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Tulyaganova Nodirahon Malikovna, Assistant of Department child neurology, Tashkent Institute of Postgraduate Medical education, Uzbekistan
E-mail: [email protected]
Shamansurov Shaanvar Shamuradovich, Professor, Head of Department child neurology, Tashkent Institute of Postgraduate Medical education E-mail: [email protected]
Nazarova Sadokat Odilovna, Research scientist of Pediatric neurology department, Tashkent Institute of Postgraduate Medical Education E-mail: [email protected]
Shadybekova Oksana Borisovna, Doctor-laboratory assistant, Department of Molecular Medicine and Cell Technology Research, Institute of Hematology and Blood Transfusion MoH E-mail: [email protected]
Nasimov Sobir Tohirovich, Research scientist of child neurosurgery department, Republican Scientific Center for Emergency Medical Aid, Uzbekistan
E-mail: [email protected]
Hemorrhagic stroke in children: link between clinic-anamnestic data and hemostasis
Abstract: To conduct the correlation analysis between clinical and anamnestic data and indicators of the system of hemostasis of children who had a hemorrhagic stroke (HS).
Keywords: childhood stroke, etiology, hemostasis, hemorrhagic strokes, ischemic stroke.
Background
One of the major problems of neonatal and pediatric neurology is the Acute Cerebrovascular Accident (CVA) in neonates and infants children (from birth to 3 years). Over the past two decades, the world's attention is given to the group of a formidable cerebral pathology. There is a growing identification of strokes in infants and young children, but the questions of diagnosis and treatment require further improvements, as in present time, it is well known that there is multiple factorial cases of the stroke in this age category. Besides that, even greater difficulty is the lack of common approaches to the treatment required. Thus, in contrast to adults, where ischemic stroke (IS) makes 85 % and hemorrhagic strokes 15 % of children which are divided almost equally in to approximately 55 % of ischemic and 45 % of hemorrhagic strokes (HS) [8; 9]. The level of incidence rate varies depending on geographic location, country, nationality and way of life. As noted by Lynch J. K., Hirtz D. G., De Veber G., the incidence rate of stroke of children below 1 year in the USA is 7.8, in France —
about 13, and in older age is barely 2-3 person per 100 thousand of population annually [2; 6; 7].
Hemorrhagic strokes — is intracranial hemorrhage acquired due to changes in blood vessel malformations: anatomic changes of small perforating lentikulo-striatal arteries; saccular cerebral aneurysms; arteriovenous malformations (AVM); amyloid angiopathy; mikroangiomas; arteriovenous fistulas of the dura mater; Intracranial venous thrombosis; septic arteritis and mycotic cerebral aneurysms; carotid-cavernous fistula syndrome Moya-Moya [1; 2; 3; 9].
If we analyze the direct causes of death in the neonatal period, it is revealed that one of the most frequent complications of severe neonatal disease is trombohemorrhagic disorders. It was not enough researched backup capabilities of the system hemostasis especially in preterm infants, both in normal and in other various forms of pathology.
Hemostasis, its mechanisms, as well as the hemostatic system reaction to these or other etiological factors and risk factors, create
Hemorrhagic stroke in children: link between clinic-anamnestic data and hemostasis
the preconditions for the emergence of complexity in the study of types of hemorrhagic strokes of children in particular.
Objective
To conduct the correlation analysis between clinical and anamnestic data and indicators of the system of hemostasis of children who had a hemorrhagic stroke.
Study design
In total, the clinical part of the study, 40 patients took part in the different periods of the HS, out ofwhich 72.7 % were male (24 children), and 27.3 % — girls (9 children) aged from birth to 1.5 years (mean age 62.4 ± 16.3 days).
The control group included 20 children aged from 0 to 1.5 years (mean age 72.4 ± 19.2 days), of which 14 boys (70 %) and 6 girls (30 %) had no evidence of acute cerebrovascular circulation at the time of the study.
The main criteria for inclusion in the study were: hospitalized patients, aged from birth to 1.5 years with acute cerebrovascular accident on hemorrhagic type, neuroimaging verified and who gave written informed consent from the parents to participate in the study.
Exclusion criteria were age of patients over 1.5 years, with acute disorders of cerebral circulation on ischemic type, lack of informed written consent of the parents of the patient to participate in a clinical trial.
Methods
In the surveyed group it was studied: the main risk factors for hemorrhagic stroke were extragenital history of mothers, complications of pregnancy and childbirth, newborn condition at birth. In the laboratory it was studied the main parts of hemostasis systems: platelet, coagulation and fibrinolytic and anticoagulant systems. Hemostasis indices were determined by the following methods:
1) Platelet Aggregation with ADP inducer method "for Born" on the analyzer platelet aggregation "Biola", Russia;
2) coagulation hemostasis: activated partial thromboplastin time (aPTT), prothrombin activity of the Quick, thrombin time, fibrinogen concentration on Klaus;
3) fibrinolytic system: Xll-dependent and fibrinolysis;
4) anticoagulant system: antithrombin-III, a modified test system "Reaklot AT-III», protein "C" — screening method.
It was also determined the Soluble Fibrin Monomer Complex (SFMC) and ortofenantrolinic method by Willibrand factor of concentration in the blood plasma.
Statistical analysis
Data were analyzed using SPSS v 19 (IBM SPSS Statistics, Ar-monk, New York). During research, descriptive methods and variation statistics were used.
Results
Anamnestic characteristics were studied and highlighted risk factors, as well as the clinical-neurological manifestations ofhemor-rhagic strokes of children.
Once again, it is confirmed by the opinions of the greater vulnerability of male children (80:20 %). There was no effect of gestational age on the manifestation of the HS, as in our study emp-tive number of patients was born in gestational age of39-40 weeks (90 %). This once again confirms the view that the small gestational age can accompany IVH that was not part of our criteria for inclusion of patients. This fact is well correlated with weight indicators at children birth of the study group.
In 55 % of cases of neonatal condition was assessed as good and 35 % — as satisfactory. Only 10 % of children were born in a serious condition, but later developed HS Clinic, differed its severe neurological and somatic symptoms.
Indeed, virtually every child with persistent j aundice is in group of risk for bleeding, i.e., 50 % of the children in our study had hyperbilirubinemia (indirect) and the protracted nature. In 20 % of cases occurred before the development of hemorrhagic diarrhea disaster and Background Anemia occurred in 12.5 % of cases.
The 35 % was observed entanglement fetal umbilical cord at birth, they likely served as background "disadvantage" for children with HS.
With regard to risk factors for HS, it should be, however, noted that the value of such somatic diseases of mothers of infants with acute violation of cerebral circulation had been, such as anemia 30 (0.75 ± 0.69), renal disease 16 (0.40 ± 0.78), varicose veins in the mother 7 (0.18 ± 0.61), nosebleeds 5 (0.13 ± 0.53). Endocrine pathology was detected in 15 (0.38 ± 0.78) ofcases. TORCH infection during pregnancy was detected in 9 (0.23 ± 0.67) — infection in the form of carriers of CMV and HSV. It remains debated issue, which has its «pros» and «cons» as TORCH infections affect on the development of placental insufficiency, chronic fetal hypoxia, and formation of hemorrhagic and ischemic brain lesions of children in the perinatal period. During pregnancy mothers were taking drugs: antibiotics — 9 (27.27 %), anti varicose medicines — 4 (12.12 %), cardiovascular medicines including kurantil — 2 (6.06 %), and in a few cases anticoagulants, antispasmodics.
Table 1. - Characteristics history of children at birth
Indicators n = 40 %
Gestational age
28-37 2 (0.5 ± 0.35) 5
38-40 36 (0.90 ± 0.48) 90
> 41 2 (0.5 ± 0.35) 5
Birth weight:
> 2500 37 (0.93 ± 0.42) 92.5
1500-2500 2 (0.5 ± 0.35) 5.0
< 1500 1 (0.03 ± 0.025) 2.5
Condition at birth:
Good 22 (0.55 ± 0.80) 55
Satisfactory 14 (0.35 ± 0.76) 35
Severe 4 (0.10 ± 0.48) 10
Neonatal diseases:
Anemia 5 (0.13 ± 0.53) 12.5
Diarrhea 8 (0.20 ± 0.64) 20
Bilirubinopathy (HDN) 20 (0.50 ± 0.80) 50
Cord entanglement 14 (0.35 ± .076) 35
It is worth to note that mattered intranatal factors such as:
1) the weakness oflabor — prolonged labor 21 (0.53 ± 0.80);
2) the rapid birth 13 (0.33 ± 0.75);
3) the premature discharge amniotic fluid 9 (0.23 ± 0.67) cases.
Genetically complicated hemostasiological history among relatives (parents, siblings) was diagnosed in 6 (0.15 ± 0.57) patients.
Analysis of obstetric history revealed in 34 (0.85 ± 0.57) cases showed that the children were born by physiological way and in 6 (0.15 ± 0.57) — by Caesarean section.
Neurological examination was carried out in the very acute/acute stage of hemorrhagic stroke type. So, the children observed this pathology often manifested cerebral symptoms vomiting 16 (0.40 ± 0.78), convulsions 25 (0.63 ± 0.78), coma 8 (0.38 ± 0.132) and exit from this state in the form of motor 17 violations (0.43 ± 0.79). Right-sided hemiparesis was formed in 14 (0.35 ± 0.76), the left-hand hemiparesis — 9 (0.23 ± 0.67) cases. Regression of neurological deficits after stroke of children in 70 % of cases there is much better than in adults 33 %.
Clinical ICE statement does not always fit into the framework and had differences with hemostasiogram data. The distortion of the data, an incorrect perception can cause a lack of the correct approach to the treatment of children.
In the study the hemostatic system in children with hemorrhagic stroke, it was found that the indicators of screening tests (APTT, PTI, thrombin time, fibrinogen plasma) were not significantly different from those of the control group (Table 4).
Table 2. - Risk factors for hemorrhagic stroke of children
Table 3. - Clinical and neurological symptoms of children with HS
Table 4. - Indicators of the hemostatic system in children with stroke on the hemorrhagic type
Aggregation of platelet function with ADP inducer decreased 2-fold compared to the control group. Antitrombin-III concentration did not differ from the control group.
Despite the fact that on average the «C» protein indexes were normal and 5 children (15.0 %) of the normalized ratio had reduced protein. The concentration of the von Willebrand factor corresponded to normal values. Content SFMC increased in the third times compared to the control group. It should be noted that 100 % of children surveyed plasma fibrinolytic activity was reduced, which leads to thrombosis and indicates the beginning of ICE syndrome.
It is known that in preterm and full-term immature children more pronounced decrease in contact factors (XII factor, prekalli-krein, high molecular kiningogen). There has been even more active than in full-term transient fibrinolysis in the first hour of life, followed by a deep depression at its very low level of plasminogen and anticoagulants (antithrombin-III, «S» of the protein). Taken together, these changes cause less resistance hemostasis system, a significantly higher incidence of as bleeding and intravascular coagulation in the newborn group. Virtually any abnormality, observed in premature and immature infants, can be complicated by bleeding, or DIC.
Discussion: In this way, according to a survey of literature, the HS of young children are quite common and require more detailed study into force polyetiology state database. In particular, it is a serious problem the neonatal stroke, perinatal stroke, the outcome of which, in the absence of adequate interpretation may be the highest disability, mortality. The greatest number of violations of cerebral circulation on hemorrhagic type (almost a quarter of all cases) were in children under the age of 1.5 years. Currently existing hematological diagnostic methods, not being available to the public (means hemostasiogram), constitute an obstacle to a more adequate assessment of the HS in infants. Determination offibrinogen, APTT, PTI, thrombin time is a screening to determine disorders of hemo-stasis, in particular the disseminated intravascular coagulation.
Thus, the causes of CVD can be malformations of cerebral vessels (aneurysms, arteriovenous malformations), heart disease (malformations, infectious diseases), blood system disorders (coagulopathy, anemia, thrombocytopathy), metabolic and systemic diseases (vasculitis, etc.) What is most important that it is functional immaturity of the liver, especially in infants and young children which requires a more detailed diagnosis through the study and analysis of the hemostatic system.
Conclusions:
1. Virtually every child with persistent jaundice is risk for bleeding, i. e., 50 % of the children in our study had hyperbilirubinemia (indirect) and the protracted nature. The 35 % was observed entanglement fetal umbilical cord at birth, they likely served as background "disadvantage" for children with HS.
2. Anemia during pregnancy 30 (0.75 ± 0.69), uterine inertia — prolonged labor 21 (0.53 ± 0.80) are the main factors subsequent fetal hypoxia.
3. Manifest HS determined expressed concern (87.5 %), seizures (62.5 %), a sharp decrease in motor activity (42.5 %), which should be considered by physicians in the prehospital phase.
4. Determination of fibrinogen, APTT, PTI, thrombin time was a screening to determine disorders of hemostasis, in particular the disseminated intravascular coagulation.
5. To put the disseminated intravascular coagulation for diagnostic value: APTT, PTI, decrease platelet aggregation (even to 0); reduction of antithrombin time. In the presence of normal parameters hemostasiogram it is necessary to conduct an analysis of anticoagulant factors protein C system.
Test name Group HS (n = 40) Control group (n = 20)
Aggregation ADP concentration 2*10-4 ( %) 25.0 ± 5.0 50.0 ± 5.0
APTT, sec. 30.0 ± 2.0 26.0 ± 2.0
Prothrombin index, % 77.0 ± 7.0 96.0 ± 4.0
thrombin time 15.0 ± 2.0 10.0 ± 2.0
Plasma Fibrinogen, g/l 2.9 ± 0.5 3.1 ± 1.0
XII a-dependent fibrinolysis (min.) 20.0 ± 3.0 7.0 ± 2.0
Antithrombin-III, % 99.8 ± 3.0 98.0 ± 2.0
Protein «C», BUT 1.0 ± 0.3 0.9 ± 0.1
Von Willebrand factor, % 94.4 ± 2.0 80.0 ± 10.0
SFMC, mg/ % 9.1 ± 1.1 4.5 ± 0.9
Note: P < 0.05
Indicators n = 40 %
Motherboard
Hepatitis 10 (0.25 ± 0.69) 25
TORCH 9 (0.23 ± 0.67) 22.5
Kidney disease 16 (0.40 ± 0.78) 40
Anemia 30 (0.75 ± 0.69) 75
Endocrine pathology 15 (0.38 ± 0.78) 37.5
Phlebeurysm 7 (0.18 ± 0.61) 17.5
Nosebleeds 5 (0.13 ± 0.53) 12.5
Gynecological diseases 11 (0.28 ± 0.71) 27.5
Perinatal
Premature discharge of water 9 (0.23 ± 0.67) 22.5
Applications obstetric benefits 2 (0.05 ± 0.35) 5
Precipitated labor 13 (0.33 ± 0.75) 32.7
Prolonged labor 21 (0.53 ± 0.80) 52.5
Evidence n = 40 %
Physiological childbirth 34 (0.85 ± 0.57) 85
Cesarean section 6 (0.15 ± 0.57) 15
Heredity 6 (0.15 ± 0.57) 15
Complaints
Bleedings 8 (0.20 ± 0.64) 20
Anxiety 35 (0.88 ± 0.53) 87.5
Vomiting 16 (0.40 ± 078) 40
Seizures 25 (0.63 ± 0.78) 62.5
Movement disorders 17 (0.43 ± 0.79) 42.5
Hemiparesis D 14 (0.35 ± 0.76) 35
Hemiparesis S 9 (0.23 ± 0.67) 22.5
Impaired consciousness 8 (0.38 ± 0.132) 20
Coma 1-stage 3 (0.08 ± 0.42) 7.5
Coma 2-stage 3 (0.08 ± 0.42) 7.5
Coma 3-stage 2 (0.05 ± 0.35) 5.0
Study levels of emotional empathy patients with relapse of opioid dependence
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Tursunhodzhaeva Lyudmila Alexandrovna, Head of the Department of Addiction and adolescent psychopathology of the Tashkent Institute of Postgraduate Education, Republic of Uzbekistan Muzaffarova Lily Zhavdatovna, Assistant, Department of Addiction and adolescent psychopathology of the Tashkent Institute of Postgraduate Education, Republic of Uzbekistan E-mail: [email protected]
Study levels of emotional empathy patients with relapse of opioid dependence
Abstract: Use the "Scale of emotional response» (Balanced Emotional Empathy Scale — BEES) studied the effect of empathy on the emotional level of social adaptation of persons dependent on opioids. Research has shown that in all patients a low level of emotional empathy, which can be seen as a barrier to the successful restoration of family and environmental links between drug addicts in therapeutic remission and impedes their social reinsertion.
Keywords: emotional empathy, relapse, opioid dependence.
The relevance of research of drug addiction [1]. Exploring the personality traits that facilitate
Numerous scientific studies show that the level of social adapta- or hinder its harmonious existence in all spheres of interaction with tion of persons dependent on opioids, is one of the most important the environment, we can successfully meet the challenges of coping factors influencing the stabilization of remission after discontinua- and adaptation of patients with opioid addiction [2; 3; 4]. This, in tion of the drug [5; 7]. Achieving the goals of social rehabilitation, turn, can serve as an additional resource for stabilizing and prolong-re-socialization and reintegration of patients into society substan- ing remission.
tially reduces the risk of recurrent disease [6]. In this connection, The purpose of research: the study of the influence of emo-
great interest is the study of social conditions and personality traits tional empathy to the level of social adaptation of persons dependent that contribute to or hinder the full social rehabilitation of patients on opioids. after therapeutic intervention performed. Material and methods
We have attempted to study the quality of the personality of In terms of Republican Drug Treatment Center (Tashkent) clini-
drug addicts, as emotional empathy, that is, the ability to empathize cal and follow-up method examined 51 male patient with the syn-with another person, the capacity for emotional response to the ex- drome of dependence on opioid drugs series (code ICD-10 F11.2). perience of other people in their daily lives. Studies have shown All patients had repeated (at least three) attempts to treat with
that empathy reflects the level of development of skills of interac- the emergence of drug relapse after a short-term remissions. The tion with other people, so it is closely related to social adaptation average age ofpatients at the time of the survey was 34.2 ± 5.9 years.
