13卷2期

• Link 原著 Original Article
• 生物劑量偵測應用於輻射過量暴露民眾之簡介Biological Dosimetry and Monitoring for Citizens with Excessive Ionizing Radiation Exposure
• 張武修
  Wushou P. Chang
• 游離輻射 ； 生物劑量 ； 生物指標
  Ionizing radiation ; biological dosimetry ; biological markers
• 對於長期或短期意外暴露於異常過量輻射線的民眾或工作人員，如何妥當地準確評估身體所接受之劑量，以及協助維護其往後的健康，長久以來即為臨床醫學與公共衛生學者所關心的事情。過去，由於已知的一些生物劑量偵測方法並不靈敏，科學界對於輻射線如何影響生物的了解，相當有限。然而近十年來，隨著生物科技的進步，科學家們已致力發展出一些較前靈敏的生物劑量偵測法，也在近年許多輻射污染人員的檢體中加以應用評估。本文就這些新發展，評估良好的偵測方法，簡要記述如下，以備國人參考與採用。
  More than two hundreds of citizens are recently suspected to have been exposed to unexpectedly excessive dose of ionizing radiation in the residential environment in Metropolitan Taipei, Taiwan. A much higher risk of radiation-induced neoplasm, hereditary or genetic damage might have been incurred in these victims without appropriate warning. There is urgent need for well-designed and organized medical or public health professionals to provide estimation of biological dosimetry for all these individuals. Several biological markers specific for ionizing radiation exposure have been employed in the previous radiation accidents in several countries. A few newly developed markers are playing more important roles for estimation of chronic low level, low linear- energy-transfer (LET) radiation. A review of these biological dosimetry and monitoring for citizens described is offered, though not comprehensive. This is intended to provide update informations and to frame better direction of medical responses in the coming future.
• 105 - 112
• 10.6288/CJPH1994-13-02-01

• Link 原著 Original Article
• 台灣地區砷、汞、鎘及其化合物之用途和用量調查研究Usage and Amount of Arsenic, Mercury and Cadmium Compounds in Taiwan Area
• 邱弘毅、葉錦瑩、薛玉梅、陳建仁
  Hung-Yi Chiou, Ching-Ying Yeh, Yu-Mei Hsueh, Chien-Jen Chen
• 砷 ； 汞 ； 鎘 ； 用途 ；
  Arsenic ; Mercury ; Cadmium ; Usage
• 砷、汞、鎘及其化合物在工業、農業及製藥的使用相當廣泛，但也是美國環境保護署列為最優先列管的毒性化學物質。我國台灣地區本地並未出產砷、汞、鎘等金屬，全仰賴進口以供應各產業之需求。為瞭解砷、汞、鎘及其化合物在國內的用途和用量，本研究依據經濟部國貿局商務中心建檔之進口資料加以統計分析，並實地訪查大宗進口之廠商，以瞭解其產品與製程。調查結果顯示：砷及其化合物之進口量，民國71年為574公噸，76年高達769公噸，79年（1-8月）為398公噸；主要用於農藥製造業和玻璃製造業。汞及其化合物之進口量，民國71年為10公噸，76年高達48公噸，79年（1-8月）為20公噸；主要用於中藥業、儀器製造業、電子製造業和燈管製造業。鎘及其化合物之進口量，民國71年為174公噸，75年高達477公噸，78年以後因氧化鎘不必申報，故申報進口量降至79年的9公噸；主要用於化學製造業。為確實掌握砷、汞、鎘及其化合物的用途和用量，宜加強砷、汞、鎘及其化合物進口廠商的海關申報作業，環保單位應嚴格要求製造及使用廠商確實定期申報進口量，使用量及庫存量等運作記錄，並隨時不定期查核，此外更應社絕地下工廠獲得原料的管道，才能真正掌握台灣地區砷，汞、鎘及其化合物的用途和用量。
  Arsenic, mercury and cadmium compounds are used widespreadly in industry, agriculture and pharmaceutical manufacture. They are also listed as the important toxic substances to be controlled with top priorities by the U.S.A. Environmental Protection Agency. The specific aim of this study is to estimate the usage and amount of arsenic, mercury, and cadmium compounds in Taiwan area. Based on the analysis of official data and field survey, all materials of arsenic, mercury, and cadmium compounds were imported. The imported arsenic compounds were 574 kilotons in 1982, 769 kilotons in 1987 and 398 kilotons in 1990 (from January through August). These compounds were used mainly in pesticide and glass manufacturing industry. The imported mercury compounds were 10 kilotons in 1982, 48 kilotons in 1987 and 20 kilotons in 1990 (from January through August). They were used mainly in manufacturing Chinese pharmaceuticals and electronic utilities. The imported cadmium compounds were 174 kilotons in 1982, 477 kilotons in 1986. The imported amount of cadmium oxide was no longer reported after 1990. They were used in chemical manufacturing industry. In order to control the usage and amount of these toxic compounds effectively, it is important to enforce the official imported materials reporting system and a manufacture recording system of these compounds.
• 113 - 125
• 10.6288/CJPH1994-13-02-02

• Link 原著 Original Article
• 某廢鉛蓄電池回收工廠附近土壤與空氣鉛污染之流佈Distribution of Lead Pollution in Soil and Air around a Storage Battery Recycling Plant
• 韓柏檉、陳叡瑜、邱弘毅、葉錦瑩、 許東榮
  Bor-Cheng Han, Ruey-Yu Chen, Hung-I Chin, Ching-Ying Yeh, Tong-Jong Hsu
• 鉛污染 ； 物種鑑定 ； 電池回收工廠
  lead pollution ; speciation ; storage battery recycling plant
• 本文之目的乃在調查研究廢鉛蓄電池回收工廠附近環境之土壤與空氣鉛污染之現況及其濃度之分佈。由環境的數據顯示回收工廠附近之表層土壤鉛之平均含量高於1000μg/g，而遠離該工廠2公里左右的較深層土壤(15~30cm)鉛含量下降至小於100μg/g。一般而言，土壤中的鉛含量與該工廠距離之遠近有著極明顯的負相關。另一方面，利用不同之試劑與連續步驟萃取土壤中不同物種的鉛，結果顯示，土壤中的鉛較易以可交換相與碳酸鹽相存在，這可說明源自陸源的鉛回收廠之鉛污染是佔優勢的。該工廠附近環境空氣的鉛平均濃度為2.58±4.17μg/立方公尺，（介於0.04~18.2μg/立方公尺），比背景測站之空氣鉛濃度(0.12±0.13μg/立方公尺)為高。同時，空氣中高濃度的鉛(5.18±6.53μg/立方公尺)被發現於晚間採樣的樣本中。
  The purpose of this study was to investigate the distribution of lead contamination in the environment (such as soil and air) near a storage battery recycling plant. All samples were collected in various seasons during the period from Oct. 1990 to June 1991, and analyzed by atomic absorption spectrometry (flame or graphite). The environmental data showed that the average value of lead in surface soil near plant ”X” was >1000µg/g and decreased to less than 100µg/g in 15-30 cm deep soil about 2 Km away from the plant. In general, the concentrations of lead in soil were strongly and negative by correlated with the distance from plant ”X”. On the other hand, lead speciation in soil was extracted by sequential procedures using several reagents. The results reveal that lead is preferentially accumulated in the exchangeable and carbonate fractions. This suggests that the lead pollution is dominated synchthonously by the storage battery recycling plant. The average concentrations of lead of 2.58±4.17µg/m^3 (from 0.04 to 18.2µg/m^3) in the air near plant ”X” were higher than those at the background stations, the mean value of which is 0.12±0.13µg/m^3. In addition, the high contents of lead (5.18±6.53µg/m^3) in air were found at midnight during a 24 hour period.
• 126 - 137
• 10.6288/CJPH1994-13-02-03

• Link 原著 Original Article
• 腦神經上皮細胞瘤之p53基因突變的研究P53 Mutation in Neuroepithelial Cell Tumor of Brain
• 夏長鳳、何逸僊、王豊裕、 陳建仁、 謝玲玲
  Chang-Feng Hsia, Yat-Sen Ho, Li-Yu Wang, Chien-Jen Chen, Ling-Ling Hsieh
• 腦神經上皮細胞瘤 ； p53基因
  brain tumor ; p53 gene
• 中樞神經腫瘤大約占臺灣地區所有癌症的1.84%，大部份的原發性腦瘤為神經膠質細胞瘤，其中以星細胞瘤最常見，於治療後容易再發，存活率不高。最近研究顯示癌症的產生是多步驟的機制，必須累積相當的遺傳缺陷，特別是致癌基因的活化和抑癌基因的去活化。本研究以116名接受外科手術治療的腦瘤個案為研究對象，進行其腦組織中P53基因的突變分析。以聚合?鏈鎖反應－單股構造多形性分析62個星細胞瘤、23個寡樹突細胞瘤、11個室管膜瘤、和20個原始性神經上皮細胞瘤的組織。其中的17個腦瘤組織發生p53基因突變(14.70%)，且位在表現序列5、7和8。p53突變並非隨機分佈在各類組織，而是好發於第Ⅱ、Ⅲ級星細胞瘤(17.30%)，第Ⅲ級寡樹突細胞瘤(22.2%)和原始性神經上皮細胞瘤(25%)。p53基因的突變形式皆為單一核?酸位置的改變，大部份是誤意義的突變(85%)。G:C轉變為A:T，或C:G轉變為T:A有60%；CpG二核?酸位置的突變率則是60%。這些結果顯示p53基因的去活化，在腦瘤發展過程中扮演極重要的角色。
  Tumors of the central nervous system account for approximately 1.84% of all human cancers in Taiwan. Most of adult primary brain tumors are gliomas, of which astrocytomas are the most common ones. These tumors are progressive, tend to recur following treatment, and are usually fatal. Recent studies have shown that cancers progress as a result of several sequential genetic events, occurring stepwise over time, and may involve either activation of oncogenes or inactivation of tumor suppressor genes. Tumor suppressor genes, especially p53, are now known to play an important role in the development of a wide variety of human cancers. In the study, polymerase chain reaction and single-strand conformation polymorphism (PCR-SSCP) analysis was used to investigate the mutation of p53 gene in 116 surgically removed primary brain tumor tissues which include 62 astrocytomas, 23 oligodendrogliomas, 11 ependymomas and 20 primitive neuroepithelial tumors (PNET). 14.7% (17/116) of the brain tumors had p53 mutation and were found to be localized in exons 5, 7, and 8. Mutations do not follow a random distribution among different subtypes, but occurred in 17.3% (9/52) of grade ? and ? of astrocytomas, 22.2% (2/9) of grade ? oligodendrogliomas and 25% of PNETs. All p53 mutations were single nucleotide change, mostly missense mutations (17 events). The majority of mutations identified in this study were G:C to A:T or C:G to T:A transitions (60%, 12 of 20) and occurred frequently (60%, 12 of 20) at sites of CpG dinucleotides, which are known to be hot spots for mutations in the p53 gene in many other types of human cancers. These results suggest that the inactivation of p53 gene plays an important role in the development of brain tumor.
• 138 - 148
• 10.6288/CJPH1994-13-02-04

• Link 原著 Original Article
• 醫師目標收入理論之試證A Test on Target-Income Hypothesis for Physician
• 郭信智、楊志良
  Hsin-Chih Kuo, Chih-Liang Yaung
• 目標收入 ； 需求創造 ； 醫師行為
  Target-income ; demand creation ; physician behavior
• 全民健康保險將於民國八十三年實施，醫療供給者對於醫療保險透過支付制度強制約束醫療行為與醫療報酬計算方式，常持反對態度，並嘗試以量制價，以為因應。茲探討勞保甲乙丙表實施後，勞保門診醫療費用支付制度，對醫師診療行為（以申報金額與件數為指標）之影響，以供全民健保規劃之參考。 研究母全體係八十年三月台閩地區勞工保險局收受醫療院所申報之「勞工保險醫療給付門診就診單」，採分層二階段系統集束隨機方法抽樣，共獲有效樣本3831件。主要發現如下：當透過支付制度降低每件申報金額時，醫師為了維持收入水準，傾向於增加申報件數。
  We randomly sampled 3831 OPD medical records submitted by hospital to the Bureau of Labor Insurance for reimbursement in March 1991 for this study Regression analysis is applied to eliminate the effect of the level of care. Results indicate those providers charged lower average costs per OPD took care of more patients in order to maintain their income levels.
• 149 - 155
• 10.6288/CJPH1994-13-02-05

• Link 原著 Original Article
• 台灣地區中醫師生產力函數推估Estimating Production Functions of Traditional Chinese Medicine Physicians in Taiwan
• 李卓倫、賴俊雄、陳世堅、紀駿輝、張淑桂、 陳秋瑩
  Jwo-Lenn Lee, Jim-Shoung Lai, Shish-Chien Frank Chen, Chunhuei Chi, Shu-Kuei Chang, Chiu-Yin Chen
• 生產力 ； 中醫師
  Productivity ; Chinese Medicine Physican
• 本研究針對全台灣地區中醫師的生產力函數作推估，樣本中醫師共300位，回收208位。研究依變項為中醫師看診人次與毛收入，而自變項為中醫師投入時間、非中醫師投入時間與資本投入，並加入一部分的組織模式變項和健康保險變項來推估中醫師的生產力。 研究結果顯示影響中醫師每週看診人次的重要變項包括：中醫師投入時間、資本投入、中藥調劑人員投入時間、醫療院所規模、保險病人比率、有無保險特約、當地西醫師人口比。在控制其他重要變項的情況下，中醫師每週看診人次的投入時間彈性係數為0.5，資本投入的彈性係數為0.24，醫療院所規模的彈性係數為0.3。中醫師每雇用一位專職中藥調劑人員，每週看診人次增加13.2%。健康保險特約是否會增加中醫師的看診人次，端視保險特約是否提高其看診保險病患的比率而定。在其他條件相同下，假如有保險特約的中醫師看診保險病患的比率超過46%，則其看診人次才會超過與保險特約的中醫師。1992年的中醫師每週看診人次為195，推估1996年和2000年的每週看診人次為332和350。
  Studying health care provider's production function can be very useful in determining reimbursement rate, and improve the efficiency of the provider. This study focuses on investigating the production function of Chinese medicine medicine physicians (CMPs), which we know very little so far. Such information is especially crucial when National Health Insurance will cover Chinese medicine services. Based on a national sample survey of 208 CMPs, this study examines several input factors that affect the outputs of CMPs. The input factors are time input of CMP, time input of non-CMP, capital input, and organizational structure. Health insurance contract is included as a control variable. The number of patient visits per week is the main output measurement. Results of this study indicate that there are several factors that can best predict CMP's output. They are, the time input of CMP, the capital input, the time input of Chinese medicine pharmacist, the size of the organization, the proportion of patients who have health insurance, whether the CMP has health insurance contract, and the ratio of population to modern Western medicine physician in the local area. This study also estimates several input-output elasticity. Using the number of patient visit as the output measure, the estimated input elasticity is 0.5 for CMP's time input, 0.24 for capital input, 0.3 for the size of organization, and 0.13 for Chinese medicine pharmacist. The effect of health insurance contract on the productivities of CMPs is dependent on whether such contract will increase the proportion of patients who have health insurance. This study suggests that only when there is more than 46% of a CMP's patients are insured, will health insurance contract affect a higher output of CMP. Finally, this study estimates that the average patient visits per CMP are 195 per week in 1992. Based the estimated production function, the forecasted patient visits per week per CMP for the years of 1996 and 2000 are 332 and 350, respectively.
• 156 - 167
• 10.6288/CJPH1994-13-02-06

• Link 原著 Original Article
• 台灣老人醫療服務之使用Utilization of Health Services among the Elderly in Taiwan
• 吳淑瓊、 梁浙西、張明正、林惠生、孟蘿拉
  Shwu Chong Wu, Jersey Liang, Ming-Cheng Chang, Hui-Sheng Lin, Nora Maloy
• 醫療服務使用 ； 結構公式模式 ； 老人 ； 台灣
  Health Services Utilization ; Structural Equation Modeling ; Aged ; Taiwan
• 本研究提出並實徵評估一個台灣老人醫療服務使用模式。為反應台灣複雜的醫療服務環境，本模式包括西醫門診、中醫門診、西藥房／局、中藥房、與住院等五個向度的醫療服務使用。利用台灣省家庭計畫研究所1989年台灣地區老人保健與生活問題調查的3846位60歲以上老人資料，及結構公式模式(structural equation modeling)評估本模式，結果發現無論全模式的適合度檢定或各相關參數值的顯著檢定，均能支持此模式之適合性。模式可解釋28%至32%的西醫門診利用變異量，並可解釋12%至15%的西藥房利用變異量。老人中自述較多疾病、自評健康較差、且教育程度較高者較多使用西醫門診服務；男性老人、自述較多疾病、及教育程度較差者較多使用西藥房／局服務；教育程度較低者較多使用中藥房服務，經濟變項雖然對醫療服務使用不具直接影響，但卻能透過自述疾病或自評健康變項間接影響醫療服務之使用。
  This study presents and empirically evaluates a structural model of health services utilization among the aged in Taiwan. As a reflection of the medical pluralism in Taiwan, five dimensions of health services utilization are specified involving the use of services provided by: (1) physicians trained in western biomedicine, (2) western pharmacies, (3) physicians trained in traditional Chinese medicine, (4) traditional Chinese drug stores, and (5) hospitals. Data came from the 1989 Survey of Health and Living Status of the Elderly in Taiwan, involving 3,846 respondents. The proposed model was supported in terms of both overall and component goodness-of-fit and estimates of free parameters. 28% to 32% of the variance in the use of health services provided by physicians of biomedicine and 12% to 15% of the variance in the use of services provided by western pharmacies are explained by the model. Study findings indicate that the older Chinese with more self-reported illness, poorer self-rated health, and more education are more likely to utilize physicians of biomedicine. In addition, the male and the elderly with more self-reported illness and less education have a higher propensity to use western pharmacies. The use of Chinese drug stores is negatively related to education. Age is negatively related to the use of hospitals. Finally, there is no direct effect of economic status on utilization, whereas, economic status through its influence on self-reported illness and self-rated health was found to have an indirect effect on utilization.
• 168 - 182
• 10.6288/CJPH1994-13-02-07

• Link 原著 Original Article
• 七十九年度暨八十年度台灣地區醫院評鑑結果之分析Comparison Studies of 1990 and 1991 Hospital Accreditation in Taiwan
• 蘇喜、戴政
  Syi Su, J. J. Tai
• 評鑑 ； 醫院評鑑
  Accreditation ; Hospital Accreditation
• 我國醫院評鑑制度肇始於民國67年，當時教育部及衛生署為了有客觀標準選定教學醫院，以為醫學生實習之場所，辦理第一次的教學醫院評鑑。75年醫療法實施後，衛生署期藉擴大醫院評鑑的範圍，提昇整個醫療服務水準，以保障病患之權益。木研究旨在比較衛生署接辦醫院評鑑工作以來之民國79年及80年二次之評鑑結果。 分析結果顯示： 1．在總得分方面，醫學中心及區域醫院二個年度平均分數相近而地區教學及地區非教學醫院則達顯著差異。 2．二評鑑年度之床位配置水準。醫學中心、區域醫院、地區教學醫院均未達顯著差異，而80年地區非教學醫院之各類床數（洗腎及嬰兒床除外）數目大於79年。 3．二評鑑年度之人員配置上，80年醫學中心之病壓人員配置較79年多，80年區域醫院之核醫技術人員比79年多。80年地區教學醫院之藥劑、放射技術及病歷管理人員均較79年增加，而80年地區非教學醫院除住院醫師、復健及社服人員外，其餘之專業人員均較79年多。 4．業務量方面，醫學中心及區域醫院二評鑑年度之業務量大致相同，地區非教學醫院之急診人次顯著減少，其餘業務量均增加或顯著增加。 目前評鑑表之設計對於品質項目之量化及測定不易，故只能注重硬體設施及人力配置之結構面，導致醫院群往人員、設備方面下具體可見之投資。結構面的充裕，雖不能保證醫療服務之品質，但至少是優良品質的根本。向此研究中發現，政策對醫療營運方向可能是頗具影響的，故屬醫療過程及結果面的可量化指標應是努力發展及期待的目標。
  The Hospital accreditation program in Taiwan was launched first time in 1978 for the purpose of assigning teaching hospitals as practice site for medical students. The enactment of the Medical Law authorizes the Health Department to be responsible for supervising the hospital accreditation program in coorepration with the Ministry of Education. Since then the database are available. This research aims at comparing the evaluation data of the two accreditation programs. The findings are as follows: 1. The total scores of medical centers and regional hospitals between the two accreditation runs are not significantly different, while those of district teaching and district non-teaching hospitals differ significantly. 2. The facility installment levels of medical centers, regional hospitals and district teaching hospitals between the two accreditation runs are not different while that of district non-teaching hospital has significant progress in installment level (kidney dialysis and infant bed are exceptions). 3. The medical related personnel staffing level of district non-teaching hospital has significant increase between the two accreditation programs, except residents, physical therapists, and social workers. Medical Centers have significant increase in the medical record management personnel while regional hospitals recruit more nuclear technologists significantly. 4. The productivity of medical centers and regional hospitals do not differ significantly between two accreditation runs while district non-teaching hospital has significant lower productivity amount in emergency care services but has significant higher amount in other services. Owing to the difficulty in quantifying services, the current accreditation program focus mainly on structural explarotory investigation. The facility installment level, personnel staffing level and productivity amount seem all have progressed as were expected by the Health Department. In terms of the findings, the district non-teaching hospitals seem to reflect the most satisfactory result toward what are expected. The guiding power of policy are shown meaningful. The development of objective process and outcome indicators are thus highly recommended.
• 183 - 201
• 10.6288/CJPH1994-13-02-08