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УДК 617-002.3-036.22-053.2 DOI 10.24412/2220-7880-2021-4-18-22
PECULIARITIES OF THE COURSE OF PURULENT-SEPTIC DISEASES IN CHILDREN IN THE COMMONWEALTH OF INDEPENDENT STATES: A MULTICENTER STUDY
'Razin M.P., 2Yusupov Sh.A., 2Shamsiev J.A., 3Minaev S.V, 4Aksel'rovM.A., 1Agalakova T.B., 1Suetina I.G., 'Semakin A.S., 3Timofeev S.I.
'Kirov State Medical University, Kirov, Russia (610027, Kirov, K. Marx St., 112), е-mail: [email protected] 2Samarkand State Medical Institute, Samarkand, Republic of Uzbekistan (140100, Samarkand, A. Temur St., 18), e-mail: [email protected]
3Stavropol State Medical University, Stavropol, Russia (355017, Stavropol, Mira St., 310) 4Tyumen State Medical University, Tyumen, Russia (625023, Tyumen, Odesskaya St., 54)
In recent years a significant decline in the incidence of purulent-septic diseases has been recorded in many regions of the Commonwealth of Independent States (CIS). However, the problem remains urgent for pediatric surgery. In 1995-2014 we studied 2 groups of the patients: 3337 children with destructive pneumonia, diffuse appendicular peritonitis and acute osteomyelitis treated in pediatric surgery clinics in Kirov Region, Stavropol Territory and Tyumen Region and 2636 patients with the same diseases treated in Samarkand State Medical Institute of the Republic of Uzbekistan interregional clinic of pediatric surgery. Two chronological periods -1995-2004 and 2005-2014 - were studied and compared. It has been found that in the second period these septic diseases were much less common. The largest decrease in the number of the patients with destructive pneumonia (-74.4%) and diffuse appendicular peritonitis (-52.8%) was observed in Tyumen Region; while the number of the patients with osteomyelitis decreased greatly in Kirov (-68.3%). In the southern regions of the Russian Federation (North Caucasus, Central Asia) the decrease in the number of the patients with septic diseases was the least. Thus, differences in the incidence and local features of the course of purulent-septic diseases in children require patient-centred approach while organizing and providing pediatric surgical service.
Keywords: destructive pneumonia, appendicular peritonitis, acute hematogenous osteomyelitis, children.
ОСОБЕННОСТИ ТЕЧЕНИЯ ГНОЙНО-СЕПТИЧЕСКИХ ЗАБОЛЕВАНИИ У ДЕТЕЙ В РАЗНЫХ РЕГИОНАХ СОДРУЖЕСТВА НЕЗАВИСИМЫХ ГОСУДАРСТВ: МУЛЬТИЦЕНТРОВОЕ ИССЛЕДОВАНИЕ
1Разин М.П., 2Юсупов Ш.А., 2ШамсиевЖ.А., Минаев С.В., 4Аксельров М.А., 1Агалакова Т.Б., 'Суетина И.Г., 1Семакин А.С., 3Тимофеев С.И.
'ФГБОУ ВО «Кировский государственный медицинский университет» Минздрава России, Киров, Россия (610027, г. Киров, ул. К. Маркса, 112), e-mail: [email protected]
2«Самаркандский государственный медицинский институт» Минздрава Республики Узбекистан, Самарканд, Узбекистан (140100, г. Самарканд, ул. А. Темура, 18), e-mail: [email protected]
3ФГБОУ ВО «Ставропольский государственный медицинский университет» Минздрава России, Ставрополь, Россия (355017, г. Ставрополь, ул. Мира, 310)
4ФГБОУ ВО «Тюменский государственный медицинский университет» Минздрава России, Тюмень, Россия (625023, г. Тюмень, ул. Одесская, 54)
Несмотря на то, что в последние годы во многих регионах СНГ зафиксирован существенный спад заболеваемости гнойно-септическими заболеваниями (ГСЗ), проблема остается актуальной для детской хирургии. Авторами исследованы 2 группы больных за период 1995-2014 гг.: 3337 детей с деструктивными пневмониями (ДП), распространенным аппендикулярным перитонитом (РАП) и острым гематогенным остеомиелитом (ОГО), пролеченных в клиниках детской хирургии регионов Российской Федерации (Кировская и Тюменская области, Ставропольский край), и 2636 больных с теми же заболеваниями, пролеченных в межрегиональной клинике детской хирургии СамМИ (Республика Узбекистан). Изучались два хронологических периода - 1995-2004 и 2005-2014 гг. Выяснено, что эти ГСЗ стали встречаться во втором периоде существенно реже, чем в первом. Наибольшее снижение количества больных с ДП (-74,4%) и РАП (-52,8%) характерно для Тюменской области; с ОГО (-68,3%) - для Кировской. В меньшей степени снижение количества больных ГСЗ коснулось южных регионов (Северный Кавказ, Центральная Азия). Таким образом, различная структура заболеваемости и территориальные особенности течения ГСЗ у детей в различных регионах СНГ требуют персонифицированного подхода в организации и оказании детской хирургической помощи.
Ключевые слова: деструктивная пневмония, аппендикулярный перитонит, острый гематогенный остеомиелит, дети.
Timely diagnosis and appropriate treatment of purulent-septic diseases (PSD) in children remain currently important due to wide spread and severity of the pathology [1, 2]. In recent decades, there has been a decrease in the incidence of PSD with quantitative change in the nosological spectrum of the pathology [3, 4]. It is associated, firstly, with changes in pathomorphosis of pathogens, secondly, with the widespread use of modern diagnostic methods that allow for full recovery before septic complications develop, and thirdly, with the use of new more effective treatments and medicines [5-10]. More than that, the regions that differ significantly from each other geographically had different levels of socio-economic development in the Soviet era. Modern characteristics of these tendencies have received limited attention in specialist literature. Endogenous intoxication syndrome is one of the most common pathogenetic syndromes in children with PSD, which is, in our opinion, the most important factor in possible improvement of therapy measures [4, 8, 9, 11, 12].
Material and methods
We retrospectively analyzed medical charts of 3,747 patients (aged 1-15 years) with PSD who were treated in the emergency pediatric surgery of Kirov State Medical University, Tyumen State Medical University, Stavropol State Medical University and Samarkand State Medical Institute of the Republic of Uzbekistan (the interregional center for five regions of the South-Western region of the Republic of Uzbekistan) from 1995 to 2004. 851 patients had destructive pneumonia (DP), 976 children had diffuse appendicular peritonitis (DAP) and 1920 patients had acute hematogenous osteomyelitis (AHO). All the children received generally accepted intensive therapy
(infusion, detoxification, antibacterial, heparin therapy, hydro-electrolitic (HE) and acid base (AB) balance correction, syndromic therapy, topical treatment). Empiric antibiotic therapy included cefomandol and tobramycin. Group 1 included 150 patients with each of the nosological forms of the pathology (450 people, blind sampling).
Since 2005, non-specific immunosupportive therapy (normal human immunoglobulin, NHI) has been used in our clinic for emergency treatment of patients with PSD. Initially antibiotic therapy included second generation cephalosporin and aminoglycoside. During this chronological period, we formed Group 2 out of 2217 patients (510 children diagnosed with DP, 585 patients diagnosed with DAP and 1122 patients diagnosed with AHO). The latter included 204 children with DP, 206 children with DAP and 327 children with AHO (737 patients, all received NHI). NHI was administered on the 2nd day after the admission to the emergency pediatric surgery (EPS) if there were clinical and laboratory signs of inflammation. NHI was given intravenously at a dose of 3-4 ml per 1 kg of the body weight (but not more than 25 ml) in accordance with the instruction, one infusion as a rule. In some patients, reinfusion was required (with an interval of 7 days), but we excluded such children from the study.
An arithmetic average and mean squared error (MSE) were calculated. Statistical confidence (p) was determined using variation statistics. The material obtained in the study of the patients was compared with the results of the study of the same indicators in 400 children of the same age in health status groups I and II (100 people from each region, the control group), Groups 1 and 2 were compared with one another, as well. Statistical
calculations were performed on a personal computer using Microsoft Excel and Statistica 6.0 for Windows (Statine., USA). The level of statistical significance was recorded at p<0.05. Correlation analysis according to Mann - Whitney was carried out by calculation of the U-empirical criterion and determination of the zone in
which the results were located (significance, uncertainty, insignificance).
Results and discussion
The research reveals a significant decrease in the number of the patients with PSD in all the regions.
Table 1
Regional Distribution of the Patients with PSD in Accordance with the Nosological Form
of the Disease, Absolute Values
Region Nosological Forms Total
DP DAP AHO
1995 -2004 2005 -2014 1995 -2004 2005 -2014 1995 -2004 2005 -2014
Kirov Region 58 24 183 160 290 92 807
Stavropol Territory 171 99 322 188 487 316 1583
Tyumen Region 82 21 207 99 355 183 947
Kirov Region, Stavropol Territory and Tyumen Region together 311 144 712 447 1132 591 3337
Samarkand Interregional Center 540 375 264 138 788 531 2636
Total 851 510 976 585 1920 1122 5973
This decrease was more significant for Tyumen region (-52.9%), and less significant for Samarkand Interregional Center (-34.4%). In Kirov region, cases of AHO (-68.3%) and DP (-58.6%) in Tyumen Region cases of DP (-74.4%) and DAP (-52.8%), in Samarkand
cases of DAP (-47.7%) became much less frequent. In Stavropol Territory, there was no significant difference in various nosological forms of PSD. On average, the greatest decrease in the number of the patients with PSD by 41% was stated (Tables 1 and 2).
Таble 2
PSD Morbidity Dynamics in 2005-2014 in comparison with 1995-2004, %
Region Nosological Forms Total
DP DAP AHO
Kirov Region -58,6 -12,6 -68,3 -48,0
Stavropol Territory -42,1 -41,6 -35,1 -38,5
Tyumen Region -74,4 -52,8 -48,4 -52,9
Samarkand Interregional Center -30,6 -47,7 -32,6 -34,4
average -40,07 -40,06 -41,56 -40,83
On admission to the EPS all the patients in Group 1 had leukocytal intoxication index (LII, according to Ya.Ya. Kalf-Kalif, T.V Krasovskaya and N.V. Beloborodova) and middle molecules (MM). The SM norm was taken as a value of 0.240±0.10 un.p.pl. LII in group 1 patients upon admission to the ICU was 6.32±0.31 (p<0.001).
The value of 0.240±0.10 units of optical density was taken as the norm of MM.
LII in Group I patients upon admission to the EPS was 6,32±0,31 (p<0,001). The normal MM level was recorded as 0.442±0.021 (p<0.001).
Таble 3
Changes in clinical and laboratory parameters in DP patients
A Parameter Group 1, n=150 Reference Range Group 2, n=204 Reference Range P Exact Value
LII upon admission 3,40-3,82 3,03-3,91 0,0238
LII upon discharge from the EPS 1,03-1,29 1,22-1,41 0,0311
MM upon admission, units of optical density 0,314-0,415 0,308-0,398 0,0202
MM upon discharge from the EPS, units of optical density 0,286-0,334 0,204-0,292 0,0011
Bed-day in the EPS 4,00-9,00 3,00-6,00 0,4676
All the children received conventional intensive (ICU). The LII was 3.65±0.23 (p<0.001), the MM level care without NHE. As the condition stabilized, the was 0.310±0.004 with the same reliability. patients were transferred from the intensive care unit
ruble 4
Changes in clinical and laboratory parameters in DAP patients
A Parameter Group 1, n=150 Reference Range Group 2, n=206 Reference Range P Exact Value
LII upon admission 6,50-7,52 6,50-7,12 0,0223
LII upon discharge from the EPS 4,00-4,61 3,55-4,43 0,0844
MM upon admission, units of optical density 0,509-0,551 0,460-0,567 0,0450
MM upon discharge from the EPS, units of optical density 0,295-0,305 0,244-0,267 0,0027
Bed-day in the EPS 3,00-4,00 2,00-4,00 0,9502
The average EPS bed-day in patients of this group was 5.30±0.52.
Таble 5
Changes in clinical and laboratory parameters in AHO patients
A Parameter Group 1, n=150 Reference Range Group 2, n=323 Reference Range P Exact Value
LII upon admission 6,94-8,00 5,72-6,99 0,0012
LII upon discharge from the EPS 3,46-4,18 2,14-3,32 0,0001
MM upon admission, units of optical density 0,370-0,410 0,380±0,410 0,0799
MM upon discharge from the EPS, units of optical density 0,284-0,296 0,269-0,295 0,0860
Bed-day in the EPS 3,00-6,00 3,00-4,00 0,8802
We were interested in whether there is a correlation between these important laboratory parameters and the intensive care bed-day. So, we carried out a correlation analysis, the Mann - Whitney criterion was calculated. It turned out that the size of the resuscitation bed-day did not correlate with LII on admission (Uemp=298, the result is in the zone of uncertainty), but correlated with MM level on admission (Uemp=0, the result is in the zone of significance).
,65±0,2 )
94z0,40#
,442+0,021'
Л
io±oroh4
225±0,00 #
,99±0,26#
LU upon admission LU upon discharge MM upon admission MM npon discharge
Bed-dry in the EPS
О Gronp2 □ Gronp 1
Fig. Dynamics of selected clinical and laboratory parameters in patients of different groups (*p<0.001 if compared with healthy patients, # p< 0.05-0.01 if compared with Group 1)
2217 patients with PSD were treated in 2005-2014 (510 patients with DP, 585 patients with DAP and 1122 patients with AHO). Group 2 included 204 children with DP, 206 children with DAP and 327 children with AHO (737 patients in total, all of them received NIT). The LII in the patients of Group II, when transferred to the general department, was 2.94±0.40 (p<0.001), the MM level was 0.225±0.003. The resuscitation bed-day in this group was 3.99±0.26 (Fig.). All the facts above prove that administration of nonspecific human immunoglobulin helps to minimize the manifestations of endogenous intoxication syndrome and contributes to a shorter period of time in the EPS.
Our earlier research [12] found that Staphylococcus aureus was the main etiological agent in 552 children with PSD (88.4% of all the cases). More than that, the increase in the incidence of multiresistant strains of staphylococci and enterobacteria makes it necessary to carry out bacteriological monitoring of discharge from wounds for early antibiotic therapy correction.
In the paper [13] the authors mentioned that in the United States the incidence of pleural empyema increased from 3.7 cases per 100,000 in 1996-1998 to 10.3 cases per 100,000 in 2005-2007. In addition, mortality among children under 5 decreased by more than 50% since 2000 in the world; in 2015 it fell below 1 million. The most common etiological agents were pneumococcus and Staphylococcus aureus [14].
In our research the collection of the material was completed in 2014. Until that time, determination of such indicators as LII and MM was generally accepted. Nowadays new markers are determined in our clinics. Children are often administered Pentaglobin, not NHI, as immunosupportive therapy. This situation is typical for all the clinics participating in the research.
So, different morbidity structure and local features of the course of PSD in children in different regions of the CIS require a patient-centred approach to organization and provision of surgical service.
Conclusions
1) In 2005-2014 the number of patients with PSD (destructive pneumonia, diffuse appendicular peritonitis, acute hematogenous osteomyelitis) decreased by 40.8% in comparison with 1995-2004.
2) Decrease in the incidence of PSD affected the southern regions (Central Asia, North Caucasus) to a lesser extent. Decrease in the number of patients with specific nosological forms of the disease is different in different regions and depends on their social and geographical features.
3) The dynamic level of MM is a more objective indicator in comparison with LII for assessing the severity of endogenous intoxication syndrome and effectiveness of intensive therapy in patients with PSD.
4) Comparative evaluation of two regimens of intensive therapy in children with PSD testifies in favor of NHI in the complex treatment of such patients.
Disclosures. The authors declare no conflict of interest.
Funding. The study had no sponsorship.
Конфликт интересов. Авторы заявляют об отсутствии явного или потенциального конфликта интересов, связанного с публикацией статьи.
Финансирование. Исследование не имело спонсорской поддержки.
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УДК 612.15-612.397-612.178 DOI 10.24412/2220-7880-2021-4-22-25
ОСОБЕННОСТИ СПЕКТРАЛЬНЫХ ХАРАКТЕРИСТИК СЕРДЕЧНОГО РИТМА, ЛИПИДНОГО ОБМЕНА И ВЫСОКОСПЕЦИФИЧЕСКИХ МАРКЕРОВ ЭНДОТЕЛИАЛЬНОЙ ДИСФУНКЦИИ У ЮНОШЕЙ-СТУДЕНТОВ: ЭТНИЧЕСКИЙ АСПЕКТ
Цатурян Л.Д., Княжецкая Л.О., Меликбекян Е.О., Абдулаева Р.Х., ТабунщиковаМ.О., Васильева В.А., Товмасян В. Э.
ФГБОУ ВО «Ставропольский государственный медицинский университет» Минздрава России, Ставрополь, Россия (355017, г. Ставрополь, ул. Мира, 310), e-mail: [email protected]
