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HealthMED

Volume 5 / Number 6 / 2011

Journal of Society for development in new net environment in B&H

EDITORIAL BOARD

Editor-in-chief Mensura Kudumovic Execute Editor Mostafa Nejati Associate Editor Azra Kudumovic Editorial assistant Jasmin Musanovic Technical editor Eldin Huremovic Members Paul Andrew Bourne (Jamaica) Xiuxiang Liu (China) Nicolas Zdanowicz (Belgique) Farah Mustafa (Pakistan) Yann Meunier (USA) Forouzan Bayat Nejad (Iran) Suresh Vatsyayann (New Zealand) Maizirwan Mel (Malaysia) Budimka Novakovic (Serbia) Diaa Eldin Abdel Hameed Mohamad (Egypt) Zmago Turk (Slovenia) Bakir Mehic (Bosnia & Herzegovina) Farid Ljuca (Bosnia & Herzegovina) Sukrija Zvizdic (Bosnia & Herzegovina) Damir Marjanovic (Bosnia & Herzegovina) Emina Nakas-Icindic (Bosnia & Herzegovina) Aida Hasanovic(Bosnia & Herzegovina) Bozo Banjanin (Bosnia & Herzegovina)

Address of the Editorial Board

Sarajevo, Bolnicka BB phone/fax 00387 33 956 080 [email protected] http://www.healthmedjournal.com

Published by DRUNPP, Sarajevo Volume 5 Number 6, 2011 ISSN 1840-2291 HealthMED journal with impact factor indexed in: - Thomson Reuters ISI web of Science, - Science Citation Index-Expanded, - Scopus, - EBSCO Academic Search Premier, - Index Copernicus, - getCITED, and etc.

Sadržaj / Table of Contents

Chest associated to motor physiotherapy acutely improves oxygen saturation, heart rate and respiratory rate in premature newborns with periventricular-intraventricular hemorrhage ... 1381

Luiz Carlos de Abreu, Vitor E. Valenti , Oséas Florêncio de Moura Filho, Luiz Carlos M. Vanderlei, Tatiana Dias de Carvalho, Maria A. F. Vertamatti , Adriana G. Oliveira, Isadora L. Moreno, Ana Clara C. R. Gonçalves, Arnaldo A. F. Siqueira

The causes of chest pain among Korean outpatients in primary care practice ....................................... 1389 Jongwoo Kim, Seon Yeong Lee, Kyunam Kim, Sun Mi Yoo

Are patient falls in the hospital associated with days of the week and hours of the day? A retrospective observational study using Rasch modeling ........ 1395 Su-Chen Hsu, Huan-Fang Lee, Tsair-Wei Chien

Knowledge, Attitudes and Practices on Hypertension in patients attending Family Practice Clinics .... 1404 Nada A. Yasein, Farouq M. Shakhatreh, Ahmad A. Suleiman, Farihan F. Barghouti, Lana J. Halaseh, Noor K. Abdulbaqi

The analisys of the syndroms appearing among children living with autism in Hungary . ............ 1415 Orsolya Tobak, Mónika Balogh, Kinga Lampek

Health financing reform towards universal insurance coverage: a case study of six cities in China ................................................................. 1420 Cheng Li, Yuan Yu, Kieke G.H.Okma, Min Yu

Stories of illness in a changing world of medicine . ................................................................ 1430

Modesto Leite Rolim Neto, Alberto Olavo Advincula Reis, Irineide Beserra Braga, Cícero Hedilberto Filguêiras Macêdo

The Relationship between Weight Status and Selfreported Mental Health Outcomes in Korean Adolescents ............................................................. 1435 Seong-Ik Baek, Wi-Young So

Sadržaj / Table of Contents An Oxygen-sensing Signal Cascade of Evaluating the problems of mothers in exclusive Cardiomyocyte Adaptations to Moderate breastfeeding and educational intervention for Endurance Training .............................................. 1440 improving nutrition status in Iran ..................... 1517

Zong-Yan Cai, Cheng-Chen Hsu, Mei-Chich Hsu, Mao-Shung Huang, Chao-Pin Yang, Yung-Yu Tsai, Borcherng Su

Hadigheh Kazemi, Fatemeh Ranjkesh

Risk Factors Associated with Metabolic Syndrome in Iranian Middle Aged Women ......................... 1522

Hematological and serological changes in Mouloud Agajani Delavar, Munn Sann Lye, Geok Lin Khor, the pre - and post-treatment breast cancer Syed Tajuddin B Syed Hassan, Parichehr Hanachi patients . .................................................................. 1449 Nadeem Sheikh, Maria Masood and Naila Naz The effects of Vitamin C and E Supplements on eradication rate of Helicobacter pylori Serum Leptin changes following a selected aerobic receiving omeprazol- clarithromycin-amoxicillin training program in un-trained Females ............. 1458 regimen ................................................................... 1531 Masoumeh Azizi

Ehsani Ardakani MJ, Samiy S, Norouzinia M, Mostafavi SA, Mohaghegh Shalmani H

Effect of serum urea and creatinine levels in aneurysmal subarachnoid hemorrhage .............. 1463 Coeliac disease; Prevalence and Outcome in Sayantani Ghosh, Saugat Dey, Mitchell Maltenfort, Jack Jallo Pregnancy ............................................................... 1537 Mohsen Norouzinia, Kamran Rostami, Marzyeh Amini,

Stress coping among nurses in Latvia . ............... 1468 Farhad Lahmi, Mohammad Roshani, Homayoun Zojaji, Liana Deklava, Inga Millere, Kristaps Circenis

Mohammad Rostami Nejad, Chris J Mulder, Mohammad Reza Zali

The Effects of LPG Massage System on Delayed Criteria for Priority-setting in Iran Basic Health Onset Muscle Soreness and Muscular Performance after Resistance Exercise .............. 1474 Insurance Package: Exploring the Perceptions Vahideh Kianmarz of Health Insurance Experts ................................. 1542 Outcomes of patients with low risk cardiac chest pain underwent immediate exercise testing: two months fallow up .................................................. 1479

Reza Dehnavieh, Arash Rashidian, Mohammad reza Maleki, Seyedjamal Aldin Tabibi, Hosein Ibrahimi Pour, Somayeh Noori Hekmat

Examination Of Critical Thinking Disposition Saeed Abbasi, Kambiz Masoumi, Mohsen Ebrahimi, Mohammad Amin Zare, Mohammad Javad Alemzadeh Ansari In Nursing .............................................................. 1549 Belgin Yildirim, Şükran Özkahraman, Medet Korkmaz, Maternal obesity and preeclampsia .................... 1484 Sıddıka Ersoy Azar Aghamohammadi

Tuberculosis as an occupational disease: based on health care centers in Turkey ......................... 1558

Perceptions regarding the use of long-lasting Abdurrahman Abakay, Abdullah Cetin Tanrikulu, Ozlem insecticide -treated bed nets for preventing Abakay, Hadice Selimoglu Şen malaria among rural females of Pakistan .......... 1488 Nelofer Amir, Ejaz Ahmad Khan, Haris Habib, Hamayun Rathor

Qualıty assessment of prımary care guıdelınes ın Turkey ................................................................ 1565

Aylin Baydar Artantas, Rabia Kahveci, Didem Sunay, Study of Catastrophic Health Expenditure in Ayşe Caylan China’s Basic Health Insurance .......................... 1498 Zhongliang Zhou, Jianmin Gao

The Effect of Using Sauna (Dry and Steam) and Cold

The effect methods to cope with stress in high school students on hopelessness and self-esteem ........... 1573

Dilek Kılıç, Gülcan Erol, Battal Kılıç Water on BP (Systolic and Diastolic) and HR in Male Athletes ......................................................... 1508 The Effects of Acute Submaximal Exercise on Alireza Rahimi, Jaber Safarkhan Mo’azeni, Zynalabedin Trace Element Metabolism 1580 Fallah, Abbas Esfandiari Ersan Kara

A Clinical trial to compare the effectiveness of The effect of planned education given to students Lavender essential oil and olive oil at healing postpartum mother’s perinea .............................. 1512 on their menstrual hygiene behaviors: learning Fereshteh Behmanesh, Maryam Tofighi, Mouloud Agajani and forgetting . ....................................................... 1586 Delavar, Mahtab Zeinalzadeh, Ali Akbar Moghadamnia, Soraya Khafri

Hatice Kumcagız, Ilknur Aydin Avci

Sadržaj / Table of Contents Problem solving skills related with baby care Cryopreservation - challenge of platelet of mothers who have normal and premature concentrates long time preservation ................... 1683 newborns* .............................................................. 1593 Radmila Jovanovic, Jasmina Grujic, Vladan Radlovacki, Kuguoglu S, Cinar N, Ergun A

Bato Kamberovic

Oral fungal and bacterial infection in Incidence of smoking among the primary school students in Turkey and its reasons ...................... 1597 smokers ................................................................... 1695 Nazlı Hacıalioğlu, Afife Yurttaş, Meral Kiliç

Cankovic M, Bokor-Bratic M, Cankovic D

Patients’ satisfaction as key point in Characteristics of patients who are newly healthcare services . ............................................... 1701 diagnosed with cancer after visiting the emergency department ......................................... 1605 Radmila Janicic, Danica Lecic-Cvetkovic, Vinka Filipovic, Neslihan Yücel, Feride Sinem Akgün, Cem Ertan, Meltem Serin, Karcıoğlu Özgür

Zoran Vukasinovic, Vesna Jovanovic

Nur Özlem Kilinç, Ayfer Tezel

Sandra Stefan-Mikic, Sinisa Sevic, Radoslava Doder, Dejan Cvjetkovic, Nataša Jovanovic, Maja Ruzic

Implementation influence of antibiotic An evaluation of self-efficacy and nicotine-addiction prescribing guidelines on their usage and levels of smoker university students . .................. 1613 costs of therapy ...................................................... 1710 The investigation of life styles adopted by Secondary Lymphedema of the arm in breast women living in Erzurum as regards cervical cancer risk . .............................................. 1625 carcinoma at the Oncology institute of Vojvodina: Özlem Karabulutlu, Nesrin Reis 2001 – 2006 ............................................................. 1719 Svetlana Popovic-Petrovic, Miroslav Nedeljkovic, Lazar

Popovic, Vasa Petrovic How Much Residents “Don’t Know” About Feeding Children 6 - 24 Months of Age .............. 1632 Assessment of air quality impact on human Rabia Kahveci, İlknur Bostancı, Yıldız Dallar health in the city of Novi Sad ............................... 1725 Sanja Bijelovic, Budimka Novakovic, Ljiljana TrajkovicNursing Students’ Perception of the Internet in Turkey: A Questionnaire Survey ......................... 1636 Pavlovic, Milorad Bijelovic Sevinc Tastan, Birhan Tastan, Emine Iyigun, Hatice Ayhan

T4 Glottic carcinoma: oncological results and survival rate.............................................................1737

An investigation into the knowledge about the Slavisa Jancic, Misko Zivic, Zoran Radovanovic, Biljana menstruation period among the female university Milicic, Natasa Djindjic, Boris Djindjic, Snezana Jancic students at Eastern Black Sea region of Turkey ... 1643 Birsel Canan Demirbağ, Zeynep Güngörmüş

Peripartal Cardiomyopathy – alwaus diagnostic dilemma: clinical and therapeutic Free radicals and intrinsic skin aging: basic principles ................................................................ 1647 procedures . ............................................................ 1744 Raja Dahmane, Borut Poljsak

Mirjana Bogavac, Olivera Rankov, Jadranka Dejanovic, Milica Medic-Stojanoska

Microbiological finding of urine in patients Digital radiography in root canal working with benign prostatic hyperplasia ....................... 1655 length determination.............................................. 1749 Vineta Vuksanovic, Natasa Terzic, Danijela Vujosevic Tatjana Brkanic, Ivana Stojsin, Karolina Vukoje, Duska Blagojevic, Vladan Osatovic

Effects of air pollution on red blood cells in pregnancy ............................................................... 1664 Surgical wounds complications in two different Stankovic A, Nikolic M, Arandjelovic M. techniques of a cesarian section ........................... 1754 Vejnovic T, Grahovac M, Veselovski A, Koledin S

Pheochromocytoma in pregnancy, a diagnosis not to miss . ............................................................. 1670 Measuring health of countries: a novel Bogavac Mirjana, Stojic Sinisa, Malenkovic Goran, Medic approach ................................................................. 1762 Stojanoska Milica Veljko Jeremic, Kristina Seke, Zoran Radojicic, Danka Jeremic, Aleksandar Markovic, Dragoslav Slovic, Aca Aleksic

Mid-life women’s knowledge about perimenopause in Vojvodina . .............................. 1674 Psychopathological response of torture victims ... 1767

Dragana Milutinovic, Aleksandar Curcic, Sanja Sumonja, Dragana Simin, Branislava Brestovacki

Alma Bravo-Mehmedbasic, Senadin Fadilpasic

Effects of dispersed radiation on the thyroid and the gonads during mammography .............. 1774 Suad Kunosic, Denis Ceke, Adnan Beganovic, Begzada Basic,

Qualitative methods of identification of acetylsalicylic acid by differential scanning calorimetry and melting point method ............... 1782 Ekrem Pehlic, Aida Sapcanin, Mirza Nuhanovic, Bozo Banjanin, Husein Nanic, Safeta Redzic, Amir Muric, Cazim Salimovic, Melita Poljakovic, Majda Srabovic

Incidence of urinary tract infections of male paraplegics population compared to the way of bladder treatment ............................................. 1788

Selimovic M, Hiros M, Spahovic H, Sadovic S, Mehmedbasic S, Cavaljuga S

Therapeutic Approach to Large Jaw Cysts ....... 1793 Naida Hadziabdic, Halid Sulejmanagic, Edin Selimovic, Nedim Sulejmanagic

Evaluation of methods in identifying hilar supernumerary renal arteries originating near the aorta ......................................................... 1800 Elvira Talovic, Alma Voljevica, Amela Kulenovic

VAP frequency at central intensive care unit of Canton hospital Zenica within the period 2008/2009 ................................................................ 1806 Ranka Filipovic, Ismet Suljevic, Ismana Surkovic, Azra Kudumovic

Assessment of quality of life in patients with heart failure using Minnesota questionnaire . .............. 1811 Sadat Kurtalic, Fahir Barakovic, Farid Ljuca, Zumreta Kusljugic, Midhat Tabakovic, Zlatko Midzic, Nermina Kurtalic, Dzenan Halilovic

New simplified formula for RPI-reticulocyte production index . .................................................. 1815

Secic D, Omerbasic A, Drljo M, Dizdarevic A

Anti-Suicide effects of clozapine in treatment of schizophrenia and schizoaffective disorder . ...... 1821 Saida Fisekovic, Damir Celik, Svjetlana Loga-Zec Contribution to the epidemiology prolonged forms hepatitis “A” ............................................... 1829 Dautovic-Krkic S, Hadzic A, Gojak R, Mesic A

Instructions for the authors ................................. 1835 Uputstvo za autore ................................................ 1836

HealthMED - Volume 5 / Number 6 / 2011

Chest associated to motor physiotherapy acutely improves oxygen saturation, heart rate and respiratory rate in premature newborns with periventricularintraventricular hemorrhage Luiz Carlos de Abreu1, 2, Vitor E. Valenti 2, 3, Oséas Florêncio de Moura Filho2, Luiz Carlos M. Vanderlei4, Tatiana Dias de Carvalho2, 3, Maria A. F. Vertamatti 4, Adriana G. Oliveira1, Isadora L. Moreno2, 3, Ana Clara C. R. Gonçalves2, 3,Arnaldo A. F. Siqueira1 1 2

3 4

5

Departamento de Saúde Materno-infantil, Universidade de São Paulo (USP), São Paulo, SP, Brasil, Laboratório de Escrita Científica, Departamento de Morfologia e Fisiologia, Faculdade de Medicina do ABC, Santo André, SP, Brasil, Departamento de Medicina, Disciplina de Cardiologia, Universidade Federal de São Paulo, SP, Brasil, Departamento de Fisioterapia da Faculdade de Ciências e Tecnologia, Universidade Estadual Paulista, Presidente Prudente, São Paulo, Brasil, Departamento de Ginecologia e Obstetrícia, Faculdade de Medicina do ABC, Santo André, SP, Brasil.

Abstract Background: The literature presents contradictory data regarding physiotherapy effects on premature newborns. Thus, we aimed to evaluate the effects of chest associated to motor physiotherapy on oxygen saturation (SO2%), heart rate (HR) and respiratory rate (RR) in premature newborns with peri-intraventricular hemorrhage (PIVH). Methods: This study was performed in an intensive care unit. We included newborns with birth weights below 2,000g and we used Papille classification, which classifies PVIH into four grades according to the degree. Newborns were divided in control (n=38) and PIVH (n=32) groups. The protocol followed this sequence: monitoring, physiotherapy, respiratory therapy, physiotherapy and motor monitoring. We compared the cardiorespiratory parameters between before the first physiotherapy session and after the third (last) physiotherapy session in one day. Results: SO2% increased after physiotherapy procedures in control and PIVH groups (p30 on the preeclampsia. Methods: This study was a descriptive-comparative study two hundred fifty singleton pregnancies of women with first trimester BMI >30 who delivered at Emam Hospital, Sari Iran during 2008–2009 were studied A control group with two hundred fifty nine women of normal body mass index matched for age and parity were selected and incidence of preeclampsia were compared between groups. χ2 and Odds-ratio and 95% confidence were used to analyze the data. Statistical significance was defined as P < 0.05. Results: There was a significant relation between obesity and preeclampsia (20.8 vs. 5.8%, P0.05), because the obtained values (146, 47, 0.04) are in the 95% confidence interval of the average population exposure to suspended particles of 174.13 μg/m3 (Table 3). If the annual average concentration of suspended particulate matter are reduced by 10 μg/m3, provided concentration of TSP per year will amount to 164.13 μg/m3 and then the expected total number of deaths (E2) of the residents of the City of Novi Sad, dependent on short-term presence and concentration of PM10 in the air will amount to 115 (95% CI;98-163), the expected number of deaths (E2) of cardiopulmonary disease in population aged above 30, dependent on long-term presence and concentration of PM2.5 in the air, will amount to 37 (95% CI; 31-62) and the expected number of deaths (E2) of respiratory disease of children under five years, dependent on short-term presence and concentration of PM10 in the air, will amount to 0.03 (95% CI; 0.03 to 0.04) (Table 4 ). Decreased average population exposure to suspended particles in 10 µg/m3 is correlated to reduction of the expected total number of deaths for 16 (from 131 to 115), reduction of expected number of deaths from cardiopulmonary disease in population aged above 30 for five (from 42 to 37) and reduce the expected number of deaths from respiratory disease of children under five for 0.006 (from 0.036 to 0.03). Reported decrease in the expected number of deaths does not represent a statistically significant reduction in the level of 0.05 (p>0.05), because the obtained values (115, 42; 0.03) are in the 95% confidence interval of the average population exposure to suspended particles of 174.13 μg/m3 (Table 4). The increase in total number of deaths for 15 cases (n=3637+15=3652) and increased number of deaths from cardiopulmonary disease for 5 cases

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(n2=2315+5=2320), correlated to TSP concentration increase of 10 μg/m3, increased total mortality rate for 0.047 (0.4%) without statistical significance (p=0.29299) and increased cardiopulmonary mortality for 0.016 (0.2%) without statistical significance (p=0.404149) (Table 5). In terms of decreased TSP of 10 μg/m3, a reduction in total number of deaths for 16 cases (n=3637-16=3621) and reduce the number of deaths of persons aged above 30 of cardiopulmonary disease for 5 cases (n=2315-5=2310), which causes further reduction in total mortality of 0.051 (0.4%) without statistical significance (p = 0.26355) and a reduction in cardiopulmonary mortality of 0.016 (0.2%) without statistical significance (p = 0.404055 ) (Table 5). Since the established number of deaths from respiratory disease of children under five in 2006 amounts to one, and that the increase or reduction of TSP for 10 µg/m3 does not exceed one case in the expected number of deaths of children under five (Tables 3 and 4), statistical analysis of data are not implemented.

Table 1. Total amount of suspended particulate on annual level in the City of Novi Sad during 2006 Statistical indicators LV* Number of measurment Average daily level on annual level C50* C95* C98* Minimum Maximum Standard deviation Coefficient of variation Exceeding LV annually (%)

TSP (μg/m3) 70 204 174,13 155,00 325,00 342,00 35,00 593,00 81,38 46,74 148,76

*LV – limit value; C50, C95 i C98 –percentile values

Table 2. The expected number of deaths dependent on the presence and concentration of pollutants in the air in the City of Novi Sad Expected mortality/ lenght of exposure / age

ß

PM10/ PM2,5/ X TSP TSP* PM10** RRPM10 RRPM2,5 AF§ (µg/m3) (µg/m3) (µg/m3)

Total mortality/ short-term exposure 0,0008 174,13 95,77 of PM10/all ages of population

-

1,037

Cardiopulmonary mortality/ long-term 0,0008 174,13 95,77 exposure of PM2.5/ aged above 30

47,88

-

Respiratory mortality/ short-term 0,0008 174,13 95,77 exposure of PM10/ children under 5

-

1,037

B§§

P§§§



CI (95%)

0,036 0,011576 314192 131

114148

1,018 0,018 0,007368 314192 42

36-75

-

-

0,036 0,000115 8669 0,036

0,0310,040

*factor 0,55 for calculating PM10 from TSP; ** factor 0,5 for calculating PM2.5 from PM10, not calculated in total mortality and respiratory mortality; § - relative risk RR=exp [ß (X-Xo)] § AF (atributable factor) - AF=RR-1/RR; §§B – number of deaths for 1000 people; §§§P – exposed populations; ǂ E (expected number of deaths) - E=AF x B x P

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Table 3. The expected number of deaths dependent on the presence and concentration of pollutants in the air in the City of Novi Sad with calculated increase of TSP on annual level for 10 µg/m3 Indicators ß X TSP1 (µg/m3) PM10/TSP1* (µg/m3) PM2.5/PM10**(µg/m3) RR1PM10 RR1PM2.5** AF§1 B* P** E1 CI (95%) Ex (95%CI) Difference Ex/E1 (number)

Total mortality/short- Cardiopulmonary mortality/ Respiratory mortality/ term exposure of PM10/ long-term exposure of PM2.5/ short-term exposure of all ages of population aged above 30 PM10/children under five 0,0008 184,13 101,27 1,04 0,04 0,011576 314192 146 129-163 131 (114-148)

0,0008 184,13 101,27 50,64 1,02 0,02 0,007368 314192 47 41-82 42 (36-75)

0,0008 184,13 101,27 1,04 0,04 0,000115 8669 0,04 0,03-0,05 0,036 (0,031-0,040)

15 (p>0,05)

5 (p>0,05)

0,004 (p>0,05)

* factor 0,55 for calculating PM10 from TSP; **factor 0,5 for calculating PM2.5 from PM10, not calculated in total mortality and respiratory mortality; § - relative risk RR=exp [ß (X-Xo)]; TSP1 – increasing TSP for 10 µg/m3; RR1 – relative risk with increasing TSP for 10; § AF (atributable factor) – AF=RR-1/RR; *B – number of deaths for 1000 people; **P – exposed populations; E (expected number of deaths) – E=AF x B x P; AF§1 – atributable factor with increasing TSP for 10 µg/m3 ; E1- expected number of deaths with increasing TSP for 10 µg/m3; Ex - expected number of deaths with TSP 174,13 µg/m3

Table 4. The expected number of deaths dependent on the presence and concentration of pollutants in the air in the City of Novi Sad with calculated decrease of TSP on annual level for 10 µg/m3 Indicators ß X TSP2 (µg/m3) PM10/TSP2* (µg/m3) PM2.5/PM10**(µg/m3) RR2PM10 RR2PM2.5** AF§2 B* P** E2 CI (95%) Ex (95%CI) Difference Ex/E2 (number)

Total mortality/short- Cardiopulmonary mortali- Respiratory mortality/ term exposure of PM10/ ty/ long-term exposure short-term exposure of all ages of population of PM2.5/aged above 30 PM10/children under five 0,0008 164,13 90,27 1,03 0,03 0,011576 314192 115 98-163 131 (114-148)

0,0008 164,13 90,27 45,13 1,02 0,02 0,007368 314192 37 31-62 42 (36-75)

0,0008 164,13 90,27 1,03 0,03 0,000115 8669 0,03 0,03-0,04 0,036 (0,031-0,040)

16 (p>0,05)

5 (p>0,05)

0,006 (p>0,05)

* factor 0,55 for calculating PM10 from TSP; **factor 0,5 for calculating PM2.5 from PM10, not calculated in total mortality and respiratory mortality; §- relative risk RR=exp [ß (X-Xo)]; TSP2 – decreasing TSP for 10 µg/m3; RR2 – relative risk with decreasing TSP for 10; §AF (atributable factor) – AF=RR-1/RR; *B – number of deaths for 1000 people; **P – exposed populations; E (expected number of deaths) – E=AF x B x P; AF§2 – atributable factor with decreasing TSP for 10 µg/m3 ; E2- expected number of deaths with decreasing TSP for 10 µg/m3; Ex - expected number of deaths with TSP 174,13 µg/m3 Journal of Society for development in new net environment in B&H

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Table 5. Changing mortality rates caused by increased or decreased TSP concentration in the air of the City of Novi Sad

Total mortality Cardiopulmonary mortality of persons aged above 30

Established Mortality rate Changing mortality Mortality rate Changing mortality mortality rate with increased rate caused by incre- with decreased rate caused by decrefor 2006 in TSP concen- ased TSP concentra- TSP concen- ased TSP concentratitration for the City of tration for 10 tion for 10 µg/m3/ on for 10 µg/m3/ 3 3 Novi Sad µg/m statistical significance 10 µg/m statistical significance + 0,047 (+0,4%) - 0,051 11,576 11,623 11,525 (p=0,29299) (-0,4%) (p=0,26355) 7,368

+ 0,016 (+0,2%) (p=0,404149)

7,384

Discussion Conducted research has indicated that the use of internationally recognized methodology allows interconnection and assessment depending on the existing data on the harmful substances in the air and population health of the City of Novi Sad. Available data provides estimate of the influence of analyzed harmful substances from the air on people health. Conducted research indicated to the increased concentrations of TSP in the City of Novi Sad and that TSP and PM10 and PM2.5 calculated from established concentration of TSP, contribute to overall mortality, cardiopulmonary mortality of persons aged over 30 and respiratory mortality of children under five years. The survey also indicated that the amount of TSP or amount of PM10 and PM2.5 calculated from established concentration of TSP, contribute to the increased or decreased overall mortality rates and cardiopulmonary mortality rates among people aged over 30, without statistical significance per annum. It is also shown that the improved air quality of the environment in terms of decreased concentration of suspended particulate matter by 10 μg/m3 annually saves 16 adults and one child living in the community of Novi Sad. The research results obtained in the City of Novi Sad in 2006 indicating that the established TSP concentration and calculated concentration of PM10 and PM2.5 contribute to overall mortality in the City of Novi Sad in 2006 for 3.6%, and therefore represent data that matches the WHO data on the contribution of air pollutants to total population mortality (11). 1732

7,352

- 0,016 (-0,2%) (p=0,404055)

Unlike the research in the City of Novi Sad, where the concentrations of suspended particulate matter of 10 μg/m3 have not made significant changes to total mortality rate and cardiopulmonary mortality observed annually, the studies of American researchers proved that an increased or decreased suspended particles PM2.5 made a statistically significant influence on changes in observed mortality rate of diseases (32,33, 34, 35). Increase in total mortality of the population of the City of Novi Sad for 0.4% in the anticipated increase in the total amount of suspended particles of 10 μg/m3, is less than the percentage increase in total mortality with increasing PM2.5 in the U.S., which, according to data from 2000, for the period 1979-1983 is 4.8%, according to data from 2002 for the period 19992000 amounted to 3.1%, i.e. 4% generally (32, 35). Researches in the U.S. also indicated the existence of mutual dependence of long-term exposure to PM10 concentrations and total mortality and cardiopulmonary mortality (36, 37). Interdependence of long-term exposure to PM10 concentrations and cardiovascular disease among the adult population has been demonstrated in studies conducted in France, Italy, Netherlands and China (38). Based on research conducted in the U.S. and some European countries (36, 37, 38), it can be assumed that determination of the interdependence of increased or decreased TSP in the air with an increased or decreased overall mortality, cardiopulmonary mortality of people aged above 30 and respiratory mortality of children under five years in the City of Novi Sad, anticipated daily variation in the concentration of PM10 and PM2.5, as well as long periods of analyses, is possible to be proved (11).

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The outcome of research is certainly influenced by the fact that they are used to assess the impact of budget but not really fixed value of the concentration of PM10 and PM2.5, and for calculating the PM10 and PM2.5 concentration from the TSP, in the absence of national factors for conversion are used internationally recommended factors which are not sufficiently specific for the environment of the City of Novi Sad (14, 16,). Applied terms chosen to present the impact assessment factors of environment on the population health of the City of Novi Sad were determined on the basis of existing statistics, which are partly based on official data of the Republic of Serbia and the last census conducted in 2002, as well as on the data of public institutions based on the number of registered residents by address and place of residence in the real-timetesting. The data of mortality and morbidity are related to the settlement and health care and cannot bind to address subjects, thus preventing accurate assessment of the effects of pollutants from the environment on human health. In our country, the data of the total mortality by codes of illness are not available and the expression of the influence factors of the environment can be done only in relation to the hospital or outpatient morbidity. Problem in data collecting on number and frequency of the disease are an inadequate set of data in the application form, imprecise instructions to report on methodology and data processing, the lack of unified information technology in data processing and presentation of data and lack of systematic data in real-time events (39). The average annual concentration of TSP is an indicator that is rarely monitored in developed countries. It is replaced with more modern and more accurate measurements of small respirable particles, or PM10, PM2.5 and PM1. Therefore, data for mutual comparison of results are difficult to access, or the data of TSP are presented for the period of 90 years of the last century. According to available data for comparison can be concluded that the average annual concentrations of TSP in the City of Novi Sad in 2006 are higher than average annual concentrations of TSP in U.S. cities and towns of Europe (35, 38). According to data from studies of six cities in the U.S., the average concentration of TSP in the period 1977-1985 ranged from 34.1 to 89.9 μg/m3 (34), which is less than the determined

TSP value in Novi Sad in 2006. Epidemiological data of U.S. studies conducted in 156 capitals in the period 1980-1981 indicated that the average annual concentration of TSP was 68.0 μg/m3, in 58 capitals in the period 1979-1983 73.7 μg/m3, and 150 capitals in the period 1982-1998 56.7 μg/m3 (35). The average annual concentration of TSP in Helsinki in the period 1987-1989. year amounted to 76 μg/m3 (38). However, according to the European Environment Agency in the European Union in 1993 the excess of the average daily value of TSP at the annual level of 150 μg/m3, was established in Italy, Portugal, Austria, Czech Republic, Denmark, Finland, Germany and Spain, where they are especially emphasized by the maximum daily value of TSP in the Czech Republic (from 450 to 709 μg/ m3) and Portugal (from 136 to 600 μg/m3) (40). According to the Institute of Public Health of Serbia "Dr Milan Jovanovic Batut" for 2009 it can be concluded that the average annual TSP concentration ranges from 54 μg/m3 in Kosjerić to 147.8 μg/ m3 in Novi Sad (41). In Vojvodina, the mean annual concentration of TSP in 2008 ranges from 87 μg/m3 in Petrovaradin over 99 μg/m3 in Pancevo, 115 μg/m3 in Kikinda, 164 μg/m3 in Zrenjanin to 227 μg/m3 in Novi Sad (42, 43). The calculated concentration of PM10 in the city of Novi Sad in 2006 of 95.77 μg/m3, is derived from the determined concentrations of TSP, according to the data on directly measured concentrations of PM10 in urban areas of cities of the European Union (43 μg/m3 in Dusseldorf, 42 μg/ m3 in Berlin, 44 μg/m3 in Madrid, 48 μg/m3 in London) and is in average 50% larger (14). The calculated concentration of PM2.5 in the City of Novi Sad in 2006 of 47.88 μg/m3, is derived from the determined concentrations of TSP and PM10 (PM2.5/PM10 0.5), according to the data on directly measured concentrations of PM2.5 is higher than the annual mean concentration of PM2.5 provided for in the U.S. (in the period 19791983 20.61±4.36 μg/m3, in the period 1999-2000 14.10±2.86 μg/m3), in Central Europe (in urban areas 16-30 μg/m3, the background zones 12-20 μg/m3 and in zones along the roads 22-39 μg/m3), in the countries of Northern Europe (in urban areas 8-15 μg/m3, 7-13 μg/m3 in the background zones, along roads 13-19 μg/m3) and in the countries

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of Southern Europe (in urban areas 19-25 μg/m3, 12-16 μg/m3 in a background zones and along roads 28-35 μg/m3) (14, 32, 33). Details of the research should be examined as the first research in this area, and determined correlation of concentration of suspended particles in the air and mortality of the population of the City of Novi Sad requires the implementation of further researches based on established data, but not calculated concentration of PM10 and PM2.5, data on the exact number of inhabitants per residence and systematized data on the number and type of deaths, particularly from cardiopulmonary and respiratory diseases, collected by address of residence of the population of the City of Novi Sad. Conclusion Conducted research has established that in the City of Novi Sad there are evident increased concentrations of TSP, which may contribute to increasing rates of total mortality and respiratory mortality of children under five years for 3.6% and to increased cardiopulmonary mortality rates of adult population aged above 30 for 1.81%, as well as that improved air quality in terms of reduced TSP for 10 μg/m3 annually saves 16 adults and one child living in the community of Novi Sad.

References 1. Air quality guidelines. Global update 2005. Particulate matter, ozone, nitrogen dioxide and sulfur dioxide. Copenhagen (Denmark): World Health Organization Regional Office for Europe; 2006. 2. Erzen I, Kukec A, Zaletel-Kragelj L. Air Pollution as a potential Risk Factor for Chronic Respiratory Diseases in Children: A Prevalence Study in Koper Municipality. HealthMED. 2010; 4: 945-54 3. Bingheng Ch, Haidong Kan. Air pollution and population health: a global challenge. Environ Health Prev Med. 2008; 13:94–101 4. Schneider A, Hampel R, Ibald-Mulli A, Zareba W, Schmidt G, Schneider R et al. Changes in deceleration capacity of heart rate and heart rate variability induced by ambient air pollution in individuals with coronary artery disease. Particle and Fibre Toxicology 2010, 7:29 5. Von Schirnding Y. Health in sustainable development planning: the role of indicators. Geneva (Switzerland): World Health Organization; 2002. P. 5-30. 6. Indicators for policy and decision making in environmental health (draft). Geneva (Switzerland): World Health Organization; 1997 Jul. 7. The world health report 2002. Reducing risks, promoting healthy life. Geneva (Switzerland): World Health Organization; 2002. 8. Quantification of the health effects of exposure to air pollution. Copenhagen (Denmark): WHO Regional Office for Europe; 2001. Report No.: EUR/01/5026342 9. Environmental health indicators for Europe: A pilot indicator-based report. Background document of Fourth Ministerial Conference on Environment and Health. World Health Organization Regional Office for Europe; 2004 June. Report No.: EUR/04/5046267/BD/4 10. Health and environment in Europe: Progress Assessment. Copenhagen (Denmark): WHO Regional Office for Europe; 2010. 11. Outdoor air pollution. Assesing the environmental burden of disease at national and local levels. Geneva (Switzerland): World Health Organization; 2004. Environmental Burden of Disease Series No5.

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12. Orru H, Teinemaa E, Lai T, Tamm T, Kaasik M, Kimmel V et al. Health imapct assessment of particulate pollution in Tallinn using finr spatial resolution and modeling techniques. Environmental Health. 2009;8:7. Available at URL: http://www. ehjournal.net/content/pdf/1476-069X-8-7.pdf. Accessed March 13,2011. 13. Stieb DM, Judek S, Burnett RT. Meta-analysis of time-series of air pollution and mortality: effects of gases and particles and the influence of cause of death, age, and season. J Air Waste Manag Assoc. 2002; 52:470-84 14. The Clean Air for Europe (CAFE) Programme: Towards a Thematic Strategy for Air Quality. Brussels: Commission of The European Communities; 2001 May 4 15. Larssen S. State of air quality in Europe 19902002. In: Eerens H et al. European environmental outlook 2005: background document air quality 1990-2030. Bilthoven (Netherlands): European Topic Centre on Air and Climate Change; 2005. ETC/ACC Technical Paper 2005/2. 16. Ostro B. Estimating health effects of air pollutants: a methodology with an application to Jakarta. Washington (DC): The World Bank; 1994. Policy Research Working Paper 1301. 17. Schwartz J. The distributed lag between air pollution and daily deaths. Epidemiology 2000;11:320-6. 18. English P, Gunier R, Kreutzer R, Lee D, McLaughlin R, Parikh-Patel A et al. California environmental health indicators. California Department of Health Servicies, Environmental Health Investigations Branch; 2002 Jul. P. 1-7. 19. Havelaar AH, Melse JM. Quantifying public health risk in the WHO guidelines for drinkingwater quality. A burden of disease approach. Bilthoven (Netherlands); 2003. RIVM report 734301022/2003.

23. Izveštaj o zagađenosti vazduha na području grada Pančeva tokom 2006. godine. Pančevo (Srbija): Zavod za javno zdravlje Pančevo; [Internet] 2007 [citirano 24. oktobra 2010]. Dostupno na: URL: http:// www.zzzzpa.org.rs/GI/AZ%202006%20GI.pdf 24. Pravilnik o graničnim vrednostima, metodama merenja imisije, kriterijuma za uspostavljanje mernih mesta i evidenciji podataka, Sl.glasnik RS br. 54/92, 30/99 i 19/06 25. Uredba o utvrđivanju programa kontrole kvaliteta vazduha u 2006. i 2007. godini, Sl.glasnik RS br. 23/06. 26. Uputstvo za korišćenje aparata AT – 2000. Q3.XИ.204. Novi Sad (Srbija): Institut za zaštitu zdravlja Novi Sad; 24.09.2004. 27. Rešenje o utvrđivanju obima akreditacije. Beograd (Srbija): Akreditaciono Telo Srbije; 14.03.2007. Akreditacioni broj 01-131. 28. Environmental health indicators for the WHO European region. Update of methodology. WHO Regional Office for Europe; 2002 May. Report No.:EUR/02/5039762 29. Development of environment and health indicators for the European Union countries. ECOEHIS. Final Report. Grant Agreement. European Centre for Environment and Health Bonn Office: World Health Organization Regional Office for Europe; 2004. Report No.:SPC 2002300 30. Environmental health indicators: development of methodology for the WHO European Region. Interim report. Copenhagen (Denmark): World Health Organization Regional Office for Europe; 2000 Nov. P. 1.1-4.4. 31. Savezni zavod za zaštitu i unapređenje zdravlja. Međunarodna klasifikacija bolesti. MKB 10, Deseta revizija, Knjiga 1. Beograd (Srbija): Savremena administracija; 1996. P. 385-463

20. Quality of live counts. London (UK): U.K. Department of Environment, Transport and the Regions (DETR). Goverment Statistical Service; 1999.

32. Pope III CA, Ezzati M, Dockery DW. Fine-Particulate Air Pollution and Life Expectancy in the United States. N Engl J Med 2009;360:376-86

21. Environmental Health Indicators for The WHO European Region. Towards Reporting. World Health Organization Regional Office for Europe; 2002

33. Dominici F, Peng RD, Bell ML, Pham L, McDermott A, Zeger S at al. Fine Particulate Air Pollution and hospital Admission for Cardiovascular and Respiratory Diseases. JAMA, 2006;295:1127-34

22. Environment and health performance review in Serbia. Copenhagen (Denmark): World Health Organization Regional Office for Europe; 2009

34. Dockery DW, Pope A, Xu X, Spengler JD, Ware JH, Fay ME et al. An Association between Air Po-

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llution and Mortality in Six U.S. Cities. N Engl J Med 1993;329:1753-59 35. Pope III CA, Burnett RT, Thun MJ, Calle EE, Krewski D, Ito K at al. Lung Cancer, Cardiopulminary Mortality, and Long-term Exposure to Fine Particulate Air Pollution. JAMA, 2002;287:113241



Corresponding author Sanja Bijelovic, Institute of Public Health of Vojvodina, Serbia, E-mail: [email protected]

36. Samet JM, Dominici F, Currierro FC, Coursac I, Zeger SL. Fine Particulate Air Pollution and Mortality in 20 U.S.Cities 1987-1994. N Engl J Med 2000;343:1742-9 37. Pope III CA, Burnett RT, Thurston GD, Thun MJ, Calle EE, Krewski D at al. Cardiovascular Mortality and Long-Term Exposure to Particulate Air Pollution: Epidemiological Evidence on General Pathophysiological Pathways of Disease. Circulation, 2004;109:71-7 38. Maitre A, Bonneterre V, Huillard L, Sabatier Ph, de Gaudemaris R. Impact of urban atmospheric pollution on coronary disease. European Heart Journal 2006;27:2275-84 39. Incidencija i mortalitet od akutnog koronarnog sindroma u Srbiji. Registar za akutni koronarni sindrom u Srbiji. Beograd (Srbija). Institut za javno zdravlje Srbije „Dr Milan Jovanović Batut“. Beograd. 2007. Izveštaj br.1. (ISBN 978-86-7358-045-6) 40. Air Quality in Europe, 1993 - A Pilot Report. Topic Report. Copenhagen (Denmark): European Environment Agency; 1996. Report No.:25 41. Pokazatelji stanja životne sredine u Republici Srbiji za 2009. godinu. Beograd (Srbija): Institut za javno zdravlje Srbije „Dr Milan Jovanović Batut“; 2010. 42. Bijelović S, Živadinović E. Zdravstvena ispravnost vode za piće u AP Vojvodini tokom 2008. Praćenje kvaliteta vazduha životne sredine u AP Vojvodini. Zdravstvena ispravnost vode otvorenih i zatvorenih bazena u AP Vojvodini tokom 2008. godine. Kvalitet površinske vode javnih kupališta reka i jezera u AP Vojvodini tokom 2008. godine. U: Jevtić M. Zdravstveno stanje stanovništva AP Vojvodine 2008. godine. Novi Sad (Srbija): Institut za javno zdravlje Vojvodine; 2009. P. 101-61. ISBN 978-8686185-18-1; COBISS.SR-ID 245008903. 43. Novaković B, Kristoforović-Ilić M, TrajkovićPavlović Lj, Torović Lj, Jevtić M, Bijelović S et al. Zdravlje i životne sredina. Med Pregl 2007;LX (11-12):569-74.

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T4 Glottic carcinoma: oncological results and survival rate Slavisa Jancic1, Misko Zivic1, Zoran Radovanovic2, Biljana Milicic3, Natasa Djindjic4, Boris Djindjic4, Snezana Jancic5 1 2 3 4 5

Oncology and ENT Clinic, Clinical Center Nis, Serbia, Institute of Radiology, Clinical Center Nis, Serbia, Scool of Dentisty, Department of statistics, Belgrade, Serbia, Faculty of Medicine, University in Nis, Serbia, Institute of Pathology, Faculty of Medicine in Kragujevac, Serbia.

Abstract Objectives/Background: The best course of action in the case of T4 glottic carcinoma is chosen for each individual case. The aim of this study was to evaluate the potential prognostic factors and influence of postoperative and radical radiotherapy on the survival rate of patients suffering from T4 glottic carcinoma and to analyze the most appropriate conservative treatment for these patients. Methods: Study Design: A retrospective study (1995-2000) enrolled 63 patients with squamocellular glottic cancer in T4N1M0 stage, monitored for 5 years, divided into two groups: 30 postoperatively irradiated patients and 33 radically irradiated patients. Analysed variables were: age, sex, total therapeutical dose, number of fractions, dose per fraction and type of radiotherapeutical treatment. Standard therapeutical fractionation regimens were used, with daily sessions of 2-3 Gy, five times a week. Radiotherapy consisted of mega-voltage 10 MEV X-ray therapy. Log Rank test, Kaplan-Meier survival study, t- test, Pearson X2 – test and Cox regression were used in order to select the factors with independent effect. Results: Multivariate analysis demonstrated that none of the predictors, not even the type of radiation therapy, were statistically significant, with independent influence on survival. Conclusion: There is no significant difference in survival of patients with T4 glottic carcinoma among postoperatively and radically irradiated patients. Our results imply that the optimal radiotherapeutic modality for these patients is a total

therapeutical dose no less than 65 Gy and daily fractionation with dose no less than 2,51Gy. Key words: T4 glottic cancer, prognostic factors, radical radiotherapy, postoperative radiotherapy, survival Introduction Many studies have indicated that the therapy protocols in the case of T4 glottic carcinoma are applied flexibly, and that the best course of action is chosen for each individual case. At the same time, in addition to any objective findings, other non-medical factors also affect the choice of therapeutic treatment. Many therapeutic procedures are used in T4 glottic carcinoma therapy, including different surgery methods, radical radiotherapy, chemotherapy, a combination of radiological-surgical therapy and concomitant chemoradiotherapy [1-7]. It is still the case in the clinical treatment of T4 glottic carcinoma that combined surgical-radiological therapy (postoperative radiotherapy) and radical radiotherapy are utilized most frequently. Surgical treatment usually means using different methods, such as conservative-functional and palliative surgery [3,8,9]. The aim of any kind of postoperative radiotherapy is achieving locoregional control of the malign illness, accompanied by an acceptable level of complications that may occur during the course of therapy, while radical radiotherapy is traditionally reserved only for patients who will undergo a complete laryngectomy or are generally of poor

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health and therefore are not good candidates for more extensive surgery. Radical radiotherapy is indicated also in the case of inoperable carcinoma in the T4 stages [5,9,10]. There are many controversial reports regarding the influence that the choice of therapy can have on the increased survival rate of the patients suffering from T4N1M0 glottic carcinoma. The aim of this study was to evaluate the potential prognostic factors and influence of postoperative and radical radiotherapy on the survival rate of patients suffering from T4 glottic carcinoma and to analyze the most appropriate conservative treatment for these patients. Materials and methods The patients A total of 63 patients suffering from squamocellular glottic carcinoma, stage T4N1M0, that underwent radiotherapy at the Oncology Clinic of the Faculty of Medicine in Nis from September the 1st, 1995 until September the 1st, 2000, were included in the study. The clinical T stage was defined according to the TNM system, on the basis of the UICC criteria [11]. Megavoltage therapy using 10 MeV X-rays was used as part of the radiotherapy treatment. All of the patients received treatment in the same manner, by utilizing the technique of two separate parallel planes (5x5 do 5x7cm). They all underwent daily fractionation, with daily session of 2-3Gy per fraction, five times a week. All patients included in the study signed writen permision for therapeutical intervention and appropriate institutional research oversight committee from the Medical faculty in Nis gave permision for study realisation. The patients were divided into two groups: a group of patients who underwent postoperative radiotherapy and a group of patients who underwent radical radiation therapy. The patients that underwent postoperative radiation therapy This group numbered a total of 30 patients. A complete laryngectomy was performed on a total 1738

of 28 patients (93.3%), either separately, or combined with pharyngectomy or the concomitant removal of the base of the tongue, in accordance to how the cancer was spreading. Only one patient had a subtotal laryngectomy (3.3%) and one (3.3%) had a hemilaryngectomy. A radical dissection of the neck had to be performed on 8 of the patients, while a complete laryngectomy and a functional dissection on both sides had to be carried out on another 8 patients. There was only one female patient in this group (3.3%). The youngest patient was 38, and the oldest 79 (the median was 60 years of age). The total therapeutic dose per patient was 42 - 66Gy (the median for the group was 60Gy). The number of fractions per patient was 16–28 (a median of 24). The therapeutic dose was 2-3Gy per fraction (median of 2.5Gy). The patients who underwent radical radiation therapy This group consists of 33 patients. There were 3 women (9.1%). The youngest patient was 39, and the oldest was 79 (the median was 65). The overall number of therapeutic doses per patient was 42-127Gy (the median was 67Gy). The number of fractions per patient was 20–34 (the median was 28), and the therapeutic dose per fraction was 2-3Gy (the median was 2.39Gy). The patients were monitored over a period of 5 years, following radical or postoperative radiotherapy. The study did not encompass patients who could no longer be found or patients who had died from other illnesses before the end of the five-year period following radiation. Statistical analysis An analysis of the predictor variables was carried out first, along with an analysis of their frequency among patients who underwent different forms of therapy: radical or postoperative radiation therapy. An analysis of the survival rate was carried out over a five-year period, followed by an analysis of the survival rate of the subjects in relation to the predictors.

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A regression analysis was used to study the influence of each of the monitored factors on the survival rate of these patients. The factors that exhibited their statistically significant influence on the survival rate in the univariate analysis were added to the multivariate Cox model. The Kaplan-Meier survival analysis was used to present the results, and LogRank test to determine the statistical significance of the length of the survival period. In order to compare the parametric numeric features of observation, the t-test was used. The Pearson c2-test was used to compare the differences in the frequency. Results The analysis of the predictors There were no significant differences in age and gender between subjects with different therapeutic procedures (Table 1). The total dose was significantly lower and dose of radiation per fraction was higher in the group

of patients who underwent postoperative radiation compared to radical radiation therapy. The patients who underwent radical radiation therapy received a larger number of fractions during their radiation therapy (Table 2). The analysis of the survival rate in relation to the predictors Among the subjects with T4 glottic carcinoma, the survival rate after one year was 57.14%, while at the end of the 62-months’ period, the survival rate was 9.52% (Table 3). There was no significant difference in the survival rate related to sex (median survival for males 14 months vs. 8 months for females), but there was significant difference in the rate of survival according to age (Log-Rank test; p=0.018) (Table 3). There was no statistically significant difference in the survival rate of the patients suffering from T4 glottic carcinoma in relation to the chosen therapeutic treatment between the groups: either postope-

Table 1. Patients’ characteristics Subjects with different therapeutic procedures

Monitored factors

Postoperative radiation therapy 2 (6.7%) 15 (50%) 13 (43.3%) 29 (96.7%) 1 (3.3%)

Under 45 Age groupsBetween 45-60 T4 stage Over 60 Male Sex – T4 stage Female

Radical radiation therapy 3 (9.1%) 10 (30.3%) 20 (60.6%) 30 (90,9%) 3 (9,1%)

Value p p=0.280 p=0.343

Data are presented as numbers (%)

Table 2. Treatment characteristics Monitored factors Total dose T4 stage Number of fractionsT4 stage Dose per fractionT4 stage

45-50Gy 50.1-57.5Gy 57.6-65Gy Over 65Gy 16-20 21-25 26-30 Over 30 2-2.25Gy 2.26-2.5Gy 2.51-3Gy

Subjects with different therapeutic treatment Postoperative radiation therapy Radical radiation therapy 5 (17.2%) 3 (10.3%) 6 (20.7%) 1 (3.4%) 15 (51.7%) 9 (31%) 3 (10.3%) 16 (55.2%) 5 (17.2%) 4 (12.9%) 14 (48.3%) 1 (3.2%) 10 (34.5%) 16 (51.6%) 0 (0%) 10 (32.3%) 2 (6.7%) 11 (33.3%) 22 (73.3%) 19 (57.6%) 6 (20%) 3 (9.1%)

p

p=0.002

p=0.002

p=0.026

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Table 3. The survival rate of the subjects with T4 glottic carcinoma 2 yr 25,40% 25,42% 25,00% 0,00% 32,00% 24,24% 30,00% 21,21%

3yr 17,46% 16,95% 25,00% 0,00% 24,00% 15,15% 20,00% 15,15%

4yr 5yr 11,11% 9,52% 11,86% 10,17% 0,00% 0,00% 0,00% 0,00% 20,00% 16,00% 6,06% 6,06% 13,33% 10,00% 9,09% 9,09%

45-50

50,00% 25,00%

0,00%

0,00%

0,00%

50,1-57,5

57,14%

0,00%

0,00%

0,00%

57,6-65

58,33% 33,33% 25,00% 20,80% 16,67%

Over 65

73,68% 31,58% 26,32% 10,53% 10,53%

16-20

33,33% 11,11%

Total survival Male Sex Female Under 45 Age Between 45-60 Over 60 Postoperative radiation therapy Type of therapy Radical radiation therapy

Total dose

0,00%

Value p / 0,542 1vs2=0,006* 1vs3=0,034* 2vs3=0,212 0,643 1vs2=0,973 1vs3=0,135 1vs4=0,068 2vs3=0,442 2vs4=0,237 3vs4=0,758

Over 30

70,00% 10,00% 10,00% 10,00% 10,00%

1vs2=0,011* 1vs3=0,023* 1vs4=0,126 2vs3=0,656 2vs4=0,568 3vs4=0,920

2-2,25 2,26-2,5 2,51-3

61,54% 0,00% 0,00% 0,00% 0,00% 56,10% 34,15% 24,39% 17,07% 14,63% 55,56% 22,22% 11,11% 0,00% 0,00%

1vs2=0,184 1vs3=0,385 2vs3=0,320

Number 21-25 of fractions 26-30

Dose per fraction

1yr 57,14% 57,63% 50,00% 20,00% 68,00% 54,55% 60,00% 54,55%

0,00%

0,00%

0,00%

60,00% 40,00% 26,67% 20,00% 13,33% 65,38% 30,77% 23,08% 11,54% 11,54%

*Statistically significant difference,

rative radiation therapy or radical radiation therapy (Log-Rank test; p=0,643). The five-year survival rate for the subjects who underwent postoperative radiation therapy was 10%. The survival median for this group of subjects was 14 months (CI95% 9, 72 - 18, 28). In the group of subjects who underwent radical radiation therapy, the survival rate after five years was 9, 09%. The patients who underwent radical radiation therapy had a survival median of also 14 months (CI95% 6, 15 - 21, 85) (Table 3 and Figure 1). No statistically significant interrelation was noted between the rate of survival of the subjects and the total dose of radiation for the group with T4 glottic carcinoma. A statistically significant difference in the survival rate was noted between the subjects who received different amounts of radiation fractions (Log-Rank test; p=0,049). The poorest survival rate was in the group with the smallest number of fractions. (Table 3). The radiation dose per fraction has no statistically significant influence on the rate of survival of subjects with T4 glottic carcinoma. 1740

Figure 1. The survival rate of the subjects with T4 glottic carcinoma and different therapeutic procedures None of the analysed factors stood out as significant, or had an independent influence on the further course of the illness or the survival rate of the patients (Table 4).

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Table 4. The Cox regression analysis of the survival rate of the subjects with T4 glottic carcinoma Monitored factors Sex Age Total radiation dose Number of fractions Dose per fraction Type of therapy

exp (B)=RR 1,362 0,967 0,778 0,831 0,891 1,128

Value p p=0,553 p=0,886 p=0,076 p=0,256 p=0,640 p=0,651

Univariant Cox regression analysis, RR-Relative risk

Discussion Radical radiotherapy should allow a complete and permanent remission of the malign illnesses. In classic tumor fractionation, literature data suggest the optimal daily doses of 2 - 3Gy, weekly doses of 8 - 10Gy, and the total therapeutic doses range from 30 - 90Gy, depending on the type of tumor, its localization, size and biological properties (5,14). In our group of patients that underwent radical radiation therapy, the total therapeutic dose was 42 - 127Gy, with a median of 67Gy. Postoperative radiotherapy is indicated in all cases with an expanded tumor with unclear resection edges, and is utilized usually 4-6 weeks after surgery [13-15]. The indications for postoperative radiation therapy include subglottic expansion, cartilage infiltration, perineural invasion, expansion of the primary tumor into the soft tissue of the neck, multiple positive lymph nodes of the neck and expansion of the tumor outside the scope of the lymph node [3, 13-15]. In the data that we gathered, in the group of patients that underwent postoperative radiation therapy, the greatest number of patients (93.33%) underwent complete laryngectomy, either independently or in combination with a radical dissection of the neck or functional dissection on both sides of the neck. The total therapeutic dose during postoperative radiation, for these patients, was from 42 to 66Gy, with a median of 60Gy. For all of the subjects with T4N1M0 glottic carcinoma, the five-year survival rate was 9.52% (median 14 months). Our results differ from the average data found in literature where a five-year rate of survival was 25-52%, irrespective of the choice of treatment [10,12,16]. This discrepancy can, in part, be accounted for by our limited ra-

dio therapeutic capacities (waiting lists), which extend the waiting period prior to the start of any kind of treatment. As a result, a great number of patients actually start therapy palliatively. At the same time, what must not be overlooked is that the presence of metastases in the neck decreases the survival rate by 40-50% [4]. The following factors play an important role in local control of glottic carcinoma: age, sex, histological structure of the tumor and its edges, stage, size, total therapeutic dose, dose per fraction and duration of the therapeutic treatment. As less significant factors, we can single out smoking, diabetes, alcohol consumption and dietary habits [17-19]. We found no statistically significant difference in age between the patients who underwent postoperative radiation therapy and those who underwent radical radiation therapy. Glottic carcinoma is more frequent among the elderly, and usually occurs after the age of 40. Nevertheless, if it occurs among younger people, it takes a more aggressive form [20,21]. The evidence gathered in our study support this claim, considering the fact that none of our patients under 45 lived longer than 14 months, and the median for these subjects was only 8 months. The subjects aged 45-60 had the best rate of survival, with a survival median of 18 months. There were no significant difference in survival period of the subjects in relation to sex, even though it has often been emphasized that sex is an important prognostic factor and that women usually have a better prognosis both in terms of local control and survival [22,23]. Glottic carcinoma in European countries occurs 7-22 times more frequently among men than women which can also be seen in our study. This can be accounted for by the effects of certain hormonal factors or continued irritation. It is assumed that men who work in industry suffer from chronic laryngitis and throat irritation more often than women and chronic inflammatory changes are usually accompanied by dysplasia and metaplasia of the epithelium [20,24]. No statistically significant interdependence of the rate of survival and the total therapeutic dose of radiation was noted, but the longest period of survival with a median of 21 months was calculated for the subjects with a total therapeutic dose of over 65Gy. In regards to the total therapeutic dose

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for local control and survival, many heated debates can be found in much of the literature on the subject, and there is even a suggestion that with the increase in the total therapeutic dose, the risk of a laryngeal edema also increases (5, 23-28). Even though we did not find that the dose of radiation had a statistically significant influence on the rate of survival of the subjects with T4 glottic carcinoma, we found that the subjects who received doses of 2.51-3Gy per fraction had the best survival rate. Our results support the claims of the so far small number of researchers who have suggested that a greater dose per fraction gives better rates of survival, and that the total therapeutic dose is less important in this respect [12, 14, 28]. We found no statistically significant difference in the survival rate when comparing patients who underwent postoperative radiation therapy and those who underwent radical radiation therapy. The survival median for the patients from both groups was 14 months. Nevertheless, it is important to point out that in our working conditions, it is usually the elderly patients, those with an advanced tumor, and who are generally in poor health and have other concomitant illnesses, who are sent to radical radiotherapy, which is supported by the fact that more than half of the patients who underwent this kind of procedure (60, 6%) were over the age of 60. Our retrospective study has shown that a similar percentage of patients who survive glottic carcinoma can be reached both with postoperative and radical radiation therapy, which has been documented in the Cox regression analysis, in which none of the studied factors, including the type of radiotherapy treatment, was singled out as being significant, nor having an independent influence on the rate of survival of the patients with T4N1Mo glottic carcinoma. That there are no significant differences in the rate of survival of patients with advanced glottic carcinoma who underwent postoperative radiation therapy and those who underwent radical radiation therapy has also been argued by other authors (29, 30-31, 32). Spector at al. 2004. also showed that the type of therapy (surgical, radiation (postoperative or radical)) is not a significant factor which influences the survival rate of the patients with T4 stage glottic carcinoma [9]. 1742

Conclusion The type of radiation therapy (postoperative or radical) is not a significant factor which influences the survival rate of the patients with T4N1MO glottic carcinoma. The optimum radiotherapeutic method for these patients is a total therapeutic dose which is no less than 65Gy and a daily fractionation with a dose of no less than 2.51Gy. Acknowledgement This paper is supported by Ministry of Science, Republic of Serbia, projects III43012, III41018 References 1. Devlin JG, Langer CJ. Combined modality treatment of laryngeal squamous cell carcinoma. Expert Rev Anticancer Ther 2007; 7 (3): 331-350. 2. Hinni ML, Salssa JR, Grant Dg, et al. Transoral laser microsurgery for advanced laryngeal cancer. Arch Otorynol Head Neck Surg 2007; 133 (12): 1198-1204. 3. Ampill FL, Nathan CA, Caldito G, et al. Total laringectomy and postoperative radiotherapy for T4 laryngeal cancer, a 14 year review. Am J Otolaryngol 2004; 25(2):88-93. 4. Spiric P, Spiric S, Stankovic M. Modified technique of total laryngectomy. Acta Medica Medianae 2010; ;49(4):39-42. 5. Jones T, Parsons MD, Willam M, et al. T4 laringeal carcinoma: Radiotherapy alone with surgery reserved for salvage, Int. J Radiation Oncol Biol Phys 1998; 40:549-552. 6. National Comprehesive Cancer Network: Practice Guidelines in Oncology: Head and Neck Cancers. Version 1, 2001. 7. Vokes EE, Kies MS, Haraf DJ, et al. Concomitant chemoradiotherapy as primary therapy for locoregionally advanced head and neck cancer. J Clin Oncol 2000; 8:1652-1661. 8. Iseli TA, Brown CL, Sizeland AM, Berkowitz RG. Palliative surgery for neoplastic unilateral vocal cord paralysis. ANZ J Surg 2001;71(11):672-674.

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9. Spector JG, Sessions DG, Lenox J, et al. Menamegent of stage IV glottic carcinoma. therapeutic outcomes. Laringoscope 2004; 114:1438-1446. 10. Chung CK, Chung Js, Brace Kc, Modlin B. Radiotherapy for cancer of the Larynx: review of a communit hospital experience. Md Med J 1994; 43: 971-975.

20. Raitiola H, Pukander J, Laippala P. Glottic and supraglottic laryngeal carcinoma: differences in epidemiology,clinical characteristics and prognosis. Acta Otolaryngol 1999; 119(7):847-851. 21. Vallicioni JM, Giovani A, Triglia JM, Zanaret M. Laringeal cancer in young adult. Press Med 1999; 78:908-910.

11. International Union against Cancer (UICC): TNM Classification of malignant tumour. 5th ed, 2nd revision. Heidelberg, Germany: Springer, 1992.

22. Bien S, Kaninski R, Zylka S, et al: The evaluation of epidemiology and clinical chaeacteristics of laryngeal carcinoma in Poland. Otolaryngeol Pol 2005; 59:169-181.

12. Hinerman RW, Mendenhall WM, Morrs CG, Amdur RJ, Werning JW, Villaret DB. T3 and T4 true vocal cord squamous carcinomas treated with external beam irradiation : a single institutions 35-year experience. Am J Clin Oncol 2007; 30(2): 181-185.

23. Sas-Korczynska H, Korzeniowski S. Cancer of the larinx in females. Cancer Radiother 2003; 7:380-385.

13. Tian WD, Zeng ZY, Chen FJ, Wu GH, Guo ZM, Zhang O. Treatment and prognosis of stage IIIIV laryngeal squamous cell carcinoma. Ai Zheng 2006; 25 (1): 80-84. 14. Yamazaki H, Nishiyama K, Tanaka E et al. Radiotherapy for early glottic carcinoma (T1N0M0): results of prospective randomized study of radiation fraction size and overall treatment time. Int J of Radiation Oncol Biol Physics 2006; 64:77-82. 15. Schwartz DL, Barker J Jr, Chansky K, Yueh B, Raminfar L, Cha C. Postradiotherapy surveillance practice for head and neck squamous cell carcinoma--too much for too little? Head Neck 2003; 25(12):990-999. 16. Bergqvist M, Brodin O, Linder A, Hesselius P, Blomquist E. Radiation treatment of T1-T4 squamous cell carcinoma of the larinx : a retrospective analysis and long-term follow-up of 135 patients. Anticancer Res 2002; 22(28):1239-1242. 17. Nguyen-Tan PF, Le Quivey JM, Singer M, Terris DJ, Goffinet DR, Fu KK. Treatment results and prognostic factors of advanced T3-T4 laryngeal carcinoma: the University Hospital (SUH)experience. Int J Radiat Oncol Biol Phys 2001; 1:50 (5): 1172-1180. 18. Vlachtsis K, Nikolaou A, Markou K, Fountzilas G, Daniilidis I. Clinical and molecular prognostic factors in operable laryngeal cancer. Eur Arch Otorhinolaryngol 2005; 262(11):890-898. 19. Novakovic B, Jovicic J, Milic N, Jusupovic F, Grujicic M, Djuric D. Nutrition care process in cancer. Healthmed 2010; 4(2): 427-433

24. Ibrulj S, Haveric A, Haveric S, Rahmanovic A, Alendar F. Basal Cell Carcinoma: Cultivation Potential and Results of Chromosome Aberrations Analysis. Healthmed 2010; 4(3): 605-609 25. Van Putten WLJ, Van der Sangen MJC, Hoekstra CJM et al. Dose, fractionation and overall treatment time in radiation therapy – the effects on local control for cancer of the larynx. Radiother Oncol 1994; 30:97-108. 26. Le QT, Fu KK, Kroll S, et al. Influence of fraction size, total dose and overall time on local control of T1-T2 glottic carcinoma. Int. J Radiation Oncol Biol Phys 1997; 39: 115-126. 27. Fu KK, Wodhouse RJ, Quivey JM et all. The significance of laryngeal edema following radiotherapy of carcinoma of the vocal cord. Cancer 1982; 49:655-658. 28. Leon X, Quer M, Orus C, Lopez-Pousa A, Pericay C, Vega M. How much does it cost to preserve a larynx? An economic study. Eur Arch Otorhinolaryngol 2000; 257(2):72-76. 29. Yamazaki H, Nishiyama K, Tanaka E et al : Radiotherapy for early glottic carcinoma (T1N0M0): results of prospective randomized study of radiation fraction size and overall treatment time. Int J of Radiation Oncol, Biol, Physics,2006, 64:77-82. 30. Yu WB, Zeng ZY, Chen FJ, Peng HW: Treatment and prognosis of stage T3 glottic laryngeal cancer – a report of 65 cases. Ai Zheng, 2006, 25(1): 85-87.

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Corresponding author Snezana Jancic, Institute of Pathology, Faculty of Medicine in Kragujevac, Serbia, E-mail: [email protected]

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Peripartal Cardiomyopathy – alwaus diagnostic dilemma: clinical and therapeutic procedures Mirjana Bogavac¹, Olivera Rankov¹, Jadranka Dejanović², Milica Medic-Stojanoska3 ¹ University of Novi Sad, Faculty of Medicine, Clinical Center of Vojvodina - Department of Obstetrics and Gynecology, Novi Sad, AP Vojvodina – Serbia, ² University of Novi Sad, Faculty of Medicine, Institute of Cardiovascular Diseases, Sremska Kamenica, AP Vojvodina – Serbia, ³ University of Novi Sad, Faculty of Medicine, Clinical centre of Vojvodina, Department of endocrinology Novi Sad, AP Vojvodina – Serbia.

Abstract Introduction Peripartal cardiomyopathy is a rare, life-threatening complication previously healthy mother. Incidence of this disease ranges 1 to 3000 to 4000 births [1,2]. Diagnosis is based on the next criteria: weakness of myocard in peripartal period (4 weeks prior to 5 months after delivery), the inability to find out the reasons leading to heart failure, the absence of heart disease up to 4 weeks before delivery, as well as the absence electrocardiographic seen systolic dysfunction of left ventricular before pregnancy [3]. Case report 1 Patient was a few days after discharge complaining of feeling of fatigue, dyspnea and shortness of breath, especially when she lies on her back or at the slightest exertion, dry cough and oedema of the legs and abdomen. Fourteenth day after birth she is admitted as an emergency in the intensive care unit in Institute of cardiovascular disease of Vojvodina with symptoms and signs of global heart failure caused by postpartal dilated cardiomyopathy. She doesn’t have any cardiovascular disease or investigations about cardiovascular system before. Case report 2 Mothers aged 26 years, labored in 38 gestational week (GW). The first 2 days postpartum subjectively and objectively was good. On the third day after cesarean section she reported a sudden dispnea, ortopnea, fatigue and chest pain. Shortly thereafter she reported blood in her sputum. After internal, pulmological and cardiological examinations, and after clinical and labo1744

ratory findings, x-ray lung and echocardiography, doctors confirmed the diagnosis of dilated cardiomyopathy and the third degree of mitral insufficiency. Cardiologist suggest moving patient to the intensive care unit in Institute of cardiovascular disease in Sremska Kamenica. Adequate therapy leads to withdrawal symptoms. Conclusion Peripartal cardiomyopathy although still unknown cause, is a life-threatening complication of childbirth. Aim of our report is to emphasize the importance of early echocardiography in sudden cardiac decompensation in the peripartal period, and to emphasize importance of multi-disciplinary approach to this kind of patients. Key words: peripartal cardiomyopathy, dilated cardiomyopathy, heart failure in the peripartal period Introduction Peripartal cardiomyopathy is a rare, life-threatening complication of a previously healthy mothers, whose incidence is approximately 1 per 3000 to 4000 births [1,2], while in Haiti it is 1 in 300 births [3] Criteria for diagnosis include: heart failure resulting from the last month of pregnancy up to 5 months after delivery, the absence of known cause for the occurrence of heart failure, the absence of heart disease before the last month of pregnancy and noted the absence of electrocardiographic left ventricular systolic dysfunction before pregnancy. [4] The diagnosis is made after echocardiography

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during which the observed disorder left ventricular function during systole. The proposed criteria include ejection fraction (EF)