TAP CHi Y HOC V l i T NAM TAP 465 - THANG 4 • SO 2 - 2018 Vidu: Benh nhan Nguyen HOv Th 65 tudi: Ma BA: 21071160961
Hinh 1: MRI cd ton thu'dng C3-4 ep tuy, co ap xe du'di day chang doc tru'dc (A); goc gu tren XQ cdt song cd nghieng (B); khim lai 11/2017 hinh anh da lien xu'dng ghep (C).
V. KET LUiDLN
Trieu chutig lam sang thudng gap eiia LCSC dau va han che van dpng cdt sdng, hep khe khdp tren Xquang cd nghieng.
TAI U | U T H A M KHAO
1. J. T. Qu, Y. Q. Jiang, G. H. Xu, et al. (2015).
Clinical characteristics and neurologic recovery of patients with cervical spinal tuberculosis: should conservative treatment be preferred? A retrospective follow-up study of 115 cases. World Neurosurg, 83(5), 700-707.
2. T. Shi, Z. Zhang, F. Dal, et al. (2016).
Retrospective Study of 967 Patients Vl/ith Spinal Tuber^losis. Ortiiwedlcs, 39(5), e838-843.
.3. Nguyen XiiSn Dien (2016)^ Dac dtem lam sang, c$n lam sang va ket qua phau thuat ldi trUdc 19
ben^h nhan lao cot sdng co. Hoi nghi Ngoai khoa vi phau thuat noi soi - noi soi Viet Nam, 13,1 -10.
. N. Mao, Z. Shi, H. (ii, et al. (2013). Long-term outcomes of one-stage anterior debridement, bone grafting, and internal fixation for the treatment of lower cen/ieal tuberculosis with kyphosis. Br J Neumsurg, 27(2), 160-166.
. Bhandari A, Garg RK, Malhotra HS et al (2014). Outcome assessment in conservatively managed patients with cen/ical spine tuberculosis.
Spinal Cord, 52(6), 489-493.
. Hsu LC, Leong JC (1984). Tuberculosis of the lower cervical spine (C2 to C7) A report on 40 cases. 3 Bone Joint Surg Br, 66,1-5.
. Y. Yao, W. Song, K. Wang, et al. (2017).
Features of 921 Patients Widi Spinal Tuberculosis:
A 16-Year Investigation of a General Hospital in Southwest Oiina. Orthopedics, 1-7.
NHOI M A U c a TIM CAP ST CHENH LEN ^ BENH NHAN XUAT HUYET GIAM TIEU CAU MIEN DICH: M O T TRU'DNG HOT LAM SANG
Nguyen Hoang Tai My', Mai Tri Lu^n^ Hoang Van Sy''^
T O M TAT
Xuat huyet giam tieu cau mien djch (XHGTCMD) la mot benh 1^^ mien dieh dupc dac trUng bdi sU giam tieu c3u (TC) thoang qua hay dai dang. Xuat huyet giam beu diu mien djch rat hiem dupe ghi nhan gay bien ehiing nhdi mau cd bm (^MMCT) cap khi y van the gidi den hien tai chi ghi nhan dUpe khoang hdn 10 trudng hpp va day eung la mpt thif thach dieu trj vdi nhiiu nguy ed xuSt huyet lan huyet khdi. Chung toi mo ta mpt trUdng hpp benh nhan nam 39 tuoi dUpc chan doin tinh cd xuat huyet giam tieu cau mien djch
^Benh vien OipRay
^{kihgc YDupc Tp. Ho OiiMlnh Chju trach nhiem chinh; Nguyen Hoang Tai My Email: [email protected] Ngay nhan bai: 18.2.2018 Ngay phan bien khoa hoe: 2.4.2018 Ngay duyet bat: 13.4.2018
nhap vien^vi nhoi mau ed tim cap thanh dUdi. Cho den hien tai van chUa co mpt khuyen eao ehinh thii'c nao hudng dan viee dieu trj nhdi mau cd tim tren nhiJYig benh nhan xuat huyet giam tieu c3u mien dieh. Qua tim hieu tai lieu va y van, chiing toi mudn thao lu|n ve CO che benh sinh gii^a xuat huyet giam tieu cau mien dich vdi sU tao lap huyet khoi dpng mach eung nhu caeh dieu trj ndi khoa va can thiep mach vanh d nhffng benh nhan nay.
Tdkhda: nhoi mau cd tim, xuat huyet giam tieu cau mien dich, thude chong ket tap tieu cau (CKTTC), thuSc ehdng dong, can thiep maeh vanh.
SUMMARY
ACUTE ST ELEVATION MYOCARDIAL INFARCTION I N PAHENTS W I T H IMMUNE THROMBOCYTOPENEA PURPURA: ACASE RQiORT Immune thrombocytopenic purpura (ITP) is an acquired immune-mediated disease characterized by a
VIETNAM MEDICAL JOURNAL H°2 - APRIL - 2018 transient or persistent decrease of platelets. Immune
thrombocytopenic purpura has rarely been implicated in cases of acute myocardial infarction (AMI) whidi presents a treatment challenge laden with increased risks of botJi bleeding and thrombosis. We describe a case of a 39-year-old male with occasionally diagnosed Immune thrombocytopenic purpura who presented with an inferior wall ST-elevation myocardial infarction. There are no current guidelines available for management of immune thrombocytopenic purpura patients with acute myocardial infarction. In tills review of literature, we discuss the proposed pathophysiological link between immune thrombocytopenic purpura and arterial thrombosis and the challenging medical and interventional treatment of these patients.
Key words: myocardial infarction, purpura, thrombocytopenia, percutaneous coronary intervention, anticoagulation, heparin-induced thrombocytopenia (HIT).
I. DAT VAN OE
XHGTCP1D ia mpt benh ly hiem gap vdi tan suat mac benh Udc tinh khoang 100 ca tren 1 trieu ngUdl moi nam. Ben canh dd, cho dii tan suat xd vt?a dpng mach ndi chung va nhoi mau cd tim ndi rieng d nhu'ng benh nhan ed rdt loan ddng mau va giam tteu c^u man tinh la rat thap nhUng y van the gidi cung da ghi nhan cd sd lien quan giu'a XHGTCI^D vdi Nt^CT. Cd che sinh ly
benh cdn chUa ro rang va viec dieu trj chuan vdi eac thudc chdng huyet khdi tren nhD'ng benh nhan nay thUe sU la mdt thach thUc.
II. T R U d ^ G HOP LAM SANG
Benh nhan nam, 39 tudi vUa dddc chuyen tif benh vien dja phUdng den khoa cap ciru v<5i ctian doan NMCT cap thanh dUdi gid thU 20 Kiilip I. Tten can khong ghi nhan bat thUdng benh iy npi ngoai khoa. Oien tam do (OTO) ghi nhan ST ctienh len, sdng Q d eae chuyen dao DII, DIII, aVF, ST chenh len nhe d DI, aVL va chenh xudng d aVR (hinh IA). Tong phan tich te bao mau ghi nhan giam tieu cau 15 G/L vdi sd lUdng hong cau va tieu dau binh thudng; Troponin I tang 1,65 ng/ml, chUc nang co bdp that tral tdt tren sieu am tim va eac xet nghiem sinh hda khae eho ket qua binh thUdng. Benh nhan dUdc chup mach vanh cap cUu va ket qua eho thay he dpng maeh vanh khdng hep (hinh 2A, 2B). C^c xet nghiem ANA, anti-dsDNA, antiHIV binh thudng.
Tiiy do ghi nhan tinh trang hiiy tieu ciau do mien djch. Benh nhan dUde chuyen khoa Huyet hoc dteu trj tiep vdi chan doan Viem cd tim va xuat huyet giam tieu cau mien djch. Xuat vien sau nira thang vdi sd IUdng tieu cau la 230G/L.
Hinh 1. DTD du'dc ghi nhin vio ngiy nhip vien lan dau (IA) vi Un sau (IB).
Hinh 3A va 3B. Kit qui chup mach vinh phai lan hai nhieu huyet khdi (3A) va hinh inh mach vinh chup lai sau 1 tuan (SB)
TAP CHl Y HOC VliT NAM TAP 465 - THANG 4 - SO 2 - 2018 Sau thang sau, benh nhan nhap vten lat vi
tinh trang xuat huyet dUdi da vdi sd IUdng tieu cau la 9 G/L. Benh nhan dddc truyen 2 ddn vj tieu rau dam dac. Den ngay thU 4, sd iUdng tieu cau la 235 G/L va benh nhan dot ngpt than dau ngUe diT dpi vdi tfnh chat tUdng t i i ian trUdc.
OTD ghi nhan sdng Q, ST chenh ien d DII, I I I , aVF, ST chenh xuong d aVR cung tUdng tU nhU 6 thang trUde (hinh IB). Cae xet nghiem Troponin I tang 98ng/ml, CK-I^B tang 262,3 U/L, chUe nang co bdp that trai binh thudng vdi EF 65%. Ket qua cliup mach vanh cho thay hep 90% dpng mach vanh phai do huyet khoi (hinh 3A). Benh nhan dUdc dieu trj ndi khoa vdi thudc ehdng huyet khdi (Enoxaparin, elopidogrei va aspirin) va chup mach vanli kiem tra sau 7 ngay eho thay ddng mach vanh phai khdng edn huyet khdi, khdng xd vii'a gay hep dang ke (hinh 3B).
Sau dd, benh nhan dUdc duy tri thudc aspirin 81mg, elopidogrei 75mg mot ngay vdi sd IUdng tieu cau dn dinh 200G/L.
IV. BAN LUAN
XHGTCI^D la mdt rdi loan tieu cau t u mien hiem gap dae trUng bdt tinh trang giam tieu cau va xuat huyet da niem. XHGTCI^D thudng diidc ehan doan sau khi loai trU eae nguyen nhan gay giam tieu ciau khac. Ben canh dd, HCVC thUdng xay ra do sU ket tap va hinh thanh nut tieu c^u tren cac mang xd vii'a khdng dn dinh bi nirt v3 gay hep hoac tac nghen Idng ddng mach vanh.
Tinh trang giam tieu cau trong benh ty XHGTCMD thudng gay bien chUng xuat huyet nhUng da dddc ghi nhan co lien quan vdi nguy cd cao xay ra nhihig bien co huyet khdi nhU tiMCV, nhdi mau nao va huyet khoi ddng tTnh maeh. Nhutig bien cd nay dUdc ghi nhan xuat hien trong va sau qua trinh dieu trj khi mUc tieu cau bat dau tang va tham chf ngay trong pha giam tieu rau trung binh den nang [ 4 ] .
Nguyen nhan hinh thanh huyet khdi trong XHGTCMD [ 6 ]
- Mdt gia thuyet cho rang la do phan utig khang the chong tieu rau va giai phong nhUng vi phan tU tU tieu eau. Nhtitig phan tU nay ki'ch hoat hinh thanh huyet khdi. Chfnh nhu'ng vi phan tU nay ddng vai trd bao ve trong tinh trang giam tieu eau. Trong trUdng hdp nay, cd le hoat dpng tang ddng vUdt qua hieu qua bao ve.
- Tieu CBU trong XHGTCMD thi Idn hdn, tre hdn va hoat b'nh manh hdn. Kht dieu tri, sd IUdng tieu a u tSng nhanh la nguyen nhan gay benh.
- Mpt sd bien phap dieu trj, nhU cat lach, cung ed the gay bien ca huyet khdi: huyet khdi tJnh mach cii^, thuyen tac phdi, huyet khdi tinhx
maeh sau.
- Dieu tri sterciid diidc biet oo the gay nhutig thay ddi ehuyen hda va trang thai tang ddng nhU tang dp nhdt mau, hoat hda tieu cau hay eo that maeh.
- Dieu tn Danazoi cung dUdc ghi nhan gay huyet khdi dpng mach.
- Mpt nguyen nhan cd the la sU tUdng ddng ve cau true khang nguyen tren tieu cau va te bao npi md. Vi vay, nhu'ng tU khang the tan cdng trUc tiep khdng nhu'ng tieu eau ma edn gay ton hai te bao npi md, hinh thanh huyet khdi va huyet tac ddng maeh.
- Mdt sd nhd benh nhan XHGTCMD ed khang the khang phospholipid (aPL) rao. Mdt nghien cUu cho thay_ ty ie nay ia 26% d nhDtig benh nhan mdi chan doan vdi sd IUdng tieu cau dUdi 50 G/L, nhUng ndng dp aPL eao khdng lien quan vdi sU xuat hien XHGTCMD. Vi vay, vai trd ciia aPL trong cd che benh sinh XHGTCMD van cdn nhieu tranh cai.
Thu* thach trong Sieu trj NMCT d benh nhan XHGTCMD: Dieu trj HCVC d nhutig benh nhan XHGTTCMD hien van cdn nhieu diem ctiua thong nhat. Oau tien, dieu tn thude tieu sdi huyet d benh nhan XHGTCMD la chdng chi djnh vi nguy ed xuat huyet rao. Can thiep mach vanh la mpt bien phap hieu qua nhUng cung ia mpt thU thach. "Cd can tliiet dat stent khdng va neu cd thi ehpn loai stent thudng hay stent phu thude?" hay "SU dung thude ehdng ddng va chdng ket tap tieu cau trong va sau khi tien hanh ran thiep maeh vanh nhu the nao?" cting nhU
"Can can nhac gi khi dieu tri benh nhan XHGTCMD khi ddi mat vdi HCVC?" la nhOtig cau hdi Idn can dat ra cho eac bae sT khi dieu trj benh ly phdi hdp dae biet nay. Tdm iai, khi tien hanh can thiep mach vanh d nhu'ng benh nhan nay, dieu quan trpng nhat ia iam sao Ue che hieu qua ehUc nang tieu eau de tien hanh ran thiep an toan nhUng cung khdng lam cho tinh trang xuat huyet xay ra.
Ddi vdi nhij'ng benh nhan XHGTTCMD kem benh mach vanh phdi hdp, dUdng tiep can ddng maeh quay thUdng diidc du tten de de dang bang ep cam mau tat cho. TrUdng hdp ciia Chung tdi, bdi vi benh nhan khdng phat hien thay mang xd vda gay hep dang ke dpng mach vanh trong tan dau tien ehup maeh vanh cung nhu nhan thay kha nang hep dpng mach vanh trong lan chup thir hai la do huyet khdi cap nen viec dat stent da khdng dUdc dat ra. Neu quyet djnh dat stent, stent tran cung dddc du tien sir dung hdn stent phii thude do thdi gian dimg thudc ehdng ket tap tieu cau kep cung ngan hdn.
VIETNAM MEDICAL JOURNAL N°2 - APRIL - 2016 Tuy nhien, cho den hien tai van chUa cd di? lieu
nghien cUu so sanh hteu qua trUc tiep ve mUe dp an toan va hieu qua kht tu^ ehpn hat loat stent tren d cae ddi tUdng benh nhan XHGTCMD cd NMCT cap. Nhti'ng trUdng hdp dau tien XHGTCMD bi NMCT ST chenh len dUde md bac cau tuy nhien can thiep mach vanh qua da da dddc chiing minh la bien phap dieu tri an toan.
Cae thudc chdng ddng ddng heparin, bao gom heparin khdng phan doan va fondaparinux, da dUdc dimg thanh cong khi tien hanh can thiep mach vanh d benh nhan XHGTCMD. Hien tat, tieu heparin tot Uu dddc sd dung la bao nhieu van cdn la mdt van de bd ngd. Tuy nhien, cd te lieu heparin chuan tfnh theo can nang hay la tteu dUde giam ket hdp vdi gamma globulin trong pha giam tieu cau la dUdc chap nhan rdng rat. Tuy nhien, dieu nay xay ra hoan toan la do ket qua tU nhdm so sanh gida fondaparinux va placebo (HR=0,79; p<0,05) trong khi nhdm so sanh giu^ fondaparinux va heparin khdng phan doan cho thay khdng ed sU khae biet cd y nghTa (HR=0,96; p=NS). Trong dd, mdt Icet qua dang quan tam la nguy cd huyet khdt eatiieter tang cao trong nhdm benh nhan sd dung fondaparinux hdn trong nhdm cdn tai. Hdn nite, fondaparinux khdng gidng nhU heparin khdng phan doan va heparin trpng IUdng 75 phan tU Uiap d clio khdng ii'c che chu'c nang tteu cau va do dd gtam dUdc nguy cd xuat huyet tren nhutig dcH tUdng nay. Dteu nay nghe cd ve hdp ly tuy nhien can nhan manh la cho den hten tat van chda CO nghien eiru nao dddc thdc liien nham Idiao sat hieu qua thUe sU cua fondaparinux tren nhdm benh nhan XHGTCMD bj NMCT nhU trUdng hdp chung tdi.
Nhdm thudc Uc ehe thrombin trUc tiep cung dUde can nhSc la mpt ly^ chpn thay the trong trudng hdp nay. Bivatirudin la thudc duy nhat trong nhdm nay dddc chap nhan kht benh nhan cd giam tieu cau do heparin. Vi the, cd le day la thudc nen dUdc can nhac sU dung, nhat la trong trudng hdp benh nhSn bj NMCT trong pha giam tieu cau ma kho phan biet vdi tinh trang giam tieu c3u kht dang dieu tri heparin khdng phan doan. Thudc Uc ehe thu the I l b / l I I a can tranh sir dyng do nguy cd xuat huyet rao cung nhU gay giam tieu cau nang hdn dii mdt sd trUdng hdp td ra hieu qua.
du hdt tiep theo can tra ldi ta "Lieu cd nen tiep tuc heparin sau ran thiep hut huyet khdi?"
va neu cd thi "Thdt gian sir dung la bao lau?"
Mdt trudng hdp tUdng tU da dUdc ghi nhan bdt Fengyi Shen va cs [6] cho thay sU tai lap huyet
khdt sdm dii dupc tien hanh hut huyet khoi thanh eong kht benh nhan khdng dUdc duy tri heparin sau qua trinh hut huyet khdi. Trong trUdng hdp ciia ehiing tdi, benh nhan bf XHGTCMD dang dUde dac trj vdi eae thudc nhani' lam tang sd IUdng tteu cau nen loat khang ddng dddc liu tten sir dung nhat phai la fondaparinux;, hoac bivallrudin nham han che kha nang Uc che hay giam sd IUdng tteu cau do heparin gay nen.
Tuy nhien, vi thUe te tai benh vien ehiing tdi ai6i diem nay ehi cd hai lu^ clipn thudc khang dong trong dieu tri NMCT cap la heparin khdng phan doan va heparin trpng lUdng phan tU thap nen benh nhan da dUdc sU dyng enoxaparin (heparin TLPTT) vdi lieu etiuan trong thdi gian 7 ngay sau khi chyp mach vanh. Hieu qua hoan toan dat dddc vdi ddng mach vanh phai khdng huyg't khdt, khdng sang thUdng xd vu^ khi chup kiem tra va khi theo dor 3 thang sau dd va khdng co bjen ehiTng ehay mau. ThUc sU lieu enoxaparin t S Uu trong hot chutig mach vanh cap cd giam tieu eau chUa dUdc khuyen cao.
Dieu trj thuoc CtCTTC kep dUdc khuyen cao sif dyng trong thdi gian ngan d nhutig benh nhan can thiep dat stent de cho phep qua trinh not mac hda xay ra nhUng se tam tang nguy cd xuSt h^yet. Ddi vdi nhiitig benh nhan ed giam tieu rau phdj hdp, nguy cd xuat huyet cdn cao hdn gap nhieu I3n. Ben ranh do, mac dii dieu tri thudc CtCTTC kep day'dii thdi gian, cac benh nhan nay van cd nguy cd rao tai hep trong stent va can tien hanh can thiep lai. Nht^u trudng hdp da dUde ghi nhan hien tUdng tai hep trong stent trong khoang thdi gian rat ngan sau ran thtep.
Tuy nhien, con sd can thiet dat dude la bao nhieu van dang cdn la van de tranh cat va lUu y eac thudc chdng huyet khdi bj chdng chi iKnh khi so IUdng tieu cau dUdi 30 G/L Ben canh do, n^u benh nhan cd cac bien chutig xuat liuyet nang, de dpa tfnh mang hay khi sd IUdng tteu cau xudng dUdi 5 G/L thi can dieu tri ciap ciili bang each truyen tieu cau dam dac hay cac thudc lit ehe mien djch dac hieu nhir gamma globubln, eac thudc nhdm corticoldes va tham chi la phffl hdp cac bien phap tren. Chi djnh nhap vien dieu trj khdng phai cap cUu vdi li@u rao corticoldes khi sd IUdng tieu cau thap hdn 20-30 G/L. Trong trUdng hdp benh nhan ciia chung tdi, tai th6i diem dd khdng cd cac bien chUng xuat huyet nang hay de dpa tinh mang cung nhU so ludng tteu eau la 235 G/L nen lienh nhan da dUdc tiep tyc dieu tri vdt hai loai CKTTC cung vdt lieu thap prednisolqn lOmg de duy tri on djnh sd IUdng tieu eau. It nhat sau 3 thang, benh nhan khdng ed cdn dau ngUe tai phat.
TAP CHi Y HOC VIET NAM TAP 465 • THANG 4 • SO 2 • 201S Rd rang viec sU dyng bd ba - 1 thude ehdng
ddng va 2 thude CKTTC nhUeae khuyen cao hien hanh trong dteu tri NMCT cap la can thiet va pliti hdp. Tuy nhien, trong trUdng hdp XHGTCMD la mdt van de hoan toan khac bdi vi nguy cd xuat huyet gia tang. Vay, lieu chi sU dung bd hai - 1 thudc chdng ddng va 1 thudc CKTTC trong pha cap cd lam tang nguy cd tac stent hdn d eac ddi tUdng nay? Cac nghien cUu ngau nhien, mil ddi nh'u RE-DUAL PQ [2] va PIONEER AF-PCI [1] khi khao sat eae bien ed ehi'nh xuat huyet tren cac BN rung nhT bi HCVC can ran thiep maeh vanh da cho thay viee sU dung bd hai - dabigatran (RE-DUAL PQ) hay rivaroxaban (PIONEER AF- PQ) cdng vdi duy nhat elopidogrei cho ket qua cac bten ed xuat liuyet xuat hien it hdn trong khi cac bien co huyet khdt thuyen tae, NMCT, tU vong do NMCT khdng tang.
Cudi ciing, viec phat tiep tyc sU dyng thudc ehdng ddng va thuoc CKTTC kep d benh nhan XHGTCMD cdn dat ra mpt van de quan trpng kht nd doi hoi phai theo ddt sat sd IUdng tieu cau de tranh sd luWng t e u cau giam qua mUc va cd the kfch hoat hinh thanh huyet khdt mdi. Hdn nda, sau khi ngutig heparin, viec theo ddi tiep tuc sd IUdng beu cau cung quan trpng khdng kem va la muc tieu trong dteu tri va ttieo dot benh ly XHGTCMD.
Trong trudng hdp nay, benh nhan ciia ehiing ^ 1 duac xet nghiem theo doi sat sd IUdng f e u rau moi 2 ngay trong tuan dau tien va sau do la moi 1 va 2 tuan trong 3 thang sau dd vcfi sd IUdng tieu cau duUc duy tri dn djnh tren 200 G/L.
V. KFT LUAN
Tdm lai, nhoi mau ed ttm cap van cd the gap d nhij'ng benh nhan xuat huyet giam tieu cau.
Oieu trj ddi tUdng benh nhan nay van edn la mdt thach thUe. Cac thudc chdng huyet khdi bao gom cae thudc chdng ddng va thudc CKTTC kep eho den hten tai van td ra an toan. Tuy nhien, viec sU dung cae thudc nay can het sUe than tnpng, can chinh lieu va ehpn loai thude ehdng huyet khdi phii hdp, va cian theo ddi sat bten ehutig chay mau va sd lUdng tieu cau trong khi dieu tri eac thudc nay va thude Uc che mien djch nham lam giam thap nhat kha nang xay ra cac bien cd huyet khdi cung nhU xuiit huyet.
TAI UEU T H A M KHAO
1. C. Michael G, Roxana M, Christoph B, Prevention of Bleeding in Patients with Atrial Fibrillation Undergoing PQ. N Engl J Med. 2016;
375:2423-2434.
2. Christopher P. C, Deepak L B, Jonas O, Dual AntShrombote Theraov with Dabiaatran after PQ in Atrial Rbrillation. N Engl J Med. 2017; 377:1513-1524.
3. Dhillon SK, Lee E, Fox : i , Rachko M. Acute ST elevation myocardial inferction in patients with immune thnambocytopenia purpura: a case report.
Cardiol Res. 2011:2:42-45.
4. Fruchter O, Blich M, Jacob G. Fatal acute myocardial infarction dunng severe thrombocytopenia in a patient with idiopathic thnDmbocytopenic purpura. Am J Med Sd. 2002; 323: 279-80.
5. Neskovic AN, Stankovic I , Milicevic P, Aleksic A, Vlahovic-Slipae A, Calija B, et al. Primary PQ for acute myocardial infarction in a patient with idiopathic thrombocytopenic purpura. Herz. 2010; 35: 43-49.
6. Shen F, Nfor T, Bajwa T. Recurrent acute myocardial infarction in patients with immune thnambocytopenic purpura. J Patient Cent Res Rev.
2014;1:4H5. doi: 10.17294/2330-0698.1010.
7. Yusuf S, Mehta S. R, Chrolavicius S. Effects of fondaparinux on mortality and reinfarction In patients with acute ST-segment elevation myocardial infarction: the OASIS-6 randomized trial, JAMA. 2006 Apr 5;295(13): 1519-30.
KIEN THITC VA THITC HANH VE SINH AN TOAN THU'C PHAM NGurcri TRirc TIEP CHE BIEN, PHUC VU TAI BEP AN TAP THE cCiA CAC TRU'CTNG MAM NON TREN DIA BAN THANH P H 6 saN LA
Lu Thi Hoa', Pham Thi Dung^' Ph^m Thi Tinh^
T 6 M TAT
Muc tieu: D^nh _gia kien thUc va thUc hanh _ye sinh an toan thUe pham ciia ngy/cfi trUe tiep che bten, phuc vu tai eae bep 3n tap the ciia eac trUdng mam ' Trung tim y te thinh phd Sdn La
'Tnrdng Dal hgc YDddc Thii Binh Chju trach nhiem ehinli: Lii Thj Hoa Email: [email protected] Ngdy nhan bai: 20.01.2018 Ngay phan bien khoa hpc: 22.3.2018 Ngay duyet b^i: 30.3.2018
non tren dja ban thanh phd Sdn La. PhUdng phap:
phUdng phap dieh te hpc md ta qua dieu tra cat ngang. Kei qui: 67,7% so nhan vien dUdc tap huan kien thii'e ATVSTP; 76,9% so nhSn vign dUd'c kham sUc khoe djnh ky. 57,6% hieu biet tUOng ddi dSy dii ve nguyen nhan gay d nhiem^ thut pham. 53,2% hieu biet ve tac hai cua thUe pham khong an toan. 49%
hieu biet ve cac benh khi mae khong dUOc bep xiic vdi thue pham. 90,8% m|c tap de; 60% rihSn vien dau tdc gpn gang, dpi mu' khi che bien; 89,2% sd nhan vi§n khdng dung tay bdc thii'c an; 63,0% sd nhan vten che bien, phuc vu eo ban tay sach, mong tay cat ngan va 83% so nhan vten khong khae nhd khi che bien. Ty
