RU2533732C1 - Diagnostic technique for risk of developing stress-induced pitted keratolysis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to physiology and dermatovenerology, to diagnostic technique for a risk of developing pitted keratolysis accompanied by stress as an uncurable element of the professional environment for the purpose of the goal-oriented prevention of the above disease in the individuals having hazardous occupations. A heart rate variability is examined twice - before and 15 minutes after a hot test on a plantar surface. If observing no decrease of the LF/HF value as compared to the reference, a risk of developing stress-induced pitted keratolysis is diagnosed.

EFFECT: technique provides more accurate diagnosis of a risk of developing stress-induced pitted keratolysis by examining the heart rate variability and using the hot test.

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Description

The invention relates to medicine, namely to physiology and dermatovenerology, to methods for diagnosing the risk of developing small-point keratolysis under stress as an unremovable element of the professional environment, for the implementation of targeted preventive treatment of this disease in persons of dangerous professions.

Assessment of the severity of stress exposure and the completeness of recovery after it, including the diagnosis and rehabilitation of stress-induced diseases, for professions in which stress is an unremovable element of the professional environment, is extremely relevant. The profession of firefighter and rescuer is distinguished by the fourth, highest class of severity of labor in terms of physical and neuropsychic stress, and takes 2nd place in the top ten professions most dangerous to life. Significant physical and psychological stresses, special protective clothing and shoes during work (the weight of the breathing apparatus only is 14-16 kg), constant tension while waiting for a call - all this causes a high stress load.

According to the patent information search, a number of methods are known for assessing the professional suitability of personnel for stress resistance in the selection of personnel, described, for example, in A.S. USSR No. 1607777 (operators - with an assessment of the dynamics of the nervous system for various motor reactions in response to various positive color stimuli), A.S. No. 1452515 (operators - with an assessment of the cost of resources to complete the task according to the values of the maximum heart rate), А.с. No. 2164776 (testing on the dynamics of changes in the indicators of a set of significant questions, the answers to which cause a deviation in the magnitude of the following recorded indicators: skin-galvanic reaction, frequency of chest and diaphragmatic respiration, heart rate, reactions of motor and voice activity in response to tests containing three groups questions of different importance). However, these well-known methods determine either the physiological abilities of the subject (A.S. No. 1607777, A.S. No. 1452515), or his motivation for choosing this profession (A.S. No. 2164776), but not a psychophysiological state with an assessment of the risk of developing stress -induced conditions and diseases.

A known method for determining emotional stress and a device for its implementation (RF patent No. 2073484, IPC A61B 5/02, A61B 5/04, 02.20.1997), based on the registration of vegetative indicators of a person (heart rate, respiratory rate and galvanic skin resistance) with the subsequent calculation of cross-correlation coefficients reflecting the degree of stress development, and a method for determining the level of stress (RF patent No. 2147831, IPC AB 5/02, 04/27/2000) with the calculation of the "stress indicator" by body weight, heart rate and heart rate about blood pressure. This method is not applicable to persons of "dangerous" professions and a specific disease, because it does not take into account “population” norms and does not imply an initial selection of persons most stress-resistant according to the requirements of the profession.

There is a method of assessing the risk of development of prenosological, premorbid and pathological conditions in a long space flight (RF patent No. 2448644, IPC АВВ 5/02, September 15, 2010) by referring the patient to a certain type of vegetative regulation and calculating posterior probabilities. The main disadvantage of this method is its probabilistic nature and inapplicability in the dynamics of extreme loads.

A known method for the diagnosis of hidden suffering of children with atopic dermatitis, by assessing heart rate variability indicators (according to the application for invention No. 2005122100/14, 07/12/2005) by assessing the severity of atopic dermatitis and choosing treatment by summing conditional scores, including assessing the prevalence of cutaneous process, clinical manifestations of the disease and indicators of heart rate variability with the calculation of threshold values according to the proposed formula. The main disadvantage of this method is its narrow focus: applicability for a clinically defined disease only in children, which cannot be used in healthy adults outside the outlined nosological form of skin disease.

Significant relationships were identified between the development of small-point keratolysis and foot hyperhidrosis (90.8%), wearing tight shoes (79.1%), intense sports (30.1%) and a combination of these risk factors (69.9%) (E. N. Efanova, Punctate keratolysis: clinical manifestations, optimization of diagnostic methods, therapy and prophylaxis: abstract of thesis ... Candidate of Medical Sciences: 14.01.10. - Novosibirsk, 2012. - 22 pp.), But the criteria applicable to assessing the likelihood of developing a disease depending on the individual characteristics of the body to respond to stress in the presence of well-known "risk factors for the development of the disease, not found.

A known method for assessing the psychophysiological state of a person by heart rhythm (RF patent No. 2246251, IPC AB 5/00, 02/20/2005), including measuring the current total power in the low-frequency and high-frequency regions of the dynamic range of cardio intervals and assessing the psychophysiological state of a person by the stress index. The stress index gives a low accuracy of measurement, it is not individual and not applicable for people of “dangerous” professions, and the frequency spectrum ratios are not applicable to assessing the risk of developing a stress-induced disease, because the “width” of their population “norm” is not defined. It is known that the mechanisms of tolerance to occupational stress and response to stress as an external stimulus can be identified during an active orthostatic test (AOP) (V. M. Mikhailov. Heart rate variability. Experience in the practical application of the method. - Ivanovo, 2000. - 200 p. ), while the predominance of parasympathetic influences is a factor in the individual sustainability of a healthy organism (S.V. Koroleva et al. Pathogenetic mechanisms of professional adaptation of persons in dangerous professions // Materials of the XXIV International Scientific and Practical conference on fire safety, dedicated to the 75th anniversary of the institute. - Moscow: FSBI VNIIPO EMERCOM of Russia, 2012. - S.142-145.). Initially, professionally oriented selection of individuals with a predominance of parasympathetic influences requires an individual approach to assessing changes in specific stress-induced conditions, since the “traditional” response to the load is changed due to a certain imbalance of autonomic support of the heart.

Closest to the proposed method is the author's "Method for assessing the professional adaptation of cadets of educational institutions of the Ministry of Emergencies of Russia" (patent for invention No. 2480151 according to application No. 2012103772/14 (005634), priority dated 02/03/2012, registered in the State Register of Inventions of the Russian Federation 04/27/2013 ), including a study of heart rate variability before and after modeling extreme stress in a fire. The professional adaptation of the cadet is considered satisfactory if, as a result, the TP (background sample) is reduced by no more than 50%, the 30/15 indicator is no more than 20% of the initial values, and the LF / HF (AOP) is increased by no more than 30% of the original.

The pathogenetic basis of the proposed method is the postulate of the relationship between the autonomic support of the heart and the nonspecific nature of the body's response to stress, including in the form of skin reactions: J.F. studies Thayer et al., 2012 (A meta-analysis of heart rate variability and neuroimaging studies: Implications for heart rate variability as a marker of stress and health // Neuroscience and Biobehavioral Reviews. - 36 (2012). - P.747-756 ), confirm the relationship between heart rate variability and the activity of higher centers that control the stress response (amygdala and medial prefrontal cortex). Previous studies have found that the professionally “beneficial” type of stress response for firefighters and rescuers is the activation of the parasympathetic departments of the autonomic nervous system, which expands the “corridor” of the body's adaptive capabilities to extreme conditions of activity (K.V. Kopeikin, S.V. Koroleva, Pathogenetic mechanisms of the formation of psychophysiological maladaptation in persons of dangerous professions // International Journal of Applied and Fundamental Research. - 2012. - No. 1. - P.28.). At the same time, it was morphologically established that the sweat glands of the feet are innervated by the sympathetic nerves. The terminals of their nerve fibers secrete acetylcholine, i.e. are cholinergic, like parasympathetic fibers (Trifonov E.V., Human pneumo-psychosomatology. Russian-English-Russian encyclopedia, 16th ed. 2013 [electronic resource]). Therefore, we can say that the sweat glands of the skin of the feet have a double cholinergic innervation, therefore stress as an adrenergic reaction is both a “trigger” and a mechanism supporting the disease due to hyperhidrosis. Consequently, the state of psychophysiological stress, manifested in an increase in segmental sympathetic influences, in individuals with high individual stress resistance is prone to adaptive "transition" to the predominance of parasympathetic influences. Accordingly, the torpidity in the "adjustment" of the body and rigidity in maintaining segmental (adrenergic) effects under stress exposure is a manifestation of a tendency to develop stress-induced conditions and diseases.

The technical result of the proposed method for diagnosing the risk of stress-induced small-point keratolysis is that the study of heart rate variability is carried out twice - before and after a 15-minute heat test on the plantar surface of the feet, and in the absence of a decrease in the LF / HF indicator (background sample) compared with the initial one, the risk of developing stress-induced small-point keratolysis is diagnosed.

The studies were carried out in standard conditions of the research laboratory of FSBEI HPE IVI GPS EMERCOM of Russia "Catastrophe Medicine" in compliance with ethical and legal standards for a decreed group of patients. Certified standard equipment and hardware and software of Neurosoft (VNS-Micro) were used to study heart rate variability, including the dynamics of a standard active orthostatic test (AOP), NS-Psychotest to determine the parameters of the psychophysiological response to professional workload). The experimental group consisted of 35 cadets randomly selected from 2 groups of 1 course in the process of “pilot” examination to identify stress-induced conditions. All cadets noted the presence of all risk factors for the development of small-point keratolysis: prolonged wearing of berets, the impossibility of changing shoes frequently (the cadets were in a suburban training center), intensive training in conditions as close as possible to combat (recreation of technological disasters in rail and air transport, in residential in rooms, on industrial blockages, etc., a heat smoke chamber in maximum physical load modes on built-in simulators). All cadets were in the same living conditions, life and nutrition. The saturation of training, duty and outfits was also the same. According to the health group, they were all assigned to group 1. Initially, all respondents underwent a general clinical and laboratory examination that did not reveal pathological changes. Special research methods included determining the heart rate variability for a short period (5 minutes lying down) with an active orthostatic test, with registration of standard indicators in accordance with the “International Standard” (Task Force of the European of Cardiology and the North American Society of Pacing and Electrophysiology. Heart Rate Variability. Standards of Measurements, Physiological Interpretation, and Clinical use. Circulation. - 1996. - No. 93. - C.1043-1065) twice - before and after the proposed heat test. A thermal test was carried out for 15 minutes on the plantar surface of the feet: an electric heating pad was applied at the maximum intensity mode (heating temperature at 3 modes - 55-60 ° C, surfaces - 40-45 ° C, a PW-210 certified heating pad was used for home use ) The data obtained were processed by the methods of variation and correlation statistics, Wilcoxon's test, the sign method and Student's paired criterion were used to compare successive measurements, the most informative indicators were identified using factor analysis in Latin square forms with a restriction on randomization (a linear effect of the load on the LF / HF). The method of blinding was used: the doctor of the demo-venereologist at the institute's polyclinic did not know the names of the cadets included in the experimental group.

To clarify the epidemiology of small-point keratolysis (MK), a study was conducted on the prevalence of this disease among students of the institute. In 2012, there were 408 initial complaints about skin diseases to a dermatovenerologist. Of these, cadets of the 1st year of study - 143 (35% of all primary applicants for diseases). 100 cadets complained of changes in the skin and its appendages on the feet, which accounted for 70% of the number of first-year students who first came up for diseases. 64 patients with MK were identified, which accounted for 44% of all cadets who applied for dermatological help for the first year of study, or 64% of the number of cadets who complained about changes in the skin and its appendages on the feet. Thus, the proportion of MK patients in the population of cadets of the first year of study was 15.68% of all initial illness calls to a dermatologist in 2012 (which is more than 2 times higher than the population incidence). Among 74 cadets of 2 years of study, two MK patients were identified, which amounted to 2.7% of cadets who applied to a dermatovenerologist for 2 years of study, or 0.5% of all initial visits to a dermatologist in 2012. For students from the third to fifth years of study, complaints about MK were not registered. An additional study (100 cadets of all courses of study, 20 people each year) determined that subjectively the maximum stress load (according to the methodology “Scale of Life Events” by G.E. Anderson, designed to measure the stress load of students as the basis for the formation of psychosomatic Diseases: G.E. Anderson, “College Schedule of Recent Experience.” North Dakota State University (1972) experienced 1 year students (results before Tavlya the drawing). It has been clearly demonstrated that the stress load clinically significant in the development of stress-induced diseases is maximum for 1 year of study, then it decreases to clinically insignificant (Koroleva SV et al., Dynamics of copying strategies among cadets of higher education institutions of the Ministry of Emergencies of Russia in the process of training // Collection scientific articles of 1 Internet conference with international participation "Actual problems of military and extreme medicine." - Gomel, 2013. - P.97-106).

In terms of heart rate variability (HRV) before and after the heat test, all respondents were clearly divided into 2 groups:

1. 14 people, the LF / HF after a heat test decreased by an average of 39%.

2. 21 people, the LF / HF indicator after a thermal test did not change or increased.

Training at the suburban training center lasted 7 days. Within a month after returning, all cadets were examined by a specialist doctor. Diagnosis criteria for MK: characteristic complaints, medical history, specific clinical and dermatoscopic picture, negative result of microscopic examination of scales from the foci to the fungus, lack of brick-red glow on the soles in the rays of Wood.

It was found that in 1 experimental group, signs of MK were noted in 4 people, and 10 cadets were recognized as healthy. In group 2, only 2 people were recognized as healthy, the remaining cadets showed varying degrees of severity of MK course.

Confidence Interval (Yates adjusted): 0.49 <p1-p2 <0.73

Thus, with a probability of 95%, it can be argued that the application of the proposed method to identify the risk of developing small-point keratolysis allows the disease to be predicted from 49% to 73%.

For further research, 2 groups were formed on the basis of the presence of the disease.

1. Patients MK. 23 cadets. Inclusion criteria: characteristic complaints, medical history, specific clinical and dermatoscopic picture, negative result of microscopic examination of scales from the foci to the fungus, lack of brick-red glow on the soles in the rays of Wood, lack of preliminary treatment.

2. Control group - 12 students of the same year of study, under the same conditions of training and training without clinical signs of MK according to the results of a clinical examination by a dermatovenerologist.

In the experimental group, maladaptive indicators (professional adaptation) of HRV (according to the prototype) are already observed during the execution of AOP according to the LF / HF indicator (from 0.74 to 3.22, p≤0.05). In the control group, changes during AOP were unreliable. In the control group, the decrease in the LF / HF indicator in the dynamics of the heat test according to the Wilcoxon criterion and the sign method was reliable (from 0.92 ± 0.28 to 0.55 ± 0.10, p≤0.0284 and p≤0.0269 respectively).

The correlation analysis revealed that there is a reverse direction of medium strength, the relationship between the degree of reduction of adrenergic effects (in terms of LF / HF, before and after the heat test) and the reactivity of the parasympathetic nervous system (indicator 30/15 before the heat test: Spearman's rank correlation r = -0.54, Tau Kendall = -0.38, Gamma = -0.38 p≤0.05; exponent 30/15 after the heat test: Spearman's rank correlation r = -0.71, Tau Kendall = -0.54 , Gamma = -0.55 p≤0.05), which not only confirms the methodological hypothesis of the experiment about target professionally significant parasympathetic response to stress, but also proves its pathogenetic mechanism in the development of MK.

After the treatment (erythromycin ointment for external use, 10000 units / g, manufacturer Synthesis OJSC, Kurgan, twice a day for 7 days), control measurements of HRV by the proposed complex in the group of patients with MK were performed. It was found that after treatment only in 10 out of 23 people the LF / HF indicator showed a decrease in the dynamics of the heat test, while in 13 the changes remained, which confirms the clinical data on the frequent relapse of this disease.

Objective indicators of the diagnostic value of the proposed method for diagnosing the risk of developing stress-induced MK before treatment (T. Grinhalkh. Fundamentals of evidence-based medicine: Transl. From English / T. Grinhalh. - M .: GEOTAR - Media, 2006. - P.125-140) :

- sensitivity 83%;

- specificity of 83%;

- predictive value of a positive result 90%;

- predictive value of a negative result 71%;

- accuracy index of 83%.

After treatment, the proposed method can be considered as an indicator of the risk of recurrence of MK, while maintaining its significance:

- sensitivity 57%;

- specificity of 83%;

- predictive value of a positive result 87%;

- prognostic value of a negative result of 50%;

- an accuracy index of 66%.

An assessment of the effect of intervention (the use of a thermal test) was carried out according to the standard scheme before and after treatment in the experimental group (T. Grinhalkh. Fundamentals of evidence-based medicine: Transl. From English / T. Grinhalh. - M.: GEOTAR-Media, 2006. - P. 237.):

- odds ratio for a specific outcome = 23.75.

After treatment in the experimental group:

- odds ratio for a specific outcome = 6.5.

Thus, even after the standard treatment of MK, the use of a heat test increases the chance of identifying the risk of a relapse of this disease by 6.5 times more effective, and before treatment, the use of a heat test increases the chance of detecting this condition by more than 23 times.

Testing of the proposed method was carried out when recruiting cadets 2013/14 academic year. years, when they were in the suburban educational center in July-August 2013, 2 groups of cadets of 25 people each were examined by the proposed method and a risk group of 18 people was identified whose LF / HF did not decrease after the heat test. A part of the cadets (9 people) agreed to carry out preventive treatment (erythromycin ointment for external use, 10000 units / g, manufacturer Sintez OJSC, Kurgan, twice a day for 7 days), 9 people refused subjective complaints for various reasons. The control was carried out after 1 month (after returning from the suburban training center, where they took the course of a young fighter). It was established that 11 people turned to a dermatovenerologist with characteristic complaints, all were diagnosed with MK. At the same time, out of 11 people, 9 were from the risk group and only 2 from the experimental group, with preventive treatment.

Objective indicators of the diagnostic value of the proposed method for diagnosing the risk of stress-induced small-point keratolysis (Grinhalh, T. Fundamentals of evidence-based medicine: Transl. From English / T. Grinhalh - M .: GEOTAR - Media, 2006. - P.125-140):

- sensitivity of 78.6%;

- specificity of 80.6%;

- prognostic value of a positive result 61.1%;

- predictive value of a negative result 90%;

- an accuracy index of 80%.

Thus, it has been convincingly demonstrated that with a sufficient degree of repeatability, sensitivity and specificity, the application of the proposed method improves the accuracy of diagnosing the risk of development and recurrence of stress-induced MK in unfavorable conditions from the point of view of hygiene, which reduces the incidence by preventive treatment.

Clinical examples:

1. Cadet V., 17 years old. According to the results of the initial examination, an increase in the LF / HF indicator was found before and after the heat test. The risk of developing stress-induced small-point keratolysis was diagnosed. He refused from preventive treatment.

1 month after returning from the training suburban center, where the stressful extreme conditions of professional activity were modeled, the patient was examined again - the development / realization of the risk of stress-induced small-point keratolysis was confirmed. The results of HRV in the initial examination and after corrective autonomic treatment disorders are presented in table. one.

It was clearly demonstrated that in the initial examination, the response to a thermal test (+ t) in terms of LF / HF increased from 0.468 to 0.715, which made it possible to diagnose the risk of stress-induced small-point keratolysis. After 1 month of being in conditions simulating extreme conditions (in a suburban training center), a doctor examined him and confirmed the development / realization of the risk of stress-induced small-point keratolysis. After treatment, including special methods of vegetative correction, the LF / HF index in the dynamics of the heat sample decreased from 0.425 to 0.410. The risk of re-development of stress-induced small-point keratolysis is low. During the follow-up during the school year, the disease did not recur.

2. Cadet S., 17 years old. According to the results of the initial survey, a decrease in the LF / HF after a thermal sample was found. Diagnosed with no risk of developing small-point keratolysis.

1 month after returning from the educational suburban center, it was re-examined. Small-point keratolysis was not detected, the absence of a risk of developing the disease is confirmed.

HRV indicators in the dynamics of observation are presented in table. 2.

It was clearly demonstrated that in the initial examination, and after the influence of the stress-modeling load, the response to the thermal sample was “beneficial”: the LF / HF index in both examinations decreased. The risk of developing stress-induced small-point keratolysis in this case has not been established, which was subsequently confirmed.

 HRV indicators before and after (+ t) a heat test in the initial examination and after treatment with cadet B., 17 years old

HRV indicators in the dynamics of observation in cadet S., 17 years old

Claims (1)

A method for diagnosing the risk of stress-induced small-point keratolysis (MK), including performing heart rate variability (HRV), characterized in that HRV is performed twice - before and after a 15-minute heat test on the plantar surface of the feet, and in the absence of a decrease in LF / HF compared with the original diagnose the risk of stress-induced MK.

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