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Graves甲状腺功能亢进症(简称甲亢)患者伴有骨量减少甚至骨质疏松,这已引起临床医师的普遍重视。131I治疗通过破坏甲状腺滤泡,使甲状腺激素水平恢复正常或降低,骨转化动力减弱,骨代谢可趋于正常[1]。双能X线吸收法(dual energy X-ray absorptiometry, DXA)测定骨密度(bone mineral density, BMD)是目前诊断骨质疏松的有效手段与金标准,并能很好地预测骨折风险[2],但腰椎骨质增生会造成常规前后位BMD测定结果的假阳性增高,影响对患者骨量的准确评价[3]。腰椎能谱CT可通测定椎体中间层面松质骨中钙(水)的含量,更加灵敏、精确地评价骨矿含量[4]。本研究通过能谱CT测定68例Graves甲亢患者腰椎钙(水)密度,分析其与DXA测定BMD结果的相关性,并了解131I治疗前后腰椎钙(水)密度的变化,探讨能谱CT成像对Graves甲亢患者骨量评估的价值,以及131I治疗对甲亢患者骨量的影响。
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DXA测定腰椎BMD的结果显示,68例Graves甲亢患者中骨量正常40例(58.8%),骨量减少21例(30.9%),骨质疏松7例(10.3%)。男性甲亢患者的BMD(0.92±0.35)g/cm3与女性患者(1.03±0.25)g/cm3比较,差异无统计学意义(t=-1.284,P>0.05)。高龄组患者的BMD(0.72±0.35)g/cm3低于青年组患者(1.03±0.29)g/cm3,差异有统计学意义(t=-3.660,P < 0.01)。高龄组患者的BMD(0.72±0.35)g/cm3低于青年组患者[(1.03±0.29)g/cm2],差异有统计学意义(t=-3.660, P < 0.01)。
骨量正常组患者、骨量减少组、骨质疏松组进行第3腰椎钙(水)密度比较,3组间差异有统计学意义(χ2=35.811,P < 0.001)。骨量正常组腰椎钙(水)密度高于骨量减少组与骨质疏松组,差异均有统计学意义(Z=4.903、3.974,均P < 0.001),骨量减少组腰椎钙(水)密度高于骨质疏松组,差异有统计学意义(Z=-3.502, P < 0.001)(表 1)。
组别 例数 最小值 最大值 x±s χ2值 P值 骨量正常组 40 34.62 112.48 64.33±14.65 35.811 0.000 骨量减少组 21 36.96 55.77 48.29±4.45 骨质疏松组 7 40.22 43.30 41.65±1.21 表 1 不同骨量组别的Graves甲状腺功能亢进症患者第3腰椎钙(水)密度比较(g/cm3)
Table 1. Comparison of calcium (water) densities of L3 in Graves hyperthyroidism patients with different bone mass(g/cm3)
骨量正常组患者的第3腰椎BMD为(1.252±0.305)g/cm2,骨量减少组为(1.103±0.254)g/cm2,而骨质疏松组为(0.539±0.066)g/cm2,3组间差异有统计学意义(F=12.968, P < 0.001)。其中骨量正常组和骨量减少组第3腰椎BMD的差异无统计学意义(t=1.910, P>0.05),但均高于骨质疏松组(t=6.294、4.589, 均P < 0.001)(表 2)。
组别 例数 最小值 最大值 x±s χ2值 F值 骨量正常组 40 1.04 1.44 1.252±0.305 12.968 0.000 骨量减少组 21 0.96 1.32 1.103±0.254 骨质疏松组 7 0.42 0.60 0.539±0.066 表 2 不同骨量组别的Graves甲状腺功能亢进症患者第3腰椎骨密度比较(g/cm2)
Table 2. Comparison of bone mineral densitys of L3 in Graves hyperthyroidism patients with different bone mass (g/cm2)
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以DXA测定的腰椎BMD为横坐标,能谱CT测定第3腰椎钙(水)密度为纵坐标,将每例甲亢患者成对的数据描述在直角坐标系上,形成散点图(图 2)。由图 2可见二者大致呈线性正相关趋势。
图 2 Graves甲亢患者腰椎能谱CT与DXA测定结果的相关性
Figure 2. The relationship between calcium(water) densities and BMDs in Graves hyperthyroidism patients
由图 2可见,DXA测定的BMD在1.0~1.5 g/cm2范围内,椎体钙(水)密度值波动比较大。将BMD测定结果代入线性回归方程计算所得的椎体钙(水)密度与实测值进行比较,其中8例患者二者接近(差异≤2 g/cm3),7例患者后者高于前者,而另外15例(占50%)患者前者高于后者。这15例患者的年龄为(48.2±5.7)岁,其中10例患者相应CT图像见腰椎骨质增生。
进一步对甲亢患者的第3腰椎钙(水)密度与DXA测定的腰椎BMD进行Pearson相关分析,结果呈高度相关(r=0.794)。对其进行假设检验,检验水准α=0.01、t=10.605、P < 0.001,故可认为二者之间有正相关关系。由线性回归分析得到线性回归方程:第3腰椎钙(水)密度=24.485+34.529腰椎BMD。由此可见,我们可以用Graves甲亢患者的腰椎钙(水)密度来评估患者骨量。
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全部患者131I治疗后半年复查腰椎能谱CT,再次测定第3腰椎钙(水)密度值,131I治疗后Graves甲亢患者的腰椎钙(水)密度(62.23±11.77)g/cm3较治疗前(57.04±14.54)g/cm3增加,即患者的骨量改善,差异有统计学意义(t=8.84,P < 0.001)。
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本组68例Graves甲亢患者131I治疗后随访半年,完全缓解36例,甲状腺功能减退(简称甲减)15例,部分缓解13例,无效或复发4例。我们将完全缓解及甲减定义为甲亢治愈,将部分缓解、无效或复发定义为甲亢未愈。甲亢治愈组患者131I治疗后腰椎钙(水)密度(65.01±11.74)g/cm3较治疗前(59.26±15.61)g/cm3增加(t=7.86,P < 0.001),而甲亢未愈组患者治疗后腰椎钙(水)密度(52.17±7.65)g/cm3较治疗前(50.39±7.82)g/cm3变化不显著,差异无统计学意义(t=2.29,P=0.062)。
腰椎能谱CT评估Graves甲状腺功能亢进症患者131I治疗前后骨量变化的价值
Changes of bone mass in patients with Graves' hyperthyroidism before and after 131I therapy based on CT spectral imaging
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摘要:
目的探讨能谱CT成像对Graves甲状腺功能亢进症(简称甲亢)患者骨量评估的价值,以及131I治疗对Graves甲亢患者骨量的影响。 方法收集2015年6月至10月期间在我科接受131I治疗的68例Graves甲亢患者[(男性13例、女性55例,年龄(40.6±10.7)岁],治疗前采用双能X线吸收法(DXA)测定腰椎骨密度(BMD),能谱CT测定第3腰椎钙(水)密度,采用Pearson相关分析及线性回归探讨二者的相关性。治疗后半年随访评价疗效,复查腰椎能谱CT,采用配对t检验比较131I治疗前后骨量变化。 结果DXA的测定结果显示,68例Graves甲亢患者中有21例伴有骨量减少(30.9%),7例伴有骨质疏松(10.3%)。骨量正常组患者的第3腰椎钙(水)密度为(64.33±14.65)g/cm3,骨量减少组为(48.29±4.45)g/cm3,而骨质疏松组为(41.65±1.21)g/cm3,3组间差异有统计学意义(χ2=35.811,P < 0.001)。骨量正常组患者的第3腰椎BMD为(1.252±0.305)g/cm2,骨量减少组为(1.103±0.254)g/cm2,而骨质疏松组为(0.539±0.066)g/cm2,3组间差异有统计学意义(F=12.968,P < 0.001)。Graves甲亢患者的第3腰椎钙(水)密度与DXA测定的腰椎BMD呈高度正相关(r=0.794,假设检验水准α=0.01,t=10.605,P < 0.001)。由线性回归分析得到线性回归方程:第3腰椎钙(水)密度=24.485+34.529腰椎BMD。治疗后半年随访发现,甲亢治愈组患者131I治疗后腰椎钙(水)密度较治疗前增加,骨量改善,差异有统计学意义(t=7.86,P < 0.001);而甲亢未愈组患者较治疗前变化不显著,差异无统计学意义(t=2.29,P=0.062)。 结论能谱CT测得的腰椎钙(水)密度可用于评估Graves甲亢患者的骨量。患者经131I治疗后,骨量可随着甲亢的有效缓解而显著改善。 Abstract:ObjectiveTo investigate the value of CT spectral imaging to evaluate bone mass in patients with Graves' hyperthyroidism, and the changes of bone mass before and after 131I therapy. MethodsSixty-eight patients(13 males, 55 females; age 40.6±10.7yr) with Graves' hyperthyroidism who received 131I therapy from June to October 2015 were involved in our study. The bone mineral density(BMD) of lumbar was obtained by dual energy X-ray absorptiometry(DXA), and the calcium-water concentration of L3 was measured by CT spectral imaging before 131I therapy. Pearson correlation analysis and linear regression were performed to explore the relationship between them. All clinical data were collected to assess the efficacy of 131I therapy after 6 months. CT spectral imaging was repeated, in order to compare the changes of bone mass using comparative t-test. ResultsOf these patients with Graves' hyperthyroidism, 30.9% (21/68) patients with osteopenia and 10.3%(7/68) patients with osteoporosis were diagnosed according to the results of BMD by DXA. The calcium (water) densities of L3 were (64.33±14.65), (48.29±4.45) and (41.65±1.21) g/cm3 in patients with normal bone mass, bone loss and osteoporosis, respectively. The differences between the three groups were statistically significant (χ2=35.811, P < 0.001). The bone mineral density of L3 were (1.252±0.305), (1.103±0.254) and (0.539±0.066) g/cm3 in patients with normal bone mass, bone loss and osteoporosis, respectively. The differences between the three groups were statistically significant (F=12.968, P < 0.001). The calcium-water concentrations of L3 (g/cm3) were highly correlated with BMD values (g/cm2) of lumbar determined by DXA(r=0.794, hypothesis testing standard α=0.01, t=10.605, P < 0.001). Equation of linear regression:the calcium-water concentration of L3=24.485+34.529 BMD value of lumbar. Furthermore, after 131I therapy, the calcium-water concentrations of L3 increased(t=7.86, P < 0.001) in the cured group of patients. But there weren't significant difference in the uncured group of patients(t=2.29, P=0.062). ConclusionsCT spectral imaging can be used to evaluate bone mass in patients with Graves' hyperthyroidism. Bone mass can be improved with remission of hyperthyroidism after 131I therapy. -
Key words:
- Graves disease /
- Hyperthyroidism /
- Tomograp, X-ray computed /
- Bone mass /
- Radionuclide therapy /
- Iodine Radioisotopes
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表 1 不同骨量组别的Graves甲状腺功能亢进症患者第3腰椎钙(水)密度比较(g/cm3)
Table 1. Comparison of calcium (water) densities of L3 in Graves hyperthyroidism patients with different bone mass(g/cm3)
组别 例数 最小值 最大值 x±s χ2值 P值 骨量正常组 40 34.62 112.48 64.33±14.65 35.811 0.000 骨量减少组 21 36.96 55.77 48.29±4.45 骨质疏松组 7 40.22 43.30 41.65±1.21 表 2 不同骨量组别的Graves甲状腺功能亢进症患者第3腰椎骨密度比较(g/cm2)
Table 2. Comparison of bone mineral densitys of L3 in Graves hyperthyroidism patients with different bone mass (g/cm2)
组别 例数 最小值 最大值 x±s χ2值 F值 骨量正常组 40 1.04 1.44 1.252±0.305 12.968 0.000 骨量减少组 21 0.96 1.32 1.103±0.254 骨质疏松组 7 0.42 0.60 0.539±0.066 -
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