From Heart Murmur to Echocardiography - Congenital Heart Defects Diagnostics Using Machine-Learning Algorithms.

The most common clinical sign in pediatric cardiology is heart murmur, which can often be uncharacteristic. The aim of this research was to present the results of development of a classifier based on machine learning algorithms whose purpose is to classify organic murmur that occur in congenital heart defect (CHD). The study is based on the data collected at Pediatric Clinic, Clinical Center University of Sarajevo during three-year period. Totally, 116 children aged from 1 to 15 years were enrolled in the study. Input parameters for classification are parameters obtained during basic physical examination and assessment of patient. First, analysis of relevance of the feature for classification was done using InfoGain, GainRatio, Relief and Correlation method. In the second step, classifiers based on Naive Bayes, Logistic Regression, Decision Tree, Random Forest and Support Vector Machine were developed and compared by performance. The results of this research suggest that high accuracy (>90%) classifier for detection of CHD based on 16 parameters can be developed. Such classifier with appropriate user interface would be valuable diagnostic aid to doctors and pediatricians at primary healthcare level for diagnostic of heart murmurs.

Impact of Insulin Delivery Method on Hypoglycemia Incidence in Pediatric Type 1 Diabetes Mellitus Patients.

INTRODUCTION: Insulin therapy of pediatric patients with type 1 diabetes mellitus (T1DM) is highly demanding due to their dynamic growth, development and different daily life activities. GOAL: To determine the optimal insulin delivery method for the prevention of hypoglycemia recorded by continuous monitoring of glucose in patients with insulin pump and PEN. MATERIAL AND METHODS: The study included patients up to 18 years of age with diagnosed T1DM and treated with insulin pump and by insulin therapy with PEN at the Pediatric Clinic of the Clinical Center in Sarajevo. The study involved 149 patients, and lasted for 3 years. Patients were divided into two groups: group of patients on insulin pump therapy and group on insulin PEN. RESULTS: There were 73 patients (49.6%) on insulin pump therapy and 79 patients (52.4%) on the insulin PEN therapy. There was no significant difference in the age between genders nor groups with different insulin application methods. There were no significant differences in the number of anamnestic hypoglycemia in patients with a different mode of insulin application (83.56% vs. 81.58%, p=0.114, F=2.533 < Fk=3.919). The number of hypoglycemia episodes in history is higher with the PEN therapy than in the insulin pump group. CONCLUSION: The number of anamnesis hypoglycemia as well as hypoglycemia from CGM records did not differ significantly in patients with IP and PEN therapy. The CGM record was significantly more valuable in the presentation of hypoglycemia compared to the history of hypoglycemia in all patients studied. Continuous monitoring of glycemia due to the ability to show glycemia variability and unrecognized hypoglycemia as well as predictive options for long-term metabolic control should be performed for all T1DM patients at least once a year.

Chronic mild to moderate mitral regurgitation will not have an impact on left atrial strain parameters in the pediatric population.

BACKGROUND: Left atrial strain (LAS) analysis represents a newer non-invasive, sensitive and specific technique for assessing left atrial (LA) function and early detection of its deformation and dysfunction. However, its applicability in mitral regurgitation (MR) in pediatric population remains unexplored, raising pertinent questions regarding its potential role in evaluating the severity and progression of the disease. OBJECTIVE: To investigate the impact of chronic MR in children and adolescents on LA remodeling and function. METHODS: The study included 100 participants. Patients with primary and secondary chronic MR lasting at least 5 years fit our inclusion criteria. The exclusion criteria from the study were: patients with functional mitral regurgitation due to primary cardiomyopathies, patients with artificial mitral valve, patients with MR who had previously undergone surgery due to obstructive lesions of the left heart (aortic stenosis, coarctation of the aorta), patients with significant atrial rhythm disorders (atrial fibrillation, atrial flutter). The echocardiographic recordings were conducted by two different cardiologists. Outcome data was reported as mean and standard deviation (SD) or median and interquartile range (Q1-Q3). RESULTS: The study included 100 participants, of whom 50 had MR and the remaining 50 were without MR. The average age of all participants was 15.8 ± 1.2 years, with a gender distribution of 37 males and 63 females. There was a significant difference in the values of LA volume index (LAVI), which were higher in patients with MR (p= 0.0001), S/D ratio (and parameters S and D; p= 0.001, p= 0.0001, p= 0.013), mitral annulus radius (p= 0.0001), E/A ratio (p= 0.0001), as well as septal e' (m/s), lateral e' (m/s), and average E/e' ratio, along with the values of TV peak gradient and LV global longitudinal strain (%). There was no significant difference in LA strain parameters, nor in LA stiffness index (LASI). CONCLUSION: Our findings revealed significant differences in several echocardiographic parameters in pediatric patients with MR relative to those without MR, providing insight into the multifaceted cardiac structural and functional effects of MR in this vulnerable population.

Left atrial stiffness is in correlation with left atrial reservoir strain in pediatric patients with mitral regurgitation.

BACKGROUND: Left atrial stiffness index (LASI), defined as the ratio of early diastolic transmitral flow velocity/lateral mitral annulus myocardial velocity (E/e') to peak atrial strain, reflects reduced left atrial (LA) compliance and represents an emerging marker that can be used for noninvasive measurement of fibrosis of LA in patients with mitral regurgitation (MR). OBJECTIVE: To investigate the impact of chronic MR in children and adolescents on the remodeling and function of the LA, quantified through strain parameters and diastolic function. METHODS: The study included fifty patients (n= 50) diagnosed with primary and secondary chronic MR lasting at least 5 years. The echocardiographic recordings were performed by a third party, two cardiologists actively engaged in echocardiography on a daily basis. RESULTS: Older participants had higher values of the LASI (r= 0.467, p= 0.001). Participants with higher LASI values had a smaller LA reservoir (r= 0.784, p= 0.0001) and smaller LA conduit values (r=-0.374, p= 0.00). Participants with higher LASI values had a larger LA diameter (r= 0.444, p-value= 0.001) and higher average E/e' ratio (r= 0.718, p= 0.0001). There was a significant difference (p= 0.04) in the LASI among participants based on the MR jet area (< 20.85% ⩾ 20.85%), LASI was higher in participants with an area greater than 20.85%. Differences in other parameters such as LA reservoir, LA conduit, LA contractile were not statistically significant. CONCLUSION: Increased LA stiffness is associated with diminished atrial compliance and reservoir capacity, and LASI has a potential to as an early marker for assessing disease severity and progression in pediatric MR.

Association of HLA-B27 antigen with clinical and laboratory parameters in patients with juvenile idiopathic arthritis.

Aim To analyse the association of human leukocyte antigen B27 with clinical and laboratory parameters in patients with juvenile idiopathic arthritis (JIA) at the disease onset. Methods A retrospective review of medical records of 25 HLAB27 positive and 25 HLA-B27 negative JIA patients was performed. The diagnosis of JIA was based on the 1997-2001 International League Against Rheumatism (ILAR) criteria. Collected data: age, sex, HLA- B27 antigen presence, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), rheumatoid-factor (RF), antinuclear antibody (ANA), fever, rash, uveitis, enthesitis, inflamed joints and subtype of JIA. Results HLA- B27 positive study group had more boys (p=0.01), higher erythrocyte sedimentation rate (p=0.038), higher presence of fever (p= 0.025) and enthesitis (p=0.024). Any significant difference in age of the disease onset, CRP, ANA, RF, rash, uveitis, inflamed joint and dactylitis was not noticed. The most common subtype of JIA in the HLA-B27 positive patients was ERA (60%). Conclusion This study showed that the presence of HLA- B27 antigen plays a significant role in determining the presenting clinical and laboratory characteristics in JIA patients.

Efficacy of nebulized hypertonic saline versus normal saline in the treatment of acute bronchiolitis in inpatient infants.

Aim Compare the efficacy of nebulized hypertonic saline and normal saline in the treatment of infants hospitalized for bronchiolitis. Methods This retrospective study was conducted at the Department of Pulmonology, Paediatric Clinic, Clinical Centre University of Sarajevo, covering the period from January 2015 to December 2019 and comprising 380 children aged between 1 and 12 months having bronchiolitis. One group received nebulized hypertonic saline (NHS, 3% NaCl)), and another group received nebulized normal saline (NNS, 0.9% NaCl). The control group did not receive any of these treatment options. Results There was no statistically significant difference between the treatment groups regarding length of hospital stay (LOS) and Clinical Severity Score (CSS) at admission and discharge as well as in oxygen therapy duration and antibiotic use, the duration of symptoms before hospital admission, frequency of nasal discharge, elevated temperature, dyspnoea, cough and dehydration. Conclusion The results of this study are consistent with several recent studies or meta-analyses and support the evidence against the use of NHS in hospitalized infants with mild or moderate bronchiolitis.

Left atrial strain analysis in the realm of pediatric cardiology: Advantages and implications.

BACKGROUND: Left atrial (LA) strain analysis has emerged as a noninvasive technique for assessing LA function and early detection of myocardial deformation. Recently, its application has also shown promise in the pediatric population, spanning diverse cardiac conditions that demand accurate and sensitive diagnostic measures. OBJECTIVE: This research endeavors to explore the role of LA strain parameters and contribute to the growing body of knowledge in pediatric cardiology, paving the way for more effective and tailored approaches to patient care. METHODS: A comprehensive literature review was conducted to gather evidence from studies using echocardiographic strain imaging techniques across pediatric populations. RESULTS: LA strain parameters exhibited greater sensitivity than conventional atrial function indicators, with early detection of diastolic dysfunction and LA remodeling in pediatric cardiomyopathy, children with multisystem inflammatory syndrome, rheumatic heart disease, as well as childhood renal insufficiency and obesity offering prognostic relevance as potential markers in these pediatric subpopulations. However, there remains a paucity of evidence concerning pediatric mitral valve pathology, justifying further exploration. CONCLUSION: LA strain analysis carries crucial clinical and prognostic implications in pediatric cardiac conditions, with reliable accuracy and sensitivity to early functional changes.

Biochemical predictors of death before discharge in cooled newborns following perinatal asphyxia.

Aim To analyse biochemical markers as possible predictors of death before discharge in cooled newborns following perinatal asphyxia. Methods A total of 91 infants that underwent therapeutic hypothermia after perinatal asphyxia were included. Inclusion criteria for therapeutic hypothermia were Sarnat stage 2 or 3. Data were collected from medical histories regarding gender, gestational age, birth weight, Apgar and Sarnat score; additionally, gas analyses, liver and cardiac enzymes before, and in the first 12 hours after starting therapeutic hypothermia, were evaluated. The patients' characteristics were compared between two groups, survivors and non-survivors. Results Statistical difference was not found between groups regarding gender, gestational age, birth weight, delivery type, 1st and 5th minute Apgar score, seizures, alanine aminotransferase (ALT), creatine kinase (CK), troponin and fibrinogen level. Groups were significantly different regarding acid-base balance (p=0.012), base excess (BE) (p=0.025), lactate (p=0.002), aspartate aminotransferaze (AST), (p=0.011), lactate dehydrogenase (LDH) (p=0.006), activated partial thromboplastin clotting time (aPTT) (p=0.001) and international normalized ratio (INR) (p=0.001). Conclusion Acid-base balance, BE, lactate, AST, LDH, aPTT and INR were significantly higher in the group of cooled newborns after perinatal asphyxia (non-survivors), and can serve as predictors of death before discharge. Combining diagnostic modalities raises a chance for accurate prediction of outcomes of asphyxiated infants.

Hemodialysis Parameters and Pulse Wave Velocity.

Aim: The study aimed to evaluate the acute effect of ultrafiltration on the mechanical properties of the aorta using brachial-ankle pulse wave velocity (PWV) before and after hemodialysis (HD). Patients and Methods: This study included 80 patients who were on a long-term HD program. The input variables were anamnestic data, body composition monitor (BCM) parameters, and echocardiography findings. The assessment of hydration status was determined by BCM, whose work is based on the principle of multifrequency bioimpedance spectroscopy. Another diagnostic procedure was the use of an arteriograph apparatus to assess PWV and Augmentation Index (AIx). All measurements were performed before and after dialysis on the middle dialysis day of the week. Results: The participants were divided into two groups based on hydration status: the experimental group consisted of 40 overhydrated participants and the control group consisted of 40 normovolemic participants. Statistically, the following BCM parameters correlated significantly positively with PWV: total body fat (r = 0.222; P < 0.05), overhydration (r = 0.290; P < 0.001), and relative overhydration (r = 0.290; P < 0.001). From echocardiography findings, only left atrial diameter correlated statistically significantly positively with PWV (r = 0.359; P < 0.001). Comparison of the mean PWV values within the experimental group before and after HD showed a statistically significant decrease from 14.32 ± 2.34 m/s to 8.72 ± 1.52 m/s (Z = 3.254; P = 0.0001). Mean PWV values within the control group did not decrease significantly from 13.39 ± 1.32 m/s to 10.39 ± 1.18 m/s (Z = 0.524; P = 0.742). If we compare the mean values of PWV between groups, then before HD treatment, there was no statistically significant difference between groups with PWV values in the experimental group of 14.32 ± 2.34 m/s and the control group of 13.39 ± 1.32 m/s (Z = 0.762; P = 0.852). According to the results of univariate regression analysis before and after HD treatment, only overhydration showed an absolute effect on PWV before and after HD. Conclusion: Overhydration showed an effect on brachial-ankle PWV before and after HD, and brachial-ankle PWV should be followed in HD patients.

Serum Creatinine versus Corrected Cockcroft-Gault Equation According to Poggio Reference Values in Patients with Arterial Hypertension.

Introduction: Serum creatinine is not enough sensitive marker for the evaluation of glomerular filtration rate (GFR). Cockcroft-Gault (CG) formula is often used to assess GFR, but it is necessary to correct original one for body surface area (BSA), adipositas, and the creatinine tubular secretion. The values of the estimated creatinine clearance and GFR are considered to Poggio reference ones according to biological parameters (age and gender). The aim of the study was to determine the difference in renal function estimation between serum creatinine and corrected CG equation according to the Poggio reference values in the arterial hypertension patients. Materials and Methods: The research included 124 patients of both gender with arterial hypertension, excluding ones with the already verified chronic kidney disease. We estimated creatinine clearance and GFR by CG method corrected for the BSA, body mass index (BMI), and the creatinine tubular secretion according to Poggio reference values. Results: There was no significant difference in both age and gender groups among patients with physiological and pathological values of the renal function determined by the serum creatinine and estimated creatinine clearance by CG equation corrected for BMI, BSA. In both age and gender groups there was significant difference among subjects with physiological and pathological values of the renal function determined by serum creatinine and estimated GFR by CG method corrected for BMI, BSA, and creatinine tubular secretion. Conclusion: There is the most striking difference in the assessment of renal function between serum creatinine and estimated GFR by CG method with three corrections (BSA, BMI, the creatinine tubular secretion). Estimated GFR by CG method with three corrections can help in the early diagnosis of renal dysfunction and optimal treatment in patients with arterial hypertension.

Pericardial Effusion in Postcoronavirus Disease Patients with Preserved Ejection Fraction of the Left Ventricle and Normal Values of N-Terminal-Pro B-Type Natriuretic Peptide-Link with C-Reactive Protein and D-Dimer.

Aim: The aim of this study was to link the values of D-dimer and C-reactive protein (CRP), with the occurrence of pericardial effusion in patients who had coronavirus disease 2019 (COVID-19) and have preserved systolic function of the left ventricle (LV). Methods: This was a prospective study and included 146 patients who underwent echocardiographic examination 30 days after the acute phase of COVID-19. Patients who were placed on mechanical ventilation, patients who had pulmonary thromboembolism or acute coronary syndrome during the acute period of the disease, patients who had an ejection fraction of the LV <50%, patients who were diagnosed with pericarditis during acute illness or clinical signs of heart failure (or had elevated N-terminal-pro hormone B-type natriuretic peptide value), with verified renal or hepatic dysfunction were excluded from the study, including patients with diabetes mellitus Type 1, patients with cancer, connective tissue disease, or pregnant women. The existence of cardiovascular risk factors (hypertension, diabetes mellitus Type 2, and hyperlipidemia), the presence of previous ischemic heart disease, maximum values of D-dimer, and CRP (during the first 15 days of the disease) was taken into the analysis. Results: Effusion was verified around the right atrium (RA) in 104 patients (3.85 ± 1.75 mm), in 135 patients next to the free wall of the right ventricle (RV) (5.24 ± 2.29 mm), in front of the apex of the LV in 27 patients (2.44 ± 0.97 mm), next to the lateral wall of LV in 35 patients (4.43 ± 3.21 mm), and behind the posterior wall of LV in 30 patients (2.83 ± 1.62 mm). Mean CRP values during the acute phase of the disease were 43.0 mg/L (8.6-76.2 mg/L), whereas D-dimer mean value was 880.00 µg/L (467.00 -2000.00 µg/L). CRP values correlated with effusion next to the free wall of RV (rho = 0.202; P = 0.018). The D dimer correlated with effusion around RA (rho = 0.308; P = 0.0001). Conclusion: The clinical picture of the post-COVID patients could be explained by the appearance of pericardial effusion. D-dimer value correlates with the occurrence of effusion around RA, whereas CRP value correlates with effusion next to the free wall of RV.

Impact of load on the knee in relation to a treadmill angle.

Aim To determine the effect of the load on the meniscus in relation to a different angle, and to present the impact of force on eventual injury of menisci. Methods Research included 200 males with average height of 178.5 cm, mass 83.5 kg, and average age of 22 years. The simulation of treadmill that was used in the evaluation of ischemic heart disease was made. Effects on the knee were evaluated by measuring at different inclinations (5°70', 6°80', 7°90', 9°10', 10°20', 11°30' and 12°40'). Results With increasing ascent of treadmill the load on the meniscus also increased. Each increase in ascent after 22% (which corresponded to the angle of 12°40' and seventh degree of load according to the Bruce protocol) at given anthropological values was an etiological factor for meniscus injury. Conclusion The seventh degree of load according to the Bruce protocol can lead to the meniscus injury.

Prevention of Possible Toxic Effects on the Kidney Graft with Parvus Tardus Waveform.

The aim of this study was to present a patient (acute allograft dysfunction after a kidney transplantation) with previously detected minimum plaque on both iliac arteries by scintigram and afterward a pathological Color Doppler Ultrasound (CDU) record and to point on possibility of avoiding toxic computed tomography (CT) angiography in certain renal graft recipients. Ultrasound (US) findings showed normal graft size, whereas Doppler signals detected parvus-tardus waveforms pointing to arterial stenosis. Isotope perfusion scintigraphy registered a slow flow on both iliac arteries and normal graft perfusion. CT angiography has not been performed because of the possible toxic effects to the graft. We believe that favorable clinical and biochemical findings along with US and isotope ratio monitoring are sufficient to avoid CT contrast angiography.

Validity of Scientometric Analysis of Medical Research Output.

The aim of this paper is to point out the errors in scientometric analysis of an author's work, as well as the inconsistency of Google Scholars when performing such analyzes. Development of information technology has led to the development of the scientometric analyzes, which already have great significance for many decisions in the academic medical community, and represents a cross section of work of an author. Scientometric indices in the medical community become a tool in selecting the management of institutions, as well as membership in many academies. This paper should be a basis, as well as guidance in the development of a better and more accurate algorithm for more accurate analysis of the work of authors, and should also point the importance of accurate citations during writing scientific papers. The lack of selectivity of Google Scholar, and the possible individual manipulation of content, implies the need for further development of these platforms, so that the scientometric analysis can become a valid tool in the academic community.

USE AND KNOWLEDGE ON THE INFORMATION TECHNOLOGIES IN MEDICAL EDUCATION -BOSNIAN AND HERZEGOVINIAN EXPERIENCE.

INTRODUCTION: Information technologies (IT) are becoming a tool without which further education of both medical students and doctors would not be possible. AIM: The aim of this paper was to analyze the use of IT in the prism of two systems, the old system and the Bologna system. MATERIAL AND METHODS: Answers from questionnaires from total of 459 students (2012/13-2015/16 generation) were analyzed. RESULTS: The presence of large number of female students, in both systems is significant (p <0.05). About 92% of students of the old system and 98% of students of the Bologna system use computer in everyday work (only 36% of old system and 47% of the Bologna system are using "faculties" computers). The computer is used for entertainment, education, information (via Internet) and for communication (e-mail, chat, social networks) (68.5% of the old system and 84% of students of the Bologna system have chosen all 4 offered answers). MS Word and MS Power Point are significantly more used compared to the use of MS Excel in both systems (p <0.05). The knowledge necessary to use their computers student of both systems have acquired through individual work. Students feel that they need to improve knowledge of the treatment of sub-base (76% of students of the old system and 62% of students of the Bologna system). Having analyzed the generation of 2015/16, 84.5% of students of the Bologna system and 75% of students of the old system used smartphones or tablets. The purpose of using a smartphone is, in most cases for accessing the social networks. 77.4% of smartphone users of the Bologna system, or 73.3% of the users of the old system have installed an application from the medical field. We analyzed the opinions of the availability of online course content and the degree of computerization of the study process and the possibility of electronic access to the literature - the results are not at the appropriate level. CONCLUSION: Education in software solutions that are connected to databases processing, must be imperative in reform of the teaching process. IT can only improve the teaching process, the organization of the education system in most eminent universities is undeniably linked to information technologies.

Socio-demographic Characteristics of Patients with Diagnosis of Leukemia in Bosnia and Herzegovina During Six-year Period.

INTRODUCTION: Malignancies in children are second most frequent cause of death after accidents in pediatric age, while leukemias represents 30% of all malignancies of children age. AIM: To present the social and demographic characteristics of patients with a diagnosis of leukemia in Bosnia and Herzegovina during six years period. PATIENTS AND METHODS: The study included 97 patients (from birth to 18 years old) with diagnosis of acute leukemia. RESULTS: During the aforementioned period at the Pediatric Clinic of University Clinical Centre Sarajevo, 244 patients with the diagnosis of malignancy were treated (99 children were with leukemia (40.6%). Acute leukemia's were diagnosed in 97 patients and chronic in 2 patients. Out of 97 treated patients with acute leukemia, they almost of all cantons of Federation of Bosnia and Herzegovina, Brcko District and the Republic Srpska. Patients were usually coming from the Tuzla Canton Federation of Bosnia and Herzegovina (28 patients). Based on the cytomorphological diagnosis of patients according to the FAB classification, the most was a present ALL-L1 type of acute leukemia's. Mortality of patients with ALL was 15,3%, while mortality of patient with AML was 36,8%. CONCLUSION: In Bosnia and Herzegovina, during six year period, the largest number of patients with leukaemia came from Tuzla Canton. The most common age of patients was preschool and school ages. Male sex was dominant in patients with diagnosis AML. According to the FAB classification, ALL-L1 type of acute leukemia was the most common.