Y Hpc TP. Hb Chi Minh * T§p 20 * Sb 6 * 2016 Nghien ciiu Y hpc
HIEU QUA PHUC HOI VAN D O N G VA T H 6 I GIAN HOI PHUC 6 BENH NHAN DOT QUY TAI BENH VIEN Y HOC CO TRUYEN CAN THO
Pham Nguyen Bdo Nggc*, Nguyin Thi Son**, Nguyen DS Nguyen***
TOMTAT
Ddt vdn ^: Tai biih mqch mdu nao (TBMMN) dio t&i nay van Id mdt van di thdi su cap thiet vi le ngdy cdng hay gap, tyle tie vong cao vd delqi nhieu di chiing nang rii vi van dgng vd tiian kinh, ddn din su tdn phe ddi hdi cd sie chdm soc ddi ngdy. Tqi binh vien Da khoa Thdnh phd'Cdn Tha mdi ndm nhqn dieu tri trung binh 1200 heat benh nhdn TBMMN. Do dd ta thay rang TBMMN mang tinh cap thiei vi ngdy cdng hay gap, ty le tie wng cao. Nghien cuu ndy Hm hdnh tqi benh viin y hgc co truyin CSn Tho nham xdc dfnh ty li phuc hoi di chimg van ddng, ngdn ngU, cam gidc & nhieng binh nhdn ddt quy hiin nay diiu Hi bang nhiiu phucmg phdp trong dd cd kii hop y hgc hien dai (YHHD) vd y hoc co truyin (YHCT)
Muc tieu n^ien cdu- Xdc dinh ty le benh nhdn Hoi phuc van ddng vd Hung binh thdi gian Kdi phuc a benh nhdn dot quy dieu tri tai binh viin y hgc co'truyen Cdn Tha.
Do'i tugng vd phuong phdp nghien cdu: Nghiin deu cat ngang md td Hen hdnh tii thdng 12/2015-06/2016 tqi Binh vien y hgc co Huyen CAU Tha v&i ki thuqt chgn mdu thuan tien. Nghien cieu ghi nhan dugc 333 binh nhdn thoa Heu chudn chgn mdu.
Kei qud: Ty li hoi phuc van dgng dm thdi diem ngdy 30 theo dimi Barthel > 60, ngdy thu Ityli Hoi phuc dqt 0,6%, ngdy thie 17 ty le Hm phuc dqt 50%, ngdy thie 29 ty le Hdi phuc dqt 68%, thdi gian /wi phuc trung zri Id ngdy thd 17 sau dieu tri cdc yeu liin quan dm phuc hoi van ddng sau dot quy. Binh nhdn khdng cd tien su ddi thdo dudng cd khd ndng Kdi phuc cao hem 60% benh nhdn cd tiin sie ddi thdo dudng su khde biit Id cdy nghia thong ke(p = 0,049). Binh nhdn dot quy do nhoi mdu ndo cd khd ndng hdi phuc vdn ddng cao hem 53°/o so v&i benh nhdn xuai huyii nao nhung su khac biit khong cd y nghia thdng kev&ip = 0,09. Binh nhdn diiu tri sau ngdy 1 dot quy cd khd ndng Kdi phuc kem han 27% so v&i bmh nhdn dugc tri ngay Hong ngdy ddu tien su khde biit Midng cd y nghia thong ki(p = 0,09).
KA ludn: Theo doi hieu qud diiu Hi phuc hdi van ddng cua bmh nhdn sau TBMMN cdn ddnh gid kii qud (sie dung thang dimi Barihel) ngay ngdy ddu tien.
Tiikhda: Dot quy, tai bim mqch mdu ndo, phuc Hdi van ddng, thang dimt Barthel.
ABSTRACT
EFFECTIVE RECOVERY TIME ACTIVITY AND RECOVERY IN STROKE PATIENTS COMBINATION TREATl^iENT IN CAN THO TRADmONAL MEDICINE HOSPITAL
Pham Nguyen Bao Ngoc, Nguyen Thi Son, Nguyen Do Nguyen
* Y Hoc TP. Ho Chi Minh * VoL 20 - No 6 - 2016:167 -172 Background: SHoke has so far is a matter (rfurgmcy because perhaps more commonly, high mortality rates and leaves more severe sequelae arui nmrohgical movement, leads to disability requiring long-term care General Hospital in Can Tho dty recdves Heatment far a median patimt sHoke 1200 respecHvely each year. It is showed
' Benh vien Y hgc co truyen Thanh Pho C^n Tho
" Khoa y hpc co truySn - Dai hgc Y Duoc Thanh pho Ho Chi Minh
~ Vi&i Y T^ Cong C$ng - Dai hgc Y Du^c Thanh pho Ho Chi Minh
Tdc gid lien lac ThS.BS. Pham Nguy&n Bao Ngpc DT: 091 3938718 Email: [email protected] 167
Nghien cijeu Y hpc Y Hpc TP. Hb Chi Minh * TSp 20 * Sb 6 * 2016
that stroke is urgmt because of increasingly common wiih high moriality rates. This study vm conducted in TradiHonal Medidne Hospital in Can Tito City to determine recovery rates sequelae motor, language, sense of stroke in patients mrrently Heated with a variety of methods including combinations modem medicine and Haditional medidne.
Research objectives: Determining the percmtage of patients recovers motor and average recovery time of stroke in patients zvith combination therapy in hospital medidne and Western medidne to Haditional medidne.
Study design and Methods: Cross-sectional descriptive study from 12/2015 to 06/2016 in the first phase cf Heatment at the Cmtral Hospital, General Hospital and Hospital 121 in Can Tho City with convmimt sampling technique. Research recorded 333 patients were eligible far sampling.
Results: The rate of recovery movenimt by tiie time of day according to Barthel > 60 30, day 1 ratio reached 0.6% recovery, the 17th day of recovery rate readied 50%, the 29th day recovery rate for 68%, the median recovery time was the 17th day with recovery treatment after stroke. The patient had no history of diabetes have a higher ability to recover 60%, of patients zoith a history of diabetes, the differmce is statistically significant (p = 0.049). SHoke patients with cerebral infarction recxxvery racer 53% higher compared to patients with cerebrd hemorrhage, but the difference was not statistically significant vnth p = 0.09. Patients were treated after sHoke one day with recovery less than 27% compared zvith patients who zoere Heated zmthin the first days, the difference was not statistically significant (p - 0.09).
Conclusion: Monitoring the effectixjeness of Heatment advocacy recovery of patients after TBMMN should evaluate the results (using Barihel scale) on the first day.
Keyzvords: Stroke, motor recovery, Barthel scale.
D A T V A N D E
Tai bi&i mach mau nao (TBMMN) cho toi nay van la mot van de thoi sy cap thiet vi Ie ngay cang hay gap, ty le tii vong cao va de lai nhieu di chiing nang he ve van dong va than kinh, dan d&i sir tan phe doi hoi co su cham soc dai ngay.
Dieu nay gay thiet hai to Ion khfing nhung v^
kinh te ma eon suy giam chat luong cuoc song do chinh la ganh nang cho gia dinh va toan xa hpi. Hien nay dot quy dung hang thu 3 ty le tu vongf^J sau benh tim va ung thu. Theo Russel, ty ie tu vong 6 giai doan dau la 15% va 50% benh nhan song sot bi tan phe'^'. Nam ty le mac benh d6t quy cao hon 33% va ty 1| dot quy cao hon 41% so voi nix. Theo thong ke phan Ion hay gap 6 do tuoi 50 nhung hien nay cung hay gap 6 tuoi 30-40'*', TBMMN thuang lien quan d « i cac benh kem theo nhu tang huyet ap, dai thao duong, xa vua dong mach, benh viem noi tam mgc, benh van tim,...
Tgi benh vien Da khoa Thanh pho Can Tha moi nam nhan dieu tri tnmg binh 1200 luat benh
nhan TBMMN. Do do ta thay rang TBMMN mang tinh cap thi^t vi ngay cang hay gap, ty le tiJ vong cao. Hien nay, de phuc hoi di chiing van dpng, ngon ngu, cam giac 6 nhiing benh nhSn dot quy hien nay dieu tri bang nhieu phuong phap trong do CO ket hgp y hoc hien dai (YHHD) va y hoc co truyen (YHCT). Nhiing nam gan day tai Thanh Pho Can Tho chua c6 de tai nghi&i a i u danh gia su phuc hoi van dong va thoi gian phuc hoi ciia benh nhan di chiing tai bim mach mau nao bSng thang di&n Barthel, vi vay nghien ciiu nay dupe tien hanh vdi muc tieu nhu sau:
"Xac dinh ty le benh nhan hoi phtic van dpng va trung binh thoi gian hoi phuc 6 benh nhan dot quy tgi benh vien y hpe co truyen Can Tha", cu the la:
1. Xac dinh ty 1| phuc hoi van dpng theo thang diem Barthel va trung vi thai gian hoi phuc a benh nhan dot quy tai benh vien y hpc co truyen {3n Tho.
2. Xac djnh cac yeu to hen quan d&i hieu qua dieu trj: Tuoi, gioi, chi so khoi co the (BMI), trinh dp hpc van, nghe nghiep, tinh trang gia ^ n h .
Y Hpc TP. Hb Chi Minh * Tap 20 * Sb 6 * 2016 Nghien cmi Y hoc
b&ih kem theo (tang huyet ap, dai thao duong, roi loan lipid, beo phi), nguyen nhSn dot quy, dot quy Ian thii may, thai gian m^c berth.
PHU'ONG FHAP NGHIEN CLTU Nghien ciiu tien ctiu, mo ta
Tat ca benh nhan dot quy dupe dieu tri npi tru tai benh vien y hpc co truyen Can Tha tti thang 12/2015-6/2016 sau khi da duoc chan doan va dieu tri giai doan ^ u tai benh vien Da khoa Trung Uong Can Tha, benh vien Da Khoa Thanh Pho Can Iho, benh vien 121 tai Thanh Pho Can Tho.
Comlu
n=Z^^TT(l-TC)/d2
n = 0,5 ty le hoi phiic sau dieu tri Zo,97s= 1,96, voi xac suat sai Iam loai 1 a=0,05 d= dp sai so: 0,05
Thay vao cong Ihiic co n = 384 benh nhan TBMMN
Ky thult chpn mau
Chpn mau diuan tien cho toi khi du mau nghien ciiu
Tieu chi chon benh
Tieu chuan chan doan lam sang TBMMN ciia to diiie Y te The gioi: 'TBMMN dugc djnh nghia nhu mot hpi chiing thieu sot than kinh xay ra dot ngpt voi cac trieu ehiing khu tni hom la lan toa, ton tai qua 24 gio hoac tii vong trong 24 gia (loai trii do chah thuong sp nao).
- Bang ehiing nhoi mau nao hay xuat huyet nao dua tren CT Scan, MRI.
- Tinh nguyen tham gia nghien ciiu.
- l i n h tao, hgp tac dieu tri voi fliay thuoc.
Tieu chi loqi trit
- B^nh nhan liet nua nguoi sau cheui thuong spnao, u n a o . . .
- Benh nhan dot quy co 16 loet, viem nhiim dpc vung cot s6ng, hoac suy kiet do nam lau.
- Sinh hieu chua bn, co nhung benh ly dang dien ti&i cap tdih.
Phuong phap thu thap sb lieu
Dimg bieu mSu dang phieu dieu tra, lay so lieu ciia eae benh an mau ciia benh vien thoa tieu cW chgn benh va ti^u chi loai benh.
Phan tich va xir ly sb li^u
Nhiing dae tinh nen a i a benh nhan dugc mo ta voi tan so va ti le phan tram. Ty le hoi phuc van dpng va trung vj thai diem phuc hoi van dgng dugc uac lugng voi phuong phap phan tich song con.
Kiem dinh log-rank dugc sii dung de so sanh xac suat hoi phuc van dgng theo nhiing d§c tfnh cua dbi tugng nghien ciiu. Hoi qui Cox da biai dugc sti dyng de xac djnh nhiing yeu to lien quan voi hoi phuc van dgng. Nhiing bi&i so dugc dua vao mo hinh da bian khi moi lien quan don bien co gia tri p < 0,20. Muc dp lien quan dugc uoc lugng vdi ti so nguy hai (HR: hazard ratio) va khoang tin cay 95% ciia HR.
KET QUA VA BAN LUAN
Trong so benh nhan dot quy dieu tri tai benh vien y hpc co truyen C ^ Tha tii thang 12/2015- 6/2016, ghi nhan cd 333 truang hgp thoa ti%a ehuah nhan mau. Nghien ciiu ghi nhan ty le benh nhan la ngudi cao tuoi (> 60) la 62,2%. Benh nhan nam cd ty le cao hon nii gidi (56,2% so vdi 43,8%). Da so benh nhan cd trinh do hpc van khbng cao. Phan ldn la tii tieu hgc d a i trung hpc ca sd chiem 74,1%%. Hau het berih nhan c6 nghe nghiep kh6ng phii thugc gid hanh chinh la nhung nguai lam rupng, ray, can bp da nghi huu, ph\i viec nha, buon ban nho le, chan nuoi thijy hai san, npi trg (95,5%). Ty le benh nhan song vdi vg/chbng tuong duong vdi benh nhan khong song vdi vg/chong (51,1%, 48,9%). Cac benh nhan dot quy dugc dieu trj tai benh vien y hpe cb truyen Can Tha nguyen nhan chii yeii la nhoi mau nao (85,6%). Benh nhan khong thira can, beo phi thi chiem ty le cao hon benh nhan thua can, beo phi (79,3% so vdi 20,7%). Benh nhan co tien sii tang huyet ap chiem ty le cao (79,58%). Tuy nhien, doi vdi benh dai thao duang va roi loan lipit mau tiu ket qua nghien
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Nghien ciiu Y hpc Y Hpc TP. Ho Chi Minh * Tap 20 * So 6 * 2016
ciiu cho thay cac benh nhan khong mac cac benh nay chiem ty Ie cao hon so vdi cac b | n h nhan mac benh. Tir ngay ^ u hen dieu tri cd 02 truong hgp hoi phue, ty Ie hoi phuc la 0,6%. Den ngay thii 15 so truang hgp hoi phuc la 125, ty le hBi phuc la 50%. Den ngay tiiu 29 thi co 151 trudng hgp hoi phuc, ty le hoi phuc la 68%. Ty le hoi phuc tang dan theo thdi gian theo doi va thai gian trung vi aia hoi phuc la ngay thii 17, co nghia la d&i ngay thii 17 sau dieu tii co 50% da hoi phuc van dgng. Ket qua ding cho thay ngay ngay dau tien sau dieu tri da cd berth nhan hoi phuc van dgng nhiing thong tin c6 the ftiay tien dudng cong Kaplan-Meir 6 bieu do 1.
Thoi gian hoi phuc
Bdng 1. Thai gian fwi phuc (trung zn, khodng Hi zn)
Thoitlilm (ng^y)
_ j
1^-
1"
r
= '
Bich phSn vj 25
9 50 17
75 Khong xdc
^nh
Bign do (ngdy) 1-29 Kaptan-Meier failure estimales
HalDfiucsaudlcutrt xettiop Dong-TayY
-
-- J - * " ^ - ~
10 ao 30 39 1 85=iCI Failure ftjncSon 1
Bim (io I. liac lugng xdc suai Koi phuc sau dieu tri (dudng cong Kaplan-Meier).
Nhung yeu to lien quan voi hoi phuc van dpng
Bdng 2. Nhiing yeit td'lien quan v&i Koi phuc (phdn tich da bim v&i hoi qui Cox).
Bi4n sd Nguygn nhan dpt quy
Xu^t huyit n3o Nh6i mdu nSo Tien si> DTD
C6 Khang
HR 1 1,53
1 1,60
Khodng tin c^y 95%
0,94-2,49
1,002-2,67 P
0,09
0,049
Bi4n s6 Khong biet
HR 1,38 Thiri gian t£F khi dgt qu
Ngdyl Ngay £ 2
1 0,73
Khoang tin c^y 95%
0,66-2,22 din Ithi diiu tri
0,51-1,06 P 0,63
0,09 Benh nhan khong cd tien sii dai thao dudng cd kha nang hoi phuc cao hon 60% benh nhan cd tien sii dai thao dudng su khac biet la ed y nghia thong ke (p - 0,049). Benh nhan dot quy do nhoi mau nao cd kha nang hoi phuc van dpng cao ban 53% so vol benh nhan xuat huyet nao nhimg sij khac biet khong co y nghia thong ke vdi p = 0,09. B$nh nhan dieu trj sau ngay 1 dot quy CO kha nang hoi phuc kem han 27% so voi benh nhan dugc tri ngay trong ngay dau tien su khac biet khdng cd y nghia thong ke (p = 0,09).
Nguyen nhan dot quy: Trong nghien ciiu nay, benh nhan nhoi mau nao kha nang hoi phuc van dgng tang 53% so vdi xuat huyet nao 6 day (p = 0,09 > 0,05), khong cd y nghia thong ke. Co the ^d co mau nghien ctiu qua it lai them tiong khi nghien ciiu chi tinh ca mau ty Ie phuc hoi van d6ng va trung binh thai gian hoi phuc, khdng tinh ea mau ciia cac yeu tS lien quan.
Cl tien sii dai thao dudng: Nguai khong bi dai thao dudng kha nang hoi phue van dpng tang 60% so vdi bi dai thao dudng cd y nghia ftiong ke Cling nhu ve mat lam sang. Nhung benh nhan dot quy cd kem theo nhung benh man tinh kha nang phuc hoi van dgng rat cham Nguyen Quoc Anh va Ngo Quy Chau'*», Nguyen Van Tri<«. Doi vdi truong hgp benh nhan khong biet nunh cd bi hay khong bj dai tiiao dudng (DTD) tiii kha nang hoi phuc tang 38% nd cd y nghia ftiong ke vi cd ftie benh nhan khong ro minh cd mac benh dai thao dudng.
Thdi gian tir khi dot quy doi dieu tri: Lay ngay thii 1 diJeu tri lam chuart thi > sau 2 ngay dieu tri I^ha nang hoi phuc van dpng a benh nhan giam 27%, khong cd y thcng ke nhung tien lam sang rat cd y ngWa vi benh nhan den cang sdm cang tot cho viec phuc hoi van dgng (b^ng thai gian nay la thai gian vang ciia phiic hoi van dpng vimg tranh toi tranh sangi^i.
Y Hpc TP. H o Chi Minh * Tap 20 * So 6 * 2016 N g h i e n cmi Y hpc
Chiing ta biet rang xuat huyet nao va nhoi mau nao nguyen nhan la do tang huyet ap, dai thao dudng, roi loan lipid gay nen. Nhung trieu chiing a i a xuat huyet nao rat nang va dien tien rat nhanh, nhoi mau nao thi dien tien cham nhung kha nang phuc hoi vgn dgng tiiy theo vi tri ton thuang, di§n tich ton thuong, thdi gian den berth vien som hay muon (gio vang) va dugc dfeu tri on dinh cae benh Iy kem theo.
Trtmg nghien ciiu nay hieu qua hoi phue 6 benh nhan nhoi mau nao cao hon xuat huyet nao, giong vdi nhiing nghien ciiu ciia cae tac gia 6 tien. Tgi benh vien y hgc co truyen C ^ Tho nguyen nhan dot quy khong anh hudng d m ket qua phyc hoi van dgng (p = 0,06) co kha nang khi benh nhan dot quy do nhoi mau nao hay xuat huyet nao d&i nhap vien vdi tinh tiang rat nang kem fheo d&i qua muon.
Nguyen nhan dot quy; Neu nguyen nhan la xuat huyet nao tiii benh dien tien nhanh, trieu chiing nang ne va ram rg ban nhoi mau nao. Yi vay, xuat huyet nao tien lugng nang hon nhoi mau nao. Xuat huyet nao va nhoi mau nao cd anh huong den kha nang phuc hoi van dgng (p = 0,06). Ket qua nghien ciiu tai benh vi^n y hgc co tmyen Can Tha: Nhdm nhoi mau nao phuc hoi tot hon xuat huyet nao. Tren benh nhan xuat huyet nao nam vien lau ngay lai tiiem nhimg benh di kem nen nhan vien y te phai theo doi nhiing bi&i chiing nhu viem phoi, loet vimg ty de, nhiem trimg tieu,.. .va hudng dan cho ngudi nha berth nhan each cham sdc.
Dai thao duang, roi loan lipid cd anh hudng phue hoi van dgng. Dai thao dudng va roi loan lipid khong dugc ki&n so^t tot, ket hgp them thdi gian mac benh lau ngay gay bien chiing nang ne, lam ton thuong nhung mach mau nhd cung nhu mgch mau ldn. Chinh dieu nay lam qua trinh xa viia dien ra nhanh hon ngudi binh thudng, khi mach mau ton thuang la co hgi hinh thanh cue huyet khoi trong Idng dgng mach hay cue xa viia lam bit tac long dgng mach. Su kiem soat duong huyet khong ed hieu qua, si^ hieu biet ciia benh nhan ve benh dai thao dudng, roi
loan lipid cung han hep nen de tinh trang dai thao dudng, roi logn lipid nang ne va anh hudng den phuc hoi van dgng.
Thdi gian dot quy deh khi nhap vi?n cd anh phuc hoi van dgng sau dot quy, khi benh nhan den benh vien dfeu tri cang sdm thi kha nang hoi phuc van dpng cang tot, den benh vi^n dieu tri ngay thii 1 se tot hon nhiing ngay con Igi.
Nghien ciiu ket qua nay cimg phu hgp vdi nhiing ket luan trong cac nghien ciiu trudc day:
Hoang Thanh HienP>, Nguyen Van Tungi«: Thai gjan d&i d£eu tii cang ngan thi hieu qua hoi phyc cang cao, Ha Thi Hong LinhW; Thai gian mac benh trudc dieu tri cang lau thi hieu qua dieu tri cang giam.
Thoi diem hoi phiic v ^ dpng sau dieu tri Ngay ngay thii nhat benh nhan da bat dau hoi phuc va dSi ngay thii 17 t^ le hoi phuc la 50%, khi ty le dat tien 75% flii khong xac dinh duge ngay hoi phuc, vi benh nhan khong a qua 30 ngay do cd nhung benh nhan khi hoi phuc van dgng (diem Barthel > 60) ra vien, cd nhiing benh nhan khong cd kha nang nam vien, v\ kho khan ve mgt kinh te dii khong cai thien cung xin ra vien truoc 30 ngay dieu tri va cd nhiing benh nhan dieu tri khong Ihay cai thien phuc hoi van dgng, nen tu y ra vien du barthel < 60.
Ket qua nghien ciiu cho tha'y ngay ngay thii nhat sau dfeu tri da cd benh nhan hoi phuc van dgng (0,6%). Dieu nay eho thay danh gia hieu qua dieu tri phuc hoi vgn dgng can dugc thuc hien ngay ngay dau tien va moi ngay de nit ngan thdi gian nam vien.
KETLUAN
Ty le hoi phuc van dgng den thdi diem ngay 30 tiieo diem Barthel S 60, ngay thii 1 ty Ie hoi phuc dat 0,6%, ngay thii 17 ty le hoi phuc dgt 50%, ngay thii 29 ty le hoi phue dgt 68%. Benh nhan dieu tri sau ngay 1 dgt quy co kha nang hoi phuc kem hon 27% so vdi benh nhan dugc tri ngay tiong ngay dau tien su khac biet khong cd y nghia thong ke (p = 0,09). Do vay, theo doi hieu qua dieu tri phue hoi vgn dgng ciia benh nhan
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Nghien cuu Y hoc Y Hpc TP. Ho Chi Minh • Tap 20 * So 6 * 2016
sau TBMMN can danh gia ket qua (sir dung thang diem Barthel) ngay ngay dau tien.
TAI llfiu THAM KHAO
1. Bo Y Te Phuc Koi chuc nBng Nha xuat ban Y hpc, tr.l92.
2. H a Thi Hong Linh (2005). Hieu qua phuc hSi v^n dgng ciia phiBjng p h a p ftie cham cai ti&i tren b?nh nhan tai bi&i m^ch mau nao. Y hgc thuc hdnh TPHCM 2:64
3. Hoang Thanh Hien (2012), Khao sat n h u n g yeu to co anh h u o n g tren hieu qua p h y c hoi v3n dgng sau dot qui bang p h u o n g p h a p d i a m cuu cai ti&i phra h q p v§t ly trj L?u t?i Tp.
HCM. YhocOiuchanh TPHCM, 1.61.
4 N g u y i n QuSc Anh va Ngo Quy ChSu p012). Hudng dSn chan do&n v& dilu tn benh noi Ishoa. Nxb Y hgc, tr.220,426,
N g u y ^ v a n BSng (2003). Tai biSh mach man nao N h a xuat ban Y hpc H& Ngi, tr.9-32.
Nguyen VSn Tri (2013). Bfnh hoc nguiri cao lim. Nha xuat ban Y hpc TPHCM, lr,333
Nguyen VSn Tiing (20O4). Danh gia hieu q u i the' cham ttong ph^c hoi di dtuxig van d ^ i g benh nhan tai b i a i m a d i mau nao. Y^ioc fhuc Wnh TPHCM, 1 5 1 ,
Vii Anh Nhi (2005). TTiSn kinh hoc. Nha xuat ban Y hpc TPHCM, bJ36.
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Ngay phdn bien nh4n xet bai bao:
Ngay bai bdo dime dang:
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