Y HOC VIET NAM THANG 5 - SO 2^014
lam dung BHYT va bj benh mdi mua the bao hiem; L i m ro quy dmh ve dong chi tra.Than trpng v6i nhffng €bng chi tra so tien ldn (benh hiem ngheo, benh man tinh...)
TAI L l | U T H A M KHAO
1 . Bao cao so 98/BC-BYT ngay 20/12/2013 cua Bo Y te ve ket qua thu'c hien chfnh sach, phap luat v i BHYT giai doan 2009-2012.
2. Bao cao so 1163/BC-BHXH ngay 29/3/2013 cua Bao hi^m xa hoi Viet Nam ve k ^ qua thi/c hi^n chinh sach, pliap luat ve BHYT giai doan 2009-2012.
3. Cdng vSn so 1016/VPQH-TH ngay 05/6/2013 cua Van ph6ng Quoc hfii ve viec Giam sat thyt hien chinh sadi, phap luSt ve BHYT giai doan 2009-2012 tai tinh Binh DuUng.
Cong van so 1017/VPQH-TH ngay 05/6/2013 cua Van phong Quoc hpi ve viec Giam sat thut hien chfnh sach, phap luat ve BHYT giai doan 2009-2012 tai tinh Dakiak.
Cong van so 1018/VPQH-TH ngay 05/6/201^
cua Van phong Quoc hpi ve viec Giam sat ttiut hien chfnh sach, phap luat ve BHYT giai doan
2009-2012 tai tinh Ninh Thuan j;
Cong van bao cao cua cac tinh Binh DMngi\
Oaklak, Ninh Thuan, Ha Giang, An Giani^
Bac Ninh, Cao bang. Lam Dong, Ba Rja »v.
Vung Tau, Vinh Phuc va mot so tinh khac ve thu'c hien chinh sach, phap luat BHYT giai doan 2009-2012.
Ho scf b$nh an b^nh nhan cd so the BHYT HT5190016500058-19-001 tai khoa HSCC b#nh vien Thai Nguyen, ma y te HSCC - 1042.
NGHIEN CU'U MOI LIEN QUAN GIU'A SU* THAY DOI DOAN ST TRU'aC VA SAU CAN THIEP V a i CAC BIEN CO TIM MACH
TRONG NHOI M A U CO TIM CAP
T 6 M
TAT
Vdi myc tieu nghien CLTU m6i Ii6n quan giuS mufc dp chenh cLia do?n ST tru'dc va sau can thiep dong mach vanh (OMV) vdi cac bien co tim mach chinh s6m trong vong 30 ngSy. Nghien ciitJ da du'oc thu'c hien tren 300 b^nh nhin nhoi mau cd tim (NI^CT) dutfc can thiep dpng m?ch veinh qua da tai Vien "Hm mach Viet Nam trong thdi gian tu* thang 3 den thang 9/2013. Kgt qua thu du'dc nhu* sau:
- TSC OMV phai d benh nhSn cd ^ n thu'tfng nhieu than OMV se Wiien ST chlnh cao hdn han so vdi benh nhan chi co ton thu'dng ddn thuan OMV phai. Anh hudng nay khong ro neu tac OM lien that tru'dc hoSc DM mu - Tong dai so c^c mii'c dO chSnh ST tn/dc va sau can thiep CO lien quan ch^t vdi bien co tii' vong trong vong 30 ngay d b^nh nhan NMCT cap.
- NhuTig tru'dng hdp sau can thiip gia tri trung binh cua tong ST con chenh len > 7nim thi tien lu'dng nguy cd til* vong cao.
Tu* khda: NhBi mau cd Cm, ton thu'dng dpng mgdi vanh, can tiiiep vanh.
* BM Hoi su'c cap cuU, Tru&ng DH Y DUdc Thai Binh
**Khoa Ndi Tim m^ch, BVDa khoa Thai Binh Phan bl$n khoa hpc: PGS.TS Nguyin Ngpc Chut
Nguyen Duy Cwong*, Vu Thj Anh Tuyet**
S U M M A R Y
RESEARCH THE CHANGES OF ST SEGMENT BEFORE A N D AFTER CORONARY
I N T E R V E N T I O N W I T H CARDIOVASCULAR EVENTS I N ACUTE M Y O C A R D I A L I N F A R C I O N With the aim of studying the relationship between^
the degree of ST segment difference before and ws coronary Intervention with the early cardiovascM events within 30 days, research was performed o n : ^ patients with myocardial infarction coronary intervention percutaneous. Results as follows:
- Coronary artery lesions in patients with multiple coronary artery itself will cause ST segment significantly higher ttian patients with simple lemons only right coronary arteries. This effect is not evtdenfel, the previous ventricular septal artery or arteries hat, '<•
' Algebraic sum of ST level difference before and after intervention correlated closely to mortality events witiiin 30 days in patients with acute myocardial infarction.
- In the post-intervention case the average value of remaining total ST segment elevation > 7mm wages higher risk of death
Keywords: Acute myocardial infarction; coronary artery lessions; coronary intervention.
YHpCVl|TNAMTHANG5-so 2/2014 I.OATVSNOI
Nhoi mau cd tim la benh iy nang, ngay mpt gia tang, nhieu bien chutig nguy hiem de doa ttnh mang ngu'cfi benh. Tren the gicfi moi nam co 2,5 trieu ngu'di chet do benh nhSi mau cO Hm, trong do 25 % chet trong giai doan cap tinh ciiia benh. 0 My, ty ie nay Ichoang 30%, co tdi 50%
trong so do til vong trong gic) dau tien. Tai Viet Nam, theo thong i(g ciia Tong hpi Y du'dc hpc Viet Nam nSm 2001, ty ie tu' vong do nguyen nhSn benh tim mach noi chung la 7,7%, trong dd 1,02% chet vl NMCT [1]
Tru'dc day vi$c dieu trj nhoi mau cd tim chu yeu d i u trj npl khoa nhuhg ty le thanh cdng khong cao ma lai nhleu bien chiing dac biet la xuat huyet nao de dpa den tfnh mang ngu'di b^nh. Va gan dly viec md thong mach vanh bSng can thl^p dpng m^ch vanh qua da da dem Ial nhleu hl|u qua dang ke [2],
Phat hien, chan doan va dieu trj sdm se cai thl^n rat Idn ty le sdng cdn cua benh nhan. Viec ghi di^n tlm dS sdm ngay khi benh nhan vao vl$n II rit cd ^ nghla giiip cho ngu'di bac sy cd chi djnh kjp thdi dol vdl b$nh nhin nhoi mlu cd tlm, ml d$c trung cua nd la sir thay dol cua doan ST. VI Slf thay dSl doan ST tren di$n tam do tru'dc vl sau can thl^p dpng mach vanh rat cd gll tr| tISn lu'png b?nh nhan. 6 Viet Nam, da cd mpt vai nghiin ciJu ndi den sif thay dpi ciia dpan ST nhung tren mpt lu^ng benh nhan cdn kha nhd. Xuat phit tir van de dd, chung tdi da tien hinh nghien cuXi de tai nay nhim muc tieu:
Nghiin ciru moi lien quan giifa mifc dp chenh cua do?n ST tru'dc v l sau can thiSp DMV vdl cac bien CO tlm mach chinh sdm trong vdng 30 ngay.
II. OOI TirONG VA mtrONG PHAP NGHIEN ClJU 2.1. Soi tu'dng nghien cihi
2.1.1. Tieu chuan Ida chpn benh nhin:
Tat ca cac benh nhan du'dc chan doan xac djnh NMCT cap, du'dc chup DMV, nong va dat Stent DMV thi dau tai Vien Tim mach Viet Nam tif thang 3 den thang 9 nam 2013.
Chan doan xac djnh NMCT: Cd bat ky mpt trong nhCfng tieu chuan sau:
-Xac djnh cd tang gia trj chat chi diem sinh hpc:
Troponin T, Troponin I, CK-MB, Lactat dehydrogenase (LDH).
Kem theo it nhat mdt trong cac tieu chuan sau:
+ Trieu chifng cd nang cua TMCBCT.
+ Bien doi ST-T rd mdi xuat hien {hoac xem nhu* mdi), hoac bloc nhanh trai mdi phit hien.
2.1.2. Tieu chuMn lo^i trd:
- Benh nhan du'dc chan doan la NMCT cap nhung khong dUdc can thiep DMV
- Benh nhan du'dc can thiep ddng mach vanh ma diln tlm do cd block nhanh.
2.2. Pliu'dng p h i p nghlSn cihi 2.2.1, Thiet ke nghien cdu
Sly la nghiin cu\i tien cifu va theo diil dpc theo thdi gian
DTD ciia nhdm benh nhan bien thien theo thdi gian: tru'dc va ngay sau can thiep SMV cho den thdi diem 24 gid sau can thiep DMV, theo diri benh nhon trong 30 ngiy.
2.2.2. Xdlysolifu
So lieu thu dudc trong nghien cu\j ddc xu' ly bang cac thuat toan thong ke tren may vl tinh cd sif dung phan mem EPI - INFO 6.04 cua TCYTTG (WHO) va SPSS 17.0
IILKETQUAVABANLUAN
3.1.0$c diem chung ciia nhdm dol tu'ang nghien clhi
Trpng thdi gian tif thing 3/2013 den thing 9/2013, chiing tdi da Uen hanh nghien cihi 300 b?nh nhin duljc chin doan nhoi mlu cd tlm cap v l du'dc can thiep dpng mach vanh qua da tai Vl$n Tim m ^ Vl$t Nam.
Bing 1. Die diem benh nhan theo tuoi va gidi
Gidi Nam NO-
%
Nhdm tuoi
<4a
4 0 1.3
40-49 19
1 6.7
50-59 60
7 22.3
60-69 76 13 31.3
> = 7 0 71 44 38.3
T£ng 230
70
300
Y Hpc VIET NAM THANG 5 • s 6 2/2014
Tuoi trung binh ia 66, bvng dd 76.7% ia nam gidl. Kit qua nay kha phu hpp vdi cac nghien^ cuU^ bong va ngoai nUdc dUcfc md ta trUdc day [1], [2], [3]. Tuy nhlen neu nhu" trong 3 nghien cihi gan day nhat tai Vien Vm mach tren benh nhan NMCT dutic can thiep DMV thi Ida tud'i cao nhat chung tdl gip la 86 iud'l dUdc dieu tn thanh cdng va xuat vien sau can thiep.
Bina 2. Jtidi oian bi benh tru'dc khi vao vien Thdi gian (h)
<3 3-12 12-24 24-72
>72 TSng
So benh nhan 15 121
35 65 64 300
% 5
40.3 11.7
21.7 21.3 100
Co 57% b$nh nhin vio vien dong 24 gid dau. Boi tudng benh nhin vio vien sau 72 gid chiim tdi 21.3% benh nhan dudc can thiep, ty le nay li khi cao da ndi lin tam quan trpng die biet cuaytS tuyen cd sd trong viec giao due cho nhin din hieu biit ve benh NMCT cung nhd viec phit hl$n sM va chuyin din vien chuyen khoa dedieu di kip thdi.
Bing 3. Phan bd theo dpng mach thii pham
edng mach tSn thiTtfng
Than Chung OMV trai LAD LCX RCA
n 1 231 101' 146
0.3 %
77
33.7 48.777ieo nghien ciiti cua chung tdi, ddng mach liin that trddc hay bl ton thddng nhat chiim 77%, sau ii li den dpng mach vanh phai, chiim 48.7%, cdn ddng mach mult gap ton thddng nhat (33.7%),
3.2. Moi lien quan glD'a s ^ ch€nh cua do^n ST trifdc va sau can thiep vdi bien cff tlm m^ch chlnh sdm trong 30 ngay
Bang 4. Cac bien c6 tim mach chinh trong 30 ngay BISncS
Tif vpng Tai bl€n mach nao
TII nhap vien ,.'
So' benh nhan 7 0 0
°/o 2.3 0 0
Khi tiin hanh theo doi benh nhan trong 30 ngay, cd 7 binh nhin td vong chiim tyli 2.3% vi tit d nhutig benh nhin nay deu td vong t^i vien, khdng cd tienh nhin nio bl tai biin mach nio va 0 nhap viin vi biin colon thddng dpng mach thu pham can thiep trudc dd.
3.3. Moi Men quan giii'a bien cff tif vong vdl mu'c do chenh cua doan ST tru'dc v l sau can thi$p dong m^ch vanh
3.3.1. Vdi tSn thddng dgng mach Ilin thit trude
BingS. Moi lien quan glij^ mifc dp chenh ciia doan ST d chuyen d?o cd ST ldn nhSt vdl bl&
CO tu* vong d benh nhan ton thu'dng LAD (n=230) Tif vong
Cd Khdng
P
Tru'dc can thiep 3.4 ± 2.2 1.3 ± 2.1
<0.05
Sau can thi§p 2.7 ± 1.0 1.2 ± 1.8
<0.05
Sau can thi^p 24h 2.1 ± 1.3 0.6 ± 1.2
<0.05
Nhan thay ring, doi vdi ton thudng ddng mach lien that trddc, doan ST chenh cao hdn nhieu d hilt
nhin td vong so vdi khong td vong vi giam dan sau can thiep dac biet sau can thiip 24 gid.
Y HQC V|£T NAM THANG S • SO 2Q014
3.3.2. Vdi ton Uiu&ng adng mach mO
Bing 6. Moi lien quan giij:a mut do chenh aia doan ST vdi bien co tiy vong o benh nhan ton thu'dnq LCX (n=lbl)
Tiif vong
Cd Khong
P
Tru'dc can thiep DII
0.6 ± 1.5 0.4 ±
1.0
>0.05 Dili 0.5 ±
1.8 0.6 ±
1.4
>0.05 aVF 0.3 ±
2.1 0.5 ±
1.2
>0.05
Sau can thiep DII
-0.8 ± 1.4 0.1 ±
0.5
>0.05 DIII -0.3 ±
0.6 0.3 ±
0.7
>0.05 aVF -0.5 ±
0.8 0.2 ±
0.5
>0.05 Sau DII -0.3 ±
0.6 0.1 ±
0.5
>0.05
can tiilep 24h DIII 0.0 ±
0.0 0.2 ±
0.5
>0.05 aVF 0.0 ±
0.0 0.1 ±
0.5
>0.05 3,3.3. Vdi tdn thddng dpng mpch vanh phii
Bing 7. Moi lien quan glDS stf chenh ciia doan ST vdi bien co tif vong d binh nhan ton thuo-ng RCA (n=146)
Trtfdc can thl§p Sau can thi j p 24h
T i T
vong DII
DIIIaVF DII
Sau can thiep
DIII
aVF DII
DIIIAvf
0.4 ± 0.9
-0.5 ± 1.3
0.0 ± 1.4
-0.4 ± 1.4
-0.1 ± 0.6
-0.1 ± 1.0
-0.1 ± 0.6
0.2 ± 0.5
0.2 ± 0.5 Khdng 0.7 ±
1.1 1.1 ±
1.6 0.8 ±
1.3 0.3±
0.9 0.6 ±
1.1 0.5 ±
0.8 0.1 ±
0.4 0.3 ±
0.5 0.2 ±
0.5 p I >0.q5 I >0.I15 I >0.05 I >0.05 [ >0.05 |_ >0.05 I >0.05 J >0.05 I >0.05 Theo nghien cud cua chung tdi, nhom td vong va nhdm khong td vong khac biet khong co y nghia thong ke dbenh nhin cd ton thddng dpng mach mu va dpng mach vanh phii
3.3,4, Vdi tdng STdl2 chuyin d?o (Chinh len vi chenh xuong).
Bing 8. Moi lien quan giua bien co tif vong vdi mifc dp chenh ciia teng ST d 12 chuyen dgo BIffn cff tiif vong
Tong ST P-value
Tru'dc can thiep C6 12.1± 9.6
Khdng 4.4 ± 6.6
<0.05
Sau can thiep Cd 9.3 ± 6.3
Khdng 4.3 ± 6.0
<a.05
Sau can thl^p 24h Cd
7.1 ±6.7 Khdng 2.2 ± 4.1
<0.05
GU tn dung binh cua tdng ST aia 12 chuyin dao d binh nhin td vong ldn hdn nhleu so vdi benh nhin khdng tdvor^ mic du tong ST dbenh nhin khdng td vong cd kin hdn vdi dp Un cay >95%. DSvdIbinh nhin td vong mic du da sau can thi$p 24h do^n ST chenh iin van lit cao. DSu niy cd the ndi ring nhdng benh nhan mi sau can thiep tdng ST cdn chenh len >7mm thi tien ludng nguy cd bj' vong cao.
3.3.5. Vdi tSngd^isS 612 chuyin a^o vi vdi ST Idn nhat.
Bing 9. Moi tu'dng quan aXitasii thay ddi ciia doan SI" va ST Idn nhat vdi bien co tif vong ii tu'dng quan gl
Bien dif batdy' bio ttf vong
Tong aal so ST chenh trydc can thiep Tonq 5ai so ST chenh nqay sau can thiep Tonq dai so ST chenh sau can thiep 24 gid Thoai trien tonq Sal so ST nqay sau can thiep Thoai trien tonq flai so ST sau can thiep 24 qid
ST chenh cao nhat tronq 12 chuyen dao . . I °'^^ (0.49-0.88)
tlh$n thiy tdng dai sd do^n ST chenh dudc can thiep vi thoai diin tdng dai so ST sau can thidp 24 gidcdmdl tudng quan chit vdi biin co tdvong.
AUC
0.85 (0.74-0.95) 0.74 (0.52-0.96) 0.71 (0.50-0.91) 0.74 (0.64-0.84) 0.80 (0.71-0.90)
iv.KfriuAN
Qua nghiin cifu 300 b?nh nhin NMCT cap d- uVc can thl?p OMV tai vien Tlm m?ch Vl$t Nam, diOng l»l riit ra mpt so ket luan sau:
• 'rac DMV phil d b?nh nhin cd tSn thu'dng nlil?u thin OMV se khi§n ST chlnh cao hdn hin
so vdi benh nhin chi cd ton thu'dng ddn thuin OMV phai. Anh hu'dng nay khdng ro neu tie OM lien that tru'dc hole OM mu
- Tong dai so cac mifc dp chenh ST bi/dc can
thi|p va tong dai so cac miic dp chenh ST trong
vdng 24 gid sau can thi|p cd lien quan chit i&
Y HOC Vl|T NAM T H A N G 5 - SO 2^014
bien co tir vong trong vong 30 ngay 6 benh nhan NMCT cap di/dc can thiep OMV qua da
- NhiTng benh nhan ma sau can thiep gia trj trung binh cua tong ST con chenh len > 7mm thi tien lu'dng nguy cd tu" vong cao. ^
Nhir vay SLT thay doi cua dien tam do dien bieri theo thdi gian rat co gia tri giup bac sy co the den lu'dng sdm benh nhan va d u ^ ra cac chi djnh thich lidp.
TAI L l | U THAIVI K H A O
X. Nguyen Quang Tuan "Nghien cull phu'dng phap can thiep OMV qua da trong dieu tri NMCT cap".
Cac de tai Ichoa hoc Hoi nghi Tim mach Mien Trung md rong lan I I , 20dl;{40);tr 115-116.
2. Barrabes, JA.^ Figueras 3., e t a l . (2000).
Prognostic significance of ST segment depression
in lateral leads I, aVL, V5 and V6 on the admission electrocardiogram in patients with a first acute myocardial infarction without ST segment elevation, J Am Coll Cardiol, 35:1813-1819.
Bowbrick, S. and Borg AN (2005). Role of ambulatory ECG monitoring. ECG complete:34'35, Crawford MH, Bernstein SJ, et al. (1999)1 ACC/AHA guidelines for ambulataj elecbwardiography. J Am Cbll Cardiol, 34:912-94ff Deedwania PC. and Carbajaf EV (1990). Sila|
ischemra during daily life is an independent predictor of mortality in stable angina. Circulation^
81:748-756.
Drew BJ, Peter MM, et a l . (2002). Frequency, characterristics and clinical significance of ST segment elevation in the patients with acute coronary syndromes. European Heart Joumal^
23:941-947.
MOT SO DAC DIEM LAM SANG VA DICH TE HOC
COA BENH M A Y D A Y MAN TINH DIEU TRI TAI B E N H VIEN 103
T6M TAT
Nghien CLTU 135 b^nh nhan ban may day man tinh den khdm va dieu trj t^i Benh vien 103 tii thang 8/2012 den thang 7/2013, ket qua cho ^S^: Ti le % b<?nh nhan m^y day mgn tfnh trong do tuoi tiy 20-49 la 66,6%. Ti ie benh d nam va nS bang nhau. So benh nhan cd tien siJ di litig chiem 94,1%. B$nh mSy day m^n tfnh co the xuat hien quanh n3m. B|nh gSp nhieu nhat vao mua he (37%). Oa so trudng hdp mac benh trong vong 1 nSm chiem 69,6%. So tru'dng hdp mac tren 5 nam la 11,1%. Mu'c dp benh nang chiem tj le 65,9%, miJfC dO vi!ra chiem 3 i , 9 % va mu'c do nhe la 2,2%. Co 14 yeu to thuan ldi dio viec xuat hien benh, trong do yeu to thdi ti^i: chiem ti l# cao nhat 60,7%.
06 34,8% tru'dng hdp khong tim thay yeu to lien quan.
Tiy khda: B|nh da lieu; Benh may day m^n tinh.
Hoang VSn Manh'^, Ph^m Hoang KhSm**
August, 2012 to July, 2013, the results showed that:
The percentage of the patients with chronic urticaria from 20-49 years old was 66.6%. The rate of males and females was equal. Personal allergic history was:
94.1%. Chronic urticaria occur all year round. The percentage of the patients with chronic urticaria In the summer was the highest (37%). Most of the patients suffer from Chronic urticaria within a year ( 69,6%).
The rate of patients who were ill over 5 years was 11,1%. The level of severity disease was 65,9%, moderate: 31,9% and lighter was 2.2%. There were 14 favorable fectors to occurrence of the disease.
The percentage of the climatic fector was the highest: 60.7%. There were 34.8% cases no find relevant factors.
Keywords: skin diseases. Chronic Urticaria.
SUMIVIARY
SOME C L I N I C A L A N D E P I D E M I O L O G I C A L CHARACTERISTICS W I T H C H R O N I C
U R T I C A R I A WERE TREATED I N 1 0 3 H O S P I T A L
Study of 135 patients with chronic urticaria who were examined and treated in 103 Hospital, from
* B$nh w$n Da lieu Thanh Hda
* * Hgc \^$n Quan y
Phan bi$n khoa hgc: PGS.TS Tr^n OSng Quyet
I. OAT V A N o l
May day (Urticaria) la mpt benh da thudng gap vdi ty le 15 - 2 0 % dan so da tCmg bj cac bl&
hien cua b4nh may day trong cuoc ddi [1]. C6 khoang 8 0 % tru'dng hdp la may day tu" p h ^ 10% cd nguyen nhan va 1 0 % tru'dng hdp 1^ cic dang dSc biet [ 4 ] . May day man tfnh ia si/ tii dien lien tuc hoac hau nhu" hang ngay cOa tk san phu tren da, keo dai t r ^ n 6 tu3n [7]. (J6 khoang 5 0 % tn/dng hdp co kem theo phii macti [ 3 ] . Dieu tri benh may day man tinh khd pliOt
