RU2416365C1 - Method of determining anamnestic index of bleeding sickness - Google Patents

Abstract

FIELD: medicine. ^ SUBSTANCE: invention relates to field of medicine, in particular to dentistry. In order to determine bleeding sickness type clinical manifestations are determined and assigned point marks, by table 2, contained in the description. Obtained points are summed up, and is the sum of points equals 3 and more index Z is calculated by formula: Z=10R, where R is index of the degree, to which it is necessary to raise figure 10 in case if clinical manifestations, given in table 3, contained in the description, are present. If index Z is within the range 10-30, made is conclusion about high probability of inherent haemorrhagic disease with microcirculation type of bleeding sickness; from 50 to 499 - of acquired haemorrhagic disease with microcirculation type of bleeding sickness; from 500 to 3000 - of inherent haemorrhagic disease with mixed type of bleeding sickness; from 10000 to 50000 - of inherent haemorrhagic disease with hematoma type of bleeding sickness; from 100000 to 500000 - of acquired hemophilia; and if Z value is higher than 1000000 - simulation of haemorrhagic disease. ^ EFFECT: method increases efficiency of detection of patients who may develop bleeding after tooth extraction. ^ 4 dwg, 1 ex, 5 tbl

Description

The invention relates to medicine, in particular dentistry, and can be used to assess the risk of bleeding during dental interventions.

To assess the pathology of the dentition, traditionally practicing dentists use index diagnostic methods. Most of these indices evaluate the condition of teeth and gums and allow you to evaluate the effectiveness of the treatment methods used. Meanwhile, the screening detection of hemorrhagic diseases and syndromes in the clinical practice of the dentist is not fully developed, although it is known that hemophilia (and other hemorrhagic diseases, such as von Willebrand disease, thrombocytopenia, etc.) have a high probability of developing life-threatening bleeding during dental procedures , including when removing a tooth. Due to the lack of a public indicator that can identify patients at high risk of bleeding after tooth extraction, hemorrhages after such dental interventions are not uncommon. The development of new approaches for identifying hemorrhagic diseases will quickly detect patients who are more likely to develop bleeding after tooth extraction and other invasive procedures.

A known method for determining bleeding Kotzschke (1975) [E.M. Melnichenko. / Prevention of dental diseases. Tutorial. / Minsk. High school, 1990. - S. 49], which is a definition of a three-stage gradation of the severity of gingival bleeding.

However, the known method is not suitable for detecting hemorrhagic disease, since it does not take into account most other manifestations of bleeding.

The technical result of the proposed method is to increase the efficiency of detection of patients who may develop bleeding after tooth extraction.

The technical result is achieved by determining the anamnestic bleeding index (AICr) in the complex of diagnostic measures of the dentist prior to tooth extraction.

The authors propose a method for determining the anamnestic hemorrhage index, which allows not only to detect patients with hemorrhagic diseases, but also provide a preliminary judgment on nosology.

The method is as follows.

A schematic representation of the sequence for determining the anamnestic hemorrhage index with the calculation of the indicator Z is presented in figure 1.

The method consists of four successive steps.

Stage 1. Interview with a patient who contacted the dentist for tooth extraction in order to identify anamnestic manifestations of hemorrhagic disease.

Based on a survey of the patient in order to identify a hemorrhagic history in a patient who is planning to perform tooth extraction, various clinical manifestations of bleeding are recorded according to table 1.

Stage 2. Calculation of anamnestic index AICr.

If there is any clinical manifestation of hemorrhagic syndrome from table 1, the result in the marking field is taken into account, then the scores obtained are summarized, and the result of summing the scores from this table is the anamnestic bleeding index (AICr).

Formula for calculating AICr

AICr = Σ (X),

where X - points obtained according to a survey of the patient, from table 1.

Table 1 Clinical manifestations (according to complaints and anamnesis) Points (X) Marking field 1. Episodes of nosebleeds 2 2. Bruises spontaneous and / or with minor injuries 3 3. There were hemorrhages in the joints (hemarthrosis) 5 4. Abundant and / or prolonged (more than 5 days) monthly 2 5. Bleeding during childbirth 2 6. The presence of large subcutaneous hematomas during examination (their total area is more than 4 palms). 5 7. The presence in the history of oncohematological disease (except for erythremia) 3 8. There is spontaneous bleeding from the ears and / or from under the nails. -33 9. Bleeding after tooth extraction for an hour or more 5 10. There is bleeding in blood relatives 2 11. Iron deficiency anemia or history of iron supplementation 2 12. Bleeding during surgery or in the postoperative period 2 AICr calculation results:

With an AICr of less than 3, the likelihood of a hemorrhagic disease is small, therefore, such dental procedures, including tooth extraction, are not contraindicated for such patients. With an AIKr of 3 or more, the Z indicator is calculated to clarify the hemorrhagic disease variant.

Stage 3. Detailing the clinical manifestations of hemorrhagic disease and calculating the indicator Z.

To form a judgment on the variant of hemorrhagic disease, the indicator Z is calculated based on the refinement of the features of the same 12 clinical manifestations by their detailing and mathematical processing according to the questionnaire (Table 2).

The numbers from column R are indicators of the degree to which it is necessary to raise the number 10 with a positive answer to the question about the features of the clinical manifestations described in table 2. After raising to the power, the obtained values are summarized.

The formula for calculating the indicator Z

z = Σ10 ^R ,

where R is an indicator of the degree to which it is necessary to raise the number 10 in the presence of any of the clinical manifestations listed in the questionnaire, Fig 3.

Accounting for the results of determining the indicator Z

Index Z distributes patients into different groups, therefore, after calculating it, it becomes possible to form a preliminary opinion about the disease. In the event that the obtained Z value is in the range of 10-30, the patient is more likely to have a congenital hemorrhagic disease with microcirculatory type of bleeding (thrombocytopathy or von Willebrand disease). If the Z index falls in the range from 50 to 500, the patient has a high probability of acquired hemorrhagic disease with microcirculatory type of bleeding (thrombocytopenia). If the indicator Z was in the range from 500 to 3000, the patient is more likely to have a congenital hemorrhagic disease with mixed

table 2 Clinical manifestations (according to history) R (exponent in calculating Z) Marking field 1. Episodes of nosebleeds observed from birth or from childhood one not previously, however, nasal hemorrhages have appeared recently 2 2. Bruises spontaneous and / or with minor injuries observed from birth or from childhood one not before, but bruises have appeared recently 2 3. There were hemorrhages in the joints (hemarthrosis) in male patients with the formation of persistent loss of joint function four there were single such hemorrhages in male patients without the formation of a permanent loss of joint function 3 in female patients 3 4. Abundant and / or long (6 or more days) monthly since the onset of menstruation one was not during the formation of menstruation, however, they appeared only recently 2 5. Bleeding during childbirth 0 6. The presence of large subcutaneous hematomas during examination (their total area is more than 4 palms). When clarifying, a spontaneous mechanism of their occurrence is characteristic 5 7. The presence in the history of oncohematological disease (except for erythremia) 2 8. There is spontaneous bleeding from the ears and / or from under the nails. 6 9. Bleeding after tooth extraction for an hour or more 0 10. There is bleeding in blood relatives 0 11. Iron deficiency anemia or history of iron supplementation 0 12. Bleeding during surgery or in the postoperative period 0 Formula: Z = Σ10 ^R

type of bleeding (severe course of von Willebrand disease, Rosenthal disease or other rare deficiency of coagulation factors). The range from 10,000 to 50,000 of this indicator is observed in congenital hemorrhagic disease with a hematoma type of bleeding (hemophilia A or hemophilia B). With indications of Z from 100,000 to 500,000, the patient has a high probability of acquired hemophilia. If the calculated Z value exceeds 1,000,000, then the likelihood of simulating a hemorrhagic disease is high.

Stage 4. Formulation of a preliminary diagnosis of hemorrhagic disease and clarification of recommendations for the prevention of life-threatening bleeding after tooth extraction.

Differentiation of the hemorrhagic disease variant is extremely important, since the prevention of hemorrhage during dental procedures varies significantly and depends on the pathogenetic features of the pathology of hemostasis. So, with hemophilia A, concentrates of coagulation factor VIII should be used, with hemophilia B - concentrates of factor IX, with von Willebrand disease - plasma concentrates of von Willebrand factor, with Bernard-Sulie syndrome or Glanzmann's disease, Novoseven or platelet concentrates are recommended, etc. Therefore, the identification of hemorrhagic disease using AIKr taking into account the indicator Z helps to formulate a preliminary diagnosis, and also allows you to significantly narrow down the diagnostic search in a specialized laboratory of hemostasis.

Clinical testing of AICr and indicator Z.

There are a lot of clinical manifestations of hemorrhagic diseases and syndromes, however, the developed questionnaire (Table 2) presents the most important ones that can detect hemorrhagic disease. In the process of testing in the clinical practice of the dentist AIKr it was found that this indicator only allows to identify hemorrhagic disease, however, it was impossible to form a preliminary judgment on its variant using this indicator. This becomes possible only after the formation of an additional scale for detailing anamnestic data and the calculation of the Z indicator based on the same 12 points as the AICr.

Indicators assessing the informativeness of AICr and indicator Z.

Having developed a new diagnostic indicator, it was necessary to determine the indicators that most effectively assess the quality of the diagnostic procedure, namely its sensitivity and specificity. For this purpose, the value of AICr and indicator Z were compared with the results of the diagnosis of hemorrhagic disease in a specialized laboratory of hemostasis.

It is known that the sensitivity of a diagnostic method refers to its ability to detect a disease. This indicator is calculated by the formula

To assess the sensitivity of the indicator AIKr used accounting anamnestic data for the most common hemorrhagic diseases (figure 2).

As can be seen from Fig. Z, with the most common hemorrhagic diseases, the sensitivity of the AICr is quite high. The greatest sensitivity was noted with hemophilia, and the least with thrombocytopenia. Since hemorrhagic manifestations with thrombocytopenia are observed only with a significant decrease in the number of platelets, lower values of AICr with thrombocytopenia are completely justified and expected.

The specificity of the diagnostic method is the probability of a positive result in healthy people, i.e. this indicator determines the ability of the method to produce false positive results. Therefore, specificity determines how accurately the diagnostic method determines the absence of the disease. The specificity of the diagnostic method is calculated by the following formula:

The specificity of AICr for the most common hemorrhagic diseases is presented in Fig.3. As can be seen from figure 3, with the most frequent hemorrhagic diathesis developed indicator has a very low specificity.

However, supplementing AICr with indicator Z, which makes it possible to make a preliminary judgment about the variant of hemorrhagic disease, the specificity of diagnosis in hemophilia and thrombocytopenia is significantly increased. The results of determining the sensitivity of the indicator Z with hemophilia and thrombocytopenia are presented in figure 4.

Examples of the practical use of the method.

Patient No. 1, age 15, resident of Rubtsovsk. In October 2006, the patient developed an intense toothache. The dentist did not determine the Kechke index and did not ask about any clinical manifestations of a hemorrhagic disease (and this patient had many of its signs) and removed the molar from the patient. In this case, the patient did not take any preventive measures to prevent bleeding. Since hemostatic therapy was not used, anemic bleeding developed after tooth extraction and continued for several days. Then, a huge hematoma formed in the lower jaw of the patient, which was suppurated in two weeks. Soon, clinical and laboratory signs of iron deficiency anemia appeared. After a month of ineffective treatment, osteomyelitis of the lower jaw developed, then an operation was performed under general anesthesia in the department of maxillofacial surgery for osteomyelitis of the lower jaw. Given the presence of hemorrhagic syndrome against osteomyelitis of the lower jaw, the patient was examined in the Altai branch of the State Research Center of the Russian Academy of Medical Sciences, where von Willebrand disease was detected.

The results of the study of the hemostatic system in patient No. 1 are presented in table 3. The results of a study of peripheral blood: Hb - 95 g / l; ROE 41 mm / h; white blood cells - 14.4 × 10 ⁹ / l; leukocyte formula B-2% E-2% P-10% C-50% L-28% M-8%.

For the patient were also calculated indicators AIKr and Z. The results are presented in tables 4 and 5.

According to the determination of the AICr indicator, the patient revealed hemorrhagic diathesis (AICr = 22; Z = 1036).

According to the results of determining the anamnestic hemorrhage index and indicator Z, a congenital hemorrhagic disease with a mixed type of bleeding was revealed in the patient. The most common variant of the disease that causes a congenital hemorrhagic disease with a mixed type of bleeding is von Willebrand disease.

Thus, if the dentist used the proposed index, the patient would have been diagnosed with a hemorrhagic disease with a mixed type of bleeding in time, and the recommendations of the hematologist on the use of hemostatic therapy and management of such patients would be used. This would avoid numerous serious complications of tooth extraction in this patient (bleeding, hematoma, hematoma infection, lower jaw osteomyelitis, surgical intervention). In addition, the financial cost of treatment would be significantly less.

Table 3 Research methods Sick The control APTV, s 55 30-40 Prothrombin, with fifteen 14-15 Thrombin time, s 19 13-17 Antististron, with 17 14-22 Fibrinogen, g / l 2.4 2-4 Factor VIIIC,% 5 70-130 Factor IX,% one hundred 70-130 Factor XI,% 75 70-130 Platelets × 10 ⁹ / L 232 170-380 Platelet Aggregation with ADP,% 57 55-65 Platelet aggregation with adrenaline,% 60 55-65 Platelet Aggregation with Collagen,% 54 55-65 Platelet Aggregation with Ristocetin,% 21 70-80 Von Willebrand factor,% fourteen 50-150

Table 4 Clinical manifestations (according to complaints and anamnesis) Points Marking field 1. Episodes of nosebleeds 2 √ 2. Bruises spontaneous and / or with minor injuries 3 √ 3. There were hemorrhages in the joints (hemarthrosis) 5 √ 4. Abundant and / or prolonged (more than 5 days) monthly 2 √ 5. Bleeding during childbirth 2 - 6. The presence of large subcutaneous hematomas during examination (their total area is more than 4 palms). 5 - 7. The presence in the history of oncohematological disease (except for erythremia) 3 - 8. There is spontaneous bleeding from the ears and / or from under the nails. -33 - 9. Bleeding after tooth extraction for an hour or more 5 √ 10. There is bleeding in blood relatives 2 √ 11. Iron deficiency anemia or history of iron supplementation 2 √ 12. Bleeding during surgery or in the postoperative period 2 - AICr calculation results: 22

Table 5 Clinical manifestations (according to history) R (exponent in calculating Z) Marking field 1. Episodes of nosebleeds observed since childhood one √ not previously, however, nasal hemorrhages have appeared recently 2 2. Bruises spontaneous and / or with minor injuries observed since childhood one √ not before, but bruises have appeared recently 2 3. There were hemorrhages in the joints (hemarthrosis) in male patients with the formation of persistent loss of joint function four there were single such hemorrhages in male patients without the formation of a permanent loss of joint function 3 in female patients 3 √ 4. Abundant and / or long (6 or more days) monthly since the onset of menstruation one √ was not during the formation of menstruation, however, they appeared only recently 2 5. Bleeding during childbirth 0 6. The presence of large subcutaneous hematomas during examination (their total area is more than 4 palms). When clarifying, a spontaneous mechanism of their occurrence is characteristic 5 7. The presence in the history of oncohematological disease (except for erythremia) 2 8. There is spontaneous bleeding from the ears and / or from under the nails. 6 9. Bleeding after tooth extraction for an hour or more 0 √ 10. There is bleeding in blood relatives 0 √ 11. Iron deficiency anemia or history of iron supplementation 0 √ 12. Bleeding during surgery or in the postoperative period 0 Formula: Z = Σ10 ^R 1036

Claims (1)

A method for determining the type of bleeding, including the determination of clinical manifestations and assigning them scores according to table 2 contained in the description; summation of the points; and with the sum of points equal to 3 or more, calculate the Z indicator by the formula: Z = Σ10 ^R , where R is the degree of degree to which the number 10 should be raised in the presence of the clinical manifestations listed in table 3 contained in the description; and with a value of Z in the range of 10-30, a conclusion is made about the high probability of a congenital hemorrhagic disease with microcirculatory type of bleeding; from 50 to 499 - acquired hemorrhagic disease with microcirculatory type of bleeding; from 500 to 3000 - congenital hemorrhagic disease with a mixed type of bleeding; from 10,000 to 50,000 - a congenital hemorrhagic disease with a hematoma type of bleeding; from 100,000 to 500,000 - acquired hemophilia; and with a value of Z above 1,000,000 - simulations of hemorrhagic disease.

Images