JHSCI 2012 v2 I3 December

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

Editorial Board
Editor in chief
Advisory Board
Dijana Avdi (BiH)
Kasim Bajrovi
Mirza Dili
Associate editor
Faris Gavrankapetanovi
Demal Pecar (BiH)
Ismet Gavrankapetanovi
Mirsada Huki
Secretary
Sebija Izetbegovi
Aida Rudi (BiH)
Lidija Lincender
Slobodan Loga
Members
Farid Ljuca
Renata Dobrila Dintinjana (CRO)
Senka Mesihovi-Dinarevi
Fatima Jusupovi (BiH)
Muzafer Muji
Mirsad Mufti (BiH)
Ljerka Ostoji
Budimka Novakovi (SRB)

Naris Pojski (BiH)
Electronic Publishing
Borut Poljak (SI)
Refet Gojak
Isabelle Rishard (F)
Muris Pecar
Sandra Vegar-Zubovi (BiH)

Zarema Obradovi (BiH)
Technical editor
Faruk pilja
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Volume 2, Number 3, December 2012
Table of contents:
REVIEW
Osteoporosis and osteoarthritis: similarities and differences
DIJANA AVDI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165-168
RESEARCH ARTICLES
Serum Matrix Metalloproteinase-2, -7 and -9 (MMP-2, MMP-7, MMP-9) levels as Prognostic Markers
in Patients with Colorectal Cancer
ELENA KOSTOVA, MAJA SLANINKA-MICESKA, NIKOLA LABACEVSKI, KRUME JAKJOVSKI,
JASMINA TROJACANEC, EMILIJA ATANASOVSKA, VLADO JANEVSKI, REDZEP SELMANI,
GORDANA PETRUSHEVSKA, VESNA JANEVSKA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169-175
A comparison of efficacy of femoral and tibial fractures healing treated by static and dynamic intramedullary nails
EMIL OMEROVI, DIJANA AVDI, FARUK LAZOVI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176-183
Age and gender related differences in free fatty acid levels in patients with type 2 diabetes mellitus
AIRA MANDAL, ADLIJA AUEVI, MAJA MALENICA, EHERZADA HADIDEDI,
BESIM PRNJAVORAC, SABINA SEMIZ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184-191
Chemical composition, antimicrobial and antioxidant properties of Mentha longifolia (L.) Huds. essential oil
HARIS NIKI, ELVIRA KOVA-BEOVI, ELMA MAKAREVI, KEMAL DURI . . . . . . . . . . . . . . . . . . . 192-200
Translation and validation of the instrument for the oral health-related quality of life assessment
in 3 to 5 years old children in Bosnia-Herzegovina
AMRA HADIPAI-NAZDRAJI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201-206
The role of multi slice computed tomography in the evaluation of acute non-cardiac chest pain
SANDRA VEGAR-ZUBOVI, SPOMENKA KRISTI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207-214
Motivation of health professionals and associates to perform daily job activities
SUVADA VRAKI, AMER OVINA, ELVEDIN DERVIEVI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215-219
Distribution of ABO blood group in children with acute leukemias
MELIHA SAKI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220-223
Analysis of the relation between intelligence and criminal behavior
DRAGAN JOVANOVIC, MILAN NOVAKOVIC, ALEKSANDRA SALAMADI,
NOVICA PETROVIC, SANJA MARIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224-231
CASE REPORTS
Ruptured intracranial dermoid cyst: a case report
AJLA RAHIMI-ATI, MAIDA NIKI, ZLATA KADENI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232-235
Awake fiberoptic intubation of a patient with amyotrophic lateral sclerosis: case report
ELIF BAKI, ELIF BUYUKERKMEN, YKSEL ELA, SERDAR KOKULU, REMZIYE SIVACI . . . . . . . . . . . . 236-237
INSTRUCTIONS TO AUTHORS
Instructions and guidelines to authors for the preparation and submission of manuscripts
in the Journal of Health Sciences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238-241
www.jhsci.ba
Osteoporosis and osteoarthritis:

similarities and differences
Dijana Avdi
Faculty of Health Studies, University of Sarajevo, Bolnika 25, Sarajevo, Bosnia and Herzegovina
Abstract
Osteoporosis and osteoarthritis are two different medical conditions, which beside the first part of their name
osteo, have very little in common. Osteoporosis is a disorder which influences bones in terms of reduction
of quality and quantity, which can easily result in bone fracture. Clinical signs of osteoporosis show no pain
or other symptoms which could point to changes in bone structure, unless a bone fracture is diagnosed.
Osteoarthritis is a disease which influences joints and its surrounding tissues. Seeing through clinical signs,
changes could be verified in terms of pain and limitations of movement and the cause of pain and way of its
treatment are numerous. A person can suffer from osteoporosis and osteoarthritis at the same time. Although
these medical conditions are more frequent in female than in male population, mechanisms which lead to
them may interfere. Osteoporosis and osteoarthritis are muscular-bone disorders with significant morbidity
and mortality, but clinical experiences and epidemiological studies have shown their negative correlation.
2012 All rights reserved
Keywords: osteoporosis, osteoarthritis, similarities, differences
Introduction
Although osteoporosis and osteoarthritis, as medical disorders, have different etiology, pathology
as well as clinical signs and symptoms, having
similar name often leads to a confusion between
patients and doctors. Beside the same first part of
the name of these two medical disorders, osteo,
osteoporosis and osteoarthritis have very little in
common. Osteoporosis is a disease which influences bones in terms of reduction of quality and
quantity, which can easily result in bone fracture.
Clinical signs of osteoporosis show no pain or
other symptoms which could point to changes
in bone structure, unless a bone fracture is diagnosed. Osteoarthritis is a disease which influences
joints and surrounding tissues of a body. Seeing
through clinical signs, changes could be verified
in terms of pain and limitations of movement and
the cause of pain and way of its treatment are numerous. Osteoporosis is commonly accepted as
* Corresponding author: Dijana Avdi,
Faculty of Health Studies, University of Sarajevo,
Bolnika 25, Sarajevo, Bosnia and Herzegovina
Phone: +387 62 83 80 37
E-mail: dijana2007@gmail.com
Submitted 3 November 2012/ Acceped 6 December 2012
JOURNAL OF HEALTH SCIENCES 2012; 2 (3)
a bone disorder while osteoarthritis is generally

considered as a joint' cartilage disorder. The causes
which are included in the pathophysiology of osteoporosis can also be included in the pathophysiology of osteoarthritis of the subchondral bone.
The treatment is available for both medical disorders and it can help in reduction of medical disorder' symptoms and improve the quality of life (1,2).
If the person suffers from osteoporosis and osteoarthritis at the same time, specifically planned
program of treatment should be applied in terms
of changes' control in both disorders. This situation requires management of both disorders in
terms of determination of proper and adequate
physical activity. The recommended program of
treatment for osteoporosis includes regular physical activity and the same can be extremely hard to
follow if the patient has significant osteoarthritic
degenerative changes verified in hip or knee joint.
Therefore the physical activity program should be
adapted to one and another degenerative disorder.
What is osteoporosis?
According to the definition of the World Health
Organization (WHO) osteoporosis is a disease
which appears as a consequence of bone mass re165
DIJANA AVDI: OSTEOPOROSIS AND OSTEOARTHRITIS: SIMILARITIES AND DIFFERENCES
duction and bone morphology disorder. Therefore

bone fractures become more often. According to
the WHO' data, osteoporosis is the most frequent
bone metabolic disorder (3,4). Nowadays, it is
even more present than ever and the most frequent
cause of it is modern way of living and extended
life expectancy. Osteoporosis is a condition of reduced quantity (mass) of the bone below the limits
necessary to preserve the integrity of the skeleton.
The leading symptom is loss of bone mass, which
results in brittle bones easily. The cells in bones are
constantly renewed, but with the bone age it is becoming less valuable mechanically so as to maintain the mechanical quality, it is being remodeled.
Osteoporosis is characterized by low bone mass
due to an imbalance in favor of bone resorption,
leading to changes in bone remodeling. Osteoporosis represents changes in bone density as well
as in bone quality, including not only changes in
the microarchitecture, but also changes in bone
remodeling, remodeling and mineralization of
microcracks (5). The remodeling process takes 3-4
months, and the same amount of bone that was
destroyed is being renewed. The complete reconstruction of the bone takes 10 years. In the process
of osteoporosis the destroyed bone is not restored
completely and bone mass decreases. The bones become hollow and crumbling at the least shock (1).
Pathogenesis and pathophysiology of osteoporosis
is multifactorial: genetics, age, a lack of estrogen,
diet and insufficient physical activity. Osteoporosis
is followed by reduced mobility, pain in bones and
joints, cramps and muscle weakness, a decrease in
body height, an increased risk of bone fractures,
and even spontaneous fractures. More than 90%
of hip and spine fractures are caused by osteoporosis, and osteoporotic fractures constitute of 45%
of vertebral fractures, 16% of the upper femur
(hip), 16% of distal forearm and 20-25% are other
fracture localization (pelvis, upper arm, ribs) (1).
What is osteoarthritis?
Osteoarthritis is the most common rheumatic
disease that affects the joints, although various
extra-articular structures can be affected. Approximately 10% of the population in general
has problems due to osteoarthritis. This disease
particularly affects older people and it is estimated that more than 60% of people aged above
166
35 years suffer from osteoarthritis. About 55% of

people with osteoarthritis have difficulty in performing activities of daily living, and about 25%
of them do not perform these activities. Only
osteoarthritis of knee joint causes disability as
chronic heart and lung disease combined (5).
Pathogenesis and pathophysiology of osteoarthritis is multifactorial: being overweight, the aging
process, joint injury or stress, heredity, muscle
weakness. Osteoarthritis often develops in the
joints in which vicinity were fractured bones. It often affects cervical or lumbar spine, hip and knee.
Cartilage damage in osteoarthritis is the result of
an imbalance of enzymes that are released from
the cells of articular cartilage (matrix metalloproteinases, aggrecanases and other enzymes). When
the enzymes that destroy and build cartilage are
produced in equal amounts, cartilage naturally
regenerates, and when enzymes of degradation are over-produced, cartilage damage occurs.
Differential characteristics of reduction of
muscle fibers in osteoporosis and osteoarthritis
Osteoporosis is associated with the presence of
type II muscle fibers in the stage of decrease in
muscle mass, bone mineral density and with reduced levels of AKT (protein kinase B - PKB), as
the main regulator of muscle mass. Osteoarthritis
is connected with the muscle reduction which is
expressed to a lesser extent, but in direct relation
with disease duration and severity. Osteoarthritis and osteoporosis are associated with reduced
muscle mass and muscle strength, but still there
are no morphological studies on the reduction of
muscle tissue, so the basic mechanisms of reduction of muscle mass are not yet known. The aim
of the study Terracciano C. et al. was to assess the
relationship osteoporosis - osteoarthritis with a reduction in muscle mass and correlation with disease severity. Muscle protein levels of AKT, specifically a component IGF-1/PI3K/Akt pathway is a
major regulator of muscle mass. AKT is known as
protein kinase B (PKB); it is the serine / threoninespecific protein kinase that plays a key role in several cellular processes such as glucose metabolism,
apoptosis, cell proliferation, transcription and cell
migration. Muscle biopsy was performed in 15
women with osteoporosis and in 15 women with
osteoarthritis (age range, 60-85 years). According

to statistical analysis, type II fibers are decreased
in muscle mass which correlates with bone mineral density (BMD) in the group of women with
osteoporosis and Harris Hip Score (HHS), and
duration of illness in a group of women with osteoarthritis. HHS is a tool for assessing the functionality after hip arthroplasty. The results showed
that in women with osteoporosis, type II muscular fiber atrophy correlates inversely with BMD.
In the group of women with osteoarthritis, muscle
atrophy was noticed to a lesser extent, and there
was homogeneity among the types of fiber related
to duration of disease and HHS. Within a group
of women with osteoporosis, the level of AKT was
significantly reduced compared to the muscles
in the group of women with osteoarthritis. This
study shows that osteoporosis is connected with
frequent diffuse type II muscle fiber atrophy, in
proportion to the degree of bone loss, whereas
in osteoarthritis, muscle atrophy is associated
with functional impairment caused by disease (7).
Osteoarthritis and osteoporosis clinical and
research evidence of inverse relationship
Osteoporosis and osteoarthritis, as serious medical
conditions, have two characteristics in common;
both are associated with aging and multifactorial.
Although the relationship between osteoporosis
and osteoarthritis is especially important, as the
inverse relationship, the two diseases are studied
for the last 30 years, and yet their relationship is
controversial and stimulating for further study.
Regarding the anthropometric characteristics of
patients with osteoarthritis compared to people
with osteoporosis, following are well established.
People who have osteoarthritis have a stronger
body structure and more obesity, and increased
BMD. This increase in BMD was also linked to
higher values of bone mass. With aging, bone
loss in osteoarthritis is lower unless when measured in the vicinity of the affected joints (hand,
hip, knee). A small degree of bone loss with aging is explained by lower degree of bone resorption. People with osteoarthritis in effective have
higher bone density, but wider measures of skeletal geometry, the diameter of long bones and
trabeculae, which positively contributes to better
strength and lower bone fragility. Osteoarthritis is characterized with an increased content of
growth factors such as IGF and TGF beta, which

are required for the regeneration of bone. Experimental evidence show that osteoclasts have metalloproteinase that directly or indirectly from the
matrix creates a precondition for a deterioration
of a medical finding of cartilage. The capacity of
osteoblastic bone regeneration in osteoporosis is
compromised in comparison with osteoarthritis.
The claim that drugs which suppress bone transport in osteoporosis may be useful for osteoarthritis, such as bisphosphonates, is incorrect (8).
Differences in the distribution of adaptive
mechanisms of femoral neck in osteoarthritis and osteoporotic fracture
Study of Rubinacci A. et al. refers to diversity of
adaptive mechanisms in the distribution of femoral neck in osteoarthritis and osteoporotic fracture.
It was done by comparative analysis of peripheral quantitative computed tomography (pQCT)
of femoral bone in 32 postmenopausal women
which were undertaken the hip arthroplasty due
to osteoarthritis or osteoporotic femoral fracture.
Adaptive mechanisms that are present on the
wrist, which is affected by osteoarthritis, lead to a
reduction in fracture risk, despite the presence of
osteoporosis, low bone density and bone mass. It
was found that the cortical bone volume and trabecular thickness is significantly (p <0.05) higher
in the group of women with osteoarthritis than
in the group with fractures. This study confirms
the presence of compensatory mechanisms in osteoarthritis in the preservation of the mechanical
ability of bone structure, regardless of low bone
density, bone mass and lower fracture risk (9).
Conclusion
Osteoporosis and osteoarthritis are two major
health problems of modern society, and can affect
the quality of life in different ways. Since both diseases are part of the aging process, one should take
all preventive measures and identify any joint pain,
and bone density test should be done in particular
age in order to check whether there are changes
that would indicate to osteoporosis. Both diseases
are complex disorders of the musculoskeletal system, although they show effect on different tissues, both are affecting the bones. A person may
have osteoporosis and osteoarthritis at the same
167
time. Although these disorders are more present

in women than men, the mechanisms that lead to
them may overlap. Osteoarthritis and osteoporosis are senile musculoskeletal disorders with significant morbidity and mortality, and clinical ex-
perience and epidemiological studies have shown

that there is a negative correlation between them.
Conflict of interest
None to declare.
References
[1] Avdi D, Buljugi E.: Kako sprijeiti, kako lijeiti osteoporozu. Tuzla: Off-set, 2008.
[2] Lajeunes se D, Pelletier J-P, Martel-Pelletier J. Osteoporosis and osteoarthritis: bone is the common battleground.
Medicographia. 2010;32:391-398
[3] Rizzoli R, Bruyere O, Cannata-Andia JB, Devogelaer J-P, Lyritis G, Ringe JD, et al. Management of
osteoporosis in the elderly. Curr Med Res Opin
2009;25(10):2373-2387. PubMed PMID: 19650751. doi:
10.1185/03007990903169262.
[4] Watts NB, Lewiecki EM, Miller PD, Baim S. National Osteoporosis Foundation 2008 Clinicians Guide to Prevention and Treatment of Osteoporosis and the World Health
Organization Fracture Risk Assessment Tool (FRAX):
what they mean to the bone densitometrist and bone technologist. J Clin Densitom 2008;11(4):473-477. PubMed
PMID: 18562228. doi: 10.1016/j.jocd.2008.04.003.
[5] Jang IG, Kim IY. Computational simulation of simultaneous cortical and trabecular bone change in human
proximal femur during bone remodeling. J Biomech
168
[6]
[7]
[8]
[9]
2009;43(2):294-301. PubMed PMID: 19762027. doi:

10.1016/j.jbiomech.2009.08.012.
Sluka KA. Osteoarthritis and rheumatoid arthritis. In:
Sluka KA, editor. Mechanisms and management of pain
for the physical therapist. Seattle: IASP Press; 2009.
Terracciano C, Celi M, Lecce D, Baldi J, Rastelli E, Lena
E, et al. Differential features of muscle fiber atrophy in
osteoporosis and osteoarthritis. Osteoporos Int 2012 Apr.
PubMed PMID: 22535191. doi: 10.1007/s00198-0121990-1.
Dequeker J, Aerssens J, Luyten FP. Osteoarthritis and
osteoporosis: clinical and research evidence of inverse
relationship. Aging Clin Exp Res 2003;15(5):426-439.
PubMed PMID: 14703009.
Rubinacci A, Tresoldi D, Scalco E, Villa I, Adorni F, Moro
GL, et al. Comparative high-resolution pQCT analysis of
femoral neck indicates different bone mass distribution
in osteoporosis and osteoarthritis. Osteoporos Int. 2012
Jul;23(7): 1967-75. Epub 2011;23(7):1967-75. PubMed
PMID: 21947103. doi: 10.1007/s00198-011-1795-7.
www.jhsci.ba
Serum Matrix Metalloproteinase-2, -7 and -9

(MMP-2, MMP-7, MMP-9) levels as Prognostic
Markers in Patients with Colorectal Cancer
Elena Kostova1*, Maja Slaninka-Miceska1, Nikola Labacevski1, Krume Jakjovski1, Jasmina Trojacanec1,
Emilija Atanasovska1, Vlado Janevski2, Redzep Selmani2, Gordana Petrushevska3, Vesna Janevska3
Department of Preclinical and Clinical Pharmacology and Toxicology, Faculty of Medicine, Ss. Cyril and Methodius University,
50 Divizija bb, 1000 Skopje, Republic of Macedonia. 2 Digestive Surgery Clinic, Faculty of Medicine, Ss. Cyril and Methodius
University, Skopje, R. Macedonia. 3 Department of Pathology, Faculty of Medicine, Ss. Cyril and Methodius University, 1000
Skopje, Republic of Macedonia.
Abstract
Introduction: Matrix metalloproteinases are produced by tumour cells, hence, they may be associated with
tumour progression including invasion, migration, angiogenesis and metastasis. Finding prognostic markers
to better identify patients with higher risk for poor survival would be valuable in order to customize pre- and
postoperative treatment as well as to enable closer follow-up of these patients. Aim of our study was to examine MMP-2, MMP-7 and MMP-9 serum levels and correlated them with pathological data such as stage of
the colorectal cancer (CRC) and outcome.
Methods: The investigation included 82 patients with operable CRC without distant metastases, who had
underwent blood tests in order to determine the MMP-2, MMP-7 and MMP-9 serum levels in the following
time periods: preoperatively, 3, 6, 9 and 12 months postoperatively.
Results: The values of the investigated MMPs decrease postoperatively and start to increase 6 month later
in patients of all stages of the disease, reaching the highest value 12 month postoperatively with statistically
important differences of MMP-2, MMP-7 and MMP-7 serum levels in terms of disease staging and defined
points of time. Analysis of the results showed that the MMP-2 serum levels obtained 3 and 12 months postoperatively, than MMP-7 serum levels 12 months postoperatively and the MMP-9 serum levels in all analyzed
points in time were in significant association with the CRC patientsoutcome.
Conclusion: The MMP-2, MMP-7 and especially MMP-9 serum values could be important indicators for
diagnosis of the patients with CRC and for monitoring of disease progression.
Keywords: colorectal cancer, matrix metalloproteinases, staging, prognosis.
Introduction
The degradation of extracellular matrix (ECM)
is a crucial step in tumour progression, aggressive growth and metastases. The invasion of
cancer cells within the basement membrane depends on matrix metalloproteinases (MMPs)
and their inhibition activities (1). MMPs are a
family of extracellular structurally related zinc* Corresponding author: Elena Kostova, Department of
Preclinical and Clinical Pharmacology and Toxicology,
Faculty of Medicine, Ss. Cyril and Methodius University,
50 Divizija bb, 1000 Skopje, Republic of Macedonia
E-mail: eli_kos_pet@yahoo.com, Phone: +389 70 323534
Submitted 14 November 2012 / Accepted 16 December 2012
dependent endoproteases capable of degrading all the ECM components. At present, 23

members of the human MMP gene family are
known. Based on their structure and substrate
specificity, MMPs are classified into subgroups
of collagenases, stromelysins and stromelysinlike MMPs, matrilysins, gelatinases, membranetype MMPs (MT-MMPs) and other MMPs (1).
MMPs play an important role in the physiologic
degradation of ECM, e.g., in tissue morphogenesis,
tissue repair and angiogenesis. MMPs have also
important functions in pathologic conditions characterized by excessive degradation of ECM, such
as rheumatoid arthritis, osteoarthritis, periodon169
ELENA KOSTOVA ET AL.: SERUM MATRIX METALLOPROTEINASE-2, -7 AND -9 (MMP-2, MMP-7, MMP9) LEVELS AS PROGNOSTIC MARKERS IN PATIENTS WITH COLORECTAL CANCER
titis, autoimmune blistering disorders of the skin

and in tumour invasion and metastasis. MMPs are
produced by tumour cells; hence, they may be associated with tumour progression including invasion, migration, angiogenesis and metastasis (2, 3).
Among the MMPs, matrix metalloproteinase
2 (MMP-2) and matrix metalloproteinase 9
(MMP-9), as members of gelatinases, plays important roles in the migration of malignant cells,
because of their ability to degrade type IV collagen (4). The mechanisms of activation of these
enzymes are different. MMP-9 modulates permeability of the vascular endothelium, whereas
MMP-2 promotes cleavage of extracellular matrix proteins and is intensively expressed by tumour and stromal components of cancer (5).
Matrix metalloproteinase 7 (MMP-7) or matrilysin, as a member of stromelysins is able to induce
cell apoptotic impairment. Matrilysin can regulate
angiogenesis either by inducing a direct proliferative effect on vascular endothelial cells or producing angiogenesis inhibitors (angiostatin, endostatin and neostatin-7) or by enriching the variety
of angiogenesis mediators, such as the soluble
vascular endothelial growth factor (sVEGF) (6).
Increased levels of matrix metalloproteinase
in tumour tissues or in blood circulation have
been found to correlate with many cancers, including colorectal cancer (CRC). Several previous studies have shown that MMPs may
play an important role as an indicator for appearance of CRC and its progression (7, 8, 9).
Colorectal cancer (CRC) is a common disease
and it is one of the leading causes of cancer related deaths in developed countries (10). Despite
improvements in surgical techniques, adjuvant
and neo-adjuvant chemotherapy, the 5-year survival rate in patients with CRC ranges from 5-90%
with tumour progression (stages: I: 90-95%, II:
75-85%, III: 50-60% and IV: 0-10%). The prognosis in patients without distant metastasis varies
from 50-95% depending on the tumour stage (11).
The correct staging of each CRC patient is crucial
in order to plan an optimal treatment regimen. It
is widely recognised that prognostic information
based on clinical and histopathological investigation is insufficient, although tumour stage and
lymph node involvement are the main prognostic
tools in evaluating cancer specific survival. It is
170
questionable to expose a large number of patients

to adjuvant treatment with considerable side effects without indications that they will benefit
from such treatment. Finding prognostic markers to better identify patients with higher risk for
poor survival (12, 13) would be valuable in order
to customise pre- and postoperative treatment as
well as to enable closer follow-up of these patients.
In our study, we examined MMP-2, MMP7 and MMP-9 serum levels and correlated
them with pathological data such as stage
of the disease and the patients outcome.
Methods
The study included a total of 82 previously untreated CRC patients, 30 (36.58%) females and
52 (63.41) males (aged 43 to 75 years, mean age
of 67.85; SD9.67) with operable CRC, without detectable distant metastases, who respected the medical instructions and were available for follow-up. All patients underwent a
surgical resection of the primary neoplasm at
the University Clinic for Abdominal Surgery
in Skopje in the period of 2 years (2007-2009).
Blood samples from all patients were drawn before surgical treatment, as well as 3, 6, 9, and
12 months postoperatively in order to examine MMP-2, MMP-7 and MMP-9 serum levels. None of the CRC patients had received chemotherapy before blood sample collection. To
standardize clotting conditions, all sera were
separated within 1 h after blood collection,
aliquoted and stored at 80C until assayed.
Serum levels of MMP-2, MMP-7 and MMP9 were determined using a quantitative solid
phase sandwich enzyme-linked immunosorbent
assay (ELISA) (R&D Systems, USA) according to the manufacturer's instructions. MMP-2,
MMP-7 and MMP-9 technique can detect both
pro- and active forms of recombinant human
MMP-2, MMP-7 and MMP-9. High concentrations of MMP-2, MMP-7 and MMP-9 were diluted with calibrator, to produce samples with
values within the dynamic range of the assay.
The surgically removed specimens were histopathologically analyzed at the Institute of Pathology of the Faculty of Medicine, Skopje, where
the pathological stage was defined for every
patient according to the International Union
against Cancer (UICC-pTNM) and American Joint Committee on Cancer (AJCC) 2010.
Forty-three patients with stage II B and III (A,B,C)
received adjuvant chemotherapy at the Institute for Radiotherapy and Oncology in Skopje.
Correlations were made between the MMPs
serum levels and the pathological parameters.
Statistical analysis
Descriptive statistics (mean) are given according to normality of the distribution. Normality of
the distribution was determined by KolmogorovSmirnovs test. Analysis of variance with KruskallWallis test was first used in the analysis of different
sample types. In the case of significant results, the
analyses were continued by pairing the variables
and analysing them with Mann-Whitneys U-test.
Fishers exact probability test and Pearsons ChiSquare test (r) were used for testing the association (linearity of the correlation of serum concentrations) between MMPs and major prognostic
variables in CRC, such as grade and stage. P-values
less than 0.05 (p<0.05) were considered as statistically significant.
Results
There have been 17 (20.73%) patients in stage I of
the disease, 40 (48.78%) patients in stage II and
25 (30,48%) patients in stage III. Lymph node
TABLE 1. Staging of the disease in CRC patients according

to AJCC
Stage
I
II
III
pTNM
pT1 N0 M0
pT2 N0 M0
pT3 N0 M0
pT4a N0 M0
pT3 N1b M0
pT3 N2a M0
pT4a N1b M0
pT4a N2b M0
Number of
patients (n=82)
8
9
22
18
7
9
4
5
%
20.73
48.78
30.48
metastases were substantiated in 25 (30.48%)

patients and were not found in 57 (69.51%)
patients with different pT category (Table 1).
The majority of patients were with pT3N0M0 (26.82%), i.e. patients in stage II A
of the disease, and the smallest number of
patients were with pT4aN1M0 (4.87%),
i.e. patients in stage III B of the disease.
The mean MMP-2, MMP-7 and MMP-9 serum levels in terms of disease staging and defined points
of time are shown in Table 2, Figure 1 and Figure 2.
The mean MMP-2 serum levels shown in Table 1
and Figure 1, in patients with stage I of the disease,
decreased after the operation and started slightly to
increase after the 3th month postoperatively. This
might be due to the 6 patients with poor outcome in
FIGURE 1. Mean MMP-2 and MMP-9 (ng/mL) serum values in terms of disease staging and defined points of time
171
FIGURE 2. Mean MMP-7 (ng/mL) serum levels in terms of

disease staging and defined points of time
this group, with mean survival time of 28.5 months.

The obtained MMP-2 mean serum levels of the patients in stage II of the disease goes very similarly
to the mean serum levels of patients in stage I and
reaches the peak in the 12th month postoperatively; that may be due to the 19 out of 40 patients with
poor outcome, with mean survival of 26.66 months.
The mean levels of MMP-2 in patients in stage III of
the disease, decreased after tumour resection, increased abruptly after the 3 months postoperatively and continued to increase slightly after 6 months
postoperatively. This might be due to the poor outcome of more than half of the patients, 18 out of 25
patients with mean survival time of 21.8 months.

There was a significant difference between the
mean MMP-2 serum levels before tumour resection and after the operation, i.e. between the preoperative and postoperative levels during defined
control points of time in all encompassed CRC
stages. There was a significant difference of the
MMP-2 serum levels among the stages (p<0.05).
The mean MMP-7 serum levels are separately
shown in Figure 2, and they show a similar tendency of postoperative decreasing and permanent increasing after the 3 months, especially
in stage III. We did not find a significant difference between the MMP-7 serum levels in stage
I and stage II during each control points in time,
but there was a significant difference between
the MMP-7 serum levels from stage I and II
in terms of stage III (p<0.05). There was a significant difference between preoperative and
postoperative MMP-7 serum levels (p<0.05).
There were significant differences between
MMP-9 serum levels in all stages (p<0.01), as
well as between preoperative and postoperative serum levels in all defined points of time.
The number of patients who received chemotherapy and the outcome of all included
patients in the study are shown in Table 3.
We found significant differences in terms of
TABLE 2. Mean serum levels of MMP-2, MMP-7 and MMP-9 (ng/mL) in terms of disease staging and defined points of time
Stage
Preoperatively
3 months postoperat.
I
117.62
104.85
117.33
126.99
140.73
MMP-2 (ng/mL)
II
147.96
137.5
162.45
186
223.34
III
169.72
154.38
231.9
252
271.51
I
4.04
3.38
3.92
4.76
5.14
MMP-7 (ng/mL)
II
4.66
3.6
5.37
7.15
8
III
5.38
3.86
7.42
9.96
12.24
I
259.03
234
298.63
329.43
341.11
MMP-9 (ng/mL)
II
313.35
249.31
358.143
429.83
521.65
III
384.34
307.54
576.86
717.11
846.45
TABLE 3. Patients with different stage of the disease who received chemotherapy and the outcome of the disease
Stage
N=82
Stage I
Stage II A
Stage II B
Stage III B
Stage III C
Total
172
With
chemotherapy
/
/
18
20
5
43
%
/
/
21.95
24.39
6.09
52.43
Without
chemotherapy
17
22
/
/
/
39
%
20.73
26.82
/
/
/
47.56
Poor
outcome
6
8
11
15
3
43
%
7.31
9.75
13.41
18.29
3.65
52.43
TABLE 4. Statistically significant correlations with poor outcome in CRC patients

Parameter
Stage
pT
pN
MMP-2 preoperatively
MMP-2 3 months postoperat.
MMP-2 6 m postoperatively
P
<0.01
<0.05
<0.05
<0.01
<0.05
NS
NS
<0.01
<0.05
NS
NS
NS
<0.05
<0.01
<0.01
NS
<0.01
<0.01
r
0.635
0.331
0.618
0.156
0.793
/
/
0.548
0.391
/
/
/
0.728
0.619
0.351
/
0.219
0.416
the poor outcome in the CRC patients between stage I and stage II B (p<0.05), between stage I and stage III (p<0.01), as well
as between stage II A and stage III (p<0.01).
Associations of the examined parameters and poor
outcome are shown in Table 4, where it is shown
that MMP-2 serum levels preoperatively, at 3 and
12 months postoperatively, are in a significant correlation with the lethal outcome of the CRC patients, than MMP-7 serum levels preoperatively
and at 12 months, as well as MMP-9 preoperatively and at 3, 9 and 12 months postoperatively.
Discussion
MMP-2 is a collagenase discovered for the first
time in metastatic murine tumours and in cultured human melanoma cells. It is secreted by
fibroblasts, endothelial cells, osteoblasts, keratocytes, macrophages and many malignant cells (14).
MMP-2 is expressed in numerous normal tissues as the lungs, heart, kidneys, placenta, and
the muscles. MMP-2 is synthesized and secreted
as an inactive proenzyme, while as an active enzyme it degrades the type-IV collagen as well as
the type I, V, VII and X, the laminin, the elastin,
the fibronectin and the proteoglycans (15, 16).
MMP-7 (matrilysin) is a proteolytic enzyme,
which is expressed in glandular and ductal epithelium of many tissues. It degrades type IV and
X collagen, the elastin, the fibronectin, the laminin, the osteopontin, the proteoglycans, as well
as numerous other substrates. MMP-7 is also
synthesized and secreted by cancer cells as an
inactive proenzyme. After the activation, the
MMP-7 is found in soluble active form or bound
to the membrane of the tumour epithelium
cells, which has also a proteolitic capability (17).
MMP-9 was discovered for the first time as an
elastin binding protein, which is synthesized
by the macrophages and the polymorphonuclears. In normal conditions, MMP-9 is expressed
only in several cell types as trophoblasts, osteoclasts, leukocytes, and dendritic cells. It is also
being expressed by several types of tumours, in
the tumour cells and in the stromal cells. MMP9 also degrades the components of the ECM, especially type IV, V, VII, X, XI, XIV collagen, fibronectin, elastin, osteonectin and entactin (18).
Diverse results have been obtained from numerous examinations which have been made in order to determine the significance of the MMPs
in the diagnosing of malignancies and to determine their influence on the disease outcome (19).
In 1998, in order to determine the active and inactive
MMP-2 and MMP-9 expression, Pearsons, Warson,
Collins, et al. examined 53 colorectal carcinomas,
15 colorectal adenomas and 15 gastric carcinomas.
They found out overexpression of the two enzymes
in both the colorectal and gastric carcinomas (20).
The aim of the examination conducted by Tuton,
George, Eccles, et al. was to determine the MMP2 and MMP-9 distribution in CRC patients and
to compare the levels of the two enzymes in patients' plasma and the changes that occur in the
plasma after the resection. They wanted to discover whether plasma levels are a reflection of
the clinical staging and the development of the
disease. Their results showed that MMP-2 plasma
levels were considerably elevated in patients with
CRC; they considerably decreased after surgical
resection of the tumour, and MMP-9 serum levels were considerably elevated in all stages of the
disease in CRC patients, while they decreased
after the surgical resection of the neoplasm (21).
On the contrary, the Ruokolainens investigation for the prognostic role of the MMP-2 and
173
MMP-9 and their tissue inhibitors (TIMP-1

and TIMP-2) in squamous head and neck cancer, showed that serum MMP-2 immunoreactive protein levels in healthy patients were higher
than those in patients with cancer, while the
MMP-9 and TIMP-1 levels were considerably
higher in patients with squamous carcinoma.
The authors determined an important correlation between the serum levels of MMP-9 and
TIMP-1 with immunohistochemical expression
of MMP-9 and TIMP-1 from tumour tissue (22).
Dragutinovic, Radonjic, Petronijevic, et al. in their
study of 32 CRC patients and another 11 controls
using immunohistochemistry and serum values
of CEA, CA 19-9 and MMP-2 and 9 reported an
important correlation of the MMP levels with
the staging, but not with the CEA and CA 19-9
serum levels. They concluded that the serum
MMP-2 and MMP-9 detection can be a useful
tool for identification of the CRC patients (23).
Maurel, Nadal, Garcia-Albeniz et al. examined the
MMP-7 serum levels in 87 healthy patients and
in 120 CRC patients in order to determine the serum level prognostic significance of this enzyme.
They found out that patients with advanced cancer had considerably higher mean MMP-7 levels
in comparison with those without metastases and
in comparison with healthy subjects. They discovered a significant correlation between the MMP-7
levels and shorter survival time, which led them
to the conclusion that the elevated MMP-7 serum levels are an independent prognostic factor
for survival in patients with advanced CRC (24).
We have observed (unpublished data) that in CRC
patients with low MMP-7 but high LDH levels,
MMP-7 values can increase during chemotherapy
treatment, and would be therefore implicated in
early acquired resistance, after initial response.
Therefore, we speculate that MMP-7 would be

implicated in primary chemoresistance in the subgroup of patients with well-known poor prognosis,
to an even more aggressive phenotype, or both.
Leelawat, Sakchinabut, Narog, and Wannaprasert
analyzing the CEA, CA 19.9, MMP-7 and MMP-9
serum levels in patients with cholangiocarcinoma
detected that only MMP-7 level was considerably
higher in patients with cancer (25). Levels of total MMP-7 can be measured in human serum and
it is feasible using a simple ELISA technique, as
this has been recently shown in few other studies.
Serum measurements of total MMP-2, MMP-7
and MMP-9 can be considered as an indirect estimation of tumour MMP-2, MMP-7 and MMP-9
expression. Other techniques, such as zymography,
are useful to distinguish between activated MMP2, MMP-7, MMP-9 and pro-forms and might be
implemented in the near future for further analysis.
Conclusion
In our examination, we have determined that
the MMP-2, MMP-7 and MMP-9 serum levels
decrease considerably after the resection of the
primary neoplasm, as well as the MMP-2 serum
levels at 3th and 12th month postoperatively, than
MMP-7 serum levels preoperatively and at 12th
month and the MMP-9 serum levels at 3th, 9th
and 12th month postoperatively are in correlation with the poor outcome of the CRC patients.
Subsequently, detection of serum MMP-2, MMP-7
and MMP-9 is feasible and done through a noninvasive technique. They could be potential serum
markers which may be useful in the CRC detection and in monitoring of the disease progression.
Competing interests
Authors declare no competing interests.
References
[1] Birkedal-Hansen H, Moore WGI, Bodden MK, et al.
Matrix metalloproteinases: a review. Crit Rev Bio Med
1993;42:197-250.
[2] Sternlicht MD, Werb Z. How matrix metalloproteinases
regulate cell behavior. Ann Rev Cell Dev Biol 2001;17:463516.
[3] Nelson AR, Fingleton B, Rothenberg ML, Matrisian
LM. Matrix metalloproteinases: biologic activity and
clinical implications. J Clin Oncol 2000;18(5):1135-1149.
174

[4] Nagase H, Woessner Jr, J.F. . Matrix metalloproteinases..
J Biol Chem 1999;274(31):21491-21494. PubMed PMID:
10419448.
[5] Liabakk NB, Talbot E, Smith RA, et al. Matrix metalloproteinase 2 (MMP-2) and matrix metalloproteinase 9
(MMP-9) type IV collagenases in colorectal cancer. Cancer Res 1996;56(1):190-196. PubMed PMID: 8548762.
[6] Ii M, Yamamoto H, Adachi Y, Maruyama Y, Shinomura
[7]
[8]
[9]
[10]
[11]
[12]
[13]
[14]
[15]
[16]
[17]
Y. Role of Matrix Metalloproteinase-7 (Matrilysin) in Human Cancer. Invasion, Apoptosis, Growth, and Angiogenesis. Exp Biol Med J 2006;231(1):20-27.
Roy R, Yang J, Moses MA. Matrix Metalloproteinases As
Novel Biomarkers and Potential Therapeutic Targets in
Human Cancer. J Clin On col 2009;27(31):5287-97.
Bendarda FR, Lamlum H, Pyrhonen S. Prognostic and
predictive molecular markers in colorectal carcinoma.
Anticancer Res 2004;24(4):2519-30.
Vihinen P, Kahari VM. Matrix Metalloproteinases in
Cancer: Prognostic Markers and Therapeutic Targets. Int
J Cancer 2002;99(2):157-166. PubMed PMID: 11979428.
doi: 10.1002/ijc.10329.
Zlobec I and Lugli A . Prognostic and predictive factors in
colorectal cancer. Postgrad Med J 2008;84:403-411.
O'Connell JB, Maggard MA, Ko CY. Colon cancer survival rates with the new American Joint Committee on Cancer sixth edition staging. J Natl Cancer Inst 2004;96:14201425.
Galanis E, Alberts SR, O' Connell MJ. New adjuvant therapy for colon cancer: justified hope or commercial hype.
Surg Oncol Clin N Am 2000;9:813-823.
Graziano F, Cascinu S. Prognostic molecular markers
for planning adjuvant chemotherapy trials in Dukes' B
colorectal cancer patients: how much evidence is enough?.
Ann Oncol 2003;14(7):1026-1038. PubMed PMID:
12853343.
Liotta LA, Abe S, Robey PG, Martin GR. Preferential digestion of basement membrane collagen by an enzyme
derived from a metastatic murine tumor. Proc Natl Acad
Sci U S A 1979;76(5):2268-2272. PubMed PMID: 221920.
Salo T, Liotta LA, Tryggvason K. Purification and characterization of a murine basement membrane collagendegrading enzyme secreted by metastatic tumour cells. J
Biol Chem 1983;258:3058.
Langenskiold M, Holmdahl L, Falk P. Ivarsson ML. Increased plasma MMP-2 protein expression in lymph
node-positive patients with colorectal cancer. Int J
Colorectal Dis 2005;20(3):245-252. PubMed PMID:
15592677. doi: 10.1007/s00384-004-0667-4.
Pesta M, Topolcano O, Holubec L, et al. Clinicopathological Assessment and Quantitative Estimation of the Matrix
Metalloproteinases MMP-2 and MMP-7 and the Inhibi-
[18]
[19]
[20]
[21]
[22]
[23]
[24]
[25]
tors TIMP-1 and TIMP-2 in Colorectal Carcinoma Tissue

Samples. Anticancer Research 2007;27(4A):1863-1868.
Ishida H, Murata N, Tada M, Okada N, Hashimoto D,
Kubota S, et al. Determining the levels of matrix metalloproteinase-9 in portal and peripheral blood is useful for
predicting liver metastasis of colorectal cancer. Jpn J Clin
Oncol 2003;33(4):186-191. PubMed PMID: 12810833.
Hersznyi L, Hritz I, Lakatos G, Varga MZ, Tulassay Z. The Behavior of Matrix Metalloproteinases and
Their Inhibitors in Colorectal Cancer. Int J Mol Sci
2012;13(10):13240-63. PubMed PMID: 23202950. doi:
10.3390/ijms131013240.
Pearsons SL, Watson SA, Collins HM, et al. Gelatinase
(MMP-2 and 9) expression in gastrointestinal malignancy. Br J Cancer 1998;78(11):1495-1502.
Tuton MG, George ML, Eccles SA, et al. Use of Plasma
MMP-2 Aand MMP-9 Levels as a Surrogate for Tumour
Expression in Colorectal Cancer Patients. Int J Cancer
2003;107:541.
Ruokolainen H. The Prognostic Role of Matrix Metalloproteinase-2 and -9 (MMP-2, MMP-9) and their Tissue
Inhibitors -1 and -2 (TIMP-1, TIMP-2) in Head and Neck
Squamous cell Carcinoma. Oulu: University of Oulu;
2005.
Dragutinovi VV, Radonji NV, Petronijevi ND, Tati SB,
Dimitrijevi IB, Radovanovi NS, et al. Matrix metalloproteinase-2 (MMP-2) and -9 (MMP-9) in preoperative
serum as independent prognostic markers in patients
with colorectal cancer. Mol Cell Biochem 2011;355(12):173-178. PubMed PMID: 21541674. doi: 10.1007/
s11010-011-0851-0.
Maurel J, Nadal C, Garcia-Albeniz X, Gallego R, Carcereny E, Almendro V, et al. Serum matrix metalloproteinase
7 levels identifies poor prognosis advanced colorectal
cancer patients. Int J Cancer 2007;121(5):1066-1071.
PubMed PMID: 17487834. doi: 10.1002/ijc.22799.
Leelawat K, Sakchinabut S, Narong S, Wannaprasert J.
Detection of serum MMP-7 and MMP-9 in cholangiocarcinoma patients: evaluation of diagnostic accuracy. BMC
Gastroenterol 2009;9:30-38. PubMed PMID: 19405942.
doi: 10.1186/1471-230X-9-30.
175
www.jhsci.ba
A comparison of efficacy of femoral and tibial

fractures healing treated by static and dynamic
intramedullary nails
emil Omerovi*, Dijana Avdi, Faruk Lazovi
Orthopedic and Traumatology Clinic, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
Abstract
Introduction: Intramedullary nailing is synthesis and consolidation of fracture fragments with the main goal
to gain strength and permanent placement of the implants. Two techniques of intramedullary osteosynthesis
are used: with dynamic or with static intramedullary nail. Dynamization include conversion of static nail by
removing screws from the longest fragment.
The aim of this study is to determine whether there is a difference in the speed and quality of healing of the
type A and B fractures of the femur and tibia treated by static or dynamic intramedullary nails and to compare
the results.
Methods: The study was conducted on a total of 129 patients with closed fractures of the diaphysis of the
femur and tibia type A and type B. Patients were divided into two groups, based on the applied operating
method, static or dynamic intramedullary osteosynthesis.
Results: The average number of weeks of healing femoral and tibial fractures was slightly in advantage of
static intramedullary osteosynthesis, it was 17.08 weeks (SD=3.382). The average number of weeks of healing in 23 patients with fractures of the femur, treated by dynamic intramedullary osteosynthesis was 17.83
(SD=2.978).
Conclusion: We can conclude that static intramedullary nailing osteosynthesis unable movements between
fragments which directly stimulates bone formation and formation of minimal callus. Static intramedullary
ostesinthesys resolve the problem of stabilizing the fracture, limb shortening and rotation of fragments.
Keywords: fracture healing, intramedullary nailing, dynamic and static intramedullary nail.
Introduction
In 1943 Bohler said that the installation of the nail
in the bony canal is osteosynthesis that will be used
in a future. Indication for osteosynthesis with intramedullary nail are fractures of the middle part
of the long bones, most of the transverse and short
oblique fractures, mostly of femur and tibia. This
kind of stabilization has three main advantages :
1. Closed fractures can be treated in a closed
technique, i.e. without additional exposure of
fragments and damage of soft tissues. Circulation supply of the fragments remains fully
* Corresponding author: emil Omerovi,
Orthopedic and Traumatology Clinic
Clinical Center University of Sarajevo,
Bolnika 25,71 000 Sarajevo, Bosnia and Herzegovina
Phone:+387 297 626; Email: dr.omerovic@gmail.com
Submitted 1 September 2012 / Accepted 12 November 2012
176
sustained, and its expected bone to heal in a

similar way as by the non surgical treatment.
The incidence of infection with this technique
of osteosynthesis was significantly reduced.
2. Early stability and early function of extremities are achieved by axial (biomechanically optimal) use of implants, in favorable circumstances; the patient will be
mobilized almost immediately after surgery.
3. Third, which occurs regularly, are loosening
nail into the medullary canal within a few
months of use, thus encourages formation of
biological callus growth and fracture crack that
gradually accepts on greater force. The exception to this rule is statically embedded nail.
The ideal goal in intramedullary nailing osteosynthesis is achieved when the nail is inserted
with elasticity in both fragments. The greater the
EMIL OMEROVI ET AL.: A COMPARISON OF EFFICACY OF FEMORAL AND TIBIAL FRACTURES

HEALING TREATED BY STATIC AND DYNAMIC INTRAMEDULLARY NAILS
area of contact between the implant and the inner cortical means greater stability of the complex, and thus a better stability of the fractured
fragments. The last model of intramedullary
nail has the shape of three-leafed clover with
longitudinal slit, and so far it is the optimal solution. Also in addition, it is possible ingrowth
of new blood vessels from the medullary canal.
It is especially significant technological solutions - the top of the nail has a conical shape and
breakthrough medullary canal, but also prevents
notching the nail in the cortex during guidance
through the medullary canal. At the other end is
a separate opening in which the instrument hooks
during the extraction of the intramedullary nails.
There are different lengths and thicknesses of intramedullary nails, and its width is 0.9 to 1.0 mm.
For each region there are special instruments. Intramedullary nailing osteosynthesis requires adequate technical conditions-instruments, x-rays in
the room with one or two monitors, adequate operating table, experienced radiological technician,
it is necessary that the patient is in the right position to do reposition of fractured fragments (1).
Nowadays two techniques are mainly used, with
static and with dynamic intramedullary nails:
Static intramedullary nails use additional fixation
with screws, which are inserted into the proximal,
distal, or at both ends of the nail. When the nail
is stabilized with screws at each end of nail, then
fixation is static (2). This method avoids the problems losing of fixation, stabilization, shortening,
rotation that occur in plain intramedullary nail.
Axially unstable fractures are best treated by static
intramedullary nailing. The most common indication for the locking pin is comminuted fractures.
Dynamic intramedullary nails are used in axially
stable fractures of the bone and as well as in delayed bone healing process. Dynamic intramedullary nail has two screws, in the distal fragment
and in the proximal fragment one screw which is
axially movable by longitudinal slot in the implant.
Dynamic intramedullary nail control bending and
rotational deformity of the bones and implants,
but the main advantage is to provide almost complete transfer of axial pressure on the bone fragments. Dynamization is a process of converting
static intramedullary osteosynthesis into dynamic
intramedullary osteosynthesis. Dynamization reJOURNAL OF HEALTH SCIENCES 2012; 2 (3)
quires removing farthest screw, 10-16 weeks after

surgery. Earlier it was considered that the task of
dynamization is to promote callus remodeling. Today's latest experimental studies and clinical studies do not consider dynamization as mandatory;
some consider it detrimental to the healing time
and frequent occurrence of limb shortening after
dynamization. Majority believe that dynamization
is necessary only in those cases where there is a
permanent gap between the fragments, and the
conversion from static to dynamic fixation is rarely
necessary, especially in fractures of the femur (3).
Preoperative planning and measurement of implants should be performed on radiography of the
bone that is not injured. TMD method is the best,
cheapest and most accurate of all methods in determining nail length (the tibial tubercle-medial malleolar distance - distance between the highest points
on the medial malleolus of tibia and tibial tubercle).
Diameter of nail is assessed by measuring the
tibia or femur on the tightest spot of medullary
canal, which can be determined on lateral radiographs. There are two types of intramedullary
nails, rimmed and non rimmed type. Those who
support non rimmed type of nails, highlight maleficent effects such as fat embolism from bone
marrow into the lungs. This effect is not clinically
significant in most patients; some authors suggest
that the development of pulmonary complications
may further connect with the associated chest
injuries than with rimming of medullary canal.
Potential advantages of non-rimmed technique
over rimmed nail technique include shorter time
of surgery, less blood loss and less disruption of
endosteal blood supply in patients with severe
closed injuries of soft tissues. Nowadays mostly it
is preferred rimming technique and applications
of rimmed type of nails, where there is no present
significant damage of soft tissues. Rimming type of
nails enables application of stronger implants with
larger diameter. Non rimmed nail insertion usually
requires nails with a diameter of 8-10 mm, depending on the medullary canal diameter and cannot
be used in patients with medullary canal narrower
than 8 mm. Application of intramedullary nail in
the short tubular bones of wrist and feet is a failure. Setting intramedullary nails in children contraindicate due to open epiphyseal growth plates.
The aims of this study is to determine whether there
177

is a difference in the speed and quality of healing of

the simple fractures of the femur and tibia of type A
and B treated by static or dynamic intramedullary
osteosynthesis and to compare the results of healing of fractures of the femur and tibia treated by
static or dynamic intramedullary osteosynthesis.
Methods
The study was conducted at the Clinic for Orthopaedic and Traumatology, Clical Center University Sarajevo from January 2004 to June 2009. The
study was retrospective-prospective, manipulative,
controlled. The study was conducted on a total of
129 patients with closed fractures of the diaphysis
of the femur and tibia type A and type B, with different segments of bone, regardless of sex and age
structure, with the exception of children under 14
years of age. Precisely there were 47 patients with
femoral fractures and 82 patients with tibial fractures. Patients were divided into two groups, based
on the applied operating method, static or dynamic intramedullary osteosynthesis:
1. Patients with fracture of the femur or tibia treated with static method of intramedullary nailing, where the static intramedullary nail fastened cross screws (3 or 4 screws) on both ends,
and by that controls the axial and rotation instability and bending (24 patients with femoral
fractures and 58 patients with tibial fractures)
2. Patients with fracture of the femur or tibia treated with dynamic method of intramedullary osteosynthesis (or patients whom had performed
"dynamization"), which allows the complete axial pressure with control of bending and rotation.
By applying of intramedullary nail, it is important

to achieve elastic fixation of long flexible fragment
of long tubular bones, and so that only the shorter
fragment is fixed with two transverse self-tapping
screws for intramedullary implant. Mainly is used
for axial stable nonunion fractures and bone (23
femoral fractures and 24 tibial fractures). Diagnostic performance of fracture healing of femur
and tibia treated by static or dynamic intramedullary osteosynthesis is carried out at regular intervals, based on clinical and radiographic assessments. Clinical signs of healing, the rigidity and
the absence of crepitation at the site of the fracture,
the absence of pain at the site of the fracture during palpation and rough percussion, and absence
of pain in full support and a walk, in comparison
with the radiographic analysis that was performed
in a study by Corrales, Morshed, Bhadari and Miclauie, the presence of cortical bypass on three of
the four cortical fracture gap, are the definitive
signs that process of fracture healing has finished
at a median of three independent examiners.
The percentage of identical or different answers
that are presented in tables is directly dependent
on several factors, primarily the experience of
physician-investigator, technical conditions (quality radiograph, quality negatoscope, the light in the
room where the examination is being conducted),
the possibilities of perception (sight), stress, etc.
The study was retrospective-prospective, manipulative, controlled. T-test was performed
for analysis of statistically significant difference between groups. The research results
are presented as absolute and relative values.
TABLE 1. Clinical and radiographic signs of fracture healing

HISTOLOGICAL SCALE (COMPLETE BONE FORMATION =10)
TISSUE CALLUS DIFFERENTIATION
BLOOD CLOT AND
WITHOUT CALLUS
0
GRANULATION TISSUE
FIBROUS CONNECTIVE
SMALL TO MEDIUM CALLUS
1
TISSUE
CONNECTIVE CARTIMASSIVE CALLUS TISSUE
2
LAGE TISSUE
BRIDGING PERIOSTEAL CALLUS 3 APPEARANCE OF BONE
MATURE CALLUS WITH IN4 FULLY BONE FORMATION
TRAFRAGMENTARY BAYPASS
AFTER OWERGROWING CALLUS
COMPLETE RESTORA5
RESORPTION
TION OF DYAPHYSIS
178
RADIOGRAPHIC SCALE OF CALLUS FORMATION IN

FRACTURE GAP
0
WITHOUT CALLUS
SMALL TO MEDIUM CALLUS
MASSIVE CALLUS TISSUE
BRIDGING PERIOSTEAL CALLUS

MATURE CALLUS WITH INTRAFRAGMENTARY BAYPASS
AFTER OWERGROWING CALLUS RESORPTION
4
5
4
5

Results
According to the results of clinical and radiological study conducted by three independent examiners, the average number of healing of fractures
of the femur and tibia expressed in the weeks go
slightly in advantage of static intramedullary osteosynthesis and it was 17.08 weeks with a standard deviation of 3.382. The average number of
weeks of healing in 23 patients with fractures of
the femur, treated by dynamic intramedullary osteosynthesis was 17.83, with a standard deviation
of 2.978. The difference in the number of weeks
of healing of fractures of the femur, depending
on the type of nail (dynamic-static) was not statistically significant. Value of t-test is: t = 0.897.
According to the results, average number of weeks
of bone healing of the tibial fractures were 14.02
in 82 patients treated with rimmed intramedullary
FIGURE 1. The average number of weeks of femoral fracture

healing presented by the type of nail. (A) Patients treated by
static indramedullary osteosynthesis. (B) Patients treated by
dynamic indramedullary osteosynthesis. (C) Total number of
treated patients.
FIGURE 2. The average number of weeks of tibial fracture

healing presented by the type of nail. (A) Patients treated by
static indramedullary osteosynthesis. (B) Patients treated by
dynamic indramedullary osteosynthesis. (C) Total number of
treated patients.
179

TABLE 2. The average number of weeks of femoral fracture

healing by a nail.
YEAR OF
OPERATION
STATIC NAILS:
2004.
2005.
2006.
2007.
2008.
2009.
TOTAL
DYNAMIC
NAILS:
2004.
2005.
2006.
2007.
2008.
2009.
TOTAL
TOTAL FEMUR
STATIC +
DYNAMIC
2004.
2005.
2006.
2007.
2008.
2009.
TOTAL
AVERAGE
NUMBER OF
NUMBER OF
WEEKS
PATIENTS
OF BONE
HEALING
STANDARD
DEVIATION
SD
1
4
5
11
3
24
20,0
19,6
18,8
16,00
14,67
17,08
0
5,196
3,633
1,789
2,309
3,382
6
3
4
5
5
23
17,33
18,67
19,00
19,20
15,6
17,83
2,665
2,309
3,464
3,033
3,847
2,978
7
3
8
10
16
3
47
17,71
18,67
19,00
19,99
15,87
14,67
17,44
1,982
2,309
4,242
3,00
2,39
2,31
3,04
nailing. Of this number, 58 were treated with a

static intramedullary nail with an average healing
time of 13.55 weeks, and 24 treated with dynamic
intramedullary nail with an average healing time
of 15.17 weeks. The difference in the number of
weeks of tibial fracture healing, in dependence of
the nail (dynamic-static), it was significant. Value
of t-test is: t = 2.227, level of significance of p <0.05.
Discussion
Intramedullary nail provide fragments stability and contributes to the process of osteogenesis. Biomechanical role of intramedullary nails
is to keep the bone fragments in a good correlation, but also to prevent torsion and shear forces.
It was considered that in a given moment should
be provided an axial load transmission through
180
TABLE 3. The average number of weeks of tibial fracture

healing by the type of nail.
YEAR OF
OPERATION
STATIC NAILS:
2004.
2005.
2006..
2007.
2008.
2009.
TOTAL
DYNAMIC
NAILS:
2004.
2005.
2006.
2007.
2008.
2009.
TOTAL
TOTAL TIBIA
(STATIC +
DYNAMIC)
2004.
2005.
2006.
2007.
2008.
2009.
TOTAL
AVERAGE
NUMBER OF STANDARD
NUMBER OF
WEEKS OF DEVIATION
PATIENTS
BONE HEALSD
ING
2
4
8
36
8
58
16,0
13,5
16,25
13,28
11,5
13,55
0
13,43
2,49
4,38
3,66
2,89
9
6
3
3
2
1
24
15,11
15,33
13,33
18,67
14,0
12,0
15,17
2,47
3,27
2,31
4,62
8,48
0
3,46
9
8
7
11
38
9
82
15,11
15,5
13,43
16,91
13,32
11,56
14,02
2,47
2,60
3,659
3,48
4,33
3,26
3,17
the bone and fracture by the phenomenon of "dynamization", which accelerates osteogenesis by
allowing micro-movements at the site of the fracture process, explanation was that the axial movements of fragments reduces fracture area, accelerates fracture callus maturation and remodeling of
bone. Such recommendations for "dynamization"
or converting static to dynamic intramedullary
nailing for us surgeons are still unclear. Its constant dilemma, is the "dynamization" still needed,
and when is the real indication and the optimal
time for performing the same. Legacy of the 80's
recommends to convert static into the dynamic
form of intramedullary osteosynthesis in the period of 10-16 weeks, when the fibrous callus provide stability of the bone fragments, while other
authors believe this procedure is unnecessary

or even harmful. Infections associated with implants for osteosynthesis according to the literature generally occur with prevalence of 5-10% (4).
On the other hand it can be said that perfect intramedullary nail has not yet been designed. The
assumption of stable ostesinthesys is the strength
and permanent position of the implant that is
well tolerated by the tissues. The objective of such
osteosynthesis is a direct angiogenic bone formation in conditions of absolute stability of the fragments and good vascularization. The fact is that
healing of cortical bone of the femur and tibia
and begins periosteal and endosteal. A review of
available literature and published articles, we
found limitations in the number and quality of
studies published in longitudinal evaluations of
available radiological and clinical methods for detailed analysis of the processes of bone healing (4).
Also, we found that lack of consensus among
orthopedic surgeons in terms of the definition of fracture healing. Without valid and reliable indicators of clinical and radiological
signs of fracture healing, the interpretation of
the fracture treatment success is difficult (5)
The question is, which method is the most commonly used to evaluate the healing of long bones?
Grigoryan and associates in their study tried to assess the quantitative and qualitative characteristics
of bone healing using volumetric computerized
tomography (CT) and to compare the results obtained by conventional radiological methods to assess healing of long bones (4) McClelland and associates in their study made a comparison between
radiological assess fracture healing and strength
measurements (stiffness) of the layout (6). According to the method in which we are committed
in this study, the author Corrales Morshed, Bhandaria & Miclaua shows the qualitative and quantitative fracture healing (3). Radiological Assessment of healing of fractures of the femur and tibia
"cortical bridging" is based on data estimates healing each of the 4 cortical bone (anterior, posterior,
medial and lateral) with a record of time until the
appearance of callus, the time to the occurrence
of mature callus fracture lines and loss of fracture line at different stages fracture healing, performed by three independent examiners ( 6 ; 1 ; 7).
In our study it was reported an average of 73.64%
of identical responses and 25.58% of different anJOURNAL OF HEALTH SCIENCES 2012; 2 (3)
swers. Radiological assessment of fracture healing

may be supplemented with bone densitometry
and by measuring ultrasonic transmission. In certain cases of large callus due to the "fracture movements it is possible to make additional mathematical processing generated callus summarized with
clinical and radiological signs of fracture healing.
Our research can be divided into the period of
2004-2007. when the results are summarized by
the examiner, and was a retrospective study, and
research since 2008. until the second half of 2009,
which was a prospective study. As can be seen from
the tables, the number of patients treated surgically with fractures of the femur or with tibial fracture of each year has increased, especially those
treated with static intramedullary osteosynthesis.
According to the results of clinical and radiological
study conducted by three independent examiners,
the average number of healing of fractures of the
femur and tibia expressed in the weeks go slightly
in favor of static intramedullary osteosynthesis
and it was 17.08 weeks with a standard deviation
of 3.382. The average number of weeks of healing
in 23 patients with fractures of the femur, treated
by dynamic intramedullary osteosynthesis was
17.83, with a standard deviation of 2.978. Significant is that the fractures are of type 3 2 A and 3 2
B according to the AO classification, had a slightly
faster flow of healing in patients treated with intramedullary nailing with static method, which is
in line with research Brumback, who investigated
the healing of 87 shaft fractures of the femur with
static intramedullary nails and scored bone healing in 98% of cases without translation into static
dynamic intramedullary nailing. Similar research
by D.Tigani, M.Favisini C.Stagni r: S.Boriani Pascarella, in a series of 179 closed fractures of the femur, has shown that the time to bone healing was
significantly shorter in the that were treated with
static intramedullary nail (103 days) compared
with those treated with dynamic intramedullary
nail (126 days). Another study conducted over a
period of about 20 years in Bologna (Rizzoli Orthopaedic Institute and Hospital Pizzardi Maggiore Italy), showed that the bone healing time
was shorter than in the group of patients were dynamization was not performed. According to the
conclusions from the study by Wu and Chen, only
half of segmental fractures of the femur with per181

formed "dynamization" has been successful, and

they have suggested the use of bone grafting to fill
spaces between the bone fragments for faster healing. Intramedullary nailing is basically designed
for the reduction and stabilization of closed fractures of the femur and tibia, while fully preserving periosteal vascularization and soft tissue (1,7).
Our research from 2004 until the second half of
2009. showed average of 14.02 weeks of bone healing of the fracture of the tibia in 82 treated with
rimmed intramedullary nailing. Of this number,
58 was treated with a static intramedullary nail
with an average healing time of 13.55 weeks, and
24 treated with dynamic intramedullary nail with
an average healing time of 15.17 weeks. In this way,
it was found out that the dynamic intramedullary
nailing, or "dynamization", are indicated only with
fractures of tibia, where there is a permanent gap
between the bone fragments and with a reasonable
risk of shortening and changes in axis of extremities, often breaking of screws or /and of whole
nails, and it was confirmed in already published
studies by Wayne State University, Department of
Orthopedic Surgery, Detroit-Michigan from November 1986, as well as in study by Dagrenate in
the late 80-ies and his in vivo experimental study.
What this research has definitely been sort out in
relation to similar studies is that all fractures of
the femur and tibia healed in a very short time, if
they were perfectly operatively treated in an optimal time by an experienced operating team in
strict compliance with the indications, and where
the fragments diastasis were less than 0.2 mm.
Necessary transformation to higher levels of care,
with a well-trained surgical and monitoring team
(anesthesiologist, instruments, support staff, operating rooms, a physiatrist and physiotherapist)
and secured the technical conditions for the operation, make the optimum conditions for carry-
ing out the method of osteosynthesis. This team

has to be continuously available from the existing
staff, with compulsory continuous training. The
results of this study showed that adequacy of our
suspicions of doctrinal conduction "of dynamization", and additional hospitalization for surgery,
of "static screw" removal in the period of 10-16
weeks. The significance is the same only in those
cases where there is a bone fragment diastasis
greater than 0.2 mm, and the conversion itself is
rarely necessary in fractures of the femur. In the
end, we would say that the study of treatment of
fractures of the femur and tibia by static and dynamic intramedullary osteosynthesis showed all
the good effects of early stabilization of fractures
in relation to morbidity and length of hospitalization. The guarantee of success and quality of healing of fractures of the femur and tibia, treated by
static and dynamic intramedullary osteosynthesis
are proven low incidence of infection, high stability and strength of the fragments, the possibility
of early mobilization of the patient with preservation of soft tissue and peripheral circulation.
Conclusions
Static intramedullary nailing unable movements
between fragments which directly stimulates bone
formation and formation of angiogenic minimal
callus with sharp edges and a dense structure. Also
static intramedullary ostesinthesys resolve the
problem of stabilizing the fracture, limb shortening, rotation of bone fragments are the best recommendations for treatment are comminuted
fractures. Dynamic intramedullary opsteosinethesys use of force on the fracture, causing bone resorption and thus looseness implants due to mechanical instability, which creates large (stimulus)
callus with vague contours and turbulent structure.
References
[1] Hanevi J, Antoljak T, Mikuli D, ani-Matani D,
Kora . Lomovi i iaenja. Jastrebarsko: Naklada
Slap;1988.
[2] Chhabra A, Zijerdi D, Zhang J, Kline A, Balian G, Hurwitz S. BMP-14 deficiency inhibits long bone fracture
healing: a biochemical, histologic, and radiographic assessment. J Orthop Trauma 2005;19(9):629-634. PubMed
PMID: 16247308.
182
[3] Krestan CR, Noske H, Vasilevska V, Weber M, Schueller

G, Imhof H, et al. MDCT Versus Digital Radiography in
the Evaluation of Bone Healing in Orthopedic Patients.
Sceletal Radiol 2001;30(6):151-156. PubMed PMID:
16714670. doi: 10.2214/AJR.05.0478.
[4] Corrales LA, Morshed S, Bhandari M, Miclaull T. Variability in the Assessment of Fracture-Healing in Orthopaedic Trauma Studies. J Bone Joint Surg Am

2008;90(9):1862-1868. PubMed PMID: 18762645. doi:

10.2106/JBJS.G.01580.
[5] Grigorian M, Lynch JA, Fierlinger A, Guermazi A, Fan
B, MacLean DB, et al. Genant HK. Quantitative and
qualitative assessment of closed fracture healing using multimodality imaging. Acad Radiol. Acad Radiol
2003;10(11):1267-1273. PubMed PMID: 14626301.
[6] Tigani D, Fravisini M. Stagni C et al. Interlocking nail for
femoral shaft fractures; is dynamisation alwayz necessary? Int Orthop. Int Orthop 2005;29:101-104.
[7] Joslin CC, Eastaugh-Waring SJ, Hardy JRW, Cunningam

JL. Weight bearing after tibial fracture as a guide to healing. Clinical Biomechanics 2008;23(3):329-333. PubMed
PMID: 17997205. doi: 10.1016/j.clinbiomech.2007.09.013.
[8] Stojiljkovi PM, Golubovi ZS, Mitkovi MB, Mladenovi
DS, Mici LD, Stojiljkovi DM i dr . Leenje preloma dijafize femura u sklopu politraume unutranjim fiksatorom
tipa Mitkovi. Acta chirurgica Iugoslavica 2007;54(2):3338.
183
www.jhsci.ba
Age and gender related differences in free

fatty acid levels in patients with type 2
diabetes mellitus
aira Mandal1*, Adlija auevi2, Maja Malenica2, eherzada Hadidedi3,
Besim Prnjavorac4, Sabina Semiz2
Department of Natural Science in Pharmacy, Faculty of Pharmacy, University of Sarajevo, ekalua 90, 71 000 Sarajevo,
Bosnia and Herzegovina. 2 Department of Biochemistry and Clinical Analysis, Faculty of Pharmacy, University of Sarajevo,
ekalua 90, 71 000 Sarajevo, Bosnia and Herzegovina. 3 Agency for Medicinal Products and Medical Devices of Bosnia and
Herzegovina, Titova 9, 71 000 Sarajevo, Bosnia and Herzegovina. 4 Department of Internal Medicine, General Hospital Teanj,
Brae Pobria 17, 74260 Teanj, Bosnia and Herzegovina.
Abstract
Introduction: Several decades of basic science and animal research provided considerable support for
significant role of plasma free fatty acids (FFAs) in etiology of Type 2 diabetes mellitus (T2DM). Contradicting
data related to significance of elevated FFAs in plasma of patients with Type 2 diabetes prompted us to study
concentrations of palmitic acid, stearic acid, and linoleic acid, in patients and healthy controls in an attempt
to possibly use them as potential biomarkers in progression of the disease. Since aging is associated with
increased plasma glucose and insulin levels that are consistent with an insulin resistant state, in this study,
age differences in the concentration of the above mentioned acids were tested.
Methods: Progressive changes in their concentrations were followed through a period 6 months. All subjects
included in the study were free of evidence of hepatitis B or C viral infection or active liver and kidney damage. Analysis of glucose and glycated hemoglobin levels were performed on BT PLUS 2000 analyzer using
standard IFCC protocols, while concentrations of FFAs were analyzed by gas chromatography.
Results: Our data demonstrated significantly higher FFA values in plasma of diabetic patients as compared
to healthy controls. There was a trend of correlation of FFAs levels with the blood glucose levels in diabetic
patients, which was more prominent in diabetic men than in women.
Conclusion: With aging, levels of free fatty acids significantly increased in plasma of diabetic patients, and
this effect was also more profound in male than in female diabetics.
Keywords: Diabetes mellitus, free fatty acids, insulin resistance, biomarkers
Introduction
Diabetes is associated with a variety of derangements manifested through defects in the use of
carbohydrates, synthesis and catabolism of proteins, and lipid metabolism. So far, it has been
demonstrated that age is a significant risk factor
for the development of Type 2 diabetes (T2D)
(1). Namely, numerous studies have reported a
* Corresponding author: aira Mandal,
Department of Natural Science in Pharmacy, Faculty
of Pharmacy, University of Sarajevo, ekalua 90,
71 000 Sarajevo, Bosnia and Herzegovina;
E-mail: mandalshakira@yahoo.co.uk
Submitted 13 November 2012/ Accepted 10 December 2012
184
significantly higher prevalence of impaired glucose tolerance test (IGT), obesity, and type 2 diabetes in people older than 65 years. Moreover, in
all studies related to this phenomenon, insulin
secretion decreased with age, while insulin resistance and fasting plasma free fatty acids (FFAs)
concentrations increased in older subjects (2-4).
Free fatty acids represent important nutrients
and the key oxidative fuel for the heart, liver, and
skeletal muscle. They are thought to be potent
signaling molecules (5-9), whose presence in the
circulation is a result of dietary intake and endogenous relase from stored fat, primarily adipocytes. Growing evidence indicates that FFAs
AIRA MANDAL ET AL.: AGE AND GENDER RELATED DIFFERENCES IN FREE FATTY ACID LEVELS IN PATIENTS WITH TYPE 2 DIABETES MELLITUS
may be involved in pathogenesis of T2D and obesity through mechanisms of insulin resistance (IR)
(10-14). An important consequence of IR at the
level of adipose tissues is enhanced lipolysis and
reduced free fatty acid uptake and esterification,
leading to an increased flux of FFA into nonadipose tissues, such as liver and muscle. Although
both unsaturated and saturated fatty acids have
been linked to insulin resistance, there is evidence
that saturated fat intake more effectively induces
IR. The data indicate that FFAs cause IR both in
vitro and in vivo. The potent effects of long-chain
saturated fatty acids (LCSFA) on IR development
were confirmed in adipocytes in vitro (10, 15).
Furthermore, overnight reduction in FFAs improved insulin sensitivity in vivo in obese patients,
Type 2 diabetics and nondiabetics. In addition,
substantial evidence from both, humans and animals, has indicated that essential fatty acid (EFA)
metabolism is also abnormal in diabetes (15, 16).
In this study, a potential biomarker role of three
most abundant FFAs (palmitic, stearic, and linoleic acid) was examined in T2D patients and respective healthy controls. In addition, the effects of optimal glucose control, patientsgender and age on
plasma FFAs were also evaluated in these patients.
Methods
Patients
In this study we have analyzed FFAs levels in a
group of 40 patients diagnosed with Type 2 diabetes mellitus with a mean age of 61 years and
40 healthy, nondiabetic controls with a mean
age of 43 years. All humans subjects involved in
this study were patients of General Hospital in
Teanj, BH. All research involving human subjects and material derived from human subjects
in this study was done in accordance with the
ethical recommendations and practices of the
Teanj General Hospital and complied with ethical principles outlined in World Medical Association Declaration of Helsinki Ethical Principles
for Medical Research Involving Human Subjects
(initiated in June 1964, last amendment in October 2000). Subjects included in this study were
free of evidence of hepatitis B or C viral infection
or active liver and kidney damage. Patients were
selected for the study on the basis of presence of
history of diabetes for more than five years and

were receiving standard drug therapy of 250 mg
Metformine. Patients receiving drugs known to
influence FFA levels were excluded from this study.
Initial diagnosis of T2D was established by a
specialist of internal medicine. Nondiabetic
controls were of approximately same age (35-87
years old), with normal glucose tolerance (fasting plasma glucose less than 6.2 mmol/l and
two hours postprandial glycaemia less than
7.8 mmol/l). They also had no abdominal obesity as a clinical criteria for insulin resistance.
Sample Analysis
Blood samples were obtained from patients and
nondiabetic controls subjects in fasting conditions
from antecubital vein into siliconized tubes (BD
Vacutainer Systems, Plymouth, UK). Analysis of
glucose and glycated hemoglobin levels (HbA1c)
in plasma were performed by employing BT PLUS
2000-Biotechnic Instruments. Standard IFCC
(International Federation for Clinical Chemistry)
protocols were used for all analyses. For fatty acid
analysis, lipids were extracted with chloroformmethanol 2:1 (vol/vol) than, sample of fatty acid
methyl esters (FAMEs) of free fatty acids were prepared according to method self-modifying Lepage
and Roy. Samples were analyzed on a Shimadzu
QP-5000 GC/MS gas chromatograph equipped
with mass spectrometer detector, Shimadzu 20A
GC/FID gas chromatograph equipped with a
flame ionization detector and capillary column
Resterkorp OPTIMA 120 (30mx0.32x0.25m
film thickness). The identity of each fatty acid
peak was obtained by comparing the retention
time of the peak with the retention times of referent standards with known fatty acids composition.
Statistical Analysis
Data are expressed as mean SEM. The significance of differences among groups was analyzed
statistically by ANOVA, followed by Spearman's
coefficient correlation and Student's t test. Calculations were done using SPSS 17.0 for Windows. Statistical significance was set as p<0.05.
Results
Our study analyzed plasma levels of palmitic,
stearic and linoleic acid in a group of 40 patients
185
(a)
(b)
(c)
FIGURE 1. Average concentration of palmitic acid (a), stearic acid (b), linoleic acid (c) in plasma of patients with Type 2 dibetes
mellitus and control subjects, no statistically significant.
(a)
(b)
(c)
FIGURE 2. Average concentration of palmitic acid (a), stearic acid (b), linoleic acid (c) in plasma of male patients with Type 2
dibetes mellitus and control subjects, no statistically significant.
(a)
(b)
(c)
FIGURE 3. Average concentration of palmitic acid (a), stearic acid (b), linoleic acid (c) in plasma of female patients with Type 2
dibetes mellitus and control subjects, no statistically significant.
diagnosed with Type 2 diabetes mellitus (average

age of 61 years) and 40 adequate controls (average
age of 43 years). Strikingly, as shown in Figure 1
the concentrations of examined FFAs were higher
in diabetic patients when compared to controls.
Plasma levels of individul FFAs and sex differences are presented in Figures 2 and 3. As shown
in Figure 2 and 3, levels of palmitic and linoleic
186
acids i.e palmitic and stearic acids were higher in

both, male and female diabetic patients. Interestingly, as shown in Figure 2, plasma levels of stearic
acid were lower in male T2D patients as compared
to nondiabetic subjects, while concentration of
linoleic acid was lower in diabetic female patients
as compared to control sujects (Figure 3). Our
data demonstrated a trend in positive and statis
(a)
(b)
(c)
FIGURE 4. The correlation between age and plasma levels of palmitic acid (a), stearic acid (b), linoleic acid (c) in the patients
with Type 2 diabetes mellitus. Spearmans rho correlation coefficients =0.040, =0.021, and = -0.135, respectively.
(a)
(b)
(c)
FIGURE 5. The correlation between age and plasma levels of palmitic acid (a), stearic acid (b), linoleic acid (c) in male patients
with Type 2 diabetes mellitus. Spearmans correlation coefficients = -0.100, = -0.204, and = -0.178, respectively.
tically significant correlation of concentrations of

palmitic and stearic acid (p<0.001, p<0.05; respectively) with the blood glucose levels and glycated
hemoglobin in diabetic patients, which was more
prominent in male than female patients (Figure 5). As shown in Figures 4 and 5, a significant
correlation between plasma FFA levels, age and
sex was demonstrated only in diabetic patients.
Discussion
Elevated levels of free fatty acid have been closely
associated with insulin resistance, hyperinsulinemia, and diabetes (2-3, 9-10). Diabetic patients
who are lipidemic appear to be at increased risk
for developing diabetic complications and cardiovascular disease. In Type 2 diabetes, hypertriglyceridemia seems to be associated with the insulin
resistance syndrome, impaired glucose tolerance,
and an early onset of endothelial dysfunction,
while dyslipidemia is associated with nonadequte
metabolic control, hyperinsulinemia and a late onJOURNAL OF HEALTH SCIENCES 2012; 2 (3)
set of overt dysfunction of -cells (4, 11, 13, 17).

Multiple disturbances in free fatty acid metabolism,
including day-long elevated plasma FFA levels and
accelerated rates of lipolysis, are characteristic features of T2D. Elevated plasma FFA concentrations
impair glucose metabolism by inhibiting the more
proximal steps of insulin action in muscle as well
by augmenting basal hepatic gluconeogenesis and
impairing the insulin-mediated suppression of hepatic glucose production (8, 16, 19). In addition to
increased FFA plasma levels, Type 2 diabetic and
obese patients have increased stores of triglycerides in muscle and liver, which correlates closely
with IR in these tissues (16, 20-21). Chronic elevated plasma FFAs are also closely linked to the
various components of the metabolic syndrome
and represent a possible link between fatty acids
levels and cardiovascular morbidity and mortality (7-8). A possible link of FFA levels and T2D
incidence have been recently reported in different
ethnic groups, including Caucasian (22), Chinese
187
(13), American (23) and Japanese (24) population.

In addition to inhibiting insulin action, FFAs also
have an important role in the regulation of pancreatic -cell function (25-28). Acute elevations of FFA
produce insulin resistance dose-dependently in
diabetic and non-diabetic individuals (1, 5-8). The
acute or short-term stimulatory effect of FFAs on
glucose-stimulated insulin secretion has been well
described both in vitro and in vivo. Data from recent studies, however, have shown that prolonged
(48h ) exposure of rat and human islets to fatty acids
decreases glucose-stimulated insulin secretion (9).
The effects of prolonged elevation of FFAs plasma
levels on insulin secretion in humans remain controversial. Several investigators have reported that
24h to 48h elevation of FFAs either increased and
decreased insulin secretion (24, 28). Although the
increased blood glucose levels could result from
the FFA-induced insulin resistance, some studies
implied that the amount of secreted insulin was
inadequate to maintain normal glucose homeostasis. In line with these results, Belfort et al. recently
reported that although a 4-day lipid infusion impaired insulin secretion, did not worsen IR in already insulin-resistant subjects. In addition, the
high levels of polyunsaturated fatty acids (PUFAs)
have been shown to impair endothelial function
and nitric oxide (NO) production (17, 26, 29).
There are no data reported related to concentrations of FFAs in diabetic population on Bosnia
Herzegovina territory, this is one of the first studies
in which concentration of plasma palmitic, stearic,
and linoleic acid was evaluated in these patients.
Our results demonstrated a profound increase in
the concentrations of the above mentioned FFAs
in T2D patients as compared to nondiabetic controls. This is in line with data reported in previous
studies, in which acute and chronic elevations of
FFAs have been associated with the higher risk for
developing impaired glucose tolerance and T2D
(22, 30). This was complemented with our results,
which demonstrated that the FFAs, especially saturated fatty acids (SFAs) and PUFAs levels, were
higher in diabetic patients than in controls. IR
might represent the link between elevated glucose and FFA levels, however, our group (data not
shown) as well as the others did find a significant
correlation between these parameters in T2D patients. In our study, correlations between glucose
188
levels and concentrations of FFA (positive correlation with palmitic and stearic acids, negative with
linoleic acid) were demonstrated. A positive correlation was found between glycated hemoglobin
and concentration of palmitic and stearic acids.
Saturated fatty acids, i.e. palmitic and stearic acid,
decrease insulin-induced glycogen synthesis, glucose oxidation and lactate production by impairment of mitochondrial function as demonstrated
by decrease of both mitochondrial hyperpolarization and ATP generation as reported in numerous
studies (23-24). Furthermore, basal glucose oxidation and activation by insulin is also reduced. Interestingly, our data suggest a trend of positive correlation between FFAs and plasma glucose levels
with age, which was more profound in male than
female diabetic patients. These results complement
previous studies in American and French men in
which the correlation between plasma FFAs and
fasting glucose levels (with aging) was also positive (22, 26, 31), while study in Japanese men did
not find a significant correlation between plasma
FFAs and glucose levels (24). Based on our results,
it appears that in male patients with inadequate
glucose control, concentrations of FFA were higher
when compared to diabetic patients with adequate
glucose control. This is in line with previous reports, where an effect of sex and age on FFA levels
in relation to glucose control was also observed in
diabetic patients (10). However, the effects of gender on concentrations of FFA in diabetics are still
controversial (7-8). Recently, Boden reported that
athough elevated FFAs (SFAs and PUFAs) predicted incident Type 2 diabetes in both sexes, their further analysis, stratified by glucose tolerance status,
showed that FFAs, especially saturated fatty acids,
predicted Type 2 diabetes development in women
with impaired fasting glucose, but not in men (8,
32-33). Here we demonstrated an effect of aging
on plasma SFAs and PUFAs in diabetic patients,
and there was a positive correlation between diabetic patients age, SFA and PUFA levels in plasma,
particularly in diabetic men. Plasma FFA levels
were significantly higher in older male and female
as compared to control subjects, thus, with aging
the levels of palmitic, stearic, and linoleic acid
increased in plasma of diabetic patients, probably due to impaired glucose tolerance, increased
levels of metabolites FFAs (diacylglycerol DAG,
ceramide and fatty acyl CoA) in these patients.

Interestingly, our data demonstrated a significant
correlation between concentration of palmitic,
stearic, and linoleic acid and plasma glucose levels
and glycated hemoglobin with aging, as compared
to data obtained by other researchers. This is in
line with recent report, which has demonstrated
that the inverse association between diabetic (or
HbA1c level > 7%) and plasma FFA levels was
significantly more profound in older men and
women. In general, our results demonstrated effects of gender on FFA (SFAs and PUFAs) levels
in both, control and diabetic patients. Although
there was a trend of increased concentrations of
FFA in males as compared to females, this difference was not significant. This is in line with the
recent report in which plasma FFA levels were
analyzed in larger group of people (about 2400),
where increased incidence of elevated FFAs in
males as compared to females was reported. Since
estrogen promotes FFA excertion, this could explain higher incidence of dyslipidemia in men
and increased levels of plasma FFA in postmenopausal women (23, 32-35). This may also explain,
at least partially, our findings that plasma concentrations of FFA (SFA, PUFA) in diabetic patients
increased significantlly with aging. Furthermore,
recent study by Pankow et al. (5) identified SFA
(palmitic and stearic acids), and PUFA (linoleic
acid) that are associated with FFA plasma concentrations, with profound gender specific effects
of specific gene(s) on free fatty acids regulation.
Therefore, it appears that there are strong genetic,
age, and gender effects on FFA levels in diabetic
patients. On the basis of these findings, it would
be pertinent to perform more studies on genetic
variations and their effects on FFA levels (35-36).
Conclusions
In summary, this study showed significantly el-
evated plasma levels of free fatty acids, especially

saturated fatty acids, in patients with Type 2 diabetes as compared to nondiabetic controls. This is in
line with previous studies, which suggest a possible
link between FFA levels and diabetes. Interestingly,
this phenomenon seemed to be more profound
in male diabetic patients, who also demonstarted
more prominent effects of an optimal glucose control on FFAs clearance than their female counterparts. Since, to our knowledge, this is one of the
first studies in Bosnia and Herzegovina addressing
free fatty acids and their role in diabetic progression, more emphasis should be put on their potential use as a risk factor for developing metabolic
and cardiovascular diseases in BH clinical practice.
Additional genetic studies addressing gender and
ethnospecific effects on FFA levels in T2D patients
appear also to be justified. Thus, considering the
potential link of elevated concentrations of free
fatty acid with insulin resistance, impaired glucose
tolerance, and progression of diabetes, further
research should attempt to determine wheather
it is effective to utilize FFA levels as a predictor
in prevention of Type 2 diabetes development.
Acknowledgments
Authors thank all subject who participated in the
study, medical doctors from the Department of
Internal Medicine , Teanj General Hospital, and
paramedical staff who assisted in the study. Also,
we thank our colleagues from The Laboratory for
Quality control of Medicines, Agency for Medicinal Products and Medical Devices of Bosnia and
Herzegovina for their engagement in development
of experimental protocol used for the FFA analysis.
Competing Interest
Authors received no grant for this study and have
no conflict of interest to declare.
References
[1] Chang MA, Halter BJ. Aging and insulin secretion. Am J
Physiol Endocrinol Metab. 2003;284:E7-E12
[2] Savage DB, Petersen KF, Shulman GI. Disordered
lipid metabolism and the pathogenesis of insulin resistance.. Physiol Rev 2007;87(2):507-520. PubMed PMID:
17429039. doi: 10.1152/physrev.00024.2006.
[3] Einstein HF, Huffman MD, Fishman S, Jerschow E, Heo
JH, Atzmon G, et al. Aging per se increases the susceptibility to free fatty acidinduced insulin resistance. J
Gerontol A Biol Sci Med Sci 2010;65(8):800-808. PubMed
PMID: 20504893. doi: 10.1093/gerona/glq078.
[4] Hussain A, Hydrie MZI, Claussen B, Asghar S. Type 2
Diabetes and obesity: A review. Journal of Diabetology
2010;2:1.
189
[5] Pankow SJ, Duncan BB, Schmidt MI, Ballantyne MC,

Couper JD, Hoogeveen CR, et al. Fasting plasma free
fatty acids and risk of Type 2 diabetes. Diabetes Care
2004;27:77-82
[6] Boden G. Obesity and Free Fatty Acids (FFA. Endocrinol Metab Clin North Am 2008;37(3):635-646. PubMed
PMID: 18775356. doi: 10.1016/j.ecl.2008.06.007.
[7] Kovacs P, Stumvoll M. Fatty acids and insulin resistance
in musle and liver. Best Pract Res Clin Endocrinol Metab
2005;19(4):625-35.
[8] Ragheb R, Medhat MA. Mechanisms of fatty acid-induced insulin resistance in muscle and liver. J Diabetes
Metab 2011;2:127. doi:10.4172/2155-6156.1000127
[9] Wolf G. Role of fatty acids in the development of insulin
resistance and type 2 diabetes mellitus. Nutrition Reviews
2008;66(10):597-600. PubMed PMID: 18826455. doi:
10.1111/j.1753-4887.2008.00110.x.
[10] Hardy WR, Meckling-Gill AK, Williford J, Desmond AR,
Wei H. Energy restriction reduces long-chain saturated
fatty acids associated with plasma lipids in aging male
rats. J Nutr 2002;132(10):3172-3177. PubMed PMID:
12368414.
[11] Abel ED. Free fatty acid oxidation in insulin resistance
and obesity. Heart Metab 2010;48:5-10.
[12] Hendrich S. (n-3) Fatty Acids: Clinical Trials in People
with Type 2 Diabetes. Adv. Nutr 2010;1:3-7. doi: 10.3945/
an.110.1003.
[13] Muzumdar R, Ma X, Atzmon G, Vuguin P, Yang X, Barzilai N. Decrease in glucose-stimulated insulin secretion
with aging is independent of insulin action.. Diabetes
2004;53(2):441-446. PubMed PMID: 14747296. doi:
10.2337/diabetes.53.2.441.
[14] Stirban A, Nandrean S, Gtting C, Tamler R, Pop A,
Negrean M, et al. Effects of n-3 fatty acids on macroand microvascular function in subjects with type 2 diabetes mellitus. Am J Clin Nutr 2010 Jan;91(3):808-813.
PubMed PMID: 20071644. doi: 10.3945/ajcn.2009.28374.
[15] Wang S, Li J, Li XJ. Morphological and functional characteristics of pancreatic isler beta cells in natural aging SD
rats. Sichuan Da Xue Xue Bao Yi Xue Ban 2008;39(2):197201. PubMed PMID: 18630682.
[16] Cahov M, Vavnkov H, Kazdov L. Glucose-Fatty Acid
Interaction in Skeletal Muscle and Adipose Tissue in Insulin Resistance. Physiol Res 2007;56(1):1-15. PubMed
PMID: 16497094.
[17] Novgorodtseva PT, Karaman KY, Zhukova VZ, Lobanova
GE, Antonyuk VM, Kantur AT. Composition of fatty
acids in plasma and erythrocytes and eicosanoids level
in patients with metabolic syndrome. Lipids in Health
and Disease 2011;10:82. PubMed PMID: 21595891. doi:
10.1186/1476-511X-10-82.
[18] L KA, Ventura EE, Fisher QJ, Davis NJ, Weigensberg JM,
Punyanitya M, et al. Ethnic differences in pancreatic fat accumulation and its relationship with other fat depots and
inflammatory markers. Diabetes Care 2011;34(2):485490. PubMed PMID: 21270204. doi: 10.2337/dc10-0760.
[19] Flack DK, Davy PK, Hulver WM, Winett AR, Frisard I, Davy MB. Resistance Training, and Diabetes Prevention. Journal of Aging Research 2011. doi:
10.4061/2011/127315.
[20] Qatanani M, Lazar MA. Mechanisms of obesity-associated insulin resistance: many choices on the menu.
190
[21]
[22]
[23]
[24]
[25]
[26]
[27]
[28]
[29]
[30]
[31]
[32]
[33]
Genes Dev 2007 Jun;21(12):1443-1455. PubMed PMID:

17575046. doi: 10.1101/gad.1550907.
Gastaldelli A, Cusi K, Pettiti M, Hardies J, Miyazaki Y,
Berria R, et al. Relationship between hepatic/visceral fat
and hepatic insulin resistance in nondiabetic and type 2
diabetic subjects. Gastroenterology 2007 May;133(2):496506. PubMed PMID: 17681171. doi: 10.1053/j.gastro.2007.04.068.
Charles MA, Eschwge E, Thibult N, Claude JR, Warner
JM, Rosselin GE, et al. The role of non-esterified fatty acids in the deterioration of glucose tolerance in Caucasian
subjects:results of the Paris Prospective Study. Diabetologia 1997;40(9):1101-6. PubMed PMID: 9300248.
DeNino FW, Tchernof A, Dionne JI, Toth JM, Ades AP,
Sites KC, et al. Contribution of abdominal adiposity to
age-related differences in insulin sensitivity and plasma lipids in healthy nonobese women. Diabetes Care
2001;24(5):925-932. PubMed PMID: 11347756.
Hirabara MS, Curi R, Maechler P. Saturated fatty acidinduced insulin resistance is associated with mitochondrial dysfunction in skeletal muscle cells. Journal of Cellular Physiology 2010;222(1):187-194. PubMed PMID:
19780047. doi: 10.1002/jcp.21936.
Reers C, Erbel S, Esposito I, Schmied B, Bchler MW,
Nawroth PP, et al. Impaired islet turnover in human
donor pancreata with aging. Eur J Endocrinol 2008
Nov;160(2):185-191. PubMed PMID: 19004984. doi:
10.1530/EJE-08-0596.
Maedler K, Schumann MD, Schulthess F, Oberholzer J,
Bosco D, Berney T, et al. Aging correlates with decreased
-cell proliferative capacity and enchanced sensitivity to
apoptosis. Diabetes 2006;55:2455-2462
Szoke E, Shrayyef ZM, Messing S, et al. Effect of aging on
glucose homeostasis: accelerated deterioration of -cell
function in individuals with impaired glucose tolerance. Diabetes Care 2008;31(3):539-543. PubMed PMID:
18083793. doi: 10.2337/dc07-1443.
Nolan JC, Madiraju SRM, Delghingaro-Augusto V, Peyot
ML, Prentki M. Fatty acid signaling in the -Cell and insulin secretion. Diabetes 2006;55 (Suppl. 2):S16S23
Belfort R, Mandarino L, Kashyap S, Wirfel K,
Pratipanawatr T, Berria R, et al. Dose-response effect of
elevated plasma free fatty acid on insulin signaling. Diabetes 2005;54(6):1640-1648. PubMed PMID: 15919784.
Stefan N, Stumvoll M, Bogardus C, Tataranni PA. Elevated plasma nonesterified fatty acids are associated with deterioration of acute insulin response in IGT but not NGT.
Am J Physiol Endocrinol Metab. 2003;284:E1156-E1161
Paolisso G, Tataranni PA, Foley JE, Bogardus C, Howard
BV, Ravussin E. A high concentration of fasting plasma
non-esterified fatty acids is a risk factor for the development of NIDDM.. Diabetologia 1995;38(10):1213-1217.
Miyazaki Y, DeFronzo RA. Visceral fat dominant distribution in male type 2 diabetic patients is closely related
to hepatic insulin resistance, irrespective of body type.
Cardiovasc Diabetol 2009 Aug;8:44. PubMed PMID:
19656356. doi: 10.1186/1475-2840-8-44.
Blouin K, Boivin A, Tchernof A. Androgen and body
fat distribution. J Steroid Biochem Mol Biol 2008;108(35):272-280. PubMed PMID: 17945484. doi: 10.1016/j.jsbmb.2007.09.001.
[34] Mittendorfer B. Sexual dimorphism in human lipid metabolism.. J Nutr 2005;135(4):681-686. PubMed PMID:
15795418.
[35] Li M, Fu W, Li XA. Differential fatty acid profile in adipose and non-adipose tissues in obese mice. Int J Clin
Exp Med 2010;3(4):303-307. PubMed PMID: 21072264.
[36] Tushuizen ME, Bunck MC, Pouwels PJ, Bontemps S, van
Waesberghe JHT, Schindhelm RK, et al. Pancreatic fat
content and beta-cell function in men with and without
type 2 diabetes. Diabetes Care 2007 Jul;30(11):2916-2921.
PubMed PMID: 17666465. doi: 10.2337/dc07-0326.
[37] Ijzerman GR, Stehouwer DAC, Serne HE, Voordouw JJ,
Smulders MY, Delemarre-van de Waal AH, et al. Incorporation of the fasting free fatty acid concentration into
quantitative insulin sensitivity check index improves its

association with insulin sensitivity in adults, but not in
children. Eur J Endocrinol 2009;160:59-64
[38] Schrauwen P, Hoeks J, Hesselink KCM. Lipid-induced cell
stress and insulin resistance. Scandinavian Journal of Nutrition 2006;50(2):62-67
[39] Poynten MA, Gan KS, Kriketos DA, Campbell VL, Chisholm JD. Circulating fatty acids, non-high density lipoprotein cholesterol, and insulin-infused fat oxidation
acutely infuence whole body insulin sensitivity in nondiabetic men. J Clin Endocrinol Metab 2005;90:1035-1040
[40] Hesselink KCM, Mensink M, Schrauwen P. Lipotoxicity
and Mitochondrial Dysfunction in Type 2 Diabetes. Immun Endoc Metab Agents in Med Chem 2007;7:3-17
191
www.jhsci.ba
Chemical composition, antimicrobial and

antioxidant properties of Mentha longifolia (L.)
Huds. essential oil
Haris Niki*, Elvira Kova-Beovi, Elma Makarevi, Kemal Duri
Faculty of Pharmacy University of Sarajevo, Zmaja od Bosne 8 , 71 000 Sarajevo, Bosnia and Herzegovina
Abstract
Introduction: Present study describes the antimicrobial activity and free radical scavenging capacity (RSC)
of essential oil from Mentha longifolia (L.) Huds. Aim of this study to investigate the quality, antimicrobial and
antioxidant activity of wild species Mentha longifolia essential oil from Bosnia and Herzegovina.
Methods: The chemical profile of essential oil was evaluated by the means of gas chromatography-mass
spectrometry (GC-MS) and thin-layer chromatography (TLC). Antimicrobial activity was tested against 6
bacterial strains. RSC was assessed by measuring the scavenging activity of essential oils on 2,2- diphenyl1-picrylhydrazil (DPPH).
Results: The main constituents of the essential oil of M. longifoliae folium were oxygenated monoterpenes,
piperitone oxide (63.58%) and 1,8-cineole (12.03%). Essential oil exhibited very strong antibacterial activity.
The most important antibacterial activity essential oil was expressed on Gram negative strains: Escherichia
coli, Pseudomonas aerginosa and Salmonella enterica. subsp.enterica serotype ABONY. Antioxidant activity
was evaluated as a RSC. Investigated essential oil was able to reduce DPPH radicals into the neutral DPPHH form (IC50=10.5 g/ml) and this activity was dose dependent.
Conclusion: The study revealed significant antimicrobial activity of the investigated essential
oil. The examined oil exhibited high RSC, which was found to be in correlation to the content of mainly monoterpene ketones and aldehydes. These results indicate that essential oils could serve as safe antioxidant and
antiseptic supplements in pharmaceuticals.
Keywords: Mentha longifolia (L.) Huds, essential oil, chemical composition, antimicrobial activity,
antioxidant activity
Introduction
Since ancient times, herbs and spices have been
added to different types of food to improve the flavor and organoleptic properties. Also, herbal medicines have a great potential in the emerging nutrition industry, because these materials are often
considered foods as well as medicines and are used
in preventive and curative treatments throughout
the world (1). Especially popular today is the concept of foods that combine nutritional and medicinal benefits, so-called functional foods. Many
natural compounds extracted from plants have
* Corresponding author: Haris Niki,
Farmaceutski fakultet Sarajevo
Zmaja od Bosne 8, Sarajevo
E mail: harisniksic@gmail.com
Phone:+387 61 219 444
192
demonstrated biological activities. Among these

various kinds of natural substances, essential oils
from aromatic and medicinal plants receive particular attention as potential natural agents for food
preservation. In fact, their effectiveness against a
wide range of microorganisms has been repeatedly demonstrated (2-5). Moreover, essential oils
are proved to have various pharmacological effects,
such as spasmolytic, carminative, hepatoprotective, antiviral, and anticarcinogenic effects, etc. (6).
Recently, many essential oils have been qualified
as natural antioxidants (3, 5-8) and proposed as
potential substitutes of synthetic antioxidants
in specific sectors of food preservation. Furthermore, biologically active natural compounds are
of interest to the pharmaceutical industry for the
control of human diseases of microbial origin
and for the prevention of lipid peroxidative damJOURNAL OF HEALTH SCIENCES 2012; 2 (3)
HARIS NIKI ET AL.: CHEMICAL COMPOSITION, ANTIMICROBIAL AND ANTIOXIDANT PROPERTIES OF MENTHA LONGIFOLIA (L.) HUDS. ESSENTIAL OIL
age, which has been implicated in several pathological disorders, such as ischemia-reperfusion
injury, coronary atherosclerosis, Alzheimers disease, carcinogenesis, and aging processes (9, 10).
The genus Mentha L., member of the family Lamiaceae, subfamily Nepetoideae, and the tribe
Mentheae is divided into 5 sections (Audibertia,
Preslia, Pulegium, Mentha and Eriodontes) (11,12).
The most complex section Mentha further can be
subdivided into the three groups, reflecting their
differences in the inflorescence form (Verticillatae,
Capitatae and Spicatae) (12,13). Furthermore, for
the genus Mentha the correct number of species is
still not defined. According to the authors, the genus consists approximately 14-25 species (11,12).
Most of the species are characterized by a great
polymorphism, which is reflected in the leaf shape,
indumentum, type of flowers and inflorescences
etc. In addition to the morphological variation,
most of the Mentha species also displays a considerable chemical diversity in essential oil composition, depending on the growth location (14).
Examination of the published literature on the
oil composition of M. longifolia reveals that it can
exist in a myriad of chemical forms, as can be
seen from the main constituents found in these
oils. The main constituents in essential oil were
piperitone oxide (13.90-50.50 %), 1,8-cineole
(8.18-17.80%), carvone (0.5-21.5%), beta caryophyllene (2.0-22.0%) and menthol (0.0-32.50%).
The genus Mentha clearly has marked antimicrobial characteristics across the spectrum from
fungi and parasites, through bacteria, to viruses. There is some difficulty in comparing the
different results obtained by research groups
across the world since so many variables exist.
Antimicrobial activity along with the antioxidant effectiveness of essential oils is one of the
most examined features, important for both
food preservation and control of human and
animal diseases of microbial origin. Numerous
reports suggest strong antibacterial and antifungal activities of a wide range of essential oils,
especially those belonging to the Lamiaceae
family (12). In general, Gram-positive strains of
bacteria are more sensitive to the mint essential oils.
Mentha longifolia (L) Huds. is perennial herb
40-120 cm high with musty scent. Stem white or
grey-villous, sometimes sparsely hairy. Leaves are

sessile or shortly petiolate usually oblong elliptical,
hairs simple. Extremely variable in height, leaf size
and shape, indumentum and inflorescence and
complicated by the occurrence of hybrids. Mentha longifolia, is often used as a domestic herbal
remedy, being valued especially for its antiseptic
properties and its beneficial effect on the digestion as it is a well-know treatment for flatulence.
The objectives of this study were to analyze the
composition, antimicrobial and antioxidant activity of the essential oil of Mentha longifolia growing
wild in Bosnia and Herzegovina.
Methods
Plant Material: Aerial parts of wild growing
flowering plants of Mentha longifolia (L.) Huds.
during three phenophases (before flowering,
flowering and after flowering) were collected
in 2011. on the bank of the Jablanicko lake, near
Konjic, in Bosnia and Herzegovina.
Isolation of the Essential Oil:
Air-dried plants of Mentha longifolia were submitted to hydrodistillation according to European Pharmacopoeia 7ed. (15), using Clevenger
apparature (Klaus Hofmann GmbH, Germany).
The essential oil samples of each phenophase were
dried over anhydrous sodium sulfate. The quantity
of the predestilated essential oils were determined
volumetrically.
Essential Oil Analysis: Qualitative and quantitative
analyses of the essential oils were carried out using
a gas chromatography/mass spectrometry system
(GC-MS, Agilent Tecnologies series 6890N/5975B,
United States of America) at electron energy=70
eV, equipped with a split-splitless injector (2000C)
and a flame ionization detector (FID) (2500C).
As a carrier gas helium (1ml/min) was used. The
capillary columns (HP 5MS 30m x 0.25mm; film
thickness 0.25m Agilent Tecnologies) were used.
The temperature programmes were 500C to 2800C
at a rate of 100C/min until 1300C and 130-2800C at a
rate of 120C/min, respectively with split ratio, 1:10.
Coelution and mass spectrometry MS analysis
based on the identification of the individual compounds, and the comparison of their relative retention times (RI) with those of the reference samples
193
were performed. For the components, mostly sesquiterpenes and aliphatic compounds, for which
reference substances were not available, the identification was performed by matching their retention
times and mass spectra with those obtained from
the authentic samples and/or the The National Institute of Standards and Technology, known as the
National Bureau of Standards (NIST/NBS), Wiley
libraries spectra as well as with literature data (16).
Evaluation of Antibacterial Activity.
Antimicrobial activity of essential oils, isolated
from Mentha longifolia (L.) Huds., using diffusion
method was performed in this study. A collection of 6 test organisms, including three Grampositive and three Gram-negative bacterial strains,
was used. The groups included five organisms of
American Type of Culture Collection (ATCC) and
one organism of National Collection of Type Cultures (NCTC). The source of the bacterial strains
is shown in Table 2. All test organisms were stored
at +4 C on Mueller-Hinton (MH) agar slants, sub
cultured every 2 weeks and checked for purity.
Antibiotics which are therapeutically important
in treating infections caused by these microorganisms were used as comparative substances (as
positive control): ciprofloxacine for evaluation of
antimicrobial activity of Pseudomonas aeruginosa,
Penicilin for Bacillus subtilis, Gentamycin for Escherichia coli, Staphylococcus aureus and Staphylococcus epidermidis and tetracycline for Salmonella enterica subsp.enterica serotype ABONY. All
samples were applied as solution in n-hexane. The
effect of the solvent (n-hexane) on the microbial
growth was also analyzed. On the surface of the
agar, the 6 mm holes in diameter were punched.
Hundred microliters of the tested essential oils
(10 %, 5%, 1%, 0.5% and 0.1% solutions in nhexane was applied to the holes. The plates were
incubated overnight at 37 C, and the diameter
of the resulting zone of inhibition was measured.
The evaluation of the antibacterial activities of the
essential oils was carried out in three repetitions.
Antioxidant Activity.
Chemicals and Apparatus: 1,1-Diphenyl-2-picrylhydrazyl (DPPH) as free radical form (90%
purity) and 6-hydroxy-2,5,7,8 tetramethylchroman-2- carboxylic acid (Trolox) were obtained
194
TABLE 1. Chemical Composition of M. longifolia Essential Oil

pick
no.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
Components
RIa
monoterpene hydrocarbons
alfa-pinene
Sabinene
beta-pinene
beta-myrcene
Terpinolene
Limonene
oxygenated monoterpenes
1.8-cineole
trans-sabinene hydrate
cis-sabinol
Borneol
piperitone oxide
4-terpineol (terpinen-4-ol)
1-alfa-terpineol
thymol
piperitenone
piperitenone oxide
cis-jasmone
sesquiterpene hydrocarbons
alfa-kopaene
beta-burbonene
beta-kubebene
beta-elemene
cis-Caryophyllene
trans-Caryophyllene
alfa-humulene
allo-aromadendrene
alfa-amorfene
germacren D
alfa-murolene
gama-cadinene
delta-cadinene
oxygenated sesquiterpenes
caryophyllene oxide
cedrol
tau-muurolol
alfa-cadinol
aliphatic compounds
3-octanol
n-udecanol
total identified
938
974
978
992
1008
1035
1036
1098
1143
1167
1170
1178
1188
1291
1343
1369
1395
1375
1383
1390
1391
1405
1419
1452
1462
1485
1490
1500
1514
1523
1582
1601
1651
1654
991
1370
percentage
(%)
3,06
0,78
0,47
0,99
0,69
0,07
0,06
87,1
12,03
0,68
0,16
0,52
63,58
0,1
0,91
1,69
1,98
4,81
0,64
6,79
0,19
0,54
0,48
0,18
0,82
2,98
0,44
0,23
0,26
0,16
0,11
0,31
0,09
5,57
4,33
0,51
0,2
0,53
1,22
1,16
0,06
98,17
Compounds listed in order of elution from a HP-5 MS column.

Retention indices relative to C9-C24 n-alkanes on the HP-5 MS
column
TABLE 2. Antibacterial Activity (Inhibition Zone Measured in mm, Including Hole 6 mm in Diameter) of Essential Oils of Mentha
longifolia
source
organism
ATCC 6633 Bacillus subtilis
Staphylococcus
ATCC 6538
aureus
Staphylococcus
ATCC 11228
epidermidis
ATCC 8739 Escherichia coli
Pseudomonas
ATCC 9027
aeruginosa
Salmonella enterica
NCTC 6017 subsp.enterica
serotype ABONY
10 %
110,81
5%
9,50,80
1%
80,71
0,5%
-
0,1%
-
13,61,52
141,62
80,71
10,50,00 gentamycine
122,11
10,91,12
15,2 0,00 gentamycine
190,71
171,22
130,61
90,51
70,33
252,12
221,71
190,77
190,87
111,85 28 0,85 ciprofloxacine
200,33
150,56
100,99
Positive control
320,70 penicilin
17 0,22 gentamycine
200,22 tetracycline
The values shown represent the average of three determinations standard deviations. All essential oils were diluted in n-hexane
(solvent expressed no activity on bacterial growth).
from SigmaAldrich Quimica (Alcobendas,

Spain). N- hexane was provided by Merck (Mollet
del Valles, Spain). All reagents were of analytical
grade. Double distilled water (Millipore Co.) was
used throughout. Absorbance measurements were
recorded on a UV/VIS mini-1240 Spectrophotometer (Shimadzu, Japan).
DPPH and analyzed compound was reached.

0.1 M Trolox was used as positive control. For
each samples three replicates were recorded.
Free radical scavenging capacity in percent (RSC
(%)) was calculated by following Equation (1):
DPPH Method
A hexanic solution (90 M ) of the radical DPPH
was prepared daily and protected from light.
Absorbance was recorded to check the stability of the radical throughout the time of analysis.
2 mL of the stock solution of essential oil (61.92
g/ml) was mixed with 2 mL of 90 M DPPH.
solution. Absorbance at 515 nm was recorded at
different time intervals until the reaction reached
an equilibrium. The initial absorbance was 0.700.
The blank reference cuvette contained hexane.
1.25; 3.75; 2; 5 and 10 ml of concentrated stock
solutions (61.92 g/ml) were diluted to 10 ml
with n-hexane to yiled the concentrations of 7.74;
15.48; 23.22; 30.96 and 61.92 g/ml, respectively.
Absorbance intensity of DPPH on wavelength 515 nm was measured in the test solutions that were contained 2 ml of 90 M
DPPH solution and 2 ml of tested dilutions
of essential oil (from 7.74 to 61.92 g/ml).
Absorbencies intensity of the test solutions and
the blank (with same chemicals, except sample) were measured at the 0 min and at the time
when the steady state of the reaction between
From the obtained RSC values the EC50 values, which represent the concentration of the
essential oil that caused 50% neutralization,
were determined by linear regression analysis.
The antiradical efficiency (AE) was calculated considering the EC50 value and the necessary time to
reach the EC50 (TEC50), according to the following Equation (2):
RSC (%)=100*(Ablank-Asample)/ABlank (1)
Results
Essential oil content and chemical composition
The content of the essential oil in the flowering stage, expressed in percentage was 1.9%
v/w (volume of essential oil/weight dry leaf).
A total of 36 compounds were identified, grouped
as classes of compounds, in the essential oils extracted from M. longifolia plants collected in Bosnia and Herzegovina (Table 1). A total of the 36
chemical constituents representing 98.17% of the
total content.
195
Antimicrobial Activity
The antibacterial activity of essential oil against
a range of Gram-positive (three strains) and
FIGURE 1. Reaction curves between 90 M DPPH and different solutions essential oil of M. longifolia.
Gram-negative (three strains) is shown in Table

2 and figures 2-7. Obtained results revealed that
essential oil exhibited variable levels of antibacterial activity against all tested bacterial strains.
Antioxidant Activity
This study, also, determined the antioxidant activity of one species of the family Lamiaceae. The
results indicate that the hexan extract of the plant
demonstrated antioxidant activity, and showed
the high activity with a EC50 value of 10.5 g/mL
(Table 3). The reaction of essential oil and DPPH.
is quite slow. Time at equilibrium state depends
on the concentration used (Figure 1). TEC50, as
the time at equilibrium reached with a concentration of essential oil equal to EC50 is 95. Calculated
value of AE of tested essential oil is 10.58*10-3.
M.L.A 0,5%
M.longifoliae aetheroleum 0,5%
M.L.A 10%
M.longifoliae aetheroleum 10%
M.L.A 5%
M.L.A 1%
M.L.A 0,1%
M.L.A 0,5%
M.L.A 10%
M.L.A 5%
M.L.A 1%
M.L.A 0,1%
FIGURE 2. Antimicrobial activity against Staphylococcus aureus
FIGURE 3. Antimicrobial activity against Staphylococcus epidermidis

196
M.L.A 0,5%
M.L.A 10%
M.L.A 5%
M.L.A 1%
M.L.A 0,1%
M.L.A 0,5%
M.L.A 10%
M.L.A 5%
M.L.A 1%
M.L.A 0,1%
M.L.A 0,5%
M.L.A 10%
M.L.A 5%
M.L.A 1%
M.L.A 0,1%
FIGURE 4. Antimicrobial activity against Bacillus subtilis
FIGURE 5. Antimicrobial activity against Escherichia coli
FIGURE 6. Antimicrobial activity against Pseudomonas aeruginosa

197
M.L.A 0,5%
M.L.A 10%
M.L.A 5%
M.L.A 1%
M.L.A 0,1%
FIGURE 7. Antimicrobial activity against Salmonella enterica subsp.enterica

TABLE 3. Percentage of neutralization of DPPH. of essential oil of M. longifolia and trolox as positive control in DPPH assay
Source
M. longifolia
Concentration [g/ml]
7.74
15.48
23.22
30.96
61.82
RSC (%)
45.22
56.09
63.20
70.22
98.50
Discussion
M. longifolia essential oils from other geographical
locations have been extensively studied. The essential oil content (1.9% v/w in dry leaf) was in accordance with the earlier published data (3). In the oil
obtained from the plants collected in the flowering
stage the oxygenated monoterpenes were found to
be the major class of substances (87.1%), followed
by the sesquiterpene hydrocarbons (6.79%) and
oxygenated sesquiterpenes (5.57%). The main constituents of the essential oil of M. longifoliae folium
were oxygenated monoterpenes, piperitone oxide
(63.58%) and 1.8-cineole (12.03%). Caryophyllene
oxide (4.33%) was dominant component in class
of oxygenated sesquiterpenes, and trans-caryophyllene (2.98%) and cis-caryophyllene (0.82%) were
dominant components in class of sesquiterpene
hydrocarbons. These results are in accordance with
the previously published data except compound
piperitone oxide whose concentration is a little
higher then usual. Main constituents in Mentha
198
EC50 [g/ml]
10.50
TEC50 [min]
95
AE (*10-3)
10,58
longifolia samples collected at various locations:

Croatia, carvone, piperitenone oxide, limonene
and -caryophyllene (17); Serbia, trans-dihydrocarvone (24%), piperitone (17%), cis-dihydrocarvone (16%) (6); Turkey, piperitone oxide (65%),
piperitenone oxide (12%) (18); Iran, piperitone
(44%), limonene (14%) and trans-piperitol (13%)
(19); France, carvone (57%), 1,8-cineole (13%)
and limonene (7%) (20); South Africa, menthone
(51%), pulegone (19%), 1,8-cineole (12%) (21).
Gram-negative bacteria seemed to be more sensitive to the different examined essential oils
than Gram-positive bacteria. These results are
partially according to the literature data (2-5).
Significant antimicrobial activity of essential oil
was recorded against of examined multiresistant
Gram-negative pathogenic bacteria, such are
Pseudomonas aeruginosa, Salmonella enterica and
Escherichia coli. Especially considerable is that
the highest sensitivity to essential oil of M. longifolia was observed by Pseudomonas aeruginosa
ATCC 9027 (11-25 mm depend of concetration).

It is well known that the antioxidant activity of
essential oil containing phenol components is
due to their capacity to be donors of hydrogen
atoms or electrons and to capture the free radicals (22). DPPH analysis is the test used to prove
the ability of the components of the essential oil
of Mentha longifolia to act as donors of hydrogen
atoms. Essential oil of Mentha longifolia showed
a signicant effect in inhibiting DPPH., reaching up to 50% at concentration of 10.50 g/ml.
The antiradical efficiency (AE) is a new parameter for the measurement the free radical scavenging of samples, and it combines
the potency (1/EC50) and the reaction time
(TEC50) (23). According to AE samples were
divided into four antiradical efficiency groups:
AE 1 10-3 low antiradical activity
1 10-3 < AE 5 10-3 medium antiradical activity
5 10-3 < AE 10 10-3 high antiradical activity
AE > 10 10-3 very high antiradical activity
It was find that AE of tested essential oil was
10.58*10-3, which places it into grupe with very
high antiradical activity.
Conclusion
In conclusion, the study revealed significant antimicrobial, particularly antibacterial, activity of
the investigated essential oil. The examined oil
exhibited high RSC, which was found to be in
correlation to the content of mainly monoterpene
ketones and aldehydes. These results indicate
that essential oils could serve not only as flavor
agents but also as safe antioxidant and antiseptic supplements in preventing d eterioration of
foodstuff and beverage products and pharmaceuticals. Also, consumption of food produced
with natural essential oils or aromatic plant
extracts (functional foods) is expected to prevent the risk of free radical dependent diseases.
This study represents the first time investigation
content, chemical composition, animicrobial and
antioxidant activity essential oil of wild mint species from the area of Bosnia and Herzegovina.
Competing interests
Authors declare no conflict of interest.
References
[1] Lawrence BM. Mint: The Genus Mentha. Boca Raton,
Florida: CRC Press; 2007.
[2] Gulluce M, Sahin F, Sokmen M, Ozer H, Daferera D, Sokmen A, et al. Antimicrobial and antioxidant properties of
the essential oils and methanol extract from Mentha longifolia L. ssp. longifolia. Food Chem 2007;103:1449-1456.
[3] Mkaddem M, , Bouajila J, Ennajar M, Lebrihi A, Mathieu F,
Romdhane M. Chemical composition and antimicrobial
and antioxidant activities of Mentha longifolia L. and viridis essential oils. J Food Sci 2009;74(7):358-363. PubMed
PMID: 19895481. doi: 10.1111/j.1750-3841.2009.01272.x.
[4] Marino M, Bersani C, Comi G. Impendance measurements to study the antimicrobial activity of essential oils
from Lamiaceae and Compositae. Int J Food Microbiol.
2001; 67 (3):187-195
[5] Bozin B, Mimica-Dukic N, Simin, N, Anackov G. Characterization of the Volatile Composition of Essential Oils
of Some Lamiaceae Species and the Antimicrobial and
Antioxidant Activities of the Entire Oils. Journal of Agricultural and Food Chemistr.2006;54:1822-1828
[6] Dzamic AM, Sokovic MD, Ristic MS, Novakovic M, Grujic-Jovanovic S, Tesevic V, et al. Antifungal and antioxidant activity of Mentha longifolia (L.) Hudson (Lamiaceae) essential oil. Bot Serb. 2010;34:57-61
[7] Hussain AI, Anwar F, Nigam PS, Ashraf M, Gilani AH.
Seasonal variation in content, chemical composition and
antimicrobial and cytotoxic activities of essential oils
[8]
[9]
[10]
[11]
[12]
[13]
[14]
[15]
from four Mentha species. J Sci Food Agric 2010;90:18271836.

Bruneton J. Pharmacognosy, Phytochemistry, Medicinal
Plants. 2nd ed. London, Paris, New York: Intercept Ltd;
1999.
Khalaf AN, Shakya KA, Al-Othman A, El-Agbar Z, Farah
H. Antioxidant Activity of Some Common Plants. Turk J
Biol. 2008;32:51-55.
Smith MA, Perry G, Pryor WA. Causes and consequences
of oxidative stress in Alzheimers disease. Free Radical
Biol Med 2002;3(11):1049
Harley RM. Mentha L. in: Flora Europaea III. Cambridge:
Cambridge University Press; 1972.
Gobert V, Moja S, Colson M, Taberlet P. Hybridization
in the section Mentha (Lamiaceae) inferred from AFLP
markers. Am J Bot 2002;89(12):2017-2023. PubMed
PMID: 21665630. doi: 10.3732/ajb.89.12.2017.
Nickavar B, Alinaghi A, Kamalinejad M. Evaluation of the
Antioxidant Properties of Five Mentha Species. Iranian
Journal of Pharmaceutical Research 2008;7(3):203-208.
Santos AKL, Costa JGM, Menezes IRA, Cansano IF,
Santos KKA, Matias EFF, et al. Antioxidant activity of five
Brazilian plants used as traditional medicines and food
in Brazil. Pharmacogn Mag 2010;6(24):335-338. PubMed
PMID: 21120039. doi: 10.4103/0973-1296.71789.
European Pharmacopeia, 7th ed.; Council of Europe European (COE) - European Directorate for the Quality of
199
[16]
[17]
[18]
[19]
200
Medicines (EDQM): Strasbourg Cedex, France: 2010;

2.8.12, p 183-184
Adams RP. Identification of Essential Oil Components by
Gas Chromatography/Mass Spectroscopy. Carol Stream,
Illinois: 4th Ed. Allured Publishing;2007.
Mastelic J, Jerkovic I. Free and glycosidically bound volatiles of Mentha longifolia growing in Croatia. Chem Nat
Comp 2002;38:561-564.
Baser KHC, Kurkcuglu M, Tarimcila G, Kaynak G. Essential oils of Mentha species from northern Turkey. J Essent
Oil Res 1999;11:579-588.
Rasooli I, Rezaei MB. Bioactivity and chemical properties
of essential oils from Zataria multiflora Boiss and Mentha
longifolia (L.) Huds. J Essent Oil Res 2002;14:141-146.
[20] Vidal JP, Noleau I, Bertholon G, Lamy J, Richard H. Constituants volatils des huiles essentielles de Menthes sylvestres de la Drme. Parf. Cosm. Aromes 1985;64:83-87
[21] Oyedeji AO, Afolayan AJ. Chemical composition and
antibacterial activity of the essential oil isolated from
South African Mentha longifolia (L.) L. subsp. Capensis
(Thunb.) Briq. J Essent Oil Res 2006;18:57-59.
[22] Husain IA. Caracterization And Biological Activities Of
Essential Oil Of Some Species Of Lamiaceae. PhD Thesis.
Faculty Of Sciences, University Of Agroculture, Faisalbad,
Pakistan,2009.
[23] Sanchez-Moreno C, Larrauri JA, Saura-Calixto F. A procedure to measure the antiradical efficiency of polyphenols. J Sci Food Agric 1998;76:270-276.
www.jhsci.ba
Translation and validation of the instrument

for the oral health-related quality of life
assessment in 3 to 5 years old children in
Bosnia-Herzegovina
Amra Hadipai-Nazdraji
Public Institution Health Centar of Sarajevo Canton, Health Centar "Dom zdravlja Stari Grad", Dentistry Department,
Alajbegovia 1, 71000 Sarajevo, Bosnia and Herzegovina
Abstract
Introduction: During 2007. in the U.S. was developed the questionnaire for caregivers with 13 items for assessing the oral health-related quality of life in children 3-5 years of age, The Early Childhood Oral Health Impact Scale, The ECOHIS. The aim of this study was to perform the first part of the adaptation process for this
instrument in Bosnia-Herzegovina: translation, cross-cultural adaptation and the comprehensibility testing.
Methods: ECOHIS was translated from English into the one of the languages in Bosnia-Herzegovina using a
standardized forward-backward translation method. Two licensed, professional English-language translators,
one dentist and one pediatrician, participated in the development of the preliminary BH-ECOHIS version. All
translators were native Bosnian speakers. After translation and adaptation of ECOHIS to Bosnia and Herzegovina setting, pilot-research was performed in order to check the comprehensibility of the questionnaire.
Results: The original and the back-translated version were the same. Because not all children in BosniaHerzegovina attend preschool, school or daycare, we replaced the question number five from the original
English version missed preschool, daycare or school with had difficulties in everyday activities. Translated
and culturally adapted version of the ECOHIS was applied in a form of an interview (N=16). Parents/caregivers had no difficulties to understand the questionnaire.
Conclusions: BH-ECOHIS showed excellent comprehensibility. Next step in the validation process should
be the testing of its measurement characteristic.
Keywords: ECOHIS, translation, validation
Introduction
A large number of instruments for measuring
social impacts of oral disorders have been developed during the last two decades (1). Instruments
for testing the effects of the oral health on everyday living for adult population and for children
from 8 to 10 and from 11 to 14 years have already
been translated in Bosnia-Herzegovina (2-4) .
Children younger than seven do not have a
perception of days in the week, or a percep* Corresponding author: Amra Hadipai-Nazdraji,
Public Institution Health Centar of Sarajevo Canton, Health
Centar "Dom zdravlja Stari Grad" , Dentistry Department,
Alajbegovia 1, 71000 Sarajevo, Bosnia and Herzegovina
Phone:+3876117690; Fax:+ 38733460094
E-mail: amrahadzipasic@msn.com
Submitted 27 September 2012/ Accepted 10 December 2012
tion of a month or a season (5). At about 6

years, they become capable of abstract thinking, which means that children younger than 6
do not have perception of health or disease (6).
The burden of responsibility for general and oral
health in very young children lies on their parents (5).
Considering all that was previously said, in 2007.
was developed the questionnaire caregivers with 13
items for assessing the oral health-related quality
of life in population of children 3-5 years of age (7).
Questionnaire, named the Early Childhood
Oral Health Impact Scale (ECOHIS), has been
developed in the United States in English language (Appendix 1). The ECOHIS requires
translation and validation if used in other languages, or if used in cultural unique region.
The ECOHIS has been developed from the
201
AMRA HADIPAI-NAZDRAJI: TRANSLATION AND VALIDATION OF THE INSTRUMENT FOR THE ORAL HEALTHRELATED QUALITY OF LIFE ASSESSMENT IN 3 TO 5 YEARS OLD CHILDREN IN BOSNIA-HERZEGOVINA
initial pull of 45 questions, recruited for the HIS scores are calculated as a simple sum of the
development of P-CPQ, which is a question- response codes for CIS and FIS, after recording
naire for parents/caregivers of children 6 to 14 Don't know answer as the missing answer. If a
years. These questions were reduced by den- questionnaire has two or more Don't know antists to 36 items. Further reduction, made by swers in CIS and/or one in FIS section, the parparents/caregivers, led to 13 final questions (8). ticipant should be excluded. Jokovic (8) stress
The original ECOHIS questionnaire has two
the importance of including Don't know reparts. The first part, Child Impact Section (CIS) sponse option in studies where respondents are
has 9 items, and the second part, Family Impact asked to assess someone else's health or quality of
Section (FIS), 4 items. CIS has four subscales: life. By Jokovic (8), Don't know answer should
child symptom, child function, child psychol- be treated as a reflection of the construct being
ogy and child self-image/social interaction. The
measured i.e. Oral Health-Related Quality of Life
Family Impact Section, or FIS, has two sub- - OHRQoL, rather than a limitation of this scale.
scales: parental distress and family function. Answers are given in a form of the five-step Likert Translation into the Bosnian language
scale. Response options record frequency of the Translation methodology had six steps (11):
event, considering the entire life of the child. 1. Dentist with experience in work with children,
Since 2007, the ECOHIS has been translated
previously participated in translation and
and adapted for use in many languages. Authors
validation of OHIP-BH49, Child Perceptions
of the Brazilian (9) and French (10) version
Questionnaire for children aged 8 to 10 years
consider ECOHIS as a questionnaire for chilold - CPQ8-10 and Child Perceptions Quesdren 0-5 years of age, and not for children the
tionnaire for children aged 11 to 14 years old
3-5 years, which is a recommendation from the
- CPQ11-14 (2,3,4), translated the ECOHIS from
American authors. During the development of
English into the Bosnian language,
the French version, referral time for questions 2. Pediatrician who works with very young chilwas the previous two weeks, and not the endren on daily bases translated the ECOHIS
tire life of the child, as in the American version.
from English into Bosnian,
The aim of this study was to develop the Bos- 3. Licensed translator with experience in translatnia-Herzegovina version of the ECOHIS.
ing the English manuscripts in area of medical
science, dentistry and social science translated
Methods
the ECOHIS from Bosnian into the English,
During this study, we performed the first part of 4. All three versions were compared, and after
minor adaptation, preliminary version was
the adaptation process for the ECOHIS: transmade,
lation of the English version into the one of the
languages in Bosnia and Herzegovina, cross-cul- 5. Translated version of the ECOHIS was backtranslated into English by the second licensed
tural adaptation of the questionnaire, and testtranslator,
ing its comprehensibility in a qualitative study.
6. English translation was compared to the original English language version of the ECOHIS,
Structure of the instrument
and evaluated differences between translated
ECOHIS consists of 13 questions. The reEnglish version and the original.
sponse options, according to five-point Lickert scale, are: Never = 0; Once/twice = 1;
Sometimes = 2; Often = 3; and Every day/ Cross-cultural adaptation
almost every day = 4. An overall ECOHIS Cross-cultural adaptation was conducted acscore should be computed by addition of all cording to the international instructions (12).
item scores, and scores for each of the two do- One question, no. 5, required some changes, bemains also. The total score can vary from 0 to 52. cause many young children in Bosnia and Herzegovina do not attend preschool, daycare or
The sixth answer, option Don't know, was added
by the American authors of the ECOHIS. ECO- school.
202
Field study for assessing the comprehensibility of the

questionnaire
After the preliminary version of the BH-ECOHIS
was made, we assessed the comprehensibility of
the questionnaire. BH-ECOHIS was applied in a
form of an interview to a study sample of 16 children. We focused on the comprehensibility of the
words used in every item and on the sentence
construction. Subjects were randomly selected. To
be included in the study, children had to be 3-5
years old and accompanied by a Bosnian-speaking
caregiver. The field study was carried out in The
Canton Health Centre "Dom zdravlja Stari Grad",
Department of Dentistry and in The Department
of Pediatrics. All children were interviewed while
waiting for the appointment at the dentist or pediatrician, regardless they had some acute dental
problem or not. The introduction and 13 questions were read to the parent/caregiver from the
printed questionnaire. The interviewer wrote the
answers. Answers were not statistically analyzed
because this was a qualitative study on the comprehensibility of the questionnaire. This study
was in accordance with the ethical standards
and Declaration of Helsinki. The caregivers gave
their written consent before starting the interview.
Results
During the final stage of the translation process, comparation of the original and the backtranslated version showed no differences. No
changes had to be made on the translated version.
Cross-cultural adaptation of the questionnaire demanded replacement of the question no. 5 in the
English version: how often has your child missed
preschool, daycare or school with: had difficulties doing daily activities (e.g. playing, jumping,
running or missing school, preschool or daycare).
Comprehensibility of the Bosnia-Herzegovina
version ( BH-ECOHIS) was tested on a sample
of 16 children, 9/16 or 56% girls and 7/16 or 44%
boys. They were accompanied by 9/16 or 56%
mothers, 4/16 or 25% fathers and 3/16 or 19%
grandmothers. Not any of those 16 subjects had
difficulties to understand the items of the questionnaire. We had no invalid questionnaires. Only
two Don't know answers were noted in two separate questionnaires. We had no need to change
the BH-ECOHIS after the comprehensibility test.
Discussion
Our study resulted with the Bosnia-Herzegovina version of the questionnaire for assessing the oral health related quality of life
in children 3 to 5 years of age (Appendix 2).
How the quality of life is influenced by oral health
is getting more and more interesting for dental
researchers. Instrument for assessing effects of
oral health on everyday living of the adult population has already been translated in Bosnia and
Herzegovina (2). In the last eight years, similar instruments were developed for children (7, 13, 14).
Those instruments were mostly developed
in English speaking region, and they are not
available in countries with other languages.
Translation and verification of the instruments are
therefore very important for precise and correct
life quality assessment. During the validation and
adaptation process, changes in original version are
inevitable. For example, during the verification of
the Brazilian version of ECOHIS, changes were
made in question number 5. due to cultural differences between Brazil and the U.S. Questionnaire
with the original item missing preschool, daycare
or school was compared to the questionnaire
where the item was replaced with had difficulties doing daily activities (e.g. playing, jumping,
running and going to school, preschool or daycare). After testing reliability and construct validity, no change in results was observed between
two versions of the questionnaire (8). We made
the same replacement in the BH-ECOHIS version.
General recommendation is that the BH-ECOHIS
should be used in children 3-5 years of age. The
questions could refer to the period that best suits
the researcher, but we recommend, according to
the American authors, the entire life of the child.
The question no. 13, has your child had dental problems or dental treatments that had a financial impact on your family has not been
changed, although the dental services for children
in public institutions are free of charge in Bosnia and Herzegovina. A caregiver can decide to
solve child's dental problem in a private practice.
Conclusions
In our study, we translated the ECOHIS (Early
Childhood Oral Health Impact Scale) from English into the one of the languages in Bosnia and
203
Herzegovina using the forward-backward translation method. Cross-cultural adaptation, including

a qualitative study on the comprehensibility of
this measurement, was also conducted. The BHECOHIS showed very good comprehensibility.
Next step in the validation of the BH-ECOHIS should be the verification of its psychometric properties in a separate research.
Competing interests
None declared
Acknowledgements
Author is thankful to dr. Emina Hadimuratovi,
sub-specialist in neonatal pediatrics, and the Language Lab translating agency Sarajevo.
References
[1] P F Allen. Assessment of oral health related quality of life.
Health and Quality of Life Outcomes 2003, 1:40
[2] Hadipai-Nazdraji A. Quality of life with removable
dentures. Mat Soc Med 2011, 23(4):192-197
[3] Hadipai-Nazdraji A. Validation of The Child Perceptions Questionnaire 8-10 in Bosnia and Herzegovina .
Mat Soc Med 2012, 24(3):157-161
[4] Hadipai-Nazdraji A, Hadimuratovi E: The BosniaHerzegovina version of the Child Perceptions Questionnaire 11-14 (BH-CPQ11-14). Medical Journal 2012,
18(1):37-41
[5] Richard E. Behrman: Nelson Textbook of Pediatrics. Phyladelphia:W.B. Saunders Co.June 2003 ISBN
9780721603902
[6] Hetherington EM, Parke RD, Locke VO: Child psychology: a contemporary viewpoint. 5th edition. New York,
The McGraw-Hill Companies; 1999.
[7] Bhavna T Pahel, R Gary Rozier and Gary D Slade. Parental perceptions of children's oral health: The Early Childhood Oral Health Impact Scale (ECOHIS). Health and
Quality of Life Outcomes 2007, 5:6
[8] Jokovic A, Locker D, Stephens M, Kenny D, Tompson
B, Guyatt G. Measuring parental perceptions of child
oral health-related quality of life.. J Public Health Dent
2003;63(2):67-72. PubMed PMID: 12816135.
[9] Scarpelli AC, Oliveira BH, Tesch FC, Leo AT, Pordeus
[10]
[11]
[12]
[13]
[14]
[15]
IA, Paiva SM. Psychometric properties of the Brazilian

version of the Early Childhood Oral Health Impact Scale
(B-ECOHIS).. BMC Oral Health 2011 Jun;11:19. PubMed
PMID: 21668959. doi: 10.1186/1472-6831-11-19.
Li S, Veronneau J, Allison PJ.Validation of a French language version of the Early Childhood Oral Health Impact
Scale (ECOHIS).Health Qual Life Outcomes 2008 , 6:9.
Behling O, Law K. In: Translating questionnaires and other research instruments: Problems and Solutions. LewisBeck MS, editor. Thousand Oaks: Sage; 2000. pp. 170.
Meadows K, Bentzen N, Touw-Otten F. Cross-cultural issues: an outline of the important principles in establishing
cross-cultural validity in health outcome assessment. In:
Hutchinson A, Bentzen N, Knig-Zahn C, editor.
Cross Cultural Health Outcome Assessment; a user's
guide. ERGHO; European Research Group on Health
Outcomes; 1996. pp. 3440.
Jokovic A, Locker D, Tompson B, Guyatt G. Questionnaire for measuring oral health-related quality of life in
eight- to ten-year-old children. Pediatr Dent;26(6):512518. PubMed PMID: 15646914.
Jokovic A, Locker D, Guyatt G.Short forms of the Child
Perceptions Questionnaire for 11-14-year-old children
(CPQ11-14): development and initial evaluation. Health
Qual Life Outcomes 2006 Jan 19;4:4.
Appendix 1
The Early Childhood Oral Health Impact Scale (ECOHIS)
"Problems with the teeth, mouth or jaws and their treatment can affect the well-being and everyday
lives of children and their families. For each of the following questions please circle the number next
to the response that best describes your child's experiences or your own. Consider the child's entire
life from birth until now when answering each question. If a question does not apply, check 'Never"'
Response options: 1. Never, 2. Hardly ever, 3. Occasionally, 4. Often, 5. Very often and 6. Don't know.
1. How often has your child had pain in the teeth, mouth or jaws? (Child symptoms domain)
How often has your child......because of dental problems or dental treatments? (Child function domain)
2. had difficulty drinking hot or cold beverages
204
3. had difficulty eating some foods

4. had difficulty pronouncing any words
5. missed preschool, daycare or school
How often has your child......because of dental problems or dental treatments? (Child psychological
domain)
6. had trouble sleeping
7. been irritable or frustrated
How often as your child......because of dental problems or dental treatments? (Child self-image/social
interaction domain)
8. avoided smiling or laughing when around other children
9. avoided talking with other children
How often have you or another family member......because of your child's dental problems or dental
treatments? (Parent distress domain)
10. been upset
11. felt guilty
How often.... (Family function domain)
12. have you or another family member taken time off from work .....because of your child's dental problems or dental treatments
13. has your child had dental problems or dental treatments that had a financial impact on your family?
Appendix 2
Bosanskohercegovaki upitnik za mjerenje utjecaja oralnog zdravlja u ranom djetinjstvu (BH-ECOHIS)
Problemi sa zubima, ustima ili eljustima i njihovo lijeenje moe utjecati na dobrobit i svakodnevnicu djece i njihovih obitelji. Za svako od sljedeih pitanja, molim Vas da zaokruite
broj koji se nalazi pored odgovora, a koji najbolje opisuje iskustvo Vaeg djeteta, ili Vae vlastito. Kada odgovarate na pitanja, uzmite u obzir ..... period ivota djeteta. Ukoliko ne moete
odgovoriti na pitanje, jer se ono ne moe primijeniti u Vaem sluaju, zaokruite Nikad.
Mogui odgovori:1. Nikad, 2. Skoro nikad, 3. Ponekad, 4.esto, 5. Veoma esto i 6. Ne znam .
Utjecaj na dijete
Domena simptomatologije djeteta
1. Koliko esto je Vae dijete imalo zubobolju, bol u ustima ili vilici?
Domena funkcionisanja djeteta
2. Koliko esto je Vae dijete imalo potekoe kada je pilo vrue ili hladne napitke zbog stomatolokih
problema ili stomatoloke terapije?
205
3. Koliko esto je Vae dijete imalo potekoe pri jelu zbog stomatolokih problema ili stomatoloke
terapije?
4. Koliko esto je Vae dijete imalo potekoe prilikom izgovora nekih rijei zbog stomatolokih problema ili stomatoloke terapije?
5. Koliko esto je Vae dijete imalo potekoe u svakodnevnim aktivnostima (npr. igri,tranju,skakanju
ili je izostalo iz igraonice,obdanita ili kole) zbog stomatolokih problema ili stomatoloke terapije?
Domena psihologije djeteta
6. Koliko esto je Vae dijete teko zaspalo ili se budilo zbog stomatolokih problema ili stomatoloke
terapije?
7. Koliko esto je Vae dijete bilo nervozno ili nezadovoljno zbog stomatolokih problema ili stomatoloke
terapije?
Domena samopercepcije/socijalnih interakcija djeteta
8. Koliko esto je Vae dijete izbjegavalo osmjehivati se ili smijati kada je bilo okrueno drugom djecom
zbog stomatolokih problema ili stomatoloke terapije?
9. Koliko esto je Vae dijete izbjegavalo razgovarati sa ostalom djecom zbog stomatolokih problema ili
stomatoloke terapije?
Utjecaj na obitelj
Domena roditeljske uznemirenosti
10. Koliko ste Vi ili neki drugi lan porodice bili uznemireni zbog stomatolokih problema ili stomatoloke
terapije Vaeg djeteta?
11. Koliko ste se Vi ili neki drugi lan porodice osjeali krivim zbog stomatolokih problema ili
stomatoloke terapije Vaeg djeteta?
Domena funkcioniranja porodice
12. Koliko esto ste Vi ili drugi lan obitelji izostali s posla zbog stomatolokih problema ili stomatoloke
terapije Vaeg djeteta?
13. Koliko esto je Vae dijete imalo stomatolokih problema ili stomatoloku terapiju koja je predstavljala znaajan novani izdatak za Vau porodicu?
The English-version of the ECOHIS questionnaire was obtained from an Open Access article (7), distributed under the terms of the Creative Commons Attribution License which permits unrestricted use, distribution, and reproduction in any medium, provided that the original work is properly cited or translated.
206
www.jhsci.ba
The role of multi slice computed tomography

in the evaluation of acute non-cardiac chest
pain
Sandra Vegar-Zubovi*, Spomenka Kristi
Clinic of Radiology, Clinical Center University of Sarajevo, Bolnika 25, 71000 Sarajevo, Bosnia and Herzegovina
Abstract
Introduction: Differential diagnosis of acute chest pain encompasses a broad spectrum of illnesses which
are most likely followed by benign outcomes (pneumonia, pneumothorax, pleurisy, pericardial effusion, hiatus hernia), but also illnesses of lethal outcomes (pulmonary embolism, myocardial infarction, aortic dissection, thoracic aortic aneurysms, thoracic aortic aneurysm rupture, etc). Illnesses associated with benign and
lethal outcomes may present very similar if not the same symptoms, resulting in a difficult establishment of
accurate diagnosis.
Methods: During the period of one year, 123 patients presented with non-cardiac acute chest pain were
referred for the multi slice computed tomography (MSCT) examination. Scanning of thorax was conducted
in two series: unenhanced and contrast-enhanced, using a window for pulmonary parenchyma and mediastinum.
Results: From a total number of patients 21.1% had normal results while the other 79.9% had pathological
results. Out of the total number of patients with pathological result MSCT established potentially lethal outcome for 35.0%, out of which 83.7% was contributed to vascular territory of pulmonary artery, while 16.3%
was contributed to aorta.
Conclusion: MSCT scanning, owe to its ability of simultaneous analysis of vascular and non-vascular thoracic structures, represents a very efficient and reliable method for establishing accurate diagnosis and appropriate triage of patients with acute chest pain. Accurate and efficient diagnosis enables beneficial outcome
for the patient in this group of illness. MSCT enables the differentiation of etiological factors, which present
as acute onset of non-cardiac chest pain.
Keywords: acute chest pain, MSCT
Introduction
Many patient admissions to Emergency Department are due to acute chest pain (1,2). Differential diagnosis of acute chest pain encompasses a
broad spectrum of illnesses which are most likely
followed by benign outcomes (pneumonia, pneumothorax, pleurisy, pericardial effusion, hiatus
hernia), but also illnesses of lethal outcomes (pulmonary embolism, myocardial infarction, aortic
dissection, thoracic aortic aneurysms, thoracic
aortic aneurysm rupture, etc). Illnesses associated
* Corresponding author: Sandra Vegar-Zubovi,
Clinic of Radiology, Clinical Center University of Sarajevo,

Bolnika 25, 71000 Sarajevo, Bosnia and Herzegovina
Phone: +387 33 297541; Fax: +387 33 2977811
e-mail: sandra.vegar@gmail.com

with benign and lethal outcomes may present very

similar if not the same symptoms, resulting in a
difficult establishment of accurate diagnosis (2,3).
Specialist in the field of emergency medicine can
utilize a number of methods (anamnesis, systematic examination, chest X-ray, ECG, biological
markers: troponin, CK-MB, D-dimmer) to diagnose chest pain and accurately identify the cause
or contributing factors. However, in some cases
these tests are insufficient in identifying a cause,
and consequently leading to low confidence in
establishing accurate diagnosis. Specialist often
resort to repetition of the same tests, which leads
to mismanagement of time and resource, resulting
in an expensive investigation which often delays
the initiation of the appropriate treatment and the
healing process for the patient (2,4). Numerous
207
SANDRA VEGAR-ZUBOVI, SPOMENKA KRISTI: THE ROLE OF MULTI SLICE COMPUTED

TOMOGRAPHY IN THE EVALUATION OF ACUTE NON-CARDIAC CHEST PAIN
researchers consider MSCT, owning to its ability

of simultaneously analyzing all vascular and non
vascular thoracic structures, as a very efficient
and reliable tool for establishing accurate diagnosis and appropriate triage of patients with acute
chest pain, resulting in a better outcome (1,2,3,5).
In this study we present causes of non-cardiac acute chest pain established by the MSCT.
Methods
In this study, conducted over 12 month period
(JanuaryDecember 2011), 123 patients were triaged by emergency department as having acute
non-cardiac chest pain. All the patients admitted to the clinic, had the same medical conduct
which entailed thorough anamnesis, systematic
examination, ECG, and the laboratory analysis of
urea, creatinine, and biological markers: troponin,
CK-MB, D-dimmer. Patients with pathological
ECG, elevated levels of troponin and CK-MB were
eliminated from the study. Likewise, patients with
elevated levels of urea and creatinine, and patients
with anamnesis which included known allergic
reaction to iodine contrast were also eliminated
from the study mainly due to inability of administering the contrast intravenously. Patients who
were included into the study were of different
ages: the youngest patient was 18 years old and the
making the average age of the patient 54.4. Out of
the total number of patients 46.3% (n=57) were
females, while the remaining 53.7% (n=66) were
males. Immediately prior to MSCT scanning, patients did not undergo any specific preparation.
All the MSCT scans were performed using GE
BrightSpeed 4-slice and GE LightSpeed VCT
64-slice in supine position (General Electric Company, Fairfield, Connecticut, USA). On acquired
coronal topogram scanning field was planned so
that it encompasses the whole of thorax, from
the level of first rib to the level of the diaphragm.
Scanning of thorax was initially conducted in native serial progression, following intravenous administration of contrast; scanning was conducted
using a window for pulmonary parenchyma and
mediastinum. Patients were instructed to hold
their breath prior to the onset of scanning. Iodine contrast (Ultravist 370, Schering, Germany)
was administered via automatic injector; quantity
and application speed was adjusted to the age and
208
body weight of each patient. The waiting period

was determined using smart preparation technique. During analysis of scanned images MPR,
MIP and volume rendering techniques were used.
Results
All 123 patients were successfully examined. Acquired scanning images were satisfactory in
quality and suitable for analysis and establishment of diagnosis. Out of the total 123 patients,
8 were unable to hold their breath during the
scanning time, which created minor artifacts
on the scanning images; however, this did not
prevent images to be used in analysis. A satisfactory opacification of arterial blood vessels
within the thorax was established by all patients.
Out of the total number of examined patients,
21.1% (n=26) had a normal result, while the other
79.9% (n=97) of patients had results which were
pathological in nature. Out of the total number
of patients with pathological result, MSCT scanning had enabled diagnosis leading to potentially lethal outcome for 35% (n=43). Out of the
total number of diagnosis with potential lethal
outcome, 83.7% (n=36) was due to vascular territory of the pulmonary artery; more precisely,
these patients were diagnosed with pulmonary
embolism. Out of the total number of diagnosis
with potentially lethal outcome 16.3% (n=7) was
FIGURE 1. Number of diagnosis (n=43), MSCT results with

potentially lethal outcome

FIGURE 2. Number of diagnosis (n=49), MSCT results with potentially benign outcome
due to aortal vascular territory, more precisely

2 diagnosis of dissection of thoracic aorta were
established, 3 aneurisms of thoracic aorta, and 1
rupture of thoracic aorta due to aneurism and 1
intramural hematoma of ascending aorta (fig. 1).
Out of the total number of patients with pathological result MSCT identified most probable benign
outcome for 50.5% (n=49). Out of the total number of patients with diagnosis leading to benign
outcome 79.6% (n=39) was due to the lungs, 8.2%
(n=4) due to aorta, 4.4% (n=2) due to intestinal tract
and 4.4% (n=2) due to spontaneous rupture of the
diaphragm. Also diagnosed were individual cases
of hilar lymphadenopathy and pericardial effusion,
and 4 cases of primary pulmonary cancer (fig. 2).
Discussion
Acute chest pain is one of the most common
causes of admission to the emergency department.
Traditional non radiology based examination protocol, in certain number of cases, does not allow
for the establishment of successful diagnosis or
origin of chest pain. This is a common scenario
in particular with cases which present atypical
symptoms, leading to delayed administration of
appropriate treatment. Delayed medical treatment
carries significant risks, in particular if the diagnosis of the patient has a potentially lethal outcome.
Countless studies have shown that MSCT is a reliable diagnostic method which enables to establish
early and accurate diagnosis of pathological conditions which often present with acute chest pain.
Due to its ability to quickly scan the entire chest
area, the MSCT is regarded universal diagnostic
instrument for the evaluation of acute chest pain
(4,6,7). Apart from the evaluation of pulmonary
parenchyma, pleural and pericardial spaces and
thoracic part of gastrointestinal tract, the contrast
enhanced angiography phase of scanning enables
for analysis of coronary and pulmonary arteries, as
well as thoracic aorta via MSCT (6-8). The greatest proportion of cases with potentially lethal noncardiac related acute chest pain is in fact related to
pathology of pulmonary arteries and aorta (6-8).
In this study pulmonary embolism was identified
to be the most common, potentially lethal cause
of acute chest pain. MSCT is a golden standard in
diagnosis of acute pulmonary embolism, and as a
first-line imaging modality it has replaced previously used conventional pulmonary angiography
and ventilation perfusion scintigraphy (9-11).
On the other hand, the greatest number of patients
with normal results was referred for MSCT scanning under preliminary diagnosis of pulmonary
embolism. This diagnosis is most probably related
to the fact that the positive D-dimmer test is not
specific enough to establish accurate diagnosis of
pulmonary embolism. This, together with inadequate assessment of risk factors (such as immobilization, malignant illnesses, conditions related to
209

FIGURE 3. Massive pulmonary embolism: thrombotic masses in both pulmonary arteries
elevated levels of estrogen, hyper coagulating conditions, previous vein thrombosis, and age greater
than 65 years old) brings about the overuse of this
method. MSCT scanning can therefore be exposed
to a risk of misuse as a more of a screening rather
than diagnostic test. This type of negligent practice is directly related to non effective use of this
resource, which leads to increased costs of health
care and unnecessary exposure of patients to radiation and iodine contrast medium (fig. 3) (11,12).
Acute thoracic aortic dissection is a life threatening
condition that requires immediate diagnosis and
210
treatment and is the most common cause of aortic

emergency. Due to the fact that MSCT sensitivity
and specificity is almost 100% accurate in diagnosis of acute aortic dissection, this method should
therefore be used as a first-line of diagnostic tests
that should be performed as soon as acute dissection of thoracic aorta is suspected (13,14). MSCT
enables not only the detection of dissection of the
thoracic aorta, but also provides the information
necessary for classification according to the Stanford system. MSCT also differentiates between
true and false lumen, which is very important

FIGURE 4. Dissection of thoracic aorta: Stanford type A
FIGURE 5. Rupture of the thoracic aorta aneurism with hematoma formed in the place of rupture
from the perspective of furthering our abilities in the field of endovascular treatment (13,
14). In this study all the cases of thoracic aortic
dissection fall within the category A according to Stanford classification system (Figure 4).
In the case of aneurism of thoracic aorta,
and in particular the rupture of aortic aneurism as a most serious related complication
which requires immediate prompt and aggressive treatment, MSCT angiography is the
preferred method for the evaluation of these
cases (15, 16). This method enables a total
analysis of thoracic aorta aneurism; more
specifically, it enables detailed morphology,
expansion, relation to nearby structures and
branches, exact location of rupture and associated measurements necessary for undertaking of endovascular treatment (15, 16). In this
study one case of rupture of aneurism of thoracic aorta was diagnosed. Successful MSCT
angiography provided results for accurate
and efficient diagnosis which resulted in the
endovascular treatment of the patient (fig. 5).
Spontaneous rupture of the diaphragm is a
rare cause of acute chest pain. Although the
initial method for evaluating of this condition
is chest X ray, MSCT is a method of choice
due to its coronal and sagittal reconstruction
ability. MSCT scanning in emergency cases
enables not only diagnosis of rupture but
also the analysis of the herniated contents in
thoracic area and possible subsequent pathological conditions in the chest (17, 18). In
this study we diagnosed two cases of spontaneous rupture of left hemi-diaphragm with
consequential herniation of intestine into
the left hemi-thorax. Patients were successfully treated through necessary surgery (fig. 6).
In this study most often acute chest pain
with probable benign outcome was identified via MSCT in patients suffering from inflammatory changes in the lungs and pleura,
spontaneous pneumothorax, hiatus hernia
and pericardial effusion. The importance of
MSCT scanning is not only reflected in the
fact that these conditions were accurately diagnosed, furthermore differentiation between
this group of pathological conditions and
conditions requiring immediate attentions
211

FIGURE 6. Spontaneous rupture of the diaphragm with the herniation of stomach and intestine in the left hemi-thorax
where patients were in life threatening situations

was promptly established (Figure 7 and 8) (2-5).
Conclusion
MSCT scanning, owning to its ability of simultaneously analyzing vascular and non vascular
thoracic structures represents a very efficient and
reliable method for establishing accurate diagnosis and appropriate triage of patients with acute
chest pain. Accurate and efficient diagnosis enables beneficial outcomes for the patient in this
group of illness. MSCT enables the differentiation
212
of etiological factors which present as acute onset

of non cardio vascular chest pain that may lead
to a benign or lethal outcome. Because of all the
previously mentioned advantages, MSCT should
be a first choice method in evaluating acute noncardiac chest pain which is more sensitive and specific in comparison to more conventional physiological, laboratory or other radiological methods.
Competing interests
None declared

FIGURE 7. Spontaneous pneumothorax with large bullae
FIGURE 8. Hiatus hernia as the cause of acute non-cardiac

chest pain
References
[1] Donnelly PM, Hoffman Udo. Assessment of Acute Chest
Pain by CT. Current Cardiovascular Imaging Reports
2008; 1:87-95.
[2] Coche E. Acute chest pain in emergency room. Preliminary findings with 40-64slise CT ECG-gated of whole
chest. JBR-BTR. 2007 Mart-Apr; 90:89-91.
[3] Oliver TB, Murchison JT, Reid JH. Spiral CT in acute noncardiac chest pain. Clin Radiol 1999; 54(1):38-45.
[4] White C, Read K, Kuo D. Assessment of chest pain in the
emergency room: What is the role of multidetector CT?
Eur J Radiol 2006; 57(3):368-372.
[5] Urbania TH, Hope MD, Huffaker SD, Reddy GP. Role of
computed tomography in the evaluation of acute chest
pain. J Cardiovasc Comput Tomogr. 2009 Jan-Feb; 3(1

Suppl):S13-22.
[6] Johnson TRC, Nikolau K, Becker A, Leber AW, Rist C,
Wintersperger BJ, et al. Dual-source CT for chest pain assessment. Eur Radiol. 2008 Apr; 18(4):773-780.
[7] Gallagher MJ, Raff GL. Use of Multislice CT for the Evaluation of Emergency Room Patients With Chest Pain: The
So-Called Triple Rule-Out. Cathet Cardiovasc Interv.
2008 Jan; 71(1):92-99.
[8] Chiles C, Carr JJ. Vascular diseases of the thorax: evaluation with multidetector CT. Radiol Clin North Am. 2005;
43:543-569.
213

[9]
[10]
[11]
[12]
[13]
214
Henzler T, Barraza JM, Nance JW Costello P, Krissak R,

Fink C, Schoepf UJ. CT imaging of acute pulmonary embolism. J Cardiovasc Comput Tomogr. 2011; 5(1):3-11.
Hartmanna IJC, Wittenbergb R, Schaefer-Prokop C. Imaging of acute pulmonary embolism using multi-detector
CT angiography: An update on imaging technique and
interpretation. Eur J Radiol. 2010; 74(1):40-49.
Pistolesi M. Pulmonary CT Angiography in Patients Suspected of Having Pulmonary Embolism : Case Finding or
Screening Procedure ? Radiology. 2010 Aug ; 256 (2):334337.
Costantino MM, Randall G, Gosselin M, Brandt M, Spinning K, Vegas CD. CT Angiography in the Evaluation of
Acute Pulmonary Embolus. AJR Am J Roentgenol. 2008
Aug;191(2):471-4.
Castaner E, Andreu M, Gallardo X, Mata JM, Cabezuelo
MA, Pallard Y. CT in Nontraumatic Acute Thoracic Aortic Disease: Typical and Atypical Features and Complica-
tions. Radiographics 2003 Oct; 23 Spec No:S93-S110.

[14] McMahon MA, Squirrell CA. Multidetector CT of Aortic
Dissection: A Pictorial Review. Radiographics. 2010 Mar;
30(2):445-460.
[15] Agarwal PP, Chugtai A, Matzinger FR, Kazerooni EA.
Multidetector CT of Thoracic Aneurysms. Radiographics.
2009 Mart-Apr; 29(2):537-552.
[16] Juvonen T, Ergin MA, Galla JD, Lansman SL, Nguyen KH,
McCullough JN, Levy D, et al. Prospective study of the
natural history of thoracic aneurysms. Ann Thorac Surg.
1997 Jun; 63(6):1533-45.
[17] Ringler L, Lavy R, Gayer G. Traumatic Rupture of
the Diaphragm: CT Diagnosis. Isr Med Assoc J. 2003
Dec;5(12):899-900.
[18] Larici AR, Gotway MB, Litt HI, Reddy GP, Webb WR,
Gotway CA, et al. Helical CT with sagittal and coronal
reconstructions: accuracy for detection of diaphragmatic
injury. AJR Am J Roentgenol. 2002 Aug; 179 (2):451-7.
www.jhsci.ba
Motivation of health professionals and

associates to perform daily job activities
Suvada vraki*, Amer Ovina, Elvedin Dervievi
Clinical Center of Sarajevo University and Faculty of Health Studies, University of Sarajevo, Bolnika 25, Sarajevo, Bosnia and
Herzegovina
Abstract
Introduction: Motivation is one of the most complex elements of human behavior, it is the subject of debates
by which we answer to the question of why someone behaves in a certain way. The aim of this study was
to examine the factors of motivation for health workers and staff in working with difficult patients in intensive
care units and to evaluate implementation of motivation factors by managers in their daily work with a team
of health professionals.
Methods: The study was designed as prospective. It was conducted on 27 employees who work in intensive
care units in Clinical Center of Sarajevo University. The survey questionnaire was used with a clear and
concise questions , aimed at testing the factors of motivation for daily work with difficult patients, as well as
implementation of motivational factors by managers in the organizational unit (OU).
Results: Respondents indicated that motivates them, good organization of work - 10 of them (37%), while
26% of respondents indicated that they are motivated by financial gain. In our study 21 (77%) of respondents
said that their managers infuenced the motivation for a better job. Mobbing at the workplace did not had 80%
of respondents, while 8% of respondents stated that they had some form of mobbing, and 12% of respondents give partial response.
Conclusions: The survey showed that most respondents have a good motivation factors for the performance of daily activities to work with difficult patients. As the main motivating factors respondents reported
good organization of work, as well as positive examples of their managers.
Keywords: motivation, intensive care, organizations, health workers
Introduction
Motivation is one of the most complex elements
of human behavior, it is the subject of debates by
which we answer to the question of why someone
behaves in a certain way. By this response,people
are devising events in their environment, satisfy
their curiosity, discover the initiators of changes,
willing elements of human behavior. Motivation is one of the explanations used to explain
the variability of behavior. Terms such as initiators, goals, needs, clarify the appearance of conflicts which indicate that in identical situations,
there are large differences in human behavior (1).
By the motives we mean those driving forces of
* Corresponding author: Suvada vraki
Clinical Center of Sarajevo University and Faculty
of Health Studies, University of Sarajevo, Bolnika
25, Sarajevo, Bosnia and Herzegovina
Submitted 15 July 2012 / Accepted 10 November 2012
the human body aimed to satisfy specific needs.

The concept of motivation today has a number of
synonyms for terms that basically have identical
meanings: desire, will, preference, and need (1).
Motivation is the internal incentive why people
behave - just the way they behave. Someone can
make that people behave irrationally and unpredictably. However, if we would be able to "peek"
into their past and their emotional mechanism,
we would understand that human behavior is
logical and predictable. Knowing these facts, with
great certainty we are able to predict how some
people react to criticism, or to request to stay
to work in the office after business hours. The
reasons for such different behavior for the same
incentives lie in the uniqueness of each individual. That uniqueness gives the stamp the parents,
home education, education, social life, works
experience etc. The sooner managers realize and
215
SUVADA VRAKI ET AL.: MOTIVATION OF HEALTH PROFESSIONALS AND ASSOCIATES TO PERFORM DAILY JOB ACTIVITIES
accept the fact that they are communicating with

people who are unique, which are very different
among themselves and who have brought with
them all their previous experience , they will
be much easier manage them and will have before it opened the way for a successful career (2).
It is important that managers their subordinates
and their colleagues are seen as individuals who
have their own unique needs and the need to respect and to be consistent with these findings on
behavior - the way to help them to meet those needs.
Managers are, thanks to their function and authority, often in a position to influence the satisfaction of these needs. In this way they are
in a position to influence the satisfaction and
motivation of their subordinates, they will certainly return them in the best way - through
the good achieved results and objectives.
For some of these needs managers cannot influence directly. Often the question is salary, bonus
awards and other outside their competence, but
as we know it is not all in cash. The fact is that
money is a big motivation, because it represents
a means to satisfy a variety of other needs - from
basic needs, increase living standards and the
needs for esteem and reputation in society, but
we know that there are organizations in which the
financial burden is not the primary, and where
there is high motivation and job satisfaction.
When viewed from the side, in these organizations
there is an "irrational" loyalty to the company, a
lot of overtime and new taken responsibilities of
employees, without the simultaneous material
compensation. These are environments in which
management respects their subordinates and
their needs, and where the recognition, praise
and "applause" are an everyday occurrence (1).
According to William Glasser, an American psychiatrist and a leading representative of the relative treatment and control theory, person has
five requirements. As he says, they are powerful forces that are constantly forcing us to satisfy
them. They are: the need for survival and reproduction, the need for belonging, loving, giving
and sharing, the need for entertainment, the
need for power and the need for freedom (2).
The goals of this study were: to examine the
factors of motivation for health workers and
staff in working with difficult patients in inten216
sive care units and to assess the application of

the factors of motivation by managers in their
daily work with a team of health professionals.
Methods
Sample
The study was designed as a prospective. It was conducted on 27 employees who work in intensive care
units in Clinical Center of Sarajevo University. In
research participated 17 health care workers with
secondary education, 4 healthcare workers with
university degrees and 3 support staff (workers
on maintaining cleanliness and physical workers).
Methods
The survey questionnaire was used with a clear and
concise questions, aimed at testing the factors of
motivation for daily work with difficult patients, as
well as the application of the factors of motivation
by managers in the organizational unit (OU). The
survey was anonymous, did not contain questions
which would revealed the identity of respondents.
The study was conducted during January 2012.
Data processing
Survey results were analyzed in Microsoft Access database, presented as charts and tables.
Results
FIGURE 1. Distribution of respondents by gender
FIGURE 2. Distribution of respondents according to age

FIGURE 3. Distribution of respondents by education
FIGURE 4. Motivation for working with difficult patients
FIGURE 5. The influence of superiors on the job motivation
FIGURE 6. Rewarding for work by superiors
FIGURE 7. Respecting opinions and suggestions by the managers (head, chief nurse)
FIGURE 8. The presence of mobbing at work
TABLE 1. Suggestions for improving the motivation to work

Suggestions for motivation
Respect opinions
Better interpersonal
relationships
more money
More education
Frequent rewards for work
Number
20
8
26
14
25
FIGURE 9. Understanding of the organizational units managers - supervisors for unpredicted situations of the employee
(illness, family member illness, exams, etc.)
217
Discussion
The survey was conducted among 27 employees who work in the Intensive Care Unit
of the Clinical Center of Sarajevo University.
Looking at the distribution of respondents by sex,
was observed higher number of women 24 (89%),
while the number of male respondents was 3 (11%).
Most of the respondents belonged to age group
20-35 years - 20 (74%), while 7 (26%) of respondents belonged to age group 35-45 years.
In the study there were no respondents who
belong to other age groups. When we observe
the structure by education it shows that majority are health care workers with secondary
education - 20 (74%), small number of subjects
had a university degree 4 (15%) of respondents,
while 3 (11%) respondents was physical workers.
Respondents indicated that motivates them
to work is good organization of work - 10 of
them (37%), while 26% of respondents indicated that they are motivated by financial gain.
Managers (heads, managers) should directly affect on more effective work of their employees, especially by their good practices. In our
study 21 (77%) of respondents said that their
managers affect the motivation for a better job.
A large number of respondents 24 (88%) said
that the managers reward them for successful work, such as a day off, going to seminars, conferences, financial incentives, etc.
The study showed that managers respect the
opinion of their employees in full 22 (81%), only
a small number said that their opinion is not respected - 2 (7%). Mobbing at the workplace did
not had 80% of respondents, while 8% of respondents stated that they had some form of mobbing,
and 12% of respondents give partial response.
Managers sometimes from preoccupation with
work commitments do not manage the problems of interest to employees. Employees sometimes because of personal problems (disease,
illness, family member, etc.) are not able to adequately respond to business tasks, and there
is necessity for support by OU managers and
other supervisors, which has a positive effect
for the employees, including health care users.
Looking at the respondents answers about their
managers understanding of personal problems it
can be seen that the greater number of respondents stated that their superiors have an understanding of absence from work - 25 (93%) with
a small number of respondents who said that
their personal problems are not respected 2 (7%) .
Research has shown that a larger number of
respondents want to improve motivation to
work through the increase of wages, respect for
opinions and frequent rewards for a job done.
Conclusions
The survey showed that most respondents have a
good motivation factors for the performance of
daily activities to work with difficult patients. As
the main motivating factors respondents reported
good organization of work, as well as positive examples of their managers. Most respondents indicated that their managers respect their opinions
and reward them in certain ways. The organizational unit for intensive care requires the maximum involvement of employees, so it is necessary
to motivate employees in certain ways to work.
Teamwork
and
good
communication in the team are prerequisite for the
good operation of the organizational unit.
Competeing interests
None to declare.
References
[1] Manzoni Lebedina M. Motivacije. U: Psiholoke osnove
poremeaja u ponaanju. Naklada Slap, Zagreb 2006.g.
[2] Motivacije u menadmentu. http:// www. plark.cominternet. posjeeno 02.februara 2012.g.
[3] egota I. Etika sestrinstva. Pergamena- Zagreb. Medicinski fakultet Rijeka, 1997.g.
[4] auevi R. Psiholoke osnove menadmenta u obrazovanju. TDP, Sarajevo 2007.g.
218
[5] Moreno P. R, Rhodes A. The intensive care unit of the future. In: Organisation and Management of Intensive Care.
European Society of Intensive Care Medicine. 2010. 27-34
[6] Jan Wernerman. The role of the intensive care unit in the
modern hospital. In: Organisation and Management of
Intensive Care. European Society of Intensive Care Medicine. 2010.
[7] Rhoten. U Hans. Organising the workflow in an ICU. In:
Organisation and Management of Intensive Care. European Society of Intensive Care Medicine. 2010.
[8] Juki M, Gaparovi V, Husedinovi I, Majeri V, Peri
M, uni J. Intenzivna medicina. Medicinska naklada,
Zagreb 2008.g.
[9] Hawker F. Design and organisation of intensive care units.
In: Organisation and Management of Intensive Care. European Society of Intensive Care Medicine. 2010.
[10] Alvarez G. Coiera E. Interuptive communication patterns
in the intensive care unit ward round. Int.Med. inform.
2005; 74:791-796.
219
www.jhsci.ba
Distribution of ABO blood group in children

with acute leukemias
Meliha Saki
Pediatric Clinic,Clinical center University of Sarajevo, Bolnika 25, Sarajevo, Bosnia and Herzegovina
Abstract
Introduction: This study is the first study about the distribution ABO blood types at children with acute leukemia in Federation of Bosnia and Herzegovina. The aim of the study is to point out distribution of blood type
groups at children with acute leukemia (AL)
Methods: The number of children in this study was the following: 145 children with acute leukemia and 27 of
children with acute myeloblastic leukemia (AML). All of the children were treated at Hemato- Oncology Unit
of Pediatric Clinic in Sarajevo, in the period January 2000 until December 2010. Age of children was between
1 month and 15 years.
Results: The results showed that different blood types were registered in 93. 1% of children who got ill and
treated from acute leukemia for the mentioned period. At 6. 9 % of children, none of the blood types were
registered. It was noticed that 40.9 % children who have registered blood type O, 37% blood type A,16%
blood type B and 6.5% blood type AB had AL, too. It has been observed that children with following blood
types had AML: O, 47.8%, A, 47.7% and AB, 30.4%.
Conclusion: Significance ABO types distribution was confirmed for children with ALL, p<0, 05. The analysis
of the distribution of ABO types based on gender showed that significance was confirmed at females with
both ALL and AML (p<0.05).
Keywords: ABO types, distribution, acute leukemia, children, Federation of Bosnia and Herzegovina
Introduction
Acute leukemia is the most common disease at
childs age. During one-year period 3 to 5 out of
100 000 children age between 0-15 get this disease.
Incidence of this disease in Federation of Bosnia
and Herzegovina is 3.1 per 100000 in the retrospective study, for the period 1997-2005. In the
world this disease is more frequent at boys population 1.2:2 to girls population, while Federation of
Bosnia and Herzegovina it is 4:1 (1). Lower rate
of leukemia is recorded among Afro-American
population, while different variations of incidence
have been noticed among caucasian children.
Higher incidence of disease has been recorded in
New Zealand and Australia compared to Europe.
Distribution of all diseases, including leukemia, has
been followed through the distribution of blood type.
* Corresponding author: Meliha Saki
Pediatric Clinic,Clinical center University of Sarajevo,
Bolnika 25, Sarajevo, Bosnia and Herzegovina
Phone: +387 33 566 400 ext. 424; E-mail: info@pedijatrija-sa.ba
Submitted 20 June 2012 / Accepted 17 November 2012
220
Blood types are more known since 19th century,

when the science on blood transfusion was more
successful than previous years and centuries. in
1492, Stefano Infessura described first historical
attempt of blood transfusion. In the 17th century
when Willian Harvey has discovered blood circulation through the mens body, and it was period when the research of blood transfusion was
more detailed and has succeeded with first experiments on the animals. First documented transfusion was imputable to Jean-Baptist Denys, who
had transfused blood of the sheep to the blood
system o the fifteen years old boy in the 1667 (2).
James Blundel, British obstetrician did
first human blood transfusion successfully in 1818. In 1840 first successful blood
transfusion
efficiently
cured
hemophilia.
Thanks to the science on BT, there has been found
representation of BT by blood analyses, and representation of BT O was represented at 40%, BT A
at 30%, BT B at 24%, BT AB at 6% of population. Some of the nations such as Brazilians have
MELIHA SAKI: DISTRIBUTION OF ABO BLOOD GROUP IN CHILDREN WITH ACUTE LEUKEMIAS
100% representation of BT O. Malignant diseases such as belly, intestine cancer, hematologica

malignant diseases are connected to the different
blood types (3-6). The purpose of this study is to
indicate distribution ABO groups at children with
leukemia in Federation of Bosnia and Herzegovina
Methods
This is retrospective study which includes
all the children who have been cured from
acute leukemia on the Department Haematooncology of the Pediatric Clinic in Sarajevo.
It has been included 145 of sick children who
were sick with acute lymphoblastic leukemia
and 27 of children with acute myeloid leukemia. All the children were treated in the period
from2000 to December 2010. Blood types were
recorded at 160 children (137 children treated
from acute lymphoblast leukemia and 23 children treated from acute myeloid leukemia).
Blood type was not recorded at 12 children, most
probably reason for that was technical issue. Determination of blood type was for the purpose of
blood transfusion in the most number of the cases.
Results
Distribution of blood types at children with acute
lymphoblastic leukemia and acute myeloid leukemia was analyzed on the Pediatric Clinic during the
period that has been mentioned previously in the text.
ALL was confirmed at 84.3 % of children while
AML was noticed at 15.6 % of children. (Table 1)
Table 2 shows that blood types were confirmed at
93.1 % of children, while at 6.9 % of children blood
types were not confirmed probably because of the
technical reasons.
In the further analyses blood type distribution has
been confirmed at children with ALL and AML
according to the diagnosis and gender of the sick
children. (Table 4)
Boys have been more frequently sick with ALL
(2:1) compared to the girls, while that percentage
at sick children with AML was equal between boys
and girls. (Table 4).
Table 5 and Chart 1 points distribution of the ABO
at sick children.
BT O was represented at 40% of children with
ALL and BT A was nearly similar 37% , BT B 16
% and BT AB 6.5%.
TABLE 1. ALL and AML sick children

ALL
145
84.3%
AML
27
15.6%
Total
172
100%
TABLE 2. ConfirmedBlood types:

Confirmed BT
BT that were not
confirmed
Total
ALL
137
AML
23
Total
160(93.1%)
8(5.5%)
4(14.8%)
12(6.9%)
145
27
172
TABLE 3. Points precentage of confirmed blood types according to the diagnosis of sick children
ALL
137/145
85.65%
AML
23/27
14.47%
Total
160/172
93.02%
TABLE 4. Children sick with ALL and AML based on the gender
M
F
Total
ALL
94 (68.7%)
43 (31.4%)
137
AML
11 (47.8%)
12 (52.1%)
23
Total
105
65
170
TABLE 5. Distribution of blood types

Blood types
O
A
B
AB
Total
ALL
55/40.9%
51/37.2%
22/16%
9/6.5%
137
AML
11/47.8%
5/21.7%
7/30.4%
0
23
For ALL: X=34.2 SD=19.4 T=3.5 p<0.05

For AML x 5.7 SD=4.0 T=2.85 p>0.05
TABLE 6. Distribution of blood types based on the gender

Blood types
ALL
AML
Gender
M
F
M
F
O
37 (67.2%) 18 (32.7%) 7 (63.6%) 4 (36.3%)
A
37 (72.5%) 14 (27.4%) 2 (40%) 3 (60%)
B
14 (63.6%) 8 (36.3%) 2 (28.5%) 5 (71.4%)
AB
6 (66.6%) 3 (33.3%)
0
0
For ALL M: X=2.35 SD=18 T=2.6 p >0.05 For AML M: X =2.75
SD=6.69 T=0.8 p >0.05
F X =10.7 SD=5.7. T = 3.77 p<0.05 F: X= 3; SD SD=1.8 T = 3.3
p<0.05
221
FIGURE 1. Gender distribution of ALL (A) and AML (B) in children in FBiH
FIGURE 2. Distribution of blood types in ALL (A) and AML (B) based on gender.
AML occurred among children with blood

types: O 47.8%, and it was much higher thanat children with A blood type who had 21 %
while blood type AB was not represented.
Statistical analysis showed that sick children with
ALL shows significance compared to the children
with AML where significant of sick children according to the ABO groups has not been confirmed.
Analysis of the distribution of ABO groups, based
on gender of the sick children shows that boys
with ALL had higher percentage of A blood
type, while boys with AML had higher percentage of blood type O. (Table 6 and Figure 2)
Discussion
Different studies have been published inconsistent results on the distribution of blood types in
children with acute leukemia. In this study chil222
dren with ALL have equal percentage of blood

type O, and blood type A. At children with AML
most percentage were with blood type O, and then
blood type B. The Alvi S study (7) shows higher
percentage of blood type O, and lower percentage of blood type A versus B in children with
ALL. This study shows that higher percentage
of children with blood type A had AML. That is
what study (3) was presenting. Some of the previous studies on acute leukemia did not show
significant difference with ABO blood types distribution between patients with leukemia and
healthy ones (8,9). Some of the studies discovered
significant difference and higher percentage of O
blood type of the patients with acute leukemia.
On the other side Jackson and associates (12) have
reached different results in their study. Study from
Turkey, based on 166 sick children with ALL and
184 patients with AML did not show significant dren with AML had BT O 47.8 % than follows
differences in distribution of blood types (13). BT B 30%. Statistical analysis did not show sigStudy 7 shows significant difference in distribu- nificant difference between the blood types. Based
tion of the ABO groups between genders of the
on gender: boys with ALL had same percentage of
children with acute lymphoblast leukemia, while
sickness among BT A and O, while among the
significant number of children with myeloid leuke- girls who had ALL the percentage of blood type
mia was not confirmed among gender. Significant O was higher then the other blood types. Considbetween the blood types was confirmed in this
ering children with AML it was noticed that highstudy between girls with ALL and girls with AML. er percentage of boys with this disease had blood
type O and higher percentage of girls with this
Conclusions
disease had blood type B. Significant was shown
It was almost equal percentage of sickness among for female children who had both ALL and AML.
the children with ALL with BT O 40 % and BT A
37% , and this shows significant difference to the Competing interests
other blood types. The highest percentage of chil- None to declare.
References
[1] Saki M . Leukemije kod djece .IPSvjetlostd.d, Sarajevo
2006
[2] Gharouni M, Abouzari M, Rashidi A, Sodagari N, Behzadi M. Low frequency of blood group A in primary
central nervous system lymphoma. J Neurooncol. 2008
May;87(3):363-4. doi: 10.1007/s11060-008-9516-6.
[3] Vadivelu MK, Damodaran S, Solomon J, Rajaseharan A.
Distribution of ABO blood groups in acute leukaemias
and lymphomas. Ann Hematol. 2004 Sep;83(9):584-7.
[4] Biondi A, Cimino G, Pieters R, Pui CH. Biological and
therapeutic aspects of infant leukemia. Blood. 2000 Jul
1;96(1):24-33.
[5] Sandler DP, Ross JA. Epidemiology of acute leukemia in
children and adults. Semin Oncol. 1997 Feb;24(1):3-16.
[6] Emerenciano M, Koifman S, Pombo-de-Oliveira MS.
Acute leukemia in early childhood. Braz J Med Biol Res.
2007 Jun;40(6):749-60.
[7] Alavi S, Ashraf H, Rashidi A, Hosseini N, Abouzari
M, Naderifar M. Distribution of ABO blood groups in
childhood acute leukemia. Pediatr Hematol Oncol. 2006
Dec;23(8):611-7
[8] Shirley R,Desai RG.Association of leukemia and blood
groups. J Mol Genet 1965;2:189-191
[9] Steinberg AG. The genetics of acute leukemia in children.
Cancer 1960;13:985-999.
[10] Mustacchi P, Schoeneld EM, Lucia SP. Survival in acute
leukemia: the influence of blood groups, sex and age at
onset. Ann Internet Med.1960;52:1099-1107.
[11] Nagy P, Jak J, Kiss A, Tams E, Telek B, Rak K. Sex-linked
difference in blood-group distribution among patients
suffering from acute leukaemias. Br J Haematol. 1981
Jul;48(3):507-8.
[12] Jackson N, Menon BS, Zarina W, Zawawi N, Naing NN.
Why is acute leukemia more common in males? A possible sex-determined risk linked to the ABO blood group
genes. Ann Hematol. 1999 May;78(5):233-6.
[13] Nevruz O, Ocal R, Ifran A. Distribution of ABO blood
groups in patients with acute and chronic leukemia, lymphoma and multiple myeloma in Turkish population.
Turkish J Haematol ( suppl).2005;22:795
223
www.jhsci.ba
Analysis of the relation between intelligence

and criminal behavior
Dragan Jovanovic1, Milan Novakovic2, Aleksandra Salamadi1, Novica Petrovic1, Sanja Maric3
Faculty of Medicine Foca, University of East Sarajevo and Neuropsychiatry Department, University Hospital Foca, Studentska
5, Foa Bosnia and Hercegovina. Faculty of Medicine Foca, University of East Sarajevo, Studentska 5, Foa, Bosnia and
Hercegovina. Faculty of Medicine Foca, University of East Sarajevo, University Hospital Foca, Anaesthesiology and Reanimation
Department, Studentska 5, Foa, Bosnia and Hercegovina
Abstract
Introduction: One of the cognitive aspects of personality is intelligence. A large number of previous studies
have shown that the intelligence within the criminal population is decreased, particularly in its verbal aspect.
The aim of this study is to determine whether there is a link between intelligence and criminal behavior and
how it is manifested.
Methods: The research involved criminal inmates of the Correctional institutes of Republic of Srpska and
Court Department of Psychiatry Clinic Sokolac who committed homicide and various non-homicide acts. The
test group consisted of 60 inmates who have committed homicide (homicide offenders) and a control group
of 60 inmates who did not commit homicide (non-homicide offenders). The study was controlled, transverse
or cross-sectional study.
Results: Average intelligence of inmates (homicidal and non-homicidal) was IQ 95.7. Intelligence of homicide inmates was IQ 97.4 and non-homicide IQ 94.09. Intelligence coefficients for non-homicide inmate
subgroups were as follows - subgroup consisting of robbery offenders (IQ 96.9), subgroup consisting of theft
perpetrators (IQ 93.83), subgroups consisting of other criminal offenders (IQ 92.8). Verbal intellectual ability
IQw of homicide inmates was 91.22, and 91.10 IQw of non-homicide inmates. Intellectual abilities in nonverbal or manipulative part were average, but they were higher in homicide inmates group (IQm 103.65) than
in the group of non-homicide inmates (IQm 97.08).
Conclusion: Average intelligence of investigated inmates (homicide and non-homicide) is lower than in the
general population and corresponds to low average. Verbal part of intelligence is lowered while nonverbal
part is within the average range.
Keywords: Analysis, intelligence, criminals, criminal behavior.
Introduction
An individual has all the characteristics of a person, its uniqueness and individuality, which
makes it different from all the others. Personality
is formed in the interaction of heredity and external environment. By the word of HJ Eysenck:
"Personality is more or less solid organization of
character, temperament, intellect and physical
constitution"(1-3). Intelligence in its essence is
constitutionally and genetically defined capacity,
but it is also to a large extent shaped by the envi* Corresponding author: Prim. Dr. Dragan Jovanovic, MD, PhD
Faculty of Medicine, Foca, University of East Sarajevo
Studentska 5, 73300 Foca, Bosnia and Hercegovina.
Phone: 065 987 685; E-mail: drdragan@teol.net
Submitted 3 November 2012 / Accepted 7 December 2012
224
ronment (by upbringing and education and possibility of flow of information). It is defined as a
complex ability to assimilate factual knowledge;
to respond to logical and to manipulate concepts,
to translate literally to abstract, to cope meaningfully and clearly with problems and priorities
assessed and valued as important in certain situation, the ability to solve new problems and mentally adapt to new roles. It is defined as the capacity
for learning and usage of things learned (3,5,6).
NMR studies associate the brain of violent
criminals diagnosed with psychopathy, their
emotional and cognitive deficits, with a reduced orbitofrontal areas of the brain as well
as abnormalities of amygdala nuclei (4).
Numerous studies prove that the intelligence of deJOURNAL OF HEALTH SCIENCES 2012; 2 (3)
DRAGAN JOVANOVIC ET AL.: ANALYSIS OF THE RELATION BETWEEN INTELLIGENCE AND CRIMINAL BEHAVIOR
linquents is lower in comparison with the general

population. We can even see the differences between groups of delinquents. Lowest intelligence
is associated with groups of violent offenders. Delinquents achieve lowest score in the area of verbal ability and abstract reasoning, while in terms
of other cognitive abilities they dont fall behind
in comparison to the general population (5-11).
Sample of 370 inmates convicted for non-sexual violent offenses proved that convicts with
no diagnosis of psychopathy have higher overall coefficient of intelligence, as well as in its
verbal part, from those having this diagnosis. The study proves that non psychopaths
start much later with criminal activities (12).
Linkage of lower intelligence with criminal behavior is explained in various ways: low intelligence
leads to poor school performance and those who
fail in school are less likely to succeed in life and
will probably resort to delinquent behavior. School
failure, the frustration that causes uncomfortable
feelings lead to a drop in self-esteem, and it may
already be sufficient cause for delinquent behavior
apart in drop in verbal skills which are important
for communication that can be used to solve many
problems. People of low verbal ability are having
hard time coping with various social situations
which at some point can be the impetus for delinquent behavior; persons of low verbal abilities find it
hard to adopt the moral standards of society (6-13).
We compared the samples of juvenile delinquents
and non-delinquents and found that the delinquents
had pronounced impairment of cognitive abilities
(the lag in verbal abilities) than non-delinquents.
We also showed that delinquents present conative
disorders of depressive and obsessive type (6-13).
Impulsivity is one of the main reasons behind
committing crimes by mentally retarded persons
as well as their suggestibility paired with insufficient understanding of moral rules and the possibility of learning from experience. Increased
suggestibility of mentally retarded people, in
addition to committing criminal acts, has a profound effect on making false confessions. The
most common forms of criminal offenses among
mentally retarded persons were property crimes
(theft, robbery and burglary), sexual offenses,
violent offenses (murder and causing grievous bodily harm) and intentional arson (6-13).
Dementia can be associated with delinquent behavior in terms of harmful behaviors of demented
people to himself and to others. As a result of severe
memory impairment and confusion demented
people can cause fires, and as a result of delusional
ideas of persecution and emotional instability
they can hurt or even kill another person (6-13).
The aim of this study is to determine whether there
is a correlation between intelligence and criminal
behavior and how these linkages are manifested.
Methods
Research involved the inmates of correctional institutes from the Republic of Srpska (KPZ "Tunjice") Banja Luka, Prison "Kula" of Eastern Sarajevo,
(Foca prison) and the Court Department of the
Psychiatry Clinic Sokolac. A total of 105 inmates
who had committed suicide and 100 resident perpetrators of non-homicide acts have been examined. 15 inmates who have been convicted on the
issue of war crimes (war criminals were not covered by our study) were excluded from the group
as well as 30 inmates for incompletely and incorrectly completion of psychological tests. Exclusion
from the group of non-homicidal inmates was
performed due to excessive link between criminal acts with war situations (12 inmates) as well
as because of incomplete and / or incorrectly completed psychological tests (28 inmates). After these
exclusions, test group was formed consisting of
homicide persons (murderers)- 60 inmates and a
control group of non-homicide persons(non murderers), also 60 inmates. The control group was
formed from the perpetrators of robbery (N = 22),
theft (N = 18) and other offenses (N = 20). In the
subgroup of non-homicide perpetrators of other
crimes were the perpetrators of illegal production
and traffic of drugs (N = 7), endangering public
transportation (N = 4), rape (N = 3), tax evasion
(N = 2), illicit production and trade of weapons
and explosive devices (N = 1), counterfeiting (N
= 1), sexual child abuse (N = 1) and fraud (N = 1).
Subjects in the test group and the control group
approached to the research on a voluntary basis.
The study was controlled, transverse (cross-sectional study). Intelligence tests, verbal and nonverbal, were used for the purposes of exploration of
problem as well as exploration of objectives of study.
Verbal intelligence test was informative test
225
consisting of twenty questions on which in- eter (Student's t-test) and non parameter (Fisher,
mates answered textually. Questions were tai- Pearson Chi-Square - chi-square test, Mann-Whitlored to various levels of education and in ney U test, Kolmogorov-Smirnov Z-test) statistithe domain of the various scientific fields. cal methods. Using statistical methods (ANOVA
Nonverbal or manipulative intelligence test was - analysis of variance and LSD - test least signifithe Revised Beta test consisting of six subtests. cant difference), differences between the groups
Intellectual skills assessed on the basis of these in- and subgroups of homicide and non-homicide
inmates were analyzed (subgroup perpetrators of
telligence tests were expressed using intelligence
robbery, theft perpetrators subgroup and subcoefficients (IQ):
group of perpetrators of other crimes). Results of
statistical analysis were presented in tabular form.
1) IQ 70 and <- defective intelligence
2) IQ 71-79 - low
Results
3) IQ 80-89 - below average
Spreadsheet of statistical analysis of the re4) IQ 90-109 - average
sults of psychological processing of non5) IQ 110 -119 - above average
verbal and verbal intelligence tests of ex6) IQ 120 -128 - high
perimental and control groups is presented.
7) IQ of 129 -> - very high
Intergroup differences test(t-test) shows that
there is a statistically significant difference beStatistical analysis
characteristics observed in the study were subject- tween the groups on nonverbal intelligence tests
ed to descriptive statistical methods - measures of T 2, a highly statistically significant difference
central tendency (mean, median, minimum, maxi- in non verbal test T 4, and a highly statistically
mum, measures of variability (standard deviation) significant difference in the overall non-verbal
and relative numbers as indicators of the structure. (manipulative) intelligence test- nonverbal inIn order to make relevant conclusions, notable dif- telligence coefficient of homicide inmates (IQm
ferences between groups were analyzed by param- 103.65) and non non-homicide (IQm 97.8).
TABLE 1. Non-verbal tests (T 1 - T 6), verbal intelligence tests - descriptive statistics and intergroup differences test (T-test).
Test
T 1 Non verb.
T 2 Non verb.
T3 Non verb.
T 4 Non verb.
T 5 Non verb.
T 6 Non verb.
Iqm
Iqw
Descriptive statistical data

Group
N
Mean
Homicide
60
13.05
Non homicide
60
12.55
Homicide
60
12.70
Non homicide
60
11.65
Homicide
60
9.65
Non homicide
60
9.87
Homicide
60
10.33
Non homicide
60
9.07
Homicide
60
10.70
Non homicide
60
10.02
Homicide
60
5.35
Non homicide
60
4.05
Homicide
60
103.65
Non homicide
60
97.08
Homicide
60
91.22
Non homicide
60
91.10
SD
2.49
2.95
2.24
3.00
1.96
2.05
1.99
2.41
2.40
2.80
4.48
3.65
10.83
11.70
14.61
15.29
t
-1.003
df
118
T-test
P
0.318
-2.173
118
0.032
-1.050
0.591
118
0.556
0.216
-3.137
118
0.002
-1.266
-1.434
118
0.154
-0.683
-1.744
118
0.084
-1.300
-3.191
118
0.002
-6.566
-0.043
118
0.966
-0.116
Mean diff.
-0.5000
N - number of respondents, the Mean - the mean value, t - value of T-test, df - degree of freedom, P - probability, Mean diff - differences
in mean values.
226
Analysis of variance showed a statistically significant difference between the groups in T 3, T 5 and
T6 nonverbal intelligence tests, as well as the overall IQm (nonverbal or manipulative intelligence
TABLE 2. ANOVA (analysis of variance) - statistical analysis of intergroup, intragroup and total variability in verbal and nonverbal
intelligence tests.
Test
Test 1
Test 2
Test 3
Test 4
Test 5
Test 6
IQm
IQw
Variability
Intergroup
Intragroup
Total
Intergroup
Intragroup
Total
Intergroup
Intragroup
Total
Intergroup
Intragroup
Total
Intergroup
Intragroup
Total
Intergroup
Intragroup
Total
Intergroup
Intragroup
Total
Intergroup
Intragroup
Total
Sum of squares
15,356
871.844
887.200
90.152
769.173
859.325
34.241
443.751
477992
50.131
575.069
625.200
53.351
764.241
817.592
115.432
1901.768
2017.200
1503.125
14780.741
16283.867
125.346
26266.646
26391.992
df
3
116
119
3
116
119
3
116
119
3
116
119
3
116
119
3
116
119
3
116
119
3
116
119
Mean square value

5.119
7.516
F variant quotient
0.681
P
0.565
30.051
6.631
4.532
0.005
11.414
3.825
2.984
0.034
16.710
4.957
3.371
0.21
17.784
6.588
2.699
0.049
38.477
16.395
2.347
0.076
501.042
127.420
3.932
0.010
41.782
226.437
0.185
0.907
TABLE 3. . Structure IQw (verbal intelligence coefficient) for each group of inmates with regard to the type of crime
IQ
Value IQw
<70
71-79
Verbal
Intelligence
Quotient
IQw
80-89
90-109
110-119
120-128
Total
Number
%
Number
%
Number
%
Number
%
Number
%
Number
%
Number
%
Robbery
1
4.5%
3
13.6%
4
18.2%
11
50.0%
3
13,6%
0
0%
22
100%
Theft
2
11.1%
5
27.8%
2
11.1%
7
38,9%
2
11,1%
0
0%
18
100%
Criminal offense
Other offenses
1
5.0%
4
20.0%
3
15.0%
9
45.0%
2
10%
1
5.0%
20
100%
Murderers
5
8.3%
11
18.3%
8
13.3%
31
51.7%
5
8.3%
0
0%
60
100%
Total
9
7.5%
23
19.2%
17
14.2%
58
48.3%
12
10.0%
1
0.83
120
100%
227
coefficient), as well as high statistically significant

difference in the T 2 nonverbal intelligence test.
The least significant difference test (LSD test).
Multiple intergroup comparisons by the means of
least significant difference test(LSD test) showed
that there is: a statistically significant difference
between subgroups of non-homicide perpetrators of theft and other subgroups of non-homicide
perpetrators of crimes, as well as between groups
of perpetrators of killings and other subgroups of
non-homicide perpetrators of crimes on the T 2
nonverbal intelligence test; statistically significant
differences between subgroups of non-homicide
perpetrators of robbery and subgroups of nonhomicide perpetrators of other crimes, as well as
a highly statistically significant difference between
subgroups of non-homicide perpetrators of theft
and subgroups of non-homicide perpetrators of
other crimes in the T 3 nonverbal intelligence
test; a statistically significant difference between

subgroups of non-homicide robbery perpetrators
and a group of killers as well as group of murderers and subgroups of non-homicide perpetrators
of theft in T 4 nonverbal intelligence test; a statistically significant difference between subgroups
of non-homicide perpetrators of theft and subgroups of non-homicide perpetrators of other
crimes, as well as between groups of murderers
and subgroup of non-homicide perpetrators of
other crimes in the T 5 nonverbal intelligence
test; statistically significant differences between
subgroups of non-homicide perpetrators of theft
and subgroups of non-homicide perpetrators of
other crimes as well as between groups of murderers and subgroups of non-homicide perpetrators of other crimes, and a highly significant
difference between the groups of murderers and
subgroups of non-homicide perpetrators of oth-
TABLE 4. Testing the significance of difference in coefficients of verbal intelligence (IQw) between groups of inmates with regard
to the type of crime by means of factorial analysis of varianceranks (Kruskal-Wallis test)
IQ
Verbal
Intelligence
coefficient
IQw
Type of crime
Robbery
Theft
Other
Murderers
Total
N
22
18
20
60
120
Mean rank value - Chi-square

65.27
1.349
54.08
63.28
59.75
df
3
P
0.717
TABLE 5. Structure of IQm (non-verbal or manipulative intelligence coefficient) for each group of inmates with regard to the
type of crime
IQ - Intelligence
coefficient.
Value Iqm
<70
71-79
Non verbal
Intelligence
coefficient
IQm
80-89
90-109
110-119
120-128
Total
228
Type of crime
Number
%
Number
%
Number
%
Number
%
Number
%
Number
%
Number
%
Robbery
0
0%
2
9.09%
2
9.09%
15
68.18%
2
9.09%
1
4.54%
22
100%
Theft
0
0%
3
16.66%
1
5.55%
11
61.11%
2
11.11%
1
5.55%
18
100%
Other
0
0%
2
10.00%
5
25.00%
12
60.00%
1
5.00%
0
0%
20
100%
Total
Murderers
0
0%
1
1.66%
5
8.33%
32
53.33%
17
28.33
5
8.33%
60
100%
0
0%
8
6.66%
13
10.83%
70
58.33%
22
18.33%
7
5.83%
120
100%
TABLE 6. Testing the IQm significance of difference between all groups and sub-groups of inmates using factorial analysis of
variance ranks (Kruskal-Wallis test)
IQ
Non verbal or
manipulative
intelligence
coefficient
IQm
Type of crime
Robbery
Theft
Other
Murderers
Total
N
22
18
20
60
120
Mean ranks value

55.32
54.36
43.55
69. 89
- Chi-Square
12.944
df
3
P
0.005
TABLE 7. Testing the significance of IQm differences between subgroups of non-homicide inmates considering the type of crime
committed using Kruskal-Wallis test.
IQ
Manipulative or
non verbal
intelligence
coefficient
IQm
Type of crime
Robbery
Theft
Other
Total
Total
N
22
18
20
60
120
Mean ranks value

32.73
31.92
26.78
er crimes in the T 6 nonverbal intelligence test.

There was high percentage of inmates with belowaverage verbal intellectual abilities in all groups
- subgroup of non-homicide robbery offenders
36.3%, with 4.5% of mental defective individuals,
the subgroup of non-homicide theft perpetrators
50.00%, with as much as 11.1% of the defective
persons, a subset of non-homicide perpetrators
of other offenses 40% with 5% defective persons
and perpetrators of the murder group 39.9%,
with 8.3% of mental defective persons. There
was an average of 7.5% of mental defective inmates in terms of verbal intelligence coefficient.
Test showed no statistically significant differences between groups of inmates in terms of verbal
IQ with regard to the type of crime committed.
Manipulative or nonverbal intellectual abilities
were larger than the verbal ones in all groups and
subgroups. Kruskal-Wallis test shows that there is
a statistically significant difference between groups
of inmates, according to type of criminal offense
in terms of nonverbal intelligence coefficient.
Kruskal-Wallis test showed no statistically significant difference in terms of nonverbal intelligence
coefficient between subgroups of non-homicide
inmates, considering the type of crime committed.
Discussion
Average total intelligence number in all investigated inmates (homicide and non-homicide) was IQ
- Chi-square
1.869
df
2
P
0.393
95.7, corresponding to a deviation toward a low average. Overall intelligence coefficient for homicide
inmates was IQ 97.4 and 94.09 for non-homicidal.
Intelligence coefficient for subgroups of non-homicide inmates was as follows: subgroup robbery
offenders (IQ 95.4), subset of the perpetrators
of theft (IQ 93.83) and other criminal offenders
subgroups (IQ 92.8). According to these data, the
highest reduction in overall intellectual ability was
observed in subgroups of non-homicide theft offenders and perpetrators of other crimes which
were, perhaps, related to the easier identification
of the crimes committed and the weaker ability to
hide the crime by inmates from this subgroup. It
is evident that intellectual abilities in non-verbal
or manipulative part were average, but they were
higher in homicide inmates (IQm 103.65) than
in the group of non-homicide (IQm 97.08) - perpetrators of the robbery (IQm 98.22), theft (IQm
98.61) and other criminal acts (IQm 94.45). IQm
average for all inmates was 100. At the same time,
verbal intellectual ability (IQw) was lower than the
average in relation to the general population and it
was in low level of the average (homicide inmates
91.22 IQw and non-homicide IQw 91.10), which
generally agrees with previous studies showing
that violent offenders have lower verbal intellectual
abilities compared to the general population (5-13).
Particularly striking was the high percentage
(40-50%) of inmates with below-average verbal
229
intellectual abilities. Profile of verbal intelligence

coefficient indicated lower verbal intellectual
abilities from the average in the general population because of the high percentage of inmates
with below-average verbal intellectual abilities. This was most pronounced in the subgroup
of theft perpetrators - 50% with below-average
verbal intelligence coefficient followed by a subgroup of non-homicide perpetrators of other
crimes with 40%, homicide inmates group with
39.9% and subgroups of non-homicide perpetrators of robbery with 36.3% of the perpetrators
with a below-average verbal intelligence coefficient. In addition, the homicide inmate group,
five (8.33%) had verbal intelligence coefficient on
the level of defective intelligence, and in group
of non-homicide inmates, four (6.66%) of them
had aforementioned verbal intellectual abilities.
Profile of non-verbal or manipulative intelligence
coefficient was performed within groups of inmates with regard to the type of crime that showed
that non-verbal or manipulative abilities in all
groups were larger than verbal, i.e., there were
lower percentage of inmates with below-average
nonverbal intellectual coefficient - a group of homicide inmates 17.49 %, non-homicide robbery
offenders subgroup 18.18%, subgroup of non-homicide theft perpetrators 22:21% and subgroup of
non-homicide perpetrators of other crimes 35% of
inmates with below-average nonverbal intellectual
abilities. At the same time it was found that 13.6%
of robbery offenders, 16.6% perpetrators of theft,
5% of the perpetrators of other offenses and 36%
of homicide offenders had above average nonverbal or manipulative intelligence coefficient.
According to the literature, lower verbal intellectual abilities may be due to lower levels of education,
but they may exist before going to school and be
a result of neurophysiologic deficit. Reduced intel-
lectual ability, particularly decreased verbal intelligence factor, can have a significant impact on the
development of delinquent properties of inmates.
Lower intelligence lead to poor school performance and people who fail in school are less likely
to succeed in life so they easily resort to delinquent
behavior. Failure in school is a strong frustration
that can lead to the occurrence of aggression and
criminal behavior. People with reduced verbal
communication skills are weak and disoriented
in various social situations, which can lead to the
development of delinquent behavior. People with
low verbal abilities find it hard to adopt the norms
of morality and recourse to asocial or even delinquent actions. Verbal skills are important in the
control of behavior, that is, the ability to connect
potential reactions with potential consequences.
Poor academic performance and low educational
level and thus the weaker verbal abilities have its
roots in asocial-psychopathic features that are
prominent in the group of homicide inmates,
which has been proven in research. Better performance on nonverbal or manipulative part probably
provides skill in some types of delinquency (5-13).
Conclusion
Average intelligence of investigated inmates (homicide and non-homicide) is lower than in the
general population. Homicide inmates intelligence was shown to be slightly greater than nonhomicide group. Intellectual skills were average in
verbal or manipulative part, but were more pronounced in the homicide group than in the nonhomicide group. Verbal intellectual abilities were
lower than average for the general population and
they were in lower border range in both groups.
Competing interests
Authors declare no competing interests.
References
[1] Kalianin P. Psihijatrija. Beograd:Velarta; 1997. str. 119120.
[2] Kecmanovi D. Psihijatrija. Medicinska knjiga BeogradZagreb; 1989. str. 1238-1242.
[3] Jaovi Gai M, Lei Toevski D. Psihijatrija. Udbenik
za studente medicine. Beograd: Univerzitet u Beogradu,
Medicinski fakultet; 2007. str. 196-204.
230
[4] Boccardi M, Frisoni N, Hare R, Cavedo E, Najt P, Pievani

M. et al. Cortex and amygdala morphology in psychopathy. Psychiatry Res 2011;193(2):85-92.
[5] Mejovek M. Uvod u penoloku psihologiju. Naklada Slap
- Jastrebarsko i Edukacijsko - Rehabilitacijski Fakultet
Sveuilita u Zagrebu; 2002.
[6] Moffit TE, Lynam DR, Silva PA. Neuropsychological tests
predicting persisting male delinquency. Criminology

1994;32:277-300.
[7] Kljaji S, Prilin R. Struktura rezultata u verbalnim i neverbalnim testovima WISC kod delinkventne djece. Primijenjena psihologija 1984;5:1-6.
[8] Stattin H, Klackenberg-Larsson I. Early language and
intelligence development and their relationship to
future criminal behaviour. J Abnorm Psychol 1993
Aug;102(3):369-378.
[9] Momirovi K, Viski-talec N, Mejovek M. Relacije
kognitivnih i konativnih karakteristika maloljetnih delinkvenata i efikasnosti resocijalizacije nakon penalnog
tretmana. Defektologija 1974;10:155-173.
[10] Kovaevi V, Momirovi K, Singer M. Razlike u strukturi

linosti izmeu delinkventne i nedelikventne populacije.
Defektologija 1971;7:3-8.
[11] Kova M, arkovi Palijan T , Kovaevi D, Mustapi J.
Neubrojivi mentalno retardirani poinitelji kaznenog
djela. KD Polic Sigur Zagreb 2008;1-2:90-100.
[12] Guay JP, Ouimet M, Proulks J. On intellingence and
crime: A comparison of incarcerated sex offenders and
serious non-sexual violent criminals.Int J Law Psychiat.
2005;28:405-17.
[13] Kennedy TD, Burnett KF, Edmonds WA. Intellectual,
behavioral, and personality correlates of violent vs. nonviolent juvenile offenders. Agress. Behav. 2011;37:315-25.
231
www.jhsci.ba
Ruptured intracranial dermoid cyst:

a case report
Ajla Rahimi-ati*, Maida Niki, Zlata Kadeni
Clinic of Radiology, Clinical Center University of Sarajevo, Bolnika 25, Sarajevo, Bosnia and Herzegovina
Abstract
Intracranial dermoid cysts are congenital, usually nonmalignant lesions with an incidence of 0.5% of all intracranial tumors. They tend to occur in the midline sellar, parasellar, or frontonasal regions. Although their
nature is benign, dermoid cysts have a high morbidity and mortality risk, especially when rupture occurs. A
40 year old woman presented with head injury after she experienced sudden loss of consciousness. She had
a history of headache, loss of consciousness; her past medical history was not remarkable. The patient had
no complaints of nausea, vomiting, or seizures. Vital signs were stable, neurologic deficit was not identified.
Computed tomography (CT) and magnetic resonance imaging (MRI) showed right temporobasal zone with
fat droplets within right fissure Sylvii and interhemispheric fissure indicating a rupture of a dermoid cyst. Craniotomy and cyst resection were done, and diagnosis was confirmed with pathological examination following
surgery. After surgery the patient did not recover. Cerebral ischemia from chemical meningitis was fatal for
our patient. Headache as a symptom has many causes. It is rarely due to chemical meningitis arising from a
ruptured dermoid cyst. This case report illustrated the importance of investigating a cause of the headache,
CT and MRI being diagnostic methods. In this way, mortality as well as morbidity from complications such as
chemical arachnoiditis can be significantly reduced if imaging is done early in these patients.
Keywords: dermoid, intracranial, rupture, chemical meningitis
Introduction
Intracranial dermoid cysts are rare, congenital,
usually benign lesions. They are usually detected
accidentally but often become symptomatic after
rupture. The presence of fat droplets in the subarachnoid space and ventricular system is typical
finding in computed tomography (CT) and magnetic resonance imaging (MRI). Rupture leads to
aseptic chemical meningitis, vasospasm, cerebral
ischemia and coma (1, 2). Chemical meningitis
may lead to transient cerebral ischemia secondary
to vasospasm with complicating infarction and the
death of the patient (3), as happened in our case.
In this report, we present CT and MRI findings of
a ruptured intracranial dermoid cyst with postoperative complications. Cerebral ischemia due
to chemical meningitis was fatal for our patient.
* Corresponding author: Ajla Rahimi-ati, MD.
Clinic of Radiology. Bolnika 25, 71 000
Sarajevo, Bosnia and Herzegovina.
Phone: +387 61 760 899. E-mail: catic.ajla@yahoo.com
232
Case Report
A 40 year old female presented with a head injury after she experienced sudden loss of consciousness. She had a history of headache and
loss of consciousness, but other than that her
past medical history was not remarkable. The
patient had no complaints of nausea, vomiting or seizures. Vital signs were within normal
limits and neurologic deficit was not evident.
CT scan of the head showed right temporobasal,
well defined lobular hypodense zone with calx
density zones within it (Figure 1). CT also showed
tiny, partially confluent, low attenuation areas of fat
density within right fissure Sylvii and interhemispheric fissure (Figure 2). The appearance of fat
droplets usually follows rupture of a dermoid cyst.
Magnetic resonance imaging was requested, which
revealed right temporobasal cystic lesion returning a high signal intensity on T1-weighted imaging (T1W) (Figure 3) and heterogeneous signal intensity on T2-weighted imaging (T2W) (Figure 4).
The appearance of fat intensity areas within right
AJLA RAHIMI-ATI ET AL.: RUPTURED INTRACRANIAL DERMOID CYST : A CASE REPORT
FIGURE 1. Brain CT of dermoid cyst in right temporabasal

region.
FIGURE 2. Brain CT showing fat droplets within right fissure

Sylvii and interhemispheric fissure.
fissure Sylvii and interhemispheric fissure was also

apparent. No contrast enhancement was seen. MRI
scan confirmed CT diagnosis of a ruptured dermoid cyst, and the patient was referred for a neurosurgical opinion. The decision was made to conduct a craniotomy and cyst resection. Pathological
examination, following surgery, determined that
histological type of the mass was dermoid cyst.

After surgery the patient remained in coma,
so CT was performed, and multiple hypodense zones corresponding to ischemic
vascular lesions were observed in parietal
and occipital area, as well as in the basal ganglia. The final outcome of the patient was fatal.
FIGURE 3. Brain T1-weighted MRI of dermoid cyst.
FIGURE 4. Brain T2-weighted MRI of dermoid cyst.
233
Discussion
Intracranial dermoid cysts are congenital ectodermal inclusion cysts. They are usually nonmalignant lesions with an incidence of 0.5% of all
intracranial tumors. They tend to occur in the
midline sellar, parasellar, or frontonasal regions.
They emerge from the inclusion of ectodermal
primitive pluripotent cells due to defects in neural tube closure (gestational weeks 3-5) (1). The
capsule of dermoid cysts consists of simple epithelium supported by collagen. It contains a dense
liquid composed of cholesterol, keratin, lipid
metabolites, calcifications, hair and teeth (1-3).
They are detected accidentally, but also may
give symptoms of seizures and headache, and
rarely olfactory delusions. Although their nature is benign and development is slow, dermoid cysts have a high morbidity and mortality risk, especially when rupture occurs (4).
They can rupture and release lipid droplets in
the subarachnoid space and ventricular system (1, 3). Rupture is usually spontaneous, even
though in some cases is due to surgery or head
injury (4, 5). The rupture of dermoid cyst and
the presence of lipid in the subarachnoid space
and ventricular system may cause chemical
meningitis, hydrocephalus, vasospasm and cerebral ischemia (6). Clinical symptoms of acute
rupture are headache, nausea, vomiting, vertigo, vision problems, aseptic chemical meningitis, hemiplegia, mental changes, and coma (4).
Aseptic chemical meningitis is rare complication
and is found only in 7% of patients (7). Chemical meningitis may lead to transient cerebral
ischemia, secondary to vasospasm with complicating infarction and the death of the patient (35). Symptoms usually do not occur at the time of
rupture, but may be delayed from 3 months to 6.5
years after rupture, because the irritative effects of
the spilled contents require time to develop (3, 8).
CT and MRI imaging are diagnostic methods. On
CT scans these lesions have internal density characteristics consistent with fat (negative Hounsfield
units) and their wall is usually calcified. Occasionally the wall can partially enhance after the administration of CT-iodinated contrast material (3).
On MRI scans, dermoids are hyperintense on T1weighted imaging due to high lipid content, and
heterogeneous on T2-weighted imaging because
234
of different components in the cyst such as bones,

cartilage and calcifications (3, 4). If the internal
fat content is relatively low, the lesion reveals cerebrospinal fluidlike signal intensity. In such cases, fluid attenuation inversion recovery (FLAIR)
is useful, because the fat appears hyperintense
(bright), while fluid signal is suppressed (dark).
When a dermoid cyst ruptures, fat droplets appear
hypodense on CT or T1 hyperintense on MRI within ventricular system and/or subarachnoid space
(3). Differential diagnosis includes epidermoid
cyst, teratomas, lipomas, cystic craniopharyngiomas and occasionally arachnoid cysts (3, 4, 8).
Intracranial epidermoids are 4 - 9 times more
common than intracranial dermoids (8). Epidermoid cyst and dermoid cyst both usually appear
as sharply defined, low density or intensity mass
lesions with no contrast enhancement on CT
and MRI. Nevertheless the location of epidermoid is more variable than that of dermoid cyst
and shows greater deviation from midline (8).
Teratomas can be confused with dermoid
because they may contain fat, but teratomas cause contrast medium enhancement.
Lipomas are similar to dermoids as they both have
a hyperintense appearance in T1W and T2W, but
they are differentiated from dermoids by their
smooth borders and typical midline localization
(4). Cystic craniopharyngiomas and arachnoid
cyst can be differentiated from dermoids based
on signal characteristics and demonstration of
fat in dermoids and using FLAIR sequences (8).
Patients typically do well after operative intervention. Recurrence is rare but is more common
if there are retained portions of the tumor wall.
Rare reports describe malignant transformation
of dermoid cysts into squamous cell carcinoma
(1,3). Prognosis of patients with ruptured intracranial dermoids depends on the spread of the
contents and the time period after rupture (5).
Conclusion
Headache as a symptom has many causes. Loss
of consciousness as well. Headache due to dermoid cyst or due to chemical meningitis arising
from a ruptured dermoid cyst is not so common.
This case report illustrated the importance of investigating a cause of the headache, CT and MRI
being diagnostic methods. In this way, mortalJOURNAL OF HEALTH SCIENCES 2012; 2 (3)
ity as well as morbidity from complications such

as chemical meningitis can be significantly reduced if imaging is done early in these patients.
Competing Interests
Authors declare no conflict of interest related to
this study.
References
[1] Osborn AG, Preece MT. Intracranial cysts: radiologicpathologic correlation and imaging approach. Radiology 2006;239(3):650-664. PubMed PMID: 16714456. doi:
10.1148/radiol.2393050823.
[2] Bhatia R, Anderson S, Bradley V. Akinwunmi JA.
Neuropsychological profiling of ischemic deficit secondary to ruptured dermoid cyst: a case report. Applied neuropsychology 2008. Applied neuropsychology 2008;15(4):293-297. PubMed PMID: 19023747. doi:
10.1080/09084280802312478.
[3] Ray MJ, Barnett DW, Snipes GJ, Layton KF, Opatowsky
MJ. Ruptured intracranial dermoid cyst. Proc (Bayl Univ
Med Cent). 2012;25(1):235.
[4] Altay H, Kiti , all C, Ynten N. A spinal dermoid
tumor that ruptured into the subarachnoidal space and
syrinx cavity. Diagn Interv Radiol 2006;12(4):171-173.
[5] Patkar D, Krishnan A, Patankar T, Prasad S, Shah J, Limdi

J. Ruptured intracranial dermoids: magnetic resonance
imaging. J Postgrad Med 1999;45(2):49-2. PubMed
PMID: 10734333.
[6] Carberry GA, Medhkour A, Elsamaloty H. Intraventricular rupture of an intracranial dermoid cyst in a woman
with pseudotumour cerebri. Pan Arab Journal of Neurosurgery 2011;15(2):64-66.
[7] Das CJ, Tahir M, Debnath J, Pangtey GS. Neurological
picture. Ruptured intracranial dermoid. J Neurol Neurosurg Psychiatry 2007;78(6):624-625. PubMed PMID:
17507446. doi: 10.1136/jnnp.2006.109835.
[8] Venkatesh SK, Phadke RV, Trivedi P, Bannerji D. Asymptomatic spontaneous rupture of suprasellar dermoid cyst:
a case report. Neurol India 2002;50(4):480-3. PubMed
PMID: 12577101.
235
www.jhsci.ba
Awake fiberoptic intubation of a patient with

amyotrophic lateral sclerosis: case report
Elif Bak, Elif Buyukerkmen, Yksel Ela, Serdar Kokulu, Remziye Svac*
Department of Anesthesiology and Reanimation, Kocatepe University School of Medicine, Ali etinkaya Kampus Afyonkarahisar,
Afyon, Turkey
Abstract
Amyotrophic Lateral Sclerosis is a rapidly progressive disease from the fifth to sixth decades of life causing
degeneration and death of the upper and lower motor neurons and no effective treatment. The diagnosis is
dependent on the clinical presentation and consistent electrodiagnostic studies. Progressive denervation affects the muscles, causing muscular weakness and atrophy, when the ventilation muscles are affected death
due to respiratory failure occurs within a few years. We present the case of a 54 years old, 180 cm height
and 94 kg weight male patient with amyotrophic lateral sclerosis who underwent surgical treatment of thyroid
cancer. Fiberoptic intubation was orally performed providing spontaneus breathing. Propofol was applied
after passing vocal cords. Anesthesia was maintained with sevoflorane (%2) and a mixture of oxygen and air
under volume controlled ventilation. Rocuronium was used 20 mg at the beginning of the surgery. At the end
of surgery, he wasnt extubated and transferred to anesthesia intensive care unit. He was extubated after ten
hours and he was awaked perfectly. The patient was discharged from intensive care unit after 24 hours and
from hospital after ten days. We reported that amyotrophic lateral sclerosis patient with limited mouth opening who underwent thyroid surgery, using awake intubation.
Keywords: Amyotrophic lateral sclerosis, fiberoptic, awake intubation.
Introduction
Amyotrophic lateral sclerosis (ALS) is a progressive neurologic disease of motor ganglia in the anterior horn of the spinal cord and spinal pyramidal
tracts. The onset is usually in the fourth decade of
life and it is more common in men (1). Anesthesia
procedures in patients with ALS often require certain special consideration (2). To our knowledge,
it hasnt been reported on anesthesia procedures
in awake fiberoptic intubated patient with ALS.
Case report
A 54 years old, 180 cm height and 94 kg weight
is a male patient with ALS who underwent surgical treatment of thyroid cancer. At age 47 muscle
weakness of the upper and lower extremites de* Corresponding author: Remziye Sivaci, MD.
Dumlupinar Mh. Turabi Cd. Tutuncu Apt.
B Blok NO: 2/1 D:9 03200 AFYON- TURKEY
Tel: + 90 272 2145511;
Fax: + 90 272 2158281
E-mail: remziyesivaci@gmail.com
Submitted 15 May 2012 / Accepted 22 July 2012
236
veloped and the diagnosis of ALS was made. In

personal history, he had been applied left anterior
descending artery (LAD) stent eight years ago.
He was awake, oriented and had muscle atrophy,
weakness. He had no difficulty in speaking, but
a little difficulty in swallowing. In preoperative
evaluation, we saw that the patient interincisal distance was 5 mm and his mallampathy score was
not assessed. Blood pressure was 150/80 mmHg
and heart rate was 85/beat in patient. Routine laboratory data, electrocardiogram and chest graphy
were normal. We planned to perform fiberoptic
intubation since difficult intubation was kept in
mind. In the operating room electrocardiogram,
pulseoximetry and continuous blood pressure via
a radial artery catheter were applied for monitoring. Laryngeal mask, nasopharyngeal and oropharyngeal airways were also prepared for difficult
airway. Topical anesthesia was provided by xylocaine. For sedation and analgesia, midazolam 0.3
mg/kg and fentanyl 1 mcg/kg were given as bolus
doses. Fiberoptic intubation was orally performed
providing spontaneous breathing. Propofol were
ELIF BAKI ET AL.: AWAKE FIBEROPTIC INTUBATION OF A PATIENT WITH AMYOTROPHIC LATERAL SCLEROSIS: CASE REPORT
applied after passing vocal cords and started volume controlled ventilation. Anesthesia was maintained with sevoflorane 2 % oxygen 50 % in air.
Rocuronium was used 20 mg at the beginning
of the surgery and was not added during surgery.
The intraoperative course was continued for four
hours, uneventfully. At the end of surgery, he was
not extubated and transferred to anesthesia intensive care unit. He was extubated after ten hours
and awaked perfectly. He was aspirated regularly
for his difficulty in swallowing by suction system.
The patient was discharged from intensive care
unit after 24 hours and from hospital after ten days.
Discussion
The presentation of amyotrophic lateral sclerosis,
however, may be variable. ALS is usually lethal,
rapidly progressive and neurodegenerative disease
that occurs mainly after the age of 50. It is most
common and severe motor neuron disease (3-4).
Typically, there is a combination of upper and
lower motor neuron signs as well as electrodiagnostic studies indicative of diffuse motor axonal
injury. The diagnosis is dependent on the clinical presentation and consistent electrodiagnostic
studies. The main cause of death in patients with
ALS is respiratory failure (5). At the same time,
there is no effective treatment and most important anesthesia management. They were applied
general anesthesia and neuromuscular blockers
in these patients since they can increase the weakness of the respiratory muscle (6). Prolonged paralysis and residual neuromuscular blockage can
be complicated tracheal intubation. In anesthesia
management, awake intubation and administration of small doses of neuromuscular blockers may be chosen (7). We didnt see any report
about difficult intubation with ALS patients. Thus,
we preferred awake fiberoptic intubation for our
patient since we didnt want to use neuromuscular blockage agents for anesthesia induction
and difficult intubation was thought for limited
mouth opening. Although lots of techniques for
fiberoptic intubation are known and used, there
is an association of thoughts for some important
points. First, patient cooperation and spontaneous breathing should be provided while fiberoptic
intubation is being performed. Second, sufficient
topical anesthesia must be kept (8). A lot of kinds
of drugs can be used for patient comfort and cooperation for awake fiberoptic intubation. In our
case, we performed fiberoptic intubation providing spontaneus breathing using topical anesthesia.
Fentanyl and midazolam combination are preferred usually. We used fentanyl and midazolam
for sedation during awake fiberoptic intubation.
In summary, We presented the successful anesthetic management of an adult patient with ALS
underwent thyroid surgery. We reported that ALS
patient with limited mouth opening using awake
intubation. We concluded that following a careful preoperative preparation, fiberoptic intubation
can be performed providing spontaneous breathing in patients having restricted mouth opening.
Competing Interests
Authors declare no conflict of interest related to
this study.
References
[1] Ferguson TA, Elman LB. Clinical presentation and diagnosis of amyotrophic lateral sclerosis. NeuroRehabilitation, 2007;22:409-416
[2] Miller RD. Anesthesia 4th edition. New York: Churchill
Livingstone Inc; 1994.
[3] Van den Berg-Vos RM, Visser J, Franssen H, de Jong
JMBV, Kalmijn S, Wokke JHJ, Berg LH Van den. Sporadic
lower motor neuron disease with adult onset: classification of subtypes. Brain 2003;126:1036-1047.
[4] Rowland LP, Shneider NA. Amyotrophic Lateral Sclerosis.
N Engl J Med 2001;344:1688-1700.
[5] Gregory SA Evaluation and management of respira-
tory muscle dysfunction in ALS. NeuroRehabilitation,

2007;22:435-443.
[6] Mashio H, Ito Y, Yanagita Y et al. Anesthetic management of a patient with amyotrophic lateral sclerosis. Masui 2000;49:191-194.
[7] Mishima Y, Katsuki S, Sawada M et al. Anesthetic management of a patient with amyotrophic lateral sclerosis
(ALS). Masui 2002;51:762-764.
[8] Grant SA, Breslin DS, MacLeod DB, Gleason D, Martin
G. Dexmedetomidine infusion for sedation during fiberoptic intubation: A report of three cases. J Clin Anest
2004;16:124-6.
237
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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
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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
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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
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All the authors must sign a submission form. It contains the permission to publish the submitted manuscript, statement of conflict of
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form (ZIP); 2. Manuscript (doc, docx, rtf). IT IS NOT NECESSARY to send the printed version, unless the authors want to pres-
238
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
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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).
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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
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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-
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).
239
www.jhsci.ba
UPUTSTVO AUTORIMA
Upute i smjernice autorima za pripremu i predaju rukopisa u Journal of Health Sciences
Ciljevi i okvir asopisa
The Journal of Health Sciences (JHSci) je internacionalni asopis
na engleskom jeziku, koji objavljuje orginalne radove iz oblasti fizikalne terapije, medicinsko-laboratorijske dijagnostike, radioloke
tehnike, sanitarnog inenjerstva, zdravlja i ekologije, zdravstvene
njege i terapije, te drugih srodnih oblasti.
Vrste znanstvenih radova koje se mogu poslati za objavljivanje
u JHS
Orginalni radovi: orginalne laboratorijske eksperimentalne i klinike studije ne bi trebao prelaziti 4500 ukljuujui tabele i reference.
Prikaz sluajeva: prezentacije klinikih sluajeva koji mogu sugerisati kreiranje nove radne hipoteze, uz prikaz odgovarajue literature. Tekst ne bi trebao prelaziti 2400 rijei.
Pregledni lanci: lanci afirmiranih znanstvenika, pozvanih da ih
napiu za asopis. Redakcija e, takoer, razmatrati i samostalne
aplikacije.
Uvodnici: lanci ili kratki uvodniki komentari koji predstavljaju
miljenja prepoznatih lidera u medicinskim istraivanjima.
Podnoenje rada za objavljivanje
Rad koji se alje u JHSci mora biti u skladu sa propozicijama o sadraju, izgledu i kvalitetu, koje je urnal propisao u ovim instrukcijama za autore i na web stranici urnala, www.jhsci.ba. Propozicije
o sadraju, izgledu i kvalitetu naunog rada u skladu su sa meunarodnim propozicijama i preporukama datim od strane International Committee of Medical Journal Editors. Uniform Requirements
for Manuscripts Submitted to Biomedical Journals New Engl J
Med 1997, 336:309315 (www.icmje.org), te preporuka meunarodnih radnih grupa za standardizaciju izgleda i kvaliteta naunih
radova: STROBE (www.strobe-statement.org) , CONSORT (www.
consort-statement.org), STARD (www.stard-statement.org) i drugih.
Predloci
JHSci je pripremio predloke (engl. template) za izgled i sadraj
naunog rada. Predloci sadre sve neophodne podnaslove i obogaeni su uputama o sadraju svakog poglavlja naunog rada, te e
autorima znatno olakati proces pisanja rada. JHSci preporuuje
koritenje predloaka za pisanje naunih radova koji se nalaze na
web stranici urnala www.jhsci.ba u dijelu Information for authors.
autori ele predstaviti rukopis, pismo ili dijelove koji ne mogu biti
poslani elektronski, ili je to zatraeno od urednitva. Za autore koji
nemaju mogunost elktronskog slanja rada, potrebno je poslati
potom jedan primjerak rada, zajedno s elektronskom verzijom na
CD-u ili DVD-u na sljedeu adresu: za Journal of Health Sciences,
Fakultet zdravstvenih studija Univerziteta u Sarajevu, 71000 Sarajevo, Bolnika 25, Bosna i Hercegovina.
Pravila redakcije
Autorstvo
Svi autori morati potpisati formular za podnoenje rada (Manuscript Submission form). Potrebno je da svi autori potpisom potvrde
da: su zadovoljili kriterije za autorstvo u radu, utvreno od strane
International Committee of Medical Journal Editors; vjeruju da
rukopis predstavlja poteni rad i da su u mogunosti potvrditi valjanost navedenih rezultata. Autori su odgovorni za sve navode i
stavove u njihovim radovima. Vie informacija se moe dobiti na
(http://bmj.com/cgi/collection/authorship).
Plagijarizam ili dupliciranje objavljenog rada
Od autora se zahtjeva da svojim potpisom potvrde da u momentu
podnoenja rad nije objavljen u sadanjem obliku ili bitno slinom
obliku (u tampanom ili elektronskom obliku, ukljuujui i na web
stranici), da nije prihvaen za objavljivanje u drugom asopisu ili
razmatran za objavljivanje u drugom asopisu. Meunarodni odbor urednika medicinskih asopisa dao je detaljno objanjenje ta
jeste, a ta nije duplikat (www.icmje.org). Vie informacija moe se
nai i na stranici www.jhsci.ba.
Formular saglasnosti bolesnika
Zatita prava pacijenta na privatnost je od iznimnog znaaja. Autori trebaju, ako redakcija zahtjeva, poslati kopije formulara Suglasnosti bolesnika iz kojih se jasno vidi da bolesnici ili drugi subjekti
eksperimenata daju doputenje za objavljivanje fotografija i drugih
materijala koji bi ih identificirali. Ako autori nemaju potrebnu saglasnost za istraivanje, moraju je dobiti ili iskljuiti podatke koji
identificiraju subjekte, a za koje nisu dobili saglasnost.
Odobrenje Etikog komiteta
Autori moraju u formularu za podnoenje rada i u dijelu rada
Metode jasno navesti da su studije koje su proveli na humanim
subjektima, odnosno pacijentima, odobrene od strane odgovoarajueg etikog komiteta. Vie informacija moete nai u najnovijoj verziji Helsinke deklaracije (http://www.wma.net/e/policy/
b3.htm). Isto tako, autori moraju potvrditi da su eksperimenti koji
ukljuuju ivotinje provedeni u skladu sa etikim standardima.
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 ako
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
240
UPUTE I SMJERNICE AUTORIMA ZA PRIPREMU I PREDAJU RUKOPISA U JOURNAL OF HEALTH SCIENCES
koriste, autori moraju dobiti pismenu dozvolu izdavaa i navesti

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

UNIVERZITET U SARAJEVU FAKULTET ZDRAVSTVENIH STUDIJA

Journal of Health Sciences

Dijana Avdi (BiH)

Demal Pecar (BiH)

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)

Journal of Health Sciences

Volume 2, Number 3, December 2012

Journal of Health Sciences

Volume 2, Number 3, December 2012

Osteoporosis and osteoarthritis:

a bone disorder while osteoarthritis is generally

DIJANA AVDI: OSTEOPOROSIS AND OSTEOARTHRITIS: SIMILARITIES AND DIFFERENCES

duction and bone morphology disorder. Therefore

35 years suffer from osteoarthritis. About 55% of

DIJANA AVDI: OSTEOPOROSIS AND OSTEOARTHRITIS: SIMILARITIES AND DIFFERENCES

osteoarthritis (age range, 60-85 years). According

growth factors such as IGF and TGF beta, which

DIJANA AVDI: OSTEOPOROSIS AND OSTEOARTHRITIS: SIMILARITIES AND DIFFERENCES

time. Although these disorders are more present

perience and epidemiological studies have shown

2009;43(2):294-301. PubMed PMID: 19762027. doi:

JOURNAL OF HEALTH SCIENCES 2012; 2 (3)

Journal of Health Sciences

Volume 2, Number 3, December 2012

Serum Matrix Metalloproteinase-2, -7 and -9

dependent endoproteases capable of degrading all the ECM components. At present, 23

titis, autoimmune blistering disorders of the skin

questionable to expose a large number of patients

TABLE 1. Staging of the disease in CRC patients according

metastases were substantiated in 25 (30.48%)

FIGURE 2. Mean MMP-7 (ng/mL) serum levels in terms of

this group, with mean survival time of 28.5 months.

patients with mean survival time of 21.8 months.

JOURNAL OF HEALTH SCIENCES 2012; 2 (3)

TABLE 4. Statistically significant correlations with poor outcome in CRC patients

MMP-9 and their tissue inhibitors (TIMP-1

Therefore, we speculate that MMP-7 would be

PubMed PMID: 10694567.

JOURNAL OF HEALTH SCIENCES 2012; 2 (3)

JOURNAL OF HEALTH SCIENCES 2012; 2 (3)

tors TIMP-1 and TIMP-2 in Colorectal Carcinoma Tissue

Journal of Health Sciences

Volume 2, Number 3, December 2012

A comparison of efficacy of femoral and tibial

sustained, and its expected bone to heal in a

EMIL OMEROVI ET AL.: A COMPARISON OF EFFICACY OF FEMORAL AND TIBIAL FRACTURES

quires removing farthest screw, 10-16 weeks after

EMIL OMEROVI ET AL.: A COMPARISON OF EFFICACY OF FEMORAL AND TIBIAL FRACTURES

is a difference in the speed and quality of healing of

By applying of intramedullary nail, it is important

TABLE 1. Clinical and radiographic signs of fracture healing

RADIOGRAPHIC SCALE OF CALLUS FORMATION IN

SMALL TO MEDIUM CALLUS

MASSIVE CALLUS TISSUE

BRIDGING PERIOSTEAL CALLUS