TCNCYH 68 (3) - 2010
abscess. Data regarding: age, sex, ethnicity, number of patients per year, seasonality, prior history of tonsillar infection, prior antibiotic treatment, length of hospitalization, surgical treatment, bacterial results and in hospital antibiotic treatment was collected the patients. Results: 34.78% of the patients were from 1 5 - 3 0 years of age. 66.67 % have a general infection. 69.56 % of the patients have complication.
95.65% have surgerieal treatments. The bacterial culture was negative in 2 (8.7%) patients. In 23 patients we have 14 typs of bacterias, 6 typs were positive for anaerobes. 96.1 5% of the patients were treated with Ampeillin/ Sulbactam. Conclusion: Peritonsillar abscess, a potentially life threatening infection, is in every ages, has many complications and need to do surgery. Based on our review we conclude that peritonsillar abscess in can be effectively treated byAmpeillin/Sulbactam.
Keywords: paratonsillar abscess, high dose antibiotics
DANH GIA MAT DO XUONG, T I N H TRANG LOANG X U O N G
VA M O T SO Y E U TO ANH H U 6 N G 6 BENH NHAN SUY THAN M/\N TL/ 50 TUOI T R 6 LEN
N g u y i n M i n h T h u y \ D6 Thj Khanh H y ^ Pham Thang' 'Benh vien E Trung dang, '^Trddng dai hoe Y Ha Noi; ^Benh vien Lao khoa Trung dang
Ciing vdi sd tien tnen cua suy than man, nhdng rdi loan ve chuyen hda chat khodng cung se xay ra ddn den cdc rdi loan vd chu chuyen xddng, lam giam mat do xddng. Muc tieu: (1) Md ta ty le giam mat do xdang va loang xddng d benh nhan suy than man giai doan 4 vd 5 td 50 tudi trd len. (2) Xdc dinh mdt sd yeu to anh hddng de'n mat do xdang d nhdm benh nhan nay. Ddi tUgng va phuang phap nghien cdu: 66 benh nhdn suy than man td 50 tudi trd len ddac do mat do xddng theo phdang phdp hap thu tia X nang Idang kep d hai vi td cd xdang dui va cot sd'ng thdt Idng. Ke't qud: ty le gidm mat do xdang, lodng xdang theo vi tn:
45,5%; 28,8% tai cd xdang dui; 34,8%; 36,4% tai cot sdng that Idng. Ndng do PTH huyet thanh cd mdi lien quan nghich vdi mat do xdang tai ca hai vi tn. Ndng do calci ion hda cd mdi lien quan thuan vdi MDX tai cd xddng dui. Benh nhan nd cd ty le lodng xddng cao han so vdi benh nhdn nam. Cd mdi tdang quan thudn gida mdc loc cau than vdi mat do xdang d ca hai vi td. Ke't luan: giam mdt do xddng thddng gap d benh nhan suy than man. Nhdng benh nhdn cd mdc loc cau than cdng giam, ndng do PTH > 20U/L vd ndng do calci ion hda tha'p cd mat do xdang thap han so vdi benh nhdn cd ndng do PTH < 19,9 U/L, nong do calci ion hda binh thddng.
Tii khoa: suy than man, mat dp xUdng, loang xUdng
I. D A T V A N D E ra cddng can giap thd phdt va eae benh ly v l Khi than bj suy man tinh, td ehdc nhu md than xddng. Ta't ea nhdng rdi loan nay ed the dan den bj xd hda d i n , mde lpc e l u than giam sdt, than tde dp huy xUOng manh hdn tao xddng va k i t qua khdng edn du k h i nang duy tri can b i n g chuyen la gay nen tinh trang thda xUdng, loang xddng va hda calci va phospho trong huye't thanh d i n den tang nguy cd gay xUdng d nhdng benh nhan STM hang loat cde bien logn x l y ra ma hau q u i la gay [9]. Nghien edu eua Rix M va cpng sd eho tha'y
TCNCYH 68 (3) - 2010
ty le loang xUdng d benh nhan STM d i l u trj b i o tdn la 3 0 % [7]. N h i m gdp phan vao sd hieu biet, phdt hien sdm va phdng loang xddng, tranh bien chdng gay xdOng d benh nhdn suy than man, ehung tdi tien hanh nghien edu vdi muc tieu:
/ . Md ta ty le giam mat do xuang va loang xUang d benh nhan suy than man giai doan 4 va 5 td 50 tudi trd len.
2. Xac dinh mgt so' ye'u to' anh hudng den tinh trang mat do xUang d nhdm benh nhan nay.
II. DOI TUONG vA PHUONG
PHAPNGHIEN CUU
1. Doi tuong nghien cu'u
66 benh nhan td 50 tudi trd len, bj suy than man giai doan 4 vd 5 chUa ddde d i l u trj thay the than suy, dieu trj npi tru tai Vien Lao khoa Qudc gia va khoa Than - T i l t nieu Benh vien Bach Mai.
- Chan dodn suy than dda vao tinh mde Ipe eau than (MLCT) theo dp thai saeh creatinin npi sinh.
dp, dai thao dudng...);
-I- Lam sang: cd eac trieu chdng eua hpi chdng ure mau cao;
-I- Xet nghiem sd lUpng hdng c l u g i i m , thieu mau tddng dddng mde dp suy than.
+ Sieu am than: tuy nguyen nhan gay ra suy than man, ed the tha'y tang hoac giam kieh thdde than;
2. Phuong phap nghien cufu: md ta e l t ngang - Kham benh nhan: do chieu eao, can nang, dien tich da theo bang Dubois. Phdt hien ede trieu chdng ed nang va thirc the eua hdi chdng ure mau eao.
- Xet nghiem te bao mau ngoai vi: sd Iddng hdng eau, Iddng huyet sle td. *
- Sinh hda mau: creatinin, calci toan phan, calci ion hod, phospho mau, PTH.
- Nddc tieu: lay nddc tieu 24 gid, xet nghiem ure, creatinin, protein nieu 24h.
- Sieu am he than - tiet nieu
- Chan dodn tinh chat man tinh:
4- T i l n sd: ed tien sd benh than tiet nieu hoac ede benh lien quan tdi than tiet nieu (tang huyet
III. KETQuA
1 . Ty If benh nhan suy than man bi giam mat dg xUOng, loang xUOng
- Do mat dp xddng (MDX) bang hap thu tia X nang Iddng kep, tai cpt sdng t h i t ldng (CSTL) va ed xddng dui (CXD). G i l i n M D X : -1 > T- score
> -2,5; loang xddng: T- secre < - 2,5.
50 45 40 35 30 25 20 15 10 5 0 -[
D Ty le
Giam MDX CXD Loang xu-cng CXD Giam MDX CSTL Loang xu-cng CSTL
Bieu do 1. Ty le giam mat do xUang, loang xUang
Ty le giaiv mat do xdang, loang xdang d CXD Id 45,5% vd 28,8%; d CSTL Id 34,8%o vd 36,4%.
TCNCYH 68 (3)-2010
2. Mpt sd yeu to anh hudng de'n mat do xUOng 2.1. Mdi lien quan gida gidi va ty le loang xUang
Ty le loang xiFcng theo gid'i
50
Loang xtFcyng CXD Loang xifong CSTL
Bieu do 2. Ty le loang xUang theo gidi
Ty le loang xdang CXD, CSTL benh nhan nd (43,8%; 50%) cao han benh nhan nam (14,7%,; 23,5%o)
vdi p< 0,05. ' 2.2. Lien quan gida PTH, calci ion hda, phospho mau va mat do xUoing
Bang 1. Lien quan mat do xUang vdi PTH, calci ion hda, phospho huye't tuang
Veu to lien quan M D X CXD (g/cm^) M D X CSTL (g/cm^)
PTH (U/L)
<19,9
> 2 0 Tdng
<1,0
> 1,0 Tdng
<1,5
>1,5
25 41 66 35 31 66 24 42
0,79 ±0,13 0,66 ±0,11
p < 0 , 0 1 0,67 ±0,1 5 0,79 ±0,11
p<0,05 0,73 ±0,17 0,69 ±0,11
0,88 ±0,11 0,76 ±0,18
p < 0 , 0 1 0,79 ±0,14 0,85 ±0,21 p > 0,05 0,85 ±0,18
0,78 ±0,16 Calci ion hda
(mmol/L)
Phospho (mmol/L)
Tdng 66 p > 0,05 p > 0,05
Nhan xet:
- Gia tri trung binh cua MDX CXD, CSTL thap ban d nhdm cd ndng do PTH cao han. Sd khac biet nay cd y ngbla thd'ng ke vdi p < 0,01.
- MDX CXD cua nhdm cd nong do calci ion hda < 1,0 mmol/l thap han MDX cua nhdm cd ndng do calci ion hda > 1,0 mmol/l mot each cd y nghTa thdng ke vdi p < 0,05.
- Khdng cd sif khac biet ve mat do xdang a hai vi tn gida cdc mdc ciia phospho mau . 2.3. He so tuang quan gida MDX va mdc Igc ciu than
Bang 2. He sd tuang quan gida MDX va mdc Igc cau than Vj tri do mat do xUdng
CXD (g/em') CSTL (g/em')
H f sd tUdng quan vdi miifc loc cau than 0,443
0,244
P
< 0 , 0 1
< 0 , 0 5
Cd mdi tdang quan thudn gida MLCT va MDX tai CXD vdi r = 0,443; p < 0,01; tai CSTL vdi r = 0,224; p< 0,05.
IV. BAN LUAN
1. Ty le benh nhan suy than man bj giam mat dp xUOng, loang xUOng
, Ty le loang xddng tai CXD vd CSTL d benh nhan suy than man l l n Iddt la 28,8% va 36,4%.
T'y le giam MDX tai CXD va CSTL l l n Iddt la 45,5% va 34,8%. Ty le lodng xddng eua ehung tdi cao hon so vdi n h i l u nghien edu eua ede tde gid tren the gidi. Nghien cdu cua Rix M va cdng sd (Dan Maeh - 1999) nghien edu tren 113 benh nhan STM d i l u trj b i o tdn td 18 tudi trd len, bao gdm c l td suy than giai doan nhe. Ke't q u i eho tha'y ty le loang xddng la 19 - 2 6 % [7]. Stavrou- lopoulos A vd cdng sd (2008) nghien edu tren 89 benh nhan STM giai doan 3 va 4, tudi td 26 - 65 tudi. Ket q u i eho tha'y ty le benh nhan ed loang xddng va g i i m MDX tai vj tri ed xddng dui la 3 7 %
[8]. Dieu dd chdng td sd md't xddng dd tudi eung ddng gdp vai trd quan trpng dd'i vdi sd mat xddng d benh nhan suy than man.
Mdt sd tde g i i eho rang sd ma't xddng d nhdng benh nhan STM la sd ket hdp sd ma't xddng dd tudi, ma't xddng sau man kinh va do loan dddng xddng [91. Td 50 tudi trd len qua trinh huy xddng dien ra manh hdn qua trinh tad xUong d i n den sd g i i m d i n khd'i Iddng xddng eung vdi thdi gian va khi da cd suy than thi mat xddng dien ra eang nhanh hon.
2. Mot sd yeu td anh huoing den mat dp xUdng
2. / . Md'i lien quan gida gidi va loang xUang
Giam ndng dp estrdgen vao giai doan man kinh dan den giam hap thu calci, gia tang hoat ddng buy xddng va td dd dan den sd mat xdong [4]. Ket qua nghien edu eho thdy ty le loang xddng tai hai vj tri CXD va CSTL cua benh nhan nd l l n Iddt la 4 3 , 8 % vd 50,0%. 6 benh nhdn nam ty le loang xddng tddng dng tai hai vj tri la 14,7%
va 23,5%. Ty le loang xddng eua benh nhan nd gidi eao hdn t'y le lodng xddng eua benh nhan nam, sd khde biet nay ed y nghTa thdng ke vdi p <
0,05. Ket qua nay phd hdp vdi ket q u i nghien cdu eua Luisetto G va cpng sd eho r i n g MDX d benh nhan nd giam hdn so vdi nhdm nam mdt cdch eo y nghTa thd'ng ke tai e l hai vi trf CSTL va CXD [6|.
2.2. Lien quan gida PTH, calci ion boa, phospho mau va mat do xuang
- Khi suy than eang nang thi ndng dp PTH mau eang tang [1]. Trong ket q u i nghien edu eua chdng tdi, khi xem xet md'i lien quan gida ndng dp PTH va MDX, chdng tdi phan chia ndng do PTH ra lam hai mde < 19,9 pinol/L (mde ed ndng dp PTH tang gap khoang 3 l l n gia tri binh thddng eao, la mde ma nhieu tac g i i eho la v i n gid anh hudng ed ldi ddi vdi xddng) va mde PTH
> 20,0 pmol/L. Ke't qua nghien edu chd tha'y PTH eang tang thi MDX tai ea hai vi tri eang giam. Sd khac biet nay ed y nghTa thdng ke vdi p < 0,01.
Nghien edu nay phd hdp vdi mpt sd nghien edu
TCNCYH 68 (3)-2010
da ddde edng b d d tren the gidi [5]. Trong dieu kien sinh ly binh thddng PTH la yeu td quan trpng de duy tri tai thie't xddng binh thddng. 6 nhdng benh nhan STM, sd bdi tiet qua mde PTH lam tang qud trinh trinh buy xddng, ddng thdi PTH eung kich thieh tang sinh tao cdt bao [2). Tuy nhien t r i i qua mdt qud trinh lau dai, qua trinh hCiy xddng vd tao xddng khong ddde can bang den mdc sd mat mat d i n d i n khdi Iddng xddng da gay ra thda xddng.
- Ke't qua nghien edu eho tha'y MDX CXD, CSTL eua nhdm cd ndng dd calci ien < 1,0 inmnl/L tha'p hdn eua nhdm ed ndng dd calci > 1,0 mmol/L. Tuy nhien sd khac biet ve MDX gida hai nhdm ehi ed y nghia thdng ke tai vj tri CXD vdi p < 0,05. G i i m ndng dp calci trong mdu kieh thieh gidn tiep hoat dpng eua eac te bao huy xUdng thdng qua kieh thieh sd bai t i l t PTH. Taal M W va edng sd (1999) nghien edu tren nhdng benh nhan d i l u tri bang lpc mdu nhan thay cd mdi lien quan thuan gida viec bd xung calci vdi tang trj s d m a t d d xdong [9].
- Ndng dp phospho huyet tddng: Ket qua nghien edu chd tha'y MDX CXD, CSTL khdng lien quan vdi ndng dp phospho mau (p > 0,05). Ket qua eua ehung tdi phu hdp vdi mpt sd tac g i i khde: Huang G - S va cpng sd Dai Loan (2009) eho r i n g ndng dp phospho mau khdng I n h hddng den MDX d nhdng benh nhan STM lpc mau [3].
Khi than bj suy man tinh kha nang dao t h i i phos- pho cua than bj g i i m va xua't hien tang phospho mdu 18]. Su tang phospho mau t i e dpng trdc tie'p hoac gidn tiep len sd tang tiet PTH ma td dd I n h hddng den mat dp xddng.
2.3. Md'i tuang quan gida mat do xUang va mdc Igc cau than
Cd mdi tddng quan thuan gida MLCT va MDX tai CXD vdi r = 0,443; p < 0 , 0 1 , tai CSTL vdi r = 0,224; p < 0,05. Suy than edng nang thi MLCT eang g i i m . Chuyen hda ve xddng thay ddi khdng ngdng qua eac giai doan eua STM [8]. STM gay ra
nhdng bien loan v l chuyen hda nhd chuyen hda calci - phospho, ba't thddng ve hang djnh hormon vitamin D - PTH. NhQ'ng bie'n loan nay ed the x l y ra td giai doan sdm va nang d i n len theo sd g i i m MLCT. Ket q u i nghien edu cua chung tdi phu hdp vdi k i t luan eua Ha Sung - Kyu eung eho r i n g cd mdi tddng quan thuan gida mat dp xddng tai hai vj tri ed xddng dui va xddng cpt sdng vdi MLCT.
V. KET LUAN
Ty le g j l i n mat dp xddng, loang xddng d benh nhan suy than man giai doan 4 va 5 td 50 tudi trd len: 4 5 , 5 % ; 2 8 , 8 % tai CXD, 34,8%;
36,4% tai CSTL.
Cae yeu td lien quan den mat dp xddng:
- Benh nhan nd suy than man ed nguy ed Idang xddng eao hon benh nhan nam suy than man.
- Nhdng benh nhan ed ndng dp PTH eao hdn ed mat dd xddng tha'p hdn.Ngdde lai nhdng benh nhan ed ndng dp calci ion hda tha'p hdn thi mat dd xddng tai vj tri cd xddng dui eung tha'p hdn.
- Cd mdi tddng quan thuan gida mat dp xddng va mde Ice e l u than.
T A I LIEU THAM K H A O
1. Ha Sung - Kyu, Park Chong - Hoon, Seo Jung - Kun, Park Seung - Ho, Kang Shin - Wook, Choi Kyu - Hun, Lee Ho - Vung, Han Dae - Suk (1996)
"studies on bone markers and bone mineral den- sity in patients with chrcnic renal failure", Yonsei Medical Journal, Vol. 37(5), pp. 350 - 356.
2. Hruska KA, Saab G, Chaudharr LR, et al (2004), "Kidney - bone, bone - kidney, and cell - cell communications in renal osteodystrophy", Semin Nephrol 24: pp. 25 - 38.
3. Huang Guey - Shin, Chu Tzong - Shinn, Lou Meei - Fang, Hwang Shiow - Li, Yang Rong - Sen (2009), " Factors associated with low bone mass in the hemodialysis patients - a erross - sectional
correlation study", BMC Musculoskeletal Disor- ders, 10(60).
4. Lindberg JS, Moe SM (1999), "Osteoporosis in end - stage renal disease", Semin Nephrol 19:
115 - 122.
5. Lobao R, Carvalho AB, Cuppari L, Ventura R, Lazaretti - Castro M , Jorgetti V, Vieira JG, Cendoroglo M, Draibe SA (2004), "High prevalence of low turndver bone mineral density in pre - dialysis chronic kidney disease patients:
Bone histomorphometrie analysis", Clin nephrol 6 2 : 4 3 2 - 9 .
6. Luisetto G, Bertoli M (1994), "Sexual influence on bone metabolism in uremic patients on regular dialytie treatment", Nephrol 67: 150 - 1 5 7 .
7. Rix M, Andreassen H, Eskildsen P, Langdahl B, Olgaard K (1999), " Bone mineral density and biochemical markers of bone turnover in patients with predialysis chronic renal failure". Kidney International, Vol. 56(3), pp. 1084 - 1093.
8. Stavroulopoulos A, Porter CJ, Roe SD, Hosking DJ, Cassidy JD (2008), "Relationship between vitamin D status, parathyroid hormone levels and bone mineral density in patients with chronic kidney disease stages 3 and 4", Nephrology 1 3:63 - 67.
9. Taal M W , Masud T, Grren D, Cassidy MJ (1999), " Risk factors for reduced bone density in haemodialysis patients", Nephrol Dial Transplant 1 4 : 1 9 2 2 - 8 .
Summary
EVALUATION ON BONE IVIASS DENSITY, OSTEOPOROSIS AND RISK FACTORS IN PATIENTS WITH CHRONIC RENAL FAILURE
With progression of chronic renal failure, disorder of mineral metabolism appear, as a result of this, serum calcium decreases and parathyroid hormone (PTH) is stimulated, producing the forms of the turnover bone disease. All of these disfunctions decrease bone mineral density (BMD), which in turn leads to osteopenia, osteoporosis. Objectives: (1) To describe the decreased ratio in the bone mineral density, osteoporosis proportion in patients with chronic renal failure on state 4; 5 in over 50 years old. (2) To search some risk factors related to the bone mineral density. Methods: 66 patients from 50 years old were surveyed, examined and measured the bone mineral density using double - energy X - rays absorbing method. Results: decreased ratio in the bone mineral density, osteoporosis proportion : 45.5%, 28.8% at femoral neck, 34.8%; 36.4% at lumbar spine. Conclusion: Patients with chronic renal failure have decreased BMD values at both the spine and femur. Serum PTH had associaticn w i t h the femdral neek and lumbar spine BMD. Idnized calcium had association with the femoral neek B M D . Women had a significantly higher osteoporosis proportion than men. And the other hand, MLCT had correlation with femoral neek and lumbar spine B M D .
Keywords: ehoronic renal failure, bone mineral density, steoporosis