B Y T TRNG I HC DC H NI NGUYN TH HI NH GI TC DNG TRN M HNH GY SI TIT NIU IN VIVO V C TNH CA BI THUC GM BA V DC LIU: D, B , XU H KHA LUN TT NGHIP DC S H NI - 2013 B Y T TRNG I HC DC H NI NGUYN TH HI NH GI TC DNG TRN M HNH GY SI TIT NIU IN VIVO V C TNH CA BI THUC GM BA V DC LIU: D, B , XU H KHA LUN TT NGHIP DC S Ngi hng dn: TS. Nguyn Thy Dng Ni thc hin: B mn Dc l H NI - 2013 i LI CM N Trc tin, ti xin chn thnh gi li cm n n qu thy c trng i hc DcHNitrangbchotinhiukinthcqubutrongsutnhngnmhc va qua. Ti xin by t lng bit n su sc ti TS. Nguyn Thy Dng, ngi thy tn tnh hng dn v quan tm gip ti trong sut qu trnh thc hin ti. TicngxingilicmnchnthnhtiTS.NguynHongAnh,TS. Nguyn Qunh Chi c nhng gp , gip ti trong qu trnh thc hin ti. Trong qu trnh lm thc nghim, ti cn nhn c s gip nhit tnh ca cc thy c, anh ch k thut vin B mn Dc l. Ti xin chn thnh cm n s gip ht sc qu bu . Tixingilicmnnccthyc,ccanhchkthutvinBmn Dc liu, cc anh ch Vin Dc liu h tr ti trong thi gian thc hin ti. Licuicng,tixinchnthnhcmnnnhngngithntronggia nh, nhng ngi bn tn tnh h tr, gp , gip v lun bn cnh ti trong sut thi gian hc tp v nghin cu. H ni, ngy 20 thng 5 nm 2013 Sinh vin Nguyn Th Hi ii MC LC T VN .................................................... ...............1 CHNG 1.TNG QUAN2 1.1.S lc v bnh l si tit niu....2 1.1.1. Bnh si tit niu theo Y hc hin i..2 1.1.2. Bnh si tit niu theo Y hc c truyn...9 1.2.Cc nghin cu thc nghim iu tr bnh si tit niu bng tho dc .10 1.2.1. Tnh hnh nghin cu iu tr si tit niu bng tho dc trn th gii....10 1.2.2. Tnh hnh nghin cu iu tr si tit niu bng tho dc Vit Nam....11 1.3.Bi thuc nghin cu..........12 1.3.1. Cc dc liu s dng trong bi thuc...............12 1.3.2. Nhng kt qu nghin cu bc u v bi thuc.....17 CHNG 2. I TNG V PHNG PHP NGHIN CU.......18 2.1.Nguyn liu nghin cu.....................18 2.2.Phng tin nghin cu.........18 2.2.1. ng vt th nghim.......18 2.2.2. Ha cht thuc th.....19 2.2.3. Thit b v dng c....19 2.3.Ni dung nghin cu.........19 2.4.Phng php nghin cu.......19 2.4.1. Phng php nh gi tc dng ca bi thuc trn si tit niu in vivo....19 2.4.2. Phng php xc nh c tnh cp v c tnh bn trng din ca bi thuc nghincu......23 2.4.3. Phng php x l s liu......25 CHNG 3. KT QU NGHIN CU..26 3.1.Kt qu th tc dng ca bi thuc nghin cu trn m hnh gy si tit niu in vivo....26 iii 3.1.1. nh hng ca bi thuc nghin cu n s tng trng khi lng c th chuttrn m hnh gy si tit niu in vivo.....26 3.1.2. nh hng ca bi thuc nghin cu n th tch v pH nc tiu ca chutcng trng trn m hnh gy si tit niu in vivo....27 3.1.3. nh hng ca bi thuc nghin cu n cc ion ,, trn m hnh gysi tit niu in vivo...28 3.1.4. nh hng ca bi thuc nghin cu ti tinh th niu ca chut trn m hnh gy si tit niu in vivo....29 3.1.5. nh hng ca bi thuc nghin cu n m bnh hc ca thn trn m hnh gy si tit niu in vivo....32 3.2.Kt qu xc nh c tnh cp v c tnh bn trng din ca bi thucnghin cu...................39 3.2.1. Kt qu th c tnh cp ca bi thuc nghin cu.......39 3.2.2. Kt qu xc nh c tnh bn trng din (28 ngy) ca bi thuc nghin cu......39 CHNG 4. BN LUN..49 4.1.V tc dng ca bi thuc nghin cu trn m hnh gy si tit niu in vivo...49 4.2.V c tnh cp v c tnh bn trng din ca bi thuc nghin cu...52 4.3.1. V c tnh cp ca bi thuc nghin cu..........52 4.3.2. V c tnh bn trng din ca bi thuc nghin cu..............52 KT LUN V XUT.....54 TI LIU THAM KHO...56 iv DANH MC CC K HIU, CC CH VIT TT ALT:Alanin aminotransferase AST:Aspartat aminotransferase COD: Calci oxalat monohydrat COM: Calci oxalat dihydrat DC1: Dch chit bi thuc nghin cu vi liu 2,52 g/kg DC2: Dch chit bi thuc nghin cu vi liu 5,04 g/kg DC3: Dch chit bi thuc nghincu vi liu 10,08 g/kg LD50: Lethal dose 50 (liu gy cht 50% s ng vt quan st) PAM: Phosphat amoni magnesium v DANH MC CC BNG Trang Bng 1.1:Danh sch mt s thuc t dc liu dng iu tr si thn, si mt, sitit niu...11Bng 2.1:Thang im nh gi....22 Bng 3.1:nh hng ca bi thuc nghin cu n th tch nc tiu..27 Bng 3.2:nh hng ca bi thuc nghin cu n cc ion,,29 Bng 3.3:im nh gi v tinh th niu ca cc l chut30 Bng 3.4:nh hng ca bi thuc nghin cu n khi lng thn....32 Bng 3.5:nh hng ca bi thuc nghin cu vi liu 8,64 g/kg vliu 25,92 g/kg chut dng lin tc 28 ngy n cc ch s huyt hc trn chut nht trng....41 Bng 3.6:nh hng ca bi thuc nghin cu vi liu 8,64 g/kg v liu 25,92 g/kg chut dng lin tc 28 ngy n cc ch s ha sinh chut nht trng........43 Bng 3.7:nh hng ca bi thuc nghin cu vi liu 8,64g/kg v liu 25,92g/kg chut dng lin tc 28 ngy n khi lng cc c quan ca chut nht trng.......................................................................................................44 vi DANH MC CC HNH, TH Trang Hnh 1.1: Hnh nh tinh th dng COD (c) v COM (a,b) di knh hin viin t....3 Hnh 1.2:Cy D (Coix lachrymal-jobi L. Poaceae)....13 Hnh 1.3:L cy b (Ficus religinosa L.Moraceae).......15 Hnh 1.4:Cy xu h (Mimosa pudica L.Mimosaceae)......16 Hnh 2.1: Quy trnh th nghim gy si tit niu........21 Hnh 3.1:nh hng ca bi thuc nghin cu n tng khi lng c th ca chut.....26 Hnh 3.2:nh hng ca bi thuc nghin cu n pH nc tiu chut28 Hnh 3.3:Hnh nh tinh th niu ca chut cng trng...31 Hnh 3.4:Hnh nh vi th thn chut l chng trng..34Hnh 3.5:Hnh nh vi th thn chut l chng bnh...35 Hnh 3.6:Hnh nh vi th thn chut l ung DC1.....36 Hnh 3.7:Hnh nh vi th thn chut l ung DC2........37 Hnh 3.8:Hnh nh vi th thn chut l ung DC3........38 Hnh 3.9:nh hng ca bi thuc nghin cu liu 8,64 g/kg v liu25,92 g/kg chut dng lin tc 28 ngy n khi lng c th chut nht trng....40 Hnh 3.10:nh hng ca bi thuc nghin cu vi liu 8,64g/kg v liu 25,92g/kgchut n cu trc vi th gan thn chut nht c th nghim sau 28 ngy ung thuc.......................................................46 Hnh 3.11: nh hng ca bi thuc nghin cu vi liu 8,64g/kg v liu 25,92g/kg chut n cu trc vi th gan thn chut nht ci sau28 ngy ung thuc.47 1 T VN SingtitniulmtbnhkhphbintrnthgiivVitNam. Bnh hay ti pht do s kt thch ca mt s thnh phn trong nc tiu nhng iukinl ha nht nh.Sigytcngtitniu, nhimkhunv au,lm nguy hi ti sc khe v tnh mng ca ngi bnh [19]. gii quyt si tit niu, y hc hin i c nhiu phng php.M ly si l phngphpthngdng,chiutrongtrnghpsitohockhisigytc ngtitniu.Tuynhin,viphngphpnysithngbtiphtsau mtthi gian.Tn dc iu tr si cng c mt s loi nhng tc dng tng i hn ch [21], [28].Gn yc phng phptnsi ngoic th,tnsi qua danhngvncn nhiu tai bin. Y hc c truyn c nhiu cy thuc, bi thuc c cho l c tc dng cha si tit niu nhng cha c nghin cu y to iu kin cho thy thuc v nhn dntin dng.Vinmtrli y,mts tinghincuthc nghimv tcdng iu tr si tit niu ca cc cy thuc v bi thuc c thc hin. Trong , ti nghin cu tc dng ca bi thuc gm ba v dc liu: d, B , Xu h trn si titniuinvitrochoktqukhquan[14].chngminhtcdngcabithuc trn thc nghim, lm c s khoa hc cho vic s dng thuc trn lm sng, chng ti tip tc thc hin ti nh gi tc dng trn m hnh gy si tit niu in vivo v c tnh ca bi thuc gm ba v dc liu: d, B , Xu h vi hai mc tiu: 1- nhgictcdngcabithuctrnmhnhgysititniubng ethylen glycol v amoni clorid. 2- Xc nh c c tnh cp v bn trng din ca bi thuc. 2 CHNG 1. TNG QUAN 1.1.S LC V BNH LSI TIT NIU1.1.1.Bnh si tit niu theo Y hc hin i 1.1.1.1. nh ngha bnh l si tit niu Sitit niul mt bnhthng gpv hayti pht ngtit niu dos kt thch ca mt s thnh phn trong nc tiu iu kin l ha nht nh. Sigynghntcngtitniu, huqucth dnn ncthn,hy hoi t chc thn, gy nhim khun, gy au, nh hng n sc khe v tnh mng ngi bnh [4]. 1.1.1.2. Dch t hc bnh l si tit niu Si tit niu l bnh ph bin trn th gii.Tuy nhin, s phn b khng ng u.Bnh t gp chu Phi, cn chu M t l gp trung bnh 20/10.000 ngi mi nm[2].BnhctlkhcaophaNamTrungQuc,VitNam,Indonexia, Mailaixia,ThiLan,n,Pakixtan,HiLp,AnhvbnoXcandinavo[2]. Tuimcbnhthngt35-55tuynhinthi im mcbnhkhcnhautytheo loi si [2], [44]. Thnh phn ha hc ca si v t l gp nh sau: si calci oxalat kthpvicalciphosphat80%,sistruvit17%,siaciduricvcystin3%[2], [24], [38]. Nam gii mc bnh si nhiu gp 3 ln n gii [2], [24], [38], [39].Tuy nhin, t l bnh thay i ty theo thnh phn ha hc ca si. Trong khi nam gii b si calci nhiu hn (88,4 % so vi 58% n gii) th n gii b si struvit nhiu hn (38% so vi 8,8% nam gii) [2], [24]. T l nhng ngi c nguy c cao b si tit niu vo khong 2 - 3% dn s v khong 50% bnh nhn c tin s si tit niu s b si ti pht trong vng 10 nm sau khi can thip ly si [24], [27]. 1.1.1.3. Cu trc, thnh phn ha hc ca si tit niu Thnh phn kt thch ca si tit niu gm cc loi sau [4]: Si calci: calci oxalat, calci phosphat. Si phosphat amoni magnesium PAM (struvit). Si do chuyn ha: acid uric, cystin. 3 Lichwitz(1928),Meyers(1952),Boyce(1956)cutrccasi:Mngcht hu c (matric organique) nh mucopolysaccharid, mucoprotein cng vi s lng ng ca cc cht v c calci, phosphat. Trong si c 90% trng lng l tinh th, cn li 5% l nc, 3% l protein v 2% l cc cht vi lng khc nh carbonat, citrat, natri, kali, fluor [15]. Theo Nguyn Bu Triu [19], si calci oxalat kt tinh c th ngm mt phn tnc(calcioxalatmonohydrat-COM)hochaiphntnc(calcioxalat dihydrat-COD),rtcnquang,muvnghocen,rtrn,bmtlmchm nhiu gai, hay gp nam gii hn n gii. Si calci phosphat di dng brusbit hay apatit, cn quang c mu trng, kch thc to, c nhiu lp, d v hn calci oxalat, tlnamvngnbngnhau.Sistruvitckchthcto,hnhsanh,mu trng ng, cn quang, hay gp ph n, hnh thnh do nhim khun, c bit l vi khun Proteus. Si urat c mu nu, rn chc, khng cn quang, hay kt hp vi si calci oxalat, thng gp n gii v ngi cao tui. Si cystin cn quang va phi, mutrngng,haykthpvisicalciphosphat,thnggpngitr[15], [24]. Trongccloisitrn,sicalcioxalatlloisiphbinnht,chimkhong80%,tntihaidngtinhthcalcioxalatmonohydrat(COM)vcalci oxalat dihydrat (COD) [2], [19]. (a) (b)(c) Hnh 1.1: Hnh nh tinh th dng COD (c) v COM (a,b) di knh hin vi in t 4 1.1.1.4. L thuyt v hnh thnh si Thnh phn cu to si rt khc nhau v qu trnh hnh thnh si cng rt phc tp.V vy, hin nay cha c mt l thuyt tng qut v qu trnh hnh thnh si.C rt nhiu thuyt trnh by v c ch hnh thnh si nh sau: Thuyt v cht keo che ch ca Butt: Butt cho rng, cc cht keo nh mucin, mucoproteinc tc dng ngn cn khng cho cc tinh th kt hp li vi nhau to thnh si. Khi c si, cht keo ny c tc dng ngn cn s ln ln ca vin si. Cc nhim khun ng tit niu, ri lon ni tit, hi chng Cushing, u nng cn gip, vt l trong nc tiu, nc tiu qu kim hoc qu acid, lm cho cht keo trn gim i, gy ra si tit niu [19]. Thuyt ca Randall (1937), Carr (1954):Khi c s tn thng ca thp, i thn,sxyrasktttothnhsititniu.Gny,mtsnghincutrn ng vt th nghim cho thy, nhng mnh v ca cc t bo ng thn b tn thng cng c vai tr nh mt nhn d th si calci oxalat d kt tinh [21], [19]. ThuytkhunmucaBoyce(1965):Khinctiutoanchtkhun mucoprotein, polysaccharid d kt hp vi calci to thnh nhng hn hp khng tan lm khi im cho s kt si. C polysaccharid thuc loi keo che ch ngn cn s kttinhsithcngcnhngmucoproteintoanthucloilmhtnhnchosi urat hnh thnh [19]. Thuyt do tng tit: Khi nc tiu trng thi bo ha, cc tinh th t chng lin kt li thnh si [19]. Thuyt v cc cht c ch s kt tinh: Nc tiu c kh nng ha tan cc tinh th cao hn mc bnh thng v nc tiu thng trng thi bo ha vi mc khcnhau.Nuthiuchtcchskttinhcacctinhthcngssinhsi. H.G.Ruston v M.Spector (1982) cho rng s thiu ht yu t magie s lm tng s kt tinh cc tinh th calci oxalat [19]. Trn thc t, cc c ch hnh thnh si tit niu lun lun phi hp, b sung cho nhau gii thch v qu trnh sinh si ch khng th tch ri. 5 1.1.1.5. Nguyn nhn gy si Nguyn nhn ca s hnh thnh si khng phi do mt bnh c bit no m l bin chng ca nhiu bnh. V vy, s pht sinh si c nhiu ngun gc khc nhau ty tng loi si [2], [4], [15]. Yu t di truyn ivisicystinvsiurat,yutditruynngvaitrquantrng.Si cystin xut hin nhng bnh nhn c kiu gen ng hp t. Vai tr di truyn trong si urat, si oxalat r rng. i vi cc loi khcyu t di truyn kh xc nh hn. Cc d dng bm sinh Trn thc t, nhng d dng bm sinh v mc phi ch l nhngyu t thun li to si do ng v nhim khun. Nguyn nhn ch yu do ri lon chuyn ha cc thnh phn trong nc tiu c bi tit qua thn. Yu t a d v kh hu Yut nythngcccnh dchthcara.Khhu nngvkh vng sa mc v vng nhit i l yu t mi trng tc ng rt nhiu n s pht sinh bnh si ng tit niu. Ch n ung Chnunglmttrong nhng nguynnhngytcngtrctip n bnh si. V d thc n cha nhiu purin, oxalat, calci, phosphatc kh nng sinh si cao hn. Ri lon chuyn ha Nng calci, acid uric mu qu cao, c cystin trong nc tiu. Cc nguyn nhn khc Nc tiu bi tit ra qu t, nng magnesi v acid citric trong nc tiu qu thp,pHqukimhayquacid.Sidonhimkhunnhloisistruvit.Cc trng hp gy xng, nm bt ng lu cng l nhng iu kin hnh thnh si. 6 1.1.1.6. Chn on bnh si thn Triu chng lm sng[15] [24] +auvngthtlng(cbitlcsidichuynvgytcngtit niu). + Cn au qun thn (do si tc b thn hay niu qun). + i c. + V niu (si lm tc ng tit niu ca thn). Chp X quang[15] 90% si c hnh nh cn quang v chp X quang khng chun b c th pht hin phn ln si tit niu (tr si acid uric khng cn quang).Cn chp nghing v t nht chp niu tit niu. C th chp ct lp pht hin si nh, p dng khi si khng cn quang Siu m[15] Phng php ny b sung cho chp X quang, trong trng hp ph n c thai, bnh nhn v niu hoc b suy thn vi ure huyt cao hn 1g/l. Xt nghim[15] Xtnghimcngrtquantrngtrongvicchnonbnhsingtit niu.Cc xt nghim thng lm bao gm: o pH nc tiu, soi vi th cn, nu nghi c nhim trng tin hnh cy nc tiu, nh lng cc yu t calci, natri, acid uric, creatinintrongnctiukhicnthit,nhndngccvinsibnhnhnira c. 1.1.1.7.Phng bnh Phthinsmnhngnguynnhnnhcalcimuqucao,vimngtit niu, d dng bm sinh ng tit niu iu tr ngay [15]. Ung nhiu nc lng nc tiu bi tit mi ngyt nht l 1,5 lt n 2 lt,ri utrong 24gi.Nu ranhium hidolao ng, thitit nng bc,cn ungthmnc,ttnhtlnckhongcbicarbonat,nchoaqu.Ung nc trc khi i ng, v ban m nng mui trong nc tiu tng mnh, si d hnh thnh. Khng nn lm dng nc ch en v c nhiu oxalat, khng nn ung 7 nhiu coca cola, bia v hm lng mui oxalat v acid uric trong nc tiu s tng [15]. Cn c ch n ung thch hp khi xt nghim nc tiu thy c nhiu calci, calcioxalat,aciduric.Nucsiacidurickhngnnnnhiuthcphmgiu purin,kimha nctiu bngccmui natribicarbonat, natricitratn pHtrn 6,5.Tngcngnthmrau,qu tngthiacidcitric,mtyutcnthit km hm s hnh thnh si. Nn n nhiu rau qu c si, trnh cc rau cha nhiu oxalat. iu chnh pH nc tiu ty loi si bnh nhn mc phi (v d: si struvit cn phi toan ha nc tiu) [2], [15]. i vi tng loi si, ch loi tr nhng yu t thun li cho qu trnh hnh thnhsi,tchnungnviciuchnhccyutsinhlhacatng bnh nhn. 1.1.1.8. iu tr iu tr ni khoa [2], [15], [24] iu tr ni khoa ch yu d phng, p dng vi si nh hay bnh nhn iu tr ngoi khoa. i vi tt c cc loi si ch ung nc nhiu 2 lt/ngy l bin php c a dng. iu tr ni khoa da vo thnh phn ha hc ca si v nguyn nhn gy ra tng loi si. iutrsicalci oxalat baogmvic hnchcc ngunthcncha nhiu calcivoxalatngthisdngmtsloithucnhhydrochlothiazid, cellolophosphat, orthophosphat. iu tr si struvit, dng cc khng sinh thch hp nh penicillin v cc loi fluoroquinolon iviiutrsiaciduric,khuynbnhnhnkhngnnnthcncha nhiupurin.Dngallopurinol,kimhanctiubngbicarbonathaycitrat( gi nc tiu c pH ln hn 6). 8 iutrsicystinbngcchungnhiunc,kimhanctiubng bicarbonat. Tmliiutrnikhoanhmgiiquytnguynnhnvcccchgy bnh, c tc dng hn ch ti pht si, gim bt cc ch nh iu tr ngoi khoa v trnh cc bin chng khc ngoi thn.iu tr ni khoa ngy cng c hiu lc v t gy tc dng ph cho bnh nhn. iu tr ngoi khoa[15] Trong vng vi thp nin gn y, phng php iu tr si tit niu trn th gii c nhiu bin i to ln nh nhng tin b trong lnh vc quang hc, siu m vlaser.Vicc phng php hin i nhTnsi ngoicth,lysithn qua da, ly si qua ng soi niu qunPhng php phu thut c in dn dn thu hp phm vi ch nh. +Tn si ngoi c th Tn si ngoi c th l mt phng php t gy hoc khng gy sang chn, p dng rng ri trong nhng nm gn y. Vphng php:Sngxungngt hthngin phocint,nhv sibngX quang hocbngsium.Sngxungtptrungvo mttiu imvi mt p lc cao (trung bnh 800 1000 bares) lm v hoc lm vn sau bi xut ra ngoi theo ng t nhin. Phngphpnypdngvisiibthnhocniuquntrnving knh nh bng 2cm +Ly si thn qua da Phngphp:tngsoivothnxuynquathnhlngvnhumthn, dng dng c c bit a qua ng ni soi ly si. Kthut tngsoi kh, dgytai binchymu,nhimkhun,thngi trng, thng mng phi. Phng php ny p dng vi hu ht cc loi si 9 +Phng php phu thut Mlysivdnluthn,mlythnvtohnhbthn,ctthnmt phn, ct thn. Phng php ny p dng vi si gy tc ng bi tit. 1.1.2.Bnh si tit niu theo Y hc c truyn 1.1.2.1. Nguyn nhn sinh bnh Bnh si tit niu cn gi l Thch lm Theo y hc c truyn, lm chng do nhiu nguyn nhn gy ra. Nguyn nhn chnh do thp nhit kt h tiu lm cho cn nc tiu ng li. Cn nh gi l sa (ct),sitogilthch().Savthchlmtrnginsvnhnhcathy dch. Thp nhit ut kt di khin kh ha bng quang khng thun li, dn n tiu tin kh v au but, l chng nhit lm.Nu thp nhit yu tr lu ng tit niu m kt thnh si th s gy ra chng thch lm, cn nu thp nhit hi n phn huyt kinh lc, s xy ra hin tng i ra mu, l chng huyt lm. Nu thp nhittrhtiu,khhakhngthunli,trongclnln,mvthy dch theo ng nc tiu ra gi l chng cao lm [2], [21]. Nguyn nhn th hai l t thn dng h. Do bnh lu ngy khng khi, thp nhitlm haotnchnh kh, hoc ngigiscyu, m au lu,kh nhc nhiu, lmchothndnghdnnbngquangkhngkhhac,tdngh khng vn ha c thy thp gy ra bnh lm [2], [21]. 1.1.2.2. Phn loi v iu tr Th thp nhit: Do n nhiu cc thc n cay nng bo ngt hoc nghin ru, thp nhit lu ngy lm cho cn trong nc tiu t li thnh si. iu tr: s dng thuc thanh nhit, bi thch, tr thp, li niu. Bithuc nam kinhnghim dngian[2]: Kimtintho40g,Satint20g, Ut kim 16g, Ngu tt 10g, Trch t 10g. Thcan ut kh tr: Do tinh thn khng th thi, cu gin tn thng gan, gy nngan ut khtr,khtrkhngtuynthngutha ha, ha ut htiu,nh hng kh ha ca bng quang dn n tiu tin kh, au tiu khng ht bi. 10 iu tr: s dng thuc hnh kh li niu, thng lm bi thch. Bithuc namkinh nghim dngian[2]:o nhn 8g,Utkim 8g,Ngutt 8g, Ch xc 6g, Kim tin tho 20g, Sa tin t 12g, K ni kim 8g, d 12g, Bch mao cn 16g, Ngu tt 8g. Ththnmhsuy:Silungykhngkhi,thpnhitgyhaothng chnhkh,tuigi, bnhlu ngycthb h nhc,thin nhin bttc, lao lc qu,dntithnmsuy,mhhavng,hhabc huytvong hnhgy nn tiu tin ra mu. iu tr: s dng thuc b thn, li niu, thng lm. Bi thuc nam kinh nghim dn gian [2]: Dy t hng 30g, Th phc linh 20g, C mi 30g, T gii 30g, M 16g, Ht sen 30g. 1.2.CC NGHINCUTHCNGHIMIUTRBNHSITITNIU BNG THO DC 1.2.1.Tnh hnh nghin cu iu tr si tit niu bng tho dc trn th gii Ngaycgiaion phttrincc phngphpiutr ngoikhoa, iutr bng ni khoa vn c quan tm. Theo Trung y, t nhng nm 141 - 208, Hoa nu cc triu chng ca sa lm,thchlm,huytlmvccbithucchabnhsichoktqutt(ccv thucchyugm:Kimtintho,Hotthch)[6].Chonngynayvnc nhiu tc gi tha k v ng dng. Trong Thin gia diu phng gii thiu 11 bi thuc kinh nghim dng cha bnh si tit niu nh: Ging thch tang, Chn kim thang gia gim, Niu l kt thch thang, Kim hi bi thch thang, Thng phao thangT l chung i c ra si l 50 - 70% khi dng bi thuc trn [16]. NhtBn, nhiunghincuchothytpqunn ungcnh hng n vicphngviutrbnhsititniu[35],[36].Nm1995,khoatitniuca mts bnhvinNht Bnkthpvicctrngi hcYDc, thchin nghin cu Tc dng c ch ca 16 dch chit tho mc trn s kt tinh ca calci oxalatinvitrovtrnshnhthnhsingtitniuinvivo[34].Trong16v thuc nghin cu, Trch t v H kh tho c tc dng c ch tng i tt. 11 Bng 1.1: Danh sch mt s thuc t dc liu dng iu tr si thn, si mt, si tit niu [24]. Tn cyTn thng dng Bphn dngTc dng 1.Alhagi mannifera 2.Armoracia lopathifolia 3.Barbarea vulgaris 4.Capsella bursapastori 5.Cucumis sativus 6.Ficus carica 7.Olea europeae 8.Theobroma cocao Camels thom Horse radish Rocket Mothers heart Cucu Fig Olive Cacoa R cy Ht R v l cy Ton b cy L V qu, qu Du Ht Tr si thn Li niu Tr si thn Tr si thn Li niu Tr si thn, si mt Tr si thn Liniu,gimau thn 1.2.2.Tnh hnh nghin cu iu tr si tit niu bng tho dc Vit Nam. Si tit niu Vit Nam c nghin cu t rt lu. Tu Tnh (th k XIV) trong tc phm Nam dc thn hiu a ra nhiu v thuc c tc dng iu tr lmchngnh:Rctranh,Trcht,Hot thch, Da di,Kimtintho,M [18]. Trong qu trnh tha k v pht huy nny hc c truyn dn tc, nhng nm quacmtsnghincuiutrbnhnybngccbithucdngcyKim tin tho. Khi ngm si vo nc sc Kim tin tho, mt thng sau thy si nh i [3].TipthukinhnghimdngiancLc,lngyctruynVVnHi dng bi thuc vi thnh phn ch yu l Kim tin tho v Ct toi b cho kt qu kh quan [9]. n nm 1989 lng y Nguyn Vn Yn s dng bi thuc c thnh 12 phn ch yu l Trch t, Hot thch, Mc thng, Th phc linh iu tr cho nhiu bnh nhn v cho kt qu tt [9]. Vi phng chm kt hp y hc c truyn vi y hc hin i trong nghin cu nhm nng cao hiu qu iu tr, t nm 1997 n 1999 vin Qun Y 108 (Nguyn T, L Th Chnh, Chu Hong Vn) nghin cu nc sc thn cy l Giang s dng iutrbnhsititniu[5].Cctcginhnthythucctcdng:liniu, chng vim lm mn si v i ra si vi kt qu 54%. VinyhcctruynsdngbithucNglinhtngiavvithnh phn: L ci xay, Kim tin tho, K ni kim, Bch trut, Phc linh, Tr linh, Trch t, Qu chi iu tr si tit niu v thu c kt qu tt [20]. Nghin cu thc nghimchothybithucctcdngbomnsiinvitro,tcdnglitiukh mnh v ko di 6 gi sau khi ung thuc ng thi khng lm mt cn bng in gii qu mc nh hypothiazid. Ngoi ra, trong kho tng thuc nam v kinh nghim dn gian t trc ti nay cng c nhiu v thuc v bi thuc cha si ng tit niu, hin nay vn cn c lu truyn rng ri trong dn gian nhng cha c nghin cu nh [9], [10], [17]: BithuccalngyHDngTip:Mcthng12g,Rsi8g,Kimtintho 12g,Chitg,Satin 12g,Trcht 8g,Mao cn 20g,Ngutt 8g.Bithucca bc s chuyn khoa II Nguyn Hng Sim: Cy ru mo 30g, Trn b 10g, Kim tin tho 30g,Bn h 12g,K ni kim 12g,Qu chi 8g,Xchthc 20g,Chxc 10g, Trch t 15g, Hong b 8g. 1.3.BI THUC NGHIN CU 1.3.1.Cc dc liu s dng trong bi thuc 1.3.1.1. d Tn khoa hc: Coix lachrymal-jobi L. Poaceae. c im thc vt v phn b: d l mt loi cy sng hng nm, mc thnh bi, cao 1-2m, ging cy ng. Thn cy thng, t phn cnh, nhn bng khng c lng, c vch dc, rut xp. L mcsole,hnhdi,di10-50cm,rng2-5cm,gctrnhochnhtim,uthun 13 nhn, mpunln,gn giatonirtrmtdi; b ldivrng,bchia nh. Hoa n tnh, cng gc, mc thng ng thnh bng k l; Hoa c mc trn, 2-3 ci xp lp; Hoa ci pha di hnh trng, c bao bc bi mt l bc rt dy. Qu c my cng bao bc, nhn bong. Ht c ni nh bt. d mc t nhin phn b ri rc mt s tnh vng ni pha bc nh Lo Cai,HGiang,LaiChuCythngmcgnngunnc,dcbkhesui ca rng hay trong thung lng [13]. Hnh 1.2:Cy D (Coix lachrymal-jobi L. Poaceae) Thnh phn ha hc: Htd:Tinhbt,protein,ccacidamin,coixenolid,-monolinolein,cc polycosanol, cc amid, cc hp cht lactam, cc hp cht phenol, cc polysaccharid v mt s acid bo. R: Cha tinh bt, protein, cht bo, benzoxazolon, mt s dn cht lignin. L: Cha benzoxazolon. Thn:Tphnondchchitchloroformthncyd,mtshpcht trong thn cy d: stigmast-4-en-3-one, -sitosterol, 4-hydroxy benzaldehyd 14 Tc dng: Ht d c dng lm thuc gip tiu ha, cha tiu chy, vim rut, mn nht [25]. Theo dn gian ht d c dng lm thuc li sa, thuc bi dng c th [13]. Rchavimnhimngniu,sithn,phongthp,axng,trema chy, bch i, ri lon kinh nguyt, kinh b [13]. Thndmicnghincuctcdnghnghuyt.Mtsti nghin cu v dch chit nc ton phn thn cy d cho thy c tc dng trn si tit niu in vitro [14], [22]. 1.3.1.2. B Tn khoa hc: Ficus religiosa L.Moraceae. c im thc vt v phn b: B l cy g ln, hon ton nhn. L mu xanh m, c kch thc 10 18 x7,5x10cm,hnhtrng,thuhpdnkhitingnlvnhlginghnhmi mc.Ckhong 5 n 7gnltrn minal.Hoact, mckgn nh ngn v khng cung, i hoa gm 2 - 3 thy, c 1 nh nh v ngn. Hoa ci khng cung, i hoa c 4 thy, bu nhy hnh cu. Qu dng sung, xp 1 - 2 ci trn cc nhnh c l, khng cung, hnh cu ng knh 7 - 8mm, lc chn c mu m [13]. Ma hoa qu vo khong thng 1 - 4. Cy B phn b cc nc cn nhit i v nhit i, ch yu cc nc chunh:n,TrungQuc,VitNam.Cythngctrngcccha, cc ch, cng vin. 15 Hnh 1.3: L cy b (Ficus religinosa L.Moraceae). Thnh phn ha hc: Phenol, tannin, steroid, alkaloid, flavonoid, -sitosteryl-D-glucosid, vitamin K, n-octacosanol, methyl oleanolat, lanosterol[8]. Tc dng dc l: Dch chit nc l B c tc dng bo v cc cn co git; dch chit cn l B c tc dng h ng huyt, lm lnh vt thng, tc dng khng khun v tc dng chng oxy ha [41]. Dch chit nc v thn cy B c tc dng h ng huyt, lm lnh vt thng, chng vim, gim au; dch chit cn v cy c tc dng trn h min dch, c ch cn hen thc nghim [40], ngoi ra cn c tc dng chng oxy ha [47]. QuB ctcdngchngcogitvlmgimcccn ngkinhvtc dng chng oxy ha [49]. Mt s ti nghin cu trn in vitro kt qu cho thy dch chit l B c tcdngcchslngtinhthsitothnhvlmtngtlCOD/COM[8], [14]. 16 1.3.1.3. Xu h Tn khc: Trinh n, Cy mc c, Cy thn. Tn khoa hc: Mimosa pudica L.Mimosaceae. c im thc vt v phn b: Cynh,phnnhiunhnh,mcthnhbi,laxatrnmtt,cao50 cm,thncnhiugaihnhmc.Lkplngchim,hailn,cungphxphnh chn vt, khi ng chm nh th l cp xp li, hoc bui ti cng cp li. L cht nh gm 12 - 14 i. Hoa nh, mu tm nht, t li thnh hnh u. Qa gip nh, di 2 cm, rng 2 - 3mm, t li thnh hnh ngi sao, c lng cng, ht nh, dt di 2mm, rng 1 - 1,5mm [13]. Hnh 1.4:Cy xu h(Mimosa pudica L.Mimosaceae). Ma hoa vo khong thng 6 - 8. Cy xu h mc hoang nhiu ni nc ta: ven ng, b rung, trn i. Thnh phn ha hc: 17 Ngoialkaloid(mimosin )vcrocetincncflavonoid,ccloi alcol,acidamin,acidhac.Htchachtnhy,lchitramtchttngt adrenalin. Trong l v qu u c selen. Tc dng dc l: R cy c tc dng iu tr hen, chng co git, chng vim, gii nhit [26]. L cyctcdnghnghuyt,chngoxyha,khngkhun.Thncyctc dng kch thch lm lnh vt thng, khng khun [33]. 1.3.2.Nhng kt qu nghin cu bc u v bi thuc Bi thuc gm ba v dc liu: d, B , Xu h bc u c nghin cu in vitro bi Trn Thy Ngn v cng s trong ti: Nghin cu tc dng c chhnhthnhsititniuinvitrocamtbithucvccdcliuthnh phn trn m hnh to si bn nhn 96 ging [14]. Kt qu nghin cu tng v dc liu cho thy, dch chit nc pha long 1/4 ca d c tc dng c ch s lng tinh th to thnh v lm tng t l COD/COM. Tuy nhin, lng tinh th COM to thnh cn nhiu v kch thc tinh th COD to thnh tng i ln, tc dng ca d ph thuc vo nng . Dch chit nc pha long 1/3 ca B cch mnhslngtinhthtothnh,tcdngcaB khngphthuc vo nng dch chit. Tuy nhin, c s ph thuc gia t l COD/COM vi nng dch chit B , t l COD/COM tng khi nng tng. Dch chit nc pha long 1/4 ca Xu h khng c tc dng c ch lng si to thnh, ngc li nng cao dch chit Xu h lm tng s lng tinh th to thnh. Tuy nhin, dch chit Xu h th hin kh tt kh nng c ch s chuyn dng t COD sang COM. Nghin cu trn bi thuc, dch chit nc pha long 1/4 ca bi thuc khng th hin tc dng c ch s lng tinh th si to thnh. Tuy nhin, bi thuc cng th hin tc dng c ch s chuyn dng t COD thnh COM v c ch s ln ln catinh th.Ditcdng ca dchchit nc pha long 1/4ca bithuc, hu ht tinh th to thnh dng COD vi kch thc tinh th to thnh tng i nh. Nhng kt qu bc u ny l tin cho nghin cu tip theo trn ng vt th nghim. 18 CHNG 2. I TNG V PHNG PHP NGHIN CU 2.1.NGUYN LIU NGHIN CU Thnh phn bi thuc nghin cu gm 3 dc liu: +L cy B (Ficus religinosa L.Moraceae) +Thn cy d (Coix lachrymal-jobi L.Poaceae) +B phn trn mt t ca cy Xu h (Mimosa pudica L.Mimosaceae) Cc dc liu c thu hi ngoi thnh H Ni vo thng 10 nm 2012 v c xc nh tn khoa hc bi tin s Trn Th Bch (Vin Sinh Thi Ti Nguyn Sinh Vt Vin Khoa Hc Vit Nam). Dc liu c ra sch, ct nh, phi sy kh, ct, tn nh. Chun b dch chit dc liu: Dch chit cn ca tng v dc liu c chun b bng phng php ngm lnh.Ngmlnh48giuthucdchchitln1.Lnth2vth3cng ngmlnhvicn70vtinhnhrtdch chitsau24gi.Gpdchchit,lc qua giy lc 0,45 m, ct thu hi dung mi di p sut gim, tip tc tin hnh c dchchitccaolng5:1.Gpccdchchitcatngvdcliuvitl bng nhau thu c ch phm cui cng th tc dng sinh hc v c tnh. 2.2.PHNG TIN NGHIN CU 2.2.1.ng vt th nghim Chut cng trng, c 2 ging, cn nng khong 150 , do Hc vin qun y cung cp. Chut nht trng chng Swiss, c 2 ging, cn nng khong 20 2 g do Vin V sinh dch t Trung ng cung cp. 19 ngvtcnuinnhviiukinphngthnghimtnht5ngy trc khi thc hin nghin cu, c nui dng bng thc n tiu chun do Vin V sinh dch t trung ng cung cp, ung nc t do. 2.2.2.Ha cht thuc th Ethylenglycol(),1,111 1,115g/ml, Xilong chemical. Amoni clorid ( ), 99,5% - 100,5%, Xilong chemical. Cc dung mi, ha cht v thuc th khc: formol, ethanol, natri hydroxid, b ktnhlngprotein,cholesterol,creatinin,bilirubinttiuchunphn tch. 2.2.3.Thit b v dng c My ct nc 2 ln Hamillton ca hng Hamillton Laboratory Glas Limited,Knh hin vi kt ni my nh ca hng Laica. My iu chnh pH, model Euteck instrument pH 510. My li tm HERMLE Z300. My ct quay Buchi Rotavapor R210. T sy chn khng Heraeus-instrument vacutherm-Kelvitront. Cn k thut Precisa-BJ610C, TE 412 (Sartorius). Dng c hng nc tiu. Cc dng c khc nh : micropipett, ng nghim, u cn cc loi 2.3.NI DUNG NGHIN CU nhgitcdngcabithuctrnmhnhgysititniubngethylen glycol v amoni clorid. Xc nh c tnh cp v bn trng din ca bi thuc nghin cu. 2.4.PHNG PHP NGHIN CU 20 2.4.1.Phng php nh gi tc dng ca bi thuc trn si tit niu in vivo MhnhtosititniuinvivoctinhnhtheomtbiJieFan, Michael A.Glass and Paramjit S.Chandhoke [37] c thay i cho ph hp vi iu kinthnghim.Gysichochutbngethylenglycolvamonicloridvicc nng khc nhau. Da vo kt qu nghin cu chng ti tin hnh nh gi tc dngca bithuc nghincutrnchut gy sititniubngethylenglycol 1% v amoni clorid 0,5%. Nguyn tc ca m hnh nghin cu l to si calci oxalate in vivo, theo di s hnhthnhsivkh nngc ch hnhthnhsicabithuc nghincuthng quavicquansttinhthcalcioxalateniuctothnhdiknhhinviv quan st s lng ng ca tinh th calci oxalat trong thn. Tnh ton mc liu s dng trong nghin cu Mcliusdngtrongnghincucquyidatrnliudcliu thng dng theo kinh nghim, ngoi suy cho ng vt th nghim. Nghin cu s dng 3 mc liu ca bi thuc vi cc bc nhy liu theo cp s nhn c th nh sau: DC1:Dchchitdcliuviliu2,52g/kgchochutcngtrngtng ng vi liu 18g bi thuc/50kg ngi (tnh theo dc liu kh). DC2:Dchchit dcliuviliu 5,04g/kg chochutcngtrnggp2ln DC1tngngviliu36gbithuc/50kgngi(tnhtheodcliu kh). DC3: Dch chit dc liu vi liu 10,08 g/kg cho chut cng trng gp 2 ln DC2tngngviliu72gbithuc/50kgngi(tnhtheodcliu kh). Thit k nghin cuChut cng trng c chia ngu nhin 5 l, mi l 6 con trong : L 1: L chng trng, ung nc. L 2: L chng bnh, ung nc. 21 L 3: L ung DC1 (vi liu 2,52g/kg chut cng tnh theo dc liu kh). L 4: L ung DC2 (vi liu 5,04g/kg chut cng tnh theo dc liu kh). L 5: L ung DC3 (vi liu 10,08 g/kg chut cng tnh theo dc liu kh). Tt c chut cng trng c nui thch nghi vi iu kin th nghim (nhit 25C, 12 gisng/12giti)trongvng 5 ngy.Sautin hnhgysi tit niu trong 28 ngy. Tt c cc l ngoi tr l 1 c thay ung nc hng ngy bng dung dch c cha ethylen glycol 1% v amoni clorid 0,5%. Hng ngy, chut cc l c ung nc hoc ung ch phm th tng ng vi cng th tch vo buisng,lci(1ml/100g).Chutungchphmthlintctrongvng28 ngy. Thu gom nc tiu 5 gi vo cc ngytrc khi gy si v ngy 28 ca t th nghim. Kt thc th nghim gy m chut bng ether, ct ly 2 thn lm gii phu thn. Quy trnh th nghim c m t hnh 2.1. Thng s nh gi Cch thu v phn tch nc tiu:Nc tiu c thu vo cc ngy trc khi gy si v ngy 28. Mi ng vt cchovo mtlng hng nctiuring,nctiucatngchut cgom sau mi 30 pht 1 gi. Gp nc tiu thu c sau 5 gi ca tng ng vt. Trong qutrnhthunctiukhngchochutn,choungncbngkimut 5 ngy28 ngy Thchnghi iukin th nghim Gy si v ung ch phm th hng ngy 0 Bt u 28 Hng nc tiu 5 giThu thn Hnh 2.1: Quy trnh th nghim gy si tit Kt thc 22 1ml/100g chut/gi. Sau khi thu nc tiu tin hnh xc nh th tch, pH nc tiu. Tin hnhlitm nctiuvitc 3000rpm(revolutions per minute) trong 10 pht, phn cn tin hnh soi trn knh hin vi vt knh x40 xc nh s lng, loi tinh th, kch thc tinh th v chp li hnh nh trn vi trng bng my nh c kt ni vi knh hin vi. Thu thn: Vo ngy cui cng ca t th nghim, sau khi tin hnh thu nc tiu 5 gi, ttcngvtth nghim cgy mbngether, ctly2thn.Xcnhkhi lng ca 2 thn.Thn phi ca chut c bo qun trong formol 10% lm gii phu m bnh hc. Thng s nh gi: +Khi lng chut th nghim. +Th tch nc tiu trong 5 gi. +pH nc tiu chut th nghim. +nh lng ion,,. +Mt tinh th, hnh dng tinh th calci oxalat trong nc tiu. Choimdavoslngtinhth,hnhdngtinhth(datheocchcho im ca F.Atmani [27]) c th nh sau: Bng 2.1: Thang im nh gi S lng tinh th COD imS lng tinh th COM im Khng tinh th 0Khng tinh th 0 1 - 3 tinh th11 - 3 tinh th1 23 4- 5 tinh th24 - 5 tinh th2 6 tinh th3 6 tinh th3 +i th c quan thn: Quan st thn ngay sau khi ly khi c th chut. Cn ngay khi lng thn v tnh t l so vi khi lng ton b c th. +M bnh hc: Tiu bn m bnh hc thn c soi di knh hin vi quang hcphnccxcnhcctinhthlngngtrongthn.Tiubncthc hin ti B mn Gii phu bnh, Trng i hc Y H Ni. Kt qu c nh gi bi PGS.TS.Trn Vn Hp. 2.4.2. Phng php xc nh c tnh cp v c tnh bn trng din ca bi thuc nghin cu 2.4.2.1. Phng php xc nh c tnh cp Xcnh ctnhcptheo hng dnkmtheo quytnhs 371/BTY-Q ca By t ngy 12/03/1996 v xc nh an ton cho thuc c truyn, c tham kho hng dn ca OECD v 1 s tc gi khc [1], [7], [43]. Thnghimctinhnhtrnchutnhttrnggingcikhemnhkhi lng c th 18 - 22g. chut nhn i 2 gi trc khi dng thuc. Chut c chia thnh nhiu l. Cho tng l ung ch phm th vi liu tng dn. Th tch ch phm th cho ung tng ngvi0,2ml/10gchut.Saukhiungchphmth,chutctheo di trong vng 72 gi v tnh t l chut cht ca mi l th nghim trong khong thi gian trn. Nu c chut cht, m quan st nhng thay i c quan ni tng bng mt thng. LD50 (nu c) c tnh bng phng php Litch field Wilcoxon. 2.4.2.2. Phng php xc nh c tnh bn trng din 24 Xcnh ctnh bntrng dinca bithuc nghincutheo hng dn ca OECD [42]. ng vt th nghim Chut nht trng trng lng 18 2g nui iu kin phng th nghim (nhit 25 C, 12 gi sng/12gi ti) trong vng 5 ngy. Tin hnh Chia ngu nhin chut nht trng mi ging (c hoc ci) thnh 3 l, mi l 10 ng vt. L 1: L chng ung nc. L2:Lungcaolngbithucnghincuviliu8,64g/kgchutnht (liu gp i liu th hin tc dng dc l). L3:Lungcaolngbithucnghincuviliu25,92g/kgchutnht (liu gp 6 ln liu th hin tc dng dc l). Chutcungnchocthuchngngyvobuisngviliu 0,1ml/10gtrckhin,lintctrongvng 28 ngy.Kim tracn nngcachut hng tun. Kt thc th nghim ly mu mt ca chut cho vo 2 loi ng nghim: ngchngnglmccxtnghimhuythcvngkhngchachtchng ng, ly tm ly huyt thanh lm cc xt nghim ha sinh. M ton b ng vt th nghim quan st i th cc c quan, ly ngu nhin 3 chut c v 3 chut ci trong mi l lm tiu bn vi th gan v thn. Thng s nh gi Tnhtrngtonthn:hngngytheodiccbiuhincangvtthc nghim(tnhtrngda,lng,mt,stitdchmi,ming,hhp,phn,nc tiu). Hng tun cn ng vt thc nghim theo di s thay i khi lng c th, ng thi iu chnh lng thuc cho chut ung. Ccthngshuythc:slnghngcu,nnghemoglobin,tl hematocrit,thtchtrungbnhhngcu,lnghuytscttrungbnhhngcu, nng huyt sc t trung bnh hng cu, s lng tiu cu, s lng bch cu. 25 Ccthngshasinh:hottransaminnasehuytthanh(AST,ALT), glucose,cholesteroltonphn,proteintonphn,creatininhuytthanh,bilirubin ton phn. i th c quan: quan st cm quan cc c quan tim, gan, thn. Cn ngay khi lng cc c quan v tnh t l so vi khi lng ton b c th. M bnh hc: sau khi git ng vt th nghim, cc mu gan v thn c bo qun trong dung dch formol 10%, ct cc lt mng, nhum hematoxylin eosin v quan st di knh hin vi phn cc nh gi cu trc hnh thi vi th gan, thn. Tiubn cthchintiBmnGiiphubnh,TrngiHcYHNi. Kt qu c nh gi bi PGS.TS. Trn Vn Hp. 2.4.3.Phng php x l s liu Kt qu c biu din di dng M SE (M: gi tr trung bnh tng l, SE: sai s chun). So snh gi tr trung bnh gia cc l bng one-way ANOVA, dng hu kim Dunnett test so snh gi tr trung bnh ca cc l th vi l chng bnh (vithitk nhiu l) hocTTestsosnh gitrtrung bnhcalchng bnh vi l chng trng. Viccsliukhngthucphnphichun,ktquctrnhbydi dng trung v v khong (gi tr cc tiu gi tr cc i). Dng thut ton Kruskal Wallis so snh gia cc l, Mann Whitney U test so snh kt qu gia l th vi l chng. Phn tch thng k bng phn mm SPSS 16.0, s khc bit gia cc l c coi l c ngha khi p