TP TRUNG I131 TI TUYN GIP CA NGI TRNG THNH BNH GIP DNG MUI, CH PHM C I-T ( VNG C PH MUI

I I-T > 90%)

T Vn Bnh, Hong Thu H, ng Tun Thanh Lng Quc Hi, Nguyn B S Bnh vin Ni tit Trung ng Summary. This study was conducted to determine the thyroid I-131 uptake of euthyroid adults 9 years following the addition of iodine to salt and foodstuffs. We studied I-131 uptake percentage and urinary iodine level on 900 euthyroid adults in 10 districts of Nam dinh province. The normal uptake of our population was standardized in the range between 15 to 35% in 1970-1980; However in this study the average 2-24 hours uptake is 6-23% this result is good reference in the determination of the function of thyroid and assessing uptake after universal iodination of common salt. Tm tt Vic xc nh tp trung I131 ti tuyn gip ngi trng thnh bnh gip cc thi im sau mt thi gian di dng mui v cc ch phm c i-t l v cng cn thit. Qua iu tra trn 900 mu ti 10 huyn ca tnh Nam nh thy tp trung I-131 gim r rt t (15-35%) nhng nm 70-80 gim xung cn (623%). Kt qu ny gip cho cc thy thuc tham kho khi lm cc xt nghim y hc ht nhn. Ngoi ra cng vi i-t niu, qua kt qu ny nh gi hiu qu ca vic ph mui i-t ton dn.

1. t vn Trong chn on v iu tr cc bnh tuyn gip, nghim php o tp trung I-131 ti tuyn gip cho n nay vn l mt xt nghim quan trng. Kt qu ca xt nghim ny gip cho cc thy thuc bit c chc nng ca tuyn gip (Cng gip, suy gip, bnh gip hay ho i-t vng bu c a phng). tp trung I-131 ti tuyn gip thi im 24 gi cn l mt ch s quan trng trong tnh liu iu tr bng I-131 bnh nhn Basedow. Trn th gii nghim php ny c s dng rng ri ti Hoa k, chu u t nhng thp k 50 ca th k XX v ngy nay vn tip tc s dng. Hng s tp trung I-131 ca ngi bnh thng bnh gip cng c xy dng cc quc gia t nhng nm 50 v Vit Nam t nhng thp k 70 v 80. Vit Nam trong 10 nm qua phng chng bnh bu c do thiu i-t c s quan tm ca ng, Chnh ph, ton dn c n mui v cc ch phm c trn i-t theo Quyt nh 481/TTg ca Th tng chnh ph v Ngh nh s 19/1999/NCP v vic sn xut v cung ng mui i-t cho ton dn. Do vic ph i-t cho ton dn nn tc ng n cc hng s v tp trung i-t ti tuyn gip ca ngi bnh gip c xy dng t nhng nm 70-80 khi ton

dn cha dng mui, ch phm c it. Vit Nam c mt s tc gi a ra a ra mt vi ch s v tp trung I-131 ngi dng mui c trn I-t nhng s liu ch dng s t bnh nhn v vic iu tra nghin cu cha ng b. xy dng ch s tp trung I-131 tuyn gip ngi trng thnh bnh gip thi im 2gi v 24 gi phc v cho chn on v iu tr cn c mt cuc iu tra ng b cc vng c ph mui i-t > 90%. Chng ti xy dng v tin hnh ti ny vi cc mc tiu sau: 1. Xc nh tp trung I-131 ti tuyn gip thi im 2 gi v 24 gi ca ngi trng thnh bnh gip ang dng mui, ch phm c i-t vng c ph mui i-t > 90%. 2. nh gi nh hng ca vic n mui v cc ch phm c i-t nh hng ti tp trung I-131 tuyn gip. 2. i tng v phng php nghin cu: 2.1. i tng nghin cu: trnh cc tc ng ho i-t ca cc vng bu c a phng chng ti chn i tng nghin cu l nhng ngi trng thnh bnh gip tui t 16-55 khng phn bit nam n mt tnh ng bng Bc b c ph mui i-t > 90%. l tnh Nam nh v tin hnh chn mu trn c 10 huyn ca tnh. Nam nh l tnh ng bng Bc b c ph mui i-t ton tnh > 90% h gia nh (Theo ti liu cng b ca D n PCBC B Y t). 2.2. Phng php nghin cu: y l mt nghin cu iu tra ct ngang xc nh tp trung I131 tuyn gip thi im sau ung I131 2 gi v 24 gi ngi trng thnh bnh gip tui t 1655 khng phn bit nam n. V chn mu chng ti s dng cng thc xc nh c mu cho nghin cu c lng t l Px. Px(1-Px) n = Z1- /2 d2 Trong : n: c mu Z1- /2: 1,96 tng ng vi tin cy l 95%. d: H s gii hn tin cy 3%. Nu Px: tp trung I131 ti thi im 2 gi, c on l 10% th s mu n cn ly l: 384 mu. Nu Px: tp trung I131 ti thi im 24 gi, c on l 30% th s mu n cn ly l: 896 mu. Chng ti chn c mu chung l n = 900 mu. * Tiu chun la chn mu: chn ngi bnh gip, cc i tng chn mu c khm s tuyn vi cc du hiu lm sng sau: - Nam hoc N c tui t 16 n 55. - Khng c bu c. - Tay khng run

- Nhp tim t 60 n 80 chu k/pht. - Cc du hiu lm sng khc bnh thng. * Cc tiu chun loi tr: - Nhng ngi ang mang thai, cho con b, ngi b suy thn, suy tim... - Nhng ngi ang dng thuc c i-t (Lugol, thuc cn quang...), hormon tuyn gip (T3, T4...) hoc khng gip tng hp (PTU, MTU...), mt s cht c gc ion ho tr -1: Perclorat, Thiocynat, Nitrat... - Nhng ngi tuyn gip c nhn, nang, bu c, tuyn gip hn hp. - C tin s v iu tr cng gip, phu thut tuyn gip, suy gip... - C bnh l v tuyn gip mn tnh, vim tuyn gip cp, bn cp... * Cc xt nghim cn lm sng: - I-t niu trong gii hn bnh thng. - Ton b ngi chn mu u dc lm siu m tuyn gip tnh th tch tuyn gip, loi tr cc trng hp c nhn, nang... c hnh nh bnh l. - TSH huyt tng: Trong gi tr ngi bnh gip 0,35 - 5,5 mU/l. * Chun b mu: Ti 01 im chn ngu nhin trong mt huyn, khm lm sng vi cc tiu chun loi tr v tiu chun chn mu trn chn ra 100 ngi. - Tin hnh ly mu tnh mch nh lng TSH, s mu mu ly 25% ca tng s mu cn tin hnh l 225 mu, mi im s ly t 20 n 25 mu. - Tin hnh ly mu nc tiu nh lng i-t niu ca ton b s mu. Cc mu mu, nc tiu c bo qun a v tin hnh nh lng TSH ti phng nh lng hormon khoa Ho sinh BVNT v phng nh lng i-t niu thuc phng CCK BVNT. - Tin hnh siu m tuyn gip. - B/n c ung mt lng dc cht phng x NaI-131 dng dung dch c hot phng x t 3 n 5 Ci (Dc cht phng x c dng ca hng ISOTOP (Hungari). - o tp trung I131 tuyn gip sau khi ung thi im 2 gi v 24 gi. - o theo phng php o p st bng my o dng trung bnh c u m tinh th nhp nhy NaI (Tl) ng knh 5cm ca hng Bi-tx - Hoa K. My c lm cc nghim php th chun bng ngun 137Cs v o so snh tuyn tnh vi h o c Collimator v o c khong cch ca my o tp trung ca hng Bi-tx Hoa K. * Kt qu c tnh theo cng thc sau: S o TG - Phng mu ca c th tp trung I131 TG (%) = Chun 100% liu ung - Phng t nhin (Phng mu ca c th o i) 2.3. X l s liu: S liu c x l bng chng trnh EPI INFO ca WHO. 3. Kt qu v bn lun

Cuc iu tra c tin hnh trn 10 huyn ca tnh Nam nh t 01/3 n 30/3/2004. Kt qu thu c nh sau: Bng 1: Thng k kt qu iu tra ti Nam nh Khm Mu 131 Siu m N I lm sng (TSH) n v TT c (X - Huyn) Na Na Un Nam N N N tiu 2h 24h m m g 1 2 3 4 5 6 7 8 9 10 Yn lng - yn Gi - V bn M trung - M lc 31 43 36 125 31 149 43 188 36 158 20 105 16 113 32 134 28 102 22 175 32 143 19 59 59 70 74 68 78 96 70 92 89 9 16 12 6 9 14 15 14 18 2 16 19 19 18 17 15 1 5 0 0 88 90 78 75 91 79 76 102 102 102 99 104 106 97 79 81 94 84 74 71

Lc h - Tp.Nam 20 nh Ngha ng-Ngha 16 hng Nam tin - Nam trc 32 Giao thanh - Giao 28 thu Xun hng-Xun 22 trng Hi nam - Hi hu 32 Vit hng - Trc 19 ninh

110 110 105 106 116 124 102 104 88 91 84 80

119 124 118 113 95 108 90 87

Tng s Gii Th tch tuyn Nam gip trung bnh N

279 1392 279 755 115 110 982 1033 921 910 S mu 282 718 Mean (g) 14.53 12.52 STD 2.98 7.25

Bng 2: Kt qu Siu m tuyn gip

Bng 3: Kt qu xt nghim i-t niu. TT 1 2 3 4 5 n v iu tra Yn Lng - Yn Gi - V Bn M Trung - M Lc Lc H - TP Nam nh Ngha ng - Ngha Hng S mu 88 97 104 79 81 Mc i-t niu trung v ( g / dl) 10.3 12.1 14.65 8.5 12.3

6 7 8 9 10

Nam Tin - Nam Trc Giao Thanh - Giao Thu Xun Hng - Xun Trng Hi Nam - Hi Hu Vit Hng - Trc Ninh

120 104 87 119 22 901

12.8 11.2 6.4 5.9 7.65 9.9

Ton Tnh

Bng 4: Kt qu xt nghim hormon TSH S mu 224 S mu 915 900 Tn xt nghim Min TSH Thi im o 2h 24 h 0.13 Min(%) 0.7 10.1 Max 4.87 Max(%) 20.8 39.8 Mean (mU/l) 1.274 Mean(%) 6.362 23.399 Std 0.689 Std(%) 2.976 7.246

Bng 5: Kt qu o tp trung I131

4. Bn lun: Theo mt s tc gi ch s kinh in trong cc iu tra vi s mu >10.000 v lm trn hng vn ngi bnh thng ch s tp trung I 131 ti tuyn gip thi im 2gi v 24gi ca 100% liu ung vo nh sau (Radionuclides for Medical Application. Handbook. USA. 1969) TT 1 2 3 Tc gi 2h(%) 24h(%) Sisson 10,5 38,9 Werner 10 40 Gaffney 20 50 Vit Nam Phan vn Duyt v CS xy dng gi tr tp trung I131 ngi bnh thng l 14,4% thi im 2 gi v 32,5% thi im 24h. Mt s quc gia khc k c cc nc chu u chp nhn tp trung I 131 ngi bnh thng thi im 24 h t 20-50%. Gi tr tp trung I131 b nh hng rt nhiu do vic s dng mui i-t v cc ch phm c it, c bit l dng i-t di ngy. Qua cc cuc iu tra d ngoi ti cc vng bu c a phng do thiu it. Vic b xung mui i-t t hiu qu rt tt, tp trung I131 ca nhng ngi ho i-t 80% gim xung 32% sau 8 thng v 23,5% sau 18 thng. Ti mt s cc quc gia c chng trnh ph mui i-t ton dn cng a ra mt s kt qu c th. Theo Jackson (1983) vic b xung i-t trong ch n lm gim tp trung I131 tuyn gip ti thi im 24h t 15-45% xung cn 6-35%, cn SidneyH.ingbar (1993) gi tr l 5-30% thi im 24 gi.

Bng 6. So snh kt qu iu tra ca Vit Nam Bangladesh (Mi tng quan gia tp trung I131 tuyn gip v i-t niu) Quc gia Thi im Banladesh 1998 2004 Vit Nam 3/2004 Nam: 252 ; N: 648 TT I131 thi im S mu 24h 0-4,9% n1=8 4,91-9,9% 10-30% >30% n2=40 n3=696 n4=156

S mu Nam: 86 ; N: 214 131 TT I thi im S mu I-t niu 24h 0-4,9% n1=99 43,31mg/d l 4,91-9,9% 10-30% >30% N2=100 33,95mg/d l n3=73 n4=28 12,97mg/d l 9,35mg/dl

I-t niu 23,96mg/dl 18,74mg/dl 12,29mg/dl 8,95mg/dl

Ti Bangladesh, mt quc gia rt gn chng ta v a l, t nhin, vng kh hu v mc sng cng nh tp tc sau mt thi gian di ph mui i-t ton dn nghin cu trong 2 nm (1998-2000) trn 300 ngi (gm c 84 nam v 216 n) th thy tp trung I-131 tuyn gip thi im 24 h nm 1980 t 10-45% gim xung 14,12 8,33%. Trong ti ny Bnh vin Ni tit Trung ng tin hnh iu tra hon chnh, tin hnh cc bc thm khm lm sng, xt nghim cn lm sng chn la s mu theo cc tiu chun ca t chc y t th gii (WHO). Vi cc xt nghim chn la t cc tiu chun ca ngi bnh gip, ti tin hnh iu tra trn 900 ngi, kt qu t c nh sau: * Siu m tuyn gip : Nam: 14,53 2,98g N: 12,52 7,25g * I-t niu : 9,9 g / dl * tp trung I131 thi im : 2h: 6,36 2,97% 24h: 23,39 7,24% Vi lng I-t c a thm vo ba n t 200-300 g/ngy (bo co ca d n PCBC v cc RLTI) tc ng ti mc d tr i-t trong tuyn gip, lm gim lng i-t tp trung thm vo tuyn gip v vy gi tr tp vo tuyn gip s gim. Bng 7. So snh kt qu tp trung I-131 tuyn gip thi im 24h sau khi dng mui i-t ca mt s tc gi. tp trung I131 TT Tc gi tuyn gip thi im Ghi ch 24h (%) ph mui i-t >90% t nm 1 BVNT 2004 23,39 7,24 1995 - i-t niu t 9,9mg/dl 2 Phan Vn Sau dng mui i-t 18 thng

3 4 5

Sau 25 nm dng mui trn i-t 300mg/ngy Sau nhiu nm dng mui i-t Bangladesh 6 1993 78,74% s dn i-t niu t 14,12 8,33 2003 > 10mg/dl Nu so snh kt qu chng ti thy tp trung I131 tuyn gip ca ngi trng thnh bnh gip sau khi dng mui v cc ch phm c i-t c gi tr gn vi gi tr ca ngi bnh thng trong cc vng bu c a phng sau thi gian di dng mui i-t chng ti tin hnh nhng thp k 70-80. So vi Bangladesh quc gia hin nay cng ang c chng trnh ph mui i-t nh Vit Nam th thy tp trung I131 ca Bangladesh thp hn nhiu so vi Vit Nam. Chng ti khng r lng i-t a thm vo ba n v c th trong 24h l bao nhiu? Nhng qua gi tr i-t niu trung bnh th theo kt qu iu tra nm 1993 th 78,74% s ngi iu tra c mc i-t niu >10 g/dl so vi mc i-t niu iu tra trong s kt qu iu tra nghin cu ca chng ti l 9,9 g/dl. Kt qu tp trung I131 tuyn gip ca chng ti ph hp vi cc tc gi trn th gii v ph hp vi cc kt qu ca cc nghin cu ca chng ti tin hnh t nhng thp k 70-80. 22 5. Kt lun - Vi kt qu iu tra ton din trn mt vng a l ph mui i-t >90% v vi thi gian 10 nm ca 900 ngi, tp trung I131 tuyn gip gim r rt ngi trng thnh bnh gip t (14-35%) xung (6-23%). - Qua vic xc nh gi tr trung bnh tp trung I131 tuyn gip ngi trng thnh bnh gip gip cho cc thy thuc c mt ch s tham chiu trong vic nh gi chc nng tuyn gip khi lm cc xt nghim Y hc ht nhn. - Trong iu tra ny ny c thm mt thng tin v mi tng quan gia tp trung I131 tuyn gip v nng i-t niu qua nh gi mc gi i-t v thi i-t ca dn c cc vng ph mui it, nh gi hiu qu ca vic dng mui it. - Trong iu tra ny c thm mt s thng s v khi lng tuyn gip v nng TSH ca ngi trng thnh bnh gip lm ti liu tham kho cho cc thy thuc v cho cc nghin cu khc ca ngi dn dng mui v cc ch phm c i-t thi gian di. Ti liu tham kho 1. Phan Vn Duyt: Phng x y hc - Nh xut bn y hc, H Ni 1979. 2. ng Trn Du ch bin - Bnh tuyn gip v cc ri lon do thiu it. 1995. Trg 162-194.

Duyt v CS 1979 Jackson v CS 1982 Sidney H.ingbar v CS 1993 Lamberg B.A v CS 1995

23,5 6 - 35 5 - 30

(iu tr BC n thun vng BCP)

Nguyn Xun Phch: S dng ng v phng x trong chn on lm sng v nghin cu y sinh hc - Vin Qun Y 103, H Ni 1987. 4. Phm Song: ch bin: Bch khoa th bnh hc-tp 1. Trg 28-34. 5. Mai Th Trch-Nguyn Thy Khu: Ni tit hc i cng, nh xut bn Y hc thnh ph H Ch Minh 2003, Trg 139-202. 6. Nguyn Th The: Tm hiu nh hng ca ph mui i-t trong cng ng vi vic nh gi chc nng tuyn gip bng mt s nghim php y hc ht nhn-Lun vn cao hc-i hc y H Ni 1999. 7. Mt s chuyn cng trnh nghin cu khoa dc. Nh xut bn Y hc 1985, Trg 22-37. 8. Handbook of Radioactive Nuclides.USA.1969. Radionuclides for Medical Application. Trg:398-406. 9. Gyrgyi Sandor s Krasznai istvan: orvosi isotoptechnika Medicina knyv kiado. Budapest 1985. 364-372. 10. Werner Ingbar s. The Thyroid A fundamental and clinic 8.Edition. New york.2000. 11. F Alam, 0.Faruque, F Begum...INM, BAEC, BSMNU Bangladesh J.nucl. med. Vol6.No1.January 2003. Status of urinary iodine and I131 uptake after universal iodination of common Salt. Dhaka.Bangladesh.
3.