(y BENH NHVaC TU"

(1)

Y Hpc VI$T NAM THAHC 9 - S01/2014 chcfi d i i n t d v i xem ti vi vdi thdl Iddng tren 2

gid/ n g i y deu cd mdi lien quan chat cihe vdi can thi hpc dddng. Nhihig HS tham gia hoat dpng ngoii trdi t r i n 2 gid/ n g i y vdi cac heipt ddng da bong, da cau, cau Idng, chay, n h i y day hoSc cac hoat ddng the due the thao khac thi nguy cxJ mSc b i i i h can thj g l i m 4 7 % so vdi hpc sinh hoat ddng ngoai trdi dudi 2 g i d / n g i y .

Chung tdi cho r i n g thdi quen HS dinh_ thdi gian ranh roi cho cac hoat ddng nhin gan se lajn tang thdi gian ddi hdl hoat ddng cua thj giac dan tdi g i n h nang cho cd quan thi giac.

4.3.Z TifthSngoihpa

Qua nghiin cdu thay nhdm HS < j n Uij cd ty I i ngdl hoc sai t d the (ngoi Ipch, dau ciil q u i ttiap...) (49,4%) nhieu hdn so vdi nhdm khdng can thi (16,1%), s d khac b i i t cd y nghia thdng ke vdi 0 R = 5,08 ('p<0,001). Ket qua n i y cung tddng t d nhd nh$n x i t cua Pham Hong Quang va cs. (2011) [ 2 ] : HS cd thdi quen ngoi hpc khdng dung m i c c$n thi cao hdn so vdi ngdl hoc dung (0R= 2,6; 95% d = 1,7 - 3,9).

Chung tdi cho rSng day la van de rat quan trpng ddi vdi cac bac cha/mp, g l i p v i i n v i HS d^c biet I i d nhihig HS dSu cap Tieu hpc. Luc n i y , HS mdi b i t dau nhap tin/dng, chda b i i t each ngnl hpc dung t d U i i l i i n cha/me v i glap v l i n p h i l thddng x u y i n quan tam den each ngdl hpc v i udn n i n c i c h ngdl hpc cua cpn em minh tal n h i cung nhd tal cac ldp hpc.

V.K^LUAN

H i i can thj d hpc sinh tieu hpc v i THCS d Ha Npi i i 33,7%. Hoc sinh nff cd ty Ip can thi (35,0%) nhieu hdn hoc sinh nam (32,5%),

(p<0,05). Mot sd yeu t d nguy cd l i i n quan den can till hoc dddng la tien s d gia dinh cd ngddi mSc b i n h can thi ( 0 R = 5,54); nhin gan t r e n S gid/ngiy (OR = 8,19); xem ti vl, chdi dien t d tren 3 gid/ngiy ( 0 R = 11,78); ngoi sai t d t h e khi hpc, dpc sach, bao ( 0 R = 5,08).

T A I L i | U T H A M KHAO

1. Vii Quang Dung ( 2 0 1 3 ) , Nghiin d i d thi/c trang va mot so giai phap phong chong can thi d hpc sinh trung hpc cO s6 khu vuc trung du tinh Thii Nguyen, Lu|n an Tiin sT Y hoc, Dai hgc Y D i # Thai Nguyin.

2. Ph;m Hong Quang, Ph^m van Tan (2011),'CSn thj d hgc sinh vS veil to Snh hudng tai bdh dudng tiung hoc cd sd thanh pho BSc Ninh nSm 2010*, Tap Oi Nghiin cud Y hpc, 73(2), Ir. 112-116.

3. Czepita P., Mojsa A., Ustlanowska M. et al.

(2010), "Reading, writing, working on a computer or watching television, and myopia', Klin. Oczna., 112(10-12): 293-5.

4. Guo Y., Liu L. ] . , Xu L. et al. ( 2 0 1 3 ) , "Outdoor activity and myopia among primary students in rural and urban regions of Beijing', Ophthalmology, 120(2): 277-83.

5. Xiang P., He M., Morgan I . G. (2012), "The impact of severity of parental myopia on myopia in Chinese children", Optom Vis Sd., 89(6); 884-91.

6. Yingyong P. ( 2 0 1 0 ) , "Risk factors for refractive errors in primary school children (6-12 years okl) in Nakhon Pathom Province", 3. Med Assoc. Thai., 93(11): 1288-93.

7. You Q. S., Wu L. ] . , Duan ] . L. et al. (2012),

"Factors associated with myopia in school children in China: the Beijing childhood eye study", PLoS One., 7(12): e52668.

DANH GIA N 5 N G D S TU" KHANG THE KHANG THU CAM THE ACETYLCHOLINE (y BENH NHAN NHVaC CO

Phan Thanh Hieu*, Phan Viet Nga*, NbO' Dinh Sam*

Nguyen Giang Nam*, B 3 Kh4c D?i**

T6MTAT

Nghien cud t d khang the khang thu cam the acetylcholine (AChR Ab) d 92 binh nhan ddpc chSn

* Binh vign 103

**Hpcvl|nQuSny

Chju trSch nhiim chinh: Phan Thanh Hieu Email: [email protected] Dt: 0915472544 Phan bipn khoa hpc: PGS.TS Nguyin Minh Hien Ngay nhan bai: K.7.2U14

doan nhuac cd, xet nghiem AchR Ab dddc thuc hien bing x i t nghiim mien djch hap tiiu lien ket vdi enzyme (Enzyme-linked immunosorbent assays - EUSA), hieu g i i dddc ti'nh bSng nmof/l, ngu9ng dudng ti'nh dude xac djnh vdi hieu gia > 0.52nmole / L Trong nhdm binh nhudc cd vdi tuoi tning binh la 45, ti I i nd / nam l i 1.96:1. TSt ca cac bpnh nhan t^i thdi diem nghiin ciiti deu d trong nhdm I, Ila va l i b theo phan loai Iim sang cua Osserman. Kit qua AchR Ab dddng tinh d 84 dong so 92 binh nhan (91.30%). Trong nhdm kiem tra doi chiing xet nghigm d i u am tinh. KS

32

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Y Hex: VIST NAM THANG 9 - S01/2014 qua xit nghl#m co dp nhay 91.30%, vS do dSc hieu

100%, gid tri tien doan dudng 10Q%, gia trj tien doan Sm la 78.94%. Khong co moi liin quan giu^ hieu gia AchR Ab va dSc diem lam s^ng. Day la mpt xet nghiim rat gia tri trong Chan doan xac djnh benh nhu'pc cd.

Tit khoa: khang the khang thy the Acetylcholine, nhu'pc co, EUISA.

SUMMARY

EVALUATION OF ACETYLCHOUNE RECEPTOR AUTOANTIBODIES OF MYASTHENIA GRAVIS PATIENTS The studied Acetylcholine receptor antibody (AChR Ab) in 92 patients diagnosed myasthenia gravis, AChR Ab assay was done by Enzyme-linked immunosorbent assays - EUSA technique and reported by titer in nmole/L. The positive result was defined by titer a 0.52nmote/L. In the myasthenia gravis group, witii age mean of 45 years old. The female: male ratio was 1.96:1. All of the patients at the time of presentation were in group I, Ila and lib of dinicai grades of Ossemian's classification. AChR Ab-positlve results in 84 out of 92 patients (91.30%). In tiie control group, tests were all negative. The results of the test made the sensitivity of 91.30% and spedfldty of 100%. The positive predictive value was 100%, the negative predictive value was 78.94%, There was no relative between AChR Ab titer and dinicai features. This test is a very valuable in the definitive diagnosis of myasthenia gravis.

Keywords: Acetylcholine receptor antibody.

Myasthenia gravis, EUSA l.oATVANOt

NhuBc cd (Myasthenia Graws) la binh h/

mien mac phai cua qui trinh dan ti'uyen than kinh cd liin quan din tdn thddng thu cam Uie AcetylchoHne d xi - nap than kinh - cd "J, do cd t h i ngudi b^nh cd cac t d khang the khang Uiu cam the Acetylcholine d riiang sau xi - nap than kinh - cd. Tren Hie gidl da cd nhieu cdiig trinh nghiin cdu xic dinh nong dd td khang the khang tiiM ttie Aetylchollne v i cd nhieu nghien cdu da xem day l i " tliu chuan ving "de chan doan xac dinh benh nhddc cd •''•".Tuy nhien xet nghiim nay chua dddc nghien cirti nhieu d Vlit Nam, dp vay chung tdi tien hanh nghien cdu xac ^nh nong dd td khang the khang thu cim t h i Ace^lchdline trong huyet thanh benh nhan nhudc cd v i danh gia mdi liin quan giDa nong dp td khang the niy vdi dp ning lam sing cua bpnh nhan nhddc cd.

II. Cdl TU(?NQ VA PHUOIMG PHAP NGHIEN CUU 2.1. Bol tu'dng, phu'dng phap v i vat lieu nghlSn cSta

2.1.1. Doi tWdng nghien atu - Nhdm binh nhan nghien cdu (BNNC): gom 92 benh nhan dddc chan doan la nhddc cd dieu til tai khoa Npi -than kinh (A4) Benli viin 103 - tioc viin Quan Y td thing 10 / 2010 den thing 04 / 2014 theo tieu chuan chan doan cua Klaus V. Toyka, Ralf Gold (2004)™.

Tieu chuan loai trCT:

+ Binh nhddc cd kit hdp vdi tdn thddng day than kinh.

•f Cac hpi chdng nhddc cd khac.

- Nhdm chdng: gom 30 ngddi khde manh td nguyin cho mau^ Iim xet nghiem djnh Iddng nong dp khang the khang thu the Acetylcholine.

2.1.2. Phu'dng pliap nghien aiti Xet nghiem djnh ludng nong dp b/ khang tiie khang thu cam tiie Aoetyichollne (AChRAib) dude tiin hinh Uieo phutJng phap phip xet nghiem miin djch lien kit Enzyme (Enzyme-linked immunosorbent assays - EUSA) bien tiie canh danh''".

2.2. Tien hanh nghien cu'u

2.2.1. Khim Iim sang binh nhin nghiin citu

- Binh nhan nghien cull (NC) dddc kham lam sing v i lam cac test chan doan roi thdng k i theo mau benh an NC thdng nhit, nhim thu thap v i xac djnh cac yiu td sau:

-f D^c diem chung cua nhdm BNNC, khai thac benh sd, tien sd.

•I- Chan doan, phan loai binh va Iddng gia dp nang lam sing theo phan loai lam sing nhddc cd cua Osserman.

2.2.2. Tiin hanh xit nghi$m EUSA xic dinh nong dp ty'khing the khing thy thi Acetylcholine (AchnAb).

- Lay 3 ml miu cua BNNC va nhdm chuhg cho vao dng xet nghiim khdng cd chat chdng ddng chuyen den khoa Huyet hpc- Binh viin 103 6i tich huyet thanh, bac quan mau rdi xet nghiim xac djnh ndng dp AchRAb bing phddng phap ELISA canh tranh tai Labo Mien djcli - Trung tim nghiin cdu dng dung sinh - y duHc hpc - Hpc viin Quan y. Dpc ket qui ngay sau dd bSng may do mit dd quang DTX 880 d bddc song 450 nm.

Kit qui cua cac mau xet nghiim dddc ti'nh toan theo dddng chuan xay ddng dda trin 5 diem chuan la 0,2; 0,5; 1; 6,5 v i 20 nmpl/l.

-Phan tich kit qua:

+ Kit qui duHng tfnh khi nong dp AchAb >

•*'ct,i«,™-l-2SD

( Chdng am lay theo khuySn cao cua nhi sin xuat bd Kit; < 0.45 nmpi)

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Y HOC VIJT NAM THANG 9 • S01/2014 + Kit qua am tfnh kht ndng dp

AchRAb<-f *0Bgi,„+2SD

( ^ chittig am: ndng dp AChRAb trung binh cua 30 mau chimg am; 2SD: dp lech chuan cua cac gia tri nong dp chutig am).

-I-' So sanh kit qua xet nghiim va ndng dp trung binh (TB) ciia AchRAb giffa cac nhdm binh va dp nang lam sing theo phan Ioal ciia Osserman.

Z2.3. Xit ii so lieu: tren may vi tinh bang cac thuat toin thdng ki,sd dung phan mem SPSS version 16.0

III. Kit QUA VA B A N L U A N

3.1. Oac diem chung ciia doS tu'dng nghien culi

92 BNNC gom 61 nO'va 31 nam (ti le nUImm

= 1.96/1) vdi tuoi TB la 44.96 ± 15.74 trong do tuoi TB cua nam la 47.74 ± 20.48, cua nU li 43.54 ± 12.29.

30 ngddi khde manh t d nguyen cho mau xet nghiem ddi chdng' gdrnlS ni?, 12 nam;

(nii'/nam=1.5/l), tudiTB: 20.53± 1.04 3.2. Nong do khang the khang thu cam th^ Acetylcholine cua nhdm benh nhan nghien cuti v i nhdm chihig

Bang 3.1. Dac diim ndng dp khang the khing thu the Acetylcholine trong miu binh nhan nghiin cuu v i nhdm chdng

Danh muc Ndng dd trung binh (nmol) Dd lech chuan Sd c^uan sat Khoang tin cay

Nhdm BNNC 32.67 20.18 92

Nhdm chiifng 0.37 0.075

30 99.99%

T-test: t =15.35; p < 0.0001 Nh$n x4t: Nong dp TB cua nhom benh cao hdn nhom chutig rat nhieu, sy" khac biet nay co y nghia thong ke vdi p <0.05. Ngu'Sng chan doan (cut of) > 0.52 nmol/l

Bang 3.2: Ket qua xet nghiem vdi ngu@ng nong dp (cut off) >0.52 nmoi/l ciia doi tu'dng benh nhan nghien culi va nhom chiTng

Nhan x^t'Oo nhay: 91.30%, do dac hieu; 100%, gia tri tien doan du'dng: 100%), gia tri tien doan am: 78.94%, khong c6 du'dng tfnh gia.

Bang 3.3. Nong do khang the khang thu the Acetylcholine cua nhom benh nhan nghien cu\i phan bo theo phan loai ciia Osserman.

Nhdm b$nh Nhdm I (n=23 ) (1) Nhdm

11(4)

Ila (n=32 ) (2) lib (n=37) (3) Nhdm III (n=0)

Nhdm IV (n=0) Tong

Ndng dd TB (nmol/l]

25.96 36.34 33.64 0 0

Du'dng tinh SdBN

18 30 36 0 0 84

Ti l i % 78.26 93.75 97.29 0 0 91.30

Am tinh SdBN

05 02 01 0 0 08

T i l i % 21.73 6.25 2.70 0 0 8.69 _ Bing3.4. Nong dp khing the khang thu the Acetylcholine cua nhdm binh nhin nghiin cul theo dp ning Iim sang phan loai cua Osserman

Sd nang lam sing Ndng dp TB Nhe (n= 55)

Vda (n= 37) Ning (n=0) "

Cdng

32.00 33.64 Nhin xet: Khong cd sd khac biet ve nong dp AchRAb vd

Du'dng tinh SdBN Tile 48 87.27 91.30

Am tinh SdBN j T l l e V

07 12.72 2.70 dp nang lam sing.

>0.05

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Y HOC Vlfr N/VH THANG 9 - SO 1/2014

IV. BAN LU/BlN 4.1. Dac dl€m chung

Nhdm BNNC CO tuoi trung binh la 45 (nam:

48; nii':43; ti l i nif/nam: 1.96/1) deu dddc chan doan la nhddc cd dieu trj tai khoa ndi - than kinh binh viin 103. Theo phan loai cua Osserman thi tiong nghiin cdu niy nhom I: 25%, nhdm na:34.78% v i nhdm lib l i 40.21%. Lddng gia dp n^ng lam sing: loai nhp: 59.78%, loai viia:

40.22%, khdng cd benh nhin ning v i rat ning vi nghien cdu niy dddc thut hiin d khoa Npi - Than kinh nin thddng gap benh nhan nhp va vda, cac binh nhan nang hoac rat ning dutfc dieu tii tal ddn vl hdl sdc cip cuU.

4.2. Kit qua xit nghiem nong do khing the khang thu the Acetylcholine

Ndng dp TB cua nhdm BNNC l i 32.67 ± 20.18 nmol/l, ciia nhdm chdng l i 0.37 ± 0.07 nmol/l. Da cd sd khac biet rat Idn v i ndng dp A(3iRAb giOa nhom BNNC v i nhdm chdng (gap 86 lan). NguSng chin doin (cut off): > 0.52 nmol/l, vdi ngu@ng niy phu hdp vdi ngudng chan doan cua nhiiu nghiin cdu khac nhd: FE Somnier(1993)^''^>0.5nmol, Suthipun Jipimolmard (2006) >0.5 nmol.

Ti l i xet nghiem dddng ti'nh d nhdm BNNC chiem 91.30%, ket qui niy thap hdn nghiin cii\i cua Sidra Auragzeb va cdng sd (2009)"'; 100%, nhdng Iai cao hdn nghiin ciru ciia Suthipun Jipimolmard (2006): 80.7% v i Matthew N Merlggloli,{2009)™: 85%. Theo phin Ioal lam sing cua Ossemian thi nhdm I cd ti l i dddng tfnh thap nhat l i 78.26% v i nong dp TB l i 25.96 nmpl/l, nhdm Ila v i lib thi cao tddng dddng nhau (nhdm Ila: dudng tinh 93.75, nong dp TB:36.34 nmol/l, nhdm lib; dddng tfnh 97.29%, ndng dp TB: 33.64 nmol/l). Xet theo phin loai dp nang lam sing thi mite dp nhe cd ti le dddng tfnh tfiap hdn (87.27%) so vdi mdc dp viia (97.29%), tuy nhlin ndng dp TB thi tddng dddng nhau (mdc dp nhe: 32.00 nmol/l, mdc dp \iita: 33.64 nmpl/l). Nhd vay ti Ip xet nghipm huyet thanh dudng b'nh cd sd tddng iitig vdi bleu hiin lam sing (nhdm I ti l i dddng tinh thap hdn nhdm II) phu hdp vdi nghiin cii\i cua FE Somnier [1993)'*', nhdng ndng dp AchRAb thi khdng cd

sd khac biit. dieu nay phii hdp vdi y van da ghi laii'l.

V. KET LUAN

Nghien cdu ndng dp AchRAb cua 92 benh nhan nhddc cd (nhom BNNC) va 30 ngddi khde manh (nhdm chdng) kit qui cho thay:

- Tuoi trung binh cua BNNC la: 45 (nam: 48, nO':

43), ti le nir/nam: 1.96/1.

- Phan Ioal Iim sing nhddc cd theo Ossemian:

nhdm I; 25%, nhdm Ila: 34.78%, nhdm lib:

40.21%, dp ning lam sing mdc dp nhe;

59.78%, mii'c dp vda: 40.21%.

- Ndng dp trung binh AchRAb ciia nhdm BNNC:

32.67±20.18nmol/l (nguSng chan doin dddng tinh l i > 0.52 nmol/l) vdi ti l i dddng tinh:

91.30% tiong dd nhdm I: 25.96 nmol/l vdi ti l i (+); 78.26%, nhdm Ila: 36.34 nmol/l v i M le (+): 93.75%, nhdm lib: 33.64 nmol/l v i ti le (+):97.29%, dp ning lam sang mdc dp nhe:32.00 nmol/l, mdc dp vda: 33.64 nmol / I . Ndng dp TB ciia nhdm chdng l i 0.37±0.075 nmol/l (100% am ti'nh). Nhd vay khdng cd sd liin quan gliia ndng dp AchRAb vdi dp nang Iim sing ciia binh nhddc cd trong nghien cud niy.

TAI Ll|U THAM KHAO

1. Nguyin Van Chu'dng (2002), "Binh nhuBc CO", B^h hoc than kinh, Hoc vien QuSn Y, NXB Y hpc.

Ha Nol, ti. 381 - 393.

2. Klaus V. Toyka, Ralf Gold (2004)," Binh nhudc a)

", Than kjnh hoc lam smg, (Chii bien: Daniel D.TruHng, Le Ddc Hinh, Nguyen Thi Hiing, TrSn C6ng Thang djch), NXB Y Hpc, TP HCM, ti.: 614 - 629.

Tiiermo

5i:7e/7ttfcwww.piercenet.coni/method/oven/iew-elisa 5. FE Somnier (1993), " Clinical implementation of anti-acetyicholine receptor antibodies ".loumal of Neurology, Neurosurgery & Psychiatry, 1993, jnnp.bmj.com

6. Matthew N Meriggioll (200g),"Myastiienia Gravis with Antl-AcetylcholineReceptor Antibodies",fl3///77/a//d R (ed): Immune-Mediated Neummuscuiar Diseases.Front Neurol Neurascl.

Basel, Kargery^ 26, pp 94-108 7. Sidra Auragzeb (2009), " Relationship behi/een

Anti - Acetylcholine Receptor Antibody Titres and Seveity of Myastiienia Gravis".mnv.ncbi.nim.nih.gov/pubme£9i9^38131