NGHIEN CU'U OAI THAO OL/ONG VA ROI LOAN GLUCOSE MAU LUC OOI 6 CAN BO CONG NHAN VIEN HUU TRUCJC TUOI
TONG QUAN
Hien nay, tren the gididai thao duong (DTD) dang gia tang mot each dang ngai, dac biet a cac nude dang phat trien trong do co nude ta. Tai Da NSng, thoi gian qua da co mot vai bao cao cho thay ty le DTD dang gia tang nhanh nhat nude. Do vay, viec tam soat benh ly nay can co mot cac nhin tich cue.
Theo quan didm mdi gan day, trudc khi DTD xay, benh thudng trai qua mdt giai doan tiem an ma gidi chuyen mdn goi la tien DTD hay rdi loan glucose mau liic ddi (RLGMLD).
Hen nira, chi phi cho dieu tri, xir ly cac bien chirng ciia DTD la ganh nang cho toan xa hdi ciing nhu tirng gia dinh.
Do vay, su hieu biet vd DTD &
RLGMLD se giup cho chiing ta cd tam nhin tdng thd cao hem, se giiip cho cdng ddng cd nhan thirc day dii vd DTD, RLGMLD de cd thai dp canh giac phat hien benh sdm, dieu chinh loi song, phong ngira, didu tri ngay tir giai doan RLGMLD trudc khi DTD xuat hien ciing cac bien chirng nang ne ciia benh.
I. OAT VAN OE
DTD la mdt nhdm cac benh ly chuyen hda dac trung bdi tang glucose mau do khiem khuyet tiet insulin hoac khiem khuyet hoat ddng ciia insulin hoac ca hai (ADA, nam 2004).
*TTGDYK Du Ndng
Truong Cdng Dung*
Nguyen Huu Chien*, Le Thi Nga*
Diy la benh man tinh rat phd bien, chie'm den 60-70% cac benh ndi tiet tren the gidi. Theo WHO nam 1995, An Dp la nude cd so ngudi DTD cao nhat 19 trieu, tiep theo la Trung Qudc 16 trieu, Hoa Ky 14 trieu va con so nay cang ngay cang gia tang, dac biet la cac nude dang phat trien. Tai Viet Nam theo thd'ng ke nam 2006 cd den 4,4% dan so trong ca nude mdc phai benh ly nay va xa'p xi 65% ngudi benh DTD chua dupe phat hien.
Nguyen nhan DTD cd the do di truydn, nhidm trung, nhidm dpc, miln dich cung nhu do yeu to mdi trudng nhu: tudi, beo phi, it van ddng...
Hien nay, ngudi ta chia DTD thanh hai thd loai chinh. DTD the 1 dac trung bdi sir huy hoai te bao beta ciia dao Langherhans gay thieu hut gan nhu tuyet ddi insulin. DTD thd 2 (chiem deh 85-90%) dac trung bdi rdi loan hoat ddng hay rdi loan tiet insulin.
Cac bien chirng do DTD cd the cap tinh nhu: hdn me tang tham thau, nhidm toan aceton, nhidm toan acide lactic, ha glucose mau... hoac man tinh o nhieu co quan nhu vong mac mat, vi mach than, than kinh, tim mach, da, nhidm triing, ban chan DTD... Vi vay, DTD anh hudng rat nhidu deh chat lupng cudc sdng ciia ngudi benh va day cung la mot van de nan giai cho nganh y te' cung nhu ganh nang cho kinh te cua gia dinh.
Nhu phan tdng quan da trinh bay, trudc
khi DTD xay ra, benh co the trai qua mot thai ky tiem an goi la giai doan tien DTD hay RLGMLD. Vi vay, phat hien sdm RLGMLD ngay tir giai doan tiem an rat quan trong de co cac bien phap didu chinh loi sdng, can bang duong mau nham lam cham su phat trien DTD cung nhu phong ngira sdm cac bien chirng nang nd ciia benh.
Trong qua trinh cong tac, chung toi nhan thay co nhidu can bp cong nhan vien (CBCNV) huu trudc tudi mac du chua co bidu hien lam sang ciia DTD nhung cac xet nghiem can lam sang da the hien su RLGMLD.
Vi vay, chiing toi tien hanh nghien ciiru de tai nay nham tim hieu them ve DTD ciing nhu RLGMLD va dua ra mot so kien nghi cho CBCNV nghi huu trudc tudi ciing mot so giai phap trong viec cham soc siic khoe ban dau qua kham siic khoe dinh ky trong thai gian den.
II. MUC TIEU NGHIEN CUU
1. Xac dinh ty le RLGMLD & DTD 6 CBCNV huu trudc tuoi tai HDGDYK TP. Da Nang nam 2008 - 2009.
2. Tim hidu md'i lien quan giua chi so BMI (chi so khdi co the) vdi RLGMLD &
DTD.
III. OOI TUONG VA PHUONG PHAP NGHIEN CUU
Nghien ciiu nay dupe thuc hien trong thdi gian tir thang 8/2008 den thang 8/2009 tai HDGDYK TP. Da NSng.
1. Ddi tupng nghien ciiru
/./. Chgn mdu: toan bp CBCNV giam dinh huu trudc tudi tai HDGDYK TP. Da
Nang, theo cac tieu chuan quy dinh ciia BHXH Viet Nam d dp tudi < 59 vdi nam va <
54 vdi nu va du tham nien cdng tac (tu 20 nam trd len).
1.2. Cd mdu: Chpn theo cdng thirc v2 P0-P)
a
Trong do: A,.a / 2 = 1.96 vdi he sd tin cay (l-ct)= 0.95
P=0,5 va d (sai so udc lupng) = 3%.
Do dd, n cho nghien cUu la 700 trudng hop
O day, chiing tdi chpn mau 722 trudng hop.
2. Phuong phap nghien ciiru
Nghien ciru theo phuang phap tien ciiu, cat ngang.
2.7. Tieu chuan chan doan:
Chiing tdi ap dung theo tieu chuan chan doan DTD ciia Hiep hdi Dai thao dudng Hoa Ky (ADA) nam 2005.
Chan doan RLGMLD: khi glucose mau liic ddi (Go)
5,6 mmol/l < Go < 70 mmol/l hoac 100 mg/dl < Go < 126 mg/dl
Chan doan DTD: Khi glucose mau liic ddi (Go)
Go > 7,0 mmol/l hoac Go > 126 mmg/1
Go phai dupe lam it nhat hai Idn tai hai thdi diem khac nhau va deu cho ket qua theo tieu chua'n neu tren. Neu chi lam mot lan, chan doan tam thdi theo ddi DTD.
Danh gia BMI: chiing tdi dua vao tieu chudn cua Td chuc Y te The gidi (WHO) danh cho ngudi trudng thanh tai chau A.
Neu BMI > 23: chan doan tang trong, beo phi
Neu BMI < 23: binh thudng
2.2. Tieu chuan loai tru:
- Sir dung cac thuoc co the' lam tang glucose mau
- Mac cac benh ly cap tinh din den anh hudng glucose mau
- Sir dung carbohydrate duoi 08 gid trudc dd.
2.3. Cach thuc tien hanh:
Mdi CBCNV cd mot phieu dieu tra.
Sau khi khai thac tidn sir ca nhan, tuoi, gidi, cac yeu to loai trir... chiing tdi tien hanh
lay can nang, chieu cao de' tinh BMI, ddng thdi xet nghiem glucose mau tinh mach liic ddi.
Ky thuat: Lay mau tinh mach liic ddi budi sang sau hon 8 gid khdng sir dung carbohydrate trudc dd, khoang 02 ml. Dinh luang Go bang may sinh hda Hitachi 911 Automatic Analyzer.
2.4. Phuang phap xu ly so lieu: Xir ly so lieu bang Exel 2003 CBCNV huu trudc tudi tai HDGDYK TP. Da Nang, chung tdi nhan thay nhu sau:
Bang 1. Tudi trung binh ciia nhdm nghien cuu Tudi
Gidi
TB + SD n % P
Nam 52,04 ±3,21 364 50,42
NO 48,3 ±3,57 358 49,58 > 0,05
Nhan xet: Ty le nam la 50,42 va nu la 49,58 gan nhu tuang duang (p>0,05).
Do tudi trung binh nam la 52,04 ± 3,21 cao hon nu 48,35 ± 3,57.
Bang 2. Nhdm tudi va gidi tinh Nhom tudi
Gidi
<50 >50
n % n %
Nam 165 45,33 199 54,67
NO 225 62,85 133 37,15
P < 0,01 <0,05
Nhan xet:
- C5 do tudi < 50: nu (62,85%) chiem uu the so vdi nam (45,33%), p<0,01 - G1 do tudi > 50: nam (54,67%) chiem uu the so vdi nu (37,15%), p<0,05.
Bang 3. Tin suat RLGMLD va DTD d nhdm nghien ciiu
Go OTO RLGMLD Binh thudng
n 74 136 512
% 10,25 18,84 70,91
P < 0,01
Nhan xet: Ty le DTD la 10,25%; RLGMLD la 18,84%, binh thudng la 70,91%
Bang 4. RLGMLD va DTD theo nhom tuoi Go
Nhom tudi —
DTD RLGMLD
n % n %
< 50(390) 38 9 74 74 18,97
> 50 (332) 36 10,84 62 18,67
P > 0,05 > 0,05
Nhgn xet:
- DTD d nhom tudi < 50 (9,74%) thap hem so vdi nhdm > 50 (10,84%), (p>0,05).
- RLGMLD hau nhu tuong duong giua 2 nhdm tudi.
Bang 5. Ty le DTD va RLGMLD theo gidi tinh Go
Gidi
OTD RLGMLD
n % n %
Nam (364) 53 14,56 79 21,70
NS(358) 21 5,87 57 15,92
P > 0,05 > 0,05
Nhgn xet:
- DTD d nam chie'm 14,56% cao hon so vdi nu 5,87%
- RLGMLD d nam chiem 21,70% cao hon so vdi nu: 15,92%.
Tuy nhien, dieu nay khdng cd y nghia thd'ng ke (p>0,05).
Bang 6. Ty le DTD va RLGMLD theo BMI tren nhdm benh ly
Chi so'khdi cd the (BMI) RLGMLD DTD
n % n %
< 23 46 33,82 38 51,35
>23 90 66,18 36 48,65
P < 0,01 > 0,05
Nhgn xet:
- Nhdm DTD: BMI > 23 chiem 48,65%; BMI < 23 chiem 51,35% (p>0,05)
- Nhdm tien DTD (RLGMLD): BMI > 23 chie'm 66,18%; BMI < 23 chiem 33,82%
(p<0,01)
Bang 7. DTD va RLGMLD phat hien mdi
Phat hien OTO RLGMLD Tong
n % n % n %
Da 23 31,08 0 0 23 10,95
M6i 51 68,92 136 100 187 89,05
P < 0,01
Nhgn xet: DTD: 31,08% phat hien trudc do, 68,92% mdi duoc phat hien qua xet nghiem Go luc ddi. RLGMLD: phat hien mdi 100%.
IV. BAN LUAN
1. Dac diem mau nghien curu
Mau nghien cuu cua chung tdi cd ty le nam/ nu tuong duong (Bang 1). Tuy nhien, dp tuoi trung binh d nam cao hon nu 04 tuoi.
Dieu nay gan lien vdi mdt so quy dinh ciia BHXH Viet Nam ve tieu chuan huu trudc tuoi (thdng thudng nam phai tu 50 trd len, nu tir 45 trd len; ngoai trir mdt so nganh nghe dac biet khdng cd quy dinh ve dp tuoi va nhdm nay thudng chiem ty le kha it).
Tren co so dd, ket qua thu duoc tai bang 2 cho thay nu gidi chiem uu the d nhdm tudi
< 50, con nam gidi lai chie'm uu the d nhdm tudi > 50 mdt each cd y nghia thd'ng ke (p<0,05). Van de nay se cd anh hudng den mot so ket qua nghien ciiu ciia chiing tdi dang tien hanh, ma cac phan sau se dupe ban luan sau hon.
2. Tan suat RLGMLD va DTD a nhdm nghien ciiru
Ket qua ciia chiing tdi tai bang 3 cho thay ty le DTD cung nhu RLGMLD cao hon d mot so nghien ciiu trudc day nhu: DTD tai Ha Ndi (2001) 2,42%, TP. Hd Chi Minh (2001) 3,7%, cac thanh phd chung trong ca nude (2006) 4,4% va DYYD Hue (2008) 6,57%.
Didu nay chiing tdi cd the ly giai nhu sau: cac nghien ciiu trudc day, ngudi ta thudng chpn mau dan trai deu kMp cac dp tudi, con mdu nghien ciiu cua chiing tdi la ty le DTD kha cao. Hon nua, hien nay DTD cd xu hudng cang ngay cang gia tang, nhat la nhdm dan thanh phd d cac nude dang phat trien.
Tuy nhien, theo Le Quang Minh (BVDK Bac Kan) nghien ciru cho thay ty 16 DTD d dp tudi 30 - 64 sau khi da lam nghiem phap tang dudng mau cung d mire 10,1% trong khi dd qua ket qua Go ciia chiing tdi, DTD chiem 10,25%. Vi the, ket qua ciia chiing tdi cd the chap nhan dupe.
Ddi vdi nhdm RLGMLD, chiing tdi chpn tieu chuan cha'n doan ADA 2005 la 5,6 mmol/l < Go < 7,0 mmol/l. Nhu vay, ket qua RLGMLD se tang hon so vdi cac ket qua nghien ciiu ap dung cac tieu chuan cu, hon nira mlu nghien ciiu chiing tdi tap trung d dp tudi 45 - 59, do vay ket qua chiing tdi 18,84%
trong khi dd tai Hue' chang han (2008) 7,58%... la dieu kha hpp ly.
Nhung khi ddi chie'u vdi mot vai ket qua nude ngoai nhu tai My cd den 16% dan so bi RLGMLD cao hon nghien ciiu chiing tdi.
Didu nay cd thd do su khac biet vd didu kien
kinh te xa hpi, muc song, tap quan an udng, sinh hoat...
3. RLGMLD va DTD theo nhom tudi Da phan cac nghien cuu trudc day deu cho thay DTD va RLGMLD tang dan theo tudi, nhu theo Le Van Chi va cs (2008) DTD, RLGMLD cao nhat 6 nhom tudi tren 60 (lan lupt la 2,52% va 4,3%) hay Nguyen Huy Cudng va cs (Ha Ndi, 2001), cho thay DTD nhdm tudi 15-39 chi 0,34%, nhung nhdm tren 65 lai den 5,68%...
Ket qua chiing tdi d dp tudi > 50, DTD cd cao hon nhdm dudi 50 (nhung p>0,05);
cdn RLGMLD gan nhu khdng cd sir chenh lech dang ke. Dieu nay do dac thu cua mau nghien ciiu tap trung d dp tudi 45-59. Hon nira, sir phan nhdm ve tudi ciia chung tdi d day la kha hep so vdi cac cdng trinh ciia cac tac gia khac. Vi vay, khi cd thd thay dupe sir khac biet mdt each rd rang giua cac nhdm tudi. Do dd, ty le DTD va RLGMLD d cac nhdm tudi tren va dudi 50 nhu tren theo chung tdi cd the tin cay dupe.
4. Ty le DTD va RLGMLD theo gidi tinh
Theo mot so cdng trinh nghien cuu trudc day, ty le DTD d nu thudng cao hon nam nhu Le Van Chi (DHYD Hue) ghi nhan nir 4,8%, nam 1,77%, Tran Huu Dang (BVTW Hue):
nu 0,64%, nam 0,32%, Nguyen Huy Cudng:
nu 3,37%, nam 1,4%, Roland F va Leonard T (Canada 2003), cung da cho so lieu DTD d nu la 4,5%, nam la 1,4%.
Nhung qua Bang 5 chiing ta thay nam cd ty le DTD cung nhu RLGMLD cao hon ntr (p>0,05). Ket qua chiing tdi cd su khac biet so vdi cac nghien cuu tren.
Nhu chiing tdi da neu tai phan dac didm mdu nghien ciiu cho thay nir gidi chiem uu
the d nhdm tudi thap < 50, con nam gidi lai chiem uu the d nhdm tudi cao > 50 (p<0,05).
Dp tudi trung binh ciia nam trong mlu nghien cuu nay la 52,04 ± 3,21 cao hon d nu la 48,35 ± 3,57. Hon nua, DTD v-a RLGMLD cang tang khi tudi cang cao. Didu nay phan nao cd the ly giai duoc ket qua nghien ciiu chung tdi, nhdm nam gidi se cd ty le DTD ciing nhu RLGMLD cao hon han nu gidi, song ket luan nay van it cd y nghTa thd'ng ke vi p>0,05.
5. Ty le DTD va RLGMLD theo BMI tren nhdm benh ly
BMI dupe xem nhu la mdt yeu to nguy co quan trong ciia DTD, nhat la DTD the 2.
Van de nay hien nay dang ndi trdi va mang tinh toan cau, dac biet cd xu hudng tre hda.
Tuy vay, qua nghien ciiu ciia chung tdi, BMI chua cd y nghTa khac biet giua hai nhdm ddi vdi DTD, ghi nhan nay cung tuong tir nhu mdt so bao cao trong va ngoai nude de cap den.
Song, khi xet den RLGMLD, chiing tdi nhan thay cd sir chenh lech dang ke giua hai nhdm BMI cao va binh thudng (p<0,01). Vdi 2/3 CBCNV cd RLGMLD bi thira can va beo phi, dieu nay gian tiep lam tang ty le DTD ciing nhu RLGMLD.
6. DTD va RLGMLD phat hien mdi Trong so cac ddi tupng dupe phat hien DTD qua nghien ciru ciia chiing tdi cd den hon 2/3 (68,92%) hoan toan khdng biet minh bi benh nay. Dieu nay kha phii hpp vdi nhieu nhan xet trudc day la DTD tien trien man, trieu chiing khdng rd rang, thudng dupe phat hien mdt each tinh cd.
Khdng rieng gi d nude ta, nam 2006, Rachel M thd'ng ke tai My mdi nam chi cd khoang 1,5 trieu ngudi dupe chan doan DTD,
song lai co den 6 trieu nguoi mac benh nay ma khong hay biet va ong cho rang con so thong ke duoc chi la "mat n6i ciia mot tang bang chim".
Ket qua ciia chiing toi ciing kha tuong dong voi thdng ke nam 2006 cua tac gia Ta Van Binh la so benh nhan chua duoc phat hien DTD la 64,9%.
Dieu nay thuc su dang lo ngai trong viec tam soat DTD khi chua co bieu hien trieu chung va can duoc cac nha chuyen mon, xa hpi quan tam dung mUc.
Ben canh do, 100% CBCNV co RLGMLD ciing khong biet minh bi rdi loan dudng mau. Neu nhu duoc phat hien sdm tai giai doan nay thi rat quan trong (nhu chiing tdi da de cap vd tien DTD d tren). Bdi vi cd den 25% RLGMLD se chyen sang DTD trong vong 5 nam tiep theo.
Trong khi dd, xet nghiem Go kha it ton kem, dd thuc hien nhung la mdt phuong phap phat hien sdm DTD va RLGMLD. Do vay, tir nghien ciiru nay gpi y giup cho chiing tdi neu len mdt sd kien nghi hpp ly, thiet thuc va rat kinh te cho viec tam soat benh ly nay, de tir dd dua ra tu van ve each phong ngira, che dp an udng, tap luyen, theo ddi sau nay... d nhung ddi tupng tren.
Vdi tam nhin xa hon, trong nhung dot kham sue khoe dinh ky cho CBCNV dang cdn trong dp tudi lao ddng, can chii trong tam soat dudng mau liic ddi dd phat hien sdm DTD, RLGMLD bdi xu the tre hda ciia benh ly nay cang ngay cang gia tang.
V . KET LUAN
Qua nghien ciin 722 trudng hpp CBCNV huu trudc tudi tai Hdi ddng GDYK TP. Da Nang nam 2008 - 2009 chiing tdi nhan thay:
1. Tyle DTD la 10,25%.
2. Ty le rdi loan glucose mau liic ddi la 18,84%.
3. Tang trong va beo phi cd lien quan vdi tien dai thao dudng (RLGMLD).
vi. KIE'N NGH!
1. Xet nghiem Go cho tat ca cac CBCNV huu trudc tudi, neu cd bat thudng thi xet nghiem lan 2 de chain doan xac dinh DTD va tu van didu tri.
2. Xet nghiem Go khi kham sue khoe dinh ky nham phat hien sdm tidn DTD hoac DTD trudc khi benh the hien tren lam sang.
TAI LIEU THAM KHAO
1. Bai giang Benh hoc npi khoa (tap 2) Trudng DHYD Hue 2007.
2. Le Van Chi, Bui Thi Thuy Nga. Tan suat hien mac dai thao dudng va rP'i loan glucosse mau ddi a ngudi Idn tren 15 tudi tai 7 phudng ciia TP. Hue.
3. Ta Van Binh (2006). Djch te hoc dai thao dudng d Viet Nam, cac phuong phap dieu tri va du phong, NXB Y hpc, Ha Npi
4. Le Van Bang. Tien dai thao dudng 2008 5. Le Quang Minh. Pham Thi Hong Van,
Nguyen Minh Tuan. Phat hien rdi loan glucosse mau va dai thao dudng typ 2 tai tinh Bac Kan.
6. Dang Van Giap (2007). Phan tich da lieu khoa hpc bang chuang trinh MS-EXCEL.
7. Dinh Thanh Hue (2002). Phuang phap dich te hoc.
