Vietnam Journal of Physiology 16(3). 12/2012 ISSN: 1859 - 2376
activities, but many students still lacked Key words: fitness, biomedical specific knowledge so that they could not knowledge, physical education faculty student calculate simple anthropometric indices.
s y KHANG THU6C CCiA VI K H U A N T R ^ N V ^ T L O ^ T NHieiW TRUNG BAN CHAN CCiA BENH NHAN D A I T H A O DU'D'NG T ^ l B|NH VI$N CH(pr R A Y
Nguyin Th| Lf, Ld Quic Tuln, Nguyin PhOc Hfu Dgi hgc Y Dugc thinh phd H6 Chl Minh Nhdn bdi 16/10/2012; su'a bdi 24/10/2012; chip nhfn ddng 15/11/2012
Nghidn cuu ndy nhim mijc tidu xdc dinh die diim khdng thudc cOa vl khuin trdn vit loit nhiim trUng bin chdn d bdnh nhdn ddi thdo dudng diiu tri tgi binh vi$n Cha Riy tu 10/2010 din 06/2011. Ddi tugng nghidn cOv gdm 50 binh nhdn cd vit lodt nhiSm tnjng bdn chdn d binh nhdn ddi thdo dudng. Nghidn cOv theo phuang phdp tiin cOv dt ngang md td. Kit qua nghidn cOv cho thiy ty 1$ tsinh nhdn dS dugc dOng khdng sinh trudc khi ciy vi khuin trong nghidn cOit khS cao, chiim 82%. Lugng HbAlc tmng binh cOa nhdm nghidn c&u la 11,00 ± 3.79 %. Sd lugng tod/ vi khuin tmng blnh khi dy khuin bing que ciy IS 1,24 ± 0,43. tmng dd Gmm (-) chiim 56,55%, Gram(+) chiim 43,45%. Cdc chung vi khuin ngdy cdng trd ndn khang thudc, nhit IS Staphylococcus sp va E. coll Diiu ndy td do da sd bdnh nhSn kiim soSt dudng huyit kem, khong tudn thO <Tiiu Ui. Vdt loet bSn chdn thudng sdu vd da dugc dung khdng sinh trudc dd. Cdc vi khuin Gmm (-) chiim ty 1$ cao han cdc vi khuin Gram (+) trong cac vit lodt.
ry lg cdc Chung di khdng khdng sinh ngdy cdng tdng cao theo thdi gian.
Tip khoa: ddi thdo dudng, vit lodt nhiSm triing bdn chan do ddi thdo dudng I.OATVANO£
Tai Vift Nam, ty If mdi mic cua bfnh ddi Gram (-), ky khi, vd ddi khi cd ca nlm. Phi vl thdo dudng (DTD) ngdy cdng gia tdng, Ndm khuin cQng nhu sy d l khdng khdng sinh cua 2002 - 2003, dilu tra quic gia v l Unh hinh vi khuin trdn vit lodt nhllm tnJng ban chdn bfnh DTD vd ylu t i nguy ea dupc tiln hdnh ludn thay dii theo thdi gian.
trdn cd nude [1]. Kit qua ghi nhdn ty If mie 2. D 6 1 Tt/Q^NG VA PHUaNG PHAP bfnh DTD todn quic la 2,7%, trong dd vung NGHIEN CI>U
dd thi va khu cdng nghifp cd ly If mdc bfnh 2.1. D i i tuvng nghidn ciru
din 4,4%.Trong sd ede blln chOng mgn tinh Bfnh nhdn DTD ed nhiim toing vit loet cua DTD thi lodt bdn chdn Id biin ehOng bdn chdn tgi l^oa Nfi tilt, bfnh vifn Chp thudng gdp, phO-c tgp, gdy nhilu tin hgi v l Riy, nhdp vifn tO' 01/2010 din 06/2011. Bfnh kinh t l va tinh thin cho ngud'i bfnh [2], [4]. nhdn dupc lya chpn thda man ca hai dilu Khi khdng dupc xu trf kjp thdi, vit lodt bdn kifn: (1) Bfnh nhdn dupc chin dodn DTD Chan s§ dien tiln din nhiim IrOng, ddy Id eh? theo tidu chi cOa ADA 2010; (2) Cd vit lodt djnh hdng ddu cQa nhfp vifn trdn bfnh nhdn nhllm trOng d bdn ehdn. Bfnh nhdn Ipa trO DTD. Tdc nhdn gdy nhllm IrOng bdn chdn d khdi nghidn cOu Id nhOng ngud'i khdng du cdc bfnh nhdn DTD thudng Id hin hyp nhilu logi tidu chuin chpn bfnh dd ndu trdn hoac khdng vi khuin, bao gim cdc vl khuin Gram (+), ding y tham gia nghidn cOu.
Vietnam Journal of Physiology 16(3), 12/2012 ISSN: 1 8 5 9 - 2 3 7 6
2.2. Phvong phdp nghlSn ci>u
Thi6t kd nghiSn ci>u; phLPOng phdp cSt ngang mft ti,
- C& m§u: chOng t6i uitc lu-ong c& mSu nhlm xSc dinh s6 lifong lodl vl triing trung binh tren mOt v6t lo6t bdn chdn nhlSm trCing d b$nh nhdn BTD U6c tuong cCr miu theo cflng thi>c n = (z'xo')/(f'
Z = 1,96, d = 0,25 vdl khodng tin c$y 96%.
Theo nghidn cCru ciJa Armstrong [5] (JO ISch chuSn cua sd lodi vl trung trung blnh phdn ldp bdng choc hut kim Id 0,9, CO- m3u til thilu id n = 50
- Xii ly s6 ll$u: Cdc s6 li$u nghiSn ci>u du-oc nhdp vd xO IJ bSng phdn mim Stata 10 0.
3. K£T QUA NGHI£N ci>u vA BAN LUAN Kit qud nghidn ci>u Sirqrc trinh bdy trdn cdc hinh 1*6.
3.1. D|c diim chung v i nhom nghidn cu>u Theo phdn b i glfl'i tinh thi gifll nil chiim ty 16 chu yeu (64%), ty 1$ nO'/nam Id 1,76. Kit qua ndy khde vdi nghiSn cu'u cua cdc tdc gid khde nhu> Bansal [6], Raja [7]. Su khde bISt ndy c6 thi giai thich Id do cdch chpn mSu
nghiin cii'u, chCing tfli khdng tiin hdnh choi mSu ngSu nhidn md chpn mdu theo pht/om., phdp lidn tgc khOng xdc suit
Tuii trung btnh cua b$nh nhdn DTD bj nhiim trOng vit lodt bdn chdn Id 65,82 ± 12,1 tuii. Trong db, da s i bSnh nhdn cfl dfl tuii tl>
50 - 79 (chiim 66%). Kit qud ciia chiing tfll phCi hop vfl'i nghlSn cO'u cda Strbova [8] (63,1
± 10,5 tuii). Bliu ndy cQng d i ly gidi vl lost bdn chdn trdn bSnh nhdn OTO Id hdu qud kit hop cua cdc bSnh ly mach mdu, thin kinh vd nhiim triing, xdy ra sau mflt thflfl gian ddi bj BTO, do dfl bSnh nhdn thirdng Id ngud'i Ifln tuii.
Luong HbAlc Irung blnh ciia nhflm nghlSn cUu Id 11,00 ± 3,79 %. Da s i bSnh nhdn (80%) cfl HbAlc i 7,6%. Kit qui ciia chiing tfll cao hon so vfl'i nghlSn ci>u cua cdc tdc gid khde nhu Nguyin Trin Tnjng Tri [3J (9,23 ± 2,62%), Bansal [6] (8,15 ± 1,75). Luong HbAlc eao ehOng 16 tinh trjng duflrng huyit ciia da s i bdnh nhdn khflng duoc kiim sodt tit vd ddy Id yiu t i nguy co cao ciia loSt bdn chdn trSn bdnh nhdn OTD
OV, 20% 4 0 % 6 0 % 8 0 % 1 0 0 %
Hinh 1. Luong HbAlc ciia nhflm nghlSn cii'u.
3.2. D|c diim vi khuin hpc v i t lodt nhllm triing bdn chin
Trong nghiSn cO'u ndy, s6 luong lodi vi khuin trung blnh khi thuc hiSn ciy khuin bdng que ciy Id 1,24 ± 0,43, thip hon so vfl'i k i t qud ciia Bansal [6] (1,52) vd
Nguyin Trin Trong Tri [3] (1,71 ± 0,76).
Oiiu ndy cfl t h i id do ty 1$ binh nhdn dd duoc sO dgng khdng sinh trufle khi liy miu ciy trong nghidn ci>u ciia ehiing tfli cao hon (82%) so vfl'i nghidn cii'u cua hai tdc gid trSn.
30
Vietnam Journal of Physiology 16{3), 12/2012 ISSN 1859-2376
Hinh 2. Phdn logi cdc lodi vi khuin hllu khi phdn l$p trdn vit lodt bdn chdn.
Trong nhdm vi khuin Gram (+), vi khuin thudng gdp nhit trong nghidn cuu cua chOng tdi Id Staphylococcus aureus (37,10%). Trong nhdm vi khuin Gram (-), VI khuin thudng gfp nhit Id E. coll (14,52%) vd Klebsiella sp (14,52%) Khi so sdnh chung hai nhdm vl khuin chOng tdi thiy vi khuin Gram (-) chiim 56,55%,
cao hon so vdi vi khuin Gram (+) 43,45%
Nguyin Trin Trpng Tri [3] khi khdo sdt vi khuin hpe eua vit lodt chdn nhllm IrOng trdn 75 trud'ng hpp DTD cOng ghi nhfn ti If vi khuin Gram (-) phdn Ifp duac Id 60,94%, cao hon Gram (+) 39,45%
3.3. Sy d l khang khdng sinh cua Staphylococcus sp
I 1
Hinh 3. Sy de khdng khdng sinh eOa vi khuin Staphylococcus sp.
Su d l khang cOa Staphylococcus sp vd]
Oxacillin thiy trong 73,90% truing hpp, cao hon so vdi ghi nhfn eOa tdc gid Nguyin Trin Trong Tn [3] ndm 2005 (30,8%). Dilu ndy cd thi Id do Oxacillin dd dupe dOng rfng rdi qua thdi gian ddi ndn ty If d l khdng tdng cao Ty
Amikacin trong nghidn cOu ndy Id 20%, thdp han so vdl nghidn ciru cua Nguydn Trdn Trpng Tri [3] Id 84.6% Dllu ndy cOng dd hieu vl Amikacin Id cdc khdng sinh thudc nhdm Aminoglycoside dd duac dOng rdng rdi qua mft thdi gian ddi ndn ty If de khdng ngay
Vietnam Journal of Physiology 16(3), 12/2012 ISSN: 1859-2376
nhay cdm thip vfli nhflm Aminoglycoside Id do cdc khdng sinh ndy cfl dfl nhay vfli cdc vi khuin Gram (-) cao hon Gram (+).
100% Staphylococcus sp trong nghiSn cii'u ndy nhay cdm vfl'i Vancomycin. TJ 1$ nhay cdm cao ciia Vancomycin cOng dS dupc ghi nhdn trong nghiSn cUu cGa Nguyin Trin Trong Th [3]. Theo nghidn cO'u ndy.
Staphylococcus sp cdn nhay cdm cao vfli
Trimethoprim/Sulfamethoxazole, Fosfomycin vd Teicoplanin lin luot Id 82,35%, 93,33% vd 100%. Su d i khdng vfl'i nhiiu loai khdng sinh cua Staphylococcus sp trong nghiSn ci>u ndy cfl thi Id do phin Ifl'n bdnh nhdn trong nghiSn CO'U dd duoc nim vISn Idu hodc diiu trf khdng sinh trufle dfl.
3.4. Sif d i khdng khdng sinh cua vl khuin
£ coll
Hinh 4. Su d i khdng khdng sinh ciia vi khuin £ coli Trong nhflm Cephalosporin, cdc
Cephalosporin thi hS 3, 4 cfln mfli nhu Sulbactam/Cefoperazone vd Cefeplme cfl dfl nhay cam vfl'i E coil (62,60% vd 66,67%) cao hon so vfli cdc Cephalosporin dd dCing nhiiu nhu Cetiriaxone vd Ceftazidime (11,11% vd 33,33%). Su nhay cam cua E coil vfli Cephalosporin trong nghlSn ci>u ndy thip hon ddng k i so vfl'i kit qud trong nghiSn eCfU cua Nguyen Tran Trpng Tri [3] Theo ghi nh$n cOa tdc gid ndy, ty id nhay cdm eiia E coll vfli cde khdng sinh Ceftriaxone, Ceftazidime vd Cefeplme lin luot id 61,1%, 88.9% vd 94,4%
Theo nghlSn ci>u ndy ty IS E coii thufle nhflm ESBL (+) khd cao, chiim ty IS 44,44% ting s6 cdc mdu phdn l|p duoc £ coli 100% E coii trong nghiSn ci>u ndy a i khdng vfli Ampiolllin, cao hon ddng k i so vfli nghiSn ciiu cua
Nguyin Trin Tnjng Tn [3] Id 41,7%. O i khdng cua E coli vfli Tlcarcillln/Clavulanlc acid trong nghlSn ciiu ndy oOng khd eao (66,7% tnrtmg hop) Su nhay cdm eua E coi/ vfli cdc khdng sinh khd mfli trong nhflm p-lactam nhu Piperaclllin/tazobaetam cfln khd cao, chiim 77,78% tnjflTig hop Oiiu ndy cOng duoc ghi nhdn trong nghiSn cO'u cua Nguyin Trin Trpng Tri [3] 100% £ coii trong nghlSn ciru cua Chung tfli nhay cdm vfln cdc khdng sinh thujc nhflm Caibapenems nhu Imipenem, Ertapenem, IMeropenem. Kit qud ndy cung duoc ghi nhdn trong nghiSn ei>u ciia Bansal [61.
Trong nhflm Aminoglycoside, tJ 1$ nhay cdm ciia £ coli vfli khdng sinh cfln tuong dii mfli nhu Netilmicin rit cao (100%), trong khi t ; IS nhay cdm vfli Gentamlcln thip, chi ciS 14,29% tnrfl'ng hop. Kit qud ndy cDng phO 32
V i e t n a m J o u r n a l o f Physiology 16(3). 12/2012 I S S N . 1 8 5 9 - 2 3 7 6
hpp vdi nghidn cO'u cua N g u y i n T r i n Trpng Tn [3], ty If nhgy cam cua E coli trong nghidn CO'U eua tdc gid ndy vd'i Gentamicin vd Neltimicin Id 55,6% vd 93,3%. D l l u ndy cOng de hieu vl Gentamicin Id khdng sinh dd d u p c s u dung r f n g rdi qua thdi gian ddi ndn ty If d l khdng gia tdng.
Trong nghidn cO'u eua chiing tdi, d l khdng cua £ coli vdi ede Fluoroquinolone cao >
80%, Idn lupt vdi Ciprofloxacin vd Levofloxacln Id 87,50% vd 88,89% K i t qua trdn cQng d u p c ghi n h f n trong nghidn cO'u cOa Nguyin T r i n Trpng Tn [3]. D i l u ndy ed le do SV sO dung nhdm Fluoroquinolone u I n g ( v i n r i t d l mua dupc) bOa bdi trong c f n g d i n g ChOng la ldm cho sg* d l khdng gia tdng 3.5. Si^ d l khdng khdng s i n h cua v i k h u i n Klebsiella sp
Hinh 5. S u d l khang khdng sinh cua vi k h u i n Klebsiella sp
Qua nghidn COTJ, chung toi t h i y Klebsiella sp cdn nhgy cam vdl ede Cephalosporin t h i h f 3 thudng dOng trdn Idm sdng nhu Ceftlaxone, Ceftazidime, Sulbactam (Cefoperazone) (ty If nhgy earn Id 88,89% tafdng hp'p). D i l u ndy cung dugc ghi nhdn tuong t y trong nghidn cO-u cua Nguyin Tran Trpng Tri [3]. Ty If nhgy cam eua Klebsiella sp vdi Ttearcillin/Clavulanic acid va Piperaciliin/tazobaelam cOng cdn khd cao, trong nghidn cOu cOa chOng tdi ty If ndy Id 55,56% va 88,89% tudng hpp. D l khdng cOa Klebsiella sp vd'i Mipicillin Id 100%, tuang t y nhu s u d l khdng cua £. coli vd'i Amplcillin, Klebsiella ^ tnang nghidn cO'u ndy nhgy cdm vdi cdc khdng sinh thufc nhdm CariDapenem.
Sy nhay cdm cua Klebsiella sp trong nghidn CO'U ndy vd'i nhdm Aminoglycoside tuang t u nhu E. coll. D i i vdi Netilmicin, ty If nhgy cdm
hpp, trong khi ty If nhgy edm d6i vdi Gentamicin chT cdn 42,86% tnrdng hop Ty If nhgy cdm vdi Gentamicin thdp han dang ke so vdi k i t qud nghidn cuu cua Nguyin Trdn Trpng Tri [3]
(73,3%). D i l u ndy cd I h l Id do Gentamicin dd dupc dOng rfng rdi trong thdi gian ddi.
Trong nghidn cuu ndy, s y d l khdng cua Klebsiella sp vdi nhdm Fluoroquinolone Id khd eao, vdl Ciprofloxacin Id 57,14% vd vdi Levofloxacin id 55.56% trudng hpp. Ty If d l khdng vdi Ciprofloxacin cao han ddng k l so vdi trong nghidn eOu eua Nguyin T r i n Trpng Tn [3], Iheo tdc gla ndy ty If de khdng Id 26,7%. D i l u ndy cOng cd t h i id do s y s u dgng bOa bdi khdng sinh nhdm Fluoroquinolone u I n g trong c f n g d i n g ngudi V i f t chOng ta
3.6. S i ^ d l khdng khdng s i n h cOa nhdm v i
Vietnam Journal of Physiology 16(3), 12/2012 ISSN; 1859-2376
II llll
i i
Hinh 6. Sy d l khdng khdng smh cua nhdm vl khudn Gram dm Cdc Cephalosporin thi hf thu 3, 4 cd dd
nhgy vdi ede vi khuin Gram (-) cdn khd cao, da s6 > 60%. Vi the nhdm Cephalosporin thi hf 3 vdn ndn dupc lya chpn trong dllu trj ban dlu. Nhdm Carbapenem cd sy nhgy cam cao vdi cac VI khuin Gram (-) > 90%. Do dd cd thi dOng khdng sinh nhdm ndy trong trudng hpp khdng ddp ung vdi dllu trj theo kinh nghidm ban dlu hay cd kit qud ciy id cdc vi khuan Gram (-) khdng Cephalosporin, nhit Id nhdm ESBL (+).
Nhdm Aminoglycoside cd df nhgy cdm khde nhau vdi vi khuin Gram (-). Gentamicin cd dp nhgy cam thip (30,77%), trong khi Neltimiein cd df nhgy edm cao (92,59%) dii vdi VI khuin Gram (-) ndn cung cd thi Id lya ehpn tot cho dllu tn ban dlu.
Qua nghidn cO'u, chOng Idi cdn thiy Piperacillin/tazobactam cd df nhgy cdm vdi cdc VI khuin Gram (-) cao (88.57%), ndn cOng cd thi kit hpp vdi Vancomycin trong trudng hpp cdn bao phu ea Gram (+) vd Gram (-).
4. K^T LUAN
Da s6 bfnh nhan kilm soat dudng huyit kdm, da s6 cde ea diln tien lodt sdu tO- df 2 trd Idn theo phdn logi Wagner S i lu^ng lodi vl khuin trung blnh trdn v i l lodt nhilm trOng
bdn chdn DTD Id 1.24 ± 0.43. Cdc vi khuan thudng gdp bao gim Staphylococcus sp. E coli, Klebsiella sp. trong dd Gram (-) ehllm ty If cao han Gram (+) Ty (f cdc ehung vf khuan khdng thule ngdy cdng gia tdng. Cdc khdng sii*
cdn nhgy cdm theo khdng sinh dd tinh cho cd hai logi vi khudn Gram (+) vd Gram (-) phdn l$p dupc trong nghidn cuu nhu sau
- Cefalosporlns t h i hf 3, 4 ± Vancomycin;
Piperacillin/tazobactam hofc Neltimicin ± Vancomycin,
- Neltimicin hay Cephalosporins thi hf 3,4 ± Trimethopnm/Sulfamethoxazole hodc Teicoplanin hofc Fosfomycin.
- Carbapenem TAI LlfU THAM K H A O
1. D6 Trung Qudn ^2006) Bien chOng bfnh ddi thdo dudng vd dilu trj. NXB Y hpe, HS Nfi.
2. H$i N$i t i l t vd Ddi thdo duvng Vlft Nam (2009) Khuyin cdo v l bfnh Ddi Thdo Dud'ng NXB Y hpc, Hd Nfi.
3. Nguydn Trdn Trpng Tri (2005) Vi khudn hpe cua nhiim trOng md mIm chi dudi d bfnh nhdn ddi thdo dud'ng. Lufn vdn thac sy ehuydn ngdnh nfi" tilt hpc, Dgi hpc Y Dupc thdnh phi H i Chl Minh.
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V i e t n a m J o u r n a l of P h y s i o l o g y 16(3), 12/2012 I S S N : 1 8 5 9 - 2 3 7 6
4. Abduirazak A, Bitar Z l , Al-Shamali AA, et al. (2005) Bacteriological study of diabetic foot infections J Diabetes Complications 19(3):138-141.
5. A r m s t r o n g DG, L i s w o o d P J , T o d d WF.
(1995) 1995 William J. Stickel Bronze Award. Prevalence of mixed infections in the diabetic pedal wound. A retrospective review of 112 infeelions. J A m Podlatr Med Assoc. 85(10):533-537.
6. Bansal E, Garg A, Bhatia S, et al. (200S) Spectrum of microbial flora in diabetic foot ulcers, Indian lan J Pathol Microbiol.
51(2):204-208.
7. Raja NS (2007) Microbiology of diabetic foot infections in a teaching hospital in Malaysia: a retrospective study of 194 cases, J Microbiol Immunol Infect.
40(1):39-44.
8. Stiiiova L, Krahulec B, Waczullkova ), et al. (2011) Influence of Infection on clinical picture of diabetic foot syndrome. Bratlsl Lek Listy. 112{4):177-182.
SUMMARY
Daig reststcdice of bacteria at infednus diabetic foot ulcers in patients at Cho Ray hospital
Nguyen Thi Le, Le Quoc T u a n , Nguyen Phuc Hau
Ho Chl Minh city University of Medicine and Pharmacy Received 16 October 2012; revised 24 October 2012; accepted 15 November 2012 This study was conducted with aims at evaluating Vie dmg resistant chamcteristics of bacteria at infectious diabetic kxA ulcers in patients at Cho Ray hospital from 2010 October to 2011 June. This was a prospective and cross section descriptive study. The results showed that pmportbn of used-antibtotics patients was high, accounting for 82% cases. The avemge amount of HbAlc in the patients was 11.00 ± 3.79%. An avemge of 1.24 ± 0.43 bacterial species per patient was isolated. Gram-negative aerobes were most fiwjuentty isolated (56.55%), folbvifed by Gram-posftA/e aerot>es (43.45%).
The bacteria tiecame resistant to antibiotic, especially E. a^ and Staphylococcus sp. Most patients contmlled the glycemia poorly, not obeyed ttie Raiment. The infectious diatietk: foot ukxrs were often deep and had been used antibioses on them before. Gmm-negative aemties prevailed more than Gram-positive ones at the uhers. The percentage of anVbiotic- resistarrt species increased over time.
Key words: diabetes mellitus, infectious diabetic foot ulcer
NGHIEN CI>U B A O Q U A N K H 6 | U UNG THU T£ B A O GAN D £ T A C H T^ B A O KH6IU
Vu Bich N g o c \ BOI N g u y i n T u A n h \ N g u y i n Thanh T d m \ Nguydn Minh H o d n g \ T r i n Cong Duy L o n g ^ D d Dinh C 6 n g ^ N g u y i n Hodng Bdc^, Phan Kim N g p c \ Phgm Vdn PhOc^
^Bgl hgc Khoa hgc T^ nhidn, Dgi hgc Qude gla thdnh pho H6 Chi Minh 'Dgi hgc Y Dwgc thanh pho Ho Chi Minh Nhdn bdl 16/10/2012; su'a bdl 22/10/2012; c h i p nhdn ddng 15/11/2012
Ung thu gan la mdt trong nhQ'ng ung thu phd biin tren todn thi gidi ndi chung vS d Vl$t Nam ndi rieng. Tuy hi$n nay nhiiu lidu phSp diiu tri mdi dugc dua ra nhung hiiu qud cdn thip. Do dd. vi$c nghidn cO-u phuang phdp mdi trong diiu tri cdn b$nh ndy vSn tiip tyc dugc thi/c hi$n.
Di tgo ngudn gen vd te bdo cho nghidn cuu vd ung di/ng diiu tri, cdc khdi u gan fi> b$nh nhdn
