TON THUONG LAM S A N G THAN KINH NGOAI VI 6 NGaOfI DAI THAO DUOfNG TYP 2
Nguyin Trong HOng TrUdng Dai hoc Y Ha Ngi Benh than kinh ngoai vi (TKNV) Ta mdt trong sd cic bien chdng ning cua dai thio dudng, die biet Ta d dai thio dddng - typ 2. Muc tieu: nghien cdd bleu hidn lim sang ton thdang TKNV d ngddi DTD typ 2 co dddng miu on djnh va khdng on djnh. Doi tUgng va phuang phap nghien ciiu: 80 benh nhan dii thio dddng typ 2 chia hai nhdm - nhdm on djnh dddng mid (38 ngddi) va nhdm khdng on dinh dddng mid (42 ngudi) vdi phdang phip tien cdu, cit ngang, md ta, so sinh cic tridu chdng vi mde do ton thddng thin kinh ngoai vi tren lim sang gida cic nhdm. Ket qua: ty le cac trieu chdng chu yeu cua ton thdang than kinh ngoai vi nhd giam/mi't phan xa gan xdang; rdi loan cam giie (chu quan vi khich quan); Hdt van ddng d nhdm on djnh dddng miu theo thd td li 68,4%,; 57,9%o; 47,4%o deu thap han cd y nghTa so vdi nhdm khdng on djnh dddng mau (theo thd td la 78,6%o;71,4%o; 57,1%,). Ty Id benh nhan cd td ba trieu chdng lam sing trd len chiem ty le cao d hai nhdm ndi tren. Ket luan: ton thuang thin kinh ngoai vi cd tinh lan tda, dd'i xdng, du the chi dddi. Da so cac trieu chdng lim sing chinh cua ton thdang than kinh ngoai vi ndi tren d nhdm khdng on djnh dddng miu cao han so vdi nhdm 6n djnh dddng mau va viec dieu tri va kiem soit td't dddng miu lam giam ding ke cic tridu chdng tdn thuang TKNV d ngddi dii thio dddng.
TO khoa: Dai thao dOdng, benh than kinh ngoai vi do dai thao dOdng, dn djnh dOdng mau, khong dn djnh dodng mau
I. DATVAN DE
Benh than kinh ngoai vi (TKNV) la mpt trong eae bien chflng nang d ngfldi dai t h i o dfldng (DTD),' dac biet la d DTD - typ 2. Ty le mac benh TKNV trong DTD tfl 50 - 8 4 % tuy theo d c nghien cflu, ty le n l y tang theo ndng dp dfldng mau va thdi gian bi benh DTD [ 1 , 2, 4, 8]. Hien nay, chan doan benh TKNV d ngfldi DTD ehu y l u dfla vao k h l m lam sang va tham dd dien sinh ly than kinh. 0 nflde ta, khdng p h i i ndi nad cung cd eae t h i l t bj tham dd dien sinh ly, nen viee kham lam sang rat quan trpng de p h l t hien benh TKNV d ngUdi DTD, va dae biet d typ 2 - la tfp cd -nhilu b i l n chflng nang va b i l n chdng TKNV hay bj bd qua. Mat k h I c , trong q u i trinh d i l u trj, n l u kiem solt tdt dudng mau thi lieu mde dp tdn thUdng TKNV ed dUdc d i thien hay khdng? Tra Idi dUde cau hdi tren se gidp p h l t hien, d i l u trj sdm v l theo ddi dupe hieu qua eua q u i trinh dieu trj de tranh b i l n ehdng TKNV trong DTD. Vi vay, chdng tdi t i l n hanh d l tai nay vdi muc tieu: Nghien cdu
lam sang tdn thuang than kinh ngoai vi trong dai thao dudng - typ 2 co dUdng mau dn dinh va khong dn dinh.
II. DOI TUONG VA PHU'ONG
PHAPNGHIEN COu
1. Doi tOdng nghien cOu
80 benh nhan DTD typ 2 dang d i l u trj d khoa Npi tieL Benh vien Lao khoa Trung UPng dUdc lUa chpn dfla vao tieu chuan ehan d o l n x l c djnh DTD cua Td chdc Y te The gidi (1999) [10]. CIc benh nhan dupe chia thanh hai nhdm de sd sinh:
nhdm dn djnh difdng mau (38 benh nhan) khi HbAiC < 7,0% va nhdm khdng dn dinh dddng mau (42 benh nhan) khi H b A i C > 7,0% (theo Hiep hpi DTD Hoa ky 2008) [3].
2. PhOdng phap nghien cOu
T i l n cflu, eat ngang, md t l , so sanh d c tridu chflng va mfle dp tdn thfldng TKNV tren lam sing gifla nhdm dn djnh difdng miu va khdng on dinh
TCNCYH 70 (SJ - 2010
dudng mau. Cae benh nhan dfldc kham lam sang, can lam sang theo m l u benh an nghien eflu de loai trO e l c nguyen nhan k h I e gay TKNV ma khdng p h i i do DTD (suy than'man tinh, nghien rUdu man tinh, suy dinh dUdng, t h i l u vitamin, benh he thdng, elc thudc da dung gay tdn thfldng TKNV...).
3. Xu' ly sd lieu
Bang ehfldng trinh EPI - INFO 6.04 va SPSS.
Dung T - tets de sd sanh hai gia trj trung binh va kiem dinh y^ so sanh hai Xy le.
2. Ty If cac trieu chOng lam sang
i n . K E T Q U A
1. Dac diem chung cua cac ddi tOdng nghien cOu Hai nhdm on djnh va khdng dn djnh dddng mau cd' sd lOdng benh nhan, tudi v l gidi tUPng dfldng nhau, d i u cd tri sd trung binh dUdng m l u luc ddi la 8,3 ± 3,52mmol/l va HbA,C la 7,4 ± 2,48%. Khi so s i n h gifla hai nhdm, Xy le difdng m l u lue ddi va H b A i C d nhdm khdng dn djnh difdng mau cao hdn ed y nghTa so vdi nhdm dn djnh dudng mau.
Bang 1. Ty le
Nhom trieu chOng
Gilm/ma't phan xa gan xUong Rdi b a n d m giae
Rd'i loan van dpng Rdi loan t h i n kinh tfl dpng Teo CO
cac trieu chiing lam sang chung d Nhom
n
dn djnh dOdng
= 38 26 22 18 12 7
(%) (68,4) (57,9) (47,4) (31,5) (18,40
mau Nh
hai nhom (n = 80)
dm khong n = 42
34 30 24 14 9
dn dinh (%) (78,6) (71,4) (57,1) (33,3) (21,4)
dodng mau P
*
*
* k k (p: p gida nhdm dn djnh va nhdm khdng dn djnh difdng mau; k : p > 0,05; * p < 0,05).
'Nhin xet: giam/init phan xa gin xifang chiem ty le cao nhat, sau den rd'i loan cam giac va van ddng.
Rdi loan thin kinh td dong va teo cd khdng khac nhau gida hai nhdm.
2.1. Rdi loan (giam/mat) phan xa gan xUang
DGan Got
• Gan go!
D C h i Tren
Nhom dn dinh dOdng mau Nhom khong dn djnh dOdng mau Bieu do 1. Rdi loan (giam/mat) phan xa gan xUang (P < 0,05.)
Nhan xet: rdi loan (giam/mi't) phan xa gin gdt cd ty le cao nhit, sau den gin gdi va chi tren. O nhdm dn dinh difdng mau, trieu chifng nay cd ty le thip han (p < 0,05).
2.2. Rdi loan cam giac
Nhin chung, d nhdm on djnh dddng mau, rdi loan cam giac chiem 6 8 , 4 % va thap hdn so vdi nhdm khdng on djnh dddng mau I I 7 8 , 6 % (p < 0,05).
Bang 2. Ty le cac trieu chiing rdi loan cam giie
Nhom trieu chOng
N h o m dn djnh dOdng mau Nhom khong dn dinh dOdng mau p n = 22 (%) n = 30 (%)
RL d m g i l c ehu
quan
Te bi kien bd Cdng budt Cham kim Ban chan rit bdng
Rung vdi am thoa Sd thd sd
Dau
16 12 9 6 18 15 11
(72,7) (54,5) (40,9) (27,3) (81,8) (68,2) (50)
25 20 12 10 26 24 18
(83,3) (65,7) (40) (33,3) (86,7) (80) (60)
+
* k
*
+
*
*
R L d m g i l c khach
quan
Ndng lanh 7 (31,8) 10 (33,3)
(p: p gida nhdm dn djnh va nhdm khong on dinh dddng mau; k : p > 0,05; * p < 0,05).
Nhan xet: rdi loan d m giac (chu quan va k h I e h quan) d nhdm khdng dn djnh dddng mau ed Xy le cao hdn so vdi nhdm dn djnh dddng mau (p < 0,05).
2.3. Rdi loan van dgng: bieu hien bang Net van ddng d d c mfle dp, flu the hai chi dfldi va dd'i xflng.
Rdi loan nay chiem 4 7 , 4 % d nhdm dn djnh dfldng mau va tha'p hpn cd y nghTa so vdi nhdm khdng on djnh dddng mau la 57,1 % (p > 0,05).
2.4. Rdi loan than kinh tU dgng: chiem 31,6% d nhdm on dinh difdng mau, chie'm 33,3% d nhdm khdng on djnh dddng mau. Bieu hien gom ha huyet ap t u t h l , rdi loan bai tiet md hdi, rdi loan co bdp da d i y - rupt va liet dUdng. Nhin chung khdng cd sfl k h I c nhau gifla hai nhdm trfl rdi loan da d i y - rupt va ha huyet I p tu the (bang 3).
Bang 3,. Ty le cac trieu chdng rdi loan than kinh tU dgng d hai ntfom
Trieu chOng
Nhom dn djnh dOdng mau Nhdm khong dn dinh dOdng mau
n = 12 (%) n = 14 (%)
Liet dfldng 8 (56,7) 9 (54,3)
Rdi Idan da day rudt 4 (33,3) 8 (57,1)
Ha h u y l t I p tfl the 4 (33,3) 7 (50)
Rdi loan bai t i l t md hdi 3 (25) 4 (28,6)
(p: p gida nhdm dn dinh va nhdm khdng dn djnh dddng mau; k : p > 0,05; * p < 0,05).
Nhin xet: bieu hien liet difdng chiem ty le cao d hai nhdm (p > 0,05). Rdi loan da day rudt va ha huyet ip td the chiem ty le cao hdn d nhdm khdng dn djnh dddng mau.
TCNCYH 70 (SJ - 2010
2.5 Teo ca: bieu hien bang teo d e nhdm cd ehu ye'u ngon chi d e l c mfle dp tfl nhe d i n nang, flu t h i hai chi dfldi va dd'i xflng. Tdn thfldng nay c h i l m 18,4% d nhdm on dinh difdng mau, chiem 2 1 , 4 % d nhdm khdng dn djnh difdng mau va khdng k h I c nhau khi so sanh gifla hai nhdm (p > 0,05).
3. Ty le xua't hien cac trieu chOng lam sang theo mOc do
T-/ le cd ft nha't mot trieu chdng lam sang la 30/38 (78,9%) trong nhdm on dinh difdng mauva 37/42 (88,1 %) d nhdm khdng dn djnh difdng mau, cdn lai la khdng trieu chflng. Ty le d c nhdm cd it nhl^t mpt trieu ehdng lam sang dflpe md t l d b i n g 3.3.
Bang 4. Ty IS tdn thuang TKNV tren lam sang theo miic do
Nhom cac trieu chOng
Nhdm 1 trieu chdng Nhdm 2 trieu chdng Nhdm 3 trieu chdng Nhdm 4 trieu chdng Nhdm 5 trieu chflng
Nhon 1 dn djnh dOdng mau n = 30
2 3 7 10 8
(%)
' (6,7) (10) (23,3) (33,3) (26,7)Nhom khong n = 37
3 4 8 12 10
dn djnh dOdng mau
(%)
(8,1) (10,8) (21,5) (37,8) (27,1)
P K K k
• k .
k (p: p gida nhdm dn djnh va nhdm khdng dn djnh dddng mau; k : p > 0,05; * p < 0,05)
Nhan xet: ty le td ba trieu chdng lam sang trd len chiem Uu the hdn so vdi cic nhdm cd mot, hai va ba trieu chdng d ca hai nhdm (p < 0,05).
IV. BAN LUAN
Trong nghien eflu nay, d hai nhdm benh nhan DTD - typ 2 dn djnh difdng mau va nhdm khdng on djnh difdng mau deu xua't hien d e trieu chdng lam sang ehung cua tdn thUdng TKNV nhu rdi loan cam g i l c d d e the, rdi loan (giam/
mat) p h i n xa g i n xUdng, liet van dpng d d c mde dp, rdi loan than kinh tfl dpng, teo cP...trong dd trieu chflng rdi loan (giam/mat) phan xa gan xflong chiem Xy le cao d hai nhdm, lan tda, ddi xflng ufl the chi dUdi va dae biet rdi loan ( g i l m / mat) p h i n xa gan gdi va gan gdt dUpc coi la dau hieu sdm eua benh TKNV trong DTD. Dieu nay cung phd hdp vdi eae nghien cdu khae ehd rang benh TKNV trong DTD - typ 2 ed lien quan den rdi loan ehuyen hda cua t l bao than kinh kem thoai hda nguyen p h l t sdi true, mang tfnh lan tda ddi xdng...va n l u kiem solt tdt dUdng mau thi se giam dUdc ty le mac cung nhU mde dp tdn thUPng
TKNV [ 1 , 2, 5, 8, 9]. Tuy nhien, khi so sanh gifla hai nhdm dn djnh va nhdm khdng dn djnh dddng mau, da sd d c trieu chflng ndi tren lai cd ty le eao hon d nhdm khdng dflpc dieu trj dn djnh va d c t i c gia k h I c cung dUa ra nhan xet tUdng tfl [4, 5]. Cu the, rdi loan d m giae ehu quan va k h i c h quan (bang 2), mac du kha thudng gap d e l hai nhdm nhUng lai ed Uu the hdn d d c benh nhan DTD cd dudng mau khdng dUde dieu trj dn djnh. T i c gia Davis tha^y mfle dp tang dfldng huyet anh hfldng trflc tiep den t i n h trang nhan e l m dau, khi dfldng huyet tang, ngfldng nhan d m dau giam xud'ng va dfldng huydt cd the anh hfldng de'n sfl d i l u hoa cae thu the morphin eua ed the;-khi dfldng huyet tang se lam giam tac dung chd'ng dauvcua morphin lam tang cfldng dp dau [9], bieu hien rat bdng la da'u hieu lam sang mudn cua tdn thflpng e l m giac d ngfldi D T D . Trieu chflng g i l m hay mat cam giae rung la
da'u hieu lam s i n g quan trpng giup phat hien sdm bien chflng TKNV d ngfldi bi D T D [8], tuy nhien vai trd cua e l m g i l c rung rat han ehe neu benh n h i n la ngUdi cao tudi [4].-Rd'i loan van dpng du'ng hang thfl ba sau giam p h i n xa gan gdt va d e rd'i loan cani gi'le, Uu the d hai chi dudi...nhin chung e l c rd'i loan v a n dpng cung tUPng tu v d i e l c nghien cflu k h I e e l trong nude va the gidi [ 1 , 2, 5, 8 ] . Tiep theo la rd'i loan t h i n kinh tfl ddng, 11 bieu hien kha dac trUng cua b i l n chflng T K N V . N h i l u t i e g i l eho rang tuy ty le gap ft hpn so v d i cac bieu hien k h I c , nhUng ne'u xua't hien trieu chflng nay thi cd the coi la da ed bien chdng T K N V d ngfldi dai thao dfldng [ 1 , 4, 5 ] . Trong nghien eflu nay, d e bieu hien rdi loan than kinh tfl ddng gdm ha h u y l t I p tu t h i , rdi loan bai t i l t md hdi, rdi loan CO bdp da d i y - rupt va Met dfldng. Trong dd bieu hien liet dUdng c h i l m Xy le eao d hai nhdm nhUng n l u dupe kiem soat tdt dUdng mail thi ty le Met dUdng giam dang ke. Nhan xet nay cua ehung tdi eung phu hdp vdi cac nghien cflu khac [5, 8, 9 ] . Bieu hien teo cd c h i l m ty le tha'p nhat va khdng khac nhau gifla hai nhdm (p > 0,05); ehu y l u teo CP ngon chi, Uu the chi dUdi. K i t qua nay eung tUdng tu nhu d c nghien cdu k h I c thay rang tuy c h i l m ty le ft nhUng tec ed la d e dau hieu quan trpng hudng den benh TKNV d ngudi D T D . N h i n ehung, viec kiem s d t td't dudng m l u tha'y rd d i thien cae trieu chflng rd'i loan cam giae va cac trieu chflng v a n ddng, nhflng cac trieu chflng rdi loan t h i n kinh tfl dpng va teo cd thfldng khdng eai thien rd "ret cd the do cac benh nhan trong nghien edu eua chung tdi da mac DTD tfl lau va da ed bien chflng tdn thflpng TKNV da d giai doan kha mudn. D i l u n a y . c u n g tha'y rd khi so sanh ve mde dp tdn thuPng TKNV gifla hai nhdm dn djnh va nhdm khdng dn djnh dudng mau (bang 3), chdng t d i , thay ty le d e benh nhan cd tfl ba trieu chflng trd len chiem da sd, chflng td d e benh nhan
dflpc Ifla chpn vao nghien eflu da cd tdn thUdng TKNV dang d giai doan tie'n t r i l n . D i l u can thiet de tiep tue bd xung cho nghien cdu nay la can p h i i md rpng dd'i tUdng d d c benh nhan mdi bi D T D typ 2 nhUng chUa hoac m d i bj mac bie'n ehdng tdn thfldng T K N V v d i muc dfch de tha'y re viec kiem soat td't va sdm dUdng mau cd vai trd quan trpng de g i l m bie'n chflng T K N V d ngUdi D T D typ 2. .
V. KET LUAN
ToQ thUdng TKNV d 80 benh nhan DTD typ 2 ed tfnh lan tda, ddi xdng, UU the chi dUdi, bieu hiln hay gap la g i l m / m a t p h i n xa gan xUdng, rdi loan d m g i l c ehu quan va k h i c h quan. Met van dpng b d c mde dp, rdi loan than kinh tfl dpng. Da sd eac trieu chflng lam sang eua tdn thfldng TKNV ndi tren d nhdm khdng dn djnh dfldng mau cao hdn so vdi nhdm dn djnh dUdng m l u . Do vay, viec d i l u trj va kiem solt tdt dUdng m l u lam giam dang ke eac trieu chdng tdn thUdng TKNV d ngfldi DTD.
T A I
LIEU
T H A MKHAO
1. Le Quang Codng (1999). Nghien cflu bieu hien t h i n kinh ngoai vi d ngUdi trUdng thanh dai t h i o dudng bang ky thuat ghi dien cd va do tdc dp dan truyen than kinh. Luan an "Tien sT Y hpe.
TrUdng Dai hpe Y Ha Npi.
2. Vu Anh Nhj (1996). Nghien eflu benh ly than kinh ngoai bien do dai t h i o duSng bang phUdng p h l p ehan d o l n dien. Luan an Phd Tien sT Y hpe, Dai hpe Y dUde khoa TP Ho Chi Minh,
3. ADS (American Diabetes Association) (2008). Standards of medical care in diabetes - 2008. Diabetes Care, 3 1 , 1 7 - 1 9 .
4. Davles M , Brophy S, Williams R, Taylor A (2006). The prevalence, severity, and impact of painful diabetic peripheral neuropathy in type 2 diabetes. Diabetes Care; 29: 1518 - 1522.
5. Dobretsov M , Romanovsky D, Stimers JR
TCNCYH 70 (SJ - 2010
(2007). Early diabetic neuropathy: triggers and polyneuropathy: an update. Current Opinion in mechanisms. World J Gastroenterol; 1 3: 1 75 - 191. Neurology, 2 1 : 527 - 533.
6. Huang CC et al (2005). Effect of Glycemic 9. UK Prospective Diabetes Study (UKPDS) Control on Electrophysiologic Changes of Diabetic Group (1998). Effect of intensive blood - glucose Neuropathy Type 2 Diabetic Patients. Kaohsing J control with metformin on complications in Med Sci; 2 1 ; 15 - 2 1 . overweight patients with type 2 diabetes (UKPDS
7. NDIC (National Diabetes Information 34). Lancet. 352: 8: 54 - 865.
Clearinghouse) (2008). Diabetic Neuropathies: I Q . W H O (1999). Definition; Diagnosis and Thenervedamageofdiabetes.W.W. Norton. 1 - 1 2 . classification of Diabetes Mellitus and its
8. Zochodne D . W (2008). D i a b e t i c Complications. Report of a W H O consultation.
Summary
C L I N I C A L I N V E S T I G A T I O N OF P O L Y N E U R O P A T H Y I N T H E P A T I E N T S W I T H T Y P E 2 D I A B E T E S
Peripheral neuropathy is one of the serious complications of diabetes mellitus, especially in diabetes - type 2. Objective: To describe a clinical neuropathy in the patients with type - 2 diabetes glycemic control (DGC) and glycemic non - control (DGNG) groups. Methods: Clinical neurological examinations were performed in 80 patients with type 2 diabetes divided into two groups (38 patients of DGC and 42 of DGNG group) with cross - sectional description and comparison of symptoms and severity of diabetic neuropathy between groups. Results: The rate of major symptoms of neuropathy such as the loss of tendon reflexes, sensory disorders (subjective and objective), weakness (listed is 68.4%, 57.9%, 47.4%) in DGC group were significantly lower compared to DGNG group (listed is 78.6%, 71,4%, 57.1%). The rate of patients from three clinical symptoms over a high proportion in the two groups. Conclusion:
Clinical diabetic neuropathy as a distal symmetrical process with greater lower - limb than upper - limb involvement is more common. Majority of clinical symptoms of the DGNG group is higher than the DGC group and good control of glyeemia significantly reduce symptoms of neuropathy in diabetes - type 2 patients.
Keywords: diabetes - type 2, diabetic polyneuropathy, diabetes glycemic control, diabetes glycemic non - control
