Y HOC VI$T NAM THANG 7 - SO 2/2013
C O N G T R I N H N G H I E N C O u
DANH GlA SUTTinmG QUAN GIO'A DIEM FOUR VOTI DIEM HON ME GLASGOW TRONG CHAN THUffNG SO NAO NANG
T O M T A T
Nghien ciTu tien cdu c3t ngang d 60 benh nhan (BN) chan thu'dng sp nao nang (CTSN) cd GCS < 8 diem tai phong Hoi syc tfch cyc cho thay cac thang diem f=OUR v^ GCS cd tu'dng quan ch|t (r = 0,60) d toan bp cac BN, tu'dng quan rat chat d BN thd may va 6 t y vong (thy t y lar = 0,93 v a r =0,82).
Td' Ichoa: Chan thu'dng so nao nang, FOtJR, GCS, tu'cfng quan.
SUAAMARY
CORRELATION BETWEEN FOUR AND GCS I N SEVERE HEAD INJURY A prospective, cross-sectional study conducted in 60 patients with severe head injury showed that FOUR and GCS were overall in rather dose correlation (r = 0.60), in very close correlation in mechanically- ventilated or dead subgroups (r = 0.93 and r = 0.82, respectively).
Key words: Severe head injury, FOUR, GCS, correlation.
I. OAT V A N D E
Thang diem hdn me Glasgow (GCS: Glasgow Coma Scale) hien du'dc dung de danh gia tri giac trong hdn me ndi chung va trong CTSN ndi rieng, dya vao m d mat, cu" ddng, dap iTng bang ldi ndi cua BN nhu'ng khd danh gia khi tdn thu'dng mat, khdng ndi du'dc do dat ndi khi quan hay md khf quan va khdng danh gia dydc chu'c nang than nao. Nam 2005, thang diem FOUR (Full Outline UnResponsiveness Score) [7] du'dc ap dung tai
Nguyen Quoc K i n h * , Pham Dinh K i e n * * lu^ chgn gdm cac benh nhan (BN) tren 16 tudi bi CTSN nang (GCS < 8 diem) dydc dieu trj tai phdng Hoi sifc tfch cyc benh vien Viet Ou'c. Tieu chuan loai trir gdm da chan thydng, chuyen vien hoac gia dinh xin du'a ve; nhan thuoc trd tim, thudc me hoac an than, gian cd hoac chet lam sang trydc khi den benh vien; cd tien sir tam than hay rdi loan tri nhd.
2.2. Ptiudng phap ngliien cu'u:
2.2.1. Thiet ke nghien cdu: Nghien cdu lam sang tien ciTu, cat ngang du'dc thyc hien tren 60 benh nhan CTSN nang cd GCS < 8 diem, du'dc thyc hien tai phdng
Hdi sire tfch cu'c benh vien Viet ^dc trong thdi gian 1/2011 - 6/2011.
2.2.2. Cac tieu chi danh gia:
- Phan bd diem FOUR va diem GCS - Sy tu'dng quan giife diem FOUR va diem GCS:
-I- He sd tu'dng quan r (Pearson) giiJa diem FOUR va diem GCS.
-H s y phii hdp (agreement) theo Bland - Almant giffa diem FOUR va GCS.
+ He sd tu'dng quan r giffa diem FOUR va diem GCS d benh nhan thd may.
-I- He sd tu'dng quan r giffa diem FOUR va diem GCS d benh nhan tff vong..
2.2.3. tlotsdtieu chuan va djnh nghia dung trong nghien cu'u:
- Thang diem GCS (Teasdale, 1974) [ 6 ] : Md mat {md mat tif nhien = 4 diem; md mat theo lenh = 4 diem; md mat khi gay dau = 2 diem;
Mayo Clinics (My) do khac phuc du'dc nhu'dc khong md mat khi gay dau = 1 diem); cd dang (cd diem ciia thang diem GCS. Tai phdng Hoi sffc dpng nhanh theo lenh = 6 d^'m; gat dung gay Idii ti'ch cyc, da so benh nhan CTSN nang cd dng npi dau = 5 diem; oo chi khi gay dau = 4 diem; gap khl quan hoac m d khi quan de kiem soat hd hap cuhg khl gay dau = 3 diem; duoi cuhg ki&j mat vo va gan day csn chan doan chet nao. Vi vay, = 2 di&n; khong cd dong khi gay dau = 1 dieni);
chung tdi tien hanh nghien ciru nham danh gia mdi tydng quan giffa diem FOUR vdi GCS d benh nhan CTSN nang.
II. DO'I TL/ONG VA P H J O N G PHAP NGHIEN CCfU 2 . 1 . b o l tu'dng nghien cu'u: Tieu chuan
* Benh vien Viet Ddc, ** Trung tam y te huyen Thuy Nguyen Phan bien khoa hpc: PGS.TS. D6ng Van H?
ndi {tra Idi nhanh = 5 dimi; da Icff Ion xpn = 4 d'^;
tia ldi khong phu hop = 3 di&n; khong ro noigi = 2 diem; khong tra idi = 1 diem).
- Thang diem FOUR [ 7 ] : Md mat (md mat hoac nhap nhay mat theo lenh = 4
diem; md mat nhuhg khong doi mat theo = 3 diem; mat nham nhung md mat khi gpi to = 2
Y Hpc VigT NAM THANG 7 - S6 2/2013 diem; mat nham nhutig md mat khi gay dau = 1
diem; mat nham khi gay dau = 0 diem}, cff ddng (thdc hien dung cac menh lenh = 4 diem; gat dung cho khi gay dau = 3 diem; gip cdng lihi gay dau = 2 di em; duoi cuhg khi gay dau = 1 diem/, than nao (phan xa ddng td va giac mac binh thddng = 4 if lem; dong tdgian va co dinh
= 3 diem; mat phan xa dong td hay giic mac;
mat ca phan xa dong td va giac mac = 1 diem;
mat ca phan xa dong td, giac mac va phan xa ho khi hut dng ngi khf quan hoac dng md khf quan
= 0 diem}, hd hap (thd deu binh thu'dng = 4 diem; thd kieu Cheyne - Stokes = 3 diem; thd khong deu = 2 die'm; thd khong hoan toan theo may = 1 diem; ngiitig thd hay thd hoan toan theo may = 0 diem).
- Sdng va tir vong: BN sdng la ra vien ma khdng can ho trd tuan hoan va hd hap; BN tff
III. KET QUA
3.1. Dac diem benh nhan: 60 BN gdm 53 nam va 7 nff, tuol 36,45 ± 16,57 nam, tai nan giao thdng 53 BN (88,3%), 33 (55%) BN tff vong va 27 (45%) BN sdng.
3.2. Sd tddng quan giita diem FOUR va diem GCS:
vong gom nhffng benh nhan tff vong tai vien va nhffng benh nhan qua
nang hap hoi gia dinh xin ve (sau do dffdc kiem tra va xac djnh).
2.2.4. TiSh hanh: Tat ca cac benh nhan CTSN nSng dydc binh dn tuan hoan va hd hap, thd may qua dng ndi khf quan hoac dng md khf quan khi d phdng Hoi sffc ti'ch cffc. Benh nhan ti/
thd qua dng md khi' quan khi chuyen khoa ngoai than kinh. Diem FOUR va diem GCS dydc hai bac sy ndi tru Gay me Hoi sffc danh gia doc lap vao 2 gid sau khl ngffng thudc an than tai phdng Hoi sffc ti'ch cffc.
2.2.5. Xu"Iys6'li$u \^ng chutJng trinh thong ke y sinh SPSS 12.0. Tinh he so tffdng quan r theo Pearson va sy phii hdp (agreement) theo Bland - Almant gitfe diem FOUR va GCS d toan bo 60 BN, 6 cac BN thd may va d cac BN tff vong.
jjuLliuk DFOUR • GCS
Hinh 1. Phan bo diem FOUR va diem GCS
Nhan xet: So BN co FOUR phan bo tu" 2 den 9 diem (FOUR = 2 diem d 5 BN, FOUR = 9 diem d 3 BN). So BN CO diem GCS phan bo tir 3 den 8 diem, chu yeu 5 va 6 diem (5 BN co GCS = 3 diem du'dc phan tich^them vdi FOUR = 2 diem).
Hinh 2. Tu'dng quan FOUR-GCS
" " ; - ; ; , -2SD
Trung binh cong diem FOUR va GCS
Hinh 3. Sir phu hdp FOUR- GCS
Y HQC V I $ T NAM THANG 7 - SO 2/2013
Nh$n xet: 6 toan bd 60 b|nh nhan, diem FOUR va diem GCS cd sff tffdng quan thuan kha chat (r = 0,60 vdi p<0,05) va sff phii hdp tot (chf 1,7% cap gia tri nam ngoai'khoang ± 2SD).
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Hinh 4. Tffdng quan giffa diem FOUR Hinh 5. Tffdng quan giffa diem FOUR va diem GCS d 56 BN thd may va diem GCS d 33 BN tff vong Nhan xet: Diem FOUR va diem GCS co tffdng quan thuan rat chat trong tien Iffdng nguy cd thd may (r = 0,93; p < 0,05) va tff vong (r = 0,82; p < 0,05),
IV. BAN LUAN
4 . 1 . Dac d i e m benh nhan va phan bo diem FOUR va diem GCS: Cac benh nhan trong nghien cffu chii yeu la nam, d tudi thanh men va trung nien (36,45 ± 16,57 nam), hau het bi CTSN nang do tai nan giao thdng, ty le tff vong 55% d phdng Hdi sffc tfch cffc va cung tffdng t y nhff nghien cffu ciia Hoang Xuan Tue [ 2 ] .
4 . 2 . Tu'dng quan giu'a diem FOUR va diem GCS d cac benh nhan CTSN nang: Nam 2005, Wijdick (Mayo clinics. My) nghien cffu benh d 120 ddn vi dieu tri tfch cffc than kinh la ndi cac dieu dudng vien va bac sT dffdc tap huan each sff dung thang diem FOUR. Tac gia thay thang diem FOUR cd ffu diem vffdt trdi trong danh gia benh nhan nang dang cd dng noi khi quan, cho cac thdng tin ve phan xa than nao vdn khdng cd trong GCS, cd the phat hien trang thai sdng thyc vat, giup c^nh gia xa hdn d cac benh nhan cd dian GCS thap, chfnh xac hdn diem GCS do each do ft phy thudc vao benh nhan va thang diem FOUR cd moi tydng quan ket qua giffa cac nhan vien danh gia tdt hdn vdi so vdi GCS [ 7 ] . Tuy hien nay thang diem GCS van dydc diing rpng rai nhffng thang diem FOUR bat dau dffdc ap dung d mot sd benh vien tai My, Thuy Sy, An Dp, ... Ket qua cho thay do nang ciia benh nhan lien quan chat vdi diem FOUR, ty le t h d may va tff vong tang len cd y nghTa khi diem FOUR giam. Idrovo L va cdng s y nghien cffu 60 BN tai ddn vi dot quy ciia benh vien La Paz (Tay Ban Nha) gom 41 BN nhdi mau nao, 15 BN xuat huyet nao, 4 BN thieu mau cyc bd nao va thay cd tffdng quan thuan rat chat
giffa diem FOUR va GCS (r = 0,83; p < 0,01) [ 4 ] . Cac benh nhan cd diem GCS thap nhat se dffdc danh gia va phan loai tiep bang thang diem FOUR. Thang diem FOUR cung cap thdng tin chi tiet hdn ve tinh trang than kmh hdn GCS, giiip phat hien ra hgi chffng khda trong (lock-in syndrom) va ffu viet hdn GCS khi danh gia phan xa than nao cung nhff cd kha nang phat hien cac giai doan khac nhau ciia thoat vi nao va chet nao. Nhffng benh nhan cd diem FOUR thap cd nguy cd tff vong Idn hdn nhffng benh nhan cd GCS thap do vay tien Iffdng nang tdt hdn [ 4 ] , [5]^ Ket qua bang 1 cho thay hau het cac benh nhan CTSN nang trung lap diem FOUR vdi diem GCS trong khoang gia tri 4 - 8 diem nhffng khac nhau d khoang 2 - 3 diem. Chiing tdi cijng thay thang diem FOUR cd tffdng quan kha chat vdi GCS (r = 0,6 va p < 0,05) va cd tinh phu hdp tdt vdl diem GCS (bieu dd Bland - Almant cho thay chf cd 1,7% cap gia tri nam trong khoang ± 2SD). Nguyen Trffdng Giang (2007) nghien cffu 532 benh nhan tai benh vien 103 thay hieu Iffc tien Iffdng cua bang GCS kha cao vdi ROC = 0,82 cho nguy cd thd may [ 1 ] . Trong nghien cffu nay, diem FOUR tffdng quan rat chat vdi diem GCS (r
= py93; p < 0,05) d cac benh nhan thd may khdng ndi dffdc do cd dng ndi khi quan hoac ong md khi quan, mot tinh trang rat thffdng gap tai phdng Hoi sffc tfch cffc. Theo mdt nghien cffu tai benh vien Viet Offc, 7 0 % cd GCS < 7 diem bj tff vong [ 3 ] . Trong nghien cffu nay, diem FOUR va GCS cd tffdng quan thuan rat chat vdi r = 0,82 (p
< 0,05) d 33 benh nhan tff vong. Theo Marcati E
Y HQC VI$T NAM THANG 7 - S6' 2/2013 et al (2011) [ 3 ] , dff doan tff vong tai benh vien
cd dien ti'ch dffdi dffdng ROC ciia thang diem FOUR la 0,935 va ciia thang diem GSC la 0,953.
V. KET LUAN
Diem FOUR tffdng quan thuan kha chSt vdi r = 0,6 (p < 0,05) va phii hdp t d t vdl diem GCS d cac benh nhan chan thffdng so nao nSng dffdc dieu trj tai phdng Hoi sffc. Sff tydng quan giij^ FOUR va GCS rat ch5t che d nhdm b?nh nhan thd may (r = 0,93) va nhdm tff vong (r = 0,82) vdi p < 0,05. Thang diem FOUR cung cho phep danh gia sau hdn khi GCS = 3 diem.
TAI LIEU T H A M K H A O
1. Nguyen Tru'dng Giang (2007) "Nghien cuU gia tii cua bang diem RT5, ISS, NISS tmng phan loai, tien lu'dng va dieu tri benh nhin da chan thddng", Luan an Tien si Y dffdc hpc, Hpc vien Quan Y.
Hoang Xuan Tu? ( 2 0 0 3 ) , "panh gia kit qua chan doan va xd tif phau thuat chin thudng so nao tai b?nh vien tinh Ha Tiy", Luan vSn bac sy chuyen khoa cap I I , Hoc vien quan Y.
Nguyen Thu'dng XuSn (1995), Kinh nghiem chan doan chet nao tai benh vien Viet Dffc, Tap chf ngoai khoa, sd 5, tr -12.
Idrovo L et al ( 2 0 1 0 ) , Validation of the FOUR score (Spanish version) in acute stroke:
an interobserver vanability study, Eur Neun^, 63, 364-9.
Marcati E, Ricci S, Casalena A (2012),
"Validation of the Italian version of a new scale: the FOUR score". Internal and Emergency Medicine, 7 (2):145-152.
Teadale G; Jennet B; Hadley D (1974), Computerized tomographic and resonance imaging classification head injury, J.
Neurusurg, vol 9, pp249-257.
Wijdick. F.M ( 2 0 0 5 ) , "Validation of a New Coma Scale: The FOUR Score", Ann Neurit, 58, 585-593.
LIEN QUAN GIUfA DOT BIEN GEN JAK2 V617F VOH MOT SO DAC DIEM TE BAO MAU or BENH NHAN DA HONG CAU VA TANG TIEU CAU TIEN PHAT
Pham Quang Vinh^^"^^,, N g u y e n Thien LB**', I v o Quoc V i n h ^ Vu'dng Sdn Thanh'*^
TOM T A T
Sff dyng ky thuat ASO-PCR de xac djnh gen dot bien JAK2 V617F 6 42 benh nhan da hong cau nguyen phat (DHCNP) va 57 benh nhan tang tieu cau tien phat (TTCTP) tir thang 5/2011-10/2012, so sanh mpt so dac diem te bao mau giffa nhom benh nhan dot bien va nhom khong dot bien JAK2 cho hay: 85,71% benh nhan DHCNP va 66,67% benh nhan TTCTP co gen Aqt bien JAK2 V617F; nong do HST, so Iffdng bach cau d benh nhan TTCTP c6 dot bien gen JAK2 V617F cao hdn nhom khong co dot bien; so IffOng tieu cau d benh nhan DHCNP co dot bien gen JAK2V617F cao hdn nhom khong co dot bien gen.
Tif viet tat; ASO PCR: Allele specific oligonucleotide Polymerase Cham Reaction, TTCTP:
Tang tteu cau ben phat, DHCNP: Da hong cau nguyen phat, SLBC: so Iffdng bach cau, SLTC: so lUOng tieu cau, HST: huyet sac td, PV: Polycythemia Vera, ET:
Essential Thrombocythemia. WBC: White blood Cell (so Iffpng bach cau)
(1) Khoa Huyet hgc- Truyen mau BV Bach P4ai; (2) Tru'dng Dai Hoc Y Ha Ngi Phan bien khoa hgc: PGS.TS. Bach Khanh Hoa
SUMMARY
RELATION BETWEEN THE MUTATION JAK2V617F WITH SOME CHARATERISTICS OF
BLOOD CELL
Using ASO-PCR assay to detect JAK2V617F mutation in 42 patient with Polycythemia vera (PV), 57 patient with Essential thrombocythemia (ET) from 5/2011 to 10/2012 showed that: 85,71% patientswith PV and 66,67% pabents with ET expressing 3AK2 V617F mutation; hemoglobin concentration, WBC of ET patient with JAK2V617F(-H) higher than patient JAK2 V617F (-); platelets of PV patient with JAK2V617F i+) higher than patent JAK2 V617F (-).
I.
OAT V A No l
Dot bien gen JAK2 V617F du'dc cdng bo lan dau tien vao nam 2005 da md r a ' m g t hu'dng di mdi trong chan doan va dieu t n nhdm benh tang sinh tuy man, ac tinh khong cd nhiem sac the
