16卷6期

• Link 綜論 Review Article
• 氣候溫暖化對台灣登革熱流行之影響Effect of Warming Climate on the Epidemic of Dengue Fever in Taiwan
• 王正雄、陳秀玲
  Cheng-Hsung Wang, Hsiu-Ling Chen
• 氣候溫暖化 ； 流行病學影響 ； 登革熱 ； 媒病潛能
  warming climate ; epidemiological effect ; dengue ; vector potential
• 台灣地區可能因受全球溫室效應的影響，氣候溫暖化，三十年來年平均溫升高0.2~0.9℃；冬季月平均溫升高0.9~3.0℃，冬季月平均低溫升高1.5~4.0℃，而呈暖冬現象。氣候之變遷，已改變登革熱病媒紋的媒病潛能，且埃及斑紋、白線斑紋兩種病媒之密度有逐年提升，分布地點有逐漸擴展、活動季節有逐漸延長之現象。因此，導效1994、1995年登革熱之異常流行。台灣之登革熱自1988年爆發之後，每三年一次小流行，且本上病例多侷限於高屏縣市。流行季節亦多於十一月寒流來襲後歇止。1994年登革熱向北延伸到台南市，並持續流行到1995年元月。199三年登革熱更在北部、中部發生，而十二月底仍有感染病例報告。
  The climate in Taiwan is getting warm, possibly a result of the global greenhouse effect. During the last 30 years, the yearly mean air temperature has risen 0.2~0.9?. Specifically, the monthly mean air temperature in winter has risen 0.9~3.0?, and the monthly mean minimal temperature has risen 1.5~4.0?, resulting in warm winters. This warming trend affects the infection potential of dengue vectors. Aedes albopictus has now become an important vector in the northern and central parts of Taiwan. Both Ae. aegypti and Ae. albopictus have been increasing in density and in area of distribution yearly. In the meanwhile, their activity season has also lengthened. This had led to abnormal epidemics of dengue in 1994 and 1995. Since the outbreak of dengue in 1988, limited epidemics have occurred every three years, mainly in the cities of Kaohsiung and Pingtung. They usually ended in November--the start of the cold season. However, in 1994 the occurrence of dengue extended to Tainan (north of Kaohsiung) and lasted till January 1995. The 1995 epidemic occurred farther up to northern and central Taiwan, and cases were found even at the end of December.
• 455 - 465
• 10.6288/CJPH1997-16-06-01

• Link 原著 Original Article
• 鼻咽癌多重危險因子之世代追蹤研究A Cohort Study on Multiple Risk Factors of Nasopharyngeal Carcinoma
• 林宇旋、陳建仁
  Yu-Hsuan Lin, Chien-Jen Chen
• 鼻咽癌 ； 世代追蹤研究 ； 危險因子
  nasopharyngeal carcinoma ; cohort study ; risk factors
• 本研完以台灣地區六個鄉鎮之9775名男性為對象，採世代追蹤研究法探討鼻咽癌與多重危險因子相關。研究對象於收案時，均利用結構式問卷收集其人口學基本特徵與各項危險因子暴露資料，並採集血液檢體進行EB病毒抗體測定。在平均8.1年追蹤期間，共發現13名鼻咽癌新病例，以Cox氏比例危害模式與多變項對數迴歸分析結果如下：EB病毒VCA/IgA抗體效價大於1:10或DNase抗體高於2.0單位者，罹患鼻咽癌之相對危險性顯著偏高。無論被診斷出鼻咽癌的時間是在追蹤兩年內或兩年後，抗體效價高者，皆具有顯著偏高之鼻咽癌危險性。在調整年齡與病毒抗體效價後，攝取豆類發酵食物、鼻竇炎病史和鼻咽癌家族史，皆與鼻咽癌的發生有關。EB病毒DNase抗體效價偏高與抽菸、攝取豆類發酵食物間則有顯著交互作用。
  In order to explore multiple risk factors of nasopharyngeal carcinoma (NPC), a total of 9775 male adult residents in six townships were studied. Sociodemographic characteristics, history of cigarettes smoking and alcohol drinking, dietary habits, personal history of sinusitis and family history of NPC were collected by well-trained interviewers with structured questionnaires at the recruitment. Blood samples were also obtained and tested for immunoglobulin A antibodies against viral capsid antigen (anti-EBV VCA/IgA) of Epstein-Barr virus (EBV) and antibodies to EBV-specific DNase (anti-EBV DNase). A total of 13 new NPC cases occurred during an average follow-up period of 8.1 years. Cox's proportional hazard models and multiple logistic regression models were used to analyze multiple risk factors for NPC. The multivariate-adjusted relative risk of developing NPC for anti-EBV VCA/IgA was 40.6 (95%CI 7.5-220.1) for a titer equal to 1:10, and 726.7 (95%CI 177, 9-2967.7) for a titer greater than or equal to 1:40. The multivariate-adjusted relative risk for anti-EBV DNase was 3.4 (95%CI 0.4-32.9) for a level of 2.0- 3.9 units, 34.1 (95%CI 6.8-171.1) for 4.0-5.9 units, and 113.6 (95%CI 27.7-465.9) for 6.0 or more units. Stratification analysis of NPC cases diagnosed within and after first two years of follow-up, the significantly high relative risks associated with elevated EBV antibodies remained. After adjustment for age and anti-EBV antibody level, consumption of fermented soy bean products, family history of NPC, and personal history of sinusitis were also associated with the development of NPC. Interactions were found between seropositivity of anti-EBV DNase and cigarette smoking and fermented soy bean products consumption.
• 466 - 477
• 10.6288/CJPH1997-16-06-02

• Link 原著 Original Article
• 精神病患居家自我照顧現象探討The Phenomena of Self Care for Psychotic Patients in Community
• 蕭淑貞、 陳賢佳、葉櫻媛、 陳杏佳、邱淑貞
  Shu-Jen Shiau, Hsien-Chia Chen, Ying-Yung Yeh, Shing-Chia Chen, Shu-Jen Chiou
• 精神疾病 ； 自我照顧
  psychotic disorder ; self-care
• 目前精神病患大多回歸社區，自我照顧能力是病患在社會生活成功與否一重要指標。本研究以台灣大學附設醫院、台北市立療養院、省立桃園療養院精神分裂症或情感性疾患，年齡在16~65歲之間，與家人同住的病患共151名為對象，採問卷調查法，探討影響精神疾病個案自我照顧的因素。結果發現：(1)精神分裂症病患之自我照顧執行情形得分較情感性疾患低；(2)「盥洗」之自我照顧情形較其他分向表現佳；(3)「藥物結盟」之依賴程度最高：(4)精神分裂症自我照顧與生病年數、疾病症狀、家庭擔憂感受呈負相關，但與家庭功能、因應效能呈正相關；(5)情感性疾患自我照顧與負性症狀、住院次數、生病年數、家庭擔憂感受呈負相關，但與家庭功能、因應效能呈正相關；(6)與精神分裂症自我照顧執行達顯著相關的變項為負性症狀、家庭因應效能；與情感性疾急自我照顧執行達顯著相關的變項為家庭因應效能。
  The purpose of this study was to explore the factors influencing the self-care performance and self-care dependence for the patients with schizophrenia or mood disorder in community. Subjects were chosen by convenience sampling from National Taiwan University Hospital, Taipei City Psychiatric Center and Provincial Tau-Yun Psychiatric Center. One hundred and fifty-one questionnaires were completed. The result revealed: (l) the self-care of schizophrenic patients was worse than that of manic-depressive patients. (2)Self-care performance of personal hygiene by these patients was better than other factors. (3)The degree of dependence on drug alliance was higher than other factors. (4)Factors influencing self-care of schizophrenic patients included patients' age, the symptoms of the disease, degree of concerns regarding their illness, family function and the effect of the coping behavior. (5)Factors influencing self-care of mood disorder patients included the number of hospitalization, the duration of the disease, the negative symptoms degree of concerns regarding their illness, family function and the effect of the coping behavior. (6)The negative symptoms and the effect of coping were significant correlated with self-care of schizophrenic patients. The effect of coping were significant correlated with self-care of mood disorder patients.
• 478 - 487
• 10.6288/CJPH1997-16-06-03

• Link 原著 Original Article
• 從住院費用以統計模式探討中風病人轉診至長期照護機構之臨界日－某醫學中心為例Referring CVA Patients from Acute Hospitals to Long Term Care Institutes: Determination of the Most Appropriate Time Using Statistical Modeling on Hospital Charges-An Example from a Medical Center
• 盧成皆、 黃靜宜、史麗珠
  Sing-Kai Lo, Jang-Yee Huang, Lai-Chu See
• 中風 ； 轉診 ； 臨界日 ； 長期照護 ； 統計模式
  CVA ; referral day ; long term care ; statistical model
• 本文目的是以統計模式之建立為出發點，對每天之平均及累積住院費用進行分析，探討腦中風病患向急性醫院「轉診」至長期照護機構之臨界日。在病患住院初期，進行大部份的檢驗及急性治療，住院費用最高、待病情較穩定，不需要急性醫院的醫療設備後，費用便會下降。因此，基於病情能反映於費用上的假設，對住院費用及住院天數進行兩段迴歸分析，前後兩段之迴歸線斜率差異為最大、或前後兩段平均費用差距最大，便可視為轉診的臨界日。除此之外亦可以累積住院費用達某百分比（如75%，80%或90%）時作為切點討論。
  A few statistical models were constructed to investigate the most appropriate time to refer hospitalized CVA patients from a medical center to long term care institutes. Based on the assumption that patients' physical conditions can be reflected in their hospital fees, the cumulative charges were examined by a two-piece regression. It is perhaps most efficient, from hospital management's point of view, to transfer patients at the time where the difference between the slopes of the regression lines before and after this point is maximized. Alternatively, one can also maximize the difference in average daily charges before and after such point, or when the cumulative charges reach, say, 75%, 80% or 90%. The studied sample consisted of 1357 CVA inpatients randomly drawn from a medical center in northern Taiwan. Their average length of stay (LOS) was 22.9 days, with a mean hospital fee of NT$76325. Results of the piece-wise regression analysis show that most patients can be referred in 3 to 5 days. On the other hand, we also found that 75%-90% of the total fee was accumulated in the first 12-13 days. Should patients be transferred within the derived days, operating efficiency can increase by 12%-34%. Since only fees are used in the modeling process as the dependent variable, but physical conditions and outcomes of the patients have been largely ignored, results of this research can by no means be considered complete. Yet this still seems to be one of the pioneer projects investigating ”referral date”, instead of the reasonably well studied ”length of stay”. Therefore, it is suggested that further research be carried out from a more medical point of view, so that the combined results will be more comprehensive.
• 488 - 498
• 10.6288/CJPH1997-16-06-04

• Link 原著 Original Article
• 聚氯乙烯工人GST T1，GST M1及CYP2E1基因型與其肝功能之相關研究The Relationship between the GST T1, GST M1, CYP2E1 Genotype and Abnormal Liver Function in PVC Workers
• 黃忠英、鄭尊仁、黃國良、王榮德、謝玲玲
  Chung-Ying Huang, Tsun-Jen Cheng, Kuo-Liang Huang, Jung-Der Wang, Ling-Ling Hsieh
• 氯乙烯 ； 麩胺基硫轉移 ； 細胞色素P450 2E1 ； 肝功能
  vinyl ; chloride ; glutathione s-transferases ; CYP 2E1 ; liver function
• 無
  Vinyl chloride monomer (VCM) is hepatotoxic as well as carcinogenic in humans. There are reports that exposure to VCM seems to induce abnormal liver function, liver fibrosis, cirrhosis, and angiosarcoma of the liver. In vivo, VCM is metabolized by cytochrome P450 2E1 (CYP2E1) to form chloroethylene oxide (CEO) and chloroactetaldehyde (CAA), both electrophilic metabolites, which may either cause cell damage or are further metabolized and detoxified by glutathione S-transferases (GSTs). This study investigated whether or not the genotypes, CYP2E1, glutathione S-transferase ? (GST T1) and µ (GST M1), correlated the abnormal liver function in vinyl chloride exposed workers. We enrolled 251 workers from 5 polyvinyl chloride plants for this study. The workers who were exposed to VCM were classified into two, high and low exposure groups and the degree of exposure was determined based on their job titles and airborne VCM concentration. The enzyme activities of serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were used as the parameters of liver function. The genotypes, CYP2E1, GST T1 and GST M1, were determined by performing PCR and RFLP on peripheral white blood cell DNA, Other potential risk factors were also ascertained and the confounding effect was adjusted accordingly. Stratified analyses were used to explore the correlation between the alteration of liver function and the genotypes, CYP2E1, GST T1 and GST M1, among the workers exposed to different levels of VCM.
• 499 - 512
• 10.6288/CJPH1997-16-06-05

• Link 實務 Public Health Practice
• 健康保險資料庫之學術應用：重大傷病證明資料檔分析之經驗Use of National Health Insurance Database in Academic Research: Experiences from Analysis of Major Disease Certification Profile
• 陳建仁、林莉華
  Chien-Jen Chen, Lin-Hwa Lin
• 健保資料庫 ； 應用範圍 ； 特性 ； 限制
  health insurance database ; applicability ; essential characteristics ; limitation
• 健康保險資料庫之學術應用，不僅有助於醫療保健工作之規劃、執行與考核，也有助於國民健康狀況、衛生需求及疾病致因之分析與探討。我國全民健康保險於一九九五年三月一日開始實施以來，即建立相當可觀之資料庫，可以提供學術研究所需之資訊。本文根據中央健保局委託分析「重大傷病證明領用保險對象檔案」之經驗，說明健康保險資料庫之學術應用範圍、應具備之特質、可能限制、以及未來改善提昇之方向。
  The database of health insurance is important for the planning, monitoring and evaluation of health care programs. It is also useful for the assessment of health need and exploration of risk factors for diseases. After the implementation of national health insurance program in Taiwan, a large-scale database been collected for administrative and managerial purposes. It may also provide essential information for academic researches. Based on our experiences in the analysis of major disease certification profile of national health insurance program, we describe the applocability, essential characteristics, limitations and future perspectives of national health insurance database.
• 513 - 521
• 10.6288/CJPH1997-16-06-06

• Link 實務 Public Health Practice
• 健保資料庫整體規劃及其架構Planning and Suggested Framework for Healthcare Databases Integration
• 游張松、 蘇喜
  Chang-Sung Yu, Syi Su
• 健保 ； 資料庫 ； 規劃 ； 架構
  healthcare ; database ; planning ; framwork
• 我國健保制度施行以來，為以期加速資料處理能力，正傾全力建立健保給付電腦系統。然而，本土學者很難由此取得我國健保資料，乃以美國資料，作美國的個案研究，殊為可惜。本文期望透過健保資料庫之規劃與建立，為我國研究人員提供可以獲取(access)之資料，推動本土醫療成效研究。健全的健保資料庫之建立有助於分析健保營運成果，明瞭醫療單位之醫療成效，形成自然的良性循環，提昇國民醫療品質。 本文分析健保資料庫之重要性，理想條件及其策略功能，從而說明其與提昇醫療品質之關係，並且整合科技、網路與管理，提出系統架構及建置之建議。
  Since the introduction of healthcare program, the healthcare bureau has been devoted to the computerization in order to speedup the process of healthcare payment. However, the local researchers are not easy to access the local healthcare data, and therefore, use the American data for American case study instead. We believe that, through the planning and the establishment of loca healthcare database integration, we will be able to provide the researchers with valuable data, which will in turn encourage the research of local healthcare performance. A well-planned integrated database can be used to analyze the effectiveness of healthcare operations, to understand the medical institutions' performance, and thus to enhance national healthcare quality. In this paper, we analyze the importance of the healthcare database integration, the required conditions, and the related strategic functions. We, therefore, depict how the healthcare database can automatically enhance the quality of the healthcare implementation. Finally, through the utilization of information technology, internetworking and systems management, we propose planning building blocks and a framwork for healthcare databases integration.
• 522 - 526
• 10.6288/CJPH1997-16-06-07

• Link 實務 Public Health Practice
• 健保資料庫在醫療資源耗用及醫療品質偵測上之功用Monitoring the Utilization and Quality of Medical Care Using Data Base of National Health Insurance Clients
• 蘇喜、黃月桂、李丞華、郝宏恕、湯靜怡
  Syi Su, Yueh-Kuei Huang, Cheng-Hua Li, Hung-Shu Hao, Ching-I Tang
• 健保資料庫 ； 醫療資源 ； 醫療品質 ； 定性指標
  health insurance data bank ; medical resource ; medical quality
• 在獨買的保險制度下，健保局握有95%的醫療資訊，作為政策擬定及品管的有效資料。本文係以健保局現有之資料庫，研擬如何抽取所需的數據，加以運算處理作趨勢分析，將台灣醫療界之資源耗用，及醫療品質的現況，匯集成具有意義的管理資訊系統。俾使健保審查，因分析報表的詳盡，能建立醫療品質管理模式，而提昇審查結果之合理性。現今各界關注的問題，不外乎健保實行後，各項相關的資源耗用、醫療費用、以及醫療品質的變化。本文乃透過健保局及中華民國公共衛生學會，所召開之“健保資料庫應用”研討會，凝聚醫管相關專家意見，建議整合各參與醫院、健保局、及衛生署各醫事機構資料庫，而建立品質計畫與定性指標，諸如：資源耗用指標、品質指標、哨兵事件指標、結構指標、過程指標、結果指標、績效指標等，以作為管理政策的參考。
  Being under the single buyer insurance system, the National Health Insurance Bureau gathered 95 percent of medical care delivery information How to maximize the utilization information is a key issue faced by governmental officials, scholars, and health industry C.E.O.s. In order to fulfill more efficient and reasonable management system. A forum concerned with the data base utilization had been conducted, this report represent the consensus among scholars of health care administration. Recently, the society tend to pay more attention to the variation of resource consumption, medical costs, and health care quality. The objective of the study intend to establish the fixed indices to entail problems of inequality under the impact of the national health insurance program. Research on the data base of the National Health Insurance Bureau was reviewed in detail. From the results, we suggested that the data base of NHI need to be improved to increase their adjustment and efficiency by following indices such as: Resource Consumption Indicators, Quality Indicators, Sentinel Event Indicators, Outcome Indicators, Structure Indicators, and Performance Indicators.
• 527 - 537
• 10.6288/CJPH1997-16-06-08