Y HQC VlgT NAM THANG - SO 2/2014 MO TA THITC TRANG CUNG CAP DICH VU CHAM SOC Y TE CHU'ONG TRINH D O N G THUOC THAY THE METHADONE CAN THIEP TRONG NHOM NGHIEN CHICH MA TUY TAI T H A N H PHO H A NOI Bui Thi Nga=^, Nguyen Anh Quang*, Nguyen Thanh Long** T M TAT Nghien cuff mo ta cat ngang du'dc thyc hien tren 400 ngu'di nghien chich ma (NCMT) tai 02 cO sd dieu tn Methadone tai Ha Ndi. Ket qua nghien ciru cho thay: Lieu khdi Oau trung binh ciia cac benh nhan tham gia nghien ciTu la 20 mg/ngay, lieu tn trung binh la 105 mg/ngay, T^n suat sff dung Heroin hSng ciia benh nhan giam di ro ret: trffdc dieu tri 1,24 in/ngay; giai doan dd lieu 1,07 fan/ngay sau ngay, 0,33 lan/ngay sau 30 va sau thang dieu trj la 0,08 lan/ngay. Ty le benh nhan dffpc chuyen giil den cac dich vu y te khac: NhLr dieu tri ARV la 44,5%, dieu tri nhiem triing cd hpi 30,8%, cung cap BKT sach 2i,3%, tu van xet nghiem ty nguyen 8,3%. Day chinh la cac can thiep dff phong nham lam giam ty le lay nhiem HIV nhom ngffdi nghien chfch ma tuy, Tif khoa: HIV/AIDS, dieu tri. Methadone, nghien chich ma tuy, Ha Ngi. SUMMARY EVALUATION ON I N J E C T I O N DRUG USERS (IDUS) I N T W O METHADONE TREATMENT CENTERS I N H A N O I CITY The cross-sectional descriptive study was done on 400 Injection drug users (IDUs) in 02 methadone treatment centers in Hanoi city. The study results show that: average initial dose for patients participating in ttie study is 20mg/day; average maintenance dose is 105mg/day. The frequency of daily heroin use of patients is considerably reduced: pretreatment frequency is 1,24 times/day, dose-finding tnal frequency after days is 1,07 times/day, after 30 days: 0,33 times/day, after months: 0,08 time/day. The rate of patents being transferred to other health services: antiretroviral therapy is 44,5%; opportunistic infection treatment is 30,8%, clean needle provision is 21,3%; voluntary counseling test is 8,3%, These are preventive intervenhon in order to reduce HIV prevalence among injection drug users. I. £)AT VXN 0^ Tiem chfch ma da trd mot van nan toAn cau, khdng loai trff mot qudc gia hay mdt vung lanh tho nao, khdng chi anh hffdng tdi sffc * Tntng tSm phdng chdng HIV/AIDS Ha Ngi '*B$ Yte Phin bl$n khoa hgc:JS. NguySn Quoc Tru'dng khoe cdng ddng ma cdn anh hu'dng tdi phat trien kinh te va an ninh chfnh tri ciia mdi qudc gia. Tren the gidi, chffdng trinh dieu tri nghien cae ehat dang thudc phien thay the bang Methadone da dffdc trien khai cac qudc gia nhff: LJc, My, Ha Lan, An Op, Thai Lan, Trung Quoc. Tai nhffng nffde chffdng trinh dffde trien khai can thiep nhdm nghien chfch ma tiiy (NCMT) 6a gdp phan giam hanh vi tdi pham va giam sff lay truyen HIV cdng dong. Tai Viet Nam, lay truyen HIV chii yeu la dydng tiem chfch ma vdi tren 50 % tong sd ca nhiem tren toan qudc. Viet Nam mdi chi ap dyng mpt sd md hinh dff phdng lay nhiem cho ngffdi NCMT nhff phan phat Bdm kim tiem (BKT) sach, phan phat Bao cao su (BCS), truyen thdng thay ddi hanh vi, tff van thdng qua ban dong dang, hoat ddng ciia cae cau lac bo phdng chong ma tuy. [1], [7] Hien nay, tai Ha Ndi ed nhieu md hinh can thiep d y phdng lay nhiem HIV eho nhdm NCMT dang dffdc sff dung la chien Iffdc giam thieu tac hai nhff chffdng trinh dieu tri nghien cac chat dang thudc phien thay the bang Methadone. Tuy nhien, tai Ha Ndi cung chffa cd danh gia de tong ket va lya chpn dffdc md hinh ed hieu qua phdng chdng lay truyen HIV, Do vay, nghien cffu dffdc thyc hien nham muc tieu md ta ket qua cua chu'dng trinh dieu tri nghien eae chat dang thudc phien thay the bang Methadone can thiep d y phdng lay nhiem HIV tren nhdm NCMT [1]^ [3]; [4], [5], [6]. II. OOI T U p N G VA PHU'aNG PHAP N G H I ! N CUD - Oja diem : 02 ed sd dieu tri methadone; huyen T y Item, quan Ha Ddng. - Thdi gian nghien cyu: tff thang 1/ 2012 den thang 12/2012 - Odi tffdng nghien cffu; La ngffdi nghien chfch ma sff dung cac loai ma tiiy bang BKT theo tinh maeh, - Phffdng phap nghien ciTu: Ap dung thiet ke nghien cuff md ta cat ngang. Cd mau dffdc tinh theo cdng thffc tfnh: Y HOC VIET NAM THANG - SO 2/2014 Trong do: n : la c5 mau Z : la he sd tin cay, vdi ngffdng sac xuat a = 5%, tacd: Z,,.^ ,,= 1,96 P = 0,4 • Ty le nhiem HIV nhom doi t&dng NCMT nam 2009 (theo dieu tra IBBS nam 2009 ciia TP Ha Ndi). d = 0,023 sai sd cho phep ^ n = 370 ngffdi. Dff phdng phieu khdng hdp_le 10%, ffdc ti'nh bo eude va lam trdn ta cd cd mau nghien cffu la 400. .KET QUA NGHIEN CU'U Bieu 1. Ty le benh nhan giai doan dd lieu va dieu trj tri 87.5 100 50 12,5 Giai doan lieu Giai doan lieu on dinh Trong 400 binh nhan dang tham gia diiu tri nghien cac chit dang thudc phien bang thudc Methad tai quan/huyin Ha Dong va T&Llim vdi ty li benh nhan giai doan lieu 12,5% va giai doan lieu on dinh 87,5%. Khoang 10% benh nhan cho rang thdi gian lieu la chu^ thich hdp, keo dai n benh nhan tlip tuc cd cac bleu hien cua hpi ch&ng cat. Tinh trung binh ty le binh nhan d&dc xet c va tham gia dieu tri chiem 59% tong so benh nhan xa/ph&dng gu7 len Ban xet chpn. Bieu ZT"/ le lieu dieu tri cho benh nhan Methadone Kit qua nghiin c&u cho thiy lieu khdi dau trung^ binh cua cac binh nhan tham gia nghien c&u la mg/ngay. Lieu tri trung binh la 43,5mg/ngay. Bieu 3. Ty le BN sff dung Heroin dieu tri Methadone thang qua o.s 0.6 Tan suit s& dung Heroin hang cua binh nhan giam di ro ret: tr&dc dieu tri 1,24 lan/ngay; gl3 doan lieu 1,07 lan/ngay sau ngay, 0,33 lan/ngay sau 30 va sau thang la 0,08 lari/rtg Nh& vay tinh trang tiep tuc s& dung heroin qua trinh diiu tri Methadone ctJa nhom NCMTch yiu thdi gian lieu. Y HOC VIET NAM THANG - SO 2/2014 Bleu 4. Ty le benh nhan bj tac dung phu dieu tn bang Methadone 80 71.3 60 1 40 20 '. 14.3 Tao bo NgiJa 22.8 21.5 11 J • • • 8.8 libriMid , Non Mat ngii Suy giam tinh due ' _J Khac Trong cac tac dung phu thi tao bon la trieu chiing phd biin nhit d&dc BN bao cao chiim 71,3%. B canh binh nhan co the gap mot sd tac dung khong mong mudn khac nh& suy giam tinh due 22,8%, non, mitngtj va ng&a .t&8,8% den 14,3%. BieudoS.ly le benh nhan tuan thii quy trinh dieu tri Kit qua cho thiy quan diem cua binh nhan vi quy trinh xet nghiem, thdi gian nop ddn va quy trin don dip binh nhan diu chiem ty le i^ 100% dat tiiu chi hdp ly. Tuy nhien van 2,4 % binh nh cho ring quy trinh xet nghiem la ch&a thich hdp, keo dai Bieu 6. Ty le benh nhan hai Idng ve thai dp ciia nhan vien y te Da sdb$nh nhan dude dieu tn deu rit hai Idng, hai long vdi quy trinh don tUp, thai dp lam viec cua bac sy, thai dp nhan vtin t& van . cOng nh& hai long vdi thai dp cua cac nhan vlin cong tac tai cd dieu tri f i chiem tyle dm&c cao (t&95,0% • 98,0%). Tuy vay van co mot so nho (chiim 2,5%) bin nh$n cho kng thdi gian tiep don can linh hoat hdn, ban di lam nin khong din udng thudc kip g md a/^ cua cd sd dieu tri. Y HOC VIET NAM THANG - SO 2/2014 IV. BAN LUAN Chffdng trinh Methadone can thiep cho nhdm benh nhan NCMT vdi giai doan lieu dn dinh 87,5% va giai doan dd lieu 12,5%. Tai thdi diem nghien cffu lieu khdi dau trung binh ciia cac benh nhan tham gia nghien cffu la 20 mg/ngay, lieu tri trung binh la 105 mg/ngay, Ben eanh viec dieu tri thay the bang thudc Methadone thi mdt sd nhffng yeu td lien quan tdi viec benh nhan han ehe sff dung heroin da dat tdi lieu tri phu thudc vao viec cung cap cac dich vu ho trd. Lieu dieu tri Methadone cung cd vai trd quan trpng viec dff phdng lay nhiem HIV, ket qua nghien cffu cua cac tac gia nffdc ngoai eho thay benh nhan dffdc dieu trj vdi lieu hdn 80mg/ngay cd ty le lay nhiem HIV thap hdn han so vdi benh nhan dimg lieu thap hdn. Ve tae dung phu ciia thudc Methadone cae benh nhan ty bao eao cho thay tao bdn la trieu chyng phd bien nhat chiem 71,3% sd benh nhan dieu tri. Ben canh dd benh nhan cd the gap mdt sd tac dung khdng mong mudn khac nhy suy giam tinh due 22,8% va non, mat ngii, ngya vdi ty le 8,8% den 14,3%. Nghien cffu cua Bd Y te cijng chi tren benh nhan dieu trj Methadone: tao bdn la trieu chiffig phd bien nhat dffdc benh nhan bao cao, ehiem 60,8% sd benh nhan dieu trj va sd benh nhan ed the gap mpt sd tac dung khdng mong mudn khac nhff suy giam tinh due, non, mat ngii, ngffa . cac tac dung phu deu d mffc 10 den 11%. Da so benh nhan bao cao bleu hien tao bdn da giam dan theo thdi gian dieu tri. Dieu benh nhan da thay ddi che dp an udng, the due va benh nhan thfch nghi dan vdi trang thai tao bdn sau dieu tri mpt thdi gian dai [2]. benh nhan ve thai dp cua nhan vien y te cung nhff quy trinh dieu trj va ho trd dieu tn dieu trj Methadone da gop phan Idn cho cdng dieu tri nghien cac chat dang thuoc phien thay the bang Methadone. Benh nhan dffdc thffdng xuyen tff van ve van de sffc khde, tinh than, cae van de xa hdi anh hffdng den viec dieu trj trd giiip cho benh nhan tuan thii dieu trj, dac biet hd trd dieu trj cho benh nhan khac phue tac dung phu, nguy cd qua lieu ciia thudc. Nghien cffu ciia Bd Y te cung chf 6a sd benh nhan hien dang dffdc dieu tri tai cae cd sd cho biet ho hai Idng vdi eae djch vu nhan dffdc cung nhff hai Idng vdi thai dp ciia cac nhan vien cdng tac tai cd sd dieu tri. Tuy vay van cd hdn 10% benh nhan cho rang thdi gian tiep ddn can linh hoat hdn, benh nhan cd the ban di lam nen khdng den udng thudc kip gid md cffa ciia cd sd dieu trj, Khoang 14% benh nhan cho rang thdi gian lieu la chffa thi'ch hdp, keo dai nen benh nhan tiep tuc cd eae bieu hien ciia hdi chffng cai [2]. Tai cac cd sd dieu tri cd eac djch vu chuyen gffi benh nhan den cac djch vy y te khac, cu the viec chuyen girl benh nhan tdi dieu trj ARV la 44,5%, dieu tri nhiem triing cd hpi 30,8%, ndi cung cap BKT sach, BCS va cac djch vy khac. Tuy nhien ty le benh nhan dffdc gidi thieu tdi cac djch vu eon thap, dae biet la cac ho trd ve viec lam hoac cac hd trd xa hdi khae danh cho ngffdi sau cai nghien. Ket qua nhieu nghien cffu djnh tfnh va djnh Iffdng tren the gidi cho thay, ben canh viec dieu tri thay the bang thudc Methadone thi mdt sd nhffng yeu td lien quan tdi viec benh nhan han ehe sff dyng heroin da dat tdi lieu tri phu thupc vao viec cung cap cac djch vu ho trd. Ket qua nghien cffu cho thay tan suat sff dung heroin hang ciia benh nhan giam di rd ret: trydc dieu tn 1,24 lan/ngay; giai doan dd lieu 1,07 lan/ngay sau ngay, 0,33 lan/ngay sau 30 va sau thang dieu tri la 0,08 lan/ngay. Nhy vay tinh trang tiep tuc sy dung heroin qua trinh dieu trj Methadone cua nhdm ddi typng nghien cyu chii yeu thdi gian dd lieu. Mdt sd nghien cffu da cho thay dieu trj Metahdone lam giam sff dung ma bat hdp phap. Oe danh gia chat Iffdng ve quy trinh ddn tiep benh nhan, thai dp cua nhan vien y te nghien cffu chimg tdi da sff dung bp cau hdi vdi cac tieu chf hdp ly, khdng hdp ly,qua cac nhan xet ciia benh nhan tham gia dieu tri cho thay quan diem eua Mpt nghien cffu tai Hong Kong cho thay nhffng ngffdi NCMT dffdc dieu trj bang Methadone ed it ban tinh va hanh vi tinh due it nguy ed hdn. Ngoai tae dung giiip ngffdi nghien ngffng hoac giam tan suat sff dung ma tiiy, Methadone cung la mdt yeu td gdp phan lam giam hanh vl dung chung BKT tiem chich nhdm [8], [10]. V. KET LUAN Hieu qua eua dieu trj thay the bang thuoc Methadone can thiep dff phdng lay nhiem HIV nhdm tiem chfch ma la rat kha quan. Ty le lieu khdi dau trung binh cita benh nhan la 20 mg/ngay, lieu tri trung binh la 105 Y HOC VIET NAM THANG - SO 2/2014 mg/ngay. Tan suat sff dyng heroin hang eua benh nhan giam di rd ret: tru'dc dieu tri 1,24 lan/ngay; giai doan dd lieu 1,07 lan/ngay sau ngay, 0,33 lan/ngay sau 30 va sau thang dieu tri la 0,08 lan/ngay. Ty te benh nhan dffdc chuyen girl den cac dich vu y te khac nhff: Dieu trj ARV la 44,5%, dieu tn nhiem triing cd hdi 30,8%, cung cap BKT sach 21,3%, tff van xet nghiem HIV ty nguyen 8,3%, Oa sd benh nhan dang dffdc dieu trj tai cac cd sd deu cho biet hp rat hai Idng, hai Idng vdi cac djch vy ddn tiep benh nhan, thai dp bac sy lam viec, thai dp nhan vien tff van cung nhff hai Idng vdi thai dp eiia cae nhan vien cdng tac tai cd sd dieu trj Methadone. T A I L l g U T H A M KHAO 1. B$ Y te (2013), Bao cao ket qua hoat ddng phong chdng HIV/AIDS thang dau va phUOng hffdng nhiem vu thang cudi nam 2013. Bo Y te (2009), Bao cao ket qua trien khai thi diem dieu tri nghien cac chat dang thuoc phien bang thuoc Methadone tai TP. Hai Phong va TP, Ho Chi Minh nam 2008, tr, 1- 9, Bp Y te (2005), "Cac cong trinh nghien CLAJ khoa hoc ve HIV/AIDS giai doan 2000-2005", Tap chi Y hoc thifc hanh nam 2006. Bp Y te (2007), Hu'dng dan xay di/ng khung cac can thiep dPa tren hoat dong cua cac cd sd dieu tri Methadone ,yi5 Noi, tr, 5- 24. Bp Y te (2010), Hudng dan dieu tri thay the nghien cac chit dang thudc phien bang thuoc methadone, Ha Noi, tr, 3- 25. Trung tam phong chong HIV/AIDS Ha Npi (2013), Bao cao ket qua hoat dong phong chong HIV/AIDS thang dau va phUOng hUdng nhiem vu thang cuoi nam 2013, Thu tu'dng Chinh phu (2012), Chien \Mc qudc gia phong chdng HIV/AIDS d Viet Nam den nam 2020 va tam nhin 2030, NGHIEN Ciru BIEN DOI SO LU'O'NG VA HINH THAI MAU TIEU CAU 6" BENH NHAN GIAM TIEU CAU JVlAU NGOAI VI Nguyen Thj Minh Phuong* T M TAT Giam tieu cau thu'dng gap cac benh ly huyet hpc cung nhU khong huyet hpc. Xet nghiem tiiy ddng mpt vai trd quan trong chan doan, Muc tidu: Tim hieu sif bien ddi sd lUdng va hinh thai mau tieu rau d benh nhan giam tieu cau mau ngoai vi. Doi tffdng va phu'dng phSp nghien cffu: hoi cffu ket hijp tien ciru, mo ta, cat ngang dUdc thyc hien d BVrWQD 108 ty 2008-2013, Ket qua: 400 trUdng hpp giam tieu a u mau ngoai vi ddn thuan hoac kem giam HC Tuoi trung binh la 53,2 tuoi {14-94 tudi), Oa so cic BN nhom tuoi >45 tud'i, Xuat huyet giam tieu cau vo c3n (ITP) la nguyen nhan bien nhat tiep theoja glim sin tiiy, bach cau cap, 57,25% BN so lu'dng mau tieu c3u tiiy binh thu'dng hoac giam nhffng hinh thai vln binh thu'dng. Trong 97/400 BN tang so lUdng m§u ti^u d u vdi hinh thai dang non thi hau het la ITP KSt lu^n: Tiiy la xet nghiem quan de chan do^n xac djnh nguyen nhan giam tieu cau. Titldida: Giam teu cau, Chpc hiit bjy xUOng (tiiy do) • Khoa huyet hpc lam sang Benh vi$n TWQD108 PhAn bl$n khoa hgc: PGS.TS Nguyen Lieu SUMMARY STUDY OF CHANGES I N NUMBER AND MORPHOLOGY OF THE MEGAKARYOCYTES I N PATIENT W I T H THROMBOCYTOPENIA Thrombocytopenia i5 commonly encountered in haematological and non-haematological disorders. Bone marrow aspiration plays a major role in diagnosis. Objective: to analyse the changes in number and morphology of the megakaryocytes in patient with Thrombocytopenia, Patients and methods: This restrospective and prospective crosssectional study was carried out at 108 military central hospital. Results: 400 cases with thrombocytopenia. Mean age of patients was 53,2 years. Maximum number of cases was seen in age group of above 45 years. Idiopathic thrombocytopenic purpura (ITP) was the commonest cause followed by hypoplastic marrow, acute leukaemia respectively. Most patients increased number of megacaryocyte with immature form is ITP. Conclusion: bone marrow aspiration is an important diagnostic modality to determine the aetiology of thrombocytopenia. Keywords: aspiration Thrombocytopenia, bone marrow . ty nguyen 8,3%. Day chinh la cac can thiep dff phong nham lam giam ty le lay nhiem HIV trong nhom ngffdi nghien chfch ma tuy, Tif khoa: HIV/AIDS, dieu tri. Methadone, nghien chich ma. phien thay the bang Methadone. Tuy nhien, tai Ha Ndi cung chffa cd danh gia de tong ket va lya chpn dffdc md hinh ed hieu qua trong phdng chdng lay truyen HIV, Do vay, nghien cffu nay dffdc. MORPHOLOGY OF THE MEGAKARYOCYTES IN PATIENT WITH THROMBOCYTOPENIA Thrombocytopenia i5 commonly encountered in haematological and non-haematological disorders. Bone marrow aspiration plays a major