Number 2April/June 2015

Volume 21, Num

ber 2, pp 81 - 159 April/June 2015

Volume 21

83

Objavljen je drugi broj E-biltena informativno-stručnog elektronskog glasilaUniverzitetskog kliničkog centra u Sarajevu (UKCS)

The second issue of E-newsletter informative and professional electronic mediaUniversity Clinical Center Sarajevo (UCCS)

New ICU - Central Medical Building - Clinical Center University of SarajevoNova Intenzivna njega - Klinički Centar Univerziteta u Sarajevu

84

New Central Medical Building - University Clinical Center SarajevoNovi Centralni Medicinski Blok - Univerzitetski klinički centar u Sarajevu

85

New Central Medical Building - University Clinical Center SarajevoNovi Centralni Medicinski Blok - Univerzitetski klinički centar u Sarajevu

85

Medical Journal www.kcus.ba

Medical Journal www.ukcs.ba

Editor-in-ChiefMirza Dilić

Editorial Board

International Advisory Board

Kenan Arnautović (USA), Raffaele Bugiardini (Italy), Erol Ćetin (Turkey), Maria Dorobantu (Romania), Oktay Ergene (Turkey), Zlatko Fras (Slovenia), Dan Gaita (Romania), Mario Ivanuša (Croatia), Steen Dalby Kristensen (Denmark), Mimoza Lezhe (Albania), Mario Marzilli (Italy), Milica Medić-Stojanovska (Serbia), Davor Miličić (Croatia), Fausto Pinto (Portugal), Mihailo Popovici (Moldova), Marcella Rietschel (Germany), Nadan Rustemović (Croatia), Georges Saade (Lebanon), Petar Seferović (Serbia), Dragan Stanisavljević (Slovenia), Bojan Tršinar (Slovenia), Panos Vardas (Greece), Gordan Vujanić (UK), Jose Zamorano (Spain)

English language revisionSvjetlana Baroševčić

Medical Journal is Indexed in

EBSCO publishing USAwww.ebscohost.com

Member of National Journals Networks of the European Society of Cardiology

PUBLISHERInstitute for Research and Development University Clinical Center Sarajevo71000 Sarajevo, Bolnička 25Bosnia and Herzegovina

For publisher: Rusmir Mesihović, MD, PhDGeneral Manager UCCS

AIMS AND SCOPE

EDITORIAL OFFICEAddress: Medical Journal, Institute for Research and Development, University Clinical Center Sarajevo71000 Sarajevo, Bolnička 25, Bosnia and Herzegovina, Phone: +387 33 668 415; +387 33 297 264. Email: institutnir@bih.net.ba Web. www.ukcs.ba Technical secretariat: svjetlana.barosevcic@kcus.baEditor-in-Chief: mdilic@bih.net.ba

SUBSCRIPTIONAnnual subscription rates: Bosnia and Herzegovina € 50; Europe € 80; and other € 100.

SUPPLEMENTS, REPRINTS AND CORPORATE SALESFor requests from industry and companies regarding supplements, bulk articles reprints, spon-sored subscriptions, translation opportunities for previously published material, and corporate online opportunities, please contact;Email: institutnir@bih.net.ba

PRINTEurografika ZvornikPrinted on acid-free paper.

TECHNICAL EDITOREurografika

CIRCULATION500 copies

Zoran Hadžiahmetović, President,Rusmir Mesihović, Ismet Gavrankapetanović, Damir Aganović, Mehmed Gribajčević, Safet Guska, Almira Hadžović-Džuvo, Bećir Heljić, Sebija Izetbegović, Adnan Kapidžić, Abdulah Kučukalić, Bakir Mehić, Senka Mesihović-Dinarević, Nermina Obralić, Łilijana Oruč, Sead Redžepagić, Svjetlana Radović, Senija Rašić, Sandra Vegar-Zubović, Mustafa Hiroš, Secretary

The Medical Journal is the official quarterly journal of the Institute for Research and Develop-ment of the University Clinical Center Sarajevo and has been published regularly since 1994. It is published in the languages of the people of Bosnia and Herzegovina i.e. Bosnian, Croatian and Serbian as well as in English.

The Medical Journal aims to publish the highest quality materials, both clinical and scientific, on all aspects of clinical medicine. It offers the reader a collection of contemporary, original, peer-re-viewed papers, professional articles, review articles, editorials, along with special articles and case reports.

Copyright: the full text of the articles published in the Medical Journal can be used for education-al and personal aims i.e. references cited upon the authors’ permission. If the basic aim is commercial no parts of the published materials may be used or reproduced without the permis-sion of the publisher. Special permission is available for educational and non-profit educational classroom use. Electronic storage or usage: except as outlined above, no parts of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means without prior written permission from the Publisher.All rights reserved©2015. Institute for Research and Development UCCS.

Notice: The authors, editor and publisher do not accept responsibility for any loss or damage arising from actions or decisions based on information contained in this publication; ultimate responsibility for the treatment of patients and interpretation of published materials lies with the medical practitioner. The opinions expressed are those of the authors and the inclusion in this publication of materials relating to a specific product, method or technique does not amount to an endorsement of its value or quality, or of the claims made by its manufacturer.

Content Medical Journal (2015) Vol. 21, No. 2

Original articlePulsed electromagnetic field and transcutaneous electrical nerve stimulation in the treatment of lumbar pain syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Ksenija Miladinović, Narcisa Vavra-Hadžiahmetović, Aldijana Kadić, Dževad Vrabac

Efficiency of prenatal diagnostics of congenital heart defects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Lejla Imširija, Naima Imširija, Sanjin Deković, Edin Idrizbegović, Mohammad Abou El-Ardat

Comparation of biomarkers in patients with and without histologycally proven prostate cancer and moderately elevated values of prostate specific antigen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Nermina Obralić, Benjamin Kulovac

Anatomic-radiological study of supernumerary kidney arteries: supernumerary kidney artery originating from the renal artery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Elvira Talović, Alma Voljevica

Evaluation of hemodynamic and respiratory stability during general anesthesia with propofol and sevoflurane for age group 1-14 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 Selma Vanis-Vatrenjak, Aida Smajić, Zlatan Zvizdić, Kenan Karavdić

Diagnostic value of nitric oxide for detection of acute appendicitis in children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Sadeta Begić-Kapetanović, Nesina Avdagić, Adnan Hadžimuratović

Influence of anatomic variations of cerebral blood vessels on aneurysms occurrence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 Alma Voljevica, Elvira Talović, Esad Pepić, Amna Pleho-Kapić, Almir Fajkić, Miralem Musić

Size of localized renal cell carcinoma is important prognostic factor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 Mustafa Hiroš, Munira Hasanbegović, Hajrudin Spahović, Mirsad Selimović, Sabina Sadović

Early postoperative cardiac complications of hip fractures in the third age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 Adnana Talić-Tanović, Šejla Šehović, Ismet Gavrankapetanović, Damir Džafić, Zenaida Dedović

Effects of atorvastatin on flow mediated dilatation of brachial artery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 Akif Mlačo, Mirza Dilić, Abel Baltić, Muhamed Spužić

Microsurgical anatomic study of septocutaneous blood vessels of the posterior interosseous artery . . . . . . . . . . . . . 129 Darko Jović, Aleksandar Jakovljević, Jovan Ćulum, Branislava Jakovljević, Ljiljana Latinović, Marinko Domuzin, Darko Lukić

Evaluation of sensitivity, specificity, and predictive values of laboratory findings in children with appendicitis . . . . . . . . 132 Senaida Begović-Karavdić, Kenan Karavdić, Alena Firdus, Haris Tanović

Professional articleInfluence of asthma level control on physical, mental and social status of children suffering from asthma . . . . 135 Selma Dizdar, Verica Mišanović, Danina Tafro, Asmir Jonuzi

Catamnestic follow up of alcoholics with psychiatric comorbidity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 Rasema Okić, Sabina Mađar, Miloš Pokrajac

Review articleNevoid basal cell carcinoma syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 Asja Prohić, Tamara Jovović-Sadiković, Nina Solaković, Sihana Čekić-Čaušević, Una Stojanović

Case reportThe role of ultrasound diagnostics in fetal anomalies: the prune belly syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 Naima Imširija, Lejla Imširija, Senad Murtezić, Edin Idrizbegović, Fatima Gavrankapetanović, Armina Rovčanin

Mediastinal immature teratoma which endangers life of the newborn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 Kenan Karavdić, Suada Heljić, Sabina Terzić, Raho Spahović, Ilijas Pilav, Safet Guska, Nurija Bilalović

Training of left ventricle in infant with transposition of great arteries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 Mirza Halimić, Senka Mesihović-Dinarević, Zijo Begić, Almira Kadić, Edin Omerbašić, Sanko Pandur, Nusreta Hadžimuratović

Instructions to authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156

Uputstva autorima . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158

Medical Journal (2015) Vol. 21, No. 2, 89 - 93 Original article

Pulsed electromagnetic field and transcutaneous electrical nerve stimulation in the treatment of lumbar pain syndrome

Pulsno elektromagnetno polje i transkutana elektronervna stimulacija u tretmanu bola kodlumbalnog bolnog sindroma

Ksenija Miladinović*, Narcisa Vavra-Hadžiahmetović, Aldijana Kadić, Dževad Vrabac

Clinic of Physical Medicine and Rehabilitation, University Clinical Center Sarajevo, Bolnička 25, 71000 Sarajevo, Bosnia and Herzegovina

* Corresponding author

ABSTRACT

Introduction: pulsed electromagnetic field (PEMF) and transcutane-ous electrical nerve stimulation (TENS) are used as physical procedures in the treatment of pain. Objective: to analyze the effects of PEMF and TENS in the treatment of pain in chronic lumbar syndrome as single physical modalities, as well as to analyze the overall effect of both thera-pies. Materials and methods: a prospective, comparative study included 33 patients with exacerbation of chronic lumbosacral syndrome. They underwent 10 outpatient physical treatments at the Clinic of Physical Medicine and Rehabilitation, in the period from January to June 2014. One group of patients (n=16) was treated with TENS, and the oth-er (n=17) with PEMF at the region of lumbosacral spine. Pain and its impact on activities of daily living were evaluated with visual analogue scale (VAS) for pain and with Oswestry questionnaire (OSWI), at the beginning and at the end of the treatment cycle. Results: 48.5% patients were treated with TENS and 51.5% with PEMF. Analysis of the total sample showed a difference in OSWI score of 9.4 ± 4.4 (range 3-19), with insignificantly higher average reduction in the group treated with PEMF, 9.8 ± 3.2 (range 5-13), compared to TENS, 9 ± 5, 5 (range 3-19). Significant reduction in VAS pain was found in the total sample (2.6 ± 1.3), with statistically significantly higher average reduction in the group of patients treated with PEMF (3.1 ± 1.3) compared to patients treated with TENS (2.1 ± 1.1). According to the VAS score women showed statistically significant difference in the total sample (p

INTRODUCTION

Nowadays, lumbar pain syndrome is one of the most common health problems and the most common cause of absence from work. It is estimated that 80% of the population at least once in their life feel pain in the lower, lumbar spine, which recurs in at least 50% of these patients. The problem of “back pain” is most common in the most productive period of life in man, between thirty and fifty years of age, equally often in individuals of both sexes. In majority of them this problem is accompanied with reduced work capacity and need for adequate medical treatment. Lumbar pain syndrome is a set of different etiology symptoms, presented in the form of pain in this region, located at transitional region from lumbar spine to sacral spine, between moving and load-ed the last lumbar vertebra and slow moving sacral bone (1).

Classification of lumbar syndrome by clinical picture:

• Non-specific lumbar syndrome - pain in the lower back and the surrounding paravertebral regions

• Sciatica syndrome - pain extending along the leg, which indicates irritation/compression of nerve roots

• Progressive neurological deficit

Classification of lumbar syndrome by duration of symptoms:

• Acute lumbar pain (12 weeks)

The most common causes of low back pain syndrome are as fol-lows:

• Spondylosis, spondyloarthritis, spondylolisthesis, intervertebral disc herniation with varying degrees of displacement of nucleus pulposus, spinal canal stenosis

• Structural disorders: scoliosis, kyphosis and lordosis• Injuries of bone, muscle and ligament segments of spinal column• Osteoporosis• Rheumatic diseases• Tumors

Lumbar pain syndrome is characterized by pain, increased tone of paravertebral muscles and by limited mobility of the lumbar spine in all directions. The clinical picture occurs suddenly (acute) or grad-ually (chronic) from the beginning, or has recurrent flow. The pain is localized in the lumbosacral area, or through the gluteal region extending towards the rear and lateral side of the thigh to feet and toes. Both constant and pulsed electromagnetic fields (PEMF) have good analgesic effects achieved in different ways. This effect is achieved directly and indirectly. Direct analgesic effects are achieved by reduction of neuronal transmission, increased mobility of calci-um ions, changing the membrane potential, impact on the level of endorphins, nitric oxide, dopamine and prostaglandins. Indirect an-algesic effects of magnetic field are evident in physiological effect in the form of increased basal metabolism in tissues, particularly in

muscle, reducing edema, increased oxygenation, anti-inflammatory effect, regeneration, by influencing the prostaglandins, the cell me-tabolism and its energy level. The magnetic field also has the effect of acupuncture and leads to nerve regeneration. PEMF significantly reduces pain, improves the function of the spine and reduces the tension of the paravertebral muscles. In addition to the previously mentioned analgesic mechanisms, PEMF stimulates the production of opioid peptides, activates mast cells and increases the electrical capacity of muscle fibers. Many studies have confirmed the extremely low risk for ther-apeutic application of PEMF and the absence of side effects in the treatment of pain (2). There is no “gold standard” for the PEMF analgesic parameters. Good effects have been achieved by different intensities and fre-quencies of magnetic field, and due to different etiology of the pain choice of parameters remains empirical and is adjusted to the ther-apeutic response. Transcutaneous electrical nerve stimulation (TENS) has an es-tablished use in the treatment of pain. It can be applied in different frequencies, from small ( 50 Hz). The strength may also vary, from sensory to motor intensity. Sensory intensity is when the patient feels strong, but pleasant stimuli, without motor contraction. High intensity is usually applied for provoking muscle contraction. Sensory intensity is usually combined with a higher fre-quency and less power. Some studies related to the analgesic effects of TENS show that, regardless of the intensity, frequency activates certain central mech-anisms of analgesia. Specifically, the low-frequency TENS activates the μ-opioid receptors in the spinal cord and brain stem, and the high frequency TENS activated δ-opioid receptors in the spinal cord and brain stem (3,4). Subsequent studies have investigated the role of low-frequency and high-frequency TENS on serotonergic, norad-renergic, muscarinic and γ-aminobutyric acid system (GABA) in the analgesic processes (5). Other studies have looked at the effect of the intensity of stimulation TENS on pain relief, as the key parame-ter.

Objective

This research was aimed to analyze and compare the effects of pulsed electromagnetic field and transcutaneous electrical nerve stimulation as single physical modalities in the treatment of pain in chronic lumbar syndrome, as well as to analyze the overall effect of both therapies.

MATERIALS AND METHODS

A prospective, comparative study included 33 patients with ex-acerbation of chronic lumbar syndrome, degenerative and discogen-ic origin, without operative treatment. Leading clinical symptom was pain, with or without spreading to the lower limbs, and which had the consequent impact on the patient’s functionality. The intensity of pain was assessed by subjective visual analogue scale (VAS) for pain, ranging from 0 to 10, where the state without pain was rated with 0, and the most intense pain with 10. Impact of

90 K. Miladinović et al.

TENSPEMFTotalTENSPEMFTotalTENSPEMFTotalTENSPEMFTotal

161733161733161733161733

21.1319.5320.3012.139.76

10.915.006.125.582.883.062.97

5.76010.7308.5904.8849.3517.5061.5491.7281.7141.0882.0451.630

1.4402.6021.4951.2212.2681.307.387.419.298.272.496.284

131010500343200

294242203030799577

.278

.810

3.810

.102

.602

.375

.060

.752

Descriptive

OSWIbefore

OSWIafter

VAS for painbefore

VAS for painafter

t N AS SD SG Min. Max. t P

Table 1 Average value of OSWI and VAS for pain before and after treatment.

TENSPEMFTotal

161733

9.00009.76479.3939

5.465043.211884.39417

1.36626.77900.76493

3.005.003.00

19.0013.0019.00

OSWI difference

N AS SD SG Min. Max.

Table 2 Effects of TENS and PEMF on OSWI score in the total sample.

pain on the functionality of the patient was assessed by Oswestry index (OSWI), where 0 indicated the state of intact functionality, and 50 indicated the state of the most endangered functionality. Pa-tients underwent 10 outpatient physical treatments at the Clinic of Physical Medicine and Rehabilitation, in the period from January to June 2014. One group of patients (n=16) was treated with transcu-taneous electrical nerve stimulation (TENS), and the other (n=17) with pulsed electromagnetic fields (PEMF) at the lumbosacral spine region. At the beginning and at the end of the treatment cycle VAS and OSWI scores were assessed for each patient. The difference of the obtained values showed the effect of the applied physical modality.Treatment of pulsed electromagnetic fields was performed on the Magnetopulsar, Magnetobed 2 Chinesport, Italy. The following pa-rameters were used: frequency 16 Hz, intensity 8 mT, time of ap-plication 15 minutes. Transcutaneous electrical nerve stimulation was performed on TENS 492, ENRAFNONIUS, Netherlands. The following parameters were used: constant shape of pulse, frequency 100 Hz, intensity of 40 mA to 50 mA, time of application 15 min-utes. The used statistical methods included descriptive statistics, and Spearman and Pearson correlation coefficients.

RESULTS

Analysis of the total sample shows that out of 33 patients, 16 or 48.5% were treated with TENS, and 17 or 51.5% with PEMF. χ2=0.971; p=0.270

Analysis by gender shows that in both therapeutic modalities men were more represented, but with no statistically significant differenc-es according to the applied therapy (p> 0. t=0.182; p=0.672). The average age of the total sample was 48.8 ± 9.2 years (range 27-66 years). The average age of patients treated with PEMF was 48.1 ± 10.1 years (range 27-60 years), and patients treated with TENS was 49.5 ± 8.4 years (range 40-66 years). There were no statistically significant differences (p> 0.05) between the two groups in relation to the age of patients.

Before and after the treatment the average OSWI score values were higher in patients treated with TENS, and the average VAS value for pain was higher in patients treated with PEMF.

t=0.244; p=0.625

Pulsed electromagnetic field and transcutaneous electrical nerve stimulation in the treatment of lumbar pain syndrome 91

Figure 1 Distribution of individual physical modalities (n=33).

Figure 2 Gender distribution of patients (n=33).

Figure 3 Average age of patients (n=33).

t=4.986; p=0.033

Average decrease of VAS for pain score in the total sample was 2.6 ± 1.3, ranging from 1-5, which was statistically significant. The average decrease in the group of patients treated with a PEMF was 3.1 ± 1.3, ranging from 2 to 5, and in the group treated with TENS it was 2.1 ± 1.1, ranging from 1 to 4. The difference was statistically significant. In the group of patients treated with TENS, statistically significant difference was noted in correlation of gender and VAS score chang-es, e.g. according to VAS women had worse therapeutic response to pain. In the group of patients treated with PEMF no statistically signifi-cant difference was found in correlation of gender and age regarding the therapy effects.

DISCUSSION

Analgesic effect of pulsed electromagnetic field and transcutane-ous electrical nerve stimulation has been confirmed by many studies. The aim of this study was to analyze and compared the effect of PEMF and TENS as individual physical modalities in chronic lumbar syndrome pain treatment, and to analyze the overall effect of these two therapies. Analysis of the total sample study results in showed that both physical modalities had good effects on pain reduction and improved

functionality of patients. The difference of OSWI score in the total sample was 9.4 ± 4.4, which was statistically significant, ranging from 3 to 19. The average reduction in pain by values of the VAS score difference for pain in the total sample was 2.6 ± 1.3 (ranging from 1 to 5), which was also statistically significant. The effects of the PEMF were also evaluated in this study, with VAS for pain and OSWI questionnaire, which score values were compared before and after 10 applications of pulsed electromag-netic field. Differences in values pointed to significant pain reduction and significant improvement of patient’s functionality. The average reduction of pain by VAS in the group of patients treated with PEMF was 3.1 ± 1.3. The average decrease of OSWI score in the group of patients treated with PEMF was 9.8 ± 3.2, ranging from 5 to 13, which was statistically significant improvement. Study of Omar et al. analyzed the effects of PEMF in 20 patients with low back pain of discogenic etiology (2). The effects of treat-ment were evaluated after 10 applications by visual analogue scale for pain, by somatosensory evoked potentials (SSEP) for selected dermatome, and by modified Oswestry questionnaire, which values were compared before and after the therapy. The study reported that PEMF was an effective method for conservative treatment of lumbar radiculopathy caused by prolapsed intervertebral discus, and that record of improvements of SSEP parameters made it effective in reducing compression of spinal nerve root. Pulsed electromagnetic field of smaller and larger intensity has analgesic effect. Effects of pulsed electromagnetic field of higher intensity in chronic lumbar pain were analyzed by Lee et al. and Lo et al. (6,7). Frequencies were 5:10 Hz, intensity from 1.3 to 2.1 T, time of appli-cation 15 minutes. After 10 applications of applied PEMF, there was improvement in the functionality of patients; the pain was reduced in over 60% of patients, compared to the placebo group in which pain reduction was registered in 6% of patients. PEMF of lower intensity was applied in this study, with the fol-lowing parameters: frequency 10 Hz, intensity 8 mT, time of applica-tion 15 minutes. Based on the results, there was a significant analgesic effect both according to VAS for pain and OSWI. The effects of TENS were also evaluated by VAS for pain and by OSWI questionnaire, which values were compared before and after 10 applications of TENS. Differences in values pointed to significant reduction of pain and improved functionality of patients. The aver-age reduction of pain by VAS in the group of patients treated with TENS was 9.0 ± 5.4, ranging from 3 to 19, which was statistically significant improvement. Average reduction of the OSWI score in this group was 9.0 ± 5.4, ranging from 3 to 19, which was statistically significant improvement. Meta-analysis of Johnson and Martinson merged and analyzed 32 studies examining the effects of high, low and variable frequency TENS, for chronic musculoskeletal pain (8). The study included 1227 patients with lumbar syndrome caused by herniated intervertebral discus, spondylosis, osteoarthritis, and myofascial pain. The results showed a significant decline in pain compared with placebo. Many studies have underlined the importance of the used pa-rameters for analgesic effect of TENS, namely different intensities, frequencies and pulsation. Chen et al. reported an experimental study of the analgesic ef-fects of pulsed type TENS (9). Their review included thirteen stud-

92 K. Miladinović et al.

TENSPEMFTotal

161733

2.12503.05882.6061

1.087811.297621.27327

.27195

.31472

.22165

1.002.001.00

4.005.005.00

VAS difference

N AS SD SG Min. Max.

Table 3 Effects of TENS and PEMF on VAS for pain score in the total sample.

Gender

Age

RhoPNRhoPN

.382

.14416

.128

.63516

.754**.001

16.139.607

16

TENS Correlations

OSWI diff VAS diff

**. Correlation significance level p

ies, and only three of them pointed to the difference in the analgesic effect in pulsed type TENS. The authors concluded that their review did not support the belief that the pulsed type TENS is a key deter-minant for good analgesic outcome. This study used TENS of high frequency and intensity, constant impulses: frequency 100 Hz, inten-sity of 40 mA to 50 mA, time of application 15 minutes. Comparison of the individual effects of PEMF and TENS showed significantly better effect of PEMF in the reduction of pain according to VAS. The average decrease in the group of patients treated with PEMF was 3.1 ± 1.3, as compared to the group treated with TENS, which was 2.1 ± 1.1. Post therapeutic changes of OSWI score reflecting the improved functionality of patients showed no significant difference between these two physical modalities. Slightly higher average reduction was noted in patients treated with PEMF, which was 9.8 ± 3.2 points, ranging from 5-13, as compared to patients treated with TENS with average reduction of 9 ± 5.5, ranging from 3-19 points. No studies were found comparing the analgesic effects of PEMF and TENS.In the group of patients treated with TENS statistically significant dif-ference was noted in correlation of sex and changes of VAS for pain score, e.g. women had worse therapeutic response according to VAS for pain, while in the group of patients treated with PEMF there was no statistically significant correlation of sex and age to the effects of therapy.

CONCLUSION

Pulsed electromagnetic field and transcutaneous electrical nerve stimulation showed significant analgesic effects in patients with lum-bar pain syndrome. Pulsed electromagnetic field showed more sig-nificant reduction in pain according to VAS for pain compared to transcutaneous electrical nerve stimulation, while OSWI showed no difference in analgesic effect between the two individual physical modalities.

Conflict of interest: none declared.

REFERENCES

1. Mačak A, Čustović A, Mujezinović A. Vodič za prevenciju i tretman lumbalnog

bolnog sindroma. Ministarstvo zdravstva Kantona Sarajevo i Institut za naučnois-

traživački rad i razvoj Kliničkog centra Univerziteta u Sarajevu. 2009. ISBN 978-

9958-631-57-3

2. Omar AS, Awadalla MA, El-Latif MA. Evaluation of pulsed electromagnetic field

therapy in the management of patients with discogenic lumbar radiculopathy. Int J

Rheum Dis. 2012;15(5): e101-8.

3. Sluka KA, Deacon M, Stibal A, Strissel S, Terpstra A. Spinal blockade of opioid

receptors prevents the analgesia produced by TENS in arthritic rats. J Pharmacol

Exp Ther. 1999;289(2):840-6.

4. Sluka KA, Chandran P. Enhanced reduction in hyperalgesia by combined administra-

tion of clonidine and TENS. Pain. 2002;100:183-190.

5. DeSantana JM, Walsh DM, Vance C, Rakel BA, Sluka KA Effectiveness of Transcu-

taneous Electrical Nerve Stimulation for Treatment of Hyperalgesia and Pain. Curr

Rheumatol Rep. 2008;10(6):492-9.

6. Lee PB, Kim YC, Lim YJ, Lee CJ, Choi SS, Park SH et al. Efficacy of pulsed electro-

magnetic therapy for chronic lower back pain: a randomized, double-blind, place-

bo-controlled study. J Int Med Res. 2006;34(2):160-7.

7. Yew L. Lo, Stephanie Fook-Chong, Antonio P. Huerto, Jane M. George. A Random-

ized, Placebo-Controlled Trial of Repetitive Spinal Magnetic Stimulation in Lumbo-

sacral Spondylotic Pain. Pain Medicine. 2011;12(7):1041–1045.

8. Johnson M, Martinson M. Efficacy of electrical nerve stimulation for chronic muscu-

loskeletal pain: a meta-analysis of randomized controlled trials. Pain. 2007; 130:157-

165.

9. Chen C, Tabasam G, Johnson MI. Does the pulse frequency of transcutaneous

electrical nerve stimulation (TENS) influence hypoalgesia? A systematic review of

studies using experimental pain and healthy human participants. Physiotherapy.

2008;94:11-20.

Reprint requests and correspondence:Ksenija Miladinović, MD, PhDClinic of Physical Medicine and RehabilitationUniversity Clinical Center SarajevoBolnička 25, 71000 SarajevoBosnia and HerzegovinaEmail: k.miladinovic@yahoo.com

Pulsed electromagnetic field and transcutaneous electrical nerve stimulation in the treatment of lumbar pain syndrome 93

Efficiency of prenatal diagnostics of congenital heart defects

Efikasnost prenatalne dijagnostike kongenitalnih srčanih mana

Lejla Imširija*, Naima Imširija, Sanjin Deković, Edin Idrizbegović, Mohammad Abou El-Ardat

Clinic of Gynecology and Obstetrics, University Clinical Center Sarajevo, Patriotske lige 81, 71000 Sarajevo, Bosnia and Herzegovina

*Corresponding author

ABSTRACT

The incidence of congenital heart defects is approximately 6-8%, relating to liveborn babies. Some pregnancies are terminat-ed following the establishment of defects incompatible with life, and some pregnancies end in miscarriages. Therefore, this number is even higher. This is a retrospective study conducted over the period of 7 years at the Clinic of Obstetrics and Gynecology of the University Clinical Center Sarajevo (UCCS). We concluded that the significant number of congenital heart defects was detected after birth.

Key words: congenital heart defects, fetus, ultrasound diagnostics

SAŽETAK

Incidenca kongenitalnih srčanih mana iznosi oko 6 - 8%, ali se to odnosi na rođenu djecu. Neke trudnoće se prekinu na-kon utvrđivanja mana nespojivih sa životom, a neke trudnoće se završe spontanim pobačajem, pa je ovaj broj i veći. U ovom radu smo napravili retrospektivno istraživanje u periodu od 7 godina na Ginekološko-akušerskoj klinici, UKCS. Konstatovali smo da se najveći broj kongenitalnih srčanih mana otkrio nakon porođaja.

Ključne riječi: kongenitalne srčane mane, fetus, ultrazvučna di-jagnostika

INTRODUCTION

Technological improvement of the ultrasound machines has enabled more detailed presentation of the fetal heart and accord-ingly diagnostic of fetal heart malformations (1). Congenital heart diseases are important factor of neonatal morbidity and mortality (2). On the one hand, antenatal diagnostics of fetal heart anom-alies should enable that such fetuses are born at places providing maximal assistance during antenatal and postnatal life (3-5). On the other hand, timely detection of life incompatible fetus heart defects or those with poor prognosis enables termination of such pregnancy. It is considered that the incidence of congenital heart defects is 6-8% (6-8). However, this data refers to newborns and thus includes only fetuses brought up to delivery time (9). If we take into account that part of fetuses with congenital heart de-fect is miscarried without even being detected for this disease, we become aware that the frequency of congenital heart defects is certainly higher in respect to number of conceived babies (10). The aim of this study was to determine the incidence of the congenital heart defects at the Clinic of Obstetrics and to show the efficiency of the prenatal ultrasound diagnostic of heart anom-aly.

MATERIALS AND METHODS

A clinic-descriptive and retrospective-epidemiological study was conducted in the period from 2005 to 2012. The study included all cases with congenital heart defects diagnosed in the antenatal or postnatal period immediately after birth. The study was carried out at the Clinic of Obstetrics of the University Clinical Center Sarajevo. We used data of the ultrasound diagnostic unit, delivery room pro-tocols, and reports of the neonatologist-pediatrician attending deliv-ery. The date is sorted and entered into the statistic program SPSS ver. 20.0 and the statistic processing was done with the application of Chi square and ANOVA tests. The level of significance was p

Efficiency of prenatal diagnostics of congenital heart defects 95

Out of total number of diagnosed congenital heart defects (n=7), 22.9% (n=16) was diagnosed in the prenatal period, whereas 77.1% (n=54) was diagnosed in the postnatal period. Statistically sig-nificant difference in the number of cases diagnosed in the prenatal period shows that postnatal diagnostics took more significant place, χ2=20.629; df=1; p=0.05. Table 3 shows frequency of certain congenital heart defects in the examined period. The largest number of cases related to VCC (40%), followed by ASD (12.9%), VSD/ASD (11.4%), and 10% of cases related to VSD and foramen ovale apertum respectively, whereas the frequency of other defects was under 4.3%. The Chi square test did not show any statistically significant dif-ferences in the period of certain congenital heart defect diagnosis; an equal percentage was diagnosed in prenatal and postnatal period, χ2=0.877; df=1; p=0.349.

The ANOVA test showed that there was no statistically significant difference between the body weight and the length of gestation pe-riod in respect to type of congenital heart defect, and the newborns were mainly delivered on time with the appropriate body weight.

DISCUSSION

Given that majority of practitioners of the Clinic of Obstetrics of the UCCS, involved in the obstetrics ultrasound, have not been adequately trained for thorough examination of fetal heart, and given that the echographic examination of fetal heart requires more time then available during the daily routine work, detection of a fetus with congenital heart defect requires an organized intellectual approach (6). In the period from 2005 to 2012, 70 babies with congenital heart defects were born at the Clinic of Obstetrics. The majority of de-fects were recognized in postnatal period, whereas in only 22.9% (n=16) of cases prenatal ultrasound diagnostics suspected certain heart anomalies or set consequently confirmed diagnosis. Out of the total number of newborns with heart defects 40 % were diagnosed with VCC, the most frequent defect. All newborns diagnosed with congenital heart defects were generally born with appropriate body weight and on time. This fact shows that these heart defects are to

PERCENT

2005

2006

2007

2008

2009

2010

2011

2012

Total

7

9

7

7

8

16

12

4

70

Frequency

10.0

12.9

10.0

10.0

11.4

22.9

17.1

5.7

100.0

Percent

10.0

22.9

32.9

42.9

54.3

77.1

94.3

100.0

Cumulative

10.0

12.9

10.0

10.0

11.4

22.9

17.1

5.7

100.0

Valid percent

χ2=10.914; df=7; p=0.142

Table 1 Frequency of diagnosed congenital heart defects in the examined period.

CO

NG

ENIT

AL

HEA

RT

DEF

ECT

S

ASD

VSD

VSD/ASD

VCC

IAS

Ductus arteriosus persistents

Foramen ovale apertum

Tetralogy of Fallot

Ectopia cordis

Hypoplastic heart syndrome

Total

9

7

8

28

2

3

7

2

1

3

70

Frequency

12.9

10.0

11.4

40.0

2.9

4.3

10.0

2.9

1.4

4.3

100.0

Percent

12.9

22.9

34.3

34.3

77.1

81.4

91.4

94.3

95.7

100.0

Cumulative

12.9

10.0

11.4

40.0

2.9

4.3

10.0

2.9

1.4

4.3

100.0

Valid percent

Table 3 Frequency of certain types of congenital heart defects.

BO

DY

WEI

GT

ASD

VSD

VSD/ASD

VCC

IAS

Ductus arteriosus persistens

Foramen ovale apertum

Tetralogy of Fallot

Ectopia cordis

Hypoplastic heart syndrome

N

8

6

7

27

2

3

7

2

1

3

Mean

3281.25

2800.00

3382.85

2932.96

3900.00

3416.66

3050.00

3200.00

2500.00

3263.33

SD

720.08

920.32

809.87

821.98

212.13

1229.15

553.02

1131.37

295.01

Std.error

254.58

375-72

306.10

158.19

150.00

709.65

209.02

800.00

170.32

Minimum

2200.00

1750.00

2350.00

300.00

3750.00

2000.00

2150.00

2400.00

2500.00

3050.00

Maximum

4550.00

3950.00

4800.00

4100.00

4050.00

4200.00

3750.00

4000.00

2500.00

3600.00

F=0.726; p=0.683

GES

TA

TIO

N W

EEK

ASD

VSD

VSD/ASD

VCC

IAS

Ductus arteriosus persistens

Foramen ovale apertum

Tetralogy of Fallot

Ectopia cordis

Hypoplastic heart syndrome

9

7

7

26

2

3

7

1

1

3

38.22

36.85

38.28

37.61

38.00

38.00

38.42

38.00

39.00

37.66

0.66

2.85

1.49

2.15

0.00

1.73

1.27

1.52

0.22

1.07

0.56

0.42

0.00

1.00

0.48

0.88

37.00

32.00

35.00

32.00

38.00

36.00

36.00

38.00

39.00

36.00

39.00

39.00

39.00

39.00

38.00

39.00

40.00

38.00

39.00

39.00

F=0.455; p=0.898

Table 5 Mean body weight and length of gestation period in newborns with congenital heart defects.

CO

NG

ENIT

AL

HEA

RT

DEF

ECT

S

ASD

VSD

VSD/ASD

VCC

IAS

Ductus arteriosus persistents

Foramen ovale apertum

Tetralogy of Fallot

Ectopia cordis

Hypoplastic heart syndrome

Total

TotalPrenatalPostnatal

Diagnostics

No.

%

No.

%

No.

%

No.

%

No.

%

No.

%

No.

%

No.

%

No.

%

No.

%

No.

%

8

14.8%

6

11.1%

6

11.1%

20

37.0%

2

3.7%

2

3.7%

6

11.1%

2

3.7%

1

1.9%

1

1.9%

54

100.0%

8

14.8%

6

11.1%

6

11.1%

20

37.0%

2

3.7%

2

3.7%

6

11.1%

2

3.7%

1

1.9%

1

1.9%

54

100.0%

8

14.8%

6

11.1%

6

11.1%

20

37.0%

2

3.7%

2

3.7%

6

11.1%

2

3.7%

1

1.9%

1

1.9%

54

100.0%

χ2=0.877; df=1; p=0.349

Table 4 Time of certain congenital heart defect diagnosis.

CO

NG

ENIT

AL

HEA

RT

DEF

ECT

S

ASD

VSD

VSD/ASD

VCC

IAS

Ductus arteriosus persistents

Foramen ovale apertum

Tetralogy of Fallot

Ectopia cordis

Hypoplastic heart syndrome

Total

TotalPrenatalPostnatal

Diagnostics

No.

%

No.

%

No.

%

No.

%

No.

%

No.

%

No.

%

No.

%

No.

%

No.

%

No.

%

8

14.8%

6

11.1%

6

11.1%

20

37.0%

2

3.7%

2

3.7%

6

11.1%

2

3.7%

1

1.9%

1

1.9%

54

100.0%

8

14.8%

6

11.1%

6

11.1%

20

37.0%

2

3.7%

2

3.7%

6

11.1%

2

3.7%

1

1.9%

1

1.9%

54

100.0%

8

14.8%

6

11.1%

6

11.1%

20

37.0%

2

3.7%

2

3.7%

6

11.1%

2

3.7%

1

1.9%

1

1.9%

54

100.0%

χ2=0.877; df=1; p=0.349

Diagnostics

54

16

70

Frequency

77.1

22.9

100.00

Percent

77.1

100.00

Cumulative percent

77.1

22.9

100.00

Valid percent

χ2=10.914; df=7; p=0.142

Postnatal

Prenatal

Total

Table 2 Relation between prenatal and postnatal diagnos-tics of congenital heart defects.

certain extent life compatible, and they require quick intervention in setting up diagnosis, treatment and adequate approach to a newborn as a patient. This will result in lower rate of morbidity and mortality, disability and in higher rate of recovery.

CONCLUSION

Fetal echocardiography enables prenatal detection of majority of congenital heart defects with a high rate of reliability. Doppler fetal echocardiography has increasingly entering the sphere of dy-namic fetal heart evaluation. Unfortunately, at the Clinic of Obstet-rics the term fetus, as cardiac patient, has so far been referred to as a fetus with congenital heart defect or velocity and heart rhythm disorder.

Conflict of interest: none declared.

REFERENCES

1. Hamar BD, Dziura J, Friedman A, Kleinman CS, Copel JA. Trends in fetal echocar-

diography and implications for clinical practice: 1985 to 2003. J Ultrasound Med.

2006;25(2):197-202.

2. Hyett J, Moscoso G, Nicolaides K. Abnormalities of the heart and great ar-

teries in the first trimester chromosomally abnormal fetuses. Am J Med Genet.

1997;69(2):207-16.

3. Li M, Wang W, Yang X, Yan Y, Wu Q. Evaluation of referral indications for fetal

echocardiography in Beijing. J Ultrasound Med. 2008;27(9):1291-6.

4. Berg KA, Clark EB, Astemborski JA, Bonghman JA. Detection of cardiovascular

malformations by echocardiography: an indication for cytogenetic evaluation. Am J

Obstet Gynecol. 1998;159(2):477-81.

5. De Luca I, Ianniruberto A, Colonna L. Aspetti ecografici del cuore fetale. G Ital

Cariol. 1978;8(7):776-80.

6. Nelson TR, Sklansky MS, Preotorius DH. Prikaz fetalnog srca trodimenzionalnom

tehnologijom. U: Merz E (ur.) 3D ultrazvuk u ginekologiji i porodništvu. Naprijed:

Zagreb, 1999;125-34.

7. Sklansky M. Fetal echocardiography: can early imaging identify fetuses at risk of

congenital heart disease? Nat Clin Pract Cardiovasc Med. 2005;2(1):12-3.

8. Rottem S, Bronstein M, Thaler JM. First trimester transvaginal sonographic diagnosis

of fetal anomalies. Lancet. 1989;1(8635):444-5.

9. Volpe P, Stanziano A, Volpe G, Gentile M. Early transvaginal echocardiography. In:

Kurjak A, Arenas JB, (eds.). Transvaginal sonography. New Delhi: Jaypee. 2005;96-

104.

10. Marques Carvalho, Mendes MC, Poli Neto OB, Berezowski AT. First trimester

echocardiography. Gynecol Obstet Invest. 2008;65(3):162-8.

Reprint requests and correspondence:Lejla Imširija, MD, PhDClinic of Gynecology and ObstetricsUniversity Clinical Center SarajevoPatriotske lige 81, 71000 SarajevoBosnia and HerzegovinaPhone: + 387 61 190 622Email: lejlaimsirija@hotmail.com

96 L. Imširija et al.

Comparation of biomarkers in patients with and without histologycally proven prostate cancer and moderately elevated values of prostate specific antigen

Komparacija biomarkera kod pacijenata sa i bezhistološki dokazanog karcinoma prostate i umjereno povišenim vrijednostima prostata specifičnog antigena

Nermina Obralić1*, Benjamin Kulovac2

1Oncology Clinic, University Clinical Center Sarajevo, Bolnička 25, 71000 Sarajevo, Bosnia and Herzegovina; 2Urology Clinic, University Clinical Center Sarajevo,

Bolnička 25, 71000 Sarajevo, Bosnia and Herzegovina

*Corresponding author

ABSTRACT

The aim of the study was to determine if prostate specific anti-gen (PSA) related parameters may help to predict prostate carcino-ma in men without final digital rectal examination findings and with moderately elevated tumor marker values. The study included 365 men with initial PSA level 2-10 ng/ml, who following the clinical indi-cations underwent ultrasound–guided prostate biopsy. Out of that number 85 were diagnosed with prostate carcinoma. We determi-nate and compared the means and variances of total and free PSA, their ratio and density between the groups of patients, ascertained performance characteristics of these tests, and defined their cut-off points to detect prostate cancer. Mean value of total PSA was higher in patients with prostate carcinoma as compared to patients without prostate carcinoma (6.976 ng/ml vs. 6.176 ng/ml P=0.0054), while val-ues of free PSA were significantly lower (0.912 vs. 1.137 P=0.0081), as well as ratio of free/total PSA (0.13 vs. 0.18; P

INTRODUCTION

Digital rectal examination (DRE), transrectal ultrasound (TRUS) and prostate specific antigen (PSA) have been used in ear-ly diagnostic of prostate carcinoma (1,2,3). Available diagnostic procedures for prostate cancer are not ideal with a result of ei-ther “cancer present” or “cancer not present”. They do not have dichotomous (positive or negative) but continuous result (4-16). Tests based on biologic markers must be assigned to a cut-off level to produce likelihood ratios of presence or absence of disease. Formal evaluations of the operating characteristics of the test are useful in clinical interpretation as its characteristics. The aim of the study was to examine whether PSA related pa-rameters may help to predict prostate carcinoma in men without definitive DRE and TRUS findings and with initial PSA values be-tween 2 and 10 ng/ml. For this purpose we:

• Compared mean values of total, free and ratio free/total PSA and PSAD in men with and without prostate carcinoma

• Ascertained performance characteristics of quoted biomark-er tests

• Defined useful biomarkers and cut-off points to detect pros-tate cancer in patients with serum PSA levels of 2-10 ng/mL

MATERIALS AND METHODS

We studied patients after their first needle biopsy performed based on clinical indications, not included in the screening program. We selected only men between 50 and 70 years of age, with initial PSA level between 2-10 ng/ml, without definitive DRE and/or TRUS tumor of prostate findings. DRE was performed initially, followed by TRUS (Siemens Sono-line G 40). Three days after serum fPSA and tPSA levels were mea-sured, their ratio (R fPSA/tPSA) and PSAD were calculated. Patient with suspicious DRE findings and/or elevated PSA level underwent ultrasound –guided biopsy (“biopsy gun” produced by Bard with nee-dle of 18 Gauge). Number of samples depended on prostate volume and age of patients according to Vienna nomogram (17,18). The to-tal PSA was measured by Chemoluminiscent Microparticle Immuno-assay (CMIA) for the quantitative determination of total PSA (both free and PSA complexes to alpha-1-antichymotrypsin) in human se-rum - the ARCHITECT Total PSA assay. Free PSA was determined by ARCHITECT Free PSA assay Chemoluminiscent Microparticle Immunoassay (CMIA) for the quantitative determination of free PSA in human serum. Based on the pathohistological diagnosis after first needle biopsy the selected patients were divided in 2 groups for analysis: 85 pa-tients with prostate carcinoma - PCa (Group 1), and 280 patients without prostate cancer or premalignant lesions of prostate (high grade prostate intraepithelial neoplasia- HPIN or atypical small acinar proliferation -ASAP) (Group 2). Group 2 consisted of 183 patients diagnosed with BPH, chronic prostatitis (43 patients), prostate atro-phy (23 patients) or normal prostate (31 patients). Mean values of prostate volume, total PSA, free PSA, ratio free/total PSA and PSA density were calculated and compared between the two groups. We evaluated accuracy of PSA related parameters to discriminate patients with carcinoma from those without carcino-

ma using Receiver Operating Characteristic (ROC) curve analysis. We also used the ROC curves to compare the diagnostic perfor-mance of biomarkers. For statistical evaluation continuous variables were transformed into logarithmic scale, because they were more symmetric. Equality of Variances was tested by LOG ANOVA Test on log-transformed data. Student-Newman-Keuls test was used for pair wise compari-sons. The ROC curve analysis was used to compare the diagnostic performance of the tests evaluated in the study. Statistical analyses were performed using software MedCalc for Windows, version 9.5.1.0 (MedCalc Software, Mairiakerke, Belgium).

RESULTS

The investigation was conducted on 365 patients who under-went prostate biopsy, aged 50 to 70 years. Out of them 85 had histologically proven prostate cancer (23.3%), while in other 280 findings related to prostate cancer were negative. Mean values of age, volume of prostate, and PSA related parameters in men with and without prostate carcinoma and comparisons of these parame-ters between the two groups are presented in Table 1.

Performance of PSA, free PSA, ratio free PSA/PSA and PSA density to discriminate patients with and without obtained prostate carcinoma according to ROC curves are presented in Figure 1, and values of PSA, free PSA, ratio free PSA/PSA and PSA density cor-responding to highest sensitivity, specificity and accuracy in ROC curves analyses are presented in Table 2.

98 N. Obralić et al.

PARAMETER Average values in men

diagnosed withprostate carcinoma

Average values in mennot diagnosed withprostate carcinoma

T-test (assuming equal variances)Test statistic t

Two-tailedprobability

Age

Total PSAng/ml

Free PSAng/ml

Ratio free/totalPSA

Prostate volume ml

PSA densityng/ml

65.129(SD 4,798; range 52-70)

6.976(SD 2.017; range 2,33-10)

0.912(SD 0.459 ; range 0.03-2.67)

0.133(SD 0.053; range 0.007-0.3)

44.412(SD 13.491; range 25-100)

0.162(SD 0.076; range 0.02-0.6)

64.636(SD 5.294; range 50-70)

6.176(SD 2.389; range 0.57-10)

1.137(SD 0.734; range 0.04-4.8)

0.18(SD 0.092; range 0.008-0.9)

48.493(SD 17.872; range 25-120)

0.157(SD 0.154; range 0.01-2)

0.769

-2.801

2.661

4.468

1.943

-0.292

P=0.44

P=0.0054

P=0.0081

P

Comparation of biomarkers in patients with and without histologycally proven prostate cancer and moderately elevated values of prostate specific antigen 99

DISCUSSION

Indication for prostate biopsy is based on suspicious DRE find-ings (with optional TRUS) and/or elevated PSA values. The cancer is found by biopsy in almost every fifth patient. It might be recognized that the biopsy in majority of men was, in retrospect, unnecessary. This especially relates to PSA level of 4-10 ng/ml , which is called “diagnostic gray zone”, as it can be frequently seen in men with BPH, inflammatory and degenerative conditions of prostate (19, 20, 21). Accurate estimate of the mean and variance of PSA values for men with or without prostate cancer may provide PSA thresholds for bi-opsy that are more specific.

We selected 365 patients who had biopsy of prostate due to clinical indications, aged 50-70, with initial PSA values in range of 2-10 ng/ml, and without palpatory reliable indicators of prostate cancer. In 85 patients with these characteristics cancer was diagnosed during the first biopsy, while others had normal pathohistological findings or were diagnosed with BPH, chronic prostatitis or prostate atrophy. There is no significant difference in age, prostate volume and PSA density in man with and without diagnosed cancer. Average PSA value in cancer group was 6.976 ng/ml, and 6.176 ng/ml in those without cancer, and the difference between these values is significant on the level of P = 0.0054. FPSA values in this study were significantly lower in group of patients with cancer (0.912 vs. 1.137). In other studies which compared patients findings with and with-out proven prostate cancer statistically significant differences were recorded for total PSA, even though the differences depended on participants’ age, prostate volume and established PSA values range (15, 16, 22, 23, 24, 25). Unlike our patients there are reports that PSA density differed significantly between patients with prostate carcinoma and patients with benign prostate hyperplasia in all analyzed ranges of total PSA, especially within the PSA range of 2-4 ng/ml (23). ROC curve for total PSA demonstrates significant discrimination between groups of men with and without cancer on level of signifi-cance of P=0.008, AUC 0.596. The value corresponding to highest accuracy was 5.29 ng/ml with sensitivity of 81.2, and specificity of 36,8. In other studies the level of PSA significantly separated patients with prostate cancer from those with non malignant conditions with AUC in ROC curves of 0.56 to 0.68 (16, 19). ROC curve for free PSA demonstrates significant discrimination between the groups of participants with and without cancer on level of significance of P=0.0226, AUC 0.578 The value corresponding to highest accuracy was 0.1 (sensitivity 83.33, specificity 36.79).

CONCLUSION

Values of ratio free/total PSA, free PSA and total PSA are signifi-cantly different between patients with and without prostate cancer in so called grey diagnostic zone of PSA to 10 ng/ml. Cut-off points that with highest accuracy discriminate patients with or without pros-tate carcinoma are: total PSA 5.29; free PSA 1.3; ratio free/total PSA 0.18. These specific thresholds of PSA related parameters for men with or without cancer may provide better strategy in determining which patients should undergo repeated biopsy.

Conflict of interest: none declared.

PSAReceiver operating

characteristicsanalysis

Free PSA Ratiofree/total PSAPSA

density

0.596

0.0362

0.544 to 0.647

2.652

0.0080

0.578

0.0344

0.526 to 0.630

2.280

0.0226

0.677

0.0309

0.626 to 0.725

5.733

0.0001

0.570

0.0364

0.517 to 0.622

1.924

0.0543

Area under theROC curve (AUC)

Standard error

95% Confidenceinterval

z statistic

Significance levelP (Area=0.5)

Table 2 Values of PSA, free PSA, ratio free PSA/PSA and PSA density corresponding to highest sensitivity, specific-ity and accuracy in ROC curves analyses.

TEST Criterion Sensitivity 95% CI Specificity 95% CI +LR -LR +PV -PV

PSA

Free PSA

PSAD

Ratio fPSA/tPSA

>2.3

>9.9

>5.29 *

REFERENCES

1. Eric A. Klein, Elizabeth A. Platz, Jan Thompson, Gras JA, Kay RA, Ohara JF. Prostate

carcinoma; 2854-2873 In: Walsh PC, Retik AB, Vaughan EDJr, Wein AJ. Campbell’s

Urology (9.ed.). W.B. Saunders Company, 2007. Philadelphia.

2. Galić J, Karner I, Čenan LJ, Tucak A. Comparison of digital rectal examination

and prostate specific antigen in early detection of prostate cancer. Coll Antropol.

2003;27(Suppl.1):61-6.

3. Klein EA, Platz EA, Thompson J, Gras JA, Kay RA, Ohara JF. Campbell’s Urology.

Philadelphia: W.B. Saunders Company. 2007;2854-2873.

4. Catalona WJ, Richie JP, Ahmann FR, Hudson MA, Scardino PT, Flanigan RC, et al.

Comparison of digital rectal examination and serum prostate specific antigen in the

early detection of prostate cancer: Results of a multicenter clinical trial of 6,630

men. J Urol. 1994;151(5):1283-90.

5. Ellis WJ, Chetner MP, Preston SD, Brawer MK. Diagnosis of prostatic carcinoma:

the yield of serum prostate specific antigen, digital rectal examination and transrectal

ultrasonography. J Urol. 1994;52:1520-5.

6. Sedelaar JP, Vijverberg PL, De Reijke TM, de la Rosette JJ, Kil PJ, Braeckman JG,

Hendrikx AJ. Transrectal ultrasound in diagnosis of prostate cancer: State of the art

and perspectives. Eur Urol. 2001;40(3):275-284.

7. Bahn D. Color Doppler and Tissue Harmonic Ultrasound in the Early Detection and

Staging of Prostate Cancer. PCRI Insights. 2002; 5(2): 1-10.

8. Kirby R, Abbou C, Akdas A, et al. Diagnosis and staging of prostate cancer. Proceed-

ings from 1st International Consultation on prostate cancer. SCI Ltd.1997;211-26.

9. Hudson MA, Bahnson RR, Catalona WJ. Clinical use of prostate specific antigen in

patients with prostate cancer. J Urol. 1999;142:1011-117.

10. Karazanshvili G, Abrahamsson PA. Prostate specific antigen and human glandular

kallikrein 2 in early detection of prostate cancer. J Urol. 2003;169: 445-457.

11. Ian M. Thompson AM, Donna P. Prostate-specific antigen in the early detection of

prostate cancer. CMAJ. 2007;176(13):1853-1858.

12. Kinjo M, Ohta M, Miura I, Horie S, Nutahara K, Higashihara E. Predictors of prostate

cancer on repeat prostatic biopsy in men with serum total prostate-specific antigen

between 4.1 and 10 ng/mL. Int J Urol. 2003;10(4):201-6.

13. Partin AW, Brawer MK, Bartsch G, Horninger W, Taneja SS, Lepor H, et al. Com-

plexed prostate specific antigen improves specificity for prostate cancer detection:

results of a prospective multicenter clinical trial. J Urol. 2003;170(5):1787-91.

14. Remzi M, Fong YK, Dobrovits M, Anagnostou T, Seitz C, Waldert M, Harik M, et

al. The Vienna nomogram: validation of a novel biopsy strategy defining the op-

timal number of cores based on patient age and total prostate volume. J Urol.

2005;174(4):1256-60.

15. Presti JC Jr. Prostate biopsy: how many cores are enough? Urol Oncol.

2003,21(2):135-40.

16. Parsons JK, Brawer MK, Cheli CD, Partin AW, Djavan R. Complexed prostate spe-

cific antigen (PSA) reduces unnecessary prostate biopsies in the 2.6-4.0 ng/mL range

of total PSA. BJU Int. 2004;94(1):47-50.

17. Vollmer RT. Predictive probability of serum prostate-specific antigen for prostate

cancer: an approach using Bayes rule. Am J Clin Pathol. 2006;125(3):336-42.

18. Punglia RS, D’Amico AV, Catalona WJ, Roehl KA, Kuntz KM. Impact of age, benign

prostatic hyperplasia, and cancer on prostate-specific antigen level. Cancer. 2006;

106(7):1507-13.

19. Lacher DA, Thompson TD, Hughes JP, Saraiya M. Total, free, and percent free pros-

tate-specific antigen levels among U.S. men, 2001-04. Adv Data. 2006;(379):1-12.

20. Stephan C, Stroebel G, Heinau M, Lenz A, Roemer A, Lein M, et al. The ratio of

prostate-specific antigen (PSA) to prostate volume (PSA density) as a parameter to

improve the detection of prostate carcinoma in PSA values in the range of

Anatomic-radiological study of supernumerary kidney arteries: supernumerary kidney artery originating from the renal artery

Anatomsko–radiološka studija o prekobrojnim arterijama bubrega: prekobrojne bubrežne arterije porijeklom od bubrežne arterije

Elvira Talović*, Alma Voljevica

Department of Anatomy, Faculty of Medicine University of Sarajevo, Čekaluša 90, 71000 Sarajevo, Bosnia and Herzegovina

*Corresponding author

ABSTRACT

Background: classically, each kidney is supplied by a single renal artery originating from abdominal aorta. However, accessory renal arteries can also exist. The aim of this study was to determine the number of supernumerary renal artery originating from the renal ar-tery. Materials and methods: the formalin-fixed thirty-nine cadavers presented the material for the study. During routine abdominal dis-section conducted at the Department of Anatomy, the kidneys along with their arteries were explored and the morphological variations of renal arteries were noted. In the preparation of this study analyzed 213 aortograma made by the method of selective angiography by Seldinger and 37 angiogram made selective subtraction angiography. For statistical analysis of the data in the paper SPSS software version 13.0 was used. Results: we observed supernumerary renal arteries originating from main renal arteries in 6/39 cadavers (15.38%) cases, 12/213 (5.63%) aortogram and 5/37 (13.51%) angiogram. Supernu-merary renal arteries entered the kidney through superior pole and inferior pole. Conclusion: awareness of variations of renal artery is necessary for surgical management during renal transplantation, re-pair of abdominal aorta aneurysm, and urological procedures and for angiographic interventions.

Key words: kidney, renal artery, supernumerary renal artery

SAŽETAK

Uvod: klasično, svaki bubreg dobiva krvnu obskrbu od jedne bubrežne arterije porijeklom od trbušne aorte. Međutim, prekobro-jne bubrežne arterije također mogu postojati. Cilj ovog istraživan-ja bio je utvrditi broj prekobrojnih bubrežnih arterija porijeklom iz bubrežne arterije. Materijali i metode: kao material u izradi ove studi-je korišteno je trideset devet formalinskih lješnih preparata. Tokom rutinske abdominalne sekcije provedene na Katedri za anatomiju, bubrezi zajedno sa njihovim arterijama su analizirani i na njima su noti-rane morfološke varijacije bubrežnih arterija. U pripremi ove studije analizirano je 213 aortograma dobivenih postupkom selektivne an-giografije po Seldingeru i 37 angiogram dobivenih selektivnom sub-trakcionom angiografijom. Za statističku analizu podataka u radu ko-rišten je SPSS softwer verzija 13.0. Rezultati: prekobrojne bubrežne arterije porijeklom od glavne bubrežne arterije uočene su na lješnim preparatima u 6/39 (15.38%) slučajeva, u 12/213 (5.63%) aortogram i u 5/37 (13.51%) angiogram. Prekobrojne bubrežne arterije ulazile su u bubreg na njegovom gornjem i donjem polu. Zaključak: poznavanje varijacija bubrežnih arterija neophodno je u hirurškim pripremama za bubrežne transplantacije, aneurizmatične promjene na abdominalnoj aorti, uroloških procedura i angiografskih intervencija.

Ključne riječi: bubreg, bubrežna arterija, prekobrojne bubrežne arterije

Medical Journal (2015) Vol. 21, No. 2, 101 - 104 Original article

INTRODUCTION

Classically, the description of a single renal artery arising from abdominal aorta that supplies the respective kidney occurs in less than 25% of cases (1,2,3,4). Analyzing data from the literature shows that the authors describe a large number of variations in the arterial supply of kidneys. Differences in the number of variations are present due to the use of different test methods and different

criteria to classify these variations. Merklin in their study of the sup-ply of a kidney with multiple renal arteries records the range of vari-ation and the occurrence of 14-55% of cases (5). Bilge summarizing the results of other authors reported the presence of these changes in the range of 8.7 to 75.7% of cases (6). Such a large range of sta-tistical variation of the occurrence of supernumerary kidney artery is the result of observation of the problem from different angles by many authors, or from the use of different methods in different clinical purposes.

Variations in renal arteries have been called aberrant, supple-mentary, and accessory, among other terms. We used the term su-pernumerary and analyze it in accordance with Merklin classification (5). We believe that prior knowledge of these possible variations of renal arteries may help the surgeon in planning renal transplantation, repair of abdominal aorta aneurysm, urological procedures, and also for angiographic interventions (7,8,9).

MATERIALS AND METHODS

The formalin-fixed thirty-nine cadavers constituted 213 aorto-grams made by the method of selective angiography by Seldinger and 37 angiograms made selective subtraction angiography for the study. During routine abdominal dissection conducted at the de-partment of anatomy, the kidneys along with their arteries were explored and the morphological variations of renal arteries were noted. During the course of dissection various abdominal viscera were removed and preserved as specimens for teaching purposes. In the above material we studied the origin of supernumerary renal arteries in accordance to the nomenclature of Merklin and Michels (7):

• supernumerary renal arteries originating from the aorta;• supernumerary renal arteries originating from main renal ar-

teries;• supernumerary renal arteries that can come from other

sources.

In our study we observed only supernumerary renal artery orig-inating from main renal artery. The paper examining the significance of the results applied statistical software SPSS version 13.0, contain-ing the Kruskal-Wallis test.

RESULTS Supernumerary renal artery originating from the renal arteries was observed in 6 (15.38%) of 39 dissection preparations. In five cases the supernumerary artery was on the right and in one case on the left side. Of this number of supernumerary artery in five cases

(12.82%) it was the upper polar artery and only in one case (2.56%) it was a lower polar artery (Figure 1A). Analyzing 213 aortograms, performed by classical non-selective renal angiography by Seldinger, the supernumerary kidney artery originating from the renal arteries was found in 12 analyzed aorto-grams or 5.63%. Of this number the upper polar supernumerary arteries and the lower polar artery were registered in 6 (2.82%) cases (Figure 1B). The analyzed angiograms of (37) supernumerary kidney ar-tery originating from the renal arteries was found in 5 angiograms (13.51%) and they were on the right side. Lower polar arteries were registered in 4 (10.81%) cases, while the upper polar artery was registered in one (2.70%) case (Figure 3 C). Below is a graphical representation of the number of detected supernumerary artery originating from the renal artery, with the use of three different methods.

Results of statistical analysis

Given that the pattern of the paper used three uneven groups, using three different test methods for identification of supernumer-ary renal arteries, the statistical analysis of variance was performed with the support of non-parametric Kruskal-Wallis test. In order to facilitate interpretation of the results of analysis of variance values the Kruskal-Wallis test were shown over-value Chi-

Figure 2 Graphic supernumerary renal artery originat-ing from the renal artery detected using three different methods.

Figure 1 Supernumerary renal artery: A - dissection metod; B - aortogram, C – angiogram; 1. abdominal aorta, 2. right renal artery, 3. upper polar supernumerary artery originating from main renal arteries; 4. left renal artery.

102 E. Talović et al.

square test (X2), in order to demonstrate the presence of the dif-ference of the results of the three methods. Table 1 and 2 presents the results of statistical data processing. As the value of X2=4.589 with a degree of freedom is less than 2 table values for the significance level of p=0.05, we can safely con-clude that the differences in the frequency distribution within the three groups were not statistically significant.

DISCUSSION

The various types of (accessory, additional, supplementary and aberrant) renal arteries, their positions, method of entry to the kidney, and segmentation were studied extensively by a number of authors (10,11) but the generally accepted and precise terminology for these arteries has not been unified by the majority of authors (12). As these arteries occupy a certain vascular area within the kid-ney and there is no anastomosis, either with the branches of the main or with branches of segmental renal arteries, we preferred the terminology supernumerary for these arteries and classified them in accordance with Merklin and Michels (5). They classified these supernumerary renal arteries depending upon origin as supernu-merary renal arteries originating from aorta, supernumerary renal arteries originating from the main renal artery, and supernumerary renal arteries originating from other arterial sources, but in their study none of the hilar supernumerary renal artery took origin from renal artery. In the presented study we analyzed the number of supernu-merary renal artery originating from the renal arteries using three different methods. Supernumerary renal artery originating from the renal arteries were observed in 6 (15.38%) of 39 dissection preparations. In five cases the supernumerary artery on the right and in one case on the left side. Of this number of supernumerary artery in five cases

(12.82%) it was the upper polar artery and only in one case (2.56%) was a lower polar artery. Analyzing 213 aortograms, performed by classical non-selective renal angiography by Seldinger, the supernumerary kidney artery originating from the renal arteries was found in 12 analyzed aorto-grams or 5.63%. Of this number the upper polar supernumerary arteries and the lower polar artery were registered in 6 (2.82%) cases. In 37 analyzed angiograms, supernumerary kidney artery origi-nating from the renal arteries was found in 5 angiograms (13.51%) and they were on the right side. Lower polar arteries were regis-tered in 4 (10.81%) cases, while the upper polar artery was regis-tered in one (2.70%) case. Other authors did not pay much attention to the analysis of this group of redundant renal arteries and the literature data refer only to types of supernumerary kidney artery originating from the renal artery. Bergman and Makiyama reported that the upper polar artery origins of the renal arteries more frequently (12%) than the lower polar (1.4%) (13,14). The opposite view was presented in the study of Bakheiti who claims that the upper polar artery is always separat-ed from the abdominal aorta, while the lower polar artery is always separated from the renal artery (15). Clinically, the supernumerary renal arteries are very important. Upper polar and lower polar supernumerary renal arteries originat-ing from renal arteries, directed towards superior or inferior pole, have vertical trajectory in comparison to supernumerary renal ar-teries taking origin from aorta. Vertical trajectory of these arteries can lead to polar infarction (16) and they can also be injured during mobilization and other surgical procedures (17). Lower polar super-numerary renal arteries of aortic or renal origin can be a cause of ureteropelvic junction obstruction (18). The anatomical knowledge of supernumerary renal arteries is essential before performing any transplantation surgeries where mi-crovascular techniques are employed to reconstruct the renal arteries (19). One has to keep in mind that transplanting a kidney with acces-sory renal arteries has several theoretical disadvantages: acute tubular necrosis and rejection episodes and decreased graft function (17). We believe that awareness of variations is necessary for surgical management during renal transplantation, repair of abdominal aorta an-eurysm, and urological procedures and for angiographic interventions.

CONCLUSION

Arteriogram has its value in the identification and assessment of preoperative arterial anatomy of the kidney. Our results are in favor of this claim. The the Kruskal-Waills test for the evaluation of all three methods used in this study to identify redundant renal arteries and division of the renal artery to the segmental branches did not prove statistical significance of the differences. Some authors prefer a dissection methods, and other angiographic methods to identify their supernumerary kidney artery (20,21). However, this certifi-cate requires comparison of angiographic results with intraoperative findings in the same person.

Conflict of interest: none declared.

Anatomic-radiological study of supernumerary kidney arteries: supernumerary kidney artery originating from the renal artery 103

Test method

Dissection Aortogram AngiogramTotal

%

%

%

%

92.3

6.4

1.3

100.0

97.2

1.4

1.4

100.0

93.2

1.4

5.4

100.0

96.0

2.1

1.9

100.0

Kidney no supernumeraryarteries

Upper polar artery

Lower polar artery

Total

Table 1 Analysis of supernumerary kidney artery originat-ing from the renal artery.

Test methods N Range

39

213

37

289

13.6

19.25

24.40

Dissection

Aortogram

Angiogram

Total

4.589

2

0.268

Supernumerary renal

arteries originating from

main renal arteries

X2 - value

The degree of freedom

The level of significance (p)

Table 2 Results of the Kruskal-Wallis test statistical signif-icance of differences.

REFERENCES

1. Beregi JP, Mauroy B, Willoteaux S, Mounier-Vehier C, Remy-Jardin M, Francke JP.

Anatomic variation in the origin of the main renal arteries: spiral CTA evaluation.

Eur J Radiol. 1999;9(7):1330-4.

2. Ozkan U, Oˇguzkurt L, Tercan F, Kizilkilic O, Koc Z, Koca N. Renal artery origins

and variations: angiographic evaluation of 855 consecutive patients. Diagn Interv

Radiol. 2006;12(4):183-6.

3. Awojobi OA, Ogunbiyi OA, Nkposong EO. Unusual relationship of multiple renal

arteries. Urology. 1983;21(2):205-6.

4. Çiçekcibaşi AE, Ziylan T, Salbacak A, Şeker M, Büyükmumcu M, Tuncer I. An inves-

tigation of the origin, location and variations of the renal arteries in human fetuses

and their clinical relevance. Annals of Anatomy. 2005;187(4):421-7.

5. Merklin RJ, Michels NA. The variant renal and suprarenal blood supply with data on

the inferior phrenic, ureteral and gonadal arteries: a statistical analysis based on 185

dissections and review of the literature. J Int Coll Surg. 1958;29(1):41-76.

6. Bilge O, Aktan AA. Multiple variations of abdominal vessels in a single cadaver.

Clinic Anat. 2003;16(1):37-9.

7. Olsson O, Wholey M. Vascular abnormalities in gross anomalies of kidneys. Acta

Radiologica. 1964;(2):420-432.

8. Nathan H, Glezer I. Right and left accessory renal arteries arising from a common

trunk associated with unrotated kidneys. Journal of Urology. 1984;132(1):7-9.

9. Satyapal KS, Haffejee AA, Singh B. Additional renal arteries: incidence and mor-

phometry. Surg Radiol Anat. 2001;23(1):33-8.

10. Anson BJ, Richardson GA, Minear WL. Variations in the number and arrangement

of the renal vessels. A study of the blood supply of four hundred kidneys. J Urol.

1936;36:211-219.

11. Sykes D. The arterial supply of the human kidney with special reference to accesso-

ry renal arteries. Brit J Surg. 1963;50:368-74.

12. Singh G, Ng YK, Bay BH. Bilateral accessory renal arteries associated with some

anomalies of the ovarian arteries: a case study. Clin. Anat. 1998;11:417-20.

13. Bergman RA. Renal arteries. Illustrated Encyclopedia of Human Anatomic Varia-

tion. 2003; Opus II.

14. Makiyama K, Tanabe K, Ishida H, Tokumoto T, Shimmura H, Omoto K, Toma H.

Successful renovascular reconstruction for renal allografts with multiple renal arter-

ies. Transplantation. 2003;75(6):828-32.

15. Bakheit MA. Anomalies of the renal, phrenic and suprarenal arteries: case. East Afr

Med J. 2003; 80:497-498.

16. Beyer RW, Daily PO. Renal Artery Dissection Associated with Gz Acceleration.

Aviat Space Environ Med. 2004;75(3):284-7.

17. Sampaio FJ, Passos MA. Renal arteries: anatomic study for surgical and radiological

practice. Surg Radiol Anat. 1992;14:113-7.

18. Shoja MM, Tubbs RS, Shakeri A, Ardalan MR, Rahimi-Ardabili B, Ghabili K. Asymp-

tomatic bilateral ureteropelvic junction obstruction due to supernumerary renal

arteries. Saudi J Kidney Dis Transpl. 2008;19(5):806-8.

19. Brannen GE, Bush WH, Correa RJ. Microvascular management of multiple renal

arteries in transplantation. Journal of Urology. 1982;128(1):112-5.

20. Kamina P, Koumare AK, Rideau Y. Contribution a l’etude des variations de

l’origine de l’artere renale. A propos de 800 arteriographies. Arch Anat Pathol.

1975;23(4):287-90.

21. Glodny B, Cromme S, Wortler K, Winde G. A possible explanation for the frequent

concomitance of arterial hypertension and multiple renal arteries. Med Hypothe-

ses. 2001; 56(2):129-33.

Reprint requests and correspondence:Elvira Talović, MD, MScInstitute of Anatomy „Prof. Dr. Hajrudin Hadžiselimović”Faculty of Medicine University of SarajevoČekaluša 90, 71000 SarajevoBosnia and HerzegovinaPhone: + 387 61 101 956Email: elviratalovicka@gimail.com

104 E. Talović et al.

Evaluation of hemodynamic and respiratory stability during general anesthesia with propofol and sevoflurane for age group 1-14 years

Procjena hemodinamske i respiratorne stabilnosti u toku opšte anestezije propofolom i sevofluranom u starosnoj dobi od 1-14 godina

Selma Vanis-Vatrenjak1*, Aida Smajić1, Zlatan Zvizdić2, Kenan Karavdić2

1Clinic of Anesthesiology and Reanimation, University Clinical Center Sarajevo, Bolnička 25, 71000 Sarajevo, Bosnia and Herzegovina, 2Clinic of Pediatric Surgery, University Clinical Center Sarajevo, Bolnička 25, 71000 Sarajevo, Bosnia and Herzegovina

*Corresponding author

ABSTRACT

Pediatric anesthesia represents a separate entity within clinical anesthesia, due to special anatomic characteristics and physical, bio-chemical and psychological status of children in the period of the most intensive growth and development. All preparations and the proce-dure itself in children require professional medical team, adapted equipment, monitoring and drugs. This study investigated and proved the safety and quality of general anesthesia for children aged 1 to 14 years, by comparison of hemodynamic and respiratory effects when using two hypnotics of new generation - propofol and sevoflurane. The study included 160 patient aged 1-14 years, ASA (The American Society of Anesthesiology) grade I, hospitalized at the Clinics of Pedi-atric Surgery. The patients were divided in two groups (n=80) based on hypnotics used for introduction and management of general total intravenous (TIVA) and inhalatory anesthesia (propofol group and sevoflurane group). Statistical analysis of the obtained values which included arterial pressure, heart rate and peripheral blood oxygen saturation with acid-base status, measured before introduction to anesthesia, during and immediately after the procedure, showed a total hemodynamic and respiratory stability with use of propofol and sevoflurane for general anesthesia in children age group 1-14 years, ASA group I.

Key words: propofol, sevoflurane, pediatric anesthesia

SAŽETAK

Pedijatrijska anestezija se izdvaja kao poseban entitet u sklopu kliničke anestezije, kako zbog posebnosti anatomskih karakteristi-ka, tako i zbog fizi¬kalnog, biohemijskog i psihološkog statusa djece u periodu najintenzivnijeg rasta i razvoja. Sve pripreme i samo iz-vođenje opšte anestezije kod djece zahtijevaju stručni medicinski tim, prilagođenu aparaturu, monitoring i medi¬kamente. U ovoj studiji se ispitivala i dokazala sigurnost i kvalitet opšte anestezije za djecu od 1 do 14 godina starosti, upoređivanjem hemodinamskih i respiratornih efekata, pri korištenju dva hipnotika novije generacije – propofola i sevoflurana. Istraživanje je rađeno na 160 pacijenata starosne dobi od 1-14 godina ASA gradacije I (Američko udruženje anesteziologa), hospitalizovanih na Klinici za dječiju hirurgiju. Pacijenti su bili podjeljeni u dvije grupe (n=80) prema hipnotiku koji je korišten za uvod i vod-jenje opšte totalne intravenske (TIVA) i inhalacione anestezije (grupa propofol i grupa sevofluran). Statističke analize dobivenih vrijedno-sti arterijskog pritiska, srčane frekvence i saturacije periferne krvi kiseonikom uz acidobazni status, mjerenih prije uvoda u anesteziju, tokom trajanja i neposredno postoperativno, ukazuju na potpunu he-modinamsku i respiratornu stabilnost pri upotrebi propofola i sevo-flurana za opštu anesteziju kod djece starosne dobi od 1-14 godina ASA skupine I.

Ključne riječi: propofol, sevofluran, pedijatrijska anestezija

Medical Journal (2015) Vol. 21, No. 2, 105 - 108 Original article

INTRODUCTION

Propofol and sevoflurane represent intravenous, relatively inhala-tory anesthetic of the novel generation that are used in our country in the last two decades. At the very beginning of their use, in the world and in our country, both of them were mainly used for introduction and leading of general anesthesia in adult patients based on the rec-ommendation of the pharmaceutical company producing them. The use in children, especially in those under 3 years of age, was not rec-ommended given that there was no sufficient data and experiences

on the side effects and drug adverse reactions. Strauss JM et al. per-formed a study on total intravenous anesthesia with propofol as a standard care for pediatric anesthesia and they did not spare words to praise it for quality, efficiency, hemodynamic stability and minimal side effects during the total anesthesia, but they also emphasized the need for high precautions and experience in work with propofol and total intravenous anesthesia in children (1). Study by Shmidt J et al. was done on 120 infants and preschool children divided in two groups, with propofol and sevoflurane, and higher hemodynamic stability was demonstrated in patients done with propofol (2,3).

The aim of our investigation was to prove reliability and quality of general anesthesia lead by the propofol or sevoflurane in children aged 1-14 years, ASA grade I, for the elective surgical procedures lasting up to 60 minutes, measured by the following parameters: val-ue of arterial pressure immediately before introduction in anesthe-sia, every 15 minutes during the surgical procedure and immediately after the anesthesia; the value of heart rate continuously during the introduction, duration and waking up from anesthesia; the value of peripheral blood oxygen saturation (pulse oximetry) with laboratory findings of acid-base status right before introduction and immediately after waking up from general anesthesia. Also, the aim of this study was to statistically evaluate the differences between general propo-fol and sevuflorane anesthesia in particularly sensitive and numerous population of patients, measured by vital parameters via noninvasive monitoring and laboratory findings.

MATERIALS AND METHODS

There was no investigation in our region aimed at monitoring he-modynamic and respiratory parameters during the introduction and duration of general anesthesia while using propofol and sevoflurane in children age group 1-14 years. This study is a prospective, descriptive and randomized clinical study. It is based on the previous knowledge and experiences of this defined issue. The investigation was public and conducted with strict adherence to requirements of ethic and humanity in accordance with Helsinki declaration. The investigation did not ha