TW法在女性患儿特发性性早熟尺桡骨和手短骨骨龄评价的诊断性试验研究

doi:10.3877/cma.j.issn.1673-5250.2008.05.105

目的

比较TW₂法英国人标准(TW₂)、TW₂法中国人南方标准(TW₂CH)和TW₃法尺桡骨和手短骨(radius ulna and short bones, RUS)骨龄评价方法对特发性性早熟(idiopathic precocious puberty，IPP)女性患儿的诊断价值。

方法

以1995年1月到2002年8月约8年间在四川大学华西第二医院儿科门诊和妇科生殖内分泌门诊就诊并确诊为特发性性早熟女性患儿55例为病例组；对照组(n＝83)为同期在本院因10岁以后月经初潮，8～10岁体重偏轻、正常、偏重而行骨龄检查的女性儿童。本研究采用WHO推荐使用的美国国家卫生统计中心(NCHS)身高、体重发育参考标准，回顾性分析初诊时左手腕X射线摄片，用TW骨龄评分法盲法分期，用TW₂法、TW₂CH法和TW₃法分别评价尺桡骨和手短骨骨龄及其相应百分位，每个系统分5个工作点，骨龄以百分位(P)表示：①>P97；②>P90；③>P75；④>P50；⑤≤P50。

结果

敏感度(Sen)和特异度(Spe)都比较高的有以下4个工作点：①TW₂CH ">P90" ；②TW₃ ">P90" ；③TW₂CH ">P75" ；④TW₃ ">P75" 。三条受试者工作特征曲线(receiver operating characteristic curve，ROC曲线)下相对面积最大的是TW₂CH(0.942±0.019)，其次是TW₃法(0.886±0.028)，最小的是TW₂法(0.766±0.040)。

结论

用TW系列三种尺桡骨和手短骨骨龄评价特发性性早熟女性患儿骨龄都有诊断价值，TW₂CH法的诊断价值最高，TW₃和TW₂的诊断价值为中等，其中TW₂法的诊断价值最低。

关键词: 骨骼测定年龄, TW₂法, TW₃法, 特发性性早熟, 诊断性试验, 受试者工作特征曲线

Objective

To compare the TW₂, TW₂CH and TW₃ methods in Chinese girls with idiopathic precocious puberty (IPP) for the radius ulna and short bones (RUS) bone age.

Methods

55 girls (aged from 3.2 to 9.9 years) with idiopathic precocious puberty were admitted in the Department of Pediatrics and Gynecology and Obstetrics, West China Second University Hospital from January 1995 to August 2002 as the test group. Among them, 36 cases started breast development before age 8 (aged from 1.50 to 7.90 years). 20 girls had menarche before age 10 (aged from 5.00 to 9.75 years). The control group includes: ① 14 girls started menarche after age 10 (11.45±1.05) years; ②25 girls who started menarche aged from 8 to 10 (9.20±0.67) years with lower weight; ③ 32 girls who started menarche aged from 8 to 10 (9.11±0.74) years with normal weight; ④ 12 girls who started menarche aged from 8 to 10 (9.61±0.66) years with overweight. Their left hand-wrist radiographs taken at their first visit were retrospectively analyzed. Bone age was staged single-blind using the radius ulna and short bones. TW₂ London standard radius ulna and short bones (TW₂), TW₂ in the south of China standard radius ulna and short bones (TW₂CH) and TW₃ systems were used in bone age estimation. Five decision thresholds were recorded for each system. They were >97^th percentile, >90^th percentile, >75^th percentile, >50^th percentile and ≤50^th percentile.

Results

The following four thresholds were relatively high in both sensitivity and specificity: ①>90^th percentile of TW₂CH (Sen=0.836, Spe=0.915), by which there were 16 cases of missed diagnosis and misdiagnosis, with a diagnosis accuracy of 88.41%; ②>90^th percentile of TW₃ (Sen=72.73%, Spe=86.75%), by which there were 26 cases of missed diagnosis and misdiagnosis, with a diagnosis accuracy of 81.16%; ③>75^th percentile of TW₂CH, by which there were 28 cases of missed diagnosis and misdiagnosis, with a diagnosis accuracy of 79.71%; ④>75^th percentile of TW₃, by which there were 30 cases of missed diagnosis and misdiagnosis, with a diagnosis accuracy of 78.26%. Area under the receiver operating characteristic curve (AUR) with TW₂CH: 0.942±0.019 (95% CI 0.905~0.978). Area under the receiver operating characteristic curve with TW₃: 0.886±0.028 (95% CI 0.831~0.941). Area under the receiver operating characteristic curve with TW₂ is the smallest: 0.766±0.040 (95%CI 0.688~0.843).

Conclusion

To evaluate bone age and its percentile with TW-RUS system, the TW₂CH has the highest value in diagnosing idiopathic precocious puberty. TW₃ and TW₂ systems are moderate. The TW₂ Britisher standard radius ulna and short bones is the lowest.

Key words: age determination by skeleton, TW₂ method, TW₃ method, idiopathic precocious puberty, diagnostic test, receiver operating characteristic (ROC) curve

图1　三种RUS骨龄的ROC曲线

	1　Tanner JM, Whitehouse RH, Cameron N, et al. Assessment of skeletal maturity and prediction of adult height (TW2 method). 2nd ed. London: Acad Press, 1983, 50－88.
	2　Ye YY, ed. The methodologies of scorers and atlases measuring skeletal age in children and adolescents: Introduction and application. Changsha: Hunan Science and Technology Publishing House, 1994，145－177.[叶义言主编．儿童青少年骨龄的评分法图谱及应用. 长沙：湖南科技出版社，1994, 145－177.]
	3　Ye YY, ed. The methodologies for assessing bone age of Chinese children. Beijing: People's Medical Publishing House, 2005, 83－183.[叶义言主编．中国儿童骨龄评分法. 北京：人民卫生出版社，2005, 83－183.]
	4　Tanner JM, Healy MJR, Goldstein H, et al. Assessment of skeletal maturity and prediction of adult height (TW3 method). 3rd ed. London: Harcourt Publishers Limited, 2001, 9－22.
	5　Mo ZH, Su X. Sex premature in girls. In: Liao EY, Chao CS, editor－in－chief. Endocrinology. Beijing: People's Medical Publishing House, 2001，1191－1201.[莫朝晖，苏欣．女性性早熟．见：廖二元，超楚生主编．内分泌学．北京：人民卫生出版社，2001，1191－1201.]
	6　Zhu J, Zhou JP. The current diagnosis and treatment of idiopathic central precocious puberty. Progr Obstet Gynecol, 2000, 9(1)：47.[朱瑾，周剑萍. 特发性真性性早熟的诊治现状. 现代妇产科进展，2000，9(1)：47.]
	7　Wang JS. The application and clinical value of diagnostic test. In: Wang JL, editor－in－chief. Clinical Epidemiology: Scientific design, measurement and assessment. 2nd ed. Shanghai: Shanghai Science and Technology Publishing House, 2001，261－272.[王觉生．诊断性试验的应用及其临床意义．见：王家良主编．临床流行病学——临床科研设计、衡量与评价. 第2版．上海：上海科技出版社，2001，261－272.]
	8　Xu YY, Yu CH, Chen YP, et al. The research design and analysis of diagnostic and screening test. In: Fang JG, ed. Medical statistics and computer experiments. 2nd ed. Shanghai: Shanghai Science and Technology Publishing House, 2003, 327－344.[徐勇勇，宇传华，陈平雁等．诊断和筛查试验的研究设计与分析．见：方积乾主编．医学统计学与电脑实验．第2版．上海：上海科技出版社，2003, 327－344.]
	9　Swets JA. Measuring the accuracy of diagnostic systems. Science, 1988, 240：1285.
	10　Sun YY, Li HL. Idiopathic central precocious puberty: the pathogenesis and diagnosis. Foreign Medical Sciences: Section of Pediatrics, 2002, 29(2)：97.[孙跃玉，李海浪. 特发性中枢性性早熟的发病机制及其诊断. 国外医学儿科学分册，2002, 29(2): 97.]
	11　Ning G, Wu KM, Li KM, et al. The software of assessment of skeletal maturity and prediction of adult height: The value of clinical application in pediatrics. J West China Univ Med Sci, 2002, 33(2)：302.[宁刚，吴康敏，李开明等．骨龄测定及成年身高预测软件在儿科临床的应用价值．华西医科大学学报，2002, 33(2)：302.]
	12　Salardi S, Cacciari E, Mainetti B, et al. Outcome of premature thelarche: Relation to puberty and final height. Arch Dis Child, 1998, 79(2): 173.
	13　Della MT, Setian N, Damiani D, et al. Premature thelarche: Identification of clinical and laboratory data for the diagnosis of precocious puberty. Rev Hosp Clin Fac Med Sao Paulo，2002, 57(2): 49.
	14　Hanley JA, McNeil BJ. The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology, 1982，143: 29.
	15　Sun J, Chen F, Zheng KE. The application of receiver operating characteristic (ROC) curve analysis in radiology. Chin J Radiol, 2001, 35(8): 574.[孙军，陈峰，郑凯尔. ROC曲线分析在放射学中的应用．中华放射学杂志，2001, 35(8): 574.]
	16　Swets JA, Pickett RM, Whitehead SF, et al. Assessment of diagnostic technologies. Science, 1979, 205: 753.
	17　Yip WM, Pang SY, Yim WS, et al. ROC cure analysis of lesion delectability on phantoms: Comparison of digital spot mammography with conventional spot mammography. B J R, 2001, 74: 621.
	18　Kaiser S, Frenckner B, Jorulf HK. Suspected appendicitis in children: US and CT－A prospective randomized study. Radiology, 2002, 223(3): 633－638.
	19　Hwang SA, Seo JB, Choi BK, et al. Liquid－crystal display monitors and cathode－ray tube monitors: A comparison of observer performance in the detection of small solitary pulmonary Nodules. Korean J Radiol, 2003, 4(3): 153－156.
	20　Ning G, Zhou XP, Liu GJ, et al. Receiver operating characteristic curve analysis in bone age for Chinese girls with IPP[J/CD]. Chin J Obs/Gyne & Pediatr (Electronic Version), 2005, 1(1)：15－19.[宁刚，周翔平，刘关键等．ROC曲线分析在性早熟女孩骨龄评价中的应用[J/CD]．中华妇幼临床医学杂志：电子版，2005，1(1)：15－19.]

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Diagnostic Test of TW System Bone Age of the Radius Ulna and Short of Bones in Chinese Girls With Idiopathic Precocious Puberty

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Diagnostic Test of TW System Bone Age of the Radius Ulna and Short of Bones in Chinese Girls With Idiopathic Precocious Puberty