JHSCI 2011 v1 I1 April

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

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

Budimka Novakovi (SRB)
Electronic Publishing
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Refet Gojak
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Technical editor
Zerema Obradovi Zubovi (BiH)
Faruk pilja
Dragi Bankovi (SRB)
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Volume 1, Number 1, April 2011
Table of contents:
Editorial
Uvodnik
Dijana Avdi. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Research articles
The concentration of homocysteine in patients after
ischemic brain stroke and vascular dementia
Nafija Serdarevi, Lejla Begi, Adaleta Mulaomerovi - Softi. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 - 9
Lumbosacral pain caused by blockage of dynamic

vertebrogenic segments of thoracolumbar transition
Sead ebi, Demal Pecar, Muris Pecar, Suad Sivi. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 - 13
Perioperative blood loss and diclofenac in major arthroplastic surgery
Ljiljana V. Gvozdenovi, Vesna M. Pajti, Nemanja M. Gvozdenovi, Saa D. Mili, Zoran B. Gojkovi . . . . . . . 14 - 17
A retrospective study of surgical treatment of spinal injuries with rehabilitation program

Dijana Avdi, Amila Jaganjac, Bakir Katana, Samir Bojii. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 - 22
The presence of risk factors for diabetes mellitus type 2 in patients of family practice medicine
Fatima Jusupovi, Dijana Avdi, Jasmina Mahmutovi, Aida Rudi, Arzija Paali,
Suada Brankovi, Almedina Beri, Amra Maak-Hadiomerovi. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 - 27
Influence of osteoporosis risk faktors on bone mass loss in postmenopausal women
Amila Kapetanovi, Dijana Avdi, Katarina Markovi,

Ata Teskeredi, Mustafa Basari, Eldan Lokmi. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 - 30
Epidemiological characterisics of gastrointestinal infectious

diseases and viral hepatitis A in the Canton Sarajevo
Zarema Obradovi, Arzija Paali, Amar ili. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 - 35
Effects of improper posture during work on
lumbal pain syndrome of discogenic etiology
Eldad Kalji . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 - 38
Salt in nutrition of University of Sarajevo students
Fatima Jusupovi, Dijana Avdi, Budimka Novakovi, Arzija Paali, Jasmina Mahmutovi,
Suada Brankovi, Aida Rudi, Aida Kevri, Amra Maak-Hadiomerovi. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 - 43
Relation of diet and physical activity to obesity in children in elementary schools

Senka Dinarevi, Suada Brankovi, Snjeana Hasanbegovi. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 - 49
Review articles
Sonoelastography: the method of choice for evaluation of tissue elasticity
Fahrudin Smajlovic, Aladin Carovac, Deniz Bulja. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 - 55
Health promotion in families who have children with intellectual and developmental disabilities
Emira vraka, Slobodan Loga, Dijana Avdi, Jasmina Berbi-Fazlagi. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 - 60
INSTRUCTIONS TO AUTHORS
Instructions and guidelines to authors for the preparation and
submission of manuscripts in the Journal of Health Sciences. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 - 64
www.jhsci.ba
Editorial
Uvodnik
Prva registracija Fakulteta zdravstvenih studija Univerziteta u Sarajevu je glasila: Univerzitetsko-medicinski centar
zajednica organizacija udruenog rada Via medicinska kola, koja je zapoela sa radom 19.12.1973.godine. Prolazei kroz iste faze kao i drugi dijelovi sloenog sistema Univerzitetskog medicinskog centra, Stomatoloki i Farmaceutski fakultet, Fakultet zdravstvenih studija je u poetnoj organizaciji imao edukaciju koja se odvijala u sklopu
Medicinskog fakulteta.
U toku proteklih 38 godina rada, fakultet je prolazio kroz razne faze u kojima su vrene razne organizacione promjene, donoeni planovi i programi, vrena njihova dopuna i inovacija. Nakon dvogodinjeg, zatim trogodinjeg studija,
akademske 2002/03. godine upisana je prva generacija etverogodinjeg studija tadanje Visoke zdravstvene kole,
pet studija u oblasti zdravstva, koji omoguava zavrenim studentima ravnopravnu participaciju na postdiplomskim
studijama, izradu magistarskih i doktorskih teza iz svojih naunih oblasti. Od 2008. godine Visoka zdravstvena kola
preimenovana je u FAKULTET ZDRAVSTVENIH STUDIJA U SARAJEVU
U akademskoj 2009/10. godini Fakultet je organizovao studij po Bolonjskoj deklaraciji za svih pet Studijskih programa:
Zdravstvena njega i terapija (ranije: sestrinstvo)
Fizikalna terapija (ranije: fizioterapija)
Okolinsko zdravlje i humana ekologija (ranije: sanitarno ininjerstvo)
Radioloke tehnologije (ranije: radioloke tehnike)
Laboratorijske tehnologije (ranije: medicinsko-laboratorijska dijagnostika)
Specifinost ovako osmiljenog Fakulteta je u tome to se brine za one dijelove zdravstvene zatite neophodne da
zadovolji sve iru i sveobuhvatniju multidisciplinarnu, neinvazivnu i invazivnu dijagnostiku i terapiju na najviem
nivou, sa najsavremenijom opremom i metodama koje se koriste u svijetu. Organizovani moderni fundament za
ove ambiciozne ideje na ovaj nain je postao realnost, pa i ovih 5 znaajnih oblasti tzv. Medicinske logistike postaje
integralni dio sistema koji dinamikom sustie i prati savremene trendove medicinske znanosti.
Journal of Health Sciences 2011; 1 (1)
Prof. dr Dijana Avdi

glavni urednik
www.jhsci.ba
The concentration of homocysteine in patients

after ischemic brain stroke and vascular
dementia
Nafija Serdarevi1*, Lejla Begi2, Adaleta Mulaomerovi - Softi2
1
2
Department for Clinical Chemistry, University of Sarajevo Clinical Center, Bolnika 25, 71000 Sarajevo, Bosnia and Herzegovina.
Department of Biochemistry, Faculty of Pharmacy, University of Tuzla, Univerzitetska 8, 75000 Tuzla, Bosnia and Herzegovina.
Abstract
Introduction: The aim of this study is to examine whether moderate hiperhomocysteinemia is an independent risk factor for cerebral infarction.
Methods: We have measured homocysteine levels in 50 patients with ischemic stroke during acute phase and postacute phase, 50 patients diagnosed with vascular dementia and healthy group of 50 subjects. Homocysteine concentration in serum was measured, on the basis of fluorescent polarisation measuring.
Results: The study demonstrated that homocysteine concentration was 16.93 mol/L in the patient group with ischemic
stroke, and in the group of patients with vascular dementia was 20.39 mol/L. Homocysteine increases during the postacute phase of ischemic stroke after 7 days for 1.54 mol/L and 14 days for 3.66 mol/L compared to the concentration
of homocysteine after the first hours of hospitalization. Using Wilcoxon signed ranks and Mann-Whitney (P < 0.05) tests
we got significant difference between homocysteine concentration at acute phase and post-acute phase of ischemic
stroke and it was significant difference between concentrations of homocysteine in the acute and post-acute phase of
ischemic stroke and vascular dementia. The Spearman correlation test was found significant correlation between the
number of strokes and the concentration of homocysteine in serum of patients with vascular dementia.
Conclusions: The homocysteine concentration rises significantly during of acute phase of ischemic brain stroke, and
it is significantly increased during post-acute phase, which is a predictor factor for further development of vascular dementia, or a new ischemic brain stroke.
2011 University of Sarajevo Faculty of Health Studies
Keywords: homocysteine, ischemic brain stroke and vascular dementia.
Introduction
The ischemic stroke (IS) is major cause of global disability and is the second most common cause of death
worldwide. Elevated tolal plasma homocysteine level
is common in the old age and is well-established risk
factor for cardiovascular and cerebrovascular disease (1). The amino acid homocysteine occurs by demethylation of methionine, essential amino acid, which
in enters the human body with food. It is found in
the plasma mainly in the oxidized state (homocysteine or homocysteine-cysteine disulfide) and bound to
proteins, mostly albumin (2,3). It was first described
in work of Butz and Vigneaud who have synthesized
amino acid homocysteine in a reaction of strong concentrated acid with methionine. (4). Based on findings
* Corresponding author: Nafija Serdarevi; Institute
for Clinical Chemistry and Biochemistry, University of
Sarajevo Clinics Center, Bolnika 25, 71000 Sarajevo,
Bosnia and Herzegovina; Phone: +38733663353, Fax:
+38733663353; E-mail: serdarevicnafija@yahoo.com
Submitted 21 January 2011 / Accepted 25 February 2011
observed in patients with homocystinuria, McCully

postulated that hyperhomocysteinemia may play a
role in the pathogenesis of atherotrombotic vascular
disease (5). Elevated levels of homocysteine can therefore cause damage to several key pathways in the central nervous system, either directly or by changing the
methylation potential. The hyperhomocysteinemia is
very common in patients with stroke and is suggested
to be an independent risk factor for the disease (6,7).
The elevated concentrations of homocysteine are responsible for occurrence of atherosclerosis in at least 3 ways:
1) toxic effect of homocysteine in endothelium of arteries, 2) interference of homocysteine with clotting factors and 3) oxidation of low-density lipoprotein (LDL).
Although there are data on homocysteine metabolism,
the pathogenesis of hyperhomocysteinemia is still not
clear. Homocysteine is turned into a methionine by
remethylation; methyl group donor in most tissues is
5-methyltetrahydrofolate, nevertheless betaine is donor in the liver, kidney and eye lens. The reaction is
catalyzed by methionine-synthase (MS) with vitamin
JOURNAL OF HEALTH SCIENCES 2011; 1 (1)
NAFIJA SERDAREVI ET AL.: THE CONCENTRATION OF HOMOCYSTEINE AT PATIENTS AFTER ISCHEMIC BRAIN STROKE AND VASCULAR DEMENTIA
B12 as a cofactor. Tetrahydrofolate incurred converts to

5,10-methyl-tetrahydrofolate with the enzyme methylene-tetrahydrofolate reductase (MTHFR) and then in
5-methyl-tetrahydrofolate. Another pathway of homocysteine metabolism is trans-sulphuration pathway
in which homocysteine with serine turns to cystathionine under the action of enzymes cistationine--synthase
(CBS) and cofactor vitamin B6. After that cystathionine
goes into cysteine under the influence of the enzyme
-cystathionase (GCT) (8-10). Homocysteine metabolism is regulated by the concentration of methionine that
is normally used for protein synthesis and synthesis of
S-adenosyl-methionine. Homocysteine lies at the intersection two of metabolic pathways, transsulphuration
pathway and remethylation cycle. Current availability
of methionine determines the pathway by which the
homocystein will be metabolized. Decrease of folic acid
and vitamin B12 leads to increase of homocysteine and
decreases the remethylation of homocysteine (11,12).
It could be postulated that elevated total homocysteine
is a risk factor for atherotrombic stroke in particular.
Moreover, there is a debate whether homocysteine is a
causative risk factor in stroke and myocard infarction or
is merely a secondary marker of risk in survivors (13).
Date regarding to homocysteine concentration immediately after stroke would help to resolve this question,
because the observation of a raised homocysteine at
this time would be more suggestive of a causal association that the occurrence of hyperhomocysteinemia
in survivous sampled at a time distant from the event.
Methods
Patients
The investigation included 100 patients and 50 healthy
subjects. 250 blood samples were collected during 2008
and 2009. All investigation was done respecting ethical standards by the Helsinki Declaration. The patients
were hospitalised at Clinic of Neurology, Clinical Centre University of Sarajevo, Old home "Nedarii, and
Old home "Ernest Grin". The patients group included
patients with first ischemic stroke (50 subjects) and
vascular dementia (50 subjects). The control group
included 50 healthy subjects who were protg at Old
home "Nedarii. Criteria for inclusion of patients
with stroke and vascular dementia were: diagnosis of
first ischemic stroke determined by computerized tomography (CT), presence of vascular dementia identified using computerized tomography (CT) and nuclear
magnetic resonance (NMR), Hachinski ischemic score
grater or equal to 7 for patients with vascular dementia,
age over 65 years for both sexes, two weeks of hospital stay for patients with ischemic stroke, stroke in patients with vascular dementia in last three to six years.
The study inclusion criteria for control group were:
excluded ischemic stroke or vascular dementia by

computed tomography (CT) and nuclear magnetic resonance (NMR), age over 65 years for both
sexes, excluded kidney, heart or vascular diseases.
Criteria for exclusion from the study, for both patients
and controls, were: diseases that are associated with impaired renal function and renal failure (determined by
serum creatinine concentration), chronic inflammatory
disease, rheumatoid arthritis, SLE, multiple sclerosis and
psoriasis, acute lymphoblastic leukaemia, intestinal disorders atrophic gastritis, Crohn's disease and ulcerative
colitis, Hypothyroidism, patients on treatment with methotrexat, carbamazepine, phenytoin, and theophylline.
The blood samples were collected at the mornings before the first meal. For the group of 50 patients diagnosed
with the first ischemic brain stroke, blood samples were
taken during the acute phase (initial 24-48 hospitalization hours), and post-acute phase (after 71 days, and
after 11-14 hospitalization days). For the group of 50
patients diagnosed with vascular dementia developed
as a consequence of ischemic brain stroke, i.e. of many
small ischemic focus of various age. The study included
27 men and 23 women in control group. There were
27 males and 23 females in the group with ischemic
stroke and 28 men and 22 women in the group with
vascular dementia. By analyzing the history of disease
we collected data about radiological examinations of
brain computed tomography (CT) and brain nuclear magnetic resonance (NMR). 92% (46) of patients
suffering from ischemic stroke had the diagnosis ICV
per trombosim and at 8% (4) patients the diagnosis was
ICV per emboliam. Level of albumin was obtained from
patients history and was in normal range (35-50g/L).
The value of serum homocysteine concentration was
determined using AxSYM (Abbott), based on measurements of fluorescence polarization immunoassay
(FPIA) technology. The reaction principle is conversion of homocystine, mixed disulfide and protein-bound
forms of homocysteine in the sample to form of free
homocysteine by the use of dithiothreitol (DTT). After
that, free homocysteine is converted to S-adenosyl-Lhomocysteine (SAH). Under physiological conditions,
SAH hydrolases convert SAH to homocysteine. Levels
of L-homocysteine are determined in human serum.
Normal homocysteine concentration in serum is 3.3620.44 mol/L for women and 5.90-16 mol/L for men.
The creatinin was determined using automatic analyzer
Dimension (Dade Behring). Method for determination
of creatinine is a modification of the kinetic reaction of
Jaffee. The reference value for serum creatinine concentration is 45-115 mol/ L. The patient samples of blood were collected in serum separation Vacutainer test
tubes (Beckton Dickinson, Rutherford, NJ 07,070 U.S.)
in volume of 3.5 mL. We used test tubes with gel. After
collection, samples were placed in ice and, after 30 to 60
5
TABLE 1. Serum concentration of homocysteine (Hcy) at patients with ischemic brain stroke, vascular dementia and control group.
Patients with ischemic
brain stroke
Time of determination
24-48 hours
13.27
Xsr
S.D.
5.62
S.E.
0.79
Number of patients
50

brain stroke
7 days
14.81
6.03
0.85
50

brain stroke
14 days
16.93
7.63
1.07
50
Patients with vascular

dementia
20.39
10.15
1.43
50
Control group
10.49
1.92
0.27
50
minutes serum samples were obtained by centrifugation

at 3000 rpm using centrifuge (Sigma 4-10). After centrifuging, concentration of homocysteine and creatinine
in sera were determined. All subjects (patients and controls) had concentration of creatinine in reference values.
Statistical analysis
The results were statistically analyzed using SPSS
version 11 and Microsoft Office Excel 2003. Average values (), standard deviation (SD) and Spearman correlation coefficient (r) were calculated, as
well as Wilcoxon signed ranks and Mann-Whitney
test with statistical significance level of 0.05 (P <0.05).
Results
The average age in the control group was 69.34 years. In
the group with vascular dementia, the average age was
73.74 years. The group with ischemic stroke had an average age of 70.12 years.
Mean concentrations of homocysteine in patients after ischemic stroke (24-48 hours, 7 days
and 14 days), patients with vascular dementia and control groups are shown in Table 1.
The average concentration of homocysteine and +
/ - SD in patients after ischemic stroke (24-48 hours,
7 days and 14 days), patients with vascular dementia
and control groups are graphically show in Figure 1.
The homocysteine serum concentrations were increased during the acute phase to the post acute phase of
ischemic stroke, as shown by results in Figure 2. During
hospitalization serum concentrations of homocysteine
increased after seven days and then increased significantly after the fourteenth day. In the acute phase after
7 days of hospital treatment homocysteine concentration was increased for 1.54 mol/L, after 14 days for 3.66
mol/L compared to the concentration after the first 2448 hours. Between 7 and 14 days of treatment the concentration of homocysteine increases for 2.12 mol / L.
Analysis of distribution showed assimetrical distribution of homocysteine levels in patients with
ischemic stroke, vascular dementia and control
group. We used Wilcoxon signed ranks for comparison of serum homocysteine concentration in patients with ischemic brain stroke during acute phase
and post-acute phase. Results are shown in Table 2.
6
FIGURE 1. The mean serum homocysteine concentration +/S.D in risk of patients (ischemic stroke (IS), vascular dementia)
and control group
FIGURE 2. Serum concentration of homocysteine in patient with

ischemic stroke during acute phase and post-acute phase.
TABLE 2. Comparison of serum homocysteine concentration
(Hcy) in patients with ischemic brain stroke during acute phase
and post-acute phase
Z
P
(after 7 days)
(after 14 days)
(after 14 days)
with (24-48 hours) with (24-48 hours) with (after 7 days)
-5.850
-6.1543
-5.927
0.000*
0.000*
0.000*
* P < 0.05 (Wilcoxon signed ranks)
In Table 2. Z and P values of average serum homocysteine concentrations in patients during acute and post-acute phase of ischemic stroke are shown. Using Wilcoxon
signed ranks test we have concluded that the average
TABLE 3. Comparison of serum homocysteine concentration

(Hcy) in risk group of patients with control group
Comparison groups
Ischemic brain stroke
with control group
with control group
with control group
ischemic brain stroke
with vascular dementia
vascular dementia
with control group
Time of deter- Mannmination

Whitney U
24-48 hours
1046.00
-1.406 0.160
7 days
696.50 -3.816 0.000*
14 days
335.50 -6.605 0.000*
24-48 hours
486.00 -5.267 0.000*
7 days
614.50 -4.381 0.000*
14 days
790.50 -3.168 0.002*

44.000 -8.314 0.000*
serum homocysteine concentration 24-48 hours after

the first symptoms of ischemic stroke were significantly
differed from the concentration of homocysteine after
7 and 14 days of hospital treatment (p < 0.05). There
was a significant difference between the average homocysteine concentration after 7 and 14 days of hospital treatment (p<0.05). Using Mann-Whitney U-test
we made comparison of serum homocysteine between
risk groups (ischemic stroke, vascular dementia) and
control healthy group, the results are shown in Table 3.
According to Mann-Whitney test for = 5%, the difference between concentrations of homocysteine in the
acute phase of ischemic stroke and control healthy
groups is not significant. The same test for = 5% has
shown a significant difference between concentrations
of homocysteine in the acute phase of ischemic stroke and control group. The serum concentrations of
homocysteine increase after 7 days and significantly
increased after 14 days of hospital treatment. We found significant difference between concentrations of
homocysteine in the acute and the post-acute phase
of ischemic stroke and a group with vascular dementia (p<0.05). The concentration of serum homocysteine concentration was higher in the group with vascular dementia than in the group with ischemic stroke.
Average serum concentrations of homocysteine in the
group with vascular dementia was significantly different from control healthy group (p <0.05). The serum
creatinene concentration was in reference value (45-115
mol/ L) for all patients in risk groups and in control
group. So we can exclude that serum concentration of
homocysteine was increased for kidney demage. In the
group of patients with vascular dementia, 52% (26 patients) had an extensive one stroke, 32% (16 patients) two
* P < 0.05 (Mann-Whitney U-test )
FIGURE 3. Number of brain attacks in patients with vascular dementia. (0- many) small focus i without ischemic stroke (16 %),
1- one ischemic stroke (52 %) , 2- ischemic stroke (16 %)
strokes, 16% (8 patients), many small ischemic focus

without ischemic stroke the results are shown in Figure 3. According to the Spearman correlation test, it was
found a statistically significant correlation between the
number of strokes and concentrations of homocysteine in the serum of patients with vascular dementia
of p <0.05 (correlation coefficient = 0.341, p = 0.015).
The serum homocysteine concentration is increasing with
number of strokes infarctions and more ischemic focus.
Discussion
Homocysteine is an independent risk factor for developing peripheral vascular, cerebrovascular and coronary
heart disease. The mechanism by which the total homocysteine may cause vascular disease includes thrombosis, endothelial dysfunction and increased oxidation
of LDH (low density cholesterol) (15). About 50% of
patients with hyperhomocysteinemia have vascular
changes before ther thirty years of old (16). Our study
showed that the group of patients with ischemic stroke 30% (15 patients) had moderate hyperhomocysteinemia, from the total sample number it was 44 % of
men and 13% of woman. The results of our study have
shown that the mean concentration of homocysteine after 24- 48 hours of hospital treatment was 13.27 mol/L,
after 7 days 14.81 mol/L and 14 day 16.93 mol/L in
comparison to serum concentration in control group
it was 10.49 mol/L (Table 1). At the post-acute phase
of ischemic stroke after 7 days homocysteine increces
for 1.54 mol/L in compared to the concentration of
homocysteine after the first 24-48 hours of patients hospitalization. In our study, after 14 days of hospitalization
of patients with ischemic stroke average homocysteine concentration was increased from 0.20 mol/L to
20.42 mol/L (average 3.66 mol/L). The mean serum
homocysteine concentration increases during first to
second week for 2.12 mol/L. The results are shown in
Figure 1 and Figure 2. In a two retrospective studies, the
British regional health study and the Framingham Heart Study, that there is independent association betwe7
en serum homocysteine and the incidence of ischemic

stroke if homocysteine concentrations were equal or
greater than 15.4 mol/L and homocysteine concentrations were equal or greater than 14.24 mol/L. In the
Rotterdam study it is showed a significant increase in
stroke risk with increasing serum homocysteine levels
above 18.6 mol/L (17). High concentrations of homocysteine are closely correlated with the risk of silent
stroke (18). It was concluded that homocysteine is an
independent risk factor for stroke in people older than
sixty years, and homocysteine concentrations above
14 mol/L increased to 80% risk of stroke (19). If the
concentration of serum homocysteine increases for 1
mol/L the risk for new ischemic stroke increases for
22% (20). The increase of homocysteine concentration
for 5 mol/Lincreased the risk for coronary heart disease 1.6 times for men and 1.8 times for women, and cerebrovascular disease increases the risk for both sexes 1.5
times (21). It is believed that during the first week after
ischemic stroke homocysteine concentration increases
for about 10% (22). Our research has shown that during
the first week after ischemic stroke, homocysteine concentration increases for about 11.6%. Using Wilcoxon
signed ranks the mean value of serum homocysteine
in patients with ischemic stroke after 24-48 hours was
significantly different than the mean values of homocysteine after 7 and 14 days of patients hospitalisation with significance of p < 0.05. Our result have show
using same test that there was a significant difference
between the average homocysteine concentration after
7 and 14 days of hospital treatment (p < 0.05) (Table 2).
According to our results using the Mann-Whitney test
average concentrations of homocysteine in the acute
phase of ischemic stroke after 24-48 hours showed no
significant difference with control group. A significant
increase in homocysteine concentration occurs only in
the acute phase in which there was a significant difference compared to the control group (Table 3). The results have shown that it is evident that the concentration of serum homocysteine increase after stroke. There
are two possible explanations for the change in serum
homocysteine concentration after acute phase and during the pos-tacute phase of ischemic stroke recovery:
The acute phase of ischemic stroke following
stress which leads to short-term decrease in
serum homocysteine. Damage to cerebral tissue increases the production of oxygen radicals, increases oxidative stress, leading to
possible subsequent changes in the degree of
elimination of thiols, including homocysteine.
Serum homocysteine increases after the acute phase
of ischemic stroke as a reason of folate and vitamins
B6 or B12 deficiency which is particularly common in
elderly people. Impairment of renal function also leads to increased concentrations of homocysteine (23).
8
Therefore, we excluded from our study patients with a

high concentration of creatinine. The first early signs of
dementia are presented with a reduction in the volume
of brain mass and the occurrence of silent stroke (4). In
our study, another group of patients who are determined
homocysteine concentration had vascular dementia as a
consequence of ischemic stroke. At group with vascular
dementia hyperhomocysteinemia was present in 62%
(81.4% men and 39.1% women). According to our results in the group of patients with vascular dementia, the
average homocysteine concentration was 20.39 mol / L.
Homocysteine in the group of patients with vascular dementia was significantly higher than in the group with
ischemic stroke and control group (Table 1). According
to Mann-Whitney test for = 5%, a significant difference between concentrations of homocysteine in the
acute phase of ischemic stroke and vascular dementia.
Using the same test for = 5%, a significant difference
between concentrations of homocysteine in the postacute phase of ischemic stroke and concentrations of
homocysteine in vascular dementia. Comparing the results showed significant differences between the average
concentrations of homocysteine with vascular dementia
group and control group (p < 0.05) (Table 3). In the group of patients with vascular dementia, 52% (26 patients)
had one extensive stroke, 32% (16 patients) two, and
16% (8 patients), many small ischemic focus without ischemic stroke (Figure 3). We got significant correlation
(Spearman correlation test) between the number of strokes and concentrations of homocysteine in the serum
of patients with vascular dementia. The results of our
study showed that with increasing number of attacks
increased concentrations of homocysteine what can
lead to evolution of vascular dementia after ischemic
stroke. Our results shown that more males has hyperhomocysteinemia in relation to females, so they have move
prevalence for developing new ischemic stroke or vascular dementia. If homocysteine concentration increases above 14 mol/L increased the risk for Alzheimer's
disease or vascular dementia for 4.6 times higher than
in patients in who has concentration of homocysteine
is less than 11 mol/L (24). According to our results,
homoysteine concentration increasing from acute to
post-acute phase at patients with ischemic stroke and
patients with vascular dementia have higher concentration of homocysteine then patients with ischemic stroke.
Conclusion
The homocysteine could be an independent risk factor
for development of cerebrovascular disease. The possible limitation of of our study are limited number of
patients and we have not informations about concentration of homocysteine before ischemic brain stroke or vascular dementia. Hyperhomocysteinemia is
present in about 30% (44% men and 13% females) of
patients with ischemic stroke and in about 62% of patients with vascular dementia (81.4% men and 39.1%
women). The concentration of homocysteine increases
during 14 days of hospital treatment in comparison of
homocysteine concentration 24-48 hours after ischemic stroke. The patients with elevated concentration
of homocysteine after stroke have longer hospitalization than patients with reference value of homocysteine.
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www.jhsci.ba
Lumbosakralna bol uzrokovana blokiranjem

vertebrogenih dinamikih segmenata
torakolumbalnog prijelaza
Lumbosacral pain caused by blockage of dynamic
vertebrogenic segments of thoracolumbar transition
Sead ebi1*, Demal Pecar2, Muris Pecar3, Suad Sivi4
Privatna specijalistika ordinacija ebi, Dr. Pinkasa 2, 72220, Zavidovii, BiH
Fakultet zdravstvenih studija, Univerzitet u Sarajevu, Bolnika 25, 71000 Sarajevo, Bosna i Hercegovina,
3
ZU Praxis Sarajevo-Centar za fizikalnu medicinu i rehabilitaciju, umurija 3, 71000 Sarajevo, Bosna i Hercegovina.
4
Kantonalni zavod za javno zdravstvo, 72000 Zenica, Bosna i Hercegovina.
1
2
Abstract
Introduction: In the case of the Thoraco-lumbar Junction Syndrome the pain is located in the region of the
lumbo-sacral junction. Sudden torsion movements and
lifting of objects while the spine is in position of torsion
is the cause in most cases. In those cases, a blockade
on the Th11-Th12-L1 vertebrae occurs. The aim of this
research was to determine the number of patients with
the Low Back Pain whose origin is in the thoracic vertebral dynamic segments, in relation to the total number of
patients according to gender, age and profession.
Methods: In this retrospective, descrtiptive study we
have analyzed patients treated for Lumbosacral syndrome of thoracic origin in private specialist ambulant
Cebic in Zavidovici during one year period. We analyzed
data from patients medical records and history.
Results: Total of 1882 patients were treated for the Low
Back Pain, of which 67 (3.56%) had an origin of the pain
in the Thoraco-lumbar Junction. In the analyzed group,
there were 49 (73.1%) man and 18 (26.8%) women. The
largest number of males, 21 (42.8%), were between
40-49 years old, while the largest number of woman, 9
(50%), was 20 to 29 years old. Largest number of male
patients, 35 (71.8%), were physical workers, while most
of the female subjects, 7 (38.8%), were office workers.
Conclusions: Our research concludes that the number of patients with Low Back Pain of the thoracic origin
(3.56%) is not disregarded, but these facts are usually
overlooked. Therapy for those kinds of patients is in most
cases concentrated to the lower segments of the lumbar
spine, which gives unsatisfactory therapeutic results.
2011 University of Sarajevo
Faculty of Health Studies
Keywords: Low Back Pain, Thoraco-lumbar Junction,
Manipulation
* Corresponding author: Sead ebi; Specijalistika
ordinacija ebi, Dr. Pinkasa 2, 72220 Zavidovii, BiH;
Tel: +38732878701; Email: manusead@bih.net.ba
10
Saetak
Uvod: Kod sindroma torakolumbalnog prijelaza bol se
uvijek ispoljava u lumboskralnom prijelazu. Uzrok nastanka je najee nagli torzioni pokret i podizanje tereta u torziji. U takvim sluajevima dolazi do blokiranja
na nivou Th11-Th12-L1 kraljeaka. Ciljevi istraivanja:
utvrditi broj pacijenata sa lumbosakralnim sindromom
iji je uzrok u torakalnim vertebrogenim dinamikim segmentima, u odnosu na ukupan broj pacijenata sa lumbosakralnim sindromom, te strukturu pacijenata po spolu,
dobi i zanimanju.
Metode: U ovom retrospektivnom, deskriptivnom istraivanju analizirali smo sve pacijente koji su lijeeni zbog
lumbosakralnog sindroma torakalnog porijekla u Privatnoj specijalistikoj ordinaciji ebi iz Zavidovia u jednogodinjem periodu. Koristei se medicinskim zapisima
iz protokola bolesnika i istorijom bolesti o svakom pacijentu iz raunara, izvrili smo navedenu analizu.
Rezultati: Ukupno je lijeeno 1882 pacijenta zbog
lumbosakralnog sindroma, od ega 67 (3,56%) je imalo uzrok boli u torakolumbalnom prijelazu. U ispitivanoj
grupi mukaraca je bilo 49 (73,1%), a ena 18 (26,8%).
Najvei broj mukaraca je bilo u dobi 40-49 godina: 21
(42,8%), dok je kod ena najvei broj bio u dobi 20-29
godina: 9 (50%). Kod ispitanika mukog spola najzastupljeniji su bili fiziki radnici: 35 (71,8%), a kod enskog
spola osobe iz administracije: 7 (38,8%).
Zakljuci: Nae israivanje pokazuje da nije zanemarljiv
broj pacijenata sa lumbosakralnom boli torakalnog porijekla (3,56%), ali to se najee previdi. Terapija takvih
pacijenata je uglavnom pogreno usmjerena na nie
segmente lumbalne kraljenice, tako da rezultati lijenja
nisu zadovoljavajui.
2011 Univerzitet u Sarajevu
Fakultet zdravstvenih studija
Kljune rijei: lumboskralna bol, torakolumbalni prijelaz,
manipulacija
Uvod
Kod sindroma torakolumbalnog prijelaza bol se uvijek ispoljava u lumboskralnom prijelazu, a nikada na
mjestu izvorita (1). Uzrok nastanka je najee nagli
SEAD EBI ET AL.: LUMBOSACRAL PAIN CAUSED BY BLOCKAGE OF DYNAMIC VERTEBROGENIC SEGMENTS OF THORACOLUMBAR TRANSITION
torzioni pokret i podizanje tereta u poloaju torzije

trupa, kao to je npr. uzimanje predmeta sa zadnjeg
sjedita automobila i slino (2). U takvim sluajevima
dolazi do preoptereenja na nivou Th11-Th12-L1 kraljeaka gdje fasetni zglobovi mijenjaju svoju orjentaciju (1,2). Ti tranzicijski kraljeci izvrgnuti su velikim
torzionim pritiscima to dovodi do blokade funkcije, a tu su najee i kompresivne frakture (1, 2, 3).
Prednje grane grudnih ivaca su mjeoviti ivci. Dvanaesti (TH12) ivac je nazvan n. subcostalis i ide strmo dolje te ulazi u sklop lumbosakralnog pleksusa.
Lei na musculus quadratus lumborum, retrorenalno, probija unutarnji kosi trbuni mii i zavrava na
piramidalnom miiu. Iz Th11-Th12-L1 segmenata
kraljenine modine odlaze i niti za nervus iliohypogastricus (Th12, L1) i nervus ilioinguinalis (Th12, L1),
koji probijaju dorzalnu aponeurozu na samom rubu
cristae iliacae 7-8 cm. od medijalne linije (processus
spinosus) pa se bolnost javlja na cristi iliaci, nie i lateralno za jednu podlanicu, gdje se nalaze senzibilne
projekcije za L1 segment kraljenine modine (1, 2, 4).
Lumbosakralna bol je stalna, a pojaava se u toku hodanja, sagibanja, vonje automobila unazad, dok kaalj i kihanje ne provocira bol. Objektivan nalaz: pri laterofleksiji
trupa javlja se lumbosakralna bol sa suprotne strane (2),
pozitivan je test nabiranja koe (1, 2, 3) na Th11-Th12L1 segmentu, guranjem procesus spinozusa Th11 i Th12
kraljeka bono izazivamo bol istih kraljeaka (1, 2, 5, ).
Izrazito je bolna trigger taka na cristi iliaci udaljena oko
7-8 cm. od medijalne linije kraljenice (2, 3). Musculus
psoas je rigidan i bolan na palpaciju na strani bola (1, 2,
6), hiperalgetska zona veliine jedne ake je locirana na
cristi iliaci i usmjerena je dole i lateralno (1, 2). Manualnim testovima se diferencira funkcijska blokada Th11Th12-L1 segmenata. Lasegue je negativan, ne evidentira
se neuroloki deficit na donjim ekstremitetima (2, 3).
Od dijagnostikih procedura se koriste: anamneza, fizikalni pregled, Rtg L/S kraljenice sa torakolumbalnim
prijelazom, CT i MRI L/S kraljenice, EMNG donjih ekstremiteta (1, 2, 3). Lijeenje: manualna dekontrakcija i
postizometrika relaksacija musculus psoas-a, a potom
trakcijsko-rotacijska manipulacija funkcijski blokiranih
segmenata Th11-Th12-L1. To daje trenutne rezultate
odmah nakon uraenog tretmana. Nesteroidni antinflamatorni antireumatici (NSA), fizikalne procedure, paravertebralne infiltracije lokalnog anestetika i kortikosteroida ne daju zadovoljavajue rezultate (1, 2, 3, 5, 6, 7).
Ciljevi istraivanja ukljuuju utvrvanje broja pacijenata
sa lumbosakralnim sindromom iji je uzrok u torakalnim
vertebrogenim dinamikim segmentima, u odnosu na
ukupan broj pacijenata sa lumbosakralnim sindromom,
zatim polnu strukturu, starosnu zastupljenost, zastupljenost pacijenata prema godinjim i strukturu pacijenata
sa lumbosakralnim sindromom torakalnog porijekla po
zanimanju u periodu 04.01.2009. 30.12.2009. godine.
Metode
U ovom retrospektivnom, deskriptivnom istraivanju
analizirali smo pacijente koji su lijeeni zbog lumbosakralnog sindroma torakalnog porijekla u Privatnoj specijalistikoj ordinaciji ebi iz Zavidovia u periodu
04.01.2009.-30.12.2009. godine. U tom periodu zbog
lumbosakralne boli je lijeeno ukupno 1882 pacijenta,
a od ega je kod 67 uzrok lumbosakralne boli imalo u
torkolumbalnom prijelazu. Pacijenti su bili iz raznih podruja Bosne i Hercegovine. Koristei se medicinskim
zapisima iz protokola bolesnika i istorijom bolesti o svakom pacijentu iz raunara, izvrili smo analizu pacijenata sa lumbosakralnim sindromom torakalnog porijekla
obzirom na ukupan broj oboljelih od lumbosakralnog
sindroma, na spol, dob, godinje doba i zanimanje. Istraivanje je provedeno u skladu sa etikim standardima.
Kriteriji za ukljuivanje u istraivanje su bili: pacijenti oba spola, pacijenti svih dobnih skupina, verificiran lumbosakralni sindrom torakalnog porijekla.
Kriteriji za iskljuivanje iz istraivanja su bili: pacijenti
koji ne posjeduju niti jednu od radiolokih dijagnostikih procedura, pacijenti koji nisu doli na kontrolni pregled, pacijenti sa destruktivnim oboljenjima kraljenice
(tumori, Tbc, frakture...).
Rezultati
Kao to se vidi iz Slike 1, od ukupnog broja pacijenata (1882) koji su lijeeni zbog lumbosakralnog sindroma, njih 67 (3,56%) je imalo uzrok boli u torakolumbalnom prijelazu, odnosno zbog funkcijske blokade
Th11-Th12-L1 vertebrogenih dinamikih segmenata,
dok pacijenti sa ostalim uzrocima lumbosakralne boli:
1.815 sluajeva (96,44%) nisu predmet ovog istraivanja.
U ispitivanoj grupi mukaraca je bilo 49 (73,13%), a
ena 18 (26,86%, Tabela 1). Najvei broj mukaraca je
bilo u dobi 40-49 godina: 21 (42,85%, Tabela 2), aritmetika sredina X = 42,32, dok je kod ena najvei broj bio
u dobi 20-29 godina: 9 (50%, Tabela 3), aritmetika sredina 2= 29,11. Zanemarljiv broj pacijenata mukog spola je bio u dobi preko 60, a kod enskog spola preko 50
SLIKA 1. Broj pacijenata sa lumbosakralnim sindromom

torakalnog porijekla
11
TABELA 1. Polna struktura pacijenata ukljuenih u istraivanje

Pol
Mukarci
ene
Ukupno
Broj pacijenata
49
18
67
Procenat
73,13
26,88
100
TABELA 2. Broj mukih pacijenata ukljuenih u istraivanje

svrstanih prema starosnoj dobi
Starost
10-19
20-29
30-39
40-49
50-59
60-69
UKUPNO
Broj pacijenata
3
4
12
21
7
2
49
Procenat
6,12%
8,13%
24,48%
42,85%
14,28%
4,08%
100%
TABELA 3. Broj enskih pacijenata ukljuenih u istraivanje

svrstanih prema starosnoj dobi
Starost
10-19
20-29
30-39
40-49
UKUPNO
Broj pacijenata
3
9
3
3
18
Procenat
16,66%
50,00%
16,66%
16,66%
100%
godina. Najvei broj pacijenata sa lumbosakralnom boli

torakalnog porijekla je bilo u ljetnom periodu: mukarci
29 (59,18%), ene 7 (38,88% Slika 2). Najvei broj ispitanika mukog spola su bili fiziki radnici: 35 (71,42%,
Tabela 4), a kod enskog spola su to bile osobe koje se
bave kancelarijskim radom: 7 (38,88%, Tabela 5).
Diskusija
Prema literarnim podacima, lumbosakralna bol je
jedna od najeih bolnih manifestacija. Oko 75-80
SLIKA 2. Broj pacijenata ukljuenih u istraivanje svrstanih

prema pojavi simptoma u svim godinjim dobima
12
% populacije u toku ivota ima iskustvo sa lumbosakralnom boli. Jasno se namee potreba za istraivanjima na tom podruju. Samo visokodiferenciranim
manualnim testovima moemo utvrditi reverzibilne
segmentalne funkcionalne smetnje kraljenice (1, 2,
3), kao to je blokiranje segmenata torakolumbalnog
prijelaza. Kako je u naoj zemlji zanemarljivo mali
broj lijenika educiranih iz oblasti manualne medicine, tako se lumbosakralna bol torakalnog porijekla uglavnom previdi i lijeenje je usmjereno na
lumbalnu regiju, a ne na mjesto uzronih promjena.
Zastupljenost lumbosakralnog sindroma torakalnog
porijekla u odnosu na ostale uzroke istog sindroma
moe iznositi i do 30 % sluajeva. U naem istraivanju iznosi 3,56 %. U istraivanje su ukljueni pacijenti samo sa funkcionalnim blokiranjem torakolumbalnog prijelaza, izizimajui ostale uzroke (1, 3).
Lumbosakralni sindrom se javlja ee u mukaraca (2 : 1) nego u ena (1, 2, 3), dok je u naem istraivanju odnos oko 3 : 1. Znaajnu razliku
objanjavamo time to je studija raena ciljano za torakalni uzrok lumbosakralne boli, dok su ostala istraivanja raena za lumbosakralnu bol svih uzroka.
Prema veini autora, lumbosakralni sindrom se javlja
najee izmeu 30 40. godine ivota (1, 2, 3, 5) , a
prema naim istraivanjima aritmetika (prosjena) starosna sredina za mukarce iznosi 42,32, za ene 29,11,
a sveukupna 35,11 godina. Dakle, rezultati naeg istraivanja ne odudaraju od istraivanja drugih autora.
Nae istraivanje ukazuje na najveu zastupljenost pacijenata sa lumbosakralnom boli torakalnog porijekla
u ljetnom periodu. Vei broj isrtraivanja ukazuje na
najveu zastupljenost lumbosakralne boli kod fizikih radnika (2, 3, 5), a to potvruju i nai rezultati.
Zakljuci
Nae istraivanje pokazuje da nije zanemarljiv broj pacijenata sa lumbosakralnom boli torakalnog porijekla
(3,56 %), a to se najee previdi. Zastupljenost mukaraca u strukturi pacijenata sa lumbalnom boli uzrokovanom blokadom torakolumbalnog prelaza je znaajno
vea od zastupljenosti ispitanika enskog pola. U enskoj populaciji najee obolijevaju ispitanici iz administrativnih zanimanja, a kod mukaraca fiziki radnici.
Zbog neprecizne lokacije dijagnoze kod blokade torakolubalnog prelaza, standardni tretman je najee bezuspjean, jer se obavlja ispod mjesta gdje su locirane
promjene. Kod tretmana torakolumbalnog prelaza, posebnu panju treba posvetiti postavljanju precizne lokacije pri dijagnostici i adekvatnom manuelnom tretmanu.
Sukob interesa
Istraivanje je provedeno u vlastitoj ordinaciji, tako
da istraivanje nije iziskivalo posebno finansiranje.
Literatura
1.
2.
3.
Maigne R, Diagnosis and treatment of

pain of vertebral origin. Taylor & Francis Group, 2006; 60 (383-6, 435-54)
Rychlikova E, Manualni medicina. Praha: Avicenum, 1985; 259-64.
Lewit K, Manuelle Medizin. Heidelberg-Leipzig, 1997; 148-157, 240-259,
472-3.
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Krmpoti Nemani J, Anatomija ovjeka.Zagreb:JUMENA,1982; 327-43.

Grgi V, Manualna medicina.U: Bobinac-Georgievski A, ur. Fizikalna
medicina i rehabilitacija u Hrvatskoj,
Zagreb: Naklada Fran; 2000; 235-76.
Grgi V, Sindrom miia iliopsoasa,
funkcionalni poremeaji; skraenje,
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spazam i slabost strukturno nepromijenjenih miia. Lijeniki vjesnik, 3-4,

Oujak-Travanj 2009.
In: Joseph D Fortin, Thoracolumbar
syndrome in athletes. Pain Physician.2003 Jul;6(3):373-5.
13
www.jhsci.ba
Perioperative blood loss and diclofenac in

major arthroplastic surgery
Ljiljana V. Gvozdenovi1*, Vesna M. Pajti2, Nemanja M. Gvozdenovi2, Saa D. Mili3,
Zoran B. Gojkovi4
Clinic of Anaesthesiology and Intensive Care Medicine, Clinical Center of Vojvodina, Novi Sad, Republic of Serbia
Urgent Center, Clinical Center of Vojvodina, Novi Sad, Republic of Serbia
3
Emergency Medical Service, Health Centre of Inija, Inija
4
Clinic of Orthopaedic surgery and Traumatology, Clinical Center of Vojvodina, Novi Sad, Republic of Serbia
1
2
Abstract
Introduction: Contemporary literature indicates precaution over the perioperative use of non-steroidal anti-inflammatory drugs, since they can potentially increase perioperative blood loss related to their mechanism of action. The aim of
this study was to assess the influence of non-steroidal anti-inflammatory drugs on perioperative blood loss undergoing
hip arthroplasty and its correlation with general and regional anesthesia.
Methods: This prospective study included 120 patients who had undergone elective unilateral total hip arthroplasty.
Patients were allocated into four groups. Groups 1 and 2 were pretreated with diclofenac and operated in general and
regional anesthesia. Group 3 and 4 werent pretreated with any non-steroidal anti-inflammatory drug and were, as well,
operated in general and regional anesthesia. Diclofenac was administered orally two times a day 75 mg (total 150 mg)
and also as intramuscular injection (75 mg) preoperatively and 12 hours later on a day of surgery.
Results: The perioperative blood loss in the first 24 hours showed an increase of 29.4% in the diclofenac group operated in general anesthesia and increase of 26.8% in patients operated in regional anesthesia (P < 0.05) compared to
control group. Statistical data evaluation of patients operated in general anesthesia compared to regional anesthesia,
the overall blood loss in the first 24 h after surgery, showed an increase of 6.4% in the diclofenac group and increase of
3.6% in placebo group. This was not statistically significant.
Conclusion: Pretreatment with non-steroidal anti-inflammatory drugs (diclofenac) before elective unilateral total hip
arthroplasty increases the perioperative blood loss significantly. Early discontinuation of non-selective non-steroidal
anti-inflammatory drugs is advised.
Keywords: perioperative blood loss, non-steroidal anti-inflammatory drugs, hip arthroplasty.
Introduction
The anti-inflammatory, analgesic and antipyretic action
of non-steroidal anti-inflammatory drugs (NSAIDs)
are mediated through inhibition of prostaglandin
synthesis by inhibiting cyclo-oxygenase (COX) (1).
COX is the major enzyme in the biosynthesis of prostanoids. Following the discovery in the early 1990s
of an inducible isoform of COX, it is now known that
COX exists in at least two isoforms: COX-1 and COX2. COX-1 exists in the stomach, intestine, kidneys and
blood platelets. It synthesizes the prostaglandins that
(a) regulate the normal physiological processes involved in protecting the gastrointestinal mucosa and (b)
maintain the renal function and vascular homeostasis
(2). This role of COX-1 has been referred as a 'house* Corresponding author: Academic Ljiljana
Gvozdenovi, PhD., M.D., anaesthesiologyst
Gagarinova 18, Novi Sad, 21000, Republic of Serbia
Tel.: +38163-529-409
e-mail: profgvozdenovic@hotmail.com
Submitted 6 April 2011/ Accepted 11 April 2011
14
keeping' function. In contrast, the inducible isoform

COX-2, after expression induced by several cytokines
or lipopolysaccharide, produces large amounts of prostanoids that mainly contribute to the pathophysiological process of inflammation. The therapeutic effects
of NSAIDs are largely the result of inhibition of the
enzyme COX-2, whereas the toxic effects (disturbing
platelets, the gut and the kidney) are primarily due to
the inhibition of COX-1. This leads to a lack of thromboxane synthesis and impaired platelet aggregation (3).
Diclofenac as non-steroidal anti-inflammatory drug
(NSAID) is used in the preoperative and perioperative
period for alalgesia, for reduction of inflamation and reduction of oedema before major orthopaedic procedures. Beside these benifits, there are some unwanted side
effects: rash, ringing in the ears, headaches, dizziness,
drowsiness, abdominal pain, nausea, diarrhea, constipation, hearthburn. NSAIDs reduce ability of blood to
clot and therfore increase bleeding after an injury (4,5).
NSAIDs are widely used in orthopaedic surgery, and
diclofenac is a very commonly used NSAID in Ortho-
LJILJANA V. GVOZDENOVI ET AL.: PERIOPERATIVE BLOOD LOSS AND DICLOFENAC IN MAJOR ARTHROPLASTIC SURGERY
paedic Clinic in Clinical Centre of Vojvodina. There

is concern over the perioperative use of NSAIDs since they have the potential to increase perioperative
blood loss related to their mechanism of action (6).
We decided to assess the effect of diklofenac
on perioperative blood loss in routine practice in patients undergoing hip arthroplasty by
means of a randomized and controlled study.
Methods
Randomized controlled study was performed in Orthopaedic Clinic, Clinical Centre of Vojvodina in Novi
Sad, Serbia, during 2008. Investigation included 120
patients who were to undergo elective total hip replacement for coxarthrosis during spinal (intrathecal)
and general anaesthesia. Patients were allocated and
randomized to four equal groups of 30 patients. Group 1 and 2 which were pretreated with diclofenac and
operated in general and regional anaesthaesia. Group 3
and 4 which werent pretreated with any analgesic drugs and operated in general and regional anaesthaesia.
Two groups of patients (who were operated in general
and regional anaesthesia) were pretreated before surgery
with diclofenac i.v., on a day before and on a day of surgery. Diclofenac injection were given i.v. three times a
day. Other two control group (who were operated in general and regional anaesthesia) didnt get any analgesic
drug. We used 75 mg of diklofenak-sodium (Diklofen
injection solution 75 mg/3ml Galenika AD, Belgrade).
The exclusion factors were: any patients receiving
NSAIDs, aspirin or anticoagulants before starting
the trial, and any patients with a history of peptic ulcer, renal or liver dysfunction or allergy to any NSAID.
On the day of surgery patients who were operated in
general anaesthaesia, were premedicated with Midazolam. General anaesthesia was performed in each
patient by administering of Propofol, Fentanyl. Rocuronium was used as non-depolarising neuromuscular
blocker. Sevofluran and N2O-oxidul as inhalated anaesthetics is used during general anaesthesia. Patients
were intubated and connected to mechanical ventilation by volume controlled ventilation. Patients are
also monitored by standard anaesthesiology parametres: noninvasive blood pressure, heart rate (from the
electrocardiograph), transcutaneous oxygen saturation,
respiratory rate, EtCO2 and standard respiratory parameters. These standard anaesthesiology parameters
was also observed during first 24 hours of operation.
Ringer saline solution was given intravenously immediatey before starting surgery. A continous infusion
of the same solution was administered during surgery and after surgery. A colloid solution (Haemaccel)
was also given to match the volume of blood lost.
On the day of surgery all patients who were operated
in regional anaesthaesia, were premedicated with MiJOURNAL OF HEALTH SCIENCES 2011; 1 (1)
dazolam 2 mg. Regional anaesthesia was performed

in each patient by administering bupivacaine. Ringer
saline solution was given intravenously immediatey before starting surgery. A continuous infusion of
the same solution was administeted during surgery
and after surgery. A colloid solution (Haemaccel)
was also given to match the volume of blood lost.
Adequate sedation was provided by the patient's request
during the procedure: the anaesthesiologist administered midazolam 2 mg at a minimum interval of 5 min
until the patient indicated that the desited level of sedation had been reached. Noninvasive blood pressure,
heart rate (from the electrocardiograph), transcutaneous oxygen saturation and respitatory rate were
continuously monitored during anaesthesia and in the
intensive care unit during the first 24 h after surgery.
Perioperative blood loss
All operations were performed by the same orthopaedic
surgeons team. Prophylaxis against thromboembolism
was started in all patients on the evening before surgery
with Fraxiparin 0.3 mg s.c. (protocol in our country).
On the day of surgery, fraxiparin 0.3 mg s.c was given 24 h after the initial dose. Nurses in the operating room measured perioperative blood loss. Total blood loss was calculated by taking into account
the amount in the suction bottles, the weight of
the surgical sponges and the irrigation fluid used.
The volume of blood collected in the high-vacuum wound drainage containers was measured for
24 h after surgery. The transfusion trigger for homologous packed cells was a haemoglobin concentration <8 g/L in the whole postoperative period.
Statistical analysis
The t-test tested for differences between the groups.
p<0.05 was considered as significant.
Results
Patient characteristics data are given in Table I. The
two groups did not differ for age, height, weight or
gender. Likewise other variables, e.g. preoperative
use of -adrenoceptor receptor blocking drugs, patients who received sedation during surgery, the use
of cement and a decline in blood pressure (>25% decrease in mean arterial pressure after cementation),
showed no differences between groups. There was no
difference in the duration of surgery in either group.
Perioperative blood loss
The volume of blood loss was significantly higher in
patients pretreated with diclofenac than with placebo. The volume of blood loss was higher in patient operated in general anaesthaesia in both groups, but the blood loss wasnt statistically significant.
15
TABLE 1. Patients characteristic data

Group
Number of patients
Gender (m/f)
Age (yr)
Heigh (cm)
Weight (kg)
Duration of surgery (min)
Group 1:
Diclofenac group (in
general anaesthesia)
30
8/12
56
174
84
112
Group 2:
regional anaesthesia)
30
9/14
59
168
82
107
Group 3:
Placebo group (in general
anaesthesia)
30
8/11
61
175
79
123
Group 4:
Placebo group (in
30
10/14
58
170
79
116
asured perioperative blood loss and blood loss during first 24 h showed not statistically different.
The study had an 86% power to demonstrate a 45%
difference in expected blood loss at a P=0.05 level of
significance. The number of homologous blood transfusions was nineteen in the diclofenac group and
sixteen in the placebo group (not significant) during
the whole period the patients remained in the hospital.
FIGURE 1. Total blood loss in Diclofenac and placebo groups
The volume of perioperative blood loss was 47.1%

greater in the diclofenac group in general anaethesia
and 56% greater in patients operated in regional anaesthesia compared with the placebo groups (P<0.05).
The measured blood loss in the first 24 h after surgery
also showed a 19.7% higher blood loss in the diclofenac
group in general anaethesia and 11,4% higher in patients operated in regional anaesthesia compared with
the placebo groups. This was not statistically different.
The overall blood loss, i.e. the perioperative blood loss
plus the blood loss in the first 24 h after surgery, showed
an increase of 34.8% in the diclofenac group operated
in general anaethesia and increase of 32.9% in patients
operated in regional anaesthesia (P<0.05) (Table 2).
The overall blood loss, i.e. the perioperative blood
loss plus the blood loss in the first 24 h after surgery,
in general anaesthesia compared to regional anaesthesia showed an increase of 5,2% in the diclofenac group and increase of 3.6% placebo group. This
was not statistically significant (Figure I). Also me-
Discussion
The main finding is that pretreatment with diclofenac
before total hip replacement surgery was associated with
an increase in blood loss both during operation and for
the first 24 h afterwards, in regional and in general anaesthaesia. Blood loss in regional anaesthaesia compared
with general anaesthaesia is less but not statisticlly significant. Besides the useful anti-inflammatory, analgesic
and antipyretic action of the NSAIDs, the study demonstrated an undesirable effect, namely increased blood loss.
Researchers from the Case Western Reserve University School of Dental Medicine also recommend the
discontinuation of NSAIDs prior to surgery to correct
gum disease because blood loss is two times greater for
those using the NSAIDs than those not taking it (7).
Study which compared diclofenac and melocsicam
also showed that perioperative blood loss patients pretreated with diclofenac is significant and patient pretreated with meloxicam is less than after diclofenac (8).
A. Schmidt et al. concluded that preoperative rectal
diclofenac offers no advantage over paracetamol with
respect to postoperative analgesia in tonsillectomy
patients but increases intraoperative blood loss (9).
R. Slappendel et al. from St. Maartenskliniek in
Netherlands in their investigation finds that pretre-
TABLE 2. Blood loss during and after operation

Group
Blood loss during surgery (ml)
Blood loss 24 h after surgery (ml)
Total blood loss (ml)
16
Group I
665
431
1096
Group II
646
412
1042
Group III
Placebo group (in
452
360
812
Group IV
Placebo group (in
414
370
784
atment with ibuprofen before elective total hip surgery increases the perioperative blood loss significantly and that early discontinuation of non-selective
non-steroidal anti-inflammatory drugs is advised (10).
It has been suggested that NSAIDs that selectively inhibit COX-2 have fewer side-effects (11,12). The relationship berween platelet aggregation, thromboxane production and serum concentrations of the non-COX-2
selective drug as diclofenac has been examined (13). A
single dose of diclofenac-sodium (75 mg) blocked platelet aggregation 2h after administration (13, 14). However, the effect was lost within 24 h. After diclofenac, had
been given to healthy volunteers, platelet aggregation
was inhibited for 6, 8 and 11 h, respectively. In the light of the half-life of diclofenac, these data suggest that
diclofenac should be stopped 24 h before surgery (15,19).
Although we tried to reduce as much possible the confounding factors in the study (one type of surgery performed one orthopaedic surgeon team), the use of fraxiparin for prophylaxis against thromboembolism could
affect the outcome of the study. Diclofenac, but not the
placebo, increases the prothrombin time (16,18). Other
weaknesses of the study are the technique of measuring
blood loss and the relatively high dropout rate. The study
was probably not powerful enough to show whether an
increase in blood loss resulted in an increased transfusion requirement or perioperative morbidity or mortality.
These are much more important outcome measures for
the patient compared with the actual measured blood
loss. However, they are much more difficult to measure
and therefore were not primary end-points of the study.
It is concluded that ceasing NSAIDs sufficiently long
before major orthopaedic surgery reduces perioperative
blood loss (17). NSAIDs should be replaced before surgery with other analgesics, e.g. paracetamol, or possibly
COX-2 selective anti-inflammatory agents, which have a
better safety profile concerning peroperative blood loss.
The study had an 86% power to demonstrate a 45%
difference in expected blood loss at a P=0.05 level of
significance. The number of homologous blood transfusions was nineteen in the diclofenac group and
sixteen in the placebo group (not significant) during
the whole period the patients remained in the hospital.
Conclussion
Pretreatment with diclofenac before major hip
surgery either general or regional anaesthesia significantly increases blood loss. Considering the
presence of relevant adverse effects, pretreatment
with a non-selective NSAID is not recommended.
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Schafer A. Effects of nonsreroidal antiinflammarory drugs on platelet function and systemic hemostasis. Clin.
Pharmarol 1995; 35: 209-219.
Wuolijoki E, Oikarinen VJ, Ylipaavalniemi P, Hampf G, Tolvanen M. Effective postoperative pain control by preoperative injection of diclofenac. Eur J
Clin Pharm 1987; 32: 24952.
Roraris M, Miralles J, Baer GA. Diclofenac vs Indomethacin given as IV infusion their effect on hemodynamics
and beeding time. Annals of Clin Research 1985;17:308-9.
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M. COX 2 selectivity of non-steroidal
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Anaesthesiol. 2003 Dec;20(12):963-6
Schmidt A, Bjrkman S, keson J.
Preoperative rectal diclofenac versus
paracetamol for tonsillectomy: effects
on pain and blood loss Acta Anaesthesiologica Scandinavica, Volume 45,
Number 1, January 2001 , pp. 48-52(5)
R. Slappendel, E. W. G. Weber, B.
Benraad, R. Dirksen and M. L. T.
Bugter Does ibuprofen increase perioperative blood loss during hip arthroplasty? European Journal of Anaesthesiology (2002), 19:11:829-831
Cryer B, Feldman M. Cyclooxygenase-1 and cyclooxygenase-2 selectivity
of widely used nonsreroidal anriinflammarory drugs. Am J Med 1998;
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Green GA. "Understanding NSAIDs:
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Cox SR, VanderLugt JT, Gumbleton
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Merritt JC, Bhatt DL. The efficacy and
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Patrono C, Coller B, Dalen JE et al.
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Pope JE. Hypertension, nonsteroidal
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Fitzgerald D, Hjemdahl P. Dose- and time-dependent antiplatelet effects of aspirin. Thromb Haemost 2006;95:652-8
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17
www.jhsci.ba
A retrospective study of surgical treatment of

spinal injuries with rehabilitation program
Retrospektivna studija hirurkog tretmana povreda
kimenog stuba sa programom rehabilitacije
Dijana Avdi*, Amila Jaganjac, Bakir Katana, Samir Bojii
Faculty of Health Studies, Bolnika 25, 71 000 Sarajevo, Bosnia & Herzegovina
Abstract
Saetak
Introduction: Traumatic injuries of the spinal column are

among the most devastating injuries in orthopedics. The
primary goals of rehabilitation of these injuries are prevention of secondary complications, maximizing physical
functioning and reintegration into the community. Rehabilitation after spinal injury reqires multidisciplinary team
approach. Team members include, but are not limited to,
physical therapists, occupational therapists, nurses, psychologists, health care managers and social workers, with
each member having role and responsibility in their area
of expertise. This study aimed to determine the difference
in the occurrence of spinal injuries according to gender,
age, cause of injury, neurological phenomenon in injured
patients, the treatment and physical procedures used in
the early stages of rehabilitation.
Methods: The study was conducted as a retrospective
and comparative at the Department of Orthopedics and
Traumatology of Clinical Center University of Sarajevo.
Medical records of 100 patients, treated at from January 1st 2007 till June 30th 2008, were processed and data
about outpatient protocols and surgery protocols analyzed.
Results: The results obtained from the data showed
greater proportion of women (56%) compared to men
(44%). Most patients were in the age group between 41
and 60. Injuries were most often due to falls from height
and make 32%, fall from a tree 25%, traffic accidents
12% (=17.94, p=0.0061). 88% of patients were without
neurologic events, while the neurological disturbances
occurred 12% (=3.397, p=0.3343). 56% of patients with
spinal injuries were treated surgically, while 41% were
treated conservatively (=7.264, p= 0.00153). 73% patient had physical therapy program of early rehabilitation
exercises, with at least at least only a massage in 4% of
patients ( = 6.573, p = 0.04270).
Conclusion: The adoption of national protocols is necessary for future treatment of patients with spinal fractures.
Keywords: spinal injuries, rehabilitation, physical therapy.
Uvod: Traumatske povrede kimenog stuba spadaju

meu nejvie razarajue povrede u ortopediji. Primarni
ciljevi rehabilitacije ovih povreda su prevencija sekundarnih komplikacija, maksimiziranje fizikih funkcija i
reintegracija u zajednicu. Rehabilitacija nakon povrede
kime zahtjeva multidisciplinarni timski pristup. U lanove tima ukljueni su fizioterapeut, radni terapeut, medicinske sestre, psiholog, zdravstveni menader i socijalni
radnik, svaki sa svojom ulogom i odgovornou u svojoj
oblasti strunosti. Ova studija ima za cilj utvrditi razlike u
pojavi povreda kimenog stuba prema spolu, starosnoj
dobi, uzroku povrede, pojavi neurolokih ispada, nainu
lijeenja i koritenih fizikalnih procedura u ranoj fazi rehabilitacije.
Metode: Istraivanje je provedeno kao retrospektivno i
komparativno na Klinici za ortopediju i traumatologiju
KCU Sarajevo. Historije bolesti 100 bolesnika, tretiranih
od 01.01.2007. do 30.06.2008. su obraeni i podaci o ambulantnim i hirurkim protokolima analizirani.
Rezultati: Rezultati su pokazali vei udio ena (56%) u
odnosu na mukarce (44%). Veina pacijenata je bilo u
starosnoj grupi izmeu 41 i 60 godina. Najee uzrok
povreda je bio pad sa visine (32%), pad sa drveta (25%),
saobraajna nezgoda (12%) (=17,94, p=0,0061). 88%
pacijenata je bilo bez neurolokih ispada, dok je 12%
imalo takve poremeaje (=3,397, p=0,3343). 56% pacijenata sa povredom kime je tretirano hirurki, dok je
41% tretirano konzervativno (=7,264, p= 0,00153). Od
koritenih procedura fizikalne terapije u programu rane
rehabilitacije su bile vjebe 73 %, a najmanje samo masaa kod 4 % pacijenata (= 6,573, p= 0,04270).
Zakljuak: Usvajanje Nacionalnog protokola pruanja
pomoi osobama sa prelomom kime potrebno je za adekvatan tretman ovih pacijenata.
* Corresponding author: Prof. Dijana Avdi, MD, PhD; Faculty

of Health Studies, University of Sarajevo, Bolnika 25, 71000
Sarajevo, Bosnia & Herzegovina; Phone: +387 33 444 901;
Fax: +387 33 264 821; e-mail: dijana2007@gmail.com
Introduction
OboInjuries of the spinal column can occur in different ways. Usually occur as a result of falls from a
height or traffic accidents. The treatment of these injuries, particularly the fractures of the vertebrae, is usu-
Submitted 17 February 2011/ Accepted 13 March 2011
18
Kljune rijei: spinalne povrede, rehabilitacija, fizikalna

terapija
DIJANA AVDI ET AL.: A RETROSPECTIVE STUDY OF SURGICAL TREATMENT OF SPINAL INJURIES WITH REHABILITATION PROGRAM
ally surgical. Different types of long and short stabilization is used and the installation of various fixations.
Rehabilitation after such injuries is a long process (1).
The incidence of spinal cord injury with spinal injuries is ranging from 5 to 55 million people each year,
depending on the country's industrial development,
transportation development, cultural habits etc. The
highest incidence is in the age group of 40 to 50. The
ratio men to women is 4:1. The largest number of injuries is in the level C1-C2, C4-C6 to Th11 - L1, 2. These
are not just the most mobile spine parts, but also regions in which cervical and lumbar spinal cord intensely
reduces the space between nerve and bone structure.
It is believed that the following factors cause damage
to the spinal cord by blunt injury: compression and
"imprints" (bones, ligaments, hematoma, disc protrusion), over-stretching of the contact pressure and
spinal cord injuries, traumatic edema, disruption of
arterial and venous circulation, hemorrhage etc. Penetrant spinal cord injury with or without damage of
the spinal column, arise from objects penetrating into
the spinal cord, such as sharps, blades, missiles etc.
Mechanical forces affects on the spinal column in the
form of compression, extension, torsion and sliding
disintegration "(translation). These forces cause the
proper tension, deformation and migration of certain
elements of spine: vertebral body, intervertebral discs, posterolateral joints and ligaments. Similar effects
on these structures have forced movements of the spinal column such as flexion, extension, lateral bending
and axial rotation. The effect of these mechanisms
of injury depends on the anatomical structure: occipito-atlanto epistropheus complex is anatomically
different from "the lower cervical spine (C3 - C7).
Surgery may be indicated after attempt of closed reduction still persist "stuck" articular socket, compression of the spinal cord and spinal
nerves. In the case of articular fractures and arch
extensions immediately undertake operative reduction.
Depending on the neurological deficits and associated injuries, the patient is allowed to get out of
bed in the next postoperative day. In severe cases,
requires a longer period of immobilization (2). In
the thoracic spine flexion - compression fractures
(wedge compression) were followed normal neurological findings or incomplete lesion medullae spinalis. Axial - compression fractures (burst), sagittal
- broken fracture and anterior dislocation are accompanied by complete lesion of spinal cord injury (3).
Minimal subluxation and small bending - compression
fracture of thoracic spine are treated conservatively, casting (with the help of prosthetic device) in hyperextension of the thoracic spine during the 3 to 4 months.
In other cases, these injuries are treated with internal
fixation and operational fusion. Treatment of patients
with fractures of the thoracolumbar and lumbar spine

without neurological deficit contains lying in bed. If a
neurological deficit more is pronounced, in the treatment of external immobilization (in hyperextension)
orthopedic tools. If many signs of posterior ligament
rupture occur, last fusion and fixation is performed (4).
Physical therapy of patients after injury of the spinal
column is divided into: early postoperative inpatient
therapy and late continuing physical therapy. Early
physical therapy is done in order to prevent post
injury - post-operative complications (thrombosis and
thromboembolism, pneumonia, prepares muscles for
walking with crutches and the rapid re-socialization).
Prerequisites are operated on a patient - the stabilization of the fracture was made, the funds are protected with anticoagulant and catheterized with paper diapers, eliminated primary postoperative pain.
Physical Therapy in the program includes: breathing
exercises, active and passive exercises, massage, electro,
etc. (5-7). At a later stage (3 weeks) begins the process of
mobilization of the patient (sitting and rising). Getting up
and walking is performed using the additions to stabilize the patient in the form of chest corset (different types)
and crutches or walkers and with neurologic defects necessary to provide and orthotics for the lower extremities.
After the expiration of a period of 3 weeks of stay in
surgical facility the patient was transferred to the Institute of Physical Therapy, where rehabilitation is done
in a period of 4-6 weeks or longer, if it is verified neurological impairments. Due to specific spine fractures a patient is required to perform independently in
a home program taught therapeutic procedure. Later, organized intensive physical therapy begins upon
expiration of the primary period of fracture healing.
It is necessary that from the date of injury (stabilization) passes a period of three months (10 - 12 weeks).
If the process is organized, the patient is capable of
independent physical therapy in which places special emphasis on strengthening segment of paravertebral muscle. Paravertebral muscle strength is one
of the prerequisites for the successful healing of creation and the reduction of residual spine gibus and
compression of the spinal canal and paravertebral
important structures, especially radicular nerve (8).
This study aimed to determine the difference in
the occurrence of spinal injuries according to gender, age, cause of injury, neurological phenomenon
in injured patients, the treatment and physical procedures used in the early stages of rehabilitation.
The working hypothesis suggests that there is a statistically significant difference in the use of certain procedures of physical therapy at an early stage of rehabilitation of patients with injury of the spinal column.
Null hypothesis indicates that there is no statistically
19
TABLE 2. Cause of injury

Cause
Men
Transport accidents
The fall from the tree
Fall from height
Other (ladders, tumor
metastasis, osteoporosis)
Total
7
12
21
5
13
17
12
25
38
10
15
25
50
50
100
= 17.94
FIGURE 1. The gender distribution of patients
= 0.10
p= 0.9198
significant difference in the use of certain procedures of physical therapy at an early stage of rehabilitation of patients with injury to the spinal column.
Methods
The study was conducted as a retrospective and comparative to the department of Orthopedics and Traumatology at the Clinical Center University of Sarajevo. Hundred of patients treated at this clinic from January 1st 2007
till June 30th 2008 were processed inquiring the medical
records of outpatient protocols and surgery protocols.
During statistical analysis, the level of significance was
determined by - test, and correlation was analyzed
using Pearson's correlation coefficient. The level of significance was defined as p <0.05. Average age of patients was calculated by the arithmetic mean and the age
structure is determined by the standard deviation and
median. The results are presented in tables and graphs.
Results
There were accounted 44% of male and 56% of female
patients, as can be seen from the tables and graphics.
The average age of our patients was 50.4, with
the youngest patient age 18 and the oldest 80 years old. Most patients were in the age group of
41-60, at least in the age group of 61-70 years old.
Women
Total
p= 0.0061
Most often injuries 38%, were due to falls from a

height, falling from a tree was the cause of injuries in 25% of cases of aught other causes involved
made, while traffic accidents accounted for 12%.
TABLE 3. The occurrence of neurologic events in patients with
spinal injury
Neurological impairments
Without neurological impairments
Paresis
Paraplegia (paralysis)
Total
= 3.397
Men
Women
Total
41
1
2
44
47
4
5
56
88
5
7
100
p= 0.3343
Without neurologic impairments were 88% of patients,

while the neurological disturbances were 12% of patients.
TABLE 4. Method of treatment of spinal fractures
Type of treatment
Number of patients
Percent
56
41
1
2
100
56
41
1
2
100
Operational
Conservative
Refuses hospitalization
Deaths
Total
= 7.264
p= 0.00153
TABLE 1. Age distribution of patients with fractures of spine

Age of patients
18 30 years old
31 40
41 50
51 60
61 70
71 and more
TOTAL
= 6.687
20
p= 0.8238
Male
Number
11
9
7
9
2
6
44
%
11
9
7
9
2
6
44
Female
Total
Number % Number %
7
7 18
18
8
8 17
17
7
7 14
14
20
20 29
29
4
4
6
6
10
10 16
16
56
56 100
100
TABLE 5. Physical therapy methods used in early rehabilitation

Type of physical therapy
Passive and active exercises
Massage
Massage + passive exercise
Massage + active exercise
Electro stimulation
Total
= 6.573
Number of
patients
73
4
10
7
6
100
Percent
73
4
10
7
6
100
p= 0.04270
Most patients with spinal injuries were treated surgically,

56% of them and 42% of patients treated with conservative measures.
As can be seen from the table, the most used procedures of physical therapy in early rehabilitation exercises
73%, and the only massage in case of 4% of patients. In
case of all patients breathing exercises were performed.
Discussion
In the period from January 2007 until June 2008, at
the Clinic of Orthopedics and Traumatology there were 3600 bone fractures, of which 270 fractures of the spinal column. This survey included patients older than 18 and those with pathological
fractures. Based on these data we can conclude that
spine fractures represent 3.6% of total fractures.
Of the total registered 100 cases of spine fractures in patients older than 18 years, who are selected randomly,
44% of fractures refer to men, while 56% of fractures refer to women. Injury of the spine mainly occurs in case
of middle aged and elderly people. The highest incidence of injuries on the subject of men is ranging from 40
to 70 and for women aged 30 to 70. Our results are similar for men and women, so the most common injuries
occur in the age between 40 and 45. Based on these data
we can conclude that injuries arise at the time of greatest
creativity in life of each individual. Injuries of the spinal
column are very complicated and beside health damages,
those injuries lead to frequent absenteeism and jeopardizing social - economic opportunity for the injured.
Certainly, the most difficult consequence of spinal
injury is a disability which leads to the psychological trauma of patients and their families, as well
as society as a whole. This is particularly true for
paraplegics, who need 24 - hour medical care (9).
With thoracolumbar fractures and lumbar spine there is no correlation between neurological deficit and
recovery pattern with the extent of canal compromise.
Like other bones, vertebral fractures are also undergoing significant remodeling, so that the size and shape of
the spinal canal improves with time. However, this remodeling has no impact on neurological recovery (10).
Regarding the presence of fractures due to seasons, we
can see that the most common fractures appear in the

period of spring and winter. This phenomenon can be
explained by the beginning of intensive agriculture
and construction, as well as falls on the ice in winter.
It is important to note that the seemingly simple falls at
home (especially the female population) result in fractures of the spine. In addition to these, a common cause of spinal fractures of women is osteoporosis, which
usually affects young and middle-aged women (11).
The most common cause of injury is fall from height
(especially tree fall) during the summer period, then
after followed by traffic accidents, something more
commonly men involved. Very often the injury occurs
as a result of tumor metastases in the vertebral column,
which secondarily damages the vertebral and spinal cord.
According to data from English authors we can find the
following:
The ratio of injured men compared to women is 4:1,
while in our country this ratio is approximately 1: 1.6.
According to their data the most affected are men
between 25 and 60 and women aged 60 and more. Our
results are similar for men and women, so the most
frequent injuries occur in the age between 40 and 45.
Differences also exist in the nature of injury. According to English author most common cause of injury
of males are traffic accidents, while in case of women injury was result of osteoporosis bone fractures.
A large number of fractures are treated surgically,
which is also the case with the treatment of our patients. According to English author, conservative
treatment causes a high percentage of deformities
of flexional type: further increase in vertebral body
compression in 40% of cases, gibbous in 23%, scoliosis in 23% and spondylotic changes in 46% of cases. Also, they found that the relationship between
the spine and symptoms statistically significant (12).
Conclusion
Based on the foregoing, we conclude that one of the
necessary things for the future treatment of these patients is the adoption of national protocols to assist
people with spinal fractures. It is necessary to educate a certain number of qualified personnel and provide funds for the purchase of necessary equipment.
References
1.
2.
3.
Dietz V, Harkema SJ. Locomotor activity in spinal cord-injured persons. J

Appl Physiol. 2004;96(5):1954-60.
Barker E, Saulino MF. First-ever guidelines for spinal cord injuries. RN.
2002;65(10):32-7.
McDonald JW, Sadowsky C. Spinalcord injury. Lancet. 2002;359(9304):
4.
5.
417-25.
McKinley WO, Gittler MS, Kirshblum
SC, et al. Spinal cord injury medicine.
2. Medical complications after spinal
cord injury: Identification and management. Arch Phys Med Rehabil.
2002;83(3 Suppl 1):S58-64, S90-8.
Cosortium for Spinal Cord Medicine.
6.
Respiratory management following

spinal cord injury: a clinical practice
guideline for health-care professionals.
J Spinal Cord Med. 2005;28(3):259-93.
Sheffler LR, Chae J. Neuromuscular
electrical stimulation in neurorehabilitation. Muscle Nerve. 2007;35(5):56290.
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Thrasher TA, Popovic MR. Functional

electrical stimulation of walking: function, exercise and rehabilitation. Ann
Readapt Med Phys. 2008;51(6):452-60.
Dietz V, Harkema SJ. Locomotor activity in spinal cord-injured persons. J
Appl Physiol. 2004;96(5):1954-60.
Kirshblum S. New rehabilitation interventions in spinal cord injury. J Spinal
Cord Med. 2004;27(4):342-50.

10. Mohanty SP, Venkatram N. Does neurological recovery in thoracolumbar
and lumbar burst fractures depend
on the extent of canal compromise?
2002;40 (6):295-299
11. Leung Y, Samartzis D, Cheung KM,
Luk KD. Osteoporotic vertebral compression fracture: the clinical im-
pact of "intravertebral clefts".Spine J.

2010;10(11):1035-6.
12. Dickson R.A. et al. Hospital Episode
Statistics. Department of Health, England, 2004-2005.
www.jhsci.ba
Prisustvo riziko faktora za diabetes mellitus tip

2 kod pacijenata u praksi obiteljske medicine
The presence of risk factors for diabetes mellitus type 2
in patients of family practice medicine
Fatima Jusupovi*, Dijana Avdi, Jasmina Mahmutovi, Aida Rudi, Arzija Paali,
Suada Brankovi, Almedina Beri, Amra Maak-Hadiomerovi
Faculty of Health Studies, University of Sarajevo, Bolnika 25, 71 000 Sarajevo, Bosnia and Herzegovina
Abstract
Saetak
Introduction: Diabetes mellitus (DM) type 2 is a heterogeneous disorder of complex etiology that occurs in
response to genetic influences and impacts of the external environment. There are numerous risk factors that
contribute to the development of type 2 diabetes such
as: heritage, overabundant food and as a consequence
of obesity in animals, physical inactivity, the presence of
hypertension, psychogenic stress and many others. The
aim of this study is to analyze and determine the existence of risk factors for type 2 diabetes in patients of all
ages and both sexes treated in the general practice of
the Health Centres for municipality Ilidza.
Methods: The research is cross-sectional study, which
is carried out in February 2010 in the general practice
of the Health Centres for municipality Ilida. Research
instrument was a questionnaire and anthropometric
measurements.
Results: The results show us that in our sample 62% of
patients had increased body mass index 25% of male
respondents and 48% of females has waist I and II risks,
both sexes are fairly large percentage (40%) inactive, a
large percentage of respondents (52%) taking antihypertensive medications, 21% of respondents have a genetic
predisposition of developing diabetes.
Conclusions: There is a risk of developing type 2 diabetes in a large percentage of patients. Risk factors, important for the development of type 2 diabetes, were present
at more than half of examinees and promotion of health
and healthy lifestyles is necessary in all age groups.
Uvod: Diabetes mellitus (DM) tip 2 je heterogeni poremeaj kompleksne etiologije koji se javlja kao odgovor
na genetske uticaje i uticaje spoljanje sredine. Brojni su
riziko faktori koji doprinose nastanku diabetes mellitus tip
2 kao to su: nasljee, preobilna ishrana te kao posljedica takve ishrane gojaznost, tjelesna neaktivnost, prisustvo hipertenzije, psihogeni stres i mnogi drugi. Cilj rada
je analizirati i utvrditi postojanje faktora rizika za nastanak dijabetesa tip 2 kod pacijenata svih dobnih skupina,
oba pola, lijeenih u slubi Opte prakse Doma zdravlja
Ilida.
Metode: Istraivanje je presjena studija, provedena u
februaru mjesecu 2010. godine na podruju optine Ilida, u Domu zdravlja Ilida. Instrument istraivanja su anketni upitnik i antropometrijska mjerenja.
Rezultati: Rezultati nas upozoravaju da u naem uzorku
62% ispitanika ima povean indeks tjelesne mase, 25%
ispitanika mukog pola i 48% ispitanika enskog pola
ima obim struka I i II rizika, oba pola su u prilino velikom procentu (40%) neaktivna, veliki procenat ispitanika
(52%) uzima antihipertenzivne lijekove, 21% ispitanika
ima genetsku predispoziciju da oboli od dijabetesa.
Zakljuci: Veoma je znaajno istai da je rizik za razvoj
dijabetesa tip 2 prisutan u velikom procentu ispitivanih
pacijenata, te je stoga neophodna promocija zdravlja i
zdravih stilova ivota u svim starosnim grupama.
Fakultet zdravstvenih studija.
Keywords: risk factors, diabetes mellitus
Kljune rijei: riziko faktori, diabetes mellitus
Uvod
Diabetes mellitus tip 2, ranije nazivan insulin nezavisni diabetes mellitus (NIDDM), predstavlja najuestaliji
oblik diabetes mellitusa u svijetu (1, 2). Tip 2 diabetes
mellitusa nastaje kada je stvaranje insulina nedovoljno

da prevazie vodee postojee patofizioloko stanje insulinsku rezistenciju. Rani stadijum diabetes mellitusa
tipa 2 oznaen je poveanim stvaranjem i izluivanjem
insulina; kako bolest napreduje, stvaranje insulina od
strane beta elija pankreasa se smanjuje. Ogromno, stalno poveanje ekonomskih i medicinskih trokova za
diabetes mellitus tip 2 trai pravovremenu prevenciju
ovog oboljenja i energino lijeenje ve postojee bolesti.
* Corresponding author: Fatima Jusupovi; Faculty of Health

Studies, University of Sarajevo; Bolnika 25, 71 000 Sarajevo,
Bosnia and Herzegovina; Phone: 00 387 33 444 901;
Fax: 00 387 33 264 821; e-mail: fatimajusupovic@yahoo.com
23
FATIMA JUSUPOVI ET AL.: THE PRESENCE OF RISK FACTORS FOR DIABETES MELLITUS TYPE 2 IN PATIENTS OF FAMILY PRACTICE MEDICINE
Diabetes mellitus tip 2 je izrazito preventabilna bolest

(3). U svijetu rast broja oboljelih poprima pandemijske
razmjere. U zemljama u razvoju prevalencija diabetes
mellitusa e se, prema predvianjima WHO, poveati vie od 2,5 puta, sa 84 miliona 1995. godine na 228
miliona u 2025. godini (4). Prema podacima DECODE
studije i Toumilheta (5) od 15 do 20% odraslih Evropljana se lijei od tipa 2 diabetes mellitusa. Procjene ove
studije su da jo 20% odraslih Evropljana ima ovo oboljenje, ali je u ovih osoba diabetes mellitus tip 2 nedijagnostikovan (6). U FBiH raste broj oboljelih od diabetes
mellitusa. Godinja stopa morbiditeta je iznosila na 10
000 stanovnika 149 u 1999., te 157 u 2004. godini. Prevalenca se kretala od 1.6 do 1.8% u 2004. godini i ima
tendenciju porasta. U mortalitetu se biljei porast broja
umrlih od dijabetesa, opa stopa mortaliteta porasla je
od 16 u 1999. godini, na 34 u 2003. godini na 100 000
stanovnika (7). Brojni su riziko faktori koji doprinose
nastanku dijabetesa tip 2, kao: genetski faktori (na koje
ne moemo uticati), preobilna ishrana, a kao posljedica
takve ishrane veoma esto gojaznost, tjelesna neaktivnost, psihogeni stres, hipertenzija i mnogi drugi. Genetski faktori imaju mnogo vaniju ulogu u nastanku tip
2 dijabetesa te se smatra da 25% cjelokupne populacije
u svijetu posjeduju neki genetski defekt za diabetes (8).
Gojaznost je znaajan riziko faktor u nastanku dijabetesa tipa 2. Ocjenjivanje stanja uhranjenosti se vri
osim ostalih metoda i mjerenjem indeksa tjelesne
mase (ITM). Normalno uhranjene osobe imaju ITM
18.5 24.9. Vrijednosti ITM >30 oznaavaju pojavu gojaznosti (9). U zadnje vrijeme sve se vie znaaj
daje odnosu obima struka (OS) i obima bokova (OB),
za koji neki autori smatraju da je vei faktor rizika od
ITM. Rizik prvog stepena za obim struka izraen u cm
kod ena su vrijednosti 88, a kod mukaraca 94, dok
rizik II stepena predstavljaju vrijednosti obima struka
u cm, 92 za ene, odnosno 102 kod mukaraca (10).
Udruenost gojaznosti, naroito centralne gojaznosti, i nastanka diabetes mellitusa tip 2 je potvrena
(11). Nepovoljan, centralni raspored tjelesne masti udruen je sa insulinskom rezistencijom (11).
Tjelesna neaktivnost ili smanjena tjelesna aktivnost, kao
rezultat sedentarnog naina ivota, dovode do smanjenja potronje energije. Poveana fizika aktivnost meutim, izaziva koristan efekat na lipidni metabolizam,
a njegovim poboljanjem dolazi do gubitka tjelesne
mase. Na taj nain se podrava mehanizam koji dokazuje da poveana tjelesna aktivnost moe imati utjecaj
na prevenciju razvoja dijabetesa (12). WHO naglaava
da je brojnim naunim istraivanjima dokazano da nekretanje, odnosno nedovoljna tjelesna aktivnost, utie
na pojavu dijabetesa, bolesti srca i krvnih sudova, na
gojaznost i svih negativnih posljedica gojaznosti (13).
Fizika neaktivnost uzrokuje najmanje 22% ishemijskih bolesti srca, 16% karcinoma kolona, 14% dijabete24
sa, 11% sranih udara, te se procjenjuje da bi uspjena

promocija fizike aktivnosti, bolji ivotni stil, prevenirali 2 miliona preranih smrti, godinje u svijetu (14 ).
Neki dogaaj u porodici ili blioj rodbini, na radnom
mjestu ili u intimnom ivotu ljudi, mogu izazvati stanje produene neizvjesnosti, zabrinutosti i straha, koji,
kao i hronini psihogeni stres, predstavlja dugotrajni podraaj na poveano lunje stresnih hormona
koji imaju metabolike efekte suprotne inzulinu (8).
Cilj rada je analizirati i utvrditi postojanje faktora rizika za nastanak dijabetesa tip 2 kod pacijenata svih dobnih skupina, oba pola, lijeenih u slubi Opte prakse Doma zdravlja Ilida.
Metode
Istraivanje
je
presjena
studija,
provedena u februaru mjesecu 2010. godine na podruju optine Ilida, u Domu zdravlja Ilida.
Kriterij za ukljuivanje u istraivanje su pacijenti koji ostvaruju pravo na zdravstvenu zatitu u
ovom Domu zdravlja, a obuhvaeno je 100 ispitanika, izabranih metodom sluajnog uzorka.
Metode istraivanja su antropometrijska mjerenja (mjerenje tjelesne visine, tjelesne mase i preraunavanje
BMI, te mjerenje obima struka) i metod anketiranja.
Anketa je sastavljena od 8 pitanja, podijeljenih na opti i
specifini dio. Opti dio sadri line podatke o ispitanicima, dok se u specifinom dijelu ankete pitanja odnose
na zastupljenosti fizike aktivnosti ispitanika, ishrani i
zdravstvenim pokazateljima, na osnovu kojih se moe
zakljuiti povean rizik za nastanak dijabetesa tip 2.
Rezultati
U ovom istraivanju je obuhvaeno 100 ispitanika. Prema starosnoj strukturi najzastupljeniji ispita-nici su osobe mlae od 45 godina i njihov
procenat iznosi 38%, to je prikazano u Tabeli 1.
Prema polnoj strukturi ispitanici enskog pola su
zastupljeni sa 62%, dok je istim ispitivanjem obuhvaeno 38% mukaraca, prikazano na Slici 1.
Izraunavanjem ITM dokazujemo da 62% ispitanika
ima poveane vrijednosti ITM (39% ispitanika enskog
pola, 23 % ispitanika mukog pola). Struktura naeg
uzorka prema vrijednostima ITM prikazana je na Slici 2.
Povean obim struka ima 47,36 % mukaraca i 46,77%
ena to se vidi iz Slike 3 i 4. Ovaj pokazatelj nam goTABELA 1. Starosna zastupljenost ispitanika
Broj godina
> 45
45 54
55 64
> 64
Ukupno
(%)
38
17
36
9
100
SLIKA 1. Polna struktura ispitanika
SLIKA 2. Indeks tjelesne mase ITM (kg/m2)
SLIKA 3. Obim struka kod mukaraca
SLIKA 4. Obim struka kod ena
SLIKA 5. Fizika aktivnost
SLIKA 6. Koritenje antihipertenzivnih lijekova
vori o poremeenoj distribuciji masnog tkiva, odnosno poveanom obimu struka, to se dovodi u korelaciju sa metabolikim poremeajima u organizmu.
Na pitanje, da li se u toku dana ispitanici bave nekom fizikom aktivnou, 60% anketiranih je dalo
potvrdan odgovor, dok se njih 40% ne bavi fizikom aktivnosti tokom dana, to se vidi iz Slike 5.
Od 100 anketiranih ispitanika u Domu zdravlja Ilida njih
52% se izjasnilo da ima hipertenziju te da koristi lijekove
za povien krvni pritisak, dok je 48% ispitanika normotonino i ne koristi iste lijekove, to se moe vidjeti na Slici 6.
Kod 60% ispitanika obuhvaenih ovim anketiranjem tokom rutinskih pretraga nije utvrena poviena vrijednost eera u krvi, dok je kod 40% ispitanika nivo eera u krvi bio povien (Slika 7).
Na pitanje da li neko u porodici boluje od dijabetesa,
21% ispitanika je potvrdilo prisustvo bolesti u porodici,
dok je 64% ispitanika dalo negativne odgovore (Slika 8).
25
SLIKA 5. Poviena vrijednost eera u krvi
SLIKA 6. Porodina predispozicija
Diskusija
Naim istraivanjem je na osnovu ITM utvreno da
62% ispitanika ima povean indeks tjelesne mase
(23% ispitanika mukog pola i 39% ispitanika enskog
pola) od 2530, to predstavlja znaajan riziko faktor za nastanak dijabetesa tip 2. Takoe je utvreno
da je 4% mukaraca i 8% ena gojazno sa ITM > 30.
Istraivanjem provedenim na 80 hiljada stanovnika
na podruju Vojvodine u 2003. godini sa ciljem ranog otkrivanja eerne bolesti, utvreno je da prekomjernu tjelesnu teinu ima 41% ispitanika (10),
to je manje od dobivenih vrijednosti naeg istraivanja iji uzorak je znatno manji od navedenog
u Vojvodini, te upuuje na neophodnost ovakvih
istraivanja na veem uzorku i na naem podruju.
Za obim struka kao vaan riziko faktor u nastanku dijabetesa tip 2, rezultati pokazuju da 18% mukaraca ima rizik I stepena (94 102) kao i 29% ena
(sa obimom struka od 80 88). Izrazito povien
obim struka, te rizik II stepena ima 7% mukaraca
(obim struka: >102) i ena 19% (obim struka: >88).
Navedena istraivanja u Vojvodini pokazuje da jedna
petina ispitivanog stranovnitva Vojvodine ima poeljan obim struka, dok rizinu vrijednost obima struka
ima 20,7% osoba, to je vea vrijednost od dobijenog
u naem istraivanju. Najvei broj ispitanika (42,5%)
nalazi se u grupi rizinog obima struka II stepena (10).
Fiziku aktivnost u toku dana upranjava 60% ispitanika, dok se njih 40% ne bavi fizikom aktivnosti
tokom dana, to se neznatno razlikuje od istraivanja
koje su sproveli CDC i Ameriko ministarstvo zdrav-
lja, gdje je utvreno da je samo 32 do 37,9% odraslog stanovnitva oba pola u SAD fiziki aktivno (15).
Podaci koji se odnose na fiziku neaktivnost, iz
naeg istraivanja su slini podacima koji su dobiveni istraivanjem drugih autora, tako su Miigoj-Durakovi i saradnici, ustanovili da je 35,8%
ispitanika u Hrvatskoj fiziki neaktivno (16).
Kao znaajan faktor rizika u nastanu diabetesa tip 2. je
injenica da se 52% ispitanika izjasnilo da ima hipertenziju te da koristi lijekove za povien krvni pritisak. Naim
ispitivanjem je utvreno da 64% ispitanika nije imalo
sluajeve dijabetesa u porodici, 15% ispitanika je izjavilo
da je dijabetes registrovan u iroj familiji dok 21% ispitanika izjavljuje da je dijabetes registrovan u uoj porodici.
Odavno je poznato da naslijee utie na nastanak ovog
oboljenja, ali je taj uticaj jo uvijek nedovoljno ispitan i
samo je epidemioloki potpuno dokumentovan. Smatra
se da oko 25% cjelokupne populacije u svijetu posjeduje
neki genetski defekt za dijabetes. Poveanom uticaju nasljeivanja u pojavi eerne bolesti doprinose produenje ivotnog vijeka dijabetinih bolesnika, naroito mlaih osoba i produenje ivotnog vijeka stanovnitva (8).
Zakljuci
Povean ITM kod ispitivanih pacijenata, te povean
obim struka i nedostatak fizike aktivnosti, ukazuju
na prisustvo rizika za pojavu diabetes mellitus tip 2,
to opravdava i dalja istraivanja na ovom podruju u
pripadajuoj obiteljskoj medicini. Rezultati ove studije
opravdavaju preventivne aktivnosti u pogledu uticaja
na promjenu stilova ivota u svim starosnim grupama.
Literatura
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Diagnosis and Classification of Diabetes Mellitus and its Complications. Part
1: Diagnosis and Classification of Diabetes Mellitus, Geneva, Department
of Noncommunicable Disease Surveillance, 1999.
26
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on the Diagnosis and Classification of
Diabetes Mellitus, Diabetes Care 25:
S5-S20, 2002.
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of the Global Forum on Noncommunicable Disease Prevention and Control,
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Department of Noncommunicable Disease and Health Promotion, Geneva.
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Diabetes
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Prevent Type 2 Disease. 63rd Annual
Scientific Sessions, Publication date 15.
06. 2003
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Body Fat Distribution. Diabetes Care
1994; 14 (12): 1132-1142
(12) Ai-Buturovi B., Preddijabetes i dijabetes melitus tip 2, Sarajevo, 2009, pp.
12-95
(13) Dishman RK, Washburn RA, Healt
GW. Physical activity epidemiology.
Human Kinetics, Chicago 2004.
(14) Bull FC, Armstrong TP, Dixon T, Ham
S, Neiman A, Pratt M (2004) Physi-
cal inactivity. In: Ezzati M, Lopez AD,

Rodgers A, Murray CJL, editors. Comparative Quantification of Health Risks
Global and Regional Burden of Disease Attributable to Selected Major Risk
Factors. Geneva: World Health Organization; pp.729-881.
(15) U.S. Department of Health and Human
Services, Public Health Service, Centers for Disease
Control and Prevention, National Center for Chronic Disease Prevention
and Health Promotion, Division of
Nutrition and Physical Activity. Promoting Physical Activity: A Guide for
Community Action. Champaign, IL:
Human Kinetics,1999.
(16) Miigoj-Durakovi M, Heimer S, Gredelj M, Heimer , Sori M. Tjelesna
neaktivnost u Republici Hrvatskoj.
Acta Med Croat 2007; 61: 253-258.
27
www.jhsci.ba
Uticaj rizikofaktora za osteoporozu na gubitak

kotane mase kod ena u postmenopauzi
Influence of osteoporosis risk faktors on bone mass
loss in postmenopausal women
Amila Kapetanovi1*, Dijana Avdi2, Katarina Markovi3,
Ata Teskeredi1, Mustafa Basari1, Eldan Lokmi1
Rehabilitation Center Fojnica, Banjska bb, Fojnica. Bosnia and Herzegovina
Orthopedic and Traumatology Clinic, University Clinics Center, Bolnika 25, Sarajevo, Bosnia and Herzegovina
3
Institute for treatment and rehabilitation of rheumatic and cardiovascular diseases, 18205 Nika Banja, Serbia
1
2
Abstract
Saetak
Introduction: Estrogen deficiency plays a critical role in

the development of osteoporosis. However, some other
factors may contribute to bone loss as well.
Aim: To show presence of osteoporosis risk factors and
to examine its influence on bone mass loss in women
with normal menstrual history.
Methods: The study included 30 postmenopausal women, ages from 50 to 65 with osteoporosis who entered
into menopause before the age of 45, and 30 postmenopausal women, ages from 50 to 65 with osteoporosis who
had normal menstrual history. Presence of risk factors
has been calculated for both groups and statistical significance of differences between two groups presented.
Results: In the group with normal menstrual history 33.33% women had low level of physical activities, 56.66% suffered from insuficient intake of calcium,
63.33% of women were active smokers. Body mass index bellow 19 had 6.66% women, insuficient exposure
to the sun was registered in 60%, and 23.33% women
were either taking medicaments or had diseases that
could cause osteoporosis. Statistical significance of differencies in presence of certain risk factors between
two groups was registered for : insuficient daily intake
of calcium (p <0.001), insuficient exposure to the sun (p
<0.001), and smoking (p <0.001).
Conclusion: Results of the study indicate high presence of osteoporosis risk factors in women with normal
menstrual history and indicate influence of certain factors (calcium, sun exposure, smoking) on occurence of
osteoporosis in this group.
Uvod: Centralno mjesto u patogenezi postmenopauzalne osteoporoze ima deficit estrogena. Meutim i drugi
faktori mogu doprinijeti gubitku kotane mase. Cilj je prikazati zastupljenost rizikofaktora za osteoporozu i ispitati
njihov uticaj na gubitak kotane mase kod ena kod kojih
je menstrualna historija bila uredna.
Metode: U studiju je bilo ukljueno 30 ena u postmenopauzi, starosne dobi 50 do 65 godina sa osteoporozom
kod kojih je menopauza nastupila prije 45. godine ivota
i 30 ena u postmenopauzi , starosne dobi 50 do 65 godina sa osteoporozom kod kojih je menstrualna historija
bila uredna. U obje skupine izraunata je zastupljenost rizikofaktora i prikazana statistika signifikantnost razlika u
zastupljenosti pojedinih rizikofaktora izmeu ovih skupina.
Rezultati: U skupini ena sa urednom menstrualnom
historijom 33,33% ena imalo je nizak nivo tjelesne aktivnosti, 56,66% ena nije unosilo dnevno dovoljno kalcijuma ishranom, puilo je 63,33% ena, body mass index
nii od 19 imalo je 6,66% ena, nedovoljno se izlagalo
suncu 60% ena, a 23,33% ena uzimalo je lijekove ili
imalo bolesti koje mogu uzrokovati osteoporozu. Statistika signifikantnost razlika u zastupljenosti pojedinih
faktora izmeu dvije skupine registrirana je za nedovoljan dnevni unos kalcijuma (p <0,001), nedovoljno izlaganje suncu (p <0,001), puenje (p <0,001).
Zakljuak: Rezultati istraivanja pokazuju visoku zastupljenost rizikofaktora za osteoporozu kod ena kod kojih
je menstrualna historija bila uredna i ukazuju na uticaj
pojedinih faktora (kalcijum, izlaganje suncu, puenje) na
nastanak osteoporoze kod ovih ena.


Keywords: risk factors, osteoporosis
Kljune rijei: faktori rizika, osteoporoza
* Corresponding author: Amila Kapetanovi;

Rehabilitation Center Fojnica, Banjska bb, Fojnica;
Bosnia and Herzegovina; Phone: 00 387 030 838 862,
E-mail: amila.kapetanovic@bih.net.ba
Uvod
Osteoporoza je uzrokovana kompleksnom interakcijom genetskih, hormonalnih, metabolikih i okolinih
faktora (1). Centralno mjesto u patogenezi postmenopauzalne osteoporoze zauzima estrogen. Deficit estrogena poveava ratu kotanog remodeliranja i pomjera
28
AMILA KAPETANOVI ET AL.: INFLUENCE OF OSTEOPOROSIS RISK FAKTORS ON BONE MASS LOSS IN POSTMENOPAUSAL WOMEN
ravnoteu izmeu kotane resorpcije

i formacije u korist resorpcije (2).
Rizik od osteoporoze poveavaju
brojni endogeni i egzogeni faktori.
Rizikofaktori se mogu definisati kao
mjerljive vrijednosti ili osobine za
koje se u kontroliranim epidemiolokim studijama (kohortne studije)
ili paljivo voenim Case control
studijama moe dokazati statistiki
znaajan uticaj na rizik od bolesti.
Studije o pojedinim rizikofaktorima
za osteoporozu nisu konzistentne,
to sugerira neophodnost daljnih
istraivanja.
Ciljevi ove studije su prikazati zastupljenost rizikofaktora za osteoporozu kod ena u postmenopauzi kod
kojih je menstrualna historija bila
uredna i ispitati uticaj pojedinih rizikofaktora za osteoporozu na gubitak
kotane mase kod ena u postmenopauzi kod kojih je menstrualna historija bila uredna.
TABELA 1. Zastupljenost pojedinih rizikofaktora za osteoporozu i statistika signifikantnost razlika prema pojedinim rizikofaktorima
Rizikofaktori
Ispitanice
sa urednom
menstrualnom
historijom
(n=30)
Smanjena tjelesna aktivnost
3,33 %
10
33,33%
Nedovoljan
unos kalcijuma
ishranom
10,00 %
17
56,66%
Puenje
23,33 %
19
63,33 %
Nedovoljno
izlaganje suncu
13,33%
18
60,00%
BMI
0%
6,66%
Lijekovi i bolesti
koji mogu
uzrokovati
osteoporozu
6,66%
23,33%
Metode
U studiju je bilo ukljueno 30 ena
u postmenopauzi, starosne dobi 50
do 65 godina sa osteoporozom kod kojih je menopauza nastupila prije 45. godine ivota i 30 ena u postmenopauzi , starosne dobi 50 do 65 godina sa osteoporozom kod kojih je menstrualna historija bila uredna. U
obje skupine izraunata je zastupljenost rizikofaktora
i prikazana statistika signifikantnost razlika u zastupljenosti pojedinih rizikofaktora izmeu ovih skupina.
Rezultati
Prosjena starosna dob u skupini ena kod kojih je
menopauza nastupila prije 45. godine ivota bila je 57,
40 godina, a u skupini ena kod kojih je menstrualna
historija bila uredna prosjena starosna dob bila je 57,
60 godina. Razlika u prosjenoj starosnoj dobi izmeu ove dvije skupine nije bila statistiki signifikantna.
U skupini ena u postmenopauzi kod kojih
je menopaza nastupila prije 45. godine ivota
3,33% ena imalo je nizak nivo tjelesne aktivnosti,
10,00% ena nije unosilo dnevno dovoljno kalcijuma
ishranom, puilo je 23,33% ena, body mass index nii
od 19 nije imala nijedna ena, nedovoljno se izlagalo
suncu 13,33% ena, a 6,66% ena uzimalo je lijekove
ili imalo bolesti koje mogu uzrokovati osteoporozu.
U skupini ena sa urednom menstrualnom historijom
33,33% ena imalo je nizak nivo tjelesne aktivnosti,
56,66% ena nije unosilo dnevno dovoljno kalcijuJOURNAL OF HEALTH SCIENCES 2011; 1 (1)
Ispitanice kod
kojih je menopauza nastupila
prije 45. godine
ivota (n=30)
Neupareni dvostrani T-test niza

pacijentkinja kod kojih je menopauza nastupila pre 45 godine
i niza pacijentkinja sa urednom
menstrualnom historijom u zavisnosti od faktora rizika
0,002212
p>0,001
nije statistiki signifikantno
0,0000058101
p<0,001
statistiki je signifikantno
(znaajno)
0,000985
p<0,001
statistiki je signifikantno
(znaajno)
0,0003594
p<0,001
statistiki signifikantno (znaajno)
0,5614
p>0,001
0,0727
p>0,001
ma ishranom, puilo je 63,33% ena, body mass index

nii od 19 imalo je 6,66% ena, nedovoljno se izlagalo suncu 60% ena, a 23,33% ena uzimalo je lijekove
ili imalo bolesti koje mogu uzrokovati osteoporozu.
Statistika signifikantnost razlika u zastupljenosti pojedinih faktora izmeu dvije skupine registrirana je za
nedovoljan dnevni unos kalcijuma (p <0,001), nedovoljno izlaganje suncu (p <0,001), puenje (p <0,001).
Diskusija
Rezultati istraivanja pokazuju nii nivo zaustapljenosti pojedinih rizikofaktora za osteoporozu (smanjena tjelesna aktivnost, nedovoljan unos kalcijuma
ishranom, puenje, nedovoljno izlaganje suncu, BMI,
lijekovi i bolesti koji mogu uzrokovati osteoporozu)
u skupini ena u postmenopauzi kod kojih je menopauza nastala prije 45. godine ivota u odnosu na zastupljenost tih rizikofaktora kod ena u
postmenopauzi kod kojih je menstrualna historija bila uredna, to sugerira centralnu ulogu deficita estrogena u nastanku osteoporoze kod ovih ena.
Prijevremena menopauza je jaka determinanta gustine kosti i poveanog rizika od frakture (3). Gubitak
funkcije ovarija u menopauzi predstavlja najvaniji
faktor za razvoj osteoporoze, metabolike bolesti koja
pogae milione ljudi irom svijeta i znaajno doprinosi
29
AMILA KAPETANOVI ET AL.: INFLUENCE OF OSTEOPOROSIS RISK FAKTORS ON BONE MASS LOSS IN POSTMENOPAUSAL WOMEN
morbiditetu i mortalitetu kod starijih ena (2). Gubitak

kotane mase nakon menopauze uzrokovan je padom
estrogena to potkrepljuje i injenica da se korekcijom
deficita estrogena prevenira gubitak kotane mase (4, 5)
Rezultati istraivanja pokazuju visok stepen zastupljenosti rizikofaktora za osteoporozu u skupini ena
u postmenopauzi kod kojih je menstrualna historija bila uredna, a koje imaju osteoporozu, to sugerira ukjluenost i drugih faktora u nastanak bolesti.
Statistika signjifikantnost razlika prema pojedini rizikofaktorima izmeu ispitivanih skupina registrirana je
za sljedee rizikofaktore: unos kalcijuma (p <0,001), nedovoljno izlaganje suncu (p <0,001), puenje (p <0,001).
Ilich i suradnici pokazuju da postoji signifikantna veza
izmeu mineralne gustine kosti i ishrane, ukljuujui i
unos kalcijuma (6).
Budak i sur. nalaze da stil oblaenja pri kom je pokrivena

cijela koa izuzev lica i ruku izaziva deficit vitamina D
(7). Stil oblaenja je vaan faktor koji utie na produkciju
vitamina D, prema tome i na mineralnu gustinu kosti (8).
Puenje je jedan od najveih rizikofaktora za ljudsko zdravlje. Skoranje meta analize efekata puenja na kost pokazuju da puai starosne dobi 50
i vie godina imaju smanjenu kotanu masu (9).
Zakljuak
Rezultati istraivanja pokazuju visoku zastupljenost rizikofaktora za osteoporozu kod ena kod kojih je menstrualna historija bila uredna i ukazuju
na uticaj pojedinih faktora (kalcijum, izlaganje suncu, puenje) na nastanak osteoporoze kod ovih ena.
Literatura
(1) Raisz LG. Pathogenesis of osteoporosis: concepts, conflicts, and prospects. J.
Clin. Invest. 115:3318-3325 (2005)
2. Manolagas SC, Kousteni S, Jilka RL.
Sex Steroids and Bone. Recent Prog
Horm Res. 2002;57:385-409
3. World Health organization. Prevention and management of osteoporosis.
WHO Technical Report Series 921,
2003
4. U.S. Department of Health and Human
Services. Bone Health and Osteoporosis: A Report of the Surgeon General.
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5.
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7.
Rockville, MD; 2004

Baum E, Dren M, Hadji P, et al. DVOLeitlinien: Osteoporose bei postmenopausalen Frauen. Leitlinien DVO, 2003
Ilich JZ, Brownbill RA, Tamborini L.
Bone and nutrition in elderly women:
protein, energy, and calcium as main
determinants of bone mineral density.
Eur J Clin Nutr. 2003;57(4):554-65
Budak N, Cicek B, Sahin H, Tutus
A. Bone mineral density and serum
25-hydroxyvitamin D level: is there
any difference according to the dre-
8.
9.
ssing style of the female university

students. Int J Food Sci Nutr. 2004;
55(7):569-75
Allali F, El Aichaoui S, Saoud B, Maaroufi H, Abouqal R, Hajjaj-Hassouni N.
The impact of clothing style on bone
mineral density among post menopausal women in Morocco: a case-control
study. BMC Public Health. 2006 May
19;6:135
Iki M. Osteoporosis and smoking. Clin
Calcium. 2005 ;15(7):156-8.
www.jhsci.ba
Epidemioloke karakteristike crijevnih

zaraznih oboljenja i virusnog hepatitisa A
u Kantonu Sarajevo
Epidemiological characterisics of gastrointestinal infectious
diseases and viral hepatitis A in the Canton Sarajevo
Zarema Obradovi1,2*, Arzija Paali2, Amar ili1
1
2
Institute for Public Health of Canton Sarajevo, Vrazova 11/IV, 71000 Sarajevo, Bosnia and Herzegovina
Faculty for Health Studies, University of Sarajevo, Bolnika 25, 71000 Sarajevo, Bosnia and Herzegovina
Abstract
Saetak
Introduction: Gastrointestinal infectious diseases are

a group of frequent diseases in developing countries as
a result of industrialization in food production and often
consuming of the food in public places. In Bosnia and
Herzegovina and in Canton Sarajevo these diseases are
frequent. The aim of this work is to investigate epidemiological characteristics of the most often gastrointestinal infectious diseases in Canton Sarajevo (Enterocolitis acuta,
Toxiinfectio alimentaris, Salmonellosis, Amoebiasis) compared with Viral Hepatitis A and to estimate the need for
the implementation of vaccination against this disease.
Methods: We used individual reports as well as monthly
and annual bulletins about the movement of infectious
diseases which are obligatory for reporting from the Epidemiology department of the Institute for public health in
Canton Sarajevo. This work is a retrospective study, for
the period 2005-2009. Descriptive- analytical method
was used. In statistical processing we used mean, structure index and trend index.
Results: The research showed that gastrointestinal infectious diseases are registered in a huge number in all the
observed years. The most often was Enterocolitis acuta,
and the rarest was Viral Hepatitis A. The diseases were
mostly sporadic. Distinct seasonality and coherence with
warm months in the year is expressed in Enterocolitis
acuta and Intoxicatio alimentaris, while the other diseases
are registered during the whole year.
Conclusions: Incidence of gastrointestinal infectious diseases in Canton Sarajevo is high and we need to work
intensively to improve sanitary conditions as the most efficient preventive measures. There is no justification for
implementing of the vaccine against Viral hepatitis A.
.
Keywords: gastrointestinal infectious diseases, VHA,
Canton Sarajevo, preventive measures
Uvod: Crijevne zarazne bolesti spadaju u grupu veoma

uestalih oboljenja, kako u zemljama sa loim higijenskosanitarnim uslovima, tako i u visoko razvijenim zemljama,
a to je posljedica porasta industrijalizacije u proizvodnji
hrane i sve eeg konzumiranja hrane u javnim objektima. I u Bosni i Hercegovini pa tako i u Kantonu Sarajevo,
ova oboljenja su uestala. Cilj rada je istraiti epidemioloke karakteristike najuestalijih crijevnih zaraznih oboljenja u Kantonu Sarajevo (enterocolitis acuta, toxiinfectio
alimentaris, salmonellosis, amebiasis) u odnosu na hepatitis virosa A te procijeniti potrebu za uvoenje vakcinacije
protiv ovog oboljenja.
Metode: Koritene su pojedinane prijave i mjeseni i godinji bilteni o kretanju zaraznih oboljenja koja se obavezno prijavljuju iz Slube za epidemiologiju Zavoda za javno
zdravstvo Kantona Sarajevo. Rad je retrospektivna studija,
za period 2005-2009. godine. Koriten je deskriptivno-analitiki epidemioloki metod. U statistikoj obradi su koritene srednje vrijednosti, index strukture i index trenda.
Rezultati: Istraivanje je pokazalo da su crijevna zarazna
oboljenja sa velikim brojem oboljelih registrovana svih posmatranih godina. Najuestaliji je bio enterocolitis acuta,
a najrjei VHA. Oboljenja su, veinom bila sporadina.
Izrazita sezonalnost i povezanost sa toplim mjesecima
u godini je izraena kod enterocolitis acuta i intoxicatio
alimentaris, dok su ostala oboljenja registrovana tokom
cijele godine.
Zakljuci: Incidenca crijevnih zaraznih oboljenja na Kantonu Sarajevo je visoka te treba intenzivno raditi na poboljanju higijensko-sanitarnih uslova kao najefikasnije
preventivne mjera. Za sada nema opravdanja uvoenje
vakcine protiv VHA.
* Corresponding author: Zarema Obradovi; Institute for Public

Health of Canton Sarajevo; Vrazova 11/IV, 71000 Sarajevo,
Bosna i Herzegovina; Tel/fax: +387 33 667 691, Mob:
+387 61 216 291; e-mail: zobradovic9@gmail.com
Uvod
Oboljenja koja se prenose preko probavnog sistema ine
veliku skupinu zaraznih bolesti koje imaju jedno zajedniko epidemioloko obiljeje, a to je fekalno oralni
put prenoenja (1). Najee nain unoenja patogenih
Kljune rijei: crijevna zarazna oboljenja, VHA, kanton

Sarajevo, preventivne mjere
31
ZAREMA OBRADOVI ET AL.: EPIDEMIOLOGICAL CHARACTERISICS OF GASTROINTESTINAL INFECTIOUS DISEASES AND VIRAL HEPATITIS A IN THE CANTON SARAJEVO
mikroorganizama je putem hrane. Uoljiv je njihov

globalni trend rasta, a to se povezuje sa porastom industrijske proizvodnje hrane (2). U Bosni i Hercegovini zemlji zakonskoj obavezi prijavljivanja podlijeu:
salmoneloza, amebijajaza, alimentarne toksoinfekcije,
akutni enterokolitis i virusni hepatitis A (VHA). Radi
se o grupi oboljenja koja su izazvana razliitim uzronicima, ali koja se prenose istim, ili slinim putevima, a to su dominatno: hrana i voda, te rjee kontakt.
Zbog slinog naina prenosa, sline su i preventivne
mjere za suzbijanje nastanka i irenja ovih oboljenja.
Izuzetak je VHA za koji postoji i vakcina koju su neke
zemlje uvele u rutinski program vakcinacije to je dovelo do znaajnog pada broja oboljelih (3). Do sada
se kod nas ova preventivna mjera nije koristila kao
rutinska, ve su se vakcinisale samo osobe koje putuju u zemlje sa visokim rizikom za ovo oboljenje (4).
Virus hepatitisa A je uzronik epidemijskog, infektivnog hepatitisa za koji je jedini rezervoar ovjek (5). U
irenju oboljenja sudjeluju kako bolesnici sa tipinom,
tako i oni sa atipinom klinikom slikom bolesti, a naroito veliki rizik predstavljaju oni sa anikterinom formom bolesti (5). Virusni hepatitis A je bolest koja se u
pojedinim dijelovima svijeta pojavljuje endemo-epidemijski. U tim podrujima je to najee oboljenje osoba mlae ivotne dobi i sa visokom uestalou lakih
anikterinih oblika bolesti (5). Nasuprot tome, u razvijenim zemljama, poboljanjem socioekonomskih uslova
ivljenja, infekcija virusom hepatitisom se A deava u
kasnijoj ivotnoj dobi, a pojava bolesti je sporadina. U
rijetkim sluajevima je hepatitis A teko oboljenje, odnosno mortalitet i letalitet su niski. Nakon rekonvalescencije ostaje trajan i solidan imunitet (6). U prenoenju
virusa hepatitisa A i odravanju epidemijskog procesa
najvaniji je kontaktni (fekalno-oralni) put prenosa koji
je uslovljen prisutnou svjee fekalne kontaminacije.
Kontaktne epidemije se najee javljaju u kolskim i
pretkolskim objektima, a naroito u onim u kojim su
loi higijensko-sanitarni uslovi. Ove epidemije su razvuene i dugo traju, a broj oboljelih nije visok (1-3%) (7).
Pored kontaktnog, vaan je i prenos oboljenja vodom, a to se esto manifestuje u vidu hidrinih epidemija. Njihova karakteristika je da se eksplozivno
javljaju te da dovode do masovnog obolijevanja, sa
morbiditetom veim od 5 %. Hidrine epidemije
kratko traju, osim kad doe do daljeg prenosa virusa od oboljelih na osobe iz njihovog okruenja kontaktnim putem, to se naziva epidemijski rep (1).
Topografska rasprostranjenost oboljelih se, kod hidrinog naina irenja oboljenja, poklapa sa distributivnom
mreom u kojoj je kontaminirana vode. Osim hidrinih
epidemija, opisane su i epidemije virusnog hepatitisa A
alimentarnog toka. Uglavnom se radi o namirnicama
koje ne prolaze termiku obradu ili je ona nedovoljna,
odnosno zagaenje nastaje sekundarnom kontaminaci32
jom (8). este su epidemije nakon konzumiranja koljki koje se uzgajaju u blizini izlijevanja kanalizacije (9).
Obojenje se u umjerenom klimatskom pojasu, gdje
se nalazi i BiH, najee javlja u jesen. Pojava oboljenja zavisi od sanitarnog stanja okoline, higijenskih navika i brojnosti kontaktne skupine. Zahvaene su sve dobne skupine, mada se oboljenje
najee javlja u djeijoj dobi, tako da na djecu do
15 godina starosti otpada preko 50% sluajeva (10).
Kako postoje dileme da li uvesti vakcinaciju protiv
virusnog hepatitisa tipa A u redovni program imunizacije ili ne, eljeli smo istraiti uestalost ovog oboljenja na podruju Kantona Sarajevo u odnosu na
druga, naprijed pomenuta crijevna zarazna oboljenja.
Sva ova oboljenja se konstantno registruju na podruju Federacije BiH i Kantona Sarajevo, a enterocolitis
acuta, salmonelosis, toxiinfectio alimentaris se nalaze
meu dest vodeih zaraznih oboljenja. Cilj ove studije je ispitati i analizirati epidemioloke karakteristike
najuestalijih crijevnih zaraznih oboljenja na Kantonu
Sarajevo, a to su: enterocolitis acuta, toxiinfectio alimentaris, salmonellosis, amebiasis u odnosu na hepatitis virosa A za period 2005.-2009. godine te procijeniti
potrebu za uvoenje vakcinacije protiv ovog oboljenja.
Metode
U ovom radu su kao materijal koritene pojedinane
prijave zaraznih oboljenja te mjeseni i godinji bilteni o kretanju zaraznih oboljenja koja podlijeu obaveznom prijavljivanju prikupljeni u Slubi za epidemiologiju Zavoda za javno zdravstvo Kantona Sarajevo.
Rad je retrospektivna studija, period istraivanja je
2005-2009. godina. Koriten je deskriptivno- analitiki
epidemioloki metod. Prikupljeni podaci su analizirani
u programu EpiINFO. U statistikoj obradi su koritene srednje vrijednosti, index strukture i index trenda.
Rezultati
U periodu od 2005-2009. na podruju Kantona Sarajevo je ukupno registrovano 7626 osoba oboljelih od
enterocolitis acuta, toxiinfectio alimentaris, salmonellosis, amoebiasis i hepatitis virosa tip A (Slika 1).
Kao to se vidi na prethodnom grafikonu najvei
broj oboljelih je registrovan 2007., a najmanji 2005.
godine. Incidenca se kretala od 216/100000 stanovnika pa do 478/100000 stanovnika. Dominiralo je
sporadino obolijevanje, osim 2007. godine kada
je registrovana epidemija toxiinfectio alimentaris.
Enterocolitis acuta je bio najuestalije oboljenje sa registrovanih 5657 oboljelih. Obolijevanje od VHA je bilo sporadino sa najveim brojem oboljelih u 2007. godini, ukupno 28 (Slika 3).
Analizirajui dobnu distribuciju pojedinih oboljenja uoljivo je najvei broj oboljelih bio u dobnoj grupi 25-49 godina sa 3265 oboljelih (Tabela 1).
SLIKA 1. Oboljeli od crijevnih zaraznih oboljenja po godinama
SLIKA 2. Oboljeli od crijevnih zaraznih oboljenja po vrsti

oboljenja
SLIKA 3. Kretanje virusnog hepatitisa tipa A
SLIKA 4. Dobna distribucija crijevnih zaraznih oboljenja
ma uoava se da je prosjean indeks strukture bio

0,7% (Slika 6) a kretao se u rasponu od 0,3% - 1,4%.
Analizirali smo i distribuciju crijevnih zaraznih oboljenja
po vremenu javljanja, odnosno po mjesecima. Alimentarne toksiinfekcije i anterocolitis acuta pokazuju izrazitu sezonalnost i najee se javljaju u toplim mjesecima
u godinii pa je najvei broj oboljelih od alimentranih toksikoinfekcija registrovan krajem proljea i poetkom ljeta, a od enterocolitis acuta krajem ljeta i poetkom jeseni.
Za razliku od prethodnih oboljenja, salmoneloze, amebijaza i VHA ne pokazuju izrazitu sezonalnost i javljuju
se tokom cijele godine (mada se VHA neto ee javlja poetkom jeseni). Ovi podaci su od velikog znaaja za provoenje preventivnih mjera, kako onih
TABELA 1. Dobna distribucija crijevnih zaraznih oboljenja, ukljuujui i VHA
vezanih za linu higijenu,
tako i onih koje se odnoDobne
VHA
Salmoneloze Toksikoinfek. Enterocol. Ac Amebiasis
UKUPNO
se
na higijenu namirnica
grupe
broj % broj
% broj
% broj
%
broj
%
broj
%
i predmeta ope upotrebe.
U ovoj dobnoj grupi je bilo 42,9% svih oboljelih

od posmatranih oboljenja i to: 66,8% od toxiinfectio alimetaris, 55,0% od amebiasis, 43,6% oboljelih od salmoneloza, 38,7% od enterocolitis acuta te 33,9% oboljelih od virusnog hepatitisa tipa A.
U strukturi oboljelih od salmonellosis, enterocolitis acuta i amebiasis dobna grupa od 0-6 godina je druga po uestalosti, dok je za VHA to
dobna grupa od 15-24 godine sa 32,1% uea u strukturi obolijevanja od ovog oboljenja.VHA se iskljuivo javljao kod osoba mlaih od 49 godina (Slika 5).
Analizirajui odnos javljanja virusnog hepatitisa
tipa A prema drugim crijevnim zaraznim oboljenji-
0-6
7-14
15-24
25-49
50-64
65 i vie
Ukupno
3
16
18
19
0
0
56
5,4
28,6
32,1
33,9
0
0
100
264
128
52
370
14
29
848
31,1
15,0
6,1
43,6
1,7
3,4
100
49
127
126
630
6
2
940
5,1
13,5
13,4
66,8
0,6
0,2
100
1740
987
539
2188
103
100
5657
30,7
17.4
9,5
38,7
1,8
1,7
100
23
7
9
49
1
0
89
25,8
7,9
10,1
55,0
1,2
0
100
2079
1265
744
3256
124
122
7590
27,4
16,6
9,8
42,9
1,6
1,6
100
Diskusija
Epidemiologija crijevnih
zaraznih oboljenja, ukljuujui i hepatitisa A, se u
cijelom svijetu pa tako i na
podruju Kantona Sarajevo
33
SLIKA 5. Distribucija oboljelih od VHA po dobnim grupama
SLIKA 6. Indeks strukture crijevnih zaraznih oboljenja
SLIKA 7. Kretanje Enterocolitis acuta i Toxiinfectio alimentaris

po mjesecima
SLIKA 8. Kretanje hepatitis virosa tipa A, salmoneloze i amebiasis po mjesecima
posljednjih godina znaajno mijenja, a to je posljedica

promjena naina ivljenja. Prosjena incidenca je bila
455/100 000 stanovnika. Nae istraivanje je pokazalo
da su enterocolitis acuta i toxiinfectio alimentaris najea oboljenja, dok je VHA registrovan znatno rjee.
U prevenciji crijevnih zaraznih oboljenja su postignuti
dobri efekti primjenom jednostavnih mjera kao to
su: pranje ruku i edukacija o higijenskim principima
osoblja koje rukuje sa hranom (11). Ipak, uprkos poboljanju higijensko-sanitarnih uslova, evidentan je
porast broja oboljelih od ovih oboljenja, a to je posljedica porasta industrijske proizvodnje hrane (1,12). Posebno velike promjene su u epidemiologija hepatitisa A.
Poboljanje sanitarnih uslova i higijenskih navika su
smanjili uestalost VHA infekcije (13). Evidentno je da
je broj oboljelih smanjen, a posebno je vano istai da
obolijeva manje mladih ljudi, to se pokazalo i u naem
istraivanju. Na Kantonu Sarajevo od VHA obolijevaju
osobe starosti do 49 godina, pri emu je broj oboljelih
do est godina veoma mali. U Engleskoj i Walesu VAH
infekcija je rijetka, oboli oko 1000 osoba godinje, a
smatra se da to posljedica adekvatne line higijene, kao
glavne preventivne mjere za spreavanje VAH infekcije
i njezina irenja (15). Meutim, poboljanje higijenskih
uslova smanjuje ansu da se u djetinjstvu doe u kon-
takt sa virusom hepatitisa A i da se razviju antitijela, a

to dovodi do porasta broja mladih ljudi bez antitijela.
Zbog toga su oboljenja ea u starijim dobnim grupama, a kada je obino i klinika slika ozbiljnija te je
esto ta injenica razlog za uvoenje vakcinacije protiv
ovog oboljenja (16). Tako je smanjenja uestalost VHA
infekcije u Istonoj Evropi, a to je posljedica provoenja higijensko-sanitarnih mjera kao i vakcinacije djece
i visoko rizinih grupa stanovnitva (15). U SAD-u je
incidenca VHA pala za 92%, od 12,0/100 000 stanovnika u 1995 do 1/100 000 stanovnika u 2007, to je najnia stopa ikada registrovana. Najvei pad je zabiljeen
u dravama u kojim je uvedena rutinska vakcinacija
djece starosti 12-23 mjeseca koja je preporuena 1999
(17). Sline rezulatate je pokazala i studija provedena
u Finskoj od 1990-2007 godine u kojoj je prosjena incidenca hepatitisa A veoma niska (0,3-3,6/100 000 stanovnika), a dolo je do porasta seropozitivnih osoba (sa
30%- 45%) (18). Meutim, jo uvijek je u nekim zemljama stopa oboljevanja od VHA visoka, kao npr. u Indiji
gdje je to veliki javnozdravstveni problem. Istraivanje
provedeno na 926 ispitanika starosti do 24 godine je pokazalo 92,2% sa pozitivnim anti-VAH antitijelima (19).
Ukupno optereenje zaraznim oboljenjima, a naroito
crijevnim, je jo uvijek veoma visoko i posebno je zna-
34
ajno za oboljenja kod kojih nije uspostavljena potpuna

kontrola, a meu koja spada i VHA (20). Trokovi se
naroito uveavaju kod pojave epidemija, to kod crijevnih zaraznih obojenja (i VHA) nije rijetkost (21, 22).
U posmatranom periodu je registrovana samo jedna epidemija toxiinfectio alimentaris (2007. godine), dok su se sva
ostala oboljenja u ostalim godinama javljala sporadino.
U zemljama sa niskom incidencom, kao npr. Kanada
preporuuje se vakcinacija protiv virusa hepatitisa tipa
A samo za osobe sa visokim rizikom, a to su u prvom
redu putnici koji putuju u podruja hiperendemina ili endemina za VHA (23). Isti princip se primjenjuje i u naoj zemlji, a to je i ekonomski opravdano.
Zakljuci
Crijevne zarazne bolesti se konstantno registruju na
podruju Kantona Sarajevo, sa velikim brojem obo-
ljelih i prosjenom incidencom od 455/100 000 stanovnika. Najvei broj oboljelih su osobe starosti od
25-49 godina, odnosno radno aktivno stanovnitvo,
a to se povezuje sa ishranom u javnim objektima.
Virusni hepatitis tipa A se javljao svih posmatranih godina sa sporadinim sluajevima i u ukupnoj
strukturi zaraznih bolesti je uestvovao sa 0,7%.
Alimentarne intoksikacije i Enterocolitis acuta su imali izrazitu sezonalnost i javljali su se u toplim mjesecima u godini, dok se VHA javljao tokom cijele godine, sa neto veim brojem sluajeva poetkom jeseni.
U prevenciji crijevnih zaraznih oboljenja vano
je nastaviti sa poboljavanjem higijensko-sanitarnih uslova kao najbolje opte preventivne mjere.
Pri ovako niskoj incidenci VHA ne bi bilo opravdano uvoenje vakcinacije protiv ovog oboljenja.
Literatura
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(3) Daniels D, Grytdal S, Wasley A. Surveillance for acute viral hepatitis.United
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(8) Kocijani I.R. i sar . Higijena Zavod
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(10) Puvai Z i sar. Epidemiologija zaraznih bolesti, Je Sarajevo, 2007; pp.
108-109
(11) Lee MB, Greig JD. A review of gastrointestinal outbreaks in shools: effective
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al. Food-borne diseases-the challenges
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ones continue to emrge. Int J Food
Microbiol 2010; 139 (Suppl 1): S3-15
(13) Shapiro CN, Margolis HS. Worldwide
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Vaccine, 2000; 18 (Suppl 1(2):S68-S70.
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2009;58(3):1-27.
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Infectious diseases in India. Lancet
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(21) Much P, Pichler J, Kasper SS. Allerberger F: Foodborne outbreaks, Austria
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35
www.jhsci.ba
Uticaj nepravilnog poloaja u toku rada

na nastanak lumbalnog bolnog sindroma
diskogene etiologije
Effects of improper posture during work on lumbal pain
syndrome of discogenic etiology
Eldad Kalji
Fakultet zdravstvenih studija Univerziteta u Sarajevu, Bolnika 25. 71000 Sarajevo, Bosna i Hercegovina
Abstract
Introduction: Lumbar pain syndrome is the most common cause of why patients, especially the active ones,
are reported to physicians. It is manifested as nonspecific or non-radicular lumbar pain syndrome which is not
associated with neurological symptoms, and specific
which is associated with spinal nerve root compression.
Aims of this study were to determine correlation between
inadequate equipment and improper position for work
with disk caused lumbar pain syndrome.
Methods: The study included 913 patients who have
visited the Community-based rehabilitation ambulance
"Praxis" due to low back pain syndrome and verified disc
hernia in the five year period. Lumbar pain syndrome was
diagnosed by clinical examination (history, inspection,
palpation, Lasegue sign, neurologic and motoric dysfunction tests), then radiologic diagnostic methods (CT, MRI).
The data about inadequate equipment and position during work were obtained in interview with patients.
Results: Lumbar pain syndrome is most common among
workers (268 or 29.35%), followed by officials (239 or
26.17%). With the conducted research we determine that
all the patients had inadequate equipment and the position of labor and weak abdominal and spinal muscles.
Conclusion: Based on research conducted through the
aforementioned variables, we can determine not only the
association, but a strong influence of inadequate equipment and improper position for work to the occurrence of
disk caused lumbar pain syndrome.
Saetak
Uvod: Lumbalni bolni sindrom predstavlja najei razlog zbog kojeg se lijenicima javljaju radno aktivni pacijenti. Manifestuje se kao nespecifini ili neradikularni
lumbalni bolni sindrom koji nije povezan sa neurolokim
simptomima, i specifini koji je povezan sa kompresijom
korijena spinalnog nerva. Cilj istraivanja je ustanoviti
povezanost izmeu lumbalnog bolnog sindroma diskogene etiologije i nepravilne pozicije za rad.
Metode: Istraivanje obuhvata uzorak od 913 pacijenta
lijeenih u CBR (engl. Community-based rehabilitation)
ambulante Praxis zbog lumbalnog bolnog sindroma i
verifikovanom hernijom diska u petogodinjem periodu.
Lumbalni bolni sindrom je dijagnosticiran na osnovu klinikog pregleda (anamneza, inspekcija, palpacija, Lasegue-ov test i testovi za dokazivanje neurolokih i motornih
ispada), te radiolokih dijagnostikih metoda (CT, MRI).
Podaci o neadekvatnoj opremi i nepravilnom poloaju u
toku rada su dobiveni na osnovu anamnestikih podataka.
Rezultati: Lumbalni bolni sindrom je najzastupljeniji kod
radnika (268 ili 29,35 %), a zatim slijede slubenici (239
ili 26,17 %), jer njihova oprema za rad i radne aktivnosti
direktno utiu na nepravilan poloaj tijela. Provedenim
istraivanjem utvrujemo da su svi pacijenti imali neadekvatnu opremu i poloaj za rad.
Zakljuak: Na osnovu provedenog istraivanja kroz pomenute varijable moemo utvrditi ne samo povezanost,
nego veliki uticaj neadekvatne opreme i nepravilnog poloaja za rad na nastanak lumbalnog bolnog sindroma
diskogene etiologije.
Keywords: Lumbar pain syndrome, inadequate position

for work, inadequate equipment for work
Kljune rijei: Lumbalni bolni sindrom, nepravilan poloaj u toku rada, neadekvatna oprema za rad
Uvod
Lumbalni bolni sindrom je skup simptoma, prvenstveno bola, koji moe biti praen motornim ili ne-
urolokim deficitom zahvaenog spinalnog nerva.

Lumbalni bol doivi oko 80 % ljudi tokom svog ivota. Podjednako je est kod osoba oba spola i ima osobinu da recidivira. (1) U literaturi se navodi ak 130
razliitih uzroka lumbalnog bola, poput upalnih bolesti,
neurolokih oboljenja, vaskularnih poremeaja, tumora pa sve do psihogenog lumbalnog bola. Ipak oko 80%
sluajeva lumbalnog bola nastaje zbog isto mehanikih razloga tj. diskus hernije. (2) To je veoma znaajan
* Corresponding author: Eldad Kalji;

Fakultet zdravstvenih studija Univerziteta u Sarajevu,
Bolnika 25. 71000 Sarajevo, Bosna i Hercegovina
Phone: 00387 61 748 - 959; E-mail: ekaljic@gmail.com
36
ELDAD KALJI: EFFECTS OF IMPROPER POSTURE DURING WORK ON LUMBAL PAIN SYNDROME OF DISCOGENIC ETIOLOGY
zdravstveni i socio-ekonomski problem i najei uzrok

privremene radne nesposobnosti kod ljudi ispod 45
god. starosti, drugi po uestalosti posjeta lijeniku, peti
najei razlog hospitalizacije, a esto zavrava hirurkom intervencijom i prelazi u hronicitet. (3) Smatra
se da 50-80% stanovnitva razvijenih zapadnih zemalja
boluje ili je bolovalo od lumbalnog bola. Ona se javlja
u svakoj ivotnoj dobi, najuestalije u srednjoj i starijoj, a kako je to jedan od najeih uzroka dolasku lijeniku ope medicine poprima obiljeje socijalne
bolesti i iziskuje znaajna financijska sredstva vezana
uz lijeenje, rehablitaciju, te trokove bolovanja. (4)
Lumbalni bolni sindrom je akutan ukoliko je njegovo
trajanje jedan mjesec ili manje. Hronini lumbalni bolni sindrom je obino definiran simptomima u trajanju
od dva ili tri mjeseca. Nesepecifini ili neradikularni
lumbalni bolni sindrom nije povezan sa neurolokim
simptomima ili znakovima. Openito, bol je lokaliziran
u kimi i/ili u regijama oko kime bez radijacije u nogu.
Lumbalni bolni sindrom u kombinaciji sa oteenjem korijena spinalnog ivca je obino povezan sa neurolokim
znacima ili simptomima, i opisan je kao radikulopatija. (5)
Lijeenje ukljuuje kontroliranu tjelesnu aktivnost, primjenu analgetika i nesteroidnih antireumatika u odgovarajuim dozama, prema procjeni i slabih opioida, uz adjuvantnu terapiju, fizikalne procedure i balneorehablitaciju,
manuelnu medicinu, akupunkturu, no jedinstvenog terpijskog pristupa za sve oblike kriobolje nema. (4,6,7,8).
Nepravilni poloaj tijela uslovljen dugotrajnim radom
ili neadekvatnom opremom za rad remeti pravilnu
posturu tijela. Takav poloaj dovodi do smanjenja
ishrane hrskavice izmeu prljenova, a funkcija hrskavice izmeu diskusa direktno ovisi o mobilnosti
kime, tada nepravilni poloaj tijela usljed rada dovodi do razliitog stepena degeneracije hrskavice
uzrokujui simptome lumbalnog bolnog simptoma.
Cilj studije je ispitati uticaj nepravilnog poloaja na
radnom mjestu na nastanak lumbalnog bolnog sindroma diskogene etiologije, ispitati zanimanje koje
najee dovodi do nastanka lumbalnog bolnog sindroma. Utvrditi starosnu i spolnu strukturu ispitanika.
Metode
Ispitanici
Na osnovu baze podataka ambulante u zajednici (CBR)
Praxis u Sarajevu u periodu od 01.01.2004 do 31.12.2009
godine. zbog bolova u lumbalnom dijelu kime usljed
nepravilne pozicije rada lijeeno je 913 pacijenta.
U istraivanje su ukljueni svi pacijenti koji su se javili u
CBR ambulantu Praxis zbog lumbalnog bolnog sindroma i verifikovanom hernijom diska u navedenom periodu.
Nepravila pozicija rada podrazumijeva neadekvatnu
opremu za rad (previsoka ili preniska stolica, previsok ili prenizak sto, kao i poloaj monitora koji moe
biti izuzetno nizak u odnosu na nivo oiju), kao i neadekvatan poloaj rada (dugotrajno stajanje ili sjedenje, teak fiziki napor, neadekvatan poloaj kime,
obino pognuti poloaj, koji ometa statiku kime).
Da bi pokazali da se lumbalni bolni sindrom javlja kod nepravilne pozicije rada u istraivanje smo uvrstili slijedea
zanimanja: Doktor, veterinar, nastavnik, ininjer, pravnik,
ekonomist, slubenik, radnik, zanatlija, poljoprivrednik, domaica, penzioner, uenik, student i penzioner.
Ispitanici su podijeljeni u 8 starosnih skupina
da bi ispitali uestalost javljanja lumbalnog bolnog sindroma kod radno aktivnog stanovnitva
koje podrazumjeva dob od 25 65 godina starosti.
Studija e ispitivati spolnu strukturu bolesnika da se
utvrdi da li ee oboljevaju mukarci u odnosu na
ene. Izvor podataka o nepravilnom poloaju na radnom mjestu je adekvatna anamneza. Svi pacijenti koji su
ukljueni u istraivanje su sa podruja kantona Sarajevo.
Kriteriji za ukljuivanje u istraivanje
Kriteriji za ukljuivanje u istraivanje su:
1. Verifikovana hernija diska (CT, MRI, Kliniki pregled)
2. Osobe oba pola i svih starosnih grupa
3. Osobe iz navedenih zanimanja
4. Osobe koje navode neadekvatnu poziciju rada prema gore navedenim parametrima
Kriteriji za iskljuivanje iz istraivanja
Kriteriji za iskljuivanje iz istraivanja su:
1. Neadekvatna dijagnoza (radiografska analiza ne
potvruje postojanje lezije intervertebralnog diska)
2. Ne poznavanje pozicije pacijenta u toku rada (neadekvatna anamneza za ovu studiju)
Metode Istraivanja
Metoda rada je deskriptivna i analitika. Za prikupljanje
podataka koristimo se retrospektivnom metodom.
Koriteni su gore navedeni instrumenti za:
Dokazivanje lumbalnog bolnog sindroma,
verifikaciju hernije diska i
utvrivanje povezanosti diskus hernije sa nepravilnom pozicijom u toku rada.
Rezultati i diskusija
Analizom baze podataka iz CBR ambulante Stari Grad u
periodu od 01.01.2004. do 31.12.2009. godine zbog bolova u lumbalnom dijelu kime lijeeno je 913 pacijenata.
TABELA 1. Polna struktura pacijenata
Polna struktura
Mukarci
ene
Ukupno:
Br. pacijenata
537
376
913
Procentualna zastupljenost
59%
41%
100%
37
ELDAD KALJI: EFFECTS OF IMPROPER POSTURE DURING WORK ON LUMBAL PAIN SYNDROME OF DISCOGENIC ETIOLOGY
TABELA 2. Struktura pacijenata po dobnim skupinama

Starosna
struktura
00 - 07 godina
08 - 14 godina
15 - 24 godina
25 - 34 godina
35 - 44 godina
45 - 54 godina
55 - 64 godina
65 - 99 godina
UKUPNO:
Br.
pacijenata
0
1
29
137
232
283
165
66
913
%
0
0,10%
3,17%
15,00%
25,41%
30,99%
18,07%
7,22%
100%
U ukupnom uzorku od 913 pacijenata 537 (59 %) pacijenata su bili mukarci, a 376 (41 %) su bile ene. Mukarci
zbog svoje fizike konstitucije i obavljanja teih poslova
vie su izloeni nastanku lumbalnog bolnog sindroma.
Po zanimanju najvie pacijenata su radnici (268 ili
29,35 %), slijede slubenici (239 ili 26,17 %), jer su na
radnom mjestu izloeni nepravilnom poloaju. Ako
uzmemo u obzir da i ostala zanimanja koja su navedena izvan pomenute dvije grupe (radnik i slubenik),
kao to su ljekar, veterinar, nastavnik, ininjer, pravnik,
ekonomist, svrstamo u ne-radnika zanimanja, onda se
moe zakljuiti da slubenika zanimanja obuhvataju
207 sluajeva u uzorku. Prema tome u patologiji lumbalnog bola diskogene etiologije slubenika zanimanja
su najbrojnija (ukupno 466 ili 51% ukupnog uzorka).
Na osnovu anamnestikih podataka utvreno je da svih 913 pacijenata obuhvaeni studijom
ima nepravilnu poziciju tijela na radnom mjestu.
Najvei broj tretiranih pacijenata pripadao je dobnoj skupini od 45 do 54 godine (283 ili 30,99 %)
a slijede pacijenti sa starou od 35 do 44 godine
(232 ili 25,41 %), te pacijenti iz grupe 55 64 godine (165 ili 18,07 %) i 25 34 godine (137 ili 15 %).
Ispitana starosna struktura ispitanika nam ukazuje na uestalost lumbalnog bolnog sindroma izmeu 25 i 65 godina
starosti, to predstavlja radno aktivnu skupinu ispitanika.
Na osnovu registriranih podataka moemo zakljui-
TABELA 3. Struktura pacijenata po zanimanju

Redni br.
zanimanja
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Zanimanje
Ljekar
Veterinar
Nastavnik
Ininjer
Pravnik
Ekonomist
Radnik
Poljoprivrednik
Slubenik
Zanatlija
Domaica
Uenik
Student
Penzioner
Ostali
UKUPNO
Br. pacijenata
15
2
27
79
24
60
268
2
239
0
63
9
24
92
9
913
1,64%
0,21%
2,95%
8,65%
2,62%
6,57%
29,35%
0,21%
26,17%
0%
6,9%
0,98%
2,62%
10,07%
0,98%
100%
ti da su radnici bili najbrojniji pacijenti meu naim

ispitanicima (268 ili 29,35 %), a zatim slijede slubenici (239 ili 26,17 %), jer su obavljali svoje poslove u
nefiziolokom poloaju kroz dui vremenski period..
Studija je pokazala da svi ispitanici u toku radnog vremena zauzimaju poloaje tijela koji nisu optimalni i
znaajno doprinose nastanku diskogenih promjena sa
bolovima u predjelu lumbalnog dijela kimenog stuba.
Zakljuci
Najvei broj ispitanika u toku radnog vremena obavlja svakodnevne poslove u nepovoljnom
polozaju, bez ergonomski optimaliziranih uslova rada, to je osnovni razlog uestalog oboljevanja radno aktivnih od lumbalnog bolnog sindroma.
U patologiji lumbalnog bola diskogene etiologije
slubenika
zanimanja
su
najbrojnija (ukupno 466 ili 51% ukupnog uzorka).
U naem uzorku ispitanici muke populacije su bili
brojniji, sto je identino s podacima iz literature.
Literatura
1.
2.
3.
4.
38
Keli Slaana Lumbalni sindrom, Autorski rad, PANS Poslovni adresar,

Novi Sad, 2009, 1.
M. Vodanovic, Grgurev I. Profesionalne bolesti stomatologa: sindrom
bolnog vrata i sindrom bolnih kria,
Hrvatski stomatoloki vjesnik, 2007, 4.
Pecar, D. Komparacija efekata primjene Praxis metode i klasinog
pristupa u lijeenju lumbalnog bolnog
sindroma, doktorska disertacija, Medicinski fakultet Univerziteta u Sarajevu,
poseban tisak, 2003.
Poredo D., Kova M., Renduli S. Utje-
5.
6.
caj socijalno-ekonomskih uvjeta ivota na rehabilitaciju pacijenata nakon

operacije lumbalne hernije diska, Trei
kongres fizikalne medicine i rehabilitacije u Opatiji, 2004, 1.
Levin K.H.: Low Back Pain, Cleveland
Clinic, Center for Continuing education Disease Management Project Published, 2009, 1.
Laerum E., Dullerud R., Kirkesola
G., Mengshoel A.M., Nygaard Q P.,
Skouen J S., Stig L-C.,Werner E. The
Norwegian Back Pain Network- The
communication unit, Acute low back
7.
8.
pain, Interdisciplinary clinical guidelines, Oslo, 2002, 5-6.

Mclntosh G., Hall H. Low back pain
(acute), BMJ Clinical Evidence, London, 2008, 2
Pecar D., Mai I., Kari M., Kulenovi H., Pecar M., Muji M. Tretman
lumbalnog bolnog sindroma u ambulanti za fizikalnu medicinu i rehabilitaciju (Praxis), asopis ljekara Lijenika Bosne i Hercegovine, Medicinski
Arhiv,2003: 57 (2): 97-100.
www.jhsci.ba
So u ishrani studentske populacije

Univerziteta u Sarajevu
Salt in nutrition of University of Sarajevo students
Fatima Jusupovi*, Dijana Avdi, Budimka Novakovi, Arzija Paali, Jasmina Mahmutovi,
Suada Brankovi, Aida Rudi, Aida Kevri, Amra Maak-Hadiomerovi
Fakultet zdravstvenih studija, Univerzitet u Sarajevu, Bolnika 25, 71 000 Sarajevo, Bosna i Hercegovina
Medicinski fakultet, Univerzitet u Novom Sadu, Hajduk Veljkova 3, 21 000 Novi Sad, Republika Srbija
Abstract
Saetak
Introduction: The role of salt in the diet is very important,

however what effect will lead to its entry into the organism depends on the amount of salt ingested. Elevated
salt intake is a risk factor for hypertension, heart disease,
adversely affects the kidneys, helps the development of
osteoporosis. The aim was to examine sodium intake
in the student population through an objective assessment of nutrition students and the students' subjective
experience of salty foods and salty foods influence on
the organism.
Methods: The research is cross-sectional study, which is
carried out in April 2010 among students at the University
of Sarajevo.
Results: More than half of students from the FHS considers that the greatest amount of salt into the body, adding salt to food during the meal, 34% considered that it
was during the preparation of food by 10% of processed
products in the food industry and 4% said that it was the
intake of salt, which naturally found in foods. Not in a
group of students there who suffer from hypertension,
while in their families the disease is present.
Conclusions: Subjects eat a quantity of salt that are
well above the recommended. This problem must be approached in a more organized educational, health educational and research terms.
Uvod: Uloga soli u ishrani je veoma vana, meutim

kakav e efekat njen unos izazvati u organizmu, zavisi od koliine soli unesene u organizam. Povien unos
soli je faktor rizika za nastanak hipertenzije, bolesti srca,
negativno utie na rad bubrega, pogoduje razvoju osteoporoze. Cilj rada je ispitati unos natrija u studentskoj
populaciji kroz objektivnu ocjenu prehrane studenta i
kroz subjektivni doivljaj studenata o slanoj hrani i uticaju
slane hrane na organizam.
Metode: Istraivanje predstavlja cross sectional studiju
raenu u aprilu 2010. godine o znanju i praksi koritenja
soli u ishrani, na uzorku od 100 studenata Univerziteta
u Sarajevu.
Rezultati: Vie od polovine studenata sa FZS smatra
da najveu koliinu soli u organizam unose dodajui so
u hranu tokom obroka, 34 % smatraju da je to tokom
pripreme hrane, 10% putem preraenih proizvoda u prehrambenoj industriji i 4 % smatra da je to onaj unos soli
koji je prirodno sadran u namirnicama. Ni u jednoj grupi
nema studenata koji boluju od hipertenzije, dok je u njihovim porodicama ta bolest prisutna.
Zakljuci: Ispitanici u ishrani koriste koliine soli koje su
znatno iznad preporuenih. Ovom problemu neophodno
je pristupiti organizovanije u edukativnom, zdravstveno
vaspitnom i istraivakom smislu.
Keywords: students, salt, food
Kljune rijei: studenti, so, ishrana
Uvod
So je jedan od rijetkih minerala u ishrani, koji se koristi
kao zain. Rafinirana so se danas najee koristi i u najveem postotku sadri jone natrijuma i hlora, za razliku
od prirodne soli koja moe sadrati i druge mineralne
primjese. Uloga soli u ishrani je veoma vana, meutim
kakav e efekat njen unos izazvati u organizmu, zavisi
prije svega od koliine unijete soli. Vei dio soli u organizam se unosi putem gotove i polugotove hrane i konzumacijom obroka u restoranima. Skrivenu sol nalazimo u
namirnicama koje svakodnevno upotrebljavamo (1, 2).
Kao dodatak hrani je znaajan i neophodan za zdravu
probavu, za regulaciju tekuine u tijelu, za kvalitetno
funkcionisanje nervnog sistema, a kao nosilac joda, u
funkciji je preventivne zatite od guavosti, ali unos
soli mora biti u umjerenim koliinama jer nekontrolisano, preveliko unoenje soli, moe imati svoje negativne posljedice. Povien unos soli je faktor rizika
za nastanak hipertenzije, bolesti srca, negativno utie na rad bubrega, pogoduje razvoju osteoporoze (3).
* Corresponding author: Fatima Jusupovi; Faculty of Health

Studies, University of Sarajevo; Bolnika 25, 71 000 Sarajevo,
Bosnia and Herzegovina; Phone: 00 387 33 444 901
Fax: 00 387 33 264 821; e-mail: fatimajusupovic@yahoo.com
39
FATIMA JUSUPOVI ET AL.: SALT IN NUTRITION OF SARAJEVO UNIVERSITY STUDENTS
TABELA 1. Gdje se studenti najee hrane?
Mnoga istraivanja ukljuujui genetska, epidemioloka i intervencijska ukazuju na uzronu povezanost unosa soli i kardiovaskularnih
bolesti (4), te posledino i na poFakultet zdravvezanost sa mortalitetom (5). Postvenih studija
znato je da redukcija soli rezultira
Drtvenosmanjenjem krvnog tlaka i kardiotehniki fakulteti
vaskularnih incidenata. Smanjenje
soli u prehrani za samo 3 grama
dnevno moglo doprinijeti smanjenju za 13 % modanog udara i za 10% ishemine bolesti srca (6). Ako bi
smo unos soli smanjili za 50% to bi rezultiralo spaavanjem gotovo 180 000 ivota u Evropi godinje (7).
Od svih javnozdravstvenih strategija, smanjenje soli u
prehrani jedna je od najlake provedivih javnozdravstvenih mjera za iju je implementaciju potrebna meusektorska saradnja (8). Upravo zbog veliine javnozdravstvenog problema i vanosti smanjenja unosa soli 2005.
godine osnovana je Svjetska inicijativa za smanjenje
unosa kuhinjske soli u organizam (World Action on Salt
and Health WASH) koja razliitim akcijama nastoji uticati na smanjenje dnevnog unosa soli u organizam (8).
Razvijeni dio svijeta (ne samo u odnosu na tehnologiju nego i na razum) ve je prije vie godina shvatio da
je prekomjeran unos kuhinjske soli zaista viestruko
tetan za zdravlje pa poduzima niz mjera za smanjenje
unosa (9), emu bi se morala prikljuiti i naa zemlja.
Istraivanja u Hrvatskoj ukazala su na nunu podrku inicijativi za smanjenje soli, koja ukljuuje
edukaciju nae populacije s ciljem usvajanja zdravih prehrambenih navika s naglaskom na smanjeni
unos soli, promjenu zakona u smislu deklaracije prehrambenih proizvoda i uticaj na prehrambenu industriju za smanjenje soli u proizvodnom procesu (10).
Cilj rada je ispitati unos natrija u studentskoj populaciji
kroz objektivnu ocjenu prehrane studenta i kroz subjektivni doivljaj studenta o slanoj hrani i uticaju slane hrane na organizam i procijeniti potrebu za preventivnim
zdravstveno vaspitnim radom.
Metode
Istraivanje predstavlja cross sectional studiju raenu u aprilu 2010. godine o znanju, i praksi koritenja
soli u ishrani, na uzorku od 100 studenata, od kojih
je 50 studenata Fakulteta zdravstvenih studija (FZS)
i 50 studenata drutveno - tehnikih fakulteta, izabranih metodom sluajnog izbora. Istraivanje ukljuuje studente oba pola na razliitim godinama studija.
Rezultati
Analizom prehrambenih navika koje se odnose na konzumiranje soli, studenata FZS i drutveno-tehnikih
fakulteta, uoene su stanovite razlike u odnosu gdje
se studenti hrane (studentska menza, u porodici sami
40
Studentska
menza
Br.
%
U porodinom
domainstvu
Br.
%
Sami pripremaju hranu

Br.
%
Gotova
hrana
Br.
%
29
58
13
26
14
28
11
22
21
42
SLIKA 1. Uestalost dosoljavanja hrane tokom obroka kod

studenata
pripremaju hranu ili jedu gotovu hranu), to je predstavljeno na slijedeem tabelarnom prikazu (Tabela 1).
Iz Tabele 1. je vidljivo da anketirani studenti sa FZSa najee hrane u porodici (58 % ), a samo 8 % se
hrani u studentskoj menzi. Studenti sa drugih fakulteta najee hranu pripremaju sami (42%), a znaajan broj (28%) se hrani u studentskoj menzi, to
moe znaajno uticati na kvalitet ishrane. Odnos
prema dosoljavanju hrane predstavljen je na Slici 1.
Slika 1 prikazuje uestalost dosoljavanja hrane tokom obroka. U grupi ispitanika sa FZS samo 10 % ispitanika nikad ne dodaju so tokom obroka, dok 24%
uvijek dosoljava hranu, dok najvei broj ispitanika
sa drutvenih i tehnikih fakulteta hranu dosoljava
ponekad, a 16 % njih nikad hranu naknadno ne soli.
Vie od polovine studenata sa FZS smatra da najveu
koliinu soli u organizam unose dodajui so u hranu
tokom obroka, 34 % smatraju da je to tokom pripreme
hrane, 10 % putem preraenih proizvoda u prehrambenoj industriji i 4 % smatra da je to onaj unos soli koji je
prirodno sadran u namirnicama. U drugoj grupi 52 %
studenata smatraju da se najvea koliina soli unese tokom pripreme hrane, 34 % dodavajui sol tokom obroka, 8 % smatra da je to onaj unos soli koji je prirodno
sadran u namirnicama a 6 % smatra da se najvie soli
unese putem gotovih prehrambenih proizvoda (Slika 2).
SLIKA 2. Znanje o putevima kojim se tokom uobiajene ishrane najvie unese soli u organizam.
TABELA 2. Znanje o preporuenom dnevnom unosu soli.

Fakultet zdravstvenih
Drutvenostudija
tehniki fakulteti
Br.
%
Br.
%
26
52
18
36
22
44
28
56
2
4
4
8
28 studenata (56 %) smatra da je taj unos manje od

jedne kaiice, dok 8 studenata, odnosno 16 % smatra da je potrebno manje od dvije kaiice soli dnevno.
U Tabeli 2 prikazano je znanje studenata o preporuenom dnevnom unosu soli u organizam. Sa FZS 26 studenata (52 %) smatra da je dnevni preporueni unos
soli manje od pola kaiice, 22 studenta, odnosno 44
% smatra da je taj unos manje od jedne kaiice, dok
2 studenta odnosno 4 % smatraju da je potrebno manje od dvije kaiice soli dnevno. Sa drutveno-tehnikih fakulteta 18 studenata, odnosno 36 % smatra da je
dnevni preporueni unos soli manje od pola kaiice,
Slika 3 prikazuje najea oboljenja koja se po miljenju ispitanika dovode u vezu sa poveanim unosom soli u organizam. Najvei broj anketiranih
studenata smatra da povean unos soli predstavlja
rizik za nastanak hipertenzije, potom sranih problema, gojaznosti, osteoporozu i malignih oboljenja.
Slika 4 pokazuje da ni u jednoj grupi nema studenata koji
boluju od hipertenzije, dok je u njihovim porodicama ta
bolest prisutna i to u 16 porodica kod studenata FZS odnosno 32 % i u 12 porodica studenata sa drugih fakulteta.
Slika 5 pokazuje koliko esto studenti FZS konzumiraju namirnice sa visokim sadrajem soli. 64 % studenata
konzumira bijeli hljeb vie puta dnevno, 72 % studenta konzumira instant supu vie puta sedmino. Ribu u
konzervi konzumira 60 % studenta vie puta mjeseno.
SLIKA 3. Znanje o najeim oboljenjima koja su uzrokovana

poveanim unosom soli
SLIKA 4. Prisustvo hipertenzije kod studenata i kod lanova

porodice studenata
Manje od pola kaiice

Manje od jedne kaiice
Manje od dvije kaiice
41
SLIKA 5a. Uestalost konzumiranja prehrambenih namirnica sa najveim sadrajem soli kod studenata Fakulteta zdravstvenih
studija
SLIKA 5b. Uestalost konzumiranja prehrambenih namirnica sa najveim sadrajem soli kod studenata drutveno-tehnikih
fakulteta
Diskusija
U istraivanje o koliini i nainu koritenja soli u svakodnevnoj ishrani, stavovima o uticaju soli na zdravlje
uestvovalo je 100 studenata Univerziteta u Sarajevu.
Prvu grupu ine 50 studenata sa Fakulteta zdravstvenih
studija (FZS), a drugu grupu ine 50 studenata sa razliitih fakulteta drutvenog ili tehnikog usmjerenja. Studenti nisu iste dobi, spola i sa razliitih su godina studija.
Poznato je da je natrij u svjeim namirnicama prisutan
u neznatnoj koliini, a najvie ga nalazimo u gotovim ili
polu gotovim prehrambenim proizvodima. Samo 10 %
studenata prve grupe smatra da se najvie soli unosi pu42
tem proizvoda iz prehrambene industrije a taj postotak

je kod druge grupe studenata jo manji i iznosi 6 %, to
je zabrinjavajue jer do 80% dnevnog unosa natrija dobivamo pripremanjem hrane i konzumiranjem gotovih
pripravaka. Znai, glavno preventivno mjesto djelovanja trebala bi biti prehrambena industrija s ciljem smanjenog unosa natrija u razliite prehrambene proizvode.
Kao gornju granicu unosa kuhinjske soli za zdravu
populaciju, preporuuje se 6 g dnevno (1), a po nekim
autorima, u ishrani treba koristiti to manje soli - npr.
pola kaike, oko 3-4 g (2). U prvoj grupi veinski broj
studenata odnosno njih 26 smatra da je preporueni
unos soli manje od pola kaice a u drugoj grupi veina

smatra da je taj unos manje od jedne kaice odnosno
28 ispitanka se dre tog miljenja. Ispitanici prepoznaju
mogue posljedice poveanog unosa soli. Srane probleme je prepoznalo 58 % iz prve grupe i 38 % iz druge
grupe. Povien krvni pritisak su vidjeli kao posljedicu
88 % iz prve i 62 % iz druge grupe. Nedavno publicirani
podaci studije TOHP I i II (Trials of Hypertension Prevention) (11) potvrdili su povoljan uinak smanjenog
unosa soli na uestalost kardiovaskularnih komplikacija. Naime, smanjenje unosa soli za 2-2,5 g/d smanjilo je za 30% nastanak kardiovaskularnih komplikacija.
Uvaavajui znaajnu uestalost konzumacije soli u prehrani neophodna je stalna promocija pravilne prehrane,
kao i prosvjeivanje i obrazovanje cjelokupne populacije
potroaa to potvruje i nekoliko pitanja u okviru provedene studije koja su postavljena studentima Univerziteta Sarajevo. Postoji mala ali ipak znaajna razlika u
odgovorima izmeu dvije anketirane grupe. Studenti sa
Fakulteta zdravstvenih studija u poreenju sa drugom
grupom studenata manje konzumiraju sol, svjesniji su
posljedica koje donosi povean unos soli u organizam
odnosno prepoznali su vie bolesti koje se dovode u vezu
sa poveanim unosom soli u organizam. Ova razlika o
svjesnosti i znanju o uticaju soli nam pokazuje koliko je
edukacija i informiranost o odreenom problemu bitna. Studenti sa Fakulteta zdravstvenih studija su u toku
svog kolovanja sluali predmete koj se tiu pravilne
ishrane za razliku od studenata sa drutveno-tehnikih
fakulteta, to je moda razlog bolje pokazanog znanja
prve grupe. Studenti sa Fakulteta zdravstvenih studija
manje konzumiraju namirnice sa visokim sadrajem

soli od studenata sa drugih fakulteta koji su uestvovali u istraivanju, moda iz razloga to se u veem procentu hrane u porodinom domainstvu, mada je i ta
frekvenca zabrinjavajua. Ova injenica nam govori da
je potrebno uiniti puno vie u preventivnom pogledu,
to su u svom istraivanju potvrdili i u Hrvatskoj (10).
Da je razliit omjer soli koja se konzumira u populaciji
govori i Intersalt studija, provedena u 52 centra u svijetu
(uzorak inilo 10.079 osoba starih 20 59 godina) koja
je utvrdila veoma irok opseg unosa soli u razliitim
populacijama u svijetu a koji iznosi od 210 grama (3).
Rezultati istraivanja provedenog kod pacijenata lijeenih u Klinikom Centru Univerziteta u Sarajevu pokazali su da je prosjena koliina soli po lanu domainstva
vea od koliine koju preporuuje SZO. Naime, jednolana i dvolana porodica troe prosjeno po 200 grama
soli mjeseno, dok se koliina soli sa porastom broja
lanova domainstva smanjuje. Tako vielana porodica
u toku mjeseca prosjeno potroi 500 grama soli (12).
Zakljuci
Znanje studenata o preporuenim dnevnim koliinama soli nije zadovoljavajue. Prisutno je veliko uee
konzumiranja pojedinih namirnica sa visokim sadrajem soli, kao i nekontrolisano dosoljavanje hrane. Studenti su nedovoljno informisani o zastupljenosti soli u
namirnicama kao i oboljenjima koja se mogu dovesti
u vezu sa nekontrolisanim unosom soli. Ovom problemu neophodno je pristupiti organizovanije u edukativnom, zdravstveno vaspitnom i istraivakom smislu.
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Acta Medica Croatica 2010; 64: 143150.
43
www.jhsci.ba
Ishrana i fizika aktivnost uenika osnovnih

kola u odnosu na gojaznost
Relation of diet and physical activity to obesity in children
in elementary schools
Senka Dinarevi1, Suada Brankovi2*, Snjeana Hasanbegovi1
1
2
Pedijatrijska Klinika KCU Sarajevo, Patriotske lige 81, 71000 Sarajevo, Bosna i Hercegovina
Fakultet zdravstvenih studija Univerzitet u Sarajevu, Bolnika 25, 71.000 Sarajevo
Abstract
Introduction: The prevalence of pediatric obesity is increasing. Finding the most effective preventive measures
for the development of obesity in each country requires
accurate epidemiological data on the number of obese
children and adolescents, and their habits regarding nutrition and activity. The objective of this study was evaluate diet and physical activity in primary school students
in relation to the occurrence of obesity, to determine the
prevalence of overweight, mark the basic causes of this
phenomenon and to establish measures for treatment
and prevention.
Methods: pupils 1-8. grades of primary schools were
surveyed in written forms in terms of nutrition and physical activity, and measured height and weight, body mass
index (BMI-body mass index) was calculated by which
was estimated the level of nourishment: BMI> p (percentile) 5-malnutrition, p 5-85 proper body weight, p 85-95
over-nutrition, p> 95 obesity.
Results: The study comprised 2329 pupils from 10 primary schools in the Canton of Sarajevo. Number of respondents by age and gender was balanced: I-IV 1077,
V-VIII 1252; M-1226 and -1103 W. Obese and overweight
was 22.46%, 62.53% of normal weight and 15 underweight, 01%. Most children eat a sandwich from school
34.63%, and food from the bakery 23.36% and 23.64% a
sandwich from home. Still-dense juices are mostly drunk,
even 22.34% of the students, a maximum of 52.8% water. Daily candy had taken 53.21% of all primary school
students. 33.80% of the students were active on physical
activity lessons and daily only 28.27%.
Conclusions: The overweight problem in relation to the
way of nutrition and physical activity is evident. The most
important factors influencing the development of obesity:
undernutrition of children in school, the high frequency of
intake of sweets and thick juice, an inadequate level of
physical activity and sedanteran way of life.
Keywords: nutrition, obesity, physical activity
Saetak
Uvod: Prevalenca pedijatrijske gojaznosti je u porastu.
Pronalaenje najefikasnijih preventivnih mjera za nastanak gojaznosti zahtijeva precizne epidemioloke podatke o broju gojazne djece, njihovim navikama u pogledu
ishrane i aktivnosti. Cilj ove studije je bio evaluirati nain
ishrane i fiziku aktivnost kod uenika osnovnih kola
u odnosu na pojavu gojaznosti, utvrditi prevalencu prekomjerne tjelesne teine; oznaiti osnovne uzroke ove
pojave, te na ustanoviti mjere za lijeenje i prevenciju.
Metode: uenici 1-8. razreda osnovne kole su pismeno
anketirani u pogledu ishrane i fizike aktivnosti, mjerena
je tjelesna visina i teina, izraunat indeks tjelesne mase
(BMI-body mass index) prema kome je procijenjen stepen uhranjenosti: BMI > p5-pothranjenost, p 5-85 uredna
tjelesna teina, p 85-95 preuhranjenost, p > 95 gojaznost.
Rezultati: Studiju je inilo 2329 uenika iz 10 osnovnih
kola u Kantonu Sarajevo. Broj ispitanika po dobi i spolu
je bio uravnoteen: I-IV 1077, V-VIII 1252; M-1226 te
-1103. Prekomjerno tekih i pretilih je bilo 22,46%, normalno uhranjenih 62,53% a pothranjenih 15, 01%. Najvie djece je jelo sendvi iz kole 34,63%, te hranu iz
pekare 23,36%, a 23,64% sendvi od kue. Negazirane-guste sokove su najvie pili ak 22,34% uenika, a
najvie vodu 52,8%. Svakodnevno je uzimalo slatkie
53,21% svih uenika. Na asovima tjelesnog je bilo aktivno 33,80% uenika, a svakodnevno samo 28,27%.
Zakljuci: Problem prekomjerne tjelesne teine u odnosu na nain ishrane i fiziku aktivnost je evidentan.
Najznaajniji faktori koji utiu na nastanak gojaznosti su:
neadekvatna ishrana djece u koli, velika uestalost uzimanja slatkia i gustih sokova, neadekvatan nivo fizike
aktivnosti kao i sedanteran nain ivota.
Kljune rijei: ishrana, gojaznost, fizika aktivnost
* Corresponding author: Suada Brankovi, Tel. 061 145 005; 033

444 901; Fax: 033 264 821; E-mail: suada.brankovic@gmail.com
44
SENKA DINAREVI ET AL.: RELATION OF DIET AND PHYSICAL ACTIVITY TO OBESITY IN CHILDREN IN ELEMENTARY SCHOOLS
Uvod
Pandepidemija gojaznosti prema Svjetskoj Zdravstvenoj Organizaciji je jedan od najozbiljnijih zdravstvenih problema sadanjice. Prekomjernu tjelesnu
teinu ima ve 50% odraslih, a 20-30 % djece i adolescenata evropskog regiona imaju prekomjernu tjelesnu teinu (1, 2). Statistike Amerikog Centra za
kontrolu i prevenciju bolesti (CDC) takoe govore
o utrostruenju broja gojaznih u posljednjih 20 godina, te navode da 16 % djece i adolescenta dobi
6-19 godina ima prekomjernu tjelesnu teinu (3-5).
Gojaznost, smanjen nivo fizike aktivnosti i metabolike nestabilnosti predstavljaju riziko faktore za nastanak
kardiovaskularnih bolesti. Oko 60-85 % gojazne djece
postaju gojazni odrasli ljudi, to rezultira u ranijem i eem pojavljivanju hroninih nezaraznih oboljenja: hipertenzije, rane ateroskleroze, dijabetes mellitusa TIP 2,
te endokrinih, ortopedskih i psihosocijalnih poremeaja (6,7). Stoga je veoma vano dizajnirati efikasne intervencije s ciljem uspjenih strategija tretiranja i prevencije ovih stanja kod djece. Iako su genetski i hormonski
faktori mogui uzroci poveane tjelesne teine kod djece,
prekomjerno uzimanje hrane i slaba fizika aktivnost su
nedvojbeno osnovni razlog nastajanja gojaznosti (8, 9.)
Sjedenje pred televizorom i raunarom uz konzumiranje
kalorijama bogate brze hrane i slatkih napitaka dugorono stvaraju neravnoteu izmeu unoenja i potronje
energije u organizmu. Rezultat ovog disbalansa je prekomjerna tjelesna teina. (5, 10, 11, 32). Trenutno procjena
je da 20-25% dnevne energije se konzumira ispred televizora (TV). Postoji pozitivna relacija izmeu broja provedenih sati ispred TV i njihovog indexa tjelesne mase
(engl. body mass index, BMI) (33). Najegzaktniji parametar za procjenu gojaznosti je BMI koji predstavlja odnos tjelesne teine i kvadrata tjelesne visine izraen u kg/
m2. Gojazni imaju BMI vei od p (percentila) 95 (3, 8).
Alarmantan trend irenja epidemije gojaznosti, a naroito porast prevalencije kod mladih suoavaju svaku
zajednicu sa problemom koji ima znaajen ekonomske i socijalne posljedice (12, 13). Globalne mjere za
prevenciju gojaznosti su za zemlje Evropskog regiona
date u Evropskoj povelji o suprostavljanju gojaznosti
2006.godine. Pronalaenje najefikasnijih preventivnih
mjera za nastanak gojaznosti u svakoj zemlji zahtijeva precizne epidemioloke podatke o broju gojazne
djece i mladih, te o njihovom navikama u pogledu
ishrane i aktivnosti (14, 15). Ciljevi rada su bili: evaluacija naina ishrane i fizike aktivnosti u odnosu na
gojaznost, utvrivanje prevalence prekomjerne tjelesne
teine kod uenika osnovnih kola sarajevskog kantona, markiranje osnovnih uzroka, kao prijedlog mjera za lijeenje i prevenciju gojaznosti ove populacije.
Metode
U studiji koja je provedena u periodu od 1.1.2008.godine do 31.12.2009.godine, uestvovalo je 2329 uenika
deset osnovnih kola iz Kantona Sarajevo. Kod svih ispitanika je provedena anketa i mjerenje antropometrijskih parametara. Osnovne kole odabrane su po principu sluajnog izbora uzorka. Broj ispitanika po svim
razredima osnovne kole je bio uravnoteen. Uenici
su anketirani pismenim putem. Anketni listovi su originalno dizajnirani i obuhvataju pitanja o navikama u
uzimanju hrane (uestalost, koliina i vrsta) i tenosti,
te o uestalosti i intenzitetu fizike aktivnosti. Dizajn uputnika bio je prilagoen za uenike 1-4 razreda
kao i 5-8 razreda osnovne kole. Kljuna pitanja koja
su postavljena uenicima od I-IV razreda odnosila su
se na: broj obroka, vrstu hrane koja se konzumirala
na odmoru u koli (sendvi od kue, sendvi iz kole,
grickalice, ne konzumiranje hrane u koli), uestalost
konzumiraja voa i povra, vrste napitka (tokom dana
konzumiranje vode, negaziranih sokova, mlijeka, gaziranih pia), vrste hrane tokom glavnom obroka, konzumiranja hrane svakog dana, vremena provedenog u
sportu. Uenici V-VIII razreda su odgovarali na ista
pitanja kao i uenicima u niim razredima, uz odgovore i na pitanja o intenzivnoj fizikoj aktivnosti, provedenom vremenu pred kompjuterom i televizorom.
Vreno je mjerenje antropometrijskih parametara:
tjelesne visine i tjelesne teine kod svih ispitanika. Visina je odreena vertikalnim statometrom, izraena
u centimetrima (cm), a rezultati su zaokrueni na 0,5
cm. Tjelesna teina je mjerena podnom elektronskom
vagom, izraena je u kilogramima (kg), a rezultati su
zaokrueni na 0,5 kg. Istraivaki tim su inili lijenik
i diplomirana medicinska sestra. U istraivanju su uestvovala 2 tima. Ispitanici su svojevoljno uestvovali u
anketi i mjerenju. Podaci nakon unoenja u informacioni sistem bili su anonimni za sve ispitanike. Svi podaci
su statistiki obraeni prema dobnim grupama: za ispitanike od I-IV , kao i V-VIII razreda osnovne kole.
Stepen uhranjenosti je dobiven automatski na osnovu
CDC kriterija (16):
BMI < 5 percentile oznaava pothranjenost,
BMI < 85 a > 5 percentile ukazuje na urednu tjelesnu
teinu,
BMI > 85 a < 95 se ocjenjuje kao preuhranjenost,
BMI > 95 percentile se smatra gojaznou.
Rezultati
Studija je inio uzorak od 2329 ispitanika deset osnovnih kola grada Sarajeva. Odnos broja djeaka odnosno mukih ispitanika i djevojica tj. enskih ispitanika, bio je uravnoteen. Broj
ispitanika po dobi i spolu u razredima osnovne kole
iznosio je: I-IV 1077, V-VIII 1252; M-1226 te -1103.
Prikaz distrubucije pregledanih uenika po razredi45
SLIKA 2. Distribucija stepena sportske aktivnosti
SLIKA 1. Distribucija pregledanih uenika po razredima u

odnosu na pol.
TABELA 1. BMI klasifikacija uenika prema razredima i polu.
Pothranjeni (%)
BMI klasifikacija
Idealne
Prekomjerna
teine (%)
teina (%)
pretilost
(%)
I-IV
Osnovna
U: 20,86
M: 7,72
: 13,14
U: 55,26
M: 28,68
: 26,58
U: 12,28
M: 7,47
: 4,81
U: 11,58
M: 6,77
: 4,81
V-VIII
Osnovna
U: 9,16
M: 4,65
: 4,51
U: 69,80
M: 37,98
: 31,82
U: 13,07
M: 7,49
: 5,58
U: 8,00
M: 3,69
: 4,31
UKUPNO
U: 5,01
M: 6,18
: 8,82
U: 62,53
M: 33,33
: 29,20
U: 12,67
M: 7,48
: 5,19
U: 9,79
M: 3,69
: 4,56
Razredi
Osnovne
kole
TABELA 2. Distribucija kvaliteta ishrane uenika u koli.

Razredi
Osnovne
kole
I-IV
Osnovna
sendvi
od kue
(%)
sendvi
iz kole
(%)
hrana iz
pekare
(%)
ne
grickajedem u
lice (%)
koli(%)
30,69
44,63
5,04
17,68
1,98
V-VIII
Osnovna
16,57
24,62
42,67
10,96
5,27
UKUPNO
23,64
34,63
23,36
14,33
3,64
ma u odnosu na pol (Slika 1). Najvei broj djece u

koli jede sendvi iz kole 34,63%, te hranu iz pekare
23,36%, a 23,64% sendvi od kue. Grickalice u koli
jedu najvie u niim razredima osnovne kole 17,68%.
Negazirane-guste sokove su pili 22,34% uenika, a najvie vodu 52,8%.
Svakodnevno je uzimalo slatkie 53,21% svih uenika
osnovne kole.
Intenzivnu fiziku aktivnost svakog dana upranjava
36.42% uenika V-VIII razreda.
36.62% uenika V-VIII razreda osnovne kole provodi
46
TABELA 3. Distribucija vrste napitka koje uenici piju u toku

dana.
Razredi
Osnovne
kole
I-IV
Osnovna
V-VIII
Osnovna
UKUPNO
voda (%)
negazirani
sokovi
mlijeko
gazirana
pia (%)
50,88
23,19
23,37
2,6
54,72
21,50
12,23
11,55
52,80
22,34
17,80
7,08
TABELA 4. Distribucija uestalosti uzimanja slatkia

Razredi
Osnovne
kole
I-IV
Osnovna
V-VIII
Osnovna
UKUPNO
jedu slatkie svaki dan

(%)
rijetko ili povremeno

(%)
40,89
59,11
65,53
34,47
53,21
46, 79
TABELA 5. Distribucija duine vremena provedenog pred

kompjuterom i televizorom
Razredi
Osnovne
kole
V-VIII
Osnovna
<1sat (%)
23,60
1-2sata (%) 2-3 sata (%)

36,62
18,51
> 3 sata.
20,89
1-2 sata dnevno pred raunarom i televizorom, a 20.89%

vie od tri sata.
Diskusija
Gojaznost je predisponirajui faktor za nastanak mnogih hroninih nezaraznih bolesti kao to su: kardiovaskularne, hipertenzija, rana ateroskleroze, dijabetes
mellitus TIP 2, endokrine, ortopedske, psihosocijalnih
poremeaja i drugih. Prevalenca pedijatrijske gojaznosti
je u porastu. Na djetetova tjelesnu teinu utiu mnogu
faktori i to: pristup visoko energetskoj hrani, duina proJOURNAL OF HEALTH SCIENCES 2011; 1 (1)
SLIKA 3. Distribucija duine vremena provedenog pred kompjuterom i televizorom uenika V-VIII razreda osnovne kole
vedenog vremena u sedentarnim aktivnostima npr. gledanje televizije, igranje video igrica. Porast prevalencije
gojaznosti kod mladih suoava svaku zajednicu sa problemom koji ima ogromne ekonomske i socijalne posljedice. Pronalaenje najefikasnijih preventivnih mjera za
nastanak gojaznosti u svakoj zemlji zahtijeva precizne
epidemioloke podatke o broju gojazne djece i mladih,
te o njihovom navikama u pogledu ishrane i aktivnosti.
Studija uzorka 2329 ispitanika deset osnovnih kola
grada Sarajeva, u odnosu na broj djeaka odnosno mukih ispitanika i djevojica tj. enskih ispitanika je bila
uravnoteena. Stoga je ovo istraivanje reprezentativno
za kolsku populaciju osnovnih kola Kantona Sarajevo.
Kao to smo naveli, broj ispitanika po dobi i spolu je
bio uravnoteen i to: I-IV 1077, V-VIII 1252; M-1226
te -1103. Prekomjerno tekih i pretilih je bilo 22,46 %,
normalno uhranjenih 62,53% a pothranjenih 15, 01%.
Rezultati studije ukazuju da je gotovo 22.4% djece uzrasta 1-8 godina prekomjerne tjelesne teine (preuhranjeni i gojazni). Pregled 21 studije iz razliitih evropskih
zemalja indicira veu prevalencu preuhranjenosti u zapadnoj i junoj Evropi. U Mediteranskoj arei prevalenca
gojaznosti djece je ak 20-40 %, dok je broj gojaznih u
sjevernim zemljama neto nii i to u rangu 10-20 % (2).
Uestalost prekomjerne teine i gojaznosti meu djecom je u periodu izmeu 1980. i 1990. godine poveana
u razvijenim zemljama dva do pet puta: npr. za djeake
u Kanadi sa 11% na 30%. Statistika ukazuje na oko etiri
puta veu uestalost preuhranjenosti za zemlje u razvoju kao npr. u Brazilu sa 4% na 14% (6). U periodu od
1984 do 1994. godine broj preuhranjene djece dobi 4-11
godine u Velikoj Britaniji rastao je za djeake sa 10,2 %
na 13,8 %, a za djevojice sa 5,4% na 9,0% (2,6). Prema
NHANES (National Health and Nutrition Examination
Survey) studiji iz Sjedinjenih Amerikih Drava u periodu 1999-2002. godine 31.0 % djece i adolescenata dobi
2-19 godina su bili sa BMI > p 85 tj. riziko grupa za gojaznost, a 16,3 % sa BMI > 95 tj. gojazni (17). U rezultatima
nae studije prekomjernu tjelesnu teinu (BMI 85-95) su
imali priblino isti broj djeaka i djevojica analizirajui
zbirni rezultat za sve kole. Uenici sa ovakvim BMI su
riziko grupa za nastanak prave gojaznosti sa BMI > 95.
Gojaznih djevojica je bilo vie nego djeaka i to: 4.56

% prema 3,69 %. U Holandskoj studiji djevojice su u
svim vremenskim periodima od 1980-2003. godine
bile gojaznije nego djeaci. Ukupan broj preuhranjene
djece u Holandiji dobi 4-16 godina znaajno rastao od
1980. do 2003. godine. U 1980. godini prevalenca gojaznosti u Holandiji je iznosila 3,9% kod djeaka i 6,9%
kod djevojica. Ve 1997. godine ovi procenti su se poveali na 9,7% za djeake a 13% za djevojice, a posljednja studija iz 2003. godine navodi da je preuhranjenih
djeaka bili 14,5% a djevojica 17,5% (18). Prevalenca
gojaznih meu naim ispitanicima opada od 11,58 u
niim razredima osnovne kole. Ovi rezultati su slini
rezultatima holandske studije koja je pokazala najvei
broj gojazne djece meu uenicima osnovnih kola (11).
Interesantan rezultat odnosi se na injenicu da je uoeno ak 12,49 % pothranjenih uenika, sa trendom opadanja broja u viim razredima osnovne kole: od 20.869.16%. Rezultati NHANES studije iz 2003-2006. godine
ukazuju na 3,3% pothranjenh amerikanaca u dobi 2-19
godina (19), uzrokovan neredovnom ishranom i nepostojanjem regularnog kuhanog obroka u koli za
svu djecu koja bi pohaala smo jednu smjenu-ujutro.
Studija irskih i britanskih autora naglaava znaaj uine
za unoenje energetskog suvika hrane, posebno za mlau djecu (5-9 godina). Uinom se uzme i do 20% dnevnog kalorijskog unosa. Upravo je prekomjerna tjelesna
masa naih ispitanika najvie zastupljena kod mlaih
uenika. Hrana iz pekare koju najvie jedu nai uenici V-VIII razreda (42.67%) bi bila kompatibilna svojom
kalorijskom vrijednou uine britanskih adolescenata.
Pored vode koju najvie konzumira 52,80% uenika,
nazastupljenije je bilo uzimanje negaziranih sokova:
20,65%. Uenici niih razreda su najvei konzumenti ovog napitka 23,19%). Osvjeavajua pia sa dodatkom eera su postala dio svakodnevnice i navika
koja se smatra zdravom i poeljnom, pogotovu ako
se radi o vonim sokovima. Svjetska zdravstvena organizacija preporuuje da napitku dodati eeri ne bi
smjeli davati vie od 10 % dnevnog kalorijskog unosa
(21,30,31). Zaeereni napici na bazi sode imaju mali
nutritivni benefit, ali poveavaju tjelesnu teinu i rizik
od dijabetesa, karijesa zuba i fraktura kostiju. Treba
initi napore za propagiranje konzumacije vode, niskokalorijskog mlijeka i malih koliina 100% vonog
soka i to tako da na ove napitke otpada manje od 10
% ukupne kalorijske dnevne potrebe (22, 23). Slatkie,
kao najvei izvor kalorija zbog visokog sadraja eera
i masnoa, svakodnevno je konzumiralo ak 53,21 %
uenika kola Sarajevskog Kantona. Najjednostavnije je
potrebu za hranom utaiti nekim slatkiem koji trenutno, subjektivno, daje osjeaj stitosti, a takoe se veoma
brzo konzumira kako bi uenicima ostalo vremena i za
druge aktivnosti u vrijeme odmora (18, 24). etvrtina
ispitanika niih razreda osnovne kole jede slatkie sva47
ki dan, a djece ove dobne skupine je najvie meu prekomjerno tekim i gojaznim (ukupno 11,58 %). Gotovo
20 % djece dobi 3-17 godina u Njemakoj jede slatkie
svaki dan, a okoladu 16 % ispitanika. Cijenei nae
iznesene podatke, smatramo da su slatkii bitan izvor
suvine enegije ali ih grupa najvitkijih jede najvie (25).
Sportske aktivnosti je svakodnevno imala etvrtina svih
ispitivanih uenika, a 11,50 % od njih se rijetko bavi sportom. Upravo je prekomjerna tjelesna teina bila najea
kod uenika niih razreda osnovne kole koji se istovremeno najmanje svakodnevno bave sportskim aktivnostima (20%). Holandska studija navodi da samo 3-5% djece
iz osnovnih kola u velikim gradovima ima preporuenu
dnevnu fiziku aktivnost u trajanju od 1 sat (11,13,29).
Evidentna je pozitivna korelacija izmeu vremena provedenog pred televizorom i prekomjerne tjelesne teine
(14). Trenutno procjena je da se 20-25% dnevne energije konzumira ispred TV. Postoji pozitivna relacija izmeu broja provedenih sati ispred TV i njihovog BMI (33).
Giammattei i sar. navode sjedenje pred televizorom i
konzumaciju pia sa sodom kao vodei uzrok gojaznosti kod djece dobi 11-13 godina (26). Ovaj dio populacije nae kolske djece (36,62%) provodi pred televizorom
ili kompjuterom 1 ili vie sati. Polovina svih ispitivanih
uenika provodi pred ekranom 2 ili vie sati. Preporuke
iz razvijenih zemalja preporuuju maksimalno dnevno
2 sata provesti pred ekranom (26-28).Veoma je vano
vriti istraivanja u mlaim dobnim skupinama djece s
ciljem ispitivanja mehanizama koji su ukljueni u razvoj
strategija za prevenciju gojaznosti i hroninih bolesti
(32). Gledanje televizije kod djece je udrueno sa veim
BMI, ali nije poznato da li ova injenca reflektuje tjelesni fitnes ili ne i ako da, zato. Studija iz 2009.godine
navodi podatak da djeca koja gledaju TV su deblja i manje aktivna, a da aktivnost utie na dnevnu potronju
energije, to je u saglasnosti sa navodima iz nae studije.
Prezentirana studija ukazuje na postojanje gojaznosti
meu djecom sarajevskog Kantona to signalizira potrebu planiranja i provoenja preventivnih studija u
ovoj populaciji. Prventivne mjere bi se odnosile na: provoenje edukacije o principima zdrave ishrane u svim
osnovnim i srednjima kolama, prvo Kantona Sarajevo,
a zatim i Bosne i Hercegovine. Potrebno je uspostaviti

kvalitetnije asove fizikog vaspitanja, kampanje zdrave ishrane, edukacije roditelja, psihosocijalne edukacije,
strategije zdrave kolske ishrane, te intenzivirati shvatanje o pravilnom izboru ishrane i adekvatnoj fizikoj
aktivnosti. Ishranu provoditi prema savremenim smjernicam u odnosu na unos ugljenih hidrata, masti, bjelanevina, vitamina i tenosti; upranjavati redovnu fiziku
aktivnost od najmanje 1 sat vremena dnevno kako i
koli tako i u slobodnom vremenu; markirati ispitanike
sa prekomjernom tjelesnom teinom (p izmeu 85-95)
kao i gojazne (p>95), te ih uputiti u odgovarajue ustanove radi evaluacije stanja i lijeenja; angaovati timove
porodinih ljekara za praenje statusa uhranjenosti kod
kolske djece i omladine. Naim istraivanjem markirani su glavni uzroci ove pojave u naoj sredini koji mogu
biti validni u odnosu na populaciju pedijatrijske dobne
skupine uenika osnovnih kola.Najznaajniji faktori
koji utjeu na nastanak gojaznosti kod nas su: sedanteran nain ivota, velika uestalost uzimanja slatkia
i gustih sokova, te neadekvatna ishrana djece u koli.
Potrebno je uspostaviti dijaloge u kardiovaskularnoj
medicini koji se odnose na problem gojaznosti u pedijatrijskoj populaciji. Finansirati preventivne programe iz
ovog domena od strane ire drutvene zajednice. Razviti
sistematski pristup problemu kao i partnerstvo sa drutvenom zajednicom u kreiranju zdravog naina ivota.
Zakljuci
Rezultati ove studije ukazali su na evidentno postojanje
problema prekomjerne tjelesne teine uenika osnovnih kola u odnosu na nain ishrane i fiziku aktivnost.
Gotovo djece niih razreda je gojazno, a u viim razredima je to 1/5 uenika. Fizika aktivnost je slabo zastupljena kod mlae djece, a kod starijih uz neto vie
fiziki aktivnih imamo veliki procenat koji ak 1-2 sata
dnevno sjede uz televizor o raunalr to uz sjdenje u
pkoli i prilikom uenja znai da sjedei provode najvei
dio dana. Najjznaajniji faktori koji utiu na nastanak
gojaznosti su: neadekvatna ishrana djece u koli, velika
uestalost uzimanja slatkia i gustih sokova, neadekvatan nivo fizike aktivnosti kao i sedanteran nain ivota
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49
www.jhsci.ba
Sonoelastography: the method of choice for

evaluation of tissue elasticity
Fahrudin Smajlovic1*, Aladin Carovac1, Deniz Bulja2
1
2
Ultrasound private practice Doc. Dr Smajlovic, Stari drum 14, 71000 Sarajevo, Bosnia and Hercegovina
Department of Radiology, Clinical Center of University of Sarajevo, Bolnicka 25, 71000 Sarajevo, Bosnia and Herzegovina
Abstract
Ultrasound devices and methodologies have been continuously evolving and becoming more important as tools in
diagnostic medicine. Recently a new ultrasound diagnostic technique has been developed. Named sonoelastography,
the technique enables evaluation of tissue elasticity and is based on differences in stiffness (hardness, compressibility,
elasticity) of pathological changes and normal adjacent tissue. Sonoelastography (SE) is also known as Real-time
tissue elastography (RTE), Real-time sonoelastography (RTSE), Tissue type imaging (TTI) and Ultrasound Strain
Imaging Technology. It has been found useful in many medicine fields and adopted readily by clinicians of different specialties. It gives more information than conventional ultrasound in evaluation of tumors, liver disease, skeletal muscles,
rheumatoid nodules and other pathological changes. This review covers the basics of elastography, its applications,
instruments, techniques, the scoring system and the indications for elastography.
Keywords: ultrasound, elastography, sonoelastography
Introduction
A number of ultrasound modalities have been developed on the basis of knowledge about the physical
properties of ultrasonic waves and their changes during
the passing through an insonated region. Ultrasound
(US) was first used in medical application more than
50 years ago by Dr George Ludwig in United States
of America. Since that time, US devices and methodologies have been continuously evolving and becoming more important as tools in diagnostic medicine.
The second half of twentieth century is characterized
by development of many digital methods in medical
diagnostics, such as ultrasound. Each of them (us, CT,
MRI, DSA, termovision, nuclear medicine) has its advantages and limits, which resulted with their multi
dependencies (1, 2). Continuous technical advancements improved diagnostically quality of methods
mentioned above. Since 1950th many innovations
resulted in diagnostic improvements of ultrasound: Bmode, Doppler and 3d modality, harmonic imagining
and contrast (3). In last couple of years, big improvement was brought by introduction of sonoelastography, which is used for precise identification of character of pathoanatomical changes, as well as their stages.
* Corresponding author: Fahrudin Smajlovic; Ultrasound
private practice Doc. Dr Smajlovic, Stari drum 14, 71000
Sarajevo, Bosnia and Hercegovina; Tel: +387 62 790 300
Fax: +387 33 264 821; Email: charovatz@gmail.com
50
Anatomical images obtained by US devices are the result of the digital processing of reflected waves from
the part of the body investigated. The images are
composed of gray-scale structures and shapes of the
organs, as a result of different properties of the reflected waves which are caused by variations in tissue
absorption, and thus wave diffraction and reflection.
Doppler modality is developed based on the modified frequency of transmitted and reflected waves, resulting from interaction with mobile media in the
body (3, 4). Harmonic imaging has led to improvements in image resolution due to digital processing of
higher frequency of reflected and transmitted waves.
Recently a new technique in ultrasound diagnostics,
called sonoelastography, has been developed. Sonoelastography evaluates tissue elasticity and thus provides
additional information to that offered by conventional
ultrasound images (5-7). It is based on the mechanical
effect of ultrasound in the human body and its changes
depending on transmitting media (8). Elastography
analysis can also be done by magnetic resonance (MR
Elastography) ehoplanar using short sequences and low
frequency (65 Hz) of longitudinal mechanical waves
(9). Elastography in terms of transmission resembles
Hippocrates palpation, used to determine the size,
shape, hardness and flexibility of pathological changes.
Sonoelastography
Sonoelastography (SE) is also known as Real-time tissue
elastography (RTE) (Hitachi), Real-time sonoelastograJOURNAL OF HEALTH SCIENCES 2011; 1 (1)
FAHRUDIN SMAJLOVIC ET AL.: SONOELASTOGRAPHY: THE METHOD OF CHOICE FOR EVALUATION OF TISSUE ELASTICITY
sizing, has found that there

was a low interobserver
variability of results, which
favors
sonoelastography
for preoperative diagnostics of breast tumors, since
it may be less dependent
on the observer than conventional B-mode imaging
(15). Combined with BIRADS(R)-US classification
system sonoelastography
shows improved diagnostic
performance in differentiating benign and malignant
breast lesions, as reported
by the Wojcinski et al. (16).
Transabdominal sonoelasFIGURE 1. Displacement due to compression varies according to tissue stiffness. displacement in
tography has demonstrated
soft tissue is high, whereas stiff tissue show no or very little displacement.
its usefulness in diagnosis
of diffuse liver diseases, alphy (RTSE), Tissue type imaging (TTI) and Ultrasound
though this has to be confirmed in large multicentric
Strain Imaging Technology (Siemens). Elastography is
studies (17). In the study of Botar-Jid et al. there has
based on differences in stiffness (hardness, compress- been found a positive correlation between the quantitaibility, elasticity) of pathological changes and a normal
tive color parameters from the elastographic images and
adjacent tissue (10, 11). A tumor or a suspicious can- the laboratory studies (18). Preliminary results from the
cerous growth is normally 5-28 times stiffer than the
study of Hoyt et al. are encouraging and quantitative sobackground of normal soft tissue. Other pathological
noelastography may prove clinically feasible for in vivo
changes in tissue also differ in elasticity from normal
characterization of the dynamic viscoelastic properties
background tissue, which is a basis for their detection
of human skeletal muscle (19). In the musculoskeletal
and characterization. When a mechanical compres- field, sonoelastography can help improve estimation
sion or vibration is applied, the tumor deforms less
of tendon stiffness. The usefulness of elastography can
than the surrounding tissue which means that the the
be expected to increase rapidly in the musculoskelstrain in the tumor is less than the surrounding tis- etal field, as the medical professionals learn to intersue. Elastograms (images of tissue strain) have been
pret elastographic artifacts as well as to take advantage
shown to be affected by the degree of adherence of the
of the new information provided by sonoelastography
tumor to its surroundings, indicating a potential to ex- (5). Sonoelastography may help in the differential ditend elastography to tumor mobility characterisation
agnosis between rheumatoid nodules and tophi (20).
to improve diagnostic accuracy and surgical guidance.
Medical applications od sonoelastography are
Instruments and Techniques of Elastography
growing in their number every day. Many stud- Leader in sonoelastography technology is a Japanese
ies in different fields of medicine are explor- company Hitachi whose ultrasound machine, HITACHI
ing the possibilities to use this imaging tech- HI Vision with the probes EUB 8500 L 54 M, 6-13 MHz,
nique, as it is safe and gives important information. EUB L 53S, 5-9 MHz and EUB L 52, 3-7 MHZ, now
Sonoelastography has enabled new aspects in the struc- makes high-quality real-time elastography view. On the
tural and functional analysis of testicular tissue and
market we can find appliances from other companies
therefore male fertility. Schurich et al. found different
(Esaote, Toshiba, Siemens) with equal features. The first
elasticity values dependent on testicular volume and
generation of these machines appeared in 1997 (Ophir
function (12). The value of real-time elastography in
et al.), and work on them was based on processing difthe diagnosis of prostate cancer is the matter of cur- ferential radio frequency signal before and after tissue
rent research and it is possibile that this techique will
compression with probe, so called static elastography. In
be reliable diagnostic procedure in prostate cancer de- period from 2003 to 2007 was developed 2nd generation
tection (13, 14). Prospective study from Issrman et al. machines, so called Supersonic shear wave elastography
researching breast lesion sizing by B-mode imaging and
technology, rapid time options with new single crystal
probe. Probe is the sender of strong pulse waves that exsonoelastography in comparison to histopathological
51
FIGURE 2. Sonoelastographic classification by the Italian MultiCenter Team of study
and on the right presented

in gray scale. It is sufficient
to hold the probe with the
same continuous pressure
on the skin with less movement. Region of interest
(ROI) must be 1 cm wider
than the lesions because
of the possibility of comparing the difference in
compression (elasticity) to
changes and the surrounding healthy tissue. Prior
training of medical professionals is required for performing proper SE investigation. Digital processing
in SE is somewhat similar
to the Doppler modalities.
Elastography colour image,
which displays the degree of
hardness (compression) of
tissue, occurs on the basis of
the analysis and processing
of the spectrum reflected
echo signal before they are
converted into 2D image
(extended auto correlation
combined methodECAM).
Scores in Elastography
The degree of elasticity (deformation, compression)
and pathological changes
and/or parenchyma is determined in two ways: the
numerical value expressed
in kilopascals (kPa) and colFIGURE 3. Fibroadenoma with elasticity score 2. On conventional B-mode image, the lesion was
oring
with one of the three
classified as BI-RADS 4
primary colors: red, green
and blue. On the basis of
cluded the need to perform external compression (21, 22). Young module came a formula to measure the degree of
The relative stiffness of the tissues within area of in- tissue elasticity, which is as follows: E = q / E = elasticterest is described by colours superimposing on
ity, q = external pressure, = tissue deformation (comthe B-mode image. Real-time elastography can be
pression).Previous studies have shown that the value of
performed with linear scanners for transcutane- elasticity > 20kPa (E score of IIII) is characterized by
ous use, rigid endocavitary probes and with flex- benign, and those above 20kPa malignant lesions. Great
ible echoendoscopes. The probes can be used to
importance is associated to the values of E with which
compress the tissue. The elasticity modulus is calcu- we assess the degree of the diffuse changes in the liver
lated from the resulting deformation of the tissue (23). parenchyma (24). Thus, the values obtained <3kPa indiExamination technique starts an analysis of previous
cate fat infiltration of the liver, if they are 3 to 5kPa the
lesions or body parts in B-mode. After that, the simul- minimal fibrosis, from 5 to 12 its intermediate intensity,
taneous sonoelastography program starts and monitor
up to 20kPa on a strong fibrosis, and from 20 to 75kPa
screen is divided into two images a dual mode. In the
the liver cirrhosis. Real-time sonoelastography has a dileft image appears echo anatomical color display layer, agnostic specificity of 93%, sensitivity of up to 90% which
52
is higher than B-mode (25).

Another way of assessing elasticity (deformation) of the tissue is with
color (encoding) view of
scanned echo tomography
layer presented by E scores
from 1 to 3, or from 1 to
5 (Ueno et al. 2006 score
system, Italian Team of
the Multi Center Study).
Changes with the greatest
intensity of deformation
(liquid, necrotic, hemorFIGURE 4. Displacement is encoded in different colors: hard tissue is blue and soft tissue red.
rhagic, edematous content)
Conventional ultrasound image of phantom is homogenous, and shows only light shadowing dorare colored in red-yellow
sal to undefined structure. Rtse reveals well-defined, hard structure.
color, and marked with
score 1, with green on
green-yellow color are colored structures with high
intensity of deformation
(elasticity) such as normal parenchyma, and are
marked with score 2. In
blue are colored is inelastic,
rigid zones (fibrosis, infiltration) and marked with
score 3. These colors in SE
unit of I and II generation
have reversed importance:
FIGURE 5. normal elasticity of insertional portion of Achilles tendon in a health volunteer. longired color corresponding
tudinal rtse scan shows hard structured tendon (thick arrows, blue to green-coloured) and soft
on the first generation de- (yellow to red-colored) retrocalcaneal bursa (thin arrow) and and peritendinous tissue (stars)
vice correspond to blue
from second generation.
At the scale with interval 1 to 5, score 1 denote the red
(hemorrhage and fibrosis) from the tumor changes.
colored changes, score 2 areas dominated by green, This modality has proven to be useful also at echo mamscore 3 dominance of green with some blue spots (26). mography in review of breast with more density, with
Changes with score 2 and 3 are medium compress- palpation undetectable tumefact and states which are by
ible and usually are benign. Lesions with score
BI-RADS (Brest Reporting Imaging and Data System4 (domination of blue with green spots) and 5 (dark blue
USA) are graded of 3 and more (33). Normal tissues of
with pale blue ring) detect their rigid, inelastic structure
the breasts have greenish blue colours from the fat and
(fibrosis, malignancies).
orange aspect of the duct structure. Ordinary cysts are
colored in red-yellow, as opposed to those with denser
Indications for Elastography
content in which the layered coloring is in three colors
Sonoelastography is useful in determining the structure
(bull eyes). Fibro adenomas are characterized by mixed
and differentiation of focal lesions and parenchyma
colors with possible minimal blue note, with blue domiorgans. It is performed after completing the review in
nating carcinomas, and in case hyper vascularisation,
B-mode, and because of reliable detection of occult le- in addition to blue we found the zones of mixed colsions in apparently normal cases. Use is recommended
ors. Great importance elastography demonstrated durfor the ultrasound exam of brain in children, lymph
ing TRUS examination of the prostate with early cancer
nodes, thyroid, breast, scrotum and muscular-bone
detection and secure determination of the target suspistructures (27-29), liver, prostate gland, and esophagus, cious lesion for biopsy (Feloppa, Eggert-Bochum) (34).
stomach and pancreas (endoscopic SE) (14, 20, 30-33). This method will surely eventually prove even more
In review of muscle-bone system is easier to differen- quality and expand its indication area.
tiate inflammatory (edema lower score), traumatic
53
Conclusion
Sonoelastography is a complementary option to ultrasound B-mode with high diagnostic sensitivity in
detecting and assessing the nature and structure of
pathological changes in the body. It is proved to be
reliable in determining the type of cyst content in the
diagnosis of hematoma, edema, fibrosis, solid benign
and malignant lesions and the precise staging. It is
already possible to detect early stage of prostate and

many other cancers. Elastography contributes to obtaining representative samples from the suspicious lesions and directly reduces unnecessary organ trauma.
Real-time elastography will be important for providing diagnostic information and tends to become an
integral part of any quality ultrasound examination.
References
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T, Suzuki Y, Kondo H, Goshima S, et
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55
www.jhsci.ba
Promocija zdravlja obitelji djece s

intelektualnim i razvojnim onesposobljenjima
Health promotion in families who have children with
intellectual and developmental disabilities
Emira vraka*, Slobodan Loga, Dijana Avdi, Jasmina Berbi-Fazlagi
1
2
Faculty of Health Studies, University of Sarajevo, Bolnika 25, 71000 Sarajevo, Bosnia and Herzegovina
Academy of science and art of Bosnia and Herzegovina, Bistrik 7, 71000 Sarajevo, Bosnia and Herzegovina
Abstract
Saetak
Intellectual disability is the state of stopped or incomplete

mental development which is featured by the impairment
of abilities occurring at the development age and contributes to general level of intelligence, such as speech,
cognitive, motor and social abilities. Disability can occur
together or separately from other mental or physical disorders. 290 million people worldwide are estimated to have
disabilities. Health is a core element in quality of life, but
poverty, marginalization, limited access to primary health
care, and lack of health promotion knowledge compromise health. Based on a research results in all nine areas
of the family life quality (health, financial status, family
relations, support of other, support of services, influence
of values, career, leisure and recreation, and community
interaction) community could influence with the permanent preventive measures on 6 concepts of family life
quality: importance, possibility, initiative, achievement,
stability and satisfaction. The research could be of great
help for the development of comprehensive strategies for
improvement of quality of life for families that have one
or more members with intellectual disability. From inclusion we expect approach to individual and his/her family
by the society, to take into account all their diversities,
preservation and improvement of their personal physical
and mental health, for optimal possible functioning, at all
personal and social levels.
Intelektualno onesposobljenje je stanje zaustavljenog ili

nepotpunog psihikog razvoja, koje se naroito karakterie poremeajem onih sposobnosti koje se pojavljuju
tokom razvojnog perioda i koje doprinose optem nivou
inteligencije, kao to su govorne, kognitivne, motorike i
socijalne sposobnosti. Onesposobljenje moe da se javi
sa ili bez drugih mentalnih ili fizikih poremeaja. Procjenjuje se da irom svijeta ima 290 miliona ljudi s onesposobljenjima. Zdravlje je sutinski element kvaliteta ivota,
ali siromatvo, marginalizacija, ogranien pristup primarnoj zdravstvenoj zatiti i nedostatak promocije znanja o
zdravlju, ugroavaju zdravlje. Na osnovu rezultata istraivanja u svih devet domena obiteljskog kvaliteta ivota
(zdravlje, finansijsko blagostanje, odnosi u obitelji, podrka drugih ljudi, podrka servisa, uticaj vrijednosti, karijera, odmor i rekreacija i interakcija zajednice) zajednica
bi kontinuiranim preventivnim mjerama mogla da djeluje
na 6 koncepata obiteljskog kvaliteta ivota: znaaj, mogunosti, inicijative, postignua, stabilnosti i zadovoljstva.
Istraivanje bi moglo da pomogne razvoju sveobuhvatne
strategije poboljanja kvaliteta ivota obitelji koje imaju
jednog ili vie lanovana s intelektualnim onesposobljenjem. Od inkluzije oekujemo pristup pojedincu od strane drutva, koje uzima u obzir sve njegove razliitosti,
ouvanja i unapreenja njegovog tjelesnog i duevnog
zdravlja, za optimalnu moguu funkciju, na svim osobnim
i drutvenim nivoima.
Keywords: health promotion, intellectual and developmental disabilities, inclusion
Kljune rijei: promocija zdravlja, intelektualna i razvojna onesposobljenja, inkluzija
Uvod
Intelektualno onesposobljenje je stanje zaustavljenog ili
nepotpunog psihikog razvoja, koje se naroito karakterie poremeajem onih sposobnosti koje se pojavljuju
* Corresponding author: Emira vraka; Faculty of Health
Studies, University of Sarajevo, Bolnika 25, 71000 Sarajevo,
Bosnia and Herzegovina; Phone: + 387 33 444 901, Fax:
+ 387 33 264 821 E-mail: goldy_emi@yahoo.com
56
tokom razvojnog perioda i koje doprinose optem nivou

inteligencije, kao to su govorne, kognitivne, motorike
i socijalne sposobnosti. Onesposobljenje moe da se javi
sa ili bez drugih mentalnih ili fizikih poremeaja (1).
U zavisnosti od vrijednosti IQ, osobe s intelektualnim onesposobljenjem su osobe s niim IQ od 70 (2).
- Teko intelektualno onesposobljenje
- IQ < 20
- Tee intelektualno onesposobljenje
- IQ = 21-34
- Umjereno intelektualno onesposobljenje -IQ = 35-50
- Lako intelektualno onesposobljenje
- IQ = 51-70
EMIRA VRAKA ET AL.: HEALTH PROMOTION IN FAMILIES WHO HAVE CHILDREN WITH INTELLECTUAL AND DEVELOPMENTAL DISABILITIES
- Granine intelektualne sposobnosti

- IQ = 71 - 90
- Prosjena inteligencija
- IQ = 91 - 110
- Visoka inteligencija
- IQ = 111 - 120
- Vrlo visoka inteligencija
- IQ = 121 - 140
- Genijalni
- IQ > 140
Procjenjuje se da irom svijeta ima 290 miliona ljudi s
onesposobljenjima. Fondaciija za osobe s potekoama u
uenju u Velikoj Britaniji sakupila je procjene iz Evrope,
Sjeverne Amerike i Australije i sugerisala da priblino 2
% ovih populacija ima intelektualna onesposobljenja (3).
Intelektualno onesposobljenje je prilino esto u
optoj populaciji. Epidemioloka istraivanja pokazuju da priblino 1 % - 2 % cjelokupnog stanovnitva ima intelektualno onesposobljenje. ee je
zastupljeno kod mukog pola nego kod enskog (2).
Na prevalencu intelektualnog onesposobljenja utiu i brojni drugi inioci kao to je rana dijagnostika,
posebno u odnosu na genetske uzroke intelektualnog onesposobljenja. Kontrola trudnica, lijekova, socijalni uslovi ivljenja, stepen zdravstvene svijesti i
organizacija zdravstvene slube, kao i brojni drugi.
Intelektualna onesposobljenja su posljedica genetskih
faktora i faktora okruenja, posebno ili u kombinaciji.
Genetski faktori se odnose na promjene sekvenci DNA
u hromozomima elija. Faktori okruenja ukljuuju toksine (hemijske) faktore; faktore ishrane; socijalne faktore povezane s drutvenom i obiteljskom interakcijom,
takve kao stimulacija djeteta i razumjevanje odraslih;
faktore ponaanja povezane sa tetnim ponaanjem (4).
Etioloki faktori intelektualnih onesposobljenja mogu
se iroko klasifikovati na opte i specifine. Unutar
svake od ove dvije klasifikacije, etioloki faktori mogu
biti genetiki ili faktori okruenja. Priroda i stepen
onesposobljenja osobe mogu biti rezultat zajednikog
djelovanja genetskih faktora i faktora okruenja (4).
Obitelji djece s intelektualnim
i razvojnim onesposobljenjima
Obitelji djece s intelektualnim i razvojnim onesposobljenjima preivljavaju visok stepen psiholokih i
socijalnih tekoa. Te tekoe se razlikuju u zavisnosti
od prirode oboljenja djeteta (Sy. L. Down, fragilni X
sy, autizam, djeija cerebralna paraliza, epilepsija...),
uoljivosti ili teini psihofizikog stanja, odnosno od
stepena onesposobljenja (lako, umjereno, tee i teko
intelektualno onesposobljenje). Sve one izazivaju specifian stres i nameu posebne zahtjeve pred obitelj. I
obitelj i dijete moraju se prilagoditi nizu neeljenih i
neugodnih okolnosti. Nivo adaptacije obitelji na dijete
s intelektualnim i/ili razvojnim onesposobljenjem je
od izuzetnog znaaja, jer utie na cjelokupni psihofiziki razvoj djeteta. Zbog toga je veoma vano shvatiti
procese koji se dogaaju u obitelji prilikom prihvatanja i adaptacije na nastalo stanje, kako bismo unaprijed mogli prepoznati one koji su izloeni riziku (5).
Dijete s onesposobljenjem utie na obiteljsku dinamiku

i odnose lanova obitelji koji su razliiti od drugih obitelji. Za neke obitelji, ovi odnosi trpe znaajne promjene
tokom vremena. Ovo moe biti djelimino zbog nesigurnog zdravstvenog statusa djeteta, ili zbog veeg broja
odgovornosti koje se postavljaju pred lanove obitelji.
Vremenom moe doi do konflikta u obitelji, ali, s druge
strane, obitelj moe postati jaa i bliskije povezana (6).
Istraivanja su pokazala da prilagoavanje obitelji varira
prema tipu i stepenu onesposobljenja. Obitelji sa djecom
s Down-ovim sindromom su izvjestili o niem stresu od
obitelji sa djecom s autizmom ili razvojnim onesposobljenjem nepoznatog uzroka. Ovakve razlike mogu biti
rezultat djetetovog temperamenta, socijalnih odgovora
i ponaanja, pristupanosti slubi za podrku, posebno u ranom djetinjstvu. Dvije karakteristike koje su
esto udruene s visinom stepena obiteljskog stresa su:
problem ponaanja osobe s onesposobljenjem i komplikovane potrebe za njegu. Najsavremeniji nain
podrke obiteljima je prepoznavanje da je njihov
kvalitet ivota kao obitelji veoma vaan i da partnerstvo obitelj-strunjak moe biti od pomoi u pristupu svakoj oblasti obiteljskog kvaliteta ivota (7).
Kvalitet ivota obitelji
Obiteljski kvalitet ivota je holistiki multidimenzionalni koncept koji ima namjeru da predstavi sveukupnost
obiteljskog ivota. Njegova multidimenzionalna priroda
je esto predstavljena kroz sastavne dijelove, oblasti (7).
Obiteljski kvalitet ivota je predstavljen holistiki preko 9 oblasti: zdravlje obitelji, finansijsko blagostanje, obiteljski odnosi, podrka drugih, podrka slubi, uticaj vrijednosti, karijere, odmor i
rekreacija i integracija u zajednici. Svih 9 oblasti su
praene kroz 6 koncepata: znaaj, mogunosti, inicijativa, postignue, stabilnost i zadovoljstvo (8).
Zdravlje je sutinski element kvaliteta ivota, ali
siromatvo, marginalizaciija, ogranien pristup
primarnoj zdravstvenoj zatiti i nedostatak promocije znanja o zdravlju, ugroavaju zdravlje (9).
Kvalitet ivota obitelji koje imaju sina ili erku s onesposobljenjem je bilo proputeno polje od strane istraivaa kvaliteta ivota do nedavno. Koncept obiteljskog
kvaliteta ivota nije bio usmjeren na sistematski nain. Na kraju 1990-ih, zapoeta su dva velika projekta
porodinog kvaliteta ivota, jedan na Univerzitetu u
Kanzasu i drugi voen od tima istraivaa iz Australije, Kanade i Izraela. Rezultati su izneseni na meunarodnom simpozijumu u Seattle-u, u avgustu 2000 (10).
Evropska deklaracija o zdravlju djece i mladih s
intelektualnim onesposobljenjima
Evropska deklaracija o zdravlju djece i mladih s intelektualnim onesposobljenjima i njihovih obitelji potpisana je na Konferenciji Regionalnog ureda za Evropu
57
Svjetske zdravstvene organizacije Bolje zdravlje, bolji

ivot: djeca i mladi s intelektualnim onesposobljenjima i njihove obitelji, odranoj 26.-27. novembra
2010. godine u Bukuretu, Rumunija. Pokretanje ove
inicijative odraava nastojanje Svjetske zdravstvene
organizacije da prui podrku zemljama lanicama u
preduzimanju mjera i aktivnosti neophodnih za prevladavanje mnogih nedostataka u sistemima zatite
zdravlja i blaghostanja ove izuzetno vulnerabilne populacije. Cilj cjelokupne inicijative je poboljanje kvaliteta ivota i osiguranja ravnopravnog uea djece
i mladih s intelektualnim i razvojnim onesposobljenjima i njihovih obitelji u drutvenoj zajednici (11).
Deklaracija identifikuje 10 prioriteta:
1. zatita djece i mladih s intelektualnim onesposobljenjima od svih oblika zlostavljanja i zanemarivanja,
2. pravo djece na odrastanje u obiteljskom okruenju,
3. transfer njege iz ustanova u lokalnu zajednicu.
4. - 6. prioriteti bave se ranom identifikacijom intelektualnih onesposobljenja i ranom intervencijom,
osiguranjem kvalitetnih zdravstvenih usluga, te
zatitom zdravlja lanova obitelji.
7. Osnaivanje djece i mladih s intelektualnim onesposobljenjima i njihovih obitelji.
8. Edukacija ljudskih resursa u svim relevantnim
slubama i sektorima.
9. - 10. Prikupljanje podataka o potrebama djece i mladih s intelektualnim onesposobljenjima i osiguranje
kvaliteta usluga, te osiguranje finansijskih sredstava.
Stanje u Bosni i Hercegovini
U periodu 2000 - 2004. godine, Zavod za zdravstvenu
zatitu Bosne i Hercegovine je proveo istraivanje na
cijeloj teritoriji Bosne i Hercegovine, u oba entiteta i
Distriktu Brko, u 33 optine, na uzorku od 5651 porodica Bonjaka, Hrvata i Srba i ostalih. Alarmantan
podatak je da 3,4 % ispitanika ne moe ostvariti prava
na obrazovanje; 14 % nije u mogunosti dobiti zdravstvenu uslugu u najblioj zdrvstvenoj ustanovi u sluaju kada je ivot u opasnosti; 36 % ispitanih smatra da
im nije omogueno ostvarivanje prava na zdravstvenu
zatitu; 40,6 % nije u mogunosti ostvariti pravo na
rad, 50,4 % djece nije redovno vakcinisano, kod 55,7
% djece se ne prati rast i razvoj; 77,1 % trudnica nije
u mogunosti redovno i besplatno kontrolisati trudnou i obaviti porod; a 77,1 % ispitanih odustaje od lijeenja zbog nemogunosti da dobije ili plati lijek (12).
Prema podacima Federalnog ministarstva zdravstva
(2008), koja se temelje na procjeni Federalnog zavoda
za statistiku za 2006. godinu, evidentan je porast starih osoba, starijih od 65 i vie godina u strukturi stanovnitva (65%). Predviena oekivana duina ivota
u Federaciji BiH pri roenju, kree se izmeu 71 i 75
godina, to je slino podacima za BiH iz 1990, kao i
58
prosjeku zemalja koje su postale lanice EU do 2007.

godine. Stopa nataliteta je 9,3 i pokazuje trend stalnog opadanja i slina je zemljama u okruenju. Stopa
opteg mortaliteta ima srednju vrijednost od 8%/1000
stanovnika i u laganom je porastu. Dojenaka smrtnost je 9,5%/1000 ivoroenih, to je indikator dobre
zdravstvene zatite u ovom domenu. Kao posljedica
pada stope nataliteta i laganog porasta stope mortaliteta, prirataj pokazuje trend opadanja i s vrijednou od
1,3% u 2006. godini ima izrazito nepovoljno znaenje.
Osim toga, evidentno je poveanje broja oboljelih od
malignih, kardiovaskularnih oboljenja, kao i stresom
izazvanih psihikih poremeaja, dok se istovremeno
biljei pad incidencije i prevalencije tuberkuloze (13).
Prioritetni problemi za obitelji djece i adolescenata s intelektualnim onesposobljenjima, u Bosni i Hercegovini su:
nepostojanje Registra razvojnih i intelektualnih onesposobljenja, nepostojanje kontinuiranih preventivnih
mjera za sprijeavanje nastanka onesposobljenja, nepostojanje kontinuirane edukacije strunjaka multiprofesionalnog tima za rad sa obiteljima djece s intelektualnim
i razvojnim onesposobljenjima, nepostojanje kontinuirane edukacije nastavnika u redovnim kolama za rad
s djecom obuhvaenom obrazovnom inkluzijom, nepostojanje adekvatne i kontinuirane multidisciplinarne podrke zajednice za sve nivoe obrazovanja djece i
adolescenata s intelektualnim onesposobljenjima, nepostojanje odgovarajuih programa profesionalne orjentacije i zapoljavanja, kao i pratee zakonske regulative,
visoki trokovi habilitaciono-edukacionih programa za
djecu i adolescente s intelektualnim onesposobljenjima
i neadekvatno finansiranje / budetska sredstva (14).
Inkluzija
Inkluzija je postala opti termin za snani meunarodni
pokret koji zahtjeva poboljanje uslova ivota osoba s
intelektualnim i drugim onesposobljenjima. Inkluzija nastoji da osigura da osobe s onesposobljenjima ne
samo ive u zajednici, ve takoe budu vrijednovane,
prihvaene, potovane, ukljuene i imaju iste ivotne mogunosti kao osobe bez onesposobljenja (15).
U odreivanju ivotnog stila osoba s intelektualnim
onesposobljenjima uestvuju dva kljuna faktora: gdje
ive i stepen uspjeha inkluzije. Tri vana aspekta inkluzije ukljuuju integraciju, socijalnu podrku i lini
izbor. Brojne faktore koji utiu na ivotni stil osoba s
intelektualnim i razvojnim onesposobljenjima treba
podraviti da bi se na njih pozivali u budunosti. Ovo
ukljuuje line karakteristike, socijalne vrijednosti
i stavove, uloge obitelji, profesionalaca i vlade (16).
Samoodreenje se posmatra kao pravljenje izbora i
donoenje odluka u pogledu kvaliteta sopstvenog ivota bez nepotrebnog spoljanjeg uticaja. Meutim,
osobe s intelektualnim onesposobljenjima (IO) rijetko
imaju prilike da prave izbore koji se tiu njihovog iJOURNAL OF HEALTH SCIENCES 2011; 1 (1)
vota, ukljuujui i one vezane za socijalne odnose koje

e uspostavljati ili aktivnosti u kojima e uestvovati.
Okruenje koje osobama s IO ne omoguava da donosu odluke koje se tiu njihovog ivota podstie nauenu
bespomonost. Ona podrazumjeva pasivan stav prema
ivotu, u kojem osoba internalizuje negativnu sliku o
sebi, koja je dijelom kreirana i zbog njenog socijalnog
statusa - osjea se bespomonom da promjeni sopstveni ivot. Nasuprot tome, socijalna inkluzija promovie
samoodreenje, to je jo jedan razlog zbog koga su aktivnosti u zajednici znaajne u ivotima osoba s IO (17).
Kanadska studija, iz Ontarija, imala je uzorak od 504
odrasle osobe s intelektualnim i razvojnim onesposobljenjima, izdvojene od 26 000 stanovnika koji koriste
usluge vladinih servisa. 10% ive u velikim ustanovama za njegu, 19% ive u malim stanovima u zajednici,
25% ive nezavisno u zajednici sa ili bez podrke, 46%
ive sa obiteljima. Priblino 75% ivi sa obiteljima u
urbanom podruju. Veina osoba izlaze i obavljaju
poslove u zajednici, ukljuujui zabavne i rekreativne aktivnosti, bar jednom u nedjelji, i mnogi od njih
izlaze skoro svaki dan. Na suprot tome, oko dvije treine onih koji ive u institucijama izlaze i obavljaju
poslove u zajednici manje od jednom nedjeljno (18).
Svjetska zdravstvena organizacija (WHO) podrala je osnovni koncept zdravog grada, te je danas u
Evropi u Asocijaciju mrea zdravih gradova ulanjeno 16 nacionalnih mrea sa oko 1000 gradova. Plan
zdravlja trebalo bi da bude temelj javne politike u
strategiji razvoja grada Sarajeva, a za njegovo provoenje u ivot nuno je partnerstvo graana sa
strunim institucijama i svim nivoima vlasti (19).
Zakljuci
Na osnovu rezultata istraivanja u svih devet domena
obiteljskog kvaliteta ivota (zdravlje, finansijsko blagostanje, odnosi u obitelji, podrka drugih ljudi, podrka
servisa, uticaj vrijednosti, karijera, odmor i rekreacija i interakcija zajednice) zajednica bi kontinuiranim
preventivnim mjerama mogla da djeluje na 6 koncepata obiteljskog kvaliteta ivota: znaaj, mogunosti,
inicijative, postignua, stabilnosti i zadovoljstva (14).
Istraivanje bi moglo da pomogne razvoju sveobuhvatne strategije poboljanja kvaliteta ivota obitelji koje imaju jednog ili vie lanovana
s
intelektualnim
onesposobljenjem.
Od inkluzije oekujemo pristup pojedincu od strane drutva, koje uzima u obzir sve njegove razliitosti, ouvanja i unapreenja njegovog tjelesnog i duevnog zdravlja, za optimalnu moguu
funkciju, na svim osobnim i drutvenim nivoima.
Literatura
(1) Boriev Lj. Mentalna retardacija. U: Pediatrijska rehabilitacija. Savi K, Mikov
A, Nedeljkovi M. Novi Sad: Ortomedics; 1999. p. 82-85.
2. Kalianin P. Psihijatrija. Beograd: Velarta; 2001. p. 259-261.
3. Brown I, Percy M. i Machalek K. Education for Individuals with Intellectual
and Developmental Disabilities. U:
Brown I. & Percy M. A Comprehensive
Guide to Intellectual & Developmental
Disabilities. Paul H. Brookes Publishing Co. Baltimore, 2007. p. 489- 510.
4. Percy M. Factors that Cause or Contribute to Intellectual and Developmental
Disabilities. U: Brown I. & Percy M. A
Comprehensive Guide to Intellectual
& Developmental Disabilities. Paul
H. Brookes Publishing Co. Baltimore,
2007. 125-148.
5 . vraka E, Klini B. Edukacioni program za lanove obitelji djece Centra
Vladimir Nazor i osnovnih kola
Kantona Sarajevo. Veternik: Norme i
standardi u radu sa viestruko ometenim osobama. Zbornik radova sa meunarodnog Okruglog stola odranog
u Domu za decu i omladinu ometenu
u razvoju; 2006.
6. Brown I, Anand S, Fung A, Isaacs B. i
Baum N. Family quality of life: Canadi-
an Results from an international study.

Journal of developmental and Physical
disabilities. Vol. 15, No.3, September
2003.
7. Turnbull A, Poston D, Minnes P. i
Summers J. Providing Supports and
Services that Enhance a Family's Quality of Life. U: Brown I. & Percy M. A
2007. p. 561-571.
8. Brown I, Brown R, Baum N, Isaacs
B, Mzerscough T, Neikrug S, Roth D,
Shearer J and Wang M. Family Quality of Life Survay Main Caregivers
of People with Intellectual Disabilities.
Surrey Place Centre, Toronto, Canada,
2006.
9. Walsh P. A Gendered Approach to
Intellectual and Developmental Disabilities. U: Brown I. & Percy M. A
2007. p. 585-593.
10. Brown I, Anand S, Fung A, Isaacs B. i
Baum N. Family quality of life: Canadian Results from an international study.
Journal of developmental and Physical
disabilities. Vol. 15, No.3, September
2003.
11. Murko M. Evropska deklaracija o
zdravlju djece i mladih s intelektualnim tekoama i njihovih obitelji. U:
Simpozij sa meunarodnim ueem:
Analiza stanja i projekcije razvoja institucija socio-zdravstvene zatite u BiH.
Fojnica: Zbornik izlaganja, 2011. p.43.
12. Smajki A. i sar. Zdravlje stanovnitva
i zdravstveni sistem u tranziciji Bosne
i Hercegovine. Izvjetaj za 2004. Godinu. Bosna i Hercegovina Ministarstvo
civilnih poslova Zavod za zdravstvenu zatitu BiH. Sarajevo, 2005.
13. Loga S. Tranzicija Bosanskohercegovakog drutva i njene posljedice u
sferi zdravstvene zatite graana. U:
Meunarodni simpozijum. Bosna i
Hercegovina 15 godina Dejtonskog
mirovnog sporazuma. Knjiga saetaka.
Sarajevo, 2011. p. 58-60.
14. vraka E. Dvije strane sree Kvalitet
ivota obitelji kolske djece s intelektualnim onesposobljenjima. Bosanska
rije Tuzla, 2010.
15. Brown I, Parmenter T. R. i Percy M.
Trends and Issues in Intellectual and
Developmental Disabilities. U: Brown
I. & Percy M. A Comprehensive Guide
to Intellectual & Developmental Disabilities. Paul H. Brookes Publishing Co.
59
Baltimore, 2007. p.45-57

16. vraka E. ivotni stil osoba s intelektualnim onesposobljenjima. U: Simpozij
sa meunarodnim ueem: Analiza
stanja i projekcije razvoja institucija
socio-zdravstvene zatite u BiH. Fojnica: Zbornik izlaganja, 2011. p.15-17
17. Glumbi N, Brojin B, uni-Pavlovi
V. ivot u zajednici osoba s intelektu-
60
alnim potekoama. U: Unapreenje

kvalitete ivota djece i mladih. Udruenje za podrku i kreativni razvoj djece i
mladih. Tuzla, 2010. p. 307-313
18. Brown I, Buell M. K, Birkan R. and
Percy M. Lifestyles of Adults with
Intellectual and Developmental Disabilities. U: Brown I. & Percy M. A

2007. p.545-560
19. Zavod za javno zdravstvo Kantona
Sarajevo, Grad Sarajevo, Ministarstvo
zdravstva kantona Sarajevo, Sarajevo
zdravi grad. Plan zdravlja stanovnika
Grada Sarajeva. Sarajevo, 2003.
www.jhsci.ba
INSTRUCTIONS FOR AUTHORS

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

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

The manuscript to be sent to JHSci must be in accordance to the
policy on the content, appearance and quality, which is defined
in these instructions for authors and the web site of the Journal,
www.jhsci.ba. Policy about the content, appearance and quality
of scientific research in JHSci is in accordance with international
recommendations and propositions given by the International
Committee of Medical Journal Editors: "Uniform Requirements for
Manuscripts Submitted to Biomedical Journals" New Engl J Med
1997, 336:309-315 (www.icmje.org), and the recommendations of
the international working group to standardize the appearance and
quality of scientific papers: STROBE (www.strobe-statement. org),
CONSORT (www.consort-statement.org) STARDA (www.stardstatement.org) and others.
Templates
JHSci prepared templates for the layout and content of scientific
work. Templates contain all the necessary subheadings and are
supplemented with the instructions on the contents of each chapter
which could facilitate the process of writing of paper. JHSci recommends the use of templates for writing research papers. Templates
can be found on the website of the journal www.jhsci.ba at the Information for authors section.
Submission form
All the authors must sign a submission form. It contains the permission to publish the submitted manuscript, statement of conflict of
interest, a statement of respecting the ethical principles in research
and a statement on the transfer of copyright to JHSci. This form has
to be downloaded from the web site www.jhsci.ba, printed, filled
out and scanned. If there are two scanned files they must be compressed to a ZIP file.
Uploading the files
Uploading of files is exclusively done through the website www.jhsci.ba, using the web form. Web form contains four pages: 1. list of
items to be considered prior to the submission of work; 2. Information on the author for correspondence; 3. information on the
manuscript; 4. part for sending files. In the web form, authors are
required to properly fill out the information, enter correct e-mail
address for correspondence, and send the 2 files: 1. submission
form (ZIP); 2. Manuscript (doc, docx, rtf). IT IS NOT NECESSARY to send the printed version, unless the authors want to pres-
Plagiarism or duplication of a published work

Authors confirm with signature that at the time of submitting the
manuscript has not been published in its present form or substantially similar form (in paper or electronic form, including on the
website), that has not been accepted for publication in another
journal, or considered for publication in another journal. The International Committee of Medical Journal Editors has given a detailed
explanation of what is a duplicate (www.icmje.org). More information can be found on www.jhsci.ba.
Patient consent form
Protecting patients' rights on privacy is of paramount importance.
Authors should, if the editors request, send copies of patient consent form which clearly show that patients, or other subjects of the
experiments, give permission for publishing of photographs and
other material that could identify them. If authors do not have the
necessary consent for research, they must exclude the data that
identifies the subject.
Approval of the Ethics Committee
Authors must clearly state in the submission form and in the manuscript, in section "Methods", that the study conducted on human
subjects or patients is approved by the national or local Ethics committee. More information can be found in the latest version of the
Helsinki Declaration (http://www.wma.net/e/policy/b3.htm). Also,
authors must confirm that experiments involving animals were
conducted in accordance with ethical standards.
Statement on Conflict of Interest
Authors are required to include all sources of financial assistance
they received for research (grants for projects, or other sources of
funding). If you are sure that there is no conflict of interest, then
state it briefly. For more information, see the editorial in the British
Medical Journal, "Beyond conflict of interest '(http://bmj.com/cgi/
content/short/317/7154/291).
Publishing Rights
In the submission form the authors are required to transfer publishing rights to the Faculty of Health Studies. The transfer of the
copyright becomes valid if and when the manuscript is accepted for
publication. The general public has the right to reproduce the contents or a list of articles, including abstracts for internal use at their
institutions. Publisher's consent is required for the sale or distribution outside the institution and for other activities arising from the
distribution, including compilations and translations. If the copy-
61
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-
62
tions whose financial interests may depend on the material in the

manuscript, or that might affect the independence of the study. If
you are sure that there is no conflict of interest, indicate that in the
manuscript. More information can be found here:
(http://bmj.com/cgi/content/short/317/7154/291).
References
References should be numbered in order of appearance in the paper. In text, references should be put in brackets, i.e. (12). When the
reference has up to 6 authors, list all authors. If 7 or more authors,
list only first 6 and add et al. References should include name and
source of information (Vancouver style). Names of journals should
be abbreviated as in PubMed. http://www.ncbi.nlm.nih.gov/journals
Examples of references:
Article: Meneton P, Jeunemaitre X, de Wardener HE, MacGregor
GA.Links between dietary salt intake, renal salt handling, blood
pressure, and cardiovascular diseases. Rev. Physiol. 2005;85(2):679715
More than 6 authors: Hallal AH, Amortegui JD, Jeroukhimov IM,
Casillas J, Schulman CI, Manning RJ, et al. Magnetic resonance
cholangiopancreatography accurately detects common bile duct
stones in resolving gallstone pancreatitis. J Am Coll Surg.2005;
200(6):869-75.
Books: Jenkins PF. Making Sense of the chest x-ray: a hands-on
guide. New York: Oxford University Press; 2005. 194 p.
Book Chapter: Blaxter PS, Farnsworth TP. Social health and class
inequalities. In: Carter C, Peel SA, editors. Equalities and inequalities in health. 2nd ed. London: Academic Press; 1976th p. 165-78.
Internet source: HeartCentreOnline. Boca Raton, FL: HeartCentreOnline, Inc.., C2000-2004 [cited 2004 Oct 15]. Available from:
http://www.heartcenteronline.com/
Personal communications and unpublished works should not appear in the references and should be put in parentheses in the text.
Unpublished paper, accepted for publication, may be cited as a reference with the words "in press", next to the name of the journal. All
the references must be verified by the author.
Tables
Tables have to be placed after the references. Each table must be on
a separate page. Tables should NOT be formatted other than simple
borders and no colors.
Table number and title is written above the table. Table gets number
in the order of appearance in the text, with a clear and sufficiently
informative title, i.e. "Table 3. Text table name.... A reference to the
table in text is written in parentheses, i.e. (Table 3). All the abbreviations in the table must be explained in full below the table. It is desirable to give explanations and comments below the table, which
are essential for the presented results to be understood. Display the
statistical measures of variations such as standard deviation and
standard error of the mean, when applicable.
Figures
Figures have to be placed behind the references and tables (if any).
Each figure must be on a separate page. Figures get the titles by the
order of appearance in the text. The title and number are written
below the figure, for example, "Figure 3. Title text When referring to a figure in the manuscript text, number of the figure has to
be written in parentheses, eg (Figure 3). It is essential that the figure
has a clear and informative title and text below the title which explains the presented results with sufficient details. Figure resolution
must be at least 250-300 dpi, JPG or TIFF.
Units of Measure
Measures of length, weight and volume should be written in metric units (meter, kilogram, liter). Hematological and biochemical
parameters should be expressed in metric units according to the
International System of Units (SI).
www.jhsci.ba
UPUTSTVO AUTORIMA
Upute i smjernice autorima za pripremu i predaju rukopisa u Journal of Health Sciences
Ciljevi i okvir asopisa
The Journal of Health Sciences (JHSci) je internacionalni asopis
na engleskom jeziku, koji objavljuje orginalne radove iz oblasti fizikalne terapije, medicinsko-laboratorijske dijagnostike, radioloke
tehnike, sanitarnog inenjerstva, zdravlja i ekologije, zdravstvene
njege i terapije, te drugih srodnih oblasti.
Vrste znanstvenih radova koje se mogu poslati za objavljivanje
u JHS
Orginalni radovi: orginalne laboratorijske eksperimentalne i klinike studije ne bi trebao prelaziti 4500 ukljuujui tabele i reference.
Prikaz sluajeva: prezentacije klinikih sluajeva koji mogu sugerisati kreiranje nove radne hipoteze, uz prikaz odgovarajue literature. Tekst ne bi trebao prelaziti 2400 rijei.
Pregledni lanci: lanci afirmiranih znanstvenika, pozvanih da ih
napiu za asopis. Redakcija e, takoer, razmatrati i samostalne
aplikacije.
Uvodnici: lanci ili kratki uvodniki komentari koji predstavljaju
miljenja prepoznatih lidera u medicinskim istraivanjima.
Podnoenje rada za objavljivanje
Rad koji se alje u JHSci mora biti u skladu sa propozicijama o sadraju, izgledu i kvalitetu, koje je urnal propisao u ovim instrukcijama za autore i na web stranici urnala, www.jhsci.ba. Propozicije
o sadraju, izgledu i kvalitetu naunog rada u skladu su sa meunarodnim propozicijama i preporukama datim od strane International Committee of Medical Journal Editors. Uniform Requirements
for Manuscripts Submitted to Biomedical Journals New Engl J
Med 1997, 336:309315 (www.icmje.org), te preporuka meunarodnih radnih grupa za standardizaciju izgleda i kvaliteta naunih
radova: STROBE (www.strobe-statement.org) , CONSORT (www.
consort-statement.org), STARD (www.stard-statement.org) i drugih.
Predloci
JHSci je pripremio predloke (engl. template) za izgled i sadraj
naunog rada. Predloci sadre sve neophodne podnaslove i obogaeni su uputama o sadraju svakog poglavlja naunog rada, te e
autorima znatno olakati proces pisanja rada. JHSci preporuuje
koritenje predloaka za pisanje naunih radova koji se nalaze na
web stranici urnala www.jhsci.ba u dijelu Information for authors.
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
63
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
64
materijala u radu, ili koji bi mogli uticati na nepristranost studije. Ako ste sigurni da ne postoji sukob interesa, navedite to u radu.
Jo informacija se moe nai ovdje: (http://bmj.com/cgi/content/
short/317/7154/291).
Reference
Reference se trebaju numerisati prema redoslijedu pojavljivanja u
radu. U tekstu, reference je potrebno navesti u zagradama, npr. (12).
Kada rad koji citirate ima do 6 autora, navesti sve autore. Ukoliko
je 7 ili vie autora, navesti samo provih 6 i dodati et al. Reference
moraju ukljuivati puni naziv i izvor informacija (Vancouver style).
Imena urnala trebaju biti skraena kao na PubMedu. http://www.
ncbi.nlm.nih.gov/journals
Primjeri referenci:
Standardni rad: Meneton P, Jeunemaitre X, de Wardener HE,
MacGregor GA. Links between dietary salt intake, renal salt handling, blood pressure, and cardiovascular diseases. Physiol Rev.
2005;85(2):679-715
Vie od 6 autora: Hallal AH, Amortegui JD, Jeroukhimov IM, Casillas J, Schulman CI, Manning RJ, et al. Magnetic resonance cholangiopancreatography accurately detects common bile duct stones in
resolving gallstone pancreatitis. J Am Coll Surg. 2005;200(6):86975.
Knjige: Jenkins PF. Making sense of the chest x-ray: a hands-on
guide. New York: Oxford University Press; 2005. 194 p.
Poglavlje u knjizi: Blaxter PS, Farnsworth TP. Social health and
class inequalities. In: Carter C, Peel JR, editors. Equalities and
inequalities in health. 2nd ed. London: Academic Press; 1976. p.
165-78.
Internet lokacija: HeartCentreOnline. Boca Raton, FL: HeartCentreOnline, Inc.; c2000-2004 [cited 2004 Oct 15]. Available from:
http://www.heartcenteronline.com/
Osobne komunikacije i nepublicirani radovi ne bi se trebali nai u
referencama ve biti navedeni u zagradama u tekstu. Neobjavljeni
radovi, prihvaeni za publiciranje mogu se navesti kao referenca sa
rijeima U tampi (engl. In press), pored imena urnala. Reference moraju biti provjerene od strane autora.
Tabele
Tabele se moraju staviti iza referenci. Svaka tabela mora biti na posebnoj stranici. Tabele NE TREBA grafiki ureivati.
Broj tabele i njen naziv pie se IZNAD tabele. Tabela dobija broj
prema redoslijedu pojavljivanja u tekstu, a naziv treba biti jasan i
dovoljno opisan da je jasno ta tabela prikazuje. npr Table 3. Tekst
naziva tabele..... U radu prilikom pozivanja na tabelu treba napisati
broj tabele u zagradi, npr. (Table 3). Za skraenice u tabeli potrebno
je dati puni naziv ispod tabele. Poeljno je ispod tabele dati objanjenja i komentar, koji su neophodni da se rezultati u tabeli mogu
razumjeti. Prikazati statistike mjere varijacije, kao to je standardna devijacija i standardna greka sredine, gdje je primjenjivo.
Slike
Slike staviti iza referenci i tabela (ako postoje). Svaka slika mora biti
na posebnoj stranici. Slika dobija broj prema redoslijedu pojavljivanja u tekstu. Naziv i broj se piu ISPOD slike, npr. Slika 3. Tekst
naziva slike... U radu, prilikom pozivanja na sliku treba napisati
broj slike u zagradi, npr (Slika 3). Neophodno je da slika ima jasan
i indikativan naziv, a u tekstu ipod slike objasniti sliku i rezultat
koji ona prikazuje, sa dovoljno detalja da ona moe biti jasna bez
pretrage teksta koji je objanjava u radu. Slika mora biti kvaliteta
najmanje 250-300 dpi, formata JPG, TIFF ili BMP.
Jedinice mjere
Mjere duine, teine i volumena trebaju se pisati u metrikim jedinicama (meter, kilogram, liter). Hematoloki i biohemijski parametri se trebaju izraavati u metrikim jedinicama prema International System of Units (SI).

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UNIVERSITY OF SARAJEVO FACULTY OF HEALTH STUDIES

UNIVERZITET U SARAJEVU FAKULTET ZDRAVSTVENIH STUDIJA

Journal of Health Sciences

Dijana Avdi (BiH)

Demal Pecar (BiH)

Jasmina Berbi Fazlagi (BiH)

Amira Duri (BiH)

Fatima Jusupovi (BiH)

Mirsad Mufti (BiH)

Emela Muji Skiki (UAE)

Naris Pojski (BiH)

Borut Poljak (Sl)

Isabelle Rishard (F)

Zerema Obradovi Zubovi (BiH)

Dragi Bankovi (SRB)

Journal of Health Sciences

Volume 1, Number 1, April 2011

Nafija Serdarevi, Lejla Begi, Adaleta Mulaomerovi - Softi. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 - 9

Lumbosacral pain caused by blockage of dynamic

Sead ebi, Demal Pecar, Muris Pecar, Suad Sivi. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 - 13

Perioperative blood loss and diclofenac in major arthroplastic surgery

A retrospective study of surgical treatment of spinal injuries with rehabilitation program

Influence of osteoporosis risk faktors on bone mass loss in postmenopausal women

Amila Kapetanovi, Dijana Avdi, Katarina Markovi,

Epidemiological characterisics of gastrointestinal infectious

Relation of diet and physical activity to obesity in children in elementary schools

Fahrudin Smajlovic, Aladin Carovac, Deniz Bulja. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 - 55

Journal of Health Sciences

Volume 1, Number 1, April 2011

Journal of Health Sciences 2011; 1 (1)

Prof. dr Dijana Avdi

Journal of Health Sciences

Volume 1, Number 1, April 2011

The concentration of homocysteine in patients

observed in patients with homocystinuria, McCully

JOURNAL OF HEALTH SCIENCES 2011; 1 (1)

B12 as a cofactor. Tetrahydrofolate incurred converts to

excluded ischemic stroke or vascular dementia by

Patients with ischemic

Patients with ischemic

Patients with vascular

minutes serum samples were obtained by centrifugation

FIGURE 2. Serum concentration of homocysteine in patient with

* P < 0.05 (Wilcoxon signed ranks)

TABLE 3. Comparison of serum homocysteine concentration

Time of deter- Mannmination

696.50 -3.816 0.000*

335.50 -6.605 0.000*

486.00 -5.267 0.000*

614.50 -4.381 0.000*

790.50 -3.168 0.002*

serum homocysteine concentration 24-48 hours after

JOURNAL OF HEALTH SCIENCES 2011; 1 (1)

strokes, 16% (8 patients), many small ischemic focus

en serum homocysteine and the incidence of ischemic

Therefore, we excluded from our study patients with a

JOURNAL OF HEALTH SCIENCES 2011; 1 (1)

2004; 35: 2263-2269.

Journal of Health Sciences

Volume 1, Number 1, April 2011

Lumbosakralna bol uzrokovana blokiranjem

torzioni pokret i podizanje tereta u poloaju torzije

SLIKA 1. Broj pacijenata sa lumbosakralnim sindromom