***
'I
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SO SANH MOT SO DAC BIEM LAM SANG V A CAN LAM SANG 6' BfiNH NHAN BASEDOW TRlTaC VA SAU DIEU TRI BANG " i l
TAI BfiNH VlfiN DA KHOA TRUNG UONG THAI NGUYEN
Vu Thj Hien*- Nguyin Thu Hmmg", Phan Thanh Ngpc*, Nguyin Kim Thanh*, Nguyin B i Thing*
SlCi,r6MTAT
la,^ Mvc tilu: So sanh mpt si (tjc dilm lam sang Bvifi c|n :am sing cua 42 bfnh nhSn Basedow trmJc
»4 sau diSu hi bSng " ' l tt,l Bfnh vifn Da khoa IjigTrang uong Thii Nguyen. Kef qui: Sau dieu trj fiijU I* '^ trifu chiing lam sing da giam xuong r«
I ttjfel so vdi trmSc khi d i k ttj. Gii tri trung binh ciia mft s6 xft nghifm c6ng thilc miu vi sinh hoa lljjjmiu w ^ v i sau Hiu frj khic bift khong 06 y I li i,J'8''ra^^P(p>0,05). Gii tri tnmg binh cua T, ini''* ^' S"" "i^" hi giim ding kl so v4i trudc
dilu tri (P < 0,001). Gii d-j trung binh cila TSH tSng rS rft so v4i tnnSo dilu n-j (p<0,05). Gid n-j trong blnh ciia thi tich TG tren sifu »m san dilu trj giim rO rft so vfti truftc dilu trj p < 0,001).
Oii n-j trong blnh eUa MBF, PSV, EDV sau dieu trj giim c6 j nghTa so vdi truftc dilu trj (p-=0,01).
Tir khia: Bfnh Basedow, dilu trj bing '"l.
SUMIVIARY
COIWPARISON SOME SUB CLINICAL AND CLINICAL FEATURES IN BASEDOW PATIENTS BEFORE AND AFTER THE TREATMENT BY " ' l AT THAI NGUYEN NATIONAL GENERAL
HOSPITAL OBJECTIVE
* Truing Cao Oing Yti Thdi Nguyen, ' • Bfnh vlfn Tnmg uang Thai Nguyin Chju trich nhifm chlnh: Va Thj Hifn Email: [email protected] Ngiy nh«n bii: 12.9.2016 Ngiy phin bifn khoa hgc: 11.11.2016 Ngiy duyft bii:30.1l.20l6
To compare with some sub clinical and clinical features in 42 patients with basedow before and after treating by '^'l at Thai Nguyen National General Hopital. Result: After treatment, tile rate of clinical symptoms was significantiy reduced compared to before treatment. The average value of a number of tests and biochemical blood count blood before and after treatment difference was not statistically significant (p> 0.05). The average value of T3 and FT4 decreased significantly after treahnent than before treatment (p <0.001). The average value of TSH increased significantiy compared to before treatment (p <0.05). The average value of tiie volume by ultrasonography TG treatment significantly reduced compared witii before treatment, p O.OOl). The average value of tiie MBF, PSV, EDV after Ueatment significantly reduced compared with before treatment (p
<0.01).
S^st Basedow patients, Ueannent by "'l
LOiJirV^Nol
Basedow l i b$nh cudng chiic ntag tuyfa giip xudt hifn theo co che miln djch. Biiu hifn djc tnmg \k sif biin doi cua tuyln giip c i ve chiic ning v i htoh tiiai, cau tnic. din din r6i lojn huyet dpng toin than v i t?i tuyln gidp. Sii dgng '^'l d l dilu trj cuimg chiic ntag tuyln giip do Basedow l i phuang phip hifn dang dupc 4p dyng rpng rii va mang lfi hifu qui rfl rft X» trj chuyin hfta btag iod phftng x* " ' l giup djt binh giip nhanh hcm, giim c i nSng d? hoimon v i till
UI1KH T DUOC - KY WltM M " » « «S<>Y TRUYtN T H O M G TRUaNG CAO OAWS V TH/il N G U Y B N 11966-2111)^1
n'ch TG. Do nhung mi diem ciia I trong dilu tri cuong chiic ning TG la don gian, dl diuc hifn, kinh tl, darn bio tfiim mi, an toan va dat hifu qui cao nen ngay nay cic CO so y hpc hat nhan ciia nuftc ta da i p dyng rpng rai phucmg phap dilu tri niy cho BN Basedow [11, [2], [5].
Myc lieu nghien cuu: So sdnh mot so dgc diim ldm sdng vd cgn ldm sdng cda 42 benh nhdn Basedow tru&c vd sau diiu tri bdng '^'l tgi Binh vien Da khoa Trung ucmg Thdi Nguyen
iiodtTUpNGVAPHiroi^G PHAP NGHISN cOu 1. Doi tir^vg nghiSa ciru
42 b^nh nhan Basedow du(;rc theo doi trudc va sau dISu tri bang '^'l-
1.1. TiSu chuan 1 ^ ch^n doi tirgng - B?nh nhSn dugc chSn doan xac djnh Basedow.
- Dugc di^u tri bang '^'l theo phac d6 th6ng nhdt.
- Th&i gian sau di^u trj I ciia BN>3 thang.
- Dirge xet nghiem day du c^c chi sJ
nghien ciiu. -, 1.2. TiSu chi loai trir doi ttrgmg
- Tien su: ho|c hien tai dang mic cic h^i
tim mach ket hgp ; - Benh nhan Basedow c6 bien chiing sof
tim, rung nhT
- Da phau thuat TG trudc khi dieu trj '^' 2. Phinmg phap nghien ciru 2.1. Thi^t k^ nghien ciVu: tiSn cuu, mdti, theo doi dgc, so sdnh trudc va sau dieu trj
2.2. Phuomg phap chgn mau: chgn IDIDI CO chu dich: tat ca BN Basedow dugc theo doi tmdc vh sau dieu tri bfing '^'l l^i B^nh vifin Da khoa Trung uong Thai Nguyen
2.3. Chi tieu nghiSn cihi: cdc thong tin chung, triSu chumg lam sang, c|tn lam sang (cong thuc mdu, hda sinh mdu, djnh lugng hormone tuyen gidp, TSH, siSu Sm TG x^c djnh thg tich vd cdc CSHD).
IH.K^QUANGHlgNCUru
Bdng 3.1. M$t s6 trieu chdns cff ndng ciia b$nh nhdn tru-dc vd sau diiu trj
Tri^u chirng Trudc di^u trj
n = 42 (%) '
Sau di^u trj n = 42 (%) Slit can > 10% kg thS trpne
Da ndng am. co con ndng bimg Run tay dhs ngdn
45,2 Khdt. udng nhieu
92,9 35,7
Hoi hgp danh trdng ngyc
90,5 Cam giac nong bite
33,3 Mau ddi. an nhi^u
26,2 Ra nhieu mo hdi
69,0 Thay ddi tinh tinh
69,0 9,5
Da khd
66,7 0 Nhdnxit:
' ^^\^^^ *^*"^S 1 ^ sdng ca nang di€n hinh d BN Basedow c6 ti I? cao.
- Sau diSu tri ti 1? cdc trieu chimg ca nfing diSn hinh cd ti 1? thap.
YHOCVieTHAIITAP449-TllA)IGi;.SOBACBgT.;il16 BissJJ. Trifu chmtg Ihuc the cua binh nhin trudc vi sau Oiiu Oi
Trifu chirng Nhjp lim > n n rt/ph Nhiptim90-120cli/ph Nhip tim < 90 clc^ph Nhip tim < 60 cl(/ph Tilng tiidi tai TO
Co loi mat
BO Iftrn cua TG
IV Phi mi mit
Tnrftic dieu tri n = 4 2 f % )
4,8 143
Sau dieu tri '*2{%)
16,7 83,3 19,0 47,6 31,0 35,7 19,0 9,5 4,8
14,3
J
• • • • f u chftng tfiuc thi o BN Basedow cft ti If cao (> 66,7%) bao gdm: nhip tim
inanh, loi mat, tuyen giip to. • - Ti If BN cft trifu chiing bat tiiuong giim sau dilu trj.
- Dp Iftn ciia TG vi hifu chftng I6i mit sau dilu trj con gip vfti U If cao
- Sau dieu tn xuit hifn mOt sft trifu chftng cfta BN suy giap: Nhip tim chjm, phu mi mat.
<20ml 20-40ml «20ml 2 0 - « m l >-lCmt
Biiu id 3.2. Thi lich luyin gidp Iren sieu dm sau Heu tri Biiu ii 3.1. Thi lich luyin giip
Irin silu im truic iieu Iri Nhfn xit:
' ^ i '!'l! l^ " ! " ''^^ «"*">*= 20 - 40cm^ chilm H If cao nhit (59,5%)
• T i ' l y i I ^ r T H ^ * " * = ^20cm'chilm21,4%vi>40cm'chilm 19,1%
- Sau dilu m tiie uch tuyen giip < 20cm= ting; tiil tich myln giip > 40cm' giim
^ ^ ^ • Y K f g C - K V M j s O ' HAM H G A Y T R U Y £ N T H O N G TRUdTJG C A O E I A N G Y "mAl H G U Y £ N (1966^imi
CUso TJ FT.
TSH
Don vi tinh ng/dl ng/dl ulU/ml
Truffc BT (n = 42) Tang %
83,3 83.3 0
Giam % 0 0 100
SauDT(n = 42) Ting %
33,3 42,9 19.01
Giiim % 11,9 9,5 52,4 Nhfn xet: ^ I - Bfnh nhan Basedow cft tang nong dft T3, FT4 chiem ti If cao (83,3%) va khong cft miimj
^ J cft giam nftng dp T3 va FT.,^
-100% bfnh nhan Basedow cft nftng do TSH 6 mftc ttiip.
- Ti If BN cft ttag nftng do T3, FT4 va giim TSH sau dilu tri dS giim rft.
- Sau dieu tri 11,9% BN cis giim T3,9,5% BN cft giim FT,, 19,01% BN cft ttog TSH.
IB Blnh gifip 1
• Chuablnh gidp' n Nhuyc giAp Biiu di 3.3. Mpt s6 d^c itiim cua bfnh nhdn ddnh gid sau ^iu tri Nh^n xit: Nhdm BN binh gidp sau diSu trj chifim ti 1§ cao nhdt (46%) vd thdp nhdt Id nhfim BN nhugc gidp (14%).
Bdng 3.4. So sdnh gid trj irung bJnh cua m$i s6 xdt nghi$m tru&c vd sau diiu trj Chis6
HC Hb BC TC Glucose
Ure Creatinin
Protein Choleslerol Triglycerid SOOT SGPT
Donvj g/l tfi T/L 10' mmol/1 mmol/I
|imol/l g/l mmol/l mmol/1 37"C U/L 37"C U/L
Truftc difu tri ( X ±SD)(n=42)
5.11 ± 0,60 140,24 ± 12,50
6,73 ± 1,69 278,24 ± 76,56
5,32 ±1,81 5,08 ±1,84 65,51 ± 16,15
77,99 ±6,75 4,98 ±4,26 1,16±0,61 34,48 ±18,41 32,39 ±27,10
Sau dieu trj {X ± SD) (n=42)
5,06 ± 0,64 138,95 ±13,84
6,31 ± 1,63 286,40 ±58,65
5,31 ± 1,44 4,42 ±1,24 72,27 ± 15,85
77,27 ± 6,33 4,68 ± 1,31 1,19±0,65 33,34 ± 14,30 29,08 ±21,23
P
>0,05
>0,05
>0,05
>0,05
>0,05
<0,05
>0,05
>0,05
>0,05
>0.05
>0.0S
>0,05 . ...^.. .^... ^ , 1 . ,^1 uiuig L/iiui vua liiyi su ACS 11^1^
vd sau dieu trj khde bi?t khdng cd y nghla thong ke.
Y HQC VliT HAM TAP 449-THAMG 12. so PAC 81^-2016
Bine 3.5. So sinh tii tj mmg hinh cia hormon Iruac va sau mku tri
- Gii tri trung binh cfta Tj v i FT4 sau dieu tin giim so voi mroc dilu tri (p < 0 OOI) j p . - Gii tri trung binh cfta TSH ttag so voi truftc dilu tri (p < 0,05).
* ^ Mra^ft&jdnAria tri Inmg blnh cua Ihi lich luyin giip trin sieu am Irudc v
^^mn tif Oia .trj tnmg blnh cua ttie tich TG tt€n sieu am sau dilu ttj giim so vfti truftc
m«xil; Gii tri trung binh cua N4BF, PSV, EDV sau dieu tri giim cft j nghla so vfti tnrftc dieu tri. RI, PI sau dieu tri giim khftng cft y nghla so vfti mrftc dieu tri.
IV. BAN LUiiiN
Bfnh nhta Basedow giai dota nhiem dpc hormon TG tiiuftng cft cic trieu chftng Iam stog rit da djuig v i phong phft. Co thf noi rit nhilu CO quan, th chfts: bi inh huftng chftc ntag lifn quan dfn ttag nftng dO homion TG.
Chlnh vi vjy nhilu tic gii cho ring Basedow la bfnh 1^ cfta TG song l(u bilu hifn tota Uita vi mang tmh hf tiiJng [2]. Nhihig trifu chftng lim sing kinh diln gSp vfti ti If cao (>
69% cic tnrimg hpp).
Sau dilu tri cic hifu chiing di giim xu6ng rft rft so vfti truftc khi dieu tri. Mpt so
ttuftng hpp cdn tftn tai cic trifu chftng co ntag tiiufttng gip ft BN Basedow chft ylu tjp tiimg ft nhftin BN chua on dinh. Dl xuat hifn thfm mftt sft trifu chftng co ntag (di ngoii phta Iftng, da kho, ta it, ttag eta, sp lanh) ft nhftm BN nhupc giap sau dieu tri.
Nhip tmi nhanh gip ft hau hit cic BN (85,8%). Sau diiu trj ti If BN cft nhjp tim nhanh > 90 ck/ph da giim rft (tnrftc dilu tri 14 85,8%, sau dieu tri li 16,7%), chft ylu gSp ft nhftm BN cftn cuftng giip. Trifu chftng nhip tim chjm < 60 ck/ph cft o nhftm BN nhupc giip. Trifu chftng loi mat chilm ti If cao
^ • p
u u f H Y niraC - KY Nl£M 50 NAM N G A Y TRUYDN T H O N G TRU-Q^NG CAO O A N G Y THAI NGUYEN ( 1 9 6 6 ^ 6 | _
(66,7%) va phuc hdi mudn sau dieu tri (47,6%).
Hau hk cdc BN Basedow deu cd TG to khi tham kham trong do dp III, IV chi6m ti li cao nhat (54,8%). 78,6% cd tang the tich TG tren sieu am, trong dd miic do tnmg binh (20 - 40cm') chi^m ti le cao nhat (59,5%). Mac du 100% BN cd TG nhd iai sau didu tri xong ti le BN cd TG to tren si6u am van con d miic cao (76,14%), nhmig chi cdn 2,38% BN cd thfi U'ch tuyfin giap > 40cm^ (tnrdc DT la 19,1%). V^y day la tri?u chiing cung ph\ic hdi mupn sau dieu trj.
M$t so chi sd x6t nghiam huy6t hgc va sinh hda m^u cung dugc quan sat d BN Basedow. Da so cac chi s6 xet nghiem d gidi h?m binh thudng (> 76%). BN cd mOt so chi s6 x6t nghiam t ^ g chiem ti If thdp vk muc ting thdp. Cd the nhihig bien ddi n^y la do h§u qua cua hormon TG ti€t qua nhieu vao mdu gdy anh hudng tdi chiic nSng cua mdt so CO quan trong ca t h i Cd 45,2% truemg hgp tSng SGOT dcrn thuan dfiu khdng cd bieu hifn bfnh gan kfit hgp, miic dp tSng dfiu thdp dudi 2 lan so vdi chi so binh thucmg chua dugc xem Id tdng men gan bfnh ly. Ddy cOng Id nhitng bieu hifn t ^ gan lien quan den nhi?m dfc hormon TG d BN. Sau difiu tri ti If BN cd chi sd xet nghifm tdng dS gidm rS song song vdi giam mitc dp nhiem dOc nong dg homion TG len mpt sd ca quan trong co the.
Nong dp hormon TG vd TSH la nhiing chi s6 cd gid trj chdn dodn quy^ djnh chiic ndng TG, cd the dugc coi Id tifiu chudn vdng trong xdc djnh cudng hay suy chiic ndng TG. Su bifin ddi nong dp TSH khi cd r^i logn ch^c nfing TG xudt hifn sdm han tnrdc khi cd bifin ddi Tihng d$ hormon TG. Ndng dp TSH la xet nghifm khdi ddu tot nhdt vd Id chi so, tieu chuin quan trpng trung chdn dodn cudng ho$c suy gidp dudi ldm sang (5], [6]. Trong
nghifin cmi nay ti le BN tang T3 la 833V tang FT4 la 83,3%, TSH giam la 100%. day la bang chiing quan trpng de chdn doan vt phli hgp voi tieu chuan lira chpn ddi t u m Tuy nhifin van cdn mgt phdn nhd cd cbi 4 nong dp T3 ho^c FT4 d gioi han binh thu6B|
(16,7%), cd le bai vi da sd cac BN tnrdc Ida dugc difiu ri bang '""l tiii deu da dugc uoi^
thudc khang giap trang nen phan ndo co anh hudng den nong dg hormon, ddng thdi voi chan doan cudng chiic ndng TG thi lice chudn bdt bupc la gidm TSH cdn n6ng <!f Tj va/ho|c FT4 cd thfi tdng hojc binh thuSsg.!
[5]. Ti If BN cd tdng nong dg T3, FT4 vi' gidm TSH sau dieu trj da giam rd. Sau di^
tri dd xudt hifn 11,9% bfnh nhdn cd giam T3.
9,5% bfnh nhan cd gidm FT^ vd 19,01% 8^, cd tdng TSH. MOt sd tnrdng hgp BN d?t binh gidp sau difiu trj cd gia trj TSH cdn thap, di^
nay phii hgp vdi quan diem cua mOt s6 \k gid Id sau khi di^u tq BN trd ve binh giip khi xet nghifm T3 vd FT^ trd vfi binh thudng cdn TSH cd the trd ve binh thudng ho$c van c6o d gidi han thdp hcm binh thudng [4], [7\.
Khi so sdnh gid trj trung blnh ciia mgt s^
chi so x^t nghifm cdng thiic mdu va sinh h6|
mdu trudc vd sau dilu trj thi diu khong flffl' thdy s\r khde bift cd ^ nghia thdng kfi (p >
0,05), ngo^ trir chi s6 ure. Dieu ndy chiing 16 bdng phuong phdp difiu trj '^'l dd khong gfty nhiing biin ddi dnh hudng tdi chirc ndng cia mgt s6 CO quan khde trong co thi nhu li^
xuong, gan, th§n. Rifing ure cd gid trj tnmg binh khac nhau cd y nghTa thong kfi trudc v*
sau dilu trj, nhung khdng dii co sd dl kil lu§n la sau dilu trj dd ldm thay d6i chiic ofcig thdn vi; creatinin Id mgt chi so cd gii trj danh gid chiic ndng th|n chinh xdc vd WAI quan hcm so vdi ure, ma gia trj trung iHA cua creatinin lai khac bift khdng cd ^ r\^
thdng kfi trudc vd sau dilu trj. Mdt khde I*
Y HOC V l ^ HAM TAP 449 - THANG 12 - SO BAC BIFT - 2016
fclll ^"3 xet nghiem gii tri ure miu con phu tiiuoc V. KFT LU;kN
j(i^^ vio mftt sft ylu tft khich quan t»i flioi dilm Benh nhan Basedow sau khi dilu tri
|a%j Isy t^su nhu che do in, van dftng...Day cung b ^ g '^'l cft cac chi sft huyft dpng (ngogi trit
•**! ' * . " ? ' ' ' ^ 8 Chung d l chftng to su dung " ' l Rl va PI) tang theo tin sft tim v i tSng dftng 'kk * * ^ ' ' "^ Basedow l i mpt phuang phap dilu * ' " ™ "^B the tich myln giip tren sieu am i j j ' ui an toan [3], [6]. (P « 0,05 v i p < 0,001); Co mfti tiiong quan jj,j^ Sau dilu tri n^ng do cua hormon TO giam 1 5 * " : ° * ngM" (p < 0,05) vfti nftng dp T3,
«li> ^^.^^'^ ' ^ S CO y nghta ttiftng ke so voi ttuftc
« L " ' ^ " ' ^ (P * " - " l ; P < 0,05). Vay sft dung ' ' "
. ™'dl(J"* • •"•ti Basedow l i mOt phuang phip dieu ,y, ' hi rf tiln, hifu qui.
' " " Sau dilu tii 100% BN cft thi tich TO nhft 5"; sifu am mrftc vi sau dilu hi khic bift cft y
" • " nghla th6ng ke (p < 0,01). Dufti tic dung cfta '*"'• tia p cic tl bio tuyln bi hfty hoai hoic giim
™ s i n h . H ' ' ™ ' ^^ q"4 li tuyln nhft lai, dat Wll du(rc muc dfch dieu tri [3]. Diy li phuong S'n' phip phSu tiiuit khong cin dao, tao nen tinh
•'M thim mf cao, khftng dl lai bit ky mpt vit seo ivii! nio trln co nguoi bfnh [3] . Viy vfti quy iSilli Utah dilu hi don giin, dl fliuc hifn, thi day
»|1» li phuong phip dieu tri kinh tf,tiiimmf.
m% Cimg vfti su thuyen giim cfta bfnh ttii cic Mt CSHD cung bien dfti sau dilu ti-). Khi so sinh
•iiiii gii tri trung binh cua cic CSHD dOng mjch iiAi TO mrftrc vi sau dilu tn diu nhin thiy cft su ,|i(l hiln doi ra rft. Gii tri trung binh cua MBF, ji^ijij PSV, EDV sau difu tri diu giim cft j nghia i|jl so vfti tiirftc dilu ti-j(p < 0,05 din p < 0,001.
ija Cftng vfti sir thuyen giim mftc d0 hoat d^ng jjljr cfta bfnh sf giim n^ng dp hormon TG. giim jij! sftc CO bftp cfta tim, giim rajt dp vi mjch tai
FT4, tuong quan nghich co y nghia (p < 6,05) voi nftng dp TSH;
- Sau dieu tri gia tri trung binh cfta MBF, PSV, EDV thupc nhom bfnh nhin cftn cuong giip cao nhit va tiiip nhat l i nhom bfnh nhan nhupc giip.
TAI Ufu THAM KHAO
1. Bo moil Y h9c hat nhin HVQY (2010), Giao irlnh Y hgc hgl nhdn(Glang day dgl hoc). Nxb.Quan dpi nhan dan.
2. Nguyin Lan Hmmg, Nguyen HSu Nghla (2009), "Danh gia kit qua dilu uj 5170 bfnh nhan Basedow bang '^'l tji vifn VHP va UBQD", Tgp chi Ydupc idm sang IOS, tjp 4, so djc bift, 9/20009, ti-.104-108.
3. Nguyen Thu Hirong (2012), Nghien cmi Hin idl chi so huyit dgng Igi igng mgch luyin gidp bing sleu im Doppler a bfnh nhdn Basedow intuc vi sau iliu Iri Npi khoa. Lufn in tiln sj Y hoc. Hpc vifn Quan y.
4. Thii Hong Qnang (2008),£ffiA ngl lift, Nha xuat ban y hpc, tr. 111-122.
5. Nguyen Danh Thanh, Phan Vin DSn (2010), "Kit qua dilu trj Basedow bing dong vi phftng XS "'I ft khoa Y hpc hst nhin bfnh vifn 103",7cf;3 chi Y hgc qudn stf, s6 chuyfn dl7,tr.l23-125.
tilyln va hau qui lim giim vfn toe, luu '• ^ '*'"'" ^uan (2012), Binh gld Ufu qua lij)i lupng tuin hoin tji ch§. Duoi tic dyng cfta
I * '''?" pWp iMeu til till Hnh trjng tim ting jjJ dfng, tSng cung lupng tim cung s8 giam [2]
,j,i sf dan din giim cac chi so chftc nang tam ,-g ttiu, tim UTiong cfta mjng lufti mjch mau tji
•ji ch5 Iren TO. Tft dft din din giim cic CSHD (Ijii 191 luy^n-
ciia 1 Irong dieu ni bfnh nhdn Basedow bdng mgt so thing si mlin dich vd Y hoc hgl nhdn.
Luan an tiln sj Y hpc. Hpc vifn Quan y.
. Nguyen Lan Viet, Pham Thii Son (2003), "
Chan doan va dilu tri cic bilu hifn tim mjch ft mpt sl bfnh ly ftiyin giap", Chuong Irlnh lim mgch sau igl hgc ldn thu 17. Tuyin glip vd bfnh llm mgch, ti'.37-59.
