TRAM CAM a BENH NHAN DAI THAO DUDNG
TRAN TH! HA AN
Vign sue khoe tam than, BVBgch Mai
Cung vdi su phat trien cda xd hgi, bgnh ly dai thao dudng vd tram cam cdng ngdy cang gia tdng va gdy ra ganh ngng Idn cho cd nhdn, gia dinh vd cgng ddng. Tuy nhidn, khi tram cam xuat hign d bdnh nhdn ddi thao dudng thi hgu qua khdng chi thuan tuy la tdng hgp bieu hign cda hai bgnh 1^ ndy md ca trim cam vd ddi thao dudng deu trd nen tram trgng them. Han nua,'du tram cam Id ngng hay nhg thi nd cung Idm cho ty Ig tu yong d bgnh nhdn ddi thdo dudng tdng Idn rdt nhieu.
Dgi cirang
Ddi thdo du'dng (DTD) Id tinh trgng rdi logn chuyen hod gluxit gdy tang dudng huyet mgn tinh do thilu insulin tuang ddi hay tuygt ddi cua tuy d i n d i n suy giam hoge rdi logn chUc ndng cua nhieu ca quan.
DTD Id mdt bgnh xd hgi vdi xu hudng tang rd rgt trong nhung thgp ky gan ddy. Theo To chu-c y t l t h i gidi, sd ngudi mac DTD toan cau Id 132 trigu nam 1996, 175 trigu nam 2000, 240 trigu nam 2010 vd u'dc tinh se Id 330 trigu ndm 2025.
DTD gdy ra hdng logt cdc biln chUng bao gdm cdc biln chung chuyen hod cap tinh (hdn me do tang tham thau, nhiim toan ceton, nhiem toan axit lactic), cdc biln chung mgch mdu lan (tang huylt dp, suy vdnh, tai biln mgch mau nao...), cac bien chung vi mgch (biln chung vdng mgc, biln chUng thgn do DTD,...), biln chUng nhiem khudn vd cdc bien chung khde.
Tram cam (TC) thudng khdng dugc coi Id biln chung cua DTD nhung nhilu tac gia cho rdng, thuc t l , TC Id mgt trong cac biln chung phd biln va ngng ne nhdt cda DTD. Theo du" ligu cua Hgi Dai thdo dudng My, ty Ig mac TC d bgnh nhdn DTD cao gap 3 den 4 lan d quan the chung tuc la khoang 15-20% bgnh nhdn DTD cd bieu hign TC.
Bleu hign cua TC d bgnh nhdn DTD:
Bgnh nhdn (BN) DTD cd the ed bilu hign cda tram cam diln hinh hoge khdng dien hinh.
Cac trigu chung cua TC dien hinh:
- Khi sac tram: khi sac tram Id trigu chung dgc trung nhdt trong tram cam, xay ra d 90% bgnh nhdn. Ngudi bgnh thudng cd cam giac budn chdn, trdng trai, vd vgng, am dgm. Mgt sd BN thudng hay khde md khdng cd su tdc ddng dang ke ndo tU ben ngoai, trong khi dd mgt sd khac Igi md ta cam giac khdng the khde dugc.
Mat quan tam thich thu: Id trigu chung hau nhu ludn ludn xudt hign, ngudi bgnh thudng phdn nan ve cam gidc it thich thd, it vui ve trong cac hogt dgng md hg da tung ydu thich trudc dd.
- Giam hoge mit sinh lye, nang lugng: bilu hign bang trigu chung mau mdt mdi ngay ca sau mdt cd gang nhd, cdc cdng vide quen thugc hang ngdy cung tra ndn khd khdn, BN cam thay ca the suy kigt, khdng cd sue sdng.
Thay doi nhung hogt dgng ca thi: BN thudng vgn dgng chgm chgp, suy nghT khd khan, ndi nhd, nhjp chgm, keo ddi thdi gian giua cdc Idi ndi. Ngugc Igi, cd mdt sd ngudi Igi bilu hign bang mgt trgng thdi kich thich vdi dung ngdi khdng ydn, xoan vdn tay, gd tay lidn tgc xudng ban...Trong nhu-ng trudng hgp ngng ngudi bgnh cd the xudt hign trgng thai sirng sd, bdt dgng.
Nhung y nghT ty ti, ty buge tdi: BN tram thudng tu tl, giam tu trgng vd tu tin, bi quan vdi ( sdng, hg cho rang minh la ngudi thdt bgi, tu bug minh vi nhung Idi lam nhd cda ban thdn hay that bgi ngu'di khac vd cda ban than. Hgu qua cda nhu'ng y bi quan ndy Id 9 tudng vd hdnh vi tu sat vi BN cho i ehl cd cdi chit mdi Id each giai thoat duy nhat.
- Giam tgp tmng chu y: Nhilu ngudi bgnh than p khdng the suy nghT tdt nhu tru'dc, mau quen, kem trung chd y, d l bj dang tri. Hg thudng cam thdy khdn khi phai quylt djnh mgt vdn de gi ngay ca nh vigc nhd, kha ndng phdn doan, phdn tich, giai quylt hudng giam.
Thay doi khau vj: BN tram cam thudng cd cam khdng ngon midng d i n d i n chan dn vd sgt can.
nhien, cung cd mdt sd it trudng hgp, ngudi bgnh I;
nhieu dan d i n tdng cdn.
Roi logn giic ngd: Thudng ggp nhdt la mat i Trong tram cam cd the cd nhieu logi mat ngu nhu' ngd dau giac, giO'a giac hoge cudi gidc nhung mat cudi gidc thudng hay ggp nhat. BN thu-dng thuc sdm han thudng Ig khoang 1- 2gid.
Ngodi ra, BN cdn cd the cd cdc trigu chung khac giam hoge mdt khd ndng tinh dgc, tao bdn hoge n trigu chung cda rdi logn than kinh thuc vgt. Lo du c Id mgt bilu hign thudng di kem trong trim cam
Tram cam khong dien hinh:
Bdn cgnh bgnh canh Idm sdng diln hinh nhu ^ tram cam khdng diln hinh cd bilu hign la khi sac I vd thu-dng than phien ve cac trigu chung ca thd, d kich thich, hay cau gdt, giam giao tilp, dn nhilu, nhieu...
Mgt s6 bieu hign lim sing thudng ggp:
+ Giam vgn ddng mgt cdch rd rgt, xudt hign s ngudi bgnh nam nhieu mgt chd, khdng mudn tdp li t h i dgc, ngu nhieu han.
+ Khi sac giam
+ Bi quan, suy nghT tidu cue ve bgnh tdt, cho i bdnh cda minh khdng t h i chua dugc vd minh Id £ ngng cda gia dinh.
+ Ngdn ngu" giam: it keu than han so vdi thu'ang
+ De bj kich thich, khdng dn djnh.
+ Tinh cdch thay ddi
+ Tang cam gidc dau, trigu chung dau than kini phd biln va kdo ddi d ngudi mdc DT.
+ An ii, ddi khi Igi an nhieu, khdng tudn thd c h i d udng ddi vdi ngudi bgnh ddi thao dudng.
Nhung trigu chung nay rat de bj ngudi thdn vd t chi cd bdc sy bd qua vl cho rdng dd Id nhirng bilu tat y l u vd thudng ggp d BN ddi thao dudng.
Hgu qua cua TC gdy ra d* BN DTD
Ngoai hgu qua tieu cue v l tdm 1^ xd hdi cda than bgnh ly TC, d BN DTD, TC cdn anh hudng ngn d i n bgnh ly DTD do Idi sdng bdt thudng cda n bgnh. BN khdng cdn quan tdm tdi sue khoe cda i nhu trudc ndn khdng duy tri e h l dg dn nghiem i khdng tgp luygn hogt dgng t h i luc d i u ddn, cd nl
82 Y HOC THirC HANH (767) - s6 6ll
hdnh vi cd hgi chd sire khoe nhu hdt thudc, udng rugu bia vd ddc bidt khdng tudn thu chi djnh dilu trj cda thdy thudc. NhO-ng dieu ndy d i n din:
+ Gidm chat lugng cudc sdng: BN tang trdi nghigm budn chdn, suy gidm cdc chUc ndng cda ca t h i .
•I- Kdm kilm sodt dudng mdu: Do e h l dg dn udng, tdp luydn, dung thudc vd ca do BN khdng chd y d i n vigc kiem tra dudng mdu.
+ Tdng muc dd tram trgng vd kdo ddi cae trigu chUng cua bdnh DTD din d i n kdo ddi thdi gian ndm vign.
+ Tdng cdc biln chung cda DTD, dgc bigt cdc biln ehUng tim mgch.
+ Kdm hilu bilt v l bgnh 1;^ DTD
+ Tdng vide su- dgng vd gid thdnh cdc djch vg y t l . Oilu trj TC a BN DTD
Mdc du TC rdt thudng ggp vd gdy ra nhirng hdu qua nghidm trgng d BN DTD nhung ngu'di ta udc tinh chi ed khoang 1/3 sd BN DTD cd TC dugc phdt hign vd dugc dilu trj ca hai bdnh. Ca 2 phuang phap tri ligu bdng cdc thudc chdng trdm cdm vd trj ligu tdm ly d i u du'gc cho Id cd hidu qud trong dieu tq TC d BN DTD
Cdc thuoc chong tram dm:
1. Thudc chdng tram cam 3 vdng (amitriptyline, imipramine, nortriptyline, desipramine): Ngodi tdc dgng chong trdm cdm, giai lo du tot, chdng cdn cd higu qua trong vi$c gdy ngd, giam dau thdn kinh. Tuy nhidn, mdt sd tdc dgng phg cda nhdm thudc ndy nhu tdng cdn, tdng dudng mdu, khdng cholinergic (khd midng, tao bdn, nhin md...) vd Idm suy giam nhdn thUe khiln cdc thay thudc hgn ehl chi djnh chdng cho cdc BN DTD cd TC.
2. Cdc thudc Uc e h l tdi hap thu chgn lgc serotonin - SSRI (paroxetine, fluoxetine, sertraline): Cdc thudc nhdm ndy dugc coi Id lua chgn ddu tidn trong dieu tri trdm cdm vdi higu qua nhu nhdm 3 vdng nhu'ng it tdc dgng phg han trdn tim mgch vd khdng cholinergic, mdt sd thudc cdn giam cdn nhung chdng Igi ed the gdy giam chirc ndng tinh dgc, rdi logn tidu hod vd gdy hdn vd it hidu qua gidm dau thdn kinh.
3. Cdc thudc chdng trdm cdm mdi khde cd ca c h i tdc ddng kdp nhu Uc c h i tdi hap thu serotonin - norepinephrine - SNRI (duloxetine, venlafaxine), Uc c h i tdi hdp thu norepinephrine - dopamine NDRI (bupropion), cdc thudc chdng trdm cam tac ddng tren hg
norepinephrinergic vd dgc hidu trdn hg serotoninergie - NASSA (mirtazapine) hidn nay dang du'gc su dgng rdng rdi. Cung gidng nhu' nhdm SSRI, cdc thudc ndy an todn han so vdi cdc thudc nhdm 3 vdng trong dilu tn tram cam. Mgc du cdc nghidn cUu ve cdc nhdm thudc mdi nay cdn it nhu'ng chdng dugc chi djnh nhu- Id Iga chgn dau tidn trong dieu tri TC hoge khi BN khdng dap Ung vdi cdc thudc nhdm SSRI hoge nhdm 3 vdng.
Lf gu phap tim ly:
Lfu t h i cda cdc ligu phdp tdm ly Id khdng ed cae tdc dgng phg nhu cac thudc chdng tram cam nhu-ng ddi hdi su tham gia chu ddng cda BN vd vi t h i khdng t h i dp dgng cho tdt ca cdc BN. Ligu phap thudng dugc su dgng Id ligu phdp nhgn thue hdnh vi dugc nhgn thdy Id cd higu qua trong dilu tri TC d BN DTD.
TAI LI|U THAM K H A O
1. Ciechanowski PS, Katon WJ, Jusso JE (2003), "The relationship of depressive symptoms to symptom reporting, self - care and glucose control in diabetes ", Gen Hosp Psychiatry 25: 246 - 252.
2. Eaton WW (2002), "Epidemiologic evidence on the comorbidity of depression and diabetes", J Psychosom Res 53: 903 - 906.
3. Goldney RD, Phillips PJ, Fisher LJ, Wilson DH (2004), "Diabetes, depression and quality of life ", Diabetes Care 27:1066-1070.
4. Gonzalez JS, Safren SA, Cagliero E et al (2007),
"Depression, self - care and medication adherence in type 2 diabetes: relationships across the full range of symptom severity", Diabetes Care 30: 2222 - 2227.
5. Lustman PJ, Clouse RE (2002), "Treatment of depression in diabetes: impact on mood and medical outcome", J Psychosom Res 53: 917 - 924.
6. Lustman PJ, Griffith LS, Freedland KE (1997), "The course of major depression in diabetes ", Gen Hosp Psychiatry 17:160-166.
7. McKellar JD, Humphreys K, Piette JD (2004),
"Depression increases diabetes symptoms by complicating patients' self - care adherence ", Diabetes Educ 30: 485 - 492.
8. Rush WA. Whitebird RR, Rush MR, et al (2008),
"Depression in patients with diabetes: does it impact clinical goals?", J Am Board Fam Med 21(5): 392 - 397.
KHAO SAT TINH TINH SUTDUNG KHANG SINH TAI BENH VIEN DA KHOA THANH TRJ HA NOI
^$,
T6M TATKhio sit 250 b$nh in su dgng khing sinh (KS)
^0 frong diiu trj nii khoa tgi b$nh vl$n Da khoa huygn Thanh Tri td thing 01/2009 din thing 12/2009 cho thiy:
Mi B$nh nhin (BN) nam it han BN nu: 90% BN ty den m0 ^'^" ^^ ^^-^^ 6/V cd thi bio hiim y ti. Thdi gian diiu
trj tmng binh li 10,9 ±4,7 ngiy vi thdi gian su dgng KS tmng binh Ii9,1± 3,5 ngiy.
.|(jjl Bjnh nhiim khuin g$p nhiiu nhit li nhiim khuin Z ( * ^t ^°P, (^^-^ *^9 si lugt BN nhiim khuin vi 88.0%
, i | '''"ff so flW). 100.0% BN khdng dugc lim xit nghi$m vi U < khuin vi lim KS di. 68,0% BN khdng khai thic tiin sd fflh»i< * " *'*"'^ '^^ ^ " ^ 'f'"' "^^P '"'^'^ ^^-^^ tmdng hgp I i$ * ^ cA^dfn/? diing KS cd chin doin nhiim khuin.
^ Y HOC THVC H A N H (767) - S6 6/2011
NGUYEN VAN YEN vA CS.
SdYti Hi Ngi
Hai nhdm KS dugc su dgng rdng rai nhit li betalactam vi aminoglycosid
Tmng nhdm betalactam, t} Ig su dgng nhiiu nhit li phin nhdm cephalosporin thi hg HI (37.1%) vi betalactam + chat uc chi betalactamase (33.9%).
Phic do su dgng 1 KS chiim ty ig cao (66%).
Phic do su dgng 2 KS tra lin khdng nhiiu song mdt vii chi djnh cd syphoi hgp KS chua hgp lyf.
Td khda: khing sinh, b$nh vi^n Da khoa huyin Thanh Tn
SUMMARY:
SevemI msults have been found after surveying patient mcords using antibiotics for internal tmatment at
Thanh Tri hospital:
