VIETNAM MEDICAL JOURNAL N°1 - FEBRUARY - 2013 2.Can thiet phai nang cap cae cd sd phdng ky
thuat dam bao dung tieu chuan ve sinh do Bd Y te quy dinh.
TAI LIEU THAM KHAO
1. Bd V te (2003), "Ngan ngiTa nhiegi khuan tai khoa phay thuat", Tai lieu hudng dan quy trinh chong nhiem khan benh vien " tr. 161-164.
2. Sd Y te tinh Nghe An (2016), "Sd ket eong tac y te 6 thang dau nam 2016 ", tr. 45-48.
3. Ha Manh Tupn. (2006), Yeu to nguy ai va tac nhan 'gay nhiem khuan benh vien tai Khoa Hoi su'c cap cuU benh vien Nhi dong I, Lujn an Tien sT Y hoc, Dai hoc Y DUdc Thanh phd Ho Chi Minh, Thanh pho Ho Chi Minh.
4. Tran Quy TUffng (2013), "HUdng dan thUe hanh kiem soat nhiem khuan moi trUdng benh vien (Tai lieu tham khao)", Nha xuat ban Y hoe. Ha Ngi, tr. 19.
3. Belcaro G, Cesarone MR, Ledda A et al.
(2008), "New concepts and new roles for vascular medieine/angiology and vascular surgery. A developing role for vascular specialists: from the hospital, to the community, to the enviroment. The example of environmental estrogens'^ Minerva Cardioangiol, 56(5 Suppl):l-2.
6. Joseph S. Solomkin et al. (2011), "Diagnosis and Management of Complicated Intra-abdominal Infection in Adults and Children: Guidelines by the Surgical Infection Society and the Infectious Diseases Society of America", Clinical Infectious Diseases, 50(2), pp. 133-164.
DANH GIA HIEU QUA VA TI'NH AN TOAN COA DIEU TRI TIEU So-I HUYeT DU-o-NG TINH MaCH LIEU THAP TREN BeNH N H A N D O T QUy CaP TRONG C^A So 0-3 Glff
T O M TAT
Cd sd va muc tieu nghien cuti: danh gia hieu qua cua phUdng phap dieu tri tieu sdi huyet tTnh mach lieu thap (0,6mg/kg) tren benh nhan dot quy cap trong cii^ so 3 gid tai Benh vien Nhan dan 115.
PhUtfng phap: nghien cuU Oen ciru, tat ca cac trUdng hdp dot quy cap da dUdc dieu trj tieu sdi huyet tTnh mach theo protocol dieu trj eiia nghien cUu NINDS, ghi nhan diem NIHSS ban dau tai thdi diem nhap vien va danh gla mRS tai thdi diem 3 thang, theo doi cac bien eo xuat huyet he thdng va xuat huyet nao do dieu tr; Ueu sdi huyet. Ket qua: trong so 6171 benh nhan dot quy nhap vien trong thdi gian theo doi 3 nam chi cd 121 benh nhan (2%) dUde dilu tri tieu sdi huyet tTnh maeh. tuoi trung binh la 57 tudi, diem NIHSS trung binh la 12. Thdi gian tir lue khdi phat trieu chiing den khi dUOc dieu tri tieu sdi huyet tinh maeh la 143 phiit (sdm nhat la 50 phut va cham nhat la 210 phut). Trong do, 73 benh nhan dUdc dieu tri v<S lieu rtPA chuan, edn lai 48 benh nhan dUdc sir dung lieu thap (trung binh 0,62mg/kg). Ty le benh nhan mRS tii 0-1 d nhdm dieu tri lieu thap la 56,3%, cao jidn so vdi 34,2% d nhdm benh nhan diSu trj lieu chuan. Ty le tir vong d nhdm dieu tri lieu chuan cung cao hdn so vdi nhdm benh nhan dieu tri vdi lieu thap (12,5% so vdi 2,1% P=0,004). Bon trUdng hpp xuat huySt nao cd trilu chUng dUde ghi nhSn d nhdm dieu tri vdi lieu chuan so vdi chi mot benli nhan d nhdm dupe dieu trj lieu thap (P=0,36). ket luSn: dieu tri tieu sdi huyet tTnh maeh eho benh nhan dot quy cap
*Dal hgc Y khoa Pham Nggc Thach Chju trach nhiem chfnh: Nguyen Huy Thang Email: [email protected] Ngay nhan bai: 22.10.2017 Ngay phan bien khoa hoc: 25.12.2017 Ngay duyet bai: 30.12.2017
Nguyen Huy Thang*
vdi lieu thap doi vdi dan so Viet Nam cd hieu qua va tinh an toan vUdt trpi so vdi lieu chuan.
SUMMARY
EFFICACY AND SAFETY OF LOW DOSE ALTEPLASE FOR INTRAVENOUS THROMBOLYSIS I N STROKE PATIENTS I N
0-3 HOURS W I N D O W Background and objectives: To compare the efficacy and safety of low dose alteplase with standard dose for intravenous thnDmbolysis in stroke patients.
Methods: A prospective study of all acute stroke patients treated with intravenous fibrinolysis under the protocol of the NINDS study, initial NIHSS score at admission and mRS assessment at age score of 3 months, followed by systemic haemorrhagic events and cerebral haemorrhage resulting from fibnnolysis.
Results; Of 6171 stroke patients hospitalized for 3 years follow-up, only 121 patients (2%) were treated with intravenous fibrinolysis. The median age was 57 years, mean NIHSS score was 12. The time from onset of symptoms to folic acid was 143 minutes (50 minutes at the earliest and 210 minutes at the earliest). Of these, 73 were treated with standard rtPA and 48 were low-dose (mean 0.62mg/kg). The prevalence of mRS from 0 to 1 in the low-dose treatment group was 56.3% higher compared to 34.2% in the standard treatment group. Mortality rates in the standard treatment group were also higher than those in the low dose group (12.5% vs.
2.1% P = 0.004). Four cases of symptomatic cerebral hemorrhage were reported in the standard treatment group compared with only one patient in the low-dose group (P =0.36). Conclusion: Intravenous fibrinolytic therapy with low dose of rtpa is superior than standard dose for acute stroke patients in the selective population of Viet Nam.
TAP CHl Y HOC VIET NAM TAP 463 - THANG 2 • SO 1 - 2018 I . O A i A N O E
Hd ':hi Minh la thanh phd Idn nhat Viet Nam.
Tuy nhien, vdi dan so len den 8 trieu, thanh pho Ho^Chi^Minh chi ed ba trung tam dot quy Idn ed the trien khai phUdng phap tieu sdi huyet tTnh maeh cho benh nhan dot quy cap: Benh vien Nhan dan 115, Benh vien Nhan dan Gia Oinh va Benh vien An Binh. Chung toi tien hanh nghien ClTu cac dU lieu ve tieu sdi huyet diidc ghi nhan ti!r thang 5 nam 2006 den thang 5 nam 2009, nham gdp phan trinh bay nhiivig ket qua ban dau ciia phuttng phap dieu trj tieu sdi huyet tTnh mach tren benh nhan dot quy cap tai f p . Hd Chf Minh, II.DOI nrOlMG VA PHU'OIMG PHAP NGHIEN CLTU
Chan doan xae djnh dot quy thieu mau nao cap dUdc dUa vao hinh anh hpe chup cat Idp vi h'nh nao {CY scan nao) hoac cpng hudng tir nao (MRI nao) va diidc phan loai dUa theo phan loai TOAST. Tieu ehuan thu nhan va tieu ehuan loai trjj' eiia dieu tri tieu sdi huyet tTnh maeh eho benh nhan dot quy cap trong cu'a sd dieu trj 3 gid diia vao protocol cua nghien cu'u NINDS.
Chung tdi loai tru* tat ca cac benh nhan cd diem NIHSS <4 diem, CT scan cho tiiay hinh anh thieu mau nao sdm Idn hdn 1/3 vimg chi phoi ciia dpng mach nao giij^ hoae mRS >2 trUdc khi khdi phat dot quy. Lieu thudc tPA theo khuyen cao la 0,9mg/kg. Tuy nhien, de giam chi phf dieu tri ddi vdi nhD'ng benh nhan khdng the chi tra cho Ip thudc thir hai chung tdi se sir dung lieu thap hdn
(dao ddng tU 0,6 den 0,86mg/kg). Viec sii dung lieu thap da dUdc chu'ng minh la hieu qua va an toan cho ngUdi chau A [5,6].
Sau khi tinh lieu tPA d u ^ vao can nang ciia benh nhan, 10% tdng lieu se diidc bolus, edn lai dUdc truyen tTnh mach trong vdng 1 gid. Kham lam sang, danh gia thang diem NIHSS va mRS diidc ghi j i h a n trUde va sau khi dieu tri tieu spi huyet, diem NIHSS dUdc danh gia tai thdi diem mdt gid, 24 gid sau dieu tn tieu sdi huyet, va danh gla moi ngay cho den khi benh nhan xuat vien hoae t i i vong. Lam sang th'an kinh diidc danh gla la cd cai thien khi diem NIHSS giam >4 diem hoae NIHSS bang 0 tai thdi diem 24 gid. CT scan hoac MRI -MRA nao dUdc lap lai sau 24 gid hoac ngay tai thdi diem lam sang dien tien xau.
Bien CO xuat huyet nao diidc chan doan dy^ vao CT scan nao, va xuat huyet nao cd trieu chimg dUdc djnh nghta la cd hinh anh xuat huyet nao tren CY scan va diem NIHSS tang >4 diem. Cac benh nhan tiep tue diidc theo doi va danh gia diem NIHSS, mRS tai thdi diem 3 thang sau dieu tri tieu sdi huyet tmh mach.
So lieu dupe xir' ly bang phan mem SPSS phien ban 11.5, sau dd dUdc trinh bay dUdi dang thdng ke md ta gom gia trj trung binh, dp lech chuan va ty le phan tram. Phan tich mcM tUdng quan dUa vao phep kiem binh phUdng ddi vdi ty le va phep kiem T doi vdi gia tri trung binh.
P< 6,05 dUde eoi la ed y nghTa thong ke.
II. KET QUA
Bang i. Bac diem nhom benh nhan diieu trilV-tPA lieu thap va lieu chuan fiac di@m
Tuoi trung binh Gidi nam (%) Tang huyet ap (%) Dai thao (lu'cfng (%) Diem NIHSS trung binh Tlidi gian trung binh tit luc Ithdi phat
den dieu tri (phut) Lieu IV-tPA trung binh HA tam thu tru'dc dieu tri (mmHg) HA tam tru'dng tru'dc dieu t n (mmHg)
Du'dng huyet tru'dc dieu trj (mg/dl) Phan ioal dot quy tiieo TOAST (%)
Lap mach do tim Xd vi^a dgng mach Nhoi mau io khuyet Khac/khdnq xac dinh
Lieu thap 57 ± 1 3
31 60 13
10.5 141 ± 33 0.62 (0.6-0.86)139 ± 23 83 ± 1 2 124 ± 54
27 19 10 44
Lieu chuan 59 ± 1 4
56 62 21
145 ± 3312
0.9 146 ± 29 86 ± 1 6 129 ± 52
28 22 25 25
P
0.699 0.007 0.892 0.253 0.127 0.520 0.162 0.321 0.582 0.112Trong tdng sd 6171 benh nhan dot quy nhap tieu sdi huyet la 2% (121 benh nhan). Bac diern ba trung tam dot quy tir thang 5 nam 2006 den dich te hpc, yeu t d nguy ed, phan loai dot quy va thang 5 nam 2009, ty- le benh nhan dUdc dieu tri dac diem lam sang dUde ghi nhan trong bang 1.
VIETNAM MEDICAL JOURNAL N°1 - FEBRUARY - 2018 Tuoi trung binh trong nghien cu'u la 75 tudi, nam
chiem ty le 46%. Tang huyet ap la yeu t d nguy cd quan tnang nhat (61%), tiep theo la rung nhT (21%) va i3ai thao dUdng (17%). Diem NIHSS trung binh luc nhap vien la 12 diem (dao ddng tir 5-23 diem). Thdi gian trung binh tU khi khdi phat trieu chu'ng den khi dUde sir dung tieu sdi huyet 1^ 143 phut (dao ddng tir 50- 210 phut).
Thdi gian trung binh t i i khi nhap vien den khi diidc sir dung tieu sdi huyet la 73 phut, trong dd 38,9% benh nhan dUpc sii dung trong vdng 60 phut sau khi nhap v i i n .
Ca sd lieu nghien ciru cho thay ed 60,3% (73 benh nhan) diidc sii dung lieu chuan (d,9mg/kg), 36,9% benh nhan dUdc sir dung lieu thap (trung binh la 0,62 mg/kg, dao dpng t i i 0,6- 0,86 mg/kg). Cac dac diem lam sang, djch t l hpc va yeu to nguy cd gidng nhau giu^ liai nhdm, ngoai trU ty le nLi d nhdm benh nhan diidc sir dung lieu thap eao hdn so vdi nhdm diing lieu cliuan (P=0,007).
Bang 2. Cac kit cue d benh nhan diet/ tii IV-tPA leSu thSp (n-48} va lieu chuan (n=73J
Bien so mRS 0-1
XHnao Tu' vonq
Lieu thap 27 (56.3) 1(2.1) 1 (2.1)
Lieu chuan 25 (34.2)
4 (5.5) 9(12.5)
P 0.01 0.36 0.04
Cac benh nhan dUdc dieu trj vdi lieu rtPA thap cho thay sU cai thien ve ket cue vdi mRS 0,1 eao hdn so vdi nhdm benh nhan dieu tri vdi lieu ehuan (56,3% so vdi 34,2%, P=0,01) (Bang 2).Chung tdi cdn ghi nhan nhdm dieu tn vdi lieu thap cd it bien cd xuat huyet ndi sp hdn so vdi lieu chuan, tuy nhien sU khac biet nay khdng cd y nghia thdng ke (p=0,36). Sau 3 thang theo doi ty le t i i vong dddc ghi nhan cao hdn cd y nghTa thdng ke (P=0.04) d nhdm sir dung lieu chuan (12,5%) so vdi lieu thap (2,1%).
IV. BAN LUjShN
SU an toan va hieu qua eiia rtPA tinh mach tnDng dieu trj dot quy cap da diidc chdng minh qua eae t h i i nghiem lam sang ddi vdi chiing tdc chau Au. Tuy nhien cho den thdi diem chung tdi thUc hien nghien,cu'u van edn thieu eac du' lieu cho ngUdi chau A, ngoai cae nghien cu'u dUde ttiUe hien trUdc day d Thai Lan, An Dp, Singapore, Nhat Ban ddi vdi lieu thap. Nhiing ket qua ban dau cua dieu tri tieu sdi huyet d Viet Nam gan nhU tUdng^tUvdi ket qua ciia nghien ciiu NINDS.
^ Phan Idn cac benh nhan khdng dii dieu kien de dUdc sir dun^ rtPA ttnh mach do den ngoai thdi gian ciia so dieu t n , chi 8,7% benh nhan nhap vien trong cii^ so dieu tri 3 gid, nguyen
nhan nam d van de ve nhan thirc cac trieu chUng eiia dot quy, he thdng van ehuyen cap ciru cdn han che cung nhU tri tioan ciia nhan vien y te trong viec dUa ra quyet dinh dieu trj TPA, tinh hinh qua tai cua cae benh vien, ed sd vat chat cdn thieu thdn hay thdi gian tra ket qua eiia eae xet nghiem can thiet cdn cham t r i . Cd den 5% benh nhan khdng ddng y sir dyng rtPA vi lo ngai nguy ed xuat huyet. Tat ca cac nguyen nhan tren dan den viec tri hoan thdi gian dUdc su' dung thude ciia benh nhan (143 phut) va chi cd 38,9% benh nhan tU khi nhap vien den khi dUdc bolus nhd hdn 60 phut
Ty le benh nhan cd the sdng dpc lap (mRS 0,1) sau 3 thang trong nghien ciiu ciia chiing tdi la 43%, eao hdn so vdi ket qua ciia nghien ciiu NINDS 39%, J-ACT, CASES 37%, SITS-MOS 40,6%. TPA lieu thap va lieu chuan deu eho thay su an toan khi ty le xuat huyet nao ed trieu chirng la 5,5% so vdi 6,4% eiia nghien eUu NINDS va 4,6% eiia nghien edu CASES. Dieu thii vi trong nghien eiia chung tdi la eae benh nhan dUdc sii dung lieu thap cho ket cue to sau 3 thang (mRS 0,1) chiem ty le 56,3% cao hdn so vdi lieu chuan va t / le t i i vong thap 2 , 1 % .
Tuy nhien nghien cu'u ciia ehung tdi cung con mdt sd han che. Dau tien, chi ed mdt t / le nhd cac benh nhan dUdc sd dung rtPA lanh mach trong quan the rat Idn eac benh nhan nhap vien trong thdi gian nghien cu'u. T h i i hai, cac benh nhan dupe danh gia ket cue sau dieu tn bdi eiing cac bac sT dieu tri ban dau, dieu nay se dan den cac ket luan ed the khdng hoan toan mang tfnh khach quan. Ngoai ra, mdt sd benh nhan la uhg cii vien eiia dieu tn tieu sdi huyet nhUng lai khdng the thUc hien do van de tai chfnh. CT Viet Nam chi phf cho dieu trj rtPA khdng dUdc chi tra bdi chfnh phu hay eac cdng ty bao hiem, trong khi dd, gia tien ciia mdt lo rtPA SOmg khoang 11 trieu dSng, tUdng dUdng vdi 3 thang thu nhap trung binh hang thang ciia ngUdi Viet Nam. De dat dUdc mue tieu ngay eang ed nhieu benh nlian dot quy cap dUdc dieu tri rtPA can nang cao nhan thii'c eiia ngudi dan ve nhan biet trieu chu'ng cua dot quy cung nhU cai thien he th6n_g van chuyen bang xe rap ciiu va nang cao chat lUdng quan ly va dieu tri dot quy cap.
V. KET L U A N
Qua nghien cu'u nay, viec dieu tn tieu sdi huyet ttnh mach cho benh nhan dot quy Vi$t Nam da mang lai ket qua tUdng ddi an toan va hoan toan kha ttii, dac biet, lieu thap cd hieu qua va tfnh an toan vUdt trpi so vdi lieu chuan.
TAP CHi Y HQC VigT NAM TAP 463 - THANG 2 - SO 1 - 2018 TAI LI|U THAM KHAO
I, The National Institute of Neurological Disonders and Stroke rt-PA Stroke Study Group, Tissue masminogen activator for acute ischemic stroke,
^The National Institute of Neurological Disorders and Stroke rt-PA Stnake Study Group. N Engl J Med
#1995; 333: 1581-1587.
2i Adams HP Jr, Adams RJ, Brott T, del Zoppo GJ, et al. Stroke Council of the American Stroke Association. Guidelines for the early management of patients with ischemic stroke. A scientific statement from the Stroke Council of the American stroke Association. Stroke 2003; 34; 1056-1083.
3. Ueshima S, Matsuo O. "Rie differences in thrombolytic effects of administrated recombinant t-PA between Japanese and Caucasians. Thromb Haemost 2002; 87: 544-546.
4. Adams HP Jr, Bendixen BH, Kappelle 13, et al.
Classification of subtype of acute ischemic stroke.
Definitions for use in a muitieenter clinical trial.
Trial of Org 10172 in Acute Stroke Treatment.
Stroke 1993; 24: 35-41.
5. Hacke W, Donnan G, Fieschi C, et al.
Association of outcome with early stroke treatment: pooled analysis of ATU\NTIS, ECASS, and NINDS rt-PA stroke trials, lancet 2004: 363:
768-774.
6. Wahlgren N, Ahmed N, Dait:valos A, et al.
Thrombolysis with alteplase for acute ischaemic stroke in the Safe Implementation of Thrombolysis in Stroke Monitoring Study (SITS-MOST): an observational study. Lancet 2007; 369: 275-282.
7. Suwanwela NC, PhanUiumdiinda K, Likitjaroen Y. Thnambolydc therapy in acute ischemic sUoke in Asia: the first pnaspecdve evaluabon. Qin Neural Neurosurg 2006; 108: 549-552.
THirC TRANG PHONG BENH UNG THIT CO TU CUNG CUA PHU NU"
Tir 2 1 - 7 0 TUOI vA MOT SO YEU TO LIEN QUAN TAI HAI XA HUYEN DONG HU'NG TJNH THAI BINH NAM 2 0 1 5
T6MTAT
Nghi§n ciiu dUpe tien hanh tren 400 phu nH tudi tir 21-70 tai 2 xa eiia huyen Dong HUng, tinh Thai Binh rhSm cung cap thong tin ve thUc trang va mpt s5 yeu t5 lien quan ve phdng benh ung thU c6 tii cung (UTCTC) cua phu nH. Ket qua nghien eUu eho thay:
81,8% phu nff thUe hanh ve sinh dudng sinh due dl^ng cach va 25,5% thUc hien kham phu khoa dinh ky; 1,5% doi tuong da tiem vac xin HPV va 55,5%
chift tiihg tiem vac xin HPV. Ly do khong ti§m vac xin HPV la khong thuoe dot tUpng dUpc tiem (48,2%);
22,8% phu nU di kham sanq loc oliat hien sdm unq thir CO tir cunq. Nhdm phu nC khonq lam ndng nghiep CO hanh vi kham phu khoa dinh kv (OR=l,95; 95%CI:
1,23-3,08) va kham sanq loc UTCTC (OR=l,82; 95%a:
1,13-2,92) cao hdn so vdi nhdm lam n&ig nghiep _ Td khda: Phong ung thu eo tir cung d phu nff;
Phong ung thu CO tU cung; Phu nii;; Ung thUeotU cung.
SUMMARY
CURRENT STATUS OF CERVICAL CANCER PREVENTION AMONG WOMEN AGED 2 1 - 7 0 AND SOME RELATED FACTORS I N 2 COMMUNES OF DONG HUNG DISTRICT,
THAI B I N H PROVINCE I N 2 0 1 5 This study aimed to provide information on the status of cen/ieal cancer prevention among women
*Trddng Dal hgc YDudc Thii Binh Qiju trach nhiem chinh: l-e DiTc CUdng Email: [email protected] Ngay nhan bai: 16.10.2017 Ngay phan bien khoa hpc: 24.12.2017 Mgayduyef bai: 30.12.2017
Le Dii-c Cird-ng', Nguyin Thi HiSn'
aged 21-70 in two communes of Dong Hung district.Thai Binh province, and thereby identify some factors related to this issue. W/ith a cross-sectional design of over 400 women aged 21-70 in the study area, the results showed that: 81.8% of women had proper hygiene practices and 25.5% had periodic gynecological exams; 1.5% have injected HPV vaccine and 55.5% never have injected HPV vaccine. The reasons for not vaccinating with HPV is not being injected (48.2%); 22.8% of women screened for early detection of cervical cancer. Women are not famer having periodic gynecological exams and screened for early detection of cervical cancer higher than famer women, relatively: (OR=l,95; 95%a: 1,23-3,08) and (OR=l,82; 95%a: 1,13-2,92)
Keywords: cervical cancer among women;
cervical cancer prevention; women; cervical cancer.
I. BAT VAN DE
Ung t h u cd tu* eung (LfTCTC) la mdt trong nhi?ng ung thU thudng gap, ed tan suat diing thir hai trong cac ung thU phu nu' tren the gidi, vdi khoang 500.000 ca mdi va 250.000 ca chet moi nam. Khoang 80% sd ca ung thU co td eung xay ra d eae nUde cd miic song thap [1]. Tai Viet Nam, UTCrc va ung thU vu la 2 loai cd tan suat cao nhat. Theo so lieu bao cao nam 2010 cd 5.664 phu nu' mac UTCTC, t / le mac la 13,6/100.000 phu nu' [ 1 ] . Tan suat mac UTCTC trong khoang 20-30 trUdng hcfp mdi mac/
100.000 phu ndjnam. Mot trong nhutig ly do dan den tinh trang nay la phu nd cdn han ehe ve kien thirc phdng ngiia UTCTC, chu^ dUdc sang Ipc djnh ky va chUa cd he thong phat hien sdm
