大骨节病病例罹患氟骨症的流行病学调查

Epidemiological survey of cases suffering Kaschin- Beck disease and skeletal fluorosis

目的证实大骨节病与饮茶型氟中毒重叠病区中存在大骨节病病例罹患氟骨症的特征性病例,为诊断、预防和控制同患此两种疾病提供科学依据。方法 （1）按大骨节病诊断标准进行临床和X线检查,筛选出大骨节病病例人群做为研究对象;（2）每个研究对象进行调查日饮茶量等信息并采集所饮砖茶水和尿液,用氟离子选择电极法测定茶水和尿氟含量,计算人群摄氟量、人群尿氟值,并就大骨节病病例罹患氟骨症人群（氟骨症人群组）与大骨节病病例未患氟骨症人群（大骨节病人群组）进行比较;（3）每个研究对象拍摄前臂（包括肘关节）X线片,按氟骨症X线诊断标准诊断氟骨症,并就氟骨症人群组与大骨节病人群组掌指、前臂的临床体征以及X线影像进行比较。结果 （1）40-78岁之间的自愿受试者共61人中确诊大骨节病病例45人,其中Ⅰ度病例检出34例、Ⅱ度病例检出5例、Ⅲ度病例检出6例;（2）45例大骨节病病例共确诊氟骨症19人,其中Ⅰ度病例检出4人、Ⅱ度病例检出2人、Ⅲ度病例检出13人;（3）氟骨症人群组摄氟量人均日为7.69 mg,是大骨节病人群组人均日摄氟量的2倍,也是人群总摄氟量卫生标准的2倍;氟骨症人群组尿氟含量几何均值为3.03 mg/L,是大骨节病人群组尿氟值的1.5倍,是人群尿氟正常值的2倍。（4）氟骨症人群组与大骨节病人群组掌指、前臂的临床体征以及X线影像进行比较,掌指临床体征及其X线影像基本无差异;氟骨症人群肘关节（被动）后伸10-70度的为84.21%（16/19）,大骨节病人群组肘关节（被动）后伸10-30度的为30.77%（7/26）,卡方检验,χ^2=4.89〉χ^20.05（1）=3.84,P〈0.05两者之间有显著统计学差异,并且,大骨节病人群组肘关节后伸曲度均在30度以内,而氟骨症人群组大于30度的达到56.25%（9/16）;X线影像上大骨节病人群组除无桡尺骨间膜骨化外,表现为肘关节退变和骨质增生,而氟骨症人群组表现为肘关节退变、骨质增生并伴有膨大、变形以及肌腱韧带附着点和关节囊骨化。结论 （1）证实了大骨节病与饮茶型氟中毒重叠病区中存在大骨节病病例罹患氟骨症的特征性病例;（2）大骨节病发病在前,氟骨症发病在后;（3）掌指临床体征和X线影像基本无差异;（4）氟骨症人群组的肘关节损害体征重于大骨节病人群组,X线影像具有双重性。

Objective To prove the characteristic cases suffering both Kaschin-Beck disease（KBD） and skeletal fluorosis existing in the overlap endemic areas of KBD and drinking tea type fluorosis, and provide scientific basis for diagnosing, prevention andcontrol of such cases. Methods ①Chose the KBD cases as the object of study by clinic and X-ray examination according to the diagnosis of KBD（ WS/T 207-2010） criteria.②Took the forearm （ including elbow joint） X- ray picture of each case, selectedthe skeletal fluorosis cases according to the X- ray diagnosis of skeletal fluorosis criteria. Compaired the clinic sign and X- ray image of palm and forearm in the skeletal fluorosis cases and KBD cases. ③Asking the object of study about their quantity ofdrinking tea every day, collecting the brick tea water and their urine. The fluorine content of tea water and urine were detected by fluorion selective electrode method. The daily intake fluorine and urine fluorine levels were calculated. The results of above werecompaired between the cases suffering both KBD and skeletal fluorosis and the cases only suffering KBD. Results ①Confirmed 45 KBD cases from 61 volunteer subjects aged 40 to 78, 34 cases of Ⅰ degree, 5 cases of Ⅱ degree cases, 6 cases of Ⅲ degreewere checked out among the 45 cases. ②Confirmed 19 skeletal fluorosis cases from the 45 KBD cases, 4 cases of Ⅰ degree, 2 cases of Ⅱ degree cases, 13 cases of Ⅲ degree were checked out among the 19 cases. ③The per capita fluorine intaking amount ofskeletal fluorosis cases group was 7.69 mg/d, which was two times as that of KBD cases group, and was also two times as that of the hygienic standard for daily total intake fluorine. The urine fluorine geometric mean value of skeletal fluorosis cases group was3.03 mg/L, which was the 1.5 times as that of KBD cases group, and was two times as the normal concentration of urinary flu-oride of population. ④There were no differences in the palm finger clinic sign and X-ray image between the skeletal fluorosis ca- ses group and KBD cases group. The rate of elbow joint passivity backward extension reached 100 to 700 was 84.21% （16/19） inthe skeletal fluorosis cases group, and the rate of elbow joint passivity backward extension reached 100 to 300 was 30.77% （7/26） in the KBD cases group. The result of the chisquare test showed that there was a significant statistics difference in the twogroups（ X^2 =4.89〉X^20.05（1） =3.84, P 〈0.05）. The elbow joint backward extension range of KBD cases were all within 300, while the rate of elbow joint backward extension range reached 300 was 56.25% （9/16） in the skeletal fluorosis cases group. TheX-ray image characters of KBD cases were the degeneration and hyperostosis of elbow joint without radioulna interosseous membrane ossify. The X-ray image characters of skeletal fluorosis cases were the degeneration, hyperostosis accompanied enlargement, transformation in the elbow joints and ossify in the tendon ligament attachment points and joint capsule. Conclusions ① The characteristic cases suffered both KBD and skeletal fluorosis existing in the overlap endemic areas of KBD and drinking teatype fluorosis was verified. ② The onset of KBD was in the illness earlier stage, and the development of skeletal fluorosis was in the illness later stage of the characteristic cases. ③ There were no differences in the palm fingers clinic sign and X-ray image be-tween the skeletal fluorosis cases group and KBD cases. ④The elbow joint damage signs of skeletal fluorosis cases were worse than those of KBD cases, the X-ray images of the characteristic cases had the dualism of the two kinds of disease.