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45публикуют ВОЗ и ООН. Как следует из перечисленного, круг знаний медицинского статистика должен быть достаточно широк и предполагает использование специальных знаний, навыков и умений, существенно отличающиеся от тех, которые необходимы другим категориям медицинского персонала. Так, медицинский статистик должен не просто знать правила эксплуатации компьютерной техники, но и активно использовать ее в своей работе, уметь формировать электронные таблицы с необходимым набором формул, извлекать из имеющихся баз данных необходимую для ответов на запросы информации; графически представлять данные для анализа и т.д. Для внедрения повсеместной информатизации медицинских учреждений именно медицинскому статистику принадлежит роль уверенного пользователя основными математическими методами, статистическими приемами (расчеты средних значений и относительных показателей, анализ динамических рядов и т.д.), организатора статистического исследования. Кроме собственно учета статистик значительную часть времени занимается составлением отчетов, что требует большого кропотливого труда, особенно в последнее время. Так, статистиками проводятся многочисленные мониторинги по модернизации здравоохранения, контроль за состоянием здоровья населения, анализ текущих показателей работы всего лечебного учреждения, критериев эффективности работы врачей, качества медицинской помощи и т.д. Следует отметить, что в соответствии с Постановлением Кабинета Министров Украины от 30 декабря 2013 г. № 977 «Некоторые вопросы оплаты труда медицинских работников, оказывающих первичную медицинскую помощь» к обязанностям медицинских статистиков добавилась задача по определению соответствующих средних показателей, согласно которым и определяют надбавку к заработной плате врачей за 20 качество работы. Таким образом, роль медицинских статистиков в деятельности учреждений здравоохранения неоспорима.
ЛИТЕРАТУРА
1. Блауберг, И.В. Становление и сущность системного подхода / И.В. Блауберг, Э.Г. Юдин. - М.: Наука, 1973. - 270 с.
2. Свидиненко, Ю. Нанотехнологии в медицине [Электронный ресурс]. - Режим доступа: http://old.nanonewsnet.ru. - Дата доступа 04.04.2014.
3. Boisseau, P. Nanomedicine: nanotechnology in medicine / P. Boisseau; B. Loubaton // Comptes Rendus Physique. - 2011. - Vol. 12, № 7. - Р. 620-626.
DIAGNOSTIC VALUE OF CALCULATING INDICES OF INSULIN RESISTANCE HOMA-IR, QUICKI AND CARO IN PATIENTS WITH CHRONIC PANCREATITIS COMBINED WITH OBESITY AND TYPE 2 DIABETES
Ferfetska K. V.
Ukraine, Chernivtsi city, Bukovina State Medical University,
Internal medicine department
Abstract. The results of studies of insulin resistance index HOMA-IR, QUICKI, CARO and in patients with chronic pancreatitis, combined with obesity and type 2 diabetes, are defined by their sensitivity and specificity. It has been found that levels of hyperglycemia, hyperinsulinemia and insulin resistance are higher in patients with chronic pancreatitis by comorbidity due to a compensatory response to reduced [-cell sensitivity to insulin. Among the indexes defining sensitivity and specificity CARO has the largest index. The research can be recommended for early detection of insulin resistance in patients with chronic pancreatitis.
Key words: chronic pancreatitis, obesity, diabetes, insulin resistance, index HOMA-IR, index QUICKI, index CARO.
The pancreas takes part in may physiological organism processes, for example, digestion, adaptation, because it is an organ that performs ferment and endocrine functions producing the corresponding peptides and hormones [2,4] As a proof we can refer to the researches that describe the correlation dependence of the damage of acinar cells and disbalance of its endocrine functions [8]. Hormones are means of regulation which are secreted by pancreas: insulin, glucagon, somatostatin,
pancreatic polypeptide, vasoactive intestinal polypeptide, etc. One of the most studied ones is insulin level, on the basis of which they study the insulin resistance level (IP). Hyperglycemia and hyperinsulinemia atherogenically affect the vessels walls, leads to dyslipidemia development, a number of hormone and metabolic dysfunctions and triggers development of obesity and type 2 diabetes (D).
According to M. Laakso [1, 7, 6], the easiest method to do is testing immune reactive insuline (IRI) in the plasma of the drainage blood on an empty stomach. This index precisely characterizes IR in people with normoglicemia and some less inpeople with damaged tolerance to carbohydrates (DTC) or D. That is why studying IRI as an independent index has not been researched. Usually to evaluate IR different indices are used in the basis of which it is laid the correlation of insulin concentration on an empty stomach and glycaemia in the blood serum. The most important of them is index IP HOMA-IR (a small model of homeostasis), suggested by D.R. Matthews and coauthors in 1985[1, 3, 6].
The higher index HOMA-IR, the lower sensitivity to insulin is and, correspondingly, higher IR. A. Katzea and coauthors in 2000 [3, 5, 6] suggested quantitative method of detecting IR — index QUICKI. Since 1991 there has also been used index of F. Caro [3, 6]:
According the data of G. M. Reaven, F. Abbasi [6], the mathematical models HOMA-IR and QUICKI are very convenient, they require only one blood sample and can be used as for the people without D so as for the people with DTC and most patients with type 2 D (with preserved secretion of pancreas); and index HOMA-IR is the most frequently used method in large scale epidemic and clinical examinations and researches.
The most precise diagnostic value in the medical statistics is characterized by indices of sensitivity and specificity. Sensitivity is an ability of the method to detect a disease or pathological condition. Specificity is an ability of the method to disprove a disease or pathological condition. The lower its specificity, the higher its hyper-diagnostics of the pathological condition is.
The goal is to define the diagnostic value of insulin resistance in patients with chronic pancreatitis and chronic pancreatitis accompanied with obesity and type 2 diabetes by evaluating the glucose level, insulin and insulin resistance indices HOMA-IR, QUICKI, CARO and to calculate the sensitivity and specificity method.
The object of the research is chronic pancreas and chronic pancreatitis accompanied with obesity and type 2 diabetes.
The subject of the research is indices of insulin resistance HOMA-IR, QUICKI, CARO, their specificity and sensitivity.
The research methods. 90 patients with ChP were examined, among them there were 57 women (63,33 %) and 33 men (36,67 %) aged from 27 to 71. All patients were divided into groups: ill with ChP - 40 people (1 group), ill with ChP combined with type 2 D - 50 people (2 group). The control group consisted of 15 practically healthy people. The age of the examined people was on average (49,0±1,7 years old).
The examination design was approved by the ethic commission of the Bukovina State Medical University.
The diagnosis ChP was set according to the clinical protocol of the act of Ministry of Health of Ukraine on 13.06.2005 №271, «The clinical protocol of giving medical help to patients with chronic pancreatitis». All patients who were included into the research were thoroughly examined using generally accepted clinical, laboratory and instrumental test and examinations and they were also surveyed. To diagnose ChP it was detected activity of a-amylasof the blood serum (colorimetric method of Caraway) and urine diastase, the exocrine function of pancreas was detected by fat content in the feces (by method of Van de Kramer) and coroutine results (assessment was done by methods of L.V. Kozlovska and A.Y. Nikolayev). Moreover the biochemical blood count included testing glucose in the blood on the empty stomach, activity of alanine-transferase (ATF), aspartataminotransferase (AST), alkaline phosphatase (APh), content of general bilirubin, proteinogram, coagulogram.
The structural changes of P were detected with the ultrasound examination («Aloka» SS-630 (Japan)). If it was necessary the patients were prescribed gastros duodenal fiberoptic scope (GDFS), x-ray of the stomach and duodenum.
Moreover the patients were examined anthropologically: height (m), weight (kg), body mass index was calculated (BMI, kg/m2) by the formula of Quetelet. As a norm of BMI it was taken 20-24,9kg/m2, IMT 25-29,9kg/m2 was considered as overweight and IMT over 30kg/m - as obesity.
Obesity and abdominal form was considered if the values of waist (W) were >94 cm for men and for women - >80 cm.
The diagnosis of type 2 D was done according to the clinical protocol of the act Ministry of Health of Ukraine on 21.12.2012 №1118.
The insulin content was detected with the help of the set to insulin detection Insulin Test System № 2425-300 made by Monobind Inc.(USA). The concentration of glucose (mcmole/l) in the plasma of the drainage blood was tested by glucose-oxidative method. The IR indices by formulas:
HOMA-IR = insulin of serum (mcU/ml) x glucose of plasma (mmole/l) / 22,5, index CARO = concentration of glucose (mmole/l) / concentration of insulin (mcU/ml), index QUICKI =1 / log insulin (mcU/ml) + log glucose (mg/dl).
The values of the insulin level >2,7 mcU/ml, index HOMA-IR >2,6, CARO<0.33, QUICKI<0,331 proves the existence of IP.
The statistical processing of the results was done using the program «Statistica for Windows Bepcii 8.0». The average value was calculated (M), standard deviation of the average (m), U-criterion of Mann-Whitney and sensitivity and specificity.
The research results. The anthropological parameters of the examined patients are given in table 1. According to the received data the body mass index of the patients of group 2 was much higher and testified obesity of II degree that masks the clinical symptomatic picture of ChP, promoted developing of IR and is a risk of cardiovascular disorders.
Table 1. Anthropological parameters of the examined patients (M±m)
Indices Groups
1 group(n=40) 2 group(n=50) Healthy
IMT, kg/m2 24,3±2,1* 37,4±1,9* 19,6±1,8
OT, cm 78,43±2,1* 115,12±7,4* 70,3±3,3
* -P<0,05-in comparison with the control group.
The average level of immune reactive insulin in the blood of the patients of group 2 was reliably higher (66,4±2,06 mcU/ml) than of the patients of group 1 (27,82±1,7 mcU/ml) and practically healthy people (10,82±0,62 mcU/ml), p<0,05 that proves existence of IR. At the same time patients of 2 group had hyperglycemia (10,05±0,1 mmole/l) in comparison with 1 group 5,67±0,09 mmole/l and the control one -5,46±0,07 mmole/l, p<0,05. Hyperinsulinemia and hyperglycemia prove existence of IR that is explained by the compensation reaction to the reduced sensitivity of P-cells to insulin.
Accordign to the received by us data at comorbidity of ChP with type 2 D and obesity the average level of the index HOMA-IR in group2y was higher and constituted 30,05±2,35 in relation to the practically healthy group of people (P<0,05). As for the result of indices QUICKI and CARO, it has been found out, that their values in group 2were the lowest in comparison with practically healthy people (P<0,05). So, by the indices data it was determined the reliability of insulin resistance in group of patients with ChP by comorbidity with obesity and type 2 D.
It has been detected that with ChP insulin resistance occurs not so often and it has in most cases a compensatory genesis to the increase of TNF-alpha which nowadays is considered also adipokine; it was of much interest to study the diagnostic value of every IR index, sensitivity and specificity if the insulin resistance indices (table 3).
Table 2. Average values of insulin resistance indices
Index IP 1 group 2 group Control group
Glucose, mmole/l 5,67±0,09* 10,05±0,1** 5,46±0,07
Insulin, mcU/ml 27,82±1,7* 66,4±2,06** 10,82±0,62
Index HOMA-IR 7,03±2,8* 30,05±2,35** 2,69±0,16
Index CARO 0,21±0,02* 0,16±0,01** 0,53±0,01
Index QUICKI 0,46±0,04* 0,36±0,03** 0,56±0,02
* -P<0,05-in comparison with the control group,
** -P<0,05-in comparison with 2 group
Table 3 Sensitivity and specificity of calculating indices of insulin resistance indices in ratients with chronic pancreatitis_
Index HOMA-IR Index CARO Index QUICKI
Sensitivity,% 93,3 93,3 14,3
Specificity,% 33,3 90 90
By the calculations results it was established that the most sensitive at detecting IR of the patients who are ill with ChP are indices HOMA-IR (93,3%) and CARO (93,3%), whereas as sensitivity of index QUICKI was only 14,3 %. At the same time, at specificity analysis it was found out that the highest index value was CARO (90,0%) and QUICKI(90,0%), and for the index HOMA-IR - only 33,3%. As, indices HOMA-IR and CARO have the highest sensitivity their calculation allows most probably detecting IR in patients with ChP. However, it is necessary to take into account the index of specificity that allows disproving existence IR in those cases when it is surely absent. As it is low for the index HOMA-IR, then the most diagnostic important value to detect IR in patients with ChP has index CARO.
Conclusions
1. In patients with chronic pancreatitis combined with obesity and type 2 diabetes there have been detected reliably higher indices of glucose (10,05±0,1 mmole/l), immune reactive insulin on the empty stomach 66,4±2,06 mcU/mland index HOMA-IR (30,05±2,35) and reliably lower indices levels CARO (0,16±0,01) and QUICKI (0,36±0,03) than in patients with isolated chronic pancreatitis (5,67±0,09 mmole/l, 27,82±1,7 mcU/ml, 7,03±2,8, 0,21±0,02, 0,46±0,04 correspondingly) and practically healthy people 5,46±0,07 mmole/l, 10,82±0,62 mcU/ml, 2,69±0,16, 0,53±0,01, 0,56±0,02 correspondingly), Р<0,05.
2. Among calculating indices of insulin resistance the most diagnostic important of people with chronic pancreatitis has index CARO because it has proved the highest sensitivity (93,3%) and specificity of the method (90%). That is why testing of this index can be recommended for early detecting insulin resistance in people who are ill with chronic pancreatitis.
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