JHSCI 2013 v3 I3 December

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

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Table of contents:
RESEARCH ARTICLES
Post anesthesia recovery rate evaluated by using
White fast tracking scoring system
MUNEVERA HADIMEI, SEMIR IMAMOVI, MIRSAD HODI,
VASVIJA ULJI, DELIL KORKUT, FATIMA ILJAZAGI HALILOVI,
LEJLA SELIMOVI EKE, AIDA POJSKI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190-195
The effects of sex, age and cigarette smoking on micronucleus and degenerative
nuclear alteration frequencies in human buccal cells of healthy Bosnian subjects
HILADA NEFIC, JASMIN MUSANOVIC, KEMAJL KURTESHI, ENIDA PRUTINA, ELVIRA TURCALO . . . . . . . . 196-204
Physical activity and bone mineral density in postmenopausal women
without estrogen deficiency in menstrual history
AMILA KAPETANOVI, DIJANA AVDI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205-209
Oral surgical procedures and prevalence of oral diseases in Oral Surgery
Department in Faculty of Dentistry Sarajevo
SADETA EI, SAMIR PROHI, SANJA KOMI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210-215
Efficiency of trunk stabilizing exercises in treatment of patients
with lumbar pain syndrome
ELDAD KALJI, DIJANA AVDI, MURIS PECAR, NAMIK TRTAK,
BAKIR KATANA, NERINA KALJI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216-221
Frequency of joined disabilities of children with cerebral palsy in Tuzla canton
MIRELA BABAJI, EMIRA VRAKA, DIJANA AVDI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222-226
Monitoring changes in serum 8-isoprostane concentration
as a possible marker of oxidative stress in pregnancy
JASMINA GRADAEVI GUBALJEVI, ADLIJA AUEVI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227-231
Is it possible to determine firearm calibre and shooting range from
the examination of gunshot residue in close range gunshot wounds?
An experimental study.
ANISA GRADAEVI, EMINA RESI, NERMIN SARAJLI, BRUNO FRANJI,
ARIF SALKI, AMIRA DUZDANOVI-PAALI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232-237
The synergistic antinociceptive effect of lornoxicam in combination with tramadol
AMELA SARAEVI, FAHIR BEI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238-242
Effects of intraneural and perineural injection and concentration of Ropivacaine
on nerve injury during peripheral nerve block in Wistar rats
ILVANA HASANBEGOVIC, AMELA KULENOVIC, SUADA HASANOVIC . . . . . . . . . . . . . . . . . . . . . . . . . . . 243-249
Air pollution by nitrogen oxides in Sarajevo from 2005 to 2010
SUAD HABE, ZAREMA OBRADOVI, AIDA RIDAL, ASMIR ALDI . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250-254
Impact of management on employees communication in medical

and hospital centers in Sarajevo
MUNIB SMAJOVI, REDO AUEVI, MIRSAD MUFTI, SLAVICA BABI. . . . . . . . . . . . . . . . . . . . . . . . 255-260
REVIEW
Innovating in Health Care Modern Challenges
SEBIJA IZETBEGOVI, GORAN STOJKANOVI, SUVADA VRAKI, ELDAR MEHMEDBAI . . . . . . . . . . . 261-266
CASE REPORT
Palliative care in the home: a case study of secondary
histiocytic sarcoma in a 3-year-old child
ZUZANA KARABOV, LUBICA ILIEVOV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267-270
INSTRUCTIONS TO AUTHORS
Instructions and guidelines to authors for the preparation and submission of manuscripts
in the Journal of Health Sciences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271-274
Munevera Hadimei et al. Journal of Health Sciences 2013;3(3):88-195
http://www.jhsci.ba

RESEARCH ARTICLE
Open Access
Post anesthesia recovery rate evaluated by using

Munevera Hadimei1*, Semir Imamovi1, Mirsad Hodi2, Vasvija Ulji1, Delil Korkut2,
Fatima Iljazagi Halilovi1, Lejla Selimovi eke1, Aida Pojski1
1
Department of Anesthesiology and Reanimatology, University Clinical Centre Tuzla, Trnovac bb, 75000 Tuzla, Bosnia and
Herzegovina. 2Department of Neurosurgery, University Clinical Centre Tuzla, Trnovac bb, 75000 Tuzla, Bosnia and Herzegovina.
ABSTRACT
Introduction: Postponed recuperation from anesthesia can lead to different complications such as apnoea, aspiration of gastric content whit consequent development of aspiration pneumonia, laryngospasm,
bradycardia, and hypoxia. Aim of this research was to determine influence of propofol, sevoflurane and
isoflurane anesthesia on post anesthesia recovery rate.
Methods: This was a prospective study; it included 90 patients hospitalized in period form October 2011
to may 2012 year, all patients included in the study underwent lumbar microdiscectomy surgery. Patients
were randomly allocated to one of three groups: group 1: propofol maintained anesthesia, group 2: sevoflurane and group 3: isoflurane maintained anesthesia. Assessments of recovery rate were done 1, 5 and
10 minutes post extubation using White fast tracking scoring system.
Results: Significant difference was observed only 1 minute after extubation (p=0,025) finding recovery
rate to be superior in propofol group. Propofol group compared to inhaled anesthesia with sevoflurane
group, shows significantly faster recovery from anesthesia only one minute after extubation (p=0,046). In
comparison of propofol group and isoflurane anesthesia group, statistical significance was noticed one
minute following extubation (p=0,008). Comparison of propofol group and inhaled anesthesia groups recovery rates were not significantly different at all times measured. When we were comparing sevoflurane
and isoflurane anesthesia, recovery rates shoved no significant statistical difference.
Conclusions: Recovery rate evaluated by using White fast tracking scoring system was superior and with
fewer complications in propofol maintained in comparison to sevoflurane and isoflurane maintained anesthesia only one minute post extubation, while after fifth and tenth minute difference was lost.
Keywords: Post anesthesia, recovery, propofol, sevoflurane, isoflurane.
INTRODUCTION
*Corresponding author: Munevera Hadimei
Department of Anesthesiology and Reanimatology, University Clinical Centre Tuzla, Trnovac bb, 75000 Tuzla, Bosnia and Herzegovina
Phone: +3873561152300
E-mail: mhadzimesic@rotech.ba
Submitted 18 May 2013 / Accepted 30 September 2013
UNIVERSITY OF SARAJEVO
FACULTY OF HEALTH STUDIES
Delayed post anesthesia recovery is often multifactorial and it might be influenced by pharmacological
and organic causes as well as metabolic abnormalities. Postponed recuperation from anesthesia can
lead to different complications such as apnoea, as-
2013 Munevera Hadimei et al.; licensee University of Sarajevo - Faculty of Health Studies.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.
http://www.jhsci.ba
piration of gastric content whit consequent development of aspiration pneumonia, laryngospasm,

bradycardia, and hypoxia. Because of the fact that
these complications can appear, it is very important
to ensure that the patient is fully awake, adequately
breathing, with completely recovered cough and
swallowing reflexes (1).
Choice of anesthetic is influenced by different factors; knowledge and experience of anaesthesiologist,
available equipment, patient related indications,
and economic circumstances.
Propofol is most widely used intravenous anesthetic
today, it is used to induce and maintain anesthesia.
Main advantage of propofol in clinical practice is
rapid recovery of consciousness and full awareness
when bolus doses are used to induce anesthesia. No
significant cumulation of propofol in the tissues occurs even after prolonged continuous infusion (1, 3).
Propofol is one of the mostly suitable anesthetics
for total intravenous anesthesia (4). Inhaled anesthetics are among most rapidly acting drugs today,
they have high safety ratio. Isoflurane, a halogenated
methyl ethyl ether, it is a clear, non-flammable liquid at room temperature and has a high degree of
pungency (5). Isoflurane is relatively insoluble and
has a low bloodgas partition coefficient 1, 4 that
combined with a high potency, permits rapid onset
and recovery from anesthesia using isoflurane alone
or in combination with nitrous oxide or injected
drugs, such as opioids (2, 3). Sevoflurane is relatively
insoluble in blood and has a low bloodgas partition
coefficient which allows rapid induction and recovery from anesthesia (2). Sevoflurane is approximately half as potent as isoflurane, has minimal odour,
no pungency, and is a potent bronchodilator. These
attributes make sevoflurane an excellent candidate
for administration via the facemask on induction of
anesthesia in both children and adults (5).
Aim of this research was to determine emergence
quality after anesthesia with propofol, sevoflurane
and isoflurane in order to assure safe discharge of
the patient from operating room in every day practice
gery. It included 90 patients hospitalized in period

form October 2011 to May 2012 year. All patients
included in the study undergone lumbar microdiscectomy surgery due to herniated lumbar disc, and
were assessed as ASA I (American Society of Anesthesiologists) physical status. Written consent was
obtained from all the patients included in the study
and they were randomly allocated to one of three
groups, each group consisting of thirty patients:
group 1: propofol maintained anesthesia, group 2:
sevoflurane maintained anesthesia and group 3: isoflurane maintained anesthesia.
In all three groups, patients where premedicated
using either diazepam 5 mg or 2.5 mg midazolam
plus fentanyl 0.10 mg. Following induction with
propofol 1.5 to 2.5 mg/kg, tracheal intubation was
facilitated with atracurium, which was also used in
maintaining muscular relaxation in a doze 0. 3 - 0. 6
mg. All patients were ventilated to maintain normocapnia with oxygen (O2)/nitrous oxide (N2O) mixture in ratio 60:40, in all three groups, and in group
1 with continuous propofol infusion 8 to 10 mg/
kg/h were used to maintain anesthesia. In group 2 to
N2 O: O2 mixture, 1. 0 volume percentage of sevoflurane was added for maintaining anesthesia and in
group 3, 1.0 volume percentage of isoflurane. In all
three groups, analgesia was provided with fentanyl
boluses ranging form 0.05 to 0.10 mg per dose.
Assessments of recovery rate were done 1, 5 and 10
minutes post extubation using White fast tracking
scoring system (6) (appendix 1). This scoring system is based on evaluation of pain, nausea, vomiting,
awakens of the patient, physical activity and hemodynamic and respiratory stability. Maximal score is
14 points and score of 12 points is considered sufficient (as long as there are no scores less then one) in
order to sent the patient from operating ward (post
anesthesia care unit) to hospital room.
METHODS
This was a prospective study; conducted at University Clinical Centre Tuzla, Department of neurosur191
Statistical analysis
Results are displayed in numeric-percentual form,

as well as mean value with standard deviation (SD).
Significance was evaluated using Chi square test and
Student test, statistical analysis was performed with
a confidence interval of 95%, a value of p <0.05 was
considered statistically significant.
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TABLE 1. Recovery rate measured with White fast tracking scoring system, comparison of propofol, sevoflurane and isoflurane
anesthesia
Test
time
1 minute post extubation
5 minutes post extubation
Propofol
12.40 2.78
12.93 2.64
12.53 3.54
Sevoflurane
10.90 2.92
12.37 2.65
12.73 2.60
Isoflurane
10.67 2.07
12.53 1.25
13.27 1.01
p
0.025
0.616
0.532
TABLE 2. Recovery rate measured with White fast tracking scoring system, comparison of propofol and sevoflurane anesthesia
Test
time
Propofol
12.40 2.78
12.93 2.64
12.53 3.54
Sevoflurane
10.90 2.92
12.37 2.65
12.73 2.60
p
0.046*
0.412
0.804
p
0.025
0.616
0.532
TABLE 3. Recovery rate measured with White fast tracking scoring system, comparison of propofol and isoflurane anesthesia
Test
time
RESULTS
Study was conducted in University Clinical Centre

Tuzla, Department of Neurosurgery; it enrolled 90
patients allocated to three groups each consisting of
30 patients. Based on White fast tracking scoring
system influence of anesthetic on speed and quality
of post anesthesia recovery was evaluated.
In order to test quality and rate of recovery from anesthesia we used White fast tracking scoring system.
Based on this test in first group one minute after
extubation score was 12. 4 (SD2. 78), in second
group 10. 90 (SD 2. 92) and in third group 10. 67
(SD 2. 07) (Table 1.) Comparing results between
the groups, significant difference was established
(p=0.025) finding recovery rate to be superior in
propofol group 1 minute post extubation. Estimate
carried out five minutes post extubation showed following results; in group 1 score were 12. 93 (SD 2.
64), in group 2 score was 12. 37 (SD 2. 65) and in
group 3 score 12. 53 (SD 1. 25), without statistical significance (p=0. 61). Ten minutes after extubation assessment using fast tracking scoring system
was repeated again and next results were obtained;
in group 1 score 12. 53 (SD 3. 54), in group 2
score 12. 73 (SD 2. 60) and in group 3 score 13.
27 (SD 1. 01). Comparison of these results showed
Propofol
12.40 2.78
12.93 2.64
12.53 3.54
Isoflurane
10.67 2.07
12.53 1.25
13.27 1.01
p
0.008*
0.460
0.280
p
0.025
0.616
0.532
no significant difference (p=0. 61). Depending on

anesthetic used to maintain anesthesia important
difference in recovery rate, was observed only one
minute after extubation, while five and ten minutes
post extubation significance was lost (Table 1).
As seen in table 2, propofol group compared to inhaled anesthesia with sevoflurane, group 1 shows
192
FIGURE 1. White fast tracking scoring system, assessment

preformed 1, 5 and 10 minutes post extubation
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TABLE 4. Recovery rate measured with White fast tracking scoring system, comparison of sevoflurane and isoflurane anesthesia
Test
time
Sevoflurane
10.90 2.92
12.37 2.65
12.73 2.60
Isoflurane
10.67 2.07
12.53 1.25
13.27 1.01
p
0.722
0.756
0.299
p
0.025
0.616
0.532
TABLE 5. White fast tracking scoring system, measurements preformed ten minutes post extubation
Parameters (10 minutes post extubation)
Awakens level
Physical activity
Hemodynamic stability
Respiratory stability
Oxygen saturation
Postoperative pain level
Vomiting
Propofol
1.93 0.37
1.87 0.44
1.70 0.53
1.87 0.43
1.87 0.43
1.83 0.46
1.93 0.36
Sevoflurane
2.00 0.00
1.87 0.35
1.53 0.51
1.97 0.18
2.00 0.00
1.87 0.35
1.92 0.25
significantly faster recovery from anesthesia only

one minute after extubation (p=0. 046), while at
second and third measurements difference was not
established (p=0. 4 after 5 minutes and p=0. 8 ten
minutes post extubation).
In comparison of propofol group and isoflurane
anesthesia group, statistical significance was noticed
one minute following extubation (p=0. 008), while
after fifth and tenth minute no considerable difference was found (p=0. 46 after 5 minutes and p=0.
28 after 10) (Table 3).
As seen from table 4, when we were comparing
sevoflurane and isoflurane anesthesia, recovery rates
shoved no significant statistical difference at all
times measured (p=0. 72 after 1 minute; p=0. 756
after 5 minutes; p=0.299 after 10 minutes).
White fast tracking scoring system evaluated recovery quality and rate ten minutes post extubation, test
examined level of awakens, physical activity, hemodynamic stability, respiratory stability, percentage of
oxygen saturation, pain intensity in post-operative
period and presence of nausea and vomiting. Assessment of these parameters ten minutes after extubation showed no significant difference in relation to
anesthetic used (Table 5).
Analysis of the results established that although
some difference in recovery speed was noticed oneminute post extubation it was not significant and it
was not observed after five and ten minutes.
Isoflurane
1.97 0.19
1.90 0.30
1.63 0.49
2.00 0.00
1.93 2.54
1.83 0.46
2.00 0.00
p
0.551
0.920
0.449
0.148
0.211
0.941
0.512
DISCUSSION
White and Song in there study examined 216 women

who underwent laparoscopic hysterectomy and fallopian tube ligation in Medical Centre Dallas Texas
University. From the study are excluded all patients
that are not evaluated using modified Aldretes score
for discharge, as well as the patients that declined
preventive preoperative analgesia and anti-emetic
pre-treatment. Demographic characteristics of patients in all three groups were similar, average age
was 33 years in desflurane group, 34 years in sevoflurane and 31 year in propofol group. Their study investigated recovery speed, following anesthesia with
propofol, sevoflurane and desflurane; they measured
time to extubation, awaking time and determined
how well the patient is orientated in early postoperative period. They concluded that recovery time
is significantly shorter in desflurane and sevoflurane
group in comparison to propofol group. Estimate
is performed using modified Aldretes score, and
authors proved that recovery is faster after propofol
anesthesia in comparison to desflurane and sevoflurane (p<0, 05) (7). While in our study, propofol was
superior to inhaled anesthesia concerning speed and
quality of recovery measured in early postoperative
period.
Larsen et alt. also examined quality of recovery form
anesthesia in early postoperative period in patients
who underwent elective surgical procedures using
propofol, desflurane and isoflurane, all patients
193
are assessed as ASA I and II physical status. Exclusion criteria in this study matched these criteria in
our study, and examines showed no significance
regarding demographic characteristics. Propofol
maintained anesthesia proved superior in terms of
recovery sped, compared to desflurane and sevoflurane anesthesia. Significance is found in early post
extubation period, they also concluded that there is
no significance concerning hemodynamic parameters, side effects, pain level, and nausea and vomiting among compared groups (4). In our study, we
compared characteristics of post anesthesia recovery
depending on anesthetic used to maintain anesthesia (propofol, sevoflurane, isoflurane) one, five and
ten minutes post extubation. Our inspection was
based on test that is modification of Aldretes score
same as it is done in study conducted by Larsen and
associates (4).
Fredman et alt. compared sevoflurane to propofol in
outpatient anesthesia, forty six ASA I and II physical status undergoing either gynaecological or otolaryngology procedures participated in there study.
Emergence times from discontinuation of the primary maintenance anesthetics to spontaneous eye
opening, response to verbal commands, extubation,
and to correctly stating name, age, and date of birth
were similar in all treatment groups (8). Bharti et alt.
conducted study to compare hemodynamic changes
and emergence characteristics of sevoflurane versus
propofol anesthesia for microlaryngeal surgery. They
find that emergence time, extubation times and recovery time were similar in both groups (9). In our
study comparison of recovery rate after propofol vs.
sevoflurane anesthesia one minute post extubation
proved propofol anesthesia superior to sevoflurane,
five and ten minutes post extubation recovery was
similar in both groups.
In there systematic review Gupta et alt. focused on
postoperative recovery and complications using four
different anesthetic techniques. They searched database MEDLINE via PubMed (1966 to June 2002)
using the search words anesthesia and with ambulatory surgical procedures limited to randomized
controlled trials in adults (>19 yr), in the English
language, and in humans. A second search strategy
was used combining two of the words propofol,
isoflurane, sevoflurane, or desflurane. No difference was found between propofol and isoflurane
194
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in early recovery of cognitive function, incidence

of side effects, specifically postoperative nausea and
vomiting, was less frequent with propofol (10). In
our study recovery rate one minute post extubation in comparison propofol versus isoflurane anesthesia proved that faster recovery after propofol
maintained anesthesia when measured one minute
post extubation, while after fifth and tenth minute
superiority of propofol to isoflurane was lost. We
found no significant difference in inhaled anesthesia groups (sevoflurane versus isoflurane) at all times
measured.
CONCLUSIONS
Evaluation of emergence quality after anesthesia regarding different types of anesthetics is important
in order to assure safe discharge of the patient from
operating room in every day practice. Recovery rate
evaluated by using White fast tracking scoring system was superior and with fewer complications in
propofol maintained in comparison to sevoflurane
and isoflurane maintained anesthesia only one minute post extubation, while after fifth and tenth minute difference was lost.
COMPETING INTERESTS
None to declare.
REFERENCES
1. Ronald D Miller, Lars I Eriksson, Lee A Fleisher, Jeanine P Wiener-Kronish, William L Young. Miller's Anesthesia: 7 Ed. Churchill Livingstone;
2008.567p-789p.
2. T N Calvey, N E Williams. Principles and Practice of Pharmacology for
Anaesthetists: Fifth Edition. Blackwell Publishing; 2008. 118p-157p.
3. Stoelting Robert K, Hillier, Simon C. Handbook of Pharmacology and Physiology in Anesthetic Practice: 2nd Edition. Lippincott Williams & Wilkins;
2006.46p-177p.
4. Larsen B, Seitz A, Larsen R. Recovery of cognitive function after remifentanil-propofol anesthesia: a comparison with desflurane and sevoflurane
anesthesia. Anesth Analg.2000;90:168-174.
5. Paul G Barash, Bruce F Collen, Robert K Stoelting. Clinical Anesthesia: 5th
Ed. Lippincott Williams &Wilkins Publishers;2006:281p-311p.
6. White PF, Song D. New criteria for fast tracking after outpatient anesthesia:
a comparison with the modified Aldretes scoring system. Anesth Analg.
1999;88: 1062-1072.
7. Song D, Joshi GP, White PF. Fast-track eligibility after ambulatory anesthesia: A comparison of Desflurane, Sevoflurane and Propofol. Anesth Analg.
1998;86: 267-273.
8. Brian Fredman, Michael H Nathanson, Ian Smith, Junke Wang, Kevin Klein,
Paul F White. Sevoflurane for outpatient anesthesia: a comparison with
propofol. Anesth Analg. 1995;81:823-8.
http://www.jhsci.ba
9. N Bharti, P Chari, P Kumar. Effect of sevoflurane versus propofol based

anesthesia on the hemodynamic response and recovery characteristics
in patients undergoing microlaryngeal surgery. Saudi Journal of Anaesthesia.2012; 6:380-384.
10. A Gupta, T Stierer, R Zuckerman, N Sakima, S D Parker, LA Fleisher. Comparison of Recovery Profile after Ambulatory Anesthesia with Propofol, Isoflurane, Sevoflurane and Desflurane: A Systematic Review. Anesth Analg.
2004;98:63241
APPENDIX 1
White fast tracking scoring system (17)
Score
Awake and oriented
Arousable with minimal stimulation
Responsive only to tactile stimulation
Physical activity
Able to move all extremities on command
Some weakness in movement of extremities
Unable to voluntarily move extremities
Homodynamic stability
Blood pressure 15% of baselines MAP value
Blood pressure 15%30% of baseline MAP value
Blood pressure 30% below baseline MAP value
Respiratory stability
Able to breathe deeply
Tachypnea with good coughs
Dyspneic with weak cough
Oxygen saturation status
Maintains value 90% on room air
Requires supplemental oxygen (nasal prongs) 1
Saturation, 90% with supplemental oxygen
Postoperative pain assessment
None or mild discomfort
Moderate to severe pain controlled with IV analgesics
Persistent severe pain
Postoperative emetic symptoms
None or mild nausea with no active vomiting
Transient vomiting or retching
Persistent moderate to severe nausea and vomiting
Total score 14
MAP mean arterial pressure.
195
1 minute
2
1
0
5 minutes
2
1
0
10 minutes
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
2
0
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
Hilada Nefic et al. Journal of Health Sciences 2013;3(3):196-204
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RESEARCH ARTICLE
Open Access
The effects of sex, age and cigarette smoking on

micronucleus and degenerative nuclear alteration
frequencies in human buccal cells of healthy
Bosnian subjects
Hilada Nefic1*, Jasmin Musanovic2, Kemajl Kurteshi3, Enida Prutina1, Elvira Turcalo1
1
Department of Biology, Faculty of Science, University of Sarajevo, Bosnia and Herzegovina. 2Department for Biology and
Human Genetics, Medical Faculty, University of Sarajevo, Bosnia and Herzegovina. 3Department of Biology, Faculty of Science, University of Prishtina, Prishtina, Kosovo.
ABSTRACT
Introduction: This study was performed to establish a baseline value of micronucleus frequency in buccal
cells and to estimate the impact of the most common factors (sex and age, and smoking) on micronucleus
and degenerative nuclear alteration frequencies in the sample of healthy Bosnian subjects.
Methods: The Buccal Micronucleus Cytome (BMCyt) assay, based on scoring not only micronucleus frequency but also other genome damage markers, dead or degenerated cells, provides a measure of cytotoxic and genotoxic effects.
Results: Our results showed the baseline buccal micronucleus frequency was 0.135% or 1.35, as well
as positive correlations between micronucleus frequencies and formations of degenerative nuclear alterations (nuclear buds, karyolytic and karyorrhectic cells). The number of micronuclei in buccal cells was significantly higher in females than in males. There was positive association between the age and frequency
of analysed cytogenetic biomarkers. Buccal cell micronuclei and degenerative nuclear alternations were
more frequent among cigarette smokers than non-smokers and significantly higher in female smokers
than in male smokers. Cytogenetic damages showed significantly positive correlation between intensity of
smoking and the number of nuclear alterations. The years of smoking had a significant influence not only
on the number of nuclear alterations but also in micronuclei and nuclear buds in buccal cells.
Conclusions: The sex influences the number of micronuclei in human buccal cells. The ageing increased
the number of micronuclei and other biomarkers of DNA damage. The cigarette smoking significantly
increases the frequencies of micronuclei and nuclear buds, pyknotic, karyolytic and karyorrhectic cells.
Keywords: Micronuclei, Degenerative nuclear alterations, Buccal cells, Sex, Age, Smoking
*Corresponding author: Hilada Nefic

Department of Biology, Faculty of Science, University of Sarajevo, Bosnia and Herzegovina
Phone: +38733723717; Fax: +38733649359
E-mail: hnefic@gmail.com
Submitted 8 June 2013 / Accepted 1 October 2013
INTRODUCTION
The Buccal Micronucleus Cytome (BMCyt) assay

is a method for studying the effects of lifestyle factors, nutrition, genotoxin exposure and genotype
on DNA damage, chromosomal aberrations and
2013 Hilada Nefic et al.; licensee University of Sarajevo - Faculty of Health Studies. This is
an Open Access article distributed under the terms of the Creative Commons Attribution
License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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malsegregation, cell death and regenerative potential of human buccal cells. Demographic factors, sex
and age, also affect micronucleus (MN) frequency
in buccal cells. Epithelial cells do not need to be
stimulated and micronuclei (MNi) in exfoliated
cells reflect genotoxic events that occurred in the dividing basal cell layer 1-3 weeks earlier. This method
is minimally invasive and repeated sampling is acceptable (1, 2).
The human micronucleus assay in exfoliated buccal cells (HUMNXL) project, established in 2009, is
an international collaborative project for studying
DNA damage in human populations. This project
was aimed to standardize micronucleus assay in oral
buccal cells (2).
Baseline frequencies for micronucleated cells (MNC)
in the BMCyt are usually within the 0.52.5 MNi
per 1,000 cells range (3). The factors potentially affecting baseline buccal MN frequency are methodological, exposure, diet, lifestyle and demographic
(age and sex). The age, sex and smoking habit were
the most commonly studied factors. Piyathilake et
al (4) reported that frequencies of micronucleated
cells are higher in females after adjusting for age
and smoking habit, whereas in a Brazilian study (5)
the number of micronuclei was significantly higher
in males. Higher frequency of micronuclei was ob-
served in cells collected from female smokers than

male smokers but sex and age did not influence micronuclei frequency of non-smokers (6). Nersesyan
et al (7) observed a weak association between the
age of the participants and the overall frequency of
MNC cells. Some studies showed an increase with
age (4, 8) and in another a decrease with age (9),
but in some studies no effect was detected (5, 1011). Cigarette smoking is one of the factors that may
influence the number of MNi in buccal cells (4, 12).
Smoking is also reported to increase the MN frequency in human lymphocytes (13, 14).
The BMCyt assay has been used to measure biomarkers of DNA damage (micronuclei and nuclear buds,
NBUDs), cytokinetic defects (binucleated cells) and
proliferative potential (basal cell frequency) and cell
death (condensed chromatin; karyorrhectic, KHC;
pyknotic, PYK and karyolitic, KYL cells). In the
BMCyt assay, buccal cells are classified into categories that distinguish between normal cells and cells
that are damaged on the basis of cytological and
nuclear features (Figure 1).
Besides, the BMCyt assay can detect an increase in
MN frequency in exfoliated buccal cells after exposure to different genotoxic factors (e.g. chemicals,
radiation, lifestyle factors); this assay also has the potential to identify inherited genomic instability such
FIGURE 1. Schematic diagram of different types of buccal cells and the possible mechanisms for their origin; (a) normal differentiated cell (normal genome); (b) binucleated cell (cytokinesis defect); (c); micronucleated cell (chromosome breakage or loss);
(d) nuclear bud (gene amplification); (e) condensed chromatin (apoptotic cell death); (f) karyorrhexis (apoptotic cell death); (g)
pyknosis (apoptotic cell death); (h) karyolysis (necrotic cell death).
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as Blooms syndrome. The biomarkers measured in

this assay have been associated with normal ageing
and premature ageing in clinical outcomes such as
Downs syndrome and Alzheimers disease. The buccal MN assay is used as a biomarker of cancer risk.
The aim of the present study was to evaluate the
baseline micronucleus frequency in human buccal cells in the sample of healthy Bosnian subjects.
In addition to counting micronuclei, degenerative
nuclear alterations indicative of apoptosis (karyorrhectic, pyknotic and karyolytic cells) were also investigated in the BMCyt assay.
We hypothesized that sex and age of participants affect MN and other biomarker frequencies in human
buccal cells. Smoking habit was also taken into account.
METHODS
Exfoliated cells of the human buccal mucosa for the

buccal micronucleus cytome (BMCyt) assay were
collected from 120 healthy females and males, mostly younger subjects from Central Bosnia and Herzegovina. Participants were aged between 19 and 50
years (with mean age of 25.33 4.90 years). Signed
informed consent was obtained from each individual. Information on date of birth, sex and smoking
status and history (the number of cigarettes smoked
per day and duration of smoking in year) was obtained by the questionnaire.
In this study, the BMCyt assay was used for studying biomarkers of DNA damage, cytokinetic defects
and cell death. Individuals rinsed their mouth with
water and wooden tongue depressor was used to col-
lect cells from the inner wall of the cheek. The slides
were prepared by direct smearing of buccal cells to
cleaned microscope slide. The smears were air dried
and slides were stained by 2% acetorcein (Gurr
Orcein, BDH Chemicals Ltd., Poole, England).
Stained slides were used for microscopic analysis.
Exfoliated buccal cells were analysed under a total
magnification of x1000 using a Jenaval microscope.
Only cells that were not clumped or overlapped and
that contained intact nuclei were included in the
analysis of MNi. The frequency of micronuclei and
degenerative nuclear alterations (nuclear buds, pyknotic, karyolytic and karyorrhectic cells) in differentiated human buccal cells were recorded. Applied
criteria for identifying and scoring cell types in the
BMCyt assay, based on morphological features of
cells, were described by Tolbert et al. (1), Sarto et al.
(15) and Thomas et al. (16). According to these criteria, normal differentiated cell has a smaller nuclearcytoplasmic ratio relative to basal cell, more angular
and flatter than basal cells, uniformly stained round
nucleus. The micronucleated cell contains both the
main nucleus and micronucleus and micronuclei are
round or oval with similar stain intensity as the main
nucleus. The micronuclei usually have 1/31/16 diameter of the main nucleus located in cellular cytoplasm. Most cells with MNi contain only one MN
but it is possible to find cells with two or more MNi.
The cells with nuclear bud on the main nucleus have
a sharp constriction forming a bud. The bud is attached to the main nucleus and has a similar staining intensity as the main nucleus. Its diameter can
be a quarter to half of nuclear diameter. The karyorrhectic cells have nucleus with extensive aggregated
TABLE 1. Selected characteristics of the studied subjects (mean SD per subject).

Subjects Mean age at test (yrs)
N
%
Total
120 100
25.334.90
Females
67 55.8
25.544.76
Smokers
37 30.8
25.766.02
Non-smokers 30 25.0
25.272.53
Males
53 44.2
25.065.10
Smokers
23 19.2
25.396.49
Non-smokers 30 25.0
24.803.83
Current smokers Cigarettes per day Years smoking

N
%
60
100
17.629.26
6.975.78
37
61.7
15.198.69
6.304.95
23
38.3
21.528.97*
8.046.89
SD, standard deviation. Significance was accepted at P < 0.05. Significant results in bold. Sex: *P < 0.001.
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Period of sampling
2009-2012
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chromatin, while nuclear fragmentation may be evident. The pyknotic cell has small shrunken nucleus.
The nucleus is uniformly and intensely stained and
its diameter is 1/32/3 diameter of normal nucleus.
The karyolytic cells are cells in which the nucleus is
completely depleted of DNA. The nucleus is apparent as a ghost-like image that has no Orcein staining.
First, we determined the number of karyorrhectic,
pyknotic and karyolitic cells per 1,000 differentiated cells for score slides in the BMCyt assay. The
number of DNA damage biomarkers (MNi and
NBUDs) is scored in 1,000 differentiated cells, because of the very low number of basal cells. Data
were expressed as the mean standard deviation
(SD) of the means. The frequencies of various cell
types in the assay are represented as the number of
cells in a 1,000 cells.
In our study, sex, age and lifestyle-related variable of smoking habits (the number of cigarettes
smoked per day and duration of smoking in a year),
that could affect the number of studied biomarkers, was considered. The subjects were divided into
groups, according to their sex (females and males).
Additionally, females and males were divided into
subgroups with regard to smoking habit (smokers
and non-smokers), based on their responses to the
questionnaire. Smoking habit was ranked as smoker
or non-smoker. Individuals who had consumed four
or more cigarettes per day for at least two years were
considered to be smokers. These groups (smokers

and non-smokers) were divided into subgroup with
regard to sex (Table 1).
The presence of statistically significant differences

in the occurrence of damaged cells between studied
groups and subgroups is tested with a Students ttest (comparing two means). Also, to evaluate the
association between age or smoking and each biomarker, Pearson's method (r) was performed. The
value of P < 0.05 was considered statistically significant. All statistical analyses were carried out using
Microsoft Excel 2010 (Microsoft Corporation) and
the Windows Kwikstat Winks SDA 7.0.2 statistical
software package (Texa Soft Cedar Hill, Texas).
RESULTS
The sample included 120 subjects, 67 females

(55.8%) and 53 males (44.2%) with ages ranging
from 19 to 50 years (mean SD: 25.33 4.90).
The mean ages of the females and males were 25.06
5.10 (ages ranging from 19 to 50 years) and 25.54
4.76 years (ages ranging from 20 to 50 years), respectively. Table 2 presents the effects of sex and
smoking on buccal cell micronucleus and nuclear
alteration frequencies in healthy persons. Students
t-test showed there wasnt significant difference
TABLE 2. Effects of sex and smoking on buccal cell MN and nuclear alteration frequencies in healthy persons (mean SD per
subject).
Samples
Total
Females
Males
Subjects
(N)
120
67
53
Mean age
Cigarettes
Years
PYK cell
KYL cell
at test (yrs)
per day
smoking
25.334.90 17.629.26 6.975.78 2.082.9 1.931.54
25.544.76 15.198.69 6.304.95 1.661.86 1.721.20
25.065.10 21.528.97** 8.046.89 2.573.74 2.181.85
KHC cell
NBUD
MN
5.723.53 0.020.13 1.351.15

5.222.94 0.000.00 1.571.34*
6.294.09 0.040.19 1.080.78
Females
Smokers
Non-smokers
67
37
30
25.544.76
25.766.02
25.272.53
15.198.69
15.198.69
6.304.95 1.661.86 1.721.20 5.222.94 0.000.00 1.571.34

6.304.95 2.062.22 2.061.34b 6.353.41c 0.000.00 2.051.53c
1.201.26 1.330.90 3.931.58 0.000.00 0.970.72
Males
Smokers
Non-smokers
53
23
30
25.065.10
25.396.49
24.803.83
21.528.97
21.528.97
8.046.89 2.573.74 2.181.85 6.294.09 0.040.19 1.080.78

8.046.89 3.545.24 2.852.34a 8.235.07b 0.080.28 1.300.88a
1.731.33 1.601.06 4.601.92 0.000.00 0.900.70
Results shown are per 1,000 cells. SD, standard deviation. Significance was accepted at P < 0.05. Significant results in bold.
Sex: *P < 0.05; **P <0.001. Smoking: aP < 0.05; bP < 0.01; cP < 0.001.
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TABLE 3. Comparison of cytogenetic biomarker frequencies by stratification of sex and smoking status. All values are given as
mean SD per subject.
Samples
Total
Smoker
Non-smoker
Subjects
(N)
120
60
60
Mean age
at test (y)
25.334.90
25.626.15
25.033.23
Cigarettes
per day
17.629.26
17.629.26
Smoking
PYK cell
KYL cell
KHC cell
NBUD
MN
duration (y)
6.975.78 2.082.9 1.931.54 5.723.53 0.020.13 1.351.15
6.975.78 2.703.83a 2.401.85b 7.174.24b 0.030.18 1.781.35b
1.471.31 1.470.97 4.271.76 0.000.00 0.930.71
Smoker
Females
Males
60
37
23
25.626.15 17.629.26 6.975.78

25.766.02 15.198.69 6.304.95
25.396.49 21.528.97** 8.046.89
2.703.83
2.062.22
3.545.24
2.401.85
2.061.34
2.852.34
7.174.24 0.030.18 1.781.35

6.353.41 0.000.00 2.051.53*
8.235.07 0.080.28 1.300.88
Non-smoker
Females
Males
60
30
30
25.033.23
25.272.53
24.803.83
1.471.31
1.201.26
1.731.33
1.470.97
1.330.90
1.601.06
4.271.76 0.000.00 0.930.71

3.931.58 0.000.00 0.970.72
4.601.92 0.000.00 0.900.70
Results shown are per 1,000 cells. SD, standard deviation. Significance was accepted at P 0.05. Statistically significant values are
indicated in bold. Sex: *P < 0.05; **P < 0.001. Smoking: aP < 0.05; bP < 0.001.
between males and females in relation to age (t =

0.53; p = 0.599), which is important, given the fact
that the influence of sex and smoking on the occurrence of cytogenetic markers is observed. The males
consumed statistically significant higher number of
cigarettes per day than females (t = 3.91; p 0.001).
The mean baseline MN frequency in the examined
sample of individuals was 1.35 1.15 per subject
(per 1,000 cells), 0.135% or 1.35. We didnt observe MNi in buccal cells of 23 subjects. Most MNC
cells contain only one MN (97.5% of micronucleated cells) but it is possible to find cells with two or
even more MNi (range 1 - 6 MNi per thousand buccal cells). Therefore, the frequency of MNC cells and
the frequency of MNi per 1,000 cells were almost
identical (Figure 2). We didnt observe degenerative
nuclear alterations (Figure 3) in differentiated cells
of only three subjects, and nuclear alterations ranging between 1 and 35 per thousand buccal cells.
The data obtained by Students t-test showed that
the number of MNi was higher in females (mean
SD: 1.57 1.34), as compared with males (mean
SD: 1.08 0.78), the difference being statistically
significant (t = 2.5; p = 0.014). The ratio between
females and males was 1.45. On the other side, the
number of cells with NBUDs was higher in males
than in females, but the difference was statistically
non-significant. The number of degenerated cells
resulting from karyorrhesis (KHC cells), karyolysis
200
(KYL cells) and nucleus fragmentation (PYC cells)

was also increased in males, but these differences
were not statistically significant. The female or male
smokers had statistically significant more MNi (females: t = 3.81; p 0.001 and males: t = 2.07; p =
0.043), KYL (females: t = 2.66; p = 0.01 and males:
t = 2.38; p = 0.024) and KHC cells (females: t =
3.84; p 0.001 and males: t = 3.26; p = 0.003) than
female or male non-smokers.
To determine the correlation between age and cytogenetic biomarkers, Pearson's method was per-
FIGURE 2. The frequencies of micronuclei and other nuclear

alterations in exfoliated buccal cells of studied subjects. Average cells scored per subject (per 1,000 cells). PYK, pyknotic;
KYL, karyolytic; KHC, karyorrhectic; NBUD, nuclear bud;
MNC, micronucleated cells; MN, micronucleus.
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FIGURE 3. Photomicrographs of exfoliated buccal cells stained using acetorcein in the BMCyt assay; (a) differentiated cell with
two micronuclei; (b) cell with a micronucleus and nuclear bud; (c) and (d) cells with more micronuclei; (e) karyorrhectic cell; (f)
pycnotic cell; (g) karyolytic cell; (h) fragmented nucleus. All photos were taken at 1,000x magnification.
formed. In the sample including both males and

females during this study, we found significantly
positive correlation between ageing and the number of MNi (r = 0.4300; p < 0.001), NBUDs (r =
0.2959; p = 0.022), KHC (r = 0.3109; p = 0.016)
and KYL cells (r = 0.3623; p = 0.004). These results
showed that micronucleus and other cytogenetic
markers frequencies tended to be greater in older
subjects than in younger subjects.
Pearsons analysis was applied in order to investigate
the association between micronucleus formations in
human buccal cells and the number of degenerative
nuclear alterations. We found significantly positive
correlation between the number of MNi in cells and
the number of degenerative nuclear alterations in
differentiated buccal cells; for NBUDs: r = 0.3644;
p = 0.004, KHC cells: r = 0.2905; p = 0.024 and for
KYL cells: r = 0.3076; p = 0.017.
Sample included 60 smokers, 37 females (61.67%)
and 23 males (38.33%). The average age of smokers
was 25.62 6.15 and non-smokers 25.03 3.23
(Table 3). This difference was not statistically significant and we can study effects of sex on the number
of examined biomarkers.
The frequency of MNi of oral epithelial cells was
twice as high in smokers as in non-smokers; recorded MNi frequency values were 1.78 1.35 and 0.93
0.71, respectively.
The cells with anomalies other than MNi, such as

PYK, KYL, KHC cells, are significantly increased
in smokers. In Students t-test, the smokers had statistically significant increased number of MNi (t =
4.32; p 0.001), PYK (t = 2.35; p = 0.021), KYL
(t = 3.45; p 0.001) and KHC cells (t = 4.99; p
0.001) than non-smokers. Regarding the sex of
smokers, females had significantly higher number of
MNi in exfoliated buccal cells (t = 2.25; p = 0.028)
when compared with males, although males smoke
significantly more cigarettes per day (t = 2.71; p
= 0.009) than females. The ratio of MNi between
females and males was 1.52. The males had higher
number of other biomarkers examined (PYK, KYL
and KHC cells, also NBUDs) when compared with
females, however these differences were not statistically significant. In the group of non-smokers, there
is not statistically significant difference in the number of observed cytogenetic markers between males
and females (Table 3).
We also noticed statistically significant positive correlation between cumulative smoking (duration
of smoking in years) and the number of MNi (r =
0.5074; p < 0.001) and NBUDs in the cells (r =
0.6999; p < 0.001), PYK (r = 0.4818; p = 0.007),
KYL (r = 0.6592; p < 0.001) and KHC cells (r =
0.7702; p < 0.001). Similarly, smoking intensity
(number of consumed cigarettes per day) had an
effect on statistically significant increased number
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of nuclear alterations, PYK (r = 0.5198; p = 0.003),

KYL (r = 0.4430; p = 0.014) and KHC cells (r =
0.5265; p = 0.003).
DISCUSSION
BMCyt assay is useful as a biomarker of genetic

damage caused by genotoxic and lifestyle factors,
environmental and occupational exposures, dietary
deficiencies, medical procedures, different diseases,
as well as inherited genetic defects in DNA repair.
The sex, age, smoking and alcohol consumption can
affect MN frequency in buccal cells.
In this study, the baseline frequency of micronuclei
was determined in exfoliated cells of the human
buccal mucosa of 120 healthy subjects. The sex, age
and smoking habits were taken into account. We
found the baseline MN frequency in human buccal cells was 0.135% or 1.35 in examined sample,
which is in agreement with the other published reports: 0.16% (1), 0.1 to 0.3% (17) and 0.5 - 2.5
MNi per 1,000 cells (3). Micronuclei are regarded
as biomarkers of abnormal mitoses involving chromosomal breakage or mis-segregated chromatin. We
demonstrated that sex influences the number of
MNi in buccal cells. The number of MNi was significantly higher in females as compared with males.
The ratio between females and males was 1.45. Also,
there was association between the age of the participants and frequency of MNi, NBUDs, KYL and
KHC cells. The number of these cytogenetic markers statistically increased with ageing. Concerning
sex, the other studies also reported that biomarker
frequencies were higher in females than in males by
a factor of 1.2 - 1.6, depending on the age group
(17-19). However, other authors have shown the
spontaneous buccal cell MN frequencies in males
and females did not substantially differ, with a slight
but not significant excess in males (20). Some studies did not find any association between sex and micronucleus occurrence (6, 21), although this association has been reported by others (22-24).
Some authors did not find association between age
and micronucleus occurrence (6, 21). However, other authors were able to establish a statistically significant effect by age (8, 25-27). Results of the study of
Piyathilake et al (4) indicated that age and sex were
important variables affecting micronucleus frequen-
cy. It has been shown that in vivo ageing leads to an

increased micronucleus frequency in lymphocytes.
Loss of the X chromosome in females and males and
loss of the Y chromosome in males are among the
primary mechanisms explaining this increase (14).
The higher incidence of MN in both sexes is more
manifested in older age groups and the effect of sex
becomes more pronounced as age increases. Cytogenetically, ageing is associated with a number of cellular changes, including altered size and morphology, genomic instability and changes in expression
and proliferation (28, 29). It has been shown that
a higher MN frequency is directly associated with
decreased efficiency of DNA repair and increased
genomic instability (30, 31).
In our study, males had a slightly higher number of
cells with NBUD and the number of degenerative
nuclear alterations indicative of apoptosis (PYK and
KYL cells and KHC cells) than females. However,
significantly positive correlations were observed
between micronuclei frequencies in human buccal
cells and the formation of cells with NBUD, KYL
and KHC cells. The PYK, condensed chromatin
and KYL are normal correlates of epithelial cell differentiation and maturation. However, they occur
at elevated levels in response to cellular injury. The
PYK, KHC and condensed chromatin are associated
with both cytotoxicity (necrosis and keratinization)
and genotoxicity (apoptosis), but KYL is associated with cytotoxicity only. Apoptosis is the major
mechanism of cell death in living tissues. Because
it is stimulated both by ionizing radiation and by
chemicals that bind to DNA, apoptosis may also act
as a surveillance mechanism, eliminating cells with
genetic damage. Thus, apoptosis may be an indicator of genotoxic insult. Therefore, the BMCyt offers evaluation of chromosomal instability and gene
amplification (NBUDs), cytokinesis arrest due to
aneuploidy (binucleated cells), and different cell
death events (e.g. KHC and PYK cells). Correlation analyses showed that micronucleus frequencies
correlated significantly with karyorrhexis, karyolysis,
condensed chromatin and binucleates (7).
The most frequently studied lifestyle parameter is
smoking. This study showed that buccal cell MNi
and degenerative nuclear alternations were more frequent among cigarette smokers than non-smokers.
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Also, cigarette smoking (the number of cigarettes

smoked per day or years of smoking) significantly
increases the frequencies of PYK, KYL and KHC
cells and years of smoking also increases the frequencies of MNi and NBUDs in buccal cells. Concerning the number of cigarettes smoked per day or years
of smoking, genetic damage shows that only the
subjects who smoked the most had a significant increase in MNi and NBUDs. Statistically significant
higher frequency of MNi, PYK, KYL and KHC cells
was observed in cells collected from female or male
smokers than from non-smokers.
There are different results in the literature about the
effects of smoking on induction of MNi in exfoliated buccal cells. Konopacka (6) reported that the
frequency of MNi of oral epithelial cells was three
times higher in smokers than non-smokers. It has
been suggested that this association is dependent
on the number of cigarettes consumed (26, 27).
Haveric et al (32) studied the effects of cigarette consumption on micronucleus frequencies in peripheral
blood lymphocytes and exfoliated buccal cells of
young smokers. They observed significantly higher
frequency of apoptotic buccal cells in smokers and
the frequency of apoptotic cells in this group was
significantly influenced by the age of participants
and duration of smoking. Yet other publications report no difference between smokers and non-smokers or men and women (33).
statistically increased the number of analysed cytogenetic markers.

Statistically significant higher frequency of MNi,
PYK, KYL and KHC cells was observed in cells
collected from female or male smokers than from
non-smokers. Our findings indicated that cigarette
smoking (the number of consumed cigarettes per
day or years of smoking) significantly increases the
frequencies of PYK, KYL and KHC cells. Cytogenetic damages show that subjects who smoked more
years had a significant increase in MNi and NBUDs
in buccal cells.
COMPETING INTERESTS
The authors declare no conflict of interest.

ACKNOWLEDGEMENTS
We acknowledge numerous students who have contributed to the research that has led to a better understanding of the mechanisms underlying micronucleus formation.
CONCLUSIONS
The BMCyt assay, based on scoring not only MN

frequency but also other genome damage markers,
dead or degenerated cells, provides a measure of cytotoxic and genotoxic effects.
Our results suggest that the baseline MN frequency
in human buccal cells of 120 healthy subjects was
0.135% or 1.35. Significant positive correlations
were observed between MN frequencies and formation of NBUD, KYL and KHC cells.
We demonstrated that sex influences the number of
MNi in human buccal cells. The number of MNi
in cells was significantly higher in females than in
males, regardless of the number of consumed cigarettes per day. There was positive association between the age of the participants and frequency of
MNi, NBUDs, KYL and KHC cells. The ageing
203
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Amila Kapetanovi, Dijana Avdi Journal of Health Sciences 2013;3(3):205-209

RESEARCH ARTICLE
Open Access
Physical activity and bone mineral density in

postmenopausal women without estrogen
deficiency in menstrual history
Amila Kapetanovi1, Dijana Avdi2
1
Medical Rehabilitation Center Fojnica, Fojnica, Bosnia and Herzegovina. 2Clinic for orthopedics and traumatology, Clinical
Center of the University of Sarajevo, Sarajevo, Bosnia and Herzegovina.
ABSTRACT
Introduction: The estrogen deficiency after menopause leads to accelerated loss of bone mass. The aim
of this study was to examine influence of physical activity on bone mineral density in postmenopausal
women who hadnt a deficit of estrogen in their menstrual history.
Methods: This prospective study included 100 postmenopausal women, ages between 50 and 65, living in Sarajevo area without estrogen deficiency in menstrual history. The women in the examination
group had osteoporosis. The women in the control group had osteopenia or normal mineral bone density.
Mineral bone density was measured at the lumbar spine and proximal femur by DualEnergy Xray Absorptiometry using Hologic QDR-4000 scanner. To assess level of physical activity an International Physical
Activity Questionnaire - Long Form was used.
Results: In the examination group of women who had no history of menstrual estrogen deficit, level of
physical activity was low in 52.00% female, and in 48.00% women level of physical activity was moderate.
In the control group of women who had no history of menstrual estrogen deficit in 10.00% female level
of physical activity was low, and in 90.00% female level of physical activity was moderate. The difference
in levels of physical activity between the two groups was statistically significant, X2 test = 20.6, p <0.005.
Conclusion: Results of this study suggest that moderate physical activity has positive impact on bone
mineral density in postmenopausal women without estrogen deficiency in menstrual history and has the
potential to reduce rapid bone loss after menopause.
Keywords: osteoporosis, physical activity.
INTRODUCTION
Osteoporosis is characterized by low bone mass

which may be the consequence of development of
*Corresponding author: Amila Kapetanovi
Medical Rehabilitation Center Fojnica, Fojnica,
Bosnia and Herzegovina
E-mail: nermin1a@bih.net.ba
Submitted 5 August 2013 / Accepted 10 September 2013
the skeleton during adolescence (low peak bone

mass) and/or exessive bone loss thereafter (1). Sex
hormones are crucial for keeping bone mass in balance, and the lack of either estrogen or testosterone
leads to decreased bone mass and increased risk for
osteoporosis (2). After menopause phase of accelerated bone degradation occurs and lasts 4-8 years,
initiated by dramatic reduction in estrogen production by the ovaries (3, 4).
2013 Amila Kapetanovi, Dijana Avdi; licensee University of Sarajevo - Faculty of Health
Studies. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted
use, distribution, and reproduction in any medium, provided the original work is properly cited.
Both estrogen and androgens inhibit bone resorption via effects on the receptor activator of NF-kappaB ligand RANKL/RANK/osteoprotegerin system,
as well as by reducing the production of a number
of pro-resorptive cytokines, along with direct effects
on osteoclast activity and lifespan (5). Estrogens
and androgens also exert effects on the lifespan of
mature bone cells: pro-apoptotic effects on osteoclasts but anti-apoptotic effects on osteoblasts and
osteocytes (6). Sex steroid effects on bone formation
are also likely mediated by multiple mechanisms,
including a prolongation of osteoblast lifespan via
non-genotropic mechanisms, as well as effects on
osteoblast differentiation and function (5). Estrogen
is known to have a variety of effects on the proliferation and synthesis of enzymes and bone matrix
proteins by osteoblast like cells through a process
mediated by complex biomolecular biologic signals
and mechanisms (7).
The activities of osteoblasts and osteoclasts are controlled by a variety of hormones and cytokines, as
well as by mechanical loading (2).
Biochemical and molecular biological studies have
resulted in the identification of the gene of which
expression level is changed by mechanical stress (8).
Bone tissue has a mechanosensing apparatus that
directs osteogenesis to where it is most needed to
increase bone strength and the most likely sensors
of mechanical loading are the osteocytes, which are
visco-elastically coupled to the bone matrix so that
their biological response increases with loading rate;
thus, increasing loading frequency improves the responsiveness of bone to loading (9).
Research shows that physical activity modifies level
of various hormones involved in bone metabolism,
including gonadal sex hormone levels and calciotropic hormone levels (10, 11, 12). The reproductive abnormalities observed in female athletes generally originate in hypothalamic dysfunction and
disturbance of the gonadotropin-releasing hormone
(GnRH) pulse generator, although specific mechanisms triggering reproductive dysfunction may vary
across athletic disciplines, the clinical consequences
associated with suppression of GnRH include infertility and compromised bone density, which appears
to be irreversible (13).
The aim of this study was to examine influence of
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physical activity on bone mineral density in postmenopausal women without estrogen deficiency in
their menstrual history (no late menarche, no premature menopause).
METHODS
This prospective study included 100 postmenopausal women living in Sarajevo area (Sarajevo Canton)
without estrogen deficiency in menstrual history
(normal menstrual history).
Mineral bone density was measured at the lumbar
spine and proximal femur by DualEnergy Xray
Absorptiometry using Hologic QDR-4000 scanner.
Examination group included 50 postmenopausal
women, ages between 50 and 65, with osteoporosis
(a value of BMD 2.5 standard deviations or more
below the young adult mean)
Control group included 50 postmenopausal women,
ages between 50 and 65, with osteopenia
(a value of BMD more than 1 standard deviations
below the young adult mean, but less than 2.5 standard deviations below this value) or normal bone
mineral density (a value of BMD within 1 standard
deviation of the young adult reference mean)
The women in the both group had normal menstrual history, without estrogen deficiency in
menstrual history (no late menarche, no premature
menopause).
The inclusion criteria were: women aged 50-65
years, women who live in the Sarajevo Canton, postmenopausal women without estrogen deficiency in
menstrual history (no late menarche, no premature
menopause), women who do not use hormone replacement therapy, women whose finding's of bone
densitometry (DEXA) was at the level of osteoporosis, women whose finding's of bone densitometry
(DEXA) was at the level of osteopenia or normal.
The exclusion criteria were: women younger than 50
and older than 65 years, women who do not live in
the Sarajevo Canton, postmenopausal women with
estrogen deficiency in menstrual history (late menarche, premature menopause), women who are not
postmenopausal, women who use hormone replacement therapy, women who have a disease that can
cause osteoporosis, women who use medicines that
may cause osteoporosis.
206
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To assess level of physical activity an International

Physical Activity Questionnaire - Long Form (IPAQ
Long Form), was used. Physical activity was assessed in the four domains: work-related physical
activity, transport-related physical activity, domestic and gardening (yard) activities and leisure time
physical activity, in the last 7 days. There are three
levels of physical activity (categorical score): low
physical activity, moderate physical activity and high
physical activity. Mentioned are only those activities
which were carried out for at least 10 minutes.
Statistical significance between examination and

control group in physical activity level was tested by
Chi square test. P < 0.05 was considered statistically
significant.
RESULTS
FIGURE 2. Level of physical activity of women without estrogen deficiency (low physical activity)
The average age of women without estrogen deficiency in their menstrual history in the examination
group was 58.64 years, and in the control group was
57.9 years. There was no statistically significant differences between these two groups, t = 0.746.
In the examination group of women who had no
history of menstrual estrogen deficit, level of physical activity was low in 26 (52.00%) female, and in
24 (48%) women level of physical activity was moderate. In the control group of women who had no
history of menstrual estrogen deficit in 5 (10.00%)
female level of physical activity was low, and in 45
(90.00%) female level of physical activity was moderate. The difference in levels of physical activity between the two groups was statistically significant, X
test = 20.6, p <0.005.
FIGURE 1. The average age of women without estrogen deficiency in menstrual history
t = 0.746, no statistically significant
TABLE 1. Level of physical activity of women without estrogen deficiency and statistical significance of difference in
the level of physical activity between examination and control
group
Level of
physical
activity
Low
Moderate
Total number
of women
Examination
group
n
%
26 52.00
24 48.00
Control
group
n
%
5
10.00
45 90.00
50
50
100.00
100.00
FIGURE 3. Level of physical activity of women without estrogen deficiency (moderate physical activity)
Hi square test,
Significance
level
DISCUSSION
test =20.6
p < 0.005
Among the estrogen target organs, bone has recently

drawn increasing attention because postmenopausal
207
osteoporosis induced by estrogen deficiency has

emerged as the most widely spread bone/joint disease in developed countries (14). Loss of estrogen
leads to increased rate of remodeling and tilts the
balance between bone resorption and formation in
favor of the former (6). Post-menopausal osteoporosis is characterized by increased fracture risk due
to deficiencies in both the quantity and quality of
bone (15). The aim of this study was to examine
influence of physical activity on bone mineral density in postmenopausal women who hadnt a deficit
of estrogen in their menstrual history (no late menarche, no premature menopause). The mechanisms
through which physical activity affects the bone tissue are incompletely understood, and some results
of research are contradictory (16). Model of the
osteogenic potential of exercise has not been established in humans (17). Research suggest that the frequency, intensity, time and type of physical activity,
is directly related to its effects on bone tissue.
In the study of Bonaiuti D et al. showed that aerobics, weight bearing and resistance exercises are all
effective in increasing the BMD of the spine in postmenopausal women, and walking is also effective on
the hip (18). Hagberg JM. et al. find that prolonged
low-to-moderate-intensity physical activity, but not
the same number of years of higher-intensity training for competitive events, was independently associated with higher BMD (19). The results of the
study of Feskanich D. et al. showed that moderate
levels of activity, including walking, are associated
with substantially lower risk of hip fracture in postmenopausal women (20). Schmitt et al. find that
physical activity effectively slows bone loss in postmenopausal women in a dose-dependent manner
and that in order to maximize the goals of public
health most effective, individually adapted, intense,
high impact exercise programs are needed (21).
As indicated in the Ryan et all. study, 6-month of
whole-body resistive training increases muscle mass
and improves BMD of the femoral region in young
and healthy older men and women as a group, with
a trend for this to be greater in young subjects (22).
Roghani T. et al. evaluated the effect of submaximal
aerobic exercise with and without external loading
on bone metabolism and balance in postmenopausal women with osteoporosis. Results showed
that the two exercise programs (aerobic, weighted
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vest) stimulate bone synthesis and decrease bone

resorption in postmenopausal women with osteoporosis (23). Although the study of Kemmler W et al.
marginally failed to determine significant effects on
overall fracture risk or rate ratio, the study increased
the body of evidence for the fracture prevention efficiency of exercise programs, with special regard on
bone strength (as assessed by bone mineral density
measurement) (24).
Ethnic differences in absolute fracture risk may warrant ethnic-specific clinical recommendations (25).
There is a large variation in hip fracture incidence
from different regions of the world (26). Bone loss
subsequently occurs with ageing in both sexes, and
in females accelerated loss occurs at the menopause
(27). Due to these variations it is necessary that
research be carried out within certain population
groups. In this study, investigated was the influence
of physical activity on bone mineral density in postmenopausal women, aged 50-65 years, who live in
the area of Sarajevo Canton, who did not have a
deficit of estrogen in their menstrual history (no late
menarche, no premature menopause).
Physical activity in daily life was examined in the
four domains: work-related physical activity, transport-related physical activity, domestic and gardening (yard) activities and leisure time physical activity.
There were three levels of physical activity (categorical score): low physical activity, moderate physical
activity and high physical activity. It was shown that
moderate intensity physical activity, performed during daily life, positively affects bone mineral density.
Based on the results of the research, physical activity
of moderate intensity is recommended in the course
of daily life, in order to maintain and improve bone
health in postmenopausal women (menstrual history without estrogen deficiency), aged 50-65 years,
who live in the area of Sarajevo Canton.
208
CONCLUSION
Results of this study suggest that moderate physical

activity has positive impact on bone mineral density
in postmenopausal women (without estrogen deficiency in menstrual history) and has the potential
to reduce rapid bone loss associated with decrease in
estrogen at the time of menopause.
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COMPETING INTERESTS
osteoporosis. Best Pract Res Clin Endocrinol Metab, 2003;17(1):53-71.

16. De Melo Ocarino N, Serakides R. Effect of the physical activity on normal
bone and on the osteoporosis prevention and treatment. Rev Bras Med
Esporto Vol.12. No 3 Mai/Jun, 2006.
The authors declare no conflict of interest

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reproductive system. Journal of Endocrinology 2001;170(1):3-11.
14. Imai Y , Kondoh S, Kouzmenko A, Kato S. Minireview: Osteoprotective
Action of Estrogens is Mediated by Osteoclastic Estrogen Receptor-. Molecular Endocrinology 2010; 24(5):877-885
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RESEARCH ARTICLE
Open Access
Oral surgical procedures and prevalence of oral

diseases in Oral Surgery Department in Faculty of
Dentistry Sarajevo
Sadeta ei*, Samir Prohi, Sanja Komi
Department of Oral Surgery, Faculty of Dentistry, University of Sarajevo
ABSTRACT
Introduction: The aim of this study is to determine prevalence of oral diseases and oral surgical procedures at Department of Oral Surgery, Faculty of Dental Medicine, University in Sarajevo.
Methods: The current study is retrospective analysis of oral surgical procedures performed from January
2011 to December 2012 at Department of Oral Surgery, Faculty of Dental Medicine, University in Sarajevo.
The data were statistically analyzed by T-test of independent samples and using Chi-squared test. P value
lower than 0,001 was considered to be statistically significant.
Results: A total of 1299 patients were included in study. The age range is from 18 to 84 years, with mean
age SD= 3515 years. There were 42 different clinical diagnoses, and 13 diagnoses appeared in more
than 1% of all patients. Impacted and semi-impacted teeth, periapical lesions and retained roots are the
most frequent diagnoses and represent 68% of all diagnoses. Embedded and impacted teeth (35%) and
diseases of pulp and periapical tissues (31%) are the most frequent diagnoses with respect of ICD-10.
Impacted teeth is the most common diagnosis and removal of impacted third molars is the most common
oral surgical procedure.
Conclusion: Study points out variety of dentoalveolar patology and complexity of dental health care that
often requires interdisciplinary approach in order to achieve optimal outcome for patient.
Keywords: cross-sectional studies; dental health surveys; prevalence; public health dentistry; surgery, oral
INTRODUCTION
Oral health is considered as important part of patient's general health. Oral diseases are the most
*Corresponding author: Sadeta ei, DDS, PhD

Department of Oral Surgery, Faculty of Dentistry
University of Sarajevo, Bolnika 4a, 71000 Sarajevo
Bosnia and Herzegovina
Email address: sadetas@gnet.ba
Submitted 6 November 2013 / Accepted 8 December 2013
common of the chronic diseases and are important

public health problems because of their prevalence,
their impact on individuals and society, and the
expense of their treatment (1) . Therefore improvement of oral health and the quality of life is the aim
of contemporary dental care. Oral health, quality of
life and public health are closely related (2). Quality
of dental care is based on integrity of health services
and their mutually harmonization through system
of primary, secondary and tertiary health care. Oral
2013 Sadeta ei et al.; licensee University of Sarajevo - Faculty of Health Studies. This is
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surgery as a dental speciality that deals with diagnostics and treatment of diseases, trauma and defects
of dentoalveolar structures is represented in every
level of health care. Relatively simple procedures are
performed in dental offices by general dental practitioners according to their competence and training.
Majority of oral-surgical procedures are performed
by specialist oral surgeons in Departments of oral
surgery in hospitals. The most difficult and complex
cases are referred to specialized consultative health
care on Department of Oral surgery Faculty of
Dentistry University of Sarajevo. This arrangement
of health care provides high quality of health care
services, efficiency in the use of health technologies
and human resources as well as optimal patient outcome. Because of this, epidemiological analysis of
oral-surgical procedures is not just representation of
prevalence of oral diseases in population, but also
is an important indicator of quality and organization of health care overall. Several epidemiological
studies are done in neighbour countries of Bosnia
and Herzegovina. Epidemiological study of oral surgery procedures of patients reffered to Department
of Oral Surgery at Clinical Center in Rijeka, Croatia showed the most common referral diagnosis is
chronic osteitic processes, followed by retained roots
and impacted teeth (3). Analysis of ambulatory oral
surgery diagnoses at the Department of Oral Surgery
at University Hospital Dubrava in Zagreb, Croatia
showed retained roots, chronic periapical lesions,
and deep caries represented 70% of all ambulatory
diagnoses (4). This kind of epidemiological study
has not been conducted in Bosnia and Herzegovina.
The aim of this study is to determine prevalence of
oral diseases and oral surgical procedures at Department od Oral Surgery, Faculty of Dental Medicine,
University in Sarajevo.
the only exclusion criteria was patients younger than

18 years of age, as growth is essentially completed by
this age. All patients with indication for oral surgical treatment accepted the invitation to participate
in study. A total of 1299 patients were included in
study. There were 511 males and 788 females, the
patients's age ranged from 18 to 84 years. After diagnostics that includes complete medical and dental
history, clinical and radiographical examination and
blood laboratory tests, the surgical treatment was
indicated. Medically compromised patients underwent internistic preparation if needed and internistic agreement was necessary for dental treatment.
After informing patients about medical procedure
patients signed informed consent. Study was conducted in accordance with Helsinki declaration of
ethical principles for medical research. All procedures were performed by different surgeons in local
anesthesia 1,8 ml Lidocain 2% Adrenalin 1:80000
(Alkaloid, Skopje, Republic of Macedonia) in the
same operating room under same conditions. The
data were entered in operation protocols, and then
in specially designed data base created for this study
containing the following information: number of
protocol, gender, age, age group and diagnosis. Diagnosis was established according to International
Classification of Diseases (ICD-10) (5). To ensure
protection of privacy, patient's names and number
of dental form and dental charts were not recorded in data base and only the main researcher had
complete access to data-base and oral-surgery protocols. Data were processed and analyzed in statistical
software SPSS 20.0 (SPSS Inc, Chicago, IL, USA).
The data were statistically analyzed by T-test of independent samples and the comparision between the
groups was made using Chi-squared test. P value
lower than 0,001 was considered to be statistically
significant.
METHODS
The current study is retrospective analysis of oral

surgical procedures performed in Department of
Oral surgery from January 2011 to December 2012.
The total of 1584 patients from the Canton of Sarajevo consecutively referred to Department of Oral
Surgery by general dental practitioners in two-year
period. To ensure representative and randomized
sample of general population in Canton of Sarajevo,
RESULTS
The total of 1299 patients were included in this

study: 511 males and 788 females, gender ratio
1:1.54 in favor of females. The age range is from 18
to 84 years, with mean age SD= 3515 years. Majority of patients is in age group 20-29 years (n=503;
39%), followed by <19 years (n=237; 18%), 30-39
years (n=235; 18%), 40-49 years (n=156; 12%),
50-59 years (n=141, 11%) and >60 years (n=121;
211
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TABLE 1. Clinical diagnoses of oral surgical procedures performed at Department of Oral Surgery, Faculty of Dentistry Sarajevo, from January 2011 to December 2012
Number
Percent
of patients
(%)
(frequency)
Dens subimpactus
244
17.7
Dens impactus
239
17.4
Periodontitis periapicalis chronica
216
15.7
Radix relicta
178
12.9
Cystis radicularis maxillae
162
11.7
Exostosis processus alveolaris maxillae
36
2.6
Cystis radicularis mandibulae
35
2.5
Hyperplasio mucosae vestibuli oris maxillae
28
2.0
Sinus maxillaris apertus
26
1.9
Retentio dentis
22
1.6
Dens germinatus
20
1.4
Frenulum labii superior tectolabialis
19
1.4
Exostosis pars alveolaris mandibulae
18
1.3
Tu buccae
13
.9
Cystis e retentione labii inferioris
11
.8
Cystis residualis maxillae
10
.7
Dens supernumerarius
10
.7
Epulis
8
.6
Cystis residualis mandibulae
5
.4
Cystis follicularis
5
.4
Hyperplasio mucosae oris pars alveolaris
5
.4
mandibulae
Fistula oroantralis
5
.4
Sinus maxillaris apertus cum dentis in antro
4
.3
Odontoma
4
.3
Tu mucosae vestibuli oris
4
.3
Tu labii inferior
4
.3
Tu linguae
4
.3
Dentitio difficilis
3
.2
Tu labii superior
3
.2
Tu palati duri
3
.2
Hyperplasio tuberis maxillae
2
.1
Lingua acreta
2
.1
Plica buccalis tectolabialis
2
.1
Proptosis buccae
2
.1
Sinusitis maxillaris chronica
2
.1
Focalosis
2
.1
Papillomatosis palati duri
2
.1
Mandibular tori
2
.1
Verucca vulgaris
1
.1
Fibromatosis palati duri
1
.1
Osteoma
1
.1
Corpus alienum in sinus maxillaris
1
.1
Clinical diagnose
212
9%). There were 42 different clinical diagnoses,

and 13 diagnoses appeared in more than 1%
of all patients. Frequency of clinical diagnoses
is shown in Table 1. Impacted and semi-impacted teeth (n=483; 35%), periapical lesions
(n=216; 15,7%) and retained roots (n=178;
13%) are the most frequent diagnoses and represent 64% of all diagnoses. Embedded and
impacted teeth (35%) and diseases of pulp and
periapical tissues (31%) are the most frequent
diagnoses with respect of ICD-10.
Impacted teeth are the most frequent diagnosis
in younger age groups: 50% in age group 2029 years, and 90% in age group to 39 years. Radicular cysts and periapical lesions are also the
most frequent in age group 20-29: 39% and
45% of patients are in that age group, respectively. Pre-prosthetic surgery is represented in
elderly age groups: 85% of pre-prosthetic surgical procedures is performed in patients older
than 40 years. Diseases of maxillary sinus most
commonly develop in third decade (36%),
84% of patients are in age group 20-59 years.
Mandibular third molars are the most frequently impacted teeth. Frequency of impacted teeth is shown in figure 1. Impactions
have gender-prevalence: frequency of impacted
teeth (except mandibular premolars) is higher
in females (p<0,001). Impacted third molars
are the most frequent in age group 20-29 years
(p<0,001): impacted maxillary third molars
55%, impacted mandibular third molars 53%,
semi-impacted maxillary third molars 52%
and semi-impacted mandibular molars 61%.
Radicular and residual cysts are more common
in maxilla: 11.7% vs. 2.5% and 0.7% vs.0.4%
respectively. Radicular cysts predominantly
affect the anterior region of maxilla- canine
to canine segment (n=139; 86%; p<0.001),
while there is no statistical significance in occurence of radicular cysts in anterior (n=20;
57%) and posterior (n=15; 43%) segment of
the mandible (p>0.001). Radicular maxillary
and mandibular cysts are the most common in
third decade: 39% and 42%, respectively, and
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TABLE 2. Surgical treatments performed at Department of

Oral Surgery, Faculty of Dentistry Sarajevo, from January
2011 to December 2012
Surgical treatment
Surgical extraction
Cystectomy
Apicoectomy
Excision
Alveoloplasty
Frenectomy
Number of patients
647
226
204
64
52
21
The cause of oro-sinus communication is extraction

of maxillary first molar (56%), second molar (20%),
second premolar (12%), third molar (8%) and first
premolar (4%). Highest number of oroantral communication and fistula are in age groups 30-39 years
(34%) and 58% in age group 20-39 years. Mucoceles of sinus presented in 2% of maxillary sinus
diagnoses.
Surgical extraction including extraction of impacted
teeth and retained roots is the most common surgical procedure. Table 2 shows surgical treatments
performed more than 20 times.
%
49.8
17.4
15.7
4.9
4
1.6
DISCUSSION
FIGURE 1. Frequency of impacted teeth.
FIGURE 2. Localization of non-malignant lesions in oral cavity
residual cysts in fifth decade of life (50%). Higher

prevalence of radicular cysts is found in male patients (p<0.001).
Majority of non-malignant oral lesions is in forth
decade of life (23%). Localization of non-malignant
lesions of oral cavity is shown in figure 2.
The most common disease of maxillary sinus is oroantral communication (81%), with 9% of oroantral
communications with tooth or root displaced in sinus. Oroantral fistula was identified in 14% of cases.
Impacted teeth is the most common diagnosis and

removal of impacted third molars is the most common oral surgical procedure. This is in accordance
with results of other studies, thus showing increase
of prevalence of impacted teeth in oral-surgical procedures (6,7). The analysis of available literature
shows that in the Anglo-Saxon population groups
the problems with the third molars are much more
common, which may be related to lesser incidence
of caries as a result of better prevention, better
availability of dental health care and treatment and
significantly smaller number of extractions, particularly of the first molars (6). Retained teeth and dentitio difficilis were the most common diagnosis in
younger age groups (<19 years) and impacted teeth
in older age groups (20-29 years). The predominant
age group for impacted teeth in our study is third
decade, which is in accordance with results of other
international studies (8-10). Several studies reported
gender predilection in third molar impactions (1113). Results of our study are in agreement with previous reports, since there is statistical significance in
distribution of impacted teeth between females and
males (p<0.001). The higher frequency reported
in females is due to the consequence of difference
between the growth of males and females. Females
usually stop growing when the third molars just begin to erupt, whereas in males, the growth of the
jaws continues during the time of eruption of the
third molars, creating more space for third molar
eruption (14) .
Odontogenic cysts ammount for 7-13% of the lesions diagnosed in oral cavity (15-17). Radicular
213
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cysts are the most prevalent odontogenic cysts according to all studies reviewed, with variations only
in percentages (18). Radicular cysts are more common in maxilla, which is consistent with findings
of other studies (18-20). Radicular cysts were more
common in the third decade of life, consistent with
the findings of Selvamani (20) and Souza (21). The
higher prevalence of male gender in some studies
may be explained by the fact that men usually have
poorer oral hygiene habits and are more susceptible
to trauma than women (22). The current study has
some limitations and results are difficult to compare
with other studies, due to different sampling method. In our study diagnosis was based upon clinical
findings, unlike other studies where roendgenographic data analysis was performed or samples were
obtained periapical lesions.
Pre-prosthetic surgery is found in 9% of oral-surgical procedures. Approximately 66% of exostoses
are encountered on maxilla, which is in accordance
with findings of Bouquot and Gundlach (23). Same
studies showed higher prevalence in older age
groups, similar to our study: 37% patients in age
group older then 60 years, but in our study exostoses are frequent also in younger age groups (fifth decade 29% and sixth decade 26%). Our findings suggest prevalence of exostoses is increasing after forth
decade of life, which may be related with increasing
of edentulism in elderly age groups. Different prevalence of exostoses in various race and ethnic groups
sugests genetic factors, and higher prevalence in elderly age groups suggests environmental factors such
as masticatory stress in their development (24). Recently, several authors have postulated that the etiology of tori consists of an interplay of multifactorial
genetic and environmental factors (25). Prevalence
of tori mandibularis is higher in males (2:1 ratio;
p<0.001), which is an accordance with findings of
Jainkittivong (24). Jainkittivong observed an increasing correlation between marked exostoses and
a significant attrition of teeth in some older subjects.
This may be a similar phenomenon as that which
occurs in subpontic hyperostosis, which postulates
that stress causes the crestal alveolar bone to grow
under the pontic along a vector opposing the forces
of occlusion. That suggest funcional influences may
contribute to the development of exostoses, and posibly may explain the higher prevalence in elderly
214
people such as cumulative effect of occlusal forces

and higher prevalence in male patients since male
patients have significantly larger values of occlusal
forces than females (26).
Oral non-malignant lesions are most frequently localized in gingiva and buccal mucosa, similarly to
other studies (27,28).
Prevalence of oroantral communication is reported
in range 0.31-4.7% (29) and in our study is represented with 2.5%. Extraction of maxillary first molar
(56%) is the main etiologic factor of oroantral communication, which is in accordance with Hernando
(30). The maxillary sinus reaches its greatest size
during the third decade of life; consequently, the incidence of oro-sinus communication is higher after
that, which is in accordance with results of our study
(p<0.001) and the results of other authors (29).
CONCLUSION
Present study shows variety of oral-surgical procedures is performed in Department of Oral Surgery
University of Sarajevo: diagnostics and treatment of
dental diseases, jaw lesions, cysts, non-malignant lesions of oral cavity, diseases of maxillary sinus, odontogenic infections and pre-prosthetic surgery. Study
showed impacted teeth are the most frequent diagnosis and surgical removal of impacted mandibular
third molars is the most common procedure. Radicular cysts and chronic periapical lesions are the most
frequent jaw lesions. Oral non-malignant lesions
are most frequently localized in gingiva and buccal
mucosa. The highest prevalence of oroantral communication is in third decade of life and the most
common etiologic factor is extraction of maxillary
first molar. Study points out variety of dentoalveolar
patology and complexity of dental health care that
often requires interdisciplinary approach in order to
achieve optimal outcome for patient.
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Eldad Kalji et al. Journal of Health Sciences 2013;3(3):216-221
http://www.jhsci.ba

RESEARCH ARTICLE
Open Access
Efficiency of trunk stabilizing exercises in treatment

of patients with lumbar pain syndrome
Eldad Kalji1*, Dijana Avdi1, Muris Pecar1, Namik Trtak1, Bakir Katana1, Nerina Kalji2
1
Faculty of Health Studies, University of Sarajevo, Bolnika 25, Sarajevo, Bosnia and Herzegovina. 2Faculty of Medicine,
University of Sarajevo, ekalua 90, Sarajevo, Bosnia and Herzegovina.
ABSTRACT
Introduction: Lumbar pain syndrome is the most common cause of temporary work disability in people
under 45 years of age. The aim of this study was to detect the frequency of acute and chronic lumbar pain
syndrome in people of both gender, different age structures, different occupations and in active working
population, and to determine the efficiency of trunk stabilizing exercises in its treatment.
Methods: We analyzed 27 patients with acute and 33 patients with chronic lumbar pain syndrome from
01.01.2010 to 31.12.2012 which undergone trunk stabilizing exercises. We evaluated and scored 0 to 5
the condition of respondents before treatment and after the treatment.
Research results: The mean score of condition of respondents with acute lumbar pain syndrome before
therapy is 2.96, whereas after treatment is 4.71. The mean score of condition of respondents with chronic
lumbar pain syndrome before therapy is 3.76, whereas after treatment is 4.63.
Conclusion: Treatment with trunk stabilizing exercises performed in the clinic "Praxis leads to improved
scores of condition of respondents after treatment.
Keywords: Trunk stabilizing exercises, lumbar pain syndrome, treatment.
INTRODUCTION
Lumbar pain syndrome is the most common cause

of temporary work disability in people under 45
years of age (1). In most of the patients the condition is followed by work disability and the need for
*Corresponding author: Eldad Kalji

Faculty of Health Studies, University of Sarajevo,
Bolnika 25, Sarajevo, Bosnia and Herzegovina
Phone: +38761748959
E-mail: ekaljic@gmail.com
Submitted 3 September 2013 / Accepted 25 October 2013
adequate medical treatment (2). It is defined as pain

in the area between the 12th thoracic rib and gluteal
segment, with or without radiation to the lower extremities (3). It is the second leading cause of pain
occurrence (4). If the aforementioned symptomatology lasts less than 6 weeks, then the lumbar pain
syndrome is acute. Duration from 6 to 12 weeks
indicates the subacute stage, while over 12 weeks is
chronic stage (5).
Diagnosis is based on medical history, clinical examination, tests for evaluation of functional status and
radiological verification. Treatment can be conser-
2013 Eldad Kalji et al.; licensee University of Sarajevo - Faculty of Health Studies. This is
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vative (pharmacological and physical therapy), surgical and combined (manual and pharmacological
therapy, bed rest, physical therapy and acupuncture).
In addition to the treatment of syndrome causes, it
is necessary to reduce the risk of re-occurrence with
trunk stabilizing exercises leading to the strengthening of the hull muscles and improvement of functional status of patient (6). Effects of trunk musculature exercises are reflected in the reduction of pain
and disabilities caused by syndrome and in improvement of function of the lumbar spine (7, 8). Studies
show that educational programs for exercises significantly improve functional status of office workers
(9).
The aim of this study was to detect the frequency of
acute and chronic lumbar pain syndrome in people
of both gender, different age structures, different
occupations and in active working population, and
to determine the efficiency of trunk stabilizing exercises in their treatment.
METHODS
Patients
The study included 27 patients with diagnosis of

acute lumbar pain syndrome and 33 patients with
diagnosis of chronic lumbar pain syndrome who
were treated in the clinic "Praxis" in the period
from 01.01.2010 to 31.12.2012 year. The patients
were of both gender, different age groups and active working respondents of 15 different professions:
doctor, veterinarian, teacher, engineer, lawyer, economist, official, laborer, craftsman, farmer, housewife,
retired, pupil, student and others. Criteria for inclusion of the respondents in the study: the research
included respondents of both gender, different age
groups and active working respondents of 15 different professions treated in the mentioned period and
with verified lumbar pain syndrome (clinical examination, radiological tests) and estimated condition
before treatment (clinical examination). Criteria for
exclusion of the respondents in the study were patients without estimated condition after treatment,
those who left treatment or did not abide by the
treatment protocols.
Research methods
The study was conducted as a retrospective, analytical, non-experimental before-and-after study. Data
were obtained from a special software program
which is used for collecting and analyzing the variables needed for research.
Condition of respondents before and after treatment was estimated by the following methodology:
0 - immobile
1 - difficult mobility with the assistance of someone else
2 - difficult mobility with the help of aids
3 - satisfactory functional status and capable of everyday activities
4 - good functional status
5 - normal functional status for every day life activities and work (10).
Method of treatment of lumbar pain syndrome in
the clinic "Praxis" consists of trunk stabilizing exercises which include:
- trunk stretching exercises
- exercises to strengthen ventral abdominal musculature
- exercises to strengthen lateral abdominal musculature
exercises to strengthen the back musculature
Research results were estimated by the following
methodology:
0 - condition remains unaffected
2 - minimal improvement
3 - satisfactory improvement with the consequences
of injury or illness
4 - good improvement with satisfactory functional
restitution
5 - good functional restitution without sequel
6 - left treatment
7 - further medical treatment, diagnostic or surgical,
is required (10).
217
In this research, we used the percentages of representation and the mean values of condition of respondents before and after treatment.
http://www.jhsci.ba
RESULTS
TABLE 1. Gender and age structure of respondents with acute lumbar pain syndrome
Age structure of respondents (years)
25 - 34
35 - 44
45 - 54
55 - 64
Over 65
Total
Gender structure
Male
Female
4
1
3
8
3
2
2
1
2
1
14
13
Total
Percentage of representation
5
11
5
3
3
27
18.51%
40.74%
18.51%
11.11%
11.11%
100%
TABLE 2. Gender and age structure of respondents with chronic lumbar pain syndrome
Age structure of respondents (years)
25 - 34
35 - 44
45 - 54
55 - 64
Over 65
Total
Gender structure
Male
Female
1
6
2
2
3
5
5
2
2
5
13
20
TABLE 3. Structure of the respondents according to occupation - Acute lumbar pain syndrome
Sequence
no. of
occupation
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Type of
occupation
Doctor
Veterinarian
Teacher
Engineer
Lawyer
Economist
Laborer
Farmer
Official
Craftsman
Housewife
Pupil
Student
Retired
Others
Total
No. of
respondents
Percentage of
representation
1
0
0
2
4
5
0
0
10
0
1
0
1
2
1
27
3.70%
0%
0%
7.40%
14.81%
18.51%
0%
0%
37.04%
0%
3.70%
0%
3.70%
7.40%
3.70%
100%
Total
7
4
8
7
7
33
21.21%
12.12%
24.24%
21.21%
21.21%
100%
TABLE 4. Structure of the respondents according to occupation - Chronic lumbar pain syndrome
Sequence
no. of occupation
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
218
Type of occupation
Doctor
Veterinarian
Teacher
Engineer
Lawyer
Economist
Laborer
Farmer
Official
Craftsman
Housewife
Pupil
Student
Retired
Others
Total
No. of respon- Percentage of

dents
representation
1
0
1
5
2
3
1
0
13
0
1
0
0
6
0
33
3.03%
0%
3.03%
15.15%
6.06%
9.09%
3.03%
0%
39.39%
0%
3.03%
0%
0%
18.18%
0%
100%
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TABLE 5. Condition of respondents before treatment - Acute lumbar pain syndrome

Score
No. of respondents
Score
0
0
0%
Score
1
1
3.70%
Score
2
4
14.81%
Score
3
17
62.96%
Score
4
5
18.51%
Score
5
0
0%
TOTAL:
27
100 %
= 2.96
TABLE 6. Condition of respondents after treatment - Acute lumbar pain syndrome

Score
No. of respondents
Score
0
0
0%
Score
1
0
0%
Score
2
0
0%
Score
3
0
0%
Score
4
8
29.63%
Score
5
19
70.37%
TOTAL:
27
100 %
= 4.71
TABLE 7. Condition of respondents before treatment - Chronic lumbar pain syndrome

Score
No. of respondents
Score
0
0
0%
Score
1
0
0%
Score
2
0
0%
Score
3
9
27.27%
Score
4
23
69.70%
Score
5
1
3.03%
TOTAL:
33
100 %
= 3.76
TABLE 8. . Condition of respondents after treatment - Chronic lumbar pain syndrome

Score
No. of respondents
Score
0
0
0%
Score
1
0
0%
Score
2
0
0%
Score
3
0
0%
Score
4
12
36.36%
Score
5
21
63.64%
TOTAL:
33
100 %
= 4.63
TABLE 9. Treatment results - Chronic lumbar pain syndrome

Treatment results
0
2
3
4
5
6
7
Total
Mean score
Number of respondents
Acute lumbar pain syndrome
0
0
0
8
19
0
0
27
= 4.71
Number of respondents
Chronic lumbar pain syndrome
0
0
6
6
21
0
0
33
= 4.27
%
0%
0%
0%
29.63%
70.37%
0%
0%
100%
DISCUSSION
By data analysis in the clinic "Praxis" 27 respondents suffering from acute lumbar pain syndrome
and 33 respondents suffering from chronic lumbar
pain syndrome were treated during the period from
01.01.2010 to 31.12.2012 year.
%
0%
0%
18.18%
18.18%
63.64%
0%
0%
100%
The age structure of respondents suffering from

acute lumbar pain syndrome consisted of 4 male respondents and 1 female respondent age group from
25 to 34 years, 3 male respondents and 8 female
respondents age group from 35 to 44 years, 3 male
respondents and 2 female respondents age group
219
http://www.jhsci.ba
from 45 to 54 years and per 2 male respondents and

1 female respondent each age groups from 55 to 64
and over 65 years of age.
For chronic lumbar pain syndrome 1 male respondent and 6 female respondents belonged to the age
group from 25 to 34 years, 2 male respondents and
2 female respondents to the group from 35 to 44
years, 3 male respondents and 5 female respondents
to the group from 45 to 54 years, 5 male respondents and 2 female respondents to the group from
55 to 64 years and 2 male respondents and 5 female
respondents to the age group over 65 years of age.
The largest number of respondents suffering from
acute lumbar pain syndrome were officials by profession 10 (37.04%), the second largest number were
economists 5 (18:51%) and lawyers 4 (14.81%). A
smaller number of respondents were engineers and
retired people 2 (7:40%), while the least represented
occupations were doctor, housewife, student and
others 1 (3.70%) respondent per each. For chronic
lumbar pain syndrome 13 (39.39%) of the respondents were officials, followed by retired people 6
(18:18%), engineers 5 (15:15%), economists 3
(9.09%) and lawyers (6.06%), whereas the smallest number of respondents 1 (3.3%) per occupation
were doctor, teacher, laborer and housewife.
Moore C. and associates have been investigating the
occurrence of lumbar pain syndrome in healthcare
workers with sitting jobs during the period of one
year. Among the respondents who have been doing
exercises daily there was no occurrence of lumbar
pain syndrome, whereas 60% of respondents of the
control group experienced pain in the lumbar spine
(11).
The mean score of condition of respondents with
acute lumbar pain syndrome before therapy is 2.96,
whereas after treatment is 4.71. The mean score of
condition of respondents with chronic lumbar pain
syndrome before therapy is 3.76, whereas after treatment is 4.63. Mean score of treatment results of patients suffering from acute lumbar pain syndrome
is 4.71, while for chronic lumbar pain syndrome
is 4.27. The research conducted by Frana FR. and
associates showed that lumbar spine stabilizing exercises lasting for 6 weeks, twice a week for half an
hour, are effective in reducing pain and disabilities
caused by lumbar pain syndrome (12). G. Morone
and associates conducted the research about improving quality of life of patients with chronic lumbar
pain syndrome. They used a multidisciplinary program of exercises for the back. The results showed a
significant reduction in pain and disabilities caused
by chronic lumbar pain syndrome after three and
six months (13).
CONCLUSIONS
From acute lumbar pain syndrome most often suffered female respondents age group from 35 to 44
years old, while in the male respondents was equally
represented in all age groups. Chronic lumbar pain
syndrome was most often represented in male respondents life age from 55 to 64 years and in female
respondents age group from 25 to 34 years old. Respondents who are officials by occupation are most
commonly affected by acute and chronic lumbar
pain syndrome. Treatment with trunk stabilizing
exercises performed in the clinic "Praxis" leads to an
improved scores of condition of respondents after
treatment. Ratings of treatment results indicate that
the treatment with trunk stabilizing exercises in the
early stages of lumbar pain syndrome is more successful.
COMPETING INTERESTS
220
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1. Pecar D. Komparacija efekata primjene Praxis metode i klasinog pristupa u lijeenju lumbarnog bolnog sindroma. Doktorska disertacija, Medicinski fakultet Univerziteta u Sarajevu, poseban tisak, 2002.
2. Kapetanovi N H, Pecar D. Vodi u rehabilitaciju. Univerzitetska knjiga, I.P.
Svjetlost d.d. Sarajevo, 2005.
3. Laerum E, Dullerud R, Kirkesola G, Mengshoel M A, Nygaard P Q, Skouen
S J, Stig L-C, Werner E. The Norwegian Back Pain Network - The communication unit. Acute low back pain. Interdisciplinary clinical guidelines, Oslo,
2002.
4. Braddom L. Randall. Handbook of Physical Medicine and Rehabilitation.
Department of Physical Medicine and Rehabilitation, Indiana University
School of Medicine, Indianapolis, Indiana, 2004.
5. Keli S. Lumbarni sindrom. Autorski rad, PANS - Poslovni adresar, Novi
Sad, 2009.
6. Low Back Pain Exercises. University of Michigan Health System, UMHS
Clinical Care Guidelines Committee, Michigan, 2007.
7. Davarian S, Maroufi N, Ebrahimi I, Farahmand F, Parnianpour M. Trunk
muscles strength and endurance in chronic low back pain patients with and
without clinical instability. Faculty of Rehabilitation, Teheran University of
Medical Sciences, Teheran, Iran, J Back Musculoskelet Rehabil. 2012 Jan
1; 25 (2): 123 - 9.
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8. Bronfort G, Maiers M J, Evans R L, Schulz C A, Bracha Y, Svendsen K

H, Grimm R H Jr, Owens E F Jr, Garvey T A, Transfeldt E E. Supervised
exercise, spinal manipulation, and home exercise for chronic low back
pain: a randomized clinical trial. Wolfe Harris Center for Clinical Studies,
Northwestern Health Sciences University, Bloomington, MN 55431, USA,
Spine J. 2011 Jul; 11 (7): 585 - 98. Epub 2011 May 31.
tion of Low Back Pain in Sedentary Healthy Workers: A Pilot Study. From
the University of Louisville School of Medicine (CM, FS, EC, CS, MM);
Department of Sport Medicine (JH), Frazier Rehab Institute; and James
Graham Brown Cancer Center (CM, EC, CS, MM), University of Louisville,
Louisville, Kentucky, Am J Med Sci. 2011 Dec 14.
9. Del Pozo - Cruz B, Gusi N, Del Pozo - Cruz J, Adsuar J C, Hernandez Mocholi M, Parraca J A. Clinical effects of a nine - month web - based
intervention in subacute non - specific low back pain patients: a randomized controlled trial. Faculty of Sport Science, University of Extremadura,
Caceres, Spain, Clin Rehabil. 2012 May 31.
10. Pecar D. Ocjena modela baze podataka za fizikalnu rehabilitaciju u zajednici. Magistarski rad, Medicinski fakultet Univerziteta u Sarajevu, poseban
tisak, 2000.
11. Moore C, Holland J, Shaib F, Ceridan E, Schonrad C, Marasa M. Preven-
221
12. Frana F R, Burke T N, Caffaro R R, Ramos L A, Marques A P. Effects of

muscular stretching and segmental stabilization on functional disability and
pain in patients with chronic low back pain: a randomized, controlled trial. J
Manipulative Physiol Ther. 2012 May; 35 (4): 279 85.
13. Morone G, Paolucci T, Alcuri M R, Vulpiani M C, Matano A, Bureca I,
Paolucci S, Saraceni V M. Quality of life improved by multidisciplinary
back school program in patients with chronic non - specific low back pain:
asingle blind randomized controlled trial. Movement and Brain Laboratory,
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(4): 533 - 41. Epub 2011 Apr 20.
Mirela Babaji et al. Journal of Health Sciences 2013;3(3):222-226
http://www.jhsci.ba

RESEARCH ARTICLE
Open Access
Frequency of joined disabilities of children with

cerebral palsy in Tuzla canton
Mirela Babaji1*, Emira vraka2, Dijana Avdi2
1
Centre for physical medicine, rehabilitation and spa treatment Ilida Gradaac, Hazna b.b. 76250 Gradaac. 2University
of Sarajevo, Faculty of Health Studies, Bolnika 25, 71000 Sarajevo.
ABSTRACT
Introduction: Cerebral palsy (CP) connotes a group of non-progressive, but often variable symptoms
of motor impairment of movement and posture, as well as other impairments which are a consequence
of anomalies or brain impairment in different phases of its development. CP is a pathological condition
characterised in the first place by motor function impairment to which other disorders such as: visual and
hearing impairment, intellectual deficit, emotional problems, behaviour disorder, speech disorder, epileptic seizure and similar can join. The aim of this study is to determine frequency of joined disabilities of
children with cerebral palsy in Tuzla Canton.
Methods: The research covers a total sample of 48 examinees, chronological age from 2-19 years, in
Tuzla Canton. Research instrument was a Structural Questionnaire for the parents of children and adolescents with cerebral palsy. Research data were processed by nonparametric statistics method. Basic
statistical parameters of frequency and percentages were calculated, and tabular presentation was made.
Results: After classification of examinees as per frequency of joined disabilities was done, work results
have shown that speech impairment occurred with 35.4 % of children, visual impairment 33.3 %, epilepsy 29.3 %, whereas hearing impairment occurred with 2 % of children.
Conclusion: In research of frequency of joined disabilities of children with cerebral palsy in Tuzla Canton,
most expressed are speech and visual disorders with children, then epilepsy, whereas a small percentage
of children are with hearing disorder.
Keywords: joined disabilities, children with cerebral palsy
INTRODUCTION
Cerebral palsy is a pathological condition characterised in the first place by impairment of motor
*Corresponding author: Mirela Babaji

Centre for physical medicine, rehabilitation and
spa treatment Ilida Gradaac; Hazna b.b.
76250 Gradaac, Bosnia and Herzegovina
e-mail: babajicmirela@gmail.com
Submitted 8 September 2013 / Accepted 15 November 2013
function to which other disorders such as: visual

and hearing impairment, intellectual deficit, emotional problems, behaviour disorder, speech disorder,
epileptic seizures and similar can join. Martin Bax
defines this entity as disorder of moves and postural
balance due to defects or impairment of immature
brain (1). Majority of previous research in the world
was focused on the prevalence, determination of the
motor abilities, and perinatal etiological factors of
the cerebral palsy. Evidences indicated that 70-80 %
2013 Mirela Babaji et al.; licensee University of Sarajevo - Faculty of Health Studies. This
is an Open Access article distributed under the terms of the Creative Commons Attribution
http://www.jhsci.ba
METHODS
of cerebral palsy is caused by the prenatal factors and
that the birth asphyxia has a relatively minor role The study included 48 children with cerebral palsy,
with the less than 10 % (2). Cerebral palsy occurs
age from 2-19 years, with the place of residence in
with frequency from 2-3 on 1000 live births (3).
Tuzla Canton, which have been treated in Centre for
As per Institute for public health of Tuzla Canton, physical medicine, rehabilitation and spa treatment
on the area of this Canton, 52 children with ce- Ilida Gradaac, in Bosnia and Herzegovina. The
patients formed two groups: children with cerebral
rebral palsy of the age from 1 to 14 are registered
palsy whose mothers have had health problem/sick(4). Multiple disabilities of persons with physical
impairment represent a special problem in daily ness during pregnancy, and children with cerebral
practice. Research done as per methodology of In- palsy whose mothers have not had health problem/
ternational Classification of Impairment, Disabili- sickness during pregnancy. Structural Questionties and Handicap (ICDH; WHO, Geneva, 1980) naire for the parents of children and adolescents
has shown that, as much as 95.8 % of children with with cerebral palsy was used (9).
cerebral palsy in specialized primary schools have
Structural Questionnaire consisted of 69 multiple
multiply disabilities (4).
choice or fill in questions. Questions can be divided
Disability can occur together or separately from oth- into eight groups:
er mental or physical disorders. 290 million people - First group of questions (1-8) are general quesworldwide are estimated to have disabilities (5). It
tions and questions on possible hereditary
is considered that 50 to 90% of children with cerehealth issues.
bral palsy have some ophthalmological abnormali- - Second group of questions (9-18) are on pregties, such as strabismus, amblyopia and other. Other
nancy control and sicknesses during pregnancy.
joined disabilities are: speech defect, cognitive defect,
Th
ird group of questions (19-23) are on the
emotional defect as well as epileptic seizures (6). Apnumber
of children and stillborn children.
proximately 25-35 % of children with cerebral palsy
have epilepsy. Much smaller percentage of children - Fourth group of questions (24-35) are on confinement.
with epilepsy has cerebral palsy (7).
In Tuzla Canton, children with multiple disabilities - Fifth group of questions (36-42) are on motor
development, type of cerebral palsy and physiare included in daily Centre Steps of hope. The
cal and surgical therapy.
Centre focuses on social model of work with children, which connotes inclusion into community, - Sixth group of questions (43-56) are on intelintroducing the parents of the children with their
lectual and sensor disabilities.
remaining abilities, introducing the community to - Seventh group of questions (57-67) are on educhildren with disabilities, education and rehabilitacation and abilities of teaching a child about
tion of children which includes education of parents
defined grades of different subjects per teaching
for conducting physical therapy at home, and inplan for special education and
clusion of children with disabilities in development
- Last two questions are on membership of parinto regular system of education where possible (8).
ents in Association of parents which relate to
The goals of education and rehabilitation in B&H,
childrens cerebral palsy.
similar to most other countries of the world, are to
work towards community inclusion, acceptance of Methods used in the research include testing of statistical differences by Hi-quadrant test and specific
diversity, optimal physical and mental health, and
methods
for cohort groups relation of sickness risk.
personal and social well-being. The focus of family
quality of life is a step towards understanding how
RESULTS
we can move closer to achieving these goals (9).
The aim of this study is to determine frequency of In the group of sickness during pregnancy, 20 (60.6
joined disabilities of children with cerebral palsy in %) are of male examinees and 13 (39.4 %) are of
female examinees, which all together represent a toTuzla Canton.
223
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TABLE 1. Sickness during pregnancy and gender

Male
Sickness
N
Sickness during
pregnancy
No sickness during
pregnancy
Total
Gender
Female
%
N
%
TABLE 2. Sickness during pregnancy and visual impairment

Visual
Total
N
20
60.6
13
39.4
33
100
10
66.7
33.3
15
100
30
62.5
18
37.5
48
100
No
Sickness
Sickness during
pregnancy
No sickness during
pregnancy
Total
Total
Yes
10
30.3
23
69.7
33
100
33.3
10
66.7
15
100
15
31.2
33
68.8
48
100
tal of 33 examinees in the group with influence of

prenatal ethological factors. In relation to the group
without sickness during pregnancy, it is 10 (66.7 %)
of male and 5 (33.3 %) of female.
Achieved results show that there are no statistically
important differences (h2=0.16; p0.05).
With mothers with sickness during pregnancy, 23
(69.7 %) of children are with visual impairment,
while with mothers with no sickness during pregnancy it is 10 (66.7 %) children. In relation to the
group of mothers with no sickness during pregnancy it can be seen that 5 (33.3 %) of children are
without visual impairment, while that percentage
with mothers with sickness during pregnancy is 10
(30.3 %) children. As per calculated h2 test, achieved
results point out to the fact that there are no statistically important differences between the groups
(h2=2.08; p0.05). The relation of risk is 1.01, both
group of examinees have nearly the same possibility
for their children to have visual impairment.
In the group of mothers with sickness and without sickness during pregnancy, a percentage which
shows that children have no hearing impairment is
more expressed, and which is in proportion 97 %
: 93.3 %. There is one examinee in each group of
mothers with sickness and without sickness during

pregnancies that have hearing impairment.
Results achieved by h2 test show that there is no
statistically important difference (h2=0.34; p0.05),
the relation of risks show that mothers with sickness
during pregnancy have 2.28 times higher chance
that they will not have a child with hearing impairment.
With mothers with sickness during pregnancy, 22
(66.7 %) of children are with speech disorder,
whereas 11 (33.3 %) of children are without disorder. In relation to the group of mothers without
sickness, percentage of children with speech disorder 13 (86.7 %) is more expressed, whereas 2 (13.3
%) of children are without disorder.
There are no statistically important differences in relation to sickness of mothers during pregnancy and
speech disorder with children (h2=0.04; p0.05).
Children from the group of mothers with sickness
during pregnancy have 3.25 times higher possibility
that they will not have children with speech disorder.
19 (57.6 %) of examinees have epilepsy where mothers have sickness during pregnancy, whereas 14 (42.4
%) of examinees do not have it. The percentage of
children who have epilepsy and whose mothers have
TABLE 3. Sickness during pregnancy and hearing impairment
TABLE 4. The relation of sickness during pregnancy and

speech disorder
Hearing
No
Sickness
N
Sickness during
pregnancy
No sickness during
pregnancy
Total
Speech
Total
Yes
%
32
97
33
100
14
93.3
6.7
15
100
46
95.8
4.2
48
100
No
Sickness
Sickness during
pregnancy
No sickness during
pregnancy
Total
224
Total
Yes
11
33.3
22
66.7
33
100
13.3
13
86.7
15
100
13
27.1
35
72.9
48
100
http://www.jhsci.ba
not had sickness during pregnancy is more expressed

10 (66.7 %), in relation to mothers with sickness
during pregnancy.
There are no statistically important differences
(h2=0.35; p0.05).
On basis of risk evaluation, children from the group
of mothers with sickness during pregnancy have
1.27 times higher possibility that their child will
have epilepsy.
DISCUSSION
Out of 33 examinees, 23 (69.7 %) of children

whose mothers have had sickness during pregnancy
are with visual impairment, while there are 10 (66.7
%) such examinees whose mothers have not had
sickness during pregnancy.
Depending of the study, the prevalence of visuomotor and perceptual problems among children with
spastic CP varies from 39 % to 100 % (2).
In study of vraka E. (2004), out of 80 examinees,
there were 40 (50 %) examinees with visual impairment. Out of 30 mothers with sickness during
pregnancy, 18 (60 %) of children have visual impairment. Out of 50 mothers without sickness during pregnancy, 22 (44 %) of examinees have visual
impairment (10).
In the group of mothers with sickness and without
sickness during pregnancy, the percentage which
shows that children have no hearing impairment is
more expressed, and which is in balance 97 %: 3 %.
Only one examinee in the group of mothers with
sickness and without sickness has hearing impairment.
In the Study of neuroimpairments, activity limitations, and participation restrictions in children with
cerebral palsy in Sweden, of 176 children with CP,
severe hearing impairment have 2 children (2).
Only 3 children (3.75 %) have hearing impairment
in relation to the whole sample of 80 children (10).
With mothers who have had sickness during pregnancy, 33.22 (66.7 %) of children have had speech
disorder, whereas 11 (33.3 %) were without disorder.
In relation to the group of mothers without sickness,
the percentage of children with speech disorder is
more expressed 13 (86.7 %), whereas 2 (13.3 %) of
children were without disorder.
56 (70 %) of examinees have speech disorder. Out

of 30 examinees with sickness during pregnancy, 22
(73.3 %) have speech disorder. Out of 50 examinees
without sickness during pregnancy, 34 (68 %) of examinees have speech disorder (10).
Nineteen (57.6 %) of examinees have epilepsy
where mothers have had sickness during pregnancy,
while 14 (42.4 %) do not have it.
Epilepsy is a common disorder among children with
CP. Of all children (n= 127) included in the Dutch
population based study, 18.9 % had active epilepsy
at the time of examination, and a further 21.3 %
had a history of epilepsy. Of the children with quadriplegic CP 44.8 % never had epilepsy, compared
with 66.7 % of the children with spastic diplegia,
triplegia and hemiplegia, and 37.5 % of the children
with ataxia and dyskinesia (2).
Out of 80 examinees, 33 (41.25 %) of examinees
have epilepsy. Out of 30 examinees whose mothers
have had sickness during pregnancy, 16 (53.3 %)
of examinees have epilepsy. Out of 50 examinees
whose mothers were without sickness during pregnancy, 17 (34 %) of examines have epilepsy (10).
After classification of examinees as per frequency
of joined disabilities was done, work results have
shown that speech impairment occurred with 35.4
% of children, visual impairment 33.3 %, epilepsy
29.3 %, whereas hearing impairment occurred with
2 % of children.
CONCLUSION
In research of frequency of joined disabilities of children with cerebral palsy in Tuzla Canton, most expressed are speech and visual disorders with children,
then epilepsy, whereas a small percentage of children
are with hearing disorder.
COMPETING INTERESTS
Authors declare no conflict of interest.
225
REFERENCES
1. vraka E. Dvije strane sree: Kvalitet ivota obitelji kolske djece s intelektualnim onesposobljenima. ISBN 978-9958-12-156-2 COBISS BH-ID
18386438 Tuzla: Bosanska rije. Oktobar 2010. godine
2. vraka E. Children with cerebral palsy and epilepsy. In: Dejan Stevanovic,
editor. Epilepsy - Histological, Electroencephalographic and Psychological
Aspects. Rijeka: INTECH, 2012; p. 251-276
http://www.jhsci.ba
3. Surveillance of Cerebral Palsy in Europe. Developmental Medicine & Child

Neurology 2000, 42:816-24.
7. vraka E, Loga S. Djeija cerebralna paraliza i epilepsija. Medicinski arhiv,

59(3): 188-190. Sarajevo, 2005.
4. Babaji M. Uticaj prenatalnih etiolokih faktora na razvoj djeije cerebralne

paralize. Magistarski rad, Fakultet zdravstvenih studija, Univerziteta u Sarajevu. Sarajevo, 2012.
8. Bratovi V, Mujanovi A. Primjene novih metoda rada u Centru Koraci nade-Tuzla, 6. meunarodni simpozij umjetnost i znanost u razvoju
ivotnog potencijala. Pula, 2011.
5. Emira vraka, Slobodan Loga, Dijana Avdi, Jasmina Berbi-Fazlagi.

Health promotion in families who have children with intellectual and developmental disabilities. Journal of Health Sciences. 2011; 1 (1): 56 - 60
9. Svraka E, Loga S, Brown I. Family quality of life: adult school children with
intellectual disabilities in Bosnia and Herzegovina. Journal of Intellectual
Disability Research 2011; 55: 11151122.
6. Konjikui V, Kocev N. Zdravstvena njega u rehabilitaciji. Beograd, 2005.
10. vraka E. Druga strana ivota. Potekoe u uenju djece s cerebralnom

paralizom. 2. obnovljeno i dopunjeno izdanje. TDP d.o.o. Sarajevo, 2007.
226
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Jasmina Gradaevi Gubaljevi, Adlija auevi Journal of Health Sciences 2013;3(3):227-231

RESEARCH ARTICLE
Open Access
Monitoring changes in serum 8-isoprostane

concentration as a possible marker of oxidative
stress in pregnancy
Jasmina Gradaevi Gubaljevi1*, Adlija auevi2
1
PHI Adonis, Lukavac, Bosnia and Herzegovina. 2Department of Biochemistry and clinical analyses, University of Sarajevo
Faculty of Pharmacy, Sarajevo, Bosnia and Herzegovina.
ABSTRACT
Introduction: Oxidative stress represents a pathophysiological mechanism lying behind occurrence of
different acute and chronic diseases. Pregnancy, mainly due to placenta rich with mitochondria, is also
being associated with the state of oxidative stress. Numerous markers have been proposed in order to test
oxidative stress in pregnancy state, one of them being 8-isoprostane.
The aim of this study was to analyse serum concentrations of 8-isoprostane as a possible oxidative stress
marker in pregnancy.
Methods: Serum concentrations of 8-isoprostane were measured in overall population of 84 woman,
between 20 and 30 years of age. Tested population was divided in 2 groups: 42 pregnant woman were
classified as being either in the first or second trimester of pregnancy. In the control group healthy nonpregnant women were included. Concentration of 8-isoprostane in serum was determined by commercial
8-isoprostane EIA test kit of Cayman Chemical Company, USA.
Results: The 8-isoprostane levels were significantly increased in pregnant women in relation to healthy
non pregnant women (p<0.05). The 8-isoprostane levels were significantly increased in second and third
trimester of pregnancy (p<0.05).
Conclusions: According to the obtained results, 8-isoprostane might be used as a possible marker of
oxidative stress in pregnancy state, but not as a biomarker for the risk of complications development in
pregnancy in analysed population.
Keywords: oxidative stress, pregnancy, 8-isoprostane
INTRODUCTION
Oxidative stress generally describes a state where

a cell antioxidative defence is inadequate to com*Corresponding author: Jasmina Gradaevi Gubaljevi
PHI Adonis, Lukavac, Bosnia and Herzegovina
Phone:+38761 011 012; Fax:+38735 369 869
E-mail: jas_grad@yahoo.com
Submitted 5 August 2013 / Accepted 10 September 2013
pletely inactivate reactive oxygen compounds which

are being generated due to increased production,
decreased antioxidative defence, or both. The main
consequence of oxidative stress is the damage of
DNA, lipids and proteins, which then compromise
the health of a cell or induce production of different reactive compounds leading to the death of the
cells by necrosis or apoptosis. Oxidative stress can be
2013 Jasmina G. Gubaljevi, Adlija auevi; licensee University of Sarajevo - Faculty of Health
monitored by the analysis of special oxidative stress

biomarkers isolated from biological fluids and tissues (1).
Lipid peroxidation represents an oxidative damage
seizing cell membranes, lipoproteins and other molecules containing lipids in conditions of oxidative
stress existence. Peroxidation of membrane lipids
caused by oxidative stress leads to changes in membrane biological characteristics, such as fluid degree
change, leading to inactivation of membrane receptors and enzymes. Lipid peroxidation can lead to
increased cell damage through piling of oxidative
products, out of which some are chemically reactive
and modify macromolecules by creating covalent
bounds. Lipid peroxidation products are therefore
used as oxidative stress biomarkers. Different and
relatively weaker final products are created by lipid
peroxidation, mostly ,- unsaturated reactive aldehydes, such as malondialdehyde (MDA), 4-hidroxynonenal (HNE), 2-propenal (acrolein) and isoprostanes, which can be determined in plasma and urine
and serve as indirect oxidative stress indicators (2).
Isoprostanes represent stabile products of lipid peroxidation, being present in all normal biological fluids and tissues in detectable quantities (3). They are
created by initial peroxidation of arachidonic acid
esterified by tissue lipids (4). Their in vivo synthesis,
as it has been found in animal models, increases due
to oxidative damage. 8-isoprostane, is one of their
representatives and can serve for accurate estimate of
overall F2-isoprostane endogenous production (2).
Oxidative stress is part of pregnancy physiology and,
according to literature data, important factor for
embryogenesis (5,6).
Numerous data suggest that lipid peroxidation
products and antioxidative protection components
change significantly in pregnancy (7). Increased
intensity of lipid peroxidation in pregnant woman
placenta (8,9) has been reported. However, antioxidative response in healthy pregnant women is
present at the level that ensures the protection from
increased risk and it is a part of pregnancy physiology (2).
According to the research results and data from literature in the last years, the level of oxidative stress
is increased in pregnant women carrying a risk for
the development of pregnancy complications or for
228
http://www.jhsci.ba
those that already have some of the complications:

hypertensia, diabetes, preeclampsia, fetal growth
lagging (10-20).
Elevated levels of 8-isoprostane, as a marker of oxidative stress have been reported during normal pregnancy (21). On the other hand, isoprostanes, including 8-isoprostane have also been associated with
an increased risk of an preeclampsia and a decreased
proportion of female births (22,23).
Having in mind contradictory research results related to the importance of isoprostane monitoring as
one of the biomarkers of oxidative stress in pregnant
women, in this work, the imperative was to investigate the level of oxidative stress in the population
of pregnant women in the first and in the second
trimester of pregnancy, when the beginning of potential complications of oxidative stress occur. The
validity of serum 8-isoprostane concentration as
a biomarker for pregnancy complications risk assumptions was investigated, too.
METHODS
In this case-control study, serum 8-isoprostane

concentrations were analysed in both pregnant and
nonpregnant women. All 84 blood samples from
Gradaac and near region, Bosnia and Herzegovina, were collected in the biochemical laboratory of
Gradaac hospital during two months, and 8-isoprostane serum levels were investigated. Average age
of tested population was between 20 and 30 years.
Main experimental group was divided into two subgroups: 42 women in the first and 42 women in the
second trimester of pregnancy. Pregnant women in
the test group were controlled by specialists from
Gynecological department of Gradaac hospital,
Bosnia and Herzegovina. All of them were users
of prenatal vitamins and folic acid. The total of 42
healthy fertile non pregnant women were used as
control group.
From all patients recruited, informed consent was
obtained. Exlusion criteria for both test and the control group were chronic diseases, inflammatory processes and infections. This study has been approved
by the Hospital Ethic committee.
8-isoprostane concentration was detected with EIA
kit, Cayman Chemical Company. This assay is
based on competition between 8-isoprostane and
http://www.jhsci.ba
conjugate 8-isoprostane-acetylcholinesterase (8-isoprostane indicator) for a limited number of 8-isoprostane specific rabbit antiserum binding sites. Because the concentration of 8-isoprostane indicator is
constant, while the concentration of 8-isoprostane
varies, the amount of 8-isoprostane indicator that is
able to bind to antiserum is inversely proportional
to the concentration of 8-isoprostane in the sample.
The results were evaluated by T-test. For performed

test, p<0.05 was considered as statistically significant. For statistical analyses we used SPSS 15.0 software (SPSS Inc., USA).
RESULTS
FIGURE 2. - 8 - isoprostane average values for the first trimester pregnant women and the control
*p significancy (if p<0.05 then there is significant correlation
between investigated parameters)
Concentration of 8-isoprostane in serum was found

to be significantly higher in pregnant woman when
compared to control group (p<0.0001) (Figure 1).
There was statistically significant difference between
serum 8-isoprostane average values in the first trimester pregnant women and in the control group
(p<0.0001) (Figure 2).
Statistically significant differences of serum 8-isoprostane concentration were also found in second
trimester pregnant women and in the control group

(p<0.0001) (Figure 3).
When concentrations of 8-isoprostane levels were
compared between the first and the second trimes-
FIGURE 1. - 8 - isoprostane average values for pregnant

women and control group
FIGURE 3. - 8 - isoprostane average values for the second

trimester pregnant women and the control
229
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ing development of pregnancy (4). This seems to

be in accordance with results obtained in our study
where higher level of 8- isoprostane was detected in
both, first and second trimester pregnant woman
when compared to controls, proving out the fact
that pregnancy by itself is a state of oxidative stress
(7,8). As described earlier, results of recent studies
also showed that detecting high levels of oxidative
stress early in pregnancy, during first two trimesters,
is associated with later complications (22,23). In
this study we found high level of oxidative stress in
early stage of pregnancy, during first two trimesters
while we have no results in the third trimester and
pregnancy complications. This is one of study drawbacks together with possible analytical problems
based on cross reactions of 8-isoprostane with other
F2-isoprostane metabolites, which can be formed in
vivo in the examined sample.
FIGURE 4. - 8 - isoprostane average values for the first trimester and the second trimester pregnant women
CONCLUSIONS
In this work, statistical difference between concentration of serum 8-isoprostane was found between
the test group and the control group, between pregnant women in the first and in the second trimester
of pregnancy and the control group, as well as between pregnant women in the two different trimesters of pregnancy. Patients in later stage of pregnancy
have higher serum concentrations of 8-isoprostane
than women in earlier stage.
Evidentially, pregnancy is by itself state of higher
level of oxidative stress. 8-isoprostane is useful biomarker of oxidative stress in pregnancy, but at least
in this work, in tested Bosnian population, it could
not be established that it is useful marker for risk for
pregnancy complications.
ter, statistically significant increase in 8-isoprostane

concentration was found in the second trimester
pregnant women compared to the first trimester
pregnant women (p<0.005) (Figure 4).
DISCUSSION
Level of oxidative stress is important factor in embryogenesis, as well as in pregnancy and normal
birth. Under conditions of oxygen deficiency in
tissues (10), stimulation of neovascularisation process and induced angiogenesis occurs in pregnancy,
which itself is the result of hypoxia. On the other
hand, overproduction of pro oxidants and increased
oxidative stress lead to increased lipid peroxidation
and accumulation of increased lipid peroxidation
biomarkers in placenta (4). This occurs due to decreased intracellular space and disordered metabolism. The consequence of increased oxidative stress
is apoptosis which results in embryo fragmentation
and fetal embryopathies (24).
Numerous studies suggest that 8-isoprostane as an
oxidative stress indicator is increased in pregnancy
and in pathological states of pregnancy (11-20),
while a few suggest no differences in its levels dur-
COMPETING INTERESTS
The authors declare no competing interests.

ACKNOWLEDGEMENTS
The authors greatly appreciate all the support and

technical help provided by the staff of Department of Gynecology and Biochemical laboratory in
Gradaac hospital, Bosnia and Herzegovina.
230
http://www.jhsci.ba
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18. Holemans K, Gerber R, O'Brien-Coker I, Mallet A, Van Bree R, Van Assche
FA et all. Raised saturated-fat intake worsens vascular function in virgin
and pregnant offspring of streptozotocin-induced diabetic rats. British Journal of Nutrition. 2000;84: 285-296.
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Dysplasia or Periventricular Leukomalacia. Pediatric Research. 2004;56:
88-93.
20. Hung TH, Liang-Ming L, Tsung-Hong C, Meng-Jen L, Yi-Lin Y, Szu-Fu C
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Women With Uncomplicated Pregnancies Throughout Gestation. Reproductive Sciences. 2010; 17(4):401-9.
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Biochemical markers for disease states and genes for identification of biochemical defects. Patentscope, WIPO US, 2008.
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Anisa Gradaevi et al. Journal of Health Sciences 2013;3(3):232-237
http://www.jhsci.ba

RESEARCH ARTICLE
Open Access
Is it possible to determine firearm calibre and

shooting range from the examination of gunshot
residue in close range gunshot wounds?
An experimental study.
Anisa Gradaevi1, Emina Resi2, Nermin Sarajli1, Bruno Franji3, Arif Salki4,
Amira Duzdanovi-Paali4
1
Institute of Forensic Medicine, University of Sarajevo School of Medicine, Bosnia and Herzegovina. 2Institute of Medical
Statistics and Informatics, University of Sarajevo Faculty of Economics, Bosnia and Herzegovina. 3Ballistic and Mechanical
Expertise Section, Forensic and IT Support Center, Directorate of Federation Police, Bosnia and Herzegovina. 4Laboratory of
Chemical analysis, Institute of metallurgy Kemal Kapetanovic, University of Zenica, Bosnia and Herzegovina.
ABSTRACT
Introduction: The aim of the study was determining the type of weapon and shooting distance depending on chemical analysis of inorganic gunshot residue from the skin gunshot wounds in experimental
animals (pigs).
Methods: Experimental study was conducted in order to determine components and their percentage in
gunshot residue (GSR). In 60 samples, pig skin was shot by firing projectiles from four different weapons
and from three different distances (contact wound and near contact wound from 5 cm and 10 cm). The
methodology included determining the presence of inorganic material: antimony, barium, lead, nickel,
zinc and copper in the skin and subcutaneous tissue using atomic absorption spectrophotometry (AAS).
Results: Formula for determining weapon type was provided cutt-off points for different weapons, with
78.6% of original grouped cases being correctly classified. Formula for determining weapon type was
provided cutt-off points for different distances, with 58.9% of original grouped cases being correctly classified, which was slightly less reliable compared to weapon type discrimination analysis.
Conclusion: The presented study showed that chemical analysis of GSR in entrance wound with AAS
could be useful in determining the type of weapon, as well as the shooting distance, i.e. in our study, determining whether the wound is contact or near contact. This could be particularly useful in postmortally
putrefied or charred bodies with gunshot wounds.
Keywords: near contact wound, experimental study, gunshot residue, AAS (atomic absorption spectrometry).
INTRODUCTION
*Corresponding author: Anisa Gradaevi, Institute of Forensic
Medicine, ekalua 90, 71000 Sarajevo, Bosnia and Herzegovina
Fax. +387 33 666 545;
E-mail: anisa.gradascevic@forensic-sarajevo.org
Submitted 28 August 2013/Accepted 1 October 2013
Gunshot residue (GSR) consists of particles composed of antimony, barium and lead that arise from
the condensation of primer vapors (1) and also soot
debris consisting of carbon and metallic fragments
2013 Anisa Gradaevi et al.; licensee University of Sarajevo - Faculty of Health Studies.
http://www.jhsci.ba
from the bullet and cartridge case (2). In the matter of reconstruction of gunshot fatalities, the macroscopic examination of gunshot wounds as well as
the investigation of GSR particles gains extensive
forensic significance (1,2). Physical and chemical investigations of firearm discharge residues are
nowadays performed routinely in order to solve a
number of forensic problems such as identification
of gunshot wounds together with establishing of the
entrance and exit (3), estimation of the time since
discharge of a firearm (4, 5), distribution of GSR at
the crime scene, estimation of shooting distance (6,
7), as well as establishing whether a person has fired
a gun (8). Sensitive analytical methods are required
for the identification of inorganic gunshot residues
that are usually presented in very small quantities on
a substratum, and commonly used methods include
atomic absorption spectroscopy (AAS), neutron
activating analysis (NAA) (1) , X-ray fluorescence
spectrometry (XRF), inductively coupled plasma
mass spectrometry (ICP-MS) (9).
The aim of the study was determining the type of
weapon and shooting distance depending on chemical analysis of inorganic gunshot residue from the
skin gunshot wounds in experimental animals (pigs).
METHODS
Experimental study was conducted in order to determine components and their percentage in gunshot
residue (GSR). In 60 samples, pig skin was shot by
firing projectiles from four different weapons and
from three different distances, five times from each
distances (contact wound, and near contact wound
5 cm and 10 cm). Characteristics of weapons and
projectiles are presented in (Table 1). The research is
performed in accordance with the ethical principles
in compliance with the law on the protection of animals in our country.
Part of the pig body size is approximately 120 x 45x
20 m composed of skin, subcutaneous and muscle
tissue, areas of the chest and abdomen, which is
attached to a solid surface. Shooting was conducted using a system for safe firing from the firearm
(Verifire-The Secure Firing Device, Twin Tooling,
Canada). The weapons used in the experiment were
most commonly used in the Balkan region in last
10 years according to Federal and local police. The
methodology included determining the presence of

inorganic material: antimony, barium, lead, nickel,
zinc and copper in the skin and subcutaneous tissue
using Atomic Absorption Spectrometry (AAS) Inductively Coupled Plasma Optical Emission Spectrometry (ICP-OES). Samples for chemical analysis
were clips of skin and subcutaneous tissue size about
3x3x3 cm, each sample was labeled and packed in a
plastic container filled with buffered 10% of formalaldehyde.
In order to perform an AAS and ICP-OES analysis
and determine content of these elements using an
appropriate method, it was necessary to put each
sample in the acid-water solution. To achieve this,
it was necessary to perform so-called mineralization, i.e. destruction of all organic material. Given
the amount of organic matter from several grams
(even tens of grams), "mineralization" samples corresponding mineral acids (nitric, sulphuric and
hydrochloric) would be completely impractical, because it would require the use of large amounts of
these acids. This would be a great possibility of contamination of the sample metals (which are, as a rule
contained in these acids, regardless of the degree of
purity) whose content is determined, and would be
increased and the detection limit. Because it is dedicated to the mineralization patterns make burning
in platinum dishes.
After the process of burning the sample is placed in
a bowl incandescent furnace where, at a temperature
of 900oC for 30 minutes, elemental carbon burn
completely.
Temperature at which the thermal process unfolded
mineralization samples were below 1000oC, which
is more than 400oC temperature below the sublimation of lead oxide, which has a lowest temperature of
vaporization or sublimation (1470oC). Here, based
on the realistic assumption that metals whose content determination completely oxidized, as are the
non-precious metals, and the samples are accumulated in the form of very fine particles (large specific
surface area), where the whole process of mineralization took place in contact with air.
After incineration of elementary carbon, content in
the container was moistened with about 1 ml of redistilled water, after which exactly 3 ml of nitric acid
(1.65%) very high purity (Aristar) were added and
233
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TABLE 1. Weapons used in the experiment

Weapons
Pistol Crvena zastava
'M70'
Pistol Crvena zastava
'M57'
Pistol eka Zbrojovka
Model CZ 85 B
Automatic rifle Zavod
Crvena zastava M70AB2
Caliber
Ammunition
Mark missiles
7.65 mm
7.65x17 mm
(.32AUTO)
PPU .32AUTO
7.62 mm
7.62x25 mm
2001
9 mm
LUGER
9x19 mm
PPU 9mm
LUGER
7.62 mm
7.62x39 mm
IK 91
Manufacturer
Number of
shoots
Notation of
GSR sample
15
15
15
15
' Prvi Partizan' Uice,

Serbia
'Prvi Partizan' Uice,
Serbia
'Prvi Partizan' Uice,
Serbia
Igman Konjic, Bosnia
and Herzegovina
TABLE 2. Distribution of percentage different elements in weapon with regard to shooting distance
A 10 cm
A 5 cm
A contact
Total average A
B 10 cm
B 5 cm
B contact
Total average B
C 10 cm
C 5 cm
C contact
Total average C
D 10 cm
D 5 cm
D contact
Total average D
%Pb
54.89
37.57
29.66
40.93
47.55
28.4
14.62
27.52
46.46
37.86
35.08
39.8
17.7
11.89
12.28
13.96
%Cu
13.55
14.64
21.31
16.63
25.51
39.08
52.45
41.09
27.39
21.78
34.21
27.79
42
67.09
60.33
56.47
%Zn
14.25
37.14
32.58
27.34
18.21
21.96
14.72
18.31
15.75
21.98
5.75
14.49
33.75
7.07
5.73
15.52
%Ni
1.89
1.78
1.84
1.84
1.01
0.56
0.33
0.57
0.31
0.63
0.83
0.59
0.18
0.1
0.28
0.18
%Sb
4.44
3.78
6.42
4.85
6.71
8.74
17.16
11.51
3.27
11.72
14.24
9.74
5.28
12.75
20.59
12.87
%Ba
10.99
5.08
9.47
8.76
1.02
1.26
0.73
1
6.83
6.03
9.9
7.59
1.1
1.11
0.79
1
Legend: A (caliber 7,65x17mm), B (caliber 7,62x25mm), C (caliber 9x19mm), D (caliber 7,62x39mm), Pb (lead), Cu (copper), Zn (zinc),
Ni (nickel), Sb (antimony), Ba (barium)
slightly heated in order to completely dissolve salts.

Preliminary measurements were used for calibration,
after which final measurements were performed
with types of AAS. Contents of lead, copper, zinc
and nickel in all solutions samples were determined
on flame AAS. Due to interference of antimony and
barium on flame AAS, probably caused by chemical
interactions due to its high content of sodium (occurring during atomization in flames), we also used
ICP-OES which was due to significantly higher
temperatures atomisation, resistant to chemical interference.
All data were analyzed using the following: descriptive statistics, Kruskal-Wallis one way test, discriminatory equations. P <0.05 was considered significant
and p <0.01 was considered highly significant.
234
RESULTS
Distribution of different percentage of different elements in different types of weapon with regard to
shooting distance is presented in Table 2.
Since the samples were rather small, due to significant cost of the study, in statistical analysis we used
http://www.jhsci.ba
TABLE 3. Kruskal-Wallis one way test to determine differences in elements distribution depending on type of weapon
within the same shooting distance
Shooting
distance
Chi10 Square
cm
P
Chi5 Square
cm
P
Chicon- Square
tact
P
%Pb
%Cu
%Zn
%Ni
%Sb
%Ba
10.825 9.889 5.604 11.487 5.014 13.477

0.013 0.020 0.133 0.009 0.171 0.004
10.094 15.632 11.938 12.442 8.970 13.983
0.018 0.001 0.008 0.006 0.030 0.003
11.549 12.680 15.549 8.775 8.305 14.311
0.009 0.005 0.001 0.032 0.040 0.003
Pb (lead), Cu (copper), Zn (zinc), Ni (nickel), Sb (antimony), Ba

(barium)
TABLE 4. Cutt-off points for different weapons

Weapon
A
C
B
D
Result for discriminant function

(cutt-off discriminant score)
(-1.984)
(-1.985) 0.125
0.126 1.984
1.985
Legend: A (pistol, caliber 7,65x17mm), B (pistol, caliber

7,62x25mm), C (pistol, caliber 9x19mm), D (automatic rifle, caliber 7,62x39mm)
nonparametric Kruskal-Wallis one way test in order

to analyze differences in elements distribution depending on the type of weapon (Table 3), regardless of the shooting distance. Since this analysis has
shown that differences in elements distribution depending on type of weapon within the same shooting distance were mainly statistically significant (for
88.89% of cases), we analyzed it further using statistical discrimination function. The analysis showed
statistical significance for all elements except barium
which didnt meet tolerance criteria (canonical correlation 0,911, Eigen value = 4,874, Wilks' Lambda
= 0,101, p<0,001), with 78,6% of original grouped
cases being correctly classified. The following formula for determining weapon type is provided
(cutt-off points for different weapons are presented
in Table 4):
weapon type = 3.691+0.313%Pb+0.344% Cu+
0.315%Zn-0.66%Ni+0.354%Sb
In order to determine differences in elements distribution depending on shooting distance within the
same type of weapon, we used the Kruskal-Wallis
one way test once more (Table 5). Since this analysis has shown that differences in elements distribution depending on the shooting distances within
the same type of weapon were mainly statistically
significant (for 54.17% of cases), we again analyzed
it further using statistical discrimination function.
The analysis showed statistical significance for the
all elements again except barium which didnt meet
tolerance criteria (canonical correlation 0,669, Eigen value = 0,811, Wilks' Lambda = 0,51, p<0,001),
with 58,9% of original grouped cases being correctly classified, which was slightly less reliable compared to weapon type discrimination analysis. The
following formula for determining weapon type is
provided (cutt-off points for different distances are
presented in Table 6):
shooting distance = 8.917+0.13%Pb+0.099%Cu+
0.111%Zn-0.145%Ni-0.053%Sb
We used atomic absorption spectrophotometry
(AAS) as a method of gunshot residue particles analysis from gunshot entrance wounds for determining
which type of weapon was used in contact or near
contact wound. Due to the fact that we have used
small number of samples it was necessary to perform
discrimination analysis in a way to show the formulas for determining weapon type and shooting distances. Mentioned analysis showed that formulas for
determining types of weapon were precise in nearly
80% of cases.
235
DISCUSSION
Gunshot residue particles form during the discharge

of a firearm. As the firing pin strikes the primer cap,
the primer mixture is ignited, creating an environment of rapid temperature and pressure increases
within the cartridge. This increase in temperature
melts the primer mixture and within a few milliseconds the vaporization points of lead (Pb), barium
(Ba), and antimony (Sb) are exceeded (Pb 1620/C,
Ba 1140/C, Sb 1380/C). The effects of supersaturation cause vaporized particles to condense back onto
the liquefied primer surface as droplets. There has
been evidence to suggest that inorganic GSR particles of materials originating solely from the primer
TABLE 5. Kruskal-Wallis one way test in order to analyze

differences in elements distribution depending on the shooting
distances within the same type of weapon
Weapon
ChiA Square
P
ChiB Square
P
ChiC Square
P
ChiD Square
P
%Pb
%Cu
7.586
%Zn
%Ni
%Sb
%Ba
3.103 7.491
0.463
1.876 8.691
0.023
0.212 0.024
0.793
0.391 0.013
6.251
8.316 1.829
1.325
8.264 1.280
0.044
0.016 0.401
0.516
0.016 0.527
1.220
2.060 9.780
4.371
9.420 4.348
0.543
0.357 0.008
0.112
0.009 0.114
3.892
8.240 9.980
9.512
9.740 8.325
0.143
0.016 0.007
0.009
0.008 0.016
Legend: A (pistol, caliber 7,65x17mm), B (pistol, caliber

7,62x25mm), C (pistol, caliber 9x19mm), D (automatic rifle, caliber 7,62x39mm), Pb (lead), Cu (copper), Zn (zinc), Ni (nickel), Sb
(antimony), Ba (barium)
TABLE 6. Cutt-off points for different shooting distances

Result for discriminant function (cutt-off discriminant
score)
Contact
(-0.484)
5 cm
(-0.485) 0.575
10 cm
0.576
Distance
(primer GSR) are formed even before the propellant

is ignited. As the primer mix ignites the propellant
powder, a second rapid increase in pressure and
temperature occurs and the bullet is expelled from
the firearm barrel. During this process, the particles
involved are subjected to extreme temperature and
pressure is followed by rapid cooling. Particles form
as liquid droplets, which subsequently solidify (11).
The areas from which GSR may be collected are wide
ranging. Skin, vehicles (seats and seat backs, doors,
windows, dashboards, headliners, interiors, and exteriors), the surroundings of an incident, doors, windows, body parts, clothing, and any surfaces in the
immediate vicinity of a firearm discharge may all be
sample targets (11). We analyzed these components
in gunshot entrance wound.
When the reconstruction of gunshot fatalities is in
question, the macroscopic examination of gunshot
http://www.jhsci.ba
wounds as well as the investigation of GSR particles

gains extensive forensic significance (1). Gunshot
analysis has been widely studied in the forensic literature for the estimation of the firing range and in
the last decades a lot of techniques have been used
for the detection and identification of GSR particles
in the gunshot wound (11). These experiments have
clarified that the amount is strictly correlated to the
shooting distance (2, 12, 13). There are many histochemistry (12-15) studies and electron microscopy
methods who are accurate and precise for estimating firing distance (16,17). However, most of these
studies, if not all of them, are not applicable in every
day forensic work, mostly due to their cost, as well
as a necessity for sophisticated and expensive equipment.
A lot of different methods in GSR analyzing have
been used (3,11), but only a few of them dealt with
analyzing gunshot wounds. In one of them, gunshot
wounds from previously amputated human parts,
both normal and charred, were used in analysis with
micro CT, and the conclusion was that this analysis could provide the differential diagnosis between
gunshot and sharp force wounds, entry and exit
holes (1, 2) artefacts and gunshot lesions. In another study by the same authors, micro CT analysis
was conducted on fresh and decomposed gunshot
wounds, suggesting it could be useful screening tool
for differentiating entrance from exit wounds (18).
Other authors analyzed GSR in gunshot wounds
using confocal laser scanning microscopy (13), or
radiochemical neutron activation analysis (19). Regardless of the good results of these studies in analyzing gunshot wounds, these types of methods and
devices (such as micro CT, confocal laser scanning
microscopy, neutron activation analysis etc.) are
often neither accessible, nor affordable in everyday
forensic practice.
In practical work different difficulties and controversies may arise in forensic evaluation of gunshot
wounds, which may include estimation of calibre,
shooting distance, and sometimes even estimation
of whether the wound is entrance or exit may be
difficult. Our presented method in GSR analysis
atomic absorber spectrophotometry (AAS) in the
close range entrance gunshot wounds could bridge
these difficulties. This method is easily available,
relatively cheap and practicable. In the case where
236
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we have small samples and differences in elements

distributions which were depending of type of
weapon within the same shooting distances, we can
use discriminant functions. It could provide help in
determining the type of weapon (of four different
weapons in our study) with relatively good precision
(nearly 80%, or in 4 out of 5 cases). This gives rise
to the possible weakness of our study, since we have
examined for the most commonly used weapons in
the Balkans' region. In other regions and parts of
the world, the other types of weapons are possibly
used, which could be the possible subject for some
future studies. Although all the examined cases were
in close range shots (contact, 5 cm, 10 cm). This
method could be helpful in determining whether
the gunshot wound is contact or near contact, even
though with slightly lesser precision (nearly 60%, or
in 3 out of 5 cases).
This analysis could be especially useful in cases
where for some reason it is not easy to determine
whether the gunshot wound is entrance or exit. One
of such situations could be in cases of postmortally
putrefied bodies. Putrefaction changes will eventually dissolve all of the bodys soft tissues and organs,
to an extent that even makes them unrecognizable
(19). However, inorganic materials such as examined metals (lead, copper, zinc, nickel, antimony
and barium) remain unchanged and therefore they
could be further analyzed, regardless of the putrefaction changes. This could be particularly useful in
cases where missile trajectory only involves only soft
tissue. Another possible application of this method
could be in charred bodies with gunshot injuries, or
even in some cases in fresh bodies when its not easy
to macroscopically differentiate entrance from exit
wound.
in the Balkans' region, and therefore its applicability

to other regions must be taken cautiously, also another limitation of the study, is small sample, but we
think this could be a subject for the future studies.
COMPETING INTERESTS

REFERENCES
1. Fais P, Giraudo C, Boscolo-Berto R, Amagliani A, Miotto D, Feltrin G, Viel
G, Ferrara SD, Cecchetto G. Micro-CT features of intermediate gunshot
wounds severely damaged by fire. Int J Legal Med 2013, 127;2:419-25.
2. Cecchetto G, Amagliani A, Viel G, Fais P, Cavarzeran F, Feltrin G, Ferrara
SD, Montisci M. Estimation of the firing distance through micro-CT analysis
of gunshot wounds. Int J Leg Med 2011, 125:245-251.
3. Brozek-Mucha Z, Jankowicz A. Evaluation of the possibility of differentiation between various types of ammunition by means of GSR examination
with SEMEDX method. For Sci Int 2001, 123;1: 3947.
4. Di Maio VJM, Gunshot Wounds: Practical Aspects of Firearms, Ballistics
and Forensic Techniques, 2nd Edition, CRC Press, Boca Raton, FL, 1999.
5. Andrasko J, Stahling S. Time since discharge of spent cartridges. J Forensic Sci 1999, 44;3:487495.
6. Nag NK, Sinha PA. A note on assessability of firing distance from gunshot
residues. Forensic Sci Int 1999, 56;117.
7. Glattstein B, Vinokurov A, Levin N, Zeichner A. Improved method for shooting distance estimation. Part 1. Bullet holes in clothing items. J Forensic Sci
2000, 45; 4: 801806.
8. Meng H, Caddy B. Gunshot residue analysis: a review. J Forensic Sci 1997,
42; 4:553570.
9. Saferstein R. Forensic Science Handbook, Prentice-Hall, Englewood Cliffs,
NJ, 1982.
10. Koons RD. Analysis of gunshot residue collections swabs by ICP-MS. J
Forensic Sci 1998, 43; 4:748754.
11. Dalby O, Butler D, Birkett JW. Analysis of gunshot residue and associated
materials-a rewiew. J Forensic Sci 2010, 55; 4: 924-43.
12. Brown H, Cauchi DM, Holden JL, Wrobel H, Cordner S, Thatcher P. Image
analysis of gunshot residue on entry wounds. II-A statistical estimation of
firing range. Forensic Sci Int 1999, 100; 3:179-86.
13. Neri M, Di, Turillazi E, Riezoo I, Fineschi V. The determination of firing
distance applying a microscopic quantitative method and confocal laser
scanning microscopi for detection of gunshot residue particles. Int J Legal
Med 2007; 121:287-92.
14. Tschirhat DL, Noguchi TT, Klatt EC: A simple histochemical technique for
the identification of gunshot residue. J Forensic Sci 1991; 36:543-7.
CONCLUSION
The presented study showed that chemical analysis

of GSR in entrance wound with atomic absorber
spectrophotometry could be useful in determining
the type of weapon, as well as the shooting distance,
i.e. in our study, suggesting whether the wound is
contact or near contact. This could be particularly
useful in postmortally putrefied or charred bodies
with gunshot wounds. The limitation of this survey
is that it is based on most commonly used weapons
237
15. Andreola S, Gentile G, Battistini A, Cattaneo C, Zoja R. Forensic applications of sodium rhodizonate and hydrochloric acid: a new histological techniques for detection of gunshot residues. J Forensic Sci 2011; 56:771-4.
16. Amadasi A, Brandone A, Rizzi A, Mazzarelli D, Cattaneo C. The survival
of metallic residues from gunshot wounds in cremated bone: a SEM-Edx
study. Int J Legal Med 2012, 126; 4:525-31.
17. Ueyama M, Taylor RL, Noguchi TT. SEMS/EDS analysis of muzzle deposits at different target distances. Scann Elect Microsc 1980; 1:367-74.
18. Gibelli D, Brandone A, Andreola S, Porta D, Giuidici E, Grandi MA, Cattaneo C. Macroscopic, microscopic and chemical assessment of gunshot
lesions on decomposed pig skin. J Forensic Sci 2010, 55; 4:1092-97.
19. Saukko P, Knight B. Knights forensic pathology. 3rd ed. London: Arnold,
2008.
Amela Saraevi, Fahir Bei Journal of Health Sciences 2013;3(3):238-242
http://www.jhsci.ba

RESEARCH ARTICLE
Open Access
The synergistic antinociceptive effect of lornoxicam

in combination with tramadol
Amela Saraevi1*, Fahir Bei2
1
Agency for Medicinal Products and Medical Devices of Bosnia and Herzegovina, Control Laboratory Sarajevo, Sarajevo,
Bosnia and Herzegovina. 2Department of Pharmacology, University of Sarajevo Faculty of Pharmacy, Sarajevo, Bosnia and
Herzegovina.
ABSTRACT
Introduction: One of the most important priorities in therapy is pain control. Therefore, many different
groups of drugs are being used for this purpose, primarily opioid analgesics and non-steroidal anti-inflammatory drugs (NSAIDs). Opioid analgesic tramadol, by binding to specific receptors, modulates the perception and response to painful stimuli and inhibits transmitting and further processing of pain impulses.
Lornoxicam, which belongs to the oxicam class of NSAIDs, is a non-selective cyclooxygenase inhibitor with
strong analgesic and anti-inflammatory effects, and better tolerance profile. Preliminary research, which
requires further verification, suggests that lornoxicam may be a better alternative or adjunctive therapy
to opioid analgesics in the treatment of moderate to severe pain. The aim of this study was to investigate
antinociceptive effects of lornoxicam, as well as the combination of lornoxicam with tramadol.
Methods: Analgesic effect of combination of lornoxicam and tramadol or lornoxicam applied alone was
examined on female albino mice, using a hot plate method. Measurements were made 30, 60, 90 and
120 minutes after intraperitoneal and subcutaneous administration, in dose of 10 mg/kg.
Results: Combination of lornoxicam and tramadol, applied intraperitoneally, increases the threshold of
sensitivity to painful stimuli, which was not the case with subcutaneous administration.
Conclusions: Lornoxicam significantly increases analgesic effect when applied intraperitoneally in combination with tramadol. On the other hand, lornoxicam in combination with tramadol, did not increase
the threshold of sensitivity to painful stimuli with significant difference, after subcutaneous administration.
Keywords: antinociceptive effect, tramadol, lornoxicam, combination of analgesics.
INTRODUCTION
Pain is defined by the International Association for the

Study of Pain as unpleasant sensory and emotional
experience associated with actual or potential tissue
*Corresponding author: Amela Saraevi,
Agency for Medicinal Products and Medical Devices
of Bosnia and Herzegovina, Control Laboratory Sarajevo,
Sarajevo, Bosnia and Herzegovina; Phone: +38761279888
E-mail addresses: a.saracevic@almbih.gov.ba
damage, and it is caused by nociceptive stimulus.

Although pain is a reaction of the body to harmful stimuli and is therefore a protective early warning system, the sensation of pain in postoperative
patients has little positive effect. Hence, the term
pain, derived from the Latin poena for punishment,
reflects the deleterious effects that can be inflicted
upon the body (1). The goal of postoperative pain
relief is to achieve optimal analgesia, facilitating a
quick return to normal physiological organ function
Submitted 30 August 2013 / Accepted 30 October 2013
2013 Amela Saraevi, Fahir Bei; licensee University of Sarajevo - Faculty of Health Studies. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use,
http://www.jhsci.ba
with minimal side effects (2). Many different groups

of drugs are being used in pain control, primarily
opioid analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs).
Tramadol, a centrally acting analgesic, consists of
two enantiomers, both of which contribute to analgesic activity via different mechanisms. Tramadol
is effective as analgesics and seems to have a better
profile of adverse effects than most opioids. Its analgesic efficacy can further be improved by combination with a non-opioid analgesic (3-5).
Lornoxicam is a new NSAID belonging to the
oxicam class. Compared to the other NSAIDs,
lornoxicam demonstrates strong analgesic and anti-inflammatory effects, along with an improved gastrointestinal toxicity profile. Its analgesic activity is
comparable to that of opioids. High therapeutic potency is indicated in low doses, with a reduced risk
of side effects (6-8). Preliminary research, which requires further confirmation, suggest that lornoxicam
may be a better alternative or adjunctive therapy to
opioid analgesics in the treatment of moderate to
severe pain (9, 10).
Studies have also shown that opioids may act in
synergy with some NSAIDs, and that such combinations may have therapeutic benefit in the clinical
treatment of inflammatory pain (11). This effect is
expected when combining analgesics that act at different areas along the route of painful stimulus, for
example by combining nonsteroidal anti-inflammatory drug (NSAID), which operates mainly in the
periphery, and opioid, which operates centrally. The
objective of development of analgesics combination
is to achieve efficacy, that is, to improve therapeutic
effect while using lower dosages and having less side
effects. (11, 12).
The use of combination of oral analgesics as opposed
to an individual therapy offers potential benefits for
the patients. Combining analgesics into a single
product may facilitate prescribing and compliance
by reducing the number of medicines that a patient
must take during the pain control therapy. Combining products with different mechanism of action
may provide multimodal approach in pain therapy,
and, in addition, enable the individual agents potentially to act synergistically. Furthermore, with regard
to safety, lower doses of each individual analgesic,
used in combination, may result in a lower incidence of individual adverse events (13).
The data obtained in one study indicated that the
combination of atypical opioid tramadol and atypical NSAID propacetamol had more potent antinociceptive effects that those of tramadol and propacetamol, in mouse and rat models with acute and
persistent pain. Study suggests that it is possible to
increase the antinociceptive effects and decrease the
undesirable side effects of tramadol, by coadministrating propacetamol (14).
The fundamental concept that underlies the appropriate and successful management of pain by the use
of opioid and nonopioid analgesics is individualization of analgesic therapy (15). During the development of multimodal analgesia, apart from increasing
antinociception which was the primary goal, clinical evaluation of combinations' benefits should be
based on the benefits coming from reduction of adverse effects of opioids in comparation to the side
effects of non-opioids involved in such combination.
The aim of this study was to examine whether the
coadministration of tramadol and lornoxicam
change the threshold of sensitivity to painful stimuli
and to examine the relationship between analgesia
and method of application of the tested substances.
METHODS
Analgesic effects of lornoxicam in combination

with tramadol was analysed on female albino mice,
weighing 25-30 g. Four groups were formed, each
consisting of ten mice. The sense of pain was induced by thermal stimulus by the method of hot
plate. The temperature of the plate was constantly
55C during the experiment. Analgesic effect was
measured after a single intraperitoneal (i.p.) and
subcutaneous (s.c.) administration of lornoxicam
(in a dose of 10 mg/kg body weight), tramadol (in a
dose of 10 mg/kg body weight) and their combination (lornoxicam and tramadol each in a dose of 10
mg/kg body weight) in time intervals of 30, 60, 90
and 120 minutes. Physiological solution in the same
volume was administered to a control group.
The study was conducted on animal models (in vivo),
in accordance with OECD, EPA regulation and European convention for the protection of vertebrate animals used for experimental and other scientific purposes.
239
http://www.jhsci.ba
SPSS for Windows (version 20.0, SPSS Inc, Chicago, Illinois, USA). The Students t-test was used
in order to determine if two sets of data are significantly different from each other
by calculating statistically significant difference between the
two arithmetic means.
The results are presented in the
diagram, showing the calculated mean (average of ten measurements), standard deviation
and standard error (the ratio of
the standard deviation and the
square root of the number of
measurements).
Calculated p value is based on
a two-tailed distribution, comparing two sets of measurements of unequal variances.
Level of significance was set at
p<0.05.
Statistical analysis was done using Microsoft Excel

(Microsoft Corporation, Redmond, WA, USA) and
RESULTS
FIGURE 1. Comparation of analgesic effect of tested substances, after intraperitoneal administration
FIGURE 2. Comparation of analgesic effect of tested substances, after subcutaneous administration

240
Latency period of lornoxicam

was increased as compared to
the control group after intraperitoneal administration (i.p.)
and after subcutaneous administration (s.c.) as well. Lornoxicam applied intraperitoneally
in dose of 10 mg/kg showed
an analgesic effect, statistically
different compared to the control group 60, 90 and 120 minutes after application (p<0.05).
However, 30 minutes after the
i.p. application, the latency
period of lornoxicam was increased, as compared to the control group, but with no statistically significant difference (p =
0.053). Subcutaneously applied
lornoxicam showed analgesic effect compared to control group,
in all observed time intervals
(p<0.05).
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The results have shown that lornoxicam in combination with tramadol, applied intraperitoneally, increase the threshold of sensitivity to painful stimuli,
which was not the case with subcutaneous administration. Latency period of lornoxicam itself was 8.3,
9.6, 9.1 and 9.4 seconds, after 30, 60, 90 and 120
minutes respectively, after i.p. administration. On
the other hand, latency period of lornoxicam in
combination with tramadol was 11.6, 11.1, 12.0
and 12.7 seconds at the same measuring points. The
calculated statistical difference for this combination
was significant (p<0.05).
Subcutaneously administrated lornoxicam showed
the latency period of 8.3, 9.1, 10.0 and 10.4 seconds after 30, 60, 90 and 120 minutes respectively.
Latency period of lornoxicam in combination with
tramadol, administrated subcutaneously, was 10.1,
10.3, 11.0 and 10.6 seconds at the same measuring points. The calculated statistical difference for
this method of application was significant only 30
minutes after application of tested combination
(p<0.05). At later time points (60, 90 and 120 minutes), calculated differences were p=0.063, p= 0.069
and p= 0.739, respectively.
DISCUSSION
Studies have shown that the use of the combinations of opioids and nonsteroidal anti-inflammatory
drugs (NSAIDs) can increase their antinociceptive
activity and improve the therapeutic effect, and
lead to the use of lower doses of opioids, resulting
in a reduction of side effects. Data obtained in the
study carried out by Zhang et al (14) indicated that
the combination of atypical opioid, tramadol and
atypical NSAIDs, propacetamol had more potent
antinociceptive effects than those of tramadol and
propacetamol, in mouse and rat models, in the
treatment of acute persistent pain. If propacetamol
is used together with tramadol clinically, the dose of
tramadol could be minimized and then enhance the
analgesic effect. The study suggests that it is possible
to increase the antinociceptive effects and decrease
the undesirable adverse effects of tramadol by coadministrating propacetamol.
Fernndez - Dueas et al. (16) investigated a synergistic interaction between fentanyl, tramadol and
paracetamol, or whether the analgesic effect of this
mixture has increased activity compared to the very

strong opioid fentanyl, and whether it leads to a reduction in the dose of fentanyl, and consequently
reduced side effects. The results showed that there is
a synergistic interaction between these three drugs
in reducing nociception induced by acetic acid in
mice. Such a multimodal approach also permits
reducing the dose of fentanyl, and reduced the incidence of adverse effects, primarily gastrointestinal
inhibition passage, which is a common side effect of
opioid therapy.
Combinations of two analgesic drugs of the same
or different class are widely used in clinical therapy
to enhance its antinociceptive effects and reduce the
side effects. Moreno-Rocha et al. (17) were evaluating a possible antinociceptive synergistic interaction
of metamizol (NSAID) and tramadol (an atypical
opioid, opioid receptor agonist), when administered
alone or in combination, as well as the possible development of pharmacological tolerance produced by
such combination. The results of the study showed
that both metamizol and tramadol produced antinociceptive effects with a low rate trend towards
tolerance development at the end of the treatment.
The antinociceptive efficacy of tested combination
gradually decreased after the second injection. These
data suggested that when the combination is given
in a unique administration it results in an important potentiation of their individual antinociceptive
effects. But, the repeated coadministration of tramadol and metamizol results in a development of
tolerance.
The experimental part of our study presents the
similar results. Application of individual substances
lornoxicam and tramadol showed the expected results. Both, tramadol and lornoxicam produced a
significant analgesic effect in applied doses, which
was statistically different compared to the control
group, for each method of application.
The combination of tramadol and lornoxicam, after
i.p. application, produced increased pain reaction
(enhanced antinociception) when compared to lornoxicam alone under the same conditions (p<0.05).
These results confirm the literature data on combining opioids and drugs from the group of NSAIDs.
Subcutaneous administration of tested combination showed some different results. Just in the first
241
observed time interval after application, the combination of tramadol and lornoxicam produced
significantly better analgesic effect compared to lornoxicam alone (p < 0.05). At later time points (60,
90 and 120 minutes), the effect of this combination
is almost the same as the effect of lornoxicam, thus,
increased latency was demonstrated, but with no
statistically significant difference.
http://www.jhsci.ba
REFERENCES
1. Welch SP, Martin BR. Opioid and nonopioid analgesics. In: Craig RC and
Stitzel RE, eds. Modern pharmacology with clinical applications. 5th Edition.
Philadelphia: Lippincott Williams & Wilkins, 1997: 310-327
2. Beaulieu P. Non-opioid strategies for acute pain management. Can J Anaesth 2007;54(6):481-5
3. Grond S, Sablotzki A. Clinical pharmacology of tramadol. Clin Pharmacokinet 2004;43(13):879-923
4. Rang HP, Dale MM, Ritter JM, Moore PK. Farmakologija. 5. ed. (1. serbian
ed.) Beograd: Data status, 2005:562-584
5. Leppert W. Tramadol as an analgesic for mild to moderate cancer pain.
Pharmacol Rep 2009;61(6):978-92
CONCLUSIONS
After intraperitoneal administration, latency period

of lornoxicam was increased as compared to the control group, with significant difference after 60, 90
and 120 minutes of test. Lornoxicam also showed
increased latency when administered subcutaneously.
Lornoxicam significantly increases analgesic effect
when applied intraperitoneally in combination with
tramadol. On the other hand, lornoxicam in combination with tramadol, did not increase the threshold
of sensitivity to painful stimuli with significant difference, after subcutaneous administration.
The findings of the combination that includes opioid and nonopioid reveal that it has potential for
development as one of the new strategies of analgesics. Any clinical decision of using such multimodal
approach in pain therapy, in addition to increasing
the antinociception which has been experimentally
demonstrated in our study, should also be based on
the benefits coming from reduction of adverse effects of opioids in comparation to the side effects of
non-opioids involved in such combination.
COMPETING INTERESTS
242
6. Buritova J, Besson JM. Potent anti inflammatory/analgesic effect of lornoxicam in comparasion to other nsaids: a c-fos study in the rat. Inflammopharmacology 1997;5(4):331-41
7. Radhofer-Welte S, Rabasseda X. Lornoxicam, a new potent NSAID with an
improved tolerability profile. Drugs Today (Barc) 2000;36(1):55-76
8. Byrav PDS, Medhi B, Prakash A, Patyar S, Wadhwa S. Lornoxicam: a
Newer NSAID. IJPMR 2009;20(1):27-31
9. Balfour JA, Fitton A, Barradell LB. Lornoxicam. A review of its pharmacology and therapeutic potential in the management of painful and inflammatory conditions. Drugs 1996;51(4):639-57
10. Staunstrup H, Ovesen J, Larsen UT, Elbaek K, Larsen U, Krner K. Efficacy and tolerability of lornoxicam versus tramadol in postoperative pain.
J Clin Pharmacol 1999;39(8):834-41
11. Smith HS. Combination opioid analgesics. Pain Physician 2008;11(2):20114
12. Demeules J, Rollason V, Piguet V, Dayer P. Clinical pharmacology and
rationale of analgesic combinations. Eur J Anaesthesiol 2003;20(Suppl
28):7-12
13. Raffa RB. Pharmacology of oral combination analgesics: rational therapy
for pain. J Clin Pharm Ther 2001;26(4):257-64
14. Zhang Y, Du L, Pan H, Li L, Su X. Enhanced analgesic effects of propacetamol and tramadol combination in rats and mice. Biol Pharm Bull
2011;34(3):349-53
15. Inturrisi CE. Clinical pharmacology of opioids for pain. Clin J Pain 2002,
18(4 Suppl):3-13
16. Fernndez-Dueas V, Poveda R, Snchez S, Ciruela F. Synergistic interaction between fentanyl and a tramadol:paracetamol combination on the
inhibition of nociception in mice. J Pharmacol Sci 2012;118(2):299-302
17. Moreno-Rocha LA, Domnquez-Ramrez AM, Corts-Arroyo AR, Bravo G,
Lpez-Muoz FJ. Antinociceptive effects of tramadol in co-administration
with metamizol after single and repeated administrations in rats. Pharmacol Biochem Behav 2012;103(1):1-5
http://www.jhsci.ba
Ilvana Hasanbegovic et al. Journal of Health Sciences 2013;3(3):243-249

RESEARCH ARTICLE
Open Access
Effects of intraneural and perineural injection and

concentration of Ropivacaine on nerve injury during
peripheral nerve block in Wistar rats
Ilvana Hasanbegovic1*, Amela Kulenovic1, Suada Hasanovic2
1
Department of Anatomy, University of Sarajevo Medical Faculty, Sarajevo, Bosnia and Herzegovina. 2Clinic of Radiology,
Clinical center University of Sarajevo, Sarajevo, Bosnia and Herzegovina.
ABSTRACT
Introduction: Injury during peripheral nerve blocks is relatively uncommon, but potentially devastating
complication. Recent studies emphasized that location of needle insertion in relationship to the fascicles
may be the predominant factor that determines the risk for neurologic complications. However, it is wellestablished that concentration of local anesthetic is also associated with the risk for injury. In this study,
we examined the effect of location of injection and concentration of Ropivacaine on risk for neurologic
complications. Our hypothesis is that location of the injection is more prognostic for occurrence of nerve
injury than the concentration of Ropivacaine.
Methods: In experimental design of the study fifty Wistar rats were used and sciatic nerves were randomized to receive: Ropivacaine or 0.9% NaCl, either intraneurally or perineurally. Pressure data during
application was acquired by using a manometer and was analyzed using software package BioBench. Neurologic examination was performed thought the following seven days, there after the rats were sacrificed
while sciatic nerves were extracted for histological examination.
Results: Independently of tested solution intraneural injections in most of cases resulted with high injection pressure, followed by obvious neurologic deficit and microscopic destruction of peripheral nerves.
Also, low injection pressure, applied either in perineural or intraneural extrafascicular area, resulted with
transitory neurologic deficit and without destruction of the nerve normal histological structure.
Conclusions: The main mechanism which leads to neurologic injury combined with peripheral nerve
blockade is intrafascicular injection. Higher concentrations of Ropivacaine during intrafascicular applications magnify nerve injury.
Keywords: Ropivacaine neurotoxicity, intraneural injection, perineural injection.
INTRODUCTION
*Corresponding author: Ilvana Hasanbegovic MD, PhD
Department of Anatomy, Sarajevo University School of Medicine
ekalua 90, 71000 Sarajevo, Bosnia and Herzegovina
Phone: +38761211249;
E-mail address: ilvana2810@hotmail.com
Submitted 25th September 2013 / Accepted 3rd November 2013
Injury during application of peripheral nerve blocks

(PNB) is relatively uncommon, but potentially devastating, complication of regional anaesthesia. Possible mechanisms of neurologic injury may be related
to mechanical needle injury, injection force, vascular
2013 Ilvana Hasanbegovic et al.; licensee University of Sarajevo - Faculty of Health Studies.
http://www.jhsci.ba
injury, or neurotoxicity of local anesthetics and their Neurologic examinations were performed hourly for
the next 6 hour and daily for the next 7 days, and
additives (e.g., vasoconstrictors).
included
assessment of proprioception, motor funcRecent studies emphasized that location of needle
tion
and
nociception
by the following criteria:
insertion and injection of local anesthetic (LA) in
relationship to the fascicles may be the predominant Proprioception was evaluated by testing postural
reactions (tactile placement response - the rat was
factor that determines the risk for neurologic comkept in a normal resting posture, toes of one foot
plications (1,2). However, it is well-established that
were flexed with their dorsal part placed onto the
concentration of the injected solutions in the vicinsupporting surface and the ability to reposition
ity of the nerves and duration of exposure to LA are
the toes was evaluated). The functional deficit was
also associated with the risk for injury (3-5). In this
graded as: 0 - normal; 1 - slightly impaired; 2 - sestudy, we examined the effect of location of injecverely impaired; 3 - absent.
tion (intraneural vs. perineural) and concentration
of Ropivacaine on risk for neurologic complications Motor function was evaluated by measuring the
in Wistar rats.
extensor postural thrust: the rat was held upright
with the hind limb extended so that the body's
We hypothesized that location of the injection durweight was supported by the distal metatarsus
ing application of peripheral nerve blocks has higher
and toes and the extensor postural thrust could
prognostic value in occurrence of nerve injury over
be measured as the force applied to the digital balconcentration of injected Ropivacaine.
ance, the force that resists contact of the platform
balance
by the heel. The reduction in the force,
METHODS
representing reduced extensor muscle tone, was
After animal care Ethics committee approval of the
considered as a deficit of motor function and exUniversity of Sarajevo, 50 adult Wistar rats were
pressed as a percentage of the control force.
used in experimental designed type of the study.
The animals were anesthetized with an intraperi- Nociception was evaluated by observing the withdrawal of the limb in response to a noxious stimutoneal injection of pentobarbital 50 mg/kg. The
lation as:
sciatic nerve was surgically exposed bilaterally to
insert a 27 G needle (Terumo Europe NV, Leuven, 4 - Normal withdrawal reaction, rapid withdrawal of
Belgium) intraneurally on one side and perineu- the paw, vocalization, bites the forceps;
rally on the contralateral side, laterality determined 3 - Slower withdrawal reaction, slower withdrawal of
randomly (by the method of sealed envelopes). For the pinched extremity, vocalization, no attempts to
perineural injections needle was placed within the
bite the forceps;
epineural tissue but outside the perineurium, while 2 - Slow withdrawal reaction, no vocalization, no
for intraneural injections the needle was placed in- attempts to bite the forceps;
traneurally inside the perineurium. The selection of
1 - Barely perceptible withdrawal, no vocalization,
concentration of 2 ml of 0.2%, 0.5%, 0.75%, and
no attempts to bite the forceps;
1% Ropivacaine or 0.9% NaCl was randomized (us0 - no withdrawal, no vocalization, no attempts to
ing a computer-generated sequence). An automated
injection pump (PHD 2000 Harvard Apparatus, bite the forceps;
Holliston, MA) administered the injections at a The block duration was defined as time which passes
speed of 5 ml/min. Injection pressure was continu- until the response returns to score 3 (75 % of norously recorded using an in-line digital manometer mal).
(BioBench). Increased injection pressure was used to The animals were euthanized 7 days after injection
distinguish intrafascicular from extrafascicular intra- of the test solutions, and specimens of the sciatic
neural injections.
nerve on block with neighboring tissues were reAfter injection, animals were allowed to wake up
moved. The samples were fixed in formalin and parfrom anaesthesia and were given a series of neuro- affin followed by microtomal sections and stained
logic examinations according to Thalhammer (6). with hematoxylin and eosin methods. Qualitative
244
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histological analysis of the samples was performed

by pathologist blinded to the study groups.
A study sample size of 100 sciatic nerves (50 rats)

were required for the 80% power and a 5% type I
error rate for a two-tailed T-test designed to detect a
1.5 SD difference in peak injection pressure in two
groups defined as perineural vs. intraneural injections. Rates of neurologic and histological injuries
were compared between intraneural and perineural
injection by using McNemar's test for paired proportions. Fisher's exact test was used to compare injury rates during the intraneural injection, based on
injected solution. Statistical analysis was performed
by using SPSS and a p value of <0.05 was considered to be significant.
FIGURE 1. Proprioception of rat's hind limb after injection

application; i.n. inraneural; p.n. perineural.
RESULTS
Injection pressures
All experiments were completed as planned. All perineural injections resulted with the low pressure (<
24.5 kPa), while the majority of intraneural injections resulted with the high pressure ( 109.8 kPa).
Only two intraneural injections resulted in lower injection pressures which are indicated as intraneural
extrafascicular injections.
During intraneural applications the maximum pressure was 187.3 kPa, while the minimum pressure
was 26.4 kPa, achieved in peak effect. Maximum
pressure reached in all perineural applications was
24.5 kPa and minimum was 14.6 kPa, also achieved
in peak effect. The average value of maximum pressure achieved in peak effect for intraneural injection
was 138.130.9 kPa (mean value standard deviation), in comparison to 16.91.9 kPa for perineural
injection (p<0.05). The difference between average values of intra and perineural injections (with
95% confidence interval) was statistically significant
(t=3.14; DF=6; p=0.02).
Neurologic outcome
After recovery from general anesthesia, sensory-motor sciatic blockade was evident in rats that received
Ropivacaine in each concentration but not in rats
received saline.
245
FIGURE 2. Motor function of rat's hind limb after injection

application; i.n. inraneural; p.n. perineural.
FIGURE 3. Nociception of rat's hind limb after injection application. i.n. inraneural; p.n. perineural.
Following neurological exam, it has been found that

all intraneural injections which were associated with
high application pressure (independent of the tested
solution and concentration) resulted with deficits
which lasted more than 24 hours, and neurological
deficits were evident also at the end of experiment,
after 7 days, which clearly shows that intraneural intrafascicular injection caused the nerve damage.
On the contrary, all injections associated with low
injection pressure, whether they were intraneural or
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perineural didnt result with neurological sequels at

the end of the experiment (p<0.05). Furthermore,
in most cases neurological deficit has withdrawn
within first 24 hours of experiment, (Figure 1-3).
FIGURE 4. (A) Perineural application of 0.75% Ropivacaine with low injection pressure (HE, X10). Cross-section of rat's sciatic
nerve composed of two nerve fasciculus. Connective tissue of nerve and nerve fibers preserved structures. (B) Perineural application of 0.75% Ropivacaine with low injection pressure (HE, X100). Epineurium infused with erythrocytes. Perineurium lamellas
preserved, as well as structure of nerve fibres intrafasciculary. (C) Perineural application of 0.75% Ropivacaine with low injection
pressure (HE, X400). No deviation from the normal histological structure of nerve fibers visible intrafasciculary. (D) Intraneural
application of 0.2% Ropivacaine with high injection pressure (HE, X40). Noticeable invaginations of epineural connective tissue
(indicated by arrow), with loss of structural space intrafasciculary. Perineurium is shown as division of lamellas with its significant
disintegration, while nerve fibers evidence of nerve injury. (E) Intraneural application of 0.2% Ropivacaine with high injection
pressure (HE, X100). Visible damage of epineurium, perineurium, which continues to the fasciculus and nerve fibers, which
probably corresponds to place of needle penetration (marked arrow). Diffuse damage of nerve fibers. (F) Intraneural application
of 0.2% Ropivacaine with high injection pressure (HE, X250).Nerve fibers are disarranged in the space and of increased volume.
Most of the axons of those fibers are dislocated and hyperacidophile. Advanced axolysis and myelin disintegration is noticed.
Some of the erythrocytes are located extravasally. (G) Intraneural application of 1% Ropivacaine with high injection pressure
(HE, X 40). Place the cursor shows a marked rupture of perineurium. Degenerative changes through entire fasciculus are noted.
Groups of adipocytes with hyperemic blood vessels are evident. (H) Intraneural application of 1% Ropivacaine with high injection
pressure (HE, X 250). Diffuse axonal swelling and an advanced axolysis up to degree of complete disintegration was apparent.
No normal axons are seen. Schwann's cells are enlarged with hyperchromatic nuclei. Ep-epineurium; Pe-perineurium; Nf-nerve
fibres; Er- erythrocytes; Ed-edema; Ad- adipocytes; Ic- inflammatory cells; Bv-blood vessels; Sc- Schwann's cells.
246
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Histopathological examination
Histological examination revealed normal sciatic

nerve structure in all low pressure injections (50
perineural and 2 intraneural extrafascicular). Perineurial and extrafascicular injections (independent
of the tested solution and concentration) didn't
result in any significant nerve injury as assessed by
light microscopy (Figure 4 A-C).
By contrast, pathological changes which varied from
occasional nerve fiber injury at the site of injection
to severe axonal and myelin degeneration were observed following intrafascicular injections. In addition marked cellular infiltration, subperineurial
edema and diffuse axonal swelling was apparent in
most of intrafascicular injections, (Figure 4 D-H).
Pathological conditions in the periphery of the
fascicle were more prominent than in central zone.
With higher concentration of Ropivacaine injected
intrafasciculary pathological findings were more
marked, with evidence of wide-spread axonal and
myelin degeneration of the entire fascicle. The high
injection pressure group had a significantly greater
rate of injury (98%) as compared with the low injection pressure group. Using higher concentration
of Ropivacaine during intrafascicular injections the
degree of nerve injury was increased (0%; Fisher exact test p=0.03).
DISCUSSION
Peripheral nerve blockade with local anesthetics is

common practice in providing pain control for wide
range of surgical procedures and pain syndromes.
Inadvertent intrafascicular injection of a local anesthetic can generate a variety of nerve injuries, some
of which may result in long-term disability (7).
Ropivacaine in any concentration used in this study
produced some degree of damage to the nerve when
injected intrafascicularly, as evidenced by disintegration and demyelization of nerve fibers.
It is well known that all local anesthetics are potentially neurotoxic if they have been used in higher
concentrations than prescribed or if they act on
nerve through prolonged time period (8). However,
the previous experience shows that perineural application of local anesthetic significantly reduces neurotoxic potential, meaning that it carries very small
risk of nerve damage. The reason for this is prob-
ably the fact that in normal circumstances applied

amount of local anesthetic equalizes pressure with
surrounding tissue. In that moment the diffusion
into surrounding tissue occurs, the interstitial liquid
rapidly dilutes local anesthetic and its concentration further decreases by system absorption. As in
previous studies, in our study as well all perineural
injections of Ropivacaine (independent of concentrations used) have not resulted with significant
damage of nerve fibers.
In contrast to perineural injections, the intraneural
injections of local anesthetic may result with nerve
damage (9,10). Our results correspond with results
from previous studies showing that intraneural injection increases the risk of nerve damage.
While some authors consider that for the emergence
of nerve defect multi-factorial impact is needed (mechanical trauma and toxic effect of local anesthetic),
others showed that the main cause of nerve injury
during application of intrafascicular injection is mechanical trauma, depending on the kind and dose of
applied solution and on the addition of epinephrine,
we can find various types of nerve damages (11). In
our study most of intraneural injections, independent to the kind of applied solution and concentrations, also associated with high injection pressure
(48 out of 50 injections) have resulted with persistent neurological deficit, which shows that mechanical insult caused by intrafascicular placed needle is
critical in the occurrence of nerve injury. In other
words, our results show that the place of application is crucial factor in determination the grade of
nerve injury. Higher concentrations of Ropivacaine
applied intrafasciculary resulted with increased level
of nerve injury.
Contrary to our and many others results Iohom
and associates in 2005 applied intraneurally Ropivacaine into sciatic nerve of rat and concluded that
intraneural injection of Ropivacaine has no noxious
effect on nerve motor function (12). Unfortunately
authors ignored that intraneural injection can be intra or extrafascicular, what would have great impact
on final outcome. Also, authors analyzed only motor
function, without examination of sensory function
and without histological verification of those findings. Whitlock et al showed that Ropivacaine is associated with marked histological abnormality when
247
injected intrafasciculary, while milder histological

damage were seen when Ropivacaine was injected
extraneuraly or extrafasciculary (13). The authors
used finger pressure to distinguish intrafascicular
and extrafascicular injections. Unfortunately, anesthesiologists often rely on subjective estimation of
abnormal resistance to injection using finger pressure during the performance of peripheral nerve
block, knowing that intraneural injection results
with bigger resistance to needle. Hadzic and associates showed that the perception of the resistance can
rather vary among the anesthesiologists, that this
method is inconsistent and can be affected by different designs of needles (14).
Selander and Hadzic have demonstrated that intraneural injections into sciatic nerve of the dog in
most of cases were combined with high injection
pressure, while perineural injections were associated
with low application pressure (15,16). In our study
48 intra neural injections were combined with injection pressure higher than 109 kPa, while neither
one perineural injection was resulted with pressure
higher than 24.5 kPa. Even more important, intraneural high injection pressures in our study were
also associated both with neurological deficit and
histological evidence of injury to nerve fascicles.
Two low pressure intraneural injections did not result in neurological consequences because the needles were not lodged intraneurally but between the
fascicles instead of intrafasciculary. Since peripheral
nerves have natural protective mechanisms, like relative resistant membrane of perineurium, it is hard
to assure intrafascicular lodged needle. In that case
local anesthetic is deposited out of fascicle and such
blockade lasts for hours after injection, but there is
no histological evidence of nerve fibers damage.
In our study fascicular injury and neurological deficit were developed only after intraneural injection
joined with high injection pressure. Study of Kapur
and associated gave similar results (17). In fact, they
used sciatic nerves of dogs and injected 20 intra
neural injections in which only 8 resulted with intrafascicular lodged needle and were combined with
high injection pressure. Remaining 12 intraneural
injections were combined with lower injection pressure and there was no evidence of nerve fibers injury.
Opposed to the mentioned study in our study num-
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ber of intraneural extrafascicular injection was much

lower (2 from 50). The reason is that sciatic nerves
differ in rats and dogs. In rats nerve is composed
mostly from 1 big and 1-2 small fascicles with little
epineural tissue. It is not case with sciatic nerve of
dogs, pigs, rabbit and humans, where nerve is mostly multifascicular or composed from more equal fascicles with extensive epineurium. This is the reason
why in other species was more difficult lodging the
needle intrafasciculary than in our case.
Besides proven neurotoxic properties of Ropivacaine
when injected intrafasciculary, feature which is characteristic for all other local anesthetics, Ropivacaine
applied perineuraly is good choice for intraoperative
and postoperative regional anaesthesia and analgesia.
In general, all tested solutions caused nerve injury
when injected intrafascicularly, and in contrast, extrafascicular injections produced little to no damage.
This clearly showed that place of injection is crucial
factor in determining nerve injury, while high concentration of LA only amplifies the level of injury.
CONCLUSIONS
Combination of intraneural intrafascicular needle

placement and high injection pressures leads to severe fascicular injury and persistent neurologic deficits. The main mechanism which lead to neurologic
injury combined with peripheral nerve blockade
is intrafascicular injection. Higher concentration
of Ropivacaine during intrafascicular applications
magnify nerve injury. Ropivacaine applied in intrafascicular space is neurotoxic, similar like any other
local anesthetics. Ropivacaine applied in perineural
area is potent long lasting local anesthetic appropriate for intraoperative and postoperative regional anaesthesia and analgesia.
COMPETING INTERESTS
The authors declare no competing interests.
248
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anesthetic agents: a light and electron microscopic, fluorescent microscopic, and horseradish peroxidase study. Neurosurgery. 1980 Mar;6(3):263-72.
2. Kalichman MW, Powell HC, Myers RR. Quantitative histologic analysis of
local anesthetic-induced injury to rat sciatic nerve. J Pharmacol Exp Ther.
1989 Jul;250(1):406-13.
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3. Fredrickson MJ, Smith KR, Wong AC. Importance of volume and concentration for ropivacaine interscalene block in preventing recovery room pain
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5. Powell HC, Kalichman MW, Garrett RS, Myers RR. Selective vulnerability
of unmyelinated fiber Schwann cells in nerves exposed to local anesthetics.
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6. Thalhammer JG, Vladimirova M, Bershadshy B, Strichartz GR. Neurologic
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7. Auroy Y, Benhamou D, Bargues L, Ecoffey C, Falissard B, Mercier FJ,
Bouaziz H, Samii K. Major complications of regional anesthesia in France:
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8. Chambers W.A. (1992). Peripheral nerve damage and regional anesthesia.
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Divanovi K.A, Kapur E, osovi E, Voljevica A. Detection of neurovascular structures using injection pressure in blockade of brachial plexus in rat,
Bosn. J. Med. Sci.2005;5(3):79-85.
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11. Mornjakovi Z, Dilberovi F, Cosovi E, Divanovi KA, Zaciragi A, Kapur E,
Vuckovi I. Histological changes of the sciatic nerve in dogs after intraneu-
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Granier G, Cahn V, Bouaziz H. Long-term evaluation of motor function following intraneural injection of ropivacaine using walking track analysis in
rats. Br J Anaesth. 2005 Apr;94(4):524-9.
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SE. Ropivacaine-induced peripheral nerve injection injury in the rodent
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14. Claudio R, Hadzic A, Shih H, Vloka JD, Castro J, Koscielniak-Nielsen
Z, Thys DM, Santos AC. Injection pressures by anesthesiologists during simulated peripheral nerve block. Reg Anesth Pain Med. 2004 MayJun;29(3):201-5.
15. Selander D, Brattsand R, Lundborg G, Nordborg C, Olsson Y. Local anesthetics: importance of mode of application, concentration and adrenaline for the appearance of nerve lesions. An experimental study of axonal
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E, Vukovi I, Divanovi KA, Mornjakovi Z, Thys DM, Santos AC. Combination of intraneural injection and high injection pressure leads to fascicular
injury and neurologic deficits in dogs. Reg Anesth Pain Med. 2004 SepOct; 29(5):417-23.
17. Kapur E, Vuckovic I, Dilberovic F, Zaciragic A, Cosovic E, Divanovic KA,
Mornjakovic Z, Babic M, Borgeat A, Thys DM, Hadzic A. Neurologic and
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Suad Habe et al. Journal of Health Sciences 2013;3(3):250-254
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RESEARCH ARTICLE
Open Access
Air pollution by nitrogen oxides in Sarajevo

from 2005 to 2010
Suad Habe, Zarema Obradovi, Aida Ridal, Asmir Aldi
Faculty of health studies, University of Sarajevo, Bolnika 25, Bosnia and Herzegovina.
ABSTRACT
Introduction: Air pollution occurs when the concentration of certain substances (pollutants) reaches a
size which causes its toxicity, or in other words, begins to cause harm to human health, flora and wildlife.
Methods: Measurements were performed in the period from 2005 to 2010, at the measuring point
Bjelave-Sarajevo by the method of Griess-Saltzmann. It encompasses the following parameters: NO, NO2,
NOx, measured concentrations of pollutants in the atmosphere reduced to normal atmospheric conditions
of 293 K (Kelvin) and pressure of 101.3 kPa (kilopascal).
Results: NO concentration in the period from 2005 to 2008 was above the permitted value, but the
results of research in the period between 2009 and 2010, have shown that there was a decrease in NO
concentration in the atmosphere. Measurements show that the concentration of this pollutant is currently
declining, which is a positive result compared to the pollution of the atmosphere by nitrogen monoxide.
Furthermore, the results of the research showed that the concentration of NO2 for the period of 2005 to
2010, is in the limited values, and that has a decreasing trend, which is also a positive result compared
to the pollution of the atmosphere by nitrogen dioxide. Related to the total concentration of NOx in the
atmosphere, the results of the research show that their representation corresponds to the limit values
existing in the Rulebook on limit values for air quality.
Conclusion: The results of the research for the pollution of the atmosphere by nitrogen oxides in the
investigated area show that the amount of nitrogen oxides in the atmosphere is in constant decline.
Keywords: atmosphere, pollution, nitrogen, nitrogen oxides.
INTRODUCTION
The environment is a specific medium in which easiest thing is recognizing negative human activities (1).
*Corresponding author: Prof. Dr. Suad Habe,
Bolnika 25, 71000 Sarajevo
Phone:+38761228003;
E-mail: hsuad@hotmail.com
Therefore, the increase in public interest in thematic

areas of protecting the nature and improvement of
environmental conditions is apparent. Development of awareness of the citizens is evident through
increased interest in environmental activism with
goal of solving general and specific problems. Most
of the pollutants that pollute the atmosphere originate from industrial activities, but a significant part
originates from the traffic (2). Before the war in our
Submitted 4 August 2013 / Accepted 20 November 2013
2013 Suad Habe et al.; licensee University of Sarajevo - Faculty of Health Studies. This is
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country, industry was the most significant air pollutant. Most industrial plants have stopped operating
during the war and still have not reached pre-war
level. As a result, it is expected that the pollution of
the atmosphere is now much lower. Environmental
sustainability implies that the degree of pollutants
that are emitted, do not overcome the ability of air,
water and land to absorb and process them (3). At
the same time this implies a permanent conservation of biological diversity, human health, and the
quality of air, water and land, according to the standards that are still sufficient for the life and wellbeing of people, and the preservation of flora and
fauna (4). Air pollution is created by emissions of
harmful gaseous and particulate matters, usually as
a result of human activity, but also from the emissions from natural sources (5). During the burn of
the fuel in all furnaces and engines, formation of
nitrogen oxides at high temperatures occurs (6). In
addition to the two basic components that make up
the atmosphere: oxygen (circa 20%) and nitrogen
(circa 78%), small amounts of gases, vapors and particles are naturally present in the atmosphere (7). If
in the air, same or other components in concentrations which are higher than naturally present concentration occur, then we have the pollution of air
appearance. This phenomenon came to the expression in the previous and current century due to the
rapid development of industry, energetic and traffic.
Allowed NOx emissions from power plants (fireboxes) depends on the fuel type and the capacity of
the firebox, and that is prescribed by the legislation
on permitted emissions into the environment, the
Air Protection Act (Sl. Novine FBiH, No. 33/03)
(8). Air pollution occurs when the concentration of
certain substances (pollutants) reaches a size that affects its toxicity, or in other words, begins to cause
harm to human health, flora and fauna (8). Nitrogen oxides are binary compounds of nitrogen and
oxygen, which are: nitric oxide, NO, nitrogen dioxide, NO2; dinitrogen trioxide, N2O3; dinitrogen
tetroxide, N2O4; dinitrogen pentoxide, N2O5 (9).
Among them, there is the nitrous oxide N2O known
as "laughing gas" or "heavenly gas." Although nitrogen oxides make up a large group, the expression
NOX is commonly used for a mixture of NO and
NO2, which are considered major polluters of the
atmosphere. These two nitrogen oxides occur from
fossil fuel combustion, especially at high temperatures over 1000 C (10). The aim of this study was
to determine the pollution of the atmosphere caused
by nitrogen oxides NO and NO2 in Sarajevo from
2005 to 2010, and based on the obtained results,
suggest preventive measures that affect the reduction of atmospheric pollution by nitrogen oxides.
METHODS
Concentration of nitrogen oxides NO and NO2

and total nitrogen oxides NOx was determined by
the Griess-Saltzmanna method, with the help of automatic station for measurement. Method by GriessSaltzmanna is based on standard techniques of collecting samples in the absorbing solution, in which
the nitrogen is determined spectrophotometrically.
The air is vacuumed through the absorbing solution,
which was consisted of sulfanilic acid. Nitrogen
dioxide from the air first reacts with sulfanilic acid
forming diazonium salt. That salt combines with the
N-(l- naphthyl)-ethylene-diamine-dichloride giving
an intense red-purple color, from which the concentration is directly proportional to the concentration
of NO2 concentration. Due to the rapid formation
of the color, sampling time is not more than 30
minutes. The method is suitable for determining the
concentration of atmospheric NO2 - oxide from 40
to 1500 g/m3. This method is adapted to the automatic analysis used by the automatic station Bjelave.
Also, this method determines NOx, in other words;
sum of NO + NO2, with condition that the sample
was previously released through the KMnO4 solution which performs the oxidation of NO to NO2.
Calculated concentrations of NO and NO2 in the
atmosphere are reduced to normal atmospheric conditions of 293 K (Kelvin) and pressure of 101.3 kPa
(kilopascal).
Displayed values for nitrogen oxides (24 - hour
samples) obtained by this method are compared
with the limit values prescribed by the Regulation
on limit values for air quality (11). The study used
the data from the Federal Hydrometeorological Institute BiH in the period from 2005 to 2010.
251
RESULTS
In accordance with the established dynamics and

methodology of the research, measurement of atmo-
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TABLE 1. Limit values (LV) of air quality in order to protect

human health
Polluting
substance
SO2
SO2
NO2
NO2
L 10
UL
dim
CO
O3
a
b
c
d
Sampling
period
1 hour
24 hours
1 hour
24 hours
24 hours
24 hours
24 hours
8 hours
8 hours
The average annual

value (g/m3)
90
90
60
60
50
150
30
High value
(g/m3)
500 a
240 b
300 c
140 b
100 b
350 b
60 b
10.000
150 d
must not exceed more than 24 times in a calendar year.

must not exceed more than 7 times in a calendar year (98th
percentile).
percentile)
TABLE 2. Limit values (LV) of air in order to protect the ecosystem are:
Polluting
substance
SO2
NOx
O3
a
b
Sampling
The average annual High value
period
value (g/m3)
(g/m3)
calendar year
20 a
and winter
calendar year
30
Five years
18000 b

percentile).
TABLE 3. Statistical overview NO concentration g / m

(hourly samples) Sarajevo-automatic station Bjelave
CONCENTRATIONS
Csr
Cmax
C-50
C-95
C-98
C-99.9
% of valid
samples
Number of
samples taken
2005 2006
43
35
692 526
24
17
146 143
249 226
506 415
PARAMETAR
NO (g/m3)
2007 2008
39
35
434 523
21
19
139 125
207 189
396 392
2009 2010
20
27
258 180
10
21
72
56
120
77
212 153
98,22 99,35 91,75 93,81 97,75 80,43

8604 8703 8037 8240 8563 7046
FIGURE 1. Average annual concentrations of NO automatic

station Bjelave
spheric pollution by nitrogen oxides was conducted

in Sarajevo at the measuring station Bjelave period
from period of 2005th to 2010th year. All data are
appropriately processed and presented in tables and
graphs. The results are compared with the limit values prescribed by the Rulebook on air quality (GV)
in aim to protect human health (Table 1) and the
limit values of air (GV) in order to protect the ecosystem (Table 2).
By using automatic station Bjelave, concentrations of pollutants NOx, NO2, NO, are obtained,
which are presented as the mean annual value-CSR
maximum hourly value-Cmax and percentile valuesC-50, C-95, C-98, C-99.9. Percentile values indicate the number of exceeding concentration of some
pollutant in a specified number of hours in a year. In
the course of one year is 8760 hours, and the C-50
= 4380 hours, C-95 = 438 hours, C-98 = 175 hours
= 99.9 C-9 hours. In the stated tables, number of
samples taken in the course of one year is given, as
well as the percentage of valid samples (Source: Automated station Bjelave - Sarajevo).
In Table 3, the highest maximum concentration
value is measured in year 2005 and amounted was
692 g/m3 and the maximum measured mean value
of nitric oxide was 43 g/m3 and it was measured in
year 2005. Shown values of NO concentration in
Table 3 do not meet the limit values prescribed by
the Rulebook on limit values for air quality.
In Table 4 we see that in 2005 the highest maximum
concentration of nitrogen dioxide was measured and
252
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FIGURE 2. Annual average concentration of NO2 automatic

station Bjelave
TABLE 4. Statistical overview of NO2 concentrations g / m
(hourly samples) Sarajevo-automatic station Bjelave
CONCENTRATIONS
Csr
Cmax
C-50
C-95
C-98
C-99.9
% of valid
samples
Number of
samples taken
PARAMETAR
NO2 (g/m3)
2005 2006 2007 2008 2009 2010
26
19
18
15
9
18
299 187 165 137 168 119
17
12
14
12
7
16
81
63
47
38
25
30
122
93
63
53
33
37
250 145 129 122
66
59
98,14 99,03 92,42 93,83 97,82 80,43
8597 8675 8096 8242 8569 7046
TABLE 5. Statistical overview of the concentration of total

nitrogen oxides NOx (hourly samples) Sarajevo-automatic
station Bjelave
CONCENTRATIONS
Csr
Cmax
C-50
C-95
C-98
C-99.9
% of valid
samples
Number of
samples taken
it was 299 g/m3, as well as the largest annual mean

concentration which was 26 g/m3. The minimum
values were measured in the 2010 year. Cmaxwas
119 g/m3, while in the year of 2009 Csr was 9 g/m3.
Shown concentrations of NO2 shown in the Table
4 correspond to limit values prescribed by the rulebook.
In the Table 5, we see that in the 2005, the highest
concentrations of nitrogen oxides was measured, in
the reporting period. The maximum concentration
of NOx was 692 g/m3 and the average concentration was 43 g/m3.
Shown concentrations of total nitrogen oxides in
Table 5 correspond with the values specified in the
Rulebook on air quality values limit.
Chart 1 shows the average annual concentration of
NOg/m3 forthe period of 2005 to 2010. From the
shown chart we can see that the highest concentration of NO was in 2005 and it was 43.22%, however, the lowest was measured in 2009 and it was
20.10%.
In the Figure 2, we can see that the average annual
concentration of NO2g/m3 for the period of 2005
to 2010. From the given chart we can see that the
highest concentration of NO2 was in 2005, and it
was 26.25% and the lowest in 2009 amounted to
9.9%.
2005 2006
43
35
692 526
24
17
146 143
249 226
506 415
PARAMETAR
NOx (g/m3)
2007 2008
39
35
434 523
21
19
139 125
207 189
396 392
2009 2010
20
19
258 255
10
10
72
65
120 115
212 210
98.22 99.35 91.75 93,81 97,75 95,75

8604 8703 8037 8242 8563 8553
DISCUSION
This paper presents the results of research of pollution of the atmosphere by nitrogen oxides in the
Sarajevo area. Measurements included the period
from 2005 to 2010 at the meteorological station at
Bjelave. For grading the state of the pollution of the
atmosphere by nitrogen oxides analysis of the following parameters were performed:
Nitric oxide, NO
Nitrogen dioxide, NO2
The total nitrogen oxides NOx
By analysis of the concentration for nitric oxide, we
can see that the highest maximum and the highest average annual value of the concentration was
measured in 2005. The highest measured value of
nitrous oxide was 692g/m3. Average annual nitrogen oxide value is 43g/m3, which is more than the
253
http://www.jhsci.ba
limit value of 40 g/m3. Obtained concentrations

of nitrous oxide did not meet the limit values that
were prescribed by the Rulebook on limit values
for air quality. Concentrations of nitrogen dioxide
matched the limit values prescribed in the Rulebookon GV air quality. In 2005, the highest measured
maximum concentration of nitrogen dioxide was
299 g/m3, and in 2005, the measured maximum
annual mean concentration was 26 g/m3. The minimum values were measured in 2010. Cmax was to
119g/m3, and in 2009Csr was9 g/m3 in.
Concentrations of total nitrogen oxides did not exceed the prescribed GV Rulebook on air quality for
the entire observed period. In the 2005, the highest
concentrations in total nitrogen oxides were measured. Maximum NOx concentration was 692 g/
m3, and the average concentration was 43 g/m3.
investigated area, is in the allowed value margins

prescribed by the Rulebook on limit values for air
quality, and the amount of nitrogen oxides in the
atmosphere of the area is in a constant decline.
In order for conditions of living and working in Sarajevo, on the issue of pollution of the atmosphere
by nitrogen oxides to be enhanced it is necessary to
modernize and diversify monitoring atmospheric
pollution by nitrogen oxides and to improve the
quality of traffic in selection of vehicles on the roads,
by checking the quality of fuel and the use of green
fuels.
COMPETING INTERESTS

REFERENCES
1. Aliwell SR, Jones RL. Measurements of troposphere NO3 at midlatitude, J
Geophys Res 1999;103:5719-5727,
CONCLUSION
Based on the research results of pollution of the atmosphere by nitrogen oxides in the measuring station Bjelave area, we came up with the following
conclusions:
Concentration of NO in the period from 2005 to
2008 was above the allowed value, but in the period
since 2009 to 2010, there was a decline in the concentration below the limit value.
Concentration of NO2 in the period from 2005 to
2010 was in limit values and had a decreasing trend,
which is also a positive result compared to the pollution of the atmosphere.
Given the above, conclusion is that the concentration of nitrogen oxides, in the atmosphere of the
254
2. Bedekovi G, Salopek B. Zatitazraka. Sveuilite u Zagrebu, 2010.

3. Alloway BJ, Ayres DC. Chemical Principles of Environmental Pollution. 2nd
ed., Chapman & Hall, Andover, 336, 1996
4. Vali F i sar. Zdravstvena ekologija. Medicinska naklada Zagreb, Zagreb.
13-18, 2001
5. armati imon A. Zagaenje i zatita vazduha. Beograd, 2007
6. Stojiljkovi D. Azotni oksidi pri sagorijevanju domai lignita Beograd, 2001
7. Schnelle, K.B., Brown C.A. Air Pollution Control Technology Handbook,
The Mechanical Engineering Handbook Series, CRC Press LLL, New York,
2002
8. Zakon o zatiti zraka (Slubene novine Federacije BiH, broj: 33/03)
9. McMichael AJ. The environment. In: Detels R et al. (eds) Oxford textbook
of Public Health, 4th ed. Oxford: Oxford University Press, p195-214, 2002
10. Vallero D. Fundamentals of Air Pollution, Academic Press, Amsterdam,
2008
11. Pravilnik o graninim vrijednostima kvaliteta zraka lan. 27. stav (1). i lan
38. stav (2). Zakona o zatiti zraka (Slubene novine Federacije BiH,
broj: 33/03)
http://www.jhsci.ba
Munib Smajovi et al. Journal of Health Sciences 2013;3(3):255-260

RESEARCH ARTICLE
Open Access
Impact of management on employees communication

in medical and hospital centers in Sarajevo
Munib Smajovi1*, Redo auevi1, Mirsad Mufti1, Slavica Babi2
1
College of health studies, University in Sarajevo, Bolnika 25, 71000 Sarajevo, Bosnia and Herzegovina. 2College Lavoslav
Ruika in Vukovar, upanijska 50, 32000 Vukovar, Croatia.
ABSTRACT
Introduction: A persons response and functioning under condition of stress and conflict is fundamentally
different from its usual behavior.
Aim: To point out what type of attitude toward the management of healthcare institutions is worth developing as well as to determine which psychological dimensions of employed the best reflect the efficacy
of the management.
Methods: The study included a sample of 52 subjects employed at the Clinical center at University of
Sarajevo and 64 subjects employed in Healthcare clinic in Sarajevo Canton. Survey method and a method
of a theoretical analysis were used in the data collection and processing.
Results: The study concluded that there is no statistically significant gender difference in attitude about
the value of talent development at managerial level as a factor in development of attitude toward communication in healthcare. We find t-value of 2,213 for the Clinical center at University of Sarajevo and
2,210 for Healthcare clinic in Sarajevo Canton.
Conclusion: No statistically significant results have been found for any of the factors considered in the
study with respect to the gender differences.
Keywords: management, gender, healthcare occupation.
INTRODUCTION
In those relationships a person sends and receives

messages, behavioral cues, in short it communicates.
Communication is an integral part of human relationship process and originates from the human
need to establish contacts with others and in the
process to gain self-understanding and direction
*Corresponding author: Munib Smajovi,
Bolnika 25, 71000 Sarajevo, Bosnia and Herzegovina,
Phone: +387 33 569 800; E-mail: munib.smajovic@fzs.unsa.ba
Submitted 8 June 2013 / Accepted 18 September 2013
about his own behavior. Also, communication generates emotional satisfaction, a result of establishing
of relationships, as well as a consequence of feeling
connected and being part of a group (1).
Poor communication between patients and healthcare providers frequently occurs in todays healthcare practice (2). If a patient becomes dissatisfied
with a provided service, it is less likely that it will use
that type of service in the future. Dissatisfied patient
will more likely use services that satisfy its emotional
needs than the ones that satisfy his medical needs. In
addition, an unhappy patient is more likely to want
2013 Munib Smajovi et al.; licensee University of Sarajevo - Faculty of Health Studies. This
is an Open Access article distributed under the terms of the Creative Commons Attribution
http://www.jhsci.ba
to seek to get another physician or avoid healthcare The Survey method is a descriptive modality that
services, potentially leading to endangering his/her aims to collect data with help of appropriate instruments and techniques, and processes the informaown health (3).
tion gathered with certain statistical processing techImprovements in the area of communication are an
niques.
After the conducted analysis the relevant
important factor in the process of providing healthconclusions
were derived.
care services. The communication improvements
aspect is in a significant degree dependent on the There are numerous sources and implementations
for the theoretical analysis method. In this study the
leadership style (4).
key focus was on general and the subject specific litIf a manager cannot satisfactorily to address his job
erature in the field of management phycology and
needs, the resulting stress and conflict will make
the field of healthcare facilities organization and ophim dissatisfied, ultimately leading to difficulties in
making decisions and concentrating, loss of motiva- eration. Applying this method, we tried to indicate,
where and when possible, the theoretical and praction, lack of enthusiasm and similar. If widespread
such systemic deficiencies affect the healthcare sys- tical importance of the key factors that arose from
tem: healthcare workers and patients. Consequently, the realized empirical study of work practice in the
the quality of service can decline, indirectly expos- investigated segment of the healthcare system.
The participants in the study did a self-assessment
ing the patients to the consequences of stress (5).
Managers and those in the healthcare management of the level of importance of skill developments for
roles who work with people need to understand hu- managers. The self-assessment consisted of 13 quesman behavior in order to correctly address relation- tions/indicators. (Appendix 1). The questions related to the influence of management on their leadership challenges and better utilize human resources
while striving to achieve organizational and profes- ship role in leading the healthcare institutions, to
what type of competence such persons should have
sional aims (6).
and to the communication among team members.
The aim of this study is in advancement in the comThe participants were asked to mark with X one
munication processes, especially in the domain of
of the offered answers: I completely agree with this
management psychology and organizational effica A, I agree with this B, Im not certain C,
cies that could be improved through a better efficacy
or I dont agree D, I completely disagree - E.
in managing healthcare facilities.
Typically, this kind of assessment is called a five-step
process of Likert type.
METHODS
The participants categorical data type answers, in
The study consisted of a sample of 52 study subjects
the data processing step, were converted to the folfrom the Clinical center at University of Sarajevo
lowing numerical values:
who were at the time of the study employed at the
functions of chief and/or lead medical nurse/technician. The subjects were placed in two groups, ac- A = 5 points, B = 4 points, C = 3 points, D = 2
cording to their gender. There were 34 (65.38%) points, E = 1 point.
female subjects. The second sample of the subjects
was drawn from the employees from Healthcare In 6 out of 13 statements (questions: 2, 4, 6, 8, 9
clinic in Sarajevo Canton. 64 subjects were included. and 10), the answers were scored on a reverse scale.
The subjects drawn were from the functional roles The maximum possible total score for this survey
of chief and/or lead nurse/technician. Our sample
was 65 and the minimum 13. A high total indicates
consisted of 38 (59%) females. All participants
on a high and a low score on a low value of managevoluntarily participated in the study that started in ment development initiative.
January 2011 and lasted until February 2012.
Participation in the survey was voluntary and anonSurvey method and a method of a theoretical analy- ymous with the written consent provided by the disis were used in the data collection and processing.
rectors of Clinical center at University of Sarajevo
256
http://www.jhsci.ba
TABLE 1. General opinion about the value of development of

managers, as a factor that affects communication in healthcare. The data given is for the Clinical center at University of
Sarajevo.
and the Healthcare clinic in Sarajevo Canton. Same

questionnaire and the data collection style were used
in both facilities, not to introduce any systematic
differences between the two study groups. Moreover,
from the point of the subject of the study, there
was no a-priori reason to believe that one facility is
different from the other in any employment based,
professional or management factor that was relevant
for our study.
Gender
Male
Female
18
34
Arithmetic
mean
3.54
3.36
Standard t-test
Significance
deviation score
1.012
2.213
0.989
0.916
RESULTS
Participants from Clinical center
at University of Sarajevo
Of the total number of the participants, 52 (100%),

from the Clinical center at University of Sarajevo 34
(65.34%) were females .
Based on the research conducted and the analytical
data processing it was determined that there was no
statistically significant gender difference about the
general opinion about the value of development of
managers, as a factor that affects communication in
healthcare (t-test score equals 2.213) (Table 1).
The detail scores for the individual indicators are
given in Table 2.
FIGURE 1. Occurrence frequency for different type of answers given by the participants in Clinical center at University
of Sarajevo.
The results given in Table 2 indicate the indicator

13 as the one with the highest score, at 235. The
indicator suggests that the physicians and medical
TABLE 2. Study results for Clinical center at University of Sarajevo
Index Indicator
1
2
3
4
5
6
7
8
9
10
11
12
13
1
2
3
4
5
6
7
8
9
10
11
12
13
A
f
19
3
27
7
0
8
2
14
9
7
12
9
32
149
fx5
95
15
135
35
0
40
10
70
45
35
60
45
160
745
Subjects from Clinical center at Univeristy of Sarajevo

Attitude toward the value of development of managers as a factor that drives
the attitude toward communication's in healthcare
B
C
D
E
Total
f
score
f
fx4
f
fx3
f
fx2
f
fx1
21
12
21
7
1
14
2
18
12
10
26
9
16
169
84
48
84
28
4
56
8
72
48
40
104
36
64
676
6
11
1
11
2
10
6
13
11
11
7
10
3
102
18
33
3
33
6
30
18
39
33
33
21
30
9
306
257
4
17
2
18
18
11
16
7
11
12
5
20
1
142
8
34
4
36
36
22
32
14
22
24
10
40
2
284
2
9
1
9
31
9
26
0
9
12
2
4
0
114
2
9
1
9
31
9
26
0
9
12
2
4
0
114
52
52
52
52
52
52
52
52
52
52
52
52
52
676
207
139
227
141
77
157
94
195
157
144
197
155
235
2125
Rank
3
11
2
10
13
6
12
5
6
9
4
8
1
http://www.jhsci.ba
nurses should be deciding who should lead a healthcare institution. On the other hand, the lowest score
of 77 goes to the indicator five, which is about the
claim that the management role is a responsible and
demanding job.
Figure 2 shows the occurrence frequency for the
type of answers given by the participants. The answer I completely disagree is the most dominant in
8.22% of the participants, I dont agree in 8.49%,
Im not certain in 17.99%, I agree in 19.69% and
I completely agree with this in 45.61%. Figure 1
shows the total frequency of the occurrence of different type of answers.
TABLE 3. General opinion about the value of development of

managers, as a factor that affects communication in healthcare. The data given is for the Healthcare center Sarajevo
Canton.
Participants from Healthcare center

from Sarajevo Canton
Among the participants from the Healthcare center

from Sarajevo Canton 38 (59%) were females and
26 (41%) were male.
The study shows that there was no statistically significant gender difference about the general opinion
about the value of development of managers, as a
factor that affects communication in healthcare(t
score equals 2.210) (Table 3).
Gender
Male
Female
26
38
Arithmetic
mean
3.24
3.39
Standard t-test
Significance
deviation score
1.002
2.210
0.981
0.926
The detail scores for the individual indicators are

given in Table 4.
Indicator No. 13 doctors and nurses should be deciding who should lead health institutions, not politics and politicians show results got the highest score
at 280. The indicator number 5, Managerial role in
healthcare is an important and a high responsibility
function, ranked the lowestat 102 (Table 4).
The study shows that 12.89% participants answered
I completely disagree as the most dominant answer,
8.91% had I dont agree, 11.85% had Im not
certain, 19.68% I agree and 46.57% had I completely agree with this as the most dominant answer.
Figure 4 shows the total frequency of the occurrence
of different type of answers for the participants from
Healthcare center Sarajevo Canton.
TABLE 4. Detail study results for Healthcare center Sarajevo Canton.
Index Indicator
1
2
3
4
5
6
7
8
9
10
11
12
13
1
2
3
4
5
6
7
8
9
10
11
12
13
A
f
13
2
24
4
0
5
0
5
4
3
9
6
35
110
fx5
65
10
120
20
0
25
0
25
20
15
45
30
175
550
Participants from Healthcare center Sarajevo Canton

Attitude toward the value of development of managers as a factor that drives
the attitude toward communication's in healthcare
B
C
D
E
Total
f
score
f
fx4
f
fx3
f
fx2
f
fx1
29
13
32
10
1
13
0
17
11
12
28
15
20
201
116
52
128
40
4
52
0
68
44
48
112
60
80
804
10
24
6
23
2
14
9
22
28
22
21
19
8
208
30
72
18
69
6
42
27
66
84
66
63
57
24
624
258
7
15
1
14
31
15
23
15
14
18
5
17
0
175
14
30
2
28
62
30
46
30
28
36
10
34
0
350
5
10
1
13
30
17
32
5
7
9
1
7
1
138
5
10
1
13
30
17
32
5
7
9
1
7
1
138
64
64
64
64
64
64
64
64
64
64
64
64
64
832
230
174
269
170
102
166
105
194
183
174
231
188
280
2466
Rank
4
8
2
10
13
11
12
5
7
8
3
6
1
http://www.jhsci.ba
FIGURE 2. Absolute and relative score comparison of the distribution of scores across the thirteen indicators for the two healthcare institutions.
DISCUSSION
Communication is a form of most commonly

thought about as interaction among live beings.
Thus it is not very appropriate to include as a form
of communication exchange of information among
objects, e.g. data exchange among computer systems.
A quality personal interactions and relationships, in
the professional domain as well, do not form accidentally, but as a result of quality communication
and mutual respect (7). A quality communication
and group work generate opportunity for new ideas
and problem solving, due to efficient exchange of
experience and knowledge (8). Managing, as a concept, is about managing human resources and utilizing the most effective usage for those resources, as
well as about making organizationally critical decisions. A number of studies show that the knowledge
and skills about successful managing are universal,
even though some analysis have shown that managers in healthcare filed tend to be more successful if
they have some clinical experience (9). Healthcare
system is somewhat specific in that aspect that most
of the managers come from the ranks of healthcare
professionals. Such managers can be more successful in development of healthcare practice that would
champion quality communication with patients (in
an indirect way) and the healthcare professionals
employed in the team (in a direct way) (10).
Comparing the study results from the two participating medical institution, we determine that there
is no statistically significant difference in the frequency of the I completely agree with this answer,
while the answer I completely disagree is higher for

4.5% for the group from Healthcare center Sarajevo
Canton relative to the group from Clinical center at
University of Sarajevo. The response I agree gave
18.28% of participants in Healthcare center Sarajevo Canton and 19.69% of participants in Clinical
center at University of Sarajevo.
Comparing the results from the two healthcare institutions, we find similar response. For both groups
the highest score goes to the indicator 13, with the
score 280 for Healthcare center Sarajevo Canton
and 235 for the group from Clinical center at University of Sarajevo, which is 11.35% and 11.06% of
the total score respectively. The lowest score gets the
indicator 5 for both institutions, 102 for the Healthcare center and 77 for the Clinical center, which is
4.14% and 3.62% of the total score respectively. In
general, as seen in Figure 2 the distributions of the
scores are very similar for both institutions with the
largest percentage deviation being for the indicator
8, which scores 7.87% for the Healthcare center and
9.18% for the Clinical center.
T-test was used in investigating the gender based difference in opinion about the value of development
of managers as an influencing factor about attitude
toward communications in healthcare. Based on the
arithmetic mean measure, the study concludes that
there is no statistically significant gender difference
in the opinions. Specifically, for the Clinical center
at University of Sarajevo t-test score was 2.213 and
for the participants from Healthcare center Sarajevo
Canton t-test score was 2.210.
259
http://www.jhsci.ba
CONCLUSION
kolska knjiga: Zagreb, 1990; 17-24.

2. Velji K, Baker GR., Fancott C.Effectiveness of an Adapted SBAR Communication Tool for a Rehabilitation Setting. Healthcare Q 2008; 11(3):72-9.
A study about gender difference in opinion toward

the perceived value of development of managers as
an influencing factor about attitude toward communications in healthcare has been conducted. Based
on the statistical analysis of the data collected in the
study, no statistically significant results have been
found for any of the factors considered in the study
with respect to the gender differences.
3. Taylor ST. Health Psychology Inc. McGraw-Hill. Los Angeles 1995; 228-30.
4. Williams M, Hevelone N, Alban RF.Measuring communication in the surgical ICU: better communication equals better care. J Am CollSurg 2010;
210(1):17-22.
5. Murphy HA, Hildebrandt HW, Thomas JP. Effective Business
Communications.7th ed. McGraw-Hill/Irwin. 1997.
6. auevi R. Psychological basics of managerial education. DTP: Sarajevo,
2008; 47-53.
7. Oandasan I, Baker GR, Barker K. Teamwork in Healthcare: Promoting
Effective Teamwork in Healthcare in Canada Canadian Health Research
Foundation (CHSRF), 2009; 3-7.
COMPETING INTEREST
8. Risti D. Foundations of management. Cekom: Novi Sad, 2002; 18-78.
9. Kotter J, Cohen D. The Heart of Change: Real Life Stories of How People
Change Their Organization. Boston, MA: Harvard Business School Press;
2002.
REFERENCES
10. Len Sperry. Becoming an Effective Healthcare Manager. The Essential

Skills of Leadership, Ph, USA, 2010 ; 35-47.
1. Andrilovi V, udina M. Basics of general and developmental psyhology.
APPENDIX 1. Below statements express a range of different attitudes towards the value of dealing with the management of
health institutions. We expect that in the appropriate column with an X mark the extent to which you agree or disagree with any
of the listed claims:
Straight
No
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Degree of agreement
In general
Disagree I'm not sure Agree
I do not agree
FACTS
When I am asked, I formed a special college for the
training of management in health institutions.
Health management in our society is given too much
importance.
I appreciate very much the successful directors of
healthcare institutions.
Every successful doctor can be a successful director of
health facilities.
In health care management is a very responsible and
important job.
Be an effective director of health facilities and tolerant
attitude towards the employees do not go together.
Can not be considered successful healthcare facilities
that do not have good management.
Their targets medical institutions generate far more
thanks than dirket nurses and their aides.
I would not want my child to perform management
tasks in a medical institution.
Managerial positions in health institutions usually deal
with people who do not have enough self-confidence
as doctors.
Dealing with the management of health care institutions to develop positive character.
Today, the health institution only valid address managerial jobs.
Doctors and nurses need to decide who will run the
health institutions, not politics and politicians.
260
I completely
agree
http://www.jhsci.ba
Sebija Izetbegovi et al. Journal of Health Sciences 2013;3(3):261-266

REVIEW
Open Access
Innovating in Health Care Modern Challenges

Sebija Izetbegovi1*, Goran Stojkanovi2, Suvada vraki3, Eldar Mehmedbai4
1
General Hospital Prim. dr. Abdulah Naka, Kranjevia 12, 71000 Sarajevo, Bosnia and Herzegovina. 2Gynecology
Clinic, Clinical Center University of Sarajevo, Bolnika 25, 71000 Sarajevo, Bosnia and Herzegovina. 3Agency for Quality
and Accreditation in Health Care (AKAZ), Clinical Center University of Sarajevo, Bolnika 25, 71000 Sarajevo, Bosnia and
Herzegovina. 4Polyclinic S.M., Grbavika 6A, 71000 Sarajevo, Bosnia and Herzegovina.
ABSTRACT
Introduction: The goal of this article is to present that innovating in health care begins to become an imperative in present time. Innovating will enable the achievement of the highest quality health care results
and the patients' satisfaction with the least amount of financial resources.
Methods: The thorough literature review of multifaceted sources was conducted including: studies,
books, monographies and peer reviewed journals with the goal of achieving the clearer picture of today's modern challenges in the complex field of health care innovation.
Discussion: Theoretical and empirical studies clearly indicate that the innovation is one of the key factors
in the competitiveness of the organization and its survival in the market. Developed countries of the world
today are making significant efforts in order for innovation to become a national priority, with special emphasis placed on measuring innovation performance. Results of theoretical and practical studies show that
in the future, treatment of the most difficult and complex diseases of our time, through the entirely new
discoveries and results, derived from the process of innovation, will project entirely new positive forms and
outcomes in the health care.
Conclusion: There is no doubt that the humanity and medical science will through innovation succeed to
win the battles against the majority of the most complex contemporary diseases. Malignant neoplasm of
tomorrow, through the application of a new, innovative approaches to research, processes and treatments
will become a chronic diseases. Among many, the particular problem in the process of innovation will
represent the cost of research and development (R&D), production and the safety of prescription drugs.
Keywords: health care, innovation, measurement of innovation, quality, cost, malignant neoplasm, prescription drugs.
INTRODUCTION
The aim of this paper is to present that innovating

in health care begins to become an imperative in
*Corresponding author: Sebija Izetbegovi,
General Hospital Prim. dr. Abdulah Naka,
Kranjevia 12, 71000 Sarajevo, Bosnia and Herzegovina
Phone: +38733285102, Fax: +38733285370
E-mail: sebija.izetbegovic@obs.ba
the contemporary time. Innovating will create the

achievement of the highest quality health care results
and the patients' satisfaction by utilizing the least
amount of financial resources. Developed countries
of the world, today, are making significant efforts for
innovation to become a national priority. Innovation process becomes a key to a successful organization of health care in the future (1). Innovation will
be possible to the full extent, if we, as a whole society,
Submitted 5 September 2013 / Accepted 23 October 2013
2013 Sebija Izetbegovi et al.; licensee University of Sarajevo - Faculty of Health Studies.
agree with its importance and fully understand the

nature of challenges faced while managing to mobilize human resources for these changes. Innovating
and simultaneously managing these processes is necessary for several reasons : 1.) the financial resources
at our disposal are limited, today, and will be limited
in the future and 2 ) the second part of the challenge
represent the serious and ever deteriorating problem
of the aging population (2). People are living longer
and for maintenance of health for elderly population, from year to year, the society and taxpayers
must allocate more and more resources. Innovation
will improve the quality of health services, shorten
treatment time, increase the number of cured , reduce the cost of treatment and medications, and
create the patients from observers, today, to active
and satisfied partners in the future. In the future, in
order to make the treatment of the most serious and
complex illnesses of the present; such as: heart and
blood vessels diseases, malignant neoplasms, diabetes and auto immune diseases (i.e. multiple sclerosis,
lupus and others), more effective and efficient the
process of innovation will have to get a completely
new forms and outcomes (3).
METHODS
A detailed literature review of various sources was

conducted, including: studies, books, monographies and peer reviewed journals with the goal of
achieving the clearer picture of today's modern challenges in the complex field of health care innovation.
DISCUSSION
Theoretical and practical studies clearly indicate that

the innovation is one of the key factors responsible
for the competitiveness of the service sector oriented health care organizations and their survival in
the increasingly competitive and globalized market.
In the present, developed countries of the world are
making significant efforts in order for the innovation to become a national priority, with special emphasis being placed on measuring of innovation performance. Already, in 1950, J. Schumpeter, in his
work, titled "Capitalism, Socialism and Democracy
", heralded innovation as the main factor of technological progress and economic development. He
distinguished two types of innovation: the radical
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and incremental (gradual) innovation. Both of these

terms can be defined in different ways, depending on the perspective of the person who evaluates
them. Although, many papers on this complex subject have been written, today's literature, has been
still unable to define measure(s), through which, we
could measure the "radicalism" of some innovations.
Innovations which are by some researchers labeled
as "radical" , were evaluated as incremental or discontinued by other researchers. Analogously, there
is no clear demarcation when considering high, medium or low levels of innovation. In the process of
identifying the innovation, it is important to consider the marketing and technological perspective and
the perspective of the macro and micro levels (4-6).
These definitions should be taken into account in
applying innovation in healthcare service sector. Developed countries are now making significant efforts
to measure innovation. This is a serious problem that
we are facing. Without proper measurement we cannot talk about an efficient and effective innovation.
Theoretical and empirical research clearly shows that
innovation is a complex and multidimensional process. It never follows a straight line, and some of the
stages of human history were stagnating or accelerating based on the dynamics of innovative processes.
It is interesting to consider the reasons which contributed to these dynamics (7-8).
Returning to the short history, we can see that for
our ancestors, which existed thousands of years before us, the life expectancy was 20 to 25 years. In the
1800s, the life expectancy has increased to 35 years
and in 1900's was 48 years. In 2000, the average
life expectancy has reached 78 years, an increase of
66 percent, or an additional 30 years of life, compared to the year in 1900. From the 1900's until
the 1950s, life was constantly extended for, and by
the mid -50s to mid- 60s of last century, the trend
was stopped. After that, the life expectancy begins
to grow again and continues this trend in the 21st
century. The reason for this increase was that, in the
first half of the last century, the modern medical
discoveries managed to win battles over numerous
infectious diseases, while providing the human kind
with cleaner water, better sanitation and better child
care. At the same time, for the first time in history,
mankind has managed to conquer infectious diseases due to exceptional drugs including penicillin ,
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streptomycin and others. But, in mid-20th-century,

after the fight against infectious diseases was completed, the medicine did not have adequate means
to counter new diseases, such as; heart disease, autoimmune and malignant diseases. Since the mid -50s
to mid- 60s of the last century, medicine has little
to offer for the prevention or treatment of chronic
and degenerative diseases , which are dominated by
pathological picture of his society . Medical innovations have had a significant effect on the heart and
blood vessels and malignant neoplasm, which in
those years referred greatest number of lives . Many
techniques , such as surgery bridging (Eng. bypass
surgery), mounting pads or stents , heart transplantation , new drugs to control blood pressure, lowering cholesterol , or clot-busting , have the effect that
the 1975th mortality from heart disease and blood
vessels was reduced by 60%. Reducing mortality
due to malignant neoplasms was less dramatic, but
it had a constant decline (9-10).
In 1975, the five-year survival period for all types of
malignancy was 50%. Today, the five-year survival
period of almost 70 percent. Prior to the 1950 children diagnosed with leukemia had a prognosis of
three months. Today, children diagnosed with leukemia have a 85 % chance to heal . With the help of
medical innovation we just bought extra decade of
life and health , but we also got a year of productive
work and economic value added, increased household spending and increase tax revenues . The study,
which was conducted at Columbia University (New
York City , USA ) by Frank Lichtenberg has shown
that the use of new drugs for the 40 % increase over
the lifespan in 1980. up in 1990. In other words,
for each year of life extension , five months is a result of the application of new drugs. If we manage
that complex process of innovation in healthcare in
detail clarify, would allow practitioners and decision
makers to help evaluate , adapt and perform services
in such a way to give priority to innovation in health
care, representing true value . It is evident that prioritization is also a challenge. They need access to the
full appreciation of the specificities of each community. In the modern world, innovation is considered
a critical component of business productivity and
condition of survival in the market (10-11).
In the second half of the last century, medical science has progressed exponentially. Unfortunately,
the system of paper documents (medical records)

still provides information vital to the delivery of
health care . Patient information is routinely kept
in archives and keep the same mentality with which
preserves and other stored goods. Paper registration
is always associated with errors that are in health
care is very expensive. From U.S. $ 600 billion,
which is spent on laboratory tests each year in the
U.S., 70 percent is paid for the paper records. Huge
savings possible with the introduction of electronic
medical records ( EMR) . This electronic record can
easily detect and troubleshoot errors. Treatment of
patients and exchange of information on his health
, according to medical records , it is very tedious
and often impossible task. Without this insight it
is impossible to know the patient's medical history .
Electronic patient record status allows the doctor to
quickly exchange images and test results with colleagues in the same clinic , other clinics around the
country and the continent (12).
It is estimated that the electronic medical record
(EMR) will be one of the priorities of innovation
in developing countries. Unfortunately, a number
of employees in health care, it is still a new fashion
trend, not an essential need in improving the health
care quality. Empirical research shows that managers of healthcare organizations recognize the importance of this document, but that its application
should eliminate many barriers. Results of theoretical and empirical research suggest that in the future
treatment of the most difficult and complex diseases
of our time, in the process of innovation , get entirely new forms and outcomes (13).
For malignant neoplasms of tomorrow, a new, innovative approach to therapy will become a chronic
disease. Cancer, though will not be eradicated , will
create less fear patients , who, better informed , learn
more easily live with this chronic disease. How true
this will be the image will depend on the number
and quality of new technologies that will emerge
innovation. It is evident that the longer the life of
these patients increased many times over the cost
of their treatment , creating a tension between the
demands of patients and those who pay for services.
In treatment of malignant tumors the primary goal
is to turn malignant disease into a chronic illness.
To achieve this it is necessary to promote a healthy
lifestyle and diet, to educate health care profession-
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als and patients on the general basis to organize early

control and reporting at the first signs of illness. In
Bosnia and Herzegovina today, there are five oncology centers. In the treatment of malignant diseases
they apply modern principles of surgery , chemotherapy, radiotherapy , chemotherapy and immunotherapy . Through education and prevention in
the current phase , the goal is to reduce 10-20% of
patients who are too late occur physicians for review
(14).
Innovations in the treatment of malignant diseases
are inevitable because of the complexity of disease
and mortality. Innovation would primarily had to
be transformed into useful therapies, which will be
aimed at the right biological target , the appropriate patient and in a way that is acceptable to patients, healthcare professionals and society. Innovation must be successfully introduced to the market
as professionals , and patients and those who pay
the costs. All they need to see the potential benefits.
Today we see an explosion of new therapies to treat
cancer, and their prices remain very high . It is estimated that the global value of drugs for treatment of
malignant neoplasms in 2005 amounted to 24 billion U.S.$. From this amount, approximately U.S. $
15 billion was spent in the United States (15). Technology will detect which patients do not respond
well to therapy. In this way , today known drugs in
the near future will become obsolete. Doctors will
be able to, very accurately, at any stage of the disease,
undertake the essential treatment. As cancer will be
transformed into the chronic disease, the patients
will live longer, but, at the same time look for a
more demanding care. Ten years ago the average cost
to develop a new anti-cancer drug amounted to 400
million U.S.$. Today, these costs amount to about
$ 1 billion. If they continue at this pace of growth ,
the costs of developing new drugs could soon reach
U.S.$ 2 billion , which is the amount that the existing market , by many parameters , hardly endure.
The increase in the number of drugs that are intended to correct a specific group of patients , at the same
time means that it will eventually disappear tempted
to find drugs that are acceptable for all patients (15).
Data from the United States for 2005 show that the
costs of care for cancer patients in the last six months
the patient's life is 70 percent of the total cost , and
that will grow four times until 2025, since patients
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will live longer and that will necessarily arise new

therapies. This increase in cost will inevitably create tensions between those who provide the funds
and those who consume them . This rapid increase
in costs will necessarily lead to the fact that the
expensive therapies are directed , and to use fewer
hospitals , and more home care. One of the dilemmas in the future there will be political influences
aging population , which will expect better service
than what is offered today, the majority of older people. A small number of elderly people will be able
to provide all the necessary care. The vast majority
of others will have to rely on state protection. It is
estimated that on a global scale in the future be a
shortage of those who provide health care. Cancer or
malignant neoplasms, cardiovascular disease and dementia in the future will be controlled and will join
the list of chronic diseases as diabetes , asthma and
high blood pressure . New ethical and moral dilemmas appear to be parallel to the successes brought
down the incidence of the disease. Live longer and
die more quickly , according to some, will be one of
the basic principles of Western medicine of the 21st
century (16) .
An overarching goal is that we must define its way
to the limited resources we have at our disposal for
health, ensure maximum for patients, their families
and society, as a whole. Theoretical studies indicate
that innovation in health care relates to products,
processes or structures. The product is what the patient pays for and consists of goods or services (e.g.
innovation in clinical procedures). Innovation in
processes implies to the innovation in the production or delivery method. The patient usually does
not pay for the process, but it is necessary to deliver
the desired product or services. Structural innovations usually affect the internal and external infrastructures and create new business models (17) .
Information technologies are becoming a key factor
for innovation in health care. Hospitals and clinics
in the world are trying, as soon as possible, to start
applying the newest technologies related to medical equipment, procedures and treatments , paying
less attention to innovation in communications and
networking. One reason is the possibility of compromising the security and privacy of patients' intrusion into information systems. In recent years,
improving safety in this segment and the possibility
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of transmitting data and images around the world ,

grows the opportunity for significant innovation in
this part of health care (18).
The modern world is increasingly using the services
of other (i.e. outsourcing ) in diagnostic services especially medical images, such as: mammograms ,
X-rays and consultation specialists. Telemedicine is
used in the U.S. and other countries , in order to
provide care to patients in remote and inaccessible
locations. Most of today's health information system is designed to function autonomously , with its
own rules and formats. They often prevent information to be globally integrated and always available
. In some cases, the patient's electronic ticket from
one hospital is not readable in another. Not only
different languages and measurements, but also the
conflicts and different decryption software, are the
reason as to why it is impossible for the systems to
exchange electronic data. Eliminating these barriers
at local, regional and state levels, our ultimate goal
should be the creation of medical records , which
can travel along with patients around the world (19).
A particular problem in the process of innovation
is the production of drugs and their safety. From
today's tendency to produce drugs that are universally acceptable to all patients, drug manufacturers
will have in the future to shift to the production of
drugs that are precisely targeted to specific groups
or even individuals. Analysis carried out in developed countries show that ( for 88 percent of chronic
and complex diseases) drugs are the first choice for
medical intervention. Americans with chronic and
complex diseases, such as diabetes, heart disease, osteoporosis and cancer, contribute 75 percent of the
cost for medical treatment in the USA. Regardless of
the significant side effects, drugs today are remarkable segment of health care. Considering just diabetes, if not controlled, diabetes can lead to a cascade
of potential complications that result in increasing
the human , social and economic costs , including
blindness, amputation, kidney disease, heart and ultimately death. Patients, who regularly take medications for diabetes medication costs increase, but the
overall cost of treating diabetes and complications
that it produces, are declining. For many diseases
the situation is very similar. For all these innovative
medicines are often both medically and economically most effective alternative. In developed coun-
tries, about 60 percent of patients with diabetes do

not keep the disease under control in order to avoid
serious complications.
Innovation and appropriate management innovation modern medical science adjusts medications
individual needs of patients , providing them with
the right medicine to the right dose at the right
time From the standpoint of value for money drugs
adapted to the needs of patients will also reduce the
high costs associated with those who do not respond
to them. This type of innovation is exactly what patients want today (20).
CONCLUSION
Improving health care through innovation is one

of the most important tasks facing healthcare providers, other organizations and individuals whose
activities are related to health. Innovation is a continuous process that cannot be delayed. Innovation
should be approached systematically taking into account the specificities of every country. Since this is
a very broad field it is necessary to define priorities
by taking into account the financial resources available in this area.
Health care today is abundant with basic innovations. Innovations that have been successfully applied to a single location, often spread very slowly, or
are not spread at all, to other locations. Diffusion of
innovations, today, creates an enormous challenge
for all industries, health care systems and markets.
Then, when the humanity significantly innovated,
life expectancy and quality of life were also significantly increased . Thanks to innovation, especially in
eliminating infectious diseases, ensuring the population with drinking water and sufficient food, life
span increased from 1900 until 2000 for nearly 30
years. Today's medical science is facing new challenges, these are diseases of cardio - vascular disease,
malignant neoplasm, diabetes, auto - immune disease and dementia. There is no dilemma that science
and health innovation will find a remedy to these
diseases. Innovation is a very complex and multidimensional process, which requires a critical mass
of trained personnel. To achieve maximum effect in
updating all of our activities it must be subject to
measurement. In this way we will be able to identify
key indicators of quality health services, to observe
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Innovation. (2nd ed.). Sudbury: Jones & Bartlett Publishing. 2007.
these indicators and measure quality outcomes. In

this way we practice quality assurance shift towards
constant improvement of quality. Quality must be a
constant task for all stakeholders in health care.
9. Rachlis M. Prescription for Excellence: How Innovation is saving Canadian

Health Care System? Toronto: Herper Perennial Publishing Inc. 2004.
10. Raffel MW. Health Care and Reform in Industrialized Countries. University
Park: The Pennsylvania State University Press. 1997.
11. Reid TR. The Healing of America: A Global Quest for better, cheaper and
fairer Health Care. New York: Penguin Press. 2009.
COMPETING INTERESTS
12. Bessant J, Maher L. Developing Radical Service Innovations in Health

Care: The Role of Design Methods. International Journal of Innovation
Management 2009;13(4):555-568.
13. Borger C, Smith S, Truffer C. Health spending projections through 2015:

Changes on the horizon. Health Affairs Web Exclusive. 2006; 61-73.
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1. Graham NO. Quality in Health Care: Theory, Application, and Evolution.
Gaithersburg: Aspen Publishers Inc. 1995.
14. Camacho J., Rodriguez M. How Innovative are Services?: An Empirical

Analysis for Spain. The Services Industries Journal 2005; 25 (2).
2. Davila T. Making Innovation Work How to Manage It, Measure It and

Profit from It. Wharton School Publishing. 2005.
15. Definition of Innovation. Journal of Management Practice;2000(3).
3. Davis MS. Health Care: Innovation, Impact and Challenge. School of Policy
Studies-School of Public Administration, Queens University. 1992.
16. Fleming, C. Innovations in Health Care Delivery. Health Affairs. http://

healthaffairs.org/blog/2011/03/08/march-health-affairs-issue-innovationsin-health-care-delivery/. 2011.
4. Narayanan VK. Managing Technology and Innovation for Competitive Advantage. New York: Prentice Hall. 2001.
17. Han JK, Kim N, Sristava RK. Market orientation and organizational performance: Is Innovation a missing link. Journal of Marketing 1998;62(4):30-45.
5. North N, Bradshaw I. Perspectives in Health Care. London: Macmillan

Press Ltd. 1997.
18. Rigby DK, Gruber K, Allen J. Innovation in Turbulent Times. Harvard Business Review 2009:79-86.
6. Porter ME. Competitive Advantage: Creating and Sustaining Superior Performance. New York: The Free Press. 1998.
19. Sikora K. Development and Innovation in Cancer Medicine. International

Journal of Innovation Management. Imperial College Press 2007;11(2):259278.
7. Porter ME, Teisberg EO. Redefining Health Care: Creating value-based

competition on results. Boston: Harvard Business School Publishing. 2006.
8. Porter T. O' Grady MK. Quantum Leadership: A Resource for Health Care
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20. Wilson, A., Ramamurthy, K., Nystrom, C. A Multi Attribute Measure for
Innovation Adoption: The Context of Imaging Technology. IEEE. 1999: 46.
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Zuzana Karabov, Lubica Ilievov Journal of Health Sciences 2013;3(3):88-270

CASE REPORT
Open Access
Palliative care in the home: a case study of

secondary histiocytic sarcoma in a 3-year-old child
Zuzana Karabov1,3, Lubica Ilievov2
1
Faculty of Health Sciences and Social Work, Department of Nursing, University of Trnava, Slovakia. 2Faculty of Health Sciences and Social Work, Department of Nursing, University of Trnava, Slovakia. 3Childrens University Hospital and Clinic,
Department of Pediatric Hematology and Oncology, Bratislava, Slovakia.
ABSTRACT
This article describes the medical, psychological, and social challenges encountered during home-based,
family-centred palliative care of a 3-year-old female with secondary histiocytic sarcoma diagnosed during
treatment for T-cell acute lymphoblastic leukaemia. Histiocytic sarcoma is an exceedingly rare cancer in
adults, but even less frequent and highly aggressive when presenting as a secondary cancer in children.
Comprehensive, multidisciplinary paediatric hospice care services are not widely available across Slovakia,
thus limiting the number of patients and families offered such highly specialized end-of-life care. This case
study illustrates the primary benefits for the child and family of such a program as well as the impact on
the medical and nursing professionals working in the field of paediatric haematology-oncology.
Keywords: paediatric; palliative; secondary cancer; histiocytic sarcoma; home care; hospice.
INTRODUCTION
Cancer is relatively rare in childhood, with almost

1 in 500 children developing some form of cancer
by 14 years of age (1). Acute lymphoblastic leukaemia (ALL) is the most common malignancy diagnosed in children (2). In Europe, ALL accounts for
approximately 80% of leukaemias among children
aged 014 years with a peak incidence in children
aged 2-5 years (1,3). More than 80% of children
with ALL are cured with current treatment regimens
but are at risk of developing secondary cancers (3,4).
*Corresponding author: ubica Ilievov
Faculty of Health Sciences and Social Work,
Department of Nursing, University of Trnava,
Univerzitn nmestie 1, Trnava, 918 43, Slovakia
E-mail: ilievova.lubica@truni.sk
Submitted 22 September 2013 / Accepted 10 December 2013
We present a case study that highlights the challenges to providing comprehensive, family-centred,
home-based hospice care to a 3-year-old female battling the terminal stages of histiocytic sarcoma, an
aggressive secondary malignancy. Histiocytic sarcoma is an exceedingly rare malignancy accounting for
less than 1% of all haemato-lymphoid cancers and
most commonly occurs in adults (5,6). Only a few
reports of bona fide histiocytic sarcoma exist in the
literature, mostly involving adults (7,8). A recent
literature search uncovered only four published case
reports of secondary histiocytic sarcoma in children
(8-11).
Believes that the family home is the place that best
meets the needs of terminally ill children and that
symptom management must be an integral part
of palliative care (12). A crucial element of com-
2013 Zuzana Karabov, Lubica Ilievov; licensee University of Sarajevo - Faculty of Health
prehensive, family-centred, paediatric hospice care

is to provide consistent, seamless care, regardless
of where the child is being treated (13). The child
discussed in this case study was diagnosed with histiocytic sarcoma during maintenance treatment for
T-cell ALL. Given the poor prognosis of childhood
secondary histiocytic sarcoma, the paediatric patient
described here received family-centred hospice care
in the home.
CASE STUDY
A case study report was selected as the most suitable method to describe the home-based palliative
nursing care of this terminally ill child, referred to
here by the pseudonym Katarina. Information was
extracted from medical records and nursing notes
covering the period when she received palliative care
in the family home. During informal interviews,
special attention was paid to elements of Katarinas
verbal and non-verbal communication. How the
mother adapted to the provision of palliative care
was also noted. The mother provided written consent for the use of all information presented in this
report.
Katarinas social and medical history
Katarina was the only child of healthy parents. Katarina enjoyed a stable emotional relationship with her
mother and maternal grandparents with whom she
lived in a common family home. Her father did not
reside with Katarina and her mother. Katarina was
born by caesarean section at 26 weeks of gestation
weighing 690 grams and suffering from respiratory
insufficiency and anaemia.
At two and a half years of age, Katarina developed
low-grade fever, loss of appetite, abdominal pain and
a white cell count of 458,900. Bone marrow biopsy
confirmed the diagnosis of T-cell ALL. Katarina
completed the induction and consolidation phases
of the IC BFM 2002 protocol for ALL (14) and prophylactic cranial irradiation. Two months into ALL
maintenance chemotherapy with oral mercaptopurine and intrathecal methotrexate, Katarina, now 3
years of age, developed abdominal pain, colitis, and
abdominal lymphadenopathy. Lymph node biopsy
revealed histiocytic sarcoma. Shortly thereafter, intestinal invagination resulted in laparotomy with
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lymphadenectomy and bowel resection. Histological examination confirmed the presence of a secondary malignancy consistent with histiocytic sarcoma.
Katarinas clinical course was characterized by rapid
progression of her histiocytic sarcoma in the abdomen, pelvis, and lungs. Over the ensuing four
months, Katarina received curative chemotherapy
consisting of dexamethasone and cyclophosphamide followed by reduced-dose clofarabine, etoposide and cyclophosphamide. Her clinical condition
worsened with profound myelosuppression and further progression of the abdominal tumour masses.
Intensive chemotherapy was therefore stopped.
End of life care in the home
Katarinas parents agreed to end of life palliative

care in the family home. A multidisciplinary team
from an established 24-hour paediatric mobile hospice care service assumed responsibility of Katarinas
complete symptom management. The home was
equipped with oxygen and a supply of anti-emetics,
laxatives, and sterile dressings. The nursing team incorporated Katarinas mother into the daily routine
of her daughters care while staying directly involved
in the childs hygiene to ensure that she didnt develop pressure ulcers. They also monitored Katarinas pain using the Faces Pain Rating ScaleFPRS
(15) alerting the team physician when modification
to her analgesic therapy was required, thus resulting in superior pain control. Katarina was at high
risk for difficult to manage constipation owing to
her opiod dependence and reduced mobility caused
by increasing ascites. Oral laxatives, rectal suppositories, and enemas were used prophylactically and
therapeutically.
Katarinas first nights at home were characterized by
restlessness during sleep until she achieved an undisturbed sleeping pattern. She repeatedly verified her
mothers presence in the room throughout the night
via eye contact. Despite the medical management of
her shortness of breath and cough, she spent most
of the day and night in the Fowler position to alleviate her laboured breathing. Hydration and nutrition
were ensured with an oral regimen, easily digestible
foods, and nutritional supplements.
Short hospitals stays were necessary on occasion for
transfusions and albumin therapy to manage in-
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creasing ascites. During this time, she repeatedly verbalized her immediate wish to return home. While
in the hospital playroom, she drew predominantly
black and grey-coloured pictures throwing aside red
or yellow pencils when they were offered only to return to draw again with the black or grey pencils.
Once back in the family home and in the care of
the hospice team, the mother, nurses and a special
educator kept Katarina constantly stimulated and
motivated in playful activities. She found stability
and consolation in being read the same fairy tales
and watching the same videos repeatedly.
Parallel family care
The hospice nurses practiced effective communication with both Katarina and her mother. Their work
was based on interaction. In general it is true that
person's personality traits predetermine how to person establishes relationships with the surroungings
and whether the person contributes, when communicating, to the atmosphere of trust or on the
contrary sets it back. Also the nurse's approach and
communication leaves a response in the patient's
experiencing that may be even stronger due to the
patient's vulnerability. If the patient experiences
anxiety , uncertainty or fear owing to their state of
health or a situation they are in, than the patient requires the atmosphere of safety, understanding and
support (16). Katarinas mother received medical,
psychological, and emotional support from hospice
care doctors, nurses, psychologists and the case social worker. She was exhausted both mentally and
physically having accompanied Katarina through
her initial lengthy treatment for ALL, the diagnosis of her secondary histiocyctic sarcoma, its failed
treatment culminating in home-based end of life
palliative care. Her anxiety and fears were managed
through psychological support and anti-anxiety
medication while the childs grandparents provided
additional emotional support.
The Final Stage
While still in the family home, Katarina gradually

stopped communicating with the multidisciplinary
team members, her grandparents, and then her
mother. She exhibited signs of silent suffering, preferred to remain alone in her room and communi-
cated only minimally with her favourite stuffed toy.

Her clinical status deteriorated over several days
with a decrease in level of consciousness, worsening
dyspnoea, a cold grey paling of the skin, urinary retention, marked facial, and lower extremity oedema.
Approximately 7 months following the diagnosis of
histiocyctic sarcoma, Katarina died surrounded by
her mother and grandparents, in a quiet home environment from progression of the underlying disease,
respiratory failure, and cardiac arrest.
DISCUSSION
The World Health Organization defines palliative

care for children as the active total care of the child's
body, mind, and spirit, which also involves giving
support to the family. Its purpose is to improve the
quality of life of young patients and their families,
and in the vast majority of cases the home is the best
place to provide such care (17). Paediatric palliative
hospice care relies on the value of the home as the
place where one lives, rejoices, dies, and mourns. To
be at home is a natural need of each child. Home
is the place that best meets the needs of terminally
ill and dying children (12). This case study demonstrates that the goals of paediatric palliative care can
be achieved in the home environment by a multidisciplinary professional hospice health care team even
in children with difficult to treat, rare, fatal malignancies. Reported that the death of a child due to
cancer brings more distress to the childs parents
than the death of a child due to another chronic illness (18). That life after the loss of a child is difficult,
full of pain and sorrow and that such pain cannot
be removed or avoided. It can be however, partially
shared with others.
The benefits of an established paediatric hospice
home care program also extend beyond the child
and the childs family to the oncology nurses working in large specialized paediatric haematology-oncology institutions. End of life paediatric palliative
hospice home care therefore provides a certain degree of emotional protection for nurses by relieving
these hospital-based professionals from the repeated
experience of sharing in the dying process.
Given the benefits of the paediatric home-based
hospice care illustrated by this single case study,
implementation of such services on a national scale
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would thus greatly improve the provision of quality

multidisciplinary paediatric oncology health care in
Slovakia.
4. Hunger SP, Lu X, Devidas M, Camitta BM, Gaynon PS, Winick NJ, Reaman GH, Carroll WL. Improved Survival for Children and Adolescents With
Acute Lymphoblastic Leukemia Between 1990 and 2005: A Report From
the Children's Oncology Group. J Clin Oncol. 2012; 30(14):1663-9
CONCLUSION
5. Vos J, Abbondanzo SL, Barekman CL, Andriko JW, Miettinen M, Aguilera

NS. Histiocytic sarcoma: a study of five cases including the histiocyte
marker CD163. Modern Pathology. 2005; (18):693704.
In this case report, we describe the case of a 3-yearold child who received family-centered palliative
care in the home for the rare secondary malignancy
of histiocytic sarcoma. Through case reporting we
have highlighted the challenges encountered in providing home-based hospice care to a child in the
terminal stages of life and identified its concrete
benefits to the child, her family, hospital-based oncology nurses, and its potential impact on a nationwide basis. This case report also serves to underscore
the importance of cooperation between the childs
parents, in this case the mother, and the paediatric
hospice home care multidisciplinary team, as well as
the participation of the university department paediatric haematology-oncology health care team.
6. Chang KL. Histiocytic Sarcoma. Accessed May 2013. www.lasop.org/pgs/

hdouts/2006-05_Case5.pdf
7. Pileri SA, Grogan TM, Harris NL, et al. Tumours of histiocytes and accessory dendritic cells: an immunohistochemical approach to classification
from the International Lymphoma Study Group based on 61 cases. Histopathology. 2002;41(1):129.
8. Buonocore S, Valente AL, Nightingale D, Bogart J, Souid AK. Histiocytic
Sarcoma in a 3-Year-Old Male: A Case Report. Pediatrics, published online
July 15, 2005.
9. Jain M, Nangia A, Bajaj P. Malignant histiocytosis in childhood: A case report. Diagn Cytopathol. 1999;21(5):359-61.
10. Dalle JH, Leblond P, Decouvelaere A, Yakoub-Agha I, Preudhomme I,
Nelken B, Mazingue F. Efficacy of thalidomide in a child with histiocytic sarcoma following allogeneic bone marrow tranplantation for T-ALL. Leukemia.
2003;(17):20562057.
11. Li YX, Wu HJ, Zhang JJ, Pan KL, Yu P, Fu X, Wang Z. A case report
of childhood histocytic sarcoma. Zhongguo Dang Dai Er Ke Za Zhi.
2010;12(5):405-6. [Article in Chinese]
12. Jasenkov, M. How to live together unitl the end. 1st edition. Bratislava:
Cicero, 2005. p 13.
13. Shivani S. Tripathi, et al. Pediatric Palliative Care in the Medical Home.
Pediatric Annals. 2012;41(3):112-116.
COMPETING INTERESTS
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Wongs Essentials of Pediatric Nursing, 6th ed, St. Louis, 2001, p. 1301.
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Journal of Health Sciences 2013;3(3)
http://www.jhsci.ba
INSTRUCTIONS FOR AUTHORS

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

or it is requested by the editorial staff. For authors who do not have
the possibility to submit online, the printed manuscript has to be
mailed, together with an electronic version on CD or DVD at the
following address: the Journal of Health Sciences, Faculty of Health
Studies, University of Sarajevo, 71000 Sarajevo, Bolnicka 25, Bosnia
and Herzegovina.
Types of papers that can be sent for publication in the JHS
Editorial policy
Original paper: original experimental laboratory and clinical studies should not exceed 4500, including tables and references.
Case report: presentation of clinical cases that may suggest the creation of new working hypotheses, with appropriate overview and
references. The text should not exceed 2400 words.
Review Article: Articles of renowned scholars, invited to write
them for the JHSci. The editorial board will also review individual
applications.
Editorial: short articles or comments which represent the opinions
of recognized leaders in medical research.
Authorship
All authors must sign the submission form. It is necessary that all
authors of confirm with their signature that: they meet the criteria
for authorship in the work, established by the International Committee of Medical Journal Editors; believe the manuscript represents honest work and being able to validate these results. Authors
are responsible for all statements and opinions in their papers.
More information is available at (http://bmj.com/cgi/collection/
authorship).
Submitting a manuscript for publication

The manuscript to be sent to JHSci must be in accordance to the
policy on the content, appearance and quality, which is defined
in these instructions for authors and the web site of the Journal,
www.jhsci.ba. Policy about the content, appearance and quality
of scientific research in JHSci is in accordance with international
recommendations and propositions given by the International
Committee of Medical Journal Editors: "Uniform Requirements for
Manuscripts Submitted to Biomedical Journals" New Engl J Med
1997, 336:309-315 (www.icmje.org), and the recommendations of
the international working group to standardize the appearance and
quality of scientific papers: STROBE (www.strobe-statement. org),
CONSORT (www.consort-statement.org) STARDA (www.stardstatement.org) and others.
Templates
JHSci prepared templates for the layout and content of scientific
work. Templates contain all the necessary subheadings and are
supplemented with the instructions on the contents of each chapter
which could facilitate the process of writing of paper. JHSci recommends the use of templates for writing research papers. Templates
can be found on the website of the journal www.jhsci.ba at the Information for authors section.
Submission form
All the authors must sign a submission form. It contains the permission to publish the submitted manuscript, statement of conflict of
interest, a statement of respecting the ethical principles in research
and a statement on the transfer of copyright to JHSci. This form has
to be downloaded from the web site www.jhsci.ba, printed, filled
out and scanned. If there are two scanned files they must be compressed to a ZIP file.
Plagiarism or duplication of a published work

Authors confirm with signature that at the time of submitting the
manuscript has not been published in its present form or substantially similar form (in paper or electronic form, including on the
website), that has not been accepted for publication in another
journal, or considered for publication in another journal. The International Committee of Medical Journal Editors has given a detailed
explanation of what is a duplicate (www.icmje.org). More information can be found on www.jhsci.ba.
Patient consent form
Protecting patients' rights on privacy is of paramount importance.
Authors should, if the editors request, send copies of patient consent form which clearly show that patients, or other subjects of the
experiments, give permission for publishing of photographs and
other material that could identify them. If authors do not have the
necessary consent for research, they must exclude the data that
identifies the subject.
Approval of the Ethics Committee
Authors must clearly state in the submission form and in the manuscript, in section "Methods", that the study conducted on human
subjects or patients is approved by the national or local Ethics committee. More information can be found in the latest version of the
Helsinki Declaration (http://www.wma.net/e/policy/b3.htm). Also,
authors must confirm that experiments involving animals were
conducted in accordance with ethical standards.
Statement on Conflict of Interest
Authors are required to include all sources of financial assistance
they received for research (grants for projects, or other sources of
funding). If you are sure that there is no conflict of interest, then
state it briefly. For more information, see the editorial in the British
Medical Journal, "Beyond conflict of interest '(http://bmj.com/cgi/
content/short/317/7154/291).
Uploading the files

Uploading of files is exclusively done through the website www.jhsci.ba, using the web form. Web form contains four pages: 1. list of
items to be considered prior to the submission of work; 2. Information on the author for correspondence; 3. information on the
manuscript; 4. part for sending files. In the web form, authors are
required to properly fill out the information, enter correct e-mail
address for correspondence, and send the 2 files: 1. submission
form (ZIP); 2. Manuscript (doc, docx, rtf). IT IS NOT NECESSARY to send the printed version, unless the authors want to pres-
271
Publishing Rights
In the submission form the authors are required to transfer publishing rights to the Faculty of Health Studies. The transfer of the
copyright becomes valid if and when the manuscript is accepted for
publication. The general public has the right to reproduce the contents or a list of articles, including abstracts for internal use at their
institutions. Publisher's consent is required for the sale or distribution outside the institution and for other activities arising from the
distribution, including compilations and translations. If the copy-
Instructions and guidelines to authors for the preparation and submission of manuscripts in the Journal of Health Sciences
righted materials are used, authors must obtain written permission

from the publisher and properly cite the reference in the article.
Formatting (appearance, layout) of manuscripts
Templates
JHSci has provided template on its website www.jhsci.ba according
to which manuscript should be formatted. Templates also contain
instructions made by the working group to standardize the format
of writing of scientific papers and objectively show the results of
the study. More information about the structure of scientific papers can be found on the website www.jhsci.ba and on the website
of the working groups www.consort-statement.org, www.strobestatement.org, www.stard-statement.org, and others. Templates can
be downloaded at the following link: http://jhsci.ba/informationfor-authors.html
Abbreviations and symbols
Abbreviations should be defined at their first appearance in the
text. Those not internationally recognized should be avoided. Use
of standard abbreviations is recommended. It is necessary to avoid
abbreviations in the title of manuscript and abstract.
Keywords
After the abstract, 3-10 key words or short phrases should be written, that will assist in indexing the article. Whenever possible, use
terms from Medical Subject Headings list of the National Medical
Library (MeSH, NLM). For more information:
(http://www.nlm.nih.gov/mesh/meshhome.html).
Text
The text of the work must be formatted in standard scientific format.
More information can be obtained by downloading templates from the
website of the journal: http://jhsci.ba/information-for-authors.html
Review articles may have a different structure.
The introduction is a concise part of manuscript. It must contain a
description of the problem that this paper deals with, by showing
the problem from the broader context and current situation, moving to specific problem which this paper tries to resolve. At the end
of the introduction it is necessary to clearly point out the purpose,
goals and/or hypothesis this study.
Methods. This section should be brief. The templates that JHSci has
provided on the website have more information about the content
of this chapter.
Results. Give priority to a graphical representation of the results of
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-
272
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).
Journal of Health Sciences 2013;3(3)
http://www.jhsci.ba
UPUTSTVO AUTORIMA
Upute i smjernice autorima za pripremu i predaju rukopisa u Journal of Health Sciences
Ciljevi i okvir asopisa
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.
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.
Pravila redakcije
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.
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.
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.
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.
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.
Izjava o sukobu interesa

Od autora se zahtjeva da navedu sve izvore finansijske pomoi koje
su dobili za istraivanje (grantovi za projekte, ili drugi izvori finansiranja). Ako ste sigurni da nema sukoba interesa, onda to i navedite kratko. Za vie informacija pogledajte uvodnik u British Medical
Journal, 'Beyond conflict of interest' (http://bmj.com/cgi/content/
short/317/7154/291).
Slanje rada
Vri se iskljuivo preko web stranice www.jhsci.ba preko predvienog web formulara. Web formular sadri etiri stranice na kojima
se nalazi: 1. popis stavki koje treba ostvariti prije podnoenja rada;
2. informacije o autoru za korespondenciju; 3. informacije o naunom radu; 4. dio za slanje fajlova. U web formularu autori su
duni ispravno popuniti informacije, unijeti ispravnu e-mail adresu za korespondenciju, te poslati 2 fajla: 1. Pismo za podnoenje
rada; 2. Nauni rad. NIJE POTREBNO slati tampanu verziju, osim
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
273
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.
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).
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
274
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)

Aida Rudi (BiH)

Renata Dobrila Dintinjana (CRO)

Fatima Jusupovi (BiH)

Mirsad Mufti (BiH)

Budimka Novakovi (SRB)

Borut Poljak (SI)

Isabelle Rishard (F)

Sandra Vegar-Zubovi (BiH)

Impact of management on employees communication in medical

Munevera Hadimei et al. Journal of Health Sciences 2013;3(3):88-195

Journal of Health Sciences

Post anesthesia recovery rate evaluated by using

Munevera Hadimei et al. Journal of Health Sciences 2013;3(3):88-195

piration of gastric content whit consequent development of aspiration pneumonia, laryngospasm,

gery. It included 90 patients hospitalized in period

Results are displayed in numeric-percentual form,

Munevera Hadimei et al. Journal of Health Sciences 2013;3(3):88-195

Study was conducted in University Clinical Centre

no significant difference (p=0. 61). Depending on

FIGURE 1. White fast tracking scoring system, assessment

Munevera Hadimei et al. Journal of Health Sciences 2013;3(3):88-195

significantly faster recovery from anesthesia only

White and Song in there study examined 216 women

Munevera Hadimei et al. Journal of Health Sciences 2013;3(3):88-195

in early recovery of cognitive function, incidence

Munevera Hadimei et al. Journal of Health Sciences 2013;3(3):88-195

9. N Bharti, P Chari, P Kumar. Effect of sevoflurane versus propofol based

Hilada Nefic et al. Journal of Health Sciences 2013;3(3):196-204

Journal of Health Sciences

The effects of sex, age and cigarette smoking on

*Corresponding author: Hilada Nefic

The Buccal Micronucleus Cytome (BMCyt) assay

Hilada Nefic et al. Journal of Health Sciences 2013;3(3):196-204

served in cells collected from female smokers than

Hilada Nefic et al. Journal of Health Sciences 2013;3(3):196-204

as Blooms syndrome. The biomarkers measured in

Exfoliated cells of the human buccal mucosa for the

TABLE 1. Selected characteristics of the studied subjects (mean SD per subject).

Current smokers Cigarettes per day Years smoking

Hilada Nefic et al. Journal of Health Sciences 2013;3(3):196-204

considered to be smokers. These groups (smokers

The presence of statistically significant differences

The sample included 120 subjects, 67 females

5.723.53 0.020.13 1.351.15

6.304.95 1.661.86 1.721.20 5.222.94 0.000.00 1.571.34

8.046.89 2.573.74 2.181.85 6.294.09 0.040.19 1.080.78

Hilada Nefic et al. Journal of Health Sciences 2013;3(3):196-204

25.626.15 17.629.26 6.975.78

7.174.24 0.030.18 1.781.35

4.271.76 0.000.00 0.930.71

between males and females in relation to age (t =

(KYL cells) and nucleus fragmentation (PYC cells)

FIGURE 2. The frequencies of micronuclei and other nuclear

Hilada Nefic et al. Journal of Health Sciences 2013;3(3):196-204

formed. In the sample including both males and

The cells with anomalies other than MNi, such as

Hilada Nefic et al. Journal of Health Sciences 2013;3(3):196-204

of nuclear alterations, PYK (r = 0.5198; p = 0.003),