DIEN D A N YHOC
Nghien cuu khoa hoc
NHAN XET TENH TRANG ROI LOAN GLUCOSE MAU O BENH NHAN CO HQI CHCTNG BUONG TRIING DA NANG
!' '' Nguyen Khoa Dieu Van*; Do Xuan Manh**
TOM TAT
Muc tiSu.- nhgn xet tinh trgng roi logn glucose mdu va ddnh gid mdi tucmg quan giira glucose mdu vdi mpt sd yen td khac a henh nhdn (BN) co hpi chimg budng trimg da nang (HCBTDN). Ddi tuong nghiSn ciiu.' 49 BN cd HCBTDN tudi tie 18 den 38 den khdm tgi Benh vien Phu sdn Trung uong. Phuong phip nghiSn cuu.' md td cdt ngang. Ddnh gid cdc rdi logn glucose mdu theo tieu chudn cita ADA 2003. Ket qua.' dp tudi tnmg binh ciia BN la 25,27 ± 4.58 tudi, BMI trung binh a BN Id 20.3 ± 1,99 kg/nr. Trong 49 BN cd HCBTDN. 28,6% BN bi roi logn glucose mdu (RLGM) (trong do 26.5%, BN rdi logn dung ngp GMvd I BN hi ddi thdo duang chiem 2.1%). Khdng cd mdi tucmg quan giiea ndng dp GM luc ddi vdi dp tudi vd BMI ciia BN (p > 0.05). Cd mdi tircmg quan thugn giiea ndng dp GMthdi diem 120 phiit (G2) trong nghiem phdp dung ngp glucose mdu (NPDNGM) vdi dp tudi cua benh nhdn (r = 0.377; p < 0,05), nhimg khong co tucmg quan giua G2 vai BMI (p > 0,05). KSt luan.- BN co HCBTDN co nguy ca mac cdc roi logn GMdu cdn ndng binh thuang vd nguy ca mac RLGMcd xu hudng tdng ddn theo tudi.
L D A T V A N D E
Hdi chiing budng trung da nang (HCBTDN) II rdi loan ndi tiSt thudng gap d phu nu', ty IS benh cd the dat tdi 12% phu nu' trong dp tudi sinh de.
HCBTDN dugc dac trung bang tinh trang cudng androgen (ram Idng, trung cl, tang tiet ba nhdn...), vd sinh do mat phdng noan va/hoac budng triing da nang. Benh dS lai nhieu hlu qui trudc mat, cung nhu llu dii. Hlu qua trirdc mat la gay phiSn mudn eho cac phu nu' trS bj HCBCDN II tinh trang rdi loan kinh nguyet va vd sinh. Nhung dieu dang lo ngai ho'n la hau qua lau dai ciia benh vdi nguy ca mac dai thao dudng (DTD), biSn chiing tim mach do liSn quan tdi tinh trang rdi loan dung nap glu- cose mau (RLDNGM). Vi vay, viec phat hien kjp thdi nhung RLGM bang djnh lupng glucose mau va lam ngbiem phip dung nap GM (NPDNGM) khi
can se giiip ich eho viec phat hien sdin va sang Ipe biSn ehung DTD d BN cd HCBTDN [2] [6]. Tren thS gidi da cd nhieu nghien ciiu dinh gia rdi loan GM d BN cd HCBTDN, nhung cho tdi nay tai Viet Nam hien ed rat it nghien cuu vS van de nly. Vi vay, ehiing tdi tiSn hinh de tii vdi 2 mue tiSu:
/. Nhgn xet tinh trgng roi glucose mdu a benh nhdn CO hpi chimg buong trimg da nang.
2. Ddnh gid moi tieong quan giiea glucose mdu vai mpt sd yeu td khac a benh nhdn co hpi chimg budng trimg da nang.
II. DOI TirONG VA PHirONG PHAP NGHIEN c t r u
1. Doi tugng nghien cuu
49 BN cd HCBTDN tudi tu 18 den 38 dSn kham tai Benh vien Phu san Trung uong trong thdi
* Khoa Npi tiet - Ddi thdo dudng, Benh vien Bgch Mai
** Dgi hgc YHd Npi
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Nghien ciru khoa hoc
gian tir 8/2008 dSn 9/2009. ' • 'f "^ I - Tiiu chudn lua chgn BN: dya theo quy trinh chin doan do Homburg de xuat nam 2002. ehung tdi lya chpn nhung BN tir 1 8-49 tudi. cd it nhat mdt trong ele trieu ehung sau: rdi loan kinh nguyet (kinh thua, vd kinh, kinh nguyet khdng deu), vd sinh, ram Idng, trirng ca. BN dugc siSu am danh gil hinh thai budng trirng vdi hinh anh budng triing da nang (the tich budng trung > 8 cm', ed it nhat 10 nang tning kich thude tu 2-9 mm phan bd a ngoai biSn ciia budng trirng) [4].
- Tiiu chudn logi tni: chiTng tdi loai ra khdi nghiSn cuu nhung ngudi cd mdt trong cac biSu hien sau:
dang ed benh cap tinh hoac man tinh, dung thude anh hudng tdi chuySn hoa glucose (corticoide, salbutamol, lgi tiSu thiazid...) hoac sir dung thude tranh thai trong vdng 3 thang trudc khi dSn kham.
2. Phuong phap nghien cuu Md ta cat ngang cd ddi cbiing.
3. Thu thap so lieu
Sau khi giai thich ve quy trinh nghiSn ctiu va dugc sy ddng y cua ddi tugng tham gia nghiSn ciiu, ehung tdi thu thap sd lieu theo mau benh an thdng nhat:
- Khai thae tiSn sir kinh nguyet, thai san.
- Do chieu cao: diing thude do gan liSn vdi ban can.
KSt qua tinh bang met (m).
- Do can nang: diing can ban da dugc kiSm nghiSm sai sd < I OOg. KSt qua tinh bang kilogram (kg).
- Danh gia cudng androgen: ram Idng. trung ea...
- SA danh gia hinh thai budng trung tai khoa Chan doan hinh anh - Benh vien Phu san Trung uong.
- XN sinh hoa dupe lam tai khoa Hoa sinh - Benh vien Bach Mai. BN nhjn an sang va lay mau tTnh mach:
+ Djnh lupng hormon LH, FSH (tinh ty IS LH/
FSH). testosterone toan phan, prolactin, estradiol vao ngly thii 2-4 eua chu ky kinh nguyet. NSu BN
vd kinh (>182 ngay khdng cd kinh nguyet) tbi lay xet nghiem vao bit ky thdi diSm nao. Cae hormon nay se dugc djnh lugng blng phuang phap mien djch enzym (Enzym Immuno Assay).
+ Djnh lugng insulin ddi theo phuong phap miSn djch dien hda trSn may ELESSYS - 2010.
+ Djnh lugng glucose mau bang phuong phap enzym so m l u trSn may phan tich ty ddng Hitachi 9 1 2.
- Tat ca cac BN cd xet nghiem GM liic ddi dudi 7 mmol/l se duge lam NPDNGM (theo khuySn eua WHO) tai khoa Not tiet - DTD, Benh vien Bach Mai:
+ Chuan bj BN: benh nhan dugc thdng bao vS each thiic tiSn hanh NPTDH va cac budc chuan bj dS thyc hien. BN dugc lay xSt nghiSm GM va insulin trudc khi tiSn hinh nghiem phap.
• 3 ngay trirdc kbi lam nghiSn phip: khau phan an dam bao lugng caebonbydrat (150g - 200g/ngay).
• BN nhjn an 8 - 12 gid trudc khi tiSn hanh nghiem
p b l p . ,. ••.:: .,':f.:
• Khdng van ddng qua siie trudc khi lam nghiem phap.
• BN dSn lam nghiem pblp lue 8 gid sang.
+ TiSn hanh nghiem phap: udng 75g glucose hoa vdi 250inl nudc sdi dS ngudi trong 5 phut. Xet nghiSm GM tai thdi diSm 120 pbiit sau khi udng 75g dudng. . ^ , ^, .,.,;,,, j.
. •: : > • • -Il : • ; y\:i i ,
4. Danh gia
Chi sd khdi cathe BMI = cln nang/chiSu cao2 (kg/in)2 vl phln loai BMI theo tiSu chuan eiia Td cblic Y tS ThS gidi (WHO) danh cho ngudi chiu A.
Danh gia GM luc ddi va GM thdi diSm 120 phut (G2) theo tiSu chuin ciia ADA 2003 [I] [II].
' a - , i ! ':Ui>b. qiUm !•• : i\[ji; jV
5. Xu ly so lieu
Tren chuang trinh SPSS 16.0. Tinh va so sanh cac gia trj trung binh bang test Student vdi p < 0.05.
Tinh he sd tuong quan r theo phuong trinh Spearman.
541 Y H O C L A M S A N G S652(Thang05/2010
D I E N D A N Y HOC Nghien CLPU khoa hoc
IILKETQUA rn
Trong thdi gian hi 8/2008 dSn 9/2009, cbung tdi thu thap so lieu ciia 49 BN ed HCBTDN.
Bdng 1. Mpt sd dgc diem lam sdng vd can lam sdng cua doi tuong nghiin cuu
Dac diem Tudi (nam) Can nang (kg) CbiSu cao (m) BMI (kg/(m)2) LH (mU/ml) FSH (mU/ml) Testosterone (nmol/1) Estradiol (pmol/l) Prolactin (ng/ml) Go (mmol/1) G2 (mmol/I)
Gia tri trung binh 25,27 ± 4,58
49,4 ±5,83 1,56 ±0,576
20,3 ±1,99 12,25 ± 5,477
6,82 ±3,011 1,70 ±1,09 171,07 ±72,01 92,54 ±106,78 5,12 ±0,56
7,51 ±1,25
Nhdn xet: dp tudi trung binb cua BN II 25,27 ± 4,58 tudi, nam trong kboang 18-38 tudi. Pban ldn cd dp tudi trong khoang bi 20 dSn dudi 30 tudi (19,6%), 8,2%) BN ed dp tudi dudi 20 va 12,2%) BN > 30 tuoi.
BMI trung binb d BN la 20,3 ± 1,99 kg/ml Phln ldn BN cd cln nang binb tbudng (18,5 < BMI < 23 kg/m-), 20,4% BN tbiSu can (BMI < 18,5 kg/m^), ty IS BN qua ean-beo pbi (BMI > 30 kg/m^) cbi cbiSm 4,1%.
1. Nhan xet tinh trang roi loan glucose mau d BN co HCBTDN
Trong 49 BN tbam gia ngbiSn ciiu, cd 9/49 BN (18,4%) biSu bien rdi loan GM ddi (Go tii 5,6-6,9 mmol/l), kbdng cd BN nao cd GM ddi > 7 mmol/1. Nbu vay, tit ca BN trong ngbiSn ciiu dSu dugc lam NPDNGM. ,, -
DTD
n M V ' . ' .. 2 , 1 %
RLDNGM 26,5%
Binb thudng 71,4%
Biiu dd 1. Ddnh gid GM tgi th&i diim 120phiit trong NPDNGM
Nhgn xet: sau khi danh gia GM thdi diSm 120 pbiit trong NPDNGM tbi chiing tdi thly 28,6%) ed rdi loan GM (ti-ong do 26,5%) BN rdi loan dung nap GM vdi G2 tii 7,8 dSn 11 mmol/1 vl 1 BN bi DTD chiSm 2,1%) (biSu dd 1). 12/14 BN cd bit thudng GM 2h sau llm NPTGM nhung GM ddi lai binh thudng.
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2. Danh gia tuong quan giira glucose mau vdi tuoi, BMI d BN cd HCBTDN
Bang 2. He so tuong quan giira GM v&i tudi vd BMI & BN cd HCBTDN
Tuoi BMI
r P r P
GM liic doi 0,099
>0,05 - 0,26
>0,05
GM 120 phut 0,377
<0,05 0,075
>0,05 Nhdn xet:
- Khdng cd sy tuong quan giua gia trj GM ddi vdi tudi va BMI ciia BN (p > 0,05).
- GM thdi diSm 120 phut trong NPDNGM cd mdi tuong quan thuan vdi tudi ciia BN (p < 0,05), nhtrng khdng cd sy tuong quan vdi BMI d BN cd HCBTDN (p > 0,05).
Bdng 3. So sdnh tudi, BMI trung binh giira BN cd RLGM vd khdng cd RLGM Nhom
Thong so Tudi (nam) BMI (kglnr)
RLGM (n = 14) 27,3 ± 5.50 20,4 ±1,69
Khong RLGM (n = 35) 24,5 ± 3,98 20,3 ±2,12
P
<0,05
>0,05 Nhdn xet:
- Do tudi trung binh ciia BN rdi loan GM cao hon so vdi BN khdng rdi loan GM, sy khlc biet cd y nghTa thdng ke (p < 0.05).
- Khdng thay cd sy khae biet ed y nghTa ve BMI trung binh d nhdm BN cd RLGM va nhdm BN khdng RLGM (P>0,05). ;, , ,
TV. BAN LUAN
1. Nhan xet rdi loan glucose man doi d BN cd HCBTDN
(3 BN ed HCBTDN. rdi loan glucose mau (RLGM) la hau qua cua sy dS khang insulin.
RLGM nSu khdng dupe phat hien sdm va dieu trj kjp thdi se dan tdi cac biSn chiing DTD va benh ly tim mach trong tuong lai. Mdt trong nhtrng bieu hien sdm ciia rdi loan chuyen boa glucose la tinh trang RLGM luc ddi. Nhung BN ed RLGM luc ddi cd nguy ca trd thanh DTD cao hon so vdi nhung ngudi cd GM ddi binh thudng [0]. Theo nghiSn ciiu cua ehung tdi, trong 49 BN ed HCBTDN thi cd 18.4 % bj RLGM liic ddi (GM luc ddi tir 5,6 dSn
< 7 mmol/l). Vi vay, BN cd HCBTDN can dugc xSt nghiem GM luc ddi djnh ky dS phat hien sdm
cac rdi loan GM va cd kS hoach diSu trj kjp thdi.
NPDNGM la mdt xet nghiem sang Ipc dS phlt hien DTD va RLDNGM d nhung nhdm ngudi cd ySu td nguy CO' cao dS mac DTD nhu: beo phi, THA. ySu td gia dinh... va dae biet d BN ed HCBTDN. Mac dii, trong ngbiSn cuu ctia ehung tdi, phan Idn BN trong nghiSn cuu cd BMI binh thudng (75,5%), tham ehi ed 20.4% BN thiSu can, nhung cd tdi 28,6% BN cd RLGM, trong do cd I BN bj DTD (chiSm 2,1%). Nhu vay. d BN cd HCTBDN thi cac RLGM cd thS gap d nhung ngudi cd can nang binh thudng.
Ty IS BN cd HCBTDN bj RLGM trong nghiSn ctiu cua chiing tdi thap hon so vdi nghiSn ciiu cua Ta Chin Lin tren nhdm BN ngudi Dai Loan (46,8%, n = 45) hay ciia Seneviratne trSn nhdm BN ngudi Srilanka (33,33%, n = 168). NguySn nhan ciia sy khac biet nay
56 I Y HOC L A M S A N G S6 52 (Thang 05 / 2010)
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Cling la do t\' IS BN cd HCBTDN beo phi trong nghiSn cuu ctia Ta Chin Lin (65.9%), Seneviratne (77,38%) cao hon trong nghiSn ciiu ciia ehung tdi (4,1%), vi beo phi la mdt trong nhfrng ySu td thiic day tinh trang RLDNGM va din tdi DTD trong HCBTDN [0] [0].
Theo Theresa. BN cd HCBTDN bj rdi loan GM se cd nguy ca phat triSn thanh DTD cao gap 5-10 lan so vdi nhiing ngudi khdng ed HCBTDN. tdc dp xuat hien DTD se tang nhanh nSu di kSm vdi cac ySu td nguy CO' khae nhu tiSn sir gia dinh, beo phi va khi di kem cac rdi loan chuyen hoa khac se lam tang nguy ca mac va tii vong do cac benh ly tim mach [0]. Do dd, BN cd HCBTDN cung can dugc xet nghiem GM ddi thudng xuySn va can dugc tam soat DTD bang NP- DNGM khi can thiet. Theo ADA, djnh lupng GM ddi la xet nghiem dugc thyc hien don gian, dS dang, it tdn kem hon so vdi NPDNGM, nhirng gia trj GM trong NPDNGM lai dang tin cay hon khi chan doan DTD [0], blng chimg la 14 BN ed HCBTDN bj rdi loan GM trong nghiSn ciiu ciia ehung tdi khi lam NPDNGM thi cd 12 BN cd miic GM ddi binh thudng (GM ddi < 5.6 mmol/l), chi ed 2 BN cd biSu hien rdi loan GM ddi.
:••; Vi vay, can tbiSt phai lam NPDNGM cho BN ed HCBTDN ngay cl khi GM ddi binh thudng. Tuy nhiSn, diSu nay se gay nhiSu thdi gian va gay tdn kSni eho BN. Do dd. can phai xac djnh mdt diem ngudng GM ddi thich hpp dS tiSn hanh NPDNGM. Theo tac gia Richard, vd'i GM ddi > 5 mmol/l la cd gia trj sang Ipc rdi loan GM d BN cd HCBTDN vdi dp nhay 71 % va dp dac hieu 68% [0].
2. Danh gia moi tuo'ng quan giira GM vd'i tudi va BMI dBN CO HCBTDN
2.1. Mdi tuong quan gida GM v&i tudi cda BN cd HCBTDN
Chung tdi thly tudi trung binh d nhung BN ed RLGM (27.3 ± 5.5 tudi; n = 14) cao hon cd y nghTa so vdi nhung BN khdng RLGM (24,5 ± 3,98 tudi; n
= 35). KSt qua na)' cung tuong ty vdi nghien eiiu ciia cac tac gia Mohlig (2006) [0] hay Dabadghao (2007) [0]. Hon nua, ehung tdi nhan thay cd mdi tuong
quan thuan (r = 0,377; p < 0.05) giiia chi sd GM thdi diSm 120 phiit trong NPDNGM vdi dp tudi cua BN cd HCBTDN. Nhu vay, khi tudi ciia BN cd HCBTDN cang cao thi BN cang cd nguy co' mac cac RLGM. 0 nhung BN ed HCBTDN, sy de khang insulin tang dan theo tudi ciia BN, dac biet d nhtmg ngudi > 40 tudi;
keo theo dd la sir gia tang cac rdi loan GM. Vi vay, theo thdi gian, nhiing BN cd HCTBDN cang ngay cang can phai dugc kiSm soat chat chS cac RLGM.
Trong nghiSn ciiu. chting tdi khdng thay cd mdi tuong quan gitra ndng dp GM ddi vdi tudi ctia BN (r
=0,099; p > 0.05). Cd le do so lugng BN nghiSn cuu khdng diT idn va phan Idii BN lai tap trung trong dp tudi tir 20 dSn dudi 30 tudi, nSn chiing tdi khdng thay cd mdi tuong quan giua hai gia trj nay. Hon niia. theo ADA. muc dd tin cay ciia xet nghiem GM ddi thap hon so vdi NPDNGM. Vi vay. theo cbung tdi, gia trj GM ddi d BN cd HCBTDN chi cd y nghTa trong sang Ipc nhung BN can phai lam NGDNGM.
2.2. Mdi tuffng quan giira GM vdi BMI & BN cd HCBTDN
Trong nghiSn ciiu eiia ehung tdi, BMI trung binh d BN ed HCBTDN bj rdi loan GM (20.4 ± 1,69 kg/m=) khdng cd sy khac biet so vdi nhdm khdng cd rdi loan GM (20.3 ± 2.12 kg/m^) (p > 0.05). Day la sy khac biet so vd'i cac nghiSn ciiu eua Dabadghao, Mohlig [0] [0].
Sy khac biet nay cd thS do ca mau trong nghiSn cini ciia ehung tdi it hon so vdi cae nghiSn ciru eua cac tae gia nay nen khdng thay cd sy khac biet giij'a nhdm BN cd HCBTDN bj RLGM vanhdin khdng RLGM. Nhu vay. rdi loan GM cd tbS gap d nhung BN cd HCBTDN vdi can nang binh thudng.
V. K £ T LUAN
BN cd HCBTDN cd xu budng xuat hien cae rdi loan GM, vdi ty IS RLGM II 28,6%) (trong dd RLDNGM chiSm 26,5% va2,1 % BN bj DTD). RLGM d BN cd HCBTDN ed xu hudng tang theo tudi. Do dd, can thiSt xet nghiem GM djnh ky va lam NPDNGM dS sang Ipc cac RLGM d BN ed HCBTDN.
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TAI LIEU THAM KHAO
. ' ' : ' • ' • - i n i ; i > ! ; ! Kf'
1. ADA (2008). "Stundurds of medicolcure in diabetes 2008". Diabetes care, vol31, supplement 1. s55-60.
2. Aniiju Dokixis. Willium I. Sivitz (2003). "Polycystic ovury .Syndrome ". Early dianosis and treatment of endocrine disorders. Humanu Press pp. 181-195.
3. Dabadghao P. Roberts BJ. Wang.I Duvies MJ, Normun RJ. (2007), "Glucose tolerance abnormalities in Aiistraliun women with polycystic ovary .syndrome". Med J Aust. Sep 17. 187(6):328-31.
4. Hamburg R (2002). What is polycystic ovarian .syndrome? A proposal for a consensus on the definition und diugnosis of polycystic ovarian .syndrome. Hum Reprod, 17, pp. 2495-2499.
5. Mohlig M. FloterA.. SprangerJ. Weickeri M. O. Schill T. Schlo.sser H. W.. Brahunt G.. Pfeiffer A. F H.. SelbigJ.. C. SchofI (2006). "Predicting impuired glucose metuholism in women with polycystic ovaiy .syndrome hy decision tree modelling". Diahetologiu. 49. pp. 2572-2579.
6. R. Jeffi-ey Chung (2008). " Recommendations for the Early Recognition and prevention of Polycystic ovary .syndrome". Polycystic Ovury Syndrome Current Controversies, from the Ovury to the Puncreus. Humana Press, pp. 147-155.
7. Richard S. Legro. Diane Finegood. Andreu Dimuifl 1998). "A fusling glucose to insulin ratio is a useful mea.siire of insulin sensitivitv in women with polycystic ovury .syndrome". J Clinicul Endocrinol Metab.
VoI83. (8),p 2694-98.
8. Seneviratne HR. Lunkeshwuru D. Wijerulne S. Somusimderum N. Athukorale D (2009). "Serum insulin patterns und the relutionship between insulin sensitivity and glycaemic profile in women with polycystic ovary syndrome". B.IOG. Vol 116. (10), pp 1457-61.
9. Ta Chin Lin. Jul Mei Yen2. Kum Bing Gongl. Tsung Cheng Kiiol. Dong Chi Ku3. Shu Fen Liang.
Ming Jiucm Wu (2006). "Ahnormol glucose tolerunce and insulin resistunce in polycystic ovary syndrome umongsl the Tuiwcmese popululion- not correluted with insulin receptor substrate-lGly972Arg/Ala513Pro polymorphism". BMC Medical Genetics. (7).p 36. ' ' '
10. Theresa L.Marx, Adi E.Mehta (2003), "Polycystic ovary syndrome: Pathogenesis and treatment over the short and long term", Cleveland clinic journul of medecine, vol 70, (l),pp. 31-41.
11. WHO (2004), "Appropriute body-mass index for Asian populations and its implications for policy and intervention strategies". Lancet: vol363. pp. 157-63.
RESUME • • '
LETUDE DE TROUBLE DE LA GLYCEMIE CHEZ LES PATIENTS ATTEINTS LE SYNDROME DES OVAIRES POLYKYSTIQUES CIBLE
Commentaire I u perturbation de la glycemie et evuler la correlation en tre la glycemie avec quelqiies dements chez les putients presenlunt le syndromes des ovaires polykysliques (SOP). Objeetif.' les 49 patients atteints dgees de 18 u 49 uns etant consultes u Thdpital d'obsteo-gynecologie nationnale.
Methode recherche.- description tran.sversale. Evahie les troubles glucosemiques sur le critere d'ADA 2003. Resultat.' I'dgee moyen de patients est 25.27 ± 4.58 uns, leur index de mass corporel (IMC) moyen est 20.3 ± 1.99 kg/iu. Le taiix de patients qui ont la trouble glucosemiques, est 28.6% (26.5% de reduction de tolerance ghicosemique. 2.l%o diabete). Pas de correlation entre la glucosemie avec I 'dgee et IMC de patients (p > 0.05). II y a la correlation dirrecte entre la glucosemie a I 'epreuve de tolerance glucosemie oral de patients (G2) avec leur dgee. (r = 0.377; p < 0.05). ma is pas de correlation entre G2 avec IMC (p
> 0.05). Conclusion.' les patients atteints le syndrome des ovuires polykysliques ont risque des troubles de glycemie meme leur paid normul et ces riqiies soni deve parullelement uvec leur dgee.
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