Relationship between hemostatic indexes and severity of pneumonia in children in Hainan
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https://www.eduzhai.net American Journal of Medicine and Medical Sciences 2021, 11(8): 557-562 DOI: 10.5923/j.ajmms.20211108.02 Relationship of Hemostasis Indicators and Severity of Pneumonia in Children from the South Area of Aral T. A. Bobomuratov1,*, U. U. Yusupova2, M. M. Bakirova2, N. A. Karimova2, J. N. Abduraxmonov3 1Prof. Head of the Department of Propaedeutics of Children’s Diseases of the Tashkent Medical Academy, Tashkent, Uzbekistan 2Teacher of the Department of Propaedeutics of Children’s Diseases of the Tashkent Medical Academy, Tashkent, Uzbekistan 3Teacher of the 3rd Pediatric and Genetics Department Samarkand State Medical Institute, Uzbekistan Abstract Object. To assess the features of the clinical course and the hemostasis system in children with acute pneumonia in environmentally unfavorable living conditions. Methods. We studied 55 children with acute community-acquired pneumonia aged 1 to 3 years living in different regional conditions, of which 35 sick children (main group), permanently residing in the Aral Sea region (in the Khorezm region) and 20 children with community-acquired pneumonia (comparison group) living in Tashkent. The control groups consisted of 20 practically healthy children permanently residing in the Aral Sea region (in the Khorezm region) and 20 children with community-acquired pneumonia living in Tashkent. Results: the main risk factors for the development of community-acquired pneumonia in patients living in ecologically unfavorable regions was a premorbid background. Analysis of the data obtained showed that 89.1% of children admitted to inpatient treatment had concomitant diseases. In this case, rickets were diagnosed in 80.0% of children, protein-energy deficiency of PEM - in 62.9% of children, anemia - in 97.1% of children. Whereas in children from Tashkent, the burden of premorbid background was recorded in 65% of children, which is 24.1% lower than in children from Khorezm. The severity of the condition of the children at admission was assessed as moderately severe - in 48.6% of cases in the main group and as severe - in 51.4% of cases, in the comparison group 45% of children were admitted to a serious condition, and 55% - in a moderately severe condition. The unfavorable influence of the ecological environment on the development of imbalance in the hemostasis system, characterized by the transition of hypercoagulation to hypocoagulation in 45.7% and the development of hemorrhagic syndrome, has been established. In children living in Khorezm, the indicators of the coagulation link of the hemostasis system showed high thrombotic readiness for DVS syndrome. The imbalance of hemostasis indices dictates the advisability of correcting and preventing these conditions for more successful control over the process and timely complete treatment. Keywords Acute pneumonia, Hemostasis system, Ecology Ecology and health of the population of the Aral Sea region is an urgent problem not only for Uzbekistan, but for the entire world community [3,5]. The poor environmental situation is a heavy burden on the entire population of the Republic of Karakalpakstan, but children are especially affected, since the child's body, due to the functional immaturity of tissues and systems of adaptation and protection, is especially sensitive to the influence of environmental factors. Recently, due to significant environmental pollution, the problem of the environment and its impact on the health of the child has become one of the most pressing . In connection with the deterioration of the ecological situation in the world, for medical science in general and * Corresponding author: firstname.lastname@example.org (T. A. Bobomuratov) Received: Jul. 1, 2021; Accepted: Jul. 23, 2021; Published: Aug. 15, 2021 Published online at https://www.eduzhai.net preventive medicine in particular, ecologically dependent diseases are of particular interest. The largest percentage of them are diseases of the respiratory system. Changes in the environment in the Aral Sea region are reflected in the health of the younger generation in many ways, it is an increased incidence of respiratory diseases, among which acute respiratory infections, bronchitis and pneumonia come out on top . According to the World Health Organization (WHO), pneumonia is the most frequent cause of death of children in the world, in particular, in the structure of mortality of children under 5 years of age, it is 17.5%, annually claiming the lives of about 1.1 million children in this age group (WHO, 2016). The prevalence of pneumonia among children and adolescents in the Republic of Uzbekistan ranges from 17.7% to 19.5% . In young children and children with a burdened premorbid background, regardless of age, with all clinical forms of ARI, in older children - with severe forms, including complicated 558 T. A. Bobomuratov et al.: Relationship of Hemostasis Indicators and Severity of Pneumonia in Children from the South Area of Aral ones . The severity and duration of these changes in the immunity of children with infectious diseases is influenced not only by age, but also by the state of the premorbid background, ecological living conditions, and other reasons. Currently, the inflammatory process as part of the body's response to the course of pneumonia outside the influence of the hemostasis system cannot be considered, since the influence of the blood coagulation system on the course of the inflammatory process is important in the pathogenesis of the disease . There are isolated studies devoted to the study of the state of the hemostatic system in pneumonia in children. Involvement of the hemostatic system in an acute purulent-destructive process is characterized by a different direction of changes and the absence of certain patient examination schemes to obtain complete information about the nature and stage of the process . A feature of pneumonia in children is the frequent development of infectious-toxic shock with impaired hemostasis according to the type of consumption phase DIC syndrome . An acute inflammatory process in the lungs leads to a disruption of their metabolic function, which is manifested in the loss of the lungs' ability to regulate the balance of proteases-antiproteases of the hemostatic system . According to a number of authors, in children with various forms of acute bronchopulmonary pathology, the imbalance of proteases-antiproteases of the blood hemostasis system depends on the severity of the pathological process in the lungs, manifested in the activation of procoagulant and anticoagulant insufficiency of blood coagulation links . However, the degree and nature of the revealed changes in hemostasis indicators in children with pneumonia indicate the presence of current intravascular blood coagulation , the severity of which directly depends on the severity of the pathological process in the lungs [6,8]. The state of this problem in pediatrics dictates the need for more extensive research and substantiated conclusions about the state of the hemostatic system. Khorezm region) and 20 children with community-acquired pneumonia living in Tashkent. The average age of children in the main group was 1.95 ± 0.14 years, while the average age in the comparison group was 2.19 ± 0.21 years. The frequency of occurrence of boys in the main group was 40%, and for girls - 60%, in the comparison group, boys and girls were observed in 50% of cases, respectively. The diagnosis was verified according to the classification of the main clinical forms of bronchopulmonary diseases in children, approved at a special meeting of the XVIII National Congress on Respiratory Diseases (2009). In 100% of cases, the diagnosis of community-acquired pneumonia was verified by chest X-ray. Inclusion criteria: age from 1 to 3 years; informed consent; clinically and radiologic ally confirmed community-acquired pneumonia, absence of concomitant bacterial infections. Exclusion criteria: non-compliance with inclusion criteria; the presence of chronic respiratory diseases (bronchial asthma); a history of repeated cases of pneumonia, malformations of the bronchopulmonary system. The homeostasis system included determination of prothrombin time (PT), fibrinogen concentration (FIB), partial thromboplastin time (APTT) activity, prothrombin index (PTI) on the apparatus (HUMAN CLOT DUO plus), platelet count using an analyzer - "Couiter MD", coagulation blood according to Fonio. To assess the reference values, a control group was created, consisting of 20 apparently healthy children of the same age and gender. Statistical processing of the research results was carried out using modern computing systems such as IBM using the standard Excel software package. To identify the relationships between the analyzed indicators, a correlation analysis was performed using the correlation coefficient and checking its significance using the Student's t and Pearson χ2 tests. 1. Object To assess the features of the clinical course and the hemostasis system in children with acute pneumonia in environmentally unfavorable living conditions. 2. Methods We studied 55 children with acute community-acquired pneumonia aged 1 to 3 years living in different regional conditions, of which 35 sick children (main group), permanently residing in the Aral Sea region (in the Khorezm region) and 20 children with community-acquired pneumonia (comparison group) living in Tashkent. The control groups consisted of 20 practically healthy children permanently residing in the Aral Sea region (in the 3. Results The main risk factors for the development of community-acquired pneumonia in patients living in ecologically unfavorable regions was a premorbid background. Analysis of the data obtained showed that 89.1% of children admitted to inpatient treatment had concomitant diseases. In this case, rickets were diagnosed in 80.0% of children, protein-energy deficiency of PEM - in 62.9% of children, anemia - in 97.1% of children. Whereas in children from Tashkent, the burden of premorbid background was recorded in 65% of children, which is 24.1% lower than in children from Khorezm. The severity of the condition of the children at admission was assessed as moderately severe - in 48.6% of cases in the main group and as severe - in 51.4% of cases, in the comparison group 45% of children were admitted to a American Journal of Medicine and Medical Sciences 2021, 11(8): 557-562 559 serious condition, and 55% - in a moderately severe condition. ... Children from Khorezm were more often admitted to the hospital in a serious condition in relation to children living in Tashkent, however, there was no reliability between the data (P >0.05). Table 1. Characteristics of the examined children with community-acquired pneumonia Forms of pneumonia Age, years (M±m) Condition upon admission: moderate (n/%) heavy (n/%) Focal pneumonia (n/%) Segmental pneumonia (n/%) Lobar pneumonia (n/%) Unilateral pneumonia (n/%) Bilateral pneumonia (n/%) Main group (n=35) (abs) (%) 2,19±0,21 Comparison group (n=20) (abs) (%) 1,95±0,14 18 51,4 9 45 17 48,6 11 55 25 71,4 11 55 9 25,7 6 30 1 2,9 3 15 20 57,1 16 80 15 42,9 4 20 Focal pneumonia was more common in the main group (71.4% versus 55%, respectively), while segmental pneumonia was less common (25.7% versus 30%, respectively), but the indicators were not reliable. Most often in the comparison group, lobar pneumonia is recorded (15%), while in the main group its percentage was 2.9% (P <0.05). In children of the Khorezm region, bilateral pneumonia was observed significantly more often during examination (42.9% versus 20%; P <0.05). An objective examination in children of the main group showed pronounced symptoms of intoxication and respiratory failure, which were characterized by hyperthermic syndrome (average body temperature 39.9 ± 0.10), hyperventilation with an average respiratory rate of 77.2 ± 0.2 per minute. A wet cough was noted in 85.7% of children. In 100% of the main group, there was a pallor of the skin with a pronounced marble tint and cyanosis of the nasolabial triangle. The participation of the auxiliary muscles in the act of breathing with retraction of the compliant areas of the chest occurred in 98.2%. Auscultation in 78.2% of cases over the affected areas of the lungs heard dry fine bubbling moist rales. The boundaries of relative cardiac dullness were somewhat expanded in 65.5% of cases, manifestations of sinus tachycardia occurred in 82.9% of patients. It should be noted that in all 17 children of the main group with a symptomatic complex of severe pneumonia with manifestation of microcirculatory disorders, all cases were accompanied by bleeding from the injection sites. Two-thirds of the children had obvious oliguria (70.3%), and in one-third of the patients, the daily volume of urine was significantly reduced (less than 52%). In 14 (40.0%) children of the main group, extravagates of a hemorrhagic nature were revealed, which, as a rule, was combined with bloody vomit in the form of coffee grounds and tarry stools. One child had hemorrhage into the conjunctiva, and two children (8.6%) had epitasis. All children of the comparison group showed symptoms of intoxication, accompanied by an increase in temperature from 38.8 ± 0.5°C in combination with manifestations of microcirculatory disorders in the form of pallor of the skin with a marble tint (100%). Intoxication syndrome was accompanied by severe respiratory failure with an increase in respiratory rate in 85% of cases. In 3/4 of the patients, cyanosis of the nasolabial triangle was observed. In 2/3 of patients in this group, fine-bubbling moist rales were heard auscultation at the height of inspiration. A change from the side of the cardiovascular system in the form of some muffling of heart sounds was observed in 85% of patients, and in 95.0% there was a manifestation of sinus tachycardia. On the part of the urinary system, practically all patients (97.1%) had oliguric phenomena with a decrease in daily urine output in the range from 62.0% to 74.0%. It should be noted the aforementioned symptoms of intoxication, respiratory failure with manifestations of stasis on the skin (marble shade), in 55.0% of cases there was bleeding from the injection sites. Bloody vomiting in the form of coffee grounds was observed in 25.0% of children, tarry stools were observed in ¼ of the patients. In the general blood analysis of patients in the comparison group with pneumonia, the number of erythrocytes was within 3.9x1012 / l, hemoglobin (107.5 ± 1.1 g / l), leukocytes (10.1 ± 0.6x109 / l) with a stab shift (10.5 ± 0.1%), ESR (17.5 ± 1.1 mm / h), which indicates a tendency to anemia, leukocytes, accelerated erythrocyte sedimentation rate in this category of children. In the gemmogram in children of the main group, a clear tendency to anemization (Er 3.15 ± 0.2x1012 / l; HB 89.5 ± 1.3 g / l), leukocytosis (15.3 ± 0.3x109 / l) with a noticeable stab shift (28.5 ± 1.1%) and acceleration of ESR (29.5 ± 1.2 mm / h). The revealed changes in the peripheral blood of an infectious and inflammatory nature in patients from the comparison group were moderate, and in patients of the main group they were more significant. The development of the inflammatory process in acute pneumonia cannot be imagined without changes in the hemostatic system, since the coagulating and anti-coagulating blood system is especially important in the pathogenesis of this disease. In the coagulogram of sick children from Tashkent, the blood coagulation time according to Lee-White (7.2 ± 0.12 minutes) was significantly longer (p <0.05), and in sick children from Khorezm (11.4 ± 0, 22 min.) - significantly longer (p <0.001), compared with the same indicator for healthy children (5.7 ± 0.14 min). 560 T. A. Bobomuratov et al.: Relationship of Hemostasis Indicators and Severity of Pneumonia in Children from the South Area of Aral At the same time, the content of fibrinogen and prothrombin index in patients of the comparison group (276.95 ± 14.3 mg / L; 116.2 ± 8.2%, respectively) and patients of the main group with pneumonia (256.7 ± 15.8 mg / L; 98.5 ± 6.3%, respectively) was significantly higher compared to the same indicators in the control group (p <0.001). The APTT indicators in the children of the comparison group were within the standard values and did not have a significant difference in comparison with the control group (24.87 ± 1.6 sec and 27.9 ± 1.3 sec, respectively). However, in children living in Khorezm, there is an increase in this indicator both in relation to the comparison group and in relation to the control group (33.73 ± 1.9 sec, 27.9 ± 1.3 sec and 24.87 ± 1, 6 sec respectively). In children from the main group, the INR values tended to increase in relation to the data of the control group and the comparison group (1.19 ± 0.05% versus 1.13 ± 0.03 and 1.07 ± 0.04%, respectively), which indicates the risk of developing hemorrhagic syndrome (Fig. 1). PTI 140 120 100 80 INR 60 40 20 0 APTT Thrombin Fibrinogen Comparison group Main group Control Figure 1. Percentage deviation of homeostasis indices from control values in children with community-acquired pneumonia, depending on the region of residence When analyzing laboratory parameters in 25% of patients in the comparison group and in 14.3% of patients in the main group, normal or insignificant changes in indicators were revealed, in 20% of patients in the comparison group and in 40.0% of children in the main group, compensatory hypercoagulation was revealed, in 55% of patients the comparison group revealed sub compensatory hypercoagulation, in 45.7% of sick children from the main group, decompensatory hypercoagulation was revealed (transition of hypercoagulation to hypocoagulation, various bleeding). In children living in Khorezm, the indicators of the coagulation link of the hemostasis system showed high thrombotic readiness for DIC syndrome. Timely unfulfilled corrective therapy in sick children with hypercoagulable syndrome led to a further deterioration in their general condition and the transition of the hypercoagulable state to decamping changes. 4. Discussion It should be noted that in the future, the doctrine of hemostasis was made by G.F. Lang. After his discoveries in the field of hemostasiology, science has stepped forward in this regard, and now we know a lot about the functional system of hemostasis. The components of the hemostasis system conditionally perform the following functions: 1. The primary role belongs to the blood vessel, which spasm and secrete factors that attract platelets to the site of damage. A special place is occupied by blood corpuscles, mainly platelets. Erythrocytes and leukocytes are also actively involved, lingering in the fibrin filaments and increasing the mass of the thrombus, and also contain most of the factors of the blood coagulation system. Plasma factors of the blood coagulation system, which are contained in large quantities in the lumen of blood vessels, also participate. At the same time, the balance and anticoagulation factors of the blood regulate. In people of different age groups, especially in newborns and children of the first year of life, the hemostasis system is considered to be quite an invaluable biological system that allows blood to remain in a liquid state under physiological conditions, responds in a timely manner to damage to the vascular wall, forms a clot in order to prevent bleeding or the development of a pathological process (DIC syndrome). In many works, the parameters of hemostasis are presented, based on the study of blood obtained from the umbilical cord vessels. Meanwhile, it turned out that the parameters of hemostasis in this non-circulating blood, in which, moreover, the process of thrombus formation has started, differ significantly from those in the general blood flow. Physiological and pathological changes in hemocoagulation in newborns were also not clearly distinguished, which complicates the diagnosis and timely correction of hemorrhagic and thrombohemorrhagic diseases and syndromes in them. Only in recent years, on the basis of new methodological approaches and a more versatile study of the hemostasis system, the ambiguities and mistakes of the past began to be overcome, a unified concept was formulated about physiological and pathological shifts in the hemostasis system in newborns and children of the first year of life, which determines the death of a patient with bacterial infections. 5. Conclusions 1. The unfavorable influence of the ecological environment on the development of imbalance in the hemostasis system, characterized by the transition of hyper coagulation to hypocoagulation in 45.7% and the development of hemorrhagic syndrome, has been established. 2. 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