Резюме
Сябренко Г.П.¹, Ромаданова О.І.², Сухомлин Г.М.¹, Шкляр А.С.³, Неєлова О.В.², Панченко М.С.², Кіча Н.В.⁴, Крилова О.Б.², Сергеєва О.Ю.² Методичні та патогенетичні аспекти імунореабілітації осіб молодого віку з поєднаною патологією
За результатами клініко-імунологічного дослідження обґрунтований алгоритм діагностики імунорегуляторних рекцій компенсації у осіб молодого віку з ХЗ ШКТ та ХЗЛ враховує діагностичну цінність виявлених функціональних змін, клітинно-морфологічних та гуморальних механізмів впродовж виникнення та розвитку поєднаної патології. Функціональні тести, які містяться у алгоритмі дозволяють зменшити об’єм діагностичних обстежень при збереженні точності діагностики імунорегуляторних реакцій компенсації.
Ключові слова: методика, імунореабілітація, поєднана патологія.
Резюме
Сябренко Г.П., Ромаданова О.И., Сухомлин Г.Н., Шкляр А.С., Неелова О.В., Панченко Н.С., Кича Н.В., Крылова О.Б., Сергеева О.Ю. Методические и патогенетические аспекты иммунореабилитации лиц молодого возраста с сочетанной патологией.
По результатам клинико-иммунологического исследования обоснован алгоритм диагностики иммунорегуляторных реакций компенсации у лиц молодого возраста с сочетанным течением хронических заболеваний желудочно-кишечного тракта и лёгких, который учитывает диагностическую ценность функциональных изменений, клеточно - морфологических и гуморальних механизмов развития сочетанной патологии. Функциональные тесты, которые содержит алгоритм позволяют уменшить объём диагностических обследований при сохранении точности диагностики иммунорегуляторных реакций компенсации.
Ключевые слова: методика, иммунореабилитация, сочетанная патология.
Summary
Siabrenko H.P., Romadanova О.І., Sukhomlyn H.M., Shklyar A.S., Neyеlova O.V., Panchenko М.S., Кіcha Н.V., Кrylova О.B., Sergeeva О.Yu. Methodological and pathogenetic aspects of immunorehabilitation in young people with comorbidity.
Substantiated by the results of clinical and immunological research, the diagnostic algorithm of immunoregulatory compensation responses in young people with CD of GIT and CLD takes into account the diagnostic value of the discovered functional changes, cellular, morphological and humoral mechanisms during the process of emerging and development of comorbidity. Functional tests, contained in the algorithm, allow reducing the volume of diagnostic examinations, maintaining diagnostic accuracy of the immunoregulatory compensation responses.
Key words: methodologia, immunorehabilitation, comorbiditi.
Рецензент: д.мед.н., проф. С.П. Шкляр

УДК 616.71+612.75-053.5/6:616.2/6-036.12 (477)

¹ Кіровоградський університет «Україна» МОН України

Kirovohrad University "Ukraine"

Кировоградский университет «Украина» МОН Украины

^₂ Харківська медична академія післядипломної освіти МОЗ України

Харьковская медицинская академия последипломного образования

Kharkov medical academy of Postgraduate Education

oksana.neelova78@gmail.com
^₃ Харківський національний медичний університет МОЗ України

Харьковский национальный медицинский университет

Kharkiv National Medical University 

serg_shklyar@ukr.net

^₄ Національна медична академія післядипломної освіти ім. П.Л. Шупика

Национальная медицинская академия последипломноого образования им. П.Л. Шупика

Shupyk National Medical Academy of Postgraduate Education

n_kicha@mail.ru

Introduction. Immune mechanisms in the pathogenesis of concomitant chronic diseases cannot be considered an exhaustively studied issue, though it has been discovered that the state of cellular and humoral immune protection is characterized by multi-directional disorders [9, 11]. Given that the overall non-specific immune defense is defined by multivariate intrasystem interaction between separate indicators and nexuses of the immune system, the study of the mechanisms and hysteresis of compensatory reactions, their orientation and expression in young patients with chronic diseases of the gastrointestinal tract (CD of GIT) and chronic lung diseases (CLD) is quite relevant. Determining the characteristics of the immune system in its interaction with the duration of the disease seems topical, since even in case of no evident relapse they are clinically manifested through immunodeficiency states (IDS), which leads to worsening of concomitant chronic diseases.

The research objective was to develop a generally affordable algorithm of diagnosing immunoregulatory responses based on the assessment of the system of non-specific immune protection in adolescents with comorbidity.

Material and methods. The research program included studying the state of T-, B-, and phagocytic immunity chain in groups of patients with concomitant CD of GIT and CLD and in the control group. The blood for immunological studies was taken from the median cubital vein in the morning, the patient's stomach being empty. The quantitative content of T-lymphocytes (CD3+), their subpopulations (CD4+ and CD8+) and B-lymphocytes (CD19+) was determined by indirect membrane immunofluorescence. The number of T-active subpopulation of lymphocytes was determined during their reaction of rosette formation with sheep erythrocytes [10]. Conclusions about the violation of receptor reaction to immunocompetent cells (ICC) were made on the basis of the observed increase in the weight share of E-ROC and CD3+ cells [3]. The functional activity of ICC was assessed according to the level of spontaneous proliferation of lymphocytes and  judging by the intensity of proliferation under the influence of PHA [4]; the blocking activity of auto-serum was assessed according to the inhibition degree of blasttransformation of lymphocytes with PHA (with and without auto-serum) [ 1]. The content of serum immunoglobulins (IgG, IgA, IgM) and secretory immunoglobulin (sIgA) in saliva was determined with the help of the spectrophotometric method, using 7.0% PEG and monospecific serum against human immunoglobulins [2]. Phagocytic immunity was assessed by metabolic and phagocytic activity of blood neutrophils. As an object of phagocytosis, inactivated daily aureus culture (strain 209) was used, phagocytic number (PN) and phagocytic index (PI) of neutrophils were determined (using the average number of microbes) [6]. Metabolic activity of phagocytic cells was assessed through spontaneous and induced NBT testing [8]. Daily inactivated culture of staphylococcus (strain 209) was used as a catalyst for this test.

To display the patterns of the immune system, the method of constructing hysterography (in the form of a standardized formula) of compensatory changes in the immune status has been used, which reflects the degree of immune disorders (D) for each of the analyzed parameters of immunography that was calculated using the following formula: D = 100(d_n/d₀)-100, where d_n is the analyzed indicator of the patient's immunography, d₀ is the reference value of the index. To construct a hysterography of the immune system (HIS) and immune disorders formula (IDF), diagnostic value ratio was used, which was calculated according to the formula G_J = 2(σ₁² + σ₂²)/(M₁-M₂) where σ₁ and σ₂ are standard deviation indices, and M₁ and M₂  are average arithmetic indicators. Analysis of the results was conducted using the methods of variation statistics and principles of pathology informatics [5, 7], Algorithms of applied statistical methods from the standard set of statistical inventory of the EHEL licensed software environment were used.

Presentation of the results. Formation of the discovered compensatory reactions in the system of non-specific immune defense made it possible to determine separate quantitative patterns. Pathometric analysis of these quantitative patterns was performed among the patients with concomitant CD of GIT and CLD with their preliminary division into two groups: the first group included 73 patients with less than 5-year-long clinical manifestations, and the second group included 37 patients with clinical manifestations over 5 years. Defining the informative value and diagnostic value indices of the most significant signals of a certain non-specific immune defense system condition was the distinguishing feature of pathometric analysis of the altered physiological responses in patients.

The most valuable diagnostic indicator (3,495 bits) of the availability of immunoregulatory compensation responses (Table 1) is the relative index of T_act lymphocytes number. It has been revealed that its reduction to the level of 0.8 T_ref is almost five times more frequent among the patients from the second group (in (14.0+5.3)% and (72,1±6,8)% of the patients respectively). Pathometric coefficients of the indicator are PC ^– = -7.1 and PC⁺ = +4.1. This pathometric indicator takes the first rank place in the diagnostic algorithm; the presence of inhibition in the T-chain of nonspecific immune defense in the patients with clinical manifestations over 5 years is credibly higher (p<0.0001) and, unlike the early period of concomitant pathology, it is not compensated for by an increase in the absolute number of lymphocytes.

The second ranked site according to the diagnostic value index (I=3.045 bits) goes to the ratio between the value of SI RBTL of a patient and the reference value of SI RBTL. We have discovered that the decrease in this index is more characteristic of a long course of concomitant CD of GIT and CLD (observed in (60.9±7.2)% of the patients from the second group and (9.3±4.4)% of the patients from the first group; p<0.0001). Pathometric coefficients of the indicator are PC ^– = -8.1 and PC⁺= +3.6; pathophysiological role of the indicator lies in the fact that RBTL inhibition evidences for a regulatory imbalance and the presence of immunoregulatory decompensation (p<0.001).

The third place in the rank belongs to the diagnostic index value ​​(I=2.453 bits) as the ratio between the measured and the reference SI value of the NBT test, which characterizes the state of the phagocytic chain and, as we found, is significantly more frequently recorded (p<0.001) in the patients with clinical manifestations of over 5 years: in (80.4±5.8)%, while in the first group the result is (30.2±7.0)% of the patients. Since the NBT test reflects compensatory reserves of the phagocytic chain, its relative reduction during a longer period indicates the deregulatory changes and depletion of adaptation reserves of the non-specific immune defense system (PC ^– = -4.2 and PC⁺=+5.5).

During the study, we have also found that in terms of information and diagnostic value, there are a number of criteria that can be used in the diagnostic algorithm of immunoregulatory compensation responses.

In particular, this is the standard rate of spontaneous NBT test (I=2.109 bits), the ratio between the baselines of B- and T-chains (I=2.024 bits), the standardized rate of spontaneous lymphocyte proliferation (I=2.012 bits), the ratio between standardized rates of secretory and serum immunoglobulin A (I=1.684 bits) and others.

Pathometric factors, the power of influence and diagnostic value have been defined for each of the indicators, which made it possible to apply the principles of pathology informatics and use the principles, which have the highest information content. Diagnostic indicators of the immunoregulatory functional compensation of non-specific immune defense depend on the period of clinical manifestation of concomitant CD of GIT and CLD and are characterized by different diagnostic value and various pathometric coefficients (PC). However, to simplify the process of diagnosing immunoregulatory compensation responses, a table algorithm has been offered, since it is relatively simpler and equally informative. The advantages of the specified algorithm (Table 1) are as follows: after the laboratory research is conducted, its results are analyzed in a particular algorithmic sequence and evaluated in accordance with pathometric importance of relevant indicators. It should be noted that the procedure of consistent pathometric analysis of the indicators (diagnostic features), applied for the development of diagnostic algorithm, is based on the fact that the preliminary use of the expert method helped to establish the maximum allowable errors of the first type (α=1.5% - hyperdiagnosis error) and the second type (hypodiagnosis error β=1.5%). They do not exceed 1.0-3.0%, which determines the maximum (DS_MAX= +19) and minimum (DS_MIN= -19.0) diagnostic sum (DS) of pathometric coefficients.

Applying the algorithm of diagnosing immunoregulatory compensation responses presupposes high sensitivity and specificity, the level of which will be at least 98.5%. Diagnosis of immunoregulatory compensation responses in young people with concomitant CD of GIT and CLD determines the following stages of the developed technology:

the first (laboratory) stage - a particular patient undergoes immunological examination;

the second (quantitative and analytical) stage - standardized ratios are defined and values ​​of diagnostic criteria are obtained;

Table 1

Diagnostic algorithm* of immunoregulatory responses in adolescents with concomitant cases of CD of GIT and CLD

* each indicator is used to evaluate the role of diagnostic criteria, the corresponding pathometric coefficients are added; when the diagnostic margin (-19 or +19) is reached; the result scale is used to define the type of reaction;

the third (functional and diagnostic) stage – the developed algorithm is used by means of successively adding coefficients to achieve one of the diagnostic margins (PS_MIN=-19; PS_MAX=+19), while the pathometric scale is used to simplify the diagnostic process (Fig. 1).

Fig.1. Assessment scale of immunoregulatory compensation responses

Conclusions.

1. Substantiated by the results of clinical and immunological research, the diagnostic algorithm of immunoregulatory compensation responses in young people with CD of GIT and CLD takes into account the diagnostic value of the discovered functional changes, cellular, morphological and humoral mechanisms during the process of emerging and development of comorbidity.

2. Functional tests, contained in the algorithm, allow reducing the volume of diagnostic examinations, maintaining diagnostic accuracy of the immunoregulatory compensation responses.

3. Method guidelines of the sector level have been prepared and implemented for the purpose of practical application of the diagnostic algorithm of immunoregulatory compensation responses in the system of medical examination of youth and adolescents.

The perspectives of further research are related to the study of effective implementation of the developed algorithm in general medical practitioners' activity and in family medicine.

Література

1. Белозоров А.П. Сравнительная характеристика некоторых методов иммуноферментного определения суммарных иммуноглобулинов / А.П. Белозоров, С.О. Навольнев, Г.И. Мавров // ЖМЭИ. - 1985. - № 1. - С. 78-81.
2. Гомоляко І.В. Нові аспекти вивчення морфофункціональної недостатності епітелію бронхів / І.В. Гомоляко // Тер. архив. - 1989. - № 2. - С. 82-84.
3. Кэтти Д. Иммуноферментный анализ / Д. Кэтти, Ч. Райкундалиа // Антитела. Методы. – М.: Мир, 1991. – Кн. 2. – С. 152–238.
4. Маянский Д.Н. Хроническое воспаление / Д.Н. Маянский. - М.: Медицина, 1991. - 271 с.
5. Петрович М.Л. Статистическое оценивание и проверка гипотез на ЭВМ: математическое обеспечение прикладной статистики / М.Л. Петрович, М.И. Данилович. – М.: Наука, 1988. – 410 с.
6. Райт А. Основы иммунологии / А. Райт. - М.: Медицина, 1991. - 606 с.
7. Реброва О.Ю. Статистический анализ медицинских данных (применение пакета прикладных программ STATISTICA) / О.Ю. Реброва. - М.: Медиа Сфера, 2003. - 312 с.
8. Ткач В.Є. Комплексне визначення прилипаючих клітин, поглинальної здатності полінуклеарів та проведення НСТ тесту в мікродозах периферичної крові / В.Є.Ткач, О.Д. Александрук // Галузевий реєстр нововведень у практику охорони здоров’я. - Івано-Франківськ, 1998. - С. 64.
9. Федосеев Г.В. Механизмы обструкции бронхов / Г.В. Федосеев. - СПб.: МИА, 1995. - 333 с.
10. Чередеев А.Н. Количественная и функциональная оценка Т– и В– систем иммунитета. Общие вопросы / А.Н. Чередеев. – М.: Медицина, 1976. - № 74. - С. 26–28.
11. Santag S.J. Gastroesophageal reflux and astma / S.J. Santag // Clin. Gastroenterology. - 2000. - № 5. - Р. 9-30.