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whereas the favorable outcome of patients experienced a uniform reduction of both cytokines to deadline monitoring. The same dependence observed with IL-4 and TNF-a, remained low in patients with severe forms of the pyo-septic complication (sepsis syndrome and septic shock) and death.
Conclusions:
1. Elevated levels of proinflammatory cytokines source such as IL-6, IL-8 and TNF-a, and expression of their subsequent decline in patients with PSD, may reflect a change in focus of the immune response during treatment by switching
to a cell initially dominant humoral that should be considered as a favorable prognostic indicator.
2. The initial reduced concentration of serum TNF-a and IL-4 suggests expressed cytokine imbalance that same clinic severe sepsis, often with fatal consequences.
3. The lack of decline in IL-6 and IL-8, while increasing the concentration of IL-8, shows significant changes in serum concentrations of cytokines induced and perhaps a sign of growing depletion of the immune system and, consequently, its areactivity.
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Бережная Н. М.. Иммунологические исследования в клинике -состояние вопроса//Иммунология. - 2006. - № 1. -С. 18-23.
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10. Нестерова И. В. Стратегия и тактика иммунотерапии вторичных иммунодефицитных состояний с инфекционным синдромом//Аллергология и иммунология. - 2005. - Том.6, № 2. - С. 302.
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13. Lowry S. F., Van Zee R. L., Rock C. S. Shock, sepsis and Organ failure: Third Wiggers Bernard Conference//Cytokine Network. - Schlag Berlin, 1993. - Р. 3-17.
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9.
Muratova Shakhlo Tahirjanovna, MD, PhD, researcher at the Thyroidology Department of Republican Specialized Scientific and Practical Medical Center of Endocrinology, Uzbekistan.
E- mail thyrlab@list.ru Ismailov Saidganihodja Ibragimovich, MD, PhD, professor, director of Republican Specialized Scientific and Practical Medical Center of Endocrinology, Uzbekistan.
E-mail: endocrin@uzsci.net
Mental characteristics of teenagers with graves' disease in Uzbekistan
Abstract: Thyrotoxicosis affects the intelligence in teenagers. IQlevel of children with Graves' disease (77.8%) were below average (OR = 22.8, 95% CI = 2.8-244.8, p = 0.001) and in 22.2% mild dementia was diagnosed. Keywords: intelligence quotient (IQ), Graves' disease, teenagers.
Nowadays, on state scale and in scientific literature potential of children and teenagers is observed, especially increased attention to issues of health and intellectual in iodine deficiency regions due to high urgency and social
Section 7. Medical science
meaningfulness [3].
Depending on iodine deficiency, incidence of new cases of Graves' disease (GD) in different countries varies from 5-7 to 30-200 per 100,000 people a year [2, 8]. In pediatrics GD is a rare endocrinopathy. Its incidence is 0.1 case per 100,000 preschool children and up to 1-3 cases per 100,000 teenagers [12; 15; 16]. Uzbekistan is a region with severe iodine deficiency [4; 10]. According to 2014 market report of endocrine service of clinics in Uzbekistan, 56 children and 113 teenagers, which is 0.64 and 6.02 cases per 100,000 people accordingly, were diagnosed with diffuse toxic goiter (DTG).
In GD somatogenic exposure on psyche is conditioned by redundant amount of thyroid hormones circulating in blood and activation of sympathetic nervous system via indirect action of catecholamines [11]. Toxins accumulating in blood and hypoxia influence the brain directly which lead to disturbances of neuropsyche [14]. At the same time low prevalence of GD in children considerably limits possibility of carrying out large control studies in this age group [5, 6]. Nevertheless, scientific publications with high level of validity which actually prove associative connection of thyrotoxicosis and high risk of mental disorders development appeared only recently [9; 13]. It should be noted, however, that the majority of existing works deal with psycho-cognitive state of adults with GD (i.e., older than 18 years old) not with those of children and teenagers.
Research objective:to study IQin children and teenagers with GD.
Materials and methods
18 teenagers with GD were observed in Republican Specialized Scientific and Practical Medical Center of Endocrinology under the Ministry of Health of the Republic of Uzbekistan (RSSPMC of Endocrinology), Tashkent, Uzbekistan. Comparison group included 15 healthy children (control group). Diagnosis of thyroid gland pathology was made basing on clinical data (examination, palpation), laboratory research, radioimmunoassay (TSH, free T3, free T4, Ab-TPO), aspiration fine-needle biopsy (if necessary), and thyroid gland ultrasound. From the moment of diagnosis, all GD children underwent standard adequate thyrostatic therapy by preparations registered on the territory of the republic of Uzbekistan.
In order to determine IQ level House-Tree-Person test (HTP) developed by John Buck in 1948 was used [1]. The choice of abovementioned items for drawing is reasoned by the fact that they are familiar to every subject and easy to draw while rang correlation coefficient with other tests for intellect evaluation is 0.4-0.75 [1]. In HTP level of mental development is determined from the point of view of basic information (detail), spatial correlations (proportions and perspective), formed concept (basing on arrangement and quality of a picture in general), reproduction of memory images and their combination on 2 or 3 measured drawings. Due to simplicity of expression mean (drawing), subjects,
who may find it difficult to express orally, can show on pictures their hidden mental abilities or their potential. This matches with the data of traditional diagnostics of intelligence with the help of a drawing [8]. HTP test taken by teenagers in this research reflects the level of their mastering of key concepts and hence indicates level of mental developmentsufficiently apart from acquired knowledge and skills [7].
Subjects were offered with a standard white blank A4 sheet of paper, a 2M pencil and an eraser. The following instructions were given: "Please, draw a house as good as you can. You can draw a house of any type, any you wish. You can erase your drawing as much as you like - it will not influence your assessment. You may think over your drawing as much time as you need. Just try to draw a house as best as you can. Then, please, draw a tree and a person just as best as you can." Next the analysis according to the plan developed was carried out. Then, with the help of special tables all results were transferred into IQ[1]. Thus, system of quantitative HTP test handling gives several measurement units correlation of which has diagnostic meaning and shows actual IQ level, which can be lowered by so called non-mental personality traits including somatic genesis (reversible and irreversible).
Statistical analysis of the results was made on Microsoft Excel and STATISTIKA._6 programs. In order to evaluate importance of differences between samples, odds ratio (OR) and 95% confidence interval (95% CI) for mean difference were calculated. x2 was used for statistical analysis of differences of two groups by quality features distribution.
Results and discussion
Average age of the teenager subjects in control group was 13.7±0.2 years, with gender distribution of 7 (46.7%) girls and 8 (53.3%) boys. Average age of the teenager subjects in GD group was 13.8±0.6 years and there were no valid differences found compared to control group yet gender distribution differed reliably - GD was 8 times more often diagnosed in girls than in boys (16 cases (88.9%) against 2 cases (11.1%), accordingly), x2=6,9, p=0.01, OR = 9,1, 95% CI = 1.2-84.6). Duration of thyrotoxicosis in teenagers was from 2 months to 8 years, 3±0.6 average.
Quantitative analysis of IQlevel HTP test results showed that in teenagers in thyrotoxicosis group percent of raw G-points was 17.6 points lower compared to those in control group (p<0,001). After transferring these values into IQ this index appeared to be 29.2 points lower and as a mean corresponded to lower average IQlevel (Figure 1).
Share of raw G-points indicates potential (not implemented today) level of mental functioning, while net balanced estimate - of current intelligence. When comparing mean of net balanced estimate of teenagers in control group with those in GD difference appeared to be quite significant and made 71.1 points (p<0.001). Net balanced estimate of GD teenagers was 3.5 times lower that of control group teenagers. In children with thyrotoxicosis these results in IQ equivalent were lower average while in children from control group they were above average (Figure 2).
Control group
GD
115,3
Raw G-points, % |Q
Figure 1. Raw points, %, and IQ HTP test results in GD group of teenagers
GD
150
lOO
118.7
50
Net balanced estimate
Figure 2.Net balanced estimate and IQ
Mean of IQfrom raw G-points and IQfrom net balanced estimate in children with thyrotoxicosis did not differ reliably (p>0.05). It is assumed that IQ percent of raw G-points represents awareness of the subject and understanding of basic spatial correlations which are quite rough and precise components of mental functioning, while net balanced estimate of IQ represents assessment of developed concepts in subject which is a little bit more subtle and abstract
IQ
results of HTP test in teenagers with GD
component of mental functioning. Nevertheless, lower mean of net balanced estimate (27.9±6.1) were diagnosed in teenagers with thyrotoxicosis compared to raw G-points results (70.7±2.0, p<0.001), which probably indicates influence of emotional and/or organic factors.
Analysis of averaged IQresults in all groups showed that GD children had lower IQcompared to healthy ones, p<0.001 (Figure 3).
Averaged IQ
112.5 j
82.1
11
r
Control group
Figure 3. Averaged IQ HTP
When studying individual results of mean IQit was revealed that intelligence level in majority of healthy children (13/86.7%) was above average and only in two children (13,3%) — below average. While in GD group majority ofchildren (14/77.8%) were with IQlevel below average (OR = 22.8, 95% CI = 2.8-244.8, p = 0.001) and in 22.2% (4 subjects) mild dementia was diagnosed.
It should me mentioned that among thyrotoxicosis group the worst results were connected with proportions. We can assume that due to thyrotoxicosis teenagers' abstract-logical thinking disturbs while specific-conceptive remains, shift from perceptional cognition to rational and from specific generalization to abstract are impeded.
DTG
test results in teenagers
Conclusion
1. Lower IQresults were shown in GD group compared to healthy children group which indicates active involvement of intelligence in pathogenetic mechanisms of developing structural and functional disturbances in thyrotoxicosis.
2. Formation of mental deviations may be considered as cognitive thinking development disturbance.
3. There is a need in further study of mental abilities of teenagers with GD.
4. Further psychological rehabilitation of children with thyroid pathology and detection of disturbances in cognitive sphere seem to be important.
