15卷5期

• Link 原著 Original Article
• GEE之敏感度分析－偵測高影響之觀察值Sensitivity Analysis in Gee-Identification of High Influential Observations
• 張玉坤
  Yue-Cune Chang
• 敏感度分析 ； 高影響觀察值 ； 廣義線性模型 ； 長期資料
  sensitivity analysis ; high influential observations ; generalized linear models ; longitudinal data
• 高影響觀察值(high influential observations)的確認(identification)在統計迴歸模型(regression model)的應用上有其不容置疑重要性。在早期的一般線性模型(general linear model)及近幾年來被多位學者廣泛探討的廣義線性模型(generalized linear model)中，對此問題已有多篇論文發表。但是，處理長期資料(longitudinal data)線性模型的統計方法－GEE(generalized estimating equation)[1]，對此問題至今尚未見任何有開之論文刊載。本文對此問題提出一個簡單可行的圖形判讀法，並將原來的SAS/IML Macro程式，GEE1，加以修改後納入此項功能，以利原使用者之應用。我們也成功地將此方法應用在台灣省立新竹醫院眼科的一組資料上。
  The importance of identification of high influential observations in the applications of regression model is indubitable. There are a lot of related papers published for the general linear model and the generalized linear model as well. However, for the longitudinal data analysis, we haven't seen any literature published yet. In this paper, we proposed a simple graphic method to handle this sensitivity analysis problem. We also modified the original longitudinal data analysis SASIIML macro program, GEE1, to include the proposed graphic method. For those GEE1 user, the modified macro program is easy to use. We successfully applied this graphic method to analyze a real data set which was conducted by the Provincial Hsin-chu hospital in Taiwan.
• 403 - 410
• 10.6288/CJPH1996-15-05-01

• Link 原著 Original Article
• 子宮頸癌篩檢工具之評估Assessing the Performance of Two Cervical Cancer Screening Methods
• 林幼平、郭旭崧、謝長堯、黃文哲、陳建仁
  You-Ping Lin, Hsu-Sung Kuo, Chang-Yao Hsieh, Thomas W. Huang, Chien-Jen Chen
• 子宮頸癌 ； 子宮頸抹片 ； 子宮頸攝影 ； 敏感度
  cervical cancer ; Pap smear ; cervicography ; sensitivity
• 子宮頸癌高居臺灣地區女性癌症發生率之第一位。臺灣地區歷年子宮頸癌死亡車並未因實施子宮頸癌篩檢而有明顯下降，除受檢率偏低而外，篩檢工具因效度不佳以致未達其最大效用亦可能是重要的原因。本研究旨在評估子宮頸抹片及子宮頸攝影兩種子宮頸癌篩檢工具，並進而探討決定篩檢效度之可能因子“本所究利用子宮頸林片及子宮頸攝影在臺灣地區七個鄉鎮市的10,628名婦女進行子宮頸癌篩檢，兩種篩檢中任一結果為陽性者即予以切片確診。結果發現子宮頸抹片在子宮頸癌前低度病變及高度病變之「最高敏感度」分別為49.4%、94.2%，特異度為99.7%、98.9%，陽性預測值為89.9%、57.0%。子宮頸攝影之「最高敏感度」則分別為70.7%、45.9%，特異度為98.5%、94.8%，陽性預測值為74.7%、13.5%。合併使用兩種工具進行平行檢定後低度及高度病變之教感度分別為85.3%、96.6%，特異度為98.0%、93.5%，陽性預測值為79.9%、28.8%。子宮頸抹片及子宮頸攝影之檢體品質對於篩檢工具效度並無顯著影響，但年齡、採檢時間等個案特性與採檢狀況則和篩檢工具之效度有關。
  Cervical cancer is the leading cancer for women in Taiwan. The age-adjusted incidence rate of cervical cancer was as high as 33.5 per 100,000 in Taiwan area, 1987. There are evidences suggesting early screening can reduce incidence and mortality of cervical cancer. However, the decline in cervical cancer mortality in Taiwan has not been compatible with those observed in other countries. Low participation rate of screening is a major reason for high mortality. Nevertheless, it is also likely the screening tool was not employed in an effective and accurate way. This study aimed to evaluate the validity of two cervical cancer screening tools, Pap smear and cervicography, and to explore factors affecting the validity. There were a total of 10,628 women from seven townships in Taiwan received cervical cancer screening by Pap smear and cervicography. Confirmation by colposcopy-guided biopsy was carried out for those who were suspected to have cervical cancer or precancerous lesion found by smear and/or cervicography. The maximal sensitivity of Pap smear for LSIL (low-grade squamous intraepithelial neoplasia) and HSIL (high-grade squamous intraepithelial neoplasia) were 49.4% and 94.2%, respectively. The specificity of Pap smear for LSIL and HSIL were 99.7% and 98.9%, respectively. The positive predictive values of Pap smear were 899% and 57.0% for LSIL and HSIL, respectively. The maximal sensitivity of cervicography for LSIL and HSIL were 70.7% and 45.9%. The specificity of cervicography for LSIL and HSIL were 98.5% and 94.8%. The positive predictive values of cervicography for LSIL and HSIL were 74.7% and 13.5%, respectively. The combination of Pap smear and cervicography increased the maximal sensitivity for LSIL and HSIL up to 85.3% and 96.6%. Whereas the specificity slightly decreased to 98.0% and 93.5%. The positive predictive values for the combined screening were 79.9% and 28.2%, respectively. The validity of Pap smear and cervicography was not affected by sampling quality, but was affected by subject characteristics and sampling conditions.
• 411 - 424
• 10.6288/CJPH1996-15-05-02

• Link 原著 Original Article
• 臺灣鄉村地區七個抽煙家庭呼吸性懸浮微粒及尼古丁濃度評估Mass Concentrations of Respirable Particulate and Nicotine in Seven Smoker's Homes in Rural Area of Taiwan
• 詹長權、黃勝凱、陳怡君、王榮德
  Chang-Chuan Chan, Shen-Kai Huang, Yi-Chun Chen, Jung-Der Wang
• 二手煙 ； 呼吸性微粒 ； 尼古丁 ； 道路粉塵 ； 暴露評估
  environmental tobacco smoke ; respirable particulates ; nicotine ; road dust ; exposure assessment
• 本研究是抽煙者對家庭內空氣品質及其家人暴露於呼吸性微粒與尼古丁的影響，1991年夏季及冬季在臺灣鄉村地區，選取七個抽煙家庭每天測量呼吸性微粒及尼古丁濃度，各為期一個星期。從這七個家庭中又找出14個人做抽煙家庭呼吸性微粒及尼古丁濃度暴露量評估。呼吸性微粒是利用以旋風式集塵器為採樣頭的個人呼吸採樣幫浦（流量為1.91/min）收集在聚氯乙烯濾紙，而尼古丁是利用有玻璃纖維的鐵氟龍濾紙裱敷硫酸氫鈉加以收集，經氨化庚烷萃取後，以氣相層析儀－氮磷偵測器分析。研究結果顯示兩季的室內呼吸性微粒濃度(44-107μg/立方公尺)都比室外(27-92μg/立方公尺)高，夏季室內尼古丁濃度平均為0.7±0.6μg/立方公尺，個人尼古丁暴露量則為0.5±0.5μg/立方公尺，冬季室內尼古丁濃度平均為0.7±1.1μg/立方公尺，個人尼古丁暴露量則為0.4±0.5μg/立方公尺。相關性分析顯示，室內呼吸性微粒是趨向由室外道路粉塵產生而較少來自二手煙。
  This study examines smoker's impact on his indoor air quality and his relative exposure to respirable particulate and nicotine. The daily indoor/outdoor respirable particulate and nicotine concentrations of seven smoker's homes were concurrently measured over a week in a rural area of Taiwan in the summer and the winter. Personal exposures to respirable particulate and nicotine of sixteen members from these seven families were also measured. Respirable particulate samples were collected on PVC filters by personal pumps with cyclone (flow rate=1.9l/min). Nicotine samples were actively collected on the teflon coated glass fiber filters impregnated with sodium bisulfate, extracted by ammoniated heptane, and analyzed by the gas chromatographic method. Indoor respirable particulate concentrations (44 to 107µ/m^3) were higher than outdoor (27 to 92µ/m^3) in both the summer and winter. In summer, the nicotine concentrations averaged at 0.7±0.6µ/m^3 indoors and about 0.5±0.5µ/m^3 for personal exposure. In winter, the nicotine concentrations averaged 0.7±1.1µ/m^3 indoors and about 0.4±0.5µ/m^3 for personal exposure. From correlation analysis, the indoor respirable particulates appeared to be generated from outdoor road dust rather from environmental tobacco smoke.
• 425 - 433
• 10.6288/CJPH1996-15-05-03

• Link 原著 Original Article
• 以吸附劑採集經熱脫附後以氣相色層分析質譜儀(GC/MS)分析大氣中揮發性有機化合物(VOCs)及3-Ethenylpyridine(3-EP)方法之開發Development of a Sampling and Analytical Method for Volatile Organic Compounds (VOCs) and 3-Ethenylpyridine (3-Ep) Using Solid Adsorbent, Thermal Desorption Procedure and Gas Chromatograph/Mass Spectr
• 詹長權、顧家華
  Chang-Chuan Chan, Chia-Hua Ku
• 揮發性有機化合物 ； Tenax ； Carbotrap ； 環境二手煙
  volatile organic compounds VOCs ; Tenax ; Carbotrap ; environmental tobacco smoke
• 本研究嘗試將Tenax-TA(上標 R)與Carbotrap(上標 R)，製成一複合式吸附劑(multisorbent)的採樣管，用以採集室內及室外揮發性有機化合物，並且以熱脫附(thermal desorption)的方法，將樣本脫附濃縮後，注入氣相層析儀／質譜儀(GC/MS)分析。此採樣分析方法，可準確定量12種C6-C10的化合物，以及三種砒碇類的化合物。分析測定結果發現：熱脫附裝置的脫附效率可達97%。各主要分析標的化合物的偵測極限，範圍由0.714ng(l,3,5-Trilnethvlbenzene)到4.88ng(2-picolinee)。分析系統對於標的化合物的重複測試，其變異係數範圍從0.4%~13.6%。本採樣管在25℃相對濕度65%，注入15種化合物總量達7500ng的狀況下進行破出實驗，當測試體積達14L時，僅有benzene與heptene有破出的現象，其中benzene在測試體積小淤7.2L時，不會有破出情況發生。將本採樣系統與Tenax-GC採樣設備，一起進行大氣環境的採樣，可發現同一種採樣設備，其對照樣本結果的差異，多在10%~20左右，差異性不大。將本採樣、分析設備實際應用在台北市的居家室內環境中，發現一個晚上大約抽14-35支香煙的家戶，其室內環境的benzene的平均濃度為14.1ppb；3-Eethenylpyridine的平均濃度為0.15ppb。
  This study was designed to develop a technique to sample indoor/outdoor volatile organic compounds (VOCs) in Taipei. About 12 VOCs of C6-C12 and 3 pyridines, including 3-ethenylpyridine (3-EP), were successfully collected by the multi-sorbent sampling tubes, which contain Tenax-TA(superscript R) and Carbotrap(superscript R), and accurately analyzed by a thermal desorption unit coupled with a gas chromatography with mass spectrometer. The desorption efficiencies for most of the target compounds were above 97%. The detection limits (LOD) ranged from 0.714ng for 1,3,5-trimethylbenzene to 4.88ng for picoline per sampling tube. Based on the 14L sampling volume, the LOD's were 0.07 for benzene, and 0.08ppb for toluene. The coefficient of variance (CV) of the 6 analyzed sampling tubes with the same amounts of VOCs ranged from 0.4% to 13.6% for most of the target compounds. The breakthrough volumes of 15 VOCs with a total amount of 7,500ng under the condition of 25? and 65% relative humidity were all greater than 14L except for benzene, which was less than 7.2L. The differences between Tenax-GC(superscript R) tubes and the multi-sorbent sampling tube in measuring VOCs in the field were within 20% for most of the VOCs. In the field application of 6 homes with smokers, the sampling and analytical system had measured an average concentrations of benzene at 14.1 ppb and 3-EP at 0.15ppb.
• 434 - 446
• 10.6288/CJPH1996-15-05-04

• Link 原著 Original Article
• L-myc和麩胺基硫轉移酶M1之基因多形性與肝細胞癌感受性的相關研究Polymorphism of l-myc and Glutathione S-Transferase M1 Genes and Susceptibility to Hepatocellular Carcinoma
• 黃仁彰、陳建仁、廖運範、于明暉、謝玲玲
  Jen-Chang Huang, Chien-Jen Chen, Yun-Fan Liaw, Ming-Whei Yu, Ling-Ling Hsieh
• L-myc前致癌基因 ； GST M1基因 ； 肝細胞癌
  L-myc proto-oncogene ; GST M1 gene ; hepatocellular carcinoma
• 環境因子和遺傳因子可能皆和肝細胞癌的發展有關。因此本研究嘗試以病例對照研究來探討B型／C型肝炎病毒感染，及宿主L-myc和GST M1基因之多形性與肝細胞癌感受性的相關性。以聚合?鏈鎖反應分析每個個體的L-myc和GST M1永因型，研究對象包括73位病例和以年齡、性別變項進行頻率配對取樣的191位健康對照。 結果要現GST M1基因型在病例、對照組之間沒有分布上的差異，L-myc基因型在兩組之間則有分布上的差異；和SS基因型比較，屬LS基因型個體罹患肝細胞癌的相對危險性為1.48（95%信賴區間0.69-3.17），屬LL基因型的相對危險性為2.12（95%信賴區間0.96-4.69），以趨勢檢定分析達邊緣性統計意義(P=0.051)。進一步以B型肝炎病毒表面抗原進行分組，姿現在帶原者組別中，屬LL基因型個體罹患肝細胞癌的相對危險性為1.80（95%信賴區間0.67-4.94），屬LL基因型個體的相對危險性為3.05（95%信賴區間1.10-8.70），達統計上顯著差異(P=0.021)。在年齡不大於50歲和男性的組別中，也發現相似的結果。對數複迴歸分析也顯示在調整肝炎病毒標記、GST M1基因型等變項復，L-myc LL基因型和肝細胞癌之間仍有顯著相關的情形。綜合言之，雖然目前對於不同L-myc基因型所產生不同的癌變機率，其分子機轉尚未明瞭，不過本研究結果顯示帶有L-myc SS基因型的個體可能有較低的相對危險性罹患肝細胞癌。
  Both environmental and genetic factors may be involved in hepatocarcinogenesis. This study was carried out to investigate the relationship between the host L-myc and GST M1 genetic polymorphism and susceptibility of HCC. Using a polymerase chain reaction (PCR)-based assay on DNA extracted from liver and peripheral blood samples, the L-myc and GST M1 genotype of 73 HCC cases and 191 age-sex matched healthy controls was determined. This case-control study showed a slight difference in the distribution of L-myc genotypes between HCC patients and controls (p=0.l24). Compared with individuals who carried the SS genotype, the odds ratio associated with HCC was 1.48 (95% confidence interval [CI]=0.69-3.17) for those who carried the LS genotype and 2.12 (95%CI=0.96-4.69) for those who carried the LL genotype, respectively. There was a significant trend for the odds ratio of developing HCC with an increasing number of the L allele among men, hepatitis B virus carriers, and individuals aged 50 years or younger. Multiple logistic regression analysis indicated that persons with L-myc LL genotype tend to have a higher risk to develop HCC. There was no difference in the distribution of GST M1 genotypes between HCC patients and controls (p=0.499).
• 447 - 456
• 10.6288/CJPH1996-15-05-05

• Link 原著 Original Article
• 外籍生適應問題及相關因素之探討Adjustment of Foreign Students and the Related Factors
• 黃璉華、 羅漢強
  Lian-Hua Huang, Hann-Chung Lo
• 外籍生 ； 適應問題 ； 相關因素
  foreign students ; adjustment problem ; related factor
• 外藉生離鄉背井來台求學，面臨生活與環境的改變，若沒有適當的調適，種種壓力會對外籍生的生理、心理健康造成影響。因此，外籍生適應問題需要學校輔導等相關人員加以關注和正視。本研究以臺灣北部九所大學八十四學年度第二學期註冊之外籍生為研究對象，探討其來台後的適應情形和相關因素，問卷共寄發623份，回收175份，回收率為28.1%。 外籍生主要的適應問題為：課業問題、考試方式、表達意見及交通工具等。常遭遇的生活事件是生病、受傷。當有情緒上的困擾、計劃做某事及生病時，最常提供協助的是相同國籍的朋友。在台求學期間外籍生最常出現的健康相關問題有傷風感冒、緊張、頭痛、容易疲勞及想家等。外籍生使用僑外室、學校健康中心的頻率偏低。外籍生適應的相關因素有國籍、在臺灣的時間、課業量、先前出國經驗、來臺前後的心理準備、社會網絡、壓力調適、生活型態及個人特質等。建議提供跨文化的諮商以協助外籍生在台求學期間的適應過程。
  Foreign students must leave home when they come to Taiwan to study. The changes in life and environment could be a stress for the student and could also affect his/her physical and mental health. The issue of the foreign students' personal adjustment has become a practical concern that needs to be faced by the university personnel advising these foreign students. The purpose of this study was to investigate the adjustment problems of foreign students who registered for the 1994 academic year at nine universities in Northern Taiwan. Also analyzed were the factors which related the adjustment of the student. Questionnaires were mailed to 623 foreign students and 175 students responded. The response rate was 28.1%. Major problems of foreign student adjustment were: academic/curriculum problems; the method of examination; the language problems and the transportation problems. The most frequent life event that had happened in the past year was either illness or injury. When the students experienced emotional distress, were frustrated or ill, they got assistance mostly from friends of the same country. For health-related problems during the stay in Taiwan, most students reported the common cold, being nervous, headache, fatigue and homesickness. An under use of the Foreign Students Affair Office and School Health Center was also noted. Factors affecting adjustment include: nationality, length of stay in Taiwan, study workload, previous experiences of going abroad, degree of psychological preparation, social network, stress coping strategies, life style, and personality. It is suggested that cross-cultural adjustment counseling strategies be devised to facilitate foreign students' adjustment process in Taiwan.
• 457 - 468
• 10.6288/CJPH1996-15-05-06

• Link 原著 Original Article
• 公私立綜合醫院服務層面效率差異之探討A Study on the Efficiency Difference between Public and Private General Hospitals
• 石淦生、羅紀琼、陳國樑
  Kan-Shan Shih, Joan C. Lo, Kuo-Liang Chen
• 醫院效率 ； 醫院所有權 ； 資料包絡分析法
  Hospital Efficiency ; Hospital Ownership ; Data Envelopment Analysis
• 過去國外文獻針對醫院所有權對其效率影響的分析，結論頗為分歧，美國的研究文獻中，有公立醫院效率較私立醫院為低者[1]；亦有公立醫院效率較私立醫院為高者[2]；還有公私立醫院效率與顯著差異者[3]。日本的研究結果則一致顯示合立醫院效率較高[4,5]。 羅紀?等[6]採用民國八十二年『台灣地區公私立醫療院所現況與服務量調查』青料，以DBA的分析方法，對台灣地區公立及私立綜合醫院的效率予以衡量，研究結果顯示，公立醫院較私立醫院與效率。 本研究採用了羅紀?等的資料，嘗試分解公私立醫院效率差異的原因，分析結果顯示，公立醫院相對於私立醫院的與效率，有一部份應歸因於二者生產技術的差異，另有一部分則和醫療產業多屬遞減規模報酬有關。由於公立醫院一般而言規模較大，適減規模的特性即會使公立醫院效率較差。Logit模式?歸結果更進一步證實，護士與病床比值和遞減規模報酬呈正相關，醫院所在地區的醫療需求則和遞減規模報酬呈負相關。
  There were numerous studies concerning the impact of hospital ownership on their technical efficiencies, however, the results were inconclusive. Some studies have demonstrated that the efficiency of public hospitals is higher than that of private hospitals [1]. Some studies have demonstrated that the efficiency of private hospitals is higher [2], and there were also studies exhibited that there were no differences [3] between the two. The similar studies in Japan have indicated the efficiency of public hospitals is consistently higher [4,5]. Joan C. Lo et. al. [6] employed the DEAmethod on the 1993 Medical Facility Survey of Taiwan, and reached the conclusion that public hospitals uniformly had a lower technical efficiency for all three input-output combinations. Even after taking into consideration of inefficiency of the public hospitals, hospitals affiliated with medical schools still had a lower technical efficiency. In this study, we adopted the same data and same analytical method, i.e. DEA, as Joan Lo et. al., but further decomposed the efficiency. The empirical evidence has shown that not only the difference in production technology, but also the characteristics of decreasing returns to scale pertaining to the medical industry warrant the result that public hospitals are relatively inefficient to private hospitals. Moreover, the regression result of the Logit model indicates the positive correlation between bed-staff ratio and decreasing returns to scale, and the negative correlation between area medical needs and decreasing returns to scale.
• 469 - 482
• 10.6288/CJPH1996-15-05-07

• Link 原著 Original Article
• 臺灣地區捐血中心篩檢愛滋病毒第一型及第二型之成本效益分析Cost-Benefit Analyses of the HIV-1 or Combined HIV-1/HIV-2 Screening Program in Blood Donation Centers in Taiwan
• 姚權、郭旭崧、陳宜民
  Chuan Yao, Sung-Ko Hsu, Yi-Ming A. Chen
• 成本效益分析 ； 愛滋病 ； 愛滋病毒第一型 ； 愛滋病毒第二型 ； 篩檢 ； 捐血中心 ； 輸血
  Cost-benefit analysis ; HIV-1 ; HIV-2 ; Screening ; Blood bank
• 臺灣地區捐血中心除現行的愛滋病毒第一型(HIV-1)篩檢外，亦考慮增加篩檢愛滋病毒第二型(HIV-2)，但對篩檢的成本效益尚未評估。因此，本研究評估篩檢HIV-1的成本效益，以及增加篩檢HIV-2的附加成本效益。我們採用社會的觀點進行分析，以人力資本法換算生命的價值。所採用的折現率是3%。除了進行敏感性分析外，也計算各參數的彈性。研究結果顯示臺灣地區捐血中心1993年篩檢HIV-1，總成本估計為＄97,894,950元。篩檢共發現21袋HIV-1陽性的血液，43個受血者因而得以避免發生愛滋病，總效益是＄133,663.077元。效益成本比是1.37。每一個血來的HIV-1篩檢產生＄29元的淨效益。對HIV-1篩檢之效益成本比影響最大的參數是HIV-1篩檢方法之特異性。估計捐血中心將現有的HIV-1篩檢，改成HIV-1/HIV-2混合試劑篩檢，一年所必須增加的總成本約為＄13,433,120元。當改用HIV-1/HIV-2混合試劑進行篩檢時，在全部血袋中至少必須有11個HIV-2陽性血袋，附加效益成本比才會達到平衡點。
  Societal perspective was used to analyze the cost and benefit of the current HIV-1 screening program in national blood donation centers in Taiwan. In addition, incremental cost-benefit analysis was performed to evaluate the combined HIV-1/HIV-2 screening program which may be implemented in the near future. The costs of the following items were estimated: enzyme immunoassay (ETA), confirmatory Western blot assay, disposal of the contaminated blood, marginal blood donor recruitment and follow-up of the HIV-1/HIV-2 cases found in the screening program. The benefits of the screening program included the saves of the following two aspects: cost of the medical care and the earnings loss of the transfusion-acquired HIV-1/HIV-2 patients. The discount rate of the benefit was set at 3% per year. The results showed that the total cost of HIV-1 screening in the national blood donation centers in Taiwan was NT$ 97,894,950 for 1,242,535 blood units in 1993. Since the screening program will prevent 43 cases of transfusion-acquired HIV/AIDS case, the total benefit was NT$ 133,663,077. Therefore, the benefit-cost ratio of HIV-1 blood screening program in blood donation centers in Taiwan was 1.37. The sensitivity and elasticity analyses showed that the most important factor affecting the projection is the specificity of the screening test. Finally, if the blood donation centers change their current screening test to combined HIV-l/HIV-2 EIA, the total incremental cost will be NT$ 13,433,120. To reach the break-even point of the incremental benefit-cost ratio, it requires at least 11 HIV-2 seropositive blood units found in the combined HIV-1/HIV-2 screening program.
• 483 - 496
• 10.6288/CJPH1996-15-05-08