B Y T TRNG I HC Y H NI U TH HIP ĐáNH GIá CHỉ Số SCORE TRONG SàNG LọC NGUY CƠ LOãNG XƯƠNG PHụ Nữ MãN KINH Chuyờn ngnh: Ni Xng khp Mó s : 62722010 LUN VN BC S CHUYấN KHOA CP II Ngi hng dn khoa hc: PGS.TS NGUYN TH NGC LAN H NI - 2015 LI CM N hon thnh lun ny, tụi xin chõn thnh cm n: Ban Giỏm hiu, Phũng o to sau i hc, B mụn Ni tng hp -Trng i hc Y H Ni; Ban lónh o Bnh vin Bch Mai, Khoa C xng khp, Khoa Khỏm bnh theo yờu cu - Bnh vin Bch Mai;Ban lónh o Bnh vin Bc Thng Long ó to mi iu kin thun li cho tụi sut quỏ trỡnh hc v hon thnh lun c bit, tụi xin by t lũng bit n sõu sc ti PGS.TS Nguyn Th Ngc Lan nguyờn phú trng b mụn Ni Tng hp - Trng i hc Y H Ni, ngi ó ht lũng dy bo, dỡu dt tụi sut quỏ trỡnh hc v trc tip hng dn tụi hon thnh lun ny Vi tt c lũng kớnh trng, tụi gi li cm n chõn thnh ti cỏc Thy,Cụ giỏo, cỏc anh ch Bỏc s, iu dng khoa C xng khp, khoa Khỏm cha bnh theo yờu cu-Bnh vin Bch Mai, nhng ngi thy ó tn tỡnh hng dn, dỡu dt tụi thc hnh lõm sng hng ngy sut thi gian hc v gúp ý cho tụi hon thnh lun Tụi xin chõn thnh cm n ti cỏc Thy, Cụ Hi ng chm lun ó cho tụi nhiu ý kin quý bỏu hon thin lun ny Tụi xin trõn trng cm n cỏc Thy,Cụ B mụn Ni tng hp-Trng i hc Y H Ni ó ht lũng dy d, ch bo tụi quỏ trỡnh hc v hon thnh lun Cui cựng, tụi cng xin vụ cựng bit n gia ỡnh, bn bố v ng nghip luụn l nhng ngi ng viờn, khớch l v ng h nhit tỡnh giỳp tụi vt qua mi khú khn cuc sng v hc H Ni, ngy 10 thỏng 11 nm 2015 u Th Hip LI CAM OAN Tụi l u Th Hip, hc viờn Bỏc s chuyờn khoa II khúa 27, chuyờn ngnh Ni Xng khp, Trng i hc Y H Ni xin cam oan: õy l lun bn thõn tụi trc tip thc hin di s hng dn ca PGS.TS Nguyn Th Ngc Lan Cụng trỡnh ny khụng trựng lp vi bt k nghiờn cu no khỏc ó c cụng b ti Vit Nam Cỏc s liu v thụng tin nghiờn cu l hon ton chớnh xỏc, trung thc v khỏch quan, ó c xỏc nhn v chp nhn ca c s ni nghiờn cu cho phộp ly s liu v xỏc nhn Tụi xin hon ton chu trỏch nhim v nhng cam kt ny H Ni, ngy 10 thỏng 11 nm 2015 Ngi vit cam oan u Th Hip CC CH VIT TT AUC : Area Under the Curve (Din tớch di ng cong) BMC : Bone Mineral Content (Khi lng cht khoỏng xng) BMD : Bone Mineral Density (Mt xng) BMI : Body Mass Index (Ch c th) CSTL : Ct sng tht lng CX : C xng ựi DEXA : Dual Energy X ray Absorptiometry (Hp th tia X nng lng kộp) TNC : i tng nghiờn cu MX : Mt xng OSTA : Osteoporosis Self assessment Tool for Asian index (ch s t ỏnh giỏ loóng xng cho ngi chõu ) ORAI : Osteoporosis Risk Assessment Instrument (Cụng c ỏnh giỏ nguy c loóng xng) OSIRIS SCORE : Osteoporosis Index of Risk (Ch s nguy c loóng xng) : Simple Calculated Osteoporosis Risk Estimation (Tớnh toỏn n gin c lng nguy c loóng xng) SD : Standard Deviatio ( lch chun) Se : Sensitivity ( nhy) Sp : Specificity ( c hiu) PPV : Positive Predictive Value (Giỏ tr d bỏo dng tớnh) NPV : Negative Predictive Value (Giỏ tr d bỏo õm tớnh) VKDT : Viờm khp dng thp WHO : T chc Y t th gii(World Health Organization) MC LC T VN Chng 1: TNG QUAN TI LIU 1.1 i cng v loóng xng 1.1.1 nh ngha loóng xng 1.1.2 Phõn loi loóng xng 1.2 Loóng xng ph n sau kinh 1.2.1 Vi nột v kinh 1.2.2 C ch bnh sinh loóng xng ph n sau kinh 1.2.3 Mt s nguy c gõy loóng xng 10 1.2.4 Triu chng lõm sng 13 1.3 Cỏc phng phỏp ỏnh giỏ tỡnh trng loóng xng 14 1.3.1 Phng phỏp o MX bng Hp th tia X nng lng kộp 14 1.3.2 Cỏc phng phỏp ỏnh giỏ tỡnh trng loóng xng khỏc 15 1.4 Ch s SCORE v mt s mụ hỡnh tiờn lng nguy c loóng xng 15 1.4.1 Ch s ORAI 15 1.4.2 Ch s OSIRIS 16 1.4.3 Ch s OSTA 16 1.4.4 Ch s SCORE 16 1.5 Tỡnh hỡnh nghiờn cu v bnh loóng xng v ngoi nc 21 Chng 2: I TNG V PHNG PHP NGHIấN CU 23 2.1 a im v thi gian nghiờn cu 23 2.2 i tng nghiờn cu 23 2.3 Phng phỏp nghiờn cu 23 2.3.1 Thit k nghiờn cu 23 2.3.2 Phng phỏp 23 2.3.3 C mu 24 2.3.4 Cỏch chn mu v phng phỏp thu thp s liu 24 2.3.5 Cỏc bc tin hnh nghiờn cu 28 2.4 Phõn tớch v x lý s liu 28 2.5 Khớa cnh o c 29 Chng 3: KT QU NGHIấN CU 30 3.1 c im ca i tng nghiờn cu 30 3.1.1 c im chung 30 3.1.2 c im MX o bng phng phỏp DEXA ca TNC 33 3.2 c im kho sỏt ch s SCORE ca TNC 38 3.2.1 T l nguy c loóng xng theo ch s SCORE ca TNC 38 3.2.2 Liờn quan ch s SCORE vi tỡnh trng loóng xng theo T-score 38 3.2.3 Liờn quan ch s SCORE trung bỡnh vi tui 39 3.2.4 Liờn quan ch s SCORE trung bỡnh vi BMI 40 3.2.5 Liờn quan ch s SCORE trung bỡnh vi tỡnh trng kinh 40 3.2.6 Liờn quan ch s SCORE trung bỡnh vi tin s VKDT, dựng Estrogen, góy xng sau 45 tui 41 3.3 ỏnh giỏ giỏ tr ca ch s SCORE so vi o MX bng phng phỏp DEXA 42 3.3.1 nhy, c hiu ca ch s SCORE vi T- score -1 SD 42 3.3.2 nhy, c hiu ca ch s SCORE vi T- score -2.5 SD 45 3.3.3 Giỏ tr ca ch s SCORE chn oỏn sng lc loóng xng48 Chng 4: BN LUN 51 4.1 c im ca i tng nghiờn cu 51 4.1.1 c im chung ca i tng nghiờn cu 53 4.1.2 c im v MX o bng phng phỏp DEXA ca TNC 54 4.2 c im kho sỏt ch s SCORE ca TNC 64 4.2.1 T l phõn tng nguy c ca TNC theo ch s SCORE 65 4.2.2 Liờn quan ch s SCORE vi MX tớnh theo T-score 65 4.2.3 Liờn quan ch s SCORE vi mt s yu t nguy c 66 4.3 ỏnh giỏ giỏ tr ca ch s SCORE so vi o MX bng phng phỏp DEXA n gii t 45 tui tr lờn 68 4.3.1 Giỏ tr ca ch s SCORE d oỏn MX thp 69 4.3.2 Giỏ tr ca ch s SCORE d oỏn loóng xng 70 4.3.3 ỏnh giỏ giỏ tr ca ch s SCORE 71 4.4 Hn ch ca ti 76 KT LUN 77 KIN NGH 78 TI LIU THAM KHO PH LC DANH MC BNG Bng 1.1 Cỏc v cỏc yu t liờn quan n loóng xng 18 Bng 2.1 Cỏc bin s v ch s nghiờn cu 27 Bng 3.1 Phõn b TNC theo tin s góy xng 33 Bng 3.2 T-score trung bỡnh 34 Bng 3.3 T-score trung bỡnh v nhúm tui 35 Bng 3.4 T-score trung bỡnh v BMI 35 Bng 3.5 T-score trung bỡnh v tỡnh trng kinh 36 Bng 3.6 T-score trung bỡnh v tin s VKDT, dựng Estrogen, góy xng 37 Bng 3.7 c im ca SCORE trung bỡnh theo tỡnh trng loóng xng 38 Bng 3.8 Ch s SCORE trung bỡnh vi tui 39 Bng 3.9 Ch s SCORE trung bỡnh vi BMI 40 Bng 3.10 Ch s SCORE trung bỡnh vi tỡnh trng kinh 40 Bng 3.11 Ch s SCORE vi tin s VKDT, dựng Estrogen, góy xng 41 Bng 3.12 nhy c hiu ca ch s SCORE vi T- score -1 SD 42 Bng 3.13 Ch s SCORE vi T- score -1 SD 43 Bng 3.14 Ch s SCORE vi T- score -1 SD CSTL 44 Bng 3.15 Ch s SCORE vi T- score -1 SD CX 44 Bng 3.16 nhy, c hiu ca ch s SCORE vi T- score -2.5 SD 45 Bng 3.17 nhy, c hiu ca ch s SCORE ti cut off 14 v 15 chn oỏn sng lc loóng xng 46 Bng 3.18 Ch s SCORE vi T- score -2.5 SD 47 Bng 3.19 Ch s SCORE vi T- score -2.5 SD ti CSTL 47 Bng 3.20 Ch s SCORE vi T- score -2.5 SD ti CX 47 Bng 3.21 Giỏ tr ca ch s SCORE 48 Bng 3.22 Mi liờn quan gia nguy c loóng xng theo SCORE v loóng xng theo T-score 49 DANH MC BIU Biu 3.1 Phõn b TNC theo tui 30 Biu 3.2 Phõn b TNC theo BMI 31 Biu 3.3 Phõn b TNC theo tui kinh 31 Biu 3.4 Phõn b TNC theo thi gian kinh 32 Biu 3.5 Phõn b TNC theo tin s VKDT v tin s dựng Estrogen 32 Biu 3.6 T l loóng xng 33 Biu 3.7 T l loóng xng v nhúm tui 34 Biu 3.8 T l nguy c loóng xng theo ch s SCORE 38 Biu 3.9 Liờn quan gia nguy c loóng xng theo SCORE v t l loóng xng 39 Biu 3.10 ng cong ROC vi T-score-1SD 43 Biu 3.11 ng cong ROC vi T-score -2,5SD 46 Biu 3.12 Phõn b TNC theo ch s SCORE ti cut off v 14 50 DANH MC HèNH NH Hỡnh 1.1 Mi liờn quan RANK/RANKL/OPG v mt xng 77 KT LUN Qua nghiờn cu ỏnh giỏ nguy c loóng xng theo ch s SCORE so sỏnh vi o mt xng bng DEXA 290 ph n sau kinh t 45 tui tr lờn, chỳng tụi rỳt mt s kt lun sau: c im kho sỏt ch s SCORE ca TNC - Nguy c thp (SCORE6) chim t l 7,2% (90,5% s ph n khụng mc loóng xng) - Nguy c trung bỡnh (614) chim t l 22,4% (84,6% ph n mc loóng xng) Giỏ tr ca ch s SCORE so vi o MX bng phng phỏp DEXA * Trong chn oỏn sng lc nguy c gim MX (T-score -1SD): - im cut off = 6: + Se 95,1% v Sp 20,9 % + AUC 0,776 im ct ny tng t nh nghiờn cu gc * Trong chn oỏn sng lc nguy c loóng xng (T-score -2,5SD): - Ti im cut off 15 (nh nghiờn cu gc), b sút thờm 7,9% i tng b loóng xng nhng khụng c sng lc - im cut off = 14: + Se 39,3% v Sp 93,3% + AUC 0,779 Nh vy, cn dch chuyn im cut off t 15 v 14 phự hp ỏp dng vi ph n Vit Nam 78 KIN NGH - Ch s SCORE l mt cụng c n gin, cú th ỏp dng vic xỏc nh nguy c loóng xng ph n sau kinh phự hp vi iu kin Vit Nam d phũng v iu tr loóng xng mt cỏch tit kim v hiu qu - Cn dch chuyn im cut off t 15 v 14 phự hp vi ngi Vit Nam TI LIU THAM KHO NIH Consensus Development Panel on 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Bnh c chn oỏn: Tin s iu tr thuc loóng xng T trc n gi bỏc ó bao gi iu tr loóng xng cha? A.Cú B Cha Tin s góy xng: - Bỏc cú b góy xng bao gi khụng? A.Cú B.Khụng - Nu cú thỡ góy xng V trớ no Tui no - Bỏc cú c chn oỏn góy lỳn t sng tht lng bao gi khụng ? A Cú V trớ no B Khụng (Nu hin ti cú chp X quang thỡ cp nht luụn kt qu) Lớ góy: A T nhiờn hoc sau mt chn thng nh (bc ht, ho ) B Tai nn giao thụng hoc sinh hot C Khỏc: Tin s gia ỡnh: - Trong gia ỡnh h hng cú b góy xng d dng khụng? A Cú B Khụng - Góy tui - Lớ góy: A Do tai nn giao thụng B Do tai nn sinh hot C T nhiờn hoc sau chn thng nh (bc ht) D Khỏc (ghi rừ lớ ) - Quan h ca mỡnh vi ngi góy xng: Tin s dựng thuc Bỏc cú dựng thuc Estrogen bao gi khụng ? A Cú B Khụng Nu cú : Tờn thuc .liu .mg/ngy, bao lõu Tin s b bnh viờm khp dng thp Bỏc cú c chn oỏn bnh viờm khp dng thp khụng? A Cú B Khụng Nu cú bao nhiờu nm: B ó kinh hay ct bung trng? A Món kinh Nm bao nhiờu tui?: B Ct bung trng Nm bao nhiờu tui?: C Cha kinh III KT QU O MT XNG Chiu cao: cm Cõn nng:kg BMI: Kt qu MX: CX CSTL Region BMD (g/cm2) T-score Region L1 Neck L2 Trock L3 Inter L4 Total Total Wards BMD (g/cm2) T-score IV PHN TNG NGUY C LONG XNG DA VO CH S SCORE Ch s SCORE - Nguy c cao: - Nguy c trung bỡnh: - Nguy c thp: 30-34,38,39,42,43,45-47,49 1-29,35-37,40,41,44,48,50- 15 101 ... sát số SCORE phụ nữ mãn kinh từ 45 tuổi trở lên Đánh giá giá trị dự đoán nguy loãng xương số SCORE so với đo mật độ xương phương pháp DEXA 3 Chương TỔNG QUAN TÀI LIỆU 1.1 Đại cương loãng xương. .. cường cận giáp trạng thứ phát 1.1.1.2 Loãng xương thứ phát Là loại loãng xương tìm thấy nguy n nhân số bệnh số thuốc gây nên 1.2 Loãng xương phụ nữ sau mãn kinh 1.2.1 Vài nét mãn kinh Mãn kinh tình... phương pháp đánh giá tình trạng loãng xương khác 15 1.4 Chỉ số SCORE số mô hình tiên lượng nguy loãng xương 15 1.4.1 Chỉ số ORAI 15 1.4.2 Chỉ số OSIRIS 16 1.4.3 Chỉ số OSTA