JHSCI 2014 v4 I2 September

Table of contents:
RESEARCH ARTICLES
Use of colposcopy for detection of squamous intraepithelial lesions
FEA OMERAGI, AZUR TULUMOVI, ERMINA ILJAZOVI, AMELA ADAJLI,
ALIJA UKO, LARISA MEI OGIC, VLADIMIR PERENDIJA .............................................................72-76
The evaluation of B-type Natriuretic Peptide and Troponin I in acute
myocardial infarction and unstable angina
NAFIJA SERDAREVIC, AZRA DURAK-NALBANTIC ............................................................................. 77-82
Prevalence of behavioral risk factors of non-communicable diseases among
urban and rural population in the Federation of Bosnia and Herzegovina
AIDA PILAV, AIDA RUDI, SUADA BRANKOVI, VILDANA DODER................................................... 83-89
Nurses knowledge and responsibility toward nutritional assessment
for patients in intensive care units
MAHMOUD AL KALALDEH, MAHMOUD SHAHEIN.......................................................................... 90-96
The effects of education and training on self-esteem of nurse leaders
ANDREJA KVAS, JANKO SELJAK ..................................................................................................... 97-104
Influence of coffee consumption on bone mineral density in
postmenopausal women with estrogen deficiency in menstrual history
AMILA KAPETANOVI, DIJANA AVDI ........................................................................................... 105-109
Evaluation of the treatment efficacy of patients with multiple sclerosis
using Barthel index and expanded disability status scale
EDINA TANOVI, DEVAD VRABAC, ALDIJANA KADI, ADMIR RAMA, HARIS TANOVI ................. 110-113
Adherence to oral anticoagulation therapy
LANA LEKI, ALEN LEKI, ALDEN BEGI ......................................................................................... 114-119
Knowledge, perception, practices and barriers of healthcare
professionals in Bosnia and Herzegovina towards adverse drug
reaction reporting and pharmacovigilance
MAA AMRAIN, FAHIR BEI ......................................................................................................... 120-125
CASE REPORTS
Mental foramen mimicking as periapical pathology - A case report
ANUSHA RANGARE LAKSHMAN, SHAM KISHOR KANNEPADY,
CHAITHRA KALKUR ....................................................................................................................... 126-129
Gastric antral vascular ectasia: A case report
AMIR EHAJI, DENIS MAKI, ELVIRA DAMBASOVI,
FARUK USTOVI, AIDA MUJAKOVI, NIJAZ TUCAKOVI.............................................................. 130-133
LETTERS TO EDITOR
An extremely rare case of testicular malign neoplasm; alveolar subtype
of rhabdomyosarcoma with long term follow-up
TUMAY IPEKCI, YIGIT AKIN, BURAK HOSCAN, AHMET TUNCKIRAN ................................................ 134-135
http://www.jhsci.ba
Fea Omeragi, et al. Journal of Health Sciences 2014;4(2):72-76
Journal of Health Sciences

RESEARCH ARTICLE
Open Access
Use of colposcopy for detection of squamous

intraepithelial lesions
Fea Omeragi1,2*, Azur Tulumovi1,3, Ermina Iljazovi1,4, Amela Adajli5, Alija uko6,
Larisa Mei ogic7, Vladimir Perendija8
1
Department of Gynecology and Obstetrics, University of Tuzla Medical Faculty, Tuzla, Bosnia and Herzegovina, 2Obstetrics
and Gynecology Practice Omeragi, Tuzla, Bosnia and Herzegovina, 3Obstetrics and Gynecology Clinic, University Clinical
Centre Tuzla, Tuzla, Bosnia and Herzegovina, 4Institute for Pathology, University Clinical Centre Tuzla, Tuzla, Bosnia and
Herzegovina, 5Obstetrics and Gynecology Department, Health Centre Tuzla, Tuzla, Bosnia and Herzegovina, 6Obstetrics
and Gynecology Department, Cantonal Hospital Dr Safet Muji, Mostar, Bosnia and Herzegovina, 7Obstetrics and
Gynecology Department, General Hospital, Teanj, Bosnia and Herzegovina, 8Obstetrics and Gynecology Department,
Clinical Centre, Banjaluka, Bosnia and Herzegovina
ABSTRACT
Introduction: Pap smear, the main tool of cervical cancer screening is not always available, but some
patients are in urgent need for proper diagnostic. Aim of this article was to investigate accuracy of colposcopy for detection of squamous intraepithelial lesions of low or high grade (LGSIL, HGSIL) and to promote
colposcopy as useful tool for detection of patients in need for immediate further diagnostics.
Methods: Prospective multicentric study performed in B&H in 2012-2014 included 87 patients with colposcopic images related to squamous intraepithelial lesion (SIL) who formed experimental group: 56 patients
with colposcopic images related to LGSIL and 31 patients related to HGSIL. Control group included 50
patients without colposcopic abnormalities. To test accuracy of colposcopy, PAP smear and histology were
used. For statistical analysis 2 was used.
Results: 94.5% patients in experimental group had abnormal PAP test: 64.3% correlated to LGSIL
(2 = 60.48 P < 0.0001), while 64.5% correlated to HGSIL (2 = 54.23 P < 0.0001) Odds Ratio = 490; 95%
CI = 42.024 to 5713.304). HGSIL was conrmed in 27 (87%) cases by histology (CIN II/CIN III). There were
no statistically signicant differences between colposcopic nding and histology results (Yates-corrected
2 = 0.33 P = .5637).
Conclusions: This study showed high level of correlation between colposcopy and PAP results (63-64%)
and to histology for HGSIL (87%). In absence of PAP test colposcopy could be used to select patients in
need for biopsy.
Keywords: Papanicolaou test; cervical intraepithelial neoplasia; colposcopic surgical procedures
INTRODUCTION
*Corresponding author: Fea Omeragi,
M. Tita 157, 75000 Tuzla, Bosnia and Herzegovina
Phone: +387 35 262 622
E-mail: fedja_o@hotmail.com
Submitted March 27 2014 / Accepted June 1 2014
UNIVERSITY OF SARAJEVO
FACULTY OF HEALTH STUDIES
Squamous intraepithelial lesion (SIL) starts at

the cellular level as transformation and abnormal
growth of squamous cells on the surface of the cervix. In the cervical channel intraepithelial lesion
2014 Fea Omeragi, et al.; licensee University of Sarajevo - Faculty of Health Studies. This
is an Open Access article distributed under the terms of the Creative Commons Attribution
License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
http://www.jhsci.ba
METHODS
starts as squamous metaplasia, which includes

proliferation of undifferentiated reserve cells,
columnar cells and their transformation into the
squamous cells. SIL begin as cellular change at low
grade level (LGSIL) and during the time could
advance to high grade lesion (HGSIL) and cervical cancer. When detected, SIL can be successfully
treated at any stage. It is well known and scientifically proven fact that cervical cancer screening
program decreases incidence of cervical cancer by
detecting early stages of intraepithelial changes
(SIL) using PAP test as main tool (1). For the
patients with abnormal PAP smear, colposcopy is
usually the next step. However, what happens if the
cervical cancer screening is not available and there
is lack of information about disease prevention
possibility? What happens if PAP control depends
only on patients awareness of disease? In such circumstances usually, incidence of inoperable cervical cancer is very high. Where does Bosnia and
Herzegovina stand in this respect?
Study design
This was prospective multi-centric study that took

a place in Obstetrics and Gynecology practice
Omeragi, Tuzla, Health Centre of Tuzla, Health
Centre Teaanj, Cantonal Hospitals of Mostar
and Clinical Centre Banjaluka, during the period
January 2012 to January 2014.
Patients
The patients in the study were selected in accordance to colposcopic criteria for squamous intraepithelial lesions.
Experimental group marked as GroupA was formed
by 87patients. They were selected by means of colposcopy which showed one or more coploscopic
images (markers) related to squamous intraepithelial
lesion (SIL).
Colposcopic assessment of lesions was based on
the following characteristics: location of the lesion
related to Transformation zone (within or outside
of the Transformation zone), reaction to 3-5% solution of acetic acid, color intensity, surface and borders, vascularization (inter-capillary distance), speed
of emergence and time of duration.
Health system in Bosnia and Herzegovina does not

provide cervical cancer screening at the any level
(State level, Entity level, Cantonal level). System
for education of patients does not exist. Even more,
there is no cancer database. First official reports
about cancer incidence including cervical cancer were published by Public Health Institute of
Federation Bosnia and Herzegovina (PBIFB&H)
in 2007. According to that Report cervical cancer is second most common cancer in females in
the Federation Bosnia and Herzegovina (FB&H).
Furthermore in the period 1996 -2007 there were
20-25/100.000 newly detected cervical cancers in
Tuzla Canton. Only 20.3% of those cases were in
operable stages (2).
GroupA was divided in two subgroups: A1 and A2.

SubgroupA1 included 56patients with colposcopic
images that are clearly defined as characteristics of
LGSIL. SubgroupA2 included 31patients with colposcopy images that are clearly defined as characteristics of HGSIL. Extensive lesion that was spread
over the broad area of surface of the cervix, in the
same time, was indication for biopsy.
A group of 50 patients without any colposcopic
changes related to SIL formed Control group
marked as GroupB.
If we do not have cervical cancer screening program

and if we cannot provide a PAP test as frequently as
needed (due to lack of means), could we use colposcopy to select patients who are in need for a kind of
immediate PAP smear or even biopsy?
To test accuracy of colposcopy
1.
The aim of this article was to investigate accuracy

of colposcopy for detection of squamous intraepithelial lesions (SIL) and to promote colposcopy as
tool for detection of patients in need for immediate
PAP smear in the health systems without screening
program.
73
PAP smear that was taken from all patients

including experimental and control group
was analyzed. Results were interpreted using
Bethesda system: BCC - Benign Cellular
Changes, ASCUS-atypical squamous cells
undetermined significance, ASC H- atypical
squamous cell which does not exclude HGSIL,
LGSIL-low grade squamous cell intraepithelial
http://www.jhsci.ba
2.
lesion, HGSIL-high grade squamous cell

intraepithelial lesion (3).
Colposcopy directed biopsy was done in all
patients from SubgroupA2. Histological results
were analyzed as well.
as a single marker (50 or 89.3%) or associated with

vascular changes, mosaic (M) or/and punctuation
(P) (3 or 5.35%).
When detected outside of Transformation zone
(31 patients) more than one markers were seen
most often. Aceto-white epithelium (AW) is most
frequently seen, but only in two cases as a single marker (6.4%). Vascular changes (Mosaic,
Punctuations) associated with AW epithelium were
present in 29 (93.5%) cases. These images (markers) are defined as colposcopic criteria for HGSIL.
Patients with such images formed Subgroup A2
(Table1).
PAP smear was performed in all patients including control group. Distribution of PAP diagnosis (Bethesda categories) per groups was shown in
Table2.
Correlation between colposcopy and PAP diagnosis
is shown of Figure 2.
In control group there were 17(34%) PAP results
marked as abnormal. In 12 (24%) cases it was
ASC-US, atypical cells were related to inflammation
or lack of hormonal activity, while only 8% had SIL.
Previous colposcopy and/or PAP smear were without any abnormality and were not taken 24months
prior to the beginning of the study. Cancers of any
stage were not included in the study. Patients with
unclear finding were not included in study.
Statistical analysis
Results were analyzed by descriptive and analytical

statistics. Chi square test with or without Yates
correction, Odds ratio, Fischer exact test were used.
The level of significance was defined as p<0.05. For
statistical analysis software GrahPad Prism 6 for
Windows, version6 was used.
RESULTS
Experimental group and control group were homogenous. There were:

1. similar participation of nulliparous GroupA 31
or 35%, GroupB 16 or 32%,
2. similar distribution within the age groups
20-50year
3. similar participation of those who previously
did not have PAP smear and colposcopy
GroupA 31 or 35% and GroupB 19 or 38%.
In experimental group (Group A) there were
87patients with single or multiply markers for SIL.
Out of all 82(94.2%) had abnormal PAP test results
including all varieties of Bethesda nomenclature.
FIGURE 1. PAP test results in experimental and control group.
In control group (Group B) out of all, 17 (34%)

patients had abnormal PAP test. Difference is statistically significant (2 = 18.91 P < 0.0001: Odds
Ratio = 3.027; 95% CI = 1.851 to 4.951) According
to statistical analysis it means that patient with positive colposcopic markers for SIL have 3times higher
chances to have abnormal PAP test (Figure1).
Out of all patients in experimental group there
were 56 patients with colposcopic images defined
as markers for LGSIL. They formed SubgroupA1.
Those patients had markers located within the transformation zone (100%). Aceto-white (AW) epithelium was the most frequently seen (53 or 94.6%)
FIGURE 2. Results of PAP test compared to colposcopy results.

74
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ASCUS was also seen in subgroupsA1(7.1%) and

A2(3.2%).
Analysis of LGSIL and HGSIL results showed
significant differences compared to control group
LGSIL (2= 60.48 P < 0.0001); Odds Ratio = 141;
95% CI = 29.670 to 670.067), HGSIL (2 = 54.23
P < 0.0001 Odds Ratio = 490;95% CI = 42.024
to 5713.304) which means that chances for LGSIL
or HGSIL in PAP test are very high if colposcopy
result are positive too.
All thirty-one (31) patients with extensive cervical
tissue deterioration diagnosed by colposcopy as
HGSIL (Subgroup A2) had biopsy. The following
correlation between colposcopy and histopathology
diagnosis was noticed (Table3).
There are no statistically significant differences
between colposcopic finding and histology results
(Yates-corrected 2 = 0.33 P =.5637) but there is
a four times higher possibility that histology will
show cervical intraepithelial lesion of medium grade
(CINII) and two times higher possibility that histology will show high grade dysplasia (CIN III)
[Odds Ratio = 2.086; 95% CI (logit method)=
0.627202 to 6.940587] if colposcopic images

related to HGSIL are present [Odds Ratio = 4; 95%
CI (logit method)= 0.362 to 44.112].
DISCUSSION
Correlation between colposcopy and PAP, including all varieties of Bethesda nomenclature is high.
Out of all 94.2% patient had both colposcopy
and PAP results abnormal. According to statistical
analyses patient with present colposcopic images
(markers) for SIL have 3 times higher chances to
have abnormal PAP test. Such results show that colposcopy markers have high accuracy in detection
of cellular pathology. High level of correlation is
reported by other researches (3-6). PAP test results
correlate with colposcopic staging, too: 64.3% for
LGSIL (2=60.48 P < 0.0001), 64.5% for HGSIL
(2=54.23 P<0.0001). In literature similar results
are shown. Parvin at all reported correlation in
76.1% patients. Koigi-Kamau R at all reported correlation in 59-65% cases (7-9).
Biopsy or Loop excision of transformation zone
(LETZ) was performed in 31 patients from subgroupA2/HGSIL. Medium and high grade intraepithelial dysplasia (CIN II/CIN III) were found by
histology in 87% cases. There are no statistically significant differences between colposcopic finding and
histology results (Yates-corrected 2 = 0.33 P=.5637).
Correlation between colposcopic findings and histology studied by many researchers showed high level
of correlation. Savage EW at all reported accuracy
of directed biopsies in 96% cases (10). Boelter WC
3rdat all found 96-98% correlation between the colposcopic findings, biopsies and cone specimens (11).
Recent study by Boicea A at all showed correlation of
78.5% in the CIN I category, 84% in the CIN II category, 88.6% in the CIN III category (12).
TABLE 1. Frequency of the basic colposcopic

images (markers)
AW Epithelium Mosaic Punctation Total
N (%)
N (%)
N (%)
*Subgroup A1
53 (94.6)
1 (1.78) 1 (1.78)
56
**Subgroup A2
31 (100)
28 (90.3) 29 (83.5) 31
*Colposcopic images related to LGSIL; **Colposcopic images
related to HGSIL
TABLE 2. PAP test results

Groups
BCC ASC-US ASC-H LGSIL HGSIL

N (%) N (%) N (%) N (%)
N (%)
*Subgroup A1 4 (7.1) 6 (10.7) 8 (14.3) 36 (64.3) 2 (3.5)
**Subgroup A2 1 (3.2) 2 (6.4) 3 (9.6) 4 (12.9) 20 (64.5)
Group B
33 (66) 12 (24) 1 (2)
3 (6)
1 (2)
*Colposcopic images related to LGSIL; **Colposcopic images
related to HGSIL; No colposcopic abnormalities
ASC-H was detected in 12% patients in GroupA.

However, ASC-H does not exclude LG or
HGSIL(13-17). In the same time 34% abnormal
PAP smear results in control group additionally
confirm hypothesis that the tissue architecture is not
necessarily deteriorated from the beginning, particularly in cases of HPV infection.
TABLE 3. Results of histology - Subgroup A2*

Lesion
CIN I
CIN II
CIN III
N (%)
N (%)
N (%)
Patients
2 (6.4)
18 (58)
11 (35.4)
*Subgroup A2, Colposcopic images related to HGSIL
Those patients were selected for intense follow-up. Same protocol were reported by other
researchers(14,18,19).
75
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CONCLUSIONS
8. Koigi-Kamau R, Kabare LW, Machoki JM. Impact of colposcopy on management outcomes of patients with abnormal cervical cytology. East Afr
Med J. 2007;84(3):110-6.
Colposcopy is useful method for detection of early

stages of SIL. This study showed high level of correlation between colposcopy and both, PAP test and
histology. In the absence of cancer screening program and regular frequency of PAP smear diagnostics or if PAP test is not available, it can be used as a
non-invasive, inexpensive and accurate tool.
9. Gadre SS, Gupta SG, Gadre AS. Descriptive analytical study looking for
agreement between colposcopic cervical findings and cervical exfoliative
cytology. Int J Reprod Contracept Obstet Gynecol. 2013;2(3):402-405
http://dx.doi.org/10.5455/2320-1770.ijrcog20130928.
10. Savage EW. Correlation of colposcopically directed biopsy and conization
with histologic diagnosis of cervical lesions. J Reprod Med.1975;15(6):211-3.
11. Boelter WC 3rd, Newman RL. The correlation between colposcopic grading, directed punch biopsy and conisation. Am J Obstet
Gynecol.1975;122(8):945.
12. Boicea A, Ptracu A, urlin V, Iliescu D, Schenker M, Chiuu L.
Correlations between colposcopy and histologic results from colposcopically directed biopsy in cervical precancerous lesions Rom J Morphol
Embryol. 2012;53(3):735741.
CONFLICT OF INTEREST
The authors declare no conflict of interest. No specific funding was received for this study.
13. Sherman ME, Castle PE, Solomon D. Cervical cytology of atypical squamous cells-cannot exclude high-grade squamous intraepithelial lesion
(ASC-H): characteristics and histologic outcomes. Cancer 2006;108:298
305 http://dx.doi.org/10.1002/cncr.21844.
REFERENCES
1. Massad LS, Einstein MH, Huh WK et al. 2012th Updated Consensus
Guidelines for the Management of Abnormal Cervical Cancer Screening
Tests and Cancer Precursors. J Low Genit Tract Dis 2013;17(5):S1-S27
http://dx.doi.org/10.1097/LGT.0b013e318287d329.
14. Apgar BS, Kittendorf AL, Bettcher CM, Wong J, Kaufman AJ. Update on
SCCP consensus guidelines for abnormal cervical screening tests and
cervical histology. Am Fam Physician 2009;80:147-155.
2. Iljazovi E, Kesi V. Patologija cervikalne epitelne neoplazije. Univerzitet u

Tuzli. Grin, Graanica; 2011.
15. American Society for Colposcopy and Cervical Pathology. Management

of women with atypical squamous cells of undetermined significance
(ASC-US). Hagerstown (MD): ASCCP; 2007.
3. Solomon D, Davey D, Kurman R, et al. The 2001 Bethesda System: terminology for reporting results of cervical cytology. JAMA. 2002;28(16):21149
http://dx.doi.org/10.1001/jama.287.16.2114.
16. Kim JJ, Wright TC, Goldie SJ. Cost-effectiveness of alternative triage
strategies for atypical squamous cells of undetermined significance. JAMA
2002;287:2382 http://dx.doi.org/10.1001/jama.287.18.2382.
4. Singer A, Monaghan J. M, QuekS.C., Deery A.R.S. Lower Genital

Tract Precancer.Turin Italy: Bleckwell Science Ltd; 2000 http://dx.doi.
org/10.1002/9780470760093.
17. Darragh TM, Colgan TJ, Thomas Cox J, et al. The Lower Anogenital
Squamous Terminology Standardization project for HPV-associated
lesions: background and consensus recommendations from the College
of American Pathologists and the American Society for Colposcopy
and Cervical Pathology. Int J Gynecol Pathol 2013;32:76 http://dx.doi.
org/10.1097/PGP.0b013e31826916c7.
5. Gonzlez SJL, Prez GC, Celorio AG, Chvez BJ, Ros MFA. Cytologic
correlation between the Bethesda system and colposcopy biopsy. Ginecol
Obstet Mex.1998;66:330-4.
18. Waxman AG, Chelmow D, Darragh TM, et al. Revised terminology for cervical histopathology and its implications for management of high-grade squamous intraepithelial lesions of the cervix. Obstet Gynecol. 2012;120:1465.
6. Cervical cancer in adolescents: screening, evaluation, and management. Committee Opinion No. 463. American College of Obstetricians
and Gynecologists. Obstet Gynecol. 2010;116:46972 http://dx.doi.
org/10.1097/AOG.0b013e3181eeb30f.
19. Ferlay J, Shin HR, Bray F, Forman D, Mathers C and Parkin DM.
GLOBOCAN 2008, Cancer Incidence and Mortality Worldwide: IARC
CancerBase No.10 Lyon, France: International Agency for Research on
Cancer; 2010.[cited 2013 October 28]. Available from: http://globocan.
iarc.fr.
7. Parvin S, Kabir N, Lipe YS, Nasreen K, Nurul- Alam KM. Correlation of pap
smear and colposcopic finding of cervix with histopatholgiocal report in a
group of patient attending in a tertiary hospital. J Dhaka Medical College.
2013;22(1):39-44 http://dx.doi.org/10.3329/jdmc.v22i1.15604.
76
Naja Serdarevic and Azra Durak-Nalbantic. Journal of Health Sciences 2014;4(2):77-82
http://www.jhsci.ba

RESEARCH ARTICLE
Open Access
The evaluation of B-type Natriuretic Peptide and

Troponin I in acute myocardial infarction and
unstable angina
Naja Serdarevic1*, Azra Durak-Nalbantic2
1
Institute for Clinical Chemistry and Biochemistry, Faculty of Health Sciences, University Clinical Centre Sarajevo, Bolnika 25,
71000 Sarajevo, Bosnia and Herzegovina, 2Clinic for Hearth Disease and Rheumatism, University Clinical Centre Sarajevo,
Bolnika 25, 71000 Sarajevo, Bosnia and Herzegovina
ABSTRACT
Introduction: The diagnostic utility of B-type natriuretic peptide (BNP) has prompted interest in its use as
an aid in the detection of early heart failure and assessment of diseases. The rst objective of this study was
measurement of BNP and troponin I (TnI) blood levels in patients with acute myocardial infarction (AMI) and
unstable angina. The second objective of this study was to nd a correlation between TnI and BNP in blood.
Methods: The concentrations of BNP and TnI in 150 blood levels were determined using CMIA (chemiluminescent microparticle immunoassay) Architect and 2000 (Abbott diagnostics). The retrospective study
included 100 patients who were hospitalized at the Department of Internal Medicine of the University
Clinical Center Sarajevo and 50 healthy control. The reference blood range of BNP is 0-100 pg/mL and
TnI is 0.00-0.4 ng/mL.
Results: In the patients with AMI the mean value of BNP is 764.48 639.52 pg/mL and TnI is
2.50 2.28 ng/mL. The patients with unstable angina have BNP 287.18 593.20 pg/mL and TnI
0.10 0.23 ng/mL. Our studies have shown that the correlation between BNP and TnI was statistically
signicant for p < 0.05 using Student t test with correlation coefcient r = 0.36.
Conclusions: BNP and TnI levels can help to identify the patients with a high risk for cardiovascular diseases.
Keywords: BNP; TnI; acute myocardial infarction; unstable angina
INTRODUCTION
Since the discovery of the natriuretic peptides in

the 1980s and their subsequent introduction into
*Corresponding author: Assistant Professor Naja Serdarevic, PhD.,
Institute for Clinical Chemistry and Biochemistry, University Clinical
Centre Sarajevo, Faculty of Health Sciences, Bolnika 25, 71000
Sarajevo, Bosnia and Herzegovina
E-mail: serdarevicnaja@yahoo.com
Submitted June 20 2014 / Accepted August 30 2014
clinical laboratory testing in the 2000s, assays of

B-type Natriuretic peptides (BNP) have gained
widespread acceptance as important tools for
diagnosis and risk stratification in the acute-care
setting (1,2). BNP was first isolated from porcine
brain tissue, but heart has been determined to be
the major source. It is synthesized and released in
the blood in response to volume overload or conditions that cause ventricular stretch, to control fluid
and electrolyte homeostasis by interaction with
2014 Naja Serdarevic and Azra Durak-Nalbantic; licensee University of Sarajevo - Faculty
of Health Studies. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work
is properly cited.
http://www.jhsci.ba
detection of myocardial injury based on improved

sensitivity and superior tissue-specificity compared
to other available biomarkers of necrosis, including
CK-MB, myoglobin, lactate dehydrogenase, and
others. The high specificity of cTnI measurements is
beneficial in identify cardiac injury for clinical conditions involving skeletal muscle injury resulting from
surgery, trauma or muscular disease (11). The Joint
European Society of Cardiology/American College
of Cardiology/American Heart Association/World
Heart Federation Task Force redefinition of acute
myocardial infarction (AMI) is predicated on the
detection of increase or decrease of cardiac troponin
(cTn), with at least 1 concentration above the 99th
presence reference value in patients with evidence of
myocardial ischemia. Blood samples for measurement
of cTn are recommended to be drawn at presentation
and 6-9 h later to optimize clinical sensitivity for ruling in AMI (12,13). The reference range for troponin
I (TnI) in serum is 0.00-0.032g/mL.
renin-angiotensin-aldosterone system. Pre-proBNP

(134 amino acids) is synthesized in the cardiac myocytes and it is processed to a proBNP (108 amino
acids) precursor molecule.
BNP is realized from cardiac myocytes due to
their stretching, volume overload and high filling
pressure(3-5). It is a neurohormone produced in the
ventricular myocardium in response to dilatation and
pressure overload, and its plasma concentration correlates with the magnitude of pressure and/or volume
overload. As markers of neurohormonal activation,
BNP and NT-proBNP were subsequently studied
within clinical trials of acute coronary syndrome
(ACS) as adjuncts to risk stratification and have
been associated with short and long term mortality
in (ACS) patients, even after adjusting for the presence of congestive heart failure (6,7). The levels of
BNP increase with decreasing functional capacities
and elevated levels in the patients with heart failure
(HF) indicate disease progression. BNP levels are very
high in the patients with HF, but remain low in the
patients with acute dyspnea due to other causes such
as chronic obstructive pulmonary disease, asthma or
obesity. Plasma BNPvalues increase with increasing
age and are higher in women than in men (2).
In our study we have measured BNP and TnI blood

levels in the patients with ACS in a first 12 hours
and investigate correlation with peak value of TnI.
METHODS
Unstable angina, for example is a common transitory phase of coronary ischemia, bordering on myocardial infarction (MI). It is a strong relationship
with BNP and outcomes in ACS patients (8).
Patients
Our research included patients (n = 100) and

50healthy control group in period from January till
September 2011. The retrospective study included
patients who were hospitalized at the Heart Disease
Department at the University Clinical Center
Sarajevo. In our study we included patients with acute
myocardial infarction (AMI) and unstable angina.
The clinical spectrum of ACS consists of ST elevated
myocardial infarction (STEMI) and non-ST elevated
myocardial infarction (NSTEMI)/or unstable angina
(UA), which are classified using electrocardiography
(ECG) changes. The study included patients who had
a level of BNP more than 100 pg/mL and level of
TnI more than 0.032g/mL. Our research included
determination of BNP and TnI in blood of patients
in a first 12hours of ACS symptoms.
It has been previously reported that 21% of ambulatory patients with established chronic heart failure
who are stable may have plasma BNP levels less than
100 pg/mL. All commercially available BNP assays
incorporate the value 100 pg/mL as the diagnostic cut off (9). If BNP level is 100-500 pg/mL that
requires further diagnostic evaluation (grey zone).
If BNP is higher than 500 pg/mL there is probability of the hearth failure (10).
Troponins I, T and C are structural proteins bound to
the thin filaments (actin) in striated muscle. Asmall
amount (5-8%) of troponin exists free in the cytosol.
Elevated levels of cTnI (above the values established
for non-MI specimens) are detectable in serum within
4 to 6 hours after the onset of chest pain, reach peak
concentration in approximately after 8 to 28hours,
and remain elevated for 3 to 10 days following MI.
Cardiac troponin is the preferred biomarker for the
The healthy control group included patients without AMI and unstable angina using electrocardiography (ECG), BNP level < 100 pg/mL and TnI
level <0.032 g/mL. The patients with history of
78
pulmonary thromboembolism, acute and chronic

renal failure, end stage renal disease, sepsis, liver
cirrhosis, chronic obstructive lung disease, hyperthyroidism and adult respiratory distress syndrome
were excluded from the study. The research was
done respecting ethical standards in the Helsinki
Declaration.
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Following another incubation and wash, pre-trigger

and trigger solutions are then added to the reaction
mixture. The pre-trigger solution (hydrogen peroxide)
creates an acidic environment to prevent early release
of energy (light emission), helps to keep microparticles
from clumping and splits acridinium dye off the conjugate bound to the microparticle complex (this action
prepares the acridinium dye for the next step). The
trigger solution (sodium hydroxide) dispenses to the
reaction mixture. The acridinium undergoes an oxidative reaction when it is exposed to peroxide and an
alkaline solution. This reaction causes the occurrence
of chemiluminescent reaction. N-methylacridone
forms and releases energy (light emission) as it returns
to its ground state. The resulting chemiluminescent
reaction is measured as relative light units (RLU).
A direct relationship exists between the amount of
BNP in the sample and RLU detected by Architect
System optics. The concentration of BNP or TnI will
be read relative to a standard curve established with
calibrators of known BNP and TnI concentration.
Specimen preparation
Na-EDTA plasma should be used for the Architect

BNP assay. Samples should be collected in plastic
collection tubes, because the BNP molecule has
proven to be unstable in glass containers. Specimens
containing blood cells or particle matters may give
inconsistent results and must be clarified by centrifugation prior to testing. Specimens with BNP assay
value exceeding 5000.0 pg/mL are flagged with the
code >5000.0pg/mL and may be diluted using
the Automated Dilution Protocol. The samples for
determination of TnI should be collected in the
tubes with gel. The TnI assay concentration greater
than 50 ng/mL may be diluted using the Automated
Dilution Protocol. The patients samples of blood
were collected in Na-EDTA and gel Vacutainer
test tubes (Becton Dickinson, Rutherford, NJ
07,070U.S.) in volume of 3.5 mL.
The results were statistically analyzed using NCSS

and statistical software SPSS version 12.0 software,
determined by the average value (x), standard deviation (SD) or median and interval. The date were not
distributed normally we use Mann Whitney U-test.
Pearson correlation test was used to assess association between measured parameters. P Values less
than <0.05 was considered as statistically significant.
Assays
All immunoassays require the use of labeled material

in order to measure the amount of antigen or antibody. A label is a molecule that will react as a part of
the assay, so that a change in signal can be measured
in the blood after added reagent solution. CMIA is a
noncompetitive sandwich assay technology to measure analytes. The amount of signal is directly proportional to the amount of analyte present in the sample.
RESULTS
The serum concentrations of BNP and TnI in the

patients with AMI (acute myocardial infarction)
and unstable angina are shown in Table 1. The study
included 100 patients (53 men and 57women), they
were classified depending on their diagnosis and
healthy control group without ACS. The average age
was 64 years for the AMI patients, and 61 years for
the patients with unstable angina. The value of BNP
and TnI was higher in the group with AMI than
the group with unstable angina. The healthy control
group had a lower concentration of BNP and TnI
than the patient groups.
Chemiluminescent microparticle
immunoassay CMIA
Architect BNP or TnI assay is a two-step immunoassay to determine the presence of BNP and TnI in
human blood using CMIA technology. As a first
step, sample, assay diluent and anti-antibody-coated
paramagnetic particles are combined. BNP or TnI
present in the sample binds to the anti-coated microparticles. After incubation and wash, anti-acridinium-labeled conjugate is added in the second step.
Using Mann Whitney U test we made comparison of

BNP and TnI levels among the groups including the
79
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TABLE 1. The mean concentration of biochemical parameters in groups with AMI, unstable angina and healthy control
BNP (pg/mL)
SD
SEM
Median
Interval
TnI (ng/mL)
SD
SEM
Median
Interval
AMI group
764.48
639.52
90.44
585.25
260-4441
2.5
2.28
0.32
2.19
0.31-7.07
Unstable angina group

287.18
593.2
83.44
98.1
18-2514
0.1
0.23
0.0033
0.02
0.00-1.10
patients with AMI, unstable angina and the healthy

control group. According to Mann-Whitney U test
for = 5% the difference between concentrations of
BNP in the patients with AMI and the patients with
unstable angina were significant. The same test for
= 5% has shown a significant difference between
concentrations of BNP in patients with AMI and
healthy control group. Using Mann Whitney U test
we made comparison between serum TnI concentration in the group of AMI patients and the healthy
control group. The results between the groups were
statistically significant for P<0.05. The same test
has shown a significant difference between concentrations of TnI in the patients with AMI and the
patients with unstable angina for P<0.05.
Healthy control group

18.74
7.64
1.08
19.1
10-33.10
0.01
0.024
0.0034
0
0.00-0.09
P value
p <0.001
p <0.001
ischemia induced by increase in ventricular wall

stress that induced release of BNP. The TnI elevations
are seen in multiple chronic cardiac and noncardiac
conditions, a rise or fall in serial measurement of
TnI levels strongly supports an acutely evolving
cardiac injury such as, most commonly, acute myocardial infarction(14). In our study we found significant elevated levels of plasma BNP and TnI in
acute myocardial infarction. In our study we determined the value of BNP 764.48 639.52 pg/mL
(260-4441 pg/mL) in the patients with AMI. The level
of TnI in the group with AMI was 2.502.28ng/mL
(0.31-7.07 ng/mL). Grybauskiene R. and al. (15)
have got the mean concentration of TnI 0.499ng/mL
(0.07-2.89 ng/mL) and BNP level 758 pg/mL
(206-2158 pg/mL). In our study patients with
unstable angina had the concentration of BNP
287.18 593.20 pg/mL (18-2514 pg/mL) and
TnI level 0.10 0.23 ng/mL (0.00-1.10 ng/mL)
and healthy control group has concentration of
BNP 18.74 7.64 pg/mL (10-33.10 pg/mL) and
TnI level 0.010.024 ng/mL (0.00-0.09 ng/mL).
It is a lower concentration of BNP and TnI than
in the patients with AMI, the results are shown
in Table 1. The other researchers have got results
of BNP 70.2 53.3 pg/mL in the patients with
unstable angina (16). In the present study, we
have shown significantly higher BNP plasma
level by patients with AMI in compare BNP level
in healthy group results are shown in Table 1.
The similarly results have got Morita and al. (17)
and Richards and al. (18). Patients with elevated
plasma BNP levels (>80pg/mL) had a significantly
higher incidence of new heart failure and all-cause
In our study we found a significant correlation

between the average concentrations of TnI and
BNP with Pearson correlation coefficient (r=0.36).
Regression equation revealed a slope of 344.09 and
a y axis intercept of 457.83. The results between
average concentrations of TnI and BNP were statistically significant for P<0.05 using Student ttest,
the results are shown in Figure 1.
DISCUSSION
Natriuretic peptides elevations have shown the correlation with wall stress, and thus provided functional information. The level of plasma BNP depends
on the equilibrium between myocardial secretion as
compensatory response to injury or wall stress and
an amount and activity of expressed guanylyl cyclasetype BNP receptors and also peripheral degradation
rate of BNP through neutral endopeptidases. The
80
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Correlation between Troponin I and BNP
Plasma BNP concentration (pg/mL)
6000
5000
y = 344,09x + 457,83
2
R = 0,1334
4000
3000
2000
1000
0
0
Serum concentration of Troponin I (ng/mL)
FIGURE 1. Comparison of TnI and BNP in blood measured by Architect CMIA correlation coefficient r = 0.36.
and it surrounding ischemic but viable myocardium

whose extent differs(20). Studies have shown that
BNP secretion and BNP mRNA expression are
increased mainly in the borderline region between
the infracted and non-infracted regions. The stimulus for this appears to be increased all stress directly
related to the infarction. The clinical ischemia is
result of extensive necrosis is associated with release
of BNP. Ischemia itself rather than changes in wall
stress secondary to ischemia might promote BNP
release (21,22). Our study show that BNP can predict high risk features in ACS such as more severe
underlying atherosclerosis, left ventricular hypertrophy and burden of ischemic insult. The patients
with higher BNP have worse prognosis of AMI even
with normal value of TnI. Therefore BNP could be
used as a marker of myocardial necrosis as well as
marker of risk for myocardium ischemic viable.
mortality than those with a normal plasma BNP

level (<or=80pg/mL) (19). In our study, patients
with BNP level 80 pg/mL have stayed longer in the
Department of Heart Diseases and had a higher
incidence of new heart failure. The data of While
HD and al. (14) have shown that BNP concentration is increased during AMI and occurring after
the first AMI. BNP concentration in plasma during
AMI is strongly related to the marker of myocardial necrosis reflecting the extent of injured myocardium, and to degree of acute heart failure. During
AMI BNP levels correlated strongly with TnI. In
our study we have got good correlation of BNP and
TnI in patients with AMI. In correlation between
BNP and troponin we got correlation coefficient
r=0.36 with statistical significance for p<0.05. The
results are shown in Figure1. The other researchers
have got results of BNP and troponin correlation
with correlation coefficient r=0.273-0.70 (15, 19).
Necrosis and apoptosis of myocytes in AMI are contributions of progressive left ventricle dysfunction.
Therefore we have done a correlation between BNP
and TnI to contribute that BNP as TnI could be a
marker of myocytes necrosis in patients with AMI.
The results of Karcaiauskaite have shown a correlation coefficient r=0.72 indicating strongly correlation between BNP and TnI. The reason why we got
lower correlation coefficient is a fact that BNP gene
transcription is increased both in infracted tissue
CONCLUSION
In our study BNP plasma levels are significant

higher in AMI in compared with unstable angina
group and healthy control group. Plasma level BNP
was elevated in patients with left ventricular (LV)
dysfunction. Serial measurements of plasma BNP
and TnI concentrations might be a useful tool for
identification of patients at risk of developing AMI
and unstable angina. In patients with ACS BNP
81
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10. Maisel A, Mueller C, Adams JRK, Anker DS, Aspromonte N, Cleland JG

et al. Review: Sstate of art: Using natriuretic peptide levels in clinical
practice. Eur J Heart Fail 2008:10 (9):824-39. http://dx.doi.org/10.1016/j.
ejheart.2008.07.014.
adds important prognostic information to clinical

and laboratory variables as well as levels of troponin.
Determination of BNP rise could be used for quick
and easy estimation of infarction size. BNP together
with TnI levels in acute phase of myocardial infarction might be useful in predicting subsequent cardiac function.
11. Hamm CW, Basssand JP, Angewall S. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent
ST evaluation. Eur Heart J 2011:32:2999-3054.
12. Mehta SR, Granger CB, Boden WE. TIMACS Investigatiors. Early versus
delayed invasive intervention in acute coronary syndromes. N Engl J Med.
2009;360 (21):2165-2175. http://dx.doi.org/10.1056/NEJMoa0807986.
13. Alpert JS, Thygesen K, Antman E, Bassand JP. Myocardial infarction redefined: a consensus document of The Joint European Society of Cardiology/
American College of Cardiology Committee for the redefinition of myocardial infarction. J Am Coll Cardiol. 2000; 36 (3):959-969. http://dx.doi.
org/10.1016/S0735-1097(00)00804-4.
The authors declare that they have no competing

interests.
14. While HD, Norris RM, Brown MA, Brandt PW, Whitlock RM, Wil CJ. Left
ventricular end systolic volume as the major determinant of survival after
recovery from myocardial infarction. Circulation 1987;76:44-51. http://dx.
doi.org/10.1161/01.CIR.76.1.44.
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McCabe CH, et al. The prognostic value of B-type natriuretic peptide in
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Aida Pilav, et al. Journal of Health Sciences 2014;4(2):83-89
http://www.jhsci.ba

RESEARCH ARTICLE
Open Access
Prevalence of behavioral risk factors of

non-communicable diseases among urban and
rural population in the Federation of Bosnia and
Herzegovina
Aida Pilav1,2*, Aida Rudi2, Suada Brankovi2, Vildana Doder3
1
Sector for Public Health, Monitoring and Evaluation, Federal Ministry of Health, Sarajevo, Bosnia and Herzegovina, 2Faculty
of Health Studies, University Sarajevo, Sarajevo, Bosnia and Herzegovina, 3Sector for Project Implementation, Federal
Ministry of Health, Sarajevo, Bosnia and Herzegovina
ABSTRACT
Introduction: The objective of the paper is to analyze and to assess prevalence of the major behavioral
risk factors among adult population (25-64 years of age) in the rural and urban areas in the Federation of
Bosnia and Herzegovina (FBIH).
Methods: Data were taken from cross-sectional population survey on the health status population in the
FBIH. To ensure a sample representative for the adult population in the FBIH it was applied the two-stage
stratied systematic sample. The survey covered a total of 2735 adult population aged 25-64 years, of
which 1087 in the urban areas and 1648 in rural areas.
Results: The prevalence of smoking among men in rural areas is signicantly higher than among men
in urban areas (69% vs. 55%), while the prevalence of smoking among women is higher in urban than
in rural areas (45% vs. 31%). There is no statistically signicant difference in prevalence of obesity and
physical activity according to the age groups among men and women in the urban and rural areas. The
frequency of changes in behavior related to acquiring healthy living habits in the rural areas is statistically
signicant among men and women, while in the urban areas there is no statistical signicance among
the sexes.
Conclusions:. The results indicate that there are no signicant differences in prevalence of factor risks in
urban and rural areas. Prevalence of unhealthy lifestyles is high, and the results should be used to improve
standard planning of health promotion-prevention programs.
Keywords: smoking; obesity; urban-rural differences
INTRODUCTION
*Corresponding author: Aida Pilav, MD PhD, Sector for Public
Health, Monitoring and Evaluation, Federal Ministry of Health,
Titova 9, 71 000, Sarajevo, Bosnia and Herzegovina
Telephone: +357 33 210 114, E-mail: idanap@bih.net.ba
Submitted May 20 2014 / Accepted August 24 2014
The health care systems of countries are facing challenges of ensuring comprehensive protection aimed
at reducing burden of diseases and early death from
the non-communicable diseases (NCDs) through
2014 Aida Pilav, et al.; licensee University of Sarajevo - Faculty of Health Studies. This is
an Open Access article distributed under the terms of the Creative Commons Attribution
http://www.jhsci.ba
areas in the FBIH in order to examine possibilities

of existence of differences, which is necessary for
designing evidence-based population programs and
interventions.
integrative approaches from health promotion and

disease prevention to the management of NCDs at
strategic level (1).
Smoking, unhealthy eating habits and lack of physical activity with consequent obesity are proven
major risk factors for NCDs, especially diseases of
the cardiovascular system (CVDs), as well as for
subsequent events; hypertension, glucose intolerance and hyperlipidemia. These risk factors are also
indicators of major preventable health problems
and their regular monitoring within the population
makes a good basis for setting and implementing
evidence-based preventive and promotional programs (1,2).
METHODS
Data were taken from cross-sectional population

surveys on the health status population in the
FBIH. Population surveys were carried out by the
Federal Ministry of Health (FMoH) and the Federal
Public Health Institute (FPHI) in the period from
November 2012 to January 2013, as a part of primary health care reform process in the FBIH with
purpose to measure performance in the health care
system and public health.
In the last decades the health care systems of countries with clear and strong recommendations of the
World Health Organization (WHO) implement
activities to reduce prevalence of these risk factors
that are proven to be preventable. These are not
activities of health care sector only, but also activities of other government bodies, which represents
the base of the new WHO European policy Health
2020 (3,4).
To ensure a sample representative for the adult

population in the FBIH it was applied the twostage stratified systematic sample. Sample frame is a
master sample of visiting sites and households from
2009, which was prepared by the Federal Institute
of Statistics (FIS).
The first sampling stratums were visiting sites stratified by type of settlement-urban and rural, and by
the cantons in the FBIH (ten cantons). The second
sampling stratums were households. The visiting
sites were selected by Lahiri method of sampling,
which means the selection probabilities are not
equal, but the probability of selection is proportional
to the size of the primary unit, wherein the size of
the primary unit is represented by the number of
secondary sampling units, or households within the
primary unit. Households were selected by systematic method, which means that the choise probabilities were the same. Stratification of units was made
according to the type of settlement (urban/rural).
The allocation of households was made proportionally to size of settlement types, taking care to include
all cantons in the FBIH. In this population were not
included collective households such as student hostels, residential colleges, nursing homes, prisons etc.
The increase in emergence of NCDs is recorded in

the Federation of Bosnia and Herzegovina (FBIH)
through the figures from the regular health-statistical data, including mortality and morbidity
data(5,6). Prevalence of the risk factors is assessed
from periodic cross-sectional population surveys.
The first cross-sectional study population and risk
factors for NCDs in a representative sample of
the population in the FBIH was conducted in the
autumn of 2002. The survey conducted in FBIH in
2002 was taken as a baseline survey, when significant prevalence of smoking habits, physical inactivity and obesity, as critical risk factors for emergence
of NCDs, was assessed among adult population in
the FBIH (7).
Ten years later, in 2012, a cross-sectional survey
was conducted on the sample of adult population
aimed at evaluating state of health of population
and assessing prevalence of risk factors in the FBIH.
The survey was conducted in line with internationally established standards and protocols (8-10).
Out of 1752 households that made the pattern in

the FBIH, the survey was conducted in 1402households (RR 80%). From this number, 40% of households were in urban areas and 60% in rural areas.
Respondents were all adult members of the household aged 18 years and older. For the purpose of
comparison with the results of a cross-sectional
The paper shows analyses and assessment of prevalence of main behavioral risk factors among adult
population (25-64years of age) in urban and rural
84
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survey that was conducted in the FBIH in 2002,

the document analyzed the results of the adult
population aged 25-64 years. The survey covered
a total of 2735 adult population aged 25-64years,
of which 1087 in the urban areas and 1648 in rural
areas.
represent the data index of structure and relative

relations. Statistical significance was tested by 2
test. Frequency of each observed variable relative
to the place of residence (urban/rural), sex and age
subgroup was examined by descriptive statistical
analysis.
The study was conducted in accordance with the

Helsinki Declaration, which defines the ethical principles of biomedical research on humans. All participants were informed of the purpose of research, and
were explained that use of data is needed solely for
research purposes. The study included a standardized
questionnaire and anthropometric measurements.
RESULTS
Smoking
In the total sample in FBIH 37% of women and

63% of men are every day smokers. Prevalence of
smokers among men in rural areas is significantly
higher than among men in urban areas (69% vs.
55%), while the prevalence of smoking among
women is significantly higher in urban than in rural
areas (45% vs. 31%).
The questionnaire included questions about behavioral risk factors (smoking, physical activity, nutrition habits), while anthropometric measurements
included measurements of height, weight, blood
pressure and biochemical analysis of capillary blood
samples (blood sugar, cholesterol and triglycerides).
Prevalence of daily cigarette smokers in urban areas

is increased by the respondents age among both
sexes, especially among women. In the group of
respondents between 55-64years of age the prevalence is equal both among men and women (18%).
There is no statistically significant difference in
prevalence of smoking according to the age groups
among respondents of both sexes in the urban areas
(2=3.2 df=2 p=0.358) (Table1).
Information on smoking was obtained from a set

of questions that were set to respondents. Daily
smokers were respondents who currently smoke or
who have smoked in the previous month prior to
the survey.
Physical activity was estimated from a set of questions about the frequency of physical activity in leisure time. Respondents who identified themselves
to exercise two or more times a week (issue related to
the intensity of exercise that accelerates breathing or
sweating), were all categorized as having moderate
physical activity.
In the rural areas prevalence of smoking habits is

higher among men and lower among women and
it also increases with age of respondents of both
sexes, especially among women. In the group of
respondents between 45-54years of age prevalence
TABLE 1. Prevalence of smoking according to age and sex,
urban/rural differences
Increased awareness of risk factors and the change

in eating habits, were both estimated by set of questions about habit changes in the past year.
Physical measurements, among others things,
included the measurements of height and weight.
Height was measured by an stadiometer that was
attached to the wall or to a special holder. Weight
was measured in light clothing using digital scales.
Obesity has been described in terms of BMI (body
mass index) and was expressed in kg/m3.
Men
Women
Age (years)
Men 25-34 y
Women 25-34 y
Men 35-44 y
Women 35-44 y
Men 45-54 y
Women 45-54 y
Men 55-64 y
Women 55-64 y
Fieldwork was carried out by ten trained teams.

The data were analyzed using SPSS for Windows,

version 17.0. Descriptive statistics was used to
85
Urban areas
Daily smokers
N
%
197
55
163
45
Rural areas p value

Daily smokers
N
%
329
69
p<0.01
148
31
p<0.01
53
36
53
38
55
59
36
30
66
33
104
41
87
53
72
21
27
22
27
23
28
36
18
19
20
22
32
28
26
36
22
14
p>0.1
p>0.1
p>0.1
p>0.1
p>0.1
p>0.1
p>0.1
p>0.1
http://www.jhsci.ba
is higher among women than among men (36%

vs.26%). There is no statistically significant difference in prevalence of smoking according to the age
groups among respondents of both sexes in the rural
areas (2=6.91 df=2 p=0.075) (Table1).
Generally, there is no significant difference in the

recommended physical activity among men and
women in the urban areas (2=3.43 df=3 p=0.330)
(Table 3). The percent of physically active women
and men, especially in younger age groups, is the
same in urban areas. Generally, there is no significant difference in the recommended physical
activity among men and women in the rural areas
(2=2.66 df=3 p=0.446) (Table3).
Obesity
In total 22% of respondents in the FBIH is obese

(BMI >30kg/m2). Prevalence of obesity in urban
areas is 20%, while the prevalence of obesity in
rural areas is 24%. In the urban areas prevalence of
obesity is higher among men than among women
(18% vs. 17%), while in the rural areas prevalence
of obesity is higher among women than among
men (37% vs. 28%). There is no statistically significant difference in prevalence of obesity among
men and women in the urban areas and rural areas
(Table2).
Healthy behaviors
The respondents were asked whether, in the last

TABLE 2. Prevalence of obesity according to age and sex,
urban/rural differences
Men
Women
Age (years)
Men 25-34 y
Women 25-34 y
Men 35-44 y
Women 35-44 y
Men 45-54 y
Women 45-54 y
Men 55-64 y
Women 55-64 y
Prevalence of obesity in the urban areas increases by

the respondents age among both sexes. There is no
statistically significant difference in prevalence of
obesity according to the age groups among men and
women in the urban areas (2=5.50 df=3 p=0.138)
(Table2).
Prevalence of obesity in the rural areas increases by
the respondents age among both sexes, and among
both sexes aged between 35-54years it grows much
faster than in the urban areas. Prevalence of obesity
is lower among both sexes between 55-64years in
the rural areas than among respondents in the urban
areas. There is no statistically significant difference
in prevalence of obesity according to the age groups
among men and women in the rural areas (2=4.41
df=3 p=0.250) (Table2).
Urban areas
BMI>=30
N
%
111
18
105
17
Rural areas
BMI>=30
N
%
166
28
220
37
p value
14
8
20
10
31
37
46
50
13
20
46
42
54
83
53
75
p>0.01
p>0.01
p>0.01
p>0.01
p>0.01
p>0.01
p>0.01
p>0.01
13
8
18
9
28
35
41
48
8
9
28
19
32
38
32
34
p>0.01
p>0.01
TABLE 3. Physical activity according to age and sex, urban/

rural differences
Physical activity
Men
Women
Age (years)
Men 25-34 y
Women 25-34 y
Men 35-44 y
Women 35-44 y
Men 45-54 y
Women 45-54 y
Men 55-64 y
Women 55-64 y
Physical activity was measured as a physical activity lasting 30minutes where the respondent would
be out of breath or sweat, but in different intervals
during seven days. 2-3times a week as the recommended frequency of the physical activity. Total of
36% of respondents in the FBIH is physical inactive, while 14% of respondents is physically active
2-3 times a week, whereof 45% are women and
55% are men.
The percent of physically active women and men
aged between 25-34years is the same in urban areas.
86
Urban areas
Rural areas
p value
Physical activity Physical activity
23 times a
23 times a
week
week
N
%
N
%
97
24
119
30
p=0.120
92
24
85
21
p=0.120
32
34
22
13
19
25
24
20
33
37
23
14
19
27
25
22
29
23
36
21
28
27
26
14
24
27
30
25
24
32
22
16
p>0.01
p>0.01
p>0.01
p>0.01
p>0.01
p>0.01
p>0.01
p>0.01
http://www.jhsci.ba
12month, they have changed their behavior related

to the diet, increase in physical activity, giving up
smoking and alcohol consumption.
reduction of smoking habits was recorded only in

small percent.
The frequency of changes in behavior related to
acquiring healthy living habits in the rural areas is statistically significant among men and women, because
women in rural areas change living habits rather more
frequently than men, while in the urban areas there is
no statistical significance among the sexes (Figure1).
The changes in behavior are more frequent in the

older age groups, between 45-64 years of age.
Generally, the most frequently changed habits
relate to increase in fruit and vegetable consumption, as well as reduction of fat intake, while the
FIGURE 1. Prevalence of changes in behavior according to the area, age and sex, urban/rural difference.
87
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DISCUSSION
treat causes and not consequences of the problem.

As important actors in both prevention and promotional activities, apart from the health system,
seems to be definitely local communities where people live. At the same time it is necessary to increase
the knowledge and skills of healthcare workers in
primary health care (PHC), especially for nurses,
in treatments of smoking cessation, considering
that the strengthening of PHC through continuous
improvement of family medicine teams is a fundamental commitment to the reform of the health sector in the FBIH. These treatments should become
standard practice in teams of family medicine in
PHC, given the very high prevalence of smoking
in the FBIH, which is significantly higher than in
neighboring countries (12-13).
Obesity is one of major public health challenges
in the 21st century. The prevalence of obesity
fromthe 1980s nearly tripled in many countries of
the European region, and consequently led to an
increase in various physical disabilities and development of non-communicable diseases, especially
diabetes mellitus. In the FBIH, the prevalence of
obesity increases with age in both sexes. If we add
this to an increasing prevalence of other risk factors
in middle and old age, this creates an additional burden in the accumulation of unhealthy habits within
the population. Enhancing public awareness about
healthy eating and increasing knowledge about
influences of obesity on health must be a method
of everyday work in primary health care, in collaboration with the local community. Increasing prevalence of obesity in rural areas is significant and this
should be given special attention in the future.
Prevalence of physical activity is insufficient and
there is certainly a space for public health improvements. In recent population surveys conducted in
Serbia, the prevalence of physical activity of the
adult population was similar to those in the FBIH,
indicating that the lack of physical activity in leisure time is almost culturally adopted a pattern of
behavior in both the FBIH and the neighboring
countries(14).
It is especially necessary to improve awareness of
population about the importance of physical activity in all age groups. At the same time, it is necessary
to create conditions for the massification of physical activity. The role of local communities in these
The prevalence of risk factors for NCDs in the

FBIH in the last decade was evaluated through a few
isolated studies on risk factors and health behavior
in different samples of the population.
The first cross-sectional study population and risk
factors for NCDs in a representative sample of the
population in the FBIH was conducted in 2002. The
prevalence of risk factors related to the health behavior of the population in the study from 2002year was
relatively high and there were significant differences
in the level of the main risk factors-smoking, physical activity and obesity in urban and rural areas(11).
Ten years later it was conducted a follow-up study in
order to monitor trends in preventable risk factors
and in getting real information about the profile of
risk factors for NVDs among the adult population
in the FBIH. Great significance of this research lies
in representation of FBIH in both urban and rural
areas, and the high response rate.
Data from routine health statistics in the FBIH
show a slight increase in circulatory system diseases, particularly CVDs, followed by malignant
diseases. Therefore, monitoring and control of risk
factors are necessary measures to protect the health
of the population. Conducting periodic surveys
enables monitoring of trends and creation of evidences for development of public health activities
and algorithms for clinical work within primary
health care.
Results of cross-sectional studies identify smoking
as the most important risk factor in the occurrence of NCDs among the adult population in the
FBIH. Despite the existence of clear legislation
in the FBIH regarding the limited use of tobacco
products, the prevalence of smoking in the FBIH is
still very high, what, among other things, speak in
favor of an inconsistent implementation of the Law.
Consistent implementation of the Law on the limited use of tobacco products in the FBIH, promotion of non-smoking places and work environment
free of tobacco smoke should be basic measures.
In accordance with the practice in EU countries
and in the region, part of the revenue from excise
taxes on tobacco products would be redirected to
funding for preventive and promotional programs
related to reducing smoking prevalence, what would
88
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activities is also necessary to be strengthened, as the

creation of conditions for the implementation of
physical activity in leisure time lies precisely within
the places of residence of the population.
principle of the WHO European policy Health

2020 and is reflected in the approach Health in all
policies and is necessary to follow in strategic and
operational approaches in the FBIH.
Changing behavior related to the acquisition

healthy habits in the last year prior to the survey
was low in both men and women, and there are
no significant differences between urban and rural
areas. Enhancing awareness of healthy habits is a
long process and requires very lengthy preventive
work. This is work that needs to be strengthened
intensively in the coming period through individual
and group counselings, work within the local community, particularly through the work of nurses in
primary health care. The advantage of the FBIH can
be continuous strengthening of family medicine
teams in PHC, and obtained matrix with several
important indicators which should serve as proof
for posting prevention programs and increasing
awareness of the risk factors. Experiences in many
countries show that a well-planned health intervention programs at the community level in order to
promote health and health behavior changes have
good results (15-16).
ACKNOWLEDGEMENTS
The survey was made as a part of the Health sector

enhancement project in the Federation of Bosnia
and Herzegovina, funded by the World Bank from
the International Development Association (IDA)
credit and authors would like to acknowledge.
REFERENCES
1. World Health Report 2002: Reducing risks, promoting healthy life. Geneva:
World Health Organization; 2002.
2. World Health Report 2003: Shaping the future. Geneva: World Health
Organization; 2003.
3. Action plan for implementation of the European Strategy for the Prevention
and Control of Non-communicable Diseases 20122016. Copenhagen:
World Health Organization Regional Office for Europe; 2011.
4. Health 2020. A European policy framework and strategy for the 21st century.
Copenhagen: World Health Organization Regional Office for Europe; 2013.
5. Raljevi E, Dili M, erkez F. Prevencija kardivaskularnih bolesti.
Udruenje kardiologa i angiologa BiH; 2003. p.171.
6. Zdravstveno stanje i organizacija zdravstvene zatite u Federaciji
Bosne i Hercegovine 2012. Zavod za javno zdravstvo Federacije Bosne i
Hercegovine; 2013.
The results of surveys showed no significant differences in the prevalence of risk factors for NCDs
in both urban and rural areas. The prevalence of
unhealthy lifestyles in the FBIH is quite high and
it is necessary to conduct vigorous public health
action to reduce risk factors, as well as individual
access to high-risk individuals.
7. Study of risk factors of non-communicable diseases in the

Federation of Bosnia and Herzegovina 2002. Public Health Institute of the
FBIH; 2002.
8. Survey protocol. [homepage on the Internet]. WHO MONICA Project; [cited
2011. Oct 15]. Available from: http://www.thl.fi/publications/monica/manual/
index.htm
9. Protocol and Guidelines. Countrywide Integrated Non-communicable
Diseases Intervention (CINDI) Programme. Copenhagen: World Health
Organization Regional Office for Europe; 1995.
10. European Health Interview Survey: Methodological manual. EUROSTAT
2010.
CONCLUSIONS
11. Pilav A, Joki I, Niki D, Gusinac-kopo A. Prevalence of behavioral risk

factors among urban and rural population in the Federation of Bosnia and
Herzegovina. Mat Soc Med. 2004; 16(1-2): 7-11.
Social responsibility for health in the local

community includes the creation of preventive
health programs and proposed measures for improving and enhancing the health of the population.
This is particularly important for rural areas, where
the impacts of local communities can be significant.
Active involvement of all actors in the social system
and the coordination of all government sectors,
from the health sector to the education sector, the
inspectorate, finance and other sectors, as well as
active cooperation with non-governmental sectors
in the implementation of the current legislation, can
all create a favorable environment for reducing these
risk factors. Intersectoral cooperation is the main
12. Djikanovic B, Marinkovic J, Jankovic J, Vujanac V, Simic S. Gender differences in smoking experience and cessation: do wealth and education
matter equally for women and men in Serbia? J Public Health. 2011; 33 (1):
31-38.
13. Samardi S, Vuleti G, Tadijan D. Five-year cumulative incidence of
smoking in adult croatian population: the CoHort Study. Coll. Antropol.
2012; 36 (1):99-103.
14. National Health Survey Serbia, 2006. Ministry of Health of the Republic of
Serbia; 2007.
15. Puska P. Successful prevention of non-communicable disease: 25 year
experiences with North Karelia Project in Finland. Public Health Medicine.
2002;4(1):5-7.
16. Nissinen A, Ximena B, Puska P. Community-based non-communicable disease interventions: lessons from developed countries for developing ones.
Bulletin of the World Health Organization. 2001;79:963-970.
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Mahmoud Al Kalaldeh and Mahmoud Shahin. Journal of Health Sciences 2014;4(2):90-96

RESEARCH ARTICLE
Open Access
Nurses knowledge and responsibility

toward nutritional assessment for patients in
intensive care units
Mahmoud Al Kalaldeh1*, Mahmoud Shahin2
1
Faculty of Nursing, Zarqa University, Zarqa, Jordan, 2Faculty of Nursing, Isra University, Amman, Jordan
ABSTRACT
Introduction: Nutritional assessment is a prerequisite for nutritional delivery. Patients in intensive care
suffer from under-nutrition and nutritional failure due to poor assessment. Nursing ability to early detect
nutritional failure is the key for minimizing imparities in practice and attaining nutritional goals. Aim of
this article is to examine the ability of Jordanian ICU nurses to assess the nutritional status of critically ill
patients, considering biophysical and biochemical measures.
Methods: This cross sectional study recruited nurses from different health sectors in Jordan. ICU nurses
from the governmental sector (two hospitals) and private sectors (two hospitals) were surveyed using
a self-administered questionnaire. Nurses knowledge and responsibility towards nutritional assessment
were examined.
Results: A total of 220 nurses from both sectors have completed the questionnaire. Nurses were consistent in regard to knowledge, responsibility, and documentation of nutritional assessment. Nurses in
the governmental hospitals inappropriately perceived the application of aspiration reduction measures.
However, they scored higher in applying physical examination and anthropometric assessment. Although
both nurses claimed higher use of biochemical measurements, biophysical measurements were less frequently used. Older nurses with longer clinical experience exhibited better adherence to biophysical measurement than younger nurses.
Conclusion: Nursing nutritional assessment is still suboptimal to attain nutritional goals. Assessment of
body weight, history of nutrition intake, severity of illness, and function of gastrointestinal tract should
be considered over measuring albumin and pre-albumin levels. A well-dened evidence-based protocol
as well as a multidisciplinary nutritional team for nutritional assessment is the best to minimize episodes
of under-nutrition.
Keywords: assessment; nutritional status; nurse
INTRODUCTION
*Corresponding author: Mahmoud Al Kalaldeh, PhD RN MSN CNS,
Faculty of Nursing, Zarqa University, Zarqa, Jordan
Phone: +962 5 3821100,
E-mail: kalaldeh82@yahoo.com
Submitted July 21 2014 / Accepted August 21 2014
Critical illness is associated with many complications

such as anorexia, hyper metabolism, malabsorption;
atrophy of muscles, liver, kidney, gastrointestinal
tract & heart; impaired cell mediated immunity,
2014 Mahmoud AL Kalaldeh and Mahmoud Shahin; licensee University of Sarajevo Faculty of Health Studies. This is an Open Access article distributed under the terms of the
Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
http://www.jhsci.ba
susceptibility to infections, poor wound healing,

anemia, death (1,2). Enteral nutrition (EN) is the
preferred nutritional method whenever is possible to
feed critically ill patients (3,4). When gut is used for
nutrition, bacterial translocation and septicemia are
prevented.
outcomes of the delivered feeding although lack of

expertise and training is sometime evident (23,24).
Unfortunately, a limited number of tools for nutritional assessment are available in the Jordanian hospitals; in addition to poor academic preparations
that suffice this domain (22).
Malnutrition is a term used frequently in healthcare

system which is the analogy of under-nutrition or
inadequate energy intake less than the metabolic
demands (5,6). Under-nutrition can also be resulted
from abnormal digestion or absorption of protein
and calories (5,6). It is also acknowledged that
malnutrition in the critically ill is associated with
impaired immune functions; impaired ventilator
drive, and weakened respiratory muscles, leading
to prolonged ventilator dependence and increased
infectious morbidity and mortality (7,8).
The most recommended nutritional assessment

tools are as follows: (a) biophysical assessment and
anthropometric measurement which include body
mass index (BMI), mid-arm muscle circumference,
triceps skin fold thickness, in addition to measuring
Gastric Residual Volume (GRV) and detecting tube
placement for enteral fed patients (16,17). However,
the ratio of subcutaneous layer to total body fat may
vary from 20% to 70% in the normal individuals;
so they are not recommended in extreme weight
change due to the risk for overestimating body fat in
malnourished patients (16). (b) Physical examination which includes history of weight loss, alcohol
abuse, dietary habits, skin, mouth, and neurological system monitoring (25,26). Body temperature
is also a part of the physical examination (27,28).
(c) Biochemical assessment includes serum albumin, transferrin, transthyretin (prealbumin), retinol-binding protein, somatolin C and fibronectin
(29,30). However, changes in fluid distribution
may result in pseudo rise or fall in the value of albumin level causing false medical interpretation (31).
(d) Dietary assessment which includes 24 hours
recall, food records (diaries), diet history and food
frequency questionnaires (32). These methods may
however be impractical for critically ill patients who
are unable to communicate effectively with practitioners (18,33).
Proper nutritional assessment is strongly linked

to successful nutritional plans for critically ill
patients (4,9,10). The current focus on nutrition in critical care settings is that carefully selecting patients parameters that would highly reflect
patients outcome (11-13). In order to design an
appropriate and effective strategy for nutritional
assessment in the intensive care, a crucial guidelines
have to be applied systematically for all critically ill
patients (14,15).
Nurses in intensive care are in a key position to
maintain patients nutritional status at an optimal
level and closer to the nutritional goals (16,17).
While most of the critical care nurses are responsible for establishing nutritional access and initiating
feeding, in some instances, they calculate the caloric
needs according to the body requirements and measure the daily calories delivered (16,17). However,
imparity in nursing practices contributes to developing serious deficiencies and complications due
lack of unified guidelines (18,19). When adherence
to evidence-based guidelines is assured, the discrepancy inherent in nursing practice can be curtailed
and the effectiveness of nutritional practices are
maintained (20,21).
The purpose of this study was to assess Jordanian

nurses knowledge and responsibility of nutritional
assessment in the critical care, considering biophysical and biochemical measures.
METHODS
This descriptive cross sectional study employed

nurses from four hospitals in Jordan; two governmental hospitals and two private hospitals. It is
assumed that there are many differences between
heath care sectors in Jordan in terms of medical protocols and nursing practice (22). For that reason,
nurses in different heath care sectors may exhibit
In Jordan, critical care nurses have no obvious role

regarding nutritional care (22). While dietitians
are available in the most of Jordanian hospitals,
nurses often hold the responsibility for early detecting the sings of under-nutrition and assessing the
91
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various level of adherence to nutritional assessment

tools. Nurses working in any intensive care units
and had at least one year of clinical experience and
hold the bachelors or diploma degree in nursing
was eligible for participation. Convenient sampling
technique was used to select participants from each
involved hospital. The estimation of sample size was
based on the medium effect size, power of 0.80, and
of 0.05(34). All selected hospitals are located in
Amman, the capital of Jordan, and all are considered as major and referral hospitals that operate well
occupied intensive care units.
sciences (SPSS) software, version 17. Descriptive

statistics including number, percent, mean,
Standard Deviation (SD) were used and followed by
comparing differences between study groups using
Chi-square and Kruskal-Wallis test.
RESULTS
Participants demographics
A total of two hundred and twenty intensive care

nurse participated in the study and returned the
completed questionnaires. As shown in Table 1,
the majority of the study participants were female
accounting 65% while 34% were male. Regarding
the ages, around 38% were aged less than 25years
old and the second majority age group was between
25-45years old. About the half of the sample had
a clinical experience of less than five years and very
few had an experience of more than 20years. While
the majority of participants (71.4%) hold the bachelor degree of nursing, the vast majority (82.3%)
claimed no previous clinical training received with
the respect of nutritional assessment (Table1).
Study instrument included a self-administered

questionnaire developed to assess nurses ability to
assess patients nutritional status while staying in
the intensive care. This questionnaire consisted of
five demographic questions; six questions related
to the attitudes towards nutritional assessment
including aspiration-reduction measures; and five
questions related to using different bio-physical
and biochemical measures. The scoring system
ranged from 1 (toa very small extent) to 5 (very
great extent). Apilot study was carried out by 10
nurses from the same study target to test the clarity, applicability, and feasibility of the questionnaire. Minor modifications were done after piloting and those nurses participated in the pilot study
were excluded from the study sample. The content
validity was also assessed by a panel of experts in
this field, including a physician, a dietitian, and
two expert nurses.
TABLE 1. Participants demographics

Variable
Category Governmental
n (%)
Gender
Male
46 (35.7)
Female
83 (64.3)
Total
129 (100)
Age
<25
51 (39.6)
25-35
33 (25.5)
36-45
29 (22.5)
>45
16 (12.4)
Total
129 (100)
Years of
<1
36 (27.9)
experience 1-5
28 (21.7)
6-10
24 (18.6)
11-15
24 (18.6)
16-20
12 (9.3)
>20
5 (3.9)
Total
129 (100)
Level of
Diploma
45 (34.9)
Education Bachelor
84 (65.1)
Total
129 (100)
Attending Yes
13 (10.1)
Nutrition
No
116 (89.9)
Course
Total
129 (100)
Ethical approvals were anticipated from each

hospitals authority prior to data collection. Awritten permission (informed consent) for participation was obtained from each participant after
providing complete information about the study
and its significance. Anonymous participations
and confidentiality of data were also assured. Data
were collected in collaboration with the head nurses
of the unit in which they contributed in selecting
the eligible participants, handing, and returning
the completed questionnaires in a sealed envelope
within one week.
After returning all completed questionnaires,

data were entered the statistical package for social
92
Private
n (%)
31 (34.1)
60 (65.9)
91 (100)
33 (36.3)
25 (27.5)
25 (27.5)
8 (8.7)
91 (100)
26 (28.5)
17 (18.7)
15 (16.5)
16 (17.6)
9 (9.9)
8 (8.8)
91 (100)
18 (19.8)
73 (80.2)
91 (100)
26 (28.6)
65 (71.4)
91 (100)
Total
n (%)
77 (35)
143 (65)
220 (100)
84 (38.1)
58 (26.4)
54 (24.6)
24 (10.9)
220 (100)
62 (28.2)
45 (20.5)
39 (17.7)
40 (18.2)
21 (9.5)
13 (5.9)
220 (100)
63 (28.6)
157 (71.4)
220 (100)
39 (17.7)
181 (82.3)
220 (100)
Attitudes to nutritional assessment
http://www.jhsci.ba
and screening for nutritional risks as main tools for

assessing the nutritional status (Table3).
As shown in Table 2, the nurses showed a consistent adherence to the use of nutritional assessment in the ordinary nursing process. There were
no any significant differences between nurses from
both groups in relation to the importance of assessment in acquiring knowledge, having responsibility, and documenting nutritional changes. Scores
were mainly above the midpoint of 2.5, indicating
that nurses perceived the importance of assessment
through their nursing process. Regarding some
nutritional assessment tools, nurses in the private
sectors claimed measuring gastric aspirate more
frequently than nurses in governmental sectors.
Similarly, detecting tube placement was also scored
higher among nurses in the private sectors than
governmental nurses. In addition, nurses in the private hospitals claimed using other aspiration reduction measures such as degree of head of the bed,
controlling feeding rates, and using of promotility
agents more frequently than nurses in the governmental hospitals.
Variations in nutritional assessment between

demographic groups
While no significant differences between male and

female nurses in regard to the adherence to nutritional assessment, older nurses with longer clinical experience scored higher in applying a nutritional assessment using biophysical measurements
(x = 24.261, df=3, p=0.043). However, younger
nurses with shorter clinical experience scored higher
in having a nutritional assessment using biochemical
measurements (x=35.171, df=3, p<0.001). Although
bachelor and diploma degree holders did not differ
significantly in term of nutritional assessment, nurses
who received previous nutritional training were more
likely to adhere to different assessment measures than
those who did not (x=76.184, df=1, p<0.001).
DISCUSSION
It was evident that nurses well perceived the knowledge and responsibility for nutritional assessment
and claimed competency in undertaking nutritional assessment while examining the effectiveness
of delivered feeding. This premise is supported by
other researchers who reinforced the importance of
nutritional assessment as the first step of nutritional
care (14,35,36).
Adherence to various nutrition assessment

tools
This section shows nurses attitudes towards adherence to various nutritional assessment tasks while
providing EN care for critically ill patients. There
were a statistical significant differences between
governmental and private sector nurses in regard
to adherence to these nutritional assessment provisions. Nurses in the governmental hospitals scored
significantly higher in undertaking assessment using
physical examination, anthropometric assessment,
and dietary assessment than nurses working in the
private sector. However, both groups had equally
showed the extent of using biomedical assessment
Aspiration is the most common dangerous side

effect resulting from EN. Aspiration-reduction measures can be applied individually; however, most of
them are combined into one protocol especially in
patients with mechanical ventilation. For instance,
Bowman et al. (2005) established and implemented
a new evidence-based feeding protocol and an
TABLE 2. Attitude to nutritional assessment

Governmental (n=129)
Private (n=91)
Total (n=220)
M
SD
M
SD
M
SD
Knowledge of assessment
2.79
1.28
3.22
1.22
2.97
1.21
Responsibility of assessment
2.87
1.19
3.26
1.11
3.03
1.13
Documentation of assessment
3.13
1.32
3.00
1.08
3.01
1.17
Measuring gastric aspirates
3.14
1.36
4.05
1.29
3.70
1.33
Detecting tube placement
3.88
1.31
4.31
0.93
4.00
1.14
Other aspiration reduction measures
3.06
1.19
3.59
0.99
3.27
1.14
Scores range from 1 (to a very small extent) to 5 (very great extent) * M: Mean, * SD: Standard deviation
93
Kruskal-Wallis test
test
p-value
5.782
0.056
5.696
0.058
1.598
0.450
25.909
<0.001
10.176
0.006
9.249
0.010
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TABLE 3. Adherence to nutritional assessment

Governmental
Mean (SD) (n=129)
Private
Mean (SD) (n=91)
Physical examination
2.28 (1.03)
Anthropometric assessment
2.56 (1.35)
Dietary assessment
4.31 (0.93)
Biochemical assessment
3.51 (1.33)
Screening for nutritional risks
3.27 (1.64)
Scores range from 1 (to a very small extent) to 5 (very great extent)
aspiration reduction algorithm for enteral fed,

mechanically ventilated patients in the ICUs. Also,
Metheny et al. (2010) evaluated the effectiveness of
using Aspiration Risk-Reduction Protocol (ARRP)
for enteral fed patients with mechanical ventilation.
The importance of controlling GRVs was adequately
perceived by nurses as a protective measure to prevent higher GRV limits (28, 37). This conforms to
the evidence-based recommendations that measuring GRV is an essential element in EN and should
be maintained under the universal threshold of
200-500ml (10). It is also accepted to define GRV
as the cutoff point of 30% of the last given feeding
amount which is remaining in the stomach (38,39).
However, previous studies addressed that GRVs
should not be taken into account for all potential
risks for pulmonary aspiration, the evidence showed
that many other factors should be considered along
with GRVs to reduce the risk of aspiration such as
trauma, head injury, using of sedation, and mental
instability (40). A number of other recommendations are helpful to accomplish nutritional goals
such as avoiding inappropriate feeding cessation,
using prokinetic agents with EN, keeping the head
of the bed elevated at 35-45, increasing feeding rate
in a constant manner and using pre-prepared feeding packs (10,41,42).
1.48 (0.87)
1.74 (1.08)
3.79 (1.09)
3.69 (1.09)
3.46 (1.23)
Kruskal-Wallis test
test
p-value
22.43
19.65
24.09
5.54
8.17
<0.001
<0.001
<0.001
0.590
0.360
the risk of radiation exposure, but if not available,

pH method can be applied (10,38,46-50).
The use of bio-physiological and bio-chemical
parameters such as body weight, abdominal girth,
bowel exam, skin integrity, and urine and stool analysis in addition to serum protein level in the blood
were assessed in this study. The nurses showed a
higher reliance on the bio-chemical indicator than
bio-physical measurement. Previous studies revealed
that not all patients in intensive care have a regular
nutritional assessment and the essential aspects of
nutritional documentation are missing(23,51). Also,
it is unlikely to have entire screening tool for evaluating nutritional outcomes (52, 53). Evidence-based
guidelines stressed on investigating weight, history
of nutrition intake, severity of illness, and function
of gastrointestinal tract prior to admission instead of
measuring albumin and pre-albumin (10,54). The
frequent assessment of BMI should also be measured by dividing weight in kilograms by the square
of the height in meters (Normal range 19-25) (55).
In general, all studies confirmed the significance
of using evidence-based guidelines for nutritional
assessment as the majority of nurses showed inconsistency in having the systematic tools for measuring
nutritional outcomes (52).
Although the study recruited sample from two heath
care sectors in Jordan, involving the other heath sectors such as the military heath sector would enhance
the external validity of the study. In addition,
including other hospitals from different geographical location, away from the capital, would provide
further understanding about the phenomenon and
enhance generalizability.
Studies stressed on the regular checking for tube

position which is strongly associated with low
complication incidences. Feeding tube should be
checked regularly before each feeding administration
or at least every day using a reliable indicator such as
radiographic confirmation (X-ray) which is still considered as a gold standard (43-45). Measuring pH of
gastric aspirate is another reliable indicator for tube
placement. However, studies have confirmed that
radiography is superior to other technique despite
Nurses require understanding factors associated

with under-nutrition and hypo-caloric feeding
through undertaking such nutritional assessment
94
http://www.jhsci.ba
2. Schiesser M, Kirchhoff P, Mller M, Schfer M, Clavien P. The correlation

of nutrition risk index, nutrition risk score, and bioimpedance analysis
with postoperative complications in patients undergoing gastrointestinal
surgery. Surgery. 2009;145(5):519-26. http://dx.doi.org/10.1016/j.
surg.2009.02.001.
measures that assist to early detecting the risk for

these episodes. The application of bio-physical measurements in the intensive care is still deficient so
further insight about the usefulness of these measures should practically be applied.
3. Heyland DK, Dhaliwal R. Early enteral nutrition vs. early parenteral nutrition: an irrelevant question for the critically ill? Critical
Care
Medicine.
2005;33(1):260-1.
http://dx.doi.org/10.1097/01.
CCM.0000150749.13940.37.
Future researchers are invited to conduct other

extensive research works that involve more aspects
about nutritional care. Investigating the role of
multidisciplinary work is also a priority to provide
further understanding about the role of physicians
and dietitians in assessing patients nutritional status
while being in the intensive care.
4. Heighes P, Doig G, Sweetman E, Simpson F. An overview of evidence

from systematic re-views evaluating early enteral nutrition in critically ill
patients: more convincing evidence is needed. Anaesth Intensive Care.
2010;38:167-74.
5. Hofhuis J, Spronk P, van Stel H, Schrijvers A, Rommes J, Bakker J.
Experiences of critically ill patients in the ICU. Intensive and Critcal Care
Nursing. 2008;24(5):300-13. http://dx.doi.org/10.1016/j.iccn.2008.03.004.
6. Huber O. Hospitalized mechanically ventilated patients are at higher risk
of enteral underfeeding than non-ventilated patients. Clinical Nutrition.
2006;25(5):727-35. http://dx.doi.org/10.1016/j.clnu.2006.03.011.
CONCLUSION
7. Casaer M, Mesotten D, Hermans G. Early versus late parenteral nutrition

in critically ill adults. N Engl J Med. 2011;DOI: 10.1056/NEJMoa1102662.
http://dx.doi.org/10.1056/NEJMoa1102662.
Nursing nutritional assessment is still suboptimal to promote patients successful nutrition. The
impact of nutritional assessment on determining the
patients status and detecting some complications
such as aspiration pneumonia is well-known, but
nurses need to underpin their practice with some
evidence-based guidelines to manage these issues
effectively.
8. Kang W, Gomez F, Lan J, Sano Y, Ueno C, Kudsk K. Parenteral nutrition

impairs gut-associated lymphoid tissue and mucosal immunity by reducing
lymphotoxin beta receptor expression. Ann Surg. 2006;244:392-9.
9. Jones NE, Heyland DK. Implementing Nutrition Guidelines in the Critical
Care Setting; A Worthwhile and Achievable Goal? Journal of American
Medical Association. 2008;300(23):2798-9. http://dx.doi.org/10.1001/
jama.2008.814.
10. McClave SA, Martindale RG, Vanek VW, McCarthy M, Roberts P,
Taylor B, et al. Guidelines for the Provision and Assessment of
Nutrition Support Therapy in the Adult Critically Ill Patient:. Journal of
Parenteral and Enteral Nutrition. 2009;33(3):277-316. http://dx.doi.
org/10.1177/0148607109335234.
This study provides overview to the body of knowledge about the role of intensive care nurses in
maintaining optimal nutritional therapy In Jordan.
Awareness about the current feature of nutritional
assessment sheds the light on the future development strategies. In eventual, nurses practitioners
would emphasize of the role of training to improve
their professional competency in the light of nutritional delivery in the critically ill.
11. Correia M, Campos A. Prevalence of hospital malnutrition in Latin America:

the multicenter ELAN study. Nutrition. 2003;19:823-5. http://dx.doi.
org/10.1016/S0899-9007(03)00168-0.
12. Cahill NE, Murch L, Jeejeebhoy K, McClave SA, Day AG, Wang M, et al.
When early enteral feeding is not possible in critically ill patients: results of
a multicenter observational study. JPEN Journal of Parenteral & Enteral
Nutrition. 2011;35(2):160-8. http://dx.doi.org/10.1177/0148607110381405.
13. Fang JC, Delegge MH. Enteral feeding in the critically ill: the role of the gastroenterologist. American Journal of Gastroenterology. 2011;106(6):1032-7.
http://dx.doi.org/10.1038/ajg.2011.77.
14. Anthony P. Nutrition screening tools for hospitalized patients.
Nutrition in Clinical Practice. 2008;23:373-82. http://dx.doi.
org/10.1177/0884533608321130.

interests.
15. Campillo B, Richardet J, Bories P. Validation of body mass index for the
diagnosis of malnutrition in patients with liver cirrhosis. Gastroenterol Clin
Biol. 2006;30:1137-43. http://dx.doi.org/10.1016/S0399-8320(06)73491-1.
16. Christensson L, Unosson M, Ek A. Evaluation of nutritional assessment
techniques in elderly people newly admitted to municipal care. European
Journal of Clinical Nutrition. 2002;56(9):810-7. http://dx.doi.org/10.1038/
sj.ejcn.1601394.
ACKNOWLEDGMENT
Authors are indebted to all nurses participated in

this study including nursing staff, head nurses, and
nurse managers.
17. OMeara D, Mireles-Cabodevila E, Frame F, Hummell C, Hammel J,

Dweik RA, et al. Evaluation of delivery of enteral nutrition in critically ill
patients receiving mechanical ventilation. American Journal of Critical
Care. 2008;17(1):53-61.
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Andreja Kvas and Janko Seljak. Journal of Health Sciences 2014;4(2):97-104
http://www.jhsci.ba

RESEARCH ARTICLE
Open Access
The effects of education and training on self-esteem

of nurse leaders
Andreja Kvas1, Janko Seljak2*
1
Faculty of Health Sciences, University of Ljubljana, Ljubljana, Slovenia, 2Faculty of Administration, University of Ljubljana,
Ljubljana, Slovenia
ABSTRACT
Introduction: A successful leader must have high self-esteem. The main aims of this study were to identify changes in the self-esteem of nurse leaders in Slovenia from 2001 to 2011 and to determine homogeneous groups of leaders with similar personal characteristics.
Methods: The study used a version of a personal characteristics questionnaire with 16 self-descriptive
statements. Two surveys were conducted among nurse leaders in Slovenian public hospitals, one in 2001
and the other in 2011. Relationships between variables were analysed using chi-square tests for categorical variables and the one-way analysis of variance for quantiable variables. Factor analysis was used to
determine groups of leaders with similar personal characteristics.
Results: A total of 327 nurse leaders participated in the survey in 2001 and 296 lled in questionnaires
in 2011. The analysis showed that the level of self-assessment of personal characteristics among nurse
leaders in Slovenian public hospitals was signicantly higher in 2011 than in 2001, and that differences
among individual leaders decreased in most areas. Based on the assessments of personal characteristics,
four groups of nurse leaders were established: task-oriented, knowledge and creativity oriented, relationship oriented and extroverted nurse leaders. In the 2011 data, the groups of personal characteristics
were much more clearly dened. These groups were established in accordance with leadership theory and
research from other elds.
Conclusions: The positive effects of better education and training are visible in nurse leaders in terms of
both their higher self-esteem and in the establishment of more homogeneous groups of leaders.
Keywords: education; nursing; leadership; self-esteem; Slovenia
INTRODUCTION
Only a leader with high self-esteem can be a good

leader as high self-esteem is the foundation on which
*Corresponding Author: Seljak Janko, Faculty of Administration,
University of Ljubljana, Gosarjeva Ulica 5, 1000 Ljubljana,
Slovenia, Phone: +386 41 998 499,
E-mail: janko.seljak@kabelnet.net
Submitted July 09 2014 / Accepted September 02 2014
he or she builds positive relationships with colleagues

and superiors and is able to influence them. The
leaders who are capable of appropriately motivating
their co-workers to achieve targets are key elements
of the excellence, efficiency and effectiveness of every
organization (1-3). Increasing attention is therefore
being paid to leadership in nursing (4).
Leadership styles have significantly changed over
the past 25years, and nurse leaders must also adapt
2014 Andreja Kvas and Janko Seljak; licensee University of Sarajevo - Faculty of Health
Studies. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted
use, distribution, and reproduction in any medium, provided the original work is properly cited.
http://www.jhsci.ba
important characteristic of professionalism is the

integrity of systematic and generalized knowledge
which must be used by professionals to solve different problems (16,17). The basis for the nursing
profession and nurses knowledge is a good educational system that must be supplemented with
continuing education following graduation and
should be provided by professional associations
and health care organisations (18). The significance of continuing education and development
after graduation has been emphasized since the
beginning of the nursing profession (19), including among others, within international nursing
organisations (20).
accordingly. The autocratic style of leadership, which

prevailed in nursing in the past, needs to be replaced
with more democratic leadership styles: transformational, sharing, authentic, servant, etc. (5,6). In
addition to high integrity, all these leadership styles
call for leaders with high self-esteem as only such
leaders are capable of sharing leadership with their
subordinates and patients. Because only secure leaders, which have a strong sense of self-worth are able
to give themselves away (7).
Defining self-esteem is beyond the scope of this
article. Our study used the concept of self-esteem
in its broadest sense: Positive self-concept can be
equated with a positive self-evaluation, self-respect, self-esteem, self-acceptance, while a negative
self-concept becomes synonymous with a negative
self-evaluation, self-hatred, inferiority and a lack
of feelings of personal worthiness and self-acceptance (8). In this way, concepts like self-concept,
self-perception, self-attitude and self-esteem
become synonymous and, if considered attitudes
toward self, can be seen to exist on a positive
negative continuum, or scale (9).
The health care system in Slovenia employs 16.783

nurses, or 36.6% of all employees in health care (21).
The field of education in nursing in Slovenia has
changed significantly since 2000. In 2000 Slovenia
had two nursing colleges with 974 students, while
in 2010 there were three faculties and three nursing colleges with 2.435 students (bachelor of science in nursing, master of nursing) (21,22). The
higher number of colleges and faculties also resulted
in an increased scope of research into leadership in
nursing.
Leaders with low self-esteem who doubt their

abilities, knowledge and views do not get respect
and appreciation and are not satisfied with themselves (10). Insecure leaders are dangerous to
themselves, their followers, and the organizations
they lead because a leadership position amplifies
personal flaws (11). If a leader cannot rely on his or
her own abilities, he or she will doubt others abilities, and in turn cause mistrust in them as well (12).
Leadership training programmes within professional organisations have also undergone significant changes resulting in a greater awareness of
the importance of good leadership. In 2000, the
Professional Group of Nurses in Management was
established as part of the Nurses and Midwives
Association of Slovenia (23). Its aim is to provide
nursing leaders with modern knowledge, attitudes
and skills relating to the management of organisations and human resources. Nurse leaders now have
more opportunities to meet and exchange leadership
experiences and ideas. Such meetings are intended
both for training and for shaping and reinforcing
their professional self-confidence and the homogeneity of their professional group.
Individuals self-esteem is shaped gradually through

their psychological development and interaction
with their environment from early childhood,
through adolescence and maturity (13). An individuals self-esteem is the basis for the development of professional self-confidence and the two
influence each other throughout ones professional
career (14). Therefore, the creation of a professional
group of self-confident and balanced leaders is a
process influenced by many factors the results of
which only become apparent over a longer period of
time. However, appropriate education and training
are key factors in this process.
These changes will undoubtedly lead to significant

improvement in leaders self-esteem. We were interested in (research questions):
The development of professions has been most

pronounced within the health care system (15). An
98
whether there were significant changes in the

self-assessment of personal characteristics
between 2001 and 2011 that would indicate
changes in leaders self-esteem?
http://www.jhsci.ba
TABLE 1. Demographic data on the sample of nurse leaders
whether it was possible to determine homogeneous groups of leaders with similar characteristics based on self-assessments of personal
characteristics?
Sample 1
nurse leaders
in 2011
Number %
Leadership level
Head nurse and heads
of departments
Ward head nurses and
nurses supervising
several teams
Team leader nurse
Gender
Female
Male
N/A
Education
Secondary school
Professional college
degree
University degree
Specialisation, masters
degree, doctorate
N/A
Age
Under 30
30 to 40
41 to 50
Over 50
N/A
Total
METHODS
Study design
This study was part of a larger research project entitled Leaders in Nursing conducted between the
autumn of 2010 and the spring of 2011. The authors
of the study had previously obtained approval from
the Management Board of the Nurses and Midwives
Association of Slovenia and the managements of
individual hospitals. The survey was conducted
at the 15 largest Slovenian public hospitals: two
university medical centers, six general hospitals,
and seven specialized hospitals. These institutions
employ 87% of all hospital nurses in Slovenia. The
participating institutions employ 526 nurse leaders,
296 of whom (56% the sample) answered the questionnaire (Table 1).
A comparative study (13) entitled Nurses in
Slovenia was conducted on a representative sample of nurses in 2001. A sample of 2,450 nurses
in Slovenia was established based on the National
Register of Nurses and Midwives. Atotal of 1,067
nurses (44% of the sample) participated in the survey. Asecondary data analysis was used to include in
Sample 2 only 327 nurse leaders who were employed
in public hospitals in 2001.
Statistically significant differences between the samples were recorded at the leadership level (2=7.32,
p=0.039). The larger share of team leaders in the
2011sample was the consequence of a reorganisation of nursing care in hospitals aimed at increasing
the importance of team work.
Sample 2
nurse leaders in
2001
Number
%
19
6.4
30
9.2
111
37.5
149
45.6
166
56.1
148
45.3
273
23
0
92.2
7.8
0.0
302
22
3
92.4
6.7
0.9
6
38
2.0
12.8
95
172
29.1
52.6
216
36
73.0
12.2
45
12
13.8
3.7
0.0
0.9
40
93
101
59
3
296
13.5
31.4
34.1
19.9
1.0
100.0
60
102
110
55
0
327
18.3
31.2
33.6
16.8
0.0
100.0
Measurement instrument
To enable direct comparison, in 2011 the study

used the same group of statements that were used in
2001 and other studies of the population of nurses
in Slovenia (13, 24). The study focused on personal
characteristics relating to:
The greatest changes in the population of nurses

in Slovenia occurred in the area of formal education. The difference is even more pronounced in
the group of nurse leaders, which is also reflected
in the sample (statistically significant differences
at2=287.0, p=0.0001). In 2001, 17.5 % of nurse
leaders had at least a university education, while in
2011 their share rose to 85.2%.
In terms of gender (2=0.22; p=0.638) and age

(2=3.1, p=0.379), there were no statistically significant differences between the samples.
99
leaders self-image (self-satisfaction and personal-self (25), personal self-esteem (26), self-image and self-values (27), self-mastery (28),
agreeableness/neuroticism/conscientiousness
(29,30) item number 1-9 (Table2),
leaders opinion about their relationships with
others: social self (25), social self-esteem (26),
interpersonal values (27), people skills (28),
extraversion/openness (29, 30) item number
10-16 (Table2).
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TABLE 2. Comparison of assessment results between years and groups of nurse leaders
Item To what degree,
no. in your opinion,
are you
Mean
Std. deviation Index - mean Index - std. Differences between groups according to the
(2001=100) deviation
F-test (ANOVA)
Year
Year
(2001=100) Leadership level Education Age Gender
2011 2001 2011 2001
A
B
C
D
E
F
G
H
I
J
K
L
1
Reliable
2.92 2.80 0.26
0.41
104.3
64.1
2
Diligent
2.83 2.56 0.40
0.53
110.5
76.0
**
3
Responsible
2.94 2.82 0.24
0.39
104.1
61.8
**
4
Practical
2.83 2.58 0.39
0.53
109.5
72.9
*
*
5
Independent
2.83 2.62 0.38
0.50
108.1
75.6
**
6
Intelligent
2.47 2.15 0.51
0.39
114.8
130.0
7
Educated
2.40 2.13 0.49
0.37
112.9
132.0
*/**
*
**
8
Reasonable
2.81 2.57 0.39
0.51
109.3
77.7
9
Creative
2.58 2.25 0.50
0.49
114.9
101.5
10 Understanding
2.82 2.68 0.39
0.48
105.0
80.6
*
11
Sociable
2.57 2.34 0.52
0.55
109.6
94.1
**
12 Willing to put your 2.40 2.11 0.50
0.53
113.7
95.2
ideas into practice
13 Interested in
2.49 2.15 0.53
0.55
115.7
97.7
**
*/**
social issues
14 Critical
2.64 2.52 0.49
0.55
105.1
90.1
*
15 Articulate
2.43 2.16 0.51
0.50
112.4
101.2
*
16 Interested in new 2.62 2.43 0.52
0.59
107.8
88.3
*
fields of study
* - Year 2011: difference between groups is significant at p<0.05. ** - Year 2001: difference between groups is significant at p<0.05
The study used a version of a personal characteristics

questionnaire with 16 self-descriptive statements
(Table 2). The statements were formulated so that
they expressed positive self-esteem. The respondents
used a three-grade scale to answer the following
question: To what degree, in your opinion, are
you (1-Not at all, 2-Moderately, 3 Very).
tests for categorical variables and the one-way analysis of variance for quantifiable variables (ANOVA).
Asignificance level of alpha = 0.05 was used for all
statistical tests.
Reliability and validity of measurement
instrument
First, we verified the degree of reliability of the measurement instrument. Cronbachs Alpha was 0.79
in 2011 and 0.81 in 2001. The value indicated a
high level of reliability of the measuring instrument.
Asimilar degree of reliability was produced by the
questionnaire in studies on nursing students and
nurses conducted in previous years (13,24).
The data was analysed using SPSS 19.0. Descriptive

statistics were used to describe the sample. Internal
consistency was examined using the Cronbachs
alpha. Factor analysis was used to determine groups
of leaders with similar personal characteristics. In
the factor analysis, principal component analysis
with varimax rotations was used to examine which
factors of the scale comprised coherent groups of
items (31,32). The Kaiser-Meyer-Olkin (KMO)
test and Bartletts test of sphericity was applied to
measure sampling adequacy (33). Relationships
between variables were analysed using chi-square
Factor Analysis was applied to determine the construct validity of the measurement instrument. The
KMO measure of sampling adequacy was 0.822 in
2001 and 0.793 in 2011 and indicated that factor
analysis was appropriate. Bartletts test was significant (p-value less than 0.005). This indicates good
construct validity.
100
Ethical consideration
The study was approved by the Honorary Court

of Arbitration of the Nurses and Midwives
Association of Slovenia. Participants were assured
that there was no risk from participating in the
study and that their responses would be treated
confidentially.
Changes in the self-esteem of nurse leaders
The average ratings of the detected personal characteristics increased in 2011 as compared to 2001
in all areas (Table2). Nurse leaders in 2011 were
significantly more interested in social issues, and
they saw themselves as more creative and intelligent and more willing to put their ideas into practice. The results of the analysis clearly show that
the self-esteem of the observed leaders increased
significantly.
Statistically significant differences between the

results of the self-assessments of personal characteristics between groups defined according to the level
of leadership, gender, education and age were evident only in a small number of areas. Therefore, differences between these groups cannot be seen as the
reason for such a pronounced increase in self-esteem
between 2001 and 2011.
The order of importance of individual personal

characteristics did not change in any significant
way. Most nurse leaders in both years believed
they were responsible, reliable and, at least, sufficiently educated and willing to put their ideas into
practice.
Homogeneous groups of nurse leaders with

similar characteristics
By using factor analysis we were able to define

groups of personal characteristics, and each of these
groups was characteristic of one of the groups of
nurse leaders. The Principal Component Analysis
(PCA) method was applied to the extraction of
components. According to Kaiser criterion, only the
factors that have eigenvalues greater than one are
retained. Four factors were extracted that accounted
for 49.5% (2011) and 50.4% (2001) of total variability. Varimax rotation was applied in order to
optimize the loading factor of each item on the
extracted components.
A comparison of standard deviations in 2001

and 2011 shows in which areas the differences
between nurse leaders increased and in which they
decreased. The variability of assessment results
decreased, which indicates a higher homogeneity
of the observed group. The greatest decreases were
recorded in the areas of responsibility (38.2%)
and reliability (35.9%) (Colum H in Table 2).
Differences between the results of the self-assessments of personal characteristics among nurse leaders increased in the areas of education (32.0 %) and
intelligence (30.0%).
In the 2011 data, we defined four groups of nurse

leaders. The first group comprised leaders who
believed they were reliable, responsible, practical
and independent. This group was oriented towards
the management of tasks, work, procedures, but
less so towards the leadership of people. They are
believed to be conscientious and precise.
We examined whether the self-assessments of personal characteristics had been influenced by the level
of leadership, gender, education or age. Statistically
significant differences were evident in the following
areas (year 2011):
interested in new areas of work, but less interested in social issues.

Older nurse leaders assessed they were more
critical and more interested in social issues, but
less articulate.
No differences between genders were apparent
in any of the areas.
The differences between the genders were greater

in 2001: the women said they were more educated,
responsible and diligent, but less independent and
sociable than men.
RESULTS
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The second group comprised leaders who believed

they were intelligent, educated, creative and reasonable. These leaders are defined by knowledge,
on which they also base their actions. They are
supposed to be characteristically self-restrained and
emotionally stable.
Nurse leaders at the highest leadership levels

said they were more practical and educated, but
less understanding.
Nurse leaders with the highest education said
they were more educated, practical and more
101
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DISCUSSION
The third group comprised leaders who believed

they were understanding and sociable. Their primary leadership style is people-oriented and inclusive. They are open and kind to people around them.
Their actions are defined by empathy.
The analysis shows that the self-assessments of

personal characteristics, on the basis of which the
self-esteem of a group of nurse leaders was evaluated, improved between 2001 and 2011 (first
research question). In both observed periods (2001
and 2011) the highest ratings were assigned to personal characteristics related to the nature of work
in nursing (reliability and responsibility). Other
research also shows personal characteristics related
to work be the most important for workers in nursing care (34,35).
The fourth group comprised leaders who were willing to put their ideas into practice, interested in
social issues and critical, as well as interested in new
areas of work and articulate. Leaders in this group
are characteristically outward-oriented and tend to
shape and influence relationships with other people.
Their actions are supposedly defined by their extroverted nature.
The greatest increase was recorded in characteristics indicating leaders high self-esteem: the share
of nurse leaders who believed they were intelligent,
creative and interested in social issues increased
from 2001 to 2011. Differences between assessment
results were smaller than in 2001. This is indicative of the creation of a more homogenous and
successful group of leaders as a solid and realistic
self-image is one of the key characteristics of a good
leader (36). Professional identity, which is shaped
by the educational process (37) can only be preserved through appropriate organized continuing
The results of the factor analysis for 2001 data paint

a slightly different picture (Table3). Here, four factors stand out as well. The first factor, which could
arguably be linked to extraverted nature and intelligence, clearly stands out. The groups of characteristics defined on the basis of the remaining factors
would be difficult to relate to the personal characteristics of a leader. In the 2011 data, the groups of
characteristics were much more clearly defined and
in accordance with the theory of leadership in other
fields.
TABLE 3. Rotated component matrix
To what degree, in your opinion, are
you
1
0.74
0.63
0.61
0.56
0.55
Component 2011a
2
3
Component 2001a
2
3
Reliable
Diligent
0.74
Responsible
Practical
0.40
Independent
0.48
Intelligent
0.84
0.63
Educated
0.77
0.46
Reasonable
0.38
0.49
Creative
0.37
0.61
Understanding
0.71
0.64
Sociable
0.64
0.74
Willing to put your ideas into practice
0.70
0.70
Interested in social issues
0.58
0.51
Critical
0.50
Interested in new fields of study
0.44
0.55
Articulate
0.41
0.75
Total variance explained
49.5%
50.4%
Cronbachs Alpha
0.79
0.81
a
Extraction Method: Principal Component Analysis; Rotation Method: Varimax with Kaiser Normalization
102
4
0.55
0.58
0.76
education programs (38). A nurses career path

from graduation to the highest leadership position
takes 10-15years (39). The positive dimensions of
improved self-esteem and better training and education will only start to show results after a few years,
which needs to be confirmed through additional
research.
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potential is realised in the form of a higher quality

of nursing care.
COMPETING INTERESTS
There was no funding source. The authors declare

that there is no conflict of interest.
By using the factor analysis of the 2011 data, we

defined four groups of nurse leaders with similar
personal characteristics (second research question).
The data shows three groups that are most often
defined as positive for leadership in the Big Five
model (10,40,41): extraversion (fourth factor), conscientiousness (first factor) and openness (third factor). Other studies also confirm that those factors
are most directly linked to leadership (29,30,40).
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Amila Kapetanovi and Dijana Avdi. Journal of Health Sciences 2014;4(2):105-109
http://www.jhsci.ba

RESEARCH ARTICLE
Open Access
Inuence of coffee consumption on bone mineral

density in postmenopausal women with estrogen
deciency in menstrual history
Amila Kapetanovi1*, Dijana Avdi2
1
Medical Rehabilitation Center Fojnica, Fojnica, Bosnia and Herzegovina, 2Clinic for orthopedics and traumatology,
University Clinical Center of Sarajevo, Sarajevo, Bosnia and Herzegovina
ABSTRACT
Introduction: Complex etiology of osteoporosis include genetic, hormonal, environmental and nutritional
factors. The aim of this study was to examine inuence of coffee consumption on bone mineral density
in postmenopausal women with estrogen deciency in menstrual history.
Methods: This prospective study included 100 postmenopausal women, aged 50-65 years living in
Sarajevo area, with estrogen deciency in their menstrual history. The controlled clinical trials were conducted. Two groups were formed (based on bone mineral density values). The examination group included
50 women who had osteoporosis, while the control group included 50 women without osteoporosis
(osteopenia, normal bone mineral density). The lumbar spine and proximal femur bone mineral density
was measured by DualEnergy Xray Absorptiometry using Hologic QDR-4000 scanner. Coffee drinking
habits were assessed for each subject.
Results: The average daily intake of coffee in women with estrogen deciency in menstrual history was at
267.6 ml in the examination group and in the control group 111.6 ml. The difference in the average daily
intake of coffee between the two groups was statistically signicant (p < 0.001). There was registered
signicant correlation between intake of coffee and bone mineral density in examination (p < 0.01) and
in control group (p < 0.05).
Conclusion: This study indicates that coffee consumption is a risk factor for osteoporosis in postmenopausal women, aged 50-65 years living in Sarajevo area, with estrogen deciency in their menstrual history. It was shown that the effects of coffee on bone mineral density are dose-dependent.
Keywords: coffee consumption; osteoporosis
INTRODUCTION
*Corresponding author: Amila Kapetanovi,

Medical Rehabilitation Center Fojnica, Fojnica, Bosnia and
Herzegovina
E-mail nermin1a@bih.net.ba
Submitted August 3 2014 / Accepted September 9 2014
The female reproductive system plays a major role

in regulating the acquisition and loss of bone by the
skeleton from menarche through senescence (1).
Longer exposure to estrogen, either through natural menstruation or postmenopausal Estrogen
Replacement Therapy, have protective effects
2014 Amila Kapetanovi and Dijana Avdi; licensee University of Sarajevo - Faculty of
Health Studies. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work
is properly cited.
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for this deleterious effect of caffeine on bone was

indicated in the study of Rapuri PB et al. (11).
Direct negative effects of caffeine on osteoblastic
cells (deleterious effect on the osteoblasts viability)
was suggested in the study of Tsuang YH et al. (12).
Goto et al. have found that plasma concentration
sex hormone-binding globulin (SHBG) that binds
estrogen (lower bioavailability of sex hormones) was
higher in women who consumed four or more cups
than women who did not consume coffee (13). The
results of WedickNMetal. study do not indicate a
consistent effect of caffeinated coffee consumption
on SHBG in men or women (14).
on bone mineral density (2). The loss of ovarian

function, whether premature or not, lead to an
increased risk of bone mineral loss and developing
of osteoporosis because of the lengthened time of
exposure to reduced estrogen (3).
Osteoporosis has a complex etiology and is considered as a multifactorial polygenic disease in
which genetic determinants are modulated by hormonal, environmental, and nutritional factors (4).
Determination of osteoporosis risk factors related
to habits (lifestyle) is important for both, prevention as well as disease treatment, as these factors
can be modified. Caffeine for years is under discussion, whether has positive whether adverse impact
on health (5). Opinions about impact of coffee
consumption on bone metabolism are still controversial. Study of Hasling C. et al. found that a
coffee intake in excess of 1000ml could induce an
extra calcium loss of 1.6 mmol calcium/d, whereas
intakes of 1-2cups of coffee per day would have little impact on calcium balance in postmenopausal
osteoporotic women, age 48 to 77years, with postmenopausal crush fracture (6). Barger-Lux MJet
Heaney RP analyzed data from 560 calcium balance
studies carried out on women aged from 34.8 to
69.3 years. The authors found a caffeine relationship such that for every 177.5 ml serving of caffeine-containing coffee, calcium balance was more
negative by 0.114 mmol/day (4.6 mg/day). There
was no evidence that the putative caffeine effect is
confined to, or is greater among, subjects with low
calcium intakes or those who are older or estrogen-deprived (7). Heaney RP found no evidence
that caffeine has any harmful effect on bone status or on the calcium economy in individuals who
ingest the currently recommended daily allowances
of calcium (8). Study of Lacerda et al. examining
effects of coffee on bone metabolism of mousses,
indicated that coffee consumption has an effect on
metabolism of calcium (including increased level
of calcium in urine and plasma, decreased bone
mineral density and lower bone volume) (9). Study
of Sakamoto et al havent found that coffee stimulates loss of bone tissue in mousses (10). That
intakes of caffeine in amounts >300mg/d accelerate bone loss at the spine in elderly postmenopausal
women and that women with the genetic variant
of vitamin D receptor appear to be at a greater risk
The data about the effects of coffee on bone are

inconsistent. The aim of this study was to examine
influence of coffee consumption on bone mineral
density in postmenopausal women with estrogen
deficiency in menstrual history.
METHODS
Study design
This prospective study included 100 postmenopausal women, aged 50-65years living in Sarajevo
area, with estrogen deficiency in their menstrual
history. The controled clinical trials were conducted. Two groups were formed (based on
bone mineral density values, according to the
WHO criteria). The examination group included
50women who had osteoporosis, while the control group included 50 women without osteoporosis (osteopenia, normal bone mineral density).
The lumbar spine and proximal femur bone mineral density was measured by DualEnergy Xray
Absorptiometry using Hologic QDR-4000 scanner. Coffee drinking habits were assessed for each
subject.
The women who met the following criteria were
included in the study: postmenopausal women with
estrogen deficiency in menstrual history (fewer than
30 years menstruation, menopause before age of
45 years), women aged 50-65 years, women who
live in the Sarajevo area, women with osteoporosis,
women without osteoporosis (osteopenia or normal
bone mineral density), women who do not use hormone replacement therapy. The exclusion criteria
were postmenopausal women without estrogen deficiency in menstrual history, women younger than
106
50 and older than 65 years, women who do not

live in the Sarajevo area, women who are not postmenopausal, women who use hormone replacement
therapy, women who have a disease that can cause
osteoporosis, women who use drugs that may cause
osteoporosis.
80
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58.48
70
57.3
Age (years)
60
50
40
30
20
10
Statistical significance between examination and

control group in intake of coffee was tested by
Students t-test. The coefficient of linear correlation
between intake of coffee and bone mineral density
was calculated. Pvalues less than 0.05 was considered as statistically significant. Data is presented in
graphical and tabular forms.
EXAMINATION GROUP
CONTROL GROUP
FIGURE 1. The average age of women with estrogen deficiency

in menstrual history t = 1.169; no statistically significant.
Average daily intake of

coffee(ml)
300
RESULTS
The average age of women with estrogen deficiency

in their menstrual history in the examination group
was 58.48 years, and in the control group was
57.30 years (Figure 1). There was no statistically
significant differences between these two groups,
t=1.169.
267.6
250
200
150
111.6
100
50
0
EXAMINATION GROUP
CONTROL GROUP
FIGURE 2. The average daily intake of coffee in women with

estrogen deficiency in menstrual history, p < 0.001.
The average daily intake of coffee in women with

estrogen deficiency in menstrual history was
267.6 ml in the examination group and in the
control group 111.6 ml (Figure 2). The difference
in the average daily intake of coffee between the
two groups was statistically significant, t = 8.697;
p<0.001.
TABLE 1. The coefficient of linear correlation between

T scores and the daily intake of coffee among women with
estrogen deficiency in menstrual history
Parameters
Coefficient of
linear correlation
The coefficient of linear correlation between Tscores

and the average daily intake of coffee among women
with estrogen deficiency in menstrual history in
the examination group was statistically significant,
r=0.491; p < 0.01. The coefficient of linear correlation between T scores (Table 1) and the daily
intake of coffee among women with estrogen deficiency in menstrual history in the control group was
statistically significant, r =0.356; p < 0.05.
Examination group
r = 0.491
p < 0.01
Control group
r = 0.356
p < 0.05
Coffee, a beverage used worldwide, includes a

wide array of components that can have potential
implication on health (16). Results of the studies
on influence of coffee consumption on calcium
metabolism, bone mineral density and fracture
risk are contradicting. (6-8, 1722). Potential of
coffee intake as an osteoporosis risk factor is under
debate (16). Lloyd T. et al. found no association
between dietary caffeine intake and total body or
femoral neck bone density or bone mass and found
no associations between caffeine consumption and
longitudinal changes in total body or femoral neck
bone measurements (with and without statistical
adjustment for calcium intake) (17). In the study
of Choi EJ et al. coffee consumption showed no
DISCUSSION
The peak bone mass in the young can be increased

and the rate of bone loss in the elderly possibly be
reduced by dietary manipulation, which would be
important and beneficial in the prevention of osteoporosis (15).
107
http://www.jhsci.ba
caffeine effects on the bone in non-ovariectomized

rats (normal estrogen levels) (24).
significant association with bone mineral density

of either femoral neck or lumbar spine in Korean
premenopausal women (18). Ilich JZ et al. found
that caffeine is negatively associated with bone
mineral density of different skeletal sites in elderly
women (19). Hallstrm H. et al. studied the relation between coffee intake and bone mineral density, taking into account, genotypes for cytochrome
P4501A2 (CYP1A2) associated with metabolism of
caffeine. Men consuming 4 cups of coffee or more
per day had 4% lower bone mineral density at the
proximal femur compared with low or non-consumers of coffee. This difference was not present in
women. High consumers of coffee with C/C genotype, rapid metabolism of caffeine, had lower bone
mineral density than slow metabolizers (T/T and
C/T genotypes). Calcium intake did not modify
the relation between coffee and bone mineral density (20). In their study Tavani A. et al. found no
association between hip fractures among women
and consumption of regular or decaffeinated coffee,
tea, and cola (21). Hallstrom H. et al. found that
a high coffee consumption significantly increased
the risk of osteoporotic fractures. The results of the
study indicate that a daily intake of 330mg of caffeine, equivalent to 4 cups (600 ml) of coffee, or
more, may be associated with a modestly increased
risk of osteoporotic fractures, especially in women
with a low intake of calcium (22).
In this study influence of coffee consumption on

bone mineral density in postmenopausal women,
aged 50-65years living in Sarajevo area with estrogen deficiency in their menstrual history was examined. The difference in the average daily intake of
coffee between the group of women with osteoporosis and group of women without osteoporosis was
statistically significant (p < 0.001). The coefficient
of linear correlation between T scores and the average daily intake of coffee was statistically significant in both, group of women with osteoporosis
(p < 0.01) and group of women without osteoporosis (p < 0.05). Results of this study showed that
intake of coffee has an impact on bone mineral density in postmenopausal women, aged 50-65 years
living in the Sarajevo area, with estrogen deficiency
in their menstrual history. The effect of coffee on
bone mineral density was dose-dependent. The
average amount of consumed coffee in women with
osteoporosis was 267.7ml, and in women without
osteoporosis 116.6ml.
CONCLUSION
This study indicates that coffee consumption is

a risk factor for osteoporosis in postmenopausal
women, aged 50-65 years living in Sarajevo area,
with estrogen deficiency in their menstrual history. It was shown that the effects of coffee on bone
mineral density are dose-dependent. Based on the
results of this research, it recommended that daily
consumption of coffee be limited in order to preserve bone health of postmenopausal women with
estrogen deficiency in their menstrual history (the
average amount of consumed coffee in women without osteoporosis was 116.6ml).
Data from animal studies are also inconsistent(9,10). In animal studies the influence of individual constituents of coffee on bone tissue was
examined (23,24). The aim of Folwarczna J. et al.
study was to investigate the effects of trigonelline,
an alkaloid present in coffee, on bone mechanical
properties of rats with normal estrogen level and
estrogen deficiency. Administration of trigonelline
did not affect the bone turnover markers, bone mineralization and mechanical properties of the tibial
metaphysis, femoral diaphysis, and femoral neck in
non-ovariectomized rats, but it worsened the mineralization and mechanical properties of cancellous
bone in ovariectomized rats (estrogen-deficient
rats)(23). The results of Folwarczna J. et al. study
showed that caffeine has favorably affected on the
skeletal system of ovariectomized rats, slightly inhibiting the development of bone changes induced
by estrogen deficiency. Study found no significant

interests.
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14. Wedick NM, Mantzoros CS, Ding EL, Brennan AM, Rosner B, Rimm EB,
Hu FB, van Dam RM. The effects of caffeinated and decaffeinated coffee on sex hormone-binding globulin and endogenous sex hormone levels: a randomized controlled trial. Nutr J. 2012 Oct 19;1186. http//dx.doi.
org/10.1186/1475-2891-11-86.
3. Kurtoglu-Aksoy N, Akhan SE, Bastu E, Gungor-Ugurlucan F, Telci A,

Iyibozkurt AC, Topuz S. Implications of premature ovarian failure on bone
turnover markers and bone mineral density. Clin Exp Obstet Gynecol.
2014;41(2):149-53.
15. Wang P, Zhang H. Review of dietary risk factors for osteoporosis. Wei
Sheng Yan Jiu. 2003 Jan;32(1):81-3.
4. Gennari L, Merlotti D, De Paola V, Calabr A, Becherini L, Martini G,

Nuti R. Estrogen Receptor Gene Polymorphisms and the Genetics of
Osteoporosis: A HuGE Review Am. J. Epidemiol. (2005)161 (4): 307-320.
http//dx.doi.org/10.1093/aje/kwi055.
16. Cano-Marquina A, Tarn JJ, Cano A. The impact of coffee on

health. Maturitas. 2013 May;75(1):7-21. http://dx.doi.org/10.1016/j.
maturitas.2013.02.002.
5. Wierzejska R. Caffeine - common ingredient in a diet and its influence on

human health. Rocz Panstw Zakl Hig. 2012;63(2):141-7.
17. Lloyd T, Rollings N, Eggli DF, Kieselhorst K, Chinchilli VM. Dietary caffeine intake and bone status of postmenopausal women Am J Clin Nutr.
1997 Jun;65(6):1826-30.
6. Hasling C, Sndergaard K, Charles P, Mosekilde L. Calcium metabolism in

postmenopausal osteoporotic women is determined by dietary calcium and
coffee intake. J Nutr. 1992 May;122(5):1119-26.
18. Choi EJ, Kim KH, Koh YJ, Lee JS, Lee DR, Park SM. Coffee consumption
and bone mineral density in korean premenopausal women. Korean J Fam
Med. 2014 Jan;35(1):11-8. http://dx.doi.org/10.4082/kjfm.2014.35.1.11.
7. Barger-Lux MJ, Heaney RP. Caffeine and the calcium economy revisited.
Osteoporos Int. 1995 Mar;5(2):97-102. http://dx.doi.org/10.1007/BF01623310.
19. Ilich JZ, Brownbill RA, Tamborini L, Crncevic-Orlic Z. To drink or not to

drink: how are alcohol, caffeine and past smoking related to bone mineral
density in elderly women? J Am Coll Nutr. 2002 Dec;21(6):536-44. http://
dx.doi.org/10.1080/07315724.2002.10719252.
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consumption and CYP1A2 genotype in relation to bone mineral density of
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women in northern Italy. Prev Med. 1995 Jul;24(4):396-400. http://dx.doi.
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Yukawa S. Effect of coffee consumption on bone metabolism. Bone.
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increases the rate of bone loss in elderly women and interacts with
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consumption in relation to osteoporotic fracture risk in a cohort of Swedish
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s00198-006-0109-y.
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on osteoblastic cells metabolism the possible causal effect of caffeine on
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of trigonelline, an alkaloid present in coffee and fenugreek, on bone
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Nowiska B, Sliwiski L. Favorable effect of moderate dose caffeine
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2013 Oct;57(10):1772-84.
109
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Edina Tanovi, et al. Journal of Health Sciences 2014;4(2):110-113

RESEARCH ARTICLE
Open Access
Evaluation of the treatment efcacy of patients

with multiple sclerosis using Barthel index and
expanded disability status scale
Edina Tanovi1*, Devad Vrabac1, Aldijana Kadi1, Admir Rama2, Haris Tanovi3
1
Clinic for Abdominal Surgery, University Clinical Center Sarajevo, Bosnia and Hercegovina, 2Turkish Clinic Bahceci,
Sarajevo, Bosnia and Hercegovina, 3Clinic for Physical Medicine and Rehabilitation, University Clinical Center Sarajevo,
Bosnia and Hercegovina
ABSTRACT
Introduction: Multiple sclerosis (MS) is a chronic, autoimmune and progressive multifocal demyelinating
disease of the central nervous system. The aim of this study was to evaluate rehabilitation of patients with
multiple sclerosis using BI (Barthel index) and EDSS (Expanded Disability Status Scale).
Methods: A clinical observational study was made at the clinic for physical medicine and rehabilitation in
Sarajevo. We analyzed 49 patients with MS in relation of gender, age and level of disability at admission
and discharge, patient disability were estimated using EDSS scale. The ability of patients in their activities
of daily living were also analyzed according to the BI at admission and discharge.
Results: Of the total number of patients (n=49) there were 15 men and 34 women. The average age of
female patient was 42.3813.48 and male patient 46.069.56. EDSS values were signicantly different
at the beginning and at the end of the therapy (p=0.001) as was the value of BI (p=0.001).
Conclusion: MS patients, after the rehabilitation in hospital conditions show signicant recovery and
a reduced level of disability; they show higher independence in activities but rehabilitation demands
individual approach and adjustment with what patients are currently capable of achieving.
Keywords: rehabilitation; MS (Multiple Sclerosis); EDSS (Expanded Disability Status Scale); BI (Barthel
Index)
INTRODUCTION
Multiple sclerosis (MS) is a chronic, demyelinating

and progressive multi-focal disease which affects
*Corresponding author: Prof. Dr Edina Tanovi,
Clinic for Physical medicine and rehabilitation,
University Clinical Center Sarajevo,
Bolnika 25, 71000 Sarajevo,
Bosnia & Herzegovina
E-mail: tanovicedina@hotmail.com
Submitted August 03, 2014 / Accepted September 08, 2014
the auto-immunity of the central nervous system.

When a certain part of the myelin sheath is inflamed
and damaged, transfer of impulses through neurons
is disturbed, slow or intermittent (1-3). Clinical
symptoms of MS include nystagmus, tremors and
dysarthria, eye disorder, movement disorders, sensibility problems with the coordination and balance
of movement, problems with urination and defecation, sexual dysfunction, disturbances in cognition,
fatigue, pain etc. (4,5).
2014 Edina Tanovi, et al.; licensee University of Sarajevo - Faculty of Health Studies. This
http://www.jhsci.ba
lower level of disability. We have also analyzed the

abilities of the patients in their activities of daily living according to the Barthel index at admission and
discharge. This scale ranges from 0 to 20. Apatient
is fully dependent when the sum of point was 0-4,
5-12 shows high level of dependence, 13-18 shows
moderate level, 19 shows low level and 20 shows
total independence.
Symptomatic treatment includes a full range of procedures that aim to alleviate the existing symptoms,
in order to maintain active mobility for as long as
possible and reduce the degree of disability of these
patients (6,7).
The plan of rehabilitation of these patients is made
to the status of disability by EDSS scale. The
minimum value of the EDSS scale is 0 (normal
neurological examination result) and the highest 10
(death due to complications of MS).
All the analytical data are presented in tables with

an absolute number of cases, the arithmetic mean,
standard deviation and range of value 2 - square
test. We also used ANOVA and Wilcoxon nonparametric test. All the tests with p<0.05 were considered statistically significant.
Activities of daily living were assessed by the Barthel

Index with the lowest value of 0 (total dependence
on others for care and assistance) to 20 (independent in activities of daily living) (8,9).
MS is often diagnosed in people between the ages of
25 and 50, but rarely in children and persons above
age of 60. Women are 2 to 3times more prone than
man in contracting MS (6,7).
RESULTS
The aim of this study was to evaluate rehabilitation

of patients with multiple sclerosis using BI (Barthel
index) and EDSS (Expanded Disability Status
Scale).
Of the total number of patients (n=49) there

were 15 men and 34 women. The average age was
43.5112.43, the average age of female patients
was 42.3813.48years, and the average age of male
patients was 46.069.56years (Table1).
METHODS
By using a nonparametric Wilcoxon test, there was a

statistically significant difference in the EDSS value
before and after therapy (Table2). The EDSS value
before therapy was 6.041.52 (required regular or
occasional assistance to walk up to 100m with or
without rest), whereas after therapy, the value fell
to 5.461.51 (mobile without aid or rest, but with
restrictions in daily activities), Z=-0.514; p=0.001.
A clinical observational study was made at the

Clinic for physiology and rehabilitation, University
Clinical center Sarajevo. The study included
49patients with MS of both genders aged between
18 and 65 who were diagnosed with MS and who
have undergone the recommended physical therapy
as per the protocol. The study excluded patients
who have not undergone physical therapy as per the
protocol or had their treatment continued at the
Neurological clinic in Sarajevo due to the worsening of the underlying disease. Level of disability of
patients at admission and discharge in accordance
with the EDSS (Expanded Disability Status Scale) is
used as a measure of disease progression. This scale
ranges from 0 to 10, with lower scores indicating
By analyzing activities of daily living of the

patients-before and after the therapy-based on the
Barthel index and by implementing the Wilcoxon
test, we have established a statistically significant
difference in the clinical status. Before the therapy
and after reception, based on the Barthel index, the
patients were classified in the heavily dependent category (12.895.52), while after therapy their clinical
TABLE 1. Gender and age of patients
Female
Male
Total
Mean
SD
SE
34
15
49
42.38
46.06
43.51
13.48
9.56
12.43
2.31
2.46
1.77
95% CI for mean

Lower bound
Upper bound
37.67
47.08
40.76
51.36
39.98
47.08
111
Minimum
Maximum
18.00
28.00
18.00
66.00
65.00
66.00
http://www.jhsci.ba
condition improved and they were classified, according to the Barthel index, with moderate dependence
(14.48 5.37), Z=-4.843; p=0.001 (Table 3).
Analysis of the age structure of patients shows that

the average age was 43.5112.43, the average age of
female patients was 42.3813.48years, and for male
patients, it was 46.069.56years. This data indicates
that there is no statistically significant difference in
age structure of the respondents in relation to their
gender (p=0.344). Research conducted earlier show
that the average age of patients with MS in rehabilitation was lower. We think that reason for this
difference is better diagnosis and the earlier involvement of patients in the rehabilitation process, but it
is also possible that other studies involved younger
patients (10,11).
DISCUSSION
Multiple sclerosis (MS) is a chronic disease of the

central nervous system. It was named after lesions
where histopathological samples of brain tissue
appear as indurated areas-plaques (6). These plaques
are disseminated in different areas of the central nervous system and appear at irregular intervals. With the development of neuro-radiological
techniques, especially MRI (magnetic resonance
imaging) of the brain, the number of diagnosed and
newly diagnosed patients with MS has dramatically
increased. It was found that in patients with MS,
typically only one clinical manifestation of the disease occurs for each new 8 to 10 new lesions in the
brain, that were confirmed by MRI (7).
Clinical features of patients with MS is actually
very diverse with different symptoms that vary in
severity. These patients, after diagnosis and neurological therapy, register for the rehabilitation mainly
because of the problems with their motor skills and
their inability to control their sphincters (8,9).
Study results show statistically significant difference
in the gender representation of the respondents,
and in the examined sample women dominated
(p=0.007). These figures correspond to data from
the literature; female patients suffer from MS, 2 to
3times more than men.
The assessment of the degree of disability is shown

through EDSS and used as a measure of the progression of the disease and severity of neurological
disorder in these patients (12). During the process
of rehabilitation, patients tried to increase their
mobility by kinesiotherapy (13). Also, all patients
underwent occupational therapy to gain competence in day to day activities. The analysis of the
EDSS values before and after the therapy showed
statistically significant differences. The EDSS value
before therapy was V6.041.52 which means that
patients needed permanent or temporary orthopedic aid such as the use of canes, crutches or walking frame to walk up to 100 m, with or without
rest; while after the therapy, the value dropped to
5.461.51, which means that the patient is mobile
without assistance or rest, but is limited in daily
activities (p=0.001). Our research shows that
patients with a greater degree of disability were
registered for the rehabilitation then what other
studies have shown (14,15). Research conducted
in France and England have shown that inpatient
rehabilitations is carried out for small disabilities
and in the earlier phases of the disease when they
expect the effects of the treatment to be better
(16-18).
TABLE 2. EDSS scale values at admission and discharge

N Mean Std. deviation Minimum Maximum
EDSS at 49 6.0408
1.52697
3.00
9.00
admission
EDSS at 49 5.4694
1.51523
3.00
9.00
discharge
Z=-0.514; p=0.001
By analyzing the activities of daily living according to the Barthel index, significant statistical
difference in clinical conditions was established
(p=0.001) before and after physical therapy. Upon
reception, the patients were classified as being heavily dependent (12.895.52), while after the treatment, their clinical condition improved and they
were, according to the Barthel index, classified as
being moderately dependent (14.485.37). These
TABLE 3. Barthel index value at admission and discharge

N Mean Std. deviation Minimum Maximum
BI at
49 12.89
5.52
3.00
20.00
admission
BI at
49 14.48
5.37
4.00
20.00
discharge
Z=-4.834; p=0.001
112
http://www.jhsci.ba
(05)01017-3.5. Christensen T. The role of EBV in MS pathogenesis. INT

MSJ 2006; 13(2): 52-7.
data confirm that physical therapy (kinesiotherapy

and occupational therapy) is of great importance in
enabling patients in carrying out day to day activities. Research done in the last three years also gives
similar results. It is recommended that the evaluation of different possibilities and aspects of physical therapy should be tailored to each patient and
to respect current possibilities of these patients in
each therapeutic procedure (19,20). An important
prognostic factor is the movement in the Barthel
index at the beginning, during and after physical
therapy which will, if stagnant, show that the best
clinical recovery in day to day life activities has been
reached (20).
6. Rovira A, Swanton J, Tintor M, Huerga E, Barkhof F, Filippi M,

Frederiksen JL, Langkilde A, et all. A single, early magnetic resonance imaging study in the diagnosis of multiple sclerosis. Arch Neurol.
2009;66(5):587-92. http://dx.doi.org/10.1001/archneurol.2009.49.
7. Okuda DT, Mowry EM, Beheshtian A, Waubant E, Baranzini SE,
Goodin DS, et all. Incidental MRI anomalies suggestive of multiple sclerosis: the radiologically isolated syndrome. Neurology. 2009;72(9):800-5.
http://dx.doi.org/10.1212/01.wnl.0000335764.14513.1a.
8. Amarenco G, Denys P. Urinary disorders in multiple sclerosis: Algorythm
and guidelines, the FLUE-MS. Europ J of Phys and Rehabil Med
2014;50(1) 110.
9. Denys P, Even A, Phe V, Chartier-Kastler E. Therapeutic management of
urinary disorders in MS. Europ J of Phys and Rehabil Med 2014;50(1) 111.
10. Previnaire JG, Lecort G, Soler JM. Sexual disorders in multiple sclerosis: evaluation and management. Europ J of Phys and Rehabil Med
2014;50(1) 110.
11. Lacoste-Guinet A, Verollet D, Le Breton F, Peyrat L, Amarenco G.
Prevalence of stress urinary incontinence in women with multiple sclerosis.
Europ J of Phys and Rehabil Med 2014;50(1) 111.
CONCLUSION
12. Pelletier J, Rico A, Adoin B. Multiple Scerosis treatment options: Update

2014 Europ J of Phys and Rehabil Med 2014;50(1) 111.
Patients with the MS, after rehabilitation in hospital

conditions, show significant recovery and reduced
degrees of disability. In activities of daily living
they were more independent, but the rehabilitation
demands an individual approach and adaptation to
the current capacities of the patients.
13. Robinet E, Favre A, Zaaraoui W, Guye M, Asquinazi P, Bardot P, Pelletier J,

Ranjeva JP, Audoin B. Physical rehabilitation in associated with structural
and functional brain plasticity in patients with multiple sclerosis. Europ J of
Phys and Rehabil Med 2014;50(1) 111.
14. Gallien P, Nicolas B, Durufle A, Robineau S, Petrilli S, Autret K, Houdakor J,
Le Meur C. Physical training and muscle strengthening im multiple sclerosis. Europ J of Phys and Rehabil Med 2014;50(1) 112.
15. Thoumie P. Balance in multiple sclerosis. Evaluation and rehabilitation.
Europ J of Phys and Rehabil Med 2014;50(1) 112.
16. Allart E, Benoit A, Thevenon A, Tiffreau V, Outteryck O, Zephir H, Lacour A,

Vermersch P, Blanchard A. Characteristics of walking fatigability in Mutiple
Sclerosis. Europ J of Phys and Rehabil Med 2014;50(1) 112-3.
The authors declare no conflict of interest.
17. Rasova K. Describing availability and characteristics of ohysical therapy in

Multiple Sclerosis across Europe: a qualitative study. Europ J of Phys and
Rehabil Med 2014;50(1) 115.
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multiple sclerosis patients: our experience vs United-Kingdom consensus.
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113
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Lana Leki, et al. Journal of Health Sciences 2014;4(2):114-119

RESEARCH ARTICLE
Open Access
Adherence to oral anticoagulation therapy

Lana Leki1*, Alen Leki2, Alden Begi3
1
Boehringer Ingelheim RCV GmbH&Co.KG, Representative Ofce, Grbavika 4, 71000 Sarajevo, Bosnia and Herzegovina,
Sano-aventis Groupe, Representative Ofce in Bosnia and Herzegovina, Fra Anela Zvizdovia 1/VIII, 71000 Sarajevo,
Bosnia and Herzegovina, 3Clinic for Vascular Diseases, Clinical Center of Sarajevo University, Bolnika 25, 71000 Sarajevo,
Bosnia and Herzegovina
2
ABSTRACT
Introduction: Warfarin is the most frequently prescribed anticoagulant. Clinical treatment is demanding
because of the narrow therapeutic range and considerable differences between the patients. The aim of
this survey is to establish adherence to warfarin in subjects who have been prescribed warfarin as a longterm therapy.
Methods: The survey included 30 subjects, and was conducted at local pharmacy store. Statistical
processing was carried out using the SPSS (ver. 21.) software. Used for qualitative variables was the
Chi-square test, and for quantitative ones the ANOVA test. Data were provided in the form of tables and
charts. Level of signicance was p=0.05.
Results: The survey included 30 subjects, 14 men and 16 women. Of the total number of polled subjects,
15 were informed by a health care professional about the specicities of warfarin use, 7 said they were
not informed, while 8 said they did not know. Most compliant in terms of regularly taking their medicines
were pensioners, followed by the unemployed, 2=13.231; p<0.05. The number of subjects within the
expected therapeutic INR range was 22 (p<0.05).
Conclusion: Strict compliance with the warfarin regimen is important in order to increase its effectiveness, extend the time and strengthen the intensity of anticoagulant action in the body. That is why the
target groups of patients, who use warfarin, need additional information before and during therapy, in
order to avoid side effects, and at the same time maintain therapeutic efcacy of the medicine throughout the treatment.
Keywords: adherence; compliance; anticoagulation therapy
INTRODUCTION
Warfarin is the most frequently prescribed anticoagulant; it is prescribed to more than 2 million
*Corresponding Author: Lana Leki, mr sci pharm spec
Boehringer Ingelheim RCV GmbH&Co.KG, Representative Ofce
Grbavika 4, 71000 Sarajevo, Bosnia and Herzegovina
Phone: +387 62 205950
E-mail: lana.lekic@hotmail.com
Submitted August 12, 2014 / Accepted September 11, 2014
new patients every year. Warfarin is often used

as a permanent therapy for prevention of embolism in patients with atrial fibrillation, heart valve
disease, and for primary and secondary prevention of venous thromboembolism (1). Warfarin
is also used to prevent thromboembolic attacks
in patients with acute myocardial infarction and
angina pectoris, in patients with biological heart
valves, and after certain orthopedic surgeries.
Clinical treatment is demanding because of the
2014 Lana Leki, et al.; licensee University of Sarajevo - Faculty of Health Studies. This is
an Open Access article distributed under the terms of the Creative Commons Attribution
http://www.jhsci.ba
METHODS
narrow therapeutic range and considerable differences between the patients. In the absence of
data obtained by genetic research or clinical information to predict the necessary dose of warfarin
for each individual patient (2), initial prescribed
doses may be too low, which increases the risk of
thrombosis, or too high, which leads to the risk
of excessive anticoagulation and heavy bleeding.
In the United States, there are annually up to 800
adverse events related to the use of warfarin that
are encompassed by the reporting rule (3). The risk
of serious warfarin-related side-effects, its narrow
therapeutic range and large inter-individual dosing
differences require a preparation of algorithms in
order to be able to predict, as closely as possible, the
dose necessary at the initial stage(s) of treatment.
Because proper administration of therapy remains
a clinically significant problem despite years of
research (4), a new assessment of basic issues, such
as the terms used in the field, may be necessary to
be able to identify innovative strategies of clinical
interventions and investigations (5). Adherence
is defined as: the extent to which patients follow the instructions they are given for prescribed
treatments (6). Adherence to warfarin treatment,
as well to that of other medicines (7), is essential
for a good health condition of elderly patients and
is thus a critical health care component. Noncompliance with the recommendations for the
therapy at old age has been proven to increase the
likelihood of therapeutic failure (8) and is responsible for unnecessary complications leading to
increased health protection costs, early functional
disability and premature death (9). Poor adherence
to therapy was reported in all age groups. However,
a larger prevalence of cognitive and functional disorders in elderly persons increases the risk of poor
adherence. Multiple concomitant diseases and a
complex medical treatment may further compromise warfarin adherence. Age-related changes in
pharmacokinetics and pharmacodynamics render
this population even more sensitive to the problems caused by poor adherence to therapy (10).
The survey included 30 subjects, who were undergoing an anticoagulant therapy. The survey was conducted at local pharmacy store in Sarajevo in 2013.
The main inclusion criterion was continuous warfarin therapy through at least 12 months. Within
the group of subjects who met inclusion criteria,
30 patients were randomly chosen. The subjects
were polled, and the answers received were statistically processed. Modified Morisky questionnaire on
chronic therapy adherence has been used. Subjects
have had 4 measurements of INR values during the
therapy course.
Statistical processing was carried out using the SPSS

(ver. 21.) software. Used for qualitative variables was
the Chi-square test, and for quantitative ones the
ANOVA test. Data were provided in the form of
tables and charts. Level of significance was p=0.05.
RESULTS
The survey included 30 subjects, 14 men and

16women. An analysis of average age of the subjects,
by applying the ANOVA test, did not find a statistically significant difference (Table 1). The average
age of male subjects was 55.1416.96 years, and
that of female subjects 54.4315.48years, F=0.014;
p=0.906.
An analysis of marital status of the subjects included
in the survey found that the majority of the subjects
were married (n=22), while three subjects from each
group have never been married or have the status
of a widow(er). One of the subjects was divorced
(Figure1).
Figure 2 shows INR values during measurement.
Established with the use of the Chi-square test,
there was a statistically significant difference in the
frequency of findings within the expected therapeutic range (p<0.05). On first measurement, in
12 subjects the INR values were within the expected
therapeutic range, on the second measurement
14, on the third measurement 17, and finally on
the ultimate, fourth, measurement the number of
subjects whose results were within the expected INR
therapeutic range was 22.
The aim of the study was to determine the adherence to warfarin in patients whom warfarin is a
long-term therapy and to evaluate the factors that
directly or indirectly reduce or increase the level of
adherence.
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TABLE 1. Age and gender of subjects
Male
Female
Total
Mean
SD
Std.
Error
14
16
30
55.14
54.43
54.76
16.96
15.48
15.91
4.53
3.87
2.90
25
95% confidence interval for mean

Lower bound
Upper bound
45.3473
64.9384
46.1848
62.6902
48.8247
60.7086
23.00
30.00
23.00
75.00
75.00
75.00
Frequency Percent
15
Answer Yes
No
Do not
know
Total
10
Maximum
TABLE 2. Level of information concerning the specificities of

warfarin use, provided by health care professional
22
20
Minimum
never married marred
dvorced
widower
1
widower living
with the Partner
15
7
8
50.0
23.3
26.7
30
100.0
Valid Cumulative
percent
percent
50.0
50.0
23.3
73.3
26.7
100.0
100.0
FIGURE 1. Marital status of subjects.

the anticipated therapeutic range
below the targeted therapeutic value
above the target therapeutic value
22
25
20
15
12 12
11
7
Based on the answers to the question on adherence,

the subjects mostly said they did not forget to take
medicines while traveling; also they never stop using
medicines without prior consultation with the relevant doctor. When asked whether they feel under
pressure because daily administration of medicines
might be impractical, they mostly said they never
felt that way, while 5 subjects said they sometimes
do feel under pressure (Table5).
17
14 13
10
5
in relation to the employment status, 2=14.948;

p<0.05.
I measurement II measurement III measurement IV measurement
FIGURE 2. INR values during measurement period.
DISCUSSION
Coumarine derivatives (warfarin and acenocoumarol) are vitamin K antagonists (VKA) and are used
for long-term treatment of patients with venous
thrombo-embolism (VTE). Warfarin therapy
usually starts within 24-72 hours of the onset of
parenteral heparin treatment. The usual initial dose
is 5-10mg, while lower doses are recommended to
elderly patients, or those with lower body weight,
or underweight patients. Warfarin doses and their
monitoring have been adjusted to the INR (international normalized ratio) values(11). The survey
polled 30 patients on warfarin. The average age
of the subjects was 55. Most of the subjects were
married. While measuring INR values during
the treatment statistically significant difference
in terms of the number of subjects with referent
Of the total number of polled subjects, 15 were

informed by a health care professional about the
specificities of warfarin use, 7 said they were not
informed, while 8 said they did not know (Table 2).
Answers to the question about the frequency of
forgetting to take the medicine have produced
statistically significant difference (Table 3). Most
compliant in terms of regularly taking their medicines were pensioners, followed by the unemployed,
2=13.231; p<0.05.
Over the past two weeks, the frequency of forgetting
to take medicine was the lowest in pensioners and
the unemployed (Table4), while those employed and
students tend to forget to take their medicines more
often, so there is a statistically significant difference
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TABLE 3. Frequency of forgetting to take medicine
I never forget to take medicine

I forget to take medicine once a week
I forget to take medicine 2 to 3 times a week
Total
Unemployed
9
2
0
11
TABLE 4. Frequency of forgetting to take medicine over the

past two weeks
Not once
Once or
twice
3 to 5 times
Total
0
7
1
1
0
11
Total
Pensioner
11
0
0
11
25
4
1
30
frequency of forgetting to take medicines was

most often reported in those employed, while pensioners were most regular in taking their therapy.
The subjects polled mostly said they did not forget to take warfarin even when they traveled. Of
the total number of subjects (n=30), 28 said they
never stopped taking warfarin without consulting a
physician, despite good clinical picture of primary
disease for which warfarin has been administered.
Most of the subjects never feel pressure on account
of the medicine administration regimen, while
5 subjects said they sometimes felt pressure, and
4 subjects feel pressure more often. Unemployed
subjects are the ones who have most difficulties
remembering to take warfarin. Astudy conducted
in Japan analyzed warfarin adherence in subjects
who took therapy for atrial fibrillation(14). Of the
total number of subjects (n=330), as many as 52%
did not know the therapeutic significance of warfarin. Aquestionnaire found that only 51% ofthe
subjects had a basic preliminary knowledge of warfarin, atrial fibrillation and heart attack (14).
Employment status
Total
Unemployed Employed Student Pensioner
11
5
0
11
27
0
2
0
0
2
0
11
Employment status
Employed
Student
5
0
2
0
0
1
7
1
1
30
values during 4 measurements was discovered. On

first measurement, the figure was 12, and after
the fourth measurement the number of subjects
within the expected therapeutic INR range was 22
(p<0.05) (Chart 2). Randomized clinical studies
during which the patients indicated for anticoagulant therapy were randomly prescribed warfarin
or some other alternative anticoagulant were rather
helpful by showing the risk of warfarin-related
non-compliance (5,12), independently from the
potentially confounding factors affecting the validity of observational studies. When it comes to
patients who were prescribed warfarin or an alternative medicine, it is necessary to analyze additional factors affecting the treatment outcome due
to non-compliance or improper drug administration (6,8). In such studies, regular INR testing was
carried out mostly on randomized patients using
warfarin. In these studies, both the side-effects
and the monitoring may be factors affecting poor
adherence (13). Some trials have shown that subjects using oral anticoagulants tend to discontinue
their therapy more often, while some have shown
no difference in terms of non-compliance with the
prescribed therapy in relation to placebo (13). In
the polled group, only 50% of the subjects were
informed by a health care professional about
the specificities of warfarin administration. The
CONCLUSION
Strict compliance with the warfarin regimen is

important in order to increase its effectiveness,
extend the time and strengthen the intensity of
anticoagulant action in the body. That is why the
target groups of patients, who use warfarin, need
additional information before and during therapy,
and a quality interaction between the health care
professional and the patient, in order to avoid side
effects, and at the same time maintain therapeutic
efficacy of the medicine throughout the treatment.
Adherence to warfarin can be successfully monitored by determining the value of INR, however
adherence itself is directly affected by patients
knowledge on warfarins mode of action, patients
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TABLE 5. Answers to questions on compliance

Unemployed
When you travel, do you forget to take your medicines with you?
I do not travel
Never
2=1.197; p=0.754
5
6
Employment status
Employed
Student
4
3
1
0
Total
Pensioner
6
5
16
14
When you feel your health is under control, do you sometimes stop taking medicines on your own, without consulting a
doctor?
I never do it alone
11
6
0
11
28
I sometimes do it alone
0
1
0
0
1
I always do it alone
0
0
1
0
1
2
=11.727; p=0.068
Taking medicines every day is impractical for many people. Do you feel under pressure because you need to follow
recommendations for your treatment?
I never feel that way
8
5
0
7
I sometimes feel that way
1
2
0
2
I often feel that way
2
0
0
2
I always feel that way
0
0
1
0
2=12.006; p=0.213
How often do you have difficulties remembering to take your medicine?
Never
8
Sometimes
3
Often
0
2
=0.249; p=0.168
6
1
0
0
0
1
10
1
0
20
5
4
1
24
5
1
intraethnic variability of CYP2C8 and CYP2C9 polymorphisms in healthy

individuals. Mol Diagn Ther 2006;10:29-40. http://dx.doi.org/10.1007/
BF03256440.
daily and professional activities as well as form of the

drug and therapy regimen.
5. Kearon C, Kahn SR, Agnelli G, et al. Antithrombotic therapy

for venous thromboembolic disease: American College of
Chest Physicians Evidence-Based Clinical Practice Guidelines
(8th Edition) Chest. 2008;133(6 Suppl):454S545S.
COMPETING INTERESTS
Lana Leki works as a medical representative for

1
Boehringer Ingelheim RCV GmbH&Co.KG. Alen
Leki works as a medical representative for Sanofi
Aventis groupe.
6. Fanikos J, Stapinski C, Koo S, Kucher N, Tsilimingras K, Goldhaber SZ.

Medication errors associated with anticoagulant therapy in the hospital. Am J Cardiol. 2004;94(4):532535. http://dx.doi.org/10.1016/j.
amjcard.2004.04.075.
7. Brandolese R, Scordo MG, Spina E, Gusella M, Padrini R. Severe phenytoin intoxication in a subject homozygous for CYP2C9*3. Clin Pharmacol
Ther 2001;70:391-4.
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9. Rollason V, Samer C, Piguet V, Dayer P, Desmeules J. Pharmacogenetics of

analgesics: toward the individualization of prescription. Pharmacogenomics
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2. Redman AR, Zheng J, Shamsi SA, Huo J, Kelly EJ, Ho RJY, et al.
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of atral fbrllaton and warfarn: adherence and complance to warfarn and frequency dstrbuton of nternatonal normalzed rato values
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Maa Amrain and Fahir Bei. Journal of Health Sciences 2014;4(2):120-125

ORIGINAL ARTICLE
Open Access
Knowledge, perception, practices and barriers of

healthcare professionals in Bosnia and Herzegovina
towards adverse drug reaction reporting
Maa Amrain1*, Fahir Bei2
1
Boehringer Ingelheim BH d.o.o., Regulatory Affairs Department, Sarajevo, Bosnia and Herzegovina,
Pharmacology, University of Sarajevo Faculty of Pharmacy, Sarajevo, Bosnia and Herzegovina
Department of
ABSTRACT
Introduction: Pharmacovigilance is an arm of patient care. No one wants to harm patients, but
unfortunately any medicine will sometimes do just this. Underreporting of adverse drug reactions by
healthcare professionals is a major problem in many countries. In order to determine whether our pharmacovigilance system could be improved, and identify reasons for under-reporting, a study to investigate
the role of health care professionals in adverse drug reaction (ADR) reporting was performed.
Methods: A pretested questionnaire comprising of 20 questions was designed for assessment of knowledge, perceptions, practice and barriers toward ADR reporting on a random sample of 1000 healthcare
professionals in Bosnia and Herzegovina.
Results: Of the 1000 respondents, 870 (87%) completed the questionnaire. The survey showed that
62.9% health care professionals would report ADR to the Agency for Medicinal Products and Medical
Device of Bosnia and Herzegovina (ALMBIH). Most of surveyed respondents has a positive perception
towards ADR reporting, and believes that this is part of their professional and legal obligation, and they
also recognize the importance of reporting adverse drug reactions. Only small percent (15.4%) of surveyed
health care professionals reported adverse drug reaction.
Conclusions: The knowledge of ADRs and how to report them is inadequate among health care professionals. Perception toward ADR reporting was positive, but it is not reected in the actual practice of
ADRs, probably because of little experience and knowledge regarding pharmacovigilance. Interventions
such as education and training, focusing on the aims of pharmacovigilance, completing the ADR form
and clarifying the reporting criteria are strongly recommended.
Keywords: knowledge; health care professionals; adverse drug reaction (ADR); pharmacovigilance;
Bosnia and Herzegovina
INTRODUCTION
*Corresponding author: Maa Amrain,

Boehringer Ingelheim BH d.o.o.,
Regulatory Affairs department Sarajevo,
Bosnia and Herzegovina,
Phone:+38762849727,
E-mail: masa.amrain@boehringer-ingelheim.com
Submitted August 3 2014 / Accepted September 20 2014
Any drug/medicine during its normal therapeutic use has a potential to produce adverse drug
reaction(s) (ADRs). ADRs contribute to a significant number of morbidity and mortality all over
the world (1). It has been estimated that around
2014 Maa Amrain and Fahir Bei; licensee University of Sarajevo - Faculty of Health
http://www.jhsci.ba
of Bosnia and Herzegovina as the competent body

responsible for the field of medicinal products and
medical devices manufactured and used in BiH.
It began operating on May 1 2009. (13). ADR
reporting in BiH is closely linked to economic
problems in the local healthcare system, which is
still being developed. The level of ADR reporting is
inadequate despite the fact that information on the
safety of medicinal products is of vital importance
and despite the fact that reporting on adverse effects
to the ALMBiH is a legal obligation. This obligation
is defined in the Book of rules on the manner of
reporting, collecting and following adverse effects of
the medicinal product, in Article 11 (14) medicinal
product manufacturers, health care institutions and
health care professionals (medicinal doctors, dentists,
pharmacists, health technicians, nurses) are under
the obligation to report to the Agency any suspicion
about the adverse effects of a medicinal product.
2.9-5.6% of all hospital admissions are due to ADRs

and as many as 35% of hospitalized patients experience an ADR during their hospitalization (2). The
economic burden of ADRs is also considerable; for
example in the United States, annual total cost of
$47.4 billion for 8.7 million drug related admissions were reported (3).
Many developed countries have strong and efficient
pharmacovigilance systems. Good pharmacovigilance system will identify the risks and the risk factors in the shortest possible time so that harm can
be avoided or minimized (4). These systems among
other use spontaneous reporting to collect and analyze adverse events associated with the use of drugs.
Though this process is not perfect, it can provide
evidence that can be used to establish regulatory
action to protect public health, and in addition it is
fast and cost-efficient method.
Several studies (5) have indicated a variety of obstacles to the spontaneous reporting of ADRs, such as
lack of time (6,7) different care priorities (7), uncertainty about the drug causing the ADR (7-10),
difficulty in accessing reporting forms (6), lack of
awareness of the requirements for reporting (7,10)
and lack of understanding of the purpose of spontaneous reporting systems (6).
The objective of this study was to gain insight into

the perceptions, practices and barriers of HCP in
BiH with respect to the reporting of ADRs and
pharmacovigilance.
METHODS
Knowledge, perceptions, practices and barriers of

healthcare professionals about terms related to pharmacovigilance and reporting of adverse drug reactions have been tested with the help of a structured
questionnaire that was distributed in person (the
response to the survey was either obtained at the
same time or collected at a later time) or via e-mail.
Arandom sample of healthcare professionals (doctors
of different specialties, pharmacist, dentists, technicians and nurses) were randomly selected from different hospitals and health centers, distributed over
all regions of BiH. As there is no common database
of HCP in BiH there is no guarantee they represent
country profile. The questionnaire included issues
addressed in previous studies examining the same
problem (6-8,15-20), but was modified by taking
into account local features and simplified to exclude
non relevant questions. A draft questionnaire was
pretested by administering it to 6 healthcare professionals, which consisted of three pharmacists, two
physicians and two dentists. Based on their comments and suggestions a final questionnaire was
Physicians, pharmacists, dentists and nurses are in

a position to play a major key role in pharmacovigilance programs (11,12) but underreporting is very
common, with an estimated median underreporting
rate (defined as percentage of ADRs detected from
intensive data collection that were not reported to
relevant spontaneous reporting systems) of 94% (5).
Pharmacovigilance is still in its infancy in Bosnia
and Herzegovina (BiH) and there exists very limited
knowledge about this discipline. In the period after
the war, until the establishment of the Agency for
Medicinal Products and Medical Devices of Bosnia
and Herzegovina (ALMBIH) there were two regional
centers where health care professionals (HCP) were
able to report ADR. In the Federation of Bosnia
and Herzegovina (FBiH), this was a Center for
Medicine at the Institute of Pharmacology, Faculty
of Medicine in Sarajevo, while in the Republic of
Srpska (RS) this was Drug Agency RS.
The ALMBIH was established in accordance with
the Medicinal Products and Medical Devices Act
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prepared for conducting the survey. The final version consisted of five sections containing 20 questions. Among these questions, 5 items were related
to the demographical and professional profiles, 3 to
the knowledge, 3 to the perception, 2 were related
to practice aspects and the remaining 7 items were
related to the barriers. Except questions related to
demographical and professional profile, questions
were worded as a series of statements and the healthcare professionals were asked to indicate their agreement or disagreement on a 4-point Likert scale from
strongly agree to strongly disagree.
Most respondents were in Sarajevo (36.9%), Tuzla

(22.8%) and Banja Luka (21.5%). The remaining
18.8% of respondents were interviewed in other
cities.
The majority of respondents (84. 6%, i.e. 736
respondents) provided a negative response to the
question Have you ever reported an adverse drug
reaction? and only 15.4% (133 respondents) gave
a positive response. 17.1% of them were physicians,
25.2% pharmacists, 6.6% dentists, 10.7% nurses
and 13.8% technicians.
62.9% of respondents recognize the Agency for
Medicinal Products and Medical Devices of Bosnia
and Herzegovina as the institution to which ADR
of a medicinal product are to be reported. Afurther
question we used to establish how informed the
respondents are on the issue pharmacovigilance was
whether they agreed with the assertion that ADR
reporting forms are available. Pharmacists in many
cases (43.4%) claimed that the reporting forms are
available, while not even a fifth of the respondents
from the other categories agreed that this was the
case.
This questionnaire survey was conducted during

January 2012 to September 2012.
The collected data were entered into the Excel table

and then analyzed using the IBM Statistical Package
for Social Sciences (SPSS) version20.0.
RESULTS
A total of 1000 questionnaires were distributed/

sent and 870 were returned completed, so all analyses were therefore made based on the 870 filled in
questionnaires. The demographic and professional
details of the respondents are shown in Table1.
Asked about their experience in filling out the ADR

reporting form, 46.6 % of the respondents from
our sample stated that they do not have enough
experience.
Almost three quarters (79.1%) of respondents
report ADR only if they are certain that it is linked
to a specific medicinal product, 80.5% of respondents would consult with a physician/pharmacist/
dentist before reporting an ADR and only 4.1% do
not share such a view.
TABLE 1. Demographic and professional details of HCP
Sex
Profession
Work experience
Entity
nw
Male
Female
Doctor
Pharmacist
Dentist
Nurse
Technician
0-5 year
6-10 year
11-20 year
21-30 year
More than 30 year
FBiH
RS
Brko district
Respondents
Number
%
870
100.0
243
27.9
627
72.1
258
29.7
143
16.4
61
7.0
234
26.9
174
20.0
181
20.8
186
21.4
206
23.7
201
23.1
95
10.9
644
74.0
225
25.9
1
0.1
It was found out from the result that almost all

health providers agree towards the fact that reporting about ADR is part of their ethical (83.2%) and
legal (82.2%) duty and that the science of pharmacovigilance is important (92.6%).
Several factors were reported that negatively affected
health care professionals willingness to report.
Table 2 lists factors that may act as deterrents to
reporting by HCP.
DISCUSSION
This is the first survey, which we are aware of, to

explore healthcare professionals knowledge, attitude,
122
TABLE 2. Barriers to spontaneous reporting of ADRs

Barriers
Reporting form
too complicated
Reporting ADRs is
time consuming
Difficult to admit
harm to patient
Fear of liability
Insufficient clinical
knowledge
Patient confidence
No motivation
The percentage of reported adverse reactions

is very low when compared to the number of
adverse reactions reported by physicians in Great
Britain (23), the Netherlands (24), Spain (25) and
China (26). Differences in the number of reported
ADRs can be attributed to the priority, care and
commitment to pharmacovigilance on the part
of the national governments of those countries.
Regulatory bodies in BiH should also adopt such
an approach. It is evident that pharmacovigilance
activities in BiH are not adequately presented or
advertised.
Level of agreement (percentage)

Agree Partially Partially Disagree
Agree disagree
19.9
31.3
10.8
37.0
20.2
29.5
10.6
38.6
26.6
27.7
9.2
36.4
10.6
13.1
14.9
19.2
12.3
10.3
62.1
57.2
11.3
9.2
26.4
18.4
14.4
11.4
47.5
60.9
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Questions concerning perception focused on the

general perception of healthcare professionals
regarding the standard aspects of ADR reporting.
The survey has shown that healthcare professionals have a positive attitude towards ADR reporting. The vast majority consider reporting a part of
their professional obligations, as well as an integral
part of the code of ethics. These results are largely
similar to the results of surveys carried out among
pharmacists working in pharmacies in cities in the
Netherlands (27) and Great Britain (28).
perceptions and their barriers towards ADR reporting and pharmacovigilance in BiH. The survey
response rate was good (87%).
Although the majority of healthcare professionals
correctly responded to whom they should report
adverse reactions, it needs to be noted that almost
a third gave a wrong answer to this question. This
is a relatively high percentage of healthcare professionals who failed to provide a correct answer. This
also indicates that although more than 4years have
passed since the establishment of ALMBIH, not
enough publicity has been given to this. Results of
the survey in one of Istanbuls districts show that
only 6.7% of pharmacists would send their reports
to the national pharmacovigilance center (TUFAM),
i.e.the correct address (21).
Although the majority of healthcare professionals covered by the survey expressed a proper and
positive attitude towards ADR reporting, actual
hands-on experience in reporting is still lacking.
Similar responses were obtained through three
surveys conducted in India (29-31) where both the
knowledge and a positive attitude exist, but adverse
reactions are still not being reported.
Even though the Book of Rules on Adverse
Effects (14) stipulates that all adverse effects are to
be reported, even when a link has not been established, healthcare professionals have stressed that
they must be certain that a link between a medicinal product and an adverse effect does exist. This
is in line with the conclusions from earlier surveys
conducted among pharmacists and physicians in
other countries (10,32,33) who expressed concern
over showing a lack of knowledge because they are
uncertain whether a medicinal product has caused
an adverse reaction or not. This problem needs to be
approached carefully and educational programs need
to be organized to alleviate the anxiety of healthcare
professionals and strengthen their confidence in
reporting adverse reactions.
It has transpired that the unavailability of ADR

reporting forms is significantly impacting the
informedness of healthcare professionals, despite the
fact that the forms are also on the ALMBIH website, as well as in the Register of Medicinal Products.
The Rhode Island survey (22) provided similar
results with 38% of physicians stating that they do
not know where to find the forms and that this is
why they were not reporting adverse reactions.
Asked about their experience in filling in the ADR
reporting form, just under 50% of healthcare professionals included in the survey stated that they do
not have enough experience.
The majority of healthcare professional in our survey have never reported an adverse reactions.
123
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A large percentage of healthcare professionals have

indicated that they would consult a colleague
(physician/pharmacist/dentist) before reporting an
adverse effect even though they are not under an
obligation to do so. This could indicate a lack of
confidence in their own knowledge, and perhaps
even fear of legal consequences. Similar results came
out of previous surveys (27,28). Colleagues should
not be consulted in relation to reporting an adverse
effect because that could be an obstacle to reporting
and lead to a situation where the person reporting
the adverse effect is dependent on someone elses
opinion.
characteristics reported in other surveys. The ADR

reporting rate can therefore be increased by overcoming the abovementioned obstacles as has been
confirmed by certain studies. Some of these obstacles can be addressed by proper management and
the promotion of a pharmacovigilance program, and
with relevant guidelines that would be available to all.
Also there is an urgent need for postgraduate educational programs to emphasize the role and responsibility of the HCP in pharmacovigilance practices, to
underline the importance of pharmacovigilance and
ADR reporting. In conclusion, it is necessary to offer
continuous educational programs until we reach the
point that voluntary reporting of ADRs become customary and habitual among all HCP.
It is widely accepted that reporting on adverse

effects is linked to a high degree of side effects not
being reported, however, it is difficult to assess the
scope of this problem. It is estimated that 90-95%
of adverse effects go unreported (34). To identify
the reasons for underreporting, several studies were
conducted where different authors investigated the
knowledge, attitudes and practices of healthcare
professionals toward the ADR reporting. According
to the findings of the studies (1,5,26,32) healthcare professionals mentioned different factors that
have contributed towards their underreporting:
lack of awareness of the requirement for reporting,
lack of resources for surveillance and reporting,
time-consuming reporting process, well-known
reactions, an uncertain association, what is similar
to our results. Of all obstacles mentioned in the
survey, respondents have identified two as being the
dominant reasons for the failure to report adverse
effects, including lack of experience in filling out the
ADR reporting forms (71.4%) and unavailability of
ADR reporting forms (72.7%). Other reasons mentioned in the survey include: the ADR reporting
form is too complicated (51.6%), reporting requires
a lot of time (50.2%), reporting could show a lack
of knowledge (32.3%), reporting requires the use of
my own resources and I am not motivated to do
that (27.6%), fear of responsibility (25.6%) and the
position that one case that goes unreported does not
make a difference (18.1%).
The limitation of this study is the fact that surveyed HCP as well as related institutions and cities, which are randomly selected, do not represent
HPC in all BiH. Another limitation of this study
is the answer reliability - inherent problem with
surveys and interviews, and whether the responses
of HCP are truly representative. Third limitation
of study is small number of questions in the survey
which evaluated knowledge and perception of PV.
Although this study has certain limitations and it
would be inappropriate to plan interventions based
on the findings of this study alone, however, it does
provide an insight into the possible interventions
that could be planned in future.
CONCLUSION
Under-reporting of adverse reactions is a phenomenon present in all parts of the world, this has been
confirmed by surveys already conducted, and it can
be attributed to all healthcare professionals.
The results of this survey have shown that even
though the majority of healthcare professionals have
never reported an ADR, although they do have a
positive perspective towards pharmacovigilance. The
results suggest that ADR under-reporting is a result
of unfamiliarity with the existing reporting system.
Regulatory bodies need to improve the management
and promotion of the reporting system in BiH in
order to address the issue of healthcare professionals
lacking the necessary knowledge on ways to report.
It could take a while before healthcare professionals accept ADR reporting as part of their everyday
According to responses provided by healthcare professionals covered by the survey, non-reporting of

adverse effects in BiH appears to be linked with a
lack of knowledge concerning the ADR reporting
process and not with the personal and professional
124
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practice, but on the long run, this is definitely worth

the effort.
17. Figueiras A, Tato F, Fontainas J, et al. Physicians attitudes towards voluntary reporting of adverse drug events. J Eval Clin Pract 2001;7:347-54
http://dx.doi.org/10.1046/j.1365-2753.2001.00295.x.
COMPETING INTERESTS
18. Vallano A, Cereza G, Pedro s C, et al. Obstacles and solutions for spontaneous reporting of adverse drug reactions in the hospital. Br J Clin Pharmacol
2005;60:653-8 http://dx.doi.org/10.1111/j.1365-2125.2005.02504.x.
The authors declare no conflict of interest.
19. Herdeiro MT, Figueiras A, Polonia J, Gestal-Otero JJ. Physicians attitudes

and adverse drug reaction reporting: a casecontrol study in Portugal. Drug Saf
2005;28:825-33 http://dx.doi.org/10.2165/00002018-200528090-00007.
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23. Bateman DN, Sanders GL, Rawlins MD. Attitudes to adverse drug reaction
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24. Eland I.A, Belton KJ, Van Grootheest AC, Meiners AP, Rawlins MD,
Stricker B.H. Attitudinal survey of voluntary reporting of adverse
drug reactions. Br J Clin Pharmacol. 1999;48:623-7 http://dx.doi.
org/10.1046/j.1365-2125.1999.00060.x.
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health care professionals across the European Union. The European
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Anusha Rangare Lakshman, et al. Journal of Health Sciences 2014;4(2):126-129

CASE REPORT
Open Access
Mental foramen mimicking as periapical

pathology - A case report
Anusha Rangare Lakshman1*, Sham Kishor Kannepady2, Chaithra Kalkur1
1
Department of Oral Medicine and Radiology, Century International Institute of Dental Science and Research Centre,
Poinachi, Kasaragod 671541, Kerala, India, 2School of Dentistry, International Medical University, Kuala Lumpur, Malaysia
ABSTRACT
The radiographic recognition of any disease requires a thorough knowledge of the radiographic appearance of normal structure. Intelligent diagnosis mandates an appreciation of the wide range of variation
in the appearance of normal anatomical structures. The mental foramen is usually the anterior limit of
the inferior dental canal that is apparent on radiographs. It opens on the facial aspect of the mandible in
the region of the premolars. It can pose diagnostic dilemma radiographically because of its anatomical
variation which can mimic as a periapical pathosis. Hereby we are reporting a rare case of superimposed
mental foramen over the apex of right mandibular second premolar mimicking as periapical pathology.
Keywords: mental foramen; periapical radiolucency; mandibular premolars
INTRODUCTION
Many articles have been reported about various

conditions that may mimic periapical inflammatory
lesion such as carcinoma (1), odontogenic cyst (2)
and periapical cemental dysplasia (3) etc. Film processing errors has also been reported to mimic the
appearance of periapical infection (4), while normal
anatomies such as the mental foramen or incisive
foramina are familiar as radiolucencies that may
overlie teeth and cause diagnostic confusion. This
case report enlightens an anatomical variation of
mental foramen (MF) manifesting as well defined
periapical radiolucency in relation to the roots of
*Corresponding author: Anusha Rangare Lakshman,
Department of Oral Medicine and Radiology,
Century International Institute of Dental Science and Research
Centre, Poinachi, Kasaragod 671541, Kerala, India
E-mail: dr.anusharl@gmail.com
lower right second premolar, which was suggestive

of periapical pathology.
CASE REPORT
A 30 year old male patient reported to the

Department of Oral Medicine and Radiology with
the complaint of tooth decay in the lower right back
tooth jaw region since six months. It was associated
with dull, intermittent, non-radiating type of pain.
Medical, family and dental histories were non-contributory. On intra oral examination, deep classII
cavity with respect to right second premolar, first
and second molar was observed. Provisional diagnosis of chronic irreversible pulpitis was considered for
right mandibular first and second molar and deep
dental caries with respect to right mandibular second premolar.
Periapical radiograph of right mandibular posterior region revealed diffuse coronal radiolucency
2014 Anusha Rangare Lakshman, et al.; licensee University of Sarajevo - Faculty of Health
involving pulp with no periapical changes noticed

with respect to mandibular molars. The mandibular second premolar revealed diffuse coronal radiolucency approximating the pulp with intact lamina
dura in the periapical region. Hazy periapical radiolucency (Figure1) noticed at the apex of mandibular second premolar with poor defined borders
mimicking as periapical pathology. To rule out, a
second radiograph (Figure2) was taken at different
angulation which revealed the same finding but the
radiolucency had moved mesially with an intact the
lamina dura around the tooth, hence we arrived at a
provisional diagnosis of mental foramen which was
mimicking as periapical pathology. We also noticed
http://www.jhsci.ba
increased in the width of root at the apical one third

of the second premolar suggestive of hypercementosis. The patient was referred to the Department
of Conservative Dentistry and Endodontics for the
further treatment.
DISCUSSION
The MF is an opening on the anterolateral surface

of the mandible, which is generally seen to be oval
or circular in shape from where the mental neurovascular bundle exits. After passing through the
mandibular foramen, the inferior alveolar nerve
and artery, exit at the mental foramen as the mental nerves and vessels which innervate the lower
teeth, lip, gingiva and soft tissues of chin area.
The foramen opens directed posteriorly, outward
and upwards. There are variations in the position of mental foramen. Frequent position is in
between and below the apices of first and second
premolars(5).
The mental nerve is a somatic afferent sensory
nerve and corresponds to the terminal branch of
the mandibular nerve, which is the third division
of the trigeminal nerve. In the premolar region, the
inferior alveolar nerve, a branch of the mandibular
nerve, usually splits into two branches, the mental
nerve and the incisive nerve. The incisive nerve runs
intra-osseously along with veins and innervates the
anterior mandibular teeth (incisors, canines, and
premolars) (6). The mental nerve emerges at the
mental foramen and divides into four branches:
angular (innervations of the angle of the mouth
region), medial and lateral inferior labial (skin of the
lower lip, oral mucosa, and gingiva as far posterior
as the second premolar), and mental branch (skin of
the mental region) (7).
FIGURE 1. Intraoral periapical radiograph showing the poordefined periapical radiolucency at the apex of mandibular second
premolar with intact lamina dura around the root, mimicking as
periapical pathology.
It is usually the anterior limit of the inferior dental

canal that is apparent on radiographs. Its image is
quite variable and it may be identified only about
half the time because the opening of the mental
canal is directed superiorly and posteriorly. Because
of this, the usual view of the premolars is not projected through the long axis of the canal opening.
This circumstance is responsible for the variable
appearance of the mental foramen (8).
FIGURE 2. The second radiograph of mandibular premolar region

from different angulation showed slight mesial shift in the periapical radiolucency with intact lamina dura.
Mental foramen variations are often encountered,

ranging from difference in position of foramen
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However, radiography is not a perfect diagnostic

tool, partly because radiographs are two-dimensional representations of three-dimensional structures, and partly because particular clinical and
biological features may not be reflected in radiographic changes. The presence of a lesion may not
be directly evident and its real extent and the spatial
relationships to important anatomical landmarks are
not always easily visualized. The diagnosis and management of periapical pathosis requires a thorough
clinical and radiographic examination. As chronic
apical periodontitis often develops without subjective symptoms, the radiological diagnosis is particularly important and should not be confused with
the variations of the normal anatomical landmarks.
on anterolateral surface of mandible or presence

of accessory foramina or even complete absence
in some rare cases. The location of mental foramen also changes along with the age changes (9).
Usually the MF is seen to be closer to the alveolar ridge in children before tooth eruption; as the
teeth starts to erupt the MF starts descending to
the midway between the upper margin and lower
border and in adults with the teeth present for
long time, the MF moves is somewhat closer to
the inferior border comparatively. In old age eventually with the loss of teeth and bone resorption
of the edentulous ridge the MF moves relatively
up towards the alveolar ridge. In extreme cases of
resorption, the MF and the adjacent part of the
mandibular canal are open at the alveolar margin.
According to the degree of resorption, in severe
cases, the mental nerve and the final part of the
inferior alveolar nerve may be found directly under
the oral mucosa (10).
CONCLUSION
A basic knowledge of the variations of the normal

anatomical landmarks of jaw bones is mandatory for
all the dental physicians, so that we can avoid misdiagnosing as any periapical pathology. In this paper,
we have highlighted about the variations of mental
foramen which was mimicking as periapical pathology. As the routine dental intraoral radiographs are
the two dimensional representation of the three
dimensional object, the newer radiographic methods
has to be implemented to overcome this limitation.
Radiographically, this foramen appears as small,

ovoid or round radiolucent area located in the apical region of the mandibular premolars (11). The
absence of a MF (12) and the presence of multiple
MF (13) are rarely reported. The presence of more
than one MF, referred to as accessory mental foramina, has been noted on dissection, surgical findings,
conventional radiographs, spiral computed tomography (CT), and cone beam CT.
When it is projected over one of the premolar apices, it may mimics periapical disease as seen in our
case. In such cases, evidence of the mandibular canal
extending to the suspected radiolucency or a lamina
dura traceable around the root apex would suggest
the true nature of the radiolucency. In the case presented here, there was intact lamina dura around the
root. However, the lamina dura superimposed on
the radiolucent foramen may be of too low a density to be recognized in the image (burn out) (14).
Nevertheless, a second radiograph from another
angle is likely to show the lamina dura clearly, as
well as some shift in position of the radiolucent
foramen relative to the apex (8). Similarly, the second radiograph was taken in the present case which
showed intact lamina dura with slight mesial shift
in the periapical radiolucency. Thus, confirming our
diagnosis of mental foramen mimicking as periapical pathology.

interests.
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Amir ehaji, et al. Journal of Health Sciences 2014;4(2):130-133

CASE REPORT
Open Access
Gastric antral vascular ectasia: a case report

Amir ehaji*, Denis Maki, Elvira Dambasovi, Faruk ustovi, Aida Mujakovi,
Nijaz Tucakovi
Department of Internal Medicine, General Hospital Prim. dr Abdulah Naka, Sarajevo, Bosnia and Herzegovina
ABSTRACT
Gastric antral vascular ectasia (GAVE) is a vascular gastric malformation which represents a rare cause of
upper gastrointestinal system bleeding, mostly in elderly. It is usually presented with a signicant anemia
and it is diagnosed with an endoscopic examination of the upper gastrointestinal system. The disease is
often associated with other chronic illnesses such as liver cirrhosis, scleroderma, diabetes mellitus and
arterial hypertension. It is treated symptomatically in terms of anemia correction with blood transfusions
and iron supplements, proton pump inhibitors, beta-blockers and endoscopic procedures such as argon
plasma coagulation which currently represents the treatment of choice in Sy. GAVE cases. We report a
case of a 76 years old female patient who was admitted to the hospital because of general weakness,
exhaustion and abdominal pain. Laboratory analysis of blood went in favor of anemia. Proximal endoscopy showed no changes on the esophagus, the stomach had a normal volume with pale mucosa and
signs of antral vascular ectasia which is presented typically as a watermelon stomach due to the longitudinal creases oriented toward pylorus. The patient was treated symptomatically in terms of anemia correction with blood transfusions and iron supplements, proton pump inhibitors, beta-blockers. Five months
later control proximal endoscopy ndings were identical to those found in the previous hospitalization.
Keywords: endoscopy; GAVE; gastric antral vascular ectasia; gastrointestinal bleeding
INTRODUCTION
Gastric antral vascular ectasia, scientifically identified

also as Sy. GAVE is a rare and usually undiagnosed
cause of the occult gastrointestinal bleeding, mostly
in elderly. Proximal endoscopy usually reveals longitudinal creases oriented towards pylorus. It is also
known as a watermelon stomach due to the longitudinal stripes. It is histologically characterized
with dilated and thrombosed capillaries as well as
*Corresponding author: Amir ehaji, MD,
Department of Internal Medicine, General Hospital
Prim.dr. Abdulah Naka, Kranjevieva 12, 71 000, Sarajevo
Bosnia and Herzegovina, Phone: 387 33 285 100,
E-mail: amircehajic@hotmail.com
with fibro muscular hyperplasia of lamina propria.

The treatment includes conservative procedures
such as blood transfusions and endoscopic therapy
with argon plasma coagulation. Recent reports suggest that Endoscopic Band Ligation (EBL) is a regular and efficient alternative treatment.
A study by Irish authors reported an overall
treatment of 23 Sy. GAVE cases. Eight patients
were treated with EBL, with a mean number of 2.5
treatments. Six (75%) of those eight patients had
previously failed APC (argon plasma coagulation
treatment) despite having a mean of 4.7 sessions.
Band ligation was not associated with any complications. EBL treatment resulted with the significant
improvement of endoscopic finding and the need
2014 Amir ehaji, et al; licensee University of Sarajevo - Faculty of Health Studies. This
http://www.jhsci.ba
for blood transfusions was periodical (1). Antral

vascular ectasia is considered as a cause of nonvariceal upper gastrointestinal system bleeding in 4%
of cases (2).
2012. The symptoms on the day of the admission

were general weakness, exhaustion and abdominal
pain. Laboratory findings on the admission reported
signs of anemia: RBC 3.71 1012, Hemoglobin
87.4 g/L, Hematocrit 0.28, MCV 74.8 fL, MCH
23.6pg, MCHC 315g/L, Reticulocytes 8 103/E.
Plt 103 109/L, WBC 4.1109/L. Serum iron level
3.7 umol/L, TIBC 66.0 umol/L, UIBC 62.3umol/L.
The abdominal ultrasound showed signs of chronic
calculous cholecystitis, with a bended gallbladder
and a slightly larger spleen - craniocaudal diameter of 15.5 cm. Proximal endoscopy - showed no
changes on the esophagus, the stomach had a normal volume with pale mucosa and antral vascular
ectasia typical watermelon finding (Figure 1).
Duodenal bulb showed no changes, D1 and D2
were neat.
During hospitalization, the patient was treated
with deplasmatized erythrocytes transfusions
(a total of 300 ml), parenteral iron supplements,
primarily intravenously administered proton
pump inhibitors followed with peroral administration of the same. The patient was discharged with
a recommendation of per oral use of proton pump
inhibitors in a single dose of 40mg per day with
non-selective beta blockers, Propranolol in a single
dose of 40mg per day. On April, 2013 the patient
was readmitted to the Department because of severe
anemia signs: RBC 2.54 10*12, Hemoglobin
51.0g/L, Hematocrit 0.17 I, MCV 65.7 fL, MCH
20.1pg, MCHC 305g/L, Plt 171 10*9/L, WBC
5.6 10*9/L, RDW 18%. Follow up proximal
endoscopy findings were identical to those found
in previous hospitalization antral vascular ectasia
was still present (Figure2).
The disease can be presented with occult bleeding

which demands blood transfusions or as acute gastrointestinal bleeding. It is often associated with a
significant mortality and morbidity rate and following comorbidities: scleroderma, diabetes mellitus and arterial hypertension. Sy. GAVE may also
be developed as a complication after haematopoetic
stem cell transplantation or after per oral or intravenous application of busulfan (3). An average of
30% of Sy GAVE cases is associated with liver cirrhosis (4). The treatment of the syndrome is divided
into three categories: pharmacological, endoscopic
and surgical. Afew studies compared the efficiency
and complications of endoscopic and medicamentous treatment of Sy. GAVE. Current evidence of
endoscopic Sy. GAVE treatment are insufficient.
Sy. GAVE diagnosis is often based on endoscopic
examination according to its characteristical appearance, thus it can be easily misinterpreted with mild
to severe form of gastritis. Radiofrequency ablation represents an alternative therapeutic option
for Sy. GAVE. It is considered a secure and effective method(5). Among the most frequent illnesses
associated with Sy GAVE is a chronic renal insufficiency (6).
CASE REPORT
A female patient, 76years old, was admitted to the

Department of Internal Medicine, General hospital
Prim.dr. Abdulah Naka, Sarajevo in December,
FIGURE 1. Endoscopic image of GAVE. Typical endoscopic appearance of watermelon stomach after the first exam.
131
http://www.jhsci.ba
FIGURE 2. Control endoscopic image GAVE still present - Four months after the first exam the same findings still persisting.
DISCUSSION
are proved to be efficient in stopping hemorrhage.

Antrectomia represents the final and only definitive therapeutic solution specially in patients with
severe symptoms such as severe anemia and recurrent profuse bleeding (9).
Gastric antral vascular ectasia represents a vascular malformation of gastrointestinal system and
a rare cause of upper gastrointestinal tract bleeding. Hemorrhage within Sy GAVE may be profound as well as occult with signs of mild, moderate or severe anemia. The disease may be treated
conservatively by anemia correction with blood
transfusion and iron supplements as well as with
proton pump inhibitors and beta blockers. Welldesigned controlled randomized studies will be
necessary to prove the efficacy and complications
of conservative and endoscopic treatment of Sy.
GAVE (7). According to some authors capsule
endoscopy is superior in GAVE syndrome cases,
compared to classic endoscopic examination. The
diagnosis may be established with an endoscopic
examination only, although it may be misdiagnosed with moderate to severe form of gastritis.
Classic endoscopic examination is considered to
be physiological without need for air insufflations
and consequent vascular compression and therefore misdiagnosis of the same (8). Current model
of invasive treatment is proximal endoscopy with
argon plasma coagulation. Proximal endoscopy
with APC is in general more acceptable way of
treatment for Sy. GAVE patients, although many
of them continue to bleed and demand continuous blood transfusions after the treatment and
show a low level of endoscopic improvement.
Endoscopic band ligation (EBL) according to
mentioned studies proved to be a safe and effective treatment of GAVE. Radiofrequency ablation
may serve as an alternative therapeutic method.
Endoscopic laser photocoagulation or diathermia
CONCLUSION
Gastric antral vascular ectasia or Sy. GAVE represents a group of vascular gastric malformations
and is a rare cause of upper gastrointestinal system
bleeding. The diagnosis is set throughout a proximal
endoscopy exclusively. It may be treated conservatively with proton pump inhibitors and beta blockers or using invasive methods such as argon plasma
coagulation, radiofrequency ablation or endoscopic
band ligation.

interests.
REFERENCES
1. Keohane J, Berro W, Harewood GC, Murray FE, Patchett SE. Band
ligation of gastric antral vascular ectasia is a safe and effective endoscopic treatment. Dig Endosc. 2013 Jul;25(4):392-6. http://dx.doi.
org/10.1111/j.1443-1661.2012.01410.x
2. Liu F, Ji F, Du Y. Gastric antral vascular ectasia (GAVE) in two non-cirrhotic
patients involved large area of stomach: Case report and literature review.
J Interv Gastroenterol. 2013 Jul;3(3):107-110. http://dx.doi.org/10.7178/
jig.113.
3. Fukuda K, Kurita N, Sakamoto T, Nishikkii H, Okoshi Y, Sugano M, Chiba S.
Post-transplant gastric antral vascular ectasia after intra-venous busulfan
regimen. Int J Hematol. 2013 Jul;98(1):135-8. http://dx.doi.org/10.1007/
s12185-013-1342-8.
4. Kar P, Mitra S, Resnick JM, Torbey CF. Gastric antral vascular ectasia: Case
report and review of the literature. Clin Med Res. 2013 Jun;11(2):80-5.
http://dx.doi.org/10.3121/cmr.2012.1036.
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5. McGorisk T, Krishnan K, Keefer L, Komanduir S. Radiofrequency ablation for refractory gastric antral vascular ectasia. Gastroinest Endosc.
2013 Oct;78(4):584-8. http://dx.doi.org/10.1016/j.gie.2013.04.173.
8. Ohira T, Hokama A, Kinjo N, Nakamoto M, Kobashigawa C, Kise Y et al.

Detection of active bleeding from gastric antral vascular ectasia by capsule
endoscopy. World J Gastrointest Endosc. 2013 Mar 16;5(3):138-40. http://
dx.doi.org/10.4253/wjge.v5.i3.138.
6. Pisharam JK; Ramaswami A, Chong VH, Tan J. Watermelon stomach:

A rare cause of anemia in patients with end-stage renal disease. Clin
Nephrol. 2014 Jan;81(1):58-62. http://dx.doi.org/10.5414/CN107527.
9. Sciume C, Geraci G, Pisello F, Facella T, Pinto G, Fernandez P. et al.

Ectasia vascolare gastrica antrale (GAVE) o Watermelon Stomach
Syndrome: Report di 3 casi ed indicazioni cliniche e terapeutiche. Ann.
Ital. Chir. 2003; 74(4):477-484.
7. Swanson E, Mahgoub A, Macdonald R, Shaukat A. Clin Gastroenterol

Hepatol. 2013 Sep 5 S 1542-3565(13)01289-5.
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Tumay Ipekci, et al. Journal of Health Sciences 2014;4(2):134-135

LETTER TO EDITOR
Open Access
An extremely rare case of testicular malign

neoplasm; alveolar subtype of rhabdomyosarcoma
with long term follow-up
Dear Editor,
We would like to draw readers attention to testis tumours, notably rare ones in this letter. Yue
et al. recently reported rare tumours in testis (1).
However, subtypes of testicular tumours with their
incidences are well-defined in published literature,
some rare types of them could be reported by pathology (2). Overcome these issues, we would like to
affix an extremely case of paratesicular alveolar rhabdomyosarcome. Ahandful of cases were published
in literature and also most of them were including
childhood series. A23-year-old man was admitted
to our urology outpatient clinic with main symptoms of right scrotum. In detailed physical examinations, there was a nodular mass with 6cm diameter
in upper part of right testis. Ultrasonography (US)
revealed 654cm and computed tomography
(CT) showed an 119mm parailiac lymph node.
Radical orchiectomy was performed and pathology
reported paratesticular alveolar rhabdoyosarcoma
(Figure 1). He has no metastasis after 6 cycles of
chemotherapy with vincristine, actinomycin, and
cyclophosphamide. However, rare tumour can occur
in testis, early diagnosis and adequate treatments
can provide long-term survival without metastasis.
Paratesticular and testicular tumours usually occur
in childhood and most of these have benign characteristics (3). They are originated from mesenchymal
tissue of testis and spermatic cord. Besides these,
paratesticular tumours may be felt like arising from
testis during physical examinations, US is useful
for differential diagnosis. Nevertheless, the exact

diagnosis can be made by histopathology examinations. There were hyperchromatic nucleuses and
spindle cytoplasmic cells with haematoxylineosin
(Figure 1). Additionally actin, desmin, and myoglobulin were positive (Figure1). Alveolar subtype
was reported by pathology, in the present case.
Sarcomas consist of 1% of all malign tumours,
and they are originated from embryonic tissues.
The common sites of sarcomas are skeletal system.
However, paratesticular rhabdomyosarcom is an
extremely rare. Specifically, embryonic subtype of
rhabdomyosarcoma were reported in literature (4).
Subtypes can be diagnosed by pathology examinations. Alveolar subtype of rhabdomyosarcoma is an
extremely entity for paratesticular tumours, as in
our case. The main clinical sign of this tumour is
painless scrotal mass. Weakness and tiredness with
palpable lymph nodes in inguinal and abdominal
area may come into question, in advanced stages.
Radical orchiectomy, chemotherapy, and radiotherapy are the main parts of treatment. Our case
had clinical stage 1 tumour with intermediate
risk (5). Thus, he underwent chemotherapy for
6 cycles, after operation. He did not need radiotherapy. Chest x-ray, abdominal and pelvic CT has
been used for follow-up. He has been in follow-up
period for 7years and he had no metastasis.
Differential diagnosis is an important entity for
testicular and paratesticular masses. Surgery with
adjuvant therapy options are used for contemporary
2014 Tumay Ipekci, et al; licensee University of Sarajevo - Faculty of Health Studies. This
Tumay Ipekci, et al. Journal of Health Sciences 2014;4(2):134-135
http://www.jhsci.ba
FIGURE 1. Histopathologic features of paratesticular alveolar subtype rhabdomyosarcoma (a) Tumour cells are seen with hyperchromatic nucleus and spindle eosinophilic cytoplasm. Alveolar subtype of rhabdomyosarcoma were presented with desquamated small,
round, and poorly differentiated cells (HE.x10), (b) Tumour cells were positive with actin (x10), (c) Tumour cells were positive with desmin
(x10), (d) Tumour cells were positive with myoglobulin (x10).
REFERENCES
treatment. Long-survival can be provided by suitable treatment options with close follow-up.
1
2*
1. Yue X, Wang JZ, Tian Y, Wang KJ. Paratesticular desmoplastic small round
cell tumor with metastasis: A report of two cases. Kaohsiung J Med Sci
2014;30:104-5. http://dx.doi.org/10.1016/j.kjms.2013.01.018.
Tumay Ipekci , Yigit Akin , Burak Hoscan ,

Ahmet Tunckiran1
2. Emerson RE, Cheng L. Premalignancy of the testis and paratestis. Pathology

2013;45:264-72. http://dx.doi.org/10.1097/PAT.0b013e32835f3e1a.
3. Khoubehi B, Mishra V, Ali M, Motiwala H, Karim O. Adult paratesticular
tumors.
BJU
Int
2002;90:707-15.
http://dx.doi.
org/10.1046/j.1464-410X.2002.02992.x.
Department of Urology, Baskent University Alanya Research

Hospital, Alanya, Antalya, Turkey, 2Department of Urology,
Harran University School of Medicine, Sanliurfa, Turkey
4. Kizer WS, Dykes TE, Brent EL, Chatham JR, Schwartz BF. Paratesticular
spindle cell rhabdomyosarcoma in an adult. J Urol 2001; 166: 606-7. http://
dx.doi.org/10.1016/S0022-5347(05)65997-6.
*Corresponding author: Yigit Akin, M.D. Assistant Professor of

Urology, Department of Urology, Harran University School of
Medicine, 63100, Sanliurfa, Turkey. Tel: +90-506-533 49 99,
Fax: +90-414-318 30 05. E-mail: yigitakin@yahoo.com
5. Mondaini N, Palli D, Saieva C, Nesi G, Franchi A, Ponchietti R et al. Clinical

characteristics and overall survival in genitourinary sarcomas treated with
curative intent: a multicenter study. Eur Urol 2005;47:468-73. http://dx.doi.
org/10.1016/j.eururo.2004.09.013.
Submitted 2 September 2014 / Accepted 12 September 2014
135

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Table of contents:

Fea Omeragi, et al. Journal of Health Sciences 2014;4(2):72-76

Journal of Health Sciences

Use of colposcopy for detection of squamous

Squamous intraepithelial lesion (SIL) starts at

Fea Omeragi, et al. Journal of Health Sciences 2014;4(2):72-76

starts as squamous metaplasia, which includes

This was prospective multi-centric study that took

Health system in Bosnia and Herzegovina does not

GroupA was divided in two subgroups: A1 and A2.

If we do not have cervical cancer screening program

To test accuracy of colposcopy

The aim of this article was to investigate accuracy

PAP smear that was taken from all patients

Fea Omeragi, et al. Journal of Health Sciences 2014;4(2):72-76

lesion, HGSIL-high grade squamous cell

as a single marker (50 or 89.3%) or associated with

Results were analyzed by descriptive and analytical

Experimental group and control group were homogenous. There were:

FIGURE 1. PAP test results in experimental and control group.

In control group (Group B) out of all, 17 (34%)

FIGURE 2. Results of PAP test compared to colposcopy results.

Fea Omeragi, et al. Journal of Health Sciences 2014;4(2):72-76

ASCUS was also seen in subgroupsA1(7.1%) and

0.627202 to 6.940587] if colposcopic images

TABLE 1. Frequency of the basic colposcopic

TABLE 2. PAP test results

BCC ASC-US ASC-H LGSIL HGSIL

ASC-H was detected in 12% patients in GroupA.

TABLE 3. Results of histology - Subgroup A2*

Fea Omeragi, et al. Journal of Health Sciences 2014;4(2):72-76

Colposcopy is useful method for detection of early

2. Iljazovi E, Kesi V. Patologija cervikalne epitelne neoplazije. Univerzitet u

15. American Society for Colposcopy and Cervical Pathology. Management

4. Singer A, Monaghan J. M, QuekS.C., Deery A.R.S. Lower Genital

Naja Serdarevic and Azra Durak-Nalbantic. Journal of Health Sciences 2014;4(2):77-82

Journal of Health Sciences

The evaluation of B-type Natriuretic Peptide and

Since the discovery of the natriuretic peptides in

clinical laboratory testing in the 2000s, assays of

Naja Serdarevic and Azra Durak-Nalbantic. Journal of Health Sciences 2014;4(2):77-82

detection of myocardial injury based on improved

renin-angiotensin-aldosterone system. Pre-proBNP

In our study we have measured BNP and TnI blood

Our research included patients (n = 100) and

Naja Serdarevic and Azra Durak-Nalbantic. Journal of Health Sciences 2014;4(2):77-82

pulmonary thromboembolism, acute and chronic

Following another incubation and wash, pre-trigger

Na-EDTA plasma should be used for the Architect

The results were statistically analyzed using NCSS

All immunoassays require the use of labeled material

The serum concentrations of BNP and TnI in the

Using Mann Whitney U test we made comparison of

Naja Serdarevic and Azra Durak-Nalbantic. Journal of Health Sciences 2014;4(2):77-82

Unstable angina group

patients with AMI, unstable angina and the healthy

Healthy control group

ischemia induced by increase in ventricular wall

In our study we found a significant correlation

Naja Serdarevic and Azra Durak-Nalbantic. Journal of Health Sciences 2014;4(2):77-82

Correlation between Troponin I and BNP

Plasma BNP concentration (pg/mL)

Serum concentration of Troponin I (ng/mL)