16卷5期

• Link 綜論 Review Article
• 肺癌之流行病學特徵、危險因子及防治策略Epidemiologic Characteristics, Risk Factors, and Control Strategies of Primary Lung Cancer
• 廖國盟、 陳建仁
  Gao-Meng Liaw, Chien-Jen Chen
• 流行病學 ； 危險因子 ； 肺癌
  Epidemiology ; risk factors ; lung cancer
• 本文回顧綜述近年來肺癌的流行病學特徵及危險因子之文獻。台灣地區的肺癌發生率在三十年來增加近八倍，是增加最快的癌症之一。按其增加的速率估計，在二十一世紀初可能就會成為國人最重要的癌症。在基礎醫學、臨床醫學及流行病學上，都有一致的證據顯示吸菸是肺癌最重要的因子，二手菸暴露也被證實為肺癌之危險因子。職業及居家之氣氣暴露及其他化學致癌物如：石綿、砷、多環芳香烴的暴露，以及遺傳之易罹癌性、營養攝取不足也是重要的致病因子。吸菸率偏低的華人女性卻有偏高的肺癌發生率，其重要危險因子有特探討，烹調油煙、二手菸、遺傳之易罹癌性、性荷爾蒙都是值得鑽研的主題。初級預防是防治肺癌的根本之道，低焦油香菸不能根本解決問題，戒菸才是最為重要。化學預防可能會降低戒菸者之肺癌今生率，但目前所得到的結果卻仍有爭議。早期發現癌症也是防治肺癌的新方向，利用痰細胞學檢驗輔以單株抗體進行免疫細胞化學分析法，是一個有潛力的篩檢工具。p53基因的突變，有可能成為早期診斷的指標。
  This article reviews the researches on the epidemiologic characteristics and risk factors of primary lung cancer in the recent decade Primary lung cancer incidence and mortality have ‘been increasing rapidly during past thirty years in Taiwan. Consistent evidences in basic researches, clinical observations, and epidemiological studies have shown that cigarette smoking is the most important risk factor for lung cancer. Environmental tobacco smoking has also been documented as lung cancer risk factor. Occupational and domestic radon exposure and other occupational hazards, including asbestos, arsenic, and polycyclic aryl hydrocarbon have also been reported to be associated with the development of lung cancer. The association of genetic susceptibility and micro-nutrients with lung cancer needs further assessment. The low prevalence of cigarette smoking and relatively high incidence rate of primary lung adenocarcinoma among Chinese and Taiwanese women suggests the existence of some important risk factors to be elucid. The associations with lung cancer risk for cooking oil fumes, history of lung diseases, and reproductive factors have been intensively investigated. Among the strategies toward the prevention of lung cancer, smoking cessation is the most important. Chemoprevention may reduce the risk of lung cancer among ex-smokers, but there remains debates about the protective effect of b-carotene and retinoids. Early detection is an alternative to reduce lung cancer mortality. Immuno-cytochemical analysis of sputum using monoclonal antibody may be a potential tool for the screening of lung cancer. Polymerase chain reaction aiming to search for an activated ras gene or p53 mutation from exfoliated bronchial epithelial cells is another promising technique for early detection of lung cancer.
• 375 - 395
• 10.6288/CJPH1997-16-05-01

• Link 綜論 Review Article
• 花蓮縣高中職學生騎機車危險行為的盛行率及相關因子Prevalence and Correlates of Hazardous Motorcycling Behavior among Students in Hualien Senior High School
• 李蘭、李燕嗚
  Lee-Lan Yen, Yin-Ming Li
• 騎機車 ； 行為 ； 安全 ； 青少年
  motorcycling ; behavior ; safety ; adolescent
• 為探討高中職學生騎機車時之危險行為及相關因子，花蓮縣九所一般高級中學與職業學校的學生，以班級為單位自各校的各個年級中被隨機抽出，共有二十七班，合計1152名高一、高二和高三的學生，以不記名方式填答問卷。結果顯示，騎機車時最盛行的危險行為是：無照駕駛、騎上快車道、沒戴安全帽和超速。有這些行為者所佔比率分別為79.0%，70.9%，60.7%和63.9%。與騎機車時之危險行為顯著相關的因子包括性別、族群、校別、外控傾向、對安全的態度和是否有吸菸。依據本研究結果，建議強制戴安全帽的規定應該執行、安全帽的結構設計應予改進、禁止騎機車之危險行為的相關法規應及早制訂實施、並為青少年提供騎機車之安全教育計畫。
  The prevalence and correlates of hazardous motorcycling behavior among senior high school students in Haulien County were examined. Students were grouped by school and grade level, then were randomly selected by class. In total, 1152 students in the tenth, eleventh, and twelfth grades representing 27 classes in nine schools from Hualien County completed an anonymous questionnaire. Results indicate that the most prevalent hazardous motorcycling behaviors among the respondents were not getting a license to operate a motorcycle, motorcycling in the fast lane, not wearing a helmet, and motorcycling at high speed. The rates were 79.0%, 70.9%, 60.7%, and 63.9%, respectively. Gender, race, school, the extrovert trait, attitudes toward safety, and current smoking were found to be significantly associated with hazardous motorcycling behaviors. Enforcing mandatory helmet regulations, improving the structural design of helmets, establishing laws to prohibit hazardous mortorcycling behaviors, and providing educational programs for adolescents are recommended.
• 396 - 403
• 10.6288/CJPH1997-16-05-02

• Link 原著 Original Article
• 健康相關生活品質之效用測量方法信度與效度的評估：以血液透析之末期腎病患者為例Reliability and Validity of Utility Approach to Measuring Health Related Quality of Life: An Example of Patients on Hemodialysis
• 林榮第、游芝亭、姚開屏、王榮德
  Rong-Dih Lin, Chin-Tin Yu, Kai-Ping Grace Yao, Jung-Der Wang
• 健康相關生活品質 ； 效用 ； 信度 ； 效度
  healthy-related quality of life ; utility ; reliability ; validity
• 健康相關生活品質的測量已逐漸被運用於臨床決策、決定衛生政策優先順序、評估衛生計畫效益及經濟學之成本－效用分析上。本研究首先嘗試以血液透析患者為研究對象，對時間交換及評價等級兩種效用測量方法在健康相關生活品質之測量上的信度及效度進行評估，希望能建立起一個適合我國國情的健康狀態效用評估方法，並逐步修改而推廣到其他健康狀態的效用評估上，以作為臨床決策、衛生政策分析及計畫評估的參考指標。本研究採橫斷研究法，以1993年8月至11月期間，在臺北市三所教學醫院之血液透析中心接受長期血液透析，能夠並願意接受訪問的所有末期腎病息者為研究對象。由標準化訪視員以結構式問卷進行訪視及再測。共有125名患者完成訪問，回應率為90%。研究結果發現，時間交換及評價等級兩種效用測量方法對於不同的訪視者、不同的訪視時間及不同的訪視方法或訪現情境，都可得到穩定的結果，而且兩種方法在建構效度及效標相關效度等效度檢定上，均具有良好的表現。標準賭博、時間交換及評價等級等方法所測得的血液透析患者之健康相關生活品質的效用數值分別為0.75、0.61與0.57。 在健康狀態效用的測量方法中，標準賭博、時間交換及評價等級皆具有良好的信度及效度。但說可行性而言，時間交換及評價等級是較受大多數學者所建議採行的方法。另外，由終評價等級施測貿易且所得結果與其他方法同樣具有信度及效度，故很適合應用於大規模的研究
  The measure of health-related quality of life has been used progressively in clinical decision making, public health priority setting, assessing the effectiveness of health programs and economic cost-utility analysis. The purpose of this study is to evaluate the reliability and validity of two utility measurement techniques including time tradeoff and rating scale in the measure of health-related quality of life in order that we could develop an indicator for health policy decision and program evaluation based on Chinese cultural background. Subjects of this cross-sectional study consisted of all the patients of end-stage renal disease receiving maintenance hemodialysis at the hemodialysis room of three teaching hospitals in the Taipei between August 1993 and November 1993. Interviews were undertaken by standardized interviewers with a structured questionnaire. 125 subjects completed the interview. The response rate was about 90%. The results showed that both time tradeoff and rating scale measurement techniques got consistent results by different interviewers and method and at different interviewing time and situations. These two measurement techniques had good performance in the assessment of validity including construct validity and criterion-related validity. The utility values measured by standard gamble, time tradeoff, and rating scale were 0.75, 0.61, and 0.57 respectively. Standard gamble, time tradeoff and rating scale are all reliable and valid techniques in the measure of health-related quality of life. Based on feasibility, the time tradeoff and rating scale methods are more popular with most investigators. The rating scale method is easiest to administer and appears to yield results that are as valid as any other method. Thus, this would seem to be the method of choice in large-sample studies.
• 404 - 416
• 10.6288/CJPH1997-16-05-03

• Link 原著 Original Article
• 尿液黃麴毒素代謝產物和肝細胞癌之重疊病例對照研究Urinary Aflatoxin Metabolites and Hepatocellular Carcinoma-A Nested Case-Control Study
• 連如蘋、 廖運範、于明暉、 陳建仁
  Ju-Ping Lien, Yun-Fan Liaw, Ming-Whei Yu, Chien-Jen Chen
• 黃麴毒素 ； 肝細胞癌 ； 重疊病例對照研究
  Aflatoxin ; Hepatocellular carcinoma ; Nested case-control study
• 為探討台灣地區黃麴毒素暴露和肝細胞癌發生的關孫，本研究係以民國77-81年收案自公保健診中心和長庚醫院肝病中心的4841名男性B型肝炎病毒帶原者和2501名男性非帶原者為研究世代，利用追蹤期間發生肝細胞癌且有庫存尿液檢體的43名個案為病例組，每名病例選取一名B型肝炎表面抗原(HBsAg)陽性及一名HBsAg陰性未罹患肝細胞癌個案為對照組。研究結果顯示，尿液黃麴毒素代謝產物間的相關性在肝細胞癌病例組，HBsAg陽性對照組及HBsAg陰性對照組不同，且各種尿液代謝產物佔黃麴毒素總量的百分比在三組中亦有差異，AFM1%在HBsAg陰性對照組最高，AFP1%在HBsAg陰性對照組最低，AFB1%在病例組聶高。黃麴毒素總量及大多數代謝產物濃度念高，罹患肝細胞癌的相對危險性愈高，在控制了其它重要危險因子作用後，尿液黃麴毒素總量及黃麴毒素M1(AFM1)和罹患肝細胞癌的危險性有相關。AFM1和肝細胞癌的相對危險性在不抽菸、不喝酒、或年齡50歲以下者較高。
  In order to elucidate the association between aflatoxin exposure and hepatocellular carcinoma (HCC), a cohort of 4841 male asymptomatic chronic hepatitis B virus (HBV) carriers and 2501 male non-carriers aged 30 years or above was recruited from Government Employees Central Clinics and the Liver Unit of Chung-Gung Memorial Hospital between August, 1988 and June, 1992. There were 43 newly-developed HCC cases identified during follow-up periods. For each case, one HBV carrier and one HBV non-carrier were randomly selected as controls from cohort members without HCC. Cases and controls were matched with respect to age (within 3 years) and the season of urine collection. Correlation among various urinary aflatoxin metabolites were quite different for HCC cases, chronic HBV carriers, and HBV non-carriers. The relative risk of developing HCC was increased with urinary levels of total aflatoxins, aflatoxin P,. aflatoxin Mi, aflatoxin-N7-guanine, and aflatoxin Bi. After adjusting for other risk factors, urinary level of total aflatoxins and aflatoxin Mi were associated with the development of HCC. The relative risks of HCC associated with urinary atlatoxin M1 were more marked among individuals aged less than 50 years and those who smoked or drunk.
• 417 - 427
• 10.6288/CJPH1997-16-05-04

• Link 原著 Original Article
• 群體執業與單獨執業醫師之生產力比較Comparison of Physician Productivity in Solo and Group Practice
• 鄭守夏、何玉雪
  Shou-Hsia Cheng, Yu-Hsueh Ho
• 群體執業 ； 開業醫師 ； 生產力
  group practice ; clinic physician ; productivity
• 開業醫師群體執業在國外較為普遍，而過去的研究也顯示群體執業比單獨執業較有效率。本研究即在探討國內開業醫師群體執業的狀況並檢視其營運效率。資料係於民國85年以郵寄問卷方式，對全國所有8666名開業醫師做調查，回收率為21.2%，其中計有1804份有效問卷。樣本中只有159位醫師（佔8.8%）所在的診所為群體執業（至少有兩位醫師執業）。本研究初步要現，由醫師群體執業的診所比單獨執業者聘用較多的工作人員，而受訪醫師的工作時間較少，且其每日的門診人次較多。另以複迴歸模型控制醫師個人特質、診所特性及診所投入變項後發現，採群體執業的開業醫師比單獨執業的醫師有較高的門診生產力，平約每天多看16%的病人；但由於樣本中群體執業的醫師過少且為橫斷性資料，分析的結果宜保守推論。
  Physician group practice is more popular in industrialized countries than in Taiwan. A number of studies show that group practice tends to be more efficient than solo practice. This study examines current situation of physician group practice and compares physician productivities in solo and group practice settings. Data were obtained from mailing questionnaires to clinic physicians nation-wide in 1996. A total of 1804 subjects with completed information were included in the analysis. Only 159 physicians (8.8%) were in group- practice settings. Results showed that group-practice clinics hired more ancillary personnel than solo practice; physicians in group practice settings had fewer working-hours per week and had more out-patient visits. After controlling variables of physician characteristics, clinic features and practice inputs in the model, the multiple regression analysis revealed that physicians in group practice settings had higher productivity than the solo ones (with 16% more patients per day). However, due to the nature of cross-sectional data and the low rate of group practice, implications of the findings should be made conservatively. Results from the analysis suggest that group practice is more productive and might be more efficient than solo practice.
• 428 - 434
• 10.6288/CJPH1997-16-05-05

• Link 原著 Original Article
• 立委選舉之醫療保健政見分析，1969~1995Health Care Political Views Showed in Legislator Election Campaigns, 1969~1995
• 魏中仁、楊志良
  Chung-Jen Wey, Chih-Liang Yaung
• 立法委員 ； 選舉 ； 醫療保健政見
  legislator ; election ; health care political view
• 本研究以內容分析的方法，探討自1969至1995年立法委員選舉候選人所提出的醫療保健政見。資料來源係以台灣地區9次立委選舉合報中1,438名候選人的選舉政見為分析對象。研究結果發現：(1)46%的候選人所提的政見論及醫療保健相關的主題；(2)健康保險是醫療保健類中最受重現的議題，有超過三分之一的候選人提出，排名所有69類政見的第任位；(3)醫政類政見次之，有14.5%的候選人提出，其餘依序為藥政類(1.9%)、食品類(1.5%)、保健類(1.1%)與防疫類(0.1%)。
  To examine the trend for health care political views showed in legislator election campaigns held in Taiwan form 1969 to 1995, content analysis method was used to analyze and categorize the campaign documents from 1,438 candidates in 9 elections. The result showed: (1)46.0% candidates brought the health care political views up; (2)On health care issues, national health insurance program was the most popular one to be showed by over 1/3 candidates; and (3) The remaining political views in sequence were medical affairs (14.5%), pharmaceutical affairs (1.9%), food sanitation (1.5%), health promotion and protection (1.1%), and communicable disease control (0.1%).
• 435 - 442
• 10.6288/CJPH1997-16-05-06

• Link 實務 Public Health Practice
• 軍眷對全民健保後選擇就醫場所之態度及其影響因素Factors Affecting the Attitudes of Military Dependents toward Choices of Medical Care Providers under the National Health Insurance Plan
• 高森永、申慕韓、王運昌、林金定、吳孟娜、黃純昭
  Senyeong Kao, Muh-Han Shen, Yun-Chang Wang, Jin-Ding Lin, Minna Wu, Chung-Jau Huang
• 就醫選擇 ； 軍眷 ； 全民健康保險
  choices of medical care providers ; military dependents ; National Health Insurance NHI
• 本研究在全民健保實施前對軍眷從事問卷調查，旨在探討軍眷期望於全民健保實施後，對於選擇就醫場所的條件並分析其就醫選擇之可能影響因素，研究於1995年2月以系統隨機抽樣方法抽取8,148位軍眷，採郵寄問卷法，共回收有效問卷數3089份，回收率為37.9%。研究結果要現：(1)有多數的軍眷希望軍方醫療院所可繼續提供完全免費或減免優待的醫療服務且不需受轉診制度之限制；(2)若軍方院所可提拱軍眷減免優待，則多數的軍眷將會優先選擇軍方院所就醫；反之，若亦需負擔部分醫療費用，則會優先選擇軍方以外之健保特約院所就醫；(3)部分負擔比率愈高，願意選擇至軍方院所就醫者就愈少；以及(4)反對實施及不願意加入全民健保者均有較高的比率表示會選擇軍方醫療院所就醫。根據以上發現，本研究推論，未來軍眷是否仍會以軍方醫療院所為優先考慮的就醫場所將取決於軍方醫療院所所提供的減免優惠程度。
  This study was to examine military dependents preference for medical care providers under the implementation of the National Health Insurance (NHI). 8,148 samples were drawn from the Ministry of Defense dependent database through systematic sampling in February 1995. There were 3,089 effective responses for the questionnaires sent by mail, with a response rate of 37.9%. Findings of the study show: (1) Most of the dependents desire to keep the benefits of the medical services provided by the military medical care system with special copayment rates or entirely free services without restrictions of the defined referral regulations; (2) Most of them will select military hospitals for medical care needs if free services or special copayment rates are offered, otherwise, they will select NHI contract hospitals; (3) The higher the copayment rates are raised, the less military dependents will keep their loyalty to military hospitals; and (4) A higher percentage of those who are opposing the implementation of the NHI, and unwilling to join it show that they will prefer military hospitals over other medical care providers.
• 443 - 452
• 10.6288/CJPH1997-16-05-07

• Link 其他 Others
• 無Re: Improving TB Control with Selected Isoniazid Preventive Therapy in Children and Adolescents
• 無
  Ronald J. Bowerman
• 無
  none
• 無
  none
• 453 - 454
• 10.6288/CJPH1997-16-05-08