved to excellent in maximum of 7 days.
Conclusions: Conservative treatment of Trigger finger shows good therapeutic effects and taking into account the benefits, convenience and generally lower cost of conservative treatment for the patient, should be
considered as an effective alternative to surgical treatment.
Keywords: trigger finger, conservative therapy, corticosteroids
Introduction
Treatment of flexor muscle tendons of finger represents one of the most challenging problems of the
pathophysiology of the hand. Although the stability is very important for the function of the hand,
additional problem is to recover the movement of
the fingers that is often compromised by created
adhesions. Usually, the factors which provide stability - prevent mobility, which in this case means
that the creation of adhesions leads to restriction
of mobility and stiffness (1). Previous studies have
focused more on achieving the optimal balance of
stability-mobility and less on increasing the power
of motion which solves the problem (2,3). The
problem, however, is not that simple. Tendon injury
is usually associated with synovial sheath damage
* Corresponding author: Muris Pecar, Faculty of Health Studies,
University of Sarajevo, Bolnika 25, 71 000 Sarajevo,
Bosnia and Herzegovina, Phone: +387 33 444 901;
Fax: +387 33 264 821; E-mail: m.pecar@gmail.com
Submitted 13. November 2011 / Accepted 8. December 2011
138
which results in loss of the synovial fluid which is

the only way for delivering nutrition to tendon, by
diffusion process. This will decrease the pressure
of the synovial fluid resulting in reduced nutrition
of the tendon and increase of the stiffness, finally
leading to complete immobility of the joint (4).
The common name for a group of disorders of
muscles, their tendons with membranes and
nerves, often caused by repeated movements of
the muscle-connective tissue, accompanied by
significant local morphophysiological changes
in muscles, ligaments and nerves is 'Repetitive
Strain Injury' (RSI). Trigger finger, as a specific
disease, belongs to this group (5-7). Etiology of
Trigger finger is a multicausal, idiopathic, without
a clear cause and usually occurs due to repeated,
automated actions in non-physiological position during long time (8,9). Movements, such as
handling the computer mouse or working on a
factory production line, affect the muscles and
ligaments and when they persist for a long time,
Muris Pecar et al.: Evaluation of the conservative treatment of Trigger finger by local instillation of corticosteroids
they result in injuries that manifest themselves

as pain and reduced mobility. High-risk professions include a wide variety of human activities:
the workers on the production line, workers by
a computer, miners, butchers, musicians (10-13).
Recovery of the flexor muscles tendons is often
complicated by the formation peritendinous adhesions that result in loss of normal smoothness,
stiffness of the fingers, and functional disability.
Trigger finger is also called the stenosing tenosynovitis, which can be misleading, because the inflammation is not of dominant importance, but repetitive movements and forceful use of the fingers,
which leads to a narrowing of the finger fibrous
membranes that reduces the usability of the hands.
The collagen fibrils are parallel to each other and
closely packed, but show a wave-like appearance
due to planar undulations, or crimps, on a scale of
several micrometers (13). In tendons, the collagen
I fibers have some flexibility due to the absence
of hydroxyproline and proline residues at specific locations in the amino acid sequence, which
allows the formation of other conformations
such as bends or internal loops in the triple helix and results in the development of crimps (14).
The first sign of this condition is pain in the affected finger. Eventually, progression occurs and
stretching out the finger becomes difficult with
loss of functional capacity of the hand. Pain is primarily treated by the application of available analgesics. Initiation of topically applied anesthetic
and steroid preparations has opened new possibilities of conservative treatment. All conservative
methods primarily help the patient in the painful stage. Most used corticosteroid preparations
are cortisone, prednisolone, dexamethasone and
more successful steroids with prolonged action:
betamethasone and triamcinolone. Cortisone is a
powerful anti-inflammatory drug, but not analgesic. Analgesic effect is achieved by reduction of the
inflammatory process. In chronic inflammation
the treatment is extended and may require repeated injections. Cortisone injection in an area of inflammation can locally attain very high drug concentrations, with minimal drug entering into the
circulation, thereby minimizing side effects (14).
Along with Cortisone, analgesics and anesthetics,
such as Lidokain or Marcain, are often injected
to achieve a quick pain relief. Topical anesthetics
help numb the skin in an area being injected. Satisfactory rates can be predicted in patients with single digit involvement, short duration of symptoms
(less than four months), no associated conditions,
or a small palpable nodule. Besides conservative,
common treatment of Trigger finger is surgical (15).
Recent advances our understanding of biology of
tissue reparation can lead to improved therapies
for tendons and their sheaths. Research in this
field provides the basic understanding of tendon
healing after injury. Reparation takes place in 3
phases: inflammatory, fibroblast, and remodeling
phase (16,17). During the inflammatory phase,
inflammatory cells from the surrounding tissue
migrate to the location of the injury site. Cells
(phagocytes) engulf necrotic tissues and cells
(17). During fibroblast phase, fibroblasts proliferate around injured sites and synthesize collagen
and other extracellular matrix components. Finally, during the phase of remodeling new collagen fibers are produced and are placed longitudinally along the shaft and tendon. Fibroblasts
are the main cells in healing reactions and are
responsible for the formation of collagen and scar.
It is assumed that there are two mechanisms of
tendon healing. The first is called extrinsic, in
which fibroblasts and inflammatory cells from
the periphery enter the site of damage and promote recovery and healing of injured tendons.
The second mechanism is called intrinsic, in
which the so-called inner fibroblasts and inflammatory cells enter the site of the injury between
the tendon and epitendon hastening recovery
(3,18,19). Most likely, cure is achieved by a combination of external and internal mechanisms (1).
It appears that extrinsic mechanism is active early,
while intrinsic follows subsequently (1,20,21).
Some studies have shown that the synovial membrane reacts with more proliferation and inflammatory response compared to endoten and tendon (22). Other studies have shown that synovial
fibroblasts are more reactive to cytokines and to
have a greater capacity for degradation of extracellular matrix (21). It is believed that the predominance of external mechanisms of healing
leads to an increase in collagen content on the
site of injury, and that the predominance of external healing mechanism leads to the formation
of scar tissue and adhesions between the tendon
139
and surrounding peritendinous structures (22,23).

Manipulation of cytokine levels by introducing
genetic material into cells, as well as additional
pluripotent mesenchymal stem cells to the site
of recovery is a potential therapeutic strategy
to modulate tendon injury and scar formation.
Restoration of normal hand function after flexor
tendon laceration requires restoring not only the
continuity of the tendon fibers, but also a mechanism for smooth communication between the
tendon and surrounding structures. Like many
other tissues, the healing of tendon injury creates scar tissue. Although the initial formation of
scar tissue between the vessels provides physical
continuity at the break, the proliferation of scar
tissue between the tendon and adjacent tissues
is undesirable, indeed harmful, because the scars
of the tendons reduce the smoothness of motion
that is of particular importance for the function
when tendon is sliding through the bends in the
fiber bone channels. This becomes more serious if adhesions occur after healing, which can
lead to disability due to restrictions or loss of
mobility, contractures and functional disability.
Most of the research on the tendon reparations
and recovery is focused on the mechanical aspects:
improvement and repair techniques and rehabilitation protocols which encourage early start of the
motion. Due to innovations that are introduced
recently, experts advocate delayed rather than primary surgical reconstruction. Even with the best
techniques and optimal rehabilitation protocols,
functional restoration can not be achieved with
certainty and the results are unpredictable (1).
In the last two decades, our understanding of
the molecular biology of growth and repair of
soft tissues has expanded dramatically. We now
know, though incomplete, how genes are regulated, how genes are expressed, and protein synthesis, and how these proteins affect the macroscopic and biomechanical changes in the tissue.
Methods
The study included 45 patients who were admitted into the physical therapy outpatient practice
Praxis, and diagnosed as Trigger Finger with pain
of varying intensity. The study was conducted between January 1st 2009 and June 30th 2011. All
admitted patients gave informed consent for par140
ticipation into the study. They were subjected to

a detailed medical history and physical examination during their first visit and their condition is
scored 1 to 5, based on local findings, the intensity
of pain, local changes (one or more than one digits affected, active and passive mobility, dominant
hand), then duration of the painful phase, working ability, the duration of the recovery phase and
working ability for their or other job. The scoring
has been done according to the criteria, as follows:
Score 0 or 1. Severe clinical conditions that
impair function and require additional assistance.
Grade IV (contractures): evident contracture of
interphalangeal joints, with no possible movement.
Score 2. Difficult function and the need for
prosthetic device. Grade III B (passive): Demonstrable locking in which the patient is unable to
actively flex the digit.
Score 3. Satisfactory function in daily activities,
but not capable for working. Grade III A (passive):
Demonstrable locking in which passive extension
is required.
Score 4. Satisfactory functional status with the
minor difficulties that do not adversely affect the
working ability. Grade II (active) - Demonstrable
catching, but with the ability of active movements
of flexion and digit extension, with a painful "snap".
Score 5. Minor changes and slight dysfunction.
Grade I (pretriggering): pain; history of catching
that is not demonstrable on clinical examination;
tenderness.
FIGURE 1. Movement of the needle with flexion of the digit

confirms correct positioning of the needle for injection treatment. The patient is actively encouraged to move the digit; in
most cases, the triggering is relieved. A follow-up appointment
is made after 1 week.
After clinical examination and confirmation of diagnosis, all the patients were treated by single, local instillation of corticosteroids. Patients were followed up, and re-evaluated 7 days after the treatment.
To evaluate the efficacy of conservative treatment, we have recorded additional parameters
which could have influenced the outcomes:
gender structure (male/female), age of the patients, profession, relapse and dominant hand.
A common technique for local instillation of corticosteroids in the tendon sheath is a simple routine
that runs an outpatient basis, with strict precautions. The inflammation nodule is identified, localized and marked, then instillation of corticosteroids in the sheath is performed. A 26-gauge
needle is introduced in a proximal-to-distal direction in the nodule, under the annular ligament,
making an angle of 45 with the palm (Figure 1).
Results
To research the effects of the conservative treatment by local corticosteroid instillation we have
made a clinical examination and evaluation of
the patients before the treatment and 7 days after
the single, local corticosteroid instillation. The
patients were scored at follow up examination
by same scale as on initial examination. Before
the treatment none of the patients had score of
1, only 1 patient (2%) was evaluated with score
2. Score 3 was assigned to 28 patients (62%) and
score 4 to 16 (36%) patients. None of the patient
had score of 5 before the treatment (Figure 2).
All the treated patients restored the working
ability 7 days after the therapy, which was confirmed on the follow up examination (Table 1).
To check whether the age influences the prevalence
of Tigger finger, the study patients age was recorded. Most of the patients were older than 45 years
(Table 2). The average age of the patients treated
FIGURE 2. Evaluation of the patients before and 7 days after

the treatment of Trigger finger with local corticosteroid instillation.
with conservative method was 56.84, the youngest patient was 31, and the oldest was 83 years old.
To see whether sex of the patients has influence on prevalence of the Trigger finger, we recorded this parameter. There were
66.7% women in the study group (Figure 3).
We wanted to see whether pathophysiological
process is related to the dominant hand of the
patient, therefore we recorded this data (Figure 4). The pathophysiological process occurs
more frequently at the dominant hand. However, affected digit and hand dominance are not
always correlated. Treatment and hand (left or
right) are independent (p=0.083). Conservative treatment was applied 13 times on the left
hand, and 32 times on the right hand (Figure 4).
We found significantly higher incidence of the
thumb affection compared to all other fingers.
Thumb was merely affected in nearly 60% of
cases. Index, the second finger was not affected
Table 1. Summary of age, duration of symtoms, duration of pain, recovery of hand function, sicl leave days and days to relapse
age
days with symptoms
duration of pain in days
recoverd hand function
sick leave days
days to relapse
N
45
45
44
45
0
45
Mean
56.84
143.86
0.13
0.42
Std. dev.
11.69
199.30
0.34
0.69
Minimum
31.00
15.00
0.00
0.00
Maximum
83.00
730.00
1.00
2.00
25th
49.50
45.00
0.00
0.00
50th (Mediana)
56.00
60.00
0.00
0.00
75th
65.00
120.00
0.00
1.00
63.77
168.60
0.00
660.00
0.00
0.00
0.00
141
Table 2. The age of the patients conservatively treated for

Trigger finger
Age group 15-24
Number of
0
patients
25-34
35-44
45-54
55-64
65-99
16
14
13
by the pathophysiological changes (Table 4).

Greatest number of treated patients (active and
retired) belongs to a group of non-physical
workers. Physical workers were less than one
fifth (17.8%). Given the rapid spreading and involvement of information technologies in clerk
professions, this trend is expected. Jobs which
require manual labor in the long term are considered risk factor for Trigger finger. As women
are more involved in clerk professions, that
could be the reason for twice higher morbidity in women, compared to the male population.
In the first seven days of conservative treatment
68.9% of patients achieved the optimum function
of the hand (Figure 6). Treatment and sick leave
are dependent (p = 0.035). After completion of
corticosteroid instillation a full working capacity
was established and patients were able to work and
did not use sick leave. Complications are extremely rare with conservative treatment of Trigger Finger. In our sample there were no complications.
Relapses occurred in 15.6% of treated patients,
while 84.4% were with no relapse during two years
of follow up period. Treatment and relapse are independent (p = 0.077). The average time to relapse
was 410 207 days.
FIGURE 3. Trigger finger affects women more than man

142
Table 3. Comparison of pathophysiological process on one

or two fingers in treated patients.
Number of fingers affected
1 finger
2 fingers
Total
Number of patients
39
6
45
%
86,7
13,3
100,0
Discussion
Injection treatment has long followed a subjective "feeling" and experience. Today, technological advances introduce ultrasound techniques
that can maximize the accuracy of the application of steroid injections, and thus its favorable
effects in the treatment of Trigger finger (25).
There is no rule how many times can cortisone
injection be repeated. Often, physicians do not
want to repeat more than three, but actually the
limits are not specified. However, there are some
practical limitations If a cortisone injection wears
off quickly or does not help the problem, then
repeating it may not be worthwhile. Also, animal studies have shown effects of weakening of
tendons and softening of cartilage with cortisone
injections. Repeated cortisone injections multiply these effects and increase the risk of potential
problems. This is the reason many physicians limit
the number of injections they offer to a patient.
The success of treatment depends on the ability of
physician to identify the difference between dif-
FIGURE 4. Right hand was more affected with Trigger finger

but the affected finger and hand dominance are not always
correlated
Table 4. Comparison of digits affected

in study patients. Thumb was the most
affected digit.
Digit
1 - Thumb
2 - Middle finger
4 - Ring finger
5- Little finger
Thumb + index
Ring finger + little
finger
Total
Number of
patients
26
8
6
3
1
57,8
17,8
13,3
6,7
2,2
2,2
45
100,0
fuse and nodular changes in the

tendon, that is, to determine the
FIGURE 5. Profession of the patients with Trigger finger. Most of the patients
precise location nodular altered
where retired, but of actively working population physical workers are most fretendon, where it will apply a cure.
quently affected
Splinting is not used routinely
in these cases, though the splint
is described as useful. It is also necessary to ap- sone flare). This can cause increased pain sensation of shorter duration and can be treated with
ply immobilization in patients when injection is
contraindicated. In those cases metacarpo-pha- local application of ice. Injections may cause
langeal joint is immobilized at about 15 of flexion. skin injury and infection, so it is necessary to
perform strict disinfection of the skin which reCorticosteroids may cause a temporary rise in
blood and urine sugar levels in patients with dia- duces this risk. Patients with darker skin have
betes. In addition, repeated steroid injections may to be informed about the the possibility of lolead to tendon rupture. In patients with insulin- cal skin discolor, before applying cortisone (27).
dependent diabetes, and higher nodule incidence According to literature, a different ways of Trigger
on several fingers, according to some authors, sur- finger treatment were described as successful. It is
gical treatment is required more frequently than estimated that 85% of cases will respond well to
patients who were not insulin-dependent (26). conservative treatment (28). If conservative treatThe most common side effect is the condition in ment is not effective surgical treatment is recomwhich cortisone crystallizes after injection (corti- mended (29). Similar results were published by
Shaw-Ruey Lyu (30). The best description of the
Trigger Finger was made by Charles Sorbie (31).
Conclusions
Conservative treatment of Trigger finger had
satisfactory effect and can be considered as a
first line treatment of this disease in patients
where corticosteroids are not contraindicated.
Further, conservative treatment demonstrated
short functional and working ability recovery
time and may be considered cheaper than surgical treatment due to less sick leave days used.
FIGURE 6. Time to complete recovery of hand function

Conflict of interest
There is no conflict of interest
143
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www.jhsci.ba
Antibiotic prophylaxis and inflammatory

complications after Cesarean section
Hasan Karahasan1*, Denita Ljuca2, Nermin Karahasan3,
Alija uko4, Adnan Babovi2, Hidajet Rahimi5
1
Department of Gynecology, Perinatology and Neonatology, Cantonal Hospital Zenica, Crkvice 67, 72000, Zenica, Bosnia and
Herzegovina. 2 Department of Gynecology and Obstetrics, University Clinical Centre Tuzla, Trnovac bb, 75000 Tuzla, Bosnia
and Herzegovina. 3 Medical centre of Zagreb CountyDitrict, 7 svibnja 14, 10 340 Vrbovec, Croatia. 4 Department of Gynecology,
Medical Centre Mostar, Marala Tita 294, 88000 Mostar, Bosnia and Herzegovina. 5 Department of Gynecology, Medical Centre,
ivinice, Alije Izetbegovia 17, 75270 ivinice, Bosnia and Herzegovina.
Abstract
Introduction: Gynaecological and obstetric surgeries are high risk operations for the development of postoperative inflammatory complications due to the proximity of the genitourinary tract. The aim of this study was to
compare the frequency of inflammatory complications in emergency or elective cases of caesarean sections
as well as the frequency of complications related to the method of surgical treatment used.
Methods: We analyzed inflammatory complications in 450 caesarean sections, which developed in a oneyear period from June 1st, 2000. to June 1st 2001. Patients were grouped according to the method of the
surgery, and on emergency or elective case. Misgav Ladach or Dorfler surgical methods were used.
Results: The most common inflammatory complication was wound infection and the most common risk factors for inflammatory complications were premature rupture of membranes and anemia.
Conclusions: Long term use of one antibiotic was the most commonly implemented form of antibiotic prophylaxis.
Keywords: antibiotic prophylaxis, inflammatory complications, Caesarean section
Introduction
Gynaecological and obstetric surgeries are high
risk operations for the development of postoperative inflammatory complications due to the
proximity of the genitourinary tract. The possibility of developing a postoperative infection after a
caesarean section ranges from 30% to 85% without prophylactic use of antibiotics, and up to 19%
with the use of antibiotic prophylaxis (ABP) (1).
Postoperative wound infections have an enormous impact on the patient quality of life and to
the contribution of the financial costs of patient's
care. The potential consequences of such postoperative wounds range from increased pain and
care of an open wound to sepsis and even death.
In the United States each year approximately
* Corresponding author: Hasan Karahasan, Department of
gynaecology, perinatology and neonatology, Cantonal Hospital
Zenica, Crkvice 67, 72000, Zenica, Bosnia and Herzegovina
Phone: ++ 387 32 405-133; Fax: ++ 387 32 226-576
E-mail: spec_ordinacija@yahoo.com
one million patients suffer from such infection

which extending the average hospitalization for
a week thus increasing the cost of hospitalization by 20%. In short, this adds an additional cost
of 1.5 billion dollars in healthcare annually (2).
Antibiotic prophylaxis (ABP) is the application
of antibiotics in patients without the presence
of infection in order to prevent postoperative
complications and infections (3). Inflammatory
complications during elective caesarean section
while using ABP were rarer (1.9 times), which of
course justifies the use of ABP with elective caesarean section (4). The most common inflammatory complications after caesarean section include:
endometritis, urinary tract infections, infections in the operative incision and peritonitis (5).
The aim of this study was to compare the frequency of inflammatory complications in emergency or elective cases of caesarean sections
as well as the frequency of complications related to the method of surgical treatment used.
Submitted 10. August 2011 / Accepted 14. October 2011

145
Hasan Karahasan et al.: Antibiotic prophylaxis and inflammatory complications after Cesarean section
Methods
Samples and Procedures
We analyzed inflammatory complications in
450 caesarean sections, which developed in a
one-year period from from June 1st, 2000. to
June 1st 2001. in the Department of Gynaecology, Perinatology and Neonatology of the Cantonal Hospital in Zenica. Caesarean sections
are divided according to the method of the surgery, and on emergency and elective (Table 1)
The table clearly shows that 85% of the caesarean
sections were performed as an emergency-surgery shortly after the patients admission to the
hospital. These are mainly the under-prepared
patients (often there is no baseline data or lab
findings). During all of the surgeries ABP were
used -380 cases (84.4%) repeatedly one antibiotic, 49 (11%) cases repeated with more than one
antibiotic in 21 (4.6%) case of a single antibiotic.
Data is expressed as mean SD. Comparison of
means between two groups was made by using
Table 1. Frequency of types and ways of performing of Caesarean sections
Type of
surgery
Misgav Ladach
(ML)
Dorfler (D)
TOTAL
EMERGENCY
ELECTIVE
TOTAL
129 (28.66 %)
18 (4 %)
147 (32.66 %)
253 (56.22 %) 50 (11.1 %) 303 (67.32 %)

382 (84.88 %) 68 (15.12 %) 450 (100 %)
two-sample t tests. 2 analysis was used to compare frequencies between groups. p<0.05 was considered significant.
Results
Inflammatory complications developed in 25
(5.5%) cases, without regards to which ABP was
applied. The most common inflammatory complication was wound infection: 21 cases (84%, ie
4.6% of all cases). Other inflammatory complications were very rare: endometritis in 2 cases
(0.66%) and peritonitis in 2 cases (0.66%) (Table 2).
The most common risk factors for inflammatory
complications were premature rupture of membranes (RVP) (40.6%) and anemia (18.5%). Other
risk factors were the average of all caesarean sections, without much variation in the methods
applied. It is also important to emphasize that
the time duration from labour up to the point
of making the decision to perform the caesarean section was on average 5.8 hours (Table 3).
The most common risk factors in developed inflammatory complications were anemia and
RVP, anemia in 59.2% and RVP in 40.7%. Anemia and RVP were the most common finding
in wound infection, which is the most common
inflammatory complication (Table 4). Also, it is
significant to note the duration of labour to the
decision to perform a caesarean section, an average of 10.6 hours for all cases who developed
inflammatory complications. In particular, the
prolonged average duration of labour for ML: 18
hours, wound infections: 14 hours, which is about
3 times longer than the average of all C-sections.
Table 2. Inflammatory complications after Caesarean section
ML (147)
D (303)
Th./number of drugs
Profilaxes
One
Two
Three
Profilaxes
One
Two
Three
Total
Endom.
UI
1
1
2
Inc. I
Sepsis
Tromboph.
Peritonitis
7
2
12
21
(Endom.=endometritis, UI=uroinfection, Inc. I=incision infection, Trombo.=trombophlebitis)
146
Table 3. Risk factors for inflammatory complications after Caesarean section

Risk factors
Anemia
RVP
The average number of examinations
The average duration of hospitalization
The average duration of labor
The average number of ASC
Dorfler (303)
71 (23,4%)
134 (44,2%)
2.5
3.2 days
5.5 h
0.71
Misgav Ladach 147

13 (8.8 %)
49 (33.3 %)
3.58
2,65 days
6.3 h
0.95
Total 450
84 (18.5%)
183 (40.66%)
2,87
3.0 days
5.8 h
0,79
(RVP= premature rupture of membranes, ASC=amnioscopy)
Table 4. Common risk factors in developed inflammatory complications

Risk factors
Anemia
RVP
The average duration
of hospitalization
The average duration of labour
The average number
of ASC
MISGAV LADACH-11(7,48)
Endomet. Infec. r.
Perit.
6 (54.5)
1 (9.4)
4 (36.3)
Total
16 (59)
11 (41)
1.8 days
1.9 days
3.1 days
5.6 h, for incision infection 4.1 hour
18 h, for incision infection 14 hour
10.6 h
Average 0,93.
Average 0.8
0.9
Ileus
1 (6.2)
DORFLER 16 (5,2%)
Endomet.
Inc. I.
1 (6.2)
1 (6.2)
5 (31)
Perit
Ileus
5 (31)
(ASC=amnioscopy, RVP= premature rupture of membranes, Prit..=peritonitis, Endomet.=endometritis, Inc. I.=incision infection)
Discussion
In our study inflammatory complications developed in 25 (5.5%) cases, without regards to which
ABP was applied. The most common inflammatory complication was wound infection: 21
cases (84%). Other inflammatory complications
were very rare: endometritis in 2 cases (0.66%)
and peritonitis in 2 cases (0.66%). With the use
of ABP of a single dose of antibiotics we had no
inflammatory complications, but unfortunately
this was the least common form of ABP (4.6%).
Other studies have shown, infection occurs in up
to 50% without the use of ABP and while during the use of ABP it appears in only 3% of cases
(6,7,8). It is more common in emergency caesarean sections in relation to planned surgery, which
contributes to quick, sometimes superficial abdominal wall preparation as in previous vaginal
examinations after the rupture of the membranes.
Complications of emergency surgery occur in ap-
proximately 25-50% of surgical patients, despite

improvement of surgical techniques, anaesthesia,
compensation for biochemical and electrolyte
disorders, blood infusion, antibiotic therapy, and
other modern methods of treatment and care.
Conclusion
In order to bring the inflammatory complications
to a minimum it is indicated to reduce risk: to
reduce the number of emergency operations, increase the number of elective surgeries, lower the
number of anemia and RVP (the most common
risk factors) and to reduce the length of confinement to a decision for surgery. In all cases, except
in those with high-risk for the development of inflammatory complications, ABP with a single dose
of antibiotic should be used.
Competing interests
Authors declare no conflict of interest.
147
References
1. Rouzi AA, Khalifa H, Baaqeel H,
Al-Hamdan HS, Bondagji N. The
routine use of cefazolin in cesarean
section. Int J Gynaecol Obstet. 2000;
69:107-112.
2. Chelmow D, Hennesy M, Evantash
EG. Prophylactic antibiotics for nonlaboring patients with intact membranes undergoing cesarean delivery:
an economic analysis. Am J Obstet
Gynecol. 2004;191(5):1661-5.
148
3.
Antimicrobial
prophylaxis
in
surgery. Med Lett Drugs Ther.
1987;29(750):91-4.
4. Pelle H, Jepsen OB, Larsen SO, Bo
J, Christensen F, Dreisler A, et al.
Wound infection after cesarean section. Infect Control. 1986;7(9):45661.
5. Nielsen TF, Hkegrd KH. Postoperative cesarean section morbidity: a
prospective study. Am J Obstet Gyne-
col 1983; 146(8): 911-916.

6. Karimov ZD, Khodzhaeva RK. 1991.
Endometritis after cesarean section:
mutually aggravating risk factors.
Akusherstvo i Ginekologiia 1991; 7:
51-54.
7. Paczyk T, Grudzie M, Kraczkowski J, Oleszczuk J. Clinical aspects of
peritonitis after cesarean section.
Wiad Lek. 198; 42(11): 720-724.
www.jhsci.ba
Knowledge and practice of health managers

in using information technology
in health system
Suvada vraki*1,2, Amer Ovina1,2
1
2
Clinic for vascular diseases, Clinical Center of University of Sarajevo, Bolnika 25, 71 000 Sarajevo, Bosnia and Herzegovina
Faculty of Health Studies, University of Sarajevo, Bolnika 25, 71 000 Sarajevo, Bosnia and Herzegovina
Abstract
Introduction: Information systems today are an inevitable link in the health care system. Health care institutions and health workers in modern society, depend on information systems in everyday tasks of organizing
institutions.The goals of the study were to determine the existence and application of information technology
in the health care system and of the Clinical Center of Sarajevo University and, Primary Health Care Center
of Sarajevo Canton, as well as to assess knowledge and practice of managers in nursing of the Organizational units of the University Clinical Center in Sarajevo and Primary Health Care Center of Sarajevo Canton.
Method: The study is of a prospective type. It will use a questionnaire based on which we will be able to
determine the knowledge and application in practice of managers in nursing of knowledge about information
technology in the health care system. The study was conducted from June 1st August 1st 2010.
Results: It is expected that most health institutions in the Canton Sarajevo has no organized information network system. Most managers nurses use e-mail in order to quickly contact other colleagues and exchange
experiences. A large number of nurses managers in health institutions use computer technology in their daily
work in order to make medical reports.
Conclusions: Health system and information technology are in close relationship, although still insufficiently
applied in everyday work. Management of organizational units in health care in the future will not be able to
successfully function without the use of information technology in their daily work.

Keywords: health managers, information technology, health system.
Introduction
Information technology (IT) by the American Association for Information Technology is defined as
"the study, design, development, implementation
and support or management of computer information systems (IS) trough software applications
and hardware". IT is using computers and computer programs to convert, store, protect, process,
and to securely send and receive information.
The term "Information technology" often includes
a much broader array of technology areas. All
those activities deal with IT professionals, from
installing application programs to designing com* Corresponding author: Suvada vraki,
Clinical Center of University of Sarajevo, Bolnika
25, 71 000 Sarajevo, Bosnia and Herzegovin
Phone: +387 33 29 70 00; Fax: +387 33 44 18 15
E-mail: imarinov@inet.ba
Submitted 10. October 2011 / Accepted 24. November 2011
plex computer networks and information systems. Some of these activities include: networking
and computer hardware engineering, design of
software and databases, as well as management
and administration of information systems (1).
Information technology is a general term
that describes a technology that helps the
production,
manipulation,
storage,
communication and information distribution.
First to use the term "Information Technology"
was Jim Domsik from Michigan in November
1981. The term is used in order to modernize until then used term "data processing". At that time
Domsik worked as a computer manager in the
auto industry (2). Today, information technology
increases the speed, power, and become very sophisticated, and can link together a wide range of
devices in the network that surrounds the globe.
They provide new ways of learning, work, enter149
Suvada vraki, Amer Ovina: knowledge and practice of health managers in using information technology in health system
tainment, and new ways of conducting business. in the health system of Clinical Center University
Some have suggested that these changes are revo- of Sarajevo and Public Health Care Institutions of
lutionary and that they change the world, while Canton Sarajevo, as well as to assess knowledge
others argue that changes are evolutionary. It is
and practice on the use of information technology
reasonable to study the phenomenon that cre- managers in the nursing organizational unit of the
ated a new world and new economy through Clinical Center of Sarajevo University and Pritechnological innovation, increase in economic mary Health Care Institutions of Canton Sarajevo.
performance and connectivity of the world on
a global level (3). Medical informatics is a pre- Methods
requisite for the development of modern medicine and health systems with a significant role Study design
in collecting, processing and publication of data. The study was of prospective type and it was
The patient is an active participant in the proceed- conducted in two separate medical instituings of treatment, and for this are partly respon- tions Primary Health Care Institutions of Cansible also the IT technologies with which we en- ton Sarajevo and the Clinical Center of Saracounter every day. Medical facilities are available
jevo University (CCUS), among the chief nurses
on the internet today which is for the medicine of - managers of organizational units. The survey
immeasurable educational significance, because
covered 17 chief nurses of the organizational
ease of online search of published data makes them units in CCUS and 8 chief nurses of the Primaavailable to all users (4). It should be noted that the
ry Health Care Centers of the Sarajevo Canton.
possibilities of information technology to develop
are much faster than the legal regulation why this Procedure
area the legal acts have yet to cover, and therefore We used a questionnaire composed of quesdoes not rely on data protection only on legal and
tions related to knowledge, attitudes and practechnical protection, but it is also extremely impor- tices of information technology use in the health
tant to respect the moral and ethical principles (4). system. The questionnaire was anonymous, so
Information systems can play an important role in
that respondents could feel free to answer quesknowledge management, helping organizations to
tions honestly. The study was carried out from
create and store them, while managing information June 1st 2010 to July 1st 2010. The research resystem helps managers to better plan, effectively sults were processed in the Microsoft Access
database and presented as graphics and tables.
organize, direct and control the functioning of the
organization, in short, to effectively and efficiently
Results
manage its storing, dissemination and application
of knowledge, and embrace basis of this knowledge. The results of our study are listed in Figures 1-11,
and Tables 1-3.
One of the basic functions of information systems
(IS) is that managers, supplying relevant information, obtain insight into the behavior of organizations so that they can more effective and efficient
use their skills of planning, organizing, directing
and controlling in order to achieve desirable development, growth and prosperity of the organization.
From the information systems is expected
to assist the effective and efficient functioning of the health organization by providing
the right information at the right time, in the
proper form and in the right quantity to the
right person user or the organization (5).
The goals of this study were to determine the exFIGURE 1. Distribution of respondents according to age
istence and application of information technology structure
150
FIGURE 2. Years of service of respondents
FIGURE 3. Having a computer in the workplace
FIGURE 4. The existence of a network system at the workplace
FIGURE 5. Links with other organizational units within the

health network
FIGURE 6. Frequency of Internet use in daily work
FIGURE 8. Number of employees at the organizational unit

FIGURE 7. Help from the use of the Internet in their daily work
(reports, decisions, etc.)
FIGURE 9. Education of employees to use information technology

151
FIGURE 10. Satisfaction with knowledge and use of information technology in managerial work
Table 1. Self evaluation of knowledge about the Internet
Evaluation
1
2
3
4
5
N
15
0
6
4
0
%
60
0
24
16
0
FIGURE 11. Correlation of using IT in their daily work of nurses, managers at the Primary Health Care Center and Clinical
Center University of Sarajevo
Table 2. Evaluation of the use of information technology in
decision-making in everyday work
Evaluation
1
2
3
4
5
N
2
6
0
12
5
%
8
24
0
48
20
Table 3. Evaluation of health care assistants work on computer and with information technologies
Evaluation
1
2
3
4
5
N
0
6
9
8
2
%
0
24
36
32
8
Discussion
The survey was conducted among 17 chief
nurses managers of organizational units of
the CCUS and 8 chief nurses managers of Primary Health Care Centers in Sarajevo Canton.
In our study there were no male respondents,
given that the nursing profession is largely female profession. The largest number of respondents belonged to age group 45-55 years
9 (36%), while a smaller number belonged to
the age group 20-35 years 7 (28%) subjects.
Regarded the years of service it can bee seen that
these are the respondents with the service of 15-20
years or 11 (44%) of them. Total of 23 (92%) respondents cited the fact that they have workplace
with computer equipment. Network system within
152
the organizational unit has 10 (40%) subjects, while

from total of 10 (40%) only 2 (20%) respondents
stated that the system is connected to network
with other organizational units. It is surprising that
15 (60%) respondents assessed their knowledge of
internet with grade 1, while 4 (16%) respondents
rated their knowledge of the Internet with grade 4.
The same number of respondents stated that the
Internet during the day is using 7h and 7 (28%)
respondents that they does not use it at all, the
majority of respondents reported that the Internet is used once during the week or 32%. Worrying is the fact that only 6 (24%) respondents
reported that the internet helps them make decisions for daily work, preparation of reports and
other guidelines for the work. Number of employees in the institution (OU) is between 50-80,
which stated 18 (72%) subjects. Most respondents
were trained to work on a computer - 13 (52%).
When asked to assess the computer skills of their
staff, the responses were divided, and approximately equal in the evaluation from 1-5. Most of the
chief nurses - managers said that they are satisfied
with the level of knowledge of computer skills and
knowledge of information technology - 22 (88%).

Comparing the results of using IT in their
daily work we can notice that there is greater use by the chief nurses in CCUS in relation to the Primary Health Care Institution of Canton Sarajevo or in 41% of cases.
Conclusions
Research has shown that knowledge of information technology and its application is unsatisfactory for nurses and managers of major organizational units in health care. Age structure, as well
as respondents years of service are not motivating factor for additional training for the more
sophisticated use of information technology. The
existing physical resources (computer equipment,

Internet access) are not adequately used in health
care organizations. Preoccupation with everyday
tasks of chief nurses managers at the organizational units does not provide enough space for
active use of information technology. By use of
information technology (network system, internet) nurses - managers can fully facilitate the conduct of daily work - contracting, report writing,
faster and more efficient exchange of experiences
which contribute to improving health services.
Competing interests
Authors declare that there are no competing interests related to this study.
References
1. Flower J. Transformations of 21st
century health care, Part 1. Beyond
the digital divide. Health Forum J
2003;46:8-13
2. Gell G. Side effects and responsibility
of medical informatics. Int J Med Inform 2001;64:69-81.
3. Information Technology in Health
Care - a General Outline of Ethical

Issues. European Network for Biomedical Ethics. Dostupno na URL
adresi 2007.: http://www.izew.unituebingen.de/bme/volume42.html
4. Majdani . Medicina, informatika,
etika. U: Kern J. Hercigonja-Szekeres
M. Medicinska informatika
5. Kudumovi M. Zdravstvena informatika i informacioni sistemi za

zdravstveni menadment. Skripta za
postdiplomski studij menadment
u zdravstvu. Fakultet zdravstvenih
studija, Univerzitet u Sarajevu.
153
www.jhsci.ba
Comparison of ARCHITECT chemiluminiscent

microparticle immunoassay for determination
of Troponin I in serum with AXYM MEIA
technology
Nafija Serdarevic
Institute for Clinical Chemistry and Biochemistry, University of Sarajevo Clinics Center; Faculty of health sciences, Bolnika 25,
71000 Sarajevo, Bosnia and Herzegovina
Abstract
Introduction: The aim of this study was determination of troponin I at serum using Architect (Abbott) and
AxSYM System (Abbott). Troponin is regulatory subunit of the troponin complex associate with actin filament
within muscle cells and it is a marker for diagnosis of myocardial damage.
Methods: We used Architect STAT chemiluminescent microparticle immunoassay (CMIA) and AxSYM microparticle Enzyme Immunoassay (MEIA), techniques for quantitative determination of cardiac TnI in human
serum or plasma. At our study we have proved precision, reproducibility and accuracy from both methods.
The investigation included patients (n=119) who have myocardial infarction or ischemic heart damage and
were treated at cardiology, emergency, internal medicine and neurology unit in Clinical Center University in
Sarajevo.
Results: The precision for three controls using Architect STAT TnI asssay technology were 3.6 5.2 % and
reproducibility was 3.7 to 5.6 %. The AxSYM STAT TnI has precision for three controls 4.36.6 % and reproducibility was from 4.8 to 7.8 %. We have got very good correlation between Architect and AxSYM technology
r = 0.999 in the investigation of troponin I in serum.
Conclusions: We can conclude that chemiluminescent troponin assay I (Architect) showed good analytical
performance and gave new possibility at troponin I determination.
Keywords: Troponin, MEIA and CMIA
Introduction
Acute myocardial infarction is a major cause of
death and disability. Approximately 15 million
patients per year in the United States and Europe
present to the emergency department with chest
pain or other symptoms suggestive of acute myocardial infarction (1). Clinical studies have demonstrated the release of troponin concentration
(cTnI) into the blood steam within hours following myocardial infarction (MI) or ischemic damage. Elevated levels of cTnI (above the values established for non-MI specimens) are detectable
in serum within 4 to 6 hours after the onset of
* Corresponding author: Nafija Serdarevic, Institute for Clinical
Chemistry and Biochemistry, University of Sarajevo Clinics Center;
Faculty of health sciences, Bolnika 25, 71000 Sarajevo, Bosnia
and Herzegovina; Tel: +387 33 29 70 00; Fax: +387 33 44 18 15
E-mail: serdarevicnafija@yahoo.com
Submitted 13. November 2011 / Accepted 1. December 2011
154
chest pain, reach peak concentration in approximately after 8 to 28 hours, and remain elevated
for 3 to 10 days following MI. Cardiac troponin
is the preferred biomarker for the detection of
myocardial injury based on improved sensitivity
and superior tissue-specificity compared to other
available biomarkers of necrosis, including CKMB, myoglobin, lactate dehydrogenase, and others. The high specificity of cTnI measurements is
beneficial in identify cardiac injury for clinical
conditions involving skeletal muscle injury resulting from surgery, trauma or muscular disease (2).
The Joint European Society of Cardiology/American College of Cardiology/American Heart Association/ World Heart Federation Task Force
redefinition of acute myocardial infarction (AMI)
is predicated on the detection of increase or decrease of cardiac troponin (cTn), with at least 1
concentration above the 99th presence reference
Nafija Serdarevic: comparison of architect chemiluminescent microparticle immunoassay

for determination troponin i in serum with axsym meia technology
value in patients with evidence of myocardial

ischemia. Blood samples for measurement of cTn
are recommended to be drawn at presentation
and 6-9 h later to optimize clinical sensitivity for
ruling in AMI (3,4). The Architect STAT chemiluminescent microparticle immunoassay (CMIA)
and AxSYM microparticle Enzyme Immunoassay (MEIA), are techniques for quantitative determination of cardiac TnI in human serum or
plasma. Immunoassays utilize one or more select
antibodies to detect analytes of interest. Analytes
being measured may be those that are naturally
presented in the body, those that the body produced but are not typically present (such as troponin antigen). At the CMIA a chemiluminescent
label conjugated to the antibody or antigen, and it
produces light when combined with its substrate.
This method is very similar to MEIA, though the
chemiluminescent reaction offers high sensitivity
and ease measurement. A noncompetive sandwich format yields results that are directly proportional to the amount of analyte present (5,6).
Using patient samples collected in our laboratory
we analyzed troponin concentration by CMIA and
MEIA technology methods and compared the results.
Methods
Patients
The patient samples of blood were collected in
serum separation Vacutainer test tubes (Beckton
Dickinson, Rutherford, NJ 07,070 U.S.) in volume of 3.5 mL. We used test tubes with gel. Serum samples were obtained by centrifugation at
3000 rpm using centrifuge (Sigma 4-10). After
centrifuging, serum concentration of TnI was
determined. The investigation was done respecting ethical standards in the Helsinki Declaration. The investigation included patients (n=119)
in period from February till May in 2008. The
patients who have myocardial infarction or
ischemic heart damage were treated at cardiology, emergency, internal medicine and neurology unit in Clinical Centre University in Sarajevo.
Chemiluminescent microparticle immunoassay
CMIA
All immunoassays require the use of labeled material in order to measure the amount of antiJournal of Health Sciences 2011; 1 (3)
gen or antibody. A label is a molecule that will

react as a part of the assay, so a change in signal
can be measured in the blood after added reagent solution. CMIA is noncompetitive sandwich assay technology to measure analytes. The
amount of signal is directly proportional to
the amount of analyte present in the sample.
Architect STAT Troponin I assay is two-step immunoassay to determine the presence TnI in human
serum using CMIA technology. In the first step,
sample, assay diluent and anti-troponin-I-antibody-coated paramagnetic particles are combined.
TnI present in the sample binds to the anti-troponin-I coated microparticles. After incubation and
wash, anti-troponin-I-acridinium-labeled conjugate is added in the second step. Following another
incubation and wash, pre-trigger and trigger solutions are then added to the reaction mixture. The
pre-trigger solution (hydrogen peroxide) performs
the following functions: 1) Creates an acidic environment to prevent early release of energy (light
emission), 2) Helps to keep microparticles from
clumping, 3) Splits acridinium dye off the conjugate bound to the microparticle complex. This action prepares the acridinium dye for the next step.
The trigger solution (sodium hydroxide) dispenses to the reaction mixture. The acridinium
undergoes an oxidative reaction when exposed
to peroxide and an alkaline solution. This reaction causes the chemiluminescent reaction to occur. N-methylacridone forms and releases energy
(light emission) as it returns to its ground state.
The resulting chemiluminescent reaction is measured as relative light units (RLU). A direct relationship exists between the amount of TnI in the sample
and RLU detected by Architect System optics (2,5).
Microparticle enzyme immunoassay - MEIA
MEIA is an immunoassay method that utilizes the isolation of antibody/antigen complexes on solid phase surface of small beads
called microparticles. It is automate technology for measurement of large molecules such
as markers associate with cardiac testing.
The proces of the MEIA technology includes: Microparticles coated with anti-analyte antibodies and
sample are incubated together to form reaction
mixture. 1) An aliquot of the reaction mixture is
transfer to the glass fiber matrix. 2) Alkaline phosphatase-labeled anti-analyte antibodies are allowed
155

Table 1. Quality control testing
to bind to the microparticle comConcentra- Concentration found Precision Concentration found Reproplex. 3) The substrate 4-methytion spiked intra-day (mean SD, intra-day inter-day (mean SD, ducibility
lumbelliferyl phosphate (MUP)
(ng/mL)
n= 20) (ng/mL)
(%)
n= 20) (ng/mL)
(%)
is added to the matrix. The fluoArchitect Troponin I assay CMIA technology
rescent product, methylumbel0.145
0.155 0.01
5.3
0.144 0.03
5.6
liferone (MU) is measured. The
0.580
0.632 0.03
3.9
0.577 0.09
4.9
flourescent product is measured
15.67
16.03 0.82
3.6
15.93 2.49
3.7
by MEIA optical assemby (4,5).
AxSYM Troponin I assay MEIA technology
The AxSym dynamic range is 0.020.28
0.30 0.017
4.3
0.26 0.026
4.8
22.8 g/L and imprecision (10%
1.14
1.15 0.054
4.7
1.11 0.047
5.2
CV): 0.16-0.56 g/L. The Archi9.49
9.44 0.627
6.6
9.38 0.728
7.8
tect cTnI dynamic range is 0.0150 g/L and imprecision (10%
testing. Measurements were done during 10 days
CV): 0.032-0.055 g/L (7). The patients specimens
for AxSym greater than 22.78 ng/mL or Architect period. The average value (), standard deviation
greater than 50 ng/mL we used dilution protocol. (SD) and coefficient of variation (CV) are shown
The CMIA is new immunochemistry technique
in Table 1. The precision has coefficient of variawith analytical sensitivity 0.01 for cTnI detection
tion (CV) for three controls using Architect STAT
in serum compared with MEIA with analytical sen- TnI assay technology were 3.6 5.2 %. Reproducsitivity 0.02. The advantages of CIMA is detection ibility was determined by running controls in the
of lowest concentration of troponin that can be
morning over 10 consecutive day. Coefficient of
measured at patents serum after MI (2,3). The ref- variation (CV) for the reproducibility of TnI assay
erence range for TnI in serum is 0.00-0.40 ng/mL. varied from 3.7 to 5.6 %. The precision has coefficient of variation (CV) for three controls using
Quality control
AxSYM STAT TnI assay technology were 4.36.6
The low, medium and high TnI controls of com- %. Reproducibility was determined by running
mercially available Architect ABBOTT and controls in the morning over 10 consecutive
AxSYM ABBOTT were used. The precision day. Coefficient of variation (CV) for the repro(intra-day variation) was tested by measuring ducibility of TnI assay varied from 4.8 to 7.8 %.
(n=20) of three different controls of TnI. The
reproducibility (inter-day variation) for same Accurancy testing
controls was tested all controls once a day over We compared TnI concentration measured in
10 consecutive days. The accuracy of measur- 119 blood serum by Architect CMIA and AxSYM
ing was tested in 119 of serum patient who were MEIA technology. The results of the comparidetermined TnI. Measures were obtained by Ar- son between Architect CMIA and AxSYM MEIA
chitect CMIA and AxSYM MEIA technology. technology analysis are shown in Figure 1. Sizable correlation was noted between Architect and
AxSYM technology in the investigation of 119
blood samplers (r = 0.999). Regression equation
The results were statistically analyzed using NCSS
and statistical software SPSS version 12.0 software. revealed a slope of 0.9187 and a y axis intercept
of 0.077. The difference between the methods
Determined by the average value (), standard
deviation (SD), Pearson correlation coefficient was statistically significant for p <0.05 accord(r), equations of linear regression and Student t ing Student t-test. The Architect STAT TnI assay
test with statistical significance level of p <0.05. had a limit of detection of 0.004 g/L and a CV
of 10% at concentrations approaching 0.03 g/L.
The concentration of serum TnI using Architect
Results
CMIA is higher than AxSYM MEIA technology.
Quality control testing
Three controls low, medium and high Abbott tech- Ten of the 119 samples (in 5 patients) were likely
to be true AxSYM negatives because there were no
nology (n = 20) were measured for quality control
156

FIGURE 1. Comparison of TnI concentration (ng/mL) in serum measured by Architect CMIA (x-axis)and AxSYM MEIA
technology (y-axis).
FIGURE 2. The comparison of Troponin I in patient serum

using different methods.
detected cardiac events during follow-up. The Architect values in these 10 samples ranged from 0.04
to 0.09 g/L. These findings highlight the potential
of the Architect assay to reclassify patients previously labeled as "normal". The mean concentration
of TnI by patients with no detected cardiac events
in Architect assay was 0.005 g/L and in AXSYM
assay was 0.000 g/L. The average concentration of
TnI in serum from all patients in study measured
by Architect assay was 16.07 g/L and in AXSYM
assay was 14.84 g/L. The results of the mean
concentration of Architect CMIA and AxSYM
MEIA technology analysis are shown in Figure 2.
ity 0.01 of Architect CMIA in comparison with

AxSYM MEIA technology with lower analytical
sensitivity 0.02. Comparison with the clinically evaluated AxSYM cTnI assay (9-11) showed
that the Architect STAT TnI assay identified additional patients who have not clinical evidence
of cardiac damage. This is in keeping with studies
showing that the AxSYM assay may miss patients
who later developed poor cardiac outcomes. Furthermore, the Architect TnI showed good agreement with the measurement at the lower end of
range (9,11). At our study we have got possibility of early detection of troponin in patient serum with CMIA in the moment when the same
serum was not detectable using MEIA. The measurement of CMIA 0.01-50 g/L and MEIA 0.0222.8 and it can explain better sensibility of CMIA
technology for detection troponin in serum.
The definition of high-sensitive assay would be
one that had total imprecision less than 10 % at
the 99th percentile. Our 99th percentile value is
higher than that reported by the manufacturer (0.012 g/L) and may be attributable to our
use of freshly collected blood bank specimens.
Discussion
The Quality control testing using all three controls
in Architect CMIA and AxSYM MEIA technology
using Levey Jennings report were under range of
two S.D. The CMIA have broader range of controls
then MEIA technology. The new CMIA technology
has higher precision and reproducibility of TnI assay and better improvement in quality of assay. Our
results have shown the possibility of detection lower concentration of troponin in serum with CIMA.
The similar results have got other groups (8-10).
The accuracy testing, we found very good correlation between two technologies CMIA and MEIA
with correlation coefficient r = 0.99. The investigation from Lam at all have found good factor of
correlation too (8). The methods have correlation
but great difference in mean troponin concentration patient with MI and low concentration
of patients that have not myocardial infarction.
We can explain it in difference of troponin mean
concentration with higher analytical sensitivJournal of Health Sciences 2011; 1 (3)
Conclusion
Architect CMIA Abbott technology is an applicative method in monitoring TnI in patients after
myocardial infarction. In comparing methods we
have got better precision and reproducibility of
TnI assay for Architect STAT TnI assay technology
then AxSYM MEIA technology. CMIA method
is technology improved and has possibilities for
detection lower and higher concentration of TnI
than MEIA. The mean differences between CIMA
157

and MEIA methods was statistically significant

for p <0.05 using Student t test with very good
factor of correlation r = 0.99. We conclude that
Architect CMIA Abbott technology is method
proves reliable TnI concentration in patient serum and it has better precision limits and ability to detect troponin at the low end of the range.
References
1. Reichlin T, Hochholzer W, Bassetti
S, Steuer S, Stelzing C, Harnwiger S,
Biedert S, Schlaub N, Buerge C, Potocki M, Noveanu M, Breidthardt T,
Twerenbold R, Winker K, Bringisser
R, Mueller C. Early diagnosis of
myocardial infarction with sensitive
cardiac troponin assay. N Engl J Med
2009; 361(9): 858-913.
2. Operators Manual STAT Troponin I
ARCHITECT SYSTEM Abbott Diagnostic, REF 2K41-840653/R08 2010.
3. Giannitsis E, Becker M, Kurz K, Hess
G, Zdunek D, Katus HA. High sensitivity cardiac troponin T for early
prediction of evolving non-ST-segment elevation myocardial infarction
in patients with suspected acute coronary syndrome and negative troponin results on admission. Clin Chem
2010;56 (4): 642-650.
4. Operator Manuel STAT Troponin I
AxSYM SYSTEM Abbott Diagnostic,
REF 2J44-34-3355/R2 2005.
5. Learning Guide: Immunoassay: Introduction to Immunoassays. Learn-
158
ing Objectives. After completion of

this chapter, you will be able to: define immunoassay, Abbottt (Accessed
October 29, 2011)
6. Mills N, Churchhouse A, Lee KK,
Gamble D, Shah A.S, Peterson E,
MacLeod M, Graham C, Walker S,
Denvir M, Fox AA, Newby DE. Implementation of sensitive troponin I
assay and risk of recurrent myocardial infarction and death in patients
with suspected acute coronary syndrome. JAMA 2011; 305: 23-30.
7. Tate JR, Panteghini M. Measurement
of cardiac troponins revisited. Biochimica Clinica, 2008; 32( 6): 535546
8. Lam O, Black M, Youdell O, Spilsbury Y. Schneider H.G. Performance
Evaluation and Subsequent Clinical
Experience with the Abbott Automated Architect STAT Troponin-I
Assay. Clin Chem 2006;52: 298-300.
9. Heeschen C, Hamm CW, Goldmann
B, Deu A, Langenbrink L, White HD.
Troponin concentrations for stratifi-
cation of patients with acute coronary

syndromes in relation to therapeutic
efficacy of tirofiban. PRISM Study Investigators: Platelet Receptor Inhibition in Ischemic Syndrome Management. Lancet 1999;354:1757-1762.
10. Apple FS, Maturen AJ, Mullins RE,
Painter PC, Pessin-Minsley MS,
Webster RA, et al. Multicenter clinical and analytical evaluation of the
AxSYM troponin-I immunoassay to
assist in the diagnosis of myocardial
infarction. Clin Chem 1999;45:206212.
11. Wilcox G, Archer PD, Bailey M,
Dziukas L, Lim CF, Schneider HG.
Measurement of cardiac troponin I
concentrations in the emergency department: predictive value for cardiac
and all-cause mortality. Med J Aust
2001;174:170-173.
www.jhsci.ba
Doppler measurements of feto-placental blood

stream in pregnant smokers
Gordana Bogdanovi1*, Denita Ljuca1, Edin Ostrvica2, Adnan
Babovi1, Enida Nevainovi1, Hidajet Rahimi3
Department of Gynecology and Obstetrics, Universitiy Clinical Center Tuzla, Trnovac bb, 75000 Tuzla, Bosnia and Herzegovina
Health Center Dr. Mustafa ehovi Tuzla, Albina Herljevia 1, 75000 Tuzla, Bosnia and Herzegovina. 3 Medical Centre,
ivinice, Alije Izetbegovia 17, 75270 ivinice, Bosnia and Herzegovina
Abstract
Introduction: Doppler analysis of the feto-placental and fetal circulation give dynamic information on the
condition of the bloodstream during pregnancy, and early detection of fetal hypoxia. The objectives of the
study were: testing whether there is influence of smoking on feto-placental circulation; determining whether
there is a link to a number of smoked cigarettes during the day; assessing the benefits of Doppler ultrasonographic screening in detection of fetal hypoxia in pregnant women who smoke during pregnancy.
Methods: 300 pregnancies were included in the prospective research. With regard to a number of smoked
cigarettes the pregnant women were divided into three groups: I. the first group (moderate smokers) consisted of 100 pregnant women who smoked up to 15 cigarettes a day during pregnancy; II. the second group
(heavy smokers) 100 pregnant women who smoked more than 15 cigarettes a day during pregnancy and
III. the third group (control group) 100 pregnant women who did not smoke during pregnancy. All pregnant
women underwent Doppler measurements of blood circulation (determination of resistance index RI) in the
umbilical artery, fetal aorta and middle cerebral artery.
Results: The intensity of smoking has influence to circulation because RI in the umbilical artery and fetal
aorta is increased and RI is decreased in the middle cerebral artery in pregnant women heavy smokers in
comparison to pregnant women moderate smokers.
Conclusion: Doppler sonography of the blood vessels could have an important role in detection of hypoxia
and monitoring of the condition of the fetus of pregnant women who smoked during pregnancy.

Keywords: Doppler, cigarette smoking, fetus, cerebral blood flow, placenta
Introduction
Tobacco smoking is one of the biggest threats
to human health which could be prevented and
stopped. Tobacco and its ingredients are identified as the main cause of morbidity and mortality of human starting from conception and to
late age (1). Smoking has multiple influences
on reproduction health. Tobacco smoking during pregnancy is connected to increased number
of miscarriages, preterm births, more frequent
bleeding during pregnancy, increased percentage
of placenta previa and ablation of the placenta,
horioamnionitis and preterm rupture of membranes (2). There is also fetal growth retardation,
* Corresponding author: Gordana Bogdanovi, MD, PhD;
Department of Gynecology and Obstetrics,
Universitiy Clinical Center Tuzla, Trnovac bb,
75000 Tuzla, Bosnia and Herzegovina; Phone:
+387 61 727 958; e-mail: imarinov@inet.ba
which results in birth of children with decreased

birth weight and length (3). More frequently they
have hypoglycemia, disturbed regulation of body
temperature, and due to sensitivity of blood vessels, cerebral hemorrhage is more frequent and
subsequently neurological defects (4). Children of
mothers who smoke have in their early age respiratory and neurological complications more often,
they are hospitalized more frequently and placed
in the intensive care unit (5). Tobacco smoke contains 4000 chemical ingredients, of which some 30
are linked to different harmful impact to human
health. Nicotine from the tobacco smoke influences the blood vessels causing vaso-constriction
(due to increased quantity of released catecholamine), and decreases uteri-placental perfusions.
In addition to nicotine tobacco smoke contains
other vasoactive substances: endothelin, corticotrophin releasing factor, sodium-nitropruside,
cadmium and prostaglandin. All these substances
159
Gordana Bogdanovi et al.: doppler measurements of feto-placental blood stream in pregnant smokers
cause mechanical changes to villous arteries, and

that causes functional changes i.e. decrease of
blood circulation through feto-placental unit (6).
It has been almost 30 years since the first Doppler analysis of feto-placental circulation and until today thanks to this method knowledge about
circulatory changes in fetuses during physiological and pathological pregnancy is significantly
complemented (7). Today it is well known that
certain Doppler registered changes of umbilical
circulation and some fetal arteries in risky pregnancies are directly linked to high perinatal
mortality (20-100%) and morbidity (8). Doppler
measurements enable non-invasive estimation
of the hypoxemia that is hypoxia (9). Due to big
significance attached to harmful impact of smoking tobacco during pregnancy in the world the
objective of the study was: 1. Research whether
there is impact of smoking tobacco during pregnancy to hemodynamic changes to feto-placental
blood stream, 2. Determine whether these changes are linked to a number of smoked cigarettes
during a day and 3. Estimate benefits of Doppler-ultrasound screening in such pregnancies.
Methods
Study design
The prospective research was carried out at the Gynecology-obstetrics clinic UKC Tuzla in the period
of 2001-2005 years. Criteria for inclusion into the
study were: singleton pregnancy; pregnant women
who smoked during pregnancy, without other risk
factor or disease which could influence course or
outcome of pregnancy; age of pregnant women
from 25th to 35th years; exact gestation age of pregnancy (determined according to the last period,
which was later confirmed by ultrasound examination). In comparison to the number of smoked cigarettes during a day the examinees were divided into
three groups (as recommended by WHO, 1992):
1. The first group (moderate smokers) consisted
of 100 pregnant women who smoked up to 15
cigarettes a day during pregnancy
2. The second group (heavy smokers) consisted
of 100 pregnant women who smoked more
than 15 cigarettes a day during pregnancy
3. The third group (control group), consisted of
100 pregnant women who did not smoke during pregnancy
160
Procedure
We got information on smoking habits by questionnaire, which is an integral part of the history of disease. Doppler measurement of blood
circulation by apparatus Kretz technik, Voluson
530 D with semi convex 3,5 MHz tube was carried out for pregnant women from all groups.
Analysis of blood circulation using Doppler effect was done by analyzing sonogram of umbilical artery, fetal aorta and middle cerebral
artery. For the analysis of sonogram resistance
index RI (10) was used. Measured mean of resistance index was compared with mean for the
respective gestation of the normal pregnancy (11).
Pathological index of resistance in the umbilical artery and aorta is defined as increase of mean for two
standard deviations (+2SD), and pathological resistance index in middle cerebral artery as decrease
of mean values (-2SD), in comparison to gestation.
Derived values were processed by standard
statistical methods such as calculation of
mean and standard deviation. While comparing derived results Student ttest was
used. Statistical significance of distinction
was determined on the risk level less than 5%.
Results
Results of Doppler measurement of resistance index in the umbilical artery (grouped
by weeks of pregnancy) are shown in the Table
1. Mean difference of resistance index in the
umbilical artery between heavy smokers, moderate smokers and control group, is statistically significant in the gestation age from 32nd
to 41st week of pregnancy (p<0.05) (Table 1).
For the complete number of moderate smokers we
calculated mean resistance index ( =0.68 0.05), in
Table 1. Resistance index in umbilical artery
Week of
pregnancy
28-31
32-35
36-37
38-41
Moderate smokers (N=100)

SD
0.780.005
0.700.03
0.670.04
0.660.04
Heavy smokers (N=100)

SD
0.790.01
0.760.03
0.760.03
0.750.02
Control group
(N=100)
SD
0.700.01
0.640.03
0.640.03
0.630.02
FIGURE 1. Mean, standard deviation, and upper and lower

limits of data of resistance index values in umbilical artery in
moderate, heavy and non-smokers (control) groups of pregnant women
FIGURE 2. Mean values, standard deviations, and upper and

lower values of resistance index in middle cerebral artery in
moderate, heavy and non-smokers (control) groups of pregnant women
heavy smokers that value is ( =0.76 0.03), and in

the control group ( =0.64 0.03). Comparing the
mean and standard deviations of resistance index in
the umbilical artery, we found that all three groups
are statistically significantly different (p<0.05). The
results given of complete series of resistance index
in the umbilical artery in moderate smokers, heavy
smokers and control group are shown in Figure 2.
Figure 1. Graphic display of mean, standard
deviation, and upper and lower limits of data
of resistance index values in umbilical artery of examinee groups of pregnant women
In Table 2. Results of measured and calculated
mean of resistance index are shown (for the respective gestation) in fetal aorta. We see from
the shown table that mean values of resistance
index in fetal aorta in fetuses of heavy smokers
in comparison to control group are significantly
higher for the gestation (p<0.05). The group of
moderate smokers has higher mean values of
resistance index in fetal aorta in comparison to
control group in gestation age from 28th to 37th
week (p<0.05). Group of moderate and heavy
smokers statistically significantly differ in gesta-
tion from 36th to 41st week of pregnancy (Table 2).

In Table 3. Resistance index values in middle
cerebral artery are shown (for certain gestation
age). Between the group of heavy smokers fetuses and control group resistance index values
differ for gestation age from 32nd to 41st week
of pregnancy. Lower values of resistance index
in middle cerebral artery in fetuses of moderate smokers in comparison to control group are
considerably lower in gestation age from 32nd
to 41st week (p<0.05 ). Comparing the group of
heavy and moderate smokers significant difference in resistance index values in middle cerebral artery is present in all examined pregnancy
periods, and in the gestation age from 38th to 41st
week on the significance level p<0.01 (Table 3).
In Figure 2 mean values and standard deviations
of resistance index in the middle cerebral artery
for complete series of fetuses of moderate smokers, heavy smokers and control group regardless of gestation age are shown. There is significant statistical difference between three groups
(t1=2.51; t2=1.99; t3=2.05; p<0.05) (Figure 2).
Figure 2. Mean values, standard deviations, and
Table 2. Resistance index in fetal aorta
Table 3. Resistance index in the middle cerebral artery
Week of
pregnancy
28-31
32-35
36-37
38-41

SD
0.87
0.860.01
0.790.02
0.790.03

SD
0.87
0.870.01
0.840.02
0.870.01
Control group
(N=100)
SD
0.79
0.740.01
0.770.02
0.790.03
Week of
pregnancy
28-31
32-35
36-37
38-41

SD
0.800.01
0.780.03
0.740.04
0.650.04

SD
0.77
0.700.02
0.650.01
0.570.01
Control group
(N=100)
SD
0.810.01
0.770.05
0.750.04
0.680.06
161
upper and lower values of resistance index in middle cerebral artery in examined groups of pregnant
women.
Discussion
From the first trimester and to the end of pregnancy feto-placental circulation is developed and
functions as low resistance circulation system,
in which low vascular resistance allows constant
and good vascularization of feto-placental unit.
There is relatively high resistance only in cerebral
blood circulation, which is interpreted as protective mechanism, because in such a way there is
physiological vascular reserve for vasodilatation
in order to provide better circulation for brain
in case of hypoxia. Doppler record of blood circulation through umbilical artery (AU) is characteristic for blood vessels of low vascular resistance, with considerable decrease of resistance as
the pregnancy progresses, which is consequence
of increase of growth of placenta and expansion
of its blood vessels, and increase of fetal minute
cardiac volume (9). Campbell (12) examined relation between the resistance in umbilical artery
and number of small arteries and arterioles in tertiary villis. He determined that in increased resistance in AU this number is significantly reduced
because of their obliteration. All pathological
conditions which change placenta blood vessels
(sclerosis, degeneration, obliteration, thrombosis) influence the diastolic circulation in umbilical arteries, which reflects in increased values of
resistance index. Decreased utero-placental perfusion leads to placental ischemia and it leads to
vasoconstriction and obliteration of blood vessels.
Smoking during pregnancy is understood as antepartal (maternal) cause of fetal hypoxia and fetoplacental respiratory insufficiency. Carboxichemoglobinemia and chronic hypoxemia influence in
chronic placental hystoarchitectony, vasoconstriction feto-placental circulation and disturbance
of intermedial metabolism (13). ome researchers
have examined changes in blood circulation in UA
and MCA before and after smoking one cigarette.
They did not found acute hemodynamic resistance
changes in fetus, indicating significance of chronic
tobacco use and chronic changes of small placental blood vessels (14, 15). Sindberg obtained the
same results (16) and concluded that after smok162
ing one cigarette there is increase in central circulation, but peripheral resistance is unchanged.
Our results indicate that there is significant difference between the group of pregnant moderate smokers and control group, for gestation age
from 32nd to 41st week of pregnancy. Smoking of
up to 15 cigarettes a day has influence to blood
circulation through umbilical artery both in preterm and also term pregnancies, which results in
lower perfusion and thereby oxygen and nutrients
transport to fetus. In pregnant heavy smokers in
comparison to control group increased values of
RI in UA are found in gestation age 32nd to 41st
week, which is in line with results of other authors
(17, 18, 19). Increased resistance in umbilical artery in heavy smokers reflects disturbed vascular
tone and sclerosis of placental blood vessels. Increased RI in UA in heavy smokers in comparison
to control group indicates possibility for development or existence of intrauterine fetal hypoxia and
all consequences it entails. Also there is increased
resistance index in heavy smokers in comparison to the group of moderate smokers, which is
in line with Ates claims (19) that only in chronic
and intensive use of tobacco there is increased
vascular resistance in placenta and umbilical cord.
Vascular resistance is in irreversible relation with
blood circulation through the respective organ
(20). The increased resistance in UA indicates
compromised feto-placental bloodstream, which
results in a number of complications in fetus: lower birth weight, intrauterine retardation, poorer
vitality at birth and etc. Wang and authors (21)
published that stagnation in the growth of fetus
while smoking during pregnancy is linked to vascular changes in feto-placental microcirculation.
Based on significant increase of RI in umbilical artery in pregnant women, both moderate
and heavy smokers in comparison to the control
group, we conclude that smoking tobacco during
pregnancy influences blood circulation in UA, regardless of pregnancy gestation. Due to disturbed
blood circulation fetuses of pregnant smokers are
endangered, because they are without an adequate
support for normal growth and development.
In compromised feto-placental circulation (in
chronic tobacco smoking), in fetal aorta similar
like in UA resistance of blood stream is increased,
which also has predictive values to eventual outJournal of Health Sciences 2011; 1 (3)
come of pregnancy (16). According to our research smoking of up to 15 cigarettes a day has
influence on blood circulation through fetal aorta
in comparison to the control group it is only in
preterm pregnancy. That is, in moderate smokers preterm pregnancy is threatened, while term
pregnancies have compensatory ability of the fetus response to hypoxia. A number of studies (22,
23) showed that increased RI in blood circulation
in fetal aorta is connected to smoking cigarettes
during pregnancy. Comparing the group of heavy
smokers and the control group we found increased RI in fetal aorta in all gestation age, and
we conclude that in heavy smokers both pre-term
and term pregnancies are threatened. Difference
between the group of moderate and heavy smokers is significant from 36th to 41st week of pregnancy. The higher vulnerability of term fetuses
of heavy smokers in comparison to the control
group, and also to the group of moderate smokers indicate that resistance of fetuses to harmful
influence of tobacco depends less on gestation age
and maturity and more on intensity of smoking.
Comparing the mean values of RI for the
whole series of studied groups, we found significant difference, and characterized smoking as significant factor which influences blood
circulation in fetal structures, which is consistent with the results of other authors (24).
The blood circulation in the central nervous system is subject to auto-regulation and depends
on the oxygen concentration in the blood coming to brain. Metabolic activity of brain cells is
the second important regulation factor of blood
circulation. Vascular resistance in the middle
cerebral artery (MCA) shows low values in the
period from 15th to 20th week and after 36th week
of pregnancy, that is periods when brain is most
intensely developing (9). In some pathological conditions with increased resistance in fetoplacental circulation there is redistribution of
bloodstream in fetus' vessels favoring central nervous system (brainsparing effect). In cerebral
blood vessels vascular resistance is decreasing
and diastolic flow is significantly increased. Decreased values of these indexes are in correlation
with fetal hypoxia and acidosis (25). There are
number of data in literature on decreased values
of RI in MCA in pregnant women who smoke
during pregnancy (15, 17, 26). All authors point

out significance of long that is more intensive
smoking for occurrence of changes in blood vessels and disturbance of feto-placental circulation.
Our results are consistent with previous reports.
The difference of mean of RI in MCA between fetuses of heavy smokers and the control group is
significant in all studied gestation age. We conclude that fetuses of heavy smokers, decreased
placental blood circulation and possible tissue hypoxia are compensated by centralization of blood.
They are vulnerable group and have increased risk
for inadequate growth and development regardless of gestation age. Smoking of up to 15 cigarettes
a day also influences cerebral blood circulation,
because the resistance indexes in fetuses of that
group are significantly lower, in comparison to
the control group (for each studied gestation period), and they also indicate fetus' ability to adjust
to the insufficient support for normal growth and
development. Although details of that circulation
adjustment and their mechanisms are incomplete,
it is possible that when partial oxygen pressure
decreases and partial carbon monoxide pressure
increases above acute level, the aortic and carotid
chemo receptors are activated. That is probably
the mechanism which regulates middle vasodilator response for guaranteeing adequate oxygenation of the fetal brain (27). Testing values of RI in
MCA between fetuses of pregnant moderate and
heavy smokers, we found significantly decreased
resistance in heavy smokers, which we explain by
stronger and longer disturbances of fetal circulation, as consequence of more intensive toxic activity of tobacco smoke. Significant difference is particularly important for gestation age from 38th to
41st week of pregnancy. In this period of pregnancy
(around birth term), fetal intravenous sinusoids
are the closest to the mother's blood, so the circulation disturbance i.e. reduction of the flow of oxygen and nutrients is reflected directly on the fetus
(28). Greater vulnerability of term fetuses of heavy
smokers in comparison to term fetuses of moderate smokers shows that intensity of smoking has
big influence because other predisposing factors
are excluded, such as prematurity and immaturity.
Analysis of the cerebral blood circulation by
method of colored Doppler in pregnant women
who smoked during pregnancy in our study is
163
consistent with the results of other authors (27,

29). The comparative analysis of mean values of
RI in MCA for the whole series of fetuses of the
pregnant moderate smokers, heavy smokers and
the control group we found the significant difference, which proves that smoking has influence
on the cerebral blood circulation and that it is
connected with fetal hemodynamic adjustments.
Conclusions
In this study, using the method of Doppler sonography we found that cigarettes smoking during pregnancy influences feto-placental circulation due to:
increased resistance index in u umbilical artery
and fetal aorta, and decreased resistance index in
the middle cerebral artery. Smoking interferes with

physiological feto-placental circulation and influence fetus' supply by nutrients and oxygen. Negative effect of smoking to blood circulation is connected with intensity of smoking. Considering the
good correlation of Doppler changes in the flow of
certain fetal blood vessels with unfavorable perinatal outcome in pregnant women who smoked
cigarettes during pregnancy, it is a method which
contributes significantly to the ability to monitor these pregnancies. Our results which identify
cigarettes smoking during pregnancy as risk factor for increased perinatal morbidity and mortality could help in health education of population
and taking measures to combat tobacco smoking.
References
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M.A.K. Golden; 2001. 50.
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elmi J. Utjecaj puenja tijekom
trudnoe na rani i kasni razvoj djeteta. Gynecol Perinatol. 2006; 15(1): 306.
4. Roy T, Sabherwal U. Effect of perinatal nicotine exposure on the morphogenesis of somatosensory cortex.
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www.jhsci.ba
Analysis of disease spectrum of corporate

executives after physical examination
Li Qing1, Guo Huailan2,3, Chen Jin3, Chen Jianhua2*, Yanjun Zeng4*
Renaming Hospital Affiliated to Hubei University of Medicine. 2 Physical Examination Center, Taihe Hospital Affiliated to
Hubei University of Medicine. 3 Department of Preventive Medicine, Hubei University of Medicine, Shiyan 442000,China.
4
Biomechanics and Medical Information Institute, Beijing University of Technology, Beijing 100022, China
1
Abstract
Introduction: To find out the disease spectrum of corporate executives and screen the common chronic
diseases.
Methods: The physical examination data of corporate executives were collected to carry out cross-sectional
study.
Results: Among 231 subjects, there were one hundred and ninety four males, which made up 85.3%, and
thirty seven females, which made up 14.7%. The detection rate of chronic diseases in corporate executive
was high. Specifically, the incidence rate of blood viscosity rise was 87.8%; the incidence rate of blood lipid
rise was 79.5%; the incidence rate of obesity and overweight was 76.7%; the infection rate of Helicobacter
pylori was 55.7%; the prevalence rate of fatty liver was 52.1%; the prevalence rate of kidney stones was
43.5%; the incidence of abnormal pancreatic echo was 52.3%; the incidence rate of abnormal TCD was
66.2%; the detection rate of coarse gallbladder wall was 35.5%. The prevalence rate of bone mineral density
reduction was 39.6%; the detection rate of reduction of diastolic function of left ventricle was 37.5%; the
incidence rate of raised serum uric acid was 28.6%; the incidence rate of blood glucose going up was 22%;
the incidence rate of liver cyst was 19.5%. The prevalence rate of blood LDL rise was 23.9%; the prevalence
rate of abnormal thyroid was 21.3%; the incidence rate of arteriosclerosis was 17.5%; the prevalence rate of
hypertension was 17.4%.
Conclusion: The corporate executives are high risk group of common metabolic diseases and cardiovascular and cerebrovascular diseases. Therefore, screening should be strengthened for them.

Keywords: Corporate executive; Physical examination; Chronic diseases; Survey
Introduction
Disease spectrum refers to the spectrum of various diseases arranged in the order of hazard degree and harmful for human health in a certain
region. The disease spectrum varies with location and population. The investigation of disease
spectrum is useful for relevant departments in
implementing measures for diseases prevention
targetedly. The national survey of disease spectrum in 2008 showed that, the top 3 diseases in
the national disease spectrum were malignant tumor, heart disease, and cerebrovascular diseases;
* Corresponding authors:
Chen Jianhua, e-mail: 1324542799@qq.com
Yanjun Zeng, e-mail: yjzeng@bjut.edu.cn
Submitted 10. April 2011 / Accepted 20. September 2011
166
the top 3 in disease spectrum of inpatients were

circulatory system disease, injury, toxicosis and
tumor (1). High work pressure, imbalanced nutrition, and lack of physical exercise for long pervasively existed in white collars. For the purpose of
understanding the health status of white collars
and preventing the harm arising from chronic diseases particularly in an early stage, an analysis of
the disease spectrum of corporate executives after
physical examination was conducted in the study.
Methods
Research subjects
231 corporate executives from one state-owned
enterprise; 194 male, and 37 female, aged averagely about 48.110.1 years. The 231 corporate executives all accepted the physical
Li Qing et al.: analysis of disease spectrum of corporate executives after physical examination
Table 1. Constitution of the subjects gender and age

Age
(year)
<30
30~
40~
50~
60~
70~79
Sum
Male
Female
Sum
Number % Number % Number %
3
1.5
1
2.7
4
1.7
10
5.2
4
10.8
14
6.1
76
39.2
18
48.7
94
40.7
95
49.0
11
29.7
106
45.9
8
4.1
1
2.7
9
3.9
2
1.0
2
5.4
4
1.7
194
100
37
100
231
100
examination at the Physical Examination Center, Taihe Hospital Affiliated to Hubei Medical
University from April 15th to May 30th of 2009.
Research methods and contents
Statistical analysis was conducted on results of their ages, genders, body mass index, blood pressure, blood lipid, blood
glucose, serum uric acid, liver, Type-B ultrasonic examination of thyroid, ultrasonic transcmnial Doppler(TCD), bone mineral density examination, helicobacter pylori examination, etc..
Index of anthropometry: height and weight measurement, calculation of the body mass index
(BMI), and measurement of artery blood pressure
at the top right cantilever was conducted. Venous
blood was collected after fasting for 8 to 10 hours
to detect triglyceride (TG), high density lipoprotein cholesterol (HDL-C), low density lipoprotein
cholesterol (LDL-C), and serum uric acid (UA)
using Enzyme method (Japanese Hitachi 7170A
Automatic Analyzer). The fasting blood-glucose
(FBG) was detected by glucose oxidase method.
Type-B ultrasonic examination: Three attending
physicians with imageology expertise used PHILIPS Color Doppler Ultrasonic Device (extraordinary type, 3.5 Hz frequency of ultrasonic probe)
to conduct Doppler ultrasonic examinations of
liver, gallbladder, pancreas, kidney, and thyroid.
Detection by transcranial Doppler (TCD): The
transcranial Doppler Type TCD2020 of German
EME Company with 2 MHz frequency of ultrasonic probe was used to detect the maximum
blood flow velocity, minimum blood flow velocity, average blood flow velocity and resistance index of the anterior, middle and posterior artery
of left and right cerebral hemispheres, through
temporal window and pulvinar window. The

mean value of the artery of left and right cerebral hemisphere was used in statistical analysis. Japanese OMRON Arteriosclerosis Detector
was used to detect the degree of arteriosclerosis.
Diagnostic standards
According to the diagnostic standards of
WHO in 1999, when BMI<18.5kg/m2, the subject is considered to be relatively thin; when
18.5kg/m2BMI<23.9kg/m2, the subject is
considered as normal; and when BMI24kg/
m2, the subject is considered as overweight.
According to Guidelines for Prevention and
Treatment of Hypertension of China in 2004, subjects with twice systolic pressure (SBP) 140mmHg
and twice diastolic pressure (BDP) 90mmHg
and/ or those diagnosed as hypertension and
accepted treatment are hypertensive patients.
According to Guidelines on Prevention and
Treatment of Blood Lipid Abnormality in Chinese Adults (2): when TG2.26mmol/L, the
subject is abnormal; if LDL-C4.14mmol/L,
the subject is abnormal; and if LDLC1.04mmol/L, the subject is abnormal.
Male subjects with UA>420ummol/L or female subjects with UA>350ummol/L are diagnosed as patients with high serum uric acid..
Ultrasonic diagnostic standards of fatty liver (3):
1) mild or moderate liver hyperplasia with smooth
surface; 2) the intrahepatic echo is magnified, with
the front half fine and intense, which varies like
clouds; and the strength of echo decreases from the
surface to the depth of liver, even undetectable in
the depth under normal sensitivity; 3) most of the
intrahepatic blood vessels are hard to be display.
Statistics analysis
SPSS16.0 software was used to conduct statistics analysis, and -test was used for single factor analysis. The difference with P
<0.05 was of certain statistical significance.
Results
The constitution of the gender and age of the subjects was shown in Table 1. Among the subjects,
there were 194 males, amounting to 85.3%, and
37 females, amounting to 14.7%; subjects of 40 to
60 years accounted for 88.2% of all the subjects.
167
Table 2. Disease Spectrum of Corporate Executives

Disease
Obesity and overweight

Fatty liver
Helicobacter pylori
Kidney stones
Abnormal echo in
pancreas
Abnormal TCD
Coarse gallbladder
wall
Abnormal bone
mineral density
Left ventricular
diastolic function
High blood viscosity
Raised serum uric
acid
Enlargement of
male prostate
Blood glucose rise
Hepatic cyst
Blood LDLrise
TG rise
Hypertension
Thyroid disease
Arteriosclerosis
Number of
Subjects
Male
Positive
Number
Female
Sum
Positive Number of Positive Positive Number of Positive Positive
rate(%) Subjects number rate(%) subjects number rate(%)
142
118
83.1
25
10
40
167
128
76.7
<0.05
144
135
145
79
74
70
54.9
54.8
48.3
25
23
23
9
14
3
36
60.9
12
169
88
168
88
158
73
52.1
55.7
43.5
>0.05
0.05
<0.05
144
62
43.1
24
25
168
88
52.3
>0.05
57
37
64.9
11
72.7
68
45
66.2
>0.05
144
55
38.2
25
20
169
60
35.5
>0.05
122
48
39.3
12
41.7
134
53
39.6
<0.05
127
49
38.6
22.2
136
51
37.5
>0.05
40
36
90
77.8
49
43
87.8
>0.05
143
47
32.9
25
169
48
28.6
<0.05
128
39
30.5
128
39
30.5
143
144
127
35
142
127
135
34
30
31
29
27
28
26
23.8
20.8
24.4
82.9
19
22.1
19.1
25
25
11
4
25
9
24
3
3
2
2
2
1
2
12
12
18.2
50
8
11.1
8.3
168
169
138
39
167
136
159
37
33
33
31
29
37
28
22
19.5
23.9
79.5
17.4
21.3
17.5
Disease spectrum of subjects

It can be seen from Table 2 that, the detection
rate of chronic diseases in corporate executive
was high: the incidence rate of blood viscosity
rise was 87.8%; the incidence rate of blood lipid
rise was 79.5%; the incidence rate of obesity and
overweight was 76.7%; the infection rate of Helicobacter pylori was 55.7%; the prevalence rate of
fatty liver was 52.1%; the prevalence rate of kidney
stones was 43.5%; the prevalence rate of abnormal
echo in pancreas was 52.3%; the incidence rate of
abnormal TCD was 66.2%; the incidence rate of
coarse gallbladder wall was 35.5%; the prevalence
rate of bone mineral density reduction was 39.6%;
the incidence rate of reduction of left ventricular
diastolic function was 37.5%; the incidence rate of
raised serum uric acid was 28.6%; the incidence
rate of blood glucose rise was 22%; the incidence
168
>0.05
>0.05
>0.05
>0.05
>0.05
>0.05
>0.05
rate of liver cyst was 19.5%; the prevalence rate of

blood LDL rise was 23.9%; the prevalence rate of
abnormal thyroid was 21.3%; the prevalence rate
of arteriosclerosis was 17.5%; the prevalence rate
of hypertension was 17.4%; and the prevalence
rate of enlargement of male prostate was 30.5%.
Difference in disease spectrum of the subjects of different gender
Compared with the female subjects, the male subjects were more prone to obesity and overweight,
kidney stones, serum uric acid, fatty liver, abnormal echo in pancreas, coarse gallbladder wall, reduction of left ventricle diastolic function, hepatic
cyst, thyroid examination, arteriosclerosis, blood
viscosity rise, LDL, serum triglyceride, and abnormal blood glucose. The difference in overweight
and obesity, kidney stone, serum uric acid beJournal of Health Sciences 2011; 1 (3)
tween male and female subjects had statistical significance. The female had higher rates of abnormal
bone mineral density, positive helicobacter pylori,
and abnormal TCD than that of the male, and the
difference in the rate of abnormal bone mineral
density between them had statistical significance.
Discussion
The 2002 national nutrition survey showed that (1),
the incidence of adult chronic disease rose apparently compared with that of 1992. The incidence
of hyperlipaemia was 18.6%, with 160 million
patients, while the rate of adult overweight was
22.8%, and obesity rate was 7.1%, with 200 million
and 60 million patients respectively. The incidence
of adult hypertension was 18.8%, with 160 million
patients; the incidence of adult glycuresis was 9.7%,
and the prevalence was 2.6%, with over 20 million
patients. The prevalence of diabetes of the adults
over the age of 20 in Beijing was 10.16%, and that of
early phase glycuresis was 11.19%; and the prevalence of metabolic syndrome was as high as 20.39%.
According to the results of this examination, the
abnormal rates of various examination results of
corporate executives were between 17.4% and
87.8%, with hypertension of the lowest abnormal
rate and blood viscosity rise of the highest abnormal rate. The incidence rates of blood viscosity
rise, positive helicobacter pylori, abnormal echo in
pancreas, positive TCD, and blood lipid rise were
all above 50%. The disease with the highest incidence was blood viscosity rise, with blood lipid rise,
overweight, obesity, and abnormal TCD followed.
A national survey showed that endocrine and
metabolic diseases ranked the fifth in disease
spectrum. And this survey also indicated that the
blood viscosity of corporate executives was 87.8%,
far beyond that of public servants as 19.6% (4);
the incidence of blood lipid rise was as high as
79.5%, which was also much higher than that of
public servants as 18.6%; the incidence of blood
glucose rise was 22%, higher than that of residents
as 5.23% (5,6) as well as that of public servants as
10.5%; the incidence of fatty liver reached 52.1%,
significantly higher than that of other populations
as teachers(29.3%) (7); the positive rate of kidney
stones was 43.5%, greatly higher than that of the
populations as 4.87% (8) ; and the overweight and
obesity rates were 76.7%, greatly higher than that
of the populations as 22.8% (1,9). Incrassation and

sclerosis of vascular intima could be sensed by
TCD at pathologic phases of mild, moderate and
severe vascular stenosis, and the nature, position,
degree, scope and prognosis of cerebrovascular
diseases can be predicted or reported in real
time so as to provide accurate diagnosis for the
patients. The arteriosclerosis detector can detect
cardiovascular and cerebrovescular diseases at an
early period. In this survey, the positive rates of
TCD and arteriosclerosis were 66.2% and 17.5%,
respectively, which indicated that the incidence of
chronic diseases, especially the metabolic diseases
and cardiovascular and cerebrovascular diseases,
were significantly higher than those of the general
populations. In 2008, Chinese Diabetes Society
conducted a survey over the incidence status in
fifteen cities and districts across the whole country
(10), and discovered that the incidence of Chinese
diabetes was 9.7%. According to the relevant estimate, there were about 92.4 million Chinese diabetes patients, and the diabetes incidence increased
rapidly among the business men of 30 to 45 years
old. Such research results show that, the corporate
executives are the high risk group of chronic diseases, which may be in relation to their high work
pressure, intensive social activities, and lack of
exercises. Therefore, it is necessary to strengthen
the examination of chronic diseases of corporate
executives, especially metabolic diseases, such as
obesity, fatty liver, diabetes, and gout; and at the
same time, screening of their cardiovascular and
cerebrovascular disease requires more attention.
It is worthy to note that, the positive rate of thyroid disease was 21.3% in this survey, while
the incidence of thyroid nodule was 18.6% according to the epidemiology survey result of
national thyroid disease. The reasons for such
thyroid disease include the lack of iodine, excessive iodine, and immunological factors. The
cause for the high positive rate of thyroid disease of corporate executives was not clear.
The study indicates that corporate executives are
the high risk group of metabolic diseases and
cardiovascular diseases based on the analysis of
disease spectrum of corporate executives after
physical examination, and provides the foundation to determine the keys in prevention and treatment of chronic diseases of corporate executives.
169
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www.jhsci.ba
Implementation of the hemoprophylactic

protocol in orthopedic surgery
Elvedin Osmanovic1*, Mensura Asceric2, Esed Omerkic1
Emergency Department, Public Health Institution Health Centre Zivinice, Bosnia and Herzegovina. 2 Department of Clinical
Pharmacology and Toxicology, Medical Faculty Tuzla, University of Tuzla, Bosnia and Herzegovina, Univerzitetska 1, 75000
Tuzla
Abstract
Introduction: Antibiotic prophylaxis is defined as the use of antimicrobials in the absence of symptoms of
infection, with the aim of preventing or reducing the incidence of infection after surgery. We analyzed the
incidence of surgical wound infection in patients in whom a protection of hemoprophylaxis conducted using
cefazolin and gentamicin, and determine the frequency of surgical wound infection in patients in whom there
was a deviation in the implementation of hemoprophylaxis protection.
Methods: This retrospective-prospective study included 100 patients surgically treated at the The Department of Orthopedics and Traumatology, University Clinical Center in Tuzla from December 2007 to February
2010, which examined the incidence of surgical wound infection after surgical treatment of fractures or degenerative changes in the hip, thigh and lower leg fractures.
Results: In the first group, in patients who were treated with cefazolin were detected in 2 cases (5.7%) while
the length of hemoprophylaxis was 7 days, patients who were treated with cefazolin and gentamicin were
detected in 1 case (2.8%) and duration hemoprophylaxis was 7 days. In another control group tah was found
9 cases of wound infection (30%), and hemoprophylaxis duration was 10 days.
Conclusion: The combination of cefazolin and gentamycin for a period of 5 days significantly reduces the
incidence of infection and significantly shortened the time of antibiotics in group that is respected application
protocol in accordance with international recommendation.
Keywords: infections, orthopaedic, prophylaxis, antibiotic, cefazolin, gentamycin.
Introduction
Hemoprophylaxis is defined as the use of antimicrobial drugs in surgery in the absence of symptoms of infection, in order to prevent or reduce
the incidence of infection of surgical wounds (1).
After commencing of a therapy with antibiotics,
one needs to define if there is a favorable clinical effect after the period of 24 to 72 hours. If the effect is
present prophylaxis is terminated and if there isn't
any effect the application of antibiotic continues,
which is the antibiotic therapy. Antibiotic therapy is a continuous application of antimicrobial
drugs after a surgery applied to prevent infections.
Although it is considered that all the wounds resulting from injuries, as well as some surgical wounds,
are contaminated with bacteria in most patients,
* Corresponding author: Elvedin Osmanovic,
Miroslava Krlee 10, Tuzla 75000, Tel: 061/424-904;
E-mail:elveos@hotmail.com
the infection does not develop due to organism's

defense capacity to eliminate microorganisms.
Table 1 illustrates general and local risk factors
which may affect an infection of a wound and which
Table 1. Factors associated with increased risk of surgical
wound infection
General factors
Diabetes
Use of corticosteroids
Obesity
Elderly population
Malnutrition
Recent surgery
Local factors
Foreign body
An injection of adrenaline
Shaved area
Preliminary radiation of the
surgical field
Improper bending
Massive blood transfusion

Long-lasting surgery
Multiple comorbidities
Hemorrhage
ASA (American Society of
Anesthesiologists) classification III-IV-V
171
Elvedin Osmanovic et al.: Implementation of the hemoprophylactic protocol in orthopedic surgery
Table 2. Causes of surgical wounds infections

Pathogen
Staphylococcus aureus
Coagulase-negative staphylococci
Enterococcus spp.
Escherichia coli
Pseudomonas aeruginosa
Enterobacter spp.
Proteus mirabilis
Klebsiella pneumoniae
Streptococcus spp.
Candida albicans
comply with the American Society of Anesthesiologists. The organism's defense capacity can be affected by the influence of general and local risk factors
(2). Most surgical wound infections are caused
by bacteria which form colonies in patients
and which are a part of the patient's physiological flora or bacteria from the environment
(3). The exception is patients hospitalized for
a longer period of time who may be infected
by multiple-resistant hospital pathogens (4).
Infections may be caused by various pathogens.
Table 2. ilustrates the most common pathogens
encountered in orthopedic surgery. An antibiotic
should affect the most common causes of surgical
wound infections. The first generation of cephalosporins (cefazolin) is the first choice for all clean
and most clean-contaminated wounds (where the
main problem is bacterial contamination from the
skin). It eliminates gram-positive bacteria which
are the main causers of contamination from the skin.
The second generation of cephalosporins (cefuroxime) is recommended in case of contamination
with aerobic gram-negative pathogens while drugs
with anti-anaerobic activity are recommended for
contamination with anaerobic microorganisms.
Vancomycin is applied when the cause of an infection is resistant to cephalosporins, such as methicillin-resistant staphylococcus aureus (MRSAMethicillin-resistant Staphylococcus aureus) (5).
The aim of this study was to determine the incidence of surgical wound infections in patients who received haemioprophylaxis with
cefazolin and gentamicin and to determine the
incidence of surgical wound infections in patients in whom discrepancies in the implementation of hemoprophylactic protocol occured.
172
Methods
The Department of Orthopedics and Traumatology of the Clinical Center in Tuzla conducted a
retrospective-prospective study in the period from
December 1, 2007 to February 28, 2010. It examined the incidence of surgical wound infections after surgical treatments of fractures or degenerative
changes in the hip, thigh and lower leg fractures.
Two groups were formed, a group of examined
patients, and a control group and the total sample contained 100 respondents (patients) of both
sexes.The first study group consisted of 70 respondents of both sexes older than 18, which wad
divided into two sub-groups. The first sub-group
consisted of 35 patients receiving cefazolin dose
of 1 g twice a day preoperativelly during 4 postoperative days to prevent wound infection after
a surgical treatment of fractures or degenerative
The second sub-group consisted of 35 patients
receiving 2 grams of cefazolin for one preoperative day and the first postoperative day and receiving 120 mg of gentamicin twice a day during
the second, the third and the fourth postoperative day for prevention of wound infection after
surgical treatments of fractures or degenerative
The control group consisted of 30 respondents of
both sexes older than 18 years of age, with a discrepancy in the implementation of hemoprophylaxis for the prevention of wound infection after
a surgical treatment of fractures or degenerative
A statistical analysis was performed with a program
for biomedical applications called ''MedCalc for
Windows version 11.2.1'', Copyright 1993-2010
Frank Schoonjans. Numerical data were presented
by measures of central tendency and dispersion of
appropriate measures. Normality of distribution
was checked by Kolmogorov-Smirnov test checking homogeneity of variance applied in F-test. To
test the hypothesis of variability of the dependent
variable and one independent factor (group) one
applied one-way ANOVA for multiple independent groups and the Kruskall-Wallis test, if there
was a discrepancy in the distribution of the dependent variable. To determine the frequency one
Table 3. Duration of hemoprophylactic therapy
Duration
of therapy
(days)
Days spent
in hospital
Table 4. Distribution of respondents by age and sex
Hemoprophylactic Protocol Deviation

Cefazolin+
Cefazolin
Control p value
Gentamycin
n=35
n=30
n=35
5
7
10
2 days C +
0.0001
(5-11)
(7-15)
3 days G
11.02
9.82
14.36
0.02
used Hi contingency 2 test. The results are presented in the tables. For statistically significant value p,
one selected the usual level of significance p <0.05.
Results
In the first group of patients who were treated with cefazolin, there were 2 cases of infection (5.7%), while the hemoprophylaxis
lasted 7 days. Infection occurred in 1 case
(2.8%) in patients treated with and gentamycin while the hemoprophylaxis lasted 5 days.
A statistically significant difference was found
in the duration hemioprophylactic therapy. The
control group of respondents was treated with
antibiotics for 10 days, while treatments of other
two sub-groups lasted shorter (p <0.05). The
significant difference was defined in the length
of hospitalization of the patients of the control group and it was 14.36 days, while it was
9.82 days in the second sub-group (p <0.05).
The combination of cefazolin and gentamycin in a period of 5 days significantly reduces
the incidence of infection. Mean length of
hospitalization of the group terated by cefazolin and gentamicin was10 days, while it
was 12 days for the group treated by cefazolin.
Length of hospitalization of the group with a deviation from the hemioprphylactic protocol was
14 days. The minimum length of hospitalization
was 3 days and maximum 22 days. Length of hospitalization was from10 to 15 days in most cases.
Our results are similar to those in other countries from the region. A cooperation among
orthopedists is necessary in order to properly determine hemoprophylactic protocol according to international recommendations.
The significant difference is visible in the length
of hospitalization (days spent in hospital) of
Age
Sex
M
W
Hemoprophylactic Protocol Deviation

Cefazolin+
Cefazolin
Control p value
Gentamycin
n=35
n=30
n=35
45
47
62
0.0006
(28-55)
(37-55)
(52-70)
21
17
15
0.58
14
18
15
the control group and it was 14.36 days and

9.82 days in the second sub-group (p < 0,05),
which is ilustrated in Table 3. It is visible from
table 4 that the age of respondents ranged from
28 to 70. Most of the respondents were male.
Discussion
Infections of surgical wounds represent a real
problem in orthopedic surgery. Although considerable efforts have been made in recent decades
(e.g. improvement of surgical techniques, preoperative preparation of surgical field, infection control, prophylactic use of antibiotics), infections are
still occurring at surgical fields in the percentage
of 0.5-2% of all patients after surgeries of fractures
and implantation of endoprotetic material (6).
Compliance with principles of a rational antibiotic
therapy (haemoprophylaxis) plays an important
role in the prevention of surgical wound infection.
In the last two decades the number and duration of orthopedic surgeries have been increasing with implantation of endoprotetic material
such as prosthesis (7). The number of infections
of surgical wounds is increasing according to the
increase of the number of surgical procedures
and their complexity (8). Many studies tested
significance of haemoprophylaxis. One of such
studies was conducted in the Atlanta Center
for Disease Control and Prevention. It is estimated that approximately 500,000 surgical infections occur annually in the United States (9).
In the group which used haemioprophylaxis
with cefazolin infection rate was 5.7% while
in the group which used haemioprophylaxis
with cefazolin and gentamicin it was 2 .8%. In
the control group the percentage of infection
was 30%. The accepted standard for postoperative infection should not exceed 1% (10).
173
Hemoprophylactic protocol is an important factor for prevention of post-operative infections

and faster healing of patients. One defined a clinically significant difference in the presence of infections in patinets for whom hemoprophylactic
protocol was not applied according to the international recommendations in regard to the patients for whom hemoprophylactic protocol was
applied. The period of apllication of antibiotics
was significantlly reduced in the group for which
the application of hemopropilactiy protocol complied with the international recommendations.
Conslusion
The combination of cefazolin and gentamicin during the period of 5 days significantly reduces the
incidence of infection. The length of application of

antibiotic therapy and the length of hospitalization
was significantly greater in the groups for which
the hemoprophylactic protocol was not respected.
Infections most commonly occured with operative treatments of the hip and were realted to age
of patients, to the greatest number of operations
in the surgical region and to duration of a surgery. There are not any significant differences in
the occurrence of infection regarding patients' sex.
Conflict of interest
None to declare.
References
1. ibali S. Antimikrobna terapija
starijih osoba. Tuzla: PrintCom d.o.o.
Grafiki inenjering Tuzla; 2010. 161172 p.
2. Brown AR, Vicca AF, Taylor GJ. A
comparison of prophylactic antibiotic regimens against airborne orthopaedic wound contamination. J Hosp
Infect. 2001;48(2):117-121.
3. Garvin KL, Cordero GX. Infected
total knee arthroplasty: diagnosis
and treatment. Instr Course Lect.
2008;57:305-315.
4. Kirkland KB, Briggs JP, Trivette SL,
Wilkinson WE, Sexton DJ. The Impact of Surgical-Site Infections in the
1990s: Attributable Mortality, Excess
174
Length of Hospitalization, and Extra

Costs. Infect Control Hosp Epidemiol. 1999; 20:725-30.
5. Fry DE. Surgical Site Infection:
Pathogenesis and Prevention CME.
2003;2:23-25.
6. Meehan J, Jamali AA, Nguyen H. Prophylactic antibiotics in hip and knee
arthroplasty. J Bone Joint Surg Am.
2009;91(10):2480-90.
7. Classen DC, Evans RS, Pestotnik
SL, Horn SD, Menlove RL, Burke JP.
The timing ofprophylactic administration of antibiotics and the risk of
surgical-wound infection. N Engl J
Med. 1992;326:281-6.
8. Tyllianakis ME, Karageorgos AC,
Marangos MN, Saridis AG, Lambiris

EE. Antibiotic prophylaxis in primary hip and knee arthroplasty comparision between Cefuroxime and 2
specific antystaphylococcal agents. J
Arthroplasty 4. 2010:28-35.
9. Mody RM et all. Infectious complications of damage control orthopedics in war trauma. J Trauma.
2009;67(4):758-61.
10. Soldatovi G, Milenkovi S, Mitkovi
M, Bumbairevi M, Anelkovi D,
Mili D. Bone infections and antibiotic use in orthopaedics. Acta Fac
Med Naiss. 2004;21(4):245-52.
www.jhsci.ba
Health claims made on multivitamin and

mineral supplements
Jelena Jovii1*, Budimka Novakovi1, Maja Grujii2, Fatima Jusupovi3, Slobodan Mitrovi2
Department of Pharmacy, Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, 21 000 Novi Sad, Serbia. 2 Faculty of
Medicine, University of Novi Sad, Hajduk Veljkova 3, 21 000 Novi Sad, Serbia. 3 Faculty of Health Studies, University of Sarajevo,
Bolnika 25, 71 000 Sarajevo, Bosnia and Herzegovina
Abstract
Introduction: Basic purpose of health claims is consumers' benefit by providing information about healthy
eating habits. It is necessary for health claims to be scientifically substantiated and truthful. Health claims
should not attribute to food the property of preventing, treating or curing a human disease. Use of health
claims should be followed by a statement indicating the importance of a varied and balanced diet and a
healthy lifestyle. The objective of this research was to examine the compliance of health claims made on
multivitamin and mineral dietary supplements' labels on the Serbian market with national regulation concerning health safety of dietary products.
Methods: An assessment of labels of MVMs was done in two privately owned pharmacies in Novi Sad, Serbia in August 2010.
Results: In total, 48 MVMs were sampled and 22 health claims were detected. Seven out of 22 health claims
were in compliance with the national regulation. The main reason for health claims on foreign MVMs not to
be compliant with the regulation in Serbia was inadequate or nonexistent translation of original labels.
Conclusion: Detected use of terms such as "prevention", "treatment" and "indications" on vitamin and mineral dietary supplements' labels is both forbidden and misleading to consumers. Coupled with inadequate or
nonexistent translation of the labels, it leads to a low level of protection of Serbian consumers. It is necessary
to establish an effective monitoring system for dietary supplements' labeling on a national scale in order to
protect consumers and their wellbeing.
Keywords: health claims, consumers, perception of health claims, dietary supplements
Introduction
Food safety is the one of the leading public health
issues. Taking into account that dietary supplements are a specific category of food, health
claims often used on dietary supplements' labels, are contributing factors for public health.
Codex Alimentarius, joint body of Food and Agriculture Organization of the United Nations (FAO
UN) and World Health Organization (WHO) defined health claims in 1997 as "any representation
that states, suggests, or implies that a relationship
exists between a food or a constituent of that food
and health" (1). This definition was incorporated in
the Regulation 1924/2006 of the European Com* Corresponding author: Jelena Jovii,
Department of Pharmacy, Faculty of Medicine, University of
Novi Sad, Hajduk Veljkova 3, 21 000 Novi Sad, Serbia
Phone: +381 21 422 760; Fax: +381 21 422 760
E-mail: jovicic.j@gmail.com
Submitted 10. April 2011 / Accepted 28. November 2011
mission on the use of health claims on foods (2).

Health claims are a fairly new health related addition to the label in Serbia, regulated for the first time
in July 2010 (3,4). Serbian regulation is the customized translation of the European Regulation (2).
Requirements and limitations for use of health
claims are well defined (1-3). It is necessary
for health claims to be scientifically substantiated in accordance with criteria set by the PASSCLAIM project (5, 6). Health claims should not
be false, ambiguous or misleading, nor should
they attribute to food the property of preventing, treating or curing a human disease (1-3).
Use of health claims is allowed if followed by a
statement indicating the importance of a varied
and balanced diet and a healthy lifestyle, a statement addressed to persons who should avoid
using the food (where appropriate) and an appropriate warning for products that are likely to
present a health risk if consumed to excess (1-3).
175
Jelena Jovii et al.: Health claims made on multivitamin and mineral supplements
Basic purpose of health claims is consumers' ben- Methods

efit by providing information about healthy eat- Design, materials and methods
ing habits (7). The underlying principle of use of For the purpose of this research, the term "MVM
health claims is for them to be truthful, clear and
supplements" was used for every dietary suppleunderstandable. In practice, this seems to be the
ment containing 2 or more vitamins and minmost controversial and scientifically challeng- erals and no other active components. Only
ing principle. It has been shown that consumers MVMs intended for use in adult population were
aren't always capable of understanding the given
taken into consideration. An assessment of lamessages (8, 9). Inadequate wording of health
bels of MVMs was done in two privately owned
claims may mislead consumers. Promises of
pharmacies in Novi Sad, Serbia in August 2010.
"prevention" or "treatment" of disease are seen as Compliance of health claims with the national regustrongly affirmative by an average consumer (10). lation was assessed using the following parameters:
Multivitamin and mineral supplements (MVMs) whether a statement indicating the importance
are the best-selling category of dietary supple- of a varied and balanced diet and a healthy lifestyle
ments. Regardless of the fact that clinical defi- was included in the label;
ciency of vitamins and minerals in developing whether the label information attributed meand developed countries are uncommon (except dicinal properties to the MVM supplement (prefor iron deficiency), half of the adult popula- vention or treatment of disease);
tion in United States uses dietary supplements whether adequate Serbian translation of health
and one third reported regular use of multivita- claim of the original MVM supplement label (in
min and mineral supplements (11). There are no case of foreign products) was present on the prodavailable data on the percentage of MVM supple- uct.
ment users in the Republic of Serbia, but some
preliminary results show that the number is even
Results
greater than in the US (unpublished material). Total of 48 MVMs found on the market met
The fact that in Serbia, vitamin and mineral sup- the set criteria for inclusion in the research
plements are sold not only in pharmacies, but in (Figure 1). The majority of the MVMs in the
supermarkets as well is of special concern because
sample were in the form of effervescent pills.
of lack of available expert assistance from phar- Only 25 % of the sampled MVMs were of domacists to MVM users during the decision mak- mestic origin, while the others were importing process, making consumers more exposed and
ed mainly from European Union countries.
vulnerable to unsubstantiated, misleading and About two thirds of the sample was made up of MVMs
false health claims
made on MVM
supplements' labels.
The objective of
this research was
to examine the
compliance
of
health claims made
on multivitamin
and mineral dietary supplements'
labels on the Serbian market with
national regulation
concerning health
safety of dietary
products.
FIGURE 1. Sample characteristics.
176
taining 2 or more
vitamins or minerals and no other
active ingredients.
Majority of excluded dietary supplements were combinations of vitamins
FIGURE 2. MVMs with and without health claim present.
and minerals with
herbal components.
Out of the 48 sampled MVM supplements,
health
claims were detected on 22 labels.
Only one health
claim was not followed by a statement
indicating
the
importance
of a varied and
FIGURE 3. Compliance of health claims with national regulation.
balanced diet, as
well as healthy
containing both vitamins and minerals in contrast lifestyle showing good compliance with
the regulation concerning this parameter.
to 16.5 % MVMs containing only vitamins, and 19
% containing only minerals, as seen on Figure 1. Different papers pointed the importance of health
Of the 48 MVMs assessed, 46% carried a health claim wording (12-14). The more detailed the
claim (Figure 2). Health claims were present on message, the stronger the impact on the consumer will be (15). As the use of terms such as
labels of 67 % MVMs of domestic and 39 % of
foreign origin. Statement indicating the impor- "prevention" and "treatment" in health claims is
forbidden by the regulating bodies, their prestance of a varied and balanced diet, as well as
healthy lifestyle was present in all but 1 vitamin ence on the labels is highly unexpected in countries with effective mechanism of market control,
and mineral supplement carrying a health claim
(Figure 3). Wording of 25 % of health claims con- such as USA and EU. Therefore, there are limtained words such as "prevention", "treatment" ited amount of data on the consumers' underor "therapy" indicating that the product had me- standing of health claims that use those terms.
dicinal properties. About 25 % MVMs had inad- In Serbia, no effective control mechanism have yet
equate or nonexistent Serbian translation of labels. been installed, leading to the detection of words
Majority of the health claims (two out of three) "prevention" or "treatment" on 25 % of the health
claims on MVMs. Four MVMs even had "indicanonspecifically referred to overall wellbeing, while
tions" for use of supplements in question. Although
the rest referred to immune, cardiovascular and
further investigation of consumers' perception of
bone health. In all, only 7 out of 22 health claims
such claims is needed, it is likely that consumers
(32 %) were in compliance with the national
regulation (and, therefore, the EU regulation). perceive the terms "prevention" and "treatment"
as strong evidence that the use of these products
will indeed prevent or treat their diseases (10).
Discussion
Number of vitamin and mineral dietary supple- It has been shown that older people and those
ments included in the sample was limited by the with lower levels of education or income were
definition of MVMs, as dietary supplements con- least likely to understand the label (7). Given
177
that the median age of the Serbian population

is estimated to be 41.3 years in 2011 (16) and is
on the rise (17) and that only 6 % of the population have a university degree according to the last
Census (18), it is safe to assume that the majority of the Serbian population is unable to understand health claims on dietary supplements labels.
Obviously, the aforementioned wording of health
claims can give producers an unfair advantage on
the Serbian market and, at the same time, misleads
consumers and compromises public health (19).
Yet, the biggest issue noted by this research is
that 7 health claims compliant with the national
regulation were the ones on the labels of MVMs
produced in Serbia, and, in fact, produced by the
same pharmaceutical company. Further investigation showed alarming evidence that the reason for
health claims on foreign MVMs not to be compliant with the regulation in Serbia was inadequate
or nonexistent translation of original labels, otherwise, completely lawful in English language. Seven
sampled MVMs (4.5 %) even had health claims on
the original label that were not translated to Serbian.
This problem is not documented in USA and EU.
This preliminary research was done using only a
limited number of parameters of health claims use,
insufficient for conclusions to be drawn on a larger
scale.
Conclusions
Use of health claims on MVMs' labels on the
Serbian market is widespread, but only one
third of health claims on labels of sampled
MVMs comply with the national regulation.
This research indicated a problem uncommon
in USA and EU inadequate or nonexistent
translations of otherwise accurate and lawful
health claims of imported MVMs. Translation
of imported dietary supplements' labels should
be entrusted to a professional trained both in
medical and linguistic aspects of health claims.
Special attention should be directed toward health
claims indicating that dietary supplement could
prevent or treat a disease, since such claims can pose
a health risk for an average consumer. At the same
time, campaigns educating consumers on how to
use information on food labels should be carried out.
It is necessary to establish an effective monitoring system for dietary supplements' labeling on a
national scale in order to protect consumers and
their wellbeing.
Competing interests
The authors declare that we have no financial and personal relationships with other people or organizations that could inappropriately influence this work.
References
1. Codex Alimentarius. Guidelines for
use of nutrition and health claims
(CAC/GL 23-1997). Codex Alimentarius; 1997.
2. Regulation (EC) No 1924/2006 of
the European Parliament and of the
Council of 20 December 2006 on
nutrition and health claims made on
foods. Official Journal of the European Union 2007;L12/3-18.
3. Pravilnik o zdravstvenoj ispravnosti
dijetetskih namirnica. Sl. Glasnik RS
45/10. 2010.
4. Jovii J, Novakovi B, Torovi Lj.
Health claims made on food. Vojnosanit Pregl 2011;68(3):266-9.
5. Aggett PJ, Antoine JM, Asp NG, Bellisle F, Contor L, Cummings JH et al.
PASSCLAIM process for the assessment of scientific support for claims
on foods: Consensus on Criteria. Eur
J Nutr 2005; 44(Suppl 1):I/1I/2
6. Asp NG, Bryngelsson S. Health
178
Claims in Europe: New Legislation

and PASSCLAIM for Substantiation.
J Nutr 2008;138(6):1210S-5S
7. Hawkes K. Nutrition Labels & Health
Claims: the global regulatory environment. WHO, 2004.
8. Wills JM, Schmidt DB, Pillo-Blocka F,
Cairns G. Exploring global consumer
attitudes toward nutrition information on food labels. Nutr Rev 2009;
69(Suppl 1):102-6.
9. Reinhardt Kapaska W, Schmidta D,
Childsb NM, Meunierc J, Whitec
C. Consumer perceptions of graded,
graphic and text label presentations
for qualified health claims. Crit Rev
Food Sci Nutr 2008; 48(3): 248-56.
10. COI Communications. Review and
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Communications on behalf of FSA;
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Dwyer JT, Engel JS, Thomas PR et
al. Dietary supplement use in the
United States, 20032006. J Nutr
2011;141(2):261-6.
12.
Food Standards Agency. Health
claims on food packaging: consumer
related qualitative research. Final report. London, UK; FSA: 2002.
13. Gilsenan MB. Nutrition & health
claims in the European Union: A regulatory overview. Trends in Food Science & Technology 2011. Article in
press. doi:10.1016/j.tifs.2011.03.004,
14. Kleiner J. Development of EFSA
opinions on claims including suggested wording. Presented at the
Health and nutrition claims national
implementation seminar, 2010. [Cited 2011 April 30]. Available from:
http://ec.europa.eu/food/food/labellingnutrition/claims/docs/doc2_nat_
impl_reg_20100309.pdf
15.
Chung-Tung JL. How Do Consumers Interpret Health Messages
on Food Labels? Nutrition Today
2008;43(6):267-72.
16.
Central Intelligence Agency. CIA
Factbook. Field listing: median age.
[Cited 2011 April 30]. Available
from: https://www.cia.gov/library/
publications/the-world-factbook/
fields/2177.html
17. Statistiki godinjak Republike Srbije.
Beograd (Serbia): Republiki zavod
za statistiku; 2010.
18.
Stanovnitvo. Popis stanovnitva,
domainstava i stanova u 2002.
kolska sprema i pismenost. Beograd
(Serbia): Republiki zavod za statistiku; 2003.
19. Williams P. Consumer understanding and use of health claims for foods.
Nutr Rev 2005; 63: 25664.
179
www.jhsci.ba
Evaluation of breast symptoms with

mammography and ultrasonography
Emine Devolli Disha1*, Suzana Manxhuka Kerliu2, Zana Baruti Gafurri3,
Valdete Topciu3, Bukurije Zhubi3, Hidajet Paqarizi3
1
Institute of Radiology, Faculty of Medicine, University of Prishtina, Mother Theresa st., 10000 Prishtina, Kosovo. 2 Institute
of Pathology, Faculty of Medicine, University of Prishtina, Mother Theresa st., 10000, Prishtina, Kosovo. 3 Diagnostic Center,
Faculty of Medicine, University of Prishtina, Mother Theresa st., 10000 Prishtina, Kosovo
Abstract
Introduction: Aim of the study was to discern which are more frequent symptoms presented in malign and
benign masses diagnosed by mammography and ultrasonography.
Methods: Our study group consisted of 546 female patients, with breast symptoms such as palpable lumps
(40.8%), pain in the breast (26%), localized lumpiness or nodularity (13.7%), nipple retraction (11.2%), nipple
bloody discharge (5.1%) and redness and swelling of the breast (3.1%). All 546 patients were examined by
ultrasonography and mammography. Biopsy was performed according to the findings of mammography and
ultrasonography.
Results: In breast cancer detection ultrasonography showed an efficiency of 79.4% compared to 55.0% for
mammography in detecting breast lump, in the case of nipple retraction mammography showed an efficiency
of 89.1% compared to 80.4% for ultrasound, while the lowest efficiency for mammography was in the cases
with localized lumpiness or nodularity 17.1% compared to 45.7% for ultrasound. In detecting fibrocystic
changes where the most common symptoms was pain, ultrasonography showed an efficiency of 99.3 %
compared to 84.2 % for mammography.
Conclusions: Our study confirmed that breast lumps are detectable in the majority of patients with breast
cancer. The most frequent symptoms in patient with benign lesions were pain or localized discomfort. The
diagnostic accuracy for carcinomas of the breast and for benign lesions according to symptoms was higher
for ultrasound than for mammography.
Keywords: Mammography, ultrasonography, breast symptoms
Introduction
Breast cancer represents a significant public health
problem in Kosovo. Despite the gloomy prognosis,
increased morbidity and reduced survival time, it
can be controlled if detection and diagnosis are
made in the earliest stages in the pre-invasive and
clinically nonpalpable stages. Bilateral mammography should be the first imaging study performed
in patients over the age of 30 who present with
breast masses that are suspicious for carcinoma (1).
The primary reason for performing mammography in a patient with a suspicious palpable mass is
to assess the affected breast for multifocal disease
and the contralateral breast for suspicious abnor* Corresponding author: Emine Devolli Disha,
Phone: +37744193445; Fax: + 381 38 552 720
E-mail: emine_disha@yahoo.com
180
malities that should be biopsied concurrently (2).

If mammography is negative in a patient with a
clinically evident mass and dense breast, ultrasound is often suggested as a subsequent imaging study (3, 4). Women under the age of 30 who
have a focal suspicious palpable abnormality are
frequently first evaluated with ultrasound (5, 6).
Many early breast carcinomas may be asymptomatic (7). If the patient has not noticed a lump,
then symptoms indicating the possible presence of
breast cancer may include the following: change in
breast size or shape, skin dimpling, recent nipple
inversion or skin change, single-duct discharge,
particularly if bloodstained, axillary lump. Pain or
discomfort is not usually a symptom of breast cancer. A lump is the first symptom in over 80 percent
of all patients with breast cancer. The nature of palpable lumps is often difficult to determine clinically, but the following features should raise concern:
Emine Devolli Disha et al.: Evaluation of breast symptoms with mammography and ultrasonography
Hardness, irregularity, focal nodularity, asymmetry with the other breast, fixation to skin or muscle.
Mammographic features suggestive of malignancy
include asymmetry, microcalcifications, a mass or
architectural distortion. If any of these features are
identified, a diagnostic mammogram along with
a breast ultrasound should be performed prior
to obtaining a biopsy (8-10). Ultrasonographic
evaluation in addition to mammography can help
distinguish between solid and cystic lesions, accurately determine the size of a spiculated lesion
and guide accurate biopsy of a suspicious area
(11-13). As a screening device, the ultrasound is
limited by a number of factors, but most notably
by the failure to detect microcalcification. Ultrasonographic features of malignancy include the
following: Poorly defined borders, heterogeneous
internal echoes, disruption of the tissue layers, irregular shadowing, superficial echo enhancement,
depth greater than height, high vascular density
and flow rates on doppler images (14-17). Nipple
retraction may be caused by aging, ductectasia or
breast cancer. A mammogram and breast ultrasound will help determine the cause of the nipple
change (18). Breast discharge is a common problem and is rarely a symptom of cancer. The characteristics of nipple discharge that should raise
the index of suspicion for malignancy are spontaneous and unilateral discharge that is bloody,
seroanguineous or watery in consistency and is
associated with an underlying mass (19). Breast
pain can be due to many possible causes. Most
likely breast pain is from hormonal fluctuations
from menstruation, pregnancy, puberty, menopause, and breastfeeding. Breast pain can also be
associated with fibrocystic breast disease, but it is
a very unusual symptom of breast cancer (15, 20).
Aim of the study was to discern which are more
frequent symptoms presented in malign and benign masses diagnosed by mammography and ultrasonography.
Methods
A group of 546 female patients with breast
symptoms, such as palpable lumps, pain in
the breast, nipple discharge, localized lumpiness or nodularity, nipple retraction, and redness and swelling of the breast were examined
independently with ultrasound and mammogJournal of Health Sciences 2011; 1 (3)
raphy, diagnosis was confirmed with biopsy.

Mammography was performed in a stand type
Alpha RT imaging, General Electric Medical Systems. Mediolateral oblique and craniocaudal images was obtained and assessed carefully. Mammograms were interpreted according to the Breast
Imaging Reporting and Data System, diagnostic
categories on a five-point scale. Ultrasound examination were performed using a high-resolution
unit (Aloka SSD 620; Tokyo, Japan and Mindray
DP 1100 Plus) with linear array probe centred at
7.5 MHz. All ultrasound examination were performed with the patient in a supine position for
the medial parts of the breast and in a contralateral
posterior oblique position with arms raised for the
lateral parts of the breast. Diagnoses were scored
on a five-point scale identical to the mammographic BI-RADS categories. A total of 546 breast
lesions were examined by histological methodology. Histopathology results revealed the presence
of 259 invasive cancers and 287 benign lesions.
2 test and student t-test were used for statistical data
processing. The significance of differences observed
was assessed using Pearsons chi-square test, with
p< 0.01 considering being statistically significant.
Results
The study included 546 patients with breast symptoms. The most frequent malignant symptoms in
the 259 cases with breast cancer was lump with
160 cases or 61.8% , being dominant symptoms,
Table 1. Breast symptoms in malign and benign changes
Breast symptoms
Lump
Nipple retraction
Pain
Nipple bloody
discharge
Localised
nodularity
Redness and
swelling (mastitis)
Breast changes
Benign
Malign
Total
N
%
N
%
N
%
287 100.0 259 100.0 546 100.0
63 22.0 160 61.8 223 40.8
15
5.2
46 17.8 61
11.2
139 48.4
3
1.2 142 26.0
21
7.3
2.7
28
5.1
40
13.9
35
13.5
75
13.7
3.1
3.1
17
3.1
P<0.01
181
Table 2. Breast cancer symptoms according to age
nign changes of 5.2%. The

most frequent symptoms
Symptoms
70-79
in patient with benign leN
%
sions were pain or local49 100.0
ized discomfort with 139
Lump
29 59.2
cases or 48.4%, significantly
Nipple retraction
18 36.7
more frequent than in the
Pain
patient with malignant
Nipple bloddy discharge
lesions, only 1.2%. The
Localised nodularity
bloody discharge was most
Redness and swelling
2
4.1
frequent in benign lesions,
but with less frequency,
7.3%,
to 2.7% of malignant
Table 3. Benign breast symptoms according to age
lesions. Changes between
Patient age-group
malignant and benign leSymptoms
30-39
40-49
50-59
60-69
70-79
sions according to sympN
%
N
%
N
%
N
%
N
%
toms was statistically sig35 100.0 65 100.0 73 100.0 63 100.0 51 100.0
nificant (P <0. 01) (Table 1).
Lump
19 54.3 15 23.1 14 19.2 10 15.9 5
9.8 P<0.01
Table 2 shows that among
Nipple retraction
0.0 1 1.5
2
2.7
7 11.1 5
9.8
the malignant and benign
Pain
4 11.4 30 46.2 37 50.7 41 65.1 27 52.9 P<0.01
changes are presented conNipple bloddy
siderable differences in the
2 5.7 5 7.7 11 15.1 3
4.8
0.0
discharge
prevalence rate of sympLocalised
toms and the tendency of
3 8.6 12 18.5 9 12.3 2
3.2 14 27.5
nodularity
movement according to
Redness and
7 20.0 2 3.1
0.0
0.0
0.0
age group. In malign leswelling
sions lump had the highest
rate of prevalence in all age
Table 4. Breast symptoms according to patient age statistical parameters
groups, especially on young
patients, 92. 3%, while in
Breast changes
other groups was 52. 6%
T-test
Symptoms
Malign
Benign
Total
in age 40-49 up to 63. 9%
T=
P=
in the age group 60-69.
N Xb SD N Xb SD N Xb SD
Among
other symptoms,
Lump
160 55.6 13.0 63 49.1 13.4 223 53.8 13.4 3.29 P>0.01
nipple
retraction
was preNipple retraction 46 62.2 13.5 15 64.5 9.8 61 62.8 12.6
sented
at
over
40
ages
and
Pain
3 49.7 7.5 139 58.8 11.3 142 58.6 11.3
tends
to
increase
according
Nipple bloody
7 50.7 7.3 21 51.1 8.5 28 51.0 8.1
to age groups, up to 36. 7%
discharge
in
age group 70-79%. Table
Localized
35 55.4 6.9 40 57.8 14.1 75 56.7 11.3
3
shows in patient with
nodularity
benign
lesions, the most
Redness and
8 56.6 16.1 9 35.6 6.2 17 45.5 15.8 3.65 P<0.01
swelling
common symptoms, pain,
has shown a tendency to
SD- Standard deviation, Xb- average age, T- student T test, P- value.
increase according to age,
from 11. 4% in the age
and significantly more frequent than the benign group 30-39 up to a maximum of 65. 1% of age 60changes, 63 cases or 22.0% of them. In second 69. This symptom has dominated in all age group,
place comes nipple retraction with 46 cases or in addition to more young patients. Symptoms of
17.8%, significantly more frequent than in be- the second frequency, lump had the opposite tenPatient age-group
30-39
40-49
50-59
60-69
N
%
N
%
N
%
N
%
26 100.0 57 100.0 66 100.0 61 100.0
24 92.3 30 52.6 38 57.6 39 63.9
11 19.3 9 13.6 8 13.1
1
1.8
2
3.0
3 5.3
3
4.5
1
1.6
12 21.1 13 19.7 10 16.4
2 7.7
1
1.5
3
4.9
182
Table 5. Sensitivity of mammography in breast cancer diagnosis according to symptoms
Symptoms
Patients
Lump
Nipple retraction
Pain
Nipple bloody
discharge
Localized
nodularity
Redness and
swelling
Mammography detected
lesions in breast
Yes
No
N
%
N
%
135 52.1 124 47.9
88
55.0
72
45.0
41
89.1
5
10.9
0.0
3
100.0
Total
N
259
160
46
3
%
100.0
100.0
100.0
100.0
0.0
100.0
100.0
17.1
29
82.9
35
100.0
0.0
100.0
100.0
Table 7. Comparative sensitivity of mammography and ultrasound in breast cancer diagnosis according to symptoms
Patient
N
Total
259
Lump
160
Nipple retraction 46
Pain
3
Nipple bloody
7
discharge
Localised
35
nodularity
Redness and
8
swelling
Symptoms
Mammography
N
%
135
52.1
88
55.0
41
89.1
0.0
Ultrasound
N
%
188 72.6
127 79.4
37
80.4
0.0
0.0
6
0.0
17.1
16
45.7
0.0
100.0
dency, decreasing according to age. The most common has been in age group 30-39, 54.3%, while in
other age group has lower values and ranges from
23.1%, in age 40-49 to 9.8% in age 70-79. As for
the pain as well as lump differences according to
age groups were significant (P <0. 01), but with
opposite directions. Trend growth has also shown
nipple retraction, but with lower values, from 0.0%
in the 30-39 age group up to 11.1% of age group
60-69. Table 4 shows breast symptoms according
to patient age. The average age of all cases according to symptoms was higher in cases with nipple
retraction, 62.8 age and in the cases with pain, 58.6
age, while cases with mastitis was younger, the average age was 45,5. Between malignant and benign
lesions, the average age has changed significantly
only in cases with lump and those with mastitis.
Table 6. Sensitivity of ultrasound in breast cancer diagnosis

according to symptoms
Symptoms
Patients
Lump
Nipple retraction
Pain
Nipple bloody
discharge
Localized
nodularity
Redness and
swelling
Ultrasound detected
lesions in breast
Yes
No
N
%
N
%
188 72.6
71
27.4
127 79.4
33
20.6
37
80.4
9
19.6
0.0
3
100.0
Total
N
%
259 100.0
160 100.0
46 100.0
3
100.0
0.0
100.0
100.0
16
45.7
19
54.3
35
100.0
100.0
0.0
100.0
Table 8. Comparative specificity of mammography and ultrasound according to symptoms

Patient
N
Total
287
Lump
63
Nipple retraction 15
Pain
139
Nipple bloody
21
discharge
Localised
40
nodularity
Redness and
9
swelling
Symptoms
Mammography
N
%
212
73.9
55
87.3
15
100.0
117
84.2
Ultrasound
N
%
254 88.5
63 100.0
15 100.0
138 99.3
38.1
12
57.1
17
42.5
24
60.0
0.0
22.2
Cases with malignant lump were older the average

age was 55.6, to 49.1 age with benign lump. Cases
with mastitis have significant difference according
to age 56.6 in malign lesions to 35.6 in benign lesions. For other symptoms, there werent considerable changes in age. Table 5 shows that the sensitivity of mammography in breast cancer detection,
according to symptoms was variable. The higher
sensitivity was in the nipple retraction, 89.1%, on
average was in lump, 55,0%, while the lowest sensitivity was in the cases with localized lumpiness
or nodularity 17.1%. In the cases with rare symptoms like pain, nipple bloody discharge and redness and swelling (mastitis), not revealed any case
with mammography. Results of mammography
according symptoms were statistically significant,
that may indicate the interconnection of sensitiv183
ity of mammography with dominant symptoms

of patient. Table 6 shows that with ultrasound we
obtained different results according to symptoms.
Sensitivity was higher in cases with redness and
swelling (mastitis carcinomatosa), 100. 0%. In
cases with nipple retraction sensitivity was 80. 4%
and in cases with lump was 79. 4%. The sensitivity for localized lumpiness or nodularity was 45.
7%, while in the rare cases with nipple bloody discharge and pain with ultrasound is not diagnosed.
Table 7 shows that the comparing the sensitivity
of mammography and ultrasound in breast cancer detection, according to symptoms ultrasound
has better results in most symptoms, especially in
redness and swelling (mastitis carcinomatosa) and
lump, while in case with nipple retraction sensitivity was high in both methods, and the difference is
small, in favour of mammography. In 3 cases with
pain and 7 cases with nipple bloody discharge,
neither method have not shown efficacy. Table 8
shows that the specificity of mammography was
highest in cases with nipple retraction, were diagnosed all the 17 cases, 100.0%. Also, specificity was
higher on the cases with frequent symptoms, as
lump, 87.3% and pain 84.2%. Specificity was lowest in the nipple bloody discharge, 38.1% and localized lumpiness or nodularity, 42.5%, while in cases
with redness and swelling (mastitis) there wasnt
diagnosed any case. The specificity of ultrasound
was very high in cases with lump and nipple retraction, 100.0% and cases with pain, 99.3%. Specificity was lowest in cases with localized lumpiness
or nodularity, 60.0%, and nipple bloody discharge,
57.1%, while on the weak was in the cases with
redness ad swelling (mastitis) with only 22.2%.
Comparing the specificity of these methods
we noted that both methods have high specificity, especially for cases with more frequent
symptoms, but the specificity of ultrasound
has been something higher for all symptoms.
Discussion
Breast cancer is the most common cancer as well
as leading cause of cancer deaths in women worldwide (21). Early detection with screening mammography is the only proven way to lower mortality from breast cancer (8, 9). Signs and symptoms
of breast cancer may include: A breast lump or
thickening that feels different from the surround184
ing tissue, bloody discharge from the nipple,

change in the size or shape of a breast, changes to
the skin over the breast, such as dimpling, inverted
nipple, peeling or flaking of the nipple skin, redness or pitting of the skin over breast, like the skin
of an orange, a lump in the underarm area. Breast
lumps are detectable in the majority of patients
with breast cancer (10). The incidence of this
complaint can range from 65% to 76%, depending on the study. The typical breast cancer mass
tends to be solitary, unilateral, solid, hard, irregular, and nontender. Breast pain is the presenting
symptom in 5% of patients; breast enlargement,
in 1%; skin or nipple retraction, in 5%; nipple
discharge, in 2%; and nipple crusting or erosion,
in 1%. Inflammatory breast cancer is particularly
aggressive, although relatively uncommon, accounting for about 5% of all breast cancers (22,
23). More often, however, a visual examination in
woman with a malignancy shows retraction of the
overlying skin. This can be seen when tumours
deep in the breast cause shortening of fibrous
septa within the breast or when more superficial
tumours cause direct puckering of the skin. Not
all skin retraction necessarily results from cancer.
Mondor disease or superficial thrombophlebitis of the thoracoepigastric veins can cause skin
retraction of the lateral aspect of the breast (24).
Visual inspection is also important in identifying
erythema of the breast. Erythema may be secondary to cellulitis, recent breast irradiation, or an inflammatory carcinoma. Inflammatory carcinoma
is distinguished from cellulitis by the absence of
tenderness and fever. On breast palpation, there
often is no definite mass, but the breast appears
to be engorged with erythema, skin edema (peau
d'orange), and skin ridging (25). Ultrasonography
may be helpful in differentiating mastitis from
inflammatory breast cancer. Spontaneous nipple
discharge- through a mammary duct is the second
most common sign of breast cancer. Nipple discharge develops in about 3% of women with breast
cancer but is a manifestation of benign disease in
90% of patients. Discharge in patients older than
50 years of age is more likely to represent cancerous rather than benign conditions. Milky or purulent discharges are associated with a negligible
chance of cancer (19). Mammography should be
performed before any intervention. A hematoma
resulting from percutaneous fine-needle aspiration biopsy can look similar to a small carcinoma
(26). When such procedures have been performed
prior to mammography, it is best to perform a
follow-up mammogram 4 to 6 weeks later. Ultrasound findings can often confirm a cancer that is
obscured mammographically by dense breast tissue (3, 4, 7). Women under age 20 should not undergo mammography. Ultrasound is the preferred
diagnostic modality for young women under 30
with a breast mass (27). If the mass is solid and
suspicious, then mammography followed by tissue diagnosis is recommended. Ultrasonography
may be the only viable modality in pregnant and
lactating women as it does not involve ionizing radiation and also in dense breast tissue, as density
is a limiting factor for mammography (7, 11, 13).
and constitute the most common sign on history

and physical examination. The most frequent symptoms in patient with benign lesions were pain or
localized discomfort. Sensitivity of mammography
is diminished when the breast tissue is dense. The
diagnostic accuracy for carcinomas of the breast
and for benign lesions according to symptoms
was higher for ultrasound than for mammography.
Competing interests
This study was supported by the University Clinical Center, Institute of Radiology, Institute of
Pathology and Diagnostic Center in Prishtina.
Acknowledgements
We thank Muhamed Disha, Oecc PhD for his technical help and finalisation of paper.
Conclusions
Our study confirmed that breast lumps are detectable in the majority of patients with breast cancer
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studies, whenever applicable. Use subheadings in order to achieve
greater clarity of work. More information can be found in the templates.
Discussion. This section should give meaning to the results obtained, indicate the new discoveries which have been identified,
indicate the results of other studies that have dealt with a similar
problem. Compare your results with other studies and highlight the
differences and novelties in own results. In this chapter the results
should be comprehensively interpreted, analyzed and new knowledge synthesized from the analysis.
Conclusion. Should be brief and contain the most important facts
which have been identified in the paper. Conclusions must arise
from the results obtained during the investigation, and should include the possible application of these results. Both affirmative and
negating conclusions should be stated.
Acknowledgments
In this section you can specify: (a) contributions and authors who
do not meet enough criteria to be authors, such as support from
colleagues or heads of institutions, (b) thanks for technical assistance, (c) thanks for material or financial assistance, stating the
character of that assistance.
Statement on Conflict of Interest
Authors must identify all sources of funding of their studies and any
financial aid (including obtaining a salary, pay, etc.) by the institu-
188
tions whose financial interests may depend on the material in the

manuscript, or that might affect the independence of the study. If
you are sure that there is no conflict of interest, indicate that in the
manuscript. More information can be found here:
(http://bmj.com/cgi/content/short/317/7154/291).
References
References should be numbered in order of appearance in the paper. In text, references should be put in brackets, i.e. (12). When the
reference has up to 6 authors, list all authors. If 7 or more authors,
list only first 6 and add et al. References should include name and
source of information (Vancouver style). Names of journals should
be abbreviated as in PubMed. http://www.ncbi.nlm.nih.gov/journals
Examples of references:
Article: Meneton P, Jeunemaitre X, de Wardener HE, MacGregor
GA.Links between dietary salt intake, renal salt handling, blood
pressure, and cardiovascular diseases. Rev. Physiol. 2005;85(2):679715
More than 6 authors: Hallal AH, Amortegui JD, Jeroukhimov IM,
Casillas J, Schulman CI, Manning RJ, et al. Magnetic resonance
cholangiopancreatography accurately detects common bile duct
stones in resolving gallstone pancreatitis. J Am Coll Surg.2005;
200(6):869-75.
Books: Jenkins PF. Making Sense of the chest x-ray: a hands-on
guide. New York: Oxford University Press; 2005. 194 p.
Book Chapter: Blaxter PS, Farnsworth TP. Social health and class
inequalities. In: Carter C, Peel SA, editors. Equalities and inequalities in health. 2nd ed. London: Academic Press; 1976th p. 165-78.
Internet source: HeartCentreOnline. Boca Raton, FL: HeartCentreOnline, Inc.., C2000-2004 [cited 2004 Oct 15]. Available from:
http://www.heartcenteronline.com/
Personal communications and unpublished works should not appear in the references and should be put in parentheses in the text.
Unpublished paper, accepted for publication, may be cited as a reference with the words "in press", next to the name of the journal. All
the references must be verified by the author.
Tables
Tables have to be placed after the references. Each table must be on
a separate page. Tables should NOT be formatted other than simple
borders and no colors.
Table number and title is written above the table. Table gets number
in the order of appearance in the text, with a clear and sufficiently
informative title, i.e. "Table 3. Text table name.... A reference to the
table in text is written in parentheses, i.e. (Table 3). All the abbreviations in the table must be explained in full below the table. It is desirable to give explanations and comments below the table, which
are essential for the presented results to be understood. Display the
statistical measures of variations such as standard deviation and
standard error of the mean, when applicable.
Figures
Figures have to be placed behind the references and tables (if any).
Each figure must be on a separate page. Figures get the titles by the
order of appearance in the text. The title and number are written
below the figure, for example, "Figure 3. Title text When referring to a figure in the manuscript text, number of the figure has to
be written in parentheses, eg (Figure 3). It is essential that the figure
has a clear and informative title and text below the title which explains the presented results with sufficient details. Figure resolution
must be at least 250-300 dpi, JPG or TIFF.
Units of Measure
Measures of length, weight and volume should be written in metric units (meter, kilogram, liter). Hematological and biochemical
parameters should be expressed in metric units according to the
International System of Units (SI).
www.jhsci.ba
UPUTSTVO AUTORIMA
Upute i smjernice autorima za pripremu i predaju rukopisa u Journal of Health Sciences
Ciljevi i okvir asopisa
The Journal of Health Sciences (JHSci) je internacionalni asopis
na engleskom jeziku, koji objavljuje orginalne radove iz oblasti fizikalne terapije, medicinsko-laboratorijske dijagnostike, radioloke
tehnike, sanitarnog inenjerstva, zdravlja i ekologije, zdravstvene
njege i terapije, te drugih srodnih oblasti.
Vrste znanstvenih radova koje se mogu poslati za objavljivanje
u JHS
Orginalni radovi: orginalne laboratorijske eksperimentalne i klinike studije ne bi trebao prelaziti 4500 ukljuujui tabele i reference.
Prikaz sluajeva: prezentacije klinikih sluajeva koji mogu sugerisati kreiranje nove radne hipoteze, uz prikaz odgovarajue literature. Tekst ne bi trebao prelaziti 2400 rijei.
Pregledni lanci: lanci afirmiranih znanstvenika, pozvanih da ih
napiu za asopis. Redakcija e, takoer, razmatrati i samostalne
aplikacije.
Uvodnici: lanci ili kratki uvodniki komentari koji predstavljaju
miljenja prepoznatih lidera u medicinskim istraivanjima.
Podnoenje rada za objavljivanje
Rad koji se alje u JHSci mora biti u skladu sa propozicijama o sadraju, izgledu i kvalitetu, koje je urnal propisao u ovim instrukcijama za autore i na web stranici urnala, www.jhsci.ba. Propozicije
o sadraju, izgledu i kvalitetu naunog rada u skladu su sa meunarodnim propozicijama i preporukama datim od strane International Committee of Medical Journal Editors. Uniform Requirements
for Manuscripts Submitted to Biomedical Journals New Engl J
Med 1997, 336:309315 (www.icmje.org), te preporuka meunarodnih radnih grupa za standardizaciju izgleda i kvaliteta naunih
radova: STROBE (www.strobe-statement.org) , CONSORT (www.
consort-statement.org), STARD (www.stard-statement.org) i drugih.
Predloci
JHSci je pripremio predloke (engl. template) za izgled i sadraj
naunog rada. Predloci sadre sve neophodne podnaslove i obogaeni su uputama o sadraju svakog poglavlja naunog rada, te e
autorima znatno olakati proces pisanja rada. JHSci preporuuje
koritenje predloaka za pisanje naunih radova koji se nalaze na
web stranici urnala www.jhsci.ba u dijelu Information for authors.
Pismo za podnoenje rada
Svi autori rada moraju potpisati formular za podnoenje rada. On
sadri odobrenje za publiciranje poslanog rada, izjavu o sukobu
interesa, izjavu potivanju etikih principa u istraivanju i izjavu o
prijenosu autorskih prava na JHSci. Ovaj formular se mora preuzeti
sa web stranice www.jhsci.ba u dijelu Information for authors, te
odtampati, popuniti i skenirati. Ukoliko se skeniranjem dobiju dva
ili tri fajla, moraju se pretvoriti u jedan ZIP fajl.
Slanje rada
Vri se iskljuivo preko web stranice www.jhsci.ba preko predvienog web formulara. Web formular sadri etiri stranice na kojima
se nalazi: 1. popis stavki koje treba ostvariti prije podnoenja rada;
2. informacije o autoru za korespondenciju; 3. informacije o naunom radu; 4. dio za slanje fajlova. U web formularu autori su duni
ispravno popuniti informacije, unijeti ispravnu e-mail adresu za
korespondenciju, te poslati 2 fajla: 1. Pismo za podnoenje rada;
2. Nauni rad. NIJE POTREBNO slati tampanu verziju, osim ako
autori ele predstaviti rukopis, pismo ili dijelove koji ne mogu biti
poslani elektronski, ili je to zatraeno od urednitva. Za autore koji
nemaju mogunost elktronskog slanja rada, potrebno je poslati
potom jedan primjerak rada, zajedno s elektronskom verzijom na
CD-u ili DVD-u na sljedeu adresu: za Journal of Health Sciences,
Fakultet zdravstvenih studija Univerziteta u Sarajevu, 71000 Sarajevo, Bolnika 25, Bosna i Hercegovina.
Pravila redakcije
Autorstvo
Svi autori morati potpisati formular za podnoenje rada (Manuscript Submission form). Potrebno je da svi autori potpisom potvrde
da: su zadovoljili kriterije za autorstvo u radu, utvreno od strane
International Committee of Medical Journal Editors; vjeruju da
rukopis predstavlja poteni rad i da su u mogunosti potvrditi valjanost navedenih rezultata. Autori su odgovorni za sve navode i
stavove u njihovim radovima. Vie informacija se moe dobiti na
(http://bmj.com/cgi/collection/authorship).
Plagijarizam ili dupliciranje objavljenog rada
Od autora se zahtjeva da svojim potpisom potvrde da u momentu
podnoenja rad nije objavljen u sadanjem obliku ili bitno slinom
obliku (u tampanom ili elektronskom obliku, ukljuujui i na web
stranici), da nije prihvaen za objavljivanje u drugom asopisu ili
razmatran za objavljivanje u drugom asopisu. Meunarodni odbor urednika medicinskih asopisa dao je detaljno objanjenje ta
jeste, a ta nije duplikat (www.icmje.org). Vie informacija moe se
nai i na stranici www.jhsci.ba.
Formular saglasnosti bolesnika
Zatita prava pacijenta na privatnost je od iznimnog znaaja. Autori trebaju, ako redakcija zahtjeva, poslati kopije formulara Suglasnosti bolesnika iz kojih se jasno vidi da bolesnici ili drugi subjekti
eksperimenata daju doputenje za objavljivanje fotografija i drugih
materijala koji bi ih identificirali. Ako autori nemaju potrebnu saglasnost za istraivanje, moraju je dobiti ili iskljuiti podatke koji
identificiraju subjekte, a za koje nisu dobili saglasnost.
Odobrenje Etikog komiteta
Autori moraju u formularu za podnoenje rada i u dijelu rada
Metode jasno navesti da su studije koje su proveli na humanim
subjektima, odnosno pacijentima, odobrene od strane odgovoarajueg etikog komiteta. Vie informacija moete nai u najnovijoj verziji Helsinke deklaracije (http://www.wma.net/e/policy/
b3.htm). Isto tako, autori moraju potvrditi da su eksperimenti koji
ukljuuju ivotinje provedeni u skladu sa etikim standardima.
Izjava o sukobu interesa
Od autora se zahtjeva da navedu sve izvore finansijske pomoi koje
su dobili za istraivanje (grantovi za projekte, ili drugi izvori finansiranja). Ako ste sigurni da nema sukoba interesa, onda to i navedite kratko. Za vie informacija pogledajte uvodnik u British Medical
Journal, 'Beyond conflict of interest' (http://bmj.com/cgi/content/
short/317/7154/291).
Izdavaka prava
U okviru Pisma za podnoenje rada od autora se zahtjeva da prenesu izdavaka prava na Fakultet zdravstvenih studija. Prijenos izdavakih prava postaje punovaan kada i ako rad bude prihvaen
za publiciranje. ira javnost ima prava reproducirati sadraj ili listu
lanaka, ukljuujui abstrakte, za internu upotrebu u svojim institucijama. Saglasnost izdavaa je potrebna za prodaju ili distribuciju
van institucije i za druge aktivnosti koje proizilaze iz distribucije,
ukljuujui kompilacije ili prijevode. Ukoliko se zatieni materijali
189
Upute i smjernice autorima za pripremu i predaju rukopisa u Journal of Health Sciences
koriste, autori moraju dobiti pismenu dozvolu izdavaa i navesti

izvor, odnosno referencu u lanku.
Formatiranje (izgled) rada
Predloci (engl. template) za pisanje radova
JHSci je na svojoj web stranici www.jhsci.ba dao predloke (engl.
Template) prema kojima treba formatirati radove. Predloci, takoer, sadre i upute preuzete od strane radnih grupa za standardiziranje formata u pisanju naunih radova i objektivno i potpuno
prikazivanje rezultata studija. Vie informacija o strukturi naunih
radova moe se nai na web stranici www.jhsci.ba i na web stranicama radnih grupa: www.consort-statement.org, www.strobe-statement.org, www.stard-statement.org, i drugih. Predloci se mogu
preuzeti na sljedeem linku: http://jhsci.ba/information-for-authors.html
Skraenice i simboli
Skraenice se moraju definisati prilikom njihovog prvog pojavljivanja u tesktu. One koje nisu internacionalno i generalno prihvaene
trebaju se izbjegavati. Koristiti standardne skraenice. Potrebno je
izbjegavati skraenice u naslovu rada i u saetku.
Kljune rijei
Nakon abstrakta treba staviti 3-10 kljunih rijei ili kratkih fraza
koje e pomoi u indeksiranju rada. Uvijek kada je to mogue, treba koristiti termine iz Medical Subject Headings liste Nacionalne
Medicinske Bibiloteke (MeSH, NLM). Vie informacija na:
(http://www.nlm.nih.gov/mesh/meshhome.html).
Tekst rada
Tekst rada mora biti standardnog naunog formata. Vie informacija dobiete preuzimanjem predloaka sa web stranice urnala:
http://jhsci.ba/information-for-authors.html
Pregledni lanci mogu imati drugaiju strukturu.
Uvod je koncizan dio rada. U njemu se predstavlja problem kojim
se rad bavi i to kreui od ireg konteksta problema i trenutnog
stanja i dosadanjih dostignua u vezi konkrtnog problema, prema
specifinom problemu koji e obraditi ova studija. Na kraju uvoda
je potrebno jasno istaknuti svrhu, ciljeve i/ili hipoteze ove studije.
Metode. Ovaj dio ne treba biti kratak. U predlocima koje je JHSci dao na web stranici nalazi se vie informacija o sadraju ovog
poglavlja.
Rezultati. Dati prednost grafikom prikazu rezultata studije u odnosu na tabelarni, kada je god to primjenjivo. Koristiti podnaslove
radi postizanja vee jasnoe radova. Vie informacija nai u predlocima.
Diskusija. U ovoj sekciji treba dati smisao dobivenim rezultatima,
ukazati na nova otkria do kojih se dolo, ukazati na rezultate drugih studija koje su se bavile slinim problemom. Uporediti svoje
rezultate sa drugim studijama i naglasiti razlike i novine u svojim
rezultatima. U ovom poglavlju treba interpretirati, sveobuhvatno
sagledati dobijene rezultate, te sintetizirati novo znanje iz analize.
Zakljuak. Treba da bude kratak i da sadri najbitnije injenice do
kojih se dolo u radu. Navodi se zakljuak, odnosno zakljuci koji
proizilaze iz rezultata dobivenih tokom istraivanja; treba navesti
eventualnu primjenu navedenih ispitivanja. Treba navesti i afirmativne i negirajue zakljuke.
Zahvala
U ovom dijelu se mogu navesti: (a) doprinosi i autori koji ne zadovoljavaju dovoljno kriterija da budu autori, kao npr. podrka kolega
ili efova institucija; (b) zahvala za tehniku pomo; (c) zahvala za
materijalnu ili finansijsku pomo, obrazlaui karakter te pomoi.
Izjava o sukobu interesa
Autori moraju navesti sve izvore finasiranja svoje studije i bilo koju
finansijsku potporu (ukljuujui dobijanje plae, honorara, i drugo) od strane institucija iji finansijski interesi mogu zavisiti od
190
materijala u radu, ili koji bi mogli uticati na nepristranost studije. Ako ste sigurni da ne postoji sukob interesa, navedite to u radu.
Jo informacija se moe nai ovdje: (http://bmj.com/cgi/content/
short/317/7154/291).
Reference
Reference se trebaju numerisati prema redoslijedu pojavljivanja u
radu. U tekstu, reference je potrebno navesti u zagradama, npr. (12).
Kada rad koji citirate ima do 6 autora, navesti sve autore. Ukoliko
je 7 ili vie autora, navesti samo provih 6 i dodati et al. Reference
moraju ukljuivati puni naziv i izvor informacija (Vancouver style).
Imena urnala trebaju biti skraena kao na PubMedu. http://www.
ncbi.nlm.nih.gov/journals
Primjeri referenci:
Standardni rad: Meneton P, Jeunemaitre X, de Wardener HE,
MacGregor GA. Links between dietary salt intake, renal salt handling, blood pressure, and cardiovascular diseases. Physiol Rev.
2005;85(2):679-715
Vie od 6 autora: Hallal AH, Amortegui JD, Jeroukhimov IM, Casillas J, Schulman CI, Manning RJ, et al. Magnetic resonance cholangiopancreatography accurately detects common bile duct stones in
resolving gallstone pancreatitis. J Am Coll Surg. 2005;200(6):86975.
Knjige: Jenkins PF. Making sense of the chest x-ray: a hands-on
guide. New York: Oxford University Press; 2005. 194 p.
Poglavlje u knjizi: Blaxter PS, Farnsworth TP. Social health and
class inequalities. In: Carter C, Peel JR, editors. Equalities and
inequalities in health. 2nd ed. London: Academic Press; 1976. p.
165-78.
Internet lokacija: HeartCentreOnline. Boca Raton, FL: HeartCentreOnline, Inc.; c2000-2004 [cited 2004 Oct 15]. Available from:
http://www.heartcenteronline.com/
Osobne komunikacije i nepublicirani radovi ne bi se trebali nai u
referencama ve biti navedeni u zagradama u tekstu. Neobjavljeni
radovi, prihvaeni za publiciranje mogu se navesti kao referenca sa
rijeima U tampi (engl. In press), pored imena urnala. Reference moraju biti provjerene od strane autora.
Tabele
Tabele se moraju staviti iza referenci. Svaka tabela mora biti na posebnoj stranici. Tabele NE TREBA grafiki ureivati.
Broj tabele i njen naziv pie se IZNAD tabele. Tabela dobija broj
prema redoslijedu pojavljivanja u tekstu, a naziv treba biti jasan i
dovoljno opisan da je jasno ta tabela prikazuje. npr Table 3. Tekst
naziva tabele..... U radu prilikom pozivanja na tabelu treba napisati
broj tabele u zagradi, npr. (Table 3). Za skraenice u tabeli potrebno
je dati puni naziv ispod tabele. Poeljno je ispod tabele dati objanjenja i komentar, koji su neophodni da se rezultati u tabeli mogu
razumjeti. Prikazati statistike mjere varijacije, kao to je standardna devijacija i standardna greka sredine, gdje je primjenjivo.
Slike
Slike staviti iza referenci i tabela (ako postoje). Svaka slika mora biti
na posebnoj stranici. Slika dobija broj prema redoslijedu pojavljivanja u tekstu. Naziv i broj se piu ISPOD slike, npr. Slika 3. Tekst
naziva slike... U radu, prilikom pozivanja na sliku treba napisati
broj slike u zagradi, npr (Slika 3). Neophodno je da slika ima jasan
i indikativan naziv, a u tekstu ipod slike objasniti sliku i rezultat
koji ona prikazuje, sa dovoljno detalja da ona moe biti jasna bez
pretrage teksta koji je objanjava u radu. Slika mora biti kvaliteta
najmanje 250-300 dpi, formata JPG, TIFF ili BMP.
Jedinice mjere
Mjere duine, teine i volumena trebaju se pisati u metrikim jedinicama (meter, kilogram, liter). Hematoloki i biohemijski parametri se trebaju izraavati u metrikim jedinicama prema International System of Units (SI).

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UNIVERSITY OF SARAJEVO FACULTY OF HEALTH STUDIES

UNIVERZITET U SARAJEVU FAKULTET ZDRAVSTVENIH STUDIJA

Journal of Health Sciences

Dijana Avdi (BiH)

Demal Pecar (BiH)

Jasmina Berbi - Fazlagi (BiH)

Senka Mesihovi - Dinarevi

Amira Duri (BiH)

Fatima Jusupovi (BiH)

Mirsad Mufti (BiH)

Emela Muji - Skiki (UAE)

Naris Pojski (BiH)

Borut Poljak (Sl)

Isabelle Rishard (F)

Zerema Obradovi (BiH)

Dragi Bankovi (SRB)

Journal of Health Sciences

Volume 1, Number 3, December 2011

Comparison of ARCHITECT chemiluminiscent

Journal of Health Sciences

Volume 1, Number 3, December 2011

Towards the better science

Journal of Health Sciences 2011; 1 (3)

Journal of Health Sciences

Volume 1, Number 3, December 2011

The value of Pap test in women with

cytological diagnosis is not sufficiently sensitive in

Table 3. Relationship between the stage and the Pap test.

test was found in 72.2% and abnormal in 27.8%

3. Mahovli V. Endometrij. U: orui

5. Tezuka F, Namiki T, Hifashiiwai H.

Journal of Health Sciences 2011; 1 (3)

7. Salomao DR, Hughes JH, Raab SS.

Journal of Health Sciences 2011; 1 (3)

12. Ashfag R, Sharma S, Dulley T, Saboorian MH, Siddiqui MT, Warner C.

I corpus cancer. Is teletherapy necessary? Am J Obstet Gynecol 1997;

Journal of Health Sciences

Volume 1, Number 3, December 2011

Gender related differences in demographic

* Corresponding author: Gorana Sulejmanpai-Arslanagi,

Submitted 2. September 2011 / Accepted 15. November 2011

Journal of Health Sciences 2011; 1 (3)

Gorana Sulejmanpai-Arslanagi: Gender related differences in demographic and clinical

Table 1. Demographic data of subjects divided according

df, degrees of freedom

Disorders (SCID I) was used in this work. SCID

they were included in study. Average age of patient

Gorana Sulejmanpai-Arslanagi: Gender related differences in demographic and clinical

order that has no clearly identified

Journal of Health Sciences 2011; 1 (3)

Gorana Sulejmanpai-Arslanagi: Gender related differences in demographic and clinical

Journal of Health Sciences 2011; 1 (3)

atr Scan Suppl.2000;(407):58-62.

erature.Acta Psychiatr Scand Suppl.

Journal of Health Sciences

Volume 1, Number 3, December 2011

Conventional radiotherapy of localized right

volume receives less than 95% of the dose, while

of right side breast, conventional radiotherapy can

placed directly on the skin surface which is thick

Table 1. Distribution of dose for Conventional and Field in

CTV by therapy isodose, expressed as VD90% and

FIGURE 3. Comparative dose-volume histogram (DVH). It is seen